Showing papers by "Glenfield Hospital published in 2005"

The use of exhaled nitric oxide concentration to identify eosinophilic airway inflammation: an observational study in adults with asthma.

Abstract: BACKGROUND: Assessment of eosinophilic airway inflammation may be helpful in the management of asthma. Nitric oxide (NO) has potential advantages as a tool to monitor airway inflammation although little is known about the relationship between NO and eosinophilic airway inflammation and the factors which influence it. METHODS: We set out to define the relationship between exhaled NO and the sputum eosinophil count, identify the exhaled NO concentration that best identified a sputum eosinophil count >3% and investigate the impact of several potential confounding factors in 566 consecutive patients with varying severity of asthma. Finally we examined the ability of exhaled NO concentrations measured at differing exhalation flows to identify the presence of a sputum eosinophilia. RESULTS: We found a significant positive relationship between exhaled NO and sputum eosinophil count (R(2)=0.26, P 8.3 p.p.b. at 250 mL/s gave 71% sensitivity and 72% specificity for identifying a sputum eosinophil count of >3%. CONCLUSIONS: This value of exhaled NO would seem to be the best for identifying significant eosinophilic airway inflammation. It is applicable to a wide range of non-smoking patients with asthma; exhalation flow does not alter the ability of exhaled NO concentration to detect a sputum eosinophilia.

Alveolar nitric oxide in adults with asthma: evidence of distal lung inflammation in refractory asthma

Abstract: Recent studies have suggested that alveolar nitric oxide (NO) concentration is a noninvasive test of distal lung inflammation. The current study determined whether alveolar NO concentration can be measured in patients with asthma of varying severity, tested the hypothesis that there is an association between alveolar NO and bronchoalveolar lavage (BAL) eosinophil count and determined whether refractory asthma is characterised by a raised alveolar NO concentration. Finally, the present authors assessed the effect of 2 weeks of prednisolone (30 mg q.d.) on alveolar NO concentration. Alveolar NO concentration was both measurable and repeatable in patients with refractory asthma. A positive correlation was found between alveolar NO concentration and BAL eosinophil count but not with bronchial wash or sputum eosinophil count. Alveolar NO concentration was increased in patients with refractory asthma (7.1 ppb) compared with mild-to-moderate asthma (3.4 ppb) and normal controls (3.4 ppb) and reduced by treatment with prednisolone. In conclusion, these findings support the hypothesis that alveolar nitric oxide is a measure of distal airway inflammation and suggest that distal lung inflammation is present in refractory asthma.

Should acute scaphoid fractures be fixed? A randomized controlled trial.

Abstract: Background: With the proliferation of different fixation screws, there is an increasing trend to recommend early internal fixation of the broken scaphoid even if the fracture is not displaced. The benefits and risks of early fixation of scaphoid fractures have not been established. These were investigated in eighty-eight patients who were of working age with clearly defined minimally displaced or undisplaced bicortical fractures of the waist of the scaphoid. Methods: Patients who provided informed consent were randomized to treatment with early internal fixation with use of a Herbert screw without a cast (forty-four patients) or to nonoperative treatment for eight weeks with immobilization in a below-the-elbow plaster cast with the thumb left free (forty-four patients). The patients were evaluated at two, eight, twelve, twenty-six, and fifty-two weeks with respect to the severity of pain; tenderness; swelling; wrist movement; grip strength; and symptoms and disability, which were assessed with the Patient Evaluation Measure. In addition, radiographs were made and assessed at each visit. Results: No difference was detected between the groups with respect to age, sex, hand dominance, side of injury, mechanism of injury, or the occupation of the patients. The range of motion, score on the Patient Evaluation Measure, and grip strength were significantly better in the group managed operatively than in the group managed nonoperatively at the eight-week follow-up evaluation, which corresponded with the visit when the cast was removed in that group. Patients returned to work at five to six weeks after the injury in both groups. At twelve weeks, grip strength was better in patients who had had surgery. No significant difference was detected between the two groups with respect to any other outcome measure at any other time. Ten of the forty-four fractures treated nonoperatively had not healed radiographically at twelve weeks, and, as a consequence, the treatment was altered. Complications occurred in thirteen patients who had been managed operatively. All complications were minor, and ten were related to the scar. Conclusions: This study did not demonstrate a clear overall benefit of early fixation of acute scaphoid fractures beyond the decrease in the rate of a change in treatment because of a delayed union at twelve weeks. Early internal fixation of minimally displaced or nondisplaced fractures of the scaphoid waist, which would heal in a cast, could lead to overtreatment of a large proportion of such fractures, exposing such patients to avoidable surgical risk. Thus, we have adopted a program of so-called aggressive conservative treatment, whereby we carefully assess fracture-healing with plain radiographs, and computed tomography scans if necessary, after six to eight weeks of cast immobilization and recommend surgical fixation with or without bone-grafting at that time if a gap is identified at the fracture site. Such an approach should result in fracture union in over 95% of such patients. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients.

