Reproductive seasonality and the effect of the GnRH agonist deslorelin as a contraceptive in captive male Black Flying-foxes (Pteropus alecto).

Effective contraception would enhance genetic management of captive Pteropus species, which typically breed well in captivity. Male reproductive seasonality was monitored (15-mo interval) in captive P. alecto (6 controls and 5 treated with 4.7 mg deslorelin). In untreated males, there were seasonal changes in testicular volume, body weight and testosterone secretion; testicular volume and body weight peaked in February and March, respectively, whereas testosterone concentration remained >5 ng/ml before rising (P < 0.001) to 24.9 ± 3.6 ng/ml (mean ± SEM) in April. However, there was no corresponding change in sperm quality, and seminal vesicle gland (SVG) secretions remained present in ejaculates. In treated males, testosterone concentration had an initial 'flare' response (mean ± SEM peak: 19.95 ± 3.27 ng/ml) before declining (P < 0.001) by 32 d to basal levels, where it remained. In these males, there was reduced sperm motility after 1 mo (P < 0.001) and the absence of SVG secretions after 4 mo. However, aspermic ejaculates were first recorded 5 mo post-treatment. At 10 mo after treatment, spermatogenesis was still disrupted, when membrane-intact, but non-motile sperm were present in two individuals. Motile sperm were first recovered from one of these males 13 mo after deslorelin treatment. We concluded that captive P. alecto males: (a) had seasonal reproductive changes in testicular volume, body weight and testosterone secretion; (b) produced motile, membrane-intact sperm and SVG secretions throughout the year; and (c) had a rapid decline in testosterone concentration and consequent suppression of testicular function for at least 5 mo following deslorelin administration.

High activity antioxidant enzymes protect flying-fox haemoglobin against damage: an evolutionary adaptation for flight?

Flying-foxes are better able to defend haemoglobin against autoxidation than non-volant mammals such as sheep. When challenged with the common physiological oxidant, hydrogen peroxide, haemolysates of flying-fox red blood cells (RBC) were far less susceptible to methaemoglobin formation than sheep. Challenge with 1-acetyl-2-phenylhydrazine (APH) caused only half as much methaemoglobin formation in flying-fox as in ovine haemolysates. When intact cells were challenged with phenazine methosulfate (PMS), flying-fox RBC partially reversed the oxidant damage, and reduced methaemoglobin from 40 to 20% over 2 h incubation, while ovine methaemoglobin remained at 40%. This reflected flying-fox cells' capacity to replenish GSH fast enough that it did not deplete beyond 50%, while ovine RBC GSH was depleted to around 20%. The greater capacity of flying-foxes to defend haemoglobin against oxidant damage may be explained in part by antioxidant enzymes catalase, superoxide dismutase and cytochrome-b ( 5 ) reductase having two- to four-fold higher activity than in sheep (P < 0.001). Further, their capacity to limit GSH depletion to 50% and reduce methaemoglobin (in the presence of glucose), despite ongoing exposure to PMS may result from having ten-fold higher activity of G6PD and 6PGD than sheep (P < 0.001), indicating the presence of a very efficient pentose phosphate pathway in flying-foxes.

Pituitary content of luteinizing hormone reveals species differences in the reproductive synchrony between males and females in Australian flying-foxes (genus Pteropus).

