Percentage Of Predicted Value Research Articles

Pulmonary Function Changes After Various Anterior Approaches in the Treatment of Adolescent Idiopathic Scoliosis

Prospective radiographic and chart review of pulmonary function in patients who underwent 3 different anterior spinal surgery approaches for adolescent idiopathic scoliosis (AIS). To assess the impact on pulmonary function in patients with AIS after anterior surgical approaches, including open thoracotomy, thoracoscopic with and without thoracoplasty, and thoracoabdominal 2 years after surgery. Potential advantages of anterior surgery in the treatment of AIS include saving of distal motion segments and improving kyphosis restoration in the thoracic spine, possibly at the cost of pulmonary function impairment. Although thoracoscopic spinal instrumentation and fusion has recently been shown to induce less pulmonary impairment compared with open thoracotomy, no study has evaluated the effect of thoracoplasty as an adjunct to thoracoscopic surgery, nor the effects of the thoracoabdominal approach for thoracolumbar curvature. A multicenter spinal deformity database was queried for patients who underwent an anterior approach for either Lenke I or Lenke V idiopathic scoliosis. There were 68 patients in the thoracotomy group, 44 in the thoracoscopic group, and 19 in the thoracoabdominal group. Absolute and percent-predicted values of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and total lung capacity (TLC) were evaluated preoperatively and at 2-year follow-up, and comparisons were made within and between each group. Comparing between groups at 2 years postoperatively, the thoracotomy group demonstrated significantly greater decreases (-10.97% and -12.97%) in both percent-predicted FEV1 and FVC, respectively, when compared with the thoracoscopic group (-4.40% and -4.73%), respectively. Percent-predicted TLC in the thoracoscopic group increased (3.19%), but decreased in the thoracotomy group (-8.00%). Subanalysis of the thoracoscopic group at 2 years revealed that the addition of a thoracoplasty (3 to 5 ribs) significantly reduced percent-predicted FEV1 (-11.6%, P = 0.0013) and percent-predicted FVC (-16.0%, P = 0.017) from baseline. Patients who underwent thoracoscopy alone without a thoracoplasty experienced no significant detrimental changes in these parameters at 2 years, and instead experienced significant increases in absolute TLC (P < 0.001) and percent-predicted TLC (P = 0.035). There were no significant changes demonstrated in the thoracoabdominal group for all 3 parameters. Slight declines in pulmonary function at 2-year follow-up were noted in both the thoracotomy and thoracoscopic groups, but to a significantly greater extent in those with an open thoracotomy. Significantly greater impairment in pulmonary function was seen in thoracoscopic patients who underwent thoracoplasty, whereas those without thoracoplasty either had no significant declines at 2 years or experienced slight but significant improvement. No significant diminishment was noted for the thoracoabdominal approach, despite disruption of the diaphragm.

Association between Hypertension and Pulmonary Function in Rural Adults in Korea

Whilst hypertension exerts a negative effect on several organs there have been few studies regarding its effect on pulmonary function. The objective of this study was to examine the relationship between hypertension and pulmonary function in rural Korean adults. In 2006, 2534 people were recruited, aged 40 to 70, in Kangwha County. We selected 1454 (male: 624, female: 830) participants whose pulmonary function results were repeatable. Blood pressure (BP) was measured twice and the average calculated. Participants were divided into two groups (hypertensive group and non-hypertensive group) in accordance with The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Pulmonary function was measured by dry rolling seal spirometry. Forced expiratory volume in the one second and forced vital capacity were converted into percent-predicted values based on average pulmonary function amongst Koreans. The number of hypertensive participants in the present study was 460 (male: 205, female: 255) and the number of non-hypertensive participants was 994 (male: 419, female: 575). Our findings have shown that the mean values for expiratory volume in the one second and forced vital capacity were significantly lower for hypertensive people than for non-hypertensive people, among women (P=0.002 for forced expiratory volume in the one second, P<0.001 for forced vital capacity volume). Odds ratio analysis revealed that hypertensive participants were more likely to have lower pulmonary function than non-hypertensive participants, again significantly among women. The pulmonary function of hypertensive women was significantly lower than that of non-hypertensive women aged 40-70.

Pulmonary Function in Pediatric survivors of non-Malignant Disorders after Allogeneic Hematopoietic Stem Cell Transplantation.

