With the advancement of coronary arterial surgery over the last decade, cardiac catheterization and coronary angiography have become frequently performed diagnostic procedures. Previously, the usual policy was to admit the patient to the hospital one day prior to the study, followed by overnight observation after the cardiac catheterization. The increase in the number of studies performed and the ever-escalating cost of hospitalization have prompted some institutions to evaluate the safety of outpatient cardiac catheterization and coronary angiography. These studies examine the rates of complications in relatively small numbers of outpatients and do not report on the procedure-related complications of inpatient cardiac catheterization in the same institutions. We initiated this study to compare rates of complications of outpatient and inpatient cardiac catheterization when performed in the same institution by the same group of cardiologists.
Demographic Data The study population consisted of 54 patients, 42 men and 12 women. The mean age was 62 years with a range from 35 to 84 years. Table 1 illustrates the distribution of cell types and their location. As expected, these are mainly central lesions with a squamous histology.
Most patients received external beam radiotherapy at some point in their course. In 19 patients, this was concurrent with seed implantation. One hundred and eleven procedures were reviewed, a mean of two per patient (range one to ten). A mean of three seeds per procedure were implanted (range one to eight).
Three patients with non-small cell carcinoma received chemotherapy, all three prior to seed implantation. Chemotherapy was used prior to implantation in three of four patients with small cell carcinoma (one patient refused). One patient was treated with endobronchial laser prior to gold seed use and one following gold seed use.
With the usual jet velocity from MDI, aerosol particle impaction theory predicts that aerosol particles 10 |xm or greater should impact on a surface 10 cm away from the actuator orifice, the distance from the MDI orifice to the posterior pharyngeal wall. Therefore, if droplets completely vaporize to their final size before reaching the oropharyngeal surface, the impaction loss should be minimal. However, a number of studies have shown that a large fraction (50 to 65 percent) of MDI aerosols delivered from the MDI is lost in the mouth, suggesting that the droplets do not have a sufficiently long residence time for complete vaporization within the oropharyngeal space.
Effect of Therapy on Angiogenic Growth Factor Levels
The effect of medical therapy for PAH on growth factor levels was analyzed. Twelve patients (PPH, 6 patients; PAH-other, 6 patients) were not receiving prostanoid therapy, calcium-channel blockers, or endothelin blockers at the time of study (de novo patients). The median plasma bFGF level in this group of patients was significantly increased compared to control subjects (1.91 pg/mL, p = 0.02), as was the median urine bFGF level (2,338 pg/L, p = 0.002). The bFGF levels in these de novo patients were not significantly different from patients who were receiving specific therapy for PAH. Sixty-one percent of patients were receiving IV prostacyclin at the time samples were obtained for the cohort. Patients with PAH receiving prostacyclin had qualitatively higher median levels of plasma VEGF (42.9 pg/mL vs 25.4 pg/mL, p = 0. 09) than did patients not receiving prostacyclin, although this did not reach statistical significance. This trend remained when analyzed for the PPH subgroup (48.1 pg/mL vs 28.8 pg/mL, p = 0.13). When adjusted for covariates associated with severity of disease, the effect of prostacyclin on plasma VEGF was diminished, and prostacyclin was not independently associated with altered growth factor levels. Calcium-channel blocker therapy or anticoagulation with warfarin did not affect growth factor levels. Continue reading
We examined the possibility that there may be a threshold level for urine bFGF. Using the 95th percentile in our control subjects as an upper limit of normal, we found that 21% of patients with PAH had elevations in urine bFGF. Twenty-six percent of patients with PPH, and 14% of patients with PAH-other (11% CHD and 19% CTD) had abnormally elevated urine bFGF levels (p = 0.008).