Flying-foxes (genus suborder, Pteropus Megachiroptera) are long-lived tropical mammals. Their seasonal reproduction appears to be regulated by an endogenous, circannual rhythm modified by multiple environmental cues. Luteinizing hormone (LH) content in pituitary extracts was examined to establish the broad time-frame of pituitary stages in the reproductive seasonality of the flying-foxes. A comparison was made between the grey-headed flying-fox P. poliocephalus, which mates and conceives in autumn, and the little red flying-fox P. scapulatus, which mates and conceives in spring. In P. scapulatus, LH was maximum during the spring mating season at 1494 ng mg(-1) in males and 896 ng mg(-1) in females. In P. poliocephalus males, LH increased to 1082 ng mg(-1) in early summer, 4 months before the mating season; LH concentrations in male P. poliocephalus returned to a low of 222 ng mg(-1) by the time of the autumn mating, by which time the female P. poliocephalus expressed elevated LH concentrations (624 ng mg(-1)). Apparently in P. poliocephalus, the peak LH concentrations in females are delayed by 4 months relative to LH concentrations in males. This is associated with 4 months of energetic courtship on the part of male P. poliocephalus, which is not observed in P. scapulatus, the fertility of which is synchronized between the sexes. The heterologous radioimmunoassay developed using monoclonal antibody 518B7 confirmed classic suppression of LH during pregnancy and lactation in flying-foxes and LH elevation in response to gonadectomy. Juveniles generally had pituitary levels similar to non-breeding levels in adults.

Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease.

Several uncontrolled studies report improvement in lung function, gas exchange, and exercise capacity after bilateral lung volume reduction surgery (LVRS). We recruited 200 patients with severe chronic obstructive pulmonary disease (COPD) for a prospective randomized trial of pulmonary rehabilitation versus bilateral LVRS with stapling resection of 20 to 40% of each lung. Pulmonary function tests, gas exchange, 6-min walk distance, and symptom-limited maximal exercise testing were done in all patients at baseline and after 8 wk of rehabilitation. Patients were then randomized to either 3 additional months of rehabilitation or LVRS. Thirty-seven patients met study criteria and were enrolled into the trial. Eighteen patients were in the medical arm; 15 of 18 patients completed 3 mo of additional pulmonary rehabilitation. Thirty-two patients underwent LVRS (19 in the surgical arm, 13 crossover from the medical arm). After 8 wk of pulmonary rehabilitation, pulmonary function tests remained unchanged compared with baseline data. However, there was a trend toward a higher 6-min walk distance (285 +/- 96 versus 269 +/- 91 m, p = 0.14) and total exercise time on maximal exercise test was significantly longer compared with baseline values (7.4 +/- 2.1 versus 5.8 +/- 1.7 min, p < 0.001). In 15 patients who completed 3 mo of additional rehabilitation, there was a trend to a higher maximal oxygen consumption (V O(2)max) (13.3 +/- 3.0 versus 12.6 +/- 3.3, p < 0.08). In contrast, at 3 mo post-LVRS, FVC (2.79 +/- 0.59 versus 2.36 +/- 0.55 L, p < 0.001) and FEV(1) (0.85 +/- 0.3 versus 0.65 +/- 0.16 L, p < 0.005) increased whereas TLC (6.53 +/- 1.3 versus 7.65 +/- 2.1 L, p < 0.001) and residual volume (RV) (3.7 +/- 1.2 versus 4.9 +/- 1.1 L, p < 0.001) decreased when compared with 8 wk postrehabilitation data. In addition, Pa(CO(2)) decreased significantly 3 mo post-LVRS compared with 8 wk postrehabilitation. Six-minute walk distance (6MWD), total exercise time, and V O(2)max were higher after LVRS but did not reach statistical significance. However, when 13 patients who crossed over from the medical to the surgical arm were included in the analysis, the increases in 6MWD (337 +/- 99 versus 282 +/- 100 m, p < 0.001) and V O(2)max (13.8 +/- 4 versus 12.0 +/- 3 ml/kg/min, p < 0.01) 3 mo post-LVRS were highly significant when compared with postrehabilitation data. The Sickness Impact Profile (SIP), a generalized measure of quality of life (QOL), was significantly improved after 8 wk of rehabilitation and was maintained after 3 mo of additional rehabilitation. A further improvement in QOL was observed 3 mo after LVRS compared with the initial improvement gained after 8 wk of rehabilitation. There were 3 (9.4%) postoperative deaths, and one patient died before surgery (2.7%). We conclude that bilateral LVRS, in addition to pulmonary rehabilitation, improves static lung function, gas exchange, and QOL compared with pulmonary rehabilitation alone. Further studies need to evaluate the risks, benefits, and durability of LVRS over time.

