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Pulmonary arteriovenous malformations (PAVMs) are a rare clinical entity. Most of them are associated with hereditary haemorrhagic telangiectasia. The usual clinical presentation is exertional dyspnoea and hypoxaemia. The initial test of choice for screening is the 100% oxygen method. A pulmonary angiogram is needed to define the anatomy and guide transcatheter embolisation (TCE). TCE has been shown to be effective and safe with a very low recanalisation rate and has largely replaced surgery for PAVMs. Computed tomography of the chest can be used for the follow up of asymptomatic PAVMs and TCE. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy and tolerability of flunisolide given once-daily in patients with persistent asthma versus other inhaled corticosteroids given in standard multidose regimens. Patients and Methods: A total of 515 patients aged 16 to 75 years with mild to moderate asthma stabilised on multidose regimens of various inhaled corticosteroids were enrolled in an 8-week, open-label, multicentre, randomised, parallel-group study. Patients were randomised in a 4:1 ratio to receive either once-daily flunisolide (1000µg at 6pm increased if necessary up to 2000µg; n = 416) administered via AeroChamber or their previous corticosteroid regimens (triamcinolone, beclomethasone or fluticasone propionate; n = 99), which were continued on a 2- to 4-times daily basis at the previously established dosages. The transfer to once-daily flunisolide from the previous regimen was made directly without a run-in period. Results: The treatment ‘success rate’ [percentage of patients whose forced expiratory volume in 1 second (FEV) values at the study end-point were at least 90% of baseline values] was 85.7% in both treatment groups. Other efficacy parameters, including percentage predicted FEV, morning and evening peak expiratory flow rate (PEFR) values, asthma symptom scores, salbutamol (albuterol) usage, nocturnal awakenings, quality-of-life scores and global rating of change were also similar in the two groups. The incidence of drug-related adverse events such as headache, increased cough, pharyngitis, nausea and oral candidiasis were low in both groups (≤1.7% with flunisolide), and there were no notable changes in vital signs or physical examination variables in either group. The majority of patients expressed a preference for the once-daily flunisolide dosage regimen. Conclusions: Once-daily flunisolide provided asthma therapy that was at least as effective and as well tolerated as the patients' previous inhaled corticosteroid medication, indicating that individuals with mild to moderate asthma can be directly transferred to once-daily flunisolide therapy without compromising efficacy and tolerability. [ABSTRACT FROM AUTHOR]

We describe a patient with intravascular pulmonary lymphoma who presented with progressive dyspnea and hypoxemia with normal chest radiographic findings. After an unrevealing noninvasive evaluation, a high-grade B-cell intravascular lymphoma was diagnosed by bronchoscopy with transbronchial biopsy. Treatment with a modified CHOP regimen resulted in resolution of the patient's hypoxemia and exercise limitation. Although intravascular pulmonary lymphoma rarely presents with pulmonary symptoms, it should be considered in the differential diagnosis of patients presenting with hypoxemia and normal chest radiographic findings. [ABSTRACT FROM AUTHOR]

Lung volume reduction surgery (LVRS) has recently been introduced as a palliative treatment for patients with severe emphysema. The most common postoperative complication is persistent air leak requiring prolonged tube thoracostomy. We describe a unique case of a patient with severe emphysema who underwent LVRS and presented, about a year later, with the repeated expectoration of surgical staples. [ABSTRACT FROM AUTHOR]

Pulmonary function has circadian modulations. Variations in human pulmonary function during the daytime hours (diurnal variations) remain to be well characterized. Discerning these variations will contribute to better understanding the relationship between biorhythms and lung physiology and to improving clinical management of pulmonary diseases. The aim of this study was to determine the magnitude of pulmonary function variability during the usual daytime hours in a population of patients referred for pulmonary function testing. Diurnal fluctuations of human pulmonary function were examined by studying retrospectively a study population of 4,756 individuals with performed pulmonary function tests. We found the lowest and highest spirometric values in the 12:00-12:59 pm and 3:00-4:59 pm time intervals respectively. The difference in the forced expiratory volume in 1 second (FEV1) between the noon (12:00-12:59 pm) and afternoon (4:00-4:59 pm) intervals was 17.6% (P<0.01). Furthermore, the highest values of diffusing capacity of the lung for carbon monoxide [DLCO] and alveolar volume [Va] were identified in the 8:00-8:59 am time interval. These findings, identifying a model of diurnal variations of pulmonary function in individuals referred for pulmonary function testing, are of interest for better understanding lung physiology and human circadian rhythms and may have clinical value in managing lung disorders.

