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Papadopoulou E, Bin Safar S, Khalil A, Hansel J, Wang R, Corlateanu A, Kostikas K, Tryfon S, Vestbo J, Mathioudakis AG. Inhaled versus systemic corticosteroids for acute exacerbations of COPD: a systematic review and meta-analysis. Eur Respir Rev 2024; 33:230151. [PMID: 38508668 PMCID: PMC10951861 DOI: 10.1183/16000617.0151-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/02/2023] [Indexed: 03/22/2024] Open
Abstract
This meta-analysis compares the efficacy and safety of inhaled versus systemic corticosteroids for COPD exacerbations.Following a pre-registered protocol, we appraised eligible randomised controlled trials (RCTs) according to Cochrane methodology, performed random-effects meta-analyses for all outcomes prioritised in the European Respiratory Society COPD core outcome set and rated the certainty of evidence as per Grading of Recommendations Assessment, Development and Evaluation methodology.We included 20 RCTs totalling 2140 participants with moderate or severe exacerbations. All trials were at high risk of methodological bias. Low-certainty evidence did not reveal significant differences between inhaled and systemic corticosteroids for treatment failure rate (relative risk 1.75, 95% CI 0.76-4.02, n=569 participants); breathlessness (mean change: standardised mean difference (SMD) -0.11, 95% CI -0.36-0.15, n=239; post-treatment scores: SMD -0.18, 95% CI -0.41-0.05, n=293); serious adverse events (relative risk 1.47, 95% CI 0.56-3.88, n=246); or any other efficacy outcomes. Moderate-certainty evidence implied a tendency for fewer adverse events with inhaled compared to systemic corticosteroids (relative risk 0.80, 95% CI 0.64-1.0, n=480). Hyperglycaemia and oral fungal infections were observed more frequently with systemic and inhaled corticosteroids, respectively.Limited available evidence suggests potential noninferiority of inhaled to systemic corticosteroids in COPD exacerbations. Appropriately designed and powered RCTs are warranted to confirm these findings.
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Affiliation(s)
- Efthymia Papadopoulou
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
- Both authors contributed equally to this work
| | - Sulaiman Bin Safar
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- Both authors contributed equally to this work
| | - Ali Khalil
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
| | - Jan Hansel
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- Acute Intensive Care Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ran Wang
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alexandru Corlateanu
- Department of Pulmonology and Allergology, State University of Medicine and Pharmacy "Nicolae Testemitanu", Chisinau, Moldova
| | | | - Stavros Tryfon
- Pulmonology Department, General Hospital of Thessaloniki "G. Papanikolaou", Thessaloniki, Greece
| | - Jørgen Vestbo
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK
- North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Guo HJ, Ye YL, Cao R, Liu ZH, He Q. Association between the cumulative dose of glucocorticoids before the development of pneumonia and death in patients receiving long-term glucocorticoids: a secondary analysis based on a Chinese cohort study. Front Med (Lausanne) 2023; 10:1175855. [PMID: 37547616 PMCID: PMC10399627 DOI: 10.3389/fmed.2023.1175855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Background The present study aimed to evaluate the association between the cumulative dose of glucocorticoids (GCs) and case fatality in hospitalized patients who developed pneumonia while receiving glucocorticoid therapy. Methods This retrospective cohort study included 625 patients receiving long-term GC treatment who were hospitalized with pneumonia (322 male and 303 female). Data were obtained from the Dryad Digital Repository and were used to perform secondary analysis. Multivariable Cox proportional hazard regression model and restricted cubic splines (RCS) were used to evaluate the association between the cumulative dose of GCs and case fatality. Sensitivity analyses and subgroup analyses were performed. Results The 30-day and 90-day death rates were 22.9 and 26.2%, respectively. After adjusting for potential confounders, compared with those in the lowest quintile (≤ 1.5 g), the Cox proportional hazard regression model analysis showed that patients with different cumulative doses of GCs (1.5 to 2.95, 2.95 to 5, 5 to 11.5, and > 11.5 g) had lower risks for 30-day death, with respective hazard ratios of 0.86 (95% CI, 0.52 to 1.42), 0.81 (0.49 to 1.33), 0.29 (0.15 to 0.55), and 0.42 (0.22 to 0.79). The multivariable-adjusted RCS analysis suggested a statistically significant N-shaped association between the cumulative dose of GCs and 30-day death. A higher cumulative dose of GC tended to first lead to an increase in 30-day death within 1.8 g, then to a statistically significant decrease until around 8 g [HR for 1 g = 0.82 (0.69 to 0.97)], and again to an increase afterward. Similar results were found in the subgroup analyses and sensitivity analyses. Conclusion N-shaped association between the cumulative dose of GCs and case fatality was observed in patients receiving long-term GC treatment who were hospitalized with pneumonia. Our findings may help physicians manage these patients.
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Affiliation(s)
- Hui-Jie Guo
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yi-Lu Ye
- Department of Rehabilitation Medicine, Key Laboratory of Biological Targeting Diagnosis, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Rong Cao
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Zhi-Hua Liu
- State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qun He
- Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
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Lang Q, Li L, Zhang Y, He X, Liu Y, Liu Z, Yan H. Development and Validation of a Diagnostic Nomogram for Pneumocystis jirovecii Pneumonia in Non-HIV-Infected Pneumonia Patients Undergoing Oral Glucocorticoid Treatment. Infect Drug Resist 2023; 16:755-767. [PMID: 36760781 PMCID: PMC9907006 DOI: 10.2147/idr.s398850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/14/2023] [Indexed: 02/05/2023] Open
Abstract
Purpose Pneumocystis jirovecii pneumonia (PJP) is an opportunistic but potentially fatal infection with increasing prevalence in HIV-free patients. Glucocorticoid therapy is one of the most important risk factors for PJP. The delay in diagnosis contributes to poor outcomes. Hence, the aim of this study was to develop and validate a nomogram for the diagnosis of PJP in patients with non-HIV-infected pneumonia who are undergoing oral glucocorticoid treatment. Patients and Methods This study was a retrospective, cross-sectional research. The development group included 434 patients who were admitted with pneumonia from 6 hospitals. Demographics, symptomatic features, laboratory and computed tomography data were analyzed using the least absolute shrinkage and selection operator (LASSO) to select potential diagnostic indicators. Binary logistic regression was used to develop a diagnostic nomogram. Another 119 patients with pneumonia admitted at Sichuan Provincial People's Hospital was used as the validation group. The diagnostic performance of the nomogram was measured by area under the receiver-operating-characteristics curve (AUC), calibration curves, and the net benefit by decision curve. Results PJP prevalence was 25.3% in the development group. LASSO regression revealed that age, lymphocyte count, fever, dry cough, respiratory failure, ground-glass opacity in lungs, glucocorticoid therapy duration, and immunosuppressive therapy were indicators of PJP. The nomogram showed robust discrimination, with an AUC of 0.82 (95% CI 0.77-0.86) in the development group and an AUC of 0.87 (95% CI 0.80-0.94) in the validation group, both showing acceptable calibration. In the decision curve analysis, our model consistently achieved a greater net benefit across almost all ranges of clinical thresholds. Conclusion We developed a nomogram with good diagnostic power for PJP diagnosis in pneumonia patients receiving oral glucocorticoids. This nomogram may help promote timely treatment of PJP and thus reduce the mortality rate in these patients.
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Affiliation(s)
- Qin Lang
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610000, People’s Republic of China
| | - Lijuan Li
- National Clinical Research Centre for Respiratory Diseases, China-Japan Friendship Hospital, Capital Medical University, Beijing, 100000, People’s Republic of China
| | - Yue Zhang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China
| | - Xing He
- School of Clinical Medicine, Chengdu Medical College, Chengdu, 610000, People’s Republic of China
| | - Yafeng Liu
- School of Medicine, Anhui University of Science and Technology, Huainan, 232000, People’s Republic of China,Anhui Province Engineering Laboratory of Occupational Health and Safety, Huainan, 232000, People’s Republic of China
| | - Zhen Liu
- The First Hospital of Liangshan Prefecture, Xichang, 615000, People’s Republic of China
| | - Haiying Yan
- Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, 610000, People’s Republic of China,Department of Pulmonary and Critical Care Medicine, Chengdu Qing Cheng Mt. Hospital, Chengdu, 610000, People’s Republic of China,Correspondence: Haiying Yan, Department of Pulmonary and Critical Care Medicine, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, No. 32 Sec 2, 1st Ring Road, Chengdu, Sichuan, 610000, People’s Republic of China, Tel/Fax +86-18981838295, Email
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Amratia DA, Viola H, Ioachimescu OC. Glucocorticoid therapy in respiratory illness: bench to bedside. J Investig Med 2022; 70:1662-1680. [DOI: 10.1136/jim-2021-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 11/07/2022]
Abstract
Each year, hundreds of millions of individuals are affected by respiratory disease leading to approximately 4 million deaths. Most respiratory pathologies involve substantially dysregulated immune processes that either fail to resolve the underlying process or actively exacerbate the disease. Therefore, clinicians have long considered immune-modulating corticosteroids (CSs), particularly glucocorticoids (GCs), as a critical tool for management of a wide spectrum of respiratory conditions. However, the complex interplay between effectiveness, risks and side effects can lead to different results, depending on the disease in consideration. In this comprehensive review, we present a summary of the bench and the bedside evidence regarding GC treatment in a spectrum of respiratory illnesses. We first describe here the experimental evidence of GC effects in the distal airways and/or parenchyma, both in vitro and in disease-specific animal studies, then we evaluate the recent clinical evidence regarding GC treatment in over 20 respiratory pathologies. Overall, CS remain a critical tool in the management of respiratory illness, but their benefits are dependent on the underlying pathology and should be weighed against patient-specific risks.
