Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute massive pulmonary embolism: a European multicenter double-blind trial. The European Cooperative Study Group for Pulmonary Embolism.

Twelve centers participated in a double-blind study in which 63 patients with angiographically documented acute massive pulmonary embolism were randomly assigned to treatment with either urokinase (4,400 U/kg as an intravenous bolus infusion, then 4,400 U/kg per h over 12 h; n = 29) or alteplase (10 mg as an intravenous bolus infusion, then 90 mg over 2 h) followed by heparin (n = 34). The primary objective was to compare the resolution of pulmonary embolism as judged by the change in total pulmonary resistance over the initial 2 h. Further objectives were to evaluate the changes in total pulmonary resistance over the next 10 h and the degree of angiographic resolution at 12 to 18 h. At 2 h, total pulmonary resistance decreased by 18 +/- 22% in the urokinase group and by 36 +/- 17% in the alteplase group (p = 0.0009). Continuous monitoring of pulmonary artery mean pressure, cardiac index and total pulmonary resistance revealed that these variables improved faster in the alteplase group, with consistently significant intergroup differences from 30 min up to 3 to 4 h. After 12 h, the decrease in total pulmonary resistance was 53 +/- 19% in the urokinase group compared with 48 +/- 17% in the alteplase group and the reduction in the angiographic severity score was 30 +/- 25% compared with 24 +/- 18%, respectively, with no significant intergroup differences. Bleeding was equally frequent in the two treatment groups, except that more urokinase-treated patients experienced hematomas at puncture sites.

Relapsing polychondritis.

Relapsing polychondritis is a progressive multisystem disorder that predominantly affects cartilage, producing an inflammatory reaction. We present case histories from four patients having mainly respiratory symptoms in whom we measured the coronal diameters of the trachea and compared them with the tracheal measurements from radiographs of patients with no respiratory symptoms. The results showed that the disease produced diffuse narrowing of the main airway in all four patients. Early detection of tracheal narrowing is important, as patients presenting with respiratory tract disease have a worse prognosis than those who develop it later in the course of their illness. Other features of the disease are also discussed with reference to the cases presented.

Allergic broncho-pulmonary aspergillosis: the radiological appearance during long-term follow-up.

The radiographs of 100 patients with allergic bronchopulmonary aspergillosis were examined to assess the type and distribution of abnormalities seen during long-term follow-up. Lobar shrinkage occurred almost exclusively in the upper zones but other abnormalities were distributed throughout both lungs. Bronchial wall thickening was the commonest lesion observed and was usually a permanent finding. Consolidation was commonest in the perihilar regions, persisted for up to 20 weeks when transient and was a permanent finding in 10 patients. Dilated bronchi were noted to change in calibre with exacerbations and remissions of the condition. Episodes of transient collapse were segmental, lobar or involved a whole lung. Permanent collapse was always segmental. Massive shadowing, band shadows and 'gloved fingers' were seen less frequently than expected and cavitation was rare. In some patients the chest radiograph was normal between exacerbations of the disease.

Lung folding simulating peripheral pulmonary neoplasm (Blesovsky's syndrome).

Six cases are reported in whom the diagnosis of benign pleural thickening with lung folding simulating peripheral pulmonary neoplasm was made. Three patients presented with chest pain, two were asymptomatic, and the abnormality was a chance finding in one patient with asthma. The radiographs in all cases showed similar appearances--a peripheral opacity appearing to lie within the lung, usually the lower lobe, and characteristic curvilinear shadows extending from the opacity to the hilum. At thoracotomy, predominantly visceral pleural thickening had caused the underlying lung to fold. Hyaline plaques were present on the parietal pleura elsewhere and pleural adhesions were usually absent. Adequate removal of the thickened visceral pleura in five patients allowed the folded lung to re-expand, with reversion of the chest radiograph to normal. One patient in whom the underlying lung folding was not appreciated at operation still has chest pain and the chest radiograph is unchanged. The radiographic appearances of this non-malignant condition, especially the appearances on lateral tomography, are diagnostic, and recognition may obviate the need for operation in asymptomatic patients. For those patients with chest pain, thoracotomy with removal of the visceral pleura and release of the folded lung appears to be effective in relieving this symptom.

Ruptured bronchial artery aneurysm mimicking aortic dissection.

A patient is presented in whom rupture of a bronchial artery aneurysm produced a clinical picture indistinguishable from an aortic dissection. This case emphasises the importance of considering alternative diagnoses when a patient presents with symptoms typical of a particular condition.

Value of chest radiographs in severe acute asthma.

Chest radiographs were obtained in 117 adults admitted with severe acute asthma. In 10 (9%) patients abnormalities were seen that affected management and in nine the presence of pulmonary collapse or consolidation was shown which was not detected by clinical examinations. Over-inflation was common and correlated significantly with tachycardia, pulsus paradoxus and decrease in FEV1. Bronchial wall thickening was common and prominence of hilar vessels was also noted in a few patients. Chest radiography is strongly recommended in severe exacerbation of asthma and antero-posterior views are adequate for interpretation.

