Michael S. Stulbarg

Bronchoalveolar Lavage and Transbronchial Biopsy for the Diagnosis of Pulmonary Infections in the Acquired Immunodeficiency Syndrome

The efficacy of bronchoalveolar lavage and transbronchial biopsy in diagnosing lung infection was determined in 276 fiberoptic bronchoscopic examinations done on 171 patients with known or suspected acquired immunodeficiency syndrome. Of 173 pathogens (Pneumocystis carinii, cytomegalovirus, Mycobacterium avium-intracellulare, Cryptococcus neoformans, M. tuberculosis, Coccidioides immitis, and Histoplasma capsulatum) identified during the initial evaluation or in the subsequent month, the initial bronchoscopic examination detected 166 (96%). Bronchoalveolar lavage and transbronchial biopsy had sensitivities of 86% and 87%, respectively. When bronchoscopy included both bronchoalveolar lavage and transbronchial biopsy, the yield for all pathogens was 98% and the sensitivity for P. carinii infections was 100%. Follow-up for at least 3 weeks after examination failed to detect any additional false-negative results. Fiberoptic bronchoscopy is extremely accurate for the detection of pathogens in patients with the acquired immunodeficiency syndrome, especially when bronchoalveolar lavage and transbronchial biopsy are combined. In patients at high risk of complications from transbronchial biopsy, bronchoalveolar lavage is sufficiently accurate to be used alone.

Noninvasive evaluation of pulmonary artery pressure during exercise by saline-enhanced Doppler echocardiography in chronic pulmonary disease.

To determine the feasibility of noninvasive determination of right ventricular systolic pressure (RVSP) during a graded-exercise protocol, saline contrast-enhanced Doppler echocardiography of tricuspid insufficiency was performed in 36 patients with chronic lung disease and 12 normal controls. In the patients with chronic pulmonary disease, symptom-limited, incremental supine bicycle exercise and pulse oximetry were performed on and off high-flow oxygen. Technically adequate Doppler studies were initially obtained in 20 patients (56%) at rest and 14 (39%) on exercise; these numbers increased to 33 (92%) and 32 (89%), respectively, after enhancement with agitated saline (both p less than 0.001). In 10 patients with chronic lung disease who had simultaneous hemodynamic monitoring during exercise, the correlation between Doppler and catheter measurements of pulmonary artery systolic pressure was close (r = 0.98). Among controls, RVSP increased from 22 +/- 4 at rest (mean +/- SD) to 31 +/- 7 mm Hg at peak exercise. In patients with chronic lung disease, RVSP increased from 46 +/- 20 to 83 +/- 30 mm Hg (both p less than 0.001 vs. controls). Despite normal resting values for RVSP in 28% of study patients, nearly all showed abnormal increases in RVSP during supine bicycle exercise. Increases in RVSP during exercise were greatest in patients who showed oxyhemoglobin desaturation. The short-term administration of oxygen significantly blunted the increase in RVSP during exercise. Saline contrast-enhanced Doppler evaluation of tricuspid insufficiency seems a potentially valuable noninvasive method of determining the exercise response of RVSP in patients with chronic pulmonary disease.

Internet-based patient education and support interventions: a review of evaluation studies and directions for future research

The Internet provides patients, families, and health providers with unparalleled opportunities to learn, inform, and communicate with one another. This paper is a review of studies that have evaluated the impact of professionally facilitated Internet-based programs for diverse clinical populations on health outcomes, utilization, and user satisfaction. The findings suggest that some outcomes in certain groups can be moderately improved and that user satisfaction has been generally positive. Given the increasing need to provide timely and effective patient-centered care, a stronger evidence base for eHealth applications must be established before broader deployment of such programs will take place.

Right-to-left interatrial shunting through a patent foramen ovale despite normal intracardiac pressures

Abstract In summary, we have described what may be an infrequently recognized cause of dyspnea. Patients with unexplained dyspnea and arterial desaturation out of proportion to their cardiopulmonary disease can easily and inexpensively be screened with an arterial blood gas determination while inspiring 100% oxygen. If these arterial oxygen values suggest a right-to-left shunt, an echocardiograpbic contrast study with injection of contrast into the femoral vein should be performed. If contrast crosses over from the right to the left atrium, further evaluation to define right-to-left shunting at the atria1 level is indicated.

