Asthma among workers in healthcare settings: role of disinfection with quaternary ammonium compounds.

INTRODUCTION: An increased incidence of asthma has been reported among healthcare workers. The role of quaternary ammonium compounds (QACs), commonly used in cleaning/disinfection products, has not been clearly defined. The aim of this study was to analyse associations between asthma and occupational exposure to disinfectants, especially QACs. METHODS: The study was performed on a stratified random sample of the various healthcare departments of 7 healthcare settings. The study included: questionnaire, physical examination and specific IgE assays. Occupational exposure assessment was performed by means of a work questionnaire, workplace studies and a review of products ingredients. Data were analysed by logistic regression. RESULTS: Response rate was 77%; 543 workers (89% female) participated; 37.1% were registered nurses (RNs), 16.4% auxiliary nurses (ANs), 17.3% cleaners; 32.8% were atopic. 335 participants were exposed to QACs. Nursing professionals reported a significantly higher risk of reported physician-diagnosed asthma and, for RNs, of nasal symptoms at work than administrative staff working in healthcare sector. This risk was particularly marked during disinfection tasks and when exposure to QACs. Exposure to QACs increased significantly the risk of reported physician-diagnosed asthma and nasal symptoms at work (adjusted OR = 7.5 and 3.2, respectively). No significant association was found with other exposures such as latex glove use, chlorinated products/bleach or glutaraldehyde. CONCLUSION: RNs and ANs presented a higher risk of reported asthma than administrative staff. The highest risk was associated with tasks involving dilution of disinfection products by manual mixing, suggesting possible exposure to repeated peaks of concentrated products known to be strong respiratory irritants. Workplace interventions should be conducted to more clearly determine QAC exposure and improve disinfection procedures.

Systemic arterial air embolism after percutaneous lung biopsy.

Systemic arterial air embolism is a rarely encountered but much feared complication of percutaneous lung biopsy. We present a comprehensive review of iatrogenic air embolism post-lung biopsy, a complication that is often suboptimally managed. This review was inspired by our own institutional experience and we use this to demonstrate that excellent outcomes from this complication can be seen with prompt treatment using hyperbaric oxygen chamber therapy, after initial patient stabilization has been achieved. Pathophysiology, clinical features, and risk factors are reviewed and misconceptions regards venous versus arterial air embolism are examined. An algorithm is provided for radiologists to ensure suspected patients are appropriately managed with more favourable outcomes.

Fibrosing mediastinitis: successful stenting of the pulmonary artery.

Fibrosing mediastinitis is a rare benign condition, which can cause compression of the pulmonary or systemic vessels, tracheobronchial tree, coronary arteries or esophagus, leading to disabling clinical symptoms and even death. The case of a 26-year-old woman who presented with dyspnea is described. She was found to have 80% stenosis of the right pulmonary artery secondary to fibrosing mediastinitis. The stenosis was managed successfully with an endovascular Palmaz-Schatz stent, and the patient remains symptom-free 10 years later.

Use of small-bore vs large-bore chest tubes for treatment of malignant pleural effusions.

STUDY OBJECTIVE: To evaluate the efficacy of small-bore (12 French vanSonnenberg) catheters compared with standard large-bore chest tubes in the drainage and sclerotherapy of malignant pleural effusions. DESIGN: Retrospective review. SETTING: An academic tertiary care hospital. PATIENTS: Adult patients with documented neoplasms and malignant pleural effusions, treated between 1986 and 1995. INTERVENTION: All patients included in the study underwent drainage of malignant pleural effusions either by large-bore chest tube or by ultrasound-guided small-bore catheter. After drainage, pleurodesis was performed. RESULTS: Outcome as defined by recurrence of effusion was determined by blinded examination of all postpleurodesis chest radiographs. We identified 58 cases of malignant pleural effusion in which small-bore catheters were used and 44 in which large-bore chest tubes were used. The majority of patients had breast (n = 56, 55%) or lung cancer (n = 29, 28%). The median age was 65 years. Fifty-nine patients were actively being treated with chemotherapy at the time of pleurodesis. The following sclerosing agents were used: talc, 27 (26%); tetracycline, 72 (70%); bleomycin, 2 (2%); and interferon, 1 (1%). Actuarial probabilities of recurrence at 6 weeks and 4 months were 45% and 53% for the small tubes vs 45% and 51% for the large tubes. Univariate and multivariate analyses failed to demonstrate that tube size had any influence on the rate of recurrence. CONCLUSIONS: We were unable to detect any major differences in outcomes with the use of either size of chest tube. Our study suggests that small-bore catheters may be effective in the treatment of malignant pleural effusions and deserve further evaluation in prospectively designed trials.

