Left atrial tumour mimicking pulmonary embolism.

Primary cardiac tumours have been described as great imitators. They are rare, and clinical presentations are diverse. Diagnosis is usually made by two-dimensional echocardiography. The present case report describes a case where a left atrial fibrosarcoma eluded diagnosis by echocardiography, and was eventually demonstrated by computed tomography. Management was complicated by the presence of persistent mismatch demonstrated by ventilation-perfusion lung scans. The likely mechanism underlying this phenomenon is discussed.

A twelve month comparison of salmeterol with salbutamol in asthmatic patients. European Study Group.

The efficacy and tolerability of salmeterol, 50 micrograms b.i.d. was compared for three months with salbutamol, 200 micrograms q.i.d., administered from metered-dose inhaler. For the following nine months, safety and clinic lung function was monitored on salmeterol, 50 micrograms b.i.d., compared with salbutamol, 200 micrograms b.i.d. This comparison was made in a multicentre, double-blind, parallel-group study of 667 moderate asthmatics, who had a forced expiratory volume in one second (FEV1) or peak expiratory flow rate (PEFR) > 50% predicted, a 15% reversibility to inhaled salbutamol and who were experiencing symptoms. Throughout the first three month treatment period, both morning and evening PEFR were significantly higher on treatment with salmeterol than salbutamol (mean differences between the treatments 30 l.min-1 for morning, p < 0.001, and 11 l.min-1 for evening, p < 0.01). In addition, the diurnal variation in PEFR, nocturnal and daytime symptoms and use of additional salbutamol were significantly lower in the salmeterol treated group. This improvement was also apparent in the separate subpopulations of patients taking no concurrent glucocorticosteroid or concurrent inhaled and/or oral glucocorticosteroids. Both treatments were well-tolerated throughout the 12 months of treatment. There was a lower incidence of asthma and related events during salmeterol treatment compared to salbutamol treatment subgroups. The results of the study clearly demonstrate that salmeterol, 50 micrograms b.i.d., is well-tolerated and more effective than salbutamol, 200 micrograms q.i.d., in the treatment of moderate asthma.

The value of ear lobe oximetry in the assessment of disability in asbestos-related disease.

Thirty-four asbestos workers, with either asbestosis, diffuse pleural thickening, calcified pleural plaques, or with comparable asbestos exposure but no evidence of asbestos-related disease and seven normal controls underwent a progressive exercise test. The subjects were categorized on the basis of lung function tests and PA chest X-rays. During the exercise test oxygen saturation was measured continuously by an ear lobe oximeter. The asbestosis and diffuse pleural thickening groups showed significant oxygen desaturation on exertion, confirming that both these conditions give rise to appreciable respiratory disability.

Pulmonary Mycobacterium kansasii infection successfully treated with a regimen containing erythromycin.

We report a case in which erythromycin was used in place of rifampicin after a severe reaction to the latter in the treatment of pulmonary Mycobacterium kansasii infection.

Fenoterol solution via nebuliser--optimum dosage.

We report the results of a double-blind controlled study of 20 asthmatic patients to determine the optimum dose of fenoterol given by nebuliser. Lung function was monitored after four different doses (0.5 mg, 1.25 mg, 2.5 mg, 5 mg) and placebo. All four doses of fenoterol were found to be significantly superior to placebo. Doses of 5 mg and 2.5 mg were also significantly more effective than the 0.5 mg dose up to 3 h. There was no significant difference between the three highest doses. In this study of relatively stable asthmatics, the increased bronchodilatation obtained with the higher doses of fenoterol (5 mg and 2.5 mg) was not sufficient to offset the higher incidence of side-effects, and we therefore recommend 1.25 mg as a starting dose. Higher doses may be needed for severely ill patients in whom side-effects are not such an important consideration.

Domiciliary nebulisers in asthma: a district survey.

