Clinical and echocardiographic risk factors for embolism and mortality in infective endocarditis

Data about predictors of embolism in patients with infective endocarditis (IE) are conflicting. This study aimed to investigate clinical and transoesophageal echocardiography (TEE) characteristics in predicting embolism and six-month mortality. In this observational cohort study, 216 patients with definite left-sided IE, according to the modified Duke criteria, were prospectively recruited. All patients underwent TEE. ‘Any embolism’ was defined as embolism before or after initiation of antimicrobial therapy; ‘new embolism’ included embolism after initiation of antimicrobial therapy. Sixty-two of 216 patients (29%) experienced any embolism. New embolism occurred in 12 patients (6%), 7 of which were postoperative. Factors significantly associated with any embolism were community origin of IE and the etiologic microorganism, in particular staphylococci and nonviridans streptococci. Vegetation length >10 mm showed a trend towards association with new embolism and a mobile vegetation was predictive for new embolism. Six-month mortality was 24% (52/216). In multivariable analysis, age, vegetation length >10 mm, Staphylococcus aureus, and the type of treatment predicted mortality. Multiple emboli showed a trend towards association with death. In conclusion, any embolism occurred in over a fourth of patients. A mobile vegetation was significantly associated with new embolism, and vegetation length >10 mm tended to be associated with new embolism. Vegetation length >10 mm predicted six-month mortality, and multiple emboli showed a trend towards association with death. All authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors have seen and approved the final version. There are no conflicts of interest for any co-author or author.     

肺栓塞合并胸腔积液36例分析

目的提高对肺栓塞的认识，减少其误诊率。方法回顾性分析36例肺栓塞合并胸腔积液病例。结果94例肺栓塞中合并胸腔积液36例，占38％，其中少量积液30例，中等量积液4例，大量积液2例。双侧积液21例，右侧积液9例，左侧积液6例，心包积液4例。6例中、大量积液胸水检查，均为渗出性，其中4例为血性（2例为肺癌）。36例中D-二聚体升高35例；螺旋CT36例均有肺动脉栓塞改变，其中2例合并肺不张．4例合并心包积液。15例作肺通气灌注扫描均有阳性表现。结论肺栓塞是胸腔积液的常见病因之一，临床遇到不明原因的胸腔积液特别是血性积液，要考虑肺栓塞的可能，及时筛查D-二聚体，阳性者高度怀疑肺栓塞．再行肺通气灌注扫描、螺旋CT等检查进一步明确诊断。     

Right-sided EKG in pulmonary embolism

PURPOSE: To identify right-sided chest lead electrocardiographic abnormalities in acute pulmonary embolism. PATIENTS AND METHODS: Analysis of electrocardiographic changes in 100 African American patients suspected of having pulmonary embolism was made at Howard University Hospital during 2001-02 (60% women, 40% men, median age 50 years). Standard 12-lead EKGs were obtained within one hour of arrival to emergency room. Right-sided EKGs were obtained within 24 hours of onset of symptoms of pulmonary embolism. Parameters of both right- and left-sided EKGs available were measured and compared. RESULTS: Only 20% of these patients were diagnosed with pulmonary embolism. EKG changes (three of seven) suggestive of acute right ventricular strain were found in both right- and left-sided leads in 16 (80%) patients diagnosed with pulmonary embolism. These EKG changes disappeared within 24 hours of admission in 14 (87.5%) patients. Four patients with a diagnosis of pulmonary embolism had normal left-sided EKGs but the right-sided EKGs showed ST segment elevation and a qr or qs pattern (prominent q waves) in one to three of the leads V4R, V5R and V6R. These patterns were also seen in 10 of the 16 patients showing right ventricular strain pattern in their EKGs. Non-specific ST-T wave changes were seen in 20 (25%) patients not considered to have pulmonary embolism. V3R leads showed rS configuration in 90% of the patients. CONCLUSION: EKG changes in right-sided chest leads occur frequently in pulmonary embolism. The diagnostic potential of routinely recorded right-sided EKG appears to be greatest in patients with acute pulmonary embolism not manifesting typical changes in their standard 12-lead EKGs. This study also confirms previous case reports observing similar changes in the right-sided leads.     

