Latest Articles
- Lung transplantation: the Cleveland Clinic experience
BACKGROUND Lung transplantation has been steadily developing as a therapeutic option for end-stage lung disease.
METHODS Retrospective analysis of all 26 patients who underwent lung transplantation at the Cleveland Clinic Foundation between February 1990 and February 1992.
RESULTS Nineteen single-lung transplantations and seven bilateral lung transplantations were performed. The 1-year actuarial survival for all recipients was 65%. A trend was noted towards better survival in recipients with emphysema (100%) and poorer survival in those with pulmonary hypertension (37.5%). Fungal sepsis and reimplantation lung injury were the most common causes of death, and most deaths (8 of 9) occurred within the first 4 weeks. Of 119 pulmonary complications, 82% occurred in the first 3 months, with infection (39%) and acute rejection (29%) being the most common. Bacterial and fungal infections occurred mainly in the first month, and cytomegalovirus infections occurred mainly in the second and third months. The majority of survivors have shown improvement in functional status.
CONCLUSIONS The early perioperative and 1-month post-transplantation period appears critical to long-term survival. Even though the complications are numerous, they are usually manageable and, in general, do not result in long-term morbidity.
- Parkinson’s disease: where do westand?
Although a cure has not been found, certain drugs can relieve symptoms and may actually slow disease progression.
- The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure: insights and highlights from the chairman
Highlights include the new classification schema and recommendations on the use of labetalol.
- Parathyroid carcinoma: 50-year experience at The Cleveland Clinic Foundation
BACKGROUND Parathyroid carcinoma is rare, with a reported prevalence of 0.6% to 4.0% in patients presumed to have primary hyperparathyroidism. This study examines the long-term results of surgical therapy and combination chemotherapy.
PATIENTS From 1938 to 1988, 1260 operations for primary hyperparathyroidism were performed; only six patients (0.47%) were subsequently found to have parathyroid carcinoma. A seventh patient was referred to our institution after the diagnosis of parathyroid carcinoma had been made.
RESULTS All patients had excessive hypercalcemia (serum calcium concentration > 12.0 mg/dL) with a range of 12.3 to 18.3 mg/dL. Locally recurrent tumors causing recurrent hypercalcemia were managed by repeated neck exploration and tumor resection. Six of the seven patients (85%) survived 5 years, while four patients (57%) survived 10 years.
CONCLUSIONS Diagnosis of parathyroid carcinoma rests upon postoperative surveillance of patients who have undergone previous neck exploration and resection of apparently benign adenomas. Long-term survival is possible with repeated resection of locally recurrent tumors.
- The role of multiple risk factors in cardiovascular morbidity and mortality
BACKGROUND Cardiovascular disease remains the leading cause of death in the United States.
OBJECTIVE To identify important modifiable cardiovascular risk factors and appropriate interventions.
DISCUSSION The three most important modifiable risk factors are hypertension, cigarette smoking, and dyslipidemia. Systolic hypertension poses a greater risk than diastolic, but the prognostic significance of diastolic blood pressure may have been underestimated. When a smoker quits, the cardiovascular risk soon approaches that of the nonsmoker. Cardiovascular risk increases progressively with elevations of the serum total cholesterol level above 200 mg/dL. Recently identified risk factors include hyperinsulinemia and left ventricular hypertrophy.
CONCLUSION Each patient deserves an evaluation of cardiovascular risk followed by education about and therapy for those risk factors that can be changed. When more than one risk factor is present, as is often the case, the increase in risk may be synergistic rather than additive.
- Theophylline in the ambulatory treatment of chronic obstructive lung disease: resolving a controversy
BACKGROUND Recent reports of a high frequency of theophylline toxicity, which usually occurs at theophylline blood levels >20 μg/mL, coupled with the recent addition of metered-dose, inhaled anticholinergics to the beta-2 agonist inhalers already available for treatment of chronic obstructive pulmonary disease, has led some authors to suggest that theophylline should no longer be used in the ambulatory management of this disease.
OBJECTIVE The author suggests an alternate approach to theophylline dosing as a means of resolving the current controversy.
SUMMARY Because of the log-linear relationship between bronchodilation and blood level, little bronchodilator efficacy is lost by using a target therapeutic theophylline blood level of 10 ± 2 μg/mL. This target provides a greater range between therapeutic and toxic blood levels than the 17 ± 2 μg/mL therapeutic target blood level that has also been recommended.
CONCLUSIONS Because theophylline has a different mode of action than the sympathomimetic or anticholinergic drugs, it continues to have a useful place in the ambulatory management of chronic obstructive pulmonary disease.