Improved management of congestive heart failure. Use of continuous ambulatory peritoneal dialysis

Four patients suffering from end-stage congestive heart failure (CHF) refractory to conventional medical treatment were treated with continuous ambulatory peritoneal dialysis (CAPD) for one to 21 months. All four patients improved from class IV CHF to class II, as defined by the New York Heart Association, and experienced a definite improvement in their sense of well-being. Three patients, women between 42 and 59 years of age with contraindications for heart transplantation, were all professionally rehabilitated. One 21-year-old patient received CAPD until he underwent a successful orthotopic heart transplantation. We thus propose CAPD as an effective treatment for end-stage CHF refractory to conventional medical treatment.

[Transitory tetraplegia following high-pressure ventilation]

We present the case of a 22-year-old asthmatic woman, who had undergone high-pressure servo-ventilation as part of the therapy of an otherwise untreatable asthmatic attack. Ventilation-pressures reached peaks of 80 mg H2O while under relaxation and sedation arterial blood pressure fell to 50/30 mm Hg. Treatment was complicated by pulmonary ruptures, pneumothorax and massive cutaneous emphysema. After successful completion of this treatment phase (day 14), the patient was allowed to regain consciousness and was found to be in a subtotal tetraplegic state: muscles of the neck, shoulders and left leg were slightly less atonic than others. Facial muscles, different qualities of sensitivity, intellectual functions and sense organs did not seem to be afflicted. Restitution of the tetraplegia was complete by day 50 of treatment, a neurological follow up six months after discharge from hospital showed no residual deficit. We hypothesize that the extreme ventilation-pressures together with the decrease of arterial blood-pressure have impaired the blood-flow in the system of the anterior spinal arteries. Together with concordant oedema this effected a localized dysfunction mainly of the ventral medullary areas corresponding to the functions of the anterior spino-cortical tract. Diagnostically we do not fully exclude steroid myopathia, but think in this case the cumulated steroid doses were too small and the course of remission indicates a localized haemodynamic lesion.

Calcium-channel-blocking agent in the treatment of acute alcohol withdrawal--caroverine versus meprobamate in a randomized double-blind study

We present a randomized double-blind study on the efficacy of caroverine in the treatment of alcohol withdrawal symptoms. The group B Ca2+ channel blocking agent caroverine was tested against meprobamate in inpatient treatment of alcohol withdrawal. Patients of both groups were similar in age, weight, duration of drinking, ingested quantities of alcohol and intensity of withdrawal symptoms in both groups. The symptoms were quantified daily by Syndromkurztest (SKT), Nurses' Observation Scale for Inpatient Evaluation (NOSIE), NGI; the Webster scale was applied to rate tremor, speech and coping. Duration of study was scheduled for 5 days after which other medication, e.g., levopromazine was applied if needed. As caroverine is registered and used as a spasmolytic drug in Austria, patients' verbal consent was sufficient. In both compounds we registered no difference of clinical efficacy, though caroverine presented less sedative side effects. This may be an important factor in the treatment and management of alcohol withdrawal symptoms. Dose ranges were 120 mg/day vs. 2,400 mg/day of caroverine and meprobamate, respectively. Thus, drug loading and metabolism can be thoroughly reduced by the application of caroverine--another important point in treatment of alcoholism. In 4 cases of manifest delirium tremens the infusional application of caroverine was openly tested with dose ranges of 2.5-5.0 mg/kg (24 h). Clinical effects were estimated to be similar with oral application as was therapeutic efficacy. This novel indication of a group-B Ca2+ channel blocker presents an interesting feature, which seems to warrant further investigation.

The preventive effect and duration of action of nedocromil sodium and cromolyn sodium on exercise-induced asthma (EIA) in adults

Nedocromil sodium, 4 mg, from a metered-dose inhaler, cromolyn sodium, (cr) 20 mg, from a Spinhaler, and placebo (pl) were compared in their efficacy and duration of action in preventing exercise-induced asthma. Twelve patients with asthma performed treadmill exercise tests 20 minutes, 2 hours, and 4 hours after a single dose of drug in a double-blind, crossover trial. Both active drugs were significantly better than pl at 20 minutes. Two hours after drug administration, only cr was significantly different from pl. The direct comparison between nedocromil and cr demonstrated no significant difference on FEV1, and the only significant difference was with forced expiratory flow between 25% and 75% of vital capacity at 2 hours. It is concluded that at these clinically recommended doses, both drugs are equally effective in preventing exercise-induced asthma with cr possibly having a somewhat longer duration of action.

