Risk factors for recurrence of haemoptysis following bronchial artery embolisation for life-threatening haemoptysis.

SETTING: Life-threatening haemoptysis is a frequent and often fatal complication in areas with a high prevalence of tuberculosis (TB). Bronchial artery embolisation remains the standard initial treatment. Subsequent curative measures, such as surgical resection of the focus of haemorrhage, are generally recommended to prevent recurrence, but risk-based selection criteria have not been established. OBJECTIVES: To identify risk factors for the recurrence of haemoptysis following embolisation. DESIGN: Baseline characteristics were obtained from consecutive patients with life-threatening haemoptysis who were successfully embolised and followed up for at least 12 months. RESULTS: Recurrence of haemoptysis was observed in 47% and was associated with increased mortality compared to patients without recurrence (31% vs. 10%, P = 0.021). Patients with recurrence experienced residual mild haemoptysis beyond the first week after embolisation (odds ratio [OR] 7.2), received blood transfusions (OR 5.3) or presented with an aspergilloma (OR 5.1). Conversely, the presence of active TB amenable to treatment (OR 0.3) protected patients from these events. Radiographic or angiographic appearance did not predict recurrence. CONCLUSIONS: Recurrence of haemoptysis following embolisation for life-threatening haemoptysis is common and is associated with high mortality. The results of this study can contribute to the risk assessment of these patients and guide decisions regarding the urgency of definitive therapy.     

The causes of haemoptysis in malaysian patients aged over 60 and the diagnostic yield of different investigations

OBJECTIVE: In southeast Asia, pulmonary tuberculosis (TB) is the most frequently presumed diagnosis for haemoptysis. This study was designed to assess the causes of haemoptysis, the diagnostic yield of causes in different diagnostic modalities and the distribution of older patients. METHODS: All patients presenting to the University of Malaya Medical Centre, Kuala Lumpur, Malaysia with haemoptysis were recruited prospectively and evaluated. RESULTS: One hundred and sixty patients were evaluated for haemoptysis; 71 (44.4%) were aged 60 years or more. Significantly more patients smoked in the older age group (P = 0.002). The main causes of haemoptysis in the older patients were bronchogenic carcinoma (49.3%), pneumonia (11.3%), bronchiectasis (8.6%), cryptogenic (5.6%) and active TB (4.2%). Significantly more older patients had carcinoma (P < 0.001), while the younger patients more often had TB (P < 0.001). Chest pain was significantly more common in the older patients (P = 0.025), particularly in patients with carcinoma. Bronchoscopy alone or combined with CT of the thorax was significantly more diagnostic in the older patient (P = 0.006). CONCLUSION: Bronchogenic carcinoma is the commonest cause of haemoptysis in patients aged 60 years and above. Presumptive anti-TB therapy should not be encouraged despite the regional high prevalence of TB.     

Management of severe hemoptysis: experience in a specialized center

Bronchiectasis, cancer and tuberculosis account for the majority of haemoptysis requiring intensive care unit admission. Bedside evaluation (volume and bronchoscopic active bleeding) is safe to screen patients for arteriography and bronchial artery embolisation (BAE). First-line interventional arteriography should be favour over surgery in patients with non traumatic life-threatening hemoptysis. Surgery must be reserved in cases of failure or recurrence of bleeding after BAE.     

Increased TNF-alpha, IL-1 beta and IL-6 levels in the bronchoalveolar lavage fluid with the upregulation of their mRNA in macrophages lavaged from patients with active pulmonary tuberculosis.

