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Objective: Before the advent of antituberculous chemotherapy, thoracoplasty (TPL) was the definitive form of therapy for cavitary pulmonary tuberculosis. This study aimed to characterize the late functional sequelae of TPL, and to establish the degree of reversibility of any consequent airway obstruction. Methodology: Pulmonary function was studied in 21 long-term (mean 35 years) survivors of TPL between the years 1990–2001. Results: A mixed obstructive/restrictive defect was found in this patient cohort. After inhalation of bronchodilator, marginal increases in FEV1 and FVC and marginal decreases in FRC, RV and TLC were observed. Maximum mid-expiratory flow rate was severely reduced (28.8% of predicted), but reversibility after inhaled β2-agonist was highest for this parameter of pulmonary function (mean 11%). Smokers had a higher RV (P = 0.04), suggesting hyperinflation, while non-smokers had a larger increase in FEV1/FVC ratio postbronchodilator (P = 0.004), suggesting more marked reversibility of airways obstruction in this group. Conclusions: Long-term survivors of TPL have an obstructive as well as a restrictive ventilatory defect. These patients have partial reversibility of the obstructive defect. The degree of reversibility found suggests that bronchodilator therapy may help these patients.

Substance P (SP) is a proinflammatory neuropeptide that is secreted by sensory nerves and inflammatory cells. Increased levels of SP are found in sarcoid bronchoalveolar lavage fluid. SP acts by binding to the neurokinin-1 receptor and increases secretion of tumor necrosis factor-α in many cell types. We sought to determine neurokinin-1 receptor expression in patients with sarcoidosis compared with normal controls. Neurokinin-1 receptor messenger RNA and protein expression were below the limits of detection by reverse transcriptase-polymerase chain reaction and immunohistochemistry in peripheral blood mononuclear cells of healthy volunteers (n = 9) or patients with stage 1 or 2 pulmonary sarcoidosis (n = 10), but were detected in 1/9 bronchoalveolar lavage cells of controls compared with 8/10 patients with sarcoidosis (p = 0.012) and 2/9 biopsies of controls compared with 9/10 patients with sarcoidosis (p = 0.013). Immunohistochemistry localized upregulated neurokinin-1 receptor expression to bronchial and alveolar epithelial cells, macrophages, lymphocytes, and sarcoid granulomas. The patient in whom neurokinin-1 receptor was not detected was taking corticosteroids. Incubation of the type II alveolar and bronchial epithelial cell lines A549 and SK-LU 1 with dexamethasone downregulated neurokinin-1 receptor expression. Upregulated neurokinin-1 receptor expression in patients with sarcoidosis may potentiate substance P-induced proinflammatory cytokine production in patients with sarcoidosis.

A patient with the rare Melkersson-Rosenthal Syndrome is presented, illustrating the features of this disorder, its tendency to present to a multiplicity of specialists and drawing attention to the latest immunogenetic aspects surrounding its origin.

Objective: To compare the incidence of tuberculosis due to Mycobacterium bovis in humans to the prevalence of M. bovis infection in cattle in south-west Ireland and discuss possible links between them. Setting: In the south-west region of Ireland, a mixed urban and rural community (pop. 536 000), there is a residuum of human tuberculosis caused by M. bovis . Methods: A retrospective analysis of the incidence of culture-positive M. bovis disease in humans in south-west Ireland from 1983 to 1994 and of the results of tuberculin testing in cattle from 1978 to 1994 for the same region. Results: One to five cases of human tuberculosis due to M. bovis were recorded per year while the overall prevalence of bovine infection fell gradually during the period of study from 467 tuberculin-positive animals per 100 000 cattle tested in 1983 to 158 per 100 000 in 1994. Conclusion: The low incidence plateau of human tuberculosis due to M. bovis together with the decline in prevalence of animal infection in the overall period studied suggest a cut-off in the animal to human chain of infection at two points; the animal source and the ingestion of (now pasteurized) milk. This would suggest that disease in humans is now due to reactivation of previous foci of infection which were acquired when milk pasteurization was not compulsory. Based on this, we would anticipate a further reduction and possible elimination of human tuberculosis due to M. bovis in this region in the next 10–15 years.

