Diagnosis of pulmonary embolism: Ventilation perfusion scintigraphy versus helical computed tomography pulmonary angiography

The present study compared the accuracy of ventilation perfusion scintigraphy (VQS) and CT pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism. This was a prospective observational study of 112 patients with suspected pulmonary embolism (PE) who could be studied with both investigations within 24 h. Results were compared to final diagnosis at completion of 6-month follow up, using receiver operating characteristic (ROC) analysis. Pulmonary embolism was diagnosed in 27 referred patients (24%). The sensitivity and specificity of VQS and CTPA were similar to that reported from the literature. A normal VQ scan had the highest negative predictive value (100%), while a high-probability VQ scan had the highest positive predictive value (92%). There was no overall difference (area under the ROC curve (AUC)) between VQS (AUC (95% CI) = 0.82 (0.75,0.89)) and CTPA (AUC = 0.88 (0.81,0.94)) for the diagnosis of PE. Among patients with abnormal chest X-rays, CTPA (AUC 0.90 (0.83,0.97)) appeared somewhat better than VQS (AUC 0.78 (0.68,0.88)) but this difference did not reach statistical significance. In this instance, CTPA is at least as accurate as VQS and may provide an opportunity to make alternative diagnoses.     

Ultrasound examination of the hand

Twenty-five surgically confirmed soft-tissue lesions of the hand were examined prospectively by real-time ultrasound. Use of sonography enabled a reliable diagnosis of the cystic or solid nature of soft-tissue lesions, an accurate estimation of the volume, and precise three-dimensional localization of the abnormality. Sonography also facilitated the location of foreign bodies. Assessment of anatomic relationships of these lesions to tendons and surrounding structures by real-time sonography during palpation, flexion, and/or extension also aided in the surgical approach.     

Current thinking on chronic renal allograft rejection: issues, concerns, and recommendations from a 1997 roundtable discussion

Chronic rejection accounts for most renal allograft losses after the first year posttransplantation. On March 24 and 25, 1997, a roundtable of five transplant surgeons, two nephrologists, and one pathologist assembled in Dallas, Texas, to review critical issues surrounding chronic renal allograft rejection. This article summarizes the presentations and relevant discussions of this meeting regarding the cause of chronic rejection, clinical diagnoses, risk factors, future prospects for intervention strategies, and general recommendations for the transplant community. Growing evidence indicates that chronic rejection is the aggregate sum of irreversible immunologic and nonimmunologic injuries to the renal graft over time. A history of acute rejection episodes and inadequate immunosuppression, likely attributable to inconsistent cyclosporine exposure or poor patient compliance, are among the most recognizable immunologic risk factors for chronic rejection. Donor organ quality, delayed graft function, and other donor and recipient variables leading to reduced nephron mass are nonimmunologic factors that contribute to the progressive deterioration of renal graft function. Clinical management of renal transplant recipients should incorporate both immunologic- and nonimmunologic-based intervention strategies aimed at minimizing risk factors to thwart the progression of chronic rejection and improve long-term allograft and patient survival.     

Expression of p27 in Residual Rectal Cancer after Preoperative Chemoradiation Predicts Long-term Outcome

Background: Compared with surgery alone, preoperative radiotherapy and 5-fluorouracil–based chemotherapy (combined-modality therapy; CMT) improves outcomes in patients with locally advanced rectal cancer. Although numerous studies have focused on identifying molecular markers of prognosis in the primary rectal cancer before CMT, our aim was to identify markers of prognosis in residual rectal cancer after preoperative CMT.Methods: Sixty-seven patients with locally advanced (T3–4 and/or N1) rectal cancer were treated with preoperative radiotherapy (median, 5040 cGy) with or without 5-fluorouracil–based chemotherapy. Residual tumor in the resected specimen, available for 52 patients, was analyzed for tumor-node-metastasis stage, lymphovascular and/or perineural invasion, and immunohistochemical expression of p27, p21, p53, Ki-67, retinoblastoma gene, cyclin D1, and bcl-2. Recurrence-free survival (RFS) was determined by the Kaplan-Meier method and compared by the log-rank test.Results: With a median follow-up of 69 months, the overall 5-year RFS was 74%. RFS was significantly worse for patients with positive p27 expression (P = .005), T3–4 tumors (P = .02), and positive lymph nodes (P = .04) in the irradiated specimen. On multivariate analysis, positive p27 expression remained an independent negative prognostic factor for RFS (P = .04). None of the other proteins was significantly associated with RFS.Conclusions: Our results indicate that positive p27 expression in rectal cancer after preoperative chemoradiation is an independent negative predictor of RFS. Expression of p27 in the residual rectal cancer may therefore identify patients with disease likely to be refractory to standard therapy and for whom investigational approaches should be strongly considered.the 56th Annual Cancer Symposium, Society of Surgical Oncology, Los Angeles, California, March 5–9, 2003.     

