Association between Atopic Dermatitis and Hypertension: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies found conflicting results about the association of atopic dermatitis (AD) with hypertension.

OBJECTIVES

Determine whether AD and AD severity are associated with hypertension.

METHODS

A systematic review was performed of published studies in MEDLINE, EMBASE, Scopus, Web of Science, and GREAT databases. At least 2 reviewers conducted title/abstract, full-text review, and data extraction. Quality of evidence was assessed using the Newcastle-Ottawa Scale.

RESULTS

Fifty-one studies met inclusion criteria; 19 had sufficient data for meta-analysis. AD was associated with higher odds of hypertension compared to healthy controls (increased in 9 of 16 studies; pooled prevalence: 16.4% vs 13.8%; random-effects regression, pooled unadjusted odds ratio [OR][95% confidence interval <CI95>]: 1.16 [1.04-1.30]), but lower odds of hypertension compared to psoriasis (decreased in 5 of 8 studies; 15.4% vs 24.8%; 0.53 [0.37-0.76]). In particular, moderate-severe AD were associated with hypertension compared to healthy controls (increased in 4 of 6 studies; 24.9% vs 14.7%; 2.33 [1.10-4.94]). Hypertension was commonly reported as an adverse-event secondary to AD treatments, particularly systemic cyclosporine A. Limitations include lack of longitudinal studies or individual-level data and potential confounding.

CONCLUSIONS

AD, particularly moderate-to-severe disease, was associated with increased hypertension compared to healthy controls, but lower odds than psoriasis.

A randomized phase IIa study of quantified bone scan response in patients with metastatic castration-resistant prostate cancer (mCRPC) treated with radium-223 dichloride alone or in combination with abiraterone acetate/prednisone or enzalutamide

BACKGROUND

In metastatic castration-resistant prostate cancer (mCRPC), assessing treatment response and bone lesions with technetium-99m is limited by image resolution and subjectivity. We evaluated bone scan lesion area (BSLA), a quantitative imaging assessment of response in patients with mCRPC receiving radium-223 alone or in combination with androgen receptor pathway inhibitors (abiraterone/prednisone or enzalutamide).

PATIENTS AND METHODS

This randomized, non-comparative phase IIa three-arm trial (NCT02034552) evaluated technetium-99m-based BSLA response rate (RR), safety, radiologic progression-free survival (rPFS), and time to first symptomatic skeletal event (SSE) in men with mCRPC and bone metastases receiving radium-223 with/without abiraterone/prednisone or enzalutamide. The primary endpoint was week 24 BSLA RR.

RESULTS

Overall, 63 patients received treatment (abiraterone/prednisone combination, n = 22; enzalutamide combination, n = 22; radium-223 monotherapy, n = 19). Median treatment duration (first to last dose of any study treatment) was 12 months (abiraterone/prednisone combination), 10 months (enzalutamide combination), and 3 months (radium-223 monotherapy). Week 24 BSLA RR was 58% [80% confidence interval (CI) 41% to 74%; one-sided P < 0.0001; 11/19 patients] with abiraterone/prednisone combination, 50% (32% to 68%; one-sided P < 0.0001; 8/16 patients) with enzalutamide combination, and 22% (10% to 40%; one-sided P = 0.0109; 4/18 patients) with radium-223 monotherapy. Median rPFS was not evaluable for combination arms and 4 months (80% CI 4 to 12) for monotherapy. SSEs were reported in 32% of patients; median time to first SSE was not estimable. Fatigue and back pain were the most commonly reported treatment-emergent adverse events (TEAEs); more patients receiving combination therapy than monotherapy had TEAEs. Fractures were reported in 18% receiving abiraterone/prednisone, 32% receiving enzalutamide, and 11% receiving radium-223 monotherapy. Fracture rates were lower in patients taking bone health agents versus not taking bone health agents at baseline.

CONCLUSIONS

Technetium-99m imaging BSLA may offer objective, quantifiable assessment of isotope uptake changes, and potentially treatment response, in patients with mCRPC and bone metastases treated with radium-223 alone or in combination with abiraterone/prednisone or enzalutamide. In this largely treatment-naive population, BSLA RR was numerically lower with radium-223 monotherapy versus combination therapy, indicating a limited role as first-line treatment. Use of radium-223 should follow evidence-based treatment guidelines and the licensed indication.

What are the best endpoints for Eczema Area and Severity Index and Scoring Atopic Dermatitis in clinical practice? A prospective observational study

BACKGROUND

Multiple strategies have been used to evaluate the minimal important change (MIC) of the Eczema Area and Severity Index (EASI) and Scoring Atopic Dermatitis (SCORAD). The meaningfulness of these MICs is not well established across all severities of atopic dermatitis (AD).

OBJECTIVES

To determine the MIC of percentage and absolute improvement of EASI and SCORAD scores in adults and children with AD.

METHODS

We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 826). An anchor-based approach was used to determine thresholds for the percentage and absolute MICs of EASI, SCORAD and objective SCORAD (O-SCORAD) at follow-up from baseline.

RESULTS

One-grade improvements of Physician's Global Assessment (PGA) and validated Investigator Global Assessment scale for AD (vIGA-AD) were associated with 50%, 35% and 35% decreases of EASI, SCORAD and O-SCORAD, respectively. The thresholds for percentage MIC of EASI (Kruskal-Wallis test, P = 0·61), SCORAD (P = 0·07) and O-SCORAD (P = 0·09) were similar across baseline AD severities. One-grade improvements of PGA and vIGA-AD were associated with 14·0- and 14·9-point decreases of EASI, 19·9- and 14·9-point decreases of SCORAD, and 15·5- and 17·4-point decreases of O-SCORAD. The thresholds for the absolute MIC of EASI (P < 0·001), SCORAD (P < 0·001) and O-SCORAD (P < 0·001) significantly differed by baseline AD severity. Percentage and absolute MICs for EASI and SCORAD were associated with improvements of AD symptoms and quality of life.

CONCLUSIONS

EASI 50, SCORAD 35 and O-SCORAD 35 were meaningful percentage MICs regardless of baseline AD severity. The absolute MICs for EASI, SCORAD and O-SCORAD varied by baseline AD severity.

Measurement properties of the product of investigator's global assessment and body surface area in children and adults with atopic dermatitis

BACKGROUND

Multiple clinician-reported outcome measures exist for atopic dermatitis (AD) severity. However, there is no gold standard for use in clinical practice.

OBJECTIVES

To determine the measurement properties of the product of validated Investigator's Global Assessment for AD (vIGA) and body surface area (BSA) overall or divided into six categories (cBSA: 0%/0.1, <10%/10, <30%/30, <50%/50, <70%/70 and <90%/90-100%) and compare with other clinician-reported and patient-reported outcomes in adults and children with AD.

METHODS

We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 653).

