The impact of a ransomware cyber attack on a breast cancer center

e13620

Background: On the 14th of May 2021 the Irish Health Service Executive (HSE) was the victim of a “Conti” ransomware attack. The HSE is a nationwide organization providing Ireland’s public health service, consisting of approximately 4000 locations and more than 70,000 connected devices. The study aim is to quantify the impact of the cyber attack by examining the effect on the Breast Cancer services at Cork University Hospital 1 of 8 national cancer centres & 1 of 54 HSE acute hospitals. Methods: New patient referrals through the weekly Breast cancer MDT meeting were used as the study nidus. Patient referrals & key performance indexes for a period of 4 weeks prior, during & after the attack were examined. Time was the key metric examined. Results: The attack triggered a Critical Incident Protocol, resulting in the switching off of all HSE IT systems at national level. Disruption to patient care & operations within the HSE was immediate & without warning. Initially encrypted messaging groups were established to facilitate communication & paper based tracking & data management logs were created. Diagnostics, scheduling & radiotherapy services were most severely affected. The attack resulted in the immediate shut down of the hospitals radiotherapy department with all new treatments transferred off site to a private facility, ongoing treatments delayed, replanned or rescheduled. The effect on the radiology department was catastrophic, all outpatient & non-urgent scans were cancelled. Digital report & image stores were unavailable. Historic imaging & ongoing emergency imaging was unavailable. Taking 7 months to restore impacted data storage & to ensure accurate capture of all reports for examinations during the cyber downtime. The average time from surgery to completed pathology went from 7.04 to 15.03 & 11.8 days in the 4 weeks prior, during & after the attack respectively. Services that were least impacted during the IT outage were those that relied on paper records including chemotherapy administration. The average time from biopsy report to up front surgery decreased from 21.75 to 17 & 14 days in the 4 weeks prior, during & after the attack respectively. Likely due to the increased availability of theatre time, as all non cancer related elective procedures were cancelled. There was little effect on the time from MDT discussion to review by medical oncology, taking an average of 6, 5.7 & 5.8 days in the 4 weeks prior, during & after the attack respectively. The majority of new referrals to the service being seen off site in a satellite clinic & infusion unit that relied on a paper based booking system prior to the attack. Conclusions: The cyber attack had significant disruptive effects lasting months. The impact on patient outcome due to delayed or interrupted treatment will take years to clarify. The attack was facilitated by the presence of multiple, fragmented IT platforms & demonstrated a lack of preparedness in the system which needs to be addressed to prevent recurrence.

When pathological and radiological correlation is achieved, excision of fibroadenoma with lobular neoplasia on core biopsy is not warranted

BACKGROUND

The diagnosis and management of lobular neoplasia (LN) including lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH) remains controversial. Current management options after a core needle biopsy (CNB) with lobular neoplasia (LN) incorporating both ALH and LCIS include excision biopsy or careful clinical and radiologic follow up.

METHODS

A retrospective analysis of the surgical database at Cork University Hospital was performed to identify all core needle biopsies from January 1st 2010 to 31st December 2013 with a diagnosis of FA who subsequently underwent surgical excision biopsy. All cases with associated LN including ALH and classical LCIS were selected. We excluded cases with coexistent ductal carcinoma in situ (DCIS), invasive carcinoma, LN associated with necrosis, pleomorphic lobular carcinoma in situ (PLCIS) or lesions which would require excision in their own right (papilloma, radial scar, atypical ductal hyperplasia (ADH) or flat epithelial atypia (FEA)). Cases in which the radiologic targeted mass was discordant with a diagnosis of FA were also excluded.

RESULTS

2878 consecutive CNB with a diagnosis of FA were identified. 25 cases had a diagnosis of concomitant ALH or classical LCIS. Our study cohort consisted of 21 women with a mean age 53 years (age range 41-70 years). The core biopsy diagnosis was of LCIS and FA in 16 cases and ALH and FA in 5 cases. On excision biopsy, a FA was confirmed in all 21 cases. In addition to the FA, residual LCIS was present in 14 cases with residual ALH in 2 cases. One of the twenty-one cases (4.8%) was upgraded to invasive ductal carcinoma on excision.

Optimal Scoring of Brightfield Dual-Color In Situ Hybridization for Evaluation of HER2 Amplification in Breast Carcinoma: How Many Cells Are Enough?

OBJECTIVES

The purpose of this study was to determine the optimum number of cells that should be counted when scoring human epidermal growth factor receptor 2 (HER2) brightfield dual-color in situ hybridization (BDISH), including cases with HER2/chromosome 17 (Chr17) ratios in the 1.80 to 2.20 range.