Findings with cis-Z-clopenthixol in the treatment of acute mania and schizophrenia

The authors report the results of an open clinical trial with Cis(Z)-Clopenthixol (Cisordinol), the isolated Cis-isomer of the Clopenthixol racemate (Sordinol). The drug was applied to 18 patients with severe forms of manic or schizophrenic disease, diagnosed according to ICD 9. The compound was applied intravenously or orally, daily doses ranging from 10-160 mg. For the duration of the study (6 weeks) the patients were repeatedly rated with the CGI, BPRS or IMPS (abbreviated version), and several hematological and enzyme patterns, cardiac, renal function and electrolytes were monitored, as was the FFA. Due to the relatively small number of patients in relatively heterogeneous diagnostic composition, a number of items rated failed to reach statistical significance. The CGI showed a good therapeutic effect with a minimal incidence or severity of side effects. BPRS and IMPS documented an impressive decline in formal thought-disorders, agitation, logorrhea and tenseness. The sedative effects of the drug were slight and of short duration, anti-Parkinson medication was necessary in more than 50% of the patients studied. The results of the study show a good efficacy of the drug in manic and schizophrenic disorders, Cisordinol being well tolerated intravenously. The range of doses administered is approximately 50% of the dose-range of the parent-drug (Sordinol).

Beta 2-microglobulin: a prognostic parameter for graft survival after renal transplantation

The determination of beta 2-microglobulin has recently been proposed as a promising diagnostic method to monitor the state of renal allografts. Elevated levels of beta 2MG in the serum and/or urine allow the substantiation of the diagnosis of an acute graft rejection and are helpful in distinguishing acute tubular necrosis from a rejection reaction. In this paper, the usefulness of beta 2MG serum levels is evaluated, not only during the immediate post-operation phase but also for the long-term prognosis of renal allografts. The immunosuppression treatment included methylprednisolone and azathioprine in all the presented patients. The data indicate that a rapid normalization of beta 2MGSL within 6 days, even if the decrease is interrupted by re-elevation due to acute rejection episodes or inflammatory diseases, represents a good long-term prognosis for kidney allografts.

[Clinical early symptoms and CT findings in Fahr syndrome]

We present the results of an investigation on initial symptomatology of patients with bilateral, symmetrical intracerebral calcification of the basal ganglia (Fahr's syndrome). 62 patients, who because of various neurological or psychiatric symptoms or other reasons were referred to cranial computer-tomography, revealed clear manifestation of Fahr's syndrome. In these cases estimations of the volume of the opaque bodies were made, based on computer-integrated programmes (SO-MATOM D2). In 9 cases there was a history of thyroidectomy, on average 25 years previously. As a rule patients were referred in the age range between 40 to 60 years, those who had undergone thyroidectomy being on average somewhat older than the others. As presenting symptoms extrapyramidal syndromes, apoplexias, cephalea, affective organic alterations, alcoholism and dementia were noted. Cerebral localisation of bilateral, symmetrical calcification was most frequent in the pallidum, though this localisation may be responsible for numerous different neuropsychiatric symptoms. The dimensions of the opaque structures can be very greatly. Symptomatology seems to be practically independent of either cerebral localisation or volume, except that greater volumes of calcification seem to cause more pronounced neurological (extrapyramidal) symptomatology and dementia. The time-span between manifestation of the initial symptoms and diagnosis was shorter in neurological syndromes than in psychiatric cases. Like earlier workers, we found a high incidence (21%) of organic affective syndromes as an initial manifestation of Fahr's syndrome.

[Value of EEG in parathyroid gland disorders and/or symmetrical calcinosis of the basal ganglia (Fahr syndrome). Review of the literature with personal cases]

We evaluated the diagnostic value of EEG tracings in cases of non-arteriosclerotic symmetrical calcification of the basal ganglia (Fahr's syndrome). The group of 41 tracings was composed of probands and patients of a family with hereditary occurrence of the syndrome and other patients where the characteristic calcifications were discovered by chance or in CT screening of persons who had undergone thyroidectomy. The comparison of our EEG results with those presented in the relevant literature yielded no discernable diagnostic value of the investigation. All kinds of alterations of central electrophysiological activity seem possible, at least in our collection, similar to previous findings, but no characteristic EEG pattern associated with Fahr's syndrome was seen. Only a vague correlation of alterations to the age of patient could be surmised, this being, of course, wholly unspecific. Thus psychopathology, neurological data and CT are the prime techniques for diagnosis of Fahr's syndrome, the EEG so far offering only marginal assistance.

