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In order to assess patients' preferences for different inhalation devices a questionnaire has been developed. The questionnaire consisted of items covering various aspects considered important for patients who regularly use inhalation devices. The questions were designed to be of a general character so any inhalation device could be evaluated. We evaluated the questionnaire in a multicenter, open crossover study comparing patients' opinions of MDI with and without spacer and of a dry powder inhaler, Turbuhaler. One hundred twenty-three patients with stable asthma confirmed by daily peak expiratory flow rate (PEF) measurements used for 2 weeks MDI only and MDI with spacer and for 2 weeks Turbuhaler. The order was randomized. The drugs were terbutaline inhaled via MDI and Turbuhaler and budesonide inhaled via MDI with spacer and turbuhaler. At the end of each evaluation period the patients answered a number of questions about their opinion by marking on a visual analogue scale. A factor analysis revealed that the different questions represent a few common factors important for evaluating opinion about inhalation devices. These factors are handling of the device, use, time to learn how to use the device properly, how confident the patients feel about the use of it, and taste/irritation. A standardized questionnaire of reduced size seems to be a suitable method for evaluating patient preference for different inhalation devices.

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Terbutaline sulphate was administered to 40 adult asthmatic patients via an ordinary metered-dose inhaler (MDI) or one connected to a 750-ml spacer in an open, randomized, crossover study. Spirometry was obtained before the start of the study and again after four weeks of treatment with each inhaler. The patients recorded on a diary card the severity of their asthma symptoms and the peak expiratory flow rate (PEFR) in the morning before and after drug administration and in the evening. Preinhalation spirometric values were higher after four weeks with the 750-ml spacer than at the start of the study (P less than or equal to 0.05). Daily morning and evening PEFR values were higher after use of the 750-ml spacer than after use of the ordinary MDI (P less than 0.05). Daily symptom scores were generally low. A significantly better effect (P less than or equal to 0.05) with the 750-ml spacer was achieved only in daytime dyspnea. The investigators conclude that the attachment of a 750-ml spacer to an ordinary metered-dose inhaler can improve the efficacy of terbutaline sulphate in the long-term treatment of asthma.

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In a short-term, open cross-over clinical efficacy study, inhalation of budesonide 800 micrograms once daily was compared to inhalation of budesonide 400 micrograms twice daily and beclomethasone dipropionate 200 micrograms four times daily in 20 patients with stable steroid-dependent chronic asthma. Budesonide was inhaled through a spacer tube. The drugs were given in 3-week periods. Clinical symptoms, consumption of beta 2-agonists and peak flow were measured. In all but one patient, the reduced frequency of budesonide inhalations to only once daily has not given significantly different results compared with more frequent inhalations.

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Plasma cortisol concentrations have been measured in 14 asthmatics previously treated with oral steroids in addition to conventional doses of beclomethasone dipropionate. Three months after switching over to budesonide in a dose of 800 micrograms twice daily, oral steroid intake has been reduced and a return of the initially depressed adrenal function has been achieved.

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There is considerable evidence that the inducible enzyme aryl hydrocarbon hydroxylase (AHH) plays an important role in the activation of polycyclic aromatic hydrocarbons (PAH) to ultimate carcinogens. In man, a genetic heterogeneity of AHH inducibility has been demonstrated, and correlated to susceptibility to bronchogenic carcinomas following exposure to PAH. We assessed AHH inducibility in a control group of 102 healthy Swedish citizens and in 41 patients with laryngeal carcinomas. Frequencies of the three phenotypes of high, intermediate and low AHH inducibility in our control group; 8.8%, 42.2% and 49%, respectively, did not differ significantly from frequencies found in a white US population. In the laryngeal carcinoma group, there was a statistically highly significant overrepresentation of patients with high AHH inducibility, 36.6%, whereas 43.9% had an intermediate and 19.5% a low level. Most of the patients were heavy smokers. These findings add further support to the concept that susceptibility to PAH-induced carcinomas is associated with high levels of inducible AHH activity.

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In the light of substantial recent advances in knowledge regarding the use of inhaled corticosteroids, general recommendations for such treatment are reviewed. The therapeutic effect is dose-related. High dose treatment has been shown to be effective in improving asthma control and reducing oral steroid requirement, while adverse side effects are usually of little consequence. The use of metered dose inhalers using correct technique and at a convenient time is a basic prerequisite in securing maximum effect. The development of new drugs with a better separation of local and systemic effects is improving therapeutic potential.

