Gram-negative sepsis remains an urgent medical problem, with more than 200,000 cases occurring each year in the United States and an associated mortality rate of 20 to 50 percent. Since the onset of shock greatly worsens prognosis and to encourage early intervention, the term sepsis syndrome was developed to describe the features of a preshock septic state. Early clinical and metabolic indicators are discussed, and current therapy is reviewed. Better understanding of the pathophysiology of endotoxin release from Gram-negative bacteria and advances in biotechnology have led to the development of potential new treatments for sepsis. One such development--monoclonal antibodies to endotoxin--has shown great promise in the effort to block the progression to septic shock, reduce mortality, and decrease the overall costs of sepsis to the patient and to the national economy.

We report three cases of group B streptococcal endocarditis of the tricuspid valve. Two patients were intravenous drug abusers. In the literature review, and including our cases, ten patients had group B streptococcal endocarditis of the tricuspid valve. Half of the patients were intravenous drug abusers. Four of the other patients had underlying conditions. All patients were treated with a penicillin with or without an aminoglycoside. Three patients underwent tricuspid valve surgery. The overall mortality was 20 percent. Both patients who died received medical therapy only.

Saprophytic infestation with Aspergillus was observed in pathologic specimens of primary squamous cell lung carcinoma. In one case, the fungus grew in cystic scarred parenchyma and bronchi distal to an obstructing carcinoma of a segment bronchus. In the other, fungi colonized the inner surface of a peripheral cavitary carcinoma. Neither patient had roentgenographic evidence of aspergilloma and neither experienced severe pulmonary hemorrhage or other complications attributable to the presence of fungus. Although both specimens showed colonizing growth within the abnormal air spaces, in neither had the colonies detached to form a separate intracavitary fungus ball. These patients, and eight patients with similar lesions reported in the literature, demonstrate that Aspergillus colonization of a lung neoplasm frequently lacks one or both of the features characteristic of post-inflammatory intracavitary aspergilloma, a loose fungus ball and antifungal serum antibodies. No patient, to date, has developed massive hemorrhage as a complication of this lesion.

Conventional ventilatory support of patients with the adult respiratory distress syndrome (ARDS) consists of volume-cycled ventilation with applied positive end-expiratory pressure (PEEP). Unfortunately, recent evidence suggests that this strategy, as currently implemented, may perpetuate lung damage by overinflating and injuring distensible alveolar tissues. An alternative strategy--termed inverse ratio ventilation (IRV)--extends the inspiratory time, and, in concept, maintains or improves gas exchange at lower levels of PEEP and peak distending pressures. There are two methods to administer IRV: (1) volume-cycled ventilation with an end-inspiratory pause, or with a slow or decelerating inspiratory flow rate; or (2) pressure-controlled ventilation applied with a long inspiratory time. There are several real or theoretical problems common to both forms of IRV: excessive gas-trapping; adverse hemodynamic effects; and the need for sedation in most patients. Although there are many anecdotal reports of IRV, there are no controlled studies that compare outcome in ARDS patients treated with IRV as opposed to conventional ventilation. Nonetheless, clinicians are using IRV with increasing frequency. In the absence of well-designed clinical trials, we present interim guidelines for a ventilatory strategy in patients with ARDS based on the literature and our own clinical experience.