Pulmonary effects of continuous endotoxin infusion in the rat

A major hindrance to the elucidation of the pathogenesis of the adult respiratory distress syndrome (ARDS) is the lack of an animal model consistent with the clinical course in humans. A continuous intravenous infusion of endotoxin (LPS) over a several day period was used to more closely parallel the clinical setting. Male Sprague-Dawley rats infused with LPS via indwelling right atrial catheters become tachypneic, lethargic and anorectic with a steady loss in body weight. Serial blood gas analyses demonstrate an early respiratory alkalosis followed by increasing acidosis and hypoxia. Lungs demonstrate 1) pulmonary leukoaggregation, 2) interstitial and intraalveolar edema, 3) Type I pneumocyte injury, 4) proliferation of Type II pneumocytes, and 5) thickening of the microvascular walls. Differential neutrophil count in bronchoalveolar lavage (BAL) fluid increased from 1% to a peak of 59.1% +/- 3.0% and protein content was elevated. A prolonged infusion of LPS in the rat produces a lung injury which mimics many of the pathophysiologic and histologic features associated with sepsis-induced ARDS in humans.

Why surgeons prefer not to care for trauma patients

A survey of the Washington State Chapter of the American College of Surgeons was undertaken to document the opinions of surgeons on trauma care issues. Thirty-nine percent of the total sample of surgeons who responded would prefer not to treat any trauma patients. These surgeons were more likely to be older, to practice in an urban setting, to feel that trauma call has a negative impact on elective practice, and to believe more strongly that reimbursement from trauma patients is not equal to that of nontrauma patients. They also agreed more strongly with the statements that these patients require a greater time commitment and pose an increased medicolegal risk. The most significant influence on preference not to treat trauma patients was exerted by the perception of a negative impact on practice, older age, and perception of increased medicolegal risk. Reimbursement issues and location of practice were less influential factors. This information can be used to target concerns and barriers to active, willing participation in a trauma care system and to tailor strategies to deal with them effectively.

Flexion distraction and chance injuries to the thoracolumbar spine

Seat belt legislation has resulted in increased restraint use by passengers in automobiles in Washington State. At Harborview Medical Center in Seattle, we have observed an increased incidence of seat belt-related injuries. Twenty cases of Chance-type thoracolumbar flexion-distraction fractures were reviewed retrospectively. Thirteen patients (65%) had associated life-threatening intra-abdominal trauma. Twelve of these patients had bowel wall injury. Ninety percent of the children had combined abdominal and spinal injury. Operative treatment of the spinal injury resulted in correction of lumbar kyphosis and lower incidence of back pain than nonoperatively managed cases. We recommend careful physical and radiographic examination of all patients with significant abrasion or bruising about the pelvis or abdomen related to seat belts. Victims of automobile crashes who are treated for bowel injury require thoracolumbar radiographs. Similarly, patients with Chance-type fractures should undergo diagnostic peritoneal lavage or computerized abdominal tomography.

Endotoxin requirements for alveolar macrophage stimulation

Acute pulmonary failure or ARDS in severely injured patients continues to be a significant problem. The most important clinical risk factor identified is sepsis syndrome. Sepsis syndrome is the clinical correlate of a malignant systemic inflammatory process and is directed in large part by the tissue-fixed macrophage (M phi), such as the alveolar M phi. The M phi is capable of producing most of the central inflammatory mediators responsible for the pathophysiology seen during sepsis and organ injury. Two major mediators are procoagulant activity (PCA), leading to diffuse microvascular thrombosis, and tumor necrosis factor (TNF), causing much of the physiologic derangement of sepsis. Endotoxins (LPS) derived from Gram-negative bacterial cell walls are the primary inflammatory stimulus for the tissue-fixed M phi production of inflammatory mediators. It is not completely known how LPS interacts with its various cellular targets, but it is hoped that knowledge of the molecular interactions involved in stimulation of the M phi by endotoxin will lead to therapies to modulate the response and prevent deleterious processes such as ARDS. In the present studies, LPS from E. coli 0111:B4 was shown in a dose response to stimulate large levels of both PCA and TNF in alveolar M phi. LPS from Bacteroides fragilis and Lipid X (the monosaccharide precursor of endotoxin) were unable to cause stimulation of the M phi in vitro. However, both moieties, B. fragilis LPS and Lipid X, were able to effectively and specifically compete with E. coli LPS and block M phi stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of the Pediatric Trauma Score

