Prevalence and barriers of reporting needle-stick injures amongst government pharmacists working in Perak, Malaysia

INTRODUCTION

Needle-stick injuries (NSIs) are common amongst healthcare workers including pharmacists. Studies have reported a range of 0-5.65 per 1,000 pharmacists handling vaccinations that suffered at least one incident of NSI. The objective of this study was to determine the prevalence of NSI and the barriers encountered in reporting it amongst government pharmacists working in Perak.

MATERIALS AND METHODS

This was a cross-sectional study conducted amongst all government pharmacists in Perak. We excluded those who did not consent or were unreachable electronically. The researchers provided an online link that was forwarded to all heads of departments in Perak via social media. The respondents answered their demographic details, questions assessing their knowledge of NSI transmissible diseases, needle-stick handling practices, detail experiences of them suffering an NSI (all self-developed questionnaires), and their barriers in reporting an NSI (validated questionnaire). All responses were auto-tabulated in an excel sheet. A sample size of 516 pharmacists was needed for this study. A respondent was deemed to have inadequate knowledge when they answered any question wrongly about NSI knowledge-related questions and inappropriate practice in needle handling when respondents answered any questions wrongly for questions assessing practices.

RESULTS

A total of 524 pharmacists participated. The overall prevalence of NSI was 23.1% (n=121), of which, those with contaminated NSI were 10.3% (n=54, 95%CI: 7.9-13.30). Twothirds of the participants (66.6%) had inadequate knowledge and nearly all of them were unable to describe the appropriate needle-handling practices (94.7%). Amongst the reported barriers were "not knowing whose duty it was to report an NSI" (45.5%) and "busy schedules" (44.7%).

CONCLUSION

One in every five pharmacists in the state of Perak had a history of NSI, and 1 in every 10 had sustained a contaminated NSI. The barriers to reporting a NSI were mainly due to uncertainty about whose responsibility to report the incident and being too busy to report it.

Field-resolved high-order sub-cycle nonlinearities in a terahertz semiconductor laser

The exploitation of ultrafast electron dynamics in quantum cascade lasers (QCLs) holds enormous potential for intense, compact mode-locked terahertz (THz) sources, squeezed THz light, frequency mixers, and comb-based metrology systems. Yet the important sub-cycle dynamics have been notoriously difficult to access in operational THz QCLs. Here, we employ high-field THz pulses to perform the first ultrafast two-dimensional spectroscopy of a free-running THz QCL. Strong incoherent and coherent nonlinearities up to eight-wave mixing are detected below and above the laser threshold. These data not only reveal extremely short gain recovery times of 2 ps at the laser threshold, they also reflect the nonlinear polarization dynamics of the QCL laser transition for the first time, where we quantify the corresponding dephasing times between 0.9 and 1.5 ps with increasing bias currents. A density-matrix approach reproducing the emergence of all nonlinearities and their ultrafast evolution, simultaneously, allows us to map the coherently induced trajectory of the Bloch vector. The observed high-order multi-wave mixing nonlinearities benefit from resonant enhancement in the absence of absorption losses and bear potential for a number of future applications, ranging from efficient intracavity frequency conversion, mode proliferation to passive mode locking.

Placement of markers to assist minimally invasive resection of peripheral lung lesions

With development of lung cancer screening programs and increased utilization of radiographic imaging there is significantly higher detection of smaller lung nodules and subsolid lesions. These nodules could be malignant and pose a diagnostic challenge. Video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery (RATS) represent minimally invasive methods for tissue sampling. Intraoperative identification of these lesions maybe difficult, requiring marking prior to surgery. We review different techniques for the placement of markers to assist in the resection of peripheral lung lesions (PLL).

Role of bronchoscopy in management of central squamous cell lung carcinoma in situ

Squamous cell carcinoma in situ (SCIS) is the pre-invasive stage of squamous cell carcinoma. Early detection and management of SCIS can prevent further progression. Although surgery and external beam radiation therapy are treatment options for SCIS, smaller lesions can be easily managed by bronchoscopic modalities like photodynamic therapy (PDT), cryotherapy, mechanical debulking with biopsy forceps, electrocautery and argon plasma coagulation (APC). Endobronchial brachytherapy (EBBT) and lasers may be judiciously utilized in selected cases. Although, previous studies of treatment modalities may have inadvertently included cases of invasive carcinomas, the advent of new technologies like radial probe endobronchial ultrasound (RP-EBUS) and optical coherence tomography (OCT) can help accurately determine the of depth of invasion. Superficial extent can also be better demarcated with techniques like auto-fluorescence bronchoscopy and narrow band imaging (NBI). New drugs for PDT with deeper penetration and less phototoxicity are being developed. These advances hopefully will allow us to perform superior clinical trials in future and improve our understanding of diagnosis and management of SCIS.

