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Monique Cachia,1 Michael Pace-Bardon,2 Gabriella Balzan,2 Russel Tilney,2 Josef Micallef,2 Martin Balzan2 1Department of Medicine, 2Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta Background: A study evaluating subjective trainee responses to simulation training organized by the Malta Foundation Program in particular whether this changed their clinical practice. Method: Feedback using a standardized questionnaire was obtained from 120 (M=55%) participants. A 0–10 Likert scale was used to evaluate responses. Results: Participants scored the simulation sessions as “useful” at 7.7 (95% confidence interval [CI] 7.4–8.0), rated “the overall experience” at 7.5 (95% CI 7.2–7.8), and thought it made a change in “daily practice” at 5.83 (95% CI 5.4–6.3). The score for the tutor “creating a satisfactory learning environment” and “quality of simulator equipment” was 7.8 (95% CI 7.6–8.1) and 7.7 (95% CI 7.4–8), respectively. Trainees rated “how close was the simulation to a real-life scenario” as 6.24 (95% CI 5.9–6.6). When asked whether the presence of colleagues hindered or helped, the majority were neutral 50 (41.7%), 36 (30%) said it hindered, while only 21 (28.3%) felt it helped. In contrast, 94 (78.33%) stated it was useful to observe colleagues while only 5 (4.2%) stated it was not. Likelihood for future participation was 7.4 (95% CI 7–7.8). Trainees recommended a median of 3 (interquartile range 2–5) simulations per year. Conclusion: Trainees rated the sessions as useful and asked for more sessions possibly at an undergraduate level. Rating for equipment and tutors was positive; however, some felt that the effect on daily practice was limited. Most were comfortable observing others and uncomfortable being observed. The value of increasing sessions to 3–4 per year, timing them before clinical attachments and audiovisual prebriefing for candidates naïve to simulation needs to be evaluated in future studies. Keywords: simulation, foundation, training, acute, medical, mannequin

Since its recent introduction into the Mediterranean area, Tuta absoluta ( Meyrick) has become widespread and an important pest throughout the region, including in Tuscany, where it was first recorded in 2009. Although several studies have been conducted within controlled environments on the ecology and management of T. absoluta, limited information is currently available on the importance of this pest in open-field cultivations, which may lead to ineffective management strategies. This study was carried out to monitor fluctuations in adult populations of T. absoluta in organic and conventional cultivations of processing tomatoes using pheromone lures, and to collect inter-annual data on direct yield loss and fruit damage from larval feeding in two separate trials in Grosseto ( Tuscany). The first trial included eight conventionally managed fields; the second trial was carried out in four organically managed fields. Results show relatively higher crop damage for tomatoes transplanted later in the season and harvested towards the end of August to early September, and limited fruit damage from this pest during the second year of the study for both conventional and organically managed fields. Finally, biological and chemical pest management strategies for the control of T. absoluta adopted by farmers within the region are reviewed and discussed. [ABSTRACT FROM AUTHOR]

Presents a letter to the editor about the use of cyclosporin in treating discoid lupus erythematosus.

Negative transconductance is reported in a resistive gate metal-semiconductor field-effect transistor (MESFET) for the first time. The negative transconductance arises as a result of the negative differential mobility of electrons in the GaAs channel, and is adequately described by a simple equivalent circuit model. The experimental device is fabricated with a planar ion-implanted MESFET process, and shows promise as a microwave signal source for use in monolithic microwave integrated circuits. [ABSTRACT FROM AUTHOR]

