Diagnoses and treatments for participants with interstitial lung abnormalities detected in the Yorkshire Lung Screening Trial

INTRODUCTION

Interstitial lung abnormalities (ILA) are relatively common incidental findings in participants undergoing low-dose CT screening for lung cancer. Some ILA are transient and inconsequential, but others represent interstitial lung disease (ILD). Lung cancer screening therefore offers the opportunity of earlier diagnosis and treatment of ILD for some screening participants.

METHODS

The prevalence of ILA in participants in the baseline screening round of the Yorkshire Lung Screening Trial is reported, along with the proportion referred to a regional ILD service, eventual diagnoses, outcomes and treatments.

RESULTS

Of 6650 participants undergoing screening, ILA were reported in 169 (2.5%) participants. Following review in a screening review meeting, 56 participants were referred to the ILD service for further evaluation (0.8% of all screening participants). 2 participants declined referral, 1 is currently awaiting review and the remaining 53 were confirmed as having ILD. Eventual diagnoses were idiopathic pulmonary fibrosis (n=14), respiratory bronchiolitis ILD (n=4), chronic hypersensitivity pneumonitis (n=2), connective tissue disease/rheumatoid arthritis-related ILD (n=4), asbestosis (n=1), idiopathic non-specific interstitial pneumonia (n=1), sarcoidosis (n=1) and pleuroparenchymal fibroelastosis (n=1). Twenty five patients had unclassifiable idiopathic interstitial pneumonia. Overall, 10 people received pharmacotherapy (7 antifibrotics and 3 prednisolone) representing 18% of those referred to the ILD service and 0.15% of those undergoing screening. 32 people remain under surveillance in the ILD service, some of whom may require treatment in future.

DISCUSSION

Lung cancer screening detects clinically significant cases of ILD allowing early commencement of disease-modifying treatment in a proportion of participants. This is the largest screening cohort to report eventual diagnoses and treatments and provides an estimate of the level of clinical activity to be expected by ILD services as lung cancer screening is implemented. Further research is needed to clarify the optimal management of screen-detected ILD.

TRIAL REGISTRATION NUMBER

ISRCTN42704678.

Measuring spirometry in a lung cancer screening cohort highlights possible underdiagnosis and misdiagnosis of COPD

Introduction

COPD is underdiagnosed, and measurement of spirometry alongside low-dose computed tomography (LDCT) screening for lung cancer is one strategy to increase earlier diagnosis of this disease.

Methods

Ever-smokers at high risk of lung cancer were invited to the Yorkshire Lung Screening Trial for a lung health check (LHC) comprising LDCT screening, pre-bronchodilator spirometry and a smoking cessation service. In this cross-sectional study we present data on participant demographics, respiratory symptoms, lung function, emphysema on imaging and both self-reported and primary care diagnoses of COPD. Multivariable logistic regression analysis identified factors associated with possible underdiagnosis and misdiagnosis of COPD in this population, with airflow obstruction defined as forced expiratory volume in 1 s/forced vital capacity ratio <0.70.

Results

Out of 3920 LHC attendees undergoing spirometry, 17% had undiagnosed airflow obstruction with respiratory symptoms, representing potentially undiagnosed COPD. Compared to those with a primary care COPD code, this population had milder symptoms, better lung function and were more likely to be current smokers (p≤0.001 for all comparisons). Out of 836 attendees with a primary care COPD code who underwent spirometry, 19% did not have airflow obstruction, potentially representing misdiagnosed COPD, although symptom burden was high.

Discussion

Spirometry offered alongside LDCT screening can potentially identify cases of undiagnosed and misdiagnosed COPD. Future research should assess the downstream impact of these findings to determine whether any meaningful changes to treatment and outcomes occur, and to assess the impact on co-delivering spirometry on other parameters of LDCT screening performance such as participation and adherence. Additionally, work is needed to better understand the aetiology of respiratory symptoms in those with misdiagnosed COPD, to ensure that this highly symptomatic group receive evidence-based interventions.

