Sternal dehiscence in patients with and without mediastinitis.

The authors compared patients with sternal dehiscence (SD) with and without mediastinitis with respect to: 1) time interval from surgery to diagnosis; and 2) frequency of sternal wire abnormalities on chest radiographs (CXR). Using a hospital information system to identify all patients with a diagnosis of SD from January 1993 through April 1999, the authors obtained clinical data by performing a retrospective chart review. For each patient, a CXR from the date of diagnosis of SD was retrospectively compared with the first postoperative CXR to assess for sternal wire displacement, rotation, and disruption. The timing of sternal wire alterations was correlated with clinical findings of SD or mediastinitis. The authors found that sternal wire abnormalities are evident radiographically in the majority of SD patients with and without mediastinitis; there is no significant difference in the frequency of sternal wire abnormalities between these two subgroups. Patients with SD and mediastinitis generally present later in the postoperative period than patients with isolated dehiscence.

Wandering wires: frequency of sternal wire abnormalities in patients with sternal dehiscence.

OBJECTIVE: The purpose of this study is to assess the frequency of various sternal wire abnormalities on chest radiographs of patients with sternal dehiscence and to determine the role of radiography in detecting or confirming this complication. MATERIALS AND METHODS: We used our computerized hospital information system to identify all patients with a diagnosis of sternal dehiscence from January 1993 through June 1998. Clinical data were obtained by retrospective chart review. A chest radiograph from the date of diagnosis was compared with the first postoperative radiograph obtained after median sternotomy. Each radiograph was retrospectively reviewed by two radiologists who assessed three sternotomy wire abnormalities: displacement (offset of one or more wires in relation to others in the vertical row), rotation (alteration in the axis of a wire compared with its orientation on a baseline radiograph), and disruption (unraveling or fracture of a wire). We also reviewed a series of postoperative radiographs in a group of matched controls who had an uneventful postoperative course with no clinical evidence of dehiscence. RESULTS: The study cohort included 19 patients, 13 men and six women, who were 49-84 years old (mean, 66 years). The chest radiographs revealed sternal wire abnormalities in 17 (89%) of 19 patients with sternal dehiscence, including displacement in 16 (84%) of 19 patients, rotation in 10 (53%) of 19 patients, and disruption in four (21%) of 19 patients. The mean number of displaced wires per patient was 2.3 (range, 1-5). The mean distance of maximal displacement was 20 mm (range, 6-45 mm). Radiographic abnormalities preceded the clinical diagnosis in 13 (68%) of 19 patients. We observed no case of sternal wire displacement, rotation, or disruption in the control group. CONCLUSION: Sternal wire abnormalities, most notably displacement, are present in most patients with sternal dehiscence; radiographic abnormalities precede the clinical diagnosis in most cases.

Posterior inferior junction line and left pleuroesophageal stripe: their association with emphysema.

In an effort to define the posterior inferior junction line (PIJL) and its clinical associations more precisely, 64 posteroanterior radiographs demonstrating the PIJL or left pleuroesophageal stripe (LPES) were analyzed for the presence of emphysema, kyphosis, air-filled esophagus, and/or tortuous aorta. Pursuant to the possible association of a PIJL or LPES with an air-filled esophagus, posteroanterior radiographs of 66 patients with achalasia were evaluated for the presence of a PIJL or LPES. To determine the components of the PIJL or LPES, 50 randomly selected computed tomographs (CT) of the chest were reviewed. Finally, 118 posteroanterior radiographs of patients with emphysema were analyzed for the presence of a PIJL and/or LPES to determine the sensitivity of the line/stripe for emphysema. The finding of a PIJL and/or LPES had a combined sensitivity of 23% for emphysema. Although certain other anatomic constructs lead to the presence of a line or stripe, emphysema is the most commonly associated clinical entity with a positive predictive value of 65.8%. The line and/or stripe is formed by interfaces between lung/lung, lung/esophagus, or both at different levels.

Diffuse panbronchiolitis: histologic diagnosis in unsuspected cases involving North American residents of Asian descent.

OBJECTIVE: To study and report two cases of diffuse panbronchiolitis in patients of Asian ancestry residing in the United States and to review the literature pertaining to this disease. DESIGN: Diffuse panbronchiolitis is a progressive interstitial pneumonitis occurring primarily in Japan. Rare cases are now being identified in Europe and North America. Patients often have a history of sinusitis, present with dyspnea on exertion, and show a restrictive pattern on pulmonary function tests. The clinical, radiologic, and pathologic features of two cases of the disease received for consultation at the Armed Forces Institute of Pathology, Washington, DC, are reported with a review of the literature. RESULTS: Chest radiographs revealed bilateral small nodular opacities with ill-defined borders. High-resolution computed tomography demonstrated the abnormalities to have a centrilobular distribution. Histologically, there was transmural chronic inflammation centered on the terminal bronchioles and an interstitial infiltrate of foamy macrophages. CONCLUSION: Diffuse panbronchiolitis may be mistaken for other more common small airway diseases and may be underrecognized in Western nations. The immigration of Asians and sporadic case reports involving non-Asians make recognition of this disease entity important, as the implications for therapy are different than that of other small airway diseases.

