Renal drug targeting using a vector "alkylglycoside"

Cirrhosis and portal hypertension may be associated with pulmonary hypertension and pulmonary dysfunction. However, morphological pulmonary vascular lesions in patients with cirrhosis have not been well characterized morphometrically. We morphometrically evaluated pulmonary vessels in liver transplant recipients with pretransplantation cirrhosis and correlated our findings with pretransplantation cardiopulmonary function, postoperative course, and postmortem cardiopulmonary findings. Autopsy lung slides from 23 transplant recipients with pretransplantation cirrhosis were examined. External vessel diameter, intimal thickness, and arterial medial thickness were measured with a micrometer after pentachrome staining. The percent of total diameter comprised by intima or media was calculated for each vessel. Medical records were reviewed for smoking history, pretransplantation cardiopulmonary function testing, and postoperative course. Autopsy cases without liver or significant cardiopulmonary diseases, matched for age, sex, and smoking history, served as controls. Transplant recipients had significantly more pulmonary venous intimal thickening than matched controls (P <.0001). Sixty-five percent (15 of 23) of these patients had some degree of pretransplantation pulmonary dysfunction, defined by abnormalities in pulmonary function tests, oxygen saturation, and/or increased pulmonary artery pressures. However, the severity of venous intimal thickening did not correlate with the severity of pretransplantation pulmonary dysfunction. Arterial intimal and medial thickness were not statistically significantly different from controls. Pulmonary venous intimal thickening and resultant luminal impingement are morphological findings not previously described in this population. The arterial lesion, when present, is similar to that seen in pulmonary hypertension from other causes. These pulmonary vascular lesions may be implicated in pulmonary dysfunction in patients with cirrhosis and may be associated with increased posttransplantation cardiopulmonary morbidity and mortality.     

"Prohibitive" lung function and major surgical procedures

Sixteen patients with preoperative pulmonary function testing data placing them in the "prohibitive" range underwent major surgical procedures with one mortality (6 per cent) and three major pulmonary complications (19 per cent). All complications were after pulmonary resections in patients with marked muscular weakness. Patients should not be denied necessary operative procedures on the basis of pulmonary function testing placing them in the "prohibitive" range of the Miller quadrant diagram alone. This term should be changed to "increased risk."     

Use of the "chimney patch" technique for Norwood stage I procedures

The Norwood stage I procedure is often used for the initial treatment of infants with hypoplastic left heart syndrome. This procedure creates a systemic arterial to pulmonary artery shunt to establish pulmonary blood flow. We describe a method to facilitate placement of this shunt by attaching a polytetrafluoroethylene shunt to a pulmonary artery homograft patch before performing the median sternotomy. This technique facilitates the performance of the proximal shunt anastomosis and expedites the procedure.     

A congenitally "poor" pulmonary artery is a major reason for exclusion from Fontan operation

We reviewed the clinical records of 185 patients who were possible candidates for Fontan operation. We did this to clarify whether all patients with suitable anomalies ultimately underwent a Fontan operation. Of the 152 patients with decreased pulmonary blood flow, 38 (26%) did not fulfill the criteria for Fontan operation, and 17 of the 33 patients (52%) with increased pulmonary blood flow (P < 0.01) were excluded as candidates. Of 48 non-candidate survivors, 19 had high pulmonary artery (PA) pressure or resistance and small PA (which we term "poor PA"), 17 had pulmonary hypertension, 6 had a markedly distorted PA, and 6 had severe ventricular dysfunction. A significant proportion of possible candidates with a suitable anomaly ultimately did not undergo a Fontan operation, because of "poor PA", a congenital condition that precluded Fontan operation.     

