Ninety years old male was admitted to hospital due to breathlessness. The prominent findings were extensive blue-grey skin pigmentation and large left chylothorax. Drug induced lupus was diagnosed due to either minocycline chronic treatment or no alternative illness to explain his sub-acute disease. Minocycline therapy was stopped with gradual improvement of pleural effusion and skin discoloration. This case is the first presentation of minocycline induced lupus with chylothorax.

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.

Objective: To evaluate and compare retrospectively the physiological effect of beta blockers versus vasodilators in the treatment of hypertensive patients (pts). Methods: 42 diagnosed hypertensive pts (24 male, 18 female) were studied. They were divided into two groups: (1) 16 patients treated with vasodilators only and (2) 26 patients treated only with beta blockers. A cardiopulmonary exercise test (CPET) was performed in all pts while they were taking their medications as usual. The following indices were monitored and measured breath by breath during exercise: heart rate (HR), blood pressure (BP), oxygen consumption (VO2), oxygen pulse (O2P), ventilatory anaerobic threshold (VAT) and respiratory exchange ratio (RER). Maximal exercise capacity was considered as RER having reached a value of at least 1.15. Peak values of the CPET indices were compared between the two groups for each index separately by the two-tailed Student T test. P values < 0.05 were considered statistically significant. Results: No significant differences were observed between groups A and B, respectively, as follows: age 58 ± 13 vs 59 ± 10; RER 1.17 ± 0.12 vs 1.17 ± 0.1; and peak O2P 108 ± 13 vs 102 ± 33. Significant differences between the two groups were observed in: peak HR (% of predicted HR) 90 ± 8 vs 69 ± 12; peak VO2 (% of predicted VO2) 96 ± 9 vs 69 ± 11; and VAT (% of max VO2 predicted) 55 ± 8 vs 43 ± 9 (p < 0.05). Conclusions: Beta blockers in the treatment of hypertensive patients demonstrate a significant physiological disadvantage compared to vasodilator treatment. These findings further validate the CPET as an important tool for physiological evaluation of various treatments in hypertensive patients. J Clin Basic Cardiol 2008; 11 (online): 8–10.

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.

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 populationOBJECTIVES: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.

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.

BACKGROUND While increasing numbers of patients require prolonged mechanical ventilation, resources for weaning are either limited (ICU beds) or inadequate (general wards). OBJECTIVES To report on our initial experience over a 7 month period with an eight-bed mechanical ventilation weaning unit. METHODS Sixty-nine patients requiring MV for > 10 days were admitted to the unit (nurse:patient ratio 1:4). Data collected included reason for MV, duration of hospital stay, and MVWU course. Outcome results (successful weaning and mortality) were compared to those in historic controls (patients ventilated in the general wards over a 4 month period prior to the MVWU; n = 100). RESULTS The mean age of the patients was 68 +/- 16.6 years and hospital stay prior to MVWU admission 28.6 +/- 24.2 days (range 10-72). The main reasons for MV included acute exacerbation of chronic obstructive pulmonary disease (31%) and recent pneumonia (28%). Mean MVWU stay was 13.5 +/- 15.7 days (range 1-72 days). Thirty-four patients (49%) underwent tracheostomy. Fourteen patients required admission to the ICU due to deterioration in their status. Twenty-nine patients (42%) were successfully weaned and discharged to the wards. A further 20 patients were transferred to the chronic ventilation unit of a regional geriatric rehabilitation hospital, where 5 were subsequently weaned and 15 required prolonged ventilation. Compared to controls (matched for age and reason for mechanical ventilation), more MVWU patients underwent successful weaning (49% vs. 12%, P < 0.001) and their mortality rate (n = 12) was significantly lower (17% vs. 88%, P < 0.001). CONCLUSION The higher level of care possible in a MVWU may result in a significantly improved rate of weaning and lower mortality. The assessment of long-term outcome in patients discharged to pulmonary rehabilitation centers requires further investigation.

Spontaneous pneumothorax of native lung after single lung transplantation is a rare but well-known complication. Four cases of spontaneous pneumothorax after single lung transplantation in our patients are presented, primary lung disease was emphysema in 3 patients and idiopathic pulmonary fibrosis in 1. In 3 cases, pneumothorax was treated successfully with chest tube; in 1, pneumonectomy was needed for the management of a persistent air leak. Two patients died later of progressive chronic rejection; 1 had unexplained sudden death. One patient is well 8 years posttransplantation. Our experience of spontaneous pneumothorax of native lung after single lung transplantation demonstrated that this rare complication occurs more in patients with emphysema. This complication is successfully treated with standard therapy, but these patients are prone to other fatal complications such as bronchiolitis obliterans or sudden death.

