Videofluoroscopic studies of swallowing dysfunction and the relative risk of pneumonia

OBJECTIVE: The purpose of our investigation was to determine the relationship between the degree of swallowing dysfunction observed on barium studies and the likelihood of developing pneumonia in a large series of patients. MATERIALS AND METHODS: The findings on videofluoroscopic swallowing studies in 381 patients were used to classify these patients into one of five groups: those with normal swallowing; those with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration; those with laryngeal penetration; those with tracheobronchial aspiration; and those with silent tracheobronchial aspiration. Clinical data were also reviewed to determine how many patients had developed pneumonia during the 6 months before or after the barium studies. The data were then analyzed to determine whether the risk of developing pneumonia increased significantly with each level of swallowing dysfunction seen on barium studies. RESULTS: No significant difference was found in the frequency of pneumonia in patients with abnormal swallowing but no laryngeal penetration or tracheobronchial aspiration compared with patients with normal swallowing on barium studies (p = 0.85). In contrast, patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration were approximately four times (p = 0.008), 10 times (p < 0.0001), and 13 times (p < 0.0001), respectively, more likely to develop pneumonia than those with normal swallowing. CONCLUSION: Our findings indicate that the likelihood of developing pneumonia is directly related to the degree of swallowing dysfunction seen on videofluoroscopic studies. Patients with no laryngeal penetration-regardless of whether they had normal or abnormal swallowing-have the lowest risk of developing pneumonia. Patients with laryngeal penetration, tracheobronchial aspiration, or silent tracheobronchial aspiration are, in increasing order of magnitude, significantly more likely to develop pneumonia than patients with normal swallowing.     

Safety and hemodynamic effects of pulmonary angiography in patients with pulmonary hypertension: 10-year single-center experience

OBJECTIVE: We sought to examine the incidence of complications and change in pulmonary artery pressure in patients with pulmonary hypertension who were undergoing pulmonary angiography. MATERIALS AND METHODS: A retrospective review was performed for all patients who underwent pulmonary angiography over a 10-year period at a single institution. Patients with moderate pulmonary hypertension (pulmonary artery pressure, 30-59 mm Hg) and severe pulmonary hypertension (pulmonary artery pressure, >/= 60 mm Hg) served as the study population. Demographic data, clinical indication, pre- and postcontrast pulmonary artery pressure measurements, type of pulmonary hypertension, contrast agent volume, complications, and American Society of Anesthesiologists (ASA) classification were recorded for all patients and compared. RESULTS: Two hundred two of 612 patients who underwent pulmonary angiography had pulmonary hypertension. Moderate pulmonary hypertension was present in 155 patients (77%) and severe pulmonary hypertension, in 47 patients (23%). Three (2.0%) of four complications were fatal. The complication rate was higher in patients with severe pulmonary hypertension compared with patients with moderate pulmonary hypertension but not statistically significant (6.3% vs 0.6%, p = 0.63). Patients with complications had a higher mean ASA score than those without complications (4.0 vs 3.0, p = 0.03). Patients with lung transplants had the greatest increase in pulmonary artery pressure after pulmonary angiography compared with all other clinical indications (16.75 +/- 12.97 mm Hg vs 5.46 +/- 6.86 mm Hg, p = 0.003). CONCLUSION: The complication rate of pulmonary angiography in patients with pulmonary hypertension is low. However, in severely ill patients with acute pulmonary hypertension, pulmonary angiography should be undertaken with extreme caution.     

Cervical osteophytes impinging on the pharynx: importance of size and concurrent disorders for development of aspiration

OBJECTIVE: This study evaluated the clinical significance of cervical osteophytes impinging on the pharynx in patients with dysphagia and the importance of concurrent disorders that may affect swallowing function. MATERIALS AND METHODS: On videofluoroscopy, anterior cervical osteophytes were found in 55 (32 men, 23 women; mean age, 69 years) of 3318 patients with dysphagia (1.7%). Coexisting diseases that affected swallowing function were found in 28 patients (stroke, n = 7; thyroidectomy, n = 7; tongue base or laryngeal cancer surgery, n = 5; other diseases, n = 9). Swallowing function was assessed with videofluoroscopy evaluating epiglottic tilting, laryngeal closure, impression of the hypopharynx, pharyngeal residue, and aspiration. RESULTS: With advancing age, the probability of aspiration (odds ratio, 1.07; p < 0.05) and of enlarging osteophytes (odds ratio, 1.26; p < 0.01) increased; the probability was higher for osteophytes at more than one vertebrae (odds ratio, 8.00; p < 0.01) and for concurrent diseases (odds ratio, 8.02; p < 0.01). Aspiration was found in 75% of patients with osteophytes larger than 10 mm and in 34% with osteophytes smaller than or equal to 10 mm. In 88% of patients with small osteophytes who aspirated, other diseases affected swallowing function. CONCLUSION: Aspiration is common in patients with dysphagia and cervical osteophytes larger than 10 mm. Aspiration is rare in patients with osteophytes smaller than or equal to 10 mm unless these patients suffer from other disorders that may affect swallowing.     

