A prospective molecular surveillance study evaluating the clinical impact of community-acquired respiratory viruses in lung transplant recipients.

BACKGROUND: Community-acquired respiratory viral infections (RVIs) are common in lung transplant patients and may be associated with acute rejection and bronchiolitis obliterans syndrome (BOS). The use of sensitive molecular methods that can simultaneously detect a large panel of respiratory viruses may help better define their effects. METHODS: Lung transplant recipients undergoing serial surveillance and diagnostic bronchoalveolar lavages (BALs) during a period of 3 years were enrolled. BAL samples underwent multiplex testing for a panel of 19 respiratory viral types/subtypes using the Luminex xTAG respiratory virus panel assay. RESULTS: Demographics, symptoms, and forced expiratory volume in 1 sec were prospectively collected for 93 lung transplant recipients enrolled. Mean number of BAL samples was 6.2+/-3.1 per patient. A respiratory virus was isolated in 48 of 93 (51.6%) patients on at least one BAL sample. Of 81 positive samples, the viruses isolated included rhinovirus (n=46), parainfluenza 1 to 4 (n=17), coronavirus (n=11), influenza (n=4), metapneumovirus (n=4), and respiratory syncytial virus (n=2). Biopsy-proven acute rejection (> or =grade 2) or decline in forced expiratory volume in 1 sec > or =20% occurred in 16 of 48 (33.3%) patients within 3 months of RVI when compared with 3 of 45 (6.7%) RVI-negative patients within a comparable time frame (P=0.001). No significant difference was seen in incidence of acute rejection between symptomatic and asymptomatic patients. Biopsy-proven obliterative bronchiolitis or BOS was diagnosed in 10 of 16 (62.5%) patients within 1 year of infection. CONCLUSION: Community-acquired RVIs are frequently detected in BAL samples from lung transplant patients. In a significant percentage of patients, symptomatic or asymptomatic viral infection is a trigger for acute rejection and obliterative bronchiolitis/BOS.

The farmer's lung disease : occupational medicine input

Background: Although there has been an abundant literature in recent years about farmer's lung disease, few addressed occupational measures able to maintain the farmer in his work. Nevertheless we know now that most of the farmers can be kept at the workplace by the way of occupational preventive measures. Methods: This matter is discussed from a case report. A farmer affected by the farmer's lung disease was sent to us by his pneumologist, in order to estimate the possibility of maintaining him in his job and to determine relevant changes at his workplace to minimize risk of exposure to dust antigen. This approach required a visit to the workplace by occupational physician and hygienist. Results: The visit of the workplace pointed out different habits and architectural particularities which were potential sources of exposure. The two main proposed measures to reduce the risk, were to wear respiratory masks while working inside the barn, such as preparing hay, feeding the cattle or sweeping the floor, and to build a direct access from the bathroom (shower and toilet) to the outside, allowing to go out of the barn after taking a shower and changing, without risk of being contaminated again. Although upgrading the shower-toilet is not yet completed to date, the already performed modifications led currently to significant clinical improvements, despite the risk of exposure was high since the animals were in the barn for more than two months. Conclusion: The treatment of the farmer's lung disease must be multidisciplinary involving general practitioner, pneumologist, occupational hygienist and occupational physician.

Osteolytic metastasis detected by F18-FDG PET in a patient with lung carcinoma

We present a 53-year-old man with a vocal cord paralysis observed as a primary manifestation of lung carcinoma. Tc-99m MDP whole body bone scan were performed and resulted a normal scintiscan. The bone scan does not revealed suspicious foci of uptake. The possibility of bone metastasis was taken into consideration. A whole body F18-FDG-PET scan showed intense uptake in the left upper lung corresponding to the primary tumor. A bronchial biopsy confirmed infiltration by small cell lung carcinoma (SCLC). SCLC is composed of poorly differentiated, rapidly growing cells with disease usually occurring centrally rather than peripherally. It metastasizes early. The whole-body F18-FDG-PET scan clearly demonstrated a focus of increased uptake in the second lumbar vertebral body suspicious for osteolytic metastasis. A lytic bone metastasis was confirmed by MRI. The patient then received therapy and underwent follow up abdominal CT. The scan showed blastic changes in the L2 vertebra suggesting response to treatment.

