Segmental contour pattern in a case of pulmonary venoocclusive disease

A V/Q mismatch (segmental contour pattern) is described in a patient suffering from dyspnea. Chest roentgenography revealed a mild interstitial pattern and enlarged pulmonary arteries. A lung biopsy demonstrated pulmonary venoocclusive disease.     

High-resolution CT scan in the evaluation of exercise-induced interstitial pulmonary edema in cardiac patients

OBJECTIVE: To evaluate the onset of exercise-induced interstitial pulmonary edema in cardiac patients by high-resolution CT (HRCT). DESIGN: Prospective, normal controlled. PARTICIPANTS: Thirty subjects divided into three groups: group 1--10 outpatients with chronic congestive heart failure (CCHF), New York Heart Association (NYHA) class I; group 2--10 outpatients with CCHF, NYHA class II/III; and group 3 (control)--10 normal subjects. METHOD: HRCT scans were obtained at rest and 4, 8, 12, 16, and 20 min after progressive treadmill exercise test. RESULTS: The following HRCT findings consistent with interstitial edema were significantly different (p<0.05) in group 2 when compared with groups 1 and 3: artery/bronchus ratio > 1 in the upper lobes, peripheral increase in the vascular markings, interlobular septal thickening, and peribronchial "cuffing." These differences were maximal at 12 min after exercise and returned to normal values after 20 min. CONCLUSION: Interstitial pulmonary edema was present immediately after exercise in CCHF patients. It may be important in the genesis of dyspnea of these patients.     

Operative chest wall stabilization in flail chest--outcomes of patients with or without pulmonary contusion

Cytogenetic and molecular analyses such as allelotyping studies have revealed several genetic changes typical for human glial neoplasms. However, most studies to date have involved malignant gliomas and thus are likely to reflect late events of tumor progression. To elucidate the initial events of glial tumor growth, we performed a genome-wide search for genetic alterations in the DNA of 43 low-grade gliomas as compared to the constitutional DNA of the patients' peripheral blood leucocytes using the two-dimensional (2D) DNA fingerprint approach. Reliable results were obtained for 28 blood/tumor sample pairs (13 astrocytomas, 9 pilocytic astrocytomas, 1 oligodendroglioma, 3 oligoastrocytomas, and 2 ependymomas). DNA was digested with the restriction enzyme HaeIII and the resulting fragments were separated on 2D gels according to size and sequence in the first and second dimensions, respectively. Patterns of hundreds of spots were generated by hybridization with four different mini- and microsatellite core probes. A total of 655 to 1,122 spots could be visualized per sample. Comparison of blood and tumor spot patterns revealed two to 11 reproducible changes per patient. Most of the differences were spot losses (77.1%), while the others appeared to be gains or amplifications. Exactly the same changes were found in tumor recurrences which lacked histological signs of progression. When comparing different patients, many of the affected spots tended to cluster in particular areas of the gel as revealed by computer-aided comparison of all spot patterns. Eleven different spot clusters were identified which may correspond to several major deletion targets. This study provides the basis for the future molecular cloning of the candidate tumor suppressor genes affected by the common spot losses and will allow new insights into the genetic mechanisms of glial tumorigenesis.     

Pericardial thickening or effusion in patients with pulmonary artery hypertension: a CT study

OBJECTIVE: The aim of the study was to determine the prevalence of pericardial thickening or effusion revealed by CT in patients with pulmonary artery hypertension. MATERIALS AND METHODS: Forty-five patients underwent pulmonary artery catheterization and CT of the thorax. On CT, we measured the maximum pericardial thickness, total pericardial score (the sum of four measures of pericardial thickness), and thickness of the anterior pericardial recess. Patients were grouped according to mean pulmonary artery pressure: group 1, less than 21 mm Hg (n = 15); group 2, 21-35 mm Hg (n = 15); and group 3, greater than 35 mm Hg (n = 15). RESULTS: The prevalence of an increased pericardial score and increased maximum pericardial thickening was higher in group 3 than in group 1 or group 2 (p = .02 and < .001, respectively). Anterior pericardial recess thickening was markedly increased in group 3 (p < .0001). For all patients, significant correlations (Spearman's rank correlation coefficient = .44-.56, p < .005-.0001) were found between mean pulmonary artery pressure and all pericardial measures. CONCLUSION: On CT, pericardial thickening or effusion is a frequent finding in patients with severe pulmonary hypertension.     