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Xia B, Song B, Zhang J, Zhu T, Hu H. Prognostic value of blood urea nitrogen-to-serum albumin ratio for mortality of pneumonia in patients receiving glucocorticoids: Secondary analysis based on a retrospective cohort study. J Infect Chemother 2022; 28:767-773. [PMID: 35272941 DOI: 10.1016/j.jiac.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/06/2022] [Accepted: 02/18/2022] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Previous studies have revealed that blood urea nitrogen-to-serum albumin ratio (BUN/ALB) is one of major risk factors of mortality in pneumonia. However, there are fewer scientific research about the correlation between BUN/ALB ratio and outcome of pneumonia in patients receiving glucocorticoids. This study was undertaken to explore the prognostic value of BUN/ALB ratio for mortality of pneumonia in patients receiving glucocorticoids. METHODS The present study was a retrospective cohort study. 1397 subjects receiving glucocorticoids alone or glucocorticoids and other immunosuppressants from six secondary and tertiary academic hospitals in China were analyzed. The endpoint of the study was 30-day mortality. It was noted that the entire study was completed by Li et al. and uploaded the data to the DATADRYAD website. The author only used this data for secondary analysis. RESULTS After adjusting potential confounders (age, sex, WBC, persistent lymphocytopenia, PLT, ALT, AST, Cr, high-dose steroid use, and COPD), non-linear relationship was detected between BUN/ALB ratio and 30-day mortality, whose point was 0.753. The effect sizes and the confidence intervals on the left and right sides of inflection point were 23.110 (7.157, 74.623) and 0.410 (0.074, 2.283), respectively. Subgroup analysis revealed the positive association was stronger among subjects with connective tissue disease. CONCLUSIONS The relationship between BUN/ALB ratio and 30-day mortality of pneumonia in patients receiving glucocorticoids is non-linear. BUN/ALB ratio is positively related with 30-day mortality when BUN/ALB ratio is less than 0.753.
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Affiliation(s)
- Bingtian Xia
- School of Medicine, Zhejiang University, Hangzhou, PR China; Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, PR China
| | - Bingxin Song
- School of Medicine, Zhejiang University, Hangzhou, PR China
| | - Jingcheng Zhang
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, PR China
| | - Tingjun Zhu
- Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, PR China
| | - Huixian Hu
- School of Medicine, Zhejiang University, Hangzhou, PR China; Department of Hematology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, PR China.
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Liu CY, Li C. Clinical Features and Risk Factors of Severe Pneumonia in Children With Acute Lymphoblastic Leukemia. Front Pediatr 2022; 10:813638. [PMID: 35601429 PMCID: PMC9120655 DOI: 10.3389/fped.2022.813638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/23/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This study aims to analyze the clinical characteristics of pediatric acute lymphoblastic leukemia (ALL) complicated by pneumonia and the risk factors of severe cases to preliminarily construct a prediction model for ALL complicated by severe pneumonia. METHODS A retrospective analysis was carried out on the clinical data of children diagnosed with ALL complicated by pneumonia hospitalized at the Department of Pediatrics of the Affiliated Hospital of Southwest Medical University between January 2013 and December 2020. The risk factors of severe ALL complicated by pneumonia were investigated with logistic regression analysis, and the risk prediction model was constructed. RESULTS A total of 116 cases of pediatric ALL complicated by pneumonia were analyzed. There were 71 cases of mild pneumonia and 45 cases of severe pneumonia. The main clinical manifestations were cough in 112 cases and fever in 109. Pathogens were detected in 23 cases. Multiple regression factor analysis indicated that the use of hormones (OR 4.001, 95% CI: 1.505-10.632), neutropenia or agranulocytosis (OR 7.472, 95% CI: 2.710-20.602), hemoglobin (Hb) < 90 g/L (OR 3.270, 95% CI: 1.256~8.516), and C-reactive protein (CRP) >15 mg/L (OR 3.253, 95% CI: 1.209~8.751) were independent risk factors that were associated with severe pneumonia. Logistic regression was used to establish the risk prediction model of ALL with severe pneumonia. The p-value was 0.659. The area under the receiver operating characteristic curve was 0.851, and the sensitivity and specificity were 84.4 and 71.8%, respectively. CONCLUSION The development of severe pneumonia may be affected by the use of hormones, neutropenia or agranulocytosis, Hb < 90 g/L, and CRP > 15 mg/L. The prediction model based on the risk factors is effective, which can provide a reference for the clinical evaluation of acute lymphoblastic leukemia with severe pneumonia.
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Affiliation(s)
- Chun-Yan Liu
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, Luzhou, China
| | - Cheng Li
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, China.,Sichuan Clinical Research Center for Birth Defects, Luzhou, China
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Sivapalan P, Rutishauser J, Ulrik CS, Leuppi JD, Pedersen L, Mueller B, Eklöf J, Biering-Sørensen T, Gottlieb V, Armbruster K, Janner J, Moberg M, Lapperre TS, Nielsen TL, Browatzki A, Mathioudakis A, Vestbo J, Schüetz P, Jensen JU. Effect of different corticosteroid regimes for hospitalised patients with exacerbated COPD: pooled analysis of individual participant data from the REDUCE and CORTICO-COP trials. Respir Res 2021; 22:155. [PMID: 34020641 PMCID: PMC8138920 DOI: 10.1186/s12931-021-01745-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/13/2021] [Indexed: 11/10/2022] Open
Abstract
Background Systemic corticosteroid administration for severe acute exacerbations of COPD (AECOPD) reduces the duration of hospital stays. Corticosteroid-sparing regimens have showed non-inferiority to higher accumulated dose regimens regarding re-exacerbation risk in patients with AECOPD. However, it remains unclear whether 14-day or 2–5-day regimens would result in shorter admission durations and changes in mortality risk. We explored this by analysing the number of days alive and out of hospital based on two randomised controlled trials with different corticosteroid regimens. Methods We pooled individual patient data from the two available multicentre randomised trials on corticosteroid-sparing regimens for AECOPD: the REDUCE (n = 314) and CORTICO-COP (n = 318) trials. In the 14-day regimen group, patients were older, fewer patients received pre-treatment with antibiotics and more patients received pre-treatment with systemic corticosteroids. Patients randomly allocated to the 14-day and 2–5-day regimens were compared, with adjustment for baseline differences. Results The number of days alive and out of hospital within 14 days from recruitment was higher for the 2–5 day regimen group (mean 8.4 days; 95% confidence interval [CI] 8.0–8.8) than the 14-day regimen patient group (4.2 days; 95% CI3.4–4.9; p < 0.001). The 14-day AECOPD group had longer hospital stays (mean difference, 5.4 days [standard error ± 0.6]; p < 0.0001) and decreased likelihood of discharge within 30 days (hazard ratio [HR] 0.5; 95% CI 0.4–0.6; p < 0.0001). Comparing the 14-day regimen and the 2–5 day regimen group showed no differences in the composite endpoint ‘death or ICU admission’ (odds ratio [OR] 1.4; 95% CI 0.8–2.3; p = 0.15), new or aggravated hypertension (OR 1.5; 95% CI 0.9–2.7; p = 0.15), or mortality risk (HR 0.8; 95% CI 0.4–1.5; p = 0.45) during the 6-month follow-up period. Conclusion 14-day corticosteroid regimens were associated with longer hospital stays and fewer days alive and out of hospital within 14 days, with no apparent 6-month benefit regarding death or admission to ICU in COPD patients. Our results favour 2–5 day regimens for treating COPD exacerbations. However, prospective studies are needed to validate these findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01745-5.
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Affiliation(s)
- Pradeesh Sivapalan
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark. .,Department of Internal Medicine, Zealand University Hospital, University of Copenhagen, 4000, Roskilde, Denmark.
