Biomedical subjects
Publications and source records attributed to L J Faling.
The authors describe a simple computed-tomographic method, using precise surface localization, to locate small subpleural nodules or pulmonary lesions. This permits a guided minithoracotomy for chest lesions which are not visible on plain radiographs or are considered inaccessible by percutaneous or transbronchoscopic biopsy.
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This review has failed to uncover convincing evidence to support the existence of familial emphysema in patients with normal serum proteins. Although a large number of studies have documented that non-A1PI hereditary factors are important in the development of nonspecific chronic obstructive pulmonary disease, it is far less certain that emphysema accounts for this familial occurrence. To the contrary, most existing evidence fails to support this possibility. Nevertheless, the issue remains unsettled and incompletely studied. Further investigations should include a major effort to identify young persons, 20 to 45 years of age, with emphysema alone but without A1PI deficiency. Based on prior reports, 76 it is likely that such persons will be found. As emphasized by Kazazian, "this is the group that should be studied for the presence of a single mutant gene in the homozygous state." 42 It is possible that several or many rare single-gene causes of emphysema await discovery. Careful family studies of young emphysematous subjects are indicated as well to determine whether emphysema-producing genes also constitute a risk factor in heterozygous persons. If such patients and families are discovered, further hypotheses will have to be drawn-up and carefully investigated to attempt a better understanding of the etiology and pathogenesis of emphysema.
Pulmonary arteriovenous malformations (AVM) are unusual congenital lesions that may cause respiratory disability. Two cases of AVMs were diagnosed utilizing contrast enhanced computed tomography (CT). The potential role of CT as compared to conventional angiography is discussed, and the characteristic CT appearance of these abnormalities is described.
We conclude that chronic necrotizing pulmonary aspergillosis is a clinical entity which has not usually been recognized as one of the forms of pulmonary disease due to Aspergillus species. Patients are middle-aged, and often have some evidence of impairment of host defenses such as diabetes mellitus, a connective tissue disorder, poor nutrition, chronic obstructive lung disease or low dose corticosteroid therapy. They are almost always symptomatic with fever and a productive cough, and their chest roentgenogram shows infiltrative and cavitary disease, typical of a chronic destructive lung process such as tuberculosis or anaerobic infection. Cavity formation is often accompanied by the development of a mycetoma. The disease is usually of 1 to 6 months duration but can be present for years prior to diagnosis. The diagnosis is suggested by the clinical course and the isolation of the fungus from pulmonary secretions; negative cultures for other pathogens and failure to respond to antibacterial or antimycobacterial therapy are characteristic. The diagnosis is confirmed by pathologic evidence of tissue invasion by the fungus or a response to specific antimycotic therapy. The symptomatic response to antifungal chemotherapy, at times combined with surgical drainage or resection, is favorable. However, roentgenographic resolution is not uniform, and many patients have residual cavitary disease. The long-term prognosis is uncertain.
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We investigated the efficacy of 2-s breath-holding computed tomographic (CT) scans and standard posteroanterior and lateral chest roentgenograms in staging the mediastinum and pulmonary hill in lung cancer. Fifty-one comparisons were made in 49 patients thought to have non-small-cell carcinoma, consecutively chosen to be free of disseminated tumor, and to be suitable candidates for thoracotomy. The CT scans accurately predicted mediastinal neoplastic lymphadenopathy in 15 or 17 instances of proved mediastinal lymph node metastasis for a sensitivity of 88%; specificity was also high (94%) with a true-negative scan in 32 of 34 instances. Standard chest roentgenograms were much less sensitive (47%) than rapid CT scanning in mediastinal staging; there were false-negative interpretations in 9 of 17 instances. Specificity of the methods was the same. both CT scans and standard chest roentgenograms had a sensitivity of only 67% in detecting neoplastic hilar adenopathy; enlarged hilar nodes were noted in only 10 of 15 patients with proved hilar node metastasis. We concluded from this preliminary study that rapid CT scanning shows promise of being useful in the noninvasive staging of the mediastinum of patients with otherwise operable non-small-cell bronchogenic carcinoma; the technique also provides useful guidance during mediastinoscopy and may detect lymphadenopathy not so visualized, but CT scanning appears to have little advantage over standard posteroanterior and lateral chest roentgenograms in staging the pulmonary hill.
Computed tomography (CT) of the thorax shows early promise of important diagnostic advances. We believe that CT often provides information superior to that provided by standard roentgenographic techniques, is capable of significantly influencing patient management, and in selected instances, offers unique information not available by other methods. Computed tomography permits the imaging of mediastinal structures not possible with conventional roentgenographic methods and can diagnose with certainty benign mediastinal conditions such as pericardial cysts and focal or diffuse accumulations of fat. It is ideal for detecting pleural abnormalities and for displaying underlying parenchymal disease in patients with complex pleuroparenchymal shadows on conventional films. Pulmonary metastases unseen on the plain chest film can be detected with greater sensitivity than by any other method. Future applications of CT include the staging of mediastinal lymph nodes in bronchogenic carcinoma, the differentiation of benign from malignant solitary pulmonary nodules, and the detection of diffuse diseases involving the lung parenchyma before they are visible on conventional roentgenograms. Additional clinical experience and careful studies will determine CTs final role as a diagnostic aid for disorders of the thorax.
