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Corticosteroids and Pericarditis of Acute Myocardial Infarction
2 Steele P, VanDyke D, Sutton F, et al: Left ventricular ejection fraction in severe chronic obstructive airways disease. Am 1 Med 59:21-28, 1975 3 Harris WS, Weissler AM, Brooks RH: Vagal influences of left ventricular contraction in man: A cause for prolongation of the pre-ejection period. Clin Res 14:426, 1966 4 Talley RC, Meyer IF, McNay JL: Evaluation of the preejection period as an estimate of myocardial contractility in dogs. Am 1 Cardiol 27 :384-391, 1971 5 Takahashi M, Moritz DL: Systolic intervals in children with normal and diseased hearts. Am 1 Cardiol 29:294, 1972 6 Fabian 1, Epstein E], Coulshed N: Duration of phases of left ventricular systole using indirect methods: 1. Normal subjects. Br Heart 1 34 :874-881, 1972 7 Zoneraich S, Zoneraich 0, Rodenrys 1: Computerized system for noninvasive techniques: 1. Its value for systolic time intervals. Am 1 CardioI33:643-648, 1974 8 Weissler AM, Harris WS, Schoenfeld CD: Bedside technics for the evaluation of ventricular function in man. Am 1 Cardiol23:577-583, 1969
Smoking, Carboxyhemoglobin Levels, and Oxygen Therapy To the Editor:
In the article by LiIker et al entitled "Portable Oxygen in Chronic Obstructive Lung Disease with Hypoxemia
and Cor Pulmonale: A Controlled Double-Blind Cross. over Study" (Chest 68:236-241, 1975), a very important factor was either not mentioned or not considered. Nine patients with severe chronic obstructive pulmonary disease (COPD) and severe hypoxemia were studied. It does not state anywhere in the study whether or not these patients were smoking during the time of the study, and neither oxygen saturation nor carboxyhemoglobin levels were measured. Of the nine patients, three patients had improvement in exercise capacity. The authors noted that although oxygen therapy corrected the hypoxemia, there was no significant change in the red blood cell count, hemoglobin level, or reticulocyte count. The authors concluded that further studies are needed to evaluate the patients who show a striking improvement while receiving portable oxygen therapy and yet are not clearly separated from the others. Lilker et al stressed the need for studying differences in the reactivity of the pulmonary vascular bed and left ventricular failure. In our experience, it is not uncommon for patients, even with severe COPD, to continue to smoke heavily and have markedly elevated carboxyhemoglobin levels.' Many of these patients may have secondary polycythemia with severe hypoxemia; however, it is unlikely that oxygen therapy will benefit them because the desaturation is due to binding of hemoglobin with carbon monoxide. Recently, other patients have been described with polycythemia secondary to heavy smoking, so that this is a real cause of reversible secondary polycythemia.s In any study designed to determine the effects of
570
CO.UNICA~IONS
TO THE EDITOR
chronic low-How oxygen administration, an accurate smoking history and measurement of carboxyhemoglobin level or actual oxygen saturation must be done. A difference in response may have been due to the fact that the three patients who seemed to respond were nonsmokers, whereas the other six patients continued to smoke heavily. In patients who continue to smoke heavily, it would not be expected that oxygen would bring about a significant improvement of their desaturation. We feel this is a critical point to include in any study such as that presented by LiIker et al. Perhaps if they had data on smoking histories, carboxyhemoglobin levels, or oxygen saturations, they did not present it due to space limitations; however, if they neglected this factor, perhaps reassessing their patients in this way may shed light on what separates the responder from the nonresponder, Allan L. Goldman, M.D. Assistant ProfessOt' of Medicine Chief, Pulmona'l/ Disease Section Department of Internal Medicine University of South Florida College of Medicine Tampa Veteran8 Administration Hospital
Tompa, Fla
REFERENCES
1 Goldman AL: Carboxyhemoglobinemia and oxygen desaturation in cigar smokers. Am Rev Respir Dis III :942, 1975 2 Sagone AL lr, Lawrence T, Balcerzak SP: Effect of smoking on tissue oxygen supply. Blood 41:845-851, 1973
To the Editor: I thank Dr. Goldman for his Constructive criticism. To our knowledge, none of the patients smoked during the entire three months of the study, as judged by what they told us, what their families told us, and the observations made by the physician on his weekly visits, as well as the patient's reassessments while in the hospital. E. S. Laker, M.D. Director, Reapirat011l Unit St. 10seph~s Hospital, Toronto and Lecturer, Department of Medicine U niveI'dt" of Toronto