Sensitivity to Change of the Ultrasound synovitis SONAR Score in RA Patients: Results of the Scqm Cohort

Background/Purpose: Since the end of 2009, an ultrasound scoring call SONAR has been implemented for RA patients as a routine tool in the SCQM registry (Swiss Clinical Quality Management registry for rheumatic diseases). A cross-sectional evaluation of patients with active disease and clinical remission according to the DAS28ESR and the novel ACR/EULAR remission criteria from 2010 clearly indicated a good correlational external validity of synovial pathologies with clinical disease activity in RA (2012 EULAR meeting. Objective: of this study was to evaluate the sensitivity to change of B-mode and Power-Doppler scores in a longitudinal perspective along with the changes in DAS28ESR in two consecutive visits among the patients included in the SCQM registry Methods: All patients who had at least two SONAR scores and simultaneous DAS28ESR evaluations between December 2009 and June 2012 were included in this study. The data came from 20 different operators working mostly in hospitals but also in private practices, who had received a previous teaching over 3 days in a reference center. The SONAR score includes a semi-quantitative B mode and Power-Doppler evaluation of 22 joints from 0 to 3, maximum 66 points for each score. The selection of these 22 joints was done in analogy to a 28 joint count and further restricted to joint regions with published standard ultrasound images. Both elbows and wrist joints were dynamically scanned from the dorsal and the knee joints from a longitudinal suprapatellar view in flexion and in joint extension. The bilateral evaluation of the second to fifth metacarpophalangeal and proximal interphalangeal joints was done from a palmar view in full extension, and the Power-Doppler scoring from a dorsal view with hand and finger position in best relaxation. Results: From the 657 RA patients with at least one score performed, 128 RA patients with 2 or more consultations of DAS28ESR, and a complete SONAR data set could be included. The mean (SD) time between the two evaluations was 9.6 months (54). The mean (SD) DAS28ESR was: 3.5 (1.3) at the first visit and was significantly lower (mean 3.0, SD.2.0, p:_0.0001) at the second visit. The mean (SD) of the total B mode was 12 (9.5) at baseline and 9.6 (7.6) at follow-up (p_0.0004). The Power-Doppler score at entry was 2.9 (5.7) and 1.9 (3.6), at the second visit, p _0.0001. The Pearson r correlation between change in DAS28ESR and the B mode was 0.44 (95% CI: 0.29, 0.57, p_ 0.0001),and 0.35 (95% CI: 0.16, 0.50, p _ 0.0002) for the Power-Doppler score,. Clinical relevant change in DAS (_1.1) was associated with a change of total B mode score _3 in 23/32 patients and a change a Doppler score _0.5 in 19/26. Conclusion: This study confirms that the SONAR score is sensitive to change and provides a complementary method of assessing RA disease activity to the DAS that could be very useful in daily practice.

Routine use of intravascular ultrasound for endovascular aneurysm repair: angiography is not necessary.

INTRODUCTION: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography. MATERIALS/METHODS: eighty consecutive patients (median age 69 years (range 25-90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference. RESULTS: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190 ml (range: 20-350) for angiography versus 0 ml for IVUS (p<0.01). Median X-ray exposure time 24 min (range 9-65 min) versus 8 min (range 0-60 min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures. CONCLUSIONS: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.

Lack of association between beta-herpesvirus infection and bronchiolitis obliterans syndrome in lung transplant recipients in the era of antiviral prophylaxis.

BACKGROUND: Cytomegalovirus (CMV), human herpesvirus-6 and -7 (HHV-6 and -7) are beta-herpesviruses that commonly reactivate and have been proposed to trigger acute rejection and chronic allograft injury. We assessed the contribution of these viruses in the development of bronchiolitis obliterans syndrome (BOS) after lung transplantation. METHODS: Quantitative real-time polymerase chain reaction of bronchoalveolar lavage samples were performed for CMV, HHV-6 and -7 in a prospective cohort of lung transplant recipients. A time-dependent Cox regression analysis was used to correlate the risk of BOS and acute rejection in patients with and without beta-herpesviruses infection. RESULTS: Ninety-three patients were included in the study over a period of 3 years. A total of 581 samples from bronchoalveolar lavage were obtained. Sixty-one patients (65.6%) had at least one positive result for one of the beta-herpesviruses: 48 patients (51.6%) for CMV and 19 patients (20.4%) for both HHV-6 and -7. Median peak viral load was 3419 copies/mL for CMV, 258 copies/mL for HHV-6, and 665 copies/mL for HHV-7. Acute rejection (>or=grade 2) occurred in 46.2% and BOS (>or=stage 1) in 19.4% of the patients. In the Cox regression model the relative risk of acute rejection or BOS was not increased in patients with any beta-herpesviruses reactivation. Acute rejection was the only independently associated risk factor for BOS. CONCLUSIONS: In lung transplant recipients receiving prolonged antiviral prophylaxis, reactivation of beta-herpesviruses within the allograft was common. However, despite high viral loads in many patients, virus replication was not associated with the development of rejection or BOS.

