1331
8-8% has been settled (USA 737%).1 The mean population density in urbanised regions of Oman is about 68/km2 (USA 35) and since the fraction of children in Oman is twice that in the USA, the density of children in urbanised Oman is about four times higher than that in urban USA. The demographic pattern in Oman together with its hygiene standards means that much greater vaccine coverage2 is required if poliomyelitis is to be eliminated from Oman and other developing countries. Institute for Virology,
University of Cologne, D-5000 Koln 41, Germany
HANS J. EGGERS
Mathematical Institute, University of Cologne
JUERGEN WEYER
1. PCGlobe 4 2. Sabin AB.
0 (digital data bank). Tempe, Arizona: PCGlobe, 1991. Perspectives on rapid elimination and ultimate global eradication of paralytic poliomyelitis caused by polioviruses. Eur J Epidemiol 1991; 7: 95-120. Cranial
computed tomography showing (low-density areas).
Deafness after
meningococcal meningitis
SIR,-Meningitis is a leading cause of deafness in childhood. About 10% of survivors have substantial hearing 10ss,1 and one of the most common bacteria causing sensorineural deafness after meningitis is Neisseria meningitidis.2,3 We have done full audiometric assessments in 60 patients with a history of acute meningococcal meningitis in childhood. Two groups, age matched, of 30 children and adults were evaluated at least two years after the acute episode. 7 (12%) had impaired hearing. However, in one group, in which the meningitis had been caused by N meningitidis serogroup B hearing was affected in only 1 patient (3-3%; 95% CI 0-08-17-22). The second group had had meningococcal disease due to the uncommon serogroups Wl 35, X, Y, or 29E, and in this group 6 had hearing impairment (20%; 95% CI 7-71-38-57). Because other reasons for deafness could be ruled out, our results indicate that meningococcal meningitis due to uncommon serogroups may be more often associated with deafness than meningitis due to common serogroups of N meningitidis. Department of Microbiology, Hygiene, University of Heidelberg, 6900 Heidelberg 1, Germany Institute of
E. MAYATEPEK M. GRAUER H. G. SONNTAG
Meningitis and deafness: the problem, its physical, audiological, psychological and educational manifestations in children. Laryngoscope 1967; 77:
presence
of
air
massive cerebral oedema had developed. The patient deteriorated and died on the 28th day. The frequency of central air embolus with the use of subclavian catheters is under 0-05%. Cerebral air embolus is thought to result from paradoxical embolus triggered by an intracardial defect into the systemic circulation.2 Alternatively, if the filter function of the pulmonary capillary network is overloaded34 the air shunts via the physiological bronchopulmonary anastomoses into the left heart and into the systemic circulation. Our case differs in some important respects from others. An intracardiac defect was excluded by echocardiography; the CT pictures showed a massive accumulation of air in the intracerebral venous system, which was followed by a fulminant brain oedema without cerebral infarction. We therefore believe that our patient did not have a paradoxical air embolus but that the cerebral air embolus developed retrogradely via the venous system, facilitated by his being upright. Thus the air bubbles rose via the vena cava and internal jugular vein into the brain. The venous cerebral air embolus therefore led to venous stasis with capillary leakage followed by brain oedema. We believe that the routine use of central venous catheters in mobile patients should be discouraged. Nursing staff and patients should be familiarised with the nursing technique and the risks involved.
1 Vernon M
1856-74. 2 Habib RG, Girgis NI, Yassin
MW, Sippel JE, Edman DC. Hearing impairment in meningococcal meningitis. Scand J Infect Dis 1979; 11: 121-23. 3. Girgis NI, Farid Z, Podgorf JK, Hafez A. Deafness after acute bacterial meningitis. Lancet 1986; i: 1038.
Cerebral air emboli with use of central venous catheter in mobile patient
Department of Anaesthesiology and Intensive Care, Brixen Hospital,
F. PLONER
Innsbruck
Department of Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
L. SALTUARI M. J. MAROSI
Department of Radiology, Brixen Hospital
R. DOLIF A. SALSA
Jacobson WK, Bnggs BA, Mason LJ Paradoxical air embolism associated with a central total parenteral nutrition catheter. Crit Care Med 1983; 11: 388-89. 2. Gronert GA, Messick JM Jr, Cucchiara RF, Michenfelder JD. Paradoxical air embolism from a patent foramen ovale. Anesthesiology 1979; 50: 548-49. 3. Black M, Calvin J, Chan KL, Walley V. Paradoxic air embolism in the absence of an 1.