Introduction: Kyphoscoliosis is present in up to 2% of the juvenile population and can have deleterious effects on respiratory mechanics, leading to chronic respiratory failure later on in adult life., Case Presentation: Hereby we describe a 53-year-old patient with severe uncontrolled asthma who presented with chronic hypercapnic respiratory failure. During her medical workup, she was noted to have several comorbidities leading to her respiratory failure. The patient had radiological evidence of bronchiectasis with recurrent episodes of infection, and a severe deformity of the spine due to Kyphoscoliosis. Probably the kyphotic component of this deformity had worsened due to a long history of oral steroid use leading to severe osteoporosis and consequent vertebral compression fractures reaching a Cobb angle of 73 degrees. This was probably caused by the patient's non-compliance with inhaler therapy and an excessive reliance on oral steroid use. Her respiratory failure was treated with domiciliary noninvasive positive pressure ventilation and 24-hour oxygen therapy and her symptoms improved., Conclusion: A multidisciplinary approach across different specialities is necessary when managing such a patient with kyphoscoliosis, bronchiectasis, asthma with airflow limitation with respiratory failure., Competing Interests: Conflict of interest: The authors declare that they have no competing interests, and all authors confirm accuracy., (Copyright © 2024, the Author(s).)

Rheology and surface microstructure affect many drop impact processes, including in emerging printing and patterning applications. This study reports on experiments systematically addressing the influence of these parameters on drop impacts. The experiments involved drop impacts of water, glycerol, and shear-thinning carbopol solutions on ten different microstructured surfaces, captured using high-speed photography. The impact Weber number (We) was varied from 70 to 350, and the microstructures consisted of 20 μm wide pillars with circular and square cross sections arranged in square arrays. The data focus on maximum spreading, retraction rates, threshold conditions for asymmetric (non-circular) spreading, and fingers protruding from the spreading rim. The extent of spreading was reduced by the presence of micropillars, and was well-explained using a hybrid scaling model. The drop retraction rate (  ) showed moderate agreement with the inertial regime scaling  ∝ We -0.50 , but did decrease with effective viscosity. Retraction was slower when the contact line was pinned on surfaces that were flat or had relatively tall or closely-spaced pillars, and was disrupted by drop break-up at We ≳ 250 for low-viscosity fluids. Impact velocities at the onset of asymmetric spreading had weak dependence on viscosity. Fingers were more numerous for greater We, lower effective viscosity, lower pillar height, and for pillars with square cross-sections. Fingers were favoured in directions parallel to the rows of the pillar array, especially near the onset of finger formation. Consistent comparisons between Newtonian and non-Newtonian fluids were enabled by calculating an effective Reynolds number.

This case describes an uncommon presentation of type 2 respiratory failure secondary to left hemidiaphragmatic paralysis. Emphasis is on the multitude of possible causes of hemidiaphragmatic paralysis and how to manage such a presentation. https://bit.ly/3Mcd2XI., Competing Interests: Conflict of interest: All authors on this manuscript are involved in the academic teaching programme at the local teaching hospital, Mater Dei Hospital, Malta, for which some monetary remuneration is provided for teaching. No further disclosures made., (Copyright ©ERS 2022.)

The second COVID-19 wave is sweeping the globe as restrictions are lifted. Malta, the 'poster child of Europe's COVID-19 first wave success' also fell victim shortly after it welcomed the first tourists on 1st of July 2020. Only four positive cases were reported over the successive 15 days. Stability was disrupted when two major mass events were organized despite various health professional warnings. In a matter of few just days, daily cases rose to two-digit figures, with high community transmission, a drastic rise in active cases, and a rate per hundred thousand in Europe second only to Spain. Frontliners were swamped with swabbing requests while trying to sustain robust case management, contact tracing and follow-up. Indeed, the number of hospitalizations and the need for intensive ventilation increased. Despite the initial cases were among young adults, within weeks a small spill off on the more elderly population was observed. Restrictions were re-introduced including mandatory mask wearing in specific locations and capping of the total number of people in a single gathering. Malta is an island and the potential for containment would have been relatively simple and effective and permitting mass gatherings was unwise. Protecting the health of the population should take centre stage while carrying out extensive testing, contact tracing and surveillance. Containment and mitigation along with public cooperation is the key to curbing resurgences especially with the influenza season around the corner.

