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The 575 inhabitants of the remote Anatolian village of Karain suffered 11 deaths from pleural mesothelioma in 1975/76 and there were five cases of fibrosing pleurisy. In the previous five years there had been 25 cases of mesothelioma. Calcified pleural plaques were common on survey radiography. Asbestos does not occur in the local soil or rock, nor is it handled in the village, but a few fibres were found in the water. Fibres were also found in the pleural tissue of two of five cases examined. Inhabitants of the neighbouring villages are free of mesothelioma. [ABSTRACT FROM PUBLISHER]

Introduction: Biomass (organic) fuels cause indoor air pollution when used inside dwellings. We evaluated the frequencies of chronic obstructive pulmonary disease (COPD) and chronic bronchitis (CB) among rural women using biomass fuels for heating and cooking and compared them to women living in urban areas where such fuels are not used.Methods: From electoral lists we randomly selected 242 women living in rural areas near Kayseri, Turkey and 102 women living in apartments in the city having central heating and cooking with fuels other than biomass ones. Using a translated version of the American Thoracic Society questionnaire, with additional questions from the British Medical Research Council questionnaire, trained interviewers conducted personal interviews. They also collected information on fuels used for cooking and heating. All study subjects underwent a physical examination and measurement of pulmonary function.Results: We found that rural women were younger than urban women (mean age [and standard deviation], 40.5 [14.1] yr v. 43.6 [11.9] yr). More urban than rural women were current (14.7% v. 4.5%, p < 0.001) or past (11.8% v. 1.2%, p < 0.001) smokers. CB was more prevalent among rural women than urban women (20.7% v. 10.8%, p < 0.03). Similarly, COPD was more prevalent in rural women (12.4% v. 3.9%, p < 0.05). Although the pulmonary function tests were within normal limits, FEV[1] values in rural women were found to be relatively low compared with those of urban women (p < 0.05).Interpretation: Rural women exposed to biomass fumes are more likely to suffer from CB and COPD than urban women even though the prevalence of smoking is higher among the latter group. [ABSTRACT FROM AUTHOR]

Exposure to asbestos minerals has been associated with a wide variety of adverse health effects including lung cancer, pleural mesothelioma, and cancer of other organs. Many of the regions of Turkey have asbestos deposits. People in Doğanli village - one of these regions - have been environmentally exposed to chrysotile asbestos since they were born. In this study the effects of asbestos on micronucleus (MN) frequencies of inhabitants exposed to chrysotile asbestos have been examined. Thirty subjects who had been environmentally exposed to chrysotile asbestos and living in Doğanli village, and 25 controls were studied to assess the MN frequency. The control group was selected from healthy individuals with no exposure to asbestos and living in similar geographic conditions to Doğanli village. Peripheral blood samples were collected from each subject and cultured for MN assay. Cytochalasin-B was added to lymphocyte cultures for evaluation of MN in binucleated (BN) cells. The differences between those exposed to chrysotile asbestos and controls were not statistically significant in terms of BN cells with MN (p > 0.05). There was not a significant relationship between MN frequencies and age, sex, smoking, both in chrysotile asbestos-exposed subjects and in controls (p > 0.05). Although the detection of calcified pleural plaques found in the inhabitants has indicated environmental exposure to chrysotile asbestos, our results show that chrysotile asbestos was not an inducer of MN in subjects exposed to chrysotile asbestos.

