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PurposeThe aim of this study was to re-evaluate the differentiation of patients with dementia with Lewy bodies (DLB) from Alzheimer’s disease (AD) and Parkinson’s disease (PD) using a quantitative analysis of 123I-FP-CIT SPECT scans.MethodsThirty-six patients with in vivo 123I-FP-CIT SPECT and neuropathological diagnoses were included. Based on neuropathological criteria, patients were further subclassified into nine AD, eight DLB, ten PD and nine with other diagnoses. An additional 16 healthy controls (HC) scanned with 123I-FP-CIT SPECT were also included. All images were visually assessed as normal versus abnormal uptake by consensus of five nuclear medicine physicians. Bihemispheric mean was calculated for caudate binding potential (CBP), putamen binding potential (PBP) and putamen-to-caudate ratio (PCR).ResultsPatients with DLB had significantly lower CBP and PBP than patients with AD and significantly higher PCR than patients with PD. Qualitative visual analysis of the images gave an accuracy of 88% in the evaluation of the status of the nigrostriatal pathway considering all individuals, and 96% considering only the patients with PD, AD and DLB. Quantitative analyses provided a balanced accuracy of 94%, 94% and 100% in binary classifications DLB versus AD, DLB versus PD and PD versus AD, respectively, and an accuracy of 93% in the differentiation among patients with DLB, AD and PD simultaneously. No statistically significant differences were observed between the AD and HC.ConclusionsThis study demonstrates a very high diagnostic accuracy of the quantitative analysis of(123I-FP-CIT SPECT data to differentiate among patients with DLB, PD and AD.

A 64-year-old Caucasian woman presented to the emergency department with a 6-day history of dental pain and significant right-sided facial swelling. She had seen her general practitioner twice in the previous days and was prescribed oral metronidazole. There was a history of asthma, epilepsy and

Introduction Despite the advent of PET scanning and endoscopic minimally invasive methods of sampling mediastinal lymph nodes, surgical assessment, particularly by mediastinoscopy, remains an important tool for staging non-small cell lung cancer. Methods We carried out a retrospective review of mediastinoscopic lymph node biopsies taken at The Royal Infirmary of Edinburgh between 1996 and 2006 and performed additional histological investigations on select cases. Results In total, 89/802 (11%) patients had a negative mediastinoscopy but final resection stage of N2/N3. Within this group, 41/89 (46%) patients had positive resection lymph nodes in stations potentially accessible to biopsy at mediastinoscopy. Of these, 30 (34%) patients had had the metastatic station sampled at mediastinoscopy. Further histopathological examination (multiple levels and pancytokeratin immunohistochemistry) of these original biopsies detected micrometastases in two cases, one of which, in retrospect, had been missed on the original section at the time of reporting. Isolated tumour cells were detected by immunohistochemistry in another two cases. Conclusions Routine examination of additional levels and immunohistochemical staining of mediastinal lymph nodes biopsies is not required and would not improve the overall negative predictive value of the procedure.

Background: Dementia with Lewy bodies (DLB) is a common form of dementia. The presence of Alzheimer’s disease (AD) pathology modifies the clinical features of DLB, making it harder to distinguish DLB from AD clinically during life. Clinical diagnostic criteria for DLB applied at presentation can fail to identify up to 50% of cases. Our aim was to determine, in a series of patients with dementia in whom autopsy confirmation of diagnosis was available, whether functional imaging of the nigrostriatal pathway improves the accuracy of diagnosis compared with diagnosis by means of clinical criteria alone. Methods: A single photon emission computed tomography (SPECT) scan was carried out with a dopaminergic presynaptic ligand [ 123 I]-2beta-carbometoxy-3beta-(4-iodophenyl)-N-(3-fluoropropyl) nortropane (FP-CIT; ioflupane) on a group of patients with a clinical diagnosis of DLB or other dementia. An abnormal scan was defined as one in which right and left posterior putamen binding, measured semiquantitatively, was more than 2 SDs below the mean of the controls. Results: Over a 10 year period it was possible to collect 20 patients who had been followed from the time of first assessment and time of scan through to death and subsequent detailed neuropathological autopsy. Eight patients fulfilled neuropathological diagnostic criteria for DLB. Nine patients had AD, mostly with coexisting cerebrovascular disease. Three patients had other diagnoses. The sensitivity of an initial clinical diagnosis of DLB was 75% and specificity was 42%. The sensitivity of the FP-CIT scan for the diagnosis of DLB was 88% and specificity was 100%. Conclusion: FP-CIT SPECT scans substantially enhanced the accuracy of diagnosis of DLB by comparison with clinical criteria alone.

