Cardiac amyloidosis produces a restrictive cardiomyopathy with impaired diastolic function. We report a case in which low-dose verapamil resulted in marked worsening of congestive heart failure, as a result of a profound negative inotropic effect. Withdrawal of verapamil therapy demonstrated a return of systolic function to normal with improvement in heart failure. We postulate that patients with cardiac amyloidosis may be exceptionally sensitive to the negative inotropic effects of calcium-channel blockers either because of abnormal binding to amyloid fibrils or because their usual vasodilator effects are blunted.

Greenfield filter inferior vena caval interruption is an effective approach for pulmonary embolism prophylaxis. Serious complications, however, have been documented following migration of these filters. We report a case of Greenfield filter migration to the right side of the heart. Evaluation of these filters, as well as indications for retrieval, are discussed.

Protected specimen brush (PSB) is considered to be one of the standard methods for the diagnosis of ventilator-associated pneumonia, but to our knowledge, intraindividual variability in results has not been reported previously.

Acute rupture of the interventricular septum is a relatively unusual complication following acute myocardial infarction. The echocardiographic features depicted by transthoracic echocardiography are well described. However, transesophageal echocardiographic description of a ruptured septum has not been previously reported. This brief report illustrates the transesophageal features of such a defect.

Wegener's granulomatosis may present with a variety of findings and be difficult to diagnose. We report a case of a 55-year-old woman presenting with right middle lobe obstruction who was found to have limited Wegener's granulomatosis. Extensive medical evaluation was nondiagnostic and open lung biopsy specimens were required to establish the diagnosis.

The diagnostic yield of bronchoalveolar lavage (BAL) for Pneumocystis carinii pneumonia (PCP) in patients infected with human immunodeficiency virus has been reported to be 95 percent, but falls to 62 percent in patients receiving aerosolized pentamidine. Because aerosolized pentamidine appears to be preferentially deposited in the middle and lower lobes, we postulated that an upper lobe lavage would have a higher diagnostic yield than the standard middle/lower lobe lavage in patients receiving aerosolized pentamidine. Twenty-five patients receiving aerosolized pentamidine suspected of having acute PCP underwent separate BAL of an upper lobe and lower lobe as well as transbronchial biopsy. Fifteen of the 25 (60 percent) were diagnosed as having PCP. Of the 15, one had the samples inadvertently combined. In the remaining 14, BAL was positive for P carinii organisms in 12 lavages of the lower lobe and 14 of the upper lobe. Upper lobe lavage had statistically significantly more P carinii organisms by semiquantitative technique than the lower lobe. In patients receiving aerosolized pentamidine, who develop acute PCP, an upper lobe lavage may have a higher diagnostic yield than the standard middle/lower lobe lavage. In addition, the transbronchial biopsy specimen offered no treatable diagnosis that was not made by lavage alone in the 25 patients. This raises the question of the utility of transbronchial biopsies in these patients.

Continuous irrigation-suction catheter (Irri-cath) is a double-lumen device that allows for simultaneous saline solution infusion and aspiration. This system may theoretically be more effective than conventional dry intermittent suction due to its vortex principle. To test this hypothesis, we performed 200 suction maneuvers in 20 ventilated patients. Identically shaped catheters were used in a randomized sequence. For the same individual, we used equal instilled saline solution volume (40 ml), vacuum pressure (-180 cm H2O), and ventilatory parameters. Effectiveness of suction was determined by measuring the total aspirated volume, the dry lyophilized weight of secretion, the corrected dry weight (dry weight-weight of instilled salt), and protein concentration. No difference in heart rate, respiratory frequency, O2 saturation, systemic blood pressure, peak inspiratory pressure, or patient discomfort was found when the two modalities were compared; however, the total volume of secretions collected, the dry weight, the corrected dry weight, and the protein concentration were significantly higher with continuous irrigation suction catheter when compared with the conventional method (p < 0.05). The suction time was shorter with the Irri-cath (p < 0.05). We conclude that the Irri-Cath is more effective than conventional intermittent suction catheter in clearing bronchial secretions in patients on mechanical ventilation.

