Vascular postpneumonectomy syndrome: inferior vena cava and pulmonary vein compression as unusual cause for platypnea-orthodeoxia following pneumonectomy

Background: Excessive mediastinal shift into the vacated thoracic cavity after pneumonectomy can result in dyspnea without hypoxemia by compression of the tracheobronchial tree, a phenomenon called postpneumonectomy syndrome. More rarely hypoxemia in upright position (platypnea-orthodeoxia syndrome, POS) after pneumonectomy can result from re-opening of an atrial right-to-left shunt through a patent foramen ovale (PFO) due to mediastinal distorsion. Review of literature also shows a unique report of pulmonary veins stenosis resulting in POS without intracardiac shunt after pneumonectomy. Methods: We report the case of a 32-year-old woman who presented POS 6 months after right pneumonectomy for destroyed lung post tuberculosis. Results: The patient described severe dyspnea disappearing when lying. SpO2 decreased from 94% when lying to 60% sitting. Transthoracic echocardiography (TTE) suspected a possible PFO. We first tried to highlight clinical repercussions of PFO by noninvasive exams. Hyperoxia shunt quantification was not tolerated because of increased dyspnea in sitting position. Contrast bubbles TTE was difficult because of the important mediastinal shift but identified only rare left heart bubbles with/without Valsalva both in lying and sitting position, excluding a significant right-to-left shunt. A lung perfusion scintigraphy (injection while sitting) confirmed the absence of systemic isotope uptake. Computed tomographic pulmonary angiography (angio-CT) revealed a stretched but not stenosed left main bronchus, while the shift of the heart into the right cavity was major. Pulmonary angiography did not show embolism but revealed compression of the inferior vena cava (IVC) with impaired venous return to the right heart, as well as compression of the left pulmonary veins. There was no arteriovenous shunt. Cardiac MRI showed torsion of IVC at the level of the diaphragm, and strong atrial contraction contributing to a passive filling of the RV, while the right ventricle was normal. Right catheterism showed major hemodynamic disturbances with negative diastolic pressure in right heart cavities (atrium -12 mm Hg ventricle pressure -7 mm Hg). SaO2 measured in the pulmonary artery decreased from 58% when lying to 45% sitting. Conclusion: We described here an exceedingly rare and complex mechanism explaining POS after right pneumonectomy. Mediastinal repositioning with a silicone breast implant of appropriate size has been scheduled.

Scapulalgie et neuropathie sus-scapulaire en pathologie sportive [Scapular pain and supra-scapular neuropathy in sports medicine]

Eight patients with shoulder pain are reported with a history of athletic activities. On examination, performed with a delay of several months, all patients had painful paresis and atrophy of spinati fossa. Electroneuromyography was carried out in all cases and showed a suprascapular nerve axonal loss from the spinati muscles or infraspinatus muscle, signs of denervation-reinnervation in spinati or infraspinatus muscles, normal examination of other scapular girdle muscles, and a coordinate spinati contraction with shoulder displacement excluding rotator cuff tears. All patients had conservative treatment and only two improved. Six patients underwent surgical decompression of the suprascapular nerve; in three, motor function clearly improved, and in three others pain improved. The factors leading to entrapment include stretch mechanisms associated with shoulder movements, leading to suprascapular nerve liability to mechanical lesions. In patients with shoulder pain, the authors recommend an early electrophysiological work-up to recognize an isolated suprascapular neuropathy. The surgical decompression of the nerve should be based on persistent shoulder pain after conservative treatment.

The biomechanic origin of sprint performance enhancement after one-week creatine supplementation.

In order to test whether an improvement of maximal sprinting speed after creatine (Cr) supplementation was due to the increase of stride frequency (SF), stride length (SL) or both, 7 subjects ran 4 consecutive sprints after 1 week of placebo or Cr supplementation. SF and SL were assessed by a triaxial accelerometer. Compared to the placebo, Cr induced an increase of running speed (+1.4% p < 0.05) and SF (+1.5%, p < 0.01), but not of SL. The drop in performance following repeated sprints was partially prevented by Cr. In conclusion, exogenous Cr enhanced sprinting performance by increasing SF. This result may be related to the recent findings of shortening in muscular relaxation time after Cr supplementation.

