228
had unrelenting diarrhoea, tissue-culture evidence of a clostridial toxin in stools, and sigmoidoscopic confirmation of pseudomembranous colitis. Eight of the patients had fever and leucocytosis which was ascribed to the inflammatory bowel lesion. In every instance these findings were observed at periods of 10 days to 8 weeks after all antimicrobials had been discontinued. Thus, although this study had no control population for comparison, the patients were selected from a group who showed no evidence that the disease x4as improving spontaneously. Oral vancomycin seemed effective in all nine patients. Systemic signs promptly resolved and bowel habits returned to normal within 10 days of the start of treatment. Repeat sigmoidoscopy, when performed, showed substantial improvement or complete clearing of mucosal lesions 5-10 days after vancomycin began. The concentration of the toxin in stools decreased rapidly, and only one patient had continued evidence of this toxin after 7 days. Long-term follow-up in these patients showed no evidence of relapse after vancomycin was discontinued. This was an important consideration because’e animal studies have shown that hamsters with clindamycin die from colitis when vancomycin is
challenged
discontinued.’3 Oral vancomycin was well tolerated, and no adverse effects were noted. The mean stool concentration of vancomycin was approximately 3 mg/g, which is nearly 1000 times the highest minimum inhibitory concentration we have noted forisolates of C. difficile. Serum assays for vancomycin showed either no detectable drug or very low concentrations. This indicates trivial vancomycin absorption despite the inflammatory bowel lesion with high intraluminal concentrations of the drug. One patient could not receive oral vancomycin because of a colonic resection for pseudomembranous colitis complicated by a colonic perforation. This patient was given the drug parenterally. Clinical response was difficult to evaluate. However, it was disturbing that the titre of cytopathic toxin in the stool did not fall and no vancomycin was detectable in the colostomy effluent after 5 days of treatment. This case illustrates a potential therapeutic dilemma which may be encountered when patients cannot receive oral medication.
Requests for reprints should be addressed to F.J.T., Division of Gastroenterology, Department of Medicine, P.O. Box 520875, Miami,
EFFECT OF PHYSIOTHERAPY ON PULMONARY FUNCTION A
Laboratory Study
DUNCAN A. G. NEWTON
ARNOLD STEPHENSON
St. James’s University Hospital, Leeds, LS9 7TF 33 patients with acute exacerbations of chronic bronchitis were studied within 4 days of admission to hospital. Physiotherapy produced an acute rise in lung volume and conductance, without altering specific conductance. There was no consistent change in arterial-blood gases.
Summary
Introduction THE use of breathing exercises and physical exercise in the treatment of lung disorders was first described by Cortlandt MacMahon in 1915, in a report on the treatment of war wounds to the pleura, lung, and diaphragm.1 The success of this treatment led to the establishment of physiotherapy departments in thoracic surgical units throughout the United Kingdom, and later in medical units. The first controlled study in the antibiotic era showed that physiotherapy in combination with bronchodilators prevented postoperative atelectasis.2 However, a clinical study of patients admitted for exacerbations of bronchitis in Sweden showed no difference in sputum volume or control of pyrexia between a physiotherapy group and 3 a control group. Two laboratory studies on dissimilar patients showed different responses to physiotherapy. Bronchitic inpatients showed a fall in forced expiratory volume in 1 s (F.E.V.1) after physiotherapy which could be prevented by a bronchodilator.4 Bronchiectatic outpatients with copious sputum showed improvement in specific conductance, attributed to the removal of secretions, after
physiotherapy.5 We have examined the effect of physiotherapy on patients with acute exacerbations of chronic bronchitis in the early phase of their acute illness, when physiotherapy was most likely to be helpful.
Florida 33152, U.S.A.
Patients and methods REFERENCES
Finney, J. M. T. Bull Johns Hopkins Hosp. 1883, 4, 53. Bartlett, J. G., Chang, T. W., Gurwith, M., Gorbach, S. L., Onderdonk, A. B. New Engl. J. Med. 1978, 298, 531. 3. Rifkin, G. D., Fekety, F. R., Silva, J. Jr. Lancet, 1977, ii, 1103.
1. 2.
4. Larsen, H. E., Price, A. B. ibid. 1977, ii, 1312. 5. George, R. H., Symonds, J. M., Dimock, F., Brown, F. D., Arabi, Y., Shinagawa, N., Keighley, M. R. B., Alexander-Williams, J., Burdon, D. W. Br.
med. J. 1978, i, 675.
