Effect of shunt surgery on spleen size, portal pressure and oesophageal varices in patients with non-cirrhotic portal hypertension

Shunt surgery is considered to be the treatment of choice in patients with non-cirrhotic portal hypertension. There is little data on the effect of side-to-side lieno-renal (SSLR) shunt on oesophageal variceal size, splenic size and splenic pulp pressure (SPP) in patients with non-cirrhotic portal hypertension. We evaluated pre- and postoperatively endoscopic grading of varices, splenic size and SPP for predicting shunt patency in 86 patients with non-cirrhotic portal hypertension: 56 with extrahepatic portal venous obstruction (EHPVO) and 30 with non-cirrhotic portal fibrosis (NCPF). The EHPVO patients with patent shunts (n= 47) showed significant reduction in SPP (pre-operative 43.56±7.9 vs postoperative 29.96±7.7 cm of saline), splenic size (6.5±2.8 vs 4.00±2.6 cm below costal margin) and varices grades (2.96±0.5 vs 0.92±0.8). Patients with blocked shunt (n= 9) did not show significant reduction in SPP and varices grades. However, there was reduction in spleen size (8.6±3.0 vs 6.3±4.3). In the NCPF group, 28 had patent shunts and showed significant reduction in SPP (46.3±13.5 vs 33.8±7.6 cm of saline), splenic size (9.1±3.3 vs 6.8±4.6 cm below costal margin) and varices grades (2.8±0.7 vs 1.05±0.96). As only two patients with NCPF had blocked shunts, no statistical comparison between patients with patent and patients with blocked shunts could be done. In conclusion, following SSLR, there is a significant reduction in SPP and varices grades in patients with patent shunts. Endoscopic grading of varices can be used to predict shunt patency. However, spleen size is not a good criteria for predicting shunt patency.     

Pleural disease in pregnancy.

Pleural effusions, pneumomediastinum, and pneumothorax are known complications of pregnancy. Although reported in small series and anecdotal case reports, the serious nature of these complications and the potential for misdiagnosis during the events of labor and delivery warrant a careful review of the available literature. In this article the incidence, clinical manifestations, and, where appropriate, therapeutic options of these disorders are discussed.     

Effects of prostaglandin E1 on platelet attenuation of oxidant-induced edema in isolated rabbit lungs

Numerous studies suggest that platelets may contribute to preservation of normal endothelial cell permeability in models of lung injury. We have previously shown that washed human platelets prevent xanthine oxidase-induced edema in the isolated perfused lung and that protective mechanisms depend on the platelet glutathione redox cycle. It is uncertain, however, whether platelets preserve endothelial function by reducing toxic oxygen metabolites or by aggregating and releasing endothelial cell supportive factors-an activity that may require the glutathione redox cycle. In this study, we present data demonstrating that platelet prevention of oxidant lung injury occurs independent of platelet aggregation and release. Isolated rabbit lungs perfused with a cell-free medium were instilled with purine (2 mmol/L) and xanthine oxidase (0.003 U/ml) to generate oxidant lung edema. The infusion of washed human platelets (1 x 10(10) cells) prevented lung edema formation as measured by lung weight gain, wet-to-dry lung weight ratios, and lung histology. Incubation of platelets with prostaglandin E1 (PGE1), a potent inhibitor of platelet aggregation and release, did not inhibit platelet attenuation of lung edema. Additionally, with the instillation of PGE1 into the perfusate to further inhibit platelet aggregation, no prevention of lung protection by PGE1-treated platelets was seen when these results were compared with those from studies in which lungs were infused with xanthine oxidase and PGE1. Aggregometry studies documented that the inhibitory effect of PGE1 on platelet aggregation persisted for up to 60 minutes, which was the duration of the isolated lung protocol. We conclude that platelet aggregation and release of platelet factors is not required for platelet attenuation of oxidant lung edema.     

Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training

STUDY OBJECTIVE: To evaluate the attitudes and perceptions of internal medicine residents regarding pulmonary and critical care medicine (PCCM) training. DESIGN: Prospective study. SETTING: Three university hospitals. METHODS: An eight-page survey was distributed and collected between March 1, 2002, and June 30, 2002. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study. RESULTS: One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate). PCCM accounted for only 3.4% of the career choices. Forty-one percent of the residents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the more attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone more attractive. Key factors associated with a higher resident interest in PCCM subspecialty training included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 +/- 0.78 vs 3.45 +/- 0.78, p = 0.0004), and resident observations of a greater sense of satisfaction among PCCM faculty (3.07 +/- 0.82 vs 3.33 +/- 0.82, p = 0.04) and fellows (3.05 +/- 0.69 vs 3.31 +/- 0.86, p = 0.03) [mean +/- SD]. The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%). The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%). CONCLUSIONS: Internal medicine residents have serious reservations about PCCM as a career choice. Our survey demonstrated that a minority of US medical graduates actually would choose PCCM as a career, which suggests that efforts to expand PCCM training capacity might result in vacant fellowship slots. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents.     

Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline

OBJECTIVE: A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods. OPTIONS AND OUTCOMES CONSIDERED: Based on consensus of clinical opinion, the expert panel developed an annotated table for evaluating the risk for poor outcome in patients with PPE. Estimates of the risk for poor outcome were based on the clinical judgment that, without adequate drainage of the pleural space, the patient with PPE would be likely to have any or all of the following: prolonged hospitalization, prolonged evidence of systemic toxicity, increased morbidity from any drainage procedure, increased risk for residual ventilatory impairment, increased risk for local spread of the inflammatory reaction, and increased mortality. Three variables, pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, were used in this annotated table to categorize patients into four separate risk levels for poor outcome: categories 1 (very low risk), 2 (low risk), 3 (moderate risk), and 4 (high risk). The panel's consensus opinion supported drainage for patients with moderate (category 3) or high (category 4) risk for a poor outcome, but not for patients with very low (category 1) or low (category 2) risk for a poor outcome. The medical literature was reviewed to evaluate the effectiveness of medical and surgical management approaches for patients with PPE at moderate or high risk for poor outcome. The panel grouped PPE management approaches into six categories: no drainage performed, therapeutic thoracentesis, tube thoracostomy, fibrinolytics, video-assisted thoracoscopic surgery (VATS), and surgery (including thoracotoiny with or without decortication and rib resection). The fibrinolytic approach required tube thoracostomy for administration of drug, and VATS included post-procedure tube thoracostomy. Surgery may have included concomitant lung resection and always included postoperative tube thoracostomy. All management approaches included appropriate treatment of the underlying pneumonia, including systemic antibiotics. Criteria for including articles in the panel review were adequate data provided for >/=20 adult patients with PPE to allow evaluation of at least one relevant outcome (death or need for a second intervention to manage the PPE); reasonable assurance provided that drainage was clinically appropriate (patients receiving drainage were either category 3 or category 4) and drainage procedure was adequately described; and original data were presented. The strength of panel recommendations on management of PPE was based on the following approach: level A, randomized, controlled trials with consistent results or individual randomized, controlled trial with narrow confidence interval (CI); level B, controlled cohort and case control series; level C, historically controlled series and case series; and level D, expert opinion without explicit critical appraisal or based on physiology, bench research, or "first principles." EVIDENCE: The literature review revealed 24 articles eligible for full review by the panel, 19 of which dealt with the primary management approach to PPE and 5 with a rescue approach after a previous approach had failed. Of the 19 involving the primary management approach to PPE, there were 3 randomized, controlled trials, 2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small; methodologic weaknesses were found in the 19 articles describing the results of primary management approaches to PPE. The proportion and 95% CI of patients suffering each of the two relevant outcomes (death and need for a second intervention to manage the PPE) were calculated for the pooled data for each management approach from the 19 articles on the primary management approach. (ABST