Clinical predictors of the adult respiratory distress syndrome

One hundred thirty-six patients meeting our criteria for one or more of eight clinical conditions were prospectively observed for the development of the adult respiratory distress syndrome. A high risk population was identified, including those with sepsis syndrome (38 percent), documented aspiration of gastric contents (30 percent), multiple emergency transfusions (24 percent), and pulmonary contusion (17 percent). The risk from multiple major fractures appeared low but contributed to the risk from other factors. The risk associated with just one factor (25 percent) was compounded by the presence of two (42 percent) and three (85 percent) simultaneous factors, and this finding was more predictive of ARDS than the injury severity score or initial arterial oxygenation. Of the ARDS cases, 76 percent occurred in the initial 24 hours after meeting the criteria. ARDS did not occur after 72 hours unless there was late development of sepsis (3 of 136 patients).     

Delayed clearance of chylomicron remnants following vitamin-A-containing oral fat loads in broad-beta disease (type III hyperlipoproteinemia).

Chylomicron "remnants" are formed by the selective removal of triglyceride catalyzed by lipoprotein lipase. To investigate a possible defect in the clearance of these remnants in the pathophysiology of broad-beta disease (type III hyperlipoproteinemia), subjects with this disorder and comparison subjects with endogenous hypertriglyceridemia (and type IV lipoprotein patterns) ingested an oral fat load (corn oil: cocoa butter, 1:1, 50 g/sq M) containing retinyl ester, 100 mg, with or without 15 muCi 15-(14) C-retinol (43.7 mCi/mg). The content of triglyceride and vitamin A was sequentially determined in chylomicrons (Sf more than 400) and very low density lipoproteins (VLDS, Sf20-400) over the ensuing 24-72 hr. Vitamin A was chosen as a marker for exogenous sterol assimilation since, like cholesterol, it is absorbed in the small intestine and cosecreted in esterified form with triglyceride in the chylomicron core; however, unlike cholesterol, once having been removed by the liver, it cannot be recycled inot VLDL, but subsequently circulates only as a complex with the high density retinol binding protein. Thus measurements of the vitamin A/triglyceride ratio in Sf greater than 20 lipoproteins reflected the relative efficiency of vitamin A versus triglyceride removal within these lipoproteins. These studies confirmed the intital concentration of exogenous vitamin A in chylomicrons but invariably disclosed an increasing proportion of the remaining Sf greater than 20 vitamin A in VLDL 24 hr after its ingestion. The vitamin A/triglyceride ratio also invariably increased between 6 and 24 hr in the Sf20-30 subfraction, reflecting the formation of vitamin A-rich "remnants" as intermediate species in the catabolism of chylomicrons and VLDL. Among those with mild to moderate endogenous hypertriglyceridemia the Sf greater than 400 vitamin A/triglyceride ratio declined between 6 and 24 hr, reflecting the efficient passage of the vitamin A through this fraction and/or continued secretion of Sf greater than 400 particles rich in triglyceride. Among those with severe endogenous hypertriglyceridemia, both the peak and decline in the Sf greater than 400 vitamin A/triglyceride ratio were delayed. However, among those with broad-beta disease, an increasing vitamin A/triglyceride ratio between 6 and 24 hr was frequent within all VLDL subfractions and invariable among lipoproteins of Sf greater than 400 regardless of the degree of antecedent hypertriglyceridemia. Although additional experiments disclosed a similar delay in both vitamin A and triglyceride assimilation when basal triglyceride levels were high in these subjects, marked reduction of triglyceride levels did not correct the rise in the Sf greater than 400 vitamin A/triglyceride ratio between 6 and 24 hr. Experiments employing preparative electrophoresis confirmed the identity of VLDL containing a high vitamin A/triglyceride ratio with the beta-VLDL which accumulate in broad-beta disease...     

Cigarette smoking in a chest clinic population —Psychophysiologic variables

This is a cross-sectional study of the relationship of psychosocial, physiologic and epidemiologic data to the ability to stop cigarette smoking in a private chest clinic population of 240 patients. The separation of ever and never smoked categories showed the expected differences in physiologic variables. The separation of those who stopped smoking from those who continued to smoke was significant. The primary variables associated with the capacity to stop are good psychosocial assets, psychologic stability and the ability to express depression openly.The study is consistent with the hypothesis that patients with high psychosocial assets have several behaviors to substitute for that of smoking. These patients are psychologically stable and their psychologic comfort is not seriously threatened if they need to stop smoking. Smoking may be a learned behavior associated with an increase in comfort and capacity to deal with the problems of living. To some patients who have difficulty in adapting, the dangers of smoking may not outweigh the certain loss in ability to deal with the immediate environment if they stop.     