Allogeneic hematopoietic stem cell transplantation (HSCT) is used to treat children with non-malignant disorders. As the number of survivors of non-malignant disorders after allogeneic HCST rises, monitoring late sequelae becomes increasingly important. However, no studies have solely targeted this population especially on pulmonary function. We therefore performed a long-term prospective study of pulmonary function in 38 pediatric survivors of non-malignant disorders after allogeneic HCST, including aplastic anemia (n = 15), sickle cell anemia (n = 13), immunodeficiency syndromes (n = 8), Hurler syndrome (n = 1), and osteopetrosis (n = 1). A total of 260 pulmonary function tests were conducted on the patients. Older age of recipients was associated with poorer pulmonary function; lower ratio of forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC; p < 0.0001); lower percent predictives in FEV1 (p = 0.0178), forced expiratory flow (FEF25–75%; p < 0.0001), FVC (p = 0.0299), and diffusion capacity corrected for hemoglobin (DLCOcorr; p = 0.0079); higher ratio of residual volume and total lung capacity (RV/TLC; p = 0.0193); and higher percent predictives in RV (p = 0.0308) and functional residual capacity (FRC; p = 0.0489). The following percent predictive values declined over time (median follow-up: 8 years): FEF25–75% (p = 0.0064), RV (p = 0.0134), FRC (p = 0.003), FVC (p = 0.0004), TLC (p = 0.0248), and DLCOcorr (p = 0.0077). Also, busulfan use was associated with lower FEV1 (p = 0.026), FVC (p = 0.0194), and DLCOcorr (p = 0.0105). This study underscores the need to monitor risk-adapted long-term lung function and provide early interventions in this vulnerable population, especially for those who received HSCT at an older age or had been administered busulfan.

Percent Predicted Value for the 6-Minute Walk Test: Using Norm-Referenced Equations to Characterize Severity in Persons With CHF

Background The 6-minute walk test (6MWT) is a widely used measure of functional capacity in patients with chronic heart failure (CHF). Norm-referenced equations that predict the 6-minute walk distance (6MWD) according to age, height, weight, and gender have been proposed for healthy patients. We explored whether these equations apply to CHF patients. Methods and Results The sample consisted of 213 patients newly admitted to specialized CHF clinics in Montreal, Canada. Percent predicted value (PPV) for 6MWD was calculated using norm-referenced equations. We explored correlations between different measures: PPV, 6MWD, Minnesota Living with Heart Failure Quality of Life score (MLHF-QOL). We compared severity among different age, gender, and BMI (body mass index) subgroups and assessed consistency using different measures of severity. Mean age was 65.5 years and 77.5% were men. Compared with the 6MWD, PPV had a slightly better correlation with MLHF-QOL score (−0.26 versus −0.20), and slightly more predictive power in linear regressions (adjusted r 2 = 6.5% versus 4.2%). When PPV was used to differentiate severity between different age, gender, and BMI subgroups, it consistently led to similar conclusions as the MLHF-QOL score, unlike 6MWD. Conclusion The 6MWD in meters may give misleading results when used as an indicator of severity of CHF condition to compare groups with different sex, age, and BMI distributions. It may be necessary to standardize it using norm-referenced equations.

Prospective Pulmonary Function Comparison Following Posterior Segmental Spinal Instrumentation and Fusion of Adolescent Idiopathic Scoliosis