| | - Jonas Rutishauser
- Department of Medicine, Clinical Trial Unit, Kantonsspital Baden, 4054, Baden, Switzerland.,Faculty of Medicine, University of Basel, 4001, Basel, Switzerland
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Jörg D Leuppi
- Faculty of Medicine, University of Basel, 4001, Basel, Switzerland.,University Clinic of Medicine, Kantonsspital Baselland, 4410, Liestal, Switzerland
| | - Lars Pedersen
- Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Beat Mueller
- University Clinic of Medicine, Kantonsspital Baselland, 4410, Liestal, Switzerland.,Medical University Department, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Josefin Eklöf
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark.,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Gottlieb
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Karin Armbruster
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Julie Janner
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Mia Moberg
- Department of Respiratory Medicine, Copenhagen University Hospital-Hvidovre, Hvidovre, Denmark
| | - Therese S Lapperre
- Department of Respiratory Medicine, Antwerp University Hospital, and Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Thyge L Nielsen
- Department of Respiratory and Infectious Diseases, Frederiksund and Hillerød Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Andrea Browatzki
- Department of Respiratory and Infectious Diseases, Frederiksund and Hillerød Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Alexander Mathioudakis
- The North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Jørgen Vestbo
- The North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Philipp Schüetz
- Faculty of Medicine, University of Basel, 4001, Basel, Switzerland.,Medical University Department, Kantonsspital Aarau, 5001, Aarau, Switzerland
| | - Jens-Ulrik Jensen
- Section of Respiratory Medicine, Department of Internal Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
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Li L, Hsu SH, Gu X, Jiang S, Shang L, Sun G, Sun L, Zhang L, Wang C, Ren Y, Wang J, Pan J, Liu J, Bin C. Aetiology and prognostic risk factors of mortality in patients with pneumonia receiving glucocorticoids alone or glucocorticoids and other immunosuppressants: a retrospective cohort study. BMJ Open 2020; 10:e037419. [PMID: 33109645 PMCID: PMC7592294 DOI: 10.1136/bmjopen-2020-037419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Long-term use of high-dose glucocorticoids can lead to severe immunosuppression and increased risk of treatment-resistant pneumonia and mortality. We investigated the aetiology and prognostic risk factors of mortality in hospitalised patients who developed pneumonia while receiving glucocorticoid therapy alone or glucocorticoid and other immunosuppressant therapies. DESIGN Retrospective cohort study. SETTING Six secondary and tertiary academic hospitals in China. PARTICIPANTS Patients receiving glucocorticoids who were hospitalised with pneumonia between 1 January 2013 and 31 December 2019. MAIN OUTCOMES We analysed the prevalence of comorbidities, microbiology, antibiotic susceptibility patterns, 30-day and 90-day mortality and prognostic risk factors. RESULTS CONCLUSIONS: A total of 716 patients were included, with pneumonia pathogens identified in 69.8% of patients. Significant morbidities occurred, including respiratory failure (50.8%), intensive care unit transfer (40.8%) and mechanical ventilation (36%), with a 90-day mortality of 26.0%. Diagnosis of pneumonia occurred within 6 months of glucocorticoid initiation for 69.7% of patients with Cytomegalovirus (CMV) pneumonia and 79.0% of patients with Pneumocystis jirovecii pneumonia (PCP). Pathogens, including Pneumocystis, CMV and multidrug-resistant bacteria, were identified more frequently in patients with persistent lymphocytopenia and high-dose glucocorticoid treatment (≥30 mg/day of prednisolone or equivalent within 30 days before admission). The 90-day mortality was significantly lower for non-CMV viral pneumonias than for PCP (p<0.05), with a similar mortality as CMV pneumonias (24.2% vs 38.1% vs 27.4%, respectively). Cox regression analysis indicated several independent negative predictors for mortality in this patient population, including septic shock, respiratory failure, persistent lymphocytopenia, interstitial lung disease and high-dose glucocorticoid use.Patients who developed pneumonia while receiving glucocorticoid therapy experienced high rates of opportunistic infections, with significant morbidity and mortality. These findings should be carefully considered when determining treatment strategies for this patient population.
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Affiliation(s)
- Lijuan Li
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Steven H Hsu
- Department of Medical Intensive Care Unit, Houston Methodist Hospital, Houston, Texas, USA
| | - Xiaoying Gu
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Shan Jiang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lianhan Shang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Guolei Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Lingxiao Sun
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhang
- Department of Pulmonary and Critical Care Medicine, National Center for Clinical Research on Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Chuan Wang
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Yali Ren
- Department of Pulmonary and Critical Care Medicine, Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jinxiang Wang
- Department of Respiratory and Critical Care Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jianliang Pan
- Department of Pulmonary and Critical Care Medicine, Second People's Hospital of Weifang, Weifang, China
| | - Jiangbo Liu
- Department of Pulmonary and Critical Care Medicine, Tianjin First Central Hospital, Tianjin, China
| | - Cao Bin
- Department of Pulmonary and Critical Care Medicine, Laboratory of Clinical Microbiology and Infectious Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Science; Tsinghua University-Peking University Joint Center for Life Sciences, China-Japan Friendship Hospital, Beijing, China
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Ehret N, Carlier N, Marey J, Rabbat A, Burgel PR, Roche N. [Aspergillus-related respiratory conditions and COPD: Diagnostic challenges]. Rev Mal Respir 2020; 37:308-319. [PMID: 32284206 DOI: 10.1016/j.rmr.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/11/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The relations between chronic obstructive pulmonary disease (COPD) and respiratory diseases due to Aspergillus spp. are not well understood. METHODS We analysed a retrospective series of patients hospitalized with a diagnosis of COPD and respiratory disease due to Aspergillus. Patients were identified between 2010 and 2015 from the medico-administrative database of Cochin hospital, Paris. Historical, clinical, biological, microbiological and imaging data were collected and described. Diagnoses were reclassified based on reference definitions and classifications from the literature. Patients were classified according to the type of Aspergillus-related diseases and risk factors were described. RESULTS Forty patients were identified. Classifiable Aspergillus-related respiratory conditions were confirmed in 26 of them including 12 allergic bronchopulmonary aspergillosis (ABPA), 8 chronic pulmonary aspergillosis (CPA), 1 invasive pulmonary aspergillosis (IPA) and 3 diagnostic associations ABPA/CPA. Other respiratory comorbidities were present in all cases of CPA and immunodepression was recorded for semi-invasive and invasive forms. Finally, 16 patients could not be classified, among whom Aspergillus related lung disease was considered as likely in one-half. CONCLUSION The complexity of the diagnosis of pulmonary aspergillosis is related to its multiple types with sometimes unclear distinctions. Any type of pulmonary aspergillosis can be observed in patients with COPD, depending on associated risks factors. It would be helpful to establish specific classifications adapted to patients with COPD. This will require larger, prospective, multicentre studies.
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Affiliation(s)
- N Ehret
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - N Carlier
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - J Marey
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - A Rabbat
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - P-R Burgel
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - N Roche
- Service de pneumologie, université Paris Descartes, groupe hospitalier Cochin, AP-HP, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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Abstract
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality despite adequate antibiotic therapy. It is the single most common cause of infection-related mortality in the United States. An exaggerated host inflammatory response can potentially be harmful to both the lung and host, and has been associated with treatment failure and mortality. Modulation of inflammatory response may, therefore, be theoretically beneficial. The anti-inflammatory and immunosuppressive effects of steroids seem an attractive therapeutic option in severe CAP patients. Available datapoint to overall shorter time to clinical stability and decreased length-of-stay in CAP patients, with a potential mortality benefit in severe CAP. The level of evidence is, however, low to moderate regarding mortality due to high heterogeneity and insufficient power of data. Furthermore, steroids were deleterious in influenza pneumonia and in patients with pneumococcal pneumonia data suggest a lack of efficacy and potential harm. Both European and American guidelines recommend not using corticosteroids in CAP. Patients who might benefit and those that can be harmed from steroids remain to be clearly identified, as does the ideal steroid for CAP patients, based on pharmacokinetic and pharmacodynamic properties. It is essential for future studies to avoid the same methodological bias present in the available data so that high-quality evidence on the true role of steroids in CAP can be provided.
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Affiliation(s)
- David Nora
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal
| | - Wagner Nedel
- Intensive Care Unit, Hospital Nossa Senhora Da Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Hospital De Clínicas De Porto Alegre, Post-Graduation Program (PPG) Pneumology,Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Jorge Salluh
- D'or Institute for Research and Education, Rio De Janeiro, Brazil
| | - Pedro Póvoa
- Polyvalent Intensive Care Unit, São Francisco Xavier Hospital, Centro Hospitalar De Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, CHRC, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
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11
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Watanabe N, Saito K, Kiritani A, Fujimoto S, Yamanaka Y, Fujisaki I, Hosoda C, Miyagawa H, Seki Y, Kinoshita A, Takeda H, Endo Y, Kuwano K. A case of invasive pulmonary aspergillosis diagnosed by transbronchial lung biopsy during treatment for diabetic ketoacidosis in a type 1 diabetic patient. J Infect Chemother 2019; 26:274-278. [PMID: 31542205 DOI: 10.1016/j.jiac.2019.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/26/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
Invasive pulmonary aspergillosis (IPA) patients with non-hematological malignancy are far less than with hematological malignancy patients. We encountered a very rare case of IPA in which type 1 diabetes was the only conceivable risk factor. Further, according to the diagnostic categories of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) criteria for IPA, the frequency of proven diagnosis is very low. Here we report a proven IPA, which rapidly developed when the patient with type 1 diabetes was being treated for diabetic ketoacidosis, which was successfully treated with the combination therapy of voriconazole (VRCZ) and micafungin (MCFG), based on early diagnosis using bronchoscopy.
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Affiliation(s)
- Naoaki Watanabe
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan.