BACKGROUND--Preliminary experience of video assisted thoracoscopic pneumonectomy in six patients with bronchogenic carcinoma is described. METHODS--Four left and two right pneumonectomies were performed under video thoracoscopic imaging. Thoracoscopic instruments were passed through two separate stab incisions on the lateral chest wall and a separate 6 cm submammary incision was also created to allow further access for instrumentation and removal of the resected lung. In this initial experience resection was restricted to patients with bronchogenic carcinomas of less than 6 cm in diameter who had no involvement of the mediastinum. RESULTS--There were no operative deaths and no complications attributable to the technique. One patient developed postoperative atrial fibrillation and a small sacral sore and one patient was readmitted with abdominal pain and pyrexia which settled following exclusion of post pneumonectomy empyema. The remaining four patients made a rapid uncomplicated postoperative recovery with less pain and discomfort than that normally associated with a standard posterolateral thoracotomy. Postoperatively the mean (SD) patient controlled morphine consumption was 1.36 (1.90) mg per hour in the first 36 hours compared with the unit mean for open thoracotomy of 1.73 (1.68) mg per hour. The mean linear visual analogue pain score was 15.4 (15.6) in the first 24 hours compared with the unit mean for open thoracotomy of 34.5 (8.5). CONCLUSIONS--Video assisted thoracoscopic pneumonectomy can be performed safely in patients who have stage I and stage II bronchogenic carcinomas, up to 6 cm in diameter, with no mediastinal involvement on mediastinoscopy and thoracic computed tomographic assessment. This technique may result in less postoperative pain and discomfort and should allow a quicker return to normal activities.

BACKGROUND--This report describes a preliminary experience with six patients undergoing video imaged thoracoscopic pulmonary lobectomy. METHODS--Three left upper lobectomies, and one each of right upper, right lower and left lower lobectomy were undertaken. The resections were performed as orthodox dissectional lobectomy procedures but were carried out under videothoracoscopic imaging with instruments introduced through two stab incisions. The entire resected lobe was delivered through a 7 cm submammary intercostal incision. RESULTS--There were no operative deaths or complications attributable to the technique. In three other patients conversion to an open thoracotomy was required because of bleeding (two cases) or obscure anatomy (one case). Post-operative pain in those undergoing thoracoscopic resection was less than that encountered with standard thoracotomy and early clinic review showed the patients to be pain free with excellent shoulder movement. CONCLUSIONS--Major pulmonary resection according to standard cancer practices is feasible with videothoracoscopic techniques. This approach is likely to offer considerable functional benefit to patients. Specimen delivery through the submammary incision imposes a 5 cm primary lesion size limitation. Detailed mediastinal assessment is necessary to exclude N2 status before undertaking thoracoscopic surgery.

Objective Bronchoalveolar lavage (BAL) may be used to investigate acute inflammation following thoracic surgery. However, BAL has previously been found to induce an acute phase response in healthy and critically-ill patients complicating research analysis (1,2). We sought to examine the impact of BAL in thoracic surgery patients hypothesising that BAL would not lead to a significant additional acute inflammatory response. Methods Seventeen patients undergoing lung cancer staging bronchoscopy and mediastinoscopy were randomly assigned to have 220mls 0.9% NaCl BAL before surgery (n=10) or no BAL (n=7). Blood samples were taken pre-operatively followed by 6 and 24 hours post-operatively. Exhaled nitric oxide (eNO) was also measured at a flow rate of 50mls/sec at these times. All patients had a CXR at 24hrs and were evaluated for evidence of SIRS using pre-defined criteria. Results IL-6 and CRP increased post-operatively peaking at 6hrs and 24hrs respectively however there was no statistically significant difference between the increase for BAL and non-BAL patients (p>0.05). There was no significant increase or variation between the groups for IL-2, IL-4, IL-10, TNF-α or IFN-γ (p>0.05). eNO tended to decrease in the BAL group and increase in the non-BAL group at 6hrs although there was no significant difference between the groups (p=0.167). Post-operative CXR atelectasis developed in 3 patients (2 BAL). One patient in each group developed SIRS. Conclusion BAL has minimal impact on acute inflammation following bronchoscopy and mediastinoscopy. It may therefore be used to safely and reliably obtain samples for research or microbiology purposes in thoracic surgery patients. Huang Y-C T, Bassett MA, Levin D, Montilla, Ghio AJ. Acute Phase Reaction in Healthy Volunteers After Bronchoscopy with Lavage. Chest 2006; 129 (6): 1565–9. Terashima T, Amakawa K, Matsumaru A et al. BAL Induces an Increase in Peripheral Blood Neutrophils and Cytokine Levels in Healthy Volunteers and Patients with Pneumonia. Chest 2001; 119 (6): 1724–1729.

