key: cord-0034078-2h2abgfh authors: nan title: Inaugural national scientific medical meeting date: 1993 journal: Ir J Med Sci DOI: 10.1007/bf02942100 sha: 14aed261f6bc6ea9ed60ec6dcf6db5d59469a1e5 doc_id: 34078 cord_uid: 2h2abgfh nan Throughout Ireland, many parents continue to provide primary care for their adult sons or daughters with mental handicap even when this is no longer the preferred option. The carets themselves experience their own ageing while they remain active parents and companionsL This study was undertaken to chart the experiences of older mothers in Ireland providing care to adult children. A total of 280 mothers in Ireland and Northern Ireland were inter-viewed in their homes. Their perceptions of the formal services needed or received, their informal supports from family and friends, their expectations and their own health and characteristics were explored. The results suggest that (1) the mothers have more constrained social networks; (2) many feel anxious about the future "when Fm not here"; (3) the impact on mother's health is associated with perceived stress as well as a number of demographic variables. Dublin. The role of morphometry as a prognostic indicator in ovarian turnouts has been widely acknowledged. The aim of thi s study is to compare morphometry with other prognostic indicatorsclinical staging and histological grading. In this study forty (40) primary epithelial tumours ovary (20 mucinons, 15 serous and 5 endometroid) were selected, They included 20 benign and 20 malignant tumours, Patients with the same clinical stage received similar treatment, Clinical followup was available for all the patients. The morphometric features investigated included mitotic activity index (MAI), volume percentage of epithelium (VPE) and volume corrected mitotic index (M/V Index). Using relative risk and 95% confidence interval to analyse our results, it was shown that risk of death in any unit of time goes up on average by 7% (95% confidence interval 1.1 -13.3%) for each unit increase in VPE. This risk is maintained even when analysis is corrected for the effect of stage or grade. University of Newcasde Upon Tyne, England. C-erB-2 oneoprotein expression detected immunohistochemically in primary breast cancer is a potent poor prognostic variable for patients including Irish women t. 2 . Also primary C-erB-2 expression indicates hormone resistance in recurrent breast cancer and relative tumour resistance to low intensity chemotherapy with mitoxanthrone (data in press). Forty young women (median age 41 years) had staining for C-erB-2 in their primary tumonrs; 11 showed positive staining and 29 did not. All subsequently had recurrences of breast cancer and were then given intensiv e chemotherapy with doxombicin 40 mg/m 2 intravenously and ifosfamide/ mesna 5 g/m 2 by intravenous infusion over 24 hours, with mesna alone for 8 hours. Cycles repeated at 21 day intervals to a total of 4 cycles in patients with responsive tumours. Response rates in recurrences (82% C-erB-2+VE vs 72% C-erB-2-ve) median response durations, and post-treatment survival were no different between patients on the basis of primary turnout C-erB-2 expression. This strongly suggests that young women with operable breast cancer and expression of C-erB-2 should be selected for intensive doxombicin based nee-adjuvant/adjuvant chemother apy. Vol. 162 No. 3 1991 and compared survival rates. The findings were compared with previous reports between 1946 and 1970. Patients with thyroid carcinoma from 1970 through 1991 were identified and pathological and clinical data retrieved. Of 141 patients identified, 113 were female and 28 male. Fiftyseven patients had papillary, 41 follicular, 24 anaplastic and 6 medullary carcinoma. There were 10 lymphomas and 3 thryoid metastases. The 10-year actuarial disease-free survival for papinary carcinoma was 93%, follicular 80% and medullary 37%. The median overall survival for anaplastic carcinoma was 5 months. The number of cases seen increased from 2.2 per year between 1946-1965 to 7.6 per year between 1982-1991. From 1946 to 1991 the relative incidence of papillary carcinoma increased from 19% to 57%. Of interest is the change in relative incidence of the histological sub-types. Follicular carcinoma is associated with endemic goitre and increased iodine intake may explain its reduced incidence. Increased radiation may explain the increase in papillary carcinoma. There is a need for a National Tumour Registry to see if this local trend is reflected nationally. Considerable evidence from animal turnout systems suggest that proteolytic enzymes are involved in cancer invasion and metastasis. Levels of specific proteases in primary human cancers might thus be markers for metastatic potential of these turnouts. The aims of this investigation were therefore to investigate a number of different proteases as prognostic markers in breast cancer. Of six different proteases studies, two, i.e. cathespin D (CD) and urokinase plasminogen activator (u-PA) correlated significantly with both shortened disease-free interval and patient survival. Using tmivariate analysis, u-PA as a prognostic marker was of similar value to, axillary node status but stronger than that of tumour size, estrogen receptor (ER) status or CD. In multivariate analysis, u-PA as a prognostic marker was independent of nodal status, tumour size and ER status. In addition, using overall survival as end point, u-PA was a significant prognostic marker in both axillary node-negative and node-positive patients. We conclude that u-PA is a new and independent prognostic marker in breast cancer. The discovery of oncogenes and tumour suppressor genes provides a molecular basis for studying the pathogenesis of malignant disease. A number of molecular defects have been described in several types of cancer, notably retinoblastoma, Wilm's Tumour. coloreetal cancer and breast callcar. In our own time we have described allele loss on chromosome 17q in ovarian cancer. This loss of genetic material is thought to represent inactivation of a 99 tumour suppressor gene. Ovar/9-t cancer is ranked as the fifth commonest neoplasm in women with a 5 year survival of 28 percent. These studies have been taken a stage further by Vogelstein's group in the USA with the discovery of a series of progressive molecular changes in the development of colo-rectal cancer from benign adanomatous polyps to frank malignancy. We have examined the changes in various types of ovarian tumours ranging from benign lesions to borderline tumours, through advancing clinical stages of malignancy. By combining the clinical and molecular results from three centres in Belfast, Edinburgh and Aberdeen, over 150 cases have been accumulated, It is now possible to discern a progressive pattern of molecular changes in the transition from benign to malignant disease (Table) . derived factors and response to potential therapeutic agents. These cell lines exhibit the following characteristics: (1) tumourigenic in nude mice and invasive using the chick heart invasion assay, (2) produce and secrete transforming growth factors and immune suppressor factors, (3) exhibit clonigenic growth in serum free medium, (4) are cytokeratin positive and coexpruss vimentin, keratin expression is responsive to retinoid morphogenesis, (5) lack HLA antigen expressiun which can beincluded on interferon treatment, (6) exhibit uncogene amplification. (7) are sensitive to LAK cell therapy. Despite the common tissue of origin, these cell lines differed in their response to chemotherapeutic agents mad radiation sensitivities. UsIng this system factors have been identified which may, at least in part, account for the refractory nature of this turnout to conventional therapy. In addition these cells will facilitate the development of new therapeutic strategies including biotherapy/ immunotherapy. I.J.M.S. Ma~h, 1993 and hypothyroidism were not significantly different between the groups but palpable goitres were present in 18/180 (10.0%) of breast cancer patients compared to 9/150 (6.0%) of controls. Ultrasound measurement emphasised this difference in that thyroid volume was significantly enlarged (>18.0 mls) in 67/180 (37.29'0) of breast cancer patients compared to 13/150 (8.6%) of controls (p<0.001) and the mean volume of 20,2_+1.9 mls, was significantly greater than that of 12.9-+ 1.2 mls. in controls (p<0.01 ). Patients with breast tumours graded T3 had a greater mean thyroid volume than T1 (23.8+2.8 v 16.45+_1.4 mls, p<0.O1) and were associated with a greater number of enlarged thyroids (T3: 64% v TI: 24%). To exclude therapeutic intervention as a cause for thyroid enlargement. 