Probability of a positive transbronchial lung biopsy result in sarcoidosis.

Forty-one consecutive patients with suspected sarcoidosis underwent pulmonary function testing and transbronchial lung biopsy at three community teaching hospitals. Transbronchial biopsy disclosed noncaseating granulomas in 22 of 23 patients (96%) in whom parenchymal disease was roentgenographically apparent and in eight of 18 patients (44%) in whom it was not. The stage of the disease as determined by the chest roentgenogram was the most reliable determinant for a positive biopsy result. Not the presence of cough, dyspnea, or constitutional symptoms or pulmonary function as measured by forced vital capacity and carbon monoxide diffusing capacity served to predict a positive transbronchial biopsy finding any more accurately than did the roentgenographic staging of the disease itself. This study suggests that while transbronchial lung biopsy may be an acceptable initial diagnostic procedure in suspected sarcoid patients without parenchymal lung disease, clinical symptoms and pulmonary function abnormalities are not helpful in predicting the liklihood of a positive biopsy result.

Predictors of mortality in the immunocompromised patient with pulmonary infiltrates.

To determine predictors of mortality in immunocompromised patients with pulmonary infiltrates, we reviewed the records of all such patients admitted to two community teaching hospitals who underwent a lung biopsy over a ten-year period. We examined the consequences of advancing age, primary disease, fever, neutropenia, immunosuppressive corticosteroid therapy, previous lung radiation, roentgenographic pattern, result of lung biopsy, room air arterial oxygen pressure (Pao2), early mechanical ventilation, and the presence of a comorbid disease on eventual outcome. We identified 104 episodes in 99 patients. Sixty-seven (64%) survived and 37 died. By both discriminant analysis and logistic regression statistical methods, mechanical ventilation, the initial room air Pao2, and corticosteroid therapy were the dominant independent variables, in that order, to significantly predict mortality. No patient survived who simultaneously had a room air Pao2 less than or equal to 50 mm Hg, was on corticosteroids, and was mechanically ventilated. Eighty-three percent of survivors had either none or, at most, one of these three variables present. We conclude that hypoxia, immunosuppression by corticosteroids, and the necessity for mechanical ventilation within 72 hours of hospitalization indicate a poor prognosis in the immunocompromised patient with pulmonary infiltrates who has undergone a lung biopsy.

Sensitivity, specificity, and predictive values of closed pleural biopsy.

To determine the clinical value of a nonspecific pleural biopsy specimen and fluid in malignant neoplasm and tuberculosis, we retrospectively reviewed records of all patients with pleural effusions undergoing the procedure at three community hospitals over six years. Two hundred eleven patients underwent biopsies. Adequate tissue was obtained in 207. The results were compared with the ultimate clinical and pathologic outcome by follow-up for 12 to 72 months. The initial procedure was diagnostic of malignant neoplasm in 54 patients and granulomatous disease in ten. A nonspecific or normal result was found in 143 (68%). Malignant neoplasms or tuberculosis was eventually established in 30 and excluded in 101 of the 143 patients. In 12 patients, no diagnosis was made. The procedure's sensitivities were 65% (malignant neoplasm) and 90% (tuberculosis). One false-positive result occurred in a patient with nontuberculous granulomatous pleuritis. The specificity and positive predictive value were 99% and 98%, respectively. The negative predictive value was 77%. Closed pleural biopsy with simultaneous fluid analysis is a valuable diagnostic procedure in community hospital patients, but a nonspecific result does not exclude malignant disease.

The role of a cinema seminar in psychiatric education.

As the goals of psychiatric education are evaluated and innovative teaching methods are sought, the current cinema represents an untapped resource. Thoughtful viewing of contemporary films with serious discussion of them in a film discussion group as part of the residency training program is a useful and enjoyable teaching format that helps bridge the gap between the art and science of psychiatry.

Adenomas in glycogen storage disease type 1. Two cases with unusual histologic features.

Two cases of hepatic adenomas arising in patients with glycogen storage disease type I are presented. In both cases, the adenomas showed unusual histological features including marked fatty change, a polymorphonuclear infiltrate, Mallory hyalin, and lamellar fibrosis. In addition, one case was associated with amyloidosis. Such features have only recently been described in adenomas and have not been reported previously in association with glycogen storage disease type I.

Transthoracic needle biopsy of lung in nonhospitalized patients.

To confirm the safety of transthoracic needle biopsy of the lung (TNB) in the outpatient setting, we reviewed our experience with 106 such procedures over three years. We compared the operating characteristics and morbidity with the 65 similar procedures we were asked to perform on hospitalized patients during the same period. Outpatients did not differ from inpatients in mean age, sex, incidence of clinically apparent COPD, size and location of lesion, or number of needle passes. The operating characteristics of the biopsy were the same for the two groups. Pneumothorax occurred in 29 (27 percent) of 106 outpatient and 26 (40 percent) of 65 inpatient TNBs. Few pneumothoraces not present upon completion of biopsy developed during four hours of observation or later. The requirement for chest tube drainage was similar for both groups, 5.7 and 4.6 percent, respectively. With appropriate caution, TNB can be performed safely on an outpatient basis and the cost of an uncomplicated procedure reduced by 27 percent.