Fifty three patients who were found to be using a home nebuliser for asthma completed a questionnaire. The results showed some confusion about the criteria for recommending whether a patient should buy a nebuliser and for its correct use. Twelve patients had not received any instruction on the use of their nebuliser, and only 11 of those old enough used a peak flow meter in conjunction with it. Eight patients aged 7-15 were using inhaled sympathomimetic aerosols only at the time of buying a nebuliser as compared with most of the older patients, who were using regular oral steroids. Forty nine patients assessed their asthma as moderate to severe, but eight of these were not attending a hospital clinic. Several patients were using 20 mg salbutamol or more every day, and on occasion doses of up to 50 mg a day were reported. It is recommended that patients should be assessed before they buy a nebuliser and advice given on correct use by a district nebuliser service, organised either by respiratory function technicians or in physiotherapy departments for adults together with a paediatric health visitor for children.

Asthma in merchant seamen and laboratory workers caused by allergy to castor beans: analysis of allergens.

Three merchant seamen and two laboratory workers who developed allergic symptoms following exposure to castor beans have been investigated. Bronchial-provocation testing with castor beans in the merchant seamen demonstrated a late reaction in two. Specific IgE against whole castor-bean extract and ricin, ricinus agglutinin and dericinated extracts of castor bean were found in the patients' sera using radioallergosorbent tests (RAST). RAST inhibition, toxocological and haemagglutination tests suggest that the ricin and dericinated extracts contain distinct allergens.

A comparison of the bronchodilator action of pseudoephedrine and ephedrine in patients with reversible airway obstruction.

A double-blind randomised cross-over study was performed on 12 subjects suffering from reversible airway obstruction (asthma) to determine the relative bronchodilator effects of oral pseudoephedrine 60 mg, pseudoephedrine 180 mg, ephedrine 25 mg and matched placebo. Spirometry was used to measure vital capacity and forced expired volume in 1 s, and whole body plethysmography was used to measure specific airway conductance. Measurements were recorded before each drug was given, and 1 h and 2 h after each drug. Reversibility of the airway obstruction on each day of the study was demonstrated by significant improvements in all parameters of lung function in response to 400 micrograms of isoprenaline inhaled after the 2-h measurement. No significant bronchodilator effect could be shown following the ingestion of pseudoephedrine 60 mg or 180 mg. Only a week bronchodilator effect was demonstrated after ephedrine 25 mg in that the percentage change in vital capacity at 2 h after ephedrine was greater than that following either dose of pseudoephedrine or the placebo. It is concluded that oral pseudoephedrine in single doses of 60 mg or 180 mg has no significant bronchodilator action in man, and that a single dose of up to 180 mg pseudoephedrine does not cause tachycardia or hypertension.

Asbestos pleural disease.

The lung function tests on 88 asbestos workers known to have an asbestos-related abnormality on the chest radiography have been analysed with respect to pleural disease. The degree of intrapulmonary and pleural disease were assessed by reading posteroanterior and both oblique films according to a modified ILO U/C Classification (1971). The results show a highly significant decrease in lung function with increasing pleural abnormality. Analyses suggest that these changes cannot be wholly accounted for by confounding variables such as airways obstruction and/or pulmonary fibrosis. We conclude that pleural thickening alone, particularly when severe, contributes to the decreased vital capacity and to any resultant disability.

Clinical evaluation of five spirometers. Monaghan M403, Pneumoscreen, Spirotron, Vicatest and Vitalograph.

Five spirometers were compared with the Stead-Wells spirometer in 100 subjects, using the FVC and FEV1 as parameters. In addition, some physical characteristics were studied. The Stead-Wells is a water-sealed spirometer, recommended as a reference spirometer by the American Committees on Environmental Health and Respiratory Physiology. The Vicatest and Vitalograph are volume-displacement dry spirometers. They showed a very good linearity over their entire volume ranges; their FVC and FEV1 readings showed very good correlations with the readings of the Stead-Wells spirometer. The Monaghan, Pneumoscreen, and Spirotron are flow-integrating "electronic" spirometers. The volumes recorded were found to be dependent on the values of the flow; their FVC and FEV1 readings also showed good correlations with the readings of the Stead-Wells spirometer, but to a lesser extent than the two dry spirometers. Therefore, for routine assessment of ventilatory function we prefer, at present, the modern volume-displacement dry spirometers.