| | - Keisuke Saito
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Ayu Kiritani
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Shota Fujimoto
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Yumie Yamanaka
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Ikumi Fujisaki
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Chiaki Hosoda
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Hanae Miyagawa
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Yoshitaka Seki
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Akira Kinoshita
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Hiroshi Takeda
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Yasuhiko Endo
- Department of Pathology, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Kazuyoshi Kuwano
- Division of Respiratory Medicine, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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12
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Mohamed AZ, Moharrm AM, Ghanem MK, Makhlouf HA, El-Gezawy EM, Youssif SF. Role of comorbidities in acquiring pulmonary fungal infection in chronic obstructive pulmonary disease patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2016. [DOI: 10.4103/1687-8426.193629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Popovic M, Blum CA, Nigro N, Mueller B, Schuetz P, Christ-Crain M. Benefit of adjunct corticosteroids for community-acquired pneumonia in diabetic patients. Diabetologia 2016; 59:2552-2560. [PMID: 27614658 DOI: 10.1007/s00125-016-4091-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/10/2016] [Indexed: 10/21/2022]
Abstract
AIMS/HYPOTHESIS We have recently shown that adjunct prednisone shortens the time taken to reach clinical stability (time to clinical stability, TTCS) in patients with community-acquired pneumonia (CAP). Considering the hyperglycaemic effects of prednisone, there are concerns about the efficacy and safety of this therapy for diabetic patients with CAP. Our objective was to evaluate whether diabetes and/or hyperglycaemia on admission to hospital has an influence on the effect of corticosteroids on outcome in a well-defined cohort of patients with CAP. METHODS This is a preplanned subanalysis of a prospective randomised, double-blind placebo-controlled multicentre trial. Patients aged 18 years or older with CAP were eligible and were recruited from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomised (1:1 ratio) to receive either 50 mg of prednisone daily for 7 days or placebo. Allocation was concealed with a prespecified computer-generated randomisation list. Patients, treating physicians, investigators and data assessors were masked to treatment allocation. The primary endpoint was TTCS; secondary endpoints were length of stay, mortality, duration of antibiotic treatment, CAP complications and new insulin requirement at day 30. Furthermore, we analysed whether these endpoints were influenced by a glycaemic dysregulation during the study time. RESULTS Of 802 patients randomised (n = 402 in the prednisone, n = 400 in the placebo group), 726 patients were treated per protocol and included in this analysis (n = 362 in the prednisone, n = 364 in the placebo group). Nineteen per cent of 726 patients had diabetes mellitus (n = 66 in the prednisone group, n = 72 in the placebo group). Adjunct prednisone shortened TTCS in diabetic and non-diabetic patients (HR 1.65 [95% CI 1.16, 2.35], p = 0.007; 1.30 [95% CI 1.10, 1.53], p = 0.002) with no evidence for effect modification by diabetes in interaction analysis (p = 0.44). No difference was found in other clinically relevant endpoints. Although adjunct prednisone was associated with glycaemic dysregulation, this did not translate into worse clinical outcomes in either group, and there was no difference in secondary endpoints. CONCLUSIONS/INTERPRETATION The benefit of adjunct prednisone in CAP patients is also valid for those with diabetes or hyperglycaemia on admission. Hyperglycaemia in diabetic patients or due to adjunct prednisone did not have a negative effect on outcome. TRIAL REGISTRATION ClinicalTrials.gov NCT00973154 FUNDING : This study was supported by a grant from the Swiss National Foundation and by the Nora van Meeuwen Häfliger Stiftung and the Gottfried Julia Bangerter-Rhyner Stiftung.
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Affiliation(s)
- Milica Popovic
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Claudine A Blum
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
- Medical University Clinic, Departments of Internal and Emergency Medicine and Department of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicole Nigro
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Beat Mueller
- Medical University Clinic, Departments of Internal and Emergency Medicine and Department of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Clinic, Departments of Internal and Emergency Medicine and Department of Endocrinology, Diabetology and Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetology and Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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Wang Y, Zhang X, Feng X, Liu X, Deng L, Liang ZA. Expression of Toll-like receptor 4 in lungs of immune-suppressed rat with Acinetobacter baumannii infection. Exp Ther Med 2016; 12:2599-2605. [PMID: 27703512 PMCID: PMC5038893 DOI: 10.3892/etm.2016.3624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/18/2016] [Indexed: 02/05/2023] Open
Abstract
Toll-like receptor 4 (TLR4) is involved in the regulation of host responses to Acinetobacter baumannii (A. baumannii). The aim of the present study was to examine the function of TLR4 in lung inflammation in immune-suppressed rats with A. baumannii infection. A total of 72 Sprague-Dawley male rats were randomly divided into the control, A. baumannii infection and immune-suppressed infection groups. The immune-suppressed infection group was treated with 100 mg/kg hydrocortisone by subcutaneous injection every other day for 2 weeks prior to A. baumannii infection. Lung tissue was obtained on the 3rd and 7th day after tracheal inoculation with A. baumannii. The expression of TLR4 in bronchial and alveolar epithelial cells, and alveolar macrophage was examined using immunohistochemistry. The levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α in bronchoalveolar lavage fluid were detected using ELISA. The results showed that in the control group, the expression of TLR4 was upregulated in the bronchial and alveolar epithelial, and alveolar macrophages, and the levels of IL-6 and TNF-α were increased in the early phase of A. baumannii infection. On the 7th day, no significant difference in the levels of IL-6 and TNF-α was observed between the A. baumannii infection and control groups. Conversely, the expression of TLR4 was downregulated in the immune-suppressed group, and the levels of IL-6 and TNF-α were reduced on the 3rd day after infection. In the subsequent observation period, the expression of TLR4 was upregulated and the levels of IL-6 and TNF-α were increased. In conclusion, the results show a critical role of TLR4 in mediating effective immune response in the lung of rat with A. baumannii infection.
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Affiliation(s)
- Yanmei Wang
- Department of Intensive Care Unit, Sichuan Second Hospital of Traditional Chinese Medicine, Chengdu, Sichuan 610031, P.R. China
| | - Xiaohong Zhang
- Department of Emergency Intensive Care Unit, Sichuan Academy of Medical Sciences and Sichuan Province People's Hospital, Chengdu, Sichuan 610072, P.R. China
| | - Xuanlin Feng
- Department of Emergency Intensive Care Unit, Sichuan Academy of Medical Sciences and Sichuan Province People's Hospital, Chengdu, Sichuan 610072, P.R. China
| | - Xiaoshu Liu
- Department of Emergency Intensive Care Unit, Sichuan Academy of Medical Sciences and Sichuan Province People's Hospital, Chengdu, Sichuan 610072, P.R. China
| | - Lei Deng
- Department of Emergency Intensive Care Unit, Sichuan Academy of Medical Sciences and Sichuan Province People's Hospital, Chengdu, Sichuan 610072, P.R. China
| | - Zong-An Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, P.R. China
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15
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16
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Cho SH, Park HJ, Lee JH, Kim HJ, Cho S, Yoon CY, Kim WS. Monitoring of 35 illegally added steroid compounds in foods and dietary supplements. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2014; 31:1470-5. [DOI: 10.1080/19440049.2014.946100] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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17
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Sanz F, Restrepo MI, Fernández-Fabrellas E, Cervera A, Briones ML, Novella L, Aguar MC, Chiner E, Fernandez JF, Blanquer J. Does prolonged onset of symptoms have a prognostic significance in community-acquired pneumonia? Respirology 2014; 19:1073-9. [PMID: 24995803 DOI: 10.1111/resp.12346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 01/13/2014] [Accepted: 05/13/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Severity assessment is made at the time of the initial clinical presentation in patients with community-acquired pneumonia (CAP). It is unclear how the gap between time of presentation and duration of symptoms onset may impact clinical outcomes. Here we evaluate the association of prolonged onset of symptoms (POS) and the impact on clinical outcomes among hospitalized patients with CAP. METHODS This was a prospective, multicentre study of CAP in Spain. The primary outcomes were the clinical factors associated with POS defined as days from symptoms onset to pneumonia diagnosis >7 days. The secondary outcomes were intensive care unit (ICU) admission, the presence of suppurative complications, septic shock and 30-day mortality. RESULTS We enrolled 1038 patients diagnosed of CAP: 152 (14.6%) patients had a POS. In multivariate analysis, the presence of prior corticosteroid therapy, alcohol abuse, prior antibiotic therapy, and confusion, urea, respiratory rate, blood pressure and age 65 years or older score 0-1 was independently associated with POS. Patients with POS had a higher incidence of suppurative complications, but not of 30-day mortality when compared with a shorter onset of symptoms. CONCLUSIONS Approximately 15% of patients diagnosed with CAP had POS. Risk factors associated with POS were previous corticosteroids and antibiotic therapy, alcoholism and less severe pneumonia. POS was associated with a higher rate of suppurative complications and less need for ICU admission.
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Affiliation(s)
- Francisco Sanz
- Pulmonology Department, Consorci Hospital General Universitari de Valencia, Valencia, Spain
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18
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Aspergillus in the lower respiratory tract of immunocompetent critically ill patients. J Infect 2014; 69:284-92. [PMID: 24924557 DOI: 10.1016/j.jinf.2014.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 04/05/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To shed light on the meaning of Aspergillus-positive lower-respiratory-tract samples in non immunocompromized critically ill patients. METHODS Multicentre matched case-control (1:5) study. We used prospectively collected data to identify risk factors for Aspergillus-positive specimens, as well as outcomes in Aspergillus-positive patients. RESULTS 66 cases (5 with definite invasive pulmonary aspergillosis (IPA), 18 with probable IPA, and 43 colonisations) were matched to 330 controls. In the multivariate conditional logistic model, independent risk factors for at least one Aspergillus-positive respiratory-tract specimen were worse SAPSII at admission [OR, 1.10; 95%CI, 1.00-1.21], ARDS [OR, 2.64; 95%CI, 1.29-5.40]; long-term steroid therapy [OR, 4.77; 95%CI, 1.49-15.23]; steroid therapy started in the ICU [OR, 11.03; 95%CI, 4.40-27.67]; and bacterial infection [OR, 2.73; 95%CI, 1.37-5.42]. The risk of death, compared to the controls, was not higher in the cases overall [HR, 0.66; 95%CI, 0.41-1.08; p = 0.1] or in the subgroups with definite IPA [HR, 1.60; 95%CI, 0.43-5.94; p = 0.48], probable IPA [HR, 0.84; 95%CI, 0.28-2.50; p = 0.76], or colonisation [HR, 0.58; 95%CI, 0.33-1.02; p = 0.06]. In cases who received antifungal therapy, mortality was not lower than in untreated cases [HR, 0.67; 95%CI, 0.36-1.24; p = 0.20]. CONCLUSIONS In critically ill immunocompetent patients, risk factors for presence of Aspergillus in lower respiratory tract specimens are steroid therapy (either chronic or initiated in the ICU), ARDS, and high severity of the acute illness. Prospective studies are warranted to further examine these risk factors and to investigate immune functions as well as the impact of antifungal therapy on patient outcomes.
