Small bronchogenic carcinomas presenting as solitary pulmonary nodules. Bioptic approach guided by CT-positive bronchus sign.

To evaluate the utility of the CT bronchus sign in making a choice between transbronchial biopsy (TBB) and transthoracic needle aspiration (TTNA) as the first diagnostic procedure in a patient with a solitary pulmonary nodule (SPN), we reviewed the results of TBB and TTNA in 26 patients who had a bronchogenic carcinoma less than 3 cm, studied with thin-section CT. The patients were divided into two groups. Group 1 included ten cases with a third- to fifth-order bronchus sign. Group 2 included two cases with a sixth-order bronchus sign and 14 cases with absence of a bronchus sign. TBB was performed in all the patients; conversely, TTNA was carried out in 22 patients. In group 1, TBB gave a diagnostic yield in eight (80 percent) of ten patients, while TTNA was positive in three (42 percent) of seven patients (p > 0.05). Conversely, in group 2, results of TBB were normal in all the patients, while TTNA gave a diagnosis in 10 (66 percent) of 15 patients (p < 0.05). We think that TBB should be considered the method of choice in diagnosing SPNs associated with a third- to fifth-order bronchus sign; conversely, TTNA is more useful than TBB in diagnosing SPNs in the presence of a more peripheral bronchus sign or with the absence of a bronchus sign. In conclusion, we suggest routine evaluation with thin-section CT of each SPN to optimize diagnostic management.     

Osteoporosis Before Lung Transplantation: Association with Low Body Mass Index, but Not with Underlying Disease

Due to progress in lung transplantation, post-transplantation osteoporosis becomes an important problem. We determined bone mineral density (BMD) in 74 lung transplantation candidates, among them 24 patients with cysticfibrosis, 16 with chronic obstructive pulmonary disease, 14 with pulmonary fibrosis, and 11 with pulmonary hypertension. The mean T score (+/- SD) was -2.6 +/- 1.3 at femoral neck (FN), -2.2 +/- 1.6 at Ward's triangle (WT) and -2.3 +/- 1.5 at lumbar spine (LS). Osteoporosis was found in 61% of the patients at FN, 45% at WT and 50% at LS. Patients with different underlying lung diseases were similarly affected, not only those with cystic fibrosis but also others, including patients with pulmonary hypertension. No association was found between BMD and age, gender, menstrual condition in women and testosterone level in men. A negative correlation was found between chronic glucocorticoid use and T scores. Body mass index correlated positively (p < 0.01) with T scores at any site and the correlation was also significant for the 2 largest subgroups. Loss of lung function (FEV1) also was associated with lower T scores. No correlation was found between BMD and biochemical indices of bone turnover. Multivariate analysis revealed BMI and glucocorticoid use as independent risk factors. We conclude that osteoporosis is a very common condition in patients with end-stage pulmonary disease, independent of the underlying diagnosis. In view of additional bone loss under immunosuppressive treatment after lung transplantation, early diagnosis and prevention of osteoporosis in the pretransplant period should receive high priority.     

Abnormal local-circuit neurons in epilepsia partialis continua associated with focal cortical dysplasia

Summary A limited cortical resection including the rolandic fissure and the pre-and postcentral cortical regions was carried out in a patient suffering from epilepsia partialis continua resistant to antiepileptic drugs. The histological examination revealed several foci of very large neurons distributed with no laminar organization in the depth of the rolandic fissure and in the crown of the primary motor and primary somatosensory areas; these lesions were consistent with focal cortical dysplasia. In addition, decreased numbers of neurons, astrocytosis and proliferation of capillaries, compatible with chronic tissue necrosis, were found in the inferior regions of the banks of the rolandic fissure. Subpopulations of local-circuit neurons were examined with parvalbumin, calbindin D-28k and somatostatin immunocytochemistry. Focal areas of cortical dysplasia contained abnormal immunoreactive neurons. Huge parvalbumin-immunoreactive cells were distributed at random and resembled axo-axonic (chandelier) and basket neurons. Abnormal calbindin D-28k-immunoreactive cells were reminiscent of double-bouquet neurons and multipolar cells. Very large somatostatin-immunoreactive cells were seldom observed in the dysplastic foci. On the other hand, areas of tissue necrosis displayed massive reduction of immunoreactive cells and fibers. Abnormalities in the morphology and distribution of local-circuit (inhibitory) neurons observed here for the first time in focal cortical dysplasia may have a pivotal role in the appearance and prolongation of electrical discharges and continuous motor signs in human focal epilepsy.Supported in part by a grant FIS 90E1263     

Psychosocial situation and physical health in 50 patients > 1 year after lung transplantation

BACKGROUND: Lung transplants have been performed worldwide since the early 1980s. While numerous studies have been published on somatic aspects after lung transplantation, there is considerably less information available on psychosocial aspects and on the correlation between the physical and the psychosocial state of health after transplantation. METHODS: Between 1992 and 2002, 125 patients underwent lung transplantation at University Hospital Zurich. To be included into the study, patients had to have received a lung transplant > 12 months previously and to have good knowledge of the German or Italian languages. With the aid of standardized questionnaires, psychosocial variables such as levels of anxiety and depression, self-esteem, and social support were determined. In addition, self-assessments of physical and psychological health were obtained. The medical data included information on FEV1, complications such as pulmonary infections, acute or chronic allograft rejection, and assessment of the patient's physical and psychological health by the treating doctors. RESULTS: The overall degree of anxiety and depression of the lung transplant recipients was comparable to standard samples of an average population. However, male lung transplant recipients were significantly more depressed than female recipients. Self-esteem was higher than in clinical comparison samples. Preceding pulmonary complications had long-lasting effects on the level of anxiety, whereas nonpulmonary complications did not have such an effect. CONCLUSIONS: Overall, the psychological well-being of patients after lung transplantation is similar to the normal population. Subgroups of patients with increased psychological distress have been identified.     