A Pediatric Trauma Score (PTS) was recently developed and is rapidly gaining acceptance as a triage tool. This study examines the utility of the PTS as compared with the Revised Trauma Score, which is applicable to all ages. The charts of 376 children 0 to 14 years of age who were admitted to the trauma service of a level 1 trauma center were reviewed. Significant correlations were found for both the PTS and the Revised Trauma Score with survival, the Injury Severity Score, APACHE II score, vital signs, the Glasgow Coma Scale score, hematocrit, need for an operation, and number of days in an intensive care unit. The PTS was of no statistical advantage as compared with the Revised Trauma Score. Triage accuracy was 68.3% for the PTS and 78.8% for the Revised Trauma Score. The Revised Trauma Score is easy to use and universal in its applicability. The PTS involves learning a separate scoring system and is of no advantage.

Oxidant-induced endothelial leak correlates with decreased cellular energy levels

A common finding in oxidant-induced organ injury is loss of vascular endothelial cell (EC) integrity and subsequent leak. The mechanisms involved are unclear, but maintenance of EC structure and functional integrity is highly dependent on the EC energy level. This study investigates whether oxidant-induced EC injury and concomitant increased monolayer permeability correlate with decreased energy levels. Rabbit pulmonary microvascular EC in vitro were exposed to varying levels of glucose oxidase as an oxidant-generating source for 2 h. Permeability changes were determined by albumin-Evans blue dye exclusion by monolayers of EC. ATP (nm/10(6) cells) and energy charge [ATP + 1/2ADP/(ATP + ADP + AMP)] were determined by HPLC. ATP and energy charge were found to decrease as permeability increased in response to increasing glucose oxidase concentration. ATP levels were a significantly more sensitive predictor of increased permeability than was energy charge. At 24 h, both permeability and ATP levels returned toward baseline. It appears that cell energy charge is preserved despite significant increases in monolayer permeability.

Cost estimates for statewide reporting of injuries by E coding hospital discharge abstract data base systems

A key element in the study of trauma problems is the design and development of adequate and affordable surveillance systems. One proposed method is the use of data available from hospital discharge abstract data base systems. However, surveillance systems based on existing data bases usually do not include codes that can identify the external causes of injuries, a critical limitation of the ability to determine the mechanisms of injuries. One obstacle to adding external cause of injury codes, known as E codes under the International Classification of Diseases, to uniform hospital discharge abstract data base systems is the cost of such a change. This study provided an estimate of the type and size of the costs for one State, based upon a survey of hospitals, information system vendors, and medical records experts. Two categories of the costs involved in adding E codes to hospital discharge abstract data base systems were identified. One-time implementation costs, which include modification of the computerized data base and the coding guidelines used by medical record personnel, average $600 per hospital. Annual costs resulting from increased operating expenses to include E codes average about $600 per hospital, because of the increased workload of coding and entry of the additional data. Adding E codes to hospital discharge abstract data base systems appears to be financially feasible for statewide surveillance of serious injury.

Great expectations: stress and the medical family. 1987 Committee on Issues, Association for Academic Surgery

The high divorce rate and significant stress experienced by families of academic surgeons stimulated the Committee on Issues of the Association of Academic Surgery to choose medical family stress as the topic for the 1987 Committee presentation at the annual meeting. The Committee hoped to provide insight into the cause of this stress and new strategies for coping with this pervasive problem. Forty-three percent of the 505 surgeons who entered the Association from 1981 through 1984 and 38% of their spouses responded to a questionnaire covering issues of time management, response to stress, child rearing, financial security, and spouse career. A panel consisting of Shirley P. Levine, M.D., Hiram C. Polk, Jr., M.D., and Lane A. Gerber, Ph.D., after discussing the questionnaire results, recommended realistic goal setting, specific prioritization of activities, recognition of the considerable contributions of the spouse, and insight into personal limitations as mechanisms for improving family function.