Prospective clinical study. To investigate if a correlation exists between various parameters including major thoracic curve correction and postoperative pulmonary function test (PFT) improvement at 2 years postoperative following posterior segmental spinal fusion (PSSF) and instrumentation with iliac crest bone graft (ICBG). There are no studies available on the correlation between major thoracic curve correction and postoperative PFT improvement following PSSF and instrumentation with ICBG with a homogenous diagnosis, similar operation method, and similar age population. One hundred thirty-nine patients with adolescent idiopathic scoliosis (Lenke type 1-4), undergoing PSSF and instrumentation with ICBG at a single institution, were before surgery and 2 years after surgery prospectively evaluated in regard to PFTs, assessing forced vital capacity, and forced expiratory volume in 1 second. PFTs change at 2 years postoperative was compared by the various parameters including major thoracic Cobb curve correction and the types of instrumentation. We defined a significant clinical improvement as a 10% or more increase of percent predictive FEV1 value at 2 years postoperative. PSSF and instrumentation with ICBG demonstrated statistically significant improvement of absolute and percent-predicted PFTs at 2 years postoperative. There was a significant clinical improvement in 31 patients (22%) at 2 years postoperative. Significant clinical improvement was related to thoracic pedicle screw instrumentation (vs. thoracic hook instrumentation, P = 0.030). Absolute amount of major thoracic Cobb correction, magnitude of the residual curve, correction percentage of the major thoracic Cobb, the number of fused vertebrae, Risser sign, and age at surgery did not demonstrate any significant positive or negative correlation (-0.3 <Pearson correlation coefficient <0.3). Patients having a PSSF and instrumentation with ICBG statistically significant improvement of absolute and percent-predicted PFTs at 2 years postoperative. There was a significant clinical improvement in 31 patients (22%) at 2 years postoperative. A significant clinical improvement was related with thoracic pedicle screw instrumentation.

Longitudinal Assessment of Cardiovascular Exercise Performance After Pediatric Heart Transplantation

No existing longitudinal data document exercise performance after pediatric heart transplantation. We report the exercise performance findings from the longitudinal study of pediatric heart transplantation patients and the association of aerobic capacity with echocardiographic measures of graft function. We performed a retrospective analysis of 28 children after heart transplantation who underwent 87 exercise tests and echocardiograms. Subjects exercised using graded cycle or treadmill protocols. Maximal oxygen consumption (VO2), physical working capacity, peak heart rate, and anaerobic threshold were evaluated. To measure systolic and diastolic function, shortening fraction and mitral valve pressure half-time (PHT) respectively, were obtained by echocardiography. The average age at transplantation was 10.9 +/- 5.6 years, at initial exercise test was 13.8 +/- 5.0 years, and at final exercise test was 15.8 +/- 5.2 years. Percent-predicted values at the initial exercise test were VO2, 59.3%; physical working capacity, 60.2%; and peak heart rate, 75.8%; these remained similarly decreased at the final exercise test. Shortening fraction and PHT were within normal limits, but PHT was significantly greater at final test (p < 0.05). The relationship of VO2% with time was statistically significant, described by a quadratic equation that included initial VO2% and time from heart transplantation. This relationship remained significant when the shortening fraction (p < .05) but not PHT was added as a covariate in the equation. Exercise performance after pediatric heart transplantation is impaired and, despite an initial improvement, declines over time. This can be explained by increasing diastolic dysfunction independent of donor graft age. If confirmed, these findings point the direction to further research aimed at limiting this aerobic capacity decline after heart transplantation.

Effects on Lung Function of Multiple Expansion Thoracoplasty in Children With Thoracic Insufficiency Syndrome: A Longitudinal Study

Longitudinal study of intraoperative pulmonary function in young children with thoracic hypoplasia and scoliosis undergoing multiple expansion thoracoplasty using the vertical expandable prosthetic titanium ribs (VEPTRs). To test the long-term efficacy of VEPTR multiple expansion thoracoplasty. To our knowledge, no direct measurements of pulmonary function have been reported with VEPTR expansion thoracoplasty. There were 10 children with thoracic insufficiency syndrome, secondary to thoracic hypoplasia with progressive scoliosis, studied. A mobile pulmonary function laboratory unit was used to study forced vital capacity (FVC), maximum expiratory flow volume curves, and respiratory system compliance (Crs) with the patient under general anesthesia immediately before and after expansion thoracoplasty. Studies were repeated every 6 months at each subsequent operation for expansion thoracoplasty for the duration up to 33 months. At the baseline studies, FVC showed a moderate-to-severe decrease (69% of predicted values), indicating the presence of significant restrictive lung defect. Only 1 of 10 children had severe airway obstruction. The baseline Crs was markedly decreased in part because of the presence of significant atelectasis. Crs increased with an average of 42% after repeated hyperinflation (deep sighs). There was no change in lung volume or function immediately before versus after completion of expansion thoracoplasty. FVC increased significantly over time, with an average rate of 26.8% per year, the rate of increase similar to that of healthy children of comparative ages. In terms of percent-predicted values, FVC did not change significantly between the baseline and last test, indicating that in most children studied, lung growth kept up with body growth. Although it is difficult to assess the extent of the efficacy without a proper or historical control group for comparison, the present study indicates that in children with severe thoracic insufficiency syndrome, the insertion of VEPTRs with multiple expansion thoracoplasties is beneficial over time, by allowing the lungs to expand with body growth without further deterioration in lung function.

