[Chylous ascites following surgical repair of a ruptured abdominal aortic aneurysm]. / Chyloperitoneum na operatief herstel van een geruptureerd aneurysma aortae abdominalis.

Two patients, a man aged 65 years and a woman aged 75 years, developed chylous ascites after emergency abdominal aortic aneurysm repair. Both patients were still on artificial ventilation at the time of diagnosis. The first symptoms were high ventilation pressure, elevated diaphragm and abdominal distension. The patients were treated conservatively with drainage, and the man was also given tube feeding without long-chain triglycerides. The man recovered, while the woman died of sepsis. Chylous ascites is an unusual complication of retroperitoneal surgery. Abdominal paracentesis is a simple means to confirm the diagnosis. Initial treatment consists of draining the chylus, and a medium-chain triglyceride diet or total parenteral nutrition. When this fails, more invasive treatment is required, consisting of direct lymphatic repair or peritoneovenous shunting. In mechanically ventilated patients, gradually progressive symptoms of abdominal hypertension after surgery in the retroperitoneal space should arouse suspicion of this complication.

A re-appraisal of the tri-axial chart for monitoring arterial acid-base values.

OBJECTIVE: To demonstrate the practicability of a tri-axial chart for the graphical and quantitative monitoring of arterial pH, arterial carbon dioxide partial pressure (PaCO2) and actual arterial bicarbonate-ion concentration (a[HCO3-]) in intensive care patients. DESIGN: Case report. SETTING: A general intensive care unit (ICU). METHODS: Using a standard mathematical transformation, a data set of pH, log PaCO2 and log a[HCO3-] values can be transformed in such a way that a graphical display of all three variables is possible while being faithful to their linear relationship. Remarkably, the graphical display closely resembles the tri-axial chart that Hastings and Steinhaus described in 1931 for studying displacements of the acid-base balance. Two new monitoring parameters based on the chart and the transformation are described. One monitors the abnormality of the acid-base status while the other monitors the rate of acid-base changes. CONCLUSIONS: With the tri-axial acid-base chart, the complete acid-base status can be faithfully monitored. Moreover, the proposed monitoring parameters provide extra information about the arterial acid-base status that, otherwise, would remain hidden.

[Continuous pressure is preferred to flow triggering of respiration in the apnea test following the protocol for brain death determination]. / Liever druk-dan flowgestuurde beademing bij de apneutest volgens het hersendoodprotocol.

The apnea test is part of the brain death protocol of the National Health Council. If the patient is being given positive end-pressure respiration, he must not be uncoupled from the respirator. The apnea test should then be done by means of continuous positive airway pressure. Pressure triggering rather than the extremely sensitive flow triggering should then be chosen to trigger the respiration, since otherwise the patient may unjustifiably be declared 'not brain dead' as a result of slight aspecific movements (bumping against the bed, beating of the heart).

Meropenem versus cefuroxime plus gentamicin for treatment of serious infections in elderly patients.

In this multicenter study, the efficacy of and tolerability for meropenem were compared with those for the combination of cefuroxime-gentamicin (+/- metronidazole) for the treatment of serious bacterial infections in patients > or = 65 years of age. A total of 79 patients were randomized; thirty-nine received meropenem (1 g/8 h), and 40 received cefuroxime (1.5 g/8 h) plus gentamicin (4 mg/kg of body weight daily) for 5 to 10 days. Metronidazole (500 mg/6 h) could be added to the cefuroxime-gentamicin regimen for the treatment of intra-abdominal infections (n = 10). Seventy patients were evaluable for clinical efficacy; the primary diagnoses were as follows: pneumonia in 41 patients (20 treated with meropenem, 21 treated with cefuroxime-gentamicin), intra-abdominal infection in 10 patients (7 meropenem, 3 cefuroxime-gentamicin-metronidazole), urinary tract infection (UTI) in 11 patients (6 meropenem, 5 cefuroxime-gentamicin), sepsis syndrome in 7 patients (4 meropenem, 3 cefuroxime-gentamicin), and "other" in 1 patient (cefuroxime-gentamicin). The pathogens isolated from 18 patients with bacteremia were as follows: Staphylococcus spp. (n = 2), Streptococcus spp. (n = 2), members of the family Enterobacteriaceae (n = 11), and Bacteroides spp. (n = 3). A satisfactory clinical response at the end of therapy was achieved in 26 of 37 (70%) and 24 of 33 (73%) evaluable patients treated with meropenem and combination therapy, respectively. Clinical success was achieved in 23 of 31 (74%) and 21 of 28 (75%) evaluable patients with infections other than UTIs, respectively. A satisfactory microbiological response occurred in 15 of 22 (68%) patients in the meropenem group compared with 12 of 19 (63%) treated with combination therapy. Renal failure occurred during therapy in 2 of 39 (5%) meropenem recipients compared with 5 of 40 (13%) of those treated with combination therapy. The findings in this small study indicate that meropenem is as efficacious for and as well tolerated by elderly patients as the combination of cefuroxime-gentamicin (+/- metronidazole).

