Acute epiglottitis in a nonagenarian.
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Acute Disease↗
Biomedical subjects
C B Sherman
Publications and source records attributed to C B Sherman.
Late-onset asthma: making the diagnosis, choosing drug therapy.
Physicians often fail to diagnose asthma in their older patients and instead attribute respiratory symptoms to aging alone or to other common diseases of the elderly. Although asthma is a common respiratory disease in older patients, its pathophysiology is poorly understood. Most elderly asthmatics are former smokers and have evidence of allergic disease. Asthma itself does not appear to increase mortality risk for the older patient. Spirometric results may show mild reversible airflow obstruction or fixed obstruction. The recommended therapy in the older patient follows that used for younger asthmatics. Inhaled corticosteroids are first-line agents, followed by inhaled anticholinergics. Smoking cessation, proper nutrition, and exercise are important nondrug therapies.
Adrenal Cortex Hormones↗
Hantavirus pulmonary syndrome in New England and Europe.
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Adult↗
Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance.
Enterococcus faecium strains resistant to ampicillin, high levels of gentamicin, and vancomycin but susceptible to teicoplanin (vanB class vancomycin resistance) were recovered from 37 patients during an outbreak involving a 250-bed university-affiliated hospital. Three isolates with vancomycin MICs ranging from 8 to 256 micrograms/ml all hybridized with a vanB probe. Restriction endonuclease analysis of chromosomal and plasmid DNA suggested that all isolates tested were derived from a single clone. Vancomycin resistance was shown to be transferable. Risk factors for acquiring the epidemic strain included proximity to another case patient (P, 0.0005) and exposure to a nurse who cared for another case patient (P, 0.007). Contamination of the environment by the epidemic strain occurred significantly more often when case patients had diarrhea (P, 0.001). Placing patients in private rooms and requiring the use of gowns as well as gloves by personnel controlled the outbreak. These findings suggest that multidrug-resistant E. faecium strains with transferable vanB class vancomycin resistance will emerge as important nosocomial pathogens. Because extensive environmental contamination may occur when affected patients develop diarrhea, barrier precautions, including the use of both gowns and gloves, should be implemented as soon as these pathogens are encountered.
Adult↗
A clinical and structural comparison of industrial methacholine and provocholine.
Methacholine, provided by industrial sources, has traditionally been used in studies of airways responsiveness. In 1986, a Food and Drug Administration approved formulation of methacholine (Provocholine) was released and replaced industrial methacholine in many pulmonary laboratories. To determine whether methacholine and Provocholine cause an equivalent degree of bronchoconstriction, a double blind, cross-over clinical trial was undertaken. After randomization, 19 medicine residents and respiratory therapists each performed methacholine challenge testing using either methacholine or Provocholine. Forty-eight hours later, each participant returned for repeat challenge testing with the alternate agent. The log of the dose-response slope (logslope) was calculated for each test. The mean logslope with methacholine (-0.15 +/- 1.84) and with Provocholine (-0.26 +/- 1.57) did not differ (paired Student's t test, p = 0.64). Further, excellent agreement was found between each subject's logslope with methacholine and with Provocholine (intraclass correlation coefficient rI = 0.82). Proton beam nuclear magnetic resonance revealed no structural differences between the two compounds. These findings suggest that methacholine from industrial sources and Provocholine are clinically and structurally similar and that the two agents may be used interchangeably in nonspecific bronchial provocation testing.
Adult↗
Should supplemental estrogens be used as steroid-sparing agents in asthmatic women?