Exogenous IL2 partially reverts CML non-reactivity acquired during prophylactic immunosuppression with cyclosporin A of human allograft recipients

Proliferative and cytolytic lymphocyte responses and the influence of exogenous interleukin 2 (IL2) on cell-mediated lympholysis (CML) reactivity were evaluated in 12 allograft recipients. Responses were induced by mitogenic lectins or by donor and third-party cells. Patients were tested immediately before transplantation (Tx) and one and three months after grafting. Prophylactic immunosuppression consisted of Cyclosporin A (CyA) and low-dose prednisone (P). Analysis of post transplant cells revealed a reduced overall proliferative T cell responsiveness induced by both alloantigens and mitogenic lectins. No evidence for donor-specific reduction of MLC responses was seen. Overall CML reactivity of post-Tx lymphocytes was also impaired. This was accompanied by donor-specific CML non-reactivity in six of seven patients with quiescent grafts. In these patients, the cytolytic potential against donor cells could be restored when maximal T cell help via exogenous IL2 was provided.

Kill kinetics of bacteria under fluctuating concentrations of various antibiotics. II. Description of experiments

Differences in kill kinetics and regrowth patterns of bacteria under the influence of various antibiotics are frequently not represented by their MIC values. The area under the concentration curve represents antimicrobial activity more accurately than the peak concentration. Readministration of antibiotics should occur prior to bacterial regrowth for optimal efficacy. When administering antibiotics in combinations nonsimultaneous dosing is superior to simultaneous administration.

Kill kinetics of bacteria under fluctuating concentrations of various antibiotics. I. Description of the model

Traditional antimicrobial susceptibility testing uses fixed concentrations of an antibiotic over 24 hours. In order to imitate conditions closer to the actual in vivo situation we developed a model which allows us to simulate serum and tissue concentrations observed under clinical conditions in vitro. Kill kinetics and regrowth pattern of various bacteria have been investigated under the influence of different antibiotics in this kinetic model.

Forward and reverse waves in the one-dimensional model of the cochlea

Consideration of a source of oto-acoustic emission in a cochlear model implies consideration of the types of waves that such a source can emit. One wave travels in the normal, forward, direction. As any other forward wave it undergoes little or no reflection and it eventually disappears completely because of dissipation. The other wave travels in the reverse direction and it appears to undergo appreciable reflection. In the present paper this phenomenon is studied via the use of two appropriately simplified long-wave models of the cochlea. One model, the exponential model, puts emphasis on the variation of the stiffness along the length of the basilar membrane. The second model concentrates on what happens in the region of resonance. The latter model turns out to have the largest predictive power for the problem at hand. Consideration of the flow of energy in the cochlear fluid brings forth the explanation why in the used model of the cochlea reflection conditions at the stapes have such a surprisingly small influence on the operating conditions of a potential source of emission.

[Polythelia in alcoholics. Preliminary report]

We present a study comparing 650 alcoholics with 1074 patients with miscellaneous other psychiatric (665) and medical (409) diagnoses for the frequency of supernumerary nipples (SN). Also 716 adolescents and school-children in a general medical screening were investigated for this phenomenon. In alcoholics SN were found in over 6%, in the non-alcoholic group in approximately 1%. The latter figure correlates well with other findings in literature, 6% being significantly higher. In the group of adolescents/children (1,8-3,2%) polythelia correlates with familial alcoholism, albeit of the father. As polythelia may be part of fetal alcohol-syndrome, the addiction should be expected on the mother's side, the more so, as the local rate of female/male alcoholism is approximately 1:3 (administrative incidence). We suggest that polythelia may be more frequent among alcoholics. Apart from SN occurring in alcoholic embryopathy, alcoholism of the father may be an additional factor for their development. Polythelia may in certain cases offer a diagnostic clue not only for mammo-renal syndromes but also for individual or familial alcoholism.