METHODS IN TOTAL,

131 cases of breast carcinoma with HER2 immunohistochemistry and BDISH were included. For cases with a HER2/Chr17 ratio of less than 1.80 or more than 2.20 (n = 115), BDISH scoring was performed for 60 cells using three tumor fields, and for cases with a HER2/Chr17 ratio of 1.80 to 2.20 (n = 16), scoring was performed for 120 cells using six tumor fields. Mean HER2/Chr17 ratio and HER2 copy number were calculated for cumulative cell counts.

RESULTS

The HER2 status as determined by the HER2/Chr17 ratio or HER2 copy number was unchanged following counting of additional cells in 100% of cases with ratio of less than 1.80 or more than 2.20. The HER2 status of two cases with ratios of 1.80 to 2.20 changed from positive to negative following counting of 120 cells.

CONCLUSIONS

Our findings support recommendations to score 20 nuclei in conjunction with careful assessment of immunohistochemistry and scan of the BDISH slide to identify areas of heterogeneity. Scoring of additional cells/fields is likely not of benefit and might be a disadvantage since the scorer moves out of the area of strongest signal.

Reflex Repeat HER2 Testing of Grade 3 Breast Carcinoma at Excision Using Immunohistochemistry and In Situ Analysis: Frequency of HER2 Discordance and Utility of Core Needle Biopsy Parameters to Refine Case Selection

OBJECTIVES

The updated American Society of Clinical Oncology/College of American Pathologists (ASCO/CAP) guidelines (2013) for human epidermal growth factor receptor 2 (HER2) testing in breast cancer recommend repeat testing at excision of HER2-negative grade 3 breast tumors. This study aimed to identify the rate of HER2 discordance in this cohort of cases.

METHODS

All HER2-negative grade 3 tumors diagnosed at a single institution over a 15-month period had reflex repeat HER2 testing at excision : HER2 testing was performed in accordance with ASCO/CAP guidelines using immunohistochemistry (IHC) and dual in situ hybridization (ISH).

RESULTS

One hundred cases were identified over the study period. HER2 was amplified at excision in three cases. The discordant tumors showed equivocal IHC at excision with low-level amplification on dual ISH. All discordant cases showed equivocal IHC on core needle biopsy (CNB) specimens and/or tumor upgrade at excision.

CONCLUSIONS

Our series demonstrated a high concordance rate (97%) for HER2 at excision in grade 3 breast tumors with a negative core biopsy result. These findings suggest that reflex repeat HER2 testing of all these cases, which has significant cost and workload implications, may not be justified. Features that may indicate HER2 heterogeneity, such as equivocal IHC on CNB specimens or tumor upgrade at excision, may help refine selection of cases for repeat testing.

Dedifferentiated leiomyosarcoma: clinicopathological analysis of 18 cases

AIMS

To clinicopathologically characterize the dedifferentiated variant of leiomyosarcoma in a series of 18 cases.

METHODS AND RESULTS

Dedifferentiated leiomyosarcoma was defined as showing features of low-grade leiomyosarcoma associated with a discrete undifferentiated component lacking morphological or immunophenotypic features of myogenic differentiation. Tumours developed in 11 women and seven men, with an age range of 16-84 years (median, 64 years). Sites were retroperitoneum (eight cases), limbs (four), trunk (two) uterus (two), and paratesticular and prostate (one each). In 17 cases, dedifferentiation occurred de novo in the primary tumour. Tumour size ranged from 50 to 280 mm (median: 120 mm). Histologically, most showed discrete transition from well-differentiated smooth muscle morphology to high-grade pleomorphic morphology with no smooth muscle differentiation. Unusual features in the dedifferentiated component (epithelioid and rhabdomyoblast-like morphology) were present in three cases. Heterologous osseous or chondro-osseous elements were present in two cases. Dedifferentiated areas were negative for myogenic markers in all cases. Follow-up for 13 cases (median, 36 months) showed local recurrence in 38% (5/13). So far, three patients have died of disease (median survival, 8 months), and metastasis developed in five of 13 cases.

CONCLUSIONS

Dedifferentiated leiomyosarcoma has morphological parallels with other types of dedifferentiated sarcoma, and is clinically aggressive.

High Nuclear Expression of CXCR4 Is Associated with Metastases and Decreased Survival in Hormone Sensitive Breast Cancer

