Retrosternal pain is an early indicator of oxygen toxicity

To determine the most sensitive early indicator of toxicity from exposure to O2, we measured respiratory clearance of 99mTc-diethylenetriamine pentaacetate (Tc-DTPA), pulmonary function, serum Factor VIII antigen, and plasma fibronectin values and monitored symptoms in six normal volunteers who breathed 21, 40, and 100% O2, administered in random order, for 17 h at least 1 wk apart. Twenty minutes after beginning O2, arterial PO2 differed among the three exposure groups. After exposure to the three concentrations of O2, there were no differences in Tc-DTPA clearance, vital capacity, FEV1/FVC, diffusing capacity, Factor VIII antigen, or fibronectin concentration. In contrast, all subjects complained of retrosternal pain during and after breathing 100% O2 (p less than 0.001). We conclude that with exposure to 100% O2, retrosternal pain, presumably from tracheal inflammation, occurs before detectable abnormalities of epithelial solute permeability (Tc-DTPA clearance), endothelial O2 injury (fibronectin concentration and Factor VIII), or pulmonary function. These findings indicate that symptoms are more sensitive than signs in detecting early O2 toxicity.

Ineffectiveness of high-dose methylprednisolone in preventing parenchymal lung injury and improving mortality in patients with septic shock

We conducted a prospective, randomized, double-blind study to determine whether high-dose methylprednisolone could prevent parenchymal lung injury, including the adult respiratory distress syndrome (ARDS), or improve mortality when administered early in septic shock. All patients already hospitalized in or newly admitted to the medical and surgical intensive care units at San Francisco General Hospital between September 1, 1983 and August 29, 1986 were eligible for admission to the study if they had either (1) an increase in temperature of 1.5 degrees C and a decrease in systolic blood pressure of 20 mm Hg or more from baseline values (in already hospitalized patients), or (2) a temperature greater than 38.5 degrees C or less than 35.5 degrees C and a systolic blood pressure of less than 90 mm Hg (in newly admitted patients). Patients meeting these criteria were excluded if they (1) had severe immunodeficiency, (2) were less than 18 or greater than 76 yr of age, (3) had multilobar roentgenographic infiltrates, or (4) were already receiving corticosteroids. Eighty-seven patients enrolled in the study received either methylprednisolone, 30 mg/kg per dose, or mannitol placebo for a total of 4 doses every 6 h, following the presumptive diagnosis of septic shock. Of these patients, 75 ultimately were determined on the basis of culture results to have actually had septic shock at the time of entry. Thirteen of the patients who received methylprednisolone developed ARDS, compared to 14 patients who received placebo. Lesser degrees of parenchymal lung injury did not differ between the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary clearance of three aerosolized solutes in oleic acid-induced lung injury

We studied the effects of oleic acid (OA) on pulmonary clearance of three aerosolized radioactive solutes: 99mTc-diethylenetriamine pentaacetate (99mTc-DTPA), 67Ga-desferoxamine (67Ga-DFOM), and 111In-transferrin (111In-TF). Either 0.09 ml/kg OA or an equivalent volume of 0.9% NaCl (controls) was administered intravenously to 48 anesthetized, paralyzed dogs. Each animal received one aerosolized solute either 60 min after (protocol A) or 30 min before (protocol B) the infusion of OA or NaCl. In protocol A clearances of all three solutes were similar in OA and control animals. In contrast, in protocol B clearances of all three solutes increased significantly during OA infusion; during the next 60 min clearances of 99mTc-DTPA and 67Ga-DFOM returned to control values but 111In-TF remained increased. We conclude that 1) in OA-induced permeability edema pulmonary clearance of aerosolized solutes is increased when the aerosol is delivered 30 min before but not 60 min after injury, and 2) increased clearance persists only for large molecules, presumably because smaller molecules cross injured epithelium quickly and completely. These phenomena are best explained by a nonhomogeneous distribution of OA-induced injury.

