Hood versus mask nebulization in infants with evolving bronchopulmonary dysplasia in the neonatal intensive care unit.

OBJECTIVE: To compare infants' discomfort, nursing-time and caregiver preference, and assess the clinical efficiency (as a secondary outcome) of hood versus facemask nebulization in infants with evolving bronchopulmonary dysplasia (BPD) in the neonatal intensive care unit. STUDY DESIGN: A prospective, open, randomized, controlled crossover clinical trial. In total, 10 infants with BPD who were on inhaled beta-agonist bronchodilators and corticosteroids were randomly assigned to receive their nebulized treatments either by a facemask, or by a hood for 2-3 days, and then crossover to receive the same treatments with the other technique for another 2-3 days. Infants' discomfort, nursing-time, caregiver preference and clinical efficiency were compared. RESULTS: At baseline there was no significant clinical difference between the groups. Nurse-time required for administering the hood nebulization (mean+/-s.e.m.: 1.9+/-0.1 min) was significantly shorter than the time for mask nebulization (12.0+/-0.6 min, P<0.0001). Infants' discomfort score was significantly lower (0.1+/-0.04) for hood versus mask nebulization (2.5+/-0.2, P<0.0001). Nurses and parents unequivocally preferred the hood treatment. During both mask and hood nebulization therapies (2-3 days) clinical efficiency was comparable. While both methods caused an immediate (20 min post) clinical improvement, the immediate respiratory assessment change score was significantly greater for the hood versus the mask nebulization (0.62+/-0.27 versus 0.13+/-0.14, P<0.05). CONCLUSIONS: Nebulization of aerosolized medications in infants with evolving BPD by hood was less time-consuming for caregivers and was much better tolerated by the infants while being at least as effective as the conventional facemask nebulization.     

Switching from Tacrolimus to Sirolimus Halts the Appearance of New Sebaceous Neoplasms in Muir-Torre Syndrome

Little is known about the effects of immunosuppression on patients with hereditary nonpolyposis colorectal cancer (HNPCC). We describe a kidney transplant recipient with unrecognized Muir-Torre syndrome in whom the administration of a tacrolimus-based regimen led to the eruption of multiple sebaceous tumors. The patient was later found to harbor an MSH2 mutation. Switching to a sirolimus-based regimen resulted in arrest of the disease. When the patient was switched back to tacrolimus, new facial lesions rapidly appeared. Switching again to sirolimus resulted again in halting the appearance of new lesions. This finding is in line with the known antiangiogenic activity of sirolimus and reports on the regression of cutaneous Kaposi's sarcoma in kidney transplant recipients switched from another immunosuppressive regimen to sirolimus. Further studies on the potential use of sirolimus for the treatment of de novo tumors in immunosuppressed kidney transplant recipients with HNPCC are warranted.     

Bronchodilatory therapy with nebuhaler: how important is the delay between firing the dose and inhaling?

Metered dose inhalers are sometimes used in conjunction with NebuhalerR, a 750 ml holding chamber, but the permissible delay time between actuating the aerosol into Nebuhaler and commencing inhalation is unknown. We have compared in 10 asthmatic patients the bronchodilator responses following inhalations of terbutaline sulphate from Nebuhaler after delays of 1, 5 and 30 seconds and following placebo inhalation. Terbutaline sulphate was administered as 2 puffs, each of 250 micrograms, separated by approximately 15 minutes. After each delay time, terbutaline produced increases in forced expiratory volume in one second (FEV1), peak expiratory flow rate (PEFR) and maximum expiratory flow following exhalation of 75% of the forced vital capacity (V max25) significantly greater than those after placebo (P less than 0.01). Changes in PEFR did not vary significantly among the three delay times, but the increases in FEV1 and in V max25 were significantly reduced with 30 seconds' delay. It is concluded that the delay between actuation into Nebuhaler and commencing inhalation can be extended from 1 second to 5 seconds without significant loss of drug efficacy, and that further extension to 30 seconds causes only a small loss of bronchodilatation: hence the delay time is unlikely to be of major importance in clinical practice.     

Accumulation of Clarithromycin in Macrophages Infected With Mycobacterium avium

Clarithromycin is known to accumulate in polymorphonuclear leukocytes, but no accumulation studies with macrophages have been reported. We exposed J774 macrophages, grown for 4–6 days, to clarithromycin 3.0 μg/ml for 2 hours. The cells were separated from the extracellular fluid, and the concentration of clarithromycin was determined in an agar diffusion bioassay. The accumulation of clarithromycin was 15.8-fold greater in the cells than it was in the extracellular fluid when the test was performed with noninfected cells, and 17.3-fold greater for cells infected with Mycobacterium avium. However, the ratio was substantially lower, only 3.7 for dead macrophages, suggesting that intracellular accumulation is probably an active process. These data may clarify the nature of the activity of clarithromycin against M. avium in macrophages.     