Background: Proinflammatory cytokines are prime candidates as causative agents of the metabolic changes that eventually result in tuberculosis-associated weight loss. Microbial products and cytokines such as TNF and IL-1 increase leptin expression dose dependently in adipose tissue. Leptin plays an important role in cellular immunity., Objectives: In this study, we investigated serum leptin and TNF-alpha levels before and after antituberculosis therapy in patients with active pulmonary tuberculosis (TB)., Methods: Twenty five in patients with active pulmonary TB and 18 healthy controls participated in the study. Leptin and TNF-alpha levels were measured before treatment and six months after the treatment and they were compared with the control group. Body mass index (BMI) and chest X-rays before and after the treatment were also evaluated., Results: The leptin levels before and after the treatment were 1.66+/-1.68 ng/mL and 3.26+/-3.81 ng/mL, respectively. The leptin levels of tuberculous patients were significant than in healthy patients (P < .05). The BMI was 19.36+/-2.55 kg/m2 before the treatment and 22.87+/-3.13 kg/m2 after the treatment. The TNF-alpha level was 23.19+/-12.78 pg/mL before the treatment and 15.95+/-6.58 pg/mL after the treatment. There was no correlation between leptin and TNF-alpha levels. Leptin levels were low in patients who had sequela lesion on chest radiographs., Conclusion: Leptin levels are suppressed in tuberculous patients and low leptin levels may contribute to increased susceptibility to infection and recovery with sequela lesions.

Background: Bronchiolitis obliterans organizing pneumonia (BOOP) may be classified as cryptogenic (idiopathic) and secondary. There are no clear clinical and radiological features distinguishing between idiopathic and secondary BOOP., Objectives: To analyze the etiologic factors, clinical and radiological features, diagnostic approach and response to therapy at onset and outcome in subjects with BOOP., Methods: The medical files of Erciyes University Hospital from 1995 to 2003 were retrospectively reviewed. Patients with biopsy-proven BOOP were selected for evaluation. The etiology and initial features of BOOP, treatment, resolution, relapse, and survival were obtained from medical records, and a follow-up patient questionnaire., Results: We have diagnosed 26 cases (13 males /13 females) with BOOP syndrome (mean age 54 +/- 15 years, range 14-93). More than half the patients (58%) were classified as idiopathic BOOP. Patients presented with cough (92%), dyspnea (70%), pleuritic chest pain, hemoptysis and fever (50%). The biopsy specimens had been obtained by transbronchial and/or transthoracic lung biopsy in 18 cases (69%). At radiological evaluation, there were bilateral patchy alveolar and/or interstitial infiltrates in 16 patients (62%), and solitary pneumonic involvement in 10 patients (38%). Three patients recovered spontaneously, 5 remained cured after resection of the focal lesion. Corticosteroid therapy was given in 17 patients (65%). Apart from four patients who died (death was attributable to BOOP in only 1 patient) and three patients who relapsed, the prognosis was good in all patients., Conclusions: The etiology of BOOP is usually idiopathic. We observed that hemoptysis and pleuritic chest pain were a relatively frequent symptom in BOOP in the present series, in contrast to previous observations. The diversity of radiological and clinical presentations including hemotysis and pleuritic chest pain should prompt consideration of the diagnosis in patients with persisting pulmonary symptoms and radiological findings., (Copyright 2005 S. Karger AG, Basel)

Thrombosis of the brachiocephalic veins or superior vena cava (SVC) is rare. This study was conducted to determine the prevalence and characteristics of thrombosis of brachiocephalic veins and SVC , and its association with symptomatic pulmonary embolism (PE). The prevalence of thrombosis involving the brachiocephalic veins and SVC was evaluated retrospectively at a university hospital during the 3-year period. Patients were identified by hospital records and review of computer-generated lists of of all venograms, contrast-enhanced chest computed tomography, and magnetic resonance angiograms of the upper extremity and SVC. Thrombosis of the brachiocephalic veins and SVC was diagnosed in 33 (0.03 %) of 100,942 patients of all ages [(32 of 70,751 adult patients >or= 20 years; 0.04%)]. Twenty-three (70%) patients initially had secondary thrombosis with multiple risk factors: associated with malignancy in 14 (42%) patients, chronic disorders in 13 (39%) patients, central venous lines (CVL) and peripheral venous lines (PVL) in 9 (27%) patients, and thrombophilia in 10 (38%) of 26 patients. Swelling of the arm, head, and neck was present in 32 (97%) patients. Symptomatic PE developed before thrombosis being treated in 12 (36%) patients. All patients except eight (three, thrombolytic; five, thrombectomy) received anticoagulant therapy. Thrombosis of the SVC and brachiocephalic veins is an uncommon but serious complication in patients with malignancy, chronic disorders, CVL, PVL, and thrombophilia. Because it is important clinical problem with frequent PE, the patients with appropriate clinical findings should be diagnosed early with imaging tests and treated with anticoagulant drugs.

