Practice guideline for arterial blood gas measurement in the intensive care unit decreases numbers and increases appropriateness of tests

OBJECTIVE

To test the hypothesis that implementation of a practice guideline for blood gas measurement would decrease numbers and increase appropriateness of tests (according to criteria in the guideline) for up to 1 yr after introduction of the guideline.

DESIGN

Numbers of tests and appropriateness of each test were measured retrospectively during each of five periods: two baseline periods 2 yrs and 1 yr before introduction of the guideline and three follow-up periods 2 to 3 months, 6 to 7 months, and 12 to 13 months after introduction of the guideline.

SETTING

A ten-bed multidisciplinary intensive care unit (ICU) within a 500-bed tertiary teaching hospital.

PATIENTS

A random sample of 30 patients admitted to the ICU during each of the periods specified above.

INTERVENTIONS

The nominal group process was used to develop a new guideline and a multipronged educational approach was used to facilitate implementation of the guideline.

MEASUREMENTS AND MAIN RESULTS

At 2 to 3 months, test numbers decreased from 4.9 +/- 1.6 to 3.1 +/- 1.8 (SD) tests/patient/day and to 2.4 +/- 1.2 tests/patient/day at 12 to 13 months. Appropriateness increased from a mean of 44% at baseline to 78% at 2 to 3 months and 79% at 12 to 13 months. There were no differences in Acute Physiology and Chronic Health Evaluation scores or ICU mortality among the patient groups and no differences in number of ventilator days or time to wean from ventilation. Cost-minimization analysis showed that the incremental cost-saving 1 yr after introduction of the guideline was $19.18 per patient per day.

CONCLUSIONS

Implementation of this guideline for arterial blood gas measurement increases efficiency of test utilization without prolonging mechanical ventilation or affecting outcome.

Evaluation of an educational program to prevent adolescent pregnancy

The authors evaluated the effectiveness of a school-based sex education program in decreasing rates of sexual intercourse, improving birth control use, and decreasing the incidence of pregnancies among teenagers 16 years of age and younger. Twenty-one schools received either the McMaster Teen Program or the conventional didactic sex education program. Preprogram, the mean age of the students was 12.6 years. There were no statistically significant differences between groups in time to first sexual activity for males, chi 2(1) = 2.93, p = 0.09; time to first sexual activity for females, chi 2(1) = 0.50, p = 0.48; and time to first pregnancy, chi 2(1) = 1.90, p = 0.17. Significantly more experimental group males reported always using birth control at year 1 (difference 8.9%; 95% confidence interval [CI] = 0.4, 17.4). Limitations of the program that may have influenced the results were the exclusion of contraception information and its short duration.

Breaking through the barriers: healthcare for the homeless

National welfare reform is predicted to increase the number of homeless persons. This will affect the health care system by increasing the number of uninsured people and by multiplying the number of homeless persons seeking care in hospital emergency departments. Homeless persons have four major barriers to care: financial, bureaucratic, programmatic, and personal. The authors provide an overview of the homeless population, outline the barriers to health care for persons who are homeless, and highlight the major health care needs of this population. Finally, a community-based service delivery system developed by one agency in responding to the need of homeless persons is provided as a model of care.

Multicenter randomized trial of fluconazole versus amphotericin B for treatment of candidemia in non-neutropenic patients. Canadian Candidemia Study Group

A randomized trial was conducted to compare the efficacy and safety of fluconazole versus that of amphotericin B in the treatment of candidemia in non-neutropenic adults. Enrollment was stratified by disease severity (APACHE II score). Patients were randomized (1:1) to receive amphotericin B 0.6 mg/kg/day (cumulative dose 8 mg/kg) or fluconazole 800 mg intravenous loading dose, then 400 mg daily for four weeks (intravenous for at least 10 days). Patients were monitored for six months. A total of 106 patients were enrolled. A protocol amendment implemented midway through the trial required patients to be removed from the study and treated with amphotericin B if species identification indicated candidemia due to Candida glabrata or Candida krusei. Baseline characteristics were similar for the two groups; 103 patients (fluconazole, 50; amphotericin B, 53) met the major enrollment criteria. The intention-to-treat analysis indicated successful therapy in 50% of fluconazole recipients compared to 58% of the amphotericin B group (p = 0.39; one-sided 95% CI, -8 to 24%). The efficacy analysis included 84 patients (fluconazole, 42; amphotericin B, 42); successful outcomes were observed in 57% and 62% of cases in the fluconazole and amphotericin B groups, respectively (p = 0.66: one-sided 95% CI, -12 to 22%). The mortality at day 14 for the fluconazole group was 26% and for the amphotericin B group 21% (p = 0.52; chi-square test) and remained similar throughout the course of follow-up, Drug-related adverse events were more frequent with amphotericin B than with fluconazole and prompted switching of therapy for two (4%) and zero cases, respectively. Fluconazole and amphotericin B were associated with similar clinical response rates and survival in the treatment of candidemia among non-neutropenic patients; however, drug-related adverse events were more frequent with amphotericin B.

