Biologically active products of complement and acute lung injury in patients with the sepsis syndrome

To determine if biologically active products of complement appear during sepsis and to establish the relationship of these components to the respiratory and hemodynamic complications of sepsis, we measured C5a des Arg and C3a des Arg (radioimmunoassay), neutrophil chemotaxis, and neutrophil-aggregating activity in plasma obtained from 40 patients at the time sepsis was suspected clinically. Levels of C3a des Arg and C5a des Arg were elevated in 35 and 38 patients, respectively, and in all 25 with positive blood cultures. Highest C5a des Arg levels occurred in patients with hypotension (less than 90 mmHg) and/or acidemia. The C5a des Arg concentrations were significantly higher in patients with than in those without neutrophil-chemotactic activity. Neutrophil-aggregating activity was less sensitive an index of complement activation, as it was positive in only 8 patients and correlated poorly with C5a des Arg and C3a des Arg values. Using a composite scoring system to quantify sepsis-related pulmonary abnormalities, we found that neither biologic nor immunologic assays of complement activation products correlated with the initial severity nor predicted the development or worsening of associated acute lung injury.

Fracture of the hook of the hamate

Fracture of the hook of the hamate most often occurs in athletes in the hand that holds a club, racket, bat or hockey stick, when the end abuts against the palm of the hand. The authors report six patients with this rare fracture, including the only known case of spontaneous healing. Because this fracture is associated with nonunion, surgical excision of the hook through the fracture site is recommended in most cases.

Chronic air-flow limitation does not increase respiratory epithelial permeability assessed by aerosolized solute, but smoking does

To determine the separate influences of smoking and severe air-flow limitation on aerosol deposition and respiratory epithelial permeability, we studied 26 normal nonsmokers, 12 smokers without airway obstruction, 12 nonsmokers with chronic obstructive pulmonary disease (COPD), and 11 smokers with COPD. We aerosolized 99mTc-labeled diethylene triamine pentaacetic acid to particles approximately 1 micron activity median aerodynamic diameter. Levels of radioactivity were plotted semilogarithmically against time to calculate clearance as percent per minute. The distribution of radioactivity was homogeneous in control subjects and in smokers, but patchy in both groups with COPD. No difference was found between clearances of the control group (1.18 +/- 0.31% min-1), and nonsmoker COPD group (1.37 +/- 0.82% min-1), whereas values in smokers without COPD (4.00 +/- 1.70% min-1) and smokers with COPD (3.62 +/- 2.88% min-1) were significantly greater than in both nonsmoking groups. We conclude that (1) small particles appear to deposit peripherally, even with severe COPD; (2) respiratory epithelial permeability is normal in nonsmokers with COPD; (3) smoking increases permeability by a mechanism unrelated to air-flow limitation.

Effect of lung injuries on [14C]urea permeability-surface area product in dogs

To determine whether [14C]urea permeability-surface area product (PS) is a reliable indicator of changes in permeability in various injuries and its relationship to indicator-dilution and gravimetric lung water contents, we studied six groups of anesthetized, paralyzed, and mechanically ventilated dogs (5 animals each). The groups consisted of control dogs, those injured by intravenous alloxan, oleic acid, or glass beads, and those exposed to acute hypoxia or increased left atrial pressure from volume loading (Pla). Interanimal variation of PS was large (3.0-15.0 ml/s), but successive hourly values in individual animals were stable for 2 h in experimental groups and for 4 h in controls. The PS increased after alloxan, elevated Pla, and 2 h of hypoxia; PS decreased after oleic acid and microemboli. The gravimetric lung water increased after alloxan, oleic acid, and microemboli, and indicator-dilution lung water increased only after alloxan. We conclude 1) that intersubject variability requires normalization to enable detection of significant deviation from base line, and 2) that decreased PS after oleic acid and microvascular injury occurred because vascular obstruction, which decreased surface area, masked probable coexisting increases in capillary permeability.

Site of deposition and factors affecting clearance of aerosolized solute from canine lungs

We determined the influence of several factors on lung solute clearance using aerosolized 99mTc-diethylenetriaminepentaacetate. We used a jet nebulizer-plate separator-balloon system to generate particles with an activity median aerodynamic diameter of 1.1 micron, administered the aerosol in a standard fashion, and determined clearance half times (t1/2) with a gamma-scintillation camera. The following serial studies were performed in five anesthetized, paralyzed, intubated, mechanically ventilated dogs: 1) control, with ventilatory frequency (f) = 15 breaths/min and tidal volume (VT) = 15 ml/kg during solute clearance; 2) repeat control, for reproducibility; 3) increased frequency, with f = 25 breaths/min and VT = 10 ml/kg; 4) positive end-expiratory pressure (PEEP) of 10 cmH2O; 5) unilateral pulmonary arterial occlusion (PAO); and 6) bronchial arterial occlusion (BAO). Control t1/2 was 25 +/- 5 min and did not change in the repeat control, increased frequency, or BAO experiments. PEEP markedly decreased t1/2 to 13 +/- 3 min (P less than 0.01), and PAO increased it to 37 +/- 6 min (P less than 0.05). We conclude that clearance from the lungs by our method is uninfluenced by increased frequency, increases markedly with PEEP, and depends on pulmonary, not bronchial, blood flow.

