Antibiotic therapy of pleural empyema.

Most empyemas occur as a complication of pneumonia or lung abscess, but 15% to 30% occur after thoracic surgery and 10% occur in association with an intraabdominal infection. The bacteriology of empyemas that occur in association with lung infections is often polymicrobial and mixed, containing multiple species of both aerobic and anaerobic bacteria, the latter found in up to 75% of cases. In contrast, empyema following thoracic surgery is more likely to be monomicrobial and caused by common nosocomial pathogens such as Staphylococcus aureus and aerobic gram-negative bacilli. Diffusion of antibiotics into both infected and uninfected pleural fluid is good, but certain agents (aminoglycosides and some beta-lactams) may be inactivated in the presence of pus, low pH, and beta-lactamase enzymes. Single antibiotic agents that are likely to be active against the wide spectrum of potential pathogens include imipenem-cilastatin and ticarcillin-clavulanic acid. Combinations of antibiotics should include an effective agent against anaerobic bacteria (clindamycin, metronidazole) coupled with an agent active against aerobic gram-positive cocci and gram-negative bacilli.     

Immunolocalization of cytokines and their receptors in adhesive capsulitis of the shoulder

The purpose of this study was to test the hypothesis that specific cytokines are involved in the initiation and evolution of the fibrotic process in adhesive capsulitis of the shoulder. After approval from the Institutional Review Board, biopsies of shoulder capsule and synovium were collected during shoulder arthroscopy from 19 patients with adhesive capsulitis, 14 patients with nonspecific synovitis and no fibrosis or clinical evidence of adhesive capsulitis, and seven patients undergoing surgery for another pathology who had a normal capsule and synovium. Immunohistochemical localization with monoclonal antibodies to transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, basic fibroblast growth factor, interleukin-1β, tumor necrosis factor-α, and hepatocyte growth factor was performed using standard immunoperoxidase techniques. The frequency of cytokine staining was correlated with the clinical diagnosis Synovial cells, fibroblasts, T-cells, and B-cells were identified with specific antibodies, and newly synthesized matrix was examined for type-I and type-III collagen by immunohistochemical staining. The predominant cell types present were synovial cells and fibroblasts. Staining for type-III collagen in adhesive capsulitis tissues indicated new deposition of collagen in the capsule. There was staining for transforming growth factor-β and its receptor, platelet-derived growth factor and its receptor, interleukin-1β, and tumor necrosis factor-α in adhesive capsulitis and nonspecific synovitis tissues, compared with minimal staining in normal capsule. Staining was more frequent in snovial cells than in capsular cells. The frequency of cell and matrix staining for transforming growth factor-β, platelet-derived growth factor, and hepatocyte growth factor was greater in adhesive capsulitis tissues than in those from patients with nonspecific synovitis. No difference in the frequency of staining between primary (idiopathic) and secondary adhesive capsulitis was found. The results of this study indicate that adhesive/capsulitis involves both synovial hyperplasia and capsular fibrosis. Cytokines such as transforming growth factor-β and platelet-derived growth factor may be involved in the inflammatory and fibrotic processes in adhesive capsulitis. Matrix-bound transforming growth factor-β may act as a persistent stimulus, resulting in capsular fibrosis. Understanding the basic pathophysiology of adhesive capsulitis is an important step in the development of clinically useful antifibrotic agents that may serve as novel treatments for patients with this condition.     

A case of affective disorder associated with the misuse of 'anabolic steroids'.

In the pursuit of gains in muscle size and strength, body-builders may mistakenly use illicit drugs believing them to be anabolic steroids. The case described illustrates the physical and psychological dangers of such behaviour.     

Sirolimus allows renal recovery in lung and heart transplant recipients with chronic renal impairment.

BACKGROUND: Until recently, there has been no practical alternative to the use of calcineurin inhibitors (CIs) as primary immunosuppressants in lung transplantation (LTx) and heart transplantation (HTx). Sirolimus (SRL) is a novel powerful immunosuppressant without renal toxicity, a common post-transplant problem associated with CI therapy. METHODS: SRL was used in 20 LTx and 5 HTx recipients >90 days post-transplant, where serious renal impairment was limiting CI dosing. Patients started on 2 to 5 mg/day orally at a median of 1,185 days post-transplant. Dosage adjustments were made according to trough levels, toxicity and perceived efficacy. With SRL initiation, 48% ceased CI therapy and the remainder decreased their dose substantively. RESULTS: After 30 days, 4 of 5 dialyzed patients ceased dialysis and 15 of 20 patients with an elevated serum creatinine (Cr) (mean Cr 0.29 mmol/liter) improved their Cr. The direction of change in Cr at 30 days predicted longer term Cr. The starting Cr did not predict the 30-day or long-term value. There were two bouts of acute and one bout of chronic rejection. There were 35 infectious complications in 16 patients and 24 episodes of potential SRL-related toxicity in 17 patients. These events generally responded to dose reduction or temporary cessation and were level-related. Fifteen recipients presently remain on the drug. None of the 7 deaths could be directly related to toxicity. CONCLUSION: SRL is a useful alternative immunosuppressant, allowing significant CI withdrawal in transplant recipients with renal impairment. Whether the resulting improvement in Cr can be maintained in the long term probably depends on the balance between the extent of acute and chronic renal damage.     

