The relation between preprocedural C-reactive protein levels and early and late complications in patients with acute myocardial infarction undergoing interventional coronary angioplasty.

BACKGROUND: Inflammation is an important feature of arteriosclerotic disease, and the vulnerability of coronary plaques in acute myocardial infarction (AMI) may be related to the levels of serum C-reactive proteins (CRP). While some risk factors for early and late complications have been suggested, an accurate and definitive preprocedural risk stratification of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) is still lacking. HYPOTHESIS: The study was undertaken to investigate whether early and late complications after PTCA could be predicted by evaluation of baseline serum CRP levels in patients with AMI. METHODS: Levels of serum CRP were measured in a total of 230 patients with AMI undergoing PTCA and provisional stent. They were divided into two groups: Group 1 (n = 48) with elevated CRP levels (> or = 5 mg/l) and Group 2 (n = 182) with normal CRP levels (< 5 mg/l). RESULTS: There were no significant differences in baseline clinical, angiographic, and procedural characteristics between the two groups. However, the incidence of in-hospital adverse coronary events (reinfarction, coronary reocclusion, target vessel revascularization, and death) and severe left ventricular dysfunction was significantly higher in Group 1 (18.3 vs. 6.1%, p < 0.05 and 20.9 vs. 6.1%, p < 0.05, respectively). In addition, bailout stenting was performed more frequently in Group 1 than in Group 2 (60.4 vs. 36.3%, p < 0.005). No significant late complications were noted. The serum levels of CRP were the only independent predictors of early adverse events. CONCLUSIONS: Preprocedural serum CRP level might be considered a powerful predictor of early but not late complications in patients undergoing PTCA/stent procedures.

Maintenance of inspiratory muscle training in COPD patients: one year follow-up.

In most chronic obstructive pulmonary disease (COPD) patients, dyspnoea and functional exercise capacity may improve as a result of inspiratory muscle training (IMT). However, the long-term benefits of IMT have been investigated to a much lesser extent. The present study investigated the short-term and long-term benefits of IMT on inspiratory muscle performance (strength and endurance), exercise capacity and the perception of dyspnoea. Thirty-eight patients with significant COPD had 3 months of basic IMT and were then randomised into a group that received maintenance IMT for the next year, and a group that got training with very low load. Following the basic training there was a statistically significant increase in inspiratory muscle performance, 6-min walk test (6MWT), and a decrease in the dyspnoea. During the second stage of the study, the training group continued to maintain the improvement in all parameters, while there was already deterioration in the inspiratory muscle performance, exercise capacity and dyspnoea in the low intensity group during the 6-12 month period. The present study concludes that, in patients with significant chronic obstructive pulmonary disease, inspiratory muscle training results in improvement in performance, exercise capacity and in the sensation of dyspnoea. The benefits of 12-weeks of inspiratory muscle training decline gradually over 1 yr of follow-up if maintenance training is not performed.

C-reactive protein levels and arterial abnormalities in the offspring of patients with premature myocardial infarction.

AIMS: To determine whether high C-reactive protein (CRP) levels and increased intima-media thickness of the common carotid arteries are coexistent in adolescents and young adults with a family history (FH) of premature myocardial infarction (MI). METHODS: 50 healthy young subjects whose parents had had premature MI and 50 control matched subjects were enrolled in the study. CRP levels and the intima-media thickness of the distal common carotid arteries were evaluated in all subjects. RESULTS: As compared with the control subjects, the offspring of patients with premature MI had a higher CRP concentration (mean +/- SD 8.8 +/- 2.6 versus 3.9 +/- 0.6 mg/l, p < 0.02) and greater intima-media thickness of the common carotid arteries (values for combined sides, mean +/- SD 0.48 +/- 0.02 versus 0.43 +/- 0.02 mm, p < 0.03). CONCLUSION: High serum levels of CRP and arterial structural changes are coexistent at an early age in subjects with an FH of premature MI.

Long-acting bronchodilators in premenstrual exacerbation of asthma.

