Hospitalist Perceptions of Barriers to Lung Ultrasound Adoption in Diverse Hospital Environments

Despite the many advantages of lung ultrasound (LUS) in the diagnosis and management of patients with dyspnea, its adoption among hospitalists has been slow. We performed semi-structured interviews of hospitals from four diverse health systems in the United States to understand determinants of adoption within a range of clinical settings. We used the diffusion of innovation theory to guide a framework analysis of the data. Of the 27 hospitalists invited, we performed 22 interviews from four hospitals of diverse types. Median years post-residency of interviewees was 10.5 [IQR:5-15]. Four main themes emerged: (1) There are important clinical advantages to LUS despite operator dependence, (2) LUS enhances patient and clinician experience, (3) Investment of clinician time to learn and perform LUS is a barrier to adoption but yields improved efficiency for the health system and (4) Mandated training and use may be necessary to achieve broad adoption as monetary incentives are less effective. Despite the perceived benefits of LUS for patients, clinicians and health systems, a significant barrier to broad LUS adoption is the experience of time scarcity by hospitalists. Future implementation strategies should focus on changes to the clinical environment that address clinician barriers to learning and adoption of new skills.

[Bilateral auditory canal squamous cell carcinoma]

Only a small number of cases of bilateral carcinomas of the external ear canal have been described in the literature. We present the first case of a 72 year old male patient with a bilateral squamous cell carcinoma of the external ear canal at a very early stage. A computed tomography of the temporal bone revealed a well-pneumatized mastoid on both sides. Both external ear canals were filled with soft tissue without radiological signs of destruction of the adjacent bone. The carcinomas of the external ear canal were surgically removed using a canal-wall down technique and a selective neck dissection of regions II-IV. Histology confirmed a well differentiated squamous cell carcinoma of the external ear canal without lymph node metastasis on both sides (TNM classification: pT1 G2 N0 M0 R0). Bilateral radiation therapy with 59.4 Gy resulted in stenosis of both ear canals. Hearing rehabilitation was achieved with bone conductive hearing glasses. Diagnosis und therapy of bilateral external ear carcinomas are presented and discussed.

Gallbladder metastasis of non-small cell lung cancer

BACKGROUND

Although non-small cell lung cancer is known for its potency to spread to almost any organ of the body, metastasis to the gallbladder with significant clinical manifestation is rarely reported in the literature.

CASE REPORT

We report the case of a 45-year-old man with non-small cell lung cancer (NSCLC), who developed symptoms of acute cholecystitis caused by a metastasis of the gallbladder wall. Histological examination showed tumor cell invasion in regional gallbladder lymph nodes. A second primary tumor of the gallbladder was excluded by immunohistochemical methods.

CONCLUSION

Our experience showed that acute cholecystitis can occur in association with metastases of lung cancer to the gallbladder.

Assessment of satisfaction with the communication process during consultation of cancer patients with potentially curable disease, cancer patients on palliative care, and HIV-positive patients

The aim of this study was to evaluate the attitudes of cancer patients towards the medical interview and to determine their psychosocial satisfaction subsequent to the dialogue. The answers given by patients with curable cancer were compared to those given by cancer patients whose treatment intent was palliative and to the replies of patients infected with the human immunodeficiency virus (HIV), a nonmalignant but also incurable state. The subject population comprised a total of 139 patients. Patients had to complete a questionnaire with a total of 34 items. The answers to the questions were rated on a 5-point scale with response options ranging from 1 to 5 or consisting of true-false statements. Cancer patients, palliative and curative, and HIV-positive patients considered their physicians to be honest (x = 4.34, x = 4.58, and x = 4.30, respectively; p = 0.104), and they emphasized that he/she took enough time answering their questions (x = 4.00, x = 4.30 and x = 4391, respectively; p = 0.12). Cancer patients treated with potentially curable disease were more frequently afraid of being informed about additional diagnostic examinations and about the disclosure of results as compared to cancer patients on palliative care (p < 0.05 for both questions). Patients with HIV-infection considered themselves less informed about the treatment they received as compared to curative cancer patients (x = 3.73 and x = 4.28, respectively; p < 0.046). Only 8.0% of the tumor patients on palliative care, but 63.6% of the HIV-positive patients realized that their medication was given with the objective to relieve symptoms (p < 0.001). When asked about additional goals of treatment, 48% of the palliative cancer patients and 15.1% of the HIV-positive patients checked "cure" (p < 0.002). In conclusion, particularly patients with curable cancer were afraid of information they might receive during the medical interview. Cancer patients considered themselves better informed compared to patients with HIV-infection. This is in significant contrast with the actual, measurable knowledge about their disease in the latter group. It is indeed surprising that only a small minority of incurable cancer patients realized that the goal of the medical care they received was relief of symptoms, the principle objective of palliation.

