[Evaluation of examinations in medicine and surgery using multiple choice questions].
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Bayes Theorem↗
Biomedical subjects
C Giuntini
Publications and source records attributed to C Giuntini.
[Cases of pulmonary embolism diagnosed in Pisa from 1969 to 1984].
Starting from 1969, the yearly number of patients with pulmonary embolism documented in the S. Chiara Hospital of Pisa is increased, in spite of the unchanged diagnostic procedures. Aim of this work is to verify if this trend is accompanied by earlier diagnosis with an improvement in the clinical outcome of pulmonary embolism, and if a relevant diagnostic failure is still present in our hospital. A comparison of pulmonary embolism cases collected from 1969 to 1971 and from 1980 to 1982 showed that the number of diagnoses made within one week from the onset of symptoms is increased (+24.8%), whereas the number of diagnoses made after more than one month is reduced (-18.1%). At the same time we observed that cases with a standard PaO2 less than 40 mmHg are reduced (-23.1%) while cases with a standard PaO2 greater than 50 mmHg are increased (+29.9%). An earlier diagnosis of pulmonary embolism contributed to treat a larger percentage of patients (+29.7%) and to lower the early mortality (-17.4%). This diagnostic trend can be ascribed to an increased readiness in raising the clinical suspicion of pulmonary embolism and to the prompt availability of perfusion lung scan, that is the center of our diagnostic strategy. Data of our 1,010 patients, compared with those of autoptic series and with the number of admissions, surgical operations and deaths in the wards of our hospital, suggest some persistent diagnostic failure in patients with well documented embolic risk; such as injured, burned, patients affected by neoplasm or motor lesion, patients operated for orthopedic or gynaecologic problems.
Heart Diseases↗
The assessment of gas exchange by automated analysis of O2 and CO2 alveolar to arterial differences.
A computer program to measure breath by breath alveolar pressure (PA) and alveolar to arterial difference (AaD) for O2 and CO2, by a mass-spectrometer has been implemented. The program allows the determination of alveolar gas by different methods: 1. Bohr's equation (BE); 2. ideal alveolar air equation for O2 (IDO2); 3. end-tidal (ET); 4. by the Rahn's definition of 'mean alveolar gas', i.e., alveolar pressures are defined when instantaneous respiratory exchange ratio (IRQ) equals mean respiratory exchange ratio (MRQ). This automated technique has been used in 16 patients with chronic obstructive lung disease (COLD) and 15 patients with pulmonary embolism (APE). In both groups of patients it was always possible to find in each breath the point where IRQ = MRQ and therefore to measure AaD by RD. IDO2 was significantly lower than PAO2 by the other methods. Also ET values of O2 and CO2 were significantly different from RD and BE in both groups of patients, however the difference was consistently higher in COLD patients. The different shape of the expirograms (steeper expirograms in COLD) is responsible for this different result. RD and BE AaD characterize gas exchange more precisely than ET, because the contribution of high VA/Q units is also evaluated. This is particularly important in COLD patients. Consideration on dead space measurements are also reported both for COLD and APE patients. In conclusion this automated technique provides the assessment of gas exchange for the use in clinical respiratory physiology and for the monitoring of gas-exchange in critically ill patients.
Aged↗
Fatal peripheral airway cystic disease in a young woman.
Diffuse cystic transformation of both lungs was rapidly fatal in a 33-year-old woman. This disorder, a rare congenital condition in infants, has apparently not been described in adulthood.
Adult↗
Kinetics of the intrapleural distribution of a radioactive bolus.
Through the use of a gamma-camera placed horizontally over the chest of 5 supine, anesthetized and spontaneously breathing dogs we studied the kinetics of the intrapleural spreading of 1 ml saline containing 2 mg of 99mTc labelled albumin (250 microCi/kg) injected at various points on the costal side. From the postinjection sequence of gamma-camera images, we defined, along the intrapleural spreading pathways, some regions of interest (ROI) displaying a preferential label accumulation. In all the animals the ROI roughly corresponded to the apical, mediastinal and latero-diaphragmatic regions. The kinetics of the intrapleural label distribution, estimated from the time course of the activity under the ROI, displayed an initial rapid phase, lasting a few minutes, followed by a marked slowing down of the exchange processes. At 30 min regional counts reached an apparent steady state, the activity values greatly varying (even by 10 fold) among the animals, for the ROI corresponding to the same anatomical region, independently on the site of injection. The mathematical modelling of the regional activity curves required the assumption of a progressive decrease in the exchange coefficients to account for a marked slowing down of the exchange processes with increasing time.