Satisfaction of the "Mister Employee": a goal to be reached]

Six patients with pulmonary emphysema scheduled to undergo thoracoscopic lung volume reduction surgery (TLVRS) were evaluated by three-dimensional (3-D) dynamic pulmonary xenon-133 SPECT. Serial 30-second dynamic SPECT data for equilibrium and washout (for 5 min) were acquired using a continuous repetitive rotating acquisition mode with a triple-detector SPECT system. SPECT data were reconstructed to 3-D images with a color, surface-rendering technique, and a 3-D fusion image of the 3-min washout image over the equilibrium image was obtained. Regional ventilation was visually assessed on the fusion 3-D images and quantified by xenon-133 half-washout time (T1/2) and mean transit time (MTT). The 3-D fusion image localized and lateralized the worst diseased sites with xenon-133 retention. Xenon-133 retention, T1/2 and MTT were reduced on these images in five patients with improved pulmonary function tests following TLVRS. However, xenon-133 retention was greater in one with asynchronous diaphragm movement after TLVRS. This modality will assist TLVRS in determining the lung resection target and in evaluating the treatment effect.     

Afterload mismatch-related problems after "domino" heart transplantation

The heart transplants with domino technique, which uses donor hearts from heart-lung recipients, increases the pool of donors, provides the advantage of shortening the ischemic time and makes suitable hearts for patients with pulmonary hypertension. The present study aimed to characterise the pre- and post-transplant clinical and hemodynamic profiles of patients that underwent domino transplant in Pavia. METHODS: Between 1991 and 1992, 9 heart transplants were performed with the domino procedure at I.R.C.C.S. Policlinico S. Matteo of Pavia. Domino donors (6 with primary pulmonary hypertension, 2 with Eisenmenger's syndrome due to atrial septal defect, 1 with cystic fibrosis) underwent electrocardiographic, echocardiographic, chest roentgenogram studies, and right heart catheterization and coronary angiography (for donor older than 40). Domino recipients, 6 males and 3 females with a mean age of 44 years, had dilated cardiomyopathy (4 cases), coronary artery disease (4 cases) and valvular heart disease (1 case) (group 1). Seven of the 9 cases entered the study; 2 were excluded: one because had undergone heterotopic transplantation, the other had received the heart from another country and therefore the graft had suffered from a very long ischemic time. Controls group consisted of 12 patients who had consecutively undergone cardiac transplantation with non-domino donors during the same period (group 2). Immunosuppression was similar in both groups, and consisted of a combination of cyclosporin A, azathioprine and corticosteroids, plus a 7-day-course of antithymocyte globulin. Hemodynamic and echocardiographic controls were performed at 2, 3 and 4 weeks (short-term control) and at 2 and 6 months (mid-term control) after surgery. RESULTS: Domino donors (39 +/- 12.5 years) had significantly higher mean right ventricular end-diastolic diameter and lower left ventricular diameter than normal mean values. Domino recipients had significantly higher mean pulmonary arteriolar resistances than controls; mean ischemic time was also significantly lower in group 1 than in group 2. Short- and mid-term controls after surgery in group 1 showed persistently higher systemic vascular resistances and pulmonary vascular resistances and lower cardiac output than in group 1. Two patients developed an early and unexpected increase in pulmonary wedge pressure accompanied by severe paroxysmal nocturnal dyspnea and mitral regurgitation. In all cases, the left ventricles were relatively inadequate; the combination of low cardiac output and of high systemic vascular resistances favoured the occurrence of an afterload mismatch condition that was worsened by chronic hypoxia. This condition must be known and expected in these patients after transplantation in order to provide timely and effective treatment to potentially life-threatening left ventricular failure episodes. IN CONCLUSION, the subset of transplanted patients that receives domino donors may develop left-side afterload mismatch which, combined with low cardiac output, with high systemic vascular resistances and with the effects of chronic hypoxia originally suffered by the heart, may cause sudden and unexpected left-side heart failure which has to be timely recognised and managed. Although hemodynamic adaptation of this patients is highly problematic, it does not limit the value of the domino procedure.     

"Spoon bowl" deformity of proximal femoral bypass vein graft: a cause of late graft failure on four occasions

Six patients with specific pulmonary diseases had pulmonary tissue surgically resected for diagnostic purposes. All six cases were characterized by space-occupying lesions surrounded by a peculiar reaction of the pulmonary parenchyma indistinguishable from desquamative interstitial pneumonia. If small biopsies from these areas had been taken, a diagnosis of desquamative interstitial pneumonia would have been made, and the underlying process would have gone undetected. These cases corroborate even further the concept that desquamative interstitial pneumonia is a pattern of pulmonary reaction, rather than a well-defined disease entity. Furthermore, it seems advisable to make the dianosis of desquamative interstitial pneumonia only when other conditions have been carefully ruled out by thorough clinical and pathologic investigations.     