In order to determine variables that correlate with malignant pleural effusion and mortality in patients with lymphoproliferative disorders and pleural effusion, a retrospective study was performed. Clinical data of hospitalized patients with a lymphoid malignancy and pleural effusion who underwent thoracentesis from January 1993 to December 2002 were collected. A logistic regression analysis was carried out to determine prognostic variables that predict malignant pleural effusion and hospital mortality. There were 86 patients who were admitted on 91 occasions. The median age was 70 years (range 4 - 92) and the male:female ratio was 44:42. Sixty-four patients (74%) had advanced disease, 43 (50%) had received prior chemotherapy and 9 (10%) were in remission. Of 91 cases of pleural effusions, 44 (48%) were bilateral, 80 (88%) were exudates and 48 (53%) were due to malignant involvement of pleura. In multivariate analysis, symptomatic pleural effusion (odds ratio 10.3, 95% confidence interval 1.7 - 98.3), pleural fluid mesothelial cell count < 5% (odds ratio 8.0, 95% confidence interval 1.4 - 58.2), pleural fluid:serum lactate dehydrogenase (LDH) > or =1 (odds ratio 6.4, 95% confidence interval 1.2 - 45.6) and pleural fluid lymphocyte percentage > or =50 (odds ratio 6.4, 95% confidence interval 1.2 - 50) were significantly correlated with malignant effusion. A secondary cancer (odds ratio 11.9, 95% confidence interval 2.3 - 88.8), pleural fluid:serum LDH > or =1 (odds ratio 10.9, 95% confidence interval 2.6 - 64.9), and pneumonia (odds ratio 6.4, 95% confidence interval 1.7 - 28.6) were significantly correlated with hospital mortality. In conclusion, malignant pleural effusion is the common etiology of pleural effusion in patients with lymphoid malignancy. Many clinical and cytochemical markers have discriminatory values in identifying malignant effusion. A high pleural fluid to serum LDH level correlates with malignant pleural involvement and hospital mortality.

Background: Although pulmonary complications account for significant morbidity and mortality in patients with chronic lymphocytic leukemia (CLL), to the authors' knowledge there are sparse data available in published literature. The authors evaluated pulmonary complications in patients with CLL and identified prognostic variables that predict hospital mortality in these patients., Methods: Clinical data were analyzed retrospectively from patients with CLL who required hospitalization for a respiratory illness at a tertiary care institution from January 1993 to December 2001. A logistic regression analysis with a backward elimination procedure was carried out to determine prognostic variables that predict hospital mortality., Results: There were 110 patients who were admitted on 142 occasions with a pulmonary complication. The median age was 75 years (range, 43-97 years), and the male:female ratio was 1.7:1.0. Among 142 admissions, 68% were high risk according to the Rai criteria, 68% of patients admitted had received prior therapy for CLL, and 35% had received treatment within 3 months of admission. The most common pulmonary complications were pneumonias (75%), malignant pleural effusion/and or lung infiltrate due to CLL (9%), pulmonary leukostasis (4%), Richter transformation or nonsmall cell lung carcinoma (3%), and upper airway obstruction (2%). Forty-four of 110 patients (40%) died. In multivariate analysis, admission absolute neutrophil counts /= 20 mg/dL (odds ratio, 3.0; 95% CI, 1.1-8.3) were correlated significantly with mortality., Conclusions: Pneumonia was the major pulmonary complication in hospitalized patients with CLL. Severe neutropenia and high BUN levels were correlated significantly with increased mortality., (Copyright 2003 American Cancer Society.)

Objective: Pneumomediastinum is a rare complication of anorexia nervosa. Although the mechanism is unknown, severe malnutrition may affect lung mechanics by altering the connective tissue, predisposing to pneumomediastinum., Method: We describe a young male with anorexia nervosa and panic disorder who presented with symptoms similar to those of a panic attack and was diagnosed with spontaneous pneumomediastinum., Results: This case illustrates the importance of considering pneumomediastinum in the differential diagnosis of panic attack in patients with eating disorders., Discussion: Although spontaneous pneumomediastinum has a generally benign course, it must be differentiated from the potentially life-threatening secondary pneumomediastinum due to an esophageal tear., (Copyright 2002 by Wiley Periodicals, Inc.)

Levofloxacin is one of the most commonly prescribed antibiotics for both inpatient and outpatient care of respiratory tract infection. It is generally well tolerated, and it has an excellent safety profile. We report a case of severe acute liver toxicity that apparently complicated intravenous administration of levofloxacin, which resolved after discontinuation of the drug.