Large vessel aneurysm is not a classical finding in Wegener's granulomatosis. We describe a case report of WG complicated by subclavian artery aneurysm and review the literature on large-vessel and medium-vessel aneurysms in WG. The involved arteries included the aorta and the hepatic, renal, and left gastric arteries. In all but one case, abdominal pain was the presenting symptom. Treatment included medical and vascular interventions. In two patients, the involved vessel ruptured, leading to massive hemorrhage and death. We concluded that unexplained abdominal pain or extremity ischemia in patients with WG should alert the physician to the possibility of a large-vessel or medium-vessel aneurysm.

Lidocaine is an anesthetic drug that has been shown to be effective for cough suppression during bronchoscopy. Previous reports have suggested that intravenous lidocaine may be more effective than local lidocaine in preventing bronchospasm and in attenuating cough. The purpose of this study was to compare the efficacy of lidocaine administered topically or intravenously on cough suppression during elective flexible bronchoscopy. Sixty-four patients undergoing bronchoscopy were assigned randomly to receive lidocaine spray alone, intravenous lidocaine with lidocaine spray, or inhaled nebulized lidocaine solution. All patients received standard sedation with meperidine and midazolam. Cough was scored qualitatively and quantitatively by an independent observer during the procedure. Administration of additional intravenous sedation or intrabronchial lidocaine solution was recorded. The three groups were similar with regard to demographic parameters. Cough scores for the spray, intravenous, and inhaled lidocaine groups were 71.9, 73.4, and 83.7 points respectively (p = 0.87). The patients who received inhaled lidocaine required more intravenous midazolam and intrabronchial lidocaine during the procedure. No significant advantages were found for any of the routes of administration with regard to cough suppression. More patients receiving intravenous lidocaine were drowsy after the procedure. Intravenous lidocaine was without additional benefit in combination with local lidocaine compared with local lidocaine alone for cough suppression during elective bronchoscopy.

Large vessel aneurysm is not a classical finding in Wegener's granulomatosis. We describe a case report of WG complicated by subclavian artery aneurysm and review the literature on large-vessel and medium-vessel aneurysms in WG. The involved arteries included the aorta and the hepatic, renal, and left gastric arteries. In all but one case, abdominal pain was the presenting symptom. Treatment included medical and vascular interventions. In two patients, the involved vessel ruptured, leading to massive hemorrhage and death. We concluded that unexplained abdominal pain or extremity ischemia in patients with WG should alert the physician to the possibility of a large-vessel or medium-vessel aneurysm.

RESUMO: A Lidocaína é um medicamento anestésico eficaz na supressão da tosse durante a Broncofibroscopia.Trabalhos recentes sugerira que a Lidocaína endovenosa é mais eficaz do que a Lidocaína local na prevenção do broncoespasmo e da tosse durante a Broncofibroscopia.Neste estudo, os autores decidiram comparar a eficácia da lidocaína aplicada localmente e administrada endovenosamente na supressão da tosse durante a broncofibroscopia electiva.Os autores estudaram 64 doentes que foram submetidos a broncofibroscopia, tendo sido randomizados em três grupos, os que realizaram apenas Lidocaína-Spray, os que fizeram Lidocaína endovenosa e os que fizeram Lidocaína em aerossol. Todos os doentes foram submetidos a sedação com Midazolan.A tosse foi avaliada qualitativamente e quantitativamente durante a broncofibroscopia por um observador independente.A administração adicional de sedação e Lidocaína foi registada.Os registos da tosse para os três grupos – Lidocaína – Spray, Lidocaína endovenosa e Lidocaína em aerossol são respectivamente 71,9, 73,4 e 83,4 pontos (n=0,87) os doentes que fizeram aerossol de Lidocaína necessitaram de mais sedação e de Lidocaína local endobrônquica.Não se verificam vantagens reais nos diversos grupos, particularmente em relação à supressão da tosse durante Broncofibroscopia. COMENTÁRIO: Analisando os resultados do trabalho, pensamos que a tolerância à broncofibroscopia utilizando a metodologia habitual com lidocaína local é excelente, não havendo complicações major na maioria dos casos.O eventual benefício que os autores esperavam, utilizando lidocaína endovenosa, não foi encontrado, particularmente na supressão da tosse e no eventual broncoespasmo desencadeado pela lidocaína em spray e pelo aerossol de lidocaína.Perante a análise dos métodos e dos resultados, pensamos não haver indicação para lidocaína e. v. nesta situação e que devemos continuar a realizar as broncofibroscopias com aplicação tópica de lidocaína endobrônquica. Palavras-chave: Broncofibroscopia, Lidocaína

A Lidocaína é um medicamento anestésico eficaz na supressão da tosse durante a Broncofibroscopia.