Background: Malignant mesothelioma (MM) is a fatal neoplasm which frequently results from exposure to asbestos or erionite., Method: Sixty-seven patients with MM were seen between 1990 and 2001. Their clinical and radiological features, as well as the therapy, were retrospectively evaluated., Results: In 51 patients (76.1%), the MM was confined to the pleura, in 14 patients it was exclusively peritoneal and in two patients, it involved both areas. Of the 67 cases, 35 (52.2%) were women. The mean (+/- SD) age for all cases was 57.6+/-11.5 years. Dyspnea (67.2%), cough (55.2%) and chest pain (50.7%) were the most frequent symptoms of onset. Pleural effusion (92.4%) was the most common chest x-ray finding, whereas pleural effusion (60.8%), pleural nodules (34.7%) and pleural thickening (34.7%) were the most common computed tomography findings in pleural MM patients. The histological subtypes of MM were determined as epithelial in 60 patients (89.5%), sarcomatous in four patients (5.9%) and mixed in three patients (4.4%). Although 50.7% and 25.4% of the cases were exposed to erionite and asbestos, respectively, 23.9% of the cases recalled no exposure to asbestos or erionite. Exposures were environmental as opposed to occupational. Thirty-five patients (52.2%) were administered chemotherapy, and follow-up data were available for 22 patients. For these patients, the two-year survival rate was 22% and the two-year progression-free interval was 15.7%. There were no differences between patients with asbestos and erionite exposure., Conclusion: MM should be considered when exudative pleural effusion is detected in a patient who has been exposed to asbestos or erionite. MM is a major public health problem in parts of Turkey and compulsory environmental control of fibrous mineral should be considered.

Tracheobronchopathia osteochondroplastica (TO) is an unusual disorder. It mainly affects men over 50 years old and clinical manifestations are observed when obstructive or infectious complications occur. A 50-year old woman was investigated because of productive cough and 42 years old man was investigated because of haemoptysis. In two cases, at bronchoscopy, the typical picture of TO was observed. Microscopic examination of the biopsy material revealed bone formation. TO should be considered in the differential diagnosis as an unusual cause of chronic persistent cough, haemoptysis, persistent atelectasis, and recurrent segmental or lobar infection.

Our aim was to determine the efficacy of ifosfamide, mesna, and interferon alpha combination therapy in malignant mesothelioma (MM) patients. Fourty-two patients (39 evaluable) with histologically proven MM were enrolled into this study from January 1999 to October 2002. The drug schedule consisted of a combination of ifosfamide, 3000 mg/m2 1-3 d intravenous infusion (iv), the uroprotective agent mesna, 3000 mg/m2 1-3 d iv every 3 wk, and interferon alpha2a, 4.5 MU subcutaneously (sc) 3 d/wk for 6 mo as first-line chemotherapy. Overall, 140 cycles were administered to the 39 patients (median, 3.5 cycles; range, 1 to 6 cycles). Among the 39 patients, 8 partial remissions (PR) (21%) were observed. Thirteen patients (33%) had stable disease for at least 8 wk and 18 (46%) had progressive disease. Overall survival (OAS) and progression free survival (PFS) for all patients were 10.0 +/- 2.9 mo (95%CI 4.3-15.7) and 5.0 +/- 1.9 mo (95%CI 1.38-8.62), respectively. One and two year survival rates were calculated as 39% and 5%, respectively. All of the PR patients had the epithelial type of MM. Their survival time was 21.0 +/- 5.7 mo (95% CI 9.9-32.1) and significantly longer than that of nonresponders (p=0.0061). The toxicity of the drug combination was mild and well tolerated. There were no treatment-related deaths. Grade 3-4 neutropenia and febrile neutropenia were seen in 10 patients (26%) and 3 patients (8%), respectively. Chemotherapy was stopped in three patients because of renal function deficiency. One of these patients who had peritoneal MM required hemodialysis. In conclusion, this combination therapy showed encouraging antitumor activity with modest toxicity.

