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To determine the efficacy of repeat percutaneous transluminal coronary angioplasty, 74 patients were studied who underwent a third angioplasty for a second restenosis of one coronary artery segment. The procedure was successful in 93% of patients. Procedural complications included emergency bypass surgery (three patients) and in-hospital death (two patients). At late follow-up (mean 18 months, range 7 to 49), 30 patients (43%) had a third restenosis treated with either a fourth angioplasty (16 patients), coronary bypass surgery (11 patients) or medical management (1 patient). Thirty-nine patients (57%) had no restenosis on the basis of follow-up angiography or absence of symptoms previously attributed to restenosis. Factors associated with a third restenosis included a shorter time interval (<3 months) between previous angioplasty procedures and dilation of the left anterior descending coronary artery.

An unusual site and cause of disabling inspiratory and expiratory airflow limitation mimicking fixed upper airway obstruction is reported in two patients with sarcoidosis who had stenosis of almost the entire lengths of both main bronchi. The observed flows were consistent with a cross sectional airway diameter of 3 mm. The lumen of the trachea and proximal airways was not compromised.

Previous studies suggest that pulmonary function of singers and wind-instrument players may be better than normal control subjects due to breath-control training; however, prior studies were poorly controlled or limited in scope. In the present study, we compare 34 singers and 48 wind instrumentalists with a control group of 31 string or percussion instrumentalists using a pulmonary questionnaire, measurements of inspiratory and expiratory pressures, and spirometry. We found no significant difference between groups in maximum voluntary ventilation, forced expiratory volume in one second (FEV1), forced vital capacity (FVC), mean forced expiratory flow during the middle half of the FVC, the FEV1/FVC, peak expiratory pressure, or peak inspiratory pressure, independently or when corrected for age, sex, height, weight, years performing, smoking, presence or absence of cough, or sputum production. Smoking correlated negatively with measurements of pulmonary function in all groups. There was evidence of a heightened awareness of health among singers, who exercised more and smoked less than their colleagues. The differences in health habits may account in part for the myth of improved pulmonary volumes among singers.

Patients with sarcoidosis are known to have histologic pulmonary abnormalities despite normal lung fields or conventional pulmonary function or both. These patients permit a useful assessment of the alleged greater sensitivity of the various measurements made during incremental cardiorespiratory exercise testing. Abnormal responses on such testing may provide insight into such complaints as dyspnea in these patients. Incremental exercise testing was performed on 30 patients with biopsy-proven sarcoidosis who had normal spirometry; 13 had clear lung fields radiographically. Of these patients, the 21 who had normal single-breath diffusing capacity for carbon monoxide (Dsb; [group A]) were compared with the 9 who had decreased Dsb (group B). Half of the group A patients had excessive ventilation and 38% had increased dead space to tidal volume ratio (VD/VT), but frequencies of these abnormalities were greater in group B, 89 and 78%, respectively. Ventilatory response, as minute ventilation to oxygen consumption ratios ventilatory equivalents, and deadspace to tidal volume ratio (VD/VT) ratios were higher in group B. Widened alveolar-arterial oxygen pressure differences were seen in 7 of 9 group B patients but only 1 of 17 group A patients. This study supports the clinical impression that occult pulmonary impairment may be present in patients (in this case, sarcoidosis patients) with normal pulmonary function, and corroborates the utility of exercise testing in demonstrating such impairment. Reduction in Dsb predicted greater frequency of abnormal exercise responses, especially in oxygenation.

The purpose of this study was to determine whether there are any consistent spirometric or Dsb findings in patients with LV dysfunction characterized by a clinical diagnosis of CHF and an EF<40 percent. We performed spirometry and Dsb in 34 patients, and found that EF correlated only with Dsb. When we separated the patients into those with rales and those without, Dsb correlated strongly with EF only in those with rales. There was no correlation with other spirometric values. Mean Dsb percent predicted was significantly lower in patients with rales despite similar mean EF. Only two of 23 patients without rales had a reduced Dsb while only one of 11 with rales had a normal Dsb. We conclude that Dsb is a good predictor of clinically evident heart failure. When rales are absent, Dsb should be normal in patients with LV dysfunction; when present, Dsb will be diminished in proportion to the EF.

