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ABSTRACTS 43rd Anraaa [0t ~cR~eru~o~ac isem As Arnerscan College of Chest Physicians 31Z il fi Las vegas, Nevada w October 30, November 3,1977 rx .z . ~ . ~

C Influenza Immunization in Patients Receiving Long-Term R'ifampin Therapy. Richard Albert; S. Laksliminarayan; Wal- ter 1liller, Seattle Rifampim (RMI is wid'ely used! for thetreatnient of tuber- culbsis despite its significant immunosuppressive effects. Sec- ondary antibody response to influenza vaccine is unaffected~by R\1 therapy for 1-4.7 months. However, while lymphocyte stimulation in~response to influenza antigen is not diminished' after 2 weeks of RM therapy, it' is suppressed after 12-16 weeks. This suggests that the immunosuppressive effect of RM can develop gradually: Therefore, the hemagglutination«in- hibiting ( HAIi) antibody response at 4 and 8 weeks after bi- valent influenza vaccine (A Victoria /A.\'e.v Jersey ) was studied in 11 patients receiving Rli for a mean of 12.7 months. This w,as compased to an age-matched group of' 11 tuberculosis patients not on RNl. For both the treated and control groups,, 8/11 patients developed a 4-fold or greater rise in HAI titers to influenza A\ew Jersey. For A Victoria, 8/11 treated patients and 4/11 controls developed a 4-fold! rise in titer. This suggests long-term RM therapy has no sup- pressant effect on the secondary antibody response to influen- za vaccine. Quantitative Comparison of One-Hour Versus Twelve-Hour Ambulatory ECG Monitoring. Sidney Alexander, Boston; Charles. L. Feldman; Peter J. Singer, Worcester Long-term ambulatory electrocardiographic (LTECG) monitoring is a useful, but expensive and somewhat cumber- some, technique:. If sufficient info rmati on ~ about the electricali events observed in a 12- or 24-hour period svere contained" in shorter periods, these might sen,e as a usefullscreening f roce- dure for those patients who should! receive LTECG: Accord- ingly, we examined the records of 419 patients who had been monitored for a minimum of 12 hours. The results of the first hour of monitoring for, each patient were compared wIth those of the first 12 hours by a computer-based arrhythmia detection system which gises accurate, hourly counts of the number of'~ ventricular ectopic depolarizations (VED) and' also detects multif'orm (M ), repetitive (R), and R-on-T (T): VED, and ventricular bigeminy (B). Two hundred rivo patients had one or more VED during the first hour of monitoring. Of these, 182 had high-grade arrhythmias (defined as 101or more VED in any hour; M, R, T, or B) during the t'otal 12-hour period. Of the 217, patients with no VED during the first hour, only 29 had high-grade arrrytlimias during 12 hours. In the subgroup of 70 men and vcomen age 50 or over with coronary disease, 41 of' the 47 (;87'~) who had high-grade arrhythmias in 12 hours had one or more VED during the fiist hour. Only three of these patients a•ith one or more VED during the first'hour had no high-grade arrhythmias during any subsequent hour. These data sug,est that shorter monitoring periods may be useful to screen patients for high-grade ventricular ectopic activity, particularly in those with clinical coronary disease. The Significance of QRS Voltage Changes in Patients Receiv- ing Chemotherapy with Doxorubicin Hydrochloride (Adria- mycin). Khalil Ali; Soad Bekheit-Saad; Alejandro Soto; Dacid` Varoon;;roi:e; Aman U. Buzdar; George R. Blumen~chein; Gabriel Hortoba2yi, Charles K. Tashima;, C. C. Shullen- berger, Houston. One hundred forty-six patients w•itlt carcinoma of the breast , who received doxorubicin hydrochloride (Adriamyein (AD; )' .vere studied! The sum of the QRS voltage in the six limb leads was calculated before and after the conclusion of ther- apy. Seven, patients developed clinical and radiologic evidence of cardiomyopathy. The remaining 139 patients were classified according to the presence or absence of pulmonary paren- chymal or pleural disease_ Our results indicate that: 1) AD therapy produced a reduc- tion in QRS voltage in all groups except those who had significant decrease in pleural effusion during AD therapy; 2), the ma.rimum~reduction in QRS voltage .vas observed in those patients aho received the highest dose of AD and developed congesti.e cardiomyopathy; 3) caution should be exercised in j, the interpretation of QRS voltage changes in patient's with concomitant pulmonandisease, particularly pleural effusion. Effect of Carbon Monoxide on Exercise Performance in Chronic Obstructive Pulmonary Disease. Wilbert S. aronow; Jack Ferlinz; Frederick Glauser;,lrcing, California In a double-blind, randomized, crossover study we evalu- ated the effect of breathing 100 ppm~ of carbon monoxide ( CO ), versus compressed, purified air for 1 hour on exercise performance in 10 patients with chronic obstructive pulmo- nary disease (COPD), an arterial Po2 between 58 to 70 mm Hg, an arteriaP Pco_ < 42' mm Hg, no history of heart dis- ease, and no ST-segment depression after exercise. The mean arterial carboxyhemoglobin was 1.-18;= in the CO control pe- riod and increased fTom 1.43 to 4.08° after breathing CO (P < 0!001), The mean arterial carboxyhemoglobin level was 1.52°, in the air controli period and~ decreased from 1 1.47 to 1.34 ~ aft'er purified' air (P < 0.001)', The mean exercise time until marked dyspnea d'ecreased from 218:5 sec in the CO control period to 1-16.6' sec after breathing CO ( P< 0.001). The mean exercise time was 219.9 sec in the air con- trol period and:22'1.1sec after purified air (P not'significanto.Breathing 100 ppm of CO for, 1 hour caused a signifieant reduction in exercise performance in patients with COPD. Echocardiographic Differentiation of Congestive Cardiomyop- athy from Hypertensive Heart Disease and Organic Mitral Insufficiency. Stephen Arcan; Jack Kleid; Norman Cagin; Barrie Levitt, New York City. Congestive cardiomyopathy ( CC ) is often mistaken for hypertensive cardiovascular disease ( HCVD ) and organic mi- tral insufficiency ( ONIIQ. Echograms were performed' on 16 CC patients, 10 patients with O\DI, 13 patients with HCVD, and 13 normal' controls. The following measurements -were significantly d'epressed in the CC group as compared to the HCVD and OMI groupc left septal' excursion (P' <.001, P <.05 respectively ), posterior wall excursion (P <.001, P <.001 respectively), percent systolic thickening of the free left ventricular: wall ( P<.02 and P' <.01 respectivel}^);,, per- cent systolic shortening of the left ventricular cavity (P < .001, P' <.001 respectively ), and posterior w•all slope in sys- tole (1P <.01 and P' <.001 respectively). The hypertensive group also demonstrated consistent ventricular hypertrophy w hile the myocardiat thickness of the CC group was always of normal dimensions (P <.001), ~ ~ry ~ p Congestive cardiomyopathy can b u'~rn-~s ~! rom HC%'D and ONII by examining the above measured indices of left ventricular function, and by noting the presence or absence of ventricular hypertrophy onithe echogram.. 392 43R& ANNUAL SCIENT!1fIC ASSEMBLY CHEST, 72: 3, SEPTEMBER, 1977