Noninvasive determination of fetal RHD status by examination of cell‐free DNA in maternal plasma

Cell-free fetal DNA in maternal plasma opens the way for routine risk-free diagnosis of fetal D status of D- mothers. The focus was on accuracy of RHD typing and confirmation of fetal DNA in maternal plasma while RHD was not detected. Plasma DNA was extracted (by manual and/or automatic method) from 255 D- pregnant women and amplified in exons 7 and 10 and intron 4 of RHD gene with real-time polymerase chain reaction. The presence of fetal DNA was confirmed by testing SRY and, when negative, by one of 11 different polymorphisms found in the father but not in the mother. The results were compared with the D status of the newborns. After exclusion of 25 cases (10%) because of material shortage, in 230 cases (90%) available for complete study, the predictive value of the procedure of fetal RHD testing (RHD genotyping plus confirmation of fetal DNA) was 99.6 percent. SRY detection confirmed fetal DNA presence in maternal plasma in all boys, whereas the detection of various polymorphisms in all girls but one. Fetal RHD genotyping from maternal plasma may be used with confidence, although additional polymorphisms for confirmation of fetal DNA should be included for 100 percent predictive value (instead of 99.6%).

Pulmonary Function in Adolescent Idiopathic Scoliosis Relative to the Surgical Procedure

The long-term pulmonary function of patients with adolescent idiopathic scoliosis undergoing surgical correction is uncertain. To our knowledge, no report has demonstrated the changes in pulmonary function five years or more following spinal arthrodesis with use of modern segmental spinal instrumentation techniques for the treatment of all types of adolescent idiopathic scoliosis in a similar adolescent population. One hundred and eighteen patients with adolescent idiopathic scoliosis undergoing surgical treatment at a single institution were evaluated with pulmonary function tests to assess the absolute and percent-predicted value of forced vital capacity and forced expiratory volume in one second at the preoperative examination and at regular intervals postoperatively. The patients were divided into four groups depending upon the surgical procedure: Group 1 comprised forty-nine patients who had posterior spinal arthrodesis with iliac crest bone graft; Group 2, forty-one patients who had posterior spinal arthrodesis with thoracoplasty; Group 3, sixteen patients who had open anterior spinal arthrodesis with a rib resection thoracotomy; and Group 4, twelve patients who had combined anterior and posterior spinal arthrodesis with a rib resection thoracotomy and iliac crest bone graft, respectively. A comparison of absolute pulmonary function values from the preoperative and final follow-up evaluations demonstrated a significant (p < 0.0001) increase in both the forced vital capacity and the forced expiratory volume in one second for Group 1, whereas no change was seen in those values for Groups 2, 3, and 4. A comparison of the changes in the percent-predicted pulmonary function values demonstrated significant (p < 0.05) decreases in forced vital capacity and forced expiratory volume in one second for Groups 2, 3, and 4, except for the latter value for Group 4, whereas Group 1 had no change. Patients who have had any type of chest cage disruption during the surgical treatment of adolescent idiopathic scoliosis demonstrate no change in the absolute value and a significant decline in the percent-predicted value of pulmonary functions at five years following surgery. Chest cage preservation is recommended to maximize both absolute and percent-predicted pulmonary function values after surgical treatment of adolescent idiopathic scoliosis.

Reticulated platelets: a reliable measure to reduce prophylactic platelet transfusions after intensive chemotherapy