Videofluoroscopy of swallowing abnormalities in 22 symptomatic patients after cardiovascular surgery

OBJECTIVE: The aim of this study was to evaluate the types of swallowing abnormalities that occur in symptomatic patients who have undergone cardiovascular surgery. MATERIALS AND METHODS: From 1994 to 2001, 22 patients (17 males and five females; age range, 4-89 years; mean age, 64 years) who had swallowing abnormalities after cardiovascular surgery were referred for a videofluoroscopic swallowing study. Each study was analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, upper esophageal sphincter, and esophagus. Also, the performance of transesophageal echocardiography, long-term intubation, or both was noted. RESULTS: Swallowing abnormalities were present in 18 patients (81.8%) (range, one to eight functional abnormalities; mean, 3.9 functional abnormalities). The distribution of abnormalities across the functional units statistically significantly deviated (chi(2) = 14.4; df = 6; p = 0.025) from uniform distribution, with abnormalities most commonly involving the hyoid and larynx (13 patients [59.1%]) and the pharynx (10 patients [45.5%]). Aspiration was found in 13 patients (59.1%) (predeglutitive, n = 1; intradeglutitive, n = 4; postdeglutitive, n = 3; and mixed, n = 5). In the 14 patients (63.6%) who underwent transesophageal echocardiography, long-term intubation, or both, we frequently found incomplete tilting of the epiglottis, pharyngeal weakness, and postdeglutitive aspiration. CONCLUSION: Most patients with swallowing problems after cardiovascular surgery present with multiple abnormalities that most commonly affect the hyoid and larynx and the pharynx and result predominantly in intra- or postdeglutitive aspiration. The performance of transesophageal echocardiography and long-term intubation may influence the types of swallowing abnormalities.     

Correlation between the radiologic study of deglutition and the clinical picture in systemic sclerosis (scleroderma)

Fifty-one patients with systemic sclerosis (scleroderma) were studied by means of videofluoroscopy in order to evaluate the abnormalities in the oropharyngeal and esophageal phases of deglutition and to correlate the radiological patterns with the clinical features of the disease. Thirteen patients (25.5%) exhibited swallowing disorders such as oral leakage, retention, penetration, mild or moderate aspiration and abnormal upper esophageal sphincter behavior. These dysfunctions were more evident in patients with esophageal motility abnormalities. A normal radiological pattern in the esophagus was not associated with swallowing alterations. Remarkably, patients with oral-pharyngeal disorders had a higher incidence of lung diseases. Forty-five patients (88%) exhibited disorders of the esophageal phase of deglutition, such as mild or severe motility abnormalities or hiatal hernia, gastro-esophageal reflux, reflux esophagitis, and stricture. Radiological findings in the esophagus can be abnormal in the early stages of the disease. On the other hand, the radiological pattern of esophageal motility can be occasionally negative in advanced or extensive disease. This indicates a discrepancy between clinical symptoms and radiological picture of the esophagus. The radiological examination of the oral-pharyngeal and esophageal phases of deglutition is important in patients with scleroderma in order to evaluate visceral involvement, motility disorders, and risk of aspiration. Such radiological information can be useful in preventing esophagitis and pulmonary complications.     

