Double-blind study of OM-85 in patients with chronic bronchitis or mild chronic obstructive pulmonary disease

BACKGROUND

Interventions against acute exacerbations (AEs) of chronic obstructive pulmonary disease (COPD) are increasingly called for to reduce morbidity, mortality and costs. OM-85, a detoxified immunoactive bacterial extract, has been shown to prevent recurrent exacerbations of bronchitis and COPD.

OBJECTIVES

It was the aim of this study to demonstrate the protective effect of OM-85 against recurrent bronchitic exacerbations in patients with chronic bronchitis or mild COPD. The primary end point was the mean rate of AEs occurring within the study period.

METHODS

This double-blind multi-centre study enrolled adult outpatients>40 years old of both sexes with a history of chronic bronchitis or mild COPD at the time of an AE. The treatment consisted of one capsule of OM-85 or placebo per day for 30 days, followed by three 10-day courses for months 3, 4 and 5, with a 6-month study duration and monthly control visits.

RESULTS

One hundred and forty-two patients were treated with OM-85 and 131 received placebo. By the end of the treatment period, the mean number of AEs in the OM-85 group was 0.61 per patient versus 0.86 per patient in the placebo group (-29%; p=0.03). The difference between treatments was most notable in patients with a history of current or past smoking (-40%; p<0.01). No serious adverse events were attributed to the medication and no significant laboratory changes were reported.

CONCLUSIONS

OM-85 significantly reduced the frequency of AEs in patients with a history of chronic bronchitis and mild COPD and was well tolerated. This study confirms the findings of previous trials conducted in elderly patients with chronic bronchitis or COPD.

The role of Bordetella infections in patients with acute exacerbation of chronic bronchitis

BACKGROUND

Acute exacerbations of chronic bronchitis (AECB) are associated with a variety of viral and bacterial infectious agents, some of which are potentially preventable by immunization. Bordetella pertussis, which causes whooping cough, has not been studied in this context. We aimed to assess the role of Bordetella infections in patients with AECB.

PATIENTS AND METHODS

Patients with AECB, who presented to participating private practices in Basel, Switzerland, between October 2000 and June 2002, were evaluated by a standardized questionnaire, nasopharyngeal swabs for culture (Bordetella spp.), and PCR (Bordetella spp. and selected other respiratory pathogens) and paired blood samples for serologic diagnosis of Bordetella infection.

RESULTS

A total of 26 patients (34-86 years of age) were recruited. All culture and PCR samples were negative. Serology revealed Bordetella infection in eight (31%) patients. Duration of cough was shorter in patients with Bordetella infection compared to those without Bordetella infection (mean 15 days vs 41 days, p = 0.04). Cough > or = 21 days duration was present in three (43%) of seven patients with evidence of Bordetella infection compared to 17 (94%) of 18 controls (p = 0.012). Progression to convalescence from initial to follow-up visit after 4-6 weeks was comparable between both groups.

CONCLUSION

Bordetella infections appear to play a significant role in AECB and preventive measurements such as immunization with acellular pertussis vaccines should be considered. Extended investigations are necessary to confirm our preliminary and provocative findings.

Randomised double-blind comparison of oral gatifloxacin and co-amoxiclav for acute exacerbation of chronic Bronchitis

Antimicrobial therapy can have a significant impact in the treatment of acute infectious exacerbations in patients with chronic bronchitis, in whom repeated episodes are common. The aim of this randomised, double-blind, double-dummy, parallel group study was to compare the efficacy and safety of oral gatifloxacin (200 and 400 mg once daily) administered for 5 days with co-amoxiclav (500 mg amoxicillin/125 mg clavulanic acid t.i.d.) administered for 10 days in 414 adult patients with acute exacerbation of chronic bronchitis. Overall clinical response rates (cure plus improvement) were 86.2%, 79.4% and 81.7% in the gatifloxacin 200 mg, gatifloxacin 400 mg and co-amoxiclav groups, respectively, and the equivalence hypothesis used for statistical analysis showed equivalent efficacy for both gatifloxacin 200 and 400 mg compared to co-amoxiclav. The same was true for rates of bacterial response, with eradication or presumed eradication of causative pathogens achieved in 87.5%, 87.3% and 79.1% of cases in the gatifloxacin 200 mg, gatifloxacin 400 mg and co-amoxiclav groups, respectively. All treatments were well tolerated, with the nature and frequency of treatment-related adverse events similar in all groups. The results of the study show that gatifloxacin is a safe and effective agent for the treatment of patients with chronic bronchitis experiencing an acute infectious exacerbation.