Reticulated platelets (RPs) are the youngest circulating platelets (PLTs). The aim of our study was to predict PLT recovery with RP percentage (RP%) and therefore to identify PLT transfusions that could be avoided after autologous peripheral blood progenitor cell (PBPC) transplantation. With a whole-blood dual-labeling flow cytometric method, RP% was prospectively assessed in 47 patients who received myeloablative chemotherapy followed by autologous PBPC transplantation. Retrospective analysis of RP evolution identified three time points: nadir of the RP% (NRP), imminent PLT recovery (IPR) corresponding to an RP% of greater than 7 percent, and PLT transfusion autonomy (PTA). Median occurrences of NRP, IPR, and PTA were on Days +5, +8, and +12 after transplantation, respectively. The RP% value at NRP (4%) was significantly lower compared to the IPR (15%) and PTA (14%). Thirty patients (64%) achieved PTA within 4 days after IPR. On Day +8, if RP% was greater than 7 percent, positive and negative predictive values for PTA within 4 days, specificity, and sensitivity were 79, 63, 66, and 76 percent, respectively. Fever between IPR and PTA was the only factor found to negatively influence PLT recovery (p = 0.02). All patients required at least one PLT transfusion. Among patients with rapid PLT recovery (IPR-PTA interval < 4 days; n = 30), half of them received one PLT transfusion after RP increase, which could be avoided. These encouraging results may allow us to reduce the prophylactic PLT transfusion according to patients RP% increase.

Immunoglobulin and IgG subclass levels in a regional pediatric cystic fibrosis clinic

The aim of this study was to report serum immunoglobulin (Ig) and IgG subclass levels in a large pediatric population with cystic fibrosis, and relate these to measures of disease severity. Total immunoglobulin levels were measured in 154 patients, and IgG subclass levels were measured in 136 patients and compared to age-related normal population data and to levels reported in previously published studies of children with cystic fibrosis. Clinical data were also collected: genotype; height, weight, and BMI standard deviation scores; FEV(1) (as percent predicted); Shwachmann-Kulczycki (S-K) and Northern chest X-ray scores; and Pseudomonas aeruginosa infection status. The clinical well-being of patients with hypo- or hyper-gammaglobulinemia was compared with age- and sex-matched control patients who had normal levels of gammaglobulin. IgG subclass levels were measured, and the results were compared with previous studies. Eleven patients had hypergammaglobulinemia (7.8% compared with 0-69% in the published literature). Patients with hypergammaglobulinemia had lower FEV(1) percent-predicted values, and worse S-K and Northern chest X-ray scores than controls. Three patients had hypogammaglobulinemia (1.9% compared with 0-10.8% in the published literature). There was no difference in any clinical parameter between controls and those with hypogammaglobulinemia. Nineteen patients (14%) had low levels of IgG1, and 40 patients (29%) had low levels of IgG2. The low percentage of patients with abnormally high immunoglobulin levels probably reflects the improved respiratory status of today's children with CF. The low percentage of those with low IgG probably reflects better nutritional status. The finding of worse lung function and clinical scores in patients with hypergammaglobulinemia agrees with the published literature. The high percentage of patients with low IgG2 was unexpected and was not previously reported. The clinical significance of this in patients with CF is unknown.

Residual Caries Detection Using Visible Fluorescence

This study investigated the ability of a new fluorescence method to detect residual caries in vitro. Gross caries was removed from 40 teeth with D2 caries. Samples were excited with violet-blue light and viewed through a 530-nm high-pass filter. Residual caries (orange-red fluorescing dentin) was detected in all samples. Further tooth substance was removed from half of the samples until no residual caries was detectable using the new method. Half of the samples remained untreated. A blinded examiner checked all samples for residual caries using DIAGNOdent, a visual tactile examination, and Caries Detector^® dye. Presence or absence of residual caries in each sample was determined using a fluorescent nucleic acid stain in conjunction with confocal microscopy. The new method, Visible Fluorescence, had the greatest sensitivity, specificity, percent correct score and predictive values of any of the methods tested. The new method had significantly higher percent correct score than any of the other methods and significantly higher specificity than visual tactile and Caries Detector. It was concluded that Visible Fluorescence is an improvement on the currently available aids for residual caries detection.

