Histologist's original opinion compared with multidisciplinary team in determining diagnosis in interstitial lung disease.

Guidelines recommend that multidisciplinary interstitial lung disease meeting (ILD MDT) decisions become the gold standard for diagnosis, replacing the histologist from this position, and identify this as requiring supportive evidence. We have compared diagnoses from lung biopsy material made by expert histologists with the subsequent consensus opinion from a properly constituted ILD MDT in 71 consecutive patients referred to a regional thoracic unit. MDT changed the original histological diagnoses in 30% (95% CI 19.3% to 41.6%) and strengthened the diagnoses from probable to confident in a further 17% (95% CI 9.1% to 27.7%). The assessment of hypersensitivity pneumonitis, non-necrotising granulomas and organising pneumonia accounted for the majority of the changes.

Biopsy-proven hypersensitivity pneumonitis caused by a fluorocarbon waterproofing spray.

BACKGROUND: We present the case of a 35-year-old male who developed a chronic hypersensitivity pneumonitis (HP) following inhalational exposure to a fluorocarbon waterproofing aerosol spray, caused by his work for an upholstery and soft furnishings retailer. This is the first case report from inhalational fluorocarbon exposure with histological evidence of chronic HP. This is then discussed in the context of previous reports of interstitial lung disease and lung injury, caused by similar occupational and non-occupational exposures.

WISE 2005: stroke volume changes contribute to the pressor response during ischemic handgrip exercise in women.

The mechanism of the pressor response to small muscle mass (e.g., forearm) exercise and during metaboreflex activation may include elevations in cardiac output (Q) or total peripheral resistance (TPR). Increases in Q must be supported by reductions in visceral venous volume to sustain venous return as heart rate (HR) increases. Therefore, this study tested the hypothesis that increases in Q, supported by reductions in splanchnic volume (portal vein constriction), explain the pressor response during handgrip exercise and metaboreflex activation. Seventeen healthy women performed 2 min of static ischemic handgrip exercise and 2 min of postexercise circulatory occlusion (PECO) while HR, stroke volume and superficial femoral artery flow (Doppler), blood pressure (Finometer), portal vein diameter (ultrasound imaging), and muscle sympathetic nerve activity (MSNA; microneurography) were measured followed by the calculation of Q, TPR, and leg vascular resistance (LVR). Compared with baseline, mean arterial blood pressure (MAP) (P < 0.001) and Q (P < 0.001) both increased in each minute of exercise accompanied by a approximately 5% reduction in portal vein diameter (P < 0.05). MAP remained elevated during PECO, whereas Q decreased below exercise levels. MSNA was elevated above baseline during the second minute of exercise and through the PECO period (P < 0.05). Neither TPR nor LVR was changed from baseline during exercise and PECO. The data indicate that the majority of the blood pressure response to isometric handgrip exercise in women was due to mobilization of central blood volume and elevated stroke volume and Q rather than elevations in TVR or LVR resistance.

Inflammatory myofibroblastic tumours of the respiratory system and the impact of the varying patterns.

Inflammatory fibroblastic tumours are very rare. They are mostly located in the respiratory system. We present three cases of patients with fibroblastic tumours. The diversity of inflammatory fibroblastic tumours in the respiratory system and the surgical considerations are discussed. Our recommendation is that treatment should include a complete resection to prevent local recurrence and malignant transformation, and follow-up review should reflect the procedure carried out, especially in terms of the anatomical location and the extent of the surgical procedure performed.

An evaluation of partner notification for HIV infection in genitourinary medicine clinics in England.

OBJECTIVE: To evaluate the feasibility and effectiveness of a standardized HIV partner notification programme within genitourinary medicine clinics in England. DESIGN: A prospective survey of HIV partner notification activity over a 12-month period. SETTING: Nineteen genitourinary medicine clinics in England. PATIENTS AND PARTICIPANTS: A total of 501 eligible HIV-positive patients (either newly diagnosed or with whom partner notification had not been undertaken previously) seen during the study period. MAIN OUTCOME MEASURES: The numbers of partners named by patients, and the number of contacts notified, counselled and HIV-tested. RESULTS: Information on overall partner notification activity was obtained by reviewing available medical records of 471 patients; 353 (75%) had discussed partner notification with a health-care worker during the study period and 197 (42%) had undertaken partner notification. Detailed information on outcomes was obtained for only 70 patients who named 158 contacts as being at risk of acquiring HIV. Although 71 (45%) contacts were eventually notified, only 28 were subsequently seen in participating clinics. Almost all contacts (n = 27) requested HIV counselling and testing, and five were diagnosed HIV-positive. Patient referral was the most popular notification method chosen. CONCLUSIONS: This study illustrates some of the practical difficulties that limit HIV partner notification within genitourinary medicine clinics. These include health-care workers' misgivings about undertaking partner notification, insufficient locating information to identify contacts, and migration of newly diagnosed patients, which prevents continuity and completion of notification. Nevertheless, HIV partner notification uncovered previously undiagnosed HIV infections. Further work needs to be undertaken in staff training and policy implementation if higher rates of partner notification and outcome measurements are to be achieved.

