Disease Management plus Recommended Care versus Recommended Care Alone for Ambulatory Patients with Chronic Obstructive Pulmonary Disease.

Rationale: The efficacy of disease management programs in the treatment of patients with chronic obstructive pulmonary disease (COPD) remains uncertain.Objectives: To study the effect of disease management (DM) added to recommended care (RC) in ambulatory patients with COPD.Measurements and Main Results: In this trial, 1,202 patients with COPD (age, ≥40 yr), with moderate to very severe airflow limitation were randomly assigned either to DM plus RC (study intervention) or to RC alone (control intervention). RC included follow-up by pulmonologists, inhaled long-acting bronchodilators and corticosteroids, smoking cessation intervention, nutritional advice and psychosocial support when indicated, and supervised physical activity sessions. DM, delivered by trained nurses during patients' visits to the designated COPD centers and by remote contacts with the patients between these visits, included patient self-care education, monitoring patients' symptoms and adherence to treatment, provision of advice in case of acute disease exacerbation, and coordination of care vis-à-vis other healthcare providers. The primary composite endpoint was first hospital admission for respiratory symptoms or death from any cause. During 3,537 patient-years, 284 patients (47.2%) in the control group and 264 (44.0%) in the study intervention group had a primary endpoint event. The median (range) time elapsed until a primary endpoint event was 1.0 (0-4.0) years among patients assigned to the study intervention and 1.1 (0-4.1) years among patients assigned to the control intervention; adjusted hazard ratio, 0.92 (95% confidence interval, 0.77-1.08).Conclusions: DM added to RC was not superior to RC alone in delaying first hospital admission or death among ambulatory patients with COPD.

Randomized controlled crossover trial of a new oscillatory device as add-on therapy for COPD.

A new oscillatory device administers predetermined pressure oscillation sequences into the chest cavity over inhaled/exhaled air streams at low positive pressure. We assessed device safety and effect on 6MW performance, pulmonary function, and health-related quality-of-life (HRQOL) in moderate-to-very severe COPD in a randomized, double-blind, controlled, crossover study. Outcomes with an oscillatory device (Pulsehaler(TM), Respinova Ltd, Herzliya, Israel) and a "muted" sham device (control) of identical appearance that delivered continuous positive air pressure were compared in two groups receiving opposite treatment sequences: 2-week oscillatory device/control, 2-week washout, 2-week control/oscillatory device, 2-week washout. The clinical trial was registered ( www.clinicaltrials.gov , NCT00821418) and approved by the Hadassah-Hebrew University Medical Center Institutional Review Board (08-608). All participants signed informed consent; 22 patients completed the study with no marked differences in COPD exacerbations or side effects. A total of 91% of patients treated with the oscillatory device had a clinically significant improvement (increase >40 m) in 6MW performance. The 6MW distance with the oscillatory device increased significantly after 1 week of treatment (51.6 ± 7.6 m, +13.5 ± 2.3%, p < 0.001), and more after 2 weeks (61.8 ± 9.0 m, 16.3 ± 2.7%, p < 0.001). This increase with the oscillatory device was significantly greater (p < 0.001) than the 15.4 ± 10.4 m increase (4.2 ± 2.6%, NS) with control. FVC and inspiratory capacity (IC) improved significantly (p = 0.03 for each) with the oscillatory device but not with control. HRQL improved markedly (≥1 point) for dyspnea and mastery with the oscillatory device (p = 0.02) but not control. Treatment with a new oscillatory device appears to be safe, and to improve 6MW performance, pulmonary function, and HRQL in COPD. Further evaluation is warranted.

[Myocarditis in Olympic marathon runner].

