Pneumatosis cystoides intestinalis presenting as pneumoperitoneum in a patient with chronic obstructive pulmonary disease.

Pneumatosis is always an alarming sign that may result from life-threatening bowel ischaemia and infarction; however, benign intramural gas can also result from a variety of secondary conditions including chronic obstructive pulmonary disease (COPD). Pneumoperitoneum and pneumoretroperitoneum can be seen with both entities. Therefore, thorough discussions with the referring clinicians regarding the patient's medical history, clinical examination and laboratory results are mandatory.

Do-not-resuscitate orders and medical futility.

This report addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate (DNR) orders and medical futility, discusses the complex medical, legal, and ethical considerations involved, and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. Conflicts over DNR orders and medical futility should not be resolved through a policy that attempts to define futility in the abstract, but rather through a predefined and fair process that addresses specific cases and includes multiple safeguards.

An acquired factor V inhibitor: clinical and laboratory features.

A sixty-five year old white male presented with an acquired Factor V inhibitor after an episode of cholecystitis and cefotaxime therapy. Plasma Factor V activity was less than 1%. He developed lower gastrointestinal bleeding a week after onset of coagulopathy, and was treated with plasmapheresis, fresh frozen plasma, oral cyclophosphamide, and prednisone.

CD4+ and CD8+ lymphocyte and cortisol response patterns in elderly and young males after methylprednisolone exposure.

The elderly have impaired cellular immunity and are more predisposed to opportunistic infections after long term glucocorticoid treatment. No data, examining the response of lymphocyte subsets (CD4+, CD8+) under baseline conditions and after exposure to methylprednisolone in young and elderly males, are available. This crossover study examined lymphocyte subsets and cortisol response patterns in seven elderly males (66-82 years) and five young males (24-37 years) randomized into Phase I (24 hr baseline) and Phase II (10 mg intravenous dose of methylprednisolone).

An application of Orem's theory to the nursing management of pertussis.

In recent years, there has been a dramatic resurgence of Bordetella pertussis infection in the United States. This infection is affecting all age groups. A case study of one family's experience with pertussis is examined.

Complement activation by heparin-protamine complexes during cardiopulmonary bypass: effect of C4A null allele.

Objectives: The first objective was to determine the effect of inherited differences in the classic pathway complement protein C4 on complement activation by heparin-protamine complexes in cardiac surgery. Specifically, we hypothesized that patients with heterozygous C4A null phenotype (A0BB), who have decreased amounts of C4A, may have increased complement activation because of reduced clearance of heparin-protamine complexes. The second objective was to determine whether heparin-protamine-induced complement activation correlated with postoperative pulmonary shunt fractions.

Diving decompression fails to activate complement.

The present study evaluated complement activation during decompression after air dives in a hyperbaric chamber. Intravascular bubbles were quantified by Doppler ultrasound scoring. Eighteen subjects completed 92 dives, of which 74 produced bubbles.

Cortisol pharmacodynamics after methylprednisolone administration in young and elderly males.

Glucocorticoids are commonly prescribed in the elderly on an empiric basis with little consideration for the age-related alterations in pharmacologic response. The objectives of this study were to compare the effect of methylprednisolone on cortisol patterns in elderly and young healthy men, to define the relationship between pharmacokinetic parameters of methylprednisolone and pharmacodynamics of cortisol in the elderly and young men. Seven healthy, elderly males (69-82 years old) and five healthy, young males (24-37 years old) participated in a 24-hour pharmacodynamic trial with randomized assignment to a control period (Phase 1) and a methylprednisolone period (Phase II).

A desperate solution: individual autonomy and the double-blind controlled experiment.

The randomization ingredient in double-blind controlled experiments may be objectionable to patients who, in their desperation, come to such trials seeking a last chance of cure. Minogue et al., who view such a situation as inherently exploitive and undermining of patient autonomy, propose that such "desperate volunteers" instead be enrolled in the active arm, while other patients, less desperate and more committed to medical progress, continue to be randomized.

Pharmacokinetics of methylprednisolone in elderly and young healthy males.

Objective: To characterize and compare the pharmacokinetics of a single intravenous dose of methylprednisolone in elderly and young healthy males.

Design: A randomized, parallel pharmacokinetic trial.

Setting: A public university-affiliated hospital.

Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment.

The removal of life-sustaining treatment often brings physicians into conflict with patients. Because of their moral beliefs physicians often respond slowly to the request of patients or their families. People in bioethics have been quick to recommend that in cases of conflict the physician should simply sign off the case and "step aside".

Neutrophil lactoferrin release during open heart surgery is unrelated to complement activation.