80 patients subsequently diagnosed as having breast cancer had thyroid scans at the time of excision biopsy. Neither mean thyroid volumes (20.0~1.2 mls. v 20.2+1.6 mls.) nor the % of thyroid enlargements (39% v 35%) were significantly different between Retrospective and Prospective Groups. The results indicate a direct relationship between the two disorders perhaps involving a common growth stimulus. We evaluated immunoscintigraphy to assess treatment response after surgery and chemotherapy in epithelial ovarian carcinoma (21 pts). C.A.T. scan and ultrasound were insensitive. Histological assessment by laparotomy or laparoscopy was invasive and unsuitable for some patients. The monoclunal antibodies used were HMFG (15 pts). HtTF 2 (3 pts), AUA, 3 patients. DTPAmonoclonal antibody was radiolabelled with Uqndium and serial planar and tomographie images obtained after intravenous infusion. Results were compared with C.A.T. scan and/or ultrasound, serum CA 125 and where possible histological assessment. Radioimmunoseans located tumunr in 9 o f 13 patients with residual ovarian carcinoma. Serum CA 125 was elevated in 11 of these patients but did not localize tumour. All positive immunoseans were associated with elevated serum CA 125. Techniques which may increase imaging sensitivity in ovarian carcinoma are dis- Dublin. Observations on the concurrence of thyroid disease and breast cancer have yielded conflicting results. One hundred and eighty consecutive patients with breast cancer (mean age 57.5+1.0 yrs.) were investigated in this study; 100 after therapeutic intervention Previously, the outwardly-rectifying chloride channel (ORDIC) was believed to be involved in the pathogenesis of cystic fibrosis. It has now beendiscredited in favour of a small conductance linear chloride channel, recently located in cells transfected with the gene coding for the Cystic Fibrosis Transmembrane Regulator. The ORDIC but not the linear channel is sensitive to the stilbene, DIDS. Apical additions of DIDS (0.5raM) to T84 monolayers mounted in Ussing chambers were without effect on cAMPstimulated short-circuit current (Ise), thus confirming lack of involvement of the ORDIC in electrogenic chloride secretion. Baselateral additions of DIDS (10-160p.M) caused large concentration-dependent and bumetanide-sensitive increases in Ise. These responses were occlusive with those of the calciuna-etevating agent, thapsigargin, but they were synergistic with those of cyclic nucleotide-elevating agents. These results suggested a common intracenular pathway for DIDS and thapsigargin. Further, D1DS responses were blocked by calcium removal from the basolateral side. In whole-cell patch clamp experiments DIDS caused an increase In chloride conductance with characteristics similar to those of thapsigargin and innomycin. Therefore, in T84 mono layers and single cells, DIDS elevates intracellular calcium. The resulting conductance changes depend on the degree of cell differentiation. *Present address: Elan Corporation, Department of Chemistry, Trinity College, Dublin 2. tological grading systems, very little evidence is given to such systems in therapeutic decision making. This is largely because such systems lack objectivity and consequently would appear to be inaccurate assessors of histological behaviour in carcinomas. Hence the search for more objective prognosticators such as ploidy. Our study involves 252 patients assessed and treated in one centre over a five year period. All patients were treated initially with lumpeetomy and radiotherapy. The mean patient age was 57 years and 71% were post-menopeusal. Pathologic grade, necrosis and amount of in-situ tumour component were assessed on I-I/E sections. Histological grade was assessed using the Bloom and Richardson method. Ploidy was assessed via flow cytometry and image analysis. Findings suggest that pathologic grade is strongly associated with ploidy status. When the individual components of pathologic grade are examined, the correlationis greatest of thenuclear components. Plnidy also exhibited a strong positive correlation with the presence of tumour necrosis and an inverse correlation with the presence of in-situ turnout component. In multivariate analysis, however, ploidy lost its prognostic value. In conclusion, ploidy is of limited value in the light of a full rigorous histopathological assessment. Amplification failure using the pofymerase chain reaction is encountered by those using archival fixed paraffin wax-embedded histopathological material t.z. such "failures" may not be due to absent target DNA sequences in the tissues, but may be a direct effect of the type of fixative, fixation time and/or fixation temperature used. In this study, the effect of nucleic acid preservation in tissues and its suitability for use in thepolymerase chain reaction according to fixative type, time and temperature were evaluated. 100 mg pieces of tonsillar tissue were fixed in formal saline, 10% formalin, neutral buffered formaldehyde (NBF), Carney's, Bouin's buffered formaldehyde sublimate, Zenker's, Helly's and glutaraldehyde at 0-4~ room temperature and 37~ fixation temperature and for fixation periods 6, 24, 48, 72 in's and 1 week. Primers for B. globin gene were used to amplify a 110 bp. fragment of this gene using PCR3. NBF and Carnoy's fixed tissue yielded amplified product primarily yet vasiably. Room and 37~ fixation temperature and 6-48 hour fixation times favoured amplification. IgM rheumatoid factor (lgM RF) production is a characteristic feature of rheumatoid arthritis (RA). However litde is known of the mechanisms which initiate and sustain RF synthesis. The aim of this study was to determine the effects of several cytokines on in vitro IgM RF synthesis. Two groups were studied: (A) 10 untreated patients with active RA; (B) 16 healthy controls. PBMCs were cultured with and without mitogen (SAC) for 2 days. After washing, the cells were cultured for a further 5 days in the presence nf IL-2, IL-4 or IL-6. Immunoglobulins and rheumatoid factors were measured by ELISA. Experiments were performed after SAC and cytokin doses giving IgM synthesis were determined. IgM synthesis was stimulated by SAC in both control and RA groups as IL-2, but not IL-4 or IL-6, led to a further increase in lgM synthesis (p<0.05). It is speculated that these relationships are related to adipose tissue. We have studied if uterine tissue histamine and mast cell concentrations in women with normal menstruation are different from those suffereing from dysfunctional uterine bleeding (DUB). Following recruitment and menstrual blood loss (MBL) estimations, the subjects were divided into two groups. Those with endocrine disorders or uterine pathology were excluded. Subjects with blood loss over 80 ml were grouped as DUB subjects, others were considered normal. Hysterectomies were carried out in the Clinical paediatrics is usually assessed by a written paper and a conventional clinical exam in the final year. These methods of assessment focos on "simple recall of information" and the testing of clinical skills by a method that lacks objectivity, thus failing to "meet the most important.., educational function, namely that o fprovidlng feedback to learners ''~. Continual assessment requires time-consuming effort. I f it correlated well with the timehonoured methods of assessment it would be a more useful tool, since it can provide feedback. The purpose of this paper is to see whether the continual assessment score allocated at the time of the paediatric clinical attachment accurately predicted how the student would do in the f'mal paediatric examination. In our department, 30% of the f'mal paediatric examination marks are alloted to continual assessment during the 2 month clinical attachment. An assessment score is allocated using 3 different parameters: 1. a monthly assessment mark, based on performance at clinical tutorials; 2. a clinical exam at the end of each month (using both conventional exam and an OSCE); 3. completion of a case report and a project done during the attachinent. Over the past 5 years 43% of those with a poor assessment score failed the final paediatric exam, and 57% passed, while 1% of those with a high score failed, 73% passed and 26% got hononrs (p=<0.001). This study confirms that continual assessment score accurately predicts the results of the final examination. Neonatal hearing screening has not been possible because of the lack of a short, cheap, credible and robust test. Many techniques have been devised m test neonatal hearing, but none has proved convenient and efficient for mass screening. The Algo-1 Plus Infant Hearing Screener (Natus Medical Inc., Foster City, California) represents a new advance. The screener emits 35 DB clicks, which pass via two acoustic tubes bar couplers enclosing each pinna. Three surface electrodes detect the Infant's Auditory Brainstem Response which is compared to the internal ABR algorithm. Since December 1990, we have screened 197 neonates in our Intensive Care Unit. Testing, including electrode and coupler application and screener operation, takes an avenge of 30 minutes per infant. One hundred and ten infants (55.8%) were high risk for hearing deficits and nine (8.2%) of these failed the screening test, Four infants (4.6%) from the low risk group also failed. In summary, this new screener is a promising system for testing newborn infants' hearing and represents an advance in this area. A. E. Wood, P. Sweeney, M. Neligan. National Cardiac Surgery Unit, Mater Misericordiae Hospital, Eccles Street, Dublin 7. From Jan. 1, 1984, we have pursued a policy of patent duct ligation in the premature infant in intensive care using the Ohio Neonatal Nursing Unit, because of the occurrence of dangerous hypothermia when operation is performed in the standard operation room. Twenty-six infants were operated upon; all were transferred from matenity units country wide to the ITU within 24 hours of the appointed surgical time. Twenty-three patients were ventilator dependent, The diagnosis was confirmed on admission by a paediatrie cardiologist and 2D echneardiography. Surgical ligation was performed through a standard lateral thoracotomy; the infant remaining in his Ohio Neonatal Nursing Unit. Average gestation age at birth was 29 weeks, (24-33 wks). Mean age at surgery was 25 days. Operative weight ranged from 650-2,400 gs (mean 1400 gs). The duct was ligated using a simple suture ligation technique with a ligaclip applied to the pulmonary side of the duct. Chest drainage wins not routinely used. Complete temperature data was available on 22 patients (85%). The mean change in core temperature was noted to be in elevation of 0.16~ :i: 1.1. In 14 cases, the temperature fell but only in two was this greater than 1 ~ No operative or pert-operative mortality occurred. Post-operatively patients were returned to the maternity unit when stable. 