Combining clinical factors and quantitative ultrasound improves the detection of women both at low and high risk for hip fracture.

We hypothesized that combining clinical risk factors (CRF) with the heel stiffness index (SI) measured via quantitative ultrasound (QUS) would improve the detection of women both at low and high risk for hip fracture. Categorizing women by risk score improved the specificity of detection to 42.4%, versus 33.8% using CRF alone and 38.4% using the SI alone. This combined CRF-SI score could be used wherever and whenever DXA is not readily accessible. INTRODUCTION AND HYPOTHESIS: Several strategies have been proposed to identify women at high risk for osteoporosis-related fractures; we wanted to investigate whether combining clinical risk factors (CRF) and heel QUS parameters could provide a more accurate tool to identify women at both low and high risk for hip fracture than either CRF or QUS alone. METHODS: We pooled two Caucasian cohorts, EPIDOS and SEMOF, into a large database named "EPISEM", in which 12,064 women, 70 to 100 years old, were analyzed. Amongst all the CRF available in EPISEM, we used only the ones which were statistically significant in a Cox multivariate model. Then, we constructed a risk score, by combining the QUS-derived heel stiffness index (SI) and the following seven CRF: patient age, body mass index (BMI), fracture history, fall history, diabetes history, chair-test results, and past estrogen treatment. RESULTS: Using the composite SI-CRF score, 42% of the women who did not report a hip fracture were found to be at low risk at baseline, and 57% of those who subsequently sustained a fracture were at high risk. Using the SI alone, corresponding percentages were 38% and 52%; using CRF alone, 34% and 53%. The number of subjects in the intermediate group was reduced from 5,400 (including 112 hip fractures) and 5,032 (including 111 hip fractures) to 4,549 (including 100 including fractures) for the CRF and QUS alone versus the combination score. CONCLUSIONS: Combining clinical risk factors to heel bone ultrasound appears to correctly identify more women at low risk for hip fracture than either the stiffness index or the CRF alone; it improves the detection of women both at low and high risk.

A multimodality vascular imaging phantom with fiducial markers visible in DSA, CTA, MRA, and ultrasound.

The objective was to design a vascular phantom compatible with digital subtraction angiography, computerized tomography angiography, ultrasound and magnetic resonance angiography (MRA). Fiducial markers were implanted at precise known locations in the phantom to facilitate identification and orientation of plane views from three-dimensional (3-D) reconstructed images. A vascular conduit connected to tubing at the extremities of the phantom ran through an agar-based gel filling it. A vessel wall in latex was included around the conduit to avoid diffusion of contrast agents. Using a lost-material casting technique based on a low melting point metal, geometries of pathological vessels were modeled. During the experimental testing, fiducial markers were detectable in all modalities without distortion. No leak of gadolinium through the vascular wall was observed on MRA after 5 hours. Moreover, no significant deformation of the vascular conduit was noted during the fabrication process (confirmed by microtome slicing along the vessel). The potential use of the phantom for calibration, rescaling, and fusion of 3-D images obtained from the different modalities as well as its use for the evaluation of intra- and inter-modality comparative studies of imaging systems are discussed. In conclusion, the vascular phantom can allow accurate calibration of radiological imaging devices based on x-ray, magnetic resonance and ultrasound and quantitative comparisons of the geometric accuracy of the vessel lumen obtained with each of these methods on a given well defined 3-D geometry.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

Survival after lung metastasectomy in colorectal cancer patients with previously resected liver metastases

