Endotracheal intubation and mechanical ventilation in severe asthma

OBJECTIVE

To determine the occurrence rate of complications and mortality in patients with severe asthma requiring endotracheal intubation and mechanical ventilation.

DESIGN

Retrospective review of medical records from September 1982 to July 1988.

SETTING

Urban, teaching hospital serving primarily indigent patients.

PATIENTS

Fifty-seven adult patients with asthma requiring tracheal intubation and mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-seven patients requiring tracheal intubation and mechanical ventilation during 69 hospital admissions were identified. Medication noncompliance and upper respiratory tract infections were recorded as the most frequent precipitating events for exacerbation of asthma. Forty-nine intubations were initiated because of a clinical diagnosis of respiratory distress, but multiple indications were present in 42 admissions. One or more complications occurred in 31 episodes of endotracheal intubation and mechanical ventilation (45%). Death occurred in four (6%) of 69 admissions. Three of the four deaths occurred in patients who had a cardiorespiratory arrest before hospital admission.

CONCLUSIONS

While complications occurred in 45% of patients with severe asthma requiring intubation and mechanical ventilation, the mortality rate was low. We conclude that intubation and mechanical ventilation in patients with life-threatening asthma are safe and beneficial interventions.

Imaging of en bloc renal transplants: normal and abnormal postoperative findings

OBJECTIVE

Cadaveric kidneys from donors less than 5 years old, previously considered inferior graft material, are now being successfully transplanted en bloc into children and adults. On the basis of our experience with 132 patients, we describe the general principles of the procedure and review the spectrum of normal and abnormal imaging findings in patients who have undergone this promising transplantation procedure.

MATERIALS AND METHODS

Paired cadaveric kidneys obtained from donors less than 5 years old (mean age, 24 months) were transplanted en bloc to 132 patients (mean age, 37 years) at our institution between 1981 and 1991. All available medical, surgical, pathologic, and imaging records were retrospectively reviewed to define the surgical technique, 1-year survival rate of the graft, appearance of the transplant on postoperative imaging studies, and the prevalence of and imaging findings caused by vascular, urinary, infectious, and neoplastic complications after transplantation. Complications were confirmed by a definitive imaging study, surgical exploration, or study of a pathologic specimen.

RESULTS

Paired donor kidneys were transplanted en bloc extraperitoneally into the recipient's right or left iliac fossa, with intact portions of the donor aorta and inferior vena cava anastomosed to the recipient's external iliac artery and vein. One-year graft survival was 70% during the first 8 years of the study and 78% during the last 2 years. Postoperative imaging, particularly sonography and scintigraphy, clearly depicted the normal individual kidneys, urinary collecting systems, and en bloc vasculature. Postoperative complications were vascular (arterial stenoses and thromboses, venous thromboses, and pseudoaneurysms) in 18%, urinary (obstruction and anastomotic leak) in 11%, infectious (caliceal fungal balls) in 1%, and neoplastic (posttransplant lymphoma) in 1%. The complications involved one kidney in 60% of the patients and both kidneys in 40%. The imaging findings caused by these complications were similar to those caused by complications occurring after transplantation of single cadaveric kidneys; however, their detection was more difficult because of the complexity of the en bloc graft.

CONCLUSION

Because of the shortage of available donor organs, en bloc renal transplantation will most likely become increasingly popular. Familiarity with the imaging appearance of the normal transplant and of posttransplantation complications will allow radiologists to perform effective postoperative imaging evaluations.

Characteristics and distribution of nuclear medicine physicians

OBJECTIVES

The authors examined the characteristics and distribution of physicians certified by The American Board of Nuclear Medicine (ABNM).

METHODS

Three thousand seven hundred twenty-nine physicians were certified by the ABNM by 1989, and information on 3,389 physicians was obtained for this study from available databases.

