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The Hewlett-Packard 47201 A Ear Oximeter was evaluated to determine the feasibility of its use aboard aircraft. At altitudes up to 2438 m (8000 ft), there was no significant difference between the mean predicted percent saturation of hemoglobin and the measured percent saturation in 25 non-smokers (94.6 +/- 1.9 vs. 94.1 +/- 2.4; p greater than 0.10) and 20 smokers (94.9 +/- 1.8 vs. 94.2 +/- 2.5; p greater than 0.10). The accuracy of the oximeter readings on five individuals was further confirmed with a blood gas analyzer aboard the aircraft. We conclude that the ear oximeter is accurate and reliable for monitoring patients during flights.

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Three patients with Munchausen's syndrome were seen with symptoms suggesting serious pulmonary disease. One patient, a student respiratory therapist, simulated respiratory failure which resulted in a tracheostomy and prolonged ventilator support. The second, a licensed practical nurse, feigned a lupus erythematosis syndrome, with alarming, simulated hemoptysis produced by slashing the posterior tongue with a razor blade. The third patient, a nurse, underwent exhaustive testing at three hospitals for profuse "hemoptysis" until she admitted she obtained the blood from her arm by venesection.

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Twenty-four men were refueling a missile when a large spill of oxidizer occurred. Three crewmen were exposed to very high concentrations of the oxides of nitrogen. One died within minutes. Severe respiratory distress syndrome developed in the other two, one of whom survived. Twenty-one other workers were exposed to minimal to moderate concentrations of the gas. Most remained asymptomatic while six had shortness of breath, cough, or hemoptysis. The three with persistent symptoms received corticosteroid therapy; the complaints resolved in two. Corticosteroid therapy for four asymptomatic patients who had moderate hypoxemia two weeks after the accident may have aborted the second stage of nitrogen dioxide injury. Six patients with minimal exposure had persisting headaches, visual disturbances, and emotional difficulties. These latter findings may represent an unusual complication of exposure to these gases.

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By obtaining five transbronchoscopic biopsies of the lung from each of the right upper and lower lobes, the diagnosis of sarcoidosis was made in 36 of 37 prospectively studied patients. The diagnosis was made in all ten patients with stage-1 disease, but seven of the ten showed diagnostic tissue from only one lobe. Only one of the ten biopsies was diagnostic in four of those patients with a stage-1 disease. In disease of stage 2 and 3, there was good correlation between diagnostic biopsies and the radiographic distribution of infiltrates. Biopsies from the predominantly rather than the lesser involved lobe proved the diagnosis in all of these patients, except for the two patients with nodular sarcoid. We conclude that ten biopsies are optimal for obtaining the diagnosis in stage-1 disease; however, five biopsies may be adequate in non-nodular disease of stage 2 and 3 if the biopsies are of the lobe predominantly involved on the roentgenogram of the chest.

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Tuberculosis in Oriental immigrants is likely to be resistant to therapy with certain drugs. In 73 military dependents with positive cultures for tuberculosis who immigrated from six Asian countries, the tuberculosis was found to be resistant to isoniazid in 58 percent (42 patients), to streptomycin in 36 percent (26 patients), to p-amino-salicylic acid in 14 percent (ten patients), to rifampin in 7 percent (five patients), and to ethambutol in 7 percent (five patients). Despite the presence of drug-resistant organisms and often extensive disease, negative cultures were attained in all but one patient. Consideration of the high incidence of drug-resistant tuberculosis should be made in planning a program of treatment for these patients. Recognition of cultural differences may also be of value in the successful treatment of this difficult group of patients.

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Forty-two volunteers (15 of them cigarette smokers) were studied to determine the effects on the airways that might result from immunization with killed influenza virus vaccine. The forced vital capacity, the forced expiratory volume in one second, the maximal expiratory flows at 50 and 75 percnet of vital capacity, and the volume isoflow were determined before and at 24, 48, and 72 hours and one and two weeks after vaccination. For both smokers and nonsmokers, there were no significant changes in the results of these tests of pulmonary function following vaccination.

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One thousand patients receiving isoniazid chemoprophylaxis were prospectively followed up to assess the value of liver function monitoring plus monthly clinical evaluation. Two hundred twenty-two (22.2%) of the patients had at least one elevated SGOT level during the course of treatment, and 47 asymptomatic persons had isoniazid therapy discontinued because of consistent elevations greater than five times normal. Another 17 had symptoms in association with elevated SGOT levels, and therapy was stopped in these patients as well. No patient became seriously ill, and there were no deaths. Biochemical monitoring should be done routinely in patients receiving isoniazid chemoprophylaxis to avoid the development of irreversible hepatic reactions.

