Showing papers in "Thorax in 1981"

Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease.

Abstract: In 175 patients with chronic obstructive lung disease (157 chronic bronchitic and 18 emphysematous patients) exhibiting moderate to severe airway obstruction (mean FEV1/vital capacity = 40.2 +/- 11.1%), cumulative survival rates calculated by the actuarial method were compared in subgroups according to the initial level of mean pulmonary artery pressure, pulmonary volumes, and arterial blood gases. Patients were catheterised between 1968 and 1972 and were followed for at least five years. The results emphasise the high prognostic value of PAP since survival rates after four and seven years were significantly lower in the subgroup with PAP greater than 20 mmHg (2.7 kPa). Certain other parameters ("driving" pressure across the pulmonary circulation, FEV1 and Paco2) appear to be equally good at predicting survival as PAP in these obstructed patients. The effect of age should be taken into account in prognostic studies such as ours since survival rates were significantly lower in patients over 60 years of age. In 64 patients who underwent a second right heart catheterisation at least three years after the first (average delay: 5.5 +/- 2 years), the prognostic value of changes in PAP, arterial blood gases, and pulmonary volumes was studied but with the exception of Pao2 was unremarkable. Further studies are needed in this field.

Airway responsiveness to histamine and methacholine: relationship to minimum treatment to control symptoms of asthma.

Abstract: We have prospectively examined in 51 patients the relationship between the level of airway responsiveness to histamine and methacholine and the minimum medications required to control asthma. First we determined the least medication that was required to control symptoms so that they did not disturb sleep, were not present on waking, and did not require use of inhaled salbutamol (200 microgram) more than four times daily. When baseline FEV1 was greater than 70% of predicted and when there had been no respiratory infection or allergen exposure for six weeks, histamine and methacholine inhalation tests were carried out on separate days to determine the provocation concentration causing a fall in FEV1 of 20% (PC20). There was a close correlation between the PC20 to the two agents. The patients were grouped into 1, those who required no medication; 2, those who required salbutamol (200 microgram) occasionally but not daily; 3, those who required daily salbutamol; and 4, those who required additional beclomethasone dipropionate. The mean PC20 was highest in group 1 and lowest in group 4; there was a significant difference between each group. The results indicate that airway responsiveness to vasoactive amines is either an important determinant of the severity of asthma and the medication requirements or a consequence of the severity of asthma. They raise the possibility that measurement of responsiveness may be useful in some patients with established asthma to substantiate or question medication needs.

Deposition of pressurised aerosols in the human respiratory tract.

Abstract: Although the use of pressurised aerosol inhalers is widespread, little is known about the actual deposition of the aerosol in the respiratory tract, since this has previously been difficult to measure. We have incorporated Teflon particles (mean diameter 2 micrometer) with aerodynamic properties similar to those of bronchodilator drug crystals into pressurised aerosol canisters. Controlled inhalations by eight patients with obstructive airways disease showed that on average 8.8% of the dose was deposited in the lungs (3.0% in the alveoli and 5.8% on the conducting airways) and 80% in the mouth. These figures are in good agreement with previous indirect estimates of deposition based on metabolic studies. The remainder of the dose was either expired (1.0%) or deposited in the aerosol actuator (9.8%). This method should have wide application for measurement of deposition patterns under various conditions and for assessment of therapeutic effects.

Carbon monoxide in breath in relation to smoking and carboxyhaemoglobin levels.

Abstract: Carboxyhaemoglobin (COHb) levels were studied in 11 249 men. The distribution among the 2613 men who smoked cigarettes was well separated from that in 6641 non-smokers (including ex-smokers). The distribution for 2005 cigar and pipe smokers was intermediate, though some of the highest COHb levels occurred in cigar smokers. Using a COHb cut-off level of 2%, 81% of cigarette smokers, 35% of cigar and pipe smokers, and 1.0% of non-smokers had raised COHb levels. In a subsidiary experiment alveolar air samples were collected from 162 smokers and 25 non-smokers using a simple breath sampling technique. Carbon monoxide concentrations in alveolar breath were highly correlated with COHb levels (r = 0.97) indicating that COHb levels can be estimated reliably by measuring the concentration of carbon monoxide in breath. Alveolar carbon monoxide measurement is thus a simple method of estimating whether a person is likely to be a smoker.

