Bronchiectasis: correlation of high-resolution CT findings with health-related quality of life.

AIM: To evaluate the relationship between the severity of bronchiectatic diseases, as evident on high-resolution computed tomography (HRCT) and the patient's quality of life measured using the St George's Respiratory Questionnaire (SGRQ). METHODS AND MATERIALS: Forty-six patients (25 women, 21 men, mean age: 63 years) with bronchiectatic disease as evident on recent HRCT examinations were recruited. Each patient completed the SGRQ and underwent respiratory function tests. HRCT findings were blindly and independently scored by two radiologists, using the modified Bhalla scoring system. The relationships between HRCT scores, SGRQ scores and pulmonary function tests were evaluated. RESULTS: The patients' total CT score did not correlate with the SGRQ scores. However, patients with more advanced disease on HRCT, significantly differed in their SGRQ scores from patients with milder bronchiectatic disease. A significant correlation was found between the CT scores for the middle and distal lung zones and the activity, impacts and total SGRQ scores. No correlation was found between CT scores and respiratory function test indices. However, a significant correlation was found between the SGRQ scores and most of the respiratory function test indices. CONCLUSION: A correlation between the severity of bronchiectatic disease as expressed in HRCT and the health-related quality of life exists in patients with a more severe bronchiectatic disease but not in patients with mild disease. Such correlation depends on the location of the bronchiectasis in the pulmonary tree.

[Ethical considerations in mass casualty situation].

Mass casualty is a situation, in which, the physician is compelled to make critical decisions under heavy pressure load, due to severe shortage in time, personnel and information. This task is extremely difficult to fulfill, as the physician has to consider not only professional tools, but needs also to utilize ethical principles, in order to provide the best possible care to most of the casualties who might benefit from it. By definition, in the mass casualty situation the medical facility lacks temporarily the ability to deliver effective therapy to all, as the injured outnumber the medical capacity for a given time. The ethical conflicts and dilemmas that arise during such an event are enormous. Amazingly, only a few articles have addressed the issue of ethical considerations during mass casualty situation. Ethical decision making is based on four principles: beneficence, nonmaleficence, autonomy and justice. Compassion, trustworthiness, discernment and integrity are the four qualities required from those practicing medicine. These virtues should be manifested in mass casualty situations, one of the most demanding situations a physician may face.

Is nebulized aerosol treatment necessary in the pediatric emergency department?

BACKGROUND: Infants and small children admitted to the pediatric emergency department (PED) with acute wheezing episodes (AWE) are currently treated with nebulized wet aerosol (NWA). OBJECTIVE: To determine the efficacy of MDI with Nebuchamber (Astra AB; Lund, Sweden), a nonelectrostatic spacer device (NESD), as compared to NWA in the treatment of an unselected population of babies and small children with AWE. DESIGN: Randomized, double-blind, placebo-controlled trial. Forty-two children referred to the PED (median age +/- SD, 16 +/- 15 months) with AWE received either placebo MDI through a NESD (four puffs) and salbutamol 0.5 mL (2.5 mg) as a NWA (group I, n = 19), or salbutamol MDI and 0.5 mL of saline solution administered in the same manner as above (group II, n = 23). This treatment was repeated three times every 20 min. RESULTS: The respiratory rates (RRs) at baseline were as follows: group I, 45 +/- 11.2 breaths/min; and group II, 52.3 +/- 11.3 breaths/min (p = not significant [NS]). After the first, second, and third interventions, the percent fall from baseline of the RR were as follows: group I, 8.9, 13.1, and 17.9%, respectively; group II, 8. 6, 14.6, and 18.6%, respectively. There was no significant difference at any time in the results between the two groups. The clinical scores (CSs) at baseline were as follows: group I, 6.6 +/- 1.3; group II, 6.8 +/- 1.49 (p = NS). After the first, second, and third interventions, the percent fall from baseline of the CS were as follows: group I, 9.1, 17.9, and 23.2%, respectively; group II, 8. 6, 18.9, and 24.7%, respectively. These results, also, did not differ significantly at any time between the two groups. Hospitalization rate and side effects did not differ between the two groups. CONCLUSIONS: We conclude that even in the group of unselected very young children (mean age < 2 years) with AWE, the use of MDI with NESD is at least as effective as the use of NWA. As opposed to data from an adult population, no plateau was reached in the dose-response curve using the above doses over time.

Salbutamol metered-dose inhaler with spacer for hyperkalemia: how fast? How safe?