Videoradiographic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids

PURPOSE: To analyze how carbonated thin liquids affected the physiology of swallowing in dysphagic patients. MATERIAL AND METHODS: 40 patients were analyzed; 36 were neurologically impaired. During a therapeutic videoradiographic swallowing examination the patients had to swallow liquids with the following consistencies three times: thin, thickened and carbonated. The liquids were given in doses of 3 x 5 ml. The swallows were analyzed regarding penetration/aspiration, pharyngeal transit time and pharyngeal retention. RESULTS: Significant difference was found regarding penetration/aspiration when comparisons were made between thin liquid and carbonated thin liquid (p<0.0001). Carbonated liquid reduced the penetration to the airways. The comparison between thin liquid and thickened liquid (p<0.0001) showed significant less penetration with thickened liquids. Pharyngeal transit time was reduced both when comparing thin liquid with thin carbonated liquid (p<0.0001) and thickened liquid (p<0.0001). Pharyngeal retention was significantly reduced (p<0.0001) with carbonated thin liquid compared to thickened liquid. The comparison of thin liquids and carbonated thin liquids showed p=0.0013, thin and thickened liquids p=0.0097. CONCLUSIONS: Carbonated liquids reduced penetration/aspiration into the airways, reduced pharyngeal retention and pharyngeal transit time became shorter. Therefore, carbonated liquids are a valuable treatment option for patients with penetration/aspiration. Thickened liquids may still be an option for patients who cannot tolerate carbonated liquids and liquids with this consistency are safer than thin liquids.     

Functional lesions in dysphagia due to acute stroke: discordance between abnormal findings of bedside swallowing assessment and aspiration on videofluorography

Introduction

Bedside swallowing assessments are often used to assess dysphagia. However, in some patients, aspiration pneumonia occurs without any problems on bedside swallowing assessments and some patients do not suffer aspiration pneumonia despite abnormal results of bedside swallowing assessments in acute stroke. To detect the differences of lesions related to bedside swallowing assessment abnormality and aspiration, we investigated swallowing-related functional lesions in terms of cerebral blood flow in patients with dysphagia after stroke.

Methods

The study included 50 acute stroke patients who underwent bedside swallowing assessments and videofluorography as well as single-photon emission computed tomography (CT) at approximately the same time. Bedside swallowing assessments included repetitive saliva swallowing test and modified water swallowing test as dry and wet swallowing tasks. The presence or absence of aspiration was assessed using videofluorography. We divided patients into three subgroups based on the outcomes of the bedside swallowing assessments and presence or absence of aspiration. Statistical image analysis was performed using single-photon emission CT to determine their relationship with bedside swallowing assessments and videofluorography results.

Results

Twenty-seven (54.0 %) and 28 (56.0 %) patients had abnormal repetitive saliva swallowing test and modified water swallowing test results. Videofluorography indicated aspiration in 35 (70.0 %) patients. In comparing patients with and without abnormal results on each test, the groups with abnormal repetitive saliva swallowing test, abnormal modified water swallowing test, and aspiration demonstrated lower cerebral blood flow in the left precuneus, left insula, and anterior cingulate gyrus, respectively.

Conclusions

Based on the analysis of cerebral blood flow, functional lesions differed across abnormal repetitive saliva swallowing test and abnormal modified water swallowing test findings and aspiration on videofluorography, and each test may assess different functions among the many processes involved in swallowing.     

Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial

OBJECTIVE: This study was performed to determine and compare the effectiveness and incidence of complications of percutaneous cholecystostomy and gallbladder aspiration in cases of severe acute cholecystitis. SUBJECTS AND METHODS. Fifty-eight patients with severe acute cholecystitis who did not improve after antibiotic treatment were included in this study. The patients were randomized into either the percutaneous cholecystostomy group (n = 30) or the gallbladder aspiration group (n = 28). Under sonographic guidance, percutaneous cholecystostomy was performed in the usual manner using a 6.5- or 7-French catheter. Gallbladder aspiration was carried out with a 21-gauge needle under sonographic guidance. The technical success, clinical response, and complications in each group were evaluated. RESULTS: Percutaneous cholecystostomy and gallbladder aspiration were technically successful in 30 patients (100%) and 23 patients (82%), respectively (not statistically significant). In five patients (18%) of the gallbladder aspiration group, aspiration was unsuccessful because of replacement of bile with dense biliary sludge or pus. Good clinical response was obtained in 27 patients (90%) of the percutaneous cholecystostomy group and in 14 patients (61%) of the gallbladder aspiration group (p < 0.05). As for complications, dislodgment of the catheter occurred in one patient of the percutaneous cholecystostomy group and minor bleeding in one patient after gallbladder aspiration. No major complications or procedure-related deaths occurred in either group. CONCLUSION: For severe acute cholecystitis, percutaneous cholecystostomy was superior to gallbladder aspiration in terms of clinical effectiveness and had the same complication rate as gallbladder aspiration.     

