Causes of death in duodenal and gastric ulcer

An analysis has been made of 235 deaths that occurred among 1905 patients with peptic ulcer who constituted a random sample of the occurrence of ulcer disease in an area of Denmark comprising half a million inhabitants. The disease itself, according to the death certificate, was considered the primary cause of death in 10% of the cases; half of these had been operated on immediately before death. The other patients died more frequently than expected from the following causes: chronic bronchitis, pulmonary emphysema, cancer of the lung, cirrhosis of the liver, and cancer of the pancreas. Although the comorbidity with chronic bronchitis and emphysema was especially pronounced in patients with gastric ulcer, the association with liver cirrhosis and cancer of the pancreas occurred only in patients with duodenal ulcer. In women the mortality rate attributable to cardiac and vascular diseases was lower than expected. No excess coincidence of suicide was found. Berkson's fallacy is considered to be of much less importance as a possible explanation of the comorbidity found in the present study than in the majority of publications concerned with this question.     

Lung surface area in various morphologic forms of human emphysema

The relation between lung surface area and the extent and morphologic type of emphysema was examined at autopsy in 69 men. It was found to be conceptually preferable to express the area as internal surface area per unit lung volume (specific surface area) rather than to use the more conventional, inversely related, mean linear intercept for comparison with other morphometric data. In the whole group, fixed inflated lung volume generally increased with increasing per cent involvement of lung parenchyma by emphysema, and total internal surface area decreased, but those changes were not so regular as the decline in specific surface area with increasing per cent emphysema (r=-0.574). Lungs with no emphysema had a significantly higher specific surface area than did lungs with very little emphysema (1 to 9 per cent), suggesting noticeable effects on the physical properties of lung by minimal degrees of this disease at high levels of inflation. The way in which specific surface area decreased with increasing percentage of emphysema was not noticeably different among patients with centrilobular, panlobular, or mixed forms of emphysema, although lungs with only centrilobular emphysema were much more common and had a significantly lower mean percentage of emphysema than did those with only panlobular emphysema; the prevalence and mean percentage of emphysema of the mixed group were intermediate. These observations, coupled with the association of older mean age with increasing percentage of emphysema, were interpreted as support for the concept that many examples of panlobular emphysema are derived from confluence of extensive centrilobular emphysematous lesions.     

Reduction pneumoplasty for giant bullous emphysema. Implications for surgical treatment of nonbullous emphysema

A review of the literature on reduction pneumoplasty for giant bullous emphysema was undertaken to identify current criteria for this surgical treatment and in the hope of obtaining insights into evaluating reduction pneumoplasty for nonbullous emphysema. Twenty-two retrospective case series, published since 1950, were retrieved by a computer search of the literature and a search of the Index Medicus prior to 1966. Reduction pneumoplasty is most effective when bullae are larger than one third of a hemithorax with evidence of compression of adjacent lung tissue and an FEV1 of less than 50% predicted; the presence of emphysema in nonbullous lung and the amount of compression are best judged by CT. The rationale for reduction pneumoplasty for nonbullous emphysema is supported by the similar early functional changes after reduction pneumoplasty for bullous and nonbullous-improvement of blood gas values and lung mechanics. A single study showing that decline of lung function after surgery for bullous emphysema was less in those who stopped smoking than in those who continued to smoke supports the need for preoperative and maintained smoking cessation in patients receiving reduction pneumoplasty. After 4 decades, the duration of improvement in lung function, whether worsening of emphysema occurs in remaining lung, and late morbidity and mortality after reduction pneumoplasty for bullous emphysema are not well defined. A registry with an unoperated-on comparison group could more rapidly accumulate such data after reduction pneumoplasty for nonbullous emphysema.     

Diagnostic accuracy of technologies used in LBP assessment

Postoperative improvement of respiratory function has been reported with lung volume reduction surgery (LVRS) in patients with severe emphysema. Since smoking is an established risk factor for lung cancer, vascular diseases and emphysema, it is not infrequent to find these diseases associated in the same patient. Combined treatment of lung cancer and emphysema has already been reported. Surgical treatment of vascular diseases in emphysematous patients could also benefit from the application of LVRS techniques. We report resection of an aortic aneurysm combined with LVRS in a patient with concomitant thoracic aortic aneurysm and severe emphysema. Respiratory function improved in the postoperative period.     