Sarcoidosis is a common multisystem disease of unknown cause and Ireland is among the countries with the highest reported prevalence of disease worldwide. Despite this, reports on the geographical distribution of disease and differences in mortality due to sarcoidosis within Northern Ireland (NI) and the Republic of Ireland (ROI) are currently lacking.This study was performed to examine sarcoidosis prevalence and mortality in Ireland (NI and ROI) to specifically determine if geographical or temporal clusters of disease are present and if any differences in mortality exist between NI and ROI.A retrospective study, examining hospital discharge data for NI and ROI and data on deaths due to sarcoidosis, obtained from the relevant official government agencies.For 1996-2005, the prevalence of sarcoidosis was 28.13 per 100,000 for ROI compared with 11.16 per 100,000 for NI (p = 0.002). Two significant spatial clusters of disease were detected in the Northwest (Prevalence = 44.9 per 100,000) and also the Midlands region (32.1 per 100,000). Two lower-prevalence spatial clusters were also detected in the South and Southeast of ROI. Temporal clustering was also present throughout ROI and NI for the years 2000 to 2004, while space-time clustering was found in three regions, the West (ROI), the East (ROI) and Northeast (ROI and NI). The case fatality rate for ROI was 0.84%, and for NI was 1.44% (p = 0.03).Considerable heterogeneity in disease prevalence is evident in Ireland as significant spatial, temporal and space-time clusters of sarcoidosis are demonstrated in this study. Prevalence rates are also higher than that previously reported for Ireland and are comparable to those of Scandinavian countries. Although case-fatality is low in both ROI and NI, it is significantly lower in ROI. Further study is needed to investigate these findings and the creation of an all-island sarcoidosis registry would provide a mutually beneficial means of capturing this data more effectively.

Birefringent pulmonary talc granuloma are often found in lung biopsies from intravenous drug abusers (IVDA) but their clinico-pathological significance remains undefined.

BACKGROUND—The ligase chain reaction Mycobacterium tuberculosis assay uses ligase chain reaction technology to detect tuberculous DNA sequences in clinical specimens. A study was undertaken to determine its sensitivity and specificity as a primary screening tool for the detection of culture positive tuberculosis. METHODS—The study was conducted on 2420 clinical specimens (sputum, bronchoalveolar lavage fluid, pleural fluid, urine) submitted for primary screening for Mycobacterium tuberculosis to a regional medical microbiology laboratory. Specimens were tested in parallel with smear, ligase chain reaction, and culture. RESULTS—Thirty nine patients had specimens testing positive by the ligase chain reaction assay. Thirty two patients had newly diagnosed tuberculosis, one had a tuberculosis relapse, three had tuberculosis (on antituberculous therapy when tested), and three had healed tuberculosis. In the newly diagnosed group specimens were smear positive in 21 cases (66%), ligase chain reaction positive in 30 cases (94%), and culture positive in 32 cases (100%). Using a positive culture to diagnose active tuberculosis, the ligase chain reaction assay had a sensitivity of 93.9%, a specificity of 99.8%, a positive predictive value of 83.8%, and a negative predictive value of 99.9%. CONCLUSIONS—This study is the largest clinical trial to date to report the efficacy of the ligase chain reaction as a primary screening tool to detect Mycobacterium tuberculosis infection. The authors conclude that ligase chain reaction is a useful primary screening test for tuberculosis, offering speed and discrimination in the early stages of diagnosis and complementing traditional smear and culture techniques.

Farmer's lung incidence in Ireland was constant until 1996, even though hay making methods were revolutionised in late 1980's. We undertook this study to find out the incidence of farmer's lung in Ireland from 1982-2002 and its correlation with rainfall and the effect of changing farm practices. The primary cases of farmer's lung were identified from Hospital in Patients Enquiry (HIPE) unit of the national EconomicSocial Research Institute (ESRI) Dublin. Rainfall data were obtained from Met Eireann whereas population, hay production and silage production were obtained from the Central Statistics Office, Dublin. As the farming population is in decline, we used the annual working unit (AWU), which reflects the true population at risk. An AWU is the equivalent of 1800 hours per farm worker per year. The incidence rates were constant from 1982-1996, but from 1997-2002 a marked decline was observed. There was strong positive correlation with hay production (r = 0.81) and strong negative correlation with silage production (r = -0.82). This study indicates that the incidence of farmer's lung is now in decline.