Improvements in lung function, exercise, and quality of life in hypercapnic COPD patients after lung volume reduction surgery.

STUDY OBJECTIVE: To determine the impact of preoperative resting hypercapnia on patient outcome after bilateral lung volume reduction surgery (LVRS). METHODS: We prospectively examined morbidity, mortality, quality of life (QOL), and physiologic outcome, including spirometry, gas exchange, and exercise performance in 15 patients with severe emphysema and a resting PaCO2 of > 45 mm Hg (group 1), and compared the results with those from 31 patients with a PaCO2 of < 45 mm Hg (group 2). RESULTS: All preoperative physiologic and QOL indices were more impaired in the hypercapnic patients than in the eucapnic patients. The hypercapnic patients exhibited a lower preoperative FEV1, a lower diffusing capacity of the lung for carbon monoxide, a lower ratio of PaO2 to the fraction of inspired oxygen, a lower 6-min walk distance, and higher oxygen requirements. However, after surgery both groups exhibited improvements in FVC (group 1, p < 0.01; group 2, p < 0.001), FEV1 (group 1, p=0.04; group 2, p < 0.001), total lung capacity (TLC; group 1, p=0.02; group 2, p < 0.001), residual volume (RV; group 1, p=0.002; group 2, p < 0.001), RV/TLC ratio (group 1, p=0.03; group 2, p < 0.001), PaCO2 (group 1, p=0.002; group 2, p=0.02), 6-min walk distance (group 1, p=0.005; group 2, p < 0.001), oxygen consumption at peak exercise (group 1, p=0.02; group 2, p=0.02), total exercise time (group 1, p=0.02; group 2, p=0.02), and the perceived overall QOL scores (group 1, p=0.001; group 2, p < 0.001). However, because the magnitude of improvement was similar in both groups, and the hypercapnic group was more impaired, the spirometry, lung volumes, and 6-min walk distance remained significantly lower post-LVRS in the hypercapnic patients. There was no difference in mortality between the groups (p=0.9). CONCLUSIONS: Patients with moderate to severe resting hypercapnia exhibit significant improvements in spirometry, gas exchange, perceived QOL, and exercise performance after bilateral LVRS. The maximal achievable improvements in postoperative lung function are related to preoperative level of function; however, the magnitude of improvement can be expected to be similar to patients with lower resting PaCO2 levels. Patients should not be excluded from LVRS based solely on the presence of resting hypercapnia. The long-term benefit of LVRS in hypercapnic patient remains to be determined.

Enhanced emergency department referral improves primary care access.

OBJECTIVE: People who use the emergency department (ED) as their main source of medical care cite access barriers to primary care as the reason. The purpose of this study was to test an intervention designed to refer regular ED users to primary care. STUDY DESIGN: A prospective randomized clinical trial. PATIENTS AND METHODS: Adults who stated the ED is their regular source of care and have no primary care (n = 189) were randomized to 2 groups: the intervention being studied or usual care. The study took place over 3 months at a northeastern urban hospital. RESULTS: Subjects in the intervention group were more than twice as likely to keep the primary care appointment compared with the usual care group, and most also received some measure of preventive care. There was no significant difference in ED utilization by these patients in the 12-month period following study entry. CONCLUSION: Making an appointment with detailed instructions during a visit to the ED markedly improves show rates at follow-up appointments with a primary care provider and allowed for opportunity to provide important preventive services.

Bilateral apical vs nonapical stapling resection during lung volume reduction surgery.