Human endothelial cell adhesiveness for neutrophils, induced by Escherichia coli lipopolysaccharide in vitro, is inhibited by Bacteroides fragilis lipopolysaccharide

Recent studies in vitro have demonstrated that LPS from Gram-negative bacteria are capable of inducing endothelial cells to express a cell surface property that promotes the adherence of neutrophils (polymorphonuclear cells, PMN). We have investigated the effects of LPS from Bacteroides fragilis, an organism documented to have little toxicity in vivo, on the induction of this property in human endothelial cells. Monolayers of cultured human umbilical vein endothelial cells (HUVE) exhibited no increase in adhesiveness for 51Cr-radiolabeled PMN after 4 h of exposure to B. fragilis LPS from 1 ng to 10 micrograms/ml. Escherichia coli LPS elicited a dose-dependent enhancement of HUVE adhesiveness for PMN over the same concentration range, reaching a maximum of 49.4 +/- 6.6% at 10 micrograms/ml. Like E. coli LPS, B. fragilis LPS converted chromogenic substrate in the Limulus amebocyte lysate assay, and was directly cytotoxic to bovine aortic endothelial cells. Both B. fragilis LPS activities required doses two-to-three log-fold higher than for E. coli LPS. In addition, we found that B. fragilis LPS inhibited the induction of HUVE adhesiveness for PMN by E. coli LPS. This inhibition was also dose-dependent, becoming maximal (greater than 80%) when B. fragilis LPS was in 10- to 20-fold excess. Tumor necrosis factor and IL-1, two monokines which also elicit HUVE adhesiveness for PMN, were not inhibited by B. fragilis LPS, suggesting a mechanism of HUVE activation by LPS which is signal-specific, and which recognizes specificities of LPS structure.

Human endothelial cell adhesiveness for neutrophils, induced by Escherichia coli lipopolysaccharide in vitro, is inhibited by Bacteroides fragilis lipopolysaccharide

Recent studies in vitro have demonstrated that LPS from Gram-negative bacteria are capable of inducing endothelial cells to express a cell surface property that promotes the adherence of neutrophils (polymorphonuclear cells, PMN). We have investigated the effects of LPS from Bacteroides fragilis, an organism documented to have little toxicity in vivo, on the induction of this property in human endothelial cells. Monolayers of cultured human umbilical vein endothelial cells (HUVE) exhibited no increase in adhesiveness for 51Cr-radiolabeled PMN after 4 h of exposure to B. fragilis LPS from 1 ng to 10 micrograms/ml. Escherichia coli LPS elicited a dose-dependent enhancement of HUVE adhesiveness for PMN over the same concentration range, reaching a maximum of 49.4 +/- 6.6% at 10 micrograms/ml. Like E. coli LPS, B. fragilis LPS converted chromogenic substrate in the Limulus amebocyte lysate assay, and was directly cytotoxic to bovine aortic endothelial cells. Both B. fragilis LPS activities required doses two-to-three log-fold higher than for E. coli LPS. In addition, we found that B. fragilis LPS inhibited the induction of HUVE adhesiveness for PMN by E. coli LPS. This inhibition was also dose-dependent, becoming maximal (greater than 80%) when B. fragilis LPS was in 10- to 20-fold excess. Tumor necrosis factor and IL-1, two monokines which also elicit HUVE adhesiveness for PMN, were not inhibited by B. fragilis LPS, suggesting a mechanism of HUVE activation by LPS which is signal-specific, and which recognizes specificities of LPS structure.

Protein kinase C: a potential pathway of endothelial cell activation by endotoxin, tumor necrosis factor, and interleukin-1

Human endothelial cells exposed to lipopolysaccharide (LPS), tumor necrosis factor (TNF), or interleukin-1 (IL-1) in vitro acquire a cell surface property that promotes the adherence of neutrophils (PMNs). The common mechanism by which endothelial cells are activated by these agents is unknown. We examined adherence of PMNs to cultured human umbilical vein endothelium (HUVE) pretreated with LPS (100 ng/ml), TNF (100 U/ml), and IL-1 (1 U/ml) in medium alone or medium containing protein kinase inhibitors H-7 or HA-1004. Both compounds inhibit a similar spectrum of protein kinases, but H-7 is an effective inhibitor of protein kinase C, whereas HA-1004 is not. We found that H-7 (25 mumol/L) reduced the adherence of PMNs to LPS-, TNF-, and IL-1-stimulated HUVE monolayers to 16.7% +/- 3.0%, 12.1% +/- 2.5%, and 18.3% +/- 2.9% of control, respectively (mean plus or minus standard error of three experiments); HA-1004 (25 mumol/L) did not inhibit endothelial adhesiveness. Cytotoxicity of H-7 was less than 10% in LPS-, TNF-, and IL-1-treated HUVE. Protein synthesis, as measured by the incorporation of tritiated amino acids, was not significantly impaired in LPS-treated HUVE concurrently exposed to H-7. We conclude that protein kinase C appears to be a necessary common mediator of endothelial cell activation by LPS, TNF, and IL-1.

