Pulmonary embolism in the elderly patient (author's transl)]

Pulmonary embolism has a high incidence in old patients and is often not recognized. In most cases the embolism is of unknown origin, although the deep venous system of the lower extremities is involved in almost 95%. The diagnostic procedure consists of evaluation of clinical symptoms and findings. ECG and chest X-ray are often not conclusive. Confirmation of the diagnosis is possible by ventilation-perfusion scanning of the lung. Pulmonary angiography is of no value in the elderly patient, because of the lack of consequences. Besides local therapy of a thrombosis, therapy consists of administration of heparin, while oral anticoagulation should be used only with precaution. The efficacy of platelet aggregation inhibiting substances remains to be determined. The main point are prophylactic measures in patients with risk factors or in high risk situation.     

Breath analysis tests in gastrointestinal disorders (author's transl)]

From various breath tests up to now mainly measurement of respiratory 14CO2 and hydrogen have attained clinical application. Breath tests are easily performable, without discomfort for patient or in investigator and do hardly require active support of the patient. On the other hand absorption tests, as 14C-tripalmitate- and 14C-lactose-breath test, are influenced by alterations of the metabolism in a considerable degree, and clinical significance and specificity of the 14C-cholylcycline-breath test remains questionable hitherto. Nevertheless, obtained values which are independent from metabolism, high sensitivity and lack of competitive methods are arguments for the 14C-cholylglycinebreth test for the diagnosis of bacterial overgrowth in the small bowel. Breath analysis of hydrogen seems to be a very sensitive and reliable method for detecting carbohydrate malabsorption, as lactose intolerance.     

Skin tests in the diagnostic of allergic alveolitis (author's transl)]

Cutaneous tests used in the diagnostic of allergic alveolitis are reviewed. The results indicate, that cutaneous tests are useful only bird breeders lung. Usually there is dual reaction: 1st type I and 2nd type III. The basic immunologic mechanismus of the skin test results and thereby of the diseases are discussed.     

Imaging tests in the diagnosis of pulmonary embolism

Imaging modalities play an essential role in diagnosing pulmonary embolism (PE). Clinical outcome studies demonstrated that PE can be safely ruled out in patients with unlikely clinical probability in combination with a normal D-dimer test result; in all other patients additional imaging is needed. The aim is to accurately confirm or rule out the diagnosis of PE, after which, if indicated, anticoagulant treatment can be initiated. Various diagnostic tests are available, and this article reviews the different imaging techniques in patients with suspected PE. Computed tomographic pulmonary angiography (CTPA) is the imaging test of choice because of its high sensitivity and specificity. Compression ultrasonography and ventilation perfusion scintigraphy are reserved for patients with concomitant suspicion of deep vein thrombosis or contraindication for CTPA. Furthermore the diagnostic process in patients with clinically suspected recurrent PE, PE during pregnancy, and PE in the elderly and in patients with malignancy are discussed.     

Laboratory tests in the diagnosis of pulmonary embolism

The diagnosis of pulmonary embolism (PE) requires objective testing. However, all imaging techniques have their own limitations and costs and cannot be performed in every patient with suspected PE. After decades of unfruitful research, several laboratory tests have been evaluated for suspected PE, the most promising being the D-dimer test. As a general rule, the specificity of D-dimers is too low to confirm PE. Conversely, several (but not all) D-dimer assays have a high sensitivity for diagnosing PE. Outcome studies indicate that the Vidas D-dimer and SimpliRED D-dimer can be used safely to withdraw anticoagulation when the pretest probability of PE is low (SimpliRED) or when it is low or moderate (Vidas). These results may however not apply to other D-dimer assays and clinicians should know the characteristics of the test used in their hospital. Blood gas analysis does not have sufficient sensitivity and specificity to confirm or exclude PE, but it may be used to evaluate the clinical probability of PE before other testing is done. The diagnostic value of the alveolar dead space fraction in patients with suspected PE is currently investigated. Initial data suggest that it needs to be combined with a D-dimer test to safely exclude PE. Brain natriuretic peptide and cardiac troponin have limited usefulness for diagnosing PE, but both tests may identify patients with a poor prognosis, in whom more aggressive treatment may be warranted.     

Observation of a pulmonary histoplasmosis with Histoplasma capsulatum (author's transl)]

From an observation of pulmonary histoplasmosis with Histoplasma capsulatum in a Haiti woman living in France for 2 years, the authors recall the mycological and epidemiological data of this fungus as well as the main clinical radiological and biological signs of the disease. Because of its tendancy to dissemination, histoplasmosis can have a bad prognosis. It is difficult to diagnose in our countries and facing a chronic pulmonary form, a diagnosis of tuberculosis is often thought of. But its possibility is to be envisaged in case of a journey in countries of endemia, and the disease should be confirmed by: -- several samplings to trace the fungus, bringing the mycological prove of the disease; -- serum uses; -- modalities and difficulties of the treatment by Amphotericin B are also recalled.     

Isotopic indicators in the diagnosis of malignant pleurisies (author's transl)]

The tracers that are used in thoracic pathology have an elective tumoural affinity, present such a special reaction towards pleural effusions that we were led to study Bleomycin labelled with Cobalt 57 in 34 cases of pleurisy of various etiologies. The hyperfixation, circumscribed to the effusion in all these cases, presented a double problem : of radiobiological risk and of diagnostic significance. We tried to solve the last problem by means of a precise protocol applied to 16 cases, quantifying comparatively the specific radio-activity of pleural fluid and serum and studying the evolution of the pleural serous gradient, after injection of 2 mCi of labelled Bleomycin in 16 patients with suspected malignant pleurisy. From this limited study, it appeared that the sero-pleural gradient of the tracer, 24 hours after injection, was very high, above 5 and up to 15 in 7 malignant pleurisies out of 8; between 2 and 4 in others. It was sometimes below 5 and less in effusions, non malignant or doubtful. This gradient decreased very rapidly to reach 0 on the fourth day, except in recurring chronic effusions. Pending the confirmation of results, after a prolonged experiment, this protocol appeared valuable for diagnostic and physiopathological reasons.