Introduction: CXCR4 chemokine receptor and its specific ligand SDF-1alpha are thought to play an important role in breast cancer metastases. High levels of SDF-1alpha in the common destination organs of metastasis are thought to attract CXCR4-positive tumour cells.Aim: The aim of the study was to test whether CXCR4 expression in the primary tumour can indicate breast cancer with high likelihood of metastasising.Methods: Tissue slides were prepared from the paraffin embedded primary tumours of breast cancer patients. CXCR4 expression was detected using immunohistochemistry assessed by a pathologist. Disseminated tumour cells (DTC's) were detected in the bone marrow samples of patients taken at the time of surgery using anti-HEA/FITC-conjugated antibody and flow cytometry. All other clinicopathological features of the patients were also compiled.Results: CXCR4 expression was assessed in one hundred and ten patients. They had a mean age of 57.18 years and a median follow up of 84 months (range 4 – 108). 72.6% of patients had a T2 or a T3 tumour. The majority were hormone sensitive, 80.9% and Her2/neu negative, 76.1%. Disseminated tumour cells were found in the majority of patients, 85.5%, but 57.2% had greater that 1000 DTC's/100,000. There was no correlation found between cytoplasmic staining for CXCR4 and the clinicopathological features of the tumours including DTC's. High nuclear staining was associated significantly with decreased overall and disease free survival, p<0.041 and p<0.025. Tumours with high nuclear staining were significantly more likely to be hormone sensitive, tubulo-lobular tumours [p<0.008, p<0.0349], from older, post-menopausal women [p<0.081, p<0.018]. There was no correlation between her2/neu and CXCR4 expression. Disseminated tumour cells and lymph node metastases were not associated with nuclear staining but these tumours were more likely to develop distant metastases, p<0.034.Conclusion: High nuclear expression of CXCR4 was significantly associated with hormone sensitive breast cancers and development of distant metastases. These patients had decreased overall and disease free survival. Our results show CXCR4 has an important role in breast cancer metastases and has both prognostic and therapeutic potential.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3037.

Intracystic papillary carcinoma in a male as a rare presentation of breast cancer: a case report and literature review

Introduction

The term "intracystic papillary ductal carcinoma in situ" has recently changed and is now more appropriately referred to "intracystic papillary carcinoma". Intracystic papillary carcinoma in men is an extremely rare disease with only a few case presentations published in the literature so far.

Case presentation

We discuss a case of a 44-year-old Caucasian man with an intracystic papillary carcinoma treated with simple mastectomy, sentinel lymph-node biopsy and contralateral risk-reducing mastectomy. These were followed by adjuvant radiotherapy of the breast.

Conclusion

Triple assessment (i.e. clinical examination and radiological and histological assessment) with a high level of clinical suspicion is necessary to diagnose intracystic papillary carcinoma in men due to its rarity. Furthermore, genetic testing and risk-reducing mastectomy should also be considered in cases of a strong family history for male breast cancer.

Imaging of multiple mRNA targets using quantum dot based in situ hybridization and spectral deconvolution in clinical biopsies

Gene expression mapping using microarray analysis has identified useful gene signatures for predicting outcome. However, little of this has been translated into clinically effective diagnostic tools as microarrays require high quality fresh-frozen tissue samples. We describe a methodology of multiplexed in situ hybridization (ISH) using a novel combination of quantum dot (QD)-labeled oligonucleotide probes and spectral imaging analysis in routinely processed, formalin-fixed paraffin embedded human biopsies. The conditions for QD-ISH were optimized using a poly d(T) oligonucleotide in decalcified bone marrow samples. Single and multiplex QD-ISH was performed in samples with acute leukemia and follicular lymphoma using oligonucleotide probes for myeloperoxidase, bcl-2, survivin, and XIAP. Spectral imaging was used for post hybridization tissue analysis, enabling separation of spatially colocalized signals. The method allows quantitative characterization of multiple gene expression using non-bleaching fluorochromes. This is expected to facilitate multiplex in situ transcript detection in routinely processed human clinical tissue.

Mouse model for noninvasive imaging of HIF prolyl hydroxylase activity: assessment of an oral agent that stimulates erythropoietin production

Many human diseases are characterized by the development of tissue hypoxia. Inadequate oxygenation can cause cellular dysfunction and death. Tissues use many strategies, including induction of angiogenesis and alterations in metabolism, to survive under hypoxic conditions. The heterodimeric transcription factor hypoxia-inducible factor (HIF) is a master regulator of genes that promote adaptation to hypoxia. HIF activity is linked to oxygen availability because members of the EGLN family hydroxylate HIFalpha subunits on specific prolyl residues when oxygen is present, which marks them for ubiquitination and proteasomal degradation. We created a mouse that ubiquitously expresses a bioluminescent reporter consisting of firefly luciferase fused to a region of HIF that is sufficient for oxygen-dependent degradation. Our validation studies suggest that this mouse will be useful for monitoring hypoxic tissues and evaluating therapeutic agents that stabilize HIF. One such agent, the HIF prolyl hydroxylase inhibitor FG-4383, was active in the liver and kidney after systemic administration as determined by bioluminescence imaging, transcription profiling, and production of erythropoietin, indicating that the HIF transcriptional program can be manipulated in vivo with orally active organic small molecules.