Pulmonary Function in Patients With Reduced Left Ventricular Function: Influence of Smoking and Cardiac Surgery

The impact of stable, chronic heart failure on baseline pulmonary function remains controversial. Confounding influences include previous coronary artery bypass or valve surgery (CABG), history of obesity, stability of disease, and smoking history. To control for some of the variables affecting pulmonary function in patients with chronic heart failure, we analyzed data in four patient groups, all with left ventricular (LV) dysfunction (LV ejection fraction [LVEF] < or =35%): (1) chronic heart failure, nonsmokers, no CABG (n = 78); (2) chronic heart failure, nonsmokers, CABG (n = 46); (3) chronic heart failure, smokers, no CABG (n = 40); and (4) chronic heart failure, smokers, CABG (n = 48). Comparisons were made with age- and gender-matched patients with a history of coronary disease but no LV dysfunction or smoking history (control subjects, n = 112) and to age-predicted norms. Relative to control subjects and percent-predicted values, all groups with chronic heart failure had reduced lung volumes (total lung capacity [TLC] and vital capacity [VC]) and expiratory flows (p < 0.05). CABG had no influence on lung volumes and expiratory flows in smokers, but resulted in a tendency toward a reduced TLC and VC in nonsmokers. Smokers with chronic heart failure had reduced expiratory flows compared to nonsmokers (p < 0.05), indicating an additive effect of smoking. Diffusion capacity of the lung for carbon monoxide (DLCO) was reduced in smokers and in subjects who underwent CABG, but not in patients with chronic heart failure alone. There was no relationship between LV size and pulmonary function in this population, although LV function (cardiac index and stroke volume) was weakly associated with lung volumes and DLCO. We conclude that patients with chronic heart failure have primarily restrictive lung changes with smoking causing a further reduction in expiratory flows.

Fluorodeoxyglucose whole-body positron emission tomography in colorectal cancer patients studied in routine daily practice.

To evaluate the routine clinical value of attenuation-corrected whole-body fluorodeoxyglucose positron emission tomography in colorectal cancer, a total of 59 patients who were referred for evaluation of suspected or proven colorectal cancers were studied. Positron emission tomography scans were recorded using a Siemens ECAT Exact 921/47. Median follow-up after the positron emission tomography study was 11 (mean, 12.3; range, 1-21) months. According to computed tomography, coloscopy, and ultrasound, we recorded eight apparently false-positive results. During later follow-up, however, three of those cases, which were negative with computed tomography, magnetic resonance imaging, sonography, or laparoscopy, turned out to be true-positive instead. In 3 patients, a primary colorectal cancer was suspected; in 26 patients, a recurrence of colorectal cancer was suspected. Eight patients were studied for follow-up after the history of colorectal cancer with no suspicion of recurrence. In 12 patients, the rise of serum tumor marker concentrations was the reason for the positron emission tomography study; 12 patients with known metastatic disease were also included ("restaging"). With regard to the entire patient population, we found an overall sensitivity of 100 percent, a specificity of 67 percent, and positive and negative predictive values of 92 and 100 percent, respectively. Being merely confirmative with respect to tumor recurrence or distant metastases in the majority of patients, positron emission tomography revealed a primary tumor in one patient and confirmed metastatic foci in several patients that had not been delineated by other imaging modalities. A whole-body positron emission tomography scan provides optimum conditions to locate metastatic lesions that might not be seen otherwise. There is a trend showing that positron emission tomography diagnostics as a consequence of early increased tumor markers is a highly sensitive combination, because computed tomography and magnetic resonance imaging were not as sensitive in early recurrences. Positron emission tomography, as performed in daily clinical practice, proved to be a powerful diagnostic tool in our subset of colorectal cancer patients.

The Lack of Predictive Value of Prostate Specific Antigen Density in the Detection of Prostate Cancer in Patients with Normal Rectal Examinations and Intermediate Prostate Specific Antigen Levels

Purpose The management of patients with a normal digital rectal examination and a prostate specific antigen (PSA) level of 4.0 to 10.0 ng./ml. remains controversial. To improve the specificity of cancer detection in this group, PSA density has been recommended with biopsies based on a PSA density of 0.15 or more. To evaluate PSA density as a discriminator of prostate cancer we enrolled patients in a prospective study. Materials and Methods A prospective evaluation was done of 44 consecutive patients with a palpably normal digital rectal examination and a serum PSA level of 4.0 to 10.0 ng./ml. enrolled during a 13-month period. All patients underwent transrectal ultrasound with sextant biopsies regardless of calculated PSA density. Results Overall, 8 of 44 men (18 percent) had prostate cancer. There was no significant difference in the mean PSA density between the patients with positive and negative biopsies (mean 0.12 and 0.15, respectively, p = 0.258). Also, there was no significant association between PSA or PSA density and a positive biopsy in multivariate analysis (p = 0.863). Receiver operating characteristic curves for PSA and PSA density failed to demonstrate any superior benefit for PSA density in this patient population. A PSA density of 0.15 was an unreliable indicator of cancer (sensitivity 12.5 percent, specificity 61.1 percent and positive predictive value 6.7 percent). Conclusions In our study, PSA density did not discriminate between patients with positive and negative biopsies, and in fact most cancers would not have been detected if a PSA density of 0.15 or more had been used as the sole indication for biopsy. Therefore, we recommend systematic biopsies in these patients independent of calculated PSA density.