The precise clinical manifestations of tuberculosis are likely to result from a complex interaction between the host and the pathogen. We took serum samples from a group of patients with a variety of clinical and radiological stages of pulmonary tuberculosis in order to characterize tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4) and soluble interleukin-2 receptor (sIL-2R) response. We further evaluated whether the levels of TNF-alpha, IL-4 and soluble IL-2R are related with each other, and also evaluated the levels of TNF-alpha, IL-4 and sIL-2R after anti-tuberculosis therapy and relation with radiologic scores. Forty-three inpatients with active pulmonary tuberculosis and 19 healthy controls participated in the study. Patients were divided into four categories radiologically on chest X-ray (minimal, moderate-advanced, far-advanced and with miliary infiltration). Concentrations of TNF-alpha (20.9+/-10/15.4+/-8 pg/ml) and sIL-2R (2569+/-842/1444+/-514 pg/ml) were statistically different between patients and controls (p=0.02 and p=0.0001, respectively). Before chemotherapy there was a positive correlation between TNF-alpha and sIL-2R (r=0.34), but there was no correlation between IL-4 and TNF-alpha, and between IL-4 and sIL-2R (r=-0.23 and r=-0.22). The TNF-alpha level was not statistically different in four groups before and after chemotherapy. Results of this study provided some evidence confirming the previously reported role of TNF-alpha, IL-4 and sIL 2R in the control of tuberculosis, but these cytokines were not found related with disease severity.

Multiple myeloma (MM) may manifest as diffuse bony disease (myelmatosis), as a solitary plasmacytoma of bone, or as extramedullary (extraosseous) plasmacytoma (EMP). The most frequent thoracic involvement by MM is bone involvement or pulmonary infiltrate secondary to an infectious process. Because MM, which is a disorder of the aged population, with its severe clinical course and heterogeneous symptoms, the diagnosis is difficult. The aim of this study was to investigate the causes, the frequency and the effects of prognosis of the pulmonary involvement in 38 patients with this disorder who were treated between January 1995 and April 2001 at the Department of Chest and Haematology-Oncology at Erciyes University Medical School. The patients with MM; 25 (66%) was male and 13 (34%) was female, and their mean age was 61 +/- 11 range 40-80 years. Of the 38 patients; 19 (50%) had thoracal involvement which included pulmonary involvement in 13 (%35) and thoracal bone invasion in 9 (24%). According to their clinical and radiological findings, the 13 cases with pulmonary involvement were evaluated and six had pneumonia, two had mass lesion, two had multiple nodular lesion, three had intersitial infiltration. Five (13%) of the patients with respiratory symptoms were admitted to the Chest Clinic. Malign plasma cell infiltration was detected by transthoracal lung biopsy in two patients with mass lesions, and with transbronchial lung biopsy in one patient with intersitial infiltration. The cases with pulmonary involvement were associated with progressive diseases, which included mainly renal failure and pathological bone fractures. Pulmonary involvement of MM is frequently associated with rapid progression of the disease and demonstrates the variability of roentgenographic manifestations. MM should be taken into consideration in the differential diagnosis of pulmonary infiltration in older patients with systemic complaints.

