Search

Aim: To determine the patient characteristics, referral patterns and delays in assessment and treatment of patients with primary lung cancer in South Auckland, New Zealand and compare with international standards., Methods: Retrospective review of the clinical records of 80 patients referred to a secondary care respiratory service and diagnosed with primary lung cancer in 2004., Results: Eighty-five percent of inpatient referrals and 48.5% of outpatient referrals were for advanced stage lung cancers. The median interval from receipt of outpatient referral to first chest physician assessment was 18 days, with median interval from the first chest physician assessment to bronchoscopy of 17 days and for staging CT chest of 16 days. For patients requiring a CT-guided percutaneous needle aspiration for diagnosis, there was a further median delay of 37 days after the initial CT scan. The median interval from the date of receipt of initial outpatient referral to diagnosis was 38 days, but for early stage lung cancers it was 54 days. The median interval to diagnosis for inpatient admissions was 6 days after the first respiratory assessment., Conclusion: The intervals for initial assessment, diagnosis and treatment of lung cancer in South Auckland do not meet the recommendations of international guidelines, especially for early stage lung cancers. Organisational and resource changes are required at each point in the diagnostic and management pathway to reduce delays.

Background: Although there have been desensitization protocols used for ABO-incompatible (ABOi) renal transplants, there are a lack of studied protocols. Our center developed a preconditioning protocol that involved mycophenolic acid, therapeutic plasma exchange (TPE), anti-CD20 monoclonal antibody (rituximab), and intravenous immunoglobulin (IVIG) that allowed for ABOi renal transplantation., Methods: Ten patients in our institution with end-stage renal disease who were unable to procure ABO-compatible donor kidneys underwent treatment with this protocol (which included a uniform 5 TPE sessions) prior to an ABOi renal transplant. A retrospective chart review was performed on these patients and clinical endpoints including ABO antibody titers, serum creatinine, clinical complications, and graft performance were analyzed., Results: The median ABO antibody titers at presentation, after completion of the protocol, and after transplant for the patients were 32 (range, 2-128), 8 (range, 1-64), and 4 (range, 2-32), respectively. The mean serum creatinine at study conclusion was 1.45 +/- 1.04 mg/dl at an average of 262.20 days from transplant. There were four incidents of antibody-mediated rejection (AMR) and two incidents of delayed graft function (DGF). There was one incident of graft failure and no patient deaths., Conclusions: The desensitization protocol used by our institution allowed for successful ABOi renal transplantation. Although there were incidents of AMR and DGF, the majority of the transplants resulted in viable grafts. A larger patient study group may be needed to fully evaluate the efficacy and safety of this protocol.

Hypertriglyceridemia-induced pancreatitis is a serious complication of familial dyslipidemias. Hormonal influences during pregnancy can compromise otherwise controlled lipid levels in women with familial hypertriglyceridemia and predispose to pancreatitis leading to increased morbidity in both mother and fetus. We report the successful use of therapeutic plasma exchange (TPE) in the management of hypertriglyceridemia during pregnancy resulting in avoidance of pancreatitis and delivery of a healthy term infant. Thirteen TPEs were performed from 19 to 36 weeks gestation to maintain tight control of triglyceride levels., ((c) 2009 Wiley-Liss, Inc.)

Background and Objective: It has been suggested that pulmonary embolism (PE) is an under-recognized cause of pleural effusion. This study aimed to (i) establish the incidence and clinical relevance of pleural effusion in patients with pulmonary emboli; and (ii) determine if there is a relationship between development of pleural effusions and the location of emboli and number of pulmonary arteries involved., Methods: A retrospective analysis of all CT pulmonary angiograms (CTPA) performed over 12 months on adult patients with clinically suspected PE in a hospital which used CTPA as first-line imaging investigation for PE., Results: Of 285 CTPA, 60 patients (21%) had evidence of pulmonary emboli (38 had both central and peripheral clots and 22 peripheral emboli only). Emboli were bilateral in 39 cases and unilateral in 21 cases. Pleural effusion was present in almost one half (n = 29, 48%) of the patients with pulmonary emboli. Patients with pulmonary emboli were more likely to have a pleural effusion (OR 2.2 (95% CI: 1.1-4.7), P < 0.05) than patients without PE; however, the effusions were generally very small. Most (86%) of the effusions were present on the same side as the emboli. The location of emboli and number of arteries involved did not predict the presence of pleural effusions., Conclusions: Pleural effusion is common in patients with pulmonary emboli demonstrated on CTPA. These effusions are small and seldom alter clinical management. Clinicians should therefore have a high threshold of suspicion in attributing large or contralateral pleural effusions to embolic diseases without excluding alternative diagnoses.

