Long-term prognosis of survivors of Pneumocystis carinii pneumonia. Structural and functional correlates

Limited data exist detailing the long-term sequelae of Pneumocystis pneumonia. Open lung biopsies were obtained in seven renal transplant recipients within 48 hours of the onset of respiratory failure. Biopsy specimens and simultaneous chest roentgenograms were graded without clinical information according to the severity of alveolar damage and pulmonary infiltrates, respectively. Evaluation of pulmonary function and exercise physiology were performed 15 to 21 months after their illness. Pulmonary function indices were normal except FRC (2.65 +/- 0.56 L or 77 +/- 16 percent of predicted) and Dsb (20.0 +/- 7.2 ml/min/mm Hg or 79 +/- 19 percent of predicted). Two patients developed arterial desaturation with exercise. Alveolar damage scores correlated with later exercise arterial desaturation (r = 0.88, p less than 0.05). Simultaneous roentgenographic scores correlated with later abnormalities of Dsb (r = 0.81, p less than 0.05). Mild residual abnormalities of pulmonary function were found in five of seven adult survivors of Pneumocystis pneumonia. These abnormalities correlated with pathologic and radiographic features of the acute illness.     

Ventriculography and coronary arteriography in the acutely III patient. Complications, extent of coronary arterial disease, and abnormalities of left ventricular function.

Of 99 patients who underwent "emergency" diagnostic studies, 82 had "unstable angina" (group A), 15 had recent myocardial infarction (group B), and two had intractable congestive heart failure due to acute mitral regurgitation (group C). Two cardiac and two local complications occurred either during the procedure or during the following 48 hours. There were no deaths or myocardial infarctions. Ten (12 percent) patients of group A had "normal" coronary arteries and normal left ventricular function; 13, 26 and 33 patients had one, two, and three coronary arteries involved, respectively. Those with three-vessel disease had a significantly higher left ventricular end-diastolic pressure (LVEDP) and lower ejection fraction (EF) than those with one- and two-vessel disease. Those with previous myocardial infarction had a significantly higher incidence of reduced EF and of wall motion abnormalities than those without a previous myocardial infarction. All patients in group B had significant coronary arterial disease, and 80 percent (12) had abnormal left ventricular function. Their mean LVEDP and EF were significantly higher and lower, respectively, than those found in group A. In conclusion, acutely ill patients were studied with low risk. Most patients had three- or two-vessel disease. Abnormal left ventricular function was related to three-vessel disease and to recent and old myocardial infarction.     

Disturbance of pulmonary gas exchange in patients with right ventricular infarction.

To evaluate the difference in pulmonary gas exchange in patients with and without right ventricular infarction, 147 consecutive patients with their first inferior wall Q-wave acute myocardial infarction were studied. Thirty-nine patients (group 1) had electrocardiographic evidence of right ventricular infarction and it was absent in 108 patients (group 2). A significantly wider alveolar arterial oxygen difference and higher roentgenographic scores were observed in group 1 compared with group 2. Although there were no significant differences in pulmonary artery wedge pressure and colloid osmotic pressure between groups 1 and 2, mean right atrial pressure was significantly higher, while cardiac output and mixed venous oxygen saturation were lower in group 1 compared with group 2. Patients in group 1 had significantly more left ventricular segments with advanced asynergy and higher incidence of proximal right coronary artery lesions than those in group 2. Thus, our data suggest that disorder of pulmonary gas exchange in patients with right ventricular infarction may be explained by increased permeability of the alveolar capillary membrane secondary to larger extent of ischemic myocardium and by hemodynamic abnormalities associated with right ventricular infarction.     

Relation of plain chest radiographic findings to pulmonary arterial pressure and arterial blood oxygen levels in patients with acute pulmonary embolism.

Abnormalities of the plain chest radiograph of 123 patients with acute pulmonary embolism (PE) and no prior cardiac or pulmonary disease were related to the pulmonary arterial mean pressure, the partial pressure of oxygen in arterial blood, and the alveolar-arterial oxygen gradient. Patients with either a prominent central pulmonary artery or cardiomegaly had higher pulmonary arterial mean pressures than did patients with atelectasis, a pulmonary parenchymal abnormality or pleural effusion (p less than 0.001). These radiographic findings give clues to the severity of pulmonary hypertension in acute PE and suggest that pulmonary infarction or hemorrhage is associated with less severe PE.     