A 68-year-old woman was found to have synchronous soft-tissue sarcoma of the anterior chest wall and adenocarcinoma of the breast. During her initial interview, she denied prior radiation therapy. On further questioning, it was learned that the patient had been treated for tuberculosis, as a young woman, by the induction of a pneumothorax that was monitored by repeated chest fluoroscopies. Biologically important doses of ionizing radiation can be given as an incidental part of a variety of medical treatments. The importance of searching for atypical radiation exposures, particularly in patients with unusual tumor presentations, is stressed.

High-resolution computed tomography was used to directly determine the short-term effects of intravascular volume expansion on airway caliber. The change in airway cross-sectional area caused by intravascular volume expansion (30 ml/kg, Ringer's lactate) was studied in six anesthetized mini-pigs within 5 min. Twenty-five of 27 large airways (diameter, 2.01 to 5.0 mm) demonstrated decreased internal cross-sectional area (10.56 +/- 1.26 vs 8.66 +/- 1.03 mm2, p < 0.001). Twenty of 24 small airways (diameter, 0.75 to 2.0 mm) showed decreased internal cross-sectional area (1.82 +/- 0.16 vs 1.44 +/- 0.16 mm2, p < 0.001). These changes were rapidly (< 6 min) reversed by intravascular volume reduction. The external airway cross-sectional area did not change. These data suggest rapid, reversible bronchial mucosal vascular engorgement as a cause of increased airway resistance in heart failure.

Several case reports have suggested that bronchogenic carcinoma occurs more frequently in young patients who are human immunodeficiency virus (HIV) seropositive. We investigated the incidence of bronchogenic carcinoma and its clinical presentations in young patients at risk for HIV infection. The tumor registry of Bellevue Hospital was reviewed, and 261 cases of bronchogenic carcinoma during the period from 1976 to 1979 (pre-AIDS period) and 232 during the period from 1987 to 1990 (AIDS period) were identified. These cases were stratified into age groups: 45 or younger, 46 to 55, 56 to 65, and 66 years or older. All patients aged 45 years or younger in the AIDS period were subdivided by HIV risk, and clinical characteristics were compared among the subgroups. Results revealed no increased incidence of bronchogenic carcinoma from the pre-AIDS period compared with the AIDS period. These results suggest that HIV seropositivity is not a risk factor for bronchogenic carcinoma.

Exercise-induced bronchospasm (EIB) is often inferred from the reduction after exercise in one arbitrarily selected value derived from the maximum expiratory flow-volume (MEFV) curve (eg, FEV1) on a single test; however, patients with symptoms of EIB not meeting these criteria may risk being undiagnosed. To assess the ability of repeated tests using additional MEFV parameters in identifying EIB-prone patients, we investigated the effects of exercise provocation on the MEFV curve on two separate occasions. Of 95 patients with symptoms of EIB, 61 had reproducible exercise-induced changes (< 10 percent intraresponse variation), falling into four patterns: 27 (44 percent) had significantly reduced VC and airflow throughout the MEFV curve; 18 (30 percent) had unchanged VC but decreased airflow throughout the curve; 11 (18 percent) had reduced airflow above 50 percent VC but not below 50 percent VC; and 5 (8 percent) had significant reductions in airflow only at 50 percent VC or below. Of the other 34 subjects, 18 had no apparent response, and 16 responded on only one occasion, making objective assessment of these patients' EIB equivocal. We conclude that for a given individual, failure to meet arbitrary criteria does not rule out EIB. Additionally, a more subjective approach that integrates, among other factors, all routine MEFV curve parameters taken from multiple tests with clinical symptoms and history provide a more accurate assessment of EIB.

Simple arm elevation results in increased metabolic and ventilatory requirements in patients with chronic airflow obstruction (CAO). These demands contribute to the dyspnea that is frequently reported when these patients perform activities of daily living involving the arms. We hypothesized that a comprehensive pulmonary rehabilitation (PR) program that includes upper extremity training would lower the ventilatory requirement for arm elevation. Metabolic and ventilatory responses to 2 min of simple arm elevation were studied in 14 patients with CAO before and after PR. Respiratory muscle strength was determined in 11 patients by measurement of maximal transdiaphragmatic pressure (Pdimax). Oxygen uptake (VO2), carbon dioxide production (VCO2), heart rate (HR), minute ventilation (VE), tidal volume (VT), and respiratory rate were measured at rest with the arms down and during 2 min of arm elevation. Before PR, arm elevation led to significant increases in VO2, VCO2, HR, and VE. After PR, pulmonary function, Pdimax, and resting metabolic and ventilatory parameters with the arms down were unchanged; however, during arm elevation, VO2, VCO2, and VE were significantly less than they were before PR. We conclude that a comprehensive PR program that includes upper extremity exercises leads to a reduction in the ventilatory requirement for simple arm elevation. This type of program may allow patients with CAO to perform sustained upper extremity activities with less dyspnea.