70% were transferred within 3 days. Twelve (46%) were treated as day cases. No wound sepsis occurred. Patient duct ligation can be performed safely and effectively in the Ohio Neonatal Nursing Unit reducing the incidence of hypothermia significantly. FOR CALPAIN 1? Society of Medicine, London. Environmental calcium deficiency with aluminium excess'is virtually the only common factor shared by Western Pacific foci with a high incidence of amyotrophic lateral sclerosis (ALS). An experimental review was carried out to investigate this phenomenon. It Was found that a recently discovered regulatory calcium dependent pretense -Calpain 1 (CL 1) -was localized predominantly to the neural regions ~ characteristically affected in ALS. CL 1 inhibition by calcium deprivation induces characteristic neuronal accumulations of 10rim neurofilament (NF), the key feature described by Hirano in his classic neuropathological study of ALS 2. Aluminium toxicity also forms pretense resistant NFs, promoting accumulation. Thus calcium deficiency with aluminium excess (as found in water supplies to Western Pacific ALS loci) may induce ALS changes by causing CL 1 dysfunction and NF accumulation. Migration to Guam increases ALS rates but these have receded with improved water supplies. Primates on low calcium/high aluminium diets develop ALS in Western Pacific foci. teristics. 70% had classical Onset. Seasonality was not observed. 30% had a diabetic first degree relative. 70% were overweight or obese. Females had signifieandy higher BMI than males (28.9+6.9 vs 27.6+4.7, p<0.02). Obesity was twice as common as in Irish non-diabetics. 62% were treated with diet alone. Insulin treatment (14%) reflected younger age (p<0.001) and lower BMI (I)=0.024). 32% were on antihypertensives. Treated hypertension was associated with ageing (61.85:11.8 vs 54.7+12.8 yrs, p<0.001) higher BMI (30.25:6.4 vs 27.4+5.6, p<0.001) and macrovascular disease (RR 2.14). 7.2% had retinopathy and 23% macrovaseular disease and/or peripheral neuropathy. Multiple regression models revealed that age was the most significant predictor variable for complications (p<0.001). NIDDM in Ireland affects middle-aged males and elderly females. Aetiology may differ with gender and age. Obesity, hypertension and heredity may be risk factors. We present the data on 218 consecutive patients with TB treated with Rifator (combination RHZ) and who have been followed for up to 2 years post completion of treatment. Comparison with previous series (IMJ, 1989; 82: 11-13) shows: that patients had fewer visible cavities on X-ray (p--0.0004); more patients negative direct/positive culture (p=0.02); no difference in terms of radiological extent of disease, plenral effusion, extrapulmonary TB, drug toxicity, mortality, other reasons for withdrawal from therapy. More patients are consistently culture negative when treated with Rifater at one month and two months compared to the other regimens -RHEZ x 6 months, RHE x 9 months. Relanse rate: To date of the 98 patients who have completed treatment 39 have one year or more post treatment follow-up. Two patients have relapsed with fully sensitive TB. Both patients, one HIV positive, admit non-compliance with treatment. Conclusion: The 3 drug regimen of Rifampioin,lzoniazid, Pyrazinamide (Rifater) produces significantly faster consistent sputum culture conversion than other regmens. These results support a policy of ongoing treatment with Rifampicin,Izoniazid, Pyrazinamide without Ethambutol or Streptomycin in the management of "lB. This study presents the first profile of NIDDM in Ireland. The objective was to focus attention upon NIDDM as a possible health problem in Ireland. Five hundred and one cases (233 male, 268 female) presented to our clinic over five years (Jan. 1 1980 -Dec. 31 1984). Incidence in females increased progressively with age but in males peaked at 50-59 years and declined significantly thereafter. 72% males vs 47% females were younger than 60 years. These differences do not reflect Irish population charac- The objective of this study was to invastigate andrepor t morbidity and mortality in Irish diabetics with long duration DM. Five hundred and eighty-four cases (254 males, 330 females) comprise a complete cohort diagnosed diabetic between 1960-1964 (inclus.). At 20-25 years DM 183 attended regularly, 156 had defaulted and 245 were deceased. 76% females, 69% males aged 30-50 years at diagnosis survived 20 diabetes years compared with 91.4% IDDM cases (n=147). Clinic attenders were examined for complications in 1985. Nephropathy (DN) was uncommon, even in IDDM (13% including deceased), and was associated with male gender (22.5% vs 6.2% females). 70% cases had some retinopathy (DR). 20% had proliferative DR. Significant DR related to higher systolic blood pressure in IDDM cases without DN (134.5+14.8 vs 12.5.0"a:13.8 mmHg,p<0.001 ). 40% hadnetmopathy andprevalence of neuropathy increased with age. Macrovascular disease (MVD) in survivors was associated with male gender (24.3% vs 11.9% females). MVD accounted for 66% deaths. 56% males vs 41% femalas died from cardiovascular disease. Diabetes related canses accounted for 40% IDDM deaths. This study is the first audit of diabetes morbidity and mortality in Ireland, but reflects experience at a specialist centre. It reports results which can be utilised to define targets towards improving health and the life expectancy of Irish diabetics. Diabetes associated MVD is identified as a problem which requires urgent national attention. As no contemporary data was available on iodine status in Ireland, this study was established with a view to providing regional information on dietary iodine intake. Casual urine samples were obtained in a representative group from five different counties in Ireland, namely Dublin, Cork, Galway, Meath and Tipperary. Iodine levels were measured in urine specimens using the alkaline ashing technique. Mean urinary iodine excretion values + SE varied from a high of 125.4+11.4 pg in Tipperary to a low of 73.4_+4.3 ~tg in Galway. Mean values for Cork, Dublin and Meath were 88.2_+5.9/.tg, 97.2_+1.8 gg and 90.6_+6.3 p.g respectively. At low levels of iodine excretion, i.e, less than or equal to 50 pg, a.pproximately one fifth of subjects fell into this category in all counties. At the other end of the scale, i.e. values greater than or equal to 150/.tg (minimum level recommended by the WHO) the percentage of subjects in this category showed a wide variation between groups, with percentages varying from 4.1% to 25.3%. The relatively high percentage of elevated values in Tipperary (25.3%) presumably reflects an increase in dietary iodine intake due to the local practice of using iodized salt. The results, while excluding severe iodine deficiency in the study population obscure the fact that 21.6% had iodine excretion values less than or equal to 50 lag, consistent with iodine deficiency, reflecting the lack of iodine supplementation. The absence of significant regional variation in the study population cart be attributed to the homogeneity of the Irish diet. To establish some epidemiological features of chronic fatigue syndrome, questionnaires were sent to patients fulfil ling the diagnostic eriteria, Two hundred and ninety-one (74%) were returned detailing patient characteristics, course of illness and current health status. The mean age at onset was 33 years (range 5-76 years) with an overall female : male ratio of 2:1. The sex ratio varied with age; in patients under 20 years old the ratio was 1:1 compared with 2.6:1 and 1.7:1 in the 20-39 and over 40 years age groups respocfively (p=0.019). Patients had been ill for on average 5.22 years (range 6 months -26 years) and although tending to have frequent relapses most felt that they were improving. Fifty-four (18.6%) patients reported they had recovered, with younger patients (<20 years) having a significantly higher recovery rate of 40.5% (p=0.001). The average duration of illness was 2.9 years. We believe this to be the first population study of patients with chronic fatigue syndrome attending a regional referral centre using striet diagnostic criteria and helps establish the pattern of illness and prospects for recovery. Counties with the greatest deprivation were Donegal, Louth, Offaly and Dublin and the least deprived counties were Roscommon, Meath, Cavan and Leitrim. County SMR's were correlated with both deprivation indexes and no significant correlation was found to explain the apparent differences in mortality. This is in contrast to that found elsewhere. S. Jermings. Eastern Health Board. A cooperative effort between Microbiologists and Public Health doctors has resulted in anew population based surveillance system, on certain infectious diseases, called the laboratory surveillance system (L.S,S,). It is the purpose of this paper to outline the first results of population based surveillance of campylobacter in Dublin in 1991. Nine laboratories in Dublin, including all major enteric labo ratories reported to L.S.S. in 1991, Campylobacter was routinely looked for in all the labs. Reports of those resident in Dublin were included in the analysis. Eighty six isolates of campylobacter were reported in 1991 giving arate of 8.4per 100,000. A bimodal age trend, male excess and an increase in the summer months was noted. Canlpylobacter was reported less often than Rota virus, Salmonella or Shigella. The following factors were noted:-the presence of a second pathogen (5), foreign travel (3) and immunosuppression (3). Campylobacter infection appears a small problem in Dublin compared with other enteric pathogens and experience in other countries. Yet the epideminlogical pattern is similar to that of other developed countries, Ongoing surveillance, preferably throughout Ireland, is required to establish the exact nature and extent of this public health problem. There is a general perception that the North-West District of Cork City (pop. 33,325) is disadvantaged. A stratified random sample of 581 of the 8580 households in the district was interviewed to determine its health status. A quarter of respondents rated their own health as fair/poor. A very high level of contact between respondents and the Health Services was noted. 