Gastrointestinal Involvement of Posttransplant Lymphoproliferative Disorder in Lung Transplant...

RADIOLOGICAL MANIFESTATIONS OF ALLERGIC BRON-CHOPULMONARY ASPERGILLOSIS: RETROSPECTIVE STUDYOF 18 PATIENTSNirupama N. More, MD*; Nair P T V, Bachwani A S, Patel S J.Governement, Bhabha Atomic Research Center Hospital, Mumbai, India

PURPOSE: To analyse the radiological findings of 18 patients withproven allergic bronchopulmonary aspergillosis and correlate the radio-logical findings with specific IgE levels.

METHODS: 18 patients diagnosed to have ABPA on basis of history ofasthma, peripheral eosinophilia, raised IgE levels for Aspergillus fumiga-tus, chest X-ray, CT scan abnormalities and spirometry were analysed.

RESULTS: We found fleeting shadows in 11 patients, of which 10 hadproximal bronchiectasis on CT. Radiological evidence of proximal bron-chieactasis correlates with high titers of IgE & severity of restriction.Severity of obstruction correlates better with high titers of IgE ascompared to severity of restriction.

Radiological Manifestations in ABPA

Chest X-ray (n � 18) CT Thorax (n � 15)ConsolidationFleeting shadowsBronchiectasisHyperinflationAdenopathyNormal

051102010101

ConsolidationProximal bronchiectasisDistal tubularBronchiectasisEmphysematous changesAdenopathyNormal

051006030200

CONCLUSION: High index of clinical suspicion for ABPA is war-ranted in patients of Bronchial Asthma. Further prospective long termfollow up is needed to plan better investigatory and management optionsfor better treatment outcome.

CLINICAL IMPLICATIONS: It is easier to detect clinically &radiologically occult ABPA infections amongst Asthmatic populations &formulate better management plans to decrease respiratory morbidity.

DISCLOSURE: N.N. More, None.

THE MOSAIC STUDY: A NEW LANDMARK IN THE THERAPYOF ACUTE EXACERBATIONS OF CHRONIC BRONCHITISAnthony Anzueto, MD*; Robert Wilson, MD; Luigi Allegra, MD; GerardHuchon, MD; Jose-Luis Izquierdo, MD; Paul Jones, MD; Tom Schaberg,MD; Pierre Arvis, MD; Isabelle Duprat-Lomon, MD; Pierre-PhillippeSagnier, MD. University of Texas, San Antonio, TX

PURPOSE: Using an innovative study design we compared oralmoxifloxacin (MXF) 400 mg QD for 5 days with amoxicillin, clarithromy-cin or cefuroxime-axetil (CMP) at recommended doses for 7 days to treatacute exacerbations of chronic bronchitis (AECB).

METHODS: This multicenter, double-blind study included outpa-tients aged � 45 years with stable CB, history of smoking of �20packs/year, �2 documented AECB in the previous year, and FEV1 � 85%of predicted value. Patients with Anthonisen type 1 AECB within 12months of enrolment were randomised. Patients were assessed at screen-ing, end of treatment and 7-10 days after treatment, and contactedmonthly until new AECB occurred or up to 9 months. Clinical cure wasdefined as return to pre-AECB status, and clinical success as cure andimprovement combined. Other measures were bacteriological treatmentsuccess, need for further antimicrobials and time to next AECB.

RESULTS: 730 ITT patients received MXF (n�354) or CMP(n�376). Cure rates were 70.9% with MXF and 62.8% with CMP in theITT population (95% CI 1.4, 14.9; p�0.05), and 68.7% vs. 62.1% in theper protocol population (95% CI 0.3, 15.6; p�0.02). Clinical success wasseen in 83.0-87.6% of ITT patients across treatment arms and populationswith a significant difference in favor of MXF in patients not receivingsteroids (p�0.01). In the per protocol population, 91.5% of patients onMXF and 81.0% on CMP showed bacteriological success (95% CI 0.4,22.1). A significantly lower proportion of patients required additionalantimicrobials in the moxifloxacin arm (9.5% vs. 15.1%, p�0.045). Meantimes to new AECB in patients not requiring further antibiotics were132.8 days for MXF and 118.0 days for CMP (p�0.03).

CONCLUSIONS: There was a significantly greater response to MXFfor cure rates, rates of bacteriological eradication, need for additionalantimicrobials and time to next exacerbation.

CLINICAL IMPLICATIONS: The excellent clinical outcomes forMXF support the use of MXF in AECB and should be considered infuture treatment guidelines.

DISCLOSURE: A. Anzueto, None.

RELEASE OF NITRIC OXIDE FROM ENDOTHELIUM WITHPERIODIC ACCELERATION AND EFFECT ON HEALTH RE-LATED QUALITY OF LIFEMarvin A. Sackner, MD*; Emerance Gummels, MS; Jose A. Adams, MD.Hospital, Mount Sinai Medical Center, Miami Beach, FL

PURPOSE: Downward descent of dicrotic notch (DN) of digital pulsein normals occurs acutely during periodic acceleration (pGz) becausenitric oxide is released from eNOS due to pulsatile shear stress (Sackneret al: Am.J.Respir.Crit.Care Med.2003;167 (Suppl):A117). The latter aswell as health related quality of life parameters were investigated inpatients after 10 to 15 pGz treatments, i.e., 1/day, 45 min duration.

METHODS: DN position of photoelectric plethysmographic pulse wascomputed by dividing (a) pulse amplitude by (b) height of dicrotic notchabove end diastolic level. Heart rate (HR) was measured with ECG. pGzwas applied for 45 min with 5 min baseline and recovery times using amotion platform (www.at101.com, Non-Invasive Monitoring Systems,North Bay Village, FL). a/b ratio was measured in 12 normals, mean age45, and, 26 patients, mean age 62, viz. 8 with osteoarthritis, 4 Parkinson’s,2 multiple sclerosis, 2 neuropathy, 1 carpal tunnel syndrome, 1 restlesslegs, 1 COPD, 1 asthma and fibromyalgia, 1 pulmonary fibrosis, 1pulmonary hypertension, 2 coronary artery disease, 1 venous insufficiency,and 1 interstitial cystitis. In 15 patients, SF-36v2.0 form was filled outprior to and after 10-15 pGz treatments.

RESULTS: a/b ratios are expressed as peak values and HR as meansduring period (*p�.01 & **p�.001 Mann Whitney U test betweenbaseline and pGz). Baseline a/b and HR in normals were 2.5 and 63 andduring pGz, 55** and 75*, respectively. Baseline a/b and HR in patientswere 1.7 and 69 and during pGz 66** and 70, respectively. SF-36 revealedthat after 10-15 pGz treatments, Vitality improved (p�.02) and there wasa trend to improvement of body pain (p�.06).

CONCLUSIONS: Both normals and patients respond to pGz withrelease of nitric oxide into circulation.

CLINICAL IMPLICATIONS: Periodic acceleration through releaseof nitric oxide from endothelial nitric oxide synthase achieves beneficialeffects of vasodilation and immunosuppression in chronic inflammatorydiseases as reflected by significant improvement of vitality and trend toimprovement of body pain..

DISCLOSURE: M.A. Sackner, Chairman, Board of Directors, Non-Invasive Monitoring Systems, Inc., Shareholder. Discussion of productresearch or unlabeled uses of product.

IMPACT OF CO-MORBID ILLNESS AND FREQUENT EXACER-BATIONS ON THE BACTERIOLOGY OF ACUTE BACTERIALEXACERBATION OF CHRONIC BRONCHITIS (ABECB)Alan M. Tennenberg, MD*; Karen A. Walker, RN, BSN; MohammedKhashab, BS; Alan Fisher, PhD; Neringa Zadeikis, MD; James B. Kahn,MD. Ortho-McNeil Pharmaceutical, Raritan, NJ

PURPOSE: FEV1 �50% predicted is a recognized risk factor forinfection with Enterobacteriaciae (EB) and Pseudomonas aeruginosa (PA)in patients with ABECB. Other risk factors for infection with thesepathogens need to be clarified. We hypothesized that stratification basedon FEV1, number of exacerbations/year, and the presence of medicalco-morbidity would identify patients at higher risk for EB and PAinfection.

METHODS: In this phase IIIB, randomized, blinded study, patientswith ABECB were characterized as “uncomplicated” or “complicated”based on FEV1 (above or below 50% predicted), presence of medicalco-morbidity, and frequency of exacerbations/year. “Uncomplicated” pa-tients received levofloxacin 750mg/d for 3 days or azithromycin 500mg(day 1) followed by 250mg/d (days 2-5). “Complicated” patients receivedlevofloxacin 750mg/d for 5 days or amoxicillin/clavulanate 875mg bid for10 days.

RESULTS: To date, 642 patients have been randomized (345 uncom-plicated, 297 complicated) of a planned 700 patients. Thus far, 278organisms have been cultured from 102 patients. For patients recognizedas “at risk” for EB and PA due to FEV1 �50% predicted (n�26), EB orPA were recovered from 9 (34.6%) patients. Among low risk patients with

Wednesday, October 29, 2003

Airway Defenses and Infections12:30 PM- 2:00 PM

134S CHEST 2003—Poster Presentations

FEV1 �50% predicted, no medical co-morbidity, and �4 exacerbationsper year (n�53), 14 (26.4%) patients had EB or PA cultured. In contrast,among patients with FEV1 �50% predicted with medical co-morbidityand �4 exacerbations/year (n�23), EB or PA were recovered from 12(52.2%) (p�0.03 chi-square test).

CONCLUSION: ABECB patients with FEV1 �50% predicted, med-ical co-morbidity, and �4 exacerbations/year are at significantly greaterrisk for infection with EB and PA than patients with FEV1 �50%predicted but without co-morbidity and with �4 exacerbations/year.

CLINICAL IMPLICATIONS: Given the increased risk for infectionwith EB and PA, broad-spectrum antimicrobials should be employed forABECB in patients with medical co-morbidity and frequent exacerba-tions, regardless of FEV1.

DISCLOSURE: A.M. Tennenberg, Ortho-McNeil Pharmaceutical.Discussion of product research or unlabeled uses of Product.

FLUORESCENCE ASSAY FOR SPUTUM ADENOSINE DEAMI-NASEKent D. Miller, PhD, MD*. Diagnostic Ventures, Inc., Daytona Beach,FL

PURPOSE: Worldwide studies find elevated body fluid adenosinedeaminase (ADA) levels associated with mycobacterial infections inadjacent tissues. Those results are usually provided by the easily standard-ized colorimetric procedure of Giusti. However that method cannot beapplied to sputa and broncho-alveolar lavage samples because 20-25 percent of such specimens, both normal and tuberculous, contain largeamounts of low molecular weight amines that interfer with the colorimet-ric procedure. Data presented here support a quantitative fluorometricassay for ADA applicable to sputum and lavage specimens.

METHODS: The method is based on conversion of residual substrateadenosine (Adn) to the fluorescent 1,N6-ethenoadenosine (e-Adn) onreaction with chloroacetaldehyde (CAA; Barrio et al, Biochem. Biophys.Res. Comm., 46, 597-603 (1972). The assay procedure is achieved with asubstrate concentration, 4.0 mM, sufficient to assure maximum velocitiesof the enzyme levels under test, but low enough to permit accuratemeasurements of reductions in substrate concentrations. Samples fromthose reactions mixtures are added to 1,000-mole excesses of CAA inacetate buffer, pH 4.0, and heated 1 hr at 75 OC. The fluorescent e-Adnproduct is measured at an emission wavelength of 410 nm, with excitationat 313 nm.

RESULTS: While ADA assays by this procedure can be carried out atphysiologic pH the reactions described in this presentation are at pH6.4-6.5, the pH range mandated for the colorimetric assay in order to trapammonia released from the Adn. Thus, proof of efficacy of the fluoro-metric procedure is indicated by correlations between results from thetwo procedures, at the same pH and on the same specimens.

CONCLUSION: This fluorometric procedure is applicability to quan-titative ADA measurements on all sputa.

CLINICAL IMPLICATIONS: The technology extends the spectrumof quantitative sputum enzyme assays for diagnostic and therapeuticevaluations.

DISCLOSURE: K.D. Miller, None.

SUPPRESSION OF DENDRITIC CELL INDUCIBE CO-STIMU-LATORY MOLECULE EXPRESSION AND IL-12 SECRETION BYCIGARETTE SMOKE EXTRACTRobert Vassallo, MD*; Lieping Chen, MD, PhD. Mayo Clinic, Rochester,MN

PURPOSE: Dendritic cells are present in the lung in an immaturestate. Upon encounter with antigen or inflammatory stimuli, dendriticcells undergo maturation, a process associated with up-regulation ofcostimulatory molecules and secretion of IL-12. This process confers tothe dendritic cell enhanced capacity to stimulate T cell responses. Wespeculated that cigarette smoking impairs the ability of dendritic cells toundergo maturation, thereby inhibiting their ability to stimulate T cellresponses.

METHODS: Immature dendritic cells were generated frommonoyctes cultured with interleukin-4 (5ng/ml) and GM-CSF (800U/ml).Mature dendritic cells were generated by the addition of lipopolysaccha-ride (LPS, 100ng/ml) in the final 24 hours of culture. Cigarette smokeextract (CSE) was generated from cigarettes by bubbling mainstreamcigarettes smoke from one cigarette into 10ml media (nicotine concen-

tration of 2.3�0.8 microg/mL in 1% CSE). Costimulatory moleculeexpression was determined by flow cytometry. Dendritic cell interleu-kin-12 (IL-12) and interleukin-6 (IL-6) production were determined byELISA.

RESULTS: Although CSE did not alter the expression of CD-40,CD-80, CD-86, and CD1a expression on resting immature dendritic cells,CSE (1-2%) caused significant suppression of LPS-induced upregulationof these co-stimulatory molecules. In contrast, nicotine (1-100 micro-grams/ml) had no effect on resting or inducible co-stimulatory moleculeexpression. CSE also potently inhibited LPS-induced IL-12 secretion:whereas LPS-stimulated dendritic cells produced 1052 � 9 pg/ml IL-12,LPS-stimulated dendritic cells in the presence of 2% CSE produced only340 � 9 pg/ml (p�0.01). In contrast to the suppressive effect on IL-12secretion, CSE did not alter LPS-induced secretion of IL-6 by dendriticcells.

CONCLUSIONS: These data indicate that CSE suppress specificdendritic cell functions that are important in host responses to infectionand cancer. Through these effects on dendritic cell function, cigarettesmoke components may alter adaptive immune responses.

CLINICAL IMPLICATIONS: These findings have important impli-cations for the pathogenesis of disease states associated with smoking.

DISCLOSURE: R. Vassallo, None.

COMPARISON OF LINEZOLID WITH VANCOMYCIN FOR THETREATMENT OF EXACERBATION DUE TO METHICILLINRESISTANT STAPHYLOCOCCUS AUREUS IN ADULT PA-TIENTS WITH CYSTIC FIBROSISScott E. Hickey, BS*; Erich S. Lemker, BS; Subin Jain, MBBS. Universityof Louisville, Louisville, KY

PURPOSE: Intravenous vancomycin is currently preferred treatmentfor patients with infections due to methicillin-resistant Staphylococcusaureus (MRSA). There are no studies comparing vancomycin to linezolidin the management of exacerbations due to MRSA in adult patients withCF.

METHODS: Retrospective chart review of adult CF patients hospi-talized for MRSA infection between Jan. 2001 and Dec. 2002. Twentyepisodes in 6 patients treated with vancomycin compared to elevenepisodes in 3 patients treated with linezolid.

Symptoms and signs were used to compile the Cystic Fibrosis ClinicalScore (CFCS) (Kanga, 1999) during admission and follow-up and PFT’swere noted. Duration of therapy, time to next exacerbation and adverseeffects if any recorded.

RESULTS: Linezolid chosen over vancomycin due to previous adversereactions, except 1 episode where patient failed to respond to vancomycin.No failures of therapy with linezolid were noted.

Vancomycin Linezolid

No. of episodes 20 11Hospital stay 8.3 � 4.2 days 6.8 � 2.7 daysTotal treatment 12.4 � 5.5 days 13.7 � 3.8 daysMean CFCS (admission) 30.2 � 5.93 32.82 � 4.5Mean CFCS change 6.27 5.71Time to next exacerbation 72 � 55.28days 94 � 65.9 days

Both groups showed similar improvement at end of therapy as noted byCFCS. Trend towards longer interval to next exacerbation with linezolidversus vancomycin though not significant.

% predicted Discharge Follow-Up

Linezolid-FEV1 31.3 � 4.3 33.0 � 6.3Linezolid-FVC 42.2 � 7.5 46.5 � 9.3Vancomycin-FEV1 53.6 � 20.7 48.6 � 16.7Vancomycin-FVC 68.0 � 16.5 65.0 � 17.4

PFT’s showed increase in FEV1 and FVC from time of hospitaldischarge to follow-up clinic visit in linezolid group with decrease noted invancomycin group. Changes were not significant. No adverse events notedwith linezolid. One episode of red man syndrome with vancomycin.


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CONCLUSION: Linezolid is at least as effective as vancomycin in thetreatment of exacerbations in adult CF patients due to MRSA. Largerprospective studies needed to see if linezolid provides a treatmentadvantage in this group of patients.

CLINICAL IMPLICATIONS: Linezolid may be used as an alterna-tive to vancomycin in adult patients with CF and may be more effective,though this needs to be confirmed.

DISCLOSURE: S.E. Hickey, None.

THE FREQUENCY OF CFTR GENE MUTATIONS IN PATIENTSSUFFERING FROM CHRONIC BRONCHITISMarzena Kostuch, Jan Oleszczuk, Lucas Kulczycki*. University MedicalSchool, Lublin, Poland

PURPOSE: The purpose of the study was to detect CFTR genemutations in patients suffering from chronic bronchitis.

METHODS: Forty one patients admitted to the Department ofPulmonology, University Medical School of Lublin, Poland due to chronicbronchitis were included in the study. Patients were analyzed for the eightmost common mutations of the CFTR gene: delta F508, G542X, N1303K,1717-1(G-�A), W1282X, G551D, R553X and delta I507 using thereverse-hybridization method.

RESULTS: In a group of 41 adults with chronic infections of respira-tory system, among whom 9 also had bronchiectasis, 6 patients (14.6%)heterozygous for the delta F508 mutation were identified. This frequencyis much higher than the general frequency of occurence of this mutationwithin the Polish population (2.24%-2.8%)This result is statistically sig-nificant (p�0.05, Fisher’s exact test)

CONCLUSIONS: Our results suggest an increased presence of deltaF508 mutation within the CFTR gene in Polish patients suffering fromchronic bronchitis. However, further studies are warranted to investigatethe role of other uncommon CFTR gene mutations in patients withchronic bronchitis and bronchiectasis.

DISCLOSURE: M. Kostuch, None.

EVALUATION OF CHRONIC COUGH IN A TERTIARY CARECENTER IN TROPICSFazlur R. Nadri, MBBS, DNB*. Medical College, St. John’s MedicalCollege Hospital, Bangalore, India

PURPOSE: To ascertain the validity of anatomic diagnostic protocol indetermining etiology of chronic cough in tropics. Cost analyses todetermine effective ways of managing chronic cough.

METHODS: A prospective, descriptive, study of immunocompetent,non-smoking patients with chronic cough. All patients were evaluated bya validated anatomic diagnostic protocol proposed by Irwin and col-leagues. The diagnostic protocol was modified to include sputum exami-nation for acid-fast bacilli, absolute eosinophil count and stool examina-tion. The final diagnosis was based on radiological, laboratory findings anda successful response to therapy.

RESULTS: Eighty-seven consecutive patients with chronic cough wereevaluated from February 2000 to February 2002 using the modifieddiagnostic protocol. The mean age �S.D. was 35.00�11.85 years. Forty-nine patients were males.Etiology of chronic cough determined in 86(99%) patients. Cough resolved in 99% patients after successful diagnosisand treatment. Cough was due to multiple causes in 16%. Postnasal drip, 52%, Asthma, 41%, and Loeffler’s syndrome, 8%, were the three mostcommon causes. Pulmonary tuberculosis was confirmed in 5% of patients.Hence 13% of patients had conditions more prevalent in the tropics.Gastroesophageal reflux disease was seen in 6%. Rare causes of chroniccough included cardiac failure. The average cost per patient was Rs 878.55and 90% of patients were diagnosed with � Rs 1000 (1 US$�Rs 48).Using modified diagnostic protocol 90% of patients were diagnosed withminimal investigations making it cost effective.

CONCLUSION: The three most common causes of chronic cough inthe tropics are different from the west. Pulmonary tuberculosis andLoeffler’s syndrome are more prevalent and need to be considered. Usingthe modified diagnostic protocol etiology of chronic cough can bedetermined successfully in tropics in most patients. A cost effective way ofevaluating cough has been proposed and needs to be validated.

CLINICAL IMPLICATIONS: In tropical countries when evaluatingpatients with chronic cough sputum analysis for acid-fast bacilli, absoluteeosinophil count and stool examination should be included in thediagnostic protocol

DISCLOSURE: F.R. Nadri, None.

CHARACTERISTICS AND OUTCOMES OF PATIENTS WITHHEMOPTYSISDipakkumar P. Malli, MD*; Rajendra Sajjan, MD; Mazen Alakhras, MD;Vijay Baimeedi, MD; Rashmikant Doshi, MD; Kanchan Gupta, MD;Padmanabhan Krishnan, MD. Coney Island Hospital, Brooklyn, NY

PURPOSE: To determine etiology, prognosis and relationship betweenseverity and etiology in-patients presenting with hemoptysis.

METHODS: A retrospective analysis of 101 patients admitted withhemoptysis at Coney Island Hospital between 2000-2002 for etiology,prognosis and relation between etiology and severity of hemoptysis.Hemoptysis was classified as mild (�30ml), moderate (30-100ml), severe(100-600ml) and massive (�600ml) based on 24 hours collection. ChestX-ray findings were noted.

RESULTS: Of the 101 cases 66 were men and 35 were women, 49.6was mean age. 88(87.1%) patients had mild hemoptysis, 10 (9.9%)patients moderate, 1(0.99%) patient severe and 3 (2.97%) patients hadmassive hemoptysis. In 49/101(48.5%) patient’s chest x-ray finding wasinconclusive to establish etiology and in only four (8.16%) of these patientfurther work up establish a diagnosis in form of laryngeal cancer in threepatients and laryngeal ulcer in one patient. Bronchitis (39.6%), cancer(13.8%), pneumonia (10.8%), bronchiectasis (8.9%), pulmonary tubercu-losis (7.9%), coagulopathy (3.9%) accounted for most of causes ofhemoptysis. All but one of these patient’s with a diagnosis had mild tomoderate hemoptysis. 39/40 (97.5%) patient with bronchitis had mildhemoptysis and 3/4 (75%) patients with sever to massive hemoptysis noetiology was found and chest x-ray was inconclusive. All patients withhemoptysis survived.

CONCLUSIONS: Airway disease like bronchitis and bronchiectasiscontinue to be the commonest cause of hemoptysis. Majority patients hadmild hemoptysis and prognosis was good. The severity of hemoptysis wasnot a good indicator of the underlying etiology. Even in the patients withsevere & massive hemoptysis etiology was not established despite exten-sive work up. Patients with hemoptysis and in conclusive chest x-ray andchest CT scan show low yield on further work up.

CLINICAL IMPLICATIONS: In-patient presenting with hemoptysiswith non-diagnostic chest x-ray and chest CT scan further work up foretiology carries low yield and should be done only for specific purpose.

DISCLOSURE: D.P. Malli, None.

Asthma12:30 PM - 2:00 PM

SALIVARY CORTISOL MEASUREMENT AMONG ADULTSWITH ASTHMA AND RHINITISUmesh Masharani, MRCP; Mark D. Eisner, MD MPH; Edward H. Yelin,PhD; Patricia P. Katz, PhD; Susan Janson, DsN; Connie Archea, BS;Gillian Earnest, MS; Douglas Granger, PhD; Paul D. Blanc, MD FCCP*.University of California San Francisco, San Francisco, CA

PURPOSE: Assessment of perturbations in the circadian rhythm ofcortisol secretion provides a measure of the hypothalamic-pituitary-adrenal axis (HPA) function, including responses to exogenous glucocor-ticoids. Salivary cortisol sampling allows testing of free serum cortisolamong ambulatory subjects. We assessed this approach in the study ofadults with asthma and rhinitis.

METHODS: We analyzed data from an ongoing, prospective cohortstudy of adults with asthma or rhinitis. Subjects were asked to collect twosaliva samples: thirty minutes after awakening (AM) and 12 hours later(PM). Subjects placed a cotton swab under the tongue for two minutes.After home freezing, samples were later collected and stored at -20 C.until assayed for salivary cortisol using a high-sensitive enzyme immuno-assay (Salimetrics, PA). The test has a lower limit of sensitivity of 0.19nmol/l. We used the Wilcoxon rank sum to compare the differences in AMand PM cortisol levels by type of corticosteroid used.

RESULTS: We analyzed data for 153 subjects (126 with asthma; 27with rhinitis alone). The mean age was 45�9 years; 105 (69%) werefemale. Among subjects using inhaled or systemic corticosteroids in theprevious 2 weeks, AM cortisol values were lower (n�62; 8.8�5.8 nmol/l)compared to all others (n�91; 11.0�6.5; p�0.04). Excluding 8 subjects


Airway Defenses and Infections, continued


on oral glucocorticoids narrowed the difference (inhaled steroid AMcortisol�9.4�5.7; p�0.17). Within the inhaled glucocorticoid group, 39subjects used fluticasone, while 15 used other steroid types. AM valueswere somewhat lower in the fluticasone group (8.7�5.1 v. 11.4�6.9;p�0.2), while PM values were statistically lower (1.5�1.0 v. 1.9�0.8;p�0.03).

CONCLUSIONS: This report shows that (1) salivary cortisol can beused to assess HPA function in ambulatory adults with asthma or rhinitis(2) HPA suppression due to exogenous steroid can be detected, confirm-ing the validity of the sampling (3) the methodology is sensitive enough todetect effects of different glucocorticoid formulations.

CLINICAL IMPLICATIONS: Inhaled steroids, particularly highlylipid soluble forms such as fluticasone, can have detectable effects on theHPA axis.

DISCLOSURE: P.D. Blanc, None.

EFFECT OF DISTAL ESOPHAGEAL ACID INFUSION ON PEAKEXPIRATORY FLOW RATE (PEFR) IN ADULT ASTHMATICSWITH GASTROESOPHAGEAL REFLUX (GER)Bhavneesh Sharma, Resident in Internal Medicine*; Mradul K. Daga,Professor in Internal Medicine; Gopal K. Sachdev, Professor in InternalMedicine; Manisha Kaushik, Resident in Pulmonary Medicine. MaulanaAzad Medical College, New Delhi, India

PURPOSE: An association betweeen gastroesophageal reflux andasthma has been postulated though the pathophysiology underlying theassociation has been difficult to investigate. Two theories have beenproposed: aspiration of refluxed gastric contents and neurogenic refluxbronchoconstriction stimulated by esophageal exposure to acid. Thepresent study was done to study the effect of distal esophageal acidinfusion on PEFR as previous similar studies have produced inconsistentresults.

METHODS: Thirty adult asthmatics meeting the criteria of theAmerican Thoracic Society were selected. Ambulatory 24-hour esopha-geal pH monitoring was done to detect GER in the selected group.Patients with significant GER underwent a modified Bernstein test withdistal esophageal infusion of 0.1 N hydrochloric acid and PEFR measure-ment. The primary outcome measurement was peak expiratory flow rate.

RESULTS: The study population consisted of 18 (60%) females and 12(40%) males. The mean age of the study group was 33.33 years (range16-77). The mean duration of asthma was 2.64 years (range 9 months to10 years). Twenty one patients (70 %) were found to have significantGER. The mean PEFR on initial saline infusion showed 20.7% reductionon intraesophageal acid infusion (175.23 � 64.23 L/min to 138.93 �57.03L/min, p�0.001).

CONCLUSIONS: Low distal esophageal pH decreases PEFR bycausing bronchoconstriction. This supports the hypothesis of neurogenicreflux bronchoconstriction due to stimulation of vagal receptors in thedistal esophagus by acid.

CLINICAL IMPLICATIONS: Gastroesophageal reflux may contrib-ute to exacerbations of asthma in some patients. Physicians should identifyand treat GER in these patients. This may help in better asthma control,reduced dosages of antiasthma medications and higher quality of life inthese patients.

DISCLOSURE: B. Sharma, None.

ALTERATIONS IN RESPIRATORY MECHANICS RESULTINGFROM THE PROGRESSION OF AIRWAY OBSTRUCTION INASTHMATIC SUBJECTS ANALYZED BY THE FORCED OSCIL-LATION TECHNIQUE (FOT)Juliana V. Cavalcanti, PT; Agnaldo J. Lopes, MD,Msc; Jose M. Jansen,MD,PhD; Pedro L. Melo, Eng,PhD*. Education, State University of Riode Janeiro, Rio de Janeiro, Brazil

PURPOSE: The main advantages of FOT are to require only passivecooperation from the patient and to obtain new parameters that contrib-ute to a more detailed analysis of the respiratory system. The aim of thisstudy was to investigate the clinical application of the FOT in theevaluation of respiratory mechanical alterations resulting from increasedlevels of airflow obstruction in asthmatics patients, in comparison tospirometry.

METHODS AND RESULTS: 111 nonsmoking subjects were ana-lyzed using FOT and spirometry, 25 healthy (59,5�13,0 years; 66,0� 14,5kg), without history of any pulmonary disease, and 86 asthmatics divided

in 4 levels according to the spirometry report: normal to the exam (n�21;38,4� 17,3 years; 67,5�18,9 kg), mild (n�30; 40,1�16,7 years; 72,5�22,0 kg), moderate (n�24; 47,1� 18,6 years; 64,5� 12,5 kg) and severe(n�11; 44,1� 17,5 years; 66,8� 12,9 kg). The subjects with asthmasymptoms and normal respiratory response by spirometry, constitute thelevel “normal to the exam”. The FOT parameters analyzed in this studywere R0 (intercept resistance), the slope of the resistive component of theimpedance (S) associated to non-homogeneity, both evaluated in the4-16Hz frequency range, and Crs,dyn calculated from the reactance in 4Hz.

Table 1 - Spirometric and FOT results in all subjects

FEV1(L)

R0(cmH2O/L/s)

S (cmH2O/L/s/Hz)

Crs,dyn(L/cmH2O)

Control Group 2.2 � 0.7 2.4 � 1.1 -20.5 � 24.3 0.038 � 0.020Normal to the

Exam2.9 � 0.9 3.0 � 1.7 -15.7 � 30.9 0.040 � 0.036

Mild 2.5 � 0.9 3.9 � 1.9 -48.5 � 69.5 0.026 � 0.020Moderate 1.6 � 0.9 5.0 � 2.6 -108.6 � 118.2 0.022 � 0.024Severe 1.2 � 0.3 5.9 � 3.7 -167.4 � 158.3 0.025 � 0.027

One-way analysis of variance (ANOVA) showed significant increases(p�0,001) in R0 and S, among the groups. It indicated an increase in theobstruction and a decrease of the pulmonary homogeneity, as the asthmaobstruction was becoming harder, which is characterized by the decreasein FEV1. Although we can observe a clear reduction in the Crs,dyn withthe pathology progression, it was not significant (p�0,05).

CONCLUSION: The results indicated that the increasing in therespiratory obstruction in asthmatic subjects are accompanied by homo-geneity and dynamic compliance reductions.

CLINICAL IMPLICATIONS: FOT measurements supplied param-eters that were in close agreement with spirometric results and patho-physiological fundamentals, confirming the great clinical potential of thistechnique in the evaluation of asthmatic subjects.

DISCLOSURE: P.L. Melo, None. Supported by CNPq and FAPERJ.

IN VITRO COMPARISON OF FLUTICASONE RESPIRABLEDOSE FROM A METERED-DOSE INHALER AND THREERIDGED VALVED HOLDING CHAMBERSMichael J. Asmus, Pharm.D.*; Kai Wu, MS; Vikram Arya, PhD; GuntherHochhaus, PhD. University of Florida, Gainesville, FL

PURPOSE: Previous in vitro aerosol experiments suggest the quantityof corticosteroid inhaled by asthma patients via metered-dose inhaler(MDI) can vary several fold depending on the valved holding chamber(VHC). We compared in vitro aerosol deposition from a fluticasone MDI(Flovent®, GlaxoSmithKline) to the same MDI in combination with anAeroChamber-Plus™ (Monaghan) VHC, the OptiChamber® (Respiron-ics) VHC, and the OptiChamber®-Advantage (Respironics) VHC, inorder to asses how these VHCs affect the respirable quantity of fluticasoneinhaled from a MDI.

METHODS: The respirable dose (aerosol particles 1-5 �m in size) offluticasone was determined by sampling 5 runs of five 110 �g actuationsfrom each configuration (MDI alone, MDI � AeroChamber-Plus™,MDI � OptiChamber�, MDI � OptiChamber�-Advantage) using awell-established in vitro cascade impactor method (USP-24;2000:1895-1912). Fluticasone aerosol was washed from individual impactor stageswith 50% methanol and quantified via HPLC-UV. Differences among theprimary outcome were determined using ANOVA.

RESULTS: Mean fluticasone respirable dose from AeroChamber-Plus™ (45.3 � 1.8 �g/ actuation) and OptiChamber� (38.1 � 8.7 �g/actuation) were no different (p � 0.05) from the respirable dose producedby the MDI alone (46.7 � 9.7 �g/ actuation). OptiChamber�-Advantagerespirable dose (32.1 � 1.6 �g/ actuation) was significantly less than thatproduced by either the AeroChamber-Plus™ or the MDI alone (p �0.05) but not different from OptiChamber� (p � 0.05).

CONCLUSION: In vitro respirable dose of fluticasone aerosol fromthe OptiChamber®-Advantage VHC was 40-45% less than from the MDIalone or the AeroChamber-Plus™ VHC.

CLINICAL IMPLICATIONS: In asthmatics on fluticasone MDIneeding a VHC, AeroChamber-Plus™ or OptiChamber® would be a


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better choice over OptiChamber®-Advantage since they do not changethe respirable dose compared to MDI alone.

DISCLOSURE: M.J. Asmus, Monaghan Medical Corporation, Grantmonies.

ASTHMA OUTCOMES IN NORTH SHORE-LONG ISLAND JEW-ISH HEALTH SYSTEM (NS-LIJ HEALTH SYSTEM)Ali Mojaverian, MD*; Ravi Sundaram, DO; Archana Mishra, MD; RubinCohen, MD; Alan Fein, MD; Jill Karpel, MD. North Shore UniversityHospital, Manhasset, NY

PURPOSE: Asthma mortality have increased in the last decade leadingto the development of the NAEP Guidelines for asthma treatment.Asthma outcomes are reported for our Health System and compared tothe counties served by the Health System before and after the Guidelines.

METHODS: The North Shore-Long Island Jewish (NS-LIJ) HealthSystem is an intergrated system of 18 hospitals serving over 4 millionpopulation in Nassau, Suffolk, Queens and Richmond counties. Data wasavailable from 13 hospitals to compare asthma outcomes between 1997and 2001. Asthma discharge data was obtained from the SPARCS basedon International Classification of Disease, Ninth Revision (ICD-9) codes.Data from 1997 and 2001 were compared for number of hospitaldischarges, ICU admissions (mechanically ventilated), and length of stay(LOS).

RESULTS: Table 1CONCLUSION: The asthma hospital admissions were reduced more

than 60% while need for mechanical ventilation decreased by 50% andlength of stay (LOS) was reduced by 80% from 1997 to 2001. Wehypothesize that these findings were due to the implementation of theGuidelines in our hospital health system.

CLINICAL IMPLICATIONS: Our results suggest that adherence tothe NAEP Guidelines can improve asthma outcomes.

North Shore-Long Island Jewish Health System Data

1997 2001

Hospital discharges 6725 2471Number of patients on

mechanical ventilation137 (2%) 33 (1%)

Average LOS 5.37 (days) 1.1 (days)

DISCLOSURE: A. Mojaverian, None.

IS THE QUALITY OF LIFE OF ASTHMATIC OUTPATIENTSRELATED TO THEIR PULMONARY FUNCTION TESTSBranislav S. Gvozdenovic, MD, MSc*; Nebojsa Tasic, MD, MSc; DanijelaTasic, MD. Vozdovac, Belgrade, Yugoslavia

PURPOSE: The aim of our study was to evaluate the relationshipbetween the quality of life (QoL) and pulmonary function in asthmaticoutpatients.

METHODS: Thirty two ambulatory patients (19 females; mean agewas 45 � 18 years; mean asthma duration - 14 � 18 years) have filled fourQoL questionnaires: disease specific - the Mini Asthma Quality of LifeQuestionnaire (MiniAQLQ) and the St George’s Respiratory Question-naire (SGRQ), and generic forms - the SF-36 and 15D. Total SF-36, 15D,SGRQ and MiniAQLQ scores, as well as the scores for individual domainsof SF-36 (physical functioning, role-physical, bodily pain, general health,vitality, social functioning, role-emotional, mental health and healthtransition), SGRQ (symptoms, activity and impacts scores) and Min-iAQLQ (limitation of activity, asthma symptoms, emotional state, envi-ronmental stimuli), were calculated for each patient. Pulmonary functionwas determined by means of spirometry, with following parameters:FVC(L), FVC% predicted, FEV1(L), FEV1% predicted and PEF(L).

RESULTS: Among all of the spirometric parameters examined, thehighest degree of correlation with QoL scores was found (with Pearson�scoefficient of linear correlation) for the values of PEF(L). The highestcorrelation was found with the MiniAQLQ environmental stimuli domainscore (r�0.496; p�0.002), the SGRQ symptoms domain score (r�-0.498;p�0.006) and total SF-36 score (r�0.411; p�0.027).

CONCLUSIONS: The QoL in asthmatics, that could be well deter-mined by the questionnaires we used in our study, strongly reflects

impairment of their pulmonary function as assessed by means of spirom-etry.

CLINICAL IMPLICATIONS: The QoL could be successfully used inclinical research and practice as an unconventional outcome for differentprocedures in asthma.

DISCLOSURE: B.S. Gvozdenovic, None.

DIFFERENCES IN PREVALENCE OF ATOPY AMONG ADULTASTHMATICS IN SPECIALTY PRACTICESDavid Anstatt, MBA*; Felicia C. Allen-Ramey, PhD; Leona Markson,ScD; Elizabeth Desrosiers, MS; William Schoenwetter, MD; DavidWesterman, MD; Nasira Majid, MD; Jeannie Perez, MD. Merck & Co.,Inc., West Point, PA

PURPOSE: To estimate prevalence rates of atopy among asthmapatients managed by physicians of different specialties.

METHODS: A multi-center, cross-sectional study of adult asthmapatients receiving care in outpatient allergy (5), general practice (5) andpulmonary (4) settings was conducted to assess the presence of atopy(defined as elevated total IgE or specific IgE sensitivity to � 1 of 8 specificenvironmental allergens) using total serum IgE and ImmunoCap® in-vitro tests administered at time of entry into the study. Patients completeda self-administered survey on asthma and allergies (family history, symp-toms, medication use). Physicians completed a 10-item patient manage-ment survey and brief case report form. The proportion of patients withevidence of atopy and physician-diagnosed allergies were estimated byphysician specialty.

RESULTS: A total of 255 patients (mean age: 42 years, 73% female)were recruited into the study. Of these, 218 (85%) (mean age: 42 years,74% female) were tested for serum evidence of atopy. Atopy prevalenceamong asthmatics was found to be 75% among allergists (AL), 70% amongfamily practitioners (FP) and 61% among pulmonologists (PU) (p�.001).Among participants with a positive serum test for atopy, the percentagereporting physician-diagnosed allergies was 100% for AL, 73% for FP and76% for PU (p�.001). The percentage of physicians reporting that theserum test provided new information about atopy in these asthma patientswas 32% for AL, 81% for FP and 71% for PU (p�.001).

CONCLUSION: Prevalence of atopy among adult asthma patientsvaried by physician specialty, but always included a majority of patientsassessed. Atopic asthma patients managed by FPs and PUs were less likelyto report physician diagnosis of allergies. Serum testing for atopy wasmore informative for FPs and PUs.

CLINICAL IMPLICATIONS: Prevalence rates of atopy among adultasthmatics is high for all specialties in this study. For FP and PUspecialties, the added information gained from allergy tests may haveimplications for disease treatment decisions.

DISCLOSURE: D. Anstatt, Merck & Co., Inc., Industry.

INHALED CORTICOSTEROID TREATMENT FOR PREGNANTWOMEN WITH ASTHMA: US ALLERGISTS AND PULMONOLO-GISTS COMPARED WITH OBSTETRICIANS AND GYNECOLO-GISTSNancy K. Ostrom, MD*; Pamela Park, BA; Liza O’Dowd, MD. Allergyand Asthma Medical Group and Research Center, San Diego, CA

PURPOSE: In December 2001, the US FDA upgraded the pregnancycategory rating for budesonide dry-powder inhaler (BUD DPI) to Cate-gory B, making it the first ICS with this rating. Two surveys assessed thepotential impact of this change on future treatment decisions by allergistsand pulmonologists (A/Ps) and obstetricians and gynecologists (Ob/Gyns).(Budesonide inhalation suspension—indicated for use in children 12months to 8 years of age—was upgraded to Pregnancy Category B inJanuary 2003, making it the second ICS product with this rating.)

METHODS: Participating physicians who had been practicing for 2-25years were selected from a marketing database. The first survey included15 allergists and 60 pulmonologists who spent �65% and �30% of theirpractice time, respectively, in an office/outpatient clinic. The secondsurvey included 154 Ob/Gyns who were treating �5 asthma patients ofchildbearing age (15-44 years) per month.

RESULTS: Both A/Ps and Ob/Gyns frequently prescribed ICS fortheir pregnant patients requiring asthma therapy (68% and 60%, respec-tively). More A/Ps were aware of a Category B ICS treatment choice (56%of A/Ps versus 30% of Ob/Gyns were aware that an ICS had beenupgraded to Category B; 55% of the A/Ps knew that this ICS was BUD


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DPI, versus 16% of Ob/Gyns.) When informed of this upgrade, A/Psreported that they would likely prescribe BUD DPI for 61% of their next20 pregnant patients with asthma appropriate for ICS therapy versus 32%of their previous 20. Ob/Gyns reported that they would likely prescribeBUD DPI for 64% of their next 10 such patients compared with 6% oftheir previous 10.

CONCLUSIONS: Treatment of pregnant women with asthma by A/Psand Ob/Gyns is consistent with current national asthma treatment guide-lines that recommend ICS as a first-line therapy for persistent asthma.

CLINICAL IMPLICATIONS: Increased awareness of the availabilityof a Category B ICS (BUD DPI) will allow appropriate, informedconsideration of treatment options for specialists treating pregnant pa-tients with persistent asthma.

DISCLOSURE: N.K. Ostrom, AstraZeneca LP, Grant monies. Pro-fessional consultation

USE OF MACROLIDE ANTIBIOTICS IN THE TREATMENT OFASTHMAIsil F. Talasli, MD*; Tansu Cengiz Tuskan, MD; Gunseli Kılınc, Prof.MD. Istanbul University Cerrahpasa Faculty of Medicine Dept. ofPulmonology, Istanbul, Turkey

PURPOSE: Chronic infections such as Mycoplasma pneumoniae andChlamydia pneumoniae can maintain inflammatory response in chronicasthma. Macrolide antibiotics have both antimicrobial and anti-inflamma-tory effects that can potentially alter the course of inflammation in chronicasthma.

METHODS: Thirty patients with chronic and stable asthma wererecruited from outpatient clinic of Cerrahpasa Medical Faculty. The studywas randomized, double-blinded, placebo-controlled, and in crossoverdesign. IgM and IgG antibodies to Chlamydia pneumoniae and Myco-plasma pneumoniae, markers of eosinophilic inflammation, and spiromet-ric measurements were done initially, before crossover, and after cross-over. Patients were given clarithromycin 500 mg bid or placebo for 6weeks. Before crossover period there was 2 weeks given for washoutperiod.

RESULTS: Twenty-five females and 5 males with mean 35 years of agewere analyzed. The mean duration of the disease was 5.8 years. Initialworkup of lung functions, IgM and IgG antibodies to Chlamydia pneu-moniae and Mycoplasma pneumoniae, markers of eosinophilic inflamma-tion were similar in both groups. Treatment did not influenced FEV1(2730�675ml, 2610�792ml, and 2680�895ml, 2630�992ml, p�0.05)before or after crossover. There were no significant differences ineosinophil counts or antibodies in those subjects who received placebo.

CONCLUSIONS: The role of clarithromycin in the treatment ofasthma in suppression of the inflammatory response to either chronicinfections or allergic phenomena seemed not to be efficacious in ourstudy.

CLINICAL IMPLICATIONS: Considering the small number ofpatients and the short duration of study, it is not likely to conclude refutingthe use of macrolides in patients with chronic asthma.

DISCLOSURE: I.F. Talasli, None.

COMPARISON OF THE EFFICACY OF INHALED IPRATRO-PIUM BROMIDE AND SALBUTAMOL SEQUENTIALLY AND INFIXED DOSE COMBINATION IN PATIENTS WITH STABLEBRONCHIAL ASTHMAAnant Mohan, Senior Research Associate*; Randeep Guleria, AdditionalProfessor; Chinmoyee Das, Research Fellow; Rajesh Sharma, ResearchAssociate. All India Institute of Medical Sciences, New Delhi, India

PURPOSE: Inhaled anticholinergics and Beta- 2 agonists are fre-quently combined to achieve optimal bronchodilatation in bronchialasthma. Fixed dose combinations of these agents are being widely used.However, it is unclear whether sequential administration of these drugs isbetter than simultaneous administration. This study was done to comparethe bronchodilatation produced by a fixed dose combination with thatproduced by the same drugs administered sequentially.

METHODS: 27 consecutive patients with stable bronchial asthmawere randomly selected for two spirometry sessions held within a week. Inone session, they were given inhaled Ipratropium Bromide (40 �g)followed 30 minutes later by Salbutamol (200 �g ).In the other session,the same drugs in similar dosage were administered through a fixed dosecombination . Spirometry was performed at baseline and at 15,30 and 60

minutes post inhalation. The change in Forced Vital Capacity (FVC),Forced Expiration in one second (FEV1), Peak Expiratory Flow Rate(PEFR) and Forced Expiratory Flow (FEF 25-75 ) was measured andcompared.

RESULTS: The mean age was 30.5 years. There was no significantdifference between the baseline values of FVC, FEV1, PEFR and FEF25-75 in the two groups. FEV1 increased significantly by a mean of 234.4 �40, 329.6 � 44, and 335.9 � 45 ml respectively at 15,30 and 60 minutesfrom baseline in the fixed combination group, and by 202.6 � 32, 244.8 �27 and 204.8 � 31 ml in the sequential group. A similar trend was notedfor the other parameters. However, there was no significant difference inany of these parameters at 15,30 or 60 minutes between the two groups.

CONCLUSION: Inhalation of a fixed dose combination of an anticho-linergic agent and a beta-2 agonist is equally effective in producingbronchodilatation as administering the same drugs in sequential order.

CLINICAL IMPLICATIONS: Fixed dose combination inhalers areequally effective and have a better compliance compared to the use ofthese drugs separately in a sequential manner.

DISCLOSURE: A. Mohan, None.

EVALUATION OF ADEQUACY OF CONTROL OF SYMPTOMSIN BRONCHIAL ASTHMARabindra K. Dalai, Assistant Professor*; Harshal P. Bhole, MD; DigambarBehera, Professor; Ashutosh N. Aggarwal, Assistant Professor. MedicalCollege, SCB Medical College and Postgraduate Institute of MedicalEducation and Research, Cuttack, Chandigarh, India

PURPOSE: Most patients do not follow/know the guidelines particu-larly what is adequate control and the severity is often underestimated.We tried to assess the adequacy of symptom control and the factorsassociated with inadequate control in Indian patients in reference to NIHguidelines.

METHODS: A validated questionnaire was used. This included symp-toms, treatment received, drugs prescribed, adequacy of control, Adviceon avoidance of environmental exposure, home PEFR measurement.Adequacy of control was assessed by an index calculated from a totalscore, one point being given for each of the following: no exacerbationduring last one month, sos medication, no audible wheeze, FEV1� 80%,PEFR variability � 20%, absence of dyspnoea on routine activity.Evaluation of factors associated with inadequate control of symptoms wasassessed by severity of asthma, treatment recommendation as per NIHguidelines, drug dosage and duration, regularity of treatment and cause ofirregularity.

RESULT: 150 patients were included in the study (64 males and 86females, age 13-73 years). 53 patients had mild intermittent, 46 had mildpersistent, 48 had moderate, and 3 had severe persistent asthma. FEV1was � 80% in 43. The mean score of adequacy of control was 0.59. Lackof control of asthma was due to several factors like noncompliance,treatment not as per NIH guidelines, lack of education, non-affordability,and side effects of medications. These were related to behavior of patientsand physicians. Noncompliance was an ill-understood phenomenon. Nonewas using a peak flow meter.

CONCLUSION: Asthma control was not satisfactory in many patients.Better education of patient and physician is required to have adequatecontrol of asthma.

CLINICAL IMPLICATION: Patient education and following ofasthma guidelines is very important in asthma management.

DISCLOSURE: R.K. Dalai, None.

IMBALANCE BETWEEN MATRIX METALLOPROTEINASE-9AND TISSUE INHIBITOR OF METALLOPROTEINASE-1 INTOLUENE DIISOCYANATE-INDUCED ASTHMAEugene Choi, Pulmonologist*; Yong C Lee, Pulmonoloigist, ChonbukNational University. Konyang University Hospital, Daejon, Republic ofKorea

PURPOSE: Toluene diisocyanate (TDI)-induced asthma is an inflam-matory disease of the airways characterized by airway remodeling due, atleast in part, to an excess of extracellular matrix deposition in the airwaywall. The ratio of matrix metalloproteinase-9 (MMP-9) and its inhibitor,tissue inhibitor of metalloproteinase-1 (TIMP-1) may be a marker of thebalance between airway tissue destruction and repair. Objective Wedetermined whether an imbalance of the MMP-9:TIMP-1 molar ratio ispresent before and/or after challenge with TDI.


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METHODS: We used a murine model of TDI-induced asthma toevaluate the MMP-9 and TIMP-1 balance in the lung.

RESULTS: The expression of MMP-9 and TIMP-1 mRNAs andproteins in the lungs increased at 7 hours after TDI inhalation andcontinued for up to 72 hours. Immunohistochemical and immunocyto-logical analyses in the lungs of TDI-exposed mice revealed increases ofimmunoreactive MMP-9 and TIMP-1. There were significant correlationsbetween the levels of MMP-9 or TIMP-1 and the number of neutrophils,lymphocytes or eosinophils. In addition, the molar ratio of MMP-9/TIMP-1 significantly decreased at 7 hours after TDI inhalation andcontinued up to 72 hours.

CONCLUSIONS: These data suggest that airway inflammation isassociated with an imbalance between MMP-9 and TIMP-1

CLINICAL IMPLICATIONS: These data may play an important rolein the pathogenesis of TDI-induced asthma

DISCLOSURE: E. Choi, None.

NEUROTENSIN PULMONARY METABOLISMRoberto G. Carbone, MD, FCCP*; Paola Vacca, MD; Giovanni Bottino,MD. DIMI, University of Genoa, Italy, Regional Hospital, Aosta, Italy

BACKGROUND: The role of pulmonary metabolism of endogenousneurotensin (NT) in asthma is still unclear. Information on this subject inhumans is scarce.

OBJECTIVES: Evaluation of the pulmonary metabolism of the en-dogenous NT in asthmatic subjects during symptom-free periods after amethacoline challenge test and in healthy individuals.

METHODS: Ten asthmatic subjects (aged 34 to 70 years), diagnosedwith extrinsic (n�5), atopic (n�3), and mixed asthma (n�2), werecompared to a group of 10 healthy individuals (aged 45 to 69 years). Theasthmatic group of patients was evaluated with a PD20-FEV1 methacolinechallenge test 3 days after a washout period from cessation of their regularmedications. Two catheters were inserted in order to draw blood samplesfor the evaluation of NT concentration: one was inserted into thepulmonary artery and the other into the radial artery. The mean concen-tration of NT in pulmonary and systemic arterial blood, as well as thearteriovenous difference of NT and the production rate [PR] /m’/kg andproduction rate [PR] /m’/mq were calculated for each participant.

RESULTS: The mean neurotensin concentration in normal subjectswas higher in mixed venous blood (pulmonary artery) than in systemicarterial blood (p�0001). Similarly, mean NT venous levels in asthmaticsubjects was shown to be higher than mean NT levels in arterial blood,before and after the bronchoconstriction with methacoline (p�0.05 andp�0.02, respectively). In contrast, the arterovenous difference and themean values of PR of NT were similar in both groups.

CONCLUSIONS: Our findings suggest that 1) NT concentration inmixed venous blood changes in transit through the pulmonary paren-chyma, indicating that the pulmonary parenchyma is an important site ofNT metabolism; 2) Pulmonary clearance of NT is unaffected by cholin-ergic bronchoconstriction. Further clinical studies are needed in order toimprove both the understanding and the therapeutic approach of theneurogenic process in asthmatic subjects.

DISCLOSURE: R.G. Carbone, None.

NO EFFECT OF ALLERGEN EXPOSURE ON CILIARY BEATFREQUENCY OF ALLERGIC TISSUE IN VITRO: DOSE RE-SPONSE STUDYThorsten Stein, MD*; Mohamed Y. Abdel-Aziz, MD; Inge Wissen-Siegert, MD; Hans L. Hahn, MD. Deutsche Klinik fur Diagnostik,Wiesbaden, Germany

PURPOSE: To assess effects on ciliary beat frequency (CBF) of twodoses of allergen (low and high concentration x time product).

METHODS: We examined nasal cilia from 29 patients with allergicrhinitis (14M, 15F, age 36�12) in vitro following turbinate surgery.Allergic rhinitis was confirmed by allergy testing and clinical history. Thetwo doses of allergen used were 500 biological units/ml (standardintracutaneous test strength) for 15 minutes (group 1) and 2500 biologicalunits/ml for 30 minutes (group 2). Tissues were suspended in mediumM199 in Earle’s balanced salt solution, equilibrated with carbogen.Tissues were washed to remove blood and drugs. From each specimentwo biopsies were obtained and suspended in allergen or control solutionin randomized sequence. Tissues were studied in the shallow trough of amicroscopy slide closed with a cover glass, and kept at 37° C throughout.

We employed transmitted light microscopy (magnification 500 x, Zeiss)and photometry (Zeiss) to assess CBF. The photometer signal wasdigitized (Sound Technology ST191 acquisition module) and subjected toonline Fourier analysis (SpectraPro FFT analysis system). CBF wasassessed continuously and logged every 15 seconds.

RESULTS: Mean CBF was 11.2 Hz immediately after suspension incontrol solution and was 11.2 Hz in allergen (p � 0.92, low dose group).Values were 11.6 vs. 11.9 Hz in the high dose group (control vs. allergen,p � 0.44). During the subsequent 15 or 30 minutes CBF did not changesignificantly, being 11.6 vs. 10.5 Hz (control vs. allergen, p � 0.36, min.15) in group 1 and 12.1 vs. 11.6 Hz (control vs. allergen, p � 0.6, min. 30)in group 2. Thus, neither dose of allergen changed CBF significantlycompared to control.

CONCLUSIONS: Allergen does not change CBF of allergic tissue invitro at concentration x time products of 500 x 15 and 2500 x 30 (biologicalunits/ml x minutes).

CLINICAL IMPLICATIONS: Impaired ciliary beating is not a likelycause of mucus problems in respiratory tract allergy.

DISCLOSURE: T. Stein, None.

A STUDY OF AUTONOMIC DYSFUNCTION IN ADULTASTHMA PATIENTS AT A TERTIARY CARE CENTERBhavneesh Sharma, Resident in Internal Medicine*; Mradul K. Daga,Professor in Internal Medicine; Gopal K. Sachdev, Professor in InternalMedicine; Manisha Kaushik, Resident in Pulmonary Medicine. MaulanaAzad Medical College, New Delhi, India

PURPOSE: This clinical study was done to compare autonomicdysfunction in asthmatics by 6 non-invasive tests, to compare autonomicdysfunction in asthmatics and controls, to determine the relationship ofduration of asthma with autonomic dysfunction and to compare theseverity of asthma with autonomic dysfunction.

METHODS: The selected patients were divided into 2 groups. Group1 (cases)-included cases of bronchial asthma. Group 2 (controls)-compris-ing of age and sex matched normal subjects. The severity of asthma wasdefined in terms of mild intermittent, mild persistent, moderate andsevere asthma based on the symptoms, variability of peak expiratory flowrate (PEFR) and frequency of use of beta-2 agonists. Tests used for thediagnosis of autonomic dysfunction were: 1. Orthostatic test, 2. 30:15ratio, 3. Sustained hand grip test, 4. Deep beathing test, 5. Atropine testand, 6. Valsalva maneuver.

RESULTS: Out of 30 patients, 22 had autonomic dysfunction whereas8 had normal function. Eight patients had asthma duration of less than 5years out of which only 2 had autonomic dysfunction. Majority of thepatients with autonomic dysfunction (20 patients) had bronchial asthma ofduration greater than 5 years. Severe asthma was present in 16 patientsout of 30, out of which 15 patients had demonstrable autonomicdysfunction. Mild-moderate asthma was present in 14 patients, out ofwhich 7 had autonomic dysfunction. Overall, out of 30 asthma patientsenrolled in the study, 14 had pure parasympathetic dysfunction, 12 hadboth parasympathetic and sympathetic dysfunction and 4 had isolatedsympathetic dysfunction.

CONCLUSIONS: Our study shows that asthmatics display definiteautonomic dysfunction compared to controls. More the duration ofasthma, more is the incidence of autonomic dysfunction. As the severity ofasthma increases, the incidence of autonomic dysfunction also increases.

CLINICAL IMPLICATIONS: Autonomic dysfunction is present inasthma patients with increasing duration and severity. Parasympathetichyper responsiveness may contribute to severity of asthma exacerbationsand anticholinergic drugs may be useful in managing this condition.


BRONCHIAL ASTHMA PREVALENCE, MANAGEMENT, ANDEDUCATION IN NASSAU COUNTY PUBLIC SCHOOLSLiziamma George, MBBS*; Tara George, Research Assistant; TonyGeorge, Research Assistant; Ghulam Saydain, MD; Ashok Karnik, MD;Sandeep Mehrishi, MD; Suhail Raoof, MD. Nassau University MedicalCenter, East Meadow, NY

INTRODUCTION: Four million children had at least one bronchialasthma attack (BAA) in the year of 2001. BAA is increasing steadily inchildren under 18 yrs of age and is the leading cause of school absentee-ism.


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PURPOSE: A survey (S) was conducted in Nassau County (NY) PublicSchools (NCPS) to determine the prevalence of bronchial asthma andBAA, management of BAA, asthma education (AE), and use of indoor airquality tools (IAQ).

METHODS: A 21 question S was sent to the school nurses (N) at allNCPS. The results were then tabulated.

RESULTS: Of 277 NCPS, 89 (32%) returned the S. Nine percent ofstudents have asthma and 10% of them develop BAA in school. BAA ismanaged in the school by giving children medications (nebulized in 88%),calling 911 and informing parents. In 39 (73%) schools only nurses areallowed to give emergency medications. Students take their own medica-tions during after school activities in case of BAA. An asthma action cardis used in 43 (48%) of schools and AE is available in 19% of schools. Aspecific curriclum for asthma education is used in 9 schools and the AE isgiven by N. “Open airways” program is used by 74% of schools and indoorair quality tools are used in 20% of schools. Pets are allowed in 43(48%)(mostly elementary) schools.

CONCLUSIONS: 1) Acute asthma attack is not uncommon duringschool hours. 2) Asthma education in schools need to be improved. 3)Open airways and indoor air quality tools should be used more widely inschools. 4) Emergency asthma management should be taught to otherschool personnel besides the nurses.

CLINICAL IMPLICATION: Improvement in asthma education andadopting programs like the open airways program and indoor air qualitytools may decrease the incidence of acute asthma attacks in schools.

DISCLOSURE: L. George, None.

DECREASING THE EMERGENCY DEPARTMENT UTILIZA-TION AND HOSPITALIZATION RATES OF ADULT PATIENTSWITH ASTHMA FOLLOWED IN THE ASTHMA CLINICRiyad J. Basir, MD, FCCP*; Melissa Schori, MD; Anita Soni, MD; RobertLee, MD. Lincoln Medical and Mental Health Center, Bronx, NY

PURPOSE: Decrease the Emergency Department (ED) utilizationand hospitalization rate for ambulatory care patients with asthma. Asthmais the number one DRG in the ED. Adult hospializations for asthma in2000 was 1221(14%) of total adult medicine hospitalizations. Adult asthmaclinic visits-4800/year.

METHODS: We tracked the asthma clinic patients utilizing the EDand or were hspitalized. We identified the factors responsible for the highED utilization and hospitalization rates and implemented a multidisci-plinary team approach to the management of clinic patients starting May2001, with emphasis on: Standardized care according to the NHLBIguidelines; Implementation of asthma action plan on the first clinic visit;Stress on patient education including self management and smokingcessation; Expansion of asthma clinic appointment availability-open ac-cess.

RESULTS: Adult asthma ED visit or hospital admission rate for clinicpatients with asthma decreased from 510(8.4%) for 2001 to 115(1.9%) for2002.

CONCLUSION: A significant decrease in the number of patients withadult asthma utilizing the ED and or getting hospitalized was achieved byintroducing a multidisciplinary team effort involving physicians, nurses,respiratory therapists and social services with a stress on patient educationincluding attack plan and self management, open access and applyingNHLBI guidelines.

DISCLOSURE: R.J. Basir, None.

USE OF REAL-WORLD EXPERIENCE DATA IN PATIENTSTREATED WITH FORMOTEROL FUMARATE INHALATIONPOWDERC P. Fuhrmann, MD, FCCP*; D Paradis, MBA. Private Practice,Kennebunk, ME

PURPOSE: Provider-patient communication is critical to appropriateand effective health care management. This study describes a programthat communicated to providers direct-from-patient experiences withformoterol fumarate inhalation powder in the treatment of breathingdifficulties associated with asthma, chronic obstructive pulmonary disease(COPD), or exercise-induced bronchospasm (EIB).

METHODS: Physicians provide eligible patients with program mate-rials and patients consent to completing two surveys—prior to usingformoterol fumarate inhalation powder and after at least seven days of use.Surveys collect patient experiences with the medication and the device in

relation to their breathing condition. Survey results are summarized foreach patient and sent to the prescribing physician.

RESULTS: 190 patients have enrolled in this ongoing program; 94completed both surveys as of April 22, 2003. Average age was 62 years,and 68% were female. 43% indicated asthma as their breathing condition,followed by COPD (38%). 83% indicated their provider showed themhow to use the device and 67% reported the medication delivery devicewas easy to use. After use of formoterol fumarate inhalation powder,patients indicated breathing difficulties interfered less with general dailyactivities (37%), leisure activities (41%), and overall enjoyment of life(40%). 72% indicated intent to continue using formoterol fumarateinhalation powder. Patients reported their primary motivation for partic-ipating was a request from their physician (50%) or a desire to provideinformation to their physician (30%).

CONCLUSIONS: With formoterol fumarate inhalation powder, pa-tients reported less interference from their breathing condition and thatthe medication delivery device was easy to use. This study describes apractical approach to provide physicians with self-reported informationfrom their own patients regarding patients’ experiences with therapy.

CLINICAL IMPLICATIONS: Patient self-reported data can becombined with other patient data to help physicians make necessarydecisions for the effective health care management and education of theirpatients.

DISCLOSURE: C.P. Fuhrmann, InfoMedics, Inc.; presenter andparticipating physician in the study; FRN0014 5/03

ASTHMA IN PHILADELPHIA SCHOOLSSalvatore Mangione, MD*; Elaine Yuen, PhD; David Madigan, PhD.Jefferson Medical College, Philadelphia, PA

PURPOSE: The Philadelphia School District (PSD) recently sub-contracted 45 of its lowest performing schools to 7 private organizations,with Edison Inc. receiving responsibility for 21/45 schools. Since asthmais a well-known cause of absenteeism and poor academic performance(and many children are often undiagnosed), we compared the prevalenceand severity of this disease between PSD and Edison schools.

METHODS: We screened for asthma by using the ISAAC question-naire, a self-administered and validated instrument that relies on videosdepicting five asthma symptoms. Our target population comprised 6,727middle schoolers from 65 Philadelphia public schools: 6006 managed bythe PSD and 721 by Edison.

RESULTS: Overall, 23.7% of PSD children and 24.5% of Edisonreported having asthma. When limiting analysis to students unaware of thediagnosis, schools managed by Edison had higher prevalence of at leastone of three wheezy symptoms in the previous year (36.5% vs 32.3%,P�.05). They also had higher asthma severity scores, as indicated by thenumber of symptoms experienced in life (1.33 vs 1.16, P�.004) , or in theprevious year (.93 vs .79, P�.01), or more than once a month (.83 vs .60,P �.001).

CONCLUSIONS: These data indicate a significantly higher preva-lence of unrecognized asthma symptoms in the poorest-performingPhiladelphia schools. They also support previous data from us, indicatinga higher asthma prevalence in high-absentees from school (49.1 percent;N� 226) as compared to low-absentees (21.4 percent; N� 885), P�.001.

CLINICAL IMPLICATIONS: Although school management in Phil-adelphia was subcontracted to private companies based upon studentsacademic performance, the prevalence of undiagnosed asthma and itsseverity might have played a role in this decision, by possibly contributingto absenteeism and poor academic performance. The identification andtreatment of asthma in school-aged children is therefore critical to helpstudents lead healthier and more successful lives.

DISCLOSURE: S. Mangione, GlaxoSmithKline, grant monies; unre-stricted educational grant provided by GSK to our AsthmaBUS programin Philadelphia schools.

ASTHMA AND TOBACCO: A SURVEY OF 65 PHILADELPHIAMIDDLE SCHOOLSSalvatore Mangione, MD*; Elaine J. Yuen, PhD; David Madigan, PhD.Jefferson Medical College, Philadelphia, PA

PURPOSE: The Philadelphia School District (PSD) recently sub-contracted 45 of its lowest performing schools to 7 private organizations,with Edison Inc. receiving responsibility for 21/45 schools. To betterunderstand issues that might have contributed to the poor academic


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performance of these youngsters, we surveyed the use of tobacco andcorrelated it with prevalence of asthma symptoms, both diagnosed andundiagnosed. We compared data between PSD and Edison schools.

METHODS: We screened for asthma by using the ISAAC videoquestionnaire, supplemented by questions on experimentation with to-bacco and passive exposure at home. Our target population comprised6,727 middle-schoolers from 65 Philadelphia public schools: 6006 man-aged by PSD and 721 by Edison.

RESULTS: Overall, 23.7% of PSD children and 24.5% of Edisonreported having asthma. Among asthmatics, home exposure to environ-mental smoke was reported by 73.2% for Edison and 64.5% for PSD, P �.03. Experimentation with smoking was reported by 31% of Edison and24.1% of PSD, P � .05. When comparing children with self-reportedasthma to those without it, we found a significantly higher percentage oftobacco experimentation among asthmatics (24.1% vs. 20.5% at PSD and31% vs. 23.2% at Edison, P’s � .004 and .04 respectively). Children withasthma were also more exposed to secondhand smoke than non-asthmat-ics, although this difference approached statistical significance only for thePSD (64.5% vs. 61.8.1%, P�.06). When analyzed by ethnicity, smokingexperimentation was overall present in 22.5% of African-Americans, 21%of Whites, 18.4% of Hispanics, and 14.2% of Asians.

CONCLUSIONS: These data indicate a significantly higher preva-lence of tobacco exposure and experimentation among students fromschool with worse academic performance. Children with asthma weresignificantly more likely to be experimenting with tobacco.

CLINICAL IMPLICATIONS: Tobacco prevention and controlshould be incorporated in the educational activities of outreach asthmaprograms for school children.

DISCLOSURE: S. Mangione, GlaxoSmithKline, grant monies.

LESS PHYSICAL ACTIVITIES ASSOCIATED WITH ASTHMA INTHE ELDERLY BUT NOT IN CHILDREN AND YOUNGADULTS: THE CANADIAN COMMUNITY HEALTH SURVEYYue Chen, PhD*; Paula Stewart, MD; Shirley Bryan, MSc; GregoryTaylor, MD; Robert Dales, MD, MSc. University of Ottawa, Ottawa, ON,Canada

PURPOSE: Participation in regular physical activity is critical tosustaining good health. We examined the association between physicalactivity and asthma in different age groups.

METHODS: We analyzed data from approximately 130,000 Canadiansaged �12 years who participated in the Canadian Community HealthSurvey in 2000-01. Physical activity index was calculated based onself-reported time spent on specific leisure-time activities, and wascategorized into active (� 3.0 kcal/kg/day), moderate (� 1.5 and � 3.0)and inactive (�1.5) groups. Physical activity for usual day was assessed byasking the question: “Thinking over the past 3 months, which of thefollowing best describes your usual daily activities or work: Usuallysit/Stand or walk quit a lot/Usually lift or carry light loads/Do heavy workor carry very heavy loads?” A bootstrap procedure was used to takesampling weights and design effects into account.

RESULTS: The prevalence of self-reported asthma was 9.3% in the activegroup, 8.0% in the moderately active group and 8.6% in the inactive group.The prevalence of physical inactivity was 52.9% in asthmatic persons and53.5% in non-asthmatic persons. Children and young adults with asthma wereslightly more active than those without asthma at leisure time. However, menand women with asthma were less active than non-asthma counterparts inthose aged �60 years. For elderly people the prevalence of asthma wasalmost doubled in men and women who were sedentary compared with thosewho reported lifting light loads or doing heavy work for usual day. The resultswere similar when covariates (smoking, body mass index, COPD and others)were taken into consideration.

CONCLUSIONS: Less physical activities were associated with anincreased risk of asthma in elderly people but not in children and youngadults. Reasons for the age difference in the physical activity and asthmaassociation needs to be further explored.

CLINICAL IMPLICATIONS: Health benefits of physical activity arewell established. Increased attention should be paid to elderly people withasthma for physical activity programs.

DISCLOSURE: Y. Chen, None.

ASTHMA IN THE ELDERLY: A TEXAS PERSPECTIVEJay I. Peters, MD*; S Bricker, MPH; H Sorenson, MA, RRT. Univ of TxHlth Science Ctr @ S.A., San Antonio, TX

PURPOSE: Review the prevalence, hospitalization rate, and mortalityof asthma in the elderly within the state of Texas

METHODS: Extraction of data from Texas Department of Health,Bureau of Vital Statistics and Health Care Information Council, HospitalInpatient Discharge Public Use Data File.

RESULTS: The prevalence of current asthma in patients over 65 was6.5% and similar to the entire population (6.2%) for the years 1999-2001.Self-reported asthma was 3.7% for Hispanic vs. 7.2% for Black vs. 7.4%for Whites. Hospitalizations were 90.4/100,000 for elderly asthmatics vs.38.3/100,000 for the entire population. Hospitalizations were significantlyhigher for female and black patients. From 1980-2000, there were 5,386deaths from asthma in Texas. The rate of asthma deaths (150/100,000/yr)and the rise in asthma deaths was greatest in the elderly.

CONCLUSIONS: The morbidity and mortality rate in elderly asth-matics is significantly greater than in the general population.

CLINICAL IMPLICATIONS: Prospective studies need to be con-ducted to identify the reasons why elderly patients have an increasedmorbidity and mortality from asthma.

DISCLOSURE: J.I. Peters, None.

BURDEN OF ASTHMA IN THE ELDERLYArchana Mishra, MD, MS*; Joshua Novak, MD; Patricia Nowak, RN;Alan T. Aquilina, MD; Brydon J. Grant, MD. Erie County MedicalCenter, Buffalo, NY

PURPOSE: Rapid increases in the numbers and proportions of elderlyin the U.S. have lead to concerns about the impact of these changes on useof health services and the burden of chronic disease. To determine thehealth care utilization patterns among elderly asthmatics in the UpstateNew York area.

METHODS: Outpatient health care utilization patterns were deter-mined using Medicare claims data in 45 counties in upstate New Yorkfrom 9/1/01 – 8/31/02 using the International Classification of Diseasescode of 493 for asthma. Medicare is the major health insurance providerfor this age group so the prevalence of asthma based on outpatient claimswas calculated for the different counties using the population census data.

RESULTS: There were 67,000 claims that met this criteria. Using thisset of claims the corresponding beneficiary and patient ID numbers wereidentified. There were 27,669 unique identifiers in this set. From the tableof patient information, the zip code for each patient was extracted and itwas used to identify which county the patient lived in, and this allowed thedata to be summarized by county prevalence. The gender distributionamong asthmatics showed a preponderance of female gender, 67% versus33% male. Only 9,884 (36%) had spirometry performed. 3,462 out of the27,669 with asthma also had claims for heart failure showing the increasedprevalence of co-morbidities in this population.

CONCLUSIONS: Spirometry claims suggest under use of objec-tive testing in a cohort that needs it the most, given the comorbidities thatmake diagnosis and management of asthma a challenge in the elderly.


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CLINICAL IMPLICATIONS: Major problems with identifyingasthma in the elderly include a low index of suspicion by physicians, underuse of spirometry and the high frequency of co-morbid diseases whichhave similar signs and symptoms which probably contribute to the underdiagnosis and under treatment of asthma.

DISCLOSURE: A. Mishra, None.

Bronchoscopy and Other InterventionalProcedures12:30 PM - 2:00 PM

RELIABILITY OF AN INTRA-BRONCHIAL VALVE ANCHOR-ING METHOD IN A SIX-MONTH ANIMAL STUDYXavier Gonzalez, MD*; Mia Park, MS; David H. Dillard, BS; William A.Sirokman, BS; Seung Yi, BS; Laurent L. Couetil, DVM; Steven N. Mink,MD. Spiration Inc, Redmond, WA

INTRODUCTION: During the development of a non-stent basedintra-bronchial valve system (IBV) for the treatment of emphysema,evidence of device migration produced by coughing was occasionallyobserved. An anchor system was optimized to prevent device migration,minimize tissue reaction and allow removal when required.

PURPOSE: To assess safety and efficacy the IBV anchoring system,over time in two animal species.

METHODS: A total of 323 devices were implanted in 28 healthyanimals (14 dogs and 14 sheep). Devices were removed and/or replaced atintervals of 1, 3 and 6 months. At each follow-up interval, some animalswere sacrificed for pathological evaluation of the lungs. Also, each valvewas observed for fit and location using bronchoscopy. Some devices wereremoved and/or replaced. After each removal, careful inspection of theairways was done.

RESULTS: Post-procedural coughing was observed in some of theanimals. At 1 month, all 323 valves were observed in their original implantlocations. All valves were found in their original implant locations in allsubsequent follow-up procedures. Some valves were removed and re-placed without complications using bronchoscopy and biopsy forceps. In12 necropsies, no evidence of lung trauma was observed. Mild tomoderate hyperplasia was observed in the airway areas where valves wereimplanted. Six animals (2 dogs and 4 sheep) were evaluated at 6 monthsand all 36 devices were observed in their original implant locations and 14valves were removed without complication.

CONCLUSIONS: All valves remained in place up to 6 months afterimplant. The current IBV design and system is safe and effective, providesreliable, atraumatic means of preventing valve dislodgement and allowseasy removal if required.

CLINICAL IMPLICATIONS: An effective anchoring design is crit-ical for achieving a safe and reliable means for the bronchoscopictreatment of emphysema using the IBV system.

DISCLOSURE: X. Gonzalez, Spiration Inc, Industry,, Discussion ofproduct research or unlabeled uses of Product.

CHRONIC CENTRAL VENOUS CATHETERS IN SUBACUTECARE SETTING: FIVE-YEAR EXPERIENCEDeepak K. Shrivastava, MBBS,FCCP*; Sheela Kapre, MBBS,FCCP. SanJoaquin General Hospital, Stockton, CA

PURPOSE: Chronic central venous catheters (CCVC) provide promptintravenous access in sub-acute care unit patients with a high infectionrisk. Phlebosclerosis precludes insertion of peripheral venous lines. Manydrugs are infused via central route only. Percutaneous central lines areconsidered high complication risk due to tracheostomy, oro-trachealsecretions and urinary-fecal incontinence.

METHODS: We retrospectively reviewed records of 107 operativeprocedures regarding insertion or removal of CCVC done over 5 years ina 50-bed subacute unit. Data abstracted included total number ofprocedures, indications and complications. The recommendation regard-ing use of CCVC was made based on clinical rationale and risk versusbenefit analysis.

RESULTS: A total N � 66 catheters were placed via subclavian route.The most common use was intravenous antibiotic therapy and blooddraws. The most important use was emergent intravenous fluid resusci-tation for hypotension. Fifteen percent (10/66) were used for emergencydrugs. There were 21 catheters (32%) suspected as a source of infection;

15 of these were removed. Catheter site cellulites developed in sixpatients. Fifteen catheters (23 %) were blocked either due to blood clotsor precipitation of medications. Poor technique in accessing the cathetercaused clinically significant hematoma in three (5%) patients. Twopatients (3%) developed thrombosis of the subclavian vein. Only onecatheter migrated in to the right ventricle. No poor patient outcome wasnoted secondary to the CCVC. In case of infected catheters antibiotictherapy was attempted to salvage the catheter. Flushing of the obstructedcatheter with saline for 24 hours was successful in re-establishing thepatency. Five catheters required thrombolytic therapy. Catheters wereremoved due to infection, obstruction and at patient discharge.

CONCLUSIONS: We documented a 32% infection rate, a 23%obstruction rate and a thrombosis rate of 3%. Scheduled in-servicetraining for accessing the catheters may eliminate many complications.

CLINICAL IMPLICATIONS: We recommend use of CCVC insub-acute unit setting due to the clinical rationale. The complication ratesare acceptable compared to their usefulness.

DISCLOSURE: D.K. Shrivastava, None.

BRONCHIAL ARTERY EMBOLIZATION (BAE): CLEVELANDCLINIC EXPERIENCESaleh A. Ismail, MD*; Michael A. Geisinger, MD; Atul C. Mehta, MD.Department of Pulmonary and Critical Care Medicine, Cleveland ClinicFoundation, Cleveland, OH

PURPOSE: BAE is an effective modality in the management ofhemoptysis. This study aims to report the Cleveland Clinic experiencewith bronchial arteriography and BAE, to evaluate the short-terms andlong-terms outcomes, and to determine the various possible predictiveand prognostic variables.

METHODS: A review of medical records for all patients who under-went bronchial artery arteriography and embolization between January1992 and June 2002 at the Cleveland Clinic was carried out to evaluate thedemographics, clinical presentation, radiographics studies, bronchoscopy,outcomes, complications and mortality.

RESULTS: 43 patients (age 52.7�15; 22M/21F) underwent 57 angio-grams of bronchial arteries and collateral vessels and were followed upover 30.2�28.3 months. The most common indication was hemoptysis in41 (95%). The etiologies were lung malignancies (13), mycetoma (9),pulmonary hypertension (4), fibrosing mediastenitis (3), other identifiedcauses (12), and unidentified causes (2). Bronchoscopy was performedprior to 47 bronchial arteriographies, and the source of bleeding wasidentified in 44 procedures. Of the 57 angiograms,14 were for recurrenthemoptysis in 8 patients (18.6%). Embolization was successful in 54sessions in 40 patients (93%). The total number of embolized vessels was109. The average number of vessels per session was 1.9 (range:0-5).Immediate control of hemoptysis was achieved in 52 procedures corre-sponding to 39 patients (90.7%). Rebleeding occurred after 16 successfulBAE’s in 12 patients (27.9 %) within 30 days, and after 10 in 4 (9.3 %)after 30 days. Twenty one patients (48.8 %) died. Of these, 11 (26%) diedin the first 30 days. One patient had pneumothorax and another hadperforation of bronchial artery.

CONCLUSIONS: BAE is safe and effective in controlling both acuteand chronic hemoptysis. In case of recurrence, it can be safely repeated.Mortality rate is dependent mostly on the underlying pathology.

ClINICAL IMPLICATIONS: Patients with hemoptysis not controlledwith conservative measurements should be considered for BAE awaitingdefinitive surgical treatment. BAE is appropriate for patients who are notgood surgical candidates.

DISCLOSURE: S.A. Ismail, None.

BRONCHIAL ARTERY EMBOLIZATIONGamal M. Rabie, MD,FCCP*. University, Assiut University Hospital,Assiut, Egypt

PURPOSE: To report our experience with bronchial artery emboliza-tion (BAE) in the management of moderate recurrent and life threateninghemoptysis.

SETTING: Assiut University hospital.PATIENTS AND METHODS: Retrospective analysis of the demo-

graphics, clinical presentation, radiographic studies, bronchoscopy, andcomplications of bronchial arteriography and/or BAE, in our center, wasperformed during the period 1998 to 2003.


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RESULTS: One hundred forty-six patients underwent bronchial arte-riography from 1998 to 2003 in our center for the management ofmoderate recurrent or life-threatening hemoptysis. BAE was performedin 141 patients. Their mean age was 43 years (range, 17 to 79 years).Active or inactive pulmonary tuberculosis was the most common etiologyfor hemoptysis followed by bronchiectasis, mycetoma and other identifiedetiologies, while cryptogenic hemoptysis was recorded in 5 cases. Themost common angiographic sign for hemoptysis was hypervascularity(96.6%), followed by systemic-pulmonary artery shunt (40%) and pulmo-nary artery aneurysm (3.4%). All cases with systemic-pulmonary shuntshowed a sharp cut-down of pulmonary arterial blood flow with retrogradefilling of pulmonary artery from systemic arteries. The main source ofhemoptysis in our patients was bronchial arteries. BAE was effective inimmediate cessation of hemoptysis in 112 patients (79%). Recurrence ofhemoptysis was observed in 29 cases (21%). Two or more settings of BAEwere performed in 50 patients (35%), either due to recurrence ofhaemoptysis or to complete the embolization procedure for all bleedingarteries. Complications of BAE were in the form of self-limited acute andsubacute complications, while chronic complications were not recordedduring the course of this study.

CONCLUSION: We conclude that BAE is an effective line for controlof life-threatening or moderate recurrent hemoptysis and its complica-tions are usually self-limited and do not need specific intervention.

DISCLOSURE: G.M. Rabie, None.

BRONCHOSCOPIC USE OF A BALLOON CATHETER FORSELECTING APPROPRIATE INTRA-BRONCHIAL VALVES INHUMAN AIRWAYSMia Park, MS*; David H. Dillard, BS; Lauri DeVore, MS; Lyle Jackson,BS; Xavier Gonzalez, MD. Spiration Inc, Redmond, WA

INTRODUCTION: Currently, there are no clinical tools for theprecise measurement of airways during bronchoscopy. Placement of anon-stent based Intra-Bronchial Valve system (IBV) for the treatment ofemphysema may be facilitated by measurements of targeted airways.

PURPOSE: To assess the effectiveness of a balloon catheter system todetermine segmental airway diameter for selecting valve sizes using anex-vivo human lung model.

METHODS: Three sets of fresh, intact ex-vivo human lungs wereplaced into an artificial thorax and cycled with pressures corresponding totidal breathing. A prototype compliant balloon catheter, purged of air, wasinflated with saline into templates of known diameters for calibration. Inselected segments of the airways, the catheter was placed bronchoscopi-cally and the balloon inflated to volumes corresponding to 1 mmincrements to just occlude the lumen. Corresponding valves were im-planted into the appropriate airways. The fit of these devices wasevaluated bronchoscopically.

RESULTS: Thirty-six measurements (12 per each set of lungs) wereused to select appropriate valve sizes for implantation. The first set oflungs had 100% correlation between the measurements taken and the IBVselected. The second and third set of lungs had a correlation of 92% and83%, respectively. The cumulative correlation amongst all 3 sets was 92%.In the areas where the fit was not adequate, additional balloon measure-ments were not required because discrepancies were minimal andremoval/replacement of the devices was simple. Upon completion, 100%of the devices fit the airways.

CONCLUSIONS: In these experiments, a calibrated balloon catheterfor bronchoscopic airway measurement was a useful tool for selecting theappropriate valve sizes for implant. The IBV system has been designed foreasy valve removal and replacement if the fit is not appropriate.

CLINICAL IMPLICATIONS: A reliable method for sizing airways isdesirable in determining the appropriate valve size for implantation.

DISCLOSURE: M. Park, Spiration Inc., Industry, discussion of prod-uct research or unlabeled uses of product.

FLUOROSCOPICALLY GUIDED FINE NEEDLE ASPIRATION(F-FNA) OF THE SOLITARY PULMONARY NODULE: REVIS-ITEDAlbert H. Niden, MD*; Michael Koss, MD; Yan L. Ma, MD. Academic,University of Southern California, Los Angeles, CA

PURPOSE: In recent years, F-FNA has been replaced by the morecostly and time consuming CT guided FNA (CT-FNA) for the diagnosisof a solitary pulmonary nodule. We report a modified technique for

F-FNA performed in a pulmonary fellowship (PF) training program - atechnique which provides results comparable if not superior to CT-FNA.

METHODS: Since 1991, 34 PF have performed 99 F-FNA withattending supervision. The principles of the technique were: (1) an 18-Ganeedle (EZEM) was used, (2) the anesthetic needle did not enter thepleural space, (3) under fluoroscopic guidance the needle was insertedinto the lesion, (4) respirations were suspended whenever the needle washeld or immobilized and respirations allowed when the needle was notimmobilized, (5) during a single pass, 5-6 thrusts were made throughoutthe lesion with constant suction, (6) a cyto-pathologist reviewed smears attime of aspiration. If the smear was not diagnostic, a second pass was madeby the attending physician. (7) cores of tissue were embedded forhistologic exam.

RESULTS: After appropriate instruction, fifty-one F-FNA were per-formed by trainees only, 48 by trainees and attending staff and 7 byattending only (total 106). Sixty-two F-FNA were positive for malignantdisease (58%). There were 2 false negatives (sensitivity 97%) and no falsepositives (specificity 100%). A specific diagnosis was made in 19 (44%) of43 non-malignant lesions. Complications included 13 (12%) pneumotho-races, 3 (2.8%) chest tube insertions, 9 (8.5%) trace hemoptysis and nodeaths.

CONCLUSION: F-FNA is less costly and less time consuming thanCT-FNA. It is at least equal to CT-FNA regarding sensitivity, specificityand complications.

CLINICAL IMPLICATION: It is a justifiable alternative to CT-FNAfor the diagnosis of solitary pulmonary nodules.

DISCLOSURE: A.H. Niden, None.

FLEXIBLE BRONCHOSCOPY IN THE ELDERLY PATIENTPrasoon Jain, FCCP,*; Ismail Al-Ani, MD. Louis A Johnson VA MedicalCenter, Clarksburg, WV

PURPOSE: It is not known how often flexible bronchoscopy (FB)changes management in elderly patients. We studied the clinical utilityand safety of flexible bronchoscopy in patients 75 years or older.

METHODS: Computerized records of 61 elderly patients who under-went FB over a 4-year period were reviewed retrospectively. Demo-graphic information, co-morbid conditions, indications and details ofprocedure, diagnosis from FB, procedural complications and managementchanges due to FB results were recorded .

RESULTS: Median age was 78 years (range 75-88 ). Twenty-twopatients (36%) were 80 years or older. FB was performed for lung mass in29 (48%), non-resolving infiltrate in 11 (18%), and hemoptysis in 9 (15%)patients. The majority of patients were smokers; 64% had chronicobstructive pulmonary disease; 39% had coronary artery disease; 25% hadcongestive heart failure and 18% were receiving home oxygen. FB wasperformed in an outpatient setting in 44 (72%) patients. Brushing wasdone in 43 (70%), transbronchial biopsy in 26 (43%), endobronchialbiopsy in 24 (39%), and transbronchial needle aspiration in 11 (18%)patients. Multiple sampling procedures were performed in 53 (87%)patients. FB provided diagnosis in 44 (72%; 95% confidence interval [CI]60-82%) patients. Lung cancer was the most common diagnosis from FB(26 patients; 43%). Management changes due to FB occurred in 29 (48%;95% CI 36-60%) patients, including initiation of radiation therapy in 11(18%), chemotherapy in 9 (15%), and surgery in 3 (5%) patients.Procedure-related complications were observed in 7 (11%; 95% CI5-21%) patients. Majority of complications were minor and there were nodeaths after the procedure.

CONCLUSIONS: FB is safe, frequently provides diagnosis, and leadsto important management changes in elderly patients.

CLINICAL IMPLICATIONS: Advanced age by itself is not a con-traindication for FB.

DISCLOSURE: P. Jain, None.

PRACTICE OF INTERVENTIONAL PULMONOLOGY IN CAN-ADANicole Marten, RN*; Perry Sahni, MD; Anil Dhar, MBBS, FRCPC; SatSharma, MBBS, FRCPC. University of Manitoba, Winnipeg, MB, Canada

PURPOSE: Interventional pulmonology has evolved to become main-stream practice of pulmonary medicine. In Canada, how many pulmonary


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physicians perform invasive pulmonary procedures or what proceduresare performed, is not known. We conducted a mail survey to study thepractice profile of Canadian pulmonologists with respect to performanceof interventional procedures (IP).

METHODS: A questionnaire consisting of 19 questions was designedto study the demographic profile, practice pattern and performance ofinterventional procedures by pulmonary specialists in Canada. The ques-tionnaire was mailed to 621 pulmonary specialists listed on the RoyalCollege of Physicians and Surgeons’ registry, ACCP membership direc-tory and Canadian Medical Directory. A second mailing was sent out 2months later.

RESULTS: A total of 355 (62%) physicians returned the completedsurvey. The survey indicated that 87% of the pulmonologists perform atleast one interventional procedure. Flexible bronchoscopy is performedby 87%, transbronchial forceps biopsy by 80%, and transbronchial needlebiopsy by 43%. Other procedures such as rigid bronchoscopy (16%),transthoracic needle biopsy (18%), laser or stents (5.7%) and medicalthoracoscopy (8%) were infrequently performed. The physicians whoperform IP are younger (61 vs 42%), male (86 vs 62%), have been inpractice for less than 30 years (95 vs 69%), and practice in larger cities (73vs 60%). Most physicians received training during the fellowship programs(85 vs 60%).

CONCLUSIONS: In Canada, a majority of pulmonary specialistsperform fiberoptic bronchoscopy and transbronchial biopsies; and asmaller number do transbronchial needle biopsies. Practice of rigidbronchoscopy, laser/stents or medical thoracoscopy has not becomepopular in Canada yet. The physicians who perform invasive proceduresare younger, practice in larger academic centres and spend a majority oftheir time in clinical practice. These physicians acquired competency toperform invasive procedures primarily through the fellowship trainingprograms.

CLINICAL IMPLICATIONS: In order to improve the practice ofinterventional pulmonology and specifically the newer procedures, Cana-dian fellowship programs must incorporate training in interventionalpulmonology as part of the core curriculum.

DISCLOSURE: N. Marten, None.

INTERVENTIONAL BRONCHOSCOPY FOR MANAGEMENT OFBENIGN OBSTRUCTIVE AIRWAY DISEASERicardo S. Santos, MD*; Yannnis Raftopoulos, MD, PhD; Singh Deepak,MD; Richard Maley, MD; Robert J. Keenan, MD; Rodney J. Landreneau,MD. Allegheny General Hospital, Pittsburgh, PA

PURPOSE: Benign tracheal stenosis (BTS) can be a life threateningcondition for which surgical resection / reconstruction is often considered.Many patients presenting with BTS are poor surgical candidates andinterventional bronchoscopy (IB) may be an attractive alternative tosurgery in such patients.

METHODS: 26 patients not considered candidates for surgical resec-tion due to physiologic impairment underwent IB for BTS between 1995and 2002. Rigid bronchoscopic airway control was routinely utilized. Dataregarding patient demographics and duration of symptom palliation werereviewed.

RESULTS: There were 12 males and 14 females, with a median age of56 years. Expandable wire stents were used as primary treatment in 18patients. Tracheal pneumatic balloon dilation was primary treatment for 5, and laser fulguration in 3 . A total of 58 procedures were performed. Themean number of procedures per patient was 2.3 with a range of 1 to 9.These included 26 stent insertions, 23 balloon dilations and 9 laser/manualdebridements. Indication for intervention was dyspnea and/or stridor in20 (77%) patients, respiratory failure due to stenosis in 2 (7%), hemoptysiswith stenosis in 1 (7 %) and intractable cough with stenosis in 3 (11.5%).Four (15.3%) patients had complications (pneumothorax/2, hemoptysis/1,and airway obstruction requiring tracheostomy/1. There were no airwayperforations. The 30-day mortality was 11.5% (3/26). Palliation of airwaysymptoms was established and maintained in 23/26 (88.4%) patients at amedian follow up of 36 months (range 5 –53).

Endoscopic findings N

Stenosis 9Malacia 7Granulation tissue 2Pos lung TX 2Wegener’s disease 2Squamous metaplasia 1Papillomatosis 1Idiopathic 2

CONCLUSION: IB approaches appear to be a safe and effectivemanagement of BTS.

CLINICAL IMPLICATIONS: Patients with significant BTS who arenot candidates for surgical resection may receive significant palliation oftheir symptoms with these IB approaches.

DISCLOSURE: R.S. Santos, None.

PERCUTANEOUS TRACHEOSTOMY: IMMEDIATE COMPLI-CATIONSAna Zamora, MD*; Marco A. Quinonez, MD; Olvera I. Claudia, MD;Mario A. Trevino, MD; Uriel Chavarria, MD; Roberto Mercado, MD.University Hospital Universidad Autonoma Nuevo Leon, Monterrey NL,Mexico

PURPOSE: Percutaneous tracheostomy (PT) has advantages overtraditional tracheostomy as it is easy to do and complications are relativelyinfrequent. The objective was to find the complications during andimmediately after PT.

METHODS: Retrospective study of patients with PT guided withbronchoscopy from September 1999 to December 2002. Complica-tions during and after the procedure were investigated, as well as thereason for PT and length of stay (LOS). We searched for hypotension,hypoxaemia, bleeding, tracheal laceration or rupture of the trachealring, misplacement and subcutaneous emphysema. Of the immediatecomplications we looked for haemorrhage, infections, pneumothorax,pneumomediastinum, accidental dislodgement, subglothic stenosis,and a valve phenomenon.

RESULTS: We included 30 patients 21 (70%) male and 9 (30%)female with mean age of 49 � 19 (17-84) years. Causes for PT: 23 (76%)inadequate management of secretions, 6 (20%) long-term mechanicalventilation and 1 (3%) hypoxic encephalopathy. Mean time of mechanicalventilation was 18 � 11 (3-42) days and mean time for the completeprocedure was 16 � 3 (10-25) minutes. Complications during theprocedure: One (3%) patient with presented subcutaneous emphysemaand tracheal laceration. Immediate complications: infection of the woundn-1 (3%), accidental dislodgement n-1 (3%) and 2 (6%) had a valvephenomenon. Mean days of mechanical ventilation after PT were 2 � 2(1-7) days, LOS 44 � 52 (12-210) days and no patients died because of theprocedure.

CONCLUSIONS: Patients did not develop tracheal stenosis, othermajor complication or died due to the procedure. We conclude it is a safetechnique although we have to compare it with traditional surgery.

CLINICAL IMPLICATIONS: In Mexico it is rare to perform PT sowe need to increase our numbers to demonstrate the efficacy and securityof the method in our population.

DISCLOSURE: A. Zamora, None.

INCIDENCE OF PNEUMOTHORAX AFTER FIBEROPTICBRONCHOSCOPY (FOB) IN COMMUNITY-BASED HOSPITAL;ARE ROUTINE POST-PROCEDURE CHEST ROENTGENO-GRAMS NECESSARY?Sung Wu Sun, MD; Rachel N. Zabaneh, BS; Zev Carrey, MD.* TheMount Vernon Hospital, Mount Vernon, NY

PURPOSE: Fiberoptic Bronchoscopy (FOB) is a relatively safe proce-dure with minimal complications. However, the need to obtain a routine




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post-FOB chest roentgenogram (CXR) to rule out pneumothorax remainscontroversial and is dependent on the bronchoscopists’ bias. Our aim is toassess the incidence of post-FOB pneumothorax in a community hospitalsetting without pulmonary/critical care fellowship program, where all ofthe FOB’s are done by experienced bronchoscopists, and determine theneed for routine post-FOB CXR.

METHODS: All consecutive FOB’s with post-FOB CXR done atMount Vernon Hospital (Community Teaching Hospital without Pulmo-nary/Critical Care fellowship program) from November of 1999 to April of2003 were evaluated retrospectively. FOB’s were performed by threeexperienced ABIM Certified pulmonologists (95% by ZC).

RESULTS: 454 procedures with routine post-procedure CXR weredone during a 42-month period. 87 procedures were done on out-patients.371 procedures were done on in-patients. 143 were on mechanicalventilators. Of 454 total FOB, only 1 case (0.22%) resulted in iatrogenicpneumothorax which was diagnosed clinically, confirmed with CXR andrequired thoracotomy.

CONCLUSIONS: In our series of retrospective data, the incidence ofpneumothorax after FOB by experienced bronchoscopists was very low(0.22%). In order to diagnose one pneumothorax, 454 routine CXR’s weretaken.

CLINICAL IMPLICATIONS: In a community hospital environmentwithout pulmonary fellows, where all of the FOB’s are done by experi-enced ABIM certified subspecialists, routine CXR after FOB may not becost-effective or even medically necessary in patients without clinicalevidence of pneumothorax.

Patient Characteristics (N�454 procedures)

Characteristics Number(%) or Mean � SD (range)

Age 69.6 � 17.1(18 - 99)Males 160(35.9%)Females 247(55.4%)Inpatients 371(81.7%)Outpatients 87(19.2%)Patients on ventilators 143(35.5%)

DISCLOSURE: Z. Carrey, None.

BRONCHOSCOPY IN LIVER TRANSPLANT PATIENTSJonathan L. Spencer, MD*; Austin B. Thompson, MD; Debra Sudan,MD. University of Nebrsaka Medical Center, Omaha, NE

PURPOSE: Patients undergoing liver transplantation are at an in-creased risk of developing pulmonary fections. Immunosuppression leadsto increased susceptibility to bacterial as well as opportunistic pathogens.A common method to aid in the diagnosis of respiratory infections isbronchoscopy. The purpose of this study is to evaluate the clinical efficacyof bronchoscopy for the diagnosis of pulmonary infections following livertransplantation.

METHODS: A retrospective chart review of hospitalized liver trans-plant patients who underwent bronchoscopy from January 1997 throughMarch 2002. Inclusion criteria included adult patients, who had abronchoscopy preformed after liver transplantation. Indications for bron-choscopy included fever, radiographic changes on chest imaging, orrespiratory decline. Data collected included indication for bronchoscopy,ventilator status, antibiotics prior to bronchoscopy, antibiotic changesafter bronchoscopy, and culture results from BAL.

RESULTS: Over the 5 year period, 1260 bronchoscopies were per-formed. In the 48 patients a total of 74 bronchoscopies were preformed.Five patients and 9 bronchoscopies were not included do to lack of dataor did not meet the inclusion criteria. Twenty-eight patients had a singlebronchoscopy and 15 patients had multiple bronchoscopies (2-4). Aorganism was found in 36 out of the 43 (83%) patients and in 49 out of the65 (75%) of the bronchoscopies. The most common organism found wasviral (52%) followed by fungal (28%) and bacterial (19%). Of the viralpathogens, CMV was the most common (26 out of 41). Based on thebronchoscopy results antimicrobial therapy was altered in 55% of thecases with the additional of an antiviral being the most common change.

CONCLUSIONS: In our study, an organism was isolated in a greaterproportion of BAL samples as compared to previously reported studies.Of the organisms isolated, CMV remains a significant pathogen in the liver

transplant patients. Bronchoscopy had a positive impact on antimicrobi-alselection.

CLINICAL IMPLICATIONS: In liver transplant patients, bronchoscopyis an important diagnostic tool, useful for directing antimicrobial therapy.

DISCLOSURE: J.L. Spencer, None.

BRONCHOESOPHAGEAL FISTULAE SECONDARY TO BRON-CHOLITHIASIS: A CASE SERIESMonique A. Ford, MD*; Paul S. Mueller, MD; Timothy I. Morgenthaler,MD, FCCP. Mayo Medical Center, Rochester, MN

PURPOSE: Chronic cough is a common symptom that often results inexhaustive diagnostic evaluations and therapeutic trials. Bronchoesopha-geal fistulae secondary to broncholithiasis is a rare cause of chronic coughbut has specific therapeutic implications. We reviewed these cases topropose a clinical approach.

METHOD: Retrospective chart review of 8 patients admitted to ourinstitution between 1963 and 2002 with bronchoesophageal fistula sec-ondary to broncholithiasis.

RESULTS: The median age of the 8 patients (4 men, 4 women) was 55years (range 34 to 72 years). All were from the Midwest United States andmost were non-smokers. The main presenting symptom was cough worsewith drinking (7 of 8 patients). Most patients had a history of recurrentpneumonia. In addition, 5 patients reported lithoptysis. Chest examinationfindings were variable and non-specific. The diagnosis was established bybronchoscopy in 3 patients, video swallow study in 2, gastrografin swallowin 1, and at surgery in 1 patient. The fistulae were located to the rightmainstem bronchus in 3 patients, bronchus intermedius in 2, and the leftmainstem bronchus in 2 patients. All patients were managed surgically(attempted endoscopic closure was unsuccessful in 1 patient). Postoper-ative complications were common. Only 3 of 8 patients had completeresolution of their cough at follow up.

