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.

Characteristics and outcome of patients with difficult weaning from mechanical ventilation: an 18 years' experience of a respiratory intermediate unit attached to a pulmonary department.

BACKGROUND: Respiratory dysfunction often persists in post intensive care unit (ICU) patients and intermediate care facilities have been established to ensure the continuous of appropriate care. METHODS: The data of patients with difficult weaning from mechanical ventilation admitted to a respiratory intermediate unit (RIU) attached to a pulmonary department of a General Hospital, were retrospectively analyzed. Clinical characteristics, weaning from mechanical ventilation and tracheostomy, ICU readmission and RIU mortality were examined over a period of 18 years (1993- 2010) that was randomly divided into three six-year-periods. RESULTS: A total of 548 patients (age 56.7±17.9 years) [mean ± standard deviation (SD)], of whom 80% with tracheostomy in place and 37.6% with pressure ulcers, were examined. The ICU stay was 30.1±24.7 days (mean ± SD) and increased over time (p<0.05). Patients' baseline disorders were: chronic respiratory disease (41.3%), chronic cardiovascular diseases (10.6%), neuromuscular disease (22.8%) and miscellaneous (25.3%). The length of RIU stay (22.8±19.5 days) was constant over the examined periods but an increase in age and maintenance of tracheostomy were observed; 80% of patients were liberated from mechanical ventilation and 58.5% from tracheostomy, whereas the RIU mortality was 15%. CONCLUSION: In their vast majority patients with chronic respiratory failure, who were admitted to RIU,were weaned from mechanical ventilation, although in a substantial percentage the maintenance of tracheostomy was mandatory after discharge. Hippokratia 2015, 19 (1): 37-40.

Sensorineural hearing loss and word deafness caused by a mesencephalic lesion: clinicoelectrophysiologic correlations.

OBJECTIVE: To assess the role of inferior colliculi as a generator of Wave V of brainstem auditory evoked potentials and in modulating the olivocochlear efferent auditory system. STUDY DESIGN: Case review. SETTING: University and tertiary referral centers. PATIENTS: Case report of a patient with word deafness caused by mesencephalic hemorrhage according to audiologic and electrophysiologic findings. RESULTS: The patient is a 48-year-old woman who suffered word deafness caused by hemorrhage localized at the quadrigeminal plate (including the inferior colliculi). At a follow-up visit, her pure-tone audiogram revealed symmetric severe sensorineural hearing loss that had partially resolved, whereas speech audiometry showed persistent word deafness. Acoustic reflexes were elicited, with normal thresholds bilaterally. Transient evoked otoacoustic emissions were recorded from both ears, with normal response and signal-to-noise ratio, but there was a failure for their amplitude to be suppressed with contralateral sound stimulation. Brainstem auditory evoked potentials were of normal amplitude and latencies bilaterally. CONCLUSION: The finding of normal brainstem auditory evoked potentials supports the view that the neural generator of Wave V lies caudally to the inferior colliculi. Moreover, the abnormal suppression of transient evoked otoacoustic emissions indicates that descending collicular input is capable of modulating levels of excitability within the olivary nucleus and the cochlea.

Respiratory function in amyotrophic lateral sclerosis patients. The role of sleep studies.

BACKGROUND AND AIM: Respiratory function decline in association with sleep breathing abnormalities in Amyotrophic Lateral Sclerosis (ALS) patients are fully recognized as crucial manifestations in the natural course of the disease, severely affecting the prognosis. The aim of this study was to evaluate the respiratory function at daytime and during sleep in a population of ALS patients and investigate the necessity of sleep study performance for the appropriate management of the disease. PATIENTS AND METHODS: Twenty eight (10 male, 18 female) unselected patients with ALS, were evaluated in terms with their functional status by means of the ALS Functional Scale (ALSFSC). Baseline anthropometric measurements, pulmonary function tests and arterial blood gases analysis were performed, as well as evaluation of patients' perception of dyspnoea. A polysomnography was performed using a multichannel ambulatory recording. RESULTS: Nineteen patients had sleep disordered breathing with an RDI (Respiratory Disorder Index)>5/h (from 5.6/h to 83/h) and 10 patients had an RDI>15/h. All patients had impaired functional capacity by the ALSFSC and 11 patients (39.3%) reported mild to moderate dyspnoea. FVC was below 80% predictive value in 22 patients and in 8 patients hypoxaemia (PaO2<80 mmHg) and in 12 patients hypercapnia (PaCO2>40 mmHg) was present. There was no correlation found between spirometric values, maximum inspiratory and expiratory pressures and sleep study parameters. There was a significant correlation between PaCO2 and RDI (r=0.498, p<0.01), and PaO2 with nocturnal hypoxaemia (average SpO2, r=0.436,p<0.05). CONCLUSIONS: Sleep-breathing abnormality is common in ALS patients even in the absence of documented respiratory failure. Clinical evaluation and respiratory function tests alone may not be sufficient to predict sleep disordered breathing (SDB) and nocturnal breathing assessment should be included in the evaluation of respiratory function.

