Chest pain and non-respiratory symptoms in acute asthma.

The frequency and characteristics of chest pain and non-respiratory symptoms were investigated in patients admitted with acute asthma. One hundred patients with a mean admission peak flow rate of 38% normal or predicted were interviewed using a questionnaire. Chest pain occurred in 76% and was characteristically a dull ache or sharp, stabbing pain in the sternal/parasternal or subcostal areas, worsened by coughing, deep inspiration, or movement and improved by sitting upright. It was rated at or greater than 5/10 in severity by 67% of the patients. A wide variety of upper respiratory and systemic symptoms were described both before and during the attack. Non-respiratory symptoms occur commonly in the prodrome before asthma attacks and become more frequent after onset of the attack. Chest pain is usual during asthma attacks. Although it is benign and self limiting it may cause diagnostic confusion and patient distress.

Electrocardiographic changes following primary blast injury to the thorax.

Profound physiological changes occur following primary blast exposure but the contribution of cardiac arrhythmias is unknown. Thirteen rats, under intravenous anaesthesia, were exposed to a blast wave directed at the thorax (Group II); 10 other animals underwent abdominal blast (Group III) and nine animals acted as controls (Group I). Animals were monitored before, during and after blast exposure. Group II animals demonstrated apnoea, bradycardia and hypotension. No significant physiological changes were seen in Groups I or III. Group II displayed a variety of ECG disturbances, from ventricular extrasystoles to ventricular fibrillation. All abnormalities reverted to sinus rhythm within minutes except in fatally injured animals. These ECG changes probably result from stress wave injury. Significant disturbances might account for some fatalities following primary blast exposure and may exacerbate the triad of apnoea, bradycardia and hypotension. Such observations may have important consequences for the management of blast casualties.

Flitting radiographic shadows: an unusual presentation of cancer in the lungs.

Tumour involvement of pulmonary blood vessels occurs frequently in advanced lung cancer and occasionally may cause pulmonary infarction. A case is reported of diffuse obstruction of pulmonary arteries by cancer in which no primary tumour was found, and which presented as flitting radiographic opacities due to pulmonary infarction.

Clinical management. Fits, faints and funny turns.

Episodes of alteration of consciousness are a common reason for referral to hospital. This article discusses the differential diagnosis with particular emphasis on the first epileptic seizure. It stresses the importance of an accurate witness history and the comparative lack of value of investigations.

How do we manage the first seizure in adults?

This paper reports an audit of the management of a first generalised seizure in a small district general hospital and describes the management policies of 95 general physicians and 82 neurologists. The audit studied 56 patients who presented in 1990-93 after witnessed generalised convulsions without focal neurological signs or previous history of seizures. Their ages ranged from 16 to 89 (mean 38) and 47 of them were men. In 31% alcohol was incriminated in the seizure. Blood tests were done in most patients but gave little useful information. Skull and chest radiographs were taken in fewer patients but were unhelpful. An electroencephalogram was done in 77% but failed to influence management in any, and only 2 of the 50 computed tomography scans performed led to a change in management. Only 21% received the correct advice about driving. A questionnaire sent to 130 general physicians and 109 neurologists sought their policy on the management of patients after a first generalised seizure. Completed forms were received from 95 physicians and 82 neurologists (response rate 74%). Half of physicians and neurologists perform a computed tomogram on all patients while one-third scan patients only above a certain age. Neurologists perform significantly more electroencephalograms (86% vs 65%) while many more physicians order a chest radiograph (73% vs 16%). About 80% of physicians compared with about 30% of neurologists ask for routine blood tests of haematology and biochemistry. Only 4% of physicians and 1% of neurologists routinely start anticonvulsant treatment.

Investigation of pleural effusion: comparison between fibreoptic thoracoscopy, needle biopsy and cytology.

