Prognostic significance of thin-section CT scan findings in small-sized lung adenocarcinoma

OBJECTIVES: The purpose of this study is to evaluate the prognostic importance of thin-section (TS) CT scan findings in small-sized lung adenocarcinomas. PATIENTS AND METHODS: We reviewed TS-CT scan findings and pathologic specimens from 359 consecutive patients who underwent surgical resection for peripheral lung adenocarcinomas 相似文献   

CT-guided interstitial single-fraction brachytherapy of lung tumors: phase I results of a novel technique

PURPOSES: To assess the safety of CT-guided brachytherapy of lung malignancies and to evaluate the initial therapeutic response. PATIENTS AND METHODS: Fifteen patients with 30 lung malignancies were included in this prospective phase I trial (metastases, 28; non-small cell lung cancers, 2). Pre-interventionally two patients had a vital capacity of < 80% (39% and 63%). These two patients, and one other, had FEV1 values of < 80% predicted (17%, 48%, and 64%). Tumors with a maximum diameter of 4 cm were treated with a single brachytherapy catheter that was positioned under CT-fluoroscopy. In two tumors with tumor diameters of 5.5 and 6.5 cm, two applicators were used. In one patient with an 11-cm irregularly shaped tumor, nine catheters were inserted. Treatment planning for 192Ir brachytherapy was performed using three-dimensional CT data that were acquired after percutaneous applicator positioning. All procedures were performed under local anesthesia. A follow-up CT was performed 6 weeks later and every 3 months pos-tintervention. RESULTS: The mean diameter of the 30 lung tumors was 2 cm (range, 0.6 to 11 cm; median diameter, 1.5 cm). The minimal dose within the tumor margin was 20 Gy in all 30 tumors treated. Except for nausea in one patient and focal hemorrhage detected on CT in two patients, no acute adverse events were recorded. One patient developed an abscess at the previous tumor location 9 months after treatment, which proved to be a local tumor recurrence. The median follow-up period was 5+ months with a local tumor control of 97%. CONCLUSION: The novel technique of CT-guided interstitial brachytherapy was safe for the treatment of lung tumors and yielded a very low complication rate. The initial data on therapeutic response are promising.     

Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease

STUDY OBJECTIVES: To investigate the histopathologic pattern and clinical features of patients with rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) according to the American Thoracic Society (ATS)/European Respiratory Society consensus classification of idiopathic interstitial pneumonia. DESIGN: Retrospective review. SETTING: Two thousand-bed, university-affiliated, tertiary referral center. PATIENTS: Eighteen patients with RA who underwent surgical lung biopsy (SLBx) for suspected ILD. METHOD: SLBx specimens were reviewed and reclassified by three lung pathologists according to the ATS/European Respiratory Society classification. Clinical features and follow-up courses for the usual interstitial pneumonia (UIP) pattern and the nonspecific interstitial pneumonia (NSIP) pattern were compared. RESULTS: The histopathologic patterns were diverse: 10 patients with the UIP pattern, 6 patients with the NSIP pattern, and 2 patients with inflammatory airway disease with the organizing pneumonia pattern. RA preceded ILD in the majority of patients (n = 12). In three patients, ILD preceded RA; in three patients, both conditions were diagnosed simultaneously. The majority (n = 13) of patients had a restrictive defect with or without low diffusion capacity of the lung for carbon monoxide (D(LCO)) on pulmonary function testing; 2 patients had only low (D(LCO)). The UIP and NSIP groups were significantly different in their male/female ratios (8/2 vs 0/6, respectively; p = 0.007) and smoking history (current/former or nonsmokers, 8/2 vs 0/6; p = 0.007). Many of the patients with the UIP pattern had typical high-resolution CT features of UIP. Five patients with the UIP pattern died, whereas no deaths occurred among patients with the NSIP pattern during median follow-up durations of 4.2 years and 3.7 years, respectively. CONCLUSIONS: The histopathologic type of RA-ILD was diverse; in our study population, the UIP pattern seemed to be more prevalent than the NSIP pattern.     