Premenstrual exacerbation (PME) of asthma occurs during the 5-10 days leading up to the menses and can be demonstrated in about 40% of asthmatic females. Peak expiratory flow rate (PEFR) and beta2-agonist consumption were recorded during three menstrual cycles in 67 females with mild-severe asthma. All were treated with inhaled glucocorticosteroids (IGC) and beta2-agonists, as required. Following, the patients with a premenstrual reduction in PEFR > 20%, received either salmeterol, 50 microg x 2 day(-1) or placebo, in the 10 days leading up to the menses, in a randomized, double-blind, cross-over design. Thirteen patients (19.4%) showed PME (mean +/- SEM decrease in PEFR 27 +/- 2.2%) in association with a significant increase in the mean daily beta2-agonist consumption. Following administration of salmeterol, there was a complete ablation of the PME in seven patients, a partial ablation in two patients and no effect in the remaining four patients. Only one patient showed a partial ablation of the PME following placebo. There was also a significant decrease in the beta2-agonists consumption in the responders. About 20% of the women with asthma, under chronic IGC treatment, had PME of asthma. In 54% of them, it could be prevented by the use of long-acting bronchodilators (LABD) during the 10 days leading up to the menses, and partially prevented in another 15%.

Hypercalcaemia in systemic lupus erythematosus.

Hypercalcaemia is a common electrolyte abnormality. The vast majority of patients will be shown to have either hyperparathyroidism or malignancy. In less than 10% of patients other, less common causes of hypercalcaemia will be present. Systemic lupus erythematosus is a very rare cause of hypercalcaemia. It may be associated with lymphadenopathy and pleuritis to constitute a distinct clinical entity described as 'hypercalcaemia-lymphoedema syndrome'. In these cases the pathophysiology of the hypercalcaemia is not completely understood. In some cases it is associated with elevated levels of parathyroid-related peptide (PTHrP). In others the level of PTHrP is normal, and it has been suggested that autoantibodies may cause hypercalcaemia by activating the PTH receptor. We describe a case of a woman who presented with severe hypercalcaemia, developed the hypercalcaemia-lymphodema syndrome and fulfilled the diagnostic criteria of systemic lupus erythematosus.

The cumulative effect of long-acting bronchodilators, exercise, and inspiratory muscle training on the perception of dyspnea in patients with advanced COPD.

BACKGROUND: Dyspnea is a common complaint during daily activities in patients with advanced COPD. The mechanisms underlying dyspnea and the appropriate treatment strategies to relieve it are still not totally understood. We hypothesized that the perception of dyspnea (POD) may be modified by the accumulative effect of bronchodilator therapy, exercise, and inspiratory muscle training (IMT). METHODS: Spirometry, submaximal exercise performance, inspiratory muscle strength and endurance, and the POD were assessed before and following three consecutive 6-week periods of therapy with a long-acting bronchodilator (LABD), the LABD plus exercise, and the LABD plus exercise plus IMT in 30 patients with moderate-to-severe COPD. RESULTS: There was a small, statistically insignificant, increase in FEV(1) in the study group (mean [+/- SEM] increase, 1.42+/-0.3 to 1.49+/-0.4 L) following the LABD therapy period, and no additional increase following the two other periods of therapy. There was a significant increase (p<0.05) in the 6-min walk distance following the therapy period with the LABD plus exercise (mean increase, 252+/-41 to 294+/-47 m) and an additional small increase following the therapy period with the LABD plus exercise plus IMT period (mean increase, 252+/-41 to 302+/-49 m). The decrease in the POD was small and statistically not significant following the therapy periods with the LABD and the LABD plus exercise. The major and statistically significant decrease in the POD was noted following the therapy period with the LABD plus exercise plus IMT. CONCLUSIONS: In patients with moderate-to-severe COPD, following sequential periods of therapy with the LABD, the LABD plus exercise, and the LABD plus exercise plus IMT, there is a cumulative benefit in the POD. The most significant improvement was associated with IMT and not with the LABD and exercise training. The FEV(1) was moderately increased following the therapy period with the LABD, and the addition of exercise has most affected the 6-min walk distance.

Smoking and first acute myocardial infarction: age, mortality and smoking cessation rate.

BACKGROUND: Cigarette smoking is a major contributor to the risk of acute myocardial infarction and the subsequent morbidity and mortality. Physicians can play an important role in smoking cessation among patients with AMI because of their frequent contact with the patient during the event. OBJECTIVES: To study the prevalence of smoking, age, localization of coronary occlusion, mortality and rate of smoking cessation in consecutive patients who were diagnosed with a first AMI in our center in 1989-93. METHODS: The study included 1,510 consecutive patients with first AMI: 973 men (512 smokers, 52.6%) and 537 women (215 smokers, 40%), whose mean age was 64.1 +/- 6.7 and 68.6 +/- 5.2 years respectively. RESULTS: The median age at the first AMI in non-smoking and smoking men differed significantly (70.4 +/- 6.8 vs. 56.6 +/- 6.1 years, P < 0.001) while the difference in the women was smaller (70.4 +/- 6.9 vs. 66.8 +/- 7.2). The proportion of smokers/non-smokers among men was greater at a younger age and decreased proportionally with age. The overall mortality was 11.3% with a significant difference in mortality rate in the younger age groups between smokers and non-smokers (1% vs. 0% in the age group 31-40 years, P < 0.05, and 6.1% vs. 0.8% in the 41-50 year age group, P < 0.001). Only 62% of the smokers who survived the AMI declared that they had received anti-smoking advice from a physician during hospitalization. The cessation rate in this group was significantly higher than in smokers who had not been cautioned against smoking (56% vs. 18%). CONCLUSIONS: Current smokers sustained their first AMI more than one decade earlier than non-smokers, and the younger smokers had a higher mortality rate. The majority of the smokers who received anti-smoking advice during their hospitalization for AMI quit smoking in the year following the acute event.