87% visited their G.P. and 25% used hospital emergency facilities at least once in the previous year. The majority (83 %) of respondents expect to receive a prescription from a G.P. visit. Two-thirds of respondents take prescribed and 50% take non-prescribed medication routinely. 46% of respondents were smokers and of these 60% smoked more than 10 a day. The rate of combined drinking and smoking is almost double (43%) among the under 26 group compared with over 66 group. Less than 5% used alternative forms of medicine. The most common perceived problems recorded by the respondents were "back trouble" (27%), "migraine" (26%), "arthritis" (23%), "hyportension" (17%) and "digestive disorders" (15%). A Health for all strategy I fo r this area was devised using targets for action based on the study results. Response is not predictable. SAD may be a fixed irreversible phenomenon. All children were on Salbutamol by inhalation prior to entry into the study so the possibility exists that any reversibility may have already occurred. In 1991 38 cases of maningococcal disease were notified in the Cork Community Care Area. This compared with an average of 7 notifications per year for the previous 3 years. A review of all 1991 notifications was carried out in this area (population 289,501). Twenty five (66%) of the 38 notifications were clinical diagnoses only. Thirteen (34%) were bacteriologically proven, giving an incidence of proven disease of 4.49 per 100,000 population. The serogrouping of isolates showed the following distribution: group B 7 (54%), group C 5 (38%), ungrouped 1 (8%). The peak incidence was in April. Two deaths occurred. The age range was 3 months to 36 years, with the greatest number of cases in the 0-4 and 15-19 year age group. There has been a steady increase in meningococcal disease in England and Wales since 1984 and in 1990 the regional incidence varied from 1.5 to 4.5 per 1130,000 populationL The increase in Cork in 1991 to a level of 4.49/10~,000 is similar to the highest regional incidence in England and Wales. It is not possible to predict if this high incidence will continue. Using the maximum expiratory flow volume curve (MEFVC) and 3 gas mixtures (oxygen: helium & oxygen: sulfurhexafluoride & oxygen) we detected evidence of small airways dysfunction (SAD) in childhood asthma. The most sensitive test of SAD is V 50% light gas/heavy gas. We set out to determine if SAD was reversible Results: 40 children with childhood asthma and SAD were studied. Each child did not take part in each limb of the study. No. studied No. improved Salbutamol 10 2 Ipatropium 9 3 Theophylline 10 1 Intal 10 5 Inhaled steroids 10 2 Oral steroids 10 3 Ketotifen 14 5 Some children responded to more than one therapeutic agent. Conclusions: Lability of SAD varies from children who respond to several agents to those who respond poorly or not at all. The aim of this study was to determine if there was a social class gradient in the prevalence of chronic medical conditions in middle aged persons in Dublin. The one year period prevalence rate of 12 chronic conditions: coronary heart disease, stroke, chronic bronchitis, cancer, and treated cases of hypertension, diabetes, asthma, dyspepsia, rheumatic disorders, depression, anxiety disorders, and psychoses, was recorded prospectively in 3,111 persons attending 3 large general practices. A community based study of 1,024 persons was~conducmd to assess several potential biases. 95% confidence intervals were calculated to compare age/sex standardised morbidity rates between social classes. Persons from social classes 3/4 and 5/ 6 had a 21% and 70% excess morbidity, respectively. Persons from social classes 5/6 had significant excess of all conditions except asthma and cancer. Social class differences in morbidity in Dublin mirror published social class mortality differentials in Britain. In March 1990 a regular monthly medical audit w as commenced at University College Hospital, Galway. We evaluated the experience o f one year's audit of medical inpatients. Ten case notes with a specific discharge diagnosis were reviewed according to a def'med protocol. All seven physicians were included. The protocol consisted of a detailed questionnaire with yes or no answers covering admission, documentation, investigation and treatment. We evaluated the impact of medical audit by comparing the initial three months with the last three months of the year. Overall attendance was poor for both consultants and N.C.H.D.S. Significant improvement was noted in a limited number of areas (i.e. documentation). Deficiencies in management and recording of patient data were noted and recommendations to improve these have been agreed. With a part time audit assistant we are expanding the audit and expect it to have major impact on hospital care in the future. The animals were allocated to one of 2 groups. The treatment group received PTF 25 mg/kg, (n=5), 30 rain. after induction of shock. The control group (n=5) were givennormal saline. Arterial pressure, heart rate, and cardiac output were measured at 30 rain. intervals. The animals were observed for 24 hours. Haemodynemic parameters were similar in both groups before and during the shock period. All the lrl'F animals survived for 24 hours. One of the controls died during shock, the others survived for 11/2, 2~/4, 7, and 24 hours respectively. PTF significantly improved survival from hacmorrhagic shock (p<0.05, log rank test). The mechanism o f action is unclear but may involve improved microcirenlatury flow, decreased adhesiveness of activated PMN's, and TNF inhibition. A randomisod double blind study was cnndueted in patients undergoing elective knee arthruscopy, to assess the effect of intraarticular morphine on post-operative pain relief. The plasma profiles for morphine and its metabolites were assayed to determine the level of systemic uptake o f morphine to rule out systemic absorption as the mechanism of ananlgesia. Patients in the study group (n=10) received 5 mg morphine in 25 mls dilution intraarticularly, while those in the control group (n=10) received 25 mls saline. Patients in the study group showed significantly lower pain scores than those in the control group. These pain scores complemented the lower requirements of systemic analgesics in the study group. The plasma morphine levels exhibited were markedly lower than generally accepted as necessary for a systemic analgesic effect. The study provides evidence to suggest that the analgesia obtained is mediated via a local action within the knee joint. Blood lactate levels reflect the adequacy of cellular oxygenation. Elevated blood lactate has been demonstrated in the perioperative period in major surgical patients ~.2. The aim of this study was to ascertain whether a lactaemia occurs during minor surgery and to determine whether exogenous lactate administration, in the form of compound sodium lactate, contributes to a rise in blood lactate. Patients and methods: Eighteen patients (AS A 1 & 2) presenting for minor surgery were randomly allocated to receive normal saline, (NS) (N=8), 20 ml/kg or compound sodium lactate (RL) (N=10) 20 ml/kg intravenously over 36 minutes. Serum lactate was measured before commencement of infusion and serially over 60 minutes (Fig. 1) . Statistics: Student's t-test. Results: Figure 1 demonstrates lactate levels. There was no significant rise in blood lactate in either the RL or the control group and there was no significant difference between the two groups. Conclusion: The data demonstrate that peri-operative lactate administration in the form of compound sodium lactate does not elevate blood lactate levels. Further it suggests that tissue oxygen deficit is not a feature of minor surgery A rela'ospective study of transfusion practice in 150 consecutive elective primary total hip arthroplasties was undertaken, to examine blood usage and to determine the potential for reduction in its use. Predetermined criteria were used to measure unnecessary transfusions. Transfusion was considered unnecessary if the discharge haematocrit exceeded 36%, or if patients who lost less than 30% of their estimated blood volume, were transfused. Using these criteria, overtransfusion occurred in 42~15% patients. The intra-operative blood transfused correlated well with intraoperative blood lost. All other variables showed no significant correlation with both intra-operative and post-operative blood transfused. Females lost less and were transfused significantly more than males. The study corroborates previous reports of blood overuse. These results suggest that adopting .standard of practice to measure and to monitor transfusion practice (quality assurance programmes) would be a worthwhile objective. Dopamine protects against renal dysfunction in major surgery. Dopexamioc, a dopamine analogue, has 60-fold beta 2 activily and may bestow enhanced renal protection t. This study compared renal effects of prophylactic dopamine and dopexamine infusions Vol. 162 No. 3 during cardiopulmonary bypass (CPB), a fixed cardiac output state. Patients (n=19) for coronary artery bypass surgery were randomly assigned to one of