SARS-CoV-2 incidence and mortality in Europe have shown wide variation. Northern Italy in particular the Lombardy region, north-eastern French regions, Switzerland and Belgium were amongst the hardest hit, while the central and southern Italian regions, all the Balkan countries from Slovenia to Greece and the Islands of Malta and Cyprus had much fewer cases and deaths per capita, and deaths per number of cases. Differences in public health measures, and health care delivery, in the author's opinion, can only partly explain the difference. The geographical distribution of Phlebotomus sand-flies and the relative distribution of arthropod borne diseases Leishmaniasis and Phlebovirus infections especially the Sicilian Sandfly fever group corresponds to most areas of low prevalence of SARS-CoV-2. A hypothesis is proposed whereby repeated arthropod or sandfly vector infection of humans by novel viruses of zoonotic origins carrying bat or mammalian RNA/DNA, such as phleboviruses may have resulted in the development of an effective evolutionary immune response to most novel zoonotic viruses such as SARS-CoV-2 by means of survival of the fittest possibly over many generations. This process probably ran in parallel and concurrent with the progressive evolution of novel coronaviruses which spread from one mammalian species to another. Other possible, but less likely mechanisms for the role of sandfly meals within a much shorter time frame may have led to, (i) previous exposure and infection of humans with the SARS-Cov-2 virus itself, or a closely related corona virus in the previous decades, or (ii) exposure of human populations to parts coronavirus protein namely either S or more likely N protein carried mechanically by arthropods, but without clinical disease causing direct immunity or (iii) by causing infection with other arthropod borne viruses which could carry bat DNA/RNA and have similar functional proteins resulting in an immediate cross-reactive immune response rather than by natural selection. The Evidence possibly supporting or disputing this hypothesis is reviewed, however the major problem with the hypothesis is that to date no coronavirus has ever been isolated from arthropods. Such a hypothesis can only be supported by research investigating the possible biological relationship of arthropods and coronaviruses where paradoxically they may be promoting immunity rather than disease., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Understanding positive and negative influences on adult immunization status can help healthcare providers to better identify and target patients who are likely to need immunization. Our aim was to assess and compare influenza and pneumococcal (IV/PV) immunisation rates to identify vaccination predictors in Malta., Method: One group consisted of all medical patients discharged from Mater Dei Hospital (MDH) over a one week period in February 2013. Patients were administered a phone questionnaire. A second group of patients receiving community-based care at local health centres over a one week period in March 2013 were interviewed, identifying vaccination eligibility as per 2010 WHO recommendations., Results: A total of 150 community (Mean age 61.5 SD 15.8, Male 60%) and 149 hospitalised (Mean age 66.8, SD 13.6%, Male 48.3%) patients in whom influenza vaccine was indicated were recruited. In the current year, 44 and 48.3% received the seasonal influenza vaccine, while 32.0, and 49% vaccinated yearly respectively. Pneumococcal vaccination advice was less than 5% in both groups. On stepwise binary regression, vaccination predictors for the current year were regular yearly influenza vaccination (OR 93.62, CI: 31.8-275.5, p  < 0.001) and vaccination reminders (OR 27.5, CI: 9.63-78.31, p < 0.001). Nursing home residence (OR 5.78, CI: 1.22-27.4, p  = 0.011), congestive cardiac failure (OR 2.11, CI: 1.1-4.08, p  = 0.02) and diabetes mellitus (OR 1.68, CI: 1.04-2.72, p  = 0.034) were all predictors for vaccination on exclusion of the strongest two predictors. For successive yearly vaccination, influenza vaccine recommendation by healthcare professionals (OR 12.35, CI: 4.5-33.91, p  < 0.001) and vaccination reminders (OR 5.99, CI: 3.13-11.45, p  < 0.01) were main predictors. Congestive cardiac failure (OR 2.37, CI: 1.20-4.7, p  = 0.13) and nursing home residence (OR 7.07, CI: 1.45-34.5, p = 0,005) were also positive predictors. Male gender was a negative predictor (OR 0.51, CI: 0.31-0.83, p  = 0.006). Some of those who did not vaccinate were unaware of such need (40.5% of community and 15.6% of hospitalised patients)., Conclusions: Just under half of the patient population received the IV during 2012-2013 period. Hospitalized patients are more likely to vaccinate regularly while a large proportion of community patients are unaware of the indication to vaccinate., Competing Interests: Authorisation for the study was given by the Mater Dei Hospital Data Protection Committee according to the local Data Protection Act on 25th February 2013. The need for ethics approval was waived. All participants gave informed consent prior to each interview.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Cigarette smoke is the main source of indoor chemical and toxic elements. Cadmium (Cd), Thallium (Tl), Lead (Pb) and Antimony (Sb) are important contributors to smoke-related health risks. Data on the association between Rare Earth Elements (REE) Cerium (Ce) and Lanthanum (La) and domestic smoking are scanty. To evaluate the relationship between cigarette smoke, indoor levels of PM 2.5 and heavy metals, 73 children were investigated by parental questionnaire and skin prick tests. The houses of residence of 41 "cases" and 32 "controls" (children with and without respiratory symptoms, respectively) were evaluated by 48-h PM 2.5 indoor/outdoor monitoring. PM 2.5 mass concentration was determined by gravimetry; the extracted and mineralized fractions of elements (As, Cd, Ce, La, Mn, Pb, Sb, Sr, Tl) were evaluated by ICP-MS. PM 2.5 and Ce, La, Cd, and Tl indoor concentrations were higher in smoker dwellings. When corrected for confounding factors, PM 2.5 , Ce, La, Cd, and Tl were associated with more likely presence of respiratory symptoms in adolescents. We found that: i) indoor smoking is associated with increased levels of PM 2.5 , Ce, La, Cd, and Tl and ii) the latter with increased presence of respiratory symptoms in children., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The increasing mobility of patients and healthcare professionals across the countries of Europe has highlighted the wide variations in both medical training, and provision of medical competency and skills. The maintenance of the standards defining competency and skills have national and international implications and have proved challenging for national regulatory bodies. Thus each nation has introduced different types of Continuing Professional Development (CPD), recertification and relicensing systems. At the Symposium entitled: " 'Certified … now what?' On the Challenges of Lifelong Learning" in August 2017 at the Association for Medical Education in Europe (AMEE) annual conference, we reviewed differing European national relicensing systems were reviewed. The review highlighted various lifelong learning and competence assessment approaches using examples from different medical specialties across several European countries., Competing Interests: No potential conflict of interest was reported by the authors.