Immediate improvement in coronary flow reserve after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: To examine whether percutaneous alcohol septal ablation affects coronary flow reserve (CFR) in patients with hypertrophic cardiomyopathy (HCM). METHODS: CFR was measured immediately before and after septal ablation in patients with symptomatic obstructive HCM. CFR was also obtained in normal subjects (NL) for comparison. RESULTS: Patients with HCM (n = 11), compared with NL (n = 22), had a lower mean (SD) baseline CFR (1.96 (0.5) vs 3.0 (0.7), p<0.001), a lower coronary resistance (1.04 (0.45) vs 3.0 (2.6), p = 0.002), a higher coronary diastolic/systolic velocity ratio (DSVR; 5.1 (3.0) vs 1.8 (0.5), p = 0.04) and a lower hyperaemic coronary flow per left ventricular (LV) mass (0.73 (0.4) vs 1.1 (0.6) ml/min/g, p = 0.007). Septal ablation in the HCM group (n = 7) reduced the outflow tract gradient but not the left atrial or LV diastolic pressures. Ablation resulted in immediate normalisation of CFR (to 3.1 (1), p = 0.01) and DSVR (to 1.9 (0.8), p = 0.09) and an increase in coronary resistance (to 1.91 (0.6), p = 0.02). This was probably related to an improvement in the systolic coronary flow. CONCLUSIONS: This study demonstrates that successful septal ablation in patients with symptomatic HCM results in immediate improvement in CFR, which is reduced in HCM partly because of the increased systolic contraction load.

Assessment of systolic and diastolic LV function by MR myocardial tagging.

Heart failure has been divided into several different forms depending on etiology, clinical course and pathophysiology of left ventricular (LV) dysfunction. Systolic and diastolic dysfunction are characterized by a reduced cardiac output with normal (= diastolic dysfunction) or depressed (= systolic dysfunction) LV pump function. New diagnostic techniques such as magnetic resonance imaging (MRI) allow to determine noninvasively LV 3D motion by labelling specific myocardial regions (= myocardial "tagging") with a rectangular or radial grid. From the deformation of this grid rotational and translational motion of the heart can be derived. A "wringing" motion of the left ventricle has been described during systole which includes a clockwise rotation at the base and a counterclockwise rotation at the apex. During diastole, an "untwisting" motion has been demonstrated. In the normal heart, diastolic "untwisting" occurs primarily during isovolumic relaxation, analogous to the systolic "wringing" which takes place mainly during isovolumic contraction. A prolongation of the "untwisting" motion was found in the hypertrophied (aortic stenosis) and hibernating myocardium. Thus, heart failure is associated with profound alterations in the mechanical function of the heart which are manifested by changes in systolic "wringing" and diastolic "untwisting" motion.

Hemodynamic effects of sodium bicarbonate in critically ill neonates.