Abstract: Objective: Sublobar resections may offer a method of increasing resection rates in patients with lung cancer and poor lung function, but are thought to increase recurrence and therefore compromise survival for stage I non-small cell lung cancer (NSCLC). To test this hypothesis we have compared the long-term outcome from lobectomy and anatomical segmentectomy in high-risk cases as defined by predicted postoperative FEV 1 (ppoFEV 1 ) less than 40%. Methods: Over a 7-year period 55 patients (27% of all resections for stage I NSCLC) with ppoFEV 1 <40% underwent resection of stage I NSCLC. The 17 patients who underwent anatomical segmentectomy were individually matched to 17 patients operated by lobectomy on the bases of gender, age, use of VATS, tumour location and respiratory function. We compared their perioperative course, tumour recurrence and survival. Results: There were no significant differences in hospital mortality (one case in each group), complications or hospital stay. Overall 5-year survival was 69%. There were no differences in recurrence rates (18% in both groups) or survival (64% after lobectomy and 70% after segmentectomy). There was preservation of pulmonary function after segmentectomy (median gain of 12%) compared to lobectomy (median loss of 12%) (P=0.02). Conclusions: Anatomical segmentectomy allowed for surgical resection in patients with stage I NSCLC and impaired respiratory reserve without compromising oncological results but with preservation in respiratory function.

Observational study of the natural history of eosinophilic bronchitis

Abstract: Summary Background Eosinophilic bronchitis is an important cause of chronic cough. Treatment with inhaled corticosteroids is associated with a short-term improvement in cough and reduced sputum eosinophil count but the long-term outcome is uncertain. Objective To determine the long-term outcome in patients diagnosed with and treated for eosinophilic bronchitis. Methods We have performed a longitudinal study of symptoms, eosinophilic airway inflammation, spirometry and airway hyper-responsiveness in all patients diagnosed with eosinophilic bronchitis over 7 years. Results We identified 52 patients with eosinophilic bronchitis and longitudinal data of greater than 1 year (mean 3.1 years) was available in 32 patients, all of whom were treated with inhaled steroids. Three (9%) patients developed symptoms consistent with asthma and a methacholine PC20<8 mg/mL on one or more occasion. Five (16%) patients developed fixed airflow obstruction defined by a persistent post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity <70%. One (3%) patient had complete resolution of symptoms and eosinophilic airway inflammation off treatment. The remaining patients had ongoing eosinophilic airway inflammation and/or continuing symptoms. Multiple linear regression identified smoking, female gender and area under the curve of sputum eosinophil count over time as the most important predictors of decline in FEV1. Conclusions The most common outcome in eosinophilic bronchitis is continuing disease and complete resolution is rare. Asthma and fixed airflow obstruction developed in relatively few patients. The most important factors associated with a more rapid decline in FEV1 were female gender, smoking and prolonged eosinophilic airway inflammation.