RESULTS

The age distribution shows 24% (793) of patients were 60 years of age or older; 17% (560) were 55 to 59 years of age; and 21% (714) were 50 to 54 years of age. The average rate of physicians certified by the ABNM was 67.8 annually over the most recent 5 years. Those physicians with additional board certification in radiology, internal medicine, and pathology also were examined. The radiology/nuclear medicine group demonstrated the largest change, with 56.7% having dual certification in the initial 6 years of the ABNM and only 26.4% in the most recent 6 years. The ratio of state population to the number of certified nuclear medicine physicians within the state was found to vary from 30,000:1 in the District of Columbia to 370,000:1 in New Hampshire.

CONCLUSIONS

There will be a decline, and possibly a shortage, of comprehensively trained nuclear medicine physicians over the next 10 to 20 years. There is also a decreasing trend of American Board of Radiology (ABR) certification associated with ABNM certification. In addition, there is an uneven distribution of ABNM-certified physicians.

Phantom kidney: a CT correlation

The phantom kidney is a "kidney-like" apparition which may be seen in dynamic renal scintigraphy typically in post-nephrectomy patients or in patients with unilateral renal agenesis. We report a case of a phantom kidney demonstrated in the angiographic phase of renal scintigraphy with 99mTc-dimercaptosuccinic acid (99mTc-DMSA) in a patient who was nephrectomized 14 years previously. After comparison with the CT images, we conclude that our patient's finding was caused by an increased mesenteric vascularity, possibly postprandial. Several conditions which may cause the phantom kidney effect, have been reported, but increased mesenteric vascularity seems to be the most common cause.

Detection of complications after liver transplantation by technetium-99m mebrofenin hepatobiliary scintigraphy

Fifty-five hepatobiliary scintigraphic studies using 99mTc-Mebrofenin were performed in 52 orthotopic liver transplant patients to evaluate suspected biliary complications, namely biliary extravasation and extrahepatic obstruction. Final diagnosis was made by analysis of the clinical course and other procedures. Three out of three studies of biliary leak and four out of five studies of biliary obstruction were detected. There were no false positives in either complication. The sensitivity, specificity and accuracy were 100, 100, 100% for ectravasation and 80, 100, 98% for obstruction, respectively. Hepatobiliary scintigraphy appears to be an accurate means of detecting biliary leak and obstruction associated with the transplanted liver.

Colorectal carcinoma metastases: detection with In-111-labeled monoclonal antibody CCR 086

A phase I/II clinical trial with indium-111-labeled antimucin murine monoclonal antibody (MoAb) CCR 086 was conducted. Seventeen patients with histologically proved colorectal carcinoma and known metastatic disease underwent external scintigraphy after administration of 5.5 mCi (203.5 MBq) of In-111 CCR 086 at doses of 5 and 20 mg. Of 25 known lesions, 17 were detected (sensitivity, 68%). The smallest detected lesion in the lung was 1 cm and in the liver was 1.5 cm. The serum half-life of In-111-labeled CCR 086 MoAb was approximately 64 hours. The formation of human antimouse antibody (HAMA) was detected in the serum of four of five patients who received 20 mg of MoAb. No HAMAs were detected in four patients receiving 5 mg of MoAb. No side effects were encountered. Because of effective detection of liver and lung metastases with lower doses (5-20 mg) of CCR 086 conjugated with In-111, further investigations are warranted to assess clinical and therapeutic potentials of CCR 086 in the management of colorectal cancer.