three groups, receiving assigned Nsaline, dopamine or dopoxamine (2 ug/kg/min) after indocdon. Measured during CPB were MAP, CVP, temperature ABG, serum and urinary catecholamines, urinary exeretiun o f sodium, cre atinine clearance and urine output, Statistical analysis was by Student t-test. Creatinine clearance was greater (p<0.05) in the dopoxamine group than in the dopamine or control groups. Sodium excretion and urine flow were similar in the dopamine and dopexamine groups. Dopoxamine had a superior effect on renal function (i.e. increased creatinine clearance), probably beta 2 receptor mediated. Acetazolamide. a carbohic anhydrase inhibitor was used to treat the metabolic alkalosis, reduce the base excess and normalise PCO 2. We postulate that elevated PCO 2 values in these patients aggravated pulmonary hypertension causing interventricular shift. reducing cardiac output and compromising weaning from ventilation. In both cases treatment with acetazolamide and reduction in PCO 2 facilitated vuntricular weaning and we recommend it for treatment of metabolic alkalosis in this group of patients. Two post-operative patients developed oliguric renal failure which did not respond to standard therapy such as optimization of haemodynamic variables or low dose dopamine. Both patients had undergone laparuscopy for emergency bowel surgery and required further laparotomies for deteriorating conditions. Bladder pressures were used as a measure of I.A.P. and findings pre and post laparotomy are shown in Table I The renal function of patient A who had 3 litres of haematoma evacuated recovered completely. Patent B who had 3 litres bowel secretions evacuated had an initial improvement in renal function which deteriorated. These cases highlight: (1) the contribution of raised I,A.P. to oliguric renal failure. (2) That this component is not responsive to manipulation of perfusion pressure because of elevated renal vascular resistance. (3) The importance of early detection of raised LA,P. (4) That this can be done simply and non-invasibly using a Foley Catheter. We suggest therefore that patients with impairment of renal function should have measuremerits of I.A.P. as part of routine monitoring. Rising I.A.P. should be used as a criterium for re-exploration. Introduction: Minitracheostumy has been established for the management of sputum retention. High Frequency Jet Ventilation (HFJV) compared to conventional ventilation has been shown to result in similar arterial oxygenation, adequate alveolar vuntiladon, unchanged or lower mean airway pressure without high peak inspiratory pressure ~ and unchanged haumodynamie function 2. Patients and methods: In a general intensive care unit seven patients with marginal respiratory reserve who had mlnitracheostomies were weaned using HFJV. Ventilatory management initially consisted of a respiratory rate of 50-100 blma, I:E rado; 1:2 driving pressure 1-2 bar. HFJV was contiued intermittently after extubation and spontaneous respiration was allowed as long as pH remained 7.35-7.45. Results: Six patients were weaned and extubated, Arterial oxygenation and alveolar ventilation were found to be adequate in all patients. Conclusion: In patients whose respiratory reserve is poor HFJV via minitracheostomy avoids the need for re-intubatinn if further ventilatory support is required. Advantages include: adequate gas exchange, continued respiratory effort, and facilitated tracheobronchial toilet without haemodynamic instability. that occurs; to assess the effect of augmenting haemedynamic indices on oxygen delivery (DO2) and oxygen consumption (VO2) in the critically ill. Twenty four patients having elective CABG with ejection fraction >50% were randomly assigned to two groups. After induction of anaesthesia, baseline lactate, cardiac index ((2I), systemic v ascular resistance (SVR) and DO2/VO2 were measured. The treatment group received an infusion of Dolmxamine at 2 ug/kg/min and the controls received saline. Recordings continued at preset intervals for thirty hours. Lactate rose significantly in both groups (P20 years (P<0.01). Left ventricular diastolic dysfunction occurs frequently in AS pts in the absence of clinical cardiac involvement. The presence of diastolic dysfunction occurs more frequently in pts with longer disease duration and more restricted spinal movements. Further follow-up will show whether these abnormalities contribute to the long-term morbidity of this condition. Vineent's Hospital, Dublin. The assessment of aortic valve disease by standard transthoracic echocardiography is hindered by technical difficulties resulting in inadequate views or inaccurate doppler signals in a significant number of patients. Trensoesophageal echocardiography (TOE) allows enhanced echocardiographic views of the aortic valve in most patients. This study assesses the value of TOE in estimating aortic valve area in patients with aortic stennsis. Maximal aortic valve area was calculated by planimetry from the short axis view using TOE. Cardiac catheterisation was carried out during the same hospital admission and valve ~rea again calculated using the Gorlin formula. Sixteen patients (11 males and 5 females; mean age 65+8.4 years) with clinical aortic stenosis were studied. An adequate cross-sectional view of the aortic valve was obtained in 15 patients. Mean (+SD) valve area by TOE was 0.81_+0.57 cm 2 (range 0.30-2.11 cm 2) and by the Gorlin formula 0.80-L-0.48 cm 2 (range 0.44-1.7 era2). No significant difference was fmmd between each method of calculation at the 95% confidence level (P=0.48, NS). We conclude that direct measurement of the aortic valve area can be reliably made by TOE in the majority of patients with aortic stenosis. Results are comparable to those achieved at cardiac catheterisation. Belfast BT6 0RH. Intravenous streptokinase is widely used as a thrombnlytic therapy for myocardial infarction and has been shown to reduce mortality. Many patients show clinical evidence of a reaction to streptokinase and a neutralising antibody to streptokinase is believed to exist. An Elisa assay has been developed to quantitate the level of antibody. Serum samples were taken from subjects between day 0 and day 15 after administration of strepmkinase. Results are expressed as % absorbence of a standard serum known to have a high titre of struptokinase antibodies. The CV around " the mid point of the titration curve is 7.1% within day and 14.1% between days. Antibody levels rose from around day 7 (8-40%) to reach levels in the range 100-300% on days 14 or 15 post streptokinase treatment. If the level of nentralising antibody is known prior to therapy it might influence the dose of streptokinase given or it might lead to an alternative therapy being used. ine loading test. This study set out to measure cystathionine I$synthase (CS) activity in human leucocyts to evaluate its potential as a screening procedure for this condition. Leuooeytes, isolated from 20 ml of blood, were cultured in the presence of the mitogen, phyto hacmagg lutinin for 72 hr prior to homoganisation and incubation with buffered homos~,steine and [t~C]-serinc. The conversion (%) of[J4C]-serineto [1"C] -cys tathinnine, following seperatinn by thinlayer chromatography, was used as an index of enzyme activity. In a range of healthy laboratory volunteers (n=10) the mean CS activity (% conversion of [14C]-serine/mg leucocyte protein) was 12.5%. For 3 children, clinically diagnosed as homozygous homocysteinurics, no activity was detected. In the mother of one of these children, by implication hetorozygous for the condition, the CS activity was 4.7% and two adult hyperhomocysteinacmic patients had a mean activity of 7.5%. These data indicate some potential for this assay in screening individuals with homocysteinaemia for a more precise and convenient characterisation of the condition. In homocysteinaemia, raised serum homocysteine levels may play a role in superoxide production, resulting in increased free radical activity and atherosclerosis. The aim of the present study was to investigate free radical activity (by measuring serum Malondialdehyde (MDA), by the thiobarbituric acid assay), and also antioxidant status (by measuring serum vitamin E and A by HPLC) in CHD patients with homocysteinaemia (n 16, mean age (SD) 44 (4.6) years), CHD patients without homocysteinaemia (n 20, mean age (SD) 47 (4.9)years) and in control subjects without overt disease (n 19, mean age (SD) 45 (6.1) years). There was no difference in antioxidant status between the three groups, however there was some evidence for increased lipid peroxidation in CHD patients without homocysteinacmia, mean setalm MDA (SD) 1.7 (0.6) nmol/ml (P<0.05), compared with homocysteinacmics 1.3 (0.38) and controls 1.3 (0.31) nmol/1. These results do not therefore support the hypothesis that free radical activity is implicated in the pathogenesis of CHD in homocysteinaemia, though it may be of importance in CHD of different aetiologies. Cardiopulmonary bypass (CPB) allows us examine the effect of hypothermia in humans. In a controlled prospective randomised study, patients were divided into three groups of 24 patients each and theCPB in each group was managed at adifferent temperature. Group A: cooled to 25 degrees, Group B to 28 degrees and Group C to 37 degrees. Serum lactate levels were measured arid the parameters of oxygen delivery (I)O2), and oxygen consumption (vo2) were calculated at ten minute intervals during CPB. The results show that VO2 was significantly lower in the 117 hypothermic groups and that whi!e it was possible to significantly increase DO2 relative to baseline during hypothermic and normothermie CPB, this was not accompanied by a rise in VO2 at hypo thermia. There was no