Correlation Between Micturitional Urethral Pressure Profile and Pressure-Flow Criteria in Bladder Outlet Obstruction

Purpose We correlate micturitional urethral pressure profilometry with pressure-flow diagnoses of outlet obstruction. Materials and Methods Urodynamic evaluation was done of 86 consecutive men with voiding symptoms. Obstruction criteria were a micturitional urethral pressure profile (MUPP) gradient greater than 5 cm. water, Schafer's linear passive urethral resistance relation (PURR) greater than grade 1 and Abrams-Griffiths nomogram. Results Interpretable results were completed in 99 percent of the patients undergoing MUPP and 60 percent undergoing pressure-flow studies (p less than 0.00001). MUPP diagnosis agreed with PURR (p = 0.0015) and Abrams-Griffiths nomogram results (p = 0.00004). MUPP gradients correlated well with PURR (r = 0.70, p less than 0.00001). Using optimum cutoff values (11 cm. water), the sensitivity of MUPP was 83 percent, specificity 82 percent and positive predictive value 94 percent. Conclusions MUPP correlates well with and yields interpretable results more often than pressure-flow studies.

Selection of patients for laparoscopic pelvic lymphadenectomy prior to radical prostatectomy: A decision analysis

Indications for laparoscopic pelvic lymphadenectomy prior to radical prostatectomy have not been established. Criteria to predict lymph node metastases were derived from the preoperative evaluations of 164 prostate cancer patients undergoing pelvic lymphadenectomy. Decision analysis was used to determine which criteria would be optimal indicators for laparoscopic pelvic lymphadenectomy prior to intended radical prostatectomy. Besides a digital rectal examination suggesting uncontained tumor, which was the best indication for laparoscopic pelvic lymphadenectomy, the most useful criteria were sonographic tumor volume ≥ 3 cc and prostate-specific antigen (PSA) ≥ 20 ng/mL. If either parameter was met, the sensitivity for identifying patients with pelvic lymph node metastases was 88 percent and the positive predictive value was 42 percent. When both were met, the sensitivity fell to 47 percent but the positive predictive value increased to 67 percent. A combination of Gleason biopsy score and PSA was the best criterion that was independent of transrectal ultrasonography. Using a PSA ≥ 15 ng/mL for tumors with Gleason biopsy score ≥ 7 or a PSA ≥ 25 ng/mL for tumors with a Gleason biopsy score of 5–6 had a sensitivity of 71 percent and positive predictive value of 48 percent for identifying patients with pelvic lymph node metastases. In selecting patients for laparoscopic pelvic lymphadenectomy prior to radical retropubic prostatectomy, criteria with a positive predictive value greater than 39 percent maximize the utility of laparoscopic pelvic lymphadenectomy. Prior to radical perineal prostatectomy, laparoscopic pelvic lymphadenectomy will identify pelvic lymph node metastases that would otherwise be undetected by prostatectomy alone. The sensitivity of selection criteria, therefore, should be increased, as long as the positive predictive value remains above 20 percent.

Cinedefecography and electromyography in the diagnosis of nonrelaxing puborectalis syndrome.

