Massive hemoptysis.

Hemoptysis is usually a symptom of cardiopulmonary disease and is generally not in itself associated with death. A blood loss into the tracheobronchial tree of 600 ml in 24 hours or at a rate that poses a threat to life is referred to as massive hemoptysis. Hypervascularity within the bronchial circulation, usually associated with diffuse inflammatory disease of the lung, is common in patients with massive hemoptysis. Management should be directed at maintenance of oxygenation and localization of the source of bleeding. Temporizing maneuvers such as iced saline lavage, intravenous administration of vasopressin, endobronchial tamponade and bronchial artery embolization will often stabilize the patient in preparation for definitive surgery. Such a sequential plan of management may result in a 50% reduction in the rate of death from massive hemoptysis, which is otherwise 50% to 100%.     

急诊介入栓塞治疗支气管动脉-肺动脉瘘大咯血的效果

目的:观察急诊介入栓塞治疗支气管动脉-肺动脉瘘大咯血患者的疗效,分析栓塞剂的选择及合理应用,为临床研究提供参考。方法:30例支气管动脉-肺动脉瘘大咯血患者采用急诊介入造影检查,使用丙烯酸微球和明胶海绵条对出血动脉行急诊栓塞治疗,对动脉造影表现及治疗结果进行回顾性分析。结果:共找到并成功栓塞42支出血的支气管动脉,28支采用单独丙烯酸微球栓塞治疗,14支行丙烯酸微球与明胶海绵条联合栓塞治疗。栓塞术后随访1年,所有患者栓塞术后均无再次咯血及严重并发症出现。结论:急诊动脉栓塞治疗支气管动脉-肺动脉瘘大咯血是一种安全、有效的微创治疗手段。合理的选择和使用栓塞剂是确保栓塞治疗成功的的关键。     

大咯血介入治疗失败的罕见原因：腹腔动脉系统参与供血（附2例报告及文献复习）

目的：咯血的主要责任血管是支气管动脉,非支气管性体动脉参与供血是大咯血介入治疗失败的重要原因,腹腔动脉系统分支动脉参与供血更为罕见。本文通过收集相关病例,结合国内外相关研究,提高对腹腔动脉系统分支动脉为咯血责任动脉的认识,探讨其可能的病理机制、危险因素。方法：回顾分析2例腹腔动脉系统分支（胃左动脉、肝左动脉）参与大咯血供血动脉的临床及影像学资料,并报道介入栓塞治疗的效果。结果：2例患者均为支气管动脉栓塞后再发大咯血,再次血管造影显示1例肝左动脉参与供血,1例胃左动脉参与供血。栓塞上述血管后,患者止血成功。病变位于下肺、伴有胸膜增厚,提示有腹腔动脉系统分支动脉参与供血的可能。术前仔细阅读患者影像学资料,术前行主动脉分支动脉CT血管成像,可减少对责任性非支气管性体动脉的遗漏。结论：腹腔动脉系统参与供血是介入栓塞治疗后咯血复发的少见原因,了解其病理机制、危险因素,及时进行栓塞,可以降低咯血的复发率。     

Radiotherapy and technetium-99m-labeled red blood cell scintigraphy for hemoptysis from chronic MRSA infection

Aim

To discuss the application of external beam radiotherapy (EBRT) and technetium-99m-labeled red blood cell scintigraphy (LRBCS) in life-threatening hemoptysis from a non-malignant condition.

Materials and methods

This case report presents a patient with persistent hemoptysis secondary to chronic Methicillin-resistant Staphylococcus aureus (MRSA) infection in whom conventional management failed to localize the site of pulmonary bleeding or to provide effective therapy.

Results

EBRT was successfully given for life-threatening hemoptysis with improvement in quality of life for nearly 1 year. LRBCS was used to localize the source of further bleeding and facilitate targeted therapy.

Conclusion

EBRT can be an effective and well-tolerated modality in treating life-threatening hemoptysis refractory to conventional methods. LRBCS is a non-invasive diagnostic tool that can be used to detect the source of pulmonary bleeding.     

