John P. Scott

Pulmonary Embolism Associated With Acute Stroke

OBJECTIVE To describe the circumstances surrounding pulmonary embolism associated with stroke, the prophylactic measures, and the outcome in affected patients. MATERIAL AND METHODS We studied pulmonary embolism in patients with acute stroke at Mayo Clinic Rochester during a 2-decade period. Medical records of 30 patients with pulmonary embolus after stroke were reviewed. Pulmonary embolus was diagnosed on the basis of pulmonary angiograms, high-or intermediate-probability ventilation-perfusion scans, or autopsy findings. RESULTS Sudden death occurred in 15 of 30 patients (50%) with pulmonary embolism. In the other 15 patients, pleuritic pain or dyspnea was a major initial symptom. Pulmonary embolism occurred from day 3 to day 120 (median time, day 20) after the ictus. Prophylaxis against deep venous thrombosis was noted in only 4 of 30 patients. Pulmonary embolism was associated with deep venous thrombosis diagnosed clinically or at autopsy in 11 patients, invariably in the paralyzed leg. CONCLUSION Pulmonary embolism after ischemic or hemorrhagic stroke may defy antemortem diagnosis in half of the affected patients. Pulmonary embolism in patients with acute stroke can be a cause of early mortality (during the first month after the ictus).

Outcome in patients with acute basilar artery occlusion requiring mechanical ventilation

BACKGROUND AND PURPOSE Many patients with acute basilar artery occlusion may require endotracheal intubation and mechanical ventilation. The circumstances and predictive value for outcome in these patients are not well documented. METHODS We reviewed the medical records of 25 patients admitted into the intensive care unit with a clinical diagnosis of acute basilar artery occlusion and need for mechanical ventilation. The medical records were reviewed for clinical features, breathing patterns, mode of mechanical ventilation, ability to wean from the ventilator, and neurological outcome. RESULTS Apneic episodes resulted in endotracheal intubation in 8 patients. In the remaining 17 patients, intubation was needed for airway protection. Seven of 8 patients presenting with apneic episodes lost all brain stem reflexes. All 17 patients intubated for airway protection could be successfully weaned to a T-tube circuit. Outcome was generally poor and 22 patients died, of whom 7 died of early systemic complications. Only 3 of 25 patients, all with locked-in syndrome, survived. CONCLUSIONS Mortality is high in patients who require mechanical ventilation after acute basilar artery occlusion. No neurological improvement beyond a locked-in syndrome occurred in survivors. Recurrent apnea appears to predict further progression to brain stem death.

Causes and Outcome of Mechanical Ventilation in Patients With Hemispheric Ischemic Stroke

OBJECTIVE To attempt to determine factors that influence outcome in mechanically ventilated patients with ischemic hemispheric stroke. MATERIAL AND METHODS We reviewed data on 24 mechanically ventilated patients with an ischemic stroke in the territory of the middle cerebral artery, who had been admitted to a medical, neurologic, or neurosurgical intensive-care unit during the period between 1976 and 1994. RESULTS The circumstances surrounding mechanical ventilation were generalized tonic-clonic seizures or status epilepticus (N = 6), progression to stupor and inability to protect the airway from brain swelling (N = 8), or--most commonly--bilateral pulmonary edema from congestive heart failure (N = 10). Of the 24 patients, 17 patients died (12 of neurologic causes and 5 of cardiac arrest or cardiac arrhythmias). Of the seven surviving patients, however, four with seizures and one with pulmonary edema were functionally independent. CONCLUSION Three clinical scenarios generally underlie mechanical ventilation in patients with ischemic hemispheric stroke (generalized tonic-clonic seizures, brain swelling, and bilateral pulmonary edema). The outcome in patients with an ischemic hemispheric stroke and a subsequent need for mechanical ventilation is poor; however, survival and independent function are possible if seizures or pulmonary edema prompt ventilatory support.

Outcome of lung transplantation in elderly recipients.