OBJECTIVE: To determine the efficacy of inhaled salbutamol (rapidly delivered, using a metered-dose inhaler with a spacer device [MDI-S]) in lowering the serum potassium levels in patients with hyperkalemia. DESIGN: A randomized, double-blind, placebo-controlled trial. PATIENTS: Seventeen chronic renal failure patients referred to the Nephrology Unit between October 1, 1997 and March 31, 1998 for hemodialysis were randomized. INTERVENTION AND RESULTS: Group 1 received salbutamol followed by a placebo. Group 2 received a placebo followed by salbutamol. Each patient inhaled 1,200 microg salbutamol or a placebo through an MDI-S within 2 min. Blood samples were obtained repeatedly before inhalation and after 1, 3, 5, 10, and 60 min. The pulse rate and blood pressure were repeatedly measured. Insulin levels were examined in a subset of patients (n = 10) before, and 1 and 5 min following inhalation. Salbutamol's known side effects, palpitation, tachycardia tremor, and headache, were recorded. Potassium levels rose after 1 min following the completion of treatment and then decreased steadily thereafter. A rise of > or = 0.1 mEq/L was seen in 10 of 17 patients (59%) during the treatment period and there was no change (0%) seen during the placebo period (p < 0.0001). Within 3 min after inhalation of salbutamol, potassium levels declined as a function of time. Potassium levels in those patients taking the placebo did not change as a function of time (p < 0.001). The difference between the placebo and the salbutamol-treated periods reached significance after 5 min (p < 0.05). The serum glucose levels rose following inhalation of salbutamol, with a significant rise after 3 min. The heart rate rose significantly within the first 5 min following inhalation. Serum insulin levels remained unchanged 1 min after inhalation; however, after 5 min, a significant elevation was detected. CONCLUSION: Salbutamol inhalation of 1,200 microg, using an MDI-S, has a relatively rapid onset of action that induces a consistent reduction in serum potassium levels, starting 3 to 5 min following delivery. Unexpectedly, a paradoxical elevation was detected in serum potassium levels in the first minutes following inhalation. This effect, although minor (0.15 mEq/L above baseline), may cast some doubt on the role of salbutamol inhalation as the first treatment for excessive hyperkalemia.

[Acute hyperparathyroidism caused by hemorrhage into a parathyroid adenoma].

Acute hyperparathyroidism is a rare and dangerous condition. It is supposed to result from transformation of a mild chronic form into an acute and stormy illness. The causes and the mechanism of such a transformation are usually unknown. A case of acute hyperparathyroidism is presented in which hemorrhage into a parathyroid adenoma was recognized and diagnosed as the immediate cause of the transformation from the mild long-standing form of the disease into the severe acute form.

Nebulized wet aerosol treatment in emergency department--is it essential? Comparison with large spacer device for metered-dose inhaler.

OBJECTIVE: To determine the efficacy of a metered-dose inhaler (MDI) with a large spacer device as compared to nebulized wet aerosols in the treatment of an unselected population with severe airflow limitation. DESIGN: Randomized, double blind, placebo-controlled trial. SETTING: University Hospital Department of Emergency Medicine (DEM). PATIENTS: Fifty patients, referred to the DEM between October 1, 1994 and March 31, 1995 with a severe, acute obstructive pulmonary event. Thirteen patients were diagnosed as having COPD; 37 patients were diagnosed as having asthma. INTERVENTION AND RESULTS: Patients received either placebo MDI through a 750-mL cone-shaped spacer (Glaxo) [2 puffs] and nebulized salbutamol aerosol 0.5 mL in 1.5 mL saline solution (group 1, n=25) or salbutamol MDI and 0.5 mL saline solution in 1.5 mL saline solution administered in the same manner as above (group 2, n=25). The above treatment was repeated three times every 15 min, unless side effects appeared. Upon enrollment into the study, the FEV1 in group 1 was 0.78+/-0.7 L (mean+/-SD), 32% of predicted, and in group 2, 0.74+/-0.51 L, 29% of predicted (p=0.83). The FEV1 values after the first, second, and third interventions were as follows: in group 1, 1.18+/-0.99 L, 1.40+/-0.8, and 1.47+/-0.79, respectively, and in group 2, 1.17+/-0.99 L, 1.46+/-1.01, and 1.54+/-0.79 (p=0.83, 0.36, and 0.48, respectively). We observed no difference in spirometric measurements between the two groups at any time. CONCLUSION: Even in the setting of the unselected group of patient referrals to the DEM for episodes of severe airflow limitation, the clinical and the objective bronchodilator responses to the administration of salbutamol are independent of the method of delivery: MDI with a large spacer vs aerosol nebulization.

Splenogonadal fusion diagnosed by spleen scintigraphy.

Splenogonadal fusion (SGF) is a rare congenital malformation characterized by fusion of the spleen and a gonad (almost always the left one) frequently associated with orofacial and/or limb developmental abnormalities. Only 125 cases were reported between 1883 and 1994. This report concerns a case of SGF in a 20-yr-old woman with an accidental finding of a splenic space-occupying lesion protruding into the lower abdomen in ultrasound and CT. Radiocolloid spleen scintigraphy and SPECT proved to be the best procedure to establish the correct diagnosis of SGF. As SGF is often asymptomatic, more liberal use of splenic scintigraphy is suggested in patients with congenital limb and/or orofacial anomalies. SGF should be included among the differential diagnoses of left abdominal, pelvic or scrotal masses.

Extralobar sequestration presenting as massive hemothorax.

Pulmonary extralobar sequestration is a rare anomaly, usually diagnosed during the first months of life. A case of extralobar pulmonary sequestration in an adult, manifesting itself as massive hemothorax, is presented.

