Effect of inhaled atrial natriuretic peptide on methacholine bronchoconstriction in asthma

We have previously demonstrated that intravenous and inhaled atrial natriuretic peptide (ANP) significantly inhibits histamine induced bronchoconstriction in asthmatic patients. The current study was designed to determine whether inhaled ANP was also able to inhibit the effects of methacholine. Eight atopic asthmatic patients (five women) were studied: mean (SD) age 38.2 (8.3) years flow expiratory volume per second (FEV₁) 2.97 (0.60) litres, equivalent to 92 (13) % of the predicted. Each had demonstrated at least mild bronchial hyperreactivity to inhaled methacholine at screening (geometric mean PC20 l.02mg/ml; range 0.1l–6.54mg/ml). Patients attended for 3 study days and after baseline spirometry received 3.5 ml saline (placebo), 0.1 mg ANP or 1 mg ANP (ANP dissolved in 3.5ml saline) in a randomized, double-blind manner via a Mizer aerosol conservation device. Aerosolization took approximately 9 min and FEV₁ was repeated at 0.5, 1.5 and 3 min after completion. Immediately thereafter each patient received a 2 min inhalation of methacholine at a dose individually calculated to give a 25% fall in FEV₁ (as extrapolated at their initial screening visit) and the FEY₁ was followed over the next 20 min. Mean (SEM)% FEV₁ did not change significantly after ANP being -4.3 (1.7), -3.2 (2.7) and -2.4 (1.2) after placebo, 0.1 mg ANP and 1 mg ANP respectively. The mean (SEM) maximum fall in FEV₁ after methacholine was as follows: placebo 26.9 (5.7)%, 0-1 mg ANP 18.2 (4.3)% and 1.0mg 11.2(2 7)%, (P < 0.05 placebo vs 1 mg ANP). These results demonstrate that ANP offers significant protection against methacholine induced bronchoconstriction in asthmatic patients.     

COMPARISON OF PIROXICAM WITH PLACEBO IN THE MANAGEMENT OF PAIN AFTER TOTAL HIP REPLACEMENT

A randomized double-blind controlled study was undertaken toassess the analgesic efficacy of piroxicam. Twenty-four patientsunderwent total hip replacement under spinal anaesthetic; afteroperation, they received a 3-day course of either placebo (n= 12) or piroxicam (n = 12). Adequate analgesia was providedfor 48 h by a patient-controlled analgesia system deliveringmorphine. Patients receiving piroxicam required 50% less morphinethan the control group (38 mg compared with 76 mg (P < 0.002)).This technique was tolerated well and there were no significantside effects.     

The emergency physician and patient confidentiality: A review

Confidentiality is a promise rooted in tradition, law andmedical ethics. Emergency physicians treat a variety of patients to whom confidentiality is of vital importance: employees, celebrities, victims of violence or disaster, minors, students, criminals, drug abusers, and patients with STDs. EDs should develop methods of ensuring confidentiality for all patients.³⁴Although confidentiality is an important principle thatshould be respected and guarded, it is not absolute. Various laws mandate disclosure of certain patient information; in addition, an overriding moral duty may occasionally require, a breach of confidentiality. As Beauchamp and Childress noted, “the therapeutic role may sometimes have to yield to ones role as citizen and as protector of the interests of others”.¹⁹ In general, however, circumstances requiring a breach of confidentiality are rare.     

Can communication skills be assessed independently of their context?

In many examinations, communication skills tend to be treated as if they are a single attribute independent of the context of the communication. However, it is clear that such assessments are confounded by candidates' knowledge or lack of knowledge of the medical issues about which they are communicating. In the 1990 Part One examination for Membership of the Royal New Zealand College of General Practitioners candidates were provided with all the essential knowledge relevant to the problem they were to communicate about. Despite this, performance was still seen to be context specific, demonstrating that such specificity is not purely knowledge related. Candidates completing the examination were observed to share information about the cases with candidates about to commerce. There was no evidence that performance was enhanced by such breaches in examination security.