Lung cancer physicians' referral practices for palliative care consultation.

BACKGROUND: Integration of palliative care with standard oncologic care improves quality of life and survival of lung cancer patients. We surveyed physicians to identify factors influencing their decisions for referral to palliative care. METHODS: We provided a self-administered questionnaire to physicians caring for lung cancer patients at five medical centers. The questionnaire asked about practices and views with respect to palliative care referral. We used multiple regression analysis to identify predictors of low referral rates (<25%). RESULTS: Of 155 physicians who returned survey responses, 75 (48%) reported referring <25% of patients for palliative care consultation. Multivariate analysis, controlling for provider characteristics, found that low referral rates were associated with physicians' concerns that palliative care referral would alarm patients and families [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.21-0.98], while the belief that palliative care specialists have more time to discuss complex issues (OR 3.07, 95% CI 1.56-6.02) was associated with higher rates of referral. CONCLUSIONS: Although palliative care consultation is increasingly available and recommended throughout the trajectory of lung cancer, our data indicate it is underutilized. Understanding factors influencing decisions to refer can be used to improve integration of palliative care as part of lung cancer management.

Immunoglobulin levels in psychiatric patients.

In a study of 19 schizophrenic patients, 7 nonschizophrenic patients, and 31 controls, the authors found significantly higher mean serum levels of 1) immunoglobulin A in schizophrenic women then in control women and in schizophrenic blacks than in either schizophrenic whites or black controls. 2) immunoglobulin D in schizophrenic blacks than in schizophrenic whites, 3) immunoglobulin M in controls than in nonschizophrenic patients, and 4) immunoglobulin G (IgG) in schizophrenics whose urine was positive for phenothiazines than in schizophrenics whose urine was negative for phenothiazines. High serum levels of IgG were associated with no or mild hallucinations and low levels with moderate or severe hallucinations. Black female patients had significantly more severe hallucinaions than white female patients. The authors discuss the possible implications of these findings.

Development of a model system to evaluate methods for radiolabeling monoclonal antibodies.

We have developed a model system that can be used to evaluate methods for radiolabeling monoclonal antibodies. In this system, dinitrophenyl (DNP) is used as a model antigen, and HDP-1 (a monoclonal antibody specific for DNP) is used as a model monoclonal antibody. DNP-coupled agarose beads are injected into the femoral veins of rats, after which they localize in the animals' lungs. Radiolabeled antibody can then be injected and its biodistribution monitored. We describe here the development and initial testing of the model with radioiodinated antibody.

Empyema due to ventriculopleural shunt.

Empyema developing seven weeks after craniotomy in a 62-year-old black woman with an ipsilateral ventriculopleural (V-PL) shunt is described. Infection of the pleural space presumably resulted from transfer of organisms from a proximal V-PL shunt infection to the thorax. Empyema resulting from V-PL shunt infection has not previously been reported. Pleural effusions in patients with V-PL shunts must be considered as a potential site of infection with possible development of empyema.

Bronchogenic cyst causing a unilateral ventilation-perfusion defect on lung scan.

A 37-year-old woman had pleuritic chest pain, dyspnea, and normal findings on chest roentgenogram. Lung scan showed markedly diminished perfusion to the right lung with a matched ventilatory defect. Further evaluation revealed a bronchogenic cyst. After resection, the lung scan was normal. To our knowledge, this is the first report of a bronchogenic cyst causing a reversible, unilateral ventilation-perfusion defect on lung scan.

A new intraocular aspiration probe with bipolar cautery and reflux capabilities.

The design of the Mentor Wet-Field eraser (Mentor O & O Inc, Norwell, Mass) has been modified so as to include fluid aspiration and reflux capabilities. This 20-gauge disposable probe minimizes instrument exchange through sclerotomy ports and provides sensitive control over reflux action by minimizing the dead-space volume over which reflux occurs. Safer manipulation of detached retina, membranes, and clots is therefore achieved.

Congenital X-linked incomplete achromatopsia. Evidence for slow progression, carrier fundus findings, and possible genetic linkage with glucose-6-phosphate dehydrogenase locus.

Twenty-nine members of a black kindred with congenital X-linked incomplete achromatopsia were examined; nine affected males and seven carrier females were identified. The new findings of importance are the following: (1) this congenital disorder is a slowly progressive abiotrophy, with progressive macular scarring and cone dysfunction, rather than a stationary anomaly; (2) carrier females sometimes can be found by ophthalmoscopic and fluorescein angiographic abnormalities in the macula; and (3) genetic linkage studies give evidence against linkage with the locus for the Xg blood group, but they suggest possible linkage with the glucose-6-phosphate dehydrogenase locus.

Flicker fusion thresholds in Best macular dystrophy.

