[LGM inferior vena cava filters--observation of 79 patients]. / Filtry LGM zakladane do zyly glównej dolnej--obserwacja 79 chorych.

The aim of the study was to assess effectiveness and safety of the LGM inferior vena cava (IVC) filters in patients with venous thromboembolic disease. In the Department of Internal Medicine of Institute of Tuberculosis and Lung Diseases in Warsaw 79 LGM IVC filters have been inserted since 1993. Indications for filters placement were as follows: recurrent pulmonary embolism (pe) despite anticoagulation--17 patients (pts), severe bleeding complications of thrombolytic or anticoagulant therapy--11 pts, contraindications for thrombolytic and/or anticoagulant treatment--5 pts, massive pe--14 pts, chronic thromboembolic-major vessel pulmonary hypertension (CTEPH)--30 pts, extensive deep vein thrombosis of lower limbs or vena cava inferior in patients with urgent indications for surgery--24 pts. Each filter placement was preceded by cavography. The diagnostic procedures (mainly ultrasonography) were performed after 3-6 and 12 months in the first year then once yearly during follow-up period. Oral anticoagulants (OA) or low-molecular-weight heparins (LMWH) were instituted in the majority of patients. 58 patients are still alive, 21 patients died. Only two non-fatal episodes of recurrent pe were documented. Other complications were rare and insignificant. We have not observed excess rate of recurrent deep venous thrombosis nor thrombosis at the filter site. The LGM IVC filters are effective and safe in such selectively chosen group of patients.

Low molecular weight heparin versus acenocoumarol in the secondary prophylaxis of deep vein thrombosis.

The aim of this study was to determine the efficacy and safety of subcutaneous weight-adjusted dose low molecular weight heparin (LMWH) compared with oral anticoagulant (OA) in the prevention of recurrent venous thromboembolism. In a prospective multicenter trial, 202 patients with symptomatic proximal deep vein thrombosis (DVT) were included. As soon as the diagnosis of DVT was confirmed by phlebography, 101 were randomly assigned to receive LMWH (nadroparin) for secondary prophylaxis and 101 to receive OA (acenocoumarol). Patients in both groups were initially treated with nadroparin in a dose of 85 anti-Xa IU/kg s.c. every 12 h. Secondary prophylaxis with either nadroparin, 85 anti-Xa IU/kg s. c. once daily, or acenocoumarol was continued for at least 3 months. Three patients in the LMWH group and 6 in the OA group were excluded from analysis for various reasons. During the one-year combined secondary prophylaxis and surveillance period, 7 of of the 98 evaluable patients (7.1%) in the LMWH group and 9 of the 95 evaluable patients (9.5%) in the OA group had a documented recurrence of venous thromboembolism (Fisher's exact test, p = 0.61). Of these, 2 patients who received LMWH and 7 patients on acenocoumarol had recurrences in the 3-month period of secondary prophylaxis. Four patients (4.1%) in the LMWH group developed bleeding complications during this study period, as compared with 7 (7.4%) in the OA group (Fisher's exact test, p = 0.37). There were two major bleedings, one in the LMWH group and one in the OA group. Eleven patients died, 5 (5.1%) in the LMWH group and 6 (6.3%) in the OA group. It is concluded that nadroparin in a dose of 85 anti-Xa IU/kg s.c. once daily provides an effective and safe alternative to oral anticoagulants in the secondary prophylaxis of DVT.

[Secondary prophylaxis of venous thromboembolism: analysis of 49 fatal cases]. / Wtórna profilaktyka przeciwzakrzepowa zylnej choroby zakrzepowo-zatorowej: analiza 49 zgonów.

The analysis of 49 fatal cases of venous thromboembolism--VTE (15% of total ambulatory patients number during long observation was performed. The advanced age of patients, multiple risk factors, underlying circulatory and respiratory tract diseases, malignancies, previous episodes of VTE especially with secondary pulmonary hypertension were the most important factors determining fatal prognoses in those patients.

[Secondary ambulatory prophylaxis of venous thromboembolism: outcome of patients who were lost to follow-up]. / Wtórna ambulatoryjna profilaktyka zylnej choroby zakrzepowo-zatorowej: losy chorych, którzy utracili kontakt z przychodnia.

