Ultrasound-guided pleural biopsy with Tru-Cut needle.

We conducted a study of ultrasound (US)-guided pleural biopsy with a Tru-Cut needle and made a comparison with the results of a traditional pleural biopsy with an Abrams needle. A total of 49 patients with unilateral pleural effusion were included in this study. Twenty-four patients underwent a traditional pleural biopsy with an Abrams needle, and 25 patients underwent a US-guided pleural biopsy with a Tru-Cut needle. The age, sex, and underlying diseases in both groups were compatible. The amount of effusion was much less in the Tru-Cut group. In the patients who underwent the US-guided pleural biopsy with a Tru-Cut needle, the diagnostic sensitivity in pleural tuberculosis was 86 percent (6/7) and in pleural neoplasia it was 70 percent (7/10). In the patients who underwent traditional pleural biopsy with an Abrams needle, the diagnostic sensitivity in pleural tuberculosis was 20 percent (2/10) and in pleural neoplasia it was 44 percent (4/9). The result of US-guided pleural biopsy with a Tru-Cut needle was better than that of pleural biopsy with an Abrams needle, especially in pleural tuberculosis. No complication was found in the Tru-Cut group, but breakage and dislodgment of the tip of an Abrams needle occurred in one patient. The higher diagnostic yield in the Tru-Cut group may be attributed to the US guidance that can delineate the focal pleural abnormalities for biopsy. In conclusion, US-guided pleural biopsy by using a Tru-Cut needle was simple, safe, and well tolerated. It was particularly useful for patients with pleural tumor, thickened pleura, small amounts of pleural effusion, or loculated pleural effusion.

Clearance of theophylline by hemodialysis in one patient with chronic renal failure.

The clearance of theophylline by hemodialysis was determined in one patient who had polycystic kidney with chronic renal failure and bronchial asthma. The serum levels of theophylline were determined by enzymatic immunoassay on two consecutive days, once on a dialysis day and again on a nondialysis day. Clearance of theophylline by hemodialysis was 119 ml/min, and the extraction efficiency was 0.56. The elimination half-life of theophylline shortened from 5.7 h to 1.6 h during hemodialysis. The dialysis rate constant (Kd) was 0.32/h, and 79 percent of the total body store of the drug was removed during a 4-h dialysis. Patients receiving theophylline who are maintained on hemodialysis should be closely monitored for bronchospasm during and after the hemodialysis procedure. Measurement of serum concentrations of theophylline should be employed to facilitate increases in dosage during hemodialysis.

Needle aspiration biopsy of malignant lung masses with necrotic centers. Improved sensitivity with ultrasonic guidance.

False-negative results from transthoracic needle aspiration biopsy of malignant lung masses may occur if a central necrotic area is present and is the source of the biopsy material. The purpose of this study is to determine if the use of ultrasonic guidance can improve the sensitivity of lung needle biopsies in this circumstance. Sixty patients with malignant lung masses underwent ultrasonic examination in an 18-month period. In 14 cases, ultrasound showed that the mass had a large central necrotic area that was at least half the diameter of the tumor. Under ultrasonic guidance, needle biopsy specimens were taken from the central necrotic area and from the tumor wall in each case. Adequate biopsy specimens were obtained in all 14 patients. In all cases, the mural biopsy material was diagnostic for malignant tumor, while the biopsy specimen from the necrotic center was nondiagnostic in 10 of 14 patients. No complications occurred. We conclude that ultrasonically guided lung biopsy is a useful and safe tool to avoid false-negative needle biopsy specimens in malignant lung tumors with necrotic centers.

Evaluation of ultrasonically guided biopsies of mediastinal masses.

