A multicenter pilot study of a bronchial valve for the treatment of severe emphysema.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) affects millions of people and has limited treatment options. Surgical treatments for severe COPD with emphysema are effective for highly selected patients. A minimally invasive method for treating emphysema could decrease morbidity and increase acceptance by patients. OBJECTIVE: To study the safety and effectiveness of the IBV(R) Valve for the treatment of severe emphysema. METHODS: A multicenter study treated 91 patients with severe obstruction, hyperinflation and upper lobe (UL)-predominant emphysema with 609 bronchial valves placed bilaterally into ULs. RESULTS: Valves were placed in desired airways with 99.7% technical success and no migration or erosion. There were no procedure-related deaths and 30-day morbidity and mortality were 5.5 and 1.1%, respectively. Pneumothorax was the most frequent serious device-related complication and primarily occurred when all segments of a lobe, especially the left UL, were occluded. Highly significant health-related quality of life (HRQL) improvement (-8.2 +/- 16.2, mean +/- SD change at 6 months) was observed. HRQL improvement was associated with a decreased volume (mean -294 +/- 427 ml, p = 0.007) in the treated lobes without visible atelectasis. FEV(1), exercise tests, and total lung volume were not changed but there was a proportional shift, a redirection of inspired volume to the untreated lobes. Combined with perfusion scan changes, this suggests that there is improved ventilation and perfusion matching in non-UL lung parenchyma. CONCLUSION: Bronchial valve treatment of emphysema has multiple mechanisms of action and acceptable safety, and significantly improves quality of life for the majority of patients.

Dorchester Lead-Safe Yard project: a pilot program to demonstrate low-cost, on-site techniques to reduce exposure to lead-contaminated soil.

Despite a general reduction in blood lead levels in children after lead was banned in gasoline and paint, lead poisoning remains an important health problem in many older urban areas. One factor that increases risk in these places is the high levels of lead in certain residential areas. A major intervention study found that reducing lead levels in urban soils results in a reduction in exposed children's blood lead levels. Removing lead from inner-city soils or reducing exposures to lead-contaminated soils typically is expensive, technologically challenging, or beyond the ability of low-income households to undertake. This project, in conjunction with residents and community-based institutions, developed a series of in situ, low-cost, low-technology measures that worked to reduce the exposure to lead-contaminated soils in one Boston, Massachusetts, neighborhood. The project demonstrated several important results. Government, universities, residents, and community based organizations can work together effectively to reduce exposures to lead in soil. Lead-contaminated soil can be mitigated at a fraction of the cost of conventional methods in ways that increase the ability of residents, community health centers, and others to have a positive impact on their neighborhoods. A lead-safe yard program can be replicated and institutionalized by municipal home de-leading programs and other community organizations.

Surveillance for silicosis, 1993--Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin.

PROBLEM/CONDITION: Silicosis is an occupational respiratory disease caused by the inhalation of respirable dust containing crystalline silica. Public health surveillance programs to identify workers at risk for silicosis and target workplace-specific and other prevention efforts are currently being field-tested in seven U.S. states. REPORTING PERIOD COVERED: Confirmed cases ascertained by state health departments during the period January 1, 1993, through December 31, 1993; the cases and associated workplaces were followed through December 1994. DESCRIPTION OF SYSTEMS: As part of the Sentinel Event Notification System for Occupational Risks (SENSOR) program initiated by CDC's National Institute for Occupational Safety and Health (NIOSH), development of state-based surveillance and intervention programs for silicosis was initiated in 1987 in Michigan, New Jersey, Ohio, and Wisconsin and in 1992 in Illinois, North Carolina, and Texas. RESULTS: From January 1, 1993, through December 2, 1994, the SENSOR silicosis programs in Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin confirmed 256 cases of silicosis that were initially ascertained in 1993. Overall, 185 (72%) were initially identified through review of hospital discharge data or through hospital reports of silicosis diagnoses; 188 (73%) were associated with silica exposure in manufacturing industries (e.g., foundries; stone, clay, glass, and concrete manufacturers; and industrial and commercial machinery manufacture). Overall, 42 (16%) cases were associated with silica exposure from sandblasting operations. Among the 193 confirmed cases for which information was available about duration of employment in jobs with potential exposure to silica, 37 (19%) were employed < or = 10 years in such jobs and 156 (81%) were employed > or = 11 years. A total of 192 primary workplaces associated with potentially hazardous silica exposures were identified for the 256 confirmed silicosis cases. Of these, nine (5%) workplaces were inspected by state health department (SHD) industrial hygienists, 19 (10%) were referred to the Occupational Safety and Health Administration (OSHA) for follow-up, and seven (4%) were routinely monitored by the Mine Safety and Health Administration. Of the 157 (82%) remaining workplaces, follow-up activities determined that 82 were no longer in operation, eight were no longer using silica, 18 were assigned a lower priority for follow-up, six were associated with building trades and could not be inspected because of the transient nature of work in the construction industry, and 43 workplaces were not inspected for other reasons. Fourteen (7%) of the 192 workplaces were inspected. At 10 of the 14 workplaces, airborne levels of crystalline silica were measured; in nine, silica levels exceeded the NIOSH-recommended exposure level of 0.05 mg/m, and in six, airborne silica levels also exceeded federal permissible exposure limits. ACTIONS TAKEN: Employee-specific and other preventive interventions have been initiated in response to reported cases. In addition, special silicosis prevention projects have been initiated in Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin. To facilitate the implementation of silicosis surveillance by other states, efforts are ongoing to identify and standardize core data needed by surveillance programs to describe cases and the workplaces where exposure occurred. These core variables will be incorporated into a user-friendly software system that states can use for data collection and reporting.