Objective: Resection of hepatic metastases is indicated in selected Stage IV colorectal cancer (CRC) patients. A minority will eventually develop pulmonary metastases and may be candidates for lung surgery. The aim of this study was to assess clinical outcome, and identify parameters predicting survival after pulmonary metastasectomy, in patients who underwent prior resection of hepatic CRC metastases.Methods: We performed a retrospective analysis of 27 consecutive patients (median age 62 [range 33-75] years) who underwent resection of pulmonary metastases from CRC in two institutions from 1996 to 2009. All patients considered in the analysis had previously undergone colorectal and hepatic surgery with curative intent, and were considered cured in both locations (R0).Results: Median follow-up was 32 (range 3-69) months after resection of lung metastases and 65 (range 19-146) months after resection of primary CRC. Eleven (40?7%) patients had their primary tumors located in the rectum, and 12 (44%) patients presented initially with synchronous liver metastases (stage IV). Median disease-free interval between primary colorectal tumor and development of first metastasis was 6 (range 0-50) months. At the time of last follow-up, seven patients only (26%) were alive without evidence of recurrence. Three- and 5-year overall survival rates after lung surgery were 56% and 39%, respectively. Median survival after pulmonary metastasectomy was 46 months. In multivariate analysis, the number of pulmonary lesions was significantly correlated with survival (log-rank test, p = 0?035).Conclusion: Resection of lung metastases from CRC patients is compatible with prolonged (median = 4 years) survival, even when those patients had undergone prior resection of liver metastases. While prolonged, disease-free survival remains the exception, patients presentin

2012 Cancer in Iowa Report: A Focus on Lung Cancer, 2012

Cancer is a reportable disease as stated in the Iowa Administrative Code. Cancer data are collected by the State Health Registry of Iowa, located at The University of Iowa in the College of Public Health’s Department of epidemiology. The staff includes more than 50 people. Half of them, situated throughout the state, regularly visit hospitals, clinics, and medical laboratories in Iowa and neighboring states to collect cancer data. A follow-up program tracks more than 99 percent of the cancer survivors diagnosed since 1973. This program provides regular updates for follow-up and survival. The Registry maintains the confidentiality of the patients, physicians, and hospitals providing data. In 2012 data will be collected on a projected 17,500 new cancers among Iowa residents. In situ cases of bladder cancer are included in the projections for bladder cancer, to be in agreement with the definition of reportable cases of the Surveillance, Epidemiology, and End Results (SEER) Program of the NCI. Since 1973 the Iowa Registry has been funded by the SEER Program of the NCI. Iowa represents rural and Midwestern populations and provides data included in many NCI publications. Beginning in 1990 about 5-10 percent of the Registry’s annual operating budget has been provided by the state of Iowa. Beginning in 2003, the University of Iowa has also been providing cost-sharing funds. The Registry also receives funding through grants and contracts with university, state, and national researchers investigating cancer-related topics.

The value of intraoperative ultrasound in oblique corpectomy for cervical spondylotic myelopathy and ossified posterior longitudinal ligament.

Intraoperative ultrasound (IOUS) has been described to be useful during central corpectomy for compressive cervical myelopathy. This study aimed at documenting the utility of IOUS in oblique cervical corpectomy (OCC). Prospective data from 24 patients undergoing OCC for cervical spondylotic myelopathy and ossified posterior longitudinal ligament (OPLL) were collected. Patients had a preoperative cervical spine magnetic resonance (MR) image, IOUS and a postoperative cervical CT scan. Retrospective data from 16 historical controls that underwent OCC without IOUS were analysed to compare the incidence of residual compression between the two groups. IOUS identified the vertebral artery in all cases, detected residual cord compression in six (27%) and missed compression in two cases (9%). In another two cases with OPLL, IOUS was sub-optimal due to shadowing. IOUS measurement of the corpectomy width correlated well with these measurements on the postoperative CT. The extent of cord expansion noted on IOUS after decompression showed no correlation with immediate or 6-month postoperative neurological recovery. No significant difference in residual compression was noted in the retrospective and prospective groups of the study. Craniocaudal spinal cord motion was noted after the completion of the corpectomy. IOUS is an inexpensive and simple real-time imaging modality that may be used during OCC for cervical spondylotic myelopathy. It is helpful in identifying the vertebral artery and determining the trajectory of approach, however, it has limited utility in patients with OPLL due to artifacts from residual ossification.