Correlation between serial pulmonary function tests and fiberoptic bronchoscopy in patients with Pneumocystis carinii pneumonia and the acquired immune deficiency syndrome

The records of 9 adult male patients with the acquired immune deficiency syndrome (AIDS) and biopsy-proved Pneumocystis carinii pneumonia were reviewed to determine the correlation between serial pulmonary function tests and the presence or absence of Pneumocystis organisms in subsequent bronchoscopy specimens. At diagnosis, total lung capacity (TLC) or vital capacity (VC) was abnormally low in 4 patients (44%) and diffusing capacity (DLCO) was abnormally low in 8 patients (89%). The ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) was elevated in all patients. After 21 to 47 days of specific therapy for Pneumocystis pneumonia, changes in DLCO, TLC, VC, and FEV1/FVC did not correlate with the presence or absence of Pneumocystis organisms in bronchoscopy specimens from 7 patients. However, changes in DLCO 105 to 258 days after diagnosis seemed to correlate with the late response to treatment in 6 patients. These results suggest that decisions to terminate specific therapy for Pneumocystis pneumonia in patients with AIDS should not be based on short-term changes in pulmonary function.

Accurate reference measurement for postmortem lung water

To test the hypothesis that dry blood-free lung weight is increased during pulmonary edema, thereby leading to an underestimation of the ratio of extravascular lung water-to-dry lung weight, we measured postmortem lung water, dry mass, and hydroxyproline content in 33 sheep with normal lungs (n = 10), high-pressure edema (n = 9), or increased permeability edema (n = 14). Residual blood in the lung, measured using hemoglobin as the intravascular marker in all sheep, and also using 51Cr-tagged red blood cells in 24 sheep, was not different between the two methods or among the three groups of sheep. Extravascular lung water increased 64% in sheep with high-pressure edema and 82% in those with increased permeability edema compared with control values. Dry blood-free lung weight was significantly greater (33% more than control values) in sheep with increased permeability edema, causing the ratio of extravascular lung water-to-dry blood-free lung weight to underestimate accumulated lung water by about 50%. Because hydroxyproline content of the lung was not affected by edema, the ratio of extravascular lung water-to-lung hydroxyproline content was more accurate than the ratio of extravascular lung water-to-dry blood-free lung weight in the quantification of pulmonary edema.

Diagnostic utility of fiberoptic bronchoscopy in patients with Pneumocystis carinii pneumonia and the acquired immune deficiency syndrome

The records of 35 adult male patients with suspected Pneumocystis carinii pneumonia and the acquired immune deficiency syndrome were reviewed to determine the diagnostic utility of fiberoptic bronchoscopy. Twenty-two of the 24 patients (92%) shown to have Pneumocystis pneumonia were diagnosed by bronchoscopy; 20 patients were diagnosed after 1 bronchoscopy and 2 patients after 2 bronchoscopies. The sensitivity of bronchoscopy specimens for diagnosing Pneumocystis pneumonia was 79% for transbronchial biopsies (19 of 24), 78% for transbronchial biopsy touch preparations (7 of 9), 55% for bronchial washings (11 of 20), and 39% for bronchial brushings (7 of 18). The overall sensitivity of fiberoptic bronchoscopy was 85% (22 positive of 26 total bronchoscopies). Complications, occurring during 6 of the 37 bronchoscopies, were slight hemoptysis (1 patient), fever (2 patients), septic shock (1 patient), and pneumothorax (2 patients). Fiberoptic bronchoscopy is a safe and effective procedure for making the early diagnosis of Pneumocystis carinii pneumonia in adult male patients with the acquired immune deficiency syndrome.

Post-traumatic dystrophy of the extremities

A series of 126 patients who had post-traumatic dystrophy of the hand and foot, with a follow-up of more than five years in most, is described. Nearly all had continuing symptoms and signs. An additional twenty-seven patients, with twenty-eight involved extremities, who were referred from various hospitals in Toronto were treated with one or more intravenous injections of a solution of lidocaine and corticosteroid followed by standard physical therapy. The results were satisfactory or better in twenty-one extremities and poor in seven. Of the twenty-one with a satisfactory result, eleven (six patients with involvement of the hand, bilateral in one, and four patients with involvement of the foot) had an excellent result while the other ten showed substantial improvement. The most important factor in predicting improvement with treatment was a short interval (less than six months) between the onset of dystrophy and the administration of therapy.