Outcomes of Bronchial Artery Embolization for Life-Threatening Hemoptysis Secondary to Tuberculosis

Objective

To appraise the immediate and long-term outcomes of bronchial arterial embolization for life-threatening hemoptysis secondary to tuberculosis.

Methods

112 patients with life-threatening hemoptysis due to tuberculosis underwent bronchial artery embolization from January 2004 to February 2014. Life-threatening hemoptysis was defined as expectoration of at least 400 ml of blood in 24 hour. The median follow-up is 20 months, ranging from 2 to 52 months.

Results

The hemoptysis control rate was 86.6% at 14 days, 84.8% at 30 days, 78.6% at 240 days, 75.9% at 360 days, respectively. None of these characteristics, including gender, age and tuberculosis status, was significantly associated with immediate control of bleeding. Patients with active tuberculosis had a significantly longer recurrence-free duration than did patients with inactive tuberculosis (P = 0.040), which was further confirmed by Cox regression hazards model (P = 0.046). There was no spinal cord complication or mortality related to bronchial artery embolization. The most common complication was transient chest pain.

Conclusion

Bronchial arterial embolization is an effective and safe technique in the management of life-threatening hemoptysis secondary to tuberculosis. Active tuberculosis may be associated with a lower rate of recurrence of hemoptysis.     

Fatal ischaemic brain oedema after early thrombolysis with tissue plasminogen activator in acute stroke.

Two patients with acute major, disabling cerebral infarction with presumed middle cerebral artery occlusion were treated with the clot specific thrombolytic agent tissue plasminogen activator roughly three and a half hours after the onset of symptoms. Both patients had a normal computed tomography (CT) scan before treatment. No appreciable systemic bleeding complications occurred, apart from bruising. One patient had bleeding into the subarachnoid space from a microscopic angioma, which was found at necropsy. Haematological monitoring of the two patients showed pronounced fibrinogenolysis and alpha 2 antiplasmin consumption in one. One patient showed transient improvement during the infusion. In both cases extensive infarction, partly haemorrhagic in one, with massive concomitant oedema was found on repeated CT. Both patients deteriorated and eventually died as a consequence of transtentorial herniation. In the one patient who came to necropsy a moderate, probably pre-existing smooth stenosis of the ipsilateral carotid artery was found, all cerebral vessels being patent. It is concluded that thrombolytic treatment with a clot specific agent such as tissue plasminogen activator started three to four hours after a major ischaemic stroke may be hazardous, not because of haemorrhagic transformation of the original ischaemia but because early reperfusion may promote massive, potentially fatal cerebral oedema.     

D-二聚体和纤维蛋白原水平预测支气管动脉栓塞术治疗支气管扩张大咯血临床疗效及预后的临床价值

目的:探讨D-二聚体和纤维蛋白原水平预测支气管动脉栓塞术治疗支气管扩张大咯血的临床疗效及预后的临床价值。方法:选取50例2011年11月至2016年11月期间于我院治疗的支气管扩张大咯血患者进行研究,所有患者均进行支气管动脉栓塞术治疗,根据临床疗效评价标准结果分为总有效组(n=40)和无效组(n=10),随访1年,根据预后的复发情况分为预后好组(n=38)和预后差组(n=12),分别比较总有效组和无效组、预后好组和预后差组D-二聚体和纤维蛋白原水平,采用受试者工作特征(ROC)曲线分析D-二聚体和纤维蛋白原对支气管扩张大咯血患者的预测价值。结果:手术后总有效组和无效组患者D-二聚体、纤维蛋白原水平均高于手术前,且总有效组高于无效组(P0.05)。手术后预后好组和预后差组患者D-二聚体、纤维蛋白原水平均高于手术前,且预后好组高于预后差组(P0.05)。ROC曲线分析显示,D-二聚体和纤维蛋白原对支气管扩张大咯血患者均具有较高的敏感度和特异度,曲线下面积分别为0.725和0.806。结论:采用支气管动脉栓塞术治疗支气管扩张大咯血,疗效及预后比较好的患者D-二聚体和纤维蛋白原水平均较高,并且其敏感度和特异度较高,具有一定的临床预测价值。     