The anti-IgE antibody omalizumab improves asthma-related quality of life in patients with allergic asthma

The aim of the present study was to determine the effect of treatment with omalizumab, an anti-immunoglobulin E antibody, on asthma-related quality of life (AQoL) in patients with moderate-to-severe allergic asthma. A total of 546 patients with allergic asthma were randomised to double-blind subcutaneous treatment with either placebo or omalizumab for 52 weeks. A constant beclomethasone dipropionate dose was maintained during the first 16 weeks (steroid-stable phase). This was followed by a 12-week steroid-reduction phase. The core study was followed by a 24-week double-blind extension phase. AQoL was evaluated at baseline and at the end of the steroid-stable (week 16), steroid-reduction (week 28) and extension phases (week 52) using the Juniper Asthma Quality of Life Questionnaire (AQLQ). Baseline AQLQ scores were comparable for the two treatment groups. Relative to placebo, omalizumab-treated patients demonstrated statistically significant improvements from baseline across all four AQLQ domains, as well as overall AQoL score, at weeks 16 (except environmental exposure), 28 and 52. Patients on omalizumab were also more likely to achieve clinically significant improvements in AQoL during the course of the study. Overall, almost 70% of patients and investigators rated treatment with omalizumab as "excellent/good", compared with approximately 40% of placebo recipients. Clinical studies show that omalizumab enhances disease control whilst reducing corticosteroid consumption in patients with allergic asthma. The results of the present study show that these changes are paralleled by improvements in asthma-related quality of life that are meaningful to such patients.

Omalizumab provides long-term control in patients with moderate-to-severe allergic asthma

The ability of omalizumab, an anti-immnoglobulin-E agent, to maintain long-term disease control in patients with moderate-to-severe allergic asthma was investigated in a 24-week double-blind extension to a 28-week core trial. During the extension, 483 of the initial 546 patients were maintained on randomised treatment and the lowest sustainable dose of beclomethasone dipropionate (BDP) as established during the steroid-reduction phase of the core trial. The use of concomitant asthma medication was permitted and investigators were allowed to adjust the BDP dose or switch patients from BDP to other asthma medications if deemed necessary. More omalizumab-treated patients (33.5%) than placebo-treated patients (13.5%) were able to complete the extension period without requiring inhaled corticosteroid treatment. The mean BDP equivalent dose throughout the extension was lower in the omalizumab group (25 microg x day(-1)) than in the placebo group (43 microg x day(-1)). Disease control was sustained in 76% of omalizumab patients compared with 59.4% of placebo patients free from an asthma exacerbation during the extension period. Compared with placebo, fewer patients in the omalizumab group used other concomitant asthma medication during the extension. Treatment with omalizumab was well tolerated and the incidence of adverse events was similar between groups. In conclusion, these results suggest that omalizumab is a promising new agent for the long-term control of allergic asthma.

Regular follow-up after curative resection of nonsmall cell lung cancer: a real benefit for patients?

Even though complete resection is regarded as the only curative treatment for nonsmall cell lung cancer (NSCLC), >50% of resected patients die from a recurrence or a second primary tumour of the lung within 5 yrs. It remains unclear, whether follow-up in these patients is cost-effective and whether it can improve the outcome due to early detection of recurrent tumour. The benefit of regular follow-up in a consecutive series of 563 patients, who had undergone potentially curative resection for NSCLC at the University Hospital, was analysed. The follow-up consisted of clinical visits and chest radiography according to a standard protocol for up to 10 yrs. Survival rates were estimated using the Kaplan-Meier analysis method and the cost-effectiveness of the follow-up programme was assessed. A total of 23 patients (6.4% of the group with lobectomy) underwent further operation with curative intent for a second pulmonary malignancy. The regular follow-up over a 10-yr period provided the chance for a second curative treatment to 3.8% of all patients. The calculated costs per life-yr gained were 90,000 Swiss Francs. The cost-effectiveness of the follow-up protocol was far above those of comparable large-scale surveillance programmes. Based on these data, the intensity and duration of the follow-up was reduced.

Severe bronchiolitis in acute Mycoplasma pneumoniae infection

We report on a 17-year-old patient with severe bronchiolitis due to Mycoplasma pneumoniae infection. Despite an early 10-day course of clarithromycin, she developed progressive dyspnea, cough, fever, and severe obstructive ventilatory impairment. Sixteen days after onset of the disease a severe hemolytic anemia developed with only cold agglutinins positive at serologic screening. Thoracoscopic lung biopsy revealed diffuse bronchiolitis with suppurative intrabronchiolar inflammation, lymphohistiocytic "cuffing" of the bronchioli, and foam cell aggregates within neighboring alveoli. The infiltrate consisted mainly of CD3+, CD8+ lymphocytes and CD68+ macrophages. The diagnosis of Mycoplasma pneumoniae bronchiolitis was based on repeated complement fixation tests, which turned strongly positive only at day 74 after onset of the disease. Pulmonary function improved slowly under long-term prednisone treatment.

