Injection sclerotherapy for the treatment of haemorrhoids in anticoagulated patients.

BACKGROUND: Symptomatic haemorrhoids (SH) are a common condition; however, conventional outpatient treatment, including rubber band ligation, is contraindicated in patients receiving concurrent anticoagulation. Injection sclerotherapy (IST) has been proposed as a treatment option for these patients. METHODS: A retrospective review of case notes was performed in a colorectal surgery department that sits alongside a tertiary cardiothoracic surgical unit. Patients treated with an IST for SH between 1 April 2014 and 30 November 2021 were identified. Anticoagulation was not stopped in these patients as they were at high risk of developing thromboembolism, except in two patients who required alternative procedures. The primary outcome was symptom resolution, defined as no patient reporting bleeding for at least six months. The secondary outcomes were patient-reported complications, number of IST procedures and number of other procedures performed to achieve symptom resolution. RESULTS: A total of 20 patients with a median age of 64 years (range 35-86, 14 male) who underwent 32 IST treatments were identified. Symptom resolution was achieved in 18 (90%) patients using IST while continuing anticoagulation treatment, with two (10%) patients requiring alternative interventions. Ten patients (50%) required only one IST procedure, and three patients (15%) required two procedures. The remaining five (25%) patients required three or four interventions. The median time between IST treatments was 32 weeks (range 8-133). No complications were reported. CONCLUSION: Our study demonstrates that IST can be considered as a potential treatment option for patients with SH who are at a high risk of thromboembolic disease requiring anticoagulation.

Comparative evaluation of cranberry extract and sodium fluoride as mouth rinses on S. mutans counts in children: a double-blind randomized controlled trial.

BACKGROUND: Recently, research in the field of caries prevention is emphasizing upon identification of edible non-toxic compounds that can interfere with the formation of cariogenic biofilm. AIM: This trial aimed to assess the effectiveness of non-dialyzable material (NDM) containing cranberry mouth rinse (C-MR) on the Streptococcus mutans (S. mutans) counts and compare with that of a sodium fluoride (F-MR) mouth rinse. METHODS: 280 children (8-12 years old) were enrolled in this double-blind single center, parallel, one-month, IRB/IEC approved non-inferiority trial. The participants fulfilling the inclusion criteria were randomly allocated into one of the two groups: C-MR and F-MR. All participants were given verbal and written instructions about at-home mouth-rinsing regimen under parental supervision for a month. Dental plaque samples were collected before and after a month of mouth-rinsing and subjected to culture techniques. S. mutans counts were assessed and compared in both groups. Primary outcome was the difference in the S. mutans counts between two interventions. Both intention-to-treat (ITT) and per-protocol analysis were carried out using two-sample t test with equal variance. RESULTS: The mean S. mutans counts (after log transformation) in C-MR group were: 14.66 (90% CI 14.4,14.9) at baseline and 12.85 (90% CI 12.5, 13.2) colony-forming units/ml (CFU/ml) at one-month post intervention (p = 0.001); while these counts were 14.69 (90% CI 14.5, 14.9) at baseline and 12.71 (90% CI 12.3, 13.1) at one-month intervention in F-MR groups (p = 0.001). ITT analysis showed an inter- group difference of 0.14 CFU/ml (90% CI - 0.32,0.59) in post-SM counts between groups (p = 0.629). CONCLUSION: The study demonstrated that the cranberry mouth rinse was non-inferior to the fluoride mouth rinse in terms of S. mutans levels change. Cranberry-based mouth rinse can be used effectively to reduce the S. mutans counts in children. TRIAL REGISTRATION: Registration number in case of Clinical Trials-CTRI/2019/05/019395.

Serum Vitamin D status in full term neonates with severe perinatal depression.

