Search

The aim of this study was to audit the management of hyperlipidaemia in a cohort of 206 consecutive patients, with known or suspected coronary artery disease, referred for diagnostic coronary angiography. The association of lipid subfraction values with the presence and extent of coronary artery disease was explored to identify the indices of greatest potential value to the hospital cardiologist, in the management of secondary prevention.Patients were questioned about previous lipid tests performed, advice received and treatmentprescribed. Referral letters and hospital notes were reviewed to identify documentation of lipid results and treatment strategies. De novo fasting lipid estimations were obtained on 205 subjects at the time of catheterization.In only 46/206 (22%) cases was some form of lipid result recorded in the existing hospital notes or referral documentation. No patient was aware of the levels of the high or low density lipoprotein cholesterol subfractions (HDL, LDL) nor were these specifically recorded, or the subject of clinical comment, in any of the referral documentation.Patients who knew their total cholesterol (in mmol. 1−1) result either as a value or as a ‘high’ or ‘normal’ categorization proved accurate witnesses.In keeping with other angiographic studies, we found that low values of HDL and high TC/HDL ratios were significantly associated with both disease presence and extent. Total cholesterol, calculated LDL and triglyceride levels had no such association.In the group as a whole and despite current therapy, 169/206 (82%) patients had a total cholesterol >5.2 and 163/206 (79%) a TC/HDL ratio >5. Only 22(11%) patients were on drug therapy with a further 43 (21%) practising dietary modification. In the vast majority of subjects receiving some form of lipid intervention, target lipid levels had not been achieved.This study identifies the need for more intensive management of hyperlipidaemia in patients with coronary artery disease. Knowledge of HDL levels may be of value in guiding lipid secondary prevention management in the patient population evaluated at an angiographic centre. [ABSTRACT FROM PUBLISHER]

Background: Chronic pulmonary infection with transmissible Pseudomonas aeruginosa strains in individuals with cystic fibrosis (CF) has been reported, raising issues of cross infection and patient segregation. The first such strain to be described (the Liverpool epidemic strain, LES) is now widespread in many UK CF centres. However, whether such infection carries a worse prognosis is unknown. To address this, the clinical course of a group of CF patients chronically infected by LES was compared with that in patients harbouring unique strains. Methods: Using P aeruginosa strain genotyping, two cohorts of CF patients attending the Liverpool CF service were identified who were LES positive or negative in 1998 and remained so until 2002. From these, two groups of 12 patients were matched in 1998 for age, spirometric parameters, and nutritional state and their clinical course was followed for 5 years. Patients chronically infected with Burkholderia cepacia were excluded. Results: Patients chronically infected with LES had a greater annual loss of lung function than those not chronically infected by LES (mean difference between groups -4.4% (95% CI -8.1 to -0.9; p<0.02)), and by 2002 their percentage predicted forced expiratory volume in 1 second (FEV1) was worse (mean 65.0% v 82.6%, p<0.03). Their nutritional state also deteriorated over the study period (mean difference between groups in body mass index -0.7 (95% Cl -1 .2 to -0.2; p<0.01 )), such that by 2002 they were malnourished compared with LES negative patients (mean BMI 19.4 v 22.7, p<0.02). Conclusions: Chronic infection with the Liverpool epidemic P aeruginosa strain in CF patients confers a worse prognosis than infection with unique strains alone, confirming the need for patient segregation. Since this strain is common in many CF units, strain identification in all CF centres is essential. This can only be carried out using genomic typing methods. [ABSTRACT FROM AUTHOR]

Gastro-oesophageal reflux (GOR) occurs frequently in children with cystic fibrosis (CF) but has not been studied in adult CF. We surveyed such symptoms by structured questionnaire in 50 adult CF patients (mean age 26 years, range 16-50; 24 male) and performed oesophageal manometry and 24-hour pH recording in 10 who had reflux symptoms (mean age 28 years, range 21-35; 8 men). 47 patients (94%) had upper gastrointestinal symptoms: 40 (80%) heartburn (27 worse when supine); 26 (52%) regurgitation; and 28 (56%) dyspepsia. At oesophageal manometry, lower oesophageal sphincter barrier pressure (LOSBP) was subnormal in 6 of the 10 patients and 3 had uncoordinated peristalsis in the mid oesophagus. 8 patients had raised DeMeester scores, indicating significant GOR. Those patients with a LOSBP <5mm Hg had a higher DeMeester score (mean 81.0, range 47.9-128.8) than the patients with a normal LOSBP (26.9, 8.7-56.5; p < 0.002). These results show that adult CF patients have high rates of GOR symptoms, diminished LOSBP, and acid reflux. [ABSTRACT FROM AUTHOR]