Omalizumab, a monoclonal antibody against IgE for the treatment of allergic diseases

Omalizumab, a recombinant, humanised monoclonal antibody against human IgE, will be introduced soon for the treatment of allergic asthma. This antibody binds circulating IgE molecules and inhibits the type I immune response in the lung and other target organs. In the phase II and III studies performed, it demonstrated a significant and important effect in controlling and stabilising asthma by reducing exacerbations and the need for inhaled corticosteroids. The safety and tolerability up to one year of treatment were very good. This new treatment may have a role in patients with difficult-to-control asthma, with recurrent exacerbations, and those with concurrent asthma, nose and eye symptoms.

The anti-IgE antibody omalizumab reduces exacerbations and steroid requirement in allergic asthmatics

The clinical benefit and steroid-sparing effect of treatment with the anti-immunoglobulin-E (IgE) antibody, omalizumab, was assessed in patients with moderate-to-severe allergic asthma. After a run-in period, 546 allergic asthmatics (aged 12-76 yrs), symptomatic despite inhaled corticosteroids (500-1,200 microg daily of beclomethasone dipropionate), were randomized to receive double-blind either placebo or omalizumab every 2 or 4 weeks (depending on body weight and serum total IgE) subcutaneously for 7 months. A constant beclomethasone dose was maintained during a 16-week stable-steroid phase and progressively reduced to the lowest dose required for asthma control over the following 8 weeks. The latter dose was maintained for the next 4 weeks. Asthma exacerbations represented the primary variable. Compared to the placebo group, the omalizumab group showed 58% fewer exacerbations per patient during the stable-steroid phase (p<0.001). During the steroid-reduction phase, there were 52% fewer exacerbations in the omalizumab group versus the placebo group (p<0.001) despite the greater reduction of the beclomethasone dosage on omalizumab (p<0.001). Treatment with omalizumab was well tolerated. The incidence of adverse events was similar in both groups. These results indicate that omalizumab therapy safely improves asthma control in allergic asthmatics who remain symptomatic despite regular use of inhaled corticosteroids and simultaneous reduction in corticosteroid requirement.

Severe pulmonary hypertension: data from the Swiss Registry

BACKGROUND

Severe pulmonary hypertension (PH) is a rare disease with a dismal prognosis if untreated. Progress in diagnosis and in the development of effective therapeutic options has created new interest in this pathology. There are, however, only limited data on the prevalence of severe PH unrelated to chronic left ventricular failure or COPD, on the associated conditions and on the parameters with a prognostic impact. With the aid of a retrospective registry we have collected data from 5 centres in Switzerland and attempted to answer the above questions.

METHODS

Data on patients with PH from 4 university facilities (Zurich, Basle, Geneva and Lausanne) and one well-defined geographical area (Ticino) were retrospectively collected and analysed up to December 1999. Clinical and haemodynamic parameters and associated diseases were noted. We were also interested in the age distribution of the patients and the year of diagnosis of PH.

RESULTS

We found 106 patients with severe PH (43 men, 63 women, median age 43 years); 79% were in NYHA class III or IV. There was a steep rise in diagnosis of PH after 1995. In 74% PH was either primary or associated with collagen vascular disease or thromboembolic disease. By the end of the observation period 30% of the patients had died. The best distinguishing parameters between surviving patients and those who eventually died were the 6-minute walking test (363 vs. 235 metres, p = 0.002), the NYHA class (II vs III/IV, p = 0.015), and mixed venous saturation (66.5 vs. 57.9%, p = 0.006). Therapy consisted of calcium antagonists in 18% and of (inhaled) prostanoids, chiefly iloprost, in 33%. Seven patients underwent lung transplantation.

CONCLUSIONS

We conclude that PH is diagnosed more often as diagnostic and therapeutic options improve; that primary forms, and those associated with collagen vascular disease and with chronic venous thromboembolism, make up three-quarters of the aetiologies; and that the 6-minute walking test, the functional class and mixed venous saturation are the best prognostic parameters.