SIR,-In mobile patients with central venous catheters the risk of side-effects is increased. We describe a patient in whom inadequate of a subclavian catheter resulted in disconnection, leading to cerebral air embolism. As part of the lead up to surgery for oesophageal carcinoma a 68-year-old patient received a left subclavian catheter. Preoperative cardiac echocardiography showed no valve or congenital defect. Some days before operation the patient was discharged with a heparinised catheter fitted with a Luer screw-lock. He walked the short distance to his home, where he fell and became unconscious. The emergency doctor noted that the catheter screw-lock was disconnected. He was immediately intubated and artifically ventilated, and was admitted to intensive care. Cardiorespiratory examination was normal and the patient’s condition stable. Computed tomography (CT) of the cranium done immediately thereafter showed partly circuitous low-density areas spread diffusely within the intracranial venous system, indicating the presence of air (figure). These areas were most common in the sagittal sinus and in the cavernous sinus. Repeat CT on the third day showed resorption of the areas representing air bubbles, but care
4.
intracardiac defect. Chest 1991; 99: 754-55. Marquez J, Sladen A, Gendell H, Boehnke M, Mendelow H. Paradoxical cerebral air embolism without an intracardiac septal defect.J Neurosurg 1981; 55: 998-1000.
Dose reduction of
beta-agonists in asthma
SiR,—Given the deleterious effects of frequent
use
of inhaled
long-term control of asthma,’ a safe and effective means of lowering the dose of this therapy among patients with chronic severe asthma is needed. Many physicians fear that restriction of beta-agonist use will lead to greater morbidity and mortality from asthma. This fear is not substantiated by practical experience; on the contrary, morbidity from asthma can be substantially reduced, and lower mortality should follow. However, the patient often has used beta-agonists in high doses for many years, and is fearful of the consequences of reducing therapy. Once the patient is aware that frequent use may be contributing to beta-agonists
on
the
8-8% has been settled (USA 737%).1 The mean population density in urbanised regions of Oman is about 68/km2 (USA 35) and since the fraction of children in Oman is twice that in the USA, the density of children in urbanised Oman is about four times higher than that in urban USA. The demographic pattern in Oman together with its hygiene standards means that much greater vaccine coverage2 is required if poliomyelitis is to be eliminated from Oman and other developing countries. Institute for Virology,
University of Cologne, D-5000 Koln 41, Germany
HANS J. EGGERS
Mathematical Institute, University of Cologne
JUERGEN WEYER
1. PCGlobe 4 2. Sabin AB.
0 (digital data bank). Tempe, Arizona: PCGlobe, 1991. Perspectives on rapid elimination and ultimate global eradication of paralytic poliomyelitis caused by polioviruses. Eur J Epidemiol 1991; 7: 95-120. Cranial
computed tomography showing (low-density areas).
Deafness after
meningococcal meningitis
SIR,-Meningitis is a leading cause of deafness in childhood. About 10% of survivors have substantial hearing 10ss,1 and one of the most common bacteria causing sensorineural deafness after meningitis is Neisseria meningitidis.2,3 We have done full audiometric assessments in 60 patients with a history of acute meningococcal meningitis in childhood. Two groups, age matched, of 30 children and adults were evaluated at least two years after the acute episode. 7 (12%) had impaired hearing. However, in one group, in which the meningitis had been caused by N meningitidis serogroup B hearing was affected in only 1 patient (3-3%; 95% CI 0-08-17-22). The second group had had meningococcal disease due to the uncommon serogroups Wl 35, X, Y, or 29E, and in this group 6 had hearing impairment (20%; 95% CI 7-71-38-57). Because other reasons for deafness could be ruled out, our results indicate that meningococcal meningitis due to uncommon serogroups may be more often associated with deafness than meningitis due to common serogroups of N meningitidis. Department of Microbiology, Hygiene, University of Heidelberg, 6900 Heidelberg 1, Germany Institute of
E. MAYATEPEK M. GRAUER H. G. SONNTAG
Meningitis and deafness: the problem, its physical, audiological, psychological and educational manifestations in children. Laryngoscope 1967; 77:
presence
of
air
massive cerebral oedema had developed. The patient deteriorated and died on the 28th day. The frequency of central air embolus with the use of subclavian catheters is under 0-05%. Cerebral air embolus is thought to result from paradoxical embolus triggered by an intracardial defect into the systemic circulation.2 Alternatively, if the filter function of the pulmonary capillary network is overloaded34 the air shunts via the physiological bronchopulmonary anastomoses into the left heart and into the systemic circulation. Our case differs in some important respects from others. An intracardiac defect was excluded by echocardiography; the CT pictures showed a massive accumulation of air in the intracerebral venous system, which was followed by a fulminant brain oedema without cerebral infarction. We therefore believe that our patient did not have a paradoxical air embolus but that the cerebral air embolus developed retrogradely via the venous system, facilitated by his being upright. Thus the air bubbles rose via the vena cava and internal jugular vein into the brain. The venous cerebral air embolus therefore led to venous stasis with capillary leakage followed by brain oedema. We believe that the routine use of central venous catheters in mobile patients should be discouraged. Nursing staff and patients should be familiarised with the nursing technique and the risks involved.