[Adequate preservation of organs in brain-dead patients with a view to transplantation]. / Adequate preservering van organen bij hersendode patiënten voor eventuele transplantatie.

There exists a shortage of donor organs. Inadequate medical treatment of brain-dead patients results in one-third of the available organs not being suitable for transplantation. Adequate preservation of organs in brain-dead patients increases the supply and quality of donor organs. This preservation comprises the following measures: management of hypotension with a view to adequate perfusion of the organs (administration of fluid, if necessary erythrocytes, and of sympathicomimetic agents); adjustment of artificial respiration to the reduced carbon dioxide production in the tissues (lowering the respiratory minute volume) and to desired oxygenation (positive end-expiratory pressure, increase of the proportion of oxygen in the inhaled air, lengthening of the inspiration time); preventing excessive cooling of the body of the brain-dead patient due to failure of the temperature regulation (heating blanket, heating mattress, warming infusion fluids and inhaled air); treatment of diabetes insipidus in hypophyseal insufficiency (intravenous desmopressin); prevention and treatment on infections (antibiotics, bronchial toilet, variation of position).

Metastatic staphylococcal lung abscess due to a cutaneous furuncle.

A seemingly trivial infection of the skin can lead to fulminant staphylococcal pneumonia and death. This case history describes the evolution of a fatal Staphylococcus aureus sepsis complicated by the development of multiple lung abscesses in a 17-year-old patient. A pre-existing cutaneous furuncle was the only identifiable cause. Early bacteraemic symptoms are described. Multiple cavitory lesions could be seen on a CAT-scan. The authors would like to stress the importance of early and adequate antibiotic treatment.

Pulmonary rehabilitation at moderate altitude: a 1-year follow-up.

BACKGROUND: In order to evaluate a pulmonary rehabilitation program (PRP) at moderate altitude (1560 m) 62 patients with obstructive lung disease were asked to participate; 37 patients completed a 1-year follow-up at sea level, and 25 patients dropped out. The exercise training program lasted for 10 weeks and consisted of a cycling and running program of 20 min daily, 5 days a week. METHODS: Incremental exercise testing, spirometry and histamine provocation tests were performed at sea level before the PRP, on admission to the Dutch Asthma Centre, Davos, after 5 weeks of exercise training, at discharge from the Centre and 6 and 12 months after discharge at sea level. RESULTS: The PRP led to an increase in exercise capacity of the 37 patients who also completed the follow-up as reflected by an increase in Wmax (from 104 +/- 44 watt on admission to 150 +/- 8 at discharge, p < 0.001). HRmax (145 +/- 19/min to 151 +/- 21, p < 0.001), Wmax/HR (0.71 +/- 0.26 watt/beat/min to 0.99 +/- 0.29, p < 0.001), VO2max (1.4 +/- 0.4 l/min to 1.9 +/- 0.6, p < 0.001) and VEmax (49 +/- 18 l/min to 78 +/- 24, p < 0.001) measured at discharge from the Dutch Asthma Centre after the PRP were significantly higher than before the PRP at incremental exercise testing. The group of 25 patients who dropped out showed corresponding improvements in these parameters after the PRP in Davos. The 37 patients who completed the follow-up showed at incremental exercise testing 1 year after the PRP that only two of these parameters were still significantly elevated: VO2max 1.8 +/- 0.6 (p < 0.001) and VEmax 61 +/- 21 (p < 0.001). One year after the PRP arterial PCO2 values at maximum exercise were significantly lower (5.2 +/- 0.8 kPa, p < 0.05) than the baseline values (5.5 +/- 0.9 kPa). CONCLUSIONS: PRP at moderate altitude results in an increase of exercise tolerance in patients with asthma or COPD, but significant long-term effects are few.

Severe bronchial asthma improved on bamifylline. Case report and review.

We describe a 25-year-old patient with severe bronchial asthma, which was difficult to treat with oral theophylline. Bamifylline, a xanthine derivative, clearly improved the clinical signs, symptoms and lung function. We critically review the literature on bamifylline.

