Pulmonary disease due to Mycobacterium avium complex (MAC) without evidence of dissemination is uncommon in HIV-infected patients. Five cases were observed over a 2-year period. All patients had AIDS and the median CD4 cell count at the time of presentation was 90 x 10(6)/L. Radiographic patterns included unilobar alveolar infiltrates or diffuse alveolar densities. All patients had a favorable clinical response to antimycobacterial chemotherapy with a median follow-up period of 10 months. MAC should be considered in HIV-infected patients with positive respiratory samples for acid-fast bacilli and pulmonary infiltrates. Patients with such findings in whom presumptive therapy for tuberculosis has failed should receive broad-spectrum antimycobacterial chemotherapy until final identification is available.

An unusual case of a self-inflicted intracardiac injury with a sewing needle caused a pneumothorax. Fewer than ten cases of needles in the heart have been reported in the recent medical literature; none of these cases was associated with presence of a pneumothorax. The literature regarding self-inflicted injury with needles in the heart is reviewed.

The purpose of this consensus report was to address clinically relevant questions related to the diagnosis and management of acute pulmonary embolism and deep venous thrombosis.

Data from recent surveys indicate that a staggering 34.9% of US adults are overweight. Obese adults are at in increased risk for many chronic medical conditions, and this increases the likelihood of admission to an ICU. The critically ill obese patient presents the ICU team with many unique problems. Obesity may result in significant alterations of pulmonary and cardiac function, as well as the handling of many drugs. An appreciation of these and other changes is essential in the management of the obese ICU patient. The purpose of this article is to review some of the basic concepts related to the treatment of obese patients in the ICU.

With the longer life expectancy of the population, calcific aortic stenosis has become a common cardiac problem in the elderly. When patients with moderate to severe aortic stenosis become symptomatic, the prognosis is usually poor in absence of valve replacement and sudden death is a feared complication. It has been hypothesized that malignant ventricular arrhythmias could be responsible for the high incidence of sudden death in symptomatic patients with aortic stenosis. The purpose of this review is to analyze the prevalence, the electrophysiologic mechanisms, and the possible role of ventricular arrhythmias in the development of symptoms and in the outcome of adult subjects with aortic stenosis.

The first successful heart-lung and lung transplant operations in cystic fibrosis (CF) patients were performed in 1983 and 1987, respectively. Lung transplantation is now available at dozens of centers in North America, Europe, and Australia. Recent technical developments and the major limitations of donor organ availability prompted the CF Foundation to sponsor a meeting of 37 experts to evaluate the state of the art in lung transplantation for CF, highlighting areas of consensus, practice variations, and controversy. This document summarizes the work of that group.

Multifocal atrial tachycardia is typically seen in elderly patients with severe illnesses, most commonly COPD. The mechanism of the arrhythmia may be delayed afterdepolarizations leading to triggered activity, but this has not been firmly established. The initial treatment of multifocal atrial tachycardia should include supportive measures and aggressive reversal of precipitating causes. Since multifocal atrial tachycardia is commonly a secondary phenomenon, the role for antiarrhythmic therapy is unclear. Metoprolol, magnesium, and verapamil have been evaluated in a few treatment studies, and may have a role in the treatment of multifocal atrial tachycardia.

Patients with diffuse interstitial lung diseases (DILD) are challenging to treat. Many patients with DILD have inadequate information about the disease process, an imprecise diagnosis, unsatisfactory treatment or unacceptable side effects associated with therapy, and poorly controlled symptoms of progressive illness. Establishing an accurate diagnosis is necessary so that the patient and his/her family can be provided with reasonable expectations about prognosis and outcome from therapy. A pragmatic approach is presented that emphasizes diagnostic strategies and plans for therapy that are effective and resource efficient and that will help maintain patient satisfaction.

To critically appraise and summarize the studies examining the cost-effectiveness of noncardiac transitional care units (TCUs).

The incidence of esophageal cancer in the United States has been increasing in recent years. Since multimodality therapy for esophageal cancer has produced discouraging results, recent approaches have focused on molecular biological techniques, positron emission tomography, and minimally invasive surgery to improve pretreatment staging which will facilitate a more accurate assessment of new treatment. This article summarizes the results of studies investigating these approaches and outlines the strategy currently used at the University of Pittsburgh Medical Center.

The incidence of distal esophageal adenocarcinoma and primary proximal gastric carcinoma has increased substantially in the past 15 years, particularly in North America and in some European countries. Patients with curatively resected cancer consistently have a 10 to 20% 5-year survival rate. Radiation therapy alone should not be recommended. Based on the Radiation Therapy Oncology Group/Eastern Cooperative Oncology Group (ECOG) trial in patients with predominantly squamous cell carcinoma, chemoradiotherapy (fluorouracil [5-FU]/cisplatin + 50 Gy of radiotherapy) has been shown to be superior in this setting. The most active single agents against squamous cell carcinoma are cisplatin, 5-FU, bleomycin, paclitaxel, mitomycin, mitoguazone, vinorelbine, and methotrexate. The most active agents against adenocarcinoma include paclitaxel and probably mitomycin, mitoguazone, and cisplatin. To my knowledge, there is currently no effective postoperative adjuvant therapy (chemotherapy, radiation therapy, or both). Evidence that preoperative therapy can prolong survival of patients with potentially resectable carcinoma of the esophagus is lacking. Preoperative chemoradiotherapy can result in an approximately 25% complete pathologic response of the primary tumor. Preoperative chemoradiotherapy, however, results in substantial morbidity and even mortality. A recent single-institution, randomized study comparing surgery alone with preoperative 5-FU/cisplatin/vinblastine and concurrent radiotherapy demonstrated no difference in median survival (18 months). Nevertheless, combined-modality therapy holds promise. Multiple combined-modality strategies have been formulated and will be investigated in the next few years.