Primary pulmonary botryomycosis: case report

A case is presented of pulmonary botryomycosis in a 61-year-old man with a massive right-side pulmonary infiltrate which looked like a tumor (on X-ray). Microscopic examination of a transbronchial biopsy specimen revealed chronic suppurative inflammation, which did not regress despite intensive antibiotic therapy for a period of two months. Histological analysis of specimens taken during surgery for hemoptysis revealed pulmonary botryomycosis. The disease was diagnosed on the basis of characteristic eosinophilic granules in which the bacteria are surrounded by protein material (Splendore-Hoeppli phenomenon). Pulmonary actinomycosis was excluded. The case demonstrates that pulmonary botryomycosis can have the appearance of a mass which resembles pulmonary carcinoma on X-ray, and may also be mistaken for pulmonary actinomycosis. For this reason, pulmonary botryomycosis, although rare, should be excluded during differential diagnosis of hemoptysis or pulmonary infiltrates.     

Bronchial artery embolization for management of massive cryptogenic hemoptysis: a case series

Introduction

Hemoptysis constitutes a common and urgent medical problem. Swift and effective management is of crucial importance, especially in severe, life-threatening cases. In cases of idiopathic hemoptysis, in which no underlying pulmonary pathology can be identified, treatment is challenging. We report our experience with bronchial artery embolization in the treatment of massive idiopathic hemoptysis.

Cases presentation

We report three consecutive cases of acute severe idiopathic hemoptysis. Our patients (two men aged 51 and 56 years and one woman aged 46 years), were of Caucasian ethnicity. We discuss the results and management of the patients, and review the literature. All three patients were treated safely and successfully with transcatheter embolization of the bronchial arteries using tris-acryl gelatin microspheres. Hemoptysis was controlled. All cases were followed up for 12 months, and there was no recurrence of bleeding.

Conclusion

Bronchial artery embolization is an effective tool for the evaluation and treatment of massive idiopathic hemoptysis.

     

Improving Decision Making for Massive Transfusions in a Resource Poor Setting: A Preliminary Study in Kenya

BackgroundThe reality of finite resources has a real-world impact on a patient’s ability to receive life-saving care in resource-poor settings. Blood for transfusion is an example of a scarce resource. Very few studies have looked at predictors of survival in patients requiring massive transfusion. We used data from a rural hospital in Kenya to develop a prediction model of survival among patients receiving massive transfusion.MethodsPatients who received five or more units of whole blood within 48 hours between 2004 and 2010 were identified from a blood registry in a rural hospital in Kenya. Presenting characteristics and in-hospital survival were collected from charts. Using stepwise selection, a logistic model was developed to predict who would survive with massive transfusion versus those who would die despite transfusion. An ROC curve was created from this model to quantify its predictive power.ResultsNinety-five patients with data available met inclusion criteria, and 74% survived to discharge. The number of units transfused was not a predictor of mortality, and no threshold for futility could be identified. Preliminary results suggest that initial blood pressure, lack of comorbidities, and indication for transfusion are the most important predictors of survival. The ROC curve derived from our model demonstrates an area under the curve (AUC) equal to 0.757, with optimism of 0.023 based on a bootstrap validation.ConclusionsThis study provides a framework for making prioritization decisions for the use of whole blood in the setting of massive bleeding. Our analysis demonstrated an overall survival rate for patients receiving massive transfusion that was higher than clinical perception. Our analysis also produced a preliminary model to predict survival in patients with massive bleeding. Prediction analyses can contribute to more efficient prioritization decisions; these decisions must also include other considerations such as equity, acceptability, affordability and sustainability.     