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A young woman presented with the acute onset of pleuritic chest pain ahd pleural effusion which eventually proved to be secondary to an infected disk space. This complication most likely resulted from a paraspinal extension of the infection. Disk-space infection must be added to the differential diagnosis of acute pleural disease.

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A prospective study of 21 patients with presumed sarcoidosis was performed to determine the value of conjunctival biopsy in diagnosing the disease. Conjunctival lesions were seen in 15 patients on slit-lamp examination, with eight of these showing noncaseating granulomas on biopsy. The abnormalities were seen by the unaided eye in only two cases. All eight biopsies showing noncaseating granulomas occured in the 14 black patients. No clinical, biochemical, or radiographic characteristics identified those patients who would prove to have a biopsy showing such granulomas. This simple, frequently productive procedure may be helpful in the diagnosis of sarcoidosis.

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Treatment with a combination of trimethoprim and sulfamethoxazole proved lifesaving in a patient with pulmonary melioidosis after therapeutic failure occurred with other antibiotics to which the organisms were sensitive in vitro. Antagonistic interaction of drugs occurred when the combination of trimethoprim and sulfamethoxazole was given along with other antibiotics. The combination of trimethoprim and sulfamethoxazole should be considered a major addition to the pharmacologic armamentarium for the treatment of pulmonary melioidosis.

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A middle-aged white man with lymphomatoid granulomatosis was studied over the ten-year course of his disease. Both a large subcutaneous mass in his thigh and life-threatening massive involvement of the right lung occurred on separate occasions, and each responded to therapy with irradiation after immunosuppression failed. Irradiation should be considered as one of the primary forms of treatment of lymphomatoid granulomatosis in those with localized lesions.

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A 21-year-old black man had pleuritic pain as the initial symptom of his sarcoidosis. Chest roentgenographic examination showed an infiltrate in the left upper lobe and a left pleural thickening. Sarcoidosis was diagnosed by pulmonary biopsy. Thus, sarcoidosis may closely mimic tuberculosis by initially occurring as predominantly apical infiltrates and pleural reaction.

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The hepatotoxicity of isoniazid was studied in a double blind fashion in 120 adult patients receiving the drug for chemoprophylaxis. The incidence of abnormal SGOT values was significantly higher in those on the drug, 18.3% having elevated values as compared to 6.7% of those on placebo during the three-month study period. There was no statistical difference in the frequency of symptoms suggestive of liver diseases between the isoniazid and placebo groups. Furthermore, there was no significant relationship between symptoms and elevated SGOTs. Therefore, symptomatology would not appear to be a sensitive method for detecting early isoniazid liver toxicity. From available evidence, biochemical monitoring would appear to detect liver toxicity at an earlier and more reversible stage.

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Six patients with specific pulmonary diseases had pulmonary tissue surgically resected for diagnostic purposes. All six cases were characterized by space-occupying lesions surrounded by a peculiar reaction of the pulmonary parenchyma indistinguishable from desquamative interstitial pneumonia. If small biopsies from these areas had been taken, a diagnosis of desquamative interstitial pneumonia would have been made, and the underlying process would have gone undetected. These cases corroborate even further the concept that desquamative interstitial pneumonia is a pattern of pulmonary reaction, rather than a well-defined disease entity. Furthermore, it seems advisable to make the dianosis of desquamative interstitial pneumonia only when other conditions have been carefully ruled out by thorough clinical and pathologic investigations.

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Because tuberculosis is currently being treated in many instances by the nonpulmonary physician, an evaluation of the skill with which he performs in this capacity was made. A group of 130 patients who had been treated by such physicians was analyzed, using generally accepted criteria for appropriate therapy. Seventy-three of the group were found to have been treated inappropriately. The use of isoniazid in those likely to be resistant to that drug, the use of a single drug in bacteriologically positive disease, and inadequate or excessive drug dosages were among the more common errors. Two thirds of the physicians caring for these patients were internal medicine specialists, half of them board certified. Increased education efforts in regard to this disease at all levels of training must be made.

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The association of renal tuberculosis and leukoplakia of the renal pelvis was quite common in the prechemotherapy era of tuberculosis but has apparently not been seen since effective drugs became available. Despite a prompt response of the tuberculosis to chemotherapy the leukoplakia formation with intermittent passage of keratinised material continued. Surgical removal of the accumulated material was of no lasting benefit.

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An infant whose miliary tuberculosis was resolving after five months of chemotherapy developed a tuberculous cervical lymphatic abscess followed shortly thereafter by life-threatening tracheal compression from enlarged tuberculous mediastinal nodes. Both of these complications required surgical drainage. Chemotherapy alone may be ineffective in the management of lymphadenitis caused by Mycobacterium tuberculosis.

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