SETTING: We hypothesized that patients with active pulmonary tuberculosis (TB) have tubercular pneumonitis and that alveolar macrophages at these sites release proinflammatory cytokines, resulting in high levels of cytokines in alveolar epithelial lining fluid. OBJECTIVE: To measure cytokine levels in bronchoalveolar lavage fluid (BALF) and to confirm the source of any cytokines by examination of alveolar macrophage cytokine mRNA. DESIGN: Seventeen active pulmonary TB patients and 15 healthy controls were prospectively studied. Bronchoalveolar lavage (BAL) was performed, proinflammatory cytokine levels were determined and alveolar macrophages isolated from BALF were prepared for RNA extraction and Northern blot analysis. RESULTS: Compared with healthy controls, TNF-alpha, IL-1 beta and IL-6 in BALF were all significantly higher in patients with active pulmonary TB, 298.7 +/- 85.9 vs. 8.9 +/- 2.7 (P = 0.0001); 164.4 +/- 67.5 vs. 8.9 +/- 2.7 (P = 0.003); 969.2 +/- 214.2 vs. 86.4 +/- 17.0 (mean +/- SE pg/ml) (P = 0.0001), respectively. Only TNF-alpha and IL-6 levels were significantly higher in sera of active pulmonary TB patients, 92.3 +/- 28.7 vs. 3.5 +/- 1.2; 15.2 +/- 5.4 vs. 2.1 +/- 2.1, respectively. Northern blot analysis revealed increased gene expression of these alveolar macrophage cytokines in patients with active pulmonary TB compared healthy controls. CONCLUSION: Significantly higher levels of TNF-alpha, IL-1 beta and IL-6 were found in BALF from patients with active pulmonary TB, and were released by alveolar macrophages in the TB lesions.     

Does coexistence with bronchiectasis influence intensive care unit outcome in patients with chronic obstructive pulmonary disease?

BACKGROUND: Bronchiectasis is associated with chronic obstructive pulmonary disease (COPD) in 30% to 50% of patients. This study evaluated whether association with bronchiectasis has any influence on morbidity and mortality in patients with COPD during their intensive care unit (ICU) stay. METHODS: The study was conducted at a respiratory ICU of a university hospital, and 93 mechanically ventilated patients with COPD were studied. Twenty-nine (31%) of 93 patients with COPD also had bronchiectasis. Patients with bronchiectasis had more frequent hospitalizations, more severe airflow limitation, and higher pulmonary artery pressure than patients without bronchiectasis. Duration of ICU (27+/-32 days [median: 14]; 16+/-16 days [median: 9]; P=.01) and hospital stays (44+/-44 days [median: 24.5]; 28+/-26 days (median: 20); P=.046) in patients with bronchiectasis were significantly longer than in patients without bronchiectasis, respectively. Bronchiectasis was an independent predictor for ICU stay longer than 10 days (odds ratio: 5, 95% confidence interval: 1.02-21, P=.043). The development rate of ventilator-associated pneumonia, especially with Pseudomonas aeruginosa, was significantly higher in patients with bronchiectasis (P=.034). Despite these prolonged durations, bronchiectasis did not increase mortality in this study population (P=.865). RESULTS: These results suggest that the coexistence of bronchiectasis in patients with COPD may increase the duration of ICU stay and hospitalization but does not influence the mortality.     

Long-term effect of bronchial artery embolization in Korean patients with haemoptysis

OBJECTIVE AND BACKGROUND: Bronchial artery embolization (BAE) has been regarded as a bridging therapy in the management of massive haemoptysis until a more definite therapy can be pursued. The long-term effectiveness of BAE and the factors associated with failure to control bleeding in an Asian setting of tuberculosis are unknown and were investigated. METHODS: Over approximately 4 years, 139 patients received BAE to treat haemoptysis at a single centre, of these, 118 had been followed up for more than 1 year (median 23 months) and were retrospectively recruited into the study. Patients were divided into those who required readmission for treatment of recurrent haemoptysis after BAE (re-bleeding group), and those who did not (non-rebleeding group). RESULTS: Of the 118 patients, 112 (95.8%) had haemoptysis of greater than 100 mL per day. The most common underlying cause of haemoptysis was pulmonary tuberculosis. Eight patients, four of whom had advanced lung cancer, died after BAE. There were 32 patients (27.1%) in the re-bleeding group. Aspergillosis was significantly associated with re-bleeding after BAE (P<0.05). There were no differences in gender, age, degree of haemoptysis, or APACHE II scores between the re-bleeding and non-rebleeding groups. Twelve patients in the re-bleeding group had a repeat BAE only, whereas seven underwent surgery after repeat BAE. Of the 118 patients who underwent initial BAE, one showed a transient spinal ischaemia. CONCLUSIONS: BAE with appropriate medical treatment should be sufficient for most patients with massive haemoptysis. In patients with massive haemoptysis due to aspergilloma, however, elective surgery should be considered if bleeding is not controlled by repeated BAE.     

