Biomedical subjects
Publications and source records attributed to L Spratling.
Intraluminal radiation for the local control of bronchogenic carcinoma has recently undergone rapid technological progress. Remote afterloading of high intensity radiation sources into endoscopically placed multiple small catheters with computerized optimization of dosimetry is the state-of-the-art. Fractionated high dose rate (HDR) outpatient treatment has been shown to reduce airway obstruction and improve performance status and quality of life.
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PURPOSE: The study was designed to, (a) standardize endobronchial brachytherapy and, (b) to evaluate the relief of obstructive signs and symptoms. METHODS: Patients with endobronchial carcinoma were treated on a protocol (n = 342) with remote afterloading brachytherapy. Group 1 patients were treated with medium dose rate and received 1000 cGy at 5 mm depth for three fractions (n = 47). Group 2 were treated with high dose rate, 1000 cGy to a 10 mm depth for three fractions (n = 144) and Group 3 received 750 cGy delivered to a 10 mm depth for three fractions (n = 151). Each group was divided into curative, palliative, and recurrent categories. Neodymium yttrium aluminum garnet photoresection was used in 24% of patients prior to brachytherapy. RESULTS: Evaluation consisted of symptom index scoring with weighted responses of hemoptysis 99%, obstructive pneumonia 99%, cough 85%, and dyspnea 86%. Obstruction improvement was 80% overall, curative 87%, palliative 84%, and recurrent 70% of mean pretreatment scores. Survival 10% alive, 88% expired, and 2% lost to follow-up. Cause of death was intrathoracic carcinoma 41%, metastatic carcinoma 38%, intercurrent disease 9%, and unknown cause 13%. Survival from diagnosis and first treatment was, respectively, for curative 10.8 and 9.5 months, palliative 14 and 5.6 months, and recurrent 25.6 and 6.2 months. Significant complications were fatal hemoptysis 7%, and radiation bronchitis and stenosis 11%. CONCLUSION: Endoluminal brachytherapy provides excellent palliation of the endobronchial portion of neoplastic disease.
PURPOSE: To describe a new clinical entity observed in follow-up bronchoscopies in patients who were treated with high dose rate and medium dose rate remote afterloading brachytherapy of the tracheobronchial tree. METHODS AND MATERIALS: Patients treated by protocol with medium dose rate, 47 patients receiving 1000 cGy at a 5 mm depth times three fractions, high dose rate 144 patients receiving 1000 cGy at a 10 mm depth for three fractions and high dose rate 151 patients receiving 750 cGy at a 10 mm depth for three fractions followed by bronchoscopy. RESULTS: Incidence of this entity was 9% for the first group, 12% for the second, and 13% for the third group. Reactions were grade 1 consisting of mild mucosal inflammatory response with a partial whitish circumferential membrane in an asymptomatic patient; grade 2, thicker complete white circumferential membrane with cough and/or obstructive problems requiring intervention; grade 3, severe inflammatory response with marked membranous exudate and mild fibrotic reaction; and grade 4 a predominant fibrotic reaction with progressive stenosis. Variables associated with a slightly increased incidence of radiation bronchitis and stenosis included: large cell carcinoma histology, curative intent, prior laser photoresection, and/or concurrent external radiation. Survival was the strongest predictor of the reaction. CONCLUSION: Radiation bronchitis and stenosis is a new clinical entity that must be identified in the bronchial brachytherapy patients and treated appropriately.
Forty-five patients with symptomatic proximal malignant airway disease received 128 intraluminal intermediate dose rate (IDR) brachytherapy treatments by remote afterloading technique. Multiple small catheters were bronchoscopically placed. Iridium-192 sources delivering an intermediate dose rate (200-1000 rads/hr) were guided under remote computer control. Treatment times were 1-4 hr. Fourteen of these patients also received YAG laser photoresection. External beam radiation was also given (6000 rads) to 16 patients for curative intent and (3000 rads) to 9 patients for palliative intent. Twenty recurrent disease patients were also treated, but they did not receive external irradiation. An obstruction score (OS) was developed in an attempt to quantitate the improvement in intraluminal narrowing. Patients treated with curative intent showed 66% improvement after initial therapy. Initial therapy for palliative patients showed an 84% improvement and for recurrent disease patients, 64% of luminal narrowing was seen. Patients who received laser in addition to brachytherapy showed a 70% reduction. A 67% improvement was seen in those who did not receive laser therapy. The entire group averaged a 69% improvement of narrowing. Four complications, three minor, (1 bronchospasm, and 2 episodes of transient intratreatment increased ventricular irritability) and one major (pneumothorax) were noted. The relatively short treatment times allowed most of the treatments to be performed on an outpatient basis and were well-tolerated by the patients. Forty-four of the 45 patients experienced significant symptomatic improvement. The remote afterloading technique allowed improved radiation protection for personnel.