Relations between chest CT and pathologic findings in pulmonary infarction associated with lung cancer

Chest radiographic (mainly CT), and pathological findings in pulmonary infarction associated with lung cancer were studied to obtain information useful for the interpretation of CT findings, and to help determine the cause of infarction. Sixteen cases of lung infarction were chosen from among 518 cases of lung cancer. All patients were operated on between January 1980 and December 1990. Sixteen surgical cases and one autopsy case all with evidence of lung cancer and infarction were chosen. There were 13 men and 4 women with a mean age of 56 years. Adenocarcinoma was found in 8 cases, squamous cell carcinoma in 6, adenosquamous carcinoma in 2, and small cell carcinoma in 1. Chest radiographs and CT revealed infarction shadows in 8 of the 16 cases. Typical CT findings for pulmonary infarction were: shadows located in the same lobe and periphery as the cancer; ill-defined, 10-25 mm nodular shadows; and lesions located both in the subpleural zone and apart from the pleura. Lesion counts in each area were about the same. Observation of one patient for 2 months revealed a decrease in the size of the nodular shadows and clarification of their margins. In most cases, centrally extended cancer resulted in vascular stenosis and infarction.     

Clinical effects of four weeks of respiratory muscle stretch gymnastics in patients with chronic obstructive pulmonary disease

We developed a program of respiratory muscle stretch gymnastic (RMSG), and measured lung function, exercise capacity, dyspnea, and quality of life before and after 4 weeks of training with this program. Thirteen patients with chronic obstructive pulmonary disease (mean FEVi, 1.24 liters) began the program. They participated in three sessions of RMSG each day. Twelve patients completed all 4 weeks. RMSG significantly (p < 0.01) decreased functional residual capacity (from 4.19 +/- 1.27 to 3.88 +/- 1.03 liters), total lung capacity (from 5.98 +/- 1.35 to 5.66 +/- 1.20 liters), residual volume (from 3.29 +/- 1.16 to 2.89 +/- 0.89 liters), and residual volume as a percent of total lung capacity (from 53.9 +/- 11.2% to 50.6 +/- 9.74%). The distance walked in 6 min increased by an average of 43 +/- 30 meters (+ 15%, p < 0.01). Dyspnea after a 6-minute walk (measured with a 150-mm visual analog scale) decreased significantly (from 65.1 +/- 40.8 to 36.1 +/- 36.8, p < 0.05). Quality of life was measured with the Chronic Respiratory Disease Questionnaire of Guyatt, et al., and was found to have improved significantly. Respiratory muscle stretch gymnastics may be useful in pulmonary rehabilitation.     

Role of chest CT scanning in the management of patients presenting with head and neck cancer