Prognosis of bronchial artery embolization in the management of hemoptysis

BACKGROUND: Bronchial artery embolization (BAE) is a well-accepted and widely used treatment modality for the management of massive and recurrent hemoptysis. However, few reports have previously investigated the long-term results. OBJECTIVES: To investigate the prognosis of patients with hemoptysis who had undergone BAE. METHODS: Twenty-two patients with hemoptysis underwent BAE. The underlying diseases included bronchiectasis in 9, aspergillosis in 3, chronic bronchitis in 2, idiopathic bronchial bleeding in 4, and other diseases in 4. The follow-up period ranged from 25 to 88 months (median 47 months). RESULTS: After the initial BAE, 11 of 22 (50%) patients had re-bleeding (5 patients with hemoptysis and 6 patients with minor hemosputa). Among them, 1 patient suffered from recurrent massive hemoptysis and died from airway obstruction within 1 month after BAE. In addition, 10 of these 11 (90.9%) patients experienced recurrent airway bleeding within 3 years after BAE. Recurrent cases of hemoptysis were seen in 6 of 22 patients (27.3%) within 3 years and no case recurred later than 3 years after BAE. A recurrence of hemoptysis was frequently seen in patients with either bronchiectasis or pulmonary-bronchial artery (P-B) shunt. Although BAE is an effective treatment for the immediate control of hemoptysis, 5 of the patients experienced recurrent bleeding in the long-term follow-up. CONCLUSIONS: It is important to follow-up such patients until 3 years after initial BAE, especially when either ectatic changes of the bronchi on a CT scan or a P-B shunt on angiographic findings are detected.     

Noninvasive ratio indexes to evaluate fibrosis staging in chronic hepatitis C: role of platelet count/spleen diameter ratio index

OBJECTIVES: Noninvasive evaluation of fibrosis is an on-going effort in the management of chronic hepatitis C. This study was planned to noninvasively evaluate fibrosis staging. DESIGN: We evaluated the biochemical, functional [aminopyrine breath test (ABT)] and ultrasonographic variables of 75 chronic hepatitis C patients. RESULTS: Clinical [body mass index (BMI)], biochemical [aspartate aminotransferase (AST), alanine aminotransferase (ALT) and platelets (PLT)] and ratio indexes, together with the ABT, showed a higher relationship with fibrosis: initial (score2) fibrosis: BMI (24+/-2 vs. 26+/-2, P=0.0007), AST (56+/-36 vs. 88+/-65, P=0.0159), ALT (92+/-54 vs. 139+/-108, P=0.0290), PLT (220+/-64 vs. 173+/-61, P=0.0007), PLT/spleen diameter ratio (PLT/SPD) (2133+/-786 vs. 1540+/-681, P=0.0003), AST/platelet count ratio index (APRI) (0.80+/-0.87 vs. 1.51+/-1.47, P=0.0010), ABT%d/h30 min (10.8+/-4.5 vs. 7.6+/-3.8, P=0.0007), ABT%d/cum120 min (8.9+/-3.3 vs. 6.5+/-3.1, P=0.0007). Considering the differences between fibrosis score 2 and 3 patients, BMI, ABT and PLT/SPD ratio proved to be statistically significant. Multivariate stepwise analysis (with and without BMI) identified two models for distinguishing between initial and evident fibrosis: Model 1: -0.569+(BMIx0.107)+(APRIx0.169)-(PLT/SPDx0.304), and Model 2: 2.376+( APRIx0.152)-(ABTd/h30x0.043)-(PLT/SPDx0.249). These models showed concordance in identifying or ruling out evident fibrosis in 76% and 78.7% of the patients respectively. The PLT/SPD ratio also showed 78.7% concordance with the histological score. CONCLUSION: These results suggest that noninvasive evaluation of fibrosis in chronic hepatitis C may be considered an effective tool thanks to the use of an inexpensive, reproducible ratio index.     

Endovascular stent-graft treatment of aortic dissection: determinants of post-interventional outcome.