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Although radionuclide examinations are usually diagnostic for evaluating mediastinal goiters, false negative examinations do occur, and the diagnosis may not be suspected based on clinical or radiographic features. In such a setting, computed tomography (CT) may demonstrate both anatomic and physiologic evidence of thyroid mass, providing useful diagnostic information. We report a case in which CT derived data aided in an early diagnosis of mediastinal gioter.
A review of 262 consecutive 2-second CT scans (101 thoracic and 161 abdominal) revealed that 36% contributed information critical to diagnosis, prognosis or therapy. As a result of CT-derived data, major surgery was cancelled in 16 cases and planned surgery modified in 11. Similarly, CT contributed to treatment planning in 20 instances. Forty-four per cent of the studies produced new information but did not have definite clinical impact. Marked improvement in efficacy is noted when these data are compared to our previous study of 2 1/2-minute CT examinations. The improvement is ascribed to better imaging (faster scan speed), improved diagnostic skill, better patient selection, and improved credibility of CT-derived data.
Thoracic CT scanning was performed in 49 adult male patients to evaluate a suspected mediastinal mass. A correct diagnosis would have been made in only 20 instances on the basis of conventional chest radiography. Specific diagnoses established by CT included 14 cases of local or diffuse mediastinal fat deposition, five mediastinal cysts, and six anomalies or aneurysms of the great vessels. Four miscellaneous lesions were also clarified. Thoracic angiography would undoubtedly have diagnosed vascular abnormalities, but was obviated in most instances. CT accurately defined anatomic relationships and distinguished vascular from nonvascular masses in the 16 patients who underwent diagnostic thoracotomy or mediastinoscopy. When CT demonstrated a fatty or cystic lesion, no attempt at tissue confirmation was undertaken in all but two of the asymptomatic patients. Clinical follow-up from 6 months to 3 years in conjunction with select correlative radiologic procedures have supported the CT findings in the nonoperated group. CT should be the initial procedure for evaluating most patients with mediastinal abnormalities detected by plain chest radiography. If the patient is asymptomatic and the information provided by CT indicates a benign process, conservative management with careful follow-up is justified.
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We describe two patients with benign esophageal stricture in whom exfoliative esophageal cytologic features positive for squamous cell carcinoma is attributed to roentgenographically occult lung cancer. The discovery of alveolar macrophages within the esophageal washings of these patients prompted a retrospective analysis assessing the prevalence of esophageal washings contaminated by cellular material from the lower respiratory tract. Alveolar macrophages were observed in 11 of 28 patients (39%) and in 12 of 33 specimens (36%). Alveolar macrophages were noted in half of patients with benign esophageal disease, but in only one of eight cases with proved esophageal cancer. Criteria alerting physicians to the coexistence of benign esophageal stricture and occult respiratory neoplasm are given, and recommendations for a change in reporting esophageal cytologic features are proposed.
Chronic pleural effusion occurred in three patients, one of whom also developed acute pericarditis. A fourth patient developed both pleural and pericardial effusions. All patients had been receiving dantrolene sodium for at least two months. The pleural fluid was a sterile exudate with pleural and peripheral blood eosinophilia in all patients. No pulmonary parenchymal involvement was apparent. Pleural biopsy specimens showed nonspecific inflammation. Resolution of the pleural process was prolonged after dantrolene therapy was discontinued. Although a causal relationship between dantrolene and serosal inflammation remains unproved, this association in four patients warrants careful observation of others receiving long-term dantrolene therapy.
Seven types of brush catheter were studied in vitro to determine the optimal catheter design for obtaining specimens for bacterial culture using fiberoptic bronchoscopy. The various catheters were inserted through the inner channel, which was contaminated with fresh saliva. The specimen was then obtained by inserting the brush into a broth culture of a marker organism at the distal end of the bronchoscope. Relative merits were based on quantitative bacterial counts of salivary "contaminants" and the marker organism. The catheter that proved superior had telescoping cannulas with a distal occlusion. Twenty-six samplings using catheters with this design uniformly showed no contaminants and high counts of the marker organism. The catheter with telescoping cannulas and a distal occlusion composed of polyethlene glycol was then tested with bronchoscopy performed on 8 healthy volunteers and 6 patients with clinical evidence of a lower airway infection. The specimens yielded likely pulmonary pathogens in high concentrations from patients with pneumonia or lung abscess. Possible contaminants were recovered in low concentrations from 2 of 14 subjects. These in vitro studies and the preliminary clinical trial support the use of this type of catheter for obtaining bronchoscopic specimens for bacterial culture.