Breathing exercises for asthma: a randomised controlled trial.

BACKGROUND: The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain. METHODS: A prospective, parallel group, single-blind, randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention) was performed. Subjects with asthma with impaired health status managed in primary care were randomised to receive three sessions of either physiotherapist-supervised breathing training (n = 94) or asthma nurse-delivered asthma education (n = 89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyper-responsiveness, exhaled nitric oxide, induced sputum eosinophil count and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores. RESULTS: One month after the intervention there were similar improvements in AQLQ scores from baseline in both groups but at 6 months there was a significant between-group difference favouring breathing training (0.38 units, 95% CI 0.08 to 0.68). At the 6-month assessment there were significant between-group differences favouring breathing training in HAD anxiety (1.1, 95% CI 0.2 to 1.9), HAD depression (0.8, 95% CI 0.1 to 1.4) and Nijmegen (3.2, 95% CI 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 95% CI 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyper-responsiveness. CONCLUSION: Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication.

Critical limb ischaemia in patients over 80 years of age: options in a district general hospital.

A total of 114 reconstructions were performed in 82 octogenarian patients and the results compared with those of 33 patients who had primary amputation. The operative mortality rate was higher after amputation (45 versus 11 per cent) and the mean survival less (25 versus 34 months). Quality of life assessment using a Rosser scale suggested that, although there was no improvement in the 38 per cent with a failed reconstruction, there was a significant improvement in the 62 per cent whose reconstruction remained patent. There was minimal improvement in quality of life after primary amputation and this was due to relief of pain. Costs (including the costs of revisions and community costs) were assessed in detail. Although the mean total operative costs of reconstruction were higher than those of amputation (10,222 pounds versus 6475 pounds) this was more than offset by the high community costs of amputation. The total cost of reconstruction was 13,546 pounds, compared with 33,095 pounds for amputation. Following reconstruction 66 per cent of those patients independent before critical limb ischaemia occurred were able to return to their own home; only 33 per cent of amputees were able to do so.

Smoking predisposes to parotid adenolymphoma.

Of 574 patients with previously untreated, unremarkable parotid lumps, 194 proved to have pleomorphic adenomas and 73 adenolymphomas. ABO blood group details were available in 59 and 85 per cent of patients respectively. Smoking details were available in 84 per cent of a randomly chosen 46 per cent subgroup of patients with pleomorphic adenomas and in 86 per cent of all those with adenolymphomas. The incidences of smoking and of the ABO blood groups in these two diagnoses were compared with standard sources. There was no evidence that either histological diagnosis of parotid tumours was linked to an abnormal pattern of ABO blood groups. However, there was a much greater incidence of smoking among the adenolymphoma than in the pleomorphic adenoma group: only one of 63 patients with adenolymphoma as opposed to 31 of 75 with pleomorphic adenoma had never smoked, while the mean number of cigarettes smoked by each patient with an adenolymphoma was estimated to be 300,000 as opposed to 80,000 for those with pleomorphic adenoma.

Efficacy of fibrinolytic enhancement with stanozolol in the treatment of venous insufficiency.

Pericapillary fibrin cuffs have been shown in patients with chronic venous insufficiency. It has been suggested that this fibrin deposition is responsible for an oxygen diffusion block, leading to local hypoxia and resulting in ulceration. Fibrinolysis is depressed in patients with venous insufficiency and therefore pharmacological enhancement of this factor might be expected to produce clinical improvement in this condition. Sixty patients with lipodermatoscelerosis were entered into a prospective, double-blind, placebo-controlled, randomized trial. Stanozolol 5 mg or a placebo tablet was given twice daily for 6 months. All patients were supplied with below knee German/Swiss specification class 2 graduated compression stockings. The area of lipodermatosclerosis was measured at monthly intervals and transcutaneous oxygen tension within the liposclerotic area was measured at 3-monthly intervals. The control group showed a mean reduction in area of lipodermatosclerosis of 14% (95% c.i.: -2.6-31%) compared with a 28% reduction in area in the active treatment group (95% c.i.: 5.3-46%). Transcutaneous oxygen measurements showed no change in either group. Side effects were significantly more common in the active treatment group (P less than 0.02, Chi-squared). Although fibrinolytic enhancement caused a reduction in area of lipodermatosclerosis, no evidence of any effect on a possible oxygen diffusion block was indicated.