Staging criteria for thoracic malignancies are based on survival groupings that allow the stage groups to be used as prognosticators for cancer treatment. Definitive staging of esophageal cancer facilitates allocation of patients to appropriate treatment regimens according to each patient's stage. Existing noninvasive staging methods are imperfect in detecting abdominal and thoracic lymph node metastases in patients with esophageal cancer. Thoracoscopy is an excellent means for staging the chest and mediastinum. We have used thoracoscopic lymph node staging and laparoscopic lymph node staging for esophageal cancer since 1992. Thoracoscopy was performed in 45 patients with biopsy specimen-proved carcinoma of the esophagus. Laparoscopy was done in the last 20 patients. Laparoscopic-assisted feeding jejunostomies were performed in patients with obstructive symptoms. Directed liver biopsies were performed if lesions were present. Thoracoscopy was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 40 patients and N1 in 3. Celiac lymph nodes were normal in 14 patients and abnormal in 6. Esophageal resection was performed in 30 patients after thoracoscopic lymph node staging; 18 of these underwent laparoscopic lymph node staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in 2. Two of these N0 patients (7%) were found at resection to have paraesophageal lymph involvement (N1). Thoracoscopic lymph node staging was accurate in detecting the status of thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging found normal celiac nodes in 13 patients and abnormal lymph nodes in 5. After esophagectomy, final pathologic finding of the 13 N0 patients was N0 in 12 patients and N1 in 1 patient. Thus, laparoscopic lymph node staging was accurate in detecting lymph node status in 17 of 18 patients (94%). Six of 20 patients undergoing laparoscopy had unsuspected celiac axis lymph node involvement missed by standard noninvasive techniques. Three percent of thoracic lymph nodes and 17% of celiac lymph nodes were downstaged after preoperative chemoradiotherapy. Thoracoscopic and laparoscopic lymph node staging are more accurate than existing staging methods.

Basic to curative treatment for small cell lung cancer (SCLC) are the principles of dose response, combination chemotherapy, and combined-modality therapy. Theory and experimental and clinical data suggest that solid tumors recur, despite initially responding to chemotherapy due to drug resistance. Resistance to chemotherapy is potentially overcome by using 5- to 10-fold higher doses. To decrease the emergence of drug resistance, combinations of active non-cross-resistant agents are used. Hematopoietic stem cell support provides the opportunity to test dose response to the limits of organ tolerance. Dose-intensive therapy for lung cancer patients is complicated by the fact that this disease most often occurs in an older-aged population (median, 60 to 65 years) with underlying smoking-related comorbid disease, early metastatic spread, and enhanced risk of secondary smoking-related malignancies. In a phase II feasibility trial just activated, patients younger than 60 years of age with limited-stage SCLC are being treated with four cycles of cisplatin and etoposide and concurrent twice-daily chest radiotherapy to 45 Gy (150-cGy fractions). Those patients achieving complete or near-complete response will receive high-dose cyclophosphamide/cisplatin/ carmustine with autologous stem cell support. Upon recovery, prophylactic cranial irradiation will be given. Results could lead to a phase III trial testing the concept of dose intensification. This article reviews evidence for the contribution of dose intensification to response and survival in the treatment of SCLC, the adequacy of the clinical trial's design to address these relationships, and suggestions for future directions. The strategies of dose-intensive induction therapy, multicycle dose-intensive combination therapies, chest radiography, and stem cell purging trials will be discussed.

Progress in the treatment of patients with small cell lung cancer (SCLC) has come in two phases. In the first phase, SCLC was recognized, even when seemingly localized to the lung and intrathoracic lymph nodes, to be widely metastatic and to require effective systemic therapy from the outset. The development of active chemotherapeutic agents and combinations in the 1970s improved median survival from the 6 months seen with radiotherapy alone to about 1 year. In the second phase has come the recognition that local control of a disease, even one with systemic spread, is necessary for its cure. This has resulted both in a better appreciation of the role of radiation therapy in SCLC treatment and in efforts to optimize combined-modality regimens using radiotherapy and chemotherapy. With current treatment regimens involving concurrent or closely interdigitated administration of cisplatin and etoposide chemotherapy and radiation doses of 45 Gy given over 3 to 5 weeks, median survivals of 20 to 24 months have been reported by many single institutions and confirmed in large cooperative group trials. Issues remaining to be resolved include optimization of radiation dose, volume, and timing; the role of prophylactic cranial irradiation; and how to reduce acute and late toxic reactions of treatment. As we develop more specific therapies based on specific molecular and biological characteristics of SCLC, including its autocrine growth regulation, we will be challenged to integrate these successfully with current radiation and chemotherapeutic approaches.

