Efecto de un programa de ejercicio en pacientes sedentarios. Beneficio metabólico y en calidad de vida / Effect of an exercise program on sedentary patients. Metabolic benefit and quality of life

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Involvement of miR-200b-PKCα signalling in pulmonary hypertension in cor pulmonale model.

The right ventricle (RV) enlargement and pulmonary fibrosis are involved in cor pulmonale. The role of miR-200b in cor pulmonale is less well understood. This study was designed to evaluate the regulatory roles of miR-200b in cor pulmonale. Cor pulmonary mouse model was built via monocrotaline injection of monocrotaline (MCT). The expression of miR-200b in the lungs, RV and left ventricle (LV) are using real-time polymerase chain reaction. The transthoracic echocardiography was employed to determine the effects of miR-200b mimics and Gö6976 injection on MCT mice. The protein levels of protein kinase C α (PKCα), collagen, and fibronectin in the lung, RV, and LV in the mice with and without miR-200b mimics and Gö6976 injection were evaluated using western blot. The expression of miR-200b decreased in MCT mice, while there was no difference in LV. Both the miR-200b mimics and Gö6976 injection reversed the muscularization in the pulmonary artery, reversed RV hypertrophy, reduced RV systolic pressure, wall thickness and pulmonary fibrosis. The injection of miR-200b can reduce the PKCα expression in the lung, RV, and LV. This study confirmed the down-regulation of miR-200b in cor pulmonale. The reverse effects of miR-200b in the present study may provide a potential tool for cor pulmonary treatment.

Terapias intervencionistas en hipertensión pulmonar / Interventional therapies in pulmonary hypertensions

A pesar de los avances en el tratamiento farmacológico de la hipertensión pulmonar, en particular de la hipertensión arterial pulmonar (HAP), sigue siendo una enfermedad mortal. La insuficiencia ventricular derecha (IVD) debida a HAP refractaria a tratamiento finalmente se produce y permanece como una causa importante de muerte en estos pacientes. Disminuir la impedancia pulmonar con diferentes fármacos específicos para HAP es el objetivo terapéutico obvio en la IVD secundaria a una poscarga crónicamente aumentada. Sin embargo, se puede esperar una ganancia clínica potencial a partir de los intentos para descargar el corazón derecho y aumentar el gasto cardiaco. La septostomía auricular, la anastomosis de Potts y la denervación de la arteria pulmonar son procedimientos intervencionistas que sirven para este propósito. La angioplastia pulmonar percutánea con balón, otra terapia intervencionista, ha resurgido en los últimos años como una alternativa clara para el tratamiento de pacientes con hipertensión pulmonar tromboembólica crónica distal no operable. En esta revisión se presentarán los antecedentes fisiológicos, la evidencia experimental y los posibles beneficios clínicos y hemodinámicos de todas estas terapias de intervención con respecto a su uso en el contexto de la IVD secundaria a hipertensión pulmonar grave

Despite advances in drug therapy, pulmonary hypertension-particularly arterial hypertension (PAH)-remains a fatal disease. Untreatable right heart failure (RHF) from PAH eventually ensues and remains a significant cause of death in these patients. Lowering pulmonary input impedance with different PAH-specific drugs is the obvious therapeutic target in RHF due to chronically increased afterload. However, potential clinical gain can also be expected from attempts to unload the right heart and increase systemic output. Atrial septostomy, Potts anastomosis, and pulmonary artery denervation are interventional procedures serving this purpose. Percutaneous balloon pulmonary angioplasty, another interventional therapy, has re-emerged in the last few years as a clear alternative for the management of patients with distal, inoperable, chronic thromboembolic pulmonary hypertension. The current review discusses the physiological background, experimental evidence, and potential clinical and hemodynamic benefits of all these interventional therapies regarding their use in the setting of RHF due to severe pulmonary hypertension

Left lung hypoplasia with a right tuberculous pleural effusion after childbirth: A case report.