BACKGROUND: Severe perinatal depression is a significant cause of mortality and morbidity in neonates. Vitamin D levels were observed to be low in mothers and their neonates with hypoxic ischemic encephalopathy in some studies, owing to its neuroprotective properties. OBJECTIVE: Primary objective was to compare vitamin D deficiency state in full term neonates with severe perinatal depression and healthy term controls. Secondary objectives were to determine sensitivity and specificity of serum 25(OH)D<12 ng/mL in predicting mortality, development of hypoxic ischemic encephalopathy, abnormal neurological examination at discharge, and developmental outcome at 12 weeks of age. MATERIAL AND METHODS: Serum 25(OH)D levels in full term neonates with severe perinatal depression and healthy controls were compared. RESULTS: Serum 25(OH)D levels in severe perinatal depression and controls (n = 55 each group) were significantly different (7.50 ± 3.53 ng/mL vs 20.23 ± 12.70 ng/mL). At cut-off of < 12 ng/mL, serum 25(OH)D could predict mortality with 100% sensitivity and 17% specificity and poor developmental outcomes with sensitivity of 100% and specificity of 50%. CONCLUSION: Vitamin D deficiency status at birth can serve as an effective screening tool and poor prognostic markers in term neonates with severe perinatal depression.

Prevalence and predictors of adverse outcomes in neonatal seizures.

OBJECTIVES: Neonatal seizures are significant cause of neonatal mortality and morbidity. Current study was planned to study prevalence of adverse outcomes in neonatal seizures and identify its predictors. METHODS: This observational descriptive study was carried out on 220 neonates with seizures. Neonates who succumbed to illness/ death before investigations, or whose maternal records were incomplete were excluded. Blood sugar, serum calcium, serum electrolytes, and USG skull were done in all patients. CT scan, MRI and inborn errors of metabolism profile were done as and when indicated. Adverse outcomes were defined as death, phenobarbitone non responders, or abnormal examination at discharge. Antenatal, perinatal and neonatal predictors of adverse outcomes in neonatal seizures were evaluated. RESULTS: Out of 220 neonates with seizures 76(34.5%) had adverse outcomes. Very low birth weight babies (≤1500 gm) [OR 1.27(CI 0.57-2.84)], microcephaly [OR 5.93 (CI 0.55-64.41)], Apgar score≤3 at 5 minutes [OR 11.28(CI 14.18-30.45)], seizure onset within 24 hours [OR 5.99(CI 12.43-14.78)], meningitis [OR 2.63(CI 0.08-6.39)], septicemia [OR1.22(CI 0.45-3.31)] and abnormal cranial USG [OR 7.95(CI 12.61-24.22)] were significant predictors of adverse outcomes in neonates with seizures. CONCLUSION: Prematurity, very low birth weight, birth asphyxia, meningitis, septicemia and abnormal USG could predict adverse outcomes in neonatal seizures. Improved antenatal and neonatal clinical practices may help reduce adverse outcomes in these patients.

Neonatal outcomes following phenylephrine or norepinephrine for treatment of spinal anaesthesia-induced hypotension at emergency caesarean section in women with fetal compromise: a randomised controlled study.

BACKGROUND: Norepinephrine is as effective as phenylephrine for management of spinal anaesthesia-induced hypotension. Most of the studies comparing these vasopressors have been conducted in healthy pregnant women undergoing elective caesarean section. In the current study, we tested the null hypothesis that there is no difference in neonatal outcome when phenylephrine or norepinephrine is used to treat spinal anaesthesia-induced hypotension in women undergoing emergency caesarean section for fetal compromise. METHODS: Patients undergoing caesarean section for fetal compromise who developed spinal anaesthesia-induced hypotension were randomised to receive phenylephrine 100 µg or norepinephrine 8 µg for treatment of each hypotensive episode, defined as systolic blood pressure <100 mmHg. Umbilical cord arterial and venous blood samples were obtained for blood gas analysis. The primary outcome measure was umbilical artery pH. RESULTS: One hundred patients (50 in each group) were studied. There was no significant difference in umbilical artery pH between the two groups (mean difference 0.001; 95% CI -0.032 to 0.034). The number of hypotensive episodes, vasopressor boluses required, the incidence of bradycardia, heart rate and blood pressure trends following vasopressor administration, and the incidence of nausea/vomiting were not significantly different between groups. CONCLUSION: Phenylephrine 100 µg and norepinephrine 8 µg were not significantly different in terms of neonatal outcome when administered as intravenous boluses for treatment of spinal anaesthesia-induced hypotension in parturients undergoing emergency caesarean sections for fetal compromise.

Biomarkers as point of care tests (POCT) in neonatal sepsis: A state of science review.