STUDY OBJECTIVES: To determine whether biapical stapling resection alone or resection of diseased, nonapical areas of emphysematous lung provides comparable physiologic outcomes or alters morbidity and mortality after lung volume reduction surgery (LVRS). DESIGN: Consecutive case-series analysis. SETTING: Urban university hospital. PATIENTS: Forty-seven patients ([mean +/- SD] aged 58+/-8 years; 18 men) with severe emphysema (FEV1, 0.7+/-0.2 L; total lung capacity [TLC], 139+/-23% predicted). INTERVENTIONS: Thirty-two patients underwent biapical LVRS, 27 by median sternotomy (MS) and 5 by video-assisted thoracoscopic surgery (VATS), and 15 underwent nonapical resection, 9 by MS and 6 by VATS. Patients were assessed for postoperative complications (respiratory tract infections, air leak duration, and death), length of stay, and physiologic parameters, which included a 6-min walk distance, spirometry, lung volume, gas exchange, diaphragm strength, and quality-of-life measures. MEASUREMENTS AND RESULTS: Patients were studied at baseline and at 3 months postoperatively. At the preoperative baseline, both groups had similar ages (57 vs 60 years; p = 0.2), 6-min walk distance (294 vs 263 m; p = 0.3), FEV1 (28% vs 29% predicted; p = 0.6), degree of hyperinflation (TLC, 138% vs 141% predicted; p = 0.8), gas exchange (PaO2/fraction of inspired oxygen, 344 vs 313, p = 0.1; PaCO2 46 vs 48 mm Hg, p = 0.4), and diaphragm strength (maximal transdiaphragmatic pressure sniff, 54 vs 46 cm H2O, p = 0.4). Resected tissue weight was similar in both groups (94 vs 93 g, p = 0.9). There were no differences in the mean percentage of change from baseline for these physiologic parameters or for quality-of-life measures between the two groups. The 6-min walk distances increased by 20% and 33%, FEV1 increased by 37% and 38%, the degrees of hyperinflation (residual volume/TLC) decreased by 16% and 15%, and the quality-of-life scores improved by 51% and 41%, respectively, in the groups that underwent biapical and nonapical resections at 3 months post-LVRS. The length of stay in the hospital for LVRS (18 vs 23 days; p = 0.4) and the duration of air leak (10 vs 15 days; p = 0.4) were also similar. Complications between the two groups (biapical vs nonapical) were similar (respiratory tract infection, 47% vs 60%, p = 0.2; reintubation, 34% vs 33%, p = 0.2; reoperation, 9% vs 20%, p = 0.4; and death, 9% vs 7%, p = 0.2). CONCLUSIONS: LVRS, by biapical or nonapical resection, produces similar improvements in lung function, exercise, diaphragm strength, and quality of life, with comparable morbidity and mortality.

Surgery for severe COPD. Lung volume reduction and lung transplantation.

A management strategy for patients with severe emphysema is shown in figure 2 on page 199. Although the reported physiologic improvements after LVRS are significantly less than those seen after lung transplantation, LVRS has the potential to improve functional performance in a larger number of patients because of wider availability. Moreover, it accomplishes these goals without the attendant risks associated with transplantation and immunosuppression. The efficacy of LVRS over standard medical therapy in influencing survival and favorably affecting physiologic variables at rest and during exercise remains to be elucidated in NETT. Lung transplantation should be reserved for those patients deemed unsuitable or too ill for LVRS. It is to be hoped that future developments in organ preservation techniques and immunosuppressive regimens will expand the donor pool and decrease the incidence of posttransplantation bronchiolitis.

Use of the ED as a regular source of care: associated factors beyond lack of health insurance.

STUDY OBJECTIVE: To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care. METHODS: We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED. RESULTS: Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than $30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a $25 copayment were in effect. CONCLUSION: Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

Do internists and emergency physicians agree on the appropriateness of emergency department visits?

