Streptokinase in a loculated pleural effusion. Effectiveness determined by site of instillation.

A patient with a large loculated pleural effusion had streptokinase instilled into the loculation, and this was ineffective; however, when the same amount of streptokinase was instilled into the space around the loculation, there was rapid lysis of the loculation, resulting in the drainage of purulent fluid through the chest tube.

An evaluation of the accuracy of Assess and MiniWright peak flowmeters.

With the advent of small inexpensive peak flowmeters, the at-home monitoring of peak flow rates has become an invaluable aid in the treatment of asthmatic patients. In this study, we evaluated the performance of the MiniWright and Assess peak flowmeters for accuracy and reproducibility. Measurements were made at varying peak flow rates and compared with those obtained simultaneously by a calibrated pneumotachograph. When this segment of the study was completed, the peak flow devices were subjected to 200 uses and were then retested. Four MiniWright peak flowmeters that had been extensively used in our clinic were tested as well. The Assess peak flowmeter was more accurate than the MiniWright at low flow rates (less than 300 L/min), while the MiniWright meter was more accurate at high flow rates (greater than 400 L/min). We also found that the accuracy of the MiniWright meter deteriorated after 200 uses and worsened further after extensive use, while the Assess meter retained its accuracy after 200 uses.

Effect of high-dose intramuscular triamcinolone in older adults with severe, chronic asthma.

Life threatening asthma is a serious condition that is often difficult to treat. Often, despite maximal medical therapies, these patients remain functionally crippled. In addition, older patients are even more susceptible to asthma as they are less able to adapt to or tolerate the symptoms. In this paper we report the effectiveness of a new treatment regimen of high-dose intramuscular triamcinolone (360 mg) in 7 elderly patients with severe, chronic, steroid-dependent asthma. Each patient was given one intramuscular injection of 360 mg of triamcinolone (Kenalog) after maximizing traditional medicines. All 7 patients experienced resolution of their asthma symptoms within 1 week of receiving this injection. They showed marked functional improvement in their activities of daily living, and independence. Six of seven progressed from being homebound to walking, shopping, and grooming without restriction. All had a corresponding rise in peak expiratory flow rates ranging between 25 and 93%. In addition, all were able to stop taking their daily oral prednisone. Response durations ranged from 3 to 24 months. In the 6 patients who experienced relapse, all requested and received a second injection, with similar positive outcomes. Some experienced transient weakness and diabetes during the first week of the therapy but all elected to receive additional shots when they experienced break-through wheezing. Thus, we feel that high-dose intramuscular triamcinolone should be considered as a therapeutic option for a highly select group of older steroid-dependent asthma patients.

Raja pleural biopsy needle. A comparison with the Abrams needle in experimental pleural effusion.

The Raja pleural biopsy needle, 3 mm in external diameter and fitted with a titanium alloy biopsy flap, was compared with the Abrams needle in six dogs with experimentally induced pleural effusion. One hundred twenty-four pleural biopsies were performed using either the Raja needle or the Abrams needle (62 with each needle). No complication occurred with either needle. The Raja pleural biopsy needle yielded a statistically significant larger pleural tissue specimen with a statistically significant lower frequency of crush artifacts. The size of the pleura obtained by the Abrams needle averaged 4,401 +/- 559 microns2 (mean +/- SE) compared with 8,652 +/- 1,099 microns2 with the Raja needle (p less than 0.01; Student two-tailed t test). Biopsies by the Abrams needle showed crush artifacts in 25.8% of the specimens, whereas 8.06% of biopsies with the Raja needle showed crush artifacts (p less than 0.02; Fisher's two-tailed exact test). In conclusion, the Raja pleural biopsy needle is safe to use and, despite its smaller diameter (3mm versus 4mm external diameter of the Abrams needle), yields significantly larger and less frequently distorted pleural specimens.

Comparison of the Raja and the Abrams pleural biopsy needles in patients with pleural effusion.