Magnetic resonance in the diagnosis of aneurysmal bone cyst]

A patient of 12 suffering from aneurysmal cyst of the ischium was studied with traditional radiology, computed tomography (CT) and magnetic resonance imaging (MRI). The advantages of MRI in the study of this pathology compared to traditional radiography and CT are assessed. It was shown that the CT and MRI techniques are superior to standard X-ray examinations in anatomic definition and in evaluating the lesions's relationships with neighbouring structures and, in particular, that MRI is superior to CT in extension.     

Interleukin-6: effects on and production by rat granulosa cells in vitro.

Treatment of FSH-stimulated granulosa cells with increasing amounts of interleukin-6 (IL-6) caused a significant concentration-dependent suppression of progesterone biosynthesis. However, basal progesterone production in non-FSH-stimulated cells remained unresponsive to the cytokine. Quantitation of IL-6 in the conditioned media from untreated granulosa cells by the 7TD1 hybridoma cell bioassay revealed detectable levels of IL-6. Further, FSH treatment caused a significant concentration-dependent increase in IL-6 release. In contrast, both basal and FSH-stimulated IL-6 release could be significantly suppressed by interferon gamma (INF-gamma). The results of the present study suggest: 1) a role for IL-6 in the regulation of progesterone production, 2) that the granulosa cell is a source of IL-6 and 3) that the release of IL-6 by the granulosa cell is a regulated event.     

Alternative Treatments for Asthma: Assessing the Need

Alternative treatments such as troleandomycin methotrexate, gold, and intravenous gamma globulin are sometimes considered for severe asthmatics to minimize the need for systemic corticosteroids and reduce adverse effects. These alternative therapies may also be associated with significant toxicity and expense. The ability to reduce corticosteroid use and the need for alternative treatment interventions in 125 pediatric patients at our institution were reviewed. Because corticosteroid requirements were reduced significantly, only 23 of 125 children evaluated were considered for treatment alternatives with only 10 receiving such therapy. This study emphasizes the importance of a thorough and comprehensive review of corticosteroid requirements and usage prior to initiating alternative approaches to treatment in moderate to severe asthmatics as well as in patients thought to be “steroid-dependent.”     

The lateral chest X-ray: Is it necessary for emergency department patients?

To determine the utility of the lateral view of the chest in emergency department patients, records of all patients who had had 2-view chest x-rays ordered in the emergency department were reviewed retrospectively. A study radiologist recorded a reading of the posteroanterior (PA) radiograph alone. The lateral radiograph was then provided, along with the PA view, and a second reading was recorded. A comparison was then made between the first and second readings.A total of 417 sets of x-rays were included. The PA view alone successfully diagnosed or suspected 92% of pulmonary nodules, 95% of effusions, 97% of cases of emphysema, 98% of pneumonias, and 100% of cases of cardiomegaly, pulmonary edema, interstitial pulmonary disease, and atelectasis.In the emergency department patient population, lateral views of the chest have minimal diagnostic yield and therefore may be used selectively to safely decrease the amount of breast radiation exposure to young women.     

The indirect estimation of hemoglobin concentration in whole blood.

The present conventional methods for determination of Hemoglobin (Hb) concentration in whole blood depend on the direct colorimetric measurement of chemically modified Hb following its release from red cells by lysis. This paper examines an alternative, indirect method which does not require initial red cell lysis, corrects for the falsely elevated Hb due to the lipemic plasma and determines whether elevated WBC count effects a change in the Hb value, without the tedious laboratory manipulations currently required to correct for these artifacts. The method is simple, uncomplicated and is based on the observation of a constant ratio (2.98) between the Mean Corpuscular Volume (MCV) and the Mean Corpuscular Hemoglobin (MCH) indices obtained from standard electronic counters in use in most laboratories. The Hb concentration is calculated by the equation: [formula: see text]. The resultant Hb measurements show an acceptable degree of accuracy and precision when compared with the direct measurements obtained from a Coulter Model S + I, even in the presence of a high WBC or lipid.