Problems in diagnosis and treatment of tuberculosis infection.

Tuberculosis is still a major health problem in industrialized countries due to specific socioeconomic factors and there is the growing need of new rapid and accurate diagnostic methods, in order to achieve higher sensitivity and specificity compared to traditional methods of microscopic sputum examination and culture. Such methods, recently introduced, are nucleic acid amplification (NAA) tests, used directly on clinical specimens and blood tests (QuantiFERON-TB, T-SPOT.TB test), measuring the IFN-gamma released by stimulated T cells. Furthermore, new drugs for the disease need to be developed, aiming to better treatment results and to prevention of Multiple Drug Resistance (MDR) cases. Critical aspects in the management of drug resistance cases should be the careful choices of drugs combination, the close follow up of the patients alongside with the patients adherence to therapy. The role of national and international tuberculosis programs is invaluable in TB control and therapy, as well as the collaboration of all the health system departments. However, most of the clinical problems that may arise are addressed by the International Standards for Tuberculosis Care-ISTC and these guidelines should be taken into consideration, at least until future research provides more promising diagnostic and therapeutic modalities for control of the disease.

Burden and coping strategies in families of patients under noninvasive home mechanical ventilation.

BACKGROUND: It is well documented that caregivers of patients with chronic respiratory failure under noninvasive mechanical ventilation (NIMV) are at high risk to develop depression, burden, overload and declining health over time. OBJECTIVES: The purpose of the study was to investigate the subjective and objective burden imposed on families of patients under NIMV at home and explore the coping strategies they adopt. METHODS: The study population consisted of 50 informal caregivers of patients with chronic respiratory failure under NIMV at home for at least 6 months. The burden of the families, as well as the adaptation strategies, were estimated by a modified version of the Family Burden Questionnaire validated in Greek. RESULTS: Profound objective burden was reported in the field of social relations in 49%, in household management in 43.2%, in financial issues in 31.3% and in employment issues in 29.4% of the families. The subjective burden which the families experienced was usually lower and it was reported in household management in 33.4%, in employment issues in 29.4%, in social relations in 21.6% and in financial issues in 21.5% of the families. The strategies adopted by the families in order to cope with the imposed burden included reorientation of goals in 92.2%, resignation in 88.2%, passivity in 62.7%, hopefulness in 45.3%, ambivalence in 19.6% and guilt in 13.7% of the families. CONCLUSIONS: The families of patients under NIMV seem to face major problems (severe burden) in household management and their social relations. Families do not seem to subjectively experience the burden that is objectively recorded and, in the vast majority, they adopt healthy coping strategies.

Acoustic quantification: new diastolic indices of left ventricular function in hypertension correlation with Doppler echocardiography.

A study of left ventricular diastolic function in early hypertension was performed by the new method of acoustic quantification and Doppler echocardiography. A total of 23 untreated patients, five males and 18 females (mean age 53.52 +/- 9.10 years) with mild or moderate hypertension (160 +/- 13/98 +/- 10 mmHg) and 12 normal, age- and heart-rate-matched, control subjects were studied. All subjects showed normal left ventricular systolic function and wall thickness on two-dimensional echocardiography. The following indices were obtained. (1) Acoustic quantification (AQ): the time rate of area change in early diastole (dA/dt)E, in late diastole (dA/dt)A and their ratio (dA/dt)E/(dA/dt)A. (2) Doppler echocardiography: the early peak E, the late peak A flow velocities, their ratio E/A and deceleration E-F slope in early diastole. Measurements of left ventricular diastolic function by acoustic quantification showed, in the patient group, that the time rate of area change in early diastole (dA/dt)E was significantly lower (64.7 +/- 11.0 cm2/second versus 74.3 +/- 5.9 cm2/second; P < 0.01), the rate of area change in late diastole (dA/dt)A was not significantly higher (43.3 +/- 9.2 cm2/second versus 38.4 +/- 6.0 cm2/second; P > 0.05), and the ratio between the above indices (dA/dt)E/(dA/dt)A was significantly lower (1.55 +/- 0.42 versus 1.95 +/- 0.20; P < 0.01), compared with normal values. Doppler diastolic indices were all significantly abnormal in patients, in comparison with the values of the control group. Reduced left ventricular diastolic function was found in nine of 23 patients (39.1%) by the AQ method and eleven of 23 patients (47.8%) by Doppler echocardiography. Acoustic quantification was in agreement with Doppler echocardiography in identifying left ventricular diastolic dsyfunction in nine of 11 hypertensive patients with reduced Doppler diastolic values (82% sensitivity, 100% specificity). The correlation between the two methods showed that the time rate of area change in early diastole (dA/dt)E correlated well with the early peak E flow velocity (r = 0.59), the ratio between the time rates in early and late diastole (dA/dt)E/(dA/dt)A also correlated well with the Doppler E/A ratio (r = 0.89), while a poor correlation was found between the time rate of area change in late diastole (dA/dt)A and peak A flow velocity (r = 0.26). Thus abnormal diastolic filling of the left ventricle can be seen in the early stages of hypertension, even in the presence of normal systolic function and wall thickness, while acoustic quantification could be considered as a useful noninvasive modality for the early identification of left ventricular diastolic abnormalities.