One thousand five hundred runners participated in the Tiberias marathon in 2010 and more than 35,000 runners participate annuaLly in large city marathons. Elite marathon runners train strenuously, tending to ignore various symptoms of pain, aches and mild respiratory infections, as they continue training relentlessly for the upcoming marathons. Intensive training may weaken the immune system, thus increasing the susceptibility for infection, mainly viral infections. We present a case study of an Olympic marathoner, an Ethiopian of Jewish origin, aged 41 who began training for an upcoming marathon on May 1, 2010. During the following 6 weeks he ran 180-240 km/week at easy to moderate paces. In mid-June he added 2 high intensity runs per week to his running schedule. During the first 3 weeks, quality running improvement was noted, but then the runner started to feel muscle pains in his thighs, shortness of breath and chest uneasiness while running fast. The physical examination conducted on 19/7/10 was normal. Examinations showed white blood cell (WBC) count was 2800, 55% lymphocytes, 11.8% monocytes, titers for recent CMV, Epstein Bar, enteroviruses, were negative. On 24/7/10 ECG showed inverted symmetric T-wave in precordial leads, chest X-ray, echocardiogram, troponin, and WBC were normal. Clinical features, WBC, and ECG findings, suggested myocarditis, probably viral The runner stopped running. On 9/9/10 ECG was normal. On 15/9/10 cardiac virtual catheterization was normal. Cardio-pulmonary exercise test on 4/10/2011 was normal. Thereupon, the athlete resumed running. This case stressed the fact that physicians should be alert to medical complaints from marathoners, in order to prevent serious outcomes from dissimulate runners. A literature search was conducted related to distance runners and high level orienteer's myocarditis causes and prevention.

National asthma observational survey of severe asthmatics in Israel: the no-air study.

BACKGROUND: Asthma is considered a global public health issue requiring a significant medical expenditure as a result of its high prevalence and the low rate of disease control. OBJECTIVE: This is the first nationwide survey of severe asthma patients carried out in Israel. In this study we aimed to assess health resources utilization, compliance with treatment and disease-control in a subgroup of patients with severe asthma in Israel. MATERIAL AND METHOD: One hundred and twenty-three patients with a diagnosis of asthma for more then one year, as well as a hospitalization during the last 12 months due to asthma exacerbation or maintenance systemic steroids therapy, were included in this non-interventional observational study. RESULTS: Asthma was uncontrolled in 43.9%, partly controlled in 50.4% and well controlled in only 5.7%. The majority of the patients (83%) were compliant with drug treatment. CONCLUSION: The fact that 83% of the asthma patients included in this study were compliant with their asthma therapy was not manifested in asthma control. Therefore concrete tools are required for achieving and maintaining asthma control, especially in the treatment of the most severe asthmatic patients.

Pressure pulsations enhance penetration index in COPD.

This study was done in order to evaluate the effect of a novel pressure pulsation device (Pulsehaler™, Respinova Ltd., Israel) on the deposition pattern of inhaled aerosol in the lungs of COPD patients. Fifteen COPD patients were recruited to undergo spirometry and SPECT-CT lung scan following nebulization of radioactively labeled albuterol in saline solution with a jet nebulizer ("NEB") and with a combined Pulsehaler™/jet nebulizer ("PH + NEB") treatment. Central and peripheral segments of the coronal and transverse SPECT scans were evaluated for total counts and for the ratios between peripheral counts and central counts (penetration Index, "PI"). There was a significant improvement in FEV1 from before to after albuterol treatment in the PH + NEB group (151 ml ± 187, p < 0.008), but not in the NEB only group (66 ml ± 125, p = 0.06). FVC, FEF25-75, FEV1%, FVC%, FEF25, FEF50, and FEF75 also improved significantly in the PH + NEB group but not the NEB group. There were significant improvements seen between treatments for FEF25-75 (PH + NEB > NEB, p = 0.0176), FEF75 (PH + NEB > NEB, p = 0.0028), but not for the other spirometry measures. Borg scores also were improved significantly improved in PH + NEB vs NEB (p = 0.0006). Total lung deposition and total body deposition were lower in the PH + NEB treatments vs the NEB treatments. However, PI values were 3.08 ± 0.67 times greater on average with the PH + NEB (p = 0.026) as compared to NEB only. The magnitude of the increased penetration index observed in this study indicates that pressure pulsations should be further explored as means to improve drug delivery into the distal small airways of the bronchial tree. Effects of the pressure pulsations on small airway patency could be the mechanism by which the effect was achieved.

