Naushad Hirani

Delayed mobilization after microsurgical reconstruction: An independent risk factor for pneumonia

Large defects secondary to oral cancer resection are reconstructed with microsurgical free flaps. Pulmonary complications in these patients are common. Postoperative mobilization is recommended to decrease respiratory complications; however, many microsurgeons are reluctant to adopt early mobilization protocols due to the perceived risk of flap compromise. The purpose of this study was to determine the incidence of pneumonia among patients undergoing oral cancer resection and immediate free flap reconstruction and to compare the incidence of this complication between patients mobilized early (<4 days postoperative) versus later. A secondary goal was to determine whether early postoperative mobilization affected microvascular flap outcome.

Long-term therapeutic outcomes in pulmonary arterial hypertension

ABSTRACT Background: The prognosis of patients with untreated pulmonary arterial hypertension has historically been poor, but recent advances in our understanding of its pathobiology have led to the development of numerous therapeutic options over the last decade. Methods: Systematic literature review of all randomised studies performed in patients with pulmonary arterial hypertension including long-term extension observations (Medline 1990–2007). Findings: This article provides an overview of the currently available data on the short and long-term effects of emerging agents on exercise capacity, functional capacity, haemodynamics, quality of life, and survival in patients with pulmonary arterial hypertension. Prostanoids, endothelin receptor antagonists, and phosphodiesterase‐5 inhibitors have shown great promise in short-term randomised clinical trials, but the long-term effects of these classes of medication have not been well established to date. Conclusion: Several long-term cohort studies have recently suggested that these drugs can maintain their beneficial effects on important clinical outcomes, but further studies will be needed before definitive conclusions can be drawn regarding the ultimate utility and optimal role of each agent in the therapeutic repertoire.

Left ventricular dimensions in pulmonary arterial hypertension: haemodynamic and exercise correlations

ABSTRACT Background: Remodelling of the heart in patients with pulmonary arterial hypertension (PAH) involves both the right and left ventricles. The objective of the present study was to analyse the dimensions of the right and left ventricles as assessed by echocardiography, and to compare this with haemodynamics and exercise capacity in patients with PAH. Materials and methods: Transthoracic echocardiogram, exercise capacity as assessed by the 6-minute walk test and right-heart catheterization were performed within 1 week in 66 consecutive patients with PAH. Univariate correlation and multiple regression analyses were performed to relate echocardiographic and clinical variables. Results: Left ventricular end-diastolic area index had the best correlation with cardiac index (r = 0.62; p < 0.001) and 6-minute walk distance (r = 0.56; p < 0.001). The ratio of the right to left ventricular area correlated with right atrial pressure (r = 0.62; p < 0.001). Right ventricular percent change in area correlated with cardiac index (r = 0.51; p < 0.001). No correlations were observed between the right and left ventricular dimensions. Conclusions: Left ventricular dimensions and the ratio of the right to left ventricular area correlated with resting haemodynamics and exercise capacity in patients with pulmonary arterial hypertension. These correlations were stronger than those observed with right ventricular dimensions alone. Left ventricular dimensions are important for the non-invasive evaluation of severity of patients with pulmonary arterial hypertension.

Complications of pulmonary artery aneurysms in pulmonary arterial hypertension

ABSTRACT Pulmonary artery aneurysm (PAA) is a rare complication of pulmonary arterial hypertension (PAH), often occurring in patients with long-standing disease. Complications of PAA include pulmonary artery rupture, thrombosis, pulmonic valve regurgitation and coronary artery compression, which can result in myocardial ischemia. Diagnosis of coronary artery compression due to PAA is based on suggestive symptoms, imaging and coronary angiography. We present a case of a 70-year-old Caucasian female with longstanding vaso-reactive PAH complicated by a large PAA compressing the left anterior descending (LAD) coronary artery. The compressed LAD was not amenable to coronary stenting, however due to extensive coronary collateralization she was managed medically with dual antiplatelet therapy and cardiovascular risk reduction, with improvement in symptoms and stability for over 2 years.

Bronchoscopic resection of a central typical carcinoid tumour

16 A 53-year-old man with recently diagnosed, very severe chronic obstructive pulmonary disease (forced expiratory volume in 1 s [FEV1] 1.02 L, 28% of predicted, forced vital capacity [FVC] 3.24 L, 72% of predicted, FEV1/FVC ratio 0.32) had an incidental endobronchial lesion discovered on computed tomography (CT) of the chest (Figure 1). There were no enlarged hilar or mediastinal lymph nodes on CT. Bronchoscopy identified a smooth, vascularized, pedunculated tumour at the right upper lobe carina (Figure 2A). Dynamic obliteration of the bronchus intermedius was present on expiration. Initial biopsy specimens were consistent with a typical bronchial carcinoid tumour. The patient declined referral to a thoracic surgeon and underwent flexible bronchoscopy with moderate sedation. Endobronchial resection of the tumour was successfully achieved using snare electroresection, followed by cryotherapy to the base of the tumour (Figures 2B and 2C). Pathology review confirmed a typical bronchial carcinoid tumour with involvement of the tumour base. At the six-month follow-up, there was no evidence of recurrence on surveillance bronchoscopy (Figure 2D).

Evidence for Kaposi's sarcoma-associated herpes virus infection in patients with idiopathic pulmonary arterial hypertension: a case series and review of the literature

ABSTRACT Background: The pathogenesis of idiopathic pulmonary arterial hypertension (IPAH) is unknown. Recent molecular and immunohistochemical evidence has demonstrated the presence of Kaposis sarcoma-associated herpes virus (KSHV) at high frequency in lung tissue from patients with IPAH, suggesting a possible role for this virus in the pathogenesis of the disease. Materials and methods: Eighty-seven patients with IPAH (n = 45) or other forms of pulmonary hypertension (n = 42) were prospectively assessed for serologic evidence of KSHV, Epstein–Barr virus (EBV) and human cytomegalovirus (HCMV) infection. Immunofluorescence assays specific for antibodies against latency-associated and lytic antigens of KSHV, as well as commercially available kits that detect antibodies against HCMV and EBV nuclear antigens, were employed. Results: Only one patient with IPAH (2.2%) and one of the patients with other forms of pulmonary hypertension tested seropositive for KSHV. In contrast, 100% and more than 90% of patients with both forms of pulmonary hypertension were positive for EBV and HCMV antibodies, respectively. Conclusions: Italian patients with IPAH do not exhibit serologic evidence of KSHV infection despite a normal ability to mount antibody-mediated responses toward human herpes viruses. KSHV is unlikely to play a role in the pathogenesis of IPAH.