Can positron emission tomography be more than a diagnostic tool? A survey on clinical practice among radiation oncologists in India.

AIM: The purpose of the survey was to understand the role of positron emission tomography (PET) in clinical radiotherapy practice among the radiation oncologists' in India. SETTINGS AND DESIGN: An online questionnaire was developed to survey the oncologists on their use of PET, viewing protocols, contouring techniques practiced, the barriers on the use of PET and the need for training in use of PET in radiotherapy. The questionnaire was sent to about 500 oncologists and 76 completed responses were received. RESULTS: The survey shows that radiation oncologists use PET largely to assess treatment response and staging but limitedly use it for radiotherapy treatment planning. Only manual contouring and fixed threshold based delineation techniques (e.g. 40% maximum standard uptake value [SUV max ] or SUV 2.5) are used. Cost is the major barrier in the wider use of PET, followed by limited availability of FDG radionuclide tracer. Limited or no training was available for the use of PET. CONCLUSIONS: Our survey revealed the vast difference between literature suggestions and actual clinical practice on the use of PET in radiotherapy. Additional training and standardization of protocols for use of PET in radiotherapy is essential for fully utilizing the capability of PET.

Prednisone as adjunctive therapy in the management of pulmonary tuberculosis. Report of 12 cases and review of the literature.

A retrospective chart review was conducted over a 5-year period (1988 to 1993) in a tertiary inpatient care center on the effects of the addition of prednisone to the treatment regimens of 12 patients with pulmonary tuberculosis who continued to spike high temperatures and lose weight while showing bacteriologic response to effective antituberculosis therapy. After exclusion of other causes of fever, all patients were treated with 20 to 60 mg of prednisone daily until normalization of temperature and clinical improvement. Analyzed data included twice weekly sputum bacillary count, temperature record every 4 h, weekly patient weight, serum albumin level, liver function tests, and chest roentgenogram. The patients continued to spike temperatures of 38.3 degrees C to 40.5 degrees C (mean +/- SD = 39.6 degrees C +/- 0.6 degrees C) even after 18 to 53 days (mean +/- SD = 33.9 +/- 9.8 days) of antituberculosis therapy. Within 24 h after the addition of oral prednisone, temperature decreased in all 12 patients from a daily highest spike mean of 39.6 degrees C +/- 0.6 degrees C (SD) to 38.1 degrees C +/- 0.6 degrees C (SD) (p = 0.0022). The duration of required prednisone therapy was 20.1 +/- 9 days (mean +/- SD). During this period patients' appetites improved, and their weight increased from a mean (+/- SD) of 53.6 +/- 5.7 kg to 58.1 +/- 6.4 kg (p = 0.0022). The serum albumin level increased from a mean (+/- SD) of 2.51 +/- 0.4 g/dL to 3.21 +/- 0.4 g/dL (p = 0.0033). All the patients also showed clinical evidence of a decrease in toxic reactions associated with tuberculosis. There were no side effects from the addition of prednisone. This study shows the need for randomized controlled clinical trials to clarify the role of prednisone as adjunctive therapy in the management of pulmonary tuberculosis.

Recurrent massive bleeding from an intercostal artery aneurysm through an empyema chest tube.

Intercostal artery aneurysms can be of congenital, posttraumatic, or mycotic type. Intercostal arterial aneurysmal bleeding can be brisk enough to lead into shock or sudden death. Bleeding through chest tubes has been reported due to various causes; it is commonly due to injury to intercostal or pulmonary vessels and is occasionally due to leaking aortic aneurysms. We describe a patient who had development of repeated episodes of brisk bleeding through an empyema chest tube leading to shock episodes requiring resuscitations. After extensive search, the bleeding source was found to be an intercostal artery aneurysm. Transcatheter embolization of that intercostal artery with absorbable gelatin sponge (Gelfoam) was successful in obliterating the blood flow to the aneurysm and in preventing further bleeding.

Serum angiotensin-converting enzyme (SACE) activity as an indicator of total body granuloma load and prognosis in sarcoidosis.