CONCLUSIONS: Bronchoesophageal fistula secondary to broncholi-thiasis should be considered in all patients with chronic cough associatedwith drinking, lithoptysis or recurrent pneumonias. This condition mostcommonly affects the right bronchial tree. The diagnosis is most easilyestablished by bronchoscopy or video swallow study. Surgery is requiredfor this condition but postoperative complications are common. Manypatients will experience persistent cough.

CLINICAL IMPLICATIONS: Focused investigation based on suspi-cion of bronschoesopahgeal fistula due to broncholithiasis will prevent anexhaustive workup of patients presenting with cough and lithoptysis.

DISCLOSURE: M.A. Ford, None.

Broncholiths




BRONCHOSOPIC ENDOBRONCHIAL SEALING: A NOVELTECHNIQUE OF TREATING BRONCHOPLEURAL FISTULA(BPF)Parthasarathi Bhattacharyya, MD*. Institute of Pulmocare & Research,Calcutta, India

PURPOSE: Closure of BPF by a minimally invasive and economictechnique with a fibreoptic bronchoscope.

METHODS: In four patients of spontaneous BPF following informedconsent conventional fob was done and end tidal carbondioxide wasmeasured by connecting a capnograph to a polyethylene catheter passedthrough the bronchoscopic channel and placed systematically into differ-ent bronchi. The presence of BPF was suggested by the absence ofcapnographic tracing in a particular segment or subsegment by logic of itscommunication to the atmosphere from the intrcostal tube which waspreviously disconnected from under water drainage.endobronchial sealingof the selected bronchus was done with n-butyl cyanoacrylate injectedthrough the catheter.confirmation of success was done by finding absenceof air bubbling in the under water system with application of positive

pressure through an Ambu bag after intubating the patient and inflatingthe cuff of the tube.

RESULTS: All four patients had immediate closure of fistula and hadno recurrence in one year follow up.there was no significant procedurerelated complication in any of them.

CONCLUSION: Bronchoscopic endobronchial sealing of selectivebronchus is an effective , economic and minimally invasive technique ofmanaging bronchopleural fistula.

CLINICAL IMPLICATIONS: Will enable early management of BPFin a simple way.

DISCLOSURE: P. Bhattacharyya, None.

COMPARISON OF FIBEROPTIC BRONCHOSCOPY (FOB) INRENAL FAILURE (RF) AND NON-RENAL FAILURE PATIENTSM Rahman, MD; V Lakshmi, MD; M Patel, MD; R Duncalf, MD; SBlum, PhD; G Diaz-Fuentes, MD, FCCP*. Bronx Lebanon Hospital,Bronx, NY

INTRODUCTION: FOB is a valuable tool in the evaluation andmanagement of patients with pulmonary disorders. Bleeding complica-tions tend to be increased in RF patients due to coagulation abnormalitiesand platelet dysfunction.

PURPOSE: To evaluate the incidence of complications and thediagnostic yield of FOB in patients with and without RF.

METHODS: A retrospective chart review of all the pts that had RFand underwent FOB from January 2000 to January 2001 was done; acontrol group of patients during that same time period with no RF wasincluded. Patients with abnormal coagulation profile or liver function testwere excluded.

RESULTS: 50 patients, 14 in the RF and 36 in the non-RF group werereviewed. Bleeding (�100cc) was seen only in pts where TBbx was done;the 2 pts in the RF group had a creat �4. Thirtheen pts in the RF and 28in the non RF-group had FOB as part of a work up for lung infiltrate ormass; the diagnostic yield was 38% (5/13) and 46% (13/28) in the RF andnon-RF group, respectively.

CONCLUSIONS: Our study indicates there may be an increasedtendency for significant bleeding from TBbx in pts with RF.

CLINICAL IMPLICATIONS: Awareness of this risk is important asFOB plays a pivotal role in the evaluation of patients with lung disease.FOB with BAL seems to be a safe procedure in patients.with RF. Despitethe small sample we still recommend the use of TBbx when the benefitsoutweigh the risks of the procedure.

Complications of FOB

FOB

TransbronchialBiopsy(TBbx)/Bronchoalveolarlavage(BAL)

TransbronchialBiopsy (TBbx)/Bronchoalveolarlavage (BAL)Bleeding BAL alone Inspection

RF n�14 3/14 (21%) 2/3 (66%) 10 /14 (71%) 1/14 (8%)Non-RF

n�3615/36 (42%) 2 /15 (13%) 12/36 (34%) 9/36 (25%)

DISCLOSURE: G. Diaz-Fuentes, None.

Cardiovascular Disease12:30 PM - 2:00 PM

SEVERITY OF CORONARY ARTERY DISEASE IN PATIENTSWITH AND WITHOUT PERIPHERAL ARTERIAL DISEASERishi Sukhija, MD*; Kiran Yalamanchili, MD; Wilbert S. Aronow, MD.New York Medical College, Valhalla, NY

PURPOSE: To investigate in patients with and without peripheralarterial disease (PAD) undergoing coronary angiography for suspectedcoronary artery disease (CAD) the prevalence of left main CAD, 3-vesselor 4-vessel CAD, and of obstructive CAD.

CT chest showing broncholiths at the right bronchus intermedius.

Brochoscopic view of eroding broncholith at the right main stem bron-chus.




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METHODS: Coronary angiography for suspected CAD was per-formed in 279 patients, mean age 71 years, with documented PAD and in218 patients, mean age 70 years, without PAD.

RESULTS: Compared to patients without PAD, patients with PADhad a higher prevalence of current or ex-cigarette smoking (85% versus62%, p�0.001), of hypertension (71% versus 61%, p�0.05), of diabetesmellitus (53% versus 17%, p�0.001), and of dylipidemia (73% versus60%, p�0.005). Left main CAD was present in 49 of 279 patients (18%)with PAD and in 1 of 218 patients (�1%) without PAD, p�0.001.Three-vessel or 4-vessel CAD was present in 177 of 279 patients (63%)with PAD and in 25 of 218 patients (11%) without PAD, p�0.001.Obstructive CAD (�50% stenosis) was present in 273 of 279 patients(98%) with PAD versus 177 of 218 patients (81%) without PAD, p�0.001.

CONCLUSIONS: In patients undergoing coronary angiography forsuspected CAD, patients with PAD have a higher prevalence of left mainCAD, of 3-vessel or 4-vessel CAD, and of obstructive CAD than patientswithout PAD.

CLINICAL IMPLICATIONS: Patients with PAD have an increasedseverity of CAD than patients without PAD and should be treated moreaggressively with risk factor modification and with coronary revasculariza-tion.

DISCLOSURE: R. Sukhija, None.

CAN MYOCARDIAL PERFORMANCE INDEX DETECT SIGNIF-ICANT OBSTRUCTIVE CORONARY ARTERY DISEASEMaddury Jyotsna, MD.* Deemed University, Nizam’s Institute of MedicalSciences, Secunderabad, India

PURPOSE: Myocardial performance index(MPI) reflects the com-bined systolic and diastolic left ventricular function.By Dagdelen et alMPI was used to detect critical coronary stenosis.In present prospectivestudy this parameter was studied to know significant coronary arterydisease.

METHODS: Chronic stable angina patients without previous myocar-dial infarction with good left ventricular function were included in thestudy(63 patients). Patients in Group A were without critical coronarystenosis by coronary angiogram(32 patients). Patients in Group B werewith critical coronary stenosis( �70% atleast in one vessel by coronaryangiogram-31 patients). In both groups , using echocardigraphic param-eters isovolumetric contraction (ICT), isovolumetric relaxation(IVRT),ejection time(ET) , MPI (ICT�IRT)�ET,) were calculated .In bothgroups ejection fraction(EF) and fractional shortening (FS) were normal.

RESULTS: There were no significant differences in ICT,IVRT,ET andMPI in group A and group B( 62.2 � 23 and 65.7�47 msec,70.6�15.9and 72.9�25.3 msec, 268.2�67.2 and 279.5�64.5 msec, 0.47�0.11 and0.46�0.14 msec).No difference in heart rate ,and systolic and diastolicblood pressures in both groups.

CONCLUSIONS: Contradictory to previous reports none of thesystolic or diastolic or combined echo cardiographic parameters detectscritical coronary artery stenosis.

CLINICAL IMPLICATIONS: MPI is not informative in detectingsignificant obstructive coronary artery disease noninvasively .

DISCLOSURE: M. Jyotsna, None.

OUTCOME OF CARDIAC LESIONS IN SJOGREN SYNDROMEIoannis Moyssakis, MD; Nickolaos J. Pantazopoulos, MB BS*; VasiliosVasiliou, MD; Panagiotis Margos, MD; Vasilios Votteas, MD. “Laiko”Hospital, Athens, Greece

PURPOSE: The evolution of cardiac lesions in patients (pts) withprimary Sjogren’s Syndrome (pSS).

METHODS: Sixty three (61 women – 2 men, aged 52�12 years) ptswith pSS were evaluated with M-mode, 2D and Doppler echocardiogra-phy during a follow up period of 42�14 months. The left ventricular (LV)fractional shortening (FS) and the velocity of tricuspid regurgitant jet plusthe right atrial pressure served as indices of LV systolic function andpulmonary systolic pressure respectively. Organic valvular involvementwas defined as valve thickening and/or regurgitation. Left ventricular massindex was calculated by the Penn convention formula.

RESULTS: See Table. All the cases with mitral and aortic regurgitationwere mild at the beginning and during follow up, whereas of the 6 pts withtricuspid regurgitation 2 were moderate without deterioration at the endof the study.

CONCLUSIONS: Our results show that the incidence of cardiaclesions in pts with pSS is quite frequent but they are mild and theirevolution is slow.

Results Table

Parameters First Study Last Study P-value

Mitral regurgitation 21 (33%) 25 (39%) NSAortic regurgitation 14 (22%) 14 (22%) NSTricuspid regurgitation 6 (9.5%) 9 (14%) NSPericardial effusion 3 (4.7%) 5 (8%) NSPulmonary hypertension 14 (22%) 18 (28.5%) NSLV mass index (g.m-2) 105.4 � 14 109.5 � 26.4 NSLV systolic dysfunction 2 (3%) 3 (4.7%) NS

DISCLOSURE: N.J. Pantazopoulos, None.

CORONARY SYNDROMES FOLLOWING ASPIRIN WITH-DRAWALEmile Ferrari, MD*; Mustapha Benhamou, MD; Pierre Cerboni, MD;Marcel Baudouy, MD. Cardiology, University Hospital, Nice, France

PURPOSE: In patients with coronary artery disease, it is not knownwhether withdrawal of aspirin can precipitate coronary events.

METHODS: We collected consecutive cases of coronary syndromesfollowing aspirin withdrawal in patients with known coronary disease.Between September 1999 and April 2002 patients hospitalized forcoronary syndrome (MI) were questioned in order to seek withdrawalfrom any previous treatment for coronary disease.

Patients treated with coronary angioplasty and stent implantation in theprevious month were excluded as were those who had a coronary eventafter major surgery.

RESULTS: During this period, 1236 patients with coronary syndromeswere hospitalized in our center. Among these, 51 occurred less than 1week after aspirin withdrawal. This represents an incidence of 4.1% of allhospitalized coronary events.

The coronary history of these patients consisted of a previous myocar-dial infarction in 15 cases, a stable angina in 36 cases. None had anunstable coronary syndrome before aspirin withdrawal.

Coronary syndrome following aspirin withdrawal was a ST elevationcoronary syndrome in 19 cases, a non ST elevation coronary syndrome in32.

Mean delay between aspirin withdrawal and the acute coronary eventwas 10 � 4.5 days.

Among patients presenting with ST elevation coronary syndrome, astent thrombosis was the culprit lesion in 10 cases. These stents had beenimplanted 15.5 � 14.4 months previously.

The reason for aspirin withdrawal was minor surgery in 7 cases,fibroscopy in 8, dental treatment in 13, bleeding in 3 and patientnon-compliance in the remaining 20.

CONCLUSIONS: Although our results do not quantify the problem,they nevertheless support the hypothesis that aspirin withdrawal incoronary patients may represent a real risk for the occurrence of a newcoronary event. This problem deserves further study.

DISCLOSURE: E. Ferrari, None.

ACUTE CORONARY SYNDROME IN HIV PATIENTS: ANGIO-GRAPHIC FEATURES; A CASE CONTROL STUDYMustapha Benhamou, MD*; Emile Ferrari, MD; Pierre Cerboni, MD;Michel Carles, MD; Michel Thiry, MD; Marcel Baudouy, MD. PasteurHospital, Nice, France

OBJECTIVES: The purpose of this study is to analyze coronarydisease in HIV patients.

BACKGROUND: In recent years, ACS have been described in HIVpatients. We analysed coronary disease in HIV patients.


Cardiovascular Disease, continued


METHOD: A case control study was used to compare HIV patientswith 52 non-HIV patients both consecutively hospitalized with a first acutecoronary syndrome (ACS). Risk factors and coronary angiogram wereanalyzed. Clinical evolution at one year is reported.

RESULTS: From 1997 to 2002, 26 HIV patients were admitted with anACS. Mean age was 47� 8. We show in the HIV group a less frequentexcess weight: 7.6% vs 40%, p � 0.003, a lower LDL-cholesterol(LDL-C): 1.27 � 0.48 g/l vs 1.47 � 0.39 g/l, p � 0.047 and a highertriglycerides (TG) rate: 3.07 � 2.28 g/l vs 1.78 � 0.77 g/l, p � 0.0004.Type A lesions were more often found in the HIV group: 44% vs 2%, p �0.05.

Regardless the culprit lesion, atheroma was less frequently found in theHIV group: both on the culprit vessel (48% vs 81%, p � 0.007) and in thewhole coronary network (58% vs 77%, p � 0,09). Seven HIV patients(27%) vs 2 non-HIV patients (3,8%) were hospitalized within 9 monthsdue to a relapsed ACS: p�0.005.

CONCLUSION: HIV coronary patients have a greater TG rate and areduced LDL-C. Their SCA occurs in a coronary network relativelyunaffected with atherosclerosis. The culprit lesion is often a type A lesionwhich lends itself readily to revascularization by PTCA. At last, in ourstudy, coronary disease of HIV patient is characterized by a tendancy torelapse.

DISCLOSURE: M. Benhamou, None.

PROPOSAL OF A NEW REPORTING METHOD ON CINEAN-GIOGRAPHY: “COMPREHENSIVE SEGMENTAL CODING SYS-TEM”Cuneyt Konuralp, MD, FCCP, FICS, FAHA*; Mustafa Idiz, MD;Mehmet Ates, MD. Dept. of CV Surgery, Siyami Ersek Thoracic andCardiovascular Surgery Center, Istanbul, Turkey

PURPOSE: Coronary cineangiography reports are based on descrip-tion of visible lesions and anatomy by narrative technique.Without awell-prepared diagram, these reports generally do not supply enoughpractical information to the clinicians.We developed a new systematicreporting system for coronary cineangiography based on coding andformulating.

METHODS: Main principle of this method, called “comprehensivesegmental coding system”(CSCS), is based on creating a kind of mappingsystem.A part of the coronary artery (CA) that located between its twosubsequent branches is called as an “angiographic segment unit”, andanatomical borders of these segments are called as “anatomic markerpoints”.Any visible intraluminal and extraluminal condition is localizedaccording to its relationship with angiographic segment(s) and anatomicmarkers.Every unique condition that can be imagined regarding CAsystem is described with its exact localization (coordinates) and listed byusing special formulas consists of letters, numbers, signs and symbols.C-SCS also capable to describe all types of CA variations and anomalies,filling directions with grading and collateral system, and left ventricularfunction.The system marks every unique condition for each patient to ruleout misunderstandings and allow a healthy comparison of follow-upreports of the same patient.

RESULTS: Eighty different angiograms from the books and atlasseswere formulated individually by each author and the formulas werecompared.It was noted that, for each picture, all authors created the sameformule.Then, more than 600 cineangiography were reported usingCSCS.According to our experience, CSCS supplied more objective,detailed, practical, and even correct information than the current narra-tive reporting system.The definitions were very precise and clear.

CONCLUSIONS: Because it is based on a logical principle, CSCSdescribes all types of lesions that can be imagined, and lists withoutmissing any of them.It is definitely more advantageous on archiving,researching, and comparing of subsequent reports of the same patient.

CLINICAL IMPLICATIONS: By its logical and systematical ap-proach, CSCS introduces us a new dimension on reporting system.Webelieve, by introducing the clinical practice, CSCS will be a very usefultool for both cardiologists and surgeons.

DISCLOSURE: C. Konuralp, None.

LEFT BUNDLE-BRANCH BLOCK IN TYPE-2 DIABETES MEL-LITUS: A SIGN OF ADVANCED CARDIOVASCULAR INVOLVE-MENTNarpinder Singh, MD*; Ijaz A. Khan, MD, FCCP; Cesare Saponieri, MD;Harinder K. Singh, MD; Ramesh M. Gowda, MD; Balendu C. Vasavada,MD; Terrence J. Sacchi, MD; Eliscer Guzman, MD; Jennifer Yip, PA;Ronny A. Cohen, MD. Woodhull Medical Center, Brooklyn, NY

PURPOSE: To evaluate left bundle-branch block as an indicator ofadvanced cardiovascular involvement in diabetic patients by examiningleft ventricular systolic function and proteinurea.

METHODS: Data of 26 diabetic patients with left bundle-branchblock (Group 1) were compared with that of 31 diabetic patients withoutleft bundle-branch block (Group 2) and 18 non-diabetic patients with leftbundle-branch block (Group 3). The inclusion criteria were age �45 yearsand diabetes mellitus type-2 of �5 years. Age, sex, race, ethanol use,hypertension, thyroid disease, and coronary artery disease were matchedamong groups.

RESULTS: Mean age of patients in Group 1, Group 2, and Group 3was 67�8, 68�10, and 65�10 years, respectively (p�NS). Black andHispanic patients were 90%, 90%, and 88% (p�NS) and females were64%, 62%, and 63% (p�NS) in Group 1, Group 2, and Group 3,respectively. Left ventricular ejection fraction in Group 1 was significantlylower than that in Group 2 and Group 3 (30�10% vs. 49�12% and47�8%, respectively, p�0.01). Left ventricular end diastolic volume wassignificantly higher in Group 1 than that in Group 2 (188.6 ml vs. 147.5 ml,p�0.03). Similarly, left ventricular end systolic volume was significantlyhigher in Group 1 than that in Group 2 (135.4 ml vs. 83.7 ml, p�0.02). Nosignificant difference was seen in left atrial size (4.0 cm Group 1 vs. 4.3 cmGroup 2, p�NS). Proteinurea in Group 1 (79.4 mg/dL) was significantlyhigher than that in Group 2 (35.6 mg/dL, p�0.05) and Group 3 (7.1mg/dL, p�0.05). However, there was no significant difference in HbA1Clevels in Group 1 and Group 2 patients (9.01% vs. 7.81%, p�NS).

CONCLUSIONS: Left bundle-branch block in diabetic patients indi-cates advanced cardiovascular involvement manifesting with more severeleft ventricular systolic dysfunction and proteinurea.

CLINICAL IMPLICATIONS: Diabetic patients with left bundle-branch block should be evaluated for left ventricular systolic dysfunctionand proteinurea by transthoracic echo and urine analysis.

DISCLOSURE: N. Singh, None.

CAROTID PLAQUES BUT NOT INTIMA MEDIA THICKNESS(IMT) PREDICT CORONARY ANGIOGRAPHIC DISEASEKwame O. Akosah, MD*; Ana M. Schaper, PhD; Sharon I. Barnhart,BSN; Vicki L. McHugh, MS; Pat Perlock, RDCS; Troy Haider, RDCS;Abdulaziz Elfessi, PhD. Gundersen Lutheran, La Crosse, WI

PURPOSE: Identifying individuals at risk for future cardiovascularevents remains a challenge, and carotid ultrasound (CU) has beenproposed as an adjunct to clinical guidelines for primary prevention.Although CU findings have been shown to predict future events, studiesto date have shown poor correlation when compared to coronary angiog-raphy (CA). The objective of our study was to compare CU with CA andto evaluate how carotid atherosclerosis correlates with angiographicdisease.

METHODS: 175 young adults undergoing elective CA were prospec-tively enrolled for CU screening. Inclusion criteria were age (men � 55;women � 65), no previous coronary heart disease or statin therapy.Abnormal CA was defined as stenosis severity of � 50%. Criteria forabnormal CU included: maximal IMT � 1.0 mm in the main body; focalplaque at the body, bulb, or proximal branches; or calcific deposit in mainbody, bulb, or proximal branches.

RESULTS: Mean age (50.77 � 7.47). 54% of subjects were women.Mean lipid levels were within desirable range. 93% of subjects wereclassified as low risk per the National Cholesterol Education Program IIIguidelines. 55 subjects had severe coronary artery disease (CAD). Neithermean nor maximal IMT correlated with CAD. By contrast, carotid plaquewas associated with an OR of 2.1 (CI: 1.1 – 4.0, p � 0.002). Calcificplaques were not a frequent finding in young adults but were highlyspecific (90%) for CAD (OR: 2.5, CI: 1.1 – 5.8, p � 0.031). The sensitivityfor carotid atherosclerosis compared to CAD was 75%, with a negativepredictive value of 83% and specificity of 50%.

CONCLUSIONS: Young adults with coronary angiographic diseasealso have carotid atherosclerosis. IMT in the main body does not correlate




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with angiographic CAD. However, carotid plaques in the body, bulb, orproximal branches predict angiographic CAD.

CLINICAL IMPLICATIONS: CU may be a valuable tool for riskstratification of individuals at risk for CAD.

DISCLOSURE: K.O. Akosah, None.

ASSOCIATION OF DEPRESSIVE SYMPTOMS WITH ANGIO-GRAPHIC CORONARY ARTERY DISEASEShalini Chhabra, PGY3, Internal Medicine*; Sandeep Chhabra, PGY6Cardiology Fellow, SUNY HSC Brooklyn; Satish Reddy, Assistant ClinicalProfessor Of Psychiatry. The Brooklyn Hospital Center, Brooklyn, NY

PURPOSE: While the incidence of depression after myocardial infarc-tion has been studied, there is paucity of data on the prevalence ofdepression in patients presenting with angina like symptoms. We studiedwhether depressive symptoms are associated with presence & extent ofcoronary artery disease (CAD) or angina as graded by the CanadianCardiovascular Society Classification System.

METHODS: We prospectively enrolled patients who were referred forcardiac catheterization during a one month period. Patients with previ-ously established CAD diagnosis (previous MI / CABG / previous cardiaccatheterization / previous PCI etc.) were excluded. Patients were admin-istered the Hamilton Rating Scale for Depression (HAM-D) question-naire prior to undergoing cardiac catheterization. CAD was defined as anepicardial stenosis �50%.

RESULTS: 33 of 45 patients completed the questionnaire and wereincluded in the study, mean age 57 � 8 years, 48%male. 58% of patientswere found to have CAD. There was no significant difference betweenmean HAM D scores in patients with and without CAD (8.7�/-6.5 vs8.4�/-7.4 in patients without CAD. There was no relationship betweenHAM D scores and the extent of CAD (r�-.09,p�.7). Depression scoreswere strongly correlated with anginal scores (r�.7,p�.01).

CONCLUSION: In a consecutive series of patients referred forcardiac catheterization, depressive symptoms were related to anginalsymptoms but not to the presence or extent of angiographic coronaryartery disease.

CLINICAL IMPLICATIONS: The strong relationship between de-pressive symptoms and anginal symptoms suggests that depression lowersthe threshold for anginal chest pain or that anginal chest pain is anotherclinical manifestation of depression in a subset of patients.

DISCLOSURE: S. Chhabra, None.

HYPERGLYCEMIA CAN PREDICT ARTERY OCCLUSION INACUTE CORONARY SYNDROMENam D Nguyen, MD*; Su Fuhong, MD; Lieve Opdenaecker, MD; LucHuyghens, MD. AZ-VUB Hospital, Brussels, Belgium

PURPOSE: The aim of our study is to determine the associationbetween stress hyperglycemia (HG) and the occurrence of coronaryocclusion or multiple vessel disease, as well as its relationship with thedevelopment of in-hospital complications, in patients admitted with anacute coronary syndrome (ACS).

METHODS: Blood glucose and C-reactive protein (CRP) were mea-sured in 550 patients on admission and 24 hours later. Creatinin-Kinase(CK) and CK-MB were charted every 6 hours. HG was considered if thevalue was above 110 mg%. Coronarography was immediately performedto evaluate coronary artery disease in patients who needed a primaryangioplasty (PCI) after their admission, and within 72 hours in otherpatients. Wall motion score (WMS) of the16 left ventricular segments andEjection Fraction (EF) were evaluated by echocardiography and nuclearangiography during the first 48 hours after the acute cardiac event.Student-t test was used for statistics.

RESULTS: 88% of patients with ACS had no history of Diabetes andHG was detected in 445/550 patients (81%). HG above 125 mg/dl wasfound in 75% of the latter (333/445) and it was significantly associatedwith the occlusion of at least one of the three main coronary arteries or theoccurrence of multiple vessel disease in angiography (p�0.005). Thepeaks of CK, CK-MB and CRP (but not WMS and EF), were alsocorrelated with HG above 125 mg/dl (p�0.005). Higher incidence ofheart failure, shock, recurrence of angina and mortality rate in-hospitalwas observed in patients with HG (p�0.005). However, PCI reducedsignificantly the mortality of those patients who had myocardial infarctionand HG (p�0.005).

CONCLUSIONS: On admission, HG above 125 mg/dl can predict theoccurrence of coronary occlusion and multiple vessel disease in patientswith ACS. HG also associates with a high risk to develop heart failure anda higher mortality, and more aggressive treatment is needed to treat thesepatients on their admission.

DISCLOSURE: N. D Nguyen, None.

ADVANCED LIPOPROTEIN TESTING BY NUCLEAR MAG-NETIC RESONANCE (NMR) AND CAROTID ULTRASOUNDPREDICT PREMATURE CORONARY HEART DISEASEKwame O. Akosah, MD*; Ana M. Schaper, PhD; Vicki L. McHugh, MS;Sharon I. Barnhart, BSN. Gundersen Lutheran, La Crosse, WI

PURPOSE: Many individuals suffer myocardial infarction (MI) in spiteof optimal to borderline cholesterol levels. Newer tests have beenproposed as adjuncts to the NCEP III guidelines to improve riskstratification for primary prevention. However, many of these tests,including advanced lipoprotein testing and carotid ultrasound (CU) havenot been tested in the same population, and thus their incremental valueto the guidelines remains unknown.

METHODS: 212 young adults (women � age 65; men � 55)scheduled for elective coronary angiogram had CU and labs for LDLparticle concentration, size, and VLDL subtypes. Per NCEP III, 93%were stratified as low-risk for a 10-year event. Abnormal angiography wasdefined as stenosis severity of � 50%. Group 1 (n�61) had abnormalangiograms. Group 2 (n�151) had negative angiograms.

RESULTS: Sensitivity for CU was 75%, specificity was 52%, andnegative predictive value was 82%. Mean LDL (124 mg/dL) and totalcholesterol (197 mg/dL) were optimal. Group 1 had significantly higherlevels for triglyceride (172 vs. 140 mg/dL), large VLDL (70 vs. 48 mg/dL),and LDL particle concentration (LPRT) (1511 vs. 1330 nmol/L). Group 1had significantly lower values for HDL (48 vs. 53 mg/dL), large HDL (17vs. 21 mg/dL), and LDL particle size (20.5 vs. 20.8 nm). The OR for highLPRT compared to low was 2.9; CI: 1.3 – 6.9 (p � 0.01). Stepwiseregression showed that LPRT (OR 3.1; CI: 1.2 – 7.9; p � 0.02) and CU(OR 3.9; CI: 1.7 – 8.9; p �0.001) were independently predictive of severeCAD.

CONCLUSIONS: The guidelines only identified 7% at moderate orhigh risk. Advanced lipoprotein testing by NMR and CU independentlypredict angiographic CAD. Abnormal CU identifies individuals withangiographic CAD and a negative finding on CU virtually excludes CAD.

DISCLOSURE: K.O. Akosah, KOS Pharmaceuticals, grant monies.

THE ASSOCIATION BETWEEN ACTIVATED CLOTTING TIMEAND HEMORRHAGIC COMPLICATIONS IN PATIENTS UN-DERGOING PERCUTANEOUS CORONARY INTERVENTIONSWITH BIVALIRUDINJose M. Martinez, MD*; Estela M. Trimino, PharmD; Janelle M. Berg,PharmD, BCPS; Manuel P. Anton III, MD. Community Hospital, MercyHospital, Miami, FL

PURPOSE: Activated clotting time (ACT) values are used to guideanticoagulation therapy in percutaneous coronary interventions (PCI).Previous studies with heparin �/- glycoprotein inhibitors (GPI) haveshown a correlation between higher ACT values and increased hemor-rhagic complication rates. Our aim was to evaluate ACT results andhemorrhagic complications in patients who received bivalirudin �/- GPIwhile undergoing PCI.

METHODS: Retrospective chart review of 316 patients undergoingPCI was conducted. The anticoagulants used were heparin �/- GPI orbivalirudin �/- GPI. Higher ACT values were defined as � 300 secondsand lower ACT values were defined as � 300 seconds at end of procedure.Major bleeding included � 3 gram drop in hemoglobin �/- transfusion, orretroperitoneal, gastrointestinal, or intracerebral bleeds. Minor bleedingincluded oozing at sheath site, hematoma, and bleeding which did notrequire transfusion. Major, minor, and total bleeds were compared toACT values and analyzed to assess relationships.

RESULTS: Ninety-seven ACT values were obtained from 187 patientsin the bivalirudin group, of which 53 (55%) were higher and 44 (45%)were lower. In the heparin group, fifty-four ACT values from 129 patientswere obtained, all of which were lower. There were 10 major bleeds in thebivalirudin group (5.3%; ACTs: 3 higher, 3 lower, 4 unknown) and 4 in theheparin group (3.1%; ACTs: 0 higher,1 lower, 3 unknown). Additionally,




five of the ten major bleeds occurred with concomitant GPI in thebivalirudin group compared to three of four in the heparin group.Twenty-one bleeds (11%) were documented in the bivalirudin groupwhereas there were 23 (18%) in the heparin group (p � 0.001), howeverthe ACT value (higher versus lower) did not show significance (p �0.771).

CONCLUSIONS: Higher ACT values were not associated with in-creased bleeds in the bivalirudin group.

CLINICAL IMPLICATIONS: ACT values � or � 300 did notappear to correlate with hemorraghic complications in bivalirudin patientsundergoing PCI and may not be useful in adjusting anticoagulationstrategies.

DISCLOSURE: J.M. Martinez, None.

PREVALENCE OF MYOCARDIAL INFARCTION IN SYSTEMICLUPUS ERYTHEMATOSUS: THE ASSOCIATION WITH AN-TIPHOSPHOLIPID ANTIBODIESIoannis Moyssakis, MD; Konstantinos Georgakopoulos, MD; Nickolaos J.Pantazopoulos, MB BS*; Maria Kouli, MD; Vasilios Vasiliou, MD; VasiliosVotteas, MD. “Laiko” Hospital, Athens, Greece

PURPOSE: Systemic lupus erythematosus (SLE) is characterized by apancarditis involving pericardium, myocardium, endocardium and coro-nary arteries. Coronary artery disease may be due to arteritis or due toatherosclerosis. The aim of our study was the incidence of myocardialinfarction in patients (pts) with SLE.

METHODS: We studied 186 consecutive pts (168 females – 18 males,aged 51�12 years) with SLE. All the pts were evaluated with andelectrocardiogram (ECG) and an echocardiogram. Seventeen pts hadregional akinetic or hypokinetic segments and ECG findings implyingmyocardial infarction. Thirteen pts with myocardial infarction had under-gone coronary angiography.

RESULTS: Seventeen pts (16 females – 1 male) from the total (9.1%)had myocardial infarction. In 9 the infarction was anterior, in 5 inferior, in1 lateral and in 2 non-Q. Thirteen of these pts had coronary angiographyand in 6 the coronary vessels were normal. In 4 cases subtotal occlusion inthe left anterior descending coronary artery was detected and coronaryangioplasty was performed with good long-term results. Of the 17 pts withmyocardial infarction, 12 (70.6%) had increased antiphospholipid antibod-ies (APL) and 11 were less than 40 years old.

CONCLUSIONS: Our results indicate that there is a raised incidenceof myocardial infarction among pts with SLE, with greater prevalence inpts with increased APL. These findings suggest that APL possibly play acausative role in the development of these lesions. Coronary angioplastymay be useful in selective cases.


INCIDENCE OF VERRUCOUS VEGETATIONS IN SYSTEMICLUPUS ERYTHEMATOSUS: THE ASSOCIATION WITH AN-TIPHOSPHOLIPID ANTIBODIESIoannis Moyssakis, MD; Nickolaos J. Pantazopoulos, MB BS*; MariaTektonidou, MD; Katerina Boki, MD; Panagiotis Margos, MD; VasiliosVotteas, MD. “Laiko” Hospital, Athens, Greece

PURPOSE: Valvular heart disease is prevalent in systemic lupuserythematosus (SLE) and is a common cause of morbidity and mortality.Valvular thickening and verrucous valvular vegetations (Libman-Sacks)are the most common lesions. The purpose of this prospective study wasto analyze the incidence of Libman-Sacks vegetations in patients (pts) withSLE.

METHODS: Two hundred and seventeen consecutive pts (196 fe-males – 21 males, aged 53�11 years) with SLE were evaluated withM-mode, 2D and Doppler echocardiography. Libman-Sacks vegetationswere defined as distinct localized masses of varying size and shape on thesurface of the valve leaflets and exhibiting no independent motion. IN 76(35%) pts with SLE there were antiphospholipid antibodies (APL)present.

RESULTS: Thirty-two (14.7%) pts with SLE had Libman-Sacksvegetations and in 21 (65.6%) of them there was a presence of antiphos-pholipid antibodies. In 22 pts the location of the masses was in the mitral,in 9 in the aortic and in 1 in the tricuspid valve, whereas in 4 cases inBOTH valves. Valvular regurgitation was the predominant lesion in 18mitral, 9 aortic and 1 tricuspid, but only 2 cases had severe mitralregurgitation. Valvular stenosis was detected in 5 cases. Three pts had

severe mitral stenosis and one of them died, while the other two mitralstenosis was reversed with treatment of the underlying disease. Theremaining two cases had severe aortic stenosis but one of them, alsohaving severe mitral regurgitation, died suddenly.

CONCLUSIONS: Our results show that Libman-Sacks vegetations arequite frequent in pts with SLE and are related to the presence ofantiphospholipid antibodies. The most common lesion is valvular regur-gitation and rarely valvular stenosis.


CAN ST SEGMENT DEPRESSION DURING DIPYRIDAMOLEMYOCARDIAL PERFUSION STUDIES PREDICT CORONARYANATOMY ?Satish Sivasankaran, MD*; David Copen, MD; Samuel Felder, MD; YawA. Adjepong, MD, PhD; Gilead Lancaster, MD. Dept. of Cardiology,Bridgeport Hospital, Bridgeport, CT

PURPOSE: ECG changes of ST segment depression (STSD) and chestpain are known to occur in some patients who undergo Dipyridamolemyocardial perfusion (DPM) studies. Since dipyridamole does not in-crease rate- pressure product and thereby myocardial oxygen demandsignificantly, the mechanism for the STSD and chest pain is postulated tobe coronary steal phenomenon. Our aim was to see if there is anassociation between dipyridamole induced STSD and chest pain withretrograde collaterals, a form of coronary steal anatomy.

METHODS: Retrospective chart review of patients who had DPMstudy in a two year period and cardiac catheterisation within 6 months ofthe same. The reported symptom of chest pain was taken from the studyreport.The ECG and catheterisation films were analysed for the presenceor absence of STSD and retrograde collaterals respectively by two blindedreaders.

RESULTS: 286 consecutive charts were reviewed and 19 patients metcriteria. There were 9 males and 10 females with a mean age of 68.2 � 2.5(49-82). 13 had multivessel disease, 5 had single vessel disease and onehad no obstructive coronary disease. 47 % (95% confidence interval (CI):24.4-71) had STSD and 32% (95% CI: 12.6-56.6) had chest pain. Patientswho develop STSD following intravenous dipyridamole were four times aslikely to have collaterals on their catheterisation films than those who donot.( Relative risk 3.9, 95% CI: 1.1-14.1). The sensitivity and specificitywas 78% (95% CI: 40-97.2) and 80% (95% CI: 44.4-97.5) respectively.The presence of chest pain was not associated with the presence ofcollaterals.

CONCLUSION: Dipyridamole induced STSD is significantly associ-ated with the presence of retrograde coronary collaterals. There was noassociation of chest pain with the presence of collaterals.

CLINICAL IMPLICATIONS: The presence of STSD on ECGduring DPM is a clinically important finding when assessing the need forsubsequent catheterisation.

DISCLOSURE: S. Sivasankaran, None.

CLINICAL SIGNIFICANCE OF ELEVATED SERUM TROPO-NIN-T AFTER IMPLANTABLE CARDIOVERTER-DEFIBRILLA-TOR DISCHARGESCraig A. McPherson, MD; Dan Blendea, MD*. Bridgeport Hospital-YaleUniversity School of Medicine, Bridgeport, CT

PURPOSE: Although cardiac troponin, has been demonstrated to beelevated in some patients with implantable cardioverter defibrillator-s(ICDs) who receive spontaneous or induced electrical shocks, thesignificance of these elevations remains unclear. The purpose of this studywas to investigate the potential clinical significance of Troponin-T (TnT)elevation in patients who have suffered ICD discharges.

METHODS: A retrospective analysis of 257 ICD charts identified 23patients who experienced a total of 30 arrhythmic events that promptedICD discharges, after which at least one measurement of serum troponinT had been performed within 24 hours.

RESULTS: An elevated level of TnT was found in 11 episodes (36%):13 episodes had been treated with 1 shock, 3 with 2 shocks, and 14required 3 or more shocks. Arrhythmic events occurred in 7 patientswithout coronary artery disease (CAD), 19 in patients with CAD without




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acute coronary syndrome (ACS), and 4 in patients with ACS. Thecharacteristics of the three groups are presented below.

NoCAD

CADwithoutACS

ACS p

Age (yrs) 56 � 10 74 � 8 75 � 10 0.0002No. shocks/episode 3 � 3.6 3 � 1.76 6.5 � 8.5 NSTotal energy delivered/

episode (J)20 � 7 54 � 41 100 � 132 0.086

Patients withpositive TnT

1(14%) 7(36%) 3(75%) 0.141

Peak TnT (ng/ml) 0.04 � 0.05 0.07 � 0.06 0.29 � 0.26 0.011

Peak TnT values were significantly lower during the events thatoccurred in patients without CAD than in patients with CAD with orwithout ACS. Only one of the patients without CAD had abnormalTnT(�0.10 ng/ml). The abnormal TnT levels that occurred after ICDshocks were all in the 0.1-0.2ng/dl range, excepting two patients withACS. There was a weak positive correlation between peak TnT levelsand the number of shocks, and total energy delivered per arrhythmiaepisode (but without statistical significance).

CONCLUSIONS: TnT release does not occur in the majority ofspontaneous ICD discharges, even in patients with underlying CAD; TnTelevations after ICD shocks should not be assumed to be caused solely bythe electric discharges. A TnT between 0.1 and 0.2 ng/ml should promptfurther evaluation to rule out an acute coronary event.

CLINICAL IMPLICATIONS: It seems reasonable to check TnTlevels in all patients with CAD who suffer ICD discharges because thiscould lead to identification of underlying ischemic events.

DISCLOSURE: D. Blendea, None.

EFFECT OF ESMOLOL, AN ULTRA-SHORT ACTING BETABLOCKER ON OXIDANT STATUS AND ANTIOXIDANT ACTIV-ITY IN ACUTE MYOCARDIAL INFARCTION: RESULTS OF ARANDOMIZED DOUBLE-BLIND, CONTROLLED, PROSPEC-TIVE CLINICAL STUDYBhavneesh Sharma, Resident in Internal Medicine*; Mradul K. Daga,Professor in Internal Medicine; Daljeet S. Gambhir, Professor in Cardi-ology; Manisha Kaushik, Resident. Maulana Azad Medical College, NewDelhi, India

PURPOSE: The role of oxygen free radicals in reperfusion injury to theheart during thrombolytic therapy in myocardial infarction (M.I.) has beenpostulated. In this study, the clinical and antioxidant effects of esmolol, anultra-short acting beta blocker in patients of acute M.I. were studied.

METHODS: This was a randomized, double-blind, controlled, pro-spective study. Total 30 patients with acute M.I. were included. Allpatients were thrombolysed with streptokinase. Fifteen of these patientswere randomly selected to receive esmolol while other 15 patients servedas controls. The parameters compared at 0, 2 and 24 hours between theesmolol group and the controls were: malondialdehyde (MDA), superox-ide dismutase (SOD) and glutathione peroxidase (GPX).

RESULTS: Patients with M.I. had 5.16 times higher MDA level at 0hours (20.34�6.12 nmol/ml vs. 3.94�0.70 nmol/ml, p�0.0001) thanMDA level in normal healthy population. At 2 hours, patients with M.I.had 5.71 times higher MDA level compared to normal healthy population(22.51�5.51 nmol/ml vs. 3.94�0.70 nmol/ml, p�0.0001). A statisticallysignificant difference in MDA levels at 2 and 24 hours was observed inM.I. patients given esmolol (mean change 2.06�5.39 nmol/ml vs.–4.47�6.93 nmol/ml, p �0.009). Esmolol infusion also caused significantdifference in GPX level at 2 hours compared to controls (23.79�14.68U/gm Hb vs 38.3�8.95 U/gm Hb, p�0.003).

CONCLUSIONS: Free radical levels are raised in patients with M.I.which may contribute to reperfusion injury. The antioxidant action ofesmolol was clearly observed by significant difference in MDA level andGPX sparing effect.

CLINICAL IMPLICATIONS: Esmolol has significant antioxidantand myocardial protective effect in acute M.I. Esmolol has potential roleas antioxidant as adjuvant to thrombolytic therapy in M.I. in future.


LIPOPROTEIN-A [LP(A)] AND CAROTID ULTRASOUND INPRIMARY PREVENTION IN YOUNG ADULTSKwame O. Akosah, MD*; Ana M. Schaper, PhD; Sharon I. Barnhart,BSN; Vicki L. McHugh, MS; Pat Perlock, RDCS; Troy Haider, RDCS;Abdulaziz Elfessi, PhD. Gundersen Lutheran, La Crosse, WI

BACKGROUND: The first manifestation of coronary artery disease(CAD) may be sudden death. The main focus for primary prevention is toidentify individuals at risk for cardiovascular events. Cardiovascular eventsoccur from preexisting CAD, providing an opportunity for risk intervention.Carotid ultrasound (CU) and lipoprotein-a [Lp(a)] have been proposed asvaluable tools for early detection of CAD, but have not been tested togetherin the same group of young adults at low risk per clinical guidelines.

PURPOSE: To evaluate the accuracy of Lp(a) and CU in predictingCAD.

METHODS: 213 young adults (men � 55; women � 65), withoutprevious CAD or anti-lipemic therapy were evaluated with coronary angiog-raphy (CA) and CU. Blood samples were drawn for lipid analysis and Lp(a).CAD was defined as stenosis severity � 50%. CU was defined as abnormalfor maximal intima media thickness (IMT) � 1.0 mm in the main body;plaques or calcium at the main body, bulb, or proximal branches.

RESULTS: Mean age 50.6 � 7.5. Lipid profiles were normal (totalcholesterol 195.8 � 36.3, LDL 122.9 � 30.1, HDL 51.0 � 14, triglycer-ides 145.9 � 76.2). 93% were classified as low risk per NCEP IIIguidelines. 63 had severe CAD and had higher Lp(a) levels (30 vs 14, p �0.004). Lp(a) had low sensitivity (33%) but high specificity (87%) forangiographic CAD (OR 3.4; CI: 1.7 – 7.01). The sensitivity for CU was75%; specificity 50%; and negative predictive value 83% (OR 2.5; CI: 1.3– 4.8). Multivariate analysis revealed that Lp(a) and abnormal CU wereindependently predictive of angiographic CAD.

CONCLUSIONS: Lp(a) and CU are predictive of CAD in youngadults classified as low risk per NCEP III guidelines. However, CU ismore sensitive, and its accessibility may make it more preferable forscreening in primary prevention.

CLINICAL IMPLICATIONS: The ability of CU to predict CADprovides an opportunity to improve risk stratification in young adultswhose CHD risk is underestimated by clinical guidelines

DISCLOSURE: K.O. Akosah, None.

EFFICACY OF IBUTILIDE IN THE RAPID CONVERSION OFACUTE ATRIAL FIBRILLATION IN TRAUMA AND NON-CAR-DIAC SURGICAL PATIENTSDavid Turay, MD*; David T. Wong, MD; Nguyen Dao, PharmD; JoelleJakobsen, MD; Appanagari Gnanadev, MD. Hosptial, Arrowhead Re-gional Medical Center, Colton, CA

PURPOSE: New onset atrial fibrillation/flutter (AF) is a known compli-cation of trauma and non-cardiac post-surgical patients. Ibutilide has beenextensively studied in the post-cardiac surgical patient for rapid conversion ofacute AF, but there has been no study to date that examines the use of thisdrug in the non-cardiac surgical population. The goal of the study is to lookat the efficacy and safety of this class III agent in the trauma and non-cardiacpost-surgical patients as it compares to the non-surgical population.

METHODS: Patients recorded in our pharmacy database who re-ceived ibutilide were retrospectively reviewed. The data abstractedinclude demographics, ISS, APACHE II, independent risk factors for AF,types of injuries, onset, conversion success, and complications. All patientsreceived beta-blocker and/or diltiazem for rate control prior to ibutilideadministration. A uniform dose of ibutilide (1mg over 10 minutes) wasgiven to all patients. Patients were all admitted to the ICU and monitoredfor QT prolongation, torsade de pointes, and severe hypotension as part ofour hospital protocol.

RESULTS: A total of 24 patients received ibutilide since its addition toour formulary. 14 patients were surgical (12 trauma and 2 post-operative),and 10 patients were non-surgical patients. The risk stratification andibutilide outcomes are listed in table 1 and 2, respectively. Mortality listedbelow is not drug related. No patients developed drug related complica-tions. Average follow-up was 149.1 �/- 27.6 days with all patientsremaining in sinus with comparable atrial fibrillation free days betweengroups, log rank p�0.47 (see figure).




Table 1. Severity of Illness and risk factors.

Surgical(n�14) �/- SE

Non-surgical(n�10) �/- SE

P value

Age 63.6�/-3.9 68.7�/-4.5 0.30APACHE II 6.0�/-1.1 5.4�/-1.2 0.70# risk factors 1.0�/-.2 1.9�/-0.4 0.06Mortality 14.2% 30% 0.36

Table 2. Ibutilide conversion rate.

Surgical (n�13) Non-surgical(n�10) Pvalue

1st dose success 68.2%(9) 80% (8) 0.412nd dose required 15.4%(2) 10% (1) 0.40Failed conversion 15.4%(2) 10% (1) 0.93

CONCLUSIONS: Ibutilide as a AF conversion agent is comparable inboth the surgical and non-surgical population. These results are compa-rable to previously published data on cardiac surgical and medicalpatients.

CLINICAL IMPLICATIONS: Ibutilide is a safe and effective drugfor the rapid conversion of acute AF in the trauma and non-cardiacsurgical patients.

DISCLOSURE: D. Turay, None.

RAPID BEDSIDE WHOLE-BLOOD QUANTITATIVE CARDIACTROPONIN T ASSAY: RELIABILITY IN DIAGNOSING MYO-CARDIAL INJURYSalam Saadeddin, PhD*; Moh’d Habbab, MD; Hisham Siddieg, BSc;Mahmoud Fayomi, BSc; Rofaida Dafterdar, MD. Riyadh Armed ForcesHospital and Prince Sultan Cardiac Center, Riyadh, Saudi Arabia

PURPOSE: The measurement of cardiac troponin T (cTnT) is apowerful tool for the diagnosis of myocardial injury. Recently, a rapidbedside whole-blood quantitative cTnT assay has been developed. Weevaluated the reliability of this test for the diagnosis of myocardial injuryin patients with acute coronary syndrome (ACS).

METHODS: Whole-blood cTnT levels were measured in 96 patientswith ACS using the bedside Roche Cardiac Reader® and were comparedwith serum cTnT levels of the same patients measured by the RocheElecsys® Immunoanalyzer. Forty patients (Group A) had clinical evidenceof myocardial injury (13 with unstable angina and 27 with acute myocar-dial infarction) and 56 had no clinical evidence of myocardial injury

(Group B). The cut-off value of cTnT used to assess for myocardial injurywas 0.1 ng/ml.

RESULTS: Bedside cTnT tests were positive in 36 patients in GroupA and 3 patients in Group B with a sensitivity, specificity and positive andnegative predictive values of 90%, 95%, 92% and 93%, respectively. Fromqualitative point of view (reporting negative or positive tests), these resultswere identical to those obtained by the serum immunoanalyzer. Fromquantitative point of view,bedside tests could not measure the exact valuesbelow 0.1 ng/ml (reported negative) or above 2.0 ng/ml (reported � 2.0).Measurements by the bedside tests over the range of 0.1 and 2.0 ng/mlcorrelated well with those of the serum immunoanalyzer (r � 0.88), buttheir mean values were significantly lower (mean � SD, 1.20 � 0.71 vs.1.41 � 1.03, p � 0.0007).

CONCLUSIONS: Bedside cTnT assays are very sensitive and specificfor the diagnosis of myocardial injury and correlate well with theimmunoanalyzer measurements between the values of 0.1 and 2.0 ng/ml.However, they tend to give significantly lower values and fail to give exactvalues below 0.1 and above 2.0 ng/ml, which may affect their performancein monitoring and managing patients with ACS and limit their use inpredicting outcome.

DISCLOSURE: S. Saadeddin, None.

PERFORMANCE AND PRACTICABILITY EVALUATION OFFIVE CARDIAC TROPONIN I ASSAYS IN PATIENTS WITHACUTE CORONARY SYNDROMESalam Saadeddin, PhD*; Moh’d Habbab, MD; Hisham Siddieg, BSc;Mohammed Al Seeni, MSc; Ashraf Tahery, MD; Rofaida Dafterdar, MD.Riyadh Armd Forces Hospital and Prince Sultan Cardiac Center, Riyadh,Saudi Arabia

PURPOSE: An increasing body of evidence has demonstrated thevalue of strategies based on cardiac troponin I (cTnI) assays in thediagnosis, prognosis and monitoring of patients with acute coronarysyndrome (ACS). We evaluated the performance and the practicability of5 commercially available quantitative cTnI assays in patients with ACS.

METHODS: Blood samples from 96 patients, 40 with and 56 withoutclinical evidence of myocardial injury, were collected 24-48 hours afteradmission and used for the evaluation. Cardiac TnI assays were performedusing 5 different immunoanalyzers (Abbott AxSYM®, Dade BehringStratus® II, Bayer Centaur®, Bayer ACS:180® and Diagnostic ProductsCorporation Immulite®). The sensitivity, specificity and positive andnegative predictive values (PV) were calculated for all assays. For thepracticability evaluation, the general and special features related toinstallation, routine operation, quality control and other various specialparameters of each immunoanalyzer was evaluated (using the score of 1-5for each parameter) and compared with those of the other analyzers.

RESULTS: The calculated sensitivity, specificity and positive andnegative predicted values for all assays are shown below. The final scoresfor the performance evaluations for the Immulite®, AxSYM®, Stratus® II,Centour®, and ACS:180® were 77, 81, 66, 85 and 74/110, respectively.

Immunoanalyzer Sensitivity Specificity (�) PV (-) PVImmulite 100% 100% 100% 100%AxSYM 98% 100% 100% 98%Centaur 83% 100% 96% 88%Stratus II 100% 97% 96% 100%ACS-180 83% 100% 96% 88%

CONCLUSIONS: Cardiac troponin I assays have very high sensitivity,specificity and predictive values for myocardial injury. Among the evalu-ated systems, Immulite® had the highest performance value, Centaur®

had the highest practicability value and the AxSYM® had the highestcombined performance and practicability values for the cTnI measure-ment in patients with ACS.

DISCLOSURE: S. Saadeddin, None.




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RESPIRATORY FAILURE AFTER CARDIOVASCULAR SUR-GERY: IS TRACHEOSTOMY THE SOLUTION?Peter A. Walts, MD; Sudish C. Murthy, MD, PhD*; Jean-Pierre Yared,MD; Eugene H. Blackstone, MD; Thomas W. Rice, MD; Malcolm M.DeCamp, MD. Cleveland Clinic Foundation, Cleveland, OH

PURPOSE: To 1) determine risk factors for death when respiratoryfailure develops following cardiovascular surgery, 2) identify predictors oftracheostomy, and 3) define the utility of tracheostomy in this setting.

METHODS: From 1998 to 2001, 846 of 12,928 patients (6.5%) whounderwent cardiovascular surgery required postoperative ventilatory sup-port � 72 hours. Their preoperative, intraoperative, and intensive careunit (ICU) admission data were analyzed for factors associated withtime-related competing risks of tracheostomy and death before tracheos-tomy. Risk-adjusted expected mortality was compared to observed mor-tality after tracheostomy.

RESULTS: At 7, 14, and 30 days, mortality was 11%, 15%, and 21%;tracheostomy frequency was 8%, 16%, and 21%. Risk factors for deathwithout tracheostomy included long aortic clamp time (P�.001), acidosis(P�.0001), hypotension (P�.0001), lower cardiac index (P�.008), andneed for vasopressin (P�.0001) at ICU admission. Predictors of trache-ostomy were extremes of age (older, P�.0001; younger, P�.03), chronicobstructive pulmonary disease (P�.01), worse left ventricular function(P�.02), longer cardiopulmonary bypass time (P�.001), mitral valvereplacement (P�.03), and aortic surgery (P�.03). Survival after trache-ostomy (89%, 75%, and 32% at 14 and 30 days and 24 months) was worsethan expected, based on status at ICU admission (91%, 85%, and 65% atthese same intervals; figure).

CONCLUSIONS: Respiratory failure following cardiovascular surgeryportends an ominous outcome.

CLINICAL IMPLICATIONS: Worse-than-expected survival aftertracheostomy suggests that it may not prevent mortality from respiratoryfailure, but rather identify a subset of patients less able to tolerate initialsurgical stresses and the subsequent postoperative course.

DISCLOSURE: S.C. Murthy, None.

GENDER DIFFERENCES IN OUTCOMES FROM PERCUTANE-OUS TRANSLUMINAL CORONARY ANGIOPLASTYFrank Piontek, MA*; Elise Riley, MD; Laurie Frye, MS, MPH; JenniferJones, RN, MPH; Lee Schwab, MD, FCCP. Trinity Health, Novi, MI

PURPOSE: The literature on gender bias in PTCA is mixed. Severalolder studies suggest significant differences in care; later studies suggestrecent technological advances may obviate these differences. However,these later studies also exhibit assorted and sometimes contrary findings.We sought to examine recent administrative data to determine the effect,if any, of gender on outcomes in PTCA.

METHODS: Data on 7,413 consecutive single or multiple vesselinterventions were obtained from a decision support system (DSS) fromcardiac surgical hospitals in one the largest healthcare systems in the US,Trinity Health, from 2000 and 2001. Outcome measures studied weredifferences in severity adjusted: LOS (length of stay), mortality, total

hospital cost and departmental costs, prevalence of complications, diag-nostic testing, and readmissions within 31 days of discharge. Parametricand non-parametric tests were used to compare 4,838 males vs. 2,575females.

RESULTS: Significantly higher readmission rates, complication ratesand LOS were found in women. They also had higher severity adjustedICU and Lab costs while their overall adjusted costs were lower. Althougholder but presenting with significantly less AMI, they exhibited signifi-cantly higher severity adjusted in-hospital mortality. No differences werefound in thrombolytic agents, diagnostic testing or vessel disease. Addi-tional drilldowns may elucidate why females appear to have such higherseverity adjusted rates.

CONCLUSIONS: We used DSS data to study multi-hospital PTCAinterventions. We found that significant gender differences are present inPTCA outcomes. Essentially, females experience greater rates of compli-cations, readmissions and mortality than males. Further investigationusing 2002 data as a cohort and these data as a control is planned todetermine if these findings persist.

CLINICAL IMPLICATIONS: It is now appreciated that gender hasa significant impact on the outcome of treatment for coronary arterydisease, although the specifics are only now coming to light.

DISCLOSURE: F. Piontek, None.

INFLUENCE OF BICUSPID AORTIC VALVE ON AORTIC ELAS-TIC PROPERTIES IN PATIENTS WITH SEVERE AORTIC IN-SUFFICIENCYJason M. Lazar, MD*; Spyros Kokolis, MD; David Shenouda, DO; LutherT. Clark, MD. University, SUNY Downstate, Brooklyn, NY

PURPOSE: Bicuspid aortic valve (BAV) is associated with aortic rootdilation, aortic dissection, and abnormal elastic properties in patients withnone to mild aortic insufficiency (AI). The objective of this study was tocompare elastic properties of the aorta in patients with BAVs and othercauses of severe AI.

MEHTODS: We prospectively studied 23 consecutive found to havesevere AI on transesophageal echocardiography. The fractional areachange (FAC) of the descending aorta was determined at the level of theleft atrium using acoustic quantification. FAC was normalized to arterialpulse pressure (PP) and mean arterial pressure (MAP), which weredetermined from brachial artery sphygmomanmetry recording.

RESULTS: 39% of patients with severe AI had BAVs. Patients withBAVs were younger, 42�/-15 vs 70�/-12years,p�.001, and were lesslikely to have coronary artery disease 39% vs 61%,p�.04. Patients withBAVs had significantly greater FAC (11�/-4 vs 7�/-2, p�.03), FAC/PP(.20�/-.08 vs .12�/-.04, p�.015), and FAC/MAP (.15�/-.06 vs .09�/-.02,p�.049) than those without BAVs. After age adjustment, FAC, FAC/PP,and FAC/MAP remained significantly greater in the BAV group whereasCAD was no longer significant.

CONCLUSIONS: BC are associated with greater aortic elasticity ascompared to other causes of severe chronic AI.

CLINICAL IMPLICATIONS: These data further suggest an intrinsicabnormality of the aorta associated with BAV.

DISCLOSURE: J.M. Lazar, None.

EXPERIMENTAL MYOMETRIAL CELL PATCH CARDIOMYO-PLASTYSyde A. Taheri, MD*; John Naughton, SUNY at Buffalo; Arthur Orlick,MD; Judith Lampasso, MD; Sateesh Satchidanand, MD; Y V. Fang, MD.Kaleida Health, Clarence, NY

PURPOSE: To evaluate the viability and function of patches ofautologous myometrium to infarcted myocardium of rabbits.

METHOD: Seven rabbits weighing between 5-6 pounds were anes-thetized and intubated. The heart was exposed via midline sternotomy.Myocardial infarction was induced by ligating left anterior descendingcoronary artery, which was verified by ST segment changes. Then vialaparotomy incision, a small segment of uterus was removed and appliedto infarcted myometrium. This was reinforced by greater omentum.

RESULT: PET scanning of 3 rabbits revealed viable myometrium withnormal perfusion. Ventriculogram on 4 rabbits revealed slight dyskenesaeof the posterior wall with ejective fraction of 42%. Histology revealedviable myometrium which is firmly adhered to the infarcted left ventriculedemonstrating excessive angiogenesis and estrogen, progesterone recep-tors.




CONCLUSION: Experimental myometrial cell patch Cardiomyoplastyto infarcted myocardium revealed viable myometrium which is welladhered to infarcted myocardium. The viability was also further demon-strated by positive stain for smooth muscle actin, estrogen or progesteronereceptors. Transplanted myometrium synchronous contraction and satis-factory ejection fraction.

CLINICAL IMPLICATIONS: The possibility of this unusual differ-entiation of myometrial cell to cardiomyocyte phenotype may have asignificant impact on the use of human myometrium as tissue or celltherapy for cardiomyopathic patients.

DISCLOSURE: S.A. Taheri, None.

EFFICACY OF REGIONAL SPINAL CORD COOLING AND CE-REBROSPINAL FLUID (CSF) DRAINAGE IN THORACOAB-DOMINAL ANEURYSM REPAIRSSafa Farzin, MD; Achal Dhupa, MBBS*. The Miriam Hospital, Provi-dence, RI

BACKGROUND: Descending thoracic and thoracoabdominal aneu-rysm repair continue to be complicated by postoperative paraplegia. Weprovide a review of regional spinal cord cooling and cerebrospinal fluid(CSF) drainage literature, as well as a retrospective review in our hospitalover the past three years.

METHODS: Articles for review of literature were obtained via amedline search for “thoracic aorta aneurysm repair” and “thoracoabdomi-nal aneurysm repair”. The experiences of one anesthesiologist, whoroutinely employs CSF drainage and regional spinal cord cooling, werereviewed retrospectively. 20 consecutive thoracoabdominal aneurysmrepairs from 1998 to 2001 were included. Cases were analyzed forneurologic complications and mortality up until discharge. Other moni-tored parameters include; intraoperative CSF pressures, CSF coolingtemperature, total CSF drained, and aortic clamp time.

RESULTS: Incidence of paraplegia was 10% and mortality was 5%.Mean clamp time was 59 minutes. Mean CSF drained prior to removal ofthe Codman Drain was 313cc. Both cases of paraplegia were electivesurgeries. The single fatality had good neurologic function post operativelybut later developed acute renal failure and ARDS. Operative character-istics are included below:

Average CSF Drained 313ccTotal CSF Drained Range 20 – 575 ccAverage Aortic Clamp Time 59 minutesClamp Time Range 28 minutes – 115 minutesAverage CSF Operative Temperature 30.3 °CAverage Trough CSF Operative

Temperature26.3 °C

Trough CSF Temperature Range 24.5 °C – 28 °CAverage CSF Operative Pressure 33.6 mm HgCSF Operative Pressure Range 12 mm Hg – 61 mm Hg

DISCUSSION: Svensson et al. published a large retrospective reviewof thoracoabdominal aneurysm repairs in 1993. Distal aortic perfusion wasemployed in 17% of this population and intercostal artery reanastomosiswas performed in 45%. The incidence of paraplegia and paralysis was 16%and the 30-day mortality was 8% (1). Our data is comparable to thesestatistics; however, we employed multiple spinal cord protection tech-niques that were not used by Svensson. Further statistical analysis ofparalysis and mortality rates prior to the use of spinal cord cooling andCSF drainage in this institution are needed to decide whether thesetechniques had a beneficial impact on this population.

REFERENCES:1. Svensson et al. Experience with 1509 Patients Undergoing Thoraco-

abdominal Aortic Operations. Journal of Vascular Surgery. 1993. 17:357-368

DISCLOSURE: A. Dhupa, None.

CAN AN UPRIGHT T-WAVE IN LEAD AVR BE A CLINICALMARKER FOR UNDERLYING MYOCARDIAL DISEASE?Vijay K. Verma, MD*; Abdul Alkeylani, MD. UMDNJ-Robert WoodJohnson Medical School at Cooper University Hospital, Camden, NJ

PURPOSE: Upright T-wave in lead aVR (UTW-aVR) is an uncommonfinding with unclear significance in the absence of left bundle branchblock. We evaluated the incidence of an UTW-aVR with underlyingmyocardial disease.

METHODS: From 2340 consecutive inpatient and outpatient ECGs,255 (11%) were identified with UTW-aVR and 2085 (89%) with normalT-wave in lead aVR (NTW-aVR). We compared the prevalence ofmyocardial disease using 2D Echo in 100 patients with UTW-aVR and 100patients with NTW-aVR randomly selected from each group. Myocardialdisease was defined as left ventricular systolic dysfunction (LVSD) withejection fraction �50%, the presence of right ventricular systolic dysfunc-tion (RVSD), or the presence of left ventricular hypertrophy withpreserved systolic function (LVH).

RESULTS: There was no difference in age or the number of men andwomen in the two groups. The incidence of underlying myocardial diseasewas 91% in patients with UTW-aVR (LVSD: 69, LVH: 23, RVSD�LVH:2, LVSD�RVSD: 16, and Isolated RVSD:1) and 44% in patients withNTW-aVR (LVSD: 19, LVH: 25, LVSD�LVH: 5, LVSD�RVSD: 6, andRVSD�LVH:5). The likelihood ratio for overall myocardial dysfunction inthe presence of UTW-aVR was 4.86 (sens: 68%, spec: 86% & PPV: 91%,NPV: 56%). The likelihood to have LVSD in the presence of UTW-aVRwas 2.53 (sens: 76%, spec: 70% & PPV: 66%, NPV: 80%).

CONCLUSION: An upright T-wave in lead aVR is a simple clinicalmarker of underlying myocardial disease with a very high predictive value.

CLINICAL IMPLICATIONS: A clinical tool for rapid triage ofpatients with underlying myocardial disease.

Utility of UTW-aVR in Diagnosing Myocardial Dysfunction

MyocardialDisease

NormalHeart Total

UTW-aVR 91 9 100NTW-aVR 43 57 100Total 134 66 200

DISCLOSURE: V.K. Verma, None.

INCIDENCE OF CORONARY ARTERY DISEASE IN HIV-IN-FECTED PATIENTS RECEIVING HIGHLY ACTIVE ANTIRET-ROVIRAL THERAPY: A PROSPECTIVE STUDYGiuseppe Barbaro, MD*; Gabriella Di Lorenzo, MD; Augusto Cirelli,MD; Benvenuto Grisorio, MD; Alfio Lucchini, MD; Giorgio Barbarini,MD; The GISCA Group. University, University of Rome, Rome, Italy

PURPOSE: The association of highly active antiretroviral therapy(HAART) regimens including protease inhibitors (PIs) with metabolic andsomatic disorders raised concern on the possibility of an increased risk ofcoronary artery disease (CAD) in HIV-infected subjects. Aim of the studywas to assess the incidence of CAD over time in previously untreatedHIV-infected patients according to the antiretroviral therapeutic regimen.

PATIENTS AND METHODS: 1551 HIV-infected subjects (meanage 35) were randomly assigned to receive HAART either with PIs (GroupPIs�:n�776) or without PIs (Group PIs-: n�775). During the course ofthe study, clinical examination and laboratory tests were performed everyfour months. The cumulative incidence of CAD-related events, in termsof recently developed angina, unstable angina, fatal and nonfatal myocar-dial infarction was the primary outcome of the study.The median durationof follow-up was 36 months (range 34 to 42 months).Statistical analysiswas by intention-to-treat.

RESULTS: During the follow-up period CAD-related events wereobserved in 23 patients of group PIs and in 2 patients of Group PIs- (OR:11.8; 95% CI: 2.4 to 50.2). The cumulative annual incidence of CAD-related events was 9.8/1000 Group PIs� and 0.8/1000 in Group PIs-(P�0.001). The annual incidence of myocardial infarction was 5.1/1000 inGroup PIs� and 0.4/1000 in Group PIs- (P�0.001). Multivariate analysisshowed that the incidence of CAD-related events was related to dyslipi-demia (OR:14.2; 95% CI:3.06-26.7),to lipodystrophy (OR:11.2 ;95% CI:




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4.8-32.4), to smoking (OR:9.7;95% CI:3.5-16.7) and to male gender(OR:5.28; 95% CI: 1.7 to 18.3), independently of age of the patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS: PIs-includ-ing HAART may accelerate the onset CAD-related events in young malesmokers who develop metabolic disorders and lipodistrophy. Subjectswith increased coronary risk should receive a careful cardiologic monitor-ing if treated with PIs.

DISCLOSURE: G. Barbaro, None.

LEFT VENTRICULAR FLOW PROPAGATION DURING EARLYDIASTOLIC FILLING IN PATIENTS WITH LEFT BUNDLE-BRANCH BLOCKJoseph Germano, DO; Luther Clark, MD; Jason M. Lazar, MD*. StateUniversity of New York Downstate Medical Center, Brooklyn, NY

PURPOSE: Color M-mode Doppler determination of left ventricular(LV) early diastolic flow (Vp) is useful in assessing LV diastolic perfor-mance. Left bundle-branch block (LBBB) is associated with impairedsystolic and diastolic function as well as abnormal depolarization andrepolarization. In patients with LBBB, measurements of Vp have not beenwell studied. The objectives of this study were to characterize Vp inpatients with LBBB and to establish whether Vp is influenced by alteredelectrical activation of the LV or by underlying heart disease.

METHODS: We studied Vp in 38 consecutive patients with LBBB,77�/-10years old (47%male), admitted to our institution. Vp was deter-mined as the slope of the first aliasing velocity from color M-modeDoppler recordings oriented from the LV apex to the tips of the mitralleaflets.

RESULTS: 97% of patients showed a Vp�45cm/sec (mean�23�/-10).On univariate analysis, Vp correlated directly with LV ejection fraction(LVEF) (r�.43, p�0.008), inversely with LV end-systolic dimension(ESD)(r�-.40, p�0.04), and inversely with E-point septal separation(EPSS) (r�-.51, p�.0007). Vp did not relate to age, heart rate, LV mass,QRS duration, QRS axis, Q-T interval, deceleration time, or E/A ratio. Onmultiple regression analysis, Vp correlated only with LVEF (r2�0.62,p�0.0001).

CONCLUSIONS: Flow propagation is frequently abnormal in patientswith LBBB. These findings suggest that Vp is determined by LV systolicfunction and dimensions but not by altered electrical activation or diastolicparameters.

CLINCAL IMPLICATIONS: The relationship between Vp andclinical symptoms and the prognostic value of Vp in patients with LBBBare unknown and merit further study.


MANEUVERS TO ENHANCE CEPHALIC VEIN ACCESS INPERMANENT PACEMAKER AND IMPLANTABLE DEFIBRIL-LATOR PLACEMENTKoroush Khalighi, MD; Shannon E. Dodd, DO*; Judy Knecht, RN; JodySmith, RN. Easton Hospital, Easton, PA

PURPOSE: Cephalic vein access has significant advantages over thetraditional use of the subclavian and axillary veins in patients who undergopermanent pacemaker and implantable defibrillator placement. Both longand short term risk reduction occurs in forgoing the traditional approachessince pneumothorax, an unfortunate short term consequence, is elimi-nated. Additionally, subclavian crush syndrome, a common long termcomplication, is avoided by using the cephalic vein. The cephalic approachhas been thought to be a more difficult technique than traditionalapproaches, elongating the procedure time for “cut-down.” The purposeof study is to demonstrate the that the use of innovative techniques allowsboth easier access and a higher yield offering greater safety to patients.

METHODS: Standard cephalic, subclavian, and axillary approacheswere used under fluoroscopic guidance during implantation.

RESULTS: A total of 583 consecutive patients who were scheduled forimplantation of a permanent pacemaker or implantible defibrillator(ICD), were prospectively enrolled. Patient mean age was 74.3 years(range: 27 – 100) and 62% were male. Sixty-five percent (n� 379) werecandidates for permanent pacemaker implantation and 35% (n�204)required implantable defibrillator placement. The standard 0.38“ widthJ-wire, which is provided by most commercially available sheath introduc-ers, provided successful cephalic vein access in 60% of cases. However,upon use of the more flexible ”Glidewire“ for tortuous, smaller sized, and

diseased veins, access increased by 26%, allowing a total success rate ofcephalic vein access of 86%.

CONCLUSION: Successful cephalic vein access yield during implantprocedures was significantly improved from 60% to 86%.

CLINICAL IMPLICATIONS: Using the innovative maneuvers de-scribed provide greater safety, and more advantageous outcomes topatients undergoing permanent pacemaker and implantable defibrillatorplacement.

DISCLOSURE: S.E. Dodd, None.

TRANSESOPHAGEAL ECHOCARDIOGRAPHIC ASSESSMENTOF OSTIA AND BODY OF PULMONARY VEINSChittur A. Sivaram, MD*; Robin E. Germany, MD; Can Hasdemir, MD.University of Oklahoma, Oklahoma City, OK

OBJECTIVES: Pulmonary vein (PV) isolation is increasingly done fortreatment of atrial fibrillation (AF). However there is paucity of studies ofthe morphology of PV by echo imaging.

MATERIAL & METHODS: Right upper (RUPV) and left upper(LUPV) pulmonary veins were evaluated with transesophageal echo(TEE) in two orthogonal longitudinal planes (coronal and sagittal). Due todifficulties of obtaining orthogonal views, inferior PVs were excluded. PVdiameter was measured at ostial site and 1 cm away from ostium in bodyof PV. Diameter was measured for each PV in systole, diastole and duringatrial reversal (if in sinus rhythm).

RESULTS: 45 PVs (RUPV 17, LUPV 28) from 36 patients werestudied (32 male, 4 female). Rhythm was sinus in 25 pts, AF in 10 andpaced in 1. For both RUPV & LUPV, ostial diameters were different intwo orthogonal planes (RUPV 16 � 4 mm vs. 20 � 5 mm, p�0.002; LUPV14 � 3 mm vs 18 � 4 mm, p�0.0001). For RUPV the largest of theorthogonal diameters was in coronal plane in 6 pts and sagittal plane in 11.For LUPV the largest of orthogonal diameters was in coronal plane in 19pts and sagittal plane in 9 pts. Significant difference in orthogonal viewswas also seen in LUPV diameter 1 cm away from ostium (13 � 4 mm vs15 � 4 mm, p�0.01), but not in RUPV. No differences were seenbetween RUPV or LUPV diameters obtained during systole, diastole andatrial reversal phases.

CONCLUSIONS: 1. Both RUPV and LUPV ostia are asymmetrical(oval shaped) with a larger and a smaller diameter. 2.This difference indiameters is maintained in LUPV at 1 cm from ostial site, but not inRUPV. 3. No significant differences in diameter are seen during differentperiods of cardiac cycle. 4. PV diameter should be routinely measured intwo orthogonal planes since size of PV ostia has impact on selection ofcatheters for PV isolation.

DISCLOSURE: C.A. Sivaram, None.

MOBILE STRAND-LIKE THROMBI IN THE INFERIOR VENACAVA AFTER RADIOFREQUENCY ABLATIONChittur A. Sivaram, MD*; Can Hasdemir, MD; Ramprasad Kandavar,MD; Dalip Singh, MD; Ralph Lazzara, MD; Warren M. Jackman, MD.University of Oklahoma, Oklahoma City, OK

BACKGROUND: We have recently observed mobile strands theinferior vena cava (IVC) complicating radiofrequency ablation (RFA),using echocardiography.

METHODS: Retrospective review of consecutive patients with IVCstrands (Gr I) over a 30-month period. Control group (Gr II) wasage-matched RFA patients without IVC strands.

RESULTS: IVC strands were detected post RFA in 55/757 (7%)patients (Gr I)- by TTE in 47 and TEE in 8. None had IVC strand priorto RFA. Arrhythmia was AVNRT in 18 (33%), AVRT in 17(31)%), atrialtachycardia in 8 (15%), atrial flutter in 4 (7%), atrial fib in 3 (5%) and VTin 4 (7%). RFA site was RA in 38(69%), LA in 9 (16%), RV in 2 (4%), LVin 1 (2%) and none in 5 (9%). Mean width of strand was 3.4�/- 1.6 mm.In 5/55 pts IVC strands extended into RA (9%). In the remaining 50 pts,strand terminated 53 �/-28 mm below IVC-RA junction. Maximal lengthwas 51 �/- 31 mm. IVC size was normal (15�/-4.3 mm) and spontaneousecho contrast seen in IVC post RFA in 10 (18%) in Gr I. No differencebetween Gr I and Gr II was seen in no. of short sheaths (4.2�/-0.6 vs.4.3�/-0.7), long sheaths (1.1�/- 0.3 vs. 1.4�/-0.5) or duration of proce-dure (506�/-169 min vs. 483�/-143). Heparin was used during procedurein 11/55 pts in Gr I (20%) and 13/40 pts in Gr II (32.5%). Post ablationtreatment in Gr I pts consisted of ASA only in 21(38%), clopidogrel in 2(4%), LMWH with warfarin in 27 (49%), warfarin only in 3 (5%), regular




heparin and warfarin in 1 (2%) and LMWH only in 1 (2%). Symptomssuggestive of pulmonary embolism (PE) occurred in 2 patients (4%) withnegative workup. Long-term follow-up in 31 pts identified no evidence ofPE.

CONCLUSIONS: Mobile IVC thrombotic strands are seen after RFAin 7% of patients. These strands reach RA only rarely and appear to havea benign clinical course.

DISCLOSURE: C.A. Sivaram, None.

Cardiovascular Surgery Updates12:30 PM - 2:00 PM

MULTI-STAGED APPROACH TO HEMODYNAMIC CORREC-TION OF COMPLEX CONGENITAL HEART DEFECTSVladimir P. Podzolkov, MD; Mikhail R. Chiaureli, MD; Mikhail M.Zelenikin, MD; Ketevan A. Mchedlishvili, MD; Viktor B. Samsonov, MD;Tatiana O. Astrakhantseva, MD; Sergey B. Zaets, MD*. Bakoulev Scien-tific Center for Cardiovascular Surgery, Moscow, Russian Federation

PURPOSE: Although Fontan operation (FO) is a well-establishedmethod of hemodynamic correction of complex heart defects, the numberof complications and mortality rate after this procedure remain relativelyhigh. The aim of this investigation was to compare different strategies ofFO in order to reveal the least risk approach to this procedure.

METHODS: Retrospective analysis was performed on 247 FO duringthe years 1983-2001. The patients who underwent FO, were divided into3 groups according to the type of correction: 1. Primary FO; 2. FOperformed after previous systemic-pulmonary anastomosis (SPA); 3. FOperformed after bidirectional cavopulmonary anastomosis (BCPA). In ouranalysis, we took into consideration the rate of early and late morbidity/mortality as well as the functional status of patients late after theprocedure. The duration of follow-up in 145 patients, ranged from 6months to 16 years, median – 4.5�3.4 years. Physical capacity andexercise hemodynamics were evaluated by bicycle ergometry.

RESULTS: Mortality and morbidity rate was the lowest after BCPAfollowed by FO (Table: * p�0.05 vs. other groups). Patients whounderwent this type of correction also showed a higher physical capacityand more favorable exercise hemodynamics compared to other groups.

CONCLUSIONS: The best results in hemodynamic correction ofcomplex congenital heart defects (the lowest morbidity/mortality rate andmore favorable hemodynamic outcome) were achieved when bidirectionalcavopulmonary anastomosis preceded Fontan operation.

CLINICAL IMPLICATIONS: Bidirectional cavopulmonary anasto-mosis performed prior to Fontan operation reduces the risk of thisprocedure and improves its functional results.

Early and Late Results of Fontan operation

Morbidity/Mortality (%)

PrimaryFO

FO afterSPA

FO afterBCPA

Early 14.6% 12.5% 3.2%*Late 15.5% 26.5% 8.0%*

DISCLOSURE: S.B. Zaets, None.

TRANSVENTRICULAR AORTIC VALVOTOMY FOR CRITICALAORTIC STENOSIS IN NEONATES: OUTCOMES, RISK FAC-TORS, AND REOPERATIONSMark Ruzmetov, MD*; Palaniswamy Vijay, PhD; Mark D. Rodefeld, MD;Mark W. Turrentine, MD; John W. Brown, MD. Indiana UniversitySchool of Medicine, Indianapolis, IN

PURPOSE: Critical aortic stenosis (AS) in neonates necessitates urgentintervention for patient survival. The optimal treatment, however, contin-ues to be controversial and has still high morbidity and mortality. Thisstudy examined our late outcome after treatment of critical AS inneonates.

METHODS: Fifty-two neonates (34 boys and 18 girls) underwentclosed transventricular aortic valvotomy for critical AS between 1985 and2000. The mean age at the first intervention was 9.0 � 10.2 days (ranges

from 1 to 30 days). 17 patients (Group I) had isolated critical AS andnormal or dilated left ventricles. The Group II comprises 35 neonates(67%) who had associated cardiovascular anomalies (i.e. aortic annularhypoplasia, hypoplasia of the left ventricle (LV), mitral valve anomalities,endocardial fibroelastosis, and/or ductus dependant).

RESULTS: The hospital mortality was 17.3% (9/52). All nonsurvivalpatients were in group 2. 15-year survival was 100% in group 1 and 71.4%in group 2. At last follow-up (mean 7.8 � 3.1 years), 36 of the survivorswere in functional class I and 6 were in class II. Multi logistic regressionshowed that of the eight factors deemed significant on univariate analysis,only three risk factors remained significant on multivariate analysis; (1)presence of hypoplastic of LV (p�0.001), (2) low LV ejection fraction(EF; p�0.002), and (3) low LV end-diastolic volume (p�0.001). 15-yearfreedom from any reoperation in group 1 was 53.6% and 68% in group 2.In the Cox univariate analysis the best preoperative predictors of latereoperation were aortic valve annulus of less than 5.0 mm (p�0.004), andlow LVEF (p�0.02).

CONCLUSIONS: We conclude critical AS in neonates continues tocarry a significant mortality. Surgical and balloon valvotomy are bothpalliative procedures and reinterventions are usually required within 10years of initial treatment.

DISCLOSURE: M. Ruzmetov, None.

EARLY EXTRACORPOREAL MEMBRANE OXYGENATION SUP-PORT IN IMMEDIATE POST-OPERATIVE PERIOD FOR IN-FANTS WITH STAGE I REPAIR FOR HYPOPLASTIC LEFTHEART SYNDROMEMarek J. Grzeszczak, MD*; Davis Drinkwater MD; John Pietsh MD;Kevin Churchwell MD. Vanderbilt University Children’s Hospital, Nash-ville, TN

PURPOSE: Evaluate single center experience with use of extracorpo-real membrane oxygenation (ECMO) support for stage I repair ofhypoplastic left heart syndrome (HLHS). With stage I repair, thereremains a significant operative and perioperative mortality with systemichypoxemia and/or myocardial dysfunction as the main causes. If the causesof myocardial dysfunction are reversible, ECMO has been used forcardio-respiratory support. ELSO registry reports survival of 23% forneonatal HLHS after stage I repair placed on ECMO.

METHODS: Between June 1999 and June 2000 35 patients underwentstage I repair. Charts were retrospectively reviewed. Eleven patients wereplaced on ECMO including three placed on in operating room. Patientsclinical charachteristics in table.

RESULTS: Six patients survived to time of hospital discharge (54%)and 5 died (46%). Two patients placed on ECMO in operating roomsurvived. There was no statistically significant difference in length ofcross-clamp, circulatory arrest time, shunt size, length of CPR or time onECMO between groups. Statisticaly significant difference was betweentotal cardiopulmonary bypass time (t-test, p�0.03), with longer run innonsurvival group.

CONCLUSIONS: Poor ECMO outcomes for perioperative supportmay discourage some centers from offering this modality to this patientpopulation. With recent advancement in extracorporeal life supportimproved survival is possible.

CLINICAL IMPLICATIONS: Our experience suggest increasedsurvival in patients with stage I repair for HLHS after early ECMOdeployment.

SURVIVAL NON-SURVIVAL

CPB(min)

83(67-115)

109(101-125)

cross-clamp(min)

47(37-72)

46(39-50)

Circ. arrest(min)

45(34-69)

43(36-46

Shunt size(mm)

3.5 3.5

CPR(min)

28(2-45)

17(0-33)

ECMO(hr)

76(41-130)

40(2-76)

DISCLOSURE: M.J. Grzeszczak, None.




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INFLUENCE OF INTER-PAPILLARY DISTANCE ON MITRALREGURGITATION IN NORMAL AND MYOPATHIC HEARTS:IMPLICATIONS FOR VENTRICULAR GEOMETRY RESTORA-TIONVenkataramana Vijay, MD*; Bangaruraju Kolanuvada, MD; Vinod Jora-pur, MD; Ajay Nellutla, MD; Sarath Dommaraju, MD; Brian Whang,MD; Kevin McCusker, MD; Elias Zias, MD; Mohan Sarabu, MD. NewYork Medical College, Valhalla, NY

INTRODUCTION: Demonstrate role of inter-papillary distance(IPD) in MR from cardiomyopathy and its importance in ventriculargeometry restoration. Inappropriate IPD alteration affects mitral appara-tus dimensions - Apico-Papillo-Chordal length (APC), causing prolapse.

METHODS: Twenty normal and twenty - 2 ,3,and 4 fold papillarydisplacement myopathy porcine models created by author using serialdilation technique were studied before and after IPD obliteration.Complete papillary approximation suture encircled and transfixed midportion of both papillary muscles. APC and Apico-Annular distance (AA)and height of leaflet free edge above annular plane (flail) were measured.Competence of valve was judged at 50, 80, 100 and 120mm Hg using aclosed circulatory loop, static LV loading system.

RESULTS: Normal hearts: IPD was 0.6mm(0.5-0.7), AA was5.8mm(5.6-6.3). IPD obliterartion flailed both leaflets by 3–4 mmproducing moderate and severe regurgitation at 80 and 120 mm. Allchanges reversed upon releasing suture and restoring IPD to normal.

Myopathy models: IPD was 1.2, 1.8 and 2.4cms for 2, 3, and 4 foldmyopathy models, AA was 6.6cms (6.2-7.1cms) with moderate MR fromtethering in the 3 and 4 fold models only. IPD obliteration caused 4 – 5mm flail in 2 fold myopathy, with moderate regurgitation at 80mm, butsevere regurgitation at 120 mmHg. In 3 and 4 fold myopathy models, 6–8mm flail with severe regurgitation noted from 50mmHg. Release of suturereversed regurgitation and flail in 2 fold myopathy while in 3 and 4 foldmyopathy, flail reverted to tethering, with baseline MR. Degree of flailwas related to degree of over-reduction of IPD.

CONCLUSION: Apex to annulus forms hypotenuse of triangle withapico-papillary and papillo-chordal portions as sides. Obliteration of IPDflattens the sides of this triangle and, since the sum of lengths of two sidesexceeds that of hypotenuse, both leaflets flail.

CLININCAL IMPLICATION: In LV geometry restoration andvolume reduction surgery, reduction of IPD to less than normal results infunctional regurgitation from flail.

DISCLOSURE: V. Vijay, None.

OFF-PUMP CORONARY ARTERY BYPASS (OPCAB) IS THEPROCEDURE OF CHOICE FOR PATIENTS WITH CORONARYARTERY DISEASE AND ASSOCIATED MITRAL REGURGITA-TIONR. Douglas Adams, MD, FACS, ABTS*; Doug Vito, RDCS. LakeCumberland Regional Hospital, Somerset, KY

PURPOSE: To evaluate off-pump coronary artery bypass (OPCAB)grafting as therapy for coronary artery disease (CAD) with associatedmitral regurgitation (MR) of uncertain etiology.

METHODS: Retrospective analysis of all coronary artery bypassprocedures from October 2002 to April 2003

RESULTS: Sixty-four consecutive cases, 59 elective and 5 emergent,were reviewed. Sixty-two patients underwent OPCAB and two underwentconventional, on-pump, bypass procedures. All had intra-operative trans-esophageal echocardiography (ITEE) performed. Ten patients (15.6%)had MR �of 2�. Nine of 10 had immediate resolution or improvement(to � 1�) of MR upon opening bypass grafts using OPCAB techniques.One did not, and underwent subsequent Mitral Valve Repair.

CONCLUSIONS: OPCAB technique combined with ITEE providesimmediate information on the impact of bypass grafting on co-existentMR. This technique is superior to previous techniques which requireon-pump grafting, weaning from cardiopulmonary bypass (CPB), evalua-tion of MR in the context of recently arrested and stunned myocardiumwith bypass cannulae in place and a re-establishment of CPB andre-arresting of the heart if the MR require surgical correction.

CLINICAL IMPLICATIONS: OPCAB as a surgical technique visitsless physiologic insult on patients, demonstrated by lower complicationrates, fewer neurologic events and shorter hospital stays. Combination ofOPCAB with ITEE in patients with CAD/MR provides immediateinformation on the ischemic component of the MR, eliminating guesswork

in treatment and avoiding physiologically expensive bypass time andpotentially unnecessary mitral valve procedures.

DISCLOSURE: R. Adams, None.

PATIENT KNOWLEDGE AND LENGTH OF STAY AFTER COR-ONARY ARTERY BYPASSTrevor Bardell, MD*; Dimitri Petsikas, MD, FRCSC. Queen’s University,Kingston, ON, Canada

PURPOSE: Patients may present for coronary artery bypass (CAB)with varying degrees of knowledge about their disease and its treatment.We sought to assess the relationship between level of patient knowledgeand length of stay (LOS) after CAB.

METHODS: A questionnaire was designed to assess patient knowl-edge of coronary artery disease and CAB. This included what to expectduring the hospital stay and how to maximize recovery. Demographicinformation was collected and patients were asked to identify previouseducational interventions. These included: 1) prior discussion with aphysician 2) personal research using books or the internet and 3) use of ahospital-provided cardiac surgery information booklet.

RESULTS: One hundred patients were enrolled between September2001 and July 2002. Mean LOS was 7.6 � 10.4 days. Questionnaire scorewas not influenced by the following: 1) age 2) sex 3) internet research 4)reading the hospital information booklet and 5) knowing someone whorecently underwent CAB. Predictors of decreased LOS included thefollowing: 1) reading the hospital information booklet (6.6 vs. 9.5 days,p�0.010) and 2) internet research (5.1 vs. 7.9 days, p�0.0001). Predictorsof increased LOS included the following: 1) age � 75 (10.3 vs. 6.8 days,p�0.009) 2) female sex (10.5 vs. 7.1 days, p�0.022) and 3) obesity (10.3vs. 7.0 days, p�0.020).

CONCLUSIONS: No relationship between patient knowledge andLOS after CAB was demonstrated. Patient-centered efforts to learn aboutCAB surgery (by conducting internet research and reading hospital-provided materials) did not result in increased knowledge of CAB,however motivation to learn may be an important predictor of length ofstay after CAB.

CLINICAL IMPLICATIONS: Spending time educating patientsabout CAB may have low utility. Addressing poor motivation prior toelective cardiac surgery may be useful in reducing LOS.

DISCLOSURE: T. Bardell, None.

OFF-PUMP CORONARY ARTERY SURGERY IN ELDERLY PA-TIENTSPalaniswamy Vijay, PhD; Palaniswamy Vijay, PhD*; Yousuf Mahomed,MD; Thomas W. Sharp, MD. Indiana University School of Medicine,Indianapolis, IN

PURPOSE: Off-pump coronary artery bypass surgery (OPCAB) hasbecome a common technique for myocardial revascularization. A numberof studies have shown benefits for this technique compared to conven-tional on-pump bypass surgery, suggesting that older and sicker patientsmay be able to undergo surgical revascularization with acceptable mor-bidity. In this study, we analyzed the effectiveness of OPCAB in elderlypatients referred for surgical revascularization.

METHODS: From April 1998 to Oct 2002, 599 patients underwentelective coronary artery bypass using the Octopus 3/Starfish cardiacstabilization system. Among these, 84 patients (14%) were identified whowere �75 years (Group I). Their postoperative outcomes (obtained frommedical records) were compared to those patients �74 years (Group II).

RESULTS: The average age was 79.1�3.4 years in Group I and59.8�9.6 in Group II. Preoperative cardiovascular risk factors includingdiabetes, smoking, dyslipidemia, and hypertension were similar in bothgroups. The number of vessels grafted (2.9�0.5 vs 2.8�0.6) were similarin both groups. One patient (1.2%) in Group I needed dialysis (Cr 6.9)compared to 14 (2.7% of 515) in Group II (p�NS). Blood products weretransfused in 27% (23/84) of patients in Group I compared with 17%(87/515) in Group II. A significant difference was seen in transient renalfailure and mortality. Eighteen percent of patients in Group I developedrenal failure, compared with only 5.6% in Group II (p �0.008). Mortalitywas 2.7% in Group II, but it was 8.3% in Group I, with pulmonarycomplications being the predominant cause of death.

CONCLUSION: OPCAB can be used successfully in elderly patientswith acceptable results. Co-morbidities such as renal insufficiency andchronic lung disease increase perioperative morbidity and mortality.


Cardiovascular Surgery Updates,continued


CLINICAL IMPLICATIONS: The use of OPCAB is safe and reducesmortality and postoperative complications in elderly patients.

DISCLOSURE: P. Vijay, None.

PREDICTORS AND OUTCOMES OF GASTROINTESTINALCOMPLICATIONS IN PATIENTS UNDERGOING CORONARYARTERY BYPASS GRAFT SURGERY: A PROSPECTIVE, NESTEDCASE-CONTROL STUDYMatthew H. Recht, MD*; J. Michael Smith, MD FACS; Scott E. Woods,MD MPH MEd; Amy M. Engel, MA; Loren F. Hiratzka, MD FACS.Good Samaritan Hospital, Cincinnati, OH

PURPOSE: Assess the risk factors and outcomes for gastrointestinal(GI) complications in patients undergoing coronary artery bypass surgery(CABG).

METHODS: We conducted a nested case-control study from anine-year, hospitalization cohort (N�7345) in which data were collectedprospectively. Cases were patients that developed GI complications(N�66) and controls were patients that did not develop GI complications(N�330). Cases were matched to controls 1:5 on type of surgery. Therewere 16 predictor and 14 outcome variables of interest.

RESULTS: Five significant predictor variables were discovered. Caseswere more likely to be older than age seventy, with more left ventricularhypertrophy, more dialysis, greater urgency of the procedure, and morelikely to be on anticoagulants. There were no significant differencesbetween the cases and controls for the remaining 11 predictor variables ofinterest. Correlation coefficients were computed among the significantvariables. Using regression analysis, patients undergoing CABG with agegreater than 70 (RR 1.06, 95% CI 1.03-0.97), dialysis (RR1.87, 95% CI1.98-1.22), and urgency of procedure (RR 1.91, 95% CI 1.07-3.4) had athree-fold increase in the risk of GI complication. There were 11significant outcome variables. Patients with GI complications had moreadditional procedures, arrhythmia requiring treatment, mortality, neuro-logical complications, pulmonary complications, renal complications, andsternal wound complications. Patients with GI complications also hadgreater length of hospitalization (LOH), intensive care unit LOH, postoperative creatine phosphokinase levels, and ventilator time.

CONCLUSION: In patients undergoing CABG surgery, dialysis, agegreater than 70, and increased urgency of the procedure all significantlyincreased the risk of a GI complication. Patients with GI complicationsalso experienced more negative outcomes.

CLINICAL IMPLICATIONS: With this data, cardiac surgeons canaccurately counsel patients on their individual risk of getting a gastroin-testinal complication with undergoing CABG. This could lead to betterinformed decisions by both physicians and patients.

DISCLOSURE: M.H. Recht, None.

PREDICTORS OF STROKE IN PATIENTS UNDERGOING COR-ONARY ARTERY BYPASS GRAFT SURGERY: A PROSPECTIVE,NESTED, CASE-CONTROL STUDYScott E. Woods, MD, MPH, MEd*; J. Michael Smith, MD; Loren F.Hiratzka, MD; Amy Engel, MA. Bethesda Family Medcine ResidencyProgram, Cincinnati, OH

PURPOSE: To assess the risk factors for stroke (CVA) in patientsundergoing coronary artery bypass graft surgery(CABG).

METHODS: We conducted a nested case-control study from anine-year, prospective hospitalization cohort (N�6245). Data were col-lected on 225 variables prospectively during admission. Inclusion in thecohort included CABG between 10/93 and 6/02. Exclusion criteriaincluded any other simultaneously performed surgery. Patients werefollowed for thirty days after surgery. Cases were defined as patients whounderwent CABG and had a CVA, (171 cases, 2.7% of total), and controlswere patients who underwent CABG without a CVA. Cases were matchedto controls 1:3 (513 controls). The thirty-eight predictor variables werepump time, body surface area, creatinine, previous PTCA, clamp time,coronary perfusion time, previous cardiac surgeries, hypertension, race,gender, prior myocardial infarction, family history of coronary disease,cerebrovascular disease history, pre-operative neurologic disease, pulmo-nary hypertension, aortic disease, previous intervention in 30 days, anginahistory, bleeding history, prior vascular surgery, diabetes, age, myocardialfindings, chronic obstructive pulmonary disease, New York Heart Associ-ation functional class, prior gastrointestinal disease, current vasculardisease, systemic diseases, vessels at last PTCA, PTCA result, current

smoking, tobacco history, dialysis, current anticoagulants, character ofoperation, left ventricular hypertrophy, hypercholesterolemia, and chroniccorticosteroids.

RESULTS: There were fifteen significant predictors of stroke. Twelveof the variables correlated significantly with one of three final predictorvariables. We conducted logistic regression analysis to assess the risk foreach significant predictor: age greater than seventy (RR 4.61, 95%CI2.84-6.07), worse pre-op neurological status (RR 4.24, 95%CI 2.02-5.79),and previous cardiac surgery (RR 1.75, 95%CI 1.05-2.91).

CONCLUSIONS: In patients undergoing CABG the significant pre-dictors for stroke, in order of risk are age greater than seventy, then worsepre-operative neurological status, followed by previous cardiac surgery.

CLINICAL IMPLICATIONS: Patients considering CABG surgerywith these risk factors need to be counseled as to their individual risk ofCVA. A patient with all three risk factors would possess a 25% chance ofCVA folowing CABG surgery.

DISCLOSURE: S.E. Woods, None.

PREOPERATIVE PHYSIOLOGIC STATUS DETERMINES OUT-COME IN NON-EMERGENT AORTIC INJURY REPAIRJeff M. Apple, MD*; Neelan Doolabh, MD; Don Kohan, MD; BrianEastridge, MD, FACS; Michael Wait, MD, FACS. UT SouthwesternMedical Center, Dallas, TX

PURPOSE: To determine factors which affect outcome of blunt aorticinjury repair in the nonemergent setting. Our hypothesis was thatoutcome after non-emergent aortic injury repair is determined more bypreoperative physiologic status than time to repair, associated injuries anddelaying factors.

METHODS: Retrospective review of all aortic injury patients atParkland Memorial Hospital who arrived to the emergency room withvital signs from 1989-2001 and who underwent non-emergent aorticrepair. Preoperative physiologic parameters, including base deficit andp02/FIO2 ratio (PFR), were recorded prior to undergoing operation. Theeffect of ISS, time from injury to repair, and delaying factors wereanalyzed. Postoperative morbidity, mortality and ventilator dependencewere the major end-points. Statistical analysis was performed usingStudent’s t test and Chi square analysis.

RESULTS: We identified 65 patients who underwent attemptednon-emergent aortic repair. There were seven deaths (10.8%), fivepostoperative and two intraoperative. ISS in survivors was 39 �/-10.0versus 42 �/-13.1 in nonsurvivors (p�.39). PFR in survivors was 429�/-163.5 versus 197 �/-109.9 in nonsurvivors (p��.01). Preoperativebase deficit in survivors was 2�/-5.1 versus 6 �/- 2.7 in nonsurvivors(p�.05). Eighteen patients met criteria for postoperative ventilatordependence. Preoperative PFR in those patients without postoperativeventilator dependence was 451�/-183.5 versus 335 �/-107.8 in those withpostoperative ventilator dependence (p�.01). There was no significantdifference in mortality in the early and late repair groups or in thospatients with and without delaying factors prior to operation.

CONCLUSIONS: Preoperative physiologic status is more important indetermining outcome than injury severity score, delaying factors andtiming of repair. Low preoperative PFR may predict postoperativeventilatory dependence.

CLINICAL IMPLICATIONS: Preoperative correction of base deficitand PFR may assist in optimizing outcomes in patients undergoingnon-emergent aortic repair and help determine proper timing of thora-cotomy.

DISCLOSURE: J.M. Apple, None.

ROLE OF POSTOPERATIVE VASOPRESSOR USE IN OCCUR-RENCE OF ATRIAL FIBRILLATION AFTER CARDIAC SUR-GERYVikrant Salaria, MD; Nirav J. Mehta, MD; Syed Abdul-Aziz, MD; Syed M.Mohiuddin, MD, FCCP; Ijaz A. Khan, MD, FCCP*. Creighton UniversitySchool of Medicine, Omaha, NE

PURPOSE: Atrial fibrillation is common after cardiac surgery andresults in prolonged hospitalization. The purpose of this study was toevaluate the role of postoperative vasopressor use as a predictor ofpostoperative atrial fibrillation.




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METHODS: Study population consisted of 199 patients who un-derwent cardiac surgeries. The patients were divided in two groupsand compared based on whether or not they had received vasopressoragents postoperatively. The baseline and clinical variables were ana-lyzed as the possible predictors of postoperative atrial fibrillation usingthe multivariate stepwise logistic regression analysis and the Coxregression analysis.

RESULTS: Postoperative atrial fibrillation occurred in 49 of the 127patients (39%) with vasopressor use and 10 of the 72 patients (14%)without vasopressor use (p�0.01). By univariate analysis, vasopressor use,left ventricular hypertrophy, type of surgery, diabetes, advanced age, leftatrial diameter, and cross clamp time were predictors of development ofpostoperative atrial fibrillation. In multivariate logistic regression analysis,use of vasopressor agents was an independent predictor of postoperativeatrial fibrillation (odds ratio 3.35, 95% CI 1.38-8.12, p�0.016). The otherindependent predictors of postoperative atrial fibrillation were valvesurgery (odds ratio 2.88, 95% CI 1.31-6.35, p�0.002) and advanced age(odds ratio 10.73, 95% CI 10.37-11.10, p�0.0001). By Cox regressionanalysis, vasopressor use, valve surgery, advanced age, and ventricularpacing were predictors of time to atrial fibrillation. Among variousvasopressor drugs, use of those with predominantly beta-adrenergicaffinity was associated with higher incidence of postoperative atrialfibrillation (dopamine 44%, dobutamine 41% vs. phenylepherine 20%,p�0.001).