Diagnostic problems in asthma

Asthma can be over-diagnosed, but is more often under-diagnosed. The diagnosis can be made by demonstrating the reversibility of airway obstruction or by a provocation test if the baseline spirometry is normal. The most frequent causes of missing the diagnosis are (1) atypical clinical presentation, (2) misconceptions about age of onset of childhood asthma, and (3) the coexistence of another chronic respiratory illness that may have a more dramatic clinical picture and constitute a "red herring." It is fascinating to speculate on the similarities and differences between classical asthma (which has a usually completely reversible obstruction) and the hyperreactivity and partial reversibility of chronic inflammatory diseases like COPD or CF. Unfortunately much remains to be investigated and little is known at present about these questions. Even in classical asthma, chronic or recurrent inflammation (even by late allergic reaction) could worsen the basic hyperreactivity and this could be amenable to treatment or prevention.

Spacer devices used with metered-dose inhalers. Breakthrough or gimmick?

In an effort to improve the delivery of a drug to the lungs, to correct problems of hand-lung discoordination, and to reduce local side effects such as oral candidiasis, a number of spacer devices have been developed to attach to metered-dose inhalers. Administration of bronchodilator drugs to patients with faulty techniques of inhalation has been improved with the addition of spacers. In adults and older children with a correct technique of inhaling bronchodilators, the spacer devices do not seem to have any advantage over the simple metered-dose inhalers. Young children (two to five years) can benefit from inhaled bronchodilators or corticosteroids by use of spacer devices with one-way valves. Older children and especially adults who suffer from dysphonia or thrush from inhaled corticosteroids can also benefit from spacers. In patients whose condition is well controlled with the usual inhaled doses of corticosteroids with no local side effects, spacer devices show promise, but more studies are needed.

A longitudinal study of bronchodilator responsiveness in cystic fibrosis

The prevalence of bronchodilator responsiveness was evaluated in 20 outpatients with cystic fibrosis (CF) every 1 to 3 months for a 1-yr period and in 20 patients with CF during a hospital admission. All but 1 subject (95%) showed a significant bronchodilator response at least once on an outpatient basis; nonhospitalized subjects were responsive 49% of the time. Bronchodilator responsiveness was unrelated to long-term pulmonary severity or indexes of atopy but it was significantly influenced by season of the year; 70% of the population was responsive in winter compared with 25% in summer. Bronchodilator responsiveness increased during hospital admission together with improvement in baseline values; 23% of the population was responsive during the first 3 days compared with 80% by the end of the second week of admission. After discharge, a reverse pattern occurred, with decrease in bronchodilator responsiveness and a fall in baseline values. However, in some patients, bronchodilator responsiveness was lost when baseline values were still at their best. Bronchodilator responsiveness in CF tends to undulate with pulmonary exacerbations of the disease.

Normal values for forced oscillatory respiratory resistance in children

Forced oscillatory respiratory resistance was measured in 138 healthy children aged 2- to 16-years-old using a commercial unit. Regression analysis was performed using the resistance measurements obtained at frequencies of 6 Hz and 26 Hz and averages of measurements obtained at frequencies of from 6-26 Hz, 6-10 Hz, and 22-26 Hz. The analysis suggested that regression curves and 95% confidence intervals obtained using a quadratic model with height as the independent variable provided the best prediction of normal values and their ranges. Three independent sets of resistance measurements, which were obtained for all 138 subjects, were used to calculate the average individual coefficients of variation (CV) for the five resistance parameters noted above; these ranged from 9 to 13%. This analysis suggested that the expected CV of repeated measurements would be about 10%. Finally, values from 13 children who had asthma with mild bronchial obstruction (FEV1 less than 80% of predicted) were compared with the normal values derived from the regression curves. Values from all but two of the children fell within the reference intervals, suggesting that FEV1 may be a more sensitive measure of obstruction than forced oscillatory resistance. The main applications of this new approach may be in the evaluation of young children, in following individual patients, and in bronchodilation and bronchial challenge tests.

Cromolyn sodium: a review

Cromolyn is a white crystalline powder which is poorly absorbed from the gastrointestinal tract. Its therapeutic value lies in its functions as an inhaled or topically applied agent. Cromolyn has been approved in the United States for asthma therapy since 1973. It was marketed at that time as a drug to reduce the corticosteroid requirements of severe asthmatics. It clearly did not live up to that claim. Initial enthusiasm for cromolyn was replaced by disillusionment. In the last few years, investigators have taken another look at cromolyn and have a renewed interest in it. Cromolyn's mechanisms of action remain only partially understood. It appears to block allergic mediator release from certain mast cells. It may also decrease bronchial hyperreactivity. The frequency of drug toxicity at customary dosages is extremely low. Adverse effects tend to be mild, short-lived and without sequelae. Currently, cromolyn is a first line therapy for mild to moderate asthma requiring chronic treatment. It is also of proven efficacy in the treatment of allergic rhinitis, allergic conjunctivitis and vernal keratoconjunctivitis.