Evaluation of potentially preventable deaths among pedestrian and bicyclist fatalities

The prehospital, emergency department, and in-hospital care of 84 patients who died following a pedestrian- or bicycle-motor vehicle collision in a four-county area was retrospectively reviewed using a systematic, detailed scoring system. The purpose of the study was to examine the effectiveness of an advanced paramedic-regionalized trauma care system and to examine the usefulness of a systematic evaluation tool in identifying preventable and possibly preventable deaths. Among the 84 deaths, one was judged to be preventable and 18 possibly preventable. The one preventable death occurred in the emergency department, while the possibly preventable deaths more commonly occurred after 48 hours and were due to central nervous system injury, sepsis, and multiple organ failure. Prolonged prehospital and emergency department time and failure to establish an airway were the most common problems identified as contributing to fatal outcome. The use of explicit criteria was demonstrated to be an effective addition to the analysis of trauma care systems.

Superoxide production by neutrophils in a model of adult respiratory distress syndrome

Neutrophils (polymorphonuclear leukocytes [PMNs]) are thought to contribute to the pathophysiology of adult respiratory distress syndrome (ARDS) by the release of toxic oxygen metabolites. This study investigated superoxide production by circulating and bronchoalveolar lavage (BAL) PMNs in a rat model of ARDS induced by chronic Escherichia coli (lipopolysaccharide) endotoxemia. Superoxide production was stimulated by fmet-leu-phe, opsonized zymosan, and phorbol myristate acetate. Circulating and BAL PMNs from lipopolysaccharide-infused rats compared with PMNs from control rats are primed for nonselective increased superoxide production. The BAL PMNs are not only partially primed to release superoxide on adherence, they concomitantly have a depressed superoxide response to a phagocytic (opsonized zymosan) stimulus. These PMN responses may partially explain both the pulmonary injury and the increased susceptibility to pulmonary infection seen in patients with ARDS.

Risk factors for urethral injuries in men with traumatic pelvic fractures

Urethral injuries are commonly associated with pelvic fractures. The prompt recognition and appropriate management of these injuries may significantly impact subsequent morbidity, yet few studies have addressed the identification of the risk factors for urethral injury in men with pelvic fractures. We reviewed retrospectively the records of 405 men with pelvic fractures seen at our medical center, including 21 (5 per cent) with urethral injuries. Of the 21 men 14 (67 per cent) had fractures involving a pubic ramus and a sacroiliac joint, and 12 (57 per cent) had no physical signs (blood at the urethral meatus, perineal hematoma or a high-riding prostate) that would suggest a urethral injury. The likelihood for the presence of physical signs is directly related to the interval since injury. We believe that men with the combination of rami fractures and sacroiliac disruption should undergo retrograde urethrograms before urethral instrumentation, and that physical signs are unreliable indications for urethral injuries, especially soon after the injury.

A glycolipid precursor of bacterial lipopolysaccharide (lipid X) lacks activity against endothelial cells in vitro and is not toxic in vivo

Lipid X (2,3-diacylglucosamine-1-phosphate) accumulates in mutants of Escherichia coli incapable of assembling the disaccharide backbone of lipid A, the principle endotoxic moiety of bacterial lipopolysaccharide (LPS). We compared the effects of lipid X on cultured bovine aortic endothelial cell (BEC) viability and prostacyclin (PGI2) release with those of lipid A and LPS. At 10(-5) M, both LPS and lipid A produced significant BEC cytotoxicity (percentage cytotoxicity 69 +/- 4 for LPS and 51 +/- 11 for lipid A) and induced a variable but consistent increase in the release of PGI2 (11- to 73-fold increase for LPS and 4- to 6-fold increase for lipid A). Lipid X, in contrast, was not toxic and did not induce PGI2 release at 10(-4) M. Pretreatment and coincubation of BEC with lipid X, at a concentration 100 times greater than LPS, failed to prevent LPS-mediated cytotoxicity. Intravenous infusion of lipid X in goats had no effect except for a modest elevation in the pulmonary artery pressure during the period of infusion. Moreover, pretreatment of goats with lipid X (70 micrograms/kg) did not block the effects of a subsequent infusion of LPS (5 micrograms/kg). These data suggest that a fatty acid-substituted disaccharide is the minimal molecular requirement for the numerous effects in vivo and activity in vitro induced by LPS. Furthermore, these effects are not prevented by pretreatment with a monosaccharide precursor of lipopolysaccharide, lipid X, at a dose 10- to 100-fold greater than that of LPS.

