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Electroconvulsive therapy (ECT) is a safe procedure, infrequently associated with life-threatening complications. Pulmonary embolism (PE) as a complication of ECT has been rarely reported. We describe a nonfatal case of PE that developed during ECT in a 50-year-old man with depression, hypertension, and diabetes. He developed symptoms of PE immediately upon awakening from the eighth right unilateral ECT, which was later confirmed by spiral chest computed tomography. We review the literature, discussing risk factors relevant to the pathophysiology of PE and making suggestions about the management of patients with suspicious symptoms.
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PMID:Pulmonary embolism after ECT. 1579 Nov 76

Lung transplantation is currently the most effective means of improving survival and quality of life in patients with end-stage cystic fibrosis. In reviewing our 6-year experience we sought to evaluate complications and survival after sequential bilateral lung transplantation. Between October 1996 and October 2002, 114 patients with cystic fibrosis were referred to us from 15 Italian regional centers and 2 support centers for cystic fibrosis as possible candidates for lung transplantation. Of these 114 patients, 99 were included in the waiting list and 15 were refused. The mean time spent on the waiting list was 6.8+/-5.2 months (range 1 day-21 months) for those patients receiving lung transplantation, and 5.4+/-4.5 months (range 10 days-18 months) for those 35 patients who died while on the waiting list. A total 55 patients (6 children and 49 adults), mean age 25.6+/-6.6 years (range 9-52 years), 29 males, underwent bilateral sequential lung transplantation. One patient had a second transplantation 14 months after the first. The most frequent medical non-infective complications after transplantation were chronic renal failure (n=27 patients), diabetes (n=31), osteoporosis (n=17), arterial hypertension (n=14), seizures (n=4), transient cerebral ischaemia (n=1), and transient bilateral blindness (n=1). Bacterial lower airways respiratory infections with the organisms that colonized patients' airways before lung transplantation developed in 42 patients; cytomegalovirus (CMV) infection in 41; and opportunistic infections of the lung with Pneumocystis carinii in 3 patients. Cultures of sputum or bronchoalveolar lavage fluid grew Aspergillus fumigatus in nine patients; aspergillosis of right bronchial anastomosis developed in one patient and a lung infection in another. Another patient had a pulmonary infection secondary to Aspergillus niger. An average of 1.3 episodes of acute rejection developed per patient in the first 6 months after lung transplantation. Freedom from bronchiolitis obliterans syndrome was 95% at 1 year, 82.5% at 2 years, 70% at 3 years, and 65% at 4, 5 and 6 years. Actuarial survival rates were 80% at 1 month, 79% at 1 year, 74% at 2 years, 70% at 3 years and 58% at 4, 5 and 6 years. Ten patients (17.8%) died in the early postoperative period (1-30 days) for the following reasons: primary graft failure (n=4), multiorgan failure (n=3), Burkholderia cepacia sepsis (n=1), myocardial infarction (n=1), and pulmonary embolism (n=1). Mortality was accounted for by 9 patients (16%) who died from 9 to 43 months after lung transplantation, for the following reasons: P. carinii infection (n=2), bronchiolitis obliterans syndrome (n=4), A. fumigatus pulmonary infection (n=1), unknown cause (n=1) and suicide (n=1). In conclusion, the leading causes of morbidity after lung transplantation for cystic fibrosis are pulmonary bacterial infection and opportunistic infections. Bronchiolitis obliterans develops in more than half of lung transplant recipients who survive for more than 3 years and is an important cause of death in the late post transplantation period.
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PMID:Lung transplantation for cystic fibrosis: 6-year follow-up. 1591 93

Patients with Prader-Willi syndrome (PWS) are recognized to have a tendency of sudden, unexpected death (SED), but its exact cause is unknown because of paucity of such case reports. Since growth hormone (GH) treatment was applied to PWS patients worldwide, several cases of death have been reported. However, whether the therapy is directly related to their SED remains unknown, too. We collected 13 deceased PWS patients (Group A, aged 9 months to 34 years) who had never received GH therapy, and seven deceased patients (Group B, all boys aged 0.7-15 years) having received the therapy from the registration in PWS-patient-support associations and from the literature, respectively. We then compared the cause of SED between the two groups. Irrespective of GH therapy, SED of infants under age 1 year was associated with milk aspiration or hypothalamic dysregulation of respiration, while SED of patients in early childhood or adolescence occurred at sleeping in association with preceding viral infections. In contrast, SED of four adult (>20 years of age) patients who never received GH therapy was associated with complications, such as leg cellulites and pulmonary embolism, secondary to massive obesity and diabetes mellitus (DM). Two Group-B patients (aged 14 and 20 years) without any obesity-related or diabetes-related complications died of drowning in a bath tub, and their drowning death could be related to poor respiratory control. These findings indicated that the cause of SED is not essentially different between PWS patients with and without GH treatment. Deceased PWS patients may have had underlying respiratory dysregulation and hypothalamic dysfunction, and GH therapy might have led to certain obstructive respiratory disturbances that exacerbated the respiratory conditions. This will call clinicians' attention when using GH in PWS patients, for example, careful determination of the dose of GH and careful monitoring of patient's respiratory conditions, especially in male obese patients with respiratory problems.
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PMID:Cause of sudden, unexpected death of Prader-Willi syndrome patients with or without growth hormone treatment. 1593 39