Induction of apoptosis and cell cycle-specific change in expression of p53 in normal lymphocytes and MOLT-4 leukemic cells by nitrogen mustard

The diagnosis of pulmonary emphysema is often neither as obvious nor as easy as is generally assumed. In this review, the methodologies are discussed by which emphysema can be accurately diagnosed. The classification of emphysema is outlined, with the salient gross and microscopic features listed.     

Radiologic emphysema morphology is associated with outcome after surgical lung volume reduction

BACKGROUND: Lung volume reduction surgery is known to alleviate dyspnea and to improve pulmonary function, performance in daily activity, and quality of life in selected patients with severe pulmonary emphysema. We investigated the role of radiologically assessed emphysema morphology on functional outcome after a lung volume reduction operation. METHODS: The preoperative chest computed tomograms in 50 consecutive patients who had undergone surgical lung volume reduction were retrospectively reviewed by 6 physicians blinded to the clinical outcome. Emphysema morphology was determined according to a simplified classification (ie, homogeneous, moderately heterogeneous, and markedly heterogeneous; lobe predominance). We studied the impact of these morphologic aspects on functional outcome at 3 months. RESULTS: We found a fair interobserver agreement applying our classification system. Functional improvement after surgical lung volume reduction was best in markedly heterogeneous emphysema with an increase in forced expiratory volume in 1 second of 81% +/- 17% (mean +/- standard error, n = 17) compared with 44% +/- 10% (n = 16) for intermediately heterogeneous emphysema. But also in patients with homogeneous emphysema clinical relevant improvement of function could be observed (increase in forced expiratory volume in 1 second = 34% +/- 6%; n = 17). CONCLUSIONS: The morphologic type of emphysema, assessed by a simplified surgically oriented classification, is an important predictor of surgical outcome. Lung volume reduction surgery may also improve dyspnea and lung function in homogeneous emphysema.     

Bullous sarcoidosis: a report of three cases

Three cases of pulmonary sarcoidosis presented as bullous emphysema with severe airflow obstruction, and the diagnosis of sarcoidosis was unsuspected for at least 2 years. Potential mechanisms of bullous emphysema from sarcoidosis are discussed. The physician should suspect sarcoidosis as the cause of bullous emphysema when young patients who have smoked relatively few pack-years present with emphysema or severe airflow obstruction. Additional clues are the presence of mediastinal adenopathy on a chest radiograph or a CT scan and a history consistent with extrapulmonary sarcoidosis.     

Latex hypersensitivity/glove component reaction as a contributing factor to osteomyelitis of the hand: a case report and review of the literature

High-resolution computed tomography (HRCT) can be used to diagnose and quantify emphysema noninvasively, as significant correlations have been found between the histological grade on resected lung specimens and quantified (q) computed tomography (CT). In this study, we performed thin section qHRCT in patients with severe hereditary alpha-1-antitrypsin (AAT) deficiency. AAT deficiency is the most common genetic cause of emphysema in adults, and exercise intolerance is the most disabling, distressing consequence of emphysema for the majority of patients. qHRCT was used to quantify precisely the alterations in the lung parenchyma due to pulmonary emphysema. Up until now, the important relationship between the severity of emphysema and the reduced exercise capacity has received little attention. Therefore the purpose of the study was to investigate the relationship between emphysema as displayed by qHRCT and cardiopulmonary exercise testing (CPX) in patients with severe cardiopulmonary impairment. - qHRCT was performed in 21 patients with homozygous AAT deficiency. CT scans were obtained at three spirometrically standardized levels at the carina and (5 cm above and below the carina). The mean lung density at 50% of vital capacity and a quantitative histogram analysis of the frequencies of CT values were determined. All patients underwent symptom-limited CPX to analyse simultaneously cardiovascular and ventilatory systems responses. - In all patients, qualitative CT assessment demonstrated panlobular emphysema with large and extensive areas of uniform low attenuation, characteristically with a lower-lobe distribution. Mean CT density values of the patients (-845 +/- 6.9 (mean +/- SEM)) were significantly correlated with work capacity (r = 0.55, p <0.01), oxygen-pulse (r = 0.54, p <0.01) and functional dead space ventilation (r = -0.54, p <0.01). Moreover, severe emphysema index (CT values below a threshold value of 950 HU) correlated positively with functional dead space ventilation (r = 0.60, p <0.01) and alveolar-arterial oxygen difference (r = 0.70, p <0.001). - These results clearly demonstrate that CPX parameters, indicating a disturbed pulmonary gas exchange and a ventilation-perfusion-mismatch during exercise, are significantly related to the extent of lung emphysema.     

