A Safe Procedure for Diagnosis of Pneumocystis carinii Pneumonia

Regardless of the specialty interest of the readership, medical journals have many attributes in common, including similar editorial procedures. Where can the new editor learn his skills? These are no "residencies" in medical editorship. Nevertheless, the neophyte who acknowledges the complexity and responsibilities of his new profession will seek assistance. Recently, I received phone calls from Dr. Hildner and Mr. Kao; they expressed the wish to observe the scientific and administrative aspects of the publications of the American College of Chest Physicians. Frank Hildner, M.D., of the Mount Sinai Medical Center, Miami Beach, and University of Miami School of Medicine, is an accomplished investigator and teacher and an authority in the realm of cardiovascular hemodynamics. He serves as consultant for several major cardiovascular journals. Recently named Editor-in-Chief of a proposed new journal, Dr. Hildner sought knowledge of the procedures we use in editorial review. He suggested a preceptorship in my editorial offices. Those days of preceptorship were rewarding ones for both "teacher" and "pupil." I shared with him my philosophy that the editor must constantly be alert to the possibility that he may possess subtle prejudices which could result in subjective responses to certain authors or subjects. Such insight is mandatory if impartiality is to be achieved. The editor possesses awesome powers which, if exercised incorrectly, could delay or abort reports of enormously important data. There is also the possibility of error which may facilitate the publication of trite or fallacious material to burden or confuse an international readership. Conscious or unconscious bias may interfere with the judgment of referees and the editor must constantly be aware of this possibility. Obviously, friendship or an author's position of high authority cannot be a factor in decision making. I analyzed approaches which can be used to adjudicate between conflicting reviews of two or more consultants. We discussed the role of the editor in the evaluation and disposition of reports of ethically questionable research. Above all, I emphasized my faith in an open editorial office; I encourage authors to communicate by phone or by letter when they disagree with the conclusions of an editorial review. The author deserves the privilege of reading the referee's detailed criticism, and if fundamental differences of opinion exist, I believe that we should extend the privilege of further review. Later that week, we were joined by Mr. John Kao, who is particularly interested in the managerial aspects of medical journalism including circulation, office procedures, printing and artwork. Since the American College of Chest Physicians is the publisher of Chest, my staff and I are responsible for the layout, choice of paper stock, and printing

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styles. These techniques and duties were described by Mrs. Sylvia Peterson, Executive Editor of Chest; Mr. Howard Hagemann, National Advertising Representative; and Mrs. Margaret Martinecz, head of the circulation department. We considered the differences between regular issues of the journal and special supplements to Chest, as well as the characteristics of the special scientific publications of the American College of Chest Physicians. The complete medical editor must understand how the appearance of the page enhances or detracts from the learning process. The position and type size of the synopsis-abstract, the use of four-color printing, the design of the cover, the masthead, the vexing problems of "widows" at the end of paragraphs; all these are essential aspects of the editor's responsibilities. It was heartening to see the spirit of serious intent which Dr. Hildner and Mr. Kao brought to their new positions. Their quest for an editorial preceptorship manifests their belief in the unique teaching possibilities granted to the editor. Their energy, imagination and integrity augur well for the future of their periodicals. Alfred Soffer, M.D., F.C.C.P. Chicago

A Safe Procedure for Diagnosis of Pneumocysfis carinii Pneumonia Safety, simplicity, and successful results are paramount requirements of any biopsy procedure. This is true especially of patients who are desperately iII, as are many affiicted with pneumonia due to Pneumocystis carinii. Use of very small flexible forceps through a fiberoptic bronchoscope as reported by Scheinhorn, Joyner, and Whitcomb (see page 294) seems to be just such a procedure. This protozoan organism needs to be morphologically identified by staining techniques and cannot be grown on culture medium. Examination of sputum, tracheal and bronchial secretions, and even peripheral bronchial brushings has not been reliable. Examination of pulmonary tissue or touch preparations from tissue has been necessary for dependable results. The quest has been, therefore, to find the safest and simplest method of obtaining pulmonary tissue. Transbronchoscopic lung biopsy using a rigid bronchoscope and a flexible forceps with a cup of approximately 2 by 4 mm dimensions is also a safe and simple procedure. This seems to be a reasonable compromise between the pathologist's insatiable appetite for more tissue (such as the entire lungl) and his frustration with tiny flecks of material. If the small cup on the forceps with a fiberoptic bronchoscope can provide sufficient material, however, this

