Neuromechanical properties in obese patients during carbon dioxide rebreathing.

During hypercapnia-induced hyperventilation, obese patients with a prior history of alveolar hypoventilation appear to have significantly more blunted ventilatory response than simply obese patients who never retained carbon dioxide. In addition, these patients with former obesity-hypoventilation syndrome have decreased neuromuscular responses as measured by way of the mouth occlusion technique when compared with either the patients with simple obesity or normal subjects. The patients with simple obesity appear to have augmented responses in comparison with normal subjects. Simple mechanical considerations and baseline breathing variables failed to distinguish the simple obesity group from the group with former obesity-hypoventilation syndrome. Thus, the decreased neuromuscular responsiveness to carbon dioxide (mouth-occlusion pressure/end-tidal carbon dioxide pressure) among the group with former obesity-hypoventilation syndrome when compared with that in the group with simple obesity is a consequence of a blunted neural (central) drive, and not due to any apparent worse mechanical limitations. The augmented mouth-occlusion pressure/end-tidal carbon dioxide pressure and increased integrated, rectified electromyographic signal of the diaphragm found in the group with simple obesity presumably reflect their attempt to maintain ventilatory homeostasis in the presence of severe respiratory loads. Neuromechanical coupling values, as reflected in the integrated electromyographic signal of the diaphragm versus transdiaphragmatic pressure and mouth-occlusion pressure versus mean inspiratory flow, are identical in the two groups. On the basis of these studies, it would appear that although mechanical loads put all obese patients at a disadvantage, the addition of an acute extra load on the respiratory system produces the obesity-hypoventilation syndrome in those obese persons who have truly blunted central hypercapnic responses.

REM sleep episodes during the maintenance of wakefulness test in patients with sleep apnea syndrome and patients with narcolepsy.

Twelve patients with sleep apnea, 12 narcoleptic patients, and 10 controls were given 20-min opportunities to remain awake while sitting comfortably. Test sessions were administered at 10:00, 12:00, 14:00, 16:00, and 18:00. Apneic and narcoleptic subjects were less capable of maintaining wakefulness than controls. Patients with sleep apnea had an average of 1.4 daytime rapid eye movement (REM) episodes with the peak incidence at 14:00. Narcoleptics also had sleep onset REM periods (mean of 2.7), whereas none of the controls had REM episodes during the daytime testing. Narcoleptic and control groups differed in the probability of REM occurring at each session. There were time-of-day differences in the probability of REM occurring between patient groups. The amount of stage REM the night preceding testing was unrelated to the occurrence of REM episodes during the day in either patient group. In addition, there were notable differences in the frequency of sleep onset REM periods when patients were sitting as opposed to being supine during nap studies. Sleep latency and frequency of REM episodes on the maintenance of wakefulness test were independent of the subject's age. The maintenance of wakefulness test proved unsatisfactory as a diagnostic procedure, but appeared useful as an adjunct procedure in the evaluation of treatment efficacy of hypersomnia.

Obstructive sleep apnea and body weight.

A patient with obstructive sleep apnea was monitored five times during three years while his weight fluctuated within a range of 26 kg. The number of apneas per hour of sleep varied from 59.6 at 111 kg of weight to 3.1 at 85 kg. The relation between apneas per hour of sleep and body weight was a logarithmic function. A modest decrease in weight was thus associated with a disproportionally larger decrease in the rate of apneas. Typical SaO2 levels during the apneic episodes also had a logarithmic relation with body weight. Apnea-related sinus bradycardia and sinus tachycardia were only present at the highest weight. The results suggested that dieting and weight loss lead to an improvement in sleep apnea and related sequelae.

Superficial thrombophlebitis diagnosed by duplex scanning.

Since July 1982, this noninvasive vascular laboratory has performed 12,856 lower extermity venous duplex examinations. All cases of acute venous thrombosis have been categorized and entered into a computer data base. One thousand four hundred twelve examinations were positive for acute venous thrombosis. This report analyzes the laboratory's entire experience with superficial thrombophlebitis (SVT). One hundred eighty-six patients were diagnosed by duplex scanning to have SVT. Women outnumbered men 99 to 87. They were slightly older (average age 58.4 +/- 16.2 years) compared with the men (53.8 +/- 14.2 years). Men were more likely to have a complicated course of SVT (40% vs 22%; p less than 0.01). Complications included either radiographically documented pulmonary embolism or deep venous involvement. Fifty-seven (31%) patients had at least one complication of SVT. A series of predisposing factors was analyzed and six factors were associated with an increased risk of complications. They are bilateral SVT (p less than 0.01), age greater than 60 years (p less than 0.01), male sex (p less than 0.01), history of deep venous thrombosis (p less than 0.01), bed rest (p less than 0.02), and presence of infection (p less than 0.02). Location of thrombus within the greater saphenous vein (35%) was most likely to be associated with complications. Isolated varicosities (8%) were least likely to be associated with complications. Duplex scanning identifies a significant number of complications of patients with SVT and should be obtained in cases of saphenous vein involvement or in the presence of associated risk factors.