[Favorable effects of a stay in the Dutch Asthma Center Davos on medical consumption and quality of life in COPD patients]. / Gunstige effecten van een verblijf in het Nederlands Astmacentrum Davos op medische consumptie en kwaliteit van leven bij CARA-patiënten.

The Dutch Asthma Centre Davos in Switzerland is a clinic where patients with chronic nonspecific lung disease (CNSLD) are given multidisciplinary treatment. In a prospective study in the clinic, data on quality of life (functional, psychological and social characteristics) and medical consumption (use of oral corticosteroids and use of health services) were collected in a group of 147 patients with CNSLD. 18 patients were lost due to non-medical reasons. Quality of life and the use of oral corticosteroids were registered on admission, at discharge and 4 weeks, 6 and 12 months after discharge. Data on use of health services were gathered over the period between one year before admission and one year after discharge from the asthma centre. The results of this study show a decrease in the use of oral corticosteroids, in the number of visits to the family physician and outpatient department and the number and duration of hospital admissions. Favourable changes occurred in psychological functioning, (including anxiety and depression) and positive changes were observed in the degree of limitation the patients experienced in their activities of daily living. No convincing changes were found in social functioning, including social support. It can be concluded, on the basis of these results, that a stay in the Dutch Asthma Centre Davos has favourable effects on medical consumption and on some aspects of quality of life.

Nedocromil sodium inhibits the early and late asthmatic response to exercise.

A double-blind, crossover study was carried out to investigate the effect of nedocromil sodium on the dual asthmatic response to exercise challenge. Nineteen patients with a late response to bicycle exercise were randomly treated on two study days with 4 mg nedocromil sodium or a matched placebo aerosol, 30 min before commencing exercise. Peak flow was measured before exercise, at intervals up to 60 min after exercise, then hourly for up to 13 h. In 12 of the 19 patients an early reaction to exercise occurred. In 8 of these 12 patients the early reaction could be inhibited by nedocromil sodium (p less than 0.01) although in half of these patients placebo was also shown to be protective. In the case of the late reaction after exercise challenge, 4-13 h after exercise challenge, nine patients were clearly protected by pretreatment with nedocromil sodium (p less than 0.01) when the fall in peak expiratory flow rate was related to the pre-exercise baseline, four patients showed an equal protective effect of placebo and nedocromil sodium, whilst the others were not protected. When the late asthmatic response (fall in peak expiratory flow rate) after exercise challenge was related to control diurnal peak flow values, the number of responses was reduced; the protective effect of nedocromil sodium remained.

[Lung function of adult patients with bronchial asthma or chronic obstructive lung disease prior to and following a 3-month-stay in the Dutch Asthma Center in Davos]. / Longfunctie van volwassen patiënten met asthma bronchiale of chronische obstructieve longaandoening, vóór en na een verblijf van 3 maanden in het Nederlands Astmacentrum Davos.

The effect of a multidisciplinary treatment for obstructive airway disease at high altitude has not been well established for adult patients. One hundred and fifty patients with obstructive airway disease were examined at admission and at discharge after a 3-month hospitalization period in an Alpine clinic. Body plethysmographic data were collected at admission and at discharge as was medication use. Patients were subdivided into three groups, one group (n = 34) with bronchial asthma, one group (n = 97) with moderately severe chronic obstructive pulmonary disease (COPD) and one group (n = 19) with severe COPD. The greatest improvement in lung function data occurred in the moderately severe COPD group (at discharge before salbutamol administration there was an increase in FEV1 of 6%, after salbutamol administration there was an increase in FEV1 of 7%). When we divided the patient groups into atopic and non-atopic, it appeared that the non-atopic moderately severe COPD group showed the greatest improvement in lung function variables. The histamine threshold (expressed in 10logPC20) improved only in the moderately severe COPD group. There was a reduction from mean 7.5 mg per day in oral corticosteroids use to mean 5.0 mg per day in the moderately severe COPD group. We conclude that after 3 months' multidisciplinary treatment in the Alpine climate there is an improvement in lung function and a reduction in medication use in patients with airflow limitation.

Late asthmatic responses after exercise challenge are reproducible.