Bronchoscopic management of tracheal lesions using the neodynium yttrium aluminium garnet laser.

Abstract: We report our first clinical trials with the NdYAG laser in the treatment of tracheal and bronchial tumours and stenoses. The beam is carried through a flexible fibre delivering a power of 50 to 90 watts. It can be introduced through the biopsy channel of a standard bronchoscope, or through a fibrescope. Anaesthesia must avoid inflammable gases. In most cases, general anaesthesia was used, and ventilation achieved with a mixture of 50% nitrogen and oxygen, using a modification of the Sanders injector. One hundred and sixty-four cases have been treated in 317 sessions (from one to five sessions per patient). They comprised: 72 cancers, 24 of which had just been diagnosed and had acute respiratory obstruction. In 16, one single session restored the patency of the airway. Forty-eight other cases were recurrent carcinomas after either surgery or radiotherapy, nine of which were caused by cancers of other origin invading the trachea; 21 benign or moderately malignant tumours; 44 iatrogenic stenoses, including 31 narrow ones. Of those 31 cases, 17 had an immediate satisfactory result, but eight recurred; 24 granulomas on bronchial suture lines. There were two deaths not directly related to surgery or anaesthesia. Bleeding was never more than moderate. The main difficulty lies in the critical respiratory condition of the patients, sometimes seen in acute asphyxia, referred to us as a last resort, especially those with carcinomas involving the trachea or main bronchi.

Nasal mucociliary clearance and ciliary beat frequency in cystic fibrosis compared with sinusitis and bronchiectasis.

Abstract: Nasal ciliary function and mucociliary clearance were studied in patients with cystic fibrosis and in three control groups. Ciliary beat frequency and nasal clearance time were measured in groups of 10 subjects with cystic fibrosis, sinusitis and bronchiectasis and age and sex-matched control subjects. Ciliary beat frequency was also measured in normal subjects matched as bronchiectasis controls. Cystic fibrosis patients and their controls, patients with sinusitis, and the bronchiectasis controls did not differ in ciliary beat frequency, but it was slower in the patients with bronchiectasis (p less than 0.05). Nasal mucociliary clearance in cystic fibrosis and bronchiectasis was slower than in the cystic fibrosis controls (p less than 0.001) and in patients with sinusitis (p less than 0.01). The finding of a normal beat frequency in cystic fibrosis cilia studied in vitro together with abnormal nasal mucociliary clearance measured in vivo in the same patients suggests the existence of an abnormality of mucus in vivo. The innate function of cystic fibrosis cilia, as measured in vitro by beat frequency, is normal.

Relationship between asthma and gastro-oesophageal reflux.

Abstract: Twenty patients with bronchial asthma who also had gastro-oesophageal reflux were investigated. The severity of their reflux was graded using symptom score of heartburn and regurgitation and by the following investigations: barium swallow and meal, fibreoptic endoscopy and biopsy, manometry and pH monitoring of the distal oesophagus, and an acid infusion test. Full lung function studies were performed and patients were entered into a double-blind crossover study using cimetidine to control their reflux in order to assess beneficial effects with respect to their respiratory problems. Eighteen patients completed the study. Significant improvements were seen in reflux and night time asthmatic symptoms, both these indices being measured on a scoring system. Home monitoring of peak flow values showed a statistical improvement for th last peak flow reading of the day. Fourteen patients felt that their chest symptoms had significantly improved during the cimetidine period.

Randomised controlled trial of rehabilitation in chronic respiratory disability.

Abstract: A randomised controlled study of the effects of exercise training in 39 patients with chronic respiratory disability was performed Exercise training began with six weeks in a rehabilitation centre and was continued at home The original control group attended the rehabilitation centre after the controlled part of the study The treated group experienced subjective benefit from rehabilitation The 12-minute walking distance increased on average from 523 m to 643 m in the treatment group and from 564 m to 607 m in the control group The treatment effect of 77 m (SE 33 m) was significant at the 5% level Treadmill exercise performance changed little and resting lung function was unaltered after rehabilitation The treatment group maintained most of their improvement seven months later and the original control subjects improved after their rehabilitation The study confirms the beneficial effects of exercise training in the chronically breathless and it suggests that the 12-minute walking distance is a useful index of changes in everyday exercise tolerance

Influence of age on response to ipratropium and salbutamol in asthma.

