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.     

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。     

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。     

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.     

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。     

Hemoptysis: Diagnosis and Management

Hemoptysis is one of the most important symptoms of cardiopulmonary disease—first, because bleeding even in small amounts may indicate the presence of such serious diseases as bronchogenic carcinoma or active tuberculosis, and second, because untreated massive hemorrhage is associated with a high mortality rate. The cause of hemoptysis may be suggested by the history, physical examination or chest x-ray findings, but often diagnostic procedures such as bronchoscopy, bronchography and pulmonary angiography are needed for definitive diagnosis. The importance of early localization of the bleeding site and surgical intervention in patients with massive hemoptysis is stressed.     

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.

     

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.     

Palmitoyl protein thioesterase 1 protects against apoptosis mediated by Ras-Akt-caspase pathway in neuroblastoma cells

Palmitoyl protein thioesterase (PPT) 1 is an enzyme involved in deacylation of palmitoylated proteins. A deficiency in PPT1 results in a genetic disease, infantile neuronal ceroid lipofuscinosis, associated with massive death of cortical neurons. The role of PPT1 in neuronal survival and apoptosis was studied in human neuroblastoma (LA-N-5) cells overexpressing PPT1. Overexpression of PPT1 was shown both by the 200-350% increase in depalmitoylating activity over basal level (as determined by an in vitro PPT assay) and by western blot analysis of transiently expressed epitope-tagged PPT1. Overexpressed PPT1 showed the same acidic pH optimum (pH 4.0) as the endogenous enzyme, when assayed with a P0-derived octapeptide substrate, and reduced the growth rate by 30%. LA-N-5 cells underwent apoptosis, as evidenced by increased caspase 3-like activity and increased DNA fragmentation, when challenged with either C2-ceramide or a phosphatidylinositol 3-kinase inhibitor (LY294002). Overexpression of PPT1 inhibited this C2-ceramide- or LY294002-mediated activation of caspase-3 by 50%. There was also a concomitant decrease in DNA fragmentation and cell death. Consistent with increased resistance to apoptosis, we found increased phosphorylation of the antiapoptotic protein Akt (protein kinase B) in PPT1-overexpressing cells. p21Ras is known to be dynamically palmitoylated and depalmitoylated and is involved in both growth and cell death. The C2-ceramide-induced membrane association of p21Ras was reduced by 30-50% in PPT1-overexpressing cells compared with control. PPT overexpression also led to reduced membrane association of another palmitoylated protein, GAP-43, a neuron-specific protein. Our studies suggest that protein palmitoylation could be a physiological regulator of apoptosis.     

Ultrasound screening for clinically occult abdominal aortic aneurysm.

In a review of the records of 74 patients who had undergone repair of an abdominal aortic aneurysm at a community hospital between 1977 and 1983 we found that the aneurysm had been undiagnosed before rupture in 35%; these patients had an operative death rate of 50%, whereas elective repair carried a death rate of 4%. The characteristic patient was an obese man over the age of 55 years with hypertension, coronary artery disease, cerebrovascular disease or peripheral vascular disease. Ultrasound examination was performed in 45 patients with these characteristics, and six aneurysms were diagnosed. Either surgery or computed tomography confirmed the diagnosis. The rate of false-negative results was estimated by review of the charts of 100 men over the age of 55 years who had undergone abdominal ultrasonography for other indications: no undetected aneurysms were discovered over 3 years of follow-up. Routine screening in this high-risk group would improve the rate of diagnosis of this potentially fatal condition before rupture and offer the patient the lower mortality rate associated with elective surgery.     

Neonatal glutaric aciduria type II: An X-linked recessive inherited disorder

Summary A new case of neonatal glutaric aciduria type II is reported. Neonatal acidosis, hypoglycemia, and hyperammonemia were characteristic. The baby died at four days of age. Organic acid analysis revealed massive glutaric aciduria with elevated concentrations of butyric, isobutyric, n-butyric, and isovaleric acid in his urine. The baby's pedigree suggested strongly an X-linked recessive mode of inheritance. Clinically, biochemically, and genetically glutaric aciduria type II is an heterogeneous disorder. The neonatal form is an X-linked inherited disorder which presents early in life, and is associated with metabolic acidosis, hypoglycemia, and hyperammonemia, and leads to death in the neonatal period. The mild form is an autosomal recessive inherited disease which may present even in adults, and is associated with recurrent hypoglycemia without ketosis and usually improves. Nevertheless the same unusual organic acid pattern is observed in both forms. The basic biochemical defect must be distinct and has not been elucidated.     