Most reported thoracic desmoid tumors originate from the chest wall. However, intrathoracic desmoid tumors are rare. The pathogenesis of these tumors is unclear but antecedent trauma and operation have been implicated. Desmoid tumors can present either with pain or be incidentally detected on radiographic studies. We describe the case of a 60-year-old woman with an intrathoracic desmoid detected on a routine screening chest roentgenogram who underwent complete surgical resection of the tumor.

Yellow nail syndrome (YNS) is a rare entity of unknown cause in which congenitally hypoplastic lymphatics play a major role in the clinical manifestations of the disease. YNS has been associated with many malignancies and immune disorders. We report a case of new-onset YNS associated with breast cancer and dramatic improvement in the yellow nails with cancer treatment.

Lung volume reduction surgery (LVRS) is being evaluated in the treatment of emphysema. The proposed mechanisms of improvement are increased elastic recoil of the lung and improved mechanical efficiency of the muscles of respiration. We report a unique patient with emphysema who developed a giant bulla 3 years subsequent to LVRS. The patient underwent extensive evaluation, including measurements of lung mechanics. Bullectomy was performed, but it was unsuccessful. Although the mechanisms behind the development of giant bullous disease remain speculative, heterogeneous improvement in elastic recoil following LVRS may be one of the responsible mechanisms.

This prospective, longitudinal study was designed to assess the hemodynamic changes occurring in patients who undergo lung volume reduction surgery (LVRS). Patients with emphysema treated with LVRS underwent hemodynamic evaluation before and after surgery. The study group consisted of nine patients with an average age of 64.4 yr. FEV1 rose significantly from 0.64 preoperatively to 0.99 L postoperatively. After surgery, pulmonary artery (PA) systolic pressure rose to 47.9 +/- 12.4 mm Hg, meeting criteria for development of pulmonary hypertension. In six patients, the elevation in PA pressure was attributed to an increase in the pulmonary vascular resistance, but for all nine patients the change was not statistically significant. The pulmonary artery occulsion pressure (PAOP) did not change postoperatively. There was no correlation of PAOP with global left ventricular ejection fraction. While preoperatively there was a negative correlation between symptoms (Mahler dyspnea index) and PA pressure, after surgery the change in PA pressures did not correlate with the change in symptoms (Mahler transitional dyspnea index). We concluded that development of pulmonary hypertension may occur after LVRS in patients whose symptomatic status improves and in whom this condition was not present preoperatively.

This is a report of an unusual case of left, predominantly upper lobe, pulmonary edema secondary to paravalvular mitral regurgitation (MR) complicating mitral valve replacement. Transesophageal echocardiography proved helpful in making the diagnosis of MR and suggesting the mechanism of the pulmonary edema.

A case of chronic lithoptysis with unusual features was undiagnosed for 20 years. The presence of multiple broncholiths in different segments of both lungs, not previously described, was confirmed endoscopically. Areas of unusual mucosal punctate calcifications, not appreciated on concurrent high-resolution CT scan, also are described.

We report a case of primary pulmonary hypertension in an adult man with CD8/T-cell large granulocyte leukemia. Successful treatment of his leukemia with cladribine resulted in dramatic and sustained improvement of his pulmonary hypertension.

Unlabelled: This activity is designed for primary care and specialist physicians., Goal: To provide prompt and appropriate treatment for asthma of all levels of severity resulting in improved level of activity and decreased need for urgent care and hospitalization with a possible reduction in the annual decline of lung function, degree of permanent airway damage, and mortality., Objectives: 1. To provide a framework on the basis of history, physical findings, and laboratory results for the diagnosis of asthma. 2. To improve the ability to classify asthma by degree of severity. 3. To describe an incremental therapeutic approach to asthma by degree of severity. 4. To provide a systematic approach with regard to periodic reevaluation of asthma severity and modification of the treatment plan.