Eighty patients with roentgenographic evidence of mediastinal abnormalities were examined with ultrasonography. Fifty-four lesions were malignant, and 26 lesions were benign. The histologic diagnoses were confirmed by ultrasonically guided fine needle aspiration/cutting needle (Tru-Cut) biopsy, surgical specimens, or transbronchial biopsy. There were no unique ultrasonographic features for diagnosis of specific tumors. Ultrasonically guided aspiration biopsies (UGAB) were performed in 44 of the malignant lesions and in 14 of the benign lesions (nine of the noncystic lesions and five of the cystic lesions). Cytologic diagnosis of malignancies was obtained in 34 (77 percent) of these 44 malignancies; however, accurate histologic classifications of malignancies were achieved in only 24 (55 percent). Accurate diagnoses were achieved in only three (33 percent) of the nine noncystic benign lesions. Ultrasonically guided cutting biopsies (UGCB) were performed in 24 malignant and five benign lesions. All attempts yielded satisfactory specimens for histologic diagnosis. Using UGAB and UGCB together, a positive diagnosis was achieved in 89 percent (39/44) of the malignancies, and accurate histologic diagnosis was achieved in 89 percent and 78 percent (7/9) in malignant and benign noncystic lesions, respectively. Correct histologic diagnosis with UGAB alone is lower in thymoma (55 percent [6/11]) and lymphoma (30 percent [3/10]) but higher in lung cancer (67 percent [8/12]) and metastatic cancer (78 percent [7/9]). There were no complications in this series. We conclude that ultrasonography with UGAB has a high diagnostic yield in diagnosing mediastinal tumors, and UGCB is necessary for thymic tumors, lymphoma, and benign lesions.

Late survival of non-small cell lung cancer patients with brain metastases. Influence of treatment.

The presence of brain metastasis in lung cancer patients is a highly unfavorable event that usually allows only palliative treatment. A retrospective study was conducted to evaluate the prognostic factors in patients with non-small cell lung cancer (NSCLC) associated with brain metastases. From July 1984 through June 1990, a total of 50 patients with NSCLC associated with symptomatic brain metastasis seen at National Taiwan University Hospital were included. Patients who had incomplete cancer staging workup or loss of follow-up were excluded. Several possible prognostic variables were analyzed initially with univariate analysis and subsequently with multivariate analysis with maximal partial likelihood ratio test in the Cox model. In the univariate analysis, several factors, including number of brain metastases, treatment for brain metastasis with brain tumor resection (BTR) or whole brain radiation therapy (WBRT), and chemotherapy (C/T) after brain metastasis were found to have significant influence on the survival. However, in the multivariate analysis, patients receiving BTR, WBRT, and/or C/T lived significantly longer. The median survival of patients treated with BTR was nine months, eight months in patients with C/T, and seven months in patients with WBRT. Taken together, these patients had a median survival of seven months, which was significantly longer than patients treated with supportive care only (with a median survival of two months). Treatment of brain metastases with WBRT, BTR, C/T, or in combinations also improved the quality of life. We conclude that NSCLC patients with brain metastases should be more aggressively treated with WBRT, BTR, C/T, or in combinations than supportive care only.

Lung sequestration. Diagnosis with ultrasound and triplex Doppler technique in an adult.

The application of chest US with triplex Doppler technique to detect the systemic feeding artery of lung sequestration in an adult patient is described. To our best knowledge, this is the first description of the use of this technique to diagnose pulmonary sequestration in adult patients. This 35-year-old man had necrotizing pneumonia with abscess formation at the left lower lobe. Chest US demonstrated a large tortuous vessel in the central part of the lesion. Spectral wave Doppler analysis showed that this vessel was a systemic feeding artery and had pulsatile arterial wave-form. The color Doppler mapping delineated the blood flow originating from the descending aorta and toward the lesion, thus confirming the diagnosis of pulmonary sequestration. We conclude that chest US with triplex Doppler technique is a valuable method in evaluating a patient with a pulmonary lesion who was thought to have lung sequestration before performing invasive aortography.

Actinobacillus actinomycetemcomitans pneumonia with chest wall involvement and rib destruction.