CHEST, 66: 3, SEPTEMBER, 1974

is a very satisfactory method. Complications from either forceps will be less than with any transthoracic method. A word of caution may be in order. Many patients with pneumonia due to Pneumocystis carinii are critically ill and hypoxic prior to bronchoscopy. Use of a fiberoptic bronchoscope transnasally compromises the airway and may produce deepening hypoxia. In such a patient, an intratracheal tube should be used for concomitant administration of oxygen. Use of the rigid bronchoscope also allows for supplemental oxygenation. Although Scheinhorn et al have not encountered the complication of bleeding as yet, this should be an anticipated hazard, which also can be handled very satisfactorily through a rigid bronchoscope. If the endoscopist elects to use the flexible instrument for biopsy, he should have the rigid bronchoscope handy and should be capable of using it for aspiration of blood and for packing the appropriate segmental bronchus with narrow gauze tape should bleeding ensue. Observance of these precautions (supplemental oxygenation and availability of a rigid bronchoscope) makes the "bedside" performance of this type of biopsy inadvisable. The simplicity of the procedure described by Scheinhorn et al appeals to me. I hope that my pathologists will not scream when I send them even smaller bits of tissue than previously. Howard A. Andersen, M.D., F.C.C.P.· Rochester, Minn °Mayo Clinic. Reprint requests: Section of Publications, MallO Clinic,

Rochester, Minnesota 55901

Overview of the Sick Sinus Syndrome The descriptive name, sick sinus syndrome, was coined by FerrerI in 1968 in an article characterizing the various clinical subgroups of sinus dysfunction. Since Ferrer's report, extensive documentation of the wide variety of clinical situations which make up the broad syndrome of sinus dysfunction has been obtained. It is important, as presented by Aroesty and co-workers in this issue of Chest (see page 257), to recognize that there are subgroups of this syndrome characterized by: bradycardia! tachycardia, spontaneous paroxysmal sinus arrest, persistent sinus bradycardia, and hypersensitive carotid sinus. However, from a clinical standpoint in which the disease process produces symptoms, the "sickness" lies in the markedly delayed or absent escape mechanism; therefore, a better term might be the "sick escape pacemaker syndrome." Of additional import is the observation that some patients have severe but infrequent symptoms making identification of the etiologic background of their symptoms a difficult task. Of the various methods for the evaluation of sinus

CHEST, 66: 3, SEPTEMBER, 1974

node function carotid sinus massage, valsalva maneuvers, and pharmacologic intervention, the deter-" mination of sino-atrial node recovery time after atrial overdrive pacing has proved to be the most sensitive method for the detection of sinus node dysfunction. 2 Of importance, occult cases of sinus node dysfunction have been discovered utilizing overdrive pacing. Moreover, Rosen et al3 have demonstrated with atrial pacing that abnormalities of AV conduction are frequently found in patients with sinus dysfunction. Although the use of programmed premature atrial depolarizations is not as effective as overdrive pacing in demonstrating prolonged sino-atrial node recovery times, the former method has been utilized by Strauss and co-workers4 to calculate conduction time from the sinus node to the atrium. In this regard, Childers et al5 have observed in man and produced in dogs, premature atrial depolarizations resulting in sino-atrial reentry. We may postulate that in patients with sinus dysfunction the mechanism of intermittent tachyarrhythmias may be due to sino-atrial node reciprocation based, in part, on a depressed sinus to atrial conduction time. Medical management of patients with overt sinus dysfunction has not been effective because belladona preparations do not produce consistent or significant rate increases. Furthermore, beta stimulating agents are not well tolerated by the patients and their activity is short-lived. Therefore, the vast majority of symptomatic patients are ultimately treated by permanent transvenous pacemaker insertion. Since artificial pacing does not usually eliminate tachyarrhythmias in the bradycardia!tachycardia syndrome, supplemental antiarrhythmic drug therapy is frequently needed as discussed by Dr. Aroesty and co-workers. The careful perspective evaluation of a group of patients with the bradycardia!tachycardia syndrome by Aroesty and co-workers has indicated that this combination therapy can successfully modify the clinical course of patients with this syndrome. The major point of their study is that long-term prognosis for patients with this syndrome is related to the severity of underlying disease such as myocardial infarction, ventricular arrhythmias, and primary renal disease. These findings are in concert with the observations by Rubenstein et alB who found that coronary heart disease was the etiologic factor in more than half of their patients with sinus dysfunction. Dr. Aroesty and co-workers' study serves to point out again that this syndrome of sinus dysfunction is most frequently encountered in the elderly and that these patients commonly have extensive additional medical problems. Nevertheless, satisfactory therapy can be achieved in many patients with sinus dysfunction if appropriate diagEDITORIALS 223