The purpose of this study was to determine the levels of agreement between three methods of assessing appropriateness of emergency department (ED) visits. In particular, we tested the agreement between internists and emergency physicians reviewing the ED nurses' triage notes, containing information that might be available by telephone to an internist. For 892 adult patient ED visits reviewed, we found only moderate agreement (kappa = 0.47) between these groups. In cases of disagreement, emergency physicians were 10.3 times more likely than internists to classify those with minor discharge diagnoses as appropriate for ED care. As managed care grows, the determination of ED appropriateness may depend on open discussions between physician groups, as well as on access to timely care in office settings.

Surveillance bronchoscopy in lung transplant recipients.

STUDY OBJECTIVES: To establish whether a consensus exists among active transplant centers regarding the use and interpretation of information obtained by surveillance bronchoscopic lung biopsy (SBLB). DESIGN: Prospective standardized questionnaire answered via mail and telephone communications. PARTICIPANTS: A five page, 18-question survey was sent to all lung transplant programs listed by the United Network of Organ Sharing in North America, as well as eight selected international programs. Ninety-one surveys were sent to 83 North American and eight international programs. Seventy-four programs (81%) responded. Seventeen programs (19%) were excluded secondary to inactivity. The remaining 57 programs (63%) were included in final data analysis. INTERVENTIONS: None. RESULTS: Sixty-eight percent (39/57) of the responding programs perform SBLBs. Ninety-two percent of the programs performing SBLBs do so within the first month, and 69% continue to do so on a regular basis. Sixty-nine percent (27/39) of programs performing SBLBs continue to do so after 1 year. Eighty-six percent (32/37) of respondents believe that SBLB impacts on patient management at least 10% of the time. Technically, 90% (35/39) take biopsy specimens from more than one lobe per SBLB session. Fifty-nine percent (23/39) took 6 to 10 biopsy specimens per session, 33% (13/39) took three to five biopsy specimens, and 7% (4/39) took > 10 biopsy specimens per session. Eighty-six percent (32/37) of the responding centers reported treating asymptomatic rejection at grade 2A, while 14% (5/37) waited until histologic grade 3A before beginning treatment. Complications from SBLB were minimal with < 5% rates of pneumothorax, requirement for chest tube placements, or significant bleeding during SBLB reported by > 95% of the programs performing SBLB. CONCLUSIONS: Most active lung transplant centers perform SBLBs and do so on a regular basis. However, a wide range of opinion exists over the utility and technique of SBLB and the impact of its results influencing outcome in the lung transplant recipient. To answer these questions, a randomized multicentered trial or registry to determine the effect of SBLB on lung transplant recipient morbidity and mortality is required.

A heterologous assay for measuring prolactin in pituitary extracts and plasma from Australian flying foxes (genus Pteropus).

A sensitive heterologous assay was developed to measure prolactin-like activity in Pteropus alecto, P. poliocephalus, and P. scapulatus, Australian flying foxes. Adapted from an established radioimmunoassay for rabbit PRL, it utilises the well-characterised, polyclonal antiserum 33/9 (guinea pig anti-human prolactin). In the assay, pituitary extracts from P. alecto, P. poliocephalus, and P. scapulatus diluted in parallel with ovine prolactin standards, although absolute levels estimated were low. Its usefulness for investigating the role of prolactin in reproduction and seasonality in flying foxes was tested. In a survey of pituitary extracts collected from both sexes of all three species, prolactin was higher in females than in males (P < 0.001). In the few specimens from juveniles, mean prolactin levels in pituitary and plasma were similar to those of adults. Plasma and pituitary samples both contained higher concentrations of prolactin during late pregnancy (P. scapulatus, plasma P < 0.01; pituitary P < 0.01) and lactation (P. poliocephalus, plasma P < 0.005; pituitary P < 0.05) in mature females. Plasma prolactin increased at about the time of parturition, but returned to nonpregnant levels rapidly if lactation was not established. In lactating females, plasma prolactin was suppressed by temporary removal of the sucking young, and was slow to recover after the young was returned to the nipple. Pharmacological responses were tested in pregnant P. poliocephalus: plasma prolactin was low following bromocriptine administration and elevated following domperidone. Prolactin is concluded to play significant roles in the reproductive physiology of female flying foxes and, as in other species, is under dopaminergic regulation.