RESULTS

vIGA*BSA and vIGA*cBSA had good convergent validity with BSA (Spearman's ρ = 0.97 and 0.93), eczema area and severity index (ρ = 0.94 and 0.92), and objective SCORAD (ρ = 0.88 and 0.89); and weak-to-good convergent validity with Numeric Rating Scale average itch (ρ = 0.22 and 0.22) and worst itch (ρ = 0.27 and 0.28), Patient-Oriented Eczema Measure (ρ = 0.44 and 0.43), Dermatology Life Quality Index (ρ = 0.48 and 0.49), ItchyQOL (ρ = 0.45 and 0.46), PROMIS Sleep Disturbance (ρ = 0.46 and 0.37) and sleep-related impairment (ρ = 0.31 and 0.31) in adults and/or children; very good discriminant validity for physician-reported global AD severity; good responsiveness to change of severity of AD and itch; and good reliability (intraclass correlation coefficient [95% confidence interval]: 0.72 [0.60-0.81] and 0.74 [0.62-0.82]) with no floor or ceiling effects. Thresholds for interpretability bands and clinically important difference were established.

CONCLUSIONS

vIGA*BSA and vIGA*cBSA scores showed good convergent and discriminant validity, reliability, responsiveness and interpretability in adults and children with AD, and were feasible for use in clinical practice. vIGA*BSA and vIGA*cBSA had slightly lower convergent validity than EASI or objective SCORAD, but might be more efficient to collect and score.

Measurement properties of the Rajka-Langeland severity score in children and adults with atopic dermatitis

BACKGROUND

Multiple atopic dermatitis (AD) severity scales exist, with no gold standard for use in clinical practice.

OBJECTIVES

To determine the measurement properties of the Rajka-Langeland score and compare it with other clinician-reported outcomes in adults and children with AD.

METHODS

We performed a prospective dermatology practice-based study using questionnaires and evaluation by a dermatologist (n = 427).

RESULTS

Rajka-Langeland had good concurrent validity with the Eczema Area and Severity Index (Spearman rho = 0·63), SCORing AD (SCORAD) (rho = 0·61), objective-SCORAD (rho = 0·52) and body surface area (rho = 0·51); good convergent validity with the numeric rating scale average-itch (rho = 0·60) and worst-itch (rho = 0·59), Patient-Oriented Eczema Measure (rho = 0·57), Dermatology Life Quality Index (rho = 0·53), Patient-Reported Outcomes Measurement Information System Itch Questionnaire (rho = 0·35-0·55) in adults and/or children; fair discriminant validity for patient- and physician-reported global AD severity; good responsiveness to change of severity of AD and itch; good reliability; internal consistency; with no floor or ceiling effects. Interpretability bands (3, clear/almost clear; 4-5, mild; 6-7, moderate; 8-9, severe) and minimal clinically important difference (1 point) were established.

CONCLUSIONS

The Rajka-Langeland score showed good construct validity, reliability, internal consistency and responsiveness in adults and children with AD.

Risk Factors for Sputum Positive Pulmonary Tuberculosis Retreatment Cases and Factors Responsible for Treatment Outcome

BACKGROUND

Identification of the characteristics that confer higher risk of relapse, failure, or default and factors associate with treatment outcome in retreatment cases may help in planning country-specific prevention strategies.

OBJECTIVE

To evaluate the risk factors for retreatment failure, default or relapse and factors responsible for the treatment outcome.

METHODS

In this study sputum positive pulmonary TB retreatment cases were included. All patients were treated by eight months Revised National Tuberculosis Control Program (RNTCP) Cat II regimen. Outcome was recorded as Cured, Failure, Death or Defaulted.

RESULTS

Patients having body weight > 45 kgs had higher cure rates (94.74%). Poor outcome was significantly higher in patient with cavitory lesions on Chest X ray (30.43% vs 7.14%) and in patient with bilateral lesions (28.57% vs 4.35%). Patients with initial sputum of 3 + grade was significantly associated with poor outcome than having sputum of scanty to 2 + grade (26.93% vs 8%).

CONCLUSION

Patients presenting for TB retreatment have distinct demographic and clinical characteristics, important difference in retreatment outcomes in relation to different parameters. So, new country specific strategies are required to identify and address risk factor for retreatment cases and factors responsible for poor outcome of these cases.

Abstract PD8-12: Safety and efficacy of palbociclib and radiotherapy in metastatic breast cancer patients: Initial results of a novel combination

Purpose: Palbociclib is a selective CDK4/6 inhibitor approved for the treatment of metastatic ER+/HER2- breast cancer. Inhibition of CDK4/6 prevents cell cycle progression from G1 to the more radioresistant S phase, raising the possibility of an enhanced therapeutic effect if combined with radiotherapy (RT). Despite this potential benefit, clinicians seldom use this combination due to fear that RT may exacerbate palbociclib toxicity, particularly leukopenia. Our aim is to report the preliminary results of patients with metastatic breast cancer who received RT while receiving palbociclib.

Methods: We retrospectively reviewed records of all patients who were treated with palbociclib at our institution from 2015-2018. Patients who received RT for symptomatic metastases concurrently or within 14 days of last drug administration were included in our analysis. Local treatment effect was assessed by clinical exam and subsequent CT or MRI imaging, if applicable. Toxicity was graded based on CTCAE v5.0.

Results: A total of 16 females received palliative RT in association with palbociclib. The median age of the treated patients was 59.6 (range 33.3-91.0) years. The median time of closest palbociclib use to RT administration was 5 (range 0-14) days.

The following sites were treated in order of frequency: bone (10-axial skeleton [8-vertebra]; 1-ilium), brain (4: 3-WBRT & 1-SRS), and mediastinum (1). RT dose/fractionation for bone was 30 Gy/10 fxn (7), 35 Gy/14 fxn (2), 37.5 Gy/15 fxn (1), and 18 Gy/1 fxn (1). WBRT dose/fractionation was 30 Gy/10 fxn for all patients. SRS brain dose was 25 Gy/5 fxn. The patient treated to the mediastinum received 36 Gy/18 fxn.

At most recent follow-up, 12 patients are still living. The median time from RT to last known follow-up or death is 10.3 (range 1.7-29.6) months. Pain relief was achieved in 15 of 16 (93.8%) patients. No radiographic local failure was noted in the 13 patients with evaluable follow-up imaging.

The combination of RT and palbociclib was well-tolerated. Grade 1 fatigue, dermatitis, and nausea was noted in 5, 3, and 1 patient, respectively. One patient with WBRT developed Grade 1 headache. Six of 16 patients were leukopenic prior to RT initiation. Following RT, 7 patients were observed to have a drop in WBC count, of which 2 dropped into the leukopenic range. Only a total of 5 patients were leukopenic following RT, of which 3 were leukopenic before receiving RT. No acute or late Grade 2 or higher cutaneous, neurological, gastrointestinal, or hematologic toxicities were noted.

Conclusions: The use of RT in patients receiving palbociclib resulted in minimal Grade 1 and no Grade 2+ toxicities, including leukopenia. This treatment can be used safely in symptomatic patients without discontinuation of systemic therapy. Further larger prospective studies with longer follow-up are needed to confirm these results.

Citation Format: Chowdhary M, Sen N, Chowdhary A, Usha L, Cobleigh M, Patel KR, Wang D, Barry PN, Rao RD. Safety and efficacy of palbociclib and radiotherapy in metastatic breast cancer patients: Initial results of a novel combination [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD8-12.