CONCLUSIONS: Cardiac surgery patients who receive vasopres-sors postoperatively are more likely to develop postoperative atrialfibrillation, and vasopressor use is an independent predictor of atrialfibrillation.

CLINICAL IMPLICATIONS: Judicious postoperative use of vaso-pressors may reduce the incidence of atrial fibrillation after cardiacsurgery.

Variables in the Final Logistic Regression Model

Variables B P valueOddsRatio

95% ConfidenceInterval

Vasopressor use -1.094 0.016 3.35 1.38-8.12Valve surgery -1.245 0.002 2.88 1.31-6.35Age 0.070 0.0001 10.73 10.37-11.10

DISCLOSURE: I.A. Khan, None.

PHRENIC NERVE PARALYSIS AFTER OPEN-HEART SUR-GERY: ROLE OF DIAPHRAGM PLICATIONShabir Bhimji, MD*; Khavar J. Dar, MD, FACP, FCCP. Teaching,Cardiac Surgical, Odessa, TX

PURPOSE: Phrenic nerve injury is a rare complication after open-heart surgery in the pediatric population. The injury is more prevalentafter repeat open-heart procedures. We evaluate our data on phrenicnerve injury and the role of diaphragmatic plication in infants.

METHODS: Charts of 450 infants who underwent open-heart surgerywere reviewed. Of these, 56 were undergoing repeat open-heart surgery.Eight infants had phrenic nerve paralysis after open-heart surgery. Exceptfor two infants, all were dependent on the ventilator and had failedextubation. All had unilateral paralysis of the diaphragm. Phrenic nerveparalysis was initially detected on chest x-ray and confirmed by fluoros-copy and/or ultrasound. The two infants not on the ventilator hadsymptoms of fatigue and dyspnea on exertion. Lung function was subjec-tively evaluated as the ability to come off the ventilator. After failingweaning off the ventilator twice in 2 weeks, the infants underwentdiaphragm plication

RESULTS: After diaphragmatic plication, there was no operativemortality. All children were weaned off the ventilator within 4-7 days.There have been no late deaths. Four of the eight children over a periodof 4 years have recovered phrenic nerve action as assessed by ultrasound.The two symptomatic infants who did not undergo diaphragmatic plica-tion after phrenic nerve paralysis significantly improved with no moredyspnea.

CONCLUSION: Diaphragmatic plication may be required in mechan-ically ventilated infants with prior phrenic nerve injury. It offers asignificant benefit to infants with diaphragmatic paralysis and should bedone earlier in order to facilitate weaning from mechanical ventilation.

CLINICAL IMPLICATION: Infants requiring mechanical ventila-tion following phrenic nerve injury may require diaphragmatic plication,whereas extubated infants can be managed conservatively.

DISCLOSURE: S. Bhimji, None.

POST CABG ORAL AMIODARONE PROPHYLAXIS SIGNIFI-CANTLY REDUCED OVERALL HOSPITAL COSTS ANDLENGTH OF STAYRobert A. Luke, MD, FACC, FACP*; Susan Muench, RN. Pee DeeCardiology Assoc, PA / McLeod Regional Medical Center, Florence, SC

PURPOSE: Atrial fibrillation (AF) is a significant healthcare issue andcan be particularly bothersome in the post coronary artery bypass graft(CABG) period leading to increased patient morbidity and increasedhospital costs. In an effort to address this issue and to standardizemedication administration practices, a set of post CABG atrial fibrillationoral amiodarone orders were developed.

METHODS: Patients received a total of 600 mg of amiodarone dailyfor a maximum of five days or until patient discharge with the first doseadministered via NGT before leaving the operating room. The orderbecame effective fiscal year 2000 (FY00).

RESULTS: At least 83% of eligible patients have received the amio-darone prophylaxis since its institution. The atrial fibrillation incidenceprior to the protocol initiation in fiscal years 1998 and 1999 was 25.9% and23.4% respectively. The table illustrates the statistically significant re-sponse in both the average length of stay and dollar cost of thehospitalization.

CONCLUSIONS/CLINICAL IMPLICATIONS: These data demon-strate that a standardized oral amiodarone regimen administered in thepostoperative period can statistically significantly reduce overall hospitalcosts and patients’ length of stay.

TABLE:DIFFERENCES BETWEEN CABG PATIENTS WITH ANDWITHOUT ATRIAL FIBRILLATION

FY

% of PT’swith atrialfibrillation

Averageincreased

length of staywith AF(Days)

Averageincreased

cost of staywith AF ($)

P valuefor both

parameterscomparedto non-AF

CABGpatients

2000 9.7 2.1 3223. �.0012001 7.5 3.2 5060. �.0012002 12.5 1.9 5149. �.001

DISCLOSURE: R.A. Luke, None.

PRELIMINARY CLINCAL RESULTS OF CELL PATCH CARDIO-MYOPLASTYSyde A. Taheri, MD*; Hashmat Ashraf, MD; Michael Merhige, Co-Author; Alan Litwin, Co-Author; Kishore Divan, Co-Author; Qiang Zhao,Co-Author. KALEIDA HEALTH, Clarence, NY

OBJECTIVES: Loss of myocytes as a result of coronary arteryocclusion is a major effect in the genesis of cardiac failure. Laboratoryresults of experimental cell patch cardiomyoplasty and omentopexy showregeneration, viability, synchronous contraction and migration of stemcells into infarcted myocardium. These encouraging results prompted usto use autologous cell patch cardiomyoplasty and omentopexy duringcoronary bypass on 13 patients (NYHA-II, III); 11 male, 2 female. Therehas been no mortality or morbidities. All patients had improved ejectionfraction PET scanning and CT angiography revealed viable transplanted




tissue and new angiogenesis from greater omentum into myocardium.Average Age 65 years

METHOD: Following coronary bypass, the upper abdomen was openvia midline incision to expose and tailor the greater omentum to reach themediastinum. Six pieces of rectus muscle measuring 1 1⁄2 x 1 1⁄2 x 2 cmobtained, applied and sutured to dyskinetic ventricular wall, reinforced bysuturing the greater omentum over the muscle patches to the myocar-dium.

RESULTS: All had increased daily activities free from chest pain andwork capacity showed marked improvement with exercise testing. Indi-vidualized follow-up illustrates evidence of synchronous contraction of cellpatches, higher ejection fraction, and improved perfusion with viability ingrafted scar tissue proven by positron emission tomography (PET) and CTangiography.

CONCLUSION: Cell patch Cardiomyoplasty and omentopexy inconjunction with coronary bypass seems to limit fraction remodeling ofthe left ventricle, increase ejection fraction and improve contraction ofdyskinetic ventricular wall. It has revealed viable regenerated muscle withincreased perfusion, which is determined by PET scanning.

CLINICAL IMPLICATIONS: Due to encouraging results fromsegmental treatment of dyskinetic myocardium, cell patch cardiomyo-plasty may have value for surgical treatment of global cardiomyopathy.

DISCLOSURE: S.A. Taheri, None.

SEQUENTIAL EVALUATIONS OF LUNG FUNCTION PRIOR TOAND AFTER OCCLUSION OF ATRIAL SEPTAL DEFECT (ASD)BY AMPLATZ TECHNIQUEJan Sulc, MD*; Petr Tax, Kardiocentrum; Oleg Reich, Kardiocentrum; JanMarek, Kardiocentrum; Jan Skovranek, Kardiocentrum; Vaclav Cha-loupecky, Kardiocentrum; Helena Bartakova, Kardiocentrum; ViktorTomek, Kardiocentrum; Bohumil Hucin, Kardiocentrum. University Hos-pital Motol, Prague, Czech Republic

Pulmonary hemodynamics of native ASD might influence rest pulmo-nary function. A development of pulmonary function after non-invasivecorrection of ASD in identical subjects has not been yet studied.

Forty four children have been studied prior to closure of ASD byAmplatz technique (at the age of 10.7� 4.7; median 9.4 years). Thirty nineof those (identical) subjects have been also studied early after correction(i.e., at the age of 11.0� 4.7; median 9.5 years). Twenty six of them havebeen also studied 1.1� 0.1; median 1.1 years after correction again. Thesame protocol including lung volume (body plethysmography), lungelasticity and airway patency measurements has been used during thewhole study.

Results (mean value of % predicted�SD)

1st study * 2nd study 3rd study P value

Total lung capacity(TLC)

101�18 106�13 103�13 **

Residual volume (RV)to TLC (RV/TLC)

124�38 116�36 122�43 NS

Lung recoil at 100%TLC (Pst100)

118�23 125�29 120�23 NS

Specific airwayconductance (sGaw)

73�28 77�30 85�42 NS

Maximum expiratory flowat 25% VC/TLC

116�42 109�34 113�37 NS

* the first study has been performed prior to ASD correction** P�0.05 between 1st and 2nd studyIn conclusion, normal lung size without any significant airway patency

deviations have been found within all three measurements. Slightly higherlung elasticity with mild static hyperinflation has been persisting withoutchanges despite corrective event. Further measurement long-term afterASD closure could confirm such a favourable PFT development.

DISCLOSURE: J. Sulc, None.

DOES COMBINATION OF IPRATROPIUM BROMIDE AND AL-BUTEROL INCREASE DETECTION OF BRONCHODILATORRESPONSE IN PATIENTS WITH CHRONIC OBSTRUCTIVEAIRWAY DISEASE (COPD)?Lakshmipriya Kasirajan, MD*; K Gupta, MD; D Malli, MD; S Dhar, MD.Coney Island Hospital, Brooklyn, NY

PURPOSE: Reversibility with bronchodilator treatment in pulmonaryfunction testing is used to identify patients who may respond to ste-roids.About 30% of patients with COPD show reversibility when testedwith bronchodilators in PFT. We wanted to study if any additionalbronchodilator effect was seen when ipratropium was combined withalbuterol.

METHOD: 21 patients with clinical diagnosis of COPD were chosen-.The average FEV1 was 1.08�0.45.On day1 spirometry was performedbefore and 30 minutes after albuterol nebulisation(2.5g/3ml(0.083%)).Onday 7 spirometry was performed before and 30 minutes after treatmentwith combination of same dose of albuterol and ipratropium bromide(0.5g/2.5 ml (0.02%)).

RESULTS: A total of 10(47%)patients showed significant (�12% andat least 200 ml) bronchodilator response with either of the regimens.(p�.01). 4 patients (19% of the study group) showed significant broncho-dilator response to the combination alone without any significant responsewhen just albuterol was used. 1 patient showed significant bronchodilatorresponse with albuterol and failed to demonstrate bronchodilator re-sponse with the combination of atrovent and albuterol. 5 patients showedsignificant bronchodilator response to both regimens.

CONCLUSION: Use of atrovent and albuterol combination for assess-ing reversibility in PFT for COPD patients does increase the detection ofbronchodilator response.

CLINICAL IMPLICATION: There is benefit of adding ipratropiumto albuterol in testing for reversibility in pulmonary function in patientswith COPD, as it may help in unmasking bronchodilator response in somepatients,therby facilitating optimal treatment.

DISCLOSURE: L. Kasirajan, None.



Clinical Application of PFTs12:30 PM - 2:00 PM


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PULMONARY DYSFUNCTION IN TYPE 2 DIABETES MELLI-TUS PATIENTS WITH INCIPIENT DIABETIC NEPHROPATHYAND EFFECT OF GLYCEMIC CONTROL AND LOSARTANTHERAPY ON PULMONARY FUNCTIONBhavneesh Sharma, Resident in Internal Medicine*; Mradul K. Daga,Professor in Internal Medicine; Nitin Tiwari, Resident in Internal Med-icine; Manisha Kaushik, Resident in Pulmonary Medicine. Maulana AzadMedical College, New Delhi, India

PURPOSE: ’Diabetic pulmonopathy’ has been described in type 2diabetes patients though not well characterized. The present study wasdone to study the effect of type 2 diabetes on pulmonary function tests(PFTs), to find the influence of glycemic control and disease duration onPFTs and to see the effect of glycemic control and losartan therapy onPFTs.

METHODS: Thirty type 2 diabetes patients with disease duration �10years with microalbuminuria were selected. Group 1: 15 patients kept onstrict glycemic control, group 2: 15 patients on losartan 50 mg/day alongwith strict glycemic control. Spirometry, blood sugar, HbA1C and mi-croalbuminuria were measured at baseline and 12 weeks of treatment.

RESULTS: PFT parameters like FVC, FEV1, TLC, FEV1/FVC,FEF75, PEFR and DLCO were significantly decreased in diabeticscompared to controls (p�0.001). A significant correlation was foundbetween the duration of diabetes and these PFT parameters (p�0.001).HbA1C levels also correlated significantly with FEV1, FEF75, PEFR, FVCand TLC (p�0.01) and with DLCO (p�0.004). There was significantimprovement in FEV1/FVC in group 1 diabetics after 12 weeks of strictglycemic control (p�0.04) but no improvement in other PFT parameters.In group 2 diabetics, there was significant improvement in FEV1(p�0.04), TLC (p�0.02) but no improvement in other PFT parametersafter losartan therapy.

CONCLUSIONS: A mixed restrictive-obstructive pattern of pulmo-nary dysfunction is seen in patients with type 2 diabetes which is moresevere in longer duration of disease and poor glycemic control. Strictglycemic control over 12 weeks is not sufficient to improve this pulmonarydysfunction. Losartan with strict glycemic control does not improvepulmonary function.

CLINICAL IMPLICATIONS: Pulmonary dysfunction should beregarded as a specific derangement induced by diabetes mellitus. Furtherstudies may clarify whether this should be included as a long termcomplication of diabetes. The role of strict glycemic control and losartantherapy on pulmonary function in diabetics with incipient nephropathy isanother interesting aspect and needs further studies.


TECHNETIUM 99M TC-DTPA CLEARANCE AS A PREDICTOROF PULMONARY INVOLVEMENT IN ASYMPTOMATICADULTS WITH SICKLE CELL DISEASE: A PRELIMINARYREPORTBabatunde O. Onadeko, MD*. Kuwait University, Safat, Kuwait

PURPOSE: There is increasing incidence of chronic sickle cell lungdisease as survival into adulthood becomes more frequent in patients withsickle cell disease(SCD).Early detection is therefore imperative to permitprompt intervention.99m Tc-DTPA aerosol scintigraphy is a sensitivenon-invasive test of membrane permeability,which has been applied toassess degree of lung affection in diabetic patients and to predict diseaseprogression in fibrosing alveolitis.We ecided to evaluate pulmonaryinvolvement in SCD ,which is common in Kuwait,using DTPA clearance.

METHODS: Adults asymptomatic and nonsmoking SCD patients,withnormal chest radiograph,attending the Hematlogy clinic,Mubarak hospitalwere enrolled for the study.Relevant clinical and hematological param-eters,and pulmonary function tests were obtained.Tc-DTPA studies wereperformed using 35 mci,delivered through a nebuliser.Activity generat-ed(t 1/2value)was determined.Values higher than 60 � or - 4 minuteswere taken as abnormal,using the normal values established for Kuwait.

RESULTS: 27 patients(15 SS,12 SBthal) aged between 16 and 45years,consisting of 10 males and 17 females,completed the study.DTPAclearance was delayed in 18(66.7%) of the 27 patients,while the trasferfactor for carbon monoxide(TLCO)was decreased in only 7(26%)of thecases.Forced vital capacity(FVC) value was similarly decreased in

9(29%).12 of the patients who had normal TLCO value had delayedDTPA clearance.DTPA was also delayed in 10(37%) of the cases withnormal FVC value.There was a significant difference in the DTPAclearance betwwen SS and SBthal patients,(p�0.05)There was a positivecorrelation between DTPA and FVC(r�0.435,p�0.05) but not withTLCO.

CONCLUSIONS: This study revealed that DTPA clearance wasdelayed in the majority of patients,suggesting an early lung involvement-.DTPA clearance appears to be more sensitive than pulmonary functiontests in detecting pulmonary involvement in SCD.

CLINICAL IMPLICATIONS: It is apparent that SCD patients withnormal pulmonary function tests may not be entirely free of lunginvolvement.

DISCLOSURE: B.O. Onadeko, None.

COMPARATIVE EVALUATION OF LATE POSTOPERATIVE EF-FECTS ON RESPIRATORY MECHANICS PARAMETERS BE-TWEEN LAPAROSCOPIC AND OPEN CHOLECYSTECTOMYGeorge D. Bablekos, MD*; Trianthi Roussou, MD; Stylianos A.Michaelides, MD, FCCP; Torben R. Rasmussen, MD, PhD; MarkosTsakopoulos, MD, PhD; Konstantinos Charalabopoulos, MD, PhD. Dept.of Experimental Physiology, School of Medicine, University of Athens,Athens, Greece

PURPOSE: To evaluate and compare late postoperative alterations inrespiratory mechanics associated with the laparascopic and open surgicaltechnique for gall bladder removal.

METHODS: We studied 28 patients without active cardiac or pulmo-nary disease of which 18, aged 52.6 � 12.2 yrs (mean �SD) werescheduled to undergo laparoscopic cholecystectomy(LC) while the rest10, aged 54.8 � 9.2 yrs (mean � SD) were scheduled to undergo opencholecystectomy (OC). In both groups the same anesthetic protocol wasused and analgesia was not prescribed on the days when lung functionmeasurements were made. We used the Medgraphics body plethesmog-raphy system 1085D to record total lung capacity (TLC), residual volume(RV) and its ratio to TLC (RV/TLC), functional residual capacity (FRC),forced expiratory volume in 1 second (FEV1) and airways resistance(Raw). These parameters were recorded preoperatively, on the 2nd and 8th

postoperative day. For the purpose of this study evaluations and compar-isons were made between preoperative values and values of the 8th

postoperative day. Statistical analysis used the t-test for paired observa-tions.

RESULTS: Lung function parameters measured preopperatively andon the 8th postoperative day are shown in Table 1 for the laparoscopiccholecystectomy (LC) group and in Table 2 for the open cholecystectomy(OC) group.

CONCLUSIONS: By the 8th postoperative day there seemed to be asustained increase in residual volume and airway resistance only in thelaparoscopic colecystectomy group possibly attributable to a sustainedthoracoabdominal movement derangement caused by CO2 insufflationused in this technique.

CLINICAL IMPLICATIONS: Laparoscopic surgery may incurgreater postoperative compromise in respiratory function in patients withobstructive lung disease prolonging recovery and contributing to postop-erative respiratory complications.

Table 1: LC Group, Mean Values (� SD)

Variables Preoperatively 8th postop. day Significance

TLC (L) 5.03 � 0.7 5.1 � 0.9 NS (p�0.769)RV (L) 1.9 � 0.4 2.2 � 0.8 NS (p�0.210)RV/TLC(%) 36.6 � 10.6 42.3 � 13.2 mean increase by

23.3 � 10.5%9(p�0.05)FRC (L) 2.9 � 0.3 3.2 � 0.7 mean increase by

10.9 � 6.1% (p�0.10)FEV1 (L) 2.4 � 0.6 2.3 � 0.6 NS (p�0.1)Raw (% pred.) 85.3 � 20.1 101.4 � 34.2 mean increase by

16.64 � 7.4% (p�0.05)


Clinical Application of PFTs, continued


Table 2: OC Group, mean values (� SD)

Variables Preoperatively 8th postop. day Significance

TLC (L) 5.9 � 1.3 5.5 � 1.1 NS � (p�0.162)RV (L) 2.3 � 0.7 2.1 � 0.9 NS � (p�0.465)RV/TLC% 39.0 � 6.6 38.4 � 13.7 NS � (p�0.882)FRC (L) 3.4 � 0.9 3.5 � 0.6 NS � (p�0.874)FEV1 (L) 2.6 � 0.6 2.3 � 0.5 mean decrease by

9.7 � 3.7% (p�0.05)Raw (%predicted) 119.8 � 65.3 123.3 � 45.9 NS � (p�0.930)

DISCLOSURE: G.D. Bablekos, None.

DECLINE IN VITAL CAPACITY (VC) AND THE RISK FORPOSTOPERATIVE PULMONARY COMPLICATIONS (PPC’S) AF-TER ABDOMINAL SURGERY (AS) FOR NON-MALIGNANT GY-NECOLOGIC DISORDERS (N-MGD)Stephen Pappachen, MD; Peter R. Smith, MD FCCP; Siddharth Shah,MD*; Veronica Brito, MD; Fayez Bader, MD; Bhaskar Sahay, MD; KetanJani, MD; Michael Bergman, MD FCCP; David Gal, MD. Long IslandCollege Hospital, Brooklyn, NY

PURPOSE: Reduction in lung volumes after AS promotes PPCs(atelectasis and pneumonia). We studied the effect of incentive spirome-try (IS) vs. deep breathing exercises (DBE) on reducing the decline in VCin patients (Pts) undergoing elective lower AS (LAS) for N-MGD.

METHODS: Pts 18 yrs. and older were randomized to IS or DBE.Slow VC was recorded (Ohmeda 5410, Englewood CO) and Pts weretaught IS (Coach 2, DHD Healthcare, Wampsville, NY) or DBE in thepreop holding area. Postoperatively, Pts were asked to perform IS or DBE10 times hourly while awake. VC, occurrence of PPCs, and pain scoreswere recorded daily by an investigator blind to IS/DBE assignment. Datawere analyzed by a repeated measures multivariate analysis of variancemodel, and correlation analysis. P�.05 was the level of significance for allanalyses.

RESULTS: PPCs occurred in 4/119 Pts (3.4%), 2/62 (3.2%) in IS, 2/57(3.5%) in DBE. Mean VC fell 28% by postop day #1 (POD-1) in IS(n�42), and 22% in DBE (n�38). VC increased 16% and 4% in IS andDBE respectively from POD-1 to POD-2 (p�.02 for IS vs DBE).Changes in VC did not correlate with pain scores in either group.

CONCLUSIONS: VC fell significantly in Pts undergoing LAS forN-MGD, but PPCs were infrequent. Decline in VC did not correlate withpain score and is likely due to reflex inhibition of diaphragmatic function.IS may be more effective than DBE in restoring VC to preop levels.

CLINICAL IMPLICATIONS: The effect of LAS on lung volumes isconsiderable but the clinical impact (PPCs) is modest. IS may be moreeffective than DBE for performing sustained maximal inspiratory maneu-vers postoperatively.

DISCLOSURE: S. Shah, None.

COMPLIANCE WITH SUSTAINED MAXIMAL INSPIRATORYMANEUVERS (SMIM) WAS NOT DIFFERENT AMONGST PA-TIENTS (PTS) PERFORMING INCENTIVE SPIROMETRY (IS)VS DEEP BREATHING EXERCISES (DBE) AFTER LOWERABDOMINAL SURGERY (LAS)Siddharth Shah, MD; Peter R. Smith, MD, FCCP; Veronica Brito, MD*;Stephen Pappachen, MD; Fayez Bader, MD; Bhaskar Sahay, MD; KetanJani, MD; David Gal, MD. Long Island College Hospital, New York, NY

PURPOSE: It is unclear whether IS offers any benefit compared withDBE for performing SMIM postoperatively. The physical presence of theIS has been suggested as a stimulus to foster compliance with SMIM sincehospital staff are generally not available to remind Pts to perform SMIMon an hourly basis. We evaluated compliance with IS vs DBE in Ptsundergoing LAS for non-malignant gynecologic disorders (N-MGD).

METHODS: Pts �18 yrs were randomized to IS (Coach 2, DHDHealthcare, Wampsville, NY) or DBE and taught the maneuvers in thepreop holding area. Postoperatively, Pts were asked to perform IS or DBE10 times hourly while awake. They received logs to record the numbers ofrepetitions performed on an hourly basis. The exercise index (EI) wasdefined as the actual number of SMIM performed divided by the maximalnumber possible during the postop hospitalization.

RESULTS: There were no differences in baseline characteristics (age,race, BMI, comorbidities, smoking history) in the 61 Pts in the IS groupand the 56 Pts in the DBE group. EI was 18.7% in the IS group and 18.8%in the DBE group.

CONCLUSIONS: Compliance with SMIM was similar in Pts perform-ing IS and DBE postoperatively after LAS for N-MGD.

CLINICAL IMPLICATIONS: Given appropriate instruction, Pts willperform SMIM with the same compliance using IS or DBE.

DISCLOSURE: V. Brito, None.

EFFECT OF LUNG RESECTION ON CO DIFFUSING CAPAC-ITY DURING EXERCISEJeng-shing Wang, MD,MSc,FCCP*. Pingtung Christian Hospital, Ping-tung, Taiwan, Republic of China

PURPOSE: The purpose of this prospective study is to predictpostoperative lung function and exercise capacity values including DLCOduring exercise, and to evaluate the effect of lung resection on lungfunction and exercise capacity values including DLCO during exerciseafter one year.

METHODS: Lung function including FEV1 and FVC, and exercisecapacity including maximal oxygen uptake (VO2max/kg) and maximalworkload (Wmax) were obtained by routine procedure. We used amodification of the single breath DLCO technique, the 3-equationmethod (3EQ-DLCO), to determine DLCO during rest and duringsteady state exercise at 70% of the maximal workload reached in aprogressive exercise test, and the increase in 3EQ-DLCO duringexercise, (70%-R)DLCO%, was determined. Calculation of the pre-dicted postoperative (ppo) variables were performed using preopera-tive testing data and the extent of resected bronchopulmonary seg-ments. All function variables were collected from 30 patients againafter lung resection.

RESULTS: The ppo values from the calculation were lower than butnot significantly different from actual postoperative values. Following lungresection, there was a more significant reduction in lung functionincluding FEV1, FVC, and DLCO (12%, 13%, and 22%) than that inexercise capacity including VO2max/kg and Wmax (2.1 ml/min/kg (orVO2max 8%) and 12watts (or 7%)). But the postoperative DLCO increaseduring exercise was not significantly decreased (2%).

CONCLUSIONS: This study confirms that postoperative lung func-tion were significantly decreased, but (70%-R)DLCO% was not signifi-cantly decreased.

CLINICAL IMPLICATIONS: exercise capacity, especially (70%-R)DLCO%, is more conservative and accurate for preoperative evaluationand postoperative prediction.

DISCLOSURE: J. Wang, None.

THE RELATIONSHIP BETWEEN DYSPNEA, EXERCISE TOL-ERANCE, AND QUALITY OF LIFE IN PATIENTS WITH MOD-ERATE TO SEVERE COPDRick Carter, PhD*. Georgia Southern University, Statesboro, GA

PURPOSE: To determine the impact of exercise training (ExTrain) ondyspnea and quality-of-life in patients with COPD.

METHODS: 125 patients with moderate to severe COPD (%Pred-FEV1 � 45.9 �12.5%) were evaluated before and after 16 weeks ofExTrain. Patient assessments included: pulmonary function; 6-minutewalk test (6MW), ramp cycle ergometry (CE) and arm ergometry (AE)with dyspnea measured using Borg scores, the Chronic RespiratoryDisease questionnaire (CRQ) and Shortness of Breath Questionnaire(SOBQ).

RESULTS: Following ExTrain, work performance was significantlyincreased for CE, AE and 6MW (p � .0001) without a correspondingchange in pulmonary function (p � .05). The mean improvement in CRQdyspnea was 7.00 � 5.76 (p � .0001) while the SOBQ was unchanged(p � .05). Other dimensions of the CRQ improved including: emotionalfunction (4.5 � 6.3, p � .0001); fatigue (4.1 � 4.1, p � .0001); mastery(3.1 � 3.5, p � .0001) and total CRQ score (20.0 � 15.9, p � .0001). Borgscores at peak exercise decreased for CE (–0.95 � 2.8 units, p �.003); AE(-0.8 � 2.6 units, p � .02) and 6MW (-0.5 � 2.3 units, p � .05) eventhough total work was increased. Borg scores for CE and AE at isotimealso demonstrated significant improvement: CE (– 1.4 � 2.0, p � .0001),AE (– 1.0 � 2.1, p � .0001).




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CONCLUSIONS: ExTrain in COPD patients improves upper & lowerextremity work performance and leads to a reduction in dyspnea andgeneral improvement in quality-of-life. There is a lack of correlationamong the instruments used suggesting that dyspnea needs to be assessedfrom different functionality perspectives. Further, studies are needed toclarify these differences.

CLINICAL IMPLICATIONS: ExTrain improves function, decreasesdyspnea and improves HRQOL thus, enabling COPD patients to functionbetter and cope with their disease.

DISCLOSURE: R. Carter, None.

OFFICE-BASED CARDIOPULMONARY EXERCISE TESTINGEMPOWERS MEDICAL DECISION MAKINGChristopher B. Cooper, MD*; James Sowash, MA; Michael Taylor, BS;Thomas W. Storer, PhD. University, David Geffen School of Medicine atUCLA, Los Angeles, CA

PURPOSE: Diagnostic cardiopulmonary exercise testing (DXT) iden-tifies pathophysiological limitations to exercise performance enablingappropriate medical management and therapeutic interventions. Avail-ability of compact, portable and reliable apparatus has made DXT morewidely available. We report 485 sequential tests performed in generalphysician offices by a network of skilled providers using centralized datamanagement and novel algorithms for physiological interpretation.

METHODS: The patients were 299 men and 186 women, mean age(SD) was 48 (11) years, height 1.73 (0.01) m, weight 90.9 (19.7) kg.Symptoms noted on referral included: chest discomfort 27%, exertionaldyspnea 16% and fatigue 3%. Identified risk factors were: obesity 45%,hypertension 34%, family history of coronary artery disease 21%, dyslip-idemia 27%, current smoking 17% and diabetes mellitus 6%.

RESULTS: Patients were assigned to one of four diagnostic categories:(A) cardiovascular impairment (CI) due to myocardial ischemia, majordysrhythmia or abnormal chronotropic index (fC/VO2), (B) ventilatorylimitation (VL) when VE was �85% predicted and within 15 L/min ofMVV, (C) both CI and VL, (D) neither CI nor VL.

CONCLUSIONS: The distribution of patients was as follows: A 14%,B 9%, C 2% and D 75%. Those in categories A, B and C (25%) warrantedfurther investigation or specialist referral. In category D, 177 (36%) hadphysical deconditioning without evidence of more concerning cardiovas-cular abnormalities. They were advised to have repeated testing in 6months and given a scientifically derived exercise prescription. Another135 (28%) had exaggerated hypertensive responses indicating suboptimalblood pressure control or risk of future hypertension and 148 (31%) hadfunctional impairment due to obesity.

CLINICAL IMPLICATIONS: Referring physicians were providedwith physiological interpretations for clinical correlation enabling them todecide about further investigation or specialist referral. This approach toexercise testing conveniently and cost-effectively identifies early cardio-vascular and pulmonary disease, distinguishes physical deconditioning inthe absence of more concerning abnormalities, facilitates exercise pre-scription and thus empowers general practitioners in their medicaldecision making.

DISCLOSURE: C.B. Cooper, Viasys Healthcare, Inc, Universitymonies.

A RANDOMIZED CONTROLLED TRIAL OF ROLLATORWALKERS COMPARED TO OXYGEN IN CHRONIC OBSTRUC-TIVE PULMONARY DISEASELisa Waldegger, BHSc, MSc (pending); Douglas McKim, BSc, MD,FRCP*; Ian McDowell, PhD. Hospital, The Ottawa Hospital, Ottawa,ON, Canada

PURPOSE: Despite limited research and large cost differences, rolla-tor-style walkers and oxygen are both used to improve the ability to walkin people with mildly hypoxemia (PO2 55 – 65 mmHg) and exertionaldesaturation. The purpose of this trial was to compare rollator-stylewalkers to oxygen on the six minute walk test.

METHODS: A single-blind randomized controlled crossover trial wasused to assess the endpoints of distance walked, oxygen saturation,perceived exertion, and speed on the six-minute walk test. Open- andclosed-ended questions were used to elicit the subject’s values andfeelings towards the interventions.

RESULTS: Eleven participants were recruited from a tertiary rehabil-itation centre from May to December 2001. The patients mean age (�

standard deviation) was 67.5 � 16.6 years, FEV1.0 (percent predicted) was26.1 � 6.8 %, and PaO2 was 61.2 � 2.3 mmHg. There were no significantperiod by treatment interactions, or period effects on any outcome. Therewas no significant difference between walkers and oxygen on distance orspeed walked, but oxygen outperformed walkers on final oxygen saturationand perceived exertion. The mean difference between interventions was22.2 (95% CI: –76.7 to �32.4) metres for distance, 7.8 (5.0 to 10.6)percent for oxygen saturation, 1.3 (95% CI 0.1 to2.4) points for exertionaldesaturation, and 0.2 (95% CI –0.13 to 0.08) metres per second for speed.Oxygen (51.2 (95% CI 18.6 to 84.0) metres), but not walkers (31.4 (95%CI –3.4 to 66.2) metres), improved distance walked compared to unas-sisted walks. Participants indicated that both interventions improved theirwalking but more preferred the walker.

CONCLUSIONS: Despite not correcting exertional desaturation orreducing perceived exertion, walkers still resulted in similar distancewalked compared to oxygen.

IMPLICATIONS: Walkers are lower cost and have potentially betterpatient acceptability when compared to oxygen in individuals with COPDand exertional desaturation.

DISCLOSURE: D. McKim, None.

THE EFFECT OF AGE AND GENDER ON EXHALED NITRICOXIDE (NO) AND CARBON MONOXIDE (CO) IN HEALTHYINDIVIDUALSJennifer M. Duncan, BA, BS*; Jackie Pyle, RN; Mohammad Taher, MD;Daniel Laskowski, RPFT; Raed A. Dweik, MD, FCCP. Cleveland ClinicFoundation, Cleveland, OH

INTRODUCTION: Analysis of gases in exhaled breath is a non-invasive tool that may be helpful in the diagnosis and monitoring of avariety of lung and systemic diseases. Exhaled NO and CO have shownparticular promise in this area. It has been suggested that individualcharacteristics other than the disease (like age and gender) may have aneffect on the levels of these gases in exhaled breath. Understanding theeffect of such variables is crucial to the study of these gases in variousdisease states.

PURPOSE: To examine if age and/or gender have any effect on theexhaled NO and CO levels in healthy individuals.

METHODS: We evaluated 59 NO and CO measurements in non-smoking individuals with no respiratory symptoms and no history of lungdisease. Exhaled gases were collected for off-line analysis according toAmerican Thoracic Society (ATS) recommendations. NO levels weremeasured by chemiluminescence. An infrared analyzer was used tomeasure CO levels.

RESULTS: There was no correlation between exhaled NO and age(R� 0.03, p�0.8). This was also true when the individuals were stratifiedby age (ANOVA p�0.06).

(ppb� parts per billion, ppm� parts per million)

AGE GROUP (yrs.) NNO Levels (ppb)Median (25%, 75%)

21-30 19 6.9 (6.4, 7.9)31-40 20 6.3 (4.7, 8.0)41-50 18 9.2 (6.4, 10.4)51-60 2 6.4 (4.8, 7.9)

The same was true for CO (ANOVA p�0.390).

AGE GROUP (yrs.) NCO Levels (ppm)Median (25%, 75%)

21-30 19 1.2 (0.9, 1.6)31-40 20 1.4 (1.1, 2.1)41-50 18 1.7 (0.9, 2.7)51-60 2 1.2 (0.5, 1.9)

Exhaled NO levels were similar in males and females but CO levelswere higher in males.




NO Levels (ppb)Median (25%,75%)

CO Levels (ppm)Median (25%,75%)

Male (n�37) 6.8 (5.6, 8.7) 1.6 (1.1,2.1)Female (n�22) 7.9 (6.6, 9.6) 1.0 (0.8,1.9)p (t-test) 0.08 0.03

CONCLUSION: Age has no significant effect on the levels of exhaledNO and CO in healthy individuals without lung disease. Males tend tohave higher CO levels than females.

CLINICAL IMPLICATIONS: This needs to be taken into consider-ation when selecting control groups to study various lung diseases.

DISCLOSURE: J.M. Duncan, None.

NONINVASIVE TISSUE OXYGENATION MEASUREMENTS ININTENSIVE CARE PATIENTS BY RESPIRATORY CARE PRAC-TITIONERSAlan J. Marks, RRT*; Herbert Patrick, MD, MSEE; Michael S. Sherman,MD. Hahnemann University Hospital - Tenet Healthcare Corporationand Drexel University College of Medicine, Division of Pulmonary andCritical Care Medicine, Philadelphia, PA

PURPOSE: To determine the practicality of tissue oxygen StO2measurements by Respiratory Care Practitioners (RCP’s) in critically illpatients.

METHODS: Each patient in the Medical Intensive Care Unit (ICU)had a daily StO2 measurement using the Hutchinson Technology Bi-oMeasurement Division’s InSpectra™ Tissue Spectrometer Model 325(Hutchinson, MN 55350-9784) coupled to a standard bedside computerby the InSpectra™ OptoLink™ RS-232 cable. Two point calibrations wereperformed daily during start-up using the InSpectra™ Calibrator. The25mm spacing InSpectra™ electrode was used within the standardInSpectra™ adhesive Shield. The Shield was left in place on the deltoidmuscle of each patient between measurements.

RESULTS: Calibrator signals were reproducible day to day. Therewere no skin reactions to either the adhesive Shield or to the electrode’snear infrared signal. The RCP’s had no difficulty obtaining StO2 mea-surements from the deltoid muscle of each patient and downloadingrealtime StO2 measurements to the computer.

CONCLUSIONS: 1. RCP’s can obtain StO2 measurements on criticalcare patients using the InSpectra™ Tissue Spectrometer and accessories;2. RCP’s can download realtime InSpectra™ StO2 measurements to acomputer’s serial data port for storage and analyses; 3. No adverse effectson ICU patients were noted from use of the InSpectra™ Tissue Spec-trometer and accessories.

CLINICAL IMPLICATIONS: The StO2 of the deltoid muscle is asensitive indicator of shock since StO2 predicts the balance between localoxygen delivery versus oxygen consumption. Both intermittent and con-tinuous noninvasive StO2 measurements of the deltoid muscle performedby RCP’s should enhance ICU patient care and outcomes without adverseutilization of resources.

DISCLOSURE: A.J. Marks, None.

EFFECTS OF EXERCISE AND PERIODIC ACCELERATION ONNITRIC OXIDE RELEASEMarvin A. Sackner, MD*; Emerance Gummels, MS; Jose A. Adams, MD.Mount Sinai Medical Center, Miami Beach, FL

PURPOSE: Nitric oxide donor drugs cause downward descent of thedicrotic notch (DN) of the digital pulse wave due to attenuation of wavereflection (Imhof et al: Eur.J. Clin Pharmacol. 1980;18:455). Increasedshear stress to endothelium causes endothelial nitric oxide synthase toproduce nitric oxide. DN was measured during active cycling whichincreases laminar shear stress, periodic acceleration that increases pulsa-tile shear stress and passive cycling that should not change shear stress.

METHODS: DN of photoelectric plethysmographic pulse was mea-sured by dividing (a) pulse amplitude by (b) height of dicrotic notch aboveend diastolic level. Heart rate (HR) was measured with ECG. 7 men and5 women performed the following for 3 min with 5 min baseline and

recovery times: 1) supine cycling at �250 (EX1) and �450 Kg-M/min(EX2); 2) supine periodic acceleration (pGz) applied with a motionplatform (Non-Invasive Monitoring Systems, North Bay Village, FL); 3)passive cycling at 1 Hz (n�9).

RESULTS: a/b ratios are expressed as peak values during period.*p�.001 Whitney Mann U test for differences between baseline and test.Baseline a/b during EX1 was 2.2 and test 16.9.* Baseline a/b during EX2was 2.4 and test 42.6.* Baseline a/b during pGz was 2.3 and test 28.0.* Inone instance during EX1, 4 instances during EX2, and 3 instances duringpGz, DN moved to upstroke of next pulse; here, a/b was assigned a valueof 100.

CONCLUSIONS: Dicrotic notch position is a simple, sensitive meansto demonstrate that nitric oxide is released from laminar or pulsatile shearstress to endothelium.

CLINICAL IMPLICATIONS: Since periodic acceleration producesfall of dicrotic notch equivalent to low intensity exercise, it can be utilizedto passively achieve the beneficial vasodilator and immunosuppressanteffects of exercise through increased release of small quantities of NOfrom activation of endothelial nitric oxide synthase.

DISCLOSURE: M.A. Sackner, Chairman, Board of Directors, Non-Invasive Monitoring Systems, Inc., shareholder, discussion of productresearch or unlabeled uses of product.

COPD12:30 PM - 2:00 PM

IMPROVED SMALL AIRWAY FUNCTION WITH FLUTICASONEPROPIONATE/SALMETEROL VERSUS IPRATROPIUM/ALBU-TEROL THERAPY IN PATIENTS WITH CHRONIC OBSTRUC-TIVE PULMONARY DISEASE (COPD)K Knobil, MD*; M Watkins, PharmD; K Merchant, PhD; A Emmett, MS;S Schweiker, BS; J Yates, BS. GlaxoSmithKline, Research Triangle Park,NC

PURPOSE: The patency of small airways is assessed by the forcedexpiratory flow (FEF25-75%), which is decreased in obstructive airways dueto mucus secretion, bronchospasm, inflammation, and alveolar destruc-tion. The purpose of this analysis was to determine the effect offluticasone propionate 250 mcg/salmeterol 50 mcg therapy (FSC 250/50)compared to ipratropium 36mcg/ albuterol 206mcg (Ipr/Alb) on the smallairways in patients with COPD.

METHODS: In this multicenter, double-blind, double-dummy study,361 patients with COPD were randomized to FSC 250/50 BID via theDiskus or Ipr/Alb QID via a metered-dose inhaler for 8 weeks. Thefunction of the small airways was investigated by measurement of theFEF25-75% at baseline and at 1, 4 and 8 weeks of therapy. Patients hadCOPD, an extensive smoking history (mean � 59 pack years) andimpaired lung function (mean FEV1 43% of predicted).

RESULTS:

Pre-dose FEF25-75% mL/secMean from Baseline (SE)

FSC 250/50(n � 179)

Ipr/Alb(n � 181) p-value

Week 1 44.5 (13.4) -9.7 (9.5) �0.001Week 4 43.4 (12.9) -3.7 (12.5) 0.007Week 8 55.0 (16.7) -6.6 (11.7) �0.001Endpoint 56.9 (16.0) -6.8 (10.9) �0.001

CONCLUSION: In patients with COPD, FSC 250/50 caused signifi-cant improvements in small airway function within the first week and wassustained with continued therapy.

CLINICAL IMPLICATIONS: In patients with COPD treatmentwith FSC250/50 demonstrated improvements in small airway function,suggesting that the prolonged improvements in lung function may be dueto the anti-inflammatory effects of the combination.

DISCLOSURE: K. Knobil, Employee of GSK, Industry; support:GlaxoSmithKline




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THE ASSOCIATION BETWEEN INHALED CORTICOSTEROIDUSE AND FRACTURES IN VETERANS WITH CHRONIC OB-STRUCTIVE PULMONARY DISEASETodd A. Lee, PharmD, PhD*; Brian Bartle, MPH; Jianglin Xu, MS;Kourtney J. Davis, PhD; Kevin B. Weiss, MD, MPH. Hines VA Hospital,Hines, IL

PURPOSE: Patients with chronic obstructive pulmonary disease(COPD) are increasingly treated with inhaled corticosteroids (ICS).However, because these patients have increased risk for fractures, it isimportant to determine if ICS use further increases their fracture risk.The objective was to characterize the association between ICS use andnon-vertebral fractures in veterans with COPD.

METHODS: Nested case-control study in cohort of Veterans Affairs(VA) patients with COPD. Patients included had a COPD diagnosisbetween October 1, 1998 and September 30, 1999 and used VA servicesin the preceding 12-month period but did not have a COPD diagnosis.Cases had non-vertebral fractures occurring between January 1, 1999 andSeptember 30, 2002. Controls were individually matched to cases (4:1) ondate of COPD diagnosis, age, and sex. ICS exposure was identifiedthrough prescription records and converted to beclomethasone equiva-lents. Fracture risk associated with ICS exposure was estimated usingconditional logistic regression and adjusted for potential confounders.

RESULTS: From an eligible cohort of 40,157 patients, 1708 cases and6817 matched controls were identified. Patients were 94% male andaverage age was 62.7 years. ICS exposure was 21.4% in cases and 22.1%in controls. Ever exposure to ICS during follow-up was not associated withan increased fracture risk (Adjusted OR�0.97; 95% CI, 0.84 – 1.11).However, fracture risk was impacted by recent use (�30 days prior) andaverage daily dose (Figure). The proportion of patients in the recent use,high dose category differed by ICS product.

CONCLUSIONS: After controlling for variables that affect fracturerisk and corticosteroid use, COPD patients currently using ICS at high

doses had a slight increase in the risk of non-vertebral fractures comparedto COPD patients that never used ICS.

CLINICAL IMPLICATIONS: Based on results from this observa-tional analysis, the small increase in fracture risk does not warrantstopping ICS treatment in COPD patients with improved lung function,symptoms and quality of life; however, the results suggest the lowesteffective ICS dose be used.

DISCLOSURE: T.A. Lee, GlaxoSmithKline, grant monies; Pfizer,grant monies; Boehringer-Ingelheim, grant monies.

INHALED CORTICOSTEROID USE AND RISK OF NON-VER-TEBRAL FRACTURE AMONG ADULTS WITH CHRONIC OB-STRUCTIVE LUNG DISEASE IN UK GENERAL PRACTICEKourtney J. Davis, PhD*; Douglas Clark, MBA; Katherine Knobil, MD.GlaxoSmithKline Research and Development, Research Triangle Park,NC

PURPOSE: To assess the risk of non-vertebral fracture associated withinhaled corticosteroid (ICS) use among older adults with diagnosedchronic obstructive pulmonary disease (COPD).

METHODS: We conducted a population-based case-control studynested within a cohort of all diagnosed COPD patients aged 50 to 85 yearsin the General Practice Research Database (GPRD) in the UK(n�48,294), during years 1987 to 2000. Cases (n�2808) were the firstnon-vertebral fractures to occur at least twelve months after COPDdiagnosis and matched to controls (n�8453) on age, sex, and generalpractice. Data on all drug prescriptions, COPD severity, and coexistingmedical conditions were obtained for the time between cohort entry andindex date. Average daily dose of ICS was calculated in beclomethasone(BDP) equivalents. Adjusted odds ratios and 95% confidence intervals(CI) were produced from conditional logistic regression models.

RESULTS: Adjusted risk of fracture was not associated with ever ICSuse relative to never use (OR �0.70, 95%CI: 0.61, 0.79). The fracture riskfor ICS use within 30 days prior to index date was increased relative tothose with no use in the year prior (OR �1.42, 95%CI: 1.23, 1.65).Current use of BDP (OR�1.46, 95%CI: 1.26, 1.69) or budesonide(OR�1.41, 95%CI: 1.10, 1.79), but not fluticasone propionate (FP) (OR�0.78, 95%CI: 0.55, 1.09), was associated with fracture. Risk of fracturedid not differ by ICS average daily dose (OR�1.39 vs. OR�1.32 for lowand high doses, respectively). Fracture risk increased with bronchodilatoruse in the prior year (OR�2.47, p�0.05, for 2 to 5 prescriptions versus�2).

CONCLUSIONS: The risk of non-vertebral fracture associated withICS use among COPD patients was limited to use of BDP or budesonidein the 90 days prior to index date. There was not consistent evidence of adose-response relationship between ICS use and risk of non-vertebralfracture

CLINICAL IMPLICATIONS: Recent use of ICS was associated withsmall increased risk of fracture in COPD patients, although risk was notelevated among FP users.

DISCLOSURE: K.J. Davis, GlaxoSmithKline.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE-RELATEDHOSPITALIZATION COSTS ASSOCIATED WITH INITIALMEDICATION REGIMENSRichard H. Stanford, PharmD, MS*; Craig Roberts, PharmD, MPA�;Trent McLaughlin, PhD�. �NDC Health, Phoenix, AZ; GlaxoSmith-Kline, Research Triangle Park, NC

PURPOSE: Hospitalizations comprise approximately 70% of the totalCOPD costs. Treatments that reduce the number of COPD relatedhospitalizations can lead to cost savings. The purpose of this analysis wasto compare COPD hospitalization costs of various treatments..

METHODS: Retrospective observational study of patients � 45 yearsenrolled in 24 different managed care plans across the United Statesduring 1997-2000 with a diagnosis of COPD (ICD-9-CM � 491.xx, 492.x,496.xx). Subjects were classified into one of five therapy cohorts 1)ipratropium/albuterol (IPR), 2) salmeterol (SAL), 3) inhaled corticoste-roid (ICS), 4) ICS � IPR and 5) ICS � SAL and followed for 12 months. Patients were excluded if they received cromolyn, theophylline, leuko-triene modifers or had a COPD related hospitalization 12-months prior totheir initial prescription. A two part regression model was used to compareCOPD-related hospitalization costs in the follow-up period, adjusting for


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age, gender, concomitant asthma, managed care plan, baseline oralsteroid, albuterol use and physician specialty.

RESULTS: 3616 patients were identified, 1754 on IPR, 1032 on ICS,357 on ICS � IPR, 266 on SAL and 207 on ICS � SAL. The adjustedCOPD related hospitalization rate was significantly lower for ICS � SAL(8.3%, p�0.01) and ICS (10.4%, p�0.01), lower for SAL (12.7%, p�0.01)and higher for ICS � IPR (17.5%, p�0.68), compared to IPR (16.6%).The adjusted mean per patient hospitalization costs were lowest for ICS($281 � 148) followed by ICS � SAL ($359 � 192) IPR ($509 � 260),SAL ($510 � 266) and ICS � IPR ($867 � 441).

CONCLUSION: Because of significantly lower hospitalization rates,ICS and ICS � SAL had lower COPD related hospitalization costscompared to IPR, SAL, or ICS � IPR. Even though ICS � SAL had thelowest hospitalization rate, costs were lowest for ICS, suggesting thatICS � SAL had more severe COPD.

CLINICAL IMPLICATIONS: ICS and ICS � SAL as initial therapymay lead to reduced COPD related hospitalization costs.

DISCLOSURE: R.H. Stanford, Employee of GlaxoSmithKline.

PUBLIC AWARENESS OF CHRONIC OBSTRUCTIVE PULMO-NARY DISEASESteven Kesten, MD, FCCP*; Janet Ulrich, BA; Dorothy Rich, MBA.Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT

PURPOSE: COPD is a common disease responsible for significantmorbidity and mortality. Public awareness or lack of awareness has thepotential to impact progress in decreasing the prevalence and societalburden of COPD. We sought to examine awareness of COPD in thecommunity and whether changes have occurred over the last four years.

METHODS: In order to track public awareness, questions on COPDwere included in a large phone survey among approximately 1,000 adultsin the United States during the same approximate weekend in August forfour consecutive years. The objective was to take annual measurements ofpublic awareness of COPD. Respondents indicated whether they had“heard of chronic obstructive pulmonary disease, or COPD” [claimedawareness] and whether they described COPD as a respiratory disease[true awareness].

RESULTS: The “claimed awareness” of COPD from 1999-2002according to gender and age are summarized in the table below (%represents affirmative response). In 2002, 17% of the total respondentswere able to describe COPD as a respiratory disease [true awareness].Awareness was higher in women and in the older age group. Amongsmokers, claimed and true awareness of COPD was 46% and 19%respectively; not significantly higher than among the general public.The claimed awareness of chronic bronchitis was 90% and of emphy-sema was 93%. However, the respective true awareness was 63% and72%.

Claimed Awareness of COPD

Year - Total Male Female 18-44 years 45� years1999 - 41% 38% 45% 39% 46%2000 - 37% 29% 43% 36% 37%2001 - 33% 27% 38% 27% 40%2002 - 42% 34% 49% 37% 48%

CONCLUSIONS: There is continued low public awareness of COPD.Furthermore, there appears to be no visible change in awareness in thepast four years.

CLINICAL IMPLICATIONS: The study confirms the need forenhanced public education about COPD.

DISCLOSURE: S. Kesten, employee of Boehringer-Ingelheim.

QUALITY OF LIFE (QOL) AFTER LUNG REDUCTION: A RAN-DOMIZED TRIALJohn D. Miller, MD, FCCP*; Anne Moore-Cox, CRA; RichardMalthaner, MD, FCCP; Lawrence Tan, MD FCCP; Jeremy Road, MD;The Canadian Lung Volume Reduction Surgery (CLVRS) Trial Group,Canada. SJH, Mc Master University, Hamilton, ON, Canada

PURPOSE: There is no cure for emphysema. Palliation of symptoms isthe focus of medical management. In 1995, lung volume reduction surgery(LVRS) was reintroduced as a surgical treatment for symptomatic patients

with emphysema and marked lung hyperinflation. Although improvedQOL is the primary objective of treatment, few surgical reports utilizespecific QOL measures. We present early results from the CLVR Trialwith a focus on several QOL outcomes at 3 and 6 months.

METHODS: Risk (surgical mortality and hospital length of stay) andQOL assessment (Chronic respiratory questionnaire (CRDQ), short form36 (SF-36), SF-36 Utility and quality adjusted life days(QALDs)) are theoutcomes presented from the CLVR trial comparing LVR surgery withrehabilitation and best medical therapy.

RESULTS: In the CLVR, 58 patients were randomized (30 surgical, 28medical). There were no 30-days postoperative deaths. The 6-monthmortality was 3.6% in the surgical arm and 5% in the medical arm. Medianlength of hospital stay was 22 days. Patients experienced clinicallyimportant and statistically significant improvements in each domain of theCRDQ at 3 and 6 months. Domains of physical functioning in SF-36 wereremarkably improved: Physical functioning improved by 25.9 (95%CI 14,37.5; p�0.001). SF-36 Utility also demonstrated an improvement at 3months 0.07, (p�0.08) and 0.10 (p�0.13) at 6 months. A gain of 16QALDs was achieved by 6 months.

CONCLUSIONS: LVR surgery requires a lengthy and often difficulthospitalization. Clinically important and statistically significant improve-ments in QOL are observed at three and six months following LVR.

CLINICAL IMPLICATIONS: LVRS, with disclosure of surgicalrisks, should be offered to all suitable patients with moderate to severeemphysema who seek palliation of their symptoms. We await longer termresults with interest.

DISCLOSURE: J.D. Miller, The Canadian Institute of Health Re-search, grant monies.

MEETING THE NEEDS OF PATIENTS WITH COPD: A MULTI-CENTER STUDYGraeme M. Rocker, MHSc, DM, FRCP, FRCPC*. QEII Health SciencesCentre, Halifax, NS, Canada

PURPOSE: Little is known about the needs of patients with COPD inthe last months of their lives. Our aim was to determine which aspects ofcare patients considered important and the extent of satisfaction withmanagement of these aspects.

METHODS: We enrolled hospitalized patients aged � 55 withbaseline FEV1 �0.75l in 5 Canadian centres. Patients were interviewedand responded (“not at all important” to “extremely important”) to 29questions in 6 domains: medical/nursing care; community care; commu-nication/decision making; social relationships/support; meaningful exis-tence and advance care planning. Additional questions addressed prog-nosis, CPR issues and preferred decision-making roles.

RESULTS: Of the 86 patients enrolled to date, 51.2% were female,80.2% were urban-dwelling, 93% were Caucasian and 43% lived alone.Mean (SD) age was 73 (7.4) years. Of 86 patients, 61.6% felt they werecurrently facing end of life issues. Quality of life was rated as poor(38.4%), fair (30.2%), good (17.4%) very good (4.7%) and excellent(3.5%). 49 patients (57%) wanted discussions with physicians about CPRbut only 27 (23%) had done so. The top two important aspects of carewere symptom relief and trust and confidence in the treating physician.Patients were most satisfied with nursing care and opportunities tostrengthen/maintain important relationships. The top 5 areas for improve-ment (high importance score but low satisfaction score) concerned: 1)receiving adequate information; 2) having an adequate plan for home careafter discharge; 3) not being a burden on family; 4) relief of symptoms; 5)availability of the physician for easily understood discussions. Patientspreferred shared decision-making regarding cardiopulmonary resuscita-tion.

CONCLUSIONS: Symptom relief, though most important was notwell addressed. Useful and understandable information was providedinfrequently, suboptimally, and failed to address care after hospitaldischarge.

CLINICAL IMPLICATIONS: To improve quality of end of life carefor patients with advanced COPD, physicians need to improve theircommunication, achieve better symptom relief, and provide patients withplans for care after hospital discharge.

DISCLOSURE: G.M. Rocker, none.


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HISPANIC PATIENTS WITH CHRONIC OBSTRUCTIVE PUL-MONARY DISEASE HAVE MORE PROBLEMS RECEIVING OP-TIMAL CARE COMPARED TO PATIENTS OF OTHER RACIALGROUPSAngela C. Hospenthal, MD*; Antonio Anzueto, MD; Gwen M. Baillar-geon, MS; Lewis E. Kazis, ScD; Jacqueline A. Pugh, MD; Sandra G.Adams, MD. UTHSCSA, San Antonio, TX

PURPOSE: The purpose of this study is to describe the perceiveddifferences in availability and quality of health care among Hispanics withchronic obstructive pulmonary disease (COPD) in comparison to otherracial groups.

METHODS: Responses to self-reported perception of health careavailability and quality from participants in the 1999 Veterans HealthAdministration Large Health Survey who had at least 1 visit with anICD-9 code for COPD were analyzed for variations among races. Subjectswithout a reported smoking history were excluded, leaving 89,485 indi-viduals in the analysis.

RESULTS: Eighty-seven percent (77,495) of participants categorizedthemselves as “white,” 9.1% (8,139) as “black,” and 2.7% (2,413) as“Hispanic.” The remaining percentage of the cross-section was comprisedof a variety of racial groups. Hispanics reported fewer cardiac comorbidi-ties (congestive heart failure, angina, myocardial infarction) but morepsychiatric comorbidities (depression, post-traumatic stress disorder,schizophrenia) than the whites or blacks. A greater number of Hispanicsdid not have a regular doctor (12%) and also did not know the next stepin their care plan (22.9%) compared to whites, 9% and 18.8%, respec-tively. Eleven percent of Hispanics reported problems receiving carecompared to only 8% of whites, and 9% of blacks. More Hispanics hadproblems obtaining referrals to a specialist, and also rated the overallquality of care they received in the previous 2 months as “poor” or “verypoor” more frequently (5.5%) than the white (3.7%) or black (3.4%)respondents.

CONCLUSIONS: Hispanics appeared to have less participation intheir care plan compared to other racial groups, and despite the entitle-ment of equal health care among VA beneficiaries, Hispanics perceiveddecreased availability and poorer quality of care compared to other races.

CLINICAL IMPLICATIONS: This disparity in the perception of theavailability and quality of care in Hispanics with COPD requires furtherstudy to identify whether this group is indeed receiving less optimal careor whether psychiatric illness or cultural differences impact on theirperception of care received.

DISCLOSURE: A.C. Hospenthal, None.

SERUM URIC ACID LEVELS AMONG PATIENTS WITHCHRONIC OBSTRUCTIVE PULMONARY DISEASEInocencio H. Lopez, Pulmonary Fellow-in-Training*. Teaching-Training,Philippine Heart Center, Division of Pulmonary and Critical CareMedicine, East Avenue, Quezon City, Philippines

PURPOSE: Elevated serum uric acid levels were observed in clinicalconditions associated with hypoxia such as heart failure, primary pulmo-nary hypertension and congenital heart disease with no report amongCOPD patients. Thus, this study was done to correlate uric acid withhypoxemia and disease severity, and to determine level of PaO2 predictiveof increased uric acid among COPD patients.

METHODS: Included are 110 diagnosed COPD patients according tothe GOLD criteria, grouped into stable (64) or unstable (46)COPDpatients. Simultaneous blood extractions for serum uric acid and ABGwere determined with patient in upright position. Correlation analyseswere used to determine association of different variables. Independentt-test and ANOVA were employed to determine association between uricacid with ABG, age and sex, and COPD severity respectively. To test forvalidity of PaO2 predictive of increased uric acid, validity measures werecomputed and receiver operator curves were constructed.

RESULTS: A high significant correlation was noted between hypox-emia and uric acid levels in both stable and unstable COPD patients (p0.05). Likewise, a direct relationship was noted between COPD severityand uric acid levels among stable COPD patients(p �0.001), i.e., thehigher the COPD severity, the higher the uric acid levels. The samerelationship was not seen among unstable COPD patients (p 0.070).Utilizing the receiver operator curve, a PaO2 of � 68 and 70 mmHg are

predictive of increased uric acid level in both stable and unstable COPDpatients.

CONCLUSION: There is a strong correlation between hypoxemia andCOPD severity with serum uric acid level among stable COPD patients.A PaO2 of �68 and 70 mmHg were predictive of increased uric acid inboth stable and unstable COPD patients respectively.

CLINICAL IMPLICATION: Elevated serum uric acid level mayserve as a non-invasive indicator for COPD severity and hypoxemia instable COPD patients.

DISCLOSURE: I.H. Lopez, None.

AIRWAY HYPERRESPONSIVENESS IN WOOD SMOKECHRONIC OBSTRUCTIVE PULMONARY DISEASEMauricio Gonzalez-Garcıa, MD, FCCP; Carlos Torres-Duque, MD*;Adriana Bustos, FT; Carol Pena, FT; Darıo Maldonado, MD, FCCP.Fundacion Neumologica Colombiana, Bogota, Colombia

PURPOSE: Wood smoke is a risk factor for COPD in Colombia. Tostudy its pathophysiology we determined the presence of bronchialhyperreactivity (BHR) to methacholine (MC) in women with wood smokeand cigarette COPD.

METHODS: The methacholine challenge test was done according toATS in 14 patients with stable wood smoke COPD and in 10 patients withstable cigarette COPD with FEV1 �50% (Crapo reference values).COPD was defined using ATS criteria. Spirometry was done with aV-MAX 29C (Sensormedics, Inc, Yorba Linda, CA) and MC challengewith a SM-IR dosimeter (Rosenthal). The Shapiro Wilk test was used toevaluate the normality of distributions of the variables. Parametricanalyses (Students�t-test) were used to compare group means. Values ofp�0.05 were considered significant.

RESULTS: There was no difference in the spirometric indices (FEV1and IC) or the severity of dyspnea before and after the methacholinechallenge test (maximal dose used) between the two groups. In all patientsthere was a � 20% decrease of the FEV1, a decrease of the IC and anincrease of the dyspnea score. However, there was a significant differencein the geometric mean of PC20 between the wood smoke COPD (0.26mg/dL) and the cigarette smoke COPD (1.24 mg/dL) (p: 0.036) (Table).

Wood smoke (n�14) Cigarette (n�10)Baseline Post MC Baseline Post MC

FEV1 % pred 64.3 � 10.2 46.8 � 9.8 64.3 � 10.2 43.6 � 5.4Fall FEV1 % -27.8 � 6.2 -28.1 � 5.2CI % pred 78.8 � 16.3 60.2 � 8.6 87.6 � 20.6 60.9 � 18.6Fall IC % -23.7 � 12.9 -30.6 � 12.9Dyspnea, Borg 0.58 � 0.9 2.17 � 1.8 0.6 � 0.6 2.35 � 2.1PC20 mg/dL* 0.26 (0.06-1.9)‡ 1.24 (0.34-9.39)

* Geometric mean and range. ‡ p: 0.036CONCLUSION: We found BHR in all patients but it was significantly

more severe in patients with wood smoke COPD suggesting that it mightbe an important physiopathologic feature in this group.

CLINICAL IMPLICATIONS: The significant degree of BHR in thegroup with wood smoke COPD may suggest a determinant role of aninflammatory mechanism and the possibility of a response to steroidsadministration (systemic or inhaled) that should be determined in futurestudies.

DISCLOSURE: C. Torres-Duque, None.

PULMONARY FUNCTION, RESPIRATORY MUSCLESTRENGTH, ANTHROPOMETRY AND MAGNETIC RESO-NANCE SPECTROSCOPY STUDY OF BRAIN IN COPD ASIANINDIANS IN NORTH INDIASanjeev Sinha, MD*; R.Guleria, Virendra Kumar, Uma Sharma and N.R.Jagannathan. AIIMS, New Delhi, India

PURPOSE: To investigate changes in the cerebral metabolism ofnondiabetic and normolipidemic patients with COPD using localized invivo 1H MRS, and to correlate these with the severity of disease.


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METHODS: Ten symptomatic COPD patients and 19 healthy controlsparticipated in this study. All subjects underwent 1H MRS of brain,pulmonary function test, respiratory muscle strength, anthropometricmeasurements, blood sugar and lipid profile. The parieto-temporal andoccipital regions were localized for 1H MRS. The metabolic ratios NAA /Cr and Cho / Cr were calculated by integrating area under the each peak.

RESULTS: In COPD patients, the mean� SD values of FEV1 was51.4 � 12.3 (p� 0.0001)% predicted, FVC was 73.6�13.1(p� 0.0001),PEFR was 45.3�15.5 (p� 0.0001), FEF25-75 was 28.4�7.9 (p� 0.0001)and FEV1/FVC was 72�9.6 (p� 0.0001). The mean values of MIP andMEP in COPD patients were 4.2� 0.63 (p� 0.0001) and 4.3�0.48(p�0.0001). These values did not have statistical correlation with thelevels of cerebral metabolites.

The ratio of Cho/Cr (0.81�0.28, p�0.04) was significantly high inCOPD patients in occipital area. The mean value of NAA/Cr in occipitalarea was {1.84�0.31(p�0.38)}, which is same as in controls. There wereno significant differences in the mean values of ratios of NAA/Cr andCho/Cr in other regions of the brain. The mean values of NAA/Cr andCho/Cr in parieto-temporal area in COPD patients were 1.82�0.45 (p�0.81) and 0.90�0.21 (p�0.92).

CONCLUSIONS: The results demonstrate that the cerebral metabo-lism, pulmonary functions and respiratory muscle strength altered insymptomatic COPD patients. The clinical significance of other cerebralmetabolic changes in COPD patients needs to be further investigated.

CLINICAL IMPLICATIONS: Proton magnetic resonance spectros-copy is a good predictor of cerebral metabolism in COPD patients.Further investigations required in large number of patients.

DISCLOSURE: S. Sinha, None.

DEMOGRAPHICS AND CO-MORBIDITIES IN PATIENTS WITHCHRONIC OBSTRUCTIVE PULMONARY DISEASE IN THEVETERANS ADMINISTRATION MEDICAL SYSTEMDennis E. Niewoehner, MD, FCCP*; Philip M. Arnold, BA; StevenKesten, MD, FCCP. Veterans Affairs Medical Center, Minneapolis, MN

PURPOSE: The Veterans Administration (VA) medical system is ahealth care system consisting of patients who are or who have beenmembers of the United States armed forces. We sought to describe thecharacteristics of this unique population to illustrate the opportunities tostudy new interventions in this system.

METHODS: A six-month randomized, double-blind, placebo-con-trolled clinical trial (n�1,829) was undertaken with tiotropium, a once-daily inhaled anticholinergic, in patients with COPD. Patients wererequired to have an FEV1 � 60% predicted and have a smoking history �10 pack years. Exclusion criteria included a history of asthma, pulmonaryresection, respiratory tract infection in the preceding six weeks, recentMI, recent hospitalization for CHF, life-threatening cardiac arrhythmia,and active treatment for malignancy. Population demographics have beenextracted from blinded data.

RESULTS: Approximately 99% were male, 91.3% Caucasian, 8.2%Black, and 0.5% Asian. The mean age was 68 years. Patients smoked anaverage of 68 pack years, had a mean FEV1�1.04 L (35% predicted) andFEV1/FVC�48%. Concomitant diseases other than COPD were presentin 99% of patients. The most common non-respiratory categories ofdiseases were as follows: vascular (including hypertension) 64%, gastro-intestinal 48%, MSK/connective tissue 46%, cardiac 39%, metabolism/nutrition 47%, reproductive system including prostate 27%, psychiatricdisorders 26%, drug hypersensitivity 19%, neoplasm 18%, and nervoussystem 22%. The most common specific diagnoses were hypertension(54% of patients) and GE reflux (26% of patients).

CONCLUSIONS: Patients in the VA setting appear to have frequentco-morbidities with high incidences of the more common diseases in thegeneral population.

CLINICAL IMPLICATIONS: The numerous co-morbidities andassociated polypharmacy in this population provide an opportunity tostudy interventions in a specific population that might be more difficult toassess in a broader clinical trial setting.

DISCLOSURE: D.E. Niewoehner, None.

RELATIONSHIP BETWEEN HYPOXEMIA AND FEV1 IN PA-TIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DIS-EASE (COPD)S Momany, MD*; M Ismail, MD; G Wardeh, MD; A Al-Shrouf, MD; MA. Khan, MD. St. Joseph’s Regional Medical Center, Paterson, NJ andSeton Hall University, School of Graduate Medical Education, S. Orange,NJ

PURPOSE: Gax-exchange abnormalities are inevitable conse-quences of progressive COPD. Hypercapnia has a predictable corre-lation with FEV1 and usually occurs when FEV1 declines below 1Liter. Hypoxemia, on the other hand, may not be as predictable. Toassess the relationship between FEV1 and hypoxemia in COPD, wereviewed medical records of a group of hypoxemic patients with COPDreceiving home oxygen therapy.

METHODS: We retrospectively reviewed medical records of 19patients with COPD (8 females, 11 males, age rage: 49-76 years; meanage: 64.9 years) on home oxygen therapy qualifying under Medicarecriteria. Patients were subdivided into two groups, one with FEV1�1.0Land the other with FEV1�1.0L.

RESULTS: Nine (47%) patients were found to have FEV1�1.0L, 3 ofwhom (16%) had FEV1�1.5L. Ten (53%) patients had FEV1�1.0L, 1 ofwhom (5%) had FEV1�0.5L. Statistical analysis using Z-test showed nosignificant difference between the two groups (P�0.816).

CONCLUSION: Unlike hypercapnia which is usually associated withFEV1�1.0L in COPD, hypoxemia develops unpredictably and is notnecessarily associated with a specific level of FEV1, occuring even innon-severe obstruction.

CLINICAL IMPLICATIONS: Evaluation of COPD patients for thepresence of complicating hypoxemia necessitating oxygen therapy shouldbegin at an earlier stage of COPD.

FEV1 �1.0L �1.0L

�0.5 0.5-1.0 1.0-1.5 �1.5Number of Patients Males 0 4 6 1

Females 1 5 0 2Total 10 (52.6%) 9 (47.4%)

DISCLOSURE: S. Momany, None.

EFFECT OF TWICE WEEKLY PULMONARY REHABILITA-TION ON HEALTH STATUS, EXERCISE CAPACITY AND DYS-PNEA IN COPD PATIENTSRoberto P. Benzo, MD*; Rhonda Scheffel, RRT; Lori Williams, BS MPA.West Virginia University, Morgantown, WV

PURPOSE: Pulmonary rehabilitation (PR) is an accepted componentin the treatment of chronic obstructive pulmonary disease (COPD).Studies have shown that pulmonary rehabilitation, consisting of at leastthree training sessions a week, improves exercise performance and healthstatus.

We studied the effect of twice weekly PR for 12 weeks on health status,exercise capacity, and dyspnea.

METHODS: Nineteen consecutive patients (9 female) age 61�16 withdiagnosis of COPD , FEV1 55%�26 were included in a 12-week twice aweek pulmonary rehabilitation program. The program consisted in tread-mill walking or recumbent stepper for 30 minutes at 60% of the intensityattained in a maximal exercise test.

The intensity was increased to maintain a perceived dyspnea of 4according to the Borg modified dyspnea scale. Upper extremity enduranceexercise was also included for up to 15 minutes every session .

COPD disease education was on a one-on-one basis according topatients needs assessed by a questionnaire that measured patient’sknowledge of the disease. All patients watched tapes on exercise, breath-ing exercises and pulmonary rehabilitation.. Health status measured withthe Pulmonary Functional Status Scale (PFSS), 6 minutes walk test andBorg score were the outcome measures of this study measured before andafter the intervention.


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RESULTS:Pre/Post rehab results

PFSS score Pre PR Post PR P value Effect Size

Functional 3.6�0.5 3.8�0.6 0.095 0.48Psychological 3.6�0.7 3.9�0.6 0.014 0.38Sexuality 4.0�0.9 4.2�0.9 0.3 0.27Total Score 9.1�2.4 10.0�3.0 0.05 0.456 MWT 390�101 434�87 0.001 0.43Dyspnea 5�3 4.2�2.6 0.3 0.27

Attendance rate 84%CONCLUSION: Although the results showed a statistically significant

improvement in exercise performance and total quality of life score, thedifference was not clinically meaningful as expressed by the effect size . Inparticular in the post PR 6-minute walk test result did not reach theclinically meaningful difference of 54 meters.

CLINICAL IMPLICATIONS: This study failed to demonstrate thattwice a week PR produce meaningful improvements in this group ofCOPD patients.

DISCLOSURE: R.P. Benzo, None.

COMPARISON OF THE MANAGEMENT OF PATIENTS WITHCHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) BE-TWEEN GENERALISTS AND SPECIALISTS IN AN INNER-CITYHOSPITALS Sy, MD; V Lakshmi, MD; E Escalera, MD; S Blum, PhD; G Diaz-Fuentes,MD,FCCP*. Bronx Lebanon Hospital Center, New York, NY

INTRODUCTION: The increasing incidence of COPD has lead to thepublication of COPD guidelines in 1995 and recently in 2001. Althoughdifferences in quality of care and outcome between generalist andspecialist have been described for patients with coronary artery diseaseand with asthma, no study has been reported for patients with COPD.

PURPOSE: To determine whether care for COPD patients was moreconsistent with national guidelines when a specialist rather than ageneralist was the usual source of care.

METHODS: A retrospective record review of patients with COPDfollowed at the outpatient clinics during 2000-2001was done.

RESULTS: We had twenty patients in each group. The mean age inboth the group was 70 year-old.

CONCLUSIONS: Spirometry and the use of anti-cholinergics andlong-acting B2 agonists are underutilized in the primary care settingcompared with sub-specialty care. Thirty percent of the patients in theprimary care clinic had a diagnosis of COPD without pulmonary functiontest confirmation. There was a tendency for patients with more severedisease to be seen at the specialty clinic which could explain the higher useof long-acting B2 agonist.

CLINICAL IMPLICATIONS: Considering that COPD is now thefourth leading cause of mortality in the United States and that generalistsare the first physicians encountering most patients, it is of utmostimportance to educate and share the information about evaluation,management and prevention of COPD with primary care physicians.

Generalist versus Specialist in COPD care

Generalistn�20

Pulmonary Specialistn�20

Smoking Cessation addressed 19 (95%) 20 (100%)Spirometry done 14 (70%) 20 (100%)FEV1 %predicted (mean) 68% 61%Anti-cholinergic inhalers 14 (70%) 17 (85%)Use Long-acting B2 agonist 3 (15%) 15 (75%)

DISCLOSURE: G. Diaz-Fuentes, None.

THE RISK OF NON-VERTEBRAL FRACTURE RELATED TOINHALED CORTICOSTEROID EXPOSURE AMONG ADULTSWITH PHYSICIAN-DIAGNOSED RESPIRATORY DISEASECatherine B. Johannes, PhD*; Gary Schneider, MSPH; Timothy Dube,BA; Kourtney J. Davis, PhD; Alexander M. Walker, MD, DrPH. IngenixEpidemiology, Auburndale, MA

PURPOSE: To examine the risk of non-vertebral fracture in relation toinhaled corticosteroid (ICS) exposure among adults with respiratorydisease.

METHODS: Nested case-control study within a cohort of 89,877UnitedHealthcare members 40 years or older with physician insuranceclaims for chronic obstructive pulmonary disease (COPD) or asthma,enrolled for at least 1 year from 1/1/1997-6/30/2001. Cases (n�1,722)experienced treatment for a non-vertebral fracture, with the index datethe first fracture claim. Controls (n�17,220) were randomly selected andassigned a random index date. ICS, the primary exposure, was estimatedfrom pharmacy claims for dispensings 1, 3, 6, and 12 months before theindex date, with estimated cumulative dose through 0-6, 7-12 and 0-12months. Covariates included demographics, oral corticosteroid and othermedication exposure, comorbidities, health care utilization, disease sever-ity indicators, and health care utilization and costs. Odds ratios (OR)adjusted for all covariates were estimated by logistic regression.

RESULTS: Fracture risk increased with age, female gender, respira-tory disease severity, non-respiratory care costs, depression, stroke,anticonvulsant use, and bone disorders. There was little evidence forincreased fracture risk with ICS exposure. The ORs for exposure in thepreceding 30 days were 1.05 (95% CI: 0.89-1.24), 1.13 (0.90-1.40), and0.97 (0.78-1.21) for all ICS, fluticasone propionate, and other ICS,respectively, and were close to one in more distant exposure periods. Nodose-response effect was present. In analyses limited to 6,932 COPDpatients, there was no increased fracture risk for recent ICS (OR�0.86,95% CI: 0.59-1.25), fluticasone (OR�1.07, 95% CI: 0.66-1.74), or otherICS (OR�0.69, 95% CI: 0.40-1.18) exposure.

CONCLUSIONS: In data that could readily reproduce the majorepidemiologic features of non-vertebral fracture, there was no demon-strable risk with the use of ICS as a class, or with preparations containingfluticasone at any cumulative dose or duration among patients with COPDor asthma.

CLINICAL IMPLICATIONS: In contemporary managed care set-tings in the US, concern about non-vertebral fracture should not enterinto the decision as to whether to use ICS.

DISCLOSURE: C.B. Johannes, GlaxoSmithKline. This research studywas funded by GlaxoSmithKline through a contract with Ingenix Epide-miology.

EFFECT OF CILOMILAST ON QUALITY OF LIFE IMPROVE-MENT/DETERIORATION AND NON-DRUG COSTS IN PA-TIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DIS-EASERohit D. Borker, PhD*; Andrea Morris, RN; Junghee Lim, PhD; Jin Zhu,PhD; Colin Reisner, MD. GlaxoSmithKline, Research Triangle Park, NC

PURPOSE: The present analyses was performed to estimate the effectof cilomilast on chronic obstructive pulmonary disease (COPD) patients’relative risk (RR) of improvement/deterioration in quality of life (QOL)and non-drug medical costs.

METHOD: The analyses was based on a randomized, double blind,placebo-controlled study, which evaluated cilomilast (15 mg twice daily) inpatients with COPD. Patients’ QOL was measured using the St. George’sRespiratory Questionnaire (SGRQ), a disease-specific QOL question-naire. The RR estimates for QOL improvement/deterioration were deter-mined based on study results. The healthcare utilization data on physicianoffice visits, emergency department visits, and hospitalizations werecollected during the trial.

RESULTS: A total of 536 patients (cilomilast � 340, placebo � 196)were included in the analyses. A greater proportion of patients achieved aclinically meaningful QOL improvement in the cilomilast group ascompared to placebo (47.6% vs. 31.6%, respectively) resulting in asignificant RR of QOL improvement of 1.51 (95% CI: 1.21 to 1.88). Agreater proportion of patients experienced clinically relevant deteriorationin their QOL in the placebo group as compared to cilomilast (39.3% vs.22.9%, respectively) resulting in a significant RR of QOL deterioration of0.58 (95% CI: 0.45 to 0.76). Moreover, the non-drug medical cost per


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patient for the 24-week treatment period was significantly lower in thecilomilast group ($12.06, 95% CI: $3.85 to $27.89) as compared to placebogroup ($97.79, 95% CI: $35.37 to $176.24).

CONCLUSIONS: Patients in cilomilast group were 1.5 times morelikely to experience a clinically meaningful improvement in their QOL andabout 40 % less likely to experience a clinically relevant deterioration intheir QOL as compared placebo. Patients in the cilomilast group alsoexperienced significant cost reductions in terms of their non-drug medicalcosts as compared to placebo.

CLINICAL IMPLICATIONS: COPD patients on cilomilast are morelikely to experience QOL improvement and less likely to experience QOLdeterioration at significantly lower non-drug medical costs as compared toplacebo.

DISCLOSURE: R.D. Borker, Employee - GlaxoSmithKline, Industry.

CARDIOVASCULAR SAFETY OF CILOMILAST IN PATIENTSWITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE(COPD)Gary Ferguson, MD*; Tracy L. Fischer, Pharm D; Andrea Morris, RN; JinZhu, PhD; Frank Barnhart, DVM; Colin Reisner, MD. PulmonaryResearch Institute of SouthEast Michigan, Livonia, MI

PURPOSE: Patients with COPD are known to be at increased risk ofcardiovascular (CV) disease. To evaluate the CV safety of cilomilast (CIL)in patients with COPD, an integration of the CV safety data across fourpivotal studies was conducted.

METHODS: Electrocardiogram (ECG), vital sign (VS) and adverseevent (AE) data were integrated from four 24-week, randomized, double-blind, placebo-controlled, parallel-group studies in COPD patients eval-uating CIL 15mg BID versus placebo. Routine ECGs and VSs wereevaluated at baseline, Weeks 1, 2, 4, 8, 12, 16, 20, 24 and prematurediscontinuation. Additional ECGs were conducted 3 hours post studydrug administration (Cmax ECGs) at baseline and week 24.

RESULTS: A total of 2883 COPD patients were evaluated (1091placebo vs 1792 CIL). Demographic and pulmonary function character-istics were similar between treatment groups, with patient ages rangingbetween 39-84 years, mean smoking history of 53 vs. 51 pack years andmean FEV1 of 50% vs. 50% of predicted (placebo vs CIL, respectively).Forty eight percent of the placebo vs. 52% of CIL treated patients hadunderlying cardiac conditions. Mean changes from baseline to endpoint(EP) in SBP (-0.7 vs. -1.8 mmHg), DBP (-0.6 vs. -0.9 mmHg) and HR (0.7vs. 0.9 bpm) were similar between placebo vs CIL treatment groups,respectively.

QTcB (Bazett’s correction) and QTcF (Fridericia’s correction) Changefrom Baseline at EP

Parameter for Routine ECGsPlacebo(n�1091)

Cilomilast(n�1792)

QTcB (Baseline, Change fromBaseline at EP)

424msec,0.1msec

425msec,-0.4msec

QTcF (Baseline, Change fromBaseline at EP)

412msec,-1.2msec

413msec,-1.9msec

Changes in routine ECGs from baseline to EP in ventricular rate, QRSaxis, QTc, and the occurrence of treatment emergent ECG abnormalitieswere similar between treatment groups. Comparable findings were alsoobserved when assessing Cmax ECGs. The incidence of CV AEs wassimilar between treatment groups.

CONCLUSIONS: The CV safety profile of CIL is similar to that ofplacebo in patients with moderate to severe COPD, many of whom haveconcomitant cardiac conditions.

CLINCIAL IMPLICATIONS: CV disease is common in COPDpatients. These results suggest that cilomilast may be used safely inpatients with COPD.

DISCLOSURE: G. Ferguson, GlaxoSmithKline, discussion of productresearch or unlabeled uses of product.

CONTINUOUSLY NEBULIZED ALBUTEROL VERSUS INTER-MITTENTLY NEBULIZED ALBUTEROL TREATMENT IN PA-TIENTS HOSPITALIZED WITH CHRONIC OBSTRUCTIVEPULMONARY DISEASE EXACERBATIONIstvan D. Wollak, MD*; Sohail Khan, MD; Ammar Ghanem, MD; JamesJ. Walsh, MD. Community Teaching H, RPH - Guthrie, Sayre, PA

PURPOSE: No data exists on use of continuously nebulized broncho-dilators in COPD exacerbation. We investigated the outcome of contin-uously versus intermittently nebulized albuterol in the treatment of thesepatients.

METHODS: Experimental, randomized, prospective, two-groupstudy. 15 patients admitted with COPD exacerbation were enrolled in thestudy. 7 patients were randomized to the intermittent and 8 to thecontinuous group. Patients received either nebulized albuterol 2.5mgevery 4 hours or continuously nebulized albuterol at 5mg /hr for 4 hoursfollowed by 2.5mg intermittently every 4 hours in addition to standardtherapy for COPD exacerbation. Patients had baseline bedside spirome-try, notation of heart rate, blood pressure, oxygen saturation and amountof oxygen supplementation required. Data were collected again at 4 hours,day 2 and day 3.

RESULTS: Data were analyzed using a 2-tail T-test; 95% confidenceintervals were also calculated. There was no statistically significantdifference between the groups regarding baseline FVC, FEV1 andabsolute/percent change of FEV1 at 4 hours. The difference in the changeof FVC at 4 hours approached statistical significance: 0.25L � 0.21L(intermittent) and –0.013L � 0.28L (continuous); P-value 0.060. Percentchange in FVC at 4 hours was statistically greater in the intermittent(21.22% � 30.73) as compared to continuous group (–0.85% � 73.38);P-value 0.043. The difference in the absolute change of FVC on day 2approached statistical significance: 0.45L � 0.33L (intermittent) and0.02L � 0.42L (continuous); P-value 0.051.

CONCLUSION: The percentage change of FVC at 4 hours was betterin the intermittent group. There was also a trend towards a betterimprovement of absolute FVC in the intermittent group at 4 hours and onday 2. This suggests a possible decrease in air trapping in this group.

CLINICAL IMPLICATONS: Treating COPD exacerbation withcontinuous albuterol nebulization was not superior to the standardtreatment.

DISCLOSURE: I.D. Wollak, None.

BRONCHODILATOR-INDUCED DECREASE IN OXYGEN SAT-URATION (02 SAT) IN PATIENTS WITH OBSTRUCTIVE LUNGDISEASEA Al-Shrouf, MD*; M Ismail, MD; G Wardeh, MD; S Momany, MD; MA. Khan, MD, FCCP, St. Joseph’s Regional Medical Center, Paterson, NJand Seton Hall University, School of Graduate Medical Education, S.Orange, NJ

PURPOSE: Bronchodilator therapy affects ventilation-perfusion rela-tionships in the lung. In order to asess whether such therapy may impair02 Sat, we prospectively studied a group of 89 patients referred to our PFTlaboratory for lung function studies.

METHODS: Eighty-nine subjects (46 females, 43 males, age range:35-84 years; mean age:64 years) underwent pulse oximetry while perform-ing pulmonary function studies before and during bronchodilator aerosolinhalation.

RESULTS: Forty-nine patients (26 females, 23 males) were diagnosedwith obstructive lung disease (FEV1/FVC�70) while 40 patients eitherhad normal lung function or restrictive defect. Nine of 49 (18%) patientswith obstructive lung disease showed a mean drop of 3% in 02 Sat whilereceiving bronchodilator aerosol. None of the patients with normal lungfunction or restrictive defect showed a drop in 02 Sat (P�0.010).

CONCLUSION: Bronchodilator aerosol therapy resulted in 3 mmdecrease in 02 Sat in 18% patients with obstructive lung disease.

CLINICAL IMPLICATION: Patients with obstructive lung diseaseshould receive oxygen while using bronchodilator aerosol therapy toprevent a drop in 02 Sat.

DISCLOSURE: A. Al-Shrouf, None.


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TREATMENT OF ACUTE EXACERBATIONS OF CHRONICBRONCHITIS IN PATIENTS WITH CHRONIC OBSTRUCTIVEPULMONARY DISEASE: A RETROSPECTIVE COHORT ANAL-YSIS OF CLARITHROMYCIN EXTENDED RELEASE VSAZITHROMYCINRichard S. Castaldo, MD*; Mary A. Cifaldi, RPh, PhD; Alan F. Kaul,PharmD, MSc, MBA, FCCP; Alanna Castaldo, BS; Mike Chopko, BS;Beth Peterson, BS; Anthony Mato, MD. Private Research Org, BuffaloManaged Care Corporation, Buffalo, NY

PURPOSE: Ambulatory treatment of acute exacerbations of chronicbronchitis (AECB) is associated with a high risk for relapse. Risk factorsfor relapse are older age and prior medical history. Relapse rates havediffered among antibiotic classes. This study considers whether there weredifferences in relapse rates for the treatment of AECB between theadvanced macrolide antibiotics, clarithromcyin extended release (ER) andazithromycin.

METHODS: Retrospective cohort analysis of visits for AECB usingmedical record review. Patients with a diagnostic code for chronicobstructive pulmonary disease (COPD) and bronchitis treated withclarithromycin-ER or azithromycin were evaluated. A logistic regressionmodel was used to control for demographic characteristics, severity ofinfection, smoking history, caridiopulmonary diseases, and season.

RESULTS: A total of 187 unique patients accounted for 252 episodesof AECB (127 episodes for clarithromcyin ER and 125 for Azithromycin).The groups differed only in that patients treated with clarithromycin-ERtended to be older (mean ages 52.5 �/- 14.3 vs 49.1 �/- 14.2 years,respectively, p�0.053) and patients treated with azithromycin were morelikely to have a prior history of COPD (13/125 vs. 4/127, respectively,p�0.025). Of the total observations the overall relapse rate was 4% (2.3%for clarithromycin-ER and 5.6% for azithromycin). When controlling forother factors, patients treated with azithromycin were 8.8 times morelikely to fail than were patients treated with clarithromycin-ER (p�0.02).Black and Hispanic were twice as likely to fail than were White patients(p�0.008).

CONCLUSIONS: The use of advanced generation macrolide antibi-otics (i.e., clarithromycin-ER, azithromycin) demonstrated a low relapserate in patients presenting with AECB. Patients treated with clarithromy-cin-ER , were shown to have a significantly lower relapse rate than werepatients treated with azithromycin. Racial differences may also be apredictive factor for relapse.

CLINICAL IMPLICATIONS: Decreased relapses may decreasehospitalizations, provide longer time between AECB episodes requiringdrug therapy and lower mean total costs for those patients treated withclarithromycin-ER compared to azithromycin.

DISCLOSURE: R.S. Castaldo, Abbott Laboratories, grant monies,Industry.

ROLE OF AZITHROMYCIN IN BRONCHIOLITIS OBLITERANS/ OBLITERATIVE BRONCHIOLITIS IN POST-BONE MARROWTRANSPLANT (BMT) PATIENTSM Khalid, MBBS, FCCP*; A Saghir, MBBS,SBIM; E Sahovic, MBBS; NChaudhry, MBBS; M Al Jurf, MBBS; S Al Dammas, MBBS; A AlMobeireek, MBBS; M Zeitouni, MBBS. King Faisal Specialist Hospitaland Research Centre, Riyadh, Saudi Arabia

PURPOSE: Bronchiolitis obliterans syndrome (BOS) is a commonleading cause of morbidity and mortality in patients with organ transplant,particularly lung transplant and bone marrow transplantation.

Current management therapies have shown no significant benefit andare associated with significant side effects.

Azithromycin (macrolides) have proven anti-inflammatory effects and ithas been used successfully in pan bronchiolitis and bronchiectasis.

Ours if the first study asesing its effect in bos in patients with bonemarrow transplant as part of graft vs host disease syndrome (GVHD).

METHOD: All patients who received bone marrow transplant anddeveloped BOS proven by obstructive pulmonary function test (PFT)findings and in some cases substantiated by specific high resolution ctchest findings (HRCT) of mosaic pattern or air trapping on inspiration andexpiration HRCT, findings consistent with BOS.

Baseline PFT and post BMT, OBS, PFT were reviewed, patients withexisting obstructive airway disease prior to BMT were excluded.

Azithromycin 500mgs daily x 3 days then 250mgs tiw was given for 3months period. Patients were evaluated in clinic with follow-up PFTs at 6

weeks and 3 months effort was made to continue existing treatment forGVHD including steroids ans chemotherapeutic agents and not to makeany changes in treatment after azithromycin was initiated.

RESULTS: Six (6) patients included in the study so far, four (4) showedimprovement after addition of azithromycin to their treatment, one (1)stabilized with minimal improvement and one (1) patient showed deteri-oration in PFTs.

Patients PreTreatment

PostAzirthromycinTreatment

% FVC % FEV1

FVC FEV1 FVC FEV1

1 1.34L(49.8%)

0.8 L(35.1%)

0.93L(35.1%)

0.6L(26.9%)

- 14.7 - 8.2

2 2.27L 1.14L 2.29L 1.18L � .88 � 3.53 0.64

(20.8)0.54(20.7)

0.84(24.6)

0.71(23.9)

� 38.0

� 32.0

4 2.41(53.3)

1.11(29.3)

3.3(73.0)

1.25(32.8)

� 19.7

� 3.5

5 1.06L 0.6L 1.46L 0.84L � 40.0

� 37.4

6 1.25L 1.05L 1.61L 1.59L � 28.8

� 51.4

Average Improvement % FVC 18.76Average Improvement % FEV1 19.96CONCLUSION: Azithromycin led to statistically significant improve-

ment in pulmonary function in 5 of 6 patients with BOS post BMT(GHVD sydrome).

CLINICAL IMPLICATION: A randomized trial of this promising,inexpensive and low risk treatment for BOS in post BMT patients andin-patients with other organ transplantation is warranted.

DISCLOSURE: M. Khalid, None.

TOBRAMYCIN NEBULIZER SOLUTION (TNS) IN MODERATE-TO-SEVERE COPD, PSEUDOMONAS AERUGINOSA COLO-NIZED: EFFECTS ON CELLS AND INFLAMMATORY MARK-ERS FROM SPONTANEOUS SECRETIONSRoberto W. Dal Negro, MD*; Silvia Tognella, MD; Marilia Visconti, MD;Fiorenza Trevisan, MD; Claudio Micheletto, MD; Carlo Pomari, MD.Lung Dept, Bussolengo Gen. Hospital, Italy

Chronic obstructive pulmonary disease (COPD) has exacerbations ascommon events, being morbidity and mortality significant. About 25%of cases prove colonised with Pseudomonas aeruginosa (Ps.ae.) (1),being this condition an important stimulus to persistent airway inflam-mation. Inhaled antibiotics represent an alternative to oral/i.v. admin-istration due to their high concentrations at the site of infection andthe low systemic toxicity (2). Tobramycin Nebulizer Solution (TNS), apreservative-free formulation for nebulization, has recently beenlicensed for chronic Ps. ae. infection in cystic fibrosis only (3). Aim: toinvestigate the effects of a TNS sort-course on inflammatory markersof bronchial secretions from Ps.ae.-colonised COPD patients. Sub-jects: 13 moderate-to-severe COPD patients (GOLD 2b; 10 m., meanage 72.7 yr�8sd; mean basal FEV1 � 34.8% pred.�8.1sd; meanFEV1/FVC�0.6.�0.1sd) Ps.ae. colonised (persisting CFU�106) andresistant to oral/i.v. specific antibiotics, were studied after theirinformed consent. Methods: IL1b, IL8, IL6 and TNFa (pg/ml; Immu-lite, Diagnostic Product Corp, LA, Ca, USA); ECP (mcg/l), and cellcount (% total count) were measured in spontaneous bronchialsecretions before and after a 2-wk TNS course (300 mg bid, TOBIPathogenesis Limited, Dompe Farm.), and some clinical outcomes (n.fatal events; bacterial density and/or eradication; n. severe exacerba-tions; time to the next exacerbation) monitored for a 6-month period.Statistics: t test and p�0.05 accepted.Results in Tab 1. Conclusions: 1)a 2-wk TNS course decreased sub stantially the level of neutrophilicand eosinophilic chemiotactic factors, and the number of eosinophils inbron chial secretions; 2), 1 fatal event occur red in the period due toacute RSV infection;3)Ps.ae.was eradicated in 2/13 pts, and the densityreduced in other 4; 4) severe exacerbations were reduced by 42% and


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their onset delayed. Ref.: 1) Thorax 2002; 57(9): 759-64. 2) Am J RespCrit Care 2000; 162: 481-5; 3) ERJ 2002;20:658-64.

TAB1 BSLN 14 DAYS T TEST

IL1b pg/ml 1751.5�1582.7 391.4�347.9 P�0.006IL8 pg/ml 6173.2�4278.6 4616.8�3394.6 P�0.017TNFa pg/ml 546.1�1078.6 186.3�297.1 NSECP mcg/l 2776.6�2074.9 867.4�648.5 P�0.01Neutrophils % 72.5�9.7 79.5�4.5 NSEosinophils % 13.7�9.9 4.0�5.3 P�0.01Lymphocytes % 13.1�4.7 16.8�5.1 NS

DISCLOSURE: R.W. Dal Negro, None.

SYSTEMIC STEROID THERAPY FOR ACUTE EXARCEBATIONOF COPD IN THE OUTPATIENT SETTINGAbderrahmane E. Temmar, MD*; Thomas R. Emmendorfer, Pharm.D;Tazeen Ahmed, MD. Aleda E.Lutz VAMC, Saginaw, MI

PURPOSE: Although systemic steroid therapy is standard therapy forpatients hospitalized for acute exacerbation of COPD, its use in theoutpatient setting is still subject of debate. The aim of our study is toevaluate the differences in two groups treated for acute exacerbation ofCOPD (one group receiving systemic steroid therapy and one treatedwithout), as well as their rate of clinic visit and hospitalization within 2weeks.

METHODS: Retrospective chart review of patients discharged froman outpatient setting with diagnosis of acute exacerbation of COPD andcomputerized pharmacy data for systemic steroid therapy usage in thesepatients. Data abstracted included patient’s demographic data, medicalco-morbidities, FEV1 values, clinical presentation, antibiotic therapy,chronic steroid use and clinic and hospitalization within 2 weeks of initialpresentation.

RESULTS: From June 2000 to May 2002, 98 patients treated foracute exacerbation of COPD met inclusion criteria. 52 patients weretreated without systemic steroids (Group 1) and 46 patients receivedsystemic steroids (Group 2). There was no difference in the age (69.7vs. 67.9), female to male ratio (2% vs.4.5%), co-morbid state (73%vs.74%), antibiotics usage (86.6% vs. 85%), clinic visit within 2 weeks(6%vs.17% P�0.07), or hospitalization within 2 weeks (2% in eachgroup). However there was a statistically significant difference in themean Fev1: 1.62L in Group 1 vs. 1.27L in Group 2 (p�0.007). Group2 had 11(24%) patients on chronic steroid therapy vs. 0 patients inGroup 1.

CONCLUSIONS: In the outpatient setting, patients given systemicsteroids for acute exacerbation of COPD have more severe airwayobstruction and are more likely to be on chronic steroid therapy thenpatients treated without systemic steroids.

CLINICAL IMPLICATIONS: Systemic steroid therapy does notseem to offer any benefits in patients with milder airway obstruction onthe short run. This study underlines the importance to incorporate thedegree of airway obstruction in future prospective studies.

DISCLOSURE: A.E. Temmar, None.

Critical Care Outcome12:30 PM - 2:00 PM

EXCESS BODY WEIGHT IS NOT AN INDEPENDENT PREDIC-TOR OF OUTCOME FROM ACUTE LUNG INJURY AND THEACUTE RESPIRATORY DISTRESS SYNDROMEJames M. O’Brien, MD*; Carolyn H. Welsh, MD; Ronald H. Fish, MBA;Marek Ancukiewicz, PhD; Andrew M. Kramer, MD. The Acute Respira-tory Distress Syndrome Network, University of Colorado Health SciencesCenter, Denver, CO

PURPOSE: Despite an epidemic of obesity among adults and increas-ing use of intensive care unit resources, the effect of excess body weighton outcomes from critical illness is understudied. We examined the role ofexcess body weight as an independent risk factor for poorer outcomes in

patients with acute lung injury (ALI) and the acute respiratory distresssyndrome (ARDS).

METHODS: A retrospective cohort study involving the 902 mechan-ically ventilated patients enrolled in randomized, controlled trials for thetreatment of ALI/ARDS. We used the body mass index (BMI) as anindicator of excess body weight with categories of normal (BMI 18.5 –24.9 kg/m2), overweight (BMI 25 – 29.9 kg/m2) and obese (BMI �30kg/m2). We conducted multivariate analyses of subjects with calculableBMIs to determine independent factors associated with clinical outcomefrom ALI/ARDS.

RESULTS: Unadjusted analyses showed that indirect causes of lunginjury, including trauma, were more common in obese subjects. Over-weight and obese subjects also had higher pre-enrollment peak andplateau airway pressures due to higher set tidal volumes. After riskadjustment, excess body weight was not independently associated withmortality, achieving unassisted ventilation, or number of ventilator-freedays. These findings persisted with continuous and categorical measuresof BMI. We found no significant interaction between ventilator protocolassignment and obese BMI.

CONCLUSIONS: We could not demonstrate that excess body weightwas independently associated with poorer outcome from ALI/ARDS.Lower tidal volume assignment (6 mL/kg predicted body weight) showedsuperior outcomes for all BMI groups.

CLINICAL IMPLICATIONS: Overweight and obese patients withALI/ARDS have outcomes similar to those with normal BMIs, even afterrisk-adjustment. The lack of interaction between the ventilator protocolassignment and obesity suggests that the benefit of lower tidal volumeventilation for ALI/ARDS extends to patients of all BMIs.

DISCLOSURE: J.M. O’Brien, Eli Lilly, have given educational pre-sentations for company.

TRENDS IN THE USE OF PULMONARY ARTERY CATHETERIN CRITICALLY ILL VENTILATED PATIENTSGonzalo E. Gianella, MD*; Ganesan Murali, MD; Michael Lippmann,MD. Albert Einstein Medical Center, Philadelphia, PA

The use of pulmonary artery catheters (PAC) has been under scrutinyfor the past few years. The evidence favoring and discouraging its use isabundant in the medical literature. In order to observe if the evidencepublished has had any impact over the use of the PAC, we performed aretrospective chart review of all the critically ill ventilated patients from1996 to 2001. The data analysis included patients admitted to any of theCritical Care Units at Albert Einstein Medical Center in Philadelphia(CCU, SICU or MICU).

During the 6 year period the mortality rates of all the critically illventilated patients remained stable in both medical and surgical patients(fig.1). Also the demographic characteristics of both surgical and medicalpatients remained unchanged.