OBJECTIVE: To determine if supplemental estrogens should be used as steroid-sparing agents in asthmatic women. DESIGN: Case series. SETTING: Ambulatory care, community hospital. PATIENTS: Volunteer sample of three steroid-dependent asthmatic women. INTERVENTION: Addition of conjugated estrogens to existing asthma treatment. MAIN OUTCOME MEASURE: Ability to decrease oral steroid requirement. RESULTS: The mean age of the women was 55 +/- 11 years; two were former smokers (cases 1 and 2) and one was a nonsmoker (case 3). One women (case 3) was premenopausal and noted worsening of her asthma before and during menses. The other two women (cases 1 and 2) were postmenopausal. All three had been symptomatic from their asthma for 13.2 +/- 7.6 years. Each woman was being treated with maximal doses of inhaled albuterol, inhaled steroids, and therapeutic theophylline doses. Despite this aggressive management, all three women required daily supplemental steroids (mean dose, 26.7 +/- 11.5 mg of prednisone). Case 3 was started on a regimen of norethindrone/ethinyl estradiol 1/35, and cases 2 and 3 were begun on regimens of daily conjugated estrogen, 0.625 mg. Over the next 12 to 24 weeks, the conditions of all three women were symptomatically improved and their steroid therapy was discontinued. In addition, steroid-associated side effects of hypertension, weight gain, osteoporosis, and easy bruising lessened. CONCLUSION: Although this new observation of the steroid-sparing effect of estrogens remains preliminary, further study may help advance understanding of the mechanisms and treatment of asthma in women.
Administration, Oral↗
Laser treatment of endobronchial extramedullary plasmacytoma.
A 68-year-old man presented with an endobronchial lesion and was subsequently found to have a plasmacytoma. After systemic involvement with multiple myeloma was ruled out, a diagnosis of extramedullary plasmacytoma was made. The diagnosis and treatment of extramedullary plasmacytoma is discussed with specific attention to the new role of laser therapy in this disease.
Aged↗
What is this thing called RADS?
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Asthma↗
Cognitive function and spirometry performance in the elderly.
A total of 65 ambulatory subjects over the age of 65 yr were studied to determine if mild impairment in cognitive function precludes reliable spirometric measures in the aged. Standardized questionnaires were used to obtain information on demographics, cigarette smoking, respiratory symptoms, and physician-diagnosed lung disease. Each subject performed several simple standardized tasks of cognitive function and underwent spirometric testing. A total of 36 women and 29 men participated. The mean age for the group was 74.9 +/- 5.6 yr; most were nonsmokers (never smokers, n = 28; former smokers, n = 29; and current smokers, n = 8). Of the 65 participants, 8 (12.3%) individuals were unable to perform at least three ATS-acceptable FVC maneuvers after suitable demonstration. These subjects were similar to the 57 subjects able to perform three acceptable maneuvers, except for worse scores on both the symbol-digit modalities test (23.3 +/- 3.6 versus 31.6 +/- 10.5, p < 0.001) and the trail-making test, Part B (244.3 +/- 87.1 versus 160.4 +/- 71.8, p < 0.01). Of the 57 subjects able to perform spirometry, 18 (31.6%) failed to meet ATS reproducibility criteria for FEV1, FVC, or both. Cognitive impairment was not associated with the ability to achieve reproducible measures. These results suggest that the vast majority of older subjects can perform reliable spirometry; those elderly unable to perform spirometry may have impairment in cognitive function requiring further evaluation.
Aged↗
Airway responsiveness in young black and white women.
The prevalence and severity of asthma appears to be greater in blacks than in whites. To determine if racial differences in airway responsiveness may explain these findings, methacholine challenge tests from 62 black and 238 white women 20 to 35 yr of age were evaluated. Subjects served as controls for a case-control study of the relation of airway responsiveness and preterm labor. Standardized questionnaires were used to obtain information on age, obstetrical history, education, income, cigarette smoking, medication use, and respiratory illnesses and symptoms. Total serum IgE was measured using a radioimmunoassay. Methacholine challenge testing was performed on all subjects 6 wk after delivery, and the provocative dose causing a 20% decrease in FEV1 (PD20) was calculated. Black women in the study had more pregnancies and children, were younger, less well educated and more impoverished, and reported greater cigarette smoking and less medication use than did the white women. Additionally, black women had higher geometric mean serum IgE levels (blacks: 65.4 IU versus whites: 20.0 IU; p < 0.001), lower FEV1 (blacks: 2.73 +/- 0.38 SD L versus whites: 3.19 +/- 0.39 L; p < 0.001), and greater unadjusted airway responsiveness than did white women (geometric mean PD20: blacks: 28.4 mumol versus whites: 38.8 mumol; p = 0.02). After adjusting for selective demographic and smoking differences, a significant additional effect of race on mean PD20 was found. However, after adjustment for level of serum IgE and level of FEV1, racial differences were no longer apparent.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Clinical and environmental predictors of preterm labor.
