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The study reviews the patterns of acute medical receiving in Scottish hospitals. Physicians from hospitals with an accident and emergency department and more than 3,000 medical discharges per year were questioned on consultant working behaviour, acute bed usage, the presence of triage and type of geriatric liaison service. The situation as of October 1996 in 26 hospitals is described. In six Trusts consultants have time off other duties to help with acute admissions. In five there is consultant responsibility for acute patients for more than 24 hours, up to a week. Six units have a policy of triage to specialty wards. Eighteen of the 26 units have an Acute Admission Unit (AAU). The needs related geriatric service predominates, but many geriatricians now visit the medical AAU daily. Acute medical receiving systems have been stressed by competing demands and the rise in medical admissions. Most medical units in Scotland have developed new ways of working or are looking at adaptations of their receiving systems.

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The role of vagal mechanisms in the reversal of pharmacologically-induced bronchoconstriction by deep inspiration is unclear. We examined the effect of lung inflation on methacholine-induced bronchoconstriction in six patients with severe diabetic autonomic neuropathy compared with five patients with diabetes mellitus and normal tests of autonomic function. The effect of deep inspiration on bronchomotor tone was expressed as the ratio of maximal flow rates at 70% of expiratory vital capacity (V30) calculated from complete (V30(c)) and partial (V30(p)) flow-volume curves (V30(c)/V30(p)). In patients with autonomic neuropathy the mean (range) of this ratio was 1.31 (1.19-1.47) and was not significantly different from the control patients with a mean ratio of 1.69 (1.28-2.13). These results suggest that the reversal of methacholine-induced bronchoconstriction by a deep inspiration is not mediated via vagal nerves.

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Twenty one adult patients with asthma, with positive skin test responses to the European house dust mite, Dermatophagoides pteronyssinus, were randomly allocated to a control group or to a group applying house dust mite avoidance measures. These included an initial application of liquid nitrogen to mattresses and bedroom carpets to kill the live house dust mite population. Histamine airway responsiveness, symptom scores, peak expiratory flow rates (PEF), and house dust mite numbers were determined during the two week pretrial and eight week trial periods. Nine patients in each group completed the study. By the end of the study there was a significant reduction in live mites in the "avoidance" group but not in the control group. The avoidance group showed a significant improvement in symptom scores measured on a linear analogue scale, in the number of hours each day spent wheezing (mean reduced from 8.6 to 4.5 hours), and in PEF (l/min) both in the morning (from 364 to 388) and in the evening (from 368 to 392). These changes were not found in the control group. The provocative concentration (PC) of histamine causing a 20% fall in FEV1 (PC20FEV1) had increased significantly in the avoidance group at eight weeks (from 0.58 to 2.3 mg/ml), whereas no change was seen in the control group (from 0.93 to 1.21 mg/ml). These results show that house dust mite avoidance, combined with initial killing of the mite by liquid nitrogen, diminishes airway responsiveness and improves asthma symptom control over an eight week period in adult asthmatic patients with house dust mite allergy.

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Ninety five patients (57 with limited disease and 38 with extensive disease) with previously untreated small cell lung cancer were entered into a study of short duration combination chemotherapy with intravenous cyclophosphamide (750 mg/m2) on day 1, adriamycin (40 mg/m2) on day 1, and etoposide VP-16 (100 mg/m2) on days 1, 2, and 3, with the addition on day 10 of methotrexate 50 mg/m2 with folinic acid rescue and vincristine 2 mg. The treatment was repeated on day 22 and only three courses were given. No maintenance chemotherapy was given, though patients with a complete response received radiotherapy (30-40 Gy (3000-4000 rads] to the primary site in most cases. Forty nine patients (86%) with limited disease achieved a response, with 26 (46%) complete remissions. Twenty five patients (66%) with extensive disease had a response, but only eight (21%) had a complete response. Actuarial survival analysis for the whole patient population showed a median survival of 13 months for patients with limited disease and seven months for those with extensive disease. The median survival was 14 months for those patients with limited disease who achieved a complete response, but only 10 months for non-responders. Myelosuppression was the major expression of toxicity. There were three deaths related to treatment and seven patients had febrile episodes during neutropenia that required antibiotics. Mucositis, which was usually mild, occurred in 49% of patients. The primary site was the main site of initial relapse in 56% of the patients who relapsed. Among patients with limited disease who achieved a complete response, relapses at the primary site were less common in those who received radiotherapy (five out of 12) than in those who did not (all eight). The results indicate that this short duration chemotherapy in small cell lung cancer gives response rates and the potential for long term survival similar to those obtained in other series while allowing patients the maximum time free from treatment.

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We examined the effect of nedocromil sodium on histamine airway responsiveness in twelve grass-pollen sensitive patients during the 1984 pollen season. The study was a randomized double-blind crossover comparison of nedocromil sodium administered by a pressurized aerosol (4 mg b.d.) with placebo. Crossovers were made at 14-day intervals throughout 8 weeks of the grass pollen season. Histamine airway responsiveness was assessed twice before the pollen season and at the end of each 14-day treatment period. Results were expressed as the provocation concentration (PC) producing a 10% fall in FEV1 (PC10 FEV1) and a 40% fall in flow at 30% of the vital capacity (PC40 V30(P]. During the pollen season all patients developed hay fever and seven had symptoms of asthma. The observed lowest values of PC10 FEV1 and PC40 V30(P) during the placebo treatment periods were significantly lower than mean preseasonal values although not significantly lower than theoretical expected values. Geometric means PC10 FEV1 and PC40 V30(P) were significantly higher during nedocromil sodium treatment compared with placebo. These results indicate that nedocromil sodium has a small but statistically significant effect reducing histamine airway responsiveness in grass-pollen sensitive patients during the pollen season.

