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Introduction: Atypical atrial flutter (aAFL) has been described in the absence of prior atrial interventions, but prognosis for these patients after catheter ablation is poorly defined. This study was designed to define characteristics and ablation outcomes in patients with de novo aAFL. Methods: Patients with non-CTI flutter, without prior ablation or cardiac surgery, were identified from an institutional database. Clinical, mapping, ablation, and follow up data were compared to an equally sized group of randomly selected patients with typical flutter (tAFL). Results: The 35 patients with aAFL had 45 mapped non-CTI flutters. aAFL patients had similar age, gender, cardiovascular comorbidities, and LA size compared to tAFL, except aAFL patients had higher LVEF (54 ± 12 vs 46 ± 19%, p=0.04). Cycle length of aAFL was longer (268 [IQR 231, 310] vs 230 [220, 250] msec, p=0.0006). aAFL localized to the RA in 16, LA in 28, and biatrial in 1. Mechanisms were macroreentry in 23 (8 RA, 15 LA) and localized reentry in 22 (8 RA, 14 LA). Areas of scar predominated in the lateral/posterior RA (N=9), anterior LA (N=14), and posterior LA (N=6). Most common LA circuits were perimitral reentry (N=8) and roof dependent (N=8), including dual loop reentry. Localized reentry occurred most commonly in the anterior LA (N=7) or involved the pulmonary veins (N=4). Ablation was acutely successful for 41/45 aAFLs (91%) and for all tAFL. After median follow-up of 33 [6.6, 55] mo, atrial arrhythmias recurred in 23/34 aAFL patients (68%) and 24/35 tAFL patients (69%); those with aAFL had earlier recurrences (1.9 [0.43, 11] vs 19 [2.3, 36] mo, p=0.01). First recurrences after aAFL ablation were more likely to be AFL rather than AF (83% vs 17%) whereas tAFL patients were more likely to recur with AF (24% AFL vs 76% AF, p Conclusions: Patients with de novo aAFL tend to have spontaneous scar, commonly in the lateral/posterior RA and anterior LA, consistent with an atrial myopathy. Ablation can be accomplished with high acute success, but recurrent atrial arrhythmias are common, most re-presenting with atrial tachycardias. Future studies should clarify if a substrate-based approach or adjunctive antiarrhythmic drugs would result in better long term outcomes.

The study objective was to determine the relationship between lung resection and the development of postoperative hiatal hernia.Preoperative and postoperative computed tomography imaging from 373 patients from the International Early Lung Cancer Action Program and the Initiative for Early Lung Cancer Research on Treatment were compared at a median of 31.1 months of follow-up after resection of clinical early-stage non-small cell lung cancer. Incidence of new hiatal hernia or changes to preexisting hernias were recorded and evaluated by patient demographics, surgical approach, extent of resection, and resection site.New hiatal hernias were seen in 9.6% of patients after lung resection (5.6% after wedge or segmentectomy and 12.4% after lobectomy;Both open and minimally invasive lung resection for clinical early-stage lung cancer are associated with new or enlarging postoperative hiatal hernia, especially after resections involving the left lower lobe.

Purpose Chronic Obstructive Pulmonary Disease (COPD) includes chronic bronchitis, small airways disease, and emphysema. Diagnosis of COPD requires spirometric evidence and may be normal even when small airways disease or emphysema is present. Emphysema increases the risk of exacerbations, and is associated with all-cause mortality and increased risk of lung cancer. We evaluated the prevalence of emphysema in participants with and without a prior history of COPD. Methods We reviewed a prospective cohort of 52,726 subjects who underwent baseline low dose CT screening for lung cancer from 2003 to 2016 in the International Early Lung Cancer Action Program. Results Of 52,726 participants, 23.8%(12,542) had CT evidence of emphysema. Of these 12,542 participants with emphysema, 76.5%(9595/12,542) had no prior COPD diagnosis even though 23.6% (2258/9595) had moderate or severe emphysema. Among 12,542 participants, significant predictors of no prior COPD diagnosis were: male (OR = 1.47, p Conclusion Emphysema was identified in 23.8% participants undergoing LDCT and was unsuspected in 76.5%. LDCT provides an opportunity to identify emphysema, and recommend smoking cessation.

