Norman Wolkove

Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room

The effectiveness of nebulized anticholinergic and sympathomimetic regimens was evaluated in a double-blind study of 199 patients with acute airways obstruction. Patients were assigned to one of three treatment regimens according to a randomized schedule: 0.5 mg of ipratropium bromide, 1.25 mg of fenoterol hydrobromide, and 0.5 mg of ipratropium plus 1.25 mg of fenoterol. In 148 patients with acute exacerbations of asthma (mean one-second forced expiratory volume, 1.18 +/- 0.64 liters), all three regimens produced significant improvement in one-second forced expiratory volume (p less than 0.001). The greatest improvement followed treatment with the ipratropium-fenoterol combination (0.53 +/- 0.40 liters at 45 minutes; 0.57 +/- 0.51 liters at 90 minutes) and was significantly greater than that following either ipratropium alone (p less than 0.001) or fenoterol alone (p less than 0.05). In 51 patients with acute exacerbations of chronic obstructive pulmonary disease (mean one-second forced expiratory volume, 0.67 +/- 0.29 liter), each regimen produced significant improvement in one-second forced expiratory volume at both 45 and 90 minutes (for all, p less than 0.05), but there was no significant difference among the three treatment regimens. It is concluded that, in patients with acute asthma, combination therapy with sympathomimetic and anticholinergic agents is more efficacious than either one alone. In patients with acute exacerbations of chronic obstructive pulmonary disease, although either sympathomimetic or anticholinergic therapy provides bronchodilatation, no further benefit could be demonstrated from combination therapy.

Treatment of small cell lung carcinoma in the elderly

The number of elderly people with small cell lung carcinoma (SCLC) is increasing and currently nearly 25% are older than 70 years. Elderly patients may not tolerate intensive therapy and, therefore, often do not receive such treatment. Additionally, age may be an independent predictor for response and survival. We compared the investigation, staging procedure, and management of patients less than 60 years, 60 to 69, and older than 70 years who were diagnosed with SCLC between 1985 and 1991. We hypothesized that elderly patients were investigated and treated less aggressively, and that their outcome was poorer than that of younger patients with SCLC.

Uses and misuses of oxygen in hospitalized patients

PURPOSEnTo document the use/misuse of oxygen therapy as compared with antibiotics in internal medicine inpatients. To determine whether the same care was being taken in the prescription and administration of both forms of therapy.nnnPATIENTSnNinety-six eligible patients at a university teaching hospital were entered into a study examining the use of oxygen. They were compared with 60 patients for whom antibiotics were prescribed.nnnMATERIAL AND METHODSnThree hundred thirty consecutive newly admitted patients were screened for the presence of either (1) oxygen apparatus at the bedside, (2) physician orders for oxygen, or (3) oxygen orders noted in nursing kardex. Those meeting one of these three criteria were observed on up to four occasions over 48 hours following study entry. Similarly, patients were screened for medical orders or nursing medication kardex notation for antibiotics and were also observed for proper prescription and administration of medication. Procedural errors, determined by kardex audit and direct patient observation, were compared for the individuals with specific oxygen orders and those receiving antibiotics.nnnRESULTSnOxygen delivery apparatus was found in the room in 17 of 96 patients without it ever having been ordered by the physician or noted in the nursing kardex. In 27 of 96 patients, oxygen was noted in the nursing kardex and administered to patients without a physician order. There were no cases of antibiotic therapy without a physician order. Observations of 47 patients with specific orders for oxygen revealed the following errors: (1) physician order incorrectly transcribed to nursing kardex (16%), (2) flow meter off (34%), (3) oxygen delivery apparatus improperly worn (57%), (4) wrong fractional inspired oxygen concentration (58%). Improper transcription of antibiotic orders occurred on only one occasion (2%), and antibiotics were improperly administered in 5%. Arterial blood gas determinations preceded oxygen orders in 61%, whereas microbiologic cultures preceded antibiotic orders in 87% of the patients.nnnCONCLUSIONSnWe conclude that oxygen therapy is neither prescribed nor administered with the same attention that is given to other drugs such as antibiotics. Oxygen prescription and/or delivery is associated with significantly greater error than that seen with antibiotics. Education of medical personnel should stress more prudent prescription and use of oxygen in hospitalized patients.