Participation in community-based lung cancer screening: the Yorkshire Lung Screening Trial

BACKGROUND

Screening with low-dose computed tomography (LDCT) reduces lung cancer mortality; however, the most effective strategy for optimising participation is unknown. Here we present data from the Yorkshire Lung Screening Trial, including response to invitation, screening eligibility and uptake of community-based LDCT screening.

METHODS

Individuals aged 55-80 years, identified from primary care records as having ever smoked, were randomised prior to consent to invitation to telephone lung cancer risk assessment or usual care. The invitation strategy included general practitioner endorsement, pre-invitation and two reminder invitations. After telephone triage, those at higher risk were invited to a Lung Health Check (LHC) with immediate access to a mobile CT scanner.

RESULTS

Of 44 943 individuals invited, 50.8% (n=22 815) responded and underwent telephone-based risk assessment (16.7% and 7.3% following first and second reminders, respectively). A lower response rate was associated with current smoking status (adjusted OR 0.44, 95% CI 0.42-0.46) and socioeconomic deprivation (adjusted OR 0.58, 95% CI 0.54-0.62 for the most versus the least deprived quintile). Of those responding, 34.4% (n=7853) were potentially eligible for screening and offered a LHC, of whom 86.8% (n=6819) attended. Lower uptake was associated with current smoking status (adjusted OR 0.73, 95% CI 0.62-0.87) and socioeconomic deprivation (adjusted OR 0.78, 95% CI 0.62-0.98). In total, 6650 individuals had a baseline LDCT scan, representing 99.7% of eligible LHC attendees.

CONCLUSIONS

Telephone risk assessment followed by a community-based LHC is an effective strategy for lung cancer screening implementation. However, lower participation associated with current smoking status and socioeconomic deprivation underlines the importance of research to ensure equitable access to screening.

Pleural irrigation trial (PIT): a randomised controlled trial of pleural irrigation with normal saline versus standard care in patients with pleural infection

Pleural infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the pleural space with saline may be beneficial.A randomised controlled pilot study in which saline pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with pleural infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events.35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6-43.7%) reduction versus 15.3% (-5.5-28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23-41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented.Saline irrigation improves pleural fluid drainage and reduces referrals for surgery in pleural infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.

The effect of chemotherapy on health-related quality of life in mesothelioma: results from the SWAMP trial

Background:

The effect of chemotherapy on health-related quality of life (HRQoL) in malignant pleural mesothelioma (MPM) is poorly understood. Patient-individualised prognostication and prediction of treatment response from chemotherapy is useful but little evidence exists to guide practice.

Method:

Consecutive patients with MPM who were fit for first-line chemotherapy with pemetrexed and cisplatin\carboplatin were recruited and followed up for a minimum of 12 months. This study focussed on the HRQoL outcomes of these patients using the EQ-5D, EORTC QLQ-C30 and LC13.

Results:

Seventy-three patients were recruited of which 58 received chemotherapy and 15 opted for best supportive care (BSC). Compliance with HRQoL questionnaires was 98% at baseline. The chemotherapy group maintained HRQoL compared with the BSC group whose overall HRQoL fell (P=0.006) with worsening dyspnoea and pain. The impact of chemotherapy was irrespective of histological subtype although those with non-epithelioid disease had worse HRQoL at later time points (P=0.012). Additionally, those with a falling mesothelin or improvement on modified-RECIST CT at early follow-up had a better HRQoL at 16 weeks.

Conclusions:

HRQoL was maintained following chemotherapy compared with a self-selected BSC group. Once chemotherapy is initiated, a falling mesothelin or improved RECIST CT findings infer a quality-of-life advantage.