OBJECTIVE Lung transplantation is a standard treatment option for patients with end-stage lung disease. Lung transplantation in the elderly is controversial due to concerns over anticipated increased surgical risks, inferior long-term outcomes and proper stewardship in allocating limited donor organs. With demographic trends showing an increasing proportion of patients over 60 years old, we evaluated our outcomes with lung transplantation in this older cohort. METHODS Between January 1990 and July 2009, 142 patients underwent lung transplantation at our institution. A total of 15 patients receiving heart/lung transplantation and one patient declining research participation were excluded. As many as 126 patients were analyzed in two groups: <60 and ≥ 60 years old. RESULTS There were 65 females (52%) and 61 males (48%). A total of 53 patients (42%) underwent bilateral sequential lung transplantation and 73 patients single-lung transplantation (58%). Median age at transplantation was 55.3 years (range, 21.6-73.1 years) with 94 patients <60 years (75%) and 32 patients ≥ 60 years (25%). Median follow-up was 4.3 years (range, 0-17.8 years). Overall survival at 30 days was 93.7% with no difference between age groups (p=0.95). There was no difference between the groups for in-hospital, postoperative complications (p=0.86), or unplanned readmission rates within 90 days of the hospitalization (p=0.26). Postoperative pulmonary function (forced expiratory volume in 1s (FEV1) % predicted) at transplant, 4 weeks, 3 months, and 6 months after transplantation was not different between groups (p=0.93). No difference in long-term survival was observed (p=0.59), with 5-year survival of 52.2% for patients <60 years and 47.3% for patients ≥ 60 years. Overall, 20 patients developed bronchiolitis obliterans syndrome and 13 posttransplant lymphoproliferative disease, which was not statistically different between age groups (p=0.87, p=0.37, respectively). CONCLUSION Increased age of 60 years and greater, in highly selected patients, does not appear to have a significant impact on the short- or long-term outcome in patients undergoing lung transplantation. Judicious selection of older patients, who are otherwise excellent candidates for lung transplantation, remains a reasonable option.

Medical Management and Complications in the Lung Transplant Recipient

Lung transplantation has evolved as a viable therapy for patients with end-stage lung disease. Improvements in surgical techniques, avoidance of rejection by effective strategies of immunosuppression, and other aspects of medical management allow successful lung transplantation, with 1-year survivorship of 70 to 93%. In this review, we address the medical management of patients who have undergone lung transplantation. The immunosuppressive protocol used at Mayo Clinic Rochester is presented, along with a discussion of the mechanisms of action and potential complications associated with the various drugs used. The recognition and treatment of early graft dysfunction, infection, rejection, stenosis of the airway anastomosis, and posttransplantation lymphoproliferative disorder are also reviewed. Careful surveillance of patients after lung transplantation helps maintain graft function and facilitates identification, treatment, and potential avoidance of complications.

Posttransplantation physiologic features of the lung and obliterative bronchiolitis.

Obliterative bronchiolitis remains the major obstacle to long-term survival after lung transplantation. Herein we provide a brief review of the key literature as well as our own experience with this condition. Obliterative bronchiolitis has occurred in up to two-thirds of all lung transplant recipients. The characteristic physiologic changes include declines in (1) forced expiratory volume in 1 second, (2) forced vital capacity, and (3) diffusing capacity of the lungs for carbon monoxide. Lung biopsy in patients with obliterative bronchiolitis reveals occlusion of bronchioles in a patchy but extensive distribution. Mucous plugging and bronchiectasis may also be seen. Furthermore, intimal thickening of pulmonary vessels together with mild arteriosclerotic changes of the muscular and elastic pulmonary arterioles may be observed. To date, the main risk factor for the development of obliterative bronchiolitis is recurrent, severe, and persistent acute lung rejection. The recommended management is prevention because the established fibrotic condition may necessitate retransplantation.

