Survival following lung volume reduction procedures: results from the UK Lung Volume Reduction (UKLVR) registry

INTRODUCTION

Lung volume reduction surgery (LVRS) and endobronchial valve (EBV) placement can produce substantial benefits in appropriately selected people with emphysema. The UK Lung Volume Reduction (UKLVR) registry is a national multicentre observational study set up to support quality standards and assess outcomes from LVR procedures at specialist centres across the UK.

METHODS

Data were analysed for all patients undergoing an LVR procedure (LVRS/EBV) who were recruited into the study at participating centres between January 2017 and June 2022, including; disease severity and risk assessment, compliance with guidelines for selection, procedural complications and survival to February 2023.

RESULTS

Data on 541 patients from 14 participating centres were analysed. Baseline disease severity was similar in patients who had surgery n=244 (44.9%), or EBV placement n=219 (40.9%), for example, forced expiratory volume in 1 s (FEV1) 32.1 (12.1)% vs 31.2 (11.6)%. 89% of cases had discussion at a multidisciplinary meeting recorded. Median (IQR) length of stay postprocedure for LVRS and EBVs was 12 (13) vs 4 (4) days(p=0.01). Increasing age, male gender and lower FEV1%predicted were associated with mortality risk, but survival did not differ between the two procedures, with 50 (10.8%) deaths during follow-up in the LVRS group vs 45 (9.7%) following EBVs (adjusted HR 1.10 (95% CI 0.72 to 1.67) p=0.661) CONCLUSION: Based on data entered in the UKLVR registry, LVRS and EBV procedures for emphysema are being performed in people with similar disease severity and long-term survival is similar in both groups.

Development and implementation of the lung volume reduction pulmonary rehabilitation tool to identify eligibility for lung volume reduction in people with chronic obstructive pulmonary disease during pulmonary rehabilitation

BACKGROUND

Completion of pulmonary rehabilitation is recognised in chronic obstructive pulmonary disease (COPD) guidelines as a key opportunity to consider systematically whether a respiratory review to assess potential suitability for a lung volume reduction (LVR) procedure might be appropriate. We describe the development of a simple decision-support tool (the LVR-PR tool) to aid clinicians working in pulmonary rehabilitation, to operationalise this process.

METHODS

We took an iterative mixed methods approach, which was partnership-based and involved an initial consensus survey, focus groups and an observational study cohort at multiple pulmonary rehabilitation centres.

RESULTS

Diagnosis (97%), exercise capacity (84%), breathlessness (78%) and co-morbidities (76%) were acknowledged to be essential items for assessing basic LVR eligibility. Collating prior investigations and assessing patient understanding were considered useful but not essential. Clinician concerns included; streamlining the tool; access to clinical information and investigations; and care needed around introducing LVR therapies to patients in a PR setting. Access to clearer information about LVR procedures, the clinician's role in considering eligibility and how educational resources should be delivered were identified as important themes from patient group discussions. The LVR-PR tool was considered to be feasible and valid for implementation in a variety of PR services across the UK subject to the provision of appropriate health professional training. Clinicians working in specialist LVR centres across the UK who were not otherwise involved in the development process confirmed the tool's validity using the content validity index (CVI).

INTERPRETATION

The LVR-PR tool appears to be an acceptable tool that can be feasibly implemented in PR services subject to good quality educational resources for both patients and healthcare professionals.

Trajectories of pain over 6 years in early Parkinson's disease: ICICLE-PD

INTRODUCTION

Pain is a common non-motor symptom in Parkinson's disease (PD), affecting up to 85% of patients. The frequency and stability of pain over time has not been extensively studied. There is a paucity of high-quality studies investigating pain management in PD. To develop interventions, an understanding of how pain changes over the disease course is required.

METHODS

One hundred and fifty-four participants with early PD and 99 age-and-sex-matched controls were recruited as part of a longitudinal study (Incidence of Cognitive Impairment in Cohorts with Longitudinal Evaluation in PD, ICICLE-PD). Pain data were collected at 18-month intervals over 72 months in both groups using the Nonmotor Symptom Questionnaire (NMSQ), consisting of a binary yes/no response. Two questions from the Parkinson's Disease Questionnaire (PDQ-39) were analysed for the PD group only.

RESULTS

Unexplained pain was common in the PD group and occurred more frequently than in age-matched controls. 'Aches and pains' occurred more frequently than 'cramps and muscle spasms' at each time point (p < 0.001) except 54 months.

CONCLUSIONS

This study shows that pain is prevalent even in the early stages of PD, yet the frequency and type of pain fluctuates as symptoms progress. People with PD should be asked about their pain at clinical consultations and given support with describing pain given the different ways this can present.

Early constipation predicts faster dementia onset in Parkinson's disease

Constipation is a common but not a universal feature in early PD, suggesting that gut involvement is heterogeneous and may be part of a distinct PD subtype with prognostic implications. We analysed data from the Parkinson's Incidence Cohorts Collaboration, composed of incident community-based cohorts of PD patients assessed longitudinally over 8 years. Constipation was assessed with the MDS-UPDRS constipation item or a comparable categorical scale. Primary PD outcomes of interest were dementia, postural instability and death. PD patients were stratified according to constipation severity at diagnosis: none (n = 313, 67.3%), minor (n = 97, 20.9%) and major (n = 55, 11.8%). Clinical progression to all three outcomes was more rapid in those with more severe constipation at baseline (Kaplan-Meier survival analysis). Cox regression analysis, adjusting for relevant confounders, confirmed a significant relationship between constipation severity and progression to dementia, but not postural instability or death. Early constipation may predict an accelerated progression of neurodegenerative pathology.