Prenatal pericardiocentesis: its role in the management of intrapericardial teratoma.

A fetus with intrapericardial teratoma had a large pericardial effusion diagnosed by echocardiography. Cardiac tamponade, a common cause of fetal death, was averted by intrauterine pericardiocentesis. Planned obstetric and neonatal management permitted surgical treatment before cardiorespiratory distress developed. The tumor was completely excised and the infant is asymptomatic.

Transurethral prostatic tissue ablation via a single needle delivery system: initial experience with radio-frequency energy and ethanol.

We report an initial clinical experience to evaluate the safety and efficacy of outpatient prostatic ablation for the treatment of symptomatic benign prostatic hyperplasia (BPH) using local anesthesia (OPAL) with radio-frequency energy and intraprostatic absolute ethanol injection (EI). Twenty-three patients were treated with OPAL and five patients were treated with EI. Pre-operative data for all patients included international prostate symptom score (IPSS), quality of life score (QL), maximum flow rate (Q(max)), and post void residual determination. Prostate specific antigen (PSA) and transrectal ultrasound prostate volume determination were also done for EI patients. Needle deployment into the prostate was carried out at the 2, 4, 8 and 10 o'clock positions for lateral lobe hyperplasia and the 6 o'clock position for middle lobe hyperplasia. IPSS, QL, Q(max) and post void residual data were collected at 1, 3, 6 and 12 months post procedure. Both procedures resulted in statistically significant reductions of IPSS and QL. Trends towards improvement were seen both for Q(max) and post void residual, with Q(max) significantly improved after OPAL. Among EI patients, the prostate volume was reduced at 6 months post treatment to 37.2+/-17.9 g from 53.0+/-19.0 g (P=0.03) preoperatively. OPAL was safe but suffered from a high re-treatment rate. EI demonstrated encouraging results with regards to safety, symptom improvement and prostate volume reduction.

Effects of control beliefs and attributions on memory self-assessments and performance.

Individual differences in memory performance among elderly adults be due, in part to variability in personality and metamemory variables. We examined whether control beliefs, attributions, and depression were related to memory self-assessments, performance, and change in these variables across two trials. Participants were 47 elderly adults (M age = 69.72 years). Results of multiple regression analyses were consistent with predictions. Those individuals with stronger internal control beliefs made higher self-assessments at the first trial. Those who made higher assessments and those younger in age had higher performance at the first trial. Those with higher performance at the first trial and those who attributed this performance to internal, stable, and global causes were less likely to show decrements in self-assessments and performance across trials. Implications of the findings for enhancing memory performance are discussed.

Use of alfentanil sedation anesthesia with the Dornier HM3 lithotripter.

Our results with the combination anesthetic technique of midazolam-alfentanil during elective outpatient extracorporeal shock wave lithotripsy on the Dornier HM3 (N = 79) were compared with those of epidural anesthesia in the same setting (N = 81). The mean anesthesia time and recovery room time were significantly shorter (72.85 v 113.58 minutes and 115.0 v 159.20 minutes, respectively) with the combination technique. No procedures in the alfentanil group had to be discontinued because of patient discomfort. Side effects with alfentanil were minimal, and oxygen saturation remained above 90% for all patients. Combination midazolam-alfentanil anesthesia is safe and allows the urologist to treat renal and ureteral calculi effectively and efficiently without using general or regional anesthesia.

Neuroradiology critical findings lists: survey of neuroradiology training programs.