Abstract P3-12-19: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Chowdhary M, Lee A, Gao S, Barry PN, Diaz R, Decker RH, Wilson LD, Evans SB, Moran MS, Knowlton CA, Patel KR. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-19.

The mental health burden in acne vulgaris and rosacea: an analysis of the US National Inpatient Sample

BACKGROUND

Little is known about the mental health (MH) hospitalization among patients with acne and rosacea.

AIMS

To determine the MH disorders and cost burden associated with acne and rosacea.

METHODS

Data were examined from the 2002-2012 US National Inpatient Sample, comprising a sample of ~20% of all US paediatric and adult hospitalizations (n = 87 053 155 admissions).

RESULTS

A diagnosis of ≥ 1 MH disorder was much more common among all inpatients with vs. those without a diagnosis of acne (43.7% vs. 20.0%, respectively) and rosacea (35.1% vs. 20.0%, respectively). In multivariable logistic regression models controlling for sex, age, race/ethnicity and insurance status, acne (adjusted OR = 13.02; 95% CI 11.75-14.42) and rosacea (adjusted OR = 1.70; 95% CI 1.56-1.95) were associated with significantly higher odds of a primary admission for an MH disorder (13 and 8, respectively, of 15 MH disorders examined). Both acne and rosacea were associated with higher risk of mood, anxiety, impulse control and personality disorders, and with > $2 million of excess mean annual costs of hospitalization for MH disorders in the USA.

CONCLUSION

In this study, inpatients with acne or rosacea had increased odds of comorbid MH disorders. In particular, there was an increased number of hospital admissions secondary to a primary MH disorder with coexistent acne/rosacea. MH comorbidities were associated with considerable excess costs among inpatients with acne or rosacea.

Measurement properties of three assessments of burden used in atopic dermatitis in adults

BACKGROUND

Standardized quality-of-life (QoL) assessments can provide important and clinically relevant information. There is currently a lack of standardization in QoL assessments used in atopic dermatitis (AD).

OBJECTIVES

To determine the content validity, construct validity, internal consistency, differential reporting, responsiveness, floor or ceiling effects and feasibility of the Dermatology Life Quality Index (DLQI), Itchy Quality of Life (ItchyQoL) and 5-dimensions (5-D) itch scales for assessing burden of AD in adults and to compare their performance.

METHODS

Self-administered questionnaires and skin examination were performed in 340 adults with AD in a dermatology practice setting.

RESULTS

DLQI, ItchyQoL and 5-D all had good content validity. DLQI, mean ItchyQoL and 5-D itch all had strong correlations with frequency of AD symptoms (Patient-Oriented Eczema Measure) and intensity of itch (numerical rating scale for itch), and moderate correlations with AD severity (Eczema Area and Severity Index and Scoring Atopic Dermatitis) (Spearman correlations, P < 0·001 for all). DLQI and 5-D itch showed good internal consistency (Cronbach's alpha = 0·89 and 0·84), although ItchyQoL appeared to have several redundant items (alpha = 0·96). Uniform and nonuniform differential item functioning by age, sex and/or race/ethnicity was found for multiple items in DLQI, ItchyQoL and 5-D itch. DLQI, ItchyQoL and 5-D itch scores all demonstrated responsiveness, although ItchyQoL demonstrated the greatest responsiveness. There were no floor or ceiling effects for total scores. The median times for completion of DLQI, ItchyQoL and 5-D itch were 2 min.

CONCLUSIONS

The DLQI, ItchyQoL and 5-D itch scales all showed good content and construct validity, and responsiveness in the assessment of AD in adults, and were feasible for use in clinical trials and practice.

Measurement of circulating tumor cells in squamous cell carcinoma of the head and neck and patient outcomes

OBJECTIVES

We report the outcomes of patients with squamous cell carcinoma of the head and neck (HNSCC) whose circulating tumor cells (CTCs) were quantified using surface-enhanced Raman scattering (SERS) nanotechnology.

METHODS

SERS tagged with EGF was used to directly measure targeted CTCs. Patient charts were retrospectively reviewed. An optimal cut point for CTCs in 7.5 ml of peripheral blood predictive of for distant metastasis-free survival (DMFS) was identified by maximizing the log-rank statistic. An ROC analysis was also performed.

RESULTS

Of 82 patients, 13 experienced metastatic progression. The optimal cut point for DMFS was 675 CTCs (p = 0.047). For those with distant recurrence (n = 13) versus those without distant recurrence (n = 69), the CTC cut point which results in the largest combined sensitivity and specificity values is also 675 (sensitivity = 69%, specificity = 68%).

CONCLUSION

Liquid biopsy techniques in HNSCC show promise as a means of identifying patients at greater risk of disease progression.

Clinical implications of p53 alterations in oral cancer progression: a review from India

p53 plays a central role in prevention of normal cell from the development of the malignant phenotype. Somatic alterations (mutations, loss of heterozygosity, deletions) in p53 are a hallmark of most human cancers and cause defects in normal p53 function. However, in the tumors harboring wild-type p53, there are alterations in the regulation of the p53. Thus, understanding why p53 is unable to perform its role as a tumor suppressor in these wild-type tumors is very crucial. Germ-line polymorphisms in p53 are also anticipated to cause measurable disturbance in p53 function. Over-expression as well as polymorphic variants of MDM2 might have effects on cancer development. In addition, degradation of p53 by E6 protein of high risk human papillomavirus is also suggested as one of the mechanisms which attenuate p53 responses in oral carcinogenesis. p53 has also been demonstrated to mediate cellular responses upon various DNA damaging cancer therapies, importantly, apoptosis. These responses have been implicated in an individual's ability to respond to these cancer therapies. Thus, exploring mechanisms by which normal function of p53 is affected in the comprehensive way in oral cancer might aid in the identification of tumor characteristics, prognosis and thus in the development of a new approach to treat the oral cancer.

The adverse effects of an excessive folic acid intake

Folate is a vital component of a healthy diet, being essential for numerous bodily functions. Deficiency of folate is common, with studies suggesting prevalence of deficiencyas high as 85.5% as was shown in women between the ages of 16 and 49, living in the UK. Causes of folate deficiency range from diet and lifestyle, to pathological and pharmacological processes. Because of the well-known role of folate in prevention of neural tube defects, numerous countries have implemented strategies to increase folate intake, with programs such as mandatory grain fortification. As a result, the intake of folate in these countries is often higher than the recommended dietary allowance for many groups of people. Although folate is believed to be non-toxic, the potential adverse effects of excessive intake of folic acid (synthetic form of folate) have not been highlighted well by authorities to people taking supplements; despite this, many studies have addressed this issue. However, the results of these studies provide discrepant results, leading to confusion as to whether mandatory folic acid fortification should be introduced in other countries. The purpose of this review was to provide a summary of evidence related to high folic acid ingestion and to look at the unwanted effects it may have on the certain groups within the general population.

