A simple radiographic scoring method for monitoring pulmonary sarcoidosis: relations between radiographic scores, dyspnoea grade and respiratory function in the British Thoracic Society Study of Long-Term Corticosteroid Treatment.

BACKGROUND: We used a simple semi-quantitative radiographic scoring system for a controlled prospective study of long term corticosteroids in pulmonary sarcoidosis, conducted by the British Thoracic Society. METHODS: Radiographic opacities were described in 4 categories: reticulo-nodular shadows [R], mass opacities [M], confluence [C], and shadows associated with possible pulmonary fibrosis [F]. The extent of each type was scored on a 0-4 scale by quartiles, and profusion by a 0-4 scale as absent, minimal (just perceptible), mild moderate or gross. Combined scores for each film were derived by multiplying the extent and profusion for each type of opacity. In the study 149 patients were examined at entry and periodically over a 5-year period. Using the whole study population we examined the relationship between the radiographic scores for extent and profusion, how predominant types change with time and how the scores correlated with other indices of disease severity. RESULTS: R was the predominant abnormality throughout the study with a strong correlation between extent and profusion. Significant correlations in the expected directions were demonstrated between the R and F scores and a dyspnoea score, spirometry and TLCO, both at study entry, after 6 months and after 5 years. Similarly, there were significant relations between changes in spirometry and TLCO over five years and changes in R and F Scores. CONCLUSION: This scoring system would seem to be suitable, perhaps after further validation work, for other prospective clinical studies.

British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment.

BACKGROUND: Corticosteroids suppress disease activity in pulmonary sarcoidosis and their use produces symptomatic, radiographic, and functional improvement. There is, however, uncertainty regarding their effects on the overall natural history of the condition and long term benefit is unproven. METHODS: Patients with pulmonary radiographic shadowing due to sarcoidosis were recruited in a multicentre study. Those who, in the first six months after entry to the study, neither required prednisolone for symptoms nor showed radiographic improvement were allocated at six months to receive either long term steroid treatment (group L) or selective treatment (group S), with regular assessment over the subsequent five years. Patients in group L were scheduled to receive steroid treatment for at least 18 months with the policy of achieving and maintaining maximal radiographic clearing, while in group S treatment was reserved for use only if warranted by later development of symptoms or deteriorating lung function. Symptoms, radiographic appearances, and respiratory function were assessed periodically during the study. RESULTS: One hundred and forty nine patients were followed: 33 required prednisolone for troublesome symptoms within six months of entry and 58 showed radiographic improvement over this period. The remaining 58 patients were allocated to groups L (n = 27) and S (n = 31). Patients in group L showed greater improvements in symptoms, respiratory function, and radiographic appearances than those in group S, although the differences were not large. After adjusting for differences at the time of allocation, the average difference in vital capacity between groups L and S at final assessment was 9% of the predicted value. Side effects of treatment were frequent but usually mild, necessitating withdrawal in only two individuals. CONCLUSIONS: After excluding those individuals who required steroids for control of symptoms, approximately half of the remaining patients with sarcoidosis and pulmonary shadowing showed spontaneous radiographic improvement during six months of observation. In those in whom the radiograph failed to improve, prolonged steroid treatment with the aim of optimising radiographic appearances resulted in a significantly better long term functional outcome.

Expanded pectoralis major myocutaneous flaps in head and neck surgery.

The use of tissue expanders in head and neck surgery has been popularized since the early 1980s. Tissue expanders are currently used in nasal reconstruction, alopecia, and other head and neck defects when there is inadequate tissue or when transposition of a local flap would create a significant donor-site deformity. Occasionally, situations in head and neck reconstruction arise where local, regional, or free flaps are not available or sufficient for head and neck reconstruction. In these situations, the use of controlled tissue expansion can be employed for enlarging myocutaneous flaps for head and neck reconstructive surgery. Two cases illustrated here present the principles and techniques of this means of reconstruction.

Acute myelocytic leukaemia presenting as anergic pulmonary tuberculosis.

This case report describes a patient with anergic pulmonary tuberculosis who presented with pyrexia of unknown origin and vasculitis. He did not exhibit any pulmonary symptoms at his initial presentation and developed acute myelocytic leukaemia, a recognised association, during the subsequent course of his illness.

Comparative gross and histological effects of the CO2 laser, Nd-YAG laser, scalpel, Shaw scalpel and cutting cautery on skin in rats.

Surgical instruments capable of sealing blood vessels while incising skin were compared to standard scalpel incisions in rats and the resultant scars examined in the early stages of wound healing for both gross and histological appearances. Those instruments which provide for hemostasis appear to do so with a delay in the early phases of wound healing.

Histoacryl glue in microvascular surgery.

The use of Histoacryl glue in the performance of microvascular anastomosis was examined in a rat model. An improvement in efficiency as noted by the decreased ischemic time and diminished bleeding with clamp removal was noted. Histological examination of the anastomosis at one and three weeks revealed a mild foreign body type inflammatory response to glue and suture material with no media necrosis and only minimal fibrointimal proliferation.

Hemifacial atrophy: a case report of fat transplantation.

A case of hemifacial atrophy affecting a young female is presented and the manifestations of this uncommon disorder are reviewed. The various methods employed in correcting the facial deformity including the relatively new technique of fat injection are described.

Sarcoidosis: a disorder commoner in non-smokers?

