Effect of PaO2 and social circumstances on outcomes in out-patient treatment of COPD exacerbations.

The current British Thoracic Society guidelines on COPD recommend that patients with COPD exacerbations should be admitted to hospital if they either have partial pressure of arterial oxygen of <7.0 kilopascals (kPa) or if they are living alone. This study was carried out to see if either of these factors have any effect on the outcome in patients presenting with COPD exacerbation in the setting of well established COPD services. This study was to see if patients with PaO2 < 7.0 kPa or those living alone were readmitted more frequently or had higher mortality than other patients discharged through the same scheme. A retrospective analysis was carried out on 1078 patients with acute exacerbation of COPD who were discharged home through Wigan "hospital at home" scheme in the period between November 1999 and February 2004 prior to the introduction of the new guidelines. This study found that there was no statistically significant difference in the rates of readmissions in patients with low PaO2 or those living in adverse social circumstances compared to other groups of patients. The number of patients dying in this period was too small to analyse with adequate power. This study indicates that such patients can be safely managed at home in the context of well established COPD services.

Randomised placebo-controlled crossover trial on effect of inactivated influenza vaccine on pulmonary function in asthma.

BACKGROUND: Despite current recommendations, many people with asthma do not receive annual vaccination against influenza, partly because of concern that vaccine may trigger exacerbations. Colds can trigger exacerbations, which may be mistaken for vaccine-related adverse events. We undertook a double-blind placebo-controlled multicentre crossover study to assess the safety of influenza vaccine in patients with asthma, with allowance for the occurrence of colds. METHODS: We studied 262 patients, aged 18-75 years, who recorded daily peak expiratory flow (PEF), respiratory symptoms, medication, medical consultations, and hospital admissions for 2 weeks before the first injection and until 2 weeks after the second injection. Order of injection (vaccine and placebo) was assigned randomly. There was an interval of 2 weeks between injections. The main outcome measure was an exacerbation of asthma within 72 h of injection (defined as a fall in PEF of >20%). FINDINGS: Among 255 participants with paired data, 11 recorded a fall in PEF of more than 20% after vaccine compared with three after placebo (McNemar's test p=0.06); a fall of more than 30% was recorded by eight after vaccine compared with none after placebo (binomial test p=0.008). However, when participants with colds were excluded, there was no significant difference in the numbers with falls of more than 20% between vaccine and placebo (six vs three; binomial test p=0.51), although the difference for PEF decreases of more than 30% approached significance (five vs none; binomial test, p=0.06). This association was confined to first-time vaccinees. INTERPRETATION: Our findings indicate that pulmonary-function abnormalities may occur as a complication of influenza vaccination. However, the risk of pulmonary complications is very small and outweighed by the benefits of vaccination.

Etoposide compared with the combination of vincristine, doxorubicin, and cyclophosphamide in the treatment of small cell lung cancer.

One hundred and three patients with small cell lung carcinoma were stratified according to stage of disease (47 limited disease, 56 extensive disease) and then randomised to receive etoposide 300 mg/m2 alone for two days or a combination (VAC) of vincristine 1 mg/m2, doxorubicin (Adriamycin) 50 mg/m2, and cyclophosphamide 1000 mg/m2. The drugs were given at three week intervals. Patients were assessed after three cycles of treatment and continued with the same regimen if in complete remission and with the alternative regimen if in partial remission; they were withdrawn if the disease had progressed. Twenty four patients (23%) achieved complete remission and this occurred more often when patients were receiving VAC (19 of 82) than etoposide (5 of 75). There was no difference, however, in overall survival between those initially treated with etoposide and those having combination chemotherapy, whether for limited disease (both 8 months) or extensive disease (7 and 5.5 months). Toxicity was less with etoposide. Survival was disappointing, especially with limited disease, even in patients who showed a complete response to treatment.

Comparison of a combination of fenoterol with ipratropium bromide (Duovent) and salbutamol in young adults with nocturnal asthma.

In a randomized, double-blind, double-dummy, crossover study consisting of two 1-month periods with a 2-week 'run-in' we compared the effects of a combination of fenoterol with ipratropium bromide (Duovent, Boehringer Ingelheim) and salbutamol administered by standard metered dose inhalers in conventional dosage in young adults with nocturnal asthma. Seventeen patients were studied, all were aged between 19 and 35 years and showed 'morning dip' associated with nocturnal symptoms of cough, wheeze and breathlessness. They recorded morning and evening peak flows and symptoms of nocturnal asthma on diary cards. Over the 10 weeks of the study there was no difference between Duovent and salbutamol in any of the parameters measured.

Ifosfamide, etoposide, and thoracic irradiation therapy in 163 patients with unresectable small cell lung cancer.

One hundred sixty-three patients with small cell lung cancer were treated with six courses, at 3-week intervals, of ifosfamide (5 g/m2) with mesna and etoposide. Thoracic radiotherapy was delivered to the limited stage (LS) patients. The complete response rate (CR, determined clinically and radiologically) was 76% for the 78 LS patients with a further 14% partial response (PR). The majority of the CRs were confirmed on a follow-up bronchoscopy. The CR rate was 27% for extensive stage (ES) patients with another 38% undergoing a partial response. The median survival for LS patients was 11 months, (16 months for CR confirmed by rebronchoscopy) and 8 months for ES patients. The 2-year actuarial survival for LS patients is 27%, follow-up ranges from 12 months to 30 months with a median of 22 months. Toxicity was not severe for the patient population, of whom only 20% had a good performance status before chemotherapy. Parental antibiotics were required on 4% of all 844 chemotherapy courses and 12% of courses were delayed due to side effects. The majority of responses occurred within the first two courses of chemotherapy and there was a corresponding improvement in the patients' symptoms and performance status. The regimen produced rapid tumor response with corresponding improvement in symptoms without marked toxicity and allowed further treatment development.

Diffuse alveolitis on a small dose of penicillamine.

A 60-year-old man with seropositive rheumatoid arthritis developed rapidly progressive dyspnoea and bilateral pulmonary infiltrates on short exposure to 50 mg penicillamine daily. He made a satisfactory recovery following cessation of penicillamine therapy and the addition of prednisolone. This case has been reported to the Committee on Safety of Medicines and we would like to emphasize that the possibility of penicillamine-induced lung disease should be recognized, even on a small dose of short duration.

The disease spectrum in a Maldivian (Adduan) population.

The changing pattern of disease in the population of Addu Atoll, Republic of Maldives, Indian Ocean, is reviewed. Over 30 years the population has nearly trebled with an increasing percentage in those under the age of 15 years. Diarrhoeal diseases and respiratory infections are now the dominant health problems where previously malaria and filariasis were major causes of morbidity. These problems are discussed against a background of changing financial resources and standards of health care.

The spectrum of liver disease in the United Arab Emirates.

Of 209 patients with liver disease attending the Al Qassimi Hospital, Sharjah, 172 were suffering from acute hepatitis. The proportion harbouring the hepatitis B surface antigen was unknown. Of the remainder, 10 were suffering from chronic active hepatitis, five from primary hepatoma and six from cirrhosis. Infection with hepatitis virus B was regarded as of aetiological significance in three cases of chronic active hepatitis, four of primary hepatoma and two of cirrhosis.

Bronchial asthma in the southern Maldives.

A whole population survey was performed in Addu Atoll, southern Maldives to establish the prevalence of bronchial asthma. Assessments of atopic eczema, allergic rhinitis, conjunctivitis and intestinal infection were made, and serum specific IgE titres to a number of allergens were measured. Asthma is a common condition in the southern Maldives, and there is no evidence that the IgE produced by intestinal helminths prevents the condition.