Familial idiopathic pulmonary fibrosis: clinical features and outcome

STUDY OBJECTIVES: Familial idiopathic pulmonary fibrosis (FIPF) has been defined as idiopathic pulmonary fibrosis (IPF) occurring in two or more members of a family. The clinical course of FIPF has not been fully defined. Accordingly, the current study was undertaken to establish clinical, radiologic, and histologic features, and survival in a consecutive series of patients with FIPF. DESIGN: Retrospective analysis of clinical, radiologic, and pathologic data from a consecutive series of patients with FIPF who were seen at Mayo Medical Center. Survival in patients with FIPF was contrasted to that of previously characterized patients with nonfamilial IPF who were evaluated at our institution. SETTING: Tertiary referral medical center. PATIENTS: We screened 47 patients and family members with FIPF from 15 families who were identified between the years 1992 and 2002. We further analyzed the subgroup of FIPF patients that was composed of 27 patients from 15 families in whom the complete clinical course was monitored at our institution. MEASUREMENTS: All patients exhibited clinical features that were compatible with IPF and either compatible high-resolution CT (HRCT) scan findings or histologic evidence of usual interstitial pneumonia. Clinical data, including symptoms, physical findings, HRCT scan findings, lung function test results, biopsy results, and survival were abstracted from the clinical records. RESULTS: Compared to patients with nonfamilial IPF, patients with FIPF did not demonstrate any notable differences in clinical, radiologic, or pathologic features. We observed that the total number of affected members in a family with FIPF was a significant risk factor for earlier mortality (p = 0.0157; hazard ratio, 1.434). Overall, however, patients with FIPF had a statistically similar outcome to those patients with nonfamilial IPF. CONCLUSIONS: Although uncommon, FIPF represents a distinct syndrome, which has clinical features and patient survival rates that are similar to those of nonfamilial IPF.     

Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department

BACKGROUND: The role of chest ultrasonography (US) in the diagnosis of pneumothorax (PTX) has been established, but how it compares with lung CT scanning in the diagnosis of radiooccult PTX and in the determination of its topographic extension has not yet been completely evaluated. OBJECTIVE: To determine the diagnostic accuracy of chest US in the emergency department (ED) in the diagnosis of occult PTX in trauma patients and to define its ability to determine PTX extension. DESIGN: An 18-month prospective study. PATIENTS: A total of 109 conscious, spontaneously breathing patients who had been admitted to the ED for chest trauma or polytrauma. METHODS: All eligible patients underwent a standard anteroposterior supine chest radiograph (Rx) and a spiral CT lung scan within 1 h of ED admission. Lung US was carried out by an operator who was unaware of the other examination results, both for diagnosis and for the quantitative delimitation of the PTX. RESULTS: Twenty-five traumatic PTXs were detected in the 218 hemithoraxes (109 patients; 2 patients had a bilateral PTX) evaluated by spiral CT scan; of these, only 13 of 25 PTXs (52%) were revealed by chest Rx (sensitivity, 52%; specificity, 100%), while 23 of 25 PTXs (92%) were identified by lung US with one false-positive result (sensitivity, 92%; specificity, 99.4%). In 20 of 25 cases, there was agreement on the extension of the PTX between CT lung scan and lung US with a mean difference of 1.9 cm (range, 0 to 4.5 cm) in the localization of retroparietal air extension; chest Rx was not able to give quantitative results. CONCLUSIONS: Lung US scans carried out in the ED detect occult PTX and its extension with an accuracy that is almost as high as the reference standard (CT scanning).     

World Trade Center "sarcoid-like" granulomatous pulmonary disease in New York City Fire Department rescue workers

