Availability,requesting practices,and barriers to referral for high-resolution CT of the lungs: results of a survey of U.S. pulmonologists

RATIONALE AND OBJECTIVES: The authors performed this study to assess the availability of high-resolution computed tomography (CT), current referral practices, and potential barriers to the clinical use of high-resolution CT in patients with diffuse lung disease. MATERIALS AND METHODS: The authors sent a survey to 450 pulmonologists who were members of the American College of Chest Physicians. They sought information about the availability of high-resolution CT services, explored the physicians' current requesting practices and the monthly number of referrals, and assessed the influence of six factors on the decision to refer. RESULTS: The authors received completed surveys from 230 pulmonologists (52.6%). High-resolution CT services were available to all respondents and had been used by 226 (98.3%) of them during the preceding 12 months. Two-thirds of respondents referred one to four patients per month, and one-third referred five or more. Monthly referral volume did not significantly vary among different practice types. The pulmonologists expressed a preference for hospital-based imaging facilities and routinely reviewed the images from the examinations they ordered. The most frequent reason for high-resolution CT was classification of a known interstitial process. High-resolution CT was infrequently requested to evaluate symptomatic immunocompromised patients. Confidence in the radiologist's high-resolution CT interpretation was the most important factor influencing the referral decision, and radiation dose to the patient was the least important. CONCLUSION: High-resolution CT services are widely available to and frequently requested by U.S. pulmonologists in a variety of practice settings. High-resolution CT may be underutilized in symptomatic immunocompromised patients. Radiologists should be aware that the perception of their skill in high-resolution CT interpretation is an important determinant in the pulmonologist's decision to refer.     

Whole body FDG-PET for the evaluation and staging of small cell lung cancer: a preliminary study

PURPOSE: We conducted a randomized trial to investigate whether systematic nodal dissection (SND) is superior to mediastinal lymph nodal sampling (MLS) in surgical treatment of non-small cell lung cancer (NSCLC). METHODS: The patients resectable clinical Stage I-IIIA NSCLC were randomly assigned to lung resection combined with SND or lung resection combined with MLS. After postoperative pathological re-staging, eligible cases were followed up until 30 November 2000. The Kaplan-Meier method was used for survival analysis. COX proportional hazards model was used for prognostic analysis. RESULTS: Of the 532 patients who were enrolled in the study, 268 patients were assigned to lung resection combined with SND and 264 were assigned to lung resection combined with MLS. After surgical restaging only 471 cases were eligible for follow-up. The median survival was 59 months in the group given SND and 34 months in the group given MLS (P=0.0000 by the log rank test). There was significant difference in survival in Stage I (5-year survival 82.16 vs. 57.49%) and Stage IIIA (26.98 vs. 6.18%) by the log rank test and Breslow test. There was no significant yet marginal difference in survival by log rank test (10-year survival 32.04 vs. 26.92%, P=0.0523) but significant difference in survival by Breslow test (5-year survival 50.42 vs. 34.05%, P=0.0284) in Stage II. Types of mediastinal lymph node dissection, pTNM stage, tumor size and number of lymph node metastasis were four factors that influenced long-term survival rate by multivariate analysis. CONCLUSIONS: As compared with MLS, lobectomy (pneumonectomy) combined with SND can improve survival in resectable NSCLC.     

What is the rationale for the use of granulocyte and granulocyte-macrophage colony-stimulating factors in the neonatal intensive care unit

Neonatal sepsis remains an unsolved major contributor to morbidity and mortality. In the 1980s the promise of augmenting immune function using pooled intravenous gammaglobulin to supplement the exceedingly low levels of immunoglobulin G in premature infants failed to demonstrate a clear advantage. Similarly, cytokine augmentation of cellular function in the 1990s largely appeared to be suffering the same fate. However, both results may arise from a problem in experimental design where the combination of both treatments may be necessary along with specific antibody. For example, in vitro , independently of an array of other humoral and cellular immature immune system issues, opsonization of bacteria is improved in the presence of antibody. The question is whether the same result can be achieved in vivo. No experiments have been reported that directly test this hypothesis.
Conclusion : More investigation is needed in this challenging area of neonatal research.     