腹部外科常见感染性疾病的病原菌及药敏试验研究

为了了解本地区本医院腹部外科感染性疾病病原菌的构成比和药物敏感率的变化,指导临床用药,我们采用美国BD公司生产的6B和7D两种增菌瓶采集标本和培养细菌,并用该公司生产的生化板和药敏板,对1994～1996年269例常见的普外科感染性疾病患者的手术标本进行前瞻性的细菌培养和药敏试验研究.     

A modified lightwand-guided nasotracheal intubation technique for oromaxillofacial surgical patients

Study ObjectiveTo investigate the efficiency of a double curve nasotracheal tube on lightwand-guided nasotracheal intubation.DesignProspective, randomized, controlled trial.SettingUniversity medical center hospital.Patients60 ASA physical status I and II patients undergoing oromaxillofacial surgery.Interventions and MeasurementsPatients undergoing surgery with nasotracheal intubation and general anesthesia were randomly enrolled in the laryngoscopy group or the lightwand group. The same type of double curve nasotracheal tube was used in both groups. In the laryngoscopy group, intubation was assisted with a Macintosh No. 3 standard curved blade and Magill forceps. In the lightwand group, intubation was aided with a flexible lightwand device (without the inner stiff stylet). Intubation time was divided into two parts: Part one, from selected naris to oropharynx; Part two, from oropharynx into trachea. Part one, Part two, and total intubation time, hemodynamic responses to nasotracheal intubation, and adverse events or complications were recorded.Main ResultsTotal intubation times in the lightwand group and the laryngoscopy group were 22.8 ± 8.0 sec vs 30.3 ± 8.2 sec (P < 0.001), respectively. The lightwand group had comparable hemodynamic responses to those of the laryngoscopy group. Adverse events and complications were all self-limited, with similar occurrence in both groups.ConclusionFor patients undergoing oromaxillofacial surgery, modified lightwand-guided nasotracheal intubation is feasible with a double curve nasotracheal tube and is an efficient alternative technique.     

Positron Emission Tomography Detection of Distant Metastatic or Synchronous Disease in Patients with Locally Advanced Rectal Cancer Receiving Preoperative Chemoradiation

Background Patients with locally advanced rectal cancer may present with synchronous distant metastases. Choice of optimal treatment—neoadjuvant chemoradiation versus systemic chemotherapy alone—depends on accurate assessment of distant disease. We prospectively evaluated the ability of [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG) positron emission tomography (PET) to detect distant disease in patients with locally advanced rectal cancer who were otherwise eligible for combined modality therapy (CMT). Methods Ninety-three patients with locally advanced rectal cancer underwent whole-body [¹⁸F]FDG PET scanning 2–3 weeks before starting CMT. Sites other than the rectum, mesorectum, or the area along the inferior mesenteric artery were considered distant and were divided into nine groups: neck, lung, mediastinal lymph node (LN), abdomen, liver, colon, pelvis, peripheral LN, and soft tissue. Two nuclear medicine physicians blinded to clinical information used PET images and a five-point scale (0–4) to determine certainty of disease. A score greater than 3 was considered malignant. Confirmation was based on tissue diagnosis, surgical exploration, and subsequent imaging. Results At a median follow-up of 34 months, the overall accuracy, sensitivity, and specificity of PET in detecting distant disease were 93.7%, 77.8%, and 98.7% respectively. Greatest accuracy was demonstrated in detection of liver (accuracy = 99.9%, sensitivity = 100%, specificity = 98.8%) and lung (accuracy = 99.9%, sensitivity = 80%, specificity = 100%) disease; PET detected 11/12 confirmed malignant sites in liver and lung. A total of 10 patients were confirmed to have M1 stage disease. All 10 were correctly staged by pre-CMT PET; abdominopelvic computed tomography (CT) scans accurately detected nine of them. Conclusion Baseline PET in patients with locally advanced rectal cancer reliably detects metastatic disease in liver and lung. PET may play a significant role in defining extent of distant disease in selected cases, thus impacting the choice of neoadjuvant therapy. An erratum to this article can be found at