BACKGROUND: Previous reports suggest that sarcoidosis occurs with abnormally high frequency in firefighters. We sought to determine whether exposure to World Trade Center (WTC) "dust" during the collapse and rescue/recovery effort increased the incidence of sarcoidosis or "sarcoid-like" granulomatous pulmonary disease (SLGPD). METHODS: During the 5 years after the WTC disaster, enrollees in the Fire Department of New York (FDNY) WTC monitoring and treatment programs who had chest radiograph findings suggestive of sarcoidosis underwent evaluation, including the following: chest CT imaging, pulmonary function, provocative challenge, and biopsy. Annual incidence rates were compared to the 15 years before the WTC disaster. RESULTS: After WTC dust exposure, pathologic evidence consistent with new-onset sarcoidosis was found in 26 patients: all 26 patients had intrathoracic adenopathy, and 6 patients (23%) had extrathoracic disease. Thirteen patients were identified during the first year after WTC dust exposure (incidence rate, 86/100,000), and 13 patients were identified during the next 4 years (average annual incidence rate, 22/100,000; as compared to 15/100,000 during the 15 years before the WTC disaster). Eighteen of 26 patients (69%) had findings consistent with asthma. Eight of 21 patients (38%) agreeing to challenge testing had airway hyperreactivity (AHR), findings not seen in FDNY sarcoidosis patients before the WTC disaster. CONCLUSION: After the WTC disaster, the incidence of sarcoidosis or SLGPD was increased among FDNY rescue workers. This new information about the early onset of WTC-SLGPD and its association with asthma/AHR has important public health consequences for disease prevention, early detection, and treatment following environmental/occupational exposures.     

The utility of fluorodeoxyglucose positron emission tomography in the evaluation of carcinoid tumors presenting as pulmonary nodules

BACKGROUND: Fluorodeoxyglucose positron emission tomography (FDG-PET) is sensitive for detection of neoplastic solitary pulmonary nodules but may have decreased sensitivity for detection of carcinoid tumors. Our purpose was to determine the sensitivity of FDG-PET to detect pulmonary carcinoid tumors. METHODS: We performed a retrospective review of our institutional results regarding FDG-PET in the setting of thoracic carcinoid neoplasms. We identified 16 patients with a pathologic diagnosis of bronchial carcinoid who had an antecedent FDG-PET (from 2000 to 2004). All patients but one presented with pulmonary nodule(s). RESULTS: Sixteen patients had a diagnosis of carcinoid tumor, typical in 11 patients and atypical in 5 patients. The mean greatest pathologic dimension was 2.08 cm (range, 1.0 to 8.3 cm). Overall positron emission tomography (PET) sensitivity was 75% (12 true-positive and 4 false-negative results). The mean (+/- SD) size of carcinoids with false-negative PET results was not significantly different from carcinoids with true-positive results (1.6 +/- 0.81 cm and 2.35 +/- 1.87 cm, p = 0.54). Fifteen of 16 patients were staged pathologically, and positive nodes were found in 2 of these patients. PET lymph node staging agreed with pathologic staging in one stage 4 patient with positive lymph nodes and distant metastasis, but PET results were false negative in the other patient who had N2 with micrometastatic disease; stage IIIA. CONCLUSIONS: FDG-PET imaging is useful for evaluation of typical and atypical thoracic carcinoid tumors. Although overall PET sensitivity for detection of carcinoid tumors is somewhat reduced as compared to non-small cell lung cancer, it is much higher than prior reports suggest.     

Exclusive diagnostic contribution of the histology specimens obtained by 19-gauge transbronchial aspiration needle in suspected malignant intrathoracic lymphadenopathy

BACKGROUND: Transbronchial needle aspiration (TBNA) performed with a 19-gauge needle provides both cytologic and histologic specimens. However, the diagnostic yield for malignancy gained by histologic examination is unclear. Moreover, this kind of needle is often reserved only for selected cases, in part due to fear for complications. The primary aim of this study was to investigate the diagnostic contribution for malignancy added by histologic to the cytologic specimen examination. The secondary aim was to evaluate the safety of using a 19-gauge needle routinely in all patients. METHODS: Consecutive patients presenting with mediastinal and/or hilar lymph node enlargement of > or = 1 cm, in whom suspicion for malignancy was raised, underwent TBNA with a 19-gauge needle. Patients with negative aspirate test results underwent surgical investigation. RESULTS: Among 77 patients who were examined, 66 had malignant intrathoracic lymphadenopathy. TBNA proved malignancy in 58 patients, whereas it missed the diagnosis in 8 patients (sensitivity, 87.9%; negative predictive value, 57.9%). TBNA established the diagnosis in 94% of patients with small cell lung cancer (SCLC), and in 88% of patients with non-SCLC (p = 0.7). Exclusive diagnosis was obtained in 36.4% of patients by histology (compared with 18.2% of patients by cytology [p = 0.06]), representing an increase of 35.3% in the diagnostic yield of TBNA over sole cytology examination. No major complication occurred. CONCLUSIONS: Histology specimens obtained exclusively with a 19-gauge TBNA needle enabled diagnosis in about 36% of patients with malignant intrathoracic lymphadenopathy. The routine use of a 19-gauge needle is safe.     

