摘要:

The clinical value of diagnostic testing in community-acquired pneumonia is still controversial, mainly because of the lack of prospective, controlled studies that specifically address this issue. This article reviews the utility of sputum Gram stain and culture in the management of these patients. Although with limited sensitivity, Gram stain is the most cost-effective diagnostic test available before initiation of antibiotic therapy in pneumonia. When the test is interpreted by skilled personnel, it provides reliable information on the etiology of bacterial pneumonia. It is highly specific for the diagnosis of pneumococcal andHaemophilus influenzaepneumonia and permits initial pathogen-oriented therapy. The sputum culture should be interpreted in the light of Gram stain results, except for specific pathogens such asLegionella. It provides etiologic diagnosis and allows susceptibility testing for resistant bacteria.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

This is the first published case of synchronous bilateral upper lobe lung cancers occurring in a patient with silicosis. Silicosis developed in this 41-year-old man constructing underground tunnels from 1978 to 1983. He had a cigarette smoking history of 26 pack-years. His silicosis included the presence of biapical conglomerate masses, and the synchronous biapical squamous-cell cancers occurred in bronchi leading to the upper lobes in which the biapical conglomerate masses were located. He died at age 43 years of respiratory failure/arrest attributable to non—small-cell lung cancer and to terminal pneumonia. This case is unique because of the association between the unusual entity of synchronous bilateral upper lobe primary lung cancers and the presence of silicosis, a recognized risk factor for the development of lung cancer independent of cigarette smoking exposure. This case is more noteworthy because the synchronous biapical lung cancers were associated with coexistent biapical conglomerate masses in the same lobes of the lungs.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Recurrent respiratory papillomatosis (RRP) is a viral-induced disease that most commonly affects the upper aerodigestive tract of adults and children. The manifestations and clinical course of RRP differ based on the age of onset. Childhood-onset RRP is more aggressive and more common than its adult counterpart. In children, the disease is usually acquired at birth from a mother infected with human papillomavirus in the urogenital tract. Adults typically acquire RRP through sexual contact. The course of the disease is variable, but many patients, usually children, require multiple surgical procedures to maintain a patent airway. Several adjuvant therapies have been studied, including the use of interferon, photodynamic therapy, indole-3-carbinol, and cidofovir, although none has been shown to eliminate the disease. In this review, we discuss what is presently known regarding the etiology, transmission, clinical course, and treatment options of RRP.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Necrotizing pneumonia is a rare but highly lethal process that is characterized by patchy areas of necrosis. Surgery is indicated primarily for complications, specifically hemoptysis, empyema, lung abscess, or lung gangrene. This latter condition can be detected by chest computed tomography, which demonstrates progressive loss of perfusion or obstruction of the bronchus. These findings also predict failure of medical management. Surgical intervention can be difficult, however, because patients often require high degrees of ventilatory and circulatory support. We reviewed our experience with 15 patients who underwent surgical resection for lung gangrene.Streptococcus pneumoniaewas the responsible organism in nine cases. Twelve patients presented with rapidly progressive respiratory failure or radiographic evidence of gangrene over a 3 to 5 day course. Of the four patients with diffuse bilateral disease at the time of surgery, one died and one remains ventilator dependent. Resections included cavitary debridement (three), large wedge resection (one), bisegementectomy (one), lobectomy (six), bilobectomy (one), and pneumonectomy (three). There were three deaths (20%). Postoperative empyema occurred in three of seven patients who did not have an irrigation system placed intraoperatively. Two patients remain chronically ventilator dependent. These results demonstrate that lung resection is feasable. Attempts must be made to deal with the risk of postoperative empyema and residual space, including the use of irrigation systems. In patients who cannot tolerate resection, lung debridement is an option. Ultimately, outcome is affected by the extent of underlying disease.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Nutritional support in severe sepsis remains a controversial issue. Although it has not been proven yet that nutritional support improves clinical outcome, it is considered a necessary strategy in the global treatment of sepsis. Recent developments in the knowledge of new substrates, such as olive oil–based emulsions or gamma-linolenic acid, open new perspectives as substrates that may modulate the inflammatory response in severe sepsis when adult respiratory syndrome or gastrointestinal failure may develop. However, the different effects that lipids have in immunomodulation, such as actions on cellular membranes, receptors, and intracellular signaling, make it difficult to point to fats as merely energy substrates. Regarding protein support, branched-chain amino acids, arginine, and glutamine seem to offer the most convenient alternative to standard formulations. Micronutrients play an important role, especially vitamins and some trace elements that perform an important function as antioxidant scavengers. Although vitamin needs have not been established for septic patients, the varied published recommendations seem to be far below the needs of these critically ill patients. Enteral nutrition remains to be preferable to intravenous, but the changes found in intestinal absorption and transport in severe sepsis may limit the use of enteral feeding. In some cases, it may not be possible or wise to provide adequate nutritional requirements via this route.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Solitary pulmonary nodules (SPNs) are commonly encountered in clinical practice, and their diagnostic evaluation can be challenging. SPNs that cannot be easily classified as benign or malignant based on radiologic criteria and patient history must be evaluated by diagnostic testing to determine the likelihood that the lesion is malignant and thus requires additional specific treatment. Many of these nodules can be efficiently evaluated by bronchoscopy, particularly nodules that are larger than 2 cm in diameter, are located in the inner or middle lung zones, and are associated with a bronchus sign in a proximal bronchus. New imaging techniques, such as CT fluoroscopy, need to be studied additionally but show promise in improving yield. Bronchoscopy is safe, with little morbidity and mortality, making it an appealing alternative to more invasive procedures.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