Twenty-eight patients with exudative pleural effusion have been investigated by fibreoptic thoracoscopy, Abrams needle biopsy and pleural fluid cytology. Sixteen patients had previously had negative pleural biopsies and cytology. Twenty effusions were malignant (16 mesothelioma, four metastatic carcinoma), seven were due to nonspecific inflammation and in one case no abnormality was found. The diagnostic yield for all three techniques combined was 85%, for thoracoscopy alone 65%, Abrams biopsy 60% and cytology 45%. In 12 patients presenting without previous investigation all eight malignant effusions were correctly diagnosed by at least one of the techniques with individual sensitivities of 75% for thoracoscopy, 63% for Abrams and 38% for cytology. Of the 16 patients who had previously had negative investigations 12 had malignant effusions, nine (75%) of which were diagnosed by a combination of the techniques. In this group, the individual sensitivities were 58% for both thoracoscopy and Abrams and 50% for cytology. A correct diagnosis of malignancy was made by a combination of needle biopsy and cytology in 75% of patients with previous investigations and 88% of those without. Fibreoptic thoracoscopy added only two diagnoses of malignancy to those obtained by Abrams and cytology. The limitations of the technique render it unsuitable for routine investigation of pleural effusions.

Sarcoidosis in nurses: is there an association?

A retrospective survey of patients with sarcoidosis has revealed a 7.5 times greater number of nurses with the condition than expected. Nurses may be especially susceptible to sarcoidosis.

Laser therapy in 100 tracheobronchial tumours.

One hundred patients with tracheobronchial tumours were treated with the neodymium YAG (yttrium-aluminium-garnet) or argon laser for symptoms of airways obstruction caused by tumour (59 cases), complete collapse of a lung (17 cases), or recurrent haemoptysis (24 cases). Seventy four of them had relapsed or failed to respond to radiotherapy or chemotherapy and all were inoperable. Objective improvement in results of lung function tests or haemoptysis diary charts was seen in 37 patients with airways obstruction (63%), five (29%) with collapsed lung, and 14 (58%) with haemoptysis. Overall, 68 patients had symptomatic benefit and there was objective improvement in 56. Two deaths occurred in 288 treatment sessions both occurring as a result of asphyxia from minor haemorrhage in patients with advanced cylindromas and critical narrowing of the trachea or single remaining bronchus. In suitable patients with intraluminal tumour laser phototherapy is a valuable addition to conventional treatment.

Sarcoidosis in Caucasians, Blacks and Asians in London.

The incidence and clinical features of sarcoidosis were studied in a retrospective survey of 156 patients attending two South London hospitals between 1969 and 1982. Sixty-eight patients were Caucasian, 59 were Black West Indian or African immigrants and 29 were immigrants racially derived from Indo-Pakistan (Asians). The annual incidence of sarcoidosis in the local community in 1977-78 was 19.8 per 10(5) for Blacks and 16.8 per 10(5) for Asians compared with 1.5 per 10(5) for Caucasians. Erythema nodosum was a more common presenting feature in Caucasians than in Blacks (P less than 0.001) or Asians (P less than 0.05). Blacks developed sarcoidosis at a later age than Caucasians (P less than 0.05) and were less likely to present as a chance finding on a chest radiograph (P less than 0.05). They had more widespread extrathoracic disease than Caucasians (P less than 0.001) and were more commonly treated with corticosteroids (P less than 0.001). In the Asians there was a male predominance compared with Caucasians (P less than 0.01). Asians also had more extrathoracic sarcoidosis than Caucasians (P less than 0.001) and more of them were treated with corticosteroids (P less than 0.05). A stage 2 chest radiograph at presentation (P less than 0.05) and skin sarcoidosis (P less than 0.05) were less common in Asians than in Blacks, but otherwise there were no significant differences between the two groups. In this study the incidence of sarcoidosis in Asians approached that in Blacks, while the clinical features were intermediate in severity between Blacks and Caucasians. In both Blacks and Asians the disease was more common, more severe and more extensive than in Caucasians.

Pulmonary effects in man of oral prizidilol hydrochloride (SK&F 92657), a new antihypertensive agent.

The effects on heart rate, blood pressure and pulmonary function of single oral doses of prizidilol hydrochloride (400 mg SK&F 92657) and propranolol (40 mg) were compared with placebo in nine healthy volunteers, in a double blind crossover study. Prizidilol had no effect on heart rate while propranolol caused a significant reduction compared with placebo. Diastolic blood pressure was lowered to the same extent by both prizidilol and propranolol. Propranolol significantly reduced the forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and the maximal expiratory flow at 50% vital capacity (MEF 50). Prizidilol had no effect on flow-volume loop parameters. Effective pulmonary blood flow was not altered by propranolol, but it was significantly increased by prizidilol. Oral prizidilol exerts its hypotensive effect by vasodilatation without reflex tachycardia. It does not cause airways obstruction in healthy subjects.