Introduction Spontaneous pneumothorax is a well-recognised complication in cystic fibrosis and is associated with increased morbidity and mortality. Although chemical pleurodesis and surgery are successful in preventing recurrence in non-CF patients, there are few data regarding their efficacy in CF . Method To look at this further we reviewed the management and outcome of all 28 patients (mean age at first pneumothorax 26 years [range 18-54], mean FEV1 32% predicted [17-68], 18 female) in our centre who had developed a pneumothorax (58 episodes [1-7]) from 1993 to 2010. Results Nine sustained bilateral pneumothoraces (either at initial presentation or as a subsequent event) and 16 recurrence (mean interval 4 months [1-12]). The outcomes of the initial and second line treatments are shown in the Abstract P240 table 1. 14 patients (50%) died within 12 months and 20 (71%) within 2 years of their first pneumothorax, and five deaths occurred after surgery (mean 10 days [3-21]). The highest risk of recurrence occurred in the chest drain group (62%) followed by chemical pleurodesis (with 4 g talc) (57%), observation (40%) and the surgical group (20%). Conclusion Thus, we have confirmed that spontaneous pneumothorax is a poor prognostic factor in CF, with 57% of patients experiencing a recurrent pneumothorax within the first year and poor one and 2-year survival rates. Surgical treatment was associated with a lower risk of recurrence, but at the expense of an increase inmortality. Randomised controlled trials of treatment options and the formulation of guidelines are required to determine the timing and optimal management to prevent recurrent pneumothorax in CF patients. [ABSTRACT FROM AUTHOR]

Background Although resection offers the best chance of cure for most solid tumours, including the lung, <2% of elderly patients (>80 age years) undergo this treatment often because of their perceived frailty and complication rates. Since lung cancer is a disease of the elderly, with up to 30% occurring in this age group, we were interested to review the results of attempted curative resection in older patients referred to our tertiary thoracic surgical unit. Methods We reviewed the medical records of all 1481 patients aged 60 or older who had undergone single or bi-lobectomy with curative intent from 2001 to 2008, and divided them into age groups 60-79 (1360 cases, 663 female) and 80+ (121, 41).We looked at their clinical parameters, and then compared the results of surgery in terms of short-term mortality, complication rates, and length of stay. Results The older patients had smoked less (median 30 pack years [IQR 20-50] vs 40 [20-54], p<0.5), and had better lung function (FEV1 88% [73-103] vs 81% [66-93], p<0.001), but had more heart disease (41% vs 29%, p<0.001). Postoperative results are given in the Abstract P192 table 1. Conclusion Although the older patients had more postoperative complications, 94% survived the procedure, indicating that surgical resection with curative intent is a viable proposition in selected cases of lung cancer in the elderly. Thus, age should not be a bar to surgical treatment in the older age group, and this study reiterates the need to consider potentially curative surgery for all age groups with this life threatening disease. [ABSTRACT FROM AUTHOR]

Introduction PET scans are useful in lung cancer by facilitating accurate staging to ensure that optimal treatment can be offered. Although the European Association of Nuclear Medicine (EANM) has produced reporting guidelines, the utility of the test depends upon the interpretation of the obtained images by the reporting radiologist. Since most UK PET services are provided by the independent sector (IS) remote from cancer units, we were interested to assess the value of PET/CT reporting in the MDT management of lung cancer. Methods We looked at the quality of reports of all 97 PET/CT scans performed in our busy lung cancer unit between December 2010 and April 2011, measuring the reports (from 6 IS radiologists) against the EANM standards. In addition, we analysed the length of the report and documentation of PET staging. Results FDG accumulation was documented in standard guideline format (mild, moderate or intense) in 39 cases (40%), all with SUVs noted, but in 37 cases (38%) FDG accumulation was described as significant, increased or highgrade (36 with SUVs). However, 21scans (22%) had no report of FDG accumulation but 20 (90%) still described SUVs. Corresponding CT findings were reported in 93 (96%), and a summary report was issued in 94 (97%), but 33 reports (34%) were >1 page in length. Seven scans showed benign disease and 8 had no excess FDG activity: of the remaining 82 with malignancy, only 39 (48%) were staged. Reasons for not staging included "inflammatory changes" (2), "uncertain findings" (18), "further investigation required" (15), and "clinical correlation required" (8). Although all radiologists failed to stage some scans, three were responsible for the majority (30 scans, 70%). Conclusions Our results show that a significant proportion of scan reports fell below the recommended EANM standards either in the description of FDG accumulation or matching those patterns to SUV. Furthermore, many scans were unstaged, diminishing their value to the commissioning MDT. Closer liaison between IS radiologists and MDT members may assist the reporting process to ensure the maximum value is obtained from this expensive test for the benefit of this unfortunate patient group. [ABSTRACT FROM AUTHOR]

