[Goodpasture syndrome and (idiopathic) immune complex glomerulonephritis with pulmonary hemorrhage: 2 different syndromes?]

While Goodpasture syndrome was previously defined purely clinically by the combination of pneumorrhagia and glomerulonephritis, today the following immunologic criteria must also be satisfied: evidence, provided by immunofluorescent investigation of the kidneys and lungs, of antibasement membrane antibodies in the serum and linear deposits of immunoglobulins, due to direct apposition of antibasement membrane antibodies. Cases where the lesions are caused by immune complexes should no longer be designated as Goodpasture syndrome. In the light of one of our own cases of immune complex glomerulonephritis with pneumorrhagia, the question is raised whether this subdivision by means of immunologic investigations is meaningful for the clinician.

Research topics, author's specialty, and funding sources of articles published in an emergency medicine journal

All original articles published in JACEP and Annals of Emergency Medicine in 1972, 1975, 1978, and 1981 were reviewed and classified according to topic, author's specialty, and funding source. The number of articles published in each category was as follows: toxicology, 44; emergency medical services (EMS), 34; general surgery, 31; emergency department, 28; educational techniques, 19; orthopedics, 17; cardiovascular disease, 15; pulmonary, 13; cardiopulmonary resuscitation (CPR), 10; shock, 8; airway management, 8; and other, 71. The number of authors per article ranged from one to eight; the mean number of authors increased from 1.1 in 1972 to 2.6 in 1981 (P less than .001). The authors' backgrounds most frequently included were as follows: emergency medicine, 53.4%; surgery, 12.8%; internal medicine, 7.9%; and pediatrics, 1.6%. The percentage of articles with specific funding sources increased from 2.9% in 1972 to 25% in 1978, then decreased to 14.3% in 1981. The percentage for each funding source was as follows: government, 7.9%; industry, 2.0%; university, 3.3%; foundation, 2.0%; other, 1.0%; and none, 83.8%. This study demonstrates that there is a defined body of knowledge in emergency medicine, that emergency physicians author the majority of publications in this emergency medicine journal, and that emergency medicine is not supported by traditional funding sources.

A review of research methodology in an emergency medicine journal

All original articles published in JACEP and Annals of Emergency Medicine in 1972, 1975, 1978, and 1981 were reviewed and classified according to type of article, research design, specific methods utilized, and statistical analyses employed. The number of articles published annually increased during the 10-year period, from 34 in 1972 to 131 in 1981. The percentage of articles devoted to clinical research, basic science, animal studies, and health services research also increased: 1972, 8.8%; 1975, 39.6%; 1978, 41.2%; and 1981, 51.1%. In 1972, only two studies had defined research designs. In 1981, 47 studies had the following research designs: case control, 9; cohort, 9; cross-sectional, 13; uncontrolled clinical trial, 3; non-random clinical trial, 7; and randomized clinical trial, 6. Research methodologies were defined in only two studies published in 1972, but increased in each of the years reviewed to 41 in 1978. The most common methodology was the use of diagnostic categories. In 1972, statistical analysis was limited to descriptive enumeration and was included in only three articles. In 1981, 62 articles contained statistical analyses, including chi square in 11; t test in 6; Fischer's exact test in 2; ANOVA in 4; and P value (method not stated) in 10. This study reveals a major increase in both the quality and quantity of emergency medicine research published during the 10-year period reviewed.

Emergency medicine-important advances in clinical medicine: verapamil and supraventricular tachycardia

The Scientific Board of the California Medical Association presents the following inventory of items of progress in emergency medicine. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist the busy practitioner, student, research worker or scholar to stay abreast of these items of progress in emergency medicine that have recently achieved a substantial degree of authoritative acceptance, whether in his own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Emergency Medicine of the California Medical Association and the summaries were prepared under its direction.

[Pollution of room air by building materials]

Due to better insulation and airtight windows and doors, the supply of fresh air is reduced. Therefore the pollutants which are continuously emitted from different materials into the room air are considerably increased. Measurements of the formaldehyde concentrations in new buildings have shown that after a year the admissible limits are still exceeded. Stricter regulations are necessary to limit the emissions of building- and insulation materials.

Tetronomycin, a novel polyether of unusual structure

Tetronomycin, C34H50O8, isolated from a strain of Streptomyces sp. nov. represents a novel polycyclic ionophore polyether. The crystal structure and absolute configuration were established by X-ray analysis of the mono-O-acetyltetronomycin silver salt. Tetronomycin is the first metabolic polyether which contains a tetronic acid moiety instead of the essential carboxylic acid function. A trisubstituted cyclohexane ring and an interesting molecular conformation of the silver salt represent additional unique structural features. Extensive NMR-studies enabled the assignment of chemical shifts and the correlation of the proton and carbon signals. Tetronomycin exhibits activity against Gram-positive bacteria.