Detection of pulmonary aspiration of gastric contents in an animal model by assay of peptic activity in bronchoalveolar fluid.

OBJECTIVE: To determine whether peptic activity in bronchoalveolar fluid, due to the presence of the gastric proteolytic enzyme pepsin, could serve as a biochemical marker for pulmonary aspiration of gastric contents. DESIGN: Prospective, experimental trial. SETTING: A university animal research laboratory. SUBJECTS: Thirty-six New Zealand rabbits, weighing 2 to 4 kg. INTERVENTIONS: New Zealand rabbits were anesthetized, intubated via tracheostomy, and mechanically ventilated. Pulmonary aspiration was induced by the intratracheal instillation of 2 mL/kg human gastric juice (pH 1.2 +/- 0.2; pepsin activity 0.02 +/- 0.006 microgram/mL; human gastric juice group, n = 24) or normal saline solution (pH 5.2 +/- 0.2; normal saline solution group; n = 12). Mechanical ventilation was continued. Bronchoalveolar lavage was performed at 15 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), 30 mins (human gastric juice group, n = 8; normal saline solution group, n = 4), or 60 mins (human gastric juice group, n = 8; normal saline solution group, n = 4) postaspiration. MEASUREMENTS AND MAIN RESULTS: Peak airway pressure and PaO2 values were measured at baseline and 15 and 30 mins after aspiration. The pH of retrieved bronchoalveolar lavage fluid was measured and pepsin activity in sample fluid was determined. Changes from baseline in peak airway pressure and PaO2 were significant in human gastric juice animals at 15 and 30 mins when compared with normal saline solution animals (PaO2 -4% vs. -44%, peak airway pressure 20% vs. 36% at 15 mins; PaO2 -16% vs. -79%, peak airway pressure 28% vs. 69% at 30 mins; normal saline solution group vs. human gastric juice group, p < .02). Bronchoalveolar lavage fluid pH was not significantly different between groups at any time postaspiration (6.6 +/- 0.7 vs. 6.0 +/- 0.4 at 15 mins; 7.4 +/- 0.9 vs. 6.5 +/- 0.4 at 30 mins; 7.2 +/- 0.5 vs. 6.4 +/- 0.4 at 60 mins, normal saline solution group vs. human gastric juice group, p = NS). No peptic activity was present in bronchoalveolar lavage fluid from normal saline solution animals at any time. In the human gastric juice group, peptic activity was detected in postaspiration bronchoalveolar lavage fluid in eight of eight animals at 15 mins, six of eight animals at 30 mins, and five of eight animals at 60 mins (normal saline solution group vs. human gastric juice group; p < .001 at 15 mins, p < .01 at 30 mins, p = NS at 60 mins). Peptic activity of bronchoalveolar lavage fluid varied; mean values were greater at 15 mins than at 30 or 60 mins (pepsin activity: 0.004 +/- 0.002 microgram/mL vs. 0.002 +/- 0.001 microgram/mL vs. 0.0006 +/- 0.0001 microgram/mL, respectively, p < .05). CONCLUSIONS: The results of this study suggest that peptic activity in bronchoalveolar lavage fluid can be detected up to 60 mins after induced, experimental gastric juice aspiration and may prove a clinically useful biochemical marker for episodes of occult pulmonary aspiration of gastric contents.

"Inappropriate" emergency department use: a comparison of three methodologies for identification.

OBJECTIVE: To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness. METHODS: Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores. RESULTS: Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42. CONCLUSION: There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

Treatment of left pneumonectomy syndrome with an expandable endobronchial prosthesis.

