Introduction Sivelestat is neutrophil elastase inhibitor, which is widely used in Japan for the treatment of acute lung injury. However, the clinical efficacy of the medication has not been convincingly demonstrated. Methods We conducted a systematic review and meta-analysis of randomized controlled trials on sivelestat for the treatment of acute lung injury and acute respiratory distress syndrome. Studies were identified using MEDLINE, EMBASE, Cochrane library, conference proceedings, and references of included studies. Authors were contacted if necessary. ICHUSHI, the Japanese database for medical literature and conference proceedings was also used for the search, since many studies on sivelestat were published in Japanese language and not registered in major databases such as MEDLINE. The primary outcome was mortality within 28-30 days after randomization. Relative risks were pooled with the random effect model. Results 8 trials were included in the analysis. There was no difference in mortality within 28-30 days after randomization (relative risk 0.95, 95% confidence interval 0.72 to 1.26). Subgroup analysis conducted only on studies conducted in Japan showed the same result (0.59, 0.28 to 1.28). There was no difference in mechanical ventilation days (standardized mean difference -0.43, -1.12 to 0.27), but sivelestat was associated with a better short term PaO2/FiO2 ratio (0.30, 0.05 to 0.56). Heterogeneity was not significant for the main analysis and funnel plot did not suggest publication bias. Conclusion Sivelestat was not associated with decreased mortality, even when including studies published in Japanese language.

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Ninety-six sputum specimens from patiens with pneumonia were microscopically screened for leukocytes and buccal squamous epithelial (BSE) cells. Cultures of these specimens were compared with cultures of paired transtracheal aspirates (TTA). Agreement between sputa with less than 25 BSE cells per 100X field and TTA was good (79%). Only 27% of the specimens with greater than 25 BSE cells per 100X field agreed with TTA. Sixty-six of the sputa were of group 5 quality, i.e., greater than 25 leukocytes and less than 10 BSE cells per 100X field. A potential pathogen growing in one of these specimens was 94% predictive of growth in the TTA. If a group 5 sputum was negative for a potential pathogen, there was a 45% chance that a fastidious organism had been overgrown or overlooked. The presence of definite lower tract secretions in group 5 sputa as determined by visualizing bronchial epithelial cells and alveolar macrophages did not significantly increase the diagnostic value of these specimens. Microscopic screening of sputum before culture with rejection of selected specimens can increase the value of sputum in determining the etiology of bacterial pneumonia.

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Amphotericin B causes reversible concentration-dependent loss of intracellular potassium in vitro and hyperkalemic ventricular arrhythmias in dogs. Hyperkalemic ventricular arrhythmias associated with amphotericin B infusion have not been well documented in humans. Ventricular fibrillation with progressive hyperkalemia (up to 8 to 8.4 meq/liter) occurred twice in an anuric patient during rapid infusion of high-dose amphotericin B (1.4 mg/kg over 45 min). The peak amphotericin B concentration in serum at the end of infusion was 6.7 gLg/ml. Prolonged infusion (3 h) and concurrent hemodialysis each prevented the development of hyperkalemia and ventricular arrhythmia. In two anuric patients receiving 4-h infusions of amphotericin B during dialysis (0.7 and 1.0 mg/kg), peak amphotericin B concentrations in serum were lower, 1.6 ± 0.1 and 2.7 ± 0.7 ,ug/ml, respectively; serum potassium levels were maintained in the normal range; and venous access for outpatient therapy was convenient. Peak concentrations of amphotericin B in serum were also lower (1.7 + 0.7 Fg/ml) in eight patients with normal renal function who received lower doses (0.7 0.2 mg/kg) over 45 min; there were only slight increases in the serum potassium level (from 3.9 ± 0.9 to 4.4 + 0.6 meq/liter, P < 0.05). We recommend that rapid infusion of amnphotericin B not be used in patients with impaired potassium excretion unless accompanied by hemodialysis and careful potassium monitoring.Rapid infusion (30 to 60 min) of amphotericin B (AMB) is advocated in some centers as a safe and convenient method of treating outpatients with chronic fungal infections and acutely ill inpatients who require frequent intravenous infusions of incompatible medications. In the absence of comparative studies, the assumption of safety has rested on anecdotal experience. We twice observed hyperkalemic ventricular fibrillation in an anuric patient receiving rapid infusion of AMB. To assess potential risk factors for this complication, we compared the concentrations of amphotericin B in serum and potassium levels in this patient with those in two anuric patients receiving 4-h infusions during hemodialysis and in eight patients with normal renal function receiving rapid infusions of AMB. Patients 2 and 3 were anuric patients, one with coccidioidomycosis and the other with histoplasmosis, who received 4-h infusions of 60 and 50 mg of AMB (1.0 and 0.7 mg/kg), respectively, during thrice-weekly dialysis.

Subcutaneous abscesses occurred at hip and deltoid injection sites in 13 student nurse assistants following practice injections. Mycobacterium chelonei was isolated from three cases and was the presumptive pathogen in other temporally clustered cases with similar clinical findings. A 1,000 cc bottle of 0.9 N saline used as a source for practice injection solution was the apparent source of the organism.Presenting findings included tenderness (7), swelling (7), fever (3), adenopathy (1) and weight loss (1). All cases were characterized by long incubation periods (6 to 16 weeks) and delayed resolution (mean 8.8 months), and required surgical drainage or wedge excision for therapy. Antituberculous therapy was administered in three cases. Complications were limited to scarring in seven cases with keloid formation in two and persistent pain in three cases. This outbreak reinforces the importance of penetrating trauma in this cutaneous mycobacterial infection and emphasizes the emergence of this organism as an important nosocomial pathogen.

The safety of attenuated viral vaccines against measles and rubella and their efficacy in controlling a massive outbreak of these two diseases in air force recruits at Lackland Air Force Base, Texas, were studied. Recorded cases of measles declined from a high of 1,345 in 1976 to a low of 227 in 1979. Similarly, rubella cases declined from a peak before the immunization program of 1,361 in 1977 to a low of 67 in 1979. A controlled study of morbidity related to immunization revealed that there is less immediate local morbidity from immunizations against measles and rubella than with other routine immunizations. Recruits who received the attenuated viral vaccines reported fever, myalgias, and diarrhea only slightly more frequently than did recruits in the concurrent control group. The present data indicate that measles and rubella, increasingly consequential diseases among young adults, can be safely and effectively controlled with attenuated viral vaccines.