Aim: In patients on regular hemodialysis, the incidence of tuberculosis is high., Material: We present 18 (6.08%) tuberculosis patients among 296 patients on regular hemodialysis between 1980 and 1996., Results: Pulmonary tuberculosis was seen in 11 (61%) patients, 7 (38%) of whom presented with pleural effusion. Tuberculosis was extrapulmonary in 7 (38%) patients. There were 4 (22.2%) patients with tuberculous lymphadenitis, 2 (11.1%) with tuberculous peritonitis, 1 (5.5%) with urinary tuberculosis. Intermittent fever, malasia and dyspnea were the most common symptoms. The mean duration on hemodialysis before diagnosis of tuberculosis were 22.22+/-7.19 months and the mean duration of symptoms prior to treatment were 34.16+/-3.36 days. Tuberculosis was diagnosed in 10 (55.5%) patients within the first 4 months of dialysis and in 8 (44.4%) between the 1st and the 8th year of hemodialysis treatment. Our patients were treated with isoniazid, rifampicin, morfazinamid and ethambutol. Four patients died within the first 4 months of the antituberculosis therapy, in all of whom tuberculosis was diagnosed within the 4 months of dialysis. In patients who died, duration of symptoms ranged from 30 days to 60 days, mean 42 days. Overall mortality was 22.2% and correlated with the duration of symptoms prior to initiation of antituberculosis and hemodialysis therapy. Fourteen patients (77.7%) who survived longer than one year were clinically cured., Conclusion: Our results suggest that the mortality of tuberculosis is high in patients in the early phase of maintenance dialysis and delay in the disease treatment of tuberculosis. Because of their generally poor state of nutrition, and depressed cellular immunity, the mortality is high in patients in the early stage of maintenance hemodialysis. Therefore, if the diagnosis is delayed, mortality is higher. Tuberculosis should be considered strongly and treated promptly if suspected.

This population-based cross-sectional survey was carried out to determine the prevalence of chronic bronchitis and associated risk factors in a rural area of Kayseri, Central Anatolia, Turkey. Subjects (1,023) aged 20-83 yrs (81.8% of eligible subjects) were interviewed using a modified version of the adult questionnaire compiled by the European Community Respiratory Health Survey. Subjects with "presence of cough and phlegm on most days during at least three months per year for at least the two previous years" were classified as having chronic bronchitis. According to the criteria used, 138 (13.5%) were classified as having chronic bronchitis. The prevalence was higher in males (17.8%) than females (10.0%). There was no overall significant association between chronic bronchitis and age in males, but, in females, the difference between age groups was important. There was no association between chronic bronchitis and family income, although the prevalence was highest in the low-income group. Subjects who reported childhood respiratory illnesses had a 1.7-fold increased risk of chronic bronchitis compared to those without such a history. The prevalence was much higher among people exposed to biomass fuel combustion and among smokers and exsmokers than among nonsmokers. In multivariate analyses, a significant increase in the prevalence of chronic bronchitis was seen in males, those who had received poor schooling, those reporting childhood respiratory illnesses, and those exposed to biomass fuel combustion and according to smoking habit.

Adrenocortical function in patients with active pulmonary tuberculosis is a debate of matter. Previous studies related to adrenocortical function in patients with active pulmonary tuberculosis demonstrated a high rate of suboptimal cortisol response to standard dose ACTH (250 microg) stimulation test. The aim of this study was to assess the hypothalamo-pituitary-adrenal (HPA) axis in low dose (1 microg) and standard dose ACTH (250 microg) stimulation tests in the patients with active pulmonary tuberculosis. Twenty-seven patients and 21 healthy subjects were included in the study. Cortisol levels were measured before, 30 and 60 min after ACTH (1 microg or 250 microg iv) injection. Cortisol responses to 1 microg ACTH at 30 and 60 min were significantly higher in the patient group than in the control group (p<0.05). Peak cortisol levels were significantly higher in the patient group than in the control group after both 1 microg and 250 microg ACTH administration (p<0.05). Cortisol responses to 250 microg ACTH at 30 and (at 30 and 60) 60 min were significantly higher in the patient group than in the control group (p<0.05). Peak cortisol levels obtained after 250 microg ACTH and after 1 microg ACTH were similar in the patient group (p>0.05). This study shows that 1 microg ACTH iv gives an equivalent peak cortisol value to 250 microg ACTH in patients with activated HPA axis. The cortisol levels obtained at 08:00, 11:00, 17:00 and 24:00 h were significantly higher in the patients than in the controls. This study clearly shows that HPA axis is activated in active pulmonary tuberculosis rather than underactivated.

A patient with chronic cough and recent dysphagia was found to have a retrotracheal mass extending into the mediastinum on chest radiography. A computed tomographic scan confirmed a retrotracheal posterosuperior mediastinal lesion which was believed to have a neurogenic origin. A thyroid 131I scan revealed no uptake of tracer in the chest and results of thyroid function tests were normal. A large retrotracheal colloidal nodular goiter was excised through a right thoracotomy. The diagnostic approach and the safety of surgical access by thoracotomy for thyroid lesions in this unusual site are discussed.