Intrathoracic non-Hodgkin's lymphoma (NHL) usually presents with roentgenographic evidence of mediastinal lymph node enlargement, pulmonary masses, pleural effusion, and a clinical picture of a systemic disease with lymphadenopathy. The presentation of NHL with pleural effusion as the major roentgenographic abnormality and no clinical peripheral lymphadenopathy or organomegaly is unusual. During a seven-year period, we encountered 19 patients with NHL in whom pleural effusion was the major roentgenographic and clinical finding. Pleural fluid cytologic results were diagnostic in only two patients. Closed pleural biopsy was positive in three. Eight of 11 patients had diagnostic immunophenotypic lymphocyte cell marker studies. Seven of nine patients had diagnostic thoracoscopy and one thoracotomy. The CT scan identified biopsy sites when pleural fluid and tissue studies were nondiagnostic. Lymphomatous tissue was obtained from the pleura in 17 of the 19 patients supporting the contention that pleural effusion in patients with NHL is usually due to pleural lymphoma rather than obstruction to mediastinal lymphatics.

Objectives. We examined the relations of elevated creatine kinase (CK) and its myocardial band isoenzyme (CK-MB) to clinical outcomes after percutaneous coronary intervention (PCI) in patients enrolled in Integrilin (eptifibatide) to Minimize Platelet Aggregation and Coronary Thrombosis-II (trial) (IMPACT-II), a trial of the platelet glycoprotein IIb/IIIa inhibitor eptifibatide.

The purpose of this study was to compare angiography and angioscopy for the detection of thrombus during coronary interventional procedures. The diagnosis of coronary thrombus has important clinical implications. Angioscopy can directly visualize the coronary luminal surface and may be more accurate than angiography in the diagnosis of thrombus. Angiography and angioscopy were sequentially performed in 75 patients undergoing a variety of interventional cardiology procedures during 117 distinct procedural time points. The angiographic presence of thrombus was defined as a noncalcified filling defect outlined on at least 3 sides by contrast media. The angioscopic presence of thrombus was defined as red material protruding into the lumen (intraluminal thrombus) or adherent to the luminal wall (mural thrombus) that persisted despite flushing. Thrombus was detected on 14 occasions (12.0%) by angiography compared with 48 (41.0%) by angioscopy (p < 0.05). In 4 of the 14 episodes (28.6%) of angiographic filling defects, angioscopy found no evidence of thrombus and provided an alternative explanation for the angiographic filling defect. When angioscopy was used as a reference standard, the sensitivity of thrombus detection by angiography was 20.8%, with a specificity of 94.2% and a predictive value of 71.4%. The sensitivity of angiography for the detection of intraluminal (protruding into the lumen) thrombus was 100% compared with only 10% for mural (adherent to the luminal wall) thrombus (p < 0.05). Angioscopy was significantly more accurate than angiography for detecting coronary thrombus and may be considered an improved reference standard for this diagnosis.

Coronary angioscopy can directly visualize luminal morphology and stent architecture. This new technology may provide insights into the stent mechanism of action and help guide stent procedures. Visualization of the target vessel segment with a 4.5Fr angioscope was attempted before and/or after Palmaz-Schatz coronary stent implantation in 50 patients. The target vessel segment was successfully visualized in 48 patients (96%). In 24 patients, angioscopy was performed both after balloon angioplasty and then again after stenting. In 16 of these 24 patients a dissection was documented by angioscopy after balloon angioplasty, and in each patient the dissection was absent after stenting. Angioscopy influenced the clinical management of 18 (37.5%) patients. Clinical decisions directly influenced by angioscopy included intracoronary thrombolytic therapy for thrombus visualized angioscopically, which had been unsuspected by angiography (n = 7), withholding intracoronary thrombolytic therapy for patients with suspected thrombus not confirmed by angioscopy (n = 4), repeat angioplasty in patients in whom plaque was found to be bulging into the lumen at the stent articulation site (n = 4), additional stents placed when angioscopy revealed significant proximal or distal disease (n = 4), or an unsuspected gap between 2 tandem stents (n = 1). Coronary angioscopy safely visualized stented vessel segments in most patients. Angioscopic observations provided insights into the stent mechanism of action and, in some cases, influenced clinical management.

A combination chemotherapy (MACC) consisting of methotrexate, doxorubicin hydrochloride (Adriamycin), cyclophosphamide, and lomustine (CCNU) was given to 41 patients with stage III bronchogenic carcinoma, 34 of whom had disseminated disease. The objective response rate was 46% for all patients with a median actuarial survival of nine months. Response was seen in all cell types, including four of ten patients with squamous cell carcinoma, six of 17 with adenocarcinoma, and six of seven with small-cell anaplastic carcinoma. Prolongation of survival was apparent for patients of all cell types. Toxic reactions were moderate and allowed for easy outpatient use.(JAMA 237:2392-2396, 1977)

This study reports the multicenter registry experience evaluating the safety and efficacy of the Palmaz-Schatz stent in the treatment of saphenous vein graft disease.