Patients admitted to hospital with an acute exacerbation of chronic bronchitis6 were studied within 4 days of admission. An acute exacerbation was defined as an increase in cough, breathlessness, or sputum volume for more than 24 hours. The study was approved by the hospital ethical committee, and the patients gave informed consent. 33 patients with an F.E.v.,: forced-vital-capacity (v.c.) ratio
had unrelenting diarrhoea, tissue-culture evidence of a clostridial toxin in stools, and sigmoidoscopic confirmation of pseudomembranous colitis. Eight of the patients had fever and leucocytosis which was ascribed to the inflammatory bowel lesion. In every instance these findings were observed at periods of 10 days to 8 weeks after all antimicrobials had been discontinued. Thus, although this study had no control population for comparison, the patients were selected from a group who showed no evidence that the disease x4as improving spontaneously. Oral vancomycin seemed effective in all nine patients. Systemic signs promptly resolved and bowel habits returned to normal within 10 days of the start of treatment. Repeat sigmoidoscopy, when performed, showed substantial improvement or complete clearing of mucosal lesions 5-10 days after vancomycin began. The concentration of the toxin in stools decreased rapidly, and only one patient had continued evidence of this toxin after 7 days. Long-term follow-up in these patients showed no evidence of relapse after vancomycin was discontinued. This was an important consideration because’e animal studies have shown that hamsters with clindamycin die from colitis when vancomycin is
challenged
discontinued.’3 Oral vancomycin was well tolerated, and no adverse effects were noted. The mean stool concentration of vancomycin was approximately 3 mg/g, which is nearly 1000 times the highest minimum inhibitory concentration we have noted forisolates of C. difficile. Serum assays for vancomycin showed either no detectable drug or very low concentrations. This indicates trivial vancomycin absorption despite the inflammatory bowel lesion with high intraluminal concentrations of the drug. One patient could not receive oral vancomycin because of a colonic resection for pseudomembranous colitis complicated by a colonic perforation. This patient was given the drug parenterally. Clinical response was difficult to evaluate. However, it was disturbing that the titre of cytopathic toxin in the stool did not fall and no vancomycin was detectable in the colostomy effluent after 5 days of treatment. This case illustrates a potential therapeutic dilemma which may be encountered when patients cannot receive oral medication.
Requests for reprints should be addressed to F.J.T., Division of Gastroenterology, Department of Medicine, P.O. Box 520875, Miami,
EFFECT OF PHYSIOTHERAPY ON PULMONARY FUNCTION A
Laboratory Study
DUNCAN A. G. NEWTON
ARNOLD STEPHENSON
St. James’s University Hospital, Leeds, LS9 7TF 33 patients with acute exacerbations of chronic bronchitis were studied within 4 days of admission to hospital. Physiotherapy produced an acute rise in lung volume and conductance, without altering specific conductance. There was no consistent change in arterial-blood gases.
Summary
Introduction THE use of breathing exercises and physical exercise in the treatment of lung disorders was first described by Cortlandt MacMahon in 1915, in a report on the treatment of war wounds to the pleura, lung, and diaphragm.1 The success of this treatment led to the establishment of physiotherapy departments in thoracic surgical units throughout the United Kingdom, and later in medical units. The first controlled study in the antibiotic era showed that physiotherapy in combination with bronchodilators prevented postoperative atelectasis.2 However, a clinical study of patients admitted for exacerbations of bronchitis in Sweden showed no difference in sputum volume or control of pyrexia between a physiotherapy group and 3 a control group. Two laboratory studies on dissimilar patients showed different responses to physiotherapy. Bronchitic inpatients showed a fall in forced expiratory volume in 1 s (F.E.V.1) after physiotherapy which could be prevented by a bronchodilator.4 Bronchiectatic outpatients with copious sputum showed improvement in specific conductance, attributed to the removal of secretions, after
physiotherapy.5 We have examined the effect of physiotherapy on patients with acute exacerbations of chronic bronchitis in the early phase of their acute illness, when physiotherapy was most likely to be helpful.
Florida 33152, U.S.A.
Patients and methods REFERENCES
Finney, J. M. T. Bull Johns Hopkins Hosp. 1883, 4, 53. Bartlett, J. G., Chang, T. W., Gurwith, M., Gorbach, S. L., Onderdonk, A. B. New Engl. J. Med. 1978, 298, 531. 3. Rifkin, G. D., Fekety, F. R., Silva, J. Jr. Lancet, 1977, ii, 1103.
1. 2.
4. Larsen, H. E., Price, A. B. ibid. 1977, ii, 1312. 5. George, R. H., Symonds, J. M., Dimock, F., Brown, F. D., Arabi, Y., Shinagawa, N., Keighley, M. R. B., Alexander-Williams, J., Burdon, D. W. Br.
med. J. 1978, i, 675.
Patients admitted to hospital with an acute exacerbation of chronic bronchitis6 were studied within 4 days of admission. An acute exacerbation was defined as an increase in cough, breathlessness, or sputum volume for more than 24 hours. The study was approved by the hospital ethical committee, and the patients gave informed consent. 33 patients with an F.E.v.,: forced-vital-capacity (v.c.) ratio