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The effects of 2 concentrations of inhaled ketotifen (0.25 g/l and 0.5 g/l) were compared with saline in 7 extrinsic asthmatics with exercise induced asthma (EIA). Inhaled ketotifen produced bronchodilatation with a significant increase of 15.4% on mean baseline FEV1 at the higher concentration (p less than 0.05). After exercise the mean percentage fall in FEV1 was 38.4% in the saline group, with no significant difference in the ketotifen pretreated groups, although 2 patients did not have EIA after inhalation of either ketotifen concentrations.

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Thirty-nine patients with pollen hay fever were randomly allocated to receive either an alum-precipitated five-grass extract (Allpyral) or a two-grass conjugated extract (Conjuvac) prior to the 1982 pollen season. Efficacy was assessed by means of symptom scores, drug usage and specific IgE and IgG antibody response. Both nasal and eye symptom scores were significantly higher during the pollen season in those patients receiving Allpyral. Specific IgE and IgG measured after the pollen season showed similar rises in each group. Seven patients showed a marked elevation in specific IgE and nine a marked elevation in specific IgG, but no patient showed both. Those with a high specific IgE level tended to be younger. Symptom scores bore no relation to either specific IgE or IgG antibodies. Side-effects were mainly local and were equal in both groups.

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One hundred and five patients with inoperable non-small cell lung cancer were included in a randomized trial comparing the activity of vindesine as a single agent with the combination of vindesine and cisplatin. All patients were previously untreated and the majority (70%) had squamous carcinoma. The overall partial response rates in 88 evaluable patients were 7% for vindesine alone and 33% for the combined regime. There were no complete responders in either arm. The median survival of patients treated with vindesine and cisplatin was 11 months, compared with 4 months in those treated with vindesine alone (P = 0.008). Patients showing a partial or complete response to vindesine and cisplatin survived a median duration of 13 months, compared with 7 months for non-responders (P = 0.03). This survival benefit associated with the combination was particularly apparent for patients with ECOG performance status 0 or 1 (median survival greater than 18 months and 13 months respectively), locoregional disease (median survival 14 months) and squamous cell histology (median survival 13 months). Myelo-suppression was greater with the combination but was not a major treatment problem. Neurotoxicity, which was frequently dose-limiting, was of similar severity in both treatment groups. The results indicate that the combination of vindesine and cisplatin is superior to vindesine alone for remission induction in non-small cell lung cancer and confers a significant survival advantage compared with vindesine alone in patients with favourable prognostic factors.

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One hundred patients undergoing routine fibreoptic bronchoscopy were randomly allocated to receive premedication with either intramuscular papaveretum or oral temazepam in a double-blind manner. They all received atropine before and oxygen during the procedure. Patients found the drugs equally acceptable in terms of discomfort, anxiety and the possibility of repeat bronchoscopy, but more had recall of the procedure with papaveretum. There was no difference in secretions, coughing, relaxation and consciousness, as assessed by the bronchoscopist, but patients who had received papaveretum were more cooperative. Arterial blood gases were performed before and 45 minutes after bronchoscopy. Those given papaveretum had a significant fall in mean arterial oxygen tension of 0.96 kPa, while there was no significant change in the temazepam group. There was also a small mean rise in arterial carbon dioxide tension in both groups, with the mean rise in the papaveretum group (0.625 kPa) being significantly higher than the temazepam group (0.2 kPa). Premedication with temazepam is a useful alternative to papaveretum and has the advantage of oral administration and causing less respiratory depression.

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Exercise-induced asthma (EIA) was provoked by a standardized treadmill running for 8 min in seven atopic adult asthmatics. The tests were performed using a double-dummy technique after placebo, oral ketotifen, inhaled clemastine, ipratropium bromide and sodium cromoglycate (SCG), in a random single blind-fashion on different days. The mean post-exercise percentage fall in forced expiratory volume in 1 sec (FEV1) was 47 (s.e. 6.95), 39 (s.e. 8.35), 27 (s.e. 7.17), 23 (s.e. 7.69) and 7.0 (s.e. 4.62)% respectively. There was significantly less mean bronchoconstriction with SCG (P less than 0.01), ipratropium bromide and clemastine (P less than 0.05) but not with ketotifen. Six out of seven individual patients had significant protection of EIA with sodium cromoglycate, four with ipratropium bromide, three with clemastine but only one with ketotifen. Ipratropium bromide and clemastine were bronchodilators at rest, whereas SCG and ketotifen were not. Despite its claims to work as a mast cell stabilizing drug, ketotifen in a single dose does not have an effect similar to sodium cromoglycate in EIA, nor does it compare with inhaled clemastine or ipratropium bromide.

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Thirty-two patients seen in one area between 1974 and 1980 with a diagnosis of malignant pleural mesothelioma are reviewed retrospectively. Asbestos contact, often in the shipyards, was found in 80%. The average age at diagnosis was 64 years and chest pain or breathlessness were the most common initial symptoms. Radiology usually confirmed a pleural effusion, but rarely also showed pleural plaques or asbestosis. The most useful diagnostic investigation was pleural biopsy, with a 59% success rate. Post mortem examinations showed widespread infiltration of adjacent tissues in many, with haematogenous metastases in 52%. Prognosis was poor, with an average survival of 40 weeks from presentation. No treatment improved life expectancy. Thoracotomy was followed by painful chest wall masses. The incidence of mesothelioma in our area is six times higher than in the rest of Scotland. As the disease has a long latent period between asbestos exposure and appearance, it will be many years before this rate is significantly reduced.

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