Erythema induratum and active pulmonary tuberculosis.

The etiology of erythema induratum, a rare disease of the skin in the United States but occasionally seen in natives of Asian countries, remains a source of debate. Its association with tuberculosis, although strongly suspected for more than one century, has not been clearly defined. We report a case of erythema induratum occurring in a young Chinese woman in the setting of active pulmonary tuberculosis. Both diseases promptly responded to antituberculous therapy. The diagnosis of erythema induratum should urge the clinician to search for a source of active tuberculosis, and treatment should be initiated accordingly.

Acute effects of sucralfate aspiration: clinical and laboratory observations.

STUDY OBJECTIVE: To assess the complications associated with the aspiration of sucralfate. DESIGN: Clinical (case report) and bench observations. SETTING: Inpatient intensive care unit and experimental animal laboratory. SUBJECTS: The case of a critically ill patient who aspirated sucralfate is presented. Fifteen Sprague-Dawley rats served as experimental animals to investigate the acute histologic effects of large-volume aspiration of sucralfate. INTERVENTIONS: The patient underwent emergent intubation to relieve acute upper airway obstruction. All the animals were anesthetized and had tracheostomies performed. The experimental groups had acidic intratracheal injections of 2 ml/kg of a nonparticulate liquid (pH, 2.3; n = 6) or a sucralfate aspirate (1 ml/kg of a 5% sucralfate suspension of pH 3.6, followed by 1 ml/kg 0.1 of normal hydrochloric acid of pH 1.0; n = 4). Four hours after simulated aspiration, the rats were sacrificed and their lungs removed for histologic examination by light microscopy. MEASUREMENTS AND MAIN RESULTS: Differences were noted in histopathologic injury in the experimental groups compared to the control group using a numeric scoring scale. Nonparticulate acidic liquid aspiration caused a significant increase (p < 0.05) in inflammation. Sucralfate caused a significant increase (p < 0.05) in lung hemorrhage. A nonsignificant trend was seen with simulated sucralfate aspiration for edema and inflammation. No long-term sequelae were attributed to the clinical aspiration episode. CONCLUSIONS: Acute complications associated with aspiration of sucralfate have been identified. In the laboratory setting, simulated aspiration of sucralfate led to acute lung injury.

Peritoneovenous shunts--devices of last resort.

This study examines the usefulness of peritoneovenous shunts through a retrospective review of the charts of 16 patients who received this shunt at the University Hospital in Saskatoon up to May 1987. Fourteen shunts were placed for malignant ascites, 1 for alcoholic cirrhosis and 1 for nephrogenic ascites. All patients had symptoms related to abdominal pressure or dyspnea. Diuretics were most frequently used as initial management, and paracentesis was performed to relieve symptoms in all but one patient. However, a trial of sodium restriction was used in only eight patients, and only five of these trials lasted longer than 1 week. Thus, the adequacy of medical management was questionable. The death of one patient was directly attributable to the shunt, and the deaths of four others were suspected to be sequelae of surgery or shunting. Only five shunts were functioning at the time the patient died. In this study, the majority of the patients received little benefit from the peritoneovenous shunt.

Acute histologic effects of simulated large-volume aspiration of sucralfate into the lungs of rats.

Sucralfate is an effective agent in reducing the incidence of upper GI tract (UGIT) stress bleeding and nosocomial pneumonia in critically ill patients. Many of these patients are not intubated and are at increased risk for aspiration of large volumes of UGIT contents containing sucralfate. The effects of aspirated sucralfate are unknown. To investigate this, large-volume aspiration (2 ml/kg) was simulated in freshly tracheostomized rats (n = 6, all experimental groups) using normal saline, particulate antacid, and sucralfate adjusted to pH 3.6 and 5.0. Four hours after aspiration, the rats were killed and their lungs were formalin-fixed. Significant increases in lung inflammation were seen by light microscopy in all experimental groups at pH 3.6. Antacid aspirated at pH 5.0 induced significant increases in airway as well as parenchymal inflammation. At pH 3.6, the antacid aspiration led to significant increases in lung edema and hemorrhage. Sucralfate aspiration produced significant increases in pulmonary hemorrhage at pH 5.0. Our microscopic findings are consistent with the acute pulmonary histopathologic changes known to occur after large-volume aspiration of particulate materials, including antacids. Additionally, we show that large-volume aspiration of sucralfate produced significant acute pneumonitis, including pulmonary hemorrhage. In view of the proven usefulness of sucralfate, further investigations are indicated to evaluate these experimental findings before extrapolating to critically ill patients.

