Incidence of complications after carotid sinus massage in older patients with syncope.

OBJECTIVE: To review the incidence of neurological complications occurring after carotid sinus massage performed for diagnostic purposes. DESIGN: Case review and comparison with previously published work. SETTING: Syncope Clinic, Royal Victoria Infirmary, Newcastle-upon-Tyne, and Chelsea and Westminster Hospital, London. PARTICIPANTS: Patients undergoing investigation of dizziness, syncope, or unexplained falls. METHODS: Carotid sinus massage performed for 5 seconds in both supine and erect postures, both before and after atropine. Contraindications to carotid sinus massage were the presence of carotid bruits, recent myocardial or cerebral ischemia, or previous ventricular tachyarrhythmias. RESULTS: Two cases of neurological complications were reported from a total of 500 patients (2000 massage episodes) investigated in one center, giving an incidence of 0.1%. Combining this data with another center performing investigations in a similar fashion, seven neurological complications arose from a total of 5000 massage episodes, an incidence of 0.14%. Reported complications were pyramidal signs in five cases and visual field defects in two. Pyramidal weakness persisted in one case with a pre-existing stroke on the same side, and a visual field loss was permanent in one. CONCLUSIONS: Neurological complications following carotid sinus massage for diagnosis of the carotid sinus syndrome are uncommon and usually transient. Contraindications to carotid sinus massage should be respected and the standardized technique used.

Fertility in men with primary ciliary dyskinesia presenting with respiratory infection.

BACKGROUND: Primary ciliary dyskinesia is characterised by chronic rhinosinusitis, chronic bronchial sepsis (usually with bronchiectasis), dextrocardia in approximately 50% of cases, and male infertility. The latter, described in patients attending infertility clinics, results from immotile but viable spermatozoa. Experience in a respiratory clinic suggests that infertility in men is not invariable. METHODS: The seminal fluid of 12 men with primary ciliary dyskinesia, six with dextrocardia, who presented consecutively with upper and lower respiratory tract sepsis was examined. Nasal ciliary beating was dyskinetic or absent in all cases, and nasal ciliary ultrastructure was abnormal in those 11 patients examined. RESULTS: Viable but immotile spermatozoa with abnormal tail ultrastructure were found in the ejaculate of only two patients. Two other patients had apparently fathered children; seminology in both these cases showed a normal spermatozoa count, one with normal spermatozoal motility and normal ultrastructure, the other with moderately reduced spermatozoal motility and abnormal ultrastructure (dynein arm deficiency on the peripheral microtubule doublets). A further two patients had normal spermatozoa counts, normal spermatozoa tail ultrastructure, and normal or only moderately reduced motility of spermatozoa. The spermatozoa of one patient were normally motile but there was severe oligozoospermia, and five patients were azoospermic. CONCLUSIONS: Not all men with primary ciliary dyskinesia have immotile spermatozoa. Seminal analysis is recommended in men with primary ciliary dyskinesia so that accurate counselling about reproductive capability may be given.

Tracheal stenosis due to bilateral arterial aneurysms.

The case is presented of an 82 year old woman with breathlessness, stridor, and upper mediastinal widening on chest radiography. Computed tomographic scanning showed tracheal compression by aneurysms of the brachiocephalic and left common carotid arteries.

Oral verapamil with chemotherapy for advanced non-small cell lung cancer: a randomised study.

To determine if the chemotherapy resistance of non-small cell lung cancer could be modified by oral verapamil, 72 patients were entered into a randomised trial of verapamil plus chemotherapy vs the same chemotherapy alone. Verapamil 480 mg day-1 was given for 3 days starting 24 h prior to chemotherapy which consisted of bolus vindesine 7 mg followed by ifosfamide/mesna 5 g m-2 over 24 h, followed by mesna alone for a further 8 h. Cycles were repeated every 3 weeks for up to six courses. Sixty-six patients were eligible for tumour response analysis and responses occurred in 41% of those randomised to chemotherapy plus verapamil and in 18% of those randomised to chemotherapy alone (P = 0.057). Median survival from start of treatment was significantly better in the verapamil arm (P = 0.02). Toxicity of the combination of chemotherapy plus verapamil was principally neurological and was manageable. Thus the addition of oral verapamil to vindesine/ifosfamide chemotherapy is feasible and in this study was associated with improved outcome. Further confirmation of these observations is required in non-small cell lung cancer, a tumour characterised by resistance to conventional chemotherapy.

Communicating the diagnosis of lung cancer.

In order to assess their reaction to the information given, 50 patients underwent a semi-structured interview with a social worker within 1 week of having been told the diagnosis of lung cancer. There were 32 men and 18 women with a mean age of 63 (range 38-82) years. Thirty-eight (76%) belonged to Registrar General social class IV or V, and 45 (90%) had left school at the age of 15 years. Two patients were unaware of the diagnosis despite having been told that they had lung cancer. Two patients would have preferred not to have been told the diagnosis and two were unsure, while 46 (92%) felt that telling them the diagnosis truthfully had been correct. No patient felt that they had been given too much information, but 13 (26%) indicated a lack of information about prognosis. Despite being told 'bad news', 31 (62%) felt more reassured after their interview with the doctor, 5 (10%) felt less reassured, and 14 (28%) were uncertain. Twenty-one (42%) patients were experiencing a sense of guilt or regret at having smoked. Many patients had concerns about specific symptoms which they expected to suffer. In general, patients wanted to be told their diagnosis truthfully and required a high level of information. Many patients felt reassured by the discussion of such details.