Lung-resident CD4⁺ T cells are sufficient for IL-4Rα-dependent recall immunity to Nippostrongylus brasiliensis infection

Immunity to Nippostrongylus brasiliensis reinfection requires pulmonary CD4⁺ T-cell responses. We examined whether secondary lymphoid recruited or pre-existing lung CD4⁺ T-cell populations coordinated this immunity. To do this, we blocked T-cell egress from lymph nodes using Fingolimod (FTY720). This impaired host ability to resolve a primary infection but did not change effectiveness of recall immunity. Associated with this effective recall immunity was the expansion and T helper type 2 polarization of a pre-existing pulmonary CD4⁺ T-cell population. LTβR-Ig (lymphotoxin beta-receptor fusion protein)-mediated disruption of stromal cell organization of immune cells did not disrupt this recall immunity, suggesting that protection was mediated by a pulmonary interstitial residing CD4⁺ T-cell population. Adoptive transfer of N. brasiliensis-experienced pulmonary CD4⁺ T cells from FTY720-treated wild-type or T-cell interleukin (IL)-4Rα-deficient mice demonstrated protection to be IL-4Rα dependent. These results show that pre-existing CD4⁺ T cells can drive effective recall immunity to N. brasiliensis infection independently of T-cell recruitment from secondary lymphoid organs.

Thoracic complications of rheumatoid disease

Rheumatoid arthritis is a relatively common multisystem disease associated with significant mortality and morbidity. Thoracic disease, both pleural and pulmonary, is a frequent extra-articular manifestation of rheumatoid arthritis and responsible for approximately 20% of rheumatoid-associated mortality. Rheumatoid disease and its associated therapies can affect all compartments of the lung inciting a range of stereotyped pathological responses and it is not infrequent for multiple disease entities to co-exist. In some instances, development of pulmonary complications may precede typical rheumatological presentation of the disease and be the first indication of an underlying connective tissue disease. The spectrum of thoracic disease related to rheumatoid arthritis is reviewed.

Understanding Muslim patients: cross-cultural dental hygiene care

BACKGROUND

Healthcare providers who understand the basic pillars of Islamic beliefs and common religious practices can apply these concepts, anticipate the needs of the Muslim patient and family, and attract Muslim patients to the practice.

OBJECTIVE

Cross cultural knowledge can motivate dental hygienists to adopt culturally acceptable behaviors, strengthen patient-provider relationships and optimize therapeutic outcomes. Trends in Muslim population growth, Islamic history and beliefs, modesty practices, healthcare beliefs, contraception, childbearing, childrearing, pilgrimage, dietary practices, dental care considerations and communication are explained.

MATERIALS AND METHODS

This paper reviews traditional Muslim beliefs and practices regarding lifestyle, customs, healthcare and religion as derived from the literature and study abroad experiences.

RESULTS AND DISCUSSION

Recommendations are offered on how to blend western healthcare with Islamic practices when making introductions, appointments, eye contact, and selecting a practitioner. The significance of fasting and how dental hygiene care can invalidate the fast are also discussed.

CONCLUSION

The ultimate goal is for practitioners to be culturally competent in providing care to Muslim patients, while keeping in mind that beliefs and practices can vary widely within a culture.

CT appearances of congential and acquired abnormalities of the superior vena cava

A wide spectrum of congenital and acquired abnormalities can affect the superior vena cava (SVC). Congenital anomalies can present either as incidental findings or be associated with underlying cardiac abnormalities; these include left-sided or double SVCs and anomalous venous drainages. Acquired conditions involving the SVC, including SVC obstruction syndrome, can be secondary to extrinsic compression or intrinsic occlusion. The CT appearances, the incidence, and associations of these conditions are discussed.

A laboratory study to determine the effects of universal and rotating ultrasonic inserts on wrist movement and scaling time efficiency of dental hygienists

PURPOSE

The purpose of this study was to determine if differences existed in range of wrist movements and scaling time efficiency of dental hygienists using a rotating ultrasonic insert when compared with a standard universal insert.