Assessment of sleep studies in myotonic dystrophy

Myotonic dystrophy (MD) is the commonest adult muscular dystrophy and is associated with respiratory muscle weakness. The role of screening sleep studies is unclear in MD. We prospectively evaluated polysomnography/overnight oximetry in a group of MD patients and related this to the daytime respiratory function in an attempt to evaluate the usefulness of screening sleep studies. Twenty-five patients with type I MD [15 males; mean age (SD) 40.0 (10.9) years] who had at least one symptom suggestive of nocturnal hypoventilation were included in the study. We performed spirometry, maximal inspiratory and expiratory mouth pressures, sniff nasal inspiratory pressure, arterial blood gases and polysomnography or overnight oximetry. Excessive tiredness and sleepiness were the most common presenting symptoms. Prevalence of sleep related breathing disorder (SRBD) was 36%. FVC was found to be normal in 33% of subjects with significant SRBD. Mouth pressures were reduced more than FVC, even in patients with normal overnight oxygen saturation. Of all the daytime measures, FVC correlated best with arterial carbon dioxide tension ( r = -0.7). Sleep studies were useful to identify a small group of myotonic dystrophy patients (12%, three out of 25 in our series) with SRBD that would have been missed with routine daytime assessments. Targeted sleep monitoring in patients who are older, with multiple symptoms suggestive of SRBD, especially if they are over-weight seems to be the best way to utilize the existing resources. Home unattended oximetry was well tolerated and offers a practical screening tool in this challenging patient group where excess daytime sleepiness is often due to causes other than SRBD.

Synthesis, optical and electrochemical properties of new ferrocenyl substituted triphenylamine based donor–acceptor dyes for dye sensitized solar cells

Two new ferrocenyl substituted triphenylamine based donor–acceptor dyes D1 and D2 were synthesized and used as sensitizers for dye sensitized solar cells (DSSCs).

Alpha-adrenoceptor blocking drugs in asthma

The effect of alpha-adrenoceptor blocking drug, thymoxamine alone and in combination with isoprenaline, was studied on the specific airways conductance (SGaw) in ten patients with extrinsic asthma. Thymoxamine when given together with isoprenaline produced significantly greater increase in SGaw as compared to improvement achieved with isoprenaline alone. It is suggested that the potentiation of isoprenaline induced bronchodilatation by thymoxamine is mediated by increased cyclic AMP formation in the bronchial smooth muscle.

Inhaled ethanolic and aqueous solutions via Respimat Soft Mist Inhaler are well-tolerated in asthma patients

BACKGROUND

Respimat Soft Mist Inhaler (SMI) is a new-generation inhaler offering improved lung deposition compared with other devices. Bronchodilators administered via Respimat SMI are preserved and stabilized with benzalkonium chloride (BAC) and ethylene diamine tetra-acetic acid (EDTA); both have been reported to cause paradoxical bronchoconstriction if a threshold dose is exceeded.

OBJECTIVE

The aim of this randomized, double-blind, three-period, crossover study was to establish that the safety of inhaled ethanolic and aqueous placebo solutions (containing BAC and EDTA) is equivalent to that of inhaled normal saline solution when administered to asthma patients via Respimat SMI.

METHODS

Thirty-seven asthma patients with airway hyper-reactivity were randomized to receive four actuations of each of the following three treatments via Respimat SMI, one on each of 3 study days: ethanolic placebo (12 microl 96% ethanol + 0.13 mug EDTA/actuation), aqueous placebo (12 microl water + 5.5 microg EDTA + 1.1 mug BAC/actuation), and normal saline (12 microl 0.9% sodium chloride/actuation). Pulmonary function tests were performed at baseline and at 5, 15, 30, 60, 120 and 180 min after inhalation; the primary endpoint was the lowest FEV(1) recorded between 0 and 30 min.

RESULTS

The mean lowest FEV(1) recorded between 0 and 30 min after inhalation minus the study day baseline was -0.090 litres for ethanolic placebo, -0.121 litres for aqueous placebo and -0.094 litres for normal saline (SEM 0.034 litres for all). The mean treatment differences were: ethanolic placebo versus normal saline 0.004 litres (90% CI -0.075-0.083 litres, p = 0.002), and aqueous placebo versus normal saline -0.028 litres (90% CI -0.107-0.052 litres, p = 0.006). Since both 90% CIs fell within the pre-determined equivalence region of +/-0.15 litres, both treatments were considered equivalent to normal saline.

CONCLUSION

Ethanolic and aqueous solutions administered via Respimat SMI are safe with regard to paradoxical bronchoconstriction in asthma patients with airway hyper-reactivity.

Angiotensin-converting enzyme genotype and the ventilatory responseto exertional hypoxia

The "insertion" (I) rather than "deletion" (D) variant of the human angiotensin-converting enzyme (ACE) gene is associated with both lower tissue ACE activity and elite performance at high altitude. Three genotypes, II, ID and DD, are thus represented in the population. The authors examined whether an improved ventilatory response to hypoxic exercise may contribute to this effect. Subjects (n=60; 37 male, mean+/-SEM age 23.6+/-0.6 yrs, 14 II, 30 ID, 16 DD) underwent incremental cardiopulmonary exercise testing to establish maximal oxygen uptake and ventilatory threshold (VT). Four hours later, subjects exercised for 6 mins at 50% of the workload at VT. The protocol was repeated 15 mins later while breathing 12.5+/-0.5% oxygen in nitrogen. All subject characteristics were independent of genotype, as were data during normoxic exercise. However, the hypoxia-induced rise in minute ventilation was significantly greater among those of II genotype (39.6+/-4.1% versus 27.9+/-2.0% versus 28.4+/-2.2% for II versus ID versus DD, respectively). These data are supported by a significantly greater decrease in end tidal carbon dioxide (consistent with an increase in alveolar ventilation) among those homozygous for the I allele (II -18.7+/-1.3%, ID -15.7+/-0.4%, DD -15.1%+/-1.1). The ventilatory response to hypoxic exercise is influenced by angiotensin-converting enzyme genotype. Potential implications concern high altitude performance and the pathogenesis and management of hypoxic lung disease.

Ambulatory pulmonary artery pressure monitoring during sleep and exercise in normal individuals and patients with COPD

BACKGROUND

Pulmonary hypertension is a common complication of chronic obstructive airways disease (COPD) and its presence implies a poor prognosis. However, it is difficult to measure and its specific contribution to symptoms is difficult to quantify. A micromanometer tipped pulmonary artery catheter was used to measure pulmonary artery pressure (PAP) during sleep and on exercise.

METHODS

Ten patients (five with COPD receiving long term oxygen therapy and five normal individuals) were studied. Pulmonary artery pressure was recorded continuously during two periods of sleep (breathing oxygen followed by air for the COPD group) and during exercise.

RESULTS

In the COPD group PAP during sleep on oxygen was significantly lower than PAP during sleep breathing air (mean (SD) difference 9.6 (5.3) mm Hg, 95% CI 4.9 to 14.3, p= 0.016). PAP during exercise was not significantly different from PAP during sleep breathing air (mean (SD) difference 0.8 (8.9) mm Hg, 95% CI -7.0 to 8.6, p= 0.851). In normal individuals the group mean (SD) PAP was 15 (5.9) mm Hg for the first nocturnal period and 15 (5.7) mm Hg for the second nocturnal period. PAP during exercise was not significantly different from PAP during sleep breathing air (mean (SD) difference 3.3 (2.2) mm Hg, 95% CI 1.1 to 5.5, p= 0.061).