BACKGROUND AND PURPOSE: The Joint Commission has identified timely reporting of critical results as one of the National Patient Safety Goals. We surveyed directors of neuroradiology fellowships to assess and compare critical findings lists across programs. MATERIALS AND METHODS: A 3-question survey was e-mailed to directors of neuroradiology fellowships with the following questions: 1) Do you currently have a "critical findings" list that you abide by in your neuroradiology division? 2) How is that list distributed to your residents and fellows for implementation, if at all? and 3) Was this list vetted by neurology, neurosurgery, and otolaryngology departments? Programs with CF lists were asked for a copy of the list. Summary and comparative statistics were calculated. RESULTS: Fifty-one of 89 (57.3%) programs responded. Twenty-one of 51 (41.2%) programs had CF lists. Lists were distributed during orientation, sent via Web sites and e-mails, and posted in work areas. Eleven of 21 lists were developed internally, and 5 of 21, with the input from other departments. The origin of 5 of 21 lists was unknown. Forty CF entities were seen in 20 submitted lists (mean, 9.1; range, 2-23). The most frequent entities were the following: cerebral hemorrhage (18 of 20 lists), acute stroke (15 of 20), spinal cord compression (15 of 20), brain herniation (12 of 20), and spinal fracture/instability (12 of 20). Programs with no CF lists called clinicians on the basis of "common sense" and "clinical judgment." CONCLUSIONS: Less than a half (41.2%) of directors of neuroradiology fellowships that responded have implemented CF lists. CF lists have variable length and content and are predominantly developed by radiology departments without external input.

Physiological features of pericardial constriction in the absence of pericardial disease.

To sustain a clinical diagnosis of constriction it is classically held that the fibrous pericardium must be thickened and adherent to the surface of the heart. A case is presented in which leukaemic infiltration of the fat overlying the myocardium resulted in the physiological features of constriction, although all layers of the pericardium itself were normal. Constriction is thus a physiological diagnosis; it may develop in the absence of the classical anatomical findings.

Retrograde percutaneous nephrolithotomy: urological treatment of a urological problem.

We present our experience during a 22-month period with the retrograde approach to gain renal access for percutaneous stone removal in 71 consecutive patients. The retrograde puncture technique is fast and accurate, and it allows the physician to perform a 1-stage operation, saving the patient time, frustration and expense. The Lawson technique was used in all patients and it was successful in all but 2. In those 2 patients the Hawkins-Hunter technique was successful. There were no intraoperative or postoperative complications related to this approach. Except for 1 patient who suffered a post-procedure pulmonary embolus, no transfusions were required. The targeted stone was removed in 1 procedure in 61 of 71 patients (86 per cent). Ten patients required another procedure to remove the targeted stone or a second stone. Percutaneous procedures still are required for certain stone problems or when extracorporeal shock wave lithotripsy is not readily available. The ability of the urologist to perform this easy procedure will allow him more choice in how to manage stone patients.

Lymphoblastic response to autologous colon epithelial cells in ulcerative colitis in vitro.

The blastic transformation in vitro of peripheral blood lymphocytes was measured by the 72-hour uptake of tritiated thymidine ((3)H-6-thymidine) in 23 patients with mucosal ulcerative colitis, three patients with acute Crohn's colitis with rectal involvement, and seven normal subjects. The 23 patients with ulcerative colitis were subdivided into three groups, graded according to severity into seven with acute, severe, nine with active, chronic, and seven with quiescent disease. In the control cultures of lymphocytes without any added potential stimulant the uptake of (3)H-6-thymidine in the clinical subgroup of seven patients with acute, severe ulcerative colitis was significantly greater than in seven normal subjects (p<0.01). This contrasted with a reduced uptake of (3)H-6-thymidine by lymphocytes from seven patients with acute severe colitis when compared with seven normal subjects after stimulation with phytohaemagglutinin-P (PHA-P) (p<0.01). In further duplicate cultures of lymphocytes specifically stimulated by an equal number of viable autologous rectal epithelial cells, the uptake of (3)H-6-thymidine was significantly greater in seven patients with acute severe colitis when compared with seven normal subjects (p<0.01). The results in three patients with acute Crohn's colitis with rectal involvement showed no such evidence of lymphocyte sensitivity to autologous rectal epithelial cells and their uptake of (3)H-6-thymidine lay within the normal range.Evidence that the degree of lymphoblastic transformation was related to the clinical severity of ulcerative colitis was provided by the results obtained in the unstimulated and epithelial cell stimulant cultures. The uptake of (3)H-6-thymidine was directly related to the clinical severity of ulcerative colitis in the three subgroups studied. In addition, four of the seven patients with acute severe colitis were studied later in clinical remission. They were then found to have a significantly reduced uptake of (3)H-6-thymidine in response to autologous rectal epithelial cells (p < 0.01).

Marfan's disease and Erdheim's cystic medionecrosis. A study of their pathology.