The relationship between neutrophil activation and complement activation during open heart surgery was evaluated by measuring plasma lactoferrin and C3a des Arg (C3a) in 30 adult patients undergoing coronary artery surgery. Measurements were made before induction of anesthesia, before cardiopulmonary bypass, at the end of bypass, and 10 min after protamine infusion. Changes in the measured parameters thus reflected activation during the three distinct phases of cardiac surgery: pre cardiopulmonary bypass, the bypass phase, and the heparin neutralization phase.

Autoimmune neutropenia.

There have been several new developments in the field of autoimmune neutropenia over the past decade. Neutropenia caused by antibodies directed against granulocyte precursor cells, the oligoclonal nature of antineutrophil antibodies, and the expanding knowledge of neutrophil antigens, particularly in relationship to autoantibodies, are exciting new areas of investigation. Knowledge has also been advanced in the effector mechanisms of neutrophil autoantibodies and the effect of autoantibodies on the neutrophil function.

Functional heredity protein S deficiency with arterial thrombosis.

Protein S is a vitamin K-dependent protein that functions as a regulatory protein to limit clotting. The authors present and discuss the case of a 37-year-old man with a type IIa protein S deficiency. The diagnosis and treatment of a protein S deficiency is also described.

In vitro activation of human complement by polyacrilonitrile dialyzer membrane assayed by complement binding to bystander red cells.

Quantitation of complement activation by polyacrilonitrile (PAN) dialyzer membrane is complicated by the high adsorptive capacity of the membrane for fluid phase anaphylotoxins. Assays for these anaphylotoxins, therefore, underestimate the degree of complement activation produced by this membrane. Alternative methods of measuring in vitro complement activation by the PAN and Cuprophan membranes were explored by incubating normal human erythrocytes with the membranes in the presence of serum.

Complement activation by artificial blood substitute Fluosol: in vitro and in vivo studies.

A perfluorocarbon blood substitute, Fluosol, is undergoing clinical trials as an adjunct to chemotherapy. The adverse effects associated with its administration have been postulated to result from complement activation. When gel electrophoresis and Western blotting of Fluosol are used after its incubation with serum, activated C3 and factors Bb and H are bound to the Fluosol particles in a time-dependent fashion, which suggests that complement activation with Fluosol, as does that with zymosan, occurs on the surface of the particles.

Light chain composition of serum granulocyte binding immunoglobulins.

Serum granulocyte binding IgG, IgM, and the light chain composition of granulocyte binding immunoglobulins were measured in 58 adult subjects, including 8 normal individuals, 6 with Felty syndrome, 6 with chronic idiopathic neutropenia, 32 with B-cell chronic lymphocytic leukemia (CLL), and 6 with multiple myeloma. An abnormal kappa/lambda ratio of granulocyte binding immunoglobulins was detected in 12 of 32 patients with CLL. Neutropenia in patients with CLL did not correlate with an abnormal kappa/lambda ratio or excess granulocyte binding IgG, but did correlate with granulocyte binding IgM (P less than 0.

Evaluation of a toxoid for protection of rabbits against enterotoxaemia experimentally induced by trypsin-activated supernatant of Clostridium spiroforme.

Investigations were conducted into an enterotoxaemia caused by Clostridium spiroforme responsible for significant losses in commercial rabbit farms in Western Australia. Two trials using laboratory and farm bred rabbits were performed to evaluate the protective value of a toxoid prepared from the supernatant of C. spiroforme cultures against intraperitoneal challenge with the trypsin-activated toxin of C.

In vitro activation of human complement by nitrogen bubbles.

Complement activation may be responsible for some of the symptoms of decompression sickness. In the present study, complement activation was studied by exposing human sera with or without red blood cells to nitrogen bubbles. Nitrogen bubbles activated human complement as measured by generation of the fluid-phase, complement-split product C5a des Arg.

Idiopathic neutropenia: antineutrophil antibodies and clinical correlations.

Purpose: The present study was done to evaluate the clinical characteristics of a large series of adult patients with chronic idiopathic neutropenia, and correlate the presence of antineutrophil antibodies, their class (IgG or IgM), and their ability to fix complement with clinical parameters, including other hemocytopenias, splenomegaly, and infections.

Patients And Methods: One hundred twenty-one adult patients with chronic idiopathic neutropenia were studied. Serum neutrophil-binding antibodies were measured using paraformaldehyde-fixed granulocytes (PFGs) from normal volunteers as target cells.

Acquired factor VIII inhibitor with squamous cell cancer of the epiglottis.

A 73-year-old woman developed an acquired factor VIII inhibitor in association with squamous cell carcinoma of the epiglottis. The inhibitor was an IgG antibody that reacted with factor VIII in vitro and in vivo. Intravenous gamma-globulin therapy was successful in reducing the inhibitor so that curative surgery could be undertaken.