Screening with spirometry is a useful predictor of later development of noninfectious pulmonary syndromes in patients undergoing allogeneic stem cell transplantation.

Noninfectious pulmonary syndromes (NIPS) frequently complicate allogeneic stem cell transplantation (allo-SCT). The most common and serious is the bronchiolitis obliterans syndrome, characterized by irreversible fixed airflow obstruction, impaired quality of life, and a high mortality. Treatment for established symptomatic disease is relatively ineffective. We therefore sought to identify potential predictive factors for development of NIPS, which may identify patients at risk in whom earlier intervention may be of benefit. Spirometry and diffusing capacity for carbon monoxide were performed before allo-SCT, day 100, and 1 year after allo-SCT. We retrospectively analyzed spirometry in consecutive patients having allo-SCT from 2004 to 2010, along with computed tomography and bronchoalveolar lavage results to identify cases of NIPS. Cases of bronchiolitis obliterans syndrome were defined as per current National Institutes of Health consensus guidelines. Spirometry results and baseline variables were compared between patients with and without NIPS to identify early predictors and risk factors for NIPS. Of 235 assessable patients, 23 (9.8%) developed NIPS. Median time of onset was day 367 (interquartile range [IQR], 144 to 544 days). Changes in forced expiratory volume in 1 second (ΔFEV1.0) was the best predictor of later NIPS development. Median ΔFEV1.0 from pretransplant to day 100 in patients later developing NIPS was -12% (IQR, -25% to -1%) versus -1% (IQR, -7% to +6%) in unaffected patients, P = .002. From pretransplant to 1 year, ΔFEV1.0 was -19% (IQR, -37% to -6%) versus -3% (IQR, -10% to +4%) in patients later developing NIPS and unaffected patients, respectively, P < .001. Busulfan-based, but not total body irradiation-based, conditioning increased the risk of NIPS (hazard ratio, 9.4 [3.4 to 23.9], P < .001). No cases of NIPS were seen in the 53 patients who received in vivo T cell depletion with antithymocyte globulin (ATG, Genzyme Transplant, Cambridge, MA) (P < .0001). NIPS were associated with high transplant-related mortality relative to unaffected patients (hazard ratio, 6.6 [2.5 to 16.4], P < .001). Spirometry is a potentially useful screening test for identification of presymptomatic NIPS. We recommend 3-monthly spirometry surveillance for up to 2 years post-transplant. Our findings require prospective validation to identify patients in whom earlier intervention may potentially modify the natural history of this disease.

Effect of topical alkane vapocoolant spray on pain with intravenous cannulation in patients in emergency departments: randomised double blind placebo controlled trial.

OBJECTIVE: To assess the efficacy, acceptability, and safety of a topical alkane vapocoolant in reducing pain during intravenous cannulation in adults. DESIGN: Randomised double blind placebo controlled trial. SETTING: Emergency department of a metropolitan teaching hospital. PARTICIPANTS: 201 adult patients (54% male), mean (SD) age 58.2 (19.5) years, who required intravenous cannulation. INTERVENTIONS: Less than 15 seconds before cannulation, the skin area was sprayed with either water (control, n=98) or vapocoolant (intervention, n=103), from a distance of 12 cm for 2 seconds. The intervention spray was a blend of propane, butane, and pentane. MAIN OUTCOME MEASURES: Pain with cannulation and discomfort with spray, measured with a 100 mm visual analogue scale. RESULTS: Groups did not differ significantly in age, sex, indication for or site of cannulation, cannula size, or who cannulated the patient (P>0.05). Median (interquartile range) pain scores for cannulation in the control and intervention groups were 36 (19-51) and 12 (5-40) mm, respectively (P<0.001), and 59 (60%) and 33 (32%) reported pain scores >or=30 mm (P<0.001). Scores for spray discomfort also differed significantly (P<0.001) because of skewing to the right within the intervention group. The median discomfort scores, however, were 0 mm in both groups. Success rates for first cannulation attempt did not differ between groups (P=0.39). Thirty four (39%) and 62 (62%) patients said they would choose the spray they received for analgesia in the future (P=0.002). At follow-up at five days, two patients in the intervention group reported transient skin redness. CONCLUSIONS: Topical alkane vapocoolant spray is effective, acceptable, and safe in reducing pain with peripheral intravenous cannulation in adults in the emergency department. TRIAL REGISTRATION: Australian Clinical Trials ACTRN12607000470493.