Antiphospholipid antibody syndrome presenting as a refractory noninflammatory pulmonary vasculopathy.

The clinical manifestations of antiphospholipid antibody syndrome (APLAS) are protean. Pulmonary manifestations are often thromboembolic in origin; ARDS and pulmonary hypertension have been reported as features of a widespread vasculopathy associated with systemic lupus or Sjögren's syndrome. This is the report of a woman with primary APLAS who died of a noninflammatory pulmonary vasculopathy. The case is unusual in its pulmonary manifestations, its initial response to corticosteroids and antithrombotic medications, its failure to stabilize with high-intensity warfarin sodium and aspirin treatment, and finally its fulminant progression despite multiple interventions.

Simultaneous legionellosis and invasive aspergillosis in an immunocompetent patient newly treated with corticosteroids.

Invasive pulmonary aspergillosis (IPA), although unusual, has been recognized in the immunocompetent host. Several cases of IPA with rapidly progressive respiratory failure have been reported in patients receiving short-term corticosteroid therapy for chronic obstructive pulmonary disease. Atypical pneumonia caused by dual infection with Legionella pneumophila and Mycoplasma pneumoniae has also been reported. We report an unusual case of simultaneous L pneumophila pneumonia and IPA in an asthma patient with suspected allergic bronchopulmonary aspergillosis newly treated with corticosteroids.

Utility of pleural fluid analysis in predicting tube thoracostomy/decortication in parapneumonic effusions.

Recommended criteria for surgical drainage of parapneumonic effusions include evidence of frank purulence, a glucose level less than 40 mg/dl, a pH of less than 7.00, or an LDH greater than 1,000 IU/L. To test the utility of these criteria, we reviewed the three-year experience of three Rochester, NY, hospitals. We identified 133 patients undergoing thoracentesis for putative parapneumonic effusions. Of 91 patients with neutrophilic exudates, 43 met one or more criteria for tube thoracostomy: 48 did not. Twenty-one of the 43, including 9 with frank empyema, underwent immediate drainage. Of the 22 who did not, 11 eventually required tube thoracostomy and/or decortication. Of the 48 not meeting any of the criteria, 7 also came to surgery. Using whether the patients eventually underwent surgery as a measure of outcome, we calculated for those patients not undergoing immediate drainage the sensitivity, specificity, positive predictive values, and negative predictive values for each of the criteria. The four criteria have relatively high specificity ranging from 82 to 96 percent, but have low sensitivity varying from only 18 percent for a positive Gram stain to 53 percent for a fluid LDH greater than 1,000 IU/L. We conclude that these criteria have limited usefulness in predicting the need for eventual chest tube drainage/decortication. Patients not meeting the criteria require close follow-up as well.

Adult respiratory distress syndrome related to ampicillin sensitivity.

A patient with the adult respiratory distress syndrome was found to have an alveolar allergic reaction demonstrated by transbronchial lung biopsy. The clinical course and subsequent skin test reactivity suggested ampicillin as the cause. This is an unusual presentation of ampicillin allergy, and drug sensitivity is suggested as another cause of the adult respiratory distress syndrome.

Use of fiberoptic bronchoscopy in the diagnosis of bronchogenic carcinoma. A study in patients with idiopathic pleural effusions.

We reviewed our experience with 115 patients with pleural effusion in whom bronchogenic carcinoma was suspected who underwent fiberoptic bronchoscopy (FOB) to identify those for whom the procedure was useful. In 6 of 12 patients with hemoptysis, 8 of 12 with a mass or infiltrate, and 8 of 18 with atelectasis with negative fluid cytology and 3 of 7 with cytology positive, FOB was useful in diagnosis. Sixty-six patients had an isolated cytology-negative effusion. Seven of 18 with massive effusion had FOB detecting cancer. Fiberoptic bronchoscopy usually was nondiagnostic in lesser-sized effusions (47 of 48). Using outcome for those with nondiagnostic FOB, we established operating characteristics for the procedure. We conclude that FOB is useful in diagnosing bronchogenic carcinoma in such patients when there is hemoptysis, accompanying lung mass or infiltrate, atelectasis, the effusion is massive, or in cytology-positive effusions without obvious primary tumor. Due to the low prevalence of bronchogenic carcinoma in patients with effusions of lesser size, we suggest that in this group FOB not be routinely performed.

Hyperthyroidism protects against carbachol-induced bronchospasm.

