Questionnaires and twice daily peak expiratory flow measurements were used to evaluate the effects of the menstrual cycle in asthmatic women. Forty per cent of women reported premenstrual deterioration in their symptoms and this was confirmed by peak flow recordings. No correlations were found between premenstrual exacerbation of asthma and symptoms of premenstrual tension, consumption of aspirin, use of the contraceptive pill, cycle length, or behaviour of asthma during pregnancy.Although premenstrual worsening of asthma is recognised,'-3 little attention has been paid to the problem. In particular, little is known of the frequency with which it occurs, its severity, the relevance of medication such as analgesics or the contraceptive pill, or its relationship to other premenstrual symptoms. We have studied this phenomenon by means of a self administered questionnaire and by analysis of home peak flow recordings. Patients and methodsOne hundred and twenty six consecutive women aged 14-46 years attending an outpatient clinic for asthma were asked about variation of their asthma during the menstrual cycle. A questionnaire was then sent to the 114 women who had responded and it was returned by 91 of them. It included questions on the timing of any exacerbation in relation to menstruation, the frequency with which this occurred, and the perceived severity of the deterioration. The patients were also asked if they ever experienced any of the following premenstrual symptoms: headache, breast tenderness, stomach bloating, swollen ankles, nervous tension, irritability, depression, acne rash, or period pains; and the frequency of these symptoms was compared in the women with and without premenstrual asthma. We also enquired about the contraceptive pill and any drugs taken for premenstrual symptoms, and the effect of pregnancy on the severity of asthma was recorded.Twenty one women who complained of premenstrual asthma and 12 who did not recorded their peak Address for reprint requests: Dr RJ White, Department of Medicine, Frenchay Hospital, Bristol. Accepted 2 May 1984flow rate twice daily, using a mini Wright peak flow meter before bronchodilator treatment, for three consecutive months. We compared the mean morning and evening peak flow rates during the premenstrual week (the seven days preceding the menstrual period) and during the mid cycle week (days 10-16), using Student's t test. ResultsIn response to the initial question " Has your asthma ever varied with your monthly period?" 49 patients (43%) answered "Yes" and 65 (57%) answered "No." QUESTIONNAIRE RESULTSWhen asked "Does your asthma ever seem worse before the menstrual period?" 36 patients (40%) answered "Yes" and 55 (60%) said "No." Most of the women had developed asthma in childhood and adolescence, but the mean age of onset of the premenstrual exacerbations was 25 (SD 8) years. The age of the women who complained of premenstrual worsening was not significantly different from those who did not.Of those who experienced premenstrual asthma, 27 (75%) ha...

Five patients with respiratory disorders associated with hard metal exposure are described. In four patients electron microprobe analysis of bronchoalveolar lavage cells or lung tissue was used to show tungsten and other hard-metal components. Three patients had interstitial pneumonia and fibrosis with unusual multinucleate giant cells. Electron microscopy showed that the giant cells comprised both type II alveolar epithelial cells and alveolar macrophages. The multinucleate macrophages formed a distinctive feature of the bronchoalveolar lavage material but the multinucleate alveolar epithelial lining cells were evident only in lung tissue. The other two patients both suffered from work-related asthma, one of whom also had pulmonary opacities. Bronchial provocation tests in these patients supported the diagnosis of hard-metal-induced asthma and implicated cobalt as the agent responsible.Hard metal is an alloy of tungsten carbide, cobalt, and occasionally other metals such as titanium and tantalum. Because of its hardness and resistance to high temperature it is used to make drill tips, tool edges, and armament components. In the manufacturing process the raw materials are ball milled and the resultant dry powder is mixed with wax, pressed into moulds, and heated to 1000°C (presintering). The presintered hard metal has the consistency of chalk and can be easily cut into the required shape. The shaped article is then heated to about 1500°C (sintering) to produce hard metal, which can be worked only with a diamond. Ball milling, working the presintered metal, and grinding the sintered product are all processes liable to produce dust.Respiratory disease in the hard-metal industry has been recognised as a probable occupational hazard since 1940.' The initial reports emphasised interstitial lung disease but more recently asthma has also been described.

Keratoacanthoma formation after skin grafting is rare. We report the third case in the literature of multiple keratoacanthomas developed at both split-thickness skin graft donor and recipient sites. We provide possible explanations for this poorly understood phenomenon and highlight its implications on treatment options.