AIMS: To investigate the results of endovascular stent-graft placement for the treatment of patients with type B aortic dissection (B-AD). METHODS AND RESULTS: A total of 38 patients (62+/-10 years, 32 male) with acute (n=10) and chronic (n=28) type B-AD were treated with endovascular stent-grafts. The implantation procedure was successful in all patients. Peri-procedural non-fatal complications occurred in four (11%) patients. Overall, 4/38 (11%) patients died during the in-hospital period. Patients undergoing stent-graft placement for acute AD had a significantly higher in-hospital mortality than patients with chronic AD (40 vs. 0%, P=0.001). During a median follow-up of 18 (1-57) months, there were six additional deaths. Overall survival rates were 97.4+/-2.6% at 30 days, 80.4+/-6.7% at 1 year, 73.2+/-7.8% at 2 years, and 54.9+/-16.9% at 4 years. Patients with a poor clinical health status (ASA class > 3) had a significantly reduced life expectancy compared with patients with only moderate co-morbidities (ASA class 3) pre-operatively (HR=29.5, 95% CI 1.5-581.9, P=0.026) and increased age (HR=1.1, 95% CI 0.9-1.2, P=0.084) were independent determinants of post-interventional mortality. CONCLUSION: Endovascular stent-graft treatment is a safe alternative for patients with AD. The pre-operative clinical health status of the patient is the most important determinant of post-interventional outcome. Careful patient selection is thus of particular importance.     

p27(Kip1) is an independent predictor of recurrence after surgical resection in patients with small hepatocellular carcinoma

BACKGROUND/AIMS: Alterations in p27(Kip1) (p27) and cyclin E (cycE) expression are found in tumors and are related to poor prognosis. This study assesses the role of these cell cycle regulators in the development of recurrence after surgical resection in 46 cirrhotic patients (age: 61.3+/-7 years, 30 males, 44 Child-Pugh's A, 30 HCV-positive) with small hepatocellular carcinoma (HCC, size: 3.1+/-1.5cm, 40 solitary at pathological examination). METHODS: p27 and cycE expression in tumoral and non-tumoral liver were analyzed by Western blot (WB). p27 was also assessed by immunohistochemistry (IHC). RESULTS: Tumor p27 underexpression (50% decreased vs. non-tumoral liver) occurred in 12 cases. Throughout follow-up, 26 patients developed recurrence, which was significantly higher in patients with p27 underexpression than in those without (3-year recurrence: 80 vs. 44%, respectively, P=0.026). IHC showed concordant inverse findings: 13 tumors showed high p27 staining that was related to lower recurrence rate (P=0.019). Multivariate analysis identified p27 measured by WB as an improved predictor of recurrence (OR: 3.09, 95% CI: 1.26-7.08, P=0.016). By contrast, cycE, increased in 66% of the tumors, had no impact on recurrence but was associated to poor differentiation (P=0.015) and microvascular invasion (P=0.016). CONCLUSIONS: p27 underexpression is frequent in relatively early stages of HCC and constitutes an independent predictor of recurrence after surgical resection.     

Auto-antibody profiles in patients with active pulmonary tuberculosis.

OBJECTIVES: To determine the prevalence of a wide array of auto-antibodies in patients with tuberculosis (TB) compared with healthy controls. MATERIALS AND METHODS: Forty-seven consecutive patients (age 47 +/- 21 years, 29 males) with recently diagnosed active pulmonary tuberculosis (PTB) and 39 healthy controls were enrolled. Data collected on a questionnaire included clinical features of the disease, duration of symptoms, presence of fever, cough, arthralgia, myalgia, sicca symptoms and others. Serum samples were collected from the patients' before initiating TB treatment, frozen at -20 degrees C and tested for antinuclear antibodies (ANA), anti-ds DNA, anti-Sm, anti-RNP, anti-Ro, anti-La, and anti-cardiolipin (ACA) (IgG and IgM). RESULTS: Rheumatic symptoms were relatively rare: arthralgia (n = 2), myalgias (n = 2), and eye (n = 1) and mouth dryness (n = 4). The TB patients' mean serum levels of anti-ds DNA, anti-Sm, anti-RNP, anti-SSA (anti-Ro), and anti-ACA-IgM were significantly increased compared with controls (P < 0.05 for all). A significantly higher proportion of TB patients had increased pathological levels of anti-ds DNA (32% vs. 2.5%), anti-Sm (38% vs. 0%), anti-RNP (15% vs. 0%), anti-Ro (64% vs. 10%), anti-ACA-IgG (59% vs. 0%) and anti-ACA-IgM (47% vs. 7.7%) (P < 0.05 for all). CONCLUSIONS: Patients with active TB have significantly increased titres of various auto-antibodies, including highly specific serological markers, such as anti-Sm. RELEVANCE: Differential interpretation of serological studies of patients with systemic manifestations should consider the possibility of PTB.     