We studied the effect of increased thyroid function on airway reactivity. Carbachol challenge was performed to assess airway reactivity according to a standardized method. Measurements of forced expiratory volume-1 second (FEV1), specific airway conductance (SGaw), the provocative dose of carbachol for a 20 percent decrease in FEV1 (PD-20) and that for a 35 percent decrease in SGaw (PD-35) were established upon entry when each subject was hyperthyroid, and subsequently, after the subjects had returned to the euthyroid state. It was concluded that hyperthyroidism reduced the severity of carbachol-induced changes in airway reactivity as measured by SGaw.

Chronic persistent cough. Experience in diagnosis and outcome using an anatomic diagnostic protocol.

Irwin and co-workers have designed an anatomic approach to the diagnosis and treatment of cough. In their hands, diagnosis was consistently determined and treatment successful almost without exception, if sustained. We reviewed the results of a similar approach in 139 consecutive and unselected patients referred to pulmonary specialists in two community hospitals. Thirty-nine patients demonstrated hyperreactive airways (HA) by carbachol inhalation and/or eucapnic hyperventilation of cold air. Twenty-seven of 78 without HA had postnasal drip, and 13 of 78 had a persistent cough following acute upper airway inflammation. Other less common diagnoses included chronic bronchitis, gastro-esophageal reflux, occupational bronchitis, interstitial lung disease, and psychologic causes. We were able to find the cause of cough 88 percent of the time. Treatment adjusted for noncompliance was not always a success. While all patients with HA improved, 8 percent of patients without HA or specific diagnosis did not have an improvement in their cough upon retrospective inquiry. Based on this analysis, we find that the diagnosis and treatment of cough may not be as successful as originally reported using Irwin's approach.

Predicting risk of pneumothorax in needle biopsy of the lung.

We prospectively studied results of 103 consecutive transthoracic needle biopsies of lung lesions suspicious for malignancy to determine if lesion size, depth within the lung, hyperinflation, second needle passes, or 100 percent oxygen breathing influenced the incidence of pneumothorax. Thirty-eight patients (37 percent) developed pneumothorax. Ten (10 percent) required tube thoracostomy for re-expansion. Five of the ten requiring the chest tube had clinically severe obstructive lung disease. In all patients, greater depth (D) in centimeters of needle penetration significantly increased the probability (p) of pneumothorax (p much less than .001) and can be estimated by the equation: (formula see text) The estimated probability of pneumothorax is 13 percent at 1 cm, 49 percent at 4 cm, and 86 percent at 7 cm. An increase in total lung capacity above predicted added additional risk of pneumothorax (p less than .02). Oxygen breathing did not significantly reduce the incidence of pneumothorax, but may reduce size by increasing the rate of reabsorption. The other factors had little influence. We conclude that the more central location of the lesion and pre-existing lung hyperinflation determine the risk of pneumothorax.

Sensitivity, specificity, and predictive values of bronchoscopy in neoplasm metastatic to lung.

Bronchoscopic examination to diagnose lung metastases has not been as rewarding as in primary lung cancer. Despite a lower expected yield, we believe the procedure has value in certain patients, ie, those with clinical findings of endobronchial disease. To determine better the value of bronchoscopy in this population, we retrospectively reviewed records of patients at five community teaching hospitals over a 66-month period. These patients all underwent fiberoptic bronchoscopy. They had a history of prior nonpulmonary malignancy and an abnormal chest roentgenogram suspicious for recurrent malignant disease, or they presented with abnormal chest roentgenographic findings and further evaluation showed the lung disease to be metastatic. Bronchoscopy for metastatic lung disease was most likely diagnostic in patients with primary colorectal cancer (79 percent) and breast cancer (57 percent), and least likely in patients with genitourinary tract cancer (33 percent). Hemoptysis, signs of local airway obstruction, or a roentgenogram showing either atelectasis or diffuse lung disease especially favored a positive biopsy. Bronchoscopy is a valuable diagnostic procedure in selected patients with metastatic lung disease.

Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram.

The need for fiberoptic bronchoscopy in the patient with hemoptysis and a normal or nonlocalizing chest roentgenogram remains a subject of debate. Currently, diagnostic fiberoptic bronchoscopy is recommended as the investigative procedure of choice. To develop predictors that identify the patient in whom fiberoptic bronchoscopy is most likely to be diagnostic, we reviewed our community's experience with this population over a five-year period. We identified 196 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram who underwent fiberoptic bronchoscopy. Three quarters were active or previous smokers. We examined the relationship of advancing age, sex, smoking, nonspecific roentgenographic findings and the amount, duration, and previous bouts of hemoptysis to the incidence of a diagnostic fiberoptic bronchoscopy. Twelve patients (6 percent) had bronchogenic carcinoma and 33 (17 percent) another specific cause for the hemoptysis identified by fiberoptic bronchoscopy. By univariate and discriminant analyses, we found that the three factors of age of 50 years or more, male sex, and smoking of 40 pack-years or more best predicted a diagnosis of malignancy. Bleeding in excess of 30 ml daily was associated with an increase in overall diagnostic yield. The presence of two of the three factors associated with malignancy or bleeding in excess of 30 ml daily (or both) identified 100 percent of the patients with bronchogenic carcinoma and 82 percent of all of the diagnostic fiberoptic bronchoscopic procedures. use of these criteria in selecting the patient for fiberoptic bronchoscopy could have reduced our use of the bronchoscope by 28 percent, with the remaining patients safely observed.