Stroke in the Medical Intensive-Care Unit

OBJECTIVE To analyze the occurrence and outcome of new-onset stroke in critically ill patients admitted to a medical intensive-care unit. MATERIAL AND METHODS We reviewed the medical records of patients admitted to the medical intensive-care units of two hospitals between 1985 and 1995. In addition, computed tomographic scans or scan reports were assessed. RESULTS We identified 19 patients with a critical medical illness and a new-onset stroke. Of this study group, ischemic stroke developed in 10 patients, 8 of whom were found to have bihemispheric infarction. A single territory infarct (the middle cerebral artery territory) was noted in two patients. The presumed mechanisms for ischemic stroke were disseminated intravascular coagulation (N = 6), cholesterol embolization (N = 1), discontinuation of warfarin therapy before an invasive procedure (N = 1), septic emboli (N = 1), and cardioversion (N = 1). In nine patients, an intracranial hemorrhage developed. Seven patients had a single lobar hematoma, whereas multiple intracerebral hematomas were found in two patients. Disseminated intravascular coagulation and rupture of a mycotic aneurysm in proven infective endocarditis were the most common mechanisms for hemorrhagic stroke. In all patients with an ischemic stroke, sudden hemiparesis rapidly progressed to coma. In patients with an intracranial hematoma and sudden onset of coma, unilateral fixed pupil was the most common initial manifestation. Of the 19 patients, 17 died and 2 remained severely disabled. CONCLUSION Coma is a common initial manifestation of stroke in patients with a critical medical illness, and disseminated intravascular coagulation has a major etiologic role. New-onset stroke in the setting of critical medical illness generally is a complication in a terminally ill patient.

Successful Lung Transplant From Donor After Cardiac Death: A Potential Solution to Shortage of Thoracic Organs

Lung transplant is an effective treatment for patients with end-stage lung disease but is limited because of the shortage of acceptable donor organs. Organ donation after cardiac death is one possible solution to the organ shortage because it could expand the pool of potential donors beyond brain-dead and living donors. We report the preliminary experience of Mayo Clinic with donation after cardiac death, lung procurement, and transplant.

Lung transplantation : Selection of patients and analysis of outcome

Lung transplantation is an important option for patients with respiratory failure and limited life expectancy. Herein we review the current indications for and outcome after lung transplantation. These results are compared with the natural history of various respiratory diseases, estimated from available databases. Candidates for lung transplantation are generally younger than 60 years of age, have a limited life expectancy because of end-stage lung disease, and have no other major organ dysfunction. Single lung transplantation is performed most commonly for emphysema, pulmonary fibrosis, and pulmonary hypertension. Survival after single lung transplantation is approximately 70% at 1 year, 60% at 2 years, and 40% at 3 years. The median duration of survival for patients with end-stage lung diseases ranges from approximately 2 to 6 years, with wide variation based on the diagnosis and severity of illness. Currently, prolongation of the average survival has not been clearly substantiated after lung transplantation. Further evaluation of outcomes, functional status, and quality of life after lung transplantation is necessary.

Inhaled granulocyte–macrophage colony-stimulating factor for mycobacterium abscessus in cystic fibrosis

Nontuberculous mycobacteria (NTM) are an important emerging threat to cystic fibrosis (CF) patients. In North America, where the incidence of NTM in CF patients is ≥11.8%, Mycobacterium abscessus complex (MABSC), a multidrug-resistant NTM, accounts for ∼35% of these [1], is notoriously recognised as difficult to eradicate, and seriously affects morbidity and mortality in CF [2] as well as lung transplantation outcomes [3, 4]. The mechanisms for the increased incidence of MABSC infection in CF patients are not known. The immune response in CF patients is directed to the Th2 response, which is associated with poorer clinical outcome and accelerated decline in lung function. This Th2 pattern is associated with diminished interferon-γ production and lesser activation of macrophages. One activator of macrophages is granulocyte–macrophage colony-stimulating factor (GM-CSF), the Toll-like receptor activation of which includes phagocytosis, bactericidal activity, oxidative burst and cell adhesion in macrophages [5]. Two experimental findings support the plausibility that reduced GM-CSF-elicited macrophage activation may contribute to NTM and MABSC infection in CF. First, alveolar macrophages from in GM-CSF−/− mice exhibit defective phagocytosis, bacterial killing and reduced H2O2 production [6]. Second, although wild-type mouse models of M. abscessus pulmonary infection show limited morbidity and are limited in their usefulness to study NTM therapy GM-CSF knockout models of M. abscessus infection, mice either succumbed to the acute infection or the infection persisted to a chronic stage in the absence of exogenous GM-CSF [7]. Previously, we [8] and others have reported the successful use of inhaled GM-CSF to treat autoimmune pulmonary alveolar proteinosis and metastatic lung metastases [9] without toxicity. Herein, we treated two CF patients with M. abscessus who were experiencing a decline in pulmonary function and clinical stability. Inadequate innate GM-CSF may underlie the nontuberculous mycobacterium infection in cystic fibrosis http://ow.ly/26n330iggNJ