Voluntary breath holding in the obese.

Alveolar gas tensions and arterial O2 saturation (Sao2) during a voluntary breath hold at functional residual capacity (FRC) were examined in 13 healthy seated subjects. An excellent correlation (r = 0.80) was found between the fall of alveolar O2 tensions (delta PETo2) and body weight, expressed as the ratio of weight to height (wt/ht, kg/cm). An even greater correlation (r = 0.89) was found between delta PETo2 and the ratio of breath-hold time X O2 consumption/FRC. Alveolar Po2 decreased to 70 mmHg in the obese group after just 15 s of apnea, whereas this degree of hypoxia did not occur in the nonobese until the breath hold was sustained for 30 s. This variable rate of fall of alveolar Po2 during a breath hold can be ascribed to the changes of O2 consumption (Vo2) and FRC associated with changing body weight. In the obese, Vo2/FRC was twice as large as in the nonobese, thus accounting for the differences of breath-hold time needed to obtain the same alveolar Po2. Sao2 measured at the end of the breath hold was the same as that value predicted from the reduction of PETo2. This suggests that the fall of alveolar Po2 can entirely account for the observed fall of O2 saturation and that venous admixture had not increased during the 15-s apnea. In patients with sleep apnea, the ratio of Vo2/(initial lung volume) may also be an important determinant of the severity of hypoxemia observed.

Operative management of greater saphenous thrombophlebitis involving the saphenofemoral junction.

Forty-three consecutive patients with greater saphenous vein (GSV) thrombosis extending to the saphenofemoral junction (SFJ) were treated. Twenty-three patients had extension of thrombus into the common femoral vein (CFV). Twenty patients had thrombus extending to but not within the CFV. Symptoms, risk factors, and physical examination were not predictive of CFV thrombus extension. When compared with the operative record, duplex scans accurately located the extent of the thrombosis 100% of the time. Forty-one surgical procedures were performed. No patients had pulmonary emboli during the procedures. Thirty-seven patients were treated as outpatients or were discharged within 3 days of their surgical procedures. The two patients who did not undergo operative procedures in this series had complete occlusion of the CFV with extension into the external iliac vein. Thrombus within 3 cm of the SFJ is an indication for surgical intervention. Disconnection of the GSV from the CFV prevents extension of the thrombus, and a limited CFV thrombectomy can be performed when necessary. This is considerably more cost-effective than treatment with anticoagulation.

Upper extremity venous thrombosis diagnosed by duplex scanning.

The incidence of axillary-subclavian venous thrombosis continues to rise, while reports of noninvasive methods to diagnose this condition have been sparse. A review of the records of 693 consecutive upper extremity duplex scans was performed, and a diagnosis of acute venous thrombosis was made in 123 of these patients. Of these, 85 involved the axillary or subclavian vein. Use of a central venous catheter was the most common risk factor for axillary-subclavian venous thrombosis. Within this group, 8% had a pulmonary embolism, of which 25% were fatal. Follow-up of patients with axillary-subclavian venous thrombosis at a mean of 2 years revealed that 49% of these patients had died. Of the remaining patients, more than one third had evidence of the post-thrombotic syndrome. Duplex scanning of the venous system provides a safe, reliable, and repeatable method of evaluating and following patients with suspected venous thrombosis of the upper extremity.

Upper extremity venous duplex imaging.

Over 500 upper extremities have been imaged with the Duplex Scanner at the John J. Cranley Vascular laboratory. Venous anatomy and imaging techniques are presented. Reference points and zones for localizing abnormal findings are demonstrated. Abnormal venous pathology including case presentations of acute radial, basilic, cephalic, and axillary vein thrombosis are presented. Complications of subclavian and internal jugular vein catheterization are demonstrated. Soft tissue pathology including edema, lymphadenopathy, hematomas, cysts, and abscesses are visualized and differentiated. Duplex use for evaluation of aneurysm, pseudo aneurysm and graft surveillance has been increasing in frequency. Examples are demonstrated.

Load compensation in obese patients during quiet tidal breathing.