We have attempted to determine the outcome of 87 out-patients who were lost from follow-up. Several factors have been assessed: causes of lost from follow-up duration of oral anticoagulation, recurrent venous thromboembolic events, cause of death (if applicable).

[The evaluation of carcinoembryonic antigen determination in the pericardial fluid in the diagnosis of the cause of pericarditis]. / Ocena przydatnosci oznaczania antygenu rakowoplodowego w plynie osierdziowym w rozpoznawaniu przyczyn zapalenia osierdzia.

Pericardial fluid CEA level was measured with radioimmunoassay in 19 patients with large pericardial effusion of unknown origin. In 11 patients malignancy was diagnosed. In all of these patients pericardial fluid CEA levels were above 7 ng/ml (mean value 52.6 +/- 42.6 ng/ml). In 8 patients the etiology of pericarditis was non-malignant. In all of them pericardial fluid CEA levels were below 7 ng/ml (mean value 2.2 +/- 1.6 ng/ml). In 9 patients with malignant pericarditis serum CEA levels were also determined: they were found to be lower than pericardial fluid CEA values in 6 patients. It was concluded that pericardial fluid CEA elevation is a reliable criteria of neoplastic pericardial involvement.

Neuron-specific enolase in non-neoplastic lung diseases, a marker of hypoxemia?

Neuron-specific enolase (NSE) is a glycolytic enzyme localized within neuronal and neuroendocrine tissues. Serum NSE is widely used as a marker of neuroendocrine tumors. Moderate serum NSE elevation has been reported in some patients with benign lung diseases. We decided to investigate whether the elevation of serum NSE in non-neoplastic lung diseases is connected with hypoxemia and to what extent the recovery of sufficient ventilation with a respirator may influence NSE concentrations. Serum NSE was estimated by means of radioimmunoassay in 83 patients with various non-neoplastic lung diseases. Serum NSE exceeding 12.5 micrograms/L was significantly more frequent in patients with marked hypoxemia (PaO2 < 6.67 kPa; p = 0.03) than in others. The median NSE value in the group of patients without respiratory failure (Ro) was 7.2 micrograms/L (10% > 12.5 micrograms/L), in the group of patients with respiratory failure not requiring mechanical ventilation (Rf) it was 8.5 micrograms/L (24% > 12.5 micrograms/L), and in the group of patients with respiratory failure requiring mechanical ventilation (Rfv) 13.1 micrograms/L (60% > 12.5 micrograms/L). The differences between the Rfv group and the other two groups (Rf and Ro) were significant (P = 0.049 and p = 0.0004, respectively). During successful mechanical ventilation elevated serum NSE decreased to values below the cutoff in 8/10 patients. We conclude that serum NSE elevation is a frequent event in patients with terminal hypoxemia in the course of benign lung diseases. Normalization of serum NSE is observed in the majority of patients during the first week of mechanical ventilation.

The role of carcinoembryonic antigen (CEA) and neuron-specific enolase (NSE) evaluation in pericardial fluid for the recognition of malignant pericarditis.

This study was designed to assess the value of tumor marker evaluation in pericardial fluid for the recognition of malignant pericarditis. Thirty-six patients with signs and symptoms of large pericardial effusion entered the study. Pericardiocentesis with pericardial fluid drainage was performed in all of them. CEA and NSE levels were evaluated in the pericardial fluid and compared to pericardial fluid cytology. The median CEA value in malignant effusions was 80 ng/ml (range 0-305 ng/ml) and in non-malignant ones 1.26 ng/ml (range 0.2-18.4 ng/ml), p < 0.01. The sensitivity of CEA elevation above 5 ng/ml for the recognition of malignant pericarditis was 73% and the specificity was 90%. Pericardial fluid cytology was positive in 22 of 26 patients with malignant pericarditis (85%). CEA exceeding 5 ng/ml or positive cytology were seen in 96% of the patients with malignant pericarditis. The median NSE value in malignant pericardial effusions was 41.8 micrograms/l (range 2-172 micrograms/l) and in non-malignant ones 5.85 micrograms/l (range 1-83.9 micrograms/l), p < 0.3. For the differential diagnosis of large pericardial effusions we would recommend simultaneous cytologic examination of pericardial fluid and CEA assessment. NSE measurement in hemorrhagic pericardial fluid is of limited value.

