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The role of lung volume reduction surgery (LVRS) for individuals with alpha-1 antitrypsin (AAT) deficiency is unclear.To assess the role of LVRS in individuals with severe deficiency of AAT, outcomes within the National Emphysema Treatment Trial were analyzed.Of 1218 randomized subjects, 16 (1.3%) had severe AAT deficiency (serum level80 mg/dL) and a consistent phenotype (when available). Characteristics of these 16 patients include 87.5% male; median serum AAT level, 55.5 mg/dL; age, 66 years; forced expiratory volume in 1 second (FEV1), 27% predicted; and 50% had upper-lobe-predominant emphysema. All 10 subjects randomized to LVRS underwent the procedure. Although the small number of subjects hampered statistical analysis, 2-year mortality was higher with surgery (20% versus 0%) than with medical treatment. Comparison of outcomes between the 10 AAT-deficient and the 554 AAT-replete subjects undergoing LVRS showed a greater increase in exercise capacity at 6 months in replete subjects and a trend toward lower and shorter duration FEV1 rise in deficient individuals.This study extends to 49 cases the published experience of LVRS in severe AAT deficiency. Although the small number of subjects precludes firm conclusions, trends of lower magnitude and duration of FEV1 rise after surgery in AAT-deficient versus AAT-replete subjects and higher mortality in deficient individuals randomized to surgery versus medical treatment suggest caution in recommending LVRS in AAT deficiency.

Context.—The World Health Organization classification recommends categorizing grade 3 follicular lymphomas based on the presence of centrocytes (grade 3A) or of sheets of centroblasts (grade 3B). The clinical significance of this practice is not known. Objective.—To determine whether grade 3 follicular lymphoma subtype is associated with prognosis. Design.—Multi-institutional retrospective case series. Main Outcome Measure.—Overall survival. Results.—Forty-five cases of grade 3 follicular lymphoma without diffuse large B-cell lymphoma were studied (35 cases of grade 3A, 10 cases of grade 3B) from 21 men and 24 women (median age, 67 years; mean age, 63.8 years; range, 26–86 years). Follow-up information from the time of diagnosis was available in all patients, with a median follow-up time of 24 months (mean, 34 months; range, 2– 115 months). Treatment information was available in 40 patients. There was no difference in age (P = .45, Wilcoxon test) or stage (P = .76, Fisher exact test) between patients with follicular lymphoma of grade 3A or grade 3B. Furthermore, the Cochran-Armitage test for trends showed no evidence that the proportion of patients with follicular lymphoma grade 3A or 3B increased or decreased with increasing stage at presentation. Kaplan-Meier analysis showed a median overall survival of 44 months from the time grade 3 follicular lymphoma was diagnosed, with no significant difference between cases diagnosed as grade 3A or grade 3B (P = .14, log-rank test). Univariable Cox proportional hazards modeling showed no evidence that an anthracycline-containing chemotherapy regimen or history of lower grade follicular lymphoma affected overall survival. Conclusions.—In this retrospective series, subclassification of grade 3 follicular lymphoma into type 3A and 3B categories had limited clinical and prognostic significance. However, the study was limited by lack of statistical power. Since morphology often provides clues for progress in defining biologic differences, subtyping may still be useful, particularly in the setting of prospective clinical studies.

Rhabdoid differentiation has been associated with aggressive behavior in carcinomas from different organ systems. A recent consensus statement of the International Society of Urological Pathology (ISUP), in addition to proposing a nucleolar grading system (ISUP grade) for renal cell carcinoma (RCC) to replace the Fuhrman system, recommended reporting the presence of rhabdoid differentiation in RCC and considering tumors with rhabdoid differentiation to be ISUP grade 4. Although it has been shown that rhabdoid differentiation is associated with increased grade and stage of RCC, it has not been fully demonstrated whether it has an adverse effect independent of this association with increased grade and stage. We provide the largest clinicopathologic analysis of RCC with rhabdoid differentiation to date (76 cases), including characterization of metastatic disease. In addition, by constructing a multivariable model including tumor grade, stage, necrosis, and distant metastasis to compare a series of 49 clear cell RCC with rhabdoid differentiation with a cohort of 41 clear cell RCCs without rhabdoid differentiation, we demonstrate that the presence of rhabdoid differentiation in clear cell RCC confers an increased risk of death (hazard ratio=5.25; 95% confidence interval, 2.1-14.3) independent of these other adverse prognostic factors. These findings underscore the significance of rhabdoid differentiation in RCC as an adverse prognostic factor and support the recent reporting and grading recommendations of the ISUP.