significant difference in lactate production between the groups. This supports the concept of a biphasic relationship between I)O2 and VO2 and suggests that the "critical I)O2", that is the level of I)O2 at which the VO2 reaches a maximum, is lower during hypothermia. This physiological relationship would be of importance in the management of oxygen debt in the critically ill. Urgent cardiac surgery is usually recommended for atrial myxoma, although evidence from Ireland and UK to support this approach is lacking. We reviewed all patients admitted to the National Cardiac Surgery Unit with atrial myxoma to assess pre-operative diagnosis and management, surgical technique, and outcome. Twenty three patients were admitted to the Unit since 1977. Preoperative symptoms were: congestive cardiac failure ( 10 patients), embolism (8 patients), constitutional (3 patients), tachyarrhythmia (1 patient) and asymptomatic (1 patient). The diagnosis was confh'med by D2 echocardiography alone in eleven patients and by a combination of echo and angiography in twelve patients. Magnetic resonance imaging was used in one patient. One patient collapsed on induction of anaesthesia. At operation the site of the tumour was left atrial in 22 patients, with one patient having an extensive bi-atrial tumour. In all cases the turnout was examined histologically. All patients made a good post-operative recovery, although one patient developed a DVT. One patient died five months post-op with a CVA. Serial echocardiography has revealed one recurrence to date (8 years post-op); the original tumour was an extensive bi-atrial tumour in a 24 year old girl. Re-operation was successful. Although benign, atrial myxomas require both urgent surgery due to their potentially serious sequelae, and diligent long term follow-up to detect recurrence. Transcutaneous non-invasive cardiac stimulation has inherent disadvantages: low success, high current requirements, lack of atrioventricular (AV) sequential pacing capability, and poor patient tolerance. We have developed a new hexapolar gastro-oesophageal (GO) electrode which allows separate atrial, ventricular and AV sequential pacing. The electrode is passed into the stomach under light sedation and positioned by withdrawing the steerable tip until it meets the resistance of the GO junction. Ventricular pacing is performed using a cathodic point source mounted distally on the electrode tip and a high impedance chest pad. A filtered bipolar oesophageal electrogram is obtained by scanning the lower oesophagus using successive adjacent combinations of five ring Hospital, Dubliri. Cardiopulmonary bypass (CPB) is associated with renal impairment, attenuated by dopoxamine'. The effects of 3 agents on renal function were studied during CPB for elective srugery. Nineteen consented patients were randomly allocated to receive enoxime (5 mg/kg/min for 10minutes than 2 ug/kg/min), dnpamine 2 ugikg/min, dopexamine 2 ug/kg/min or normal saline 2 ml/honr for the duration of CPB using a standard anaesthetic and CPB technique with a cardiac index of 2.41/m2/min. Exclusion criteria include renal disease, diabetes mellitus and eerebrovascular disease. Arterial blood gases, urinary sodium excretion and ereatinine clearance were measured prior to and at 30 minute intervals during CPB. Creatinine clearance fell in all groups during CPB by 85% in controls, 56% with dopoxamine, 38% with enoxamine, 28% with dopamine. In this study with constant cardiac index and comparable haemodynamie indices the fall in creatinine elearance was attenuated by all 3 drugs. This is further evidence of a peripherally mediated effect on the kidney, not solely dopaminergic. Their use would appear to be beneficial during CPB. Irdaibitors of HMG COA reductase may impair stress responses due to deficient cortisol synthesis. We investigated this in patients treated with simvastatin, using a maximal treadmill exercise test as the physiological stressor. We studied 33 patients (18 males; age range 20-61 yrs) with hyperlipidaemia. We performed a maximal treadmill exercise test with cardiac monitoring (single lead CM5). Symptomatic angina was an exclusion criteria, but 6/33 patients had evidence of myocardial ischaemia during the exercise test. In this small group of patients studied 18% have shown evidence of myocardial ischaemia which is asymptomatie. Two of the six have had further investigation and one is awaiting coronary artery by-pass grafting. This raises the question as to whether all patients with hyperlipidanmia should be offered an exercise stress test. Tumour necrosis factor (TNF) is an important cytokine which has been extensively investigated since its discovery in 1975. There is little information on the flux of TNF through the circulationinvivo. Weinvestigated the dynamics of TNF by measuring levels simultaneously at different sites in the circulation. We studied 5 men with ischaemic heart disease (IHD) tmdergoing cardiac catheterisation. 2 ml of blood was withdrawn simultaneously from the pulmonary artery (PA), femoral artery (FA) and vein (V), after removal of dead space. PlasmaTNF was determined by ELISA using a monoclonal antibody CB0006. The Irish Cardiac Surgical Register has provided a continuous record of all adult cardiac operations performed in the Republic of Ireland since 1983. We present a review comparing the profile of patients presenting for coronary artery bypass grafting (CABG) less than 40 years of age with patients aged 40 years or more. There were 209 patients less than 40 years (group 1) and 6467 patients greater than 40 years (group 2). The mean age of group 1 was 36.5 years and was 56.5 years in group 2. The majority of patients in both groups were male. No difference was found between the groups when examined for sex distribution, anginal status, myocardial infarction, left ventricular function or the number of grafts performed. Group 1 patients had a higher proportion of good distal vessels and a lower proportion of poor distal vessels when compared with group 2 (p 300 mmHg 6 (12%), Group If 200-300 mmHg 30 (60%) and Group IlI< 200 mmHg 14 (28%). Coronary anatomy, myocardial size and aortic regurgitation all influenced infusion pressure. These findings indicate the wide range of perfusion pressures required for the effective administration of cardinplegia. We believe routine intra aortic monitoring will enhance post ischaemic myocardial recovery, AORTIC HOMOGRAFTS: AN ADDITIONAL BONUS TO CARDIAC TRANSPLANTATION K. Subareddy, J. P. Hurley, A. E. Wood. National Cardiac Surgery Unit, Mater Hospital, Dublin. The use of homograft (allograft) aortic valves for aortic valve replacement of complete aortic root replacement has expanded with the developement of the cardiac uransplantation programme in this country, which has provided the source of the fresh homografts from the explantod native heart at the time of transplant. There have been twenty homograft v aires inserted. Fifteen valves were harvested from the explanted heart at the time of transplant, the remaining from the unmatched donor hearts. The indications for the use of homografts were age 70 yrs (4 patients), occupation (2), poor anticoagulatinn risks (3), personal choice (1), impending surgery/risk of endecardltis (4), chronic dehiscence of prosthetic valves (1) and aortic root replacement for endocardltis (5). There was no increased morbidity associated with their use. No anticoagulation was usedpest operativaly. Tberisk ofendocarditis equals that of a normal valve. All patients have been followed up with regular doppler echocardingrephy. The hanmodynamie parformanee of the homograft most closely approximates to that of a native valve and we have found it a very acceptable alternative in a selected group of patients. Recently, we demonstrated that Pseudomonas aeruginosa exotoxin A (Exo A) produced endothelial and epithelial cell injury in vitro, which attenuated by co-incubation with dibutyrl cyclic adenosine monophosphate (db-cAMP). In the current studies, injury produced by Exo A was further characterised by quantirating the duration of exposure required to produce injury to bovine pulmonary artery endothelial cells (BPAEC). The effect of post treatment with db-cAMP was also examined. Exotoxin A was added to (BPAEC) and the release of incorporated Cr-51 used to indicate call injury. Progressive shortening of the exposure period to Exo A demonstrated that exposure as brief as 5 minutes resulted in cytotoxity comparable to 18 hours exposure. Post treatment with db-cAMP I.I.M.$. March, 1993 attenuated Exo A induced injury when added up to one hour following Exo A; 7% specific Cr-51 release compared to 29% specific Cr-51 release with Exo A alone (p<0.05). We conclude that BPAEC are injured by brief exposure to Exo A and pest treatment with db-cAMP is protective against Exo A induced endothelial injury. Mortality rate for lower respiratory tract infection (LTRI) in hospitals varies from 5-11% in Ireland but little data is available on morbidity. We report on the aetiology, progress and outcome of 200consecutive cases of clinic ally diagnosed community acquired LRTI requiring admission. Immune-compromised patients were excluded. The mean age ofpatiants was 64.3 years (range 15-87). Patients were symptomatic or had acute or chronic symptoms for an average of 7 days (1-28) prior to presentation and 45 (22.5%) patients were prescribed antibiotics prior to presentation. Sputum samples and blood cultures were obtained from 120 (60%) and 66 (33%) patients respectively. At least one organism was isolated in 40% of the sputum samples (Haemophilius influenzae 29% and Streptococcus pneumoniao 21%) and 9% of blood cultures. The mean duration of stay for all patients was 7.9 days (1-23) and the mean time to clinical improvement was 3.5 days (Ill), 145 patients were treated with 7 days of antibiotics, 18 required more than 7 days of treatment and 23 had their antibiotic treatment altered before discharge. 