Severe pulmonary hypertension: data from the Swiss Registry

BACKGROUND

Severe pulmonary hypertension (PH) is a rare disease with a dismal prognosis if untreated. Progress in diagnosis and in the development of effective therapeutic options has created new interest in this pathology. There are, however, only limited data on the prevalence of severe PH unrelated to chronic left ventricular failure or COPD, on the associated conditions and on the parameters with a prognostic impact. With the aid of a retrospective registry we have collected data from 5 centres in Switzerland and attempted to answer the above questions.

METHODS

Data on patients with PH from 4 university facilities (Zurich, Basle, Geneva and Lausanne) and one well-defined geographical area (Ticino) were retrospectively collected and analysed up to December 1999. Clinical and haemodynamic parameters and associated diseases were noted. We were also interested in the age distribution of the patients and the year of diagnosis of PH.

RESULTS

We found 106 patients with severe PH (43 men, 63 women, median age 43 years); 79% were in NYHA class III or IV. There was a steep rise in diagnosis of PH after 1995. In 74% PH was either primary or associated with collagen vascular disease or thromboembolic disease. By the end of the observation period 30% of the patients had died. The best distinguishing parameters between surviving patients and those who eventually died were the 6-minute walking test (363 vs. 235 metres, p = 0.002), the NYHA class (II vs III/IV, p = 0.015), and mixed venous saturation (66.5 vs. 57.9%, p = 0.006). Therapy consisted of calcium antagonists in 18% and of (inhaled) prostanoids, chiefly iloprost, in 33%. Seven patients underwent lung transplantation.

CONCLUSIONS

We conclude that PH is diagnosed more often as diagnostic and therapeutic options improve; that primary forms, and those associated with collagen vascular disease and with chronic venous thromboembolism, make up three-quarters of the aetiologies; and that the 6-minute walking test, the functional class and mixed venous saturation are the best prognostic parameters.

Pulmonary cytomegalovirus infection in immunocompromised patients

BACKGROUND

Cytomegalovirus (CMV) infection and CMV disease are frequent complications in immunocompromised patients. In this study, the incidence of pulmonary CMV infection was analyzed in different groups of immunocompromised patients and the diagnostic value of immunostaining with anti-CMV antibodies in BAL cells was evaluated in regard to the diagnosis of CMV pneumonitis.

METHODS

Five hundred eighty consecutive BAL procedures were analyzed prospectively in 442 immunocompromised and 126 nonimmunocompromised control subjects. CMV culture in BAL fluid was performed by shell vial assay and immunostaining using three monoclonal anti-CMV antibodies.

RESULTS

The incidence of culture results positive for CMV in the BAL fluid varied from 20 to 30% in HIV-positive patients, in patients following stem cell or renal transplantation, and in patients with autoimmune disease or lung fibrosis treated with immunosuppressive agents. CMV was cultured from 4.4% of BALs in patients treated with high-dose chemotherapy and from 2.4% of control subjects. CMV disease developed in 37 patients; in 18 of these patients, CMV pneumonitis was present. The results of CMV immunostaining were positive in a total of 22 BALs, all in patients with CMV disease. The sensitivity, specificity, and positive and negative predictive values of positive CMV immunostaining results for the diagnosis of CMV pneumonitis were 88.9%, 98.6%, 72.7%, and 99.5%, respectively.

CONCLUSION

The incidence of pulmonary CMV infection is similar in different groups of immunocompromised patients except for patients following high-dose chemotherapy. CMV immunostaining in the BAL fluid is a very helpful method to diagnose CMV pneumonitis in these patients.

Diagnostic yield of bronchoalveolar lavage following renal transplantation

Organ transplant recipients are at high risk of infectious pulmonary complications. In this retrospective study, the diagnostic yield of bronchoalveolar lavage (BAL) was evaluated in renal transplant recipients. The results were analysed in special regard to the clinical presentation of pulmonary infections and the possible impact of new immunosuppressive agents. Over a 5-year period 91 BAL were performed in 71 renal transplant recipients. Microorganisms were isolated from 69% of BAL (63/91): bacteria 32%; cytomegalovirus (CMV) 27%; Pneumocystis carinii (PC) 22%; other viruses 9% (HSV; EBV, RSV, adenovirus, HHV8); Aspergillus fumigatus 1%. Total cell counts and neutrophil counts in BAL were significantly elevated in bacterial infection, whereas BAL positive for PC showed eosinophilia (P<0.05). There was no association between clinical symptoms and the radiological pattern of infiltrates and the type of infection. Immunosuppression containing tacrolimus or mycophenolate mofetil was associated with a significantly higher percentage of PC and CMV infections compared to cyclosporin-based immunosuppression (65% vs. 30%, P<0.005). A considerable number of PC and CMV infections occurred beyond 6 months after transplantation. In conclusion, BAL has a high diagnostic yield in renal transplant recipients. Infection with CMV and PC should also be considered beyond 6 months after transplantation, and prophylaxis for opportunistic infections should be given if the immunosuppression is intensified.

