'Nocturnal noises': an isolated stridor in an adolescent.

An 18-year-old man presented to primary care with a 2-year history of exclusively nocturnal 'noisy breathing'. He was otherwise asymptomatic. He had never smoked and was previously healthy. Spirometry showed a severely obstructive picture with forced expiratory volume in 1 s (FEV1) 1.87 L (44% predicted), forced vital capacity (FVC) 4.0 L (80%) and FEV1/FVC ratio of 47%. A diagnosis of asthma was suspected and a trial of inhaled bronchodilators and corticosteroids was initiated. Failure to improve symptoms led to referral to the Respiratory Clinic, where his mother replayed a recording of the 'noisy breathing' on her mobile phone. Subsequent examination revealed a stridor on expiration. Flow volume loop showed a plateau of the expiratory limb, consistent with intrathoracic upper airway obstruction. CT of the thorax revealed a massively dilated oesophagus, filled with food residue, reflecting an achalasia, causing lower tracheal compression. He is now being considered for a myotomy procedure.

Occupational asthma due to polyethylene shrink wrapping (paper wrapper's asthma).

Occupational asthma due to the pyrolysis products of polyvinyl chloride (PVC) produced by shrink wrapping processes has previously been reported. The first case of occupational asthma in a shrink wrap worker using a different plastic, polyethylene, is reported; the association was confirmed by specific bronchial provocation testing.

Lamina propria eosinophils and mast cells in ulcerative colitis: comparison between Asians and Caucasians.

To investigate the theory of hypersensitivity in the colonic mucosa of Asian patients with ulcerative colitis the rectal biopsy specimens of Asian and Caucasian patients presenting with colitis were selectively stained for both eosinophils and mast cells. Comparisons between ethnic groups were made as well as the correlation to the blood eosinophil count and two variables of active ulcerative colitis--the blood leucocyte count and serum orosomucoid concentration. No correlation was found in either group between circulating and tissue eosinophils and no ethnic difference was identified in the lamina propria differential cell densities. The leucocyte count and serum orosomucoid concentrations, however, were significantly higher in the Caucasians. In the Asian group a strong negative association was found between the lamina propria eosinophil density and serum orosomucoids; in the Caucasian group there was a positive association between all blood variables. It is concluded that different mechanisms occur in the two ethnic groups and in Asians these might not be reflected by the more orthodox indices of colonic inflammation.

Chemotherapy plus adjuvant surgery for local small cell lung cancer.

Eight patients with local Stage II (T2N1) and III (T3N0, T3N1, T2N2) small cell lung cancer received combination chemotherapy prior to elective surgery to assess the effectiveness of such a regimen in improving operability, preventing local relapse and extending survival. The regimen was well tolerated and prevented local relapse. However, the median time to recurrence of disease was 10 months and the median survival time 13 months, results which are similar to those achieved with chemotherapy and radiotherapy. Distant metastases, particularly in the brain, occurred predictably indicating that successful adjuvant surgery, despite preventing local relapse, may not afford additional survival benefit with currently available drug regimens.

Testing new drugs in untreated small cell lung cancer may prejudice the results of standard treatment: a phase II study of oral idarubicin in extensive disease.

We have evaluated the orally active anthracycline idarubicin at a dose of 40 mg/m2 in divided doses over 24 hours in 21 previously untreated patients with extensive-stage small cell carcinoma of the lung (SCCL). Subsequent iv therapy was cyclophosphamide (1000 mg/m2), vincristine (1 mg/m2), and etoposide (120 mg/m2 iv on Day 1 and 250 mg/m2 orally in divided doses on Day 2; CVE) in patients who failed to respond to idarubicin and in relapsed patients. Three (14%) of 21 patients treated with idarubicin responded, with two complete responses (CR). Patients failing to respond promptly and those who relapsed were treated with CVE. Seven patients did not receive CVE for the following reasons: early death, four patients; early CNS disease, two; and refusal, one. Fourteen patients received CVE. Of 12 patients failing to respond to idarubicin, eight progressed on CVE, three achieved partial response (PR), and one achieved CR. Two idarubicin responders who received CVE achieved PR and CR. The median survival of all 21 patients was 6 months. For those with World Health Organization performance scores of 0 or 1 the median survival was 6.2 months and for the rest it was 2.6 months. Although CVE chemotherapy was instituted promptly in patients not responding to idarubicin, these results seem inferior to those previously seen in our center with standard treatment from the start. We believe that patients with extensive SCCL often require a rapid and more guaranteed response to their first treatment.

Ulcerative colitis in Asian immigrants.

Forty-four Asian immigrants in Birmingham and 44 age- and sex-matched white Caucasians with ulcerative colitis were compared to investigate the existence of any ethnic differences in the pattern of disease. Asian immigrants demonstrated a male preponderance of 2:1, and compared to the matched Caucasians there was a higher incidence of presenting eosinophilia and a milder course of disease, with more patients experiencing only a single initial attack. In spite of this clinical difference, total or subtotal colitis was the commonest pathological type in both white Caucasians and Indians, whereas in Pakistanis localized distal disease predominated. All ethnic groups suffered the same overall complication rate (55%) which is at variance with the experience of low complication rates in India. The age of onset of ulcerative colitis was related to age at immigration with a mean interval of 11 years. Although in some respects Asian immigrants share the disease pattern of the indigenous population, the observed significant differences could be of importance with regard to pathogenesis.

Blood eosinophilia and ulcerative colitis--influence of ethnic origin.