METHODS

A convenience sample of 32 consenting experienced dental hygienists who met inclusion criteria was invited to participate. Using a cross-over research design, the 32 participants were randomly assigned to one of the two subgroups. Subgroup A (n = 16) used the rotating universal ultrasonic insert on a typodont, rested for 15 min and the standard universal insert on a different typodont. Subgroup B (n = 16) used the standard universal ultrasonic insert on a typodont, rested for 15 min and the rotating universal ultrasonic insert on a different typodont. Each participant used the rotating and standard universal ultrasonic scaling inserts to remove 2 cm3 artificial calculus from two different typodonts for up to 15 min per insert. Scaling time efficiency was determined using a Modified Volpe-Manhold Calculus Index, measuring the amount of artificial calculus remaining after ultrasonic scaling. While scaling, each participant wore the WristSensor goniometry gloves, which determined changes in wrist movements (flexion and extension and ulnar and radial deviations), measured as a deviation from the neutral position.

RESULTS

A paired t-test (P = 0.05) using 30 subjects with useable data, revealed no statistically significant differences between the two different inserts in terms of wrist movements and scaling time efficiency. A multivariate analysis of variance revealed no statistically significant differences in the percentage of time dental hygienists were in high, medium or low-risk posture categories while using the rotating ultrasonic insert compared with the standard universal insert. Based on the results of this laboratory study, dental hygienists using a rotating ultrasonic insert appear to experience no ergonomic advantage in terms of wrist postures or timesavings over a standard insert.

Cerebral infarction following thrombolysis for massive pulmonary embolism

A 29-year-old male developed a fatal stroke 6 h after successful thrombolysis for massive pulmonary embolism. Autopsy showed thrombus protruding through a patent foramen ovale (PFO). A strand of thrombus extended from the aortic arch into the left common carotid artery. The brain showed extensive infarction of the left fronto-parietal area. Thrombolysis caused initial disintegration of the embolism. It is likely that thrombolysis caused fragments of clot to later break lose and embolise into the cerebral circulation. We discuss the need for risk stratification in patients who present with massive pulmonary embolism and PFO.

Treatment of chronic anal fissure by application of L-arginine gel: a phase II study in 15 patients

PURPOSE

Local application of exogenous nitric oxide donors, such as isosorbide dinitrate and glyceryl trinitrate, promotes fissure healing by reducing anal resting pressure and improving anodermal blood flow. The major drawback of these nitric oxide donors is headache. The overall incidence of this side effect is approximately 40 percent. Recently we have shown in healthy volunteers that L-arginine, being an intrinsic precursor of nitric oxide, reduces anal resting pressure without headache as a side effect. The aim of the present study was to evaluate the effect of L-arginine on anal resting pressure, anodermal blood flow, and fissure healing in patients with chronic anal fissure.

METHODS

Fifteen patients with a chronic anal fissure were included in the present study. Before entering the study 10 patients were unsuccessfully treated by local application of isosorbide dinitrate. Six of these patients experienced severe headache during treatment with isosorbide dinitrate. All patients were treated for at least 12 weeks by local application of a gel containing L-arginine 400 mg/ml five times a day. In patients with a persistent fissure, treatment was continued until 18 weeks. Anal manometry and laser Doppler flowmetry of the anoderm were performed before treatment, 20 minutes after local application of the first dose, and after 12 weeks of treatment. A visual analog scale was used to assess fissure-related pain and headache.

RESULTS

One patient dropped out after one day of treatment, and one was excluded because of violation of the study protocol. After 12 weeks of treatment complete fissure healing was observed in 3 of 13 (23 percent) patients, and after 18 weeks the healing rate was 8 of 13 (62 percent) patients. None of the 13 patients experienced typical nitric oxide-induced headache. The pressure recordings showed a significant reduction of maximum anal resting pressure (mean +/- SD): pretreatment 89 +/- 17 mmHg; 20 minutes after application of the first dose 67 +/- 17 mmHg; 12 weeks after treatment 74 +/- 14 mmHg (P < 0.005). Recordings of anodermal blood flow showed a significant increase in flow: pretreatment 0.36 +/- 0.25 volts; 20 minutes after application of the first dose 0.59 +/- 0.27; 12 weeks after treatment 0.64 +/- 0.33 (P < 0.005).