Neopterin levels in long-term renal allograft recipients

In this paper we present results dealing with neopterin levels in the urine of 21 kidney grafted patients during long-term allograft survival. Data dealing with results of urinary neopterin excretion to predict acute cellular allograft rejection during the immediate post-transplant period have been reported previously. The evaluation of patients included a physical investigation and numerous biochemical parameters as described below. We found that neopterin excretion is normal or elevated, but if elevated levels remain stable the prognosis for the allograft seems to be good.

[Results of a study of a family with aggregated occurrence of bilateral symmetrical basal ganglia calcinosis]

We present a familial study (45 members), in which 31 members have been examined. Seven were afflicted with bilateral symmetrical calcification of the basal ganglia (Fahr's syndrome), as verified by CT scans. The case history and biochemical results for one additional proband, who had died, strongly indicate that this patient also had Fahr's syndrome. The wide range of examinations used in our study were aimed at excluding differential diagnoses of bilateral symmetrical calcification of the basal ganglia, other than when the origin was suspected to be in the parathyroid. The examinations had to be undertaken on an outpatient basis. Some of the variables, such as Fe, Cu, and Mg in the plasma, are connected with results that have been published on the composition of the apatite deposits. Psychiatric, psychological, neurological, and EEG examinations are emphasized. Together with the case reports they are meant to illustrate the neuropsychiatric aspects of this syndrome, the composite view of which has often been previously neglected. Nineteen of 31 probands showed neurological, psychopathological, psychological, and encephalographical deviations. We also noted a high incidence of organic brain syndromes that are phenomenologically similar to affective disorders. We believe these deviations to be directly related to morphological alterations of the basal ganglia, possibly due to errors in phosphorous and calcium metabolism. Although the CT scan has greatly facilitated the diagnosis of intracerebral calcifications, we assume that basal ganglia alterations under the CT-density threshold may also be of clinical importance. Our metabolic results, genetic issues, and neuropsychiatric findings are discussed.

Kill kinetics and regrowth pattern of bacteria exposed to antibiotic concentrations simulating those observed in vivo

Antibiotic concentrations observed in vivo were simulated in an in vitro two compartment model with a dialyser interconnection. Kill kinetics and regrowth pattern of bacteria were investigated under these fluctuating antibiotic concentrations. There were large differences in the rate of reduction of viable organisms by various antibiotics not reflected in small differences in initial MIC values. Data suggested that the area under the concentration curve might be of importance in determining the antimicrobial activity of substances rather than the initial concentration. The inclusion of pharmacokinetic parameters in antimicrobial susceptibility testing might add a new dimension to the appreciation of the activity of antimicrobial substances.

Forced random noise resistance determination in childhood asthma

The forced random noise method for measuring respiratory resistance was studied in terms of reproducibility and correlation with spirometry and flow volumes in 30 older children (four to 17 years) with asthma and in 16 infants and children below three years of age. In the 30 older children, the mean value of individual coefficient of variations for three repeated measurements was 7.4 percent. Resistance parameters correlated well with spirometric parameters with all but three correlation coefficients greater than 0.7. In 20 older asthmatic patients, 180 micrograms albuterol caused a significant reduction in resistance in 11 subjects. At the same time, FEV1 increased significantly in nine subjects but showed a paradoxic decrease in five. This paradoxic response is attributed to complex reflexes caused by the maximum inspiration and forced expiration and did not occur with resistance measurements. This method requires little subject cooperation, and therefore, is well suited for infants and children.

[Long-term osteoporosis with multiple fractures as the early monosymptomatic stage of multiple myeloma]

A 44 year old man with kappa-light plasmacytoma is presented who had been treated for osteoporosis and multiple bone fractures since 12 years. On admittance he had a rapidly progressive myeloma kidney and an extensive extramedullary tumor within the pelvis. Remission was induced using combination chemotherapy according to the VMCP-protocol. It is discussed that the long-lasting osteoporosis of the present case represents an unusually long, monosymptomatic early stage of a multiple myeloma rather than an independent primary disease.

