Selective internal radiation therapy is a very effective and well-tolerated regional treatment for colorectal liver metastases, which should be considered for those with liver-only metastatic disease.

Peak expiratory flow rate (PEFR) has been recorded hourly or two-hourly from waking to sleeping in workers with respiratory symptoms who were exposed to isocyanate fumes at work. Twenty-three recordings averaging 33 days duration were recorded in 20 workers. Each worker was also admitted for bronchial provocation testing to toluene di-isocyanate (TDI) or diphenylmethane di-isocyanate (MDI) fumes or both. A final assessment of work-related asthma made from subsequent work exposure was compared with the results of bronchial provocation testing and a subjective assessment of the peak flow records. Both techniques were specific and sensitive.Physiological patterns of occupational asthma were defined from the records of PEFR. The most striking finding was the slow recovery from work-induced asthma. This commonly took several days to start and in one worker took 70 days to complete after leaving work. Several workers developed a pattern resembling fixed airways obstruction after repeated exposure at work. The consequences of these findings for the recording of symptoms of occupational asthma are discussed and recommendations are made for the recording of PEFR in workers in general.

Peak expiratory flow rate (PEFR) has been measured hourly from waking to sleeping in 29 workers with respiratory symptoms exposed to the fumes of soft soldering fluxes containing colophony (pine resin). Thirty-nine records of mean length 33 days have been analysed, and the results compared with the occupational history and bronchial provocation testing in the same workers. From (Schilling, 1956). Symptoms most severe on the first day of the working week are seen in a wide range of diseases where fever is prominent, and wheeze is often present. These include metal fume fever (Greenhow, 1862), humidifier fever (Pickering et al, 1976), meat wrapper's asthma (Sokol, 1973), feather picker's asthma (Plessner, 1960), and grain fever (Williams et al, 1964;Kleinfeld et al, 1968).Measurement of lung function before and after a working shift has formed the basis of objective tests for occupational asthma in the work situation. This has often been disappointing. Schoenberg and Mitchell (1975) (1979b) were able to show a fall in FEV1 of 10% or more over at least one of three work shifts in a third of a group of workers in an electronics factory, all of whom had symptoms highly suggestive of occupational asthma. Most workers with colophony sensitivity have immediate asthmatic reactions on bronchial provocation testing (Burge et al, 1978), which may explain these better 308 on 11 May 2018 by guest. Protected by copyright.

Bronchial provocation studies on 15 workers occupationally exposed to formaldehyde are described. The results show that formaldehyde exposure can cause asthmatic reactions, and suggest that these are sometimes due to hypersensitivity and sometimes to a direct irritant effect. Three workers had classical occupational asthma caused by formaldehyde fumes, which was likely to be due to hypersensitivity, with late asthmatic reactions following formaldehyde exposure. Six workers developed immediate asthmatic reactions, which were likely to be due to a direct irritant effect as the reactions were shorter in duration than those seen after soluble allergen exposure and were closely related to histamine reactivity. The breathing zone concentrations of formaldehyde required to elicit these irritant reactions (mean 4.8 mg/m3) were higher than those encountered in buildings recently insulated with urea formaldehyde foam, but within levels sometimes found in industry.