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.     

Management of synovial sarcoma of the median nerve at the elbow

Synovial sarcoma is a high-grade malignancy with a marked propensity for local recurrence and a moderate rate of regional lymph node involvement. It usually causes death from massive pulmonary metastases. Despite its aggressive biologic behavior, en bloc wide local resection of small extremity tumors rather than amputation may be indicated if removal of all gross disease is possible. Extremity morbidity from resection of vessels, nerves, and soft-tissue bulk can be minimized by the use of composite reconstruction techniques currently available. A case report is presented to illustrate aggressive limb-sparing surgical therapy of a small, favorably located synovial sarcoma with immediate neurovascular and soft-tissue reconstruction. The literature is reviewed to aid subsequent surgeons faced with management of this uncommon tumor.     

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.     

Is gastrinoma a medical disease?

Zollinger-Ellison syndrome (ZES) is a rare disease. Its management concerns symptoms related to the gastric acid overproduction that characterizes the syndrome and to the gastrin-producing tumor(s) usually located in the duodenal wall and/or the endocrine pancreas. Acid hypersecretion is now controlled by the use of powerful antisecretory agents. Management of the malignant process(es) has become the primary goal of modern strategy: it aims first at curing the disease and second at prolonging patient survival by prevention of hepatic metastasis. In patients with the sporadic form of the disease and without liver metastases, it is currently possible to localize and to surgically remove the endocrine tumor(s). This progress has been made feasible by refinements in modern medical imaging. At present, however, disease cure, even in the most favorable conditions, is not be greater than 30 to 50 percent at five years. In patients with ZES integrated in the context of multiple endocrine neoplasia type I, disease cure rate is extremely low, although occasional patient survival can be as good or even better than in the sporadic group. Disseminated malignancy (liver and/or extra-abdominal lymph nodes or bone localization) remains the principal determinant of early death. Surgical treatment is usually precluded in such cases. Liver transplantation has not been successful in these patients.     

Hydrogen peroxide induces programmed cell death features in cultured tobacco BY-2 cells, in a dose-dependent manner

Active oxygen species (AOS), especially hydrogen peroxide, play a critical role in the defence of plants against invading pathogens and in the hypersensitive response (HR). This is characterized by the induction of a massive production of AOS and the rapid appearance of necrotic lesions is considered as a programmed cell death (PCD) process during which a limited number of cells die at the site of infection. This work was aimed at investigating the mode of cell death observed in cultures of BY-2 tobacco cells exposed to H(2)O(2). It was shown that H(2)O(2) is able to induce various morphological cell death features in cultured tobacco BY-2 cells. The hallmarks of cell death observed with fluorescent and electron microscopy differed greatly with the amount of H(2)O(2) added to the cell culture. The appearance of nuclear fragmentation similar to 'apoptotic bodies' associated with a fragmentation of the nuclear DNA into small fragments appear for almost 18% of the cells treated with 12.5 mM H(2)O(2). The early stages of the induction of this PCD process consisted in cell shrinkage and chromatin condensation at the periphery of the nucleus. Above 50 mM, H(2)O(2) induces high necrotic cell death. These data suggest that H(2)O(2)-induced cell damage is associated with the induction of various cell death processes that could be involved differently in plant defence reactions.     