CONCLUSION

In patients with COPD, PAP rose significantly during sleep to levels similar to those measured during exercise, but this could be reversed with oxygen.

Tuberculosis of the breast presenting as carcinoma

Breast infections caused by Mycobacterium tuberculosis, although rare in western countries, should not be forgotten as a cause of a breast lump presenting clinically and radiologically as a carcinoma in the older patient who gives a history of previous tuberculosis. We report the case of an 84-year-old woman with a breast lump showing noncaseating granulomas on histology who developed a sinus track after excision biopsy of the lump. The patient responded to empiric treatment with anti-tuberculosis drugs and remains well 2 years after presentation.

Pulmonary artery pressure measurement during exercise testing in patients with suspected pulmonary hypertension

It is recognized that exercise produces abnormally large increases in pulmonary artery pressure in patients with pulmonary vascular disease as a consequence of a variety of disorders, but the relationship between pressure and cardiopulmonary exercise performance is poorly understood. This lack of understanding is due (in part) to difficulty making measurements of pulmonary haemodynamics using conventional fluid filled catheters. This article seeks to improve understanding by comparing variables measured during formal exercise testing with simultaneous measurements of pulmonary artery pressure using a micro-manometer tipped catheter. Ten patients with suspected pulmonary hypertension were studied using a micromanometer tipped pulmonary artery catheter, during cardiopulmonary exercise testing. Ventilatory equivalents for oxygen and carbon dioxide correlated with the pulmonary artery pressure measured on exercise, but oxygen pulse and oxygen uptake did not. Ventilatory equivalents, noninvasively measured during exercise, may merit further study as potential surrogates of pulmonary artery pressure and hence be useful in identifying individuals at risk of developing pulmonary hypertension.

Sputum cellular and cytokine responses to inhaled endothelin-1 in asthma

BACKGROUND

Endothelin (ET)-1 is a 21-amino acid peptide which has potent bronchoconstrictor activity. Animal studies show elevation of ET-1 during experimental airway inflammation, and inhibition of inflammation by endothelin-antagonists, suggesting pro-inflammatory activity for ET-1.

OBJECTIVE

We wanted to assess any acute influence that bronchoconstrictor doses of inhaled ET-1 might have on cells, tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, nitrite (NO2) and albumin in induced sputum in asthma.

METHODS

Bronchial challenge was performed using nebulized ET-1 (nebulized dose range 0.96-15.36 nmol) and placebo in 10 adult asthmatic subjects in a randomized double-blind placebo-controlled cross-over study. Sputum induction was performed 30 min and 4 h after placebo or ET-1 bronchial challenge.

RESULTS

All subjects experienced dose-dependent bronchoconstriction to inhaled ET-1 with a mean (range) PC15 forced expiratory volume in 1 s (FEV1) to ET-1 of 9.45 (1.2-21.7) nmol. Comparing ET-1 with placebo inhalation, there was no change in sputum differential cell counts, TNFalpha, IL-1beta, NO2 or albumin at 30 min or 4 h after inhalation, nor was there a difference in these parameters at 4 h compared with 30 min after ET-1 inhalation. There was no fall in FEV1 at 4 h after ET-1 inhalation, suggesting that ET-1 inhalation is not associated with a late bronchoconstrictor response.

CONCLUSIONS

We conclude that inhaled ET-1 does not appear to stimulate an acute inflammatory response in asthma as assessed by differential cell count, TNFalpha, IL-1beta, NO2 and albumin concentrations in induced sputum.

Impaired pulmonary diffusion during exercise in patients with chronic heart failure

BACKGROUND

Pulmonary diffusion is impaired at rest in patients with chronic heart failure (CHF) and has been implicated in the generation of symptoms and exercise intolerance. The aim of this study was to determine whether pulmonary diffusion is impaired during exercise in CHF, to examine its relationship to pulmonary blood flow, and to consider its functional significance in relation to metabolic gas exchange.

METHODS AND RESULTS

Carbon monoxide transfer factor (TLCO) and pulmonary blood flow (Q(C)) were measured by a rebreathe technique at rest and during steady-state cycling at 30 W in 24 CHF patients and 10 control subjects. Both patients and control subjects were able to raise TLCO and Q(C) during exercise. However, the patient group had a lower diffusion for a given blood flow (TLCO/Q(C)) both at rest (3.6+/-0.16 and 4.8+/-0.23 mL x L(-1) x mm Hg(-1); P<0.001) and during exercise (2.8+/-0.16 and 3.4+/-0.13 mL x L(-1) x mm Hg(-1) for CHF patients and control subjects, respectively; P<0.05). TLCO/Q(C) was related to the ventilatory equivalent for carbon dioxide (VEVCO(2)) production at 30 W (TLCO/Q(c) versus VEVCO(2), r = -0.58, P<0.01) and to peak exercise oxygen consumption measured during a progressive test (TLCO/Qc versus VO(2peak), r = 0.57, P<0.01) in these patients.

CONCLUSIONS

Patients with CHF are able to recruit reserves of TLCO and Q(C) during exercise. However, the TLCO/Q(C) ratio is consistently impaired in these patients and relates to both exercise hyperpnea and peak exercise oxygen consumption. Whether this impairment in alveolar gas exchange is reversible in CHF and therefore is a potential target for therapy has yet to be determined.

Predictors of nocturnal oxygen desaturation in patients with COPD

The aim of this study was to identify factors which might predict nocturnal desaturation (defined as a fall of > 4% from awake baseline level for > or = 5 min) in normoxic or mildly hypoxic patients with stable COPD [arterial O2 saturation (SaO2) > or = 91%]. The study was prospective in nature, had full ethical approval and was performed in the Respiratory Department of a city teaching hospital. Thirty-three patients [mean (SD) age 67.2 (9) years] with stable COPD [mean (SD) FEV1 36.8 (11.0)% pred.] were recruited via the respiratory outpatient clinics and through the respiratory wards. The following parameters were measured: daytime arterial blood gases; spirometry; lung volumes (helium dilution); single breath CO transfer factor (TLCO and KCO); maximum inspiratory (IMP) and expiratory mouth pressures; pulse oximetry (SpO2) across a 6-min walk test, and SpO2 during sleep. Seventeen patients who experienced nocturnal desaturation had significantly lower mean PaO2 and SaO2, and higher PaCO2 values compared to non-desaturators. There was a positive correlation between mean nocturnal SpO2 and daytime PaO2, SaO2, and minimum exercise SpO2, and a negative correlation between mean nocturnal SpO2 and PaCO2, and FRC. Regression analysis revealed that daytime SaO2 was the only independent predictor of mean nocturnal saturation (accounting for 61% of the variability in the mean nocturnal SpO2). We observed nocturnal desaturation in all patients with a daytime SaO2 < or = 93% but in no patient with SaO2 > or = 95%. We conclude that daytime SaO2 can be used to predict nocturnal desaturation in normoxic or mildly hypoxic patients with stable COPD. Nocturnal desaturation is likely in patients with COPD where daytime SaO2 < or = 93%, and unlikely where daytime SaO2 > or = 95%.