CONTEXT: Alzheimer disease (AD) susceptibility genes have been identified on chromosomes 1, 14, 19, and 21, and a recent study has suggested a locus on chromosome 12. OBJECTIVE: To confirm or refute the existence of a familial AD susceptibility locus on chromosome 12 in an independent sample of familial AD cases. DESIGN: Retrospective cohort study. DNA data for 6 chromosome 12 genetic markers were evaluated using parametric lod score and nonparametric linkage methods and linkage heterogeneity tests. The latter include the admixture test of homogeneity in the total group of families and the predivided sample test in families stratified by the presence or absence of an apolipoprotein E (APOE) epsilon4 allele among affected members. Parametric analyses were repeated assuming autosomal dominant inheritance of AD and either age- and sex-dependent penetrance or zero penetrance for the analysis of unaffected relatives. SETTING: Clinical populations in the continental United States, Canada, Argentina, and Italy. PATIENTS: Fifty-three white families composed of multiple members affected with AD, from whom DNA samples were obtained from 173 patients with AD whose conditions were diagnosed using established criteria and from 146 nondemented relatives. MAIN OUTCOME MEASURE: Presence of an APOE epsilon4 allele among affected family members. RESULTS: Using parametric methods, no evidence for linkage to the region spanned by the chromosome 12 markers could be detected if familial AD is assumed to arise from the same genetic locus in all 53 families. However, significant evidence for linkage was detected in the presence of locus heterogeneity using the admixture test (odds ratio, 15, 135:1). The estimated proportion of linked families within the 53 families examined varied between 0.40 and 0.65, depending on the genetic model assumed and APOE status. The precise location of the AD gene could not be determined, but includes the entire region suggested previously. Nonparametric linkage analysis confirmed linkage to chromosome 12 with the strongest evidence at D12S96 (P<.001). CONCLUSIONS: Our data provide independent confirmation of the existence of an AD susceptibility locus on chromosome 12 and suggest the existence of AD susceptibility genes on other chromosomes. Screening a larger set of families with additional chromosome markers will be necessary for identifying the chromosome 12 AD gene.     

Anticardiolipin antibodies are associated with pulmonary hypertension in patients with mixed connective tissue disease or systemic lupus erythematosus

Anticardiolipin antibodies (aCL) were studied in relation to pulmonary hypertension (PH) in 22 patients with mixed connective tissue disease (MCTD) or systemic lupus erythematosus (SLE). The mean pulmonary arterial pressure (mPAP) values were similar in the 12 MCTD and 10 SLE patients: 26 +/- 11 and 25 +/- 11 mm Hg, respectively. However, the frequency of PH was higher in SLE (60%) than in MCTD patients (33%). The titers of aCL were significantly higher in SLE (38 +/- 27 IU/ml) than in MCTD (17 +/- 7 IU/ml; p < 0.02). Two SLE patients with high titers of aCL had multiple cerebral infarction and transverse myelitis, and deep vein thrombosis, respectively. A significant correlation between the titers of aCL and mPAP was observed in patients with MCTD (p < 0.05), but not in patients with SLE.     

Intraesophageal balloon distension test in Chagas' disease patients with noncardiac chest pain

Patients with Chagas' disease often have chest pain as a prominent symptom. The objective of this study was to compare the results of intraesophageal balloon distension in chagasic and nonchagasic patients with chest pain not caused by coronary obstruction. We studied 40 patients with chest pain and angiographically normal coronary arteries, 25 with a positive serologic test for Chagas' disease (Chagas group, 16 women, mean age 53+/-10 years), and 15 with a negative serologic test (control group, 11 women, mean age 46+/-10 years). All patients had radiologic and endoscopic examinations of esophagus, stomach, and duodenum, esophageal manometry with the acid infusion test in the distal esophagus, and intraesophageal balloon distension. None of them had esophageal dilation or any signs of cardiovascular disease. A 25-mm-long latex balloon located 10 cm above the lower esophageal sphincter was inflated and deflated over a period of 10 sec at 1-ml increments of air until the subjects reported chest pain or to a maximum volume of 20 mi. The test caused chest pain in 14 subjects in the control group (93%) and in 12 in the Chagas' disease group (48%, P < 0.05). The mean volume of air that caused chest pain was 10+/-3 ml in the control group and 15+/-4 ml in the Chagas' disease group (mean+/-SD, P < 0.05). The maximum intraesophageal pressure during the examination was higher in Chagas' disease patients with chest pain during balloon distension (60 +/- 21 mm Hg) than in patients who did not have chest pain (37 +/-18 mm Hg, P < 0.05) and did not differ from the control group (48+/-16 mm Hg, P > 0.05). With the other examinations there was no difference between groups or between patients with or without chest pain during the balloon distension test. Although esophagitis was observed in 47% of patients in the control group and in 40% of the Chagas' disease group, the acid infusion test was positive in 27% of patients in the control group and in 4% of patients in the Chagas' disease group. We conclude that, as compared to a group of patients with similar chest pain, chagasic patients are less sensitive to esophageal distension. Thus, it is unlikely that their chest pain is related to esophageal mechanisms.     