Animals↗
Imaging of ventilation in chronic obstructive pulmonary disease.
Patterns of radioaerosol deposition in patients with COPD may be interpreted on the basis of derangements in convective ventilation. Thus, in patients with asthma, central deposition is consistently associated with increased airway resistance, in the absence of acute attack, indicating that in this condition major airways are usually the site of bronchial constriction. In patients with chronic bronchitis, inhomogeneous and spotty deposition patterns are strongly associated with indexes of uneven and wasted ventilation and may be explained on the basis of destruction or obstruction of peripheral airways. Spotty deposition is ascribed to very uneven convective ventilation reduced to a limited number of air streams, as opposed to the normal situation of a very high number of air streams giving rise to the uniform pattern of radioaerosol deposition. Patients with emphysema show less distinctive patterns of deposition and may resemble those of the patients with asthma and chronic bronchitis. Nevertheless, the deposition features are very useful to better characterize the patient even in the emphysematous group. From the practical point of view, the features of aerosol deposition provide useful information for evaluation and treatment of the patient with COPD. They may also prove useful to better define and characterize the different disease entities grouped as COPD.
Humans↗
Perfusion lung imaging in the adult respiratory distress syndrome.
In 29 perfusion lung scans (PLS) of 19 patients with ARDS, 20 of which were obtained within six days from the onset of respiratory symptoms, perfusion abnormalities were the rule. These included focal, nonsegmental defects, mostly peripheral and dorsal, and perfusion redistribution away from the dependent lung zones. PLS were scored for the presence and intensity of perfusion abnormalities and the scores of perfusion redistribution were validated against numerical indices of blood flow distribution per unit lung volume. PLS scores were correlated with arterial blood gas values, hemodynamic parameters, and chest radiographic scores of ARDS. Arterial oxygen tension correlated with the scores of both perfusion defects and redistribution. Perfusion defects correlated better with the radiographic score of ARDS, and perfusion redistribution with PAP and vascular resistance. ARDS patients exhibit peculiar patterns of PLS abnormalities not observed in other disorders. Thus, PLS may help considerably in the detection and evaluation of pulmonary vascular injury in ARDS.
Humans↗
Respiratory effects of occupational exposure to tobacco dust.
Few investigations of the respiratory effects of occupational exposure to tobacco dust have been carried out and the threshold limit value has not well been established. A cross sectional survey on a sample of 223 male and female workers at a cigar and cigarette factory in Lucca (Tuscany) showed a significantly higher prevalence of wheezing, attacks of shortness of breath with wheezing, dyspnoea, and rhinitis than in a reference population. A trend towards a decrease in forced end expiratory flows according to smoking habit and work duration was evident. Positive skin prick tests were observed in 26% of men and 23% of women and were positively associated with duration of work and negatively with cigarette smoking. Thin interstitial space involvement was observed on chest x ray examination in almost half the female workers with more than 35 years exposure. These findings suggest that prolonged exposure to tobacco dust may have negative health effects and that it is advisable to establish a threshold limit value for tobacco dust different from that of inert dust.
Adult↗
Routine electrocardiography in screening for pulmonary embolism.
In a group of 245 patients with clinical suspicion of pulmonary embolism we analyzed the ECG for 22 signs that have been associated with this disease. Subsequently, the patients were divided into two groups: those with confirmed embolism and those in whom embolism was not confirmed. The occurrence of the ECG signs was assessed separately for the two groups. Furthermore, we related ECG features to severity of embolism as estimated at lung scan. Tachycardia and S-T depression were the commonest findings in both groups. P-R displacement, late R in a VR, S1Q3T3, S slurred and T inversion in V1-V2 were more frequent in embolic than in nonembolic patients (p less than 0.05 or less). All the above mentioned signs were more frequent at diagnosis than at recovery in embolic patients (p less than 0.05 or less), whereas only tachycardia was more frequent at diagnosis than at control in nonembolic patients (p less than 0.001). S-T depression and T inversion in V1-V2 were also associated to severity of embolism. Since some ECG signs are very frequent or specific in pulmonary embolism, this condition should always be suspected when they are found and, particularly, when previously absent in the same patients and/or not explained by other conditions.