Intrapericardial administration of cisplatin in treatment of metastatic pericardial involvement in adenocarcinoma of the lung.

The aim of this study was to evaluate the effectiveness and side-effects of intrapericardial administration of cisplatin (IAC), in cases of abundant malignant pericardial effusion (MPE) and/or cardiac tamponade occurring in the course of adenocarcinoma of the lung (AL). Fifteen consecutive patients with abundant MPE and AL (4 females and 11 males; mean age 54 yrs) entered this prospective study. Following pericardiocentesis and insertion of a polyurethane catheter, the pericardial fluid was drained. Malignant aetiology of the pericardial fluid was confirmed by cytological examination. After confirmation of MPE, cisplatin (10 mg in 20 mL normal saline) was instilled directly into the pericardial space, over a period of 5 min for 3-5 consecutive days. Treatment was considered successful (response) if the patient survived 30 days without recurrence of symptoms of abundant MPE, and no other interventions directed to the pericardium were required. Response was achieved in 10 patients (67%). The mean (+/-SEM) dose of cisplatin was 56 (+/-18.9) mg. There were no complications related to the pericardiocentesis. Transient atrial fibrillation was detected in one patient. Mild nausea also occurred in one case. No hypotension or retrosternal pain was observed. Sclerotization of the pericardium and pericarditis constrictiva were detected after IAC in only one case. Cisplatin administered directly into pericardial space is effective and safe. Intraperitoneal administration of cisplatin appears to be the method of choice in the treatment of recurrent malignant pleural effusion in patients with primary adenocarcinoma of the lung. Sclerosis of the pericardial space is a very rare complication observed after intraperitoneal administration of cisplatin therapy.

Intrapericardial cisplatin for the management of patients with large malignant pericardial effusion in the course of the lung cancer.

Patients with cardiac tamponade or large malignant pericardial effusion, who survived longer than 30 days after withdrawal of catheter from the pericardial space, entered the study. Main goal of investigations was: evaluation of the effectiveness and side-effects of intrapericardial administration of cisplatin in cases with malignant pericardial effusion (MPE) and cardiac tamponade or large pericardial effusion in a course of the lung cancer. Sixteen patients (four women and 12 men), mean age 53 years, median age 57 years, range 27-70 years, entered this retrospective study. After pericardiocentesis and insertion of a polyurethane catheter, pericardial fluid was drained. Malignant etiology of pericardial fluid was confirmed by cytological examination and/or by echocardiography. The diagnosis of malignancy was based upon histological examination of samples obtained from primary tumor. After confirmation of MPE cisplatin (10 mg in 20 ml normal saline) was instilled over 5 min during 1-5 consecutive days (maximal total cisplatin dose in single course: 50 mg) directly into pericardial space. If a large pericardial fluid reoccurred the courses with intrapericardial administration of cisplatin were repeated. Treatment was considered successful if the patient with malignant effusion survived 30 days without recurrence of symptoms of large pericardial effusion and no other interventions directed to the pericardium were required. In 14 (87.5%) cases malignant pericardial effusion was confirmed by cytological analysis of pericardial fluid. In two cases echocardiography confirmed metastatic tumors to the pericardium. Positive effect of intrapericardial treatment with cisplatin was achieved in 15 cases (93.75%). Mean survival period in the whole group was 6.59 months (+/-6.2 months), median survival period was 3.7 months, range 2-24.1 months. There were no complications related to the pericardiocentesis. Transient atrial fibrillation was detected in three patients (18.8%). Mild nausea occurred in one case. No hypotension and retrosternal pain were observed. Cisplatin administered directly into pericardial space (CAP) seems to be effective and safe. No sclerosis of the pericardial space was observed after CAP.

[Still's disease as an example of fever of unknown origin: diagnostic and therapeutic difficulties]. / Choroba Stilla przyczyna goraczki niejasnego pochodzenia: trudnosci diagnostyczno-róznicowe i lecznicze.