Evaluation of pulmonary arterial trunk on frontal chest radiograph in patients with atrial septal defects

Atrial septal defect (ASD) is one of the most common congenital cardiac anomalies encountered in adulthood. The evaluation of the pulmonary hypertension in ASD is clinically important for operative indication and prognosis. The pulmonary vasculature in chest radiographs in patients with ASD is characterized as dilatation of the central pulmonary arteries and increase of the peripheral pulmonary vessels in patients without pulmonary arterial hypertension (PH) and constriction of the peripheral pulmonary arteries in those with pulmonary hypertension. While the dilatation of the main pulmonary artery occurs in the patients both with and without pulmonary hypertension, its precise radiographic evaluation with regard to the morphological and hemodynamic change of the right ventricle and pulmonary arteries has not been reported. This study was to determine if the contour of the main pulmonary artery segment of the cardiac silhouette in the conventional frontal chest radiograph could be used 1) as indicators of PH or raised right ventricular pressure and 2) as a reliable base for evaluation of the size of the right ventricule (RV) in ASD. The intersection of the line (line A) drawn tangentially to the lateral lower margin of the main pulmonary artery segment to the horizontal line at the left hemidiaphragm is closely related to the apex of RV as measured by right ventricular angiography in supine position. The ratios of the distance of the intersection from the midline of the frontal chest radiograph to the internal diameter of the left hemithorax in normal subjects were 0.50 +/- 0.08 (mean +/- standard deviation) for male and 0.54 +/- 0.09 for female. The ratio increased with increasing left-to-right shunt [0.59(Qp/QS < 2), and 0.71 (Qp/QS > 2)] and shows a tendency of decrease with raised right ventricular systolic pressure (0.52-0.64 in normal subjects and patients with mild raised right ventricular systolic pressure and 0.43 in patients with severe raised right ventricular systolic pressure). The measurement of the angle of the line A from the vertical line tends to show increasing decrease with raised pulmonary arterial and right ventricular systolic pressure (20.1 degrees +/- 4.9 in mild PH and 10.3 degrees +/- 4.1 in moderate to severe PH). The decrease of the angle of the line A to the vertical line was well correlated with conventional radiographic criteria of the right and left central pulmonary arteries of PH.(ABSTRACT TRUNCATED AT 400 WORDS)     

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.     

Helical CT of pulmonary nodules in patients with extrathoracic malignancy: CT-surgical correlation

OBJECTIVE: Our aim was to assess the sensitivity of helical CT for revealing pulmonary nodules. Thoracotomy with palpation of the deflated lung, resection, and histologic examination of palpable nodules was used as the gold standard. SUBJECTS AND METHODS: Thirteen patients underwent helical CT (slice thickness, 5 mm; reconstruction intervals, 3 mm and 5 mm; interpreted by two independent observers). Subsequently, patients underwent unilateral (n = 6) or bilateral (n = 7) surgical exploration, and CT-surgical correlation of 20 lungs was performed. RESULTS: Ninety nodules were resected (61 were smaller than 6 mm; 13 were 6-10 mm; 11 were larger than 10 mm; in five nodules, the size was not recorded at surgery). Sixty-nine nodules were located in the pulmonary parenchyma and 21 in the visceral pleura. Of the 90 lesions, 43 (48%) were found on histology to represent metastases. For lesions detected by at least one observer, the sensitivity of helical CT was 69% for intrapulmonary nodules smaller than 6 mm, 95% for intrapulmonary nodules larger than or equal to 6 mm, and 100% for histologically proven intrapulmonary metastases larger than or equal to 6 mm. For lesions smaller than or equal to 10 mm, sensitivity was better using a reconstruction interval of 3 mm rather than of 5 mm. CONCLUSION: In this study, the sensitivity of helical CT exceeded the sensitivity of conventional CT in previous reports. However, because of limitations in the detection of intrapulmonary nodules smaller than 6 mm and of pleural lesions, complete surgical exploration should remain the procedure of choice in patients undergoing pulmonary metastasectomy. Preoperative helical CT should be used to guide the surgeon to lesions that are difficult to palpate.     