[Is routine monitoring of theophylline blood levels really effective?].

Theophylline is widely used by patients with asthma and chronic obstructive pulmonary disease as a bronchodilator. The therapeutic range is relatively narrow: 10-20 mcg/ml. In a survey of 344 blood samples from 290 patients over a period of 12 months, 60% had levels lower than 10 mcg/ml, and only 28% were within the therapeutic range. This was especially the case among those using oral preparations. Our data raise several questions concerning the individualization of theophylline dosage, the effectiveness of its routine blood monitoring, and the implications of these results for ambulatory patients who are possibly being under treated.

[Tuberculous lymphadenitis in a general hospital].

All cases of tuberculous lymphadenitis admitted over a 43-year period (1951-1993) were surveyed. The diagnosis was validated in 188 cases. The incidence was 2.74 cases per year, but there was a cluster of 94 cases in the first 20 years. 50.8% had local signs alone, while 36.4% had both local and systemic signs. Nodes affected showed either painless or painful swelling, and sometimes there was drainage. Cervical nodes were affected most frequently, and the commonest general symptom was fever, followed by fatigue. In 28.8% there was pulmonary tuberculosis, in 14.4% other forms of extrapulmonary tuberculosis, and in 9.3% only active tuberculous lymphadenitis. Most of the patients had immigrated to Israel from eastern Europe and the Yemen. Though tuberculous lymphadenitis has become infrequent, it is still the commonest form of extrapulmonary tuberculosis. A high index of suspicion is needed to diagnose accurately and treat this potentially curable condition.

[Cat scratch disease].

Cat scratch disease (CSD) is usually manifested in children and young adults as a benign, chronic self-limited lymphadenopathy. However, various atypical presentations have been described, especially in immunocompromised hosts. 1 of 5 cases of CSD diagnosed here during 1985-1993 is presented. In 3 cases the diagnosis was supported by lymph node biopsy in which the organisms were visualized by Warthin-Starry silver impregnation staining. Recent publications indicate that Afipia felis and Rochalimaea henselae, both Gram-negative bacilli, were isolated from infected lymph nodes in CSD. The usual benign course does not necessitate antibiotic therapy. The antimicrobial agents effective in cases with systemic symptoms were rifampicin, ciprofloxacin, trimethoprim-sulfamethoxazole and gentamicin. In view of the increasing number of cats, an increased incidence of CSD may be expected. The mechanism of transmission from cat to man is still unknown. Fleas or ticks may be involved. Hopefully, recent advances in the identification of the causative organisms may lead to the development of serological tests, reducing the need for skin testing and lymph node biopsy.

Fatal asthma: where did we go wrong?

Vivid descriptions of life-threatening asthma attacks have persisted into modern medicine since antiquity. Asthma is characterized by airway hyperresponsiveness--a condition of an exaggerated bronchoconstriction in response to a variety of stimuli (irritants and triggers). Over the past decade it has become clear that in asthma significant inflammation occurs in the airways. Airway hyperresponsiveness and the clinical asthma symptomatology may be at least in part dependent on the inflammation generated by cell mediated immune mechanisms, including T cells, macrophages as well as mast cells and eosinophils in the airways. However, the recent advances in the understanding of the pathogenesis and pathophysiology of asthma, new modes for the diagnosis of the disease and the development of various therapeutic options have not been accompanied by increased survival rate. On the contrary, a gradually rising death rate from asthma has been reported worldwide. The reasons for this are not completely understood. Controversy exists whether an increase in the prevalence or the case fatality rate or both are the main cause of the reported rise in asthma death rate. Genetic, environmental and psychological factors have also been implicated. One has to consider the poorly controlled state in which some patients arrive at emergency wards, the possible delay in adequate therapy due to psychological and socioeconomic factors and also the information implicating iatrogenic factors among the possible explanations for increased asthma mortality. It is imperative to improve patient and family education to increase awareness. Conflicting results in the medical literature regarding the medical therapy of asthma impose a great responsibility on the practising physician. It is necessary to improve physician knowledge of the modern therapeutic strategies in asthma to gain better control of the disease. Pending further clarification as to optimal management of asthma, and forthcoming new and novel treatment, management should rely on current guidelines, emphasizing the role of antiinflammatory therapy in severe asthma. It is desirable to improve emergency services to deliver expert care in life-threatening conditions as soon as possible.

[Splenic hemorrhage masquerading as myeloproliferative disease].

While blunt trauma to the spleen may result in various clinical features, it sometimes may not cause symptoms. A 59-year-old man presented with fever 2 weeks after minor chest trauma. Initial investigation suggested a myeloproliferative disorder. However, abdominal ultrasonography established the diagnosis of subcapsular and intrasplenic hemorrhage. Management was conservative and he was discharged after 13 days.

Idiopathic pulmonary hemosiderosis, complete heart block and celiac disease.

A 24-year-old male with recurrent hemoptysis due to idiopathic pulmonary hemosiderosis and celiac sprue developed infranodal heart block necessitating implantation of a pacemaker. A possible common underlying mechanism is discussed.