Respiratory and psychiatric abnormalities in chronic symptomatic hyperventilation.

Many physicians believe that the hyperventilation syndrome is invariably associated with anxiety or undiagnosed organic disease such as asthma and pulmonary embolus, or both. Twenty one patients referred by specialist physicians with unexplained somatic symptoms and unequivocal chronic hypocapnia (resting end tidal Pco2 less than or equal to 4 kPa (30 mm Hg) on repeated occasions during prolonged measurement) were investigated. All but one complained of inability to take a satisfying breath. Standard lung function test results and chest radiographs were normal in all patients, but histamine challenge showed bronchial hyper-reactivity in two of 20 patients tested, and skin tests to common allergens were positive in three of 18. Ventilation-perfusion scanning was abnormal in a further three of 15 patients studied, with unmatched perfusion defects in two and isolated ventilation defects in one. None of the 21 had thyrotoxicosis, severe coronary heart disease, or other relevant cardiovascular abnormalities. Ten of the 21 patients were neurotic and suffered from chronic psychiatric disturbance characterised by anxiety, panic, and phobic symptoms. The remainder had no detectable psychiatric disorders but reported proportionately more somatic than anxiety symptoms. Severe hyperventilation can occur in the absence of formal psychiatric or detectable respiratory or other organic abnormalities. Asthma and pulmonary embolus must be specifically excluded.     

Scintillation Scanning of Lungs in Preoperative Assessment of Carcinoma of Bronchus

Lung scans with the use of macroaggregated human serum albumin labelled with technetium-99m were carried out in 52 patients before thoracotomy.Forty-three patients had carcinoma of the bronchus. Tumours less than 2 cm. in diameter on the chest radiograph were not detected. Larger tumours showed defects in perfusion, ranging in size from the mass seen on the chest radiograph to almost absent perfusion of the entire lung. The extent of the defect in perfusion was closely related to involvement of the pulmonary vessels at the hilum by distortion, compression, or invasion by the tumour. Bronchial obstruction played a less important part in producing the defects.The larger the defect in perfusion the greater was the involvement of the hilar and mediastinal structures and the more extensive was the surgery required. When perfusion of the affected lung was less than one-third of the total the tumour was found to be unresectable.     

Local streptokinase administration in massive pulmonary embolism

Five patients with acute massive pulmonary embolism were treated with streptokinase administered via the pulmonary artery as close as possible to the embolus. Streptokinase (Awelysin) was infused at a loading dose of 250,000 IU followed by a maintenance dose of 100,000 IU/hour under haemodynamic and angiographic control. In four of five patients (two patients with cardiogenic shock) the clinical signs, pulmonary artery pressure and the angiographic findings improved or they normalised within 5-12 hours. In one patient with recurrent embolisation over three weeks the clinical condition improved gradually, although the angiographic findings improved only slightly. The results demonstrate that local thrombolysis of acute massive pulmonary embolism is a highly effective form of treatment.     

Proximal Hyperdense Middle Cerebral Artery Sign Predicts Poor Response to Thrombolysis

The aim of our study was to compare the rapid neurological improvement after intravenous recombinant tissue-type plasminogen activator (rtPA) in patients with proximal hyperdense middle cerebral artery sign (p-HMCAS) to those without the sign and those with the distal hyperdense middle cerebral artery sign (d-HMCAS). Admission and 24 hour non-contrast CT scans of 120 patients with middle cerebral artery (MCA) territory stroke who were treated with intravenous rtPA were assessed for the presence of p-HMCAS and d-HMCAS. The sign was classified according to the site of occlusion. Rapid neurological improvement was defined as ≥50% improvement in the NIHSS score at 24 hours after thrombolysis. Rapid neurological recovery after thrombolysis was assessed and compared between the subgroups. Rapid neurological recovery was less common in the pooled group of patients with either p-HMCAS or d-HMCAS than those without the sign (p<0.01). Patients with p-HMCAS were less likely to have rapid neurological recovery than those with d-HMCAS (p<0.01). However, there was no difference in early neurological recovery between patients with d-HMCAS and those without any hyperdense sign. Our study showed that poor neurological recovery post rtPA was confined to p-HMCAS and not to d-HMCAS, indicating that these signs have quite different prognostic significance.     