High-speed THz spectroscopic imaging at ten kilohertz pixel rate with amplitude and phase contrast

By combining the advantages of the high-speed ASOPS technology and efficient THz generation, we have realized a high-speed laser-based spectroscopic THz imaging system with more than 10,000 pixels per second acquisition speed and an excellent signal-to-noise ratio of more than 100. Unlike THz line cameras or mm-wave intensity detectors, the present device allows for a much higher spatial resolution and attributes each imaging pixel with phase and amplitude information up to several THz while simultaneously maintaining a very high scanning speed unmatched by any other technique presented so far. The high-speed acquisition allows for samples to be scanned even at sample velocities of 5 m/s or higher while preserving the fundamental resolution limit of the THz radiation, which is on the order of 500 µm in the present case.

The value of using radial endobronchial ultrasound to guide transbronchial lung cryobiopsy

Conventional transbronchial biopsies have a low diagnostic yield for interstitial lung disease (ILD) and peripheral lung nodules due to crush artifact and smaller tissue samples. Transbronchial lung cryobiopsies (TBLC) circumvent these drawbacks but are associated with higher incidence of complications including life threatening airway bleeding and pneumothoraces. Radial probe endobronchial ultrasound (RP-EBUS) can be used during the TBLC for assessing the biopsy site prior to the cryobiopsy to avoid vasculature and to decrease the risk of complications. There is no standardized protocol for this technique and the available literature mostly consists of single center case reports/series. The aim of this review is to investigate the existing literature for RP-EBUS assisted TBLC for diagnosing both ILD and peripheral lung nodules. We will describe the techniques used and compare the diagnostic yield and complication rates with other modalities.

Effect of the number of lymph nodes examined on the survival of patients with stage I non-small cell lung cancer who undergo sublobar resection

OBJECTIVES

Early stage lung cancer is being detected at a higher frequency with the implementation of screening programs. At the same time, medically complex patients with multiple comorbidities are presenting for surgery, with a concomitant rise in rates of sublobar resection. We sought to examine the effect of sampling lymph nodes on the outcomes of patients who undergo sublobar resection for small (<2 cm) stage I non-small cell lung cancer (NSCLC).

METHODS

All patients in the Surveillance, Epidemiology, and End Results database from 2004 to 2013 with small (<2 cm) stage I NSCLC who underwent sublobar resection (wedge/segmentectomy) and no other cancer history were included. The association of the number of lymph nodes examined (LNE; categories none, 1-3, 4-6, 7-9, >9) with the overall survival as well as disease-specific survival were examined using univariate as well as multivariate analyses while controlling for covariates such as age, size (<1 cm, >1 cm), grade, histology (adenocarcinoma vs others), and extent of resection (wedge/segmentectomy).

RESULTS

Data from 3916 eligible patients were analyzed. Seven hundred fifteen patients (18.3%) had segmentectomy. No lymph nodes were examined in 49% and 23% of wedge resection and segmentectomy patients, respectively. Among all eligible patients, 1132 (29%), 474 (12%), 228 (6%), and 328 (8%) patients had 1 to 3, 4 to 6, 7 to 9 and >9 LNE, respectively. Univariate analyses showed significant associations between overall and disease-specific survivals with age, grade, histology, sex, extent of surgery, and LNE. The association between the number of LNE and survival remained significant even after adjusting for significant covariates including extent of sublobar resection (hazard ratio for groups with LNE 1-3, 4-6, 7-9, and >9 compared with 0 LNE were 0.79, 0.77, 0.68, and 0.45 for overall survival; P < .001) and 0.85, 0.77, 0.71, and 0.44 for disease-specific survival (P < .05), respectively. In multivariate modeling, LNE was retained as a significant variable and extent of resection was not. In patients in whom at least 1 lymph node was examined, extent of resection was not predictive of outcome.

