Chest
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Case Reports
Management of malignant air leak in a child with a neonatal high-frequency oscillatory ventilator.
A 10-year-old, 36-kg child with a malignant air leak who failed conventional mechanical ventilation and high-frequency jet ventilation was successfully treated with a neonatal high-frequency oscillatory ventilator for 31 days. Since the air leak resolved with minimal hemodynamic compromise, this technique may have application in the management of respiratory failure and air leak in the older and larger child for prolonged periods of time.
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A 66-year-old hypertensive woman presented with epigastric and scapular pain on the basis of type 3 aortic dissection. Appropriate therapy with a combined alpha-adrenergic and beta-adrenergic antagonist agent prevented further ongoing dissection and amelioration of symptoms. On day 5, an episode of coronary vasospasm occurred presumably due to beta-blockade with unopposed alpha-adrenergic activity.
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Exercise testing is commonly used to evaluate patients with coronary artery disease who have serious anatomic characteristics. To study the characteristic exercise test variables in patients with left main coronary artery disease, the computerized data base of the Hungarian Institute of Cardiology Exercise Test Laboratory was used. Among 2,378 patients who had undergone a supine bicycle exercise test and who had abnormal coronary angiographic results, 65 patients with significant (greater than 50 percent diameter narrowing) stenosis of the left main coronary artery were found. ⋯ For comparison, the 27 patients selected to be the control group (group C) had no history of MI but had significant stenosis of both the left anterior descending and the left circumflex arteries. Exercise time, calculated oxygen consumption, maximal work load, time to ST depression, prevalence of ST segment depression, and maximal ST depression were similar in the groups. Maximal heart rate and double product were higher in group 1, but we could find no single variable or group of variables characteristic of left main coronary artery disease.
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Case Reports
Postpericardiotomy and postmyocardial infarction syndrome presenting as noncardiac pulmonary edema.
Three cases are reported that describe acute pulmonary edema as an early manifestation of a postpericardiotomy or postmyocardial infarction syndrome. Each of these cases occurred in the presence of good left ventricular function. The cases suggest this syndrome occurs in immunologically primed patients who have had prior cardiac injury resulting in readily available heart antibody. ⋯ Two of the patients had a history of distant myocardial or pericardial injury, and the third patient had an acute anteroseptal myocardial infarction two to three weeks before cardiac surgery. All three patients with pulmonary edema responded dramatically to corticosteroids, having been resistant to diuretic and pre-load and afterload reduction therapy, suggesting an autoimmune capillary injury process. Early recognition of such a syndrome is important since all three patients were successfully treated, and might otherwise have been confused with other causes of pulmonary edema.
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A 43-year-old black man had an 18-year history of apical lung cystic-bullous disease. Following two episodes of spontaneous pneumothorax and two instances of thoracotomy for bullectomy and pleural abrasion, he was found to have an intermediate AAT deficiency with an MZ phenotype. It is believed that this is the first case of localized bullous lung disease to be reported in association with any degree of AAT deficiency. ⋯ It is postulated that the AAT deficiency may have played a role in this progression, as did the patient's cigarette smoking. Following two instances of surgery, CT scans of the lungs, compliance studies and complete pulmonary function tests show no further evidence of lung bullae or emphysema. The rarity of the Z variant of AAT in blacks is discussed.