Modulation of epithelial neoplasia and lymphoid hyperplasia in PTEN+/- mice by the p85 regulatory subunits of phosphoinositide 3-kinase

Mice with heterozygous deletion of the PTEN tumor suppressor gene develop a range of epithelial neoplasia as well as lymphoid hyperplasia. Previous studies suggest that PTEN suppresses tumor formation by acting as a phosphoinositide phosphatase to limit signaling by phosphoinositide 3-kinase (PI3K). Here, we examined the effect of deleting various regulatory subunits of PI3K (p85alpha and p85beta) on epithelial neoplasia and lymphoid hyperplasia in PTEN+/- mice. Interestingly, we found the loss of one p85alpha allele with or without the loss of p85beta led to increased incidence of intestinal polyps. Signaling downstream of PI3K was enhanced in the PTEN+/-p85alpha+/-p85beta-/- polyps, as judged by an increased fraction of both cells with cytoplasmic staining of the transcription factor FKHR and cells with positive staining for the proliferation marker Ki-67. In contrast, the incidence of prostate intraepithelial neoplasia was not significantly altered in PTEN+/- mice heterozygous for p85alpha or null for p85beta, whereas the fraction of proliferating cells in prostate intraepithelial neoplasia was reduced in mice lacking p85beta. Finally, there was no significant change in T lymphocyte hyperplasia in the PTEN+/- mice with various p85 deletions, although anti-CD3-stimulated AKT activation was somewhat reduced in the p85alpha+/- background. These results indicate that decreasing the levels of different p85 regulatory subunits can result in enhanced PI3K signaling in some tissues and decreased PI3K signaling in others, supporting the model that, although p85 proteins are essential for class I(A) PI3K signaling, they can function as inhibitors of PI3K signaling in some tissues and thus suppress tumor formation.

Cannonball metastases with favourable prognosis

BACKGROUND

Secondary 'cannonball' metastases to the lung are frequent and usually associated with disseminated malignancy and poor prognosis.

AIM

To report the case of a patient with metastatic pulmonary endometrial stromal sarcoma who had a previous hysterectomy for benign uterine fibroids and no past history of malignancy.

RESULT

A 70-year-old female presented with cannonball metastases in her lung. Four years previously she had a hysterectomy for 'fibroids'. Review of the original histology revealed endometrial stromal sarcoma, similar to the lung metastasis. She currently has a good prognosis.

CONCLUSION

A patient with 'cannonball' metastases can have a favourable prognosis. A female patient with a previous hysterectomy for uterine fibroids, should be considered to have metastatic sarcoma until proven otherwise.

Cytologic features of ciliated adenocarcinoma of the cervix: a case report

BACKGROUND

Ciliation is a normal finding in the endometrium, fallopian tubes and cervix. Because cilia are characteristically lost when malignant tumors arise at these sites, the detection of cilia on light microscopy is frequently used to support a benign diagnosis. Ciliated carcinomas of müllerian duct origin, however, do occur, albeit rarely, and can pose a potential diagnostic difficulty in cytologic specimens.

CASE

A woman with a histologically confirmed ciliated adenocarcinoma of the cervix had prior liquid-based cervical cytology showing atypical, ciliated glandular cells that initially raised the diagnostic consideration of tubal metaplasia. A concurrent biopsy, however, revealed focally ciliated adenocarcinoma of the cervix.

CONCLUSION

Awareness of the ciliated variant of adenocarcinoma of the cervix is important to avoid overreliance on ciliation as a definitive feature of benignity in cervical cytologic specimens.

The relationship between cyclooxygenase-2 expression and characteristics of malignant transformation in human colorectal adenomas

BACKGROUND AND AIMS

Cyclooxygenase 2 (COX-2) is a target of aspirin and other non-steroidal anti-inflammatory drugs and is implicated in the pathogenesis of colorectal cancer. The objective of this study was to evaluate the extent of COX-2 in pre-malignant colorectal polyps and to assess the relationship between COX-2 and the level of dysplasia in these lesions.

METHODS

Whole polypectomy specimens were retrieved from 123 patients by endoscopic or surgical resection. Following formalin fixation and paraffin embedding, the polyps were evaluated histologically for size, type and grade of dysplasia. The extent of COX-2 expression was measured by the avidin-biotin immunohistochemical technique using a monoclonal COX-2 antibody. The extent of COX-2 expression was graded according to percentage epithelial COX-2 expression.

RESULTS

The polyps were of the following histological types: 10 hyperplastic, 35 tubular adenomas, 61 tubulovillous adenomas and 17 villous adenomas. Twenty showed mild dysplasia, 65 moderate dysplasia, and 28 focal or severe dysplasia (including eight with focal invasion). The average polyp size was 1.7 cm. Nine hyperplastic polyps were COX-2-negative and one was COX-2-positive. COX-2 expression was more extensive in larger polyps and in polyps with a higher villous component. There was a significant increase in the extent of COX-2 protein with increasing severity of dysplasia. Within a polyp, there was a focal corresponding increase in COX-2 expression within epithelium showing a higher grade of dysplasia.