Lymphocytic interstitial pneumonia is a common complication of HIV infection in children, but uncommon in adults. It is characterized clinically by the presence of cough and dyspnea, diffuse pulmonary infiltrates on chest x-ray, restrictive pulmonary dysfunction, and hypoxemia. This constellation of findings usually erroneously suggests PCP, and a lung biopsy is necessary to establish the diagnosis. Typical microscopic findings include diffuse infiltration of the pulmonary interstitium with a mixture of lymphocytes and plasma cells; immunohistologic studies reveal that in association with HIV infection, these lymphocytes are T cells.

— Of 1,000 consecutive patients undergoing fiberoptic bronchoscopy, 331 eventually were proven to have primary lung cancer. Of the 331 carcinomas, 253 were beyond the visual range of the flexible bronchoscope. However, under fluoroscopic guidance, the diagnosis of carcinoma was established in 194 (76.7%) of these nonvisualized tumors. Cytologic analysis of brush specimens was more often positive for malignancy than specimens obtained by forceps biopsy. An expert cytologist and experienced bronchoscopy team are essential for a high percentage of reliable positive diagnoses in bronchogenic carcinoma.

Objectives. Data from a national registry of 23 centers using cardiopulmonary support (CPS) were analyzed to compare the risks and benefits of prophylactic CPS versus standby CPS for patients undergoing high risk coronary angioplasty.

High speed rotational coronary atherectomy was undertaken using the Rotabiator in 42 patients who were suboptimal candidates for balloon angioplasty. Most patients (71%) had diffuse coronary artery disease, defined as a stenosis >1 cm in length. Previous restenosis after balloon angioplasty was present in 21% and 10% had an ostial lesicn. Adjunctive balloon angioplasty was not used to reduce residual stenosis after atherectomy.

Three patients with the acquired immune deficiency syndrome (AIDS) or AIDS-related complex and lymphocytic interstitial pneumonia are reported. All patients presented with progressive dyspnea, nonproductive cough, fever, anorexia, weight loss, and arterial hypoxemia. Chest roentgenograms exhibited bilateral diffuse reticular-nodular densities. The diagnosis of lymphocytic interstitial pneumonia was made by fiberoptic bronchoscopy or open lung biopsy. Two patients were treated with corticosteroids, with significant improvement. The third patient died of pneumonia due to Pneumocystis cariniisix months after the diagnosis of lymphocytic interstitial pneumonia was established. Serum antibodies to human immunodeficiency virus (HIV) were demonstrable in the two patients in whom the test was performed. Lymphocytic interstitial pneumonia is probably another pulmonary manifestation of AIDS or AIDS-related complex. Although the clinical presentation may be identical to the more common opportunistic infections, the treatment differs, and the prognosis may be better.

An analysis of gallium-67 (67Ga) uptake in the lacrimal and salivary glands and intrathoracic lymph nodes was made in 162 patients with sarcoidosis, consisting of a large number with chronic “fibrotic” disease, and 167 HIV-positive patients (most of whom have/had AIDS). This study was designed to further assess the diagnostic sensitivity and to fully evaluate the diagnostic specificity of chest radiographic and/or 67Ga uptake findings found to be characteristic of sarcoidosis. A lambda 67Ga uptake image or a panda 67Ga uptake image with associated bilateral, symmetrical hilar lymphadenopathy (BSHL) or bilateral, symmetrical parenchymal infiltration indicative of pulmonary fibrosis on chest radiograph (BSIF) was commonly present in sarcoidosis. These distinctive 67Ga uptake images were frequently observed in patients with normal chest radiographs (stage 0 [33 percent]), as well as in patients with BSHL on chest radiograph whether the disease was in an “early” stage, te, stages I (74 percent) and II (90 percent) or a chronic “fibrotic” stage, ie, IVa (71 percent). A panda 67Ga uptake image was observed in 8 percent of HIV-positive patients; however, a lambda 67Ga uptake image alone or any of the other chest radiographic and/or 67Ga uptake patterns distinctive for sarcoidosis were notobserved in any of 167 HIV-positive patients. We conclude that (1) a lambda 67Ga thoracic image (usually associated with a panda 67Ga uptake image) or a panda 67Ga uptake image together with BSHL or BSIF on chest radiograph represent distinctive patterns that are highly specific and sensitive for the noninvasive diagnosis of the majority of sarcoidosis patients, and (2) the finding of a panda 67Ga uptake image, not associated with BSHL or BSIF on chest radiograph, should suggest, in addition to a limited number of readily diagnosable disorders, the presence of a positive HIV status.