The smoking habits of 202 patients presenting with sarcoidosis, as recorded in the clinical case records, were compared with figures from the General Household Surveys (GHS) to determine whether there was any association between smoking habit and sarcoidosis. In 19 there was no record of smoking habit. Of the remaining 183 patients, 40 (21.9%) were smokers, which was significantly less than expected from the GHS figures (p less than 0.001). This association between non-smoking and sarcoidosis persisted despite further analysis by sex and age distribution and socioeconomic grouping. Statistical likelihood models showed that ex-smokers were similar to current smokers with respect to the association between smoking and sarcoidosis. This association was greatest in those patients with stage I sarcoidosis and less for those with other stages of the disease.

Fishing for foreign bodies.

A guide to the radiological detection of fish bones for the sporting physician is presented. By radiologically examining fish bones superimposed on the neck, it was found that most bones are detectable, thus lending support to the use of plain neck films in screening for impacted fish bones.

Epidemiologic studies of Scottish oil shale workers: III. Causes of death.

In a mortality study of a population of 6,359 male Scottish oil shale workers, the vital status of 6,145 (96.6%) was determined. Sufficient data on occupational histories for analyses of mortality in relation to jobs held were available for 6,064 (95.4%) of the workers. No significant excess of mortality from any disease was found in relation to any jobs in the industry. Comparison of the mortality experience of those 3,161 men who joined the population prior to 1953 with that of the whole Scottish population showed an excess of deaths from skin cancer but no significant excess that was due to other disease. Comparisons with the population of the counties in which the industry was situated showed no significant excess of deaths from any cause examined. A case-control study of lung cancer in the shale area showed no excess risk of this disease in association with work in the industry.

Foreign bodies in the aerodigestive tract.

Foreign bodies in the aerodigestive tract are common. They may cause minimal disturbance of function, severe morbidity or even sudden death. They enter the aerodigestive tract because of haste during eating, disturbances in physical function, impairments due to extreme youth or age, or contamination of food with foreign bodies. Common symptoms are pain, dysphagia, odynophagia, cough, airway distress, hemoptysis and hematemesis. Signs include point tenderness, respiratory distress and surgical emphysema. Clinical, radiological and endoscopic investigations are described, as are principles of crisis and elective management.

Papillary carcinoma of the thyroid associated with sarcoidosis.

A case of papillary carcinoma of the thyroid occurring in association with systemic sarcoidosis is reported. Although benign thyroid disorders occurring in conjunction with sarcoidosis have previously been documented, a search of the literature found no report of thyroid carcinoma occurring in association with sarcoidosis. Diagnosis and therapeutic management prove difficult when thyroid carcinoma and sarcoidosis co-exist. Transbronchial biopsy of lung lesions is warranted in staging thyroid carcinoma in order to exclude the possibility of unknown co-existent disease. The management of cervical lymphadenopathy in thyroid carcinoma should not be altered because of the presence of sarcoidosis, and should include a neck dissection.

Frontal sinusitis--a 10 year experience.

Frontal sinusitis follows upper respiratory infections, sinus trauma, and swimming. Complications, often life threatening, still occur although less frequently than in the pre-antibiotic era. The course of 40 patients admitted to St. Michael's Hospital with a diagnosis of frontal sinusitis between the years 1973-83 is reviewed. The regional complications as well as the surgical procedures required to manage these problems are discussed. The osteoplastic flap with obliteration of the sinus cavity by osteoneogenesis has become the procedure of choice in dealing with most cases of chronic frontal sinusitis.

Expansion of myocutaneous flaps.

The controlled expansion of myocutaneous flaps offers a potential means of increasing their size. The pectoralis major flap was successfully expanded in pigs, giving mean percentage increases in the axial lengths of 32% and widths of 51% over nonexpanded controls. Angiographic and histomorphologic studies of the expanded flaps demonstrated the vascular and histologic changes that resulted. This new surgical technique should prove valuable in extending the field of head and neck reconstruction in man.

The management of severe nasal septal deformities.

Severe septal injuries associated with nasal deformities are a challenge both functionally and esthetically. Serious septal injuries may include comminuted caudal border fractures, septal crushes, and saddling with loss of septal height. These may result from trauma or previous ill-considered surgery. A series of 60 cases involving radical removal of the septum with caudal and dorsal border reconstructions is reviewed. An external approach septorhinoplasty was utilized in the majority of these patients. The anterior septum was usually replaced by straight posterior septum or septal fragments. In a number of cases the septum was replaced by a centre cut of rib cartilage. Upon occasion the upper laternal cartilages were replaced by composite conchal grafts with or without septal replacement. An attempt has been made to evaluate critically the results with a longterm follow-up over a number of years, as regards both functional and esthetic results.

Pneumoconiosis of shale miners.

Four patients are described in whom pneumoconiosis was diagnosed towards the end of a lifetime's work in shale mines. All developed complicated pneumoconiosis, diagnosed in two cases at necropsy, in one by lobectomy, and in one radiologically. Two of the patients were found at necropsy also to have peripheral squamous lung cancer. The clinical and histological features of the disease resembled the pneumoconioses of coalminers and kaolin workers and the lungs of three of the patients were shown to contain dust composed predominantly of kaolinite, mica, and silica. Shale miners' complicated pneumoconiosis has not previously been described. Although the British shale industry is now defunct, oil production from shale is expanding in other countries, notably the USA. It is suggested that control should be exercised over dust exposure levels in this industry and that epidemiological studies should be carried out to quantify the risks of both pneumoconiosis and bronchial carcinoma.