SPONTANEOUS SUBARACHNOID HEMORRHAGE

Sudden development of pain in the head followed by evidences of meningeal irritation, with or without motor or sensory symptoms or signs, is almost pathognomonic of subarachnoid hemorrhage. The final diagnosis rests upon the demonstration of blood in the cerebrospinal fluid. If the hemorrhage is massive, or from an aneurysm of an unprotected arterial trunk, the patient may die in a comparatively short time. If the bleeding is less abundant and from an aneurysm which is protected by adjacent structures the patient may survive. Angiography should probably be done early in most cases. If neurological signs or the results of angiography indicate that the aneurysm is in such a location that surgical treatment is feasible it should probably be undertaken. If medical treatment is to be carried out the patient should have protracted rest, frequent spinal drainage so long as the cerebrospinal fluid contains blood or is under materially increased pressure, sedatives and analgesics, and passive movements of the neck and limbs to forestall limitation of motion of joints.     

Study of statistical correlations in DNA sequences

Here we present a study of statistical correlations among different positions in DNA sequences and their implications by directly using the autocorrelation function. Such an analysis is possible now because of the availability of large sequences or even complete genomes of many organisms. After describing the way in which the autocorrelation function can be applied to DNA-sequence analysis, we show that long-range correlations, implying scale independence, appear in several bacterial genomes as well as in long human chromosome contigs. The source for such correlations in bacteria, which may extend up to 60 kb in Bacillus subtilis, may be related to massive lateral transfer of compositionally biased genes from other genomes. In the human genome, correlations extend for more than five decades and may be related to the evolution of the ’neogenome’, a modern evolutionary acquisition composed by GC-rich isochores displaying long-range correlations and scale invariance.     

经股动脉导管介入支气管动脉栓塞救治难治性大咯血

目的：1996—3至2005—12期间我科与介入放射科合作,对66例内科方法未能止血的大咯血患者行支气管动脉介入栓塞术止血。观察分析止血效果及并发症。方法：患者在1250数字减影机下,经股动脉插入美国COOK公司生产的3—5FCobra导管。找到支气管动脉,造影后确定出血部位,在明确无栓塞禁忌症后,以明胶海绵粉末或PVA颗粒栓塞支气管动脉,观察止血状况及并发症。结果：总体止血率95．3％（61／64）,半年内9例复发咯血,但咯血量明显减小,复发率14．1％（9／64）。仅1例栓塞后未止血。2例动静脉瘘患者不能实行栓塞。15例出现发热,占23．4％（15／64）,所有患者均不同程度出现气短,吸氧后缓解。结论：支气管动脉栓塞救治难治性大咯血十分有效、可靠且较为安全。     

Fetomaternal hemorrhages and their importance in perinatal pathology]

Transplacental haemorrhage is usually studied as an aspect of Rh immunisation prevention. In this paper the authors emphasize importance of this syndrome in noe-natology, as massive transplacental blood loss may result in severe foetal and neo-natal anemia or even lead to intra uterine death. Different technics for evidencing the presence of fetal cells in the mother's circulation are first discussed, the acid elution method appearing to be the easiest and fastest one. Results of nearly 40.000 Kleihauer's tests screening routinely performed in Paris at the time of delivery, are reported. The much higher frequency of very large transplacental haemorrhage is pointed out in cases of stillbirth. On a practical point of view, routine testing for transplacental haemorrhage finds its major interest in Rh prevention. A formula is proposed by one of the authors to calculate the most accurate dose of passive anti-D antibody in relation with quantitation of fetal haemorrhage. At last the autors attempt a new approach to the problem of neonatal unexplained anemias. Two different types of fetal bleeding are postulated, either chronic associated with haematologic signs of regeneration, or massive at the time of delivery without haematologic symptomatology. These condtions could lead to two different clinical pictures, either hydropsfetalis when chronic, or hypovolemic schock when massive and immediate.     

