Pulmonary embolism complicating barbiturate overdose.
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Adult↗
Biomedical subjects
W J Fulkerson
Publications and source records attributed to W J Fulkerson.
Constrictive pericarditis due to hydralazine-induced lupus erythematosus.
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Humans↗
Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit.
Patients with hepatic failure admitted to the medical ICU (MICU) generally have a poor prognosis. To determine if there were readily identifiable clinical factors associated with a high predictive value for outcome, we reviewed retrospectively the charts of 100 patients with serious liver disease admitted to the MICU. The overall mortality of the group was 64%. We found that Child's class, a need for mechanical ventilation, and an elevated serum creatinine had the greatest prognostic significance. Ninety-one percent of the patients receiving assisted ventilation, 89% of the patients in Child's class C, and 93% of the patients with creatinine values greater than 1.3 mg/dl died during their MICU admission. Furthermore, a multivariant regression analysis indicated that patients in Child's class C receiving mechanical ventilation who had an abnormal serum creatinine (greater than 1.3 mg/dl) during the first 72 h in the MICU had only a 2% survival rate.
Adult↗
Pulmonary hypertension secondary to serum hyperviscosity in a patient with rheumatoid arthritis.
A patient with rheumatoid arthritis who was evaluated for dyspnea of six months' duration is described. Although no primary cardiac or parenchymal lung disease was identified, right heart catheterization revealed marked pulmonary hypertension. The patient was presumed to have pulmonary arteritis. Evaluation of her hyperproteinemia, however, led to the discovery of a polyclonal gammopathy with a marked increase in plasma viscosity. Although the classic clinical findings of the hyperviscosity syndrome were minimal, the patient underwent plasmapheresis, resulting in a marked reduction of pulmonary artery pressures (from 53 +/- 4 mm Hg, mean +/- SD, to 30 +/- 3 mm Hg, p less than 0.05) and pulmonary vascular resistance (from 707 +/- 63 dynes/second/cm5 to 421 +/- 72 dynes/second/cm5, p less than 0.05) concomitant with a return to normal plasma viscosity. Her dyspnea completely resolved. This represents the first successful treatment of pulmonary hypertension by plasmapheresis. Protein evaluation revealed the presence of intermediate complexes of IgG rheumatoid factor. The hyperviscosity syndrome should be considered in the differential diagnosis of pulmonary hypertension in patients with rheumatoid arthritis and other disorders associated with a polyclonal or monoclonal gammopathy. Pulmonary hypertension secondary to the hyperviscosity syndrome is reversible by plasmapheresis. Immunosuppressive therapy that reduces immunoglobulin production may provide a means of long-term treatment.
Arthritis, Rheumatoid↗
Staphylococcus aureus septicemia mimicking fulminant Rocky Mountain spotted fever.
Septicemia due to Staphylococcus aureus can be a difficult diagnosis to make early in its presentation. This report illustrates a case that mimicked fulminant Rocky Mountain spotted fever in a patient with no other medical problems that might predispose her to the development of staphylococcal sepsis. Epidemiology, cerebrospinal fluid characteristics, and early biopsy of skin lesions are emphasized as important factors leading to early diagnosis and definitive treatment.
Adult↗
Occult spontaneous esophageal perforation. Unusual clinical and radiographic presentation.
We report a unique presentation of spontaneous esophageal perforation or Boerhaave's syndrome. Our patient had no risk factors predisposing her to barogenic rupture of the esophagus, and she had none of the "classic" presenting signs. She was asymptomatic, and her clinical course appeared to be chronic. Her chest roentgenogram demonstrated bilateral thick-walled cavities with air-fluid levels. Computerized axial tomography of the chest and swallow of meglumine diatrizoate (Gastrografin) showed the cavities and esophagus to communicate. This patient's presentation and radiographic studies extend the reported description of Boerhaave's syndrome.
Diatrizoate Meglumine↗
Adult respiratory distress syndrome after limited thoracic radiotherapy.
The authors report three patients who developed fatal respiratory failure after limited or unilateral thoracic radiation therapy for neoplasms. The respiratory failure was characteristic of the adult respiratory distress syndrome (ARDS) with refractory hypoxemia and diffuse bilateral infiltrates including areas of lung well outside of the radiation ports. No patient received drugs known to cause lung injury, and cardiogenic edema and infections were excluded. At autopsy the lungs exhibited interstitial fibrosis, Type II alveolar cell hyperplasia, inflammatory infiltrates, and squamous metaplasia. The etiology of the pulmonary injury is unclear.
Aged↗
Effects of methylprednisolone on lung oxygen toxicity in awake sheep.