Seventeen eucapnic massively obese patients and eight normal subjects had their respiratory cycle parameters studied while breathing room air at rest. Despite large variations in the degree of obesity, our patients demonstrated normal mean inspiratory and expiratory flow rates, duty cycles, and minute ventilation. The maintenance of normal mean inspiratory flow rates was found to be dependent on an augmentation of neuromuscular drive (P0.1); furthermore, a strong positive correlation between percentage ideal body weight (i.e., the degree of obesity) and P0.1 was present. The obese were found to partition their tidal volume preferentially to their rib cage compartment, choosing to leave the abdominal compartment relatively immobile. Analysis of the diaphragmatic electromyogram revealed a persistence of activity into early expiration, the length of which also depended on the degree of obesity. These findings suggest that the diaphragm's volume-generating function in the obese is reduced, and furthermore the persistence of its activity in expiration serves to attenuate the rate of expiratory flow. No significant difference in any respiratory cycle parameter was found between simple obesity patients and formerly hypercapnic obese patients.

Voluntary induced alterations in regional ventilation in normal humans.

We tested the hypothesis that voluntary changes of thoraco-abdominal shape can influence regional ventilation via altering regional pleural pressure swings (Ppl). Regional ventilation was measured simultaneously with regional Ppl during tidal volume breathing maneuvers in five normal subjects while they were performing one of three thoracoabdominal patterns of breathing: normal, preferential intercostal (IC), or preferential diaphragmatic (DIA). In every subject, the lower lung region's 133Xe washout rate was faster than the upper region's, regardless of the pattern of thoracoabdominal breathing adopted. Although IC breathing tended to make regional ventilation more homogeneous, DIA breathing tended to augment regional ventilation inhomogenities. On the average, the Ppl values were greatest in the lower lung region, regardless of the thoracoabdominal pattern adopted; however, IC breathing reduced and DIA breathing increased regional Ppl inhomogenities. When the ratios of the Ppl (lower/upper) were plotted vs. the ratios of the regional 133Xe washout decay constants (lower/upper), a significant positive correlation was found. These data suggest that a causal relation between regional tidal Ppl and regional ventilation exist, thus supporting the concept that thoracoabdominal shape changes can influence regional ventilation.

Activation of the parasternal intercostals during breathing efforts in human subjects.

We have tested the possibility that the electromyographic (EMG) activity present in the parasternal intercostal muscles during quiet inspiration was reflexive, rather than agonistic, in nature. Using concentric needle electrodes we measured parasternal EMG activity in four normal subjects during various inspiratory maneuvers. We found that 1) phasic inspiratory activity was invariably present in the parasternal intercostals during quiet breathing, 2) the parasternal EMG activity was generally increased during attempts to perform the tidal breathing maneuver with the diaphragm alone, 3) parasternal EMG activity was markedly decreased or suppressed in the presence of rib cage distortion during diaphragmatic isovolume maneuvers, and 4) that EMG activity could not be voluntarily suppressed during breathing unless the inspired volume was trivial. We conclude that the parasternal EMG activity detected during quiet inspiration in the normal subjects depends on a central involuntary mechanism and is not related to activation of intercostal mechanoreceptors.

Role of intercostal muscles in the rib cage distortions produced by inspiratory loads.

We studied the patterns of rib cage (RC) deformation in six normal subjects breathing against different resistive and elastic inspiratory loads, and we examined, with concentric needle electrodes, the role played by the inspiratory intercostal muscles in the development of these patterns. Four of the subjects deformed their RC to a more elliptical shape during loaded inspirations; RC anteroposterior diameter became smaller and RC lateral diameter became larger. The RC deformation increased as the load increased, but it appeared to be independent of the nature of the load. Moreover these deformations were associated with a marked increase in the inspiratory activity of the intercostals situated in the lateral parts of the RC and a striking diminution of the activity in the parasternal area. On the other hand, two subjects invariably breathed along their RC relaxation characteristic, and they showed an increased inspiratory activity in all regions of the intercostal musculature. These findings indicate that 1) the pattern of RC deformation during loaded inspirations is closely related to the activity and coordination of the various inspiratory intercostal muscles, and 2) the parasternal intercostals are not necessarily representative of all the inspiratory intercostals. They are also strong evidence against the concept that the parasternal intercostal electrical activity normally recorded during quiet breathing is an excitatory reflex activity.

The tadpole-shaped structures in human non-necrotizing granulomas.

We scrutinized the secondary lysosomal vesicle of the epitheloid cell from 9 patients whose biopsy specimens show multiple non-necrotizing granulomas by light microscopy (LM). In 4 of the 9 patients, we found tadpole-shaped structures (TSS) approximately tenfold larger than the size of the mycobacteriophage by transmission electron microscopy (TEM). In addition, we used a plasma etching method on epon-embedded tissue and successfully demonstrated the stereoscopic appearance of the TSS by scanning electron microscopy (SEM). The identified TSS were further analyzed with an X-ray energy dispersive spectrometer for their microchemistry. The TSS appeared to be integral structures by TEM and SEM and did not contain any nonbiologic elements when analyzed with the X-ray energy dispersive spectrometer. Their location as well as their morphologic features and microchemistry suggested that the TSS are a microorganism and related to the formation of the granulomas in our 4 patients.