Asbestos exposure is the most important cause of occupational lung cancer mortality. Two large randomized clinical trials in the U.S. and Europe conclusively demonstrate that annual low-dose chest CT (LDCT) scan screening reduces lung cancer mortality. Age and smoking are the chief risk factors tested in LDCT studies, but numerous risk prediction models that incorporate additional lung cancer risk factors have shown excellent performance. The studies of LDCT in asbestos-exposed populations shows favorable results but are variable in design and limited in size and generalizability. Outstanding questions include how to: (1) identify workers appropriate for screening, (2) organize screening programs, (3) inform and motivate people to screen, and (4) incorporate asbestos exposure into LDCT decision-making in clinical practice. Conclusion: Screening workers aged ≥50 years with a history of ≥5 years asbestos exposure (or fewer years given intense exposure) in combination with either (a) a history of smoking at least 10 pack-years with no limit on time since quitting, or (b) a history of asbestos-related fibrosis, chronic lung disease, family history of lung cancer, personal history of cancer, or exposure to multiple workplace lung carcinogens is a reasonable approach to LDCT eligibility, given current knowledge. The promotion of LDCT-based screening among asbestos-exposed workers is an urgent priority.

To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter.Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (≤10 mm, 11-20 mm, and 21-30 mm) and nodule consistency. Log-rank test statistics were calculated.The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] =1.07, 95% confidence interval [CI]: 1.01-1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25-7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35-75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01-5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01-1.13), whereas PAI was no longer significant (p = 0.19).Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules.

BACKGROUND One of the goals of a noninvasive test for bladder carcinoma screening would be to reduce surveillance cystoscopies among patients with a history of bladder carcinoma. In addition, an accurate bladder carcinoma marker could be used to screen a high-risk population. The authors examined the efficacy of the hyaluronic acid–hyaluronidase (HA-HAase) and BTA-Stat tests to detect and predict bladder carcinoma recurrence and tested their specificity for bladder carcinoma screening. METHODS Over a four year period, the authors prospectively collected 225 urine specimens from 70 bladder carcinoma patients and analyzed them by the HA-HAase test. Tumors were identified during 178 visits, and in 47 specimens there was no evidence of disease (NED). Twenty six of these 70 patients were randomly selected to have the BTA-Stat test (111 surveillance visits). In a separate study, 401 former Department of Energy (DOE) workers, who are likely to be at a higher risk for bladder carcinoma, were screened by the HA-HAase and BTA-Stat urine tests. RESULTS The HA-HAase test had an approximately 91.0% sensitivity, 70% specificity, 87% accuracy, 92% positive predictive value (PPV), and 67% negative predictive value (NPV) in the 70 bladder carcinoma patients. There were 14 false-positives; however, 6 of these had recurred in approximately 5 months. Only 4 out of 33 NED cases recurred in that time period (chi-square = 5.43; degrees of freedom [DF] = 1; P = 0.0198). Thus, a false-positive HA-HAase test carried a significant risk of recurrence within five months (relative risk [RR] = 3.5; odds ratio [OR] = 5.44). In a direct comparison, the HA-HAase and BTA-Stat had 94% and 61% sensitivity, 63% and 74% specificity, 87% and 64% accuracy, 89% and 88% PPV, and 77% and 38% NPV, respectively. While 6 of the 10 false-positive on the HA-HAase test recurred in 5 months (chi-square = 9.6; DF = 1; P = 0.004), only 1 of the 7 false-positives on the BTA-Stat test recurred in that time period (chi-square = 0.096; DF = 1; P = 0.756). The RR and OR for the HA-HAase test were 10.2 and 24, and for the BTA-Stat, 1.4 and 1.5, respectively. In the DOE worker screening study, the HA-HAase and BTA-Stat had 14% (56 out of 401) and 16.7% (67 out of 401) positive rates, respectively. Sixty three percent of the positives on the BTA-Stat test, but only 25% of the positives on the HA-HAase test, had benign urologic conditions. None of the biomarker positive cases with clinical follow-up (n = 29) had evidence of bladder carcinoma. CONCLUSIONS The HA-HAase test is efficient and superior to the BTA-Stat for detecting and predicting bladder carcinoma recurrence. Noninvasive tests with low false positive rates could be used for bladder carcinoma screening in high-risk populations (e.g., those with occupational exposure to carcinogens or smokers). Cancer 2002;95:61–72. © 2002 American Cancer Society. DOI 10.1002/cncr.10652