The early amniocentesis study: a randomized clinical trial of early amniocentesis and midtrimester amniocentesis. II. Evaluation of procedure details and neonatal congenital anomalies

The present study provides detailed neonatal and congenital malformation follow-up from 695 women enrolled in a prospective randomized multicenter study comparing the safety and accuracy of early (11-12 weeks of gestation) and midtrimester amniocentesis (15-16 weeks of gestation). No differences were found for total pregnancy loss (difference 0.4%; CI -3.6 to 4.4%), obstetrical or neonatal outcome. The incidence of congenital anomalies was 2.4 and 2.6% for the early amniocentesis and midtrimester amniocentesis groups, respectively. Respiratory problems were present in 2.1 and 1.6%, respectively. Musculoskeletal problems were present in 0.9 and 2.4%, respectively. It must be emphasized that before early amniocentesis can be considered as an alternative to midtrimester amniocentesis or chorionic villus sampling, careful evaluation of any fetal effects must be considered and further large randomized trials are necessary.

[Some thoughts on Bateman's equation]

The authors have investigated the characteristics of one of the basic equations of pharmacokinetics, Bateman's equation in the function of the differences between the absorption and elimination constants.

Early and late assessment of the Micro Stent PL coronary stent for restenosis and suboptimal balloon angioplasty

This prospective study represents the initial assessment of the Micro Stent PL (Arterial Vascular Engineering, Inc.) coronary stent. From one to three radiopaque stainless steel stents, each measuring 4 mm long, were premounted onto specially designed balloon catheters. A total of 123 stents were implanted in 41 patients without procedural failure or complications. Stent dislodgment proved a concern, with 7 of 123 stents (5.7%) moving > 3 mm from the site of placement and late downstream migration occurring in an additional patient. Subacute stent thrombosis occurred in two patients (5%). Six-month angiographic follow-up was available in 37 of 41 patients (90%). Minimal lumen diameter at baseline was 0.93 +/- 0.51 mm, increasing to 2.74 +/- 0.49 mm after stenting, and falling to 1.66 +/- 0.89 mm at 6 months; this represents a late loss of 60% of the initial gain. Restenosis, based on a binary definition of > 50% diameter stenosis, was documented in 18 patients (49%). Advantages of the Micro Stent PL include its radiopacity and marked ease of distal delivery. The potential for stent dislodgment has implications for future stent designs. The role of the Micro Stent PL in managing restenosis is unclear, but it appears useful in the management of dissection and threatened closure after balloon angioplasty.

Issues in the design of trials of therapies for subjects with human immunodeficiency virus infection that use plasma RNA level as an outcome

Longitudinal plasma RNA levels were examined in 326 persons infected with human immunodeficiency virus (HIV), who were participating in 4 clinical trials and 1 observational study. Variations in plasma RNA levels among individuals were analyzed, and correlations were made of replicate and longitudinal measurements, plasma RNA levels, CD4 cell counts, and plasma RNA levels at enrollment. Sample sizes were calculated for detection of differences between treatment groups in mean plasma RNA level at one time point, the average change over time, and the area under the curve. On the basis of study findings, study eligibility criteria should specify a minimum plasma RNA level at least as high as the expected size of the treatment effect, and all longitudinal data should be used when determining the effect of treatment on plasma RNA level. Duplicating plasma RNA levels resulted in a decrease in the required sample size of 14%-41%.

A comparison of two regimens for the treatment of Mycobacterium avium complex bacteremia in AIDS: rifabutin, ethambutol, and clarithromycin versus rifampin, ethambutol, clofazimine, and ciprofloxacin. Canadian HIV Trials Network Protocol 010 Study Group

BACKGROUND

Bacteremia with the Mycobacterium avium complex is common in patients with the acquired immunodeficiency syndrome (AIDS), but the most effective treatment for this infection remains unclear.