Efficacy of Inhaled Steroids (Beclomethasone Dipropionate) for Treatment of Mild to Moderately Severe Asthma in the Emergency Department: A Randomized Clinical Trial

STUDY OBJECTIVEnTo examine the efficacy of an inhaled steroid, when added to a standard regimen of beta-agonist therapy, in the treatment of patients with mild to moderately severe asthma in the emergency department.nnnMETHODSnA convenience sample of adult patients with asthma (FEV1 % predicted 40% to 69%) presenting to the ED was randomly assigned in a double-blind fashion into 2 treatment groups. The first group received 2.5 mg nebulized salbutamol plus 1 mg (4 puffs) of beclomethasone dipropionate (BDP) at baseline, 30 minutes, and at 1, 2, and 4 hours, delivered by a metered-dose inhaler (MDI) attached to a spacer device (Vent-AH-aler, Glaxo). The second group was given the same salbutamol regimen plus MDI placebo through the Vent-AH-aler. The primary endpoint was improvement in FEV1 %predicted at 6 hours.nnnRESULTSnOf 54 patients enrolled, 28 were assigned to the BDP group and 26 to the placebo group. Spirometry improved significantly in both groups over the 6 hours compared with baseline (ANOVA, P <.001). At 6 hours, the mean absolute improvement in FEV1 % predicted for BDP was 18% versus 17% for placebo (95% confidence interval for the absolute difference of 1% [-8% to 10%]). The proportion of patients in the BDP group who were hospitalized was 7% compared with 19% for patients in the placebo group (95% confidence interval for the difference of 12% [-6%, 30%]).nnnCONCLUSIONnIn this group of patients with mild to moderately severe asthma, 5 mg BDP delivered by MDI during the initial 4 hours of an emergency visit was of no added benefit over standard therapy, as measured by improvement in FEV1 % predicted at 6 hours. However, a trend toward a difference in admission favoring BDP was observed. [Afilalo M, Guttman A, Colacone A, Dankoff J, Tselios C, Stern E, Wolkove N, Kreisman H: Efficacy of inhaled steroids (beclomethasone dipropionate) for treatment of mild to moderately severe asthma in the emergency department: A randomized clinical trial.

Problems in radiographic estimation of response to chemotherapy and radiotherapy in small cell lung cancer

Assessment of the response to therapy in small cell lung cancer requires serial tumor measurements with chest radiographs before and after treatment. Those lesions that are not measurable may be evaluated for response using subjective criteria. We studied interobserver variability in tumor measurement in 21 patients with small cell lung cancer. In addition, we analyzed the effect that the variability in measurement had on the estimation of response to combination chemotherapy with and without chest radiotherapy. Half the readers agreed that pretreatment radiographs were measurable. Posttreatment, they were more often unmeasurable. Starting from a base of 100%, representing all measurable pretreatment films, posttreatment measurability rates fell to 78% and 53% on the 2‐month and 4‐month films. After radiotherapy, changes particularly reduced the readers ability to measure the tumors. There was also less interobserver agreement on response after radiotherapy. The intraclass correlation coefficient for partial or complete response versus no response was 0.42 where no chest radiotherapy had been administered and 0.17 after radiotherapy. A measurable lesion on the initial radiograph was important in improving the consistency of evaluation of complete versus partial response particularly in films taken after chemotherapy alone. These data indicate that there is only fair agreement as to whether tumors were measurable and whether a response had occurred. More consistent results were seen in films taken before administration of radiotherapy. A measurable pretreatment film was important in improving interobserver consistency in differentiating a complete from a partial response.