[Radiation protection through cytokine release by N-acetylcysteine]

BACKGROUND

Interleukin-1, tumornecrosisfactor-alpha and interferon-gamma endogenously provide protection of the hematopoietic system against radiation. Thiols have already been used successfully as radioprotective agents. In this study the effect von N-acetylcysteine (NAC) on the release of interleukin-1 alpha and beta (IL-1), interleukin-2 (IL-2), interferon-gamma (IFN-gamma) and tumornecrosisfactor-alpha (TNF-alpha) was assessed in an in vitro assay.

PATIENTS AND METHODS

Whole blood samples from 8 healthy volunteers were stimulated with 7.5 micrograms/ml PHA. NAC was added at concentrations of 0.6, 6, 12 and 24 mmol/l. Subsequently the samples were irradiated with a dose of 18 Gy according to preceding validation experiments.

RESULTS

IL-1 alpha, IL-1 beta b and IL-2: In comparison to stimulation and radiation alone the addition of 0.6 and 6 mmol/l, with IL-2 also 12 mmol/l, NAC resulted in a significant increase of the cytokine-concentrations. The highest concentration of 24 mmol/l NAC, however, resulted in a decrease beyond control levels. IFN-gamma and TNF-alpha: Until 12 mmol/l NAC no changes were observed. 24 mmol/l NAC resulted in a significant decrease, too.

CONCLUSION

N-acetylcysteine is capable to co-stimulate radioprotective cytokines like IL-1 alpha and IL-1 beta and to enhance IL-2 in vitro, whereas higher doses result in a suppression.

[Incidence of lung embolism before and after thrombectomy of deep leg and pelvic vein thrombosis]

According to scintigraphic and pathological studies, pelvic and thigh venous thrombosis led to pulmonary embolism in 50-60% of all cases. After thrombectomy, an incidence of 1% is reported, when assessed only clinically. In 29 patients with acute pelvic or thigh venous thrombosis, perfusion scintigraphic lung scans were performed immediately before operation and on day 1 or day 2 postoperatively. In 7 patients (24.1%) preoperatively and 12 patients (41.4%) postoperatively, segmental perfusion defects indicating pulmonary embolism were demonstrated. Thus the incidence of pulmonary embolism according to thrombectomy is much higher than previously suspected.

[Cytotoxicity of lipid ether ilmofosine in combination with radiotherapy in vitro]

Alkyllysophospholipids (ALP) represent a new class of cytotoxic agents. The cytotoxic potential was demonstrated by in vivo and in vitro models. In this study the interaction of the ALP Ilmofosine in combination with radiotherapy was tested in vitro using the colony forming assay. The cell lines B-16, K-562 and Meth-A were used as targets. The cell lines showed similar sensitivity to radiation therapy. The B-16 cell line proved to be resistant to Ilmofosine; the K-562 cell line showed little sensitivity whereas the Meth-A cell line was very sensitive to Ilmofosine. In the K-562 and Meth-A cell lines that were sensitive to both agents a clear addition of both effects was observed. In the case of the B-16 cell line in combination no effect was seen exceeding the pure radiation effect. No synergistic and no antagonistic effect was observed.

Clinical evaluation, ultrasound, cholescintigraphy, and endoscopic retrograde cholangiography in cholestasis. A prospective comparative clinical study

The accuracy of clinical evaluation (CE), ultrasonography (US), and cholescintigraphy (CS) was prospectively compared in a group of 72 cholestatic patients, using the results of endoscopic retrograde cholangiography (ERC) as the true standard. Forty-six cases (63.9%) had a final diagnosis of extrahepatic biliary obstruction. Clinical evaluation had a sensitivity of 82.6% and a specificity of 46.2% for the identification of mechanical obstruction. Ultrasonography was the single most powerful noninvasive diagnostic procedure, with a sensitivity of 65.2%, a specificity of 92.3%, a positive likelihood ratio of 8.5, and a positive predictive value (PVpos) of 93.8%, which was superior to the diagnostic power of CS (0.05 less than p less than 0.1). Inconclusive results or technical failures were counted as diagnostic errors. Contingency table analyses in an extended group of 112 patients, complete for CE, US, and CS, revealed that concordant results of CE and US had a high probability of correctness (combined PVpos 92.6%, PVneg 98.0%). Contradictory ratings of these two tests were unlikely to be clarified reliably by additional CS. We conclude that the combined evaluation of CE and US allows an accurate differentiation between intrahepatic cholestasis and extrahepatic biliary obstruction. When both give contradictory results, direct cholangiography, rather than further noninvasive procedures, appears to be the diagnostic strategy of choice.

[Differential diagnosis of juvenile stroke. A case of moyamoya]

Stroke before the age of 40 years is unusual and its etiology often different from that in older people. In a 29-year-old man the cause of a stroke was revealed to be bilateral vascular malformations at the base of the brain, an example of the moyamoya syndrome, rare among Europeans and published in German-speaking countries only in a few single case reports.