Pulmonary infiltrate in an asymptomatic kidney donor

A 61-year-old man with a smoking history of 30 pack-years, but no relevant disease was evaluated for kidney donation to his wife, who suffered from end-stage renal disease. Routine testing before kidney donation consisted of the patient’s history, laboratory measurements, ECG, ultrasound of the abdomen and a chest X-ray. The leukocyte number, hemoglobin level and platelet count in the blood were normal. Laboratory parameters including C-reactive protein, serum creatinine, liver enzymes and the lipid profile were also within the normal range.

Prospective randomized comparison of thoracoscopic talc poudrage under local anesthesia versus bleomycin instillation for pleurodesis in malignant pleural effusions

Induction of pleurodesis offers benefit for patients with metastatic tumors and symptomatic malignant pleural effusions, but the best method for achieving this is still unknown. In this prospective, randomized comparison of two well-established pleurodesis procedures, 36 patients with malignant pleural effusions, expanded lungs after drainage, and expected survival of > 1 mo received either bleomycin instillation (60E) via a small-bore thoracostomy tube or thoracoscopic talc poudrage (5 g) under local anesthesia. Efficacy, safety, and cost could be evaluated for 32 treatments (17 bleomycin, 15 talc) in 31 patients. Recurrence rates of effusion with bleomycin and talc poudrage after 30 d were 41% and 13% (p = 0.12), respectively, those after 90 d were 59% and 13%, respectively (p = 0.01), and those after 180 d were 65% and 13% (p = 0.005), respectively. Neither procedure showed any major adverse effect, and both were equally well tolerated. Cost estimation favored thoracoscopic talc poudrage, both for the initial hospitalization and with regard to recurrences. In conclusion, thoracoscopic talc pleurodesis under local anesthesia is superior to bleomycin instillation for pleurodesis in cases of malignant pleural effusion.

Combined chemoradiotherapy with daily low-dose cisplatin in locally advanced inoperable non-small cell lung cancer

Sixty-one consecutive patients with locally advanced inoperable non-small-cell lung cancer were treated with chemoradiation with 60 Gy and concomitant daily low-dose cisplatin (6 mg/m(2)) in a single uninterrupted course. Toxicity was mild, 80% of patients were treated as outpatients. The median survival of 70 weeks compares favorably to the literature.

[From simple snoring to sleep apnea syndrome--clinical spectrum]

About 40% of adults are habitual snorers. 2% of women and 4% of men between 30 and 60 years of age present additional sleep disordered breathing. There is a continuous spectrum from simple to disease-causing snoring ranging from merely disturbing noises to pharyngeal obstructions and breathing pauses. Repetitive episodes of upper airway obstructions lead to frequent arousals from sleep. Sleep fragmentation is responsible for non-refreshing sleep and subsequent excessive daytime sleepiness resulting in reduced performance at work, social problems and a higher risk for accidents. Furthermore there is a correlation between arousals and cardiovascular abnormalities. Anatomic narrowing of the upper airway or hypotonia of the orpharyngeal dilator muscles favour collapse of the oropharyngeal walls. Obstructive sleep apnea syndrome is characterized by repetitive oxyhemoglobin desaturations during sleep recorded by pulseoximetry. Polygraphy quantifies the average number of apneas and hypopneas which occur during one hour of sleep (apnea-hypopnea index = AHI). In upper airway resistance syndrome (= UARS), upper airway resistance is increased, but pharyngeal obstruction is not complete. Saturation doesn't decrease significantly, but arousals with consecutive sleep disruption still occur. Polysomnography is a comprehensive study including EEG-, EOG- and EMG-recordings. Sleep stages and events can be scored to evaluate sleep architecture, sleep efficiency and sleep fragmentation.

Takayasu disease with predominant pulmonary involvement

We report a case of Takayasu's arteritis with predominant pulmonary involvement, which led eventually to complete obliteration of the right pulmonary artery. Subsequently, cavitation and chronic inflammation developed in the nonperfused right lung. A right pneumonectomy was performed to control the infectious process, leading to functional improvement and better control of the underlying immunologic disorder.

[The future of asthma therapy]

Today bronchial asthma is regarded as a chronic inflammatory disease of the airways, which is modulated and controlled by immunological mechanisms. This new understanding of its pathogenesis is reflected in novel asthma treatment strategies. Newer treatments no longer aim at blocking effects of single mediators or at bronchodilation, but try to intervene in specific immunological mechanisms. An overview of future developments in asthma therapy is presented, with special emphasis on the anti-IgE concept of E-25.