Risk Factors for Hemoptysis in Idiopathic and Hereditary Pulmonary Arterial Hypertension

Introduction

When hemoptysis complicates pulmonary arterial hypertension (PAH), it is assumed to result from bronchial artery hypertrophy. In heritable PAH, the most common mutation is in the BMPR2 gene, which regulates growth, differentiation and apoptosis of mesenchymal cells. The aim of this study is to determine the relationship in PAH between the occurrence of hemoptysis, and disease progression, bronchial artery hypertrophy, pulmonary artery dilation and BMPR2 mutations.

Methods

129 IPAH patients underwent baseline pulmonary imaging (CT angio or MRI) and repeated right-sided heart catheterization. Gene mutations were assessed in a subset of patients.

Results

Hemoptysis was associated with a greater presence of hypertrophic bronchial arteries and more rapid hemodynamic deterioration. The presence of a BMPR2 mutation did not predispose to the development of hemoptysis, but was associated with a greater number of hypertrophic bronchial arteries and a worse baseline hemodynamic profile.

Conclusion

Hemoptysis in PAH is associated with bronchial artery hypertrophy and faster disease progression. Although the presence of a BMPR2 mutation did not correlate with a greater incidence of hemoptysis in our patient cohort, its association with worse hemodynamics and a trend of greater bronchial arterial hypertrophy may increase the risk of hemoptysis.     

An adult cystic fibrosis patient presenting with persistent dyspnea: case report

Background

Hemoptysis is a significant clinical presentation in respiratory medicine. Often a life threatening emergency, it mandates prompt assessment and intervention. Various investigations and management protocols are proposed globally, to advocate a standardized approach towards patients presenting with hemoptysis. It is the etiology, however, that has been known to influence clinical outcome and prognosis. With marked contrast in geographical patterns of pulmonary pathologies, etiological agents for hemoptysis vary over the world. Studies in West, usually demonstrate neoplastic and non-granulomatous causes to be the leading agents for hemoptysis. The diagnostic accuracy of various investigations and efficacy of management alternatives has been established there. Developing nations differ in their burden of diseases of lung. Lack of health resources and initiative often prevent quality research in critical areas.

Design

This is a retrospective observational study with a cross-sectional design in which charts of all patients admitted with the presentation of haemoptysis in the past ten years will be reviewed, at Aga Khan University Hospital, Karachi, Pakistan. A series of variables, based on previous literature on haemoptysis related to the objectives of present study, will be determined in the study. Demographics, co-morbids and etiology will be determined. Findings of various investigation modalities and their accuracy in localizing the bleeding site will be determined. Efficacy of different management strategies will also be observed. Also observed will be any complications and follow-up.

Discussion

Pakistan is a third world nation of over 150 million, established as highly endemic for pulmonary tuberculosis. To date no study has been generated to look into hemoptysis patterns, in this nation. Lack of evidence based medicine poses a major hindrance towards confident decision-making in the approach towards a patient presenting with hemoptysis in this country. This study is devised to obtain the first insight in this direction, from this part of the world. The etiologies, accuracy of various investigations and efficacy of treatment options will be investigated. The results and conclusions will prove to be of value not just for health administrators in this country, but many other regions that share similarities in patterns of pulmonary pathologies.     

The role of muscle flaps in pulmonary aspergillosis

Pulmonary invades the lung parenchyma and vessels, causing necrotizing pneumonia and massive hemoptysis in immunocompromised patients. Medical treatment alone often fails to clear the organism. Early surgical intervention is advocated in localized disease to remove infection near pulmonary vessels. The resection is limited in an attempt to preserve as much lung function as possible. However, preexisting cavitations and lung disease predispose to postoperative space problems, including prolonged air leak, bronchopleural fistula, and empyema. Muscle flaps provide a solution to these problems by obliterating residual space and providing protective coverage to the bronchial stump. The authors present four cases of pulmonary aspergillosis treated by multimodality therapy and extrathoracic muscle flap transposition. Factors that may contribute to successful treatment include underlying condition of the host and history of cancer, radiation therapy, and great vessel involvement. Despite aggressive medical and surgical therapy, pulmonary aspergillosis has a poor prognosis.     

