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Limited data exist to guide physicians in the cost-effective treatment of acute exacerbation of chronic bronchitis (AECB). Therefore, the main objective of this study was to determine the antimicrobial efficacy and related costs for patients with AECB. A retrospective review of 60 outpatient medical records with a diagnosis of chronic obstructive pulmonary disease (COPD) and chronic bronchitis episodes from a pulmonary clinic of a teaching institution was undertaken. The participating patients had a total of 224 episodes of AECB requiring antibiotic treatment. Before review, empirical antibiotic choices were divided into first-line (amoxycillin, co-trimoxazole, tetracyclines, erythromycin), second-line (cephradine, cefuroxime, cefaclor, cefprozil) and third-line (co-amoxiclav, azithromycin, ciprofloxacin) agents. Patients receiving first-line agents failed significantly more frequently than third-line agents (19% vs 7%, P < 0.05). Additionally, patients prescribed first-line agents were hospitalized significantly more often for AECB within 2 weeks of outpatient treatment as compared with patients prescribed third-line agents (18.0% vs 5.3% third-line agents; P < 0.02). Time between subsequent AECB episodes requiring treatment was significantly longer for patients receiving third-line agents compared with first-line and second-line agents (P < 0.005). Pharmacy costs were lowest with first-line agents (first-line US$10.30 +/- 8.76; second-line US$24.45 +/- 25.65; third-line US$45.40 +/- 11.11; P < 0.0001), but third-line agents showed a trend towards lower mean total costs of AECB treatment (first-line US$942 +/- 2173; second-line, US$563 +/- 2296; third-line, US$542 +/- 1946). The use of third-line antimicrobials, co-amoxiclav, ciprofloxacin or azithromycin, significantly reduced the failure rate and need for hospitalization, prolonged the time between AECB episodes, and showed a lower total cost for the management of AECB. Prospective studies are needed to confirm these findings.

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One of the most difficult problems facing clinicians is the evaluation and management of patients with dyspnea whose chest roentgenogram shows single or multiple large cystic spaces. This is made more difficult when underlying lung disease is present. The dilemma focuses on whether the obliteration or removal of the cystic areas will benefit or cause further deterioration of the patient's condition. The pathophysiology of the problem is not completely understood, but accumulated clinical experience has shown that surgical therapy can be beneficial but requires proper patient selection.

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Resting energy expenditure can be obtained either by indirect calorimetry or from prediction equations. Several prediction equations were compared to the measured value of REE in a group of COPD patients with moderate to severe disease. Then, using the same group of patients, a new equation was derived by regression analysis and was prospectively tested on patients with similar characteristics. Equations derived from normal populations (Harris-Benedict, Wilmore nomogram) were shown to underestimate REE by 300-400 Kcal. Equations that use body weight as the only variable were found to be easier to use and did not appear to sacrifice accuracy. Quebbeman Ausman body weight, Quebbeman Ausman body surface area and a regression equation derived from COPD patients (males, REE = 11.5 x wt [kg] + 952; females, REE = 14.1 x wt [kg] + 515) performed better than other currently used equations. In both stable COPD and COPD with exacerbation, the mean predicted values fell within a standard deviation (+/- 167 Kcal) of measured values.

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A patient with nodular sclerosing Hodgkin's disease had at least three episodes of lung involvement consisting of an infiltrate on one occasion and multiple cavitating nodules on the other two. The cytologic and histologic studies of the lung specimens disclosed the presence of Reed-Sternberg cells on each occasion without any evidence for infection. This represents the first time in which recurrent cavitating nodules have been reported with Hodgkin's disease.

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A patient with known pelvic endometriosis suffered from recurrent episodes of retrosternal pain in the chest at the time of menstruation. Evaluation during an episode revealed subcutaneous emphysema of the neck and a pneumomediastinum without pneumothorax. This is the first report in the English literature of pneumomediastinum due to endometriosis which was probably recurrent.

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This report describes a patient in the recovery phase of the adult respiratory distress syndrome in whom the persistence of severe hypoxemia was not corrected by a high fractional concentration of oxygen in the inspired gas and positive end-expiratory pressure. A right-to-left interatrial shunt was diagnosed by M-mode and cross-sectional echocardiography with saline injection, and the presence of a patent foramen ovale was confirmed at the time of cardiac surgery.

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In a randomized, double-blinded study, patients with chronic obstructive pulmonary disease and hypercapnia were fed low, moderate, and high carbohydrate diets to determine the effect on metabolic and ventilatory values. The low carbohydrate diet consisted of 28% carbohydrate calories and 55% fat calories and resulted in significantly lower production of CO2 (p less than 0.002), respiratory quotient (p less than 0.001), and arterial Pco2 (p less than 0.05). At the end of the 15-day study, both the forced vital capacity (p less than 0.05) and the forced expiratory volume in 1 second (p less than 0.05) had improved by 22% over baseline values. Total calories given surpassed daily caloric requirements. This approach, together with a low carbohydrate, high fat mixture, may be beneficial for such patients.

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Subacute or chronic dyspnea can be one of the most difficult complaints to evaluate. Dyspnea may represent the complaint of a person who is poorly fit, one who is suffering from anxiety or from some organic dysfunction, or one who is looking for secondary gain. The objectives in evaluating these patients are to determine that dyspnea is truly present and, if it is, to diagnose the specific cause so appropriate treatment can be undertaken. Often a good general evaluation is definitive enough to direct the clinician to specific tests that reveal the underlying cause of dyspnea. Some patients, however, require specialized tests both to confirm dyspnea and to indicate specific organic dysfunction.

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Acute methemoglobinemia may result from the use of several local anesthetic agents. Benzocaine (Cetacaine) spray has been shown previously to cause methemoglobinemia in two patients when applied topically to the mucous membranes. We describe a patient with respiratory failure following trauma who had two episodes of acute methemoglobinemia, one after the topical application of benzocaine and the second following lidocaine administration for endotracheal intubation. The episodes occurred more than 20 hours apart, and no other drugs known to induce methemoglobinemia were given. On both occasions, intravenous methylene blue was effective in correcting the disorder.

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The yellow nail syndrome, consisting of deformed yellow nails, lymphedema, and pleural effusions, is a rare disorder of unknown etiology. The underlying mechanism in this disease is believed to be hypoplasia of the lymphatic system. To date, only 47 cases of the yellow nail syndrome have been reported. We report an additional case, with a defect in cell-mediated immunity and development of an empyema. The patient also had a very low glucose level in the pleural fluid (10 mg/100 ml or less), which did not increase after loading with oral or intravenously administered glucose. The mechanisms for low levels of glucose in the pleural fluid are discussed.

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A total of 1,939 reported births to mothers who received isoniazid ethambutol, rifampin and streptomycin alone or in combination, for all or part of their pregnancies, were surveyed to determine teratogenicity of these agents. There was no significant increase in birth defects with isoniazid, ethambutol and rifampin, in contrast to the use of streptomycin which was associated with mild auditory and vestibular defects. Guidelines for the treatment of active tuberculosis in pregnancy are therefore established.

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The clinical and radiological findings of four patients with chronic eosinophilic pneumonia are presented. This brings the total number of cases in the English literature to 27. A comparison of all 27 patients is given. The syndrome can readily be distinguished from other eosinophilic pneumonias. After appropriate evaluation, a therapeutic trial can often be initiated with corticosteroids without the necessity for histologic confirmation of the diagnosis.

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