In this study the reproducibility of a late asthmatic reaction (LAR) after exercise challenge (EC) has been documented. Eighty-three hospitalized patients with asthma were challenged with exercise. The patients were examined according to a standardized protocol that comprised 8 minutes of bicycling at 90% of predicted heart rate. An LAR after EC was considered to have occurred when there was a fall in peak expiratory flow rate greater than or equal to 20% on three or more time points on the exercise day compared to corresponding clock time on a control day. According to these criteria, 11 patients (13.3%) experienced an LAR. Those patients were rechallenged 21 to 150 days after the first EC, without changing the therapy regimen of the patients, to study its reproducibility. Eight patients (73%) demonstrated a reproducible LAR after EC based on the criteria for a positive LAR. Although the LAR after EC was reproducible, the time points at which the LAR took place after the second EC differed from LARs after the first EC. Our results indicate that the LAR after EC occurs in a considerable number of patients with bronchial asthma and is quite reproducible.

Real and pseudo late asthmatic reactions after submaximal exercise challenge in patients with bronchial asthma. A new definition for late asthmatic responses after exercise challenge.

The late asthmatic reaction after exercise challenge remains a controversial issue. In this study, 21 patients recorded peak expiratory flow rate (PEFR) on two control days without performing exercise. There was no difference between both control days when PEFR at 1 h was compared with baseline PEFR and when PEFR at 4 to 13 hours was compared with baseline PEFR. After analyzing variation coefficients of baseline PEFR on a control day and exercise day, PEFR was not allowed to differ more than 15.3 percent in the same patient when comparing exercise day and control day for the late fall in PEFR in the study. In 17 of 81 patients, a late asthmatic reaction after exercise challenge was present when PEFR fall was greater than or equal to 20 percent compared with baseline PEFR value. In eight of the 17 patients, a real late asthmatic reaction to exercise challenge was present with a PEFR fall greater than or equal to 20 percent on at least three successive time points and who had a PEFR fall greater than or equal to 20 percent compared with corresponding clocktime on a control day. The late asthmatic reaction to exercise challenge is characterized not as a nonspecific epiphenomenon, but as a fall in PEFR of greater than or equal to 20 percent compared with baseline PEFR value and with corresponding clocktime on a control day on at least three successive time points. Graphic illustration of airway responses following exercises may facilitate the detection of a late asthmatic response.

Immediate and late asthmatic responses induced by exercise in patients with reversible airflow limitation.

The existence and prevalence of late asthmatic responses to exercise in patients is uncertain. We investigated whether the late falls of peak expiratory flow rate (PEFR) after exercise challenge were still significant after comparison with the corresponding clocktime PEFR on a control day. We examined 86 patients with reversible airflow limitation, 79 with asthma and 7 with chronic obstructive pulmonary disease (COPD), all under regular treatment with bronchodilators and/or anti-inflammatory agents. Patients were randomized for a control day and an exercise day and PEFR was recorded hourly. On the exercise day, each patient underwent an 8 minute bicycle ride at 90% of predicted heart-rate. An early and a late asthmatic response to exercise were considered to occur when PEFR decreased by 10% or more on the exercise day compared to the corresponding clocktime PEFR on the control day. Thirty-three patients (38%) had a 10% or greater fall of PEFR at 4 to 13 hours after exercise when PEFR was compared with the corresponding clocktime on a control day. Seven (8%) had an isolated late asthmatic response, and 26 (30%) had a dual asthmatic response. We conclude that true late asthmatic responses develop after exercise in a significant number of patients with well controlled reversible airflow limitation.

Continuous intravenous therapy with theophylline in a patient with brittle bronchial asthma.

Ambulant continuous intravenous theophylline therapy was used in a patient with frequent and severe asthmatic attacks. The patient could not tolerate oral theophylline preparations. We demonstrated a reduction in complaints and prednisone therapy. Activities of daily life improved, as did theophylline levels, lung function and peak-flow.

Epitopes of apolipoprotein B-100 and B-48 in both liver and intestine. Expression and evidence for local synthesis in recessive abetalipoproteinemia.

The presence of apolipoprotein (apo) B in liver and intestine from a patient with abetalipoproteinemia was evaluated by immunohistochemistry with a polyclonal and six monoclonal antibodies to different apo B-48 and B-100 epitopes. In normal liver, apo B was present inside and outside hepatocytes. The patients liver exhibited staining in the cytoplasm with the polyclonal and three monoclonal antibodies. By immunoelectron-microscopy, apo B was found to be present in the smooth endoplasmatic reticulum and the Golgi complex. Normal intestinal epithelium was labeled with polyclonal and all monoclonal antibodies, including those specific for apo B-100. The patients epithelium stained with polyclonal and six monoclonals, and apo B was present in the Golgi complex. Thus, normal intestinal mucosa expressed apo B-48 and B-100 epitopes, which indicates apo B-100 synthesis in the gut. The synthesis of the apo B molecule in the patient seems to be retained in both liver and gut, which suggests a posttranslational defect.