Organizing pneumonia and non-necrotizing granulomata on transbronchial biopsy: coexistence or bronchiolitis obliterans organizing pneumonia secondary to Mycobacterium kansasii disease.

Mycobacterium kansasii disease was diagnosed in an 85-year-old woman admitted to the hospital for cough and gradually worsening breathlessness. Transbronchial biopsy indicated either non-necrotizing granulomata or bronchiolitis obliterans organizing pneumonia (BOOP). She was cured with combined therapy of specific anti-mycobacterial medications and systemic steroids. To our knowledge, this is the first report of M. kansasii non-tuberculous mycobacterium disease with a BOOP-like pattern on lung biopsy.

Efficacy of nebulized fluticasone propionate in adult patients admitted to the emergency department due to bronchial asthma attack.

BACKGROUND: Locally delivered steroids by inhalers or nebulizers have been shown in small trials to be effective in acute asthma attack, but evidence-based data are insufficient to establish their place as routine management of adult asthma attacks. OBJECTIVES: To determine the efficacy of nebulized compared to systemic steroids in adult asthmatics admitted to the emergency department following an acute attack. METHODS: Adult asthmatics admitted to the ED were assigned in random consecutive case fashion to one of three protocol groups: group 1--nebulized steroid fluticasone (Flixotide Nebules), group 2--intravenous methylprednisolone, group 3--combined treatment by both routes. Objective and subjective parameters, such as peak expiratory flow, oxygen saturation, heart rate and dyspnea score, were registered before and 2 hours after ED treatment was initiated. Steroids were continued for 1 week following the ED visit according to the protocol arm. Data on hospital admission/discharge rate, ED readmissions in the week after enrollment and other major events related to asthma were registered. RESULTS: Altogether, 73 adult asthmatics were assigned to receive treatment: 24 patients in group 1, 23 in group 2 and 26 in group 3. Mean age was 44.4 +/- 16.8 years (range 17-75 years). Peak expiratory flow and dyspnea score significantly improved in group 1 patients compared with patients in the other groups after 2 hours of ED treatment (P = 0.021 and 0.009, respectively). The discharge rate after ED treatment was significantly higher in groups 1 and 3 than in group 2 (P = 0.05). All 73 patients were alive a week after enrollment. Five patients (20.8%) in the Flixotide treatment arm were hospitalized and required additional systemic steroids. Multivariate analysis of factors affecting hospitalization rate demonstrated that severity of asthma (odds ratio 8.11) and group 2 (OD 4.17) had a negative effect, whereas adherence to chronic anti-asthma therapy (OD 0.49) reduced the hospitalization rate. CONCLUSIONS: Our study cohort showed the advantage of nebulized steroid fluticasone versus systemic corticosteroids in adult asthmatics managed in the ED following an acute attack. Both these and previous results suggest that nebulized steroids should be used, either alone or in combination with systemic steroids, to treat adults suffering acute asthma attack.

Lung function and cardiopulmonary exercise capacity in patients with corrected tetralogy of Fallot.

BACKGROUND: Since surgical repair of tetralogy of Fallot was introduced, follow-up studies have shown that the majority of patients lead active lives and have no subjective exercise limitation. OBJECTIVES: To examine lung function, cardiopulmonary functional capacity and echo-Doppler assessment of pulmonary pressure in adult patients 20 years after repair of TOF. METHODS: Unselected consecutive patients performed full lung function testing, progressive cardiopulmonary exercise, and echo-Doppler assessments of pulmonary pressure. RESULTS: Fifty consecutive patients (33 men, 17 women) aged 29 +/- 11 years who underwent surgical repair of TOF at age 10.1 +/- 10.9 years were enrolled. Patients after TOF showed no restriction (forced expiratory vital capacity 80%, total lung capacity 91%) and had normal oxygen saturation (97%) and 6 minute walking distance (600 meters). Echocardiography showed normal pulmonary pressure and left ventricular ejection function (62%). Cardiopulmonary exercise testing showed mild limitation of exercise capacity with oxygen uptake at maximal effort of 75-78% predicted. CONCLUSIONS: After corrections of TOF the study patients had normal lung function and pulmonary arterial pressure but mild limitation in their exercise capacity.