The effects of ionizing radiation on the pulmonary vasculature of intact rats and isolated pulmonary endothelium

We studied the effects of ionizing radiation on the morphology of the pulmonary circulation using an in vivo rat model and an in vitro pulmonary artery endothelial cell model. Gamma radiation was given as either an acute (30 Gy) or fractionated (5 X 6 Gy) dose to one hemithorax of rats. An acute 30-Gy dose delivered resulted in a 70% decrease in pulmonary arterial perfusion, using technetium-99m microaggregated albumin (99mTc-MAA), in the irradiated lung by 2-3 weeks after irradiation. Pulmonary microradiographs, using a barium sulfate perfusion method, obtained 2-3 weeks after irradiation demonstrated widespread loss of capillary filling and segmentation of the vessels. Histologic examination demonstrated intact capillaries, suggesting that the alterations in pulmonary perfusion were at the precapillary level. Similar abnormalities in lung perfusion and morphology were found after delivery of fractionated doses of radiation, but the onset of the changes was delayed, occurring 4-6 weeks postirradiation. Using cultured pulmonary endothelial cell monolayers, cell sloughing and retraction from the surface substrate were observed within 24 h after in vitro delivery of 30 Gy. Similar findings occurred in monolayers given fractionated doses (5 X 6 Gy) of radiation 2-3 days after the final dose. The in vivo animal and in vitro endothelial cell models offer a useful means of examining the morphologic alterations involved in radiation lung vascular damage.     

Tissue plasminogen activator and acute pulmonary embolism

We assessed the efficacy and safety of peripheral intravenous recombinant human tissue-type plasminogen activator (rt-PA) in 47 patients with angiographically documented pulmonary embolism (PE). We administered 50 mg/2 h and, if necessary, an additional 40 mg/4 h. By 6 hours, 94% of the patients had angiographic evidence of clot lysis that was slight in 5, moderate in 12, and marked in 27 patients. Among the 34 patients with pulmonary hypertension prior to treatment, average pulmonary artery pressure decreased from 43/17 (27) to 31/13 (19) mm Hg (P less than 0.0001). The average lung scan perfusion defect decreased from 37% before therapy to 16% (P less than 0.01) after therapy among the 19 patients who had pre- and post-treatment lung scans. Of 7 patients with pre- and post-treatment imaging and Doppler echocardiograms, hypokinetic right ventricular wall movement (mild in 1, moderate in 2, and severe in 4) normalized in 5 and improved to mild hypokinesis in 2. Right ventricular diameter decreased from 3.9 +/- 1.0 to 2.0 +/- 0.5 cm (P less than 0.005). Fibrinogen decreased 33% from baseline at 2 h and 42% from baseline at 6 h. However, patients with the greatest degree of angiographic clot lysis at 2 h had a preponderance of fibrinogenolysis over fibrinolysis, demonstrated by a lower ratio of cross-linked fibrin degradation products to fibrin(ogen) degradation products (0.14 +/- 0.09 vs. 0.54 +/- 0.82) (P less than 0.04). Among selected patients, peripheral intravenous rt-PA is associated with rapid lysis of PE, improved pulmonary perfusion, and improved right ventricular function.     

Prevention of Recurrent Pulmonary Embolism

Fifty patients have been studied by bilateral phlebography following their first, or sometimes recurrent, pulmonary embolus. Nineteen were found to have fresh loose peripheral thrombus, and in eight of them the thrombus looked big enough to cause a major pulmonary artery obstruction and death. These 19 patients were treated by vein ligation in addition to anticoagulants.The incidence of recurrent embolism in the trial group is significantly lower than that found in a retrospective study of 50 patients treated with anticoagulants only. It is suggested that anticoagulants will not prevent all recurrent pulmonary emboli, and that phlebography, and if necessary surgery, should be part of the routine investigation and treatment of all patients after their first pulmonary embolus.     

Therapeutic control of anticoagulant treatment.

Control of anticoagulant treatment was studied in 250 patients. One hundred and fifty patients receiving long-term anticoagulant treatment (group 1) were studied for 52 weeks and the remaining 100 (group 2) for 12 weeks after discharge from hospital. The desired British correlated ratio range was 2.5-3.3, and a range of 2.3-3.5 was classified as satisfactory. In group 1 a satisfactory ratio was obtained for 70% of the study period and 120 of the 150 patients were maintained within this range for over 60% of the time. In group 2 only half of the patients were maintained within the satisfactory range and for 50% of the study period or less. The time and effort expended in therapeutic control were more than most clinics could afford, and the results for group 2 were disappointing. The standard of long-term anticoagulant treatment should be improved by continuous review of control and by "therapeutic quality control."     

Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis

Deep venous thrombosis and pulmonary embolus are known risks of surgery. However, the incidence of these conditions in face lift is unknown. In this study, the incidence of deep venous thrombosis/pulmonary embolus after face lift is studied and factors associated with thromboembolic complications are evaluated. One-third of the active members of the American Society for Aesthetic Plastic Surgery were randomly selected. Participating surgeons completed a one-page survey providing information on face-lift procedures during a 12-month study period. A response rate of 80 percent was achieved, with 273 of the 342 surgeons responding to the survey. A total of 9937 face-lift procedures were reported in the 1-year study period. There were 35 patients with deep venous thrombosis (0.35 percent), 14 patients with pulmonary embolus (0.14 percent), and 1 patient death in the series. Although 43.5 percent of patients underwent face lift under general anesthesia, 83.7 percent of deep venous thrombosis/pulmonary embolus events occurred with general anesthesia. For prophylaxis for deep venous thrombosis/pulmonary embolus, 19.7 percent of the surgeons used intermittent compression devices, 19.6 percent used thromboembolic disease hose or Ace wraps, and 60.7 percent used no prophylaxis. Of patients developing deep venous thrombosis/pulmonary embolus, 4.1 percent were treated prophylactically with intermittent compression devices, 36.7 percent with thromboembolic disease hose/Ace wraps, and 59.2 percent with no prophylaxis. It was found that deep venous thrombosis/pulmonary embolus after face lift is a measurable complication experienced by one of nine surgeons surveyed. Deep venous thrombosis/pulmonary embolus is more likely to occur when the procedure is performed under general anesthesia. The majority of plastic surgeons surveyed used no prophylaxis for deep venous thrombosis when performing face-lift procedures. Intermittent compression devices were associated with significantly fewer thromboembolic complications, whereas Ace wrap/thromboembolic disease hose afforded no protection against deep venous thrombosis/pulmonary embolus when used alone. In conclusion, aesthetic surgeons should consider adopting intermittent compression devices when performing face lift under general anesthesia.     

The low specificity of postoperative perfusion lung scan defects.

Ventilation and perfusion lung scans were performed preoperatively and postoperatively in 169 patients and classified blindly according to preset criteria. Perfusion lung scan abnormalities were present in 25 (15%) of the preoperative scans and 42 (25%) of the postoperative scans; 16 (38%) of the 42 abnormal postoperative scans were identical to the preoperative scans. Perfusion defects indicating a "high probability" of pulmonary embolism (lobar or segmental defects) were present in 5 preoperative scans and 10 postoperative scans; the 10 postoperative scans were classified as showing "definite" (5), "possible" (1) or "no" (4) pulmonary embolism on the basis of the preoperative scan and the ventilation scan; none of the 10 patients had clinical evidence of pulmonary embolism. Venous thrombosis was present in 12 patients, including 4 of the patients whose lung scans showed definite pulmonary embolism. Thus, postoperative perfusion lung scan defects are potentially misleading even when large.     

Pulmonary embolism due to the right atrial myxoma

A 47-year-old man was admitted to the hospital with a pleuritic pain, dyspnea, nonproductive cough and low-grade fever. An ECG documented a sinus tachycardia with S1Q3T3 pattern and incomplete right bundle branch block, and lung scintigraphy showed multiple perfusion defects. The initial diagnosis was pulmonary embolism. Echocardiography, undertaken before application of the anticoagulant therapy because of hematological disturbances reflecting possible coagulopathy (elevated erythrocyte sedimentation rate, increased leukocyte count, decreased platelet count), revealed a large mobile tumor in the right atrium. Tumor was surgically removed, and histological findings was supported a diagnosis of the cardiac myxoma. The right cardiac myxoma should be considered in the differential diagnosis of pulmonary embolism, particularly in cases presented in conjunction with constitutional symptoms and/or hematological disturbances. In these patients echocardiography should be undertaken early to exclude the rare but treatable diseases of the right heart.     

Oxygen radical scavengers improve vascular patency and bone-muscle cell survival in an ischemic extremity replant model

We examined the use of oxygen radical scavengers in preventing the no-reflow phenomenon and improving bone-muscle cell survival in an ischemic extremity replant model. A total of 70 Lewis rat modified hindlimb replants were performed after specific periods of cold ischemia and intraarterial perfusion with either superoxide dismutase and catalase, specific oxygen free-radical scavengers, or a control solution. Ischemic hindlimbs treated with superoxide dismutase and catalase showed a statistically significant (p less than 0.05) improvement in vascular patency after prolonged cold ischemia when compared to controls. Histologically, experimental extremities demonstrated greater osteoblast, osteocyte, and muscle cell survival in replanted hindlimbs with patent vascular anastomoses. The perfusion of severed limbs and digits and free vascularized tissue transfers with superoxide dismutase and catalase after a period of ischemia has already occurred may prolong the ischemic "time window" tolerated for successful tissue survival.     