[Carbon dioxide gas embolism during laparoscopic cholecystectomy].

A case of carbon dioxide gas embolism during laparoscopic cholecystetomy is presented. Prompt diagnosis and immediate treatment resulted in positive outcome. Laparascopic cholecystectomy is nowadays one of the most common operations for cholecystectomy and certainly the most frequent endoscopic surgical procedure. It is usually safe and effective. However, a number of serious complications have been reported during the procedure. Gas embolism is one of the complications that may occur during the initial gas insufflation or during dissection of the gall bladder. Symptoms are mainly related to the speed and the amount of gas that reaches the venous system. Early recognition and prompt treatment are required to prevent severe morbidity or even fatal outcome. Transesophageal echocardiography has detected many unsuspected cases of gas embolism. However, capnograph monitoring of end-tidal CO2, routinely used in everyday anesthesia, is highly reliable in alerting to the possibility of gas embolism and also in confirming its occurrence. In cases of suspected gas embolism close collaboration between anesthetist and surgeon is required.

[Acute myocardial infarction after honeybee sting].

Myocardial infarction due to honeybee sting is rare, and only a few authors have discussed the relationship between the sting, anaphylactic shock and myocardial infarction. We describe a case of acute myocardial infarction in a 44-year-old man after anaphylactic shock following honeybee sting. He did not have heart disease nor any known risk factors attributable to atherosclerotic coronary artery disease. He had almost normal coronary angiography with non-significant hemodynamic changes.

Specific inspiratory muscle training in well-trained endurance athletes.

PURPOSE: It has been reported that arterial O2 desaturation occurs during maximal aerobic exercise in elite endurance athletes and that it might be associated with respiratory muscle fatigue and relative hypoventilation. We hypothesized that specific inspiratory muscle training (SIMT) will result in improvement in respiratory muscle function and thereupon in aerobic capacity in well-trained endurance athletes. METHODS: Twenty well-trained endurance athletes volunteered to the study and were randomized into two groups: 10 athletes comprised the training group and received SIMT, and 10 athletes were assigned to a control group and received sham training. Inspiratory training was performed using a threshold inspiratory muscle trainer, for 0.5 h x d(-1) six times a week for 10 wk. Subjects in the control group received sham training with the same device, but with no resistance. RESULTS: Inspiratory muscle strength (PImax) increased significantly from 142.2 +/- 24.8 to 177.2 +/- 32.9 cm H2O (P < 0.005) in the training but remained unchanged in the control group. Inspiratory muscle endurance (PmPeak) also increased significantly, from 121.6 +/- 13.7 to 154.4 +/- 22.1 cm H2O (P < 0.005), in the training group, but not in the control group. The improvement in the inspiratory muscle performance in the training group was not associated with improvement in peak VEmax, VO2max breathing reserve (BR). or arterial O2 saturation (%SaO2), measured during or at the peak of the exercise test. CONCLUSIONS: It may be concluded that 10 wk of SIMT can increase the inspiratory muscle performance in well-trained athletes. However, this increase was not associated with improvement in aerobic capacity, as determined by VO2max, or in arterial O2 desaturation during maximal graded exercise challenge. The significance of such results is uncertain and further studies are needed to elucidate the role of respiratory muscle training in the improvement of aerobic-type exercise capacity.

The perception of dyspnoea in patients with asthma, before and following treatment with inhaled glucocorticosteroids.