Predictors of arrhythmia recurrence in patients with lone atrial fibrillation.

AIMS: The need for antiarrhythmic drugs (AAD) after a first episode of atrial fibrillation (AF) is determined by the probability of recurrence. The aim of this study was to asses the probability of relapse and the predictors of recurrence in patients with idiopathic AF. METHODS AND RESULTS: A cohort of 98 consecutive patients younger than 65 years admitted at the emergency room because of an episode of symptomatic idiopathic (lone) AF was included in this study. On admission, a complete medical history was taken, and an echocardiogram and 24-h Holter monitoring were performed. Patients were seen at 3 and 6 months after the index episode. There were 35 (35.7%) patients with a new-onset AF episode and 63 (64.3%) with a recurrent AF episode. A majority of them were male (71%), with a mean age of 48+/-11 years. Patients with new-onset AF episodes did not receive AAD. At 6 month follow-up, 57% of all patients suffered at least one symptomatic AF relapse. Patients with AF relapses belong more often to the recurrent group vs. new-onset group of AF (65.1 vs. 34.9%, respectively, P = 0.03); they had larger LA diameter indexed for body surface area (BSA) (22.6+/-3.7 vs. 19.8+/-3.2 mm/m(2), P = 0.001), larger left ventricular end-systolic diameter (18.4+/-3.1 vs. 17.2+/-2.5 mm/m(2), P = 0.05) and a tendency towards a higher proportion of atrial tachycardia runs on Holter (66.7 vs. 50%, P = 0.09). Logistic regression analysis showed that the presence of previous episodes of AF (OR: 3.2; 95% CI; 1.0-8.0, P = 0.04) and a larger anteroposterior LA diameter (OR: 1.3; 95% CI; 1.1-1.6, P = 0.001) were independent predictors of AF recurrences at 6 months. CONCLUSIONS: The recurrence rate in lone AF patients is high. The presence of previous episodes and a mildly enlarged anteroposterior LA diameter increase the probability of relapse of lone AF.     

慢性阻塞性肺疾病合并支气管扩张危险因素分析

目的探讨慢性阻塞性肺疾病(COPD)合并支气管扩张患者的临床特点及危险因素。方法收集河南省人民医院呼吸内科2016年1月至2018年5月住院诊断为中度以上COPD患者173例,其中69例患者行胸部高分辨率CT(HRCT)检查诊断合并支气管扩张,作为病例组;另104例患者行HRCT检查未合并支气管扩张(对照组)。整理两组患者首诊时病例资料,如性别、年龄、吸烟史、吸烟年限、慢阻肺评估测试问卷(CAT)评分、GOLD分级、慢性呼吸道症状(咳嗽、咳痰、呼吸困难)出现时间、既往肺结核史、既往糖尿病史、血糖、血红蛋白(Hb)、总蛋白(TP)、痰培养细菌学结果等。分析慢性阻塞性肺疾病合并支气管扩张患者的临床特点,评估易合并支气管扩张的相关因素。结果慢性阻塞性肺疾病合并支气管扩张占39.9%,大多为男性(P=0.017),有吸烟史(P=0.037),吸烟年限更长(P=0.035),CAT评分更高(P=0.002),GOLD分级更重(P=0.031),慢性呼吸道症状时间更长(P=0.001),既往有结核病史(P=0.044),既往有糖尿病史(P=0.003),血糖更高(P=0.003);多因素logistic回归分析显示与COPD合并支气管扩张的危险因素有男性(OR 2.427,95%CI 1.126~5.231,P=0.024)、CAT分(OR 1.476,95%CI 1.031~2.113,P=0.034)、慢性呼吸道症状时间(OR 3.502,95%CI 1.619~7.575,P=0.001)、既往糖尿病史(OR 4.182,95%CI 1.407~12.427,P=0.010)。结论慢性阻塞性肺疾病患者为男性、CAT评分越高、慢性呼吸道症状时间持续越长、既往有结核病史和糖尿病史时易合并支气管扩张,应得到重视,尽早明确诊断给予治疗。     