Postpneumonectomy syndrome: recognition and management.

STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.

Postpneumonectomy syndrome with an ipsilateral aortic arch after left pneumonectomy.

BACKGROUND: Previous reports have described bronchial obstruction after left pneumonectomy (so-called post-pneumonectomy syndrome) in the presence of a right aortic arch with the bronchus being compressed between the ascending aorta and thoracic spine. This study reports on 4 patients with left postpneumonectomy syndrome in the presence of a normally located left aortic arch and ascending thoracic aorta. METHODS: The case histories of 4 patients with this syndrome were reviewed and several features common to all 4 were noted. In each case, the obstruction was thought to be due to a clockwise rotation of the mediastinum with bronchial compression occurring between the right main pulmonary artery and thoracic spine. RESULTS: Three patients were treated by repositioning of the mediastinum, and all 3 obtained relief of their dyspnea. In these cases, permanent repositioning was ensured by the insertion of a prosthesis filled with saline solution. The fourth patient was successfully treated by resection of a portion of the adjacent thoracic vertebra. CONCLUSIONS: Postpneumonectomy syndrome can occur after a left pneumonectomy in the absence of a right aortic arch. We suggest that mediastinal repositioning with a prosthesis filled with saline solution is simple, is safe, and results in complete relief of preoperative symptoms.

Predictive value of extent and grade of ductal carcinoma in situ in radiologically guided core biopsy for the status of margins in lumpectomy specimens.

AIMS: The correlation between the extent and grade of ductal carcinoma in situ (DCIS) in a core needle biopsy of breast, and the presence of an extensive intraductal carcinoma component (EIC) or positive resection margins in a subsequent mastectomy, has not been adequately addressed in the literature. MATERIALS AND METHODS: Seventy-eight core needle biopsies with mammography and mastectomy correlation (27 total mastectomies, 51 lumpectomies) were reviewed. The extent and grade of DCIS in the biopsies were determined and compared with the mammographic findings and the status of the EIC and margins in subsequent mastectomy specimens. RESULTS: Twenty-four cases of core biopsies with at least three foci of low-grade DCIS or at least two foci of high grade DCIS (group I) corresponded in large part to cases of mastectomy with a positive EIC (20/23 cases, or predictive value of 87%). Nine of 15 cases of lumpectomy in this group were associated with margins positive for or close to (less than 0.1 cm from) carcinoma. Thirty-three cases of core biopsies with one or two foci of low-grade DCIS or one focus of high-grade DCIS (group II) were associated with mastectomies with a limited extent of DCIS. Only four of 22 lumpectomy specimens in this group had margins positive for or close to carcinoma. Twenty-one cases of core biopsies without DCIS (group III) represented all five mastectomy specimens without DCIS, and 16 mastectomies with DCIS and negative EIC. None of the 14 cases of lumpectomy in this group had margins positive for carcinoma. The predictive value for EIC status may be even higher if mammographic findings are used in cases with a low number of foci (two foci of low-grade DCIS or one focus of high-grade DCIS in short biopsy cores). CONCLUSIONS: There was a good correlation between the extent and grade of DCIS in core biopsies and the status of EIC in subsequent mastectomy specimens. Core needle biopsies with at least three foci of low-grade DCIS or at least two foci of high-grade DCIS are associated with a greater likelihood of positive or close margins in subsequent lumpectomies. Core biopsies without DCIS are associated with a greater likelihood of negative margins in subsequent lumpectomies.

Fine needle aspiration biopsy of pulmonary hamartomas. Radiologic, cytologic and immunocytochemical study of 15 cases.