Elastin fiber analysis in acute diffuse lung injury caused by smoke inhalation.

OBJECTIVE: The evaluation of various techniques to diagnose or exclude ventilator-associated bacterial pneumonia has been a focus of much research. One such technique involves elastin fiber detection. It has been inferred from previous work that 40% potassium hydroxide preparations of respiratory secretions that demonstrate elastin fibers have a 100% specificity in diagnosing bacterial pneumonia in intubated, mechanically ventilated patients without acute diffuse lung injury. The purpose of this investigation was to ascertain if elastin fibers might be detected in respiratory secretions in acute, diffuse lung injury in the absence of pneumonia (i.e., assess specificity). DESIGN: An animal model using a standardized smoke inhalation protocol to cause acute, diffuse lung injury was used. MATERIALS AND METHODS: Respiratory secretions collected from the endotracheal tubes from eight sheep that underwent the standardized smoke inhalation protocol and were examined with 40% potassium hydroxide. Histologic data were obtained from autopsy to diagnose or exclude lung injury and pneumonia. MEASUREMENT AND MAIN RESULTS: We found six (false) positive elastin fiber preparations in the absence of histologic pneumonia. Specificity was 0.25. CONCLUSIONS: We concluded that seeing these results, given a true specificity of 0.99 inferred from previous work, is highly improbable with a probability of 2.74 x 10(-7). Thus, elastin fiber analysis is likely to be highly nonspecific for diagnosing pneumonia in the setting of acute diffuse lung injury.

Diffuse malignant pleural mesothelioma in an urban hospital: clinical spectrum and trend in incidence over time.

This retrospective analysis reviews the clinical experience of a major urban referral hospital with diffuse malignant pleural mesothelioma during the 14-year period from 1973 through 1986. Seventy-five cases of definite or equivocal mesothelioma were identified. There were four cases of primary malignant peritoneal mesothelioma, seven cases of benign fibrous mesothelioma, and 64 cases of diffuse malignant pleural mesothelioma. In 43 cases (67%) of diffuse malignant pleural mesothelioma, there was historic evidence of asbestos exposure. In 21 cases (33%), there was no known history of asbestos exposure. An increase in annual incidence of diffuse malignant pleural mesothelioma was observed over the study period, from three cases in 1973 to ten cases in 1986. Despite greater awareness of this disease, the diagnosis remains a difficult one to establish given the nonspecific symptoms, signs and radiographic appearance, variable histologic appearance, and poor diagnostic sensitivity and specificity of thoracentesis and closed pleural biopsy. Thoracotomy, thoracoscopy, and CT-guided needle biopsies gave higher yields and are the diagnostic measures of choice when diffuse malignant pleural mesothelioma is suspected.

Acute, subacute, and chronic histologic effects of simulated aspiration of a 0.7% sucralfate suspension in rats.

OBJECTIVE: To assess the acute (4-hr), subacute (7-day), and chronic (21-day) effects of simulated aspiration of a 0.7% sucralfate suspension in rats. DESIGN: Prospective, multigroup trial in which rats were randomized to various simulated aspiration groups. SETTING: Experimental animal laboratory. SUBJECTS: Forty-five Sprague-Dawley rats. INTERVENTIONS: Simulated aspiration was induced by single, direct, tracheal instillation of 2 mL/kg of either room air, sucralfate, or normal saline. MEASUREMENTS AND MAIN RESULTS: Lung histologic changes were assessed using a quantitative numerical scoring scale. There was an increase in bronchiolar inflammation in rats undergoing acute, simulated sucralfate aspiration compared with controls. There were no significant differences (p > .05) in any other features at any time interval studied (two-way analysis of variance). CONCLUSIONS: Even though significant inflammatory airway lesions were produced in this acute model, these abnormalities resolved without evidence of subacute or chronic histologic progression. It remains to be determined if this pattern is unique to this specific experimental model or if it can be extrapolated to critically ill patients.

TNF alpha gene and protein expression in alveolar macrophages in acute and chronic hyperoxia-induced lung injury.