A cross section study was carried out in a farming community from Nova Friburgo, Rio de Janeiro state, Brazil, to examine epidemiological, clinical and laboratory aspects of multiple exposure to pesticides in a representative sample of 102 small farmers. Both males and females were submitted to an extensive protocol which included an occupation questionnaire, biological sample collection for toxicology analysis and clinical - general and neurological - evaluation. The toxicology test results showed light to moderate episodes of acute intoxication by organophosphorates either described by the farmers or observed during clinical examination. Thirteen cases of delayed neuropathies (12,8%) as well as 29 cases of neural behavioral syndromes and psychiatric disorders associated to the continued use of pesticides were diagnosed. These results indicate recurrent multiple overexposures to high concentrations of different chemicals, with serious damage to vital functions, especially considering their young age (average 35 +/- 11 years old) and the productive period in their lifetime. These results show how important it is to monitor multiple exposure to pesticides - a chain of events that may have major impacts on public health and the environment.

As the debate over health care reform continues, costs have become a critical measure in the many plans and proposals to come before us. Knowing costs is important because it allows comparisons across such disparate health conditions as AIDS, Alzheimer's disease, heart disease, and cancer. This book presents the results of a major study estimating the large and largely overlooked costs of occupational injury and illness--costs as large as those for cancer and over four times the costs of AIDS.The incidence and mortality of occupational injury and illness were assessed by reviewing data from national surveys and applied an attributable-risk-proportion method. Costs were assessed using the human capital method that decomposes costs into direct categories such as medical costs and insurance administration expenses, as well as indirect categories such as lost earnings and lost fringe benefits. The total is estimated to be $155 billion and is likely to be low as it does not include costs associated with pain and suffering or of home care provided by family members.Invaluable as an aid in the analysis of policy issues, "Costs of Occupational Injury" "and Illness" will serve as a resource and reference for economists, policy analysts, public health researchers, insurance administrators, labor unions and labor lawyers, benefits managers, and environmental scientists, among others.J. Paul Leigh is Professor in the School of Medicine, Department of Epidemiology and Preventive Medicine, University of California, Davis. Stephen Markowitz, M.D., is Professor in the Department of Community Health and Social Medicine, City University of New York Medical School. Marianne Fahs is Director of the Health Policy Research Center, Milano Graduate School of Management and Urban Policy, New School University. Philip Landrigan, M.D., is Wise Professor and Chair of the Department of Community Medicine, Mount Sinai Medical Center, New York.

The lead content of air, house dust, dirt, dirt on hands, food, and water was investigated in order to ascertain the cause of the chronically elevated blood lead levels in ten 2–6 year old Hartford children. Recent ingestion of leaded paint had been eliminated as a significant factor. The mean ambient air levels at 2 and 5 ft. from the ground where the children played varied from 1.7–7 μg/m3. On the basis of “mouthing” behavior observed among the ten subject children, the mean lead levels in dirt (1200) μg/g) and dust (11,000 μg/g) and the mean lead concentration of lead on hands (2400) μg/g), it is likely that the “hands in mouth” exposure route is the principal cause of the excessive lead accumulation in these children.