c Arterial Oc} genation and Alveolar-Arterial Gradients at Term Pregnancy. Rohert J. :Irce; 11. Brooke Nicotra; Tc•.rna, 1). \'c•tc•.som; Rohcrt l'iles, llcnrrYott Pre.-iou: reports of arterial blood gas values of pregnant, women at term are conflicting. We studied' 23 health.•„ non- smoking poung women ( niean age 22 years) with normal chest roentgenograrns at term and again,xvithin 4 days of de- livery. Arterial hlood! gas levels were measured sitting and' supine on ambient air. Closing volumes were deterrnined' while sitting. Allihut one had a normaliPaO_ (greater than 90 mm Fig ). All had hypocapnea and respii•atory alkalosis not af- fected by position. While supine, 20 patients (S 7°) had'A,a gradient of 10 1mm Hg or greater, and in 11 patients (481) the A-a was 20'mm Hg or greater. Fourteen patients (;61°) had elevated! closing volumes (greater than 10 'c of vital capacity), but there was no correlation betstieen those with elev.atediclos- in, volumes and' those with elevated A-a gradients. We con- cl'ude that' (1) the PaO., at' term pregnancy is normal;, (2) the A-a gradient is abnormally elevated at term while supine: (3) the A-a gradient' does not correlate with elevated closing volumes. to have Iaryngeal sarcoid - (-1-k ) s One patient presented with acute laryngedl obstruction necesitatiug emergency ta•ache- ostorny and after five months of corticosteroid therapy was succ•rssfully decannulated. The second patient presented with hoarseness and d:spnea sshich improsed follotsing 2 months of administration s.stemic corticosteroids: The final patient had multisystem sarcoid and deceloped progressi.e d.-spnea followed by hoarseness. We had the opportunitv to study this patient with serial pulmonary function tests. Her forced ex- piiatory flow 6olume in one second and forced c:ital'capacit}• did not significantl.- change; however, she developed maxi- mum expiratory. flos• . nlume (NlEF1' ) cun-e changes indica- tive oF upper airwa.°obstruction as described by Rotman et al (Chest 68:769, 197,511. \fEF1' curves with helium-osygen breathing demonstrated _1Vmax;,, of -i5:~ confirming central ainvav obstruction. All of these changes retlirned to normal with the patient on steroid therapy. We conclude that corticos- teroid therapy is effective in treating laryngeal sarcoid. Fur- ther..•e believe that examination of \FEFVcurves is helpful in distinguishing physiologically the etiolog7-' of respiratory symptoms in sarcoidosis and in monitoring therapy. ~ins•ays Response in Allergic and Non-Allergic Subjects. Gopal Batra;, Harold Menkes; Harold Newball; Philip Vor- man; Richard Rosenthal; Solbert Permutt, Baltimore Reactivity of airways in allergic subjects varies between allergic non-asthmatic hay fever patients and allergic asth- matic patients. Earlier studies of sensitivitg•y to inhaled meta- choline demonstrated a similari 'ty of large ains•ay responsive- ness in allergic asthmatic subjects andthose with hay feven In the present study we examined'the response to inhaled PGF._a in allergic asthmatics,, allergic non-asthmatic hay fever and nonallergic subjects. Measurements of airx ays conducta-nce ('Gas-)i and spirometry incltiding time taken betseen 40-60° of VC (Tao1so) with air and helium-ozygen mixture were made after incremental challenge with PGF_a. Normal sub- jects did not show anv changes up to a dose of 3640 r,g; Allergic subjects with, asthma demonstrated changes in Ga.v and spirornetric indices which persisted at all dose levels. The patients with hay fever showed! changes in Caw and T4o.eo with helium-O_ mixture at 10 and 30 µg dose only after which the changes were reversed in spite of incremental dose. If changes in Gaw and T+o-60 (helium-O,) reflect changes in large airways and an irritant response, these re- sults suggest the following: in allergic non-asthmatic hay fever subjects, the irritant response seen %.ith PGF_a leads to a reflex bronchodilator response whereas in asthmatic pa- tients this reflex response is deficient suggesting a neural and/" or humoral inbalance. Further experiments are being con~ ducted to test this hvpothesis. In additiom T;„.ao with he- lium-O., mixture provides a sensitive index of large airways changes asrorrelated %vith Ca.v. Lary-ngeal Sarcnidosis: Treatment and Physiologic Manifesta- tions. Jack Beld•n; James Bou•er; Dacid Dantzker; John Weg, Ann Arbor Laryngeal sarcoidosis has been found in 1-?° of patientss with sarcoidosis. There have been onh T, reported! cases treated with systemic corticosteroids and the physiologic manifestations of this disorder have not been studied prev,ious- ly. During the calendar year 19i6, we saw i,-}' patients with respiratory tract manifestations of sarcoidosis; 3' were found Left Ventricular Hypertrophy, Dilatation or Both? An Elec- troechocardiographic Correlatiom Alberto Benchimol; Pat- rick J. Browne; Kenneth B. Desser; Connie Sheasby, Phoenix The terms hypertrophy ( LN'H ) and dilatation (LVD ) are frequently used interchangeably when referring to left s•en- tricular (LV) size in tlre clinical setting or for x-ray and electrocardiographic diagnosis. In order to clarify such termi- nology, analysis of echocardiograms ( ECHO ).eas undertaken in 24 consecutive patients .%ho had an increase of either septum ( I\s'S ), left r entricular posterior .vall (LVP%V), or left ventricular internal dimensions ( LVID') and ECCs diagnostic of LVH. Conclusions: l i concentric LWl rarely co-exists with LVD oni the echocardioarams of pat ents .% itli LVII on their ECCs; 2) LVD free,uently produces ECG changes compatiblee with the diagnosis of LVH; 3) cautionishould be exercised in thediugnosis of concentric LVH by inspection of ECCs from patients with coronar.• artery disease; and 4) LV enlargement appears to be a more appropriate term for ECC diagnosis .chenithe clinical findings are not available. 037487121 Bronchocentric Cranulomatosis Simulating Pulmonary Neo- plasm. Sanford P. Benramin;, ltn .a$,ar Ahmad; fl. Scott ['an Otd.strand; Lawrence J. 11cCoruiack, Cleveland Bronchocentcic granulomatosis is an unusual pulmonary inflammatory disease .x;ith variable clinical and roentgeno- graphic features. We have evaluated four patients with com- plaints of cough, chest pain, and thick sputum production. Roeutgeno,rams re.ealed' single or multiple mass densities greater than 2 cm~ in greatest dimension. The primary diag- nostic con,ideration in each, case was neoplastic process and' lobectomy was performed. Macroscopic examination revealed saccular dilatation of smaller peripheral airways xhich .vere filled with thick inspissated' necrotic contents. Microscopy confirmed a necrotizing bronchocentric granulomatous in- Hammatory process. .aspergilli were identified in the bron- chial contents in one patient who also had a serum-precipitaM ing antibody to A.spergillus ftrmigutu_s. A second patient had a precipitating antibody to Candida albicans. Two patients reeei.ed adjuncti.e steroid therapy follo,,%•ing lobectomy. Three ot the 4 patients are clinically free of disease from 6 months to 2 years. CHEST, 72: 3, SEPTEMBER, 1977 43RD ANNUAL SCIENTIFIC ASSEMBLY 393

~ U Pulmonary Abnormality in Individuals with Mid-Systolic Click-Late Systolic Murmur (Mitral Prolapse). Kenneth R. ,=`Berunett; A. Wallace Conerly; James R: Ca1 jearr;, Hironobu :1ndv; Patrick H. Leluzn, Jackson, Jfissi.ssippi Since dyspnea is a common~ complaint in indixid'uals with mitral prolapse, we investigated 1-4 patients ( 11 women, ages 15-36 and! 3 men, ages 26-61) with documented \16GLSSf for evidence of pulmonary dysfunction. All were nonsmokers and had no, clinical or x-ray filin evidence of pulmonary dis- ease. Evaluation included history and physical e.aminationi with analysis of flow volume loops and flow volumes using thee wedge spirorneter; static lung, volumes and body mechanics using the body plethysmograph; measurement of oxygen transfer using steady state technique with CO diffusion;, arterial blood gases and calculation of the A-a O_ gradient. The thorax was evaluated for skeletal deformity and AP diameter. The patients were divided into -1' ¢roups. Group A, 6.vith a flow volume loop characteristic of restrict'ive,pulmo- nary disease; group B, 5 with a normal, flow volume loop; group C, 1 with a flow volume, loop characteristic of a. combined restrictive-obstructive disorder; and group D, 2 in whom flow volume loops were not performed. Our findinGs indicate that individuals withi.