Is high-dose fluticasone propionate via a metered-dose inhaler and Volumatic as efficacious as nebulized budesonide in adult asthmatics?

The efficacy and tolerability of fluticasone propionate (FP) 2 mg daily via a metered-dose inhaler and Volumatic (Glaxo Wellcome) spacer device was compared with nebulized budesonide (nBUD), 2 and 4 mg daily, in a multi-centre, open-label, cross-over study of adult asthmatics. Patients received, in random order, either 4 weeks of treatment with FP followed by 4 weeks of treatment with nBUD, or vice versa, with an intervening 4 week 'wash-out' period between treatments. Thirty patients completed the study, of whom 24 were evaluable. In terms of the primary efficacy parameter, change in mean morning peak expiratory flow (PEF) (l min-1) from baseline to the fourth week of each treatment period, FP was more effective than nBUD [mean difference (FP-nBUD) 21.1 l min-1, P = 0.007, 95% CI (6.5, 35.7)]. Sub-group analysis demonstrated FP to be superior to the 4 mg nBUD [mean treatment difference (FP-nBUD) 42.9 l min-1, P = 0.026, 95% CI (7.1, 78.8)] and at least as efficacious as the 2 mg nBUD sub-group [mean treatment difference (FP-nBUD) 10.2 l min-1, P = 0.211, 95% CI (-6.5, 26.9)]. Furthermore, larger reductions in diurnal variation were observed during FP treatment [mean treatment difference (FP-nBUD) -4.4 percentage points, P = 0.028, 95% CI (-8.4, -0.5)]. There was no significant difference between the treatments for the proportion of symptom-free 24 h periods. Of those expressing a preference, significantly more patients found FP via a metered-dose inhaler and spacer device both easier to administer (78%, P = 0.007) and more convenient to take (76%, P = 0.008) than nebulized budesonide. In addition, cost per patient analysis showed that nebulized budesonide was from 1.7 to 3.5 times more expensive than FP.

Femorocaval bypass with femoral crossover bypass for iliofemoral and caval occlusion

Progress in the management of major venous obstruction has lagged far behind advances in arterial reconstruction. As a result, literature reports consist of small numbers of patients, and most vascular surgeons have little or no experience in performing bypass procedures for major venous obstruction. In this setting, individual reports add to our cumulative knowledge in treating this disease. We therefore present our experience in the management of a patient with extensive bilateral femoropopliteal, iliac, and vena caval occlusion.

Massive osteolytic bone metastases from a primary aortic sarcoma: a case report

We present an unusual case of an aortic intimal sarcoma, which originally manifested itself by the presence of extensive radiologically osteolytic lesions in the long bones of the lower limbs. The histology of these was puzzling and was first considered to represent a low grade sarcoma of vasoformative tissue and subsequently skeletal angiomatosis. Despite a good initial clinical response to disodium etidronate, the patient ultimately developed small bowel infarction and the true diagnosis only came to light at autopsy. This revealed a tumour in the lower thoracic aorta which, unusually for aortic sarcoma, consisted of loosely packed bland spindle cells with no necrosis and infrequent mitoses. Immunocytochemistry was unhelpful but electron microscopy suggested myofibroblastic differentiation. The majority of previous reports of the tumour in the literature lack information on electron microscopy and immunocytochemistry and have suggested that these tumours are generally pleomorphic in appearance. Embolic phenomena and post mortem diagnosis are usual although occasional antemortem diagnosis has been made using computed tomography (CT) and magnetic resonance imaging (MRI) scanning with the latter being the investigation of choice.

Endothelin-1-induced bronchoconstriction in asthma

Endothelin-1 (ET-1) has been indirectly implicated in the pathophysiology of asthma, and it is a potent bronchoconstrictor both in vitro and by inhalation in animal models in vivo. We examined the effect of inhaled ET-1 on airway tone in comparison with methacholine in eight asthmatics and five healthy volunteers in a double-blind randomized fashion. After a screening methacholine challenge each asthmatic had two ET-1 (doubling dose range, 0.96 to 15.36 nmol) and one methacholine (doubling dose range, 0.33 to 21.0 mumol) challenge, and normal subjects had a single ET-1 challenge. Inhalations were delivered using a dosimeter, and lung function measurements were made using constant-volume body plethysmography, with end points being a 35% fall in specific airway conductance (SGaw) and a 15% fall in FEV1. Samples for plasma ET-1 were taken before and after the inhalations, and pulse, blood pressure and oxygen saturation were monitored throughout the inhalations. All the asthmatic subjects displayed rapid-onset (< 5 min) dose-dependent bronchoconstriction to ET-1 across the dose range used, with mean (range) ET-1 PC35SGaw values of 5.15 (1.4 to 13.9) nmol, and 4.3 (1.2 to 8.3) nmol for the two ET-1 inhalations, and 0.42 (0.2 to 0.7) mumol for methacholine. Albuterol completely and rapidly reversed ET-1-induced bronchoconstriction, and in two patients not given albuterol, bronchoconstriction lasted 60 to 90 min. No significant bronchoconstriction was observed in any of the healthy volunteers across the ET-1 dose range used (mean PC35SGaw > 15.36 nmol). Oxygen saturation did not alter in either group, and plasma ET-1 did not change after ET-1 inhalation. Noninvasive blood pressure measurements revealed a fall in systolic blood pressure in normal subjects, with no change in asthmatics. Endothelin-1 is a potent bronchoconstrictor in asthma, with a bronchoconstrictor potency around 100 times that of methacholine in asthma. Asthmatics exhibit bronchial hyperreactivity to ET-1, and inhaled ET-1 can safely be given to asthmatics and normal subjects in the nebulized dose range 0.96 to 15.36 nmol.

Endothelin-1 levels in induced sputum samples from asthmatic and normal subjects

BACKGROUND

Endothelin-1 (ET-1) is a potent bronchoconstrictor which may have a role in the pathogenesis of asthma. The levels of ET-1 in saliva, induced sputum, and plasma from asthmatic and non-asthmatic subjects were compared.

METHODS

Sputum induction was performed on 28 asthmatic subjects and nine normal volunteers. ET-1 levels were measured in plasma, saliva, and sputum samples and reversed phase high performance liquid chromatography (RP-HPLC) was performed on saliva and sputum samples.

RESULTS

ET-1 was present in the following order of concentration in both normal and asthmatic subjects: saliva > sputum > plasma (saliva, median 30.1 and 23.9 pg/ ml, respectively; sputum, median 15.5 and 11.2 pg/ml; plasma, median 3.1 and 3.6 pg/ ml). There were no differences between asthmatic and normal subjects in the levels of ET-1 in each fluid. The levels of ET-1 in asthmatic subjects were not influenced by whether or not they were taking inhaled steroids. RP-HPLC of sputum and saliva confirmed the presence of ET-1 in these fluids.

CONCLUSIONS

Levels of ET-1 can be measured in saliva and sputum obtained by sputum induction in asthmatic and healthy subjects and, although no difference was found in basal levels of ET-1 in sputum, saliva and plasma between normal subjects and asthmatics without bronchoconstriction, it is apparent that ET-1 is produced or released locally within the respiratory tract in concentrations higher than those in plasma.