On the other hand the use of PAC in critically ill ventilated medicalpatients has decreased from 5.5% of to 1.8% in 2001 (fig.2). The use in thesurgical setting has remained stable.

This study documents a decreasing trend in the use of PAC in themedical ventilated critically ill patient without evidence of an impact ininhospital mortality.


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DISCLOSURE: G.E. Gianella, None.

THE DIAGNOSTIC YIELD OF LUMBAR PUNCTURE IN MED-ICAL INTENSIVE CARE UNIT (MICU) PATIENTSMouhamed M. Kannass, MD*; Janet Shapiro, MD. St Luke’s-RooseveltHospital Center, New York, NY

PURPOSE: It is a common practice to perform lumbar puncture (LP)in critically ill patients with delirium and/or fever. The purpose of thisreview was to determine the diagnostic value of LPs in the MICUpatients.

METHODS: Retrospective chart review of all LPs performed in twoMICUs in an urban university hospital from January 2000 to December2001. we excluded all repeated LPs, or those done outside the MICU. Apositive LP was defined by a proved infection by culture or appropriatestain. Aseptic meningitis was diagnosed when the cerebrospinal fluid(CSF) analysis revealed lymphatic pleocytosis and no pathogens. Sus-pected nosocomial meningitis was defined if the indication for LP arose �48 hours following admission

RESULTS: 155 LP were performed to rule out meningitis in criticallyill patients with delirium and/or fever. 136 patients (88%) were considerednegative. 19 patients (12%) were found to have positive CSF results. 68patients ( 44%) were considered to be high risk (cancer, HIV positive,chronic renal failure). Out of the high risk group 14/68 patients (21%)were considered positive.Whereas, only 5 patients (5.7%) had positiveCSF among those without any risk factors (P� 0.01). Out of the 19patients with positive CSF 6 (30%) were suspected for nosocomialmeningitis (2 due to cryptococcal, 1 bacterial, 3 aseptic), 13 (70%) forcommunity acquired meningitis (2 due to cryptococcal, 1 tuberculous,2bacterial, and 8 cases were considered to be aseptic). The only case ofnosocomial meningitis due to bacterial etiology was due to iatrogenicmeningitis.

CONCLUSIONS: Bacterial etiology is a rare etiology of nosocomialmeningitis in the absence of invasive intervention to CNS. However; in anappropriate setting, LP is still an important diagnostic procedure in ICUpatients to rule out cryptococcal and tuberculous meningitis as theetiology for delirium and/or fever.

CLINICAL IMPLICATION: It is appropriate to perform LP inMICU patients with high risk factors presenting with delirium and/orfever even in the absence of meningeal irritation signs.

DISCLOSURE: M.M. Kannass, None.

ECHO IN THE MEDICAL INTENSIVE CARE UNIT: DOES ITREALLY IMPACT PATIENT MANAGEMENT? A RETROSPEC-TIVE OBSERVATIONAL STUDYJ Chandrasekhar, MD*; Naser M.Ammash, MD; Timothy R. Aksamit,MD. Mayo Clinic, Rochester, MN

PURPOSE: Echocardiography (echo) is often requested to assist in themanagement of hemodynamically unstable patients in the medical inten-sive care unit (MICU).Little is known about the actual impact of echo onclinical decision making and therapeutic choices. The objective of thisstudy is to determine the impact of transthoracic echo (TTE) onmanagement decisions and treatment strategies.

METHODS: We retrospectively reviewed 100 consecutive patientsfrom 30 June 2000 to 1 July 2001. Data included demographics, admission

diagnosis, indication for echo,findings,length of stay and major therapeu-tic interventions performed within 48 hours of the echo. The echofindings were classified as:normal, severe valvular insufficiency or steno-sis,valvular vegetations /thrombus, hemodynamic instability sec to peri-cardial effusion, right ventricular pressure �5O mm hg, left ventricularejection fraction( EF)� 40%,limited study /poorly visualized, cardiomy-opathy, aortic dissection, others. Multiple findings on the echo were oftennoted. We determined whether a change in treatment modality ordiagnostic intervention occurred on the basis of the echo findings.

RESULTS: The mean age was 70�13 years; 60% were females. 79%underwent echo within 48 hours of admission to the ICU. Vague/undescribable/unclear/none changes in clinical care attributable to echofindings occurred in 43% of patients. See Table 1,2,3.

CONCLUSIONS: The utility of TTE to influence treatment decisionsis reportedly high in the critically ill population. In our experience thisimpact may be less than expected in the MICU. A definitive attributablechange in treatment strategy occurs in only a small percentage of patients.TTE oftens confirms clinical impressions and infrequently results in achange in management or prompts additional investigations in a MICUpatient population.

CLINICAL IMPLICATIONS: Directed clinical questions and sys-tematic decision making in the use of echo may increase its usefulness inthe MICU. Specifying indications for and clinical questions to be an-swered by echo may assist the echocardiographer to optimize clinicallyimportant information.

Table 1: Indication for Echo

Assessment of LV function 47%Assessment of wall motion abnormalities 15%Assessment of PA pressures 8%Arrhythmias 8%Pulmonary embolism 5%Shock/ hypotension 5%Assessment of volume status 5%Hypoxia 4%Cardiomyopathy 1%To r/o patent foramen ovale 1%Valve thrombus 1%

Table 2: Echo Findings

Normal study 50%Hypokinesia/akinesia-EF�40% 19%Poorly visualized/limitedstudy 16%Right ventricular pressure �50mm Hg 9%Significant valvular heart disease 5%Low cardiac volume state 1%

Table 3: Interventions within 48 hours-57%

Further consults 26%Interventional procedure-Swan Ganz catheters, central venous

catheters, dialysis catheters25%

Mechanical ventilation 8%Radiological procedures including CT Scan, MRI,etc 8%IV fluids boluses 5%Fiberoptic bronchoscopy 4%Anticoagulation 4%Antibiotics(adding/delete) 2%Vasoactive drugs (adding/delete) 2%Diuretics(add/delete) 2%Coronary angiogram 2%CABG 1%

DISCLOSURE: J. Chandrasekhar, None.


Critical Care Outcome, continued


CLINICAL OUTCOMES OF PATIENTS ADMITTED DURINGROUNDS TO THE INTENSIVE CARE UNIT DURING MEDICALROUNDSIan J. Morales, MD*; Steve G. Peters, MD, FCCP; Bekele Afessa, MD,FCCP. Mayo Clinic, Rochester, MN

INTRODUCTION: In some industries, performance of systems suf-fers during information exchange time. We wanted to determine ifperformance during time of information exchange (medical rounds) in themedical ICU was lower than during other times. To assess this, wemeasured outcomes of patients admitted during rounds (8:00 am to noon)and compared them to patients admitted at all other times.

METHODS: We examined the APACHE III database of 9165 patientsconsecutively admitted to our medical ICU over a 7.75-year periodstarting April 10, 1995. Chi square, student’s t tests and logistic regressionanalyses were used. All means are � SD.

RESULTS: Differences in baseline demographics and APACHE III datacan be seen in Table 1. The patients admitted during rounds (1627 patients)had a higher mortality rate (20.0 vs 16.0%, P�0.0001) than patients admittedduring other times, even when adjusting for admission source and severity ofillness (Odds ratio (OR) for mortality 1.58, 95% CI 1.35-1.85). Patientsadmitted during rounds also had less 28-day ICU free days (20.2 � 10.8 vs21.4 � 9.9 days, P�0.0005), and their hospital LOS was longer (14.3 vs 11.2days (survivors only), P�0.0001), even when adjusting for APACHE pre-dicted LOS (OR for longer hospitalization 1.175, 1.107-1.246 95% CI).

CONCLUSIONS: Admission during the time of medical rounds to ourmedical ICU is associated with worse outcome compared to admissionduring other times.

CLINICAL IMPLICATIONS: Performance of our ICU system islower during the time of medical rounds.

TABLE 1. Demographic and APACHE III data for patients by group

Rounds Others P value

Age (years) 63.5�18.2 61.2�19.6 �0.0001Floor transfers 46.2% 34.9% �0.0001Predicted mortality (%) 15.6�19.7 17.5�22.2 0.7044Predicted LOS (days) 16.2�7.5 15.2�7.5 0.2010

DISCLOSURE: I.J. Morales, None.

ACUTE RESPIRATORY FAILURE SECONDARY TO NON-HU-MAN IMMUNODEFICIENCY VIRUS-RELATED PNEUMOCYS-TIS CARINII PNEUMONIA: OUTCOME AND ASSOCIATEDFACTORSEmir Festic, MD*; Ognjen Gajic, MD; Andrew Limper, MD; TimothyAksamit, MD. Mayo Clinic, Rochester, MN

PURPOSE: To examine outcome and associated factors of acuterespiratory failure (ARF) secondary to non-HIV-related PCP in patientsadmitted to the intensive care unit (ICU) between 1995 and 2001.

METHODS: A retrospective review of medical charts and APACHEIII database. Data abstracted included patients’ demographics, length ofstay (LOS), APACHE III score, diagnostic procedures, prophylaxis,medications, ventilator data, discharge location and mortality.

RESULTS: We identified 24 patients (13 female, 11 male) withnon-HIV-related PCP and ARF. In-hospital, 6 month and 1 year-mortalityrates were 63%, 75% and 78%, respectively. Mean age was 62. MeanAPACHE III score was 68. Mean ICU and hospital LOS were 13 and 23days. Four patients who had pneumothorax died. All but one patient hadan elevated LDH with a mean level of 547. Mean glucose level on day onewas 140. The diagnosis was made by bronchoalveolar lavage (BAL) in 22and by transbronchial biopsy in remaining 2 patients. All patients wereimmunosuppressed (7 had corticosteroids, 6 had chemotherapy andremainder combination of both). Median prednisone-equivalent dose was45 mg for 5 months. Not a single patient received PCP prophylaxis. 20patients required invasive positive pressure ventilation (PPV) for a medianof 7 days (1-42) and 4 patients required only non-invasive PPV. MeanPaO2/FiO2 ratio was 121 and in all but in one patient this ratio was lessthan 200. Mean tidal volume (TV) in ml/kg of ideal body weight was 10.4.Hospital mortality was associated with APACHE III score (p�0.04),length of PPV (p�0.016) and glucose level on day one (p�0.018).

CONCLUSION: Among patients with ARF secondary to non-HIV-related PCP poor prognostic factors include high APACHE III scores,longer duration of PPV and hyperglycemia. All patients in our cohortfailed to receive PCP prophylaxis.

CLINICAL IMPLICATIONS: ARF secondary to non-HIV-relatedPCP remains a serious illness with high hospital mortality. Primary PCPprophylaxis should be strongly considered for all non-HIV immunosup-pressed patients.

DISCLOSURE: E. Festic, None.

THE EFFECTS OF EARLY ENTERAL FEEDING ON THE CLIN-ICAL OUTCOMES OF CRITICALLY ILL PATIENTSVasken Artinian, MD*; Bruno DiGiovine, MD, MPH. Henry FordHospital, Dearborn, MI

PURPOSE: Nutritional support has emerged as an essential compo-nent in the management of critically ill patients. Previous studies that haveshown a beneficial outcome of early enteral feeding were done inpost-operative surgical, burn and severely injured trauma patients. How-ever, the optimal time to start enteral nutrion in critically ill medicalpatients is unclear with a recent study suggesting that early feeding leadsto increased infectious complications. The aim of our study was toevaluate the effect of early feeding on the mortality of critically ill medicalpatients.

METHODS: The study was a retrospective analysis of 4,389 mechan-ically-ventilated medical patients from intensive care units across thecountry included in the Project Impact database (version 3).

RESULTS: We had 4,389 patients of whom 2,689 (61%) receivedenteral feeding within 2 days of intubation(early-feeding group) and 1,700(39%) who were not fed within this time period (late-feeding group).Patients in the early feeding group were older (mean age was 62.4 versus60.1, p�0.0001) but were less severely ill (mean APACHE II score was20.6 versus 21.2, p�0.038). The absolute ICU mortality rate was lower inthe early feeding group (18.6% versus 22.8%, p�0.001) as was the hospitalmortality (29.5% versus 34.6%, p�0.001). There was no difference in therates of hospital acquired pneumonia, gastrointestinal bleeding, or ICUlength of stay between the two groups. Even after correcting for severityof illness and age in a multivariate analysis, early feeding was associatedwith a decreased risk of death in the ICU(OR: 0.80 (95% CI: 0.67-0.95))and the hospital (OR: 0.76 [95% CI: 0.65-0.89]).

CONCLUSIONS: Administration of early enteral feeding in criticallyill patients is independently associated with a lower ICU and hospitalmortality rate. Early feeding strategy did not impact the rates of hospitalacquired pneumonia or gastrointestinal bleeding.

CLINICAL IMPLICATIONS: The results of our study support theimportance of early enteral feeding in mechanically ventilated critically illpatients.

DISCLOSURE: V. Artinian, None.

METROPOLITAN AREAS MAY HAVE HIGHER MORTALITYFROM SHOCK STATESSamuel K. Appavu, MD, FCCP*; Joel B. Cowen, MA; Michelle Bunyer,MA. University of Illinois College of Medicine, Rockford, IL

PURPOSE: We performed this study to determine whether or notmortality rate of shock states in large metropolitan areas are lower than inthe non-metropolitan areas.

METHODS: We studied all the hospitalizations within the State ofIllinois with the diagnosis of shock, both primary and secondary, using theIllinois Health Care Cost Containment Council Database for 2001 and theICD-9M codes for stock diagnosis. We excluded anaphylactic, neurogenic,and obstetric shocks. Data collection included patient’s geographic area,incidence of shock, age, gender, length of hospitalization, and outcome.The data was categorized into admissions from the Chicago metropolitanstatistical area (CMSA), other metropolitan areas (OMSA), non-metro-politan (rural) areas (NMA) and unknown areas (UNKA) and was analyzedusing SPSS statistical software.

RESULTS: From a population of 12,419,293 and hospitalization of1,130,995 we found 5933 diagnoses of shock. Of these, 4038 were fromCMSA, 912 from OMSA, 828 from NMA, a rate of 357, 336 and 336 per100,000 discharges respectively and 155 from UNKA. The rate for CMSAwas significantly higher (P� 0.01). Two hundred thirteen of 5933 (3.6%)were 0-17 years of age, 2024/5933 (34.1%) were 18-64 and 3696/5933 (62.3%)were 65 or older. One thousand five hundred ninety four of 5933 (26.9%)were hospitalized for 0-2 days, 2183/5933 (36.8%) for 3-9 days and 2156/5933




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(36.3%) for 10 days or longer. There were 2711(45.7%) deaths; the mortalityof 1875/4038 (46.4%) in the CMSA was significantly higher than the 395/972(43.3%) in the OMSA and the 352/828 (42.5%) in the NMA (P�0.02). Of the2711 deaths, 1336 (49.3%) occurred during the first two days of hospitaliza-tion. Of the 3696 patients who were 65 years or older, 1453 (48.3%) died.

CONCLUSION: Metropolitan areas have higher mortality rates fromshock than non-metropolitan (rural) areas. About half of the shock deathsoccur within the first two days of hospitalization. Elderly patients havehigher incidence and mortality.

CLINICAL IMPLICATIONS: Early aggressive therapy of shock inthe elderly may improve survival.

DISCLOSURE: S.K. Appavu, None.

EFFECT OF CAROTID ANGIOPLASTY-STENTING ON MOR-TALITY AND STROKERomeo B. Mateo, MD*; Anthony L. Pucillo, MD; Wilbert S. Aronow,MD. New York Medical College, Valhalla, NY

PURPOSE: To investigate the effect of carotid angioplasty-stenting(CAS) on mortality and stroke.

METHODS: CAS was attempted in 78 carotid arteries in 74 patients (45men and 29 women), mean age 67�10 years, with significant occlusiveinternal carotid arterial disease and was technically successful in 77 of 78arteries (99%). Of 77 arteries with successful CAS, 34 arteries (44%) wereassociated with prior carotid endarterectomy with recurrence of occlusivearterial disease, and 43 arteries (56%) were associated with primary CAS.High-risk categories (prior carotid endarterectomy, cardiac symptoms, respi-ratory symptoms, radiation therapy to neck, high lesion, or end-stage renaldisease) were present in 68 of the 74 patients (92%) undergoing CAS.

RESULTS: None of the 74 patients (0%) who underwent CAS died.Minor stroke developed in 3 of the 74 patients (4%) who underwent CAS.

CONCLUSIONS: CAS can be performed in patients with significantocclusive internal carotid arterial disease and high-risk categories with alow incidence of mortality plus stroke.

CLINICAL IMPLICATIONS: The results from CAS compare veryfavorably with carotid endarterectomy in the treatment of symptomaticand asymptomatic patients with significant occlusive internal carotidarterial disease.

DISCLOSURE: R.B. Mateo, None.

BLOOD GLUCOSE CONTROL IN THE POST-ICU RESPIRA-TORY CARE UNITDavid M. Nierman, MD, MMM*; Jeffrey I. Mechanick, MD. AcademicHealth Cntr, Mount Sinai Medical Center, New York, NY

PURPOSE: Glycemic control of hospitalized patients is associated withimproved outcomes. However, in post-ICU respiratory care unit (RCU)patients there are no treatment guidelines on managing hyperglycemia.We report the results of a 2-yr process improvement project in thatsetting.

METHODS: The 14 bed Mt. Sinai Hospital RCU for post-ICU careand weaning of ventilator dependent patients has Nurse Practitioners asprimary care providers. In 2001, changes were instituted to control bloodglucoses under the supervision of a single endocrinologist: increasedawareness of hyperglycemia, stepwise reduction in target glucose levels to80-110 mg%, changing insulin from NPH BID to Lente Q8H, avoidanceof oral hypoglycemic agents, expeditious titration of enteral feeding ratesand more aggressive treatment of glucose toxicity. Blood glucoses andinsulin dosing for all RCU patients during the first quarter of 2001 (GroupI) were compared to those during the last quarter of 2002 (Group II).

RESULTS: Demographics and hospital survival between Group I(N�39, 535 glucose measurements) and Group II (N�20, 646 glucosemeasurements) were not significantly different. RCU admission glucoseswere identical in both groups (140 � 51 vs. 140 � 72, p�.99). However,over the course of the RCU stay, patients in Group II had statisticallylower glucoses (Graph 1) achieved by titration to statistically higher dosesof Lente (Graph 2). Six percent of glucoses in Group I were less than 80mg%, compared to 20% of measurements in Group II (p�.01), with noclinically significant episodes of hypoglycemia.

CONCLUSIONS: In the RCU, blood glucoses of 80-110 mg% can beachieved using a titration schedule of Lente and Regular Insulin. Thetradeoff is an increased number of non-clinically significant glucosesbelow this range.

CLINICAL IMPLICATIONS: Using these data as a baseline, proto-cols can now be developed to standardize control of blood glucoses inventilator dependent patients in the post-ICU setting

DISCLOSURE: D.M. Nierman, None.

PREVALENCE OF POORLY CONTROLLED HYPERTENSIONIN PATIENTS WITH END-STAGE KIDNEY DISEASEPeter J. Chaille, MD*; Richard S. Schofield, MD; James A. Hill, MD;Timothy S. Cleeton, ARNP; C. Richard Conti, MD; Juan M. Aranda, MD.University of Florida College of Medicine, Gainesville, FL

PURPOSE: Patients with end-stage kidney disease (ESKD) are con-sidered the highest risk group for cardiovascular disease. Hypertension isprevalent in this patient population. Our goal was to study baseline bloodpressure and its treatment in patients with ESKD referred for cardiovas-cular evaluation prior to possible renal transplantation.

METHODS: Data from patient records were collected retrospectivelyon 179 patients who underwent pre-operative cardiac evaluation forkidney transplant. Baseline demographics, blood pressure, and antihyper-tensive treatment obtained in the initial clinic visit were recorded.

RESULTS: The patient population was 64% male. Mean patient age was50 � 12 years. Sixty-five percent had diabetes, and 97% were receivingmedical treatment for hypertension. Thirty-five percent had known coronaryartery disease at baseline. For all patients evaluated, mean systolic bloodpressure was 144 � 26 mm Hg, mean diastolic blood pressure was 77 � 14mm Hg, and mean pulse pressure was 67 � 21 mm Hg. For patients withdiabetes, mean systolic blood pressure was 145 � 26 mm Hg; only 26% ofthese patients had systolic blood pressures less than 130 mm Hg. The meannumber of antihypertensive medications per patient was 2.3. Of patientstaking various combinations of antihypertensive medications, 51% were




taking either angiotensin converting enzyme (ACE) inhibitors or angiotensinreceptor blockers (ARBs), 49% were taking beta blockers, 52% were takingcalcium channel blockers, and 26% were taking diuretics.

CONCLUSIONS: A high percentage of potential candidates forkidney transplantation with diabetes and hypertension have poorly con-trolled systolic blood pressure inconsistent with current national treat-ment guidelines. Only half of these high risk patients are on ACEinhibitors or ARBs which have demonstrated benefits in reducing cardio-vascular morbidity and mortality.

CLINICAL IMPLICATIONS: More aggressive blood pressure reduc-tion is needed for patients with hypertension, diabetes, and ESKD. Thecombination of antihypertensive agents required to achieve this shouldinclude greater use of ACE inhibitors and ARBs which have been shown toreduce cardiovascular events and mortality in this high risk population.

DISCLOSURE: P.J. Chaille, None.

DOES RHEUMATOLOGIC DISORDER INFLUENCE THECLINICAL COURSE OF CRITICALLY ILL PATIENTS IN MED-ICALLY UNDERSERVED HOSPITAL?Arshad Sheikh, MD*; Jinny Job, MD; Vincent Cappello, MD; GnanarajJoseph, MD; Sandeep Mehrishi, MD; Ashok Karnik, MD; GhulamSaydain, MD; Liziamma George, MD; Suhail Raoof, MD. NUMC, EastMeadow, NY

PURPOSE: The clinical course of rheumatologic disorder (RD) inintensive care unit (ICU) remains undefined. Our objective is to study thereason of admission and clinical outcome of the patients admitted to ICUwith RD.

METHOD: We retrospectively examined the clinical course of RD(admitted with past medical history or newly diagnosed RD) in critically illpatients (admitted to the ICU between Jan 2000 and December 2002.Patients with RD and admitted to ICU were identified based on ICD-9coding and hospital database search. Data collected include demograph-ics, co-morbid conditions, APACHE II (acute physiology and chronichealth evaluation score;TISS score (therapeutic intervention scoringsystem), cause for ICU admission, respiratory failure (defined as need formechanical ventilation/ Non invasive positive pressure ventilation), hos-pital length of stay (LOS), ICU LOS and mortality were recorded.

RESULTS: Fourty nine patients met the above criteria. Diagnosisincluded systemic lupus erythematosus (SLE) (65%), rheumatoid arthritis(26%), polymyositis (4%), mixed connective tissue disorder (1%), andothers (4%) included scleroderma, Sjogrens disease, gout, vasculitis. Thecommon causes for admission to ICU were cardiac (36%) majority ofwhom were females, sepsis (12 %), neurological (8%) surgical (8%)mutlisystem (36%). 12 patients required mechanical ventilation of which3 (25%) died. The other results are shown below

Age of patients (mean� SD, years) 56 � 19M/ F 9: 40Caucasian: Black: Hispanic 29:11:8LOS in the hospital � 7 days

� 7 days57%43%

LOS in ICU � 7 days� 7 days

83%17%

Mortality 10%Need for mechanical ventilation 24%APACHE II (mean� SD) 13.26 � 6.1TISS score 18.53 � 14.9Immunosuppresive drugs 91%

CONCLUSIONS: Inhospital mortality was 10%. Mortality was higherin patients on mechanical ventialtion. Mean APACHE score was 13 whichcorrelated well with the predicted mortality of 10% to 14%. The mostcommon cause of admission to ICU was cardiac. The most commonunderlying RD was SLE.

CLINICAL IMPLICATIONS: Even though majority of the patientswere on immunosupressives, the most common admission reason wascardiac and not sepsis, hence, more attention should be paid on ambula-tory cardiac evaluation and risk stratification of patients with RD.Prognosis of these patietns can be anticipated on the basis of APACHEscore.

DISCLOSURE: A. Sheikh, None.

PHEOCHROMOCYTOMA CHARACTERISTICS IN ADRENER-GIC SHOCKBranislav Schifferdecker, MD*; Amr Atef, MD; David H. Spodick, MD,D.Sc.; Jayashri Aragam, MD. Saint Vincent Hospital at Worcester MedicalCenter, Worcester, MA

PURPOSE: Complex hemodynamic changes induced by pheochromo-cytoma may lead to adrenergic shock. Accidental discovery of adrenalmass may be a first step in diagnosis. However, clinical significance ofadrenal mass in critically ill patients is unclear because adrenal inciden-talomas are common and frequently clinically silent.

METHODS: Retrospective analysis of patient reports. Abstracted dataincluded patients’ demographics, medical history, clinical presentation,imaging results, hemodynamic parameters and pathology findings.

RESULTS: We identified 47 reports of patients with pheochromocy-toma-associated shock between 1966 and 2003. Mean patients’ age was 44(SD �13) years. Sixty-eight percent were females. Only 23% of patientshad previously documented hypertension. Minor abdominal trauma waspossibly associated with shock in two patients. Drugs such as metoclopra-mide, phenothiazines, imipramine, beta-blockers, amiodarone and mari-juana were used in 30 % of patients shortly before shock developed.Abdominal imaging (CT, MRI, and ultrasound) first identified pheochro-mocytoma in 83 % of the patient in adrenergic shock diagnosed after1980. In 23% of patients, diagnosis of pheochromocytoma was only madeat autopsy. Average diameter of pheochromocytoma in patients withadrenergic shock was 7 cm (SD�3). Central necrosis and/or hemorrhagewere present in 78% of patients. Despite a common belief, hypotensionwas associated with predominantly adrenaline secreting pheochromocy-tomas (epinephrine/norepinephrine � 1) in only 6 out of 20 patients(30%). Mortality of adrenergic shock in this case series was 32%.

CONCLUSIONS: In patients who develop adrenergic shock, pheo-chromocytoma is not suspected and is usually incidentally found byabdominal imaging. Adrenergic shock may be initiated by drugs and minorabdominal trauma. Adrenergic shock is associated with large pheochro-mocytomas with central necrosis and/or hemorrhage. Adrenergic shock isseen both in noradrenaline and adrenaline secreting tumors.

CLINICAL IMPLICATIONS: Finding of a large adrenal mass withcentral necrosis and/or hemorrhage in critically ill patient should promptrapid biochemical confirmation of pheochromocytoma. Emergent surgicalremoval of pheochromocytoma should be considered given the highmortality associated with adrenergic shock.

DISCLOSURE: B. Schifferdecker, None.

BEDSIDE PLACEMENT OF POST-PYLORIC FEEDING TUBESIN CRITICALLY ILL PATIENTSTimothy R. Aksamit, MD*; J U. DelMundo, RN; D Bronte, RN; A Hill,RN; M Johnson, RN; L Stoskopf, RN; H VanBuren, RN; P Wentzel, RN;J Huber, RN; C Helgeson, RN; A Sullivan, RN; K Roth, RN; J Elmer, RN;R Danielson, RN. Mayo Clinic, Rochester, MN

PURPOSE: Delivery of medications and nutritional support via anenteral route in critically ill patients is problematic, associated with risk,and often poorly tolerated. These drawbacks may be improved bypost-pyloric (PP) position. Placement of a PP tube may require endoscopyor transport out of the ICU for fluoroscopic guidance. We sought toinvestigate whether staff critical care nurses using a modified techniquecould successfully place PP enteral feeding tubes at the bedside.

METHODS: Critically ill patients without esophageal stricture orrecent esophageal, gastric, head and neck, or neurosurgical surgery fromtwo ICUs were enrolled prospectively in a pilot study to evaluate abedside technique of PP feeding tube placement. Staff ICU nurses placedenteral feeding tubes following limited training of a modified placementtechnique.

RESULTS: A total of 101 patients were enrolled with an average ageof 64 years. 57 of 101 patients were female. 63% of patients were receivingmechanical ventilation. Successful PP placement was established byradiographic confirmation in 84 patients ( 83%). Of the successfulplacements 75% (63 of 84) were done on the first of maximum twoattempts. Average time spent for successful placement was 16 min,unsuccessful placement time spent 17 min. No significant complicationswere noted.

CONCLUSION: Successful placement of PP feeding tubes can bedone at the bedside safely, quickly and in the majority of critically ill




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patients without complicated esophageal disease or recent select surgicalprocedures.

CLINICAL IMPLICATIONS: Post-pyloric feeding tubes may beplaced in many critically ill patients without the need for fluoroscopy orendoscopy.

DISCLOSURE: T.R. Aksamit, None.

THE IMPACT OF AN ANTIBIOTIC DISCONTINUATION PRO-TOCOL OF THE DURATION OF THERAPY FOR VENTILATOR-ASSOCIATED PNEUMONIAMarin H. Kollef, MD*; Scott Micek, Pharm.D.; Victoria Fraser, MD.Washington University School of Medicine, St. Louis, MO

PURPOSE: To assess the impact of an antibiotic discontinuationprotocol on the duration of antibiotic therapy for ventilator-associatedpneumonia (VAP).

METHODS: A randomized study of patients requiring mechanicalventilation in the medical ICU setting. Antibiotic therapy that wasempirically started for VAP was discontinued when the white blood cellcount decreased to less than 10,000 per mm3, the temperature was lessthan or equal to 38.3 degrees C, and the PaO2/FiO2 ratio was greater thanor equal to 250 in the protocol arm. All patients were treated with aninitial antibiotic regimen containing cefepime (plus ciprofloxacin orgentamicin) for gram-negative bacilli and vancomycin or linezolid forStaphylococcus aureus.

RESULTS: All patients received antibiotic therapy to which theisolated bacteria associated with VAP were sensitive in vitro. 25 patientswere randomized to the protocol intervention and 30 to standard medicalcare. The duration of antibiotic therapy was statistically shorter among thepatients managed with the antibiotic discontinuation protocol (4.8 �/- 3.7days versus 8.0 �/- 6.8 days; P � 0.02). Hospital length of stay (16.3 �/-32.1 days versus 19.2 �/- 18.2 days; P � 0.817) and mortality (28.0%versus 33.3%; P � 0.67) were not statistically different between the twostudy groups.

CONCLUSIONS: A protocol aimed at providing objective guidancefor the discontinuation of antibiotic therapy for VAP resulted in shorterdurations of antibiotic administration.

CLINICAL IMPLICATIONS: ICU practitioners should developobjective criteria for the discontinuation of empiric antibiotic therapybegun for patients with suspected VAP.

DISCLOSURE: M.H. Kollef, Elan, grant monies; Pharmacia, grantmonies; Bayer, grant monies.

AN OBSERVATIONAL PILOT STUDY OF OSMOLAR GAP MON-ITORING TO DETECT PROPYLENE GLYCOL TOXICITY INADULT ICU PATIENTS RECEIVING HIGH-DOSE LORAZEPAMJason A. Yahwak, MD*; Richard R. Riker, MD; Gilles L. Fraser, PharmD;Sarah Subak-Sharpe, MD. Maine Medical Center, Portland, ME

PURPOSE: Benzodiazepines are commonly used sedatives in the ICUand high-dose lorazepam (LOR) has been associated with complicationsrelated to propylene glycol (PG). PG levels � 18 mg/dl are potentiallytoxic. Case series reports suggest that the osmolar gap (OG) is associatedwith PG levels. This study was undertaken to compare the OG and PGlevels.

METHODS: Adult ICU patients receiving � 1mg/kg/24 hr of LORwere enrolled. Serum osmolality was determined by freezing pointdepression and OG calculated (measured serum osmolality – calcu-lated osmolality) at enrollment and every other day while receivingLOR. A PG level was obtained when the OG was first � 12 and atdiscontinuation of LOR. Correlations between drug dose, PG, and OGwere determined using the nonparametric spearman test. Data arereported as median (IQR).

RESULTS: 14 patients were enrolled. Age was 49 (40-63), 36% werefemale, APACHE II at start of drug was 16 (14-24), and mortality was57%. Patients received a total of 631 (437-972) mg LOR for 5.5 (4-8.75)days. 47 OG values were obtained, measuring 8.0 (4.6-11) on day one and10 (7.8-12) at completion of LOR with maximum OG per patient of 11(10.25-12). The correlation between OG and PG was 0.66 (p�0.0055),OG and total LOR; 0.65 (p�0.0001), OG and daily LOR; 0.6 (p�0.0001),OG and LOR/KG; 0.61 (p�0.0001), and OG and LOR/KG/DAY; 0.58(p�0.0001). Of 12 OG values � 10, 11(92%) had PG �18. Of 4 OG � 10all (100%) had PG �18.

CONCLUSIONS: OG correlates with PG levels in adult patientsreceiving high-dose LOR. OG values � 10 are associated with toxic PGlevels.

CLINICAL APPLICATIONS: Every other day OG monitoring canpredict PG toxicity in patients receiving high dose LOR.

DISCLOSURE: J.A. Yahwak, None.

INAPPROPRIATELY LOW LEVELS OF ANTIDIURETIC HOR-MONE (ADH) ASSOCIATED WITH HEPATIC FAILUREWilliam D. Marino, MD, FCCP*; Hakop H. Hrachian, MD; Sreenivas D.Gunturu, MD; Yuan Y. Li, MD; Anna W. Komorowski, MD. UniversityHospital, Our Lady of Mercy Medical Center, Bronx, NY

PURPOSE: In various forms of vasodilatory shock such as septic shockADH levels are inappropriately low. Some authors have attributed thehypotension of refractory septic shock to relative vasopressin deficiencyand clinical trials have used vasopressin successfully in the treatment ofvasodilatory shock. End stage liver disease with hypotension has apathophysiology similar to other forms of vasodilatory shock and vasopres-sin administration has been shown to improve renal function in hepato-renal syndrome. We thus speculated that vasopressin levels may be low inhepatic failure with hypotension or concurrent renal failure.

METHODS: 100% chart review of patients admitted to our institutionwith hepatic failure between November 2002 and April 2003. Hemody-namic, hematologic and serum chemistry data were recorded at the timeof measurement of the ADH level. Vital signs, demographics and outcomewere also recorded.

RESULTS: Of the 11 patients admitted, 3 survived and 8 died. Thepatients were 7 male, 4 female aged 57 � 34 years. Length of stay was 4to 40 days. Two of the patients had positive blood cultures at the time ofADH measurement, and were excluded. Of the remaining 9 patients, 4(44%) had mean arterial pressures (MAP) of � 65 mmHg. Three (33%)had systolic blood pressures of �90 mmHg. Calculated osmolarity rangedfrom 269 to 310 with average of 290.96 mOsm/L. Azotemia with BUN �30 mg/dL was present in 4 (44%) of the patients. ADH levels ranged from1.6 to 4.4 pg/ml (normal range 1-13.3 pg/ml). These levels bore norelationship to blood pressure, osmolarity or azotemia.

CONCLUSION: ADH levels were low in hepatic failure despitehypotension, hyperosmolar stimuli and renal failure, which would ordi-narily be expected to make them rise.

CLINICAL IMPLICATIONS: ADH levels in hepatic failure werelow despite stress and may contribute to vasomotor instability in thissetting. Studies are needed to evaluate the possible utility of vasopressinadministration as treatment for hypotension in hepatic failure.

DISCLOSURE: W.D. Marino, None.

RELIABILITY OF FOREHEAD PULSE OXIMETRY IN CRITI-CALLY ILL PATIENTSSung Wu Sun, MD; Bhavi Patel, MD; Wanda Gangoo, MS; Zev Carrey,MD.* The Mount Vernon Hospital, Mount Vernon, NY

PURPOSE: Pulse oximetry has been a valuable tool in monitoringcritically ill patients. The designated sites for pulse oximetry are fingers,toes, and earlobe. In many instances, the pulse oximetry sensor is placed




on the forehead for ease of access and stability. This study is done to assessthe reliability of forehead pulse oximetry measurements.

METHODS: Out of 27 total patients enrolled in the study, 15 wereventilator-dependent, 2 had baseline hypoxia, and 10 were healthyindividuals. For 16 ventilator patients and 2 hypoxic patients, arterialblood gas study (ABG), finger and forehead pulse oximetry were per-formed. Telemetry was applied to monitor heart rate and to compareoxymeter wave form. For 10 healthy volunteers, finger and forehead pulseoximetry and EKG wave forms were recorded. Nellcor Oxisensor II D-25was used for pulse oximetry.

RESULTS: Finger and forehead pulse oximetry measurements did notdiffer significantly in normal volunteers and in patients who were welloxygenated on mechanical ventilation. In 2 hypoxic patients, forehead O2saturation (SpO2) overestimated SpO2 compared to the finger (figure 1).In healthy volunteers, no significant difference was found between fingerand forehead SpO2. During induced hypoxia of normal volunteers, onevolunteer’s forehead SpO2 significantly overestimated compared to fingerSpO2 (figure 2).

CONCLUSION: Finger pulse oximetry better correlates with actualABG in patients and healthy volunteers. In addition, we observed thatforehead pulse oximetry may overestimate O2 saturation in critically illpatients who are hypoxic and may lead to adverse event of the patient.

CLINICAL IMPLICATIONS: Based on our observation in criticallyill patients and normal volunteers, forehead pulse oximetry is not a reliablemethod of monitoring tissue oxygenation; it may overestimate SpO2 andthe practice should be strongly discouraged. Further study is warrented.

DISCLOSURE: Z. Carrey, None.

SAFETY AND EFFICACY OF SHORT-ACTING SUBLINGUALNIFEDIPINE IN THE TREATMENT OF SYSTEMIC HYPERTEN-SION IN PATIENTS WITH ELEVATED INTRACRANIAL PRES-SUREWilliam D. Marino, MD, FCCP*; Anna W. Komorowski, MD; Hakop H.Hrachian, MD; John Hughes, MD; Siobhain McHale, RN. UniversityHospital, Our Lady of Mercy Medical Center, Bronx, NY

PURPOSE: Intracranial disease with increased intracranial pressure(ICP) is often attended by systemic hypertension, which must be con-trolled. Many antihypertensive medications have side effects (e.g. in-creased ICP with many vasodilators and bradycardia with beta blockers)which limit their utility in this setting. Sublingual nifedipine has no suchside effects, and has long been used in our medical intensive care unit(MICU) for the treatment of arterial hypertension accompanying elevatedICP. Recent reports of hypotension associated with the use of sublingualnifedipine have caused its safety to be questioned. We report ourexperience of the last 15 years with short acting nifedipine in this setting.

METHODS: Review of the medical records of all patients withintracranial pathology treated in our MICU during the past fifteen years.Diagnosis, therapy, vital signs, Glasgow Coma Score, APACHE II score,case mix and outcome were recorded.

RESULTS: 353 patients (6.3% of all patients treated) had intracranialdisease with systemic hypertension. Blood pressure was lowered usingnifedipine 10mg sublingually every 2 hours for mean arterial pressures(MAP) above 120 mmHg. The diseases were: 56% intracerebral hemor-rhage, 36% infarct, 5% subarachnoid hemorrhage, 2% subdural hema-toma, and 1% neoplasm. The Glasgow coma score was 8.8 � 4.6 and theAPACHE II score was 19 � 9. Mortality was 29 %, 60 % of that predictedby APACHE II. The patients were 178 males and 175 females, aged 64 �14 years. There were no episodes of hypotension or other mishap relatedto nifedipine administration. In all patients, MAP was easily controlled tothe target range of 100-115 mmHg.

CONCLUSIONS: Short acting nifedipine is a safe and effectiveantihypertensive agent when used in a structured and carefully monitoredprotocol, making its advantages for use in intracranial disease availablewith no risk of hypotension.

CLINICAL IMPLICATIONS: Current recommendations and regu-latory agency statements regarding potential risks of short acting nifedi-pine should be re-evaluated, as should the database on which they rely fortheir validity.


EVALUATION OF NEAR-INFRARED SPECTROSCOPY FOR DI-AGNOSIS AND TREATMENT OF METHEMOGLOBINEMIA INA NEW ZEALAND RABBIT MODELNaglaa H. El-Abbadi, BS*; Reza Mina-Araghi, MD; Jangwoen Lee, PhD;Nevine Mikhail-Hanna, BS; Albert Cerussi, PhD; Bruce Tromberg, PhD;Andrew Duke, MD; William Waite, BS; Tanya Burney, BS; MatthewBrenner, MD. Beckman Laser Institute, Irvine, CA

BACKGROUND: Frequency Domain Photon Migration (FDPM) is anon-invasive infrared monitoring technology that functions by directing anintensity modulated monochromatic light source at the tissue of interest.Simultaneous determination of absorption and scattering provides thecapability for non-invasive direct measurement of tissue metabolitecomposition. FDPM could potentially be used to monitor changes invarious metabolic parameters such as methemoglobin (MetHgb) andmethylene blue concentrations during treatment in vivo.

PURPOSE: The purpose of this study is to evaluate the feasibility ofFDPM to non-invasively monitor metabolic events, such as the extent ofmethemoglobinemia and reversal using methylene blue in vivo.

METHODS: In vivo detection of methemoglobinemia was evaluatedin a New Zealand Rabbit model via intravascular injection of amyl nitrite,and the effects were assessed using FDPM monitoring with a prototypedevice constructed in our laboratory. The FDPM data were then com-pared to standard arterial blood gas measurements of MetHgb using aco-oximeter.

RESULTS: In vivo, MetHgb concentration quantitatively measured byFDPM was compared to %MetHgb obtained through arterial blood gasmeasurements. Rapid development of methemoglobinemia followingamyl nitrite injection was non-invasively tracked, as shown in the figureincluded.

CONCLUSIONS & CLINICAL IMPLICATIONS: Our resultsdemonstrate the feasibility of monitoring MetHgb levels in tissue non-




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invasively via FDPM. The ability to non-invasively measure metabolicparameters may someday be useful for assessing and treating conditionssuch as methemoglobinemia and cyanide toxicity.

DISCLOSURE: N.H. El-Abbadi, TRDRP# 9RT-0094, grant monies;Air Force D/F49620-00-10371, grant monies.

ARTIFICIAL LUNG IN A PORCINE MODEL: USING PERITO-NEAL PERFUSION WITH PERFLUOROCARBONJoseph S. Friedberg, MD*; Shamus Carr, MD; Scott Cowan, MD;Annamarie Horan, PhD. Thomas Jefferson University, Philadelphia, PA

PURPOSE: Despite maximal mechanical ventilatory support, manypatients die from hypoxia in the setting of potentially reversible pulmonaryfailure from causes such as ARDS, pneumonia and pulmonary embolism.The specter of a pulmotoxic terrorist attack, as well as the recent onset ofthe severe acute respiratory syndrome (SARS) epidemic, underscores thepressing need for additional pulmonary supportive care measures. Thepurpose of this study was to see if was possible to deliver a significantamount of oxygen to a large animal, with induced hypoxia, by perfusingthe abdomen with oxygenated neat perfluorocarbon.

METHODS: 6 pigs, weighing 45 to 55 kg, were rendered hypoxic byventilating them with subatmospheric inspired oxygen concentrations(FIO2) ranging from 18%-10%, resulting in baseline arterial oxygenpressures (PaO2) of 88 to 24 mmHg, respectively. Peritoneal perfusionwas then performed in 3 animals with oxygenated perfluorocarbon and 3control animals with oxygenated saline.

RESULTS: The most clinically relevant results occurred at an FIO2 of16%. At this level we observed an average increase in the PaO2 of 13.9mmHg, from a PaO2 of 46.3 mmHg (82.2% saturation) to a PaO2 of 60.2mmHg (91.4% saturation). Although the animals were maintained essen-tially normocarbic, the addition of peritoneal perfusion with oxygenatedperfluorocarbon decreased the PaCO2 from 44 to 38 mmHg. None of thecontrol experiments demonstrated any significant gas exchange effect.

CONCLUSIONS: In our model we observed clinically relevant in-creases in arterial oxygen saturation from 82.2% to 91.4%. The results ofthese preliminary studies show that the peritoneal surface can serve as asupplemental “artificial lung” when perfused with oxygenated perfluoro-carbon.

CLINICAL IMPLICATIONS: This technique may have a potentialrole in the supportive care of patients dying from hypoxia in the setting ofa reversible lung injury.

DISCLOSURE: J.S. Friedberg, None.

HIGH TIDAL VOLUME AND POSITIVE FLUID BALANCE INACUTE LUNG INJURY ARE ASSOCIATED WITH WORSE OUT-COMEYasser Sakr, MD; Jean-Louis Vincent, MD PhD FCCP*; Jean-Roger LeGall, MD; Konrad Reinhart, MD; Charles Sprung, MD; Rui Moreno,MD; Didier Payen, MD; Jean Carlet, MD; Herwich Gerlach, MD; MarcoRanieri, MD. Erasme University Hospital, Brussels, Belgium

PURPOSE: Recent data have suggested that ventilatory strategy couldinfluence outcome from acute lung injury (ALI) and acute respiratorydistress syndrome. We tested the hypothesis that the occurrence of

infection/sepsis and violation of the “ARDSNet” protective strategy wouldworsen outcome.

METHODS: In a cohort, observational study, all patients admitted to198 centers from 24 European countries between May 1 and 15, 2002were followed up until death, hospital discharge, or for 60 days. Westudied the predictive factors for mortality in patients with ALI/ARDS,defined according to the American/European consensus conference cri-teria. “ARDSNet” protective strategy violation was defined as the use oftidal volumes �7.4 ml/kg (predicted body weight), plateau pressure �30cmH2O, or PEEP higher or lower than proposed by the protocol for agiven FiO2.

RESULTS: Of the 3147 adult patients enrolled in the study, 393 (12.5%) had ALI/ARDS. These patients had higher ICU and hospital mortal-ities (38.9 vs. 15.6%, 45.5 vs. 21.0%, respectively, p�0.001) than otherpatients. Nonsurvivors of ALI/ARDS were older (61.6 � 15.3 vs. 57.5 �17.9 years, p�0.36), and more likely to be female (52.9 vs. 34.7%,p�0.016) than survivors. Overall infection rates were similar (74.5 vs.72.0%, p�0.58); however, septic shock was more prevalent in nonsurvi-vors (55.6 vs. 32.2%, p�0.001). The average tidal volume was 9.9 � 2.4ml/kg, and the PEEP was 4.8 � 3.9 cmH2O. High tidal volumes wereused more in the nonsurvivors compared with survivors (44.4 vs. 33.5%,p�0.019). In a multivariable logistic regression analysis with ICU out-come as the dependent factor, only the presence of cancer, high tidalvolume, mean SOFA score, and higher mean fluid balance were indepen-dent risk factors for mortality.

CONCLUSIONS: In addition to comorbidities and organ dysfunction,high tidal volumes and positive fluid balance are associated with worseoutcome from ALI/ARDS.

CLINICAL IMPLICATIONS: High tidal volumes are associated withincreased mortality and yet are frequently used. More widespread use oflung protective strategies may improve outcome from ALI/ARDS.

DISCLOSURE: J. Vincent, None.

OUTCOME FOLLOWING MECHANICAL VENTILATION OFALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTPATIENTS: HAS SURVIVAL IMPROVED?Stephen M. Pastores, MD*; Margarita Alicea, RN; Lorna Schneider, RN,CCRN; Esperanza Papadopoulos, MD; Neil A. Halpern, MD. AcademicTeaching, Memorial Sloan Kettering Cancer Center, New York, NY

PURPOSE: Historically, the survival rate in patients with hematologicmalignancy who develop acute respiratory failure (ARF) requiring me-chanical ventilation (MV) following allogeneic hematopoietic stem celltransplantation (HSCT) has been very poor, ranging from 4-13%. Thepurpose of this study was to determine if there has been any change in theoutcome of this patient population in recent years.

METHODS: We retrospectively analyzed the outcomes of all ICUpatients with hematologic malignancy treated with allogeneic HSCT whodeveloped ARF and/or sepsis with ARF and required MV for � 24 h. Thestudy period was from January 1, 2000 to December 31, 2002. Patients �18 years of age were excluded. Hospital survival was extubation from MVand discharged alive from the hospital.

RESULTS: 46 allogeneic HSCT patients received MV for � 24 h.27(59%) were male and 19 (41%) were female. Mean age was 40 years(range: 19-67). Indications for HSCT were leukemia (n�28), lym-phoma (n� 10), myelodysplastic syndrome (n�7), and Waldenstrom’smacroglobulinemia (n�1). The source of the stem cells was peripheralblood in 24 (52%) and bone marrow in 22 (48%). 34 of the 46 MVpatients had documented infection. Ten (22%) of the 46 MV patientssurvived and 36 (78%) died. The mean age of survivors was 34 yr.However, only 3 (30%) of the 10 MV patients who initially survivedwere alive at 6 months.

CONCLUSIONS: The ICU survival rate of allogeneic HSCT patientswho developed ARF and received MV has improved in recent years.

CLINICAL IMPLICATIONS: The increased survival rate for MVallogeneic HSCT patients in this series may perhaps be related toadvances in ventilator and sepsis management, early shock resuscitationand ICU admission.

DISCLOSURE: S.M. Pastores, None.




A RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED,SINGLE-CENTER PILOT STUDY TO DETERMINE THE EFFI-CACY OF RECOMBINANT HUMAN INTERLEUKIN IL-11 (NEU-MEGA) IN TREATING THROMBOCYTOPENIA IN BURN PA-TIENTSBruce Friedman, MD*; Joseph R. Shaver, M.D; William Hickerson, MD;Joan Wilson, RN, BSN; Joseph M. Still, MD. Private, Doctors HospitalAugusta, Augusta, GA

PURPOSE: Thrombocytopenia is a common complication of acuteburn injury. It results from dilutional and other multi-factorial pro-cesses. IL-11 stimulates mega-karyocytopoiesis. We hypothesized us-ing IL-11 in burns would reverse thrombocytopenia and decreaseblood products usage.

METHODS: 25 patients were randomized to receive placebo or50mcg/kg SC IL-11 if the platelet count decreased by a predeterminedschema. Baseline demographics, serial lab data, adverse events andtransfusion requirements were analysed over 14 days.

RESULTS: Placebo (12), IL-11 (13) patients were statistically matchedfor age, gender, and TBSA (median 35% for both groups). Mean andmedian platelets versus time by treatment groups was not statisticallydifferent (0.756). A positive trend to reduction of platelet transfusions wasshown by Wilcoxon and Bootstrap analysis (p-0.431). No differences weredetected in RBC transfusions. Kaplan-Meier analysis on time to effect wasalso inconclusive. Adverse events were documented but no differenceswere detected between groups.

CONCLUSIONS: IL-11 stimulates mega-keryocyte function andplatelet restoration. However, when compared to placebo in acute burnsthe null hypothesis is not proven. A trend in platelet transfusion needs wasnoted in the IL-11 group. Our sample size may not have been powered todetect our clinical and scientific observations.

CLINICAL IMPLICATIONS: Neumega (IL-11) may still be animportant adjunctive therapy in the critically ill. A large multicenter trialis warranted.

DISCLOSURE: B. Friedman, Wyeth-Ayerst Pharmaceuticals, grantmonies, discussion of product research or unlabeled uses of product.

SPHINGOSINE-1-PHOSPHATE ATTENUATES ENDOTOXIN-INDUCED LUNG INJURY IN A CANINE MODELBryan J. McVerry, MD*; Brett A. Simon, MD, PhD; Joe G. N. Garcia,MD. Johns Hopkins University School of Medicine, Baltimore, MD

PURPOSE: High permeability pulmonary edema is a key feature ofacute lung injury (ALI) and is worsened by mechanical ventilation.Although ALI represents a significant cause of morbidity and mortality incritically ill patients, specific adjunctive therapies are not well character-ized. As sphingosine-1-phosphate (Sph-1-P), a biologically active phos-pholipid, enhances endothelial layer barrier function in vitro, we hypoth-esized that Sph-1-P would attenuate alveolar edema formation in a caninemodel of endotoxin (LPS)-induced ALI.

METHODS: 11 male beagles (10-15 kg) were anesthetized, intubated,and mechanically ventilated. LPS (2 mg/kg in 0.9 NS) was segmentallyinstilled intrabronchially via fiberoptic bronchoscope in four control dogsand in four dogs treated concomitantly with intravenous Sph-1-P (85�g/kg). Sham intrabronchial saline instillation was performed in threeanimals. Supportive care including mechanical ventilation (Vt�17cc/kg,PEEP�5 cm H2O, FiO2�30%), fluid resuscitation, and hemodynamicmonitoring was provided for six hours. ALI was quantified by shuntformation (Qs/Qt), bronchoalveolar lavage (BAL) protein concentration,and Evan’s Blue Dye (EB) extravasation.

RESULTS: Beagles remained hemodynamically stable throughouteach experiment. Qs/Qt increased rapidly following LPS instillationand continued to rise over time in control dogs (solid circles). Sph-1-Pattenuated increases in shunt fraction following an initial exacerbationof LPS-induced injury (open circles, p�0.05 at 90 min, p�0.05 at 330min). Saline instillation evoked mild increases in shunt (squares). BALprotein concentration was lower in Sph-1-P treated dogs (dark greybars) compared to controls (black bars) at 150 min (p�0.05) and at 330min. BAL protein was attenuated in Sph-1-P animals compared tosham injured dogs (light grey bars, p�0.05 at 330 min). Finally, EBextravasation was decreased in sham and Sph-1-P dogs compared toLPS controls.

CONCLUSIONS: Intravenous Sph-1-P attenuates vascular leak asso-ciated with LPS-induced ALI.

CLINICAL IMPLICATIONS: Sph-1-P may shorten the duration ofmechanical ventilation and thereby limit morbidity associated with ALI.

DISCLOSURE: B.J. McVerry, None.

Health Economics and PracticeAdministration12:30 PM - 2:00 PM

MANAGEMENT OF SUSPECTED AORTIC DISSECTION DUR-ING INTERFACILITY TRANSPORT: OPPORTUNITY FOR BEN-EFICIAL INTERVENTION BY THE CRITICAL CARE TRANS-PORT CREWStephen H. Thomas, MD MPH*; Greg Winsor, RN; Paul Biddinger, MD;Suzanne K. Wedel, MD, FCCP. Transport Service, Boston MedFlight,Boston, MA

PURPOSE: Blood pressure control with antihypertensive therapy (AT)is a vital component of early critical care of patients with suspected acuteaortic dissection (SAD). This study’s objective was to assess the frequencyand efficacy with which a critical care transport team (CCTT) institutedAT to patients undergoing interfacility (IF) transfer for a referring hospital(RH) diagnosis of SAD.

METHODS: The study was a retrospective review of 5 years oftransfers by a two-helicopter, nurse/paramedic staffed CCTT operatingunder protocol-guided care. Eligible patients were subjects undergoing IFtransfer for SAD who did not have hypotension (systolic blood pressure[SBP]120, the RH had provided AT in 23 (54.8%).

- In the 19 cases where pre-transport SBP�120 but no RH AT wasadministered, median pre-transport SBP was 158 (range 122 to 212,interquartile range [IQR] 141-180).

- In 20 patients (32.3% of 62) the CCTT instituted new AT. Inmultivariate modeling, CCTT AT institution was associated with higherpre-transport SBP, longer CCT time, and ultimate confirmation ofdissection diagnosis (probably as a surrogate marker for patient severityand/or likelihood of SAD diagnosis as perceived by the CCTT).

- Overall, for the 62 study patients the median SBP change from pre-to post-transport was –13.5 (IQR, –31 to �5). Post-transport average SBP(129 � 27, 95% confidence interval [CI] for mean, 122-136) wassignificantly (p � .0007) lower than the average pre-transport SBP (142 �35.5, 95% CI 133-151).

- For the 42 patients with pre-transport SBP�120, the difference inpre-transport (161 � 25, 95% CI 154 -169) and post-transport (138 � 24,95% CI 130 to 145) SBPs particularly marked (mean SBP decrementduring transport, 24 {95% CI 16-32}; p � .0001).

CONCLUSION: Despite advanced RH imaging and sufficiently highSAD suspicion to trigger helicopter transport, CCTT institution of AT in




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SAD patients is frequently indicated and appears to be efficacious. Thisrepresents an area of potentially important intervention for critical caretransport services.

DISCLOSURE: S.H. Thomas, None.

NEW CHOICES FOR CENTRAL VENOUS CATHETERS: PO-TENTIAL FINANCIAL IMPLICATIONSAndrew F. Shorr, MD*; Christopher W. Humphreys, MD; Donald L.Helman, MD; Anthony S. Ramage, DO. Walter Reed Army MedicalCenter, Washington, DC

PURPOSE: Catheter-related blood stream infections (CRBSIs) remaina challenge in critical care. Two central venous catheters (CVCs) impreg-nated with either chlorhexidine-silver sulfadiazine (CSS) or rifampin/minocycline (RM) are commercially available. The cost-effectiveness ofthese treated CVCs has not been determined.

METHODS: We modeled the cost and efficacy of the coated CVCs atpreventing CRBSIs. The primary outcome was the incremental cost (orsavings) to prevent one additional CRBSI. Model estimates were derivedfrom prospective trials of the CSS and RM CVCs and from studiesdescribing the costs of CRBSIs. We compared each newer CVC to astandard, uncoated CVC and to each other. The incremental cost-effectiveness of the treated CVCs was calculated as the savings resultingfrom CRBSIs averted less the additional costs of the newer devices.

RESULTS: In the base-case we assumed the incidence of CRBSIs was3.3% with traditional CVCs and that the CSS and RM CVC conferredrelative risk reductions of 60% and 85%, respectively. Despite their highercosts, both novel CVCs yield savings. Employing either treated CVCssaves approximately $10,000 per CRBSI prevented (relative to standardcatheters). The RM CVC saved nearly $9,600 per CRBSI averted and $81per patient in the cohort when compared to the CSS CVC. For sensitivityanalysis we adjusted all model variables by 50% individually and thensimultaneously. The model was moderately sensitive to the cost of aCRBSI. However, with all inputs skewed by 50% against both the CSSand RM CVC, these devices remained economically attractive. Under thisscenario, use of either treated device remained less costly. Thresholdanalysis showed that the newer CVCs were cost-saving until either theincidence of CRBSIs fell below 0.6% or the cost of a CRBSI drops toapproximately $1300.

CONCLUSIONS: Both the RM and CSS CVC are financially attrac-tive options for prevention of CRBSIs. The RM CVC generates moresavings than the CSS CVC.

CLINICAL IMPLICATIONS: Broader use of treated CVCs is war-ranted based on their cost-effectiveness.

DISCLOSURE: A.F. Shorr, None.

COST-EFFECTIVENESS OF LINEZOLID FOR TREATMENTOF VENTILATOR-ASSOCIATED PNEUMONIAAndrew F. Shorr, MD*; Marin H. Kolleff, MD; Gregory B. Susla,PharmD. Walter Reed Army Medical Center, Washington, DC

PURPOSE: Our goals were to determine the incremental cost-effectiveness of linezolid (LIN) compared to vancomycin (VAN) for VAPdue to S. aureus and to investigate the cost-effectiveness of broader use ofbronchoscopy (FOB) in the management of VAP.

METHODS: We modeled the cost and efficacy of LIN vs. VAN fortreatment of VAP. The primary outcome was the incremental cost-effectiveness of LIN in terms of cost per added quality-adjusted life-year(QALY) gained. A second model investigated the impact of routine FOBin patients suspected of having VAP and its potential to limit costs bydecreasing the need for either LIN or VAN. Model estimates werederived from prospective trials of LIN for VAP and from studiesdescribing the costs and outcomes for VAP.

RESULTS: The incremental cost-effectiveness of LIN was calculatedas the additional QALYs resulting from therapy with LIN divided by thesum of the incremental costs arising because of use of LIN (e.g., higherdirect costs for LIN, costs for in-hospital care of survivors, and post-hospitalization costs). Despite higher acquisition costs, LIN was cost-effective for treatment of VAP. The cost per QALY equaled approximately$30,000. Routine use of FOB improved the cost-effectiveness of LIN(cost per quality-adjusted life-year 3.4% less than baseline case). Themodel was moderately sensitive to the estimated efficacy of LIN. None-theless, with all inputs simultaneously skewed against it, LIN remained acost-effective option. Based on Monte Carlo simulation, the results of our

analysis are robust across a range of model inputs and assumptions (95%CI for cost per QALY: $23,637 to $42,785).

CONCLUSIONS: LIN is a cost-effective alternative to VAN. Broaderuse of FOB may limit costs by decreasing the need for treatment witheither LIN or VAN.

CLINICAL IMPLICATIONS: Despite higher pharmacy costs, reli-ance on LIN in VAP may be warranted based on cost-effectiveness. FOBcan help contain costs if employed as a tool to limit exposure to antibiotics.

DISCLOSURE: A.F. Shorr, Pharmacia, Grant monies.

IMPACT OF A HOSPITAL-WIDE PHARMACY IMPLEMENTEDWEIGHT-BASED DOSING PROTOCOL FOR ERYTHROPOIE-TINLeo C. Rotello, MD*; Dan Albrant, PharmD; Kaldun Nossuli, MD;George Sotos, MD; Cyrus Samet, PharmD; Thomas Rainey, MD. Sub-urban Hospital, Rockville, MD

PURPOSE: Weight-based protocols of rHuEPO have been shown toreduce the need for transfusions in critically ill patients. In our institutionICU use of erythropoietin accounts for less than 10% of total hospitalusage, however this is the only location where weight based dosing isutilized. We evaluated the impact of applying weight based dosing oferythropoietin similar to that done in the ICU to all patients in thehospital.

METHODS: The ICU, renal and hematology services collaborativelydeveloped a weight based dosing protocol based on established literature.This protocol was automatically substituted by pharmacy whenever anerythropoietin dose was written in the hospital. Data was collected ondose adjustments and total usage.

RESULTS: During the first 90 days, 42 orders were evaluated of which36 required adjustment. Prior to adjustment the total dose of erythropoi-etin ordered was 1,406,00 units. Following adjustment the total amountactually administered was 852,000 units resulting in a 39% decrease inutilization and approximately a $5,700 cost saving for that 90 day period.There were only 3 physician overrides of the protocol.

CONCLUSIONS: A pharmacy implemented weight based dosingprotocol for erythropoietin results in significant decreases in drug utiliza-tion and cost savings for the hospital.

CLINICAL IMPLICATIONS: Standardized non-physician directedprotocols are an effective tool for appropriate medication dosing andreduction of pharmacy acquisition costs.

DISCLOSURE: L.C. Rotello, Ortho Biotech. Speakers Bureau.

ASSESSING THE FINANCIAL VIABILITY OF OFFICE SPIROM-ETRYEdward Diamond, MD, MBA*; Bruce Behn, PhD.; Kim D. French,MHA, CAPPM; Kim Markwell, BS, CPFT. Private Practice, SuburbanLung Associates, Elk Grove Village, IL

PURPOSE: Office spirometry is a standard of care for the diagnosisand management of asthma and COPD, for screening of cigarettesmokers, and for the evaluation of a variety of symptoms. Limitedavailable data from payors indicates a small penetration of office spirom-etry in patients seen with respiratory related diagnostic codes. Thepenetration is much smaller in HMO plans presumably due to financialconstraints. The environment of imploding reimbursement and risingcosts appears to represent a barrier to the utilization of office spirometryin primary care. We present a practice administration tool that is useful indetermining the financial viability of purchasing an office spirometer toperform basic pulmonary function testing.

METHODS: We used a managerial concept called cost-volume-profit(or breakeven) analysis. This approach quantitates the relationship amongreimbursement, volume, variable cost, fixed cost, and payor mix. Thebreakeven volume can by calculated by dividing the fixed costs by thecontribution margin, which is the difference between receipts per test andvariable cost. The standard model was adapted to account for variance inrevenue from multiple payors, and for multiple types of tests performedby the instrument.

RESULTS: We created an Excel calculator that facilitates the analysis.The calculator guides the user through the process of inputting datarelated to fixed costs, variable costs, payor mix, and revenues. Thebreakeven volume is calculated.


Health Economics and PracticeAdministration, continued


CONCLUSION: We have developed a tool that utilizes the techniqueof cost-volume-profit analysis. We believe that it should facilitate theefforts of physicians to evaluate the financial viability of purchasing anoffice spirometer.

CLINICAL IMPLICATIONS: The ability to perform a financialanalysis may address one of the barriers that appears to contribute to thelow utilization of office spirometry by primary care physicians.

DISCLOSURE: E. Diamond, None.

THE DIAGNOSTIC YIELD AND THE THERAPEUTIC IMPACTOF THE ROUTINE DAILY CHEST RADIOGRAPHS IN ICUPATIENTSOusama Dabbagh, MD*; Yaseen Arabi, FCCP; Samir Haddad, MD; NazirAhmad, MD; Abdullah Al Shimemeri, FRCP (C). King Abdulaziz MedicalCity, Riyadh, Saudi Arabia

PURPOSE: To evaluate the yield of routine daily chest X-rays in theIntensive care patients

METHODS: All routine daily chest radiographs performed in a 21-bedmedical-surgical ICU were included. The following data was collectedprospectively: demographics, clinical presentation, ventilatory mechanics,sedation and vasoactive medications. All radiographs were reviewed by theICU consultant during morning X-ray rounds. Nothing was done toinfluence the ordering of radiographs. We documented new radiographicchanges, such as the development of new infiltrates, atelectasis, pnuemo-thorax or edema, variations in the position of tubes and lines and anyintervention based on these changes.

RESULTS: A total of 308 consecutive chest radiographs were included.The mean APACHE II score was 19.8 � 6.5. New radiographic changes wereobserved in 92 instances (29.8%). The most frequent changes were malpo-sition of endotracheal tube (36.9%), pulmonary edema (18.4%) and atelec-tasis (11.9%). Two or more findings were observed in 16.3% .Pneumothoraxwas found in only 4.3% (1.2% of all chest radiographs). Major findings wereobserved in only 13.9%. A change in therapy was made on the chestradiograph in 79 instances (25.6%). The most frequent therapeutic interven-tions were repositioning of endotracheal tube (51.8%), starting diuretics(16.1%) and several interventions (starting antibiotics, diuretics, and chestphysiotherapy) in 11.3%. There was no significant difference in the percent-age of radiographic changes between intubated vs. non-intubated patients(32.2% vs. 24.5%, p�0.26) or between patients with Glasgow coma scale ofless than 10 vs. those above 10 (34% vs. 26% p�0.41).

CONCLUSIONS: Routine daily chest radiographs revealed new find-ings in only 29.8% and resulted in management change in 25.6% ofinstances. Radiographic changes and interventions were comparableamong intubated and non-intubated patients. Life threatening findings(such as pneumothorax) were rather rare.

CLINICAL IMPLICATIONS: These findings question the practiceof routine chest radiographs in ICU patients. It is possible that many ofthese tests can safely be avoided. Randomized trial comparing routineversus as necessary ordering behavior is necessary in this field.

DISCLOSURE: O. Dabbagh, None.

WHO SHOULD MANAGE WARFARIN ANTICOAGULATION?OUTCOME DATA BY PHYSICIAN SPECIALTYSameer J. Khandhar, MD*; Allen M. Amorn, BS; J. Ronald Mikolich, MD.Northeastern Ohio Universities College of Medicine, Youngstown, OH

PURPOSE: Given the morbidity and mortality potential of diseasestates for which physicians administer warfarin, achievement of ther-apeutic INR (t-INR) values as recommended by the American Collegeof Chest Physicians (ACCP) is crucial. This study was designed tocalculate the percentage of t-INR values, compare management ofwarfarin anticoagulation between primary care physicians (defined asfamily practitioners and internists), cardiologists, and pulmonologists,and examine if frequency of INR monitoring affects percentage oft-INR values.

METHODS: A retrospective chart review was conducted on patientsreceiving warfarin. Data abstracted included patients’ demographics,indication for anticoagulation, physician specialty managing the patient,the INR values and dates of each measurement. The comparison betweent-INR measurements was done using the Chi-squared test. The studentt-test was used in comparing the frequency of measurement.

RESULTS: The charts of 244 patients (104 PCP patients, 117 cardi-ology patients, and 23 pulmonology patients) were reviewed and a total of

6952 INR values were recorded. Patients were categorized into 4 groupsbased on indication for anticoagulation, and the table below represents thepercentage of t-INR values.

IndicationPCP

%

Cardio-logists

%

Pulmono-logists

%p value PCP vs

Cardiologists

p valuePCP vs

Pulmono-logists

Deep venousthrombosis/pulmonaryembolus(DVT/PE)

51.4 56.9 48.3 .444 .313

Atrialfibrillation(AF)

46.2 56.7 n/a �.0000001 n/a

Mechanicalheartvalve (MHV)

35.0 42.7 n/a .007 n/a

AF � MHV 34.2 45.3 n/a .031 n/aOverall 45.6 52.3 48.3 .0000001 n/a

When comparing INR values below the critical value of 1.5, 12.2% ofINR values managed by PCP, 7.0% by cardiologists and 10.5% bypulmonologists were below 1.5. Cardiologists were statistically more likelythan PCP to keep the INR value above 1.5 (p�.000001) and no statisticalsignificance existed between pulmonologists and PCP (p�.093). PCP,cardiologists, and pulmonologists measured INR values on average every32.51 days, 19.41 days and 29.88 days respectively (PCP vs cardiologists,p�0.05).

CONCLUSIONS: When comparing PCP and cardiologists, statisticalsignificance was achieved for all indications except DVT/PE, demonstrat-ing that cardiologists are more likely to keep the INR value within rangeand above 1.5. No statistical significance was found between PCP andpulmonologists.

CLINICAL IMPLICATIONS: A t-INR level is more likely to beattained, especially for AF and MHV, when cardiologists manage warfarin.This could be explained by a statistically higher frequency of INRmeasurements by cardiologists.

DISCLOSURE: S.J. Khandhar, None.

CRITICAL CARE RESOURCE UTILIZATION AND OUTCOMESOF OBSTETRIC PATIENTS IN AN AMERICAN AND AN INDIANPUBLIC HOSPITALUma Munnur, MD*; Dilip R. Karnad, MD; Maya S. Suresh, MD; VenkataD. Bandi, MD; Vijay Lapsia, MD; Priya Ramshesh, MD; Kalpalatha K.Guntupalli, MD. Baylor College of Medicine, Houston, TX; King EdwardMemorial Hospital, Mumbai, India

PURPOSE: To study outcomes of pregnant patients requiring inten-sive care unit support (ICU) in two public teaching hospitals: Ben TaubGeneral Hospital, Houston, Texas and King Edward Memorial Hospital,Mumbai, India. {Similar hospitals in terms of location (major cities) andtype of population served}.

METHODS: Retrospective chart review of 174 US and 754 Indianpregnant patients admitted to ICUs between 1992 and 2001 was con-ducted. APACHE II and Multiple Organ Dysfunction Score (MODS)were collected along with outcomes.

RESULTS: Fewer Indian patients received prenatal care (27% vs.86%); presented to hospital � 24hrs later (40% vs. 10%), and were sicker(median APACHE II score 16 vs. 10). Indian patients presented predom-inantly due to seizures and AMS, while US patients with fever, SOB andbleeding. Neurologic (63% vs. 36%), renal (50% vs. 37%) and cardiovas-cular dysfunction (39% vs. 29%) were more common in Indian patients.Hematologic (63% vs. 56%) and respiratory dysfunction (59% vs. 46%)were more common in US patients. Although the number of organsaffected were similar (median 2) in both groups, the maximum MODSwas higher in the Indian patients. More US patients required mechanicalventilation and blood products, while more Indian patients receiveddialysis. Induction of labor, C-section and hysterectomy were morefrequently performed in US patients. Pre-eclampsia was the commonestillness in both groups. Among the medical disorders Malaria, viralhepatitis and cerebral venous thrombosis were common in Indian pa-




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tients, where as bacterial sepsis, drug abuse, asthma and acute abdomenwere common in US patients.

Indian Patients US Patients

Intrauterine fetal demise 12.5% 4.6%HELLP 5.6% 17.8%Puerperal sepsis 6.5% 14.9%Peripartum cardiomyopathy 0.5% 5.8%Medical disorders 30% 30%Length of stay days 4 (3-5) 3 (2-4)Fetal mortality 51% 13%Maternal mortality 25% 2.3%

CONCLUSIONS: Fetal and maternal mortality were higher in Indianpatients, probably due to less prenatal care, late admission, greaterseverity of illness and differences in health care availability. Although thespectrum of obstetric disorders is similar, medical disorders greatlydiffered, as did organ involvement and ICU needs.

DISCLOSURE: U. Munnur, None.

COMMUNITY-ACQUIRED PNEUMONIA: EVALUATION OFCODING ERRORS, CLINICAL MISDIAGNOSESIrwin M. Berlin, MD*. Elmhurst Hospital Center, Elmhurst, NY

PURPOSE: An IPRO Medicaid study evaluated charts throughoutNew York State with a principal diagnosis of community acquiredpneumonia (CAP)-period: 9/1/01-3/31/02. A risk-adjusted mortality rate of14.8% was found at Elmhurst Hospital Center. Attendings felt that x-raysreviewed at morning report and resident evaluations were at odds. Ouraim was to review the resident’s effectiveness in correlating the x-ray andthe clinical course.

METHODS: Retrospective chart review of 55 IPRO reviewed Med-icaid charts between 9/1/01-3/31/02. Data abstracted included demo-graphics, medical history, clinical presentation and review of every chestx-ray and CT scan of chest. We looked at the official x-ray report and hadaccess to prior hospital/clinic x-rays and follow up admission/clinic x-rays.

We compared initial impressions with progress note impressions andfinal diagnoses as documented on discharge summaries.

RESULTS: All 55 Medicaid charts were available for review. Fourteencharts met the criteria for CAP, including radiographic evidence forconsolidation. Forty one charts did not meet the criteria. Misdiagnosesincluded congestive heart failure, COPD with acute exacerbation, inter-stitial lung disease, pleural effusion, alelectasis, bronchogenic carcinoma.

CONCLUSIONS: Coding by medical records is dependent on accu-rate discharge diagnoses. Proper billing depends upon accurate principaldiagnoses.

Residents had been encouraged to complete charts in a timely fashionand were noted to be writing their summaries as early as night one.Residents did not correct treatments or their notes for CAP, even after abetter diagnosis had been established.

CLINICAL IMPLICATIONS: A quality control panel has beenestablished to review concurrent charts for accuracy in establishing theprincipal diagnosis of CAP prior to coding is done on a chart.

Attending physicians are being encouraged to review discharge sum-maries before they sign off on a chart with the principal diagnosis of CAP.

Accurate National Data for CAP depends on accurate principal diag-noses. This study questions national data and statistics, including morbid-ity, mortality and prevalence of disease.

DISCLOSURE: I.M. Berlin, None.

SAFETY IN THE ICU: ACHIEVING COMPLIANCE WITH HEADOF BED ELEVATION USING COMPUTERIZED PHYSICIANORDER ENTRYWilliam T. McGee, MD, MHA*; Ashraf Farid, MD; Susan Scott, RN;Thomas L. Higgins, MD, MBA; Mary Brunton, RN. Hospital, BaystateMedical Center, Springfield, MA

PURPOSE: To improve quality of care and reduce the risk ofventilator-associated pneumonia (VAP), we initiated a strict protocol forhead of the bed elevation. Prior data has shown an 76% decrease in the

incidence of ventilator associated pneumonia by employing a simplestrategy of elevating the head of the bed �30°.1

METHODS: An initial survey was done on all ventilated ICU patientstwice a week for one month. A comprehensive education program for theICU staff using a multi-modal approach was implemented. Didacticsessions were supplemented with the biweekly ICU newsletter as areminder of this project. A bulletin board displayed data as it wascollected. Finally, a line item was added to our admitting order set callingfor head of bed elevation �30°. Only a single additional mouse click wasrequired to complete the order using Computerized Physician OrderEntry (CPOE).

Patients who had injuries to their axial skeleton and those otherwiserequired to lie flat were excluded. Data was prospectively collected twicea week on all eligible patients to monitor compliance and progress over a4 month evaluation period.

RESULTS: Percent compliance with head of bed elevationAt baseline, 28% of patients had head of the bed elevated �30°.

Compliance rose significantly after the initiation of the education programto 69% and has progressively increased in the following two months.

CONCLUSION: An educational program can significantly improveICU safety. CPOE facilitated compliance with this practice.

CLINICAL IMPLICATION: Simple safety practices may be incon-sistently adhered to in the intensive care unit. A comprehensive educationprogram can significantly improve compliance with safety practices.CPOE provides a simple avenue to enhance compliance with safety goals.Mandatory orders for all ICU patients that incorporate established safetypractices may further improve ICU patient safety.

REFERENCE:1. Lancet 1999;354:1851-1858DISCLOSURE: W.T. McGee, None.

SAFETY IN THE ICU: COMPUTERIZED PHYSICIAN ORDERENTRY AIDES COMPLIANCE WITH AN ICU SAFETY PROTO-COL FOR GLYCEMIC CONTROLWilliam T. McGee, MD, MHA*; Ashraf Farid, MD; Susan Scott, RN;Brunton Mary, RN; Thomas L. Higgins, MD, MBA. Hospital, BaystateMedical Center, Springfield, MA

PURPOSE: Glycemic control has multiple potential benefits includingdecreased infection, shorter length of stay, decreased mortality and lowercost of care.1

METHODS: Phase 1 (2 months) involved an intensive educationprogram for our nurses, residents and students about the importance ofglycemic control for ICU patients. Relevant articles were distributed andinformation disseminated. Other than education, no specific protocol forglycemic control was applied during Phase 1.

In Phase 2 (2 months), patients predicted to spend �48 hours in ourintensive care unit were started a protocol using computerized physicianorder entry (CPOE) calling for insulin titration to keep blood sugarbetween 80 and 110mg/dl. Blood glucose was checked every six hours.Compliance was measured as a percentage of determinations per day thatpatients met goal, i.e. 1 of 4 would be 25% of the time vs. 4 of 4 would be100% of the time.

RESULTS: A sliding scale treatment regimen was used during Phase 1.Initially, 14% of patients achieved glycemic control on 4 out of 4measurements, dropping to 12.5% during the second month of Phase 1.During Phase 2, up to 38% of patients achieved 100% glycemic control.7.5% of patients required D50 bolus for glucose � 60.

CONCLUSION: A continuous insulin infusion protocol is significantlymore effective in achieving glycemic control in the intensive care unit thana sliding scale protocol. Glycemic control within this narrow range isdifficult to achieve 100% of the time even with a strict protocol using aninsulin infusion. CPOE facilitates implementation of a safety protocol forglycemic control.

CLINICAL IMPLICATION: Compliance with recommended proto-cols involving glycemic control in the ICU can be enhanced throughCPOE and insulin infusion.

REFERENCE:1. Van derBorghe, Greet: NEJM 345(19):1359-67.DISCLOSURE: W.T. McGee, None.




LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC INDICESIN DILATED CARDIOMYOPATHY WITH BIVENTRICULAR IN-VOLVEMENT VERSUS ISOLATED LEFT VENTRICULAR IN-VOLVEMENTIoannis Moyssakis, MD; Nickolaos J. Pantazopoulos, MB BS*; YousefHallaq, MD; Ioannis Paizis, MD; Panagiotis Margos, MD; VasiliosVotteas, MD. Cardiac Department, “Laiko” Hospital, Athens, Greece,Athens, Greece

PURPOSE: The aim of our study was to investigate and compare theleft ventricular (LV) systolic and diastolic function in patients (pts) withidiopathic dilated cardiomyopathy (DCM) with biventricular systolicdysfunction versus pts with DCM without right ventricular (RV) systolicimpairment.

METHODS: Twenty two (14 males - 8 females, aged 57�11 years) ptswith biventricular systolic dysfunction (group A) and 28 (19 males – 9females, aged 55�13 years) pts with isolated LV impairment wererecruited in the study. All pts underwent complete echocardiographicstudy. Parameters measured were LV dimensions for ejection fraction(EF) calculation, early and late transmitral flow velocities (E and A waverespectively). E/A ratio, deceleration time (DT) and isovolumic relaxationtime (IVRT). We also evaluated LV Tei index and mitral annulus planesystolic excursion (MAPSE) whereas the RV systolic dysfunction wasassessed by the tricuspid annulus plane systolic excursion (TAPSE) or RVdp/dt. Values of TAPSE equal to or less than 12.5 mm and RV dp/dt � 220mmHg/sec were considered decreased.

RESULTS: See table.CONCLUSIONS: Our findings suggest that biventricular systolic

dysfunction in DCM causes more severe impairment of systolic anddiastolic function versus isolated LV involvement.

Results tableParameters Group A Group B P-Value

LVEF (%) 28 � 10 35 � 9 �0.05MAPSE (mm) 9.3 � 0.9 10.2 � 1.0 �0.01LV Tei-index 0.57 � 0.14 0.49 � 0.12 �0.05LV E/A 1.79 � 0.32 1.66 � 0.25 �0.05LV DT (msec) 150 � 29 164 � 26 NSLV IVRT(msec) 66 � 12 71 � 8 NS


CORRELATION OF SIX MINUTE WALK TEST RESULTS WITHOTHER MEASURES OF CONGESTIVE HEART FAILUREDavid M. Safley, MD*; Shailja Parikh, Medical Student; Alap Shah,Medical Student; Roberta Sullivan, RN, MPH; Mukesh Garg, MD.University of Missouri - Kansas City, Kansas City, MO

PURPOSE: Current assessment of treatment adequacy in congestiveheart failure (CHF) relies on subjective reporting of symptoms, physicalfindings, and New York Heart Association Functional Class (NYHA-FC).Newer measures include B-Type Natriuretic Peptide (BNP) and theKansas City Cardiomyopathy Questionnaire (KCCQ), a disease-specificquality of life (QoL) measure. The six-minute walk test (6MWT) is asimple measure that is reproducible and correlates with prognosis. Thisstudy was designed to describe the relationships of the 6MWT to othermeasures.

METHODS: 55 outpatients with CHF (left ventricular ejection frac-tion (LVEF) �40% and recent hospitalization) were enrolled over sixmonths. A standard 6MWT was performed and baseline BNP wasmeasured. LVEF was obtained from echocardiogram or ventriculogram(radionuclide or angiographic). NYHA-FC was assigned by the treatingphysician. Patients completed the KCCQ, providing a global estimate ofQoL, ranging from 0 to 100. Correlation coefficients were obtained andlinear regression analyses were performed.

RESULTS: There was an inverse correlation between six-minute walkdistance (6MWT) and Functional class(NYHA-FC) (r�0.14, p�0.008)and a positive correlation with the KCCQ-QoL score (r�0.11, p�0.019).There was no significant correlation between walk distance and BNP orLVEF.

CONCLUSIONS: The 6MWT correlates well with NYHA-FC, andKCCQ-QoL - both well-validated methods of assessing patients withCHF. Objective measures such as 6MWT, BNP, QoL and LVEF provideadditional information in assessing status of CHF. The simple, reproduc-ible, and inexpensive 6MWT correlates well with NYHA functionalclassification and KCCQ scores.

CLINICAL IMPLICATIONS: The 6MWT provides similar prognos-tic information as similar information toother measures of CHF at afraction of the cost in dollars, time, and potential risk. This test iscommonly used as a research tool, but remains underutilized in practice.The results of this study suggest that the 6MWT may have a place inassessing the continuing care of CHF.

DISCLOSURE: D.M. Safley, None.

ANALYSIS OF LEFT ATRIAL VOLUME CHANGE RATE FOREVALUATION OF LEFT VENTRICULAR DIASTOLIC FUNC-TIONMing-Jui Hung, MD.* Teaching Hospital, Chang Gung Memorial Hos-pital, Keelung, Taiwan, Republic of China

OBJECTIVES: To define the role of left atrial (LA) volume changerate, as indicated by posterior aortic wall motion during the left ventricular(LV) diastolic phase, in the assessment of LV diastolic function.

METHODS: One hundred and fifty-five patients who underwentechocardiography after cardiac catheterization were included in thisstudy. These patients were classified into four groups according to theratio of early to late transmitral flow velocity (E/A ratio) and/or LVend-diastolic pressure (EDP): 42 patients with LVEDP �15 mm Hg andE/A ratio �1(normal filling); 46 patients with E/A �1 (impaired relax-ation); 46 patients with LVEDP �15 mm Hg and E/A�1 and �2(pseudonormal filling); 21 patients with E/A �2, E �70 cm/sec, and Ewave deceleration time �160 msec (restrictive filling). The slopes of earlyand late (slope E and A) diastolic motion of the LA wall were derived fromM-mode analysis, together with the LV isovolumic time constant Tau fromcardiac catheterization.

RESULTS: Values of the slope E/A were decreased in patients withrestrictive filling, pseudonormal filling, and impaired relaxation comparedto those with normal filling (0.43 � 0.15, 0.69 � 0.15, and 0.56 � 0.23 vs.1.25 � 0.26, p �0.001, respectively) and were correlated inversely withthe isovolumic time constant Tau (r � 0.79, p �0.001).

CONCLUSIONS: Analysis of the slope of LA wall motion as anindicator of LA volume change rate during the LV diastolic phase is usefulin evaluating LV diastolic function.

CLINICAL IMPLICATIONS: The analysis is free of the effects ofpseudonormalization and is well correlated with the isovolumic timeconstant Tau.

DISCLOSURE: M. Hung, None.

PREVALENCE OF THYROID ABNORMALITIES IN INDIGENTAMBULATORY SYSTOLIC HEART FAILURE PATIENTSLee M. Arcement, MD*; Kathy Hebert, MD; Sahil Bakshi, DO; HectorO. Ventura, MD. Ochsner Clinic Foundation, Metairie, LA

PURPOSE: Hyperthyroidism or hypothyroidism may contribute to thedevelopment of systolic heart failure (SHF) or may contribute to theexacerbation of existing SFH. Current guidelines recommend a screeningthyroid stimulating hormone (TSH) with the initial evaluation do the SHFpatient. However the cost effectiveness of this practice is currentlyunknown as the prevalence of thyroid disease is associated with SHF hasnot been well described.

METHODS: One hundred forty-seven patients referred to ourindigent ambulatory SHF clinic over a three-month period werescreened for thyroid perturbations with the third generation ultra-sensitive TSH assay. Patients were assigned to one of four groupsaccording tot the assay results: group 1 (TSH�0.4 IU), group II(TSH � 0.4 -4.0 IU)— the normal range at our institution, group III(TSH�0.4 - 10.0 IU), and group IV (TSH�10.0 IU). Patients withgroup II (normal range) TSH presently on thyroid replacementtherapy were deemed hypothyroid.

RESULT: The prevalence of depressed TSH (hyperthyroid) (group I)was 1.3% and the prevalence of elevated TSH (hypothyroid) (group III&IV) was 9.5%. Six patients (4%) were on thyroid replacement therapybut all were euthyroid by assay. Including this cohort, the prevalence ofhypothyroidism was 13.6%.


Heart Failure12:30 PM - 2:00 PM


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CONCLUSIONS: In our population, an elevated TSH was uncommonbut not rare. A depressed TSH was rare.

CLINICAL IMPLICATIONS: It appears that routine TSH screeningis justifiable in this patient population, but further studies are warrantedto evaluate the cost-effectiveness of such screening.

DISCLOSURE: L.M. Arcement, None.

CORRELATION BETWEEN NONINVASIVE AND INVASIVECARDIAC INDEX (CI): UTILIZATION OF NONINVASIVEECHOCARDIOGRAPHIC DOPPLER-DERIVED INDEX OFMYOCARDIAL PERFORMANCE (IMP)Ajeet D. Sharma, MD*; John C. Lucke, MD; Antoine Al-Achi, Ph.D; JohnKelemen, MD; Peter McKeown, MD; Ross W. MacIntyre, MD; JamesCalderbank, MD; Anil K. Sharma, MD. VA Asheville Medical Center,Asheville, NC

PURPOSE: Dr Tei described a doppler index for the assessment ofglobal left ventricular performance termed the Index of myocardialperformance (IMP). IMP encompasses left ventricular (LV) systoliccontraction, ejection, and diastolic relaxation, and is independent of heartrate (HR), and mean blood pressure (MBP). Diminished LV function isassociated with prolongation of IMP (�0.55 seconds). Doppler IMP canbe utilized to calculate CI noninvasively. The purpose of this study was toassess whether noninvasive post-cardiopulmonary bypass (CPB) derivedCI calculated by the equation [CI x IMP {pre-CPB} � CI x IMP{post-CPB} correlated with standard invasive thermodilution pulmonaryartery catheter (PAC) derived CI.

METHODS: 50 adult patients who underwent elective cardiac surgerywere studied. Pre-CPB IMP and CI were calculated before sternotomywith the aid of transesophageal echocardiography (TEE). IMP wascalculated by the equation in figure 1. CI was calculated by the dopplerhemodynamic equation [CI�0.785 x (LVOT diameter x 2 (cm) x LVOTTVI (cm) x HR/BSA; where LVOT: left ventricular outflow tract; TVI:time velocity integral, BSA: body surface area]. Post-CPB, IMP wascalculated 15 minutes following termination of CPB. Pre-CPB (IMP andCI value) and post-CPB (IMP value only) were then applied to theequation (CI x IMP {pre-CPB}� (CI x IMP){post-CPB}and a predictednoninvasive value of post-CPB CI was calculated. This noninvasive CIvalue was correlated with post-CPB invasive CI recorded from thepulmonary artery catheter (PAC).

RESULTS: There is linear relationship between the predicted (non-invasive) CI measurement and invasive CI measurement [p�0.0001;r�0.67](Fig 2). Data analyzed by a linear regression method and Bayes’rule of probability.

CONCLUSIONS: This study establishes that noninvasive IMP can beutilized in the calculation of CI, and that there is excellent correlationbetween predicted (noninvasive) CI and invasive CI.

CLINICAL APPLICATIONS: Echocardiographic doppler derivedIMP can be utilized in the assessment of noninvasive CI. This couldprovide a practical and safer alternative to more invasive methods ofmeasuring CI

DISCLOSURE: A.D. Sharma, None.

INSPIRATORY CAPACITY IS A DETERMINANT OF EXERCISEIN PATIENTS WITH PRIMARY DILATED CARDIOMIOPATHYEmilio Marangio, MD, FCCP; Claudia Castagnetti, MD; RaffaeleD’Ippolito, MD; Antonio Castagnaro, MD; Marina Aiello, MD; Maria V.Tonna, MD; Antonio Foresi, MD; Dario Olivieri, MD, FCCP; AlfredoChetta, MD, FCCP.* University of Parma, Parma, Italy

PURPOSE: Inspiratory capacity (IC) can determine exercise capacityin patients with lung diseases. In this study, we investigated the role of ICin the exercise capacity of patients with cardiac diseases.

METHODS: Twenty patients (4 female, age range 29-79 years, BMIrange 16-30 kg/m2) with primary dilated cardiomyopathy (NYHA classrange 1-3; mean�SD ejection fraction: 32%�11) performed spirometryand lung volumes measurement. Patients carried out exercise testingusing bicycle ergometry with ramp protocol (work rate increments range5-15 W/min). Gas exchange and ventilation were measured breath bybreath.

RESULTS: Mean(SD) values of IC, FEV1, FEV1/VC, and TLC were2.88L(0.7), 93%pred(16), 76%(6), and 96%pred(15), respectively. At peakof exercise, mean(SD) values of V’O2, HR and Work Load were1.39L(0.53), 137bpm(27), and 115watts(59). IC was related to NYHA class(rs�-0.49, p�0.05), V’O2 (r�0.75, p�0.01), and Work Load (r�0.79,p�0.01). Moreover, IC was chosen by multiple regression analysis, as themain predictor variable for V’O2 (r2 � 0.56).

CONCLUSIONS AND CLINICAL IMPLICATIONS: In patientswith primary dilated cardiomyopathy, resting inspiratory capacity isstrictly related to exercise capacity and predicts the oxygen uptake at peakof exercise. Our data suggest that inspiratory capacity can be used in theclinical assessment of primary dilated cardiomyopathy.

DISCLOSURE: A. Chetta, None.

VASCULAR PEDICLE WIDTH: AN EASILY AVAILABLE TOOLTO DETECT ISOLATED DIASTOLIC DYSFUNCTIONMobeen Iqbal, MBBS FCCP*; Raees Ahmed MBBS FCCP, HassanAlbalas MD, Salahuddin Gharad MD, Fahad D Alotaibi, Ahmed Alarfaj.King Abdul Aziz National Guard Hospital, Alhasa, Saudi Arabia

PURPOSE: To study the association of vascular pedicle width on chestroentgenogram with left atrial emptying fraction, an echocardiographicindex of diastolic dysfunction.

METHODS: 32 patients with normal systolic function on echocardio-gram were evaluated retrospectively for the measurement of left atrialdimensions. Left atrial end-diastolic (LAD) dimensions were measured atthe beginning of QRS complex and end-systolic dimensions (LAS) at theend of T-wave on electrocardiogram on M-mode tracing. Left ventricularend-systolic (LVES) and end-diastolic (LVED) diameter, left ventricularseptal and posterior wall thickness were also recorded. Postero-anterior(PA) views of chest X-rays done within four weeks of echocardiogramwere studied for the measurement of vascular pedicle width (VPW). Leftatrial emptying fraction (LAEF) was calculated as LAD/LAS. LAEF �75% was considered as an indicator of diastolic dysfunction. Patients weredivided into Group I (LAEF 75%). Ratio of E to A velocity (E/A) anddeceleration time of E-wave (DT) were also recorded on transmitralDoppler signal.

RESULTS: There were 16 patients in each group. Mean LAEF inGroup I was 0.68�0.07 and Group II was 0.83�0.05. There was nosignificant age difference between the two groups (54.38�17.97 vs.62.75�14.9;p�0.08). VPW was significantly greater in Group II(VPW62.88�9.07 vs. 48.75�5.48;p�0.0001). Though E/A ratio betweentwo groups was not significant (0.94�0.13 vs. 1.1�0.33) but DT wassignificantly higher in Group II (223.57�47.83 vs. 177.75�41.66;p�0.01). Septal (1.22�0.27 vs. 1.02�0.31;p�0.03) and posterior wallthickness (0.98�0.23 vs. 1.18�0.21;p�0.01) were significantly higher inGroup II.

CONCLUSION: Vascular pedicle width on PA chest X-ray is signifi-cantly increased in patients with LAEF �75%, an index of atrial stretchand diastolic dysfunction, with normal systolic function. Moreover,LAEF�75%, an easy to measure index, can be used to identify patientswith diastolic dysfunction.

CLINICAL IMPLICATIONS: VPW measured on PA chest X-rayscan be a reliable indicator of diastolic dysfunction. Left atrial emptying


Heart Failure, continued


fraction should be routinely measured on echocardiogram with normalsystolic function and if found high should prompt further evaluation.

DISCLOSURE: M. Iqbal, None.

ACUTE EFFECTS OF OXYGEN, CONTINUOUS POSITIVE AIR-WAY PRESSURE (CPAP) AND NONINVASIVE POSITIVE PRES-SURE VENTILATION (NIPPV) ON SLEEP APNEA IN STABLECONGESTIVE HEART FAILUREHitoshi Koito, MD*; Keiko Kohno, MD; Katsuya Maruyama, MD; SatoshiMorita, MD; Hiroshi Yutaka, MD. Kansai Medical University, OtokoyamaHospital, Yawata, Kyoto, Japan

PURPOSE: To assess the acute effects of oxygen (O2), continuouspositive airway pressure (CPAP) and noninvasive positive pressure venti-lation (NIPPV) on sleep apnea (SA) in stable congestive heart failure(CHF).

METHODS: The subjects were 11 patients (pts) with stable CHF (6;dilated cardiomyopathy, 4; old myocardial infarction, 1; valvular disease).These pts were examined with SpO2, nasal air flow sensor, chest wall andabdominal motion and ECG monitoring system (Morpheus C; Teijin),urinary noradrenaline concentration and next morning mood index duringsleep at night under room air (Control), O2, CPAP and NIPPV.

RESULTS: Although 9 pts completed all 4 studies, 2 pts completedonly Control and O2 study. Apnea hypopnea index (AHI; /hr) improvedfrom 24�10 (mean�SD) in Control to 18�10 with O2, 15�11 with CPAPand 11�10 with NIPPV. Central apnea index (CAI; /hr) improved from9�9 in Control to 5�7 with O2, 7�8 with CPAP and 2�2 with NIPPV.In 4 pts with CAI�15, CAI improved most with NIPPV but not soeffective with CPAP (from 20�4 in Control to 12�9 with O2, 14�7 withCPAP and 3�1 with NIPPV). In 5 pts with CAI�15, CPAP also improvedCAI (3�3, 1�1, 0.6�1 and 0.1�0.3, Control, O2, CPAP and NIPPV,respectively). Ventricular ectopic beats decreased 1,000�1,176 in Controlto 432�513 with NIPPV in pts with CAI�15, but in pts with CAI�15CPAP was the most effective (810�1,788 in Control to 167�345 withCPAP). No significant difference was seen in urinary noradrenalineconcentration and next morning mood index.

CONCLUSIONS: O2, CPAP and NIPPV are effective in improvingSA, and NIPPV is the most effective in pts with stable CHF anddominance of central SA. CPAP is effective in pts with CHF anddominance of obstructive SA.

CLINICAL IMPLICATIONS: O2, CPAP and NIPPV are usefulmethods for improving SA, and might be useful complementary therapiesfor treating stable CHF .

DISCLOSURE: H. Koito, None.

EFFECTS OF ONE MONTH OF DOMICILIARY NONINVASIVEPOSITIVE PRESSURE VENTILATION ON SLEEP APNEA ANDCARDIAC FUNCTION IN STABLE CONGESTIVE HEART FAIL-UREHitoshi Koito, MD*; Keiko Kohno, MD; Katsuya Maruyama, MD; SatoshiMorita, MD; Hiroshi Yutaka, MD. Kansai Medical University, OtokoyamaHospital, Yawata, Kyoto, Japan

PURPOSE: To evaluate the effects of one month of domiciliarynoninvasive positive pressure ventilation (NIPPV) on sleep apnea (SA),cardiac function and sympathetic nervous activity in stable congestiveheart failure (CHF).

METHODS: The subjects were 7 patients (pts) with stable CHF (5;dilated cardiomyopathy, 2; old myocardial infarction). These pts weredivided into 2 groups (central apnea index (CAI) �15 (CSA group) andCAI�15 (OSA group)) and examined with SpO2, chest and abdominalmotion, nasal air flow and ECG monitoring system (Morpheus C; Teijin),urinary noradrenaline and next morning mood during sleep at night underroom air (Control) and NIPPV before and after one month of domiciliaryNIPPV. Echo-Doppler cardiography, respiratory function, serum norepi-nephrine, Epworth sleepiness scale (ESS) were also evaluated before andafter one month of NIPPV.

RESULTS: Apnea hypopnea index (AHI; /hr) improved significantlyfrom 26�10 (Before, air) to 13�10 (Before, NIPPV), 11�8 (After,NIPPV) and 21�11 (After, air). After one month AHI decreased evenwithout NIPPV, whichi was due to improvement of OSA. CAI improvedfrom 12�10 (Before, air) to 2�2 (Before, NIPPV) and 4�6 (After,NIPPV). CAI in after, air did not change (11�10) and CSA contributed tothis. Next morning mood improved only in after, air. LVEF (%) and %FS

(%) after one month of NIPPV increased from 22�6 to 28�4 and 43�10to 52�6, respectively. Systolic LV dimension (LVDs;mm), systolic RVpressure (RVsP;mmHg), s-noradrenaline and ESS after one month ofNIPPV decreased from 49�4 to 45�5, 42�5 to 35�9, 0.48�0.28 and12�6 to 8�6, respectively. CSA contributed to improvement of LVDsand RVsP, and OSA contributed to improvement of LVDs, %FS andLVEF. No significant change was seen in LA dimension, diastolic LVdimesion, respilatory function or u-noradrenaline.

CONCLUSIONS: One month of domiciliary NIPPV is an effectivetherapy in imprving SA, day time sleepiness, cardiac function andsympathetic nervous activity in stable CHF.

CLINICAL IMPLICATIONS: One month of domiciliary NIPPV is auseful complimentary therapy for treating stable CHF.

DISCLOSURE: H. Koito, None.

Hosts and Pathogens in Pneumonia12:30 PM - 2:00 PM

PNEUMONIA IN THE ELDERLY: GENDER DISPARITY INPRESENTATIONAdekunle S. Ogunfuwa, Medical Resident*; Raji Ayinla, MD, FCCP;Gregory Emili, MD. Mount Sinai School of Medicine, North GeneralHospital Program, New York, NY

PURPOSE: Evaluate gender disparity in presentations among elderlypatients with pneumonia

METHODS: Review of 107 patients above 65 years hospitalized forcommunity acquired pneumonia. Medical records were abstracted forsocio-demographic characteristics, clinical presentations, triage decision,laboratory data and outcome variables.

RESULTS: The mean age for females in the study is 83.23 years versus76.86 for males. Pneumonia is commoner among males between 65 – 84years in the community (44 vs 35%). However, females above 85 years inthe same community (18 vs 4%) and those from the nursing homes above65 years (70 vs 30%) have higher percentage of pneumonia. Males havemore co morbid conditions such as COPD, CHF, neoplasm, renal diseaseand usually present with fever, cough and pleuritic chest pain whereas,females usually present with dyspnea, confusion and higher pneumoniaseverity index. Females usually require intensive care unit monitoring (26vs 15%), have longer length of stay (13.02 vs 12.02 days) and highermortality (23 vs 5%). Enteric gram-negative organisms, staph. species andpolymicrobial growth were the major organisms responsible for commu-nity acquired pneumonia for both genders either from the community ornursing homes.