Granulomatous Pneumocystis carinii pneumonia in Wegener's granulomatosis

This study reports on a first case of granulomatous Pneumocystis carinii pneumonia (PCP) in a human immunodeficiency virus-negative patient with antineutrophil cytoplasmic antibody-positive Wegener's granulomatosis whilst receiving immunosuppressive treatment. The patient presented with diffuse alveolar haemorrhage, pauci-immune rapid progressive glomerulonephritis and leukocytoclastic vasculitis of the skin. Granulomatous Pneumocystis carinii pneumonia developed under immunosuppressive treatment with cyclophosphamide and prednisone. At the time Pneumocystis carinii pneumonia developed, there was a marked lymphopenia with a very low CD8+ cell count in the blood. Grocott staining in bronchoalveolar lavage fluid revealed no Pneumocystis carinii. The diagnosis was made via a video-assisted thoracoscopic lung biopsy which showed granulomas containing high numbers of Pneumocystis carinii cysts.

Diagnostic yield of bronchoscopy in histologically proven invasive pulmonary aspergillosis

Invasive pulmonary aspergillosis (IPA) is a life-threatening infectious complication in neutropenic patients after high-dose chemotherapy or hematopoietic stem cell transplantation. Its diagnosis is mainly based on clinical symptoms, and radiological signs on thoracic CT scan. The value of bronchoscopy is controversial. We analyzed the diagnostic yield of bronchoscopy in 23 consecutive patients with histologically proven invasive pulmonary aspergillosis. In seven patients (30%) bronchoscopically obtained specimens were diagnostic for pulmonary fungal infection. Typical hyphae were detected by cytology in six patients and fungal cultures were positive in four cases. Patients with a positive bronchoscopic result presented more often with multiple changes on thoracic CT scan (71%; 5/7), but had received a lower median cumulative dose of amphotericine B (300 mg; 168-3010 mg) compared to patients with non-diagnostic bronchoscopy (25% multiple lesions (4/16); amphotericine dose 1100 mg, 260-2860 mg). The diagnostic yield of bronchoscopy was not associated with clinical symptoms or duration of neutropenia. Bronchoscopy allows the diagnosis of IPA in about one third of patients. Fungal cultures and cytological examination of intrabronchial specimens obtained during bronchoscopy have a high specificity, but its sensitivity is low. It is advisable to perform diagnostic bronchoscopy before starting antifungal therapy. Better diagnostic tools are urgently needed.

The value of transbronchial needle aspiration in the diagnosis of peripheral pulmonary lesions

BACKGROUND

Transbronchial needle aspiration (TBNA) is a bronchoscopic sampling technique used for the diagnostic workup of mediastinal lymph nodes, but the value of its routine use in evaluating peripheral pulmonary lesions is not yet firmly established.

DESIGN

Retrospective analysis of routine diagnostic bronchoscopies.

SETTING

University teaching hospital.

PATIENTS AND METHODS

One hundred seventy-two consecutive patients (126 with malignant and 46 with nonmalignant disease) who underwent bronchoscopy for a peripheral pulmonary lesion.

RESULTS

In 87 patients (51%), a final diagnosis was established by bronchoscopy; diagnoses included 81 malignant lesions (69 lung cancer and 12 pulmonary metastases) and 6 benign lesions (all tuberculosis). TBNA was used in 152 of the 172 patients (89%). Other endoscopic techniques included bronchial washing (100%), bronchial brushing (45%), and transbronchial biopsy (TBB) (27%). Concerning the different bronchoscopic sampling techniques, TBNA showed a positive result in 35% of cases, in comparison to 17% for TBB, 22% for bronchial washing, and 30% for bronchial brushing. While TBNA was diagnostic in 27.5% of the malignant lesions < 3 cm in diameter, the success rate in lesions > 3 cm was 65.5% (p = 0.03). Endoscopy-related complications included pneumothorax (n = 1), self-limiting bleeding (n = 12), prolonged coughing (n = 2), and vasovagal reactions (n = 2). None of these complications required further treatment.

CONCLUSION

TBNA is an effective bronchoscopic sampling technique in the diagnosis of peripheral pulmonary lesions. In our study, the use of TBNA increased the diagnostic yield of bronchoscopy from 35 to 51% without additional risk. The use of TBNA in the clinical routine should be encouraged.