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Schweer KE, Bangard C, Hekmat K, Cornely OA. Chronic pulmonary aspergillosis. Mycoses 2013; 57:257-70. [PMID: 24299422 DOI: 10.1111/myc.12152] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 09/28/2013] [Accepted: 10/10/2013] [Indexed: 01/15/2023]
Abstract
Chronic pulmonary aspergillosis (CPA) is a group of consuming diseases usually presenting with prolonged and relapsing cough, dyspnoea and weight loss. Acute symptoms such as haemoptysis and bronchial or pulmonary haemorrhage may occasionally occur. CPA affects patients with underlying pulmonary conditions, for example, chronic obstructive pulmonary disease or mycobacteriosis or common immunosuppressive conditions such as diabetes. Precise epidemiology is unknown, and while prevalence is considered low the chronic and relapsing nature of the disease challenges the treating physician. Diagnostics largely rely on serologic Aspergillus precipitins and findings on thoracic computed tomography. The latter are manifold comprising cavity formation, pleural involvement and sometimes aspergilloma. Other markers for aspergillosis are less helpful, in part due to the non- or semi-invasive nature of these forms of Aspergillus infection. Various antifungals were shown to be effective in CPA treatment. Azoles are the most frequently applied antifungals in the outpatient setting, but are now compromised by findings of Aspergillus resistance. Long-term prognosis is not fully elucidated and may be driven by the underlying morbidities. Prospective registry-type studies may be suitable to systematically broaden our CPA knowledge base. This article gives an overview of the available literature and proposes a clinical working algorithm for CPA management.
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Affiliation(s)
- K E Schweer
- 1st Department of Internal Medicine, Center for Clinical Studies II in Infectious Diseases, University Hospital Cologne, Cologne, Germany
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Mannu GS, Loke YK, Curtain JP, Pelpola KN, Myint PK. Prognosis of multi-lobar pneumonia in community-acquired pneumonia: a systematic review and meta-analysis. Eur J Intern Med 2013; 24:857-63. [PMID: 23747042 DOI: 10.1016/j.ejim.2013.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 04/30/2013] [Accepted: 05/02/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pneumonia is the leading cause of infection related mortality. Multilobar pneumonia (MLP) may have poorer outcomes and is a constituent of some prognostic indices. Our aim was to systematically-review and meta-analyse the impact of multi-lobar involvement in pneumonia. METHODS We searched PubMed in June 2012 for studies reporting on the association between MLP and clinical outcomes. Potentially relevant studies were cross checked by two independent reviewers before final inclusion. Odds-ratios (OR) for the association between MLP and mortality, unfavourable outcomes, and poor treatment response were pooled using random effects meta-analysis. RESULTS Twenty-two studies were included in this report. There were a total of 11,456 pneumonia patients including 2897 (25.3%) patients with MLP. As there was substantial clinical and statistical heterogeneity in the overall dataset, we limited the main meta-analysis to patients with community-acquired pneumonia (CAP). This showed that MLP was associated with increased mortality, OR 2.57 (95% CI: 1.83-3.61), with no statistical heterogeneity (I(2)=0%). Evidence from other settings suggests that MLP may also be associated with higher likelihood of other poor outcomes such as worsening clinical/radiological status, delayed resolution, and need for mechanical ventilation. CONCLUSION MLP appears to be an independent risk factor for mortality in CAP. It may be possible to improve commonly used prognostic indices in CAP by addition of MLP as a criterion.
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Affiliation(s)
- Gurdeep Singh Mannu
- Division of Medicine, Norfolk and Norwich University Hospital, Norfolk NR4 7UY, UK; Oxford University Hospitals, Oxford, OX3 7LE, UK.
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Nagy B, Gaspar I, Papp A, Bene Z, Nagy B, Voko Z, Balla G. Efficacy of methylprednisolone in children with severe community acquired pneumonia. Pediatr Pulmonol 2013; 48:168-75. [PMID: 22588852 DOI: 10.1002/ppul.22574] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 02/14/2012] [Accepted: 02/29/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND The clinical value of adjuvant corticosteroid treatment in community-acquired pneumonia (CAP) seemed to be controversial in adults, and even less data are available on the use of corticosteroids in children with CAP. MATERIALS AND METHODS In this study, we investigated the efficacy of a 5-day adjuvant methylprednisolone therapy to imipenem in 29 children with severe CAP. In parallel, 30 subjects with the same disease were treated with imipenem and placebo, and the two study groups were compared based on the different parameters of the primary and secondary end points. The primary end points were the duration of fever, the levels of white blood cells (WBC) and high sensitive C-reactive protein (hsCRP). Secondary end points were the length of hospital stay, and the number of severe complications with or without surgical interventions. RESULTS The additive methylprednisolone treatment significantly reduced the duration of fever with 2.5 days, the WBC counts (P = 0.014), the hsCRP levels showing a 48.7% decrease, and the length of hospital stay with 5.2 days versus the placebo group. Moreover, patients treated on imipenem alone had twice more complications and four times more invasive interventions compared to those on the combined therapy. CONCLUSIONS The 5-day methylprednisolone therapy with imipenem was found effective in children having severe CAP. However, trials with larger cohorts are needed to study further beneficial effects of corticosteroids in children with CAP.
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Affiliation(s)
- Bela Nagy
- Department of Pediatrics, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.
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Invasive pulmonary aspergillosis due to Emericella nidulans var. echinulata, successfully cured by voriconazole and micafungin. J Clin Microbiol 2013; 51:1327-9. [PMID: 23363828 DOI: 10.1128/jcm.02487-12] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 78-year-old male who was undergoing prolonged glucocorticoid treatment experienced cough and expectoration for 2 weeks. Galactomannan antigen analysis and a chest computed tomography (CT) scan suggested a diagnosis of invasive pulmonary aspergillosis. DNA sequencing indicated that Emericella nidulans var. echinulata was the causative agent. A combination of voriconazole and micafungin successfully treated the illness.
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Association between systemic corticosteroids and outcomes of intensive care unit-acquired pneumonia. Crit Care Med 2012; 40:2552-61. [PMID: 22732293 DOI: 10.1097/ccm.0b013e318259203d] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The use of corticosteroids is frequent in critically-ill patients. However, little information is available on their effects in patients with intensive care unit-acquired pneumonia. We assessed patients' characteristics, microbial etiology, inflammatory response, and outcomes of previous corticosteroid use in patients with intensive care unit-acquired pneumonia. DESIGN Prospective observational study. SETTING Intensive care units of a university teaching hospital. PATIENTS Three hundred sixteen patients with intensive care unit-acquired pneumonia. Patients were divided according to previous systemic steroid use at onset of pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Survival at 28 days was analyzed using Cox regression, with adjustment for the propensity for receiving steroid therapy. One hundred twenty-five (40%) patients were receiving steroids at onset of pneumonia. Despite similar baseline clinical severity, steroid treatment was associated with decreased 28-day survival (adjusted hazard ratio for propensity score and mortality predictors 2.503; 95% confidence interval 1.176-5.330; p = .017) and decreased systemic inflammatory response. In post hoc analyses, steroid treatment had an impact on survival in patients with nonventilator intensive care unit-acquired pneumonia, those with lower baseline severity and organ dysfunction, and those without etiologic diagnosis or bacteremia. The cumulative dosage of corticosteroids had no significant effect on the risk of death, but bacterial burden upon diagnosis was higher in patients receiving steroid therapy. CONCLUSIONS In critically-ill patients, systemic corticosteroids should be used very cautiously because this treatment is strongly associated with increased risk of death in patients with intensive care unit-acquired pneumonia, particularly in the absence of established indications and in patients with lower baseline severity. Decreased inflammatory response may result in delayed clinical suspicion of intensive care unit-acquired pneumonia and higher bacterial count.
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Malave A, Laserna E, Sibila O, Mortensen EM, Anzueto A, Restrepo MI. Impact of prior systemic corticosteroid use in patients admitted with community-acquired pneumonia. Ther Adv Respir Dis 2012. [PMID: 23179232 DOI: 10.1177/1753465812458985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Limited information is available regarding the impact of prior outpatient use of systemic corticosteroids (SCS) in patients subsequently developing community-acquired pneumonia (CAP). We investigate the effects of prior SCS on severity of illness, microbiology and clinical outcomes for patients hospitalized with CAP. METHODS A retrospective cohort study of subjects with CAP (according to International Classification of Diseases, 9th edition codes) was conducted over a 3-year period at two tertiary teaching hospitals. Subjects were considered to be SCS users if they received oral corticosteroids prior to admission. Primary outcomes were severity of illness, microbiology and 30-day mortality. RESULTS Data were abstracted on 698 patients [prior SCS users, 75 (10.7%) versus prior non-SCS users 623 (89.3%)]. Prior SCS users were more likely to have chronic obstructive pulmonary disease. No differences were found in severity of disease at admission, microbiological etiology including opportunistic and drug-resistant pathogens and clinical outcomes, including 30-day mortality, intensive care unit admission, length of hospital stay, need for mechanical ventilation and need for vasopressors. CONCLUSION Prior SCS use is not associated with increased 30-day mortality for patients hospitalized with CAP. In addition, no differences were found in either the severity of the disease at the time of presentation or in the presence of the resistant or opportunistic pathogens among groups.
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Affiliation(s)
- Adriel Malave
- University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, TX, USA
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Abstract
PURPOSE OF REVIEW This review evaluates the potential benefits as well as adverse effects from adjunctive therapy with systemic steroids in patients with pneumonia: either mild-to-moderate or severe, community-acquired or hospital-acquired, of bacterial or of viral origin (in particular H1N1 viral infection). RECENT FINDINGS Steroids potentially modulate the marked and persistent activation of the immune system in pneumonia. However, several recent randomized controlled trials and large prospective observational studies have repeatedly shown that steroids had no impact on survival, the clinical event of interest, but in severe pneumonia some studies pointed to potential harmful effect. In addition, adverse effects, namely hyperglycemia, superinfections, as well as increased length-of-stay, were frequent findings in the steroid-treated patients. SUMMARY According to the current evidence, there are no data to support the well tolerated use of systemic steroids as a standard of care in pneumonia, neither in mild-to-moderate and severe, nor in bacterial and viral infection. Clinical and basic research should work together to improve trial designs to identify reliable surrogate markers of outcome, in particular of mortality. This may improve the patient selection and facilitate the identification of subgroups that can benefit from adjunctive steroid therapy.