CONCLUSIONS AND CLINICAL IMPLICATIONS: This studydemonstrates that pneumonia is commoner in males between 65-84 yearsin the community. However pneumonia is seen more among femalesabove 85 years in the same community and those above 65 years who wereadmitted from the nursing homes. Atypical presentation and unusualpathogenic isolates may have contributed to higher mortality. Hence thereis need for higher index of suspicion and initial antibiotic coverage forboth gram positive and gram negative organisms.

DISCLOSURE: A.S. Ogunfuwa, None.

IN VITRO ANTIMICROBIAL ACTIVITY OF DEFENSIN FROMRABBIT NEUTROPHILS AGAINST PSEUDOMONAS AERUGI-NOSA AND ITS DRUG-RESISTANCE STRAINSBirong Dong, MD*. West China Hospital of Sichuan University,Chengdu, China

PURPOSE: To investigate the role and mechanism of defensin fromrabbit neutrophils against pseudomonas aeruginosa and its drug-resistancestrains.

METHOD: Defensin was extracted from rabbit peritoneal neutrophilgranules with citric acid, and purified by preparative acid urea polyacryl-amide gel electrophoresis(AU-PAGE). In order to investigate the role and


Heart Failure, continued


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mechanism of defensins again pseudomonas aeruginosa and its cefe-taxime-resistentance strain, We use an agrose gel radial diffusion assay forbactericidal activity in vitro and examined their ultrastructural changes bytransmission electron microscope.

RESULTS: NP2 was isolated and puried successfully by AU-PAGE.NP2 demonstrated concentration-dependent killing of pseudomonasaeruginosa and its cefetaxime-resistentance strain. When the two kinds ofPseudomonas aeruginosa cells exposed to NP2 were examined by trans-mission electron microscope, we found that components in cells con-tracted high density balls and vacuolization.

CONCLUSION: Acid urea polyacrylamide gel electrophoresis is sim-ple and convient in isolating and purifying protein and polypeptides.Defensin from rabbit neutrophils exerts potent bactericidal activity againstpseudomonas aeruginosa and its cefetaxime resistance strain. The findingsof electron microscope support the theory that defensins are capable ofdestabilizing the cell membrane permeability and causing the death ofmicroorganism.

CLINICAL IMPLICATION: Supplying the laboratory evidence fordeveloping the nature antibiotic aganist MDR bacteria for the future.

DISCLOSURE: B. Dong, None.

PNEUMOCYSTIS CARINII �-GLUCAN-INDUCED CHEMOKINESECRETION FROM ALVEOLAR EPITHELIAL CELLS RE-QUIRES ACTIVATION OF PROTEIN KINASE C AND NF-�BScott E. Evans, MD*; Peter Y. Hahn, MD; Frances M. Lebron-Ruiz, BS;Theodore J. Kottom, MS; Vishwajeet Puri, PhD; Richard E. Pagano, PhD;Andrew H. Limper, MD. Mayo Clinic and Foundation, Rochester, MN

PURPOSE: Intense neutrophilic lung infiltration characterizes severePneumocystis carinii pneumonia, with considerable morbidity and mor-tality attributed to host responses. The P. carinii cell wall constituent-1,3-glucan has been shown to induce lower respiratory tract inflamma-tory responses. Our laboratory has also recently documented elaborationof inflammatory cytokines by alveolar epithelial cells in response to P.carinii -glucan. This investigation explores the signaling events promot-ing inflammatory cytokine expression from alveolar epithelial cells in P.carinii pneumonia.

METHODS: Rat type II alveolar epithelial cells were isolated andcultured prior to challenge with P. carinii -glucan-rich cell wall isolate(PCBG). Elaboration of inflammatory cytokines was determined byELISA in the presence or absence of inhibitors of NF-�B, protein kinaseC (PKC), MEK1 and p38. Activation of NF-�B was shown by nucleartranslocation of the p50/p65 heterodimer, as demonstrated by immuno-fluorescence microscopy and electophoretic mobility shift assay (EMSA).Inhibition of NF-�B activation was shown by Northern blot analysis forPCBG-induced inflammatory cytokine mRNA in the presence or absenceof pyrridoline dithiocarbamate (PDTC). Activation of PKC was revealedby Western blot analysis for phosphorylated PKC before and after PCBGchallenge.

RESULTS: Consistent with our previous data, macrophage inflamma-tory protein-2 (MIP-2) and tumor necrosis factor-a (TNF-�) were elab-orated in response to PCBG. This effect was abrogated by inhibitors ofNF-�B or PKC, though no change was noted with inhibition of MEK1 orp38. Prompt nuclear translocation of the NF-�B p50/p65 heterodimer wasobserved following PCBG challenge by both immunofluorescence andEMSA. PDTC efficiently blocked PCBG-induced MIP-2 and TNF-�mRNA production. Significantly increased levels of phosphorylated PKCwere observed following PCBG exposure.

CONCLUSIONS: PCBG-induced MIP-2 and TNF-� expression fromalveolar epithelial cells requires activation of both PKC and NF-�B.Activation is likely sequential, with PKC phosphorylation resulting innuclear translocation of NF-�B.

CLINICAL IMPLICATIONS: Pneumocystis pneumonia results insubstantial morbidity and mortality, despite effective antimicrobial agents.This investigation suggests two novel therapeutic targets which maymoderate the exaggerated host responses to infection.

DISCLOSURE: S.E. Evans, None.

AGE IS NOT A RISK FACTOR FOR MORTALITY IN SEVERECOMMUNITY-ACQUIRED PNEUMONIAVijo Poulose, FCCP*; David Foo, MRCP; Chong-Hiok Tan, MRCP.Changi General Hospital, Singapore, Singapore

PURPOSE: Medical literature frequently identifies advanced age as apoor prognostic factor in community-acquired pneumonia(CAP). The aimof this study was to evaluate the impact of age on the outcome of severeCAP.

METHODS: A prospective observational study on all patients admit-ted to the intensive care unit (ICU) with severe CAP over a 20-monthperiod. Patients were diagnosed to have severe CAP if they met a)one oftwo major criteria; septic shock or the need for mechanical ventilation ORb) two of three minor criteria; multilobar involvement, respiratory rate �30/minute or PO2/FiO2 ratio�250.

RESULTS: There were 80 cases of severe CAP admitted to the ICUover this period. The ICU mortality rate was 30% (24 patients died, 56survived). The average age of survivors was 59.4 years(SD 16.4) and ofnon-survivors was 61.7 years(SD 20.2). There was no statistical differencebetween the two groups (p value 0.58).

CONCLUSIONS: In this study on severe CAP patients, there was nosignificant difference between the ages of survivors and non-survivors.

CLINICAL IMPLICATIONS: Advanced age is not an important riskfactor for mortality in patients with severe CAP.

DISCLOSURE: V. Poulose, None.

THE IMPACT OF EARLY NEBULIZED ANTIBIOTICS IN THECONTROL OF ENDOTRACHEAL TUBE COLONIZATION INMECHANICALLY VENTILATED PATIENTS; PRELIMINARYREPORT PROYECTO PRACTICA: THE MORELIA EXPERI-ENCEAbel. Maldonado, Pulmonary and Critical Care Departament*; VeronicaBelmonto, Critical Care; Irene Barron, Critical Care; Carlos Pineda,Critical Care; Carlos Dominguez, Surgery; Carlos Velazquez, Surgery;Ma. Dolores Salas, Bacteriology; Hector Herrera, Radiology; OliviaHerrera, Radiology. ICU Referral Center, Hospital General, Morelia,Mexico

PURPOSE: To asses the impact of early nebulized antibiotics (ENA)on endotracheal tube colonization during MV before 96 hours.

METHODS: All patients admitted to our medical/surgical ICU requir-ing MV at least for 4 days, without respiratory infections or prior antibioticadministration were evaluated. P were randomized to received ENA orplacebo once a day (4 days). Bacteriological samples were collected atadmission and repeated at 96 hours.

RESULTS: 36 patients were evaluated, group A (14 p), at 24 hrs:3(21%) negative, 8 (57.4%) normal flora, 2( 14.2%) S. Aureus meticilinsensible, 1 ( 7.14%) pneumococo. At 96 hrs: 3 (21%) negative, 3 (21%) S.Aureus meticilin sensible, 1(7.1%) pneumococo, 7 (49.7%) normal flora.Group S (13p): 4(30.4%) negative, 5(38%) normal flora , 2 (15.2%) S.Aureus meticilin sensible, 1(7.6%) E. Coli, 1 (7.6%) P. Aeuroginosa. At 96hrs. 3(22.8%) A. Baumanii, 6(45.6%) P aeuroginosa, 1(7.6%) Klebsiella,1(7.6%) S. Aureus meticilin sensible. In the group S, 95.7% of sampleswere colonized by potential pathogen microorganisms vs 28.4% in groupA at 96 hrs (p��0.005). Additionally at 96 hrs, any p of group Adeveloped clinically early VAP, in group S two patients developed VAP onborder time of study.

CONCLUSIONS: 1.- In the Morelia experience, the use of antibioticsseems to control ET colonization with potential pathogen microorganismbefore 96 hours of MV.

2.- Patients under antibiotics protocol did not developed early VAPduring the study period.

3.- Further clinical evaluation is mandatory to evaluate the really impactof ENA in reduction of PPM colonization and early VAP.

CLINICAL IMPLICATIONS: A promisory nebulized technique toavoid potential airway transcolonization by potential pathogen microor-ganism and limit additional risk factor to develop VAP

DISCLOSURE: A. Maldonado, None.


Hosts and Pathogens in Pneumonia,continued


IS COMBINATION THERAPY NEEDED IN HOSPITALIZEDPATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA?Marcos I. Restrepo, MD, MSc*; Eric M. Mortensen, MD, MSc; Jacque-line A. Pugh, MD; Antonio Anzueto, MD. VERDICT South TX VeteransHealth System and University of TX Health Science Center at SanAntonio, San Antonio, TX

PURPOSE: Previous studies showed that in patients with bacteremicpneumococcal pneumonia the use of combination (CT) antibiotic (ABX)therapy was associated with lower mortality as compared to monotherapy(MT). Limited data is available based on the different degrees of severityof illness in patients with CAP. Our aim was to compare the use of empiricMT vs. CT therapy in hospitalized patients with CAP.

METHODS: A retrospective, observational review of admitted patientswith radiological confirmed CAP at two teaching hospitals in San Antonio,Texas. Severity of illness was quantified using the pneumonia severityindex (PSI). Only those patients classified as PSI classes IV and V wereincluded. The patients were divided in two groups depending on theinitial empiric therapy (first 48 hours): MT vs. CT (� 2 ABX). Descriptiveanalyses were performed with a p-value 0.05 considered statisticallysignificant.

RESULTS: A total of 119 patients had MT and 123 had CT. In MTpatients with CAP, the mean age was older (71�12 years vs. 65�13). Inaddition, there were more Hispanic whites in the MT group (63% vs. 41%,p�0.01). The two groups had similar severity of illness with mean PSIscores of 115 and 111�33. However patients who were admitted to theICU had a tendency toward more CT (61% vs. 39% [p�0.06]). Therewere no statistically significant differences in common processes of careparameters. CT was significantly more likely to be concordant withnational guidelines (93% vs. 82%, p�0.01). Although the 30-day mortalityrates for the CT group tended to be lower, there were no statisticallysignificant differences between the two groups (13% vs. 18%).

CONCLUSIONS: There were significant differences in some clinicalcharacteristics of patients receiving MT vs. those receiving CT. Mortalitywas similar in both treatment groups despite the severity of illness.

CLINICAL IMPLICATIONS: Further study is warranted to deter-mine the association between MT and CT in patients with severe CAP.

DISCLOSURE: M.I. Restrepo, None.

MARKERS OF SEVERITY OF ILLNESS: A SURVEY ON THEIRVALUE AS PREDICTORS OF OUTCOME AND IN DECIDINGTHE ADMISSION OF PATIENTS WITH COMMUNITY-AC-QUIRED PNEUMONIA (CAP)Javier Brea Folco, MD*; Sebastian Gando, MD; Carlos M. Luna, MD,FCCP; Ricardo Mosquera, MD; Lucia Marzoratti, MD; Xavier Bocca,MD, FCCP; Adriana Robles, MD; Oscar Rizzo, MD; ENNAC studygroup, AAMR. Asociacion Argentina de Medicina Respiratoria (AAMR),Buenos Aires, Tucuman, Cordoba, Argentina

PURPOSES: Age, comorbidities or other antecedents and data fromclinical, radiographic and laboratory evaluation are usually considered riskfactors (RF) and are commonly used to decide about the site of care ofpatients with CAP. Our purpose was to evaluate the relationship betweenthe presence of RF and outcome of patients with CAP.

METHODS: Prospective evaluation of outcome in 802 patients sur-veyed during the ENNAC (Argentinean nationwide CAP epidemiologystudy). RF considered included antecedents: age � 65; comorbidities(chronical pulmonary, cerebrovascular, neuromuscular, cardiac, hepaticor renal disease, diabetes, congestive heart failure, malignancy or immu-nocompromise); alcohol abuse or prior admission for CAP; physical examabnormalities: altered consciousness, tachycardia, tachypnea, hypoten-sion; and severe laboratorial (leukocytosis or leukopenia, anemia, uremia,hypoxemia, acidosis) or radiographic (multilobar or bilateral) abnormali-ties. Pneumonia severity index (PSI) was calculated.

RESULTS: 467 patients were admitted (117 in the ICU) while 335were outpatients; 56 patients died during the 30 days following thediagnosis. At least one RF was present in 640 patients, including 345 olderthan 65 years, and 295 younger, with some other risk factor. All 412patients having � 3 RFs survived; 313 patients had � 4 RFs, including 55non-survivors. 83 patients older than 65 years (73.7 � 5.8) were cared asoutpatients, all of them recovered from CAP without complications,including 34 with � 2 RFs and 18 with � 3 RFs.

CONCLUSIONS: Independently to the presence of RFs or the PSIscore, clinical evaluation was effective to choose the site of care. CAP

patients having � 4 RFs should be considered candidates for managementas outpatients or for early discharge.

CLINICAL IMPLICATIONS: Patients with non-severe CAP must bemanaged as outpatients. Our finding demonstrate that carefully evaluatedpatients with more severe CAP (severeal RFs) can be safely managed asoutpatients or discharged early from the hospital. This could reduce theburden of economic costs and the risk of developing complications relatedto hospitalization, especially in the elderly people.

DISCLOSURE: J. Brea Folco, None.

LONG-TERM OUTCOME IN PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIARichard G. Wunderink, MD, FCCP*; Lori Kessler, PharmD; Grant W. Waterer,MBBS, FRACP, FCCP. Methodist Healthcare Memphis, Memphis, TN

PURPOSE: Pneumonia is the leading infectious cause of death in theUS. Pneumonia is also thought to be a major life event in the elderly,signaling an early point in a downward spiral of debility. More aggressivetreatment of severe community-acquired pneumonia (CAP) may there-fore not result in improved long-term outcome even if in-hospitalmortality is reduced.

METHODS: Prospective observational study of patients admitted forCAP beginning in November 1998. Subsequent mortality was determinedby direct patient contact, contact with close relative, or review of theSocial Security Death Index. The Pneumonia Severity Index (PSI) wascalculated on admission. Patients were included in the analysis if at least1 year had passed since original admission for CAP.

RESULTS: 404 subjects met analysis criteria. Mean age was 58.1 years(range 18-99), with 54.7% females and 60.1% African Americans. Theoverall long-term mortality rate was 38% at 1500 days after admission.Survival based on PSI category is seen in the Figure.No long-term mortalityoccurred in PSI class I patients while marked greater mortality rates occurredin PSI class V patients, even after hospital discharge. Acute and long-termmortality in PSI class II and III patients was virtually identical. PSI class IVpatients had greater short-term mortality but subsequent mortality closelyparalleled that of PSI class II and III patients.

CONCLUSION: The long-term mortality of community-acquiredpneumonia varies by PSI score. The major difference between PSI classIV patients and PSI Class II/III patients is due to higher acute mortalityrates with nearly identical subsequent mortality rates.

CLINICAL IMPLICATIONS: Although acute mortality of PSI classIV patients is clearly higher than PSI class II and III patients, thelong-term mortality rate is similar. Efforts to improve inpatient mortalityin this group should therefore result in equivalent improvement inlong-term mortality.

DISCLOSURE: R.G. Wunderink, None.




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UPDATE ON RESISTANCE AMONG RESPIRATORY TRACT IN-FECTION PATHOGENS: RESULTS OF THE ANTIMICROBIALRESISTANCE MANAGEMENT (ARM) PROGRAMJohn G. Gums, PharmD*. University of Florida, Gainesville, FL

PURPOSE: Streptococcus pneumoniae and Haemophilus influenzaeare the primary bacterial etiologic pathogens identified in respiratory tractinfections, with S pneumoniae causing the greatest morbidity and mortal-ity, especially among the elderly, and having the most significant resis-tance profile. The ongoing ARM program documents resistance patternsin US inpatient and outpatient isolates and includes data from 251 USinstitutions on more than 17 million isolates.

METHODS: Antibiograms and sensitivity reports of S pneumoniaeisolates collected in the ARM database from 1995-2002 were reviewed forresistance to penicillin, erythromycin, clindamycin, cefotaxime, and ceftri-axone; H influenzae isolates were reviewed for resistance to cefotaximeand ceftriaxone. Comparisons were conducted using a Web-based analysistool.

RESULTS: Nationally, S pneumoniae resistance to penicillin was37.4% (n�37,688); to erythromycin, 29.6%, (n�18,774); and to clinda-mycin, 9.9% (n�5510). Resistance to cefotaxime was 25.5% (n�10,527)and to ceftriaxone, 16.8% (n�26,594). S pneumoniae isolates in NorthCentral and Northeast remained more susceptible to penicillin anderythromycin than in South Central and Southeast. Across all regions, Spneumoniae was more resistant to cefotaxime than to ceftriaxone, with thedifference greatest in the Southeast and least in North Central. For Hinfluenzae, resistance to cefotaxime was 4.3% (n�4927) and to ceftriax-one, 1.0% (n�10,353), a difference seen largely in the Northeast.

CONCLUSIONS: Resistance rates from the ARM program showedpneumococcal and H influenzae isolates to be more susceptible toceftriaxone than cefotaxime, suggesting these third-generation cephalo-sporins may not be therapeutically equivalent. This disparity is believed tobe due to clonal variations. In addition, data through 2001 do not reflectthe new NCCLS breakpoints, artificially suppressing sensitivity numbers.

CLINICAL IMPLICATIONS: Within each antibiotic class, agentsvary significantly with respect to susceptibility to S pneumoniae; use of themore active agent (ie, ceftriaxone) may delay emergence of resistance.

DISCLOSURE: J.G. Gums, Aventis, grant monies; Roche, grantmonies; Wyeth, grant monies.

LUNG SOUND PATTERNS IN COMMON PULMONARY DISOR-DERSRaymond L. Murphy, MD*. Brigham and Womens/ Faulkner Hospitals,Boston, MA

PURPOSE: Lung sounds reflect underlying pulmonary pathophysiol-ogy. In previous work we noted consistent pattern differences in 285subjects with a variety of common pulmonary disorder. Normals had verylow wheeze and crackle rates. Wheeze rates were high in bronchialasthma. They were not uncommon in congestive heart failure. The highestcrackle rates were seen in interstitial pulmonary fibrosis. Our purpose inthis study is to determine if the patterns of abnormality seen in this largerpopulation were similar to our previous observations.

METHODS: 615 patients were studied with a Stethograph (STG)computer which automatically analyzes wheezes, rhonchi and crackles(Stethographics, Inc, Model STG1602).

RESULTS: Table 1 shows percent patients positive for crackles andwheezes in each category. These findings are similar to previous obser-vations. Squawks were found in 15% of patients with pneumonia, andwere absent or rare in the other conditions. They are a specific but notsensitive sign of lower respiratory infection.

CONCLUSION: We conclude as we did in previous work that thereare consistent differences in the acoustical patterns in a variety of commonlung disorders that can be detected with a computerized lung soundanalyzer.

CLINICAL IMPLICATION: This has been the promise of aidingclinicians in diagnosis and monitoring a variety of common pulmonarydisorders.

Table 1 –patientspositive for

abnormal soundsand average

rates*

CHF(n�71)

%(rate)

Asthma(n�51)

%(rate)

Pn(n�99)

%(rate)

IPF(n�19)

%(rate)

COPD(n�92)

%(rate)

Normals(n�283)

%(rate)

Wheeze inspiration 11(4) 41(11) 16(5) 0(0) 18(4) 1(0)Wheeze expiration 15(6) 49(25) 2(7) 0(0) 33(15) 1(0)rhonchi inspiration 10(4) 6(4) 16(5) 0(0) 12(3) 2(0)rhonchi expiration 15(3) 14(7) 18(7) 0(0) 13(7) 1(0)crackles inspiration 68(5) 35(2) 70(6) 100(24) 58(4) 12(1)crackles expiration 21(2) 18(2) 53(3) 58(7) 28(2) 2(0)

*Wheeze and rhonchi-are calculated percent per breath they occupy;crackles-number per breath.

DISCLOSURE: Dr. Murphy, and Dr. Vyshedskiy have a financialinterest in Stethographics. Supported in part by a grant from Stethograph-ics, Inc.

AUTOMATED LUNG SOUND ANALYSIS IN PATIENTS WITHPNEUMONIARaymond L. Murphy, MD*; A. Vyshedskiy, V-A Power, D. Bana, P.Marinelli, A; . Wong-Tse, R. Paciej. Brigham and Womens/FaulknerHospitals, Boston, MA

PURPOSE: Observer disagreement for the physical findings used todiagnose pneumonia is large. We have developed a computerized mul-tichannel lung sound analyzer that detects and provides objective quan-tification of sounds from 16 sites simultaneously. Our purpose was todetermine whether objectively detected lung sounds in patients withpneumonia are significantly different than those in asymptomatic agematched controls.

METHODS: A convenience sample of 100 patients, age 69�18(mean�SD), in a community teaching hospital who had a clinicaldiagnosis of pneumonia and 100 controls, age 69�7, were examined witha 16 channel lung sound analyzer (Stethographics, Inc., Model 1602). AnAcoustic Pneumonia Score (APS) was generated based on individualacoustic findings detected by the system including rates of rhonchi,automatic counts of fine and coarse crackles as well as amplitudemeasurements of inspiration and expiration.

RESULTS: Inspiratory crackles were present in 81% of these patientsas compared to 28% of controls. Expiratory crackles were also morecommon-65% as compared to 9%. Wheezes and rhonchi were morecommon in the patients with pneumonia – 18% had wheezing or rhonchiin inspiration and 19% in expiration as compared to 1% and 0%respectfully in the controls. The APS averaged 13�8 in patients withpneumonia and 3�3 in controls, p�0.0001. The positive predictive powerof a score higher than 6 was 0.90. Its sensitivity was 0.85 and specificitywas 0.91.

CONCLUSION: Lung sound analysis can provide objective evidencesupporting the diagnosis of pneumonia. The method is noninvasive andeasy to perform even in severely ill patients on ventilators.

CLINICAL IMPLICATIONS: Automated lung sound anlysis offersthe promise of assisting clinicians in the diagnosis of pneumonia particu-lary in the ICU where chest x-ray may be suboptimal (e.g. retrocardiacpneumonias and those below the diaphragmatic dome).

DISCLOSURE: R. Murphy and A. Vyshedskiy have a financial interestin Stethographics.

MORTALITY IN MONOTHERAPY VERSUS COMBINATIONTHERAPY IN SEVERE COMMUNITY-ACQUIRED PNEUMO-NIA: A SYSTEMATIC REVIEWMarcos I. Restrepo, MD, MSc*; Eric M. Mortensen, MD, MSc; AntonioAnzueto, MD; Jacqueline A. Pugh, MD. VERDICT South TX VeteransHealth System and University of TX Health Science Center at SanAntonio, San Antonio, TX

PURPOSE: Little research exists on whether monotherapy (MT) isappropriate for patients with severe community-acquired pneumonia(SCAP). Our goal was to conduct a systematic review to examine whetherpublished research supports the use of combination therapy (CT) versusMT for SCAP.




METHODS: We searched the Cochrane Controlled Trials Register,Cochrane Library Database, EMBASE, and MEDLINE for the period ofJanuary 1990 to October 2002. We scanned references of all includedstudies and pertinent reviews. Articles were selected if they were random-ized controlled trials (RCT), controlled trials, or cohort studies using MTor any CT. Other inclusion criteria included subjects over 18 years of age,meet formal criteria for SCAP, and had sufficient information to comparethe use of MT and CT. Data was extracted by one reviewer and confirmedby a second reviewer.

RESULTS: A total of 424 abstracts were initially reviewed for inclu-sion, 66 manuscripts were reviewed for abstraction, and 4 studies wereselected: one RCT and three cohort studies. The methods used todetermine severity of illness varied: two studies (RCT and cohort study)used the ATS severity criteria, and two cohort studies used the pneumoniaseverity index. Short-term (in-hospital or 30-day) mortality varied between4.2% to 67.3% for MT and 5.7% to 32.5% for CT. The RCT appeared toinclude a less severe spectrum of subjects since in-hospital mortalitywas � 6% versus 6% to 67% in the cohort studies.

CONCLUSIONS: There appears to be considerable heterogeneity inthe small number of studies of CT versus MT in SCAP.

CLINICAL IMPLICATIONS: Further research is needed to examinethe use of MT versus CT in patients with SCAP.

DISCLOSURE: M.I. Restrepo, None.

CALCIUM CHANNEL BLOCKERS ALTER REGULATION OFINTRACELLULAR PH IN RESIDENT ALVEOLAR MACRO-PHAGESAkhil Bidani, MD, PhD; Amelia Ng, MD; Bela Patel, MD; Thomas A.Heming, PhD*. University of Texas Health Science Center, Houston, TX

PURPOSE: L-type calcium channels blockers (CCB) suppress immunecell functions. CCB also influence the activity of V-type H� pumps(V-ATPase). Plasma membrane V-ATPase is important for intracellularpH (pHi) regulation in macrophages (m ). To explore the possibility thatCCB can impact immune cells via pHi, we examined CCB effects onacid-base regulation in resident alveolar m .

METHODS: Alveolar m were recovered from rabbits by bronchoal-veolar lavage. The cells were treated with diltiazem, verapamil, ornifedipine. pHi and cytosolic calcium concentration [Ca2�]i were moni-tored spectrofluorometrically.

RESULTS: The blockers caused a small, but significant, decrease inbaseline pHi and markedly inhibited pHi recovery following cytosolicacid-loading (NH4Cl prepulse). CCB effects on pHi recovery weremediated by V-ATPase inhibition. The effects were insensitive to amilo-ride and independent of external sodium or CO2/HCO3

-. Channelblockade caused a 35% decrement in [Ca2�]i. However, it is unlikely thatdisruption of cytosolic calcium homeostasis was responsible for decreasedV-ATPase activity. Treating the cells with calcium ionophores (A23187 orionomycin) to increase the [Ca2�]i had no effect on V-ATPase activity.V-ATPase activity also was insensitive to inhibition of calcium-dependentprotein kinase. Further, V-ATPase activity was unaffected by treating cellswith cholicine to inhibit intracellular transport of vesicles or proteins.Calcium channel blockade had no effect on cellular ATP content, cellvolume, or viability.

CONCLUSIONS: CCB inhibited V-ATPase in resident alveolar m and impaired pHi regulation. The effects on V-ATPase do not appear to belinked to disruption of cytosolic calcium homeostasis. Rather, the findingsmay reflect direct actions of CCB to uncouple V-ATPase, as reported byTerland et al. (Eur J Pharmacol 207: 37, 1991).

CLINICAL IMPLICATIONS: The data suggest that V-ATPase inhi-bition and the consequent disruption of pHi regulation may be responsi-ble, at least in part, for the documented immunosuppressive effects ofCCB.

DISCLOSURE: T.A. Heming, None.

CYTOLOGY CHARACTERISTICS OF BRONCHOALVEOLARLAVAGE FLUID IN HIV-POSITIVE PATIENTS: A NINE-YEARREVIEWCatherine I. Onyiuke, MD*; Ugochi K. Ohuabunwa, MD; Gloria E.Westney, MD. Morehouse School of Medicine, Atlanta, GA

PURPOSE: Bronchoscopy (BC) with bronchoalveolar lavage fluid(BALF) analysis is the most common method used in evaluating thepresence of PCP in HIV� pt. With improvements in anti-retroviral

therapy, and decreased mortality of HIV pts, changes can be expected inthe previous typical presentation of PCP lung infection in this group. Weset out to evaluate the cytology (CY) results of BALF from HIV� pts todetermine what differences have occurred in the recovery of PCP over anine year period.

METHODS: A retrospective review of BALF CY reports was done onpts in our BC database from 7/1994-12/2002.

RESULTS: 204 BCs were done in 182 HIV� pts (M�138, F�44, age41� 9yrs).The majority of CXRs showed diffuse infiltrates at the time ofBC. The majority of BC were done in the first third (1994-1996) of thenine yrs. CY showed CMV, cryptococcal, herpes, and candida species in7% of the BCs.

BALF PCP Over Nine YearsYrs PCP� (%BC) Organism - (%BC) Total BC done (%)

1994-96 42 52 531997-99 43 49 242000-02 43 47 23

CONCLUSIONS: In this group of HIV� pts, although PCP infectionis common, the isolation of PCP on BC and the number of pts beingevaluated by BC may be decreasing in the current era of HIV manage-ment. CY revealed additional organisms of possible infection in almost10% of BCs.

CLINICAL IMPLICATIONS: The use of BALF cytology analysisremains an important step in the diagnosis of lung infection in HIV�patients.

DISCLOSURE: C.I. Onyiuke, None.

Interstitial Lung Disease - Various Topics12:30 PM - 2:00 PM

PULMONARY INVOLVEMENT IN SCLERODERMA AND ITSPREDICTIVE VALUE ON PATIENTS’ PROGNOSISMohammed Khalid, MBBS, FCCP*; Ahmed Al Shaikh, MBBS, ABIM;Manal Hazmi, MBBS; M Baamer, MBBS; Sarfraz Saleemi, MBBS; SalehAl Dammas, MBBS; Salman Al Saleh, MBBS; Abdullah Saghir, MBBS;Abdullah Al Dalaan, MBBS; Walter Conca, MBBS. King Faisal SpecialistHospital and Research Centre, Riyadh, Saudi Arabia

PURPOSE: To assess progressive pulmonary involvement in patientwith scleroderma. And to establish its possible sequence and its predictivevalue on patient’s prognosis

METHOD: Retrospective review of 33 patients with establisheddiagnosis of scleroderma. Their PFTs, CT chest, assessment of pu-lomonary pressure with ultrasonography and abgs were reviewed.

RESULTS: Total 33 patients were reviewed, 27 female and 6 male. Allpatients had radiological evidence of pulmonary fibrosis, pfts were ofrestrictive pattern in 24 hile 9 patients had normal pfts, dlco was done on29 patients, 22 patients have decreased dlco, while 7 patients had normaldlco. Abgs were done on 11 patients, 5 had hypoxemia, while 6 had normalblood gases po2 decreased 92%). 32 out of 33 had pulmonary htn. Allpatients had pulmonary involvement on ct chest. 27% had normal pfts,22% patients had normal dlco. Around 54% of patient had normaloxygenation (no hypoxemia), while 97% of patients have pulmonary htn.

CONCLUSION: All patients had pulmonary involvement on ct chest,27% had normal pfts, 22% patients had normal dlco. Around 54% ofpatient had normal oxygenation (no hypoxemia), while 97% of patientshad pulmonary htn. Phtn was the most common pulmonary manifestation,it was independent of hypoxemia or pulmonary fibrosis and 2% of patientswith normal dlco and was present in almost all our patients with or withoutother asociated pulmonary abnormalities thus suggesting patients hadpulmonary htn without significant involvement of pulmonary parenchymaor interstitium.

Although we could not established the definite sequence of pulmonaryinvolvement in scleroderma, since most of our patients have advanced oninitial presentation. But based on the above data, phtn is most commonmanifestation of scleroderma and may be the earliest pulmonary involve-




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ment and may predict the development of future progressive pulmonaryfibrosis.

CLINICAL IMPLICATIONS: Further studies are needed to addressif early aggressive therapy with pulmonary htn in scleroderma mayprevent future progressive pulmonary fibrosis and improved long-termpatient’s prognosis.

DISCLOSURE: M. Khalid, None.

RESPIRATORY MECHANICS IN INTERSTITIAL LUNG DIS-EASE PATIENTS WITH AND WITHOUT FUNCTIONAL ALTER-ATIONS IN SPIROMETRY BY FORCED OSCILLATIONLeonardo C. Souza, PT; Jose M. Jansen, MD, PhD; Pedro L. Melo, Eng,PhD*. Education, Biomedical Instrumentation Laboratory, Microcircula-tion Research Laboratory, Pulmonary Function Laboratory - State Uni-versity of Rio de Janeiro, Rio deJaneiro, Brazil

PURPOSE: The aim of this study was to investigate, by means of FOTanalysis, the alterations of respiratory mechanics in patient with InterstitialLung Disease (ILD), with or without diagnose of restrictive dysfunctionby spirometry.

PATIENT AND METHODS: We analyzed 05 healthy subjects(56,8�14,3 years, 160,6�12,4 cm), 05 patients with ILP and withoutalterations on spirometry (59,4�13,45 years, 173,3�11,5 cm) and 05patients with ILD with alterations on spirometry compatible with restric-tive dysfunction (57,7�10,27 years, 161�17,7 cm). The forced vitalcapacity (FVC) and the forced expiratory volume in one second (VEF1)were measured with spirometer. FOT resistive parameters, the zerointercept resistance (R0), mean resistance (Rm), the slope of the imped-ance’s resistive component

(S) were evaluated in the 4-16 Hz frequency range. The mean reactance(Xm) and the dynamic compliance (Cdyn) were obtained in the 4-32 Hzrange. Unpaired t-tests were used in comparisons, and at p�0.05 theywere assumed to be significant.

RESULTS AND DISCUSSION:Comparing R0 and Rm in healthysubjects and ILD patients without alterations in spirometry showed nosignificantly difference (p�0.05). A comparison between ILD patientswithout alterations in spirometry and with alterations showed significantdifferences (p�0.05). This indicates that an increase in resistance couldalso be occurring in these individuals, together with their restrictivepatterns. Indexes of lung homogeneity (S and Xm) showed significantlymore negative values in individuals with restrictive patterns when com-pared to patients without restriction (p�0.03). Cdyn showed the largestdifference among the groups. Individuals without restrictive patterns alsopresented significant alterations compared to the control group (p�0.02).

CONCLUSION: The results of this study indicate that, besidesrestrictive alterations and reductions in the homogeneity lung, patientswith ILD could also present increased values of respiratory resistance.

CLINICAL IMPLICATIONS: The clinical potential of FOT in theevaluation of ILD was confirmed. It can contribute to facilitate theevaluation of these patients, since the exam is noninvasive and needs onlypassive cooperation.

Table 1 - Spirometry and FOT parameters

Control Without Disf. With Disf.

FVC(L)

3.5�1.2 3.9�0.7 1.4�0.4

FEV1(L)

2.9�0.9 2.9�0.5 1.9�0.6

R0(cmH2O/L/s)

2.4�1.1 2.2�0.6 3.5�0.8

Rm(cmH2O/L/s) 2.2�1.0 2.3�0.5 3.0�0.5S(cmH2O/L/s2) -19.9�25.8 3.9�12.3 -51.1�28.7Xm(cmH2O/L/s) -0.2�0.3 0.4�0.4 -0.8�0.8Cdyn(L/cmH2O) 0.04�0.01 0.02�0.01 0.01�0.01

DISCLOSURE: P.L. Melo, CNPq, grant monies; FAPERJ, grantmonies. Supported by CNPq and FAPERJ.

COMPONENTS OF LUNG DIFFUSION AS DETERMINANTS OFABNORMAL OXYGENATION IN CIRRHOTIC PATIENT CANDI-DATES TO LIVER TRANSPLANTFrancesca Mannucci, MD; Giosue Catapano, MD; Carolina Bauleo, MD;Cristina Carli, BS; Edo Fornai, BS; Franco Filipponi, MD; Carlo Giuntini,MD, FCCP; Renato Prediletto, MD, FCCP*. Inst of Clin Physiol,National Research Council Italy-Cardiothoracic Dept, University of Pisa,Pisa, Italy

PURPOSE: Abnormal oxygenation is a common finding in patientssuffering from cirrhosis, ranging from asymptomatic increase in thealveolar to arterial oxygen gradient, (A-a)O2, to a severe respiratoryfailure. Diffusion limitation, VA/Q disequilibrium and intrapulmonaryshunt, as determinants of hypoxemia, however don’t appear to have samerelevance.

METHODS: In order to give more evidence to lung diffusion scenarioin explaining abnormal oxygenation, the transfer factor for CO (TLCO),its components, namely capillary blood volume (Vc) and membranediffusion capacity (DM), its ratio with alveolar volume (TLCO/VA), all aspercent of predicted value, and the DM/Vc ratio (normal value 0.78) havebeen measured in 65 candidates for liver transplant classified according tothe Child-Pugh classes A, B, C.

RESULTS: Progressively reduced values of TLCO (94.6�14.4 vs79.1�17.4, A vs C, p�.0161) and TLCO/VA (83.02�15.2 vs 71.8�10.5, Avs C, p�.0141) with the severity of the disease were mainly found. At thesame time, DM (57.07�14.8 vs 44.77�14.4 A vs C, p�.0102) and Vc(124.13�36.08 vs 163.39�45.9, A vs B, p�.0129) values resulted signif-icantly decreased and increased among different classes of severity of liverdisease, respectively, their ratio being always lower than normal in thewhole group of patients and however significantly reduced in C than Aclasses of patients (0.36�0.144 vs 0.25�0.163, A vs C, p�.0154). Themost severe patients showed abnormal values of oxygenation and their A-aO2 correlated significantly with TLCO (p�.0003, r�.465) and DM(p�.0001; r�.457), but not with Vc, though its values resulted increased.

CONCLUSIONS: These findings suggest that more than 50% of theabnormal oxygenation could be explained by the hypothesis that inpatients with liver cirrhosis the lung diffusion limitation is apparently dueto morphologic changes in the alveolar-capillary membrane whereas theincrease of blood volume capillary fails to counteract the gas exchangeimpairment.

CLINICAL IMPLICATIONS: Components of lung diffusion shouldbe measured when patients with liver cirrhosis, being evaluated for theliver transplant, show reduced TLCO.

DISCLOSURE: R. Prediletto, National Research Council of Italy,Grant monies.

EXPRESSION OF APOPTOSIS-REGULATORY GENES IN EPI-THELIAL CELLS IN PATIENTS WITH IDIOPATHIC PULMO-NARY FIBROSISMaria Plataki, MD*; Anastassios Koutsopoulos, MD; John Drossitis, MD;George Delides, Prof; Nikolaos M. Siafakas, Prof; Demosthenes Bouros,Prof. Dept of Pneumonology, University General Hospital of Crete,Voutes Heraklion, Greece

PURPOSE: Idiopathic pulmonary fibrosis (IPF) begins in the alveoluswith epithelial cell injury and alveolar inflammation. Increased apoptosisof the pulmonary epithelial cells could be involved in the pathogenesis ofthe disease. We studied the expression of apoptotic markers in patientswith IPF.

METHODS: We examined by immunohistochemistry (IHC) the ex-pression of p53, bax (proapoptotic proteins), bcl-2 (antiapoptotic protein)and caspase 3 (effector of apoptosis) in association with DNA strandbreaks detected by terminal deoxynucleotidyl transferase-mediated de-oxyuridinetriphosphate nick endlabelling (TUNEL) in bronchial andalveolar epithelial cells taken by biopsy in 12 patients with IPF and 10controls.

RESULTS: Results are shown in the next table as percentage (%) ofsubjects showing positive signals in alveolar or bronchial epithelial cells.

TUNEL p53 bcl-2 bax Caspase-3

IPF 91.5 83.4 58 83.4 100Controls 20 10 100 20 100


Interstitial Lung Disease - Various Topics,continued


IHC for bcl-2 and bax in IPF patients was positive in a very smallpercentage of epithelial cells (�10%). Whereas only in 30% of controls,caspase 3 was positive in �10% of hyperplastic epithelial cells, it waspositive in �10% of epithelial cells in 66.7% of IPF patients.

CONCLUSIONS: These results show that apoptotic hyperplasticepithelial cells are present in patients with IPF and that the expression ofp53, bax and caspase 3 appears to be upregulated and that of bcl-2downregulated in these cells.

CLINICAL IMPLICATIONS: Despite current treatment ap-proaches, IPF remains a progressive and fatal disease. Understanding itspathogenesis will improve therapeutic strategies.

DISCLOSURE: M. Plataki, None.

USING PHARMACOVIGILANCE TO ASSESS THE SAFETY OFINTERFERON GAMMA-1B IN PATIENTS WITH SEVERE IDIO-PATHIC PULMONARY FIBROSIS (IPF)Randall E. Kaye, MD*; Williamson Z. Bradford, MD; Karen Starko, MD;Steven Nathan, MD. InterMune, Inc., Brisbane, CA

PURPOSE: IPF is a uniformly fatal disease with a median survival of2-3 years and limited therapeutic options. A recent Phase III, doubleblind, placebo-controlled study evaluated the safety and efficacy ofInterferon gamma-1b (IFN-� 1b) in 330 patients with mild-to-moderateIPF; however, limited data are available in patients with severe disease.The current analysis evaluated the safety of IFN-� 1b in patients withsevere IPF.

METHODS: Pharmacovigilance techniques were used to identify acohort of patients in the safety database with a baseline FVC � 50% whoreceived IFN-� 1b for the treatment of IPF. The safety database includedpatients from the Phase III clinical trial, the subsequent open-labelobservational study, and a U.S. Patient Registry.

RESULTS: More than 150 patients with a baseline FVC � 50% wereidentified. Pulmonary function, vital status as well as serious adverseexperiences (SAEs) are available for these patients. Analyses of mortalityand SAE rates will be presented.

CONCLUSIONS AND CLINICAL IMPLICATIONS: This studywill provide the first detailed assessment of the safety of IFN-� 1b in alarge cohort of patients with severe IPF, and foster a better understandingof the therapeutic utility of IFN-� 1b in patients with severe disease.

DISCLOSURE: R.E. Kaye, InterMune, Inc., Shareholder.

HOSPITALIZATION OF PATIENTS WITH IDIOPATHIC PUL-MONARY FIBROSIS (IPF) IN A PHASE 3, RANDOMIZED, DOU-BLE-BLIND, PLACEBO-CONTROLLED TRIAL OF INTER-FERON GAMMA-1B (IFN-� 1B)Williamson Z. Bradford, MD*; Karen Starko, MD; Paul W. Noble, MD;IPF Study Group. InterMune, Inc., Brisbane, CA

PURPOSE: IPF is a devastating disease with a median survival of 2-3years, and no proven treatment. Hospitalization of IPF patients is acommon occurrence, usually due to a respiratory-related diagnosis. Thisstudy evaluated the safety and efficacy of IFN-� 1b in steroid-refractoryIPF patients (pts).

METHODS: IPF pts were randomized to receive IFN-� 1b 200 �g orplacebo (PBO) SQ tiw for up to 3 years. The primary endpoint was timeto death or disease progression (�10% decrease in % pred FVC or �5mm Hg increase in A-a gradient). Other endpoints included dyspnea,measures of lung function, gas exchange, and hospitalization.

RESULTS: 330 pts were randomized. Baseline (BL) mean FVC (64%vs. 64%), % pts with surgical lung biopsy (62% vs. 67%). Death or diseaseprogression occurred in 46.3% and 51.8% of IFN-� 1b and PBO pts,respectively (11% reduction, p�0.53), while death occurred in 9.9% and16.7% overall respectively (41% reduction, p�0.08). An exploratoryanalysis of hospitalizations demonstrated a similar number of hospitaliza-tions (100 vs. 95) and respiratory-related hospitalizations (59 vs. 57) forIFN-�1b versus PBO pts, but the duration of hospitalization was shorterfor IFN-� 1b pts: Overall, 9 versus 11 days (p�0.21); respiratory-related,11.4 versus 15 days (p�0.20). In patients with a baseline FVC � 55% themean duration of respiratory-related hospitalization was significantlylower in the IFN-� 1b group, 9.2 versus 16.3 days (p�0.04).

CONCLUSIONS AND CLINICAL IMPLICATIONS: Detailedanalysis of all hospitalizations, including the reasons for hospitalizationsand the utilization of medical services will be presented.

DISCLOSURE: W.Z. Bradford, InterMune, Inc., Shareholder.

IDIOPATHIC PULMONARY FIBROSIS: SYSTEMATIC REVIEWAND META-ANALYSIS OF TREATMENT OPTIONS AND OUT-COMES, 1970 TO PRESENTKaren Schoelles, MD*; Rhonda P. Estok, RN; Linda R. Stone, NP;Catherine A. Cella, BA; Randall Kaye, MD; Steven Nathan, MD.MetaWorks Inc., Medford, MA

PURPOSE: Idiopathic pulmonary fibrosis (IPF) is a chronic, fatalinterstitial lung disease. Current treatment options for patients with IPFare limited, and marginally effective. Prescribed regimens vary greatlyamong practitioners. This study was designed to assemble a database ofbest available evidence from the literature regarding the efficacy andsafety of the various treatments for IPF, including lung transplantation.

METHODS: A systematic review of the literature from 1970 to presentwas performed utilizing MEDLINE (via PubMed) and Current Con-tents™ electronic searches as well as manual bibliography checks. Addi-tionally, the European Respiratory Society, American Thoracic Society,and American College of Chest Physicians 2002 meetings were searchedfor relevant abstracts. Study and patient characteristics, treatment detail,and outcomes were extracted from accepted studies and entered into adatabase. Data will be synthesized across studies using descriptive statis-tics with stratification by covariates, and meta-analysis will be performedif data permit.

RESULTS: A total of 5,510 abstracts were screened for inclusion in thestudy set. (#) full studies and (#) meeting abstracts were included in thefinal analysis. A total of (#) IPF patients received medical treatment, and(#) underwent lung transplantation. Results for survival, objective and/orsubjective response to treatment, reduction in concomitant treatmentand/or treatment discontinuation, and quality of life outcomes will bepresented.

CONCLUSIONS: The results of this systematic review will quantifythe efficacy of various approaches to the treatment of IPF.

CLINICAL IMPLICATIONS: This knowledge can be used in thedevelopment and testing of novel therapeutic agents and approaches inclinical trials in an effort to expand treatment options and survival forpatients with this devastating disease.

DISCLOSURE: K. Schoelles, InterMune, Inc., Industry.

FUNDOPLICATION FOR GASTROESOPHAGEAL REFLUX DIS-EASE ASSOCIATED INTERSTITIAL LUNG DISEASEHassan F. Nadrous, MD*; Eric J. Olson, MD; Jay H. Ryu, MD. MayoClinic, Rochester, MN

PURPOSE: Gastroesophageal reflux disease (GERD) has been linkedwith extraesophageal disorders, including interstitial lung disease (ILD).The nature of the GERD-ILD association and the role of fundoplicationin the management of this disorder remain incompletely defined. Accord-ingly, our aim was to characterize our patients who underwent fundopli-cation with the intent of treating both GERD and associated ILD, as wellas determining the impact of surgery on the course of their lung disease.

METHODS: Retrospective chart review of patients who had GERDassociated ILD and underwent fundoplication at Mayo Clinic, Rochester1977-2002. Data abstracted included: age, sex, smoking status, clinicalpresentation, pharmacotherapies for GERD and ILD, pulmonary func-tions; chest roentgenogram and chest computed tomography (CT) find-ings; and bronchoscopic or surgical lung biopsy reports.

RESULTS: Fifteen patients (9 women) with GERD associated ILDunderwent fundoplication at our center between 1997-2002. ILD wascharacterized clinico-radiologically as idiopathic pulmonary fibrosis/usualinterstitial pneumonia (IPF/UIP) in 13 patients; 4 of these patients hadsurgical lung biopsies demonstrating 2 UIP and 2 organizing pneumonia.Age at time of ILD diagnosis was 66 � 10 years (mean�SD); and age atthe time of anti-reflux surgery was 68 � 10 years (mean�SD). Fundo-plication was performed laparoscopically in 11 patients. One perioperativedeath occurred. Post-operatively, anti-reflux pharmacotherapy was dis-continued in all but 1 patient. Pre- and post-operative comparisons werepossible in 5 patients with a median follow-up of 16 months (range: 5-33months). Using the American Thoracic Society treatment assessmentcriteria (Am J Respir Crit Care Med 2000; 161:646-664), 2 patientsremained stable and 3 worsened.

CONCLUSIONS: Interstitial lung disease associated with GERD mayhave varying radiologic and histologic manifestations. Anti-reflux surgerydoes not uniformly result in clinical, radiologic, and physiologic improve-ment in patients with ILD-associated GERD.




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CLINICAL IMPLICATIONS: The role of fundoplication surgery inthe management of GERD associated ILD remains uncertain and needsto be explored further.

DISCLOSURE: H.F. Nadrous, None.

Lung Cancer12:30 PM - 2:00 PM

SURVEILLANCE FOR RECURRENT OR NEW CANCER IN PA-TIENTS WITH RESECTED STAGE I OR II NON-SMALL CELLLUNG CANCERManish R. Patel, DO*; Daniel W. Ray, MD; Michael J. Liptay, MD;Deanna Close, RRT; Carol Knop, RN. Evanston Northwestern Health-care, Evanston, IL

INTRODUCTION: Low-dose chest CT for surveillance of recurrentor 2nd primary lung cancer in post-operative stage I and II lung cancerpatients

PURPOSE: There is no established method for post-operative surveil-lance of patients after resection of lung cancer. We conducted anobservational study using low radiation-dose chest CT (LDCT) as asurveillance tool for recurrent or new primary lung cancer.

METHODS: From 1998 to present, patients who underwent resec-tion of stage I or II non-small cell lung cancer (NSLC) were followedwith a LDCT one year post-operatively. Suspicious non-calcifiednodules that were found were then evaluated depending upon size.Nodules �5mm were followed every 6 months. Nodules between5-9mm were followed 4-6 months later. Nodules 10mm and greaterwere evaluated with either trans-thoracic needle biopsy, bronchoscopy,PET scan, or thoracotomy. Any nodule demonstrating interval sizeincrease was biopsied.

RESULTS: Consent was obtained from 25 patients with resectedstage I and II NSLC. The average time to the first LDCT was 12months post-operatively. At 1 year follow-up, 18 nodules less than5mm in size, 5 nodules between 5 and 9mm, and 7 nodules greaterthan 10mm were found. Of the nodules that were �9mm, all wereeither stable or decreased in size on follow-up CT scans. One of the 7nodules that were greater than 10mm was observed with repeat LDCTas it was retrospectively seen on a preoperative CT scan. This nodule,after 2 subsequent LDCT’s, was found to be a 2nd primary stage Iadenocarcinoma that was resected. One nodule grew in size onfollow-up CT scan, was biopsied, and found to be negative formalignancy. The rest of the nodules �10mm nodules were eitherstable or regressed.

CONCLUSIONS: LDCT detected one new primary cancer that wasresectable. In routine surveillance, many small nodules are found that arenot of any significance.

CLINICAL IMPLICATIONS: LDCT can be used as a post-operativesurveillance tool. More data is necessary to draw any other conclusions.

DISCLOSURE: M.R. Patel, None.

USEFULNESS OF CT CHEST IN DETERMINING CLINICALLYSIGNIFICANT MEDIASTINAL LYMPHADENOPATHY IN PA-TIENTS WITH NON-SMALL CELL LUNG CANCER (NSCLC)Mazen Alakhras, MD*; Geetha Kanajam, MD; Damodhar Nerella, MD;Karthikeyan Kanagarajan, MD; Depakkumar Malli, MD; Kanchan Gupta,MBBS; Padmanabhan Krishnan, MBBS. Coney Island Hospital, Brook-lyn, NY

PURPOSE: To determine the significance of mediastinal lymphade-nopathy detected by CT chest in evaluation of patients with NSCLC.

METHODS: A retrospective study of 116 patients with NSCLCadmitted in a municipal teaching hospital over a ten-year period. Thefindings of CT Chest with contrast prior to surgery were correlated withthe histopathology after surgery to determine the sensitivity and specific-ity. Lymph nodes were considered abnormal if they were � 10 mm inshort-axis diameter.

RESULTS: The mean age of patients was 64 � 24 years; there were 80males and 36 females. 54 of 116 patients (46.6%) had mediastinallymphadenopathy and 62 of 116 patients (53.4%) had no mediastinal

lymphadenopathy on CT chest reading. The results are shown on thealgorithm below.

The sensitivity and specificity of CT chest in predicting the presence ofmalignant mediastinal lymph nodes were 69.2% and 80% respectively.

CONCLUSION: Significant adenopathy on CT Chest is not a reliableindicator on underlying malignancy.

CLINICAL IMPLICATIONS: As CT chest is not very sensitive andspecific in detecting mediastinal lymph node involvement with malig-nancy, sampling of mediastinal lymph nodes remains the definitive test todetect it.

DISCLOSURE: M. Alakhras, None.

BIOLOGICAL AGE VERSUS CHRONOLOGICAL AGE IN LUNGCANCER PATIENTSJameel F. Durrani, MBBS*; Donald P. Jones, Chief, CardiothoracicSurgery - HUMC; James Donahoo, Professor of Cardiothoracic Surgery -UMDNJ; Jeffrey Gardner, Assistant Professor of Pediatrics; AbrahamAviv, Director, Hypertension Research Center - UMDNJ. UMDNJ- NewJersey Medical School, Wallington, NJ

PURPOSE: To explore the relation between lung cancer and humanaging.

Telomeres are DNA binding proteins at the end of chromosomes. Withage the telomeres undergo shortening or attrition in normal cells,represnting the biological clock of cell’s life cycle. Patients presenting withlung cancer at a younger age than others may be genetically predisposedto this aging-related disease.

HYPOTHESIS: The biological age of patients who present with lungcancer at an early age is more advanced than their chronological agewould indicate.

METHODS: After IRB approval, informed consents were obtainedfrom 11 Patients (male � 9, female � 2) undergoing lung cancer surgery.Patients were divided into two age groups, 50-60 years (n�5) and 72-76years (n�6). Tissue samples were collected from normal lung (peripheryof the removed lobe), skin and skeletal muscle during surgery. All sampleswere tested for telomere length. Muscle telomere length was used as areference indicator representing telomere length at birth in each individ-ual . Rate of telomere attrition was calculated by subtracting the telomericlength of each proliferating tissue (skin and lung) from non-proliferatingtissue(muscle) and dividing by age of the individual . Student T-test(non-paired ) was used and regression and analysis of variance for the rateof telomeric attrition as a function of age, was calculated.

RESULTS and DISCUSSION: 1- Telomere length was consistentlylonger in the muscle than in lung and skin samples (Figure 1); 2- Therewas no significant difference in telomere length in muscle tissue in twoage groups. (p�0.2); 3- Rate of telomere attrition was higher in theyounger subjects than in the older subjects (Figure 2, 3).

CONCLUSIONS: Telomere attrition rate (that reflects biologicalaging) in cancer patients is higher in middle age patients than elderlycancer patients.

CLINICAL IMPLICATIONS: Results shed a new perspective on therelation between lung cancer and the biology of human aging. Large scalestudies are needed to further explore the genetic risks to develop lungcancer.




DISCLOSURE: J.F. Durrani, None.

QUANTIFICATION OF AUTOFLUORESCENCE BRONCHOS-COPY SUPPLEMENTS THE INTERPRETATION OF PRECAN-CEROUS LESIONSDaniel A. Orlando, MD*; Darren Hoffberger, DO; Frank Walsh, MD;Mark Rolfe, MD; John J. Bomba, BS; Melvyn S. Tockman, MD, PhD.Univ of South Florida, Tampa, FL

PURPOSE: The addition of autofluorescence bronchoscopy (AFB) tostandard white light bronchoscopy improves the capability of localizingsmall precancerous lesions. Currently visual identification alone classifiesbronchoscopic findings. We analyzed light intensity from AFB images todetermine whether abnormal pathology produced a quantitative alterationin autofluorescence.

METHODS: Abnormal AFB lesions were imaged and biopsied. Thelesions typically appeared brown or brownish-red when compared to normalareas which appeared green. All biopsies were placed in a 10% formalinsolution and sent for pathology interpretation. The images were convertedfrom a proprietary Xillix® file format to Tag Image File Format (TIFF).Using Universal Imaging’s MetaMorph® software, the biopsied site and onenormal region of interest (ROI) were defined on each image by twopulmonologists experienced in AFB who were blinded to the pathology of thelesions. The average pixel intensity for red light and green light for eachregion was determined and red to green light ratios (RGR) were calculated.

RESULTS: A training set of ROIs was initially defined for a set ofseven images in which the pathology was known to be “positive” (prein-vasive or invasive cancers). The range of RGR of the abnormal ROIs (0.41to 0.79) was found to be distinct from the range of RGR of the normalROIs (0.23 to 0.38). This range of abnormal ROIs was then used in ablinded evaluation of 30 test images. Of the 17 positive images, five hadpositive pathology (positive predictive value 0.29). Of the 13 images witha negative test (RGR less than 0.41), twelve had negative pathology(negative predictive value 0.92) for an overall accuracy of 57% ascompared to 43% with visualization alone.

CONCLUSIONS: Quantification of AFB images supplements thebronchoscopist’s interpretation of precancerous lesions of the tracheo-bronchial tree.

CLINICAL IMPLICATIONS: Quantification of red to green lightratios enhances the ability to identify neoplastic and pre-neoplastic lesionsduring fluorescence bronchoscopy.

DISCLOSURE: D.A. Orlando, None.


Lung Cancer, continued


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PRESERVATION OF PULMONARY FUNCTION FOLLOWINGSTEREOTACTIC BODY RADIOTHERAPY FOR STAGE I NON-SMALL CELL LUNG CANCERMark D. Williams, MD, FCCP*; Ronald C. McGarry, MD; RobertTimmerman, MD. Indiana University, Indianapolis, IN

PURPOSE: To determine the short-term effects of stereotactic bodyradiotherapy on pulmonary function in patients with medically unresect-able stage 1 non-small cell lung cancer (NSCLC).

METHODS: We recently completed a phase 1 study of stereotacticbody radiotherapy which enrolled patients with medically unresectablestage 1 NSCLC. The dose-limiting toxicity was not reached, but the studywas halted at a level of 2000cGy/fraction. Subsequently a phase II studywas initiated using 2000cGy/fraction times 3 fractions (6000 cGy total) forpatients with medically unresectable stage 1 NSCLC. Baseline pulmonaryfunction tests were performed (FEV1, FVC, DLCOand pO2) at baseline,6 weeks and then at 3 months.

RESULTS: At this time a total of 13 patients have completed therapyand the initial 3-month follow-up period. One patient suffered a grade 2pulmonary toxicity (pneumonitis with � 12% change in pulmonaryfunction), which required hospitalization. Baseline pulmonary functionvalues were: FEV1 1.2 liters, FVC 2.4 liters, DLCO 12.4 and pO2 74. At6 weeks values were: FEV1 1.2, FVC 2.5, DLCO 10.9 and pO2 73. At 3months post radiotherapy values were: FEV1 1.1, FVC 2.3, DLCO 10.2and pO2 72. There was no significant decrease in FEV1, FVC or p02, butthe DLCO decreased by 18% at 3 months.

CONCLUSIONS: In this population of patients with poor pulmonaryfunction, high dose stereotactic body radiotherapy for medically unresect-able stage 1 NSCLC did not decrease short-term spirometry or pO2.There was evidence of a decrease in DLCO at 6 weeks and 3 months.

CLINICAL IMPLICATIONS: Frail patients with medically unresect-able stage 1 NSCLC appear to tolerate high doses of targeted radiother-apy. Further study of pulmonary function long-term is required in thispopulation.

DISCLOSURE: M.D. Williams, None.

CHARACTERISTICS OF LUNG CANCER IN AFRICAN AMERI-CAN PATIENTS WITH HIVEmmanuel A. Nidhiry, MD*; Fitzroy W. Dawkins, MD; Vijaya Gorle,MD; Aruna Paspula, MD; Ramani Reddy, MD; Deepa E. Nidhiry, MD;Kepher Makambi, PhD; Vinod Mody, MD; Octavius D. Polk, MD.Howard University Hospital, Washington, DC

PURPOSE: The association of human immuno deficiency virus (hiv)infection and lung cancer remains unclear. This study analyzes thecharecteristics of patients with lung cancer and hiv treated at ourinstitution from 1991-2000.

METHODS: Data regarding patients with hiv and lung cancer (studygroup) was obtained retrospecteivley from medical records. We alsoanalyzed records of thiry six patients with lung cancer and unknown hivstatus as a control group.

RESULTS: Median age of patients with hiv infection and lung cancerwas 50.all patients were of african american ethnicity. Patients in the studygroup had a median survival of nine months compared to a mediansurvival of seventeen months in the control group (p�0.12).study grouphad a higher proportion of patients with adenocarcinoma . Majority ofpatients in either group were smokers and presented with advanced stagesof lung caner. All patients in the study group had non small cell lungcancer .

CONCLUSIONS: Patients with hiv seropositiity and lung cancer wereyounger compared to patients with lung cancer in the us.the highproportion of african american patients in this study reflects the patientpopulation seen at our institution.no significant differences in survival wasnoted in hiv seropositive patients with lung cancer compared to thecontrol group. Further studies in a larger patient population is needed toclarify any survival differences.

CLINICAL IMPLICATIONS: This series of african american pa-tients with hiv and lung cancer had clinical feartures similar to earlierreports in the literature. The study failed to show any significantdifferences in survival in patients with hiv infection and lung cancercompared to patients with lung cancer and undetermined hiv status.Patietns with hiv and lung cancer may benefit from aggressive treatmentapproaches since they do not appear to have a worse prognosis.

DISCLOSURE: E.A. Nidhiry, None.

PNEUMOTHORAX OCCURRENCE IN BONE AND SOFT TIS-SUE SARCOMAS: INCIDENCE, PREVALENCE, EFFECT ONMORTALITYThomas A. Horan, MD*; Paulo S. Berraldo, MD PhD; Flavia F. Santiago,MD. Hospital Sarah, Brasilia, Brazil

PURPOSE: Metastatic sarcomas to lung have been long recognized asa cause of pneumothorax. The frequency and effect on longevity of itsoccurrence has not been defined.

METHODS: Retrospective review of 2444 consecutive tumor patientsadmitted to our hospital between Jan 1990 and Sept 2000 identified 1348cases with confirmed diagnosis followed a minimum of 28 days in whomradiological examination of the chest was available. Data abstracted forpatient demographics, histological diagnosis, presence of pulmonarymetastasis, and survival, was compared with admission prevalence, andsubsequent occurrence of pneumothorax.

RESULTS: All 10 pneumothoraces occurred in the 311 patients withprimary bone and soft tissue sarcomas: incidence 1.2 % / year. Threepatients had pneumothorax at first hospital admission with two of thesebeing bilateral simultaneous occurrences for a prevalence 2.4% at admis-sion.

The 201 sarcoma patients with pulmonary metastases had all but one ofthe pneumothoraces (9 / 391 pt yr.; incidence 2.3%/yr.). Only one patientwith an osteosarcoma had no computerized tomographic evidence ofpulmonary metastases. He remained free of evidence of metastases during8 months of follow up.

No patient died as a result of pneumothorax. The timing of pneumo-thorax bore no relationship to chemotherapy. Survival for patients withpneumothorax was equal to the group with metastases as a whole withmean survival 39 months.

CONCLUSION: Pneumothorax is an uncommon complication of boneand soft tissue sarcomas metastatic to lung. It’s poor prognosis is reflectsthe prognosis of the underlying metastasis.

CLINICAL IMPLICATIONS: Prevalence at admission and incidenceof pneumothorax secondary to metastatic sarcoma is infrequent and bearsthe negative prognostic effect of the underlying tumor.

DISCLOSURE: T.A. Horan, None.

UTILITY OF POSITRON EMISSION TOMOGRAPHY IN EVALU-ATION OF CARCINOID TUMORS PRESENTING AS SOLITARYPULMONARY NODULESCraig E. Daniels, MD*; Kirk M. Doerger, MD; Val J. Lowe, MD; JamesR. Jett, MD. Mayo Clinic, Rochester, MN

PURPOSE: Carcinoid tumors are uncommon neuroendocrine malig-nancies representing 1-2% of all lung neoplasms, and present as solitarypulmonary nodules (SPN) only 20% of the time. FDG-PET is sensitive fordetection of neoplastic SPN’s. However, previous reports suggest thehypometabolic growth of carcinoid neoplasms renders FDG-PET ineffec-tive for their detection. Because of the rarity of carcinoid neoplasms, theseconclusions are based on individual case reports and small reviews, whichinclude carcinoids presenting as endobronchial lesions and pulmonarymasses. Our purpose was to study the utility of FDG-PET in theevaluation of carcinoid neoplasms presenting as SPN’s.

METHODS: Retrospective review of Mayo Clinic Rochester surgicalpathology database from 5/00 to 3/03 revealed 98 patients with thoracicsurgical resection of pathology proven typical or atypical carcinoid.Exclusion of patients with endobronchial lesions or pulmonary masses(tumor � 3cm) revealed 8 with a preceding FDG-PET study forevaluation of a pulmonary nodule. We reviewed these patients forFDG-PET result (� or –) and Standardized Uptake Value (SUV), grosspathological size of the nodule, and tumor type.

RESULTS: Pathology showed 5 typical and 3 atypical carcinoids withaverage gross pathologic size of 1.43 cm (range, 0.8 – 2.0 cm). OverallPET sensitivity for detection of carcinoid tumors presenting as pulmonarynodules was 87.5% (7 true positives and 1false negative) with average SUVof 4.8 (range, 1.4 – 10.0). The one PET false negative carcinoid was a 1.3cm, atypical carcinoid, with an SUV of 1.4.

CONCLUSIONS: FDG-PET imaging is effective in detection oftypical and atypical carcinoids presenting as SPNs. The sensitivity wereport is higher than in previous studies and represents the largest seriesto date for FDG-PET evaluation of carcinoids presenting as pulmonarynodules.




CLINICAL IMPLICATIONS: FDG-PET imaging is effective forevaluation of suspected malignant pulmonary nodules including typicaland atypical carcinoid

DISCLOSURE: C.E. Daniels, None.

THE EXPRESSION OF GLUTATHIONE-S TRANSFERASE-� (G-ST-�) AS PROGNOSTIC FACTOR FOR THE RESPONSE TOCHEMOTHERAPY AND SURVIVAL FOR PATIENTS WITH IN-OPERABLE NON-SMALL CELL LUNG CANCER (NSCLC)Georgios S. Vlachogeorgos, MD,FCCP*; Dimitrios Mermigkis, MD;Georgia Tsakalou, MD; Efrosini Manali, MD; Napoleon Karagiannidis,MD; Charis Roussos, MD, PhD, FCCP; Vlassis Polychronopoulos, MD,FCCP. Sismanoglio General Hospital 3rd Pulmonary Department, Ath-ens, Greece

PURPOSE: To study the difference in the survival between the G-st-�negative [G-st-� (-)] and G-st-� positive [G-st-� (�)] in chemotherapypatients with inoperable NSCLC. Our hypothesis was that the G-st-�(�)patients will not response to chemotherapy.

METHODS: 24 patients with NSCLC stage IIIb were studied. Allpatients were submitted in 3 cycles of chemotherapy with Ifosfamide,Cis-platin and Vinblastine. After the 3 first cycles the patients werereevaluated and characterized as complete responders (CR), partialresponders (PR), and non responders (NR) according to internationalstandards. The expression of G-st-� was determined with semiquantitativeimmunohistochemical method in cytological specimens of the patientswhich were obtained by fiberoptic bronchoscopy. The NR were switchedto palliative care . The 24 months survival was determined for all patients.

RESULTS: G-st-�(-) patients total 13, CR and PR patients 12(92.3%),NR patient 1 (7.7%). G-st-�(�) patients total 11, CR and PR patients4(36.4%), NR patients 7 (63.6%)

p value (Fisher’s exact test) 0.008G-st-�(-): 13 patients mean survival time 19 monthsG-st-�(�):11 patients mean survival time 9 monthsp value 0.0022NR 8 patients, mean survival time 5.95 monthsPR 11 patients, mean survival time 15.63 monthsCR 5 patients, mean survival time 21.84 monthsp value �0.0001CONCLUSIONS: 1)The expression of G-st-� could be used as a

prognostic factor for the response to chemotherapy2) The 24 monthssurvival time presents a statistically significant difference between G-st-�(-) and G-st-�(�) patients3) The survival time for the NR patients iscomparable with this of the patients who are submitted to the best supporttreatment.

CLINICAL APPLICATION: The use of prognostic factors for theresponse to chemotherapy in clinical practice could diminish the cost ofthe antineoplasmatic treatment, and improve the quality of life for thosepatients that would not respond to chemotherapy.

DISCLOSURE: G.S. Vlachogeorgos, None.

EXPRESSION OF PRO-APOPTOTIC CASPASE-3 CORRELATESWITH LUNG CANCER CELL GROWTH BEHAVIOR AMONGPHENOTYPES WITH DIFFERENT INTRINSIC DOUBLINGTIMESKing F. Kwong, MD*; Lindsay B. Cooper, B.S.; Mark J. Krasna, MD.Greenebaum Cancer Center, University of Maryland, Baltimore, MD

PURPOSE: Different lung cancer sub-types exhibit highly variablegrowth rate phenotypes. Apoptosis pathways are highly conserved,even among cancer cells. Caspase-3 is a critical down-stream effectorthat promotes programmed cell-death when activated. The purpose ofthis study is to identify in lung cancer cells of varying growthphenotypes whether Caspase-3 expression correlates with cancer cellgrowth.

METHODS: Non-small cell lung cancer cell lines (A549, Calu, andNCI-H596) were selected because of their divergent genetic mutationalcharacteristics and cultured in appropriate media and incubation condi-tions. Intrinsic cancer cell proliferation rates were measured using amodified MTT growth assay. Cytosolic fractions were isolated from cellextracts and were assayed for total protein concentration as well asCapase-3 protease enzymatic activity. Equivalent protein amounts fromeach lung cancer cell line were separated by 1-D gel electrophoresis and

subjected to Western immunoblotting using an antibody monospecific forCaspase-3 protein.

RESULTS: Growth rates varied between the three lung cancer celllines as represented by their estimated cell doubling times (A549- 8 hr ;Calu- 30 hr ; H596- 27 hr). Intrinsic Caspase-3 activities for A549, Calu,and H596 were 2.17�/-0.85 x 10-3 OD/ug, 3.42 �/- 1.38 x 10-3 OD/ug, and4.5 �/- 1.1 x 10-3 OD/ug, respectively. Differences in intrinsic Caspase-3activity (slow- vs. fast-growing) were significant between H596 and A549(p�0.04) but not between Calu and A549 (p�0.26). Western immuno-blotting confirmed the presence of greater Caspase-3 protein quantity inH596 than in A549.

CONCLUSIONS: Intrinsic Caspase-3 protein quantity and activityappear to be greater in the slower growing H596 lung cancer cell line ascompared to the much faster, and possibly less cell-cycle regulated, A549.This same relationship was also seen morphologically in Calu versus A549,although their data did not reach statistical significance.

CLINICAL IMPLICATIONS: Down regulation of Caspase-3 mayrepresent a critical defect in the mechanistic control pathway of lungcancer cells. Greater expression of Caspase-3 activity may possibly inhibitcellular proliferation in lung cancer.

DISCLOSURE: K.F. Kwong, None.

Lung Transplantation12:30 PM - 2:00 PM

INFORMATION DISPLAY FORMAT AND DECISION-MAKINGIN LUNG TRANSPLANT HOME MONITORING: PRELIMINARYRESULTSDavid S. Pieczkiewicz, MA*; Stanley M. Finkelstein, PhD; Marshall I.Hertz, MD. University of Minnesota, Minneapolis, MN

PURPOSE: The increased use of computer and home monitoringtechnologies requires caregivers to assess increasing amounts ofclinical information. We report preliminary results from experimentsdesigned to determine how information display format affects decisionaccuracy and time in the detection of infection/rejection events fromphysiologic and symptom data, drawn from participants in the LungTransplant Home Monitoring Program (LTHMP) at the University ofMinnesota.

METHODS: In two experiments, physicians and nurses fromtransplant medicine and related specialties (N � 6 and 10, respec-tively) were shown a series of cases consisting of pulmonary andsymptom information from the LTHMP databases (C � 12 and 20,respectively, divided equally between infection/rejection events andnonevents). In both experiments, cases were shown, in random order,in each of several display formats. Experiment 1 included paper- andcomputer screen-based graphical and tabular displays. Experiment 2included computer screen-based graphical, table, hybrid graphical/table, and control chart formats. Clinician readers provided probabilitystatements of infection/rejection status for each display, which wereused in constructing receiver operating characteristic (ROC) curves.Times required for making decisions and clinician preference rankingsfor the different display formats were also recorded.

RESULTS: No statistically significant differences were found in deci-sion accuracies for any of the display formats (Area-under-ROC ranges:0.725-0.783, P � 0.5; 0.704-0.753, P � 0.5 for Experiments 1 and 2,respectively). Decision times were not significantly different at the 0.05level (ranges: 20.1-26.8 seconds, P � 0.12; 33.8-40.5 seconds, P � 0.10,respectively). Readers overwhelmingly preferred the graphical displayformats over the tables.

CONCLUSIONS AND CLINICAL IMPLICATIONS: We concludethat screen-based, graphical displays of transplant monitoring informationwould be efficacious, well-accepted tools in clinical practice. Furtherresearch is being conducted to explore the effects of interactivity (i.e.,reader ability to manipulate views of data) on this clinical decision-makingtask.

DISCLOSURE: D.S. Pieczkiewicz, None.




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INFLUENCE OF BASELINE FORCED EXPIRATORY VOLUMEON THE DEVELOPMENT OF BRONCHIOLITIS OBLITERANSSYNDROME IN CHRONIC OBSTRUCTIVE PULMONARY DIS-EASE AND IDIOPATHIC PULMONARY FIBROSIS SINGLELUNG TRANSPLANT RECIPIENTSSteven D. Nathan, MD*; Scott D. Barnett, PhD; Shahzad Ahmad, MD;Karen Brown, RN; Nelson A. Burton, MD. Inova Transplant Center, FallsChurch, VA

PURPOSE: A 20% reduction in the FEV1 from baseline is what is usedto define the development of BOS post lung transplant (LTx). Patientbaseline is defined by the average of the two highest FEV1’s at least 3weeks apart post-LTx. Patients may establish different baselines based onas yet undetermined factors. We sought to determine whether thebaseline established has any influence on the subsequent incidence ofBOS and survival post-transplant.

METHODS: Baseline FEV1’s of all COPD and IPF SLTx recipientstransplanted between March 1997 and November 2001 were determined.In each patient, these were compared to the maximal attainable FEV1(MAFEV1) as determined from: residual native lung function pluspredicted allograft function based on recipient characteristics. The inci-dence of BOS was then compared between those patients who establisheda baseline �80% of MAFEV1 to those whose baseline was�80% of theMAFEV1.

RESULTS: There were 23 COPD and 23 IPF patients included in theanalysis. IPF patients tended to establish baselines that were closer to theMAFEV1 compared to COPD patients (85.8% vs. 76.6%, p�0.06). Therewas a trend for IPF patients taking longer to reach their first highest FEV1compared to COPD patients (249 vs 168 days, p�0.28). Patients withbaseline FEV1s 80% had a trend to a greater propensity for BOS (33.2%vs.18.2%, p�0.24), while survival in the two groups was similar (77% vs.79%, p�0.89).

CONCLUSION: IPF patients may have higher baseline FEV1’s thanCOPD patients. This could represent influence of the native lung onallograft emptying in the COPD patients or a greater contribution fromthe native lung in IPF patients. The longer time interval to establish abaseline in IPF patients is of uncertain significance.

CLINICAL IMPLICATIONS: The trend towards a higher baselineinfluencing the subsequent development of BOS may have importantclinical implications.

DISCLOSURE: S.D. Nathan, None.

THORACIC PRESENTATIONS OF POSTTRANSPLANT LYM-PHOPROLIFERATIVE DISORDERSMichael E. Halkos, MD*; Joseph I. Miller, MD; Karen P. Mann, MD;Daniel L. Miller, MD; Anthony A. Gal, MD. Emory University School ofMedicine, Atlanta, GA

PURPOSE: Post-transplant lymphoproliferative disorders (PTLD) arerare, but significant complications following transplantation. Althoughorgan-specific cases have been reported, primary presentation in thethoracic cavity has not been fully characterized.

METHODS: 11 cases of PTLD with a primary thoracic presentationwere identified among solid organ or bone marrow (BM) transplantpatients from 1990-2002.

RESULTS: Patients include 8 men and 3 women (mean age of 49years). Transplant cases were as follows: 1 heart, 3 lung, 2 kidney/pancreas, 3 kidney, 2 BM, and 0 liver. Time to presentation ranged from1 to 97 months and was �1 year in 6 and �1 year in 5 cases.Pre-transplant EBV and CMV status were negative in 8/10 and 9/10 cases,respectively. Patients presented with mediastinal adenopathy (7/11) orpulmonary parenchymal lesions (5/11). 6/11 also had extra-thoracic in-volvement. 8 presented with constitutional symptoms. Pathologic diagno-sis was achieved by CT-guided fine needle aspiration (FNA) in 8 patientsor by an open biopsy procedure in 3 patients. Pathologic analysis revealedB-cell lymphoproliferative disorder in 9/11 cases, anaplastic large celllymphoma in 1, and Hodgkin’s lymphoma in 1. 5/6 specimens evaluatedfor EBV were positive by in situ hybridization or immunohistochemistry.All patients were initially treated with reduction in immunosuppresionand 6 received adjuvant chemotherapy. Overall, mortality was 64%: 4/7patients died from complications of PTLD (1 heart, 1 BM, 2 kidney), and3/7 (3 lung) died from rejection. The mean interval from diagnosis todeath was 13 months.

CONCLUSIONS: PTLD may present in the thoracic cavity regardlessof organ transplanted and must be considered as a potentially fatalcomplication in immuno-suppressed transplant patients. Long-term sur-vival remains poor and is worse for heart or lung recipients who will nottolerate rejection associated with suboptimal drug regimens.

CLINICAL IMPLICATIONS: Most diagnoses can be obtained viaCT-guided FNA. Earlier diagnosis and improvements in chemotherapyand immunosuppresion may improve survival for these high-riskpatients.

DISCLOSURE: M.E. Halkos, None.

GASTROINTESTINAL INVOLVEMENT OF POSTTRANSPLANTLYMPHOPROLIFERATIVE DISORDER IN LUNG TRANS-PLANT RECIPIENTSShitrit David, MD*; Ariella Shitrit, MD; Gabiell Izbicki, MD; MordechaiRehuven Kramer, MD. Pulmonary Institute, Rabin Medical Center,Petach Tiqwa, Israel

PURPOSE: Lymphoproliferative disorder is a well-recognized compli-cation of lung transplantation. Risk factors include Epstein-Barr virusinfection and immunosuppression. The gastrointestinal manifestations ofposttransplant lymphoproliferative disorder (PTLD) in lung transplantrecipients have not been fully characterized.

METHODS: Case presentation and review of all reported cases ofPTLD with gastrointestinal involvement.

RESULTS: Patient ages ranged from 25 to 65 years (median 52years). Median time form lung transplantation to onset of PTLD was51 months (range 1-109 months); 65% of cases (11/17) occurred within12 months; Eighty-eight percent of patients (15/17) had positiveEpstein-Barr virus serology prior to transplantation. In five patients(29%), the PTLD also involved sites other than the gastrointestinaltract. The most common gastrointestinal site of PTLD was the colon,followed by the small intestine and stomach. Clinical features includedabdominal pain, nausea, and bloody diarrhea. Diagnosis was basedon typical pathological changes on gastrointestinal tract biopsy ob-tained mainly by colonoscopy. Treatment included a reduction inthe immunosuppressive regimen in 15 of the 17 cases (88%)and surgical resection in 10 (59%). One patient was untreated. Sevenof the 16 patients (44%) responded to treatment and 9 patients died.Median time from onset of PTLD to death was 70 days (range 10 to 85days).

CONCLUSIONS: PTLD with gastrointestinal involvement is a uniqueentity that should be considered in all Epstein-Barr-Virus-positive lungtransplant recipients who present with abdominal symptoms. Althoughimmunosuppressive modulation and resection can lead to remission, therisk of death is 50%.

CLINICAL IMPLICATIONS: PTLD with gastrointestinal involve-ment should be considered in lung transplant recipients who present withabdominal symptoms.


Lung Transplantation, continued


Table 1 Characteristics of gastrointestinal involvement of PTLD following lung transplantation: review of 17 cases

Case Sex Age Disease TxEBVstatus

Onset(Months)

GITsite

Othersite Management Outcome

Survival(Days)

Cause ofdeath Comments Ref

1 M 56 COPD SL � 36 Transversecolon

- Resection RIS Remission 360 BOS Hct 21%“Apple-core”

1

2 F 52 COPD NA � 20 Smallbowel

- NA Died NA NA 2

3 M 51 COPD NA � 8 Colon Lung Not treated Died NA PTLD 24 F 31 Bronchi-

ectasisNA � 4 Colon - Resection RIS Died NA PTLD Multiple

synchronoustumors

2

5 M 28 PVOD SL � 1 Jejunum - ResectionRIS IFN

Died 360 Infection 3

6 NA 25 NA NA � 6 Colon Lung Resection RIS Resolved 289 NA 47 M 56 COPD SL � 33 Colon - Resection RIS Resolved NA NA “Apple-core” 58 NA 49 A1AT BL � 86 GIT Liver RIS Remission 1223 NA 69 NA 32 PPH SL � 70 GIT BM RIS Chemo Died 85 PTLD 6

10 NA 32 ASD/ED SL NA 82 GIT - Resection RIS Remission 50 BOS, Pneumonia 611 NA 40 CF BL � 109 GIT - RIS Chemo Died 10 NA 612 NA 52 A1AT SL NA 95 GIT Ovary Resection RIS Died 70 PTLD, Sepsis 613 NA 52 IPF SL � 82 GIT - Resection RIS Died 50 NA 614 NA 54 PPH SL � 51 GIT - Resection RIS Remission 61 BOS 615 NA 59 COPD SL � 53 GIT - RIS Died 20 PTLD 616 NA 60 COPD SL � 13 GIT - Resection RIS Died 10 PTLD, MOF 617 M 65 IPF SL � 18 Transverse

colon- RIS Remission 360 Bloody diarrhea;

Hct 17%Present report

A1AT�alpha-one antitrypsin; ASD/ED�atrial septal defect with Eisenmenger syndrome: BL-bilateral lung transplantation; BOS-bronchiolitis obliteranssyndrome; COPD�chronic obstructive pulmonary disease; CF�cystic fibrosis; GIT�gastrointestinal tract; EBV� Epstein-Barr virus; IPF�idiopathicpulmonary hypertension; PTLD�posttransplant lymphoproliferative disorder; PVOD�pulmonary veno-occlusive disorder; RIS�reduction of immuno-suppression; SL�single-lung transplantation

DISCLOSURE: S. David, None.

BRONCHIAL COMPLICATIONS FOLLOWING LUNG TRANS-PLANTATIONWickii T. Vigneswaran, MBBS, FCCP*; Sangeeta Bhorade, MD, FCCP;Jeffrey Schwartz, MD; Thomas Hinkamp, MD; Edward Garrity, MD,FCCP; Mamdouh Bakhos, MD. Loyola University Medical Center,Maywood, IL

PURPOSE: Bronchial anastomotic complications responsible for earlyfailure of clinical lung transplantation can affect outcome today. Reportedincidence of this complication greatly varies among institutions. Donorselection, preservation technique and recipient management are likelyimportant factors as the surgical technique.

METHODS:We performed a retrospective review of patients under-going lung transplantation between August 1998 and March of 2003 forincidence of significant bronchial anastomotic complication. During thisperiod lung transplantation was performed for end-stage obstructiveairway disease in 67, for suppurative lung disease in 27, for pulmonaryfibrosis in 32, for sarcoid in 11, and for pulmonary hypertension in 8.Transplantation included 70 single lung transplantations (31 left and 39right), 72 bilateral transplantations and three heart lung transplantationaccounting for 220 bronchial anastomoses at risk for developing compli-cations. Of these 6 were repeat transplantations. The organ preservationwas with cold Euro-Collins flush for the first 81 patients and Perfedexsolution for the remaining 64 patients.

RESULTS: Twenty four patients (16.55%) developed 27 significantanastomotic bronchial complications (12.27%) requiring intervention. Inthirteen patients the pathology was stenosis (in 2 leading to completeobstruction), in 4 it was only malacia and in 7 it was a mixed type. In twopatients only a dilatation was required, in 21 a stent was placed, onerequired surgical revision of anastomosis and in the other endoscopicdebridement alone was performed. There were 20 left sided and 7 rightsided complications. Two deaths among this group could be accounted for

the bronchial complication. The side of transplant was the only significantrisk factor for developing an anastomotic complication.

CONCLUSIONS: The incidence of bronchial complication followinglung transplantation remains significant. Surgical technique and ischemiamay be significant factor in the development. Majority of the complica-tions are treated effectively with endoscopic techniques.

CLINICAL IMPLICATIONS: Future advances in the donor preser-vation and recipient management including lung implatation, treatment ofsub-clinical rejection and infection are necessary to further reduce thismorbidity following lung transplantation.

DISCLOSURE: W.T. Vigneswaran, None.

RELATIONSHIP OF TACROLIMUS LEVELS TO REJECTIONON TRANSBRONCHIAL BIOPSIES IN LUNG TRANSPLANTRECIPIENTSMarcus T. Haug, BSc, MSc, PharmD*; Jeffrey Chapman, MD; SudishMurthy, MD; Omar Minai, MD; Constance Jennings, MD; MalcolmDeCamp, MD; Mehta Atul, MD. Hospital Foundation, Cleveland ClinicFoundation, Cleveland, OH

PURPOSE: A tacrolimus trough or IV infusion level of 10 – 15 ng/mlwas targeted for preventing lung transplant rejection. We describe therelationship of tacrolimus levels, 10 ng/ml on day of acute lung rejectionon transbronchial lung biopsy (TBLB) in the first year, first 90 days andday 91 through the first year post transplant.

METHODS: All patients who received tacrolimus, had TBLBs per-formed from 1996 through March 2003 were included. We identified allTBLB results performed with tacrolimus trough or IV infusion levels 10ng/ml. Statistical tests included Chi-Square and Fisher Exact analysis (p �0.05).




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RESULTS: 134 lung transplants received tacrolimus with TBLBs. Inthe � 90 days post transplant group, 51 (34.2%) TBLBs were positive forrejection. 37 (24.8%) of the 149 TBLBs were associated with tacrolimuslevels 90 days to 1 year post transplant group, 27 (10.3%) TBLBs werepositive for rejection. 62 (31.6%) of the 196 TBLBs were associated withtacrolimus levels 10 ng/ml (p � 0.0484). TBLBs rejection was reduced atday 91 to 1 year with tacrolimus levels � 10 ng/ml (p 10 ng/ml (p �0.0008).

CONCLUSIONS: We conclude that there is greater risk for lungrejection in the first year post transplant if the tacrolimus trough or IVinfusion level is less than 10 ng/ml. This effect is most significant after thefirst 90 days post transplant, suggesting the importance of tacrolimuslevels at this time. However, other factors may be important in predictingearly rejection.

CLINICAL IMPLICATIONS: Obtaining tacrolimus levels � 10ng/ml are important in preventing lung rejection in the first year posttransplant.

DISCLOSURE: M.T. Haug, None.

OUTCOME OF TOXOPLASMA GONDII MISMATCH IN LUNGTRANSPLANT RECIPIENTS AFTER PROPHYLAXIS WITH PY-RIMETHAMINE AND LEUKOVORINAmit Gaggar, MD*; Keith Wille, MD; Kevin Leon, MD; Marisa Mitchell,BSN; George Zorn, MD; James Kirklin, MD; David McGiffin, MD; K.Randall Young, MD. University of Alabama at Birmingham, Birmingham,AL

PURPOSE: Toxoplasma gondii is an important cause of morbidity andmortality in solid organ transplant recipients. Patients with a serologicmismatch (donor positive/ recipient negative) are at higher risk fortoxoplasmosis, and prophylaxis has been effective for certain solid organtransplant recipients. The incidence of toxoplasma mismatch and theefficacy of prophylaxis have not been studied in lung transplant recipients.Our aim is to determine the incidence of T. gondii serologic mismatch inthe lung transplant population and report the incidence of toxoplasmosisin patients receiving pyrimethamine and leukovorin prophylaxis.

METHODS: This study is a retrospective review of all lung transplantrecipients at a tertiary center over an 8-year period (1995-2002). Datacollected includes patient demographics, toxoplasma serologies, prophy-laxis regimen, adverse effects due to prophylaxis, occurrence of toxoplas-mosis, and time of death post-transplant. We report the incidence of T.gondii mismatch and toxoplasmosis.

RESULTS: Over an 8-year period, 246 lung transplants were per-formed. The average age of these recipients was 47.6 years. 26 of 246patients (10.8%) had a serologic mismatch for T. gondii. 15 were womenand 11 were men. All patients received prophylaxis with pyrimethamine50 mg qd and leukovorin 10 mg qd for 6 months. There were no cases oftoxoplasmosis in the mismatch group. There were no significant adverseeffects attributed to the prophylaxis regimen. There were 10 deaths in themismatch group, with an average survival of 447.5 days post-transplant.

CONCLUSIONS: We observe a low incidence of toxoplasma mis-match in lung transplant recipients, similar to the reported incidence inother solid organ recipients. Prophylaxis with pyrimethamine and leuko-vorin in lung transplant recipients mismatched for T. gondii is effectiveand well tolerated.

CLINICAL IMPLICATIONS: Toxoplasma mismatch is relativelyuncommon in the lung transplant population, but prophylaxis, whenindicated, is effective.

DISCLOSURE: A. Gaggar, None.

IMMUNE PROCESSES LEADING TO CARTILAGE BREAK-DOWN: TRANSPLANTATION CONSTRICTIVE BRONCHIOLI-TIS OBLITERANSJennifer A. Svetlecic, MD*; Karen Kover, PhD; Agostino Molteni, MD,PhD; Betty Herndon, PhD. University, University of Missouri - KansasCity, Kansas City, MO

PURPOSE: Constrictive bronchiolitis obliterans (CBO) is the majorimpediment to lung transplant success. Donor major histocompatibilitycomplex (MHC) antigens are thought to be the stimuli for transplantCBO, but CBO develops despite immunosuppressive regimens. Ourprevious CBO models, induced through sustained pulmonary toxicantexposure, suggested that alloimmune antigens are not invariably required

for CBO. We hypothesize that both alloimmune and autoimmune pro-cesses destroy bronchial cartilage.

METHODS: We selected DA (Dark Agouti) and BBDR (Bio Breedingdiabetic resistant) inbred rats; models of collagen arthritis through geneticcontrol of gelatinase pathways. We also used SD (Sprague-Dawley)outbred rats, used for models of inflammatory collagen breakdown.Tracheas of DA rats were implanted subcutaneously on the backs ofBBDR and SD recipients and allowed to heal 6 weeks without immuno-suppressants. At necropsy, bronchoalveolar lavage (BAL) was performed.Lung, transplant sites, and tracheas were examined from basic andtrichrome-stained paraffin sections. All sera were tested for anti-nuclearantibodies (ANA). Transforming growth factor (TGF) beta was measuredon lung homogenate supernatants.

RESULTS: At 2 weeks, rejection scabs were only seen on the BBDRrats. BAL cell counts were normal (�94% macrophages), but macro-phages from BAL of BBDR rats were loaded with foreign material notseen in normals. Histology showed widespread emphysema/septal de-struction. Peribronchial lymphocytic inflammation and intraluminal gran-ulation were seen, resembling papaverine-induced CBO. No positiveANA was seen, although TGF beta was elevated.

CONCLUSIONS: Models of rejection were produced in DA/BBDRrats, with activated BAL cells and peribronchial inflammation. ANAshowed no autoimmune globulins. We reject the “autoimmune” hypoth-esis at 6 weeks; scabs at the implant site appeared only in inbred animalswith MHC mismatch.

CLINICAL IMPLICATIONS: Animal models of CBO are necessaryto determine pathways that produce this irreversible process. Our pilottests and lymphocyte studies underway have the potential to improveunderstanding of CBO.

DISCLOSURE: J.A. Svetlecic, None.

LONG -TERM WEANING OUTCOMES IN LUNG TRANSPLANTRECIPIENTSMarie M. Budev, DO MPH*; Omar A. Minai, MD FCCP; Holli Blazey,MSN CNP; Kevin McCarthy, RCPT; The Cleveland Clinic Lung Trans-plant Group. The Cleveland Clinic Foundation, Cleveland, OH

PURPOSE: Lung transplant recipients (LTR) may develop respiratoryfailure in the post transplant period requiring prolonged mechanicalventilation (PMV). Factors contributing to respiratory failure, PMVassociated complications, and long term outcomes and survival have neverbeen reported in this unique population.

METHODS: Charts of LTR who required a tracheostomy for respira-tory failure during the post transplant period were reviewed for demo-graphics, extubation history, duration and complications of PMV, dis-charge disposition, and survival.

RESULTS: Of 304 identified adult LTR during a 12-year period, 17(5%) patients [age(yrs � SD): 51.5 � 14.6, 11 females] receivedtracheostomies for PMV and weaning. Ten patients were extubated atleast once prior to tracheostomy placement. The most common reasonsfor failure to wean were nosocomial pneumonia (n�10), excessive secre-tions and mucus plugging (n�7), and the graft failure or reperfusioninjury (n�6). The median duration of mechanical ventilatory support was62 days (interquartile range, 21 to 210 days). Complications as a result ofPMV included: 1) ventilator associated pneumonia (38%), 2) sepsis orbacteremia (19%), and 3) renal insufficiency (13%). Ten patients wereweaned and decannulated from PMV. Seven patients never achievedventilator independence. Eleven LTR died and the median period ofsurvival from time of trancheostomy placement to time of death was 21.8weeks (interquartile range, 0.3 to 123 weeks). The majority of patients(n�5) died within the first month of transplantation, 2 patients within 3months post transplant, 3 patients within the first year post transplanta-tion, and only 1 patient survived past one year. The most common causesof death were pneumonia (n�6) and sepsis (n�6). Only 1 patient hadevidence of graft rejection at the time of death.

CONCLUSIONS: PMV in LTR is associated with significant mortalityand morbidity. Ventilator associated pneumonia is a significant contribu-tor to the development of respiratory failure leading to tracheostomy andPMV.

CLINICAL IMPLICATIONS: Early respiratory failure and eventualtracheostomy represent a significant risk factor for early mortality in LTR.

DISCLOSURE: M.M. Budev, None.




RIGHT-TO-LEFT INTRAPULMONARY SHUNTING THROUGHVASCULAR DILATATIONS CONTRIBUTES TO SEVERE HY-POXEMIA IN PATIENTS WITH END-STAGE PULMONARY FI-BROSIS: IMPLICATIONS FOR LUNG TRANSPLANTATIONCesar A. Keller, MD*; Francisco Alvarez, MD; Javier Aduen, MD; DavidKramer, MD; Lawrence McBride, MD; Octavio Pajaro, MD; LungTransplant Group. Mayo Clinic, Jacksonville, FL

PURPOSE: Lung transplantation is a therapeutic option for patientswith end-stage idiopathic pulmonary fibrosis (IPF). Patients with ad-vanced disease have severe hypoxemia and require increasing oxygensupplementation. IPF patients with advanced disease and severe hypox-emia have high mortality if not transplanted. Some recipients of singlelung transplant (SLT) with IPF in the remaining native lung showpersistent exertional hypoxemia after transplant despite a viable lung graft.The purpose of this study was to investigate intra-pulmonary right-to-left(R-L) shunting as a cause of hypoxemia among recipients of SLT andamong patients with severe IPF evaluated for SLT.

METHODS: Retrospective review of clinical data from 9 patients withIPF who underwent contrast echocardiogram to investigate persistenthypoxemia post SLT or severe hypoxemia while evaluated for SLT,showing intrapulmonary R-L shunting.

RESULTS: Four SLT recipients and 5 SLT candidates with IPF werefound to have echocardiographic finding of intrapulmonary (R-L) shuntevidenced by presence of air contrast visible on left heart 6-8 beats afterinjection, contributing in minor to major degree to either resting orexercise hypoxemia. When evaluated for transplant their PFT’s averagedFVC�49�21% and DLco�30�8%. Resting PaO2/FiO2 ratio averaged263�83. Resting PA mean � 28�12 mmHg. When shunting wasdiagnosed the average was Qs/Qt�22�8%.

CONCLUSIONS: Patients with end stage IPF and hypoxemia mayhave intrapulmonary shunting from vascular dilatations or malformationslikely derived from pathological vascular remodeling, contributing tohypoxemia from diffusion impairment and VQ mismatch. This physiologicabnormality will persist in the native lung of SLT recipients and mayproduce exertional hypoxemia despite normal functioning graft.

CLINICAL IMPLICATIONS: If significant intrapulmonary shuntingis present in IPF candidates for transplant, a double lung transplant maybe preferable.

DISCLOSURE: C.A. Keller, None.

HIGH EXHALED NITRIC OXIDE (NO) LEVELS IN LUNGTRANSPLANT RECIPIENTS WITH ALLOGRAFT REJECTIONMarie M. Budev, DO, MPH*; Jennifer Duncan, BS, BA; Omar A. Minai,MD, FCCP; Jackie Pyle, RN; Daniel Laskowski, RCPT; Holli Blazey,MSN, CNP; McCarthy Kevin, RCPT; Raed A. Dweik, MD, FCCP. TheCleveland Clinic Foundation, Cleveland, OH

PURPOSE: Surveillance fiberoptic bronchoscopy is performed todetect rejection in lung transplant recipients (LTX). Surveillance bron-choscopy has many drawbacks including invasiveness, cost, and compli-cations. The analysis of exhaled breath constituents such as exhaled nitricoxide (NO) and carbon monoxide (CO), are known to be elevated inairway inflammation, but may serve as a noninvasive marker of graftinfection or rejection. Previous reports of NO levels in LTX have shownmixed results. We hypothesized that the levels of NO are altered in theexhaled breath of LTX with allograft rejection when compared to healthyLTX controls.

METHODS: We measured exhaled NO, CO, CO2, and O2 in theexhaled breath of 43 LTX [age (yrs�SD): 50�13, 19 males] presenting forroutine surveillance bronchoscopy. LTX with graft rejection (n�7) wereidentified based on pathology samples. Measured exhaled NO, CO, CO2,and O2 in LTX with rejection [age (yrs�SD):48.1�10.36 3 males, 3females] were compared to measured exhaled gases in healthy LTX(n�37) [age (yrs�SD):51.0�13, 16 males].

RESULTS: All patients had negative BAL and cultures for infection.Six patients (*n�7 events) had evidence of acute rejection by bronchos-copy. LTX were all on corticosteroids (average dose of 18 mg/day). Therejecting LTX had higher mean NO levels compared to the healthynon-rejecting LTX [NO (ppb�SE): rejecting LTX 11.2� 1.5, non-rejecting LTXR 8.3� .44, p�0.04]. The CO levels were not significantlydifferent between the 2 groups [CO (ppm�SE): rejecting LTXR 1.6�0.27, non-rejecting LTXR 1.3�0.07, p�NS]. The mean O2 levels were notsignificantly different between the 2 groups [O2 (%�SE): rejecting LTXR17� 0.43, non-rejecting LTXR 17�0.12, p�NS]. After treatment for

rejection, all repeated NO levels were noted to decrease compared topretreatment measurements [NO(ppb�SE):6.8�1.28].

CONCLUSIONS: During acute graft rejection, NO levels are elevatedcompared to non-rejecting grafts. After treatment for acute rejection, NOlevels decrease to similar levels found in non-rejecting individuals.

CLINICAL IMPLICATIONS: Serial measurements of exhaled gasesmay be a useful, non-invasive method for monitoring graft function.


EFFECT OF COMBINED CAMP AND CGMP AUGMENTATIONON IRI IN LUNGS FROM NON-HEART-BEATING DONORS:SYNERGY OR COMPETITION?Scott A. Schlidt, MD*; Seiki Takashima, MD; Giovanna Koukoulis, MD;Thomas M. Egan, MD, MSc. University of North Carolina at Chapel Hill,Chapel Hill, NC

PURPOSE: If lungs could be transplanted from non-heart-beatingdonors (NHBDs), the critical shortage of lungs for transplant could beabolished. Using an isolated perfused rat lung model (IPRLM) wedemonstrated that reperfusion of NHBD lungs with either 10�M isopro-terenol (iso) or with 0.1mg/ml nitroglycerine (NTG) attenuated ischemia-reperfusion injury (IRI). To test the hypothesis that the effects weresynergistic (additive) or independent, lungs retrieved from NHBDs werereperfused with both iso and NTG (iso-NTG) in combination.

METHODS: 36 male Sprague-Dawley rats were sacrificed by intrahe-patic pentothal injection. Lungs were retrieved immediately after death(control) or following 2 hours of ischemia; NHBDs were ventilated withoxygen (O2-vent) or not ventilated (NV). Lungs were suspended in theIPRLM and reperfused with Earle’s crystalloid solution without or withiso-NTG (n�6/group). Outcome measures were filtration co-efficient(Kfc), wet:dry weight ratio (WD), and tissue levels of cAMP and cGMP(by ELISA).

