Fulminant ischaemic colitis with atypical clinical features complicating sickle cell disease.

Clinically significant ischaemic bowel injury is an exceedingly rare complication of sickle cell disease. It manifests as acute surgical abdomen and may respond to conservative treatment. An unusual fatal case of ischaemic colitis with minimal abdominal findings in a young male during a sickle cell vaso-occlusive pain crisis is described. This case demonstrates that an acute surgical abdomen should be considered in such patients who fail to respond to conservative management as untreated this condition may be fatal.

Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure.

Reexpansion pulmonary edema is a well-described complication of treatment for pleural effusion and pneumothorax. It is very rarely described in association with anesthesia and video-assisted thoracoscopic surgery. The etiology is unclear but several mechanisms have been proposed. We report a case of reexpansion pulmonary edema after video-assisted thoracoscopic surgery treated successfully with continuous positive airway pressure.

Liquid ventilation.

Liquid ventilation (LV) is an exciting, up-and-coming technique presently under investigation for the treatment of acute respiratory distress syndrome (ARDS) and infantile respiratory distress syndrome (IRDS). Two different methods of LV, total liquid ventilation (TLV) and partial liquid ventilation (PLV), are described in this article using a liquid called perflubon. This type of therapy has been shown to positively affect the physiologic derangements seen in ARDS and IRDS cases, and may have additional benefits, including anti-inflammatory properties and synergistic characteristics with other known and experimental therapies.

A "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU.

We hypothesized that a "closed" intensive care unit (ICU) was more efficient that an "open" one. ICU admissions were retrospectively analyzed before and after ICU closure at one hospital; prospective analysis in that ICU with an open ICU nearby was done. Illness severity was gauged by the Mortality Prediction Model (MPM0). Outcomes included mortality, ICU length of stay (LOS), hospital LOS, and mechanical ventilation (MV). There were no differences in age, MPM0, and use of MV. ICU and hospital LOS were lower when "closed" (ICU LOS: prospective 6.1 versus 12.6 d, p < 0.0001; retrospective 6.1 versus 9.3 d, p < 0.05; hospital LOS: prospective 19.2 versus 33.2 d, p < 0.008; retrospective 22.2 versus 31.2 d, p < 0.02). Days on MV were lower when "closed" (prospective 2.3 versus 8.5 d, p < 0.0005; retrospective 3.3 versus 6.4 d, p < 0.05). Pooled data revealed the following: MV predicted ICU LOS; ICU organization and MPM0 predicted days on MV; MV and ICU organization predicted hospital LOS; mortality predictors were open ICU (odds ratio [OR] 1.5, p < 0.04), MPM0 (OR 1.16 for MPM0 increase 0.1, p < 0.002), and MV (OR 2.43, p < 0.0001). We conclude that patient care is more efficient with a closed ICU, and that mortality is not adversely affected.

Bacterial pseudomycosis: a rare cause of haemoptysis.

Pulmonary bacterial pseudomycosis, also referred to as botryomycosis, is a very rare, indolent illness that has been described mostly in patients with immunological problems. The histological appearance is similar to that of actinomycosis; however, various Gram-positive and Gram-negative bacteria have been implicated in the pathogenesis. We illustrate a rapidly progressive case of pulmonary bacterial pseudomycosis in a normal host whose presenting complaint was haemoptysis.

Intrinsic positive end-expiratory pressure in ambulatory patients with airways obstruction.