Reproducibility of 19 F-MR ventilation imaging in healthy volunteers

Purpose

To assess the reproducibility of percentage ventilated lung volume (%VV) measurements in healthy volunteers acquired by fluorine (¹⁹F)‐MRI of inhaled perfluoropropane, implemented at two research sites.

Methods

In this prospective, ethically approved study, 40 healthy participants were recruited (May 2018‐June 2019) to one of two research sites. Participants underwent a single MRI scan session on a 3T scanner, involving periodic inhalation of a 79% perfluoropropane/21% oxygen gas mixture. Each gas inhalation session lasted about 30 seconds, consisting of three deep breaths of gas followed by a breath‐hold. Four ¹⁹F‐MR ventilation images were acquired per participant, each separated by approximately 6 minutes. The value of %VV was determined by registering separately acquired ¹H images to ventilation images before semi‐automated image segmentation, performed independently by two observers. Reproducibility of %VV measurements was assessed by components of variance, intraclass correlation coefficients, coefficients of variation (CoV), and the Dice similarity coefficient.

Results

The MRI scans were well tolerated throughout, with no adverse events. There was a high degree of consistency in %VV measurements for each participant (CoV_observer1 = 0.43%; CoV_observer2 = 0.63%), with overall precision of %VV measurements determined to be within ± 1.7% (95% confidence interval). Interobserver agreement in %VV measurements revealed a high mean Dice similarity coefficient (SD) of 0.97 (0.02), with only minor discrepancies between observers.

Conclusion

We demonstrate good reproducibility of %VV measurements in a group of healthy participants using ¹⁹F‐MRI of inhaled perfluoropropane. Our methods have been successfully implemented across two different study sites, supporting the feasibility of performing larger multicenter clinical studies.

Prevalence and duration of non-motor symptoms in prodromal Parkinson's disease

Background and purpose

The prevalence and duration of non‐motor symptoms (NMS) in prodromal Parkinson's disease (PD) has not been extensively studied. The aim of this study was to determine the prevalence and duration of prodromal NMS (pNMS) in a cohort of patients with recently diagnosed PD.

Methods

We evaluated the prevalence and duration of pNMS in patients with early PD (n = 154). NMS were screened for using the Non‐Motor Symptom Questionnaire (NMSQuest). We subtracted the duration of the presence of each individual NMS reported from the duration of the earliest motor symptom. NMS whose duration preceded the duration of motor symptoms were considered a pNMS. Individual pNMS were then grouped into relevant pNMS clusters based on the NMSQuest domains. Motor subtypes were defined as tremor dominant, postural instability gait difficulty (PIGD) and indeterminate type according to the Movement Disorder Society Unified Parkinson's Disease Rating Scale revision.

Results

Prodromal NMS were experienced by 90.3% of patients with PD and the median number experienced was 4 (interquartile range, 2–7). A gender difference existed in the pNMS experienced, with males reporting more sexual dysfunction, forgetfulness and dream re‐enactment, whereas females reported more unexplained weight change and anxiety. There was a significant association between any prodromal gastrointestinal symptoms [odds ratio (OR), 2.30; 95% confidence interval (CI), 1.08–4.89, P = 0.03] and urinary symptoms (OR, 2.54; 95% CI, 1.19–5.35, P = 0.016) and the PIGD phenotype. Further analysis revealed that total pNMS were not significantly associated with the PIGD phenotype (OR, 1.10; 95% CI, 0.99–1.21, P = 0.068).

Conclusions

Prodromal NMS are common and a gender difference in pNMS experienced in prodromal PD may exist. The PIGD phenotype had a higher prevalence of prodromal gastrointestinal and urinary tract symptoms.

Cognitive impairment in Parkinson's disease: impact on quality of life of carers

BACKGROUND

The quality of life (QoL) of informal caregivers of people with Parkinson's disease (PD) (PwP) can be affected by the caring role. Because of cognitive symptoms and diminished activities of daily living, in addition to the management of motor symptoms, carers of PwP and cognitive impairment may experience increased levels of burden and poorer QoL compared with carers of PwP without cognitive impairment. This study aimed to investigate the impact of cognitive impairment in PD upon QoL of carers.

METHODS

Approximately 36 months after diagnosis, 66 dyadic couples of PwP and carers completed assessments. PwP completed a schedule of neuropsychological assessments and QoL measures; carers of PwP completed demographic questionnaires and assessments of QoL. Factor scores of attention, memory/executive function and global cognition, as derived by principal component analysis, were used to evaluate cognitive domains.

RESULTS

Hierarchical regression analysis found lower Montreal Cognitive Assessment was a significant independent predictor of poorer carer QoL, in addition to number of hours spent caregiving, carer depression and PD motor severity. Attentional deficits accounted for the largest proportion of variance of carer QoL. Carers of PwP and dementia (n = 9) had significantly poorer QoL scores compared with PwP and mild cognitive impairment (n = 18) or normal cognition (n = 39) carers (p < 0.01).

CONCLUSIONS

Attentional deficits were the strongest predictor of carer QoL compared with other cognitive predictors. Carers for those with PD dementia reported the poorest QoL. Interventions such as respite or cognitive behavioural therapy to improve mood and self-efficacy in carers may improve carer QoL. © 2016 The Authors. International Journal of Geriatric Psychiatry published by John Wiley & Sons, Ltd.

Cerebral glucose metabolism and cognition in newly diagnosed Parkinson's disease: ICICLE-PD study

OBJECTIVE

To assess reductions of cerebral glucose metabolism in Parkinson's disease (PD) with 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), and their associations with cognitive decline.