Low-dose CT of the lung: potential value of iterative reconstructions

Objectives

To prospectively assess the impact of sinogram-affirmed iterative reconstruction (SAFIRE) on image quality of nonenhanced low-dose lung CT as compared to filtered back projection (FBP).

Methods

Nonenhanced low-dose chest CT (tube current-time product: 30?mAs) was performed on 30 patients at 100?kVp and on 30 patients at 80?kVp. Images were reconstructed with FBP and SAFIRE. Two blinded, independent readers measured image noise; two readers assessed image quality of normal anatomic lung structures on a five-point scale. Radiation dose parameters were recorded.

Results

Image noise in datasets reconstructed with FBP (57.4?±?15.9) was significantly higher than with SAFIRE (31.7?±?9.8, P?<?0.001). Image quality was significantly superior with SAFIRE than with FBP (P?<?0.01), without significant difference between FBP at 100?kVp and SAFIRE at 80?kVp (P?=?0.68). Diagnostic image quality was present with FBP in 96% of images at 100?kVp and 88% at 80?kVp, and with SAFIRE in 100% at 100?kVp and 98% at 80?kVp. There were significantly more datasets with diagnostic image quality with SAFIRE than with FBP (P?<?0.01). Mean CTDI_vol and effective doses were 1.5?±?0.7?mGy·cm and 0.7?±?0.2?mSv at 100?kVp, and 1.4?±?2.8?mGy·cm and 0.5?±?0.2?mSv at 80?kVp (P?<?0.001, both).

Conclusions

Use of SAFIRE in low-dose lung CT reduces noise, improves image quality, and renders more studies diagnostic as compared to FBP.

Key Points

? Low-dose computed tomography is an important thoracic investigation tool. ? Radiation dose can be less than 1?mSv with iterative reconstructions. ? Iterative reconstructions render more low-dose lung CTs diagnostic compared to conventional reconstructions.     

Model-based versus clinical prediction of the spirometric response to lung volume reduction surgery

BACKGROUND: Lung volume reduction surgery (LVRS) improves symptoms and lung function in selected patients with severe emphysema. OBJECTIVES: We investigated whether models based on physiologic and radiologic predictors discriminated patients with a favorable from those with a poor spirometric response to LVRS. METHODS: Data of a derivation cohort of 70 patients who had previously undergone LVRS served to develop two types of prediction models, lookup functions and logistic regression equations. Presence or absence of improvement in forced expiratory volume in 1 s (FEV1) > or =300 ml and forced vital capacity (FVC) > or =500 ml represented dichotomous outcomes. The residual volume/total lung capacity ratio, CT-radiological emphysema heterogeneity scores and diffusing capacity, a marker of emphysema severity, were the predictors. Models were used to predict spirometric outcomes for a validation cohort of 60 emphysema patients referred for LVRS. Furthermore, the surgeon preoperatively estimated outcomes based on all available clinical data but blinded to model predictions. Spirometric changes within 6 months following surgery were compared to predictions. RESULTS: Median FEV1 in the validation cohort increased from 0.69 to 1.00 liters (+41%), and FVC from 2.07 to 2.78 liters (+29%; p < 0.05 for changes). Lookup functions and logistic regression equations identified patients experiencing major increases in FEV1 > or =300 ml and FVC > or =500 ml with an accuracy quantified by areas under the receiver-operating characteristic curves of 0.72 to 0.76 (all areas >0.5, p < 0.05). Predictions by the surgeon had an accuracy of 0.71 to 0.78 (p = NS vs. models). CONCLUSIONS: The accuracy of models based on three predictors was fair and similar to assessment by an experienced surgeon based on all available clinical information. Prediction models may contribute to the consistent assessment of LVRS candidates.     

Comparative effects of oral and inhaled verapamil on antigen-induced bronchoconstriction

We investigated the comparative effects of oral and inhaled verapamil on specific airway conductance (SGaw) and allergic bronchial reactivity. Ten asymptomatic subjects with ragweed hypersensitivity and a history of bronchial asthma were studied on four different days, without and with pre-treatments by oral (160 mg) or inhaled (20 mg) verapamil. Bronchial reactivity was measured as the cumulative provocative dose of ragweed antigen which caused a 35 percent decrease in SGaw, ie PD35. The amount of inhaled verapamil actually deposited in the tracheobronchial tree was estimated to be 0.56 mg. Mean SGaw was not affected by either mode of administration; mean SGaw (SE) was 0.13(.02) and 0.12(.02) L/sec-1 before and .14(.02) and 0.12(.02) L/sec-1 after oral and inhaled verapamil, respectively. Mean (SE) PD35 was reproducible on two control days, ie 0.9(.4) and 0.8(.4) breath units, respectively. Inhaled verapamil increased mean PD35 to 18.8 (10.8) breath units (p less than 0.02), while oral verapamil had no significant effect on mean PD35. This study demonstrates that route of administration of calcium antagonist verapamil is an important factor in protection against antigen-induced bronchoconstriction. Inhalation of verapamil appears to be more effective than oral administration.