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.

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.

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.

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.

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.

HIV-positively.

PIP: Men dominate society in Uganda. Women are therefore expected to be subservient to men. This subservience and obedience are clearly demanded with regard to sexual relations between spouses. Women in Uganda are expected to comply, without debate, to their husbands' demands to engage in sexual intercourse. 18% of the adult population in Uganda, however, may be infected with HIV. In such a context, some women may not want to have sex with their husbands out of fear of contracting HIV infection. Moreover, in this polygamous society, the risk of contracting/transmitting HIV may increase as husbands take on additional wives. Socially, culturally, and legally, however, women have few, if any, alternatives but to accede to their husbands' sexual demands. A woman who refuses to have sex with her husband who she suspects of carrying HIV may be forced to do so against her will, thrown out of the home, or abandoned. The AIDS Support Organization (TASO) provides medical care, emotional support, and practical and sometimes legal help to people with AIDS and their families. TASO also works to change community attitudes about HIV. The organization's efforts are getting women to confront the practices which perpetuate their subservience in Uganda, fostering their independence and increasing emancipation.^ieng

Distribution of ferrochelatase activity in density gradient separated bone marrow cells.

A simple, reproducible, and economical procedure for separating bone marrow cells into distinct populations and stages of maturation was developed and used to investigate the distribution of ferrochelatase activity in rat bone marrow cells. Density gradient ultracentrifugation of normal rat marrows on discontinuous arabinogalactan layers of 16.5-30.0% resulted in six distinct fractions enriched for myeloblasts, neutrophils, pronormoblasts, normoblasts, or lymphocytes. Segregation reflecting different stages of cell development was demonstrated. Neutrophils appeared at a greater density and were clearly separated from precursor myeloblasts. Normoblasts appeared at a greater density and were clearly separated from precursor pronormoblasts. Lymphocyte distribution within the gradient followed a normal curve (P < 0.05). A single gradient layer which consisted of greater than 80% lymphocytes was shown to be associated with significantly increased (P < 0.05) ferrochelatase specific activity (units/mg protein); the remaining cell populations did not differ significantly from each other in specific activity.

The diagnostic histopathologic features of ocular malaria.

BACKGROUND: The ocular complications in patients with malaria have been studied clinically by many investigators, but the histopathologic changes were rarely described and generally regarded as nonspecific. METHODS: The eye of a 53-year-old man who died of chloroquine-resistant Plasmodium falciparum malaria was studied by brightfield and polarized light microscopy. FINDINGS: An epibulbar hemorrhage that involved the conjunctiva, episclera, and tendinous insertion of the medial rectus muscle was present. Cytoadherence and rosetting of the parasitized erythrocytes were observed within the partially occluded lumens of small retinal and uveal blood vessels. The birefringence of hemozoin (malarial pigment) within the lumens of small ocular blood vessels and in the hemorrhagic epibulbar area was demonstrated by polarized light. CONCLUSION: Birefringent hemozoinemia in vascular lumens of ocular tissues indicates systemic malarial infestation by any of the four species of malaria. Cytoadherence and rosetting of the parasitized erythrocytes inside ocular capillaries and venules is diagnostic of P. falciparum and is an important cause of ocular hemorrhage.

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.

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.

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.

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.

IgA:IgM and IgA:IgA hybrid hybridomas secrete heteropolymeric immunoglobulins that are polyvalent and bispecific.