ACUTE DECOMPRESSION SICKNESS

A case of acute decompression sickness presenting severe clinical features was reported. At the time of autopsy, intra-and extravascular air bubbles were found in various organs. Pulmonary fat embolism was also prominent in association with severe circulatory disturbances of the lungs. The spinal cord showed edematous and congestive swelling which was intimately related to the coagulation of blood within the epidural veins that contained innumerable fat droplets. Intravascular fat seemed to be created in and released from the injured adipose tissue, especially that of the bone marrow during decompression and to have acted as an accelerator of intravascular coagulation. The pathophysiological significance of the fat embolism for the development and the progression of decompression sickness is discussed.     

肺栓塞肺动脉能谱CT胸部扫描影像学特征及其诊断价值

目的：探讨肺栓塞（PE）肺动脉能谱CT胸部扫描影像学特征及其诊断价值。方法：回顾性分析53例高度疑似PE患者,获取单能量能谱CT肺动脉造影（CTPA）图像和碘基肺灌注图,记录CTPA图像和碘基肺灌注图检出的肺动脉栓子数目及其分布、分型情况;分析肺动脉能谱CT胸部扫描影像学特征;比较不同栓塞程度及类型能谱CT扫描碘基值;比较栓塞区与对照区能谱CT扫描碘基值、水基值和CT值等能谱CT扫描参数。结果：以CTPA为金标准,53例高度疑似PE的患者中确诊32例。能谱CTPA检出162个栓子,完全型栓子37个,非完全型栓子125个;碘基肺灌注图检出171个栓子,完全型栓子49个,非完全型栓子122个。中心型、偏心型和完全型栓子栓塞区能谱CT扫描碘基值均明显低于对照区（P<0.05）;附壁型栓子栓塞区能谱CT扫描碘基值与对照组无显著差异（P>0.05）;完全型栓塞区碘基值显著低于中心型、偏心型和附壁型等非完全型栓塞区（P<0.05）。结论：PE肺动脉能谱CT胸部扫描影像学特征主要表现为肺动脉内充盈缺损、肺动脉扩张、肺动脉高压、马赛克征、轨道征等征象,肺动脉能谱CT胸部扫描碘基肺灌注...     

PEmb-Qol量表中文版在肺栓塞患者 生活质量测评中的价值

目的 探讨PEmb-Qol量表中文版在肺栓塞患者生活质量测评中的价值。方法 通过方便抽样,使用PEmb-Qol量表中文版对2016年1月~2018年10月北京3家三甲医院的201例肺栓塞患者开展生活质量测评。结果 201例肺栓塞患者PEmb-Qol量表总分为50.44~100分,平均分为（84.89±10.49）分;其中得分最高的维度为主诉频率,平均分为（93.69±9.59）分;得分最低的维度为工作相关问题,平均为（77.24±20.76）分。结论 肺栓塞患者生活质量有所下降,PEmb-Qol量表中文版可以有效地测量肺栓塞患者生活质量。     

Familial Occurrence of Pulmonary Embolism after Intravenous,Adipose Tissue-Derived Stem Cell Therapy

The therapeutic potential of human multipotent mesenchymal stromal cells, especially human adipose tissue-derived stem cells (hASC), is promising. However, there are concerns about the safety of infusion of hASC in human. Recently, we have experienced pulmonary embolism and infarct among family members who have taken multiple infusions of intravenous autologous hASC therapy. A 41-year-old man presented with chest pain for one month. Chest CT showed multiple pulmonary artery embolism and infarct at right lung. Serum D-dimer was 0.8 µg/mL (normal; 0-0.5 µg/mL). He had received intravenous autologous adipose tissue-derived stem cell therapy for cervical herniated intervertebral disc three times (one, two, and three months prior to the visit). His parents also received the same therapy five times and their chest CT also showed multiple pulmonary embolism. These cases represent artificial pulmonary embolisms and infarct after IV injection of hASC. Follow-up chest CT showed spontaneous resolution of lesions in all three patients.     