Introduction and Objectives The End of Life Care Strategy advocates the identification and support of patients approaching the end of their lives, and to aid this, social care benefits can be awarded to those with a life expectancy <6 months by completion of a DS1500 form. Many lung cancer patients fall into this category: we wished to look at the use of this enhanced support mechanism in our busy lung cancer unit. Method We looked at the use of DS1500 in the initial period for 100 consecutive outpatients with lung cancer diagnosed through our rapid access clinic in 2007 (mean age 73 years [SD 8], mean PS=2 [IQR 2], 47 females), comparing its use with survival and histological tumour type. Mortality data were obtained from the national registry. Results Twenty two had a DS1500 completed (median 26 days [20] from presentation): there was no difference in age, sex or PS between these and the remainder. Of the 75 with a tissue diagnosis, only those with non-small cell cancer were more likely to receive a form (16/22 vs 30/78 χ²=8.1, p=0.004). Only three patients with a clinical diagnosis and three with small cell received forms (both p=NS). Overall median survival was 216 days [IQR 405], with 57 alive at 6 months and 33 at 1-year. Median survival was 193 [268] days for those with DS1500 compared with 224 [458] in the remainder (p=NS), and 31 (57%) of those who died within 6 months did not benefit from early DS1500 status. Conclusion While the DS1500 use was appropriate, the number identified represented less than a half of those who died within 6 months of presentation, and those with the poorest prognosis (small cell type or a clinical diagnosis) did not benefit the most. It seems we are missing an opportunity to support this unfortunate group of patients at the time of their greatest need. [ABSTRACT FROM AUTHOR]

Chronic infection with Pseudomonas aeruginosa is common in cystic fibrosis (CE) and certain strains are more transmissible and virulent than others. Of these, the Liverpool Epidemic Strain (LES) is highly transmissible and cross infection has been reported between patients with CE and healthy non-CE relatives. However, the risk of transmission from humans to animals is unknown. The first report of interspecies transmission of the LES strain of P aeruginosa from an adult patient with CE to a pet cat is described. This development further complicates the issue of infection control policies required to prevent the spread of this organism. [ABSTRACT FROM AUTHOR]

Colonisation with Pseudomonas aeruginosa is common in adults with cystic fibrosis (CF) and there is increasing evidence that transmissible strains may cross colonise patients. However, transmission of these strains by social contact to healthy non-CF individuals has not been described. A case is presented where an adult CF patient colonised by an epidemic P aeruginosa strain infected her parents with subsequent morbidity. [ABSTRACT FROM AUTHOR]

Epithelioid haemangioendothelioma is a rare pulmonary neoplasm with less than 40 cases described world wide. We describe the only case to have presented with hypertrophic pulmonary osteoarthropathy who has been treated with azathioprine and has remained alive and well with no deterioration in pulmonary function since being diagnosed 16 years ago. The progression of the chest radiograph and spiral CT appearances of this rare neoplasm are described, and current views regarding the cellular origin of the neoplasm, its cytological appearance, clinical presentation and prognosis are discussed. [ABSTRACT FROM AUTHOR]