Radiation Therapy for Chordoma and Chondrosarcoma of the Skull Base and the Cervical Spine

BACKGROUND: Prospective analysis of local tumor control, survival and treatment complications in 67 consecutive patients treated with fractionated photon and proton radiation for chordoma or chondrosarcoma of the base of the skull and the cervical spine. PATIENTS AND METHODS: Between December 1995 and January 2000, 67 patients with a median age of 52 years (range: 14-85 years), were treated at the Centre de Protonthérapie d'Orsay (CPO), France, using the 201-MeV proton beam, 49 for chordoma and 18 for chondrosarcoma. Irradiation combined high-energy photons and protons. Photons represented two thirds of the total dose and protons one third. The median total dose delivered within gross tumor volume (GTV) was 67 Cobalt Gray Equivalents (CGE; range: 60-70 CGE). RESULTS: Within a median follow-up of 29 months (range: 4-71 months), the 3-year local control rates were 71% and 85% for chordomas and chondrosarcomas, respectively, and the 3-year overall survival rates 88% and 75%, respectively. 14 tumors (21.5%) failed locally (eight within the GTV, four within the clinical target volume [CTV], and two without further assessment). Seven patients died from their tumor and another one from a nonrelated condition (pulmonary embolism). The maximum tumor diameter and, similarly, the GTV were larger in relapsing patients, compared with the rest of the population: 56 mm vs 44 mm (p = 0.024) and 50 ml vs 22 ml (p = 0.0083), respectively. In univariate analysis, age < or = 52 years at the time of radiotherapy (p = 0.002), maximum diameter < 45 mm (p = 0.02), and GTV < 28 ml (p = 0.02) impacted positively on local control. On multivariate analysis, only age was an independent prognostic factor of local control. CONCLUSION: In chordomas and chondrosarcomas of the skull base and cervical spine, combined photon and proton radiation therapy offers excellent chances of cure. In two thirds of the cases, relapses are located in the GTV. Maximum diameter, GTV, and age are prognostic indicators of local control. These results should be confirmed during a longer follow-up.     

CT导引下经皮肺组织活检术常见并发症及穿刺体会

目的分析CT导引下经皮肺组织活检术常见并发症,探讨穿刺操作技巧在减少手术并发症中的作用。方法收集2006年6月-2007年6月肺内实质性占位病灶行经皮肺肿块穿刺活检术116例,分析并发症的种类、主要并发症及其处理措施,探讨CT导引下经皮肺内肿物穿刺过程及其体会。结果116例经皮肺肿块穿刺活检术均穿刺成功。发生的并发症主要有气胸(15.5%)、穿刺道出血(10.3%),咯血(4.3%),其他(1.7%)。除1例气胸患者予以胸腔闭式引流外,余均未作特殊处理。结论CT导引下经皮肺穿刺术是一项安全有效的诊断技术。穿刺术前病灶评估、术中精确定位及正确训练患者呼吸运动以配合穿刺操作可减少并发症。     

Pretreatment Proliferation and Local Control in Bladder Cancer after Radiotherapy with or without Concurrent Chemotherapy

PURPOSE: To investigate whether the addition of chemotherapy to radiotherapy (RT) is beneficial particularly in bladder tumors that possess the capacity for rapid proliferation. PATIENTS AND METHODS: The Ki-67 index was evaluated by immunohistochemistry on pretreatment biopsies from 136 patients treated by transurethral tumor resection (TURBT) and RT (n=50) or platin-based radiochemotherapy (RCT; n=86). Ki-67 expression was correlated with response to RT/RCT and long-term local control rates. The median follow-up was 43 months. RESULTS: The percentage of Ki-67-positive cells ranged from 1.5% to 89%. Complete response (CR) was observed in 100/131 patients (76%, five without restaging TURBT). A statistically significant association between high Ki-67 index (>or= median) and CR was noted for patients receiving RCT (93% vs. 66% for Ki-67 < median; p=0.001), but not for patients treated with RT alone (p=0.12). Long-term local control was 39% for patients treated with RT, and 44% for patients after RCT (p=0.49). Patients with high Ki-67 index did significantly better when subjected to combined RCT (55% vs. 33% with low Ki-67 index; p=0.006), whereas no difference between high and low Ki-67 status was observed in the RT group (39% each; p=0.57). On multivariate analysis, Ki-67 status was an independent predictor for local failure in the RCT group (risk ratio, 0.43; p=0.007). Disease-specific survival was significantly better after RCT (62%) as compared with RT (42%; p=0.03), however, the Ki-67 index was not related to this endpoint. CONCLUSION: Rapid proliferation is associated with improved local control, if patients are treated with concurrent RCT. The cytostatic effect of concurrent chemotherapy may effectively inhibit repopulation during fractionated RT.     