Interpretation of the alveolar-arterial oxygen difference in patients with hypercapnia

According to conventional wisdom the difference between alveolar and arterial O2 tensions, the AaPO2, should distinguish between hypoxemia caused by alveolar hypoventilation and hypoxemia caused by alveolar hypoventilation complicated by other abnormalities of gas exchange. To test this concept we have calculated the AaPO2 from arterial blood gas measurements, breathing air, in 23 patients with hypercapnia, hypoxemia, and advanced obstructive lung disease (mean FEV1 = 0.88 L). We found that AaPO2 varied inversely with PaCO2 (r = -0.83, p less than 0.001). In five of these patients with the most severely elevated PaCO2 (range, 59 to 81 mm Hg) the AaPO2 was within normal limits. We also calculated the difference between the O2 contents of "ideal" pulmonary capillary blood and arterial blood and expressed this as the venous admixture (QVA/QT) based on an assumed arteriovenous content difference of 4.5 ml/dl. In contrast to the AaPO2, the QVA/QT, was abnormal in all patients (mean = 41 +/- 8%). We conclude that the AaPO2 may be an unreliable indicator of abnormal gas exchange in the presence of alveolar hypoventilation. This finding can be explained by substantial changes in the position of the alveolar and arterial points on the oxygen dissociation curve for hemoglobin in the presence of alveolar hypoxia secondary to hypoventilation.     

Hypoxemia in acute pulmonary embolism

Most patients with severe, acute pulmonary embolism (PE) have arterial hypoxemia. To further define the respective roles of ventilation to perfusion (VA/Q) mismatch and intrapulmonary shunt in the mechanism of hypoxemia, we used both right heart catheterization and the six inert gas elimination technique in seven patients with severe, acute PE (mean vascular obstruction, 55 percent) and hypoxemia (mean PaO2, 67 +/- 11 mm Hg). None had previous cardiopulmonary disease, and all were studied within the first ten days of initial symptoms. Increased calculated venous admixture (mean QVA/QT 16.6 +/- 5.1 percent) was present in all patients. The relative contributions of VA/Q mismatching and shunt to this venous admixture varied, however, according to pulmonary radiographic abnormalities and the time elapsed from initial symptoms to the gas exchange study. Although all patients had some degree of VA/Q mismatch, the two patients studied early (ie, less than 48 hours following acute PE) had normal chest x-ray film findings and no significant shunt; VA/Q mismatching accounted for most of the hypoxemia. In the others a shunt (3 to 17 percent of cardiac output) was recorded along with radiographic evidence of atelectasis or infiltrates and accounted for most of the venous admixture in one. In all patients, a low mixed venous oxygen tension (27 +/- 5 mm Hg) additionally contributed to the hypoxemia. Our findings suggest that the initial hypoxemia of acute PE is caused by an altered distribution of ventilation to perfusion. Intrapulmonary shunting contributes significantly to hypoxemia only when atelectasis or another cause of lung volume loss develops.     

Pulse oximetry for tapering supplemental oxygen in hospitalized patients. Evaluation of a protocol

In a randomized study, we determined the clinical and financial effects of replacing arterial blood gas measurements with finger pulse oximeter readings during the process of tapering supplemental oxygen in hospitalized patients. The 16 patients in the control group, whose management followed conventional practice in our hospital, received a total of 57 arterial blood gas measurements during the 6.6 (mean) days it took for them to taper to their discharge supplemental oxygen level (usually room air). The 13 patients randomized to the oximeter study group had their arterial oxygen saturation monitored by pulse oximetry. The physicians of patients in the oximeter group were at liberty to obtain arterial blood gas determinations during the study if they desired. The oximeter study group had fewer (p less than 0.005) arterial punctures for blood gas measurements (total of 16 for the group) and fewer (p less than 0.001) days on supplemental oxygen (mean of 2.7 days per patient). We conclude that substituting noninvasive pulse oximetry for arterial blood gas measurements during reductions of supplemental oxygen shortened the days of oxygen use and decreased the number of arterial blood gas determinations in our patients. In addition to reducing the discomfort to patients, the use of oximetry was of financial benefit in that it reduced medical personnel time, blood gas analyzer use, and duration of oxygen administration.     