There are four cases of Actinobacillus actinomycetemcomitans pulmonary infections reported in the English literature prior to 1990. We report a case of A actinomycetemcomitans pulmonary infection with invasion of overlying soft tissue, rib, and sternum. This manifestation has not been previously reported. The clinical manifestation is similar to that of Actinomyces israelii, which may be misinterpreted as malignancy initially. The portal of entry of A actinomycetemcomitans may be via hematogenous spread or aspiration. The diagnosis depends on culture after prolonged incubation of the involved tissue obtained by aspiration or biopsy. Elevated serum antibody is helpful for diagnosis of active infection. A actinomycetemcomitans is susceptible to most antibiotics, but is frequently resistant to penicillin, vancomycin, clindamycin, and erythromycin. Isolation of the organism and an in vitro drug sensitivity testing are important in managing the patient. Our patient recovered after a three-month regimen of penicillin.

Ultrasound-guided aspiration biopsy of small peripheral pulmonary nodules.

We compared the diagnostic yields of ultrasound-guided aspiration biopsy, sputum cytology, and fiberoptic bronchoscopy with biopsy in 30 patients with peripheral pulmonary nodules smaller than 3.0 cm in diameter. Among them, there were 4 minute nodules with diameter less than 1.0 cm, 12 between 1.1 to 2.0 cm, and 14 between 2.1 to 3.0 cm. The final diagnoses in these 30 patients, as confirmed by histologic findings, microbiology, and clinical follow-up, revealed 24 malignant lesions and 6 benign. All of these 30 nodules received ultrasound-guided transthoracic fine-needle aspiration biopsy, and confirmative diagnoses were obtained in 27 (90 percent). Twenty-two (92 percent) of 24 patients with malignant nodules had positive cytology for malignancy and 5 (83 percent) of 6 patients with benign lesions had diagnosis made by cytologic and microbiologic examinations. One patient developed asymptomatic pneumothorax after needle aspiration. The size of the lesions did not affect the diagnostic yield and complication rate. None of the lesions was diagnosed by sputum cytology (0 of 19; 0 percent). Two patients had diagnoses obtained by fiberoptic bronchoscopy with biopsy (2 of 10; 20 percent). We conclude that ultrasound-guided aspiration biopsy is a useful and safe method for diagnosis of peripheral pulmonary nodules, even when the size of the nodule is less than 3 cm in diameter. The diagnostic yield far exceeds that which can be obtained by sputum cytology and fiberoptic bronchoscopy with biopsy.

Clinical spectrum of tuberculosis in older patients.

OBJECTIVE: To investigate the clinical differences between old and young patients infected with Mycobacterium tuberculosis in a developing country. DESIGN: Retrospective chart and chest radiograph review. SETTING: A university-affiliated teaching hospital. PATIENTS: The medical records of patients with documented tuberculosis (TB) from January 1990 through December 1991 were analyzed. Clinical assessment included sex, age, diagnosis at first visit, past history, symptoms and signs, laboratory data, X-ray findings, bacteriological examinations, outcome, time elapsed from first visit to initiation of anti-TB therapy and the major determinants for starting anti-TB therapy. Statistical significances were analyzed by Student's t test and chi 2 tests. RESULTS: Among 205 patients with culture-proven TB, 57 were 65 years of age and older (range, 65 to 91; mean, 73) and 148 under 65 years of age (range, 16 to 64; mean, 41). There was a higher incidence of previous TB (26.3% vs. 16.2%) and diabetes mellitus (24.5% vs. 14.3%) in the elderly patients. Initial diagnosis of TB at first visit was less frequent in the elderly than in the young group (38.6% vs. 47.3%), although symptoms and signs at first visit were similar in each of the age groups. Radiographic presentation with mass lesions was more frequently encountered in elderly patients (10.5% vs. 2.1%, P < .05). Elapsed time from the first visit to suspicion of TB and the initiation of anti-TB therapy was frequently delayed in elderly patients (22 +/- 23 vs. 13 +/- 20 days, P < .05). The incidence of drug-resistance (39% vs. 16%, P < .05) and unfavorable response to anti-TB therapy (17.5% vs. 3.4%, P < .05) were significantly higher in the older patients. CONCLUSIONS: Although clinical presentation of TB in the elderly did not differ significantly from that in younger patients, this study showed that diagnosis and treatment were more often delayed in the elderly, and there was a higher incidence of treatment failure.