CT scan findings in chronic thromboembolic pulmonary hypertension: predictors of hemodynamic improvement after pulmonary thromboendarterectomy

STUDY OBJECTIVES: The aim was to correlate CT scan findings with hemodynamic measurements in patients who had undergone pulmonary thromboendarterectomy (PTE) and to evaluate whether CT scan findings can help to predict surgical outcome.Patients and method: Sixty patients who underwent PTE and preoperative helical CT scanning were included. Preoperative and postoperative hemodynamics were correlated with preoperative CT imaging features. RESULTS: The diameter of the main pulmonary artery (PA) and the ratio of the PA and the diameter of the ascending aorta correlated with preoperative mean pulmonary artery pressure (PAP) [r = 0.42; p < 0.001; and r = 0.48; p < 0.0001, respectively]. There was a significant correlation of subpleural densities with preoperative pulmonary vascular resistance (PVR) [r = 0.44; p < 0.001] and of the number of abnormal perfused lobes with preoperative PAP (r = 0.66; p < 0.0001) and PVR (r = 0.76; p < 0.0001). Postoperative PVR correlated negatively with the presence and extent of central thrombi (r = -0.36; p = 0.007) and dilated bronchial arteries (p = 0.03) seen on preoperative CT scans. Sixty percent of patients (3 of 5 patients) without visible central thromboembolic material on CT scans had an inadequate hemodynamic improvement in contrast to 4% of patients (2 of 51 patients) with central thrombi (p = 0.003). Preoperative PVR (r = 0.31; p = 0.018) and the extent of abnormal lung perfusion (r = 0.37; p = 0.007) and of subpleural densities (r = 0.32; p = 0.017) were positively correlated with postoperative PVR. CONCLUSIONS: In patients with thromboembolic pulmonary hypertension, CT scan findings can help to predict hemodynamic improvement after PTE. The absence of central thrombi is a significant risk factor for inadequate hemodynamic improvement.     

Endoscopic ultrasound-guided fine-needle aspiration for non-small cell lung cancer staging: A systematic review and metaanalysis

BACKGROUND: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a minimally invasive alternative technique for mediastinal staging of non-small cell lung cancer. A metaanalysis was performed to estimate the diagnostic accuracy of EUS-FNA for staging mediastinal lymph nodes (N2/N3 disease) in patients with lung cancer. METHODS: Relevant studies were identified using Medline (1966 to November 2005), CINAHL, and citation indexing. Included studies used histology or adequate clinical follow-up (> 6 months) as the "gold standard," and provided sufficient data for calculating sensitivity and specificity. Summary receiver operating characteristic curves metaanalysis was performed to estimate the pooled sensitivity and specificity. RESULTS: In 18 eligible studies, EUS-FNA identified 83% of patients (95% confidence interval [CI], 78 to 87%) with positive mediastinal lymph nodes (pooled sensitivity) and 97% of patients (95% CI, 96 to 98%) with negative mediastinal lymph nodes (pooled specificity). In eight studies that were limited to patients who had abnormal mediastinal lymph nodes seen on CT scans, the sensitivity was 90% (95% CI, 84 to 94%) and the specificity was 97% (95% CI, 95 to 98%). In patients without abnormal mediastinal lymph nodes seen on CT scans (four studies), the pooled sensitivity was 58% (95% CI, 39 to 75%). Minor complications were reported in 10 cases (0.8%). There were no major complications. CONCLUSIONS: EUS-FNA is a safe modality for the invasive staging of lung cancer that is highly sensitive when used to confirm metastasis to mediastinal lymph nodes seen on CT scans. In addition, among lung cancer patients with normal mediastinal adenopathy seen on CT scans, despite lower sensitivity, it has the potential to prevent unnecessary surgery in a large proportion of cases missed by CT scanning.     

Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry

BACKGROUND: There is little information on the clinical outcome of patients with upper-extremity deep vein thrombosis (DVT). METHODS: RIETE is an ongoing registry of consecutive patients with objectively confirmed, symptomatic, acute DVT or pulmonary embolism (PE). In this analysis, we analyzed the demographic characteristics, treatment, and 3-month outcome of all patients with DVT in the arm. RESULTS: Of the 11,564 DVT patients enrolled, 512 patients (4.4%) had arm DVT. They presented less often with clinically overt PE (9.0% vs 29%; odds ratio, 0.24; 95% confidence interval [CI], 0.18 to 0.33) than those with lower-limb DVT, but their 3-month outcome was similar. Of the 512 patients with arm DVT, 196 patients (38%) had cancer and 228 patients (45%) had catheter-related DVT. During follow-up, those with cancer DVT had an increased incidence of major bleeding (4.1% vs 0.9%; odds ratio, 4.4; 95% CI, 1.2 to 21), recurrent venous thromboembolism (6.1% vs 2.8%; odds ratio, 2.2; 95% CI, 0.91 to 5.6; p = 0.04), and death (22% vs 3.5%; odds ratio, 7.8; 95% CI, 4.0 to 16). Thirty patients had the composite event of recurrent DVT, symptomatic PE, or major bleeding. They were significantly older, more often had cancer, and presented more frequently with symptomatic PE on hospital admission. On multivariate analysis, only cancer patients with arm DVT had an increased risk for the composite event (odds ratio, 3.0; 95% CI, 1.4 to 6.4). CONCLUSIONS: At presentation, patients with arm DVT have less often clinically overt PE than those with lower-limb DVT, but their 3-month outcome is similar. Among patients with arm DVT, those with cancer have the worse outcome.     

Anti-endothelial cell antibodies in patients with sarcoidosis

BACKGROUND: Anti-endothelial cell antibodies (AECA) are circulating antibodies that bind to endothelial antigens and induce endothelial cell damage. These antibodies have been detected in patients with collagen vascular disease and systemic vasculitis. Sarcoidosis is a multiple granulomatous disorder of unknown etiology, and its clinical presentation, organ involvement, and prognosis are highly diverse. In this study, we aimed to investigate the expression of AECA in patients with sarcoidosis. We also examined whether these antibodies could serve as a marker for the activity, severity, and prognosis of sarcoidosis. METHODS: Forty sarcoidosis patients, whose diagnosis was established by clinicoradiologic findings and histologic confirmation of noncaseating epithelioid cell granulomas, were studied. Serum and BAL samples were examined for AECA by cellular enzyme-linked immunosorbent assay (ELISA) using human umbilical vein endothelial cells. The findings were expressed in terms of an ELISA ratio (ER). Fifty-seven subjects without any clinical, radiologic, or serologic evidence of pulmonary disease or autoimmune disorders served as the reference population to judge the positivity of AECA. RESULTS: Patients with sarcoidosis had a significantly higher positivity rate for and levels of AECA in both serum and BAL fluid than the reference population. In addition, the ER of AECA was significantly elevated in patients with multiple lesions or who required corticosteroid therapy compared with that in patients without multiple lesions or who did not need corticosteroid therapy. CONCLUSION: Expression of AECA might be a useful marker to predict the course of sarcoidosis.     

Outcomes and safety of surgical lung biopsy for interstitial lung disease

STUDY OBJECTIVES: To determine the safety of surgical lung biopsy (SLB) in patients with interstitial lung disease (ILD), and specifically in those with idiopathic pulmonary fibrosis (IPF). DESIGN: Retrospective cohort. SETTING: Tertiary care university-affiliated military medical center. PATIENTS: Individuals undergoing SLB for suspected ILD. MEASUREMENTS AND RESULTS: We examined outcomes for subjects with a clinical diagnosis of ILD who had been designated to undergo SLB. Mortality (assessed at 30 and 90 days) following SLB represented the primary end point. Morbidity resulting from complications from SLB served as a secondary end point. The cohort included 83 patients (mean [+/- SD] age, 57.3 +/- 14.2 years; men, 57.8%). IPF was eventually diagnosed in slightly more than half of the subjects. Overall, 30-day and 90-day mortality rates were low (4.8% and 6.0%, respectively). Subjects with IPF did well with SLB (30-day mortality rate, 7.1%) and did not face a higher risk of either death or complications relative to individuals with non-IPF forms of ILD. The only predictors of perioperative mortality were either the need for mechanical ventilation (MV) at the time of SLB or being immunosuppressed prior to undergoing SLB. Excluding persons who met either criterion yielded an overall 90-day post-SLB mortality rate of 1.5% in persons with IPF. Approximately 40% of patients in whom IPF was eventually diagnosed were initially thought to have another form of ILD. CONCLUSIONS: Persons with IPF tolerate SLB well. Requiring MV or being immunosuppressed is associated with an increased risk for death following SLB. Safety concerns should not preclude referral for SLB in patients who are clinically suspected of having IPF.     