METHODS

We randomly assigned 229 patients with AIDS and M. avium complex bacteremia to receive either rifampin (600 mg daily), ethambutol (approximately 15 mg per kilogram of body weight daily), clofazimine (100 mg daily), and ciprofloxacin (750 mg twice daily) (the four-drug group) or rifabutin (600 mg daily), ethambutol (as above), and clarithromycin (1000 mg twice daily) (the three-drug group). In the three-drug group the dose of rifabutin was reduced by half after 125 patients were randomized, because 24 of 63 patients had uveitis.

RESULTS

Among 187 patients who could be evaluated, blood cultures became negative more often in the three-drug group than in the four-drug group (69 percent vs. 29 percent, P<0.001). Among patients treated for at least four weeks, the bacteremia resolved more frequently in the three-drug group (78 percent vs. 40 percent, P<0.001). In the three-drug group, bacteremia resolved more often with the 600-mg dose of rifabutin than with the 300-mg dose (P=0.025), but the latter regimen was more effective than the four-drug regimen (P<0.05). The median survival was 8.6 months in the three-drug group and 5.2 months in the four-drug group (P = 0.001). The median Karnofsky performance score was higher in the three-drug group than in the four-drug group from week 2 to week 16 (P<0.05). Mild uveitis developed in 3 of the 53 patients receiving the 300-mg dose of rifabutin, an incidence about one quarter that observed with the 600-mg dose (P<0.001).

CONCLUSIONS

In patients with AIDS and M. avium complex bacteremia, treatment with the three-drug regimen of rifabutin, ethambutol, and clarithromycin leads to resolution of the bacteremia more frequently and more rapidly than treatment with rifampin, ethambutol, clofazimine, and ciprofloxacin, and survival rates are better.

Double-blind placebo-controlled pilot trial of acemannan in advanced human immunodeficiency virus disease

SUMMARY

We assessed the safety and surrogate markers' effect of acemannan as an adjunctive to antiretroviral therapy among patients with advanced HIV disease receiving zidovudine (ZDV) or didanosine (ddI) in a randomized, double-blind, placebo-controlled trial of acemannan (400 mg orally four times daily). Eligible patients of either sex had CD4 counts of 50-300/microl twice within 1 month of study entry and had received 26 months of antiretroviral treatment (ZDV or ddI) at a stable dose for the month before entry. CD4 counts were made every 4 weeks for 48 weeks. P24 antigen was measured at entry and every 12 weeks thereafter. Sequential quantitative lymphocyte cultures for HIV and ZDV pharmacokinetics were performed in a subset of patients. Sixty-three patients were randomized. All were males (mean age 39 years). The mean baseline CD4 counts were 165 and 147/microl in the placebo and acemannan groups, respectively; 90 percent of the patients were receiving ZDV at entry. Six patients in the acemannan group and five in the placebo group developed AIDS-defining illnesses. There was no statistically significant difference between the groups at 48 weeks with regard to the absolute change or rate of decline at CD4 count. Among ZDV-treated patients, the median rates of CD4 change (ACD4) in the initial 16 weeks were - 121 and - 120 cells per year in the placebo and acemannan groups, respectively ( p = 0.45), ACD4 from week 16 to 48 was 0 and - 61 cells per year in the acemannan and placebo groups (p = .11), respectively. There was no statistical difference between groups with regard to adverse events, p24 antigen, quantitative virology, or pharmacokinetics. Twenty-four patients, 11 receiving placebo and 13 receiving acemannan, discontinued study therapy prematurely, none due to serious adverse reactions. Our results demonstrate that acemannan at an oral daily dose of 1600 mg does not prevent the decline in CD4 count characteristic of progressive HIV disease. Acemannan showed no significant effect on p24 antigen and quantitative virology. Acemannan was well tolerated and showed no significant pharmacokinetic interaction with ZDV.

Impact of missing data due to dropouts on estimates of the treatment effect in a randomized trial of antiretroviral therapy for HIV-infected individuals. Canadian HIV Trials Network A002 Study Group

PURPOSE

To evaluate the impact of missing data due to nonrandom dropout on estimates of the effect of treatment on the CD4 count in a clinical trial of antiretroviral therapy for HIV infected individuals.