White matter lesions on magnetic resonance imaging and their relationship with vascular risk factors in memory clinic attenders

Abstract: Background The association between white matter lesions on magnetic resonance imaging (MRI) and the presence of vascular risk factors has been investigated in different populations, and results have varied widely. However, this relationship has not been adequately addressed in memory clinic attenders who have relatively early cognitive impairment. Objectives This study was undertaken to determine the relationship between the severity of white matter lesions and vascular risk factors in elderly subjects referred to a Memory Clinic, irrespective of their diagnoses. Patients attending the Memory Clinic had relatively early, mild cognitive impairment and differed, in this respect, from typical unselected community-based samples and from patients with established dementia. The study also investigated whether periventricular and deep white matter lesions differed in their relationship with vascular risk factors. Methods All patients assessed in the Memory Clinic at Leicester General Hospital between April 1998 and October 2000 who had undergone an MRI scan were included in the study. They received a comprehensive clinical and cognitive assessment, a standard dementia laboratory screen and evaluation of vascular risk factors. MRI scans were reviewed by two independent raters and semi-quantitative ratings of the severity of white matter lesions were made using standardised protocols. The relationship between cerebral white matter lesions and vascular risk factor variables was examined by multiple linear regression. Results One hundred and seventy-seven subjects were included in the study. The mean age was 69.8 and the mean MMSE score was 23.2. Of the risk factors investigated, only age and prior cerebrovascular disease were significantly associated with severe periventricular white matter lesions; age, hypertension and diabetes were significantly associated with severe deep white matter lesions. Conclusions Periventricular and deep white matter lesions are differentially influenced by vascular risk factors. Copyright © 2005 John Wiley & Sons, Ltd.

The effect of iron supplementation on the level of haemoglobin after lower limb arthroplasty

Abstract: We randomised 120 patients who were undergoing either primary total hip or knee arthroplasty to receive either ferrous sulphate or a placebo for three weeks after surgery. The level of haemoglobin and absolute reticulocyte count were measured at one and five days, and three and six weeks after operation. Ninety-nine patients (ferrous sulphate 50, placebo 49) completed the study. The two groups differed only in the treatment administered. Recovery of level of haemoglobin was similar at five days and three weeks and returned to 85% of the pre-operative level, irrespective of the treatment group. A small, albeit greater recovery in the level of haemoglobin was identified at six weeks in the ferrous sulphate group in both men (ferrous sulphate 5%, placebo 1.5%) and women (ferrous sulphate 6%, placebo 3%). The clinical significance of this is questionable and may be outweighed by the high incidence of reported side effects of oral iron and the cost of the medication. Administration of iron supplements after elective total hip or total knee arthroplasty does not appear to be worthwhile.

Extra-pleural pneumonectomy for malignant pleural mesothelioma: the risks of induction chemotherapy, right-sided procedures and prolonged operations.

Abstract: Objective: With the increasing incidence of malignant pleural mesothelioma and renewed interest in radical surgery as a therapeutic option, we have examined our experience of extra-pleural pneumonectomy, to document the incidence and management of its peri-operative complications. Methods: This analysis was conducted using prospectively entered data contained within the departmental database, with additional information from retrospective case note review. Details of patient selection criteria and operative modifications are included. Results: Over a 59-month period, extra-pleural pneumonectomy was carried out on 74 patients (66 men; 8 women; median age 57 years). Fifteen patients (20%) received cisplatin-doublet induction chemotherapy. The majority (80%) of patients had epithelial tumours and 85% of patients had disease in International Mesothelioma Interest Group stages III and IV. The 30-day post-operative mortality was 6.75% (five patients) and significant morbidity was recorded in 47 patients (63%). Major complications included those of technical origin (diaphragmatic patch dehiscence 8.1%; chylothorax 6.7%; intra-thoracic haemorrhage 6.7%; bronchopleural fistula 6.7%), cardiovascular morbidity (atrial fibrillation 17.5%; mediastinal shift with subacute tamponade 10.8%; right ventricular failure 4%; pulmonary embolus 2.7%) and respiratory morbidity (pneumonia 10.8%; acute lung injury 8.1%). Admission to intensive care was required in 19 patients (26%). Univariate analysis identified the incidence of acute lung injury and mediastinal shift to be significantly associated with induction chemotherapy (PZ0.005 and 0.014, respectively). In addition to this, laterality of operation influenced respiratory morbidity (PZ0.018) and admission to intensive care (PZ0.025). Finally, prolonged operations (greater than the median) were associated with an increased risk of technical (PZ0.018) and gastro-intestinal (PZ 0.023) complications. Conclusions: Extra-pleural pneumonectomy is associated with a high rate of morbidity, but an acceptable mortality rate can be achieved with increasing peri-operative experience. Surgery following induction chemotherapy requires extra vigilance for the development of post-operative respiratory complications. q 2005 Elsevier B.V. All rights reserved.