OBJECTIVE: To review the radiographic, cytologic and immunocytochemical features of pulmonary hamartomas (PHs) diagnosed on fine needle aspiration biopsy (FNAB). STUDY DESIGN: Fifteen consecutive cases of PH, diagnosed on FNAB between January 1987 and February 1993 and confirmed by surgery or follow-up, were studied. In two additional cases PH was offered as a differential diagnosis and was excluded on follow-up. Clinical notes, radiographs, cytologic smears and cell block sections stained routinely and with antibody to S-100 protein, as well as histologic slides, were reviewed. RESULTS: All cases of PH showed common radiographic features, including peripheral location, round or oval shape, sharp edges and size < 3 cm. Cytologic diagnosis of PH was based on recognition of mesenchymal component, characterized by fibromyxoid stroma, present in 94% of FNABs. Chondroid material was present in 75% of aspirates. In all cases of proven PH, fibromyxoid material showed S-100 protein positivity, characterized by finely granular, brown staining of the stellate cells. In two cases proven not to be hamartomas, the material, suspected to be fibromyxoid or chondroid, failed to show S-100 protein positivity. CONCLUSION: These findings confirm the value of FNAB in the diagnosis of PH. Immunocytochemical staining with antibody to S-100 protein is a useful diagnostic tool in confirming the cartilaginous nature of PH. The cytologic findings should be correlated with radiologic and clinical findings before a definitive diagnosis of PH is rendered on FNAB material.

Acute aortic thrombosis in patients receiving cisplatin-based chemotherapy.

The increased risk of thrombosis in patients with active cancer has multiple causes. Acute thrombosis of the aorta is an exceedingly rare but potentially devastating complication in patients with cancer receiving cisplatin-based chemotherapy. Prompt diagnosis and definitive treatment are imperative to decrease morbidity and mortality. Early diagnosis is difficult because initial presentation is often nonspecific, requiring a high degree of clinical suspicion. We report 4 cases of acute thrombosis of the abdominal aorta in patients with cancer receiving cisplatin-based chemotherapy. We review the clinical aspects, recommended investigation, and treatment of this potentially fatal complication.

Computed tomography demonstration of systemic arterial supply to lung without sequestration.

We present two cases of systemic arterial supply to lung without sequestration diagnosed confidently based on imaging findings on computed tomography scan, thereby obviating the need for invasive diagnostic procedures.

In situ central pulmonary artery thrombosis in primary pulmonary hypertension.

A rare case of extensive in situ central pulmonary artery thrombosis in primary pulmonary hypertension (PPH) is presented. The differentiation from chronic thromboembolic pulmonary arterial hypertension (CTEPH) is of paramount importance because of different therapeutic strategies. In this case, the presence of mural thrombus in the central pulmonary arteries on computed tomography made the distinction difficult. However, the possibility of in situ thrombosis was suggested on the basis of absence of other findings of CTEPH (abrupt narrowing/truncation of segmental arteries, variation in size of segmental vessels, arterial webs, mosaic attenuation, pulmonary infarcts, and dilated bronchial arteries), and this was confirmed on final pathology.

Systemic arterial supply to the lung without sequestration: an unusual cause of hemoptysis.

Systemic arterial supply to the lung without sequestration is an unusual vascular anomaly in which a portion of normal lung tissue is supplied by an artery arising from the aorta. This entity shares some features with bronchopulmonary sequestration and hypogenetic lung (scimitar syndrome) but has unique imaging features that allow preoperative diagnosis. The authors describe such a case in a 21-year-old man who presented with hemoptysis.

Pancreatic pseudocysts drained through a percutaneous transgastric approach: further experience.

Percutaneous transgastric placement of a drainage catheter under ultrasonographic and fluoroscopic guidance was performed in 12 patients with pancreatic pseudocysts. Complete resolution of the pseudocysts was obtained in eight patients, and the result was indeterminate in one patient due to early death from unrelated causes. Surgical intervention followed in two patients, one with a multiloculated pseudocyst that was incompletely drained and another with a pseudocyst that became infected following drainage. In one patient with metastatic tumor to the head of the pancreas the pseudocyst resolved initially, but a pseudocyst later recurred. There were no pancreaticocutaneous fistulas or other major complications. The transgastric route of pseudocyst drainage is safe and effective, and it offers a low risk of recurrence and fistula formation.

Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum.

A 40 year old woman with known Crohn's disease of the ileum but no abscess was found to have hepatic portal venous gas by computed tomography. Aggressive antibiotic treatment led to recovery and the ileum was resected two weeks later.

Antenatal and postnatal findings in intra-abdominal pulmonary sequestration.

A hyperechoic mass in the right upper quadrant of the abdomen was demonstrated in a fetus by antenatal ultrasonography (US) at 20 and 33 weeks' gestation. Postnatal US, myelography and computed tomography were performed preoperatively; the findings were judged consistent with neuroblastoma. Surgical excision and pathological examination revealed bronchopulmonary sequestration.

Transthoracic needle biopsy of the lung: results of early discharge in 506 outpatients.

PURPOSE: To determine the safety of early discharge (30 minutes) after transthoracic needle biopsy (TTNB) of the lung. MATERIALS AND METHODS: In a prospective study of 506 consecutive outpatients who underwent TTNB of the lung, 440 patients underwent fine-needle aspiration biopsy (FNAB) only, and 66 underwent FNAB and core biopsy. Patients were discharged after 30-minute postbiopsy chest radiography if there was no pneumothorax. Patients were discharged after 60-minute chest radiography if they had a stable asymptomatic pneumothorax. These patients were followed up 1 day and/or 1 week after biopsy to identify delayed complications. Patients with a symptomatic or enlarging pneumothorax were treated with an 8-F pigtail catheter attached to a Heimlich valve, discharged, and followed up 24 hours later for chest tube removal. RESULTS: The pneumothorax rate was 22.9% (116 patients). Eighty-one patients (16.0%) had an asymptomatic pneumothorax, and 33 (6.5%) had a pigtail catheter in place. Seven (1.4%) patients developed a symptomatic pneumothorax after discharge; two of them (0.4%) underwent large-bore chest tube insertion. The other five (1.0%) underwent delayed pigtail catheter insertion. There were no deaths or other major complications. CONCLUSION: Early discharge after outpatient TTNB of the lung is associated with little morbidity and no mortality.

Thin-walled cystic lesions in bronchioalveolar carcinoma.

In a retrospective study, thin-walled cystic lesions were identified in four patients with proved bronchioalveolar carcinoma (BAC). The radiographic appearances are described, and possible mechanisms of formation of the lesions are discussed. Although such appearances due to BAC have rarely been described in the literature, the authors believe that the differential diagnosis of thin-walled cystic lesions associated with consolidation should include BAC.

Pleurodesis with iodized talc for malignant effusions using pigtail catheters.

OBJECTIVE: To assess the efficacy of using an iodized talc slurry as a sclerosing agent instilled into the pleural space via a 12-French pigtail catheter for controlling malignant pleural effusions. DESIGN: A prospective study in which patients were followed until their death. SETTING: A university-affiliated tertiary-care teaching hospital. PATIENTS: Medical oncology patients admitted with symptomatic malignant pleural effusions were considered for iodized talc pleurodesis. MAIN OUTCOME MEASURES: The control of pleural effusion. Treatment failure was defined as any reaccumulation of fluid in the pleural space. RESULTS: Fifteen patients were treated for a total of 17 instillations. The median follow-up on all patients until death was 6 months (range 1-20). The most frequent adverse effect in the study group was pleuritic chest pain (60%). The probability of control of effusion, as determined by the method of Kaplan-Meier, was 81% (SEM 9.7%). The cost of preparing 5 g of iodized talc was $4.32 (US). CONCLUSIONS: Iodized talc slurry instilled through a small-bore pigtail catheter is a safe, economical, and effective treatment for malignant pleural effusion.

Optimal treatment of descending necrotising mediastinitis.

BACKGROUND: Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum. METHODS: The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added. RESULTS: Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05). CONCLUSIONS: Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.