Basically, this is a book about the consequences of severe spinal cord lesions, mainly traumatic injury (spinal cord injury; SCI), and the management of them. It is not a book about spinal cord diseases. So, if you are wondering about the pathogenesis of spinal interneuronitis, or the classification of spinal muscular atrophies, do not look here. But if you spend a significant amount of time involved in the care of patients who are wheelchair dependent as a consequence of SCI or a severe chronic myelopathy such as …

In an unusual case of the Eisenmenger syndrome, in which pulmonary infarction was complicated by life threatening intrapleural haemorrhage and pneumothorax, lobectomy was carried out successfully to arrest the haemorrhage.

Two patients with refractory anastomotic stenosis and symptomatic ballooning of the upper oesophageal pouch following repair of long gap oesophageal atresia are described. In both cases a circular myotomy had been used to elongate the proximal oesophageal segment at the time of primary repair. Both patients were successfully treated by Y-V plasty of the oesophageal stenosis and tailoring of the dilated segment.

The present study examined intraluminal events in the in vivo processing of a protein antigen by the intestine of normal and orally immunised rats. One hour after the administration of 125I-bovine serum albumin (125I-BSA) and unlabelled BSA by gavage, the majority of the radioactivity was found in the distal small intestine of control and immunised rats but there was a difference in the distribution of radioactivity. In contrast with controls, immunised rats retained a lesser percentage of radioactivity in the proximal small intestine and a greater percentage of radioactivity in the distal small intestine. Radioactive substances present in intestinal rinse fluids and mucosal extracts were characterised by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), density gradient ultracentrifugation, and by immunochemical methods. Rinse fluids and mucosal extracts from immunised rats fed 125I-BSA by gavage contained high molecular weight components with characteristics of antigen-antibody complexes. Rinse fluids and extracts of normal rats contained more intact BSA and less fragments of BSA than did rinse fluids and extracts from immunised animals. These findings suggest that oral immunisation alters the distribution of antigen administered into the gut and that immunisation enhances the intraluminal degradation of antigen.

A prospective double blind, randomised study was performed in 100 patients undergoing major elective thoracic surgery to assess a new method of prophylaxis of wound infection using one preincisional intraparietal infiltration of cefuroxime sodium along the line of proposed incision as the sole protection against wound infection. A significant (p less than 0.01) reduction in the incidence of wound infection occurred in the antibiotic treated group (2%) compared with the control group (20%), who received by the same route the same volume of saline only. The groups were comparable with respect to age, sex, pathological condition, and operative variables. The use of additional antibiotics was significantly greater in the control group (p less than 0.01), largely owing to a much greater incidence of postoperative pulmonary infection in the control group (60%) than in the antibiotic treated group (40%). No morbidity was associated with this technique. The organisms found in oesophageal and bronchial operative luminal specimens did not correlate with postoperative wound or pulmonary infection or with organisms causing these infections. Reductions in wound and pulmonary infection rates equivalent to those produced by conventional multiple dose parenteral regimens were achieved by this technique.

The techniques and interpretation of acid-base studies on patients undergoing open-heart surgery with extracorporeal circulation are described. The ;normal' range and duration of changes in 35 surviving patients are given; these were essentially of respiratory rather than of metabolic origin, being a respiratory alkalosis induced by the anaesthetist before perfusion, and a respiratory acidosis after assisted respiration was stopped. Gross metabolic acidosis was seen only where clinically severe complications had occurred.

Sixteen volunteers were tested when smoking their own brand of cigarettes normally and when smoking half their usual number of cigarettes. While smoking half their usual amount the subjects changed their inhalation behaviour. Over this period the percentages of carboxyhaemoglobin were not significantly different from steady-state values where plasma nicotine concentration rose significantly. With the reduction in cigarettes there were significant falls in haemoglobin concentration, packed cell volume, and red cell count. These findings suggest that the advice given to patients to smoke fewer cigarettes should be accompanied by a warning against increasing inhalation. Patients who say that they have reduced their smoking but who have unaltered carboxyhaemoglobin concentrations should not be discredited.