Ultrasound guided cytological aspiration of supraclavicular lymph nodes in patients with suspected lung cancer

Abstract: Background: Lung cancer is the leading cause of death from cancer in the UK Pathological diagnosis traditionally requires invasive procedures such as bronchoscopy, mediastinoscopy, or image guided biopsy Ultrasound of the neck with fine needle aspiration cytology (FNAC) of enlarged but impalpable supraclavicular nodes has been used in patients with suspected lung cancer who have N2 or N3 disease on staging computed tomography (CT) If positive, this technique helps to both stage the patient and provide a cytological diagnosis Methods: 101 patients were enrolled prospectively over a 1 year period FNAC was performed on all supraclavicular nodes over 5 mm in size using the capillary aspiration technique Results: Sixty one of the 101 patients had enlarged supraclavicular nodes and underwent FNAC The overall malignant yield was 455% of patients scanned and 754% of patients sampled As a result of FNAC, 43 patients (426%) avoided more invasive procedures Conclusion: Ultrasound guided FNAC is a promising, relatively non-invasive technique for the staging and diagnosis of patients with lung cancer

Direct complications of repeat median sternotomy in adults.

Abstract: Whilst the potential risk to underlying vital structures from redo-sternotomy is well recognized, the actual risk is poorly quantified. Our aim was to determine the incidence of complications directly attributable to redo-sternotomy and to ascertain whether the use of femoro-femoral CPB (FF) prior to redo-sternotomy alters operative morbidity and mortality. Case notes of 185 patients undergoing cardiac surgery necessitating redo-sternotomy between May 1998 and November 2002 were reviewed. Of 121 males and 64 females, the median age was 65.5 years (range 60.1-75 years). Elective FF was performed in 71 (38.3%) of cases and 114 (60%) were performed without the aid of prior femoro-femoral CPB (WFF). Three (1.6%) patients initially planned for WFF were converted to emergency FF due to serious complications. Complications directly attributable to redo-sternotomy occurred in 21 (11.3%) cases; 12 (16.9%) in the FF group and 9 (5.3%) in the WFF group. Overall mortality was 1.6%. In summary, our results suggest that morbidity risk for the operation increases significantly with redo-sternotomy alone. Three deaths in our series from direct complications attributable to redo-sternotomy signify an added risk. Hence the necessity for careful surgical technique and judicious use of elective FF-CPB is emphasized.

Complications Related to Intra-aortic Balloon Pump in Cardiac Surgery: A Decade Later

Abstract: Background Our centre in 1995 reported 26% of vascular complications in cardiac surgical patients treated with intra-aortic balloon pump (IABP). However, during the last decade there have been improvements in IABP technology and insertion techniques. We aimed to evaluate the impact of these changes on the incidence of IABP-related complications in cardiac surgery. Methods Demographics, indications, technique and complication rate in 186 consecutive patients treated with IABP from January 1994 to December 1998 (Group I) were compared with 323 consecutive patients treated with IABP from January 1999 to December 2003 (Group II) at our regional cardiothoracic centre. Data was variably expressed as mean with or without range and either standard deviation or range. Statistical significance was accepted at P Results There were 121 (65%) and 194 (60%) males in Group I and II, respectively. The mean age was 66±12.1 (17–88) years and the mean duration of IAPB use was 43.5h (range 3–144h). Overall complication rate was 10% in Group I and 2% in Group II whereas vascular complications accounted for 3% in Group-I and 1% in Group-II. Logistic regression analysis demonstrated cardiogenic shock being strongly correlated to in-hospital mortality (OR 4.68; P =0.004) followed by older age (OR 3.12; P =0.034) and ejection fraction P =0.03). Conclusion The study demonstrated a significant decrease in the IABP-related complications even though complexity of cases referred for surgery has increased. Henceforth, the risk of 1% vascular complications should play little influence on decision-making regarding the use of IABP.

