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One hundred patients with tracheobronchial tumours were treated with the neodymium YAG (yttrium-aluminium-garnet) or If clearance of the airways was considered inadequate at the first attempt, we were prepared to give up to three sessions of laser treatment during the initial admission to hospital, after which no further treatment was attempted if the patient did not improve. Follow up treatments were given at one to three month intervals, depending on the speed with which symptoms recurred, for as long as further response was seen and breathlessness or haemoptysis remained predominant symptoms.Response to treatment was assessed by the patients' account of their symptoms and by the results of pulmonary function tests, which included peak expiratory flow rate, spirometric values, and a flow-volume loop. Exercise tolerance was measured by the six minute walking test.5 Full pulmonary function testing was not completed in a few of our early patients and could not be performed in some patients because of extreme breathlessness, but peak flow rate was always attempted on the ward with a Wright peak flow meter. These tests were performed before and after treatment and repeated at outpatient sessions and before subsequent treatments. A symptomatic improvement was recorded if the patient said that he or she felt better and if there was an improvement in the six minute walk. Objective improvement was recorded if there was a grea-341 Hetzel, Nixon, Edmondstone, Mitchell, Millard, Nanson, Woodcock, Bridges, Humberstone ter than 25% rise in peak flow rate, since this information was consistently available. Such cases usually showed improvement in spirometric indices and flow-volume loops as well. In patients with an unrecordable peak flow 601 min-' was taken as the starting point for this calculation.In patients treated for haemoptysis diary charts were recorded from the time of admission for assessment for laser treatment. After discharge home records were continued by the patient, who was asked to record each day whether blood had been coughed up and if so how much. An objective response was defined as complete cessation of haemoptysis for at least one month. A symptomatic response was defined as a significant reduction in frequency and quantity of haemoptysis. It was considered unjustifiable to delay treatment for more than a few days to monitor haemoptyses before the first treatment. In patients who were subsequently treated again (for recurrence of haemoptyses after initial good control) it was, however, possible to compare pre-treatment and post-treatment records covering several weeks. Diary charts were also used to help in deciding when further treatment was indicated.The first 14 patients were treated with the argon laser (Spectra Physics), wavelength 488 and 514 nm, output 12 w. All other patients were treated with the neodymium YAG laser (Barr and Stroud or Medilas), wavelength 1060 nm, maximum output 100 w. The laser beam was transmitted through a 200 um quartz (argon) or 600 micron glass (Nd YAG) opti...

A retrospective survey of patients with sarcoidosis has revealed a 7 5 times greater number of nurses with the condition than expected. Nurses may be especially susceptible to sarcoidosis.A recent case-control study in the Isle of Man observed an excess of health workers with sarcoidosis' and a companion study found a clustering of cases around a hospital.2 Both studies concluded that sarcoidosis may be a communicable disease. This report provides further evidence of an association between sarcoidosis and hospital based occupations, particularly nursing. Methods

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of traveler's diarrhea by the tablet form of bismuth subsalicylate. Antimicrob Agents Chemother 1986;29:625-7. 3 Sox TE, Olson CA. Binding and killing of bacteria by bismuth subsalicylate.

The frequency and characteristics of chest pain and non-respiratory symptoms were investigated in patients admitted with acute asthma. One hundred patients with a mean admission peak flow rate of 38% normal or predicted were interviewed using a questionnaire. Chest pain occurred in 76% and was characteristically a dull ache or sharp, stabbing pain in the sternal/parasternal or subcostal areas, worsened by coughing, deep inspiration, or movement and improved by sitting upright. It was rated at or greater than 5/10 in severity by 67% of the patients. A wide variety of upper respiratory and systemic symptoms were described both before and during the attack.Non-respiratory symptoms occur commonly in the prodrome before asthma attacks and become more frequent after onset of the attack. Chest pain is usual during asthma attacks. Although it is benign and self limiting it may cause diagnostic confusion and patient distress. (Postgrad Med J 2000;76:413-414)

We have recently described the use of the neodymium yttrium aluminium garnet laser in palliative treatment of carcinoma of the bronchus. ' We now report a case of acute massive haemoptysis controlled by emergency laser photocoagulation as a primary treatment. Case reportA 70 year old man presented in October 1982 with a six week history of left shoulder pain and exertional dyspnoea, with one episode of coughing up blood streaked sputum. He had smoked 15 cigarettes a day until 1980. Examination revealed a firm, mobile nodule below the left eye but no lymphadenopathy or hepatomegaly. Histological examination of the resected facial nodule showed the appearances of a mucin secreting adenocarcinoma and the chest radiograph showed an ill defined opacity above the right hilum, which was considered to be the primary tumour.His symptoms were insufficient to merit radiotherapy and he was given no specific treatment. He began to have further blood streaking of the sputum and in early December he was readmitted to hospital after coughing up about two cupfuls of frank blood containing clots. The chest radiograph showed enlargement of the shadow above the right hilum and in addition there were multiple discrete nodular opacities throughout the lung fields. While in the ward he expectorated an estimated 200 ml of fresh blood and emergency fibreoptic bronchoscopy was performed.During this procedure a further 900 ml of fresh blood were aspirated and he became shocked, with a pulse rate of 130 beats/min and a blood pressure of 100/60 mm Hg. An intravenous line was inserted and blood was taken for grouping and cross matching. A large clot was found in the orifice of the right main bronchus at the carina, and when this had been removed a nodular haemorrhagic tumour was seen to be partially occluding the bronchus. Topical adrenaline was applied but haemostasis was only partial and transient and brisk bleeding soon developed again. A flexible glass fibre was passed through the biopsy channel of the bronchoscope and a laser beam was transmitted along it and on to the tumour. The system used was a

Summary A 25-year-old man presented with an isolated trigeminal neuropathy 13 months before developing myalgia and lymphadenopathy. The onset of Raynaud’s phenomenon 2 months later suggested a diagnosis of mixed connective tissue disease (MCTD) and this was confirmed by high serum titres of speckled pattern antinuclear antibody, and antibody to ribonuclear protein.