Pulmonary manifestations of pheochromocytoma are infrequent and are not well documented. A MEDLINE search in the English language revealed no cases of endobronchial involvement from a pheochromocytoma. We report a case of endobronchial metastases in a 37-year-old woman known to have a recurrent extra-adrenal pheochromocytoma. She presented with symptoms of wheezing and a nonproductive cough for 8 months and was being treated for asthma. A flexible bronchoscopy with endobronchial biopsy established the diagnosis. The patient underwent a Nd-YAG laser photoresection (LPR) to ablate the tumor, which was followed by placement of a Wallstent (Pfizer Medical Technology Group; Rutherford, NJ). She remains well 18 months later, having required multiple palliative LPRs. To our knowledge, this is the first reported case of endobronchial pheochromocytoma. The pulmonary manifestations of this rare disease and their management are reviewed.

Airway obstruction due to presence of blood clot occurs in a variety of clinical settings; however, it is not always preceded by hemoptysis. The impact on respiratory function may be minimal or result in life-threatening ventilatory impairment. Three illustrative cases and a comprehensive literature review are presented. The presence of endobronchial blood clot is suggested by the clinical and radiographic findings of focal airway obstruction. The diagnosis is established by direct endoscopic evaluation. Initial efforts at removal of the airway clot, if warranted, involve lavage, suctioning, and forceps extraction through a flexible bronchoscope. If unsuccessful, further management options include rigid bronchoscopy, Fogarty catheter dislodgment of the clot, and topical thrombolytic agents.

The International Staging System for Lung Cancer has been revised recently. Important changes have been made to allow better correlation of prognoses and direction of management. The classification of synchronous pulmonary nodules in the same lobe as the primary tumor as T4 stage IIIB may imply a poorer outcome than is warranted, while the designation of a similar stage for malignant pleural effusion may not be reflective of the very poor prognosis associated with this extent of disease.

The resurgence of tuberculosis (TB) in the early 1990s, including multidrug-resistant strains, led health officials to recommend the use of involuntary detention for persistently nonadherent patients. Using a series of recently published articles on the subject, this paper offers some opinions on how detention programs have balanced protection of the public's health with patients' civil liberties. Detained persons are more likely than other TB patients to come from socially disadvantaged groups. Health departments have generally used coercion appropriately, detaining patients as a last resort and providing them with due process. Yet health officials still retain great authority to bypass "least restrictive alternatives" in certain cases and to detain noninfectious patients for months or years. Misbehavior within institutions may inappropriately be used as a marker of future nonadherence with medications. As rates of TB and attention to the disease again decline, forcible confinement of sick patients should be reserved for those persons who truly threaten the public's health.

In 1997, the National Heart, Lung, and Blood Institute released the Second Expert Panel Report on the Guidelines for the Diagnosis and Management of Asthma as a follow-up to the first report issued in 1991. Implementation of the recommendations from this report could have a potentially huge impact on care and treatment of asthma in the United States. Even though the Guidelines are expansive, there are some areas related to the pharmacologic component that warrant further discussion and clarification. These are: (1) safety and efficacy of available asthma medications, (2) clinical efficacy comparisons of inhaled corticosteroids, (3) comparative risks among inhaled corticosteroids, and (4) expectations of different delivery systems used with inhaled corticosteroids.

Permanent therapy with oral anticoagulants offers the most consistent protection in patients with mechanical heart valves. Antiplatelet agents alone do not consistently protect patients with mechanical prosthetic heart valves, including patients in sinus rhythm with St. Jude valves in the aortic position. Levels of oral anticoagulants that prolong the INR to 2.0 to 3.0 appear satisfactory for patients with bileaflet mechanical valves in the aortic position, provided they are in sinus rhythm and the left atrium is not enlarged. Oral anticoagulant levels that prolong the INR to 2.5 to 3.2 are satisfactory for patients with bileaflet mechanical aortic valves and atrial fibrillation. Oral anticoagulant levels that prolong the INR to 2.5 to 3.5 are satisfactory for tilting disk valves and bileaflet prosthetic valves in the mitral position. Experience is sparse in patients with caged ball valves who had prothrombin time ratios reported in terms of INR. It has been suggested that the most advantageous INR level in patients with caged ball or caged disk valves should be as high as 4.0 to 4.9. However, others have shown a high rate of major hemorrhage with an INR that is even somewhat lower (3.0 to 4.5). The problem is self-limited, however, because few such valves are being inserted. Aspirin, in addition to oral anticoagulants, in patients with mechanical heart valves has been shown to diminish the frequency of thromboemboli. The risk of bleeding may not be increased if the INR is low. A low rate of both thromboemboli and bleeding has been shown with an INR of 2.5 to 3.5 in combination with aspirin at a dose of 100 mg/d. There are no investigations in which an aspirin dose of 81 mg/d in combination with oral anticoagulants was evaluated. Dipyripdamole may be effective in reducing the rate of thromboemboli without increasing the rate of bleeding, but data are insufficient to recommend dipyridamole over low doses of aspirin. Patients with bioprosthetic valves in the mitral position, as well as patients with bioprosthetic valves in the aortic position, may be at risk for thromboemboli during the first 3 months after surgery. Among patients during the first 3 months after surgery with bioprosthetic valves in the mitral position, oral anticoagulants administered at an INR of 2.0 to 2.3 were as effective as at an INR of 2.5 to 4.5: additionally, fewer bleeding complications were seen.