An audit of anticoagulation practice among UK cardiothoracic consultant surgeons following valve replacement/repair.

Abstract: BACKGROUND AND AIM OF THE STUDY In 1998, the American College of Cardiology and The American Heart Association (ACC/AHA) published guidelines for the postoperative anticoagulation of patients who have undergone heart valve replacement. The American College of Chest Physicians made similar recommendations in 2001. The present survey was conducted to review anticoagulation practice among UK consultant cardiac surgeons, and to assess compliance with these guidelines. METHODS An anonymous postal questionnaire was distributed to 185 adult cardiac surgeons identified from the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS). RESULTS The analysis was based upon 97 replies. All consultants use lifelong warfarin after mechanical valve replacement. In general, target INR ranges were lower for aortic valves compared with mitral valves. Some 53% (51/97) of consultants never use warfarin after bioprosthetic aortic valve replacement (AVR), compared with 33% (28/86) after bioprosthetic mitral valve replacement (MVR). Temporary (< or = 3 months) warfarin is used by 47% (46/97) of consultants after bioprosthetic AVR and by 63% (54/86) after bioprosthetic MVR. Some 64% (52/81) of consultants use warfarin after mitral valve repair, when an annuloplasty ring is inserted. This was always temporary (< or = 6 months). Aspirin is used long term by 54% (44/82) of consultants after mitral valve repair. CONCLUSION All consultant cardiac surgeons adequately anticoagulate their patients after mechanical valve replacement. Only 16% (16/97) of cardiac surgeons follow current guidelines for the postoperative anticoagulation of bioprosthetic AVR. Only 28% (24/86) of consultant cardiac surgeons comply with guidelines for bioprosthetic MVR. No guidelines exist for the anticoagulation of patients after mitral valve repair. Guidelines need to be reviewed for the anticoagulation of patients undergoing bioprosthetic valve replacement and formulated for patients undergoing mitral valve repair.

Developmental outcome in newborn infants treated for acute respiratory failure with extracorporeal membrane oxygenation: present experience.

Abstract: Objective: To describe the later health status of newborn infants who received extracorporeal membrane oxygenation (ECMO) for acute respiratory failure in the era after the UK ECMO trial. Design: Prospective follow up study of newborn infants who received ECMO at a single centre between January 1997 and January 2001. Setting: Departments of ECMO and Paediatric Intensive Care, University Hospitals of Leicester. Patients: All babies who received ECMO within 14 days of birth. Interventions: Neurodevelopment screening using the schedule for growing skills-II (SGS-II) assessment tool. Main outcome measures: Survival at 12 months of age by disease and functional development at follow up. Results: A total of 145 neonates received ECMO for treatment of respiratory failure. Of these, 108 (75%) were alive at 1 year of age. There were no deaths in children treated for respiratory failure secondary to meconium aspiration syndrome (73/145). Ninety three (86% of survivors) infants attended a follow up visit at 11–19 months postnatal age. Eighty two were classed as normal, seven as having “impairment”, and four as having “severe disability”. Conclusions: Most newborn infants with acute respiratory failure treated with ECMO will have a normal neurodevelopment screening assessment at 11–19 months of postnatal age. There is no evidence to suggest that changes in neonatal practice since the UK ECMO trial have led to changes in outcome of infants undergoing ECMO therapy.

The contribution of peripheral muscle function to shuttle walking performance in patients with chronic obstructive pulmonary disease.