Hemoptysis.

Hemoptysis is a significant pulmonary symptom. Because there are numerous causes, a systematic approach is necessary for the diagnosis and management of these patients. A thorough clinical evaluation and chest roentgenogram are pivotal in formulating a differential diagnosis. Diagnostic testing is tailored to the individual patient. This article provides an overview to help deal with patients with hemoptysis.

Effects of various salts on the steady-state enzymatic activity of E. coli alkaline phosphatase.

Seventeen salts were tested at various concentrations for their effects on E. coli alkaline phosphatase steady-state activity. Three effects were distinguished: a general ionic strength effect, and weaker cation and anion effects. 1. All salts tested, including those with "noninteracting" cations and anions, stimulate alkaline phosphatase activity usually ca. 100% at moderate (0.05-0.3 M) concentrations. 2. Cations such as Na+ and Li+ produce further increases in activity at concentrations up to 1 M. The noninteracting cations tetramethylammonium and tetrapropylammonium produce lower activities at these concentrations. These do not provide the secondary stimulatory effect of cations such as Na+ or Li+. 3. Anions associated with greater "salting in" effectiveness such as thiocyanate also reduce activity at ca. 1 M concentrations. These latter effects are not dependent on protein concentration so they probably do not involve subunit dissociation. There is little effect on the fluorescence or fluorescence-polarization spectrum of the enzyme so there is no general effect of 1 M salts on the conformation of the protein. The Michaelis constant for the substrate, p-nitrophenylphosphate, and inhibition constant for inorganic phosphate are increased to some extent by salts, but the increase in activity is due to an increase in Vmax. Our working hypothesis is that increased ionic strength weakens electrostatic interactions, enabling noncovalently bound phosphate to dissociate more rapidly.

Survival of patient with pleural involvement by breast carcinoma.

To determine factors which affect survival in patients with pleural involvement by breast carcinoma, we reviewed records of all patients at two community teaching hospitals presenting with malignant pleural effusion over a 6-year period. Forty-five patients had had mastectomy for breast cancer, no history of other malignancy, and cytologic confirmation of subsequent pleural metastases. All had received conventional combination systemic chemo- or hormonal therapy. Ten patients (group 1) in whom effusion was the initial and only site of recurrent disease had a median survival of 48 months. The median survival was 12 months in 35 patients (group 2) who developed effusion in association with other metastatic disease. Half of the patients in group 1 had no axillary node involvement at mastectomy. Twenty-eight patients (80%) in group 2 had had more advanced disease at initial diagnosis. This, and behavior of the effusion as regional rather than systemic disease, suggested by the high incidence of effusion on the ipsilateral side of the mastectomy, probably accounts for the better outlook in patients with effusion alone.

Small airway testing and smoking in predicting risk in surgical patients.

A prospective study was performed on 185 surgical patients without overt respiratory disease to determine whether three sensitive tests for early airway obstruction or cigarette smoking at the time of hospitalization were useful in identifying the patient at risk for a postoperative pulmonary complication. Subjects were evaluated by questionnaire. Pulmonary function testing consisted of the single breath nitrogen test (SBN2) to determine the closing volume (CV) and slope of the alveolar plateau, and a maximum expiratory flow volume curve (MEFV) to determine expiratory flow at low lung volumes. Fifty-five patients had upper abdominal surgery and 130 a major surgical procedure under general or spinal anesthesia upon another part of the body. Ninety-six (52%) of the 185 patients were smokers. Seventy-nine patients (43%) had one or more abnormal function parameters. The CV was abnormal in 59, alveolar plateau in 18, and MEFV in 12. Fifty-four percent of smokers and 30 percent of nonsmokers had abnormal small airway tests. Sixteen of 185 patients (8.6%) developed a postoperative respiratory complication determined by review of the hospital record. Eleven were in the 96 smokers, but 13 were in the 79 patients with abnormal small airway tests. The incidence was highest (38%) in smokers with an abnormal alveolar plateau who underwent upper abdominal surgery. Identification of the patient at risk was better served by tests of small airway abnormality than by smoking history alone.