Large serpiginous thrombus straddling the patent foramen ovale and traversing through mitral and tricuspid valves into both ventricles: a therapeutic dilemma of impending paradoxical embolism and recurrent pulmonary embolism.

A 51-year-old male with history of resected renal cell carcinoma and prior pulmonary embolism presented with tachypnea, tachycardia and progressive dyspnea on exertion. Chest computed tomography revealed bilateral acute pulmonary embolism. Transthoracic echocardiogram showed severe pulmonary hypertension with severe cor-pulmonale and presence of a large worm-like thrombus extending across the foramen ovale, entering both ventricles through the mitral and tricuspid valves. The risks of anti-coagulation, pharmacologic thrombolysis, and surgical thrombectomy, in a hemodynamically stable patient, posed a significant therapeutic dilemma. Ultimately, a collective decision was made to start anticoagulation, without incident. At 1 month follow up, complete resolution of the intracardiac thrombus, pulmonary hypertension, and cor-pulmonale were observed with full clinical recovery of the patient.

Puzzling dyspnea caused by respiratory muscle weakness.

Dyspnea is common in advanced stages of neuromuscular disorders, but it is infrequently the presenting symptom. However, dyspnea is a frequent complaint in a primary care setting but is rarely caused by a respiratory muscle weakness. Consequently, the diagnosis of respiratory muscle weakness often is delayed. First symptoms may occur when respiratory muscles are under increased load, such as when standing in the water higher than the chest, swimming, or in the supine position. We describe a patient in whom dyspnea was the first symptom of amyotrophic lateral sclerosis to remind clinicians of clinical features of respiratory muscle weakness and to help avoid the delay in diagnosis.

What is the role of PFTs in monitoring adverse effects of surgery, drug treatments, radiation therapy, and during hospitalization?

Measurement of various aspects of pulmonary function is a relatively easy, noninvasive, and inexpensive way to gauge the status of the respiratory system. Interest in using these tests to determine risk from medical and surgical interventions stems from their presumed ability to be more sensitive than history or physical examination in detecting underlying lung disease. When coupled with the assumption that early detection of pulmonary abnormalities will lead to alterations in patient management, the ultimate goal of improved patient outcomes becomes very attractive. However, despite advances in technology, achievement of this goal has proved to be more challenging than expected in many areas. This paper attempts to review the literature addressing several of the more difficult of these areas. It is clear that more research, involving more rigorously designed studies, will be necessary, before definitive answers are available.

Racial discordance in spirometry comparing four commonly used reference equations to the National Health and Nutrition Examination Study III.

Diagnosing lung function abnormalities requires application of the appropriate reference equation for a given patient population. Current guidelines recommend the National Health and Examination Study III data set for evaluating patients in the United States. In Caucasian patients, relying on older reference equations, as opposed to those derived from the NHANES III data set, will often result in a different interpretation of a patient's spirometry. The present study assessed whether similar discordance would occur in African-American patients. A cross-sectional analysis of African-American patients undergoing spirometry testing at our hospital was performed. Patients were classified as normal, restricted, obstructed or mixed based upon the ATS/ERS guidelines, using Crapo, Knudson, Morris, Glindmeyer, and NHANES III prediction equations. Differences in classification were evaluated. 4463 subjects were identified, with a mean age of 49.6. Discordance in interpretation was most common when results from prediction equations by Morris, Knudson, and Glindmeyer were compared to NHANES III (24.6%, 26.4%, and 20.1%, respectively). Discordance was less common when comparing Crapo to NHANES III (12.8%). There was a tendency for Knudson, Morris and Glindmeyer to under classify restriction, and for Crapo, Morris, and Glindmeyer to over classify obstruction. There is significant discordance in interpretation when spirometry for African-American patients is referenced to equations published by Crapo, Morris, Knudson, and Glindmeyer, compared to NHANES III.

Discordance in spirometric interpretations using three commonly used reference equations vs national health and nutrition examination study III.