Abstract: PURPOSE The contribution of muscle strength and mass to incremental and endurance walking performance in chronic obstructive pulmonary disease (COPD) is unknown. This study analyzes the relationship between field incremental and endurance walking performance and indices of peripheral muscle mass and strength. METHODS Eighty-five stable COPD patients (53 males; mean [SD] age = 67 [9] years; mean [SD] forced expiratory volume in 1 second [FEV1] = 35 [14] [% predicted]) were studied prior to participation in pulmonary rehabilitation. Isometric quadriceps and handgrip strength were measured. Total body and lower limb lean muscle mass were estimated using dual energy x-ray absorptiometry. Exercise performance was measured using the incremental shuttle walk test (ISWT) and the endurance (ESWT) shuttle walk test. RESULTS ISWT was related to muscle strength (r = 0.467, P

Adenine nucleotide loss in the skeletal muscles during exercise in chronic obstructive pulmonary disease

Abstract: Background: Skeletal muscle adenine nucleotide loss has been associated with fatigue during high intensity exercise in healthy subjects but has not been studied in patients with chronic obstructive pulmonary disease (COPD). Changes in adenine nucleotides and other metabolites in the skeletal muscles were measured in patients with COPD and age matched healthy volunteers by obtaining biopsy samples from the quadriceps muscle at rest and following a standardised exercise challenge. Methods: Eighteen patients with COPD (mean (SD) forced expiratory volume in 1 second 38.1 (16.8)%) and eight age matched healthy controls were studied. Biopsy samples were taken from the vastus lateralis muscle at rest and immediately after a 5 minute constant workload cycle test performed at 80% peak work achieved during a maximal incremental cycle test performed previously. Results: The absolute workload at which exercise was performed was substantially lower in the COPD group than in the controls (56.7 (15.9) W v 143.2 (26.3) W, p<0.01). Despite this, there was a significant loss of adenosine triphosphate (mean change 4.3 (95% CI –7.0 to –1.6), p<0.01) and accumulation of inosine monophosphate (2.03 (95% CI 0.64 to 3.42), p<0.01) during exercise in the COPD group that was similar to the control group (–4.8 (95% CI –9.7 to 0.08), p = 0.053 and 1.6 (95% CI 0.42 to 2.79), p<0.01, respectively). Conclusions: These findings indicate that the ATP demands of exercise were not met by resynthesis from oxidative and non-oxidative sources. This suggests that significant metabolic stress occurs in the skeletal muscles of COPD patients during whole body exercise at low absolute workloads similar to those required for activities of daily living.

Cytokine Imbalance in Infants Receiving Extracorporeal Membrane Oxygenation for Respiratory Failure

Abstract: Background: It is likely that the imbalance between the pro- and anti-inflammatory cytokines will determine the outcome in infants with severe respiratory failure receiving extracorporeal membrane oxygenation (ECMO). Aims: We determined if there was an imbalance between pro- and anti-inflammatory cytokines in serial bronchoalveolar lavage (BAL) fluid obtained from survivors and non-survivors of ECMO. Methods: We therefore measured the cellular changes and the molar ratios of pro-inflammatory and anti-inflammatory cytokines in serial BAL fluid obtained from survivors and non-survivors of ECMO. Fifteen infants surviving ECMO (median age 1 day, range 1–120) and 7 who did not (28 days, range 1–402) were studied. Results: In the lungs of survivors, the increased proportion of airway neutrophils at presentation decreased with time and was matched by a parallel increase in percent alveolar macrophages as the infants’ condition improved. The pro- and anti-inflammatory pulmonary cytokine ratios were static in the survivors. In the non-survivors, the ratio of tumour necrosis factor-α (TNF-α) against soluble TNF-receptor 1 (sTNF-R1) and soluble TNF receptor 2 (sTNF-R2) was increased at days 2–3 when compared to the survivors, but the molar ratio interleukin-1β (IL-1β)/soluble IL-1 receptor antagonist (sIL-1RA) was largely undetectable due to undetectable IL-1β. Conclusions: These data suggest that the infants who survive ECMO resolve their pulmonary inflammation and that in non-survivors the ratio of TNF-α against its receptor antagonists is increased and is associated with a poor outcome. Furthermore, this group of infants were unable to produce significant concentrations of IL-1β.