Non-invasive early detection of malignant pulmonary nodules by FISH-based sputum test.

BACKGROUND: Early detection decreases lung cancer mortality. The Target-FISH Lung Cancer Detection (LCD) Test is a non-invasive test designed to detect chromosomal changes (deletion or amplification) via Fluorescence in situ Hybridization (FISH) in sputum specimens from persons suspected of having lung cancer. We evaluated the performance of the LCD test in patients with highly suspicious pulmonary nodules who were scheduled for a biopsy procedure. METHODS: Induced sputum was collected from patients who were scheduled for biopsy of a solitary pulmonary nodule (0.8-3 cm) in one of 6 tertiary medical centers in the US and Israel. The lung cancer detection (LCD) Test combined sputum cytology and Target-FISH analysis on the same target cells and the results were compared to the pathology. Participants with non-surgical negative biopsy results were followed for 2 years to determine their final diagnosis. RESULTS: Of the 173 participants who were evaluated, 112 were available for analysis. Overall, the LCD test had a sensitivity of 85.5% (95% CI, 76.1-92.3), specificity of 69% (95% CI, 49.2-84.7) and an accuracy of 81.3% (95% CI, 72.8-88). The positive and negative predictive values (PPV, NPV) were 88.8% and 62.5%, respectively. The LCD test was positive in 9 of 11 lung cancer patients who had an initial negative biopsy. CONCLUSIONS: In a cohort of patients with highly suspicious lung nodules, the LCD test is a non-invasive option with good sensitivity and a high positive predictive value. A positive LCD test reinforces the need to aggressively pursue a definitive diagnosis of suspicious nodules.

Asthma control and compliance in a cohort of adult asthmatics: first survey in Israel.

BACKGROUND: Asthma control and treatment compliance are widely investigated issues around the world. Studies have demonstrated relatively low asthma compliance and control in 40-90% of asthma patients in different countries. There are no available data on the Israeli adult asthmatic population OBJECTIVES: To investigate the level of asthma control and compliance in adult asthmatic patients. METHODS: This cross-sectional study of consecutive adult asthmatic patients visiting the pulmonary clinic used a combined questionnaire that included demographics, data on asthma severity and management, and asthma control and compliance scores. Each patient was interviewed and questionnaires were filled out during a routine visit. RESULTS: The study group comprised 142 males (35.4%) and 259 females (64.6%). Compliance was found optimal in 8 patients (2%), fair in 146 (36%), partial in 156 (39%) and poor in 92 (23%) of the participating asthmatic patients. Asthma control was found optimal in 26 (7%), fair in 124 (31%), partial in 122 (30%) and poor in 129 (32%). Sephardic and Ashkenazi Jewish origin, higher level of education, and treatment protocol including either single fixed-dose inhalers or short-acting beta-agonist bronchodilators significantly improved compliance in our cohort. Socioeconomic status and compliance were found to positively affect asthma control, whereas active smoking negatively affected asthma control in the study patients. CONCLUSIONS: The figures of optimal asthma control and compliance to treatment in Israeli adult asthmatics are low and worse than reported in other studies abroad.

Is routine chest radiography after transbronchial biopsy necessary?: A prospective study of 350 cases.

BACKGROUND AND STUDY OBJECTIVE: Pneumothorax following flexible bronchoscopy (FB) with transbronchial biopsy (TBB) occurs in 1 to 6% of cases. Routine chest radiography (CXR) following TBB is therefore requested by most pulmonologists in an attempt to detect complications, particularly pneumothorax. The objective of this study was to determine if routine CXR after bronchoscopy and TBB is necessary. PATIENTS AND METHOD: The study group included 350 consecutive patients who underwent FB with TBB at our institution between December 2001 and January 2004. Routine CXR was performed up to 2 h after the procedure in all cases. Additionally, the following information was recorded in all patients: sex, age, immune status, indication for bronchoscopy, total number of biopsies done, segment sampled, pulse oxygen saturation, and development of symptoms suggestive of pneumothorax. RESULTS: Pneumothorax was diagnosed radiologically in 10 patients (2.9%). Seven patients had symptoms strongly suggestive of pneumothorax prior to CXR, including four patients with large (> 10%) pneumothorax. The other three patients were asymptomatic, with only minimal pneumothorax (

Assessment of functional capacity in patients with chronic obstructive pulmonary disease: correlation between cardiopulmonary exercise, 6 minute walk and 15 step exercise oximetry test.