Safety and efficacy of radiofrequency energy catheter ablation of atrial fibrillation in patients with pacemakers and implantable cardiac defibrillators

BACKGROUND: Catheter ablation has significantly transformed the clinical management of atrial fibrillation (AF). The safety and efficacy of this procedure are not well understood in patients with pacemakers and defibrillators. OBJECTIVES: The purpose of this study was to study the impact of radiofrequency catheter ablation of AF in patients with pacemakers and implantable cardiac defibrillators. METHODS: We studied 86 patients with pacemakers and defibrillators (group I) and a similar number of age- and gender-matched controls (group II) who underwent AF ablation between 1999 and 2004. Clinical and procedural variables were compared between the two groups. In group I, various generator and lead parameters were compared before and after the procedure. Resurgence of clinical AF after 2 months was considered recurrence. RESULTS: Both groups were similar with regard to age, gender, body mass index, and type of AF. Group I had a higher incidence of diabetes (17% vs 6%, P = .03), coronary artery disease (25% vs 13%, P = .05), less prolonged AF (31 +/- 21 vs 45 +/- 30 months, P <.001), lower left ventricular ejection fraction (49 +/- 13% vs 52 +/- 9%, P = .03), and left ventricular end-diastolic dimensions (4.97 +/- 0.81 vs 4.72 +/- 0.67, P = .03). No changes in the sensing and pacing thresholds, impedance of atrial and ventricular leads, or defibrillator coil impedance after AF ablation were observed in group I. Atrial lead dislodgment was seen in two patients. Transient abnormal but "expected" pulse generator behavior was seen in 25% of patients without permanent malfunction. Stroke (1% vs 1%, P = 1.000), pulmonary vein stenosis (2% vs 1%, P = .77), and AF recurrence rates at 12 months were similar between groups I and II, respectively (19% vs 21%, P = .73). CONCLUSION: AF ablation is safe and efficacious in patients with pacemakers and defibrillators.     

Clinical and angiographic outcome in the laser angioplasty for restenotic stents (LARS) multicenter registry.

In-stent restenosis (ISR), when treated with balloon angioplasty (PTCA) alone, has an angiographic recurrence rate of 30%-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, yet the late outcomes of such treatment have not been fully determined. This multicenter case control study assessed the angiographic and clinical outcomes of 157 consecutive procedures in 146 patients with ISR at nine institutions treated with either PTCA alone (n = 64) or excimer laser assisted coronary angioplasty (ELCA, n = 93)) for ISR. Demographics were similar except more unstable angina at presentation in ELCA-treated patients (74.5% vs. 63.5%; P = 0.141). Lesions selected for ELCA were longer (16.8 +/- 11.2 mm vs. 11.2 +/- 8.6 mm; P < 0.001), more complex (ACC/AHA type C: 35.1% vs. 13.6%; P < 0.001), and with compromised antegrade flow (TIMI flow < 3: 18.9% vs. 4.5%; P = 0.008) compared to PTCA-treated patients. ELCA-treated patients had similar rate of procedural success [93 (98.9% vs. 62 (98.4%); P = 1.0] and major clinical complications [1 (1.1%) vs. 1 (1.6%); P = 1.0]. At 30 days, repeat target site coronary intervention was lower in ELCA-treated patients (1.1% vs. 6.4% in PTCA-treated patients; P = 0.158), but not significantly so. At 1 year, ELCA-treated patients had similar rate of major cardiac events (39.1% vs. 45.2%; P = 0.456) and target lesion revascularization (30.0% vs. 32.3%; P = 0.646). These data suggest that ELCA in patients with complex in-stent restenosis is as safe and effective as balloon angioplasty alone. Despite higher lesion complexity in ELCA-treated patients, no increase in event rates was observed. Future studies should evaluate the relative benefit of ELCA over PTCA alone for the prevention of symptom recurrence specifically in patients with complex in-stent restenosis.     