Carney's triad: role of transthoracic needle biopsy.

A triad of gastric epithelioid leiomyosarcoma, functioning extra-adrenal paraganglioma, and pulmonary chondroma, has been described in 7 patients, and a partial expression of this tumor complex consisting of 2 of the 3 tumors in at least 11 others. Sixteen of these 18 patients were female. The variable presentation and course of these patients warrants special attention. We present the nineteenth reported case: a 26-yr-old woman with a pulmonary chondroma and a gastric epithelioid leiomyosarcoma. It is suggested that in cases of this type thoracotomy may not be necessary for the diagnosis of the pulmonary chondroma, and extensive gastric resection of the leiomyosarcoma may be lifesaving.

Measurement of blood flow rates in the lower extremities with use of a nuclear magnetic resonance based instrument.

Direct, noninvasive measurement of pulsatile blood flow to the human extremity is now possible by means of a flow measurement instrument that is based on the principles of nuclear magnetic resonance. The instrument uses a physically independent calibration module as a primary calibration standard. Volumetric calibration of this module indicates that it is precise and accurate over the range of 0 to 100 ml/min. The calibration module is used, in turn, to calibrate an electromagnetic flow sensor that is incorporated into the instrumentation. The calibration module and the electromagnetic sensor were found to be linearly related over the range of 5 to 100 ml/min, with a regression correlation coefficient of 0.996. The calibrated electromagnetic flow sensor is used as a secondary standard for calibration of the nuclear magnetic resonance sensor. Blood flow measurements, obtained by use of this method, agree closely with those obtained by plethysmographic methods. They differ from the plethysmographic results in that magnetic resonance flows will distinguish between the at-rest blood flow in the normal extremity and the flows seen in the extremity (also at rest) with claudication. Based on the results obtained from studying a limited number of limbs with a high degree of ischemia, the method will not distinguish the limb with ischemia from the limb with claudication. Limitations of the method and refinements required to make the method clinically useful are discussed.

Bilateral popliteal vein aneurysms.

An 82-year-old man was admitted with a left hip fracture sustained in a fall. The fracture was surgically repaired. Ipsilateral leg swelling developed over the following 2 weeks. A lower extremity venous duplex scan demonstrated isolated dilatation of the popliteal veins in both lower extremities. Chronic thrombosis was noted in both popliteal veins at the level of this dilatation. Initial duplex scanning also revealed acute thrombus in the left popliteal, posterior tibial, and peroneal veins. A repeat scan 1 week later identified propagation of thrombus into the superficial femoral vein. Popliteal vein aneurysms, although rare, can cause significant morbidity and mortality. The literature is also reviewed.

Venous and arterial anomalies of the lower extremities diagnosed by duplex scanning.

The complex embryologic development of the vascular system often results in a myriad of clinically relevant anomalies. It has been stated that the classic anatomic venous pattern in the lower extremity is found in only 16 percent of patients. Previous studies on this topic are limited to isolated venous dissections or phlebography that lack complete anatomic detail. The recent introduction of high resolution duplex scanners for the assessment of veins of the lower extremity provides a unique opportunity to determine the incidence of anatomic variation. The current prospective study was done to identify venous or arterial anomalies apparent during routine duplex scanning of the lower extremity performed to rule out deep venous thrombosis (DVT). Limbs that had evidence of acute or chronic extensive DVT were excluded. Of 1,600 consecutive extremity scans, 946 extremities (59 percent) had no evidence of DVT. Of these, there were 43 patients with 64 anomalies in 57 extremities. The mean age of the group was 53.4 years. There were 24 women (55.8 percent) and 19 men (44.2 percent). There were 59 (92.2 percent) venous and five (7.8 percent) arterial anomalies. Duplication of the superficial femoral vein was the most common anomaly noted. Duplication of the deep femoral and popliteal vein was also noted. Unilateral anomalies were more common than bilateral anomalies, namely 67.4 versus 32.6 percent, respectively. Pain and swelling, common complaints in the patients with an anomaly, were noted in 71.4 and 45.7 percent, respectively. The frequency of deep venous anomalies of the lower extremities may be less than previously reported. Knowledge concerning the incidence and distribution of venous anomalies may lead to improved assessment and treatment of venous disease.