BACKGROUND: Different exercise tests are used to evaluate the functional capacity in chronic obstructive pulmonary disease. The cardiopulmonary exercise test is considered the gold standard, but the 6 minute walk and the 15 step exercise oximetry test are considerably less expensive. OBJECTIVES: To determine whether reliable data could be obtained at lower cost. METHODS: The study sample consisted of 50 patients with mild to severe stable COPD. All underwent pulmonary function test and the cardiopulmonary exercise test, 6 minute walk and 15 step exercise oximetry test as part of their regular follow-up visit. Functional capacity was graded according to each test separately and the functional capacities obtained were correlated. RESULTS: The results showed that most of the patients had severe COPD according to pulmonary function tests (mean forced expiratory volume in the first second 46.3 +/- 19.9% of predicted value). There was a good correlation between the cardiopulmonary exercise test and the 6 minute walk functional capacity classes (r = 0.44, P = 0.0013). We did not find such correlation between the 15 step exercise oximetry test and the cardiopulmonary exercise test (r = 0.07, P = 0.64). CONCLUSIONS: The study shows that the 6 minute walk is a reliable and accurate test in the evaluation of functional capacity in COPD patients.

Recurrence of pulmonary veno-occlusive disease after heart-lung transplantation.

Pulmonary veno-occlusive disease, a rare cause of pulmonary hypertension, is characterized by extensive and diffuse occlusion of pulmonary veins by fibrous tissue. Although the diagnosis can be suspected by the presence of the classic clinical triad of severe pulmonary arterial hypertension, radiographic evidence of pulmonary hypertension and edema, and normal pulmonary artery occlusion pressure, the definitive diagnosis is histopathologic. The prognosis of pulmonary veno-occlusive disease is poor with most described patients dying within 2 years of diagnosis. Although anti-coagulation, oxygen, and vasodilator therapies are effective temporarily, the definitive treatment is lung transplantation. We describe the recurrence of pulmonary veno-occlusive disease at 3 months after heart-lung transplantation in a 26-year-old man. Recurrence after transplantation for this disease has not been reported previously, and lung transplantation was thought to be definitive treatment. With this 1st report of early recurrence of pulmonary veno-occlusive disease after heart-lung transplantation, we believe that extrapulmonary factors may play a role in the pathogenesis of this rare disease.

The relationship between left ventricular function assessed by multigated radionuclide test and cardiopulmonary exercise test in patients with ischemic heart disease.

STUDY OBJECTIVES: To compare the oxygen pulse curve (O(2)P-C) as measured during cardiopulmonary exercise testing (CPET) with left ventricular (LV) ejection fraction (LVEF) rest-exercise response as measured by multigated equilibrium (99m)Tc radionuclide cineangiography (MUGA) in patients with different degrees of ischemic heart disease (IHD). PATIENTS: Forty-six patients (39 men and 7 women; mean plus minus 1 SD age, 59.2 plus minus 11 years) with IHD, with no hypertrophic, valvular, or pericardial disease. METHODS: A supine bicycle ergometer with increments of 25 W every 2 min was used for MUGA, and an electronically braked cycle ergometer was used for upright symptoms-limited CPET. Exercise was increased by 10 to 20 W/min until the target heart rate (HR) was reached (similar peak HR for both studies). MEASUREMENTS AND RESULTS: The O(2)P-C was scored on a 10-point scale as follows: type A, normal curve (10 points); type B, normal-shaped curve with low values (8 points); type C, low and flat curve (5 points); type D, descending curve (3 points). Findings for the MUGA study were classified into four groups by the degree of ischemic response: group 1 (control), normal diastolic function (n = 10), LVEF > 55%, LVEF during exercise minus LVEF at rest [DeltaLVEF] greater-than-or-equal 5%; group 2, mild ischemia (n = 10), LVEF > 55%, < 0 DeltaLVEF < 5%, diastolic dysfunction at exercise (prominent "A" waves); group 3, LV dysfunction (n = 9), LVEF < or = 35% at rest; and group 4, significant ischemia (n = 17), LVEF > 55%, DeltaLVEF < 0, diastolic dysfunction. A highly significant relationship between the O(2)P-C score and the MUGA grouping was observed by Fisher's Exact Test and Pearson's linear regression line (p < 0.001; R = - 0.89). CONCLUSIONS: Exercise-responded O(2)P-C might serve as a good noninvasive, physiologically based, parameter to distinguish between IHD patients with normal and impaired LV function.