CT surveillance of the thorax in patients with squamous cell carcinoma of the head and neck: a preliminary experience.

PURPOSE: Our goal was to determine the number of malignancies detected by thoracic CT in patients with head and neck squamous cell carcinoma (SCCA) in three clinical settings. METHOD: We retrospectively examined 168 thorax CT scans in 93 patients with head and neck SCCA and determined the number of malignancies (second primary cancers or metastasis) (a) at the time of diagnosis of the primary neck tumor (57 patients), (b) at approximately yearly intervals following treatment of the primary cancer (93 examinations in 43 patients), and (c) at the time of local/regional recurrence of the neck neoplasm (18 patients). RESULTS: CT detected malignancy in 9 of 57 patients examined during diagnosis of the neck tumor, in 9 of 43 patients during follow-up, and in 6 of 18 patients evaluated at the time of local/regional neck recurrence. CONCLUSION: Chest CT demonstrates a high number of additional malignancies in patients presenting with advanced SCCA of the head and neck.

Sparing of some accessory lobes in diffuse pulmonary edema.

In patients with diffuse pulmonary edema we have noted a number who had sparing of accessory lobes. We postulate that this is due to a combination of two factors: diminished perfusion of the peripheral lung parenchyma and accessory fissures preventing interalveolar drift.

Two group therapy models for clients with a dual diagnosis of substance abuse and personality disorder.

OBJECTIVE: The relative effectiveness of two types of group therapy-the disease-and-recovery model and the cognitive-behavioral model-was examined in a public inpatient and outpatient setting with consumers who had a dual diagnosis of a personality disorder and a substance use disorder. Outcomes in four areas of problem severity were measured: alcohol use, drug use, social and family relations, and psychological functioning. METHODS: Using a quasiexperimental group design, 19 subjects in an inpatient mental health facility and 19 in a public outpatient facility were randomly assigned to the two experimental groups. The groups met three times a week for 12 weeks, and specific group leadership protocols were used. A third group at each setting received usual group treatment. Diagnoses of all subjects were verified using the Structured Clinical Interview for DSM-III-R. The Addiction Severity Index measured changes in problem severity. RESULTS: In the inpatient setting, subjects in both experimental groups had significantly improved social and family relations compared with the usual-treatment group; no posttest changes in the other three areas were noted. In the outpatient setting, cognitive-behavioral group therapy was significantly more effective than the other two group approaches in reducing alcohol use, improving social and family relations, and enhancing psychological functioning. CONCLUSIONS: Results suggest that the severity of mental health consumers' substance abuse problems can be substantially decreased in several areas in an outpatient public setting. In an inpatient setting, the use of either group therapy model was more effective in reducing problem severity than using no specific model.

Peripheral blood lymphocyte apoptosis: a clue to the diagnosis of acute infectious mononucleosis.

OBJECTIVE: To describe the morphology and significance of apoptotic lymphocytes in peripheral blood smears of patients with acute infectious mononucleosis. To our knowledge this has not been previously reported. DESIGN: Peripheral blood smears from 27 patients with a positive heterophile antibody test were collected and reviewed for the presence of apoptotic lymphocytes. Flow cytometry was performed on three cases to document the previously described low expression of bcl-2 in lymphocytes in infectious mononucleosis. Four control patient populations comprising 80 cases were similarly screened for the presence of apoptotic lymphocytes. SETTING: The specimens were collected over a 3-month period in two laboratories at our tertiary care hospital; all specimens were processed according to a standard protocol. PATIENTS: Young adult military recruits and their spouses, military dependent adolescents, and retired military personnel. RESULTS: Twenty-four (88.9%) of 27 peripheral blood smears of patients with acute infectious mononucleosis contained readily identifiable apoptotic lymphocytes. Three (3.75%) of 80 control peripheral blood smears were identified with rare apoptotic lymphocytes, all occurring in patients with viral upper respiratory infections. CONCLUSIONS: The finding of apoptotic lymphocytes in a peripheral blood smear is useful in the differential diagnosis of infectious mononucleosis and neoplastic hematolymphoid processes.

Case report 750: Aspergillosis of the chest wall in an apparently immunocompetent host.

This is a case of aspergillosis of the bone and soft tissues of the chest wall in a (probably) immunocompetent host. The areas of involvement and different types of this disease are described. The A. flavus group, which presumably was responsible for this involvement of the chest wall, is very uncommon as a pathogen in humans.

