Obstructive sleep apnea syndrome (OSAS) and heavy snoring during sleep, without sleep apnea, has been well described in children and adults. We report a case series of 25 full-term infants, prospectively obtained from a database of nearly 700 "apparent life-threatening event" (ALTE) cases, who presented between 3 weeks and 4 1/2 months of age an ALTE and who progressively developed more florid symptomatology and polygraphic findings. All of them were classified as OSAS patients by five years of age. These index cases are compared with two other ALTE infant groups followed in parallel during the first year of life but whose symptoms were short-lived. The index cases presented more frequently a positive family history of OSAS and an early report of snoring or noisy breathing during sleep. Usage of an esophageal balloon to monitor esophageal pressure (Pes) and usage of nasal continuous positive airway pressure (CPAP) as a test may help in the early recognition of these infants, who appear to make more effort to breathe during sleep, based on the indirect evidence of Pes measurements. It is suggested that anatomic features, including a small posterior airway space leading to an abnormal degree of upper airway resistance, may be the cause of the symptoms presented by these infants. Considering the parental anxiety generated by persistence of symptoms after the first year of life in ALTE infants, recognition of this subgroup is important.

Repeated methacholine challenge in normal nonasthmatic subjects (who require higher doses of methacholine than do asthmatic subjects to produce a 20 percent decrease in FEV1) can produce progressively diminishing methacholine responsiveness (or tolerance) with serial challenges. To determine whether tolerance to methacholine occurs in asthmatic subjects as it does in nonasthmatic subjects, we studied eight young (mean age, 24 years) mild asthmatic patients (occasional but not regular use of bronchodilator medications, PC20 methacholine range 0.1 to 7.0 mg/ml) who underwent five sequential methacholine challenges at 1.5-h intervals. Serially increasing concentrations of methacholine were given until FEV1 fell by 20 percent. Results were compared with those in seven nonasthmatic control subjects who underwent an identical protocol. As seen in previous studies, the normal subjects demonstrated significant tolerance to methacholine when each of five challenges was compared to the first. By contrast, in the asthmatic group, the mean cumulative dose of methacholine producing a 20 percent fall in FEV1 in the fifth challenge was not significantly different from the dose required in the first challenge. These results indicate that marked tolerance to methacholine does not occur in mild asthmatic patients with multiple repeated challenges over 6 h. The lower cumulative dose of methacholine required by asthmatic patients may be insufficient to produce tolerance.

Angiography in a 30-year-old man revealed the unique combination of aortic coarctation and an unusual arch anomaly. Proximal to the coarctation, a single arch vessel trifurcated into the brachiocephalic, left common carotid and left subclavian arteries. This anomalous arch vessel is a normal equine variant.

Laryngeal involvement by RA is a common finding, but there have been no studies of laryngeal function in RA patients. This study was undertaken to determine if patients with rheumatoid arthritis have functional abnormalities of the upper airway during phonation which may be the result of synovitis of the laryngeal joints caused by RA. Translaryngeal resistance was measured in six patients with RA and six matched control subjects using an interrupter method to measure PSG and V during vocalization. Patients with RA had a higher R (65.0 +/- 8.15 cm H2O/L/s) than control subjects (38.4 +/- 7.43 cm H2O/L/s [p less than 0.05]). This was the consequence of lower V rates during phonation at similar PSG. We conclude that abnormalities of the larynx in RA patients are common and cause measurable physiologic abnormalities.

Two patients eventually shown to have empyema were encountered in which the initial thoracentesis revealed fluid compatible with either a simple or a complicated parapneumonic effusion. In both cases, the diagnosis of empyema was made by a second thoracentesis done at a close interval of time from a different site. Therefore, the physician should approach parapneumonic effusions systematically, and remember that in some cases, multiple thoracenteses may be required to make the correct diagnosis of an empyema.

