193

WEBLEY et al. studied 100 patients with R.A. and normal chest radiographs, and compared them with 84 healthy controls matched for age, sex, and smoking habits. The R.A. patients had subnormal values for the forced expiratory volume in one second (F.E.V.1), forced vital capacity (F.V.C.), F.E.V./F.V.C., and 39 patients had abnormal spirometric M.M.E.F.R. and at least 32 had evidence of airways tests, of the 100 R.A. patients were non47 obstruction. smokers, and in them the F.E.v.i, F.v.c., and M.M.E.F.R. were all reduced. The R.A. patients who smoked had a lower mean F.E.v.i/F.v.c. ratio and lower mean M.M.E.F.R. than those who did not smoke. These results suggest that airways disease may be the commonest form of lung involvement in patients with R.A. It is not dependent on smoking, but smoking may increase its severity. tion

was

in the small

airways.

Although the airways disease revealed by lungtesting was mild and seldom caused important symptoms, this is not always the case.

function

GEDDES et al.4 described a severe form of progressive airways obliteration associated with R.A. in adults. In five R.A. patients there was rapidly increasing breathlessness: 4 died within eighteen months of the onset of symptoms. Chest radiographs were normal apart from distension of the lungs; and tests of lung function indicated airflow obstruction with air trapping. Post-mortem examination showed an obliterative bronchiolitis, but no

mucous-gland hypertrophy or emphysema. Seeking evidence of a genetic predisposition to airways disease, both COLLINS et awl. and GEDDES et al.5 studied the frequency of (XI-antitrypsin phenotypes. COLLINS found the phenotype MS in 5 of 18 R.A. patients with reduced M.M.E.F.R.s, compared with 5.5% of controls; while GEDDES found MS in 5 of 33 R.A. patients with a history of obstructive airways disease or recurrent chest infection, compared with 10% of controls. No conclusions can be drawn from these results, except that more extensive investigations are indicated. GEDDES went on to study fibrosing alveolitis-with and without R.A. There was a significant a’ssociation of the phenotype MZ with fibrosing alveolitis in the absence of rheumatic disease, and of both alveolitis in R.A. patients. Phenotypes other than MM were present in 14% of controls, 13% of R.A. patients without chest disease, 29% of patients with fibrosing alveolitis and no rheumatic disease, and 50% of patients with both R.A. and fibrosing alveolitis. In these findings it is tempting to seek the outMZ and MS with

fibrosing

3. Webley, M., Geddes, D. M., Emerson, P. A., Brewerton, D. A. Abstracts of the Heberden Society, June, 1978. 4. Geddes, D. M., Corrin, B., Brewerton, D. A., Davies, R. J., Turner-Warwick, M. Q.Jl Med. 1977, 46, 427. 5. Geddes, D. M., Webley, M., Brewerton, D. A., Turton, C. W., Turner-Warwick, M., Murphy, A. H., Ward, A. M. Lancet, 1977, ii, 1049.

familiar pattern-inherited susceptibility, followed by infection and then arthritis. Unfortunately, the essential evidence is still missing. Although HLA-DRW4 predisposes to R.A.,6 and the Clcantitrypsin phenotypes MZ and MS increase the risk of fibrosing alveolitis, there is no reliable clinical or laboratory. indication of inherited susceptibility to chest infection or airways disease in patients with R.A. No doubt this evidence will now be sought more intensively. Despite the increased frequency of clinical chest infections in R.A. patients as a whole, there was no definite evidence of infection in the patients with airways disease-either in those with minor abnormalities or in the 5 patients with progressive airways obliteration; and certainly there was no proof that chest infections caused R.A. Yet, the line of thought is intriguing, both for rheumatologists and for chest physicians. lines of a

now

Blood-transfusions and Renal

Transplantation REPORTS that pretransplant blood-transfusion improves graft survival aroused strong emotions in the transplantation world, and a meeting of the British Transplantation Society, in Newcastle, was devoted entirely to the topic. The day began with two reviews of the experimental data, from Dr HANS BALNER, of Holland, and Dr JOHN FABRE, of Oxford. BALNER reviewed his group’s continuing study of blood-transfusions in renal transplantation in the immuriosuppressed rhesus monkey. He showed that survival was significantly prolonged when monkeys had five blood-transfusions over several weeks before transplantation, but that the effects of a single transfusion three weeks before transplantation ranged from accelerated graft rejection to prolonged graft survival. A single transfusion immediately before operation resulted in long graft survival without any evidence of accelerated rejection. Of great importance was his finding that a single transfusion of erythrocytes had much the same effects as a whole-blood transfusion-indeed, survival was longer after erythrocyte transfusion than after lymphocyte transfusion. Best results were obtained when blood-donor and kidney donor were closely matched for the major histocompatibility system (RhLa) in this species. BALNER concluded that several transfusions give more constant results than a single transfusion, that optimal matching between blood-donor and

recipient is desirable, and that transfusion policy in man should be approached with great caution. FABRE illustrated the hazards of sensitisation found experimentally in animals and stressed that any blood-transfusion schedule in man should aim to 6. Stastny, P., Sittler, S., Fink, C. W. Tissue

Antigens, 1977, 10, 210.