CONCLUSIONS

Many patients having sublobar resection for early stage NSCLC in the United States do not have a single lymph node removed for pathologic examination. The number of LNE is associated with improved survival, presumably due to avoidance of mis-staging. This association seems greater than the association with extent of resection (segmentectomy vs wedge resection). Appropriate lymph node examination remains an important part of resection for lung cancer even if the resection is sublobar.

Concomitant Mediastinoscopy Increases the Risk of Postoperative Pneumonia After Pulmonary Lobectomy

BACKGROUND

Mediastinoscopy is considered the gold standard for preresectional staging of lung cancer. We sought to examine the effect of concomitant mediastinoscopy on postoperative pneumonia (POP) in patients undergoing lobectomy.

METHODS

All patients in our institutional database (2008-2015) undergoing lobectomy who did not receive neoadjuvant therapy were included in our study. The relationship between mediastinoscopy and POP was examined using univariate (Chi square) and multivariate analyses (binary logistic regression). In order to validate our institutional findings, lobectomy data in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2014 were analyzed for these associations.

RESULTS

Of 810 patients who underwent a lobectomy at our institution, 741 (91.5%) surgeries were performed by video-assisted thoracic surgery (VATS) and 487 (60.1%) patients underwent concomitant mediastinoscopy. Univariate analysis demonstrated an association between mediastinoscopy and POP in patients undergoing VATS [odds ratio (OR) 1.80; p = 0.003], but not open lobectomy. Multivariate analysis retained mediastinoscopy as a variable, although the relationship showed only a trend (OR 1.64; p = 0.1). In the NSQIP cohort (N = 12,562), concomitant mediastinoscopy was performed in 9.0% of patients, with 44.5% of all the lobectomies performed by VATS. Mediastinoscopy was associated with POP in patients having both open (OR1.69; p < 0.001) and VATS lobectomy (OR 1.72; p = 0.002). This effect remained in multivariate analysis in both the open and VATS lobectomy groups (OR 1.46, p = 0.003; and 1.53, p = 0.02, respectively).

CONCLUSIONS

Mediastinoscopy may be associated with an increased risk of POP after pulmonary lobectomy. This observation should be examined in other datasets as it potentially impacts preresectional staging algorithms for patients with lung cancer.

Initial experience of medical pleuroscopy via the peel-away introducer of the indwelling pleural catheter using a thin bronchoscope

We present a case series describing a modified technique of combining medical Pleuroscopy (MP) and indwelling pleural catheter (IPC) placement for obtaining pleural biopsies and managing recurrent pleural effusions. The unique feature of this technique is the introduction of a thin bronchoscope through the peel-away introducer of IPC to obtain pleural biopsies thus avoiding a bigger incision followed by placement of IPC. This procedure was performed on nine patients in an outpatient setting. A regular flexible bronchoscopy forceps was used to obtain pleural biopsies in eight out of nine patients and only one patient could not tolerate the procedure due to marginal respiratory status. A diagnosis of malignancy was successfully obtained in six patients, one patient had biopsy findings of chronic inflammation and one patient had necrotic debris and rare atypical cells despite having visible pleural lesions. No procedure related patient complications were noted.

Management of cardiac implantable electronic devices during interventional pulmonology procedures

An increasing number of patients are receiving cardiac implantable electronic devices (CIED) now. Many of them need pulmonary procedures for various indications including, but not limited to, lung cancer and benign endobronchial lesions. Over the last two decades, interventional pulmonology (IP) has expanded its scope to include various modalities that use heat and electrical energy and in the process, create electromagnetic field in the vicinity. This raises concerns for electromagnetic interference (EMI) causing abnormal behavior in the CIEDs. While guidelines and recommendations on the peri-procedural management of CIEDs do exist, none of them directly address the pulmonary procedures. In this paper, we strive to review the available literature pertaining to the management of CIEDs in the context of EMI caused by the various IP procedures.