\1SC-LS\t often have restrictive pulmonary dysfunction withi hypen<entilation ( hypocapnea ) that is not due to a small thorax. The degree of dysfunction does not appear severe, but may ezplaini dyspnea in some of these patients. Subclinical Disseminated Carcinomatosis of the Lung: Physi- ologic Abnormalities in Patients Diagnosed by Transbron- chial Lung Biopsy. Andrew Binder; Thomas E:,Addison, San Francisco The diagnosis of lymphangitic carcinoma of! the lung (LCL) is usually not suspected until distinct radiographic signs appear. We diagnosed LCL with transbronchiat lung biopsy ( TBB ) via the fiberoptic bronchoscope in three pa- tients .vho stiere minimally symptomatic and in whom chest s- ray films showed only mild parenchymal abnormalities. In our patients, LCL was considered a possibility on the basis of' abnormalities noted on physiologic testing. The prominent' abnormalities were: ( 1), reduced carbon monoxide diffusing capacity (Dco,n/V:,), (2 patients); (2')' increased flows on maxinial expiratory flow volume curve ('MEFY)( 2'patients ); (3) mild restrictive defect (2 patients;). The physiologic correlates of LCL have been poorly defined. LCL probably results from, hematogenous disseminationof neoplastic cells to small pulmonary blood vessels. Vascular invasion then occurs withispread through lymphatic channels. Significant occlusion of the pulmonary capillary bed results in reduction of Dcosa. Invasion of interstitial lymphatics could' increase elastic recoil or alternatively, invasion of' bronchial submucosall lymphatics could reduce corrlpliance of d'ownstreamiainways and result'in increased flows on \fEFV. The diagnosis of LCL, although subelinicall was suspected because of these physiologic ab- normalities. Confirmation by TBB has not been previousNy reported but was easily accomplished' in these patients. Fur- ther investigation of early diagnosis of LCL, particularly in breast' carcinoma (a hormonally sensitive tumor with a pro- clivity for lymphangitic spread) would seem to be indicatcd. Treatment of Acute Respiratory Failure «ith Albumin, Di- uretics,,and Dialysis: A Reevaluation. Roger C. Bone, Kansas City, Kansas The adult respiratory distress syndrome (ARDS), has rou- tinely been treated with positive end-expiratory pressure \. ( PEEP ) and gentle dehydration. Transient beneficial effects of treatment' with albumin and diuretics demonstrated by :mpro.ement in oxygenation and/or decrease in parenchymal infiltrates on chest roenteenograms have been observedl Whetlier recurrent treatment with albumin and diuretics or negative water balance produced by dialysis result in persis- tent beneficial effects is unknow-n. Also, the comparison of dehydration and "low PEEP" with early "high PEEP" and fluid challenge has not been compared! Twelve patients requirir:g, mechanical ventilation and PEEP were treated repeatedly with furosemide and albumin, The beneficial physiologic effects of treatment were gauged by serial measurements of effective static compliance, puhno- nary capillary wedge pressure ( PCWP ), oxygenation, and urine output. Possible detrimental effects were gauged by deterioration of mixed venous blood gas levels, hypotension, or azotemia. Two~groups xvere defined: Res-ponders (patients with a negative fluid balance [2.8 = 1.9 liters] and Non- responders (patients with a positive fluid balance [0.6 = 0:6 liters] ). In all, responders production of negative fluid balance resulted in increased oxygenation and! compliance, but one patient developed acute tubular necrosis without detectable hypotension (continuously monitored by intraarterial line ) or deterioration of mixed venous blbod ga5es and another patient developed mild azotemia after diuretic treatment. No changes occurred in oxygenation, compliance and PCNVP in the non-responders. It is concluded that production of a negative fluid balance by diuresis or dialysis is associated with improvement in oxygenation (mean increase of 38X in arteriall(alveolar ratio ). and effective static compliance (mean increase of 31K ), On the other hand, the beneficial effect of each individual treatment with albumin and a diuretic was transient; multi- ple doses were required. Evem with careful' monitoring this treatment is not without complication. Mortality was 67'. for all patients in this study. Since 197,5, mortality of' patients with ARDS using "losv PEEP" reported in the literature from seven major medical centers was 5S% (,166/298 patients)'. Recently, a new technique (high PEEP) for managing ARDS has been proposed (Douglas et al Chest 71: 1977 ),. The mortality with this technique was 20 °. De- spite these impressive data, the evaluation of one series com- pared to another is difficult because of other different methods of treatment, patient populations, and monitoring informa- tion, A randomized collaborative studyy comparing different treatment protocolk should! be organized. The importance of the issue demands speedy resolution. Q3'748 ~ 22 Electrophysiologic Risk Factors of Syncope. Harisios Bvu- doulas; Stephen F. Scliaal; Richard P. Lewis, Columbus, Ohio The usefulness of electrophysiologic studies for routine evaluation of patients with~ syncope or related symptoms was assessed in 127, patients in whom no obvious cause of syncope .vas found on the resting,electrocardiogram. Sixty-five of the patients had syncope or presyncope and' the other 62 had e.ther palpitations or minor resting atrioventricular or intra~ ventricular conduction defects. Electrophysiologic study in« cluded measurement of the corrected sinoatrial recovery time, sinoatrial conduction time, and evaluation of atrioventricu- lar conduction by means of resting A13 and HV intervals, as well as the response to atrial pacing. Patients with syncope uswillyhad 2, 3, or more than 3 abnormalities, while patients without syncope had no abnormalities in most instances. The incidence of syncope was 93° in patients with 3 or more ali- normalities (n = 31)„i i A in patients with two abnormalities 394 43R0 ANNUAL SCIENTIFIC ASSEMBLY CHEST, 72: 3, SEPTEMBER, 1977

; C (n -°_ 7), a? ~ in patient's:%vith one abnormalitr ('n -? 1), and S7,in patientt s+ith no abnonualih ln=-15". ( p<0!0d). Tlie number of ahnormalities appeared to he more important in the prediction of syncope than the se%erity of one sing(e ahnormalitv_ It iscnncluded that electmphy,iolo,ictestin;i'shiglthc usefkrli for identik ing abnonmalibies likely to produce s}mptoms. The presence of syncope becomes progressicely more likely when multiple abnormalities are found. Effect of Atropine Aerosol on .Yntigen-Induced Bronchospasm in Asthmatic Subjects. Homer Bou.shey; Je$rey Golden, San Francisco The effect of inhalation of 0.1 and 0.2' mg/kg of atropine sulf'ute on~ anti;en-induced bronchospasm was compared to placebo in 12 subjects with mild extrinsic asthma. Each subject was studied on 5 days. On days 1 and 5, serial concentrations of anti<,en were gih en until specific conduc- tance Ga.v/Y'L fell by >:35:~. On days 2, 3;, and 4 seriali chullen,e was performed 20 minutes after pre-treatment with atropine or placebo. Gas%-/X'u after anti;en was compared to both pre- and po,t-treatment values. Atropine caused si_nifi- cant increases in Canci Xr. so that values after subsequent inhalation of'antii;en stere signifiaantly greater than after pre- treatment %xith placebo. The fall in Gas-/\'t, from post- treatment values„ hosseser. «as nearli• as great after 0.1 mS: kg and 0.?'mg/k.¢ of atropine as after placebo (,mean fall ± SE --!0 ± 6:7'~ and 291, -±- 6.1 1~ vs -191~ -- 3.4 Fi, respec- tively). We conclude that atropine inhalation produces bronchodilation: so that antigen inhalation is better tolerated, but'd'oes not block the response to antigen. Comparative Experience with \fyocardial Sutureless Paoing Electrode and Transvenous Pacing Electrode. Donald Boues; Frederick Pliarr; YV'illiiun I:irnJrer; Valentine Pytko; Cliarles Laufiach, Jr.; Creg Slnnson, Dancille, Pennsyli:~.ania A comparative esperience with the myocardial sutureless pacim: electrode andl the transvenous end'ocardial pacing electrode is presented. Eizhty-eight patients had the suture- le.ss electrode inserted during the past 18 months. Comparison %.