Purpose: To identify differences, if any, in thin-section computed tomographic (CT) features between asbestosis and idiopathic pulmonary fibrosis (IPF) and to test the findings in a subset of histopathologically proved cases of usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP)., Materials and Methods: Consecutive patients with a diagnosis of IPF (n = 212) or asbestosis (n = 74) were included. The relationships derived from the initial comparison were tested in a separate group of biopsy-proved UIP (n = 30) and NSIP (n = 23) cases. Two observers independently scored thin-section CT images for extent, distribution, and coarseness of fibrosis; proportion of ground-glass opacification; severity of traction bronchiectasis; and extent of emphysema., Results: After controlling for extent of fibrosis, patients with asbestosis had coarser fibrosis than those with IPF (odds ratio, 1.52; 95% CI: 1.25, 1.84; P <.001). Compared with the biopsy-proved cases, the asbestosis cases involved coarser fibrosis (after controlling for disease extent) than the NSIP cases (odds ratio, 2.48; 95% CI: 1.49, 4.11; P <.001) but fibrosis similar to that in the UIP cases. A basal and subpleural distribution of disease was usual in all subgroups but significantly more prevalent (P, <.01 to.001) with asbestosis than with UIP or NSIP., Conclusion: The thin-section CT pattern of asbestosis closely resembles that of biopsy-proved UIP and differs markedly from that of biopsy-proved NSIP.

Aims: To document the clinical and demographic features of cases of ethambutol ocular toxicity, to review the literature on this subject and to critically review current guidelines for ethambutol administration., Methods: Cases of ocular toxicity from ethambutol were sought retrospectively at Green Lane and Wellington Hospitals between 1992 and 1995. The records of cases identified were examined., Results: Four subjects with tuberculosis developed ocular toxicity 2 1/2, 7 1/2, 8 and 12 months after starting ethambutol. Normal visual acuity returned in three cases; one patient has severe, permanent visual impairment. Language difficulties were present in three subjects., Conclusions: Impaired communication was potentially very important in this series. Special care is needed in educating patients about ethambutol. We propose additional recommendations: 1. the usual daily dose of ethambutol should be 15 mg/kg/day, not 25 mg/kg/day; using 25 mg/kg/day (or lesser doses in the presence of renal impairment) should prompt regular formal ophthalmological evaluation (e.g. monthly) in cases with comprehension or communication difficulties; 3. both ethambutol and isoniazid should be stopped immediately if severe optic neuritis occurs. Isoniazid should be stopped if less severe optic neuritis does not improve within six weeks after stopping ethambutol.

Aims: (a) To assess the mode of referral and the demographic and clinical characteristics of patients prescribed oxygen between 1 January and 31 December 1994. (b) To assess whether international guidelines for prescribing oxygen were adhered to. (c) To assess the rate and pattern of prescription of oxygen in Auckland compared with other developed countries, and (d) based on these findings, to ascertain whether changes need to be made to our practise., Method: Notes of all patients referred to the oxygen service in 1994 were reviewed., Results: The oxygen service received 304 referrals in 1994 and 196 (including 23 infants), were commenced on long-term oxygen therapy. The primary diagnosis was chronic obstructive pulmonary disease (COPD) in 90 (52%), other chronic respiratory diseases 25 (14%) and terminal malignancy in 48(28%). Of the 173 adult patients prescribed oxygen 79% of patients were referred as a result of hospital admission. Thirty three percent of chronic obstructive pulmonary disease patients died within 6 months of receiving domiciliary oxygen which is higher than any previously published report. Mortality rates were no different between patients with chronic obstructive pulmonary disease and other respiratory disorders., Conclusions: International guidelines for oxygen therapy were generally adhered to in Auckland though improvements could be made to ensure better quality information on referral and by use of blood gas analysis rather than oximetry. Fewer chronic obstructive pulmonary disease patients are receiving oxygen therapy in Auckland than expected and it is often prescribed late and as a result of hospital admission. Closer adherence to more recently published international guidelines and better targeting of patients with respiratory failure will impose a greater financial burden on the oxygen service, but may result in improved survival and reduced need of hospital admission. These findings have important resource implications, for oxygen services in New Zealand if they are to comply with International Guidelines for Domiciliary Oxygen Therapy.

A technique for the extraperitoneal removal of the adrenal gland using laparoscopic instrumentation and insufflation is described. A case of Cushing's syndrome in a 42 year old female is presented with successful removal of her adrenal tumour using the laparoscopic method. This is the first report of laparoscopic adrenalectomy employing the extraperitoneal approach.