Effect of low calorie intake on abnormal pulmonary physiology in patients with chronic hypercapneic respiratory failure

To explore the effects of low calorie, low carbohydrate intake on abnormal pulmonary physiology in chronic hypercapneic respiratory failure, spirometric, arterial blood gas tension, oximetric, and electrocardiographic studies were carried out before and after weight reduction in eight patients. During a single night of monitoring, the mean basal oxygen saturation was 68.4 +/- 20.7 percent with 38 hypoxemic "dips" (a fall in oxygen saturation of more than 10 percent for one minute or longer); six patients had resting tachycardia, four had a prolonged QTc interval, three showed multiple episodes of ST-T depression, and six patients had multiple atrial and ventricular premature contractions. After a low calorie (600 kcal per day) intake for 4.4 +/- 2.3 weeks, there was a mean weight loss of 8.5 +/- 3.6 kg, the mean arterial oxygen tension increased significantly (p less than 0.005) from 55.6 +/- 9.2 to 69.1 +/- 7.9 torr, the mean arterial carbon dioxide tension fell from 59.9 +/- 9.6 to 52.4 +/- 5.4 torr (p less than 0.01), the mean oxygen saturation increased significantly (p less than 0.05) to 85.0 +/- 9.0 percent with only two hypoxemic "dips," the resting heart rate decreased from a mean of 100 +/- 19 to 90 +/- 18 beats/per minute (p less than 0.05), there was a marked reduction in ectopic activity, the ST-T depression disappeared, and the QTc interval fell in two subjects. Follow-up data in four patients suggest that the improvements achieved in arterial blood gas values can be maintained with a low calorie intake. These studies show that a low calorie, low carbohydrate intake improves all the unfavorable physiologic abnormalities in chronic hypercapneic respiratory failure.     

Mechanisms of gas-exchange impairment in idiopathic pulmonary fibrosis

To investigate the mechanisms of pulmonary gas-exchange impairment in idiopathic pulmonary fibrosis (IPF) and to evaluate their potential relationship to the CO diffusing capacity (DLCO), we studied 15 patients with IPF (mean DLCO, 52% of predicted) at rest (breathing room air and pure O2) and during exercise. We measured pulmonary hemodynamics and respiratory gas-exchange variables, and we separated the ventilation-perfusion (VAQ) mismatching and O2 diffusion limitation components of arterial hypoxemia using the multiple inert gas elimination technique. At rest VA/Q mismatching was moderate (2 to 4% of cardiac output perfusing poorly or unventilated lung units), and 19% of AaPO2 was due to O2 diffusion limitation. During exercise VA/Q mismatch did not worsen but the diffusion component of arterial hypoxemia increased markedly (40% AaPO2, p less than 0.005). We observed that those patients with higher pulmonary vascular tone (more release of hypoxic pulmonary vasoconstriction) showed less pulmonary hypertension during exercise (p less than 0.05), less VA/Q mismatching [at rest (p less than 0.005) and during exercise (p less than 0.0025)], and higher arterial PO2 during exercise (p = 0.01). We also found that DLCO corrected for alveolar volume (KCO) correlated with the mechanisms of hypoxemia during exercise [VA/Q mismatching (p less than 0.025) and O2 diffusion limitation (p less than 0.05)] and with the increase in pulmonary vascular resistance elicited by exercise (p less than 0.005). In conclusion, we showed that the abnormalities of the pulmonary vasculature are key to modulate gas exchange in IPF, especially during exercise.(ABSTRACT TRUNCATED AT 250 WORDS)     

Correlation of pulmonary signs and symptoms with chest radiographs in the pediatric age group

One hundred twenty-five pediatric emergency department patients were studied prospectively to determine whether any findings on the physical examination were predictive of abnormalities seen on chest radiograph. We attempted to find possible correlations between such clinical examination findings, recorded prior to radiographic examination, and three subgroups of radiographic findings: pneumonia, any major radiographic abnormality, and any radiographic abnormality whatsoever. The best screen for pneumonia was presence of fever (temperature greater than two standard deviations above age-related norms), with a sensitivity of 94% and a negative predictive value of 97%. The sign with highest positive and negative predictive value for the presence of any radiographic abnormalities was tachypnea. A subgroup with either normal breath sounds, or findings limited to wheezing, prolonged expiration, cough and/or rhonchi on chest examination proved to be at low risk for any major chest radiographic abnormality. Patients with other chest examination findings comprised a high-risk group with a 34% risk of a major radiographic abnormality, as compared to a 7% incidence in the low-risk group. Thus, absence of fever suggests absence of pneumonia, while chest examination findings other than wheezing, cough, prolonged expiration, or rhonchi significantly increase the likelihood of pneumonia in this population. Physical examination findings can help the clinician determine the need for chest radiography in the pediatric emergency patient.     

