The determination of relevant goals and criteria used to select an automated patient care information system: a Delphi approach.

OBJECTIVES: To determine the relevant weighted goals and criteria for use in the selection of an automated patient care information system (PCIS) using a modified Delphi technique to achieve consensus. DESIGN: A three-phase, six-round modified Delphi process was implemented by a ten-member PCIS selection task force. The first phase consisted of an exploratory round. It was followed by the second phase, of two rounds, to determine the selection goals and finally the third phase, of three rounds, to finalize the selection criteria. RESULTS: Consensus on the goals and criteria for selecting a PCIS was measured during the Delphi process by reviewing the mean and standard deviation of the previous round's responses. After the study was completed, the results were analyzed using a limits-of-agreement indicator that showed strong agreement of each individual's responses between each of the goal determination rounds. Further analysis for variability in the group's response showed a significant movement to consensus after the first goal-determination iteration, with consensus reached on all goals by the end of the second iteration. CONCLUSION: The results indicated that the relevant weighted goals and criteria used to make the final decision for an automated PCIS were developed as a result of strong agreement among members of the PCIS selection task force. It is therefore recognized that the use of the Delphi process was beneficial in achieving consensus among clinical and nonclinical members in a relatively short time while avoiding a decision based on political biases and the "groupthink" of traditional committee meetings. The results suggest that improvements could be made in lessening the number of rounds by having information available through side conversations, by having other statistical indicators besides the mean and standard deviation available between rounds, and by having a content expert address questions between rounds.

Treatment of progressive rheumatoid interstitial lung disease with cyclosporine.

A 62-year-old man with longstanding rheumatoid arthritis (RA) presented with dyspnea. Active rheumatoid interstitial lung disease was documented by high resolution computed tomography, gallium scan, and bronchoalveolar lavage. He responded to high dose prednisone, but had unacceptable side effects. Chlorambucil and cyclophosphamide were not steroid sparing. After starting cyclosporine 3 mg/kg/day he was able to stop prednisone and his symptoms improved and stabilized. Pulmonary function showed sustained improvement during 2 years of followup. His RA has been well controlled. Side effects have been mild hypertension and increased serum creatinine.

Cryptogenic organizing pneumonia. A report of 25 cases and a review of the literature.

Cryptogenic organizing pneumonia (COP), also known as bronchiolitis obliterans organizing pneumonia (BOOP), is an uncommon lung disease characterized by the presence of granulation tissue within the alveolar ducts and alveoli. Because of the limited published literature on this topic and limited information on outcome we reviewed our own experience over an 8-year period and also critically evaluated the literature. We reviewed all cases of COP diagnosed from 1985 through 1992 at Vancouver General Hospital: 25 patients (14 male, 11 female) aged 20-77 years (mean, 49 yr, SD +/- 17 yr). Nine patients had myeloproliferative disorder, including 6 who had allogenic bone marrow transplants; 2 patients had connective tissue disease; and 14 patients had no underlying disease (idiopathic). Data retrieved retrospectively from clinical records included demographics, risk factors, symptoms, chest radiographs, computerized tomograms, lung function tests, therapy prescribed, and response to therapy. Symptoms included dyspnea and cough (n = 15) (60%), cough only (n = 10) (40%), and fever (n = 15) (60%). Twenty-two patients were diagnosed by open lung biopsy and 3 by transbronchial biopsy. Lung imaging showed bilateral patchy airspace consolidation or nodular opacities as the main finding in 22 patients. Pulmonary function tests showed a combined restrictive and obstructive pattern. All patients received prednisone therapy except 1 patient whose idiopathic findings resolved completely with minimal treatment. Eight patients died, including 4 of the 9 patients with myeloproliferative disorder--2 from a combination of respiratory failure due to COP and graft-versus-host disease. One of 2 patients with connective tissue disease died, and 3 of 14 patients with idiopathic COP died. COP is an uncommon condition but should be considered in patients with bilateral airspace disease, especially those who fail to respond to antibiotics for presumed pneumonia. Although pulmonary function tests and CT scan findings in conjunction with the clinical features usually suggest the diagnosis, definite confirmation usually requires either open lung biopsy or transbronchial biopsy. Histologic confirmation of the diagnosis is particularly warranted as therapy with corticosteroids is usually needed for a number of months. The prognosis is excellent with idiopathic cases but more guarded especially when COP is associated with lymphoproliferative or connective tissue disease.