METHODS

FDG-PET was performed on a cohort of 79 patients with newly diagnosed PD (mean disease duration 8 months) and 20 unrelated controls. PD participants were scanned while on their usual dopaminergic medication. Cognitive testing was performed at baseline, and after 18 months using the Cognitive Drug Research (CDR) and Cambridge Neuropsychological Test Automated Battery (CANTAB) computerised batteries, the Mini-Mental State Examination (MMSE), and the Montreal Cognitive Assessment (MoCA). We used statistical parametric mapping (SPM V.12) software to compare groups and investigate voxelwise correlations between FDG metabolism and cognitive score at baseline. Linear regression was used to evaluate how levels of cortical FDG metabolism were predictive of subsequent cognitive decline rated with the MMSE and MoCA.

RESULTS

PD participants showed reduced glucose metabolism in the occipital and inferior parietal lobes relative to controls. Low performance on memory-based tasks was associated with reduced FDG metabolism in posterior parietal and temporal regions, while attentional performance was associated with more frontal deficits. Baseline parietal to cerebellum FDG metabolism ratios predicted MMSE (β=0.38, p=0.001) and MoCA (β=0.3, p=0.002) at 18 months controlling for baseline score.

CONCLUSIONS

Reductions in cortical FDG metabolism were present in newly diagnosed PD, and correlated with performance on neuropsychological tests. A reduced baseline parietal metabolism is associated with risk of cognitive decline and may represent a potential biomarker for this state and the development of PD dementia.

Emphysematous changes and normal variation in smokers and COPD patients using diffusion 3He MRI

INTRODUCTION

This study aims to quantify global and regional changes of diffusive motion of 3He gas within the lung, as determined by hyperpolarized 3He MR apparent diffusion coefficient (ADC) measurement, in non-smokers, smokers and chronic obstructive pulmonary disease (COPD) patients.

METHODS

Age-matched groups of six healthy non-smokers, five healthy smokers and five patients with COPD. The experiments were performed with approval from the local Research Ethics Committee. Diffusion imaging was performed following hyperpolarized 3He gas inhalation, producing ADC maps. Mean and standard deviation of the ADCs were used to compare the subject groups and assess regional variations within individuals.

RESULTS

The intra-individual standard deviation of ADC in the healthy smokers was significantly larger than that of the non-smoking group (P < 0.02). Compared to the non-smoking group, COPD patients had significantly higher mean and standard deviation of ADC (P < 0.01). The mean ADC in the anterior half of the chest was systematically higher than in the posterior half in the healthy non-smoking subject group.

DISCUSSION

This study suggests that there are regional trends in the ADC values of healthy volunteers that may have implications for the clinical interpretation of ADC values. Less homogeneous ADC values have been detected in asymptomatic smokers, indicative of damage to the distal air spaces.

The use of iloprost in early pregnancy in patients with pulmonary arterial hypertension

In patients with pulmonary hypertension, pregnancy is associated with a high risk of maternal death. Such patients are counselled to avoid pregnancy, or if it occurs, are offered early interruption. Some patients, however, decide to continue with their pregnancy and others may present with symptoms for the first time whilst pregnant. Pulmonary vasodilator therapy provides a treatment option for these high-risk patients. The present study describes three patients with pulmonary arterial hypertension of various aetiologies who were treated with the prostacyclin analogue iloprost during pregnancy, and the post-partum period. Nebulised iloprost commenced as early as 8 weeks of gestation and patients were admitted to hospital between 24-36 weeks of gestation. All pregnancies were completed with a duration of between 25-36 weeks and all deliveries were by caesarean section under local anaesthetic. All patients delivered children free from congenital abnormalities, and there was no post-partum maternal or infant mortality. In conclusion, although pregnancy is strongly advised against in those with pulmonary hypertension, the current authors have achieved a successful outcome for mother and foetus with a multidisciplinary approach and targeted pulmonary vascular therapy.

Anaesthetic management of the newborn with multiple congenital epulides

Epulis of the newborn is a granular cell tumour that originates from the dental alveolar mucosa. We report a case of a neonate with multiple congenital masses of the alveolar mucosa who presented for surgery with a potential airway problem. Intubation was achieved uneventfully using a gaseous induction with a large facemask and displacement of the epulides to allow cautious laryngoscopy.

The role of neutrophil apoptosis in the resolution of acute lung injury in newborn infants

BACKGROUND

The persistent airway neutrophilia observed in chronic lung disease of prematurity (CLD) may reflect inappropriate suppression of neutrophil apoptosis.

METHODS

134 bronchoalveolar lavage (BAL) samples were obtained from 32 infants requiring mechanical ventilation for respiratory distress syndrome (RDS): 13 infants (median gestation 26 weeks, range 23 to 28) subsequently developed CLD (CLD group), and 19 infants (gestation 31 weeks, range 25 to 39) recovered fully (RDS group). A further 73 BAL samples were obtained from 20 infants (median age 2 days, range 1 to 402) receiving extracorporeal membrane oxygenation (ECMO) for severe respiratory failure.

RESULTS

Neutrophil apoptosis was increased in the RDS group (mean (SEM) neutrophil apoptosis on day 7 BAL: RDS 17.0 (8.6)% v CLD 0.7 (0.2)% (p<0.05)). BAL fluid obtained from RDS but not CLD patients was proapoptotic to neutrophils (apoptosis ratio BAL fluid/saline control: day 1, RDS 9.8 (5.5) v CLD 1.2 (0.1) (p<0.05); day 2, RDS 4.32 (2.8) v CLD 0.5 (0.4) (p<0.05)). There were similar findings in the ECMO group: survivors had proapoptotic BAL fluid compared with non-survivors (apoptosis ratio day 1, survivors 7.9 (2.1) v non-survivors 2.1 (0.7) (p<0.05)).

CONCLUSIONS

Inappropriate suppression of neutrophil apoptosis may be associated with a poor outcome in newborn infants with respiratory failure.