Differentiation between Marfan's disease, or its forme fruste counterpart and Erdheim's cystic medionecrosis can be made in cases of aortic dilatation or dissection. This study examined the morphological features at light microscopy of aortic tissue, removed at surgery in 10 patients with Marfan's disease. A separate group consisted of 24 patients who did not express the complete Marfan phenotype but had family members who displayed the full and typical features of the disease. This group represented the so-called 'forme fruste' variant. These two groups were compared with 12 patients in whom a histopathological diagnosis of Erdheim's cystic medionecrosis had been made. Finally normal aortic tissue from post-mortem subjects were made available representing controls. In each case the degree of elastic fragmentation and cystic change of the aortic media was assessed and tabulated. The results indicate that severe fragmentation of elastic is similarly identifiable in both Marfan and Marfan forme fruste groups and that differentiation is easy pathologically from subjects with the comparatively modest fragmentation seen in Erdheim's cystic medionecrosis. Although cystic change was encountered in all groups, its severity tended to parallel the age of the subject, and we consider from our study that Erdheim's cystic medionecrosis represents no more than an exaggerated age-related change.

The detection of serological factors in acute ulcerative colitis indicating a favourable short-term prognosis.

Large-intestinal epithelial cells were obtained from operation specimens and by biopsy at sigmoidoscopy from 16 patients with acute severe mucosal ulcerative colitis and II control subjects with normal large-bowel mucosa. The ability of lymphocytes to release 51Cr label from large-intestinal epithelial cells was quantitatively assessed as percentage lymphocyte activity. The mean +/- standard deviation of percentage lymphocyte activity in 16 patients with acute ulcerative colitis on admission to hospital (88 +/- 8) was significantly greater than that in II normal subjects (16 +/- 8) (P is less than 0.01). In each study, samples of autologous serum were added to two reactions between lymphocytes and autologous large-intestinal epithelial cells. The results in the seven patients who came to urgent colectomy differed significantly from those in the nine who responded to corticosteroids. The mean +/- S.D. of percentage serological inhibition of lymphocyte activity in the group coming to colectomy was 44 +/- 16, and in those responding to steroids 12 +/- 5. When the serum of these patients was studied for immunofluorescent autoantibodies to normal human colonic mucosa, none of the seven patients treated by colectomy had detectable autoantibodies, in contrast with three of the nine patients with a more favourable short-term prognosis, in that they responded to steroid treatment.

The in-vitro action of lymphocytes on autologous colon epithelial cells in ulcerative colitis.

The action in culture of peripheral blood lymphocytes on autologous large-intestinal epithelial cells was studied in 13 patients with severe mucosal ulcerative colitis. Two different methods were used to measure lymphocyte activity. These showed that autologous-lymphocyte-induced release of isotopic label and detachment in monolayer culture of large-intestinal epithelial cells was increased in acute ulcerative colitis when compared with findings in the same studies in six normal subjects. Subsequently in four of the six patients who responded to cortisone it was shown that lymphocyte activity against epithelial cells returned to the normal range. Further control studies showed little lymphocyte activity against autologous skin and ileum, suggesting that autologous-lymphocyte-induced damage of large-intestinal epithelial cells is a tissue-specific reaction in patients with acute ulcerative colitis. The absence of reactivity in other colonic inflammatory diseases also suggested that such increased in vitro lymphocyte activity is disease-specific for ulcerative colitis.

Metastatic rat adenocarcinoma: histochemical evaluation of fibroblasts and extracellular matrix.

This study was based on the hypothesis that after tumour transplantation, fibroblast metabolism increases adjacent to a tumour and this increase correlates with an increase in certain components of the extracellular matrix. A serial histochemical study of the cellular metabolism and extracellular matrix in a fast-growing mammary rat carcinoma was designed. The model used was the N-nitrosomethylurea-induced adenocarcinoma. At 24, 48, 72 or 96 h after transplantation, tumours and surrounding tissues were excised and processed. Ribonucleic acid and succinate dehydrogenase stains were used to indicate cellular metabolism; the extracellular matrix was stained for collagen, elastin, acid mucopolysaccharides, mucoproteins, glycoproteins and glycolipids. The results of this histology were compared with the histology of nonneoplastic transplants. In subcutaneous tissue adjacent to neoplasia, fibroblasts were abundant and showed an increase in metabolism between 24-96 h; this was correlated with an increase in collagen. For nonneoplastic transplants, fibroblasts were present only at 96 h, and collagen increases did not occur. It is inferred from the results that the tumour transplant is responsible for the increase in fibroblast metabolism in vivo which in turn increases fibre production.

Gamna-Gandy nodules in a cardiac myxoma.

A 33-year-old female was admitted for surgery for removal of a left atrial myxoma. Histological examination of the tumour showed features characteristic of myxoma. Additionally, Gamna-Gandy bodies were present in the tumour. This is a rare finding.