Bronchoscopy for the diagnosis of peripheral lung lesions

Peripheral pulmonary lesions (PPLs) are generally considered as lesions in the peripheral one-third of the lung although a precise definition and radiographic anatomical landmarks separating central and peripheral lesion does not yet exist. The radiographic detection of such lesions has increased significantly with the adoption of lung cancer screening programs. These lesions are not directly visible by regular flexible bronchoscopes as they are usually distal to the lobar and segmental bronchi. Traditionally, depending on location and clinical stage at presentation, these lesions were typically sampled by computerized tomography (CT) guided needle or surgical biopsy although some centers also used ultrasound and fluoroscopy guided percutaneous needle biopsy. Due to lack of direct visualization, the yield for bronchoscopic guided sampling especially of the small <2 cm pulmonary nodules was very low. Therefore, sampling has been preferentially performed by percutaneous CT guidance, which had high yield of above 90% but it comes at the cost of higher risk complications like pneumothorax with reported rate of 15% to 28%. Directly proceeding to surgical resection is also considered in appropriate candidates with high suspicion of malignancy without any evidence of distant metastasis but the proportion of such cases of lung cancer is low. The manuscript discussed the various bronchoscopic diagnostic modalities for peripheral pulmonary lesions. It is important to note that most of the studies in this field are relatively small, not randomized, suffer from selection bias, have considerable heterogeneity in sampling methodology/instruments and usually have been performed in high volume institutions by dedicated highly experienced proceduralists. The prevalence of malignancy in most of the reported cohorts has also been high which may result in higher diagnostic yields. All these factors need to be kept in mind before generalizing the results to individual centers and practices.

Esophago-pulmonary fistula manifesting as recurrent pneumonias and migrating mediastinal calcifications

A 43-year old man presented with recurrent pneumonias, episodes of hemoptysis and an enlarging right lower lobe mass. A clear diagnosis was not previously established in spite of multiple radiological evaluations and biopsies. Meticulous review of his CT imaging showed that he had subcarinal calcification on his prior CT scans, which had decreased in size and now multiple new small areas of calcifications were seen in the right lower lobe lesion. An esophago-pulmonary fistula due to migration of mediastinal calcifications was suspected which was identified on careful review of the CT chest and confirmed by esophagogastroduodenoscopy. Patient had surgical repair with complete recovery.

Complex multimodality central airway management of aspergillus pseudomembranous tracheobronchitis

A 69-year-old woman developed central airway obstruction due to invasive Aspergillus infection resulting in pseudomembranous tracheobronchitis (PTB). Several challenges were encountered in the airway management of this patient including her having relatively smaller airways which were more prone to obstruction by pseudomembranes and made airway interventions difficult. The patient had clinical deterioration in spite of antifungal therapy and bronchoscopic debridement. The multimodality airway techniques included the use of smaller biliary balloons for dilatation, using a hybrid stent to slowly dilate and maintain patency of right main stem and finally the insertion of right secondary carina peripheral Y stent, which resulted in clinical improvement and allowed time for antifungal therapy to take effect. To the best of our knowledge, the use of a peripheral Y stent has never been described in the setting of PTB.

Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis

BACKGROUND

The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions.

METHODS

We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study.

RESULTS

Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%-4.7%); loculation, 2.0% (95% CI, 0.0%-4.7%); dislodgement, 1.3% (95% CI, 0.0%-3.7%); leakage, 1.3% (95% CI, 0.0%-3.5%); and pneumothorax, 1.2% (95% CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%-4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%-3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%-4.0%); and other, 2.5% (95% CI, 0.0%-5.2%). One death was directly related to IPC use.

CONCLUSIONS

IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.

Endobronchial ultrasound for the detection of chronic pulmonary artery thrombus

Endobronchial ultrasound (EBUS) has been shown to be able to successfully identify acute/subacute pulmonary thromboembolism (PE). Most reported cases have required confirmation by computerized tomography (CT) angiography. This report demonstrates a case where CT angiography was not conclusive and the EBUS was useful in clarifying the chronic process inside the pulmonary artery compatible with clinical diagnosis of chronic pulmonary artery thrombosis.

Detection of an embolized central venous catheter fragment with endobronchial ultrasound

An 84-year-old woman underwent Convex-probe Endobronchial Ultrasound (CP-EBUS) for ¹⁸ F-fluorodeoxyglucose avid subcarinal lymphadenopathy on Positron Emission Tomogram (PET) scan. Endobronchial ultrasound-guided transbronchial needle aspiration of the subcarinal lymph node revealed squamous cell lung carcinoma. A small hyperechoic rounded density was noted inside the lumen of the azygous vein. Based on chest computed tomography findings and her clinical history, this was felt to be a broken fragment of a peripherally inserted central catheter, which was placed for intravenous antibiotics, a few months prior to this presentation. To the best of our knowledge, this is the first ever CP-EBUS description of a broken fragment of central venous catheter.