CONCLUSIONS

Local application of L-arginine promotes fissure healing without headache as a side effect, and L-arginine is effective even in patients not responding to isosorbide dinitrate treatment.

Long-term follow-up of retrograde colonic irrigation for defaecation disturbances

OBJECTIVE

Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long-term feasibility and outcome of RCI.

METHODS

Between 1989 and 2001, a consecutive series of 267 patients was offered RCI. All patients received instructions about RCI by one of our enterostomal therapists. Twenty-eight patients were lost to follow-up. A detailed questionnaire was sent by mail to 239 patients. The total response rate was 79% (190 patients). Based on the returned questionnaires it became clear that 21 (11%) patients never started RCI. The long-term feasibility and outcome of RCI was therefore assessed in the remaining group of 169 patients. Thirty-two patients were admitted with soiling, 71 patients with faecal incontinence, 37 patients with obstructed defaecation and 29 had defaecation disturbances after low anterior resection or pouch surgery.

RESULTS

According to the returned questionnaires, RCI was considered effective by 91 (54%) patients. Among patients with soiling and faecal incontinence, RCI was found to be effective in, respectively, 47 and 41% of the subjects. Despite of the reported effectiveness, 10 (67%) patients with soiling and 5 (17%) patients with faecal incontinence decided to stop. Among patients with obstructed defaecation and those with defaecation disturbances after low anterior resection or pouch surgery the effectiveness of RCI was found to be 65 and 79%, respectively. None of these patients ceased their therapy. The overall success-rate of long-term RCI was therefore 45%.

CONCLUSIONS

Long-term RCI is beneficial for 45% of patients with defaecation disturbances. In the group of patients who considered RCI effective and beneficial, discontinuation of therapy was only observed among those with soiling and faecal incontinence.

Diagnostically Significant Variations in Pleural Fluid pH in Loculated Parapneumonic Effusions

STUDY OBJECTIVES

Parapneumonic effusions are common, and measurement of pleural pH is one of the most useful measurements in assessing the need for tube drainage. Use of pleural pH assumes that a single measurement conveys a representative picture of pH throughout the effusion. Often effusions are multiloculated, and varying concentrations of nondiffusible acids such as lactic acid, if present in different concentrations, could mean clinically significant variations in pH between locules. If these differences were large, a single pH measurement could misrepresent the "stage" that the parapneumonic effusion had reached. We therefore set out to test the hypothesis that pH varies significantly between locules in complicated parapneumonic effusions.

DESIGN

The study was performed in seven consecutive patients presenting to our institution with complicated parapneumonic effusions.

INTERVENTIONS

In each case, pleural pH was measured in several separate pleural fluid locules, using ultrasound-guided pleural fluid sampling.

RESULTS

Significant variations were found in pleural fluid visual appearance, pH, and lactate dehydrogenase between locules in four of seven patients. Three of seven patients had variations, resulting in pH levels both above and below 7.2, which is the threshold used in our institution to indicate the need for tube drainage.

CONCLUSIONS

This is the first reported series of variation in pleural pH between different locules in complicated parapneumonic effusions. These variations are clinically important and cast light on the mechanisms responsible for the acidosis seen in infected effusions. Physicians should be aware of this when making drainage decisions in these patients using the clinical picture and a single pH result alone.

Can we successfully maintain risk patients?

The most fundamental premise in the current view of periodontal disease is that not all individuals are at equal risk for disease and disease progression. Studies reveal that about 5-20% of the population is at risk for severe disease progression. The purpose of this paper is to define at-risk patients, review risk factors and indicators of disease progression, and outline an evidence-based strategy that includes both self-care and professional care for maintaining periodontal health. Risk factors/risk indicators considered include history of previous disease, increased pocket depth and loss of clinical attachment, frequency of dental care, specific bacterial pathogens, and systemic/environmental host factors such as smoking, diabetes mellitus, genetics, and stress. Because host factors may have more influence on disease progression than periodontal pathogens, personal and professional maintenance care must include the role of the host in periodontal disease progression. By examining the evidence surrounding these complex issues, dentists and dental hygienists are able to determine the extent to which evidence supports available approaches to maintain periodontal health and control disease progression.

