[Evaluation of the effectiveness of surgically treating young children with diseases of the thoracic organs based on results of pulmonary function studies].
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Child↗
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Hypothermic circulatory arrest and hypothermic perfusion for extensive disease of the thoracic and thoracoabdominal aorta.
BACKGROUND: Hypothermic cardiopulmonary bypass with or without an interval of circulatory arrest has been evaluated for the treatment of complex aortic disease of the descending thoracic and thoracoabdominal aorta. Hypothermia has a protective effect on spinal cord function, and its use should reduce the incidence of paraplegia and paraparesis in traditionally high-risk patients. Experimentally, the protective effect of hypothermia has been related to amelioration of excitotoxic injury by reduction of neurotransmitter release and to inhibition of delayed apoptopic cell death. METHODS: During a 12-year period, 114 patients with descending thoracic or thoracoabdominal aortic disease underwent replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest. The mean age of the patients was 60 years (range 22 to 79 years). Acute or chronic dissection was present in 40 patients (35%). Sixty-four patients (56%) had Crawford Types I, II, or III thoracoabdominal aneurysms. RESULTS: The hospital mortality was 8% (9 patients). Paraplegia occured in 2 and paraparesis in 1 of the 108 patients whose lower limb function was assessed postoperatively (2.8%). None of 40 patients with aortic dissection and none of the last 81 patients in the series developed paralysis. One patient developed renal failure that required dialysis. CONCLUSIONS: Our experience with hypothermic cardiopulmonary bypass and circulatory arrest confirms that hypothermia provides substantial protection against spinal cord ischemic injury. It allows complex operations on the descending thoracic and thoracoabdominal aorta to be performed with acceptable mortality, a low incidence of renal failure, and an incidence of other complications that does not exceed that reported with other techniques.
Adult↗
Cardiovascular and pulmonary effects of epidural anaesthesia.
The cardiovascular effects observed with epidural anaesthesia are complex and are predominantly related to the extent of sympathetic denervation, autonomous balance, baseline blood volume and cardiovascular function of the patient. With epidural anaesthesia the pharmacological effect of systemically absorbed local anaesthetic agents and inclusion of adrenaline to the local anaesthetic solution may play a role. Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone prior to the block. Epidural anaesthesia per se has little effect on respiration in patients with pre-existing lung disease. Thoracic epidural anaesthesia appears to reverse the diaphragmatic dysfunction which is a major determinant of the decrease in lung volumes observed after upper abdominal surgery. This article summarizes cardiovascular and pulmonary responses to epidural anaesthesia.
Anesthesia, Epidural↗
Technique, indications, and clinical use of 24 hour esophageal pH monitoring.
The technique of 24 hour esophageal pH monitoring (24 hour pH test) is described. Experience with the 24 hour pH test in 393 patients with suspected esophageal disease has shown the clinical usefulness of the test in objectively determining the presence of gastroesophageal reflux. The test was effective in evaluating atypical symptoms of gastroesophageal reflux such as respiratory symptoms and chest pain and, in children, failure to thrive and recurrent pneumonia. The 24 hour pH test was particularly useful in evaluating patients who were referred with other abdominal or thoracic disease and had, in addition, symptoms suggestive of gastroesophageal reflux on history. The test helped to unsnarl the cause of recurrent symptoms after an esophageal myotomy for achalasia or an antireflux procedure. Of 179 patients with typical symptoms of gastroesophageal reflux, 27% had normal 24 hour test results and were subsequently diagnosed as having another cause for their symptoms. Of 146 patients who had normal findings on esophagoscopy, 54% were shown to have abnormal gastroesophageal reflux on 24 hour pH monitoring, indicating lack of sensitivity of endoscopy to detect reflux. In addition, the 24 hour pH test identified patterns of abnormal reflux and indicated those patients most at risk for development of stricture. The test is well tolerated by the patients, simple to use, and dependable when performed and read as described. The clinical use of the 24 hour pH test brings objectivity to the evaluation of exophageal disease that has hitherto not been available.
Aged↗
[Myeloma with intrathoracic tumor expression].