Pericardial effusion concomitant with specific heart muscle disease in systemic sarcoidosis.

Eighty-one consecutive patients, 32 males and 49 females, with biopsy-proven systemic sarcoidosis, none of whom had clinical evidence of heart disease, underwent M-mode and two-dimensional echocardiography, ECG and chest X-ray in order to investigate the frequency of sarcoid pericardial effusion. Mild or moderate size pericardial accumulations were found by echocardiography in 17 patients (21%), four males and 13 females (mean age 49.7 +/- 9.2 years). Pericardial effusion could not be correlated with clinical symptoms or physical signs, chest X-ray and ECG findings. All 17 patients with pericardial effusion were also studied by technetium-99m pyrophosphate radionuclide myocardial imaging, targeting to reveal the coincident presence of specific heart muscle disease or 'infiltrative cardiomyopathy'. The results showed abnormal scans in 13 of 14 patients with technically satisfactory scans, indicating the coincidence of sarcoid myocardial involvement in 92% of the patients with pericardial effusion, representing 16% of the total population studied. Thus, pericardial effusion in sarcoidosis should not be considered a rare condition, while concomitant presence of positive technetium-99m pyrophosphate radionuclide myocardial imaging could suggest that sarcoid pericardial effusion is often accompanied by specific heart muscle disease. This observation has not been well established previously in the literature.

Improvement of left ventricular diastolic dysfunction in hypertensive patients 1 month after ACE inhibition therapy: evaluation by ultrasonic automated boundary detection.

The purpose of this study was to detect any improvement in left ventricular diastolic dysfunction in hypertensive patients 1 month after cilazapril therapy. Twenty-three patients, 5 men and 18 women (mean age, 53.52 +/- 9.10 years), with mild or moderate hypertension (160 +/- 13/98 +/- 10 mm Hg), and free of other cardiac or systemic diseases, were studied using ultrasonic automated boundary detection (ABD) and pulsed Doppler echocardiography, before and 1 month after a daily dose of 2.5 mg of cilazapril. The following new ABD diastolic indices were determined: the time rate of area change in early diastole (dA/dt)E, that in late diastole (dA/dt)A, and their ratio (dA/dt)E/(dA/dt)A, while Doppler transmitral flow measurements of left ventricular diastolic filling were also simultaneously recorded. The ABD results showed left ventricular diastolic dysfunction (LVDD) in 9 of 23 patients (39%) compared with the ABD values of 12 normal volunteers. Neither method revealed any significant difference before and after treatment in the patient group as a whole. However, in the group of 9 patients with diastolic dysfunction, the ABD ratio (dA/dt)E/(dA/dt)A was significantly improved after cilazapril therapy (1.20 +/- 0.21 versus 1.41 +/- 0.17; P < 0.05). We concluded that a large percentage (39%) of patients with mild or moderate hypertension had reduced diastolic performance of the left ventricle at a stage of the disease when systolic dysfunction and/or hypertrophy were not evident. Significant improvement of diastolic dysfunction in hypertensive patients could be detected by the proposed ABD new diastolic indices 1 month after cilazapril therapy. In conclusion, automatic boundary detection should be a useful non-invasive modality for the early diagnosis of left ventricular diastolic dysfunction, as well as early recognition of its improvement.