Fifty-four of 616 patients (9 percent) with sarcoidosis exhibited upper lung field radiographic abnormalities, which mimicked adult tuberculosis. Difficulty in diagnosis occurred when patients presented with residual upper zonal shadows, which had persisted after clearing of lower and midzonal densities. The abnormalities of sarcoidosis appeared as streaks and nodules simulating acinonodose tuberculosis. Contraction of the upper zones with retraction of the mediastinal structures may be just as prominent as in fibrotic tuberculosis. Bullae can sometimes be mistaken for tuberculous cavities, and small multiple radiolucencies may be mistaken for tuberculous bronchiectasis. Awareness that upper zonal sarcoidosis represents a residual manifestation of the more usual pattern of hilar adenopathy and diffuse lower and midzonal infiltrations, aids in distinguishing this radiographic pattern from that of adult tuberculosis. Obtaining a radiograph dating back to an earlier stage can be crucial in making this differentiation. When confronted with upper lung field abnormalities, the diagnosis of sarcoidosis as well as tuberculosis should come to mind and appropriate clinical support should be sought.

1.The distribution of inspired gas was studied by the helium equilibration method using a commercially available apparatus. Of the 26 patients studied, 11 had no cardiac or pulmonary disease, ten had interstitial lung disease and five had obstructive bronchopulmonary disease.2.Previous methods of analysis of the helium equilibration curves were discussed, and a method of standardized plotting was proposed.3.The finding of a significant degree of uneven ventilation in obstructive disease was once more confirmed.4.There was no significant difference in the helium equilibration curves in the control group compared with those of patients with interstitial lung disease.

A 46-year-old man with diabetes mellitus and cadaveric kidney transplant, maintained on a regimen of prednisone and azathioprine, developed a necrotizing pneumonia. The abscess cavity became secondarily infected with Rhizopus and was cured by surgical resection. Secondary invasion of an abscess cavity by Rhizopus and the successful surgical treatment of pulmonary phycomycosis in an immunosuppressed patient have not previously been reported.

We present two cases of sarcoidosis complicated by HIV infection. Each case had a different level of sarcoidosis activity and coexisted with either an AIDS-related infection or a HIV-positive state. Manifestations of sarcoidosis were not apparent in the patient with the AIDS-defining opportunistic infection, but were active in the patient with asymptomatic HIV infection. Both patients had granulomatous reactions to Kveim antigen, and one had such a reaction following an AIDS-defining infection. These findings suggest that non-T-cell mechanisms may be involved in granuloma formation in sarcoidosis.

A 66-year-old diabetic man presented with a bilobar pneumonia two months after aspiration of a chicken bone. Flexible fiberoptic bronchoscopy demonstrated a mass in the bronchus intermedins. Histologic examination of endobronchial biopsy specimens revealed bone fragments, vegetable matter, and sulfur granules containing Actinomyces organisms. The patient responded to bronchoscopic removal of the foreign body and penicillin therapy. To our knowledge, the association of actinomycotic infection with an aspirated endobronchial foreign body has not previously been reported.

Blockade of the platelet GP IIb/IIIa receptor by the monoclonal antibody c7E3 during high-risk coronary intervention reduced the 30-day endpoint of death, MI, or urgent revascularization by 35% in the EPIC trial, but was accompanied by an increase in the rate of major bleeding. In EPIC, heparin was administered as non-weight adjusted bolus doses to a therapeutic activated clotting time (ACT): bleeding increased with maximal in-lab ACT and relative heparin dose. To evaluate the safety and efficacy of weight-adjusted heparin dosing during c7E3 administration (0.25mg/kg bolus, 10mcg/min infusion×12hrs). 103 pts undergoing coronary intervention were randomized to 1 of 2 regimens of heparin in a blinded fashion: 100U/kg bolus+additional doses to achieve ACT>300sec (Standard Dose, n=51), or 70U/kg bolus without ACT adjustment (Low Dose, n=52). ACT values immediately prior to intervention (median and interquartile range) and bleeding complications (unrelated to CABG) during the first 36hrs (compared to 708 EPIC pts receiving same c7E3 dose). femoral hematoma>5cm in size, and in-hospital death or MI were:EPIC Non Wt-AdjustedStandard Wt-AdjustedLow Wt-AdjustedHeparinHeparinHeparinACT (sec)398330257(25th, 75th)(356,468)(308,374)(229,288)Major bleeds7.8%1.9%2.0%Minor bleeds17.9%7.7%7.8%HematomaN/A15.4%3.9%Transfusions15.5%7.7%2.0%