BACKGROUND: Spirometry plays an essential role in the diagnosis and management of pulmonary diseases. The accurate interpretation of spirometric data depends on comparison to a reference population to identify abnormalities in ventilatory function. National guidelines recommended the use of the National Health and Nutrition Examination Study (NHANES) III data set as the preferred reference population for those persons 8 to 80 years of age in the United States. OBJECTIVES: To determine the effect of using NHANES III reference equations, compared to those of Crapo et al (Crapo), Knudson et al (Knudson), or Morris et al (Morris), on spirometric interpretations in non-Hispanic white patients. METHODS: We conducted a cross-sectional study of all white patients undergoing spirometry testing at our hospital from January 2000 through May 2007. Patients were classified as normal, restricted, obstructed, or mixed, based on the American Thoracic Society (ATS)/European Respiratory Society (ERS) guidelines, using the Crapo, Knudson, Morris, and NHANES III prediction equations. Differences in the classifications based on the reference data set were evaluated. RESULTS: At total of 8,733 subjects (62.4% male subjects) were identified, with a mean age of 53 years. Discordance was most common when the results from prediction equations by Knudson and Morris were compared to those of NHANES III (45.5% and 35.3%, respectively). Diagnostic recategorizations occurred less frequently when the prediction equations by Crapo were compared with those of NHANES III (15.9%). Relative to NHANES III, the prediction equations by Knudson, Crapo, and Morris tend to overclassify obstruction and underclassify restriction. CONCLUSIONS: There is significant discordance between the prediction equations put forth by Crapo, Knudson, Morris, and the NHANES III. Our data suggest that the diagnostic reclassification of many patients undergoing pulmonary function testing will occur when ATS/ERS guidelines are implemented. Pulmonologists and other physicians interpreting spirometry need to be aware of the presence and nature of these changes.

Impending paradoxical embolism presenting as a pulmonary embolism, transient ischemic attack, and myocardial infarction.

A 25-year-old man presented with complaints of nonpleuritic, substernal chest pain, dyspnea, and decreasing exercise tolerance. His vital signs were normal, with the exception of an oxygen saturation level of 93% while breathing room air. During his assessment, he developed transient left facial droop, left arm and leg weakness, and an ataxic gait, which lasted 15 min then resolved spontaneously. Cardiac enzyme levels were elevated, and an ECG revealed T-wave inversion in leads III, aVF, V1, and V2 with evolving ST-segment elevation in leads V3 through V5. The findings of a CT scan and MRI of the head were negative; a Doppler ultrasound of the right lower extremity revealed a thrombus extending from the common femoral vein to the popliteal vein. Cardiac catheterization revealed no evidence of epicardial coronary artery disease. CT pulmonary angiography revealed bilateral pulmonary emboli. Transesophageal echocardiography (TEE) showed a 4-cm, dumbbell-shaped mass lodged in a patent foramen ovale, confirming the diagnosis of an impending paradoxical embolism. The patient was started on therapy with unfractionated heparin, and his thrombus resolved spontaneously by hospital day 5. An impending paradoxical embolism is rare but should be suspected in anyone presenting with evidence of both venous and arterial emboli. The therapeutic options include anticoagulation, thrombolysis, and surgical embolectomy. We would propose that initial treatment with anticoagulation therapy and following with serial TEEs may be appropriate therapy in an otherwise stable patient, with surgical embolectomy or thrombolysis reserved for the treatment of thrombi that do not resolve with anticoagulation therapy or for patients with clinical deterioration.

Do specialists differ on do-not-resuscitate decisions?

STUDY OBJECTIVE: Opinions regarding do-not-resuscitate (DNR) decisions differ between individual physicians. We attempted to determine whether the strength of DNR recommendations varies with medical specialty and experience. DESIGN: Written survey. PARTICIPANTS: Physicians from the pulmonary/critical-care medicine (PCCM), cardiology, internal medicine, gastroenterology, hematology/oncology, and infectious disease services as well as the Department of Medicine house staff at our tertiary-care referral center participated in the study. INTERVENTIONS: Physicians were asked confidentially to quantify the strength of their opinions on discussing and recommending DNR orders for each of 20 vignettes made from the summaries of actual cases. Reasons for their opinions and demographic data also were recorded. MEASUREMENTS AND RESULTS: One hundred fifteen of 155 physicians (74%) responded. PCCM physicians (mean [+/- SD] DNR score, 157 +/- 22) more strongly recommended DNR orders than cardiologists (mean DNR score, 122 +/- 32; p = 0.006), house staff (mean DNR score, 132 +/- 24; p = 0.014), and general internists (mean DNR score, 129 +/- 30; p = 0.043). PCCM physicians also trended toward recommending DNR orders for more of the 20 patients described in the vignettes compared to cardiologists (mean DNR number, 16.5 +/- 3.0 vs 11.9 +/- 5.8, respectively; p = 0.066). There were no differences between PCCM physicians and hematology/oncology, infectious disease, and gastroenterology specialists. Among the house staff, the likelihood of recommending a DNR order correlated significantly with increasing years of experience (r = 0.45; p = 0.002). The opposite trend was present in the specialty staff groups. No significant differences in opinion by gender, religion, or personal experiences were found. CONCLUSIONS: The strength of DNR order recommendations varies with medicine specialty and years of training and experience. An awareness of these differences and the determination of the reasons behind them may help to target educational interventions and to ensure effective collaboration with colleagues and communication with patients.