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Nemec A, Pavlica Z, Nemec-Svete A, Eržen D, Milutinović A, Petelin M. Aerosolized clindamycin is superior to aerosolized dexamethasone or clindamycin-dexamethasone combination in the treatment of severePorphyromonas gingivalisaspiration pneumonia in an experimental murine model. Exp Lung Res 2011; 38:9-18. [DOI: 10.3109/01902148.2011.632063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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Cave AC, Hurst MM. The use of long acting β2-agonists, alone or in combination with inhaled corticosteroids, in Chronic Obstructive Pulmonary Disease (COPD). Pharmacol Ther 2011; 130:114-43. [DOI: 10.1016/j.pharmthera.2010.12.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 12/20/2010] [Indexed: 12/22/2022]
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Corticoides en la neumonía: argumentos a favor. Arch Bronconeumol 2011; 47:222-3. [DOI: 10.1016/j.arbres.2011.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 03/01/2011] [Accepted: 03/03/2011] [Indexed: 11/24/2022]
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Chen IJ, Tsai WP, Wu YJJ, Luo SF, Ho HH, Liou LB, Chen JY, Kuo CF, Chang HC, Yang CH, Yu KH. Infections in polymyositis and dermatomyositis: analysis of 192 cases. Rheumatology (Oxford) 2010; 49:2429-37. [DOI: 10.1093/rheumatology/keq279] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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30
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Not Your Typical Chronic Obstructive Pulmonary Disease Exacerbation: Aspergillus Tracheobronchitis in a Nonclassical Immunocompromised Host. South Med J 2010; 103:361-5. [DOI: 10.1097/smj.0b013e3181d39008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sanz Herrero F, Malanda NM, Veiga BM, Sanjuán López MP. Nuevos retos en la neumonía comunitaria. Arch Bronconeumol 2010; 46 Suppl 6:22-6. [DOI: 10.1016/s0300-2896(10)70039-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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32
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Viasus D, Garcia-Vidal C, Gudiol F, Carratalà J. Statins for community-acquired pneumonia: current state of the science. Eur J Clin Microbiol Infect Dis 2009; 29:143-52. [DOI: 10.1007/s10096-009-0835-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 10/17/2009] [Indexed: 01/13/2023]
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Twice Daily Fractionated Dose Administration of Prednisolone Compared to Standard Once Daily Administration to Patients with Glomerulonephritis or with Kidney Transplants*. ACTA ACUST UNITED AC 2009; 104:429-33. [DOI: 10.1007/s00063-009-1091-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
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Akimoto T, Saito O, Inoue M, Nishino K, Onishi A, Kotoda A, Ando Y, Muto S, Kusano E. Rapid formation of Aspergillus mycetoma in a patient receiving corticosteroid treatment. Serial radiographic observation over two months. Intern Med 2007; 46:733-7. [PMID: 17541225 DOI: 10.2169/internalmedicine.46.6238] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This study presents the case of rapidly progressing pulmonary aspergillosis in a 47-year-old woman who had healed cavitations of pulmonary tuberculosis in the right upper lobe. She had been treated for pulmonary tuberculosis seven years prior to admission. The initial manifestations of the disease on admission included cough, dyspnea, hemoptysis, pulmonary infiltrate, and renal failure. As anti-myeloperoxidase anti-neutrophil cytoplasmic antibodies (MPO-ANCA) were positive, she was diagnosed with ANCA-associated vasculitis and treated with corticosteroids. This treatment resulted in remission of the vasculitis. However, she developed new pulmonary symptoms and an enlarged cavitary lesion associated with the rapid formation of a fungal, ball-shaped shadow that was serially observed by radiological analysis. Pulmonary resection was finally performed because of acute progressive respiratory failure due to massive recurrent hemoptysis. A subsequent pathological analysis revealed a mass of hyphae with acute-angle branching, features consistent with Aspergillus, within the cavitary lesion, and she was diagnosed with pulmonary aspergillosis. The rapid development of pulmonary aspergillosis associated with the formation of an Aspergillus mycetoma should be attributed to the loss of normal immune mechanisms due to immunosuppressive treatment.
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Affiliation(s)
- Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Shimotsuke.
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Vallès X, Marcos A, Pinart M, Piñer R, Marco F, Mensa JM, Torres A. Hospitalized community-acquired pneumonia due to Streptococcus pneumoniae: Has resistance to antibiotics decreased? Chest 2006; 130:800-6. [PMID: 16963678 DOI: 10.1378/chest.130.3.800] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To determine the incidence and trends of pneumococcal community-acquired pneumonia (CAP) resistant to antibiotics, to describe clinical and microbiological features of pneumococcal CAP, and to ascertain prognostic risk factors in a third-level hospital. DESIGN AND SETTING We performed a prospective study of all well-defined pneumococcal CAP hospitalizations in the Hospital Clínic de Barcelona (Spain) over 2 years of follow-up, and results were compared with a previous study. MEASUREMENTS AND RESULTS One hundred twenty-five patients were included (mean age, 59.6 years; 71.2% male and 28.8% female). Mortality was 7% (n = 9). Twenty-four percent were HIV-1 seropositive (n = 30), and 53% had at least one comorbidity (n = 65). Nonsusceptibility to penicillin, ceftriaxone, and erythromycin accounted for 34%, 9%, and 33%, respectively. A decrease in penicillin (p = 0.01) and cephalosporin (p < 0.001) resistance was observed on comparison with a previous study, while macrolide resistance remained unchanged. Serotype 1 infection was overrepresented (8%, n = 10). A bad outcome was related to female gender (relative risk [RR], 9.1; confidence interval [CI], 1.3 to 61.3), pleural effusion (RR, 13.35; CI, 1.9 to 93.1), and prior oral corticoid intake (RR, 10.59; CI, 1.2 to 91.2), whereas drug-resistant strains were not. CONCLUSIONS We found a decrease in drug resistance compared with a previous report and a relatively high incidence of serotype 1 pneumococcal CAP. We also observed a high prevalence of HIV-1 infection among individuals with pneumococcal pneumonia. We confirm the lack of association of drug resistance with mortality and length of hospitalization. Mortality was associated with female gender, pleural effusion, and previous oral corticoid treatment. These results should be better ascertained in further studies.
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Affiliation(s)
- Xavier Vallès
- Institut Clínic de Pneumologia i Cirurgia Toràcica, Hospital Clínic de Barcelona, Villarroel 170, 08036, Barcelona, Spain
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Rañó A, Agustí C, Sibila O, Torres A. Associated inflammatory response in pneumonia: role of adjunctive therapy with glucocorticoids. Curr Opin Infect Dis 2006; 19:179-84. [PMID: 16514343 DOI: 10.1097/01.qco.0000216629.51563.f8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This article reviews the potential use of glucocorticoids as adjunctive therapy in the management of patients with severe bacterial pneumonia or pulmonary infections of other etiologies. RECENT FINDINGS The importance of an adequate assessment of the inflammatory process and the appearance of inflammatory markers that correlate with the severity of pneumonia is underlined. A recent randomized clinical trial indicates that adjunctive treatment of severe community-acquired pneumonia with glucocorticoids reduces complications and improves survival. The role of glucocorticoids in other lung infections is also reviewed. The design of new compounds with similar anti-inflammatory properties to classical glucocorticoids but with significantly fewer side effects constitutes a specific challenge for the near future. SUMMARY Although adjunctive treatment with glucocorticoids in severe pneumonia is probably indicated, further randomized clinical trials are urgently needed to confirm the preliminary positive results. In this regard, a proper evaluation of the inflammatory response is likely to be essential for the accurate selection of the target population.
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Affiliation(s)
- Ana Rañó
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, Institut d'Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Villaroel 170, 08036 Barcelona, Spain
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Ader F, Nseir S, Guery B, Tillie-Leblond I. Aspergillose pulmonaire aiguë invasive et pathologies pulmonaires chroniques. Rev Mal Respir 2006. [DOI: 10.1016/s0761-8425(06)71583-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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38
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Garcia RJ, Troya P, Edwards C. Invasive Aspergillosis with Central Nervous System Dissemination in a Presumably Immunocompetent, Non-neutropenic Patient: Case Report and Review. South Med J 2006; 99:607-10. [PMID: 16800416 DOI: 10.1097/01.smj.0000217123.43673.90] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a case of a 45-year-old gentlemen with invasive Aspergillosis who has no apparent immune deficiencies. Follow up imaging shows improvement after the initiation of therapy. The case is accompanied by a brief discussion over invasive aspergillosis.
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Affiliation(s)
- Roberto J Garcia
- University of South Florida, Department of Internal Medicine, USA.