Effects of an intensive 4-week summer camp on cystic fibrosis: pulmonary function, exercise tolerance, and nutrition.

STUDY OBJECTIVES: Cystic fibrosis (CF) patients prefer exercise to most other forms of therapy, although objective improvement remains controversial. Israeli CF patients have attended a summer program in Switzerland for many years with subjective improvement. However, CF camps worldwide have been cancelled recently, due to fears of cross-infection with resistant organisms. Therefore, we evaluated the effect of attending the camp on pulmonary function, exercise tolerance, and nutritional state in CF patients. DESIGN: Weight, resting pulmonary function, incremental exercise test results, and sputum culture findings were assessed before and after a 4-week intensive summer camp. SETTING: Davos, Switzerland (altitude, 1,500 m). PATIENTS: Thirteen Israeli CF patients (seven women and six men) with an age range of 9 to 25 years who had mild-to-moderate lung disease. No patients had Burkholderia cepacia detected in their sputum. INTERVENTIONS: The program included a high-calorie diet, chest physiotherapy, daily mountain climbing, and indoor activities. Arterial oxygen saturation (SaO(2)) was maintained at > 88% during exertion. RESULTS: Exercise tolerance improved significantly. The peak work capacity increased by 12.7%, the maximal oxygen uptake increased by 10%, and minute ventilation increased by 18.5% (p < 0.0005). Of the calculated parameters, the anaerobic threshold improved by 17%. Ventilation was always the limiting factor during exercise, although it improved. There was no significant change in resting lung function and pulse or in SaO(2) decline at maximal exercise. The mean weight gain was 1 kg. No patient acquired B cepacia. CONCLUSIONS: An intensive summer camp improved exercise tolerance and nutrition in CF patients. This may explain improved patient well-being despite unchanged values for resting lung function. The reinstitution of summer camps, with special care to avoid cross-infection, should be considered.

Significance of a plasma D-dimer test in patients with primary pulmonary hypertension.

BACKGROUND: D-dimer, a degradation product of fibrin, has been increasingly used as a marker or prognostic factor in various thrombotic diseases. OBJECTIVE: To assess the significance of a d-dimer test in patients with primary pulmonary hypertension (PPH). PATIENTS AND METHODS: Fourteen patients with PPH (12 women and 2 men) aged 25 to 68 years (mean +/- SD age, 50 +/- 14 years) entered the study. Plasma d-dimer was determined by Miniquant assay (Biopool International; Venture, CA) 3 +/- 5 months after the disease onset, and patients were followed up for 1 year. We compared the d-dimer levels to the demographic, clinical, and hemodynamic data of the patients. RESULTS: D-dimer levels were positively correlated with New York Heart Association classification (r = 0.59, p = 0.01) and pulmonary artery pressure (r = 0.43, p = 0.03) and were negatively correlated with oxygen saturation (r = - 0.45, p = 0.03) and 6-min walk distance (r = - 0.49, p = 0.04). One-year survival was also negatively correlated with d-dimer (point-biserial r = - 0.71, p = 0.004), with a higher d-dimer value associated with poorer survival. No significant correlations were found between d-dimer values and sex, age, diffusing capacity of the lung for carbon monoxide, or cardiac index. CONCLUSION: D-dimer levels may have a role in the evaluation of patients with PPH. This simple, noninvasive test may be helpful for identifying patients who are at a higher risk for severe disease.