Monthly haemoptysis in a woman with platelet storage pool disease

A 26-year-old female with known platelet storage pool disease presented with a short history of recurrent haemoptysis. Initial investigations were unhelpful until the cyclical nature of the symptoms became apparent prompting the unusual diagnosis of pulmonary endometriosis to be made. This was subsequently confirmed on premenstrual CT scanning. The introduction of a specific hormonal therapy and multidisciplinary input was ultimately successful.

Intracellular trafficking and killing of Streptococcus pneumoniae by human alveolar macrophages are influenced by opsonins

Human alveolar macrophages (HAM) are the major resident phagocytic cells of the gas-exchanging areas of the lung. Following contact with macrophages, bacteria enter phagosomes, which gradually acquire the characteristics of terminal phagolysosomes, with incorporation of lysosome-associated membrane protein (LAMP). We measured the binding of type 1 Streptococcus pneumoniae to the surface of HAM and then measured subsequent internalization and phagosomal incorporation of LAMP-1 under various opsonic conditions. Opsonization with serum containing immunoglobulin resulted in significantly greater binding of pneumococci to HAM compared with opsonization with immunoglobulin G (IgG)-depleted serum containing complement, which in turn resulted in marginally increased binding over that observed in the absence of opsonization. Internalization of opsonized S. pneumoniae gradually increased to a maximum of 20% of bound bacteria by 120 min of warm incubation, with 20% of internalized pneumococci being localized within LAMP-containing compartments by 80 min. Internalization of opsonized S. pneumoniae by HAM correlated with a reduction of bacterial viability. When inocula were adjusted so that pneumococcal binding under different conditions was equalized, subsequent internalization, trafficking to LAMP-containing compartments, and reduction of bacterial viability were less efficient in the absence of opsonization than that observed following opsonization with adsorbed or IgG-replete adsorbed serum. Once bound to the surface of HAM, pneumococci opsonized with adsorbed serum with or without IgG were internalized, processed, and killed equally well. In conclusion, binding, intracellular trafficking, and killing of S. pneumoniae by HAM are each significantly increased by opsonization with serum containing immunogloblin and/or complement.

Amethocaine gel for percutaneous local anaesthesia

Amethocaine gel is a recently developed formulation of amethocaine, designed to provide percutaneous local anaesthesia. Its pharmacological characteristics coupled with a phase-change gel formulation may confer therapeutic advantages over existing preparations. Percutaneous local anaesthesia has increasing relevance in analgesia for paediatric procedures and superficial surgical operations.

Treatment of mediastinitis: early modified Robicsek closure and pectoralis major advancement flaps

BACKGROUND

The treatment of sternal wound complications is controversial. It is our practice to combine early aggressive debridement, a modified Robicsek sternal closure, and bilateral pectoralis major advancement flaps with or without closed irrigation in a single procedure. We reviewed our experience to determine the efficacy of this approach.

METHODS

Grade II to IV mediastinitis (dehiscence and infection) developed in 47 patients 3 to 14 days after routine open heart operations between 1990 and 1995. Culture-positive infection was identified in 60% (n = 28); 62% (n = 29) had septicemia. Thirty patients underwent incision, drainage, and surgical assessment of the wound. Once systemic signs of infection were under control (no pyrexia, normal white blood cell count), formal single-stage debridement of all infected soft tissues and bones was performed. Sternal stability was achieved using a modified Robicsek closure and bilateral pectoralis major advancement flaps. Seventeen patients were treated with staged procedures.

RESULTS

Early sternal closure and coverage with pectoralis major advancement flaps can be associated with a low mortality (0%), low morbidity (13%; n = 4: three superficial wound infections, one seroma), and shortened hospital stay (median, 22 days, compared with a median of 82 days in patients managed with conservative staged treatment; p < 0.05). Sternal stability with excellent functional and aesthetic results has been achieved in all patients.

CONCLUSIONS

The combination of aggressive early surgical debridement, sternal closure, and the placement of bilateral pectoralis major advancement flaps is a simple procedure associated with a low mortality and morbidity and a short hospital stay.

Endobronchial inflammatory pseudotumour exacerbating asthma

Primary pulmonary tumours are rare in the paediatric population. Of the benign tumours, the most common is the inflammatory pseudotumour (plasma cell granuloma). It can present as a variety of non-specific symptoms which may delay diagnosis. It usually occupies a peripheral pulmonary location and gives rise to symptoms due to its local mass effect and destructive invasion. We report the case of an endobronchial inflammatory pseudotumour presenting as an exacerbation of asthma in a 10-year-old girl. Appropriate investigation lead to pre-operative diagnosis and early complete surgical resection. A good prognosis is anticipated.

Diclofenac vs oxybuprocaine eyedrops for analgesia in paediatric strabismus surgery

Forty children undergoing strabismus surgery as day patients were randomly allocated to receive oxybuprocaine 0.4% eyedrops or 0.1% diclofenac eyedrops for perioperative analgesia. A non-invasive anaesthetic technique using the reinforced laryngeal mask airway was used. The study demonstrated that both topical analgesics provided good to excellent analgesia and the anaesthetic technique was associated with a relatively low incidence of nausea and vomiting. Complications were limited to two children who were admitted with persistent postoperative nausea and vomiting.

Recovery after desflurane anaesthesia in the infant: comparison with isoflurane

We have studied 20 infants, aged 2.5-8 weeks, undergoing general anaesthesia for pyloromyotomy with either desflurane or isoflurane. Patients were anaesthetized with equivalent 1 MAC values for age and agent. A blinded observer recorded times to breathing, swallowing, movement, extubation and side effects after discontinuation of the agent. Recovery times in the desflurane group were significantly shorter than in the isoflurane group. The times to swallowing, movement and extubation in the desflurane group were 3.89 (SD 2.4) min, 5.33 (4.95) min, 7.5 (4.53) min, respectively, and 8.82 (2.40) min, 10.73 (3.93) min, 13.45 (4.20) in the isoflurane group. In addition, postoperative apnoea was documented in the isoflurane group but not in those infants receiving desflurane. There was no laryngospasm after extubation in either group. We conclude that desflurane possesses useful characteristics for recovery conditions in the infant and may be particularly useful in the ex-premature infant prone to apnoea and ventilatory depression.