Long-term administration of beraprost,an oral prostacyclin analogue,improves pulmonary diffusion capacity in patients with systemic sclerosis

The objective of this study was to assess the effect of beraprost sodium, an oral prostacyclin analogue, on pulmonary function in patients with systemic sclerosis. Seventeen patients, with systemic sclerosis and predicted percent values of carbon monoxide diffusion capacity (%DLCO) of less than 95, received beraprost sodium for at least 12 months. Conventional testing for pulmonary function was performed at 12-month intervals and changes were evaluated with special reference to DLCO. Twelve patients completed the treatment. Nine patients showed improvement in DLCO (12.1 +/- 2.3 to 15.5 +/- 4.4 ml/min/mmHg, P < 0.006) and 10 patients showed an increase in %DLCO (66.6 +/- 11.9 to 87.7 +/- 23.2%, P < 0.004). Total lung capacity, vital capacity and forced expiratory volume remained unchanged. This study showed that DLCO levels in patients with systemic sclerosis improved after the administration of beraprost sodium, probably due to the decrease in pulmonary vascular resistance accompanied by increased cardiac output.     

Pulseless electrical activity during electroconvulsive therapy: a case report

Background

Arrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.

Case presentation

We report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.

Conclusion

We recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.     

重度脊柱侧凸后路一期小切口矫形对肺功能的影响

目的:探讨采用脊柱后路分期矫形策略治疗重度脊柱侧后凸,一期小切口矫形术对患者肺功能的影响。方法:自2007年05月-2010年12月采用脊柱后路分期矫形策略中一期小切口矫形术治疗重度脊柱侧凸患者32例,其中男12例,女20例,年龄5～25(13.5±6.12)岁。一期小切口矫形术前侧凸主弯冠状面Cobb’s角为108°～150°(128.75°±13.51°),胸腰段矢状位后凸角60°～140°(97.78°±27.88°)。测量一期矫形术前及术后2周、3月、6月肺功能,包括肺活量(VC)、用力肺活量(FVC)、第一秒时间肺活量(FEV1)、最大呼气中段流速(MMEF)、最大通气量(MVV),计算其占预计值的百分比[VC%、FVC%、FEV1%、MMEF%、MVV%]。观察患者术前与术后不同时期肺功能的变化。结果:术后3月时肺功能较术前有明显提高(P<0.05),术后6月较术后3个月无显著提高(P>0.05)。结论:对于严重的脊柱侧凸患者,后路一期小切口矫形术后3月肺功能即可获得明显改善,可行二期手术治疗。     

PDE5A inhibition attenuates bleomycin-induced pulmonary fibrosis and pulmonary hypertension through inhibition of ROS generation and RhoA/Rho kinase activation

Pulmonary hypertension frequently complicates interstitial lung disease, where it is associated with a high mortality. Patients with this dual diagnosis often fare worse than those with pulmonary arterial hypertension (PAH) alone and respond poorly to standard PAH therapy, often dying of right ventricular (RV) failure. We hypothesize that nitric oxide synthase (NOS) uncoupling is important in the pathogenesis of interstitial lung disease-associated pulmonary hypertension, and this process can be abrogated by phosphodiesterase type 5 (PDE5) inhibition to improve pulmonary vascular remodeling and right ventricular function. Intratracheal bleomycin (4 U/kg) or saline control was administered to C57/BL6 mice after anesthesia. After recovery, animals were fed a diet of sildenafil (100 mg.kg(-1).day(-1)) or vehicle for 2 wk when they underwent hemodynamic measurements, and tissues were harvested. Survival was reduced in animals treated with bleomycin compared with controls and was improved with sildenafil (100.0 vs. 73.7 vs. 84.2%, P < 0.05). RV/LV+S ratio was higher in bleomycin-alone mice with improvement in ratio when sildenafil was administered (33.00 +/- 0.01% vs. 20.98 +/- 0.01% P < 0.05). Histology showed less pulmonary vascular and RV fibrosis in the group cotreated with sildenafil. Bleomycin was associated with a marked increase in superoxide generation by DHE histological staining and luminol activity in both heart and lung. Treatment with sildenafil resulted in a concomitant reduction in superoxide levels in both heart and lung. These data demonstrate that PDE5 inhibition ameliorates RV hypertrophy and pulmonary fibrosis associated with intratracheal bleomycin in a manner that is associated with improved NOS coupling and a reduction in reactive oxygen species signaling.     