Engineered far-fields of metal-metal terahertz quantum cascade lasers with integrated planar horn structures

The far-field emission profile of terahertz quantum cascade lasers (QCLs) in metal-metal waveguides is controlled in directionality and form through planar horn-type shape structures, whilst conserving a broad spectral response. The structures produce a gradual change in the high modal confinement of the waveguides and permit an improved far-field emission profile and resulting in a four-fold increase in the emitted output power. The two-dimensional far-field patterns are measured at 77 K and are agreement in with 3D modal simulations. The influence of parasitic high-order transverse modes is shown to be controlled by engineering the horn structure (ridge and horn widths), allowing only the fundamental mode to be coupled out.

A Phase I Study of Light Dose for Photodynamic Therapy Using 2-[1-Hexyloxyethyl]-2 Devinyl Pyropheophorbide-a for the Treatment of Non-Small Cell Carcinoma In Situ or Non-Small Cell Microinvasive Bronchogenic Carcinoma: A Dose Ranging Study

INTRODUCTION

We report a phase I trial of photodynamic therapy (PDT) of carcinoma in situ (CIS) and microinvasive cancer (MIC) of the central airways with the photosensitizer (PS) 2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a (HPPH). HPPH has the advantage of minimal general phototoxicity over the commonly used photosensitizer porfimer sodium (Photofrin; Pinnacle Biologics, Chicago, IL).

METHODS

The objectives of this study were (1) to determine the maximally tolerated light dose at a fixed photosensitizer dose and (2) to gain initial insight into the effectiveness of this treatment approach. Seventeen patients with 21 CIS/MIC lesions were treated with HPPH with light dose escalation starting from 75 J/cm2 and increasing to 85, 95,125, and 150 J/cm2 respectively. Follow-up bronchoscopy for response assessment was performed at 1 and 6 months, respectively.

RESULTS

The rate of pathological complete response (CR) was 82.4% (14 of 17 evaluable lesions; 14 patients) at 1 month and 72.7% (8/11 evaluable lesions; 8 patients) at 6 months. Only four patients developed mild skin erythema. One of the three patients in the 150 J/cm2 light dose group experienced a serious adverse event. This patient had respiratory distress caused by mucus plugging, which precipitated cardiac ischemia. Two additional patients treated subsequently at this light dose had no adverse events. The sixth patient in this dose group was not recruited and the study was terminated because of delays in HPPH supply. However, given the observed serious adverse event, it is recommended that the light dose does not exceed 125 J/cm2.

CONCLUSIONS

PDT with HPPH can be safely used for the treatment of CIS/MIC of the airways, with potential effectiveness comparable to that reported for porfimer sodium in earlier studies.

Endobronchial ultrasound-guided transbronchial needle aspiration of pulmonary artery tumors: A systematic review (with video)

Convex probe endobronchial ultrasound (CP-EBUS) was originally introduced as a diagnostic and staging tool for lung cancer and subsequently utilized for diagnosis of other malignant and benign mediastinal diseases such as melanoma, lymphoma, and sarcoidosis. More recently, CP-EBUS has been successfully used for the visualization and diagnosis of pulmonary emboli and other vascular lesions including primary and metastatic pulmonary artery (PA) tumors. In this review, we will underline the role of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of pulmonary arterial tumors such as sarcomas and tumor emboli. We will concisely discuss the clinical applications of EBUS-TBNA and the types of pulmonary arterial tumors and their different diagnostic modalities. We searched the Cochrane Library and PubMed from 2004 to 2014 to provide the most comprehensive review. Only 10 cases of EBUS-TBNA for intravascular lesions were identified in the literature. Although many cases of EBUS and EUS-guided transvascular tumor biopsies were described in the literature, there were no reported cases of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for intravascular tumor biopsies. Except for one paper, all cases were published as case reports.

Optical sideband generation up to room temperature with mid-infrared quantum cascade lasers

Mid-infrared (MIR) sideband generation on a near infrared (NIR) optical carrier is demonstrated within a quantum cascade laser (QCL). By employing an externally injected NIR beam, E(NIR), that is resonant with the interband transitions of the quantum wells in the QCL, the nonlinear susceptibility is enhanced, leading to both frequency mixing and sideband generation. A GaAs-based MIR QCL (E(QCL) = 135 meV) with an aluminum-reinforced waveguide was utilized to overlap the NIR and MIR modes with the optical nonlinearity of the active region. The resulting difference sideband (E(NIR) - E(QCL)) shows a resonant behavior as a function of NIR pump wavelength and a maximum second order nonlinear susceptibility, χ((2)), of ~1 nm/V was obtained. Further, the sideband intensity showed little dependence with the operating temperature of the QCL, allowing sideband generation to be realized at room temperature.