Radiological evidence of progression of bronchiectasis.

Radiological evidence of progression of bronchiectasis was sought in a group of 84 consecutive adult patients admitted to a tertiary unit with a particular interest in the disease. Methodical comparison for each patient of the earliest and most recent chest X-rays (n = 84), bronchograms (n = 1) and thoracic computed tomography (CT) scans (n = 32) was performed. Fifteen patients (18%) were considered to show radiological evidence of progression of bronchiectasis, 14 on chest X-ray, two of whom also showed progression on CT scans, and in one patient on bronchography alone. The likelihood of finding evidence of radiological progression increased the longer the interval between examinations. Serial radiology allows identification of patients with progression of disease and indicates the need to review management strategy.

Pneumolysin induces the salient histologic features of pneumococcal infection in the rat lung in vivo.

Streptococcus pneumoniae infections are common, but how they cause host tissue injury and death is incompletely understood. Immunization with pneumolysin, a thiol-activated toxin produced by the pneumococcus, partially protects animals during subsequent infection. The mechanism by which pneumolysin contributes to disease is not known. The aim of the present investigation was to determine the histologic changes induced by recombinant pneumolysin in the rat lung and to compare them with the changes induced by live organisms. Injection of either toxin (200 or 800 ng) or bacteria into the apical lobe bronchus was associated with the development of a severe lobar pneumonia restricted to the apical lobe. The changes induced by the toxin were greater at the higher concentration, and changes were most severe in those animals in which there was partial ligation of the apical lobe bronchus. The pneumonitis was less severe following injection of a modified toxin with decreased hemolytic activity, generated by site-directed mutagenesis of the cloned pneumolysin gene, indicating that this property of the toxin was important in generating pulmonary inflammation. There was still considerable pneumonitis after injection of a modified toxin with decreased capacity to activate complement.

Comparison of thin section computed tomography with bronchography for identifying bronchiectatic segments in patients with chronic sputum production.

Computed tomography is widely used in the investigation of patients in whom bronchiectasis is suspected, despite considerable variation in its reported sensitivity and specificity. The findings with 3 mm high resolution computed tomography were compared at segmental level with bronchography by two radiologists independently in 27 patients (aged 20-67 years) undergoing investigation of chronic sputum production. Fifteen patients were found to have bronchiectasis by both investigations. Five were identified by computed tomography alone, including two in whom disease was revealed in segments underfilled at bronchography. The sensitivity of computed tomography compared with bronchography in the diagnosis of bronchiectasis at segmental level was 84% and the specificity 82%. The predictive value of computed tomography in the diagnosis of bronchiectasis was 38% overall, but increased to 75% when only those segmental bronchi moderately or severely dilated on the computed tomography scan were considered. There was no relation between the degree of bronchial wall thickening on the computed tomogram and the diagnosis of bronchiectasis by bronchography. Bronchography may be avoided in patients being considered for surgical resection of their bronchiectasis in whom computed tomography shows diffuse disease.

Effect of pyocyanin and 1-hydroxyphenazine on in vivo tracheal mucus velocity.

Products of the bacterium Pseudomonas aeruginosa have been shown to slow the beating of human respiratory tract cilia in vitro. We have tested the effects of two of these compounds, pyocyanin and 1-hydroxyphenazine (given as a bolus dose dissolved in 2 microliters Ringer solution), on tracheal mucus velocity of radiolabeled erythrocytes in anesthetized guinea pigs. 1-Hydroxyphenazine (200 ng) caused a rapid slowing of tracheal mucus velocity (maximum fall 47% at 20 min) with recovery by 1 h. The effect of pyocyanin was slower in onset, 600 ng causing 60% reduction in tracheal mucus velocity at 3 h, and no recovery occurred. A combination of pyocyanin and 1-hydroxyphenazine produced an initial rapid slowing equivalent to the same dose of 1-hydroxyphenazine given alone, but the later slowing attributed to pyocyanin was greater than the same dose administered alone. This study demonstrates one mechanism by which products of P. aeruginosa may facilitate its colonization of the respiratory tract.

Chest pain in chronic sputum production: a neglected symptom.

One hundred and fifteen patients (80 with bronchiectasis and 35 with mucus hypersecretion alone) who produced sputum on a daily basis were asked if they had suffered chest pain unassociated with an acute exacerbation of their chest symptoms during the last six months. Those with bronchiectasis complained of 28 separate pains of which 18 were considered to be of respiratory origin. Seventeen of these 18 pains were in an area associated with a bronchiectatic lobe(s). Only six chest pains (three considered to be of respiratory origin) were found among the 35 patients with mucus hypersecretion.