Streptokinase Therapy in Acute Major Pulmonary Embolism: Effectiveness and Problems

Eighteen patients with major pulmonary embolism were treated with streptokinase infused by a catheter or given intravenously. Fourteen showed clinical improvement and 12 out of 16 patients investigated showed definite angiographic improvement after 24 to 48 hours of treatment with streptokinase. The angiographic improvement following streptokinase contrasted with the lack of this in three patients after 24 hours of heparin treatment.Resolution following streptokinase therapy was most noticeable in patients treated shortly after a single embolic episode, and was least marked in those with recurrent embolism complicated by associated cardiac or pulmonary disease. Of the four patients who failed to improve, two died and two had pulmonary embolectomy and survived.The results suggest that streptokinase therapy is practicable provided that adequate laboratory control is available, and that it hastens early resolution in acute major pulmonary embolism.     

Perfusion Lung Scans Provide a Guide to Which Patients With Apparent Primary Pulmonary Hypertension Merit Angiography

There is hesitancy, based on the perceived risk, to do pulmonary angiography in patients believed to have primary pulmonary hypertension. Yet pulmonary hypertension due to major-vessel, chronic thromboembolism mimics primary pulmonary hypertension clinically and on standard laboratory tests. Because thromboembolic pulmonary hypertension is potentially remediable by thromboendarterectomy and primary pulmonary hypertension is not, differentiating between these disorders is essential. Angiography is required in patients with thromboembolic pulmonary hypertension to define the anatomic location of the thrombi. In evaluating perfusion lung scans of 110 patients with pulmonary hypertension to determine whether the scan might provide a guide to selecting those patients who merit angiography, no segmentalsize perfusion defects were noted on the scans of 64 patients with primary pulmonary hypertension, whereas all 46 patients with thromboembolic hypertension had one or more defects that were segmental in size or larger. These data indicate that a perfusion lung scan should be done in patients with pulmonary hypertension of uncertain cause and that those with one or more segmental or larger defects merit pulmonary angiography before being diagnosed as having primary pulmonary hypertension.     

顺尔宁对稳定期慢性阻塞性肺疾病患者的疗效分析

目的：探讨顺尔宁治疗稳定期慢性阻塞性肺疾病（COPD）患者的临床效果。方法：将60例稳定期COPD患者随机分为研究组和对照组,每组各30例。经2周洗脱期后,对照组采用常规治疗,研究组在常规治疗基础上加用顺尔宁治疗,共治疗4周。比较两组患者肺功能参数、血气分析、生活质量以及血清LTB4、IL-8浓度的变化。结果：治疗后两组患者的肺功能参数、血气分析指标和生活质量均有改善,研究组肺功能参数改善程度较对照组显著（P〈0．05）;研究组的生活质量改善明显优于对照组（P〈0．05）：治疗后两组患者的血清LTB4、IL-8水平较治疗前均下降,且研究组明显低于对照组（P〈0．05）。结论：顺尔宁能降低稳定期慢性阻塞性肺疾病患者血清LTB4、IL-8含量,改善患者肺功能及血气分析指标,有效提高患者的生命质量,值得临床推广。     

Medical treatment of pulmonary hydatid disease: for which child?

There have been many encouraging studies on medical treatment of pulmonary hydatid disease due to Echinococcus granulosus infection. Our aims were to demonstrate the safety and efficacy of medical treatment in pulmonary hydatid disease and to describe a pediatric population who would benefit from medical treatment, especially in respect to the diameter of the hydatid cyst. All patients were treated with mebendazole or albendazole. Treatment outcome was defined as cure, improvement or failure. Among 82 patients, 34.1% were cured, 34.1% improved and 31.8% failed. When 102 cysts were individually evaluated, 36.31% were cured, 32.4% improved and 31.3% failed. The cure and the failure rates were statistically insignificant in cysts treated with mebendazole and albendazole; however statistically significantly more cysts were improved with albendazole. The results were statistically insignificant between continuous and cyclic albendazole treatment. The mean size of successfully treated cysts was 5.3+/-3.4 cm, but "failed" for cyst with a mean size of 7.3+/-4.3 cm. There was a positive, weak and statistically significant correlation between the cyst size and treatment results. The major complication was infection. We suggest that selected pediatric patients with uncomplicated pulmonary hydatid cysts sized less than 5 cm should have a trial of medical treatment with a very close follow up.