Lack of a standard definition of neonatal sepsis and a swift diagnostic method has proven detrimental in the management of this serious condition. Biomarkers have emerged as a beacon that might help us detect neonatal sepsis more effectively. The use of point-of-care biomarkers can aid in early diagnosis and timely initiation of treatment. Procalcitonin, presepsin, interleukin-6, highly specific C-reactive protein, and neutrophil gelatinase-associated lipocalin have been proven to aid in early diagnosis and timely initiation of treatment, thereby reducing sepsis-induced morbidity and mortality. These biomarkers have been found to be useful in reducing the duration of hospital stay and monitoring the response to therapy. When used in combination with each other, or with clinical scores, they have been proven to be advantageous over the gold standard by eliminating the waiting time for blood culture results. The use of biomarkers as a point of care investigation holds a future over the traditional method. We present a state of science review of literature summarizing the current status of these biomarkers in neonatal sepsis.

Impact of COVID-19 Pandemic on Ambulatory and Operating Room Rhinology Practice in the US.

INTRODUCTION: The pandemic caused by the novel coronavirus virus has altered all facets of clinical practice in the United States. The goal of this study is to better understand the impact of COVID-19 on rhinologic ambulatory and operative practice. METHODS: A 27-item survey to assess these objectives was created and approved by the Division of Rhinology faculty at Rush University Medical Center in April 2020. The survey was then distributed to rhinologists in a web based format via www.surveymonkey.com from April 10 through April 23, 2020. RESULTS: A total of 277 U.S based rhinologists responded to the survey (23.04%). The most common practice types were single specialty private (44.9%) and academic (24.6%). 90.2% practice in a state under a shelter in place order. Comparing pre-COVID baseline to during-COVID, there was statistically significant reduction in the number of patients of seen daily in clinic (p < 0.001). The number of nasal endoscopies in the office and surgical procedures fell dramatically. Overall, 5 respondent rhinologists have been infected with COVID-19 and 27 have been furloughed. CONCLUSION: COVID-19 has drastically affected rhinologic practice. There is a dramatic reduction of in person care in the office setting and surgical management of sinonasal and skull base disease. Enhanced PPE is being used in only half of potentially aerosolizing procedures which represents an area of further education. Novel approaches such as use of virtual encounters and point of care testing should be considered as options to facilitate care.

Hyperpigmentation as a cutaneous manifestation of fungal sepsis in neonates: Case series report.

With improved and prolonged survival of very and extremely low birth weight infants, invasive fungal infection has emerged as an important concern in the neonatal intensive care units. Candidiasis is the third leading cause of late onset sepsis in these neonates and is associated with 20-30% mortality. Extreme prematurity, central venous catheters, prolonged antibiotic exposure, parenteral nutrition are important risk factors. Various forms of cutaneous manifestations of candidiasis have been described ranging from local diaper dermatitis and oral thrush to widespread erosive and ulcerative lesions with extensive crusting in invasive fungal dermatitis. We report a series of four cases with cutaneous hyperpigmentation as manifestation of systemic candidiasis.

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus seroprevalence in critically ill emergency department patients at a Trauma Care Centre, India.

INTRODUCTION: Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the most common occupationally acquired infections amongst the healthcare workers (HCWs) with critically ill patients attending the emergency department being the most common source of occupationally acquired infections. Therefore, the present study was conducted at a 165 bedded level-1 trauma centre of India to ascertain the seroprevalence rate of HIV, HBV and HCV; and thus the risk associated with the occupational exposure in a busy emergency setting of the developing world. METHODOLOGY: A retrospective, 7 years study (2007-2013) was carried out at the JPNA Trauma Centre of the 2,500 bedded All India Institute of Medical Sciences, New Delhi. Records of all patients whose serum samples were sent to the laboratory for viral markers testing were obtained and those falling in the red area were included. RESULTS: A total of 11,630 patients were received in the red area; and samples from 7,650 patients were sent for testing. Seropositivity of HIV, HBV and HCV in these samples was 0.28%, 3.4% and 0.9% respectively. The number of samples received was lesser than the total number of patients received in the red area. CONCLUSION: Adopting Standard Precautions (SP) can be used as an easy method to decrease the risk of occupationally acquired infections.

A kinetic study of the photochemical inactivation of adenylate kinases of Mycobacterium marinum and bovine heart mitochondria.