Postneumonectomy syndrome has only been described after a right pneumonectomy except in cases of congenital mediastinal anomalies or right-sided aortic arch. Placement of Silastic prostheses into the empty hemithorax is the preferred surgical treatment; however, other nonsurgical options exist. Herein, we report a case of left postpneumonectomy syndrome in an adult who was successfully treated with the placement of an endobronchial stent.

Comparative morphology of the pituitary gland in Australian flying foxes (Megachiroptera: genus Pteropus).

BACKGROUND: Investigations of reproductive endocrinology of flying foxes (genus Pteropus) have been hampered by inadequate information on the normal morphology of the megachiropteran pituitary. METHODS: The novel technique of graphical three-dimensional (3-D) reconstruction, supported by more traditional anatomical techniques, have now been used to examine the shapes of, the interrelations between, the lobes of the pituitary of the little red flying fox, Pteropus scapulatus. Statistical analysis of data from three species tested whether there were changes in pituitary size with annual cycles in function, particularly with key stages of reproduction. RESULTS: In the three species of Australian flying foxes examined, the hypophyseal cleft is closed; the pars intermedia extends over the rostral, ventral, and lateral surfaces of the neural lobe. The pars distalis is broad rostrally and extends over two-thirds of the lateral and ventral pars intermedia. The hypophyseal recess is broad at the median eminence, then narrows and extends through the infundibulum to, but not into, the neural lobe. In adult animals the pituitary weight was 10.0 +/- 0.3 mg (mean +/- s.e.) in P. scapulatus, 14.7 +/- 0.5 mg in Pteropus poliocephalus (greyheaded flying foxes), and 18.7 +/- 1.5 mg in Pteropus alecto (black flying foxes). Pituitary weight was not significantly affected by reproductive stage. CONCLUSIONS: Thus histologically, the adenohypophysis and neurohypophysis are similar to those of other mammals. Comparative differences in pituitary size reflected differences in species body size rather than cyclical reproduction.

Coital behavior of male Pteropus scapulatus (little red flying foxes) in captivity.

Copulation in Pteropus scapulatus, the little red flying fox (suborder Megachiroptera), is characterised by brief orogenital grooming for 20 s; a single mount lasting 175 s; a single intromission, which includes a mean of 20 s thrusting in most copulations; ejaculation, lasting only about 9 s, observed in about 20% of copulations; and lock et copula, for about 155 s. In 65% of copulations, mating between the same pair resumes, usually after about 35 s. Each pair typically undertakes a series of two-three copulations at a time. Copulation is the dorso-ventral position, while both animals hang by their feet in their normal head-down posture. An unusual feature of their coitus is that each animal supports its own weight, and the female appears undisturbed by the male's thrusting movements. Mating is essentially silent and still. Peak mating occurs in November and December (late spring/early summer), with fertile matings being rare at other times.

Chronic pulmonary disease in the trauma patient.

Despite a better understanding of the pathophysiologic changes that occur in the respiratory system as a result of trauma and surgery, pulmonary complications remain an important contributor of morbidity and mortality. Pre-existing pulmonary disease predisposes the patient to these complications and further complicates their management. Timely identification of chronic pulmonary dysfunction and the early institution of pharmacologic measures and respiratory care, as outlined, may reduce pulmonary complications in this high-risk group.

Paranoid psychosis due to neurosarcoidosis.

We present two patients with known sarcoidosis who developed neurosarcoidosis manifested by paranoid psychosis and clinical diabetes insipidus with hypernatremia. Both had gadolinium enhanced magnetic resonance imaging which demonstrated leptomeningeal and hypothalamic enhancement. Both had elevated protein and a lymphocytosis in their cerebrospinal fluid, which improved after corticosteroid therapy. The patients improved clinically with this therapy as well. We suggest that new onset psychosis in a sarcoid patient, particularly with symptoms of hypothalamic/pituitary involvement, should be evaluated for neurosarcoidosis with an MRI and CSF examination. If the results are consistent with neurosarcoidosis, the patient should be treated promptly with corticosteroids.