The lung in progressive systemic sclerosis (scleroderma)

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Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis.

Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life

Baseline Predictors of Sputum Culture Conversion in Pulmonary Tuberculosis: Importance of Cavities, Smoking, Time to Detection and W-Beijing Genotype

Background: Time to detection (TTD) on automated liquid mycobacterial cultures is an emerging biomarker of tuberculosis outcomes. The M. tuberculosis W-Beijing genotype is spreading globally, indicating a selective advantage. There is a paucity of data on the association between baseline TTD and W-Beijing genotype and tuberculosis outcomes. Aim: To assess baseline predictors of failure of sputum culture conversion, within the first 2 months of antitubercular therapy, in participants with pulmonary tuberculosis. Design: Between May 2005 and August 2008 we conducted a prospective cohort study of time to sputum culture conversion in ambulatory participants with first episodes of smear and culture positive pulmonary tuberculosis attending two primary care clinics in Cape Town, South Africa. Rifampicin resistance (diagnosed on phenotypic susceptibility testing) was an exclusion criterion. Sputum was collected weekly for 8 weeks for mycobacterial culture on liquid media (BACTEC MGIT 960). Due to missing data, multiple imputation was performed. Time to sputum culture conversion was analysed using a Cox-proportional hazards model. Bayesian model averaging determined the posterior effect probability for each variable. Results: 113 participants were enrolled (30.1% female, 10.5% HIV-infected, 44.2% W-Beijing genotype, and 89% cavities). On Kaplan Meier analysis 50.4% of participants underwent sputum culture conversion by 8 weeks. The following baseline factors were associated with slower sputum culture conversion: TTD (adjusted hazard ratio (aHR) = 1.11, 95% CI 1.02; 1.2), lung cavities (aHR = 0.13, 95% CI 0.02; 0.95), ever smoking (aHR = 0.32, 95% CI 0.1; 1.02) and the W-Beijing genotype (aHR = 0.51, 95% CI 0.25; 1.07). On Bayesian model averaging, posterior probability effects were strong for TTD, lung cavitation and smoking and moderate for W-Beijing genotype. Conclusion: We found that baseline TTD, smoking, cavities and W-Beijing genotype were associated with delayed 2 month sputum culture. Larger studies are needed to confirm the relationship between the W-Beijing genotype and sputum culture conversion.Publisher's versio

A guide to the rational use of dopamine, dobutamine and isoprenaline in patients who need inotropic support

Which inotropic agent to use to the patient's greatest advantage is a common problem in hospital practice. Sympathetic nervous system physiology is outlined to explain the actions of dopamine, dobutamine and isoprenaline. The following suggestions are made: 1. Where a low-dosage inotropic effect is required, dopamine should probably be used because of the unique benefit of increased renal blood flow. 2. Where there are no tachyarrhythmias, dopamine should be the drug of choice. 3. In the dosages greater than 5-10 μg/kg/min, dopamine should be combined with nitroprusside. 4. If further inotropic activity is required, the effect of dopamine can be increased with the concomitant use of isoprenaline. 5. In the presence of tachyarrhythmias dobutamine may be of benefit

Laryngeal aspergilloma: A complication of inhaled fluticasone therapy for asthma

Primary laryngeal aspergillosis in immunocompetent patients is rare.We describe a case of a 59-year-old woman with laryngeal aspergillosis thought to be secondary to long-term inhaled fluticasone therapy. Laryngeal aspergillosis may be an underrecognized complication of inhaled corticosteroid therapy

The use of the flow-volume loop in assessing the results of laryngotracheal reconstruction

The difficult problem of assessing pre- and postoperative airway function in patients with laryngotracheal upper airway obstruction is discussed. A series of 26 patients with various forms of this problem is presented. The method of performing the flow-volume loop (FVL) is described and the theory behind the investigation is reviewed. Five of the series of 26 patients are described in detail as examples, and the advantages and disadvantages of this investigation are discussed fully. The FVL appears to be the only really objective test to assist the laryngotracheal reconstructive surgeon. It is easily performed in most cases and should form part of the diagnostic and postoperative workup.Articl

Invasive vascular catheterisation in the critically ill

In order to identify potential problems and thereby minimise the risk of invasive vascular catheterisation, we conducted an analysis of these procedures in our medical intensive care unit with the aid of a computer database. During the 9-month study period 114 patients underwent 247 invasive vascular catheterisations, including pulmonary arterial (PA), central venous (CV) and arterial catheter insertions. Complications unique to PA catheterisation included burst catheter balloons (6%) and one serious episode of arrhythmia. The incidence of pneumothorax (2.8%) and inadvertent arterial puncture (2.2%) with PA and CV lines and our sepsis rate of 3.6% for all types of catheters are consistent with other studies. Arterial catheterisation proved to be relatively free of complications. Our study confirmed the safety of invasive vascular catheterisation. However, we review the precautions needed to limit potential complications

A comparison between right atrial and pulmonary arterial oxygen tensions

Oxygen tensions of 50 simultaneously withdrawn blood samples from the right atrial orifice of a triple-lumen pulmonary artery catheter and from the pulmonary artery lumen were compared. Mixed venous oxygen tensions ranged from 21 mmHg to 44.9 mmHg. The correlation coefficient was 0.96 (t = 2.09; P = 0.01). The benefits and drawbacks of intermittent right atrial oxygen tension monitoring are discussed