A wide variety of lesions occur in the mediastinum in patients of every age. Twenty five to 50 percent of these primary mediastinal masses may be malignant, making early diagnosis and therapy crucial. Since most arise from normal structures in the region, localization of lesions to compartments of the mediastinum may assist in diagnosis. This article reviews imaging techniques for lesions originating in the mediastinum.

Diagnosis and particularly the management of erythema multiforme and Stevens-Johnson syndrome are controversial in medical textbooks and thus in individual cases. In these diseases, fatalities may result from various causes, including secondary infection or visceral organ damage to lung, liver, or kidneys. We present a series of 13 cases managed by one group of physicians which demonstrates the controversy in certain cases, and we review the controversy in the medical literature. Corticosteroid therapy used in this series was considered beneficial in every case by the managing physician and lifesaving in some cases. There were no fatalities in this series. Although the summation may be considered as our opinion only, the frequently suggested "controlled trial of corticosteroid therapy" can probably never be done for ethical reasons, and series such as this will have to establish the standard of therapy.

Spontaneous pneumothorax associated with Pneumocystis carinii pneumonia (PCP) in AIDS patients has been reported with increasing frequency; however, little is known about the causative histopathology. In the past year, we treated three patients with documented PCP subsequently complicated by multiple spontaneous pneumothoraces. All patients underwent open surgical repair. In contrast to traditional pathologic findings of PCP in AIDS, histologic sections of lung from each patient consistently demonstrated an extensive interstitial inflammatory process with destruction of lung tissue primarily involving the periphery of the lung. Subpleural necrosis with bleb formation as well as bullous changes persisted even in the absence of an alveolar filling process. We conclude that the mechanism for pneumothorax in PCP is spontaneous rupture of necrotic lung tissue occurring in a subgroup of AIDS patients in which the interstitial inflammatory response to Pneumocystis has been accelerated.

After almost 50 years as first-line drugs in the management of asthma and COPD, methylxanthines have been largely superceded by inhaled adrenoceptor agonist and anticholinergic bronchodilators which are more potent and far less toxic. Accumulating evidence indicates that intravenous theophylline contributes side effects, but is rarely of benefit in acute exacerbations of asthma or COPD. In the maintenance therapy of asthma, first-line therapy is dose-optimized inhaled steroids, reducing the need for bronchodilators. Inhaled adrenoceptor agonists are second line medications, anticholinergic aerosols third line, and theophylline, if needed at all, may fulfill a minor systemic steroid-sparing function in severe asthmatics on maximum doses of the inhaled medications. In the maintenance therapy of some patients with COPD, theophylline sometimes may be useful but these responders should be identified by objectively establishing therapeutic benefit. Since many patients have side effects from the methylxanthines, while their therapeutic benefit over and above dose-optimized inhaled therapy is marginal, their continued almost routine use in the management of reversible airflow obstruction is hard to justify, although this class of drugs may be useful in selected patients in whom both subjective and objective benefit can be demonstrated. In COPD, theophylline may improve exercise capacity in some patients by still incompletely understood mechanisms probably unrelated to bronchodilation.

Praziquantel is recommended as the drug of choice for all forms of schistosomiasis. We report the first case (to our knowledge) of exudative effusive polyserositis following treatment of schistosomiasis with this drug. This involved pleura, pericardium, and peritoneum and was associated with acute respiratory failure. The latter preceded the appearance of pleural effusions. We present a brief review of the literature and attract attention to the need for close observation of patients with schistosomiasis who are treated with praziquantel.

Intensive management of patients with severe head injury offers the best hope of minimizing death and functional disability in a young, working population. Secondary neurologic insult can be decreased by cardiorespiratory support and ICP control from the outset. Rapid neurologic assessment, airway management, and support of circulation are the basis of emergency management for head injury. Patients with severe head injury require intensive care management for two major reasons: management of ICP and management of organ system dysfunction. Care should not be withheld because of initially grim (and inaccurate) prognostic assessment. Newer techniques for assessing the adequacy of cerebral circulation may allow refinement of management strategies in the future.

Normal sleep provides a period of physiologically reduced workload for the cardiovascular system for almost one third of the human life span. Snoring, the most common disorder of sleep, heralds the presence of an unstable upper airway and alerts perceptive clinicians to the possibility of OSA. Epidemiologic evidence has implicated snoring as an independent risk factor for the development of hypertension, ischemic heart disease, and cerebral infarction. However, many investigators would attribute these adverse cardiovascular effects to the substantial prevalence of OSA in habitual snorers. The detrimental effects of OSA on hemodynamics and cardiac rhythm have been well documented, and recent data have linked OSA with increased cardiovascular mortality. Worsening hypoxemia during sleep likely contributes to the nocturnal mortality observed in patients with severe COPD. Effective treatment to prevent nocturnal hypoxemia is available for OSA and COPD, with current evidence supporting beneficial effects on survival.

Significant progress has been made recently in the measurement methods and instrumental approaches applicable to bedside testing of critically ill patients. While the "ideal" technology would involve the ability to obtain accurate stat profile values on a continuous basis via noninvasive methods, given the present state of noninvasive sensing technologies, this capability is unlikely to be achieved in the foreseeable future. In principle, invasive and on-line techniques offer more hope for future success in continuous bedside monitoring of all the key critical care analyses. However, success in these directions will come only when issues regarding sensor stability and sampling device/sensor biocompatibility are completely solved. Until then, it appears that the user-friendly point of care type stat analyzers that can provide accurate values for all the key analytes, used in conjunction with existing noninvasive trend monitors (eg, pulse oximetry), will offer the most attractive approach for the effective treatment of critically ill patients.

Unstable angina occurs in a heterogeneous population of patients. In the subset of patients with recent rest angina, both angiographic and angioscopic studies have suggested that coronary artery thrombus is often present and serves as a predictor of subsequent adverse clinical events, including recurrent angina, myocardial infarction, the need for urgent coronary revascularization, and death. Studies of thrombolytic therapy in small populations of patients with unstable angina suggest it may lyse coronary thrombus, raise the ischemic threshold, and possibly have a favorable influence on clinical outcome. Large multicenter trials of patients with unstable angina and non-Q-wave infarction have been designed to answer several questions: Will rt-PA produce improvement in angiographically determined coronary arterial stenoses? Is rt-PA superior to conventional therapy? Is there a need for routine angiography, followed by revascularization, in suitable patients? Until these questions are answered, the role of thrombolytic therapy in patients with unstable angina remains speculative.