The effects of exercise training on the kinetics of oxygen uptake in patients with chronic heart failure.

BACKGROUND: Prolonged oxygen uptake kinetics (O2 kinetics), following the onset of a constant workload of exercise has been associated with a poor prognosis in patients with chronic heart failure. This study aimed to determine both continuous and interval training effects on the different O2-kinetics phases in these patients. DESIGN: Twenty-one patients (60+/-8 years) with stable chronic heart failure participated in a 36-session exercise rehabilitation program (three times weekly). Patients were randomly assigned to interval training (n=11; 100% of peak work rate for 30 s, alternating with 30 s-rest) and to continuous training (n=10; 50% of peak work rate). METHODS: Before and after the completion of the program, all patients performed both incremental symptom-limited and constant workload submaximal cardiopulmonary exercise tests. Phase I O2-kinetics was evaluated by time (t), from the start of exercise until the onset of decreased respiratory exchange ratio and phase II by the time constant (tau) of the response from the end of phase I until steady state. RESULTS: After training, there was a significant increase in peak oxygen uptake and peak work rate in both continuous (15.3+/-4.4 vs. 16.6+/-4.5 ml/kg per min; P=0.03 and 81.8+/-40.1 vs. 94.7+/-46.1 W; P=0.03) and interval training groups (14.2+/-3.1 vs. 15.4+/-4.2 ml/kg per min; P=0.03 and 82.5+/-24.1 vs. 93.7+/-30.1 W; P=0.04). Patients who underwent interval training had a significant decrease in t (39.7+/-3.7 to 36.1+/-6.9 s; P=0.05), but not tau (59.6+/-9.4 to 58.9+/-8.5 s; P=ns), whereas those assigned to continuous training had a significant decrease in both t (40.6+/-6.1 to 36.4+/-5.4 s; P=0.01) and tau (63.3+/-23.6 to 42.5+/-16.7 s; P=0.03). CONCLUSIONS: Exercise training improves O2 kinetics in chronic heart failure patients. Both continuous and interval training improve phase I O2-kinetics, but continuous training results in superior improvement of the phase II O2-kinetics, an indirect index of muscle oxidative capacity.     

Percutaneous bronchial artery embolization in the management of massive hemoptysis in chronic lung diseases. Immediate and long-term outcomes

AIM: Bronchial artery embolization (BAE) is a well-established, non-surgical procedure in the emergency treatment of massive hemoptysis. This study aims to evaluate the immediate and long-term prognosis of BAE for the management of massive hemoptysis in our center. METHODS: Twenty consecutive patients (mean age: 59+/-14 years) with massive hemoptysis, underwent BAE with microspheres (Embospheres BioSphere Medical SA, Paris, France), polyvinyl alcohol particles (PVA, Ivalon, Cathmed Science; Paris, France) or/and steel coils (Cook, Denmark) after thoracic aortography and diagnostic selective and superselective catheterization of bronchial arteries and systemic collateral vessels in the bleeding lung area. Hemoptysis was due to bronchiectasis (55%), non-operable aspergillomas (15%), active tuberculosis (15%), malignancy (10%) and cystic fibrosis (5%). Mean duration of follow-up was 29+/-18 months. The recurrent-free time was calculated with Kaplan-Meier analysis. RESULTS: Immediate control of bleeding was achieved in all patients. Recurrent cases of hemoptysis were observed in 6/20 patients (30%) within 3 years and 4 of them (66.6%) occurred early in the first 3 months. Recurrent-free time was 9 months (standard error: 4) (95% confidence interval: 0-17). Repeated interventions were required in all early recurrences, due to either recanalization of the occluded arteries or non-bronchial systemic artery supply. Combined use of PVA and coils was proved effective in these cases. No serious complications were observed. CONCLUSION: BAE is an effective and safe intervention in cases of massive hemoptysis. However, recurrences are common and long-term follow-up is considered important with a view to perform repeated interventions with combination of embolic materials.     

Results of directly observed treatment for tuberculosis in Ensenada, Mexico: not all DOTS programs are created equally.