Alveolar-capillary block in patients with AIDS and Pneumocystis carinii pneumonia

To determine the value of subdividing diffusing capacity for carbon monoxide (DL) in diagnosing and monitoring the course of Pneumocystis carinii pneumonia (PCP), we measured DL, membrane diffusing capacity (DM), and pulmonary capillary blood volume (VC) in 20 control subjects, 20 patients with a low DL (less than 75% predicted) and newly diagnosed PCP, and 16 patients with a low DL in most of whom PCP had been suspected and excluded. Ten patients with PCP were restudied approximately 60 days after treatment. When clinically indicated, lung biopsies were obtained for histologic examination. Compared with mean values in control subjects (DL = 92%, DM = 101%, and VC = 35 ml/m2), all values were decreased (p less than 0.01) in patients with PCP (DL = 58%, DM = 33%, and VC = 26 ml/m2) and in those without PCP (DL = 61%, DM = 56%, and VC = 22 ml/m2). Values of DM were significantly less (p less than 0.05) in patients with, than in those without, PCP. Analysis of lung biopsies by light and electron microscopy showed overlapping morphologic abnormalities in the 2 groups of patients. In the 10 patients with PCP restudied after successful treatment, the mean DL increased from 60 to 80% (p less than 0.0005), the DM increased from 35 to 108% (p less than 0.006), and the VC did not change. These results suggest that in contrast to most disorders in which DL is decreased, PCP causes reversible alveolar-capillary block.

Mycoplasma infection of the hand acquired from a cat

Mycoplasmas, the smallest known organism capable of a free existence, have been recognized as human pathogens for 25 years. However, a soft tissue cellulitis caused by a mycoplasma has never been reported in a human subject. This case report of a mycoplasma infection of the hand acquired from an infected cat describes the clinical presentation, operative findings, mycoplasmology, and treatment of this infection.

Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon into the distal radioulnar joint: the empty sulcus sign

Two cases of distal radioulnar joint (DRUJ) disruption and diastasis secondary to distal radial fractures were associated with displacement of the ulnar styloid and extensor carpi ulnaris (ECU) into the DRUJ. Both cases had a palpable empty ECU tendon sulcus. In one case surgical exploration revealed that the ulnar styloid, triangular fibrocartilage, and extensor carpi ulnaris tendon had dislocated into the DRUJ as a unit. The end result was good. In the second case lack of recognition and reduction of the ECU tendon and ulnar styloid led to persistent subluxation and diastasis. The end result was poor. Early recognition of the dislocation of the ulnar and ECU into the DRUJ and their significance may avoid poor results.

Respiratory clearance of aerosolized radioactive solutes of varying molecular weight

To determine the influence of varying molecular weight (mol wt) on respiratory clearance of aerosolized solutes, we studied eight radiopharmaceuticals, each administered to four dogs: sodium 99mTc pertechnetate (TcO4), 99mTc glucoheptonate ([99mTc]GH), 51Cr-ethylenedinitrotetraacetate ([51Cr]EDTA), 99mTc diethylenetriaminepentaacetate ([99mTc] DTPA), 111In diethylenetriaminepentaacetate ([111In]DTPA), 67Ga desferoxaminemesylate ([67Ga]DFOM), 99mTc dextran ([99mTc]DX) and 111In transferrin ([111In]TF). After aerosolization (0.8 m MMD, 2.4 GSD), clearance was determined for 30 min and then corrected by intravenous injection for nonairspace radioactivity. In-TF clearance (0.11 +/- 0.10%/min) was lower than TcO4 (6.32 +/- 0.62%/min), [99mTc]GH (1.50 +/- 0.37%/min), [51Cr]EDTA (2.38 +/- 1.02%/min), [99mTc]DTPA (3.51 +/- 0.40%/min), [111In]DTPA (2.35 +/- 0.42%/min), [67Ga] DFOM (1.99 +/- 0.49%/min) and [99mTc]DX (1.81 +/- 0.75%/min) clearances (p less than 0.001). TcO4 clearance was higher than others (p less than 0.001). Technetium binding to DX was unsatisfactory; aerosolization caused unbinding from DTPA. We conclude that respiratory clearance of large mol wt solutes within 30 min is negligible and, that clearance of molecules between 347-5,099 daltons differs greatly, suggesting that binding and/or intrapulmonary retention affect transfer.

Aerosolized gadolinium-DTPA enhances the magnetic resonance signal of extravascular lung water

Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA), a contrast agent for magnetic resonance imaging, was administered by either aerosol or intravenous injection to rats. Proton relaxation times in excised lungs and kidneys were then measured. With increasing concentrations of aerosolized Gd-DTPA, the spin-lattice relaxation time (T1) of lungs decreased (enhanced) significantly (P less than .001), an effect that persisted for at least 80 minutes; there was no change in kidney T1. After intravenous injection of Gd-DTPA, lung T1 did not change, but kidney T1 decreased significantly (P less than .001), confirming previous observations of renal clearance. It is concluded that aerosolized Gd-DTPA is a more efficacious method of delivery of paramagnetic contrast agent to the lungs than intravenous injection, and that the lack of systemic effect after aerosolization indicates that enhancement was limited to the extravascular compartment.