[Sacral neuromodulation is effective in the treatment of fecal incontinence with intact sphincter muscles; a prospective study]

OBJECTIVE

To evaluate the therapeutic effect of sacral neuromodulation on faecal incontinence in patients with structurally intact sphincters.

DESIGN

Prospective.

METHOD

In the period April 1st, 2000 to November 30th, 2001, patients with faecal incontinence and structurally intact sphincters were included, with or without previous surgery, in whom medicinal treatment and biofeedback therapy gave no improvement. Incontinence was defined as involuntary loss of stool at least once a week, which was objectified by completion of a 3-week bowel habit diary. Patients underwent 3 weeks of trial stimulation during which they also kept a diary. The trial stimulation was considered successful if the diary showed a > or = 50% improvement in continence.

RESULTS

38 patients (31 women) with an average age of 54 years (range: 26-73) underwent trial stimulation. Trail stimulation was carried out using a permanent electrode in 6 patients and using peripheral neural evaluation in the remaining 32 patients. Two patients did not respond to peripheral neural evaluation. Upon assessment after the trial stimulation period. continence was found to have improved by > or = 50% in 31 (82%) patients. The number of incontinence episodes decreased by an average of 86% (range: 50-100). In 27 patients an implantable pulse generator was implanted for continuous stimulation. During the average follow-up of 6 months the effect remained satisfactory. Anal manometry during stimulation showed no increase of sphincter pressures.

CONCLUSION

Sacral neuromodulation was of therapeutic value in most of the patients treated for faecal incontinence without sphincter damage.

Sexual harassment in dentistry: experiences of Virginia dental hygienists

PURPOSE

The purpose of this study was to determine if dental hygienists in the Commonwealth of Virginia experienced sexual harassment while employed in oral health care settings. Other interests were to determine if dental hygienists experienced sexual harassment, to what extent they felt professionally prepared to respond to unwanted sexual behaviors; did they perceive sexual harassment as a problem in the oral health care environment; and was attrition from their employment associated with sexual harassment.

METHODS

A questionnaire, Sexual Harassment in the Dental Hygiene Profession, designed by the author, was used in this research. A list of currently licensed and registered dental hygienists was obtained from the Virginia Board of Dental Examiners and the questionnaire was sent to 540 randomly selected registered Virginia dental hygienists. Two weeks after the initial mailing, a second questionnaire was sent to non-respondents. The survey elicited data on experience, management, and personal opinions relative to sexual harassment, as well as demographic information. Results were analyzed using frequencies, percentages, and the chi-square test of association.

RESULTS

Two hundred eighty-five surveys (53%) were returned and useable. Findings revealed that 54% of the responding dental hygienists experienced sexual harassment. Of these, 50% experienced sexual harassment four or more years ago, 23% one to three years ago and 28% within the last year; these categories were mutually exclusive. The perpetrators of the harassment were reported to be either male dentists (73%) or male clients (45%). Less than 10% reported being harassed by women. While 70% of the sexually harassed respondents indicated that filing formal complaints was an effective strategy for managing sexual harassment, less than 1% actually did so. Of all dental hygienists (harassed or not), 90% did not receive training in their dental education to manage sexual harassment, and 85% would like the American Dental Hygienists' Association to develop model guidelines and policies. Demographic characteristics were typical of practicing dental hygienists in Virginia; 99% female, 96% Caucasian, and 86% married with a mean age of 40 years.

CONCLUSION

Information about managing sexual harassment needs to be incorporated into the dental hygiene curricula. This curriculum addition should include information on identifying sexual harassment incidents, strategies for controlling unacceptable behavior, the legal rights of employees, and the process of filing a formal complaint. Dental hygienists need to identify sexual harassment behaviors and receive prevention training though continuing education courses. Furthermore, the American Dental Hygienists Association and the American Dental Association need to collaboratively develop guidelines and policies for dentists and dental hygienists regarding the management of sexual harassment in the oral health care setting.