CONCLUSIONS

COX-2 expression is related directly to colorectal adenomatous polyp size, type and grade of dysplasia. This suggests that the role of COX-2 in colorectal cancer may be at an early stage in the adenoma-to-carcinoma sequence and supports the suggestion that inhibition of COX-2 may be useful chemoprevention for this disease.

Primary lymphoma of the bladder: a report of three cases

BACKGROUND

Primary lymphoma of the bladder is rare and its management is an evolving field.

AIMS

To highlight primary lymphoma of the bladder as a possible diagnosis in cases of bladder neoplasm and to illustrate the currently favoured management options.

METHODS

Three cases of primary bladder lymphoma are reported and management is reviewed.

RESULTS

Each of the three cases was managed differently with each management approach yielding a favourable outcome.

CONCLUSION

Chemotherapy combined, if necessary, with surgery or radiation therapy, should be the standard of care, depending on the full histological diagnosis.

A single amino acid substitution beyond the C2H2-zinc finger in Ros derepresses virulence and T-DNA genes in Agrobacterium tumefaciens

Ros is a chromosomally-encoded repressor containing a novel C2H2 zinc finger in Agrobacterium tumefaciens. Ros regulates the expression of six virulence genes and an oncogene on the Ti plasmid. Constitutive expression of these genes occurs in the spontaneous mutant 4011R derived from the octopine strain Ach-5, resulting in T-DNA processing in the absence of induction, and in the biosynthesis of cytokinin. Interestingly, the mutation in 4011R is an Arg to Cys conversion at amino acid residue 125 near the C-terminus well outside the zinc finger of Ros. Yet, Ros bearing this mutation is unable to bind to the Ros-box and is unable to complement other ros mutants.

Treatment of persistent dry cough: if possible, treat the cause; if not, treat the cough

Persistent dry cough is a common presenting symptom which may be associated with considerable morbidity. In the majority of patients, systematic investigation reveals an underlying cause, usually asthma, postnasal drip, gastrooesophageal reflux or various combinations of these conditions. Intensive treatment of the underlying cause usually leads to improvement or resolution of the cough. However, in a minority of patients, no underlying cause is identified despite appropriate investigation. In these patients with idiopathic persistent dry cough, cough sensitivity to inhaled tussigens is enhanced, suggesting that increased sensitivity of airway sensory nerves is important in pathogenesis. An ideal antitussive would reduce this increased sensitivity to normal levels without significant adverse effects but currently available antitussives fall short of this expectation. This review discusses the currently available antitussive therapy and explores potential avenues for the development of future novel antitussive therapies.

Capsaicin cough sensitivity increases during upper respiratory infection

The mechanism of cough associated with upper respiratory infection (URI) is poorly understood. This paper reports a study of the role of altered sensitivity of capsaicin-sensitive airway nerves. In a prospective study, baseline (B) capsaicin-induced cough and methacholine-induced airway responsiveness were measured in 103 healthy volunteers. During the following year, 31 subjects reattended for challenge testing during URI (I) and after recovery (R). The log concentration of capsaicin required to elicit two coughs (C2) was significantly lower during infection than recovery but not baseline [median (interquartile range) B = 0.59 (0.28-1.20), I = 0.27 (0-0.89), R = 0.89 (0.28-1.49)]. Log C5 (concentration causing five coughs) was lower during infection than baseline and recovery [B = 1.79 (1.20-2.70), I = 1.49 (0.89-2.08), R = 1.79 (1.20-2.40)]. FEV1 and PC15 methacholine values were unchanged during infection compared to baseline. Subjects with dry cough (n = 14) had lower C5 values during infection than both baseline and recovery, and lower C2 values during infection than recovery; in these subjects, increase in capsaicin sensitivity correlated with cough severity score. Subjects with productive cough or no cough showed no consistent changes during infection. Twenty-six control subjects who reattended without URI showed no change in capsaicin sensitivity. Upper respiratory infection may cause cough as a result of increased sensitivity of capsaicin-sensitive afferent airway nerves without affecting airway calibre or responsiveness.

Abnormal intraepithelial airway nerves in persistent unexplained cough?

