Should cervical ultrasonography be a routine staging investigation for lung cancer patients with impalpable cervical lymph nodes?

OBJECTIVES: Detection of cervical N3 lymph nodes is currently not a routine preoperative investigation for lung cancer patients. We designed a study to assess if the frequency and accuracy of detection of metastatic cervical lymph nodes using cervical ultrasonography (US) and fine needle aspiration (FNA) justify their routine use in all lung cancer patients with impalpable cervical lymph nodes. METHODS: Fifty patients with suspected and potentially operable non-small cell lung cancer were enrolled. Patients with palpable cervical lymph nodes were excluded. In addition to routine preoperative investigations, all patients received cervical US to determine the presence of cervical lymph nodes. Nodes suspicious of harboring malignancy according to a specific set of sonographic criteria (which include shape, echogenicity, nodal architecture, and vascular patterns) were subjected to biopsy by ultrasound-guided FNA. RESULTS: Normal cervical lymph nodes were detected by cervical US in 30 patients (60%). Cervical lymph nodes suspicious of harboring malignancy were detected in 10 patients (20%). FNA confirmed cervical nodal metastasis in four of these patients (8%). The TNM staging of two patients (4%) was revised up to stage IIIb as a result, excluding them from further surgery. Cost analysis suggests this technique to be cost-effective when used as a routine preoperative investigation to exclude patients from unnecessary surgical intervention. No mortality or complications were encountered in all patients. CONCLUSIONS: Cervical US and FNA is a safe and cost-effective method of evaluating the status of impalpable cervical lymph nodes in lung cancer patients. Further study is warranted to establish the role of cervical US and FNA in lung cancer staging algorithms.     

Influenza vaccination: a collaborative effort to improve the health of the community.

BACKGROUND: The need to improve influenza vaccination delivery in our community became painfully clear during the winter of 1997-1998 when high rates of respiratory illness led to congestion in the emergency department and a critical shortage of hospital beds. In response, the local hospital and the Department of Health launched a collaborative program to increase influenza vaccine coverage in the community. METHODS: The partnership was designed to increase the number of citizens receiving influenza vaccine and to moderate the severity of lower respiratory tract illness during the winter season. A variety of methods were used to increase public awareness, enhance vaccine delivery, and create a relatively seamless service for the community. RESULTS: During three seasons, influenza vaccination rates increased by a relative 150%. This represented immunization of 16% of the entire community and more than 75% of residents older than 65 years. Hospital employee vaccination rates also rose from 34% to 58%. When compared with other hospitals in the county, the campaign reduced the average number of annual visits to the emergency department for all respiratory diagnoses by 34% and exacerbations of chronic obstructive pulmonary disease by 46%. CONCLUSIONS: This influenza vaccination program illustrates the potential for synergy that exists between local departments of health and community hospitals in successfully increasing vaccine delivery to the community. Furthermore, it also suggests that such efforts can be successful in reducing use of the emergency department, resulting in a positive impact on the health of the community.     

International multicenter pilot study of the first comprehensive self-completed nonmotor symptoms questionnaire for Parkinson's disease: the NMSQuest study.

Nonmotor symptoms (NMS) of Parkinson's disease (PD) are not well recognized in clinical practice, either in primary or in secondary care, and are frequently missed during routine consultations. There is no single instrument (questionnaire or scale) that enables a comprehensive assessment of the range of NMS in PD both for the identification of problems and for the measurement of outcome. Against this background, a multidisciplinary group of experts, including patient group representatives, has developed an NMS screening questionnaire comprising 30 items. This instrument does not provide an overall score of disability and is not a graded or rating instrument. Instead, it is a screening tool designed to draw attention to the presence of NMS and initiate further investigation. In this article, we present the results from an international pilot study assessing feasibility, validity, and acceptability of a nonmotor questionnaire (NMSQuest). Data from 123 PD patients and 96 controls were analyzed. NMS were highly significantly more prevalent in PD compared to controls (PD NMS, median = 9.0, mean = 9.5 vs. control NMS, median = 5.5, mean = 4.0; Mann-Whitney, Kruskal-Wallis, and t test, P < 0.0001), with PD patients reporting at least 10 different NMS on average per patient. In PD, NMS were highly significantly more prevalent across all disease stages and the number of symptoms correlated significantly with advancing disease and duration of disease. Furthermore, frequently, problems such as diplopia, dribbling, apathy, blues, taste and smell problems were never previously disclosed to the health professionals.     