Pulmonary atresia with intact ventricular septum: long-term results of "one and a half ventricular repair"

BACKGROUND: Between 1982 and 1984, we successfully performed "one and a half ventricular repair" using a Glenn shunt for 3 patients with pulmonary atresia with intact ventricular septum. Here we review the 10-year follow-up results. METHODS: In these patients, the preoperative Z scores of the tricuspid valve diameters ranged from -5.2 to -6.5. Right ventricular outflow tract reconstruction combined with a Glenn shunt were performed in all patients. Cardiac catheterization was done at least 10 years post-operatively. RESULTS: All 3 patients have maintained New York Heart Association functional class I status for more than 10 years. Angiography in 2 patients confirms sufficient left pulmonary artery pressure with pulsatile blood flow and good right ventricular contraction. A pulmonary arteriovenous fistula has developed in 1 patient. CONCLUSIONS: Although the lower limits of the tricuspid valve diameter for "one and a half ventricular repair" using a cavopulmonary shunt have not yet been determined, we successfully performed this procedure in 3 patients with severely hypoplastic right ventricles and tricuspid valve diameter Z scores of less than -5.0. The results up to 10 years postoperatively are acceptable.     

"Acquired" congenital diaphragmatic hernia

"Acquired" congenital diaphragmatic hernia (ACDH), has been defined as delayed or late appearance of a congenital diaphragmatic hernia after a documented time periol of postnatal life with no evidence of herniation. Three new cases are presented. This diagnosis has been characterized on the basis of a review of these cases and 14 additional patients from the literature. A classification based upon timing of herniation and state of pulmonary development is presented.     

Transfectable and transplantable postmitotic human neurons: a potential "platform" for gene therapy of nervous system diseases

OBJECTIVE: To evaluate F-18 fluorodeoxyglucose positron emission tomography (PET) in terms of its sensitivity and specificity in diagnosing malignant pulmonary nodules and staging bronchogenic carcinoma. METHODS: A retrospective review of any patient that presented to the VA Palo Alto Health Care System with a pulmonary nodule between 9/94 and 3/96 revealed 49 patients (four female, 45 male) age 37-85 (mean 63) with 54 pulmonary nodules who had: chest CT scan, PET scan; and tissue characterization of the nodule. Characterization of each nodule was achieved by histopathologic (N = 44) or cytopathologic (N = 10) analysis. Of the 49 patients, 18 had bronchogenic carcinoma which was adequately staged. Mediastinal PET and CT findings in these 18 patients were compared with the surgical pathology results. N2 disease was defined as mediastinal lymph node involvement by the American Thoracic Society's classification system. Mediastinal lymph nodes were interpreted as positive by CT if they were larger that 1.0 cm in the short-axis diameter. RESULTS: Sensitivity and specificity for the diagnosis of malignant pulmonary nodules using PET was 93 and 70%, respectively. All nodules (N = 3) that were falsely positive by PET scan were infectious in origin. All nodules (N = 4) that were falsely negative by PET were technically limited studies (outdated scanner, no attenuation correction, hyperglycemia) except for one case of metastatic adenocarcinoma. The sensitivity and specificity of PET in diagnosing N2 disease was 67 and 100%, compared with 56% and 100% for CT scan (not statistically significant). However, one more patient with N2 disease was correctly diagnosed by PET than by CT scan. CONCLUSION: PET is a valuable tool in the diagnosis and management of pulmonary nodules and may more accurately stage patients with bronchogenic carcinoma than CT scanning alone.     