RATIONALE: Unilateral hypoplasia of the lung is a rare congenital condition, the mechanism of which is poorly understood. Primary pulmonary hypoplasia occurring in an adult is extremely rare and we present what is probably the first case of a link to a tuberculous pleural effusion in a young woman after childbirth. PATIENT CONCERNS: Herein, we describe a 31-year-old woman with left lung hypoplasia, and she not only survived to adulthood without problems, but was able to deliver a baby in natural labor. DIAGNOSES: Left lung hypoplasia, right tuberculous pleural effusion. INTERVENTIONS: We initiated an anti-tuberculosis treatment for this patient with dose adjustments to her weight of isoniazid (0.3 g/day), rifampicin (0.45 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for 2 months then isoniazid and rifampicin for another 4 months. OUTCOMES: Ten days later after beginning therapy, she became afebrile and the pleural effusion resolved. No recurrence was observed during a 6-month follow-up period. LESSONS: In clinical practice, if one sees a chest x-ray revealing complete or incomplete opacification of a hemithorax with volume loss and history of repeated respiratory infections, one should consider the possibility of unilateral pulmonary hypoplasia. In such cases, regular close follow-up is important to minimize infections and to prevent development of cor pulmonale or respiratory failure.

Acute cor pulmonale in ARDS: rationale for protecting the right ventricle.

The ventilatory strategy for ARDS has been regularly amended over the last 40 years as knowledge of the pathophysiology of ARDS has increased. Initially focused mainly on the lung with the objectives of "opening the lung" and optimizing arterial oxygen saturation, this strategy now also takes into account pulmonary vascular injury and its effects on the right ventricle and on hemodynamics. Hemodynamic devices now available at the bedside, such as echocardiography, allow intensivists to evaluate respiratory settings according to right ventricular tolerance. Here, we review the pathophysiology of pulmonary vascular dysfunction in ARDS, consider the beneficial and deleterious effects of mechanical ventilation, describe the incidence and meaning of acute cor pulmonale based on recent studies in large series of patients, and propose a new, although not strictly validated, approach based on the protection of both the lung and right ventricle. One of our conclusions is that evaluating the right ventricle may help intensivists to assess the balance between recruitment and overdistension induced by the ventilatory strategy. Prone positioning with its beneficial effects on the lung and also on hemodynamics (the right ventricle) is a good illustration of this. Readers should be aware that most of the information given in this article reflects the point of view of the authors. Although based on clinical observations, clinical studies, and well-known pathophysiology, there is no evidence-based medicine to support this clinical commentary. Other approaches may be favored, in which case our article should be read as another attempt to help intensivists to improve management of ARDS.

[Pulmonary heart disease--cardiologist's point of view]. / Przewlekle serce plucne--punkt widzenia kardiologa.

This paper presents cardiologist's point of view on definition, diagnosis and treatment of pulmonary heart disease. Difficulties in interpretation of definition in clinical praxis and the role of medical history, physical examination, lung function tests, gasometry, chest X-ray and ECG in initial diagnosis of pulmonary heart disease are described. Author underlines the importance of echocardiographic study and pulmonary hemodynamics in confirmation of diagnosis and in differential diagnosis of "out of proportion" pulmonary hypertension. The current results of specific for pulmonary artery hypertension vasodilatory treatment in patients with pulmonary heart disease are discussed.

[Diuretic resistance and mechanical ventilation in decompensated cor pulmonale: successful treatment by slow continuous ultrafiltration]. / Diuretikaresistenz und Beatmungspflichtigkeit bei dekompensiertem Cor pulmonale: Erfolgreiche Behandlung mit langsamer kontinuierlicher Ultrafiltration.

We report on a 53-year-old male patient who presented with severe dyspnea at rest and massive volume overload because of decompensated cor pulmonale. Furthermore he suffered from stage 3 chronic kidney disease. As there was diuretics resistance and carbon dioxide narcosis, he had to be intubated and ventilated. The massive volume overload could be successfully treated with slow continuous ultrafiltration (SCUF) with removal of a volume of 27.5 l within 3 days. The SCUF therapy is an effective and gentle method to treat even an excessive volume overload based on diuretics resistance.