Objectives: To determine whether a rigorous antiseptic hand washing of bare hands with 4% chlorhexidine and alcohol reduced fingertip microbial colonization as compared with the use of boxed, clean, nonsterile latex gloves. In addition, to investigate if aseptic donning technique and/or a prior hand washing would reduce the level of glove contamination., Design: Prospective, randomized, crossover design, with each subject serving as his/her own control., Setting: University intensive care unit., Subjects: Forty-three intensive care nurses., Interventions: The fingertips of 20 nurses were cultured before and after a strict antiseptic hand washing and before and after the routine and aseptic donning of sterile gloves. Subsequently, the fingertips of 43 nurses were cultured before and after the casual donning of nonsterile gloves over unwashed hands and before and after a strict antiseptic hand washing. Fingertip cultures were plated directly on agar, incubated for 24 hrs, and counted and recorded as the number of colony-forming units (cfu) for each hand. Different colony types were then subcultured., Measurements and Main Results: Hand washing with antiseptic reduced colonization from 84 to 2 cfu (p < .001). The proportion of cases with > or = 200 cfu/hand was reduced from 30% to 9%. Aseptic or casual donning of sterile gloves, with or without prior antiseptic hand washing, resulted in consistently low glove counts between 0 and 1.25 cfu. Nonsterile gloves casually donned over washed or unwashed bare hands diminished the bioburden to 2.17 and 1.34 cfu, respectively. No qualitative difference was found in the microorganisms recovered from gloved or bare hands., Conclusions: Antiseptic hand washing and the use of nonsterile gloves over unwashed hands confer similar reductions in the number of microorganisms. There is no additional benefit with the use of aseptic donning technique, prior antiseptic hand washing, or the use of individually packaged sterile gloves.

Hyperemesis gravidarum (HG) is a severe form of the more common nausea of early pregnancy. We report an unusual case of pneumomediastinum and bilatetral pneumothoraces presenting in the tenth week of pregnancy complicating HG.

We report two cases of tracheobronchomegaly with differing presentations. The radiologic, fiberoptic bronchoscopic, and clinical findings as well as management of this rare condition are reviewed.

Purpose: To identify the type, rate, burden, and pattern of contamination of boxed, clean but nonsterile gloves in our intensive care unit (ICU)., Materials and Methods: The fingertips of the first, middle, and last two pairs of gloves in 29 boxes in routine service in our ICU were cultured. The first of each of these three sets were removed aseptically, the second in a routine fashion., Results: We found 16 of 29 (55%) first pairs removed aseptically to be contaminated with a mean bioburden of 1.8 colony-forming units (CFU). The percentage contamination and bioburden did not change significantly with position in the box. Use of routine compared with strict aseptic technique increased the rate of contamination by only 11% (95% confidence interval [CI] -0.05 to +0.27 percentage points) and bioburden by only a mean of 3.4 colonies per pair (CI -0.51 to +4.90 CFU). The length of the time the boxes were open and in use was unrelated to whether the final aseptically removed pair was sterile or contaminated. The predominant organisms were coagulase-negative staphylococci., Conclusions: One half the pairs of latex examination gloves in our ICU were sterile despite repeated barehanded access to the boxes. Those contaminated exhibited a small bioburden of low pathogenic potential. No pattern of contamination or unsafe duration of box use were observed. The use of boxed, clean, nonsterile gloves appears safe for routine use in an ICU.

A patient with renal failure who received acute peritoneal dialysis rapidly developed a tension hydrothorax which required immediate drainage of the pleural space. Rapid identification and therapeutic intervention for this rare complication of peritoneal dialysis is necessary because of its life-threatening potential.

In an attempt to determine whether PO2 or O2 saturation is stimulus for the hypoxic ventilatory drive, we studied 2 brothers with the high O2 affinity hemoglobin Ranier (P50 approximately equal to 12 mm Hg). The ventilatory response to PO2 was normal. The O2 saturation did decrease slightly, and the ventilatory response to the decrease in O2 saturation was greatly exaggerated. We conclude that these findings are consistent with either of 2 possibilities: (1) that PO2 provides the stimulus to the hypoxic ventilatory response, or (2) that patients with high-affinity hemoglobin have increased sensitivity to arterial O2 desaturation.

The theoretic effect of increased values for the oxygen pressure at an oxygen saturation of 50 percent on oxygen delivery in arterial hypoxemia due to right-to-left shunting was analyzed using a mathematical model of the oxygen-hemoglobin equilibrium curve. We found that, regardless of the size of the shunt, a rightward shift of the curve resulted in increased mixed venous oxygen tension, increased arterial oxygen pressure, and, hence, a decreased alveolar-arterial oxygen pressure difference compared to the standard curve (hemoglobin level, cardiac output, and oxygen consumption remaining constant).

A 32-year-old man with a ten-year history of bilateral cervical adenopathy, parotid gland swelling, and a posterior mediastinal mass, presented with headaches. A CAT scan of the head revealed a suprasellar mass. Craniotomy and biopsy of this lesion led to a diagnosis of sinus histiocytosis.