The MARS trial: mesothelioma and radical surgery.

Abstract: The increasing incidence of malignant pleural mesothelioma has demanded the attention of thoracic surgeons worldwide. Can radical surgery cure mesothelioma or add usefully to the length and quality of life for its victims? The MARS (mesothelioma and radical surgery) trial is open and recruiting in Britain. If the trial proves feasible we will seek to make an international study.

Lung function and blood levels of copper, selenium, vitamin C and vitamin E in the general population.

Abstract: Lung function and blood levels of copper, selenium, vitamin C and vitamin E in the general population

Airway function and markers of airway inflammation in patients with treated hypothyroidism.

Abstract: Background: There is increasing evidence of an association between organ specific autoimmune diseases, particularly autoimmune thyroid disease and respiratory morbidity. A study was undertaken to determine whether patients with autoimmune thyroid disease have objective evidence of airway inflammation and dysfunction. Methods: Twenty six non-smoking women with treated hypothyroidism and 19 non-smoking controls completed a symptom questionnaire and underwent full lung function tests, capsaicin cough reflex sensitivity measurement, methacholine challenge test, and sputum induction over two visits. Results: Symptoms of cough (p = 0.01), dyspnoea (p = 0.01), sputum production (p = 0.004), and wheeze (p = 0.04) were reported more commonly in patients than controls. Patients with hypothyroidism had heightened cough reflex sensitivity compared with controls (geometric mean concentration of capsaicin causing five coughs: 40 v 108 mmol/l; mean difference 1.4 doubling doses; 95% confidence interval of difference 0.4 to 2.5; p = 0.008) and a significantly higher proportion of patients had airway hyperresponsiveness (methacholine provocative concentration (PC20) <8 mg/ml: 38% v 0%; p = 0.016). Patients with hypothyroidism also had a significantly higher induced sputum total neutrophil cell count (p = 0.01), total lymphocyte count (p = 0.02), and sputum supernatant interleukin-8 concentrations (p = 0.048). Conclusion: Patients with treated hypothyroidism report more respiratory symptoms and have objective evidence of airway dysfunction and inflammation.

Bowel obstruction due to Littre hernia: CT diagnosis

Abstract: Meckel diverticulum is the commonest congenital anomaly of the gastrointestinal tract. Any hernia containing the Meckel diverticulum is termed a Littre hernia. Littre hernias are commonest in the inguinal region and may cause bowel obstruction secondary to strangulation or incarceration of the diverticulum within the hernial sac. The diagnosis of an incarcerated Littre hernia on computed tomogram has not been previously reported in the scientific literature.

Successful use of venovenous extracorporeal membrane oxygenation in accidental hypothermic cardiac arrest.

Abstract: Cardiopulmonary bypass is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and cardiovascular instability. We report the first case of accidental severe hypothermia associated with prolonged cardiac arrest that was successfully managed by venovenous extracorporeal membrane oxygenation.

Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax?

Abstract: Objective: Video-assisted thoracoscopic (VATS) bullectomy and apical pleurectomy has become the preferred procedure for recurrent or complicated primary spontaneous pneumothorax (SPN). Although thoracic epidural analgesia is the gold standard after open thoracic surgical procedures, its use in the management of minimally invasive procedures in this young population has not been extensively studied. Methods: From 1997 to 2003, a single surgeon performed 118 consecutive VATS pleurectomies for primary SPN. The perioperative course, analgesic requirements, hospital stay and long-term complications were compared for 22 (18%) patients in whom a patient-controlled thoracic epidural was used for analgesia and 96 (82%) patients who did not receive an epidural (parenteral opioids). A four-point verbal pain score (0‐3) was recorded hourly in every patient at rest and on coughing following surgery. Results: One patient required additional surgery for evacuation of haemothorax. There were no mortalities or other major complications in the series. Overall median hospital stay was 3 (range 1‐10) days, the incidence of long-term pain at 3 months was 6%, and the long-term recurrence rate was 3%. Despite parenteral opioids being discontinued significantly earlier than epidurals, pain scores were similar in both groups. There were no significant differences in the duration of air-leaks, length of drainage, hospital stay, long-term pain and long-term paraesthesias between the two groups. Conclusions: Thoracic epidural analgesia does not contribute significantly to minimize neither perioperative nor long-term pain after VATS pleurectomy for primary SPN. The additional resource requirement in these patients is not justified. q 2005 Elsevier B.V. All rights reserved.