Protective effects of bone marrow mononuclear cell therapy on lung and heart in an elastase-induced emphysema model.

We hypothesized that bone marrow-derived mononuclear cell (BMDMC) therapy protects the lung and consequently the heart in experimental elastase-induced emphysema. Twenty-four female C57BL/6 mice were intratracheally instilled with saline (C group) or porcine pancreatic elastase (E group) once a week during 4 weeks. C and E groups were randomized into subgroups receiving saline (SAL) or male BMDMCs (2 × 10(6), CELL) intravenously 3h after the first saline or elastase instillation. Compared to E-SAL group, E-CELL mice showed, at 5 weeks: lower mean linear intercept, neutrophil infiltration, elastolysis, collagen fiber deposition in alveolar septa and pulmonary vessel wall, lung cell apoptosis, right ventricle wall thickness and area, higher endothelial growth factor and insulin-like growth factor mRNA expressions in lung tissue, and reduced platelet-derived growth factor, transforming growth factor-ß, and caspase-3 expressions. In conclusion, BMDMC therapy was effective at modulating the inflammatory and remodeling processes in the present model of elastase-induced emphysema.

Ultra-long-term follow-up of pediatric spinal deformity problems: 23 patients with a mean follow-up of 51 years.

BACKGROUND: The aim of this study was to analyze the true outcomes of a unique cohort of patients with spinal deformities who were treated as children and followed for 40 or more years. METHODS: Altogether, 23 patients were reviewed who had been originally treated in our community, whose original charts and radiographs were still available, and who had undergone recent evaluation. RESULTS: The diagnoses were congenital deformity in eight, adolescent idiopathic scoliosis in four, poliomyelitis in three, infantile idiopathic scoliosis in two, spondylolisthesis in two, and one each of tuberculosis and dwarfism. Sixteen had undergone fusion surgery. CONCLUSIONS: Early spine fusion for deformity produced far better results than delayed fusion. A solid fusion at the end of growth remained unchanged. Degenerative changes outside the fusion area were rare and seldom required further surgery. In summary, 23 patients with a mean follow-up of 51 years after treatment are presented. Early fusion was far superior to delayed or nonsurgical treatment.

Congenital thoracic scoliosis with unilateral unsegmented bar and concave fused ribs: rib osteotomy and posterior fusion at 1 year old, anterior and posterior fusion at 5 years old with a 36-year follow-up.

STUDY DESIGN: Case report. OBJECTIVE: To document the 36-year follow-up of a patient with a fusion at age 1 year for congenital scoliosis with a unilateral unsegmented bar, convex hemivertebrae, and fused concave ribs. SUMMARY AND BACKGROUND DATA: Although early spine fusion has been recommended as a life-saving measure for this problem, very little information exists as to the long-term effect of such treatment. METHODS: Original chart, radiographs and photographs were compared to the situation 36 years after surgery. Pulmonary function tests and blood gasses were obtained at follow-up. RESULTS: At age 37, the patient is free of any respiratory complaints, is an avid golfer, is married with 2 children, and the manager of a large factory. His pulmonary volumes are about half of normal, but his blood gasses are normal. CONCLUSION: The early fusion prevented the customary severe progression of this condition and early death due to cor pulmonale. He is a fully functioning member of society. Will more modern treatments with lengthening of the hemithorax provide a better outcome? Only time will tell.

[Pulmonary resection. Postoperative consequences]. / Lungenresektionen. Postoperative Folgezustände.

The physician involved in internal medicine and general practice is confronted with a series of challenges in patients with pulmonary resection. In the early post-operative phase, optimal analgesia and physiotherapy are the primary factors for achieving the best possible function after loss of pulmonary tissue and for the determination of complications. Post thoracotomy syndrome requires interdisciplinary therapy. In the later course, it is necessary to take into consideration effects on pulmonary circulation, on the musculoskeletal system and on the digestive tract as well as sleep disturbances due to diaphragm dysfunction. Corresponding symptoms should be considered and actively sought, for example using echocardiography for assessment of cor pulmonale or outpatient sleep monitoring for detection of sleep-disordered breathing. Thus, aftercare includes much more than the search for a relapse or formation of metastases in cases of the most common cause of pulmonary resection, bronchial cancer.