Clinical features and epidemiology of malignant pleural mesothelioma in west Glasgow 1987-1992

Malignant pleural mesothelioma is almost exclusively caused by exposure to asbestos dust. Recent epidemiological studies have suggested that the national incidence of disease may continue to rise until 2020 and that asbestos exposure in the building trade may be replacing shipyard related exposure as the main source of disease. The objective of the study was to determine if the incidence of malignant pleural mesothelioma was rising in the west of Glasgow from 1987-1992 and whether there had been a change in clinical features compared to previous studies from the same population. Case notes identified from coded returns and the local cancer registry were retrospectively examined: 144 cases were identified. This is an increase in incidence of over 50% compared to the previous study but the yearly incidence did not rise over the period studied. The clinical features and survival times have not changed since previous studies: median survival remains 30 weeks. Only three patients were given definitive treatment reflecting the lack of effective therapy. We suggest that the incidence of mesothelioma in the population studied may already have peaked resulting from the decline in the local shipyard industry over 20 years ago. Non-shipyard sources of asbestos exposure may be less important in this area.

Metabolic and histologic effects of recombinant canine somatotropin on bone healing in dogs, using an unstable ostectomy gap model

OBJECTIVE

To investigate the effect of recombinant canine somatotropin (STH) on the metabolic and histologic aspects of bone healing in dogs, using an unstable ostectomy gap model.

ANIMALS

8 mature dogs.

PROCEDURE

A 3-mm ostectomy of the mid portion of the radius was performed in all dogs. Implants designed to release STH at a rate of 4 mg/d were placed SC in 4 dogs (treated group [STHG]), and another 4 dogs received no implants (control group [CG]). Serum concentrations of STH, insulin-like growth factor I, and osteocalcin were determined before surgery, and weekly for 8 weeks. Scintigraphic evaluation of the ostectomy sites was performed before surgery, and at weeks 2, 4, 6, and 8 after surgery. Histologic evaluation ofthe ostectomy sites was performed at the conclusion of the study at week 8.

RESULTS

Significant (P < 0.05) increases in serum STH, insulin-like growth factor I, and osteocalcin concentrations were observed in dogs of the STHG during the 8-week study period. Scintigraphic activity of the ostectomy sites was increased in dogs of both groups, but dogs of the STHG had significantly (P < 0.05) greater activity, compared with dogs of the CG. Coalescence of nuclear activity across the ostectomy site was observed in dogs of the STHG, whereas dogs of the CG maintained 2 distinct areas of metabolic activity. Histologically, dogs of the STHG had bridging calluses with areas of endochondral ossification and ongoing osteogenic activity, whereas dogs of the CG had nonossified fibrocartilage typical of nonunion fractures.

CONCLUSION

Using the ostectomy gap model, recombinant canine STH enhanced the metabolic and histologic aspects of bone healing in dogs.

Acute posterior multifocal placoid pigment epitheliopathy associated with pulmonary tuberculosis

Images

Herniation of lung

Non-traumatic, acquired lung hernia of pathologic variety is rare, but can be associated with tuberculous rib osteitis.

Management of chronic airflow obstruction: differences in practice between respiratory and general physicians

An audit of inpatient care of diseases characterized by chronic airflow obstruction namely chronic bronchitis, emphysema and chronic obstructive airways disease (ICD Code Nos. 490-2 & 496) was performed and the practice of respiratory and general physicians compared. One hundred cases were sampled at random from 279 cases admitted to hospitals serving the West of Glasgow in 1988. Fifty cases were selected from those admitted under the care of respiratory physicians and 50 from those under general physicians; 89 were suitable for analysis. The main outcome measurements consisted of the use of routine respiratory investigations, comparison of the use of standard therapies during the admission and at discharge, length of stay, inpatient deaths, follow up and readmission rates. The groups were similar in age, smoking history, gender and there was no significant difference in admission arterial blood gas values. The pulse rate on admission was higher in the general group (102 beats per min) in comparison to the respiratory group (91 beats per min) (P < 0.004). A similar use of chest radiograph and arterial blood gas analysis was noted between the groups. Ninety-six per cent of respiratory patients had either spirometry or peak expiratory flow measured compared to 62% in the general group (P = 0.0001). No significant differences were noted in the use of antibiotics, bronchodilators, corticosteroids, oxygen or respiratory stimulants. The mean length of stay was similar. Two patients (4%) in the respiratory group compared with seven (18%) in the general group died during the admission (P = 0.01); there were no further early deaths at 1 month from discharge.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of physiological manoeuvres on the absorption of inhaled nedocromil sodium

In a previous study we showed, in both asthmatic patients and in healthy subjects, a marked increase in plasma concentration of nedocromil immediately following an exercise challenge with associated FEV1 measurements. To identify which component of the exercise challenge is responsible, we have now studied the effect of various manoeuvres on plasma nedocromil concentration in eight healthy subjects after inhalation of 1 ml nedocromil solution (1% w/v) via a Wright nebuliser. Each patient was dosed on six occasions, separated by at least 3 days. Between 15 and 23 min after dosing one of the following manoeuvres was performed: control (no manoeuvre); steady exercise for 8 min, a series of FEV1 measurements, exercise plus FEV1 measurements, three Valsalva manoeuvres and hyperventilation for 3 min. Mean plasma drug concentrations under control conditions were similar at 15 and 23 min after dosing. However, there were significant increases in plasma drug concentration following exercise, FEV1 manoeuvres and exercise plus FEV1 manoeuvre. There were no significant changes in plasma drug concentration following Valsalva manoeuvres and hyperventilation. The results suggest that certain manoeuvres increase the absorption of nedocromil sodium, probably as a consequence of an increase in lung volume.

Functional foot salvage after extensive plantar excision and amputations proximal to the standard transmetatarsal level

PURPOSE

It is generally accepted that when necrosis extends proximal to the transmetatarsal level a viable and functional foot can no longer be preserved and a major (above- or below-knee) amputation must be performed. However, with continuing advances in operations for limb salvage we felt the need to reexamine this concept.

METHODS

In 1983 we initiated a prospective study to evaluate the role of extended foot amputations. All ambulatory patients with necrosis extending proximal to the transmetatarsal level (but not involving the whole foot) were included in the study. Among the 21 patients studied amputations ranged from open guillotine transmetatarsal amputation to removal of the medial or lateral three fifths of the foot. Five of these patients had adequate pedal circulation by clinical and laboratory criteria. The remaining 16 required vascular reconstruction to improve pedal flow.

RESULTS

Eighteen (86%) of 21 patients had complete healing of the foot amputations and were ambulatory at the time of discharge from the hospital. Two patients required early above- or below-knee amputations. Three additional patients sustained limb loss in the follow-up period. The cumulative graft patency rate was 94% at 12 months. The cumulative limb salvage rate at 24 months was 84%. The operative mortality rate was 1 (5%) of 21.

CONCLUSION

Our experience in a small number of patients suggests that functional foot salvage is possible even when necrosis or gangrene extends proximal to the transmetatarsal level.