Rebreathing lung tissue volume of sheep with normal and edematous lungs

To determine the accuracy of measurements of lung tissue volume (Vlt) by rebreathing acetylene in normal and edematous lungs, we compared gravimetric values of total lung weight (Ql) and extravascular lung water (Qwl) with Vlt in anesthetized control sheep (C) and sheep with hydrostatic pulmonary edema (HPE) or oleic acid-induced permeability pulmonary edema (PPE), five animals each. In eight additional sheep we determined that acetylene solubility in blood (0.117 +/- 0.010 ml X 100 ml-1 X Torr-1) differed significantly from that in lung-blood homogenates (0.095 +/- 0.009 ml X 100 ml-1 X Torr-1, P = 0.0017). The latter value was used in all calculations. In C, Vlt was 194% of Qwl and 98% of Ql; in HPE, Vlt was 144% of Qwl and 87% of Ql; and in PPE, Vlt was 112% of Qwl and 77% of Ql. We conclude that when the lungs are normal, Vlt reasonably measures Ql not Qwl. However in both HPE and PPE, Vlt progressively underestimates Ql and cannot differentiate between increased blood volume and increased Qwl.

Pulmonary and systemic effects of increased negative inspiratory intrathoracic pressure in dogs

Croup and epiglottitis, which cause greater than normal negative inspiratory intrathoracic pressure (NIIP), have been associated with pulmonary edema. To examine the effects of increased NIIP per se on blood gases, hemodynamics, and lung water content, we carried out 2 types of experiments in 18 anesthetized dogs. Short-term, low-pressure experiments (6 control dogs and 6 dogs that generated intratracheal pressures of -12 cm H2O during inspiration for 3 h) and long-term, high-pressure experiments (6 dogs that generated -20 cm H2O during inspiration for 6 h). In the short-term, low-pressure experiments, animals made to generate negative inspiratory pressure differed from control dogs by demonstrating decreased pleural pressure (p less than 0.01), increased arterial PCO2 (p less than 0.05), and decreased minute volume (p less than 0.05); no differences occurred in hemodynamic data (pulmonary arterial, left atrial, and aortic pressures and cardiac index) and in extravascular lung water (indicator dilution and gravimetric analyses). Similarly, in the long-term, high-pressure dogs, arterial PCO2 increased (p less than 0.05) and lung water was normal by gravimetric analysis. We conclude that both 3 and 6 h of increased NIIP cause CO2 retention but have minimal effects on hemodynamics and lung fluid exchange.

Exercise-induced chronic compartment syndrome of the first dorsal interosseous muscle of the hand: a case report

A 21-year-old welder experienced chronic pain in the region of the first dorsal interosseous muscle after strenuous activity involving his hand. Direct measurement of the tissue pressures within the first dorsal interosseous muscle revealed an elevation of compartment pressure after lateral key pinch activity. After surgical release of the compartment, the pressures returned to normal, and the patient's symptoms improved. Exercise-induced chronic compartment syndrome of the small muscles of the hand should be considered in patients who describe aching pain in the hand after strenuous activity.

Factors affecting tissue volume measurements in normal and edematous dog lungs

To characterize further some of the factors affecting lung tissue soluble-gas rebreathing volume (Vlt), we determined the solubility of acetylene in blood and lung tissue, the influence of the presence of pulmonary edema on tissue solubility, the effects of varying tidal volume (VT), and the tissue volume actually measured in two groups of six anesthetized paralyzed dogs: controls (C) and oleic acid-induced pulmonary edema (OA). Each animal's solubility was used to compute Vlt for comparison with gravimetric lung weight (Ql) and extravascular lung water content (Qwl). Solubility at 37.5 degrees C in blood (0.125 ml X 100 ml-1 X Torr-1) exceeded that in lung tissue (P less than 0.005): C = 0.118 and OA = 0.112 ml X 100 ml-1 X Torr-1 (NS). Vlt, expressed as %Ql, increased with increasing VT (20, 35, and 50 ml/kg) in OA (62.2, 78.9, and 94.7%, respectively, P less than 0.0001) but not in C (92.4, 94.4, and 99.3%, respectively). We conclude that solubility differs in blood and lung tissue but not in normal and edematous lungs, Vlt is not affected by VT in normal dogs but is in those with pulmonary edema, and Vlt measures Ql rather than Qwl.