Corticosteroids and Pericarditis of Acute Myocardial Infarction To the Editor: In an article entitled "Pericarditis of Acute Myocardial Infarction" (Chest 67:647-653, 1975), Toole and Silverman describe the use of corticosteroids for the symptomatic treatment of pericarditis associated with acute myocardial infarction. They indicate that this therapy is without major complications and provides the advantage of decreased narcotic use. Bulkley and Roberts! described a patient treated with
CHEST, 69: 4, APRIL, 1976
hydrocortisone for 53 of 63 days after myocardial infarction. At autopsy, it was noted that the healing had been slowed to the 10- to 14-day level after infarction, with development of a large ventricular aneurysm. These investigators also cited several reports supporting the detrimental effects of corticosteroid therapy in delaying healing and in the formation of aneurysms after infarction in both humans and animals. It is interesting that in the paper by Toole and Silverman, three of their six autopsied cases had ventricular aneurysms; however, it is not stated whether these patients had received steroid therapy. In light of these observations, the use of steroid therapy for a probably self-limited condition may be unwarranted when less toxic analgesic and anti-inflammatory agents are available. It seems unlikely that the questionable benefit of decreased narcotic use in this setting justifies the risk of delayed healing of the infarct and aneurysm formation. John C. Sartini, M.D. Department of Medicine University of Kentucky Medical Center Lexington
1 Bulkley BH, Roberts we: Steroid therapy during myocardial infarction. Am J Med 56:244-250, 1974
Interpretation of Chest X-ray Films To the Editor:
The lead article in the September issue, "Disagreements in Chest Roentgen Interpretation" by Herman et al (Chest 68:278-282, 1975), is right on target. Responsible radiologists have been very honest about the problems in proper interpretation of chest films. Perhaps if more clinical infonnation and the patient's age and sex had been given, the authors' interpretation accuracy would have been higher. Nevertheless, several points must be emphasized: (1) responsible radiologists are keenly aware of problems in film interpretation; (2) when ordering a chest film at most institutions, you are asking for a radiologist's consultation, and this should be carried out as other forms of medical consultation, with dialogue between physicians, adequate clinical information, etc; (3) it is irresponsible for the referring physician to request a chest film without supplying adequate clinical information; and (4) a written radiologist's report is not equivalent to tissue diagnosis. It is my impression that practicing physicians, particularly on the primary-care level, do not listen to the radiologists discuss their own problems with chest film interpretation and simply rely on a typewritten report as the be-all and end-alI. A patient with chest symptoms and abnormal findings on the chest film needs careful interpretation and consultation on his chest film. Dr. Herman and his colleagues have written an honest,
CHEST, 69: 4, APRIL, 1976
straightforward prospective report, and its implications and conclusions need strong emphasis before the community of practicing physicians. Willard A. Ff'fJ, M.D., F.C.C.P. Evanston, fU
Phlebotomy, Hemodilution, and Autologous Transfusion in Open-Heart Surgery To the Editor:
I would like to compliment Cohn and associates on their article entitled ''The Effects of Phlebotomy, Hemodilution and Autologous Transfusion on Systemic Oxygenation and Whole Blood Utilization in Open Heart Surgery," which appeared in the September 1975 issue (Chest 68:283-287, 1975). This is certainly the correct approach, and I am sure it is not only beneficial to the patient, but also helps to save on the amount of blood used for open-heart surgery. Since late 1972, we have used phlebotomy, hemodilution, and then replacement of the blood from the heartlung machine to the patient. We then return to the patient his own blood that was withdrawn prior to cardiopulmonary bypass. By using such a technique for the last 726 consecutive patients who had vein graft surgery, 80 percent received no blood during the operative procedure nor at any time during their hospitalization. For those patients undergoing valvular surgery alone, 140 (65 percent) of 214 patients received no blood. And, for those having valvular surgery along with vein graft surgery, 132 (54 percent) of 244 patients received no blood. The technique was published in our article entitled "Coronary Artery Surgery: A New Technique with Use of Little Blood, If Any," which appeared in the August 1974 issue of The Journal of Thoracic and Cardiovascular Surgery (68:263-267, 1974). We believe that this technique is now a proven one, and we strongly urge other cardiac surgeons to use it. Jerome Harold Kay, M.D., F.C.C.P. Los Angeles