Fine needle aspiration cytology of thymic carcinoid tumor.

Carcinoid tumors of the thymus are very rare, and their cytologic findings have not been reported previously in English. Retrospective study of fine needle aspiration (FNA) cytologic features in four histopathologically verified thymic carcinoid tumors are described here in detail. The FNA cytology of thymic carcinoids is characterized by predominantly single and some loose clusters of small, round to oval cells with scanty cytoplasm, interspersed with some larger cells with moderate to abundant, granular cytoplasm. The differential diagnosis of the cytologic features between carcinoid tumor and other mediastinal tumors is also discussed.

Systemic lupus erythematosus presenting as pleural effusion: report of a case.

Systemic lupus erythematosus (SLE) presenting as a pleural effusion in a young male is not common. This paper describes a 20-year-old man who was admitted to hospital with a spiking fever, chills and cough. A chest x-ray showed alveolar infiltration and a moderate right-sided pleural effusion. The patient was treated for parapneumonic effusion. Thoracentesis was performed and cytology of the aspirated fluid was initially interpreted as showing only numerous polymorphonuclear (PMN) leukocytes. However, in spite of antibiotic treatment the symptoms persisted. A careful review of the cytology specimen showed classic lupus erythematosus (LE) cells in addition to PMN cells. Subsequent investigation, including antinuclear antibodies titer, confirmed the diagnosis of LE pleurisy. Therapy with antibiotics was discontinued and treatment with prednisolone 20 mg daily was begun. There was a rapid clinical response including resolution of the fever and pleural effusion.

Lobar bronchioloalveolar carcinoma: an ultrasound study.

To assess whether chest ultrasound (US) can be useful in the diagnosis of lobar bronchioloalveolar carcinoma, we retrospectively analyzed the US patterns of eight patients with bronchioloalveolar carcinoma presenting with lobar consolidation. For comparison, 15 patients with lobar consolidation of a benign etiology were also analyzed. We found that the US patterns of lobar bronchioloalveolar carcinoma had a characteristic homogeneous, echogenic pattern. The air-bronchograms and air-alveolograms were scarce when compared to benign consolidation. The sensitivity of using these US criteria in discriminating lobar bronchioloalveolar carcinoma was 75%, and the specificity was 93%. We also assessed the yield of US-guided transthoracic cutting biopsies in the diagnosis of lobar bronchioloalveolar carcinoma. The diagnostic rate of the US-guided cutting biopsy was 100%, which was superior to other diagnostic procedures, such as sputum cytology (37%), fiberoptic bronchoscopy with brushing or biopsy (32%) and trans-thoracic needle aspiration cytology (50%). None of the patients developed complications. We conclude that the distinct US pattern for lobar bronchioloalveolar carcinoma is a helpful diagnostic sign, and the US-guided biopsy is a useful approach in the diagnosis of lobar bronchioloalveolar carcinoma.

Age trends in lung cancer.