Adult↗
Functional aspects of reversible airway obstruction.
The determination of the prevailing site of bronchial constriction in asthma is of noteworthy interest as regards knowledge of the pathophysiological mechanisms of this disease, and of practical importance because the intrapulmonary distribution of inhaled drugs depends chiefly on airway caliber. To visualize the alteration of convective ventilation caused by the alterations of airway caliber, we developed a technique based on inhalation of a monodispersed aerosol of human albumin minimicrospheres (mean aerodynamic diameter 0.75 micron, geometric SD 1.19) labeled with 99mTc(Hamm). Intrapulmonary HAMM deposition is revealed externally by means of a gamma camera in 4 projections, soon after inhalation and 4 h later, when the mucociliary activity has removed the fraction of HAMM deposited in larger airways. In normal subjects, about 16% of the inhaled HAMM deposited in airways, mostly (90% of total deposited fraction) by sedimentation in airways peripheral to the 16th generation. We obtained 58 determinations of the HAMM deposition pattern in 38 patients (17 males and 21 females, mean age 35.2 +/- 16.8 years) with symptomatic or asymptomatic asthma, none under acute attack. At the same time we obtained the determination of bronchoconstriction degree by measuring the forced expiratory volume in 1 s (FEV1) and the airway resistance (Raw) by plethysmographic technique. In 10 asymptomatic patients with normal bronchoconstriction indexes, we revealed the pattern of HAMM deposition before and after a reduction of about 30% in FEV1 in induced by bronchial challenge with carbachol.(ABSTRACT TRUNCATED AT 250 WORDS)
Aerosols↗
The breathing pattern in dyspnoic patients with different cardiopulmonary disorders.
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Acute Disease↗
[Trichinella spiralis: evidence of pulmonary retention of the newborn larvae].
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Abdomen↗
Regional protein absorption rates from the pleural cavity in dogs.
In five supine spontaneously breathing anesthetized dogs we injected into the pleural space 0.5-1 ml of saline solution containing 2 mg/ml albumin labeled with technetium-99m. By use of a gamma camera placed horizontally over the chest, we followed, up to 120 min, the activity over the whole lung and over the preferential accumulation areas of the label (regions of interest, ROI) that corresponded to the apical, mediastinal, and laterodiaphragmatic regions. Activities were corrected for the decay rate of the isotope used. On the average, the activity over the whole lung decreased by 27% up to 120 min. The overall activity over the ROI amounted to 44.3% after the injection and decreased to 24% of total at 120 min, thus accounting for 75% of the total decrease in activity. At 10 min, the activity per unit surface of the gamma camera image (As) was from 2.2- to 5.7-fold higher over the ROI than for the rest of the lung image. The decrease of As at 120 min was 18-, 13-, and 5-fold greater for mediastinal, diaphragmatic, and apical regions, respectively, compared with the rest of the lung image. The time course of the changes in As are discussed in terms of regional albumin egress rate based on the functional interaction between the Starling and the lymphatic mechanisms.
Absorption↗
Reference equations for the single-breath diffusing capacity. A cross-sectional analysis and effect of body size and age.
A longitudinal study was implemented in an unpolluted rural area of northern Italy (near Venice), before the start of the operation of a large oil-burning thermoelectric power plant, in order to investigate the effects of the future exposure to air pollution and to elucidate the natural history of obstructive airways diseases. During the first cross-sectional survey, a sample of the general population (n=3,300, 8 to 64 yr of age) performed several lung function tests, and information on risk factors and on the presence of respiratory symptoms were obtained by a standardized questionnaire. There were 712 subjects who were classified as normal on the basis of rigid criteria and who were able to perform satisfactorily a single-breath CO diffusing capacity (DLCOsb) test. The DLCOsb values showed an increase with height and age early in life and a later decrease with age. Two age groups were selected to determine an age at which DLCOsb stopped increasing and began to decline. Reference equations were computed (using age and height) in these 2 different age groups in each of the sexes. Similar equations were calculated for the total lung capacity derived from single-breath helium dilution measurements. The DLCOsb values in this study were higher than reported by other investigators. The method of selection of the study population, the strict criteria for normal, as well as technical, differences probably explain this finding. Reference equations for diffusing capacity corrected to lung volume (DL/VA) were computed only for adults (much greater than 20) in both sexes, because age and height coefficients in young subjects were insignificant.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
The radiologic distinction of cardiogenic and noncardiogenic edema.
