Thoracic CT in the ED: a study of thoracic computed tomography utilisation.

The aim of this retrospective study was to investigate the use of thoracic Computed Tomography (CT) in the Emergency Department of a Dublin Academic Teaching Hospital over a six month period. Data was retrieved using the hospital's computerised information system. There were 202 referrals in total for thoracic CT from the Emergency Department during this time period. The most common indication for thoracic CT referral was for the investigation of pulmonary embolism with 127 (63%) referrals. There were 40 (25%) referrals for suspected malignancy and lung disease, whilst 8 (4%) of the referrals were for investigation of thoracic aortic dissection, 8 (4%) for infection, and 6 (3%) were for investigation of thoracic injury. Only 8 (4%) of all referrals were for investigation of injury as a result of chest trauma.

CAMAL: evidence for an inhibitory role in normal granulopoiesis.

Maintenance of normal granulopoiesis requires complex interactions between positive (stimulatory) and negative (inhibitory) regulatory molecules, the cells that produce them and their targets. In myeloid leukemia these signals continue to operate but in an obviously unbalanced fashion, allowing the emergence and eventual dominance of the malignant clone. In this study, a common antigen in myeloid leukemia (CAMAL) has been shown to bind to normal leukocyte membranes. At similar concentrations (between 10 and 15 micrograms/ml), leukemia-derived CAMAL caused profound inhibition of normal colony growth in the myeloid progenitor cell assay but had no inhibitory effect on granulocyte-macrophage colony-forming unit (CFU-GM) growth from myeloid leukemia patients in active disease states. These preliminary results indicated the myeloid leukemia cells possessed apparent differences in responsiveness to CAMAL-mediated regulation compared to normal cells. Lack of or decreased responsiveness to inhibition by leukemia-derived CAMAL may facilitate dominance of the malignant clone over normal cells.

A monoclonal antibody to myelogenous leukemia: isolation and characterization.

A purified antigen from human acute myelogenous leukemia (AML) cells has been used to produce a myelogenous leukemia-associated monoclonal antibody. In limited FACS-IV analyses the monoclonal antibody to leukemia (CAMAL-1) as well as a conventional rabbit antiserum have been used to positively identify AML or chronic granulocytic leukemia patient cell samples. Neither CAMAL-1 nor the rabbit antiserum bound appreciably to acute lymphocytic leukemia cells, normal bone marrow, or normal peripheral blood leukocytes. CAMAL-1 was shown to be specific for AML cell extracts in the ELISA and was successfully used as an immunoadsorbent for the purification of the AML antigen from cell extracts. No significant levels of equivalent antigen were found when cell extracts from normal cells, lymphocytic leukemia cells, and lymphoma cells were similarly absorbed. These findings indicate that CAMAL-1 shows considerable specificity for an antigen associated with cells from patients with myelogenous leukemia.

Purification of an in vitro inhibitor of normal myelopoiesis using a monoclonal antibody directed to a common antigen of myelogenous leukemia (CAMAL).

A monoclonal antibody, CAMAL-1, has been previously shown to react specifically and at high frequencies with cells of patients with acute myelogenous leukemia (AML) and chronic granulocytic leukemia (CGL). High expression of this antigen in remission patients' bone marrow cells was shown to correlate with both relapse and lower survival times. Preliminary studies showed that material extracted from leukemic cells and eluted from CAMAL-1 immunoadsorbent columns profoundly inhibited the formation of normal colony-forming units (CFU) but had no effect on formation of such colonies from cells of patients with CGL. We have used CAMAL-1 affinity chromatography in combination with FPLC gel filtration to purify the inhibitory material from leukemic cell extracts. We have successfully isolated a 30-kd component (P30) that functions as an inhibitor of normal myelopoiesis in vitro; when P30 was added to normal progenitor cell assays it significantly inhibited the growth of normal CFU but had no inhibitory effect on the growth of CGL progenitor cells at equivalent concentrations. The inhibitory effect is preferentially directed to granulocytic progenitors. Antibodies raised to P30 reacted in Western blot analyses with affinity purified material from patients' cells as well as with a 30-kd component in the cell lysates and supernatants of the leukemic cell lines HL60 and K562; this finding suggested that the P30 inhibitory component might be produced by leukemic cells.

Demonstration of a leukemia-associated antigen (CAMAL) in peripheral blood leucocytes of bone marrow transplant patients prior to relapse.