We compared bronchopulmonary distribution homogeneity of a radioaerosol before and after hospitalization in 20 patients with cystic fibrosis (CF) with pulmonary exacerbations in order to assess lung improvement. Deposition homogeneity was quantified in terms of skew (an index of distribution symmetry), derived from frequency distribution histograms generated from gamma camera images of the lungs following radioaerosol inhalation. Lower skew values indicate enhanced distribution homogeneity. Right lung skew (RLS) was significantly reduced following therapy (1.00 +/- 0.49 to 0.84 +/- 0.47), whereas skew in the left lung was unchanged (0.95 +/- 0.38 to 0.87 +/- 0.40). The reduction in RLS was significant in patients with Shwachman-Kulczycki (SK) clinical scores less than 50 (1.27 +/- 0.53 to 0.90 +/- 0.42), but not in patients with scores greater than 50 (0.81 +/- 0.38 to 0.80 +/- 0.52). These results indicate that treatment affected the right lung more than the left lung, particularly in patients with SK scores less than 50, and suggests that radioaerosol lung imaging may be valuable in identifying sites of impairment to be targeted during treatment. Statistically, skew was less sensitive an indicator of acute change than several other clinical indices that improved following hospital treatment.

We reviewed the pulmonary history, dyspnea ratings, and pulmonary function test results in 16 patients with L-tryptophan-induced eosinophilia myalgia syndrome to determine the correlation between reported pulmonary complaints and pulmonary function abnormalities. All patients reported pulmonary symptoms. Dyspnea, seen in 14 of 16 (87 percent) patients, was the most common symptom. The severity of dyspnea was graded by the baseline dyspnea index and the oxygen cost diagram. Pulmonary function testing including maximal static inspiratory and expiratory pressures were measured. The DCO was diminished in 12 of 16 (75 percent) patients. The MSIP was decreased in seven out of ten (70 percent) and the MSEP was decreased in nine out of ten (90 percent) of those patients tested. There was a statistically significant correlation between the severity of dyspnea as graded by the BDI and OCD, and the decrease in DCO. These results and a review of the literature of the pulmonary manifestations of EMS lead us to conclude that patients with EMS have a high prevalence of dyspnea, and it appears to be caused by both lung parenchymal involvement, as well as respiratory muscle weakness.

A validation study was performed on the MESAM 4, a digital recording device developed to monitor oxygen saturation, heart rate (HR), snoring, and body position in order to screen subjects for obstructive sleep apnea syndrome (OSAS). MESAM 4 recordings were scored with the computer-based automatic scoring system provided with the equipment. Nocturnal polysomnography (PSG) and MESAM 4 recordings were run simultaneously on 56 subjects presenting with any type of sleep complaint, including those secondary to OSAS. Patients were assigned to one room by hospital administration and were monitored consecutively. The polygraphic equipment and MESAM 4 equipment were placed on the subjects by separate teams. Records of PSG and MESAM 4 were analyzed in double-blind fashion. With the MESAM 4 computerized analysis, three indices based on SaO2 (ODI), on heart rate (HVI), and on snoring (ISI) were obtained, and the number of abnormal respiratory events occurring during the time selected for analysis (TAT) were determined. Polysomnographic records were scored by 30-s epochs following the American Sleep Disorders Association standards for sleep states and stages and for sleep-related events, including sleep apneas, hypopneas, and periodic leg movements. Following independent scoring, 26 subjects were identified with OSAS by PSG, while MESAM 4 identified 25 subjects with OSAS using oxygen algorithm; all had a respiratory disturbance index greater than or equal to 10 with PSG. Results of each polysomnogram and each MESAM 4 analysis were compared. With the polysomnogram used as a standard, the degree of error for each variable with the MESAM 4 was calculated. Specificity and sensitivity of the most accurate index of the MESAM 4, the ODI, were 97 percent and 92 percent, respectively. The other two indices, HVI and ISI, were less accurate: specificity and sensitivity were 32 percent and 58 percent for HVI and 27 percent and 96 percent for ISI. Nevertheless, a combination of all three indices (ODI, HVI, ISI) would have prevented the two false-positive cases we observed. The results of this validation study show that MESAM 4 can be helpful to general practitioners, clinicians, and epidemiologists as a low-cost screening device for subjects with OSAS and habitual snoring.