Pediatric renal transplantation in the Netherlands

In the Netherlands, pediatric kidney transplantation programs are available in four centers. We retrospectively analyzed the results obtained over the past decade. Between 1985 and 1995, 231 patients (139 boys) received 269 transplants, including 61 repeat. The recipients were aged 1.9-21.8 yrs (mean 10.9), the donors 0.3-63.3 yrs (median 11.4, mean 19.7). Immunosuppression consisted of corticosteroids, cyclosporin A and azathioprine, in various combinations and dosages. The patient survival during follow-up was 97%. The overall graft survival was 73% at 1 yr and 60% at 5 yrs after transplantation. Major causes of graft loss were acute rejection (21%), thrombosis (12%) and chronic rejection (28%). Acute rejection episodes were noted in 74% of all grafts. First acute rejection episodes had a moderate predictive value for graft loss (relative risk (RR), compared to rejection-free grafts, 5.9). First rejection episodes occurring later than 3 months after transplantation were considerably more predictive (RR 18.3) than early ones. Grafts from living related donors (n = 35) yielded a superior 5-yr graft survival (77%) and remained free of rejection more often than grafts from adult cadaveric donors(43% vs. 25%). The results of pre-emptive transplants were excellent (n = 13, 5-yr survival 100%). Repeat transplants had the same results as primary transplants. Recipients younger than 4 yrs showed a poor 5-yr graft survival of 38% (n = 13). Single kidney grafts from donors younger than 4 yrs (n = 35) had a 5-yr graft survival of 44%. In contrast, kidneys from these young donors did well if transplanted en bloc (n = 10, 5-yr graft survival 89%). These overall results are in line with those of others. The results may be improved by expansion of immunosuppressive therapy in the first year and by thrombosis prophylaxis in high-risk patient-donor combinations. Better results may be expected from more extensive use of living related donations, pre-emptive transplantation and en bloc transplantation instead of single kidneys of young donors.

Comparison of 2D conventional, 3D conformal, and intensity-modulated treatment planning techniques for patients with prostate cancer with regard to target-dose homogeneity and dose to critical, uninvolved structures

The purpose of this study was to compare 2-dimensional (2D), 3-dimensional (3D) and intensity-modulated radiation therapy (IMRT) techniques for external-beam radiation treatment for prostate cancer. Dose homogeneity within the target volume and doses to critical, uninvolved anatomic structures were evaluated. Computed tomography (CT) scans of 3 patients with localized prostate cancer (T2NOM0) were acquired and transferred to the treatment planning systems. The target volume and uninvolved structures were contoured on axial CT slices throughout the volume of interest. A comparison of the 3 treatment techniques was performed using isodose distributions, dose statistics, and dose-volume histograms. Dose homogeneity was found to be most uniform with the 2D technique; however, the 2D technique delivers unnecessary radiation doses to the rectum and bladder. The dose conformity observed with IMRT is increased compared with that observed with the 3D technique, as is the sparing of critical uninvolved structures; however, dose homogeneity appears to be worse with IMRT than with the 3D technique. Overall, of the 3 techniques, IMRT offers the most conformity in delivery of tumoricidal doses to the prostate while sparing dose to critical, uninvolved structures. Association of Medical Dosimetrists.

Coordinating care in an integrated delivery system

To keep patients from falling through the cracks, each point of service in a healthcare system must understand its role in the patient's overall care and have access to the right information at the right time. Communication and a system's organization play significant roles in making coordinated care work: Some health systems prefer to keep patients with common diagnoses in service lines that take them from preadmission to home care; others set up separate organizational entities to coordinate care for all patients with chronic illness. Regular meetings on patient status, standardized forms and clear job descriptions all help minimize confusion.

Optimal staffing for hospitals: in search of solutions

The best staffing models are those that give nurses and other caregivers control and flexibility in their work, say administrators who are fighting higher acuity, tighter budgets and shorter patient stays as well as the threat of staff burnout. Specialty float pools, well-trained students and carefully defined job charters all can ease the strain, staffing experts say.