Is there a safe plateau pressure in ARDS? The right heart only knows.

OBJECTIVE: Airway pressure limitation is now a largely accepted strategy in adult respiratory distress syndrome (ARDS) patients; however, some debate persists about the exact level of plateau pressure which can be safely used. The objective of the present study was to examine if the echocardiographic evaluation of right ventricular function performed in ARDS may help to answer to this question. DESIGN AND PATIENTS: For more than 20 years, we have regularly monitored right ventricular function by echocardiography in ARDS patients, during two different periods, a first (1980-1992) where airway pressure was not limited, and a second (1993-2006) where airway pressure was limited. By pooling our data, we can observe the effect of a large range of plateau pressure upon mortality rate and incidence of acute cor pulmonale. RESULTS: In this whole group of 352 ARDS patients, mortality rate and incidence of cor pulmonale were 80 and 56%, respectively, when plateau pressure was > 35 cmH(2)O; 42 and 32%, respectively, when plateau pressure was between 27 and 35 cmH(2)O; and 30 and 13%, respectively, when plateau pressure was < 27 cmH(2)O. Moreover, a clear interaction between plateau pressure and cor pulmonale was evidenced: whereas the odd ratio of dying for an increase in plateau pressure from 18-26 to 27-35 cm H(2)O in patients without cor pulmonale was 1.05 (p = 0.635), it was 3.32 in patients with cor pulmonale (p < 0.034). CONCLUSION: We hypothesize that monitoring of right ventricular function by echocardiography at bedside might help to control the safety of plateau pressure used in ARDS.

Effects of olmesartan medoxomil as an angiotensin II-receptor blocker in chronic hypoxic rats.

We established a rat chronic alveolar hypoxia in vivo model to evaluate the efficacy against hypoxic pulmonary hypertension of a new angiotensin II-receptor I blocker, olmesartan medoxomil. Three groups of rats were established: rats exposed for 2-6 weeks to 10% oxygen atmosphere in a normobaric chamber; hypoxic rats treated with olmesartan medoxomil oral administration (5 mg/day) every day; and control rats fed in a normoxic condition. After hypoxia treatment, the presence, etiology and severity of pulmonary hypertension, was echocardiographically evaluated, and expressions of brain natriuretic peptide (BNP), transforming growth factor (TGF-beta) and endothelin-1 genes measured by both immunohistochemical assay and real-time polymerase chain reaction. Olmesartan medoxomil significantly reduced the induction of hypoxic cor pulmonale not only on echocardiographical observations but also in BNP, TGF-beta and endothelin gene expressions in molecular studies. However, systolic blood pressure was independent of olmesartan medoxomil. The present study clearly indicates that the angiotensin II-type I-receptor blocker olmesartan medoxomil has significant efficacy for hypoxic cor pulmonale.

Rehabilitation for the home care patient with COPD.

Assessment techniques and treatment strategies, such as medical management, oxygen management, chest physical therapy, and pulmonary rehabilitation, for patients with chronic obstructive pulmonary disease (COPD) are discussed. Clinically appropriate, evidence-based rehabilitation programs for home care may help to reduce care costs, reduce the impact of this chronic disease on patients with COPD, and prevent emergent care and rehospitalization.

[A pilot survey of the main causes of chronic heart failure in patients treated in primary hospitals in China].