The use of cromolyn in the management of hyperreactive airways and exercise

Cromolyn given a few minutes before exercise significantly protects from exercise-induced asthma in more than 70% of patients, probably through prevention of mediator release and possibly through other mechanisms. Its efficacy is comparable to that of theophylline, alpha-adrenergic blockers, and calcium channel blockers; better than that of atropine and ketotifen; but less than that of inhaled albuterol. Cromolyn seems to be more effective than metaproterenol and theophylline for prevention of late reactions of exercise-induced asthma. The addition of cromolyn markedly improved the results in patients not completely protected by inhaled adrenergic agents. Cromolyn also protects from other triggers like hyperventilation with cold air, ultrasonically nebulized water, and sulfur dioxide. Its prolonged administration causes a reduction in the nonspecific hyperreactivity as shown by tests of histamine inhalation or hyperventilation with cold air. This effect is thought to be a result of cromolyn's protection from allergic-induced increase in nonspecific hyperreactivity, although there is some evidence that it can also occur in nonatopic patients, suggesting a broader protective effect.

Fenoterol in exercise-induced asthma. Effect of dose on efficacy and duration of action

The effectiveness of inhaled fenoterol doses of 0.4 mg and 0.8 mg in preventing exercise-induced asthma was investigated in 12 patients. Exercise-induced asthma was prevented by both doses for two hours after administration, but the effect of neither dose was significantly different from that of placebo four hours after. There was no statistically significant difference between the effects of the two fenoterol doses; and only a few patients were protected for more than two hours by the higher dose.

[Initial clinical experiences with allotransplantation of the pancreas]

Since 1979 7 pancreas transplantations have been performed in 8 type I diabetics. 5 of these 7 recipients had already been dialysed; 2 were awaiting their first dialysis. Furthermore, diabetes had caused severe retinopathy in 5 patients. The pancreas was transplanted simultaneously with a kidney from the same donor in 5 recipients; in 3 cases the pancreas was grafted 16 to 230 days after successful renal transplantation. 1 pancreas graft was removed immediately after revascularisation because of ischaemic damage. While the pancreatic duct was occluded in the first 4 patients, enteric diversion of the pancreatic juice was applied in the next 3 recipients. The first two patients were treated with conventional immunosuppression, whilst all the others received cyclosporin A and low-dose steroids. Small amounts of insulin had to be given initially for a few days in 2 cases, only. 2 grafts were lost due to surgical complications and 3 for immunological reasons. 1 functioning graft had to be removed because the patient was not willing to continue immunosuppression after irreversible rejection of her renal transplant. There was no perioperative death. 2 pancreatic and 5 renal grafts are functioning well at the present time. Technical aspects and problems in the diagnosis of rejection are discussed.

[Poisoning with elementary mercury: attempted suicide by inhalation of vapors from the heated metal]

This paper reports on a case of attempted suicide by the rare means of prolonged inhalation of fumes from heated mercury. The patient developed symptoms of acute intoxication over a period of 4 to 24 hours after the suicide attempt. This phase consisted of pulmonary, intestinal, psychopathological and neurological signs, persisting at varying intensities for approximately 3 weeks; it was succeeded by a chronic phase with peripheral nerve changes, initially of the axonal type, but later also showing signs of demyelinisation. Furthermore, a pronounced organic brain syndrome developed. The psychopathological, somatic and detoxification results are presented, whereby the symptomatology worsened even after substantial mercury excretion. A follow-up 4 months after the acute episode confirmed the chronicity of the central and peripheral nervous impairment. Therapeutic measures (BAL and aminopenicillin) are discussed; the use of these even 13 weeks after exposure caused massive mercury excretion.

Nebulized isoetharine and fenoterol in acute attacks of asthma

Nebulized, selective beta 2-adrenergic agents were shown to be a safe and effective alternative to subcutaneous epinephrine chloride in the treatment of acute asthma attacks. Results of a trial of nebulized 1% isoetharine hydrochloride and 0.5% fenoterol in 40 patients with acute attacks of wheezing is reported. Both groups showed significant improvement on forced expiratory volume in one second (FEV1), maximum expiratory flow at 25% and 50% vital capacity but those who received fenoterol therapy showed more significant bronchodilation after one hour. Based on clinical criteria and the ability to raise and maintain for four hours an FEV, by 15% above baseline, ten (50%) of the patients who received isoetharine and 16 (80%) of the patients who received fenoterol therapy were successes. Mild side effects were encountered in eight patients of each treatment group. Fenoterol therapy was significantly more effective and had a longer duration of action.

