Classification of pulmonary lesions into central and peripheral with a template applied on chest X-ray.

To facilitate the understanding of the anatomical localization of pulmonary lesions and to optimize diagnostic evaluation, a template was designed which, on conventional chest X-rays, could be employed to discriminate between central and peripheral pulmonary lesions. The term 'central' implies that the lesion should be visible in the tracheobronchial tree through a fibre-optic bronchoscope, and the term 'peripheral' suggests that the lesion is not visible through a bronchoscope. In 20 patients examined by fibre-optic bronchoscopy, the bronchoscope was wedged into four pre-selected segmental bronchi in each lung. Using fluoroscopy, the tip of the bronchoscope was marked out on the skin with leadshot. On subsequent chest X-rays, with posterior-anterior and right lateral views, the distances and angles of the markings of the bronchi were mapped out in relation to the main carina. These data were used to design the template.

Orally administered N-acetylcysteine may improve general well-being in patients with mild chronic bronchitis.

Oral N-acetylcysteine (NAC) exerts a beneficial action in chronic bronchitis by reducing the number of exacerbations. There have been few studies of the effect of NAC (or of any other drug) on general well-being in chronic bronchitis. We used an established psychiatric instrument (General Health Questionnaire; GHQ) and a visual analogue scale (VAS) to measure well-being in a 22-week, placebo-controlled, double-blind, parallel-group study of NAC administered as sustained release tablets 600 mg b.i.d., including during the winter months, to patients with mild chronic bronchitis. One hundred and fifty-three patients were accepted for randomized treatment, 129 finished the study (59 NAC, 70 placebo), and well-being was measured in 105 (46 NAC, 59 placebo). The number of observed exacerbations was unexpectedly low in both groups. The number was lowest in the NAC group, however, the difference did not reach statistical significance in the present study (P = 0.08). There were no statistically significant differences between NAC and placebo in subjective symptom scores, FEV1 or FVC. The distribution of GHQ score at baseline was uneven, but NAC was significantly superior to placebo in terms of a favourable effect on GHQ score. GHQ score correlated with the number of exacerbations, and VAS correlated with GHQ score. This study therefore demonstrates the validity of measuring general well-being in patients with mild chronic bronchitis. Future studies of the treatment of chronic bronchitis should use a battery of more specifically adapted instruments which are now becoming available to measure well-being.

A double-blind comparison of amlodipine and placebo added to open enalapril in patients with moderate to severe essential hypertension.

The antihypertensive efficacy and tolerability of amlodipine in combination with enalapril were assessed in this two-center study. Patients with moderate to severe hypertension and with diastolic blood pressure > 95 mm Hg after 4 weeks of treatment with open-label enalapril 5-10 mg daily were randomized to receive amlodipine 10 mg daily or placebo, double-blind for a further 4 weeks, in combination with open-label enalapril. There were significantly larger falls in mean supine and standing blood pressure in patients treated with enalapril plus amlodipine than in those treated with enalapril plus placebo. There was no clinically or statistically significant difference between treatment groups in pulse rate, ECG, or body weight. Side effects were generally mild or moderate with a similar incidence in both treatment groups. The study showed once-daily amlodipine to be effective and well tolerated when administered as add-on therapy to enalapril.

Amlodipine with enalapril therapy in moderate-severe essential hypertension.

The efficacy and toleration of amlodipine (10 mg once daily) was compared with placebo in a four-week double-blind parallel group two-centre study in 38 patients who were receiving enalapril. Patients were moderate to severe hypertensives whose blood pressure was not adequately controlled by enalapril (5-10 mg once daily) (diastolic blood pressure greater than 95 mmHg after four weeks). Results are expressed as the mean difference, in baseline to final changes, between the two treatment groups. At the end of the double-blind period amlodipine patients had significantly greater decreases in supine (-19.4/-10.2 mmHg, P less than 0.001/P less than 0.001) and standing (-16.2/-10.2 mmHg, P less than 0.005/P less than 0.001) blood pressures than the placebo group. There was a greater fall (P = 0.005) in standing diastolic blood pressure at the UK centre (-17.1 mmHg) than in Denmark (-11.2 mmHg). However, pooling the standing diastolic blood pressure data from the two centres gave an overall significant mean treatment difference (-10.2 +/- 2.4 mmHg/P less than 0.001). There were no clinically or statistically significant changes in mean heart rate. Nineteen out of 20 patients in the amlodipine group compared to seven out of 18 patients on placebo, were assessed as improved by the investigator. Similarly 14 out of 19 patients receiving amlodipine were classified as responding to treatment (supine diastolic blood pressure less than 90 mmHg or reduction from baseline of greater than 10 mmHg after four weeks of double-blind therapy) in contrast to four out of 17 receiving placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

The captopril test for identification of renovascular hypertension: value and immediate adverse effects.

To develop a screening test for identification of renovascular hypertension, the blood pressure and plasma renin concentration responses to an oral test dose of captopril (6.25 mg) were studied in 47 hypertensive patients of mean age 61 years (range 34-85 years). Blood pressure was measured at 15-min intervals for 90 min after administration of captopril. Blood samples for plasma renin determination were drawn immediately before and 90 min after drug administration. Eleven patients had renal artery stenosis. The fall in diastolic blood pressure in these patients was greater, on average, than in patients with other forms of hypertension (30 mmHg vs. 14 mmHg, P less than 0.01), as was the increase in plasma renin concentration (188 mU l-1 vs. 2 mU l-1, P less than 0.01). This study demonstrates that the short-term captopril test is useful for distinguishing patients with renovascular disease from those with other forms of hypertension. During the test, 7 patients (15%) exhibited reversible cerebral symptoms. In two of these subjects digital subtraction angiography was performed, which revealed stenosis of the carotid artery. Consequently, it is suggested that captopril should not be used in patients with arteriosclerotic stenoses of the carotids.