Pulmonary hypertension associated with primary biliary cirrhosis in the absence of portal hypertension: a case report.

Pulmonary hypertension is well described in association with portal hypertension of any cause including end stage primary biliary cirrhosis (PBC). The essential feature of this association is the presence of portosystemic shunting, including surgically created shunts. A patient with primary pulmonary hypertension and PBC without portal hypertension is reported. This suggests that primary pulmonary hypertension may be associated with PBC in the absence of portal hypertension. Decisions regarding appropriate organ transplantation may depend on whether pulmonary hypertension is primary or secondary to portal hypertension.

Assessment of patient acceptance and inhalation technique of a pressurized aerosol inhaler and two breath-actuated devices.

OBJECTIVE: To assess inhalation technique in patients after written instruction alone, written and verbal instruction, and clinical use of two new inhalation devices. DESIGN: Randomized, crossover evaluation of the albuterol Diskhaler and the terbutaline Turbuhaler. SETTING: Canadian tertiary-care hospital. PATIENTS: Twenty hospitalized adults with asthma or chronic obstructive pulmonary disease currently using an albuterol metered-dose inhaler (MDI). Nineteen patients received Diskhaler, 16 received Turbuhaler, 15 received both inhalers, and 10 patients used both inhalers for three days each. INTERVENTIONS: Patients were randomized to receive either Diskhaler or Turbuhaler for three days. Inhaler technique was assessed after written instruction, written plus verbal instruction, at the first scheduled dose after instruction, and after three days of clinical use. Patients remaining in the hospital after three days crossed over to the other study inhaler and the same protocol was followed. MAIN OUTCOME MEASURES: Patient inhalation technique was assessed and compared for the MDI, Diskhaler, and Turbuhaler. RESULTS: Assessment of MDI technique revealed that 35 percent of patients used their MDI correctly on the first puff, and 42 percent used it correctly on the second puff. Following written instruction alone, correct technique was demonstrated by 32 percent of patients with Diskhaler and 6 percent with Turbuhaler. Technique significantly improved following verbal instruction, although 40 percent of the patients required up to three attempts to demonstrate correct technique on at least one of the study inhalers. After three days of clinical use, correct technique was demonstrated in only 54 percent of the Diskhaler and 64 percent of the Turbuhaler assessments. Performance at this assessment was, however, significantly better on the Turbuhaler than on the MDI (p = 0.01). Performance on the Diskhaler was not significantly different from the performance on the other inhalers. CONCLUSIONS: Written instruction alone is inadequate in teaching correct inhalation technique. Verbal instruction and technique assessment are essential for patients to achieve proper technique. Patients may perform better on the Turbuhaler than on other inhalation devices.

Outcome of hepatitis B virus infection in homosexual men and its relation to prior human immunodeficiency virus infection.

To investigate the effect of human immunodeficiency virus type 1 (HIV-1) infection on subsequent hepatitis B virus (HBV) infection, HIV antibody was sought in homosexual men who developed HBV infection during a hepatitis B vaccine trial. Among 134 unvaccinated HIV-1-negative men, 7% became HBV carriers, 64% had viremia, and 42% had clinical illness. Among vaccinated HIV-1-negative men, HBV infection severity decreased with number of vaccine doses administered. When adjusted for prior hepatitis B vaccination status, persons with HIV-1 infection preceding HBV infection had a significantly higher risk of developing HBV carriage, viremia, prolonged ALT elevation, and clinical illness. Among HIV-1-infected men, the risk of HBV carriage was increased in unvaccinated persons (21%) and those who failed to respond to vaccination (31%) and further increased in those who received vaccine doses at the time they developed new HBV infection (56%-80%), suggesting inactivated hepatitis B vaccine may temporarily impair the immune response to HBV infection in HIV-1-infected persons. HIV-1 infection was also associated with reduced alanine aminotransferase elevations during the first 36 months of follow-up of men who became HBV carriers.