•as'made with a prior experience involving 186'patients who had trans%enous electrodes inserted. In the sutureless elec- trode Qrnup, 13 (1 1K)', developed! electrode impedance prob- lems requirin; repliuement' prematureh• due to failure to capture. A small number (4) were due to sensing and were atttrihuted to insertion in RV stiith its smaller R voltage. There %vere 3 additional sensing, problems in the immediate postoperati+e period re.oh in, spontaneously withim5 days. Contrary to experimental data, higher thresholds s.ere found' at the L\' apez. Therefore, most of these insertions were into the RV ..all. Unexpected, some of the lo\.est thresholds ssere on the diaphragmatic aspect of the RV. In the transvenous electrode group; lead displacement oc- currecl in 30 patients (,1fi`;)'. Increa,ing electrode impedance, with failure to capture developed in i7 patients (I47~). One patient ( 0:3:i• ) developedl RV perforation. Concl(s,ions: 1) myocardial sutureless electrode insertion is a useful niethod for management of patients with transvenous electrode dirplacement;, 2) it may he associated with the development ofhigl~er electrode impedance and' a greater incidence of electrode fuilure; 3) in our experience, with limited exception, the RV has proved to be an acceptable threshold site. CHEST, 72: 3, SEPTEMBER, 1977 C Pulrnonary Function and PaO. in Patients Undergoing Coro- nary Artery Surgery. SJieldon R. Braun;, tfarzin L. Birnliarun; ParamjeetS. Cliopra, Madison Nineteen patients with proved 3-vesset coronarydi'sease .vho underwent saphenous sein b}rpass graft surQery done through a median sternotoms- incision, were evaluated to determine preoperative pulmonary impairment, as well as tlre effects of surgerv and the length of cardiopulmonary bypass on postoperative lung function. The only positive historicat or physical findings were related to coronary artery disease: SpirometTy, single breath diffusing capacih-, and blood gas determinations were done preoperatively; 2 weeks, and 1-7 months postoperation. Preoperatively, 12 of 19 had FEVr° <70:~, 8' of 19 had DL <80° of predicted, and 12 of 15' had Po~ <80 mm Hg: Vitali capacity measurements compared to preoperative val- ues were reduced an average of 3-k2 in early (P<.0005) and 18 " in late follow-up periods ( P<.0003 ). The Dr_ was an average of 28* less at 2 sceek_s, (P<:0005 ) and 13' less in the later study ( P <.005). D/Va showed no significant change at any time. PaO:, at tsso.ceeks was lower in l0 of 12 by, an average of 10.5 mm Hg, ( P<.025). By the later study; 'they had returned to preoperatii.e levels. No relation between length on bypass and any parameter studied was seen. There was a significant amount of unsuspected pulmonary impairment' preoperatively, as detected in spirometry•, Dc. and! PaO - Postopenati~e impairment seemed reliited to chest wall' mechanics with a loss of vo!ume and not to ]ength of time on bypass. The marke& drop in PaO_ present •2 weeks postoperatiom may be a significant factor in patients %sith myocardial disease who are beginning to increase their phys- ical activity. ! Electrocardiographic Correlates of Ultrasonicall.• Determined Increase of Left Ventricular Dimensions. Patrick J. Browne; AlBerto Be°nchimol,•, kennetJr B. Desser; Connie Sheasby; Phoenix 031748723 Electrocardiograms of 6#' patients with a determined in* crease (by echocardiogram~) of interventricular septum and left ventricular posterior .vall ( LVP1V); left ventricular in« ternal dimension ( LVID ): combined concentric hypertrophy with LVID; and asymmetric septal hypertrophy were re- viewed to determine sensitivity of criteria for LV hyper- trophy ( H) as proposed by Sokolow and Lyon (S and' L, 19.8), Romhilt and Estes (~R and E, 1965), and New York Heart Association (NYHA, 19T3'). Relatise sensitivities for electrocardiographic detection of any increase of echocardio- graphic determined' LN' dimensions was: NYHA (77o) >S and L (6 7'~), >R and E (38`i). By groups, the detection rates were: 1) NYHA (91 t) >S and L (73° ) >R and E(58°); 2), NYHA an&S and L(65<,) >R'and E (61i7c); 4',), NYHA ("/9oJ >S and L (6-1'~) >R and E. (6-,'x). When isolated increased LVID is present, R(V5 or V i; )+S ( V1) >35 mm is the most sensitive independent criterion. Conclusions: 1) the NYHA electrocardiographic criteria for LVFf are more sensitive than the other t.voo criteria for diagnosis, and •2 ) isolated enlargement of LVID without increased septal or posterior wall thickness frequent- ly results in electrocardiographic findings compatible with the diagnosis of LVH. 43RD ANNUAL SCIENTIFIC ASSEMBLY 395

J C Epideminlna.- of Nursery Exposure to Pultnmiary Tubercu- ,losis. John Bhrk; JUhn Chapman. Dallas Historica1ly, the neonate has been ob.erved to be highly :-susceptible to Jf tuberculosir, Cniform questionnaires to principal iwcestigators of! Ohio. Io.•. a„ New York and' Cali- fornia exposures and personal in.-e~tication of an Alabama -exposure of infants in nurseries to hospital personnel with _actire puhnonar}• tuberculosis are reported. All index cases :wrre tuherculin-positi- e„ and in 4 of 3 exposures, the index cases .cere clinically ill srith, sputum positive for If tubercu- losis. In, 2 of 5 hospitals, infants less than 3 months of agee were offered precentii-e treatment with isoniiizid without complications. In all esposures, tuberculin testing was recom- -mended by the involved hospitals in those 2 to 3 months of age. Approximately -},562' infants were exposed, .vith~ an a% erage exposure rate of 110 infants per month ( 16 to 193). ':Of 3,196 infants tuberculin tested'; only 2 in New York were -tuberculin-positice, and they. had mllary tuberculosis. The eollective risk of tuberculosis in infants exposed to hospital personnel with pulmonary tuberculosis was 1 case per 1,598 exposed infants. Four of the fl.e hospitals provid'ed annuali ehest roentgenoRrams of hospitall employees. Chest roent- -genograms vvere not efficacious in avoiding nursery expo- sures. None of the hospitals provided annual tuberculin testing of' employees or isoniazid preventive treatment for eligible reactors. The data support the U.S. Public Health Sen•iee recommendation_to hospitals for periodic tuberculin testing and' preventive treatment of reactors. Applicatiom of current recommendations should pre•-ent hospital-acquired neonatal tuberculosis. Mouth OccIusion Pressure and Ventilatory Responses to Hy- percapnia and Hypoxia in the Sleep Apnea Syndrome. Nau- slaerecan K. &arki; Richard' O. Robinson; H. Douglas Jame- son, Lexin,ton, Kentucky ~ '*Xe have studied 3 adult male patients .cith the sleep apnea syndrome. Each of the patients presented! .vith exces- sive daytime somnolence. A sleep study was performed in each patient with continuous morm:oring of the electro- encephalogram, end-tidal Pco., and pneumogram. Pulmonary function tests, including spirometry. body plethysmography and flo..-volume curves were nitl:in nonnal' limits. One patient was found to ha~ e a"centrai' apnea" and the, other two had "upper airway apnea" (Gastaut et al Brain Res 1966). The resting .entilation and! the pressure developed in the mouth 0,1 sec after the beginning of inspiratory effort against anioccl'usionlat FRC ( P,).1) and the maximum rate of rise of' this pressure in the first' 0.2 sec ( dP/rlt,,,.x ) svere measured as well as the ventilatory; Po l and dP/dt.,,,: responses to hyperoxic hypercapnia and iso- capnic hypoxia. We ha%e found' markedly reduced response -slopes of Po i, dP/dt,. and .-entilation to hypercapnia and hypoxia in the patient with central apnea, but normal re- sponses in the patients with upper airway apnea. These differences in the neuromuscular respiratory output bet..een patients ssith central apnea compared to upper ains•ay apnea may be clinically rele.ant in terms of! irn•cstigation, and treatment of thpse patients. A Population-Based Study of the Incidence of Bronchogenic Carcinoma. David T. Carr, John F. .