METHODS

The effect of treatment on CD4 counts in a recent study of continued ZDV versus ddI in HIV-infected individuals was estimated from the observed data and after imputing missing CD4 counts for patients who dropped out of the study. Imputation methods studied were (a) carrying forward the last observed CD4 count, (b) predicting missing CD4 counts from regression models, and (c) assuming that CD4 counts of patients who dropped out declined at a rate of 100 cells per year.

RESULTS

Of the 245 patients enrolled in the study, 52% completed the planned 48 weeks of follow-up. Patients with lower CD4 counts were more likely to drop out of the study (RR = 1.77; p = 0.0001). Patients receiving ZDV had a greater tendency to drop out than patients receiving ddI (p = 0.07). Mean CD4 counts calculated after imputing missing data were lower than those obtained from the observed data at all follow-up times for both treatment groups. Imputing CD4 counts with regression models yielded higher estimates of the effect of treatment than were obtained using the observed data.

CONCLUSION

Missing outcome data due to dropouts can result in an underestimation of the treatment effect and overly optimistic statements about the outcome of participants on both treatment arms due to the selective dropout of participants with lower or decreasing CD4 counts. When there are significant dropout rates in randomized trials, imputation is a useful technique to assess the range of plausible values of the treatment effect.

Douglas-fir: a third wood-drying condensate found to exhibit in vitro cytotoxicity and genotoxicity

The present study applies the approach described in Mark et al. for the testing of toxic chemicals produced during the drying of Douglas-fir. The genotoxic potential of Douglas-fir condensate has been previously unexplored and is thus an area of appropriate concern to the forest products industry, regulatory, agencies, and the general public. Previous research conducted in this laboratory has identified two wood-drying condensates that yield positive cytotoxic and genotoxic effects. The results of testing Southern yellow pine and Eastern white pine condensates have been reported elsewhere. Douglas-fir condensate, a third wood-drying condensate, was added in vitro in concentrations ranging from 0.1 to 100 microliters/ml to cultures of Chinese Hamster Ovary (CHO-WBL) cells. A dose response curve was observed with this condensate for both cytotoxicity and genotoxicity. The number of viable cells as well as the mitotic index (MI) and proliferative rate index (PRI) varied inversely with dosage. The result of chromosome aberration (Abs) analysis and sister chromatid exchange (SCE) analysis, both cytogenetic measures of genotoxicity, also gave statistically significant results.

Growth hormone and aging change rat liver fatty acid binding protein levels

OBJECTIVE

Rat liver fatty acid binding protein (FABP) is believed relevant to understanding of homeostasis in lipid metabolism and lipid related diseases. Relatively little is known about endocrine control of FABP production. Thus, we examined endocrine effects on its hepatic content.

METHODS/RESULTS

Hypophysectomy of 300-325 g males caused statistically significant drops of FABP levels averaging 62.2% and 67.0%, expressed g/liver or 100 g/body weight, 30-52 days after surgery. Cortisol administration (3.8 mg/kg, daily, 32-36 days) did not significantly alter this effect of hypophysectomy. Recombinant human growth hormone (GH, 2.0 U/kg, b.i.d, 17-20 days) greatly decreased the effect of hypophysectomy on FABP but had no effect in intact males. Supporting the control of FABP content by GH, FABP levels decreased significantly in 12-13 and 16-22 month old males, but not in growing, 4-6 or 10-11 month old males. FABP levels in 12-13.5 month old females also dropped significantly compared to 4-6 month old females.

DISCUSSION

The importance of the data to metabolism, growth, and aging is discussed.

Prevalent left ventricular hypertrophy in the predialysis population: identifying opportunities for intervention