Background: Indoor allergens are risk factors for asthma: Thus, the characterization of indoor air quality is important for studying environment-health relationships in children. In particular, Dermatophagoides pteronyssinus is the dominant allergen for asthma. We cross-sectionally investigated the relationships among respiratory symptoms and function, airway inflammation, allergen sensitization, and indoor allergen concentration., Methods: One hundred and thirty-two children aging 10-14 years and living in a Southern Mediterranean area were evaluated by parental questionnaires. Spirometry, exhaled nitric oxide (FeNO), skin prick tests, total, and specific serum IgE analyses were performed along with the evaluation of home dust samples for the content in Der p 1 allergen. Three clusters were created on the basis of the presence/absence of wheeze in the last 12 months (Wh12m) and Der p 1-specific IgE level., Results: Cluster 1 (Wh12m+/high Der p 1 IgE) presented higher FeNO and poorer pulmonary function (lower FEV 1 and FEF 25%-75% ), while its symptom score was not different from Cluster 2 (Wh12m+/low Der p 1 IgE). Cluster 3 (Wh12m-/low IgE) showed the lowest FeNO values and pulmonary function similar to Cluster 2. Within Cluster 1, both Der p 1-specific IgE and FeNO were positively correlated with dust Der p 1., Conclusions: Similar asthma phenotypes may occur in children despite differences in their atopic state. In atopic children, sensitizing allergens in the indoor environment may increase airway inflammation worsening pulmonary function. Moreover, environmental exposures may contribute to the development of asthma-like symptoms also in the absence of atopic sensitization, thus contributing to asthma overdiagnosis., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: Corret inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients., Methods: Two hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical., Results: 23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63-8.54, p = 0.001), male gender 2.70(1.35-5.39, p = 0.004), self-score 1-10 1.21(1.05-1.39, p = 0.007), spacer use 0.38(0.19-0.79, p = 0.007), inhaled steroid 3.71(1.34-10.25, p = 0.01), heart disease 0.31(0.13-0.77, p = 0.01), pneumococcal vaccine 2.48(1.0-6.15, p = 0.043), education level 1-4 1.44(1.00-2.06, p = 0.05) and respiratory physician explained 0-7 times, 1.11(0.99-1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0-4, were: technique self-score 1-10 1.2(1.05-1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1-7.31, p = 0.03) and education level 1-4 1.41(1.02-1.95, p = 0.03 Times respiratory physician explained inhaler technique 0-7 1.1(0.98-1.24, p = 0.1), married status 1.55(0.85-2.82, p = 0.15), hypercholesterolaemia 0.52(0.25-1.01, p = 0.054) and male gender 1.76(0.97-3.18, p = 0.06)., Conclusions: Known predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients' self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.