Despite the fact that the arms are used extensively in daily life and that some of the muscles of the shoulder girdle share both a respiratory and a positional function for the arms, surprisingly little is known about the respiratory response to unsupported upper extremity activity. To determine the respiratory consequences of simple arm elevation during tidal breathing, we measured minute ventilation (VE), tidal volume (VT), respiratory rate (f), heart rate (HR), oxygen uptake (VO2), and carbon dioxide production (VCO2) in 22 normal subjects seated with arms elevated in front of them to shoulder level (AE) for 2 min and down at the sides (AD) for the same time period. The sequence was randomized. Compared with AD, during AE there were significant increases in VO2 (336 +/- 18 vs 289 +/- 14 ml/min, p less than 0.001), VCO2 (315 +/- 23 vs 245 +/- 16 ml/min, p less than 0.001), HR (84 +/- 6 vs 73 +/- 4 beats/min, p less than 0.05), VE (11.5 +/- 0.9 vs 9.3 +/- 0.6 L/min, p less than 0.001), and VT (868 +/- 66 vs 721 +/- 48 ml, p less than 0.001). In 11 subjects, breath-by-breath metabolic and ventilatory parameters were studied with AD for 2 min, AE for 2 min, and with AD for 3 min while also recording gastric (Pg), pleural (Ppl), and transdiaphragmatic pressures (Pdi). With AE, there was a significant increase in Pg at end inspiration (PgI, 15.4 +/- 3.2 vs 11.9 +/- 2.7 cm H2O, p less than 0.01) and in Pdi (26.5 +/- 3.4 vs 21.4 +/- 2.4 cm H2O, p less than 0.01) with no change in Pg at end expiration (PgE) or in Ppl. The increases in VO2, VCO2, VE, and VT during arm elevation persisted for 2 min after arm lowering, whereas Pgi and Pdi abruptly dropped as the arms were lowered. We conclude that simple arm elevation during tidal breathing results in significant increases in metabolic and ventilatory requirements. These increased demands are associated with higher PgI and Pdi suggesting an increased diaphragmatic contribution to the generation of ventilatory pressures. The sudden drop in Pg with arm lowering indicate a change in ventilatory muscle and or torso recruitment independent of the metabolic drive and ventilatory needs. These findings may help explain the limitation that has been reported in some normal subjects and in many patients with lung disease during unsupported upper extremity activity.

This study assessed the accuracy of obtaining smoking history, relationships between smoking and the histologic subtypes of lung cancer, past and present smoking history, and co-carcinogen history in 100 patients seen between 1982 and 1989. A standard questionnaire filled out by the patients, a data base filled out by the physician, and medical records were abstracted, and detailed information on smoking and co-carcinogen history was obtained. Eleven percent of the patients were nonsmokers and another 41 percent were former smokers who had quit smoking more than one year prior to the diagnosis of lung cancer. Mean ages at onset and cessation of smoking and diagnosis were 17, 59, and 62 years, respectively. The histologic subtypes were as follows: adenocarcinoma, 34; squamous, 18; small cell, 24; adenosquamous, nine; large cell, nine; and bronchioloalveolar carcinoma, six. Mean pack-years of cigarette smoking for the subtypes were as follows: squamous, 82; small cell, 78; large cell, 72; adenocarcinoma, 65; adenosquamous, 48; and bronchioloalveolar carcinoma, 41. The patient and physician questionnaires had comparable data on smoking status in continued smokers and never smokers. Many former smokers filled out the patient questionnaire as a nonsmoker, but on query by the physician admitted to smoking in the past. The physician data set was more accurate in former smokers than questionnaires completed by the patients. Patients with squamous and small cell carcinomas were heavier smokers than patients with adenosquamous and bronchioloalveolar carcinomas. About 50 percent were active smokers until the diagnosis of lung cancer, but only 18 percent of patients continued to smoke after the diagnosis. About 10 percent were never smokers and about 40 percent were former smokers. Most former smokers quit smoking less than five years antecedent to the diagnosis of lung cancer.