Profundus tendon blockage: quadriga in finger amputations

After finger amputations, spontaneous adhesions of the resected profundus tendon may occur in the finger stump or palm. Because of the normal interconnections of the profundus tendons, such adhesions can block the excursion of the profundus tendons to intact fingers, resulting in the quadriga syndrome, or profundus tendon blockage. This causes a decrease in the power and range of movement of the terminal joints of the uninjured fingers when they are fully flexed. Three degrees of severity of this weakness are described. The findings and results of surgery in 20 patients demonstrate that the condition is surgically correctable by release of the adherent profundus tendon of the amputated digit. Full active flexion and extension of the intact fingers in the early postoperative period after primary amputation should prevent them from developing profundus tendon blockage.

Effect of increases in lung volume on clearance of aerosolized solute from human lungs

To study the effect of increases in lung volume on solute uptake, we measured clearance of 99mTc-diethylenetriaminepentaacetic acid (Tc-DTPA) at different lung volumes in 19 healthy humans. Seven subjects inhaled aerosol (1 micron activity median aerodynamic diam) at ambient pressure; clearance and functional residual capacity (FRC) were measured at ambient pressure (control) and at increased lung volume produced by positive pressure [12 cmH2O continuous positive airway pressure (CPAP)] or negative pressure (voluntary breathing). Six different subjects inhaled aerosol at ambient pressure; clearance and FRC were measured at ambient pressure and CPAP of 6, 12, and 18 cmH2O pressure. Six additional subjects inhaled aerosol at ambient pressure or at CPAP of 12 cmH2O; clearance and FRC were determined at CPAP of 12 cmH2O. According to the results, Tc-DTPA clearance from human lungs is accelerated exponentially by increases in lung volume, this effect occurs whether lung volume is increased by positive or negative pressure breathing, and the effect is the same whether lung volume is increased during or after aerosol administration. The effect of lung volume must be recognized when interpreting the results of this method.

Borderline manifestations in the Rorschachs of male transsexuals

It was hypothesized that male transsexuals manifest a character structure consistent with Kernberg's criteria for borderline personality organization. Exploring this hypothesis, Kernberg's criteria for borderline personality organization were operationalized using Rorschach measures. The following variables were examined: aggression (Holt System Aggressive Content Section), object relations (Urist's Mutuality of Autonomy Scale), reality testing (Exner System X + %), and self/object differentiation (Exner System Special Scorings). A group of male college students, a group of male borderlines, and a group of male transsexuals were compared on the above variables. Compared to the normals, the transsexuals and borderlines displayed significantly more intense levels of aggression, a lower level of object relations, poorer reality testing, and impaired boundary differentiation. The transsexuals and borderlines did not differ significantly. The results were taken as suggesting that male gender dysphorics may be a sub-group of the wider borderline diagnostic category.

Fibromatosis and fibrosarcoma of the larynx and pharynx in an infant

A 14-month-old infant had congenital solitary fibromatosis of the larynx that showed fibrosarcomatous change and that spread to the pharynx and the anterior part of the neck. The histologic condition is discussed, as is the surgical treatment with total laryngopharyngectomy. A five-year postoperative follow-up is included.

Treatment of acute total atelectasis. Use of a double lumen tube

Three cases are described of complete collapse of a lung in the absence of bronchial obstruction. The condition was treated by the application of a sustained high pressure (6 kPa) to the affected lung through one limb of a double lumen bronchial tube whilst intermittent positive pressure ventilation was continued through the other limb.

Correlation between gallium lung scans and fiberoptic bronchoscopy in patients with suspected Pneumocystis carinii pneumonia and the acquired immune deficiency syndrome

We retrospectively examined the sensitivity and specificity of gallium lung scans for detecting Pneumocystis carinii pneumonia in 22 patients with known or suspected acquired immune deficiency syndrome. Correlations were made between bronchoscopic results and gallium scan findings interpreted using a simple system (normal or abnormal) and a graded score (1 to 4). All 12 patients with Pneumocystis had abnormal scans by both interpretations (sensitivity, 100%). Five of these 12 patients had normal arterial PO2 values, chest roentgenograms, or both. In the 10 patients without Pneumocystis, scans were read as abnormal in 8 using the simple system (specificity, 20%) but were abnormal in only 1 using the grading system (specificity, 90%). Five patients with Pneumocystis pneumonia had scans and bronchoscopy after treatment; neither method of interpretation correlated with the presence of organisms. We conclude: (1) gallium scanning is a sensitive initial diagnostic test in patients with suspected Pneumocystis pneumonia; (2) a graded scoring system improves specificity; (3) an abnormal gallium scan (3 or greater) in patients with suspected Pneumocystis pneumonia is an indication for biopsy, even when the PO2 and/or chest roentgenogram are normal.