Clinical features of amiodarone-induced pulmonary toxicity

The incidence and clinical predictors of amiodarone pulmonary toxicity were examined in 573 patients treated with amiodarone for recurrent ventricular (456 patients) or supraventricular (117 patients) tachyarrhythmias. Amiodarone pulmonary toxicity was diagnosed in 33 of the 573 patients (5.8%), based on symptoms and new chest radiographic abnormalities (32 of 33 patients) and supported by abnormal pulmonary biopsy (13 of 14 patients), low pulmonary diffusion capacity (DLCO) (nine of 13 patients), and/or abnormal gallium lung scan (11 of 16 patients). Toxicity occurred between 6 days and 60 months of treatment for a cumulative risk of 9.1%, with the highest incidence occurring during the first 12 months (18 of 33 patients). Older patients developed it more frequently (62.7 +/- 1.7 versus 57.4 +/- 0.5 years, p = 0.018), with no cases diagnosed in patients who started therapy at less than 40 years of age. Gender, underlying heart disease, arrhythmia, and pretreatment chest radiographic, spirometric, or lung volume abnormalities did not predict development of amiodarone pulmonary toxicity, whereas pretreatment DLCO was lower in the group developing it (76.0 +/- 5.5% versus 90.4 +/- 1.4%, p = 0.01). There was a higher mean daily amiodarone maintenance dose in the pulmonary toxicity group (517 +/- 25 versus 409 +/- 6 mg, p less than 0.001) but no difference in loading dose. No patient receiving a mean daily maintenance dose less than 305 mg developed pulmonary toxicity. Patients who developed toxicity had higher plasma desethylamiodarone (2.34 +/- 0.18 versus 1.92 +/- 0.04 micrograms/ml, p = 0.009) but not amiodarone concentrations during maintenance therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

High-yield roentgenographic criteria for cervical spine injuries

All trauma patients undergoing cervical radiography at an urban referral teaching hospital emergency department during 12 consecutive months were analyzed for indications and results of cervical spine radiograph studies. Demographic characteristics of the study group were consistent with results in the literature (55% men, mean age, 27). Cases were reviewed for 27 commonly accepted indications in the literature for cervical spine studies under these circumstances. The following radiograph findings were considered as positive studies: fracture, subluxation, spondylolisthesis, straightening, spasm, foreign body, compression, fusion, narrowing, or soft tissue swelling. Seventeen percent of radiographs were positive. Motor vehicle accidents (P less than .009), a history of direct cervical trauma (P less than .002), loss of consciousness (P less than .001), cervical tenderness (P less than .05), and drug ingestion (P less than .08) were associated with or suggestive of positive radiographs. No patients wearing seatbelts had positive radiographs (P less than .001). Only 2.4% (18 of 749) of radiographic examinations revealed clinically significant findings, and no criteria were statistically correlated with clinically significant findings. While our study suggests up to two-thirds of radiographs might be deferred without missing a clinically significant injury using these high-yield criteria, a flexible approach to cervical roentgenographs is justified pending confirmation of our results by a large, multicenter, prospective study currently under way.     

Alveolar T-cell subsets in pulmonary sarcoidosis. Correlation with disease activity and effect of steroid treatment

Alveolar lymphocytes, obtained by bronchoalveolar lavage in 35 patients with sarcoidosis, were analyzed with monoclonal antibodies to lymphocyte subsets. Untreated patients had significantly higher percentages of Leu 3a (+) T helper-inducer cells (THI) and significantly lower Leu 2a (+) T cytotoxic-suppressor cells (TCS) within the alveolar lymphocyte population than did normal control subjects (p less than 0.002). The mean ratio of alveolar THI to TCS cells was 6.20 +/- 3.76 versus 1.44 +/- 0.54 in control subjects (p less than 0.002). Untreated patients had a percentual enrichment of THI cells among alveolar lymphocytes relative to blood (p less than 0.0002), whereas TCS cells in percent of lymphocytes were lower in alveolar lavage fluid than in blood (p less than 0.002). These shifts were not observed in the control subjects. Patients with high-intensity alveolitis (i.e., T cells constituted 28% or more of alveolar inflammatory cells) had significantly greater proportions of THI cells among alveolar lymphocytes than did those with low-intensity alveolitis (p less than 0.01). This percent of alveolar THI cells correlated positively with the number of lymphocytes and T cells in percent of alveolar cells (p less than 0.03), which both are indexes of disease activity. In untreated patients who were lavaged at least twice, a decrease in the THI/TCS ratio was found to accompany or precede radiologic and clinical improvement, but the initial THI/TCS ratio was not predictive of further evolution. Steroid treatment decreased the THI/TCS ratio with a marked increase in the proportion of TCS cells. These changes were independent of an effect on the number of alveolar lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)     

Defecography and proctography

PURPOSE: Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders. MATERIALS AND METHODS: All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings. RESULTS: Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12–95) years had defecographic and proctographic examination. Four hundred forty-six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms ( P <0.0001). CONCLUSION: Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.     