~nnegers; Lewis B. It'oolru'r; Lconard T. Kurland; Rochester, lfinnesota A population-base& studv of the incidence of bronchogenic carcinoma in Olmsted County, Minnesota. from 1935 through C f 19-1-4! revealed an increase in both men and women. The increase in nien occurred tllrou.chout the:-40 .ears: the rates per 100!(y00~males heing 3.-l, 1-4'.9; 29.S and 41.0 for the four decades respectively. This increase was most marked in the srtuamous cell type, the rate increasing from 1!.0 for the decade 1935-1944 to 15.3 for the decade 19Ci3-19;-4. The incidence in .vromen was stable during the first three decades and showed a moderate increase in the fourth decade, the rates being 3.1„ -1.8,, 3.1 and 10.0 per 100!000 .comen. :Tdenncarcinoma soas the most common cell type iniwomen in every decade and accounted'for, most of the increase in the fourth decade. Tlie 5-year surx ival rate was approximately the same for men (1Q° ) as for u omen (13 ~) but ~s as much better for squamous celll carcinoma (2q') than for adeno- carcinoma (,9 'c), large cell carcinoma ( 5-'<), or small cell carcinoma ( 0 ~)~. Variability in Pulmonary Function Test (PFT) Interpreta- tion Among Respiratory Disease Physicians. Je5rey Carij; Jon Htisebp; Bruce Culver; Carl Kosanke; Richard Welsey, Seattle Several studies have established normal ranges for inter- pretation of pulmonaryy function data, but much~ less informa- tion is available regarding the modifiers commonly used to describe disease severity. Since the narrative conclusions may influence patient care, we assessed the descriptive terms used by respiratory physicians at four affiliated teaching hospitals. Ten consecutihe PFTs from one laboratory ..ere interpreted by 13 readers. Each reader ss•as gis-en the age, height' and ..eight, the predicte& values with~ the standard deviations and the test data but no further clinical informa- tion. Responses describing obstructive disease .e ere cate- gorized as normal, small, ains ay disease, mild, moderate orr severe. Each interpretution, was compared to e%ery otherr interpretation for each patient. Thus, since 10 patients had spirometric tests, there +sere 780 comparisons analyzed. Simi- larly, restrictive disease was categorized as normal, mild, moderate or severe. Fi.e patients had lung volumes ealcu- lated so there were 390 comparisons made. Each comparison was graded as agreein,; as differing by a single category l ie mildo to moderate 1', or as differinq by 2 or 3' categories. Our data point out the variabilitti•, present in PFT interpretationss e%en from a group of physicians with considerable interac- tion. The ciinical' and' physiologic problems causin! the dis- parities in narrative interpretations will be discussed. Microangiographic Demonstration of Increased Blood Flow to Areas of Myocardial Infarction during Intraaortic Balloon Pumping. Philip N. Cascarle;:Walden:ar J. Wajscccuk; \'icho- las Z. Kerin;,lfeli;yn Rulien fire, Detroit 03 I 4 8%2't Clinical evidence suggests that intraaortic balloon pumping increases coronary bloodlflow to areas of isehemia in patients with acute myocardial infarction. Microangiography was used to determine tlie effects of ballooni pumping on the development of collateral vessels. Myocardial infarction -wass induced in dog.s by ligation of the ventral descending artery. Stereo radiograplis of the heart, before and after sectioning, were obtained follon;ing injection of contrast medium (\Ii- cropaque 1 into the coronary arteries.. Vessels as small as 20 microns in diameter could be visualized with this technique. Zones of avascularity were clearlyy demonstrated in 3 of 4 control dogs, whereas 4 of 4 dogs supported by balloon pumping di& not have ava.seular areas. Colllsteral's were 398 43RD ANNUAL SCIENTIFIC ASSEMBLY CHEST, 72: 3, SEPTEMBER, 1977

ahuncL•mt in the prrrnp ~;roup and s+ere .hnrts strait;ht , and t;enerall~~ under lilt), miuron, iir diameter. \lic.rnam;io<,rapliy supports the tf eony that intraaurtic balloon purnpin(Ir fullo,x- in¢ acute mtiocardial infarction increases cullateral flow to areas of' ischernia and infarction. The Association Beta•een .atr'ral Septal' Defect and Tricuspid Valve Prolapse: An Echocardiographic Study. Premiiufra Clrand'raratna; Benjamin Littinan; Dan Wilson, Oklahoma City The echocardioerarns of 52 patients ~vith atrial septal defect were reviewed. Six patients .vere note& to have tricuspid valve prolapse. The criteria used for the diagnosis of, tricuspid valve proLrp,e s%ere the same as those used to diagnose mitral valve prollipse. Three of these subjects had assoc•iatcd, mitral valve prolapse. The di'agno;is of tricuspid valve prolapse was confirmed by anfiiography in one patient. Four patients had mid-systolic tricuspid valse prolapse; and holosystolic prolapse of the tricuspid valve vvas ohservedlin •2: In 1 patient, a striking increase in the degree of tricuspid val. e prolapse was noted after closure of the atrial septa] defect. A concomitant increase in the degree of tricuspidl res,+ureitation svas noted po.toperatively. Aggravation of tri- cuspid valve prolapse should he considered as one of' the causes of clinical!and Iremodynamic deterioration of a patient following ASD repair. Antibody Deposition in the Pleura: A Finding in Drug-In- duced Lupus. Arcot C/randra.sekiiar; Jolin Robinson; Lewis Barr, Chicago Pleural tissues from a group of 36 consecutive patie.ats comprised 15~«ith malit~nancies, 3 tuberculosis, 2 rheumatoid arthritis, 3 procainamide-induced SLE syndromes, 1 infec- tinus mononucleosis, and 12 nonspecific pleuralleffusionswlio underwent needle biopsy were studied by immunofluorescent techniques for antibodyy deposition. Specific nuclear fluores- cence was detected only improcaine amide-induced SLE and was characterized' by in cico staining with either IgG, Ig\1, and in one case, also C3! C1q could not be detected': Four other patients who had antinuclear antibodies in their pe- ripheral blood did! not have dctectablg in ciao antinuclear staining in, their pleural tissue. The presence of in cico fixation of' antinuclear antibodies in the pleura may be of etiologic and'! diagnostic significance in procaine amide-in- duced SLE syndrome., Plasma Cyclir-ANIP Levels in Cardiac Surgery. Ray, Chu- Jcng Chiu; A. Hope d1cArdle, Montreal, Canada Patients with massive myocardial infarction and cardio- genic shock have been reported to have elevated plasma levels of cyclic-AMP, the intracellular second messenger for many hormones. Cychc .3MP has been reported to have an inverse relationshipi.vith insulin, and this study was initiated in order to determine the cyclic A\1P and insulin levels in patients under4oing cardiac surgery. Methods: Thirtrc-three adult patients undergoing cardiac surgerv for either valve replacement and/or aorto-coronary bypass,grafts svere investigated. Blood specimens were taken one day prior to, surgery, at the beginning and at the end of cardiopulmonarv hypass ('CPB ), and 1 and 5-7 days after su%ery. Plasrna cyclic-AMP was determined using the method of Gilrnam and serum insulin .