1 Vernon M
1856-74. 2 Habib RG, Girgis NI, Yassin
MW, Sippel JE, Edman DC. Hearing impairment in meningococcal meningitis. Scand J Infect Dis 1979; 11: 121-23. 3. Girgis NI, Farid Z, Podgorf JK, Hafez A. Deafness after acute bacterial meningitis. Lancet 1986; i: 1038.
Cerebral air emboli with use of central venous catheter in mobile patient
Department of Anaesthesiology and Intensive Care, Brixen Hospital,
F. PLONER
Innsbruck
Department of Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria
L. SALTUARI M. J. MAROSI
Department of Radiology, Brixen Hospital
R. DOLIF A. SALSA
Jacobson WK, Bnggs BA, Mason LJ Paradoxical air embolism associated with a central total parenteral nutrition catheter. Crit Care Med 1983; 11: 388-89. 2. Gronert GA, Messick JM Jr, Cucchiara RF, Michenfelder JD. Paradoxical air embolism from a patent foramen ovale. Anesthesiology 1979; 50: 548-49. 3. Black M, Calvin J, Chan KL, Walley V. Paradoxic air embolism in the absence of an 1.
SIR,-In mobile patients with central venous catheters the risk of side-effects is increased. We describe a patient in whom inadequate of a subclavian catheter resulted in disconnection, leading to cerebral air embolism. As part of the lead up to surgery for oesophageal carcinoma a 68-year-old patient received a left subclavian catheter. Preoperative cardiac echocardiography showed no valve or congenital defect. Some days before operation the patient was discharged with a heparinised catheter fitted with a Luer screw-lock. He walked the short distance to his home, where he fell and became unconscious. The emergency doctor noted that the catheter screw-lock was disconnected. He was immediately intubated and artifically ventilated, and was admitted to intensive care. Cardiorespiratory examination was normal and the patient’s condition stable. Computed tomography (CT) of the cranium done immediately thereafter showed partly circuitous low-density areas spread diffusely within the intracranial venous system, indicating the presence of air (figure). These areas were most common in the sagittal sinus and in the cavernous sinus. Repeat CT on the third day showed resorption of the areas representing air bubbles, but care
4.
intracardiac defect. Chest 1991; 99: 754-55. Marquez J, Sladen A, Gendell H, Boehnke M, Mendelow H. Paradoxical cerebral air embolism without an intracardiac septal defect.J Neurosurg 1981; 55: 998-1000.
Dose reduction of
beta-agonists in asthma
SiR,—Given the deleterious effects of frequent
use
of inhaled
long-term control of asthma,’ a safe and effective means of lowering the dose of this therapy among patients with chronic severe asthma is needed. Many physicians fear that restriction of beta-agonist use will lead to greater morbidity and mortality from asthma. This fear is not substantiated by practical experience; on the contrary, morbidity from asthma can be substantially reduced, and lower mortality should follow. However, the patient often has used beta-agonists in high doses for many years, and is fearful of the consequences of reducing therapy. Once the patient is aware that frequent use may be contributing to beta-agonists
on
the