Melanin accelerates the tyrosinase-catalyzed oxygenation of p-hydroxyanisole (MMEH)

Although pigment melanin has long been though of as "inert," recent work has attested to its chemical reactivity. In this communication, we report that either commercial synthetic melanin prepared by persulfate oxidation of tyrosine ("Sigma melanin") or sepia melanin extracted from cuttlefish markedly accelerates the in vitro oxygenation of p-hydroxyanisole (MMEH), catalyzed by mushroom or B-16 melanoma tyrosinase. Kinetics of 4-methoxy-1,2-benzoquinone formation (lambda max = 413 nm) or of molecular O2 uptake were biphasic, with an initial slow rate ("lag time") followed by a fast linear increase. The biphasic response reflects an initial slow hydroxylation followed by a fast dehydrogenation. Added melanin markedly decreased the lag time but had little effect on subsequent dehydrogenation. Similar effects were observed for tyrosine itself. A complex between MMEH and melanin appears to be the "active" species in these reactions. The results indicate that melanin acts as an electron conduit, which accepts electrons from the substrate and transfers them to tyrosinase. The magnitude of the effect depends on the type of melanin as well as on its oxidation state. Kinetic analysis indicates that both melanins are very efficient at transferring electron to tyrosinase, and that Sigma melanin is roughly threefold more efficient than sepia melanin. The qualitative similarity of reaction between the synthetic and "natural" melanins suggests that the former may serve as a first approximation to the in vivo situation. On the other hand, the observed quantitative differences and the sensitivity of these results to the chemical state of melanin suggests that this methodology might eventually be adapted as a non-destructive probe of melanin in situ.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultraviolet radiation-induced suppression of contact hypersensitivity in relation to padimate O and oxybenzone.

Contact hypersensitivity (CHS) in mice can be induced by cutaneous sensitization followed by elicitation via ear-painting with trinitrochlorobenzene (TNCB). This CHS reaction is systemic and can be suppressed by exposure of mice to suberythemogenic doses of 280-315 nm radiation. In this study, we investigated whether a commercially available water-resistant sunscreen, either SPF-6 or SPF-15, containing Padimate O (UVB absorber) and oxybenzone (UVA absorber), was effective in preventing systemic suppression of CHS induced by either FS36 sunlamp exposure or solar simulating radiation. We observed that these two sunscreen preparations were totally incapable of preventing the immunologic suppression of contact hypersensitivity by UV radiation. These results indicate that application of sunscreen does not retard the development of suppression of CHS following repeated UV exposure under conditions where erythema is not clinically observed. Thus, erythema may not be a good end point for assessing systemic immune suppression and its consequences.

Stress-related rib and vertebral changes.

In the course of routine chest examination, 80 asymptomatic patients were observed to have localized hyperostosis of the posterior ribs and articulating transverse processes. The authors studied the distributions of lesions in these 80 patients, and records were reviewed in the 50 cases in which they were available. The occupational histories, male-to-female ratio (5:1), and ratio of right-to-left rib involvement (9:1)--in addition to results of electromyographic and histologic studies and the principles of bone remodeling--suggest that this hyperostosis occurs at sites most stressed with bending and rotation of the thorax. The authors hypothesize that this stress-related change occurs due to the pull of the iliocostalis thoracis muscle and is of no clinical significance.

Lipomatous hypertrophy of the interatrial septum. Diagnosis by magnetic resonance imaging.

A surgically proved case of lipomatous hypertrophy of the interatrial septum is demonstrated on magnetic resonance imaging. The intensity on T1-weighted images and characteristic distribution of the lesion may make the diagnosis possible without surgical intervention.

Asbestos-related pleural disease and asbestosis: a comparison of CT and chest radiography.

High-resolution CT (HRCT) has the ability to demonstrate both asbestos-related pleural disease and parenchymal abnormalities consistent with asbestosis. The role of CT in the diagnosis of asbestosis can be defined by comparing it with radiography. We evaluated 60 men who had a history of occupational exposure to asbestos and whose outside chest radiographs were considered abnormal. Chest radiographs (inside films) and HRCT were performed in all patients at our institution and were interpreted independently by experienced radiologists. Outside film results were compiled from the submitted reports. The final conclusion regarding the interpretation of the radiologic examinations was determined by consensus when disagreements existed. Positive predictive values (the likelihood that a positive report is correct) for pleural disease were: outside films 56%, inside films 79%, HRCT 100%. The positive predictive values for parenchymal disease were: outside films 51%, inside films 83%, HRCT 100%. The addition of HRCT to chest radiography is most useful in eliminating false-positive diagnoses of asbestos-related pleural disease caused by subpleural fat and false-positive diagnoses of parenchymal asbestosis in patients with extensive plaques or emphysema obscuring lung detail. The interpretation of chest radiographs in patients exposed to asbestos is often extremely difficult and subjective, and we recommend that positive findings (except calcified plaques) be confirmed with HRCT.