Polyvalent bispecific antibodies were secreted by hybrid hybridoma cells when both parental clones expressed a naturally polymerizing immunoglobulin. Hybrid hybridomas made from IgA lambda 2 anti-trinitrophenyl (TNP) and IgA kappa anti-phosphocholine (PC) parental cells secreted polymeric IgA antibodies that bound both TNP and PC. Some of the TNP binding was dissociated from the PC binding under conditions of mild reduction and alkylation suggesting that the bispecific polymeric IgA contained disulfide-linked parental monomers as well as bispecific hybrid monomers. Hybrid hybridomas constructed from IgA lambda 2 anti-TNP and IgM kappa anti-ox erythrocyte parental cells secreted bispecific, polymeric immunoglobulin that contained mu-, alpha-, kappa-, and lambda 2-chains. The mu and kappa-chains dissociated from the alpha- and lambda 2-chains under conditions of mild reduction and alkylation, indicating that both parental monomers had been incorporated into the same polymeric immunoglobulin to form a heteropolymeric antibody molecule. Heterologous pairing of alpha and mu heavy chains in monomers was not detected. Hybrid hybridomas constructed from IgA lambda 2 and IgG3 lambda 2 or IgA lambda 2 and IgG1 kappa parents co-secreted both parental immunoglobulins, but the antibodies secreted by these clones did not form heteropolymers or exhibit heterologous heavy chain pairing. These findings establish that polyvalent, bispecific, polymeric immunoglobulin molecules can be produced by hybrid hybridomas when both parents express a naturally polymerizing class of heavy chain but not when only one parent does. Hybrid hybridomas that produce heteropolymeric immunoglobulins are sources of high avidity bispecific antibodies that may find a number of basic and practical applications. The hybridoma cells that produce these antibodies may provide useful tools for investigating the in situ determinants of immunoglobulin chain association and the regulation of antibody assembly and secretion.

A biologic tissue adhesive for vitreoretinal surgery.

Commercially available tissue glue was injected subretinally under mechanically induced retinal detachments in rabbit eyes resulting in chorioretinal adhesions at the injection site. After serial enucleation all eyes underwent histologic evaluation. Results were encouraging, but pooled fibrinogen is not acceptable for human use. A substitute for the pooled fibrinogen fraction, an adhesive using autologous plasma was prepared and studied after subretinal and intravitreal injection into rabbit and pig eyes. Postoperative clinical follow-up was one year for the rabbit eyes and one month for the pig eyes, after which all globes were enucleated. Histopathologic evaluation demonstrated circumscribed chorioretinal adhesions at the injection site. The autologous bioadhesive was applied as an adjunct in vitreoretinal surgery over macular holes and large retinal tears. As it is relatively short acting (ie, 4-6 days), it may be considered as a possible addition to existing techniques, facilitating difficult surgical procedures.

Successful management of acute retinal necrosis with intravenous acyclovir.

Two patients (3 eyes) had a history and clinical findings typical of acute retinal necrosis syndrome. Ten-day treatment with intravenous acyclovir and topical cycloplegia resulted in rapid resolution of the vitreoretinal findings and a swift return to near normal vision. All three eyes have maintained normal vision, and there have been no retinal detachments over a year after treatment.

An urban nutrition education and rehabilitation centre: a description of the programme and change in nutritional status of children who were enrolled.

We report on a community-based day care nutrition rehabilitation and education centre which was established by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) in a slum in Dhaka, Bangladesh. Between March-December, 1985 approximately 10 children aged 1 to 5 years with a percent weight for height (% wt/ht) of 60 to 85 were enrolled in each of 9 sessions which were 3 to 5 weeks long. The children were fed 3 meals and 2 snacks daily made from locally available inexpensive foods. A nutrition education programme, developed with input from several feeding centres in Dhaka, included daily lessons, participatory cooking and personal hygiene sessions. Of the 85 children entering the programme, 82 (95%) completed 3 or more weeks. Relative to baseline, a median increase of 8.7% wt/ht was observed at 5 weeks (p less than 0.001), with the greatest improvement occurring in those children presenting with the lowest weights. Median increases of 7.2 and 7.4% wt/ht were noted 6 and 10 months after admission, respectively. Gender and minor illness did not have a significant impact on change in nutritional status. Poor performance of mothers in assigned chores was associated with inferior improvement in nutritional status 5 weeks but not 6 months post-admission. These results suggest that the intervention implemented by the centre may have been effective in improving nutritional status and that more rigorous evaluation of participants in relation to suitably matched concurrent controls should be performed.