Left ventricular hypertrophy (LVH) is present in over 70% of patients commencing dialysis. It is an independent risk factor for cardiac death, which is the cause of death in approximately 45% of patients in dialysis. The prevalence of LVH in patients earlier in the course of renal insufficiency is unknown. As part of a prospective longitudinal study evaluating the progression of comorbid diseases in patients with progressive renal disease, we evaluated LVH. In 175 consecutive patients attending a renal insufficiency clinic we obtained technically adequate echocardiograms and estimated left ventricular mass index (LVMI) using two-dimensional targeted M-mode echocardiography. We calculated LVMI using the American Society of Echocardiography cube formula method regressed to anatomic validation. The population consisted of 115 men and 60 women ranging in age from 20 to 82 years (mean age, 51.5 years). The mean creatinine was 403 +/- 207 micro mol/L (+/-SD), representing a creatinine clearance (Ccr) of 25.5 +/- 17 mL/min. Left ventricular hypertrophy was defined as LVMI greater than 131 g/m(2) in men and greater than 100 g/m(2) in women, and was present in 38.9% of the population studied. We demonstrate that the prevalence of LVH increased with progressive renal decline: 26.7% of patients with Ccr greater than 50 mL/min had LVH, 30.8% of those with Ccr between 25 and 49 mL/min had LVH, and 45.2% of patients with severe renal impairment (Ccr <25 L/min) had LVH (P = 0.05). The mean LVMI was significantly different among the three groups (97.5 g/m(2) v 114.4 g/m(2), respectively; P < 0.001). Univariate analyses revealed that age, hemoglobin, systolic blood pressure and Ccr were significantly different between the groups with and without LVH. The logistic regression model confirmed the findings of the univariate analysis: an increase in age of 5 years was associated with an increase of 3% in risk of LVH (P = 0.0094), as was an increase in systolic blood pressure of 5 mm Hg (P = 0.0018). For each 10 g/L decrease in hemoglobin, the risk of LVH increased by 6% (P = 0.0062), and for each 5 mL/min decline in Ccr the risk increased by 3% (P = 0.0168). We demonstrate the high prevalence of LVH in patients with renal insufficiency prior to the need for dialysis, which is associated with severity of renal impairment, and identify two modifiable factors (systolic blood pressure and anemia) as important predictors of LVH. We suggest that future studies should focus on interventions aimed at attenuating the impact of these factors.

The early amniocentesis study: a randomized clinical trial of early amniocentesis versus midtrimester amniocentesis

OBJECTIVES

The primary purpose of this pilot study was to determine whether the safety of early amniocentesis (EA; 11 weeks to 12 weeks and 6 days) is similar to midtrimester amniocentesis (MA; 15 weeks to 16 weeks and 6 days). The secondary objectives were to determine the cytogenetic success and accuracy of EA compared with MA.

METHODS

This prospective, randomized clinical trial compared continuous ultrasound-guided EA and MA (22-gauge needle) in patients at a late maternal age (> or = 35 years). The procedures were compared for safety, success and accuracy.

RESULTS

Among the 683 women randomized and followed to pregnancy completion, there was a total of 27/344 (7.8%) and 25/339 (7.4%) fetal losses (spontaneous and induced abortions) in the EA and MA groups, respectively (difference 0.4%; CI -3.6 to 4.4%). The rate of postprocedure spontaneous fetal loss was 2.4% (8/330) in the EA group and 3.3% (10/299) in the MA group (NS). The procedure success rate at the first attempt was 97.6% in the EA group and 99.7% in the MA group. There were no diagnostic errors, and all but 2 EA cultures were successful (both repeated successfully). The perinatal outcome was similar in both groups.

CONCLUSIONS

EA appears to be as safe and accurate as MA. A large multicentered, randomized trial is currently underway to verify these results.

A prospective study to determine the frequency and clinical significance of alloimmunization post-transfusion

There is debate in the literature about the frequency and importance of delayed transfusion reactions. This uncertainty could reflect the endpoints used (clinical or serological) and the type of study (typically retrospective or case series). In this report we describe a prospective investigation to determine the frequency of alloimmunization post transfusion and whether the alloantibody production is a laboratory event or has clinical relevance. A total of 2490 patients were transfused 11,218 red cell concentrates. One or more blood samples were collected within 7 d post transfusion and screened for serological evidence of alloimmunization. If any antibody was detected the patient's post-transfusion sample was screened for biochemical evidence of haemolysis and the patient's chart reviewed for documentation of clinical signs of a transfusion reaction. Post transfusion alloimmunization occurred in 2.6% of the patients (95% CI 2.1-3.6%), who had no detectable alloantibody in pre-transfusion testing. For those 86 patients (3.5%) with alloantibodies detectable pretransfusion, 8.9% (95% CI 3.6-17.4%) developed additional aloantibodies. The most common alloantibodies detected were anti-Jka, anti-E and anti-K. Despite the high frequency of serological evidence of delayed transfusion reactions, only one patient (0.05%) had clinical evidence of a delayed haemolytic transfusion reaction (95% CI 0.0-0.27%). Serological evidence of a delayed transfusion reaction is common; however, these reactions rarely cause clinical symptoms.