A 44-year-old woman was diagnosed with type II diabetes in 1998 and 1 year later she developed necrolytic migratory erythema, which is a specific skin lesion of glucagonoma. During the clinical investigation, a nodular 6 cm mass in the distal pancreatic region and multiple cystic liver metastases were found. She was operated on, and glucagonoma was detected and the long-acting, repeatable, octreotide treatment was started. 3 years after resection of a pancreatic glucagonoma she presented to a hospital emergency department with diabetic ketoacidosis. Hepatic multiple cystic metastases were visualized by computed tomography. During hospitalization she developed severe pulmonary embolism and deep-venous thrombosis of the lower extremities. Indium-labeled octeotide scintigraphy showed multiple cystic lesions in the liver with additional lesions in the iliocecal region, which had not been visualized by computed tomography. Despite somatostatin therapy the tumor had expanded in the liver. Arterial chemoembolization was performed but 6 months later she died.
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PMID:Malign cystic glucagonoma presented with diabetic ketoacidosis: case report with an update. 1594 15

The case of a 43-year-old man with diabetes and alcoholism admitted to the emergency room with shock, fever, pleuritic chest pain and systemic symptoms is presented. Laboratory tests revealed anemia, leukocytosis, thrombocytopenia, high sedimentation rate and D-dimers, hypoxemia and hypocapnea. He also had sinus tachycardia, rSR' in V1 and an opacity on the periphery of the right pulmonary field. Blood and urine cultures were negative, as were serological markers. The echocardiogram showed a large mass adhering to the tricuspid valve, suggestive of myxoma. The patient underwent surgery, and anatomopathological examination of the mass showed it to be a bacterial vegetation, with no agent isolated. It is pointed out that differential diagnosis is difficult between a myxoma with systemic symptomatology associated with a possible pulmonary embolism, and tricuspid endocarditis with negative blood culture associated with a septic pulmonary embolism, which turned out to be the diagnosis in this patient.
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PMID:Pulmonary embolism associated with a large tricuspid-related mass. 1612 78

Idiopathic pulmonary fibrosis (IPF) is a chronic fibrosing lung disease limited to the lungs and associated with the histologic appearance of usual interstitial pneumonia (UIP) on surgical lung biopsy. The estimated prevalence in the United States is between 35,000 and 55,000 cases,and evidence suggests that the prevalence is increasing for IPF. Risk factors associated with pulmonary fibrosis include smoking, environmental exposures, gastroesophageal reflux dis-ease, commonly prescribed drugs, diabetes mellitus, infectious agents, and genetic factors. The diagnosis requires a careful history and physical examination, characteristic physiological and radiological studies, and, in some cases, a surgical lung biopsy. The natural history of IPF is not known, but evidence supports the concept of a continuum of idiopathic interstitial pneumonias that may overlap in time. Most patients with IPF succumb to respiratory failure, cardiovascular disease, lung cancer, pulmonary embolism, infection, and other health problems. The median survival time for patients with IPF is less than 3 yr. Factors that predict poor outcome include older age, male gender, severe dyspnea, history of cigarette smoking, severe loss of lung function, appearance and severity of fibrosis on radiological studies, lack of response to therapy,and prominent fibroblastic foci on histopathologic evaluation. Conventional therapy (corticosteroids, azathioprine, cyclophosphamide) provides only marginal benefit. Lung transplantation should be considered for patients with IPF refractory to medical therapy. In light of the poor prognosis and lack of response to available anti-inflammatory therapy, alternative approaches to therapy are being pursued. Emerging strategies to treat patients with IPF include agents that inhibit epithelial injury or enhance repair, anti-cytokine approaches, agents that inhibit fibroblast proliferation or induce fibroblast apoptosis, and other novel approaches.
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PMID:Pulmonary fibrosis. 1613 Feb 30

Lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.The aim of this review is to examine whether the risk of obesity and related morbidity and mortality are raised in BD, and possible contributory effects of lifestyle, illness and treatment factors to this risk.Systematic search of Medline and Cochrane Collaboration for relevant studies followed by a critical review of literature was carried out.Mortality from cardiovascular causes and pulmonary embolism (standardized mortality ratio approximately 2.0), and morbidity from obesity and type 2 diabetes mellitus may be increased in BD compared to the general population. Reduced exercise and poor diet, frequent depressive episodes, comorbidity with substance misuse and poor quality general medical care contribute to the additional risk of these medical problems in people with BD. There is no evidence that patients with BD are more sensitive than other patients to weight gain and medical problems associated with long-term use of psychotropic medication; in fact long-term treatment with lithium, antipsychotics and tricyclic antidepressants may reduce overall mortality. Psychiatrists, general practitioners and other health professionals should work together to systematically assess and manage weight gain and related medical problems to reduce the morbidity and mortality associated with obesity in BD. There is insufficient evidence to associate any of these factors with specific drug treatments. More research is required to understand how BD changes the risk for physical health comorbidity.
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PMID:Metabolism, lifestyle and bipolar affective disorder. 1628 Mar 42