Prospective evaluation of an algorithm for the functional assessment of lung resection candidates

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV1, diffusing capacity of the lungs for carbon monoxide (DLCO), and maximal oxygen uptake (VO2max), as well as their respective ppo values (FEV1-ppo, DLCO-ppo, and VO2max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 (+/- 1.8) d, and the mean hospital stay was 14.6 (+/- 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results.

[Is self-management practical in bronchial asthma?]

The threat and uncertainty involved in an asthma attack reduce the quality of life for the patient. Life quality can be improved if the patient learns self-management principles. This is easy to learn and involves a simple procedure requiring the patient to refer to written instructions in the event of an asthma exacerbation. As a basis for treatment the patient needs to measure maximum peak flow, which can be done with an easy-to-use peak flow meter. A value above 80% of the personal best indicates that the treatment has been successful. By means of printed instructions in credit card format, the appropriate treatment for particular peak flow values and/or symptoms can be looked up and administered. So far there have been no self-management studies providing a definite answer on what interventions are effective and cost-effective. One clear result is that inhaled steroid therapy must be initiated early. Learning self-management patently leads to improvement in the patient's life quality and safety. In the long run this concept appears to be cost-saving with regard to days lost through sickness and hospitalization.

[Etiology, diagnosis and therapy of COPD]

COPD is a disorder characterized by chronic exspiratory airflow limitation in patients with chronic bronchitis and/or emphysema. The obstruction is generally progressive, but may be partially reversible and may be accompanied by airway hyperreactivity. In this review we discuss the epidemiology, Pathophysiology, clinical features, diagnostic approaches and therapeutic management in patients with COPD. Cigarette smoking is the main risk factor for the development and progression of COPD; environmental or occupational exposure to dust or fumes and genetic factors are further contributing factors. Therefore, smoking cessation is the most important therapeutic approach. Better knowledge of neutrophilic inflammation led to the development of new drugs for the treatment of COPD. The new long-acting inhaled beta 2-agonists fundamentally improved antiobstructive therapy. They are useful to control night-time or early morning symptoms. The role of steroids and theophylline is still unclear. Their value and efficient use are discussed.

[Pleural effusion: what next?]

This article gives an overview of the aetiology, diagnostic evaluation and treatment of pleural effusions. A systematic approach including radiological and sonographic examinations and pleural fluid analysis is proposed with a view to selecting the most appropriate therapy. Common forms of exudative pleural effusions are explained in detail. For complicated parapneumonic effusions, new therapeutic options such as the use of fibrinolytics or thoracoscopic debridement are discussed. Talc slurry and thoracoscopic talc poudrage provide effective methods for pleurodesis in case of malignant effusions.

MMP and TIMP expression pattern in pleural effusions of different origins

The matrix metalloproteinases (MMP) are proteolytic enzymes that are essentially involved in the turnover of the extracellular matrix (ECM). Their activity is counterbalanced by specific antagonists, the tissue inhibitors of metalloproteinases (TIMP). In this study, we sought to analyze the expression of MMP and TIMP isoforms in pleural effusions from 88 patients. We compared MMP and TIMP isoform expression in transudates (n = 21) and exudates (n = 67), the latter divided into exudates of paraneoplastic (n = 46) or parainfectious (n = 21) origin. Zymographic and Western blot analyses revealed constant expression of interstitial collagenase (MMP-1), gelatinase-A (MMP-2), and TIMP-1 in all 88 samples. In contrast, analyses of gelatinase-B (MMP-9) demonstrated a specific expression pattern, with high expression in exudates and lack of expression in transudates. Neutrophil collagenase (MMP-8) was detected in trace amounts, and correlated with the number of neutrophils in the effusion. Low levels of TIMP-2 were detected only in exudates and not in transudates. Quantitative analysis of the expression ratio of gelatinase-B to gelatinase-A revealed statistically significant differences between effusions of different origin. The ratio was highest in exudates of paraneoplastic origin and lowest in transudates. Our data thus suggest that interstitial collagenase, gelatinase-A, and TIMP-1 play a role in homeostasis of the pleural space in vivo as constitutively expressed proteins, whereas gelatinase-B and TIMP-2 expression are induced in specific disease states. These observations contribute to the understanding of the pathophysiology of pleural effusions, and may help to characterize and possibly distinguish effusions of different origin.

