Recurrent spontaneous pneumothorax in pulmonary histiocytosis X.

Spontaneous pneumothorax (SP) is commonly encountered by general surgeons and is usually caused by rupture of subpleural blebs. Although uncommon, SP may be due to primary pulmonary histiocytosis X, a disease characterized by eosinophilic and histiocytic infiltration of lung tissue. It primarily affects young smokers and usually presents with symptoms of cough, dyspnea, and chest pain. A young adult male with this disease presented with recurrent SP and was successfully treated with thoracoscopic stapling of bullae and pleural abrasion.

Interleukin-1 and interleukin-6 mediated skeletal muscle arteriolar vasodilation: in vitro versus in vivo studies.

Interleukin (IL) 1 and IL-6 have been implicated in the decreased systemic vascular resistance of septic shock; however, their sites of action and underlying mechanisms remain unclear. This study determined the effects of IL-1 and IL-6 on rat skeletal muscle arterioles using both in vitro and in vivo preparations. In the in vitro preparation, first order cremasteric arterioles were isolated from rats, cannulated with micropipettes, pressurized to 70 mmHg, superfused with physiologic saline solution, and allowed to achieve spontaneous basal tone in the absence of intraluminal flow. In the in vivo preparation, the cremaster muscle of anesthetized rats was surgically opened, secured as a flat sheet over an optical pedestal, and superfused with physiologic saline solution. Responses of third order arterioles were studied using transillumination video microscopy. In both arteriolar preparations, vessel diameter and phenylephrine (PE) responsiveness were assessed before and after cytokine exposure and washout. In vitro exposure of IL-1 (20 ng/mL (n=8) or 60 ng/mL (n=4)) or IL-6 (500 U/mL (n=2) or 1,000 U/mL (n=4)) for 1 h did not cause arteriolar vasodilation or change in PE responsiveness. However, during a 1 h in vivo exposure of IL-1 (.01, .1, 1.0, or 20 ng/mL), arteriolar diameter increased from 47+/-2 to 58+/-2% of maximum diameter (Dmax) (n=14, p < .0001), from 45+/-2 to 69+/-3% of Dmax (n=14, p < .0001), from 45+/-3 to 96+/-2% of Dmax (n=8, p < .0001), and from 47+/-4 to 96+/-1% of Dmax (n=14, p < .0001), respectively. Cytokine washout resulted in arteriolar return to basal diameter. Cytokine exposure and washout did not affect arteriolar PE responsiveness. In vivo exposure of IL-6 (10, 50, or 250 U/mL) for 1 h increased diameter from 47+/-2 to 57+/-2% of Dmax (n=14, p < .0001), from 46+/-2 to 75+/-3% of Dmax (n=14, p < .0001), and from 46+/-2 to 68+/-4% of Dmax (n=15, p < .0001), respectively. After washout of IL-6 (10, 50, or 250 U/mL), arteriolar dilation persisted, from 16.3+/-.5 to 20.1+/-1.4 microm (n=14, p < .003), from 16.1+/-.4 to 20.1+/-.6 microm (n=14, p < .0001), and from 17.7+/-.4 to 22.5+/-.8 microm (n=15, p < .0001), respectively. There was no change in PE responsiveness. These data indicate that the cytokines IL-1 and IL-6 are potent dilating agents for skeletal muscle resistance vessels under in vivo conditions. However, given that IL-1 and IL-6 are ineffective in causing relaxation of similar arterioles under isolated in vitro conditions, it is suggested that IL-1 and IL-6 interact with parenchymal or intravascular factors to elicit arteriolar relaxation.

Treatment and prognosis of primary malignant small bowel tumors.

Primary malignant tumors of the small bowel are a heterogeneous group of tumors and are uncommon compared to tumors in other locations of the gastrointestinal tract. These tumors have been traditionally associated with a poor prognosis. The charts of 53 patients with primary malignant small bowel tumors at major Eastern Virginia Medical School teaching hospitals were retrospectively reviewed. Patient characteristics and presenting symptoms and signs were nonspecific. No single radiographic or endoscopic procedure was performed on every patient, and the diagnosis was suspected preoperatively in only 50 per cent of the patients. Tumors were most common in the ileum, and the most common histologic types were adenocarcinoma (53 per cent) and carcinoid (32 per cent). In univariate analysis, factors determining survival included histologic type, location of tumor, and stage. There was also a trend toward worse survival in patients receiving chemotherapy or radiation therapy, possibly due to patient selection factors. In multivariate analysis, only histology and stage significantly influenced survival. The overall 10-year survival of the entire group was 44 per cent. Small bowel tumors have a variable prognosis. A high index of suspicion and more frequent use of enteroclysis may lead to earlier detection and improved survival.

Incidence and prophylaxis of deep vein thrombosis in a high risk trauma population.

BACKGROUND: Pelvic fractures, lower extremity injuries, acute head or spinal injury, and extended bedrest place trauma patients at an increased risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). We reviewed patients with traumatic brain injuries (TBI), spinal cord injuries (SCI), and lower extremity fractures (LEF) to examine our DVT and PE incidence and evaluate the success of our DVT and PE prophylaxis. METHODS: From January 1, 1994 to March 1, 1995, the records of trauma patients with TBI, SCI, and LEF who were admitted to the trauma service and transferred to an inpatient rehabilitation facility were reviewed. RESULTS: Twenty-two patients had a TBI, 16 patients with SCI, and 12 patients with LEF. Forty-nine of the 50 patients received DVT prophylaxis, with 7 inferior vena cava (IVC) filters placed. The DVT incidence was 6% and the PE incidence was 2%. CONCLUSION: The 6% incidence of DVT was lower than expected due to diligent DVT prophylaxis and appropriate screening of symptomatic patients for clinically significant DVT. The 2% incidence of PE was also lower than expected, most likely due to our lower DVT incidence and the use of IVC filters. The lower DVT and PE incidence verifies our success at DVT and PE prophylaxis.