Mathematical models have been used to describe the factors that affect cell salvage (CS) and normovolemic hemodilution (ANH). Here, the CS and ANH models were used to compare these two techniques alone or in combination with each other.Variables used for a hypothetical patient included an estimated blood volume of 5000 mL, a presurgery hematocrit (Hct) of 45 percent, and a transfusion trigger of 21 percent. The model accounts for both the effect of decreasing the Hct due to blood loss and the effect of increasing Hct due to the readministration of blood in an isovolemic patient. The efficacy of CS and ANH is defined to be the maximum allowable blood loss for a fixed blood volume and a fixed transfusion trigger.Comparison of CS with ANH showed that 3 units of ANH was comparable to CS when CS recovery rates ranged from 19 to 24 percent. For a patient with a blood volume of 5000 mL and a starting Hct of 40 percent, 3 units of ANH would allow for 3972 mL of blood to be lost before crossing a 21-percent transfusion trigger, whereas CS with a 125-mL bowl would allow for 7611 mL.When comparing ANH to CS, this mathematical model would suggest that CS has the potential to offer significantly greater red blood cell avoidance than does ANH; however, the combination of ANH with CS may offer allogeneic avoidance superior to either technique alone.

An earlier randomized, controlled trial showed that weekly or as-needed (as opposed to daily) changes of in-line suction catheters were associated with substantial cost savings, without a higher rate of ventilator-associated pneumonia (VAP). To examine the impact of decreasing the frequency of in-line suction catheter changes in our medical intensive care unit, we conducted an observational study, comparing the catheter costs and frequency of VAP during (1) a control period, during which in-line suction catheters were changed daily, and (2) a treatment period, during which the catheters were changed every 7 days or sooner if needed, for mechanical failure or soilage.All adult patients admitted to our 18-bed medical intensive care unit were evaluated for the 3-month interval 1 year prior to the practice change (May through July 1998) and for the 3 months after implementing the new policy (May through July 1999). To avoid bias related to usual seasonal variation in VAP frequency, we also determined (via medical records) the VAP rate during May through July 1997. The occurrence of VAP was ascertained by an infection control practitioner, using criteria established by the Centers for Disease Control and applied in a standard fashion. The VAP rate was calculated as the mean number of VAPs per 100 ventilator-days for each 3-month interval. Use of ventilators, humidifiers, and non-heated-wire, disposable circuits was uniform during the study, as were policies regarding humidity, temperature settings, and frequency of routine ventilator circuit changes.During the control period 146 patients accounted for 1,075 ventilator-days and there were 2 VAPs (0.19 VAPs per 100 ventilator-days). During the treatment period 143 patients accounted for 1,167 ventilator-days and there were no VAPs. The mean +/- SD duration of in-line suction catheter use during the treatment period was 3.8 +/- 0.8 days, and 51% of the patients had the same catheter in place for3 days (range 4-9 days). The actual cost of catheters used during the treatment period was lower than during the control period ($1,330 vs $6,026), predicting annual catheter cost savings of $18,782.We conclude that (1) a policy of weekly (vs daily) change of in-line suction catheter is associated with substantial cost savings, with no significant increase in the frequency of VAP, and (2) to the extent that these findings confirm the results of prior studies they support a policy of changing in-line suction catheters weekly rather than daily.