Long-term prognosis of treated acute massive pulmonary embolism.

Seventy-two patients surviving initial treatment by pulmonary embolectomy, streptokinase, or heparin for acute massive pulmonary embolism have been reviewed 1 to 9 years later. Of these patients, 17 had additional cardiorespiratory disease. There were 12 late deaths (41% of those patients with, and 9% of those patients without additional cardiorespiratory disease). No death was due to chronic pulmonary hypertension, and none to certain recurrence of pulmonary embolism. The causes of death were malignant disease (6 patients), cardiopulmonary disease other than pulmonary embolism (4 patients), and 'sudden' (2 patients). Though venous interruption surgery was not used, and long-term anticoagulation rare, the incidence of possible or probable recurrent embolism was low (6%). There was no definite evidence of persistence or subsequent development of pulmonary hypertension after treatment in any patient. Resolution of embolism as judged by symptoms, signs, electrocardiogram, and chest x-ray examination was almost always complete. Some pulmonary arteriograms 1 to 6 months after initial treatment showed minor abnormalities, but others at a later date were normal. Perfusion lung scans carried out 1 to 8 years after initial treatment often showed minor abnormalities.

Coronary artery steal via large coronary artery to bronchial artery anastomosis successfully treated by operation.

We report a patient with a large coronary artery to bronchial artery anastomosis causing angina by coronary steal. Angina was refractory to medical treatment, but successfully relieved by surgical ligation of the anastomosis.

Computed tomography in the assessment of malignant mesothelioma of the pleura.

Computed tomography (CT) and plain radiography have been performed on 32 patients with malignant mesothelioma of the pleura, in order to assess the extent of disease and suitability for radical treatment. A comparison of the assessments by the two techniques is reported, with confirmation from either thoracotomy or post-mortem findings available in 16 cases. CT was found to be more sensitive than plain radiology in the detection of pleural effusions, although routine lateral decubitus radiographs has not been performed. The two techniques were equally effective in detecting involvement by tumour of the lateral chest wall, mediastinum and lung, with no false positive assessments by either technique, and few false negative assessments. Disease was shown to be extensive and gross at presentation in mesothelioma, so that the greater sensitivity of CT was of no advantage. Diaphragmatic involvement by tumour was accurately assessed by plain radiology but there were frequent false negative assessments by CT, possibly due to difficulty of interpretation of the curved diaphragm on the cross-sectional CT image. In this study CT offered little advantage over conventional radiology.

Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism.

Massive pulmonary embolism was confirmed by pulmonary arteriography in 23 patients. All were seen between 2 and 48 hours after the onset of embolism and none had pre-existing cardiorespiratory disease. Fifteen were treated with streptokinase and eight with heparin. Factors which might influence prognosis and rate of resolution were similar in the patients in each group, and there was no significant difference between the groups in terms of pretreatment haemodynamic or arteriographic findings. Haemodynamic and arteriographic findings after treatment for 72 hours provided an objective measurement of resolution, which was significantly greater in the streptokinase-treated patients. There was no mortality in either group, but treatment had to be changed in two heparin-treated patients because of clinical deterioration. The principal complication of treatment, seen more often in the streptokinase-treated patients, was bleeding from cut-down or operation sites.

Clinical correlates of angiographically diagnosed idiopathic pulmonary hypertension.

During 1970-87 43 patients with unexplained pulmonary hypertension (mean pulmonary arterial pressure greater than 25 mm Hg) were admitted to the Brompton Hospital and classified by angiographic criteria as having either symmetrical peripheral pulmonary artery pruning (thought to represent primary plexogenic pulmonary arteriopathy), n = 21, or asymmetrical pulmonary arterial occlusions (thought to represent chronic thromboembolic disease), n = 22. Patients with symmetrical pulmonary arteriopathy had significantly higher mean pulmonary arterial pressures (67 mm Hg) at the time of presentation than those with asymmetrical pulmonary arteriopathy (49 mm Hg). Clinical distinction between these two groups was impossible. Survival from the time of diagnosis was similarly poor in the two groups (26 weeks and 38 weeks) and did not correlate with any of the haemodynamic measurements. The difficulties in making distinctions between these conditions are discussed.

Subpulmonary pleural effusions in children after cardiac surgery.

Postoperative chest radiographs on 100 children who had undergone cardiac operations were evaluated to determine the frequency of subpulmonary effusions after surgery. Of the 83 patients in whom adequate erect postoperative radiographs were available, 9 (11%) had effusions confirmed by lateral decubitus radiographs. On the frontal chest x ray film, the evidence of an effusion was an increase in distance between the diaphragm and air in the gastric fundus, or an apparent elevation of the right hemidiaphragm. None of the patients examined echocardiographically had associated pericardial effusions. When a subpulmonary effusion was detected diuretic treatment was started or continued. None of the patients had radiographic evidence of residual fluid when they were seen two weeks after their discharge from hospital.