Bronchoscopic insertion of Gianturco stents for the palliation of malignant lung disease: 10 year experience.

Malignant large airway obstruction is life threatening and may not be amenable to urgent radiotherapy. Palliative airway stenting is difficult and traditionally carried out under general anaesthesia and fluoroscopy. We have shown that self expanding Gianturco metal stents can be placed under local anaesthesia using fibreoptic bronchoscopy and direct vision for the treatment of malignant airway tumours, and report our 10 year experience. All referrals for stenting referred to our unit between 1990 and 1999 were included, looking for histological type, number and site of stents, complications of the procedure, other interventions, and survival. One hundred and sixty two patients (average age 64 years, (range 21-89)) had 307 stents inserted during 167 procedures (144 primary lung tumours, 18 secondary malignancy). There were no operative deaths, but three patients developed a pneumothorax, one requiring intercostal drain insertion. Average survival following stent insertion was less for primary lung cancer than for secondary disease (103 vs. 431 days, P<0.001). There were no excess complications in a subgroup of 64 patients treated locally by oncologists, even when stenting was the primary procedure. This technique is useful in palliating life threatening airway obstruction, particularly for secondary cancer, and can be used in any centre undertaking fibreoptic bronchoscopy.

Pneumococcal vaccine.

Streptococcus pneumoniae is a frequent cause of pneumonia and meningitis. This article looks at the pneumococcal vaccine, its uses, efficacy, and adverse effects and how vaccination may be improved. We also look at the role of the new conjugate vaccines.

Surgery for lung cancer: age alone is not a contraindication.

A retrospective analysis of the clinical features, operative procedures, postoperative complications and subsequent survival of 70 (50 male) elderly patients undergoing surgery for lung cancer compared with 74 (53 male) younger patients treated at the same hospital during the same period was performed, to determine if elderly people with lung cancer are less likely to benefit from and/or tolerate surgery. The elderly group had to wait longer for operation (p = 0.001) and were more likely to have pre-existing disease (p = 0.019). In contrast, they had fewer recognised postoperative complications (p = 0.032) and there was no difference between the two groups in perioperative mortality and subsequent survival. Surgical treatment of localised lung cancer represents the best chance for cure and this study suggests that age should not be a consideration in the decision to operate or not. The patient's general state of health should be assessed and management decisions based on individual status rather than on age.

Serum indicators of free radical activity in idiopathic pulmonary fibrosis.

Serum levels of free radical activity were measured in 37 patients with idiopathic pulmonary fibrosis (IPF) and 16 control subjects. Three assays used were (1) simultaneously measured levels of the 9,11-diene conjugate of linoleic acid and 9,12-linoleic acid expressed as a percent molar ratio (%MR), a measure of free-radical-mediated lipid peroxidation; (2) thiobarbituric acid reactive substances (TBARS), one of which is malondialdehyde; (3) desferrioxamine-chelatable iron assay, a measure of the potential iron available to catalyze free radical generation. Mean %MR, TBARS and desferrioxamine-chelatable iron were all elevated initially in patients with IPF compared with control subjects (%MR, p < 0.0001; TBARS, p = 0.0013; desferrioxamine-chelatable iron, p = 0.0029). Furthermore, the serum %MR was higher in a subset of patients with clinically worsening IPF than in those patients with clinically stable disease (p = 0.002). Treatment did not appear to affect the three different serum indicators of free radical activity. Thus, lipid peroxidation appears to be increased in patients with IPF and is associated with an increase in desferrioxamine-chelatable iron levels. Serum % MR levels appeared to correlate with clinical disease activity, and they may have a role in monitoring disease activity.

Treatment of large airway obstruction in lung cancer using expandable metal stents inserted under direct vision via the fibreoptic bronchoscope.

BACKGROUND: Self-expanding metal stents have been used successfully to overcome large airway obstruction due to malignant pulmonary disease. The technique has been modified to place stents under direct vision using the fibreoptic bronchoscope. The effect of this procedure on lung function and patient well being was investigated in a large series of patients. METHODS: Fifty six patients with malignant tracheobronchial tumours were treated for symptoms of life threatening airways obstruction or collapse of a lung by the insertion of an expandable metal stent(s) under local anaesthetic using a fibreoptic bronchoscope. All had inoperable cancer and 33 had relapsed after or failed to respond to radiotherapy, chemotherapy, or surgery. Forty seven had primary bronchial carcinomas and nine had metastases from other tumour sites. All but two patients had the stents inserted at one sitting. Measurements were performed in most of the patients before and after stenting and included objective measures (pulmonary function tests, arterial blood gas tensions) and non-objective measures (patient well being, performance status). RESULTS: Overall, 77% of patients showed symptomatic improvement. In those patients in whom measurements were performed two thirds showed improvement in forced expiratory volume in one second (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR) and arterial oxygen tension (PaO2). Medical Research Council dyspnoea score (MRC), Karnofsky, and visual analogue scores (for both breathing and well being) improved in 81% of patients. There were no perioperative deaths. Fifty one patients have died since the procedure with a mean survival of 77 days (range 1-477), and five patients are still alive after a mean of 207 days (range 135-274). CONCLUSIONS: In suitable patients with either extraluminal or intraluminal tumour, or both, the insertion of expandable metal stents using a fibreoptic bronchoscope and local anaesthetic is a valuable addition to other palliative therapies in the treatment of lung cancer.