Abstract: We studied the differential response to inhaled salbutamol and ipratropium of 29 asthmatic patients, 18 intrinsic, 11 extrinsic, using peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), and forced vital capacity (FVC). Thirty minutes after a theoretically maximally bronchodilating dose of salbutamol (400 microgram) or ipratropium (80 microgram), second doses frequently caused further bronchodilatation. We suspect that second doses may reach bronchi untouched by the first inhalation. Analysis of variance showed a powerful intrinsic versus extrinsic effect, and there were clearly differences between patients in their response to treatment (patient versus drug interaction) but these differences were not removed by dividing the patients into intrinsic and extrinsic groups. Results for the group as a whole favoured salbutamol, but examination of individual results by a pattern-recognition technique showed ipratropium equally effective in eight patients and more effective in three. All patients with a definite predominant salbutamol response were less than 40 years old. The response to salbutamol declined significantly with age, whereas that to ipratropium did not. In general in patients aged less than 40 years salbutamol is the drug of choice. With advancing age, and the apparent decline of beta-adrenergic responsiveness, the initially comparatively small response to ipratropium becomes relatively more important and may predominate. In older patients ipratropium, or continued therapy with both drugs, may be preferable.

Causes of pneumonia presenting to a district general hospital.

Abstract: The incidence of bacterial, viral, mycoplasma, and rickettsial infections has been assessed prospectively in 210 adult patients with pneumonia who presented to a district hospital over a six-year period. One hundred and thirteen infective agents were detected in 103 patients. The agent most frequently detected was Mycoplasma pneumoniae which accounted for 30 infections. A bacterial pathogen was found in 43 patients. Streptococcus pneumoniae was the most common of these (24 patients); Staphylococcus aureus (eight), Haemophilus influenzae (four), Klebsiella spp (three), and Legionella pneumophila (three) were all less common. Chlamydial or rickettsial infections (Psittacosis or Q fever) were detected in nine patients. Viral infections were found in 31 patients (22 influenza A, four influenza B, two parainfluenza, and three respiratory syncytial virus). There were 10 patients in whom more than one pathogen was identified. In 107 patients no pathogens could be identified. Seventy-five per cent of these patients had either received antibiotics before entering hospital, or were unable to produce any sputum for culture. The incidence of bacterial pneumonia has probably therefore been underestimated. Nevertheless this survey does emphasise the importance of M pneumoniae as a pathogen in patients with pneumonia presenting to hospital.

Tidal expiratory flow patterns in airflow obstruction.

Abstract: Tidal expiratory flow pattern was analysed in 99 subjects with a view to assessing it as a quantitative measurement of airflow obstruction. Fifteen normal volunteers, nine patients with dyspnoea referred for investigation in whom airway resistance was within normal limits, 24 patients with restrictive lung disorders, and 51 patients with airway obstruction were studied. The expiratory flow pattern against time had a quadrilateral configuration in airway obstruction, which differed from the more sinusoidal form that is seen in subjects without airflow obstruction. The rapid rise to tidal peak flow was analysed in two ways, percentage of volume expired at tidal peak flow (delta V/V) and percentage of expiratory time to tidal peak flow (delta t/t). Both these indices correlated significantly with conventional measurements of airway obstruction. The pattern of expiratory flow in airflow obstruction during quiet breathing resembles that of a forced expiratory maneuver at similar lung volumes. In some cases this may be caused by dynamic compression occurring during tidal breathing. In others, the pattern may result from the static recoil of the lung being permitted to drive flow freely in expiration, rather than being braked by postinspiratory contraction of inspiratory musculature.

A calcium antagonist, nifedipine, modifies exercise-induced asthma.