This study was designed in order to establish the perception of breathlessness during rest and while breathing against resistance, in patients with asthma, before and after 8 weeks of inhaled glucocorticoids (IGC) treatment and to compare these parameters in patients with and without improvement in FEV1. Sixty-seven asthmatic patients, with moderate asthma, attending the asthma clinic, and 20 normal subjects were studied. After a 2-week run-in period, in which the subjects were asked to use exclusively beta2-agonists as needed, the asthmatic patients were randomized to receive either treatment with IGC, 250 microg of fluticasone propionate (FP) twice a day, via a diskhaler (47 patients), or to receive placebo (20 patients) and to serve as a control group, for 8 weeks. Spirometry and measurements for the sensation of dyspnoea were performed before and at the end of the treatment period. The mean dyspnoea score during breathing against resistance was significantly lower (P<0.05) in the patients with asthma than in normal subjects, before entering the study. Following 8 weeks of inhaled FP, there was a significant improvement in the mean dyspnoea score during breathing against resistance in the asthmatics receiving IGCs but not in the control group (P<005). In the study group 32 patients had an improved FEV1 > 15% and 15 patients did not. There was a statistically significant difference in perception of dyspnoea (P<0.01), between the group of patients with a improved FEV1 and the group of patients that were under IGC treatment without improvement in their FEV1. There was also a difference in the mean beta2-agonists consumption between the two groups (P<0.01). Asthmatic patients have a significantly lower perception of dyspnoea compared to normal subjects. IGC treatment was associated with increased perception of dyspnoea. However, this improvement was noted only in patients with improved FEV1, while the patients without improvement remained with an equal degree of dyspnoea perception and beta2-agonists consumption.

Specific inspiratory muscle training in patients with mild asthma with high consumption of inhaled beta(2)-agonists.

BACKGROUND: It has been known for many years that there are variations between asthmatic patients in terms of their perception of breathlessness during airway obstruction. STUDY OBJECTIVE: To investigate the relationship between beta(2)-agonist consumption and the score of perception of dyspnea, in mild asthmatics, and the relationship between the effect of specific inspiratory muscle training (SIMT) on the score of perception of dyspnea and beta(2)-agonist consumption in "high perceivers." METHODS: Daily beta(2)-agonist consumption was assessed during a 4-week run-in period in 82 patients with mild asthma. Patients with a mean beta(2)-agonist consumption of > 1 puff/d ("high consumers") then were randomized into two groups: one group of patients received SIMT for 3 months; the other group of patients was assigned as a control group and received sham training. Inspiratory muscle strength and perception of dyspnea were assessed before patients entered the study, following the 4-week run-in period, and after completing the training period. RESULTS: Following the 4-week run-in period, 23 high-consumer patients (mean [+/- SEM] beta(2)-agonist consumption, 2.7 +/- 0.4 puffs/d) were detected. The mean Borg score during breathing against resistance was significantly higher (p < 0.05) in the patients with high beta(2)-agonist consumption than in the subjects with low mean beta(2)-agonist consumption. Following SIMT, the mean maximal inspiratory pressure increased significantly from 94.1 +/- 5.1 to 109.7 +/- 5.2 cm H(2)O (p < 0.005) in the training group. The increase in inspiratory muscle strength was associated with a statistically significant decrease in the mean Borg score during breathing against resistance (p < 0.05) as well as in the mean daily beta(2)-agonist consumption. CONCLUSIONS: We have shown that patients with mild asthma, who have a high beta(2)-agonist consumption, have a higher perception of dyspnea than those with normal consumption. In addition, SIMT was associated with a decrease in perception of dyspnea and a decrease in beta(2)-agonist consumption.

The effect of specific inspiratory muscle training on the sensation of dyspnea and exercise tolerance in patients with congestive heart failure.

BACKGROUND: It has been previously shown that the inspiratory muscles of patients with congestive heart failure (CHF) are weaker than those of normal persons. This weakness may contribute to the dyspnea and limit exercise capacity in these patients. The respiratory muscles can be trained for both strength and endurance. HYPOTHESIS: The present study was designed to evaluate the effect of specific inspiratory muscle training (SIMT) on inspiratory muscle performance, lung function, dyspnea, and exercise capacity in patients with moderate heart failure. METHODS: Twenty patients with CHF (NYHA functional class II-III) were recruited for the study. The subjects were randomized into two groups: 10 patients were included in the study group and received SIMT and 10 patients were assigned to the control group and received sham training. Subjects in both groups trained daily, 6 times/week, for one-half h, for 3 months. The subjects started breathing at a resistance equal to 15% of their PImax for 1 week and the resistance was then increased incrementally to 60%. Spirometry, inspiratory muscle strength (assessed by measuring the PImax at residual volume), and endurance (expressed by the relationship between PmPeak and PImax), the 12-min walk test, and peak VO2 were performed before the beginning and at the end of the training period. RESULTS: All patients in the training group showed an increase in the inspiratory muscle strength [mean (+/- standard error of the mean) PImax increased from 46.5 +/- 4.7 to 63.6 +/- 4.0 cm H2O, p < 0.005], and endurance (mean PmPeak/PImax from 47.8 +/- 3.6 to 67.7 +/- 1.7%, p < 0.05), while they remained unchanged in the control group. This was associated in the training group with a small but significant increase in forced vital capacity, a significant increase in the distance walked (458 +/- 29 to 562 +/- 32 m, p < 0.01), and an improvement in the dyspnea index score. No statistically significant change in the mean peak VO2 was noted in either group. CONCLUSIONS: Specific inspiratory muscle training resulted in increased inspiratory muscle strength and endurance. This increase was associated with decreased dyspnea, increase in submaximal exercise capacity, and no change in maximal exercise capacity. This training may probe to be a complementary therapy in patients with congestive heart failure.