Counselling for an HIV test.

Doctors may feel uncomfortable with the prospect of discussing a human immunodeficiency virus (HIV) antibody test with their patient. This is in part because they do not enquire about high risk activity as part of a medical history. With increasing medical and public awareness of both the clinical manifestations and social implications of HIV infection, it is important that all doctors receive guidance on how to deal with these issues. Counselling is not the usual term used to describe obtaining informed consent. In the general medical setting, tests for hepatitis B and syphilis are routinely carried out without specific consent even though results of these tests may have profound effects on both the patient and their sexual partners. However society and ethical considerations have made HIV testing different. HIV testing will inevitably become more widespread, and thus become a more routine part of patient investigation and management.

Indicators of free radical activity in patients developing radiation pneumonitis.

PURPOSE: Radiation pneumonitis is thought to occur as the result of excess free radical generation following radiotherapy. Various in vitro studies have shown that large doses of irradiation can cause membrane lipid peroxidation and the oxidation of protein sulphuryl groups. We, therefore, studied two circulating markers of lipid peroxidation and an indicator of "catalytic iron" (potentially available iron to catalyze the generation of free radicals) in patients undergoing radiotherapy. METHODS AND MATERIALS: The 9,11 diene conjugate of 9,12 linoleic acid, expressed as their molar ratio (percentage molar ratio (MR)) and thiobarbituric acid reactive acid-substances (TBARS), as well as levels of circulating desferrioxamine-chelatable iron assay, were assayed. Serial blood samples were taken over a 3-month period in 25 patients with inoperable nonsmall cell lung cancer. RESULTS: Ten patients developed radiation pneumonitis. The patients who developed pneumonitis showed a tendency for the serum percentage molar ratio to increase after a week. The change in the percentage molar ratio between Time 0 and 1 week of radiotherapy was significantly higher in the group that subsequently developed pneumonitis compared to the group that did not (p = 0.002). The initial serum TBARS levels in patients were not significantly elevated compared to controls and there was no difference in the serum TBARS levels in the pneumonitis and nonpneumonitis groups throughout the study period. After 1 week of radiotherapy the group that subsequently developed pneumonitis had a significantly higher level of desferrioxamine-chelatable iron (DFx-iron) compared with the nonpneumonitis group (p = 0.05). CONCLUSION: These data suggest that both the percentage MR and DFx-iron appear to reflect an increased susceptibility to develop radiation pneumonitis and after 1 week of radiotherapy they indicate patients who are likely to subsequently develop pneumonitis. Hence, these indicators could indicate the group of patients that could benefit from intervention therapies with antioxidants.

The use of expandable metal stents for large airway obstruction in older patients.

OBJECTIVE: To review the indications, management, and outcome of 30 older patients who had expandable metal stents inserted for large airway obstruction. DESIGN: Information was collected retrospectively from case notes about presentation, radiographic appearances, pulmonary function, including arterial oxygen tension, and histology. Survival data were collected by reviewing hospital or General Practice records. MEASUREMENTS: Spirometry, peak expiratory flow rate, and blood gases were recorded before and after stent insertion. MAIN RESULTS: There was a significant improvement in the patient's mean forced expiratory volume in 1-second (FEV1) and mean peak expiratory flow rate (PEFR). The arterial oxygen tension (pO2) increased from 8.6 Kpa to 10.6 Kpa. The mean length of survival for the whole group was just under 5 months. CONCLUSIONS: Airway stenting for obstruction provides palliative and functional benefits in these severely disabled patients and a consequent improvement in quality of remaining life.

Dysphagia in an HIV-positive man.

An HIV-positive man whose dysphagia was due to non-Hodgkin's lymphoma. The differential diagnosis of this symptom in the context of HIV infection is summarised in box 3.

Simultaneous tracheal and oesophageal pH measurements in asthmatic patients with gastro-oesophageal reflux.