Neutrophil phagocytosis during endotoxin-induced lung injury

Depressed neutrophil (PMN) phagocytosis in patients with ARDS may contribute to the known increased incidence of pulmonary sepsis. To evaluate changes in phagocytosis, circulating PMNs from normal rats were compared to circulating and alveolar PMNs (obtained by bronchoalveolar lavage, BAL) from rats after 72 hr of endotoxin infusion (LPS-Rx)-induced acute lung injury. Since phagocytosis correlates with adherence, PMN adherence to coverslips and to a standard nylon wool column was also measured. PMN adherence to nylon wool was 65% for control, 77% for circulating LPS-Rx, and 20% for BAL PMNs. As a measure of phagocytosis the PMNs were incubated for 30 min with opsonized fluorescent (FITC) tagged yeast. Total PMN with yeast were 95.4 +/- 2.1% for control; 96.4 +/- 1.8% for circulating LPS-Rx; and 78.7 +/- 7.8% (P less than 0.05 compared to control) for BAL PMNs. Total numbers of yeast particles per 100 PMN are 270 +/- 64 for control, 300 +/- 42 for circulating LPS-Rx, and 170 +/- 45 (P less than 0.05 compared to control) for BAL PMN.

CONCLUSIONS

(1) Intraalveolar (BAL) PMNs have decreased adherence; (2) nonadherent PMNs have decreased uptake of yeast; (3) BAL PMNs, overall, have a significantly decreased uptake of yeast; (4) this depression in BAL PMN phagocytosis may partially explain the known decreased rate of bacterial clearance in injured lungs and the increased risk of pulmonary sepsis with adult respiratory distress syndrome.

Incidence and effect of hypothermia in seriously injured patients

Hypothermia is a well recognized consequence of severe injury, even in temperate climates, and the physiologic consequences of hypothermia are known to be detrimental. To analyze the frequency and risk factors for hypothermia and its effect on patient outcome, we prospectively studied 94 intubated injured patients at a regional trauma center during a 16-month period. Esophageal temperature probes were placed in the field or ER and core temperatures (T) were followed for 24 hours or until rewarming. Patients were designated as normothermic (greater than 36 degrees C), mildly hypothermic (34 degrees C-36 degrees C) or severely hypothermic (less than 34 degrees C) based on initial T. The risk factors for hypothermia evaluated included age, severity and location of injuries, blood alcohol level, blood transfusion requirements, and time spent in the field, ER, or OR. The average initial T was 35 degrees C, with no seasonal variation. Injury severity and survival correlated with severe hypothermia. Normothermic patients had an average ISS of 28 with a 78% survival. Severely hypothermic patients had an average ISS of 36 with a 41% survival (p less than 0.05). Patient age strongly correlated with outcome although there was no relationship between age and initial temperature. Sixty-two per cent of patients tested were positive for blood alcohol, and one half were legally intoxicated (BAC greater than 100 mg%). However, no consistent correlation was found between alcohol intoxication and initial temperature or patient survival. Blood transfusion requirements paralleled injury severity and patients receiving greater than 10 unit transfusions had significantly lower core temperature (p less than 0.05). The average temperature change was positive in the ER, OR, and ICU with time to rewarming correlating with the aggressiveness of warming measures.(ABSTRACT TRUNCATED AT 250 WORDS)

The epidemiology of logging injuries in the northwest

Logging is among the most hazardous forms of employment. However, a comprehensive review of severe logging injuries and their outcome has apparently not been previously undertaken. In the present study we review 51 consecutive injured loggers requiring transfer to a regional Level I trauma center. The average age was 34 years and the mode of injury in 67% was being struck by a falling or rolling log. Orthopedic intervention was required most frequently (49%), with neurologic injury in 43%. Two patients died (4%), both secondary to severe head injury, and both survived less than 24 hours. Importantly, while most severely injured patients survived, they required long hospitalizations and had a 58% permanent disability, with more than half of these being brain or spinal cord related. Although the overall number of workers involved in logging is small, the young average age, the work years lost, and the high risk of permanent disability support continued strong efforts to improve overall safety. Particularly, the high incidence of head injury argues strongly for improved and increased use of safety helmets, which may significantly impact the mortality and morbidity of logging accidents.