Tube thoracostomy is a standard therapy for a number of pulmonary disorders. The procedure is associated with a certain incidence of morbidity related to the technique of insertion, the patient population selected, and the length of time the tube remains in place. Complications of tube placement previously described include empyema, residual pneumothorax, lung perforation, placement of the tube in the chest wall, diaphragmatic perforation, perforation of intraabdominal organs (such as spleen, liver and stomach), unilateral pulmonary edema, bronchopleural fistula, hemothorax, cardiogenic shock and Horner syndrome. A case of a delayed pulmonary perforation developing several days after placement of a chest tube is described with a discussion of the clinical and radiographic findings associated with this complication. A possible pathophysiologic mechanism by which this complication may have occurred is proposed.

The frequency of adult surgical and medical intensive care unit (ICU) admissions related to substance abuse was determined at a large community, trauma, and tertiary referral hospital. Of 435 ICU admissions, 14 percent (95 percent confidence interval [CI], 5 to 23 percent) were tobacco related generating 16 percent of costs, 9 percent (95 percent CI, 0 to 18 percent) were alcohol related generating 13 percent of costs, and 5 percent (95 percent CI, 0 to 14 percent) were illicit drug related generating 10 percent of costs. In all, 28 percent (95 percent CI, 20 to 36 percent) of ICU admissions generating 39 percent of costs were substance abuse related. Substance abuse-related admissions were significantly longer and more costly than admissions not related to substance abuse (4.2 days vs 2.8 days, p = 0.004; $9,610 vs $5,890, p = 0.001). Frequency of substance abuse-related admission was linked with the patient's insurance status (Medicare, private insurance, uninsured). In the uninsured group, 44 percent of admissions were substance abuse related (95 percent CI, 35 to 52 percent), significantly higher than in the private insurance and Medicare groups, and generating 61 percent of all ICU costs in the uninsured group. Large fractions of adult ICU admissions and costs are substance abuse related, particularly in uninsured patients.

Lung cancer infrequently may be associated with human immunodeficiency virus (HIV) infection. This retrospective case-control study was undertaken to determine if there were differences in age, sex, and stage distribution and in survival between HIV-positive and HIV-indeterminate lung cancer patients. We compared 19 patients with both pathologically verified lung cancer and HIV infection proved by serologic study with lung cancer patients with an indeterminate HIV status. All 19 HIV-positive lung cancer patients were men. This was significantly (p = 0.004) different from the 69 percent male preponderance in 1,335 HIV-indeterminate lung cancer patients. Median ages of HIV-positive and HIV-indeterminate patients were 48 and 61 years, respectively. HIV-positive patients were significantly (p = 0.0139) younger. Stage distribution was similar in both groups. Histologic features and smoking were not significantly different between the two groups. Survival data that were available in 16 HIV-positive patients were compared with 32 HIV-indeterminate control subjects matched for stage, age, sex, and race. The median survival was three months in the HIV-positive group and ten months in the HIV-indeterminate cohort. The survival was significantly different (p = 0.002). There were no one-year survivors in HIV-positive lung cancer patients.

In this study, independent contribution of age, HR, BMI, casual and ambulatory blood pressure, LVM and LVEF in evaluating diastolic filling have been investigated in 34 never-treated hypertensive patients and in 15 healthy normotensive subjects. All the subjects were free from coronary artery disease, valvular disease, heart failure, renal disease and psychiatric problems. All the hypertensive subjects (never treated) were subgrouped according to presence or absence of LVH. The PFR decreased significantly and tPFR increased significantly in hypertensive patients in comparison with normotensive subjects and they did not change in the presence vs absence of LVH. The PFR was inversely correlated with BMI, age, 24-h mean SBP and with 24-h DBP. In multiple regression analysis, PFR decreased with BMI, age, 24-h mean SBP and DBP but not with LVMI. These results suggest that BMI, age and 24-h mean blood pressure were the major determinants of PFR abnormalities in hypertensive patients.