The role of peritoneal lavage in the management of stab wounds to the abdomen

In a 2 year period, 237 patients presented with stab wounds to the lower chest and anterior abdomen. Ninety-six patients were discharged from the emergency room after negative findings on wound exploration. There were no apparent missed injuries but two wound infections in this group for an overall morbidity of 2.1 percent. One hundred forty-one patients underwent exploratory laparotomy. Seventy-seven required emergency laparotomy because of hemodynamic signs of blood loss or peritonitis. Sixty-four patients whose only indication for laparotomy was penetration of the anterior abdominal wall fascia by local wound exploration underwent peritoneal lavage before laparotomy. If 50,000 red blood cells/mm³ in the lavage fluid had been used to select patients for observation, the incidence of negative laparotomy would have been reduced from 58 to 3.2 percent, and only one significant visceral injury would have been missed.Peritoneal lavage in properly selected patients, used in combination with local wound exploration and careful clinical observation, can be a useful diagnostic modality both in predicting significant visceral injury and in lowering the incidence of negative findings at laparotomy in patients with stab wounds to the abdomen.     

Intravenous chlorimipramine and refractory depression

A total of 252 infusions of chlorimipramine were performed on 12 patients with refractory depression. It is suggested that the intravenous route of administration is safe and effective. It may, in fact, be the preferred route when the oral route of administration is not available.     

Granulocyte transfusions

Laboratory and clinical studies have demonstrated beyond question that granulocyte transfusions can have a beneficial effect on the incidence and course of bacterial infection. The increment of improved survival produced by granulocyte transfusions depends on the effectiveness of the alternative (primarily antibiotic) therapy alone, and this varies with the pattern of bacterial predominance and sensitivity, which is notoriously changeable. The absolute effectiveness of granulocyte transfusion therapy is influenced by the quality of the transfusions and the immune status of both the recipient and the granulocyte donor. The indiscriminate transfusion of inadequate quantities of granulocytes from random donors into sensitized recipients should be discouraged. Severely neutropenic patients with established infection unresponsive to antibiotic therapy are appropriate recipients of granulocyte transfusions. Well-designed programs of prophylactic granulocyte transfusions can reduce the occurrence of bacterial infection in neutropenic patients, but there are few clinical situations in which their use is justified. The use of cytomegalovirus-seropositive granulocyte donors for cytomegalovirus-seronegative recipients should be avoided. There is a need for technical advances that will increase the ease and efficiency of granulocyte procurement.     

The depression-pain syndrome and its response to antidepressants

In an attempt to elucidate the relationship between depression and pain, the authors studied 300 pain center patients; 261 (87%) of these patients referred for diagnosis and treatment of their pain syndromes were depressed. In another study of 196 private patients with depression, 116 (59%) also had recurring benign pain. When treated with antidepressant medications, 96 of these 116 (83%) obtained significant relief of their pain syndromes. The frequency with which antidepressants can significantly alleviate pain associated with depression highlights the importance of the link between pain and depression, which may be partially explained by the close relationship of enkephalins and biogenic amines     

Differentiation of lymphoma from histoplasmosis in children with mediastinal masses

The differentiation of mediastinal masses caused by lymphoma from those caused by histoplasmosis may require thoracotomy. We reviewed the medical records of 37 children undergoing initial evaluation for anterior or middle mediastinal masses. Sixteen had biopsy-proved lymphoma, and 21 had histoplasmosis; seven with histoplasmosis underwent thoracotomy. Age, sex, fever, weight loss, duration of illness, anemia, erythrocyte sedimentation rate, nonspecific reactants, and lung infiltrates and calcifications were similar in both groups. Masses were in the middle mediastinum in all patients with histoplasmosis and in 69% with lymphoma. Masses were in the anterior mediastinum in one of 21 (5%) with histoplasmosis and 13 of 16 (81%) with lymphoma. Among patients with lymphoma, histoplasmal complement fixation antibody titers were less than 1:8 in 14 of 15 (93%); a single patient had a titer of 1:16. The CF titers were greater than or equal to 1:32 in 14 of 21 (67%) with histoplasmosis. In children with middle mediastinal masses, a histoplasmal CF yeast or mycelial titer greater than or equal to 1:32 is strongly suggestive of acute histoplasmosis and biopsy is not required. Children not fulfilling these criteria should undergo diagnostic biopsy.     

Thyrotropin levels in hyperlipidemic survivors of myocardial infarction.

In an earlier investigations, the prevalence of hyperlipidemia in a group of patients who survived myocardial infarction was determined, and family studies were performed to allow genetic classification of patients with hyperlipidemia. Radioimmunoassay for thyrotropin (TSH) has now been performed on plasmas from most of these hyperlipidemic survivors. Elevated TSH values were found in five of the 18 hyperlipidemic women over age 60, and in seven of the remaining 104 hyperlipidemic subjects. Among the various genetically defined types of hyperlipidemia, the highest prevalence of TSH elevations was seen in women with sporadic (nonfamilial) hypertriglyceridemia; four of the ten had an abnormal TSH level, and two of the remainder were receiving thyroid medication. Hypercholesterolemia was not strongly correlated with TSH abnormalities. These data support the hypothesis that clinically inapparent thyroid damage may be associated with coronary artery disease.