Lung volume reduction surgery. Case selection, operative technique, and clinical results.

OBJECTIVE: A clinical study was undertaken to define optimal preoperative strategies and intraoperative techniques that would result in the least morbidity and maximum physiologic improvements in patients with end-stage emphysema selected for lung volume reduction surgery. BACKGROUND: Lung volume reduction surgery recently has been advocated as an alternative or a bridge to lung transplantation for patients with end-stage chronic obstructive pulmonary disease. The risks, benefits, and long-term results have not been clarified. METHODS: Twenty-six patients underwent lung volume reduction surgery with a 3-month follow-up on 17 patients. Preoperative and postoperative changes in pulmonary function parameters, quality of life, and oxygen requirement were analyzed. The value of preoperative localization of diseased lung segments and how this affects intraoperative resection is addressed. RESULTS: Forty-nine percent improvement in FEV1 (forced expiratory volume in 1 second) and 23% improvement in FVC (forced vital capacity) were seen after lung volume reduction surgery. Supplemental oxygen requirement was decreased and 79% of patients reported a much better quality of life. Mortality was 3.8% and air leak morbidity was 18%. CONCLUSIONS: Lung volume reduction surgery can predictably improve objective and subjective pulmonary function in selected patients with end-stage emphysema with low morbidity and mortality. Careful patient selection, accurate preoperative localization of diseased target areas, skilled anesthetic technique, meticulous operative approach, and intense postoperative support are essential to achieve favorable results.

Risk factors for infection of adult patients with cancer who have tunnelled central venous catheters.

BACKGROUND: Long-dwelling tunnelled central venous catheters provide reliable access for infusion therapy of patients with cancer, but can result in serious bloodstream infections. The incidence of such infections has been documented, but few studies have assessed potential risk factors, and to the authors' knowledge, none have measured the effect of neutropenia upon the incidence of these infections. METHODS: A cohort of 71 adult patients with cancer with long-dwelling tunnelled central venous catheters was followed for a total of 12,410 catheter days until catheter removal, death, or end of study for the occurrence of catheter-related infection or sepsis of unknown origin. Fifteen factors were assessed for association with these infections. RESULTS: Thirteen patients (18%) experienced a catheter-related infection (1.0/1000 catheter days), and 23 (32%) experienced sepsis of unknown origin. Neutropenia was associated significantly with risk for catheter-related infection (relative risk [RR] = 15.1, 95% confidence interval [CI] 2.7-86.9) and sepsis of unknown origin (RR = 10.3, 95% CI 4.0-26.8). Inpatient status, acute leukemia, and cytosine arabinoside therapy also were associated with sepsis of unknown origin, but not when adjusted for neutropenia. CONCLUSION: Of the 15 potential risk factors studied, neutropenia was the only independent risk factor for infection related to long-dwelling tunnelled central venous catheters and for sepsis of unknown origin.

Imaging of the brain by nuclear magnetic resonance.

A nuclear magnetic resonance (NMR) machine constructed by Thorn-EMI Ltd was used to produce tomographic images of the brain in eight volunteers and fourteen patients. The use of an inversion recovery technique designed to emphasise variations in the spin-lattice time constant (T1) resulted in remarkable differentiation between grey and white matter in all subjects examined. White matter was seen both centrally and peripherally to subcortical level and the basal ganglia were clearly demarcated by the surrounding white matter and ventricular system. The posterior fossa was visualised with substantially less artefact than with X-ray computed tomography (CT) and both the brainstem and middle cerebellar peduncle were clearly shown. Pathological appearances in patients with glioblastoma multiforme, cerebral infarction, and cerebral aneurysm were demonstrated and compared with those seen with CT. The technique will require thorough clinical evaluation but appears to have considerable potential in the diagnosis of neurological disease.