Occupational asthma caused by allergy to pigs' urine We report a case of asthma due to occupational exposure to pigs. The cause of the symptoms was exposure to the urine of the animals. This was proved by provoking acute asthma with an inhalation challenge of an extract of pigs' urine at a concentration of 1 g/l. On a second occasion this asthmatic response was blocked by prior treatment with 40 mg sodium cromoglycate (Intal). The patient's serum contained specific IgE antibody to the urine extract which was not found in unexposed controls. Case report The patient, a 21-year-old eczematous woman who enjoyed a vigorous sporting life, playing squash and hockey to a high standard, had not suffered respiratory symptoms since the age of 3. During her second year at university studying agricultural sciences her class visited a pig house. Within two to three minutes she had to leave because she felt as if she was being "stifled with a plastic bag." She took about an hour to recover her breath and within a few minutes her eczema had begun to itch, and this took a further two hours to settle. One year later, within five minutes after starting to watch a laparo-tomy on a pig, she again became short of breath. Her only other exposure to these animals had been during a visit to the pig house in her first year, when she remained symptomless. Skin-prick tests yielded positive reactions to grass, house-dust mite, horse, cat, dog, and pork extract. Pigs' urine (50 ml) was filtered, sterilised, and freeze dried as described1 and reconstituted in Coca's solution at 01 and 1 0 g/l. Skin testing produced a 3 mm weal with the solution at 1 0 g/l. After inhaling a nebulised dose (0-0015 g) for one minute her forced expiratory volume in one second (Vitalograph) fell by 70 % from 2-3 to 0-7 1. The same test was conducted one week later after 40 mg of sodium cromoglycate had been given by inhalation 10 minutes before the challenge. On this occasion her forced expiratory volume in one second fell by nearly 28 %0 from 2-5 to 1-8 1. In each case recordings were made for a further five hours throughout-Chcallenge 3 eDSCG (40 mg). Oi beeNo trestment 0 c 2-E '-1 0 w2 0 102030 40 5060 2 3 4 5 6 Time (minutes) Time (hours) Results of two inhalation tests performed one week apart. On each occasion subject inhaled nebulised pigs' urine 1 g/l for 60 seconds. Asthmatic response was inhibited with sodium cromoglycate (DSCG) 40 mg given 10 minutes before test. the day. No non-immediate reaction developed (figure). A radioallergo-sorbent test performed with the same urine extract showed her blood to contain specific IgE antibody, 23-9 % of the counts added in the assay being bound, as compared with 0-73 , with cord blood and a mean of 0-69 %o with six blood-bank controls. Comment Asthma has resulted from inhaling certain proteins in the urine of mice, rats, guinea-pigs, and rabbits in sensitised subjects but not from inhaling the animal serum.' 2 Our patient's sensitivity to pigs' urine raises the possibility that urine of other mammals may also cause...

Two patients are described with occupational asthma due to carmine, a natural dye extracted from the insect Coccus cactus. Both had dual asthmatic reactons after carmine inhalation. Oral challenge provoked gastrointestinal symptoms in one patient, and asthma in them both, perhaps accounting for their continuing symptoms. One patient worked extracting carmine from the insects and the other used carmine as a cosmetic colouring agent.

Summary A group of twenty‐four workers handling di‐isocyanates and with respiratory disease were investigated by occupational‐type bronchial provocation tests for sensitivity to toluene di‐isocyanate (TDI), to which all were exposed, and to diphenylmethane di‐isocyanate (MDI) and hexamethylene di‐isocyanate (HDI). Sixteen gave asthmatic reactions to TDI and eight of these also reacted to MDI. Four of the eight TDI and MDI reactors had histories of exposure only to TDI, and of them two reacted also to HDI. Of nine subjects tested with HDI, three gave asthmatic reactions, and all three also reacted to TDI and MDI. Thus reactions to MDI and HDI were elicited only in the TDI reactors. The possibility of specific sensitivity to these and other di‐isocyanates requires tests in subjects exposed to them and not to TDI.

Summary In sixty‐three workers exposed to toluene di‐isocyanate (TDI), no overall differences in bronchial reactivity to histamine inhalation and to exercise testing were found between the total groups of positive and negative TDI reactors to provocation tests. A subgroup of TDI highly sensitive subjects reacting to very low concentrations (≤0.001 p.p.m.) were more sensitive to both histamine and exercise than the group who were less sensitive to TDI, and who reacted to higher concentrations (0.002–0.02 p.p.m.) than the group of non‐reactors. There were, however, in the last group a number of subjects with high degrees of histamine reactivity who did not react to the TDI. These findings suggest that, on the one hand, the asthmatic reactions to TDI cannot be attributed solely to non‐specific mechanisms and, on the other, that in subjects with high degrees of specific sensitivity non‐specific mechanisms may also be playing a part.