SETTING: Tuberculosis (TB) program in Ensenada, Mexico. OBJECTIVE: To evaluate the impact of the DOTS strategy on adherence and cure rates in everyday practice. DESIGN: Retrospective analysis of 629 patients diagnosed with TB. MEASUREMENTS AND RESULTS: A total of 70% of the patients under directly observed treatment (DOT) were cured vs. 72.8% of those under self-administered treatment (SAT, P = 0.57). There was no difference on the length of therapy according to treatment regimen (4.82 +/- 2.41 for DOT vs. 4.93 +/- 2.16 for SAT, P = 0.61); 16.8% of patients under DOT abandoned treatment vs. 14.1% in the SAT group (P = 0.40). Logistic regression analysis confirmed the previous findings, with length of treatment under 6 months being the strongest predictive variable for treatment failure (OR 18.8, P < 0.00). The type of regimen (DOT vs. SAT) was not predictive of treatment failure (OR for failure for SAT regimen 0.65, P = 0.14). CONCLUSIONS: Cure and completion of treatment rates in our population under study did not differ significantly when comparing DOT vs. SAT. Those in charge of the DOTS programs in a given country need to assess which are the most important ingredients for success in their particular program.     

Endovascular stent-graft placement in aortic dissection: a meta-analysis.

AIMS: This article summarizes all available published data with respect to clinical success, complications, and outcomes of endovascular stent-graft placement among patients with descending aortic dissection (AD). METHODS AND RESULTS: We performed a meta-analysis of all published series on retrograde endovascular stent-graft placement encompassing >or=3 patients with AD. Thirty-nine studies, involving a total of 609 patients, were included. Procedural success was reported in 98.2+/-0.5% of patients. Major complications were reported in 11.1+/-1.4%, with the most dreaded neurologic complications in 2.9+/-0.7% patients. Periprocedural stroke was encountered more frequently than paraplegia (1.9+/-0.6% vs. 0.8+/-0.4%). Overall complications were significantly higher in patients undergoing stent-graft placement for acute AD than in patients with chronic AD (21.7+/-2.8% vs. 9.1+/-2.3%, P=0.005). The overall 30-day mortality was 5.3+/-0.9%, and was three-fold higher in patients with acute AD when compared with chronic AD (9.8+/-2.2% vs. 3.2+/-1.4%, P=0.015). In addition, 2.8+/-0.7% of patients died over a mean follow-up period of 19.5+/-7.1 months. Kaplan-Meier analysis yielded overall survival rates of 90.6+/-1.6% at 6 months, 89.9+/-1.7% at 1 year, and 88.8+/-1.9% at 2 years, respectively. CONCLUSION: Endovascular stent-graft placement in type B-AD is technically feasible with success rates of >95% in selected cohort. Although minimally invasive, major complications occurred in 14-18% of patients depending upon the acuity of presentation, with very low incidence of paraplegia. Both, acute and mid-term mortality of this novel treatment strategy appear to favourably compare with surgical treatment but further studies are necessary to compare stent-graft placement with medical treatment in uncomplicated AD.     

Completeness and timeliness of treatment initiation after laboratory diagnosis of tuberculosis in Gaborone, Botswana.

SETTING: Gaborone, the capital of Botswana. OBJECTIVE: To determine the time from positive sputum smear microscopy for acid-fast bacilli (AFB) to initiation of therapy, and to identify risk factors for delays. DESIGN: Retrospective cohort study of medical records and surveillance data for patients with positive smear microscopy and newly diagnosed tuberculosis (TB) from January to May 1997. Treatment delay was defined as more than 2 weeks from the first positive sputum smear to the initiation of TB treatment. RESULTS: Of 127 patients identified, 15 (11.8%) had treatment delay, 13 (10.2%) had an incomplete workup (only one smear performed) and were not registered for TB treatment, and six (4.5%) had two or more positive smears but were not registered for TB treatment. Risk factors for treatment delay or non-registration included TB patients who had been diagnosed in a hospital outpatient setting vs. a clinic (RR 2.9, 95% CI 1.2-3.6, P = 0.02), or in a high volume vs. low volume clinic (RR 2.2, 95% CI 1.2-5.3, P = 0.01). CONCLUSION: More than a quarter of the smear-positive TB patients identified had treatment delay or no evidence of treatment initiation. Proper monitoring of laboratory sputum results and suspect TB patient registers could potentially reduce treatment delays and patient loss.