To investigate the relationship between the stages of cancer development and the age trends in histologic type found at the time of disease diagnosis, we studied 1,669 patients with histologically proven lung cancer. These patients were examined at the National Taiwan University Hospital using Mantel-Haenszel Chi-square testing to determine a linear trend. These patients were divided into three age groups: group 1 (< 45 years), 141 patients (8%); group 2 (45-64 years), 946 patients (57%); group 3 (65 years or more), 582 patients (35%). The ratio of men to women was 1.4 in group 1, 2.5 in group 2 and 2.3 in group 3. In men, there was a significant trend for the proportion of squamous cell carcinoma to increase from 26% to 42% and that of adenocarcinoma to decrease from 52% to 34% as age increased. In women, an age trend for histologic type was not observed. There was also a significant trend for local-stage squamous cell carcinoma in men to increase from 18% in group 1 to 35% in group 2 and to 42% in group 3. In men, but not in women, local-stage large cell carcinoma increased from 20% in group 1 to 31% in group 2 and to 64% in group 3. However, the age-stage trend for other cell types was not significant in men.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrasonic evaluation of cervical lymphadenopathy.

Seventy-seven patients with various underlying diseases underwent real-time ultrasonographic study of the neck. The sonography of lymph nodes can be round or ovoid shaped, discrete hypoechoic nodules, or multiple confluent lobulated heterogeneous or homogeneous hypoechoic masses. Venous invasion by a malignant lymph node can also be demonstrated by ultrasonography as a loss of echogenicity in the vessel wall. Twenty-five patients with malignant cervical lymph nodes showed homogeneous discrete hypoechoic nodules. Eleven patients with malignant lymph nodes showed a multiple confluent lobulated hypoechoic picture, among them, 2 patients also had discrete hypoechoic nodules. Eight patients with multiple confluent lymph nodes showed evidence of venous invasion. Among 42 patients with a clinically palpable neck mass, 1 showed venous thrombosis in the internal jugular vein, 2 had abscesses, and 3 had normal musculo-skeletal tissues. Among 35 patients with clinically impalpable cervical lymph nodes, 5 patients had cervical lymphadenopathy. All 41 patients with sonographically detectable lymph nodes underwent aspiration cytology or biopsy, and 36 of these showed malignancy, 4 TB lymphadenitis and 1 nonspecific inflammation. No complication was observed in this series. We conclude that ultrasonography is a valuable tool to evaluate cervical lymphadenopathy and to clarify the histopathological features of the affected lymph nodes with the aid of aspiration cytology.

Analysis of miniature FLIR test targets.

Hughes Aircraft Company has developed a miniature forward-looking infrared test target that uses differential emissivity to simulate differential temperature. This paper provides a theoretical analysis for the emissivity target. The analysis leads to a semiempirical formula that gives a reasonably good prediction of apparent temperature differences. The formula is useful for designing future emissivity targets.

A comparative study of the mechanical properties in aging alveolar wall.

Alveolar wall from the lung of aging humans shows a progressive decrease in maximal extensibility, which should follow an increase in resting tissue length rather than a reduction in maximal length. An increase in resting tissue length is compatible with the change in lung volumes and reduction in elastic recoil that occurs with time. A model of the lung was used to compare the effects of a change in resting tissue length in diminishing elastic recoil with that of a reduction in the volume density of the elastic elements (emphysema). Such differentiation is important in selecting an animal that may model the aging or emphysematous lung. In the rat, rabbit, and horse, alveolar walls show no decrease in maximal extensibility with age. In the male monkey (M. nemestrina and M. mulatta) between birth and 2.4 years there is a decrease in maximal extensibility that lacks significance for the limited age span examined. On the other hand, the energy loss in length-tension cycling (hysteresis) of alveolar wall increases in aging humans, diminishes in rats and rabbits, and shows little change in horses and monkeys. The breaking force of alveolar wall increases with age in rats and rabbits but does not change significantly in the other species. Of these species, the monkey promises a better model of the age-related changes in maximal extensibility of alveolar wall. A measure of maximal extensibility can distinguish the effects of dilatation of air spaces from those of destruction of alveolar wall in causing loss of lung elastic recoil.

Temperature-sensitive aspects of evoked and spontaneous transmitter release at the frog neuromuscular junction.