The relationship between the level of serum angiotensin converting enzyme (SACE) and the total body granuloma load in patients with sarcoidosis was studied in two groups using SACE levels and total body gallium67 scans. The study group consisted of 22 patients with SACE levels greater than or equal to 100 U/ml (EH-SACE group) and the control group consisted of 24 patients consecutively diagnosed to have sarcoidosis in a one year period with SACE level of less than 80 U/ml. The average number of organs involved in the EH-SACE group was 3.9 +/- 1 compared to 2.3 +/- 1 in the control group (p less than 0.0001). The incidence of extra pulmonary organ involvement in the EH-SACE group was 2.2 +/- 1 organs compared to 1.0 + 0.8 in the control group (p less than 0.0002). The SACE level was correlated with the number of organs involved for all patients with sarcoidosis (r = .55; p less than .0001). Following corticosteroid therapy for 39 +/- 41 weeks the SACE dropped to 64 +/- 45 units in the EH-SACE group. But it took only 13 +/- 10 weeks to normalize the SACE level to 27 +/- 9 units in the control group. The EH-SACE group patients were followed for 114 +/- 64 weeks and 73% of them still have active sarcoidosis requiring repeated cycles of corticosteroid therapy, while after 42 +/- 23 weeks of follow up only 10% of patients from the control group were still on therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Management of major or massive hemoptysis in active pulmonary tuberculosis by bronchial arterial embolization.

Management of massive hemoptysis in patients with active pulmonary tuberculosis is complicated. Transcatheter hemostatic embolization of bleeding vessels with absorbable material has been reported to be useful in controlling this problem. Twelve patients with active pulmonary tuberculosis who had major or massive hemoptysis were managed at Cook County Hospital, Chicago, from 1982 to 1986. Various methods of treatment have been evaluated. The technique of angiographic embolization and the criteria for selection of patients for its use constitute the basis of this report.

Granular cell myoblastoma: rare localization in the trachea. Report of a case and review of the literature.

Granular cell myoblastoma is an uncommon tumor in the respiratory tract. It usually occurs in the tongue, skin, breast, or subcutaneous tissue. When it occurs in the respiratory tract, it is usually located in the bronchus or larynx. Primary tracheal location is rare with only nine such cases reported in the literature. This report describes a 26-year-old woman with granular cell myoblastoma of the trachea. She presented with a four-year history of bronchial asthma. The tumor was surgically excised by tracheal resection and reconstruction. The patient has remained well and free of obstructive airway symptoms, without recurrence of the tumor for more than one year.

Septic pulmonary emboli secondary to internal jugular vein phlebitis (postanginal sepsis) caused by Eikenella corrodens.

Postanginal sepsis is the term used to describe the life-threatening infection caused by suppurative phlebitis of the internal jugular vein secondary to infection of the parapharyngeal spaces. This begins with a history of pharyngitis followed by infection of the parapharyngeal spaces, septic pulmonary embolism, and septicemia caused by hematogenous dissemination of the infection. The oral anaerobes are the most common pathogens associated with this syndrome. Recently, we managed 2 patients who had septic pulmonary embolism from postanginal sepsis syndrome caused by Eikenella corrodens. Previously, E. corrodens has not been described in association with this syndrome. The clinical presentation, anatomic, bacteriologic, and management aspects of postanginal sepsis syndrome are reviewed based on our experience with these 2 cases. In patients with clinical evidence of septic pulmonary embolism, particularly in the nonintravenous drug abusers, postanginal sepsis and septic jugular phlebitis have to be considered as a source of septic pulmonary embolism.

Respiratory failure in pulmonary tuberculosis.

Of 852 patients admitted to Cook County Hospital with bacteriologically-proved pulmonary tuberculosis, 16 suffered respiratory failure. Of these 16, 5 died and 11 recovered. On follow-up, the survivors demonstrated significant improvement in oxygenation, but continued to show a severe restrictive ventilatory defect. Our patients, unlike those in previous reports, did not show airway obstruction. The principles of management are the same as for other pulmonary patients. Arterial blood gas analyses should be done on patients with advanced tuberculosis so that abnormalities of gas exchange will not be missed.

Occurrence with bacteriologically positive pulmonary tuberculosis.

Fever was unchanged by chemotherapy in ten patients with bacteriologically positive pulmonary tuberculosis. Blood cultures were positive for Gram-positive organisms in six patients and for Gram-negative organisms in four patients. The same organism was present in sputa and blood in six patients and in urine and blood in two patients. Leukocytosis was not found, and roentgenographic findings did not suggest superinfection. Nine of the ten patients survived. Blood cultures must be obtained in patients with pulmonary tuberculosis whose fever is not altered by antituberculous chemotherapy, so that concomitant septicemia is not neglected.

Bronchiectasis following heroin-induced pulmonary edema. Rapid clearing of pulmonary infiltrates.

We observed a patient who developed diffuse bronchiectasis subsequent to heroin-induced pulmonary edema. Unlike the previously reported cases, there was rapid clearing of pulmonary infiltrates and little evidence of severe aspiration. The development of bronchiectasis was attributed to a bronchial infection subsequent to clearing of the pulmonary edema. Physiologic dysfunction was characterized by marked obstruction, pulmonary hypertension, and mild hypoxemia.