Noninvasive venous examinations as a screening test for pulmonary embolism.

Blood clots that cause pulmonary embolism are reputed to arise in the lower extremities in 95% of cases and, therefore, testing with noninvasive venous studies has been recommended as a screening method. We evaluated plethysmography results and Doppler venous flow sounds for their concordance with pulmonary angiograms in a group of patients with suspected pulmonary embolism, and for their concordance with venograms in a second group of patients with suspected deep venous thrombosis. Fifty patients had both pulmonary angiograms and noninvasive venous studies. Of 16 patients with positive noninvasive studies, ten had angiograms positive for pulmonary embolism, and six had negative angiograms. Of 34 patients with negative noninvasive studies, 16 had positive pulmonary angiograms and 18 had negative angiograms. The positive predictive value was 63% and the negative predictive value was 53%. By contrast, in 125 patients with suspected deep venous thrombosis, the positive and negative predictive values of noninvasive studies were 94% and 92%, respectively. In this retrospective study, positive noninvasive examinations were useful clinically, but noninvasive venous studies were frequently negative in patients with documented pulmonary embolism and cannot be used to exclude this diagnosis.

Steroids for Pneumocystis carinii pneumonia and respiratory failure in the acquired immunodeficiency syndrome. A reassessment.

Patients with acquired immunodeficiency syndrome who have Pneumocystis carinii pneumonia (PCP) and respiratory failure have a high mortality. Previous reports have suggested that corticosteroids administered in conjunction with antibiotics improve the outcome in these patients. We reviewed our experience with adjunctive corticosteroids in 20 patients with acquired immunodeficiency syndrome and respiratory failure due to PCP to determine if this was the case. Fourteen patients responded to therapy with initial reversal of their respiratory failure. However, nine of these relapsed with recurrence of respiratory failure after steroid therapy was withdrawn. Eight (40%) of the patients remained alive and well 3 months or more following treatment. When the analysis was restricted to patients requiring intubation, only 25% were alive 3 months later. Despite good initial response to steroids in PCP and respiratory failure, survival remains limited. Controlled trials are needed to define better the role of steroid treatment in these patients.

Mineralocorticoid activity of 19-nor-corticosterone and 19-nor-progesterone in the toad bladder.

19-Nor-corticosteroids are potentially important mineralocorticoids and hypertensive agents. We tested the mineralocorticoid potency of 19-nor-progesterone (19-NOR-P) and 19-nor-corticosterone (19-NOR-B) compared with aldosterone using the toad bladder short-circuit current as a measure of sodium transport. 19-NOR-B (10(-7) M) increased sodium transport to a degree not different from that caused by aldosterone (10(-7) M). The onset of action and duration of activity also were not different from those of aldosterone. 19-NOR-P (10(-7) M), however, had no effect on sodium transport. We conclude that 19-NOR-B has significant mineralocorticoid activity, while under the conditions of these studies, 19-NOR-P exhibited no effect on sodium transport.

Outpatient pleurodesis of malignant pleural effusions using a small-bore pigtail catheter.

STUDY OBJECTIVE: Patients with symptomatic malignant pleural effusion are usually treated with large-bore chest tube placement and pleurodesis requiring > or = 3 days of hospitalization. We sought to demonstrate the feasibility of ambulatory drainage and sclerosis using a small-bore pigtail catheter in patients with malignant pleural effusions. We reasoned that this approach would improve symptoms and quality of life at a reduced cost. METHODS: A 14F pigtail catheter was percutaneously inserted into the pleural space and connected to a closed gravity-drainage bag system. The patients were instructed in the use of the drainage system and discharged to return for sclerosis with 4 g of talc after the drainage was < 100 mL/24 h. Patients were graded for dyspnea and performances status using the Eastern Cooperative Oncology Group score (ECOG) and baseline and transitional dyspnea index score (BDI-TDI) before tube placement and again at 30 days. Radiographic response was graded as total response, partial response, or failure. Telephone follow-up was initiated when the patient could not return for evaluation. RESULTS: Ten ambulatory women, ages 41 to 79 years, were enrolled. The chest tube was left in place from 1 to 10 days, draining a mean of 2,956 mL (1,685 to 6,050 mL). Only two patients were unable to undergo sclerosis owing to catheter dislodgment and minimal drainage. Six reported symptomatic improvement at 30 days confirmed by TDI and ECOG scores in four of six. One with a prior history of a lobectomy was found to have a chylous pleural effusion and experienced a hydropneumothorax, for which sclerosis was unsuccessful. One died in hospital on day 26 after sclerosis despite radiographic resolution. Of the four patients who had improved dyspnea and functional status by TDI and EGOG scores, radiographic response was complete in three and partial in one. Two of the six were not able to return for follow-up because of weakness but reported improvement by telephone inquiry. CONCLUSION: Ambulatory sclerosis of malignant effusion using a small-bore catheter is a feasible alternative to inpatient sclerosis with a large-bore chest tube, especially in patients with strong preferences for outpatient care.

Safety and efficacy of total dose iron dextran administration in patients on home renal replacement therapies.