Late postpartum eclampsia. Apropos of a case

We report the case of a 32-year-old multipara who presented preeclampsia on the fourth day after childbirth without receiving proper treatment that progressed to eclampsia 4 days later. Pregnancy and delivery had been uneventful. The patient presented proteinuria (30 mg/dl), serum total proteins 5.3 g/dl and serum albumin 3.3 g/dl. Blood pressure was controlled with methyldopa, 500 mg at six-hour intervals by intravenous route. The patient presented hypoxemia secondary to bilateral pleural effusion and aspirative pneumonia requiring mechanical ventilation and invasive hemodynamic monitoring. Treatment with cefotaxime, 1 g at six-hour intervals by intravenous route and clindamycin, 600 mg at six-hour intervals by intravenous route was initiated. Sedation was maintained with thiopental sodium, 3 mg/kg/hour in continuous infusion. At dismission, the patient was completely recovered from her clinical picture and needed no antihypertensive therapy. Physiopathologic features and the aforementioned complications are discussed with particular reference to differential diagnosis.     

The relation of dizziness to functional decline

OBJECTIVE: to assess the effect of dizziness on the probability that an older person will die or become functionally disabled within 2 years. Dizziness is a common symptom for which the prognosis is uncertain. This report compares the prognoses for dizzy and not-dizzy older people in order to assist clinicians who diagnose and treat these patients. DESIGN: a prospective study of a representative sample of elderly (70+) non-institutionalized Americans. Elderly subjects (n = 3,798) in the Longitudinal Study of Aging (LSOA) were asked questions about the presence of dizziness, medical conditions, and functional disability in 1984. The cohort was reinterviewed about functional disability in 1986. OUTCOME MEASURE: transition from functional ability to disability after 2 years. RESULTS: Bivariate analyses showed that dizziness predicts functional decline but not mortality. Multivariate models revealed that age, race, sensory impairment, vascular disease, and other morbidity are independent predictors of becoming disabled. Controlling for these potential confounders, dizziness does not predict an increased probability of becoming disabled. CONCLUSION: Elderly people who are dizzy should be evaluated for the presence of these related conditions.     

Ultrastructural myocardial preservation during coronary artery surgery: a controlled, prospective, randomized study in humans

Potassium cardioplegia was compared with normothermic, intermittent ischemic arrest in 30 patients undergoing multiple coronary artery bypass grafts. Group 1 comprised 15 patients in whom cold potassium cardioplegia with St. Thomas' Hospital solution was used. In Group 2 were 15 patients who underwent intermittent ischemic arrest during the construction of the distal anastomoses. Two myocardial transmural left ventricular biopsies were done in each patient. There was no operative mortality. Electron microscopical examination showed normal myocardial ultrastructure in both groups. In particular, mitochondria were well preserved in all samples. The postoperative electrocardiogram demonstrated a new Q wave in 1 patient in Group 2 whose level of the myocardial isoenzyme of creatine phosphokinase (CPK-MB) was within the normal range. The peak CPK-MB release in Group 1 was 23.2 +/- 20.1 IU and in Group 2, 19.9 +/- 15.1 IU. This difference was not statistically significant. The mean period of anoxic arrest in Group 1 was 49.5 +/- 15 minutes and in Group 2, 25.5 +/- 8 minutes (p less than 0.001). Total cardiopulmonary bypass time in Group 1 was 114.5 +/- 20 minutes and in Group 2, 90.2 +/- 16 minutes (p less than 0.01). It is concluded that both techniques can preserve myocardial subcellular architecture during multiple coronary artery bypass grafting in patients with normal left ventricular function.     

Ureterocele containing calcified stone

We describe here an uncommon case of simple ureterocele containing calcified stone, that was successfully treated.     

Childhood Malignant Thymoma: Clinical, Therapeutic, and Immunohistochemical Considerations

Malignant thymomas are among the least common mediastinal tumors in the pediatric age group. Thymomas are considered malignant on the basis of macroscopic and microscopic invasiveness. As only 20 well-documented cases involving children have been reported in the literature, the pattern of responsiveness to therapy and the value of prognostic signs is obscure. Two cases of malignant pediatric thymomas are reported with pathognomonic histoimmunological features of aggressive thymoma. One was cured, with a follow-up of 70 months, and one died while on therapy. Analysis of the histological features and the immunoperoxidase staining displays the complexity of pediatric thymomas and the inability to prognosticate the outcome, respectively.