BACKGROUND: An association between asthma and gastro-oesophageal reflux is well recognised but the underlying mechanism is unclear. One suggestion is that gastric juice is aspirated into the tracheal and upper airways but detection of these events is difficult and involves radioisotopic studies. A new method of making direct measurements of tracheal and oesophageal pH over a 24 hour period is described, together with its application to patients with asthma. METHODS: The technique involves insertion of simultaneous tracheal and oesophageal pH probes under general anaesthesia. Continuous monitoring of pH over a 24 hour period is possible, permitting comparison with peak flow readings during wakefulness and at night should the patient be disturbed. Representative data from four patients with asthma (mean FEV1 62% predicted) and symptomatic gastro-oesophageal reflux, together with data from three non-asthmatics, is presented. RESULTS: Thirty seven episodes of gastro-oesophageal reflux lasting more than five minutes were recorded. Of these, five were closely followed by a fall in tracheal pH from a mean (SE) of 7.1 (0.2) to 4.1 (0.4) and a fall in peak expiratory flow (PEFR) of 84 (16) l/min. When gastro-oesophageal reflux occurred without tracheal aspiration the fall in PEFR was 8 (4) l/min. CONCLUSIONS: This new technique was well tolerated and allowed quantitation of the number, duration, and timing of episodes of tracheal micro-aspiration. Unlike acid reflux without aspiration, these events appear to be related to significant acute changes in lung function in asthmatic patients. Further studies with this new method may elucidate the role of gastro-oesophageal reflux in asthma.

Pneumocystis carinii pneumonia presenting with pneumomediastinum in an HIV-positive patient.

A 19-year-old man presented with community-acquired pneumonia, complicated by pneumomediastinum. Subsequently he was found to be HIV-positive, and to have Pneumocystis carinii pneumonia.

Twenty-four-hour tracheal pH monitoring--a simple and non-hazardous investigation.

Prolonged oesophageal pH monitoring is commonly used in the investigation of gastro-oesophageal reflux. In contrast, tracheal pH monitoring is virtually unknown. We report a simple technique of measuring tracheal pH where the pH probe is inserted under local anaesthetic and can be left in position for 24 h to allow prolonged monitoring. Ten control individuals were studied. All completed the study without complication. One patient with mixed connective tissue disease, failed hiatal hernia repair and subsequent recurrent aspiration pneumonia was studied, on and off ranitidine, using simultaneous tracheal and oesophageal pH monitoring. This method showed evidence of gastro-oesophageal reflux and tracheal aspiration off treatment. When repeated with the patient taking ranitidine, the frequency of significant gastro-oesophageal reflux was reduced and no episodes of tracheal acid aspiration were recorded. Prolonged tracheal pH monitoring is a simple and non-hazardous technique. It is sensitive in detecting tracheal aspiration and may be more sensitive than pre-existing radiolabelled isotope techniques.

Circulating markers of free radical activity in patients with pulmonary tuberculosis.

SETTING: Toxic free radicals have been implicated in the development of lung fibrosis which may be a long-term sequela of pulmonary tuberculosis. OBJECTIVE: To measure circulating indicators of free radical activity in patients with pulmonary tuberculosis in order to determine whether patients with active pulmonary TB have elevated levels of circulating free radical activity, and whether these levels correlated with disease activity as determined by other blood markers of inflammation. DESIGN: 17 patients with active pulmonary tuberculosis were studied. Serial serum levels of 3 assays of free radical activity were measured at diagnosis (17 patients), and over a 2-7 month period on chemotherapy (8 patients). 3 patients with active lymph node tuberculosis were also studied and 4 patients with old lung scarring from previously treated tuberculosis had their serum markers analysed. RESULTS: All 3 serum markers of free radical activity were elevated in patients with active pulmonary tuberculosis. During serial measurement in 8 patients the % molar ratio of 9,11 linoleic acid/9,12 linoleic acid fell progressively with treatment. Thiobarbituric acid reactive substances (TBARS) were initially elevated in 6/8 patients and remained elevated despite treatment. In 2 patients TBARS were in the normal range at presentation but subsequently rose with treatment. Desferrioxamine-chelatable iron was initially normal in all but 1 patient, remained normal in 2 patients, rose in 4 patients and fell in 1 patient. CONCLUSIONS: These results suggest that increased circulating levels of free radical activity are found in active pulmonary tuberculosis and hence may play a role in the resultant fibrosis. It also reinforces the belief that a range of free radical activity (FRA) indicators are produced in any inflammatory process with fibrogenic potential and that these indicators may be measuring different stages of the disease process.