We evaluated two patients with systemic cholesterol embolization (SCE) associated with the development of pleural effusions. These two patients had evidence of atherosclerosis and presented with livedo reticularis, renal insufficiency, and gangrenous cutaneous changes as manifestations of their SCE. In both cases, closed pleural biopsies demonstrated acute inflammation of the parietal pleura. Our experience with these individuals and a review of the medical literature suggest that pleural injury from atheromatous embolization may occur. Physicians caring for patients with SCE should be aware of the possible association of pleural reactions with this process.

Congenital cystic adenomatoid malformation is an uncommon congenital anomaly. We present four additional children with CCAM and review the literature. Two of these children had unusual manifestations of CCAM--one presented with a "cavitary lesion" while the other is suspected of having bilateral disease.

Thiazides were responsible for severe diuretic-induced hyponatremia (serum sodium level < 115 mEq/L) in 94 percent of 129 cases reported in the literature between 1962 and 1990. The hyponatremia developed within 14 days in most of the patients receiving thiazides but in none of the patients who were treated with furosemide. Diuretic-induced hyponatremia was four times more common in women than in men. Advanced age was not associated with a higher tendency for hyponatremia. In the majority of the patients who received thiazides, excess antidiuretic hormone activity, hypokalemia, and excess water intake were accompanying findings which, singly or together, appeared to contribute to the development of hyponatremia. In 12 patients, mortality was directly related to hyponatremia. Rapid average correction of hyponatremia and a relatively high total correction (over 20 mEq/L) in the first 24 h were significantly associated with higher mortality or demyelinating syndrome. The presence of neurologic signs is an indication for active sodium replacement. The onset of thiazide-induced hyponatremia may in some cases occur within 1 day and therefore needs to be corrected rapidly, but within a total elevation of 20 mEq/L in the first 24 h. Where the onset is judged to have been slow (over several days), the level should be corrected at a slow rate, up to a total of 12 to 15 mEq/L in 24 h.

Considering the literature, a symptomatic right-to-left (R-L) shunt through a persistent foramen ovale (PFO), developing after a pulmonary resection, can occur without elevated right-sided heart pressures, but its frequency seems to be very low. However, considering the high frequency of a PFO in the normal population (20 percent) and the high frequency of pulmonary resections carried out today, it might be possible that this kind of complication is occurring more frequently, possibly in a more "benign" form, in which it is more difficult to recognize, especially if one is unaware of the possibility of this kind of complication. This R-L shunt seems to occur more frequently after a right-sided pneumonectomy. Important clinical clues suggestive for this complication are as follows: first, a relatively symptomless interval of a few months between the operation and the onset of symptoms; second, the posture dependency of the dyspnea, ie, the dyspnea becoming worse in the upright position (platypnea); and third, the volume dependency of the R-L shunt, ie, the shunt becoming worse in a dehydrated state.

Iodinated glycerol (Organidin) has recently been shown to be a useful adjunct in the symptomatic treatment of patients with chronic obstructive pulmonary disease (COPD). Over an 18-month period, we saw four patients with significant thyroid dysfunction resulting from iodinated glycerol use. All were elderly patients with COPD who had been started on standard doses of iodinated glycerol 4 to 24 months earlier. None of the patients had histories of thyroid disease. Three of the patients had symptomatic thyrotoxicosis and one had severe hypothyroidism while taking iodinated glycerol. We review the literature on the mechanisms and management of iodine-induced thyroid dysfunction and conclude the following: (1) all iodine-containing drugs may adversely affect thyroid function; (2) these compounds should be prescribed with extreme caution to any patients with underlying thyroid disease; and (3) all patients receiving iodine-containing medications should be closely monitored for evidence of thyroid dysfunction.

Sixty-nine consecutive pulmonary artery catheters (PACs) were prospectively studied in a medical-surgical intensive care unit. Fifteen (21.7 percent) and two (2.9 percent) of the PACs were associated with colonization and bacteremia, respectively. These data represent an incidence of 4.98 and 0.66 episodes per 100 catheterization-days, respectively. Coagulase-negative staphylococci were the most common isolates. The source of the colonizing microorganism was the skin in 56 percent of cases, hubs in 28 percent, and unknown in 16 percent. From multivariate analysis, only more than 5 days of catheterization was significantly associated with a greater risk of colonization. Antimicrobial use was associated with negative cultures. The most useful method to diagnose colonization was the examination of both tip and intradermal segments. In addition, we suggest associate hub cultures when catheter-related bacteremia is suspected. These data may be useful in improving efficacy in the diagnosis and prevention of PAC-related infection.

The incidence of lung cancer in the United States has stabilized in recent years, but it remains a major cause of death in the United States. Whereas the single most effective primary prevention of this disease would be to eliminate tobacco use from society, this is currently an unrealistic goal. Secondary prevention, however--that is, chemoprophylactic treatment of smokers, exsmokers, and others at risk--represents a viable option. Agents proven effective in both laboratory models and humans include vitamin A and its synthetic derivatives, the retinoids and the carotenoids. It is fairly easy to identify patients at risk of lung cancer compared with other cancers. Yet aside from patients who are under a physician's care and aware of their risk, it can be difficult to target individuals for chemoprophylactic treatment, especially those who are healthy but at high risk and not seeing a physician or other health care provider. Screening for the presence of predictive cellular and molecular changes may facilitate more accurate selection of individuals for chemoprophylactic treatment.

Lung cancer rates and mortality have risen in epidemic proportions in the United States and other industrialized nations during the 20th century. Case-control and cohort studies performed in the 1950s and 1960s firmly established cigarette smoking as the single greatest risk factor for lung cancer. In the United States, overall lung cancer mortality rates in men and women rose progressively from the 1950s. Fortunately, lung cancer incidence and mortality are now declining in middle-aged men. Smoking has significantly increased lung cancer rates among women and is on the rise in developing countries. Environmental agents found in the home and workplace, including radon and asbestos, have also been shown to increase lung cancer risk in both smokers and nonsmokers. Government regulations have helped curtail quantities of these and other atmospheric carcinogens. Efforts to reduce lung cancer risk must be continued and their scope expanded in order to have a global impact on the incidence and mortality of this fatal malignancy.