We report a case of a patient of 58 years old who suffered from a left apical opacity occurring in a context of deterioration in general health. Subsequent clinical developments were dominated by the ophthalmic disease and a frontal syndrome. The radiological work-up showed tumoral lesions which had developed from the first rib, from the structures at the base of the cranium and the frontal area and were associated with multiple lacunae of the cranial vault. There was evidence of hyperproteinaemia, and an IgG gamma monoclonal gammopathy, a significant medullary plasmocytosis with morphological anomalies of the plasmocytes leading to a diagnosis of myeloma with a plasmocytoma of the rib and the retro-orbital area. Thoracic disease associated with this pathology is common but mainly present as osteolytic lesions. The occurrence of intrathoracic plasma cell tumours is rarer as are orbital manifestations. In spite of treatment which can frequently lead to an objective response, the prognosis of this disorder remains gloomy.
Bone Neoplasms↗
Ultrasonically guided aspiration biopsy in osteolytic bone lesions of the chest wall.
Sixteen consecutive patients with one or more osteolytic bone lesions of the chest wall radiologically confirmed underwent ultrasonically guided aspiration biopsy. Nine patients (56.2 percent) had bronchogenic carcinoma with a direct extension. Other diagnostic techniques had failed to diagnose disease in these patients. The lesion showed heterogeneous echogenicity (n = 16) caused by the hyperechoic signals of bone fragments. The interruption of the cortex bone was detected in all cases and extraosseous tumor portion in 14 of 16 patients (87.5 percent). No respiratory motions of the lesion could be demonstrated (n = 16). Definitive histologic diagnosis was made in 14 of the 16 patients (87.5 percent). In malignancy, diagnosis was established in 13 of 14 patients (92.8 percent). Of two confirmed benign lesions, one diagnosis of tuberculosis was obtained. No complication occurred. Sonography and consequently ultrasonically guided aspiration biopsy are a useful, accurate, safe, and low-cost technique for osteolytic lesions in thoracic diseases.
Adult↗
Altered intravascular contrast material flow dynamics: clues for refining thoracic CT diagnosis.
The ability of helical thoracic CT to acquire data rapidly has enabled radiologists to use the dynamics of contrast medium flow more effectively to diagnose subtle abnormalities. In general, these abnormal flow dynamics manifest in two ways: diverted hyperdense venous opacification and an altered temporal relationship of vascular opacification. When observed, these findings serve as clues for the detection of elusive anatomic and physiologic abnormalities.
Adult↗
Percutaneous transthoracic needle biopsy in AIDS: analysis in 32 patients.
PURPOSE: A retrospective study was performed to determine the success of percutaneous transthoracic needle biopsy (TNB) as an aid in diagnosing focal chest and mediastinal disease in patients with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS). MATERIALS AND METHODS: The study group was composed of 32 patients seropositive for HIV; 31 of these patients had known AIDS. The subjects underwent chest radiography, computed tomography, and TNB. RESULTS: In 27 of the 32 patients a specific diagnosis was enabled by TNB. Bronchogenic carcinoma was diagnosed most frequently, although infectious agents were isolated in most patients. CONCLUSION: TNB is a safe and effective procedure for evaluation of focal thoracic disease in this patient population and provides information that is often unavailable from alternative diagnostic procedures.
Acquired Immunodeficiency Syndrome↗
[Nosocomial pneumopathies].
The criterion used for the diagnosis of nosocomial pneumonia is an infiltrate on X-ray of the chest, not present on admission, associated with new sputum production. The main causative pathogens are Staphylococcus spp. and Gram-negative bacilli. The most common pattern in the development of pneumonia is colonization of the oropharynx followed by aspiration into the lungs in patients with impaired normal defences. The factors which significantly predispose to nosocomial pneumonia are tracheal intubation, low level of consciousness, chronic lung disease, thoracic or upper abdominal surgery, large volume aspiration and age over 70 years. The fatality rate is high (32 p. 100 to 55 p. 100). In most cases the curative treatment requires a combination of antimicrobial agents. At the moment, preventive measures remain an elusive goal.
Cross Infection↗
[Arteriographic data in chronic ischemia of the hand. Study of 62 cases].
The arteriograms of sixty-two patients with chronic ischemia of the hand and fingers were reviewed. Twelve patients were considered to have Raynaud's disease. Thoracic outlet syndrome caused ischemic symptoms in thirteen patients. Arteriosclerosis obliterans affected twenty-two patients. The signs of arteriosclerosis are described including irregular constrictions, multiple occlusions and the corkscrew pattern of the collateral arteries. The differential diagnosis includes thromboangiitis obliterans and collagen vasculitis.
Adolescent↗
[Complex respiratory therapeutic measures in chronic unspecific bronchopulmonary diseases and after thoracic surgical operations].
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Breathing Exercises↗
Nontuberculous mycobacterial immune reconstitution syndrome in HIV-infected patients: spectrum of disease and long-term follow-up.