Abstract: In eight extrinsic asthmatic subjects (age range 16-38 years) there was a significant reduction (p less than 0.01) in the severity of bronchoconstriction after a treadmill exercise test performed 30 minutes after nifedipine 20 mg sublingually. The maximum fall in peak expiratory flow after exercise was 36.0 +/- SEM 5.3% compared with a maximum fall of 56.5 +/- 4.1% after matched placebo capsules when given in double-blind randomised manner on separate days. There was no significant resting bronchodilation or change in blood pressure or heart rate after nifedipine. there was a significant rise in venous plasma histamine during exercise with placebo (6.1 +/- 0.8 to 13.5 +/- 3.5 nmol/l, p less than 0.01) but no significant increase with nifedipine (4.6 +/- 0.6 to 4.7 +/- 0.6 nmol/l) suggesting that nifedipine inhibits the release of mast cell mediators. The dose of inhaled histamine which provoked a 20% fall in peak expiratory flow was also significantly higher (p less than 0.05) with nifedipine (1.5 +/- 0.31 mg/ml) compared with placebo (2.7 +/- 0.63 mg/ml), indicating that there is a small inhibitory effect on bronchial smooth muscle contractility. Nifedipine is a potent antagonist of calcium ion influx in smooth muscle and secretory cells, and these studies suggest that it may inhibit release of mast cell mediators and reduce bronchial smooth muscle contractility in asthma.

Circulating catecholamines in exercise and hyperventilation induced asthma.

Abstract: Plasma noradrenaline, adrenaline, and cyclic 3'5' AMP (cAMP) were measured in seven asthmatic patients with known exercise-induced bronchospasm and six matched non-atopic control subjects during a standard treadmill exercise test and then during matched isocapnic hyperventilation. Normal subjects showed a 5.5 fold rise in noradrenaline and a 3.2 fold rise in adrenaline during exercise compared with a 2.1 fold rise in noradrenaline and no significant rise in adrenaline in asthmatics who all developed bronchoconstriction after exercise (mean fall in peak flow rate 28.4 +/- 5.8%). Plasma cAMP rose 1.4 fold in controls but showed no significant rise in asthmatics. This reduced sympatho-adrenal response to exercise in asthmatics is difficult to explain. The failure of circulating catecholamines to rise and stimulate beta adrenoceptors on the mast cell may facilitate the release of bronchoconstrictor mediators. Matched hyperventilation produced bronchospasm in asthmatics (mean fall in peak flow rate 29.0 +/- 4.4%) but no change in catecholamines in either group suggesting that circulating catecholamines have no direct role in exercise-induced bronchospasm but may play a permissive role via the mast cell.

The pulmonary clock.

Abstract: s are invited in this area. They should not exceed 250 words in length and should be typed double spaced, including title, first and last names of all authors, and the institution where the work was performed. Please designate the address for correspondence and identify who will present the paper. Abstracts should be submitted to the Scientific Program Chairman, Third World Congress for Bronchology, American College of Chest Physicians, 911 Busse Highway, Park Ridge, Illinois 60068 USA. The deadline for abstracts is 1 September 1981. Further information about the meeting can be obtained from the same address.

Contractile properties and fatigue of the diaphragm in man.

Abstract: We studied the pressure developed by the diaphragm in response to stimulation of the phrenic nerve in the neck, in three normal men. When the phrenic was electrically stimulated at increasing frequencies the diaphragm responded by increasing transdiaphragmatic pressure to give a frequency-pressure curve similar to the frequency-force curve for other skeletal muscles. The subjects than breathed through an inspiratory resistance for as long as possible and the frequency-pressure curve was repeated. It was found that the diaphragm developed low frequency fatigue, in the same way as previously described for other muscles. We conclude that the diaphragm has contractile properties similar to these of other skeletal muscles. Low frequency fatigue of the diaphragm could contribute to respiratory failure in patients with lung disease.

Immunohistochemical study of collagen types in human foetal lung and fibrotic lung disease.

Abstract: Highly purified type-specific anti-collagen antibodies (prepared in animals to types I, II, III, and IV bovine collagen) were used in an indirect immunofluorescence method for the study of human lung collagen. The tissue localisation of each collagen type, and the apparent type I:III collagen ratio was assessed in normal foetal and adult lung and in fibrotic lung lesions. In the latter, the relationship of the findings to the natural history of the lesion was considered. This method was compared with routine connective tissue stains. The following observations were made. (1) Foetal lung in the canalicular phase of development proved a useful substrate for validating and standardizing the procedure. (2) Collagen fluorescence was more sensitive than connective tissue stains in detecting collagen in foetal tissues and sites of early fibrosis. (3) On the basis of collagen-type fluorescence, two distinctive patterns of fibrosis were recognised. Areas of mature collagen surrounding vessels and bronchi and in established scar tissue, for example in asbestotic pleural plaques, were virtually exclusively type I collagen. By contrast, areas of early active fibrosis like sarcoid nodules and organising pneumonia, which usually contained variable numbers of fibroblasts and chronic inflammatory cells, were characterised by an increased proportion of type III collagen and a greater intensity of both types I and III collagen fluorescence. The possible significance of this change in type III:I collagen ratio is discussed. Determination of the stage of fibrotic lesions by this method might have applications in the prediction of disease progression, and influence management of some conditions.