In 31 patients with exudative pleural effusions, we compared the diagnostic yield of the Abrams pleural biopsy needle with that of a new instrument, the Raja pleural biopsy needle. Each patient was randomly biopsied with both needles, and a total of 153 pleural biopsies were done, 73 with the Abrams needle and 80 with the Raja needle. No complications resulted from biopsies with either needle. Etiologic diagnoses were possible in 38 (52%) biopsies obtained using the Abrams needle, compared with 66 (82.5%) for those using the Raja needle; the difference in proportions for the diagnostic yield was statistically significant (p < 0.01, two-tailed Fisher's exact test). There were no significant differences between the needles in obtaining etiologic diagnoses in any specific disease category. The difference between the mean size of the pleural specimens obtained with the two needles was also statistically significant (p < 0.001, Mann-Whitney U test). The Raja pleural biopsy needle is easy and safe to use, and despite its smaller external diameter yields a significantly larger pleural tissue sample and significantly increases the diagnostic yield of pleural biopsies compared with the Abrams pleural biopsy needle.

High-dose intramuscular triamcinolone in severe, chronic, life-threatening asthma.

BACKGROUND: Despite oral corticosteroid therapy, some patients with asthma have frequent exacerbations requiring emergency room visits, hospitalization, and occasionally, mechanical ventilation. We compared the effects of high-dose intramuscular triamcinolone with oral prednisone in patients with severe chronic asthma. METHODS: In a double-blind, placebo-controlled, cross-over study that spanned all seasons, we treated 12 patients with high-dose intramuscular triamcinolone (360 mg over the first three days of the treatment period) or low-dose oral prednisone (median dose, 12.5 mg per day throughout the period; range 0 to 30). The two three-month treatment periods were separated by a three-month washout period. During all periods the patients were allowed to take additional doses of prednisone for acute exacerbations of asthma. RESULTS: After receiving triamcinolone, the patients had significantly better peak expiratory flow rates than while receiving prednisone (the average [+/- SEM] weekly percent of the predicted value during the triamcinolone period was 91.5 +/- 6.9, as compared with 75.0 +/- 5.9 for the prednisone period; P less than 0.05). During the prednisone period there were 21 emergency room visits and 10 hospitalizations, but there were none during the triamcinolone period (P less than 0.05). There were two episodes of ventilatory failure during the prednisone period. Total steroid doses were significantly smaller during the triamcinolone period than during the prednisone period (P less than 0.04). Steroidal side effects were more pronounced after treatment with triamcinolone than after treatment with prednisone (P less than 0.1). CONCLUSIONS: We conclude that high-dose intramuscular triamcinolone is more effective than low-dose prednisone in patients with severe, chronic, life-threatening asthma, but steroidal side effects are somewhat worse.

Single, high-dose intramuscular triamcinolone acetonide versus weekly oral methotrexate in life-threatening asthma: a double-blind study.

Effective and less toxic treatments are needed for patients with severe, steroid-dependent asthma. Both low-dose oral methotrexate and high-dose intramuscular triamcinolone have been recommended for these patients. We compared the effects of these two medications on pulmonary function, peak flow rates, airway reactivity, oral steroid use, emergency room (ER) visits, and hospitalizations in patients with steroid-dependent, life-threatening asthma. In a randomized, placebo-controlled, double-blind study, we investigated 19 such patients. Six of the patients (Group I) received a single dose of 360 mg triamcinolone intramuscularly with placebo methotrexate; seven patients (Group II) received placebo triamcinolone followed by low-dose oral methotrexate (a first dose of 7.5 mg followed by 15 mg weekly); and six patients (Group III) received placebo triamcinolone with placebo methotrexate. All patients used the same high-dose inhaled steroids. The patients took tapering courses of oral steroids when needed, but attempted to reduce their oral steroid use whenever possible. Methacholine challenge testing was performed every 6 wk, pulmonary function tests every 4 wk, and home peak-flow measurements twice daily. Oral steroid use, ER visits, and hospitalizations were also monitored. The patients in the triamcinolone treatment group showed a significant and sustained increase in home peak-flow rates, and their FEV1 persistently improved by a mean of 40% (p < 0.05), whereas the FEV1 of the patients in the methotrexate treatment and placebo groups remained near baseline. The PC20 in the triamcinolone group increased progressively (p > 0.05), and the improvements in total mean reactivity were greater in this group than in either of the other two groups (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)