20 THz broadband generation using semi-insulating GaAs interdigitated photoconductive antennas

We demonstrate broadband (20 THz), high electric field, terahertz generation using large area interdigitated antennas fabricated on semi-insulating GaAs. The bandwidth is characterized as a function of incident pulse duration (15-35 fs) and pump energy (2-30 nJ). Broadband spectroscopy of PTFE is shown. Numerical Drude-Lorentz simulations of the generated THz pulses are performed as a function of the excitation pulse duration, showing good agreement with the experimental data.

Metformin and Not Diabetes Influences the Survival of Resected Early Stage NSCLC Patients

BACKGROUND

Published data suggest that diabetes influences survival of patients with lung cancer. The anti-cancer effect of metformin confounds this association. We sought to study the association of diabetes and metformin with survival in patients undergoing resection of stage I non-small cell lung cancer (NSCLC).

METHODS

Pathologic stage I NSCLC patients undergoing anatomic resection from 2002 to 2011 were studied. A diagnosis of diabetes and diabetic medication use were identified through records. Univariate and multivariate analyses examined the association of diabetes and metformin usage with overall survival (OS).

RESULTS

409 eligible patients were included in the analysis - excluding patients with neoadjuvant therapy, more than one lung cancer, or resection less than lobectomy. 71 (17.4%) patients were diabetics and 41 (10.0%) used metformin. With a median follow up of 44 months, univariate analysis demonstrates that diabetes had no effect on OS (P=0.75); however, metformin use was associated with improved OS (median survival not reached vs. 60 months; P=0.02). Metformin use remained an important predictor of good survival in multivariate analysis (HR=3.08; P<0.01) after adjusting for age, gender, pathologic stage, histology and smoking status.

CONCLUSION

Metformin use rather than diabetes is associated with improved long-term survival in Stage I NSCLC patients.

Lung cancer screening update

Lung cancer is the leading cause of cancer-related mortality globally and the American cancer society estimates approximately 226,160 new cases and 160,340 deaths from lung cancer in the USA in the year 2012. The majority of lung cancers are diagnosed in the later stages which impacts the overall survival. The 5-year survival rate for pathological st age IA lung cancer is 73% but drops to only 13% for stage IV. Thus, early detection through screening and prevention are the keys to reduce the global burden of lung cancer. This article discusses the current state of lung cancer screening, including the results of the National Lung Cancer Screening Trial, the consideration of implementing computed tomography screening, and a brief overview of the role of bronchoscopy in early detection and potential biomarkers that may aid in the early diagnosis of lung cancer.

Advances in bronchoscopy for lung cancer

Bronchoscopic techniques have seen significant advances in the last decade. The development and refinement of different types of endobronchial ultrasound and navigation systems have led to improved diagnostic yield and lung cancer staging capabilities. The complication rate of these minimally invasive procedures is extremely low as compared to traditional transthoracic needle biopsy and surgical sampling. These advances augment the safe array of methods utilized in the work up and management algorithms of lung cancer.

Mode-locking of a terahertz laser by direct phase synchronization

A novel scheme to achieve mode-locking of a multimode laser is demonstrated. Traditional methods to produce ultrashort laser pulses are based on modulating the cavity gain or losses at the cavity roundtrip frequency, favoring the pulsed emission. Here, we rather directly act on the phases of the modes, resulting in constructive interference for the appropriated phase relationship. This was performed on a terahertz quantum cascade laser by multimode injection seeding with an external terahertz pulse, resulting in phase mode-locked terahertz laser pulses of 9 ps duration, characterized unambiguously in the time domain.

Detection of a possible case of pulmonary tumour thromboembolism by endobronchial ultrasound

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Integrated injection seeded terahertz source and amplifier for time-domain spectroscopy

We used a terahertz (THz) quantum cascade laser (QCL) as an integrated injection seeded source and amplifier for THz time-domain spectroscopy. A THz input pulse is generated inside a QCL by illuminating the laser facet with a near-IR pulse from a femtosecond laser and amplified using gain switching. The THz output from the QCL is found to saturate upon increasing the amplitude of the THz input power, which indicates that the QCL is operating in an injection seeded regime.