194

keep the risk of sensitisation extremely low. He also pointed out the varying influence of concurrent immunosuppressive drugs on the transfusion effect -a matter highly relevant to clinical practice. As regards the blood component responsible for the effect, erythrocytes, plasma and platelets as well as lymphocytes had been shown experimentally to prolong graft survival in certain circumstances. FABRE felt that the transfusion effect could still be attributed to specific immunosuppression, and that the onus was on the disbelievers to prove that this was not so.

Dr GEOFFREY TOVEY

presented U.K. Transplant findings from a prospective study of 522 recipients of first cadaver grafts, of whom three-quarters had been transfused. 66% of grafts were surviving at 1 year in patients transfused before surgery compared with 53% in those not transfused-results which do not reflect the striking differences seen in many centres. He showed that pregnancy before transplantation had much the same effects on sur-

blood-transfusions. Transfusions given the time of surgery seemed to have no only effect. Dr J. SACHS, reviewing the London Transplant data, said that a transfusion effect was seen only in patients receiving a well-matched kidney. Prof J. VAN RooD, of Holland, and Dr B. DESCAMPS, of Paris concurred, although VAN ROOD believes that matching for HLA-DR as well as HLA-A and HLA-B is very important. SACHS advised strongly against indiscriminate bloodtransfusion before transplantation, and felt that blood-transfusion donors should be well matched with the recipient to lessen the risk of sensitisation. Prof. PETER MORRIS, summarising, judged that the case had been made for a transfusion effect in human cadaveric renal transplantation (but not in living-related-donor transplantation). The mechanism, however, was still unclear, and several units were reporting very high survival rates in nontransfused patients. In Oxford, for example, actuarial cadaver-graft survival in non-transfused nulliparous and male recipients was 60% at 1 year. Could some selection factor be responsible, at least in part? The risk of sensitisation by blood transfusion was real, and the Dutch policy of a single transfusion before transplantation was attractive, although BALNER’S monkey data indicated a need for caution even here. Many questions remained. Which blood component is responsible for the effect, and is the effect an immunological one? Is frozen blood with its lower risk of sensitisation equally effective? Should we try to match both the blood-donor and the kidney donor with the recipient ? Why do a few transplant units see little or no transfusion effect? MORRIS urged clinical trials to answer some of these questions. Meanwhile, the risks of sensitisation should deter clinicians from a transfusion spree in renal transplantation. vival

as

at

NEAR-DROWNING A CLEARER understanding of the way in which people get into difficulties in the water and new thoughts on the

management of near-drowning emerged from symposia drowning and resuscitation in Los Angeles and London. Children under the age of 10 are most liable to drown in inland waterways and swimming pools, whilst those who drown in the sea tend to be young adults. In all age-groups male drownings outnumber females by almost 3 to 1-except drownings in the bath-tub, where females seem to have the edge. On Australian beaches from 1974 onwards almost 20% of those who drowned had blood-alcohol levels above 80 mg/dl. In Scotland alcohol was deemed a relevant factor in 29%.’ (Alcohol causes a sharp fall in blood-sugar after a carbohydrate on

fast in people who are exercising. 2) Despite traditional advice to raise one arm and wave it when in difficulties, unique film shot at Orchard Beach in New York shows that people are quite unable to do this. The arms are usually extended horizontally and make feeble splashing movements before the subject sinks. The patient may thus drown in close proximity to other swimmers and in full view of a crowded beach, without being noticed. In water at 4° C a strong swimmer, fully clothed but without a life-jacket, cannot exercise for much more than 7tminutes before sinking-in other words, in water at average winter temperatures a fit subject is unlikely to swim more than 100 m. Drainage procedures before resuscitation (e.g., pressure on upper abdomen) are likely to induce vomiting and have been abandoned. Over half the victims of immersion vomit during resuscitation. Portable oxygenpowered suckers are unsuitable for aspiration of vomit and life-saving organisations have been advised to discard them. As to maintenance of the airway, soft-tissue X-rays show that the best position is achieved with jaw lift in addition to neck extension, but the technique is more difficult to teach than neck extension alone. No precordial thump is given before cardiopulmonary resuscitation unless the electrocardiogram can be monitored simultaneously. Closed-chest massage is given at 60 compressions a minute, with a breath every fifth compression by the expired-air method and no pauses in compression rhythm. Blood-flow is increased if at least half the massage cycle is spent in compression of the

chest.3 The California Paramedic Service has extensive experience with an oesophageal obturator which cuffs the cesophagus and is easier to insert than an endotracheal tube, but these are not generally liked because of the risk of oesophageal rupture in untrained hands. Bag/mask resuscitators are unsuitable for use in the field because of the difficulty in forming an adequate seal round the mouth. They deliver less than 800 ml of air and so bagging at the recommended rate of 12 per minute, and with allowance for dead-space tidal volume, the patient would receive a minute volume no greater than 7-35 litres. Oxygen-powered mechanical ventilators may be helpful, but only when used by trained personnel. Pressurecycled automatic machines are condemned because 1. Report of the Working Party on Water Safety. H. M. Stationery Office, 1977. 2. Haight, J. S. J., Keatinge, W. R. J. Physiol., Lond. 1973, 229, 87. 3. Taylor, J. G., et al. New Engl. J. Med. 1977, 296, 1515; and see Lancet,

1977, ii, 54.

Blood-transfusions and renal transplantation.

193 WEBLEY et al. studied 100 patients with R.A. and normal chest radiographs, and compared them with 84 healthy controls matched for age, sex, and s...
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