Idiopathic persistent nonproductive cough (PNPC) is characterized by enhanced cough sensitivity to inhaled capsaicin, suggesting that capsaicin-sensitive afferent airway nerves are either present in increased numbers or functionally upregulated. In 16 patients with idiopathic PNPC and eight healthy control subjects, we measured cough sensitivity to inhaled capsaicin and the anatomic density in bronchial epithelium of nerves immunoreactive for the general nerve-marker protein gene product (PGP)-9.5 and the sensory neuropeptides calcitonin-gene-related-peptide (CGRP) and substance-P (SP). The log concentrations of capsaicin required to elicit at least two (C2) and five (C5) coughs were significantly lower in patients (P) than in control subjects (C) (median [range] log C2, P = 0.3 [-0.3 to 1.2] microM; C = 1.5 [0.9 to 2.1], p < 0.0005; log C5, P = 0.8 [-0.3 to 2.1]; C = 2.6 [1.8 to 3.0], p < 0.0005). In bronchial epithelium taken from the carina of the right upper lobe (RUL) and a subsegmental carina of the right lower lobe (RLL), total nerve density (PGP-9.5 immunoreactivity) was greater in P than C, although this was not significant. CGRP-immunoreactive nerve density was significantly higher in P than in C in the RUL (median [range] P = 1.05% [0.13 to 5.08]; C = 0.02% [0 to 0.24], p = 0.001) and RLL (P = 0.59% [0.04 to 3.14]; C = 0% [0 to 0.50], p < 0.02). SP-immunoreactive nerves were not significantly different in the two groups. Abnormal intraepithelial airway nerves containing increased quantities of CGRP are present in patients with idiopathic PNPC.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiopulmonary resuscitation by precordial compression but without mechanical ventilation

It is widely held that mechanical ventilation is essential for cardiopulmonary resuscitation (CPR). However, cardiac output and therefore pulmonary blood flow is reduced to less than one-third of normal during CPR. We therefore reasoned that ventilatory requirements are correspondingly reduced and postulated that gas exchange may be maintained during precordial compression with oxygen passively delivered to the airway in the absence of mechanical ventilation. After tracheal intubation, Sprague-Dawley rats were randomized. Fifteen animals were maintained on positive-pressure ventilation with room air and an additional 15 animals breathed spontaneously. Cardiac arrest was induced by electrical fibrillation. The inspired gas concentration of oxygen was then increased to 100% in both groups. Precordial compression was begun after 4 min of untreated ventricular fibrillation. After an additional 6 min of precordial compression, resuscitation was attempted by DC countershock. During cardiac resuscitation, there were no significant differences in coronary perfusion pressure between mechanically ventilated and spontaneously breathing animals, but arterial PO2 was significantly lower and arterial PCO2 was significantly higher in the absence of positive-pressure ventilation. However, neither resuscitability nor 24-h survival were affected. Postresuscitation myocardial contractility, reflected in the maximally generated dP/dt40, was also not adversely affected. In the unventilated group, only resuscitated animals developed spontaneous gaspings at an average frequency of 17 +/- 2/min-1. The current emphasis on mechanical ventilation as the highest priority for cardiopulmonary resuscitation is therefore not fully supported under the experimental conditions of this study.

New medical entities and delivery sites require specialized insurance coverage

The addition of mid-level providers to the health care continuum and the development of off-site delivery has created new insurance coverage problems. Fran O'Connell, R.N., vice president of Shand Morahan & Company Inc., explains what to look for in coverage based on the level of care provided and the variety of care centers in use.

Capsaicin cough sensitivity decreases with successful treatment of chronic cough

To assess the role of enhanced cough sensitivity in the pathogenesis of cough, we measured cough severity on a visual analogue scale (VAS) and capsaicin cough sensitivity (the concentration required to elicit two [C2] and five [C5] coughs) in 87 consecutive patients referred with chronic cough. Measurements were repeated after complete investigation and treatment, when patients were entered into one of four study groups: (1) treatment success (primary cause of cough successfully treated with elimination of the cough, n = 48); (2) primary treatment failure (treatment of potential primary cause of cough unsuccessful, n = 12); (3) cough treatment failure subgroup A (potential primary cause of cough identified and successfully treated but no improvement in cough, n = 8); and (4) cough treatment failure subgroup B (no potential primary cause of cough identified, n = 19). All patients in groups 3 and 4 were nonsmokers, had normal chest radiography and negative histamine challenge test, and failed to respond to intensive empirical treatment for rhinitis and gastroesophageal reflux. The VAS cough severity was lower and log C2 and C5 higher after treatment compared with initial values in the treatment success group but not in the other three groups. Enhanced sensitivity of airway nerves that mediate cough is important in the pathogenesis of nonproductive cough, and successful treatment is associated with a reduction in cough sensitivity. While enhanced sensitivity of airway nerves is usually present in patients with identifiable causes of chronic nonproductive cough, it is also found in other patients in whom the cause of cough is unknown.