Background: Guidelines advise annual influenza vaccination in chronic asthma. The aim of this study was to determine uptake of the influenza vaccine in a group of patients (n = 146) with moderate to severe chronic asthma and establish the main predictors of vaccination., Method: Patients attending a hospital asthma clinic were asked to complete a questionnaire in February 2012 (n = 146). These same patients were contacted a year later via telephone (n = 109 responded), and they were asked to complete the same questionnaire., Results: Vaccination rate was 50.3% in winter 2011/12, and 57.8% in 2012/13. Using binary logistic regression, the predictors for vaccination in 2012 were patient advice (Odds ratio [OR] 15.37 p = 0.001), female gender (OR 2.75, p = 0.028), past side effects (OR 0.21, p = 0.001) and comorbidity (OR 0.39, p = 0.013). Stepwise regression resulted in age as predictor (T value = 3.99, p = 0.001). On analyzing the responses from the second questionnaire at one year after attendance to asthma clinic, predictors changed to compliance to medication (OR 9.52, p= 0.001) and previous exacerbations (OR 4.19, p = 0.026). Out of the 56 patients vaccinated in 2011/12, 33 reported asthma exacerbations before 2012, and 29 reported asthma exacerbations after receiving the influenza vaccine. Out of the 46 unvaccinated patients in 2012, 27 had asthma exacerbations before 2012 and 19 patients had exacerbations in 2013. Patients vaccinated in 2011/12 needed 0.59 courses of steroid/patient/year, and 1.23 visits for nebulizer/patient/year while non-vaccinated patients needed 0.18 courses of steroids/patient/year (p = 0.048), and 0.65 visits for nebulized/patient/year (p = 0.012). Patients' subjective statements broadly confirmed the predictors. 16/69 (23.1%) received the vaccine in winter 2012/13 despite reporting previous side effects., Conclusions: Advice to patient, female gender and patients' age predicted vaccination, while past side effects to the influenza vaccine, and presence of comorbidities predicted non vaccination. Symptomatic asthma patients are more likely to be vaccinated. One year after the first contact, treatment compliance and previous asthma exacerbations gained statistical significance as predictors of vaccination.

A model that combines the results of in vivo experiment, 3D image data, and computer simulation has been developed. Twelve identical stents were implanted into six healthy pigs and explanted at a range of different post-recovery periods from 6 h to 28 days. The stented vessel segments were embedded in methacrylate resin for the preparation of transverse histological sections and imaged using ultra-high resolution micro-CT. The resulting CT data was used to reconstruct the 3D geometry of the stents and one case was used to inform a 3D computational fluid dynamic model. Derived hemodynamic parameters such as wall shear stress (WSS), axial WSS, and oscillatory shear index were correlated with the distribution of neointimal hyperplasia, assessed from histomorphometric analyses. The direct comparison of hemodynamic parameters and biological response supports the hypothesis that low and oscillatory WSS lead to a greater neointimal response within the stented region. Moreover, the realistic geometry obtained from micro-CT images, characterized by proximal overexpansion and asymmetric deployment of the stent, leads to a markedly non-uniform distribution of WSS values and correlates with asymmetric neo-intimal growth. This correlation cannot be appreciated from studies of idealized geometries.