The use of "nonanatomic" pulmonary resection in infants with extensive congenital adenomatoid malformation of the lung

In three infants with extensive congenital adenomatoid malformation of the lung, a method of nonanatomic pulmonary resection permitted preservation of small superiorly positioned pulmonary remnants. These remnants then demonstrated a surprising capacity for expansion, growth, and function during follow-up periods of 5 years, 9 months; 7 years, 6 months; and 19 years. Thus far, this small experience indicates that this method of management does not appear to entail greater short- or long-term risks than the alternative procedure of pneumonectomy.     

"Effect of mechanical deformation on structure and function of polymorphonuclear leukocytes"

The present studies were designed to test the hypothesis that mechanical deformation of polymorphonuclear leukocytes (PMN) leads to functional changes that might influence their transit in the pulmonary capillaries. Human leukocytes were passed through 5- or 3-micron-pore polycarbonate filters under controlled conditions. Morphometric analysis showed that the majority of PMN were deformed and that this deformation persisted longer after filtration through 3-micron filters than through 5-micron filters (P < 0.05) but did not result in the cytoskeletal polarization characteristic of migrating cells. Flow cytometric studies of the filtered PMN showed that there was a transient increase in the cytosolic free Ca2+ concentration after both 3- and 5-micron filtration (P < 0.01) with an increase in F-actin content after 3-micron filtration (P < 0.05). Although L-selectin expression on PMN was not changed by either 5- or 3-micron filtration, CD18 and CD11b were increased by 3-micron filtration (P < 0.05). Priming of the PMN with N-formyl-methionyl-leucyl-phenylalanine (0.5 nM) before filtration resulted in an increase of CD11b by both 5 (P < 0.05)- and 3-micron (P < 0.01) filtration. Neither 5- nor 3-micron filtration induced hydrogen peroxide production. We conclude that mechanical deformation of PMN, similar to what occurs in the pulmonary microvessels, induces both structural and functional changes in the cells, which might influence their passage through the pulmonary capillary bed.     

Day-surgery. The "Regina Elena" National Cancer Institute experience

The MRI appearance of pulmonary lesions in a patient with Wegener's granulomatosis is presented. Pulmonary involvement was characterized by multiple solid and cavitated nodules connected to vessels. Transbronchial biopsy demonstrated typical findings of granuloma. The spleen presented diffuse low signal intensity and an enhancing capsule on T1-weighted images, and inhomogeneously high signal intensity on T2-weighted images. This appearance of diffuse infarction could result from the vasculitis caused by Wegener's disease.     

Two cases of "scombroid syndrome" with severe cardiovascular compromise

Two cases of severe intoxication after ingestion of cooked tuna fish were observed. Symptoms and clinical signs were consistent with the scombroid syndrome. Cardiovascular shock was observed in both patients and was associated with subendocardial myocardial infarction in 1 case and acute pulmonary edema with myocardial ischemia in the other. The importance of ECG monitoring in the Intensive Coronary Care Unit is stressed.     

Morphological and functional aspects of the cardiovascular system related to aging: does "aging heart" exist?

Thromboembolic disease (TE) is an important cause of in-hospital morbidity and mortality. The relationship between cancer and abnormalities of blood coagulation has been recognized for well over a century. Deep venous thrombosis (DVT) of the lower extremities is the most common cause of thromboembolic disease, but pulmonary embolism, upper extremity vein thrombosis, disseminated intravascular coagulation, and other, more unusual, clinical events, may occur. Unexplained TE may serve as a marker for the presence of a hidden tumor. The frequency of pulmonary embolism (PE) among patients with a malignant neoplasm at necropsy is highly increased in the elderly patients. Among subjects with a malignant neoplasm, patients with pancreatic and gastric cancer (mucin-secreting adenocarcinomas), cancer of the large bowel and women with ovarian cancer had the highest frequency of PE. Old age, female sex, gastrointestinal and ovarian cancers must be considered as a significant risk factor for PE. The potentially responsible mechanisms for the thrombotic events, clinical manifestations, diagnostic implications and aspects of treatment of TE in malignant disease are discussed.     

Words hard to say and hard to hear: "May I give you some feedback?"