Hypercalcemia has been known to be associated with tuberculosis. In some studies it has been reported to occur commonly. It seems that the studies in which tuberculosis was complicated by hypercalcemia were retrospective and therefore the other causes of hypercalcemia could not be excluded. We have a great deal of experience concerning tuberculosis and have not seen a patient with hypercalcemia due to tuberculosis itself. Therefore we aimed to investigate whether tuberculosis really cause hypercalcemia in a prospective study. We evaluated 104 patients with tuberculosis aged between 14-85 (mean +/- SD 38.5 +/- 15) years, 73 males and 31 females, and 50 age-matched healthy subjects aged between 19-70 (mean +/- SD 39 +/- 13) years, 33 males and 17 females. No significant differences between the patients and healthy subjects were detected in terms of 250HD3, calcium and phosphate levels. Albumin levels were significantly higher in the control group than in the tuberculous group (p < 0.02). No significant difference was found between the calcium levels measured before the therapy (2.4 +/- 0.1 nmol/L) and after the therapy (2.4 +/- 0.2). We think that patients with tuberculosis are not at risk for hypercalcemia either before or during treatment and the development of hypercalcemia as a result of tuberculosis is rather doubtful and needs to be clarified.

Adrenal glands may be involved during both acute and chronic tuberculosis. They are enlarged in acute pulmonary tuberculosis. We aimed to investigate the changes in adrenal size in acute pulmonary tuberculosis before and after therapy in a prospective study. Eleven hospitalized patients with newly diagnosed sputum positive pulmonary tuberculosis were studied. Basal cortisol levels were measured in the patients before and after the therapy. Cortisol levels were also measured 30 and 60 min after Synacthen (250 micrograms i.v.) injection in the patients before the therapy. The size of the adrenal glands was measured by computerized tomography. The maximum width perpendicular to the long axis of the body of the gland, maximum width of the medial and lateral limbs and the length of the adrenals were measured. All measurements were done before and after the eight-month anti-tuberculosis therapy. All 11 patients had an intact adrenal cortisol reserve. Both the width and length of the right and left adrenal glands were significantly greater before the therapy than after the therapy. We conclude that adrenal enlargement demonstrated by computerized tomography in acute pulmonary tuberculosis is reduced after appropriate therapy.

Diaphragm fatigue was studied in isolated phrenic nerve diaphragm strips from 28 Swiss Albino rats. Three procedures were used to estimate the isometric twitch characters and force frequency responses to fatigue of the rat diaphragm at different rates of phrenic nerve stimulation. Diaphragm fatigue was induced by using low frequency stimulation (0.2 ms pulse duration, at 5 Hz frequency, 3 min), high frequency stimulation (0.2 ms pulse duration, at 50 Hz frequency, 3 min), and by production brief submaximal contraction (25 Hz, for 160 ms at the rate of 1/s for 45 contractions). Tension was reduced to 26.67 +/- 5.10% and 6.59 +/- 2.64% and 68.69 +/- 2.45% of the initial value at the end of the low and high frequency and brief submaximal stimulation, respectively. In all the fatigue experiments, twitch tension and tetanic tension decreased, contraction and 1/2 relaxation time prolonged and force-frequency curves shifted to the right. The most significant changes were observed in low frequency fatigue whereas the most moderate ones were recorded in brief submaximal fatigue. It was concluded that fatigue in the rat diaphragm depended on the frequency and duration of stimulation as well as on the number of stimuli delivered to the muscle. Various mechanisms of muscle fatigue are described in the discussion to explain the observations made in the present investigation.