Ventilatory arrest after a fluid challenge in a neonate receiving s.c. morphine

S.c. infusions of morphine have been advocated for postoperative analgesia in children, but experience with this technique is limited. We report a case in which an s.c. infusion of morphine given after operation to a neonate failed to provide acceptable analgesia until the child had been adequately rehydrated. However, restoration of peripheral perfusion with a fluid challenge was followed by sudden ventilatory arrest which required resuscitation and naloxone infusion. This report emphasizes the dangers of giving morphine by a peripheral route in the dehydrated or hypovolaemic infant.

Evaluation of an amethocaine gel preparation for percutaneous analgesia before venous cannulation in children

We have evaluated the efficacy and safety of a preparation of 4% amethocaine gel in alleviating the pain of venous cannulation in children. In an initial open study of 148 children, clinically acceptable anaesthesia was achieved in 92% of cases. The preparation was then compared with 5% EMLA cream in a single-blind study in 94 patients using an application time of 40 min. We found clinically acceptable conditions in 85% of patients receiving amethocaine gel compared with 66% in the EMLA group. There were no significant adverse effects noted in each group, although 37% of those children treated with amethocaine gel showed localized erythema at the application site. The results suggest that amethocaine gel has greater efficacy and a faster onset time than EMLA cream when used for this purpose in children.

Effects of antiplatelet therapy with indobufen or aspirin-dipyridamole on graft patency one year after coronary artery bypass grafting

Saphenous vein coronary artery bypass graft patency can be increased by antiplatelet therapy. Aspirin plus dipyridamole are effective but are associated with tolerability problems. Indobufen is a possible alternative antiplatelet agent that may be better tolerated. A prospective, randomized, double-blind, parallel-group study was undertaken to compare the efficacy and safety of indobufen 200 mg twice daily with aspirin 300 mg thrice daily plus dipyridamole 75 mg thrice daily in preventing occlusion of autologous saphenous vein coronary artery bypass grafts. A total of 803 patients were randomized in the study, of whom 552 had a follow-up coronary angiogram approximately 1 year after operation. All anastomoses were patent in 56% of indobufen-treated patients and 59% of aspirin-dipyridamole recipients (p = 0.384). The percentage of all anastomoses patent was 82% in the indobufen group and 83% in the aspirin-dipyridamole group (p = 0.297). Mean postoperative blood loss was significantly less in the indobufen group (p = 0.043). Patients who received indobufen also had significantly fewer adverse events considered to be treatment-related compared with aspirin-dipyridamole recipients (p = 0.02). At the doses tested indobufen was as effective as aspirin plus dipyridamole in preventing occlusion of saphenous vein grafts and was better tolerated. Because indobufen was associated with less postoperative blood loss it may be used before operation in coronary artery bypass grafting.

Haemodynamic effects of transurethral prostatectomy

Thoracic bio-impedance cardiography was used to study the haemodynamic changes in 28 patients undergoing transurethral prostatectomy (TURP) under either general or spinal anaesthesia. Cardiac output and mean arterial pressure fell with induction of general anaesthesia, whilst mean arterial pressure and systemic vascular resistance fell with induction of spinal anaesthesia. The transthoracic fluid index fell during resection under general anaesthesia, but no significant haemodynamic changes were seen during resection under either anaesthetic. This study suggests that resection has no specific adverse haemodynamic consequences. Spinal anaesthesia may produce less haemodynamic disturbance than general anaesthesia in patients undergoing TURP and formal comparison of the 2 techniques seems necessary.

Vascular invasion in non-small cell lung carcinoma

AIMS

To determine if there is any correlation between vascular invasion and prognosis in non-small cell carcinoma of the lung; and to look specifically at invasion of vascular channels by tumour cells.

METHODS

Eighty seven patients undergoing lobectomy or pneumonectomy for adenocarcinoma or squamous carcinoma were followed up for five years. The histological sections were studied for evidence of vascular invasion using an elastic van Gieson stain. The incidence of intimal fibrosis in arteries and veins was noted and the proportion with vascular invasion evaluated using a scoring system. The presence or absence of lymphatic permeation and tumour necrosis were noted. Survival data were analysed using the log rank test.

RESULTS

The overall five year survival was 32%. There were 64 squamous cell carcinomas and 23 adenocarcinomas. Vascular invasion was seen in 77% of patients and lymphatic invasion in 44%. Neither the presence nor absence nor the proportion of blood vessels showing vascular invasion showed any relation to prognosis. Intimal fibrosis and tumour necrosis were unrelated to prognosis. Patients with lymphatic permeation had recurrence and died earlier than those without.

CONCLUSION

The presence of arterial or venous invasion by adenocarcinoma or squamous carcinoma of the lung was unrelated to survival; lymphatic permeation was associated with poor prognosis. The two common non-small cell lung cancers behaved differently from other solid tumours, where vascular invasion was a significant factor in determination of prognosis. The presence of intimal fibrosis was unrelated to prognosis.