The diffuse neuroendocrine system consists of specialised endocrine cells and peptidergic nerves and is present in all organs of the body. Substance P (SP) is secreted by nerves and inflammatory cells such as macrophages, eosinophils, lymphocytes, and dendritic cells and acts by binding to the neurokinin-1 receptor (NK-1R). SP has proinflammatory effects in immune and epithelial cells and participates in inflammatory diseases of the respiratory, gastrointestinal, and musculoskeletal systems. Many substances induce neuropeptide release from sensory nerves in the lung, including allergen, histamine, prostaglandins, and leukotrienes. Patients with asthma are hyperresponsive to SP and NK-1R expression is increased in their bronchi. Neurogenic inflammation also participates in virus-associated respiratory infection, non-productive cough, allergic rhinitis, and sarcoidosis. SP regulates smooth muscle contractility, epithelial ion transport, vascular permeability, and immune function in the gastrointestinal tract. Elevated levels of SP and upregulated NK-1R expression have been reported in the rectum and colon of patients with inflammatory bowel disease (IBD), and correlate with disease activity. Increased levels of SP are found in the synovial fluid and serum of patients with rheumatoid arthritis (RA) and NK-1R mRNA is upregulated in RA synoviocytes. Glucocorticoids may attenuate neurogenic inflammation by decreasing NK-1R expression in epithelial and inflammatory cells and increasing production of neutral endopeptidase (NEP), an enzyme that degrades SP. Preventing the proinflammatory effects of SP using tachykinin receptor antagonists may have therapeutic potential in inflammatory diseases such as asthma, sarcoidosis, chronic bronchitis, IBD, and RA. In this paper, we review the role that SP plays in inflammatory disease.

Tenosynovitis is defined as inflammation of a tendon sheath. In established cases it often presents as painful swelling associated with gradual loss of movement and palpable synovial thickening with nodularity and crepitus in the affected tendons. The cause of such inflammation may include autoimmune phenomena as in rheumatoid arthritis, bacterial infection and in the following cases, mycobacterial infection with mycobacteria other than tuberculosis (MO-l-f). Infections of soft tissue and joints with MOTT have been previously described (14) in addition to pulmonary and other extra-pulmonary sites. Mycobacterium marinum infection has been identified as a hazard of leisure pursuits (5,6) and cutaneous mycobacteriosis (7,8) such as ‘fish tank granuloma’. This organism is less often reported involving deeper tissues such as the tendon sheaths in tenosynovitis (9,lO). Mycobacterium kansasii has been reported in pulmonary disease (11,12) but is much less often implicated in chronic bone and joint infection, especially of the wrist and hand (1,13). Both organisms share similar microbiological characteristics; both are slow growing photochromogens (M. marinum optimally cultures at 30°C; M. kansasii at 37°C) (14). These organisms have been isolated from both domestic and environmental water sources (15-17) and can be difficult to demonstrate on direct staining (1). Both organisms share sensitivities to rifampicin and resistance to pyrazinamide, and choice of an optimal second therapeutic agent can be difficult.

Setting: The Southwest of Ireland (Counties Cork and Kerry) 1987–2000, average population 549 500. Objective: Nontuberculous mycobacteria (NTM) cause significant morbidity worldwide and the study of epidemiology and characteristics helps in their prevention and treatment. This study was performed to determine the incidence of NTM disease in comparison to Mycobacterium tuberculosis ( M. tuberculosis ) and Mycobacterium bovis ( M. bovis ) in Southwest Ireland, over the above time period. Design: A retrospective study was carried out in all human isolates of NTM, M. tuberculosis and M. bovis between 1987 and 2000, in the Southwest Region of Ireland. Results: The mean incidence of NTM (0.4/100 000 population) has risen since 1995, principally of pulmonary Mycobacterium avium intracellulare complex (MAC). The annual incidence of M. tuberculosis in humans over 14 years in the same region was 9.71/100 000 population with a significant reduction since 1994 and M. bovis remained constant at 0.5/100 000 population. Conclusion: The increasing incidence of disease causing NTM noted in Southwest Ireland reflects global data and is surmised to be due to an ageing population, increased incidence related to chronic fibrotic lung disease, and environmental mycobacterial factors.

Answers on p 633. A 60 year old woman presented with a two year history of intermittent stabbing pain at her right scapula, radiating to her right upper limb. The pain was …

The period of prevalence, 1988 inclusive, of Allergic Bronchopulmonary Aspergillosis (ABPA) and Allergic Bronchopulmonary Candiasis (ABPC), the two most frequently reported forms of allergic Bronchopulmonary Mycosis (ABPM), was investigated in an Irish regional hospital respiratory medicine outpatients, catchment area population 536,000. ABPM was defined by the presence of a majority of seven criteria: asthma, eosinophilia, elevated IgE, antibodies to Aspergillus Fumigatus or Candida Albicans, immediate skin test reaction to either fungus, culture of either fungus in sputum, and otherwise unexplained transient or permanent lung field x-ray abnormalities. New referrals were investigated for ABPM if they had asthma and eosinophilia, or asthma and lung field x-ray abnormalities. Fourteen patients with ABPM were identified from a total of 1390 new referrals, a period prevalence of just over one per cent. It is concluded that (1) ABPM is a relatively common disorder in an Irish regional hospital respiratory medicine outpatient population and (2) ABPC constitutes a higher proportion of this disorder than previously considered.