Unsuspected cardiac abnormalities in the acquired immune deficiency syndrome. An echocardiographic study

To investigate the frequency of unsuspected cardiac abnormalities in AIDS, M-mode and two-dimensional echocardiograms were performed on 27 homosexual males with this syndrome. Twenty-one homosexual males without the disease were used as controls. Subjects with clinical heart disease or a history of intravenous drug abuse were excluded. Fractional shortening was reduced in eight patients (30 percent) and in one control (5 percent) (p less than 0.05). Pericardial effusions were found in seven patients (26 percent); one control subject had a small effusion (5 percent) (p = 0.05). Overall, echocardiographic abnormalities were found in 13 of 27 patients (48 percent) compared with 2 of 21 control subjects (10 percent) (p less than 0.02). We conclude that although often not diagnosed clinically, the incidence of cardiac involvement in AIDS is high.     

Clinical significance of the elevated anion gap

To determine the clinical significance of a high anion gap (more than 16 meq/liter), consecutive patients in whom electrolyte determinations were made in an emergency room and who had either a normal (8 to 16 meq/liter) (n = 571) or a high (n = 100) anion gap were contrasted. No differences were noted between the groups with regard to age or length of stay in the hospital, but in the group with a high anion gap, there was an increased severity and frequency of multiple electrolyte disorders, and higher general admission rates (66 percent with high anion gap versus 51 percent with normal anion gap, p less than 0.02), rates of admission to an intensive care unit (25 percent with high anion gap versus 14 percent with normal anion gap, p less than 0.03), and mortality within one week of admission (12 percent with high anion gap versus 0.5 percent with normal anion gap, p less than 0.001) as compared with the group with a normal anion gap. Notably, patients without severe electrolyte abnormalities and a high anion gap had higher admission rates and a 50-fold increased mortality rate as compared with the group without severe electrolyte disturbances and a normal anion gap. Thus, an elevated anion gap is associated with an increased severity of illness that is independent of concomitant severe electrolyte abnormalities. Patients with a normal or high anion gap that survived the first week of hospitalization were shown to have an extremely low risk for mortality.     

Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease

The history, physical examination, chest radiograph, electrocardiogram and blood gases were evaluated in patients with suspected acute pulmonary embolism (PE) and no history or evidence of pre-existing cardiac or pulmonary disease. The investigation focused upon patients with no previous cardiac or pulmonary disease in order to evaluate the clinical characteristics that were due only to PE. Acute PE was present in 117 patients and PE was excluded in 248 patients. Among the patients with PE, dyspnea or tachypnea (greater than or equal to 20/min) was present in 105 of 117 (90 percent). Dyspnea, hemoptysis, or pleuritic pain was present in 107 of 117 (91 percent). The partial pressure of oxygen in arterial blood on room air was less than 80 mm Hg in 65 of 88 (74 percent). The alveolar-arterial oxygen gradient was greater than 20 mm Hg in 76 of 88 (86 percent). The chest radiograph was abnormal in 98 of 117 (84 percent). Atelectasis and/or pulmonary parenchymal abnormalities were most common, 79 of 117 (68 percent). Nonspecific ST segment or T wave change was the most common electrocardiographic abnormality, in 44 of 89 (49 percent). Dyspnea, tachypnea, or signs of deep venous thrombosis was present in 107 of 117 (91 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain was present in 113 of 117 (97 percent). Dyspnea or tachypnea or pleuritic pain or atelectasis or a parenchymal abnormality on the chest radiograph was present in 115 of 117 (98 percent). In conclusion, among the patients with pulmonary embolism that were identified, only a small percentage did not have these important manifestations or combinations of manifestations. Clinical evaluation, though nonspecific, is of considerable value in the selection of patients in whom there is a need for further diagnostic studies.     

Transtracheal oxygen, nasal CPAP and nasal oxygen in five patients with obstructive sleep apnea.

