Managing asthma in accident and emergency departments: an assessment in non teaching hospitals

Background: The management and follow-up of asthma patients presenting at Accident and Emergency (A&E) departments have mostly been studied in children's hospitals or specialised teaching hospitals. Aims: To study the adequacy of assessment, treatment and follow-up of patients presenting at A&E departments in non-teaching hospitals. Methods: A twenty-five per cent sample of presentations to A&E departments in all public hospitals in the Illawarra for one year was selected for a case note audit. Information on demographics, assessment, management and referral was extracted from the A&E case notes and medical records of cases with documentation of a final diagnosis of asthma. Chi square and Fischer's Exact tests were used for comparisons among hospitals. Results: Of 359 presentations with a final diagnosis of asthma, 88% were self referred and only 5% were first presentations. Objective measures of airways obstruction was not documented in 34% of admissions and 48% of nonadmissions. There was no documented follow-up in 28% of cases. The assessment and management of asthma in A&E was significantly poorer in smaller hospitals. Conclusion: Evidence of high use of A&E as a primary care facility by asthma patients was found in the study. There is a need to implement protocols to optimise assessment and treatment of asthma in smaller hospitals. (Aust NZ J Med 1993; 23: 672–677.).     

Large granular lymphocyte expansions in patients with Felty's syndrome: analysis using anti-T cell receptor V beta-specific monoclonal antibodies.

Felty's syndrome (FS), the association of rheumatoid arthritis (RA) and idiopathic neutropenia, remains an unexplained phenomenon. HLA-DR4 is found in over 90% of cases. Patients with FS may have a T cell lymphocytosis of CD3+CD8+CD57+ large granular lymphocytes (LGL syndrome). In this study of 47 patients with FS, 19% had clear evidence for LGL expansions, while in total 42% had variable evidence for the LGL syndrome using currently available techniques. Of these T cell expansions, 76% were clonal, as demonstrated by Southern blotting and analysis with T cell receptor (TCR) beta chain constant region probes. This technique may fail to detect clonal populations in some patients. Cytofluorographic analysis using antibodies specific for TCR V beta chains identified patients with clonal LGL expansions with results comparable to those obtained with Southern blotting. No evidence for shared V beta usage among expansions from different patients was seen. The role of LGL in RA and FS is currently unclear, but this technique offers a practical and accessible means of identifying patients with LGL expansions, as a starting point for further investigation.     

Accessory left-ventricular chorda and the early ventricular repolarization syndrome

Electrocardiographic symptoms were evaluated in 53 patients with an additional left-ventricular chorda (ALVC), detected by two-dimensional echocardiography. Signs of early ventricular repolarization (EVR) were identified in 45 (84.9%) patients. A transverse ALVC was more common in EVR-free patients (87.5%), as compared to patients with ALVC + EVR combinations (51.1%; p less than 0.05).     

Stimulus-secretion coupling of arginine-induced insulin release. Resistance of arginine- and ornithine-stimulated glucagon and insulin release to D,L-alpha-difluoromethylornithine

In the isolated perfused rat pancreas, D,L-difluoromethylornithine, tested at a concentration of 3 mmol/L, failed to affect the release of glucagon and insulin caused, over 15 min stimulation, by either L-arginine or L-ornithine (2.0, 5.0 or 10.0 mmol/L) in the presence of either 3.3 or 5.6 mmol/L D-glucose. The inhibition of ornithine decarboxylase also failed to affect the release of glucagon provoked by either L-leucine (2 or 3 mmol/L) or L-glutamine (2 mmol/L) and the secretion of insulin stimulated by a rise in glucose concentration from 5.6 to 10.6 mmol/L. These data are interpreted to suggest that the rapid generation of polyamines from either L-arginine or L-ornithine does not play any significant role in the immediate glucagonotropic and insulinotropic action of these cationic amino acids.     

INCREASED RATE OF ETHANOL ELIMINATION AND ELEVATED BLOOD ACETATE IN ASTHMATICS ON CORTICOSTEROID, BETA-2-SYMPATHICOMIMETIC AND THEOPHYLLINE TREATMENT

The rate of ethanol elimination and blood acetate concentrationsafter a peroral dose of alcohol were measured in eight asthmaticpatients receiving high-dose corticosteroid, sustained releasetheophylline and beta-2-sympathicomimetic treatment and in eightnonalcoholic, healthy controls. Mean ethanol elimination rate(ER) and mean blood acetate concentration (AC) were significantly(P<0.01) higher in asthmatics (ER=134.8 ± 12.9 mg/kg/hr,AC = 1.13± 0.25 mM) than in controls (ER = 100.2 ±12.3 mg/kg/hr, AC = 0.64 ± 0.10 mM). In the asthmaticsthere was a significant negative correlation between the ageand the rate of ethanol elimination (r = –0.890, P <0.01); in the control group, however, this correlation was oflower degree (r = –0.423) and did not achieve statisticalsignificance. Enhanced ethanol metabolism in asthmatics is possiblydue to the effect of drugs. Our results suggest that ethanolelimination rate is increased in asthmatics receiving medicationand that the effect is most significant in younger age groups.     

The neutrophil oxidative burst in diarrhoea – associated haemolytic uraemic syndrome

. Neutrophil-mediated tissue damage has been implicated in the pathogenesis of diarrhoea-associated haemolytic uraemic syndrome (D+ HUS). This study evaluates priming and activation of the neutrophil oxidative burst in D+ HUS using chemiluminescent techniques. Peripheral blood neutrophils from 11 children with acute D+ HUS were examined. No difference was found in the oxidative burst of neutrophils from patients and controls. Serum elastase levels were measured in 8 patients and found to be significantly elevated. Although elastase results suggest neutrophil activation, chemiluminescence studies do not confirm this in the peripheral blood neutrophil. This does not support a significant role for circulating agents in priming and activating the peripheral blood neutrophil. Received August 17, 1995; received in revised form and accepted November 27, 1995