Spontaneous pneumomediastinum in a patient with bronchiolitis obliterans after bone marrow transplantation

After allogeneic bone marrow transplantation for chronic myelogenous leukemia, spontaneous pneumomediastinum and subcutaneous emphysema developed in a patient with bronchiolitis obliterans. Computed tomography scanning of the chest failed to reveal the cause. There was no evidence of a pulmonary process, pneumothorax, or pharyngeal or upper airway leak. Despite the alarming appearance of the patient, conservative management, including high-flow oxygen, resulted in resolution of the pneumomediastinum and subcutaneous emphysema. The cause of pneumomediastinum and subcutaneous emphysema in bone marrow transplant recipients is discussed.     

Retroperitoneal and mediastinal emphysema as a complication of colonoscopy

Retroperitoneal and mediastinal emphysema as a complication of colonoscopy, though infrequent, may occur. It is important to realize that this can be a benign clinical condition that will resolve with conservative management. A case of retroperitoneal emphysema after routine colonoscopy is reported with a review of literature and a brief discussion.     

Treatment of subdural effusion with hydrocephalus after ruptured intracranial aneurysm clipping

This study examined the role of cysteine proteinases and their inhibitor in the development of emphysema in comparison with neutrophil elastase (NE) complexed with alpha1-protease inhibitor (NE-alpha1-PI), which was previously demonstrated to be increased in bronchoalveolar lavage (BAL) fluid from subjects with subclinical emphysema. Eight nonsmokers and 31 current smokers with (n=17) and without (n=14) emphysema, as evidenced by lung computed tomographic scans, were studied. The concentrations of immunologically detected cathepsin L and cystatin C, but not cathepsin B, were significantly increased in BAL fluid from the smokers with emphysema compared with those without emphysema, although the activity of cathepsin L, measured using a synthetic substrate and cathepsin L, released from cultured alveolar macrophages at 24 h, did not show any significant difference between the two groups. When comparison was made only for the subjects aged <60 yrs, the difference between the two groups disappeared for cathepsin L, but remained for NE-alpha1-PI. There was no significant correlation between the level of cathepsin L and that of NE-alpha1-PI in BAL fluid from the subjects with emphysema. In conclusion, increased levels of cathepsin L and cystatin C were demonstrated in bronchoalveolar lavage fluid from subjects with subclinical emphysema. However, the roles of cathepsin L and neutrophil elastase in the development of emphysema may vary between subjects and between the young and the old.     

Experimental emphysema

This animal model of emphysema exhibits the same abnormalities in respiratory mechanics as those seen in human emphysema. The histologic and radiographic findings also closely resemble changes of panacinar disease. Moreover, the progressive hypoxemia preceding hypercarbia also parallels the clinical course seen in human disease. Drawbacks of this model include the long time period required to develop significant changes and the cost of maintaining the animals for such a time period. Large cystic areas were not noted in our animals and one would have to turn to another model to address the problem of giant bullous emphysema. There is no ideal animal model of pulmonary emphysema, and the usefulness of an experimental model should be judged on how well it answers the specific questions. Significant information has been obtained using various animal models of emphysema in lung transplantation, diaphragmatic function, pulmonary hemodynamics, and in several other areas. The dog appears to be a suitable model for thoracic surgical research on emphysema.     