Flicker fusion threshold intensities were measured as a function of flicker frequency for patients with Best macular dystrophy having normal or near-normal Snellen visual acuity. These data were found to differ from normal in ways that may be interpreted to be an abnormal elevation of the foveal cone threshold, a loss of cone temporal resolution, or both. The results led to the conclusion that Best macular dystrophy affects the neurosensory retina even when Snellen visual acuity is normal.

Prostacyclin and thromboxane A2 derivatives in rhegmatogenous subretinal fluid.

Aberrations in prostacyclin and thromboxane A2 metabolism have been implicated in a wide spectrum of systemic disease. To our knowledge, derivatives of prostacyclin and thromboxane A2 have not been demonstrated previously in the subretinal fluid of rhegmatogenous detachments. Radioimmunoassays to determine levels of stable derivatives of prostacyclin and thromboxane A2, 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha) and thromboxane B2, in rhegmatogenous subretinal fluid samples from ten patients showed the following: 6-keto-PGF1 alpha level, less than 100 to 1,268 pg/mL; thromboxane B2 level, less than 100 to 3,619 pg/mL. The fact that some of these concentrations are higher than the circulating plasma concentrations of 6-keto-PGF1 alpha and thromboxane B2 suggests endogenous ocular production. Our findings establish the presence of prostacyclin and thromboxane A2 derivatives in the rhegmatogenous subretinal fluid.

X-linked ocular albinism in Blacks. Ocular albinism cum pigmento.

X-linked ocular albinism can be an unsuspected cause of congenital nystagmus in blacks. In this study, eight of ten black ocular albinos from two kindreds had nonalbinotic, moderately pigmented fundi and no transillumination of the iris. We refer to this paradoxical condition as "ocular albinism cum pigmento." The only constant ophthalmoscopic feature was a foveal hypoplasia. Biopsy of clinically normal skin to demonstrate giant pigment granules is the most accurate means of diagnosis.

YAG laser treatment of cystoid macular edema.

Fourteen eyes (some aphakic and some with implanted intraocular lenses) underwent neodymium-YAG laser treatment for cystoid macular edema with vitreous incarceration in the corneoscleral wound. Visual acuity improved in all 14 eyes; ten eyes improved at least three Snellen lines and 12 eyes improved at least two Snellen lines. After follow-up periods of one to nine months, 11 eyes had visual acuities of 20/40 or better (only two had had visual acuities of 20/40 preoperatively and none had had a better visual acuity). An additional eye, which had an intraocular lens implant, was treated prophylactically. Visual acuity in this eye remained stable during a nine-month follow-up period. YAG laser treatment produced no adverse side effects or complications in any of the 15 eyes.

Efficacy of argon laser photocoagulation in the treatment of circinate diabetic retinopathy.

We evaluated 115 eyes in 105 diabetic patients with circinate retinopathy and, in most cases, associated macular edema. Of these 115 eyes, 68 were treated with argon laser photocoagulation to leaking vessels, primarily in the center of the circinate ring. Forty-seven eyes that had similar findings but received no treatment were followed up for one year and some patients were followed up for as long as three years. In each year of follow-up the treated eyes did significantly better visually than the untreated eyes. The circinate complex was eliminated in 23 of the 24 treated eyes (96%) followed up for three years, whereas it disappeared in only two of the ten untreated eyes (20%). Complete resolution of macular edema, however, was achieved in only two of the treated eyes (3%) and in none of the untreated eyes. Eyes with initial visual acuities of 6/18 (20/60) or better did significantly better with treatment than eyes treated after visual acuity was less than 6/18 (20/60). The former group was the only one to show a mean improvement in visual acuity.

A disposable vitreous cutter-aspirator with electronic vacuum control.

A sophisticated instrument system for performing vitreous surgery includes a disposable surgical tool, with all connecting tubing incorporated in a sterile template that is easy to assemble prior to surgery. The instrument console and foot switches provide all necessary surgical options, with a maximum degree of safety, for precise vitreous suction and infusion control with the disposable vitreophage or other available vitreous cutters.

Bilateral symmetry of vision disorders in typical retinitis pigmentosa.

Bilateral symmetry of disorders of vision is examined in 60 typical patients with retinitis pigmentosa. We observed a very high degree of interocular congruence in the patterns of both kinetic visual field defects and threshold profiles and in abnormalities of foveal colour discrimination and visual acuity. Abnormalities of foveal colour vision are highly correlated with the extent of visual field loss.

The antibody paradox: trying on a pair of genes.

Rodney Porter's separation of antibody molecules into Fab and Fc fragments engendered the notion that a single antibody polypeptide chain might be coded by two or more genes. This concept profoundly influenced the development of molecular immunology over the past 25 years. Our current knowledge of antibody gene organization has enabled investigators to recombine antibody genes to create 'chimeric' antibodies with a number of potentially useful applications.

Castleman's disease and superior vena cava thrombi: a rare presentation and a review of the literature.