14 (7%) patients died during the study period. Our outcome is in agreement with literature in the U.K. The above figures are important for medical audit and in helping physicians plan management of patients with community acquired LRTI. Hospital. Objective: To determine whether long term home nebulisation therapy has an effect on the quality of life of patients with severe chronic airflow obstruction and in addition affects the number of admissions and duration of hospital stay, the number of general practitioner visits and the number of courses of antibiotics received. Design: A retrospective study by questionnaire to quantify changes in quality of life parameters before and after long term domiciliary nebulisation t,~. Setting: Chest Clinic at a District General Hospital. Patients: 108 patients (6z| male, 44 female) with scvere chronic airflow obstruction (N.Y.H.A. classification grade HI and IV breathlessness) were included in the study. Main results: There was an improvement in all the parameters of quality of life with most reaching statistical significance. Conclusions: Patients admitted with acute exacerbations of COAD are more likely to die if they have elevated carbon dinxide, elevated urea or heart failure..Arrhythmias are cormnon in these patients and muhifocal atrial tachycardiais the commonest arrhythrnia. Ninety five consecutive patients had lung function assessed after treatment for pumonary TB. Lung function is expressed as % predicted standardised for age, height, weight and sex. To determine which clinical features best predicted post treatment lung function we used Multiple Regression Analysis (MRA), Linear Regression Analysis and X ~ test. Results: Low FEVI + low FEF 25-75% (46 patients); high TLC (17 patients); high RV (59 patients) high RV/TLC ratio (71 patients). Low gas transfer (18 patients); low DLCO/VA (30 patients). Likelihood of airflow obstruction was well correlated (r=0.97) with radiological extent of disease at diagnosis as was low gas transfer (r=95). Using MRA FEV1, FVC, FEF 25-75% correlated best with radiological extent of disease at diagnosis and age at completion of treatment, TLC and RV both corelated best with radiological extent of disease at diagnosis and the presence of cavities post treatment. Conclusion: Lung function after treatment is best con'elated with radiological extent of disease at diagnosis, This suggests that the pre-treatment duration of illness may be important in determining subsequent pulmonary func lion and gives added impetus to rapid diagnosis and treatment of TB. Other clinical parameters are weakly correlated with lung function after treatment. We have used a non invasive technique to sequentially measure renal blood flow in hypoxic respiratory failure. Duplex Doppler ultrasound of renal interlohar arteries was performedon 16 patients with hypoxic respiratory failure (PaO2<8kPa) while hypoxic and again following 20% improvement in arterial blood oxygen tension. (COPD-12, asthma-l, bronchiectasis-1, interstitial lung disease-1). An Acuson 128 computerised real-time sonography system with a 2.0 MHZ imaging transducer was used to scan the renal vessels via the translumbar route with the patient in the sitting position. Pulsat~lity Index (Pl) was calculated as a measure of renovascular resistance. PI is obtained by dividing the difference between the maximum systolic height and the minimum diastolic height of the waveform by the mean height. A fall in PI corresponds to a fall in the distal resistance to flow. All results were paired observations with each patient acting as his or her own control, The data was analysed using Student's t test. A rise in blood o xygen tension of >20% was accompanied by a significant fall in PI (P<0.001). This study suggests that the correction of hypoxia reduces renovascular resistance. Vincent's Hospital, Dublin Histological studies have demonstrated an increase in the relative amount of Type I to Type III collagen in the fibrotic lung. Deposition of newly synthesized collagen is aecomnpanied by the release of N-end C-terminal peptides from proenllagen precursors, The aim of the present study was to ascertain if the relative levels of Type I and Type HI procollagen peptides in B AL or serum might reflect fibrosis in patients with interstitial lung disease OLD). Procollagen peptide (PCP) levels were analysed in BAL and serum samples from 20 patients with ILl). No patient was on eorticosteroid treatment at the time of study. Patients were divided into three categories: C1 = patients with no X-ray evidence of interstitial involvement (n=5); C2 = patients with interstitial infiltrates but no evidence of fibrosis (n=9) and C3 = patients with X-ray evidence of fibrosis (n=6). BAL levels of both Type I and HI PCPs increased with increasing lung involvement (Type I vs Category: F ratio = 3.43, p<0.05; Type FII vs Category: F ratio = 8.51, p<0.00l ). The proportion of Type I to Type HI PCP in BAL also increased with increasing lung involvement. Serum levels of either peptide alone did not distinguish ILl) patients from normal control subjects. However, the contribution of Type Ill PCP to to tat serum procollagen peptide levels was increased in C3 patients (p<0.04 vs control group). These results suggest that BALlevels of PCPs reflect the alteration in deposition of Type I and Type HI collagens found in the fibrotic lung and that the relative proportion of Type HI PCP in serum may reflect increased collagen deposition in the lung. Vincent's Hospital, Dublin. Four hundred and fifty biopsy-proven patients have been followed regularly, since 1981, at the Sarcoidosis Clinic. Comprehensive clinical data was recorded using spreadsheets and databases held on a personal computer system. The aim of this study was (1) to identify useful analyses of radiological changes/patterns in the management of sarcoid; (2) to assess the effectiveness of our present database techniques in managing CXR follow-up data. Complete 5-yr data with use of a modified Siltzbach and 1LO/ UC radiological scoring system in addition to complete clinical data is available for 127 patients (68 females, mean age 30 yrs) from an initial total of 311 patients (mean age 31 yrs; 159 males). The mainpresenting complaints werepulmonary symptoms (18%); acute erythema nodosum (17%); ocular (16%) while 16% were asymptomatie at presentation. Total initial 18 76 110 71 21 296 2 yrs 36 23 61 53 25 198 5 yrs 20 6 25 50 26 127 Semi-quantitative measurements of nodal size and parenchymal perfusion showed changes in up to 50% of patients who had unchanged CXR staging. Detailed analysis of CXR and clinical patterns provides more accurate estimations of prognosis over time in sareoidosis. Our present sarcoid database requires modification to allow more efficient and accurate data maintenance and follow- Recent studies suggest that the release of small quantities of nantrophil protease may play a role in disease charaeterised by a low-grade inflammatory response. In this study, a competitive ELISA,designed to detect low levels of nentrophil elastase in biological fluids, was established. The detection limit (2.5 ng/ ml) and range (2.5 -100 ng/ml) of the assay represented an improvement in sensitivity compared m previously reported assay systems. Validation of the assay was achieved by assessment of elastase levels in plasma from normal subjects and cystic fibrosis (CF) patients. Low background absorbances indicated little non-specific interference in the system. Normal plasma levels (2.4 + 1.0 ug.ml, n=20) were similar to those reported by other investigatorsL As expected, significantly higher levels (5.5:L3.9 ug/ml, n--42; p<0.001) were observed in plasma from CE patients. Measurement of elastase in brnnchovalvenlar lavage (BAL) fluids from a group of patients with interstitial lung disease indicated that 3 of 5 patients with idiopathic pulmonary fibrosis (IPF) had elevated BAL elastase levels compared with only 2 of 30 patients with sarcoidosis and none of 4 patients with exta'insic allergic alveolitis. As IPF is associated with elevated BAL neutrophils, these results lend validity to the proposal that elastase can serve as a sensitive marker for in vivo neutrophil degranulation. Ireland has a TB rate of 22:100,000 and we treat 30% of reported cases. In the period 1980-1985 we treated 1641 patients for TB; 2 were known i.v. drug abusers (IVDA); none were positive for human immunodefieiency virus (HIV). Of 1000 TB patients seen since 1986, 18 were HIV related and 6 were 1VDA. IVDA HIV+ Homo/Bisexual 6 + --11 + + 6 -+ + Twelve HIV positive patients had atypical chest X-rays; 12 HIV positive had extrapalmonary TB; 3 HIV patients had atypical organisms; 21 had fully sensitive M.TB Conclusion: These data show an increase in TB in IVDA (HIV positive and HIV negative) and remind us that efforts m prevent 'I'B in this group must be intensified. L Comparison of high frequency jet ventilation to conventional failure in humans Clinical experience with high frequency jet ventilation Quality of life m patients with chronic airflow limitation Measuring functional status in chronic lung disease MEDICAL STUDENTS AFTER ELECTIVE PERIODS IN THE DEVELOPING WORLD Departments of Respiratory Medicine Africa) for the four years 1988-91 inclusive: 61 students (34 females; 27 males) age range 22-25 were investigated. Tuberculin testing prior to departure and on return was done using the Mantoux test 1:1000 solution. Induration _>10mm at 48-72 hours was read as positive. Fortytwo students (69%) were