The "silver-nitrate-oma"

This case report demonstrates and emphasises the unusual radiographic appearance of silver nitrate treatment in a 30-year-old patient, who subsequently underwent excision biopsy of a presumed potentially malignant lesion.

Estrogen inhibits NPY secretion through membrane-associated estrogen receptor (ER)-α in clonal, immortalized hypothalamic neurons

OBJECTIVE

Estrogen (E(2)) has an inhibitory effect on food intake by acting centrally in the hypothalamus, although it is not clear which hypothalamic neurons are involved in this process. Earlier studies from our lab and others have implicated neuropeptide Y (NPY) as an important central anorexigenic target of E(2). This study was designed to investigate whether E(2) can directly regulate NPY secretion and examine the cellular mechanisms and receptors responsible for this anorexigenic action of E(2).

DESIGN

Clonal, murine, hypothalamic neuronal cell models, mHypoE-42 and mHypoA-2/12, were investigated for NPY secretory responses to 17β-estradiol (E(2)) in the presence or absence of pharmacological inhibitors directed against the phosphatidylinositol-3-kinase (PI3K), mitogen-activated protein kinase (MAPK) and AMP-activated kinase (AMPK) pathways or to estrogen receptor (ER) specific agonists/antagonists.

MEASUREMENTS

The presence of hypothalamic markers and characterization of neuronal cell lines was completed with polymerase chain reaction. NPY levels were measured using an enzyme immunoassay (EIA). The expression of ER-α and caveolin-1 was analyzed using immunocytochemistry.

RESULTS

E(2) significantly decreased NPY secretion in both the mHypoE-42 and mHypoA-2/12 neurons. The E(2)-mediated repression of NPY secretion in the mHypoE-42 and mHypoA-2/12 neurons required ER-α, but not ER-β, as shown by studies using an ER-specific agonist/antagonists. Additionally, using immunocytochemistry we detected colocalization of ER-α and the membrane-associated signaling protein caveolin-1. Importantly, using E(2)-conjugated bovine serum albumin (E(2)-BSA) and ER antagonists, we were able to show that the E(2)-mediated decrease in NPY secretion occurred through membrane-bound ER-α. Finally, using a combination of pharmacological inhibitors, we found that inhibition of the PI3K or AMPK pathway blocked the E(2)-mediated decrease in NPY secretion.

CONCLUSION

These findings indicate that the central anorexigenic action of E(2) occurs at least partially through hypothalamic NPY-synthesizing neurons. This regulation of NPY secretion occurs through rapid signaling mechanisms through membrane bound ER-α.

Simulating the influence of vernalization, photoperiod and optimum temperature on wheat developmental rates

BACKGROUND AND AIMS

Accurately representing development is essential for applying crop simulations to investigate the effects of climate, genotypes or crop management. Development in wheat (Triticum aestivum, T. durum) is primarily driven by temperature, but affected by vernalization and photoperiod, and is often simulated by reducing thermal-time accumulation using vernalization or photoperiod factors or limiting accumulation when a lower optimum temperature (T(optl)) is exceeded. In this study T(optl) and methods for representing effects of vernalization and photoperiod on anthesis were examined using a range of planting dates and genotypes.

METHODS

An examination was made of T(optl) values of 15, 20, 25 and 50 degrees C, and either the most limiting or the multiplicative value of the vernalization and photoperiod development rate factors for simulating anthesis. Field data were from replicated trials at Ludhiana, Punjab, India with July through to December planting dates and seven cultivars varying in vernalization response.

KEY RESULTS

Simulations of anthesis were similar for T(optl) values of 20, 25 and 50 degrees C, but a T(optl) of 15 degrees C resulted in a consistent bias towards predicting anthesis late for early planting dates. Results for T(optl) above 15 degrees C may have occurred because mean temperatures rarely exceeded 20 degrees C before anthesis for many planting dates. For cultivars having a strong vernalization response, anthesis was more accurately simulated when vernalization and photoperiod factors were multiplied rather than using the most limiting of the two factors.

CONCLUSIONS

Setting T(optl) to a high value (30 degrees C) and multiplying the vernalization and photoperiod factors resulted in accurately simulating anthesis for a wide range of planting dates and genotypes. However, for environments where average temperatures exceed 20 degrees C for much of the pre-anthesis period, a lower T(optl) (23 degrees C) might be appropriate. These results highlight the value of testing a model over a wide range of environments.