Fifty-one simultaneous pancreas-kidney transplants (SPKT) were performed between 1988 and 2004 in patients of mean age 34 years and 23 years duration of diabetes treatment. All kidney and pancreas recipients were on maintenance hemodialysis therapy prior to SPKT. The pancreas with duodenal segment and the kidneys were harvested from cadaveric heart-beating donors. Cold ischemia time in UW solution varied from 4 to 14 hours (mean, 9 hours 35 minutes). Twenty patients had the duodenal segment sutured to the urinary bladder, and the remaining 31 grafts were drained to an isolated ileal loop. Quadruple immunosuppression was administered as well as an anticoagulant and antibiotic prophylaxis. Forty-nine patients (49/51, 96%) regained insulin independence in the immediate postoperative period; 44 (86%) displayed immediate graft function. The remaining patients experienced postoperative ATN, the longest duration was 18 days. Of 51 patients, 38 (14.5%) are alive (follow-up, 6 to 180 months), 26 (68.5%) have good pancreatic function, and 34 (89%), good kidney function. Nineteen (50%) patients regard their quality of life as improved compared to their pretransplant status, which is mainly attributed to being dialysis and insulin free. Of 19 patients, 14 (74%) reported measuring glycemia regularly due to fear of losing the pancreas graft. Of 19 persons, seven (37%) returned to work after transplantation. Four (8.3%) lost their kidney graft secondary to vascular complications (n = 2) or rejection (n = 2). Four pancreas grafts with bladder drainage required conversion to enteric drainage owing to persistent urinary infections or urinary fistulae. Fifteen (29%) patients lost their pancreatic grafts within 1 year of transplantation due to the following: vascular complications (n = 12), septic complications (n = 1), or rejection (n = 2). Thirteen patients died within 1 year after transplantation, 5 of septic complications, 5 of neuroinfection, 1 of pulmonary embolism, and 2 of myocardial infarction. In conclusion, SPKT is a successful treatment for diabetic nephropathy, burdened by the possibility of serious complications.
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PMID:Surgical complications of simultaneous pancreas-kidney transplantation: a 16-year-experience at one center. 1629 59

Deep venous thrombosis (DVT) is a one of the most common problems facing the clinician in medicine today. It is often asymptomatic and goes undiagnosed with potentially fatal consequences. Ultrasound has become the "gold standard" in the diagnosis of deep venous thrombosis and with proper attention to technique sensitivity of this test is approximately 97%. An understanding of anatomy, pathophysiology, and risk factors is important. Thrombus formation usually begins beneath a valve leaflet below the knee. Approximately 40% will resolve spontaneously, 40% will become organized, and 20% will propagate. Whether or not a calf vein thrombus is identified, a repeat examination in 7 to 10 days is recommended in patients with risk factors or when deep venous thrombosis is suspected. The three main risk factors for thrombus formation are age greater than 75 years, previous history of deep venous thrombosis, and underlying malignancy. Other diagnostic studies include the contrast venogram, CT or MRI venogram, Tc99m Apcitide study, and the laboratory test D-Dimer. The D-Dimer study is being used more frequently as a screening test with 99% sensitivity in detecting thrombus, whether deep venous thrombosis or pulmonary embolism. However, specificity is only approximately 50% with many conditions leading to false-positive exams. Therefore, a negative examination is useful in avoiding other diagnostic studies, but a positive one may be misleading. Conditions that can lead to a false-positive examination include, but are not limited to diabetes, pregnancy, liver disease, heart conditions, recent surgery, and some gastrointestinal diseases. Like the sonogram, two negative D-Dimer studies a week apart exclude the diagnosis of deep venous thrombosis. Compression sonography with color Doppler remains the best overall test for deep venous thrombosis. It is easy to perform, less expensive than most "high tech" studies, can be performed as a portable examination, and is highly reliable when done properly.
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PMID:Sonography for deep venous thrombosis: current and future applications. 1634 26

Patients with ovarian cancer with clear cell histology often have venous thromboembolism (VTE) even before surgery. In view of the possible association between clear cell histology and VTE in endometrial cancer, we measured the plasma levels of thrombin-antithrombin III complex (TAT) and D-dimer (DD) in the preoperative examinations of a patient with clear cell adenocarcinoma of the endometrium. Plasma TAT and DD were both highly elevated, though the patient had no symptoms of VTE or risk factors such as obesity or diabetes mellitus. Ultrasound Doppler examination and lung perfusion scintigraphy just before surgery revealed a thrombosis in the left popliteal vein and a pulmonary embolism. After implanting an inferior vena cava filter to prevent a fatal embolism of the lung, we performed abdominal total hysterectomy, bilateral salpingo-oophorectomy, and sampling of the pelvic lymph nodes. The VTE gradually disappeared and the plasma levels of TAT and DD returned to normal after surgery. Possibly, the VTE in this patient may have been associated with the clear cell histology.
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PMID:Successful diagnosis of thromboembolism before surgery in a woman with clear cell adenocarcinoma of the endometrium. 1636 52


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