+as measured usin~_ a rad`toiinimmoa,sa% technique. Conclusions: The plasma cyclic-AMP level .vas markedly ele. ated in patients durinu cardiac surgery, and returned toward normal following operation. The reciprocal relation- ship ssith plasma insulin le\el reported by others was not apparent in this series. Plasma cyclic-AMP level reflected the sum effects of'various hormones, and'may be of pathophysio- logic andiprognostic importance. Cardioversion of Atrial Flutter in Digitalized Patients by Atrial Pacing. Gopal Da.s; l:amanaliallyM. Anand; Kaur Ankineedu; Traim Cliinnaea.so; Frederick N. Talmers; Arn• old II. Weissler, Detroit In an attempt to test the application of atrial' pacing as a safe and reliable cardioversion technique for atrial flutter in patients receiving digitalis therapy, it was applied in 44 consecutive episode; of atrial flutter in 32 pat'ients. All except one ss ere receig ing digitalis and most had received larger than usual therapeutic doses. Fourteen of the 25 subjects in whom serum glycoside was measured had concentrations >2 ns;<mli The at'rial and ventricular rates prior to pacing vvere 290 = 20.6 ( SD ) and 1i3,}! -t 27.9 respectively. Successfull rhythm conversion svas achieved on 43 occasions. Atrial flutter termi- nated immediately to sinus mechanism (20) and at'rial fibril- lation (23). Atrial fibrillation spontaneousll reverted to sinus mechanism (13'), while on 10 occasions atrial flutter recurred arid! required repacing. Sinus mechanism was eventually establislred in all 31 subjects. We conclude that atrial pacing is a safe and reliable technique to cardioveft atrial' flutter in digitalized patients. `~ Characterization of Lipid Inclusions in Alveolar Nfacrophages After Tobacco Smoke Exposure. Paid'Dacies; Edward Engel; Garq, Huber, Boston 03'748 i 2S Most hypotheses linl:ing cigarette smoking to chronic lung disease in man have implied an injurious effect of the inhaled tobacco particles or gases directly on the pulmonary par- enchyma itself. Alternatively, alterations in the pulmonary alteolar macrophage, the key host defense cell of the lung, might serve as mediators of lung injury. To study this prob- lem, CD male rats were exposed experimentally to 60 con- secutive days of tobacco smoke inhalation in a dose retention equivalent to,approsimately I': packs of cigarettes per day in man: Stereologic ultrastructural anah•ses revealed! that lipid- like inclusions increased their relative volume 16-fold within alveolar macrophages recovered from animals exposed to smoke, relative to controls and sham-treated animals. To determine the nature of these inclusions, macrophages were allowed to adhere to glass cover slips and then fixed in 1~t' formaldehyde. Histochemcal studies indicated that the inclu- sions stained strongh, with oil red O, and less so with acid hematein. The inclusions displayed a.•ivid„pyridine-extract- able, autofluorescence and their peripheries were positive for lipofuscin schieh scas not attributable to nonrheme iron. Cltrastructural localization of' acid-phosphatase sas demon- strah'e in a,sociation s ith membrnne-bound lipid, and choles- terol clefts sere common. These inclusions resemble macro- pliace alterat`ons found in those lipidoses where a lysosomal storage defect is accompanied by lipid oxidation, tissue break- dosvm and fibrosis, and' their significance as mediators of tohacco-induced! lung,injury may be import'rant. CHEST, 72: 3, SEPTEMBER: 1977 43RD ANNUAL SCIENTIFIC ASSEMBLY 397

~ `. / Heart Rate Response to Intramuscular Atropine in Patients on PropranoloL Neil de Soyza; lfarivell L. Gelfand; Stardey J.. Sarnoff ; Calen S. II'agner;, Stagtrrd G. Warren, Little Rock In the patient with acute brad'ycardiac myocardial infarc- tion, atropine is useful in alleviating the hypotension and' ventricular ectopy that, not infrequently occur in such pa- tients. To determine the response to at opine in patients oni propranolol, 1.5 mg: atropine was given intramuscularly with, an auto-injector to 41 patients with angina pectoris taking propranolol. Their average age was 56.2 years (range 35-92). Average propranolol dose was 130: mg per day (range 30- .480 ). Average resting heart' rate was 58.7 beats per minute.. Forty patients responded with a heart rate increase. Average peak heart rate was 7, 7.7 BP%I. In only 3 patients was heart rate > 90 BPNt; none was > 100 BPM. The heart ratee response to 1.5 mg atropine intiamuscularly was studied in 9' patients before and during propranolol therapy. Before admin- istration of propranolol, average resting heart rate was 76.1 BP%L Average peak heart rate after atropine was 100.1 BP%f. •In 4 patients, their heart rate was > 100 BPM ( 102„ 107, 116;, 126). , While on propranolol, average resting heart rate was 60.1 BPM and average peak heart rate after atropine was 78' BP'.11: 11 > 90, none > 100. Both the increase in heart rate and the peak heart rate after administration of atropine were independent of daily dose and serum blood level of propran- olol. These data indicate that 1.5 mg atropine given intra- muscularly by autoinjector can be administered to patients taking propranolol with little or no risk of' excessive tachycar- dia. Further, bradycardia and hypotension may be more fre- quent and in patients with severe myocardial inf'arction re- clining propranolol'due to unopposed vagal'hyperactivity: Echocardiographic Specificity in the Diagnosis of Ruptured Chordae Tendineae. Sinda B. Dianzumba; Claude R. Joyner,. Pittsburgh This study ,vas undertaken to define the specificity of echocardiography for the diagnosis of ruptured chordae ten- dineae.. Records from 9 patients with surgically confirmed ruptured chordae tendineae to the, anterior mitral leaflet (7 patzents ), and posterior leaflet (2 pat'ients ), were analyzedL A constant echocardiographic feature in all! 7 patients with ruptured chordae to the anterior leaflet was a layer of systolic echoes in the left atrium just posterior to the posterior aortic root. In both patients, with ruptured chordae to the posterior leaflet, there was presystolic posterior movement and non- coaptation of the posterior leaflet in systole with multiple left atrial echoes which appeared as a mirror image of the posterior leaflet. In diastole, the leaflet executed' an abnormal ,.paradoxic anterior movement. Patterns of the type noted - above have not been found in another gmup of 135 patients with other forms of mitral regurgitation. The Additive Effects of' Body Position. Par: lysis, and PEEP on FRC and Oxygenation. Williarn N. Dimovam„ Jan D:. Smitli; W. C. Johanson, Jr, San Antoni,, The relationship between changes ir: i'i;C and hypoxemia is well recognized. We studied the ehects of PEEP,, body position„and muscular paralysis,on FRC and P(A-a)O_1.e in 10 dogs with oleic acid (0.2 mg/kg)-induced pulmonary edema. Mean baseline supine values aere: FRC 47 ml/kg and'P('A-a)O_t o 129 mm Hg. Following,injury,, FRC was 33 ml,'kg and P(.A-a)O :!t 0 52; mm Hg. «'ith PEEP (12 cm H_O ), FRC increased to 63 mllkg and P( r1-a )O:1 0..•as 381 mm Hg, On assuming an upright posture, with PEEP and paraiysis; FRC further increasedi to 112' ml/kg and P( A- a)O_i a' decreased to 69' mm Hg. Cardiovascular instability occurred' with paralysis in the upright position, but Nvas successfullyy treated with drugs and fluids. PEEP;, paraI.•sis, -and the upright position markedly increased FRC and o.xyge- .nat'ion over PEEP alone. This approach may be used to -correct severe hgToxemia in criticallt• ill patients, before resorting to more hazardous therapeutic modalities. The Effect of Positive End-Expiratory Pressure (PEEP)~ on Left' Ventricular (LV) Function im Patients with Respirator.- Failure. James F. Dorethy; Victor Lam, San Antonio, Tezas Indirect estimates of LV performance during PEEP (ie, LV function curves, pulmonary capillary wedge pressure.. central venous pressure, and systolic time intervalk ) have =produced' conflicting results. This study evaluated LV func- tion directly by echocardiography (E) in 6 thermally injured patients with~ acute respiratory failure. E parameters mea- sured vvere LV end-diastolic volume (:EDV)4 stroke volume ( SV ), LV ejection fractiom (iEF ),, and velocity of circumfer- ential fiber shortening ( V,). Serial E was obtained for 20 min periods prior to PEEP, with 10 cm PEEP and 20' cm PEEP, and post-PEEP. The results at' zero PEEP and 20 cm PEEP are as follows: EDV mli SV ml EF V,r (circisec). Pre-PEEP 117±37 76_29 0.63-10.07 1.