Extended Indications for Lung Volume Reduction Surgery in Advanced Emphysema

Background. Lung volume reduction surgery has shown early promise as a palliative therapy in severe emphysema. Selection of potential candidates has been based on certain functional and anatomic criteria, and a variety of operative contraindications have been proposed.

Methods. Over 15 months, we performed lung volume reduction surgery in 85 patients selected on the basis of severe hyperinflation with air trapping, diaphragmatic dysfunction, and disease heterogeneity. Patients were not excluded on the basis of severe hypercapnia, steroid dependence, profound pulmonary dysfunction, or inability to complete preoperative rehabilitation.

Results. We observed significant improvements in pulmonary function, exercise capacity, and dyspnea, with an acceptable 30-day perioperative mortality of 7% and actuarial survival of 90% and 83% at 6 and 12 months, respectively. In each “high-risk” group, perioperative mortality, actuarial survival to 1 year, and functional results were equivalent, and in some cases superior, to those in the corresponding “low-risk” patients.

Conclusions. Severe hypercapnia, steroid dependence, profound pulmonary dysfunction, and inability to complete preoperative rehabilitation do not preclude successful lung volume reduction surgery and should not be regarded as absolute exclusionary criteria.     

Leptospirosis and acute renal failure--clinical experiences and a review of the literature.

About 50 cases of leptospirosis are diagnosed each year in the United Kingdom, with an overall mortality of 5%. Renal failure, in association with jaundice, is commonly held responsible for this figure. Over a period of 18 years, 6 cases of leptospirosis complicated by renal failure were treated at the Royal Air Force Renal Unit; there were 4 survivors. The 2 deaths occurred before the unit policy of daily haemodialysis and total parenteral nutrition, and were both from haemorrhagic complications. The authors believe that patients with leptospirosis and progressive renal impairment should be managed in renal units experienced in the management of the hypercatabolic patient, and that this should improve their prognosis.     

Measurement and management of stress in health professionals working with advanced cancer patients

Staff working with advanced cancer patients may experience considerable stress but there have been few attempts to measure such stress systematically. This paper presents preliminary studies of staff stress in two cancer centers. Nurses in an active treatment cancer hospital were found to focus on problems with dying patients as a displacement for their feelings of personal inadequacy in stressful situations. Major problems with the work situation and with staff communications were cited just as often as problems in watching patients suffer and die. A series of discussion groups lasting eight sessions was held with the nurses to facilitate communication with other staff and patients to promote understanding of the problems of dealing with life-threatening illnesses and death.

Staff on a newly opened palliative care unit were found to experience only slightly less stress than a group of newly widowed women. While the stress decreased over time, indications are that some staff working in newly developed hospice units may be at considerable risk.

Stress among physicians has been observed (although not measured) in a number of oncology settings. The difficulties inherent in being an oncologist in an institutions where research is a major goal are discussed and recommendations are made to decrease some of the stress being experienced.     

Current guidelines for the management of UK Infants born to HIV-1 infected mothers

Transmission of the Human Immunodeficiency Virus type 1 (HIV-1) from mother to child has been associated with maternal plasma viral load and CD4 lymphocyte count, prematurity, the mode of infant delivery, length of rupture of membranes and breast feeding. Without intervention, the transmission of HIV-1 occurs in a quarter to a third of infants born to infected mothers. During the last decade, mother-to-child transmission of HIV-1 has been reduced to less than 1%, through formula feeding, prelabour Caesarean section (PLCS) and antiretroviral therapy. With such an impressive reduction in the transmission of HIV-1, attention is turning towards the minimisation of possible drug side effects both in mothers and their infants. HIV-1-infected women are increasingly choosing to conceive on combination antiretroviral therapy, hence, infants are exposed to increasing numbers, combinations and classes of drugs, often from conception. Current guidelines on the prevention of mother to child transmission of HIV-1 are discussed.