A prospective study was undertaken to assess the correlation between electromyography (EMG) and cinedefecography (CD) for the diagnosis of nonrelaxing puborectalis syndrome (NRPR). Clinical criteria for NRPR included straining, incomplete evacuation, tenesmus, and the need for enemas, suppositories, or digitation. EMG criteria included failure to achieve a significant decrease in electrical activity of the puborectalis (PR) during attempted evacuation. CD criteria included either paradoxical contraction or failure of relaxation of the PR along with incomplete evacuation. In addition, other etiologies for incomplete evacuation, such as rectoanal intussusception or nonemptying rectocele, were excluded by proctoscopy and defecography in all cases. One hundred twelve patients with constipation, 81 females and 31 males, with a mean age of 59 (range, 12-83) years were studied by routine office evaluation, CD, and EMG. Forty-two patients (37 percent) had evidence of NRPR on CD (rectal emptying: none, 24; incomplete, 18). Twenty-eight of these patients (67 percent) also had evidence of NRPR on EMG. EMG findings of NRPR were present in 12 of 70 patients (17 percent) with normal rectal emptying. Conversely, 14 of 72 patients (19 percent) with normal PR relaxation on EMG had an NRPR pattern on CD. The sensitivity and specificity for the EMG diagnosis of NRPR were 67 percent and 83 percent, and the positive and negative predictive values were 70 percent and 80 percent, respectively. Conversely, if EMG is considered as the ideal test for the diagnosis of NRPR, CD had a sensitivity of 70 percent, a specificity of 80 percent, and positive and negative predictive values of 66 percent and 82 percent, respectively. In summary, sensitivity, specificity, and predictive values of EMG and CD are suboptimal. Therefore, a combination of these two tests is suggested for the diagnosis of NRPR.

A Discriminant Analysis Applied to Methacholine Bronchoprovocation Testing Improves Classification of Patients as Normal, Asthma, or COPD

Two discriminant functions, incorporating baseline measurements of pulmonary function and measures of airway responsiveness, were developed to improve patient classification into groups of normal, asthma, or COPD. Accuracy of group classification was compared between the usual laboratory method (single discriminating cut-off) and these new mathematically developed functions. Forty-five normal subjects, 27 asthmatic patients, and ten well-defined COPD patients were entered into the analysis. Measurements of airway responsiveness were determined by measurement of both specific airway conductance (SGaw) and spirometry (FEV1) after sequential inhalation of methacholine. A single discriminant cut-off using measures of SGaw (PD35) or FEV1 (PD20) does not sufficiently discriminate asthma from groups that contain normal and COPD subjects (67 to 71 percent predictive value). On the other hand, our discriminant functions demonstrated improved patient classification (positive predictive value, 88 to 89 percent). We conclude that bronchoprovocation tests used to evaluate the diagnosis of asthma should incorporate measures of baseline lung function into the analysis. This, we believe, is especially necessary when baseline lung function demonstrates minimal airflow obstruction and the possibility of other causes of airway disease exist.

Diagnostic Value of Telescoping Plugged Catheters in HIV-Infected Patients with Pulmonary Infiltrates

To assess the diagnostic value of telescoping plugged catheters (TPC) in human immunodeficiency virus (HIV)-infected patients with pulmonary infiltrates (PI), we performed a prospective clinical study in 71 episodes of fever and PI in 66 HIV-infected patients (five patients had two different episodes of fever and PI). A control group of 12 HIV-infected patients with fever and normal chest roentgenogram was also studied. In all patients and prior to antibiotic treatment (except in mechanically ventilated patients), a TPC using quantitative cultures (cutoff point established at 10(3) CFU/ml) and a bronchoalveolar lavage (BAL) sampling were performed via fiberoptic bronchoscope. The overall incidence of bacterial pneumonia in the study group was 21 percent. The TPC cultures resulted in a microbiologic diagnosis of bacterial pneumonia in eight patients (11 percent) from the study group and in one patient (8 percent) from the control group. The TPC sensitivity in diagnosing bacterial infections was 53 percent and specificity was 76 percent. Negative predictive value was 85 percent and positive predictive value was 38 percent. By means of BAL, 35 episodes from the study group and two from the control group were diagnosed as nonbacterial or mycobacterial pulmonary infections. Considering TPC and BAL together, diagnosis was performed in 42 cases of PI (59 percent). Twenty percent (17/83) of HIV-infected patients suffered from bacterial colonization of their lower airways (a TPC culture greater than or equal to 10(3) CFU/ml without clinical evidence of bacterial infection). We conclude that the combined use of TPC and BAL may be useful in HIV-infected patients with PI, since this combined use allows the proper diagnosis of bacterial and nonbacterial infections, thereby increasing the overall diagnostic accuracy. To distinguish bacterial colonization from pulmonary infection in HIV-infected patients with PI, the cutoff point of quantitative cultures of TPC may be 10(4) CFU/ml.