High-resolution computed tomography in patients with bronchial asthma: correlation with clinical features, pulmonary functions and bronchial hyperresponsiveness

Phosphopeptides are a useful tool for the investigation of phosphorylation as a reversible posttranslational modification. There is a growing interest in using mimics of phosphoamino acids involved in phosphorylation in order to study the enzymes concerned in these processes. These mimics should contain a non-hydrolysable or isoelectrically modified phosphate moiety to be used as a specific inhibitor of phosphatases and kinases. We introduce sold-phase synthesis of H- and methylphosphonopeptides as a new class of mimics of phosphotyrosyl peptides. The peptides were synthesized on solid phase using the standard fluorenyl-methyloxycarbonyl (Fmoc) strategy. Tyrosine residues were incorporated as allyl-protected derivatives, which were selectively deprotected on the resin by treatment with Pd(PPh3)4. The peptide resin carrying the side-chain unprotected tyrosine of the model peptide Gly-Gly-Tyr-Ala was phosphonylated with di-tert-butyl-N,N-diethyl-phosphoramidite in the presence of 1H-tetrazole, yielding H-phosphonopeptides after trifluoroacetic acid (TFA) cleavage. Alternatively, phosphonylation of the unprotected tyrosine with O-tert-butyl-N,N-diethyl-P-methylphosphonamidite catalysed by 1H-tetrazole and followed by oxidation led to the methyphosphonopeptides after TFA cleavage. We obtained both the H-phosphonopeptides and the methylphosphonopeptides of the tetrapeptide in high yields and purities above 90%, according to reversed-phase high-performance liquid chromatography (RP-HPLC). To investigate the general applicability of our new methodology, we synthesized phosphonopeptides up to 13 amino acids long, corresponding to recognition sequences of tyrosine kinases. After cleavage and deprotection, all phosphonopeptides were obtained in high yields and purities of about 90%, as shown by mass spectrometry. The only by-product found was the unmodified peptide.     

Management of pulmonary tuberculosis suspects with negative sputum smears and normal or minimally abnormal chest radiographs in resource-poor settings

SETTING: Queen Elizabeth Central Hospital, Blantyre, Malawi. OBJECTIVES: 1) To determine the proportion of pulmonary tuberculosis (PTB) suspects with negative sputum smears and a normal/minimally abnormal chest radiograph (CXR) who are culture-positive for Mycobacterium tuberculosis, and 2) to determine how many develop smear or radiographic evidence of PTB (TB CXR) during follow-up. METHODS: PTB suspects with negative sputum smears and a normal/minimally abnormal CXR were given a second course of antibiotics and followed up at 3-week intervals over 3 months with repeat sputum smears and chest radiography. RESULTS: Of 79 patients (38 men and 41 women, mean age 33 years) with negative smears and a normal/minimally abnormal CXR, 16 (21%) were culture-positive for M. tuberculosis. Of 15 culture-positive patients who were alive and attended follow-up, seven (47%) developed a TB-CXR by 3 months. Of 41 culture-negative patients who were alive and attended follow-up, 13 (32%) developed a TB-CXR, including one patient who became sputum smear-positive. TB-CXRs were found only in patients with a cough. CONCLUSION: TB suspects with negative smears and normal/minimally abnormal CXRs in high human immunodeficiency virus (HIV) prevalent countries should be given a second course of antibiotics. If cough improves, patients can be advised not to return for further follow-up. If cough continues, patients should return for further follow-up with sputum smear examination and chest radiography. Approximately 50% of those who have culture-positive PTB will develop a TB-CXR by 3 months and can be identified if radiographic facilities are available.     