BACKGROUND: The long-term outcome and spectrum of disease of nontuberculous mycobacterial immune reconstitution syndrome have not been described. METHODS: We report the findings of an observational study. RESULTS: Among 51 patients (43 with Mycobacterium avium complex [MAC] infection, 2 with Mycobacterium genavense infection, and 6 whose samples were smear positive but culture negative) from 1993-2004, the median follow-up period was 29 months. The incidence of nontuberculous mycobacterial immune reconstitution syndrome was 3.5% among patients initiating highly active antiretroviral therapy (HAART) with a baseline CD4+ cell count of <100 cells/microL. Three main clinical presentations were peripheral lymphadenitis (in 17 patients), pulmonary-thoracic disease (in 15 patients), and intra-abdominal disease (in 13 patients). Six other patients had cases that involved joint, spine, prostate, skin, soft tissue, and spontaneously resolving MAC bacteremia. Disease was usually localized. Median CD4+ cell counts before initiation of HAART and at diagnosis were 20 and 120 cells/microL, respectively, and the median reduction in human immunodeficiency virus (HIV) RNA load was 2.5 log10 copies/mL. Intra-abdominal disease was frequently preceded by disseminated MAC infection (in 62% of cases, compared with 6%-33% of cases for other groups; P=.003) and accounted for 16 (43%) of 36 hospitalizations (compared with 5%-35% for other groups; P=.008). The relapse rate was not higher among 10 patients who received no MAC therapy or received MAC therapy for < or =2 weeks. Prednisone was associated with clinical responses in 8 (89%) of 9 patients with evaluable cases. In total, 7 patients (14%) had 13 subsequent culture-positive MAC events (6 of which were cases of immune reconstitution syndrome, and 7 of which were cases of disseminated MAC infection). Ten patients (20%) died (2 of disseminated MAC infection, 5 of other opportunistic infections, and 3 of HIV-unrelated causes). CONCLUSIONS: Nontuberculous mycobacterial immune reconstitution syndrome has a wide range of clinical presentations and severity. The long-term prognosis is favorable for HAART-adherent patients. Intra-abdominal disease is associated with greater morbidity than is peripheral lymphadenitis. The role of antimycobacterial therapy is uncertain, given the self-limited course of most nonabdominal cases.
Adult↗
Improved image interpretation with registered thoracic CT and positron emission tomography data sets.
OBJECTIVE: The purpose of this study was to determine if nonlinear registration of clinically acquired thoracic CT and FDG positron emission tomography (PET) data sets supports more detailed interpretation of metastatic thoracic disease when compared with interpretations from nonregistered PET studies. CONCLUSION: In 11 of 16 data sets of patients imaged for detection of metastatic disease, interpretations from PET studies were correctly altered with registration information. All changes were either improvements in tumor localization or correct interpretation of less metastatic involvement.
Adult↗
Rapidly progressive bronchiectasis complicating ulcerative colitis in a child.
Patients with ulcerative colitis may have a presentation dominated by extraintestinal manifestations. These manifestations, particularly bronchiectasis, are very rarely seen in pediatric patients. A 13-year-old boy with ulcerative colitis who was diagnosed by colonic mucosa biopsy is presented. He developed unexplained productive cough after the appearance of colonic disease. He was treated and followed up at his primary care hospital with the sole diagnosis of ulcerative colitis, with little attention given to the chest symptoms. The relation of the bronchial involvement to the ulcerative colitis was not established until two years after the onset of disease. Thoracal computed tomography (CT) examination after this period showed evidence of bronchiectasis and pulmonary involvement. Despite prophylactic inhaled corticosteroid treatment, no clinical or radiographic improvement was observed and widespread bronchial destruction developed very rapidly. More effective treatment with oral steroids was probably necessary in this patient, if the early chest symptoms were related to the ulcerative colitis.
Adolescent↗
Stage IA-IIB Hodgkin's disease: staging and treatment of patients with large mediastinal adenopathy.
Ninety-two patients with clinically staged (CS) IA-IIB Hodgkin's disease (HD) with large mediastinal adenopathy (LMA) underwent three different staging and treatment approaches between April 1969 and December 1984. These approaches included: (1) staging laparotomy followed by radiation therapy (RT) alone; (2) staging laparotomy followed by combined RT and chemotherapy (CMT); or (3) clinical staging followed by CMT. Patients treated with CMT were more likely to have "B" symptoms, extension into extranodal sites, or stage III disease. Patients treated with RT alone had a significantly higher risk of relapse as compared to patients receiving CMT. No overall survival differences were seen between the three groups of patients. For patients treated with CMT without RT to the spleen or abdominal nodes, the risk of relapse in the abdomen was low (4%). These data suggest that for those CS I-II HD patients with LMA who are treated with CMT, the role for staging laparotomy and abdominal irradiation is limited. RT alone remains an option for some patients with LMA, but careful assessment of the anatomic extent of thoracic disease as well as staging laparotomy is essential if such treatment is recommended.