OBJECTIVE: To determine the safety and efficacy of intravenous total dose iron (TDI) replacement in patients treated with home renal replacement therapy. DESIGN: Prospective open-label study on end points in the population studied. SETTING: Institutional outpatient home dialysis program. PATIENTS: The study included 20 end-stage renal disease (ESRD) patients, performing chronic peritoneal or home hemodialysis, with iron deficiency defined as ferritin < 100 ng/mL and/or an iron saturation < 20%. INTERVENTION: The total dose of iron dextran was calculated and infused at a rate not exceeding 6 mg/min. Hemoglobin, hematocrit, iron studies, and liver function tests (LFTs) were obtained before and 3 to 4 weeks after TDI infusion. Hematocrit of patients failing to achieve an increase in Hct over this period was re-examined 2 to 4 weeks later looking for a delayed response. MAIN OUTCOME MEASURES: Primary end points for efficacy were changes in Hct, ferritin, and iron saturation. Toxicity was measured as reported immediate and delayed symptoms and elevated transaminases and/or alkaline phosphatase levels. RESULTS: A median iron dose of 1000 mg (range, 325-1500 mg) was administered. The infusions were generally well tolerated. Clinical adverse effects were seen in 2 patients weighing less than 50 kg. No increase in LFT results was seen. Hematocrit increased 2.2% (95% CI, 0.5%-3.9%) from 29.0% to 31.2% (p = 0.01) within 4 weeks of infusion. Significant increases also occurred in iron saturation (from 13% to 22%, p = 0.001) and ferritin (from 234 to 305 ng/mL, p = 0.008). Among the 9 patients who did not respond with a significant increase in Hct, 2 had a delayed response, increasing the overall response from 63% at 4 weeks to 71%, 8 weeks after TDI. Inadequate erythropoietin dosing and low-grade infectious/inflammatory disorders may have contributed to a poor response in several patients. CONCLUSION: Total dose iron is a safe and effective means of restoring iron and erythropoietic response in ESRD patients weighing more than 50 kg who receive their renal replacement therapy at home.

Low doses of animal antigen attenuates the late asthmatic reaction.

Five subjects with a history of asthma after exposure to cat or dog underwent a trial of low-dose antigen injection followed by bronchoprovocation with the relevant antigen. The neutralization dose of antigen was determined by serial and point dilution skin testing. In a crossover protocol, patients received this antigen or placebo injections. They then underwent bronchoprovocation with the same antigen. The results of the early and late reaction to bronchoprovocation were compared, with each patient serving as her own control. As measured by the number of breath units to lower the FEV1 by 20%, placebo group tolerated only 6.9 +/- 2 breath units, whereas the neutralization group tolerated 29 +/- 3 breath units (p less than 0.05). The maximum decline in FEV1 during the late reaction was 27 +/- 13% after injection of placebo and 12 +/- 12% after injection of antigen (p less than 0.05). In this model of antigen-induced asthma, injection of low doses of allergen immediately preceding bronchoprovocation blunted the immediate and delayed asthmatic reaction.

Beneficial effect of low-dose transdermal estrogen on bleeding time and clinical bleeding in uremia.

Patients with renal failure frequently manifest a hemorrhagic diathesis characterized by prolonged bleeding time (BT). Oral and intravenous estrogens have been shown to correct this abnormality, but both estrogens have real and potential disadvantages, especially for long-term use. We examined the effectiveness of transdermally applied 17 beta-estradiol on clinical bleeding and BT in renal failure patients. Six patients with renal insufficiency and prolonged BT were included in the study. Four patients had recurring gastrointestinal bleeding from telangiectasias. Two patients anticipated percutaneous renal biopsy. Transdermal estradiol 50 or 100 micrograms/24 hr was applied every 3.5 days for a period of 2 months. Bleeding times were measured just prior to estrogen administration (pre-estradiol) and again on cessation of clinical bleeding or prior to renal biopsy (post-estradiol). Differences were analyzed using a paired t-test. Erythrocyte transfusion requirement 2 months before and 2 months after estradiol application also was observed. Hemorrhage in all four actively bleeding patients ceased or improved, as reflected by the reduced need for transfusion. Bleeding time improved significantly (P = 0.008) when comparing before (day 0) with after (days 1 to 17) estradiol application. No adverse reactions associated with estradiol occurred over 2 months of therapy. In conclusion, transdermal application of 17 beta-estradiol is a safe and effective means to reduce BT and clinical hemorrhage in patients with renal failure and prolonged BT.

Rothia dentocariosa pneumonia in an immunocompromised patient.

An 84-year-old woman with acute myelocytic leukemia presented with fever and a left upper lobe infiltrate on chest x-ray. She failed to respond to initial broad spectrum antibiotic therapy. Bronchoalveolar lavage fluid and a transthoracic needle aspirate subsequently both grew Rothia dentocariosa, a gram-positive branching rod. The pneumonia resolved after prolonged treatment with Clindamycin. Rothia dentocariosa must be considered a cause of opportunistic pulmonary infection.

Corticosteroid treatment as a risk factor for invasive aspergillosis in patients with lung disease.

Invasive pulmonary aspergillosis usually occurs in severely immunocompromised or neutropenic patients. Six patients with invasive aspergillosis are described whose only defence impairment was underlying lung disease and corticosteroid treatment. Cough, fever, and sputum production were the usual reasons for presentation and four patients developed the sepsis syndrome. Radiographic findings included de novo cavitation in three patients and rapid radiographic progression in four. Aspergillus species were isolated from respiratory secretions of all patients early in the course of the disease. Treatment was effective in only two patients and the subsequent progress of the others was consistent with a chronic necrotising process. Invasive pulmonary aspergillosis is uncommon in patients with respiratory diseases receiving corticosteroids, but should be considered when pneumonia and cavitary infiltrates occur.