A case of systemic form of juvenile chronic arthritis (Still's disease) is presented. Difficulties in confirmation of diagnosis are described. After nonsteroidal-antiinflammatory drugs and cytostatics administration very good therapeutical effect was achieved.

New approaches to the management and treatment of malignant pericardial effusion.

The purpose of this study was the evaluation of the effectiveness of intrapericardial administration of tetracycline, 5-fluorouracil and cisplatin in patients with recurrent malignant pericardial effusion. In 33 cases with malignant pericardial effusion 46 pericardiocenteses under two-dimensional echo-cardiography were performed. No complications were observed after this procedure. Pericardiocentesis was followed by catheterization of the pericardial space for a mean period of 15 days (range 1-64). In 4 cases bacterial pericarditis was observed during catheterization. The mean volume of the pericardial fluid was 2.41 (range 0.4-13 l). In cases with bloody pericardial fluid the PO2, PCO2 and pH of the fluid were estimated and the results compared with the values for venous blood obtained from the upper limbs. Highly statistically significant differences were documented. Twenty cases of malignant pericardial effusion were treated with direct pericardial administration of cisplatin, 3 with 5-fluorouracil and 2 with tetracycline. Good results (no fluid reaccumulation) were observed only after cisplatin therapy. We conclude that pericardiocentesis performed under two-dimensional echo cardiography, followed by pericardial catheterization and direct pericardial treatment with cisplatin are the methods of choice in cases with malignant pericardial effusion. In cases with bloody pericardial fluid PO2, PCO2 and pH analysis can be useful to differentiate the source of the bloody fluid (blood or bloody fluid).

Pulmonary thromboembolism.

Pulmonary embolism (PE) is a serious complication of chronic obstructive pulmonary disease (COPD). Retrospective studies on patients with COPD treated in the intensive care unit (ICU) were performed to determine: 1) the frequency of PE; 2) the clinical course of PE in cases of COPD in the ICU; and 3) the frequency of PE as a cause of death in the studied group. The frequency of PE was 10.9% in COPD patients. In the group analysed, clinical presentation of PE was characterized by acute severe, life-threatening complications leading to death in 86.7% of cases. PE was the most frequent cause of death (40.6%) in COPD patients in the ICU. The results of treatment of pulmonary embolism in chronic obstructive pulmonary disease are poor and mortality in this group of patients is very high. We believe that improvement of management can be achieved by antithromboembolic prophylaxis, which should be instituted as soon as possible in all patients with chronic obstructive pulmonary disease in the intensive care unit.

[Wegener's granulomatosis. Three cases with different clinical courses]. / Ziarniniakowatosc Wegenera. Opis 3 przypadków o odmiennym obrazie kliniczym.

Three cases of Wegener's granulomatosis are presented. In every case the different clinical picture was observed. In the first case dominated the pulmonary changes and fingers necrosis. In that case the excellent therapeutic effect of etoposide was observed. In the second case the most important clinical sings illustrated severe renal insufficiency. The third case demonstrated pericardial and skin changes. The significance of early diagnosis and early institution of proper therapy was discussed.

[Pulmonary embolism in malignancy of the lung: a retrospective clinical evaluation and pathomorphologic personal material]. / Zatorowosc plucna w przebiegu nowotworów zlosliwych pluc: retrospektywna ocena kliniczna i patomorfologiczna materialu wlasnego.

The incidence and clinical significance of pulmonary embolism (PE) in pulmonary malignancy were analysed among 111 autopsy cases including: 65 primary and 24 metastatic lung cancer, 8 hematological malignancies and 14-malignant pleural mesothelioma. In 34 (31%) cases PE was found, in 4 (12%) patients cancer tissue emboli was documented. In nonsmall cell lung cancer the frequency of PE was 40%, compared to 24% in small cell, 25% in metastatic lung cancer and 14% in mesothelioma. Deep venous thrombosis of lower extremities was the source of thrombotic material in 35% cases. In remaining cases the sources of thrombotic material were different (caval vein inferior, superior, and their main branches, right heart cavities, pulmonary artery). In 8 patients with PE the acute form of DIC was observed. In 15 (44%) patients the clinical ante mortem diagnosis of PE was done. In 26% of all analysed cases PE was the direct cause of death. We concluded that PE is a frequent and dangerous complication of lung neoplasms. Clinical diagnosis can be extremely difficult.