Computed tomography in pulmonary sarcoidosis.

We studied the high resolution CT (HRCT) scans of 15 patients with biopsy-proven sarcoidosis and correlated the findings with pulmonary function tests (12 patients), 67Ga scans (10 patients), bronchoalveolar lavage (five patients), recent transbronchial biopsy (six patients), and recent open lung biopsy (three patients). The HRCT features included small nodules, thickened interlobular septa, patchy focal increase in lung density, honeycombing, and central conglomeration of vessels and bronchi. Active alveolitis was present by gallium scanning criteria in 5 of 10 cases. By bronchoalveolar lavage criteria, activity was present in three of five cases. Patchy increase in density may correlate with active alveolitis as seen on 67Ga scanning. High resolution CT was better than chest X-radiography for demonstration of patchy increase in density and for distinguishing nodules from septal thickening. Both nodules and patchy density were partly reversible following therapy. Nodular densities seen on CT correlated with the presence of granulomata on histology. Resting pulmonary function tests correlated poorly with presence and extent of lung disease on HRCT. The presence on HRCT of focal fine nodules, patchy focal increase in lung density, and central crowding of bronchi and vessels should suggest the diagnosis of sarcoidosis. In some patients, HRCT can identify unsuspected parenchymal lung disease and document the reversible components of sarcoid lung disease.

Differentiation between dyspnea and its affective components.

This study investigated whether people with chronic obstructive pulmonary disease (COPD) can differentiate distress and anxiety associated with dyspnea from the intensity of dyspnea and the perceived effort of breathing. Fifty-two subjects with COPD rated their perception of the individual components of dyspnea on a 200 mm visual analog scale at rest, after a 6-min walk (6MD), and every 2 min during an incremental treadmill test (ET). Subjects differentiated among the four dyspnea components at the end of the 6MD (p <.0001) and during ET (at rest, p < 0.001; at 75% V02 max, p < 0.0001; and at end exercise, p < 0.0001). Intensity was significantly related to perceived effort of breathing (p < .0001), as distress was to anxiety (p < .0001), suggesting that each pair measures similar components. Subjects were able to differentiate their affective response to dyspnea from the intensity of the symptom. Measurement of a patients affective response to dyspnea may improve the selection of specific treatments and validity of outcomes.

Wegener's granulomatosis: isolated involvement of the trachea and larynx.

A 26 year old man with subacute hoarseness and stridor was shown to have Wegeners granulomatosis isolated to the trachea and larynx. Although isolated laryngeal Wegeners is unusual, a review of the literature suggests that early treatment with cyclophosphamide is warranted.

Supporting cardiac recovery through eHealth technology.

The Internet continues to evolve as a popular and increasingly vital channel for health information and communication among patients, families, and health providers. This article provides an overview of published studies that have described or tested Internet-based resources and interventions designed to support recovery and enhance health outcomes for the cardiac population. Three categories of applications are discussed: (1) peer support communities; (2) information support through automated, tailored patient education; and (3) professionally facilitated education and support programs. The article also address key issues such as barriers to innovation adoption, patient literacy, and the digital divide that must be overcome for successful integration of such interventions into clinical practice. How Internet-based interventions will fit with existing conventional programs and clinical practice structures is not yet clear. However, evidence that supports use of this new communication channel is likely to emerge as more programs are developed and rigorously evaluated.

Treadmill Self-Efficacy and Walking Performance in Patients With COPD

As part of a larger ongoing study of nurse-coached practice with dyspnea, 52 subjects (25 men, 27 women) with moderate to severe COPD exercised on a treadmill three times a week for 4 weeks. Subjects were randomized into a coached exercise group, which received nurse coaching during exercise, and a

Computed tomography of diffuse tracheal stenosis in Wegener granulomatosis

A patient with Wegener granulomatosis presented with diffuse tracheal narrowing and was evaluated using CT and cine-CT. The CT findings included severe laryngeal and tracheal airway narrowing, due to abnormal soft tissue within the laryngeal cartilages and tracheal rings, and enlarged abnormally calcified tracheal cartilages. Computed tomography precisely confirmed the site, level, and submucosal extent of tracheal narrowing, not obtainable on physical or bronchoscopic examination, and assisted in choosing a site for tracheostomy. Wegener granulomatosis should be considered in patients with diffuse tracheal narrowing even when the typical histology is not present.