In patients with severe expiratory airflow limitation, dynamic hyperinflation often occurs when inspiratory efforts are initiated at a thoracic volume above the relaxation point of the respiratory system. The result is intrinsic positive end-expiratory alveolar pressure (PEEPi). To determine whether PEEPi occurs in ambulatory patients, we measured alveolar pressure (Palv) noninvasively during tidal breathing in 8 normal subjects, 15 asthmatic subjects, and 19 patients with COPD, using a body plethysmographic technique that includes computerized corrections for nonlinear pneumotachometer output and for plethysmograph leakage. In all 8 normal subjects, 9 asthmatic subjects, and 3 COPD patients, Palv descended smoothly to zero at end expiration. In contrast, among each of the remaining 22 patients, there was an abrupt change in slope of the Palv tracing near end expiration, identifying the onset of the next inspiratory effort and indicating the presence of PEEPi, ranging from 0.2 to 9.5 cm H2O. PEEPi was significantly correlated with FRC (% of predicted); PEEPi = (0.040 x %FRC) - 3.65, r = 0.73, p < 0.001, and with the reciprocal of FEV1 (% of predicted), PEEPi = (138/%FEV1) - 1.34, r = 0.69, p < 0.001. PEEPi could be elicited in normal subjects by severe expiratory resistive loading but not by the increased expiratory muscle activity occurring during an MVV maneuver. We conclude that PEEPi is common in patients with airways obstruction, even without overt ventilatory failure, and that its severity is generally in proportion to the severity of the hyperinflation and the airways obstruction.

Respiratory syncytial virus infection in an adult with Wegener's granulomatosis.

Respiratory syncytial virus (RSV) has been documented as a pathogen in adults who are immunocompromised because of various underlying conditions. To our knowledge, this is the first report of a patient with Wegener's granulomatosis (WG) and RSV infection resulting in a fatal outcome.

Profile of bronchospastic disease in Puerto Rican patients in New York City. A possible relationship to alpha 1-antitrypsin variants.

A high prevalence of asthmalike symptoms was noted among patients of Puerto Rican descent attending Beth Israel and North Central Bronx Medical Centers in New York City, as compared with other ethnic groups. An evaluation of family and medical histories, pulmonary function data, and alpha 1-antitrypsin phenotypes was undertaken in such Puerto Rican patients and control subjects without asthma. The patients showed a higher proportion of MS and MV phenotypes. All the patients in both MM and variant phenotype groups, with the exception of four MM patients, had features indicative of asthma, with labile airway obstruction, and elevated serum immunoglobulin E and eosinophil levels. The latter was significantly higher in the patients with variant phenotypes than in MM patients. Patients with alpha 1-antitrypsin variants also had much shorter smoking histories as compared with the MM group, and all reported histories of asthma in first-degree relatives, as compared with 66% among the MM patients. We conclude that there is an increased incidence of asthma among Puerto Ricans in New York City, and that the antitrypsin variant phenotypes (specifically S and V) play a role in this incidence and its expression.

Maximal inspiratory pressure is not a reliable test of inspiratory muscle strength in mechanically ventilated patients.

Maximal Inspiratory pressure (MIP) is an important clinical method used to assess respiratory muscle strength. The reliability and reproducibility of this measurement in mechanically ventilated patients is not certain. In 14 stable, mechanically ventilated patients, capable of spontaneous inspiratory efforts, we assessed maximal inspiratory efforts using the technique originally described by Marini and associates. MIP was measured in triplicate, by one to five experienced investigators, on one to seven successive days, for a total of 396 determinations on 54 patient days. The coefficients of variation among the triplicate efforts averaged 12 +/- 1%, indicating the test to be highly reproducible. There was significant variation among the MIP reported by different investigators studying the same patient on the same day (32 +/- 4%). The differences between best MIP by different investigators averaged 12.6 +/- 1.3cm H2O (40 +/- 4%). In 17 of 44 cases, one investigator placed MIP above -30cm H2O, whereas another placed it below. ANOVA showed that MIP was significantly affected by investigator (p less than 0.0001) as well as by patient (p less than 0.0001). Because "true" MIP must be equal to or greater than the best measured MIP, these data indicate that the MIP is commonly underestimated in patients receiving mechanical ventilation, even when standardized technique is used. Furthermore, our data show that reproducibility of triplicate MIP determination by a single observer does not indicate that the test is reliable.