Assessment of the Physiological Adaptations to Chronic Hypoxemia in Eisenmenger Syndrome.

OBJECTIVE: Eisenmenger syndrome is characterized by severe and lifelong hypoxemia and pulmonary hypertension. Despite this, patients do surprisingly well and report a reasonable quality of life. The aim of this study was to investigate whether these patients undergo adaptation of their skeletal and cardiac muscle energy metabolism which would help explain this paradox. DESIGN AND SETTING: Ten patients with Eisenmenger syndrome and eight age- and sex-matched healthy volunteers underwent symptom-limited treadmill cardiopulmonary exercise testing, transthoracic echocardiography and (31) P magnetic resonance spectroscopy of cardiac and skeletal muscle. Five subjects from each group also underwent near infrared spectroscopy to assess muscle oxygenation. RESULTS: Despite having a significantly lower peak VO2 , patients with Eisenmenger syndrome have a similar skeletal muscle phosphocreatine (PCr) recovery, a measure of oxidative capacity, when compared to healthy controls (34.9 s ± 2.9 s vs. 35.2 s ± 1.7 s, P = .9). Furthermore their intracellular pH falls to similar levels during exercise suggesting they are not reliant on early anaerobic metabolism (0.3 ± 0.06 vs. 0.28 ± 0.04, P = .7). While their right ventricular systolic function remained good, the Eisenmenger group had a lower cardiac PCr/ATP ratio compared to the control group (1.55 ± 0.10 vs. 2.17 ± 0.15, P < .05). CONCLUSIONS: These results show that adult patients with Eisenmenger syndrome have undergone beneficial physiological adaptations of both skeletal and cardiac muscle. This may, in part, explain their surprisingly good survival despite a lifetime of severe hypoxemia and adverse cardiopulmonary hemodynamics.

Ehrlichiosis with severe pulmonary manifestations despite early treatment.

It is generally thought that if patients with ehrlichiosis are treated promptly, life-threatening illness can be avoided. We report a patient who sought medical attention 1 day after the onset of symptoms, was immediately given doxycycline, and still had serious illness with generalized edema, pulmonary infiltrates, acute respiratory distress syndrome, and noncardiogenic pulmonary edema, while receiving replacement intravenous fluids. This case alerts physicians to the serious end of the disease spectrum that can occur even though patients are given prompt, appropriate drug treatment at the onset of illness. Further studies are needed to clearly define the mechanisms involved in pulmonary complications and generalized edema, including noncardiogenic pulmonary edema, in patients with ehrlichiosis.

Renal support in critically ill patients: low-dose dopamine or low-dose dobutamine?

OBJECTIVE: Low-dose dopamine has been used in critically ill patients to minimize renal dysfunction without sufficient data to support its use. The aim of this study was to determine whether low-dose dopamine improves renal function, and whether dobutamine, a nondopaminergic inotrope, improves renal function. DESIGN: Prospective, randomized, double-blind trial. PATIENTS: Twenty-three patients at risk for renal dysfunction were entered into the study. Five patients were later withdrawn. Study data for the remaining 18 patients were: mean age 55 yrs; mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 18; mean weight 71 kg). The following conditions were present: mechanical ventilation (n = 17 [inverse-ratio ventilation, n = 6]); inotrope administration (n = 11); sepsis (n = 13); and adult respiratory distress syndrome or multiple organ failure syndrome (n = 9). INTERVENTIONS: The study patients were administered dopamine (200 micrograms/min), dobutamine (175 micrograms/min), and placebo (5% dextrose) over 5 hrs each in a randomized order. Ventilator settings, fluid management, and preexisting inotropic support were not altered during the study. MEASUREMENTS AND MAIN RESULTS: Systemic hemodynamic values and indices of renal function (4-hr urine volume, fractional excretion of sodium, and creatinine clearance) were measured during the last 4 hrs of each infusion. Dopamine produced a diuresis (145 +/- 148 mL/hr) compared with placebo (90 +/- 44 mL/hr; p < .01) without a change in creatinine clearance. Conversely, dobutamine caused a significant increase in creatinine clearance (97 +/- 54 mL/min) compared with placebo (79 +/- 38 mL/min; p < .01), without an increase in urine output. CONCLUSIONS: In stable critically ill patients, dopamine acted primarily as a diuretic and did not improve creatinine clearance. Dobutamine improved creatinine clearance without a significant change in urine output.

Extrathoracic and intrathoracic removal of O3 in tidal-breathing humans.

We measured the efficiency of O3 removal from inspired air by the extrathoracic and intrathoracic airways in 18 healthy, nonsmoking, young male volunteers. Removal efficiencies were measured as a function of O3 concentration (0.1, 0.2, and 0.4 ppm), mode of breathing (nose only, mouth only, and oronasal), and respiration frequency (12 and 24 breaths/min). Subjects were placed in a controlled environmental chamber into which O3 was introduced. A small polyethylene tube was then inserted into the nose of each subject, with the tip positioned in the posterior pharynx. Samples of air were collected from the posterior pharynx through the tube and into a rapidly responding O3 analyzer yielding inspiratory and expiratory O3 concentrations in the posterior pharynx. The O3 removal efficiency of the extrathoracic airways was computed with the use of the inspiratory concentration and the chamber concentration, and intrathoracic removal efficiency was computed with the use of the inspiratory and expiratory concentrations. The mean extrathoracic removal efficiency for all measurements was 39.6 +/- 0.7% (SE), and the mean intrathoracic removal efficiency was 91.0 +/- 0.5%. Significantly less O3 was removed both extrathoracically and intrathoracically when subjects breathed at 24 breaths/min compared with 12 breaths/min (P less than 0.001). O3 concentration had no effect on extrathoracic removal efficiency, but there was a significantly greater intrathoracic removal efficiency at 0.4 ppm than at 0.1 ppm (P less than 0.05). Mode of breathing significantly affected extrathoracic removal efficiency, with less O3 removed during nasal breathing than during either mouth breathing or oronasal breathing (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Capture methods in five subspecies of free-ranging bighorn sheep: an evaluation of drop-net, drive-net, chemical immobilization and the net-gun.