We have previously described a monoclonal antibody (CAMAL-1) that reacts in an indirect immunoperoxidase slide test at high frequency with cells of patients with acute nonlymphoblastic leukemia (ANLL), both at presentation and in remission (1). This article reports on a 12-month blind study carried out on peripheral blood leukocytes (PBL) of patients who had received bone marrow transplants for acute leukemias. PBL of patients attending the Royal Marsden Hospital were sent as cytospins to the University of British Columbia for staining and screening. Results of this study showed the following: of the 15 patients who remained in remission during the period of the study, 13 showed no abnormal increase in reactivity with CAMAL-1 (2 patients did show increased levels of reactivity over time); of the four patients relapsing but surviving within this period with ANLL, all showed elevated numbers of cells reactive with CAMAL-1 as long as 3 months prior to relapse (the two relapsing patients who had acute undifferentiated leukemia and acute lymphoblastic leukemia did not show elevations of CAMAL-1-reactive cells); of the 14 patients dying during this time of causes other than leukemia, none had elevated levels of CAMAL-1-reactive cells--and, of 4 patients dying in relapse, all had extremely elevated levels of CAMAL-1-reactive cells as long as 4 months prior to relapse. The implications of these observations are discussed.

CAMAL: a new prognostic marker for remission in acute nonlymphoblastic leukemia.

A leukemia-associated antigen, CAMAL, shown to be present in bone marrow (BM) cells from patients with acute nonlymphoblastic leukemia (ANLL) even during remission, has been examined using indirect immunoperoxidase and a monoclonal antibody, CAMAL-1. We are ending the third year of an ongoing blind study designed to monitor the number of BM cells expressing the CAMAL protein (CAMAL BM value) in ANLL patients over the course of their disease. Results thus far have revealed that the CAMAL BM value in individual patients often changed significantly post-chemotherapy. This change appeared to be a useful prognostic marker in many instances. ANLL patients at initial presentation whose CAMAL BM values increased or stayed the same post-chemotherapy had significantly (p less than 0.025) shorter remission lengths (x = 6.8 months, n = 24) than those whose CAMAL BM values decreased (x = 19.2 months, n = 10). There are indications that increasing CAMAL BM values during remission occur prior to clinical relapse.

Solitary fibrous tumor of the periosteum.

We report a solitary fibrous tumor (SFT) of the leg that presented as a pedunculated encapsulated soft tissue mass attached to the periosteum of the posterior tibia. To our knowledge this is the first reported case of an SFT in an extremity. In addition to having the typical gross and microscopic appearance of a usual SFT, this SFT also contained abundant elastic tissue, suggesting an origin from periosteal fibroblasts. This report further extends the anatomic range of the SFT, a neoplasm once thought to be of mesothelial origin but now recognized as a mesenchymal tumor of probable fibroblastic lineage. To date the behavior of the this periosteal SFT has been benign.

Bronchogenic carcinoma and coexistent bronchioloalveolar cell adenomas. Assessment of radiologic detection and follow-up in 28 patients.

PURPOSE: Bronchioloalveolar cell adenomas (BAAs) have been described in up to 10% of patients with bronchogenic carcinoma. Their prognostic significance is unknown. The purpose of this study was to determine the prognostic implications of finding BAAs coexisting in specimens resected for primary bronchogenic carcinoma and to determine how frequently BAAs can be detected radiologically. METHODS: Follow-up information for a mean of 30 months was obtained on 28 patients with a single primary bronchogenic carcinoma and one or more coexistent BAAs. Preoperative chest radiographs (n=27) and CT scans (n=24) were retrospectively reviewed to assess the number of patients in whom BAAs could be detected radiologically. RESULTS: There was no significant difference between percentage survival of patients with a primary bronchogenic carcinoma and coexistent BAAs when compared with the percentage predicted survival of these patients based on their primary bronchogenic carcinoma alone. BAAs could be detected retrospectively in 1 of 27 (4%) preoperative radiographs and 11 of 24 (46%) CT scans. CONCLUSIONS: On standard preoperative imaging for bronchogenic carcinoma, BAAs were retrospectively detected in more than one third of patients in whom they were detected pathologically. However, the presence of coexistent BAAs with bronchogenic carcinoma does not affect short- and medium-term prognosis.

Noninvasive positive pressure ventilation: successful outcome in patients with acute lung injury/ARDS.