Cryptogenic obliterative bronchiolitis in adults.

Abstract: Patients referred for assessment of severe chronic airflow obstruction over a three-year period were reviewed, and when all smokers and ex-smokers, those with asthma, chronic bronchitis, emphysema, and other specific pulmonary diagnoses were excluded 10 patients remained. Their clinical, lung function, and bronchographic features were consistent with obliterative bronchiolitis. Nine were women, five had rheumatoid arthritis, and five had survived for more than 10 years after first symptoms. Obliterative bronchiolitis has not previously been considered as a cause of chronic airflow obstruction but the distinctive features suggest that it is a true disease entity.

Hypothalamic-pituitary dysfunction in respiratory hypoxia.

Abstract: Eight hypoxic male patients with stable chronic obstructive airways disease were submitted for combined anterior pituitary function testing. All subjects showed normal growth hormone and essentially normal cortisol responses to adequate hypoglycaemia, two subjects showed delayed responses of thyroid stimulating hormone to administered thyrotrophin releasing hormone and all had basal prolactin levels within normal limits. Basal levels of luteinising hormone were significantly lower than in the group of age-matched controls (p less than 0.02) but there was a normal increment after the injection of gonadotrophin releasing hormone. Basal levels of follicle stimulating hormone were significantly lower than in the controls (p less than 0.01), and there was also a reduced response from the pituitary after injection of gonadotrophin releasing hormone (p less than 0.01). Resting levels of the thyroid hormones thyroxine and tri-iodothyronine were normal while the expected subnormal testosterone level was observed (p less than 0.05). These results show that hypoxia can produce abnormalities of hypothalamic-pituitary function and that these are primarily located in the hypothalamic-pituitary-testicular axis.

Allergic bronchopulmonary fungal disease without clinical asthma.

Abstract: During a retrospective survey of patients with pulmonary shadows and blood eosinophilia between the years 1965 and 1980, 42 patients were found with allergic bronchopulmonary fungal disease. Eleven of these had no clinical evidence of asthma. Three of these 11 had hypersensitivity to fungi other than Aspergillus sp. In the absence of asthma there was some difficulty in making a diagnosis, particularly where collapse of the upper lobe occurred in middle-aged or elderly patients and bronchogenic carcinoma was presumed responsible. We suggest that the term allergic bronchopulmonary aspergillosis be replaced by allergic bronchopulmonary fungal disease, the diagnosis be considered in patients with lung disease and blood eosinophilia even in the absence of asthma, and a wider range of fungal allergens be used for skin and precipitin tests.

Present outlook in bronchiectasis: clinical and social study and review of factors influencing prognosis.

Abstract: One hundred and sixteen patients with proven bronchiectasis diagnosed at least five years previously were studied to determine the clinical outcome, change in pulmonary function, and degree of social disability. Twenty-two patients had died and the mean duration of follow-up in the survivors was 14 years. The patients who died were characterised by a poorer initial ventilatory capacity than the survivors and cor pulmonale was present in 37% at the time of death. The survivors showed a tendency for improvement in symptoms whether treated surgically or medically. Thirty per cent were better than at diagnosis while only 11% were worse. Measurements of FEV1 and FVC were made at diagnosis and at review, mild airways obstruction being the predominant abnormality. The change in pulmonary function was expressed as the decline in FEV1 in ml/yr. The decline in FEV1 was no greater than expected in 80% of patients and in a further 15% was of the order seen in cigarette smokers with mild airways obstruction. Poor ventilatory capacity was therefore not an important limitation in these patients. Of the survivors 77% had a good work record with less than two weeks loss of work annually from chest illness. The spouses of all married patients were interviewed at home by a trained social worker. Fifty per cent reported no social problem but 46% of spouses found the patient's cough distasteful and 29% of couples had experienced difficulties with normal sexual life. Seven per cent of the patients were severely disabled. While the overall prognosis of our patients was good a minority still have severe physical and social problems as a result of bronchiectasis.

