W. Mark Brutinel

The shrinking lungs syndrome in systemic lupus erythematosus

A comprehensive review of the literature on shrinking lungs syndrome (SLS) in systemic lupus erythematosus involved a MEDLINE search (1965-1997) of case reports and clinical series of patients with the diagnosis of SLS. A total of 49 well-documented cases of SLS were reviewed. Shrinking lungs syndrome is characterized by unexplained dyspnea, a restrictive pattern on pulmonary function test results, and an elevated hemidiaphragm. The cause of SLS remains controversial, with several authors attributing the disorder to diaphragmatic weakness and others suggesting that chest wall restriction accounts for the clinical syndrome. No definitive therapy exists. Corticosteroids have been reported to lessen symptoms and improve pulmonary function in some patients with SLS, but other methods of treatment have occasionally been found to be helpful. Clinical presentation, method of diagnosis, pathogenesis, and treatment modalities are summarized in this review. An uncommon complication of systemic lupus erythematosus, SLS causes significant morbidity and, occasionally, mortality.

Monitoring and Analysis of Oxygenation and Ventilation During Rigid Bronchoscopic Neodymium-YAG Laser Resection of Airway Tumors

Neodymium-YAG (yttrium-aluminum-garnet) laser resection of obstructing and inoperable tumors of the large airways is used as palliative therapy to improve the quality of survival in patients by alleviating airway obstruction. Rapid changes in oxygenation and ventilation can occur during these procedures. In a study of 14 patients, transcutaneous oxygen (PtcO 2 ) and carbon dioxide (PtcCO 2 ) monitors responded slowly to these changes and frequently provided misleading values. Pulse oximetry (SNO 2 ) accurately reflected arterial oxygen saturation but did not indicate severe desaturation until arterial oxygen tension approached dangerously low values. Thus, we did not find PtcO 2 or PtcCO 2 monitoring to be clinically useful during neodymium-YAG laser resection of airway tumors through a rigid bronchoscope. SNO 2 was clinically useful and accurate; however, a large decrement in oxygenation may occur before changes in oxygen saturation ensue and are detected.

Clinical Characteristics in Suspected Tracheobronchial Foreign Body Aspiration in Children

The objective of this study was to assess clinical characteristics of suspected tracheobronchial foreign body (TFB) aspiration in children to determine whether any singular feature of the history, physical examination, or radiologic evaluation would predict actual TFB aspiration. Chart review of all bronchoscopies was performed for the clinical suspicion of TFB aspiration in children younger than 16 years of age. Data extracted included history (witnessed event, choking his- tory), clinical symptoms, results of physical examination, and radiographic evaluation. A total of 94 children (62 boys and 32 girls; mean age, 46.5 ± 45.9 months) were evaluated for sus- pected TFB aspiration. Bronchoscopy identified TFB in 39 children (TFB group). Bronchoscopy did not identify TFB in 55 children (non-TFB group). Overall, 57 children (61%) had a witnessed aspiration. In the TFB group, 33 of 39 children (85%) had a witnessed event whereas in the non-TFB group 24 of 55 children (44%) were witnessed (odds ratio for TFB for a witnessed event was 7.1 (95% confidence interval, 2.7-21.3; p < 0.0001)). Of the 94 children, choking was observed in 53%. In the TFB group, 79% of children had a choking event whereas choking was observed in only 35% of children in the non-TFB group (odds ratio for TFB for choking was 7.3 (95% confidence interval, 2.9-20.1; p < 0.0001)). Other clinical symptoms such as dyspnea and cough were not helpful in dif- ferentiating the presence or absence of a TFB. No specific finding on physical examination was helpful at predicting the presence of a TFB. Radiographic findings were also unhelpful unless a radiopaque TFB was visualized. In children with sus- pected TFB aspiration, each of the two clinical features—a choking episode and witnessed aspiration—is seven times more likely in those with bronchoscopically identified TFB com- pared with those without TFB. Other clinical features and chest radiographs are less helpful in predicting the presence of TFB. Nevertheless, some negative bronchoscopies are necessary to exclude TFB in children with suspected TFB aspiration. Key Words: Bronchoscopy—Tracheobronchial foreign body— Choking—Aspiration—Children.

Incidence of Tuberculosis in Olmsted County, Minnesota, 1990-2001

OBJECTIVE To describe and compare the incidence and clinical characteristics of tuberculosis in Olmsted County, Minnesota, among US-born and foreign-born persons. PATIENTS AND METHODS We performed a retrospective cohort study at the Mayo Clinic in Rochester, Minn, of all residents of Olmsted County (2000 population: 124,277) diagnosed as having tuberculosis between January 1, 1990, and December 31, 2001. Potential cases were identified with use of a computerized diagnostic coding database and microbiological laboratory data; all identified medical records were abstracted. Definite cases were those in which Mycobacterium tuberculosis was recovered in culture. Probable cases were those that met predefined clinical or radiographic evidence of tuberculosis and other criteria. Age-specific, sex-specific, and country of origin-specific incidence rates were calculated with use of Olmsted County census data. Variables were compared among risk groups using the Fisher exact test. RESULTS During a 12-year period, 71 cases of tuberculosis (53 definite, 18 probable) were identified, for an incidence of 5.3 per 100,000 person-years. Of these cases, 54 (76%) occurred during the second half of the study (incidence: 7.7 per 100,000 person-years). The incidence among US-born persons was similar throughout the study period; however, the Incidence among foreign-born persons increased more than 3-fold during the second half of the study period. Twenty-five patients (35%) were former refugees. All isoniazid-resistant infections (12% of isolates) and multidrug-resistant infections (6% of isolates) occurred among foreign-born persons. CONCLUSION The incidence of tuberculosis increased substantially in Olmsted County between 1990 and 2001, primarily because of an increase in the number of cases among foreign-born persons.