Objectives : The combination of a 43-2 agonist and an anticholinergic agent is of­ten used to manage bronchial asthma. However, it is unclear whether these drugs should be given separately in sequence or in a fixed dose combination for maximum effect. Methods : 27 patients with stable bronchial asthma were given the above two drugs in two separate sessions one week apart. In one session they were given the above two drugs as a fixed dose combination and in the other session, they were given se­quentially with salbutamol following ipratropium after 30 minutes. Spirometry was performed at baseline and 15, 30 and 60 minutes after inhaling the second drug. Results : Both groups showed significant improvement in forced vital capacity (FVC), forced expiratory time in one second (FEV ₁ ), peak expiratory flow rate (PEFR) and forced expiratory flow (FEF _25-75 ) from baseline upto one hour. FVC increased initially and then stabilized; however, the increase was more sustained in the group getting combination treatment. This group also showed a higher rise in FEV ₁ (p=0.02). Both FEV ₁ and FEF _25-75 decreased after 30 minutes in the group that received sequential therapy. PEFR increased continuously till 60 minutes in both groups and there was no significant difference between them (p=0.98). Interpretation and Conclusion: Both methods of drug dosing produce equivalent bronchodilation. Fixed dose combinations produced a more sustained rise in FVC and higher increase in FEV ₁ . Hence fixed dose combinations are more effective short-term bronchodilators and give an added advantage of reducing the number of inhalers required, thus improv­ing compliance.

Nutritional status affects outcome in acute illnesses. Weight loss is associated with poor lung functions and outcome in chronic obstructive pulmonary diseases (COPD). There is not much data on the effects of nutritional status on hospital outcome in patients with acute exacerbation of COPD. This study was conducted to address this issue. Twenty five patients with COPD admitted with acute exacerbation in a tertiary care teaching hospital in Southern India were studied. Lung functions were as­sessed by spirometry. Nutritional status was assessed using anthropometric mea­sures {body mass index (BMI), mid-arm circumference (MAC), triceps skin-fold thickness (TSF) and fat free mass (FFM)}. Resting energy expenditure (REE) was measured using indirect calorimetry. Hospital outcome was determined by mortal­ity, number of days to improve subjectively and number of days to discharge. Patients with a lower BMI, MAC and TSF took a longer time to recover. REE was found to be lower in patients with weight loss unlike the Western patients. On multivariate analysis, only a lower BMI was associated with a longer time to re­covery. Thus, nutritional status is an important predictor of hospital outcome in patients with COPD.

It was aimed to evaluate the diagnostic utility of bronchoalve Veolar lavage (BAL) from cases of infiltrative diseases of lung admitted at Choithram Hospital & Re­search Centre, Indore (M.P.) during 2003 to 2004. The analysis included gram's staining, semi quantitative bacterial culture, AFB smear and culture, WBC and dif­ferential count and cytology. The gram's staining was found to have 83.6% sensitivity as compared to semi quan­titative culture. Colony count >10,000 / ml was considered as significant and 142 specimens yielded single organism while 56 had poly-microbial infections. Gram­negative bacilli like E.coli, Klebsiella spp. and Pseudomonas aeruginosa formed pyogenic infections. The analysis revealed pyogenic infections in 51%, tuberculosis in 21%, fungal in­fections in 12% and malignancy in 2% cases. Thus, the analysis of BAL specimen is valuable in the diagnosis of infiltrative disorders of lung.

A 18 year old Hindu boy presented with left sided chest pain, shortness of breath, high fever and swelling of left side of chest and left arm. He was anaemic with fea­tures of Superior Venacaval (SVC) Obstruction. CT Scan of Thorax revealed huge heterogeneous anterior mediastinal mass. He had very high level of serum alpha fetoprotein. CT guided Fine Needle Aspiration Cytology (FNAC) gives the diagno­sis of Yolk sac tumour . As USG of abdomen and testes were normal, it is a case of primary mediastinal Yolk sac ( Endodermal sinus ) tumour. Although nonseminomatous germ cell tumour is 30-40% more common in Klinefelter's syndrome ^[1] , Karyotyping of this patient was normal.

Simultaneous bilateral spontaneous pneumothorax and pneumomediastinum with subcutaneous emphysema following burn is unreported in the literature. We de­scribe such case in an 18-year-old male patient with possible mechanism of such presentation.

Pericardial cyst are rare anomaly. Hydatid cyst in Pericardium represent only 0.5­2% of cases of systemic echinococal infection. They are usually unilocular and filled with clear liquid giving rise to term "Spring water cyst," usually do not cause symptoms only noticed because of external compression or rupture into heart. Pericardial cysts are differentiated from other benign development abnormal­ity like benign intrapericardial branching cyst which identified on 2 dimensional echocardiography and computed tomography.

Here we describe a patient who developed lung abscess caused by Candida albicans. There was no evidence of disseminated/ extrapulmonary candidiasis or any immunodeficiency. However, he was taking high doses of inhaled corticosteroid for chronic airflow obstruction. CT guided percutaneous needle aspiration provided the specimen which confirmed the diagnosis of pulmonary candidiasis. His sputum culture was also positive for Candida albicans. The patient achieved favourable out­come with a 4 weeks treatment with fluconazole. The case is presented here due to unique possible association of pulmonary candidiasis with intake of high doses of inhaled corticosteroids.

A Case of massive haemorrhagic pleural effusion with high amylase levels second­ary to asymptomatic pancreatic disease is reported. It is suggested that pleural fluid amylase content should be measured in any case of exudative pleural effusion of unknown aetiology.

COPD is the most common chronic lung disease. It is a major cause of chronic morbidity, mortality and health care used throughout the world and resulting in an economic and social burden that is both substantial and increasing also in our country. Pharmacotherapy alone does not optimize and have limited role in im­proving dyspnea, exercise limitation and quality of life which are characteristic and troublesome features of COPD. Breathing exercises are popular among patients, physician and physiotherapist and has been shown to improve efficiency of ventila­tion and exercise performance. But the efficacy of breathing exercises in relieving dyspnea varies greatly among patients. True values of these techniques have not yet been formally established, though they would seem to have intrinsic merit.