Effect of inhaled beclomethasone dipropionate on hypothalamic-pituitary-adrenal axis function in children with asthma

The hypothalamic-pituitary-adrenal axis was investigated in 15 asthmatic children treated with inhaled beclomethasone dipropionate (mean 490 micrograms/day) and 11 asthmatic control subjects receiving no corticosteroid therapy. Measurements of 24-h urinary free cortisol and 17 hydroxy corticosteroids, serum cortisol, response to ACTH, and the oral metyrapone test showed no significant difference between the two groups. All the patients' results were within normal limits, and carbohydrate metabolism, as shown by blood glucose and hemoglobin A1c, was not affected by beclomethasone therapy. Thus, in the above dose, inhaled beclomethasone does not cause suppression of the hypothalamic-pituitary-adrenal axis.

[Rhabdomyolysis with acute kidney failure after heroin poisoning]

A 24-year-old man who had been a drug addict for years, was admitted to hospital having been unconscious for several hours after injecting an overdose of heroin. He was in acute renal failure with extensive swelling of soft tissues of the right upper leg and right buttock without external signs of injury. The swelling rapidly extended to both right limbs, trunk and external genitalia. The clinical suspicion of rhabdomyolysis was confirmed by a high level of serum myoglobin (1570 mg/ml), and in a gluteus maximus muscle biopsy. The acute renal failure caused by the rhabdomyolysis was reversible after a short period of haemodialysis and, after decompression fasciotomy of the affected muscles, there were no severe sequelae. In view of the good prognosis with early diagnosis an exact clinical examination (observation of soft tissue swelling and dark urine) is of great importance in case of heroin addiction and/or poisoning.

[Experiences with continuous ambulatory peritoneal dialysis (CAPD) at the University Clinic for Internal Medicine in Innsbruck]

First described by Popovich et al. in 1978 [7], and modified by Oreopoulos et al. [6], CAPD is accepted as a simple technique which offers chronic dialysis to patients who are either unsuitable for, or noncompliant with, haemodialysis (HD). The technique of CAPD is based on the theoretical basis which predicted that adequate dialysis could be obtained if 10 litres of dialysis fluid per day are allowed to equilibrate with body fluids [5]. In practice, 2 litres of peritoneal dialysis solution are present in the peritoneal cavity, continuously, except for the periods when the patient exchanges the dialysate for fresh solution via a permanent peritoneal catheter [3]. The patient is ambulant and independent of hospital and machine. In our experience, with good technology and careful patient selection CAPD is now a well-established procedure and the preferred method of dialysis for some patients.

Subjective and objective means of assessing cystic fibrosis and asthma

The accuracy of methods of assessment was studied in 79 children with CF or asthma. Memory recall was good for CF but poor for asthma. In asthma, patients' subjective feelings and the physical examination were inaccurate in detecting airways obstruction. Of those who felt normal, 75% had abnormal FEV1. In order to avoid undertreatment the use of diary cards in asthma and pulmonary function tests in both diseases is recommended.

Comparison of oral and inhaled metaproterenol for prevention of exercise-induced asthma

The effectiveness of inhaled versus oral metaproterenol in preventing exercise-induced asthma (EIA) was studied. Inhaled metaproterenol given 10 min before the exercise significantly reduced the degree of EIA in a group of twenty-four patients, and in 75% of them completely prevented it. The mean percentage decrease in FEV1 was 6.5% with the inhaler and 30.1% with placebo. When inhaled 1 hr before the exercise, metaproterenol was still better than placebo but its effectiveness was considerably lower. Metaproterenol tablets had a slight protective effect given 1 hr before, and none when administered 2 hr before exercise. There was no correlation between the protective effect against EIA and the bronchodilating effect obtained before exercise. Metaproterenol administered by metered-dose inhaler is a very effective prophylactic medication against clinically troublesome EIA, while metaproterenol tablets should not be recommended for this purpose.