CT引导下肺内孤立性病变经皮穿刺活检并发症的分析

目的分析肺外围型孤立病变CT引导下经皮穿刺活检并发症的原因。方法选取2002-10～2004-10连续2年内的所有肺内外围型孤立病变行CT引导下肺穿刺活检的患者71例,回顾性研究总结穿刺活检的并发症发生率与年龄、性别、穿刺针所经肺组织深度、肿块周围有无肺气肿表现、穿刺的次数、穿刺针的粗细等几个方面的关系。结果并发症共26例次,气胸3例(4.23%),肺内出血9例(12.67%),出现血痰或血痰加重13例(18.3%),胸膜反应1例(1.41%)。经统计学分析,并发症的发生与穿刺针所经肺组织深度、病变周围肺气肿及穿刺次数和穿刺针的粗细有明显的相关性。结论CT引导下肺内病变经皮穿刺活检并发症以血痰最常见。病灶离胸膜的间距、病灶周围肺气肿、穿刺次数及穿刺针粗细是经皮穿刺肺活检并发症的危险因素。     

Transthoracic aspiration needle biopsy: value in the diagnosis of pulmonary infections

We reviewed 441 transthoracic needle aspiration biopsies to evaluate the use of the procedure in the diagnosis of pulmonary infections. Sixty-seven (15%) of the biopsies were performed because pulmonary infection was suspected. In these 67 cases, a specific diagnosis was made in 45 (67%). In 46 cases in which infection was ultimately found to be present, aspiration biopsy identified the organism in 35 (76%). Overall, clinically useful information was obtained in 54 (81%) of the 67 biopsies performed for pulmonary infection. In 369 biopsies performed for suspected malignant neoplasm, pulmonary infection was diagnosed in 13. The only significant complication was pneumothorax, which occurred in 18% of the biopsies. Chest tube placement was required in 5% of the biopsies. We conclude that transthoracic aspiration needle biopsy is of value in the diagnosis of suspected pulmonary infections.     

Videofluoroscopy of swallowing in symptomatic patients who have undergone long-term intubation

OBJECTIVE: The aim of this study was to evaluate whether specific patterns of swallowing dysfunction occur in symptomatic patients after long-term intubation. SUBJECTS AND METHODS: Twenty-one patients (16 men, five women; mean age, 66 years) who presented with clinical signs of aspiration after long-term intubation (mean duration, 24.6 days) underwent videofluoroscopy. They were analyzed for functional abnormalities of the tongue, soft palate, epiglottis, hyoid and larynx, pharynx, and the upper esophageal sphincter. We assessed the presence or absence of aspiration, the type of aspiration (pre-, intra-, and postdeglutitive), and a spectrum of other swallowing abnormalities. RESULTS: There were 18 patients (86%) with radiologically proven aspiration. In another patient only laryngeal penetration occurred. There were 11 combinations of pre-, intra-, and postdeglutitive aspiration. Predeglutitive aspiration was predominant and present in 52% of our patients. We found functional abnormalities of the tongue in 48%, of the soft palate in 10%, of the epiglottis in 48%, of the pharynx in 71%, and of the upper esophageal sphincter in 24%. CONCLUSION: Patients who are symptomatic after undergoing long-term intubation do not develop a specific type or pattern of swallowing dysfunction or aspiration, but show a large variety of aspiration types and associated swallowing disorders. Nevertheless, videofluoroscopy has the ability to reveal complex deglutition disorders and to aid precise planning of individualized functional swallowing therapy.     