Sterilization of the Flexible Fiberoptic Bronchoscope To the Editor:
I have read the letters from Dr. Johnson and from Dr. Miner entitled "Sterilization of the Bronchoscope" (Chest 68:607,1975). I would like to answer them as follows: My original article in Japanese covered nine pages of report and references, including some about 2-bromo-2-nitropropane-l,3-diol (Bronosol; bronopol). The version printed in Chest was very much condensed and, therefore,
COMMUNlcanONS TO THE EDITOR 571
Smoking, Carboxyhemoglobin Levels, and Oxygen Therapy To the Editor:
In the article by LiIker et al entitled "Portable Oxygen in Chronic Obstructive Lung Disease with Hypoxemia
and Cor Pulmonale: A Controlled Double-Blind Cross. over Study" (Chest 68:236-241, 1975), a very important factor was either not mentioned or not considered. Nine patients with severe chronic obstructive pulmonary disease (COPD) and severe hypoxemia were studied. It does not state anywhere in the study whether or not these patients were smoking during the time of the study, and neither oxygen saturation nor carboxyhemoglobin levels were measured. Of the nine patients, three patients had improvement in exercise capacity. The authors noted that although oxygen therapy corrected the hypoxemia, there was no significant change in the red blood cell count, hemoglobin level, or reticulocyte count. The authors concluded that further studies are needed to evaluate the patients who show a striking improvement while receiving portable oxygen therapy and yet are not clearly separated from the others. Lilker et al stressed the need for studying differences in the reactivity of the pulmonary vascular bed and left ventricular failure. In our experience, it is not uncommon for patients, even with severe COPD, to continue to smoke heavily and have markedly elevated carboxyhemoglobin levels.' Many of these patients may have secondary polycythemia with severe hypoxemia; however, it is unlikely that oxygen therapy will benefit them because the desaturation is due to binding of hemoglobin with carbon monoxide. Recently, other patients have been described with polycythemia secondary to heavy smoking, so that this is a real cause of reversible secondary polycythemia.s In any study designed to determine the effects of
570
CO.UNICA~IONS
TO THE EDITOR
chronic low-How oxygen administration, an accurate smoking history and measurement of carboxyhemoglobin level or actual oxygen saturation must be done. A difference in response may have been due to the fact that the three patients who seemed to respond were nonsmokers, whereas the other six patients continued to smoke heavily. In patients who continue to smoke heavily, it would not be expected that oxygen would bring about a significant improvement of their desaturation. We feel this is a critical point to include in any study such as that presented by LiIker et al. Perhaps if they had data on smoking histories, carboxyhemoglobin levels, or oxygen saturations, they did not present it due to space limitations; however, if they neglected this factor, perhaps reassessing their patients in this way may shed light on what separates the responder from the nonresponder, Allan L. Goldman, M.D. Assistant ProfessOt' of Medicine Chief, Pulmona'l/ Disease Section Department of Internal Medicine University of South Florida College of Medicine Tampa Veteran8 Administration Hospital
Tompa, Fla
REFERENCES
1 Goldman AL: Carboxyhemoglobinemia and oxygen desaturation in cigar smokers. Am Rev Respir Dis III :942, 1975 2 Sagone AL lr, Lawrence T, Balcerzak SP: Effect of smoking on tissue oxygen supply. Blood 41:845-851, 1973
To the Editor: I thank Dr. Goldman for his Constructive criticism. To our knowledge, none of the patients smoked during the entire three months of the study, as judged by what they told us, what their families told us, and the observations made by the physician on his weekly visits, as well as the patient's reassessments while in the hospital. E. S. Laker, M.D. Director, Reapirat011l Unit St. 10seph~s Hospital, Toronto and Lecturer, Department of Medicine U niveI'dt" of Toronto
Corticosteroids and Pericarditis of Acute Myocardial Infarction To the Editor: In an article entitled "Pericarditis of Acute Myocardial Infarction" (Chest 67:647-653, 1975), Toole and Silverman describe the use of corticosteroids for the symptomatic treatment of pericarditis associated with acute myocardial infarction. They indicate that this therapy is without major complications and provides the advantage of decreased narcotic use. Bulkley and Roberts! described a patient treated with
CHEST, 69: 4, APRIL, 1976