RESULTS: (see table). All lungs from NHBDs after 2 hours ischemiahad significantly higher Kfc than controls. Reperfusion with iso-NTGsignificantly reduced Kfc in lungs from 2 hour NV NHBDs compared toother 2 hour NHBD lungs but Kfc was surprisingly not reduced inO2-ventilated NHBD lungs reperfused with iso-NTG. Furthermore,while Kfc could be measured in lungs retrieved from NHBDs 3 hrspost-mortem reperfused with NTG alone, lungs retrieved from NHBDs 3hours post-mortem and reperfused with iso-NTG developed pulmonaryedema so Kfc could not be measured. Although there was a trend towardreduced WD in iso-NTG reperfused lungs after 2 hours of ischemia, thiswas not statistically significant.

CONCLUSIONS: Reperfusion of NHBD lungs with iso-NTG did notresult in synergistic effects on reduced IRI in lungs retrieved fromNHBDs. Contrary to our hypothesis, our results suggest that iso and NTGmay act through different and possibly competitive pathways to reduceKfc in NHBD lungs assessed in the IPRLM.

CLINICAL IMPLICATIONS: Strategies at reperfusion may minmizeIRI in lungs retrieved from NHBDs.

n�6/groupmean�SEM

Kfcml/min/cm H20/100 gm lung W/D

Control no drug 0.22�0.03 6.06�0.51Control iso-NTG 0.27�.01 5.82�0.472 hr non -vent no drug 1.49�0.12 10.08�1.422 hr O2-vent no drug 1.31�0.24 10.11�0.552 hr non-vent iso-NTG 0.63�.09* 8.42�0.892 hr O2-vent iso-NTG 1.24�0.13 7.8�0.88

DISCLOSURE: S.A. Schlidt, None.

INHALED NITRIC OXIDE AMELIORATES ISCHEMIA-REPER-FUSION LUNG INJURY IN RAT LUNGS FROM NON-HEART-BEATING DONORSSeiki Takashima, MD*; Giovanna Koukoulis, MD; Thomas M. Egan, MD,MSc. University of North Carolina at Chapel Hill, Chapel Hill, NC

PURPOSE: If lungs could be retrieved from non-heart-beating donors(NHBDs), the critical shortage of lungs for transplant could be alleviated.However, this strategy is hampered by ischemia-reperfsuion injury (IRI)




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due to unavoidable warm ischemic time. We used an isolated perfused ratlung model (IPRLM) to measure filtration coefficient (Kfc) as an index ofIRI in rat lungs retrieved from NHBDs. We evaluated the effect ofinhaled nitric oxide (NO) at reperfusion and during the period of warmischemia.

METHODS: 48 Sprague-Dawley donor rats were sacrificed, and lungsretrieved immediately or after varying intervals following death (n�6/group). Lungs were ventilated with alveolar gas and reperfused withbuffered Earle’s solution in the IPRLM. NO (40ppm) was administeredduring reperfusion or after death by ventilating the NHBD with 100%O2/40ppm NO combined with post-reperfusion NO administration. Out-come measures were: Kfc, wet-to-dry weight ratio (W/D), pulmonaryhemodynamics, and lung tissue levels of adenine nucleotides (by HPLC)and cGMP (by ELISA).

RESULTS: Lungs retrieved immediately after arrest had normal Kfc(@0.3 ml/min/100gm lung weight) and W/D (@5.8). Lungs retrieved 2hour post-mortem from NHBDs had markedly increased Kfc and W/D.Inhaled NO at reperfusion decreased Kfc and W/D significantly (p�0.01);these were further reduced when NO was administered during warmischemia. In lungs retrieved 3 hour post-mortem from NHBDs, Kfc wasnot measurable due to pulmonary edema. However, when NO wasadministered at reperfusion, Kfc could be measured. Inhaled NO duringwarm ischemia and at reperfusion decreased Kfc and W/D significantly(p�0.05) compared to lungs given NO at reperfusion alone and ventilatedwith O2 alone during warm ischemia. NO administration was associatedwith increased lung cGMP levels.

CONCLUSION: Inhaled NO at reperfusion attenuates IRI in lungsretrieved from NHBDs. The benefit is enhanced when NO is given duringwarm ischemia.

CLINICAL IMPLICATIONS: Administration of agents to cadaversvia the airway may redeuce IRI in lungs from NHBDs.

mean�SEM n�6/group

Kfcml/min/100 gmlung weight W/D

2 hourspost-mortem

Controlno vent

1.67�0.17 10.83�0.40

2 hourspost-mortem

NOreperf

0.73�0.07 8.30�0.45

2 hourspost-mortem

NOisch-reperf

0.52�0.08 7.021�0.426

3 hourspost-mortem

ControlO2 vent

1.77�0.21 9.22�0.69

3 hourspost-mortem

NOreperf

1.66�0.31 8.77�0.49

3 hourspost-mortem

NOisch-reperf

0.87�0.23 7.25�0.76

DISCLOSURE: S. Takashima, None.

SIMILAR OUTCOMES WITH THE USE OF EXTENDED DO-NORS IN LUNG TRANSPLANTATIONDeborah Levine, MD*; Luis F. Angel, MD, FCCP; Edward Sako, MD;Scott Johnson, MD; John Calhoon, MD; Stephanie M. Levine, MD,FCCP. Univ. of Texas Health Science Center, San Antonio, TX

PURPOSE: The primary limiting factor to lung transplantation is theshortage of donor lungs. A number of single center studies have suggestedthat the use of extended donor criteria may improve the donor supply anddecrease waiting times without compromising outcomes. Despite theseencouraging results, the use of extended donors is still a controversialissue. We report our center’s outcomes using extended vs. standard donor.

METHODS: We reviewed records of lung donors selected for trans-plant at UTHSCSA from 9/26/02 to 4/30/03 characterizing them as anextended (group I) vs. standard donor (Group II). Donors were consid-ered extended if any of the following criteria were met: Age � 55 years,smoking � 20 pack years, PaO2/Fi02 ratio �300, CXR infiltrate, purulentsecretions on bronchoscopy or history of pulmonary disease. We thenreviewed the early outcomes and spirometry of each recipient to evaluatepotential consequences of using extended donor lungs. Outcomes evalu-ated were total length of stay (LOS), ICU LOS, length of intubation,30-day mortality, and FEV1 (6 and 12 months) post-transplant.

RESULTS: Both groups had similar pre-transplant diagnoses andtransplant type.

Group 1* Group II* p value

Number of patients 20 11Waiting time 64 �/- 25 42 �/- 13 0.08Total LOS 11.5 �/- 4 9 �/- 1.48 0.065ICU LOS 4 �/- 2.7 3 �/- 0.89 0.08Length of intubation 2 �/- 2.76 1 �/- 0.53 0.17Re-Admissions 1.0 �/- 0.36 0.5 �/- 0.37 0.27FEV1 (6 months) 1.64 �/- 0.1 1.99 �/- 0.6 0.29FEV1 (12 months) 1.74 �/- 0.24 2.35 �/- 0.3 0.2130 day mortality 0 0* Results are median �/-

Standard Error

CONCLUSION: Our center’s results are similar to those of otherstudies showing that outcomes were no different when using extended vs.standard donors. This has allowed us to decrease the waiting time in ourprogram considerably without compromising outcomes of the recipients.

IMPLICATIONS: Because the supply of donor lungs is so limited, itis important to create new standardized donor criteria, which reflect thecurrent experience of and clinical practice at some lung transplant centers.Moreover, the results of using extended donor criteria should be incor-porated into a national database so that the clinical outcomes could beevaluated in a multi-center prospective manner.

DISCLOSURE: D. Levine, None.

IS PREOPERATIVE TRICUSPID REGURGITATION ASCER-TAINED BY DOPPLER ECHOCARDIOGRAPHY ASSOCIATEDWITH POSTOPERATIVE SUPRAVENTRICULAR ARRHYTH-MIAS IN LUNG TRANSPLANTATION RECIPIENTS?Lee M. Arcement, MD*; Leo Seoane, MD; Sahil Bakshi, DO; JohnSalvaggio, MD; Hector O. Ventura, MD; Vincent G. Valentine, MD.Ochsner Clinic Foundation, Metairie, LA

PURPOSE: Preoperative pulmonary hypertension ascertained by rightheart catheterization in the lung transplantation (LT) recipient is associ-ated with increased morbidity including supraventricular arrhythmias,especially in patients with pulmonary vascular disease. The prognosticsignificance of pre-LT tricuspid regurgitation (TR) ascertained by dopplerechocardiography regarding postoperative supraventricular arrhythmiashas not been described. We sought to evaluate the existance of anyrelationship between pre-LT TR and the occurence of postoperativesupraventricular arrhythmias in LT recipients.

METHODS: Of 154 total adult recipients who underwent LT betweenDecember 1990 and December 2001, 129 (84%) recipients had pre-operative Doppler echocardiograms performed. Their database was re-viewed. Post-operative supraventricular arrhythmias were defined as anysymptomatic or hemodynamically significant non-sinus tachycardia occur-ring in the first 30 days after LT. TR was defined as any evidence (mild,moderate or severe TR) of TR as ascertained by Doppler echocardiogra-phy.

RESULTS: Ninety-one (71%) LT recipients had pre-LT TR. Therewere no significant differences between groups (TR versus non-TR)regarding gender, race, type of transplant (single versus bilateral) ordiagnosis (COPD (35%), cystic fibrosis (37%), IPF (23%), other (5%)).Mean age (years) was 49 � 10 in the TR group verses 39 � 9 (p�0.049)in the non-TR group. There were more supraventricular arrhythmias inthe TR group (16 (76%) versus 5 (24%) (p�0.04)) as compared to thenon-TR group.

CONCLUSIONS: TR is common in patients undergoing LT. TR isseen more frequently in older LT recipients. TR is associated with moresupraventricular arrhythmias.

CLINICAL IMPLICATIONS: Post-LT arrhythmias should be antic-ipated in patients with pre-LT TR. The effect of pre-LT TR on outcomesmust be ascertained.

DISCLOSURE: L.M. Arcement, None.




MECHANICAL VENTILATORY MANAGEMENT OF PATIENTSWITH ARDS BY PULMONOLOGISTS AND SURGEONSShadi Badin, MD; Todd Gress, MD; Fuad M. Zeid, MD, FCCP*.Marshall University, Huntington, WV

BACKGROUND: Management of patient with acute respiratorydistress syndrome (ARDS) is complex and management by a specialistwith expertise in pulmonary mechanics may improve outcomes. Wecompared mechanical ventilation management of patients with ARDS bypulmonologists and surgeons.

MATERIALS: We retrospectively reviewed 71 patients with a ICD-9 diag-nosis of ARDS at two community hospitals. We collected information ondemographics and all necessary parameters to calculate the APACHE II score.Outcomes included mortality and total days spent in the intensive care unit (ICU)and on mechanical ventilation for those that survived. All outcomes were adjustedfor APACHE II score using multiple logistic regression.

RESULTS: Mechanical ventilation was managed by a pulmonologist in44 patients and by a surgeon in 27 patients. Overall mortality was 40.3%(N�29). Patients managed by a pulmonologist had a lower mortality rate(34.1% vs. 48.2; p�0.24) and spent fewer days in the ICU (14.0 days vs.19.5; p�0.16), although these differences were not statistically significant.These results were unaffected by adjustment for APACHE II score.However, days spent on mechanical ventilation was significantly lower inpatients managed by pulmonologists (10.3 days vs. 19.0; p�0.04) andthese results remained significant after adjustment for APACHE II score.

CONCLUSION: There were subtle differences in mortality, daysspent in the ICU, and days spent on mechanical ventilation in patientswith ARDS managed by either a pulmonologist or surgeon. However,sample size and the retrospective design limit our findings and furtherstudy in this area is needed.

DISCLOSURE: F.M. Zeid, None.

ARTIFICIAL VENTILATION IN THE SEMI-RECUMBENT PO-SITION IMPROVES OXYGENATION AND GAS EXCHANGEBen Speelberg, MD*; Frits Van Beers, Ventilation Practitioner. St.Elisa-beth Hospital, Tilburg, Netherlands

PURPOSE: Rotation management seems to improve ventilation in theintensive care unit. Especially lateral rotation on the left and right sidehave been studied. We investigated the effect of 30 o and 45 o semi-recumbent position on lung ventilation and oxygenation.

METHODS: During one month, all subsequent patients on artificialventilation, at our general 18 bed intensive care unit, were studied foreffects of 10 o, 30 o and 45 o position. Patients were ventilated with aSiemens Servo 300 ventilator. Body position was changed with a TotalCare bed (Hill-Rom) after results of baseline (10 o) were obtained. Half anhour after body position was changed, measures were done, whichincluded peripheral oxygen saturation, end-tidal CO2 (ET-CO2), tidalvolume (Tv-insp). The results of 30 o and 45 o position were comparedwith baseline values using paired-samples T testing.

RESULTS: 32 Patients have been studied. 2 were on PC mode, 17 onPRVC and 13 on PS mode. Oxygen saturation and Tv-insp improved from10 o to 30 o and 45 o body position. Also ET-CO2 showed an improvement.There was a progressive decline on 30 o and 45 o compared to baseline.

Mean SD Significance

Saturation baseline 96.97 2.42Saturation 30 o 97.5 2.51 p�0,01Saturation 45 o 97.72 2.39 p�0.001ET-CO2 baseline 4.23 1.02ET-CO2 30 o 4.13 0.94 p�0.001ET-CO2 45 o 4.01 0.90 p�0.001Tv-insp-baseline 542 107Tv-insp-30 o 591 114 p�0.01Tv-insp-45 o 558 94 p�0.05

CONCLUSIONS: Oxygenation and ventilation are improving afterpatients have been placed in the semi-recumbent position.

CLINICAL IMPLICATIONS: Placing ventilatory patients in thesemi-recumbent position should be done more frequent, because itimproves oxygenation and ventilation.

DISCLOSURE: B. Speelberg, None.

COMPARISON OF EVERY 4 WEEKS VERSUS EVERY 6 WEEKSROUTINE TRACHEOSTOMY TUBE CHANGES IN CHRONICVENTILATOR-DEPENDENT PATIENTSPaul J. Scalise, MD, FCCP*; Michelle Willey, RRT. Hospital for SpecialCare, New Britain, CT

PURPOSE: To determine the safety and cost-effectiveness of routinelychanging chronic tracheostomy tubes every 6 weeks in chronic ventilator-dependent patients.

METHODS: A group of chronic disease hospital patients withtracheostomy tubes who require longterm mechanical ventilation (�21days) was prospectively studied over one year. The cause of respiratoryfailure varied. (neuromuscular disease, chronic obstructive pulmonarydisease, post-op respiratory failure, spinal cord injury.) During the oneyear period, we altered our practice of changing chronic tracheostomytubes from q 4 weeks to q 6 weeks. We monitored for signs oftracheostomy tube malfunction, the incidents of ventilator-associatedpneumonia (VAP) as well as cost savings. Diagnostic criteria of VAPwere modified from those established by the ACCP. Not everysuspected case of VAP was confirmed radiographically due to extremebaseline radiographic abnormalities in some patients. In those patients,a positive tracheal aspirate, fever, leukocytosis and a change in theirventilatory demands, (i.e. increased FiO2) were considered diagnosticof a new VAP.

RESULTS: During the one year study period in our select populationof chronic ventilator dependent patients, there were �250 tracheostomytube changes. 19 had VAP at a rate of �5%. These were characterized bytrach tube cuff leaks (8), pilot balloon malfunction (2), and trach tubeocclusion by secretions (2). Additionally, we estimated a savings of �$30,000/year for that patient population.

CONCLUSION: Changing tracheostomy tubes from q 4 weeks to q 6weeks resulted in significant cost savings for our institution with noincreased risk of VAP and a low rate of trach tube malfunction. We nowroutinely change all of our chronic tracheostomy tubes every 6 weeks onall of our chronic ventilator-dependent patients.

CLINICAL IMPLICATIONS: The incidence of VAP was not af-fected by extending routine tracheostomy tube changes from every 4weeks to every 6 weeks.

DISCLOSURE: P.J. Scalise, None.

THYROID DISORDERS AND FAILURE TO WEAN IN PA-TIENTS ON PROLONGED MECHANICAL VENTILATION AT AREGIONAL WEANING CENTERDebapriya Datta, MD*; Paul Scalise, MD. Hospital for Special Care, NewBritain, CT

PURPOSE: Hypothyroidism is known to cause respiratory failure. Wehave noted the occurrence of clinically undiagnosed hypothyroidism inpatients admitted with failure to wean to this regional weaning center .The objective of this study was to determine the incidence of hypothy-roidism in patients on prolonged mechanical ventilation (PMV) withfailure to wean and assess it’s relation with successful weaning.

METHODS: Medical records of 146 patients admitted to this institu-tion between 1999-2001 were reviewed. One hundred fifteen patientswere noted to have had thyroid studies. Further parameters abstractedfrom these patients included: age, sex, TSH levels, number of patientswith clinically diagnosed hypothyroidism. Number of patients successfullyweaned from ventilator support was noted. Univariate analysis wasperformed to determine relation between serum TSH levels and success-ful weaning. p � 0.05 was considered statistically significant.

RESULTS: Of 115 patients studied, 49 were males and 56 females,with a mean age of 65.3 � 15.4 years. None of these patients had aknown history of thyroid disorders. None were on any antithyroidmedication or thyroid supplements. Of these 115 patients, 84 (73%)were successfully liberated from mecahnical ventilation while 31(27%) failed weaning. TSH levels ranged from 0.19 to 121mU/L. MeanTSH level was 4.6� 13.5 mU/L in the liberated patients and 3.5� 4.7mU/L in the failed patients (p �0.05). A clinical diagnosis of hypothy-roidism was made in 4/115 (3%) of these patients on admission to theweaning center. Fourteen out of 115 patients (12%) were found tohave elevated serum TSH levels. T3/T4 levels confirmed hypothyroid-ism in 5 (4%) of these patients. Patients diagnosed with hypothyroid-ism were treated with thyroid replacement therapy and 4 weresuccessfully weaned from the ventilator.


Mechanical Ventilation Management12:30 PM - 2:00 PM


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CONCLUSION: Hypothyroidism is an uncommon cause of failure towean, with an incidence of 4 % in patients on PMV.

CLINICAL IMPLICATION: Hypothyroidism, though uncommon, isa treatable cause and should be considered in all patients who fail to wean.

DISCLOSURE: D. Datta, None.

NONINVASIVE MEASUREMENT OF PULMONARY DEADSPACE CORRELATES WELL WITH STANDARD METHODOL-OGY IN INTUBATED PATIENTSScott E. Williams, MD*; Virginia Eddy, MD; Steve Desjardins, RRT;Stephen Prato, MA. Maine Medical Center, Portland, ME

PURPOSE: The standard for measuring dead space ventilation (Vd/Vt)relies on the analysis of CO2 in mixed expired gas and simultaneousmeasurement of arterial CO2 tension. In modern ICUs this is achievedusing bedside indirect calorimetry combined with arterial blood gasanalysis. Recently, a method has been introduced which may permitnoninvasive bedside measurement of Vd/Vt, with simpler logistics than thestandard technique. This method relies on analysis of the CO2 washoutcurves of single breaths obtained over one minute, using a CO2 sensor inline with the ventilator circuit. This technique has not been well validatedin humans. The purpose of this study was to compare Vd/Vt measure-ments obtained with calorimetry with those obtained using the singlebreath washout technique.

METHODS: All intubated adult patients with an arterial catheter inthe intensive care unit were considered for enrollment. Patients wereexcluded for lack of consent or inability to achieve steady state for exhaledgas measurement. Calorimetric Vd/Vt was calculated by the Enghoffmodification of the Bohr equation, using arterial and mixed exhaled CO2measurements. Single breath CO2 washout (NICO, Novametrix) Vd/Vtwas compared to calorimetric Vd/Vt using regression analysis and Bland –Altman analysis.

RESULTS: 40 patients met study criteria over a four month period.Vd/Vt values ranged from 0.32– 0.76.

Correlation of the results of the two methods is shown below:Bland-Altman analysis showed the mean difference (bias) between the

two methods to be 3%.CONCLUSIONS: Vd/Vt as measured by NICO correlates well with

calorimetric Vd/Vt measurement.CLINICAL IMPLICATIONS: Vd/Vt as measured by NICO is accu-

rate, rapid, noninvasive, logistically simpler than traditional techniques,and useful in critical care settings where dead space measurements areneeded.

DISCLOSURE: S.E. Williams, None.

A METHOD FOR OPTIMIZATION OF MECHANICAL VENTI-LATION IN OBSTRUCTIVE LUNG DISEASE USING NONINVA-SIVE AND EMPIRICAL PARAMETERSWilliam D. Marino, MD*; Anna W. Komorowski, MD; Hakop H.Hrachian, MD; Mary O’ Connell, MS. University Hospital, Our Lady ofMercy Medical Center, Bronx, NY

PURPOSE: Mechanical ventilation with overly long inspiratory timesand inadequate expiratory times leads to the development of intrinsicpositive end expiratory pressure (PEEPi) in patients with obstructive lungdisease. Facile means of defining appropriate inspiratory and expiratorytimes have, however, not been defined or investigated. We have createda method for defining ventilator therapy which avoids the development ofhyperinflation and PEEPi.

METHODS: The development of PEEPi at various inspiratory toexpiratory (I:E) ratios with different airway resistances (Raw) was mod-eled using a series of artificial airway resistances in line with a three-litertest lung utilizing a Puritan Bennett 7200A ventilator. With this model wasdeveloped a family of curves of PEEPi vs. duty cycle at various resistances,from which was derived an equation which predicts PEEPi from Raw andduty cycle. The level of PEEPi thus predicted was compared with thatwhich had been measured in thirteen ventilator dependent patients.

RESULTS: In the 13 patients tested, PEEPi predicted by our equationfell within 1cm H2O of the observed values of PEEPi in all cases.Invariably, use of the ramp flow profile more than doubled inspiratorytime for any peak flow rate.

CONCLUSIONS: The equation developed here seems useful in theadjustment of ventilator settings to avoid the production of PEEPi. Witha measured Raw greater than 20 cm H2O/L/sec. duty cycles of 0.5 orgreater will result in substantial levels of PEEPi.

CLINICAL IMPLICATION: Use of the equation developed here canfacilitate safer ventilator management for patients with severe airwayobstruction. The ramp flow profile should be used with caution when Rawis greater than 20 cm H2O/L/sec since short inspiratory times are clearlyneeded in this setting, and the ramp profile more than doubles theinspiratory time for any given peak flow rate.


PREDICTORS OF A FAVORABLE OUTCOME IN ELDERLYPOPULATION RECEIVING MECHANICAL VENTILATIONJila Kaberi-Otarod, MD*; Vladimir Sabayev, MD; Masood Otarod, ScD;Rajen Maniar, MD; Ihab Gabriel, MD; Jonas Giantotas, MD. FlushingHospital, Flushing, NY

PURPOSE: We attempt to identify the physiological/clinical parame-ters which are relevant to the survival rate of the elderly patients whosuffer from respiratory failure. This is helpful in targeting the patients whowill most likely benefit from mechanical ventilators.

METHODS: Subjects are patients over 80 who have been diagnosedwith respiratory failure and received mechanical ventilation. Data on age,sex, diagnosis, medical history, functional/nutritional status and acutephysiological parameters during the first 24 hours of admission to theintensive care units were collected. The analysis of data is done bychi-square tests of contingency tables.

RESULTS: 55 patients, 34 females and 22 males, with a mean age of86 and a survial rate of 42%: Patients who maintained a mean arterialpressure of more than 65 (p-value � 0.002) and did not need pressers(p-value � 0.005) with no developing acidosis (p-value � 0.023) showeda significant increase in the rate of survival. PaO2/FIO2% � 200 (p-value � .478) and albumin � 3 mg/dl (p-value � 0.211) did not seem tohave a statistically significant impact on the survival of the subject.Functional status of a patient before respiratory failure (p-value � 0.486)and blood transfusion during hospitalization ((p-value � 0.484) did notappear to be significant factors either. However, the duration of mechan-ical ventilation less than 3 days was a significant factor for survival (p-value�0.01).

CONCLUSIONS: A low mean arterial pressure, the need for pressorsand acidosis during the first 24 hours; and the duration of ventilation arethe predictors of the favorable outcome (survival) in the elderly patients.

CLINICAL IMPLICATIONS: The elderly patients who fit the aboveprofile most benefit from the ventilators.

DISCLOSURE: J. Kaberi-Otarod, None.


Mechanical Ventilation Management,continued


WEANING IS FACILITATED BY USE OF NON-FENESTRATEDTRACHEOSTOMY TUBES IN CHRONICALLY ILL TRACHEOS-TOMIZED SUBACUTE CARE PATIENTSDeepak K. Shrivastava, FCCP*; Sheela Kapre, FCCP; Robert Gray, MD.San Joaquin General Hospital, Stockton, CA

PURPOSE: Tracheostomy is common in chronically ventilated pa-tients. Many of these patients can be weaned. Two types of tracheostomytubes, fenestrated (F) and non-fenestrated (NF), are available. Withfenestrated tube use the granulation tissue tends to grow through theholes. It causes multiple complications imposing delay in weaning. Ouraim was to review our experience in weaning with fenestrated versusnon-fenestrated tubes.

METHODS: We retrospectively reviewed tracheostomy weaning in a50-bed subacute care unit. Patients had both types of tube. Observationswere made based on tracheostomy related complications like granulomaformation, difficulty in changing the tracheostomy tubes for down-sizingand need for surgical intervention. The weaning duration and successrates were recorded.

RESULTS: Medical records of 137 patients were reviewed. A total of45 patients had fenestrated tubes. Mean weaning duration was 12 (SD 1.5)days. A remaining 89 patients had non-fenestrated tubes with a meanweaning duration of 7 (SD 1.5) days (P�0.00, Pooled t-test). All thepatients were decannulated. No significant differences were noted basedon diagnosis, age or sex. Surgical intervention was needed in 15.6% (7/45)of patients with fenestrated tubes compared to 14.6% (13/89) withnon-fenestrated tubes (P�1.000, Fisher Exact). The significant differ-ences were: Total complications: F� 25/45, NF�14/89 (P�0.000),Granuloma: F�7/45, NF�2/89 (P�0.007), Tracheostomy obstruction:F� 3/45, NF�0/89 (P�0.036), Stuck tracheal tube F�7/45, NF�2/89(P�0.007). (P’s from two-sided Fisher Exact). Other complication ratesincluding bleeding, subglottic and tracheal stenosis were non-significant.

CONCLUSIONS: Non-fenestrated tracheostomy tubes in long-termclinical setting have a significantly shorter weaning duration and a lowercomplication rate compared to the fenestrated type tubes, which may bebetter suited in acute and short-term clinical setting.

CLINICAL IMPLICATIONS: Non-fenestrated tracheostomy tubesshould be used in patients who need long-term tracheal access. It is likelyto reduce complication rates and facilitate weaning from tracheostomy.

DISCLOSURE: D.K. Shrivastava, None.

DOES INTRPULMONARY PERCUSSIVE VENTILATION PHYS-IOTHERAPY HAVE ANY INFLUENCE ON HEMODYNAMICS?Nam D Nguyen, MD*; Marianne Borremans, MD; Su Fuhong, MD;Herbert Spapen, MD; Luc Huyghens, MD. AZ-VUB Hospital, Brussels,Belgium

PURPOSE: The aim of the study is to evaluate the effect of intrapul-monary percussive ventilation physiotherapy (IPVP) on the cardiac hemo-dynamics (HD), especially to determine if IPVP is safe in patients withsignificant left ventricular dysfunction.

METHODS: IPVP was delivered with constant setting conditions byBIRD IPV2 PERCUSSIONNAIR during 30 minutes in 42 stable patients,who were under mechanical ventilation and sedation in the ICU; 22 ofthem had had by-pass cardiac surgery and 20 had been treated for sepsis.Blood pressures (BP), heart rate (HR) and arterial blood gas weremeasured at baseline (t0), at 10 minutes (t10) of IPVP and at 40 minutes(t40). Transoesophageal echocardiography (TEE) was also performedwith Philips Sonos 5500, at the same times to evaluate ejection fraction(EF), left and right end-diastolic areas (LEDA and REDA), E and ADoppler wave velocities as well as the deceleration time (DT) at the mitralvalve and S and D Doppler wave velocities of the left pulmonary vein.Thoraco-pulmonary compliance and FiO2 were calculated before startingIPVP. Student-t test and ANOVA test with repeated measurement wereused for statistics.

RESULTS: At baseline, 24 patients had significant left ventricular (LV)dysfunction on TEE (57%); Thoraco-pulmonary compliance and FiO2were not different between patients with and without LVD and betweenseptic and post-operative patients. IPVP increased significantly PaO2 inpatients with and without LVD, at t10 from the baseline (p�0.05):140.4�/-42.7 mm Hg vs.114.8�/-38 mm Hg, and regardless of theirdisease. However, there was no significant variation of BP, HR and inother TEE parameters, excepted there was a trend of the increase of Ewave velocity at t10.

CONCLUSION: IPVP can significantly improve oxygenation and hasno harmful effect on the HD of ventilated patients, regardless of their LVfunction.


ETIOLOGY OF PROLONGED MECHANICAL VENTILATIONIN A TERTIARY SETTINGAlphonso A. Quinones, MA, RRT, RPSGT, RPFT, CCT*; RachaelPermell-Ali, BS, RRT; Mary Nelson, RN; Roseann Russo, MD; StevenChang, MD; Erfan Hussain, MD; Arunabh MD, FCCP; Alan Fein, MD.Hospital, North Shore University Hospital, Manhasset, NY

PURPOSE: Patients requiring chronic mechancial ventilation consumean increasing proportion of human and financial resources. Despiteincreasing focus this problem has continued to escalate nationally. Whilerespiratory patients are commonly thought to account for the greatestproportion of these patients this question has not been well studied.

We sought to evaluate the source and epidemiology of chronicallymechanically ventilated patients in our 750 bed tertiary teaching facilitythat serves as a regional cardiac center. All patients requiring MV� 10dover a 1 year period were included.

METHODS: Retrospective review of respiratory therapy quality assur-ance and APACHE III data for the period Jan. to Dec. 2002. Unit specificlong term MV data abstracted from our MICU, SICU, RCU,PICU,NICUand CTU. Long-term MV was defined as a duration of �10d.

RESULTS: 650 patients were ventilated for � 10 days. While adultpatients accounted for the majority, a significant number a pediatric cases,particularly neonatal required MV for � 10 days. The RCU had thehighest proportion of total long term MV patients (55%). Surgical units,particularly general surgery accounted for 31% of patients. 9% of allcardiac surgical patients required MV for �10d. The NICU and the SICUhad the highest absolute number of long term MV patients at 142 and 151respectively. Of all MICU/SICU patients requiring MV for �10 days 35%of ventilator days were greater than 2 weeks and 13% were more than 3weeks. The mean age for these patients was 71.

CONCLUSION: Older adult patients account for the majority ofchronically MV patients. Post-operative surgical patients are the mostfrequent source of these patients, with cardiac surgery accounting for asignificant minority. Neonatal respiratory failure also results in significantrequirements for prolonged life support.

IMPLICATIONS: Improved pre-operative evaluation and preventionof post-operative complications like aspiration and VAP may improveoutcomes in these patients. Furthermore, evidence based disease specificventilator management and weaning protocols may be utilized to aid inreducing ventilator duration.

Proportion of Individual Unit Totals: Long-Term MV Patients

RCU 55%NICU 33%SICU 31%PICU 26%MICU 19%CTU 9%

DISCLOSURE: A.A. Quinones, None.

THE EFFECT OF INSPIRATORY RISE TIME ON TOTAL PA-TIENT WORK OF BREATHING (TPWOB) DURING VOLUMECONTROL VENTILATION (VCV) IN A SPONTANEOUSBREATHING LUNG MODELDavid L. Vines, MHS, RRT*; Oswaldo Ruiz, BS, RRT; Kelvin Ziegler, BS,RRT; David C. Shelledy, PhD, RRT. The University of Texas HealthScience Center at San Antonio, San Antonio, TX

PURPOSE: Limited information is available concerning the use of risetime percentage (%) on the SERVO 300 ventilator (Siemens Medical,Danvers, MS)in the VCV mode. We compared various rise time settingsduring VCV to determine which setting resulted in the lowest TPWOBusing a two-compartment mechanical lung model to simulate spontaneousbreathing.




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METHODS: WOB was first measured on lung B alone using theVentrak 1550 (Novametrix Medical Systems, Wallingford CT) at tidalvolumes of 200, 400, and 600 mL while peak flow was varied from 40, 60,80, and 100 L/min with a sine wave flow pattern. Then WOB wasmeasured at these volumes for lung B to drive lung A at normalcompliance (0.05 L/cmH2O) and resistance (2.7 cmH2O/L/sec), de-creased compliance (0.02 L/cmH20), and increased resistance (17.6cmH2O/L/sec) while lung A received assistance through an 8.0 endotra-cheal tube from either VCV of 600 or 800 ml at I:E ratios of 1:3, 1:2, and1:1, while the rise time % setting was varied from 0 to 10. TPWOB wascalculated using the following formula: [TPWOB� WOB(B�A) – WOBB]

RESULTS: A rise time % setting of 0 (1.02�0.46 J/L) resulted in asignificantly (p�0.05) lower mean TPWOB compared to a setting of 2(1.11�0.46 J/L), 5 (1.16�0.43 J/L), 8 (1.17�0.43 J/L), or 10 (1.18�0.42J/L) across all lung conditions; however, there was no relationshipbetween rise time and TPWOB at high demand flows.

CONCLUSION: When using VCV and demand flows did not exceedthe ventilator’s set flow, a rise time % setting of 0 resulted in the lowestTPWOB.

CLINICAL IMPLICATIONS: Rise time % may influence TPWOBduring VCV and higher rise time settings may increase WOB in somepatients.

DISCLOSURE: D.L. Vines, None.

THE EFFECT OF PRONE POSITIONING ON PATIENTS WITHSEVERE PULMONARY CONTUSIONSAkella Chendrasekhar, MD*; Jennifer Beaty, MD; James Hopkins, MD.Iowa Methodist Medical Center, Des Moines, IA

PURPOSE: Prone positioning has been suggested as a means toimprove oxygenation in patients with ARDS. The role of prone positioningin patients with severe pulmonary contusion is unclear. We studied theshort term effects of prone positioning in trauma patients with severepulmonary contusion, with mechanical ventilatory support.

METHODS: We performed a retrospective analysis of 45 severelyinjured trauma patients with pulmonary contusions requiring variouslevels of mechanical ventilation that were placed in prone position. Patientrecords were reviewed for blood gas data in the supine position immedi-ately (within 1 hr) before prone position was done (supine 1), blood gasdata in the prone position (prone, at 1 hr), and blood gas data in the supineposition for 1 hour after being prone for a time between 6 and 12 hours(supine 2). Data were analyzed for immediate effect of prone positioingand sustained effect ( effect persisted or not even after return to supineposition).

RESULTS: The mean age of our patients was 36 � 12 years with anaverage injury severity score (ISS) of 30 � 12. As shown in table 1, wenoted a significant improvement in oxygenation with prone positioning.The effect of the prone postioning was sustained albeit in a very limitedway (oxygenation was statistically improved between supine 1 and supine2. We also noted a slight but statistically significant drop in the peakinspiratory pressure (PIP) with prone positioning. Arterial carbon dioxidelevels did not change significantly with prone positioning.

CONCLUSIONS: Prone positioning seems to be a simple and usefulapproach to improving oxygenation and reducing peak pressures inmechanically ventilated trauma patients with severe pulmonary contusion.A much more limited improvement in oxygenation seems to be sustainedeven with return to supine position.

CLINICAL IMPLICATIONS: Prone positioning should be consid-ered as one of the first line therapuetic interventions in the managementof mechanically ventilated trauma patients with severe pulmonary contu-sion.

Blood gas and ventilator data

PaO2 PIP

Supine 1 62 � 4 49 � 5Prone 198 � 16 *p�0.05 40 � 4 *p�0.05

Supine 2 64 � 3 *p�0.05 47 � 4

DISCLOSURE: A. Chendrasekhar, None.

RISKS AND BENEFITS OF OPEN LUNG BIOPSY IN THE ME-CHANICALLY VENTILATED, CRITICALLY ILL POPULATIONRaees Ahmed, MBBS*; Yaseen Arabi, MD, FCCP; Qanta A. Ahmed, MD,FCCP; Masood U. Rehman, MBBS, FCCP; Abdullah Al Shimemeri, MD,FCCP; Nizar Yamani, MD; Hanna Bamafleh, MD. King Abdulaziz Medic,National Guard Hospital, Riyadh, Saudi Arabia

PURPOSE: To determine the diagnostic yield, morbidity, mortalityand therapeutic impact of open lung biopsy (OLB) in the mechanicallyventilated, critically ill patients.

METHODS: We retrospectively reviewed all patients with respiratoryfailure on mechanical ventilation with diffuse pulmonary infiltrates thatunderwent OLB between 1995-2002. Patient demographics, presentingsymptoms, comorbidities, admission APACHE II and SAPS II scoreswere recorded. The diagnostic workup including bronchoalveolar lavage(BAL), high resolution CT scanning (HRCT), serology for autoimmuneand vasculitic diseases were also recorded. Hospital course was assessed interms of days on ventilation prior to the procedure and final hospitaloutcome. Peri-procedure lung injury was examined in each subject bydocumenting pre and post biopsy PaO2/FiO2 ratios, dynamic lung com-pliance and PEEP levels. The impact of histological diagnosis on themanagement was determined. Operative complications including bleed-ing, intraoperative hemodynamic instability and air leak were also re-viewed.

RESULTS: Five female (41%) and seven male (58%) patients wereidentified over a period of five years. The mean age was 52 years (SD�17). The Average ventilator-days before OLB were 12 (SD� 9). PaO2/FiO2 ratio, dynamic lung compliance and PEEP levels pre and postbiopsy were not significantly different and had no impact on the outcome.Histological diagnosis was established in all 12 patients. OLB-guidedalteration of therapy directly benefited 50% of the patients and contrib-uted to withdrawal of unnecessary therapy in 16.6%. No major perioper-ative or intraoperative complications occurred. The final outcome in termsof overall patient mortality was 41% and 58% were successfully dischargedhome.

CONCLUSIONS: We conclude OLB to be a safe procedure inmechanically ventilated critically ill patients. At present there are noclinical and biological parameters that can identify high-risk patientsundergoing OLB.

CLINICAL IMPLICATIONS: OLB is a valuable diagnostic proce-dure that leads to significant changes in the management. These changesresulted in an improved outcome in our study population.

DISCLOSURE: R. Ahmed, None.

HEMODYNAMIC EFFECTS OF NITROGLYCERIN AND LEVO-SIMENDAN DURING DIFFICULT WEANINGNektaria N. Papadopoulou, MD*; Nikolaos D. Manolakoglou, MD;Ioannis T. Stanopoulos, MD. RFU Unit, General Hospital, Thessaloniki,Greece

PURPOSE: The aim of our study was to pharmaceutically reducepreload and afterload in a group of difficult to wean MICU patients (pts)during transition from mechanical ventilation (MV) to spontaneousbreathing.

METHODS: 8 male pts were studied. All of them were catheterizedwith a Swan Ganz catheter, after following at least 2 unsuccessful T-piecetrials on 2 consecutive days. Hemodynamic and blood-gas parameterswere monitored before (pressure-support mode) and during the first 10’of the T-piece trial. In 4 pts (2 COPD with CHF and 2 IPF with corpulmonale - called N group) an IV infusion of nitroglycerin was started,titrated to maintain a normal blood pressure, while in 4 pts (4 COPD withCHF), a 24-hour infusion of levosimendan was started (L group).Measurements were repeated in 60’ of the T-piece trial.

RESULTS: Pts hemodynamics are shown in tables 1 and 2. 2 pts of theN group were successfully extubated, while in 2 MV was resumed (newinfection). All 4 pts of the L group were successfully extubated, while 2were reintubated (GI bleeding, new infection).

Comparison between the 2 drugs showed a more pronounced effect forlevosimendan in lowering Pw (p�0,0002) and VO2 (p�0,015).

CONCLUSION: Hemodynamic improvement by nitroglycerin or le-vosimendan may facilitate weaning in pts with a low cardiopulmonaryreserve.




N GROUP

T piece 10’ T piece 60’

Pw 14,5 �/- 7,5 12 �/- 4,61mBP 91 �/- 23,03 80 �/- 10,39mPAP 46,5 �/- 0,57 35 �/- 3,46*

* p�0,015CO 5,8 �/- 0,8 6,85 �/- 0,05DO2 763 �/- 322 962 �/- 295� �p�0,017VO2 248 �/- 104,5 317 �/- 104,5

L GROUP

T piece 10’ Tpiece 60’

Pw 21,5 �/- 2,88 14,5 �/- 8,66**p�0,0014

mBP 86 �/- 9,23 78,5 �/- 4,04mPAP 39 �/- 5,77 27 �/- 6,92� �p�0,0002CO 8,05 �/- 1,44 9,45 �/- 4,21DO2 1050 �/- 237 1321 �/- 692VO2 359,5 �/- 66,39 396 �/- 123,55^

^p�0,007

DISCLOSURE: N.N. Papadopoulou, None.

CONTINUOUS MONITORING OF PULMONARY MECHANICSDURING ACUTE LUNG INJURY IN RABBITSThomas A. Heming, PhD*; Juan C. Barriga, MD; Amelia Ng, MD; JohnW. Clark, PhD; Akhil Bidani, MD, PhD. University of Texas HealthScience Center, Houston, TX

PURPOSE: The mechanisms and pathophysiological changes associ-ated with ventilator-induced lung injury are unclear. We used a combinedexperimental-mathematical model approach to quantify the abnormalitiesin pulmonary mechanics associated with ventilator-induced lung injury inrabbits.

METHODS: New Zealand white rabbits were anesthetized and ven-tilated for up to 5 hours using a digitally-controlled ventilator (flexiVent,Scireq, Montreal, Canada). The ventilator can apply broadband pertur-bations in flow to the lungs to assess pulmonary mechanics. Measure-ments were made every 30 minutes of lung resistance, lung compliance,oscillation mechanics (impedance), and the pressure-volume relationship.Continuous records were made of end-tidal PCO2, arterial O2 saturation(pulse oxymetry), heart rate, arterial blood pressure, and body tempera-ture. Arterial blood gases/pH were analyzed routinely. The data wereanalyzed using mathematical models of pulmonary mechanics and gasexchange developed in our laboratory (J Appl Physiol 84:1447-69, 1998;J Biol Sys 8:115-39, 2000). These models use nonlinear characterizationsof airway resistance, airway and chest wall compliance, and lung tissueviscoelasticity.

RESULTS: Increasing tidal volume from 6 ml/kg to 25 ml/kg for 4hours was accompanied by progressive increments in lung resistance anddecrements in lung compliance. These effects primarily reflected actionson the lung parenchyma, as evidenced by changes in tissue damping andelastance over airway (Newtonian) resistance. In contrast, administrationof methacholine caused a rapid transient increase in lung resistance andfall in compliance. These effects primarily reflected actions on the airway,as evidenced by changes in airway resistance over tissue viscoelasticproperties.

CONCLUSIONS: A combined experimental-mathematical model ap-proach has been used to separate airway and parenchymal abnormalitiesduring the development of acute lung injury, and to quantify the degreeand time course of the abnormalities.

CLINICAL IMPLICATIONS: Ventilatory strategy may have impor-tant effects on both the development and time course of abnormalities inlung function during mechanical ventilation.

DISCLOSURE: T.A. Heming, None.

CONTINUOUSLY RECORDING THE WORK OF BREATHINGIN POSTOPERATIVE PATIENTSEftim J. Adhami, MD*; Andrea Gabrielli, MD; A J. Layon, MD.University of Florida College of Medicine, Gainesville, FL

PURPOSE: To demonstrate that continuous long-term recordings ofthe work of breathing can provide more information, compared tostandard short-term recordings.

METHODS: We continuously recorded the WOB (J/L/breath), powerof breathing (POB [J/min]), and pressure-time index (PTP [cm H2O .

sec/min) in 15 adult intubated surgical and cardiac intensive care unit(ICU) patients, after they had been mechanically ventilated for at least 24hrs. All WOB data, cardiovascular and respiratory parameters, andventilator settings were recorded continuously by a Novametrix MedicalSystems monitor (Wallingford, CT), and saved in a central computer foranalysis. The average recording time was 6 hrs for each patient, with amaximum of 9 hours. The treating physicians made all ventilatory ortherapeutic changes independently of the research team.

RESULTS: We observed that in all patients, when there was no changein 1) clinical condition, 2) ventilator settings, 3) sedation score, 4)therapeutic protocols, and 5) in the absence of external stimulation, WOB,POB, and PTP had a tendency to decrease over time. The figure showsthe fall over time of WOB, POB, PTP, in a 54-year-old man with acutepancreatitis, renal failure, anaphylactic shock, and sickle cell disease, after24 hours of ventilatory support. The patient was intubated with an 8.0ETT. Ventilator settings were: SIMV mode, FiO2 0.4, IMV rate 2breaths/min, PEEP 5 cm H2O, and PSV 10 cm H2O; these did not changethroughout the study.

CONCLUSIONS: A possible cause for this trend may be the adjust-ment of the patient’s respiratory system to the ventilator.

CLINICAL IMPLICATIONS: The long-term recording of the workof breathing may better assist the clinician in understanding the changesin work due to different factors, and thus, may facilitate weaning.

DISCLOSURE: E.J. Adhami, None.

SURVEILLANCE OF TRACHEOBRONCHIAL SECRETIONS INMECHANICALLY VENTILATED PATIENT: IS THERE A ROLE?Nikolaos D. Manolakoglou, MD*; Nektaria N. Papadopoulou, MD;Ioannis T. Stanopoulos, MD. RFU Unit, General Hospital, Thessaloniki,Greece

PURPOSE: The aim of this prospective observational study is todetermine whether sequential quantitative cultures of tracheobronchialsecretions (TRBS) in mechanically ventilated (MV) MICU patients (pts)correlate with clinical parameters of lower respiratory infection andinfluence patient outcome.

METHODS: The study was conducted in a 7-bed MICU for 1 yearperiod and included all MV pts for �48 hrs. Surgical, trauma,with nonpulmonary causes of infection pts and pts presenting with or subsequentlydeveloping pneumonia were excluded. Samples of TRBS were obtainedduring the first 24 hours of intubation (S1) and weekly thereafter for amaximum of 2 weeks (S2, S3) using a simple aspiration catheter and werecultured quantitatively. All had purulent secretions and received empiricalantibiotics that were modified according to the culture results.




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RESULTS: 20 pts, 17M and 3F, mean age 71.95�8.44, mean Apachescore at presentation 13.1�6.47 (12 COPD exacerbations) were studied.While 4/20 positive samples were retrieved from S1, positives rosesubsequently to 16/20 for S2 to 10/12 for S3. Resistant pseudomonasaeruginosa and acinetobacter species accounted for 4/16 and 8/16 for S2and 5/10 and 5/10 for S3, respectively. In 13 pts antibiotics were changedaccording to sensitivities. Mortality was high (15/20), especially in non-COPD pts (8/8), despite the use of appropriate antibiotics and it was notinfluenced by the type of bacteria cultured. Comparing concentrations�105 cfu to those with �105 cfu there was no positive correlation withfever (�38 C) or leucocytocis (WBC �10500) for the group as a whole, aswell as for the subgroups of 12 COPD and 8 non-COPD pts.

CONCLUSION: Positive cultures of TRBS was a common findingafter the first few days in MV MICU pts, with no correlation with fever orleucocytocis. The value of following and treating tracheobronchitis cannotbe easily appreciated, since high mortality and persistence of resistantpathogens beyond the first week despite treatment probably reflect thepoor health status of these pts. Large scale studies are needed.

DISCLOSURE: N.D. Manolakoglou, None.

OBESITY AND THE OUTCOMES OF CHRONIC VENTILATORDEPENDENCEHasan M. Al-Dorzi, MD*; Mary Ellen Kleinhenz, MD, FCCP. Division ofPulmonary, Critical Care and Occupational Medicine, Saint Louis Uni-versity HSC, St Louis, MO

PURPOSE: Obesity is a serious disorder with increasing prevalence. Itis associated with multiple abnormalities in respiratory function thatpredispose to respiratory failure. This study assessed the prevalence ofobesity among patients with chronic ventilator dependence (CVD) andevaluated the effect of BMI on their outcomes.

METHODS: We performed a retrospective study of patients withCVD discharged from an LTAC facility between 3/01/01and 4/30/02. Datacollected included age, gender, ethnicity, height, weight, number of dayson ventilator (DOV), length of stay (LOS), weaning success, mortality anddisposition.

RESULTS: We evaluated 141 patients with mean age of 69� 14 yrs,mean BMI of 30 � 12, weaning success of 62% and mortality of 29%. Weobserved the following distribution of CVD patients among standard BMIcategories: underweight (BMI�18.5) 5%; overweight (BMI�25) 63% andobesity (BMI�30) 38%. Morbid obesity (BMI�40) was present in 12% ofpatients, at a prevalence nearly 3 times that of the US population. Causesof CVD differed among the BMI categories: COPD in underweightpatients (OR� 8.4, 95% CI� 1.7-42.3, p�0.02), major CNS event inobese patients (OR� 2.4 with 95% CI�1.02-5.70, p�0.06) and multior-gan failure in morbidly obese patients (OR� 4.8, 95% CI� 1.6-13.8,p�0.005). Morbidly obese patients were among the youngest CVDpatients (61 � 12 yrs, p�0.01). While LOS and DOV were not differentfrom those of other patients, morbidly obese patients had the highestweaning success (76%), the lowest mortality (12%) and were more likelyto go home or to acute rehabilitation facility (OR�3.9, 95% CI�1.3-11.9,p�0.02).

CONCLUSIONS: We observed an increased prevalence of morbidobesity among patients with CVD. Morbidly obese patients developedCVD at a relatively younger age often in association with multiorganfailure, but had a favorable prognosis.

CLINICAL IMPLICATIONS: Critically ill patients with morbidobesity should be recognized as having high risk for CVD. A betterunderstanding of obesity related respiratory dysfunction in the ICUsetting would help to prevent this complication of critical illness.

DISCLOSURE: H.M. Al-Dorzi, None.

Mycobacterial Infection: US andInternational Perspectives12:30 PM - 2:00 PM

TUBERCULIN SKIN TEST READING: NEW SCALE TECHNIQUEJai Kishan, MBBS*; Rohit K. Singla; Gurdeep Singh. TB & ChestHospital, Patiala, India

PURPOSE: Tuberculin although projected as cure by Robert Koch,proved to be a good diagnostic tool for tuberculin hypersensitivity.

Substantial inter and intra observer variations in size of induration bycustomary palpatory method are found. The ball point method has theinherent problem of marking the skin with ink and possible skin injury/irritation. Therefore a new method needs to be evolved for reading atuberculin skin test.

METHOD: A transparent scale was slided at an angle of 45 degree,starting 2cm away from the tuberculin skin test site. The scale stopped atthe beginning of the site of induration due to resistance, slight pressure ofthe scale left the mark at the site of induration. This process was repeatedto measure the transverse and horizontal indurations. The distancebetween the opposite marks was measured. Two readers measured thetuberculin readings using palpatory method, Ball point method and theNew scale technique. They were blinded of each others readings.

RESULTS: By palpation method, measurement from the secondobserver was observed to be 4.5 mm less to 3.5 mm more than themeasurement from the 1st observer. Whereas using Ballpoint method andthe New scale method the inter observer variation was much less i.e. 3mmless to 2.5mm more. The area of imprecision was much less broad for theballpoint pen method and the new scale method then the palpationmethod. Intra observer variation between Ballpoint pen and palpation orNew Scale Method and palpation method was wide whereas differencebetween Ballpoint pen method and New Scale Method was narrow.

CONCLUSION: The inter and intra observer variations using Newscale method are less then the customary palpatory method. The Newscale method is useful for measuring tuberculin induration and eliminatesthe problem of soiling of the skin with the ink and possible injury whileusing ballpoint method.

CLINCAL IMPLICATION: The New scale method can be employedfor measuring tuberculin test indurations.

DISCLOSURE: J. Kishan, None.

ESTIMATION OF ANNUAL RISK OF INFECTION OF TUBER-CULOSIS IN DISTRICT PATIALA, INDIAJai Kishan, MBBS*; B K. Kapoor; Rohit K. Singla. TB & Chest Hospital,Patiala, India

PURPOSE: Epidemiological situation of tuberculosis needs to bestudied in order to have baseline data and to formulate strategies and tosee the impact of such strategies for control of tuberculosis. Variousepidemiological indices like tuberculin test, chest X-ray, sputum exami-nation and mortality rate etc. have been used in the past to study theepidemiological situation. However in the given scenario of high preva-lence of tuberculosis and large population these methods are found to beexpensive and time consuming. Annual risk of infection (ARI) is oneepidemiological indices which has been found to be useful to study theepidemiological situation because it is easy to perform and is costeffective. However there is controversy about the study of ARI in BCGvaccinated children. In the era of universal immunization program (UIP)it is very difficult to find sufficient number of non BCG vaccinatedchildren. Therefore ARI was estimated amongst BCG vaccinated and nonBCG vaccinated children.

METHODS: One TU of tuberculin was given to 4053 children.Induration was noted in 3922 at 48 hours with a cut off point of 10mm.The gender, rural/urban and BCG vaccination status was noted.

RESULTS: Prevalence was found to be 7.01%. It was 7.54% infemales, 6.74% in males. Prevalence of tuberculin positivity was 7.22% &6.68% in BCG vaccinated and non BCG vaccinated children respectively.The ARI was 1.12 in all the groups. There was no statistical differenceobserved between rural/urban, BCG and non BCG vaccinated, male andfemale subjects.

CONCLUSION: Study of ARI can be undertaken with ease and thereis no difference in BCG vaccinated and non BCG vaccinated children.

CLINICAL IMPLICATION: Tuberculin testing to derive ARI can beunder taken in both; BCG vaccinated and unvaccinated children to assessthe epidemiological situation of a country.





THE SEVERE BRONCHIAL TUBERCULOSIS AT THE YOUNGADULTRuxandra Ulmeanu*; Emilia Crisan; Mihai Alexe; Florin D. Mihaltan. TheNational Institute of Pneumology, Bucharest, Romania

PURPOSE: Between January-December 2002, we noticed an increaseof the severe bronchial tuberculosis (lobar, pulmonary atelectasis) at theyoung adult at the first treatment).

METHODS: Out of a total of 7641 patients investigated endoscopicallyin 2002, we detected 78 cases of bronchial tuberculosis (confirmedhystologically and bacteriologically).

Their age was between 18 and 83 years; 53 patients were under 45 yearsold (45 men and 33 women).

RESULTS: In 39 cases, tuberculosis presented localizations at the levelof lobe and segmental bronchis.

At 22 patients we have detected severe forms with a subtotal atelectasisof intermediary trunk (5), right main bronchus (11), left main bronchus(3), both atelectasis of right main bronchus (total) and left main bronchus(partial) in 2 cases!

For 8 cases, the tuberculosis was extremely severe, with tracheallocalizations and at the level of one or both main bronchis.

In 4 cases, bronchial tuberculosis coexisted with the laryngeal TBC.At 1 patient we also detected epiglotal tuberculosis.In 2 cases, it was tuberculosis at the level of the resection stumps

(lobectomy).Two patients had gangliobronchial fistula.Out of the 30 patients with severe forms (pulmonary atelectasis,

tracheal localizations etc.), 16 were between 28 and 39 years old; in 7 casesdid not exist radiological aspect suggesting tuberculosis.

The cases will be presented with an ample iconography.CONCLUSIONS: Tuberculosis can take extremely serious forms;

sometimes there are severe discordances between endoscopical aspects(severe) and those radiological (very little or absent).

CLINICAL IMPLICATIONS: The young adult with a chronic coughrepresents a major indication for fibrobronchoscopy.

DISCLOSURE: R. Ulmeanu, None.

NUTRITION STATUS OF YOUNG PULMONARY TUBERCULO-SIS PATIENTS AT TERTIARY CARE TEACHING HOSPITALRakesh C. Gupta, Asso.Professor*; Mayank Vats; Pramod Dadhich;Neeraj Gupta; Mukesh Taylor; Vinita Singh. Teaching Hospital, Jlnmedi-cal College, Ajmer, India

PURPOSE: Infectious diseases & malnutrition are major public healthproblem in developing world. Malnutrition can predispose PulomonaryTuberculosis (PTB). Conversely, PTB can result in malnutrition. TB hasbeen called ’phthisis’ due to profound wasting. This study was conductedto assess the nutritional status of PTB patients.

METHODS: This prospective study included 50 male and 38 femalepatients (30-40 years) during last 1 year. Patients were selected by nonprobability sampling. Demographic profile (Kuppuswami scale) and an-thropometric measurements were noted & patients were categorizedaccording to BMI. Detailed medical and dietary history (3 Day RecallMethod) was taken. Biochemical tests were done (Hb, protein, A/G ratioetc.). Nutrient contents were assessed & compared with Recommendeddaily allowance (RDA) & analysed to compare percentage, mean & S.D.

RESULT: 75% patients were from low socio-economic background.67% male and 83% female had BMI �17 kg/m2 (52% males and 63.2%females had Grade III CEM with BMI � 16 kg/m2). Males had mean Hblevel of 10.5 � 1.09 gm% while females had 7.8�1.8 gm%. 53.8% malesand 86.2% females were anaemic. Serum Total protein, S. Albumin, &A/G ratio in majority of patients were below normal. Mean energy intakefor male & female was 1548 �305 kcal & 1375 �260 kcal, which was low(56.29% of modified RDA).

CONCLUSION: 75% patients had lower BMI, 69.3% were anaemicand 35.2% patients had lower albumin level. These observations suggestthat the need for dietary regime is essential in the management of PTB tomaintain their desirable body weight, to reduce complication and for rapidrecovery.

CLINICAL IMPLICATIONS: Lower BMI, Hb levels & low S.albumin level may be due to attendant catabolism associated with PTB.Conversely, malnutrition leads to immunodeficiency and breakdown oftuberculosis. Therefore nutritional assessment in PTB patients should be

carried out & balanced dietary regime is recommended in managementand favourable outcome.

DISCLOSURE: R.C. Gupta, None.

TUBERCULOUS COLD ABSCESS OF THE CHEST WALL ANDLOWER NECK: REVIEW OF 40 CASES; A THREE YEAR PRO-SPECTIVE STUDYRakesh C. Gupta, Asso.Professor*; Mayank Vats; Pramod Dadhich;Neeraj Gupta; Mukesh Taylor. Teaching Hospital, Jlnmedical College,Ajmer, India

PURPOSE: Tuberculous chest wall abscess are uncommon, however,during last 3 years we have seen a sudden surge in the cases. Thisprospective study was conducted to find out the pattern of chest wallabscess, the relation with tuberculosis of adjacent organs and its associa-tion with HIV infection.

METHOD: All patients with complaints of chest wall and lower neckswelling were included in the study. Diagnosis of tuberculous cold abscesswas made by clinicoradiological assessment, AFB smear/culture, MT with10 TU and histopathologicalexamination of the aspirated material curret-taged tissue.

RESULTS: Out of 40 pts. studied, the male to female ratio was 1:4. 38patients (95%) were in age group 15-25 years. 65% had solitary abscess &35% had multiple abscesses. Majority of abscess were in supraclavicular(38%), infraclavicular (26%) and suprasternal notch (17%) 9% multipleabscess had interconnection sonographically. Average size of abscess was4x5cm. Only one patient was HIV seropositive. Surgical intervention wasrequired in almost all pts. Relapse was noticed in 7.8% Post operatively allpatients were given ATT for 6-9 months. No pt. showed MDR strain

CONCLUSION: This study has broken the myth that chest wallabscesses are more common in HIV seropositives. Repeated antigravitydraniage and currettage required in 92% In 36% patients we had to addprednisolone 1 mg / kg. for variable period

CLINICAL IMPLICATION: Tuberculous cold abscess of chest walland lower neck is increasing in day to day practice, probably due tohightened hypersensitivity reaction to tubercular protein or as a paradox-ical reaction Cases should be screened properly & combined surgical andmedical intervention required.


WITNESS OF TUBERCULOSIS: LIPOARABINOMANNAN ANTI-GENLucelia A. Henn, Physian Professor*; Sergio M. Barreto, PhysicianProfessor. Hospital de Clınicas de Porto Alegre, Porto Alegre, Brazil

PURPOSE: The major objective was to evaluated the sensitivity andspecificity of anti-LAM IgG antibodies for diagnosis of tuberculosis incases of pulmonary, extrapulmonary and associated forms.

METHODS: It was a study of diagnostic test using a specific antigen,designed Lipoarabinomannan (LAM) of Cambridge, MA, USA, Dyna-Gen Company. This test was performed in patients from our hospital,during january 1996 to december 1998. There are a case group and acontrol group without tuberculosis (TB).

RESULTS: The casuistic was 173 patients with tuberculosis, confirmedby bacteriologic and/or anatomopathologic methods in 114 cases (68,8%).In the other cases, the tuberculosis was confirmed by clinical, radiologicalfeatures and follow up of the patients after chemoterapy. The seriespresented 115 males, 58 females; 131 was caucasian, 24 black and 18 wasnon-caucasian. The total pulmonary forms was 88 cases (51%), 81 withpositive AFB in sputum and 7 with negative AFB in sputum. Three havepositive culture, two with negative cultures. Extrapulmonary tuberculosiswas found in 71 cases (41%). The predominant forms of X-ray of thethorax was miliar and necrositing lesions. HIV-positive patients were 118and negative 55. The MycoDot test results were: positive in 120 patients(69,4%) and negative in 53 patients (30,6%). In control group, MycoDotwas negative in 73 cases (94,8%) and positive in 4 cases (5,2%). The finalresults were: sensitivity of 69,4%, specificity of 94,8%, the positivepredictive value was 96,8% and the negative predictive value was 57,9%.In HIV-positive patients, the sensibility was 61,8% and the specificity was100%.

CONCLUSIONS: The conclusions were the MycoDot test is easy andideal for use in the diagnosis of active tuberculosis in special cases inconjunction with the other methods and permit to evaluate the humoralimmunity.


Mycobacterial Infection: US andInternational Perspectives, continued


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CLINICAL IMPLICATIONS: These diagnostic method representsother form to evaluate TB, especially in extrapulmonary forms.

DISCLOSURE: L.A. Henn, None.

THE CLINICAL UTILITY OF ELISA TEST PATHOZYME TBCOMPLEX PLUS IN THE DIAGNOSIS OF ACID-FAST BACILLISMEAR-NEGATIVE TB COMPARED WITH CLINICAL COURSERonila A. Santos, MD*. Tertiary-Training, University of Santo TomasHospital, Paranaque, Philippines

PURPOSE: Diagnosing tuberculosis poses a great challenge. AlthoughAFB smear is the most important criteria for the presumptive diagnosis ofTB, its major limitation is its low sensitivity. Our aim is to investigate theclinical utility and accuracy of serodiagnosis using ELISA test among AFBsmear negative TB patients.

METHODS: This a validation study/ diagnostic test evaluation. Con-secutive patients suspected of TB with AFB smear negative were evalu-ated. Data abstracted from the medical records included the patientdemographics and clinical presentation. The results of the serologic testwere compared to the standard diagnosis of TB. Histopathologic exami-nation and clinical response to treatment were used as gold standard.

RESULTS: 606 patients were included in the study. With a TBprevalence of 35.7%, the test had a sensitivity of 48%,specificity of 96.8%,LR (�) 16, LR(-) .537, positive predictive value of 89.5%, negativepredictive value of 77% and over all accuracy of 79.4%.

CONCLUSION: This serologic test is a useful armamentarium in thediagnosis of TB due to the likelihood positivity of 16 in this test comparedto standard diagnosis.

CLINICAL IMPLICATION: This serologic test will be a useful indiagnosing smear negative patients highly suspected of having TB and incases of extrapulmonary TB where the utility of conventional laboratorytests are limited.

DISCLOSURE: R.A. Santos, None.

COMORBIDITY OF HUMAN IMMUNODEFICIENCY VIRUS IN-FECTION AND DISSEMINATED TUBERCULOSIS IN PA-TIENTS AT HARLEM HOSPITAL CENTERVinette E. Coelho-D’Costa, MD*; John Salazar-Schicchi, MD; SamuelDartey-Hayford, MD; Hima Muttana, (Research Assisstant); Sami A.Nachman, MD; Wafaa El-Sadr, MD. *Harlem Hospital Center andCollege of Physicians and Surgeons of Columbia University, New York,NY

PURPOSE: To describe the presentations of patients with dissemi-nated tuberculosis (TB) and its occurrence in patients with the comor-bidity of human immunodeficiency virus (HIV) infection at HarlemHospital from 1999 to 2002.

METHODS: Retrospective chart and radiographic review. Criteria fordiagnosis of disseminated TB were: miliary pattern on chest-xray/ CT orevidence of miliary TB on biopsy/ postmortem.

RESULTS: A total of 98 cases of TB were identified. Thirty-six(36.7%)had HIV infection, 46(46.9%) were HIV-uninfected and 16(16.3%)unknown . Eight cases (8.1%) were identified with disseminated TB (5women, 3 male; age range 22-58 years; one foreigner. Seven cases (87.5%)were HIV-infected (CD4� cell count: 34-212 cells/mm3) . Three (37%)were tuberculin skin test (TST) positive. Fever, night-sweats, anorexia/weight loss were seen in all with cough and dyspnea in 5(62.5%).Twopatients had Central nervous involvement (multiple enhancing lesions).Two patients had normal chest-xrays. Five patients had miliary pattern onchest high resolution CT (HRCT) (one with normal chest-xray). Twopatients had tree and bud pattern on HRCT, suggesting endo-bronchialspread of infection. Sputum smears were positive for acid-fast organismsin 3 patients (37.5%) and cultures were positive in 5 (62.5%). Bronchos-copy was performed on 4 patients: one caseating granuloma, one non-caseating granuloma; 2 non-diagnostic. Six patients (75%) had bacterio-logical confirmation (1 patient with brain biopsy). Of the 2 culturesnegative cases: 1 was diagnosed at autopsy (cultures not done) and anotherwas diagnosed on clinical grounds and response to treatment . Appropri-ate anti-TB treatment was initiated in 7/8 patients. Three completed 6months treatment without relapses after 1 year. Four died and onecontinues on treatment with second-line anti-TB drugs due to side effectsto first-line medications.

CONCLUSIONS: Disseminated TB is a common presentation inindividuals with HIV-related TB. The severity of the disease required a

high clinical suspicion, aggressive workup and prompt treatment to avoidunfavorable outcomes.

CLININCAL IMPLICATIONS: Importance of suspicion, diagnosisand prompt treatment of Disseminated TB especially in the immunocom-promised individuals

DISCLOSURE: V.E. Coelho-D’Costa, None.

CLINICAL PRESENTATIONS OF TUBERCULOSIS IN RELA-TION TO CD4 CELL COUNTS IN PATIENTS WITH HIV INFEC-TIONNilesh I. Gupta, MD*; S Jayaram, MD. Grant Medical College & Sir J.JGroup of Hospitals, Bombay, India

PURPOSE: HIV infected patients have an increased risk of developingtuberculosis (TB) due to a loss of cell mediated immunity. along with aquantitative decline in circulating CD4� lymphocytes, there is also aqualitative change in function. As a result, at a specific CD4� count,tuberculosis occurs sooner than other opportunistic infections. Our aimwas to investigate the relationship between CD4� counts and manifes-tations of tuberculosis in HIV patients.

METHODS: Retrospective chart review was done on patients admit-ted to the hospital, or referred to our specialty clinic. Data abstractedincluded patients demographics, medical history, clinical presentation,CD4� cell counts, sputum for acid-fast bacilli (AFB), tuberculin test(PPD), and radiology findings.

RESULTS: Forty one HIV positive patients infected with tuberculosiswere included in the study. The mean was 31, with 73% being 20 - 40years old. 34 (82%) were male. 27 (66%) were married, with 95%heterosexual transmission. Sputum for AFB was negative in 90%. PPDwas negative in 35 (85%) of patients. Chest roentgenograms werereported per radiology and were classified as typical (cavitary lesions orapical infiltrates) or atypical presentations. 26 (63%) had atypical findings.CD4� cell counts were less than 200 cell/micro liter in 56% of patients.18 patients were noted to have isolated pulmonary TB. Isolated pulmo-nary TB was seen at mean CD4� cell count of 253, with extrapulmonaryTB seen at a mean count of 212.

CONCLUSIONS: The incidence of TB increases as CD4� cell countsfall. Clinically evident TB appears at CD4 counts below 500. Maximumincidence occurs when the count is below 200. Isolated pulmonary TBoccured at CD4� counts �300. Dissemination with extra-pulmonary sitesof infection occurred when CD4� counts were �100.

CLINICAL IMPLICATIONS: Pulmonary TB in HIV patients ispredominantly atypical in its presentation. CD4 cell counts are indicativeof dissemination of infection with isolated pulmonary tuberculosis occur-ing at higher levels and extrapulmonary TB seen usually when the countsare below 100 cells/microliter.

DISCLOSURE: N.I. Gupta, None.

GERIATRIC TUBERCULOSIS: AN INDIAN TEACHING HOSPI-TAL EXPERIENCEMayank Vats, Resident Doctor*; Rakesh C. Gupta; M L. Gupta; PramodDadhich; Neeraj Gupta, asso.professor; Mukesh Taylor. Teaching Hospi-tal, Jlnmedical College, Ajmer, India

PURPOSE: Weaning of cell-mediated immunity and age relatedpathophysiological respiratory changes predisposes to reactivation orre-infection tuberculosis. This comparative prospective study evaluatedclinicoradiological presentation of tuberculosis in elderly (�65 years).

METHOD: 104 elderly and 100 adults were included. Medical docu-mentation including microbiology, radiography, MT, USG and Bronchol-ogy were analysed. FNAC, Biopsy of lung/ pleura and pleural fluid analysiswere done to confirm the diagnosis.

RESULTS: There was no statistically significant difference in symp-toms however, high frequency of dry cough and low frequency of nightsweats and chills was noticed in elderly patients (EP) p�0.01. Hemoptysiswas present in 15.2% EP v/s 34% adults p�0.01. Sputum smear andculture positivity for AFB was 47% and 41% in EP. Radiologicallynon-cavitory disease, pleural effusion, miliary TB and fibrocavitory diseasewas in 87.5%, 21% 17% & 12.5% of elderly and in 43%, 10% 15%, and57% of controls respectively. Lesions located in UZ/MZ (53.8%) withMZ/LZ (21.1%) preponderance. 62% of EP had comorbid conditions[COPD/ Asthma- 21%, Diabetes- 14%, hypertension- 12%, BronchogenicCA - 5%. HIV seropositivity was less (2.8% v/s 8%). XPTB was commonin EP [pleural effusion (21%), abdominal TB (16.3%)]. MT with 10 TU




was positive in 50.9% cases. Sputum AFB was positive in 47% EP (v/s68%) BAL for AFB was positive in 3 EP. Eight EP were diagnosed byFNAC / biopsy.

CONCLUSION: Tuberculosis is very common in elderly. Because ofsocio psychological and medical aspects of ageing, co-morbid states,ignorance and misperception of symptoms, poor attention by care giversand atypical manifestation of disease the diagnosis is difficult and delayedin this population. Our study confirms the importance of consideringtuberculosis as a diagnosis in elderly even in the absence of classicalclinicoradiological presentation.

CLINICAL IMPLICATION: A high index of suspicion with appro-priate investigations may lead to early diagnosis and prompt institution oftreatment, thereby significantly decreasing the morbidity and mortalityattributed to tuberculosis in elderly.

DISCLOSURE: M. Vats, None.

MORTALITY PATTERN AMONG PULMONARY TUBERCULO-SIS PATIENTS IN A TERTIARY CARE HOSPITALRakesh C. Gupta, Asso.Professor*; Mayank Vats; Pramod Dadhich;Neeraj Gupta; Dave Lokendra; Mukesh Taylor. Teaching Hospital,Jlnmedical College, Ajmer, India

PURPOSE: This retrospective study was designed to assess the patternof mortality among pulmonary tuberculosis patients and to study variousparameters associated with increased risk of death.

METHODS: 369 PTB patients died during last 3 years. were analysedincluding demographic, clinicoradiological status, duration of illness.Comorbid states were noted. We analysed symptoms at the time ofadmission, course of progression and terminal events.

RESULTS: Out of 369 PTB pts. (M�273, F�96) who died during last3 year, 63.1% pts. were in 20-50 yr. age group. Chief complaints wereexacerbation of chronic symptoms (cough, fever, breathlessness, chestpain and hemoptysis). 58% patients had TDI of �3 years. 42% wereirregular treated and 39% were treated with DOTS, 11% were MDR. 66%males & 58% female had far advanced disease. 36% had at least onedestroyed lung. Majority of pts. (48% M & 59% F) had fibrocavitorydisease. Comorbid states included COAD/ Asthma (42%) Anemia (83%),DM (22%), HIV infection (5% ), Renal ds. [ARF, CRF, Renal Amyloid-osis (6.2%)], Hepatic ds. (3.5%), Ascites (5%) and Bronchogenic Ca.(1.3%). Terminal event was respiratory failure (36%) cor pulmonale(18%), Hemoptysis leading to choking (15%), probabale Thromboembo-lism/ pulmonary infarction (9%), Renal failure (7%), Hepatitis /HepaticComa (5%), TBM (4%), Electrolyte imbalance (4%), Diabetic ketoacido-sis / Coma 2% Cause could not be ascertained in 8% cases.

CONCLUSION: Mortality rate was significantly higher in young adultsof low socio-economic status. Mortality rate was directly related to theextent of disease, associated comorbid states, TDI, abject poverty, poornutritional status, illeteracy & hopelessness. In majority cause of deathwas respiratory failure, owing to resource constraints diagnosis of PTE/pulmonary infarction could not be confirmed.

IMPLICATION: Manageable cause of death should be given toppriority in management of these patients. Prophylaxis for airway manage-ment in massive haemoptysis, to prevent DVT, management of secondaryinfections, correction of anaemia and electrolyte imbalance in elderlypatients can prevent large number of casualties.


TUBERCULOSIS IN A UNIVERSITY HOSPITAL OF THE SOUTHOF BRAZILLucelia A. Henn, Physician Professor*; Ellen A. Almeida, MedicalStudent; Neusa G. Riera, Medical Student; Joao Claudio R. Wasniewski,Medical Student. Hospital, Hospital de Clınicas de Porto Alegre, PortoAlegre, Brazil

PURPOSE: To evaluate the profile of tuberculosis in our hospitalduring 1 year, studying the prevalence, general features, co-infection withHIV, diagnostic methods, associated diseases, therapeutic schemes, tox-icity, clinical evolution and the prevalence of mycobacterial infection bymycobacterial other than tuberculosis (MOTT).

METHODS: We evaluated 217 patients, analysing the results ofmicrobiological, radiological, anatomophatological, laboratory results,HIV serological test, viremia level and CD4 T cells and treatmentresponse.

RESULTS: Tuberculosis was found in 187 patients; MOTT in 30(16%). Among the tuberculosis cases: 126 men, 146 caucasian, 91,4%from metropolitan region, 132 had some disease, 104 HIV positive.Pulmonary forms in 108, extrapulmonary in 47 and both in 32. Among theextrapulmonar forms, ganglionar and miliar were the most prevalent.Samples were obtained through different methods, spontaneous sputumin 103 patients, being AFB positive in 39 cases and the culture in 10,induced sputum in 43, being AFB positive in 7 and the culture in 14 cases,BAL in 41 cases, being AFB positive in 6 cases and the culture in 8. Themost common radiological findings were: pleural effusion in 33, cavity in23, consolidation in 22 and miliar in 10. In the HIV positive, the viremianivel was from 1000 to 4600000 and CD4 count from zero to 570.Rifampin, Isoniazid, Pyrazinamide (RHZ) were used in 167 cases, Strep-tomicin, Isoniazid and Ethambutol (SHM) in 11 and Streptomicin,Ethionamide, Ethambutol and Pyrazinamide (SEMZ) in 1. The majorreason for change the scheme was hepatotoxicity. The cure with RHZoccured in 111 patients and with SHM in 7 patients. The mortality causedby tuberculosis was 8,5%.

CONCLUSIONS: The culture of samples represent an importantdiagnostic method. The HIV co-infection worses the evolution. Althoughthe drugs have high efficacy the cure is still low.

CLINICAL IMPLICATIONS: This infectious disease represent ahealth public problem in our country, specially with co-infection withHIV.

DISCLOSURE: L.A. Henn, None.

SPUTUM INDUCTION FOR SPUTUM SMEAR EXAMINATIONFOR ACID-FAST BACILLI: POTENTIAL COST-EFFECTIVEMETHOD IN FIELD SETTINGJai Kishan, MBBS*. TB & Chest Hospital, Patiala, India

PURPOSE: For diagnosis of pulmonary tuberculosis world over inpatients having cough of more than 3 weeks, 3 smear examinationpreferably within two days are recommended. Beside the cost of sputumsmear examination : an indirect cost of travel/cost of staying overnight, lossof wages of patient & sometimes of attendant is involved. Moreover, manypatients fail to turn up for sputum examination next day or fail to comealtogether on programme basis. A new method to avoid above disadvan-tages is need of day. Sputum induction as a method to avoid abovedisadvantages was studied.

METHODS: Sputum smear examination of 130 patients having coughof more than 3 week was undertaken by standard protocol or by sputuminduction using Jet Nebullizer and Salbutamol Solution was undertaken.Results of two methods were compared.

RESULTS: Sputum smear was positive in 22 cases using sputuminduction and 15 cases by standard method out of 130 cases. In only 9cases, sputum was positive on day one by conventional method. In 15cases out of 22 sputum positive cases gradation of sputum improved aftersputum induction when compared with spot specimen. No complicationsusing sputum induction were encountered. 20 (15.4%) cases out of 130patients failed to turn up next day.

CONCLUSIONS: Using sputum induction the results and gradation ofsputum smear examination can be improved and results can be madeavailable on same day. Disadvantage of cost of travel, cost of stay, loss ofwages of patient and of attendant for giving 2nd early morning and 3rdspot specimen on second day can be eliminated. Sputum induction ischeap, easy to perform and is devoid of complications.

CLINICAL IMPLICATIONS: Sputum induction can be employedinstead of conventional method for diagnosis of pulmonary tuberculosis bysmear examination as a cost effective method in field setting.


A PRELIMINARY SURVEY OF PRE-TREATMENT COUNSEL-LING OF PATIENTS WITH TUBERCULOSIS IN MULAGO HOS-PITAL, UGANDAIsabirye C. Charles, Physician*; Madinah N. Namaata, Clinical Officer.Referral, Hospital, Jinja, Uganda

PURPOSE: The major objective of the study was to determine whetherTB patients are knowledgeable about the disease. Other objectivesincluded to determine the percentage of TB patients who ever receivedpre-treatment counselling before initiation of treatment, to describe thedemographic features of patients recruited, to correlate the level ofeducation with the patients’ knowledge of the disease, to determine the




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prevalence of the various symptoms of TB known to the patients, toidentify some of the factors leading to failure to complete treatment, tosuggest ways of improving the efficiency of pretreatment education of TBpatients and to bridge the gaps in knowledge attitude and practice (KAP).

METHODOLOGY: A crossectional study of patients with tuberculosiswas done in Mulago Hospital. Seventy patients aged 15 years and abovewere consecutively recruited into the study. Their files were retrieved toascertain the diagnosis of tuberculosis and the following information wasobtained:

1.Demographic variables like age, sex and level of education.2.Patients’ knowledge on symptoms, medication, side effects of drugs

and duration of treatment.3. Number of patients who had ever received pre-treatment counselling

/health education prior to treatment.RESULTS: There was only 1.4% of the patients who were knowledge-

able about the disease. Pre-treatment counselling/health education wasreceived before initiating treatment by only 21.4% of the patientsrecruited. Most patients (95.7%) did not know the cause of TB. Thecommonest symptom known by the patients was cough and this contrib-uted to 51.5% of the patients recruited.

CONCLUSION: Pretreatment health education of TB patients is verylow and needs to be addressed.

CLINICAL IMPLICATION: There is a likely hood of not attainingthe WHO recommended cure rate of 85% and detection rate of 70% ofexisting smear positive cases if the health workers do not avail anyeducation to TB patients/ general population about the disease and we arelikely to see an increased number of defaulters and development ofresistance to the drugs.

DISCLOSURE: I.C. Charles, GLRA, Grant monies.

DEFAULTS UNDER REVISED NATIONAL TB CONTROL PRO-GRAM: A PROSPECTIVE ANALYSIS OF 300 PATIENTS ONDOTSMayank Vats, Resident Doctor*; Rakesh C. Gupta; M L. Gupta; PramodDadhich; Deepa Vats; Mukesh Taylor. Teaching Hospital, JlnmedicalCollege, Ajmer, India

PURPOSE: To identify the causes of default under DOTS & developpreventive strategies to ensure compliance.

METHOD: 300 patients under DOTS at various Treatment Centres 2months were recruited prospectively. After[tmsnew]63[/tmsnew](TC) re-ported after defaulting for complete evaluation & symptomatic treatment,they were administered on DOTS as per protocol or on revised treatment.

RESULTS: Demographic profile revealed: 21-40 years age group(63%), low socioeconomic background (75%), smoker (61%), alcoholic(24%), illiterate (43%), �40kg body weight group (BWG) (74.6%).Categorywise default - 48.6%(Cat. I), 38.6% (Cat. II) & 12.6% (Cat. III).Patients related causes of defaults - symptomatic benefit (20%), poor orno symptomatic benefit (7.3%), hemoptysis, pneumothorax (8.3%), be-havioural (4.6%) & socio-occupational (4.6%). Health care delivery systemrelated causes - distance to TC (8.6%), behaviour of staff (4%) andnon-availability of drug (2.6%). Drug related causes - gastric intolerance(24.6%), hapatitis (7.3%) and number of pills (3.3%). Default wasmultifactorial in 8% cases. Adverse effects of drugs were frequent in lowerBWG (78.9% in 40 kg. BWG). After evaluation, steps taken were -symptomatics and continued on DOTS (44.6%), DOTS was resumed aftercounseling and overcoming administrative problems (39.3%), switched torevised treatment (10% MDR) and failed to resume DOTS because ofpoor faith (6%). Hence, it was possible to resume DOTS in 83.9% patientswhile in 15.9% DOTS could not be resumed.

CONCLUSION: An urgent action must be taken to avoid default fromDOTS because most of these are manageable and if ignored can lead tocatastrophic consequences.

CLINICAL IMPLICATION: Prokinetic agent must be given prior toDOTS to minimise GI side effects. Doses to be modified in lower BWGand spacing may be allowed. Patient’s education, motivation and counsel-ing is must to prevent default after symptomatic benefit. Availability ofdrugs/staff should be ensured at each TC. All causes of default must betackled with appropriate measures along with sympathetic attitude.

DISCLOSURE: M. Vats, None.

CORRELATION BETWEEN ISONIAZID AND PYRIDOXINEPROPHYLAXIS AND BODY WEIGHTMohammed T. Alam, MD*; Marie F. Schmidt, MD; Alamgir A. Khan,MD; Zia U. Rehman, MD; Vaidehi Kaza, MD; Rozeena Parveen, MD;Ijaz Ahmed, MD; Joseph B. Quist, MD; Danilo Enriquez, MD; Gerald M.Greenberg, MD. Interfaith Medical Center, Brooklyn, NY

PURPOSE: To monitor the relationship of weight (wt) with Isoniazid(INH) and pyridoxine (B6) prophylaxis in patients(pts) with latent tuber-culosis infection (LTBI).

METHODS: We performed a retrospective evaluation of weight of 58pts who received INH and B6 prophylaxis in our mid Brooklyn tubercu-losis (TB) clinic between 2002 and 2003. All pts who completed 9 monthsof INH and B6 were included except pts with history of malignancy,congestive heart failure, steroid usage, psychiatric disorder and hypothy-roidism. The record of wt at the initiation of therapy (Rx) and at theconclusion of Rx was recorded from the computerized medical records.

RESULTS: Out of the study population (n � 58 pts), 39 pts (67%)gained wt ranging from 1 pound (lb.) to 42 pounds (lbs.) with an average(ave) of 8.62lbs. Four pts (7%) did not loose or gain any wt. Fifteen pts(26%) lost wt ranging from 1lb. to 11lbs with an ave of 5.2 lbs. Of the 15pts in the wt loss group (gp) 7 pts (46%), lost more than 5 lbs. and wereon a voluntary wt loosing diet. In the wt gain gp 23 pts (59%) out of 39gained more than 5lbs and 30 pts (77%) out of 39 reported increasedappetite.

CONCLUSION: In our study the association between INH and B6prophylaxis and wt shows more predilection for wt gain for which there isno reported literature. We suspect that being in a supervised program fordirectly observed therapy and regular contact with medical personnelcaused a sense of well being which might enhance the pts appetiteresulting in wt gain, though we could not compare the wt gain with acontrol population.

CLINICAL IMPLICATIONS: This is the first paper that examinesthe relation between INH and B6 prophylaxisand wt in pts with LTBI andprovides a reference for future study in this area.

DISCLOSURE: M.T. Alam, None.

A STUDY OF ROLE OF SEROTONIN AND ITS METABOLITESCAUSING JOINT PAINS/ SHOULDER HAND SYNDROME INPATIENTS WITH PULMONARY TUBERCULOSIS TAKING ISO-NIAZID-CONTAINING REGIMENSJai Kishan, MBBS*; Rennis Davis; Kiranjeet Kaur; Neelam Verma. TB &Chest Hospital, Patiala, India

PURPOSE: Joint pains/shoulder hand syndrome is known to occur inpatients on antitubercular therapy especially INH. Degradation of sero-tonin is strongly inhibited by INH. study was to find correlation betweenINH, joint pains/SHS, serotonin and its metabolites patients.




METHODS: Serotonin and 5-HIAA levels in blood and urine wereestimated by Cox and Perhach (1973) method. Group-I:30 patients ofPTB on INH containing regimen but no joint symptoms, Group-II:30Patients of PTB on INH containing regimen who developed jointsymptoms/SHS (Other causes of joint pains/SHS excluded) Group-III:20patients taking INH chemoprophylaxis.

RESULTS: In Group-I : Blood and urine serotonin was significantlyraised and blood 5-HIAA was highly significantly raised when levels atbeginning & 3rd month were compared. At 6th month only urine 5-HIAAlevels were highly significantly raised. Mean urine 5-HIAA levels were1.33�0.8 at beginning and 2.24�0.82 at 6 months.

In Group-II : Mean blood serotonin levels were 3.28�2.26 and meanurinary 5-HIAA levels were 2.47� 1.65. This was statistically highly raisedwhen compared with the levels of patients of pulmonary tuberculosis atbeginning without joint symptoms/SHS.

In Group-III : Mean 5-HIAA levels were 1.32� 0.67 at beginning and2.6� 0.71 at 3 months. Difference was statistically highly significant.

CONCLUSION: In patients of pulmonary tuberculosis correlationexists between isoniazid, joint pains/SHS, serotonin and its metabolites.Levels of serotonin and 5-HIAA changes with duration of treatment andactivity of pulmonary tuberculosis by the lungs. There is a difference inhandling of serotonin in diseased lung due to tuberculosis and relativelyhealthy lung in patients taking INH chemoprophylaxis. Probably serotonincause joint symptoms/SHS by vasoconstriction , leading to ischaemia/ischemic necrosis causing inflammation . Condition responds to steroids,vasodilators and anti-inflammatory drugs.

CLINICAL IMPLICATIONS: Joint symptoms/SHS in patients ofPTB on INH containing regimens need to be recognized at an early stage,otherwise permanent changes in the form of fibrosis or contractures maydevelop.


MYCOBACTERIUM AVIUM COMPLEX HOT TUB LUNG: INFEC-TION, INFLAMMATION, OR BOTH?Timothy R. Aksamit, MD*. Mayo Clinic, Rochester, MN

PURPOSE: Increasing numbers of patients have presented with ahypersensitivity pneumonitis-type course in association with hot tubexposure. Mycobacterium avium complex (MAC) organisms have beenisolated from both patient specimens and hot tub water with matchingfingerprints by restricted fragment length polymorphism and electro-phoresis when performed. Review of 9 patients at Mayo Clinic, Rochesterare compared with 32 patients in the published literature (referencepatients).

METHODS: Nine patients have been diagnosed with MAC-associatedhot tub lung at Mayo Clinic, Rochester. Charts were retrospectivelyreviewed for information regarding demographics, clinical characteristics,environmental sampling, diagnostic studies, treatment regimen, andclinical course. These data were compared to those reported in theliterature.

RESULTS: Mayo patients (reference patients) ranged in age from 14to 66 years ( 9 to 69) with an average age of 44 (36). Symptoms had beenpresent for an average of 2.9 months (3.0) with a range of 2 to 6 months( 2 to 4 ). Common signs and symptoms included dyspnea 100% (100%),cough 100% (100%), and fever 75% (52%). Hypoxemia was noted in 88%(52%). High resolution chest CT demonstrated diffuse infiltrates in 100%(70%) and nodules in 60% (13%). MAC organisms were isolated fromsputum in 88% (60%) and lung tissue in 66% (100%). Histopathologicfindings included nonnecrotizing granulomas in 100% (100%), necrotizinggranulomas in 12% (20%), and organizing pneumonia in 12% (20%).Lymphocytes were elevated at 57% and 62% in the two bronchoalveolarlavages that were done. Treatment involved corticosteroids in 64% ( 19%),antimycobacterial therapy in 0% (26%), combined steroids and antimy-cobacterial therapy in 12% (39%), and no therapy in 12% (16%). Allpatients returned to normal lung function.

CONCLUSION: MAC organism exposure from hot tubs may result ina hypersensitivity pneumonitis-type reaction.

CLINICAL IMPLICATIONS: Clinicians should be aware of anincreasing number of MAC associated hypersensitivity pneumonitis-type

cases related to hot tub exposure. Whether this represents infection,inflammation, or both is a matter of debate and ongoing investigation.

DISCLOSURE: T.R. Aksamit, None.

Occupational/Environmental Lung Disease12:30 PM - 2:00 PM

MORPHOLOGICAL CHANGES IN THE RESPIRATORY SYSTEMOF VIBROACOUSTIC DISEASE PATIENTSCarla P. Mendes, MD*; Jose Reis Ferreira, MD, FCCP; Ana P. Martins,MD; Emanuel Monteiro, BSc; Mariana Alves-Pereira, PhD Candidate;Nuno Castelo Branco, MD. Portuguese Air Force Hospital, Lisbon,Portugal

PURPOSE: Vibroacoustic disease (VAD) is caused by long-termexposure (years) to low frequency noise (LFN) [�500 Hz, includinginfrasound]. In LFN-exposed animal models, the respiratory system wasshown to be a target for this acoustic aggressor. Simultaneously, allrespiratory tract tumors observed in VAD patients were of a single type ofcellularity: squamous cell carcinomas. In this report, fragments of trachea,lung parenchyma and pleura of VAD patients are studied through lightand electron microscopy.

METHODS: All subjects had been previously diagnosed with VAD, 2non-smokers/7 smokers). With their informed consent, fragments wereremoved from trachea (biopsy), and lung and pleura (during the surgeryfor lung carcinomas). Specimens were prepared for light and transmissionelectron (TEM) microscopy.

RESULTS: Smokers and non-smokers disclosed very similar images. Inthe trachea, with light microscopy, all images presented scattered areaswith damaged cilia, displastic foci as well as with basal hyperplasia. InTEM, multiple ciliary axonemes are surrounded by a common membrane.Blood and lymphatic vessel walls were thickened. Bronchioli and remain-ing lung parenchyma exhibit numerous macrophages, some with brownpigment (smokers), and others with tar. Type I pneumocytes are greatlydecreased and type II greatly increased. Cells under apoptotic processeswere frequent. All cell structures seem to be under the same process ofdeath, in contrast with a marked reinforcement of the cytoskeleton andintercellular junctions. Pleural thickeness due to intense proliferation ofcollagen, as well as interstitial fibrosis foci were observed. Surfactantrelease from lamellar bodies in hypophase were frequently captured.

CONCLUSIONS: The abnormal proliferation of extra-cellular matri-ces is a response to LFN common to many organs. The reduction in thenumber of type I pneumocytes and increase in type II is also seen in otherpulmonary stress situations. The very frequent images of apoptoticprocesses and ciliary abnomalities were unexpected and indicate futureavenues of research.

CLINICAL IMPLICATIONS: Lung pathology can be caused byLFN exposure.

DISCLOSURE: C.P. Mendes, None.

PERICARDIAL MORPHOLOGY IN VIBROACOUSTIC DISEASENuno Castelo Branco, MD*; Jose I. Fragata, MD, PhD; Ana P. Martins,MD; Emanuel Monteiro, BSc; Mariana Alves-Pereira, PhD Candidate.Research, Center for Human Performance, Alverca, Portugal

PURPOSE: Pericardial thickening in the absence of an inflammatoryprocess and with no diastolic dysfunction is the hallmark of vibroacousticdisease (VAD): a whole-body pathology caused by long-term (years)exposure to low frequency noise (LFN) (�500 Hz, including infrasound).This study explores the morphological features of the human pericardialresponse to LFN exposure.

METHODS: Pericardial fragments were removed from 11 VADpatients with their informed consent, at the beginning of cardiac surgery(for other reasons), and always from the same location: anterior, ventralportion of the parietal leaflet. Specimens were prepared for light andelectron microscopy

RESULTS: All fragments were over 2mm thick (normal: less than 0.5mm thick). A newly formed loose tissue layer, sandwiched between boththickened layers of fibrosa, was quite evident. No cilia were identified inthe mesothelial layer. Both fibrosa layers, on either side of the loose tissue




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layer, were distinctly composed of wavy collagen bundles, with numerouselastic fibers. The loose tissue layer contained adipose tissue cells, neuraland blood vessels, and collagen and elastic fibers. None of the layers hadthe typical cellularity of an inflammatory process. However, a largeamount of burst cells and cellular debris is scattered throughout bothfibrosa layers and the new loose tissue layer.

CONCLUSIONS: Although the response of the pericardium to LFNseems to be an adaptation response, this does not exclude the loss offunctional capabilities, i.e., not a single cilium was identified. Possibly, thisnewly formed loose tissue layer, with numerous elastic components, playsan important pneumatic role, to maintain normal function heart in thesepatients. The observed cellular death was not necrotic, and apoptoticprocesses were not evident except for the phagocytosis. This may be anexplanation for the frequent auto-immune disorders seen in LFN-exposedindividuals. Immunohistochemical studies are underway to study cellproliferation, cell death, and auto-immune processes.

CLINICAL IMPLICATIONS: Cardiovascular problems, namelythickening of cardiac structures, and collagenous diseases can be relatedto LFN exposure.

DISCLOSURE: N. Castelo Branco, None.

RESPIRATORY DRIVE IN VIBROACOUSTIC DISEASEJose Reis Ferreira, MD*; Carla P. Mendes, MD; Marco Antunes, BSc;Mariana Alves-Pereira, PhD Candidate; Nuno Castelo Branco, MD.Portuguese Air Force Hospital, Lisbon, Portugal

PURPOSE: Vibroacoustic disease (VAD) is caused by long-termexposure (years) to low frequency noise (LFN) [�500 Hz, includinginfrasound]. Neurological problems in VAD patients are characterized bythe early onset of degenerative processes, and deregulation of theautonomic nervous system. Simultaneously, studies of LFN-exposed ratsshow that the respiratory system is a target for this agent of disease. Takentogether, this information led to speculation regarding the status of therespiratory reflex response in these patients. Concurrently, there is anongoing search for a non-invasive, objective and inexpensive diagnostictest for VAD, since echocardiograms (thickening of cardiac structures inthe absence of an inflammatory process is the hallmark of VAD) haveproven to be susceptible to technician-induced subjectivity. Pulmonaryfunctional tests might be eligible for the role.

METHODS: Thirty male VAD patients and 20 age-matched controls(range 38-63 years) performed pulmonary function tests including thefollowing parameters: forced expiratory volume in the first second ofexpiration, vital capacity (VC), peak expiratory flow, and maximal expira-tory flows at 50% and 25% of VC, airway resistance, and P0.1(CO2) index.Individuals with thickened cardiac structures, as viewed through echocar-diography, and/or with known neurological disorders were excluded fromthe control population.

RESULTS: When compared to controls, no difference in any of thepulmonary parameters were identified, with the dramatic exception of theP0.1(CO2) index (range 8 -58%; norm: �70%) [p � 0.05].

CONCLUSIONS: These data indicate that the status of the respiratoryreflex response in VAD patients is severely decreased. Taken togetherwith the already described neurological disorders associated with VAD, anew understanding of the possible pathways of LFN-induced lesions mayemerge. More immediately, it is possible that the P0.1(CO2) index mightbe the desired non-invasive, objective and inexpensive test for VADdiagnosis and clinical follow-up.

CLINICAL IMPLICATIONS: The P0.1(CO2) index may be thediagnostic tool of choice for diagnosing and monitoring VAD.

DISCLOSURE: J. Reis Ferreira, None.

FIBROGENIC DUSTS AND ANCA (ANTINEUTROPHIL CYTO-PLASMIC ANTIBODIES) POSITIVITYDaniela Pelclova, Assoc. Prof., MD, PhD.*; Jirina Bartunkova, Prof., MD,DSc.; Zdenka Fenclova, MD, PhD.; Jindriska Lebedova, MD; MarieHladíkova, PhD.; Pavlína Janu, MD; Miloslav Marel, Assoc. Prof. MD,PhD. University, Department of Occupational Medicine, Prague, CzechRepublic

PURPOSE: The analysis of the possible association between thepresence of ANCA (antineutrophil cytoplasmic antibodies) and exposureto fibrogenic dusts, containing silicon.

METHODS: ANCA were determined by indirect immunofluores-cence in 188 patients exposed previously to silica (mean length of

exposure 20.5 years), in 84 patients exposed previously to asbestos (meanlength of exposure 25.0 years), and in the control group of 73 persons.Lung functions and renal functions were measured in all the groupsstudied.

RESULTS: ANCA positivity was detected significantly more fre-quently (p�0.05) both in the group of workers exposed to silica (34x, i.e.18.1%) and workers exposed to asbestos (15x, i.e. 17.9%), than in thecontrol group (5x, i.e. 6.9%). Lung functions impairment was morefrequent (p�0.01) both in the silica and asbestos exposed subjects, renalfunctions impairment only in the silica-exposed subjects (p�0.05), com-paring with the controls.

CONCLUSIONS: Asbestos, which has not been extensively studiedyet, is another occupational factor besides silica, associated with ANCA-positivity. Asbestos’s influence seems even stronger, because ANCA-positivity was found also in subjects with the history of exposure toasbestos, without typical radiographic signs of asbestosis on the chestradiograph.

CLINICAL IMPLICATIONS: This finding suggests that asbestosrepresents another danger, even under conditions of lower exposure,when asbestosis does not develop. ANCA-associated diseases were notmore frequent among subjects previously exposed to fibrogenic dusts, butfurther follow-up of all patients with ANCA positivity is necessary.

DISCLOSURE: D. Pelclova, None.

RELATIONSHIP BETWEEN ANTHRACOSILICOSIS ANDLUNG CANCER IN A COHORT OF BELGIAN COALMINERS,DEAD BETWEEN 1999 AND 2002Dominique Lauwers, MD; Philippe E. Pierard, MD*; Olivier Gilbert,MD; Jean-Pol Quarre, MD; Michele Vilain, MD. CHU Charleroi andFonds des Maladies Professionnelles (FMP), Brussels, Belgium

PURPOSE: The relationship between lung cancer and anthracosilicosisis still controversial. The aim of this study was to determine whether lungcancers are more frequent than expected in a cohort of Belgian coalminerswho died between 1999 and 2002.

METHODS: We reviewed the causes of death of the coalminerscompensated by the Belgian Compensation Board (FMP) who diedbetween 1999 and 2002. 1188 files were so considered and analyzed. Allwere men, and had radiological evidence of silicosis. The cause of deathwas detailed in the physician’s report, extracted from the files of theCompensation Board.

RESULTS: The mean age of death was 76 years. The main cause ofdeath was respiratory disease (47.9%), cardiovascular disease (21.7%), andvarious types of cancer (20.3%). One hundred subjects had developed alung cancer. The mean average exposure duration time as coalminer was13.3 years in the lung cancer group and 15 years in the non-lung cancergroup. The last year of exposure was 1963 in the first group and 1961 inthe second one. Smoking was frequent in both groups, but less in thenon-lung cancer group (97% vs 84.3%). The histologic features of thetumors were as follows : 31 squamous cell carcinomas, 19 adenocarcino-mas, 12 other non-small cell carcinomas, 12 small cell carcinomas, 1bronchioloalveolar carcinoma, information was unavailable in 25 patients.All these results are quite similar to the data of the overall Belgian malepopulation.

CONCLUSION: These data do not support an association betweenlung cancer and anthracosilicosis.

DISCLOSURE: P.E. Pierard, None.

HIGH RESOLUTION CT OF THE CHEST FIFTEEN YEARSAFTER EXPOSURE TO SULFUR MUSTARD; OBLITERATIVEBRONCHIOLITIS, A HEAVY PRICE TO PAYMajid Mokhtari, MD, FCCP*. Beheshti University, Tehran, Iran (IslamicRepublic of)

STUDY PURPOSE: Pulmonary complications are known to occur inover half of the patients exposed to sulfur mustard (HD). Chemicalweapon agents including HD were used by Iraq during Iran-Iraq warbetween 1983 and 1989. Chest high resolution computed tomography(HRCT) of a group of patients with documented exposure to HD duringthe war with development of respiratory symptoms, were reviewed toexamine delayed HRCT features of HD exposure.

