Treating idiopathic pulmonary fibrosis with the addition of co-trimoxazole: a randomised controlled trial.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a fatal condition with limited treatment options. However, in a previous small study, co-trimoxazole was found to be beneficial. METHODS: In a double-blind multicentre study, 181 patients with fibrotic idiopathic interstitial pneumonia (89% diagnosed as definite/probable IPF) were randomised to receive co-trimoxazole 960 mg twice daily or placebo for 12 months in addition to usual care. Measurements were made of forced vital capacity (FVC) (primary endpoint), diffusing capacity of carbon monoxide (Dlco) and EuroQol (EQ5D)-based utility, 6-minute walk test (6MWT) and Medical Research Council (MRC) dyspnoea score (secondary endpoints). All-cause mortality and adverse events were recorded (tertiary endpoints). RESULTS: Co-trimoxazole had no effect on FVC (mean difference 15.5 ml (95% CI -93.6 to 124.6)), Dlco (mean difference -0.12 mmol/min/kPa (95% CI 0.41 to 0.17)), 6MWT or MRC dyspnoea score (intention-to-treat analysis). The findings of the per-protocol analysis were the same except that co-trimoxazole treatment resulted in a significant improvement in EQ5D-based utility (mean difference 0.12 (95% CI 0.01 to 0.22)), a reduction in the percentage of patients requiring an increase in oxygen therapy (OR 0.05 (95% CI 0.00 to 0.61)) and a significant reduction in all-cause mortality (co-trimoxazole 3/53, placebo 14/65, HR 0.21 (95% CI 0.06 to 0.78), p=0.02)) compared with placebo. The use of co-trimoxazole reduced respiratory tract infections but increased the incidence of nausea and rash. CONCLUSIONS: The addition of co-trimoxazole therapy to standard treatment for fibrotic idiopathic interstitial pneumonia had no effect on lung function but resulted in improved quality of life and a reduction in mortality in those adhering to treatment. ISRCTN22201583.

Use of an Amplatzer vascular plug II for aortic sac occlusion after failed surgical ligation.

PURPOSE: To present a case of aortic sac occlusion using an Amplatzer vascular plug II (AVP). CASE REPORT: A patient with sigmoid malignancy and an infrarenal aortic aneurysm ultimately required an axillobifemoral graft for acute limb ischemia. The sac was ligated at subsequent laparotomy. Persistent filling of the sac was seen post surgery, and the sac was successfully occluded with placement of an AVP in the neck of the sac in conjunction with coil embolization of lumbar arteries. Sac occlusion was confirmed at follow-up CT. CONCLUSION: The AVP was successfully used to occlude an aortic sac after failed surgical ligation, another novel indication for this versatile embolic device.

Defining normal vertebral angulation at the thoracolumbar junction.

OBJECTIVE: The purpose of this cross-sectional study is to define the normal range of endplate angulation at T12 and L1 and, by doing so, to validate the angle measurement tools that are readily available on nearly all PACS. MATERIALS AND METHODS: Two hundred consecutive lateral scout CT scans were examined in patients who were either 25 (n = 100) or 35 (n = 100) years old. The endplate angles for T12 and L1 were measured using a "Cobb angle" tool on a standard PACS workstation. Twenty-two cadaveric vertebrae were also imaged, and measurements obtained from the lateral scout CT image using electronic calipers were compared with measurements obtained with a goniometer. RESULTS: The mean endplate angle at T12 measures 4.34 degrees (2 SD, 4.5 degrees) and at L1, 4.48 degrees (4.26 degrees). The normal range of endplate angulation is therefore -0.16 degrees to 8.84 degrees at T12 and 0.22-8.74 degrees at L1. No statistically significant difference was seen in the endplate angulation when men were compared with women or 25- and 35-year-old age groups were compared. A strong correlation exists between direct and CT-derived endplate angle measurements. CONCLUSION: Vertebral endplate angulation can be reliably measured using widely available PACS workstation tools. The mean endplate angle for T12 and L1 is approximately 4.5 degrees, with an approximate range extending from 0 degrees to 9 degrees. For practical purposes, an endplate angle of 10 degrees or more can be considered outside the normal range.

Generalized tetany: an unusual complication during dobutamine stress echocardiography.

Dobutamine stress echocardiography is a frequently used noninvasive method for the evaluation of inducible myocardial ischemia, myocardial viability, and preoperative cardiac risk. Although its clinical safety has been validated, side effects and complications especially with the coadministration of atropine can occur. We report a case of generalized tetany in a 49-year-old woman undergoing dobutamine stress echocardiography.