An epidemiologic study of inflammatory bowel disease in Rochester, New York. Hospital incidence

The epidemiological understanding of inflammatory bowel disease has been limited by the referral bases of most inflammatory bowel disease studies. The Colitis-Ileitis Study Group of Rochester, N.Y., developed a community-wide, computerized cumulative registry of all inflammatory bowel disease patients hospitalized at the 8 community hospitals for 1973-86. Clinical data were abstracted from each of the 1651 identified hospital charts. All of these patients resided in Monroe County (city and suburbs) and the 5 contiguous counties (Genesee/Finger Lakes Region, population 1,030,640). Of the 1651 hospital patients identified in the study, 1358 resided in Monroe County (Rochester and its immediate suburbs, population 702,238). Incidence, defined as time of onset of symptoms of inflammatory bowel disease, rose from baseline rates in the 1930s to peak in 1980 (Crohn's disease = 50.29/10(5) per decade, ulcerative colitis = 35.12/10(5) per decade) and declined through 1986. For Crohn's disease, the age-specific incidence rates peaked in the 20-29-yr-old group in each of the 5 decades studied. Ulcerative colitis seems to occur at all ages and may have a bimodal distribution. There was a period effect, with the 1970s having the highest incidence of Crohn's disease and ulcerative colitis for each age group. However, the age-specific incidence rate for Crohn's disease showed a 40% decrease in the 1980s compared with the 1970s in the 10-39-yr-old group (p less than 0.001). The age-specific incidence rate for ulcerative colitis showed a 50% decrease in the 1980s compared with the 1970s in the 10-49-yr-old group (p less than 0.001).

Non-gastrin secretogogue in ulcerogenic tumors of the pancreas

In 18 patients with hypersecretion of acid, severe ulcer diathesis, and pancreatic islet cell tumor or hyperplasia, 14 had hypergastrinemia and 4 had normal plasma gastrin concentration. The neoplasms contained several gut peptides beside gastrin. The immunoreactive gastrin in the tumor extracts measured less than 7 ng/g, less than the amount previously reported. The extracts of each patient's tumor also contained a secretogogue other than gastrin that stimulated gastric acid secretion in rats. In addition, the plasma extracts of 2 patients also contained a secretogogue that stimulated acid secretion. After surgical resection of a recurrent metastatic tumor in 1 patient, basal acid secretion decreased from 13.9 to less than 1 meq/h, and the bioactivity of the plasma disappeared. These observations suggest the existence of a secretogogue that appears to be a protein in the pancreatic tumors of some patients with severe ulcer diathesis and hypersecretion.

Liver injury with alcoholiclike hyalin after gastroplasty for morbid obesity

Hepatic damage resembling alcoholic hepatitis has been described after jejunoileal bypass surgery for morbid obesity, but has not been previously reported as a complication of gastric partitioning operations (gastric bypass and gastroplasty). A patient who developed an alcoholic hepatitislike clinical picture 8 mo after gastroplasty is described, suggesting that malnutrition superimposed on obesity may be responsible for the injury in both settings. Reversal of the gastroplasty was associated with clinical and biochemical improvement.

Reflux esophagitis: effect of oral bethanechol on symptoms and endoscopic findings

We ascertained the effectiveness of oral bethanechol on symptoms and endoscopic evaluation of reflux esophagitis in a double-blind controlled study. Forty-four patients were treated with either 25-mg bethanechol tablets or placebo, each given four times daily for 4 weeks, in addition to conventional medical therapy. Both therapies significantly decreased symptoms as well as endoscopic lesions; however, endoscopic improvement was significantly better in the bethanechol-treated group. Bethanechol therapy resulted in complete endoscopic healing in 10 of 22 cases, whereas only three of 22 patients in the control group had such healing. No worsening of endoscopic lesions was seen in either group. Our study indicates that bethanechol is an effective drug offering advantages over conventional antacid therapy in the treatment of reflux esophagitis.

Terrestrial Atmospheric Composition from Stellar Occultations

Stellar ultraviolet light transmitted through the earth's upper atmosphere is strongly absorbed by ozone and molecular oxygen. The stellar ultraviolet photometers aboard the Orbiting Astronomical Observatory (OAO-2) satellite have measured the intensity changes of several stars during occultation of the star by the earth's atmosphere. From the occultation data the nighttime vertical number density profiles of molecular oxygen at altitudes from 120 to 200 kilometers and of ozone at altitudes from 60 to 100 kilometers have been obtained.