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The additional effect of N-acetylcysteine in combination with inhaled terbutaline was studied in a controlled randomized double-blind cross-over study of one week periods in 22 patients with stable reversible chronic obstructive pulmonary disease. The patients improved clinically, more during the period with acetylcysteine in combination with terbutaline, than during the period with placebo/terbutaline. The differences were particularly noticeable on the parameters 'difficulties in raising sputum' and 'number of coughs'. Seventeen of 22 patients felt greater improvement during the period with acetylcysteine. Also a small improvement in FEV1 was found by addition of acetylcysteine. No side-effects of acetylcysteine were reported in this combination.

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The levels of aryl hydrocarbon hydroxylase (AHH) inducibility were assessed in 173 patients with cancers statistically associated with smoking, i.e., squamous cell and transitional cell carcinomas, at various sites. In 34 patients with carcinomas of the oral cavity, 41 patients with laryngeal carcinomas, and 22 patients with pulmonary carcinomas there was a highly significant overrepresentation of high inducers, whereas 30 patients with carcinomas of the renal pelvis and ureter and 46 patients with urinary bladder carcinomas did not differ significantly in this respect from a control population comprising 92 subjects with no history of neoplastic disease. The results add further support to the concept of AHH as a major activator of carcinogens belonging to the group of polycyclic aromatic hydrocarbons (PAH) when these affect the oral cavity and/or the respiratory tract. The role of AHH in urothelial carcinogenesis seems to be less explicit.

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A pressurized inhalation aerosol should be actuated at the beginning of a slow and deep inhalation, followed by a long pause of breathholding. In this study a registration was performed on the mode of inhalation. The flow-volume curve and the moment of actuation were obtained from an aerosol actuator provided with sensors, and the breathholding pause was measured. Data were obtained from 34 asthmatic patients, regularly trained to use the pressurized aerosol, and these data were compared with those from 44 untrained patients. When the subjects used a terbutaline sulfate aerosol in their usual fashion, most of the trained subjects succeeded well. Further improvements could possibly be made regarding the depth of inhalation and, after control with the recording device, regarding the flow rate at actuation. Most of the untrained subjects did not use a deep enough inhalation with respect to their vital capacity, and their breath-holding pause was very short. It only seems possible to improve these parameters by regular training. In order to reach optimal results the asthmatic patients must be regularly controlled and instructed regarding their use of a pressurized inhalation aerosol. A recording device is useful in demonstrating to each subject which parameter can be improved.

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A total of 121 pleurodeses using instillations of quinacrine (mepacrine) in patients with recurrent pleural effusion were performed. All but three patients suffered from pleural malignancy. A comparison was made between the results achieved by repeated thoracenteses (73 cases) and by simultaneous tube drainage (48 cases). Tube drainage shortened the treatment and lowered the number of painful interventions. There was no difference in the quality of pleurodesis achieved by the two methods. The treatment failed in 12% of patients treated by repeated thoracenteses and in 14% of those treated by tube drainage. Patients with pleurodeses survive longer than non-treated subjects and have a considerably better quality of life.

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Racemic epinephrine in doses of 4.5 and 9 mg were administered by IPPV with a Bird Mark 8 in a double-blind, crossover study on consecutive days to 12 normal subjects and to 12 patients with airways obstruction. Normal subjects did not react with any clinically significant change in pulse rate or blood pressure. PEFR in the patients increased by an average of 35% from 5 to 60 minutes after 4.5 mg and by 44-42% after 9 mg. The increase after the larger dose was significantly larger five minutes after inhalation. There was no clinically significant change in pulse rate or blood pressure but a slightly greater frequency of mild side effects among the normal subjects and after the larger dose.

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Repeated transthoracic intracavitary injections of amphotericin B, nystatin and pimaricine proved a simple and safe method in the treatment of bilateral pulmonary aspergillomas in a patient with large cavities caused by lung disease in ankylosing spondylitis. Both large mycetomas were dissolved by this treatment in combination with peroral corticosteroid medication, and the patient's general condition improved markedly.

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