[Severe first dose reaction after administration of captopril to patients with carotid artery stenosis]. / Alvorlig første dosis reaktion efter indgift af captopril til patienter med arteria carotis stenose.

During recent years, ACE inhibitors have been employed to an increasing extent in the long-term treatment of arterial hypertension. As part of the investigation of arterial hypertension, the captopril test, with administration of a small oral dose of captopril and registration of the blood pressure and pulse during the subsequent period, is employed. During this test, two cases of marked fall in blood pressure accompanied by symptoms of inadequate cerebral circulation were observed. Both of these patients were subsequently submitted to digital subtraction angiography of the vessels of the neck and both found to have unilateral stenosis of the carotid artery. It is concluded that, particularly in elderly hypertensive patients, ACE inhibitor treatment should always be initiated during controlled conditions. Stethoscopic examination of the carotid arteries should always be performed.

[Peroral terbutaline in the treatment of patients with severe irreversible obstructive pulmonary disease]. / Peroral terbutalinbehandling af patienter med svaer irreversibel obstruktiv lungefunktionsnedsaettelse.

This investigation assesses the effect of oral terbutaline in doses of 7.5 mg twice daily as compared with placebo in patients with moderate to severe chronic airflow limitation (CAL) without reversibility. Seventeen patients completed this double-blind randomised cross-over trial. Diaries with reports of dyspnoea during activities of daily living and peak-flow measurements, were obtained. Measurement of pulmonary function, walking distance and various scorings of function after treatment for three and five weeks were assessed. The investigation demonstrates that in patients with CAL treatment with terbutaline tablets may lead to improvement of several subjective effect variables although no real improvement in the majority of objective effect variables is observed. In patients with irreversible obstructive reduction of pulmonary function, in whom no other form of treatment can be considered, oral treatment with beta-2-agonists may be attempted. If no effect is obtained, the treatment should be withdrawn after one to two months.

[The captopril test as a part of the examination in arterial hypertension. Value and immediate complications]. / Captopril-test som led i udredningen af hypertensio arterialis. Vaerdien heraf og umiddelbare komplikationer.

The results and immediate complications of oral administration of 6.25 mg captopril in 47 patients with arterial hypertension are described. The blood pressure was measured every 15 minutes for 90 minutes and the plasma renin concentration was measured before the test and at the conclusion of the test. Eleven of the patients had stenosis of the renal arteries. This investigation rendered it possible to differentiate this group from other patients with hypertension from other causes. Patients with renovascular hypertension had thus significant decrease in diastolic blood pressure and significant increase in plasma renin concentration in contrast to the remaining patients. Seven patients developed cerebral symptoms in connection with the decrease in blood pressure. Angiographic examination in two of these patients revealed stenosis of the vessels in the neck. Angiotensin converting enzyme inhibitors should be avoided in patients with recognized poor cerebral circulation or murmurs over the vessels in the neck.

Effects of oral terbutaline in chronic airflow limitation.

A randomized, double-blind, crossover study was conducted to assess the efficacy of five weeks' treatment with terbutaline, 15 mg daily, compared with placebo in 17 evaluable patients with moderate to severe chronic airflow limitation (CAL) with a minor reversible component. A significant improvement after terbutaline treatment compared with placebo was observed in subjective assessments of breathlessness after two of the activities of daily living, and in daily peak flow measurements recorded in patient diaries. At the clinical assessment after five weeks' terbutaline therapy, 12 of 17 patients had improved pulmonary symptom scores compared with placebo, and a slight increase in FEV1 was observed relative to placebo (0.09 L, p less than 0.05). Thus, five weeks' treatment with oral terbutaline in patients with CAL resulted in significant improvements in several subjective assessments, despite a lack of effect on the majority of the objective variables.

Diagnostic value of ferritin analysis in pleural effusions.

Ferritin was analysed with an immunoradiometric assay using anti-spleen ferritin antibodies, in pleural effusions (Pl) from 28 patients with malignant effusions (18 carcinoma, 10 mesothelioma), 15 patients with non-malignant exudative effusions of unknown aetiology, and from 12 patients with transudative effusions due to congestive cardiac failure. Geometric mean Pl-ferritin was 617 micrograms/l in carcinoma, 1301 micrograms/l in mesothelioma (p less than 0.01 against carcinoma), 931 micrograms/l in non-malignant exudates, and 178 micrograms/l in transudates (p less than 0.0001 against malignant and non-malignant exudates). There was no correlation between Pl-ferritin and Pl-protein, Pl-albumin or Pl-cell count. P1-ferritin displayed a wide overlap between the various groups, and was of no value in the discrimination between malignant and non-malignant exudates. In the differentiation between exudates and transudates, the diagnostic accuracy of Pl-ferritin was only slightly lower compared to Pl-protein and Pl-albumin. With the present method, analysis of Pl-ferritin appears to be of limited value in the routine diagnostic evaluation of pleural effusions.