Exchanges are not equally able to enhance meiotic chromosome segregation in yeast.

Homologous chromosomes pair, and then migrate to opposite poles of the spindle at meiosis I. In most eukaryotic organisms, reciprocal recombinations (crossovers) between the homologs are critical to the success of this process. Individuals with defects in meiotic recombination typically produce high levels of aneuploid gametes and exhibit low fertility or are sterile. The experiments described here were designed to test whether different crossovers are equally able to contribute to the fidelity of meiotic chromosome segregation in yeast. These experiments were performed with model chromosomes with which it was possible to control and measure the distributions of meiotic crossovers in wild-type cells. Physical and genetic approaches were used to map crossover positions on model chromosomes and to correlate crossover position with meiotic segregation behavior. The results show that crossovers at different chromosomal positions have different abilities to enhance the fidelity of meiotic segregation.

The effects of a ring chromosome on the meiotic segregation of other chromosomes in Saccharomyces cerevisiae.

Meiotic chromosome segregation must occur with high fidelity in order to prevent the generation of aneuploid cells. We have previously described the identification and genetic characterization of a yeast mutant with defects in meiotic sister-chromatid segregation. We attributed the phenotype in this mutant to a dominant allele, which we referred to as SID1-1. These mutants appeared to exhibit high levels of non-disjunction and precocious separation of sister-chromatids of chromosome III, as well as precocious separation of sister chromatids of chromosome VIII and a univalent artificial chromosome. We show here that the unusual meiotic behavior of chromosome III in these strains is due to the presence of a ring III chromosome, rather than a mutant gene. Additional experiments demonstrate that a ring III/rod III pair alters the meiotic segregation of a univalent artificial chromosome.

Respiratory failure in patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia.

Seven patients with acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia were studied to define the pathophysiology of their respiratory failure. The patients had fever, cough, dyspnea, hypoxemia, and diffuse infiltrates on chest x-ray. Biopsies revealed a spectrum of alveolar filling, interstitial edema and infiltration, and fibrosis. The patients were studied on mechanical ventilation to assess the effect of positive end-expiratory pressure (PEEP) and supplemental oxygen on shunt fraction. Mean anatomic shunt (measured on 100% oxygen) was 34 +/- 8%, which increased significantly (p less than .001) to 43 +/- 9% when the FIO2 was decreased to 40% to 60% (physiologic shunt), indicating ventilation/perfusion (V/Q) imbalance or impaired diffusion. Increasing PEEP by 9 +/- 2 cm H2O reduced the anatomic shunt to 30 +/- 7% (p less than .01) and the physiologic shunt to 37 +/- 7% (p less than .02). There was a similar decrease in anatomic and physiologic shunts in five studies, a greater decrease in physiologic shunt in four, and a greater decrease in anatomic shunt in two. Evidence of alveolar recruitment with PEEP, measured by an increase in static thoracic compliance, was found in only one study. There was no correlation between the effect of PEEP on compliance and its effect on shunt. The data suggest that in patients with AIDS and P. carinii pneumonia, PEEP can decrease shunt by reducing the anatomic shunt, improving V/Q imbalance, and converting areas of anatomic shunt to areas of low V/Q. P. carinii pneumonia in patients with AIDS can produce a clinical and pathophysiologic pattern similar to that described in the adult respiratory distress syndrome.