OBJECTIVE: To determine the magnitude of risk for preterm labor associated with specific clinical and environmental factors. METHODS: Using a case-control design, 266 women with preterm labor and 512 controls were interviewed and their medical records reviewed. Crude and adjusted odds ratios were calculated for each risk factor. Population-attributable risks were estimated. RESULTS: Third-trimester bleeding, twin gestation, and chorioamnionitis at presentation were strongly associated with preterm labor (odds ratios 11.2-48.3). A history of a prior preterm delivery, vaginal bleeding in the first or second trimester, maternal diethylstilbestrol exposure, uterine anomalies, and urinary tract infection during pregnancy were associated to a lesser extent (odds ratios 1.6-5.4), as were cigarette smoking and drug use (odds ratios 2.0 and 3.0). Cases who had preterm labor preceded by premature rupture of the membranes had a substantially higher risk of preterm labor if chorioamnionitis, vaginal bleeding early in pregnancy, or urinary tract infection was present. By contrast, women who had intact membranes at the onset of preterm labor carried higher risk when twin gestation, placental abruption, or uterine anomaly was present. The highest population-attributable risks for preterm labor were found in patients with a twin gestation or third-trimester bleeding. CONCLUSIONS: Programs to reduce the preterm delivery rate should consider the attributable risks for the factors they are intended to modify. The attributable risks we obtained suggest that medical strategies to reduce the impact of the clinical variables, especially multiple gestation, and educational programs to decrease smoking and drug use should reduce the preterm delivery rate.
Adult↗
The health consequences of cigarette smoking. Pulmonary diseases.
Cigarette smoking has significant detrimental effects on both the structure and function of the lung; it is the single most important risk factor for the development of COPD. Uncertainty remains concerning the mechanisms by which smokers develop obstructive lung disease. It is speculated, however, that an imbalance between proteolytic and antiproteolytic forces in the lung or an increase in heightened airways responsiveness is responsible. Population-based studies have documented lower levels of FEV1, accelerated loss of ventilatory function, and increased respiratory symptoms and infections among smokers compared with nonsmokers. Data from both prospective and retrospective studies have consistently shown increased mortality from COPD, pneumonia, and influenza among cigarette smokers compared with nonsmokers.
Humans↗
Longitudinal lung function decline in subjects with respiratory symptoms.
The relation of respiratory symptoms and lung function has not been extensively investigated. To determine better the rate of FEV1 decline in subjects reporting persistent wheeze, chronic cough, chronic phlegm, and/or dyspnea, longitudinal data from an adult population sample of 3,948 subjects (1,757 men; 2,191 women) followed for 12 yr were analyzed. At the initial and subsequent follow-up visits, subjects completed a standardized respiratory questionnaire and performed spirometry using the same methods and spirometers. Subjects were categorized based on the presence or absence of self-reported respiratory symptoms (persistent wheeze, chronic cough, chronic phlegm, or shortness of breath) at the initial visit. Six-specific linear regression models were fitted to determine the effect of these respiratory symptoms on lung function. In both men and women, reporting of any respiratory symptoms was associated with both a reduction in initial lung function and more rapid decline in height-adjusted FEV1. Furthermore, after adjustment for height, age, and cigarette smoking, men with cough or phlegm and women with cough alone showed accelerated loss in FEV1. Clinicians should be aware of the predictive value of these respiratory symptoms, because therapeutic intervention may modify the associated decline in lung function.
Cough↗
Health effects of cigarette smoking.
Cigarette smoking is associated with increased overall morbidity and mortality. Smoking is a cause of cancer of the lung, oral cavity, larynx, bladder, and renal pelvis and a contributing factor in the development of cancer of the pancreas, stomach, cervix, liver, penis, and rectum. Smokers are at greater risk for coronary artery disease, cerebrovascular disease, and atherosclerotic peripheral vascular disease. Cigarette smoking is the single most important risk factor for chronic obstructive pulmonary disease and is associated with lower levels of FEV1 and increased respiratory symptoms and infections. Women who smoke during pregnancy have an increased incidence of complications, especially intrauterine growth retardation. Peptic ulcer disease is more common in smokers than in nonsmokers. Finally, involuntary smoke exposure is associated in adults with an increased incidence of lung cancer and possibly greater mortality rates from ischemic heart disease and in children with more frequent lower respiratory tract illnesses and reduced lung growth.