Cervical aortic arch associated with tetralogy of Fallot

Forty-seven cases of cervical aortic arch have been reported in the literature. Eleven of these patients had congenital cardiac defects, including tetralogy of Fallot in three. An additional case of cervical aortic arch and tetralogy of Fallot is presented along with a brief review of the literature pertaining to this rare condition.

Phlegmasia cerulea dolens: the role of non-operative therapy

Thrombectomy and thrombolysis are often advocated in the treatment of phlegmasia cerulea dolens, but frequently result in incomplete clot removal, recurrence of thrombosis, local and systemic hemorrhagic complications and chronic venous stasis; this state is associated with a rate of major amputation and death of up to 50%. Non-operative therapy includes elevation, hydration and heparinization and excludes all methods aimed at surgical removal or chemical lysis of the thrombus. In 1982 it was decided to use non-operative therapy as the first line of treatment for phlegmasia cerulea dolens. In the last 9 years seven extremities in six patients with this condition have been treated. One patient had advanced gangrene on presentation and one underwent emergency thrombectomy. Five extremities (in five patients) were treated with non-operative therapy. Ischemia was rapidly corrected in all five patients. Edema resolved completely after 3-4 days in four patients. There were no complications attributable to the therapy. Two of six (33%) patients died from terminal disease. Non-operative therapy appears to be effective in preventing limb loss and avoiding the risks of thrombectomy and thrombolysis in critically ill patients.

Effect of cetirizine, a potent H1 antagonist, on platelet activating factor induced bronchoconstriction in asthma

Effect of cetirizine, a potent and specific H1 receptor antagonist, was examined on platelet activating factor-induced bronchoconstriction in 10 patients (5 male, mean [s.e.m.] aged 37.4 [3.6] years) with mild asthma in a placebo controlled, double-blind cross-over study. Airway responses were assessed by measuring specific airway conductance (SGaw). Patients were challenged with a single dose (12-96 micrograms) of PAF that had previously produced a 35% fall in SGaw. PAF challenges were performed after single dose (15 mg) and 1 week's treatment (15 mg twice daily) of cetirizine. There was no significant difference in pre- and post-treatment baseline values of SGaw on different study days and the percentage changes after cetirizine were 38.7 (7.01) and 45.6 (5.52) compared to 50.2 (2.89) and 43.9 (7.26) with placebo respectively. Similarly mean (s.e.m.) area under curve (AUC-SGaw/time course response) was 391 (143) and 514 (85) with cetirizine compared to 565 (37) and 461 (94) with placebo respectively. The difference was not statistically significant. There was no difference in facial flushing and feeling of warmth between cetirizine and placebo. We conclude that PAF induced bronchoconstriction in humans is not mediated by histamine release and that H1 receptor antagonists do not modify PAF induced bronchoconstriction.

Effect of oral and inhaled cetirizine in allergen induced bronchoconstriction

Cetirizine is a potent, selective H1 histamine receptor antagonist. The effect of oral and inhaled cetirizine was assessed on the early bronchoconstrictor response to inhaled allergen in 10 mild atopic asthmatic patients in a double-blind, randomized, placebo controlled trial. All were sensitive to Dermatophagoides pteronyssinus and this was used as the provoking allergen. The geometric mean PD20 FEV1 values obtained at allergen challenge were measured as cumulative breath units (c.b.u.) and following oral cetirizine, inhaled cetirizine and placebo were 124.5, 75.7 and 76.7 c.b.u. respectively. These did not differ significantly. We conclude that neither oral nor inhaled cetirizine significantly attenuates the early response to inhaled allergen in atopic asthmatic subjects. However, the method of repeated allergen challenge is likely to be relatively insensitive.

Dose duration of nebulized nedocromil sodium in exercise-induced asthma

The dose-duration effect of nebulized nedocromil sodium was studied in ten patients with exercise-induced asthma (7 males mean (SEM) age 30.1 (3.5) yrs and predicted forced expiratory volume in one second (FEV1) 102%). All of these patients showed > 40% protection of their exercise asthma with 4 mg of nedocromil sodium delivered via metered dose inhaler. Three concentrations of nedocromil sodium (0.5, 2.5 and 10 mg.ml-1) and placebo were administered in double-blind, randomized manner. One ml of each solution was nebulized via a Wright nebulizer. Effects were assessed from the mean maximal percentage fall in FEV1 after 6-8 min treadmill exercise at 15, 135 and 255 min following each treatment and expressed as percentage protection. The mean baseline FEV1 values before and after treatments were comparable on four days of testing. Nedocromil sodium inhibited exercise-induced fall in FEV1 at all concentrations (p < 0.001) and the inhibitory effect was still present at 255 min. No differences were observed between active treatments.

Dose duration of nebulized nedocromil sodium in exercise-induced asthma

The dose-duration effect of nebulized nedocromil sodium was studied in ten patients with exercise-induced asthma (7 males mean (SEM) age 30.1 (3.5) yrs and predicted forced expiratory volume in one second (FEV1) 102%). All of these patients showed > 40% protection of their exercise asthma with 4 mg of nedocromil sodium delivered via metered dose inhaler. Three concentrations of nedocromil sodium (0.5, 2.5 and 10 mg.ml-1) and placebo were administered in double-blind, randomized manner. One ml of each solution was nebulized via a Wright nebulizer. Effects were assessed from the mean maximal percentage fall in FEV1 after 6-8 min treadmill exercise at 15, 135 and 255 min following each treatment and expressed as percentage protection. The mean baseline FEV1 values before and after treatments were comparable on four days of testing. Nedocromil sodium inhibited exercise-induced fall in FEV1 at all concentrations (p < 0.001) and the inhibitory effect was still present at 255 min. No differences were observed between active treatments.

Metastatic breast cancer presenting as an ovarian cyst: diagnosis by fine needle aspiration cytology

A fifty-year-old woman with a history of breast cancer presented with a clinically benign ovarian cyst. Laparoscopic aspiration of cyst fluid was performed and the cytology was suspicious of epithelial neoplasia. At subsequent hysterectomy and bilateral salpingo-oophorectomy, the specimen showed extensive metastatic breast carcinoma. Although the cytological examination of fluid from ovarian cysts is often unrewarding, this case shows that metastatic carcinoma may occasionally be diagnosed in this fashion.

True venous aneurysms and arterial "steal" secondary to arteriovenous fistulae for dialysis

In patients requiring hemodialysis, arteriovenous fistulae may be created using autogenous vessels or prosthetic grafts. Complications of such operations include thrombosis, infection, venous hypertension, pseudoaneurysm, congestive heart failure, true venous aneurysms, and arterial "steal" syndrome. Of these the last two are the least common. On reviewing the English literature (Medline search: 1969-1991) we found only 8 reported cases of true venous aneurysms secondary to creation of an arteriovenous fistulae for dialysis. Hemodynamic assessment has shown that arterial "steal" is frequently present distal to an arteriovenous fistula. However, these patients rarely have ischemic symptoms. Over the last 7 years 236 patients had arteriovenous fistulae created for hemodialysis at our institution. Three of these patients (1.2%) developed true venous aneurysms. One of these 3 patients (0.4%) also had severe hand claudication due to arterial "steal". All of these patients were treated successfully without any complications. The etiology and various therapeutic options for these rare complications are discussed.