Median plasma levels of bFGF were significantly higher in patients with PAH than in control subjects (median, 1.9 pg/mL vs 0.5 pg/mL; p = 0.02). There was a difference in plasma bFGF levels based on etiology (PPH, 2.1 pg/mL; CHD, 1.7 pg/mL; CTD, 1.0 pg/mL; p = 0.3), but the only significant pairwise comparison was between PPH and control subjects (p = 0.05) [Fig 2, 3]. There was no significant difference between male and female patients. Continue reading
Blood samples were collected in a plasma ethylenediamine tetra-acetic acid tube. Samples were centrifuged at 2,500g for 10 min, and plasma was collected and stored at — 80°C until it was assayed. Repeat freeze-thaw cycles were avoided. Spot urine specimens were obtained and stored at — 80°C until they were assayed. Measurements of VEGF and bFGF were performed, by batch, in duplicate, using an enzyme-linked immunoassay for VEGF and bFGF (Quantikine; R&D Systems; Minneapolis, MN). The coefficients of variation for bFGF were 10 to 14% for urine, and 9 to 11% for plasma. The coefficients of variation for VEGF were 4 to 7% for urine, and 5 to 7% for plasma. There was no significant cross-reactivity between the bFGF or VEGF antibodies and other known growth factors. Continue reading
Although abnormal expression of bFGF and VEGF has been noted in animal models of pulmonary hypertension, their contribution to human PAH is not well understood. The detection of elevated growth factors in affected patients may help clarify the underlying mechanisms involved in the disease process. One area in which research on angiogenesis may have clinical application is the quantitation of angiogenesis. Quantitation of angiogenic proteins in body fluids has been used as an indirect measure of angiogenic growth factor activity in certain patients with tumors, as well as nonneoplastic diseases. We hypothesized that angiogenic growth factors may have a role in the cellular proliferation seen in the small vessels of the lung in PAH. We therefore measured bFGF and VEGF levels in the blood and urine of a large cohort of these patients. Continue reading
Pulmonary arterial hypertension (PAH) is a devastating illness characterized by a pulmonary vasculopathy that gives rise to an elevation in pulmonary vascular resistance. There has been considerable debate regarding the mechanisms underlying the development of PAH. Although initially focused on vasoconstriction and factors modulating vasomotor tone in the pulmonary circulation, it has more recently been proposed that cellular proliferation of endothelial and smooth-muscle cells is a more central component of the histopathologic changes seen in this disease. The search for molecular pathways that are involved in this cellular proliferation is therefore of particular interest. Continue reading
Readers should note that we are not suggesting that 99mTc-DP scintigraphy should be performed in patients with sarcoidosis. This imaging modality may add nothing to the present approach to sarcoidosis. Rather, our purpose was to demonstrate that additional trials are warranted. Beyond sarcoidosis, our findings have implications for the role for 99mTc-DP imaging in the management of suspected pulmonary malignancies. In appropriate clinical settings, nuclear radiologists and pulmonologists should consider that activity seen on 99mTc-DP imaging may represent sarcoidosis rather than cancer. Conversely, in patients with known sarcoidosis who are undergoing evaluation for a potential malignancy, 99mTc-DP imaging does not allow one to conclusively differentiate a superimposed malignant process from the underlying disease state. As such, 99mTc-DP imaging should not be considered an acceptable diagnostic alternative to biopsy. Continue reading
For extrapulmonary sarcoidosis, 99mTc-DP imaging might prove most useful. There are no standard, accepted approaches to the evaluation of suspected extrapulmonary sarcoidosis. Tl scintigraphy, for example, which has been studied in cardiac sarcoidosis patients, frequently demonstrates heterogeneous cardiac uptake in patients without clinical diseaseA More specifically, Kinney et al noted abnormal Tl cardiac scans in 30% of subjects with sarcoidosis but no suspected cardiac involvement. Similarly, other investigators have reported that positive Tl scintigraphy findings had no prognostic significance because the test was overly sensitive. In our study, although it was very small, 99mTc-DP imaging nonetheless correctly identified all sites of major, clinically significant visceral involvement in sarcoidosis patients. Continue reading