Two doses of triprolidine for treatment of allergic rhinitis.

Two doses of triprolidine (2.5 mg t.i.d. and 1.25 mg t.i.d.) were compared with placebo in 32 patients suffering from allergic rhinitis. Triprolidine 2.5 mg t.i.d. was statistically significantly better than placebo (p less than 0.05) in reducing the symptoms of sneezing and eye irritation. Neither dose of triprolidine produced significant drowsiness during the second week of treatment.

Histamine challenge and anterior nasal rhinometry: their use in the assessment of pseudoephedrine and triprolidine as nasal decongestants in subjects with hayfever.

1 Nasal airway resistance (NAR) was measured by anterior rhinometry in ten volunteers with allergic rhinitis. Measurements before and after challenge with three concentrations of histamine diphosphate showed significant rises in NAR for each challenge. 2 In a double-blind, crossover study with the same patients triprolidine (2.5 mg) and pseudoephedrine (60 mg) were shown to be equally effective in reducing the rise in NAR produced by histamine challenge to one nostril; both were significantly better than placebo. 3 The rise in NAR of both nostrils after histamine challenge to one nostril was significantly reduced after pseudoephedrine compared with placebo. This suggests that pseudoephedrine is effective in preventing reflex mucosal congestion in the unchallenged nostril. 4 No increase in the pulse rate or blood pressure of the volunteers was detected after either drug.

Serial pulmonary function tests in patients with asbestosis.

Serial lung function tests were performed on 17 patients with asbestosis. A marked fall in the transfer factor often preceded any significant decline in the vital capacity. Changes in vital capacity and transfer factor did not appear to give any indication of the prognosis in these patients. Death was more commonly due to carcinoma of the lung than to the effects of the lung fibrosis.

Evaluation of two spirometers: a comparative study of the Stead-Wells and the vitalograph spirometers.

The characterisitcs and performance of the Vitalograph dry spirometer were studied, and a direct comparison was made with the Stead-Wells spirometer, as recommended by the Committees on Environmental Health and Respiratory Physiology of the American College of Chest Physicians. The Vitalograph calibrates well against the Stead-Wells spirometer for measurements of vital capacity and forced expiratory volume in one second in normal subjects and in patients with various pulmonary conditions. Both spirometers failed to satisfy the committees' recommendations for resistance and inertia, the Stead-Wells showing the better values. Nevertheless, it is suggested that the Vitalograph is very suitable for the routine assessment of ventilatory function in the laboratory or in population surveys. Its light weight, portability, and robustness give it an added advantage.

High-dose corticosteroids in severe acute asthma.

Twenty-six patients admitted to hospital for treatment of severe exacerbations of asthma unresponsive to bronchodilators were assigned to high-, medium-, or low-dose corticosteroid treatment regimens. The rates of recovery were assessed by changes in pulse rate, peak expiratory flow rate, and spirometric measurements and were not related to the dose of corticosteroids given. Very high systemic doses of corticosteroids do not offer significant advantages in treating severe exacerbations of asthma.

Hypothalamo-pituitary-adrenal function in intrinsic non-atopic asthma.

Sixteen patients with intrinsic non-atopic asthma with persistent wheezing who had never been treated with corticosteroids showed normal adrenocortical responses to prolonged stimulation with Tetracosactin Depot. In a subgroup of six patients the hypothalamo-pituitary-adrenal (HPA) response to a standard insulin stress test was normal. It is concluded that impaired responsiveness of the HPA axis is unlikely to be a common factor in initiating or maintaining airways obstruction in patients with intrinsic asthma.