Colonoscopy as a primary diagnostic procedure in chronic gastrointestinal tract bleeding.

We compared the use of barium enema (BE) and colonoscopy in evaluating patients with chronic gastrointestinal tract bleeding by dividing into three groups 329 consecutive colonoscopies and 207 consecutive BE examinations done with chronic gastrointestinal tract bleeding as an indication. In the first group, of 96 patients with negative results of BE studies, subsequent colonoscopy showed carcinoma of the colon in 16%, polyps larger than 1 cm in 21%, and other causes in 20%. In 43% the colonoscopy gave negative results or was incomplete. In the other two groups we directly compared findings of the 207 BE and the 233 remaining colonoscopies when each was used as a primary diagnostic test. Colonoscopy was found to have fewer negative results (74% vs 43%), fewer inconclusive examinations requiring repeat (19% vs 3%), and more positive correct findings to explain the cause of bleeding (54% vs 5%).

Colonoscopy as a routine preoperative procedure for carcinoma of the colon.

Ninety patients with cancer of the colon who had total colonoscopy in the perioperative period have been reviewed. Almost half of the examinations revealed positive findings, three being unsuspected synchronous carcinomas in an area that would not have been resected with the proposed primary cancer. In addition, 79 polyps in 36 patients, the majority of which were also undetected by barium enema, were found and removed at colonoscopy. Thus, patients with carcinoma of the colon, in view of its tendency to be associated with synchronous polypoid disease, should have colonoscopy in the perioperative period. Whenever possible, this should be carried out preoperatively to confirm the diagnosis, to remove suspected or unsuspected polyps, and to detect unsuspected synchronous carcinoma.

Gastric carcinoid: two unusual presentations.

We report two cases of gastric carcinoid that presented as benign-appearing polyps. One presented with multiple, benign-appearing polyps--a particularly unusual presentation for an uncommon tumor. The second patient had a single polypoid gastric carcinoid and atropic gastritis with pernicious anemia. These atypical presentations and uncommon association of gastric carcinoid are discussed.

Impact of mammography on breast surgery in a small community hospital.

The impact of mammography on breast surgery at a small community hospital was evaluated by comparing the stage of cancer at diagnosis in a 5 year period before mammography with that in a 5 year period after its introduction. During both periods approximately the same number and stage of palpable carcinomas were diagnosed and treated. However, in the 5 year period after introduction of mammography, in addition to the 35 palpable carcinomas 11 additional nonpalpable occult carcinomas were diagnosed. These 11, with an average size of 8 mm and all in patients with negative nodes, would fit into the category of minimal breast cancer, which is associated with a 10 year disease-free interval of over 90 percent.

Use of physician's assistants in a general surgical practice.

A study has been made of three PAS employed in a rural, small town, general surgical practice during a four year period. Their work was equally divided among three areas: minor trauma, obtaining and recording data for history and physical examinations, and assisting at routine surgical procedures and endoscopies. This resulted in a significant saving of time for each surgeon who was thus freed for more time in the care of the more critically ill or injured patients.

Utilization of supervised physician's assistants in emergency room coverage in a small rural community hospital.

A study has been made of an initial 2-year experience in a 90-bed rural community hospital where emergency room primary coverage has been provided by Physician's Assistants under supervision of specialists in the field of general surgery, pediatrics, and internal medicine. Emphasis has been placed on a rigidly supervised program as well as physician supervision and availability on a patient-call basis. This supervision may take the form of immediate availability of the physician to the emergency room, telephone consultation or, in minor illnesses and injuries, continued review of the record of each individual patient seen by the Physician's Assistant. A review of the most recent 2-month ER-OPD experience showed that in a small rural hospital, a majority (62%) of the patients had an illness or injury of a minor, nonserious degree which could be handled primarily by a Physician's Assistant. This has led to emergency room care which has been judged by the patients, the emergency-room nurses, and the supervising physicians to be more efficient and prompt than had been previously provided, yet not reduced in quality. The program described was developed by physicians active in private practice working with the Physician's Assistants and RN's in the ER-OPD. The physicians' time spent in teaching, supervision and development of written policy was great, and, at times, threatened the continuation of the program. A fulltime physician in the hospital could better initiate the program of teaching, supervision, formulating written procedures, and establishing policies with different specialist.