Evaluation of the usefulness of open lung biopsies

The role of open lung biopsy (OLB) in the diagnosis of the etiology of lung infiltrates in children was analyzed for a 10-year period 1979-1989 in a tertiary referral center. A total of 18 children had 19 lung biopsies to ascertain the cause of lung infiltrates. Thirteen of these children (72%) were immunocompromised due to treatment of hematological/solid malignancies and bone marrow transplantation. The clinical diagnosis was bilateral lung infiltrates of unknown etiology in 17 of 18 children. Eight of these children were ventilated for respiratory failure. The biopsy was useful in achieving a histological diagnosis in 18 of 19 samples (diagnostic yield 95%) and an etiological diagnosis in 14 of 19 samples (etiological yield 74%). Therapeutic strategy was altered in 14 of 18 patients based on the biopsy results. Five of 14 patients responded favorably to a change in specific treatment. The time interval from onset of respiratory illness to biopsy was 2-60 days (mean 16 days). Despite the critical state of these children there were few complications associated with the biopsy and no mortality directly related to the procedure. We recommend that OLB be undertaken sooner rather than later in immunocompromised children with bilateral pulmonary infiltrates of unknown etiology.

Finger blood content, light transmission, and pulse oximetry errors

The changes in light emitting diode current necessary to maintain a constant level of light incident upon a photodetector were measured in 20 volunteers at the two wavelengths employed by pulse oximeters. Three states of finger blood content were assessed; exsanguinated, hyperaemic, and normal. The changes in light emitting diode current with changes in finger blood content were small and are not thought to represent a significant source of error in saturation as measured by pulse oximetry.

2,3-di-O-tetradecyl-1-O-(beta-D-glucopyranosyl)-sn-glycerol is a substrate for human glucocerebrosidase

Glucocerebrosidase, the lysosomal enzyme that is deficient in patients with Gaucher's disease, hydrolyses non-physiological aryl beta-D-glucosides and glucocerebroside, its substrate in vivo. We document that 2,3,-di-O-tetradecyl-1-O-(beta-D-glucopyranosyl)-sn-glycerol (2,3,-di-14:0-beta-Glc-DAG) inhibits human placental glucocerebrosidase activity in vitro (Ki 0.18 mM), and the nature of inhibition is typical of a mixed-type pattern. Furthermore, 2,3-di-14:0-beta-Glc-DAG was shown to be an excellent substrate for the lysosomal beta-glucosidase (Km 0.15 mM; Vmax. 19.8 units/mg) when compared with the natural substrate glucocerebroside (Km 0.080 mM; Vmax. 10.4 units/mg). The observations that (i) glucocerebrosidase-catalysed hydrolysis of 2,3-di-14:0-beta-Glc-DAG is inhibited by conduritol B epoxide and glucosylsphingosine, and (ii) spleen and brain extracts from patients with Gaucher's disease are unable to hydrolyse 2,3-di-14:O-beta-Glc-DAG demonstrate that the same active site on the enzyme is responsible for catalysing the hydrolysis of 4-methylumbelliferyl beta-D-glucopyranoside, glucocerebroside and 2,3-di-14:O-beta-Glc-DAG. With the aid of computer modelling we have established that the oxygen atoms in 2,3-DAG-Glc at the C-1, C-4*, C-5* (the ring oxygen in glucose) and C-2 positions correspond topologically to the oxygens at C-1, C-4* and C-5* and the nitrogen atom attached to C-2 respectively in glucocerebroside (* signifies a carbon atom in glucose); furthermore, all of the distances with respect to overlap of corresponding heteroatoms range from 0.02 A to 0.77 A (0.002-0.077 nm). A root-mean-square deviation of 0.31 A (0.031 nm) was obtained when the energy-minimized structures of 2,3-di-14:O-beta-Glc-DAG and glucocerebroside were compared using the latter four heteroatom co-ordinates.

Coronary ostial stenosis: surgical considerations

To investigate the clinical significance of coronary ostial stenosis, we reviewed eight patients with such lesions, including three with isolated stenosis at the orifice of the coronary artery. There were five male and three female patients, with an average age of 46.25 years (range 32-69 years). Their symptoms consisted mainly of angina (6 patients), with dyspnoea and palpitation being the presenting features in the remaining two patients. All patients underwent preoperative coronary angiography which confirmed stenosis at the level of the orifice with absence of reflux of contrast medium into the sinus of Valsalva as the main features. Delay in the appreciation of stenosis of the orifice of the right coronary artery resulted in the death of two patients, whose diagnosis was confirmed at post mortem examinations. Stenosis of the orifice of the right coronary artery was present in seven patients, with two patients also having stenosis of the orifice of the left coronary artery. The remaining patient had isolated stenosis of the left coronary arterial orifice. Coronary artery bypass grafting was performed in five patients, including two who had patch angioplasty to the right coronary artery. The patient with isolated stenosis of the orifice of the left coronary artery had patch angioplasty only. Follow-up of up to three years in the surviving patients showed good functional results. The ease with which it is possible to miss right coronary ostial stenosis is emphasized and angiographic features are reviewed.

Adrenal insufficiency due to bilateral metastases from oat cell carcinoma of the oesophagus

Extrapulmonary oat cell carcinoma has been reported in many organs, the oesophagus being the most common location. We report a case of adrenal insufficiency due to extensive metastatic deposits from oat cell carcinoma of the oesophagus in a patient following cardioesophagectomy.

DNA analysis by flow cytometry in malignant pleural mesothelioma: relationship to histology and survival

In a retrospective study of 70 patients with malignant pleural mesothelioma, 168 formalin-fixed, paraffin-embedded tumour specimens were examined for DNA content by flow cytometry. In 20 patients where two or more blocks of the same tumour were available, there was considerable agreement between ploidy status and S-phase percentage in the different specimens. There were no significant differences for survival for patients who had been exposed to asbestos and those in whom no exposure could be elicited, nor for aneuploid and diploid tumours. The S-phase content was examined for different areas of the same tumour and the percentages were largely in agreement. However, those patients who had tumours with an S-phase percentage greater than the median (6 per cent) had a significantly shorter survival than those with tumours of lower S-phase percentage. Differences in DNA content and other cell cycle parameters were not associated with the histological subtypes.