OBJECTIVE: To analyze the cardiovascular effects of sodium bicarbonate in neonates with metabolic acidosis. DESIGN: Prospective, open, non-randomized, before-after intervention study with hemodynamic measurements performed before and 1, 5, 10, 20, and 30 min after bicarbonate administration. SETTING: Neonatal intensive care unit, tertiary care center. PATIENTS: Sequential sample of 16 paralysed and mechanically ventilated newborn infants with a metabolic acidosis (pH < 7.25 in premature and < 7.30 in term infants, base deficit > -8). INTERVENTION: An 8.4% sodium bicarbonate solution diluted 1:1 with water (final osmolality of 1000 mOsm/l) was administered in two equal portions at a rate of 0.5 mmol/min. The dose in mmol was calculated using the formula "base deficit x body weight (kg) x 1/3 x 1/2". MEASUREMENTS AND RESULTS: Sodium bicarbonate induced a significant but transient rise in pulsed Doppler cardiac output (CO) (+27.7%), aortic blood flow velocity (+15.3%), systolic blood pressure (BP) (+9.3%), (+14.6%), transcutaneous carbon dioxide pressure (PtcCO2) (+11.8%), and transcutaneous oxygen pressure (PtcO2) (+8%). In spite of the PaCO2 elevation, pH significantly improved (from a mean of 7.24 to 7.30), and the base deficit decreased (-39.3%). Calculated systemic vascular resistance (SVR) (-10.7%) and diastolic BP (-11.7%) decreased significantly, while PaO2 and heart rate (HR) did not change. Central venous pressure (CVP) (+6.5%) increased only slightly. By 30 min after bicarbonate administration all hemodynamic parameters, with the exception of the diastolic BP, had returned to baseline. CONCLUSION: Sodium bicarbonate in neonates with metabolic acidosis induces an increase in contractility and a reduction in afterload.

Artificial muscle for end-stage heart failure.

We describe a device made of artificial muscle for the treatment of end-stage heart failure as an alternative to current heart assist devices. The key component is a matrix of nitinol wires and aramidic fibers called Biometal muscle (BM). When heated electrically, it produces a motorless, smooth, and lifelike motion. The BM is connected to a carbon fiber scaffold, tightening the heart and providing simultaneous assistance to the left and right ventricles. A pacemaker-like microprocessor drives the contraction of the BM. We tested the device in a dedicated bench model of diseased heart. It generated a systolic pressure of 75 mm Hg and ejected a maximum of 330 ml/min, with an ejection fraction of 12%. The device required a power supply of 6 V, 250 mA. This could be the beginning of an era in which BMs integrate or replace the mechanical function of natural muscles.

Early Entry Sawed Portland Cement Concrete Transverse Joint Ends, MLR-97-5, 2003

Experiments with early entry light sawing of Portland cement concrete (PCC) contraction joints began in Iowa in 1989. Since that time, changes in early sawing equipment have occurred as well as changes in specifications for sawing. The option to use early sawing for transverse contraction joints was specified in 1992. A problem happening occasionally with early sawing was the break out of some of the concrete around the end of the joint as the saw blade approached the edge of the slab. To prevent this, it was proposed that the sawing would terminate approximately 1/2" to 3/4" before the edge of the slab, creating a "short joint". This procedure would also leave a concrete "dam" to prevent the run-out and waste of the hot liquid joint sealant onto the shoulder. It would also eliminate the need for the labor and material for applying a duct tape dam at the open ends of each sawed joint to stop hot liquid sealant run-out Agreements were made with the contractor to apply the "short joint" technique for 1 day of paving. The evaluation and results are compared with an adjoining control section. The research found no negative aspects from sawing the "short joint". Three specific findings were noted. They are the following: 1) No joint end "blow-out" spalls of concrete occurred. 2) The need for the duct tape dam to stop liquid sealant overflow was eliminated. 3) Joint end corner spalls appear to be caused mainly by construction shouldering operations equipment. The "short joint" sawing technique can be routinely applied to early entry sawed transverse contraction joints with expectations of only positive results.

Evaluation of Preformed Neoprene Joint Seals, HR-318, 1994

Most pavement contraction joint seals in Iowa, in general, have been performing in less than a satisfactory manner. The effective life of the seals, in maintaining a watertight joint, has been only from two to five years. In search of improvements, research was proposed to evaluate preformed neoprene joint seals. The performance of those seals was to be compared mainly with the hot poured rubberized asphalt sealants and cold applied silicone sealants or other sealants commonly used at the time this research began. Joint designs and methods of sawing were also investigated. All evaluations were done in new portland cement concrete (PCC) pavements. Three projects were initially selected and each included a research section of joint sealing. Some additional sites were later added for evaluation. Several joint sealants were evaluated at each research site. The various sites included high, medium and low levels of traffic. Evaluations were done over a five-year period. Neoprene joint seals provided better performance than hot or cold field formed joints.