Alveolar-capillary membrane remodeling, including microvessel wall thickening and interstitial fibrosis, is a well-known sequela of cell proliferation in the hyperoxia-injured lung. The array of growth molecules released locally that potentially mediate this response, and their cell(s) of origin, are currently being defined. To elucidate the role of tumor necrosis factor alpha (TNF alpha), an effector molecule of cell injury and proliferation, and the role of the alveolar macrophage (AM) as its source during the acute (1 to 24 h) and chronic stages (3 to 28 days) of hyperoxia-induced injury, we have analyzed gene and protein expression in cells recovered from rat lung by bronchoalveolar lavage. In the hyperoxic lung, cell number was similar to that in normal lung (1 x 10(6)) except on day 7, when it was higher (5 x 10(6)). Virtually all cells recovered from the normal and hyperoxic lung were AMs, with the exception that on days 3 and 7 of hyperoxia these cells represented 69% and 55% of the population, respectively, and polymorphonuclear leukocytes and lymphocytes the remainder. Probe specificity was confirmed by detection of TNF alpha RNA (1.6 kb) from lung cells recovered after lipopolysaccharide (LPS) treatment (positive control) and from the hyperoxic lung (at day 3), with an extremely low level of constitutive expression detected in cells from normal lung. In cytospin preparations, TNF alpha mRNA transcripts were detected in few AMs recovered from normal lung and in most AMs after LPS treatment. In the hyperoxic lung, a signal was detected at 3 h, when approximately 25% of the population was positive. The number of hybridizing cells then increased, being highest on day 7 (day 1 approximately 30%, day 3 approximately 58%, day 7 approximately 90%, day 28 approximately 65%). No expression of TNF alpha protein was detected in AMs from normal lung; positive cells were detected in the hyperoxic lung from day 1 and thereafter. We conclude from upregulation of the TNF alpha gene in a significant number of cells, and from the increase in the number expressing biologically active protein, that AMs are an important source of this molecule both in the acute and chronic stages of hyperoxic lung injury. It is anticipated that an increased understanding of the cellular sources of mediators effecting vascular and alveolar wall remodeling in vivo will contribute to the development of strategies to inhibit the response.

Elastin fibers and the diagnosis of bacterial pneumonia in the adult respiratory distress syndrome.

OBJECTIVE: It has been inferred from previous work that 40% potassium hydroxide preparations of lower respiratory tract secretions that demonstrate elastin fibers have a 100% specificity and positive predictive value in diagnosing bacterial pneumonia in intubated, mechanically ventilated patients without the adult respiratory distress syndrome (ARDS). Our aim was to assess the specificity of 40% potassium hydroxide preparations in diagnosing bacterial pneumonia in patients with ARDS and suspected pneumonia. DESIGN: Prospective, case-referral clinical study. SETTING: Referral hospital. PATIENTS: Of 24 patients with ARDS who were intubated and mechanically ventilated with suspected bacterial pneumonia, 22 were assessable and evaluated for this report. INTERVENTIONS: Tracheo-bronchial aspirates were obtained from all patients and analyzed for elastin fibers using 40% potassium hydroxide. MEASUREMENTS AND MAIN RESULTS: Of the 22 assessable patients, ten patients did not have a complicating bacterial pneumonia. Six of these ten patients had potassium hydroxide preparations that demonstrated elastin fibers (false positives). The other four patients had preparations that did not demonstrate elastin fibers (true negatives). Specificity was 40%. CONCLUSION: Elastin fiber preparations are not specific for diagnosing bacterial pneumonia in patients with ARDS.

The Polycystic Ovary Syndrome Health-Related Quality of Life Questionnaire (PCOSQ): a validation.

BACKGROUND: We wished to evaluate the psychometric properties of the Polycystic Ovary Syndrome Questionnaire (PCOSQ), a questionnaire developed to measure the health-related quality of life (HRQoL) of women with polycystic ovary syndrome. METHOD: To assess reliability and validity, women recruited from an outpatient gynaecology clinic at the Jessop Wing, Royal Hallamshire Hospital, Sheffield completed two copies of the PCOSQ and the Short Form-36 (SF-36). Secondary factor analysis was carried out to verify the composition of the dimensions. Semi-structured interviews were conducted to assess face validity. RESULTS: Of the 92 women who consented, 82 women (89%) returned questionnaires at time 1, and 69 women (75%) returned questionnaires at time 2. All five PCOSQ dimensions were internally reliable with Cronbach's alpha scores ranging from 0.70 to 0.97. Intra-class correlation coefficients to evaluate test-retest reliability were high (range 0.89-0.95, P < 0.001). Construct validity was demonstrated by high correlations for all comparisons of similar scales of the SF-36 and PCOSQ (0.49 and 0.54). Acne was identified as an important area of HRQoL missing from the questionnaire. CONCLUSIONS: The PCOSQ is a reliable instrument for measuring the HRQoL in women with PCOS. However, the validity of the questionnaire needs to be improved by incorporating a dimension on acne into the instrument.