High-resolution computed tomography of chronic interstitial lung disease.

The absence of superimposition of parenchymal structures on HRCT permits better assessment of the pattern and distribution of disease than is possible on the radiograph. Several studies have shown that HRCT is superior to the chest radiograph in the diagnosis and management of patients with chronic interstitial lung disease. High-resolution studies may demonstrate extensive parenchymal disease when the radiograph is normal and allow for a confident diagnosis when the radiographic findings are nonspecific. It is superior to the chest radiograph in determining whether transbronchial or open lung biopsy is indicated, and it is essential in selecting the optimal biopsy site. Although further studies are required to determine the precise role of HRCT in interstitial lung disease, current indications for HRCT include: (1) assessment of patients with symptoms suggestive of infiltrative lung disease but normal or nonspecific findings on the radiograph; (2) further evaluation of the lung parenchyma in patients in whom the radiographic findings are not in keeping with the clinical history or symptomatology; (3) as a guide to the optimal biopsy site in all patients undergoing open or transbronchial biopsy; and (4) assessment of suspected complications (e.g., infection) in patients with diffuse lung disease.

Sarcoidosis: correlation of extent of disease at CT with clinical, functional, and radiographic findings.

Computed tomography (CT) was compared with chest radiography in the assessment of disease severity in 27 patients with sarcoidosis. The CT scans and radiographs were each read twice by two independent observers. Disease extent was assessed on CT scans by visual scoring (0%-100% involvement of the lung parenchyma) and on radiographs by using an adaptation of the International Labour Office classification. The severity of parenchymal changes on the CT scan and on the radiograph was significantly correlated with the severity of dyspnea (r = .61 and .58, respectively; P less than .001), diffusing capacity (r = -.62 and -.52, P less than .01), and vital capacity (r = -.49 and -.51, P less than .01). Patients with predominantly irregular opacities had more severe dyspnea and lower lung volumes than patients with predominantly nodular opacities (P less than .05). The authors conclude that in patients with sarcoidosis, the radiographic and CT assessments of disease severity show similar correlation with clinical and functional impairment.

Multicentricity of adenocarcinoma of the lung.

In a consecutive series of 62 lung resections for bronchogenic adenocarcinoma, 12 patients (19 percent) were found to have two or more adenocarcinomas on careful pathologic examination. These tumors all met the criteria for separate primary malignancy. In only two of the patients were the additional lesions suspected preoperatively. This incidence of multiple primary lung adenocarcinomas in apparently operable patients is several fold higher than would be anticipated from the literature. The phenomenon has important implications for preoperative radiologic evaluation, postoperative pathologic examination, assignment of TNM stage, and clinical follow-up of patients undergoing successful resection.

Pulmonary lymphangitic carcinomatosis: CT and pathologic findings.

The authors retrospectively reviewed the computed tomographic (CT) scans, biopsy specimens, autopsy results, and lobectomy specimens of 21 patients who had lymphangitic carcinomatosis. Ten-millimeter collimation CT scans were obtained from all patients, and selected 1.5-mm CT scans were obtained from ten patients. In five patients, the diagnosis was established with open lung biopsy, lobectomy, or autopsy; in nine, with bronchial biopsy or transbronchial biopsy; and in seven, with clinical and radiologic criteria. Certain characteristic findings on CT scans were evident: uneven thickening of bronchovascular bundles, thickening of isolated interstitial lines, and the presence of polygonal lines. These findings may be seen on CT scans even if the findings on chest radiographs are normal or nonspecific. The pathologic basis for these characteristic CT findings may relate to tumor thrombi in lymphatic vessels rather than edema and fibrosis, at least in the early stages of disease.

Glandular neoplasia of the lung. A proposed analogy to colonic tumors.