Castleman's disease is a clinicopathological entity in which growth of lymphoid tissue is unregulated. It may present as asymptomatic involvement of one lymph node group or as a multicentric disease with systemic symptoms. Unlike localized disease, for which surgical excision is curative regardless of the histological type, multicentric disease often necessitates aggressive systemic therapy and portends a poor outcome. Superior vena caval thrombosis is an uncommon manifestation associated with Castleman's disease.

The impact of synthesis teaching and parent training with mothers of conduct-disordered children.

A procedure to enhance the impact of parent training with multistressed mother-child dyads was explored with 29 clinic-referred dyads. The procedure, called synthesis teaching, was provided for one randomly selected group of dyads, while the other group was engaged in problem discussions about their children. Both groups received parent training as the principal intervention for the mothers' conduct-disordered children. Results showed that these interventions had no effects on dyads in the clinic setting, but had a progressively more significant effect at home for the synthesis teaching group. That is, mothers in this group showed reductions in their indiscriminate parenting and their children demonstrated behavioral improvements. In contrast, mothers in the control group did not change their behavior and their children did not demonstrate observed behavioral changes. Interpretations of the results center on how synthesis teaching might have produced these effects.

Pneumocystis carinii pneumonia as the first presentation of HIV infection in patients older than fifty.

A significant increase in the number of elderly patients first diagnosed with HIV infection at the time of presentation with an AIDS-related opportunistic infection has recently been reported. This suggests a significant delay in the diagnosis of HIV infection. Few data are available describing such cases and their outcome. We restrospectively reviewed records of all elderly patients (> 50 years of age) admitted to a New York City hospital over a 3-year period with confirmed Pneumocystis carinii pneumonia (PCP). The mean age was 57.9 +/- 6.6 years. In 80% (8 of 10 cases), the diagnosis of HIV infection was made at presentation with PCP. The mean CD4 count was 34.2 +/- 39.2/mm3 (1-117/mm3), indicating advanced AIDS. The clinical presentation of PCP was similar to that in younger patients. With prompt and appropriate therapy, a 70% survival rate for this hospitalization was achieved, similar to that reported in younger age groups. The diagnosis of HIV infection was not considered until presentation with PCP at an advanced stage of AIDS in 80% of these elderly patients, thus delaying institution of HIV treatment and counseling. Early consideration of HIV infection in the elderly is of importance because of the rising number of AIDS cases in this age group.

Small airways dysfunction in patients with AIDS and Pneumocystis carinii pneumonia.

PURPOSE: Abnormalities of small airways function may have clinical relevance in AIDS patients with Pneumocystis carinii pneumonia (PCP) since obstructive dysfunction at alveolar levels may impede delivery of aerosolized medication. This study was designed to determine if small airways dysfunction is present in AIDS patients with PCP despite normal standard spirometric results. PATIENTS: Ten AIDS patients with documented PCP and no other identifiable pulmonary infection without respiratory failure and with a normal FEV1/FVC ratio were evaluated. METHOD: Small airways function was assessed by the FEF75 and the change in maximum expiratory flow while breathing a helium-oxygen mixture compared to room air (delta Vmax50%) with and without bronchodilator administration. Testing was done before and after completion of intravenous therapy for PCP. RESULTS: Despite absence of cough or wheezing at the time of evaluation and a normal FEV1/FVC ratio, significant obstructive dysfunction of the small airways was demonstrated in 6 of 10 patients, which improved with bronchodilators. Three weeks of intravenous therapy for PCP had no effect on these abnormalities. The degree of small airways dysfunction was greater than could be explained by smoking history alone. CONCLUSIONS: Small airways dysfunction, which can be improved with bronchodilator administration, may be present in AIDS patients with PCP despite normal spirometry and absence of cough or wheezing. Screening for small airways dysfunction may identify patients who might benefit from bronchodilator administration prior to inhalation of aerosolized medications.

Role of CD4:CD8 ratio in predicting HIV co-infection in patients with newly diagnosed tuberculosis.

Because of the clinical implications of Human Immunodeficiency Virus (HIV) status on treatment of tuberculosis (TB) and in view of the low percentage of patients in whom HIV testing is performed, we evaluated immunological features of 54 patients with newly diagnosed TB and its ability to predict HIV co-infection. All 54 patients had initially unknown HIV status and had no other Acquired Immunodeficiency Syndrome (AIDS) defining illnesses. Twenty-two patients were found to be HIV seropositive and 32 were seronegative. The median CD4 and CD8 counts were statistically different between the HIV seropositive and seronegative patients, however, there was overlap between the two groups. The median CD4:CD8 ratio was 0.17 in HIV seropositive patients and 1.95 in the seronegative patients and had minimal overlap (p < 0.0001). A CD4:CD8 ratio < or = 0.7 gave a sensitivity of 100%, specificity of 94%, positive-predictive value of 92% and a negative-predictive value of 100% in predicting HIV co-infection. In conclusion, HIV-co-infection in patients with newly diagnosed TB could be predicted on the basis of the CD4:CD8 ratio.