The purpose of this study was to measure the effects of high doses of corticosteroids on the response to breathing 100% O2 in sheep. Sheep were prepared for chronic measurement of vascular pressures, cardiac output, gas exchange, and for collection of lung lymph. Tracheostomies were made for accurate delivery of gas mixtures. Eight sheep received methylprednisolone 30 mg/kg body wt every 6 h for eight doses, four for the first 48 h, and four for the final 24-48 h of 100% O2 breathing. Eight control sheep breathed 100% O2 without methylprednisolone, four sheep breathed compressed air without methylprednisolone, and two breathed compressed air and received methylprednisolone. Sheep had daily measurements of hypoxic vasoconstriction (fractional concentration of O2 in inspired gas = 0.12), gas exchange, lymph flow, and lymph and plasma protein concentration. Polymorphonuclear leukocyte (granulocyte) function in experimental and control sheep was assessed ex vivo by tests of chemotaxis, aggregation, and superoxide production. The number of granulocytes in peripheral lung was measured in biopsy tissue taken at the time of original surgery and postmortem. Methylprednisolone did not affect the time course nor magnitude of gas exchange abnormality, lymph flow and composition, loss of hypoxic vasoconstriction, lung granulocyte accumulation, nor postmortem lung water caused by 100% O2 breathing. Sheep receiving methylprednisolone had a shorter survival by several h, independent of the timing of the drug. Granulocytes from methylprednisolone-treated sheep showed normal function ex vivo by all three assays. We conclude that high doses of methylprednisolone unfavorably affect the rate and progression of lung injury in sheep breathing 100% O2.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Artificial induction of lactation in cattle: initiation of lactation and estrogen and progesterone concentrations in milk.
Thirty heifers were given 11 subcutaneous injections of 5 mg estradiol benzoate and 200 mg progesterone every 3 d to develop their mammary glands. Three days later groups of animals were treated with 1) 20 mg dexamethasone twice, 2) 500 micrograms cloprostenol thrice, 3) dexamethasone and cloprostenol, 4) oxytocin 4 IU six times, or 5) no further injections. Two further groups of six heifers each (6 and 7) were treated in a manner similar to groups 1 and 3 except the dose of estrogen to develop their mammary glands was doubled to 10 mg/3 d. Six lactating first calf heifers were controls (8). The proportion of animals lactating, combined milk yield for each group (kg), and mean days lactated were 1) 5/6, 3831, 142; 2) 1/6, 912, 195; 3) 6/6, 4898, 194; 4) 3/6, 1066, 128; 5) 1/6, 293, 154; 6) 6/6, 6109, 130; 7) 6/6, 6265, 130; and 8) 6/6, 19, 190, 251. The lactogenic response to dexamethasone and oxytocin is similar to that in sheep, but the response to cloprostenol indicates a species difference. Intensive blood sampling before and after injection of hormones, intended to trigger lactogenesis, showed that plasma prolactin rose to peaks above 210 ng/ml in cows of groups 2, 3, and 4 and were unchanged from the base below 40 ng/ml in groups 1 and 5. Monitoring of steroids after induction treatment showed estradiol-17 beta ranged between 35 and 400 pg/ml and 20 to 80 pg/ml in mammary secretion and plasma and progesterone concentrations were less than at diestrus.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Diagnosis of pulmonary embolism.
An accurate diagnosis of pulmonary embolism is essential to prevent excessive morbidity and mortality from lack of therapy or inappropriate anticoagulation. Clinical signs and symptoms are reported to be nonspecific, although published studies do not allow calculation of true specificity. Since certain clinical characteristics or groups of findings may be sensitive enough for pulmonary embolism, the diagnosis is unlikely in their absence. Ventilation-perfusion lung scanning has high sensitivity but variable specificity for pulmonary embolism. Patients with scans showing multiple segmental or lobar perfusion defects with normal ventilation have a high probability of pulmonary embolism. Scans with less extensive perfusion abnormalities or matching ventilation defects do not reliably exclude pulmonary embolism. Pulmonary angiography is the most definitive procedure for diagnosing pulmonary embolism. Digital subtraction pulmonary angiography and radiolabeled platelet scanning are promising but require more extensive validation before routine use.
Angiography↗
Prevention of amphotericin B-induced rigors by dantrolene.
Three patients had severe amphotericin B-induced rigors refractory to conventional prophylactic measures. Rigors improved or disappeared when dantrolene sodium was given prophylactically or during an episode. These observations suggest that dantrolene is useful as an alternative or adjuvant agent for severe rigors associated with amphotericin 3 infusion.
Adult↗
The effect of season on reproduction in dairy cattle.