Anatomical study comparing the thickness of the volar and dorsal cortex of cadaveric adult distal radii using digital photography

INTRODUCTION

Dorsally displaced fractures of the distal radius fractures are one of the commonest in day-to-day practice. There is still no consensus among surgeons regarding the suitability of using volar or the dorsal cortex as basis for internal fixation for dorsally displaced fractures.

BACKGROUND

We report an anatomical study, which compares the thickness of the volar and dorsal cortices of cadaveric adult radii using digital photography.

RESULTS

Results of this study show that the volar cortex was statistically, significantly thicker than the dorsal cortex. We believe that the volar cortex may behave as the calcar of the distal radius and hence internal fixation devices applied to the volar cortex may provide a more stable internal fixation compared to those based on the dorsal cortex.

Patellar tendon ruptures in a pair of brothers

The patellar tendon does not easily rupture due to its considerable high tensile strength. Therefore, in normal individuals, ruptures of the patellar tendon are uncommon. We report three episodes of patellar tendon ruptures in two normally fit and healthy brothers; postulating the possibility of inherent weakness. The treatment options for these injuries are discussed.

Palmar cortical angle of the distal radius: a radiological study

Fifty lateral radiographs of normal wrists were viewed to determine the palmar cortical angle of the distal radius. The palmar cortical angle is different to its previously described palmar tilt or angulation. The mean value for the palmar cortical angle was 37 degrees (range, 26-50 degrees). This may be clinically important in the design of palmar plates for the distal radius.

Transitional cell carcinoma manifesting as acute cor pulmonale: cause of microscopic tumor embolism

Acute cor pulmonale is an uncommon manifestation of microscopic pulmonary tumor embolism. We describe the case of an 84-year-old man with a history of transitional cell carcinoma (TCC) of the urinary bladder who had acute cor pulmonale and died within a few hours after the onset of dyspnea. Autopsy showed that the right ventricle was dilated without hypertrophy. Microscopic examination of the lung showed that the small arteries, arterioles, and capillaries were filled with micrometastases of TCC. Microscopic pulmonary tumor embolism has rarely been reported with TCC, and to the best of our knowledge, such a fulminant course has not been previously described in the English language.

Lumbosacral plexopathy after dual kidney transplantation

A 58-year-old man underwent dual kidney transplantation. He was unable to move his right leg after surgery. This was caused by extensive lumbosacral plexopathy on the side of surgery. Lumbosacral plexopathy after kidney transplantation is uncommon, because the plexus has rich anastomotic blood supply, and ischemic injury is unlikely. However, isolated femoral neuropathy after renal transplantation has been reported, as the distal portion of this nerve is supplied by branches of internal iliac artery only and is more prone to ischemic injury during surgery. Dual-kidney transplantation involves a larger dissection, and the procedure takes 60 to 90 minutes longer than single-kidney transplantation. It involves more vascular reconstruction. This may predispose the lumbosacral plexus to ischemic injury. To the best of our knowledge, this is the first reported case of lumbosacral plexopathy after a dual kidney transplantation, and this may be seen more frequently because this procedure is becoming more common.

Pneumococcal bacteremia associated with an infected central venous catheter

Pneumococcus (Streptococcus pneumoniae) bacteremia is a serious infection. Pneumococcus has never been implicated as a cause of a central venous catheter-related bacteremia. It has been isolated from the catheter tip only twice before, and in one case caused the infection of an infusion port device. We report case of a 41-year-old woman who developed pneumococcal bacteremia after 6 days of an indwelling central venous catheter. The catheter tip grew > 300 cfu of S pneumoniae by the roll-plate method described by Maki and colleagues. No other focus of infection could be found in this patient. To the best of our knowledge, this is the first reported case of pneumococcal bacteremia associated with an infected central venous catheter.

Lady Windermere syndrome: middle lobe bronchiectasis and Mycobacterium avium complex infection due to voluntary cough suppression

An 81-year-old woman who presented with middle lobe bronchiectasis and Mycobacterium avium complex infection is described. She had a history of habitual suppression of cough, as in Lady Windermere syndrome. She was thin and had mild kyphoscoliosis but had no history of smoking or connective tissue disease. The middle lobe and lingula are predisposed to chronic inflammation because of their particular anatomic structures. Inability to clear the secretions from the airway due to voluntary cough suppression may predispose to bronchiectasis and M. avium complex infection.