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39
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Pakhale SS, Hadjiliadis D, Howell DN, Palmer SM, Gutierrez C, Waddell TK, Chaparro C, Davis RD, Keshavjee S, Hutcheon MA, Singer LG. Upper lobe fibrosis: a novel manifestation of chronic allograft dysfunction in lung transplantation. J Heart Lung Transplant 2006; 24:1260-8. [PMID: 16143243 DOI: 10.1016/j.healun.2004.08.026] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Revised: 07/25/2004] [Accepted: 08/14/2004] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Lung transplantation is an established treatment modality for a number of chronic lung diseases. Long-term survival after lung transplantation is limited by chronic allograft dysfunction, usually manifested by bronchiolitis obliterans syndrome. We describe a case series with upper lobe fibrosis, a novel presentation of chronic allograft dysfunction. METHODS We reviewed lung transplants at the Toronto General Hospital and Duke University Hospital from 1990 to 2002 and identified patients with upper lobe fibrosis. RESULTS Thirteen of 686 patients (6 women) developed upper lobe fibrosis (Toronto, 9; Duke, 4); 12 of 13 had bilateral transplants. The median age at diagnosis was 42 years (range, 19-70). Primary diagnoses were cystic fibrosis, 6; emphysema, 4; sarcoidosis, 1; and pulmonary fibrosis, 2 patients. Radiographic diagnosis was made at a median of 700 days post-transplant (range, 150-2,920). Pulmonary function tests demonstrated predominantly a progressively worsening restrictive pattern. Open lung biopsy specimens revealed dense interstitial fibrosis, with occasional features of obliterative bronchitis, bronchiolitis obliterans obstructive pneumonia, and aspiration. Nine patients died at a median follow-up of 2,310 days (range, 266-3,740), 8 due to respiratory failure. CONCLUSION Upper lobe fibrosis is a novel presentation of chronic allograft dysfunction in lung transplant recipients and is differentiated from bronchiolitis obliterans syndrome on the basis of physiologic and radiologic findings.
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Affiliation(s)
- Smita Sakha Pakhale
- Toronto Lung Transplant Program, University Health Network, Toronto, Ontario, Canada
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Denning DW, Marr KA, Lau WM, Facklam DP, Ratanatharathorn V, Becker C, Ullmann AJ, Seibel NL, Flynn PM, van Burik JAH, Buell DN, Patterson TF. Micafungin (FK463), alone or in combination with other systemic antifungal agents, for the treatment of acute invasive aspergillosis. J Infect 2006; 53:337-49. [PMID: 16678903 PMCID: PMC7132396 DOI: 10.1016/j.jinf.2006.03.003] [Citation(s) in RCA: 240] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2005] [Revised: 03/06/2006] [Accepted: 03/07/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Micafungin (FK463) is a new lipopeptide compound (echinocandin) with activity against Aspergillus and Candida species. This study evaluated the safety and efficacy of micafungin in patients with proven or probable invasive aspergillosis (IA). METHODS A multinational, non-comparative study was conducted to examine proven or probable (pulmonary only) Aspergillus species infection in a wide variety of patient populations. The study employed an open-label design utilizing micafungin alone or in combination with another systemic antifungal agent. Criteria for IA and therapeutic responses were judged by an independent panel. RESULTS Of the 331 patients enrolled, only 225 met diagnostic criteria for IA as determined by the independent panel and received at least one dose of micafungin. Patients included 98/225 who had undergone hematopoietic stem cell transplantation (HSCT) (88/98 allogeneic), 48 with graft versus host disease (GVHD), and 83/225 who had received chemotherapy for hematologic malignancy. A favorable response rate at the end of therapy was seen in 35.6% (80/225) of patients. Of those only treated with micafungin, favorable responses were seen in 6/12 (50%) of the primary and 9/22 (40.9%) of the salvage therapy group, with corresponding numbers in the combination treatment groups of 5/17 (29.4%) and 60/174 (34.5%) of the primary and salvage treatment groups, respectively. Of the 326 micafungin-treated patients, 183 (56.1%) died during therapy or in the 6-week follow-up phase; 107 (58.5%) deaths were attributable to IA. CONCLUSIONS Micafungin as primary or salvage therapy proved efficacious and safe in high-risk patients with IA, although patient numbers are small in the micafungin-only groups.
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Affiliation(s)
- David W Denning
- Education and Research Centre, Wythenshawe Hospital and University of Manchester, Academic Department of Medicine and Surgery, Southmoor Road, Manchester M23 9LT, UK.
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Menéndez Calderón MJ, Nuño Mateo J, Seguí Riesco ME, Fonseca Aizpuru E. Infiltrados pulmonares en paciente en tratamiento con glucocorticoides. Rev Clin Esp 2006; 206:195-6. [PMID: 16750092 DOI: 10.1157/13086802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Cavalcanti M, Ferrer M, Ferrer R, Morforte R, Garnacho A, Torres A. Risk and prognostic factors of ventilator-associated pneumonia in trauma patients. Crit Care Med 2006; 34:1067-72. [PMID: 16484918 DOI: 10.1097/01.ccm.0000206471.44161.a0] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the risk and prognostic factors of ventilator-associated pneumonia in trauma patients, with an emphasis on the inflammatory response. DESIGN Case-control study. SETTING Trauma intensive care unit. PATIENTS Of 190 consecutive mechanically ventilated patients, those with microbiologically confirmed pneumonia (n = 62) were matched with 62 controls without pneumonia. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Clinical, microbiological, and outcome variables were recorded. Cytokines were measured in serum and blind bronchoalveolar lavage specimens at onset of pneumonia. Multivariate analyses of risk and prognostic factors for ventilator-associated pneumonia were done. Increased severity of head and neck injury (odds ratio, 11.9; p < .001) was the only independent predictor of pneumonia. Among patients with pneumonia, serum levels of interleukin-6 (p = .019) and interleukin-8 (p = .036) at onset of pneumonia were higher in nonresponders to treatment. Moreover, serum levels of tumor necrosis factor-alpha (p = .028) and interleukin-6 (p = .007) at onset of pneumonia were higher in nonsurvivors. Mortality in the intensive care unit was 23% in cases and controls. Nonresponse to antimicrobial treatment (odds ratio, 22.2; p = .001) and the use of hyperventilation (p = .021) were independent predictors of mortality in the intensive care unit for patients with pneumonia. CONCLUSIONS Severe head and neck trauma is strongly associated with ventilator-associated pneumonia. A higher inflammatory response is associated with nonresponse to treatment and mortality among patients with pneumonia. Although pneumonia did not influence mortality, nonresponse to treatment independently predicted mortality among these patients.
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Affiliation(s)
- Manuela Cavalcanti
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Spain
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Agustí C, Rañó A, Aldabó I, Torres A. Fungal pneumonia, chronic respiratory diseases and glucocorticoids. Med Mycol 2006; 44:S207-S211. [PMID: 30408905 DOI: 10.1080/13693780600857348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Invasive pulmonary aspergillosis (IPA) usually occurs in severely immunocompromised patients. The expanded use of glucocorticoids (GC) in clinical practice accounts for the increasing number of fungal infections reported in mildly or non-immunocompromised hosts. We report a series of 8 patients with fungal pneumonia in whom long term high dose GC treatment was the only risk factor for opportunistic infections. All patients except one had chronic underlying disorders (asthma, idiopathic fibrosis, chronic obstructive pulmonary disease, COPD). Seven patients were diagnosed with pulmonary aspergillosis. Etiological suspicion of fungal infection was obtained during lifetime in six cases and in one case was confirmed only in the post-mortem examination. In most cases bronchoscopic techniques allowed identification of the microorganism. However, delay in establishing the diagnosis (mean 20 days) precluded a prompt initiation of a specific treatment. The course of the fungal infection was ominous. All but one patient experienced progressive respiratory failure requiring ICU admission and mechanical ventilation support. Despite this, all of them died. The only survivor was a patient receiving early empirical antifungal treatment due to a high clinical suspicion of fungal infection. Based on the present and previous findings, antifungal treatment should be considered in chronic respiratory patients requiring high or repetitive doses of GC when there is clinical evidence of pneumonia and isolation of Aspergillus spp. from respiratory secretions.
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Affiliation(s)
- Carlos Agustí
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Ana Rañó
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Ivet Aldabó
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
| | - Antoni Torres
- Servei de Pneumologia, Institut Clínic del Tòrax, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Spain
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Ader F, Nseir S, Le Berre R, Leroy S, Tillie-Leblond I, Marquette CH, Durocher A. Invasive pulmonary aspergillosis in chronic obstructive pulmonary disease: an emerging fungal pathogen. Clin Microbiol Infect 2005; 11:427-9. [PMID: 15882191 DOI: 10.1111/j.1469-0691.2005.01143.x] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute invasive pulmonary aspergillosis occurs predominantly in immunocompromised hosts, with increasing numbers of cases of invasive aspergillosis among patients with chronic obstructive pulmonary disease (COPD) being reported. Among 13 cases of invasive aspergillosis diagnosed in COPD patients admitted to the intensive care unit with acute respiratory distress, the only risk factor for invasive fungal infection was corticosteroid treatment. Invasive aspergillosis should be suspected in COPD patients receiving steroid treatment who have extensive pulmonary infiltrates. Survival depends on rapid diagnosis and early appropriate treatment. A decrease or interruption of steroid treatment should be considered as part of the overall therapeutic strategy.
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Affiliation(s)
- F Ader
- Service de Réanimation Médicale et Maladies Infectieuses, CH de Tourcoing, Tourcoing, France.