A prospective study was undertaken by the Departments of Respiratory Medicine and Medical Microbiology at the Cork University Hospital, a. to investigate the epidemiology of Farmer’s Lung (F.L.) in the Republic of Ireland (pop. 3.5 million), with special reference to the South Western Region of this country (pop. 536,000) and b. to assess any relationship between the prevalence/incidence of F.L. with climatic factors in South West Ireland, between 1983 and 1996. F.L. incidence remained constant throughout the 13 yrs studied both on a national and a regional basis. A significant relationship was also found between total rainfall each summer and F.L. incidence and prevalence over the following yr (p

The abstract is included in the text.

Two female patients with Cystic Fibrosis, attending the Adult Regional Cystic Fibrosis centre at the Cork University Hospital, were investigated for upper abdominal pain and found to have gallstones at ultrasonography. Laparoscopic cholecystectomy was performed successfully and, without complication, in both patients.

Epidemiological and bacteriological aspects of human Mycobacterium bovis disease were investigated in south-west Ireland (counties CorkKerry, population 536,000) over the years 1983-92 inclusive and compared to M. tuberculosis. Results showed a small, stable incidence of culture positive M. bovis human disease, mean annual incidence 0.56 per 100,000 population compared to a higher but declining incidence of culture positive M. tuberculosis (15.3 per 100,000 in 1983, 9.0 per 100,000 in 1992). Male patients were the majority, 63.4 per cent of M. bovis; 62.4% of M. tuberculosis (p = 0.03). Fifty three per cent of M. bovis cases (n = 30) were pulmonary, compared to 85% of M. tuberculosis (n = 626; p = 0.0001). M. bovis patients were older (p = 0.02), mean age 58.4 years (SD 18.9) compared to 48.5 (SD 22.2). The mycobacterial smear positive rate was similar in both groups taken as a whole. No rural-urban difference in incidence was found in either disease, suggesting in the case of M. bovis initial infection in childhood via contaminated milk in the pre-pasteurisation era.

Setting: Contamination events with Mycobacterium chelonae in 7 patients undergoing bronchoscopy, out of a total of 100 patients in a 5-month period, were analysed. Objective: To identify and assess the importance of factors thought to be relevant in the aetiology of these contamination events and by removing these factors, to eradicate the problem of continuing M. chelonae contamination. Design: A retrospective analysis of the frequency of M. chelonae isolates from bronchoalveolar fluid, assessing the contribution of the following measures to the eradication of M. chelonae : (1) changes to the bronchoscopy unit's water supply; (2) insertion of bacterial filters; (3) installation of a new semi-automated cleaning machine incorporating an ultrasound cycle; (4) staff training in correct use of the new equipment. Results: Following the discontinuation of using tapwater in the cleaning process, the above changes resulted in complete eradication of contamination events, with no further events occurring in the following 12 months. Conclusion: Insertion of bacterial filters into the water supply, with the addition of a more sophisticated semiautomatic cleaning machine involving an ultrasound cycle in addition to conventional cleaning methods currently used, will help reduce or eradicate contamination events with M. chelonae in bronchos copy units.

CASE REPORT A 43-year-old male, non-smoker, presented in November 1988 to a Respiratory Medicine Department with a 2-month history of exercise-induced and nocturnal wheeze. There were no other respiratory symptoms, nor was there any history of dysphagia, sweating episodes, fever or weight loss. He had been treated with salbutamol and beclomethasone inhalers and oral steriods with no symptomatic improvement. Chest radiograph was normal. Pulmonary function tests were normal with FEV~ of 3.641 (predicted 3.84), forced vital capacity (FVC) 4-21 (predicted 4.9), with no reversibility following salbutamol inhalation. Transfer factor was normal at 37-7 ml rain-) mmHg(predicted 32.9). He was scheduled to re-attend in December 1988 for elective admission for further investigation; he did not re-attend, but in mid-January 1989 the patient's wife stated that he woke in the early hours complaining of marked dyspnoea. She also noted that he was wheezing. He went outside to get some air. Half an hour later his wife found him in a collapsed state outside the house, cyanosed and pulseless. His family doctor, urgently summoned, initiated resuscitation and arranged an ambulance. However the patient was dead on arrival at the hospital Accident and Emergency department. A postmortem was performed.

