Interobserver variation in the chest radiograph component of the lung injury score.

The lung injury score is a semi-quantitative system used in the definition and grading of the acute respiratory distress syndrome. It is composed of two, three or four equally weighted components. One component is derived from the chest radiograph, which may contribute up to 50% of the total score. A score of 1 is awarded for each quadrant on the chest radiograph which contains alveolar consolidation. We examined the interobserver variation between two anaesthetists, two radiologists and two critical care physicians who scored blindly 100 chest radiographs from patients with adult respiratory distress syndrome. There was very good agreement between the two radiologists in the total scores (kappa 0.97) and in individual scores in each of the 4 quadrants (kappa 0.97-1.0). The agreement between anaesthetists and radiologists was only fair for the total score (kappa 0.37-0.42), but moderate to good for individual quadrant scores (kappa 0.43-0.73). The agreement between the two anaesthetists was moderate for individual quadrant scores (kappa 0.44-0.60), but only fair for total score (kappa 0.34). There was poor agreement between the two critical care physicians for total score (kappa 0.05) and for individual quadrant scores (kappa 0.04-0.20). Agreement between the physicians and other observers was poor to fair for the total score (kappa 0.12-0.32) and poor to moderate for the individual quadrant scores (kappa 0.15-0.63). Both anaesthetists and physician 2 underestimated the overall chest scores (median scores 2, 3 and 1 respectively) in comparison to the radiologists (median scores 3.5). Physician 1 significantly overscored (median score 4). The chest radiograph component of the lung injury score can be consistently assessed by radiologists, but significant variations may be introduced when assessed by other clinicians. This has significant implications for the use of the lung injury score in studies of adult respiratory distress syndrome and other studies which incorporate radiographic appearances in the definition.

A phase II study of cyclophosphamide as a 24-hr infusion in advanced non-small cell lung cancer.

Twenty patients with progressive non-small cell lung cancer who had received no prior chemotherapy were treated with 24-hr infusions of cyclophosphamide at a dose of 2.5 g/m2. The median number of courses administered was three (range one to six). There was one PR and one CR, an overall response rate of 10% (95% confidence limits 2-32%). A further six patients experienced excellent relief of distressing symptoms, unresponsive to other measures, as a result of the chemotherapy. The median survival for the 20 patients was 18.5 weeks (range 4-75 weeks). The median leukocyte nadir count was 1.1 X 10(9)/1 and median platelet nadir count 226 X 10(9)/1. There were no episodes of cystitis and gastrointestinal toxicity was moderate. This study has not shown any advantage for the infusion schedule over conventional bolus regimens, but further dose escalation or more prolonged infusion times may improve results.