No abstract

Two and a half hours after the onset of chest pain he was admitted to hospital. The electrocardiogram showed evidence of an anterolateral myocardial infarction (figure). The chest radiograph was normal. He was treated with intravenous diamorphine 5 mg and' prochlorperazine 12 5 mg. Soon afterwards he had a cardiac arrest and the cardiac monitor showed ventricular fibrillation. He was successfully cardioverted by a single direct current shock of 400 J. He was subsequently given 15 megaunits of streptokinase. Over the ensuing 24 hours the electrocardiographic monitor showed frequent ventricular extrasystoles, several self-terminating runs of ventricular tachycardia, and intermittently a nodal rhythm. Thereafter he made an uncomplicated recovery. Blood taken after he was resuscitated showed a rise in serum alanine aminotransferase reaching a maximum of 224 U/l the day after admission, and in lactate dehydrogenase reaching a maximum of 556 U/l two days after admission. Gamma glutamyl transferase rose to 104 U/l two days after admission.

The effect of 5 mg nebulised salbutamol on the cardiorespiratory responses to a progressive maximal exercise test was investigated in eight asthmatic (mean forced expiratory volume in one second (FEVY) 3 48 (1 -0) litres) and eight non-asthmatic men. Exercise tests were performed on a bicycle ergometer after administration of nebulised salbutamol or matched saline placebo. In the asthmatic subjects salbutamol increased the resting FEV1 by 1 1%. The mean (SD) percentage fall in FEV1 after exercise did not change significantly (salbutamol 9-4 (12.8); placebo 15 0 ( 8 0)), but because the FEV1 before exercise was increased the lowest FEV1 after exercise was also significantly higher after salbutamol than placebo (3-60 (1.13) v 2 85 (0 80) litres). Despite the improvement in FEV1 before exercise there was no significant difference in maximal workload, oxygen uptake, heart rate, or ventilation during exercise after salbutamol compared with placebo in the asthmatic patients. Tidal volume was higher at maximal exercise after salbutamol but there was no change in perception of breathlessness or exertion in the asthmatic subjects. During submaximal progressive exercise the perceived rate ofexertion was reduced in the asthmatic patients and oxygen pulse was reduced in both groups owing to a small and non-significant increase in heart rate. The FEV, and cardiorespiratory response to the progressive maximal exercise test in the non-asthmatic subjects were otherwise unchanged after salbutamol. The results suggest that 5 mg nebulised salbutamol has little effect on the cardiorespiratory responses to progressive maximal exercise in patients with mild asthma and in non-asthmatic subjects. Salbutamol in this dose may reduce the severity of exercise induced asthma, but no ergogenic effect on maximal exercise performance was shown.

Large lung bullae are a rare manifestation of pulmonary sarcoidosis. Of three patients with this complication, all had pulmonary infiltrates at presentation and two had bilateral hilar adenopathy. Hypercalcaemia developed during the course of the illness in all three patients. In each case the bullae had developed within four years of the diagnosis of sarcoidosis. In one woman a bulla resolved almost completely after it had become infected.

A 65 year old man, an ex-smoker with severe chronic bronchitis, presented with a one day history of sharp central chest pain aggravated by breathing and coughing. For two days he had complained of increased dyspnoea and a cough productive of yellow sputum. For the past five years he had received 5-10 mg prednisolone daily, regular bronchodilators, inhaled beclomethasone dipropionate 1500 ,ug daily, and frequent courses of high dose systemic corticosteroids.On examination he was dyspnoeic at rest, cyanosed, and tender over the mid sternum with obvious crepitus. There were bilateral wheezes on auscultation of the chest. The peak expiratory flow rate was 70 1/minute.Measurement of arterial blood gas levels revealed hypoxaemia and hypercapnia. The chest radiograph showed hyperinflation with mLultiple healing rib fractures bilaterally.Sternal radiographs revealed a non-united fracture of the sternal body.Despite increased bronchodilator treatment and antibiotics his condition worsened and he later died on the ward. CASE 2 A 78 year old woman was admitted with a three week history of intermittent sharp central pain, aggravated by inspiration. She was an ex-smoker and had chronic airflow Lateral radiograph of the sternum of case 2 showing sternal angle (top arrowhead) andfracture of the mid sternum with overlapping of the sternalfragments and callus formation (lower arrowhead).