A survey was carried out in North West Tasmania to compare the breeding performance of 2,068 cows in 27 dairy herds--15 herds calving in spring and 12 in autumn. The percentage of cows submitted to artificial insemination for the first time in the first 24 days of the mating period was 87% for the spring calving group and 75% for the autumn calving group. Figures for non-return-to-service rate over the subsequent 21 days were 72% and 55%, respectively. The difference in breeding performance associated with time of calving was not attributable to age, calving to mating interval or on cow condition or daily milk fat yield at 3 weeks (+/- 1 week) after the start of mating.
Animals↗
Current concepts. Fiberoptic bronchoscopy.
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Biopsy↗
Reexpansion pulmonary edema after pneumothorax.
Spontaneous pneumothorax is a common disorder that is easily recognized and treated. Occasionally reexpansion of the collapsed lung is complicated by unilateral pulmonary edema, heralded by tachypnea, unilateral rales, and profuse expectoration of frothy secretions within several hours of reexpansion. Severe morbidity and death may result. Increased duration of pneumothorax and the use of suction are important factors in the generation of reexpansion pulmonary edema. Increased pulmonary capillary permeability rather than hydrostatic transudation is believed to underlie its development. For patients with pneumothorax of prolonged duration close observation in an intensive care unit for 24 hours after evacuation of air and the routine use of supplemental oxygen during and after lung reexpansion seem indicated.
Capillary Permeability↗
Life threatening hypoventilation in kyphoscoliosis: successful treatment with a molded body brace-ventilator.
We report sustained successful treatment of end-stage hypoventilation in a 37-yr-old patient with kyphoscoliosis caused by childhood poliomyelitis. The patient presented with progressive ventilatory failure, pure restrictive lung function, and no concurrent illness. He first responded to respiratory stimulation with medroxyprogesterone acetate and aminophylline. Because of skeletal deformity and the need for a chronic brace he was then fitted with a customized polyethylene foam body brace with an anterior free space and connecting hole for a Monaghan ventilator. No longer taking any medication, and with only nocturnal assisted ventilation, he now has normal daytime arterial blood gas values 20 months later. This approach may be useful in other patients with severe kyphoscoliosis.
Adult↗
Endogenous Cushing's syndrome complicated by Pneumocystis carinii pneumonia.
We report a case of Pneumocystis carinii pneumonia in a patient with ectopic production of adrenocorticotropic hormone (ACTH). The patient presented with Cushing's syndrome caused by a malignant thymic carcinoid. Pneumocystis carinii pneumonia should be considered in the differential diagnosis of pneumonia in patients with endogenous Cushing's syndrome.
Adult↗
Effects of 100% oxygen on lung vascular function in awake sheep.
The purpose of this study was to define the time course of pulmonary toxicity during continuous breathing of 100% oxygen in adult sheep. Sheep were prepared for chronic measurement of vascular pressures, cardiac output, gas exchange, and for collection of lung lymph. Tracheostomies allowed accurate delivery of either 100% oxygen, compressed air, or hypoxic gas. Six sheep breathed 100% oxygen for 72-96 h, and four sheep breathed compressed air for 96 h. In addition to hypoxic challenges [fractional concentration of inspired O2 (FIo2) = 0.12], some sheep received prostaglandin H2 (PGH2)-analogue infusions to further assess pulmonary vascular reactivity. Lung lymph and blood chemotactic activity were measured by granulocyte migration in modified Boyden chambers. Postmortem lung water content and light microscopy were used to measure pulmonary edema. All sheep breathing 100% oxygen died between 72 (n = 2) and 96 h (n = 4). Sheep breathing oxygen demonstrated lung toxicity by measurements of 1) a fourfold increase in flow of protein-rich lung lymph, 2) increased alveolar-arterial difference in Po2 (greater than 20 Torr on FIo2 = 0.21) and hypercapnic acidemia, and 3) a mean extravascular lung water/dry lung weight of 5.7 (controls = 3.3), and histological evidence of interstitial and alveolar edema. Chemotactic activity in lung lymph at base line increased eightfold within 72-96 h of oxygen breathing. In sheep breathing oxygen, the hypoxic pressor response decreased by 50% at 48 h, and by 72-96 h there was a total absence of hypoxic vasoconstriction. There was no increase in lung lymph prostacyclin metabolite, and sodium meclofenamate did not restore the pressor response. In sheep breathing compressed air none of these changes in pulmonary vascular reactivity, lymph flow, or chemotactic activity occurred. We conclude that prolonged breathing of pure oxygen causes pulmonary edema by increasing lung vascular permeability and that respiratory failure results from both edema and loss of pulmonary vascular reactivity.
Animals↗