Using incident light energy of about 76 mW.cm-2 in a dye-sensitized photooxidation reaction, we have investigated the possible involvement of one or both of the histidine residues in the catalytic activity of adenylate kinase (ATP:AMP phosphotransferase) of Mycobacterium marinum. We have done this by investigating the kinetics of photochemical inactivation of the enzyme. At pH 7.4, the kinetics of photoinactivation are biphasic with two different pseudo-first-order rate constants. Adenosine 5'-pentaphospho 5'-adenosine (Ap5A), ATP and, to some extent, AMP, all gave protection to the enzyme from inactivation. Amino-acid analysis of the photoinactivated enzyme indicated the loss of the two histidine residues. This, and the fact that photoinactivation occurred faster at alkaline compared to acidic pH, indicated the involvement of the histidine residues in the catalytic activity. A mathematical model is developed which assumes that both histidine residues are required for maximal catalytic activity: one is located peripherally, is exposed, and therefore is readily photooxidized (pseudo-first-order rate constant, k1 = 1.3.10(-2)s-1), while the other is located at the active site, involved in substrate-binding and is shielded (pseudo-first-order rate constant, k2 = 2.9.10(-4)s-1). However, this shielded histidine could be exposed and made more accessible to photooxidation either by raising the pH above 10, or alternatively, by the addition of 8 M acetamide (or 6 M guanidine). Under these conditions, which apparently cause unfolding of the protein molecule, the kinetics of photoinactivation change from biphasic to monophasic, suggesting that both histidine residues are equally exposed and are photooxidized at the same rate. Unlike the enzyme from M. marinum, adenylate kinase from bovine heart mitochondria shows monophasic kinetics of photoinactivation at pH 7.4, suggesting that only one of the six histidine residues is essential for catalytic activity, or if more than one, then they all must be equally exposed. Further, ATP, AMP or Ap5A did not provide protection against photoinactivation, suggesting that the histidine residue(s) involved in the catalytic activity must remain exposed after the substrates bind at the active site of the mitochondrial enzyme.

Helix stability in succinylated and acetylated ovalbumins: effect of high pH, urea and guanidine hydrochloride.

Previous studies (Batra, P.P., Roebuck, M.A. and Uetrecht, D. (1990) J. Protein Chem. 9, 37-44) showed that succinylation or acetylation of 75% of the lysine residues has little effect on the secondary structure of ovalbumin. The acylation of the remaining 25% lysine residues, which apparently are partially buried, results in a substantial loss of the helical structure. These conformational changes may be due not only to electrostatic repulsions introduced by succinylation or acetylation of the positively charged epsilon-amino groups but also to steric hindrance, since an increase in the ionic strength failed to reverse the loss of the helical structure. An increase in pH to 12.2 results in a complete helix-to-coil transition in the maximally succinylated ovalbumin (but not in the partially succinylated or in any of the acetylated ovalbumins including the maximally acetylated derivative), perhaps because it is most expanded and its molecular interior most accessible to solvent as succinylation replaces +1 charge of epsilon-amino group with a -1 charge so that a net of -2 charge per succinyl group is placed on the protein molecule. This helix-to-coil transition in the maximally succinylated ovalbumin induced by high pH is fully reversed by increasing the ionic strength, indicating that only electrostatic effects are responsible for this disruption. Studies have also shown that although there is no loss of the helical structure until after the 75% surface lysine residues have been acylated, the helical structure does become progressively destabilized with increasing degree of modification, a conclusion drawn from urea unfolding curves. This destabilization of the helical structure is due primarily to electrostatic effects, as an increase in the ionic strength led to an increase in the urea transition mid-point. Unlike urea, the guanidine hydrochloride unfolding curves indicate that the transition mid-point for the native protein, as well as for the maximally succinylated and acetylated derivatives, is about the same, perhaps because the denaturant itself acts as an electrolyte.

Purification and characterization of ATP:AMP phosphotransferase from Mycobacterium marinum.