Colonic interposition: radiographic evaluation

This report reviews the clinical and radiographic features of 40 patients who underwent visceral esophageal substitution with colon for benign or malignant lesions of the esophagus. The incidence and radiographic identification of complications are discussed. All patients were routinely examined with barium esophagrams on postoperative day 10. If an anastomotic leak was suspected clinically before this time, studies were performed using water-soluble iodinated contrast material. Follow-up barium esophagrams were obtained 1-96 months after operation (average, 60 months) in 24 patients. Eight patients (21%) demonstrated asymptomatic "jejunization" of the colonic mucosa with no attributable clinical manifestations; this finding resolved in 1-3 months, without sequelae, and has not been reported before. The spectrum of ischemic changes in the colonic segment included mucosal edema, spasm, ulceration, loss of haustration, and frank necrosis. Radiographically detectable early postoperative complications included anastomotic leak in six (three pharyngocolic, three cervical esophagocolic) and aspiration of barium into the tracheobronchial tree due to incoordinated swallowing in eight. Late postoperative complications included anastomotic narrowing (12) malfunctioning of the colon due to impaired emptying (five), recurrent aspiration pneumonia (three), small bowel obstruction (three), transhiatal herniation of small bowel through the diaphragmatic hiatus (one), and reflux into the retained bypassed esophagus (one).     

Tromboembolismo pulmonar en pacientes con COVID-19: estudio de prevalencia en un hospital terciario

IntroductionSARS-CoV-2, the virus responsible for the current pandemic, predominantly affects the respiratory tract, and a growing number of publications report the predisposition of patients with COVID-19 to develop thrombotic phenomena.ObjectiveTo determine the prevalence of pulmonary embolism in patients with COVID-19; to determine the possible relationship between the severity of pulmonary involvement and D-dimer levels; to analyze the location of pulmonary embolisms in patients with COVID-19 and to compare it with the location in patients without COVID-19.MethodsThis retrospective study analyzed all CT angiograms of the pulmonary arteries done in patients with suspected pulmonary embolisms between March 15 and April 30, 2020 and compared them with studies done in the same period one year earlier.ResultsWe included 492 pulmonary CT angiograms (342 (69.9%) in patients with COVID-19 and 147 (30.1%) in patients without COVID-19). The prevalence of pulmonary embolisms was higher in patients with COVID-19 (26% vs. 16.3% in patients without COVID-19, p=0.0197; relative risk=1.6). The prevalence of pulmonary embolisms in the same period in 2019 was 13.2%, similar to that of the group of COVID-19-negative patients in 2020 (p=0.43). There were no significant differences in D-dimer levels or the location of pulmonary embolisms between the two groups. CT showed moderate or severe pulmonary involvement in 78.7% of the patients with COVID-19.ConclusionsPatients with COVID-19 have an increased prevalence of pulmonary embolisms (26%), and most (78.7%) have moderate or severe lung involvement on CT studies. The location of pulmonary embolisms and the degree of elevation of D-dimer levels does not differ between patients with COVID-19 and those without.     

Digital cineradiography of the pharynx and the oesophagus after total or partial laryngectomy

PURPOSE: The aim of the present study is to report our experience using digital cineradiography to assess morphological and functional disorders of the pharynx in patients with prior partial or total laryngectomy. MATERIALS AND METHODS: From March 2000 to October 2002, 21 patients (18 males and 3 females) with prior total laryngectomy (12 patients), total laryngopharyngectomy (2 patients) and partial laryngectomy (7 patients) were examined. A digital cineradiography with 12 frames/second acquisition was performed in all patients. In four patients the procedure was interrupted for massive barium aspiration, without cough (silent aspiration). In 17 patients standing in the left posterior oblique position and prone in the right posterior oblique position the oesophagus and oesophagogastric junction were also examined. The water siphon test was performed at the end of the procedure. Small boluses (10 ml) of liquid (60% w/v) and high-density (250% w/v) barium, barium paste (110% w/v), and solid meal (obtained spreading a dry biscuit with barium paste) were used. RESULTS: All patients with prior total laryngectomy and total laryngopharyngectomy showed morphological and functional disorders of the neopharynx: parapharyngeal diverticulum (2 cases), submandibular pouch (6 cases), fistulas (2 cases), lumen narrowing and post-surgical stenoses (2 cases), tumour recurrence (1 case), prominent cricopharynx (5 cases) and rhinopharyngeal reflux (4 cases). All patients with prior partial laryngectomy (7 cases) presented silent aspiration. Eleven patients had an oesophageal motility disorder, which was very serious in three of them with decrease in oesophageal clearing and barium retention in the oesophagus. Oesophagogastric junction evaluation showed hiatus hernia in six cases, two of them with associated gastro-oesophageal reflux. CONCLUSIONS: Digital cineradiography appears able to identify the organic and functional postoperative complications of patient treated with partial or total laryngectomy. A special swallowing study can suggest to the speech therapist the best compensatory mechanism for improving patient swallowing and therefore quality of life.     