tuberculin negative prior to departure. Chest x-rays were done on all students before going on elective (all normal) and on tuberculin converters on return. Results show that 14 students (33% of tuberculin negatives) were tuberculin converters We examined 10g consecutive admissions with acute exacerbation of COAD to see which clinical features at admission predicted mortality or were associated with cardiac arrhythtuias (X ~ analysis). Mortality: 11 patients died. Mortality was best associated with hypercarbia (p=0.0005); elevated blood urea (p<0.06); the pres ence of heart failure (p=O.14). Patients who died were also more likely (p=0.0001) to receive i.v. Doxapram; less likely (p=0.007) to have proven bacterial infection. Arrhythrnias: 23 patients had arrhythmia: multifocal atrial tachycardia (14); atrial fibrillation (7); atrial eetopics (2). Patients with an arrhythmia were more likely to have X-ray evidence of hear t failure or pnanmonia Conclusion: Long term home nebulisation therapy improved the quality of life of patients as well as reducing the number of generalpractitioner visits, number of antibintic courses prescribed, number of hospital admissions and duration of hospital stay. In our study no significant long term problems were encountered with the practical use of nebuliser equipment due to regular surveillance undertaken by the respiratory care team. St. James's Hospital, Dublin 8. The aims of this study were to assess the incidence of tubereulosis in the Irish human immunodeficiancy virus (HIV) infected population, and to assess the usefulness of tuberculin skin testing as an indicator of active tuberculosis in this population. Between February and September 1988 thirty-eight HIV positive patients were recruited into the study. A skin test score was derived for each patient using the Mulfitest system. Patients were reviewed in January 1991, ten had died, three were lost to follow-up, and twenty-five were alive. The mean follow-up period was 22 months (range 6-34). Eleven patients were tuberculin positive on entry into the study; one of these developed tuberculosis. Twenty seven patients were tuberculin negative; three of these developed tuberculosis. Differences in the incidence of myobacterial infection between tuberculin positive and tuberculin negative individuals are not statistically significant. There was a strong negative correlation between Multilest score and advanced disease (R= -0.7 13<0.001). The incidence of mboreulosis in the population which we studied is approximately 5% in tuberculin negative and tuberculin positive individuals; this has grave implications for Irish health resources. C. O'Mahony Mersey Regional Health Authority and St. James's Hospital, Dublin. The purpose of the study was to determine if the rumours about HIV and AIDS in Dublin were true. Could two cities so similar in population and characteristics as Dublin and Liverpool be so different in the context of HIV disease? A 2-week locum for a Merseyside Genito-Urinary Medicine (GUM) Consultant in St. James's Hospital in Dublin was the method of investigation.Over 700 HIV positive patients had attended St. James's GUM department and approximately 550 of these were drug related infections either through intravenous drug use and/or sexual transmission to partier. In comparison, there were 18 HIV positive drug addicts out of a total of 192 infections recorded in Mersey Region. The comparison in services -GUM, substance abuse, outreach and needle exchange was equally disparate.In conclusion, despite the obvious dedication of the few dealing with so many, the number of infections continues to rise. As the tide of asymptomatie HIV diseaseprogresses inexorably towards full blown AIDS, the city's health services are facing a disaster. Could Dublin in 1992 become the "European City of (HIV) Culture"? inconclusive test results for antibody to hepatitis C. HCV is a single-stranded RNA flavilike virus with a lipid envelope, 50-60 rim, diameter with a ganome of jnst under 10,000 oncleotides. The sequence amplified and detected in this study was from the highy conserved non-structural 5 region. The virus RNA was extracted from serum and precipitated: reverse transcription was performed using the downstream primer NCR2. The copy DNA (cDNA) produced was amplified by the nested technique using outer primers NCRI and NCR2 and two inner primers, NCR3 and NCR4. The c270 bp prduct was detected by ethidium bromide gel electropborsesis. 1721 sera from 13 clinical categories of patients and risk-groups for hepatitis were analysed. 24 were positive and 92 were negative. An HCV probe for confirmation of these results is presently under development. PCR provided an early and sometimes only indicator of hepatitis C infection, in others it has clarified serology results. It remains the only method to detect hepatitis C virus at present. The purpose of this study was to assess the benefit of administration of tetracycline along with quinine and cotrimoxazole in the treatment of cerebral malaria, Two hundred and fifty-four eases of cerebral malaria have been studied. The patients were divided into two groups. Group A (100 patients) was treated with intravenous quinine dihydrocboride 10 mg/kg 8 hourly in 5% dextrose in aqua along with cotrimozole (800 mg sulphamethoxazole + 160 mg trimethoprim) twice daily. Group B ( 154 cases ) w as given triple therapy including intravenous quinine and co-trimoxazole in the same dose as in group A along with paranteral tetracycline 200 mg 8 hourly. Parenteral quinine and tetracycline were continued till the patients became conscious and were able to retain oral medication. Duration of treatment ranged from 7-10 days.Fatality in group without tetracycline was 18%, whereas as in the tetracycline group it was 12.33%.We conclude that co-administratinn of tetracycline with quinine and cotrimoxazol has a significant effect in lowering fatality of cerebral malaria. We used the guinea pig as an experimental model to investigate the pathogenicity of mycobecterium tuberculosis. Sputum samples were injected subcutaneusly into guinea pigs and after eight weeks the animals were killed and an autopsy performed, The likelihood of the sputum samples producing tuberculosis in the guinea pig was related to culture positivity rather than to duration of chemotherapy. This study does not support the belief 124 Inaugural National Scientific Medical Meeting that a change in pathogenicity occurs during treatment of pulmonary tuberculosis. S almonell a is a common enteric pathogen, worldwide. Throughout tile 1980's infection due to Salmonella enteritidis has dramatically increased. Eight hundred and sixty Salmonella s!0p. (human cases) were isolated at Cork Regional Hospital from 1986-1991. Over this 5 year period, S. enteritidis phage type 4 has emerged as the dominant serotype isolated, accounting for 63% of all Salmonella spp. isolated in 1991. The prevalence of this serotypo of Salmonella differs from the rest of the country. Data will be presented outlining the seasonal epidemiology of this organism from human and food sources, Following successful renal transplantation between 6 and 15% of recipients will develop erythrocytosis. The importance of this as a clinical problem is that these patients are at increased risk of thromboembolic events. Traditional therapies for this condition has involved repeated phlebotomy or bilateral native nephrectomy. A number of mechanisms have been proposed for this phenomena, most of whch involved abnormally high production of erythropoietin by the native kidneys. Enalapril has been shown in a number of settings to reduce circulating EPO levels and to exacerbate anaemia in dialysis patients.Nine renal transplant patients with a haematocrit of 0.51 or greater on two consecutive occasions were enrolled in a study in which existing anti-hypertensive medication was substituted with Enalapril 2.Smgs. Baseline measurements of haematoerit and serum EPO were made. Patients were followed at two weekly intervals for 6 months.Mean haematoerit fell from 0.52 to 0.45 after 8 weeks and remained at that level for the subsequent 12 weeks (p<0.05), serum EPO also fell from 61.12u/ml to 18.25u/ml (p<0.05) after 4 weeks.The mean blood pressure, serum K or serum creatinine did not change during the 6 month period of observation.It We concluded that percutarteous PD catheters provided a safe, reliable access for peritoneal dialysis and could be applied to the management of renal failure outside specialised units. Over 60% of women having hysterectomy for excessive menstrual bleeding have no uterine pathology and are diagnosed as unex p]ained or dysfunctional uterine bleeding (DUB). Increased local fibrinolysis has been implicated in the aetiology of DUB. This study has compared tissue plasminogen activator (tPA) in uterine biopsies taken at hysterectomy from 48 women with normal menstrual loss (mean MBL 42 ml, range 5 77) and 57 women with DUB (mean MBL 194 ml, range 81 -1,059). Endometrial tPA antigen levels were significantly higher in the pre-menstrual phase of the cycle in women with DUB (p <0.02) and showed a significant correlation with the degree of MBL (r = 0.78). The tPA was localised in endothelium of small uterine blood vessels by immunooytochemistry. High levels of tPA antigen were also found in menstrual fluid during the first 48 hours of menstruation in women with DUB. Treatment of 20 women with DUB (mean MBL 160 ml, range 82 360) with the fibrinolytic inhibitor, tranexamic acid, reduced blood loss by 56% (mean MBL 74 ml, range 22 -198). These results show an important relationship between uterine fibrinolytic activity and the degree of menstrual bleeding. Supported by the Health Research Board (Ireland).