Effect of clonidine on induced cough and bronchoconstriction in guinea pigs and healthy humans

We examined the effects of the alpha 2-receptor agonist clonidine, administered orally and by inhalation, on citric acid- and capsaicin-induced reflexes in guinea pigs and healthy human subjects. In groups (n = 8-10) of conscious guinea pigs, oral clonidine (10 and 100 micrograms/kg) was without effects, whereas inhaled clonidine (10-1,000 microM) caused a concentration-dependent inhibition of citric acid-induced cough (coughs during 3 min: control, 6.5 +/- 0.9; 1,000 microM clonidine, 1.7 +/- 1.0; P < 0.05) and reflex bronchoconstriction (time to onset of bronchoconstriction: control, 191 +/- 24 s; 1,000 microM clonidine, 317 +/- 33 s; P < 0.05). The inhibitory effect of inhaled clonidine on both reflexes was completely reversed by pretreatment with yohimbine but not with prazosin. In 12 healthy human volunteers, oral clonidine (150 mg) caused a significant fall in supine and erect systolic blood pressure and a significant increase in drowsiness as measured on a visual analogue scale 1 and 2 h after administration. Despite these effects, oral clonidine had no effect on capsaicin-induced cough or reflex bronchoconstriction in humans. In contrast to the effects in guinea pigs, inhaled clonidine (281 microM) had no effect on capsaicin-induced cough or reflex bronchoconstriction in humans. These data suggest that peripheral alpha 2-receptors exert an inhibitory effect on sensory neurotransmission in the guinea pig but not in the healthy human airway, indicating an important difference between the two species.

A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy

Propofol, a new intravenous sedative agent, was investigated in 41 asthmatic patients undergoing day-case (outpatient) fiberoptic bronchoscopy. The study design was a randomized comparison between propofol and midazolam, which is a well-established intravenous sedative agent. The age, weight, and American Society of Anesthesiologists physical status and lung function of the two groups were not significantly different. Mean (SD) induction dose of propofol was 104.7 (30.1) mg with a maintenance dose of 121.9 (38.5) mg. Corresponding values of midazolam were 9.3 (3.1) mg and 3.7 (2.3) mg. The required level of sedation was achieved significantly faster with propofol, mean (SD) 125.4 (39.8) s, compared with midazolam, 179.4 (55.2) s (p < 0.001). Significantly faster recovery was noted with propofol compared with midazolam in terms of time to recall name and date of birth 2.3 (1.7) min vs 6.3 (8.6) min, (p < 0.045). Alertness scored with the digital symbol substitution test (DSST) returned to prebronchoscopy values in the propofol group at 30 min, DSST score = 35.9 (18.2) vs 13.4 (9.1), in the midazolam group (p < .0001) and was still significantly higher at 90 min-39.4 (17.9) and 23.1 (13.8) (p < 0.01). We conclude that propofol is a useful sedating agent in fiberoptic bronchoscopy with similar efficacy to midazolam but with a faster onset of action and a more rapid recovery. These represent significant advantages for day-case procedures.

Effect of topical beclomethasone on histamine-induced increases in nasal airflow resistance and secretion in perennial rhinitis

The effects of topical beclomethasone dipropionate on changes in nasal resistance and secretion induced by topical histamine were studied in eight patients with perennial rhinitis. Patients were studied at enrollment, after 3 weeks of beclomethasone (100 micrograms spray to each nasal cavity twice daily), and after 3 weeks of placebo (saline) treatment administered in a double-blind cross-over trial. Nasal airflow resistance (Rnaw) and total protein, albumin, lysozyme and glycoconjugate secretion in nasal lavage fluids were measured after topical application of histamine to the nasal mucosa. Resistance measurements and secretory parameters were similar for the initial study and after placebo treatment. In those studies, histamine (1 and 10 mg) increased both nasal resistance and secretion of total protein, albumin and glycoconjugates. After beclomethasone treatment the rise in respiratory resistance in response to histamine was significantly attenuated (delta Rnaw, +11.57 cm H2O/l/s with placebo, +5.80 with beclomethasone, P < 0.05). Beclomethasone had no effect on histamine-induced secretion. Because nasal resistance is determined mainly by vascular processes, beclomethasone treatment appears to have a prominent action on the vascular bed to reduce mediator-induced vasodilatation in perennial rhinitis.

Decrease of histamine induced bronchoconstriction by caffeine in mild asthma

BACKGROUND

While high doses of caffeine may affect pulmonary function and bronchial challenge tests in patients with mild asthma, the effects of lower doses (< or = 5 mg/kg) are less well documented. Specific recommendations exist for withholding theophylline, but not caffeine, before bronchoprovocation and pulmonary function testing.

METHODS

To assess the effect of a single oral dose of caffeine (5 mg/kg) on FEV1 and bronchial responsiveness to histamine a double blind, placebo controlled study was performed in eight patients with mild stable asthma.