Idiopathic giant bullous emphysema (vanishing lung syndrome): imaging findings in nine patients

OBJECTIVE: We reviewed the imaging findings in nine patients with idiopathic giant bullous emphysema. This progressive condition is characterized by large bullae, usually seen in association with several forms of emphysema, and usually occurs in young men, most of whom are smokers. MATERIALS AND METHODS: Nine patients with chest radiographic evidence of a bulla or bullae occupying at least one third of a hemithorax, who had also been examined with high-resolution CT, were included in this retrospective study. We examined the size, distribution, and locations of bullae. On high-resolution CT scans, bullae were categorized as predominantly subpleural or intraparenchymal. RESULTS: In eight of the nine cases, the chest radiographs showed variable asymmetry in the distribution of bullae. Bullous disease involved predominantly the upper lobes. High-resolution CT showed bullae from 1 to 20 cm in diameter, but most were 2-8 cm in diameter. Paraseptal emphysema and subpleural bullae were the predominant findings in all nine patients. Seven patients had separate centrilobular emphysema of various degrees and intraparenchymal bullae. None of the intraparenchymal bullae were larger than 2-3 cm. Additionally, two non-small-cell lung cancers were seen in our series. CONCLUSION: The dominant and consistent feature seen on high-resolution CT scans in both smokers and nonsmokers is extensive paraseptal emphysema merging into giant bullae. Associated centrilobular emphysema, seen in cigarette smokers, is the important variable finding for determining the extent of underlying parenchymal disease, which may help in the preoperative assessment of giant bullous lung disease.     

Appetite suppressant drugs as inhibitors of human cytochromes P450: in vitro inhibition of P450-2D6 by D- and L-fenfluramine, but not phentermine

BACKGROUND: We compared our results with bullous vs diffuse emphysema by performing a bilateral thoracoscopic stapled volume reduction technique in 15 patients (age 45-80, 10 males, five females). METHODS: Eight patients demonstrated bullous emphysema and seven patients diffuse emphysema. Lung reduction was performed with a bilateral thoracoscopic stapled technique utilizing bovine pericardium in the supine position. RESULTS: Comparison of the bullous versus diffuse groups revealed no significant differences in means for the following variables: length of air leak (7.5 vs 3.3 days); length of stay (8.1 vs 6.5 days); pre-op FEV1, (23% vs 22%); pre-op dyspnea index (3.4 vs 3.6). At 3 months the bullous subset had a highly significant improvement (p < 0.007) in FEV1 (88%) compared with the diffuse subset FEV1 (59%). CONCLUSIONS: These early results suggest that patients with bullous emphysema are at no greater risk and demonstrate a significantly greater improvement in FEV1 than patients with diffuse emphysema.     

DNase activity in murine lenses: implications for cataractogenesis

Idiopathic pulmonary fibrosis (IPF) and pulmonary emphysema (PE) have distinct clinical and pathological characteristics, and have been considered to be separate disorders. However, recent animal experiments have suggested that, with regard to their pathogenesis, the diseases have some features in common. However, there are no clinical data supporting this hypothesis. We report here 9 patients (all male, 67 +/- 2 years, mean +/- SE) who had PE followed by IPF. They were found among 152 PE patients who came to Tohoku University Hospital during the past 15 years (1976-1991). All patients were male and heavy smokers and 2 patients also had prostate cancer and gastric cancer, respectively. Three patients were alive during this study and had been diagnosed as having IPF and PE by the combination of transbronchial biopsy, selective alveolobronchogram, CT examination and lung function tests. The diagnosis of IPF and PE in the other patients was based on the pathological findings of autopsied lungs in addition to clinical findings. All patients showed PE mainly in the upper lobes and IPF in the lower lobes. In all patients, in addition to all known causes of pulmonary fibrosis, the possibilities that chronic or recurrent infections in PE induced pulmonary fibrosis and that IPF produced emphysematous changes were carefully excluded by medical records and pathological findings. It is not clear whether the occurrence of emphysema and pulmonary fibrosis in these cases is coincidental, or whether the two diseases are linked by a common pathogenetic pathway.     