Localization by immunoelectron microscopy of spanning protein of triad junction in terminal cisternae/triad vesicles

Summary Polyclonal antibodies have been developed against the junctional feet or spanning protein from skeletal muscle triads. These probes in combination with immunogold labels have been used to localize the spanning protein by electron microscope of isolated vesicles from terminal cisternae/triads. The spanning protein antibodies specifically bind to the electron dense junctional feet. In vesicles permeabilized by hypotonic treatment or by saponin, some gold particles may be seen on the luminal side of the vesicle. Trypsin treatment of vesicles causes complete loss of the 300 K spanning protein from SDS gels while dot blots show that some but not all the antigenic activity is lost. This treatment is associated with the loss of the electron dense projections from the membrane surface and is coincident with the loss of immunogold staining when antibody is added to the intact vesicles. On the other hand, in experiments in which the luminal portions of the isolated vesicles have been made accessible to the polyclonal antibodies by sectioning lightly fixed vesicles before immunogold tagging, extensive gold labelling was found to occur in trypsin treated vesicles which have lost detectable projections from the cytoplasmic side of the membrane. These data support the view that the spanning protein projects from the sarcoplasmic reticulum towards the transverse tubules but further suggest that spanning protein extends into and probably through the sarcoplasmic reticulum membrane in accord with the proposition that it is a Ca²⁺ channel.Nomenclature SP spanning protein - SR sarcoplasmic reticulum - TC terminal cisternae - T-tubule transverse tubule - HMW high molecular weight - ELISA enzyme linked immunosorbent assay - PMSF phenylmethyl sulphonylfluoride - SDS sodium dodecyle sulphate     

Effective pulmonary blood flow in children with acute asthma attack requiring hospitalization

In children with acute obstructive lung disease gas exchange is affected by ventilation-perfusion mismatch and the degree of bronchoconstriction. Standard lung function measurements do not reflect the impairment in gas exchange. Alternatively, the effective pulmonary blood flow (EPBF), that is, the proportion of the cardiac output that is supplying well-ventilated lung units, can give accurate and noninvasive estimates of ventilation-perfusion mismatch. We measured EPBF with the argon freon ?22 rebreathing technique in children with acute severe asthma to assess their response to nebulized salbutamol and to determine whether induced changes in the EPBF could be predicted from baseline measurements. Twenty-four children admitted with an acute asthma attack had spirometry and triplicate EPBF measurements before and after nebulized salbutamol. Eighteen patients had repeated tests 50 days later when fully recovered; 4 patients were taking methylxanthines on at least one occasion. The mean forced expiratory volume in 1 sec (FEV₁) rose from 55% of predicted to 66% after salbutamol and to 83% with recovery. The mean coefficients of variation for EPBF measurements on the three test occasions were 11.3%, 8.2%, and 9%. Except in children on methylxanthines, the EPBF values were reduced during the acute asthma attack (median, 2.53 L/min/m²; range, 1.99–3.60 L/min/m²) compared with paired values obtained after recovery (median, 2.89 L/min/m²; range, 2.2Eb4.04 L/min/m²) (P = 0.009). Salbutamol caused a highly significant increase in EPBF from 2.88 L/min/m² (range, 1.86–3.80) before treatment to 3.34 L/min/m² (range, 2.264.65) immediately afterwards (P = 0.0003). The spirometric indices did not relate to the changes in the EPBF values. However, when the effective stroke volume index was calculated in 11 patients, the changes induced by nebulized salbutamol had a significant inverse relation with the pretreatment FEV, (P = 0.61; P = 0.02). In conclusion, the argon freon-22 rebreathing technique can be used successfully and reproducibly to measure EPBF in children with an acute asthma attack. Except in children taking methylxanthines, EPBF during the acute attack is reduced and rises significantly after salbutamol. EPBF values after recovery were significantly higher than the presalbutamol values during the attack. Spirometric indices do not relate to the EPBF changes but are inversely related to the effective stroke volume changes. Pediatr Pulmonol. 1994; 17:370–377. © 1994 Wiley-Liss, Inc.     

Reference values for 75 g oral glucose tolerance test in pregnancy

A 75 g oral glucose tolerance test was performed in 212 pregnant women with no predisposing factors suggesting glucose intolerance to establish the normal pattern of glucose metabolism in pregnancy. Reference values for the test were established for the middle of pregnancy (14-20 weeks, n = 43) and late pregnancy (28-37 weeks, n = 168). One woman was excluded because she had diabetes that required treatment with insulin. There were statistically significant differences between the two groups for samples taken both one and two hours after the glucose load. Reference ranges for the interpretation of the glucose tolerance test in pregnancy should therefore take account of the period of gestation. Arbitrary upper limits of normal (represented by the 97.5 centile) two hours after a 75 g oral glucose load are proposed at 7.5 and 9.6 mmol/l for the second and third trimesters, respectively.