hydrocortisone for 53 of 63 days after myocardial infarction. At autopsy, it was noted that the healing had been slowed to the 10- to 14-day level after infarction, with development of a large ventricular aneurysm. These investigators also cited several reports supporting the detrimental effects of corticosteroid therapy in delaying healing and in the formation of aneurysms after infarction in both humans and animals. It is interesting that in the paper by Toole and Silverman, three of their six autopsied cases had ventricular aneurysms; however, it is not stated whether these patients had received steroid therapy. In light of these observations, the use of steroid therapy for a probably self-limited condition may be unwarranted when less toxic analgesic and anti-inflammatory agents are available. It seems unlikely that the questionable benefit of decreased narcotic use in this setting justifies the risk of delayed healing of the infarct and aneurysm formation. John C. Sartini, M.D. Department of Medicine University of Kentucky Medical Center Lexington
1 Bulkley BH, Roberts we: Steroid therapy during myocardial infarction. Am J Med 56:244-250, 1974
Interpretation of Chest X-ray Films To the Editor:
The lead article in the September issue, "Disagreements in Chest Roentgen Interpretation" by Herman et al (Chest 68:278-282, 1975), is right on target. Responsible radiologists have been very honest about the problems in proper interpretation of chest films. Perhaps if more clinical infonnation and the patient's age and sex had been given, the authors' interpretation accuracy would have been higher. Nevertheless, several points must be emphasized: (1) responsible radiologists are keenly aware of problems in film interpretation; (2) when ordering a chest film at most institutions, you are asking for a radiologist's consultation, and this should be carried out as other forms of medical consultation, with dialogue between physicians, adequate clinical information, etc; (3) it is irresponsible for the referring physician to request a chest film without supplying adequate clinical information; and (4) a written radiologist's report is not equivalent to tissue diagnosis. It is my impression that practicing physicians, particularly on the primary-care level, do not listen to the radiologists discuss their own problems with chest film interpretation and simply rely on a typewritten report as the be-all and end-alI. A patient with chest symptoms and abnormal findings on the chest film needs careful interpretation and consultation on his chest film. Dr. Herman and his colleagues have written an honest,
CHEST, 69: 4, APRIL, 1976
straightforward prospective report, and its implications and conclusions need strong emphasis before the community of practicing physicians. Willard A. Ff'fJ, M.D., F.C.C.P. Evanston, fU
Phlebotomy, Hemodilution, and Autologous Transfusion in Open-Heart Surgery To the Editor:
I would like to compliment Cohn and associates on their article entitled ''The Effects of Phlebotomy, Hemodilution and Autologous Transfusion on Systemic Oxygenation and Whole Blood Utilization in Open Heart Surgery," which appeared in the September 1975 issue (Chest 68:283-287, 1975). This is certainly the correct approach, and I am sure it is not only beneficial to the patient, but also helps to save on the amount of blood used for open-heart surgery. Since late 1972, we have used phlebotomy, hemodilution, and then replacement of the blood from the heartlung machine to the patient. We then return to the patient his own blood that was withdrawn prior to cardiopulmonary bypass. By using such a technique for the last 726 consecutive patients who had vein graft surgery, 80 percent received no blood during the operative procedure nor at any time during their hospitalization. For those patients undergoing valvular surgery alone, 140 (65 percent) of 214 patients received no blood. And, for those having valvular surgery along with vein graft surgery, 132 (54 percent) of 244 patients received no blood. The technique was published in our article entitled "Coronary Artery Surgery: A New Technique with Use of Little Blood, If Any," which appeared in the August 1974 issue of The Journal of Thoracic and Cardiovascular Surgery (68:263-267, 1974). We believe that this technique is now a proven one, and we strongly urge other cardiac surgeons to use it. Jerome Harold Kay, M.D., F.C.C.P. Los Angeles
Sterilization of the Flexible Fiberoptic Bronchoscope To the Editor:
I have read the letters from Dr. Johnson and from Dr. Miner entitled "Sterilization of the Bronchoscope" (Chest 68:607,1975). I would like to answer them as follows: My original article in Japanese covered nine pages of report and references, including some about 2-bromo-2-nitropropane-l,3-diol (Bronosol; bronopol). The version printed in Chest was very much condensed and, therefore,
COMMUNlcanONS TO THE EDITOR 571