The clinical course of pulmonary embolism.

BACKGROUND. Pulmonary embolism is a potentially fatal disorder. Information about the outcome of clinically recognized pulmonary embolism is sparse, particularly given that new treatments for more seriously ill patients are now available. METHODS. We prospectively followed 399 patients with pulmonary embolism diagnosed by lung scanning and pulmonary angiography, who were enrolled in a multicenter diagnostic trial. We reviewed all hospitalizations, all new investigations of pulmonary embolism, and all deaths among the patients within one year of diagnosis. RESULTS. Of the 399 patients, 375 (94 percent) received treatment for pulmonary embolism, usually conventional anticoagulation. Only 10 patients (2.5 percent) died of pulmonary embolism; 9 of them had clinically suspected recurrent pulmonary embolism. Clinically apparent pulmonary embolism recurred in 33 patients (8.3 percent), of whom 45 percent died during follow-up. Ninety-five patients with pulmonary embolism (23.8 percent) died within one year. The conditions associated with these deaths were cancer (relative risk, 3.8; 95 percent confidence interval, 2.3 to 6.4), left-sided congestive heart failure (relative risk, 2.7; 95 percent confidence interval, 1.5 to 4.6), and chronic lung disease (relative risk, 2.2; 95 percent confidence interval, 1.2 to 4.0). The most frequent causes of death in patients with pulmonary embolism were cancer (in 34.7 percent), infection (22.1 percent), and cardiac disease (16.8 percent). CONCLUSIONS. When properly diagnosed and treated, clinically apparent pulmonary embolism was an uncommon cause of death, and it recurred in only a small minority of patients. Most deaths were due to underlying diseases. Patients with pulmonary embolism who had cancer, congestive heart failure, or chronic lung disease had a higher risk of dying within one year than did other patients with pulmonary embolism.     

Severe changes in the makeup of the blood after a contusion of the soft tissues complicated by sepsis]

A case of a comparatively mild trauma of a lower extremity in an 11-year-old child complicated with deep thrombophlebitis of the thigh and pelvic bone, thromboembolism of the pulmonary artery branches, sepsis, and massive systemic fat embolism is described. The development of fat embolism in combination with thromboembolic complications in the absence of injuries of the skeleton and fat tissue may be explained from the standpoint of physico-chemical theory of pathogenesis of fat embolism. A close correlation between fat embolism and the system of blood coagulation was noted.     

Frequency of pulmonary embolism in patients with circulatory disturbances of the lower limb or intestine. An autopsy study

The frequency of pulmonary embolism in patients with circulatory disturbances in the lower limbs (CDLL) or intestine (CDI) were investigated in an autopsy series. Pulmonary embolism was seen more frequently in patients with CDLL than in patients with CDI. This difference was maintained irrespective of duration of last admission. Patients with CDLL had pulmonary embolism in 36% of the cases when they stayed in the hospital for more than 5 days prior to death, versus 12% in CDI patients. Pulmonary embolism occurred with approximately equal frequency in all age-groups. Surgery had little influence on the occurrence of pulmonary embolism in patients with CDLL. In 85% of the CDLL cases, pulmonary embolism (n = 81) was considered the immediate cause of death at autopsy. The awareness of this life-threatening disease is poor as only 12% had been diagnosed prior to death.     