1. The temperature dependence of presynaptic processes involved in neuromuscular transmission was studied by rapidly increasing the temperature of cooled frog neuromuscular junctions by 4--10 degrees C using pulses from a neodymium laser. The temperature elevation was complete within 0.5 msec, and decayed back to control levels with a time constant of about 7--8 sec. 2. Temperature jumps completed before nerve stimulation increased the quantal content and decreased the latency of the end-plate potential (e.p.p.). The Q10 for e.p.p. quantal content in low [Ca2+] Ringer averaged about 3.9 over the range 1--18 degrees C. 3. Temperature jumps occurring during the synaptic delay (the interval between the presynaptic action potential and the onset of the e.p.p.) also increased the quantal content and decreased the latency of the e.p.p. These effects diminished as the onset of the temperature jump was moved closer to the expected onset of the e.p.p. Temperature jumps applied after the onset of the e.p.p. immediately accelerated the time course of the e.p.p. but did not significantly alter quantal content. These results demonstrate that the magnitude and timing of evoked release are influenced by temperature-sensitive processes that operate both during and shortly after the presynaptic nerve action potential, but are largely complete before the onset of release. 4. Temperature jumps were applied at various times during the interval between two nerve stimuli. The amplitude of the second e.p.p. decreased as the temperature jump was moved earlier in the interstimulus interval, suggesting that the rise in temperature following the first nerve stimulus accelerates the decay of facilitation. When the temperature jump was moved from 10 msec after to 10 msec before the onset of the first e.p.p., the amplitude of the second e.p.p. either decreased or showed no change. The fact that the second e.p.p. did not increase suggests that the temperature-sensitive processes that increase the quantal content of the conditioning e.p.p. do not greatly increase the facilitation following that e.p.p. 5. Temperature jumps immediately accelerated the time course of spontaneous miniature end-plate potentials (m.e.p.p.s) and increased their frequency. Experiments using slow temperature changes revealed that the Q10 for m.e.p.p. frequency in normal Ringer is about 10 over the range 10--20 degrees C. M.e.p.p. frequency was much less sensitive to temperature changes below about 10 degrees C. When the nerve terminal was depolarized by 20 mM-K+ in the presence of Ca2+, the Q10 for the rate of spontaneous release over the range 10--20 degrees C decreased to about 4, similar to the Q10 for e.p.p. quantal content. In the absence of extracellular Ca2+ the Q10 for m.e.p.p. frequency in 20 mM-K+ remained near 10. 6. The marked difference in Q10S for spontaneous transmitter release under different experimental conditions suggests that not all transmitter release uses identical mechanisms...

The nature of phonons and solitary waves in alpha-helical proteins.

A parametric study of the Davydov model of energy transduction in alpha-helical proteins is described. Previous investigations have shown that the Davydov model predicts that nonlinear interactions between phonons and amide-I excitations can stabilize the latter and produce a long-lived combined excitation (the so-called Davydov soliton), which propagates along the helix. The dynamics of this solitary wave are approximately those of solitons described using the nonlinear Schrödinger equation. The present study extends these previous investigations by analyzing the effect of helix length and nonlinear coupling efficiency on the phonon spectrum in short and medium length alpha-helical segments. The phonon energy accompanying amide-I excitation shows periodic variation in time with fluctuations that follow three different time scales. The phonon spectrum is highly dependent upon chain length but a majority of the energy remains localized in normal mode vibrations even in the long chain alpha-helices. Variation of the phonon-exciton coupling coefficient changes the amplitudes but not the frequencies of the phonon spectrum. The computed spectra contain frequencies ranging from 200 GHz to 6 THz, and as the chain length is increased, the long period oscillations increase in amplitude. The most important prediction of this study, however, is that the dynamics predicted by the numerical calculations have more in common with dynamics described by using the Frohlich polaron model than by using the Davydov soliton. Accordingly, the relevance of the Davydov soliton model was applied to energy transduction in alpha-helical proteins is questionable. We conclude that the Raman lines that have been assigned to solitons in E. coli are either associated with low frequency normal modes or are instrumental- or fluorescence-induced artifacts.