Long-term favourable effects of a treatment with both cyclosporin A and coumarin in a 35 year old Caucasian female patient with Beh?et's disease, presenting with haemoptysis caused by pulmonary thromboemboli and a single major pulmonary artery aneurysm, are reported. All disease activity and complications were well controlled during 9 years of follow-up.     

Retrieval of "old" foreign bodies from the cardiovascular system in children

Several techniques have been developed to retrieve catheter and guide wire fragments that have embolized to the heart and pulmonary vasculature. In most instances, retrieval of the embolized fragments is performed soon after the event has occurred. In this report, we summarize our experience with the removal of these fragments in 3 children after a significant amount of time had elapsed since the time of embolization. The embolized catheter and guide wire fragments were removed without any complications. We also describe the techniques used for their removal, and the problems encountered during the removal of these "old" foreign bodies.     

Atypical mycobacteriosis (Mycobacterium xenopi) with "initial aggravation"

A 66-year-old man was admitted to Nara Medical University Hospital because of sputum production and fevre. A chest X-ray film obtained on admission revealed many cysts and an infiltrative shadow in the right upper lung field. The patient was treated with antimycobacterial drugs (isoniazid 400 mg, streptomycin 0.75 g, and rifampicin 450 mg) because acid-fast bacilli were detected in his sputum. Although the symptoms and laboratory data improved, a new infiltrative shadow developed in the right lower lung field two months after the start of treatment. Transbronchial biopsy specimens showed intraluminal organizing exudate and alveolitis. The new lesion resolved when treated with the same antimycobacterial drugs. Mycobacterium xenopi was cultured from the sputum 80 days later. This is the third reported case of atypical mycobacteriosis (non-tuberculous mycobacteriosis) due to M. xenopi in Japan with the "initial aggravation" seen in some patients with typical pulmonary tuberculosis.     

Matchmakers'' "phossy jaw" eradicated

At the University of Maryland Medical Systems, 356 consecutive thoracoscopic procedures were performed including 147 lung resections for various indications. Forty-nine patients underwent thoracoscopy for the diagnosis of interstitial lung disease. Two patients underwent bilateral procedures after a gap of more than six months for suspected malignancy. There were 28 females and 21 males. Age ranged from 23 to 75 years. The mean length of operation was 45 minutes and the mean length of chest tube duration 1.3 days. There were no deaths, no re-explorations or need to convert to an open thoracotomy. Staphylococcal pneumonia developed in one patient postoperatively requiring admission and intravenous antibiotics. One patient with systemic pulmonary hypertension was ventilator dependent for 48 hours. All patients, except two ventilator dependent patients, were intubated with a double lumen tube. CO2 insufflation at the rate of 2 L/min and pressure of 10 mmHg was used in all patients. Biopsy of at least two lobes was performed in all patients with resection of grossly abnormal lung. A single chest tube was left at the end of the procedure. The tissue diagnosis was interstitial fibrosis in 19 patients. Bronchiolitis obliterans with organizing pneumonitis (BOOP) was seen in 7 patients. Foreign body granulomas were seen in 8 patients. Allergic alveolitis was diagnosed in 4 patients. Emphysematous changes with pneumonitis was observed in 3, nonspecific pneumonitis in 2. Anthracosis, connective tissue disorder, leukemic infiltrate with interstitial fibrosis and CMV pneumonitis were observed in one patient each. The clinical diagnosis correlated with pathological diagnosis and intraoperative findings. Thoracoscopy is a safe and effective method for diagnosis of interstitial lung disease.     

Anesthesia for bronchoscopy: application of laryngeal mask airway and "minidose midazolam anesthesia"

Bronchoscopy distresses most of the patients. Therefore, we combines a small dose of midazolam (ca. 2 mg) with laryngeal mask airway. This method of anesthesia has the following features: (1) mild discomfort, (2) day care, (3) putting bronchoscope in or out easily, (4) mild effect on respiration and circulation, and (5) easy respiratory care. But improper cases for this method include non-fasting patients, those at high risk for regurgitation, and those with low pulmonary compliance. This is a very usefull anesthetic method for bronchoscopy.