Impalpable pulmonary nodules with ground-glass opacity: Success for making pathologic sections with preoperative marking by lipiodol

BACKGROUND: The developments in high-resolution CT scanning have increased the chance of detecting small bronchioloalveolar carcinoma (BAC) or atypical adenomatous hyperplasia (AAH) that appears as a ground-glass opacity (GGO). However, these lesions are not only difficult to localize during surgery, but they are also hard to make pathologic sections of because they are usually impalpable. Here, we report a method of making pathologic sections for impalpable GGO lesions. METHODS: Twenty-nine impalpable GGO lesions < 1 cm in size were marked by 0.4 to 0.5 mL of lipiodol under CT scan before surgery. The lesions were resected under C-arm fluoroscopy. The radiopaque areas marked by lipiodol within the formalin-fixed specimens were cut serially under conventional fluoroscopy for pathologic examinations. RESULTS: The mean (+/- SD) size of the lesions was 0.5 +/- 0.2 cm (range, 0.2 to 1 cm), and the mean depth from the pleural surface was 1.6 +/- 1.4 cm (range, 0.2 to 6 cm). The mean number of sections submitted for pathologic examinations was 2.3 +/- 1.7 per lesion (range, 1 to 7 per lesion). While 11 of the 29 lesions (38%) were invisible even on the cut surface of the specimens, all were demonstrated in hematoxylin-eosin sections. The pathologic diagnosis was BAC in 17 lesions, AAH in 10 lesions, and organized pneumonia in 2 lesions. The use of lipiodol did not affect the pathologic findings. CONCLUSIONS: The use of fluoroscopy to cut sections from resected specimens after preoperative marking with lipiodol was useful for making pathologic sections of impalpable GGOs < 1 cm in size.     

Marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue: imaging findings in 21 patients

BACKGROUND: Few articles have been published on imaging findings of marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue (BALT) of the lung. We present CT scan and 18F-fluorodeoxyglucose (FDG) PET scan findings of the disease. METHODS: From March 1995 to February 2007, 21 pretreatment patients (male patients, 9; female patients, 12; age range, 35 to 76 years; mean [+/- SD] age, 54 +/- 10.4 years) were seen who had pathologic diagnoses of marginal zone B-cell lymphoma of BALT. After CT scans were reviewed searching for specific patterns and distribution of parenchymal lung lesions, patients were classified as having the following four different patterns: (1) single nodular or consolidative; (2) multiple nodular or areas of consolidation; (3) bronchiectasis and bronchiolitis; and (4) diffuse interstitial lung disease (DILD) patterns. In six patients, in whom PET/CT scanning was performed, the pattern and the extent of maximum standardized uptake values (mSUVs) of FDG uptake were described. RESULTS: A single nodular or consolidative pattern was observed in 7 of 21 (33%) patients, multiple nodular or areas of consolidation were observed in 9 patients (43%), bronchiectasis and bronchiolitis were observed in 3 patients (14%), and DILD was observed in 2 patients (10%). On PET scans (n = 6), lesions showed heterogeneous FDG uptake in five patients and homogeneous uptake in one patient, with mSUVs ranging from 2.2 to 6.3 (mean mSUV, 4.2 +/- 1.48). CONCLUSIONS: Marginal zone B-cell lymphomas of BALT manifest diverse patterns of lung abnormality on CT scans, but single or multiple nodules or areas of consolidation are the main patterns that occur in a majority (76%) of patients. Most lesions show heterogeneous but identifiable FDG uptake on PET scans.     