[LGM inferior vena cava filters--follow up 50 patients]. / Filtry LGM zakladane do zyly glównej dolnej--obserwacja 50 chorych.

In the Department of Medicine at the Institute of Tuberculosis and Lung Diseases 50 LGM inferior vena cava filters have been inserted since 1993. Indications for filters placement were as follows: recurrent pulmonary embolism (PE) despite anticoagulation-16 patients (pts), severe bleeding complications of thrombolytic or anticoagulant therapy-9 pts, contraindications for thrombolytic and/or anticoagulant treatment-3 pts, massive PE-6 pts, chronic thromboembolic-major vessel pulmonary hypertension (CTEPH)-18 pts, extensive deep vein thrombosis of lower limbs or vena cava inferior in patients with urgent indications for surgery-10 pts. In every patient diagnostic procedures were performed after 1, 3, 6, 12, 24 and 36 months of follow-up period. Only one non-fatal episode of recurrent PE was documented. Other complications were rare and insignificant. The LGM inferior vena cava filters are effective and safe in such selectively chosen group of patients.

[Implantation of LGM inferior vena cava filters in patients with chronic pulmonary hypertension during a course of major vessel thromboembolism--observation of 18 patients]. / Implantacja filtrów LGM do zyly glównej dolnej u chorych z przewleklym, nadcisnieniem plucnym w przebiegu zatorowosci do duzych naczyn--obserwacja 18 chorych.

CTEPH have not been widely recognised until recently. Introduction of the new, sophisticated, non-invasive diagnostic tools accounts for rapid progress in that field. Patients with high pulmonary hypertension have a very poor prognosis. Medical treatment (vasodilators, anticoagulants) does not change outcome. Pulmonary thromboendarterectomy is the only therapeutic option for the patients. It is essential to prevent further episodes of pulmonary embolism both over the long term and during the high risk perioperative period by means of inferior vena cava filters. In the Department of Medicine, Institute of Tuberculosis and Lung Diseases 18 LGM ivc filters have been inserted in patients with CTEPH since 1994. In 7 patients PTE was performed-in 5 cases good result was achieved, 2 patients died after surgery. In the latter group 5 patients died mainly because of severe heart failure. Only one non-fatal episode of pulmonary embolism was observed. It should be concluded that the LGM ivc filters are safe and effective in preventing episodes of pulmonary embolism in patients with CTEPH.

[Clinically silent pulmonary embolism in patients with proximal deep venous thrombosis]. / Klinicznie bezobjawowy zator tetnicy plucnej u chorych z zakrzepica odcinka proksymalnego zyl glebokich konczyn dolnych.

In 18 patients with proximal deep venous thrombosis (PDVT) confirmed by phlebography, no symptoms and signs of pulmonary embolism (PE) were observed. All patients were treated with nadroparin. During first 6 days of treatment in all patients perfusion lung scans were performed. 8 patients (44.4%) of all group developed lung scans positive for PE (silent PE). Period of successful treatment of PDVT was 10 days. No evidence of recurrent PE were observed during the period of treatment. We conclude that: 1. Frequency of silent PE in patients with PDVT is very high-lack of symptoms and signs of PE does not exclude the presence of PE in this group of patients. 2. In all patients with PDVT perfusion lung scan should be performed even in cases with no symptoms and signs of PE. 3. Low molecular weight heparins administered subcutaneously are effective in treatment either silent PE or PDVT.

[Low doses of rtPA administered as a bolus in treatment of clinically acute massive pulmonary embolism]. / Male dawki rtPA podawane w bolusach w leczeniu klinicznie masywnego zatoru tetnicy plucnej.