Evolution of acute chest syndrome in sickle cell trait: an ultrastructural and light microscopic study

Light and electron microscopic studies of a patient with sickle cell trait who had an episode of sickling during coronary artery surgery, from which he died, showed fibrin thrombi, focal alveolar wall necrosis, and epithelial cell damage. It is suggested that in cases of sickle trait full precautionary measures should be taken to prevent sickling in these circumstances.

Re-operation for recurrent coronary artery and graft disease. A review of 73 patients in a group of 2573 consecutive first operations

Between January 1980 and December 1986, 2573 patients underwent simple first time coronary artery bypass grafting, of whom 73 (65 males and 8 females) aged 34-69 years (mean 51.3 yrs) had repeat bypass grafts at Wythenshawe Hospital, Manchester. Of these 73 patients, 15 had a previous myocardial infarction, 5 hyperlipidaemia, 4 systemic hypertension, and 12 had a strong family history of ischemic heart disease. There was an overall deterioration of left ventricular function at the time of reoperation. The interval between the two operations was 5-131 months (mean 34.2 mths); recurrence of angina occurred earlier (mean 18.4 mths). Vessels grafted at the first operation were LAD (59), RCA (46), circumflex (41) and diagonal (13). The corresponding data at reoperation were LAD (55), RCA (46), circumflex (28) and diagonal (10). Blocked grafts were seen in 67 patients and new lesions noticed in 29. Reoperation was done using saphenous vein (129), internal mammary artery (5), arm veins (2) and tubular Gortex grafts (2). One patient had concurrent excision of a left ventricular aneurysm. Coronary anastomoses were performed with elective ventricular fibrillation (47) or cardioplegic arrest (91). Aortic cross clamp time varied from 0-92 minutes. Seven patients required intra-aortic balloon support. These patients died in the first 30 days, an operative mortality rate of 4.1%, and two 18 months after surgery. Sixty-eight percent of patients seen at 1 year were totally symptom free. We conclude that reoperation for coronary artery disease can be done with a low mortality and good immediate relief of symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve replacement with combined myocardial revascularisation

Early and late outcome was studied in 630 patients who underwent aortic valve replacement between 1974 and 1982. Group 1 (506 patients) did not have important coronary artery disease, group 2 (69 patients) had coronary artery disease and underwent coronary artery bypass grafting, and group 3 (55 patients) had coronary artery disease but did not undergo myocardial revascularisation. Early mortality (within 30 days of operation) was significantly lower for group 1 (6%) than for group 2 (13%) and for group 3 (16%). Operative mortality in all three groups was lower in patients operated on more recently. The three year survival of patients in group 1 (83%) was significantly higher than that of patients in group 3 (62%) but not than that of patients in group 2 (76%). The findings of this study suggest that the presence of coronary artery disease increases the risk of aortic valve replacement whether or not coronary artery grafting is performed. Myocardial revascularisation, however, seems to return patients with aortic valve and coronary artery disease to a survival curve similar to that of patients with isolated aortic valve disease.

Expression of epidermal growth factor receptor (EGF-R) in non-small cell lung cancer. Use of archival tissue and correlation of EGF-R with histology, tumour size, node status and survival

A total of 152 non-small cell lung cancers (NSCLC) were studied retrospectively to determine the relationship between epidermal growth factor receptor (EGF-R) status and the histological type, tumour size, nodal status and prognosis. EGF-R status was assessed on routinely embedded paraffin sections with an antibody to the cytoplasmic domain of the tumour (F4 antibody). EGF was demonstrated in all tumour types and every squamous and large cell carcinoma was positive for the antibody. Most tumours showed heterogeneity of staining. EGF expression was seen statistically more frequently in well differentiated tumours. Patients with 50% or more tumour cells showing positivity tended to have an improved survival but this result failed to reach statistical significance. There was no relationship between the size of the primary tumour or the lymph node status. Other cells, such as mucinous glands, bronchial epithelial cells and macrophages stained positively with the monoclonal antibody. EGF receptor status, with the antibodies presently available, adds little to help in either diagnosis or prognosis. Interpretation of data has to be guarded since the antibody was seen in some normal cells.

Squamous carcinoma of the oesophagus: histological criteria and their prognostic significance

One hundred resected cases of squamous cell carcinomas of the oesophagus were reviewed and a series of histological criteria related to the survival time. Two histological features were important in the assessment of survival. Good prognostic factors were a marked lymphocytic response to the tumour and a lack of intravenous tumour infiltration. Presence of tumour in the middle third of the oesophagus, infiltration through the muscularis propria, severe tumour necrosis, glandular or small cell tumour differentiation, lymphatic invasion and lack of peritumoural fibrosis were all factors which tended to worsen prognosis. None of these factors reached statistical significance. The degree of squamous differentiation had no effect on survival.

Postoperative neuralgia in the leg after saphenous vein coronary artery bypass graft: a prospective study

The degree of cutaneous sensory deficit in the leg was assessed after removal of the long saphenous vein in 50 consecutive patients undergoing coronary artery bypass vein grafts randomly assigned subcutaneous sutures or a single layer of sutures. Removal of the vein and repair of the leg incision were done by the same team of surgeons. In group 1 (25 patients) the leg incision was repaired with "00" Dexon subcutaneous and "00" prolene subcuticular sutures while in group 2 (25 patients) closure was effected by a single layer of interrupted "00" nylon sutures. All had crepe pressure bandage from the base of the toes to the groin for the first 24 hours followed by TED stockings for six to eight weeks. Sutures were removed on the eighth postoperative day. Cutaneous sensation in the leg and ankle was assessed 48 hours, seven days, and six to eight weeks after surgery, and a final comparison of the cosmetic effects and sensory perception after one year or more was made in 37 patients. There were no major differences between the groups at 48 hours in sensory abnormalities (anaesthesia, hyperaesthesia, and pain) but sensory recovery was significantly better in group 2 at the second and third assessments. There was some reduction in sensory abnormalities at the final review in group 1. No appreciable difference was noted in the quality of the scar between the two groups. We conclude that cutaneous sensation is better preserved by repairing the leg incision in a single layer. Subcutaneous sutures may produce neuropraxia of the long saphenous nerve by direct pressure as healing progresses.