Cerebral fat embolism syndrome after long bone fracture due to gunshot injury

Cerebral fat embolism syndrome is a lethal complication of long-bone fractures and clinically manifasted with respiratory distress, altered mental status, and petechial rash. We presented a 20-year-old male admitted with gun-shot wounds to his left leg. Twenty-four hours after the event, he had generalized tonic clonic seizures, decorticate posture and a Glascow Coma Scale of seven with localization of painful stimuli. Subsequent magnetic resonance imaging of the brain showed a star-field pattern defining multiple lesions of restricted diffusion. On a 4-week follow-up, he had returned to normal neurological function. Despite the severity of the neurological condition upon initial presentation, the case cerebral fat embolism illustrates that, cerebral dysfunction associated with cerebral fat embolism illustrates reversible.     

B型尿钠肽、肌钙蛋白I、同型半胱氨酸与急性肺栓塞的相关性分析

目的 探讨B型尿钠肽、肌钙蛋白I、同型半胱氨酸与急性肺栓塞的相关性.方法 选取2015年5月至2017年5月期间,我院收治的104例急性肺栓塞(APE)患者作为研究对象,选取同期健康体检者100例作为对照组.比较急性肺栓塞组与健康体检者以及大面积肺栓塞患者与非大面积肺栓塞患者、死亡与存活患者血清BNP、TnI及Hcy水平以及三项指标对急性肺栓塞的诊断价值.结果 急性肺栓塞组患者血清BNP、TnI及Hcy水平显著高于健康对照组(P<0.05).大面积肺栓塞患者血清BNP、TnI及Hcy水平显著高于非大面积肺栓塞患者(P<0.05).急性肺栓塞死亡患者血清BNP、TnI及Hcy水平显著高于存活者(P<0.05).血清BNP+TnI+Hcy联合检测的灵敏度(86.7%)、特异性(90.9%)及准确度(88.5%)明显高于任一项指标的检测(P<0.05).Pearson相关性分析表明,BNP、TnI及Hcy是急性肺栓塞患者发生临床不良事件的独立危险因素,血清BNP与TnI及Hcy呈正相关关系.结论 血清BNP、TnI及Hcy联合检测可反映急性肺栓塞的病情严重程度,可作为预后评估的有效指标.     

Effects of pulmonary gas embolism on circulation and respiration in the dog

Mongrel dogs weighing 15-25 kg and anesthetized with thiopental-gamma-hydroxybutyric acid were used to investigate the effects of pulmonary gas embolism on pulmonary arterial pressure (Pap), systemic arterial pressure (Pa) and cardiac output (Q). Pulmonary gas embolism was produced either by venous injecton or by venous infusion. The most marked effect of pulmonary gas embolism on circulation was an increase in Pap which returned to the original level after stopping the gas administration. 1. After gas injection Pap rose to a maximum within 30--60 s. The extent of this rise in Pap showed a positive correlation with the volume of the injected gas. The kind of gas (oxygen, helium, neon, nitrogen, air), however, did not influence the extent of the rise in Pap, but did influence the time of return of Pap to the original level. Carbon dioxide showed an exceptional behavior in that it had almost no effect on Pap at all. P a hardly changed with the volume of the gas injections (20--60 ml injected within 1 s); Q was not measured after gas injection (the direct Fick method is not usable in this situation). 2. Gas infusion caused a slow rise of Pap, its steepness and extent depending on the rate of infusion and on the physical properties of the infused gas. When the right ventricle was able to maintain its output, a constant level of Pap was reached after 10--15 min. In this circulatory steady state Pap appeared to be a measure of the degree of embolization. However, this relationship no longer held when the right ventricle failed as evidenced by a fall in Pap, Pa and Q. It may be concluded that pulmonary gas embolism produces a transient partial obstruction in the pulmonary circulation and that the performance of the right ventricle determines the maximum degree of embolization compatible with a sufficient circulation.     

An 89-year-old patient with acquired murmur associated with pulmonary embolism

Pulmonary embolism (PE) is the third most common cause of death in hospitalized patients. Diagnosis is often missed because of a non-homogeneous clinical picture. We present a case of an 89-year-old patient with an acquired murmur associated with pulmonary embolism. When examined by a family physician the patient had no symptoms typical for PE. During hospitalization, dyspnoea was exacerbated; a non-productive cough, chest pain and oliguria were observed. Pulmonary embolism was diagnosed, but because of the renal failure diagnosis was not confirmed by angio-CT.     

