had bronchitis by clinical diagnosis alone, six had infections {tuberculosis, bacterial fungal), two had CHF, and seven had other diagnoses ( interst i t ial fibrosis, granula t ion tissue, en- dometriosis, ep i s t ax i s , va scu l i t i s , a s t h m a , and l ipoid pneumonia). The three factors correlat ing best with malig- nancy were: age greater t han 40; any abnormal i ty on the chest film; and hemoptysis last ing more than one week. The authors suggest t ha t if one of these is present, bronchoscopy should be done. Smoking history, weight loss, cough, and anemia were also significant correlates, but had a h igher percentage of false positives. If these are present in the ab- sence of the major indications for bronchoscopy, the proce- dure may be indicated, part icularly if the pa t ient is at low risk for developing complications. Ken Kulig, MD

diagnostic tool, fiberoptic bronchoscopy, hemop- tysis; fiberoptic bronchoscopy, diagnostic tool

Steroid therapy for pneumonitis induced in rabbits by aspiration of foodstuff. Wynne JW, Reynolds JC, Hood CI, et al, Anesthesiology 51:11-19, (Jul) 1979. Corticosteroid therapy in aspirat ion pneumonit is is contro- versial, with exper imental studies yielding conflicting re- sults. Most of these studies have focused on damage done by acid solutions of pH 2.5 or less, th is degree of acidity hav ing been identified as the level necessary to produce damage to lung tissue. It has been suggested, however, t ha t gastric as- pirate containing small food particles can produce severe pulmonary damage even with the pH above 2.5. The damage due to small food particles in a h igher pH solution and the protective effects of pos tasp i ra t ion cort icosteroid the rapy were studied in New Zealand rabbits. The rabbi ts received either 0.5 ml/kg of normal saline (19 animals) or 0.5 ml/kg of coarsely filtered gastric aspi ra te (human, pH 4.3)(49 ani- mals) instilled via catheter into the left d iaphragmatic lobe 0fthe lung. Of the group receiving the gastric aspirate, 26 of the 49 were t reated with methylprednisolone 30 mg/kg in- tramuscularly three t imes a day. Trea tmen t began one hour post-instillation and continued for three days in unsacrificed animals. Rabbits were sacrificed at one, three, seven, and 21 days. Lungs were t hen graded for evidence of pathologic changes by taking radiographs of lung slices and evaluat ing microscopic sections. The saline control group showed no evi- dence of continuing changes by day seven. The gastric aspi- rate group showed no significant differences between the un- treated and steroid-treated subgroups ei ther in degree of in- jury or speed of resolution. Both subgroups showed extensive reaction on day seven which was nearly cleared by day 21. The steroid-treated animals had less fibroblastic proliferation and fewer macrophages present in the affected areas of the lung but also had increased numbers of polymorphonuclear leukocytes. This g roup also had a g r ea t p r e v a l e n c e of granuloma necrosis and dystrophic calcification during the resolution phase. It is concluded t ha t aspirat ion pneumonit is may be caused by foodstuff containing gastric aspirate of pH above 2.5 and t ha t no clear benefit has been demonstrated in the a d m i n i s t r a t i o n of s t e ro ids a f t e r t he a s p i r a t i o n of foodstuffs. (Editor's note: While arguing across species is al- ways dangerous, it does seem to increase a growing suspicion that steroids are overused in clinical medicine.)