Further evaluation of radical surgery following radiotherapy for advanced parotid carcinoma.

A series of 30 patients who have been treated for advanced carcinoma of the parotid gland using radiotherapy followed by radical surgery is presented. Three patients deteriorated during preoperative radiotherapy and remained unfit for surgery; the remaining 27 underwent radical parotidectomy with block dissection of the neck. Twelve patients received additional radiotherapy after operation. Of those patients undergoing surgery, three have been lost to follow-up, 17 have died and seven remain alive; the period of follow-up ranges from 3 to 133 months. Fourteen patients remained free of recurrent disease at death or when last seen, and six patients developed a local recurrence at a medium period of 10.5 (range 3-36) months after surgery. For all 30 patients, the cumulative proportion surviving for 5 years was 30 per cent.

Unremarkable parotid tumours that prove to be malignant.

Of 539 patients with clinically unremarkable lumps treated by formal parotidectomy, subsequent histological examination indicated that 20 of these lesions were malignant. After a follow-up of 1-18 years, only one patient has suffered a recurrent tumour and none has died from disease related causes. The results indicate that formal parotidectomy is an acceptable means of treating the small number of malignant tumours presenting in this way, and strengthen the argument that attempts to obtain a histological diagnosis before treatment are contraindicated.

Natural history of patients with recurrent parotitis and punctate sialectasis.

The clinical features of 68 patients (26 children and 42 adults) who suffered recurrent attacks of parotitis and in whom sialography had revealed punctate sialectasis of the affected gland is described. The sex incidence was equal in those patients in whom symptoms commenced during childhood (younger than 15). When symptoms commenced later in life, however, there was a marked preponderance of females (female:male = 7.5:1). Bilateral sialography in 16 patients with unilateral symptoms revealed punctate sialectasis in the asymptomatic gland in 11 (69 per cent) of patients. Neither the presence of the sicca syndrome nor auto-antibodies had a significant predictive value as to the outcome of the disease. Five-year follow-up of 52 patients revealed that 56 per cent of adults and 64 per cent of children had shown spontaneous improvement of symptoms with symptomatic treatment alone. In 40 per cent of adults and 4 per cent of children, however, the persistence or worsening of symptoms necessitated parotidectomy. We believe that these results of conservative management indicate that, at least in the first instance and particularly in children, conservative management is justified and that the use of radiotherapy or steroids (with their attendant morbidity) is unnecessary.

Influence of local surgery and radiotherapy on the natural history of pleomorphic adenomas.

We have analysed the interval between first treatment and tumour recurrence in 65 patients with parotid pleomorphic adenomas which had recurred following local excision. Our results indicate that 5 years is an inadequate period of follow-up and that 10-20 years may be more realistic. Radiotherapy given to 17 patients after local excision of their tumours was found to have had no significant advantageous effect in terms of recurrence-free interval either before or following formal parotidectomy or in limiting the ultimate surgery required. Major complications directly attributable to radiotherapy developed in at least 3 of these 17 patients. Malignant transformation of the pleomorphic adenoma has occurred in three patients, two of whom had been subjected to radiotherapy. We advise that caution is exercised in the interpretation of results of local excision and radiotherapy in this disease. In view of the fact that an alternative and apparently superior treatment is available in the form of formal parotidectomy, we urge that this should be universally adopted for the management of both primary and recurrent pleomorphic adenomas.

Lymphomas presenting as lumps in the parotid region.

The clinical and pathological features of 17 patients who had lymphomas of the parotid region are discussed. Although it is in general impossible on clinical grounds to make a pathological diagnosis on clinical examination of a lump in the parotid region, features which are not typically seen in the majority of patients with parotid lumps, but which were present in 11 (65 per cent) of those patients, are emphasized. Multiple ipsilateral and bilateral lumps were seen in 30 per cent of our patients with lymphomas of the parotid region. However, these are statistically more likely to indicate the benign adenolymphoma. Palpable lymph nodes were seen in association with the parotid mass in 53 per cent of our patients. Whereas a clinical diagnosis cannot be established simply by the presence of an enlarged lymph node in association with the parotid lump, we suggest that the probability of the lump being a lymphoma is sufficient to justify biopsy of the lymph node as a first line of treatment. Biopsy of associated palpable lymph nodes enabled the diagnosis to be made in seven out of eight patients subjected to biopsy, and avoided the necessity for parotidectomy in these patients.