ATP:AMP phosphotransferase (EC 2.7.4.3) (adenylate kinase) has been purified 1746-fold from Mycobacterium marinum (ATCC 927) by successive column chromatography on DEAE-cellulose (DE-53), Reactive Blue agarose, Sephadex G-75, hydroxyapatite and, finally, DEAE-Sephadex A-50. The final enzyme preparation had a specific activity of 576 mumol/min per mg protein with an overall yield of 51%. The preparation was homogeneous by sodium dodecyl sulfate polyacrylamide gel electrophoresis. The enzyme was estimated to have an Mr of 29500 and an isoelectric point of 6.7, properties which generally resemble those of the mitochondrial enzyme. Indeed, the two enzymes failed to separate when subjected to polyacrylamide gel electrophoresis under denaturing conditions. The extinction coefficient (at 276 nm) was calculated to be 3.114 X 10(4) M-1 X cm-1 and E1%1cm = 10.556. Adenylate kinase was present at a concentration of 0.06 mg/g (wet weight) bacteria. Enzyme was stable for months in 60% glycerol in the freezer; at 4 degrees C, less than 5% of the activity was lost over a 7 day period.

Secondary structural changes of non-reduced and reduced ribonuclease A in solutions of urea, guanidine hydrochloride and sodium dodecyl sulfate.

The secondary structures of ribonuclease A (RNAase A) before and after reduction of the disulfide bridges and blockage of the thiol groups with iodoacetamide were examined in solutions of urea, guanidine hydrochloride, and sodium dodecyl sulfate (SDS). The relative proportions of alpha-helix, beta-structure, and disordered structure were estimated by the curve-fitting method of circular dichroism (Chen, Y.H., Yang, J.T. and Chau, K.H. (1974) Biochemistry 13, 3350-3359). The native RNAase A, with the disulfide bridges intact, contained 19% helix and 38% beta-structure. Reduction of its disulfide bridges led to a decrease in the proportion of these structures to 9% for the alpha-helix and 17% for the beta-structure. The non-reduced RNAase A resisted unfolding in low concentrations of urea and guanidine hydrochloride. The beta-structure which remained after reduction appeared to be stable even in solutions of 6 M guanidine and 9 M urea. A considerable amount of the beta-structure in both the non-reduced and the reduced RNAase A remained unaffected by high concentrations of SDS.

Genital injuries in neonates following breech presentation.

Breech presentation is seen in 3-4% of babies born. Delivering a breech baby through vaginal route is difficult and carries a much higher complication rate than cesarean sections. Breech born babies carry an overall increased risk of maternal morbidity, neonatal mortality, birth asphyxia and birth injuries. Various types of birth injuries to the babies have been reported following breech delivery, but genital injuries are less commonly reported and thus, less anticipated. We report series of five babies with spectrum of genital injuries following breech delivery. These injuries led to significant short and long term morbidity in these babies. Keeping high index of suspicion, an early cesarean section can be an aide in preventing these complications. Once the baby is born, careful examination and early intervention should be done to prevent long term complications.

Regeneration of native ovalbumin conformation disrupted by citraconylation.

Ovalbumin was reacted with a 960-fold molar excess of citraconic anhydride, and 91% of the epsilon-amino groups, representing 18 of the 20 lysine residues, were citraconylated. As detected by fluorescence and far-ultraviolet circular dichroic (CD) measurements, the modified protein displayed significant disruption of the native conformation. Treatment at pH 2.2 for 5 h resulted in the hydrolysis of 10 of the 18 citraconyl groups, but when subjected to the acid conditions for 12 h, all 18 modifying groups were removed. Electrophoretically, the 5-h and the 12-h acid-treated proteins were homogeneous and showed decreasing anodic mobility at pH 8.3; indeed, the anodic mobility of the 12-h acid-treated protein was identical to that of the native protein. Similarly, the 12-h acid-treated protein possessed conformational properties almost indistinguishable from the native protein. These properties included similar emission fluorescence spectra and far-ultraviolet CD spectra, similar resistance to undergoing helix-to-coil transition at pH 12.2, and identical urea unfolding curves, and thus identical urea transition mid-point of about 8.0 M. These observations indicate that the protein with all the epsilon-amino groups regenerated by acid treatment has the same conformational stability as the native ovalbumin.

Pulmonary dysfunction in advanced liver disease: frequent occurrence of an abnormal diffusing capacity.