Treatment of early parapneumonic empyema by "medical" thoracoscopy

We report on a consecutive series of 16 patients with complicated parapneumonic effusion or empyema, in whom, after a failed attempt at tube drainage, thoracoscopy under local anesthesia ("medical" thoracoscopy) was performed for debridement and placement of a chest tube. This approach led to immediate clinical improvement in all patients and to definitive cure in 12 of 16. In 4 patients open surgical debridement was necessary after a few days in an elective procedure. In a subgroup of thoracoscopically treated patients, lung function tests were performed at least 6 months after the procedure and did not demonstrate significant restrictive changes. We conclude that thoracoscopy under local anesthesia is a valuable addition to the treatment options in patients with multiloculated, complicated parapneumonic effusion or empyema not responsive to simple tube thoracotomy. The procedure is less taxing for the patient and less expensive than video-assisted thoracoscopic surgery under general anesthesia or open decortication.

DNA aneuploidy, S-phase fraction, nuclear p53 positivity, and survival in non-small-cell lung carcinoma

Inactivation of the p53 gene plays a key role in tumour biology, probably through a disturbed cell cycle control and an increased genetic instability in p53-inactivated tumours. To learn more about the relationship between p53 alterations, proliferation and genetic instability (DNA aneuploidy) in lung cancer patients, specimens of 220 surgically resected lung carcinomas with clinical follow-up information were examined by immunohistochemistry (p53; CM1) and flow cytometry. Nuclear p53 positivity--found in 49.5% of the tumours--was associated with both high S-phase fraction (SPF) and DNA ploidy aberrations. SPF was higher in p53-positive tumours (15.9 +/- 10.2) than in p53-negative tumours (10.3 +/- 8.7; P = 0.03). The rate of p53 positivity was higher in 101 DNA-aneuploid and DNA-multiploid tumours (55%) than in 27 diploid and peridiploid carcinomas (33%; P = 0.0512). These results are consistent with an in vivo role of p53 inactivation for increased proliferative activity and development of genomic instability in lung cancer. There was no association between SPF and prognosis. Although prognosis was worse in DNA-aneuploid and multiploid tumours than in diploid, peridiploid and tetraploid carcinomas (P = 0.029), DNA ploidy was not an independent predictor of poor prognosis in multivariate analysis. These data show that DNA-flow cytometry has little prognostic value for patients with resected non-small-cell lung carcinoma.

[New aspects in the treatment of bronchial asthma and chronic obstructive lung diseases]

The expansion of our knowledge regarding the pathogenesis of asthma has now made clear that it is an inflammatory disease. Although the treatment of bronchospasm associated with asthma is essential, it is important to consider the inflammatory aspect of the disease. The first therapeutic approach is to control environmental hazards (allergen, air pollution, tobacco smoke). It should always be remembered that patient education is of critical importance. Patients with only occasional asthma symptoms (2-4 times a week) should receive inhaled short-acting beta-2 agonists as needed. Treatment with inhaled corticosteroids is instituted in all asthmatics except the mildest cases. Long-acting beta-2 agonists are an additional therapy for patients with unsatisfactory symptom control despite an optimal dose of inhaled steroids, particularly when there are nocturnal symptoms. Chronic obstructive pulmonary disease is defined as a disease state characterized by the presence of airflow obstruction due to chronic bronchitis or emphysema. Although the airflow obstruction is generally progressive, comprehensive therapeutic management benefits all patients including those with severe disease: stopping smoking, vaccination against influenza and pneumococcus, pharmacologic therapy. The judicious use of bronchodilators increases airflow and reduces dyspnea. Ipratropium and beta-2 agonists are equally efficacious and may work synergistically. The use of corticosteroids is controversial. Thus a closely monitored steroid trial of therapy should be considered in patients who have continuing symptoms or severe airflow limitation despite maximal therapy with other agents. Broad spectrum antibiotics are beneficial in severe exacerbations.

Dyspnea after pneumonectomy: the result of an atrial septal defect

We report the case of severe hypoxemia attributable to right-to-left shunting through an atrial septal defect after right-sided pneumonectomy that developed in a 70-year-old man. Normal right atrial and pulmonary artery pressures were measured. Right-to-left shunting through a patent foramen ovale is known as a rare complication after pneumonectomy. Our patient, however, demonstrated a true atrial septal defect (septum secundum defect) upon open operative repair of the interatrial connection.

Insufficient control of asthma: increase the dose of inhaled steroids or add long-acting beta 2-agonists?

Internationally accepted treatment guidelines for bronchial asthma have established the early introduction of inhaled corticosteroids as a disease-modifying treatment, in addition to bronchodilator treatment as needed. In a small group of patients this approach does not lead to sufficient control of asthma. It is a matter of debate whether in this situation the dose of inhaled steroids should be increased or the bronchodilator treatment intensified by the introduction of long-acting beta 2-agonists. Advantages and limitations of both treatment strategies are discussed in the light of recent data. Guidelines for the use of long-acting beta 2-agonists are proposed.