Advanced non-small cell lung cancer: induction chemotherapy and chemoradiation before operation.

BACKGROUND: Induction chemotherapy before operation is beneficial for patients with advanced locoregional non-small cell lung cancer. However, no optimal regimen has been established. This study assesses feasibility, response, resectability, and survival of chemotherapy followed by chemoradiation before operation in patients with non-small cell lung cancer. METHODS: Fifty-seven stage IIIA and selected IIIB patients with non-small cell lung cancer received 2/3 cycles of cisplatin and oral etoposide, followed in 3/4 weeks by chemoradiation with daily cisplatin before each radiation fraction. Patients achieving a resectable status underwent operation. RESULTS: Response to induction treatment was documented in 73%; 69% achieved a resectable status and 53% underwent operation. Median survival was 16 months. The 1-, 2-, and 3-year survival rates were 65%, 35% and 22%, respectively. There was no difference in survival between stage IIIA and IIIB disease. Myelotoxicity was moderate to severe (grade III/IV in 61% of patients). Three patients died of late complications of pneumonectomy. CONCLUSIONS: Our presurgery chemotherapy and chemoradiation protocol yields high response and resectability rates, with moderate to severe myelotoxicity. Pneumonectomy is associated with a relatively high rate of late complications.

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications.

OBJECTIVE: Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. METHODS: Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. RESULTS: The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. CONCLUSION: Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.

Functional evaluation in patients with chronic obstructive pulmonary disease: pulmonary function test versus cardiopulmonary exercise test.

The pulmonary function test (PFT) alone may be inadequate for predicting work-related exercise capacity in patients who file workers' compensation claims for respiratory limitation and compensation. Two hundred sixteen ambulatory patients with chronic obstructive pulmonary disease (forced expiratory volume in 1 second = 54.1 +/- 16.8% predicted) were administered the PFT and cardiopulmonary exercise test, and the results were analyzed by categorical statistical comparison, based on standard medical impairment classifications. Sixty-five patients (30.1%) were similarly classified by the two methods. Of the remaining patients, 132 (61.1%) were found to be less impaired according to the cardiopulmonary exercise test than according to the PFT, and 19 (8.8%) were more impaired according to the PFT. The results favor the use of the cardiopulmonary exercise test for the routine evaluation of respiratory impairment in patients with chronic obstructive pulmonary disease, particularly for patients with mild or moderate impairment revealed by the PFT. The large discrepancy between the two procedures emphasizes the need for a novel approach.

Continuous intravenous epoprostenol in pulmonary hypertension: the Israel experience.

BACKGROUND: Primary idiopathic pulmonary hypertension is a rapidly progressive disease with a median survival of less than 3 years. Recently its prognosis was shown to dramatically improve with the use of epoprostenol, an arachidonic acid metabolite produced by the vascular endothelium, which increases the cardiac output and decreases the pulmonary vascular resistance and pulmonary arterial pressure. This drug enhances the quality of life, increases survival and delays or eliminates the need for transplantation. OBJECTIVE: To review the experience of Israel hospitals with the use of epoprostenol. METHODS: The study group comprised 13 patients, 5 men and 8 women, with an age range of 3-53 years. All patients suffered from arterial pulmonary hypertension. Epoprostenol was administered through a central line in an increased dose during the first 3 months, after which the dose was adjusted according to the clinical syndrome and the hemodynamic parameters. RESULTS: After 3 months the mean dose was 10 ng/kg/min and the pulmonary artery pressure decreased from 7 to 38%. After one year, the PAP decreased at a slower rate. Two cases required transplantation, three patients died, and seven continued taking the drug (one of whom discontinued). Four episodes of septicemia were observed. Today 10 patients are alive and well and 7 continue to take epoprostenol. CONCLUSION: We found that epoprostenol improves survival, quality of life and hemodynamic parameters, with minimum side effects.