The treatment of small cell lung cancer (SCLC) has evolved significantly over the past 3 decades. Single-agent and combination chemotherapies given with radiotherapy have greatly improved response rates and median survival. Combination regimens such as cisplatin/etoposide, carboplatin/etoposide, ifosfamide/carboplatin/etoposide, cyclophosphamide/doxorubicin/vincristine, and etoposide/ifosfamide/cisplatin have all achieved good response rates. Improving long-term survival, however, has remained problematic. Treatment with biological response modifiers (interferons alpha and gamma) has not shown promise in this setting. New agents showing good preliminary single-agent activity in untreated SCLC include paclitaxel, vinorelbine, gemcitabine, topotecan, and teniposide. Results obtained with single-agent docetaxel and CPT-11 are thus far inconclusive. Studies evaluating response and survival rates of these new agents in combination with agents of known activity are underway.

Malignant pleural effusions are associated with significant morbidity. Prompt clinical evaluation followed by aggressive treatment often results in successful palliation. This report summarizes the traditional and experimental approaches used in the management of malignant pleural effusion and provides an attempt at analysis of cost comparison and resource utilization associated with the use of various sclerosing agents. The standard sclerotherapy for malignant pleural effusions has routinely been performed as an inpatient procedure using a large-bore chest tube for drainage and instillation of a sclerosing agent. Use of a small-bore catheter for drainage and pleurodesis is associated with reduced patient discomfort and appears to be feasible and equally efficacious in the ambulatory setting. Results with the ambulatory procedure are preliminary but promising. Future comparisons with the traditional approach will allow therapy to be based not only on efficacy, but also on the use and expense of related resources.

Malignant pleural effusions are a common problem in cancer patients with advanced disease. Patients typically present with progressive dyspnea, cough, and/or chest pain that significantly compromises their quality of life. Treatment is often palliative, usually consisting of sequential thoracenteses or tube thoracostomy with or without sclerotherapy. The traditional method of treatment--tube thoracostomy with large-bore chest tubes connected to continuous wall suction--requires hospitalization, is expensive, limits patient mobility, and can cause significant patient discomfort. More recent trials have explored new techniques, including thoracoscopic insufflation of talc and small-bore catheters. Most of these studies have been performed on inpatients, although a recent multi-institutional trial was initiated to evaluate the feasibility and efficacy of ambulatory (outpatient) pleural drainage and sclerotherapy using small-bore catheters. All patients fulfilling eligibility criteria had a small-bore catheter placed in the pleural space that was then connected to a closed gravity drainage bag system. When daily tube drainage was <100 mL, sclerotherapy was performed. Response rates at our institution demonstrated 10 patients (53%) had a complete response, 5 (26%) had a partial response, and 4 (21%) had progressive disease at 30-day follow-up. These preliminary results suggest ambulatory sclerotherapy is a safe, viable alternative to conventional inpatient treatment of malignant pleural effusions in a select group of patients.

Treatment of malignant pleural mesothelioma continues to be frustrating regardless of the modality employed. Numerous trials of chemotherapeutic agents have been performed, but until recently, these studies were small and subject to inaccuracies of disease measurement. To our knowledge, no chemotherapeutic regimen has emerged as a standard of care. A review of the literature reveals that small activity against this disease has been shown by the anthracyclines, platinum compounds, and alkylating agents, whereas higher activity has been reported with the antimetabolites. The plant alkaloids have not demonstrated any activity against mesothelioma. Dose-escalated chemotherapeutic regimens may offer an advantage, whereas combination chemotherapy has not shown any benefit over single-agent therapy. Favorable responses have been reported with the administration of intrapleural biological response modifiers. Further trials and the investigation of new agents in the treatment of this disease are necessary.

In this article, we explain the current trimodality approach used to treat malignant pleural mesothelioma. Our current approach employs extrapleural pneumonectomy as the cytoreductive procedure followed by combination chemoradiotherapy. Trimodality therapy was performed at the Dana-Farber Cancer Institute/Brigham and Women's Hospital Thoracic Oncology Program. From 1980 to 1995, we prospectively followed up a series of 120 patients with confirmed malignant pleural mesothelioma who underwent trimodality therapy. Two- and 5-year survival rates for the entire cohort were 45% and 22%, respectively. Survival rates were 65% and 27%, respectively, at 2 and 5 years for patients with epithelial histology. Patients with sarcomatous or mixed histology had the poorest prognosis, with 2- and 5-year survival rates of 20% and 0%, respectively. For patients with epithelial tumors and negative nodes, survival at 2 and 5 years was 74% and 39%, respectively. Extrapleural pneumonectomy in the context of trimodality therapy is a potential surgical option for a selected group of patients with malignant pleural mesothelioma.