When a patient is evaluated with a difficult to diagnose pleural effusion, the first question to answer is whether the effusion is transudative or exudative. This is best done by measuring the serum and pleural fluid lactate dehydrogenase and protein levels and then using Light’s criteria. The most common causes of an undiagnosed transudative effusion are congestive heart failure or occult cirrhosis. Uncommon causes of undiagnosed transudative effusions are the nephrotic syndrome, urinothorax, and a cerebrospinal fluid leak into the pleural space. The most common causes of undiagnosed exudative effusions are malignancy, pneumonia, pulmonary embolism, and tuberculosis. Less common causes are pancreatic pseudocyst, uremia, intraabdominal abscess, pericardial disease, drug-induced pleural disease, yellow nail syndrome, and trapped lung. A directed history and physical examination should be performed in all patients with an undiagnosed pleural effusion. Most patients should have a spiral CT scan of the thorax, because this will demonstrate pulmonary emboli as well as other intrathoracic pathology that may be related to the effusion. Pleural fluid test results highly suggestive of tuberculosis (elevated adenosine deaminase or interferon gamma), where available, will likely replace needle biopsy of the pleura in the diagnosis of tuberculous pleuritis. Thoracoscopy has largely replaced needle biopsy of the pleura in diagnosing malignant pleural disease.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Electrical lighting and increasing capital intensiveness have helped undermine the importance that society previously placed on obtaining adequate sleep. Even modest amounts of daily sleep loss accumulate as “sleep debt.” Sleep debt manifests in a myriad of ways, the most common being an increasing tendency to fall asleep, increased risk of accidental injury, impaired mood, and reduced psychomotor performance. Sleep debt can have far reaching consequences, both to an individual in terms of increased cardiovascular risk and to society at large, because of sleepiness-related fatigue and errors. Sleep specialists need to further their understanding of the physiologic and behavioral consequences of total, partial, and selective sleep stage deprivation, because they affect many organ systems. Studies of selective sleep stage deprivation also provide insights into the function of sleep. Evaluating the effects of sleep deprivation must take into account the following factors: (1) the duration of prior sleep, (2) circadian time frame, (3) arousal influences, and (4) subject and test characteristics. Sleep deprivation has been extensively studied in the acute experimental setting. Under extreme conditions, sleep deprivation is associated with mortality in laboratory animals. In the natural human environment, the behavioral consequence of chronic sleep debt in shift work intolerance is well described. The link between electrophysiological sleep disturbance and pathogenesis of disease is less well understood in both acute and chronic states. Additional investigation into the relationship between sleep deprivation and disease mechanisms, such as impaired glucose tolerance, hormonal dysregulation, and cytokine imbalance, will enhance our comprehension of this link.

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:1068-0640    

出版商:OVID    

年代:2003

数据来源: OVID