BACKGROUND: There is increasing support for the use of noninvasive positive pressure ventilation (NPPV) in the treatment of patients with acute respiratory failure. Highest success rates are recorded in patients with exacerbation of COPD, particularly in patients presenting primarily with hypercarbic respiratory failure. Success has been more limited in patients with acute hypoxemic respiratory failure, and there are few reports of NPPV in patients with acute lung injury (ALI) or ARDS. OBJECTIVES: We report the outcome of 12 episodes of ALI/ARDS in 10 patients treated with NPPV. DESIGN: Experiential cohort study. SETTING: Tertiary referral center and university hospital ICU. INTERVENTION: Provision of NPPV in patients with ALI/ARDS. RESULTS: Group median (range) APACHE (acute physiology and chronic health evaluation) II score was 16 (11 to 29). Success rate (avoidance of intubation and no further assisted ventilation for 72 h) was achieved on six of nine occasions (66%) when NPPV was used as the initial mode of assisted ventilation. It failed after three episodes of planned (1) or self (2) extubation. Duration of successful NPPV was 64.5 h (23.5 to 80.5 h) with ICU discharge in the next 24 to 48 h for three of six patients. Unsuccessful episodes lasted 7.3 h (0.1 to 116 h) with need for conventional ventilation for an additional 5 days (2.7 to 14 days). Survival (ICU and hospital) for the 10 patients was 70%. CONCLUSIONS: In a group of hemodynamically stable patients with severe ALI, NPPV had a high success rate. NPPV should be considered as a treatment option for patients in stable condition in the early phase of ALI/ARDS.

Acute lung disease in the immunocompromised host. Diagnostic accuracy of the chest radiograph.

PURPOSE: To assess the diagnostic accuracy of the chest radiograph in the evaluation of acute pulmonary complications in immunocompromised patients. METHODS: The study included the chest radiographs in 149 consecutive acute pulmonary complications seen in immunocompromised patients in whom a definitive diagnosis was made. Twenty-four complications were in patients with AIDS and 125 were in non-AIDS patients. The radiographs were separately reviewed in random order by two independent observers. The observers assessed pattern and distribution of radiographic findings and recorded their first-choice diagnosis. RESULTS: The most common complication in patients with AIDS was Pneumocystis carinii pneumonia (n = 21). In the non-AIDS patients, the most common complications included invasive aspergillosis (n = 25), drug reaction (n = 21), and Pneumocystis pneumonia (n = 20). A correct first-choice diagnosis was made in 90% of patients with AIDS and 34% of non-AIDS patients. IN AIDS patients with Pneumocystis pneumonia, the correct first-choice diagnosis was made in 41 of 42 (98%) readings by the two observers. In non-AIDS patients with invasive pulmonary aspergillosis, drug reaction, and Pneumocystis pneumonia, the correct first-choice diagnosis was made in 38%, 26%, and 43% of readings, respectively. CONCLUSION: The chest radiograph is helpful in the differential diagnosis of acute lung disease in the immunocompromised host, particularly in patients with AIDS.

Mouse skin photosensitization with benzoporphyrin derivatives and Photofrin: macroscopic and microscopic evaluation.

A comparative study, at both the macroscopic and microscopic level, of skin photosensitivity caused by four isomeric forms of benzoporphyrin derivative (BPD) has been carried out, and compared to effects of Photofrin. Animals injected intravenously with BPD analogues and exposed to light 3 h later showed extensive photosensitivity. Animals receiving the monoacid derivatives of BPD (BPD-MA and BPD-MB) showed markedly more photosensitivity than those receiving the diacid derivatives (BPD-DA and BPD-DB). Animals receiving BPD analogues which were exposed to light 24 h or more later showed only minimal reactivity. Histological examination of biopsies taken after photosensitizer injection and light exposure showed extensive changes in epidermis and dermis, including epidermal erosion, degranulation of the stratum granulosum, spongiosis, depletion in cellularity and mast cell degranulation. These changes were noted to be similar to changes caused by Photofrin.

Comparison of a new dual characteristic film-screen system (insight) with a standard film-screen system for chest radiology.