Disposition of prothionamide in rats and armadillos

A new method for the sensitive and selective measurement of prothionamide (PTH) and its S-oxide metabolite (PTHSO) in biological fluids was described. The limit of sensitivity was approximately 0.01 microgram of drug/ml of plasma. Endogenous materials, 2-propylisonicotinamide, ethionamide, dapsone, or monoacetyl dapsone did not interfere or contribute. Rats receiving PTH, intravenously or orally, showed a sexual dimorphism in the ability to oxidize PTH to PTHSO, with males exhibiting greater capacities for this conversion. Both sexes cleared the administered PTH more rapidly from the plasma than the metabolite, PTHSO. Following oral or intravenous administration of equimolar doses of PTHSO, both sexes exhibited an ability to reduce the administered PTHSO to PTH, with the female showing greater capacities for this conversion. Clearances after oral PTHSO administration were again more rapid for PTH than for PTHSO in both sexes. However, the total of PTH and PTHSO in the plasma during 8 hr following PTHSO administration was consistently less than following PTH dosing. Therefore, although PTHSO is retained longer than PTH after either PTH or PTHSO administration, giving PTHSO yielded less total active drug in the circulation. Comparison of plasma patterns of PTH and PTHSO in unfasted rats receiving one oral or eight daily oral doses of PTH did not indicate that PTH induces its own metabolism. Limited studies in armadillos receiving PTH and PTHSO intravenously led to the same general conclusions as those we derived from the rat studies regarding the disposition of PTH and PTHSO.

Mutagenic activity of antileprosy drugs and their derivatives

We tested the mutagenic activity of antileprosy drugs (clofazimine, ethionamide, prothionamide, prothionamide-S-oxide, rifampin, and dapsone and many of its derivatives) using the Ames Salmonella/microsome assay system. None of these, including N-acetylated and N-hydroxylated derivatives of dapsone, were found to be positive with or without metabolic activation of this test. However, the sulfoxide and sulfide analogs of dapsone were found to be mutagenic with metabolic activation. These two analogs could not be detected in pharmaceutical preparations of dapsone (less than 0.01%), nor could they be found (in either unconjugated or conjugated form) in urine from volunteers taking a single oral dose of 50 mg of dapsone or from patients receiving daily oral doses of 100 mg of dapsone. Also, urine concentrates from volunteers taking 50 mg of dapsone did not exhibit mutagenic activity in the Ames screen. These results indicate that patients receiving antileprosy therapy with clofazimine, dapsone, ethionamide, prothionamide, and/or rifampin are not being exposed to mutagenic (and thereby possible carcinogenic) drugs.

Construction of a stabilometer capable of indicating the variability of non-level performance

Construction and validation of a stabilometer as a measure of gross motor balance was achieved by using a stabilometer designed to provide a quantitative score sensitive to variability of performance in a non-horizontal position. Reliability was obtained through test-retest and by mechanically manipulating the instrument. Validity was indicated by content and construct validity techniques. Both reliability and validity were high, and the instrument was viewed as appropriate for measuring gross motor balance.

Leiomyoblastoma of the omentum. A case report

Leiomyoblastoma is an uncommon tumour derived from smooth-muscle cells. A leiomyoblastoma presenting apparently as an omental tumour, as in the case presented, is exceptionally rare. Special mention is made of the value of the left decubitus position in computed tomography scanning for omental and mesenteric masses.

Effect of different levels of positive end-expiratory pressure on lung water content

To compare the effects of 2-, 5-, and 10-cmH2O positive end-expiratory pressure (PEEP) on pulmonary extravascular water volume (PEWV), pulmonary blood volume (PBV), pulmonary dry weight (PDW), and distensibility, we separately ventilated perfused dogs' lungs in situ and produced pulmonary edema with oleic acid (0.06 ml/kg). Three groups were studied: I, PEEP, 5 cmH2O in both lung; II, PEEP, 2 cmH2O in one lung and 10 cmH2O in the other; and III, PEEP, same as II, but the chest was rotated to compensate for differences in heights. The PEWV and distensibility were less (P less than 0.05) in lungs exposed to 10-cmH2O than to either 2- or 5-cmH2O PEEP. After chest rotation, the difference between 10- and 2-cmH2O PEEP on PEWV was eliminated but that on distensibility was not. We conclude that 10-cmH2O PEEP 1) decreased water content because of lung volume-induced effects on intravascular hydrostatic pressure and 2) improved distensibility by recruitment of alveoli, irrespective of PEWV.

Uneven driving pressures and redistribution of intrapulmonary blood flow

Pulmonary arterial pressure (Ppa) and airway pressure (Paw) change equally when Paw varies widely in normal lungs under zone 2 conditions. To evaluate the mechanism underlying the decrease in Ppa at a given Paw in edematous lungs, we measured the quantity of right-to-left shunting of blood (Qs/QT) with sulfur hexafluoride (SF6) using in situ perfused dog lungs from five control animals, five animals with bronchial occlusion, and eight animals with oleic acid-induced pulmonary edema. Under base-line conditions when positive end-expiratory pressure (PEEP) was increased from 5 to 15 cmH2O, Ppa increased because Paw was fully transmitted to Ppa. After bronchial occlusion at 5 cmH2O PEEP, observed QS/QT was less than predicted (P less than 0.01) on the basis of regional conductances, but at 15 cmH2O observed and predicted QS/QT did not differ (P greater than 0.5). In five of eight dogs with oleic acid-induced pulmonary edema. QS/QT increased when PEEP was increased. We conclude that pressure barriers that create nonuniform driving pressures cause a decrease in Ppa and a redistribution of blood flow.