Serum resistin concentrations and risk of new onset heart failure in older persons: the health, aging, and body composition (Health ABC) study.

OBJECTIVE: Resistin is associated with inflammation and insulin resistance and exerts direct effects on myocardial cells including hypertrophy and altered contraction. We investigated the association of serum resistin concentrations with risk for incident heart failure (HF) in humans. METHODS AND RESULTS: We studied 2902 older persons without prevalent HF (age, 73.6+/-2.9 years; 48.1% men; 58.8% white) enrolled in the Health, Aging, and Body Composition (Health ABC) Study. Correlation between baseline serum resistin concentrations (20.3+/-10.0 ng/mL) and clinical variables, biochemistry panel, markers of inflammation and insulin resistance, adipocytokines, and measures of adiposity was weak (all rho <0.25). During a median follow-up of 9.4 years, 341 participants (11.8%) developed HF. Resistin was strongly associated with risk for incident HF in Cox proportional hazards models controlling for clinical variables, biomarkers, and measures of adiposity (HR, 1.15 per 10.0 ng/mL in adjusted model; 95% CI, 1.05 to 1.27; P=0.003). Results were comparable across sex, race, diabetes mellitus, and prevalent and incident coronary heart disease subgroups. In participants with available left ventricular ejection fraction at HF diagnosis (265 of 341; 77.7%), association of resistin with HF risk was comparable for cases with reduced versus preserved ejection fraction. CONCLUSIONS: Serum resistin concentrations are independently associated with risk for incident HF in older persons.

The effect of muscle fatigue on stimulus intensity requirements for central and peripheral fatigue quantification.

PURPOSE: The present study was designed to determine the stimulation intensity necessary for an adequate assessment of central and peripheral components of neuromuscular fatigue of the knee extensors. METHODS: Three different stimulation intensities (100, 120 and 150 % of the lowest intensity evoking a plateau in M-waves and twitch amplitudes, optimal stimulation intensity, OSI) were used to assess voluntary activation level (VAL) as well as M-wave, twitch and doublet amplitudes before, during and after an incremental isometric exercise performed by 14 (8 men) healthy and physically active volunteers. A visual analog scale was used to evaluate the associated discomfort. RESULTS: There was no difference (p > 0.05) in VAL between the three intensities before and after exercise. However, we found that stimulating at 100 % OSI may overestimate the extent of peripheral fatigue during exercise, whereas 150 % OSI stimulations led to greater discomfort associated with doublet stimulations as well as to an increased antagonist co-activation compared to 100 % OSI. CONCLUSION: We recommend using 120 % OSI, as it constitutes a good trade-off between discomfort and reliable measurements.

The L-Type Ca2+ and KATP channels may contribute to pacing-induced protection against anoxia-reoxygenation in the embryonic heart model