Stephen V. Cantrill, MD

aspiration p n e u m o n i t i s , t r e a t m e n t , s t e r o i d s ; lung , as- piration, pneumonitis, steroid treatment

Clinical indicators of left main coronary artery dis- ease in unstable angina. Plotnick GD, Greene HL, Carliner NH, et al, 91:149-153, (Aug) 1979. Studies have suggested tha t bypass surgery improves survi- val in symptomatic pat ients with left main coronary disease. The authors, in an a t tempt to determine if there are any noninvasive indicators of left main disease, reviewed 200 consecutive patients with unstable angina who underwent coronary angiography. Left main disease was found in 17.5%. No differences were noted in those with and without main

disease wi th regard to age, sex, e lec t rocard iogram, ar- r h y t h m i a s , response to medical therapy , or r i sk factors. There were h igher incidences of crescendo angina, t r ans ien t ST depression with pain, and fluoroscopic calcification of the left main coronary ar tery in the left main group, but these factors were of low sensit ivi ty land/or low predictive value. The authors conclude t ha t left main disease cannot be reli- ably predicted clinically, and tha t angiography is the only reliable diagnostic test. Brian Allen, MD cardiac disease, left main artery, noninvasive indi- cators

Physostigmine reversal of diazepam-induced hyp- nosis. Avant GR, Speeg KV, Freemon FR, et al, Ann Intern Med 91:53-55, (Jul) 1979.

Eight male volunteers were given intravenous (IV) infusion of diazepam sufficient to produce sleep. Sleep was reversed in all subjects given physostigmine IV within 5.5 min to 12.3 min, compared to none given saline infusion. Blood levels of d i azepam were not a l t e red s ign i f i can t ly by in fus ion of p h y s o s t i g m i n e . S leep r e v e r s a l was p e r m a n e n t . The mechanism of the sleep reversal is unknown. Six of eight volunteers developed nausea and one developed an episode of a t r i a l f lu t ter wi thout apparen t under ly ing h e a r t disease. (Editor's note: Since diazepam is a relatively mild drug, there will be few indications in the ED for such reversal. Exception may be the overdosed child whose vital signs are impaired. The drug d id not appear to af fect re sp i ra t ions in th is stuct~.) Peter Rosen, MD drug treatment, physost igmine, sleep reversal; physostigmine, sleep reversal

Avoidance of esophageal stricture following severe caustic burns by the use of an intraluminal stent. Mills L J, Estrera AS, Platt MR, Ann Thorac Surg 28:60-65, (Jul) 1979. Four cases of severe caustic esophageal burns t reated with explora tory l aparo tomy/gas t ro tomy and an i n t r a l u m i n a l silicone s tent are presented. Criteria for laparotomy were the presence of second and thi rd degree esophageal burns as es- tablished by esophagoscopy, or the persistence of a n alkaline gastric pH after gentle saline lavage. Full thickness gastric bu rns are t rea ted by esophagogastrectomy, whereas non- t r ansmura l gastric burns are t reated with the in t ra lumina l silicone stent. These four pat ients with non t ransmura l gas- tric burns received, in addition to the stent, a 10-day course of i n t r a v e n o u s (IV) cephalospor in t he rapy and a 21-day course of 1 mg/kg IV methylprednisolone which was then ta- pered. On the 21st day, a bar ium swallow revealed a mildly di lated esophagus with the s tent suspended freely in the lu- men. There were no late esophageal str ictures, and contrast and manometr ic studies in three of the four pat ients have revealed nearly normal esophageal function up to 20 months following injury. (Editor's note: For the ED this article reaf- f irms the necessity for early esophagoscopy. The evidence for the benefit of both steroids and antibiotics is debatable.)

Steven W. Cooley, MD burns, esophageal, intraluminal stent; stenting, pre- vention of esophageal stricture

Reduction in road fatalities and injuries after legis- lation for compulsory wearing of seat belts: experi- ence in Victoria and the rest of Australia. McDer- mott FT, Hough DE, Br J Surg 66:518-521, (Jul) 1979. The introduction of legislation in 1970 for compulsory wear- ing of seat belts in Victoria and soon after in other Austral- ian s ta tes preceded significant reductions in road injuries and fatalit ies among vehicle occupants. The wearing of seat belts increased from 15% the year before legislation to 90% by 1977. Linear regression analysis shows significantly re- duced driver and passenger injury rates throughout Aus-

9:5 (May) 1980 Ann Emerg M e d 283/71