A new dual image receptor screen-film combination has been developed by Kodak with the objective of improving mediastinal and retro-cardiac detail whilst retaining good contrast and detail in the lung fields. This system was compared with our standard chest system. The study population was 36 patients with sarcoidosis. A postero-anterior (PA) chest film using our standard system was followed by a PA chest film using the new system--both using high kVp technique. The pairs of radiographs were assessed for (1) presence or absence of lymphadenopathy; (2) visibility of anterior and posterior mediastinal and azygo-esophageal lines; (3) visibility of vessels in the outer and inner thirds of the lungs and (4) visibility of infiltrates, if present. The new film-screen combination was judged to show the mediastinal structures better in almost all instances. However, our standard combination was preferred for lung detail visualization in most cases. No significant difference was found between the two systems in their ability to demonstrate lymphadenopathy. The results were almost unchanged when the observers were given the option to score the criteria as equally well demonstrated on both films as opposed to not having this option available. We feel the advantages of the Insight system do not compensate for the significant loss of parenchymal detail resulting from the use of this system.

Lung cancer audit in an Irish teaching hospital.

BACKGROUND: Lung cancer is the most common cause of cancer-related death in Ireland. There are few complete data sets available as to the stage and cell type of lung cancers at time of presentation in Ireland. AIM: To audit the lung cancers presenting to a large Dublin teaching hospital over a 12-month period. METHOD: Prospective evaluation of all lung tumours presenting to our institution over a consecutive 12-month period. RESULTS: One hundred and ninety-eight lung cancers presented over the study period. There were 34 cases of small cell carcinoma and 150 cases of non-small cell carcinoma (NSCC). Fourteen patients were too ill or compromised at time of presentation for tissue confirmation. The most common cell type was squamous carcinoma. Eighty-four per cent of the NSCCs were either stage 3 or 4 at presentation. CONCLUSION: Most lung cancers present late in the time course of the disease. Distribution of cell type and location are similar in Ireland and other developed countries.

High resolution computed tomography in cystic fibrosis: correlation with pulmonary function and assessment of prognostic value.

OBJECTIVE: To assess the correlation between HRCT and pulmonary function in patients with CF. Further, to assess the prognostic value of HRCT in these patients. SUBJECTS AND METHODS: Clinical examination, chest radiographs and HRCT scans on 30 CF patients with an average age of 17 were scored using established scoring systems. The results were correlated with FEV1 and FVC both at time of CT scanning and after 30 months. Results were also correlated with the clinical progress of the patients over the follow-up period. RESULTS: HRCT, chest radiograph and clinical examination demonstrated similar correlation (p < 0.001) with FEV1 and FVC at the time of scanning. HRCT demonstrated the closest correlation with the clinical progress of the patients over the follow-up period and with follow-up pulmonary function. A maximum combined score for bronchiectasis and emphysema on HRCT seemed to indicate a poor prognosis. CONCLUSION: HRCT in CF patients correlates well with pulmonary function at time of scanning and at follow-up, and with clinical progress. There may be a role for CT in the identification of adolescent/adult patients who can be expected to need aggressive therapy in the future.

Painful os cuboideum secundarium. Cross-sectional imaging findings.

The authors presented the computed tomography and magnetic resonance imaging appearances of a painful os cuboideum secundarium. To the authors' knowledge, this is the first report of the cross-sectional imaging appearance of this condition, and serves to underline the utility of computed tomography and magnetic resonance imaging in the investigation of foot pain.

Radiological abnormalities associated with Aspergillus colonization in a cystic fibrosis population.

OBJECTIVE: To determine if sputum colonization with Aspergillus species in patients with cystic fibrosis (PWCF) correlates with radiological abnormalities and/or a reduction in pulmonary function (FEV1). METHODS: We prospectively evaluated 32 PWCF utilizing high resolution computed tomography (HRCT) of the thorax and pulmonary function testing (PFT). The cohort was assessed as two groups: Aspergillus positive (n=16) and Aspergillus negative (n=16) based on sputum culture for Aspergillus species. A modified Bhalla scoring system was applied to each HRCT scan by two blinded radiologists. RESULTS: Aspergillus positive patients had more severe and significant bronchiectasis compared to those Aspergillus negative (p<0.05). This was most marked in the right upper and lower lobes (RUL, RLL). Total Bhalla score was clinically significant in both groups and approached statistical significance between groups (p=0.063). No difference in pulmonary function between the groups was detected. CONCLUSION: PWCF colonized by Aspergillus species have greater radiological abnormalities undetectable by PFTs. Early radiological evaluation of Aspergillus colonized PWCF is therefore warranted.