Retained fetal lung liquid in congenital lobar emphysema: a possible predictor of polyalveolar lobe

The purpose of this study was to determine whether retention of fetal lung liquid is more prevalent in polyalveolar congenital lobar emphysema than in conventional congenital lobar emphysema. Two patients with congenital lobar emphysema were prospectively identified in a 3-year period. Twenty-five such patients were identified in a retrospective study covering 39 years. Medical records were available for 22 patients who had 23 emphysematous lobes. Both babies from the prospective study and six subjects from the retrospective group had respiratory symptoms and underwent chest X-ray in the first day of life. Six of the eight babies with respiratory symptoms and chest imaging in the first day of life had retention of fetal lung liquid in an emphysematous lobe. All six of these lobes were polyalveolar. The lobe in one child was a polyalveolar lobe but without retained fetal lung liquid, and one child exhibited conventional lobar emphysema also without retained fetal lung liquid. One polyalveolar lobe caused no neonatal symptoms and was not imaged until the child was 3 months old. No baby with conventional lobar emphysema was shown to have retained fetal lung liquid. There seems to be a correlation between polyalveolar lobe and onset of respiratory symptoms in the first day of life. Retention of fetal lung liquid within the affected lobe was documented only in cases of polyalveolar lobe.     

Associations between breathing pattern during submaximal exercise and exercise capacity in patients with pulmonary emphysema

We sought to clarify the factors associated with exercise capacity in patients with pulmonary emphysema. Exercise capacities of 20 men with pulmonary emphysema were evaluated by bicycle ergometery, and the results were used to divide the subjects into two groups: high exercise capacity (n = 10) and low exercise capacity (n = 10). Pulmonary-function tests were done, emphysema scores were computed from CT scans, breathing pattern was recorded during submaximal exercise (up to 20 watts), and index of rapid shallow breathing was computed. Neither FEV1 nor airway resistance differed between the two groups, and patients with lower exercise capacity tended to have lower tidal volumes and higher values of the index of rapid shallow breathing during submaximal exercise. Functional residual capacity measured by body plethysmography and emphysema scores were inversely associated with exercise capacity. We speculate that among patients with pulmonary emphysema and a given degree of airway obstruction, a high functional residual capacity causes breathing during submaxinal exercise to be rapid and shallow, and that this rapid and shallow breathing makes ventilation inefficient, increases the work of breathing, and limits exercise capacity.     

Pathophysiology of chronic obstructive pulmonary disease

Emphysema with bullae is a common feature of patients with chronic obstructive pulmonary disease. Central to the pathophysiology of emphysema is the presence of airflow obstruction and lung and chest hyperinflation. Because of the increased ventilatory demand and the need to maintain gas exchange, patients with emphysema increase their work of breathing. This article reviews the adaptive and maladaptive consequences of these changes. A rationale is given as to the possible mechanism by which surgery aimed at resecting hyperinflated portions of the lungs may be effective.     

Six patients in whom exacerbation of asthma was complicated by mediastinal emphysema

We encountered 6 patients with bronchial asthma complicated by mediastinal emphysema. Their average age was 21 years. All were atopic and had histories of asthma in childhood. In 5 of the 6, mediastinal emphysema developed when the patients had upper respiratory infections. In 3, the mediastinal emphysema worsened. After insertion of subcutaneous drains to decrease intramediastinal pressure, the conditions of those 3 patients improved remarkably. The conditions of the other 3 improved after medication only. During the period of this study, 1.24% of all patients treated at Hiroshima Asa Citizen's Hospital for exacerbations of asthma had mediastinal emphysema.     

Nontraumatic subcutaneous emphysema. Diagnostic and therapeutic problems

Nontraumatic subcutaneous emphysema is less frequent than traumatic. Its occurrence, unless synchronous with the treatment of spontaneous pneumothorax, usually is the consequence of exacerbation of COPD or of the obstruction of major bronchi. However, in routine clinical practice, the occurrence of subcutaneous emphysema without evident underlying disease, in combination with normal chest x-ray, still is a diagnostic and therapeutic problem. In this study typical mechanisms of this phenomenon are presented; air-trapping at the level of the main bronchus caused by endobronchial tumour growth, progressive destruction of alveoles by diffuse lung disease irrespective of its nature, and mechanism of its occurrence during dealing with the urgent clinical problem in the intensive care unit. This study does not deal with subcutaneous emphysema during the attack of severe asthma assuming it as well known situation that usually does not cause a major therapeutic problem. The sequence of necessary diagnostic and therapeutic steps is discussed taking account of possible pitfalls that usually exist in all of three described pathophysiological situations.