Six hundred thirty-four bighorn sheep (Ovis canadensis) were captured in the western United States between 1980 and 1986, using four different methods: drop-net (n = 158), drive-net (n = 249), chemical immobilization (n = 90) and net-gun (n = 137). The net-gun was found to have considerable advantages over the use of ground nets and chemical immobilization methods for capturing bighorn sheep. Evaluation of specific outcome categories for individual sheep, including normal, compromised (stress-induced), mortality from capture myopathy (CM), and accidental mortality, revealed significant differences in these rates between capture groups (P less than 0.05). The use of the net-gun resulted in the lowest proportion of compromised sheep at 11% (15/137), had no CM mortality, and resulted in a 2% (2/137) accidental mortality. The use of drop-nets resulted in 15% compromised sheep (24/158), a CM mortality rate of 2% (3/158), and an accidental mortality rate of 1% (2/158). A similar proportion of sheep were compromised with the drive-nets (16%, 39/249). This method also had the highest CM mortality rate at 3% (7/249), and an accidental mortality rate of less than 1% (2/249). Chemical immobilization resulted in the most compromised sheep at 19% (17/90), had a CM mortality rate of 2% (2/90), and caused the most accidental deaths at 6% (5/90). Drop-nets and drive-nets were comparable when combining total mortality with rates for compromised bighorn sheep, 18% and 19%, respectively (29/158 and 48/249). Chemical immobilization had the highest combined measure of risk at 27% (24/90) and net-gun lowest at 12% (17/137).(ABSTRACT TRUNCATED AT 250 WORDS)

Retrospective analysis of Naval Special Boards of Flight Surgeons, 1974-83.

The Naval Special Board of Flight Surgeons was established in 1956 for the evaluation of Navy, Marine Corps, and Coast Guard problem aeromedical cases. This paper examines a sample 248 of these cases for the period of 1974-83 with respect to the characteristics of those referred, their referral diagnostic category, and the recommendation of the Special Board regarding return to a flying status. Those cases with a referral diagnostic category of ENT and Ophthalmology were less likely to be returned to flight status. Older, more senior pilots, and pilots with more total flight time were less likely to be returned to unrestricted flying than were their younger, more junior, and less experienced counterparts. Otherwise, no significant difference in outcome based on age, rank, marital status, branch of service, specialty, or flight hours was detected. Overall, 61% of those evaluated by the SBFS were returned to flight status.

Survey of desert bighorn sheep in California for exposure to selected infectious diseases.

From February 1983 to June 1985, 188 desert bighorn sheep (Ovis canadensis nelsoni, = 161 and Oc cremnobates, = 27) from 18 herds in 17 mountain ranges and one captive herd were caught, marked, and had blood, fecal, and nasal mucus samples collected. Nasal swab specimens were cultured bacteriologically and virologically specifically for parainfluenza-3 (PI-3) virus. Bacterial flora differed from herd to herd. Pathogenic pneumophilic bacteria (eg, Pasteurella sp) seldom were found. Parainfluenza-3 virus was isolated from 6 bighorn sheep in 3 herds. Fecal specimens were examined for parasite ova and low numbers of lungworm (Protostrongylus sp) larvae were found in feces from 2 herds. Sera were evaluated for antibodies against respiratory syncytial virus, ovine progressive pneumonia, infectious bovine rhinotracheitis, PI-3, bovine viral diarrhea, brucellosis, leptospirosis, contagious ecthyma, bluetongue, and epizootic hemorrhagic disease. Blood clots were cultured virologically for bluetongue and epizootic hemorrhagic disease. Serologic evidence of bluetongue and/or epizootic hemorrhagic disease was found in 9 herds, and bluetongue virus (serotypes 10,11,13 and 17) was isolated from 3 herds. Antibody titers against PI-3 and respiratory syncytial virus were found in 9 and 13 herds, respectively. Evidence of bovine viral diarrhea infection was found in 6 herds, whereas infectious bovine rhinotracheitis was found in only 1 herd. Antibody titers against contagious ecthyma were found in 9 of 18 herds in California, and active lesions were seen occasionally. Evidence of ovine progressive pneumonia, leptospirosis, or brucellosis was not found.

Chest injuries in road trauma.

A review of major chest injuries sustained by road crash victims attending the Preston and Northcote Community Hospital over the four-year period 1971 to 1974 highlights the vulnerability of car occupants to this type of injury, particularly those involved in side-impact collisions. In this type of collision seat-belt restraint does not influence the incidence of chest injury. Major injuries to other body areas and the delayed development of serious pulmonary complications call for continuous expert medical cae with the use of the facilities of an intensive care ward. The range of complications in a survey of 60 such patients admitted to hospital in 1974 is highlighted. A regime of management is outlined.