Blood eosinophilia is an alleged manifestation of ulcerative colitis. To investigate this association and to determine the effect of race, the occurrence of eosinophilia in all 44 Asians presenting between 1968-84 was compared to that in an age- and sex-matched group of indigenous white Caucasian patients presenting over the same period. Nineteen (43%) of the Asians presented with an eosinophilia compared to only 3 Caucasians (P less than 0.0001); similar numbers (14 and 13) in both groups demonstrating transient eosinophilia on occasions during maintenance treatment although not related to clinical relapse. A control group of Asians with other disorders not known to be associated with eosinophilia did not manifest this abnormality on presentation although 3 patients did so transiently during out-patient observation. Eosinophilia is a feature of ulcerative colitis in many Asians possibly due either to an unusual racial response to ulcerative colitis or as a reflection of the underlying pathogenesis of their disease. We have not confirmed earlier suggestions of such a feature in white Caucasians. Eosinophilia occurring during maintenance treatment in both groups may be drug-related.

Ulcerative colitis in West Indian immigrants.

Over a 15-year period six patients (five female) of Afro-Caribbean origin presented with ulcerative colitis from a community of this ethnic extraction numbering 47,000 persons. The disease was characterised by an acute severe presentation, extensively affected bowel, an active course of disease and a propensity for severe hypersensitive reactions to oral sulphasalazine. These findings are of particular implication in the management of ulcerative colitis in West Indians.

Ischaemic colitis and immune complexes during gold therapy for rheumatoid arthritis.

A 35-year-old female with rheumatoid arthritis developed an ischaemic colitis and circulating immune complexes following her fourth injection of sodium aurothiomalate. The immune-complex titres fell rapidly after resolution of the colitis, and a possible association of these immune complexes and the bowel pathology is suggested.

Twice daily slow-release theophylline vs placebo for 'morning-dipping' in asthma.

We report the results of a double-blind control crossover trial of slow release theophylline Nuelin S.A. in improving symptoms of 'morning-dipping' in twelve asthmatic patients. Sleep disturbance was lessened and 'morning-dipping', though not abolished, was improved by 24% (P less than 0.01). Mean peak expiratory flow-rate (PEFR) on waking was significantly higher on active drug (262 l/min vs 226 l/min, P less than 0.001) as were the evening PEFRs (316 l/min vs 285 l/min, P less than 0.05). Seven of the 12 patients achieved 26% improvement in mean PEFR (P less than 0.05) with plasma theophylline levels in the range 28-44 mumol/l. The other five patients improved by 9% (P less than 0.02) with levels in the range 55-66 mumol/l. Mean plasma cyclic AMP 4-6 h after theophylline was significantly higher than with placebo (27.0 nmol/l vs 17.6 nmol/l, P less than 0.05) but significant correlations between cyclic AMP and theophylline levels, and cyclic AMP and PEFR were not demonstrated. A total of nine patients, 33% of those originally recruited for this study, withdrew prior to the double-blind phase because of unacceptable side-effects of theophylline, namely nausea and headache.

Severe acute polyarthropathy associated with levamisole therapy in a patient with Crohn's disease.

A 17 year old Caucasian youth with intractable Crohn's disease developed a severe, acute polyarthropathy during a second course of levamisole therapy. Rapid resolution of systemic symptoms occurred on stopping the drug but full joint recovery was not achieved until five months had elapsed. The relationship of levamisole to Crohn's disease and the underlying mechanisms of the polyarthropathy are discussed.

Predicting rapid and slow response to treatment in acute severe asthma.

The clinical features of patients admitted with acute severe asthma which discriminated between groups who respond rapidly to treatment (attain their maximum PEFR within 3 days), slowly (maximum PEFR after 7 days) and at an intermediate rate (maximum PEFR 3-7 days), have been previously identified in this unit. These included age, atopy, duration of the present attack, the presence normally of day-long wheeze or at least three admissions within the last 12 months, the use of maintenance corticosteroids, the degree of pulsus paradoxus on admission, the rise in PEFR after 6 hours of treatment and the Pao2 after 48 hours. A further study was undertaken to apply these features prospectively to individual asthmatics on admission and again at 6 and 48 hours after the start of treatment to predict the rate of response and to assess the accuracy of these predictions. Fifty-four patients were studied of whom 53 were initially classified as either rapid or slow responders. Forty patients were predicted as rapid responders on admission of whom 14 were reclassified at 6 hours as slow responders. Thirteen patients were correctly classified as slow responders on admission and all had the combined features of maintenance corticosteroids and the presence of day-long wheeze. At 6 hours 51 of the 54 patients (94%) had been correctly classified as rapid or slow responders (P less than 0.0001) as judged by the eventual outcome. Only two patients were incorrectly classified both on admission and at 6 hours. We conclude that these clinical and physiological features allow accurate predictions of the response of an individual to the treatment of acute severe asthma.

Oxprenolol, methyldopa and lipids in diabetes mellitus.

1 Twelve-week courses of oxprenolol and methyldopa were administered in a randomised, double-blind cross over study to ten insulin dependent hypertensive diabetics. 2 Prior to treatment, and at the end of each period of drug administration, fasting levels of high density lipoprotein, triglycerides, free fatty acids and cholesterol were measured. 3 Neither preparation altered levels of high density lipoprotein and cholesterol, but both drugs significantly reduced the free fatty acids. 4 Whereas oxprenolol did not alter triglyceride levels, methyldopa significantly elevated triglycerides above pre-treatment values. 5 Oxprenolol does not appear to influence lipoprotein fractions affecting the relative risks of coronary heart disease, but methyldopa seems to have potentially detrimental effects of triglyceride levels.