-15_0.37 20 em PEEP 95_41' 59~27' 0.62±0:07 1.43±0.36 Values=mean _ 1 SD; 'P= <0.05 No st'atisticallyy significant' changes occurred between zero PEEP, 10 cmi PEEP, and'post-PEEP: On 20 cm PEEP. EDV and SN'' fell approximately 15 percent, while EF and' V,r did not change. Therefore, the decreased cardiac output' fre- quently noted with PEEP therapy does not appear to be secondary to a change in myocardial contractilit.; but is most likely due to a decrease in LV filling volume. 03'748 ; zs Pulmonary Infection due to Mycobacterium Fortuitum: Asim K. Dutt; William Si'. Stead, Little Rock We have studied' the records of eight patients with symp- toms, radiographic changes,, and repeated isolation of Myco- bacterium fortuitum from the sputum, who were treated .behveen 19 7076. The age range was 50-72 years,, 7 w ere caucasian and 5 were men. Seven had other diseases. PDD was positive in 5. Organisms were resistant in vitro to antituberculosis drugs: All received chemotherapy for periods ranging:from 12-32 months, Three converted to negative in 1- 7' months and remained so during f'ollosvp. Three died still positive after 12-24 months of therapy. Two never converted, although~ both improved clinically; of these, 1 died 3 years after treatment .vas stopped and the other remains positive but clinically stable 4' months after stopping therapy. Jf fortia:tum occasionally causes pulmonary disease associated with other debilitating conditions in elderly persons. Al« though therapy is not very effective, multiple-drug therapy appeared to eradicate the infection im 3 of our 8'patients and to give clinical benefit to another t.vo. 392 43RD ANNUAL SCIENTIFIC ASSEMBLY CHEST, 72: 3, SEPTEMBER, 1977

C P+cudo-\tobiti 11 A-V Block. AVauiant of Atypical \\'encke- bach Periodicits: 1'aliil EI-Sherij; Jnan .\randa; Beniarnin &•feler, Ralph Lac-ara, lfiinni A total of 144 \Verickebach cycles (1\" ) in the A\' node and 115 \1' in theIlis-Pirrkinjesystem, (HPSI~ in 1i1 patientsssere analyzed to deter7nine the incidence of' t.picall and at~pical W \. ith partic•ulhr emphasis on 1 variant of atypi- cal \\' that mas~ simulate aMolritz type II block. This pseudo-N lohitz IIl pattermuas defined as a long \\' in which, at Icast4 the lirst 3 beats of the cycle show relatis ely constant P-R intervalS (variation of no more than 0M second in surface leads and no, more than 10 msec in His bundle electroqrruns ) and' in which the P-R interval immediately follo\%ingthe blocked heat is shorter than the P-R inten-al prior to block by 0.04 or more of a second. Atypical \l' were found to be more cormmonlhan the typical .-arietyat'both the AV node (67,f,), and l1PS (70 ',.). The pseudo-\Iobitz II . pattern N.as seen in 19.< of atypical AN' nodal \\' and in 17, 'C of' atypical HPS \\". The need to discern a"classical" Mobitz II block from a pseiido-\lohitz II pattern especially in the setting of' an acute inferior mxocardial infarction is empha- sized. The Significance of Intraventricular Conductioni Defects Oc- crUriirg in the Course of Coronary Artery Bypass Surgery. Ricfiard' M. Engel'man; Christopher \t'yndfiam; lfooideen Jfe.eran;"Kennot{i 1f. Rosen; Sidney , Levitsky, Chica.go Specific intraventricular conduction defects (IVCD) have not previously been reported as a result of aortocoronary bypass grafting ('ACBG ) in which direct surgical trauma to the conduction system is not known to occur. In 47 consecu- tive patients under,oing ACBG without associated intracar- diac procedures, nine ( 19 ~) developed IX"CD: The stud.y group consisted of 42 men and 5 .vomen, aged 35to 67 ( mean 55) years. IVCD were detected by continuous intraoperatih-e monitor- ing of 6 frontal ECG leads and \'r; and a daily 12-lead ECC postoperati.ely. I\'CD %cere diagnosed by standard ECG criteria, care being taken to exclude axis shifts due solely to pericardiotomy and cardiac displacement during surgery. Intermittent ischemic cardiac arrest ( 10-?0 min .vith each graft) at 30"C on cardiopulmonary bypass (CPB) ..itl-i reperfusion of' the beating, .ented heart Nvas the operative technique :nployedi Three patients (6.-1`c) developed left' bundle hmt,,eh , ii~ck (LBBB). In only 1was this related to intraoperati.e nNocardial infarction. In two, LBBB was transient, lastin, 3 hrs and 2 days from cessation of' CPB respectively, N.it~, no associated evidence of myocardiall in- farction (enzymes, f•:CG, or myocardial scan). Fixe patients ( 10.6 <) developed left anterior fascicular block ( LaFB )'. In all 3, this %%as transient, lkstiug 1 hr, 4 hrs. 9 hrs, 12 hrs, and 2 days respectix ely; in none ..as nivocardial infarction diag- nased. One patient (1?.1 ~) developed Itrft' posterior fascicular block ( LPFB ) transiently for 1 hr follov.'ing cessation of CPB, ssithout evidence of infarctiom A preoperatitie IVCD %vas present in one of the 9 patients (right bundle branch block subsequently d'evelbping LAFB ). No patient developed at'rioventricular block in the in-hospital postoperative period. Iroconclusion, IXfCD were a common occurrence ( 19'b) dur- in,g closely monitored ACBG in this group of' patients. LBBB was associated with intraoperative myocardial infarction in only I patient. Transient' LBBB;, LAFB; and LPFB were not associated with infarction and appeared'to be heniin.,All of these patients had! an unremarkable po,toperative recovery c %vith no evidence of late mortality or infarction during a 2-12 month follow-up period. Asbestos . Effusion. Gary , R. Epler; Edward A. Gaerisler, Boaton In 1971, we described 12 patients with often bilateral( recurrent pleural effusions without obvious cause. Biopsy demonstrated asbestos disease• Such "asbestos effusions" .cere considered! rare but, since then;, 9 have been added'. This prompted lrongitudinal studies to establish tlie preva- lence in workers esposedl in shipyards, and in asbestos prod- ucts and filter manufacturing. Criteria included confirmation by-y thoracocentesis and serial radiographs, absence of sys- temic illness and absence of tumor within 3 years. Among 763 a'or.l-ers,, 23 had "asbestos effusions." Most were asymptom- atic, tran:ient and seen on serial chest films. The percentage ranged from none in paper filter vorkers with brief sli.-ht exposure to 5ai among long-term asbestos ..rorkers. \\'e conclude that "diffuse pleural thickening" observed! in ex- posed' persons may represent a residual of undetected effu- sion. Furthermore, 3 developed mesotheliomas 4 to 13 years later,. suggesting that effirsions may predispose to mesothe- lioma or rnesothelioma may develop slowly. Finally,, clinicians should be alert to the possibility of asbestos as a cause of "idiopathic • pleural effusion. Bronchodilator Effects on Gastric Acid Secretion. Larry Fos- ter; Walter Trudeau; Allan Goldman, Tampa Patients with COPD have an increased incidence of peptic ulcer disease (PUD). Increased rates of gastric acid secretion are associated with PUD. The role of bronchodilators in causing PUD im patients with COPD has not' been adequate- ly esplored'. Nine outpatients with asthmatic bronchitis had standard gastric analtvsis, serum gastrin determinations by radioimmunoassay,, and spirometry before and after the fol- lo,wing; inhaled Freow (F), epinephrine (E), isoproterenol (11). and metaproterenoll ( JI ); and intravenous aminophyl- line ( A). There .vas no significant change in gastrins ('P> .05). Basal acid output ( BAO ) did not change after F and no patient doubled his BAO. After A, total acid increased in all patients ( P<.025)' and 6 of' 9 had' a doubling of BAO. After E,,5 of 9 patients had a doubling of BAO. Inhaled I and \I had a variable effect on gastric acid secretion. It is concluded that aminophylline andl epinephrine stimulate gastric acid secre- tion. These effects seem to be independent of gastrin and may be seeondan. to alteration of cyclic nucleotides. Electrophysiologic Properties of :1lcohol in Man. Lawrence Gould; C. \'. Rarnana Redd f; Keun-Chan,g Oh; Soo Gyum Kirn, Brooklyn 0374FP7~ 7 There is little information on the effects of alcohol, on the human conduction system. His bundle electrograms were obtained in 14 patients before and after the oral ingestion of 2 ounces of' Canadian Club whiskey. Antegrade and retro- grade refractory periods were obtained with the extra-stimu- lus method. The significant results svere as follows: the PA intenal was 31 ± 2 msec before and 35 = 2' msec after inizestion of alcohol (P<0.01). The mean A-V nodal func- tional refractory period was 438 ± 15 msec before and -l2:3'± 14 msec after ingestion of alcohol (P<0;03). The effective refractory period of the A-V node was 3S6 ~_ 21 msec before and 366 ± 19 msec after use of alcohol ( P<0.05 ). The func- tional refractory period of the ventriculoatrial conductiom CNEST, 72: 3;, SEPTEMBER, 1977 43RD ANNUAL SCIENTIFIC ASSEMBLY 399