Neutrophil function in a rat model of endotoxin-induced lung injury

Polymorphonuclear neutrophil leukocytes (PMNs) are known to cross the alveolar-capillary barrier and enter the alveolus in acute adult respiratory distress syndrome (ARDS). The pathogenic role of PMNs in both the acute lung injury and subsequent infectious susceptibility in ARDS is not clear. In the present study we investigated the functional status of various neutrophil populations using a chronic, endotoxemia-induced ARDS model. Rats infused with Escherichia coli endotoxin for three days develop an acute lung injury with a histologic picture closely resembling human ARDS. The PMNs recovered from the circulation and by bronchoalveolar lavage were compared with normal rat PMNs. In endotoxemic animals, superoxide production was markedly enhanced in circulating PMNs, indicating production of high levels of potentially cytotoxic oxygen intermediates, while myeloperoxidase activity was decreased in both circulating and lavage PMNs, indicating depressed myeloperoxidase-dependent antimicrobial activity.

Is macrophage-induced microthrombosis during endotoxemia dependent on prostaglandin synthesis?

Steroids and nonsteroidal anti-inflammatory drugs (NSAID), in addition to inhibiting prostaglandin synthesis, have recently been shown to block production of procoagulant activity (PCA) by alveolar macrophages (A-M phi). This inhibition may ameliorate one deleterious effect of endotoxin (LPS), since LPS-induced PCA may contribute to the diffuse microvascular thrombosis (DIC) and subsequent organ failure seen in endotoxemia. However, the results of treatment of endotoxemia with steroids of NSAID are variable or short-lived. To help elucidate the basis for these results, the effect of these agents on production of PCA by another M phi population, the hepatic M phi (H-M phi PCA is functionally discrete from A-M phi PCA) was evaluated. Four agents, (hydrocortisone, indomethacin, ibuprofen and acetylsalicylic acid (ASA)) used to both block production of prostaglandins and ameliorate the deleterious effects of LPS in vivo were tested on the production of rabbit M phi PCA in vitro in homogeneous cultures. PCA was measured by a standardized one-step coagulation assay. Treatment with LPS (1 to 10 g/ml) produced maximal stimulation of PCA production with a peak at 8 hr with PCA levels 20- to 30+-fold higher than controls. The effect of pretreatment (T-10 min) of M phi cultures with the various inhibitors on PCA production at 8 hr post-LPS was evaluated, (N = 6 to 10 experiments).(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of hemodynamic variables with transcutaneous PO2 measurements in critically ill adult patients

Transcutaneous oxygen (PtcO2) monitoring with miniaturized heated electrodes has been shown to continuously track arterial oxygen tension (PaO2) noninvasively in stable infants. However, the correlation between the two is less marked in unstable adults, and PtcO2 appears to be additionally influenced by perfusion. The ability of PtcO2 to detect alterations in cardiac index (CI) was evaluated in 19 critically ill adult patients. The PtcO2 was found to be influenced by the PaO2, the CI, and local vascular tone, with a rapid response time to changes in these variables. All instances of improvement in PtcO2 readings were associated with improvement in PaO2 or hemodynamic status. Because of its high sensitivity, continuous noninvasive PtcO2 monitoring should allow reduction in routine PaO2 and CI determinations. However, a decrease in PtcO2 requires immediate in-depth evaluation of the patient's PaO2 and CI because of its lack of specificity.

Idiopathic pulmonary fibrosis in adult respiratory distress syndrome. Diagnosis and treatment

Ten consecutive patients who presented initially with adult respiratory distress syndrome, and who did not respond to conventional treatment, underwent open lung biopsy early in the course of their illness. Idiopathic pulmonary fibrosis was diagnosed and aggressive treatment with methylprednisolone sodium succinate and nutritional support was initiated. Eight patients survived and have not required long-term corticosteroid therapy. Previous reports have documented a mortality of greater than 85% with this particular syndrome of idiopathic pulmonary fibrosis in adult respiratory distress syndrome.

Retroperitoneal giant lymph node hyperplasia. A case report and review of the literature

Giant lymph node hyperplasia (GLNH) is a rare tumor. The authors have reviewed the literature and brought the reported total to 235 cases. There are two types of GLNH, a hyaline-vascular and plasma-cell type. The usual presentation is as an asymptomatic solitary mass, though multicentric lesions are found. Symptoms are most frequent with the plasma-cell type. A syndrome of anemia, growth retardation, and hypergammaglobulinemia is seen in the plasma-cell type in children. The etiology is unknown, though immunologic studies indicate a reactive phenomenon. Radiologic studies are nonspecific. Therapy is surgical excision, which is usually curative.