12 patients (7 male and 5 female) with confirmed pulmonary embolism (PE) with: angiography-5 cases, conventional contrast-enhanced CT-2 cases, echocardiography-2 cases, autopsy-3 cases were diagnosed as clinically acute PE. Criteria of clinically acute PE were: cardiac arrest-1 case-2 cases, shock-1 case, acute cor pulmonale-9 cases and acute cor pulmonale with shock. All patients were treated with heparin, administered with therapeutic prolongation of aPTT. Clinically acute PE (if possible confirmed with angiography, TC and/or echocardiography) was treated with rtPA administered in 10 minutes lasting bolus in doses 0.6-0.8 mg per kg of body weight (50 mg of rtPA during 10 minutes administered into peripheral veins). In 9 patients with pulmonary hypertension, significant decrease of tricuspidal gradient (measured echocardiographically during several hours after administration of rtPA) was documented. Improvement in PaO2, SaO2 and decrease of heart rate and respiratory rate were also achieved. No serious bleeding complications were observed after mentioned treatment. Control investigations (conventional contrast-enhanced CT and spiral CT) performed several days after rtPA administration revealed thrombus in pulmonary artery. We conclude: I rtPA administered in bolus simultaneously with heparin significantly decreased pulmonaryhypertension; rtPA administered simultaneously with heparin is safe method of treatment of PE; hemodynamic improvement after administration of rtPA is not univocal with full fibrynolitic effect.

[Pericardial syndrome in the course of pulmonary embolism in personal material]. / Zespól osierdziowy w przebiegu zatoru tetnicy plucnej w materiale wlasnym.

UNLABELLED: Dressler-like syndrome has been described in about 3-4% of patients after pulmonary embolism (PE). Out of 207 patients admitted to our hospital in whom the clinical diagnosis of PE was confirmed by scintigraphy, spiral computer tomography and angiography, in 19 patients (9.2%) pericardial fluid was detected and pericardial syndrome (PS) after PE was diagnosed. Other causes of pericarditis were excluded. Mean value of pericardial fluid in echocardiographic examination-behind left ventricular posterior wall was 3.84 mm (range 2-10 mm). No clinical or echocardiographic symptoms of cardiac tamponade were observed. In 6 patients PS complicated clinically massive PE, in 3 patients-non-massive PE, in 10 patients recurrent PE. In 6 patients fibrinolytic and in 13 patients heparin therapy was instituted. In 3 cases corticosteroids were given. No increase of pericardial fluid during fibrinolytic or heparin therapy was observed. CONCLUSIONS: 1. PS after PE is more frequent, than it was estimated previously 2. During therapy of PE the echocardiographic monitoring of the amount of pericardial fluid is mandatory 3. The clinician considering in similar situations the risk-benefit ratio of fibrinolytics and anticoagulants should not abstain from the use of these drugs in the presence of PS after PE, in cases with high probability of cardiac tamponade-pericardial catheter should be used.

[The value of measuring adenosine deaminase activity in pericardial effusion fluid for diagnosing the etiology of pericardial effusion]. / Wartosc oznaczania aktywnosci deaminazy adenozyny w plynie osierdziowym w diagnostyce etiologii wysieku osierdziowego.

The diagnosis of tuberculous pericarditis is difficult. The cultures of the pericardial fluid for M.tuberculosis are often negative. The determination of ADA activity in pleural fluid in TB patients /PTS/ is very useful. It seemed reasonable to measure ADA activity in pericardial effusion. ADA activity in pericardial fluid of 40PTS/19 women and 21 men/with large pericardial effusion of different etiologies who were treated in our institute in years 1988-1995 was investigated. The median age was 44 years. In each case the pericardiocentesis was performed. PTS were grouped as follows: group I-4 PTS with strongly suspected TB pericarditis, group II-32 PTS with malignancy and group III-4 PTS with miscellaneous diseases. In group I the mean ADA activity was 24U/I(3-60), in group II 18U/I (3-60) and in group III 18U/I (0-37) (with a cutoff value for ADA activity of 40U/I). It was definitive bacteriologic diagnosis of TB pericarditis in PTS of group I. Our observation does not confirm the earlier data about the high ADA activity in clinically suspected TB pericarditis without bacteriologic diagnosis. The value of ADA determination in pericardial fluid is its high specificity (97%) in excluding of TB etiology of pericardial effusion.