METHODS: The field emergency cards and medical records of 155patients exposed to HD during Iran-Iraq war, suffered chronic respiratorycomplications and had chest HRCT were reviewed. Fifty chest HRCTs


Occupational/Environmental Lung Disease,continued


were then randomly selected and examined by a panel of pulmonologistsand radiologist for analysis.

RESULTS: Forty-five (90%) with mean age of 37.4. The most frequentfindings were; air trapping 38 (76%), bronchiectasis 37 (74%), mosaicparenchymal attenuation (MPA) 36 (72%), irregular and dilated majorairways 33 (66%) and interlobular septal thickening (SWT) 13 (26%)respectively. LLL and ML were the most and the least frequent lobesinvolved with total lesions 119 and 18 respectively. Table 1

CONCLUSIONS: Chest HRCT findings of bronchiectasis, air trap-ping, MPA and SWT were seen in patients exposed to HD fifteen yearsago. These findings are highly suggestive of obliterative bronchiolitis(OB). We did not encounter significant HRCT findings consistent withpulmonary fibrosis. Major airways dilatation and irregularity seen in twothirds of patients is not a common feature of OB.

CLINICAL IMPLICATIONS: Chronic respiratory complicationshave been the major contributor of mortality and morbidity in thesepatients. HRCT features fifteen years after exposure to HD is highlysuggestive of OB with significant major air ways abnormalities. Furtherstudies are designed to determine the followings in this population;clinical, PFT and pathological correlation with the HRCT, direct toxiceffect of HD on major airways and possibility of more favorable clinicaloutcome with early intervention considering the apparent indolent courseof this form of the disease.

DISCLOSURE: M. Mokhtari, None.

CLINICAL AND PSYCHOLOGICAL ABNORMALITIES IN NEWYORK CITY POLICE OFFICERS WHO SERVED AT THEWORLD TRADE CENTER (WTC) DISASTER SITEWalfredo J. Leon, MD*; Rosmarie Bowler, Ph.D, MPH; M A. Haseeb,PhD; Paul C. Hansard, MD. State University, SUNY, Brooklyn, NY

PURPOSE: Inhalation of dust and smoke can manifest as newsymptoms, pulmonary function abnormalities or exacerbate existing con-ditions. Psychological trauma experienced at the WTC disaster site mayalso affect symptoms. This study’s aim is to evaluate symptoms, pulmonaryfunction and posttraumatic stress disorder (PTSD) in officers involved inthe rescue effort at the WTC site.

METHODS: A questionnaire was administered to officers who servedat the site to assess respiratory symptoms. An impact event scale™ (IES)and profile mood scale (POMS) to detect PTSD was administered andspirometry (PFT) was performed.

RESULTS: Eighty-two officers participated, 71 males, 11 females.Their mean age was 40.1 (SD 6.03). Sixty-five percent were Caucasian,20% African-American, 13% Hispanic and 2% Asian. Fifty-seven (70%)were at the site within two hours of collapse, 17 (20%) were present within24 hours.

Dyspnea was the primary symptom in 91% of officers following theirservice . The FEV-1/FVC was reduced in 61% (p� 0.05). A lowerFEV-1/FVC was seen in those working closer to the collapse (p� 0.05), alower FEV-1 was seen in those working more days at the site (p� 0.05).The group’s POMS showed elevated fatigue and low vigor scores. The IESshowed 74% had at least one, and 24% had up to 9 PTSD symptoms (p�0.05).

CONCLUSIONS: Pulmonary function abnormalities although signifi-cant do not entirely explain dyspnea in our study. PFT reductions wereobserved in officers serving closer to and more days at the collapse site.Psychological abnormalities and PTSD symptoms increased with thenumber of days at the sites. Satisfaction with health was lower in officersthan the general NY population.

CLINICAL IMPLICATIONS: Distance from the collapse site andtotal days spent at the site correlated with reductions in FEV-1 andFEV-1/FVC. The reductions are small and do not entirely explaindyspnea. A propensity for PTSD and dissatisfaction with health exist. ThePOMS and IES are useful in identifying PTSD symptoms which may beperceived as dyspnea.

DISCLOSURE: W.J. Leon, None.

STEROID PULSE THERAPY IN SILICOSISRakesh C. Gupta, Asso.Professor*; Mayank Vats; Pramod Dadhich;Neeraj Gupta; Mukesh Taylor. Teaching Hospital, Jlnmedical College,Ajmer, India

PURPOSE: Ajmer is nestled in Aravali hills with plenty of stonecrushers and pulverising factories using few safeguards to prevent dust

exposure resulting in unusally high incidence of accelerated silicosis. Thisstudy was conducted to find the role of steroid pulse therapy in preventingthe progression of disease once it has been clinicoradiologically evident.

METHODS: 42 confirmed cases of silicosis were evaluated. Routineinvestigations were carried out. Tuberculosis and pyogenic infections wereruled out. Comorbid conditions having contraindications for steroids(diabetes mellitus, hypertesnsion, peptic ulcer) were excluded. Respira-tory status were asessed by PEFR, FEV1, FVC, FEV1/FVC & %Saturation of O2 (SaO2) which were found to be below normal limits. pts.put on pulse steroid therapy (dexamethasone 100 mg i.v. infusion in 5%GDW 500 c.c. over 3 hours, Day I to III) with close monitoring of fluid& electrolytes. Therapy was repeated every 28th day upto maximum ofthree cycles

RESULTS: 26 males and 16 females were put on pulse therapy, 27patients had remarkable benefit & improvement in PFT & SaO2 (averageincrease of 8-10%). 6 month f/u of 38 patients revealed that 56% patientshad sustained improvement in PFT, SaO2 & clinical status. 24.6% patientshad same status but 19.4% showed marked deterioration and died.

CONCLUSION: Dexamethasone pulse therapy showed marked im-provement but stationary x-ray findings, but this improvement waned justafter 2-3 months of last pulse.

CLINICAL IMPLICATION: Dexamethasone pulse therapy helps inimproving hypoxemia in actue condition and PFT for a period rangingfrom 2 to 6 months. However mechanism is not clear, results areunsustainable so large clinical trials are warranted.


Pediatric Critical Care12:30 PM - 2:00 PM

POSTTRAUMATIC SYMPTOMS IN CHILDREN ADMITTED TOTHE PICULudmila Zaytsev, MA*; Kiti Freier, PhD.; Daved Van Stralen, MD; MattRiggs, PhD. Loma Linda Univerity & Children’s Hospital, Loma Linda,CA

PURPOSE: Studies indicate that medical procedures may causepost-traumatic stress (PTS) symptoms (fear, avoidance, irritability) inchildren. It is suggested that midazolam hydrochloride, a sedative/amnesicmedication used in pediatric intensive care units (PICU), may prevent thedevelopment of PTS symptoms. This study examined if PTS symptoms arerelated to procedural invasiveness (PI) and whether midazolam has amoderating effect.

METHODS: English-speaking children ages 8-16 (n�20) who hadbeen in the PICU for at least 3 days were recruited at Loma LindaUniversity Children’s Hospital. During the first assessment self-reportmeasures of PTS and PI were administered. One month later childrenwere contacted for follow-up.

RESULTS: Most children (n�19) reported moderate to high levels ofstress. Boys (8-12 and 13-16) and girls (13-16) reported higher anxietylevels than the norming population (mean�7.7 vs. 6.1, 6.5 vs. 4.5, and 7.5vs. 7.0, respectively). Older girls had significantly higher level of PTS(mean�12.8 vs. 9.9). A moderate relationship existed between PI andlevel of depression (r�0.562, p�.01) and PI and anger (r�0.50, p�.02).The non-midazolam group demonstrated less PTS at first assessment,however, only the midazolam group demonstrated a clinically significantdecrease in PTS (17%), anxiety (24%), dissociation (28%), and overtdissociation (44%) at follow-up. There was a moderate effect size in theinteraction between midazolam and assessment time.

CONCLUSIONS: Children in the PICU experienced PTS symptoms.midazolam had a moderating effect on the symptoms reported one monthafter the first assessment. While children tended to under-report symp-toms, overall results revealed strong indicators of stress. Due to smallsample size, generalizability is limited. However, further investigations arewarranted.

CLINICAL IMPLICATIONS: Children report PTS. Symptoms seemto decline if midazolam was administered before an invasive procedure.Critical care units may utilize this information in improving physical andpsychological sequalae of medical interventions.

DISCLOSURE: L. Zaytsev, None.


Occupational/Environmental Lung Disease,continued


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BILEVEL POSITIVE AIRWAY PRESSURE (BIPAP) SUPPORT INA SINGLE PEDIATRIC INTENSIVE CARE UNITTito R. Monge, MD*; Joan Roberts, MD. Childrens Hospitla andRegional Medical Center, Seattle, WA

PURPOSE: To evaluate the practice of bilevel positive airway pressuremechanical ventilation in our pediatric intinsive care unit

METHOD: Retrospective chart review.RESULTS: The charts for sixteen patients (6 months to 18.5 years,

mean 10.12yrs �/- 6.3), in whom bipap was used, were reviewed. 50% ofthe patients recived bipap for post extubation respiratory insufficiency and31% for hypoxic respiratory insufficiency. The most frequent radiographicfindings were atelectasis and pulmonary edema. Median duration of bipapwas 23hrs (range 30min to 240hrs). Despite the use of bipap, 50% of thepatients required endotracheal intubation, including 50% of those whowere receiving bipap for post extubation respiratory insufficiency. Therewas a trend for decreased respiratory rate, heart rate and decrease fio2.60% of patients required sedation either to tolerate bipap, for pain aftersurgical procedures, or carry over from mechanical ventilation. Only threepatients were given enteral feeds. The only complication as a result ofbipap recorded in 25% of patients was skin breakdown.

CONCLUSIONS: Intubation rate after trial of bipap in our institutionexceeds what is reported in the literature (8% - 37%). Reintubation ratewas also high, despite low ventilator settings prior to extubation and theuse of bipap.

CLINICAL IMPLICATIONS: There are few studies on the use ofbipap in the pediatric intensive care unit. Its use, althought relative simplecompared to invasive mechanical ventilation, has not been well studied incritically ill children. Prospective studies to determine which group ofpatients best benefits from this therapy are needed. Also, more educationfor intensivist, respiratory care and nursing staff is needed.

DISCLOSURE: T.R. Monge, None.

COMPARATIVE EFFICIENCY OF NEBULIZER LOCATIONS INA PEDIATRIC MECHANICAL VENTILATOR CIRCUITJoseph D. Gutierrez, Pediatric Pulmonologist*. Makati Medical Center,Makati, Philippines

This study aims to determine the location of the nebulizer along apediatric ventilator circuit that would deliver the greatest amount ofaerosolized medication in our institution. We used an infant lungmodel and the Newport Breeze Ventilator with its own nebulizer drivesource of 8L/min that nebulizes during inspiration only. The ventilatoris set at PIP�20cm water, PEEP � 5cm water, RR � 40 , IT � 0.5 ,I:E � 1:2, Flow �10L/min. The ventilator circuit used was anon-heated plastic disposable pediatric corrugated tubing attached toa size 5mm endotracheal tube (ETT). The nebulizers were placed in 3locations as follows: at the Y-piece (proximal to the ETT) , at the watertrap (mid-way along the circuit) , and adjacent to the humidifier (distalto the ETT). The nebulizers were filled with 2.5mg salbutamolsolutions plus saline to make a volume fill of 4ml in each of the tenrandom test runs done on each location. The salbutamol content in thelung model were determined by spectrophotometry and HPLC.Results showed a mean percentage output delivered to the lung modelas follows: at the Y-piece � 0.76%(SD�1.84), at the water trap �2.86%(SD�2.45) and at the humidifier � 2.46%(SD�2.9) Analysis byOne-way ANOVA showed that the difference in the nebulizer outputsare statistically significant between that at the Y-piece and the watertrap or the humidifier (p�0.01). We conclude that the location of thenebulizer along a pediatric ventilator circuit that would deliver thegreatest amount of aerosolized medication in our institution is at thewater trap or at the humidifier. Clinical validation of these results isrecommended.

DISCLOSURE: J.D. Gutierrez, None.

EXTRACORPOREAL MEMBRANE OXYGENATION IN IN-FANTS WITH REFRACTORY HYPOXEMIC RESPIRATORYFAILURE DUE TO RESPIRATORY SYNCYTIAL VIRUS INFEC-TIONAnwarul Haque, MBBS*; Venkatramanan Shankar, MD; Paul Scott, RN;Randall Bartilson, RN; Kevin Churchwell, MD; John Pietsch, MD.Vanderbilt University Medical Center, Nashville, TN

PURPOSE: Respiratory syncytial virus (RSV) infection is a majorcause of hospitalization amongst infants. Some infants progress tosevere respiratory failure and death despite maximal respiratorysupport. Extracorporeal membrane oxygenation (ECMO) has beenused as a rescue therapy in such cases with 49- 58% survival.1,2 Thisstudy analyzes the outcomes in a small case series utilizing earlyapplication of ECMO.

METHODS: Retrospective chart review of infants with RSV infec-tion undergoing ECMO in last 2 years at a tertiary care children’shospital was undertaken. Demographic data, respiratory indices, bloodgas values, radiographic findings and length of ventilation werecollected.

RESULTS: Six children were placed on ECMO; five were infantswith ages ranging 28-61 days. Table 1 shows the respiratory indices atthe time of placement on ECMO. All had radiological evidence ofsevere lung injury including air leak syndromes in four (figure 1). Theindications for ECMO (veno-venous in 3; veno-arterial in 3 due tosmall jugular veins) were persistent hypoxemia (n�5) and severe airleaks (n�1) despite maximal ventilatory support including high fre-quency ventilation (n�4). The median ECMO duration was 358 hours(range 211- 408). All were successfully decannulated , extubated anddischarged from ICU. Complications included nonprogressive intrace-rebral bleed (n�1), cannula site bleeding(n�1) and fluid overloadrequiring hemofiltration (n�5).

CONCLUSION: All patients survived and had better than previ-ously described survival rates of 49-58%.1,2 All of our patients had apredicted mortality of 77% or more based on their respiratory indices.3

The improved survival in our small series could be due to gentlerventilation (lower MAP, PIP) and early application of ECMO. HigherP/F ratios, Lower OI, MAP & PIP have been associated with survivalin previous series suggesting early ECMO may improve survival.

CLINICAL IMPLICATION: Early application of ECMO may lead toimproved survival in severe respiratory failure secondary to RSV.

REFERENCES:1. J Pediatr 1993; 123 :462. J Pediatr 1990; 116 :3383. Anaesth Intens Care 1990; 18:385

TABLE 1

Duration of illness (range(mean)) 4-15 (8)Ventilator days 2-11 (6.5)Mean airway pressure (MAP) 12-38 (24)Peak inspiratory pressure (PIP) 32-45 (38)pH 7.25-7.44(7.32)PaCO2 32-75(58)PaO2 52-88(66)Oxygenation index (OI) 12-55(33.6)PAO2-PaO2 (A-a gradient) 353-615(457)PaO2/PAO2 0.08-0.16(0.10)PaO2/Fio2 (P/F) 60-100(68.6)


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DISCLOSURE: A. Haque, None.

Pleural Disease: Clinical to Cytokines12:30 PM - 2:00 PM

DIAGNOSTIC VALUE OF SERUM-EFFUSION ALBUMIN GRA-DIENT IN DIFFERENTIATING EXUDATIVE AND TRANSUDA-TIVE PLEURAL EFFUSIONSGurpreet Singh, juniar resident*; Nirmal C. Kajal, MD, FCCP; AmritKaur, MD; Mohinder Singh, PhD; Abhnash S. Bhatia, MD. Departmentof TB & Chest, Medical College, Amritsar, India

PURPOSE: To determine the diagnostic value of serum-effusionalbumin gradient by using Roth ’s criterion.

-To compare it with Light’s traditional criteria according to whichpleural fluid is exudate if it met any of the following criteria:

a. pleural fluid/ serum total protein � 0.5b. pleural fluid LDH � 200 IU / Lc. pleural fluid / serum LDH � 0.6METHODS: The present study was conducted on 50 consecutive

patients suffering from pleural effusion. Total Protein concentration,LDH level and albumin concentration were measured in serum andpleural fluid of all patients. All the cases were subjected to detailed historytaking, general physical examination, chest radiograph and various labo-ratory tests to arrive at a clinical diagnosis.

RESULTS: Out of 50 patients 36 (72%) were of exudative pleuraleffusion and 14 (28%) were of transudative pleural effusion. Tuberculosis(22 cases, 61.11%) was the most common cause of exudative pleuraleffusion in our study followed by paraneumonic (9 cases) and neoplasm (5cases) . The causes of transudative pleural effusion were, congestivecardiac failure (9 cases), nephrotic syndrome (3 cases) and renal failure (2cases). By applying Light’s criteria, 1 case of exudative pleural effusionand 3 cases of transudative pleural effusion were misclassified yielding asensitivity and specificity of 97.22 % and 78.57% respectively. All the

misclassified cases of transudative pleural effusion were on diuretictherapy. Using serum- effusion albumin gradient, one case of exudativepleural effusion was misclassified while all cases of transudative pleuraleffusion were correctly classified yielding a sensitivity and specificity of97.22% and 100% respectively.

CONCLUSIONS: It is concluded from the present study that themajor disadvantage of light’s criteria appears to be the misclassificationtrasudates as exudates, especially in cases of congestive cardiac failure ondiuretic therapy.

CLINICAL IMPLICATION: Misclassification of transudates as exu-dates may lead to unnecessary and costly investigations in patients.Serum-effusion albumin gradient is a reliable and cost effective criterion toodifferentiating exudates and transudates especially in cases of congestivecardiac failure treated with diuretics.

DISCLOSURE: G. Singh, none.

VISCOSITY OF THE PLEURAL FLUID IN PATIENTS WITHPULMONARY INFECTION AND MALIGNANT PULMONARYNEOPLASMOzkan Yetkin, MD*; Ibrahim Tek, MD; Funda Yetkin, MD; NumanNumanoglu, Prof. Ankara University Faculty of Medicine Department ofPulmonary Medicine, Ankara, Turkey

OBJECTIVE: We aimed to evaluate and compare the viscocity of theexudative pleural fluid according to Light criteria, in patients withpulmonary infection and malignant pulmonary neoplasm.

MATERIALS AND METHODS: Patients were divided into twogroups: group I consisted of 15 patients with pulmonary infection( 5tuberculosis pleurisy, 10 pneumoniae) and pleural effusion and group IIconsisted of 18 patients with malignant pulmonary neoplasm and pleuraleffusion. Measurements of pleural fluid viscocity were performed usingBrookfield DW-II viscometer.

RESULTS: Viscocity of the pleural fluid in patients with pulmonaryinfection was significantly higher than in those with malignant pulmonaryneoplasm (1.57�0.85 mPa vs 1.2�0.9mPa respectively p�0.001).

CONCLUSION: We have shown increased viscosity of pleural fluid inpatients with pulmonary infection compared to patients with malignantpulmonary neoplasm. With the support of furhter clinical studies, viscosityof the pleural fluid can be used in differential diagnosis of exudativepleural effusion.

DISCLOSURE: O. Yetkin, None.

CYTOKINES CORRELATED WITH THE ACUTE PHASES IN-FLAMMATORY PROCESS IN TUBERCULOUS PLEURAL EFFU-SIONMarcia Seiscento, MD*; Francisco Vargas, MD, FCCP; Leila Antonan-gelo, MD; Milena Acencio, BS; Vera Capelozzi, MD; Carlos Silva, TS;Lisete Teixeira, MD; Marcia Seiscento, MD. Division of RespiratoryDisease - InCor HCFMUSP, Sao Paulo.SP, Brazil

PURPOSE: To assess serum and pleural fluid expression of TNF-a,IL-8, VEGF and TGF-b1 in pleural effusion of patients with tuberculosis(TB) and transudate. We looked for the tuberculosis group correlatedpleural cytokines levels with biochemical (total proteins, lactic dehydro-genase), adenosine deaminase and histopathological parameters.

METHODS: Prospective descriptive study. We evaluated, a total of 47pleural fluid samples from patients with pleural effusions, which includedTB (n � 39) and transudate (n � 8). Transudate pleural effusion was usedas control. Using the ELISA method, the cytokines levels of the serumand pleural fluid were analyzed. For TB group we performed pleuralbiopsy and by morphometry method was analyzed pleural tissue type(connective tissue, granulation tissue, fibrocellular proliferation, fibrin,polymorphonuclear cells, mononuclear cells and mesothelial cells. Statis-tical analyzes were made by correlation Pearson product moment andANOVA.

RESULTS: The median levels of pleural fluid of TNF-a, IL-8, VEGFand TGF-b1 in TB group were significantly higher than transudate group.In serum only TGF-b1 serum demonstrates levels higher significantly andit could distinguish TB from transudates. In TB pleural fluid, there wasnot demonstrated correlation between the cytokines and the cells, andbiochemical parameters but a significant although not a close correlationwere demonstrated with TNF-� and lactate dehydrogenase (R�0,426).Also in TB , using an ANOVA to analyze the factors the were significantwe observed a significant and positive correlation’s between VEGF,


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TNF-� and fibrin (R�0,628), IL-8 also presented a significant andpositive correlation with fibrin and negative correlation with granuloma(R�0,339) .

CONCLUSIONS: This study brings insight that TNF-a, IL-8 andVEGF can be associated with initial phase inflammatory process in pleuraltuberculosis where were correlated with high levels of lactic dehydroge-nase enzyme and histopathological presence of fibrin.

CLINICAL IMPLICATIONS: These cytokines may have an essentialrole in coordination the acute phases inflammatory process, contribute togranuloma formation and can be associated the increase vascular perme-ability and pleural fluid formation in TB pleural effusion.

DISCLOSURE: M. Seiscento, None.

ACCURACY OF ELISA USING 16 KDA AND 38 KDA ANTIGENSIN THE DIAGNOSIS OF TUBERCULOUS PLEURAL EFFUSION(TBPE)Bernardo D. Briones, MD*; Emma Sheila P. Jorgio, MD. Dept. ofMedicine, Faculty of Medicine and Surgery, University of Santo Tomas,Manila, Philippines

PURPOSE: Establishing the etiology of pleural effusion is a diagnosticdilemma. This study aims to determine accuracy of serology (ELISA)using combined antigens in the diagnosis of TBPE compared with culture,histopathology and response to treatment.

METHOD: Design: Validation study.SETTING: University of Santo Tomas Hospital, a tertiary institution.SUBJECTS: Sera of 160 patients with effusion by x-ray and or

ultrasound and subjects of a broader validation of ELISA seen betweenJanuary, 1995 to December, 2001 were analyzed.

INTERVENTION: All had clinical evaluation, PPD test, thoracente-cis/pleural biopsy, AFB smear, pleural tissue Bactec culture and histopa-thology; sera were kept at –20oC and batches analyzed using 16kDa and38 kDa antigens (Pathozyme TB Complex Plus®, Omega Diagnostics Ltd,UK). Laboratory and pathologist had no prior knowledge of actualdiagnosis. Patients were assessed independently and followed-up by sameattending pulmonologist.

OUTCOME MEASURES: Demographic profiles, laboratory results,disease categorization based on laboratory results and response to TBtreatment; serology sensitivity, specificity, predictive values, likelihoodratios were derived.

RESULTS: At 50% TB prevalence, ELISA has 43.8% sensitivity,93.8% specificity, a 87.5% positive predictive value, 62.5% negativepredictive value, 7 likelihood ratio (�), 0.60 likelihood ratio (-), with68.8% overall accuracy.

CONCLUSION: Given 50% TB prevalence, the test showed highspecificity and positive predictive value with fairly good likelihood ratios.

CLINICAL IMPLICATION: Using a combination of antigen pro-teins, ELISA can be a useful tool in the diagnosis of TBPE.

DISCLOSURE: B.D. Briones, None.

DIAGNOSTIC YIELD OF CLOSED PLEURAL BIOPSY FORPLEURAL MALIGNANCIES IN AN INNER CITY TEACHINGHOSPITAL IN NEW YORKSanjay Dogra, MBBS*; John-Salazaar Schicchi., MD; Sami A. Nachman,MD; Yisa Sunmonu, MD. *Harlem Hospital Center and College ofPhysicians and Surgeons of Columbia University, New York, NY

PURPOSE: Given the high prevalence of tuberculosis (TB) in ourcommunity we are still relying heavily on closed pleural biopsy (CPB)when encountered with an exudative pleural effusion. The diagnostic yieldof CPB as opposed to thoracoscopic pleural biopsy is generally consideredpoor for malignancy and usually is not performed as an initial procedurewhen cancer is suspected. The objective of this study is to evaluate thediagnostic yield of CPB for cancer in our population.

METHODS: Retrospective review of closed pleural biopsies per-formed between May, 1999 and April, 2003 at Harlem Hospital.

RESULTS: Total of 20 pleural biopsies were performed. Males were14 and females 6.African-American were 16, Hispanics 3 and 1 patient waswhite. Smokers were 60 %( 12/20) of patients. HIV infection wasdocumented at the time of the study in only 20 %( 4/20). All effusionswere lymphocytic predominant exudate. The biopsy was diagnostic in 55%(11/20) and the diagnosis of cancer was made in 35 %( 7/20) while in 20%( 4/20) tuberculosis was diagnosed. Fluid cytology was positive in only20% (4/20). No major or minor complication was reported.

CONCLUSION: CPB is a safe procedure with a high diagnostic yieldwhen used in hospital with the spectrum of diseases seen in thiscommunity.

CLINICAL IMPLICATION: CPB is a safe procedure with gooddiagnostic yield. Physicians should have low threshold for utilizing it ininner city hospital serving population similar to our population in order toavoid more invasive procedures even when the suspicion of TB is not high.

DISCLOSURE: S. Dogra, None.

SPIROMETRIC EVALUATION IN PATIENTS WITH TUBERCU-LOUS PLEURAL EFFUSION BEFORE, DURING AND AFTERCHEMOTHERAPYKulwant S. Bhatia, MD*; Sanjeev Kumar Kapoor, junior resident. Govt.Medical College, Amritsar, Punjab, India

PURPOSE: The present study was conducted in patients of tubercu-lous pleural effusion to look for any initial lung function impairment,changes occurring over time after the institution of anti-tubercularchemotherapy and also to note the residual abnormalities if any left at theend of 6 months of treatment

METHODS: Fifty patients (37 male & 13 female) of untreated &uncomplicated cases who met the criteria of tuberculous pleural effusionwere enrolled for the study. Based on X-ray chest, patients were classifiedas mild, moderate and severe pleural effusion. Spirometry was performedin all patients. A minimum of three forced expiratory maneuvers wereperformed and the best value recorded. Maximum aspiration of pleuraleffusion was done and patients were put on anti-TB chemotherapy. Thepatients were subjected to further spirometry at 1st, 2nd & 6th month ofanti-TB chemotherapy. The changes in spirometric values with thoraco-centesis & anti-TB chemotherapy were noted.

RESULTS: Pleural effusion has a ventilatory restrictive and smallairway obstructive pattern on spirometry, as mean pretreatment FVC,FEV1, FEV1% and FEF25-75% were 51.06, 63.14, 107.86, and 50.90respectively. The derangements in spirometry were proportional to theseverity of pleural effusion. All values showed statistically significantimprovement after six months of treatment.

CONCLUSIONS: Pleural effusion causes restrictive ventilatory defectand small airway obstruction. Thoracocentesis and early institution ofanti-TB chemotherapy improves restriction as shown by readings of serialspirometry that were done on 1st, 2nd & 6th month of anti-TB chemother-apy. Even at the end of six months of therapy, small airway obstructivepattern improved, however some residual restrictive abnormalities wereleft which were directly proportional to the severity of pleural effusionprior to the start of treatment.

CLINICAL IMPLICATIONS: Early detection, maximal aspirationand treatment improve the outcome.

DISCLOSURE: K.S. Bhatia, None.

THE ETIOLOGY OF EXUDATIVE PLEURAL EFFUSION ANDITS ASSOCIATION WITH HIV INFECTION AMONG PATIENTSSEEN IN MULAGO HOSPITAL, UGANDAIsabirye C. Charles, Physician*. Hospital, Teaching, Jinja, Uganda

PURPOSE: The main objective of the study was to determine theaetiology of exudative PE and its association with human immune virus (HIV) infection in Mulago Hospital. Other objectives were to determinethe relative prevalence/frequency of the various aetiologies of exudativePE, the HIV sero prevalence among these patients and to describe theclinical, laboratory, radiographic and demographic features of the variouscauses of exudative PE.

METHODOLOGY: The study was done on the general medical wardsin Mulago University teaching and national referral hospital.

A descriptive cross-sectional study was carried out on patients 15-90years inclusive, who were screened for exudative PE using Light’s criteria.Clinical examination, thoracocentesis, and pleural biopsy were done.Pleural fluid (PF) and tissue culture for M.tuberculosis were done usinglowenstein jensen (LJ) media. HIV serology after pre and posttestcounseling was obtained.

RESULTS: Of the 93 patients with exudative PE recruited, tubercu-losis (TB) accounted for 66.7%. The other causes of the effusion werecancer (14%), empyema (3.1%), eosinophilic granuloma (1.1%), andconnective tissue disoder (1.1%). The cause of the effusion remainedunknown in 14% of the patients. Overall HIV prevalence among thepatients recruited was 57%. Most patients with TB were in the age range


Pleural Disease: Clinical to Cytokines,continued


20-39 years (72.6%) while over 50% of the cancer patients were above 50years. Micro bacteriological culture studies on PF was only positive forM.tuberculosis in HIV positive patients. On chest x-ray, most effusions inTB were of moderate size while in cancer of massive size.

CONCLUSION: Empirical treatment for TB in patients with exuda-tive PE is a reasonable option particularly in patients in the age range 20- 40 years with pleural fluid lymphocytosis. Cancer remains a commoncause of exudative PE in patients over 50 years.

CLINICAL IMPLICATION: Exudative PE pause a big problem inareas where there are no proper facilities for its investigation.

DISCLOSURE: I.C. Charles, American Chest Foundation, grantmonies.

EVOLUTION OF HEMORRHAGIC POST-CORONARY ARTERYBYPASS GRAFT PLEURAL EFFUSIONSIoannis T. Kalomenidis, MD*; Yubiao Guo, MD; Michael Hawthorne,MD; Randal Barnette, RRT; Kenneth B. Parkes, student; R MichaelRodriguez, MD, FCCP; Richard W. Light, MD, FCCP. Department ofPulmonary Medicine, St Thomas Hospital, Department of Allergy, Pul-monary and Critical Care Medicine, Vanderbilt University, Nashville, TN

PURPOSE: Coronary artery bypass graft (CABG) is among the mostcommon cause of pleural effusions (PEs) in the western countries. Whenthey first appear, post-CABG PEs are often bloody and contain highnumbers of eosinophils. The aim of the present study was to examine theevolution of the cellular features of post-CABG PEs. We hypothsized thatthe red blood cells (RBCs) and the percentage of the eosinophils (E%)will decrease while the percentage of the lymphocytes (L%) will increase.

METHODS: We retrospectively examined 47 patients with unilateraland 2 patients with bilateral post-CABG PEs (totally 49 PEs) who hadundergone more than one thoracentesis. Two thoracenteses had beenperformed in 41 PEs and 3-8 thoracenteses in 8 PEs.

RESULTS: In the group with 2 serial samples, the RBC increased in 9,remained stable in 1 and fell in 31(p�0.05); the E% increased in 17,remained stable in 2 and fell in 10 (p�0.05); the L% increased in 26remained stable in 2 and fall in 12 (p�0.05). In the group with more than2 serial samples, a fluctuation for all the examined features was observed.When we compared the features form the first and the last sample, theRBC increased in 1 and fell in 7; the E% increased in 3 and fell in 4; theL% increased in 7 remained stable in 3 and fell in 4.

CONCLUSION: In symptomatic post-CABG PEs the RBCs tend tofall while the E% and L% tend to rise but there is much inter-individualvariation.

CLINICAL IMPLICATIONS: In patients with recurring post-CABGPE, pleural fluid values should not be obtained, unless there is a clinicalsuspicion of other processes.

DISCLOSURE: I.T. Kalomenidis, None.

BLAKE TUBES FOR THE DRAINAGE OF THE PLEURALSPACE: A PROSPECTIVE RANDOMIZED CONTROLLEDSTUDYNoel J. Rebolledo, MD*; Freddy Morillo, MD; Aldo J. Stamile, MD; JoseM. Lopez, MD; Angel R. Caraballo, MD; Jose N. Di Sarli, MD. HospitalUniversitario de Caracas, Caracas, Venezuela

PURPOSE: Evaluation of efficacy, tolerance and complications of theBlake tubes introduced in the pleural space through a small cutaneousincision in cases of hemothorax and pneumothorax compared withconventional chest tubes.

METHODS: A prospective randomized controlled study was car-ried out in a year term. Twenty patients admitted to the ThoracicSurgical Section of the Hospital Universitario de Caracas fulfilled theinclusion criteria. Those patients were randomly assigned in twogroups equally distributed (10 with Blake tubes and 10 with conven-tional chest tube). Each group had 5 patients with hemothorax and 5with pneumothorax. The tubes were inserted following the opentechnique. Pulmonary re-expansion, magnitude of hemothorax, effec-tive drainage, in-hospital stay, pain tube related, use of analgesics andcomplications of the procedure were taken in consideration forstatistical analysis.

RESULTS: Both groups had a therapeutic success of 100 %.Effective drainage and in-hospital stay had no statistical differenceamong the groups. However there was less pain and less use ofanalgesics in the group of patients with pneumothorax drained with the

Blake tube (p� 0.05 and 0.03 respectively). No difference among thepatients with hemothorax was observed, probably related to theetiology of the problem. There were two complications with Blaketubes (obstruction, resolved with a syringe) and one with the conven-tional drainage (atelectasis)

CONCLUSIONS: Blake tubes showed a satisfactory function, similar tothe conventional chest tubes, with similar rate of complications. However,better tolerated in the cases of pneumothorax. It is necessary to increase thesize of the sample including other pathologies, in order to establish the realusefulness of the Blake tubes for drainage of the pleural space.

CLINICAL IMPLICATIONS: The use of Blake tubes for the pleuralspace seems to be an alternative for the drainage of the pleural space, withprobable better tolerance. However, further studies are needed in orderto stablish its real utility.

DISCLOSURE: N.J. Rebolledo, None.

SAFETY AND EFFICACY OF INTRAPLEURAL INSTILLATIONOF ALTEPLASE FOR THE MANAGEMENT OF CLOTTED HE-MOTHORAXFawad Tufail, MBBS*; Shabir Bhimji, MD; Khavar J. Dar, MBBS, FACP,FCCP. Texas Tech University Health Sciences Center, Odessa, TX

PURPOSE: Intrapleural instillation of Streptokinase and Urokinase hasbeen utilized in the management of loculated pleural effusions associatedwith pleural sepsis and pleural clots. Both of these agents are less readilyavailable for use due to the increasing use of Alteplase for fibrinolysis. Westudied the use of Alteplase in the management of three cases of clottedhemothorax to assess both efficacy and safety of this agent.

METHODS: Three consecutive patients with clotted hemothorax weresubjected to intrapleural instillation of Alteplase. All three patients hadsmall bore pleural catheters placed under CT scan guidance. After initialdrainage of pleural fluid had declined to less than 50 cc/ 24 hours,Alteplase 4mg diluted in 100 cc of normal saline was instilled into thepleural space. Further instillation of Alteplase 4mg was performed afterradiographic confirmation of incomplete resolution.

RESULTS: All three patients who underwent intrapleural instillationof Alteplase were female with a mean age of 64.33 years. The hemothoraxoccurred following minimally invasive direct coronary artery bypasssurgery (MIDCAB) in two patients, and was due to blunt chest trauma inthe other. An average of 3.33 instillations were required per patient.Complete resolution, which was defined as resolution of symptoms andcomplete drainage of fluid and no residual pleural space radiographically,occurred in 2 of the 3 patients. The third patient had a partial responsedefined as resolution of symptoms and a small residual pleural space. Nocomplication occurred in any of the three patients. The mean duration ofthe hemothorax was 9 days (range 7-11 days).

CONCLUSION: The intrapleural instillation of Alteplase in our smallgroup of patients was found to be both effective and safe. We recommendthat Alteplase be considered as an alternative to Streptokinase for thetreatment of clotted hemothorax.

CLINICAL IMPLICATIONS: The declining availability of Streptoki-nase requires an alternative intrapleural fibrinolytic agent. Alteplaseshould be safe and effective for this purpose although a larger study isneeded to confirm these conclusions.

DISCLOSURE: F. Tufail, None.

OUTCOME OF PLEURODESIS FOR MALIGNANT PLEURALEFFUSIONS UTILIZING SMALL-BORE CHEST TUBESKrista Kemp, MD*; Debbie Sciberras, RN; Sat Sharma, MBBS, FRCPC,FCCP. University of Manitoba, Winnipeg, MB, Canada

PURPOSE: Instillation of talc slurry to produce pleurodesis is thestandard treatment of symptomatic malignant pleural effusions. However,pleurodesis is associated with numerous complications and has variablesuccess rates. At our institution the pleurodesis is performed via smallbore chest tubes. The objective of this study was to review our localexperience with pleurodesis, in order to determine patient outcomes andto identify areas for improvement.

METHODS: We performed a two-year (2001 & 2002) retrospectivechart review at a tertiary care centre. All patients in whom a chestmedicine consultation was obtained for the purpose of pleurodesis ofa malignant pleural effusion, were included. Patients who requiredthoracoscopy or sclerosant other than talc slurry were excluded. Theoutcome was defined as success (complete or partial resolution of the




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pleural effusion) or failure (non-resolution of the pleural effusion). Anattempt was also made to identify predictors of success or failure of thisprocedure.

RESULTS: Twenty-eight patients with thirty-one malignant pleuraleffusions were identified. In twelve effusions (39%) the procedure couldnot be performed because of blockage of the chest tube. In nineteeneffusions where talc slurry was instilled, eleven (58%) had a successfuloutcome. Blockage of the chest tube appeared to be the most commonpredictor of a poor outcome for all patients referred for pleurodesis.

CONCLUSIONS: The success rate at our institution is lower than thatreported in the literature (62 – 85%). A successful outcome has beenassociated with factors including patient selection (lower tumor burden,pleural fluid pH � 7.15), chest tube size, sclerosant used and duration tosclerosis. Based on this review, we have introduced changes to thepleurodesis procedure at our institution, and have initiated a prospectivestudy to evaluate impact of these changes in practice, for this commonlyperformed procedure.

CLINICAL IMPLICATIONS: Pleurodesis for malignant pleural ef-fusions is feasible with a small-bore chest tube. However the successdepends on appropriate patient selection and meticulous follow up of anestablished protocol.

DISCLOSURE: K. Kemp, None.

EXTRACELLULAR MATRIX REMODELING IN PLEURODESISINDUCED BY SILVER NITRATE (SN) OR TALC (TL), COLLA-GEN AND ELASTIN: 1-YEAR EVALUATIONLeila Antonangelo, MD*; Milena Acencio, BS; Lisete Teixeira, MD; VeraL. Capelozzi, MD; Evaldo Marchi, MD; Francisco Vargas, MD, FCCP.Division of Respiratory Disease, Heart Institute (Incor), Sao Paulo, Brazil

PURPOSE: Chemical pleurodesis is frequently employed to obliteratethe pleural space most commonly for the treatment of neoplasia. Talc(TL) and Silver Nitrate (SN) induce pleurodesis by directly injuring thepleura. The injury results in intense inflammation with secondary collagenand elastic deposition.The aim of this study was to evaluate comparativelythe extracellular matrix collagen and elastin profiles in the experimentalpleurodesis induced by talc or silver nitrate.

METHODS: 420 rabbits divided in 2 groups received in a volume of2mL, TL 400mg/kg or 0.5% SN. Ten animals of each group weresacrificed in the following times: 15 and 30 minutes; 1, 2, 4, 6 and 12hours/ 1, 2, 3, 5, 7, 15 and 21 days and 1, 2, 4, 6, 8, 10 and 12 months. Forthe collagen evaluation pleural samples were stained by the picrosirius-polarization method. Elastic component was evaluated by histochemicalstaining for elastin. The quantitation of these parameters was done in animage analyzer system. The measurements were expressed in mm2corrected for 1000mm2 of analyzed pleura. The student t test (forparametric data) and Man-Whitney rank sun test (for non-parametricdata) were used to compare the values between groups. A p value of�0.05 was considered significant.

RESULTS: We observed an increased total collagen deposition withtime for both groups more pronounced for the SN group. (Graph 1).Elastin became more pronounced after day 21 for both groups with a peakaround 1-2 months. On the 10 month, talc group have demonstrated ahigher elastin expression than SN group (Graph 2).

CONCLUSION AND CLINICAL IMPLICATIONS: Total collagendeposition increased with time for both groups, with a tendency for highervalues in SN group when compared to talc group (significant for 2 daysand 10 months). Elastin presented a peak of deposition around 1-2

months in both groups with the higher values occurring in talc group. Insome slides of talc group persistent pleural granuloma were observed.

DISCLOSURE: L. Antonangelo, None.

THE EFFECT OF ANTI-VASCULAR ENDOTHELIAL GROWTHFACTOR ANTIBODY ON PLEURODESIS INDUCED BY TRANS-FORMING GROWTH FACTOR BETA IN RABBITSYubiao Guo, MD*; Ioannis Kalomenidis, MD**, Michael Hawthorn**,MD; Kirk B. Lane**, PhD, Richard W. Light**, MD. Saint ThomasHospital, Nashville, TN

PURPOSE: The intrapleural injection of transforming growth fac-tor-beta2 (TGF-2) produces excellent pleurodesis in rabbits. How-ever, a large transient pleural effusion, induced by the TGF-2 andpossibly mediated by the vascular endothelial growth factor (VEGF) isobserved the first 48 hours after the injection and may intervene withthe pleurodesis. The aim of this study was to investigate whetherVEGF inhibitor has any effect on the fluid production or the thepleurodesis induced by TGF- in rabbits.

METHODS: Three groups of 7 New Zealand White rabbits were givenTGF- 2 5.0 micrograms intrapleurally after chest tube placement. Onegroup received 25 mg/kg anti-VEGF antibody IV, one group received 10mg/kg anti-VEGF antibody IV and the third group served as the control.Pleural fluid was collected at 24 h, 48h and 72h after TGF-2 injection.White blood cells (WBC) count, protein and LDH in the pleural fluidswere measured and pleurodesis scores were evaluated after sacrificing therabbits at 2 weeks.

RESULTS: There were no significant difference between the controlgroup and two treatment groups for pleural fluid volume, WBC, protein,or LDH level. However, the treatment groups had significantly lowerpleurodesis scores. The pleurodesis scores of control group was 7.71 �0.76 (mean � SD), for low dose treatment group was 4.43 � 2.37 and forhigh dose treatment group was 4.57�2.36.

CONCLUSIONS: Anti-VEGF antibody partially blocks the pleurode-sis induced by the TGFbeta2 in rabbits suggesting that VEGF plays apivotal role in the production of a pleurodesis.

CLINICAL IMPLICATIONS: Pleurodesis may not be effective inpleural effusion patients treated with novel anti-angiogenic regimens thatblock VEGF.

DISCLOSURE: Y. Guo, None.

INTRAPLEURAL INJECTION OF IL-10 IN PLEURODESIS IN-DUCED BY TALC OR DOXYCYCLINELisete R. Teixeira, MD*; Milena Acencio, BS; Evaldo Marchi, MD; LeilaAntonangelo, MD; Marcelo Vaz, MD; Francisco Vargas, MD, FCCP.Division of Respiratory Diseases - Heart Institute - University of SaoPaulo Medical School, Sao Paulo, Brazil

BACKGROUND: Inflammation is the earlier event in the multistepmechanism of pleurodesis. Several mediators may regulate the outcome ofpleural inflammation, including natural endogenous mediators.

OBJECTIVE: To evaluate the influence of IL-10, an anti-inflamma-tory cytokine, in the pleurodesis induced by talc (TS) or doxycycline (DX).

METHODS: Four groups of 10 rabbits received TS (400 mg/kg) or DX(10 mg/kg) via a chest tube, with or without a previous intrapleuralinjection of IL-10 (200 ng/kg). After 24 hours the pleural fluid was assayedfor IL-8, VEGF and lactic dehydrogenase (LD). After 28 days the animalswere sacrificed and pleural adhesions were evaluated by a score from 0 to4. Statistical analysis: t-test.

RESULTS:

Groups Adhesions IL-8 VEGF LD

TS 2.2 � 0.7 594.8� 123.5 562.2 �139.3 932.6 � 229.9TS�IL10 1.1 � 0.2* 1095.3 � 343.6# 420.0 � 106.3 1203.6 � 366.3DX 3.0 � 0.7 240.8 � 128.2 331.5 �185.1 5165.8�2944.2DX�IL10 2.7 � 0.7 341.9 � 33.1 305.7 � 127.6 1240.3 � 465.6

Pleural adhesions were significantly (p � 0.05) reduced in the animals thatreceived talc and IL-10 when compared with the animals that received onlytalc. However no difference was observed in the doxycycline group. Thelevels of IL-8 they were significantly higher in the animals that received talc




plus IL10 compared to those that received only talc. No significant differencewas observed in the VEGF or LD levels in all groups.

CONCLUSION: IL-10 inhibited the pleurodesis induced by talc butnot by doxycycline. IL-10 was not capable to reduce the levels of VEGFor IL-8. New studies should be made in attempt to clarify the inflamma-tion and fibrosis mechanisms that are involved in pleurodesis.

CLINICAL IMPLICATION: IL-10 an endogenous anti-inflamma-tory mediator may influence the outcome of talc pleurodesis

DISCLOSURE: L.R. Teixeira, None.

Pulmonary Hypertension12:30 PM - 2:00 PM

PUBLIC AWARENESS OF PULMONARY HYPERTENSIONMichael L. Scharf, MD*; David M. Murphy, MD. Tertiary Care Center,Deborah Heart & Lung Center, Browns Mills, NJ

PURPOSE: To learn how familiar and knowledgable women in a targetedsegment of the population are about primary pulmonary hypertension (PPH)and secondary forms of pulmonary hypertension (PH). To understand if anyrelationships exist between women’s demographic, health or attitudinalprofiles and their overall knowledgeability about PPH and PH.

METHODS: We surveyed 201 women between the ages of 30 and 55in urban, suburban and rural New Jersey by telephone using random digitdialing concerning their awareness about PH. We also asked questions toascertain how women might access the healthcare system to learn aboutPH. Women were considered to be familiar with PH if they had everheard of PH. Women were considered to have basic knowledge about PHif they indicated that PH was a disease of high blood pressure in the lungs.Women were considered to be at greater risk for PH if they admitted toone of the following: family member with PH, history of appetitesuppressant use, chronic liver disease, scleroderma or personal diagnosisof PH.

RESULTS:

FAMILIARITY VS. BASIC KNOWLEDGE ABOUT PH

ALLWOMEN

WOMEN“AT RISK”FOR PH

FAMILIAR WITH PH 145/201(72%)

33/38(87%)

HAVE BASIC KNOWLEDGEABOUT PH

47/201(23%)

7/38(18%)

WOMEN’S ACCESS TO THE HEALTHCARE SYSTEM

ALLWOMEN

WOMEN“AT RISK”FOR PH

GYNECOLOGIST VISIT ANNUALLY 118/184(64%)

21/36(58%)

GP/FP/INTERNIST VISIT ANNUALLY 91/184(49%)

23/36(64%)

INTERNET AS SOURCE OF MEDICALINFORMATION ABOUT PH

151/188(80%)

26/35(74%)

CONCLUSIONS: Our study demonstrated that although the majority ofwomen surveyed were familiar with PH, most did not have even basicknowledge about the disease. Specifically, less than 1/4 of those women at riskfor PH had basic knowledge about PH. Those at risk for PH were equallylikely to visit a gynecologist or a medical doctor for healthcare annually.Approximately 3/4 of all women surveyed and specifically, 3/4 of those at riskfor PH would utilize the Internet to access information about PH.

CLINICAL IMPLICATIONS: This study indicates the need forimproved education about PH, particularly of those at risk for PH.

Awareness among physicians about PH should be directed toward thosespecializing in medicine and gynecology. Education of the public may bedirected via the Internet.

DISCLOSURE: M.L. Scharf, The Florence and Edgar Leslie Chari-table Trust, grant monies.

MORTALITY IN PATIENTS WITH PULMONARY HYPERTEN-SION UNDERGOING INTUBATION IN AN ICU SETTINGRajive Tandon, MD*; Ruairi J. Fahy, MD. Medical Center, Ohio StateUniversity, Columbus, OH

PURPOSE: Patients with severe pulmonary hypertension have a poorprognosis. Those admitted to the ICU may have a higher mortality. Cardio-pulmonary resuscitation is rarely effective in these patients. (HOEPER et al.,AJRCCM VOL 165, 2002) Sedation may pose a significant risk for patientswith severe pulmonary hypertension due to loss of sympathetic drive andpreload. Our purpose was to address the outcome of patients admitted to theICU with pulmonary hypertension not secondary to left ventricular failurewho underwent endotracheal intubation.

METHODS: Retrospective chart review (5 years) at The Ohio StateUniversity Medical Center of patients admitted to the ICU with pulmo-nary hypertension.

RESULTS: One hundred and twenty four patients with pulmonaryhypertension who died were identified. Nine of these patients had normalleft ventriclar function. Three of these patients died immediately follow-ing sedation with midazolam and endotracheal intubation for impendingrespiratory arrest.

Demographics of Patients Who Died Following EndotrachealIntubation

Age/Race Sex Systolic PulmonaryArtery Pressure

Cause of PulmonaryHypertensiom

44/Caucasian Male 100 mmHg.(Echocardiogram)

CREST

51/Caucasian Female 73 mmHg(SwanGanz)

Rheumatoid Arthritiswith InterstitialLung Disease

46/Caucasian Male 89 mmHg(Echocardiogram)

Hepatitis C

CONCLUSIONS: Attempt at sedation and endotracheal intubation inpatients with pulmonary hypertension may carry a high mortality. ICUadmission may also be a poor prognostic indicator in this category of patientswith pulmonary hypertension and normal left ventricular function.

CLINICAL IMPLICATIONS: Efforts to reduce this mortality mayinclude use of drugs with less effects on circulation and preload reduction(such as etomidate). Nasotracheal intubation while the patient is awakemay also prove to be an alternative measure in patients with pulmonaryhypertension who have respiratory failure.

DISCLOSURE: R. Tandon, None.

THE PREVALENCE AND SIGNIFICANCE OF EXERTIONALHYPOXEMIA IN PRIMARY PULMONARY HYPERTENSION(PPH)Saleh A. Ismail, MD*; Omar A. Minai, MD; Kay D. Stelmach, RNRRT;Alejandro C. Arroliga, MD, FCCP. Department of Pulmonary andCritical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH

PURPOSE: Patients with PPH are susceptible to mild hypoxemiathat is aggravated by exercise because of superimposed hypoxicpulmonary vasoconstriction. It has been suggested that significanthypoxemia is less common in PPH since these patients tend not to havesignificant ventilation-perfusion abnormalities. We looked at the prev-alence and predisposing variables in PPH patients with significanthypoxemia.

METHODS: Charts of PPH patients followed in the pulmonaryhypertension clinic at our institution were reviewed for demographics,exercise capacity, exercise induced hypoxemia, hemodynamic variables,and pulmonary function test results.

RESULTS: Thirty-two patients (age 46.4�10.7; 23F/9M; NYHA III/IV) with PPH (6 with familial PPH) followed in our clinic for 23.5�22.4months were included.




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O2requiring(N�16)

Non-O2requiring(N� 16)

Pvalue

Age (years) 48.6�10.9 44.1�10.2 0.2Sex 11F/5M 12F/4M 0.7Etiology: -Familial

-Sporadic4 (12.5%)12 (37.5%)

2 (6.25%)14 (43.75%)

0.4

Hypothyroidism 5 (15.62%) 0 (0%) 0.02*ANA positive 2 (6.25%) 6 (18.75%). 0.1Intra-cardiac shunt** 5 (15.62%) 1 (3.72%) 0.1PFT abnormalities 8 (25%) 7 (21.9%) 0.7MVO2-pre-therapy% Sat-on therapy

64.0�11.264.0�6.3

58.2�6.660.1�9.3

0.40.3

DLCO 53.5�22.1 70.4�15.4 0.02*Improvement in exercise

capacity with therapy4% 13.9 % 0.6

*statistically significant, ** all secondary to PFO (MVO2: mixed venousoxygen saturation).

There was no significant difference in NYHA functional class, RVSP by 2D echocardiography, mean PAP, CO, or CI between those requiring O2 andthose not requiring O2. Among O2 requiring patients, those having intra-cardiac shunts were found to have a DLCO of 51.6 � 12.4 as compared to54.36 � 25.9 for those not having intracardiac shunts. (p�0.7)

CONCLUSION: A significant proportion of PPH patients may haveexertional hypoxemia requiring oxygen supplementation. Clinicallysignificant hypoxemia may develop in the absence of right to leftshunting. A lower DLCO in the hypoxemic group without right to leftshunting may indicate significant ventilation-perfusion abnormalities.Patients with familial PPH, and those with hypothyroidism were morelikely to have significant exercise-induced hypoxemia requiring O2therapy.

CLINICAL IMPLICATIONS: All patients with PPH should beassessed for exercise-induced hypoxemia.

DISCLOSURE: S.A. Ismail, None.

SMALL AIRWAY DISEASE, AIR TRAPPING AND AIRWAYS RE-SPONSIVENESS IN PATIENTS WITH PRIMARY PULMONARYHYPERTENSIONAndreas Kyprianou, MD*; Darrin London, NP; Maria Padilla, MD; N.Kohn, MS; Al Quinones, RT; Steven Feinsilver, MD; Alan Fein, MD; XArunabh, MD. North Shore University Hospital, Manhasset, NY

PURPOSE: Pulmonary function test (PFT) abnormalities of primarypulmonary hypertension (PPH) include mild restrictive defects, reducedcarbon monoxide diffusing capacity, and recently reported, small airwaydisease (SAD). We studied the relationship between small airways disease, airways responsiveness and its association with PHTN.

METHODS: Records of all patients with PHTN [primary and thosewith collagen vascular disorders ] were reviewed. Air trapping was definedas RV/TLC � 30%, and SAD was diagnosed when forced expiratory flowbetween 25% to 75% of the vital capacity [FEF 25-75%] was � 65%predicted value. Airways responsiveness was defined as an increase inFEV1� 15% or FEF 25 –75% � 25% post inhaled Albuterol. Associationbetween sex and FEF 25-75% (�65 or �65% of predicted) and RV/TLC(�30%or �30%) was examined using the chi-square test. Compari-son of age and DLCO% by FEF 25 –75% group (�65 %or �65% ) andRV/TLC(�30%, or �30%) was made using the Mann-Whitney test.

RESULTS: 60 patients were retrospectively studied [Females (n�44),Males (n�16)]. RV/TLC was reported in 53/60 [� 30 in 8 vs, � 30 in 45],but there was no statistical difference between age , sex and DLCO inthese groups.

The FEF 25-75% was available for 60 patients . SAD was observedin 33 [55%] . Airways responsiveness occurred in 12/33 patients. Thepatients with FEF 25-75% � 65% predicted were older [ 59.5 vs. 49.4years ; p �0.02] and had lower DLCO [43.5% vs. 55.7% ;P� 0.01].

CONCLUSION: SAD is common in patients with PPH and correlateswith impairment in DLCO. A significant proportion of these patients hadbronchial hyperreactivity. High RV/TLC, an indicator of prematureairway closure, may be present in some of these patients .

CLINICAL IMPLICATIONS: Clinician’s awareness of potentialpresence of bronchial reactivity and institution of appropriate therapy mayimpact on a patients well being. Measurement of expiratory flow ratesalong with bronchodilator testing is recommended when evaluatingpatients with PHTN.

DISCLOSURE: A. Kyprianou, None.

RIGHT VENTRICLE REMODELING ASSESSED BY NUCLEARMAGNETIC RESONANCE IN CHRONIC THROMBOEMBOLICPULMONARY HYPERTENSION PATIENTS TREATED BY PUL-MONARY THROMBOENDARTERECTOMYAndrea M. D’Armini, Associate Professor of Cardiac Surgery*; GiuliaMeloni, Attending Physician in Radiology; Cristian Monterosso, AttendingPhysician in Cardiac Surgery; Massimo Boffini, Attending Physician inCardiac Surgery; Barbara Cattadori, Attending Physician in CardiacSurgery; Giorgio Zanotti, Resident in Cardiac Surgery; Mario Vigano’,Full Professor of Cardiac Surgery. University Hospital, IRCCS SanMatteo Hospital - University of Pavia, Pavia, Italy

PURPOSE: Nuclear magnetic resonance (NMR) allows more accurateright ventricle (RV) morphological and functional studies than two-dimensional echocardiography due to the complex geometry of this heartchamber. Patients (pts) affected by chronic thromboembolic pulmonaryhypertension (CTEPH) and treated with pulmonary thromboendarterec-tomy (PTE) experience dramatic changes in pulmonary hemodynamicsbefore and after PTE. The purpose of this study is to assess RVremodeling with NMR in PTE pts and also to validate NMR data with RVhemodynamics.

METHODS: Of 88 pts who underwent PTE between April 1994 andApril 2003, 27 were enrolled in this study since December 2000 (8 ptswere excluded for various reasons). All pts had concomitant RV hemody-namics. The table shows the NMR and hemodynamic data before PTE.

RESULTS: Operative mortality for study patients is 8.6% (3/35).Kaplan-Maier survival at 3 months and 1 year is 88.6% and 84.4%respectively. Complete follow-up – before discharge from the hospital(first control) and at 3 months from PTE – are available for 19 pts. BothNMR and hemodynamic data show statistically significant changes (table).All changes are maintained in the 11 pts who have undergone follow-up 1year after PTE.

CONCLUSIONS: NMR is a good tool to assess RV remodeling; NMRis consistent with hemodynamics.

CLINICAL IMPLICATIONS: After PTE the decrease in pulmonaryartery pressure is associated with complete recovery of the morphologyand function of the RV.

NMR and RV hemodynamics data

BeforePTE

Firstcontrol

Threemonths P � 0.05

Right ventricle end-diastolic diameter(mm)

42 32 31 yes

Right ventricle end-diastolic volume (ml)

110 71 66 yes

Right ventricle end-systolic volume (ml)

74 50 41 yes

Tricuspid insufficiency(absent/mild/moderate/severe)

0/5/8/6 4/9/6/0 4/14/1/0 yes

Abnormal septalmotion (yes/no)

14/5 2/17 0/19 yes

Mean pulmonary arterypressure (mmHg)

47 23 23 yes

Cardiac output (L/min) 3.0 4.7 4.7 yesPulmonary vascular

resistances(dynes*sec*cm-5)

1180 338 341 yes

DISCLOSURE: A.M. D’Armini, None.


Pulmonary Hypertension, continued


QT DISPERSION IN PATIENTS WITH PULMONARY HYPER-TENSION UNRELATED TO LEFT-SIDED HEART DISEASEAdam Frank, DO; Jason M. Lazar, MD*; Luther T. Clark, MD. Univer-sity, State University of New York Downstate Medical Center, Brooklyn,NY

PURPOSE: QT dispersion (QTD) reflects heterogeneity of myocardialrepolarization and has been proposed to be a predictor of adverseoutcomes in a variety of cardiac disease states. The objective of this studywas to characterize QTD in right-sided pressure overload.

METHODS: We identified 30 consecutive patients referred for rou-tine transthoracic echocardiography found to have pulmonary hyperten-sion (PH), defined as systolic pulmonary artery pressure�30mmHg and30 age and gender matched controls without PH. QTD was calculatedfrom 12 lead electrocardiogram as the difference between maximum andminimum QT intervals in at least 11 of 12 leads. Right and left ventriculardimensions, wall thickness, and function were assessed by echocardiogra-phy.

RESULTS: QTD was significantly higher in patients with PH ascompared to controls (70�/-12ms vs 45�/-12ms, p�.03). QTD wasunrelated to RV size, wall thickness, and function. There was a directcorrelation between increasing QTD and LV mass (r�.37, p�.04). Onmultivariate analysis, LV mass remained the only independent correlate ofQTD (r2�.15, p�.04).

CONCLUSIONS: QTD is related to LV mass but not to RV dimen-sions and function or to the degree of PH.

CLINICAL IMPLICATIONS: The prognostic significance of QTD inPH merits further study.


PARTITIONING OF EXHALED NITRIC OXIDE IN PRIMARYPULMONARY HYPERTENSIONReda E. Girgis, MBBS, FCCP*; J T. Sylvester, MD; Stacey Murray, RRT;Solbert Permutt, MD. Johns Hopkins University, Baltimore, MD

PURPOSE: Previous studies of exhaled nitric oxide (NO) in patientswith primary pulmonary hypertension (PPH) have used varying method-ologies and produced conflicting results. We compared exhaled NO usinga novel technique that derives three components, in patients with PPHcompared with controls. We also repeated these measurements after 3months of therapy with the endothelin-receptor antagonist, bosentan.

METHODS: Eleven PPH patients (on no therapy) and 11 controlswith similar demographic characteristics were studied. Exhaled NOmeasurements were obtained with a chemiluminescent analyzer (Seivers280) using the standardized procedure recommended by the ATS.Fractional concentration of NO (FENO) was obtained at expiratory flowrates of 18, 50, 100 and 250 ml/sec. Using these FENO values, airway wallconcentration (Cw), diffusion capacity from airway wall into lumen (Dno)and alveolar concentration (Calv) were calculated using a non-linearregression technique devised by Silkoff et al (Am J Resp Crit Care Med2000;161:1218). Eight PPH patients had repeat measurements made after3 months of therapy with bosentan.

RESULTS: PPH patients had a significantly reduced Cw comparedwith controls (39 �/- 8 ppb vs. 295 �/- 139; P� 0.02), while Dno wasconsiderably higher (26.5 �/- 8 nl/s/ppb x 10-3 vs 10.8 �/- 3; P�0.03). Nodifference in Calv was noted between the two groups. After 3 months ofbosentan, FENO values at 18 and 50 ml/sec increased significantly in thePPH group (P�0.02). The calculated Cw tended to increase (P�0.08)while no significant changes were observed in Dno or Calv.

CONCLUSIONS: Airway concentrations of NO are significantly re-duced in PPH compared with normal subjects, while diffusing capacity ofNO from airway wall into lumen is increased. The reduced Cw tends toincrease back towards normal with bosentan therapy.

CLINICAL IMPLICATIONS: Reduced airway wall NO concentra-tion may be a useful biomarker of PPH and could play a role in thepathogenesis of this disease. Increased Dno may reflect an attempt toincrease the NO releasing surface area of the airways.

DISCLOSURE: R.E. Girgis, Sievers Instruments (NO anaylzer),discussion of product research or unlabeled uses of product; ActelionPharmaceuticals, Industry.

BOSENTAN IN PULMONARY ARTERY HYPERTENSION SEC-ONDARY TO SYSTEMIC SCLEROSISA. Joglekar, MD*; F. B. Fausan, BS; D. A. McCloskey, RN; J. E. Wilson,RN; J. R. Seibold, MD; D. J. Riley, MD. UMDNJ-Robert Wood JohnsonMedical School, New Brunswick, NJ

INTRODUCTION: Systemic sclerosis (SSc) was underrepresented(52 patients) in preapproval trials for bosentan in pulmonary arteryhypertension (PAH). PURPOSE: Increase the experience of bosentan inPAH secondary to SSc (SSc-PAH) including those with concomitantinterstitial lung disease (ILD).

METHODS: Retrospective review of 48 SSc patients with PAH (� 35mm Hg pulmonary artery systolic pressure [PASP] by echocardiogram),WHO classes II-IV, and data available for � 9 months. Bosentan dose was62.5 mg bid 4 wk than 125 mg bid thereafter. Outcomes were WHO class,PASP and PFTs at baseline, 3, 6 and 9 months.

RESULTS: WHO class (� SD): baseline, 3.0 � 0.6 (n � 41); 3 months2.3 � 0.7* (n�37); 6 months 2.3 � 0.8* (n�37); 9 months 2.1 � 0.8*(n�32) (* P�0.001 vs. baseline by Mann-Whitney U test), indicating asignificant improvement in clinical status at 3 months that was sustainedduring therapy. Reduction in WHO class � one rank occurred at 3months in 20/41 (49%), none worsened; at 6 months, 18/37 (49%)improved, 3% worsened; at 9 months, 19/32 (59%) improved, 3%worsened. Mean PSAP at baseline (n�38) was 46 � 13 mm Hg (� SD),and there was no significant change during therapy. Mean PFTs atbaseline (all % predicted � SD) were TLC 72 � 16 (n�48), FVC 69 �14 (n�43), and DLco 39 � 13 (n�48), and none changed significantlyduring therapy. Abnormal transaminases occurred 8 times in 4 patients(10%), necessitating discontinuation of drug in two. No deaths wereascribed to bosentan therapy.

CONCLUSIONS: Bosentan is beneficial in SSc-PAH including pa-tients with ILD. Pulmonary hemodynamics (PASP, DLco) remain stableduring treatment.

CLINICAL IMPLICATIONS: The lack of change in PFTs and PASPdoes not support an antiproliferative or antifibrotic benefit of endothelinreceptor antagonism during 9 months treatment of SSc-PAH.

DISCLOSURE: A. Joglekar, None.

IMPROVEMENT IN 6 MINUTE WALK DISTANCE DURINGLONG-TERM INTRAVENOUS EPOPROSTENOL (PROSTACY-CLIN) THERAPY IN PATIENTS WITH PORTOPULMONARYHYPERTENSIONMarie M. Budev, DO, MPH*; Omar A. Minai, MD FCCP; MohammedAlam, MD; Kay D. Stelmach, RN RRT; Kevin McCarthy, RCPT;Alejandro C. Arroliga, MD FCCP. The Cleveland Clinic Foundation,Cleveland, OH

PURPOSE: Epoprostenol has been reported to improve hemodynam-ics and functional capacity in primary pulmonary hypertension. The effectof long-term epoprostenol on exercise capacity in portopulmonary hyper-tension (PoPHTN) has not been previously reported.

METHODS: Charts of PoPHTN patients who were placed on therapywith epoprostenol were reviewed for demographics, epoprostenol dose, 6minute walk distance at baseline, 1st follow up visit, and 3rd follow up visit,duration of epoprostenol therapy, and survival.

RESULTS: A total of 12 patients [age(yrs�SD) 51.4 � 6.3, 6 males]with a history of PoPHTN and long-term epoprostenol therapy wereidentified. The median duration of therapy with epoprostenol was 97.5weeks (interquartile range, 26 to 236 weeks). The dose of epoprostenolranged from 6 ng/kg/min to 46 ng/kg/min during various followup periods.Eight out of 12 patients died (67%) over the follow-up period and themost common cause of death was hepatic failure (63%). In the 8 patientswho died, the average duration of epoprostenol therapy to the time ofdeath was 128� 71.79 weeks [duration(months�SD)]. The average 6minute walk distance for all patients increased from a baseline of1079.6�395.4 (ft�SD) to 1245.5�300.02 [(ft�SD) p�NS] at the firstfollow up visit and 1247.9 � 375.19 [(ft�SD) p�NS] at the third followup visit.

CONCLUSIONS: Long-term infusion of eposprostenol may improveexercise capacity in PoPHTN as demonstrated by improved 6 minute walkdistances. Patients with PoPHTN may be safely and effectively main-tained on long-term epoprostenol therapy.




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CLINICAL IMPLICATIONS: Continuous infusion of epoprostenolmay be useful to increasing exercise capacity in PoPHTN and possiblysevering as a bridge to transplantation.


Sepsis12:30 PM - 2:00 PM

ANION GAP ESTIMATION FOR SCREENING OF HYPERLAC-TATEMIA AND LACTIC ACIDOSISAmit Banga, MD*; J N. Pande, MD; S K. Sharma, MD; R Guleria, DM;G C. Khilnani, MD. Medical school, All India Institute of MedicalSciences, Ansari Nagar, New Delhi, India

PURPOSE: Raised lactate levels are known to be a marker of pooroutcome in critically ill patients. Although bedside estimation of lactatelevels is now possible, it remains a costly investigation and is still not freelyavailable in third world countries. Anion gap (AG) has been suggested asa screening marker for LA. We examined the association of raised AG withhyperlactatemia (HL)/lactic acidosis (LA).

METHODS: 1852 lactate level estimations done on 352 patients in amedical ICU over a 6-month period were analyzed with concurrent AGlevels. HL (lactate �2 mmol/L) was seen in 733 samples (39.6%). Sampleswith LA were identified as those with HL in presence of base deficit�4mmol/L (n�313). Receiver-operator characteristic (ROC) curves weredrawn to study the utility of AG in predicting various levels of HL/LA (�2mmol/L, �5 mmol/L and �10 mmol/L). Sensitivity, specificity, positivepredictive value (PPV) and negative predictive value (NPV) were calcu-lated for best cut-off of AG for predicting various levels of HL/LA.

RESULTS: Overall incidence of raised AG in patients with HL was84% (n�615) whereas that for LA was 96% (n�300). AG estimation hadexcellent NPV for HL�5 mmol/L (�95%) as well as for any level of LA(�95%) but, at best, had a PPV of 66%. ROC curves showed AUC valuesof 0.641, 0.813 & 0.939 for HL and 0.819, 0.873 & 0.952 for LA withlactate levels �2 mmol/L, �5 mmol/L and �10 mmol/L, respectively.

CONCLUSIONS: Monitoring of AG estimation is a fairly sensitivetechnique for screening of HL/LA and even mild HL with or withoutmetabolic acidosis is associated with raised AG levels in 84% samples.Sensitivity and NPV tends to rise with increasing lactate levels and inpresence of concomitant acidosis although PPV remains low.

CLINICAL IMPLICATIONS: A normal AG level (�15 mmol/L) inpresence of metabolic acidosis almost always excludes LA although raisedlevels may not confirm its presence.

DISCLOSURE: A. Banga, None.

USE OF VASOPRESSIN INFUSION AS A SALVAGE THERAPY INSEPTIC PATIENTS ON HIGH DOSE CATHECHOLAMINESOusama Dabbagh, MD*; Hassan Ayoub, MD; Nehad Alshirawi, MRCP(UK); Yaseen Arabi, FCCP; Abdullah Al Shimemeri, FRCP (C). KingAbdulaziz Medical City, Riyadh, Saudi Arabia

PURPOSE: To evaluate the impact of vasopressin on the hemodynam-ics of septic patients when used as a last line salvage therapy.

METHODS: Retrospective chart review of patients that were onvasopressin infusion for septic shock. Data abstracted included patients’demographics, medical history, clinical presentation, and hemodynamics.Blood pressure and requirements of vasoactive medications were re-corded at baseline, one hour, four hours, twelve hours, twenty four hoursand forty eight hours after starting vasopressin infusion, and werecompared using paired t-test. Continuous variables are expressed asmean � SEM.

RESULTS: 19 patients were reviewed. The average age was 44 � 6.32% had cirrhosis as an underlying diseases. Source of septic shock wasrespiratory in 47 %. Vasopressin was initiated after a mean of 85 � 31hours of starting the first vasoactive medication and was continued for amean of 108 �37 hours. Average dose of norepinephrine and dopamineat baseline before starting vasopressin was 0.72 � 0.11 mcg/kg/min and7.83 � 2 mcg/kg/min respectively. Mean arterial blood pressure improvedduring the first hour of vasopressin infusion (61� 2 to 69 �3 p�0.01).This improvement was not sustained during subsequent points of the

study. Vasopressin did not result in statistically significant bradycardia norwas successful in reducing the requirements of other vasoactive medica-tions.

CONCLUSIONS: The use of vasopressin as a salvage therapy forseptic patients is associated with only transient improvement in hemody-namics during the first hour of infusion after failure of all other vasoactivemedications. Vasopressin was not associated with significant bradycardiaand did not succeed in reducing vasoactive medications requirements.The small numbers and retrospective design limit our results.

CLINICAL IMPLICATIONS: When used as a salvage therapy late inthe course of septic shock, vasopressin is not an effective medication inreversing shock .The late initiation of infusion may explain the ineffec-tiveness. Early infusion of vasopressin may produce different data.Randomized studies are necessary in this area.

DISCLOSURE: O. Dabbagh, None.

PROGRESS (PROMOTING GLOBAL RESEARCH EXCEL-LENCE IN SEVERE SEPSIS): A PRELIMINARY REPORT OF ANINTERNATIONAL INTERNET-BASED SEPSIS REGISTRYRichard Beale, MD*; Konrad Reinhart, MD; Geoffrey Dobb, MD;Eliezer Silva, PhD; Jacques LeClerc, MD; Bruce Basson, MS; DerekAngus, MD; on behalf of the PROGRESS Advisory Committee. Guy’s andSt Thomas’ Hospital, London, United Kingdom

PURPOSE: Better information on the global epidemiology of sepsiscan guide future research but barriers include the high costs of typicalcohort studies and the lack of incentives for participation. PROGRESS isdesigned to overcome these barriers and provide a representative,contemporary description of sepsis worldwide.

METHODS: PROGRESS is a prospective, observational registry. Thekey novel feature is that all data handling is by secure website. The websiteobviates the need for paper case report forms and has built-in liveauditing, thus reducing data management costs. All patient data isde-identified. The principal incentive for site participation is that thewebsite offers customized, on-demand, automated reports back to ICUs,comparing their data to local, national, and global averages. The softwaredevelopment and website maintenance was funded by Eli Lilly. Anindependent advisory committee with professional society representationgoverns PROGRESS, including oversight of data quality, access, andanalysis.

RESULTS: The first patient was entered December 19, 2002 and 9ICUs in 3 countries (Germany, Australia, Argentina) enrolled 80 patientsby April 18, 2003. Preliminary analysis showed results typical of severesepsis patients (male 66% [55%-76%]; ICU mortality rate 39% [28%-50%]). Approximately 250 additional ICUs in 31 countries have expressedinterest. One national society has adopted the tool for a specific sepsisproject.

CONCLUSIONS: Development of an international web-based sepsisdatabase to provide ICUs with methodologically consistent benchmarkingand on-demand reporting appears feasible.

CLINICAL IMPLICATIONS: Low-cost registry participation withautomated reporting may facilitate greater understanding of the incidenceand mortality of sepsis worldwide, improved patient care, and aid thedesign of future clinical trials. Major challenges are to expand the numberof participating ICUs and ensure system longevity.

DISCLOSURE: R. Beale, served as a paid consultant to Eli Lilly & Co.and is currently an investigator in ongoing clinical trials sponsored by EliLilly & Co.

DROTRECOGIN ALFA HAS LIMITED USEFULNESS IN THETREATMENT OF SEVERE SEPSIS IN GERIATRIC PATIENTSTehmina Khan, MD*; Yizhak Kupfer, MD; William Pascal, MD; SidneyTessler, MD. Maimonides Medical Center, Brooklyn, NY

INTRODUCTION: The PROWESS trial demonstrated that drotreco-gin Alfa (DA) reduced mortality in patients with severe sepsis and septicshock. The trial, however, excluded many patients, especially those withan increased risk of bleeding. Evidence-based medicine dictates that theresults of a trial be applied only to patients that are similar to the group




studied. We therefore, prospectively studied the utility of DA in geriatricpatients with severe sepsis.

METHODS: All patients over the age of 70 with severe sepsis, assessedby the critical care service were evaluated for administration of DA. Onlypatients with APACHE II scores of 25 or greater and who did not meetany of the PROWESS exclusion criteria were given DA. The reason fornot administering DA was recorded.

RESULTS: Between January 1 and April 30, 2003, 158 patientswere evaluated. One hundred fifty seven patients (99.4%) were noteligible for DA administration. Ninety-nine patients had low APACHEII scores (63%). Eighty-five patients (54%) had active internal bleed-ing predominantly from the GI tract. Fifty five patients (35%) requireddialysis, 15 (9.5%) had GI bleeding within 6 weeks, 8 (5%) wereconcurrently receiving heparin, 23 (15%) recently received plateletinhibitors, 6 (4%) had severe thrombocytopenia, 18 (11.4%) had a poorlife expectancy, 5 (3%) had cerebral complications and 4 (3%) hadsevere hepatic failure. Many patients had more than one contraindi-cation to DA. One patient received DA and was discharged from thehospital.

CONCLUSIONS: DA has limited utility in the treatment of severesepsis in geriatric patients. Further trials are required to accurately defineall the patients with sepsis that would potentially benefit from DA.

DISCLOSURE: T. Khan, None.

PERSISTENT OXYGEN DEBT EXPOSURE IS ASSOCIATEDWITH HYPOXEMIA AND MORTALITY IN CRITICALLY ILLBLUNT ABDOMINAL TRAUMA PATIENTSJohn P. Kepros, MD*; Lisbeth Harris, MSPH; Jobeth Northrop, RN.Swedish Medical Center, Englewood, CO

PURPOSE: Arterial base deficit (ABD) represents occult hypoperfu-sion (OH) in trauma patients and has been recommended as an endpointof resuscitation. The time to correct OH (TC) correlates with mortality inthese patients and the early identification and correction of occulthypoperfusion has been shown to improve survival and decrease compli-cation rates. The TC does not, however, directly take into account themagnitude ABD, which may have an impact on these outcomes.

METHODS: 149 blunt abdominal trauma patients with an ICU stay ofat least 48 hours were reviewed. 21 additional non-survivors were alsoreviewed. The magnitude of the ABD was combined with the TC by usinglinear regression analysis of the base deficit vs. time plot and calculatingthe area underneath the curve for each patient. This was termed theoxygen debt exposure (ODE). Both the time of TC and the ODE werecompared with the development of hypoxemia (pO2/FiO2 �250) andmortality.

RESULTS: Among the 33 patients in the initial group with OH, therewere 7 deaths (21%). The addition of the 21 non-survivors resulted in atotal of 45 patients with OH. There were 27 patients with a TC�24 hourswith 7 deaths (26%) and 22 patients with hypoxemia (81%). There were 18patients with a TC �24 hours with 9 deaths (50%) and 18 patients withhypoxemia (100%). There were 35 patients with an ODE of �5000 with9 deaths (26%) and 31 patients with hypoxemia (89%). There were 10patients with an ODE �5000 with 7 deaths (70%) and 10 patients withhypoxemia (100%).

CONCLUSIONS: An ODE of �5000 is a better predictor of mortalitythan persistent OH.

CLINICAL IMPLICATIONS: Mathematical modeling of ABD clear-ance with calculation of ODE may be useful in predicting hypoxemia andmortality in blunt abdominal trauma patients.

DISCLOSURE: J.P. Kepros, None.

BLOOD STREAM INFECTION IN CORONARY CARE UNITPATIENTS RECEIVING INVASIVE VENTILATIONAllen Ensminger, MD*; Scott Wright, MD; Bekele Afessa, MD. MayoClinic, Rochester, MN

PURPOSE: Although infectious complications are common in criticallyill patients, the incidence of blood stream infection (BSI) and the impacton outcome in coronary care unit (CCU) patients receiving invasive

mechanical ventilation (MV) have not been well described. The objectiveof the present study was to describe the incidence, pathogens and impacton outcome of BSI in CCU patients.

METHODS: Records for all patients admitted to the CCU requiringMV for � 48 hours between August 1, 2000 and July 31, 2002 wereexamined. Exclusion criteria included: non-cardiac diagnosis, transferfrom another ICU, chronic MV, CCU stay � 48 hours and lack of consentfor research. BSI was defined as the isolation of potential pathogens in theblood. Two sets of positive blood cultures were required for coagulase-negative Staphylococcus infection.

RESULTS: The study included 202 patients with a mean age of 66.1years; 61% male and 94% Caucasians. The most frequent admissioncardiac diagnoses were acute myocardial infarction (34.7%) and cardiacarrest (24.6%). The most common indications for MV were cardiac arrest(25.8%) and cardiogenic pulmonary edema (23.7%). Twenty patientsdeveloped BSI (9.9%). The BSI occurred at a median of 2 (range, 0-35)days after hospital admission. A single pathogen was identified in 18patients and two organisms in two patients. The most commonly identifiedbacterial organisms were: methicillin-sensitive Staphylococcus aureus (6)and coagulase-negative Staphylococcus aureus (3). The median length ofhospital stay was 10 days for patients with and without BSI (range, 4-61and 2-76, respectively)(p�0.9023). Hospital mortality was not significantlydifferent between patients with and without BSI (45.0 % vs 34.6%,p�0.3574).

CONCLUSION: Although BSI occurs in about 10% of patientsadmitted to CCU and receiving MV, it does not increase hospital mortalityor length of hospital stay. Methicillin-sensitive Staphylococcus aureus isthe most common organism causing blood stream infection in thesepatients.

CLINICAL IMPLICATIONS: In CCU patients receiving invasiveMV suspected of having infection, empiric antibiotic therapy should coverstaphylococcal infections.

DISCLOSURE: A. Ensminger, None.

FEVER CONTROL IN SEPTIC SHOCK: BENEFICIAL ORHARMFUL?Su Fuhong, MD*; Nam Duc Nguyen, MD; Wang Zhen, MD; PeterRogiers, MD; Jean-Louis Vincent, PhD Dr. Erasme Hospital, Brussels,Belgium

PURPOSE: The aim of this study is to investigate whether utilizationof acetaminophen and external cooling to control fever in ewe septic shockmodel is beneficial and influence HSP70.

METHODS: Twenty-four fasted, anaesthetized, invasively monitored,mechanically ventilated female sheep (27.0�4.6 Kg) received 0.5 g/kgbody weight of feces into the abdominal cavity to induce sepsis. Ringer�slactate (RL) was titrated to maintain pulmonary artery occlusion pressure(PAOP) at baseline level throughout the experimental period without anyantibiotics and vasoactive drugs utilization. After surgical operation,randomization was performed as following: if temperature� 36.0°C, theanimal was placed in the hypothermia group; the other animals wererandomized to three groups: high fever (T�39.0°C); mild fever(37.8°C�T�38.2°C) and normothermia (36.0°C�T�37.0°C) group.Acetaminophen 25 mg/ kg/ 4�6 hours combined with external cooling (icepad) was used to control core temperature in the expected range.Hemodynamic, mechanical ventilation parameters, and gas exchangevalues were obtained every hr. Plasma samples were obtained every fourhrs for HSP70 measurement (Hsp70 ELISA Kit, Stressgen, Canada).

RESULT: Survival time was longer in the fever group (25.2 � 3.0 hrs)than in the mild fever group (17.7 � 3.5 hrs), normothermia group(16.0 � 1.9 hrs) and hypothermia group (18.5 � 2.5 hrs) (p � 0.05). Therewas no significant difference in homodynamic parameters except thatDO2 (oxygen delivery) was higher in the two fever groups then the othertwo groups (p � 0.05). PaO2/FiO2 ratio was highest and blood lactatelevel was lowest in the high fever group than the other three groups (p �0.01 and 0.05 respectively). Plasma HSP70 level was higher in the twofever groups than in the other groups (p�0.05).

CONCLUSION: In this septic shock model, febrile response hadbeneficial effects on the respiratory function, blood lactate level andsurvival time. Antipyretic interventions including acetaminophen andexternal cooling were associated with lower circulating HSP70 levels.

DISCLOSURE: S. Fuhong, None.


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ELEVATION OF CARDIAC TROPONIN I IS A MARKER OFDEVELOPING MYOCARDIAL HYPOXIA IN SEPSISNam D Nguyen, MD*; Su Fuhong, MD; S Hachimi-Idrissi, MD; LucHuyghens, MD. Erasme Hospital, Brussels, Belgium

PURPOSE: Cardiac depression occurs in sepsis despite a preservationof coronary blood flow in most patients and cardiac injury can be detectedby an elevation of plasma cardiac troponin I (cTnI). The aim of our studyis to determine, whether the release of cTnI from myocytes, is related toany modification of coronary perfusion pressure (COPP) or due to a directtoxic effect of different inflammatory mediators during sepsis.

METHODS: For 4 consecutive days after admission, plasma cTnI,c-reactive- protein (CRP) and arterial lactate were charted in 185 patientswith severe sepsis and septic shock and tumor necrosis factor alpha (TNF)in 30 patients. cTnI was considered elevated if its value was more than 0.4micrograms /L.. Cardiac dysfunction was detected by Echocardiographyin all patients and Hemodynamics was assessed, especially to evaluateCOPP and left ventricular stroke work index (LVSWI). ANOVA tests wereused for statistics.

RESULTS: cTnI was elevated in a total of 62% of 185 patients after 4days. A higher incidence of cardiac dysfunction, multiple organ failure, aswell as a higher mortality rate were associated with patients that hadelevated cTnI (p�0.005).In the latter, LVSWI was also significantlyreduced during 4 days, but COPP only decreased after 72 hours(p�0.005), despite a normalization of cardiac index after 24 hours.Cardiac dysfunction was not associated with arterial lactate and TNF, butsignificantly associated with the elevation of cTnI and the maximum valueof CRP occurred (p�0.005).

CONCLUSION: Elevation of cTnI and cardiac dysfunction occurredduring severe sepsis and septic shock, which both were associated with alower COPP and a higher risk of developing myocardial hypoxia, ratherthan a direct injury effect under inflammatory mediators like TNF.


Sleep Disorders12:30 PM - 2:00 PM

CORRELATION BETWEEN THE SEVERITY OF OBSTRUCTIVESLEEP APNEA AND THE DEGREE OF RESPIRATORY DRVEDEPRESSIONHesham H. El Gamal, MD*; Maged A. Tanios, MD; Cindy Jacoby, BS;Cherryl Chicoine, BS; Carolyn D’Ambrosio, MD; John N. Unterborn,MD. Academic Hospital, Tufts University, Boston, MA

PURPOSE: It is well documented that patients with obstructive sleepapnea have a blunted respiratory drive in comparison to a normalpopulation. We explored if the severity of sleep apnea correlated with thereduction in respiratory drive.

METHODS: 21 patients with documented obstructive sleep apnea bystandard polysomnogram included in the study. These patients underwentrespiratory drive assessment with measurement of minute ventilation (Ve)and occlusion pressure at 100ms (P0.1) using standard CO2 rebreathingtechnique. Correlation between the respiratory drive parameters andapnea hypopnea index was done using linear regression.

RESULTS: There was no correlation between the respiratory driveparameters and total apnea index or total hypopnea index. Also there wasno correlation between the average duration of apnea and hypopnea andthe respiratory drive. Respiratory drive did not correlate with the lowestO2 saturation

Parameters R2 P value

P100 vs AHI 0.051 0.32P100 @ ETCO2 of 60 vs AHI 0.027 0.47Ve @ ETCO2 of 60 vs AHI 0.127 0.113

AHI � Apnea Hypopnea IndexCONCLUSIONS: The degree of respiratory drive reduction seen in

OSA does not correlate with the number or the duration of apneas andhypopneas. Also there was also no correlation between the respiratorydrive and the degree of hypoxia measured by O2 saturation.

DISCLOSURE: H.H. El Gamal, None.

INFLUENCE OF THE ANGLE’S OROFACIAL CLASSIFICA-TION ON THE AIRWAY OBSTRUCTIONFlorence M. Sekito, DDS, MScD*; Pedro L. Melo, Eng, PhD. StateUniversity of Rio de Janeiro, Rio de Janeiro, Brazil

PURPOSE: The efficiency of the oral appliance therapy in patientswith obstructive sleep apnea/hipopnea syndrome (OSAS) is a subjectunder debate in the literature. Orofacial anatomic characteristics affectthe respiratory obstruction in distinct ways. The aim of this study was toinvestigate the influence of the orofacial categories on the respiratoryobstruction. The effect of nasal obstruction was also analyzed.

METHODS: The studied patients were divided in six groups accordingto their Angle’s classification in I, II, III classes (normal, mandibularretrognathism, mandibular prognathism, respectively), and the presenceof nasal obstruction. All of these patients have no history of smoke orpreexisting respiratory disease. Their anthropometric characteristics aredescribed in Table 1.

The airway obstruction was evaluated by the respiratory impedance,measured by the forced oscillation technique using analysis from the nose(ZN) and from the mouth (ZM) at a frequency of 5 Hz One-way analysis ofvariance (ANOVA) was used to assess the differences among the classes andstatistical difference were considered with a p-value �0.05.

RESULTS: The results are presented in Table 2. Significant increasesin ZN (p�0.01) and ZM (p�0.05) were observed as a result of themodifications in Angle’s class in normal subjects. Although small increasesin ZN and ZM were observed in patients with nasal obstruction, these werenot significant (p�0.05).

CONCLUSIONS: The results demonstrated that the mandibularskeletal variation has positive influence in the airway obstruction, increas-ing the impedance with Angle’s craniofacial classification. This effect isreduced in the presence of nasal obstruction.

CLINICAL IMPLICATIONS: In order to optimize the use ofintra-oral appliances therapy in patients with sleep apnea/hypopneasyndrome, it is important to underwent a previous analysis, and eventualtreatment, of craniofacial structure differences and nasal obstruction.

Table 1 - Anthropometric characteristics of the subjects

AGE(years)

WEIGHT(kg)

HEIGHT(cm)

Class I Normal (n�20) 38.0�13.0 61.4�10.9 165.6�9.0Class I Obstruction

(n�28)40.7�14.3 64.1�.16.1 165.7�9.0

Class II Normal(n�6)

39.5�13.3 59.3�7.3 163.0�10.2

Class II Obstruction(n�10)

37.9�10.5 66.2�12.8 165.2�10.8

Class III Normal(n�5)

36.2�20.2 68.8�11.8 167.4�9.7

Class III Obstruction(n�8)

31.9�16.5 73.5�12.2 169.4�9.0

Table 2- Airway obstruction in different orofacial categories

ZN (cm H2O/L/s) ZM (cm H2O/L/s)

Class INormal

4.3�1.3 2.8�0.8

Class IObstruction

6.0�3.4 3.8�1.9

Class IINormal

4.7�1.0 3.4�0.8

Class IIObstruction

7.6�3.1 4.4�2.2

Class IIINormal

6.3�0.7 3.9�0.4

Class IIIObstruction

8.4�3.0 4.6�0.9

DISCLOSURE: F.M. Sekito, CNPq, Grant monies.


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PREDICTIVE VALUE OF OXYGEN DESATURATION IN THEDIAGNOSIS OF OBSTRUCTIVE SLEEP APNEAFlorina C. Corpuz, MD*; Ivy Melanie Tamondong, RN; Loreto J.Codamos, MD; Mercy Antoinette S. Gappi, MD. Tertiary Hospital, St.Luke’s Medical Center, Quezon City, Philippines

PURPOSE: The aim of this study is to assess the accuracy of nocturnalpulse oximetry as a confirmatory test in the diagnosis of obstructive sleepapnea (OSA) as against polysomnography (PSG) which is the goldstandard.

METHODS: Patients referred to the sleep center for PSG withsymptoms suggestive of OSA were investigated. Full night diagnosticpolysomnography with oximetry was performed at the sleep center.Baseline characteristics were taken. Respiratory disturbance index (RDI)and lowest O2 saturation (LSAT) levels were determined for each patient.5 LSAT threshold values (75%, 80%, 85%, 90% and 95%) were obtainedfor analysis. Sensitivity, specificity, false positive rate, positive predictivevalues (PPV) and negative predictive values were computed for eachthreshold level. Receiver operating characteristic (ROC) curve was con-structed to measure the diagnostic performance of LSAT.

RESULTS: 416 were included in the present study after meeting theinclusion criteria. The group consisted of 315 (75%) men and 101 (25%)women. Mean age � SD was 46.02� 12.07. The average BMI� SD was29.04� 6.10. The mean RDI was 33.27� 36.37. 284 patients had an RDIof �5/hour. Of these 244 (86%) were men and 40 (14%) were women.When compared statistically, there was a significant difference in the BMIand LSAT. Correlation of RDI �5/hour with LSAT was statisticallysignificant at p�0.000 with an r�-0.662. Using LSAT threshold of 85%gave a sensitivity of 83%, specificity of 90% with FPR of 10%, PPV of 95%and NPV of 72%. AUC�0.93.

CONCLUSION: A level of 85% may suggest that these patients hasOSA

CLINICAL IMPLICATIONS: For adults who are unlikely to haveOSA clinically, a negative oximetry result may be sufficient to exclude thediagnosis; for adults who are likely to have OSA clinically, a positiveoximetry result may be sufficient to confirm the diagnosis of OSA andtherefore would benefit from treatment to prevent the complications ofOSA.

DISCLOSURE: F.C. Corpuz, None.

EFFICACY AND SAFETY OF EMPIRIC CONTINUOUS POSI-TIVE AIRWAY PRESSURE THERAPY IN SUBJECTS WITH OB-STRUCTIVE SLEEP APNEARobert P. Skomro, MD, FRCP, FCCP*; Leane King, BSc; Joseph Mink,BSc, RPSGT. University of Saskatchewan, Saskatoon, SK, Canada

PURPOSE: Obstructive Sleep Apnea (OSA) is typically diagnosed onPolysomnography (PSG), however the access to PSG is limited. Thisprompts physicians to utilize other diagnostic methods and may lead to theprescription of Continuous Postive Airway Pressure (CPAP) therapywithout PSG. The purpose of this study was to review: 1. efficacy andsafety of empiric CPAP; 2. physicians’ diagnostic accuracy in cases ofsuspected OSA; 3. accuracy of empiric CPAP pressure as compared to theCPAP pressure established after a split-night PSG.

METHODS: Retrospective chart review of patients who were pre-scribed empiric CPAP . Subjects’ characteristics (age, sex, BMI), EpworthSleepiness Score before and after CPAP were obtained and compliancedata were downloaded. CPAP pressures prescribed after PSG werecompared with the empirically set pressures.

RESULTS: Eighty-nine patients (67 male; 52.2 �/- 11.7 years; BMI :35.3 �/- 7.9; Epworth 13.8 �/- 5.7) were prescribed empiric CPAP (meanpressure of 9.5 �/-1.6 cm H2O). The average duration of CPAP therapyprior to PSG was 254 days. In 26 (29%) cases portable oximetry was usedprior to CPAP prescription. Seventy-nine patients (89%) had OSA (meanAHI: 43.5 �/- 30.2 ). The optimal CPAP pressure, as determined on asplit-night PSG, was 9.9 �/- 1.9 cm H2O and was not significantlydifferent from the empiric CPAP pressure ( p � 0.12),however, 33patients were undertreated (empiric CPAP pressure � optimal CPAPpressure).There was significant improvement in subjective somnolence inthe entire group (ESS:13.8 �/- 5.7, after CPAP: 8.7 �/- 4.0, p �0.001).The mean CPAP compliance was 5.0 �/- 2.3 hrs/night (N� 67). Therewere no adverse effects from empiric CPAP therapy.

CONCLUSIONS: 1. Pulmonologists can accurately predict presenceof moderate and severe OSA, 2. Empiric CPAP therapy is safe and

effective in improving hypersomnolence, 3. Mean CPAP compliance inthis group is similar to compliance reported in other studies.

CLINICAL IMPLICATIONS: When access to PSG is limited, em-piric CPAP can be safely prescribed and is effective.

DISCLOSURE: R.P. Skomro, None.

UTILITY OF IMPULSE OSCILLOMETRY IN CONTINUOUSAIRWAY PRESSURE TITRATION FOR PATIENTS WITH SLEEPAPNEA/HYPOPNEA SYNDROMENaga S. Tripuraneni, MBBS*; Raj Karunakara, Downstate MedicalCenter; Satish Chada, Downstate Medical Center; Maria Zaleska, KingsCounty Hospital; Jahanara Begum, Kings County Hospital; Samir Fahmy,Downstate Medical Center; Albert E. Heurich, Downstate MedicalCenter. Downstate Medical Center, Brooklyn, NY

PURPOSE: Treatment of sleep apnea/hypopnea syndrome(SAHS)re-quires continuous positive airway pressure (CPAP). Good correlationbetween respiratory impedance measured by impulse oscillometry (IOS)during sleep and optimal CPAP has been shown by previous studies . Thepurpose of this study is to evaluate any correlation between central airwayresistance (R20), impedance(Z) measured by IOS in awake state andoptimal CPAP.

METHODS: This is a prospective, non- blinded study done in 20patients (male� 12, female�8, average weight�233 lbs, age�49) diag-nosed to have SAHS by overnight polysmnography (PSG) done at KingsCounty Hospital. The PSG (Sensor Medics, Yorba Linda, CA) and theCPAP titration study was done by certified sleep technicians. The sleepstaging and apnea/hypopnea index (AHI) scoring was done manually by acertified physician in sleep medicine according to American SleepDisorders Association guidelines.

Only patients with AHI more than 15 had CPAP titration study. CPAPwas generated with a conventional device(BiPAP S/T-D, Respironics Inc,Murrysville, PA)connected to the patient with a tightly fitted nasal mask.Every patient had 3 measurements of R20&Z in a sitting position duringnormal quiet breathing by the IOS(Jaeger System) in awake state. Averageof the 3 values was taken as the final measurement. CPAP titration wasdone after the IOS measurements, with a starting pressure of 4cm H2oand increased by 2cm H2o for every apnea/hyopnea or by 1 cm H2o forsnoring. Regression analysis of the CPAP level and R20&Z values wasdone.

RESULTS: There is increased central airway resistance and impedancebut no corelation was found between optimal CPAP and resting R20 ( cvalue 0.15) and Z ( c value 0.22).

CONCLUSIONS: Normal quiet breathing R20&Z do not predict theoptimal CPAP even though there is increased R20&Z.

CLINICAL IMPLICATIONS: The relationship between the upperairway anatomy/resistance and sleep apnea is complex.

DISCLOSURE: N.S. Tripuraneni, None.

LABORATORY EVALUATION OF BI-FLEX MODE OF THERESPIRONICS PRO BI-LEVEL SYSTEMDean R. Hess, PhD RRT FCCP*; William H. Hardy, MPM, RRT.Massachusetts General Hospital, Boston, MA

PURPOSE: An issue associated with the use of bi-level ventilation ispatient compliance. The purpose of this study was to evaluate theperformance of a new bi-level embellishment called Bi-Flex, which allowsa small amount of pressure relief at the beginning of exhalation to improvepatient compliance.

METHODS: A 2-chambered lung model was used to simulate spon-taneous breathing. Pressure and flow were measured immediately proxi-mal to the lung model. IPAP/EPAP settings of 10/8, 15/10, and 16/6 cmH2O were used with 3 levels of Bi-Flex (0 � no pressure relief, 3 �maximal pressure relief). For each combination of settings, the followingexhalation parameters were measured: time for pressure to drop fromIPAP to EPAP (Time 1), time of pressure relief below EPAP (Time 2),and maximal pressure drop below EPAP. Summary data are provided for3 breaths.

RESULTS: There was a significant decrease in Time 1 as the Bi-Flexlevel was increased (0.49 � 0.09 s for setting 0, 0.25 � 0.02 s for setting1, 0.17 � 0.01 s for setting 2, and 0.14 � 0.03 s for setting 3; P�0.001).There was no significant change in Time 2 as the Bi-Flex level wasincreased (0.80 � 0.11 s for setting 1, 0.81 � 0.12 s for setting 2, 0.90 �0.17 s for setting 3; P�0.29). The pressure drop below EPAP was 0.70 �


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0.17 cm H2O for Bi-Flex setting 1, 1.42 � 0.19 cm H2O for Bi-Flex setting2, and 2.29 � 0.11 cm H2O for Bi-Flex setting 3. These results areillustrated in the figure.

CONCLUSIONS: Bi-Flex produces a significant pressure relief at thebeginning of the exhalation phase.

CLINICAL IMPLICATIONS: The potential for Bi-Flex to improvepatient compliance should be subjected to appropriate clinical study.

DISCLOSURE: D.R. Hess, Respironics, Inc., grant monies.

THE VENUE OF TESTING (IN-HOME [H] VERSUS ATTENDED[A]) DOES NOT PRODUCE ANY SIGNIFICANT DIFFERENCEIN TEST RESULTS OR CLINICAL OUTCOMES IN PATIENTSWITH OBSTRUCTIVE SLEEP APNEA (OSA)Richard J. Pisani, MD*; Jeffrey Smoots, BA; Sid Kapnadak, BS; BethBowers, BS RRT. Richard J. Pisani, MD, Woodinville, WA

PURPOSE: One of the arguments against home testing is the lack ofoutcome data regarding testing done in that venue as opposed to testsperformed with medical personnel in attendance. We postulated that thevenue of testing doesn’t produce any significant differences in test resultsor outcomes.

METHODS: We reviewed the clinical history and sleep test results ofpatients tested at home (H) using an Edentrace system versus attended(A) studies tested in a sleep lab or hospital setting using the sameequipment. The venue of testing was determined by each patient’sinsurance company guidelines. Patients were included based on theavailability of outcome data gathered from a follow up questionnaire. Theclinical outcomes were appraised by a standardized questionnaire we havebeen using since 1995. All of the follow up data was collected afterpatients had been using continuous positive airway pressure for a monthor longer.

RESULTS: There were 332 patients in the (H) group and 541 patientsin the (A) group. Table I summarizes our findings. There was nodifference in age, gender mix, or BMI between the two groups. The apneahypopnea index was similar in both groups (A�36.0 �/-28 vs H�33.0 �/-25), as was the clinical severity score at baseline ((H) � 34.7/60 and (A) �34.0/60). The follow up clinical score was markedly improved in bothgroups to approximately the same low level (H�7.5/60, A�8.1/60).Specific improvement noted in snoring level, observed apnea, morningsleepiness, daytime sleepiness, arousals, and cognitive function was similarin both groups.