Predictors of functioning of patients with chronic obstructive pulmonary disease

The subcellular distribution of soluble and membrane-bound Arg-beta-naphthylamide-hydrolyzing activities was studied in the left and right rat brain during development and aging. During development, the soluble activity was heterogeneous, whereas adult animals showed the highest activity in the synaptosomal fraction. However, except in fetuses, membrane-bound activity was greatest in the microsomal fraction. Except in microsomal and myelin fractions, soluble and membrane-bound activities showed a decrease in 1-wk-old rats compared with fetuses and a subsequent increase to adult levels in 1-mo-old rats. This profile differed in the microsomal fraction, which increased steadily throughout development. In the synaptosomal fraction, both activities were lower in 24-mo-old rats than in 5-mo-old animals. No differences between the hemispheres were observed in soluble or membrane-bound fractions at any age tested.     

Tuberculosis of the chest wall: CT findings

To assess the CT features of tuberculosis of the chest wall, the CT findings in four patients with documented tuberculous chest wall infection were reviewed. Two patients were Caucasian and two were of Chinese origin. All had normal immune status. In two cases tuberculosis involved the ribs, in one the costal cartilage, and in one the sternoclavicular joint. Computed tomography demonstrated osseous and cartilaginous destruction (in four), soft tissue masses with calcification (in two), and rim enhancement following intravenous contrast medium administration (in two). Underlying pleuroparenchymal tuberculosis was present in two cases. Tuberculosis of the chest wall is characterized by bone or costal cartilage destruction and soft tissue masses that may demonstrate calcification or rim enhancement with or without evidence of underlying lung or pleural disease.     

Right and left ventricular dysfunction in patients with severe pulmonary disease

AIM OF STUDY: To measure the effect of specific preoperative information on postoperative anxiety, satisfaction with information, and demand for analgesia, of Chinese males having transurethral resection of the prostate (TURP). DESIGN: A controlled experimental design. The researchers allocated all patients (n = 30) undergoing TURP in a general hospital in Hong Kong, during a 3-month period, to one of two groups. The experimental group (n = 15) received a specific information pamphlet and a general preoperative counselling video. The control group (n = 15) received a video alone. PROCEDURE AND MEASURES: Following ethical approval, a researcher took baseline measures of state and trait anxiety using the Chinese State-Trait Anxiety Inventory (C -STAI). Five days after surgery the researcher administered the C-STAI (A-State), a patients' satisfaction questionnaire, and, recorded requests for analgesia during the first 5 postoperative days. RESULTS: Experimental subjects reported significantly lower anxiety levels post-operatively and a significantly higher level of satisfaction with the preoperative information, than controls. Postoperative demand for analgesia did not significantly differ between groups. CONCLUSIONS: The findings support the importance of providing patients with specific, written preoperative information about their surgery and its effects to minimize their postoperative anxiety levels, and improve their satisfaction with the care provided.     

Transjugular intrahepatic portosystemic shunt for the management of severe venoocclusive disease following bone marrow transplantation

Hepatic venoocclusive disease (VOD) is a common, life-threatening complication of bone marrow transplantation (BMT). Portal hypertension is usually present and accounts for many of the clinical manifestations of this syndrome. We describe the results of transjugular intrahepatic portosystemic shunt (TIPS) for the management of VOD after BMT TIPS was performed in six patients with histologically confirmed VOD who had progressive jaundice and ascites. Portal hypertension was improved by TIPS in all patients (mean portal pressure gradient before TIPS, 20.2 +/- 4.6 vs. 6.7 +/- 1.9 mm Hg post-TIPS, P < .004). Three patients who underwent TIPS late in the course of VOD did not demonstrate any clinical improvement after TIPS and expired within 2 weeks of the procedure. The remaining three patients had less advanced disease and demonstrated decreases in serum bilirubin, improvement in coagulopathy, and decreased ascites after TIPS. Two patients subsequently expired, one with persistent histological changes of VOD. The lone survivor continues to do well with resolution of ascites, jaundice, and coagulopathy as of her last outpatient visit. TIPS was an effective method for portal decompression in patients with VOD after BMT, and was associated with clinical improvement in some patients. However, these effects may be transient and may not improve overall survival.