Atrial fibrillation and atrial flutter share a common reentrant mechanism. However, the relationship between these arrhythmias has not been systemically studied to date. To evaluate the degree to which these arrhythmias may alternate, consecutive Holter monitor recordings which showed fibrillation or flutter in 96 patients were reviewed. One half of the patients were studied after open-heart surgery and the other half for varying indications. One quarter of the patients had atrial flutter in addition to fibrillation, and this alternation with flutter was significantly associated with the use of a type 1A antiarrhythmic drug (p = 0.007), but not with the use of digoxin or beta blockers (p = NS for both). Furthermore, this alternation with flutter was more common in the postoperative group (p = 0.01). A history of embolization was less common in patients who were in the postoperative group (p = 0.003) and patients who had flutter in addition to fibrillation (p = 0.05).

Three schizophrenic adults with previous histories of using phenothiazine derivatives developed acute pulmonary edema after taking large amounts of these drugs. The clinical manifestations included coma (three), hypothermia (two), tachycardia (two), miosis (two) and hypotension (one). All three patients underwent gastric lavage and were treated supportively. The fulminant pulmonary edema in the three cases resolved within 18 to 40 h. The etiology of pulmonary edema following overdosage of phenothiazines remains unknown. The authors hypothesize that the most likely pathogenesis is a drug-induced neurogenic pulmonary edema resulting from a disturbance of hypothalamic function.

This report describes the advantages of recording cardiac potentials in digital rather than in analog form and of using statistical methods that compare a patient's measurements with values measured in a normal population. In this study, expansion of the time axis in digitized electrocardiograms was used to accurately determine the moments when the Q, R, and S waves began and ended. This work is part of a plan to develop a portable electrocardiograph that could be available to physicians at all times. The immediate availability of such an instrument could shorten the time required to reach a diagnosis and institute treatment in cardiac emergencies occurring where diagnostic facilities are unavailable.

The purpose of this study was to evaluate factors associated with nightly variability in sleep-disordered breathing. In this study, variability in sleep-disordered breathing over two consecutive laboratory nights was evaluated in 71 aged volunteers with varying levels of sleep apnea. High variability (n = 13) and low variability (n = 58) groups were formed on the basis of an absolute two-night apnea/hypopnea index difference of a minimum ten events per hour. Results indicate high variability was related to longer soft palate measurements and the presence of nasal obstruction on physical examination. Within the high variability group, variation in sleep-disordered breathing occurred within identical gross body position over the two nights. The results suggest that local, anatomic factors affecting airway patency may not be constant from night to night.

Recommended criteria for surgical drainage of parapneumonic effusions include evidence of frank purulence, a glucose level less than 40 mg/dl, a pH of less than 7.00, or an LDH greater than 1,000 IU/L. To test the utility of these criteria, we reviewed the three-year experience of three Rochester, NY, hospitals. We identified 133 patients undergoing thoracentesis for putative parapneumonic effusions. Of 91 patients with neutrophilic exudates, 43 met one or more criteria for tube thoracostomy: 48 did not. Twenty-one of the 43, including 9 with frank empyema, underwent immediate drainage. Of the 22 who did not, 11 eventually required tube thoracostomy and/or decortication. Of the 48 not meeting any of the criteria, 7 also came to surgery. Using whether the patients eventually underwent surgery as a measure of outcome, we calculated for those patients not undergoing immediate drainage the sensitivity, specificity, positive predictive values, and negative predictive values for each of the criteria. The four criteria have relatively high specificity ranging from 82 to 96 percent, but have low sensitivity varying from only 18 percent for a positive Gram stain to 53 percent for a fluid LDH greater than 1,000 IU/L. We conclude that these criteria have limited usefulness in predicting the need for eventual chest tube drainage/decortication. Patients not meeting the criteria require close follow-up as well.

To determine if Mycobacterium gordonae is an opportunistic respiratory tract pathogen in patients infected with human immunodeficiency virus, type 1 (HIV-1).