RESULTS

While caffeine had no effect on FEV1, mean (95% confidence interval) log PC20 histamine was significantly higher 150 minutes [caffeine = 0.99 (0.2) mg/ml, placebo = 0.53 (0.29)] and 240 minutes [caffeine = 0.89 (0.24), placebo = 0.44 (0.26)] after administration of caffeine than after placebo.

CONCLUSIONS

Caffeine should be excluded from the diet for a period of more than four hours before bronchial provocation testing. The exact length of time for which it must be excluded requires further study.

Potent leukotriene D4 receptor antagonist ICI 204,219 given by the inhaled route inhibits the early but not the late phase of allergen-induced bronchoconstriction

ICI 204,219 is a potent and specific leukotriene D4 receptor antagonist that blocks both the early and late responses to allergen challenge in humans when given orally at a dose of 40 mg. Here we report our findings with an inhaled formulation of ICI 204,219 against allergen-induced bronchoconstriction. A group of 10 atopic subjects (mean age 25.6 +/- 4.2; 6 females; FEV1 > 90% of predicted; on inhaled beta 2-agonists only) were studied on 2 separate days 2 to 3 wk apart. In a randomized placebo-controlled trial they inhaled eight puffs of a standard metered dose inhaler containing either ICI 204,219 (200 micrograms/puff, total dose 1,600 micrograms) or propellant alone. They underwent bronchial allergen challenge 30 min later using a single concentration of allergen previously shown to lower the FEV1 by > or = 15%. FEV1 was monitored hourly for 10 h, and urine was collected for LTE4 determination. Inhalation of ICI 204,219 was well tolerated, with no adverse clinical or biochemical effects. There was no significant effect of ICI 204,219 inhalation on basal airway caliber (change in FEV1 30 min after inhalation was -149 +/- 67 ml after placebo versus 3 +/- 38 ml after ICI 204,219; p = 0.08). The early response to allergen was significantly inhibited by ICI 204,219 (the maximum fall in FEV1 was -21.2 +/- 6.1% after ICI 204,219 compared with -38.8 +/- 6.5% on placebo; p = 0.007).(ABSTRACT TRUNCATED AT 250 WORDS)

Regional blood flow during closed-chest cardiac resuscitation in rats

Quantitative measurement of regional blood flow during cardiac arrest and resuscitation has been confined to large animals. We report on a rodent model utilizing radioactive microspheres during cardiac arrest and resuscitation for investigation of regional blood flow. Ventricular fibrillation was electrically induced in 10 pentobarbital-anesthetized Sprague-Dawley rats. Resuscitation was attempted by precordial compression followed by external direct current countershock. During precordial compression, cardiac output corresponded to 12% of prearrest flow. Similarly low flows were observed in the myocardium and brain. However, much lower flows were observed in the adrenal glands, kidneys, intra-abdominal viscera, skin, and skeletal muscle. Five of ten animals were successfully resuscitated. During precordial compression, resuscitated animals had significantly higher cardiac output (13.1 +/- 4.1 vs. 8.6 +/- 1.46 ml/min), myocardial blood flow (0.70 +/- 0.24 vs. 0.22 +/- 0.15 ml.min-1.g-1), cerebral blood flow (0.17 +/- 0.04 vs. 0.06 +/- 0.02 ml.min-1.g-1), and adrenal blood flow (1.09 +/- 0.60 vs. 0.27 +/- 0.16 ml.min-1.g-1). Thirty minutes after successful resuscitation, cardiac output and myocardial, cerebral, renal, and adrenal blood flows and blood flow to splanchnic viscera (with the exception of the spleen) had returned to > or = 70% of prearrest flows. These studies confirm the conclusion of earlier investigations in larger animals that visceral blood flow during cardiac arrest and precordial compression is preferentially distributed to the brain and myocardium. Successful cardiac resuscitation is contingent on threshold levels of myocardial blood flow that exceed 0.4 ml.min-1.g-1.

Ipratropium bromide delivered orally by metered dose inhaler does not decrease salivary flow in normal subjects

A randomised placebo-controlled cross-over group study was conducted to ascertain the occurrence and duration of xerostomia induced by 240 micrograms (high dose) and 120 micrograms (low dose) of ipratropium bromide (IPB) delivered by metered dose inhaler (MDI) into the mouth in normal subjects. Salivary output was higher with both doses of IPB than with placebo though the differences were not statistically significant. IPB was less palatable than placebo as indicated on visual analogue scale (VAS) and the taste of the drug may have caused a reflex increase in salivary output from the major salivary glands which would have masked any possible local effect of the drug on the smaller submucosal glands of the mouth. IPB delivered into the oral cavity by MDI is therefore not a suitable treatment for hypersalivation.

Ocular hazards of nebulized bronchodilators

Three cases of pupillary dilatation associated with the development of acute glaucoma, precipitated by the use of nebulized bronchodilators are described. We suggest measures to reduce the risk of this complication.