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。     

ALLERGIC BRONCHIAL ASTHMA AND RHINITIS—The Importance of Studies for Sensitivity to Foods

The authors consider sensitivity to foods and sensitivity to inhalants about equal in importance in bronchial asthma, allergic rhinitis and allergic bronchitis. Food allergens are the sole cause of bronchial and nasal allergic disease in 20 to 40 per cent of cases throughout life, including old age; inhalants are the sole cause in approximately an equal number; and sensitivity to foods and to inhalants are often associated.Their frequent recognition of sensitivity to foods as a cause of disease, the authors believe, depends on: (1) The recognition of the fallibility of skin testing and the usual negative skin reactions to allergenic foods in chronic and recurrent bronchial asthma and allergic rhinitis. (2) The adequate use of trial diets, especially cereal-free elimination diet. (3) The realization that ingested foods remain in the body usually for two to four weeks and that the diet must be continued until symptoms have been relieved for two to three times as long as preceding relief between attacks.     

Thoracic Surgery in the Elderly

With careful attention to details of preoperative, operative and postoperative care, intrathoracic procedures can be carried out safely in the elderly patient. The authors describe such procedures in 111 patients over 60 years of age who presented with a wide variety of primary diseases. Bronchogenic carcinoma, present in 48 patients, was the commonest. One-third of the total group had significant associated disease, usually in the form of coronary artery or chronic respiratory disease. The overall mortality rate was 6.3%.Before surgery, all patients were prophylactically digitalized regardless of their cardiac status. Blood volume estimations were determined in those with excessive weight loss. At operation, measurement of central venous pressure was found to be the best guide to blood replacement.Retention of bronchial secretions was the commonest postoperative complication. This problem can be minimized with intensive chest physiotherapy, adequate hydration, minimal doses of analgesic agents and, when indicated, early tracheostomy.     

Death of the cereal root cortex: its relevance to biological control of take-all

Cell death in the root cortex of cereals was assessed by an inability to detect nuclei, using acridine orangelfluorescence microscopy after fixation and mild acid hydrolysis. Seminal roots were scanned at x 100 magnification and their cortices were considered dead when nuclei were absent from all cell layers except the innermost one, adjacent to the endodermis; this cell layer remains alive long after the rest of the cortex has died. Cortical death of wheat and barley roots occurred in the absence of major pathogens. Cell death started behind the root hair zone of the main root axis, initially in the outermost cell layer of the cortex and then progressively inwards towards the endodermis; however, the cortex remained alive for a distance of c. 800 μm around emerging root laterals. The rate of cortical death was more rapid in wheat than in barley, both under field conditions and in the glasshouse at 20 °C. Thus, field-grown spring wheat (Sicca) showed 50% death of the root cortex in the top 6 cm of first seminal roots after 35 days (growth stage 1–2), whereas spring barley (Julia) showed 50% death of the root cortex after 67 days (growth stage 8). In the glasshouse, the top 9 cm of first seminal roots on 16-day plants showed 55% cortical death in wheat (Cappelle-Desprez) but only 2.5% cortical death in barley (Igri). The same rates of death were found in all subsequent seminal roots. The wheat root cortex died at the same rate in sterile and unsterile conditions, and at the same rate in the presence/absence of Phialophora radicicola Cain var. graminicola Deacon or Aureobasidium bolleyi (Sprague) von Arx. Hence, although P. radicicola and other soil microorganisms may benefit from root cortex death they do not exert biological control of take-all by enhancing or retarding the rate of this process. To study the effects of cortical death on take-all, Gaeumannomyces graminis (Sacc.) Arx & Olivier var. tritici Walker was point-inoculated at the tips and on older (5 and 15 day) regions of wheat seminal roots. After 17 days at 20 °C the fungus had grown to the same extent as runner-hyphae in all cases, but the severity of disease decreased with increasing age of the root cortex prior to inoculation; thus, G. graminis caused most extensive vascular discoloration and most intense vascular blockage in roots inoculated at their tips. Similar experiments on wheat and barley roots inoculated separately with P. radicicola and G. graminis suggest that at least three factors associated with cortical death influence infection by these fungi: (1) initially, cell death may enhance infection because nutrients are made available to the parasites and host resistance within the cortex is reduced; (2) weak parasites and soil saprophytes may colonise dead and dying cortices in competition with G. graminis and P. radicicola and thereby reduce infection by these fungi; (3) changes in the endodermis and adjacent cell layers may be associated with cortical death and may retard invasion of the stele. Future work will seek to establish the relative importance of these factors and extend this study to other cereal host-fungus combinations.