Premedication with meloxicam exacerbates intracranial haemorrhage in an immature swine model of non-impact inertial head injury

Meloxicam is a cyclo-oxygenase-2 (COX-2) preferential non-steroidal anti-inflammatory drug with very effective analgesic and anti-inflammatory effects in swine. Previous reports in piglets have demonstrated that meloxicam also inhibits COX-1 and reduces production of thromboxane significantly. We use preinjury analgesia in our immature swine (3-5-day-old piglets) model of brain injury using rapid head rotations without impact. In 23 consecutive subjects we found that premedication with meloxicam (n = 6) produced a significantly higher mortality rate (5/6 or 83%) than buprenorphine (n = 17, 1/17 or 6%, P < 0.02). On gross neuropathological examination of the meloxicam-treated swine, we observed massive subdural and subarachnoid bleeding which were not present in buprenorphine-premedicated animals. To our knowledge there are no previous reports in swine of increased bleeding or platelet inhibition associated with meloxicam administration and further research is needed to define mechanisms of action in piglets. We caution the use of meloxicam in swine when inhibition of platelet aggregation might adversely affect refinement of experimental research protocols, such as in stroke, trauma and cardiac arrest models.     

North American paragonimiasis. A case report

BACKGROUND: Paragonimiasis is a parasitic infection with a predilection for pulmonary involvement. Paragonimus species occur throughout the world and exist in nature in a snail-crustacean-mammalian life cycle. Human disease is most frequently encountered in cultures that ingest raw or undercooked crustaceans. North American paragonimiasis, caused by an endemic Paragonimus species, Paragonimus kellicotti, predominantly causes disease in carnivorous and omnivorous animals but may cause human disease if the intermediate host, the crayfish, is ingested raw or undercooked. CASE: A previously healthy, 21-year-old male was infected with P kellicotti and developed parasitic hemoptysis. The disease was contracted through the ingestion of local, undercooked crayfish. Diagnosis was established through the morphologic examination of eggs in the cytologic preparation of bronchioalveolar lavage fluid. The patient was successfully treated with praziquantel and recovered without incident. CONCLUSION: Paragonimiasis is a cause of parasitic hemoptysis worldwide. Paragonimiasis is infrequently encountered in North America and is usually not considered in the differential diagnosis of hemoptysis unless specific risk factors are known. The cytologist or cytopathologist, therefore, may be the first to encounter the diagnostic eggs and should be familiar with this disease.     

Relations between submarginal and marginal sori in ferns IV. The sori of Osmunda and selected Schizaeaceae and their morphological relations

Developmental types of sori in Osmunda and Schizaeaceae are comparatively studied and discussed in a systematic context. (1) The ``simultaneous marginal sorus' is characterized by a minute knob-like receptacle representing the thickened tip of a short costa, simultaneous initiation of massive sporangia, and absence of indusia. (2) The ``acropetal marginal sorus' is characterized as an accessory outgrowth at the end of a costa or at the margin of a sorophore, comprising a minute or elongated bifacial receptacle, acropetal initiation of massive marginal sporangia, and minute or long-extended or hood-shaped upper indusia. The state of superficial singly-arranged massive sporangia such as in Todea may give rise to the Osmunda type of the simultaneous marginal sorus and to the Schizaeaceae types of the acropetal marginal sorus. Phase differentiation in leaf development combined with complete laminar reduction leads to the Osmunda type, while phase differentiation in leaf lamina development and additional processes may give rise to the Mohria, Anemia, and Lygodium types. These morphological results support recent phylogenetic studies by other authors in disclaiming close relationships between Osmundaceae and Gleicheniaceae, and between Marattiaceae and Ophioglossaceae (``Eusporangiatae'). They also potentially support relationships between Osmunda- ceae and Schizaeaceae or between Ophioglossaceae and Schizaeaceae. The high complexity of the sori in Marattiaceae and Ophioglossaceae is surprising if the two families are viewed as basal groups.