Changes of brain anatomy in patients with posttraumatic stress disorder: a pilot magnetic resonance imaging study

No abnormalities in magnetic resonance images were recorded in patients with posttraumatic stress disorder other than an increased incidence (50%) of a small cleft in the callosal-septal interface, a cavum of the septum pellucidum. A similar grade of cavum was obtained in 14% of normal volunteers matched for age, socioeconomic background, and military experience. The cavum is believed to have antedated the disorder and is conceived to be a neurodevelopmental aberration. The possibility that the cavum is a marker of vulnerability to stress in psychopathology is discussed.

Role-relationship models for case formulation

BACKGROUND

Personality disorders are important because they occur frequently and often complicate psychiatric symptom disorders. They are difficult to diagnose and formulate because unitary core traits and themes are hard to define for individual patients. A multiple-selves approach helps clinicians define core contradictions in belief that are frequently present.

METHOD

A configurational system for case formulation was used with an approach of states and person schemas. Transactions and stories involving self and others were observed for recurrent elements of identity, attribution, and action. These elements were systematically arranged as role relationship models for each important state of behavior. Cyclic repetitions of maladaptive interpersonal behavior patterns were then explained in terms of motivations and social events that activate enduring, but erroneous, beliefs.

RESULTS

Reliable and valid individualized formulations were derived by means of configurations of role relationship models. Inferring several levels of diverse self and other beliefs clarified the complexity usually found in disorders of personality.

CONCLUSIONS

The role relationship models method of formulation is compatible with integrative approaches to treatment planning.

Synthesis of linoleate and alpha-linolenate by chain elongation in the rat

The objective was to determine whether rats could synthesize longer chain polyunsaturates from hexadecadienoate (16:2n-6) and hexadecatrienoate (16:3n-3). Rats were gavaged with uniformly 13C-labelled hexadecadienoate or hexadecatrienoate, euthanized 24 h later, and total lipids were extracted from liver and carcass. Gas chromatography/combustion/isotope ratio mass spectrometry was used to measure 13C levels in individual liver, carcass, and whole body fatty acids. 13C Enrichment was present in desaturated and chain-elongated polyunsaturates, including linoleate, arachidonate, alpha-linolenate, and docosahexaenoate at 12-13% of the dose of tracer given. 13C Enrichment from hexadecatrienoate was highest in carcass and liver alpha-linolenate, representing 3.5 and 17.9% of the total alpha-linolenate pool, respectively. For linoleate, arachidonate, or docosahexaenoate, the contribution of 13C did not exceed 0.2% of the total body pool. Green leafy vegetables common in the human diet were shown to contain up to 1.2% of total fatty acids as hexadecadienoate and 11.6% as hexadecatrienoate. Hence, humans consuming green vegetables probably synthesize a small proportion of their total body content of linoleate and alpha-linolenate.

Effect of protriptyline, 10 mg daily, on chronic hypoxaemia in chronic obstructive pulmonary disease

A daily dose of 20 mg of protriptyline can improve daytime arterial blood gas tensions in chronic obstructive pulmonary disease (COPD). Its usefulness is limited by anticholinergic side-effects. This study examined whether a daily dose of 10 mg of protriptyline improved daytime arterial oxygen tension (PaO2) and quality of life in patients with stable mild or moderate hypoxaemia caused by COPD. Twenty six patients were randomized to receive protriptyline or placebo in a double-blind parallel-group trial for 12 weeks, following a run-in period of 4 weeks, in order to assess the stability of hypoxaemia. Patients with a change in PaO2 of > 0.7 kPa during the run-in were excluded. Spirometry, quality of life and dyspnoea score were measured at randomization and after 12 weeks, whilst arterial blood gas tensions were also measured 2 and 6 weeks after randomization. No improvement in arterial blood gas tensions, spirometry values, dyspnoea score, or quality of life was found in either the protriptyline or the placebo group. The majority of patients receiving protriptyline experienced anticholinergic side-effects, which necessitated the withdrawal of the drug in one patient. We conclude that there was no evidence that a daily dose of 10 mg of protriptyline had a significant effect on daytime arterial oxygen tension in stable mild and moderate hypoxaemia caused by COPD. Despite the low dose, anticholinergic side-effects occurred in most patients.