Making the most of data for disease management

Managed care organizations have a wealth of administrative, claims and clinical data available to them--data that could pinpoint patients who could benefit from cost-effective disease management programs. Health plans that have such efforts offer advice on how to home in on the best data.

Health care quality: from data to accountability

The many audiences for information about the quality of health care have different and sometimes conflicting interests and priorities. This is reflected in the diversity of current efforts to use health care data to identify, measure, and demonstrate quality. The author surveys three of these approaches in depth: (1) the professional approach, which relies on the actions of private-sector accreditation groups, trade associations and health plans, hospitals, and other providers to assure quality; (2) the market-driven approach, which relies on the use of quality data by health care purchasers and consumers in choosing plans and providers; and (3) the public-sector approach, which relies on the regulatory, oversight, and purchasing actions of government at the federal, state, and local levels to assure quality. The author concludes that efforts to measure and report the quality of health care invariably confront a variety of technical and political issues. Several observers maintain that it is more important for participants in quality issues to reach consensus on the issues than to reach technical perfection in the way the data are handled. Important obstacles in the technical realm include inadequate investment in sufficiently sophisticated and compatible information systems and the fact that where such systems are in place, they generally cannot be linked. But efforts, both technical and legal, are under way to overcome these obstacles. Even so, some of the issues of health care quality will remain moving targets because of constant changes in the health care environment and in technology. The author closes with the hope that the various actors within the health care industry may coordinate their efforts in dealing with these issues.

Use of thermoluminescent dosimetry to verify dose compensation in total body irradiation

For Total Body Irradiation (TBI) the midline dose along the long axis of the body should vary by no more than +/- 10% compared to the dose received at the prescription point. Compensating filters are often made to compensate for contour irregularities. This paper describes an experimental method using Thermoluminescent Dosimetry (TLD) to verify the appropriateness of dose compensation provided by compensating filters. An AP/PA treatment geometry was used with an 18 MV photon beam. TLDs were placed in the midplane and on the surface of an anthropomorphic phantom in five different areas. Three different lead compensating filters were designed to provide proper compensation, overcompensation, and undercompensation. The TLD readings were compared with calculated doses and the measurements correlated favorably. The measurements were sensitive enough to detect dose variations due to improper compensation. These results demonstrate that TLD is a reliable method of verifying dose compensation provided by compensating filters in TBI.

Health status assessment--a vital sign for planning patient therapy

To better understand patient problems, some physicians are gathering and evaluating data on patients' perceptions of their health and emotional strengths. The tool--the SF-36 or Health Status Questionnaire--can be incorporated into practice with a small investment in technology and a few minutes with the patient.

Taking a critical look at technology: smarter purchasers make smarter users

That new technology being lauded in today's medical journals may not be just what the doctor ordered for your healthcare organization. The decision to use it, the experts say, should rely on a thorough assessment of cost, quality and, especially, patient outcomes.

Healing the home

Domestic violence is one of the biggest threats to the health of women in the U.S. Here's how health plans are preventing, identifying, and treating abuse.

The use of ultrasound for monitoring breast tumour response to pro-adjuvant therapy

In a prospective study, use of serial ultrasound (US) for monitoring tumour response to pro-adjuvant chemotherapy was assessed in 16 patients. Comparison was made with mammographic and pathological tumour size measurements. Clinical and radiological response to treatment was assessed using UICC (International Union Against Cancer) criteria. Comparison of clinical and US response to treatment showed some agreement in 60% and disagreement in 40%. This was comparable with clinical versus mammographic responses (55% and 45%). Correlation between calliper and pathological measurement was similar to that between US and pathological measurement (r = 0.51, P = 0.05; r = 0.50, P < 0.05). Mammography showed poorer correlation (NS). For assessment of final tumour size, US clinical measurements were comparable and better than mammography. US may be a useful tool in monitoring the response of breast tumours to pro-adjuvant therapy.