Limitations of measurement of transdiaphragmatic pressure in detecting diaphragmatic weakness.

Abstract: Intrathoracic (oesophageal), intra-abdominal (gastric), and transdiaphragmatic (Pdi) pressures were studied in 20 untrained, healthy subjects during a full inspiration and repeated maximal static inspiratory efforts. The pattern of pressure generation during these two types of respiratory manoeuvre was highly reproducible in each subject. By contrast, it varied over a wide range among individuals. In particular a substantial number of subjects naturally had a strong recruitment of their intercostal and accessory muscles and thus, low Pdi values, during both slowly performed and forceful inspiratory manoeuvres. These observations make it clear that Pdi values, as usually obtained, are commonly open to misinterpretation. For this approach to ensure a reliable assessment of diaphragmatic function and detect diaphragm weakness adequately, it appears essential either to monitor the abdominothoracic configuration or to standardise the pattern of respiratory muscle contraction.

Arterial plasma histamine levels at rest, and during and after exercise in patients with asthma: effects of terbutaline aerosol.

Abstract: Eight asthmatic patients and two normal subjects performed two identical exercise tests 140 minutes apart (first test preceded by inhalation of saline and the second by terbutaline sulphate). A ninth asthmatic patient exercised twice after placebo 40 minutes apart. Arterial plasma levels of histamine and cyclic AMP, expiratory flow rates and volumes were measured at rest and during and after exercise. After the first test the mean +/- SEM fall in PEFR was 45.2 +/- 2.6%. In five asthmatics there was an increase in plasma histamine (mean +/- SEM 14.8 +/- 3.3 pmol ml-1) coinciding with exercise-induced asthma (EIA). Histamine levels returned to pre-exercise values within 30 minutes. After terbutaline these five patients had histamine levels greater than those observed before, during, or after the first test. This effect may have been the result of changes in pulmonary microcirculation. After the second test the levels decreased indicating no further release of histamine in response to exercise. No EIA occurred in these patients after terbutaline. The other patients and the two normal subjects had little or no change in histamine throughout the study. The one patient in whom exercise was repeated after placebo demonstrated less histamine release and less EIA after the second test.

Is cough as effective as chest physiotherapy in the removal of excessive tracheobronchial secretions

Abstract: The relative value of chest physiotherapy (including cough) and cough alone for the removal of excessive tracheobronchial secretions has been assessed in six patients with stable chronic obstructive lung disease. After labelling with inhaled radioactive tracer particles, clearance of secretions from selected central and peripheral lung regions was followed with a gamma camera linked to a computer. Cough alone and chest physiotherapy (including cough) were equally effective in the enhancement of central lung clearance. Physiotherapy but not cough along accelerated peripheral lung clearance (p less than 0.05). Sputum yield was greater during physiotherapy than during cough (p less than 0.05). These findings confirm the value of chest physiotherapy and high-light the limitation of cough in patients with excessive tracheobronchial secretion and impaired mucociliary clearance.

Non-malignant asbestos pleural disease.

Abstract: During a 10-year period (1970-79) all patients in Uppsala County found to have pleural changes related to asbestos exposure were followed. The lesions could be divided into four types: parietal pleural plaques, exudative pleurisy, thickening of the visceral pleura, and progressive pleural fibrosis. There were 891 cases. The most common type was parietal plaques, which was seen in 827 patients, some of whom later developed other changes. In 22 types exudation was proven radiologically, and in 84 more cases obliteration of the costo-phrenic angle was seen. The exudations almost all had a benign course, despite sometimes fairly large and bloody effusions. They were practically all symptom-free, being a surprise finding on chest radiography. Thickening of the visceral pleura can only be seen radiologically in the fissures and occurred in a few cases in addition to other changes. In a small group of more heavily exposed individuals, a progressive pleural fibrosis developed, sometimes after an initial effusion.