Antineoplastic Combined Chemotherapy Protocols↗
Pediatric stage IV Hodgkin disease. Long-term survival.
BACKGROUND: The optimal treatment for Stage IV Hodgkin disease (HD) remains uncertain, particularly the role of radiation therapy (RT). METHODS: A retrospective review of 43 children, 18 years of age or younger, who were seen and treated for Stage IV HD between June 1970 and June 1988, was performed. All patients were treated with combination chemotherapy (CT), and 20 patients received RT after CT (combined-modality therapy, CMT). CT consisted of mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) in 41 patients and both MOPP and doxorubicin (Adriamycin, Adria Laboratories, Columbus, OH), bleomycin, vinblastine, and dacarbazine in two patients. RT was added for patients who had a partial response (PR) to CT (n = 11) and/or for initial bulky thoracic disease (n = 12). RESULTS: With a median follow-up of 83 months, the 7-year actuarial freedom from progression (FFP) and survival rates for all patients were 69% and 78%, respectively. For patients achieving a complete response (CR) to CT, the 7-year FFP rate was 73% and for patients with a PR it was 90% (P value not significant). The actuarial overall survival rates at 7 years were 88% for patients with CR versus 80% for patients with PR. In contrast, patients with either no response (one patient) or progressive disease (four patients) after CT had a significantly worse prognosis than patients with CR, with a 7-year actuarial survival rate of 40% (P = 0.006). FFP after CT alone was significantly more prevalent in patients with Stage IVA (11 of 13 patients) than in patients with Stage IVB disease (2 of 10 patients; P = 0.003). For these symptomatic patients, failures were almost exclusively (seven of eight patients) in sites of initial nodal disease. The addition of adjuvant RT improved the progression-free survival for patients with B symptoms: 2 of 13 patients had relapses after CMT versus 8 of 10 patients treated with CT alone (P = 0.003). CONCLUSIONS: This retrospective analysis of MOPP alone compared with MOPP plus RT showed a significant difference in FFP in patients with Stage IVB HD favoring CMT.
Adolescent↗
Nosocomial pneumonia. A multivariate analysis of risk and prognosis.
One hundred and twenty consecutive episodes of nosocomial pneumonia (NP) in 118 nonneutropenic adults admitted to a 1,000-bed teaching hospital were studied in order to investigate the prognosis and risk factors. The overall fatality rate was 36.6 percent. The identification of a "high-risk" microorganism (Pseudomonas aeruginosa, Enterobacteriaceae, and other Gram-negative bacilli, Streptococcus faecalis, Staphylococcus aureus, Candida sp, Aspergillus sp, and episodes of polymicrobial pneumonia), bilateral involvement on chest x-ray examination, the presence of respiratory failure, inappropriate antibiotic therapy, and age older than 60 years or an underlying condition ultimately or rapidly fatal were those factors selected by a stepforward logistic regression analysis as independently worsening the prognosis. A series of variables frequently quoted as predisposing to NP was determined to be either present or absent in the same 120 cases of NP and in an equal number of randomly selected control subjects. After adjusting for confounding, factors significantly predisposing to NP were tracheal intubation, depressed level of consciousness, underlying chronic lung disease, thoracic or upper abdominal surgery, prior episode of a large volume aspiration, and age older than 70 years. Since some of the factors influencing the risk or the prognosis of NP are amenable to medical intervention, a percentage of NP might be prevented and its prognosis can be improved.
Adult↗
Computed tomography of adult neuroblastoma.
The computed tomographic (CT) findings in five adult patients with neuroblastoma and in one with ganglioneuroblastoma are presented. Four patients had abdominal and thoracic disease, one had abdominal disease only, and one had isolated chest involvement. The CT findings are nonspecific and may be confused with lymphoma. Nevertheless, multifocal presentation, particularly if it includes the posterior mediastinum and association with diffuse or focal bone involvement, when present, should suggest the diagnosis and lead to appropriate laboratory and histopathologic workup.
Abdominal Neoplasms↗