A transcutaneous oxygen sensor was used to detect the development of hypoxemia in patients undergoing fiberoptic bronchoscopy. Measurements of transcutaneous Po2(tcPo2) correlated well with arterial Po2(PaO2), and correctly detected all instances when PaO2was less than 65 mm Hg. The sensor was noninvasive and caused no adverse effects.

Over a five-month period, 83 consecutive patients undergoing elective Palmaz-Schatz stent placement in a target vessel of greater than 3.2 mm in diameter were evaluated for early hospital discharge without anticoagulation. Thirty-nine patients failed to meet angiographic or clinical criteria due to the presence of dissection (11 patients), TIMI flow&lt;3 (11), filling defects (7), a persistent angiographic stenosis (6) or stent placement in sole-remaining circulation (4). The average final balloon size after stent placement was 4.5mm (range 3.5 to 6.0 mm) and minimal luminal diameter within the stent was 3.75mm (range 3.0 to 4.0mm). In the remaining 44 patients, intravascular ultrasound (IVUS) was performed after a definitive angiographic result had been obtained to determine if previously established criteria (stenosis, apposition and symmetry) for discharge without anticoagulation had been fulfilled. Twenty-one patients (77%) met criteria after the initial IVUS evaluation and six (23%) after reinflation with larger balloons. Seventeen patients failed to meet IVUS criteria: 14 due to a persistent area stenosis of>15%, one who lacked apposition in an aneurysmal segment, one with an angiographically occult dissection and one who achieved&lt;60% of the reference vessel cross-sectional area. Of the 27 stents meeting IVUS criteria, mean eccentricitywas 0.86 (range 0.75 to 0.98), residual stenosis was -0.8% (range -31 to 15%) and minimal stent diameter 3.82mm (range 3.0 to 5.0mm). One patient met angiographic and IVUS criteria but received prolonged anticoagulation due to preference of the referring physician. Mean elapsed time from stent placement to femoral sheath removal was 8.2 hours (range 1 to 29 hours). Patients were discharged from the hospital within 48 hours of stent placement, all receiving aspirin 325mg per day and ticlopidine 250 mg twice a day. At 30 days of clinical follow-up, no patients experienced stent thrombosis.

Understandably, the swollen plethoric face, the conjunctival edema of chemosis, and the distended neck veins and collaterals that indicate superior vena cava syndrome (SVCS) provoke visions of impending catastrophe. Usually, the radiotherapist or oncologist is summoned to administer emergency treatment, frequently in patients without a proved diagnosis of neoplastic disease. Thereafter, diagnostic procedures may be complicated by radiation reaction, and tissue alterations owing to cytotoxic therapy may impair histological interpretation. If the same patient had presented with a mediastinal mass, but no SVCS, his physician would have embarked on a careful plan of investigation. Perhaps he would employ one or more radiological and radionuclide procedures, but eventually a biopsy would be performed to establish specific histological diagnosis.At least 50% of all patients with SVCS have primary carcinoma of the lung (increasingly, small cell carcinoma). Approximately 15% have lymphoma, 15% have other malignant neoplasms, and 15% have benign disease such

At Scripps Clinic, elective PTCA is performed without formal surgical “backup.” Instead, a policy of “standby cardiopulmonary support (CPS)” and “next available operating room” is used for all patients. Standby CPS is defined as a perfusionist physically present at and dedicated to the catheterization laboratory with immediate access, to the CPS apparatus. Standby CPS is required for all patients undergoing elective coronary intervention. Between January 1989 and June 1994 we performed a total of 2,850 elective coronary intervention procedures. Eleven patients required initiation of emergency CPS. The mean ejection fraction of this group was 50%. Causes of patient decompensation included no reflow (28%), abrupt closure (28%). refractory pulmonary edema (18%), LM dissection (18%), and target vessel perforation (9%). All patients required endotracheal intubation and CPR prior to CPS insertion. Two patients who sustained LM dissection and one patient with an LAD perforation were sustained on CPS for ±60 minutes until an operating room became available. The other 8 (73%) patients went on to complete their coronary interventional procedure while on CPS. A total of 15 lesions in 8 patients were treated; 4 patients required bailout stents.