Cloning and characterization of platelet factor 4 cDNA derived from a human erythroleukemic cell line

We report the isolation of a platelet factor 4 (PF4) cDNA clone from a lambda gt11 expression cDNA library which was derived from a human erythroleukemic (HEL) cell line. The sequence of the DNA insert includes the 3'-untranslated region, the entire amino acid coding region for the mature PF4 protein, and a 5' region containing coding information for an additional 18 amino acids. In addition, supplemental genomic DNA sequencing shows that the full-length leader sequence is 30 amino acids long plus an initial methionine and codes for a hydrophobic signal-like sequence which is probably involved in transmembrane transport. A single species mRNA of approximately 800 nucleotides was detected on blots of HEL cell poly(A) + RNA using a labeled PF4 cDNA probe. The human PF4 leader sequence shares some DNA, but no amino acid, homology with the 15 amino acids at the N-terminus of mature bovine PF4, suggesting rapid divergence in this region of PF4 between these two species. Sequence comparison of the coding regions of mature PF4 and gamma IP-10, a protein induced in a variety of cells following treatment with gamma-interferon, shows a corrected divergence of 76%. The divergence of a common ancestor protein into PF4 and gamma IP-10 may have accompanied the development of sophisticated immune and coagulation systems in vertebrates. The availability of cDNA and genomic DNA information for these genes in other species will be useful in studying the evolution of the coagulation and immune systems.     

Increased vascular pedicle width preceding burn-related pulmonary edema

Widening of the vascular pedicle on the chest roentgenogram is a recently identified sign of increased circulating blood volume. To determine whether vascular pedicle enlargement can be detected during the initial day of burn resuscitation and whether this change correlates with the early development of pulmonary edema, we reviewed the serial chest roentgenograms of 42 patients with cutaneous burns and risk factors for inhalation injury. Although no patient had pulmonary edema at the time of vascular pedicle measurements, 18 (42.9 percent) developed this complication during the 3.3 +/- 1.5 days after injury. These patients were significantly older (p less than 0.025) and had received more resuscitative fluid (P less than 0.005) than those without pulmonary edema. Initial vascular pedicle width was similar in both groups (5.9 +/- 0.9 vs 6.0 +/- 1.0 cm) and did not change in patients without pulmonary edema (5.8 +/- 0.7 cm). Vascular pedicle width increased (6.9 +/- 1.2 cm, p less than 0.01) in patients who subsequently developed pulmonary edema, and 12 of the 13 patients who had changes exceeding +1.0 cm had this problem. Enlargement of the vascular pedicle is associated with early burn-related pulmonary edema and might provide a clinically useful predictor of this cardiopulmonary complication.     

Hemoptysis: clinicians' perspectives

Clinicians who were interested and considerably experienced in assessing patients with hemoptysis were surveyed during a computer-assisted interactive presentation at the 1988 ACCP Annual Scientific Assembly. The approach to ambulatory patients with minor bleeding was consistent with recently published guidelines: fiberoptic bronchoscopy has a central role, with a less apparent impact of other new technologies. Although specific diagnostic results were significantly more useful (p less than 0.01), even nonspecific bronchoscopy findings were though to have clinical value. External factors such as medicolegal concerns and obligations to provide service were acknowledged to influence selection of patients for bronchoscopy, and community-based clinicians cited such effects more often than academicians (p less than 0.02). Approaches to patients with massive hemoptysis reflected caution essential to acute management. Bronchoscopy was performed earlier (p less than 0.01) than in patients with minor bleeding, but opinions differed regarding instrument selection, the best method of airway support, and the roles of interventional angiography. This survey suggests that real-world settings are addressed incompletely by published experiences accumulated in tertiary centers. Clarification of optimum approaches to patients with hemoptysis requires further input from practicing clinicians.     

Laparostomy management using the ABThera™ open abdomen negative pressure therapy system in a grade IV open abdomen secondary to acute pancreatitis

Wound control in laparostomy for the treatment of intra‐abdominal hypertension remains challenging and numerous techniques have been described. We report the first UK experience with a new commercially available device specifically designed to facilitate management of the open abdomen. A 44‐year‐old gentleman presented with a 3‐day history of constant severe epigastric pain and associated vomiting. Amylase was markedly elevated and he was admitted for supportive management of pancreatitis, with subsequent transfer to intensive care due to severe systemic inflammatory syndrome. The patient decompensated, developing intra‐abdominal hypertension with renal and respiratory failure. This was successfully managed by performing a laparostomy and using an ABThera? Open Abdomen Negative Pressure Therapy System (KCI, San Antonio, TX). We describe its use to facilitate wound control, including enteroatmospheric fistula, allowing granulation and eventual restoration of gastrointestinal continuity 383‐days after admission. We found the ABThera? System proved to be a useful treatment adjunct, protecting intra‐abdominal contents while removing large volumes of exudate and infected material from within the abdominal cavity. Complex cases such as this remain infrequent and this article provides a summary of our experience, including a review of indications for laparostomy and the underlying basic science in this difficult area.