Lymph-node-based malignant lymphoma and reactive lymphadenopathy in eosinophilic fasciitis.

BACKGROUND: Lymph node enlargement in patients with eosinophilic fasciitis is a rare occurrence and its clinical significance is unknown. METHODS: The literature and authors' registries were searched for eosinophilic fasciitis associated with lymphadenopathy. Clinical data, time sequence of appearance of either disorder, and pathological diagnoses were analyzed. RESULTS: Six patients presenting with eosinophilic fasciitis had a lymph-node-based lymphoma and 4 patients had a reactive lymphadenopathy. The patients with lymphoma were elderly and the subcutaneous induration preceded the lymphadenopathy by 2 to 36 months. The patients with eosinophilic fasciitis and reactive lymphadenopathy were young and the onset of subcutaneous induration and lymph node enlargement coincided with one another. Favorable response of the eosinophilic fasciitis to prednisone therapy was attained in 3 of 3 patients with reactive lymphadenopathy and in 4 of the 6 cases with lymphoma. CONCLUSIONS: Eosinophilic fasciitis is rarely associated with clinically significant lymph node enlargement. Subcutaneous induration preceding the lymphadenopathy by 6 months or more, especially in elderly patients, suggests an underlying lymphoma. A favorable response of the subcutaneous induration to prednisone treatment does not exclude the diagnosis of lymphoma; therefore, it does not supersede the need of a pathological evaluation. A lymph node biopsy is mandatory in all cases.

Nocturnal cortisol secretion in asthmatic patients after inhalation of fluticasone propionate.

OBJECTIVES: This study was designed to assess the relationship between the degree of airflow obstruction and the suppression of the hypothalamic-pituitary-adrenal axis after inhalation of fluticasone propionate (FP) in asthmatic patients with varying degrees of airway obstruction. STUDY DESIGN: The nocturnal cortisol production (from 10:00 PM to 6:00 AM), defined as the integrated area under the curve of nocturnal plasma cortisol, was measured following inhalation of a placebo or a single dose of 500 microg FP at 8:00 PM in 28 patients with mild to moderate asthma, in a single, blind, 2-night study. RESULTS: The mean morning rise of cortisol decreased significantly following a single dose of inhaled FP. When the total nocturnal cortisol production after the second night (when the FP was inhaled) was compared to that after the first night (when the placebo was administered), it was found to have decreased by 29.4%. There was a statistically significant correlation between the FEV(1) and the fall in cortisol production just before the inhalation of FP (p < 0. 001). There was no correlation between baseline cortisol production and the fall in cortisol production. CONCLUSIONS: Our findings suggest that the degree of airway obstruction affects the systemic bioavailability of FP. FP is likely to induce a more severe decrease in nocturnal cortisol secretion in less obstructed patients. In order to reduce the risk for systemic side effects, the patient's degree of airway obstruction should be considered when planning inhaled FP treatment.

Toxoplasma infection in systemic lupus erythematosus mimicking lupus cerebritis.

An opportunistic infection is a known, although under-diagnosed, complication of systemic lupus erythematosus (SLE). A 48-year-old woman with a recent diagnosis of SLE was admitted to the hospital because of a fever, confused state, and convulsive episode. Her symptoms were interpreted as being compatible with lupus cerebritis. Treatment with methylprednisolone resulted in a temporary improvement in the patient's condition. Nevertheless, during the next few weeks, her physical and mental condition deteriorated, and she died of massive pulmonary emboli. An autopsy revealed no signs of lupus cerebritis; however, disseminated cerebral toxoplasmosis was found. Cerebral toxoplasmosis is a rare complication of SLE that may be misdiagnosed as lupus cerebritis.