Surgical repair of acquired ventricular septal defect. Determinants of early and late outcome

Between January 1970 and June 1985, 60 patients underwent surgical repair of postinfarction ventricular septal defect. The preoperative cineangiograms of all patients were reviewed to measure left ventricular ejection fraction and to quantitatively assess right ventricular function by measuring the percentage reduction in right ventricular midcavity diameter. There were 23 early deaths (within 30 days) and 14 late deaths occurring between 1 and 92 months after operation. Of the 23 long-term survivors, 87% are in New York Heart Association Class I or II. The early mortality was significantly higher for inferior infarction (58%) than for anterior infarction (25%). Early mortality was also influenced by the time interval between infarction and operation (under 1 week 41%, over 4 weeks 22%). Early survival was favored by good preoperative right ventricular function; the percentage reduction in right ventricular midcavity diameter was 16.5% +/- 9.5% (mean +/- standard deviation) for the early death group and 26.7% +/- 10.6% for the early survival group. However, the early outcome was not influenced by left ventricular function before operation. Conversely, long-term survival was favored by preserved preoperative left ventricular function; left ventricular ejection fraction was 26.2% +/- 9.3% for the late death group and 35% +/- 8.5% for the late survival group. Long-term survival was not, however, affected by right ventricular function before operation. The results of surgical closure of postinfarction ventricular septal defect have improved between two successive time frames in this series, which is the largest to date.

Volvulus of the stomach--an unusual cause of pulsus paradoxus

A patient with a strangulated diaphragmatic hernia presented as an emergency and was noted to have pulsus paradoxus. The mechanism of this physical sign, previously unrecorded in association with an intrathoracic hernia, is discussed.

Aspergillus niger endocarditis complicating aortic tissue valve replacement

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Results of valve replacement with the Omniscience prosthesis

Clinical experience with the Omniscience prosthesis from two regional cardiac units in England is presented. Actuarial analysis suggests a prohibitive incidence of prosthetic thrombosis of the mitral valve, this complication occurring in 14 of a total of 96 (15%) patients studied over a mean period of approximately 1 1/2 years. Aortic valve implantations were frequently complicated by prosthetic dehiscence, which occurred in nine of a total of 88 (10%) patients who received this valve. Our results with this prosthesis contrasts markedly with our favorable experience with other types of prostheses and lead us to question the suitability of the Omniscience valve for further clinical use.

Modification of the embryo-maternal relationship in ewes by progesterone treatment early in the oestrous cycle

When 25 mg progesterone/day were injected into ewes on Days 0-3 of the oestrous cycle, (i) the subsequent cycle was shortened by 4 days and (ii) on Day 6 such ewes provided an acceptable uterine environment for the survival of 10-day-old embryos. We suggest that exposure of the non-pregnant uterus to approximately 8 days of normal luteal concentrations of progesterone may be necessary to initiate luteolysis.

Evidence for maternal control of blastocyst growth after asynchronous transfer of embryos to the uterus of the ewe

The fate of embryos transferred asynchronously in the ewe was investigated when the functional life of the corpus luteum was prolonged by both hemi-hysterectomy and by the presence of a second synchronously transferred embryo. The development of asynchronously transferred embryos was assessed at progressively later stages after transfer. Prolongation of luteal function did not enable asynchronously transferred embryos to persist. Embryos from Day 4 donors were found to be retarded in their rate of development when placed in 'younger' Day 1 or 2 uteri and appeared unable to develop beyond the early blastocyst stage. Conversely, embryos from Day 4 donors placed in 'older' Day 6 or 7 uteri showed accelerated growth and development which was maintained until the uterus reached Day 12. Thereafter further growth of the asynchronously transferred embryos was retarded, although synchronously transferred embryos then entered the phase of rapid blastodermic vesicle elongation. Asynchronously transferred embryos disappeared from the uterus when the ewe entered pro-oestrus. The experiments demonstrate the existence of an active relationship between the embryo and the maternal environment during mid-cycle and an apparent lack of association between embryo size, growth rate and physiological maturation.

Right ventricular dysfunction and surgical outcome in postinfarction ventricular septal defect

The data of 50 consecutive patients treated for postinfarction ventricular septal defect were reviewed. Cardiac catheterization was carried out in all patients and surgical repair was undertaken in 32 patients. The main factors affecting surgical outcome were the site of infarction and the extent of right ventricular damage. Anterior myocardial infarction carried a better hospital survival rate than inferior infarction (67 and 31%, respectively). Poor right ventricular free wall contraction, present in 44% of anterior infarctions and 71% of inferior infarctions carried a high mortality. Eighty per cent (12/15) of patients with good right ventricular contraction survived operation compared to only 24% (4/17) of patients with poor right ventricular contraction. Surgery within 24 h to 14 days of infarction carried a survival rate of 50% (7/14), similar to that in patients operated on more than two weeks following infarction (9/18). Seventeen out of 18 patients who did not undergo surgery either died suddenly before scheduled operation or were considered too poor a surgical risk. Of these, 12 patients died within one week of infarction and five patients survived between two weeks and three months. Early surgical repair should therefore be considered in all patients with postinfarction ventricular septal defect, the prognosis in patients with good right ventricular contraction being excellent.