Cardiovascular Diseases↗
Early childhood predictors of asthma.
To investigate potential risk factors for the development of childhood asthma, the authors undertook a longitudinal study using a cohort of 770 children aged 5-9 years from East Boston, Massachusetts, that has been under study since 1975. The disease outcome considered was age at first onset of asthma, as determined by parental or self-reporting of a physician's diagnosis. Potential risk factors were evaluated specifically in relation to their presence antecedent to a diagnosis of asthma. Standardized questionnaires were used to obtain childhood illness histories, environmental exposures, and the asthmatic and atopic statuses of first-degree relatives. Ninety-one cases of asthma were identified from 1975 to 1988 (57 males and 34 females). Significant sex-adjusted relative risk estimates were seen for antecedent pneumonia, bronchitis, hay fever, sinusitis, parental asthma, and parental atopy. Neither bronchiolitis, eczema, croup, personal cigarette smoking, maternal smoking, paternal smoking, nor delivery complications bore an apparent relation to the development of asthma. A history of parental asthma or parental atopy did not significantly alter the sex-adjusted relative risk estimates for pneumonia, bronchitis, hay fever, or sinusitis. These results support the hypothesis that asthma is a multifactor disease whose expression is dependent on both familial and environmental influences.
Asthma↗
Firefighting acutely increases airway responsiveness.
The acute effects of the products of combustion and pyrolysis on airway responsiveness among firefighters are poorly documented. To study this relationship, spirometry and methacholine challenge testing (MCT) were performed on 18 active Seattle firefighters before and 5 to 24 h after firefighting. Body plethysmography was used to measure changes in specific airway conductance (SGaw), and results of MCT were analyzed using PD35-SGaw, the cumulative dose causing a 35% decrease in SGaw. Subjects who did not react by the end of the protocol were assigned a value of 640 inhalational units, the largest cumulative dose. Fire exposure was defined as the total time (hours) spent without a self-contained breathing apparatus at the firesite and was categorized as mild (less than 1 h, n = 7), moderate (1 to 2 h, n = 5), or severe (greater than 2 h, n = 6). Mean age of the 18 firefighters was 36.7 +/- 6.7 yr (range, 25 to 51), with a mean of 9.1 +/- 7.9 active years in the trade (range, zero to 22). None was known to be asthmatic. After firefighting, FEV1 % predicted (%pred) and FEF25-75 %pred significantly decreased by means of 3.4 +/- 1.1% and 5.6 +/- 2.6%, respectively. The mean decline in PD35-SGaw after firefighting was 184.5 +/- 53.2 units (p = 0.003). This observed decline in PD35-SGaw could not be explained by decrements in prechallenge SGaw, FEV1, or FVC.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Use of oblique chest roentgenograms in detecting pleural disease in asbestos-exposed workers.
Oblique chest roentgenograms have been recommended by some for use in screening programs of asbestos-exposed workers to increase detection of pleural fibrosis not evident on posteroanterior (PA) films. As a screening test, identification of pleural abnormalities with oblique films is especially important in subjects without evidence of other asbestos-induced abnormalities on PA films, namely, parenchymal fibrosis. To evaluate the incremental value of oblique films in the identification of pleural fibrosis, a comparison was made between PA films read alone and PA films read with both oblique views in a systematic evaluation of 489 male pipefitters examined in a screening program. Analysis of the subsets of pipefitters with and without parenchymal fibrosis showed that 2.5% of workers with normal PA films (n = 326) and 13.0% of subjects with isolated parenchymal fibrosis on PA films (n = 46) had pleural fibrosis detectable only on oblique films. In only eight (1.6%) did the oblique view represent the sole evidence of an asbestos-related roentgenographic abnormality. We conclude that oblique films should not be routinely used in screening workers for evidence of asbestos-induced disease.
Adult↗