Pulmonary disposition of gallium-67 in patients with Pneumocystis pneumonia: an analysis using bronchoalveolar lavage.

Gallium-67 localizes to the cellular fraction of bronchoalveolar lavage (BAL) fluid in patients with sarcoidosis, idiopathic pulmonary fibrosis, as well as normal subjects. To further study 67Ga disposition in BAL fluid, 11 patients with Pneumocystis carinii pneumonia (PCP) and 8 patients with a variety of other lung diseases, underwent BAL 24 hr after 67Ga injection. Compared to the non-PCP patients, PCP patients had high uptake gallium scans at 24 and 72 hr, and showed significantly increased radioactivity in both unfractionated lavage and in the acellular, supernatant fraction of BAL. The mean ratio of total supernatant/cell pellet radioactivity was also higher in patients with PCP (1.23 +/- 0.27 versus 0.24 +/- 0.05, p less than 0.01). Supernatant radioactivity correlated with the presence of neutrophil alveolitis, but not with BAL transferrin concentrations. We conclude that neutrophil alveolitis in PCP promotes 67Ga accumulation in the acellular fraction of BAL fluid. However, the high uptake 67Ga scans observed in PCP patients without neutrophil alveolitis suggest that the mechanism of pulmonary uptake of 67Ga is not fully elucidated by BAL fluid analysis alone.     

Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy in cavitary pulmonary lesions

Objective

CT-guided transthoracic biopsy is a well-established method in the cytologic or histologic diagnosis of pulmonary lesions. The knowledge of its diagnostic performance and complications for cavitary pulmonary lesions is limited. The purpose of this study was to determine the diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy (FNAB) in cavitary pulmonary lesions.

Materials and methods

102 consecutive patients with pulmonary cavitary lesions received CT-guided FNAB with use of an 18-gauge (n = 35) or 20-gauge (n = 67) Chiba for histology diagnosis. The sensitivity, specificity, and diagnostic accuracy of FNAB were calculated as compared with the final diagnosis. Complications associated with FNAB were observed. The diagnostic accuracy and complications were compared between patients with different lesion sizes and different cavity wall thickness.

Results

The overall sensitivity, specificity, and accuracy of FNAB were 96.3%, 98.0%, and 96.1%, respectively. The sensitivity, specificity, and diagnosis accuracy in different lesion size (<2 cm vs ≥2 cm), or different cavity wall thickness (<5 mm vs ≥5 mm) were not different (P > 0.05; 0.235). More nondiagnostic sample was found in wall thickness <5 mm lesions (P = 0.017). Associated complications included pneumothorax in 9 (8.8%) patients and alveolar hemorrhage in 14 patients (13.7%) and hemoptysis in 1 patient (1%). No different rate of complications was found with regard to lesion size, wall thickness, length of the needle path and needle size (P > 0.05).

Conclusion

CT-guided FNAB can be effectively ad safely used for patients with pulmonary cavitary lesions.     

Conscious sedation for patients undergoing enteroclysis: comparing the safety and patient-reported effectiveness of two protocols

Objective

To compare the safety and patient-reported effectiveness of two regimens for conscious sedation during enteroclysis.

Materials and methods

We surveyed two groups of outpatients and retrospectively reviewed procedure records for conscious sedation and complications. Patients were divided into Group One (received sedative/amnesic diazepam), and Group Two, (received amnesic/sedative, midazolam and analgesic fentanyl).

Results

All enteroclyses were successfully completed; there were no hospital admissions due to complications. In Group One (n = 106), mean dose of diazepam was 12.7 mg. 25% had oxygen desaturation (n = 25), and post-procedure vomiting without aspiration (n = 1). 56% of outpatients completed phone surveys, and 68% recalled procedural discomfort. In Group Two (n = 45), mean doses were 3.9 mg midazolam and 108 mcg fentanyl. 31% had desaturation (n = 13), and post-procedure vomiting without aspiration (n = 1). 87% had only a vague recall of the procedure or of any discomfort.

Conclusion

A combination of amnesic and fentanyl prevented the recall of discomfort of nasoenteric intubation and infusion in most patients who had enteroclysis compared to diazepam. Most of the patients would undergo the procedure again, if needed.