Summary Hypercalcaemia after foreign sun holidays in four patients is described. Although only one was a known case, all had sarcoidosis. The pathogenic mechanisms are discussed and the implications of excessive sun exposure for the mode of presentation and the management of sarcoidosis are highlighted.

The cost of providing medical care is ever-increasing but the resources available are at best static. Major savings can be made by reducing inappropriate investigations. Using serological testing for organisms causing atypical pneumonia as an example, we examined the appropriateness of requests and also physicians' understanding of the test. Of 119 patients tested, only 3 had titres indicative of acute infection. Most patients were tested within 2 days of hospital admission, before receipt of results excluding more likely diagnoses. Forty-five patients had no current or recent respiratory symptoms, in whom infection was highly unlikely. Titres were most often requested by the least experienced members of the clinical team. Of 70 patients with an acute illness in whom a definitive diagnosis, bacteriological or otherwise, was not made, in only 9 was a convalescent specimen sent for follow-up titres. Most requests for serology for organisms causing atypical pneumonia were inappropriate. Furthermore, in the majority of cases the test was incorrectly used.

A 33 year old woman with irregular menses due to endometrial sarcoidosis and a family history of sarcoidosis is described. Its relative increase in importance in the wake of the decline in the incidence of genital tract tuberculosis in Ireland is discussed.

BACKGROUND: Microepidemics of tuberculosis continue to occur in countries with a low incidence of tuberculosis. METHODS AND RESULTS: A microepidemic of tuberculosis in a secondary school with 604 girls in Cork city, Ireland, in 1986 with follow up to 1990 is described. Neonatal BCG vaccination was discontinued in the city in December 1972 so most of the 342 pupils who had received BCG were aged 14 years or more. Six active cases and 75 tuberculin positive cases were found. Four of the six girls with active disease had had neonatal BCG. The 75 pupils with a positive (grade 3 or 4) Heaf test response were given chemoprophylaxis with rifampicin and isoniazid for six months; none had developed active tuberculosis four years later. The brother of the girl who was the probable index case, however, developed active tuberculosis in 1988 despite similar chemoprophylaxis. CONCLUSION: The episode highlights the fact that children who have had neonatal BCG can develop active tuberculosis as teenagers.

Patients with chronic hypoxaemia develop secondary polycythaemia that improves oxygen-carrying capacity. Therefore, normal haemoglobin and haematocrit values in the presence of chronic arterial hypoxaemia in cystic fibrosis constitute ‘relative anaemia’. We sought to determine the cause of this relative anaemia in patients with cystic fibrosis. We studied haematological indices and oxygen saturation in healthy volunteers (n=17) and in adult patients with cystic fibrosis (n=15). Patients with cystic fibrosis had lower resting arterial oxygen saturation when compared with normal volunteers (P

Massive, life-threatening hemoptysis occurred in a patient with left upper lobe bronchiectasis secondary to old tuberculosis. Selective left bronchial arteriography showed extravasation of contrast medium in the bronchiectatic area. A marked decrease in hemoptysis occurred after selective left bronchial arterial embolization. Complete cessation of bleeding followed the inflation of a Swan-Ganz balloon catheter that had been placed in the left main pulmonary artery.

THE annual notification rates for Tuberculosis (TB) in the Republic of Ireland is much higher than the rates from three notification areas of the United Kingdom (Northern Ireland, England and Wales, Scotland) and also higher than in most other states of the European Community. Accordingly to ascertain the criteria used in the Republic for notification of TB cases, with special reference to their bacteriological status (presence on absence of Mycobacterium Tuberculosis), a questionnaire was sent to the Directors of the 35 Community care areas in the country, to identify the notification criteria used in the years 1982–85 inclusive. A 94% response was obtained. Replies showed that the total cases notified gradually declined from 1982 (982 cases) to 1985 (732 cases). However the percentage of bacteriologically proven cases (of those whose bacteriological status was known) remained low and essentially unchanged from 1982 (44.7%) to 1985 (45.5%). This percentage varied widely between Health Board Areas (HBAs), for example in 1985 it was 25% in the mid-Western HBA and 77% in the adjacent Midland HBA. The overall rate of bacteriological proof of tuberculosis in the Republic of Ireland is disturbingly lower than in Northern Ireland or England and Wales, and raises questions concerning true TB incidence and prevalence in the Republic. Policy on TB notification in the Republic is in urgent need of revision and standardisation.