Comparison of inhaled and intravenous terbutaline in acute severe asthma.

Abstract: In patients with acute severe asthma, 5 mg of terbutaline by inhalation and 500 microgram intravenously in divided doses both produced equally effective but not maximal bronchodilatation. There was no difference in the production of side-effects. These results support the view that inhaled therapy can be as effective in patients with acute severe asthma as injected treatment. In view of the risks of intravenous treatment, especially using high doses, inhaled bronchodilator therapy would seem advisable as initial treatment.

Allergic bronchopulmonary disease caused by Curvularia lunata and Drechslera hawaiiensis.

Abstract: Three patients who developed bronchoceles caused by fungi other than Aspergillus sp are described. The first patient presented for investigation of a lesion at the right hilum on chest radiograph and a raised blood eosinophil count. A bronchogram showed complete block of the apical segmental bronchus which at operation was shown to be caused by inspissated material. The second patient was investigated because of a cough productive of plugs of sputum and irregular opacities in both upper zones on chest radiograph and a raised blood eosinophil count. This only cleared after one month on high dose oral prednisone therapy. The third patient with a previous history of left lingular pneumonia and bronchiectasis of the lingular segment of the left upper lobe was investigated three years later for right basal shadowing and a raised blood eosinophil count. The radiograph cleared after one month on high dose oral prednisone treatment. The aetiological agents in these cases were dematiaceous hyphomycetes, fungi ubiquitous in nature, and also agents of plant disease. The causal fungi, Curvularia lunata and Drechslera hawaiiensis, have on a few occasions been reported as causing human disease but in cases quite dissimilar to the three reported here. Septate branching dematiaceous mycelium was consistently seen in the clinical material and isolated from successive sputum specimens from each patient. Immunodiffusion tests from the third patient gave positive results for both fungi. Intraperitoneal inoculations of C lunata and D. hawaiiensis into Swiss white mice proved the pathogenicity of these isolates.

Association of HLA B8 with spontaneous resolution in sarcoidosis.

Abstract: HLA may influence the natural history of some diseases. HLA frequencies have been compared in 164 healthy control subjects, 50 patients with sarcoid lung fibrosis, and 37 patients with sarcoidosis that resolved spontaneously. B8 was increased significantly in the resolved group compared to both healthy control subjects (p less than 0.001) and the fibrotic group (p less than 0.01). The results support the findings of other investigators, and are consistent with the hypothesis that inherited host factors, perhaps related to immune response, influence the clinical expression of sarcoidosis.

Ultrastructural localisation of lactoferrin and glycoprotein in human bronchial glands.

Abstract: The distribution of lactoferrin and glycoprotein in human bronchial glands has been studied by electron microscopy using an immunoperoxidase method to stain the former and a periodic acid-chromic acid-silver methenamine sequence for the latter, each applied to ultrathin Epon sections. The distribution of lactoferrin corresponds to that of lysozyme. Lactoferrin and lysozyme are both confined to serous acini where the granules show a variable pattern of staining. Some serous granules are filled uniformly with lactoferrin, some lack lactoferrin in a small central core or a thin peripheral rim, and some are completely devoid of lactoferrin. Glycoprotein is present in all mucous granules but only certain serous granules. The latter may be filled uniformly with glycoprotein or glycoprotein may form a thin peripheral coat about centrally located lactoferrin and lysozyme. An electron-dense central core found in some serous granules contains neither glycoprotein, lactoferrin, nor lysozyme.

Mechanical inefficiency of the thoracic cage in scoliosis.

Abstract: The mechanism of impairment of ventilatory function in idiopathic scoliosis has been studied in 23 children, all girls, and compared with 27 normal children and 24 normal young adult females. The vital capacity, FEV 1, gas transfer factor, and the maximum static expiratory airway pressure were all significantly reduced. total lung capacity and the maximum inspiratory pressure were lower than in the normal subjects, but the difference was not significant. Restriction of thoracic cage movement by a belt showed that the thorax in the children with scoliosis was as mobile as in the normal subjects. The results are explained in terms of the characteristic deformity in scoliosis which causes one hemi-thorax to become relatively smaller than the other. It is concluded that this causes an inherent mechanical inefficiency of ventilation which is likely to contribute to respiratory failure in these subjects.