MR imaging of adrenal masses: value of chemical-shift imaging for distinguishing adenomas from other tumors

OBJECTIVE

CT and conventional MR imaging are helpful in characterizing adrenal tumors, but a specific diagnosis is not achieved for a substantial number of lesions. Chemical-shift imaging relies on the different resonance frequencies of protons in water and triglyceride molecules and therefore may permit a more specific diagnosis of adrenal adenomas, which are known to contain abundant lipid. The purpose of this study was to evaluate the usefulness of chemical-shift MR imaging in the differentiation of adrenal adenomas from other adrenal masses.

SUBJECTS AND METHODS

Forty-one adrenal masses (17 nonhyperfunctioning adenomas, two aldosteronomas, six pheochromocytomas, one ganglioneuroma, five adrenal carcinomas, one lymphoma, seven metastases, one case of extramedullary hematopoiesis, and one leiomyosarcoma) suspected clinically or identified by sonography or CT in 38 patients were prospectively evaluated with MR imaging. Pathologic proof of diagnosis was obtained for 28 lesions, and stability on imaging follow-up (mean, 19 months) was accepted as proof of diagnosis of benign adenoma for 13 lesions. In-phase T1-weighted spin-echo sequences (500/20 [TR/TE]) and opposed-phase gradient-echo sequences (142/6.3, flip angle = 90 degrees) of the adrenal regions were applied. Quantitative analysis of signal intensity loss in the adrenal lesions relative to reference tissues (liver, muscle, and spleen) on in-phase and opposed-phase sequences was done to differentiate adenomas from nonadenomas. Region-of-interest signal intensity measurements were obtained in a standard fashion by selection of the largest possible representative sample.

RESULTS

Using liver as the reference standard, we found that mean signal intensity ratios were 0.47 (range, 0.23-0.97) for adrenal adenomas and 0.88 (range, 0.65-1.32) for nonadenomas; signal intensity ratios for two adenomas overlapped those of the nonadenomas. Using muscle as the reference standard, we found that mean signal intensity ratios were 0.44 (range, 0.22-0.66) for adrenal adenomas and 0.85 (range, 0.59-1.39) for nonadenomas; signal intensity ratios for two adenomas overlapped those of the nonadenomas. Using spleen as the reference standard, we found that mean signal intensity ratios were 0.45 (range, 0.27-0.73) for adrenal adenomas and 0.97 (range, 0.8-1.18) for nonadenomas, with no overlap. The mean signal intensity ratios were significantly different between adenomas and nonadenomas for all three reference tissues (p < .001).

CONCLUSION

Our results show that chemical-shift MR imaging is an important new technique that enables the differentiation of adrenal adenomas from other adrenal masses, reducing the need for biopsy and prolonged imaging follow-up in patients with adrenal tumors.

Engraftment of patients with lymphoid malignancies transplanted with autologous bone marrow, peripheral blood stem cells or both

Forty six patients with lymphoid malignancies receiving autologous transplants using three different sources of hematopoietic stem cells were compared for engraftment parameters. Thirteen patients (five with multiple myeloma, seven with non-Hodgkin's lymphoma and one with Hodgkin's lymphoma) received autologous marrow with post-transplant growth factors (group 1). During the same time interval, 14 patients (five with multiple myeloma, six with non-Hodgkin's lymphoma and three with Hodgkin's lymphoma) were transplanted with autologous marrow plus recombinant granulocyte colony-stimulating factor (rhG-CSF)-mobilized peripheral blood stem cells (PBSC) and post-transplant growth factors (group 2). Nineteen patients (seven with multiple myeloma and 12 with non-Hodgkin's lymphoma) received rhG-CSF mobilized PBSC and post-transplant growth factors (group 3). All PBSC were collected after G-CSF mobilization (16 micrograms/kg/day s.c. for 6 days) without prior chemotherapy. After high-dose myeloablative chemotherapy or chemoradiotherapy, the median days to recovery of neutrophils to levels of 0.5 and 1.0 x 10(9)/l were 12 vs. 9 vs. 9 days (P = 0.0003 (group 1 vs. group 2) and P = 0.53 (group 2 vs. group 3)) and 13 vs. 10 vs. 10 days (P = 0.0003 (group 1 vs. group 2) and 0.92 (group 2 vs. group 3)) for groups 1, 2 and 3, respectively. The median day to platelet transfusion independence was 22 vs. 11 vs. 11 days (P = 0.001 (group 1 vs. group 2) and P = 0.50 (group 2 vs. group 3)) for groups 1, 2 and 3, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)