The seasonality of asthma exacerbations may reflect varying exposure to triggers. This study retrospectively analyzes the seasonality of asthma hospital admissions, at all ages, in a population-based study. Analysis of the seasonality of asthma admissions and correlation with temperature was carried out in the setting of a regional hospital covering all acute asthma admissions in an island population. Admissions were divided into pediatric (1994-8) and adult (1989-8) cases. Both pediatric (0-14 years; n = 2916) and adult (15-59 years; n = 1269) admissions showed a peak in January and a trough in August. The seasonality in pediatric admissions was far more pronounced than in adults. Both cohorts exhibited a second, smaller peak in spring. In school-aged children, the end of school in June was associated with a sharp (91%) drop in admissions, and restarting school in October was associated with an even sharper rise (165%). A negative correlation was found between admissions and mean monthly ambient temperatures, and this was most pronounced in the pediatric age groups. This marked seasonality may indicate that temperature is a proxy for the total time spent indoors. Both the start and end of school had a profound impact on pediatric admission rates. Prospective studies are necessary to establish the role of viral infections and the influence of indoor and outdoor aeroallergens on the seasonality of hospitalization rates for asthma in the local setting.

Inhaled corticosteroids have been shown to reduce morbidity and the need for hospitalization from asthma. Despite improvements in the therapy of asthma, epidemiologic data from several countries has shown that the hospital admission rates for asthma among adults at a population level are on the increase. The prevalence rate of hospital admission for asthma among Maltese adults aged 15-59 years was determined retrospectively from 1989 to 1993. Concurrent yearly total dispensal of inhaled corticosteroids for the whole population was also calculated. This study was undertaken amongst a well-defined island population served by a single medical facility offering emergency services, and a possible association between these two trends was investigated by means of logistic regression. The age-specific hospital admission rates for asthma decreased from 96.2 (95% CI: 109.7, 82.7) per 100,000 in 1989 to 38.1 (95% CI: 46.4, 29.8) per 100,000 in 1993. The prevalence rates of admission from asthma decreased from 67.6 (95% CI: 78.9, 56.3) per 100,000 in 1989 to 30.6 (95% CI: 38.0, 23.2) per 100,000 in 1993. The dispensal of inhaled beclomethasone dipropionate (BDP) increased from 0.99 defined daily dose (DDD) per 1000 population in 1989 to 3.28 DDD per 1000 in 1993. Logistic regression showed that increasing dispensal of inhaled BDP by 1 DDD per 1000 decreased the odds of an admission from asthma to 0.71 (95% CI: 0.65, 0.78) times their previous value. Similarly, the odds of an individual being hospitalized because of asthma decreased to 0.75 (95% CI: 0.67, 0.83) times their previous value. This study concludes that there was a progressive decrease in hospital admission rates for asthma in adults, and this trend correlates well with increasing use of inhaled corticosteroids at a community level. This must, however, be interpreted with care in light of the fact that increase in utilization of anti-inflammatory therapy probably also reflected improved general and widespread care for asthma.

Background: Neuroleptic Malignant Syndrome (NMS) is an adverse reaction to dopamine receptor antagonists, characterised by hyperpyrexia, extrapyramidal rigidity and impaired autonomic function. It might result from central dopamine receptor blockade that causes severe muscle contraction., Method: Case Study., Results: High dose intravenous therapy with the anticholinergic drug, procyclidine hydrochloride, temporarily diminished the muscle rigidity and reversed most of the autonomic features in a patient with NMS occurring after a single intramuscular dose of the dopamine antagonist metoclopramide. Paradoxically, however, the heart rate decreased and bowel movements increased with this atropine-like drug., Conclusion: Since the degree of tachypnoea, tachycardia, and bowel hypotonia closely paralleled the severity of the muscle rigidity, it is suggested that these autonomic features of NMS result from sustained muscle contraction rather than a direct effect of neuroleptic drugs on the central nervous system.