~l. system was 441 ± 31 msec before and 421 = 32 rnsec after adininistrat'ion of alcohol ( P<0.05). The effective refrac- tory period of the ventricular myocardium u•as 252 = 8 msec before and 238 ± 8 msec after use of alcohol (P<0!01). Thus, smalli amounts of alcohol dellry conduction at the atrial level, improve conduction through the A-V node, and shorten the effective refractory- period of the ventricular myocardium. Penetrating Trauma of the Lung. Joseph Jf. Graham; Ken- neth L. 1lattoz; Art3iurC. Bea1l;,Jr:, Hou.ston Penetrating injuries of the lung, are among the most fre- t quent encountered in victims of violent trauma. Associated injuries are seen frequently absent, thus lending the patient't amenable to simple tube thoracostomy. All penetrating wounds of the lung seen at Ben Taub General Hospitaliover a 1-year period were reviewed., Three hundred fifty-three pa- tients were treated, 282 requiring tube thoracostomy only: Thoracotomy was performed in 91 patients, 26 for repair ofli associated injuries. Only 45 patients required thoracotomy _and repair of' a pulmonary lesion. Pneumonorrhaphy was performed in 33 patients, segmentectomy in 6 and lobectomy in 2. Four required repair of traeheal' injuries. Complications attributable to lung injury were infrequent. Clotted hemo- thorax occurred in eight patients and empyema in six. There were 28 deaths, all' but nine attributable to complications of associated injuries. Penetrating lung trauma in the majprit-v of patients may be safely treated with tube thoracostomy. Pul- monary resection is required infrequently. Collagen Biosynthesis by Lung Slices from Rats Administered Paraquat, a Fibrotic Agent. Deborah B. Greenberg, Jerold A. Last, Dtzois, California Paraquat, amherbicide knoscn to cause pulmonary j"ibrosis,, was injected intraperitoneally into rats. The rate of colla;em synthesis in these animals was evaluated by measurement' of radioactive hydroxyproline, a specific marker for collagen, im hydrolysates of slices incubated with labeled proline. Lung slices from rats that received paraquat incorporated similar amounts of proline into total proteinin t;itro as did slices from, control animals: However, slices from rats administered para- quat made more collagen than did those fromi uninjected controls, both in absolute terms (total counts per minute. [cpm] of hydroxyproline) and as a percentage of the total protein made (hydroxyproline cpmvtotal' cpm in protein). We conclude that the rate of collaQen synthesis increases in lungs of rats that' receive paraquat in doses sufficient to causee pulmonary fibrosis. Further studies are required to determine the specific collagen type(s) synthesized after paraquat ad- ministration. Neuromuscular Blocking Effect of' Trimethaphan Carnsylate (Arfonad). Juan F. Gi:tierre;.; David Smith; 11. S. Lee; Thara Srichomkuan, Jforgantoun, West Virginia Our interest' in the neuromuscular blocking effect of trimethaphan camsylate (Arfonad) began when we en- countered two patients with acute respiratory paralysis which occurred during medical treatment ..ithi tritnethaphan for acute hypertensiom associated! with dissecting aortic aneu- rysm. The two patients with respiratory paralysis had' clearly demonstrable neuromuscular blockade as shown by the use of a blockade monitor. We then set out to study the effect of trimethaphan camsylate in 22 mongreli dogs anesthetized with phenoharbitol. Conclusiorr.s: 1) trimethaphan produced C i neuromuscular blockade in dose dependent fashion. In- creased concentration and: or increased rate of infusion .vill produce neuromuscular blockade at an earlier time inter:al; 2)i the EJ1G response of the blockade is similar to that produced by non-depolarizing muscle relaxants. There is a fade in tetanus and twitch stimuli' with pnst-tetanic potentia- tion: 3')it isimportant to understand that, fade in tetanus occurred early, before respiratory paralysis. In the prolonged treatment with trunethaplian, failure to sustain tetanic stimu- li at 50 Hz for 5 seconds would lie a good indication of the oncoming respiratory paralysis; Fade in twitch stimuli oc- curred at the same time or later than respiratory paralysis; 4) failure to reverse the blockade by administration of' neostig- mine; edrophonium bromide ( Tensilon ) and calcium may imply diff'eren: mechanisms of blockade from those produced by non-depolarizing muscle rela2ant's. The exact mechanism of neuromuscular blockade is to be determined. Electron-Nficroscopic Studies of Undifferentiated Lung Tu- mors. Samuel P. Hammar; Dawn Bockus;, Roger F. Wheelis;. Lucius Hill, Seattle I As part of an immunotherapy protocol for the treatment of lung caneer,,we examined 27 undifferentiated! malignant lung tumors with the electron microscope. Twel.e .vere classified as small-cell undifferentiated carcinomas and 15 as large-cell undifferentiated carcinomas by light microscopy, according to .the modifiedl World Health Organization classification of pulmonary neoplasms. Byy electron microscopy, 7 of the 12 small-cell undifferentiated carcinomas were true oat-cell car- cinomas (neurosecretory earcinomas ), 3.cere poorly-differ- entiated adenocarcinomas,, and' 2 vvere compose& of cells closely resembling the reserve cell lining the base of the bronchial epithelium. Of the 15 large-cell tumors, there .cere 7 adenocarcinomas, 3 squamous cell carcinomas. 2 malignant histiocytic tumors, 1 neurosecretory (I:ulchitskyy cell ) carci- noma, one adenosquamous carcinoma; and one tumor was unclassifiable. Also, in the ultrastructural study of .%ell-differ- entiated adenocarcinomas, we identified' 2 whose cells con- tained! numerous dense core membrane-bound neurosecretorv granules, thus indicating they were neurosecretory ( l:ulchit- sky's ) cell tumors. Our studies indicate: (1) that light microscopically diag- nosed! undifferentiated lung tumors are a heterogeneous group of neoplasms by electron microscopy; (? ) most small- -eell undifferentiated carcinomas are neurosecreton oat-cell carcinomas, and' most large-cell! undifferentiated carcinomas are either adeno- or squamous carcinomas; (3) all undiffer- entiated primary lung cancers should be studied' by electron microscopy so that accurate correlations can be made be- tween cell type and response to therapy; and (4) electron microscopy can be of primary benefit in the prospective treatment of lung cancer by accurately identifying the cell of nrigin of', the neoplasm. 03'748:28 Aerodynamic-Size Distribution of Commercially Available Metered-Dose Bronchodilator Preparations. F. Charles Hil'- ler; Jfalay K. bEazumder; J. Douglas ZF'ilsorr, Little Rock Aerodynamic size distribution ( kSD ), the most important factor determining aerosol'distribution in the lung; is difficult to measure in real time. A new instrument, the single particlee aerodynamic relaxation time analyzer, utilizes laser doppler velocimetry to measure ASD betweem-0.1oµm and 10.0µm in real time. ASD of certain metered dose bronchodilator de- vices has been studied with this instrument and mass median 400 43RD ANNUAL SCIENTIFIC ASSEMBLY CHEST, 72: 3, SEPTEMBER, 1977