动脉导管溶栓治疗急性肢体动脉栓塞14例分析

目的 探讨动脉导管溶栓治疗急性肢体动脉栓塞的方法和疗效。方法回顾性分析14例肢体动脉栓塞的诊断方法和介入手术治疗方案。结果治愈11例，治愈率78．6％(11／14)；2例好转。无患肢缺血坏死或截肢，无术后因肾功能衰竭死亡。结论动脉导管溶栓是治疗急性肢体动脉栓塞有效的方法，值得进一步开展和探索。     

11 year-old girl undergoing scoliosis surgery

We report the case of an 11-year-old girl operated on for a severe left thoracolumbar scoliosis. Pedicular screw insertion and rod positioning was technically successful, but five days later, for signs of an early infection, the wound revised and unexpectedly the patient died during surgery. Autopsy recognized a diffuse cerebral cortical venous air embolism as the cause of death and excluded pulmonary embolism and associated cardiac defects.This is the first and unique case describing a fatal paradoxical air venous cerebral embolism in a pediatric patient undergone spine surgery: the possible mechanism involving azygos and jugular veins systems is discussed.     

Reperfusion pulmonary edema after the removal of hepatocellular carcinoma embolus

To report a non-fatal case of reperfusion pulmonary edema (RPE) after the removal of a hepatocellular carcinoma embolus, which had caused an acute obstruction of the tricuspid valve and pulmonary vasculature during a hepatic lobectomy. Pulmonary embolism caused by hepatocellular carcinoma embolus is extremely rare, and, in the present case, it was associated with unusual clinical features. A 69-year-old ASA II woman with hepatocellular carcinoma was presented for an elective left hepatic lobectomy. During the surgery, the tumor embolus was dislodged from the interior of the lumen of the inferior vena cava (IVC), which then drifted into the tricuspid valve area and pulmonary vasculature. The patient showed the specific signs of acute pulmonary embolism, such as a reduction in end-tidal carbon dioxide, an increase in central venous pressure, and a decrease in arterial pressure. The patient exhibited the symptoms for about 10 minutes. After this period, however, cardiovascular variables became relatively stable, even during a mechanical obstruction due to cross-clamping the pulmonary artery for embolectomy. After several hours of pulmonary embolectomy, the patient experienced an episode of RPE. The ventilatory supports for the treatment of RPE were successful, and the patient recovered without any complications. The patient's case in the present study demonstrates that pulmonary embolism may occur as a result of a hepatocellular carcinoma extending into the IVC during operative management. The anesthesiologist should be careful of the possibilities of RPE after removal of the tumor embolus.     

家兔急性肺栓塞对肺血管内皮细胞超微结构及血清一氧化氮含量的影响

目的 探讨急性肺栓塞（APE）对肺血管内皮细胞（PVECs）的结构及血清一氧化氮（NO）含量的影响。 方法 19只日本大耳兔,随机分成假手术组、栓塞2 h、4 h组(n=3)和8 h组（n=10）。通过输入自体血栓建立家兔急性肺栓塞模型后,采用HE染色光学显微镜下观察肺的病理组织学变化;透射电子显微镜下观察PVECs在肺栓塞2 h、4 h及8 h的超微结构变化;硝酸还原酶法测定相应时间点血清NO含 结果 HE染色显示栓塞组肺动脉内有血栓,肺间质炎性病变,肺淤血;透射电子显微镜显示,栓塞组PVECs水肿、破裂,线粒体肿胀,内质网空泡化,并随栓塞时间延长PVECs出现坏死脱落,细胞器溶解。肺栓塞2 h、4 h和8 h血清NO含量均低于栓塞前,与栓塞前比较差异有显著性意义（P＜0.05）。 结论 家兔APE可致PVECs超微结构改变和血清NO含量下降,且两者间关系密切。