CONCLUSION: The venue of testing does not produce any systematicvariation in the AHI or clinical outcomes of patients with OSA.

CLINICAL IMPLICATIONS: Most patients would prefer to do testsin their home if the insurance company will pay for it. Some patients are

hesitant to undergo testing due to insurance guidelines that mandatetesting be done outside of their home. Our results suggest that suchmandates may not be clinically justified.

TABLE I

HOME (H) ATTENDED (A)

TOTAL STUDIES 332 541Gender - Male 75% 72%Gender - Female 25% 28%Average age 46.2 �/- 11 years 46.0 �/- 9 yearsAverage BMI 35.4 �/- 8kg/m2 36.5 �/- 12kg/m2Average AHI 36.0 �/- 28

events/hour33.0 �/- 25events/hour

Baseline Clinical Severity(0�Best, 60�Most severe)

34.7 �/-10 34.0 �/- 10

Clinical Severity on CPAP 7.5 �/- 5 8.1 �/- 4

DISCLOSURE: R.J. Pisani, None.

THE EFFECT OF NASAL CPAP ON PERIODIC LIMB MOVE-MENTS IN PATIENTS WITH SLEEP DISORDERED BREATH-INGZiad C. Boujaoude, MD*; Rania N. Aboujaoude, MD; Wissam B.Abouzgheib, MD; Melvin R. Pratter, MD; Stephen M. Akers, MD;Jonathan E. Kass, MD. Division of Pulmonary and Critical Care, CooperHospital/UMDNJ, Robert Wood Johnson Medical School, Camden, NJ

PURPOSE: Periodic limb movements of sleep (PLMS) is a commonsleep disorder and can occur concomitantly with obstructive sleep apnea(OSA).The effect of nasal continuous positive airway pressure (nCPAP) onPLMS has been shown to be variable. We intended to study this effect inpatients with OSA.

METHODS: We retrospectively reviewed the baseline and nCPAPpolysomnograms of 146 consecutive patients that presented for nCPAP afterinitial diagnosis of sleep disordered breathing. The periodic limb movementindex (PLMI), the periodic limb movement arousal index (PLMAI), and theapnea hypopnea index (AHI) were noted before and after nCPAP .

RESULTS: 7 patients (4.8%) had a PLMAI � 5 at baseline. ThePLMAI normalized (� 5) in 6 of those patients (86 %) with nCPAP (meanbaseline AHI�22.4, mean nCPAPAHI�8.6). 139 patients (95.2 %) had aPLMAI � 5 at baseline. After nCPAP (mean baseline AHI� 32.7, meannCPAPAHI �3.9), the PLMAI increased to � 5 in 11 of those patients(7.9 %), and remained � 5 in 128 (92.1 %). 7 of these 11 patients (63.6 %)and 44 of the 128 patients (34.4 %) had a PLMI � 5 at baseline

CONCLUSION: Effective nCPAP tended to eliminate preexistingarousing PLMS, while it increased them in a percentage of patients whodid not have them at baseline. The presence of non-arousing PLMS atbaseline did not predict the appearance of arousing PLMS with treatmentof sleep disordered breathing.

CLINICAL IMPLICATIONS: In patients with OSA, the diagnosis ofPLMS cannot be made or excluded until the OSA is eliminated becausethey may appear or disappear with treatment.

DISCLOSURE: Z.C. Boujaoude, None.

Smoking and Lung Health12:30 PM - 2:00 PM

SMOKING ACTIVE/PASSIVE ADVERSELY EFFECT THE PE-RIPHERAL BLOOD CIRCULATION AS A CONSEQUENCEOF INFLAMMATORY OCCLUSION OF DISTAL ARTERIES &SUPERFICIAL VEINS, MAY RESULT IN GANGRENOUSCHANGES, IN TERMINAL STAGESM Ishaq, MD.DTCD.MCPS.FCCP.FACP.FAAAAI*. Pulmonary/Allergy,Al-Junaid Hospital, Nowshera, Pakistan

OBJECTIVES: Individuals with long history of smoking had beenassociated with intermittent inflammatory occlusion of arteries/veins of


Sleep Disorders, continued


extremities, resulting in variable circulatory impairment of fingers & toes.The idea is to enlighten the importance of risks associated with smokingin any form.

METHODS: In the study all active /passive smokers, under 40 years,male:female, ratio 20:1 had a genetic predisposition . An early evidence ofsuperficial thrombophlebitis followed by intermittent burning/prickingpain of legs/arms, hands, diminished sensations, painful moments oflimbs, fever, Impaired pulsation of ulnar, radial posterior tibial dorsalispedis, in some painful indolent ulceration had been seen along the nailmargins. Effected parts of extremities pale/cold, sometimes hot to touchfrom acute inflammatory changes. On elevation no changes in skincoloration when pale & on dependency markedly engorged when in-flammed. There had been variable period of remissions /relapses, depend-ing upon the frequency of smoking.In cases with advanced inflammatorychanges of main vessels& collaterals coupled with infection& tissuenecrosis, evidence of gangrene was seen. Biopsy /histopathology &arteriography had confirmed the nature of disease. Smoking cessation,good nursing care & appropriate antibiotic regimen had changed theoutlook as following,

RESULTS: 75-80% patients with effective smoking cessation, goodperipheral circulation, nursing care, prompt follow up been associatedwith improvement with out proceeding to amputation.10-12%Patientswith infection impaired circulation & evidence of tissue necrosis had beenassociated with prolonged hospitalized treatment/arterial bypass of theeffected vessels, debridement etc.6-8% patients, with poor collateralcirculation, evidence of occlusion of the main vessels, complicatedinfection, with poor prognosis resulted in inevitable amputation. as the lastresort.

CONCLUSIONS: Smoking had been found to be directly proportionalto the course of diseases i.e. a strong dose response relationship exists withthe severity of disease & frequency/duration of smoking. Early notificationfor treatment, arteriography & appropriate antibiotic treatment/nursingcare had been associated with good prognosis.

CLINICAL IMPLICATIONS: Glucocorticoids & anticoagulantsfound with no active role in the prognosis / course of the disease.

DISCLOSURE: M. Ishaq, None.

HIGH RESOLUTION COMPUTED TOMOGRAPHY (HRCT)FINDINGS IN SMOKERS AND EX-SMOKERS WITHOUT LUNGFUNCTION LIMITATIONEmilio Marangio, MD FCCP; Alfredo Chetta, MD FCCP*; AlessiaVerduri, MD; Gianfranco Chiari, MD; Marina Aiello, MD; AntonioForesi, MD; Francesca Greco, MD; Dario Olivieri, MD FCCP; MaurizioZompatori, MD. University of Parma, Parma, Italy

PURPOSE: In this study, we used HRCT to assess the extent of earlymorphological changes in lung parenchyma of smokers and ex-smokerswithout lung function limitation and respiratory symptoms.

METHODS: Fifteen smokers (7F; mean�SD age: 54 years �9;mean�SD cigarette/die:17�3) and 8 ex-smokers (4F, mean�SD age: 51years �10) were studied. The HRCT scans of all subjects were indepen-dently assessed by two radiologists, in a blind manner and the overallextent of air trapping and emphysema was scored at predetermined levelsby using a visual score.

RESULTS: In smokers and ex-smokers, mean�SD of FEV1 (% pred),FEV1/VC (%), and FEF25-75 (% pred) were 100%�22 vs 98%�12,77%�11 vs 78%�8, and 82%�32 vs 81%�23, respectively. Air trappingand emphysematous changes were present in 27% and 33% HRCT scansof smokers and in 25% and 25% HRCT scans of ex-smokers, respectively.

CONCLUSIONS AND CLINICAL IMPLICATIONS: Our studyshowed that a third of asymptomatic smokers and a quarter of ex-smokerswithout lung function limitation had morphological changes of lungparenchyma, assessed by means of HRCT. Our data suggest that HRCTis a useful tool in early detection of smoking related lung diseases and canbe used to implement preventive measures.

DISCLOSURE: A. Chetta, None.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD):EVALUATION OF FAMILIAR ANTECEDENTS AS A RISK FAC-TOR AND ITS RELATIONSHIP WITH SMOKING HABITAbraham Zavala Battle, MD FCCP*. Clinica Javier Prado, Lima, Peru

INTRODUCTION: Many years ago it has been established the nearrelationship between smoking habit and the development of COPD

(chronic obstructive pulmonary disease), although we know that only 80%of COPD are produced by smoking and less than 20% of heavy smokersdevelop COPD. This take us to think that there are other risk factors forthe development of COPD.

PURPOSE: To determine if familiar antecedents for COPD are animportant risk factor to develop COPD. To determine if hereditarypredisposition associated to smoking habit increases the likelihood todevelop COPD if compared with the mentioned risk factors separately.

METHODS: This is descriptive, transversal cut type study that in-cludes 116 people of both sex between 30 and 45 years old in whom wecompare pulmonary function in smokers, non smokers, with and withoutfamily COPD antecedents. It’s considered positive the following mea-sures: FV1/FVE� 70% or FEV1 � 80% without reversibility or withreversibility less than 12% with inhaled Beta-agonists. We considerpatients with positive spirometry as an incipient COPD carrier.

RESULTS: The results show that smokers with family COPD ante-cedents showed higher positive spirometry percentage (27.6%) followedby no smokers with family COPD antecedents (17.2%). The third groupin positive spirometry percentage was the one with smokers with no familyCOPD antecedents (10.3%). The group with no smokers and no familyCOPD antecedents showed no positive spirometry. There was significa-tive statistical difference between the four groups.

CONCLUSIONS: We conclude that familiar antecedents for COPDare a significative risk factor to develop COPD. Familiar antecedents forCOPD associated to smoking habit increase the likelihood to developCOPD if compared with the mentioned risk factor separately.

CLINICAL IMPLICATIONS: To determine a risk group can helpwork hardly in prevention, diagnosis and early therapy.

DISCLOSURE: A. Zavala Battle, None.

DIABETES MELLITUS PATIENTS AND SMOKING IN ROMA-NIAFlorin D. Mihaltan*; Cristina Vladulescu. The National Institute ofPneumology - Marius Nasta, Bucharest, Romania

PURPOSE: Our study was trying to find out the impact of diabetesmellitus on the smoking habit.

METHODS: The study was made for 100 patients ( between 18-85years old , 68% men ) with diabetes mellitus type 1 and 2 , treated withinsulin and antidiabetic oral drugs .We have used patients charts and aquestionnaire with 33 questions about general smoking epidemiology .

RESULTS: We found 1/4 smokers (72% men and 28% women) and28% ex smokers; 46% of smokers began smoking . The prevalence ofdiabetes mellitus treated with insulin was of 76% to smokers and 44% ofsmokers and 28% of ex smokers had an evolution of diabetes under 5 years. From smokers and ex smokers sample 80% and 78% thought thatsmoking has influenced their disease and evolution ; they have notreceived any aid for quit smoking from their. Their attitude concerningsmoking in working places is also surprising ( 52% of smokers and 28,5%of ex smokers are accepting smoking to working places). In the last time56% of smokers, 32% of ex smokers, 17% of non smokers have had toincrease insulin doses and 20% of smokers, 7,1% of ex smokers and 19%of non smokers have had to change oral antidiabetic drugs to insulintherapy. The percentage of complications was: mixed neuropathy to 70%of smokers and 68% of non smokers, peripheral arteriopathy to 32% and10,4%,ischemic heart disease to 44% and 35,4%, nephropathy to 48% and14,5% and retinopathy to 40% and 46%. When they find out the firstcomplication 92% of smokers have smoked as much as the beginning .

CONCLUSIONS: Some complications rate in smokers with diabetesmellitus are very high and the complications have appeared earlier.

CLINICAL IMPLICATIONS: Smoking is a risk factor for this sampleof patients neglected by them and doctors. We need more educationalactions to this kind of patients.

DISCLOSURE: F.D. Mihaltan, None.

SMOKING TRENDS WITH HEALTH AND SOCIO-CULTURALDIFFERENCESM Ishaq, MD.DTCD.MCPS.FCCP.FACP.FAAAAI*. Pulmonary/Allergy,Al-Junaid Hospital, Nowshera, Pakistan

INTRODUCTION: Tobacco use (Smoking/smokeless form) in theunderdeveloped countries like Pakistan, border region with Afghanistan &Iran is according to their socio-culture presentation.


Smoking and Lung Health, continued


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AIM: Is to demarcate consumption of tobacco as per the living /culturalpattern.

MATERIAL AND METHODS: The incidence of tobacco relateddiseases had been with individual concern in relation to his/her broughtup (cultural) or in relation to place of work/living (social) .As from daily lifeevery individual follow all taught from cultural restrictions/surroundings.Pollution arising from place of work/living had additive deleterious effectson health outcome of tobacco users. The degree of health consequencesis proportional to the intensity of exposure, duration of exposure & thenature of occupational products/by products. In a study conducted invarious cities /towns/villages in Pakistan & border regions of Afghanistan/Iran the incidence of smoking/tobacco use with occupational exposure hadbeen as under,

RESULTS: Please see the attached table for details.In some communities tobacco preparations had been presented as a

mean of entertainment/hospitability, as a symbol of fashion. The steadyrise in new smokers outnumbers those willing to quit.

CONCLUSIONS: In some communities tobacco use (Smoking/smoke-less) had been interwoven right from birth as cultural follow up as an actof obligation, in others from Place of work, living as incitation.

*Smoking as cigarette more popular in civilized/educated*Smoking as cigar/pipe more common than cigarette*Smoking as Huqa & smokeless tobacco more common thanCLINICAL IMPLICATIONS: In underdeveloped countries rapid

urbanization is associated with an increased tendency to smoking specif-ically amongst youths.

Metropolitan cities

High literacyrate

Relatively Lowliteracy rate

Very lowliteracy rate

Male Female 20-30% 3-5%* Male Female 45-65%* 2-3% Male Female 60-80%* 1-2%

Small cities/Towns

Male Female 35-40% 2-6% Male Female 50-70% 4-7% Male Female 65-85% 4-7%

Villages

Male Female 40-55% 5-8% Male Female 55-70% 6-9% Male Female 70-90% 6-10%


A RANDOMIZED CLINICAL TRIAL TO TEST THE EFFEC-TIVENESS OF RISK COMMUNICATION ON READINESS TOCHANGE AMONG SMOKERS IN A PRIMARY CARE SETTINGNevin Uysal, MD*; Marilyn M. Schapira, MD, MPH; Michael J. Bron-dino, PhD; Brent Logan, PhD; Jaswinder K. Sidhu, MD. Medical Collegeof Wisconsin, Wauwatosa, WI

PURPOSE: To test the effectiveness of a risk communication programin moving smokers from precontemplation to further stages of change ascompared to brief advice.

METHODS: Randomized controlled study. Risk communication pro-gram consisted of graphical representations of numerical data regardingrisk of lung cancer and chronic obstructive lung disease (COPD), and thebenefits of smoking cessation.The stage of smoking cessation, knowledgelevels and risk perceptions were evaluated at baseline and 3 weeks afterthe intervention.

RESULTS: Of the 148 smokers recruited for the study, 132 smokerscompleted the study. The majority of participants were white women �50 years of age, with �12 years of education and in a precontemplation orcontemplation stage. The median duration of counseling was 5 and 7minutes in the brief advice and the risk communication groups respec-tively. Both the risk communication group and the brief advice groupprogressed from a precontemplation to a further stage after the interven-tion without any statistically significant difference between the groups.None of the variables that were tested predicted stage progression. Bothgroups had low levels of knowledge about lung cancer and COPD, and thebenefits of smoking cessation at baseline. There was no improvement inthe knowledge level or risk perceptions of lung disease 3 weeks after eachintervention in either of the groups.

CONCLUSIONS: The majority of the smokers in a primary caresetting were in an earlier stage of change. Providing risk information usinggraphical representations was only as effective as brief advice in movingsmokers from an earlier to a later stage of change.

CLINICAL IMPLICATIONS: The majority of the smokers encoun-tered in clinical settings are in earlier stages of change and unlikely toaccept the more traditional action oriented smoking cessation interven-

tions such as pharmacological treatments or referral to a smokingcessation clinic. Therefore, brief advice remains the most important formof counseling these smokers. The content of brief advice needs to bestudied further to increase its effectiveness.

DISCLOSURE: N. Uysal, None.

COMPARISON OF AN ENHANCED VOICE RECOGNITIONSOFTWARE SYSTEM FOR SCREENING POTENTIAL SUB-JECTS FOR INVESTIGATIONAL SMOKING CESSATION STUD-IES WITH A TRADITIONAL TELEPHONE SCREENINGMETHODJames D. Melson, RN*. University, University of Nebraska MedicalCenter, Omaha, NE

PURPOSE: To compare a traditional telephone screening method toan enhanced voice recognition software system via a web based platform.

METHODS: Subject data was extracted retrospectively from tele-phone screening documents from two investigational smoking cessationstudies. Comparison was made of duration of time from the first subjecttelephone contact to date of on-site screening under the two telephonescreening conditions.

RESULTS: 360 subjects responded to advertisement for a smokingcessation study from October 2002 to March 2003. 181 subjects wereexcluded. Prior to Jan 20th 2003 and implementation of the new system,the average time lapse for 60 subjects between the initial response to theadvertisement and the date the subject was actually seen at the site forscreening and informed consent was 12.6 days. Following the implemen-tation of the software system, 60 subjects were seen an average of 9.7 daysbetween the time of response to the advertisement and the time seen forscreening. Although this is not statistically significant, the system hasreduced, by 25%, the number of days a potential subject makes contactwith the site and the consent form is signed.

CONCLUSIONS: The enhanced voice recognition software and theability to rapidly extract the subjects that respond positively to the criticalinclusion/exclusion criteria have reduced the amount of time (required bystudy personnel) between response to the advertisement and the time thesubject is actually screened at the study site. It also drastically reduces thenumber of attempts to re-contact the individuals who are not available oran answering machine is reached at the initial effort to contact thepotential subject thus averting the proverbial “phone tag” phenomenon.

CLINICAL IMPLICATIONS: Voice response systems may improveaccrual rates for smoking cessation programs.

DISCLOSURE: J.D. Melson, None.

SMOKING CESSATION IN COPD PATIENTS WITH NEWLYDIAGNOSED AIRFLOW LIMITATION: A REAL LIFE AP-PROACHDorota M. Gorecka, MD*; Michal Bednarek, MD; Elzbieta Puscinska,MD; Adam Nowinski, MD; Anna Goljan, MD; Jan Zielinski, MD.Institute of TB & Lung Diseases, Warsaw, Poland

PURPOSE: To evaluate the effects of smoking intervention in a groupof subjects with newly diagnosed airflow limitation (AL).

METHODS: Of 558 current smokers participating in populationspirometric screening for COPD combined with smoking cessationadvice, 297 were diagnosed to have AL (FEV1/FVC �0.7). After one year193 presented for the follow-up visit. Thirty subjects (10.1%) quitsmoking. Remaining 163 smokers were invited to the smokers’ clinic.Attendees were randomised to treatment with nicotine patch (n�38) orbupropion SR (n�32). Follow-up was scheduled at 2 weeks (Visit2), endof treatment (Visit3), 6 months (Visit4) and 12 months (Visit5). After 12months a phone call assessed smoking status. Non-smoking status wasvalidated with carbon monoxide in exhaled air. Patients who did notattend the follow-up visits were considered smokers.

RESULTS: Of 70 smokers with AL attending smokers’ clinic 40 weremales and 30 females, mean (SD) age 56 (10) yrs, age at starting smoking18 (4) yrs, FEV1 73 (17) %pred, Fagerstrom score 6.5 (2.1), exposed to 43(18) packyrs. Number (%) of smokers attending follow-up were 57 (81%)at Visit2, 34 (49%) at Visit3, 14 (20%) at Visit4 and 69 (99%) after a year(Visit5). The validated quit rate after 12 months was 18.5% (13/70), 25%in the group treated with bupropion SR and 13% in the group treated withnicotine patch (NS).

CONCLUSIONS: In smokers with newly diagnosed COPD, who didnot quit smoking as the result of minimal intervention, one year validated




cessation rate after pharmacological treatment. was 18.5%. The drop-outrate in the follow-up was considerable, necessitating a phone call after oneyear to assess the smoking status.

CLINICAL IMPLICATIONS : In smokers with newly diagnosed COPDa real life smoking interventions result in considerable one year validated quitrate (10.1% after minimal intervention and 18.5% after pharmacologicaltreatment). Every effort should be applied to increase motivation to quit andparticipation in the programme of smokers with AL.

DISCLOSURE: D.M. Gorecka, None.

CHANGES IN SMOKING HABITS IN SAUDI ARABIA AND ITSIMPLICATIONSRashid N. Siddiqui, MBBS,FCCP*. Government, Security Forces Hospi-tal, Riyadh, Saudi Arabia

PURPOSE: Tobacco import and smoking were banned in Saudi Arabiafrom 1926-1960.Until then lung cancer was a rare event.From 1961 to1984,tobacco import increased 40 folds.Lung cancer is now number fourin the list of most common cancers in males in Saudi Arabia.The purposeof this study was to gauge how rife smoking is in the Saudi society.

METHODS: Patients coming to our pulmonary function laboratoryfrom all specialties,including general surgery,internal medicine and pul-monology were screened for the smoking habit over a period of 15months.In all 1370 patients were studied.

RESULTS: The prevalence of the habit of smoking was 35% in malesand 4% in females.The average age of this survey was 41.3 years and thegreatest prevalence was in the youngest groups,20-29 years(51%)and30-39 years(43%).There seemed to be no co-relation between level ofeducation and the incidence of smoking in males. More alarmingly almostall of the female smokers were young and educated.

CONCLUSION: The prevalence of smoking in Saudis in this study issimilar to others done recently in the region.

CLINICAL IMPLICATIONS: There is unequivocal evidence thatcigarette smoking is associated with lung cancer,chronic bronchitis andpremature death.It takes between 20 to 30 years of smoking for lungcancer to manifest itself. With the gradual rise of smoking in Saudi Arabiasince the 1970s an epidemic of lung cancer may well be in the making.

DISCLOSURE: R.N. Siddiqui, None.

ENDOCRINE DISORDERS AMONGST A COHORT OF PA-TIENTS UNDERGOING SMOKING CESSATIONVirginia C. Reichert, NP*; L Villano, NP; P Folan, RN; N Kohn, MA; RLoeber, NP; A Fein, MD; D Schulman, RN; NFN Arunabh, MD. NorthShore University Hospital, Great Neck, NY

PURPOSE: Early smoking cessation is a cost-effective tool for judiciousutilization of scarce health care resources. The effect of endocrine disorders(diabetes and/or thyroid diseases) on the process of quitting smoking is notwell appreciated. We studied the impact of diabetes / thyroid disordersamongst a cohort of patients undergoing smoking cessation.

METHODS: The cessation program at North Shore University Hos-pital consisted of 6 sessions emphasizing support, behavior modificationand pharmacological interventions. Data was collected from participants(N�522) from 1999- 2003 via questionnaires before and at program end;data was analyzed using SAS®.

RESULTS: Of the total (n�522) group, 72 participants with endocrinedisorders (35 diabetics, 37 thyroid disorders) were considered (20 malesand 52 females). Of these, 75% reported having other co-morbidities; 80% reported “general health concerns” as a significant reason for quitting;39.5% also cited cigarettes “controlled their lives”. A self-report “readinessto quit” scale, 70% scored highly (� 7out of 10). There was no statisticaldifference between the 2 groups (thyroid vs. diabetes) with respect to age(49.8 vs. 54.0), or number of previous quit attempts (3.1 vs. 3.0), althoughpast smoking history (i.e. pack years) was significantly different (33.6 vs.50.1; p�0.005). Quit rate upon completion of the program was 47.8% inthis endocrine cohort; with only 40.0 % diabetics quitting vs. 56.3% withthyroid disorders. Quit rate for total group of 522 participants was 50.5%

CONCLUSION: Endocrine disorders impact the process of smokingcessation particularly as diabetics in this cohort were much more addictedto nicotine yet less likely to quit than participants with thyroid disorders orthe general smoking population. Although both endocrine groups dis-played equal preparedness and desire to quit, and both received the sameinterventions, the diabetic patients did not fare well. Presence of diabetes

in particular, should alert clinicians to the need for more intense smokingcessation interventions.

CLINICAL IMPLICATIONS: Clinicians understanding of effect ofco-morbidities can positively impact smoking cessation amongst theirpatients.

DISCLOSURE: V.C. Reichert, None.

THE TOPOGRAPHY OF QUITTING BY “KHAN’S CESSATIONCYCLE,” A TIME TESTED REGIMEN FOR SPONTANEOUSSMOKING CESSATION TRIGGERING FORWARD THE CHAINOF SMOKING CESSATIONM Ishaq, MD.DTCD.MCPS.FCCP.FACP.FAAAAI*. Pulmonary/Allergy,Al-Junaid Hospital, Nowshera, Pakistan

PURPOSE: Is to treat smokers with quitting advises & referring thosewith difficult to follow up for psychological support.

MATERIALS & METHODS: Smoking uptake considered a social actof an individual’s perception is not difficult to adopt rather it is difficult toquit once smoking habit has been established. Khan’s cessation cycle hasbeen followed successfully 2000-early 2003.in a population of tobaccocultivated area district Nowhere North of Pakistan with outcomes as,

RESULTS: Please see attached graphics for details,

5-10 % of the population less likely inclined to smoking cessation, 90%agreed to comply, then 35% have no relapses on cessation.15% a singlerelapse.25% followed successfully as non-smokers after 2-3 relapses, 15%established to non smoking state with 4-5 relapses. The rest of 5%resistant to quit were referred for psychological supportive treatment.

CONCLUSIONS: Opinion leaders working in a team work couldpatronize quitting advises with lasting outcomes.

CLINICAL IMPLICATIONS: Smoking once a trademark of civiliza-tion & prestige is now a symbol of poverty&less education.


THE COST OF SMOKING AND ITS IMPACT ON A COHORT OFPATIENTS UNDERGOING THE PROCESS OF SMOKING CES-SATIONVirginia C. Reichert, NP*; L Villano, NP; P Folan, RN; N Kohn, MA; AFein, MD; D Schulman, RN; NFN Arunabh, MD. Academic, NorthShore University Hospital, Manhasset, NY

PURPOSE: Smoking results in a financial and a health burden toindividuals and society. We studied the effect of participant’s attitudeabout financial cost of smoking and its influence on quitting.

METHODS: On day one, participants were asked about “reasons forquitting” with multiple reasons listed. Participants checked off all thatapplied, one choice being “cost of cigarettes”. Participants self-rated on




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“readiness-to-quit” scale between 1-10. On last day, participants who quitsmoking were surveyed for “perceived benefits since quitting”. Partici-pants checked many; with one choice “money saved”. Data was collected1999-2003.

RESULTS: 473 participants were studied, 227 [48.0%] cited “cost ofcigarettes” as reason for quitting. There was no significant associationbetween citing cost as a reason and high readiness-to-quit, (�7 on a scaleof 1-10), (chi-square test) ). Of those who reported high readiness-to-quit,only 46.0% considered cost as a significant factor, whereas 56.4% of thosewho reported low readiness-to-quit did consider cost as a reason to quit.There was no significant association between citing cost, and sex, (chi-square test), age or pack years (Mann-Whitney test). 209 (51.9%)participants successfully quit. Survey of quitters revealed only 14.4%reported, “money saved” as a benefit. Majority of participants reportedimmediate improvement in their health as the most tangible quittingbenefit.

CONCLUSIONS: Participants who are more ready to quit [score �7out of 10) are no more likely to report the cost of cigarettes as a reason forquitting. Although nearly half of all participants initially saw cost as afactor for quitting, few were able to appreciate a tangible financial benefitof money saved after quitting. Participants realize the gain in healthimprovement as a much more important apparent benefit immediatelyafter quitting than any financial saving.

CLINICAL IMPLICATIONS: Clinicians cannot rely upon patientattitudes about cost of cigarettes as a serious indicator for their readiness-to-quit. Further studies are needed to elucidate the impact of financialcosts on smoking and its effect on the process of quitting.

DISCLOSURE: V.C. Reichert, None.

HISPANIC PATIENTS WITH CHRONIC OBSTRUCTIVE PUL-MONARY DISEASE DID NOT RECEIVE REFERRAL TO SMOK-ING CESSATION COURSES AS COMMONLY AS PATIENTS OFOTHER ETHNICITIESSandra G. Adams, MD*; Angela C. Hospenthal, MD; Gwen M. Baillar-geon, MS; Lewis E. Kazis, ScD; Jacqueline A. Pugh, MD; AntonioAnzueto, MD. UTHSCSA, San Antonio, TX

PURPOSE: To describe differences in smoking habits and in physi-cian-patient interactions of Hispanics with chronic obstructive pulmonarydisease (COPD).

METHODS: Random cross-sectional survey of veteran enrollees fromthe 1999 Large Health Survey with at least 1 visit with an ICD-9 code forCOPD. Response rate was 63% and after the “never smokers” wereexcluded, 89,485 patients were analyzed.

RESULTS: Eighty-seven percent (77,495) categorized themselves as“white,” 9.1% (8,139) as “black,” and 2.7% (2,413) as “Hispanic.” A varietyof other ethnicities made up the remaining 1.2%. Hispanics self-reportedfewer cardiac comorbidities, but significantly more psychiatric comorbidi-ties than Caucasians or African Americans (AA). Fewer Hispanics werecurrent smokers (20% vs. 28%) and they reported smoking fewercigarettes per day than the other ethnicities. Nearly 30% of Hispanicsreported that they were not asked about tobacco use by their doctor withinthe last year, compared with 20% of the other two major groups.Approximately 35% of each group reported that they were not advised toquit smoking by their physician within the last year. Only 15% of theHispanics were referred to a treatment program for smoking cessation,compared with 19% and 22% of Caucasians and AA, respectively. Inaddition, 37% of the Hispanic population reported that they did notreceive any services needed to quit smoking, compared with 31% and 29%of Caucasians and AA, respectively.

CONCLUSIONS: Despite having more psychiatric comorbidities,fewer of the Hispanic patients in this cohort with COPD were currentsmokers than either Caucasians or AA. However, the currently smokingHispanic patients did not receive, and were not referred to smokingcessation services as often as Caucasian or AA patients.

CLINICAL IMPLICATIONS: This significant gap in the manage-ment of Hispanic patients with COPD should prompt healthcare provid-ers to more aggressively inquire about smoking status and more activelyrefer this population to smoking cessation programs.

DISCLOSURE: S.G. Adams, None.

SIGNIFICANCE OF ALLOGENIC BLOOD TRANSFUSION ONDECREASED SURVIVAL IN PATIENTS WITH ESOPHAGEALADENOCARCINOMASudip Ghosh, PhD, FRCS*; Christos Alexiou, FRCS; Matti Mahmoud,MRCS; John P. Duffy, MS, FRCS; William E. Morgan, FRCS; FrederickD. Beggs, FRCS. Teaching Hospital, Nottingham City Hsopital, Notting-ham, United Kingdom

PURPOSE: The significance of allogenic blood transfusion in theprognosis of patients with esophageal carcinoma remains controversial.We have recently shown that survival in patients with adenocarcinoma(AdenoCa) is significantly lower than in patients with squamous cellcarninoma (Sq Cell Ca). The objective of the current study was toelucidate the correlation between peri-operative allogenic blood transfu-sion and the poorer prognosis in patients with adenocarcinoma.

METHODS: The study group compromised 509 consecutive patients(312 men and 197 women) with a mean age of 69 years who underwentesophagectomy between 1990 and 2001 in one unit. The clinico-patho-logical data and survival were compared between 171 patients (63.8%)with AdeonCa and 97 (36.2%) with Sq Cell Ca who received anperi-operative blood transfusion and 178 (73.9%) with AdenoCa and 63(26.1%) patients who did not.

RESULTS: The operative mortality was 5.5% (28 deaths). Medianoperative blood loss was 580 mL (range, 125 to 4,500 mL). Mean bloodtransfusion was 2.4 units (range, 0 to 8 units). Overall actuarial 1-, 5- and10 year survival rates in the AdenoCa and Sq Cell Ca groups were 52.7%,14.9% and 8.7% and 55.6%, 35.9%, 21.7% respectively. Multivariateanalysis demonstrated that the factors that appeared to independently todetermine prognosis in both groups were depth of tumour (p�0.001),lymph node metastasis (p�0.001) and post-operative complications(p�0.029). Peri-operative blood transfusion was not found to be anindependent prognostic indicator in either group.

CONCLUSIONS & CLINICAL IMPLICATIONS: This study dem-onstrates that late survival in patients with adenocarcinoma of theesophagus is significantly worse than squamous cell carcinoma but isindependent of allogenic peri-operative blood transfusion but re-affirmsthe importance of tumor invasion and lymph node involvement in theoverall poor prognosis of these patients.

DISCLOSURE: S. Ghosh, None.

ROUTINE PRE-OPERATIVE VENOUS STUDIES IN THORACICSURGICAL PATIENTS TO IDENTIFY THOSE AT HIGH RISKFOR PULMONARY EMBOLUSBarbara J. Tempesta, CRNP*; Farid Gharagozloo, MD; Nevin Katz, MD;Marc Margolis, MD; David Salter, MD; Edmund P. Alexander, MD.University Hospital, George Washington University Medical Center,Washington, DC

PURPOSE: Thromboembolic events are relatively common in patientsundergoing major thoracic surgery and are associated with high mortality.The frequency of these events may be related to the presence ofpre-operative venous thrombotic disease, which is present in a relativelyhigh proportion of patients with malignancy. We hypothesized thatroutine venous doppler studies would identify patients at high risk forpulmonary embolus (PE) and lead to interventions which would improvesurgical outcomes.

METHODS: From 1998 until 2003, routine lower extremity venousstudies were performed in all patients (344) prior to undergoing majorthoracic surgery. Positive studies led to IVC filter placement or fraction-ated heparin use peri-operatively. Negative study patients received rou-tine post-operative prophylaxis with subcutaneous unfractionated heparinand sequential compression devices. Post-operatively, suspected DVTand/or PE were evaluated with standard imaging studies and patients witha positive scan for pulmonary embolus were anti-coagulated. The pre-operative study results, management, and surgical outcomes were re-viewed utilizing our thoracic surgical database.

RESULTS: Of the 344 patients in the study group, 338 (98.3%) hadnegative pre-operative venous studies. 4 (1.2%) of these patients hadpulmonary emboli demonstrated post-operatively by spiral CT. Onepatient (25%) in this subset died. Of the 6 patients (1.7%) with positivedoppler studies pre-operatively, 4 underwent placement of an IVC filterand 2 were started on fractionated heparin therapy pre-operatively. Noneof these patients had indication of a post-operative pulmonary embolism.The overall incidence of pulmonary embolism was 4/344 (1.2%).


Smoking and Lung Health, continued Thoracic Surgery12:30 PM - 2:00 PM


CONCLUSIONS: Unsuspected DVT may be diagnosed in approxi-mately 2% of patients presenting for major thoracic resection pre-operatively. Recognition and treatment may decrease risk for thrombo-embolic events in the thoracic surgical patient.

CLINICAL IMPLICATIONS: An aggressive peri-operative manage-ment strategy appears to limit the development of PE in these patientsand warrants further study.

DISCLOSURE: B.J. Tempesta, None.

SOLITARY FIBROUS TUMOR OF THE PLEURA: REVIEW OF 19CASES FROM A SINGLE SURGICAL GROUPRui Haddad, MD, PhD, FCCP*; Carlos E. Lima, MD; Tadeu D. Ferreira,MD; Fernando D. Teixeira, MD; Heitor C. Paiva, MD; Carlos H.Boasquevisque, MD, PhD; Mario C. Reis, MD. Department of Surgery -Faculty of Medicine - Federal University of Rio de Janeiro (UFRJ) -Division of Thoracic Surgery - Thoracic Diseases Institute (IDT) - UFRJ,Rio de Janeiro, Brazil

PURPOSE: To review the clinical, radiological, surgical and diagnosticaspects of 19 patients with solitary fibrous tumor of the pleura (SFTP).

METHODS: The records of 19 patients with pleural tumors seen at theDivision of Thoracic Surgery of the Thoracic Diseases Institute - UFRJ,over a period of 13 years diagnosed as SFTP were retrospectivelyreviewed. Sex, ages, symptoms, locations and methods for diagnosis(imaging and histology) were carefully recorded and reviewed and theresults were compared to the international literature.

RESULTS: Eleven patients were female. The mean age was 58.4years. 11 patients were symptomatic: chest pain (6), SOBOE andweight loss (5), clubbing (4) and hypoglycemia (2). The chest X-ray wasabnormal in all cases. 12 cases were in the right chest. The histologicaldiagnosis was done through biopsy (needle or open) in 2 cases andcomplete surgical resection in 17. The surgical access was postero-lateral thoracotomy in 14 cases, VATS in 4 and sternotomy in 1. Seventumors weighted more than 1,100g. The sites of implantation of thelesions were: 11 in the visceral, 1 in costal and 3 in diaphragmaticpleural surface. Three malignant tumors were attached to more thanone structure, including pericardium. 18 cases were completely re-sected (one inoperable). The histology was done by hematoxyllin-eosinstain and vimentin in all cases. The cases with malignant features weresubmitted to another immuno-histochemical confirmation (CD-34).Fifteen cases were benign and 4 malignant. 3 patients died fromrelapse and metastases.

CONCLUSIONS: 58% of the cases were in male patients. The agepeak in our cases was in 6th (7 cases), 5th (4 cases) and 8th (4 cases)decades. Most of our cases were symptomatic. Some cases presented assolitary pulmonary nodules or mediastinal tumors. In 50% of the cases thesupposition of SFTP was done.

CLINICAL IMPLICATIONS: SFTP can mimic every intra-thoracicneoplasm and should be reminded in the differential diagnosis of this kindof lesions.

DISCLOSURE: R. Haddad, None.

SOLITARY FIBROUS TUMORS OF THE PLEURA: CLINICALBEHAVIOR AND SURGICAL OUTCOMEJee-Won Chang, Board of Cardiothoracic Surgeon*; Jhingook Kim, Boardof Cardiothoracic Surgeon; KwanMin Kim, Board of CardiothoracicSurgeon; YoungMog Shim, Board of Cardiothoracic Surgeon; YongSooChoi, Board of Cardiothoracic Surgeon; Joung HO Han, Board ofAnatomical Pathology. Sungkyunkwan University, Samsung Medical Cen-ter, Seoul, Republic of Korea

PURPOSE: The aim of this study is to investigate clinical characteris-tics, surgical treatment, and outcome of patients with the rare entity ofsolitary fibrous tumor of the pleura operated in our institution for 10years.

METHODS: Clinical records of all patients operated for solitaryfibrous tumors of the pleura between 1994 and 2003 were reviewedretrospectively. All tumors were classified benign or malignant by thepathologic criteria of hypercellularity, high mitotic activity, or pleomor-phism.

RESULTS: Twenty two patients (men 14, women 8) were operated inthis period. Mean age was 51 years (range 25-83). None had history ofasbestos exposure.Symptomatic patients were 13 cases (59%). Surgical

approaches included thoracotomy (n�14) and video-assisted thoracicsurgery (n�8). Mass excision at their base of pleural origin was possible in11 cases. Extended resection was performed in 11 cases (lobectomy 1,pneumonectomy 10). In pleuropneumonectomy cases, extended resetionswere performed in 7cases including diaphragm, chest wall, or pericar-dium. There was no operative mortality. Tumors were pathologicallybenign in 11 cases and malignant in 11 cases. Mean follow-up was 21months (benign 31 months, malignant 9.7 months). Resection was com-plete in all benign and malignant cases. Recurrence or distant metastasiswas observed only in malignant cases. Local recurrence was observed in 2cases and 1 was managed by completion pleuropneumonectomy. Meta-static diseases were observed in 6 cases (bone 2, brain 2, lung 2).

CONCLUSION: Complete surgical resection was curative treatmentfot benign solitary fibrous tumors of the pleura.

CLINICAL IMPLICATION: Clinical and radiologic close follow-upshould be emphasized after resection of malignant form of solitary fibroustumors of the pleura.

DISCLOSURE: J. Chang, None.

LOCAL RECURRENCE AND LONG-TERM SURVIVAL FOL-LOWING CURATIVE RESECTION OF LOCALIZED FIBROUSTUMORS OF THE PLEURARicardo S. Santos, MD*; Deepak Singh, MD; Yannis Raftopoulos, MD;Margareth Mizstal, MD; Yulin Liu, MD,; Jan Silverman, MD,; RobertKeenan, MD; Rodney Landreneau, MD. Allegheny General Hospital,Pittsburgh, PA

PURPOSE: Localized fibrous tumors of the pleura (LFTP) are rare,slow growing thoracic neoplasms with variable malignant potential. Thisstudy reviews the clinical presentation, surgical treatment, local recur-rence and long-term survival of patients undergoing curative resection ofLFTP in our department.

METHODS: This is a retrospective chart review of 13 patientsundergoing resection of LFTP. Tumors were classified as malignant, orbenign based on degree of cellularity, mitotic activity and nuclearpleomorphism.

RESULTS: There were 9 women and 4 men with a median age of 65years (range 45-81 years). Four patients (30.8%) presented with symptomsincluding chest pain and weight loss (n�1), chest pain alone (n�2) andcough (n�1). Nine patients had no symptoms and the diagnosis was madebased on incidental radiological findings. Tumor size ranged from 1.2 to24 cm, with a mean of 7.2 cm. Two tumors were considered malignant andthe remaining 11 were benign. Both patients with malignant LFTPrecurred locally and required a total of 7 additional resections. One out of11 tumors (9.1%), which was classified as benign also recurred andrequired 3 additional resections. All patients are alive at a medianfollow-up of 34.5 months.

CONCLUSIONS: Malignant LFTP have a higher incidence of localrecurrence compared to benign LFTP. Resection of recurrent tumors isrecommended as long-term survival is excellent.

CLINICAL IMPLICATIONS: LFTP is a rare pleural tumor, how-ever, pulmonary phsisician should be aware as complete resection yieldexcellent survival.

DISCLOSURE: R.S. Santos, None.

VIDEOTHORACOSCOPIC WEDGE RESECTION OF THEBRONCHIAL WALL: AN ALTERNATIVE OPTION FOR TYPI-CAL BRONCHIAL CARCINOIDSLuis C. Losso, MD, PhD*; Mario C. Ghefter, MD; Hassan A. Yassine,MD. ABC Foundation School of Medicine, Sao Paulo, Brazil

PURPOSE: Bronchial carcinoids are low-grade malignant neoplasms.Typical carcinoid represents the best differenciated form and an adequatesurgical resection offers the best prognosis. Is videothoracoscopy analternative option to the resection of selected cases of typical carcinoids?

METHODS: Videothoracoscopy was the approach for lesser curativeresections in two centrally located typical carcinoid tumors. The first, atotally videothoracoscopic wedge resection of the bed of a typicalcarcinoid located at the right main bronchus previously enucleated by asuccessful diagnostic and therapeutic bronchoscopy. The second, a partialsleeve vats bronchoplasty with a small four centimeters incision for theresection of a typical carcinoid of the left main bronchus.

RESULTS: Fronzen section analysis of the mediastinal and hilar lymphnodes and bronchial margins of the resected bronchial tissues were


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performed as well as immunohistochemical staining and electron micros-copy. All the tissues were disease-free. The postoperative period wasuneventful, with no air leaks and a five and seven days of hospitalization,respectively. Postoperative bronchoscopies showed no reductions of thebronchial lumens. There was no morbidity and no mortality in the sixmonths follow-up.

CONCLUSIONS: Videothoracoscopy in typical carcinod tumorsmaybe an alternative option for selected patients.

CLINICAL IMPLICATIONS: A less invasive approach for curativeresection of bronchial carcinoid tumors.

DISCLOSURE: L.C. Losso, None.

VATS LOBECTOMY FOR FRAIL OR COMPLEX PATIENTSTodd L. Demmy, MD*. Roswell Park Cancer Institute, Buffalo, NY

PURPOSE: This study aims to examine the preferential use of VATSlobectomy in frail or complex patients.

METHODS: Seventy-two consecutive planned VATS lobectomy casesof one surgeon at affiliated teaching hospitals were studied concurrentlyover 100 months. The primary reasons for avoiding open thoracotomieswere poor pulmonary (15), cardiac (12) or activity (10) performances, orextrathoracic malignancies (12), advanced ages (8), severe orthopedicdisabilities (9), and other problems (6). Nineteen matched comparisonopen cases were available from early in the series before VATS domi-nated.

RESULTS: Patients had mean tumor sizes of 2.9 cm and were 64�12years old, 54% female, and 46% active smokers. Patients lost to follow-up(11%) completed 37-months mean surveillance. Lobectomies [RU (18),RM (4), RL (12), LU (20), LL (15), and Bi- (3)] incorporating concomitantstaging procedures lasted 220�65 min. Three poor physical activity casesfrom the first third of cases were the only hospital deaths. Of six patientsconverted to open thoracotomies, only one was in the second half of theseries. Ten complications (pulmonary-related) extended hospitalizations.Hospital stays for surviving VATS patients compared favorably to com-bined open and converted cases (5.6�4.4 vs. 12.6�11.0 days, p � 0.01).VATS cases had faster activity resumptions and comparable cancercontrols. Subsequent urgent operations or oncologic treatments were alsoexpedited.

CONCLUSIONS: For impaired patients with advanced or complexdiseases, mortality and conversion rate trends for VATS lobectomy showprogress while pulmonary complications remain the major source ofmorbidity.

CLINICAL IMPLICATIONS: While further study and refinement iswarranted, VATS lobectomy should be considered for high risk patients orothers for whom open thoracotomy convalescence would be difficult orwould delay other important therapies.

DISCLOSURE: T.L. Demmy, None.

VIDEO-ASSISTED THORACOSCOPIC LOBECTOMY: A SINGLEINSTITUTION STUDYFrancis J. Podbielski, MD*; Ann E. Connolly, MS, NP; Patrick M.McEnaney, MD; Ciaran J. McNamee, MD; A A. Conlan, MD. Universityof Massachusetts Medical School, Worcester, MA

PURPOSE: To examine the early experience of entirely thoracoscopiclobectomy in treatment of lung nodules at a 780 bed academic medicalcenter.

METHODS: Prospective data were collected on twenty patients whounderwent successful thoracoscopic lobectomy from September 2002 toApril 2003 after flexible bronchoscopy and staging mediastinoscopy. Thestudy population consisted of 6 men and 14 women with a mean age of 61years. A thoracic surgery nurse practitioner performed daily data collec-tion and tracked operative and post-operative complications.

RESULTS: Length of stay (LOS) analysis showed a median of 4 daysand a mean of 7.3 � 5.8 days. LOS was � 4 days in 55% of studyparticipants. One death occurred in the post-operative period secondaryto mesenteric ischemia. Eighteen complications occurred in nine of thetwenty patients. Two patients suffered major complications (mesentericischemia, colonic volvulus, empyema, and atrial fibrillation). Four patientshad prolonged air leaks and two of these patients had clinical subcutane-ous emphysema. Eighteen patients were discharged in good condition.Malignant tumors were found in 80% of cases. Tumor size was � 3 cm in80% of patients. Non-malignant findings included: focal pulmonary

vascular congestion, lymphoid infiltrate (2), and emphysema with focalfibrosis.

CONCLUSIONS: The mortality of this patient population was 5%,and some type of complication occurred in 45% of patients. In patientswith cancer, 69% had stage 1a and 31% had stage 1b disease.

CLINICAL IMPLICATIONS: Thoracoscopic lobectomy is a mini-mally invasive technique that is gradually gaining acceptance in thethoracic surgery community. Our early experience with this techniquedemonstrates a favorable length of hospital stay compared to the openapproach. Complications encountered are similar to those encounteredduring minimally invasive pulmonary wedge and segmental resections.We believe that increased surgical volume will result in a lower meanLOS, mortality, and complications.

DISCLOSURE: F.J. Podbielski, None.

THORACOCOPIC TREATMENT FOR POSTPNEUMONEC-TOMY EMPYEMAHenrik J. Hansen, Chief surgeon*; Mark Krasnik, Chief surgeon. Univer-sity Hospital, Gentofte County University Hospital, Copenhagen, Den-mark

PURPOSE: Radical treatment of postpneumonectomy emphyemabronchopleural fistula with minimally invasive surgery.

METHODS: Radical debridement of the pleural cavity and packingwith wet dressing of iodine and closure of the fistula with omentopexy.Finally the pleural space is obliterated with saline contaning antibioticsafter a re-thoracotomy. In stead of repeated thoracotimies the pleuralcavity is cleared and the wet dressing is changed by video assisted thoracicsurgery (VATS). In addition systemic antibiotica treatment is given

RESULTS: 3 patients with postpneumonectomy emphyema and bron-chopleural fistula were treated with VATS follow up instead of thetraditional re-thoracotomies. All 3 had 2 VATS follow up and could bedischarged without signs of infection and without tubes. Hospitalisationtime mean 15 days (14-17 days)

CONCLUSION: Minimally invasive repeated surgical procedure com-bined with closure on bronchopleural fistula is possible

CLINICAL IMPLICATION: This procedure is less traumatic tocritically ill patients and procedure is less time consuming than thetraditionally repeated thoracotomies

DISCLOSURE: H.J. Hansen, None.

A PROSPECTIVE AUDIT OF MANAGEMENT OF AIR LEAKSAFTER PULMONARY RESECTION BASED ON AN INSTITU-TIONAL PROTOCOL OF CAREAntonio E. Martin-Ucar, MD*; Eliseo Passera, MD; Roger Vaughan, MD;Gaetano Rocco, MD, FCCP. The Price-Thomas Unit. Northern GeneralHospital, Sheffield, United Kingdom

PURPOSE: Postoperative air leaks are common after pulmonarysurgery. They can determine morbidity and hospital stay. Despite this,interpretation and management is variable and mostly based on personalexperience. We have conducted an audit to evaluate the incidence andmanagement of post-operative air leaks after pulmonary resection accord-ing to a local protocol of care.

METHODS: A prospective audit of management of postoperativeair-leaks and intercostal drains in all patients undergoing pulmonaryresection by two dedicated thoracic surgeons over a 5-month period.Endpoints: incidence and duration of air leak, length of drainage, hospitalstay and need to re-insert additional chest drains after surgery. 8 patientsundergoing pneumonectomy were excluded (none suffered bronchopleu-ral fistulae).

RESULTS: Of 78 patients [43 male and 35 female, median age 60(range 20-78)years] undergoing pulmonary resection, 38 (49%) presenteda postoperative air leak. The median drainage time was 3 (range 1-17) daysand median hospital stay was 5 (1-52) days. Prolonged air leak (PAL) over7 days occurred n 5 cases (6%). In two cases (2.6%) an additional chestdrain was inserted at one point in the post-operative period. There wasone death (1.3%) nine days after right upper lobectomy.

CONCLUSIONS: While the incidence of post-operative air leaks wassimilar to published standards, their duration appear shortened whencompared with the literature.

CLINICAL IMPLICATIONS: Our protocol of care for the managementof air-leaks and intercostals drains derived in minimal local complications.




Results in anatomical and sublobar resections

Number Air leakDrainage

timeHospital

stay

Sublobarresections

41 15(37%) 2(1-15)days 3(1-16)days

Anatomical resections 37 23(62%) 3(2-17)days 6(3-52)daysTotal resections 78 38(49%) 3(1-17)days 5(1-52)days

DISCLOSURE: A.E. Martin-Ucar, None.

MALIGNANT MEDIASTINAL TUMORS: SURGERY, HISTOL-OGY, AND SURVIVALJozsef Furak, MD*; Imre Trojan, MD; Tamas Szoke, MD; LaszloTiszlavicz, MD; Adam Balogh, MD. University, Univ. of Szeged, Szeged,Hungary

PURPOSE: To establish the distribution of malignant mediastinaltumors according to histological structure, surgery, location and age.

METHODS: Between 1992 and 2002, 71 patients were operated onfor 54 anterior, 6 middle and 11 posterior mediastinal tumors. 17 of the 54tumors were malignant. 16 (94%) of the malignant tumors were located inthe anterior, and 1 (6%) in the posterior mediastinum. They were 10females and 7 males; average age 42.6 years (13-68). The surgicalapproaches were 8 median sternotomies, 8 posterolateral thoracotomies,and for a dumb-bell tumor it was a combined exposure (posteriorlaminectomy, followed by left posterolateral thoracotomy). In 5 cases, thetumor could be removed only with extended resection (1 lobectomy withchest wall resection, 2 wedge resections, 2 pericardial resections).

RESULTS: Histology revealed an Askin tumor in the posterior medi-astinum, 11 invasive thymomas, 2 thymus epithelial carcinomas, 1 thymuslymphoma, 1 malignant teratoma and 1 liposcarcoma in the anteriormediastinum. 13 patients received postoperative irradiation, 3 chemora-diotherapy, and 1 chemotherapy. 16 (30%) of the 54 anterior mediastinaltumors and 1 (9%) of the 11 posterior mediastinal tumors were malignant,but 14 (43,7%) of the 32 thymomas were malignant. 5-year survival of themalignant thymomas is 33%. In 4 patients, younger than 18 years old,other than invasive thymoma developed, (Askin tumor, liposarcoma,lymphoma, and malignant teratoma) and 3 of them died within a year.Myasthenia gravis appeared in 18,7% of the thymomas, and in one casemyasthenia gravis developed after a partial thymectomy.

CONCLUSION: Malignant mediastinal tumor occurs most commonlyin the anterior mediastinum. Almost half of the thymomas were malig-nant. In childhood, other than malignant thymomas developed, and theprognosis was poor.

CLINICAL IMPLICATIONS: The most common location of amalignant mediastinal tumor is the thymus with good prognosis. In youngpatients the malignant mediastinal tumor located out of the thymus withpoor survival. Myasthenia gravis may develop after partial thymectomy.

DISCLOSURE: J. Furak, None.

A PROSPECTIVE AUDIT OF VIDEO-ASSISTED MEDIASTINOS-COPY AS A TRAINING TOOLAntonio E. Martin-Ucar, MD*; Govind K. Chetty, MD; Roger Vaughan,MD; David A. Waller, MD,FACCP. Glenfield General Hospital, Leices-ter, United Kingdom

PURPOSE: Cervical mediastinoscopy is an important diagnostic andstaging technique. Limited operative field and visibility have traditionallymade it a difficult procedure to learn and supervise. Video assistedtechniques can aid training in the procedure. We designed a prospectivestudy to assess video assisted mediastinoscopy (VAM) as a training tool ingeneral thoracic surgical trainees.

METHODS: 43 patients were operated upon by two trainees duringtheir initial formation in general thoracic surgery (25 patients in 15months, and 18 patients in 9 months respectively). Indications were:staging (n�23), diagnosis of enlarged mediastinal nodes (n�14), anddiagnosis/staging (n�6). Endpoints of the study: operative time, need ofconsultant assistance during procedures, and ability of the trainee toidentify all nodal stations independently.

RESULTS: There were no complications. The mean operative timewas 29 (range 18-51) minutes. Valid histological samples were obtained in

all cases. There were no false negative results in the 13 patients whounderwent subsequent lung resection (sensitivity 100%). Operative Time(R2�0.83 and 0.77), need for consultant assistance (R2�0.98 and 0.94),and failure to independently reach all nodal stations (R2�0.95 and 0.94)significantly decreased with experience in both trainees’ cases (cubiccurve fit; p�0.001 throughout).

CONCLUSIONS: VAM permits a rapid learning and adequate super-vision of the technique without compromising safety, operative time orcompleteness of the procedure. The main advantages are: increased visualfield, image magnification, adequate light source and the ability to use twoinstruments simultaneously.

CLINICAL IMPLICATIONS: VAM should be the technique ofchoice in thoracic surgical teaching units

DISCLOSURE: A.E. Martin-Ucar, None.

THE UTILITY OF HIGH-FREQUENCY CHEST WALL OSCILLA-TION THERAPY IN THE POST-OPERATIVE MANAGEMENT OFTHORACIC SURGICAL PATIENTSJames S. Allan, MD, FCCP*; Julie M. Garrity, RN; Dean M. Donahue,MD. Massachusetts General Hospital, Boston, MA

PURPOSE: Post-operative pneumonia continues to be a leading causeof mortality and morbidity in patients undergoing thoracic surgicalprocedures. High-frequency chest wall oscillation (HFCWO) is an estab-lished therapeutic adjunct to the management of patients affected by avariety of chronic disorders resulting in the impaired clearance ofbronchopulmonary secretions. This study evaluates the utility of HFCWOin the post-operative management of thoracic surgical patients, who havea similar inability to clear bronchopulmonary secretions.

METHODS: Twenty-five patients (ages 47-83) undergoing a widevariety of elective thoracic surgical procedures were randomly chosen toreceive HFCWO as part of their routine post-operative care. HFCWOwas applied by means of an air-pulse generator connected to a circum-ferential inflatable vest applied to the chest wall. The air-pulse generatorwas set to a frequency of 12Hz, and therapy was applied for 10 minutes.Routine hemodynamic and pulse oximetric data were collected before,during, and after treatment. Qualitative data regarding patient toleranceand preference (as compared to percussive chest physiotherapy) were alsocollected.

RESULTS: No major adverse events were encountered during orsubsequent to HFCWO. Hemodynamic and pulse oximetric data alsoremained stable throughout the treatment period. Eighty-four percent ofpatients reported little or no discomfort during therapy, and HFCWO waspreferred to conventional chest physiotherapy by a 2:1 margin.

CONCLUSIONS: HFCWO is a safe, well-tolerated adjunct to theroutine post-operative treatment of elective thoracic surgical patients. Theobservation of hemodynamic stability is especially significant consideringthat the patients were studied in the early post-operative period, withactive epidural pain management.

CLINICAL IMPLICATIONS: These data demonstrate that HFCWOcan be used safely with a high degree of patient acceptance in an acutesurgical population. Moreover, HFCWO was observed to provide eachpatient with chest physiotherapy that was consistent in quality, with theprospect of significant cost-savings.

DISCLOSURE: J.S. Allan, Advanced Respiratory, Inc., grant monies.

BILIO-THORACIC FISTULAEAlexandru M. Botianu, MD, Ph D, FCCP*. University, University ofMedicine and Pharmacy from Targu-Mures, Romania, Targu-Mures,Romania

PURPOSE: Bilio-thoracic fistula (communication between bile ductsand thorax) is a rare but severe disease, still having a high mortality. Thepaper analyses our 18 years experience with the aim to establish the bestsurgical management. The tactical principles of surgical treatment aim forthe next 4 objectives: removal of the suppurated hydatid cyst from theliver and treatment of the remnant cavity; resection of the pulmonaryparenchyma with or without lung decortication; repair of the diaphrag-matic defect; desobstruction of the common bile duct through abdominalapproach.




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METHODS: During 18 years we operated 8 patients: 7 cases ofhydatid origin (2 bilio-pleural, 3 bilio-pulmonary and 2 bilio-bronchialfistulae) and one of lithiasic origin (stone impacted in the Vaterianampulla). In all cases we started with a transthoracic approach withresolution of the intra-thoracic lesions, large phrenotomy, treatment of thehepatic cavity and repair of the diaphragmatic defect. In order to reducethe haemorrhage we changed the classical order, by performing theparietal pleurectomy just before closure of the thoracotomy.

RESULTS: In 4 cases we didn�t perform the abdominal part of theoperation due to intraoperative failure of blood pressure: one patient hada favourable evolution with spontaneous resolution of jaundice; onedeveloped a biliary fistula which closed after 4 months, the patient havingbeen operated before in another unit with sphinctero-papillotomy; in 2patients the bilio-pleural fistulae relapsed and needed drainage of thecommon bile duct after 14 days. One postoperative death by uncon-trolable sepsis.

CONCLUSIONS: We believe that a one-stage bipolar thoracic andabdominal approach, beginning with the thoracic part of the operation isthe best treatment for bilio-thoracic fistulae if the general condition of thepatient allows a major procedure.

CLINICAL IMPLICATIONS: The technical and tactical changespresented will improve the results by allowing to perform a complexsurgical procedure in extremely fragile patients.

DISCLOSURE: A.M. Botianu, None.

RADIOFREQUENCY ABLATION OF THE PORCINE LUNGWITH PARTIAL VASCULAR ISOLATIONChristopher Meyer, MD*; J. Michael Smith, MD FACS; Thomas Panke,MD; Frank Schleuter, MD. Good Samaritan Hospital, Cincinnati, OH

PURPOSE: Our study is based on increasing the effectiveness ofradiofrequency ablation (RFA) by eliminating heat sink. The use of RFAfor lung lesions is limited by the heat sink of surrounding vessels. Wehypothesized that partial pulmonary isolation would enlarge the volume ofnecrosis.

METHODS: RFA was used to create a sphere of necrosis in the lowerlobe of a porcine lung. Using the same RFA settings and techniqueanother sphere of necrosis was created in the opposite lung after obtainingpartial vascular isolation by clamping the pulmonary artery. The animalswere euthanized and the spheres of necrosis were compared.

RESULTS: The mean volume of necrosis in the unclamped ablationgroup was 9.75 (� 5.11). The mean volume of the clamped ablation groupwas 12.26 (� 5.68). Using a paired samples t-test, the difference betweenthe unclamped and clamped group was not statistically significant(p�0.421). The volume of the spheres of necrosis was the same for bothgross and microscopic examination.

CONCLUSION: Although we were unable to demonstrate a differ-ence in necrosis with partial vascular isolation, we did demonstrate thatthe use of RFA on lung with minimal settings could create large areas ofcoagulation necrosis.

CLINICAL IMPLICATIONS: As clinical experience with RFA andlung in inoperable patients increases, techniques to enlarge the area ofnecrosis achievable will have great value.

DISCLOSURE: C. Meyer, None.

Thromboembolic Disease12:30 PM - 2:00 PM

DEEP VENOUS THROMBOSIS: A COMPARISON OF ETHNICGROUPS FROM THE DVT FREE REGISTRYKenneth T. Horlander, MD; Kenneth T. Horlander, MD*; Kenneth V.Leeper, MD; Samuel Z. Goldhaber, MD; Victor F. Tapson, MD. EmroyUniversity School of Medicine, Atlanta, GA

PURPOSE: Identify ethnic differences among patients with newlydiagnosed DVT.

METHODS: DVT FREE; a multicenter prospective survey of 5451patients enrolled at 183 sites in the United States. Diagnosis of DVTconfirmed by venous duplex ultrasound. There were no exclusion criteria.

RESULTS: Demographics of patients with DVT (Table 1). Of 5451patients with DVT, 72% Caucasian (n�3928), 17% African American(n�930), 4% Hispanic (n�210), �1% Asian (n�23), 1% other (n�41),and 6% unknown (n�319). Median duration of symptoms prior todiagnosis was lowest among Asians (2 days), highest among other ethnicgroups (4 days) and similar among remaining groups (3 days). Uponadmission, median duration of hospitalization was longer for African-Americans and Hispanics (10 days). History of cigarette smoking (74%),hypertension (71%) and cancer (77.6%) were major comorbidities (Table2). Prior to diagnosis, 25% (n�1372) of patients received prophylaxis(pharmacologic/mechanical or both): 71% Caucasians (n�969), 19%African American (n�261), 4% Hispanic (n�50), �1% Asian (n�7), 1%other (n�13), and 5% unknown (n�72). Prior treatment received by 5%(n�291) of patients: 71% Caucasians (n�206), 16% African American(n�47), 4% Hispanic (n�12), �1% Asian (n�2), �1% other (n�2), and8% unknown (n�72). Fifty percent (n�2631) received no prior prophy-laxis/treatment. Low molecular weight heparin (LMWH) used as a“bridge” to warfarin in 2143 patients (39%) and intravenous unfraction-ated heparin (UFH) used in 1926 patients (35%).

Table 1. Demographics

Caucasian(n�3928)

AfricanAmerican(n�930)

Asian(n�23)

Hispanic(n�210)

Other(n�41)

Unknown(n�319)

Male n (%)n�2559(47%)

1866(48) 422(45) 11(48) 92(44) 17(42) 151(47)

Female n (%)n�2892(53%)

2062 (52) 508 (55) 12 (52) 118 (56) 24 (58) 168 (53)

Diagnosed asoutpatientsn (%)

2022 (51) 402 (43) 9 (39) 107 (51) 18 (44) 167 (52)

Diagnosed asinpatientsn (%)

1906 (49) 528 (57) 14 (61) 103 (49) 23 (56) 152 (48)

Median Age(yrs)

68 61 61 57 57 65

Median Height(cm)

170.2 170.2 162.6 165.1 165.1 168.9

Median BodyMass Index(kg/m2)

27.1 26.6 24.1 28.0 29.4 27.9

Table 2. Comorbidities

Comorbidity(n�5451) Caucasian

AfricanAmerican Asian Hispanic Other Unknown

Cigarette Smokingn (%) n�2182(40%)

1611(74) 374(17) 6(0.3) 62(2.8) 12(0.6) 117(5.3)

Hypertensionn (%)n�2707(50%)

1914(71) 572(21) 9(0.3) 85(3) 15(0.6) 112(4.1)

Cancer n (%)n�1782 (33%)

1382(77.6) 235(13.2) 9(0.5) 50(2.8) 11(0.6) 95(5.3)

CONCLUSIONS: There are differences between ethnic groups whenDVT is diagnosed including: demographics, comorbidities, prophylaxis,and treatment. Further analysis is needed to explain these differences aswell as the delayed diagnosis for some ethnic groups and the disparitybetween groups receiving prior DVT prophylaxis or treatment.

CLINICAL IMPLICATIONS: This data suggests there are ethnicand treatment differences between DVT patients. These differences mayimpact on morbidity and mortality associated with DVT.

DISCLOSURE: K.T. Horlander, None.




INCIDENCE OF THROMBOSIS AND OTHER COMPLICA-TIONS IN LONG-TERM CENTRAL CATHETERSRebecca L. Shriver, MD*; Dana D. Vossler, MD. University of Missouri-Kansas City School of Medicine, Kansas City, MO

PURPOSE: Prolonged use of indwelling central venous catheters isincreasing in both inpatient and outpatient settings with infection andthrombosis constituting the major complications. While recommendationsregarding prevention of catheter thrombosis have been established fordialysis and cancer patients, data regarding prevention in others remainslargely anecdotal. Our goal was to better quantify the incidence ofthrombosis and other complications in patients with indwelling centralcatheters in an attempt to evaluate the potential clinical value ofprophylactic anticoagulation.

METHODS: A retrospective chart review of patient records from1991-2002 with ICD-9 coding for central venous catheter placement.Patients included had catheters in place for greater than 5 days and werenot on anticoagulation. Patients with chronic renal failure, malignancy,sickle cell disease, acute thrombotic event within the past six months, orother known hypercoagulable state were excluded. Data was abstracted toinclude type and position of catheter, its primary use, number of days inplace and associated complications.

RESULTS: Of 874 charts reviewed, 252 patients met inclusion criteria.Line type: Triple lumen catheters 217 (86%), Peripherally Inserted

Central Catheters 35 (14%)Location: Arm 35 (14%), Femoral 32 (13%), Subclavian 64 (25%),

Internal Jugular 121 (48%)Placed by Radiology 32 (13%), Medicine 115 (46%), Surgery 65 (26%),

Anesthesiology 38 (15%), Nursing 2 (�1%)Primary Line use: antibiotics 87, nutrition 34, other medications 126,

acute dialysis 5Days indwellling: 5-9 � 175, 10-14 � 43, 15-19 � 14, 20-24 � 10,

25-30 � 6, greater than 30 � 4Complications: None in 218 (87%), confirmed or suspected infection 26

(10%), suspected thrombosis 5 (0.2%), confirmed thrombosis 0, pneumo-thorax 7 (0.3%)

CONCLUSIONS: While infection was the most common complica-tion, our study did not show a significant number of thrombotic compli-cations in patients with long term indwelling catheters.

CLINICAL IMPLICATIONS: Adults without a diagnosis of malig-nancy or other known hypercoaguable state may safely utilize centralvenous catheters without prophylactic anticoagulation.

DISCLOSURE: R.L. Shriver, None.

THE INCIDENCE OF UPPER EXTREMITY DEEP VENOUSTHROMBOSIS ASSOCIATED WITH PERIPHERALLY IN-SERTED CENTRAL CATHETERS IN AN INTENSIVE CAREUNITJonathan A. Rettmann, MD*; Robert D. Nohavec, RN, BS; Greg Denny,RN; Mary Ann Hendrix, RN, BS; John R. Michael, MD; Boaz A.Markewitz, MD, FCCP. University of Utah Health Sciences Center.Division of Respiratory, Critical Care, and Occupational PulmonaryMedicine, Salt Lake City, UT

PURPOSE: The use of peripherally inserted central catheters (PICCs)has increased significantly over the past several years. Upper extremitydeep venous thrombosis (UEDVT) is a known complication of PICCs,with a reported symptomatic incidence of 3-5% in recent large reviews;the incidence of PICC associated UEDVT has not been reportedspecifically in critically ill patients. Our goal was to determine theincidence of symptomatic PICC associated UEDVT in an intensive careunit (ICU).

METHODS: Retrospective database and chart review of all patientsadmitted to a 12-bed tertiary university hospital medical intensive careunit (MICU) during 2002. All patients having PICCs placed while in theMICU were included. The database and electronic chart were reviewed todetermine which patients with PICCs had a subsequent diagnosis ofUEDVT in the ipsilateral extremity. Diagnosis of UEDVT required apositive duplex ultrasound or venogram of the affected extremity. Suchstudies were ordered at the discretion of the treating physician based uponpatient signs/symptoms. The method of DVT prophylaxis in all PICCpatients was also obtained from the database.

RESULTS: Sixteen symptomatic UEDVTs developed in the 113patients with PICCs (incidence 14.2%). PICC lines were present for asignificantly greater number of days in those with versus those without

UEDVTs (19.5�3.8 vs. 10.8�1.1; p� .0005). There was no differencebetween groups in admitting acute physiology and chronic health evalu-ation (APACHE) II score, insertion of central venous catheters, or use ofheparin or pneumatic compression devices for lower extremity DVTprophylaxis.

CONCLUSIONS: Compared to other patient populations in theliterature, the incidence of symptomatic PICC associated UEDVT ap-pears to be considerably higher in critically ill patients. The duration ofcatheter use is significantly associated with the development of symptom-atic UEDVTs.

CLINICAL IMPLICATIONS: A high index of clinical suspicion forUEDVT should be maintained in ICU patients with PICCs, particularly inpatients with catheters in place for prolonged durations.

DISCLOSURE: J.A. Rettmann, None.

A COMMUNITY HOSPITAL ANALYSIS OF COMPUTED TO-MOGRAPHY PULMONARY ANGIOGRAM IN THE DIAGNOSISOF PULMONARY EMBOLISMAdrian S. Bucerzan, MD*; Dragos Zanchi, MD; Maydee Rosario, MD;William Dinan, MD, FCCP; Ari Klapholz, MD, FCCP. Cabrini MedicalCenter, New York, NY

PURPOSE: To assess the outcome and value of computed tomographypulmonary angiogram(CTPA) as the initial diagnostic test for pulmonaryembolism(PE). Previously, we had evaluated the diagnostic value ofventilation/perfusion scan(V/Q) in our institution.

METHODS: Retrospective review of inpatient records from 01/2001to 12/2001.

RESULTS: 92 patients had CTPA for suspected PE. They weredivided in 3 groups according to their pretest clinical probability(CP) ofPE. Of the 62 patients(67.4%) with low CP, 3(4.8%) had a positive CTPAand were anticoagulated. Of the 22 patients(23.9%) with intermediate CP,4(18.2%) had a positive CTPA and were anticoagulated. Of the 8patients(8.7%) with high CP, 4(50%) had positive CTPA and wereanticoagulated. 18 patients (8 with low CP, 8 with intermediate CP, and2 with high CP) out of the 81 with negative CTPA had additional testingfor venous thromboembolism(VTE). Only 1 (from the high CP group) ofthese 18 patients had a positive test for VTE (a high probability V/Q) andwas anticoagulated. Of all the negative CTPA, 17 of them providedsignificant, additional diagnostic information that was not evident on thechest radiograph.

CONCLUSIONS: The yield for a positive CTPA in our intermediate/high CP group was 27% (8 out of 30 patients). In the same CP group inthe PIOPED study, the yield of a high probability V/Q was 17%. Unlikethe V/Q, CTPA offers additional diagnostic information of diseases of thechest. Because of the very low yield of a positive CTPA in patients withlow CP (5%), medical centers should set up specific pathways andscreening processes to limit wasteful testing.

CLINICAL IMPLICATIONS: CTPA is emerging as the primarydiagnostic test for PE. Evaluating patient‘s CP for PE remains animportant first step before deciding on the appropriateness of a diagnosticwork-up for PE.

DISCLOSURE: A.S. Bucerzan, None.

THE IMPACT OF THE INTRODUCTION OF COMPUTED TO-MOGRAPHY WITH PULMONARY ANGIOGRAPHY AS A DIAG-NOSTIC TEST FOR PULMONARY EMBOLISMRaed A. Hamed, MBBS*; Carolina See, MD; Gonzalo Gianella, MD;Steven K. Goldberg, MD. Albert Einstein Medical Center, Philadelphia,PA

PURPOSE: Pulmonary Angiography (PA) is considered the goldstandard for the diagnosis of pulmonary embolism (PE). We conductedour study to evaluate the impact of the introduction of computedtomography with pulmonary angiography (CT. Angio) on the number ofPA and ventilation/ perfusion lung scan (V/Q) performed to diagnose PEin our hospital

METHODS: A retrospective chart review of all the patients who wereworked up for PE from January 1997 till December 2001. The charts werereviewed for the tests used to diagnose PE to evaluate the impact of theintroduction of CT angio on the number of PA and V/Q scans performed

RESULTS: CT Angio was used in 2% of patients in 1997, its useincreased to 25% in 2000. PA use continues to decrease from 20% in 1997


Thromboembolic Disease, continued


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to less than 2% in 2000. V/Q scan remains the diagnostic procedure ofchoice in our hospital with its use ranges from 69% in 1997 to 83% in2001. Doppler ultra sound of the lower extremities to detect deep veinthrombosis (DVT) remains a useful test with an increase in its use. (Seenext table for results)

Year V/Q SCAN DOPPLERS PA CT ANGIO

1997 (N�55) 69% 55% 20% 4%1998 (N�41) 80% 66% 20% 7%1999 (N�55) 87% 67% 11% 20%2000 (N�44) 84% 61% 2% 25%2001 (N�53) 83% 70% 2% 19%

CONCLUSIONS: The introduction of CT angio as a diagnostic test forPE resulted in a decrease in the number of PA performed. In our hospital,CT angio has no effect on V/Q scan, which remains the diagnostic test ofchoice for PE

CLINICAL IMPLICATIONS: The use of PA to diagnose PE isexpected to continue to decline with the increase use of CT. angio .

V/Q scan is still widely used to diagnose PE, and at this point it seemsit is not affected by the increase use of CT. angio

Doppler ultra sound of the lower extremities remains a useful support-ive test for the diagnosis of PE.

DISCLOSURE: R.A. Hamed, None.

A COMPARISON BETWEEN PULMONARY CT ANGIOGRAMAND VENTILATION-PERFUSION (V/Q) SCAN IN THE DIAG-NOSIS OF PULMONARY EMBOLISM (PE)A Al-Shrouf, MD*; M Shubair, MD; S Momany, MD; G Wardeh, MD; MA. Khan, MD, FCCP. St. Joseph’s Regional Medical Center, Paterson, NJand Seton Hall University, School of Graduate Medical Education, S.Orange, NJ

PURPOSE: CT angiogram is a new modality for the diagnosis of PE.To compare the diagnostic yield of CT angiogram with V/Q scan weretrospectively reviewed the results of both studies in patients admittedwith the diagnosis of possible PE.

METHODS: We reviewed the medical records of 30 patients (13females, 17 males, age range:32-68 years; mean age:48 years) admittedwith the clinical diagnosis of PE in whom both a CT angiogram and a V/Qscan had been performed.

RESULTS: Seventeen of 30 (57%) patients showed V/Q scans diag-nostic of PE. Only 11 of these 17 patients showed a CT angiogramdiagnostic of PE, whereas 6 patients showed a negative CT angiogram(P�0.008).

CONCLUSION: CT angiography failed to detect PE in a significantnumber of patients with diagnostic V/Q scans.

CLINICAL IMPLICATIONS: CT angiography is not yet ready toreplace V/Q scan for the diagnosis of PE in community hospitals.

DISCLOSURE: A. Al-Shrouf, None.

QT INTERVAL PROLONGATION WITH GLOBAL T WAVE IN-VERSION: A NOVEL ECG FINDING IN ACUTE PULMONARYEMBOLISMGopikrishna Punukollu, MD; Ramesh M. Gowda, MD*; Ijaz A. Khan,MD, FCCP; Sabrina L. Wilbur, MD; Victor S. Navarro, MD; Balendu C.Vasavada, MD; Terrence J. Sacchi, MD. Long Island College Hospital,Brooklyn, NY

PURPOSE: The purpose of this study was to report a novel electro-cardiographic (ECG) phenomenon in acute pulmonary embolism charac-terized by QT interval prolongation with global T wave inversion.

METHODS: Among a total of 140 study patients with a confirmeddiagnosis of acute pulmonary embolism, patients who fulfilled the inclu-sion criteria for QT interval prolongation with global T-wave inversionwere examined. Each of these patients had undergone a detailed clinicalevaluation including testing for myocardial injury and echocardiography.

RESULTS: QT interval prolongation with global T wave inversionwas found in five patients (age 51 to 68 years) with acute pulmonaryembolism. Four were women. Acute pulmonary embolism was diag-nosed by ventilation perfusion scan in three patients and by spiral

computed tomography in other two patients. None of the patients hadany right or left ventricular regional wall motion abnormalities onechocardiography. All patients had changes characteristic of hemody-namically significant pulmonary embolism, including right ventricularstunning or hypokinesis and dilatation in five patients with paradoxicalseptal motion in four. Acute coronary syndrome was ruled out in eachpatient by clinical evaluation, serial ECGs and cardiac markers, andlack of regional wall motion abnormalities on echocardiography.Prolongation of QT intervals (QTc 456 to 521 msec) with global T waveinversion was noted on presentation. The ECG changes graduallyresolved in one week in all patients with appropriate treatment of acutepulmonary embolism. One patient died.

CONCLUSIONS: Acute pulmonary embolism may occasionally resultin reversible QT interval prolongation with deep T wave inversion.

CLINICAL IMPLICATIONS: Acute pulmonary embolism should beconsidered among the acquired causes of the long QT syndrome.

Electrocardiographic Data

Patient # Rhythm Rate (beats/min) QT (msec) QTc (msec)

1 Sinus 85 411 4892 Sinus 68 490 5213 Sinus 78 426 4854 Sinus 99 355 4565 Atrial 47 524 463

DISCLOSURE: R.M. Gowda, None.

ROLE OF ECG IN IDENTIFYING PATIENTS WITH RIGHTVENTRICULAR DYSFUNCTION IN ACUTE PULMONARY EM-BOLISMGopikrishna Punukollu, MD*; Ramesh M. Gowda, MD; Ijaz A. Khan,MD, FCCP; Victor S. Navarro, MD; Balendu C. Vasavada, MD; TerrenceJ. Sacchi, MD. Long Island College Hospital, Brooklyn, NY

PURPOSE: To evaluate the role of electrocardiogram (ECG) fordetection right ventricular dysfunction in patients with acute pulmonaryembolism.

METHODS: Ninety-five consecutive patients with acute pulmonaryembolism who had transthoracic echocardiogram performed within 24 to48 hours of clinical presentation were included in study. Exclusion criteriawere chronic obstructive pulmonary disease, cor-pulmonale, primarypulmonary hypertension, dilated cardiomyopathy, and class III or IV heartfailure.

RESULTS: Fourteen patients were excluded from the study. Theremaining 81 patients comprised study population (age 65�15years,56% females, 46% blacks). By transthoracic echocardiography, rightventricular dysfunction was found in 40 patients (49%). The 12-leadECGs recorded on admission or during first 24 hours of presentationwere analyzed for T wave inversion in anterior precordial leads V1 toV3, right bundle branch block, S wave in lead-I with Q wave inlead-III, and sinus tachycardia. Inverted T wave in the anteriorprecordial leads had a sensitivity of 68% and specificity of 88% fordetection of right ventricular dysfunction with positive and negativepredictive values of 84% and 73%, respectively. The right bundlebranch block had sensitivity of 23% and specificity of 88%, S wave inlead-I with Q wave in lead-III had sensitivity of 27% and specificity of95%, and sinus tachycardia had sensitivity of 58% and specificity of68% for detection of right ventricular dysfunction. The predictivevalues of these findings are given in Table. Only 3 patients (8%) withright ventricular dysfunction had normal ECG, whereas 20 patients(49%) without right ventricular dysfunction had normal ECG.

CONCLUSIONS: Inverted T wave in anterior precordial leads has thehighest sensitivity and S wave in lead-I with Q wave in lead-III has thehighest specificity for identifying patients with right ventricular dysfunc-tion in acute pulmonary embolism at admission or during first 24 hours ofpresentation.

CLINICAL IMPLICATIONS: Electrocardiographic changes can besurrogate markers to identify patients with right ventricular dysfunction inacute pulmonary embolism and, therefore, can facilitate important urgenttherapeutic considerations.




ECG findings for detection of right ventricular dysfunction in acutepulmonary embolism

ECG Finding Sensitivity Specificity

PositivePredictiveValue

NegativePredictiveValue

T wave inversion inleads V1 to V3

68% 88% 84% 73%

Right bundle branchblock

23% 88% 64% 54%

S in lead-I with Qin lead-III

27% 95% 85% 57%

Sinus tachycardia 58% 68% 64% 62%

DISCLOSURE: G. Punukollu, None.

PROGNOSTIC VALUE OF ELECTROCARDIOGRAPHIC AB-NORMALITIES IN PATIENTS WITH ACUTE PULMONARY EM-BOLISMJohn A. Sallach, MD*; Susan M. Sallach, MD; James D. Thomas, MD;Mario J. Garcia, MD; Michael P. Hudson, MD; James K. McCord, MD.Cleveland Clinic Foundation, Cleveland, OH

PURPOSE: Acute pulmonary embolism (PE) may affect cardiac rate,rhythm, conduction pattern and repolarization manifesting a variety ofnonspecific abnormalities on 12-lead electrocardiogram (ECG). No priorstudies have examined the prognostic significance of these abnormalities.The purpose of this study was to determine the value of ECG abnormal-ities in predicting 30-day mortality in acute PE.

METHODS: Between 1998 and 2000, 144 patients admitted withacute PE had an ECG and cardiac troponin I (cTnI) measurement within24 hours of diagnosis. Medical records were abstracted for baselinecharacteristics, ECG findings and clinical outcomes. Patients were strat-ified according to 30-day mortality status. ECG findings and cTnIpositivity (a documented strong predictor of 30-day mortality) wereanalyzed in order to determine the prognostic value of these indices.

RESULTS: Eighteen percent (26/144) of patients died within 30 days ofPE diagnosis. Table 1 displays ECG findings and cTnI positivity in patientsalive (mean age 68 � 16 years, 46% male) and those dead (mean age 71 �15 years, 38% male) at 30 days. ECG findings of PVCs, atrial fibrillation andlow QRS voltage are significantly associated with increased mortality.

CONCLUSIONS: In the setting of acute PE, the presence of PVCs,atrial fibrillation and low QRS voltage on the 12-lead ECG at the time ofpresentation are significantly associated with increased 30-day mortality.

CLINICAL IMPLICATIONS: At the time of acute PE diagnosis, the12-lead EKG offers important prognostic information. An electrocardiogramshould therefore be performed on all patients presenting with acute PE.

Table 1.

Alive 30d(n�118)

Death 30d(n�26)

OR(95% CI)

Pvalue

PVCs 4% 23% 6.8 (1.6-29.0) 0.005*A. Fib 6% 23% 4.8 (1.3-18.1) 0.017*Low Volt QRS 9% 27% 4.0 (1.2-13.3) 0.021*Positive cTnI 31% 62% 3.6 (1.4-9.7) 0.006*S1S2S3 3% 12% 3.7 (0.6-21.6) 0.213RBBB 12% 19% 1.8 (0.5-6.1) 0.493Anterior ST

Depression9% 15% 1.8 (0.4-6.8) 0.574

Tachycardia 42% 54% 1.6 (0.6-4.2) 0.354Transition

Zone V518% 23% 1.4 (0.4-4.3) 0.728

DISCLOSURE: J.A. Sallach, None.

CARDIAC TROPONIN I RELEASE IN ACUTE PULMONARYEMBOLISM IN RELATION TO THE DURATION OF SYMP-TOMSGopikrishna Punukollu, MD*; Ramesh M. Gowda, MD; Gaurav Lakhan-pal, MD; Balendu C. Vasavada, MD; Terrence J. Sacchi, MD; Ijaz A.Khan, MD, FCCP. Long Island College Hospital, Brooklyn, NY

PURPOSE: To evaluate the release of cardiac troponin I in normoten-sive patients with acute pulmonary embolism in relation to the duration ofsymptoms.

METHODS: Fifty-seven normotensive patients with acute pulmonaryembolism were included in the study. Patients were divided into twogroups based on the duration of symptoms, group A with symptoms � 72hours at presentation and group B with symptoms of � 72 hours. Cardiactroponin I levels were measured twice, at presentation and 8 hours later.

RESULTS: Among the study population, 33 patients (58%) hadsymptoms of � 72 hours (group A) and 24 patients (42%) had symptomsof � 72 hours (group B). There was no difference in the severity ofpulmonary embolism between the two groups and both groups had similarprevalence of right ventricular dysfunction on echocardiography (55% ingroup A vs. 42% in group B, p�NS). Sixteen patients had elevated cardiactroponin I. All patients with elevated cardiac troponin I (n�16) were ingroup A. In group A, 67% (n�12) of patients with right ventriculardysfunction had elevated cardiac troponin I and 27% (n�4) of patientswithout right ventricular dysfunction had elevated cardiac troponin I. Onsubgroup analysis of patients with duration of symptoms � 72 hours atpresentation, 81% of patients (n�13) with elevated cardiac troponin I hadduration of symptoms � 24 hours at presentation. In patients presentingwithin 8 hours after symptom onset (n�7) the peak troponin I levels werefound at presentation in 50% (n�4) of the patients, with the median timeto peak levels being 8 hours after symptom onset.

CONCLUSION: The dynamics of cardiac troponin I in acute pulmo-nary embolism in patients who present with symptoms of � 72 hoursduration are different from those who present with longer symptomduration.

CLINICAL IMPLICATIONS: The use of cardiac troponin I in riskstratification of acute pulmonary embolism may be limited to the patientspresenting within 72 hours of the onset of symptoms.

Characteristics Based On The Duration Of Symptoms

Characteristics

Symptoms� 72 hours

(n�33patients)

Symptoms� 72 hours

(n�24patients)

Pvalue

Age (years) 63�17 64�19 NSMales 42%(n�14) 38%(n�9) NSModerate pulmonary embolism 55%(n�18) 42%(n�10) NSSmall pulmonary embolism 45%(n�15) 58%(n�14) NSElevated cardiac troponin I 48%(n�16) None �0.0001Elevated cardiac troponin

I with right ventriculardysfunction

67%(n�12) None 0.0005

Elevated cardiac troponinI without right ventriculardysfunction

27%(n�4) None NS

DISCLOSURE: G. Punukollu, None.

ELEVATED TROPONIN I PREDICTS WORSE LUNG PERFU-SION MISMATCH IN ACUTE PULMONARY EMBOLISMJohn A. Sallach, MD*; Susan M. Sallach, MD; K C. Karvelis, MD; ABrown, MD; A Pantelic, MD; Michael P. Hudson, MD; Mario J. Garcia,MD; James D. Thomas, MD; James K. McCord, MD. Cleveland ClinicFoundation, Cleveland, OH

PURPOSE: Acute pulmonary embolism (PE) may cause elevatedlevels of cardiac troponin I (cTnI) and troponin T due to right ventricularstrain and subsequent myocardial injury. We investigated whether cTnIconcentrations following acute PE correlate with the severity of radionu-clide mismatch on ventilation/perfusion (V/Q) lung scan and prognosis.

METHODS: Between 1998 and 2000, 137 consecutive patients withacute PE underwent a V/Q scan and cTnI measurement (upper limit of




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normal � 0.9 ng/mL) within 24 hours of diagnosis. Medical records wereabstracted for baseline clinical data and V/Q scans were reviewed formismatched segmental lesions. Number of V/Q mismatched defects, cTnIconcentrations and outcomes were compared.

RESULTS: At the time of PE diagnosis, 46 (33%) patients with a meanage of 72 � 14 years had elevated cTnI (�� 1 ng/mL) (mean cTnI of4.2 � 0.3 ng/mL), and 92 (67%) patients with a mean age of 65 � 17 yearshad normal cTnI (� 1 ng/mL) (mean cTnI 0.2 � 0.3 ng/mL). The meannumber of V/Q mismatched segments was significantly increased in thecTnI positive compared to cTnI negative group (5.1 � 3.8 vs. 3.6 � 2.6,p�0.005). At 30 days followup, 23 (17%) patients died and elevated cTnI(61% vs. 27%, p�0.002) was associated with higher mortality.

CONCLUSIONS: In acute PE, elevated levels of cTnI are associatedwith more extensive perfusion abnormalities and reduced survival.

CLINICAL IMPLICATIONS: Raised cTnI levels during acute PEare associated with worse survival and are a more useful prognostic factorthan the number of V/Q mismatched segments.

DISCLOSURE: J.A. Sallach, None.

EFFICACY OF FONDAPARINUX FOR THROMBOPROPHY-LAXIS IN HIGH-RISK PATIENTS UNDERGOING HIP FRAC-TURE SURGERYAlexander G. Turpie, PharmD*; Clifford W. Colwell, MD; KennethBauer, MD; Bengt I. Eriksson, MD; Michael R. Lassen, MD. HamiltonGeneral Hospital, Hamilton, ON, Canada

PURPOSE: Extended prophylaxis with fondaparinux may be evenmore beneficial for high-risk patients undergoing hip fracture surgery. Weevaluated the efficacy of fondaparinux for thromboprophylaxis in pre-defined high-risk patients (female gender, age over 75 years, and impairedrenal function) in the PENTHIFRA-PLUS trial.

METHODS: All patients received fondaparinux 2.5 mg once daily for7 days after surgery, and 656 patients were randomized double-blind toreceive placebo or to continue to receive fondaparinux for 19 to 22additional days. The primary efficacy outcome was venous thromboem-bolism (VTE) occurring during the double-blind period, defined asdeep-vein thrombosis detected by mandatory bilateral venography, ordocumented symptomatic deep-vein thrombosis or pulmonary embolism.

RESULTS:

VTE Rate n/N(Percent)

Placebo Fondaparinux77/220 (35.0) 3/208 (1.4)*

Risk Group:Gender Male 11/69 (15.9) 0/62 (0.0)

Female 66/151 (43.7) 3/146 (2.1)Age (years) �65 8/41 (19.5) 1/37 (2.7)

[65-75[ 10/36 (27.8) 1/48 (2.1)� 75 59/143 (41.3) 1/123 (0.8)

Creatinine Clearance(mL/min)

�30 8/15 (53.3) 1/14 (7.1)

[30-50[ 23/54 (42.6) 0/65 (0.0)[50-80[ 32/97 (33.0) 0/77 (0.0)�80 14/54 (25.9) 2/50 (4.0)

*P � 0.001 v Placebo, relative risk reduction 96%The rate of clinically relevant bleeding (fatal bleeding, bleeding in a

critical organ, or bleeding leading to reoperation) was similar in bothgroups.

CONCLUSIONS: Female gender, age, and impaired renal functionwere associated with an increased VTE risk without extended prophylaxis,and extended duration fondaparinux reduced the overall risk of develop-ing VTE by 96%.

CLINICAL IMPLICATIONS: VTE prophylaxis with fondaparinux upto 4 weeks after surgery for hip fracture is highly effective in all patients,including patients at high risk of developing VTE, without an increase inclinically relevant bleeding.

DISCLOSURE: A.G. Turpie, Organon Sanofi-Synthelabo, LLC, grantmonies.

TIMING OF INITIAL ADMINISTRATION OF PROPHYLAXISAGAINST DEEP VEIN THROMBOSIS IN PATIENTS FOLLOW-ING HIP OR KNEE SURGERYRussell D. Hull, MBBS*; Natasha Burke, BSc; Andrew F. Mah, BSc;Graham F. Pineo, MD. University of Calgary, Calgary, AB, Canada

PURPOSE: Current prophylactic regimens against deep-veinthrombosis (DVT) following hip surgery include subcutaneous low-molecular-weight heparin (LMWH) initiated on a delayed basis or oralanticoagulants. Recent clinical trials suggest that LMWH initiated incloser proximity to surgery, which harmonizes with the perioperativeinitiation of DVT, is more effective than current clinical practice.LMWH initiated 4-6 hours after surgery (just-in-time regimen) hasshown superior efficacy vs oral anticoagulants. LMWH initiated 12hours before surgery or 12-24 hours postoperatively was not moreeffective than oral anticoagulants. We performed a systematic reviewof the literature to assess the efficacy and safety of the direct thrombininhibitor melagatran or ximelagatran and the pentasaccharide fondapa-rinux administered at different times in relation to surgery vs LMWHor oral anticoagulants.

METHODS: Studies were identified using MEDLINE, reviewingreferences from retrieved articles and scanning abstracts from conferenceproceedings. Randomized trials comparing direct thrombin inhibitors orpentasaccharides administered at different times relative to surgery vsLMWH or oral anticoagulants for prophylaxis in hip or knee surgerypatients evaluated using contrast venography were selected. Two review-ers extracted data independently.

RESULTS: Subcutaneous melagatran given immediately prior tosurgery followed by oral ximelagatran has shown superior efficacy whencompared with LMWH started the evening before surgery (p�0.0001).With prophylaxis initiated the morning after surgery, ximelagatran wasstatistically significantly less effective than LMWH. Three additionalstudies evaluating melagatran/ximelagatran versus LMWH or oral antico-agulant prophylaxis confirm the importance of timing. When comparedwith LMWH initiated 12 hours preoperatively, fondaparinux started 6hours postoperatively revealed significantly lower incidences of DVT(p�0.0001).

CONCLUSIONS: In comparing new regimens for thromboprophy-laxis against classical regimens, initiation time of each regimen is a criticalfactor. For the melagatran-ximelagatran regimen, timing dominated theeffect of the regimen as administered.

CLINICAL IMPLICATIONS: Lower DVT rates are seen whenantithrombotic agents are initiated in close proximity to surgery.

DISCLOSURE: R.D. Hull, None.

THROMBOEMBOLISM AFTER PNEUMONECTOMY: SHOULDPROPHYLAXIS EXTEND BEYOND HOSPITAL DISCHARGE?Mohammed A. Quader, MD; Malcolm M. DeCamp, MD*; Eugene H.Blackstone, MD; Sudish C. Murthy, MD, PhD; Angela K. Quader, RN;Thomas W. Rice, MD. The Cleveland Clinic, Cleveland, OH

PURPOSE: Thromboembolism causes important morbidity and mor-tality after pneumonectomy. Objectives of this study were to determine 1)the prevalence and timing of deep venous thrombosis (DVT) andpulmonary embolism (PE) following pneumonectomy, and 2) outcome.

METHODS: From January 1990 to December 2000, 333 patientsunderwent pneumonectomy for malignancy. All received DVT prophy-




laxis (twice-daily subcutaneous heparin and compression stockings) thatwas continued to hospital discharge. Patients developing clinically evidentDVT or PE were identified and their medical records reviewed.

RESULTS: Prevalence of DVT or PE was 25/333 (7.5%). Incidencepeaked 7 days after pneumonectomy (Figure). 9 events occurred in-hospital, 8 within 15 days of discharge, and 8 thereafter to 55 months. 17had DVT only, 5 had PE only, and 3 had both. 20 patients developed DVTin 33 locations, 15 in lower extremities, 14 in upper extremities, and 4centrally. All patients were fully anticoagulated upon diagnosis. 2 patientswith PE underwent thrombolysis. 8 patients were readmitted to theintensive care unit, and 7 were intubated. Survival at 6 months was 54%.Death was attributable to DVT or PE in 10 patients, malignancy in 6, andunknown causes in 6. Low preoperative forced vital capacity was highlypredictive of poor long-term survival (P�.001).

CONCLUSIONS: DVT and PE following pneumonectomy are poorlytolerated and, surprisingly, occur frequently early after hospital discharge.

CLINICAL IMPLICATIONS: Extending prophylaxis beyond hospi-tal discharge warrants investigation.

DISCLOSURE: M.M. DeCamp, None.

A STUDY OF THE IMPACT OF INFERIOR VENA CAVA FIL-TERS ON ACUTE INPATIENT MORTALITY IN ACUTE PULMO-NARY THROMBOEMBOLISMPrashant Grover, MBBS*; Srimati Manicharatnam, MBBS; Richard Zu-Wallack, MD,FCCP; Bimalin Lahiri, MD,FCCP. University of Connect-icut, Farmington, CT

PURPOSE: Inferior Vena Cava interruption is a commonly appliedtherapeutic intervention in acute pulmonary thromboembolism. Thereis very little data on how IVC filters affect immediate patient outcome.

METHODS: A review of case records of all patients admitted to atertiary care teaching hospital over a three year period(1998-2000) wasundertaken. To be included the patients must have a high probability V/Qscan, intermediate V/Q scan with positive lower exteremity doppler study,positive pulmonary angiogram.The primary outcome measured was allcause mortality during the hospital stay.

RESULTS: 191 patients met criteria to be included in the study. Meanage was 65 years, with 88 males and 103 females. 54 patients had activemalignancy and 21 patients received thrombolytics. 58 patients hadinferior vena cava filters placed with or without anticoagulation. Inpatients who recieved thrombolytics all but one had IVC filter placed.There were no complications in the patients who were thrombolysed. Allcause mortality in patients with acute PE was 22/191(11.5%). There were19 deaths in patients who did not have IVC filters placed and 3 in thosewith IVC filters(p�0.697).

CONCLUSION:There was a trend towards decrease in all causemortality in patients with acute pulmonary thromboembolism treated withIVC filters although this did not reach statistical significance.These resultsmay be confounded by the fact that the patients who recieved thrombo-lytics did well.

CLINICAL IMPLICATIONS: In our single center data aggressiveuse of inferior vena cava filters in pulmonary thromboembolic disease wasassociated with a better short term outcome. Multicenter data may beneeded to determine the clinical significance of this study. It may beunethical to do a randomized trial with IVC filters.

DISCLOSURE: P. Grover, None.

PREDICTED DOSES OF ORAL VITAMIN K1 TO REVERSEWARFARIN ANTICOAGULATION WAS COMPARABLE TOWITHHOLDING WARFARIN PRIOR TO MINOR INVASIVEPROCEDURESThomas H. Wentzien, D.O., F.A.C.C.*; Robert A. O’Reilly, MD; PatrickJ. Kearns, MD. County Hospital, Santa Clara Valley Medical Center, SanJose, CA

PURPOSE: Reversal of warfarin anticoagulated patients prior to minorinvasive procedures can be achieved by traditional warfarin cessation andresumption (WCAR), but also using a small dose of oral vitamin K1 (VK)while continuing warfarin unchanged (VKCW). We compared thesemethods using a previously described formula to predict the dose of oralVK.

METHODS: A prospective, randomized, controlled trial to evaluateWCAR and VKCW, in stable outpatients on warfarin prior to elective,minor surgical or dental procedures was performed. Warfarin was with-held for 3 days preprocedure in the WCAR group and oral VK was given36 hours preprocedure for the VKCW group. Blood samples for pro-thrombin time International Normalized Ratio (INR) were determined3-4 days preprocedure, day of procedure, and periodically until INR �2.0. A linear regression equation described a semilog plot of lnINR as afunction of time (days) and used to calculate nadir and return. Values aremean �/- SEM

RESULTS:We enrolled 25 patients for 26 reversals (15 VKCW, 11WCAR), age 56 years (range 30-82), with various diagnosis: 15 (56%)atrial fibrillation, 7 (26%) deep venous thrombosis, 7 (26%) mechanicalvalves, 11 (41%) other. Dental procedures were performed on 18(69%) and minor surgery on 8 (31%) of patients. Weekly warfarin dosewas 37 �/- 5 mg for all patients. The oral VK, a scored 5.0 mg tab, wasdosed at 3.5 �/- 0.4 mg (range 2.5-5.0 mg). All 26 reversals weresuccessful (INR� 1.8), one procedure cancelled (VKCW) for otherreasons. Thirty days postprocedure, no thrombotic events or majorbleeds occurred in either group and there were no differences in minorbleeds. See Table 1 below.

CONCLUSIONS: Both methods reduced the INR to a safe level toperform minor invasive procedures without significant complications.VKCW may reduce the period of subtherapeutic anticoagulation.

CLINICAL IMPLICATIONS: VKCW, when using an adjusted doseof oral VK, may be a safe alternative method to reverse stable anticoag-ulated patients prior to minor invasive procedures.

TABLE 1

VKCW WCAR p value

INR, baseline 2.6�/-0.2 2.3�/-0.1 NSINR, Procedure 1.5�/-0.1 1.3�/-0.1 NSDays to Nadir 0.9�/-0.2 1.5�/-0.2 NSDays to INR � 2.0 4.3�/-0.7 5.7�/-1.8 0.09Total Days INR � 2.0 6.2�/-0.5 7.2�/-1.6 0.03

DISCLOSURE: T.H. Wentzien, DuPont Co., grant monies.




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