Hidden asthma in childhood

An unusual manifestation of asthma occurred in 11 children who had chronic cough and no wheezing. Initial, routine pulmonary function tests gave normal results in most cases. The diagnosis of asthma was confirmed by an exercise provocation test in ten children and/or a successful therapeutic trial with bronchodilators. The asthma in these cases had previously remained undiagnosed (hidden) for years, during which time the patients were treated unsuccessfully with antibiotics, antitussives, and antihistamines. Earlier diagnosis of this asthmatic illness assisted by exercise provocation testing will result in more effective management.

[Multidisciplinary diagnostic approach to Fahr's syndrome, a familial disease (author's transl)]

Fahr's syndrome is characterized by idiopathic non-arteriosclerotic, symmetric, intracerebral vascular sclerosis. On the basis of relevant literature and our own research, the necessity of multidisciplinary diagnosis is reviewed: psychiatric, neurological, medical, paediatric and radiological approaches are discussed. The early onset of diverse psychological alterations is regarded as significant. Extensive diagnosis seems justified by the at least theoretically possible means of prophylaxis and treatment in cases of Fahr's syndrome associated with hypoparathyroidism, pseudo-hypoparathyroidism and pseudo-pseudo-hypoparathyroidism. This condition otherwise irreversibly leads to dementia.

Urinary cyclic adenosine 3',5'-monophosphate (cAMP) and cyclic guanosine 3',5'-monophosphate (cGMP) in asthmatic and normal children

Urinary excretion of cAMP and cGMP was studied in nine normal and 15 asthmatic children. Bronchial lability was studied with a treadmill running test and atopy with serum IgE and skin prick tests. A circadian rhythm was found in both groups for cAMP and cGMP excretion. Cyclic GMP levels were higher in the asthma group, the difference reaching statistical significance around the time of the exercise challenge test. The fall in PEF induced by exercise showed a significant negative correlation with urinary cAMP responsiveness to isoproterenol inhalation. Exercise-induced bronchial lability correlated with 24-h cGMP excretion. High cGMP and low cAMP levels at night could be connected with nighttime exacerbations of symptoms. It is suggested that cGMP might have a more important role in asthma, than previously assumed.

Zur psychiatrischen Intensivtherapie des akuten Alkaloidentzugssyndroms

Es wird über den akuten Alkaloidentzug bei Alkaloidsüchtigen berichtet. Zwei Gruppen zu je neun Patienten wurden einerseits nach der herkömmlichen »peroralen« Neuroleptika-Entzugstherapie, andererseits über Vena-Subclavia-Katheter mit neuroleptischem Cocktail behandelt. Therapeutische Adjuvanzien und flankierende Maβnahmen waren bei beiden Gruppen identisch. Als kürzere und schonendere Entzugstherapie erwies sich mit statistischer Signifikanz die Anwendung des neuroleptischen Cocktails. Organische Parameter der Patienten wurden nicht wesentlich beeinfluβt. Zusammensetzung und Dosierungen des neuroleptischen Cocktails werden angeführt und die parenterale Methode des akuten Alkaloidentzuges diskutiert.

The relationship between croup and asthma

In 241 outpatients with asthma a higher prevalence of croup (33.2%) was found than in 131 controls (20.6%). The difference for recurrent croup was even more significant. Among inpatients with croup, compared with controls without, a greater tendency towards asthma, but not towards other atopic diseases, was found.

Use of exercise challenge to investigate possible tolerance to beta-adrenoceptor stimulation in asthma

The effect of prolonged salbutamol administration on beta-adrenoceptor function in asthma has been examined. Six adult patients received salbutamol tablets (16 mg daily) for between 4 and 20 weeks and six adolescents received salbutamol aerosol (800 microgram daily) for 2--5 weeks. Before and after the treatment period the acute bronchodilator response to inhaled salbutamol and the ability of inhaled salbutamol to protect against exercise-induced asthma were examined. Lymphocyte beta-adrenoceptor function was also measured in the patients on tablet therapy. Inhaled salbutamol was less effective in protecting against exercise-induced asthma at the end of the treatment period in the patients who had received tablet therapy, but otherwise there was no significant change in beta-receptor function of either airways or lymphocytes. This apparent loss of efficacy of inhaled salbutamol in the prevention of exercise-induced asthma in some subjects, even when its acute bronchodilator effect is preserved, might reflect differences in the susceptibility of different beta-adrenoceptors to desensitization after prolonged stimulation: its clinical importance remains uncertain.