The effect of transtracheal oxygen administration by means of a 9-French (2.7 mm) percutaneous catheter was assessed in five patients with severe obstructive sleep apnea. We hypothesized that the delivery of oxygen below the site of airway obstruction should reduce the arterial oxygen desaturation during apneas and hypopneas, thereby increasing respiratory stability. Standard sleep and respiratory measurements were recorded in these subjects with all-night polysomnography on nonconsecutive nights during four experimental conditions: room air (BL), nasal continuous positive airway pressure (CPAP), nasal O2 (NC O2), and transtracheal O2 (TT O2). In three of these subjects, room air was infused (TT RA) at flow rates comparable to TT O2. Compared with baseline room air measurements, TT O2 not only significantly increased the SaO2 nadir from 70.4 percent to 89.7 percent (p less than 0.01), but it also reduced the frequency of sleep apnea/hypopnea from 64.6 to 26.2/h sleep (p less than 0.01). NC O2 ameliorated desaturation during apnea/hypopnea (mean SaO2 nadir, 86.2 percent; p less than .01) but did not significantly alter frequency (59.0/h sleep). Nasal CPAP was the most effective means of reducing sleep apnea/hypopnea (13.8/h sleep) but did not abolish desaturations when apneas occurred (mean SaO2 nadir, 80.0 percent). Compared with oxygen, transtracheal infusion of room air appeared to be somewhat effective; however, the small number of studies with TT RA precluded statistical analysis. We believe that TT O2 is superior to NC O2 for some patients with obstructive sleep apnea because continuous oxygen flow below the site of airway obstruction more reliably prevents alveolar hypoxia and respiration is stabilized. Infusion of air or oxygen through the tracheal catheter flow may also increase mean airway pressure and reduce obstructive apnea similar to nasal CPAP. We conclude that TT O2 may be an effective alternative mode of therapy for some patients with severe sleep apnea/hypopnea when nasal CPAP is not tolerated or when combined oxygen and nasal CPAP are required.     

Routine chest radiography for the evaluation of febrile neutropenic patients after autologous stem cell transplantation

Chest radiographs are routinely obtained for diagnostic evaluation of neutropenic febrile patients. We investigated the frequency of chest radiographic abnormalities during febrile episodes after autologous PBSC transplants and assessed the relationship of these abnormalities to past history of pulmonary disease, pre-transplant chest radiographic abnormalities, and pulmonary signs or symptoms at time of fever. We also studied the impact of chest radiographic findings on patient management. Sixty-one consecutive adult autologous PBSC transplant recipients were studied. Fifty-two (85%) developed fever, and 20 (38%) of these showed new chest radiographic abnormalities suggestive of pulmonary infection. Patients with pre-transplant chest radiographic abnormalities were more likely to develop additional abnormalities with fever post-transplant. Pulmonary symptoms or signs had low sensitivity or specificity for predicting radiographic abnormalities. Only 40% of patients with pulmonary symptoms or signs had an abnormal chest radiograph. Twenty-six percent of patients with abnormal chest radiographs had no clinical findings suggestive of pulmonary infection. The identification of chest radiographic abnormality did not change empiric antibiotic treatment in any patient. The role of routine chest radiography for diagnostic evaluation of febrile autologous PBSC transplant patients should be re-evaluated.     

经纤维支气管镜局部化疗治疗气管支气管结核的疗效及方案研究

目的 探讨合理的经纤维支气管镜局部化疗治疗气管支气管结核的方案.方法 对255例予全身化疗联合经纤维支气管镜局部化疗的气管支气管结核患者的疗效等进行回顾性分析.其中局部注入异烟肼+丁胺卡那霉素+利福平者(多药组)49例,局部注入异烟肼+利福平者(双药组)152例,局部单用利福平者(单药组)54例.结果 ①多药组和双药组平均治疗次数[(4.3±3.9)次,(5.0±4.0)次]少于单药组[(9.9±5.2)次](P<0.01).②经纤维支气管镜局部化疗4周后,50%以上的患者镜下病变缩小或消失,三组的好转率差异无统计学意义.③经纤维支气管镜局部化疗4周后,三组患者胸片或胸CT病变均有不同程度的吸收,但差异无统计学意义.④局部化疗治疗终止时,三组胸片或胸CT病变吸收总有效率依次为82%、80%、44%,多药组和双药组优于单药组(P<0.05).⑤局部化疗治疗终止时,多药组支气管狭窄的发生率(16.3%)高于双药组(4.6%)和单药组(5.6%)(P<0.05).结论 经纤维支气管镜局部注人异烟肼+利福平,给药次数较少,疗效较好,不良反应小,是气管支气管结核局部治疗的最佳方案.