Pericardial abnormalities predict the presence of echocardiographically defined pulmonary arterial hypertension in systemic sclerosis-related interstitial lung disease

OBJECTIVES: To determine the prevalence and significance of pericardial abnormalities in systemic sclerosis (SSc)-related interstitial lung disease (ILD). METHODS: Retrospective study of 41 subjects with SSc-related ILD who underwent evaluation including thoracic high-resolution CT (HRCT) imaging, transthoracic echocardiography (TTE), and pulmonary function testing. HRCT review evaluated the pericardium for the presence of pericardial effusion (PEf), thickness of the anterior pericardial recess (APR) [abnormal defined as > 10 mm], and pericardial thickening as calculated by total pericardial score (TPS) [abnormal defined as > 8 mm]. Pulmonary arterial hypertension (PAH) was defined as a pulmonary artery pressure > 35 mm Hg estimated by TTE. RESULTS: Fifty-nine percent had an abnormal pericardium, 49% had a PEf, 56% had an abnormal APR, and 49% had an abnormal TPS. An abnormal pericardium was more common in men than women. Subjects with and without pericardial abnormalities were otherwise similar with respect to age, SSc classification, autoantibodies, ILD radiographic pattern, and presence of esophageal dilation. Both groups had similar median percentage of predicted total lung capacity, percentage of predicted FVC, percentage of predicted FEV(1), and percentage of predicted diffusion capacity of the lung for carbon monoxide. Subjects with pericardial abnormalities were more likely to have coexistent PAH (35% vs 75%; p = 0.02) and a higher median right ventricular systolic pressure (31 mm Hg vs 44 mm Hg; p = 0.03). Multiple logistic regression revealed that TPS was the best individual predictor of the presence of TTE-defined PAH. CONCLUSIONS: In patients with SSc-related ILD, pericardial abnormalities are commonly seen on HRCT, and their presence is strongly associated with echocardiographically defined PAH, with abnormal TPS as the best individual predictor.     

Zinc chloride (smoke bomb) inhalation lung injury: clinical presentations, high-resolution CT findings, and pulmonary function test results

STUDY OBJECTIVES: Zinc chloride smoke inhalation injury (ZCSII) is uncommon and has been rarely described in previous studies. We hypothesized that structural changes of the lung might correlate with pulmonary function. To answer this question, we correlated findings from high-resolution CT (HRCT) scan and the results of pulmonary function tests (PFTs) in patients with ZCSII. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: Twenty patients who had been hospitalized with ZCSII-related conditions. MEASUREMENTS: The study included HRCT scan scores (0 to 100), static and dynamic lung volumes, and diffusing capacity of the lung for carbon monoxide (D(LCO)). RESULTS: HRCT scans and PFTs were performed initially after injury (range, 3 to 21 days) in all patients and during the follow-up period (range, 27 to 66 days) in 10 patients. The predominant CT scan findings were patchy or diffuse ground-glass opacities with or without consolidation. The majority of patients showed a significant reduction of FVC, FEV1, total lung capacity, and D(LCO), but normal FEV1/FVC ratio values. Changes of functional parameters correlated well with HRCT scan scores. Substantial improvements in CT scan abnormalities and pulmonary function were observed at follow-up. CONCLUSIONS: The majority of our patients with ZCSII presented with a predominant parenchymal injury of the lung that was consistent with a restrictive type of functional impairment and a reduction in Dlco rather than with obstructive disease. Our results suggest that HRCT scanning and pulmonary function testing may reliably predict the severity of ZCSII.     