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Ardite E, Peinado VI, Rabinovich RA, Fernández-Checa JC, Roca J, Barberà JA. Systemic effects of cigarette smoke exposure in the guinea pig. Respir Med 2005; 100:1186-94. [PMID: 16330198 DOI: 10.1016/j.rmed.2005.10.023] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Revised: 10/21/2005] [Accepted: 10/23/2005] [Indexed: 12/23/2022]
Abstract
Chronic obstructive pulmonary disease is associated with systemic effects including reduced body weight, oxidative stress and altered circulating TNFalpha levels. The present study was aimed to investigate whether chronic exposure to cigarette smoke induces these systemic changes in a guinea pig model. Seven animals/group were exposed to the smoke of seven cigarettes/day, 5 days/week, during 2, 4 and 6 months (chronic exposure). Three animals/group were sacrificed immediately, 3 h or 24 h after exposure to seven cigarettes (acute exposure). Chronically smoke-exposed animals exhibited lower body weight gain, starting at 5th week, and goblet cell metaplasia in small bronchioles. At 6 months there was a trend for increased plasma and lung tissue TNFalpha levels. No changes, neither in skeletal muscle glutathione (GSH) nor in plasma lipid peroxidation, were observed at any time point after chronic exposure. However, skeletal muscle GSH decreased and plasma lipid peroxidation increased immediately after acute smoke exposure, equaling control levels thereafter. We conclude that cigarette smoke exposure in the guinea pig induces a transient and repeated oxidative effect, which might result in impaired systemic metabolism and consequent failure of smoke-exposed animals to gain weight. The effects of cigarette smoke on body weight antecede and appear to be independent from the alterations produced in small airways.
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Affiliation(s)
- Esther Ardite
- Department of Pulmonary Medicine, Hospital Clínic and Institut d'Investigacions Biomèdiques "August Pi i Sunyer" (IDIBAPS), University of Barcelona, Barcelona, Spain
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Wang JY, Chang YL, Lee LN, Chen JH, Tang JL, Yang PC, Lee YC. Diffuse pulmonary infiltrates after bone marrow transplantation: the role of open lung biopsy. Ann Thorac Surg 2005; 78:267-72. [PMID: 15223441 DOI: 10.1016/j.athoracsur.2004.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diffuse pulmonary infiltrates is the major complication and cause of mortality after bone marrow transplantation. We analyzed the etiologies and prognostic factors in bone marrow recipients with diffuse pulmonary infiltrates and assessed the role of open lung biopsy in managing this complication. METHODS Medical records of patients with diffuse pulmonary infiltrates after bone marrow transplantation were reviewed. Possible prognostic factors were analyzed by multivariate logistic regression. RESULTS Sixty-eight (20%) of 341 bone marrow recipients had diffuse pulmonary infiltrates and 34 died. Thirty-five underwent open lung biopsy, resulting in therapeutic changes in 22 (63%) and clinical improvement in 16 (46%). The leading diagnoses were idiopathic interstitial pneumonitis (40%) and cytomegalovirus pneumonitis (20%). Cytomegalovirus pneumonitis caused radiographically observable interstitial infiltrates exclusively and was frequently associated with hepatitis. Idiopathic interstitial pneumonitis resulted in either diffuse ground-glass opacity or interstitial infiltrates. Three (9%) patients had miliary tuberculosis. Respiratory failure (p < 0.001) and acute graft-versus-host disease (p = 0.016) were the poor prognostic factors. CONCLUSIONS Among bone marrow recipients, we found diffuse pulmonary infiltrates in 20% and a mortality rate of 50%. Idiopathic interstitial pneumonitis and cytomegalovirus pneumonitis were the most common causes and should be suspected in patients with diffuse interstitial infiltrates. In endemic areas, miliary tuberculosis should be suspected in bone marrow recipients with diffuse reticulonodular lesions. Respiratory failure and acute graft-versus-host disease were poor prognostic factors. By establishing a correct diagnosis, open lung biopsy led to treatment changes in about two-thirds of these patients.
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MESH Headings
- Adolescent
- Adult
- Biopsy
- Bone Marrow Transplantation/adverse effects
- Child
- Child, Preschool
- Cytomegalovirus Infections/diagnosis
- Cytomegalovirus Infections/etiology
- Cytomegalovirus Infections/pathology
- Female
- Graft vs Host Disease/etiology
- Hematologic Diseases/therapy
- Humans
- Infant
- Lung/pathology
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/etiology
- Lung Diseases, Interstitial/pathology
- Male
- Middle Aged
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/etiology
- Pneumonia, Viral/pathology
- Prognosis
- Respiratory Insufficiency/etiology
- Retrospective Studies
- Thoracic Surgery, Video-Assisted
- Tuberculosis, Miliary/diagnosis
- Tuberculosis, Miliary/etiology
- Tuberculosis, Miliary/pathology
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Affiliation(s)
- Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
PURPOSE OF REVIEW Pulmonary infections are the most frequent complications in non-HIV-immunocompromised patients and portend a high mortality. This scenario represents a challenging task for clinicians and an important subject of clinical research from different perspectives. This review comments on the results of relevant original articles in this area published from 2003 to the present. RECENT FINDINGS The present review addresses the etiology of the pulmonary infiltrates in immunocompromised patients, the use of new emerging diagnostic tools and medical devices in the clinical management of these infiltrates, and the greater understanding of the inflammatory immune response associated with infection in this setting. SUMMARY Advances in diagnostic tests and therapeutic devices are facilitating the clinical management of pulmonary infections. New challenges are emerging, however, such as the growing evidence regarding the important role of respiratory viruses as a common cause of lower respiratory tract infections. Finally, new insights into the mechanisms of the inflammatory response associated with pulmonary complications can help understanding their pathogenesis, improve prevention and diagnosis, and anticipate future therapeutic modalities.
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Affiliation(s)
- Ana Rañó
- Servei de Pneumologia, Hospital Mutua de Terrassa, Barcelona, Spain
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Guidelines for the Diagnosis and Treatment of Community-Acquired Pneumonia. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR). ACTA ACUST UNITED AC 2005. [PMCID: PMC7128950 DOI: 10.1016/s1579-2129(06)60222-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Czock D, Keller F, Rasche FM, Häussler U. Pharmacokinetics and pharmacodynamics of systemically administered glucocorticoids. Clin Pharmacokinet 2005; 44:61-98. [PMID: 15634032 DOI: 10.2165/00003088-200544010-00003] [Citation(s) in RCA: 537] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glucocorticoids have pleiotropic effects that are used to treat diverse diseases such as asthma, rheumatoid arthritis, systemic lupus erythematosus and acute kidney transplant rejection. The most commonly used systemic glucocorticoids are hydrocortisone, prednisolone, methylprednisolone and dexamethasone. These glucocorticoids have good oral bioavailability and are eliminated mainly by hepatic metabolism and renal excretion of the metabolites. Plasma concentrations follow a biexponential pattern. Two-compartment models are used after intravenous administration, but one-compartment models are sufficient after oral administration.The effects of glucocorticoids are mediated by genomic and possibly nongenomic mechanisms. Genomic mechanisms include activation of the cytosolic glucocorticoid receptor that leads to activation or repression of protein synthesis, including cytokines, chemokines, inflammatory enzymes and adhesion molecules. Thus, inflammation and immune response mechanisms may be modified. Nongenomic mechanisms might play an additional role in glucocorticoid pulse therapy. Clinical efficacy depends on glucocorticoid pharmacokinetics and pharmacodynamics. Pharmacokinetic parameters such as the elimination half-life, and pharmacodynamic parameters such as the concentration producing the half-maximal effect, determine the duration and intensity of glucocorticoid effects. The special contribution of either of these can be distinguished with pharmacokinetic/pharmacodynamic analysis. We performed simulations with a pharmacokinetic/pharmacodynamic model using T helper cell counts and endogenous cortisol as biomarkers for the effects of methylprednisolone. These simulations suggest that the clinical efficacy of low-dose glucocorticoid regimens might be increased with twice-daily glucocorticoid administration.
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Affiliation(s)
- David Czock
- Division of Nephrology, University Hospital Ulm, Robert-Koch-Str. 8, Ulm 89081, Germany
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Marie I, Hachulla E, Chérin P, Hellot MF, Herson S, Levesque H, Hatron PY. Opportunistic infections in polymyositis and dermatomyositis. Arthritis Care Res (Hoboken) 2005; 53:155-65. [PMID: 15818648 DOI: 10.1002/art.21083] [Citation(s) in RCA: 128] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess prevalence and characteristics of opportunistic infections in patients with polymyositis/dermatomyositis (PM/DM). To determine the predictive values for opportunistic infections on clinical presentation, biochemical findings, and paraclinical features of PM/DM to detect patients at risk of opportunistic infections. METHODS The medical records of 156 consecutive PM/DM patients in 3 medical centers were reviewed. RESULTS Eighteen PM/DM patients (11.5%) developed opportunistic infections. The majority of patients exhibited an opportunistic infection after the onset of PM/DM (89% of cases). Opportunistic infections occurred most frequently during the first year following PM/DM diagnosis (62.5%). The pathogen microorganisms responsible for opportunistic infections were various, i.e., Candida albicans, Pneumocystis carinii, Aspergillus fumigatus, Geotrichum capitatum, Mycobacterium avium-intracellulare complex, M. xenopi, M. marinum, M. tuberculosis, Helicobacter heilmanii, cytomegalovirus, and herpes simplex virus. Mortality rates were as high as 27.7% in these PM/DM patients. Higher mean daily doses of steroids, lymphopenia, and lower serum total protein levels were significantly more frequent in the group of PM/DM patients with opportunistic infections. CONCLUSION Our study underscores the high frequency of opportunistic infections in PM/DM, resulting in an increased mortality rate. It also indicates that a great variety of microorganisms are responsible for opportunistic infections, although they were more often due to fungi (>50% of cases). Our series highlights a predominance of both lung and digestive opportunistic infections (89% of cases). In addition, our results suggest that PM/DM patients presenting with factors predictive of opportunistic infection may require closer monitoring.
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Affiliation(s)
- Isabelle Marie
- Centre Hospitalier Universitaire de Rouen-Boisguillaume and Inserm Unit 644, Rouen, France.
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