Sputum eosinophilia in idiopathic pulmonary fibrosis.

Abstract: OBJECTIVES AND DESIGN: Cough is a common symptom in idiopathic pulmonary fibrosis that is difficult to treat and has a major impact on quality of life. We tested the hypothesis that the cough and increased cough reflex sensitivity seen in patients with idiopathic pulmonary fibrosis may be due to airway inflammation in a prospective, cross-sectional study. SUBJECTS AND METHODS: We measured the induced sputum inflammatory cell profile and cell-free supernatant inflammatory mediator concentrations in 15 patients with idiopathic pulmonary fibrosis, 17 healthy controls and 15 patients with chronic obstructive pulmonary disease. RESULTS: Both the geometric mean sputum differential eosinophil cell count and median eosinophilic-cationic-protein concentration were significantly higher in patients with idiopathic pulmonary fibrosis than controls (2.1% vs 0.3%; p <0.001 and 1.1 mg/ml versus 0.2 mg/ml; p=0.03 respectively). There were no significant differences in sputum eosinophil counts and eosinophilic-cationic-protein concentrations between patients with idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. Sputum leukotriene-B4 concentrations were significantly lower in patients with idiopathic pulmonary fibrosis (p=0.03) and chronic obstructive pulmonary disease (p=0.008) compared to controls. CONCLUSIONS: Idiopathic pulmonary fibrosis is characterised by the presence of active eosinophilic airway inflammation raising the possibility that airway inflammation may contribute to symptoms such as cough.

Skeletonization of internal thoracic artery affects its innervation and reactivity.

Abstract: Objective: The studies showing the superior characteristics of ITA graft and its impact on the clinical results of coronary artery surgery were performed with ITA harvested almost exclusively as a pedicle. This study assesses the impact of ITA skeletonization on its innervation and reactivity. Methods: Segments of skeletonized and non-skeletonized ITA were stained with antibodies against protein S-100 to look for the presence of sympathetic nerve fibers. The functional studies were performed on segments of discarded human pedicled ITA that were divided into two 3 mm rings, one skeletonized and another non-skeletonized. We compared concentration–effect relationships for the contraction to norepinephrine and endothelium-dependent relaxation to acetylcholine and bradykinin, as well as endothelium-independent relaxation to sodium nitroprusside in skeletonized and non-skeletonized segments of the same ITA. Results: Skeletonized ITA was devoid of protein S-100 positive nerve fibers. It contracted stronger (maximal response 37.0G2.04 vs. 25.4G1.83 mN (P!0.001)) and was twice as sensitive to norepinephrine: pD2 6.03G0.10 vs. 5.70G0.12 (PZ0.035). The endothelium-dependent relaxation responses did not differ between skeletonized and non-skeletonized ITA rings. The skeletonized ITA rings appeared over 10 times more sensitive to sodium nitroprusside: pD2 6.66G0.20 vs. 5.59G0.37 (PZ0.012)—potency ratio 11.61. The maximal responses did not differ significantly: 112.0G6.71 vs. 129.4G16.4% (PZ0.33). Conclusions: Skeletonization results in sympathectomy of ITA. It has no effect on endothelium-dependent relaxation but increases reactivity of ITA to norepinephrine. This augmented response to a-agonist is small, in comparison with over a ten-fold increase in sensitivity to sodium nitroprusside. Pedicled and skeletonized ITA are functionally significantly different vessels when studied in vitro. Q 2005 Elsevier B.V. All rights reserved.