It is a well known fact that theophylline enhances the force of diaphragmatic contraction and delays fatigue. The action of caffeine which is a methylxanthine analogue on skeletal muscle are complex. It was claimed in few studies that the caffeine was more effective on the diaphragmatic contractility than the theophylline. The aim of this study is to compare the effects of theophylline and caffeine on the tension generated by fresh and fatigued diaphragmatic muscle. Studies were performed in vitro on diaphragmatic muscle strips of rats activated by electrical stimuli applied via the phrenic nerve. Isometric twitch characteristics (twitch tension, contraction and 1/2 relaxation time) were measured. Force-frequency responses were generated using twitches and tetanic contractions produced by stimulating the phrenic nerve with 0.2 ms pulses at 10, 20, 50 and 100 Hz for 1 s with 30 s intervals. Moderate fatigue was then induced by repeated submaximal contractions (25 Hz, 160 ms, at the rate of 1/s for 45 contractions). In fresh muscle 1 mM theophylline and 1 mM caffeine increased diaphragmatic tension 40.98 +/- 8.50% and 82.30 +/- 12.21% of the initial value respectively. Theophylline did not alter contraction time but prolonged 1/2 relaxation time, whereas caffeine had no effect on any one. Theophylline induced force production in all frequencies. Caffeine caused an increase in force only in < 20 Hz, but a decrease in 50 and 100 Hz. In brief submaximal fatigue, both 1 mM theophylline and 1 mM caffeine partly prevented fatigue (effect of caffeine was more potent). This study suggests that caffeine has a greater effect than theophylline on the muscle. Possible mechanism(s) of action of theophylline and caffeine on diaphragmatic contractility and fatigue were discussed. It may well be the fact that they might have different mechanisms of action on the isolated rat diaphragm.

Objective: The adrenal glands may be involved in tuberculosis. The exact frequency and extent of adrenal involvement in tuberculosis are not well known. Although there are some studies regarding adrenal gland involvement, they are not sufficient because of inadequate endocrinological tests and radiological procedures. The aim of this study was to assess the adrenal gland in acute and chronic pulmonary tuberculosis and to compare it with the findings obtained in healthy subjects., Design and Patients: We studied 20 patients with acute pulmonary tuberculosis, 41 patients with chronic pulmonary tuberculosis and 20 healthy subjects. Involvement of the adrenal gland was assessed by basal cortisol level, cortisol response to Synacthen and adrenal computed tomography., Measurements: Cortisol levels were measured before, 30 and 60 minutes after Synacthen (250 micrograms i.v.) injection. Computerized tomography of the adrenals was carried out in 61 patients with tuberculosis and 20 healthy subjects., Results: Mean basal cortisol level and 60-minute cortisol response to Synacthen were significantly higher in acute pulmonary tuberculosis than in chronic pulmonary tuberculosis and healthy subjects. Two patients with Addison's disease were diagnosed among the chronic tuberculous patients. Both length and thickness of the right and left adrenal gland were greater in patients with acute tuberculosis., Conclusion: Adrenal enlargement demonstrated by computerized tomography is common in patients with acute pulmonary tuberculosis, but our findings show that cortisol reserve is normal, in contrast to previous suggestions.

Prompted by the unusually high death rate from cancer of the lungs, in 1975 in the Middle-Anatolian village of Karain, later in two other villages, X-ray screening investigations were carried out. These revealed pleural mesotheliomas similar to those seen following exposure to asbestos, although no asbestos was found neither in the village itself or in its immediate surroundings. Minerological tests and examinations of the lungs of the deceased, together with animal experiments involving dust obtained from the village itself, performed in 1980, demonstrated that erionite, a fibrous zeolite is responsible for tumour lesions in the lungs and pleura. Early stages of this tumour located in the pleura were also found in a group of Karain inhabitants working in Sweden. On the basis of the examination results, an immune deficiency that did not correlate with age, sex or duration of exposure was found, and thus cannot readily be classified as an epiphenomenon. Since fibrous zeolites are frequently employed in industry, industrial hygiene and occupational medical consequences need to be drawn.

The rate of new infections with tuberculosis amounting to approximately 20% among the youngest inhabitants of the town of Kayseri with a present recorded incidence of acute infectious tuberculosis of about 8:10000 makes it imperative to exercise every possible effort in disease prevention by vaccination and revaccination in addition to all other measures to combat tuberculosis.