Forty-four patients with newly discovered biopsy-proven pulmonary sarcoidosis in roentgenographic stage II (adenopathy and interstitial abnormalities) who also had abnormal pulmonary function (TLC and/or DCO less than 80 percent predicted) were assigned in alternate sequence to either a daily or alternate day prednisone treatment protocol. Both groups showed statistically significant improvement in pulmonary function (TLC, FVC, FEV1, DCO) at three or six months, but there were no significant differences between the two groups. Radiographic adenopathy and interstitial scores (interpreted by blinded readers in random sequence according to a quantitative scale) also showed significant improvement in both groups at three or six months, and again no significant difference was noted between the two groups. Thus, both daily and alternate day prednisone regimens were effective therapy for stage II sarcoidosis. Alternate day therapy may be the treatment of choice for those patients at high risk for significant adverse steroid effects.
Current understanding of exercise and sleep in normal and pathophysiologic states is outlined. Clinical laboratory techniques used in the evaluation of these disorders are presented and discussed.
Progressive respiratory failure due to massive endobronchial involvement causes death in some patients with bronchogenic carcinoma. The absence of satisfactory therapeutic modalities directed specifically at masses of endobronchial tumor has limited our ability to effectively palliate these patients. Electro-cautery is a technique which has the potential for removing large quantities of endobronchial tumor safely, painlessly , and without measurable blood loss. It is especially well suited to the patient requiring local palliation with immediate relief of airway obstruction and without a prolonged hospital stay. The report reviews: a) its use in an individual with tracheal obstruction; b) the effect of electrocautery current changes and probe type on canine trachea; and, c) the technical problems which must be considered in using endobronchial electrocautery. In the individual with tracheal obstruction, large amounts of tumor were cleared with excellent hemostasis. The canine trachea demonstrates that the amount and duration of current used are extremely important. Equipment available of gastrointestinal electrocautery can produce significant tracheal damage and must be used with great caution. Finally, fiberoptic bronchoscopes are not designed for electrocautery work, and care must be employed when performing such procedures through these instruments.
Hematogenous dissemination to the brain occurs frequently with bronchogenic carcinoma ( BGCA ). Advocates of computed tomographic (CT) scanning have proposed the use of CT scanning of the brain as a screening procedure to exclude metastasis. To establish CT's appropriate role, we have retrospectively reviewed patients who had CT scanning of the brain during the initial staging and evaluation of BGCA . Clinical factors indicative of metastatic disease, both organ-specific and nonorgan -specific, were extracted from the history, physical, and laboratory data. Eighty-nine patients were studied. Sixteen patients had abnormal CT scans of the brain (18 percent). Only nine of the 16 had evidence of central nervous system (CNS) disease on history or physical examination. All 16 patients had strong clinical indications of disseminated disease. With completely normal clinical examinations, no abnormal CT scans were identified. Among patients with three or more clinical abnormalities present, an abnormal CT scan occurred in 37.5 percent (12 of 32). The clinical examination is a sensitive indicator of metastatic CNS disease as identified by the CT scan. Both organ-specific and nonorgan -specific findings are important indicators of CNS metastatis .
Five members of a new family with hemoglobin Osler are described. Exercise studies were performed before and after phlebotomy in one patient. These studies demonstrated that anaerobic threshold was directly related to hematocrit. Our data suggest that the elevation of red cell mass seen with this high oxygen affinity hemoglobin is an appropriate physiologic response which improves tissue oxygen delivery. Despite the increase in whole blood viscosity associated with erythrocytosis, our data do not support the use of therapeutic phlebotomy to improve exercise performance in patients with hemoglobin Osler.
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