No abstract available Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction Patients with CF can expect to undergo many investigations using ionising radiation for the management of their disease: now that the majority of patients will survive well into their 5th decade, life-time exposure to such radiation, a known risk factor for the development of malignancy, may be important. To investigate this further, we looked at the amount of ionising radiation given in our adult CF clinic over a 1-year period. Methods All imaging studies associated with ionising radiation in 253 adult CF patients were reviewed and assessed for their impact on management. Radiation was calculated using standard reference doses and expressed as (milliSievert [mSv]), also referred to as the effective dose. Results A summary of the results can be found in the Abstract P239 table 1. There was an average annual radiation dose of 1.66 mSv with 54% of studies leading to a change in management. Overall, although only 11% of chest x-rays altered patient management, patients with more severe CF disease (DIOS, CFRD and infection with transmissible Pseudomonas strains) had a greater cumulative radiation dose and this was more likely to alter management. Conclusions Although the CF population receives a significant dose of radiation from medical investigations each year, many impact on patient management. CFRD, DIOS and infection with transmissible Pseudomonas are associated with greater levels of radiation than the average CF population, in keeping with more significant disease burden in these individuals. Care should be taken when ordering investigations associated with ionising radiation, to reduce the long term effects, as life expectancy is increasing. [ABSTRACT FROM AUTHOR]

Background Liverpool has the highest incidence of lung cancer in England and Wales, and a citywide audit in 1996 identified significant deficiencies in the secondary care sector management of suspected cases. As a result of this, major reforms were made to benefit the majority of Liverpool residents in 1999, including the collaboration of competing hospitals to provide a unified service, a dedicated one stop rapid access clinic with same-day CT and bronchoscopy facilities, the employment of lung cancer specialist nurses, and parallel clinics for speedy onward referral. We have continued to refine this service, the largest in the region, and wished to compare outcomes to date. Methods We compared the results of the service at three time points: at the 1996 audit, immediately after the inception of the service in 2001 and in 2010. Results The results are summarised in the Abstract P160 table 1. In addition by 2010, two thirds had CT and bronchoscopy (6 EBUS) on the same day as their rapid access clinic appointment, and 48 underwent EBUS (mean wait 5 days). The average waiting time for PET scan in 2010 was 10 days. Conclusion This study confirms that the care of lung cancer patients in Liverpool has improved since the introduction of these new services, which we encourage other units to emulate. [ABSTRACT FROM AUTHOR]

Presents several letters to the editor. Comment on a article on the survival of patients with cystic fibrosis that appeared in a previous issue; Response to a letter to the editor about the survival of patients with cystic fibrosis.

Presents a letter to the editor in response to the article "Bacterial Endorcarditis in Patients With Chronic Liver Disease," by T.M. McCashland, M.F. Sorrell and R.K. Zetterman in a 2004 issue of the "American Journal of Gastroenterology."

Aqueous mixtures of Bacillus thuringiensis Berliner var. kurstaki (Btk were applied over three plots located in a pecan orchard in New Mexico, USA at a dosage rate of 39.6 billion international units (BIU)/ha and volume rates of 9.4 Uha (Plot 1), 935 Uha (Plot 2), and 47 Uha(Plot 3). Plots 1 and 3 were sprayed aerially using a Cessna 188 aircraft fitted with Micronair AU 5000 atomizers and D8-46 disc-core (hydraulic) nozzles, respectively. Plot 2 received ground application using a Wilbur-Ellis air-blast sprayer. Spray deposit patterns on artificial samplers and live pecan substrates were determined by quantifying the delta-endotoxin at three different levels in the tree canopy and at ground level using enzyme-linked immunosorbent assay (ELISA). Droplet density (droplets/cm2) and size spectra were also assessed to evaluate the uniformity of coverage at the three canopy levels using horizontal and cylindrical (vertical) Kromekote card samplers. Droplet density and size spectra on the Kromekote cards, and deposits on artificial samplers and pecan substrates varied both within and among the plots. They were higher on the horizontal compared to the vertical artificial samplers. The droplet data on artificial samplers indicated phase separation and non-uniform distribution of Btk particles. Analysis of spray deposits on the samplers showed definite gradients in deposit levels, decreasing from the upper to lower canopyin the aerial treatments, and from lower to upper canopy levels in the ground application. Canopy coverage, indicated by the delta-endotoxin levels at the mid-canopy target sites (viz., nutlets and budlets), decreased in the order: Micronair > air-blast > hydraulic spray systems. Aerial application with hydraulic nozzles provided larger droplets at ground and canopy levels, with greater uniformity of deposits;however, the deposits at the target sites were relatively low. The delta-endotoxin was found to be short lived and the average dissipation h [ABSTRACT FROM AUTHOR]