Rapport de synthèse : Implication des canaux Ca2+ de type L et des canaux KATP dans la protection induite par pacing dans un modèle de coeur embryonnaire soumis à l'anoxieréoxygénation. Contexte et but : le canal Ca2+ de type L, les canaux K+ du sarcolemme (sarcKatp) et de la mitochondrie (mitoKatp) interviennent dans le préconditionnement ischémique ou pharmacologique du myocarde. La présente étude cherche à déterminer dans quelle mesure ces canaux peuvent aussi jouer un rôle dans la cardioprotection induite par pacing. Méthodes :des coeurs d'embryons de poulet âgés de 4 jours ont été soumis in ovo à un pacing durant 12 heures, en pratiquant une stimulation électrique ventriculaire asynchrone intermittente à 110% de la fréquence cardiaque intrinsèque. Les coeurs contrôles (sham) et les coeurs stimulés ont ensuite été soumis in vitro à une période d'anoxie de 30 minutes, suivie d'une réoxygénation de 60 minutes. Les coeurs ont été exposés à l'agoniste du canal Ca2+ de type L (Bay-K-8644, BAY-K) ou à son bloqueur (vérapamil, VERAP), à l'antagoniste non sélectif des canaux KATP (glibenclamide, GLIB), ainsi qu'à l'agoniste du canal mitoKATP (diazoxide, DIAZO), ou à son antagoniste (5-hydroxydécanoate, 5-HD). L'électrocardiogramme, le délai électro-mécanique (DEM) reflétant le couplage excitation-contraction, ainsi que la contractilité myocardique ont été systématiquement déterminés pendant l'anoxieréoxygénation. Résultats : en normoxie, la fréquence cardiaque, l'intervalle QT, la conduction atrioventriculaire, le DEM et le raccourcissement ventriculaires étaient identiques dans les coeurs sham et les coeurs stimulés. Par contre, au cours de la réoxygénation post-anoxique, les arythmies cessaient plus précocément et le DEM ventriculaire retrouvait plus rapidement son niveau initial dans les coeurs stimulés, comparés aux sham. Dans les coeurs sham, BAY-K (mais pas le VERAP), DIAZO (mais pas le 5HD) ou GLIB accéléraient la récupération du DEM ventriculaire, reproduisant ainsi la protection induite par le pacing. En revanche, aucun de ces agents n'affectait la récupération des cceurs stimulés. Conclusion : un pacing ventriculaire chronique et intermittent délivré à une fréquence quasi physiologique améliore la tolérance myocardique à une anoxie-réoxygénation ultérieure. L'approche pharmacologique amontré qu'une activation discrète du canal Ca2+ de type L, une inhibition du canal sarcKATP et/ou une ouverture du canal mitoKATP peuvent contribuer à la cardioprotection induite par le pacing.

Innovative Leak Test for Pavement Joint Seals, Progress Report, HR-318, 1993

Premature failure of concrete pavement contraction joint seals is an ongoing and costly problem for the Iowa Department of Transportation. Several joint seal test sections consisting of variations in sawing methods, joint cleaning techniques, sealant installation, and sealant types have been established over the past few years. Laboratory analysis and field inspections were done as a part of the tests, and core samples were taken for laboratory adhesion pull tests. Such methods often cover specifically small areas and may not expose hidden failures. Some tests are also labor-intensive and destructive, especially that of coring. An innovative, nondestructive, broad coverage joint seal tester that yields quick results has been designed and developed for evaluation of pavement joint seal performance. The Iowa vacuum joint seal tester (IA-VAC) applies a low vacuum above a joint seal that has been spray-covered with a foaming water solution. Any unsealed area or leak that exists along the joint will become quickly and clearly visible by the development of bubbles at the leak point. By analyzing the results from the IA-VAC tests, information on the number and types of leaks can be obtained; such information will help identify the source of the problem and direct efforts toward a solution.

Performance of Various Thicknesses of P.C. Concrete Secondary Pavement, HR-9, 1979

In 1951 Greene County and the Iowa Highway Research Board paved County Road E-33 from Iowa Highway No. 17 (now Iowa 4) to Farlin with various thicknesses [ranging from 4.5 in. (11.4 cm) to 6 in. (15.2 cm)] of portland cement concrete pavement. The project, designated HR-9, was divided into ten research sections. This formed pavement was placed on the existing grade. Eight of the sections were non-reinforced except for centerline tie bars and no contraction joints were used. Mesh reinforcing and contraction joints spaced at 29 ft 7 in. (9.02 m) intervals were used in two 4.5-in. (11.4-cm) thick sections. The concrete in one of the sections was air entrained. Signs denoting the design and limits of the research sections were placed along the roadway. The pavement has performed well over its 28-year life, carrying a light volume of traffic safely while requiring no major maintenance. The 4.5-in. (11.4-cm) thick mesh-reinforced pavement with contraction joints has exhibited the best overall performance.