Ninety-four persons from the village of Karain, Turkey, now residing in Stockholm, were investigated clinically and radiologically. In this village, environmental exposure to erionite, a fibrous zeolite, occurs, and there is an extremely high risk of mesothelioma among the villagers. Since an earlier investigation of the cohort in 1980, another 4 young persons have fallen ill with malignant mesothelioma in this group, where the incidence thus approaches 1%/year and is the most common cause of death. Solitary pleural plaques were found in 6%, thickening of the interlobar pleura in 4% and other radiologic signs of affection of the pleura in 2%. Thickening of the interlobar fissures were observed in 1 patient as the first sign of mesothelioma which has remained asymptomatic until 1 year later. The comparatively low incidence of pleural lesions in the cohort is probably due to the low mean age (36 years). Further follow-up could give clues to the pathogenesis of malignant mesothelioma.

Among inhabitants of the village of Karain in Turkey there is an extremely high incidence of malignant mesothelioma, most probably due to exposure to erionite, which is a fibrous zeolite and similar in appearance and properties to asbestos. This mineral may be found in the dust in the village. To characterise possible disturbances in the immune system of people exposed to fibrous zeolite, a phenotypic characterisation of lymphoid cells in the peripheral blood of 74 immigrants to Sweden from Karain was performed. Compared with normal controls, the mean percentages of Leu 4+ cells (Pan-T) and Leu 3a+ cells ("helper/inducer" T cells) were significantly decreased, whereas the mean percentage of Leu 2a+ cells ("suppressor/cytotoxic" T cells) was normal, leading to a significant reduction of the Leu 3a/Leu 2a subset ratio. The percentage of B cells (Leu 12+ cells) was significantly increased, whereas the percentages of both HLA-DR+ and HLA-DQ+ cells were normal. The percentage of natural killer cells (NK) and killer (K) cells as defined by the monoclonal anti-Leu 7 and anti-Leu 11b were also normal. These findings indicate that exposure to fibrous zeolite causes a numerical imbalance between the two phenotypically different T cell subsets similar to that seen in asbestos exposed individuals.

All patients seen in 1975 to 1984 with benign asbestos pleural effusion (BAPE) were studied. In all, 73 exudates occurred in 60 patients, 40 on the left side and 33 on the right. Relapses occurred on the same side in two patients; 11 had bilateral exudates, three of them concomitantly, in the other patients with a free interval of 1-15 years. The mean latency time from the first exposure to asbestos was 30 years, with a range of 1 to 58 years. The effusions lasted from 1 to 10 months, with a median of 3 months. The most common symptoms were pain, fever, cough, and/or dyspnoea; however, 46% of the episodes were symptomless. The total number of thoracocenteses was 66, with removal of 50 to 2000 ml (mean 460) each time. Fifty-three per cent of the pleural fluids were macroscopically haemorrhagic and 26% eosinophilic. Two findings contribute to a better understanding of the entity: first, even a comparatively slight occupational exposure can be sufficient; secondly, BAPE can occur many years after exposure to asbestos, and not only in the first one or two decades.

All the 303 full time day workers in a carpet weaving factory were submitted to a physical examination, chest radiography, and vitalograph test, and answered a respiratory questionnaire. Fifty four healthy non-exposed subjects served as controls. Dust concentrations and concentrations of bacterial endotoxin were measured. Of the 303 workers, 259 (85.5%) had airway symptoms and 62 (20.5%) had maximum mid-expiratory flow (MMF) values of less than 60% compared with 9.2% of the controls. The symptoms in 68 workers (22%) were compatible with byssinosis and 36 of these workers underwent vitalography before starting work and after four hours work on Mondays when significant reductions of their FEV1 and MMF were found. Twenty one of these 36 workers were tested on Tuesday and no differences in these measurements were found between measurements before work started and four hours later. The airborne dust concentrations in the factory were high and bacterial endotoxin was found. These findings suggest that a large number of workers in this carpet weaving factory suffer from a disease indistinguishable from byssinosis even though wool is used almost exclusively, the only cotton being the warp. The finding of endotoxin together with the absence of cotton confirms the theory that "byssinosis" is due to bacterial endotoxin rather than to cotton per se.