PURPOSE: Abnormalities in pulmonary function have been reported in association with chronic liver disease of varied etiology. The aim of this study was to better define the frequency and nature of these abnormalities in patients who were being evaluated for liver transplantation. PATIENTS AND METHODS: We performed a battery of pulmonary function tests and chest radiographs in 116 consecutive patients (50 men, 66 women; aged 19 to 70 years, mean 44.6 years) with severe advanced liver disease who were hospitalized specifically for evaluation for possible orthotopic liver transplantation and were able to perform technically satisfactory tests. In 17 patients, quantitative whole-body technetium-99m macroaggregated albumin perfusion scanning was also performed for assessment of possible right-to-left shunting through intrapulmonary vascular dilatations. RESULTS: The most commonly affected test of lung function was the single-breath diffusing capacity for carbon monoxide (DLCO), which was abnormal in 48%, 45%, and 71% of patients who never smoked, former smokers, and current smokers, respectively. Ventilatory restriction was noted in 25% of all patients, airflow obstruction (reduced ratio of forced expiratory volume in 1 second to forced vital expiratory volume in 1 second to forced vital capacity) in only 3%, and a widened alveolar-arterial oxygen gradient in 45%. Diffusion impairment was accompanied by a restrictive defect in only 35% of the patients and by an abnormally widened alveolar-arterial oxygen gradient in 60%. When diffusion impairment was accompanied by an oxygenation defect, it was also associated with a significantly increased right-to-left shunt fraction (mean 24.9%) assessed from quantitative whole-body perfusion imaging. On the other hand, isolated diffusion impairment unaccompanied by significant hypoxemia (noted in approximately a third of the patients with a reduced DLCO) was not associated with evidence of significant intrapulmonary shunting (mean right-to-left shunt fraction 6.7%). CONCLUSIONS: Most patients with advanced liver disease have one or more types of abnormality in lung function, a reduced DLCO being the single most common functional defect. Mechanisms accounting for the abnormality in gas transfer may include intrapulmonary vascular dilatations, diffuse interstitial lung disease, pulmonary vaso-occlusive disease, and/or ventilation-perfusion imbalance.

Current use of imaging in the evaluation of primary mediastinal masses.

A wide variety of lesions occur in the mediastinum in patients of every age. Twenty five to 50 percent of these primary mediastinal masses may be malignant, making early diagnosis and therapy crucial. Since most arise from normal structures in the region, localization of lesions to compartments of the mediastinum may assist in diagnosis. This article reviews imaging techniques for lesions originating in the mediastinum.

Imaging techniques in the evaluation of pulmonary parenchymal neoplasms.

Conventional PA and lateral chest radiographs continue to be the initial examination of choice to evaluate patients who are suspected of having a pulmonary parenchymal neoplasm. A lung lesion can be characterized as probably benign or malignant based on its radiographic appearance (size, shape, margins, presence of calcification, cavitation or air bronchograms, growth rate). A spiculated or lobulated lesion greater than 3 cm in size that is noncalcified is highly suspicious for malignancy. A lung lesion less than 3 cm in size with smooth borders that appears noncalcified on conventional radiographs should be examined by CT, including densitometry to detect calcification or fat, which indicates benignity. In patients with known lung cancer, CT can help to stage the tumor by indicating hilar or mediastinal involvement, or distant metastases. Currently, MR imaging has a limited role, but can be used as a "problem solving" modality for selected cases in evaluating pulmonary parenchymal neoplasms.

Ventilatory and diffusion abnormalities in potential heart transplant recipients.

Few data are available concerning pulmonary function in patients with severe chronic congestive heart failure. Of 315 patients evaluated for potential cardiac transplantation at UCLA, 132 underwent pulmonary function tests. The latter patients had severe heart failure with a mean left ventricular ejection fraction of 19 percent and mean cardiac index of 2.1 L/min/m2. Diffusion impairment either alone or combined with restrictive and/or obstructive ventilatory defects occurred in 67 percent of the patients evaluated. Diffusion impairment occurred as the sole abnormality in 31 percent of the patients and in combination with a restrictive ventilatory defect in 21 percent. A reduction in diffusing capacity has not been previously described as a frequent finding in patients with chronic congestive heart failure. In contrast to other studies involving patients with acute heart failure, obstructive ventilatory defects were uncommon. None of the lung function abnormalities was associated with smoking status, prior drug use, chest roentgenographic changes, hemodynamic findings, or clinical features, including duration of congestive heart failure. The mechanism for the diffusion impairment is unclear but could be due to chronic passive congestion with pulmonary fibrosis and/or recurrent pulmonary emboli. Recognition of diffusion impairment as a common finding in patients with severe chronic congestive heart failure who are candidates for heart transplantation is important for proper interpretation of possible post-transplant changes in diffusing capacity due to other causes.