OBJECTIVE: The aim of this investigation is to make clear the main causes of chronic heart failure (CHF) in patients who receive management in primary hospitals in China and to provide scientific evidence for the prevention of CHF in primary hospitals in China. METHODS: The first three main causes of CHF were determined in the way of answering questionnaires by local doctors from 2066 local hospitals (from one hospital at least one doctor) in 17 areas, we got 2100 pieces of valid answer. Input these forms to computer 2 times, check repeatedly till being sure that there were no mistakes in them and then make statistics with SPSS soft kit. RESULTS: In primary hospitals in our country, the first three main causes of CHF are coronary heart disease, hypertension and rheumatic heart disease. In some places chronic pulmonary heart disease is also a main cause of CHF in primary hospitals. CONCLUSIONS: The primary and secondary prevention of coronary heart disease and hypertension is certainly important in the prevention of CHF, but it is equally important to prevent rheumatic heart disease and chronic pulmonary heart disease.

Adaptación española de la Guía Europea de Prevención Cardiovascular / Spanish adaptation of the European Guidelines on Cardiovascular Disease Prevention

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Antiremodeling effects of iloprost and the dual-selective phosphodiesterase 3/4 inhibitor tolafentrine in chronic experimental pulmonary hypertension.

Severe pulmonary hypertension is a disabling disease with high mortality. We investigated acute and chronic effects of iloprost, a long-acting prostacyclin analogue, and the dual-selective phosphodiesterase 3/4 inhibitor tolafentrine in monocrotaline-induced pulmonary hypertension in rats. Twenty-eight and 42 days after administration of the alkaloid, right ventricular systolic pressure increased from 25.8+/-2.0 to 62.9+/-3.4 and 70.5+/-7.4 mm Hg, with concomitant decline in cardiac index, central venous oxygen saturation, and arterial oxygenation. Marked right heart hypertrophy was demonstrated by the strongly elevated ratio of right ventricle/left ventricle plus septum weight, and massive thickening of the precapillary artery smooth muscle layer was shown histologically. Western blot analysis demonstrated increased levels of matrix metalloproteinases (MMPs) -2 and -9 and increased gelatinolytic activities in isolated pulmonary arteries. In these animals, both intravenous iloprost and tolafentrine displayed characteristic features of pulmonary vasodilators. When chronically infused from days 14 to 28, both agents significantly attenuated all monocrotaline-induced hemodynamic and gas exchange abnormalities as well as right heart hypertrophy. Full normalization of all variables including right ventricle size was achieved on combined administration of both agents during this period. This was also true for MMP-2 and MMP-9 expression and activity. Moreover, when iloprost plus tolafentrine was used for late therapeutic intervention, with infusion from days 28 to 42 after full establishment of severe pulmonary hypertension and cor pulmonale, hemodynamic, gas exchange, and cardiac and pulmonary vascular remodeling changes were significantly reversed. We conclude that the combined administration of iloprost and a dual-selective phosphodiesterase 3/4 inhibitor prevents and reverses the development of pulmonary hypertension and cor pulmonale in response to monocrotaline in rats. This regimen may therefore offer a possible antiremodeling therapy in severe pulmonary hypertension.

Chronic sildenafil treatment inhibits monocrotaline-induced pulmonary hypertension in rats.

Sildenafil, a phosphodiesterase 5 inhibitor, is currently under investigation for therapy of pulmonary hypertension. This study was designed to investigate chronic effects of sildenafil in monocrotaline (MCT)-induced pulmonary hypertension in rats. Four weeks after a single subcutaneous injection of MCT, the animals displayed nearly threefold elevated pulmonary artery pressure and vascular resistance values, with a concomitant decline in central venous oxygen saturation and arterial oxygenation. Marked right heart hypertrophy was evident, and massive thickening of the precapillary artery smooth muscle layer was histologically apparent. Further deterioration of pulmonary hypertension occurred 6 weeks after MCT injection, with some animals dying during this period because of right heart failure. When chronically administered from Days 14-28, sildenafil significantly increased plasma cyclic guanosine monophosphate and inhibited the development of pulmonary hypertension and right heart hypertrophy, with preservation of gas exchange and systemic arterial pressure. A corresponding efficacy profile was also noted for long-term feeding with sildenafil from Days 28-42. Moreover, the death rate significantly decreased in those animals treated with sildenafil. We conclude that sildenafil attenuates MCT-induced pulmonary hypertension and cor pulmonale in rats.