Improvement in the ability to determine the specific cause of any given case of pulmonary edema would lead to more rapid and definitive treatment. "Wedge" pressures and measurements of cardiac output derived from Swan-Ganz catheterization assist in making this determination, but the procedure is invasive, expensive, associated with complications, and not infrequently inaccurate. A plain chest film is, however, almost invariably available in all patients with pulmonary edema, and as shown in this study, the cause of the edema can be determined with a high degree of accuracy by careful attention to certain radiographic features. An independent two-observer study was performed on 216 chest radiographs of 61 patients with cardiac disease, 30 with renal failure or overhydration, and 28 with capillary permeability edema. Three principal and seven ancillary features have been identified, all of which are statistically significant and permit the cause of the edema to be determined correctly in a high percentage of cases. The three principal features are distribution of pulmonary flow, distribution of pulmonary edema, and the width of the vascular pedicle. The ancillary features are pulmonary blood volume, peribronchial cuffing, septal lines, pleural effusions, air bronchograms, lung volume, and cardiac size. Differing constellations of these features occur, each of which is characteristic of a specific type of edema. Overall accuracy of diagnosis in this study ranged from 86% to 89%. The highest accuracy was obtained in distinguishing capillary permeability edema from all other varieties (91%), and the lowest in distinguishing chronic cardiac failure from renal failure (81%).
Blood Volume Determination↗
The chest roentgenogram in pulmonary edema.
It has been shown that the chest roentgenogram is a sensitive and accurate pool for detecting and quantitating cardiogenic pulmonary edema. This can be done at the interstitial stage, when it cannot be detected by physical examination. At the same time the chest film can provide useful information about the circulating blood volume. In patients with the ARDS, a characteristic peripheral and patchy distribution of alveolar edema associated with an absence of peribronchial cuffing, septal lines and effusions has been shown. Enlargement of the right side of the heart and main pulmonary artery may precede actual development of edema in ARDS and provide the opportunity for early diagnosis. Radiographic "scoring" in cases of ARDS correlates well with PO2 (measured with an F1O2 = .21) standardized to a PCO2 of 40 mm Hg. The three main forms of lung edema (that is, cardiogenic, renal or overhydration, and injury edema) appear to have radiographic features that can be used to separate them. The accuracy and objectivity of this approach has been confirmed by taking the radiographic signs as input variables for discriminant analysis. Different hemodynamic conditions and changes of the extravascular protein osmotic forces may be the main factors underlying the radiographic patterns in the various types of pulmonary edema.
Blood Pressure↗
Pleural effusion and recurrent broncho-pneumonia with lymphedema, yellow nails and protein-losing enteropathy.
A case is reported in whom the triad generalized lymphedema, nail dystrophy, and pleural effusion was associated to protein-losing enteropathy. This combination, not previously described, was also characterized by exacerbations of pleural effusion with recurrent episodes of broncho-pneumonia. Albumin turnover study showed depletion of the total body pool, decreased catabolic rate, and elevated albumin removal through the gastrointestinal tract. During bronchopneumonia, increased capillary permeability due to pleural involvement may worsen the basic deficit of pleural lymphatic drainage.
Bronchopneumonia↗
Radiographic assessment of perfusion impairment in pulmonary embolism.
To assess whether radiographic features of descending pulmonary artery reflect the severity of the vascular obstruction we reviewed chest radiographs and perfusion lung scans in 115 patients affected by pulmonary embolism. Patients were classified according to the radiographic appearance of the descending pulmonary artery: normal, enlarged, and markedly enlarged with "sausage" shape. At acute embolization, patients with "sausage" appearance of the artery had the most serious vascular obstruction (56% on the average), in respect to patients with simply enlarged arteries (39% obstruction on the average, p less than 0.001) and patients with normal arteries who had the smallest obstruction (26% on the average, p less than 0.001). At recovery, patients showed a parallel decrease of descending pulmonary artery width and vascular obstruction.
Adult↗