Verapamil in the treatment of PSVT

Verapamil is considered by many investigators to be the drug of choice for the acute management of uncomplicated PSVT. Several clinical investigators have demonstrated termination of PSVT in more than 90% of their patients within minutes following IV drug administration. The incidence of reported severe adverse reactions has been less than 1%. PSVT may be complicated by underlying heart disease, or by antegrade accessory pathway conduction in individuals with pre-excitation syndrome. Such conditions, or the prior use of beta-blocking agents, may contraindicate the use of verapamil. However, the history of recent myocardial ischemia or the prior use of digitalis does not appear to contraindicate verapamil therapy. Guidelines for the emergency management of the patient in PSVT are presented.

Assessment of analgesics in dental surgery outpatients

The usefulness of the dental outpatient model for evaluating the efficacy of mild analgesics, first described by Cooper and Beaver, is demonstrated in five separate, double-blind, randomised, single-dose, parallel-group studies. Pain intensity and pain relief were recorded at hourly intervals for 3 h following the administration of aspirin 1000 mg and placebo. In all five studies aspirin was significantly more effective than placebo, with relatively small variability of the response between the studies. The method is simple, reliable and sensitive and complements the inpatient studies of postoperative pain hitherto more frequently used.

Aspects of the management of shock

Shock is a state of systemic imbalance between supply and demand for oxygenated blood. We discuss here management of shock states not primarily of cardiac origin. Inadequacy or maldistribution of blood volume is important in the pathogenesis of most forms of shock. The Military Anti-Shock Trouser (MAST) suit assists the redistribution of blood from the periphery to the central circulation. Normal saline and Ringer's lactate solution may be used interchangeably for acute volume replacement. Colloid replacement requires smaller volumes but carries a higher risk of pulmonary edema, whereas crystalloid replacement requires larger volumes and leads to more systemic edema. Myocardial injury may contribute notably to the transition from reversible to irreversible shock. Naloxone, lidocaine, and indomethacin have improved survival in animal models of endotoxin shock, but proof of efficacy in humans is lacking. A role for corticosteroid administration in shock remains to be defined. Effective antibiotic therapy is the best treatment for septic shock; antisera against endotoxic antigens may develop as important adjunctive therapy.

Noboritomycins A and B, new polyether antibiotics

Noboritomycins A and B, two new polycyclic ionophoric polyethers were isolated from a strain of Streptomyces noboritoensis. The crystal structure and absolute configuration of noboritomycin A were established by X-ray analysis of its silver salt C43/63O14Ag. Noboritomycin A is the first metabolic polyether possessing two carboxylic acid functions on the carbon backbone (C-31), namely a free acid and an additional carboxylic acid ethylester group. An unusual spiroketal system as well as a salicylic acid chromophore represent further remarkable elements. Noboritomycin A shows in this respect a structural relationship to salinomycin and lasalocid respectively. Comparison of physico-chemical data, in particular the interpretation of the 1H- and 13C-NMR spectra, revealed that noboritomycins A and B are structurally closely related, noboritomycin B carrying an ethyl substituent on the aromatic ring in the place of a methyl group present in noboritomycin A. Both metabolites exhibit activity against Gram-positive bacteria and against Eimeria tenella (chicken coccidiosis).

Mutalomycin, a new polyether antibiotic taxonomy, fermentation, isolation and characterization

Mutalomycin is a new metal-complexing polyether antibiotic produced by a strain of Streptomyces mutabilis NRRL 8088. The metabolite, a monocarboxylic acid, was isolated as the sodium salt C41H69NaO12. The structure of this polyether was established by X-ray analysis of its potassium salt C41H69KO12. Mutalomycin contains six heterocyclic rings and is structurally related to nigericin. The metabolite is active against gram-positive bacteria and Eimeria tenella (chicken coccidiosis).

[Demonstration of antibodies to salmonella-R-antigens in sera of patients suffering from salmonelloses (author's transl)]

The extent of hemagglutinating antibody titers against Salmonella R-lipopolysaccharides in 189 sera of 119 human beings suffering from various salmonelloses was estimated. When compared to serum specimens of 137 healthy persons a significant rise in the number of Ra- and Rb2-titer containing sera was observed. It was further found that titers directed against chemotypes Ra, Rb2 and Rc were significantly enhanced in height when compared to the control group. Sera of healthy persons and patients did not show significant differences in Rd1-, Rd2- and Re-titers, respecively. The results indicate that the innermost part of the LPS core in Salmonella S-forms is considerably less (or even none) immunogenic in respect to antibody formation. R-titers in sera from patients suffering from salmonelloses as well as from healthy persons were predominantly directed against Ra-, Rb2- or Rc-LPS structures; the Ra-titer being the most frequent one in both groups. More detailed analyses on sera from patients suffering from salmonelloses revealed a somewhat lower content of R-titers in the early stage of infection. Furthermore in typhoid fever changes in the height of Ra-titers paralled the usual course of O-titers and in gastroenteritic infections the course of illness, respectively. The immunogenicity of the LPS core, however, was less expressed than that of the O-polysaccharides as revealed from a comparison in extent and height of R- and O-titers. Frequently the salmonelloses sera showed titers against several R-antigens. In such cases Ra-titers mostly occurred either together with Rb2-titers alone or concomitantly with both Rb2- and Rc-titers. In absorption experiments it could be demonstrated that two types of antibodies had been formed, those directed against terminal sugar residues in R-lipopolysaccharides and others with specificties against internal partial structures of the core.