In 62 consecutive resections for adenocarcinoma of the lung, 50 cases (81%) had single adenocarcinomas and 12 (19%) had multiple adenocarcinomas. In seven of these 12 patients, two adenocarcinomas were found. In the other five patients, the specimen contained a dominant adenocarcinoma and several 0.1- to 1-cm nodules of similar histologic appearance. In four of the 50 single tumor patients and one of seven double tumor patients, 1- to 2-mm nodules were found along with adenocarcinomas that we interpreted as being bronchioloalveolar tumors of uncertain malignant potential. An analogy is drawn between these four types of findings and single tumors of the colon, double tumors of the colon, polyposis syndromes, and tubular adenomas of the colon, respectively.

Disease activity in idiopathic pulmonary fibrosis: CT and pathologic correlation.

Computed tomography (CT) scans were compared with pathologic determinants of disease activity in 12 patients with idiopathic pulmonary fibrosis. The theory was that intraalveolar and interstitial cellularity would result in areas of opacification of air spaces on CT scans. All patients underwent open lung biopsy, and disease activity was assessed with a pathologic grading system. Seven patients had mild disease activity, five had moderate to marked disease activity. Opacification of air spaces was patchy in distribution, predominantly peripheral, and seen better on 1.5-mm rather than 10-mm collimation scans. Disease activity on CT scans was graded independently from 0 to 3 based on the presence and relative density of the areas of air space consolidation compared with the surrounding parenchyma. The pathologic score was significantly greater in the patients with high CT scores than in those with low CT scores (P = .001). Five patients with marked disease activity and five of seven patients with mild disease activity were correctly identified. CT may be useful in the assessment of disease activity in idiopathic pulmonary fibrosis.

Lingular and right middle lobe biopsy in the assessment of diffuse lung disease.

It has been said that the lingula and right middle lobe should be avoided for open-lung biopsy because of nonspecific fibrosis and vascular changes. To determine if the diagnostic yields of lingular or right middle lobe biopsy specimens were unsatisfactory, we reviewed the results of open-lung biopsy in 73 adult patients; 26 were immunocompromised and 47, nonimmunocompromised. We found no evidence to suggest that these two sites were inherently inferior. In 20 of the nonimmunocompromised patients, computed tomography was performed prior to biopsy, and demonstrated no particular tendency for greater involvement of the lingula or right middle lobe. We conclude that lingular and right middle lobe biopsy is useful in the diagnosis of parenchymal lung disease and that these sites should not necessarily be avoided. Computed tomographic scanning prior to biopsy is helpful in guiding the surgeon to the appropriate sites from which to obtain biopsy specimens.

Seeding of malignant cells into the needle track after lung and pleural biopsy.

Transthoracic needle biopsy is frequently performed for the diagnosis of pulmonary and pleural disease. Seeding of malignant cells is a potential complication but is extremely uncommon. We report the second patient with malignant seeding after fine-needle aspiration biopsy of a bronchogenic carcinoma. We also report a patient with seeding of bronchogenic carcinoma after a pleural biopsy. Because seeding is a rare complication, it does not affect the indications for biopsy.

Fibrosing alveolitis: CT-pathologic correlation.

Computed tomography (CT) was performed within 10 days of open lung biopsy in nine patients with fibrosing alveolitis. One-centimeter collimation contiguous scans through the chest were obtained in all patients. Additional 1.5-mm collimation scans were obtained in the area in which lung biopsy was later performed in six patients. In seven patients, CT demonstrated patchy involvement of the lung parenchyma, areas with a reticular pattern being intermingled with areas of normal lung. The reticular pattern was associated with cystic spaces 2-4 mm in diameter and was more severe in the lung periphery. Histologically, the reticular pattern corresponded to areas of irregular fibrosis. One patient had diffuse honeycombing (2-20-mm cysts), and one had honeycombing only in the lung periphery. In all patients, CT clearly defined the architectural changes seen on open lung biopsy. These changes were much better seen on the 1.5-mm than on the 10-mm collimation scans. CT may be helpful in determining the pattern and distribution of lung involvement in patients with fibrosing alveolitis and in guiding the surgeon to the most appropriate area(s) for biopsy.