Simvastatin treatment of pulmonary hypertension: an observational case series

BACKGROUND: Statins confer cardiovascular benefits beyond the reduction of serum cholesterol through antiproliferative and antiinflammatory mechanisms and induction of endothelial nitric oxide expression. In pneumonectomized rats injected with monocrotaline, simvastatin reversed established pulmonary hypertension and conferred a 100% survival advantage. STUDY OBJECTIVES: To evaluate the safety and efficacy of simvastatin for treatment of patients with pulmonary arterial hypertension (PAH). DESIGN: Open-label observational study performed at Stanford University Medical Center. Sixteen patients with primary and secondary causes of PAH, World Health Organization (WHO) classes I (n = 2), II (n = 4), III (n = 3), IV (n = 7), are described. Simvastatin was prescribed at 20 to 80 mg/d and continued in the absence of adverse effects. MEASUREMENTS AND RESULTS: Serial measurements of 6-min walk (6MW) performance, hemodynamics, and echocardiographic estimates of right ventricular systolic pressures (RVSPs) were recorded on each patient. Simvastatin treatment was not associated with hepatic dysfunction, muscle necrosis, or other adverse events. Individual patients demonstrated improvements in 6MW performance, improvements in cardiac output, or decreases in RVSP that may be attributable to simvastatin treatment. Overall, the rate of disease progression appeared to be attenuated, and WHO class IV patients demonstrated improved survival. CONCLUSIONS: Simvastatin treatment appears safe in patients with PAH.     

The natural course of hemodynamically stable pulmonary embolism: Clinical outcome and risk factors in a large prospective cohort study

BACKGROUND: Pulmonary embolism (PE) is a potentially fatal disease with risks of recurrent venous thrombotic events (venous thromboembolism [VTE]) and major bleeding from anticoagulant therapy. Identifying risk factors for recurrent VTE, bleeding, and mortality may guide clinical decision making. OBJECTIVE: To evaluate the incidence of recurrent VTE, hemorrhagic complications, and mortality in patients with PE, and to identify risk factors and the time course of these events. DESIGN: We evaluated consecutive patients with PE derived from a prospective management study, who were followed for 3 months, treated with anticoagulants, and underwent objective diagnostic testing for suspected recurrent VTE or bleeding. RESULTS: Of 673 patients with complete follow-up, 20 patients (3.0%; 95% confidence interval [CI], 1.8 to 4.6%) had recurrent VTE. Eleven of 14 patients with recurrent PE had a fatal PE (79%; 95% CI, 49 to 95%), occurring mostly in the first week after diagnosis of initial PE. In 23 patients (3.4%; 95% CI, 2.2 to 5.1%), a hemorrhagic complication occurred, 10 of which were major bleeds (1.5%; 95% CI, 0.7 to 2.7%), and 2 were fatal (0.3%; 95% CI, 0.04 to 1.1%). During the 3-month follow-up, 55 patients died (8.2%; 95% CI, 6.2 to 10.5%). Risk factors for recurrent VTE were immobilization for > 3 days and being an inpatient; having COPD or malignancies were risk factors for bleeding. Higher age, immobilization, malignancy, and being an inpatient were risk factors for mortality. CONCLUSIONS: Recurrent VTE occurred in a small percentage of patients treated for an acute PE, and the majority of recurrent PEs were fatal. Immobilization, hospitalization, age, COPD, and malignancies were risk factors for recurrent VTE, bleeding, and mortality. Close monitoring may be indicated in these patients, precluding them from out-of-hospital start of treatment.     

Portable exhaled nitric oxide measurement: Comparison with the "gold standard" technique

Background:The measurement of fractional exhaled nitric oxide (FENO) can assist in the diagnosis of asthma and may also act as a useful surrogate inflammatory marker on which to base treatment decisions in asthma management algorithms. Until recently, this technique was confined to research facilities and secondary care institutions. A portable nitric oxide analyzer (MINO; Aerocrine AB; Smidesvägen, Sweden) has been developed, but few data exist comparing this device with established, larger laboratory-based analyzers (NIOX; Aerocrine AB).Methods:A total of 101 asthmatic patients (64 treated with regular inhaled corticosteroids) and 50 healthy volunteers had simultaneous FENO measurements undertaken using NIOX and MINO devices.Results:In both asthmatic patients and healthy volunteers, there was a good correlation between the measurements obtained using each device (r= 0.94 and 0.96, respectively). Altman-Bland plots confirmed this agreement. Receiver operating characteristic curves discriminating asthmatic patients from healthy volunteers obtained using the NIOX and MINO showed a sensitivity of 83.2% and a specificity of 72% using cutoff values of 13 and 12.5 parts per billion, respectively.Conclusion:FENO values obtained using a portable analyzer correlate well with those obtained using an established laboratory analyzer and can be used to discriminate asthmatic from nonasthmatic patients. This may facilitate the measurement of asthmatic airway inflammation in primary care.