Respiratory Medicine

Association between polymorphism of glutathione S-transferase P1 and chronic obstructive pulmonary disease: A meta-analysis

Fugui Yan, Chengshui Chen, Jiyong Jing, Wen Li, Huahao Shen, Xiangdong Wang — 2010-02-01

Summary: Background: It was proposed that glutathione S-transferase P1 (GSTP1) gene involved in detoxification of electrophilic substances may be related with lung function. The present study aimed at investigating the correlation between GSTP1 105Val/Val genotype and chronic obstruct pulmonary disease (COPD) using a meta-analysis of existed studies.Methods: The Embase, Ovid, and PubMed databases were searched to identify eligible studies published before October 1, 2009. Data were extracted using standardized forms and the pooled odds ratios (ORs) with 95% confidence intervals (CI) were assessed by a model of fixed- or random effects.Results: The values of odds ratios(ORs) for COPD were 0.634 (95%CI 0.426–0.943, p = 0.025) in GSTP1 Ile/Ile, 0.625 (95%CI 0.418–0.935, p = 0.022) in GSTP1 Ile/Val, and 0.633 (95% CI 0.430–0.933, p = 0.021) in both, as compared to GSTP1 Val/Val, respectively. The individuals with GSTP1 105Ile/Ile, Ile/Val, and both have about 37% reduction in the odds of COPD, as compared to individuals with GSTP1 105Val/Val.Conclusions: The GSTP1 105Val/Val genotype is suggested to be a genetic contributor to COPD susceptibility, which should be furthermore clarified by studies with large sample sizes and careful control for age, sex, ethnicity, and cigarette smoking.

Pulmonary vasodilator testing and use of calcium channel blockers in pulmonary arterial hypertension

Adriano R. Tonelli, Hassan Alnuaimat, Kamal Mubarak — 2009-12-09

Summary: Pulmonary arterial hypertension (PAH) encompasses a number of diseases responsible for a specific set of hemodynamic findings during right heart catheterization. During initial workup, pulmonary vasodilator testing is performed. A positive acute pulmonary vasodilator test predicts better survival and response to calcium channel blocker (CCB) therapy.There is lack of consensus on the preferred agent for determining acute pulmonary vasoreactivity. The ACCP guidelines and the 4th World Symposium on Pulmonary Hypertension support the use of intravenous epoprostenol or nitric oxide (NO) as the preferred agents for pulmonary vasodilator testing.A decrease in the mean pulmonary artery pressure by at least 10 mmHg to reach an absolute value of 40 mmHg or less without a decrease in cardiac output is currently considered a positive pulmonary vasodilator test. A positive test by the current recommended criteria is observed in about 10-15% of patients with idiopathic PAH. Approximately half of these patients will experience long-term benefits with CCBs. A positive test may select patients with an earlier or less aggressive form of disease, which may carry a better prognosis. A positive vasodilator test is observed very infrequently in patients with pulmonary arterial hypertension other than idiopathic PAH or anorexigen associated PAH.This article reviews the literature regarding pulmonary vasodilator testing and use of CCB therapy in patients with PAH, while identifying the gaps in knowledge concerning this diagnostic procedure.

Rhinitis in subjects with work-exacerbated asthma

2009-11-30

Summary: Objectives: This study aimed at characterizing the nature, severity, and timing of nasal and ocular symptoms in subjects with work-exacerbated asthma (WEA).Methods: Among the 363 subjects referred to a tertiary-care hospital for the investigation of work-related asthma symptoms, 105 subjects who demonstrated non-specific bronchial hyperresponsiveness to histamine, but a negative response to a specific inhalation challenge with the suspected occupational agent(s) were considered as having WEA. Their characteristics were compared with those of 172 subjects with occupational asthma (OA), ascertained by a positive response to a specific inhalation challenge.Results: A high proportion of subjects with WEA (83%) and OA (90%) reported at least one nasal symptom at work. Sneezing/itching and rhinorrhea were more frequent in subjects with OA (78% and 70%, respectively) than in those with WEA (61%, p = 0.004 and 57%, p = 0.038, respectively), while post-nasal discharge was more common in WEA (30%) than in OA (18%, p = 0.019). Nasal symptoms were less severe in WEA (median [25th–75th percentiles] global severity score: 4 [2–6]) as compared to OA (5 [4–7], p < 0.001). Nasal symptoms preceded less frequently those of asthma in subjects with WEA (17%) than in subjects with OA (43%, p = 0.001).Conclusions: Nasal symptoms are highly prevalent in subjects with WEA, although their clinical pattern differs from that found in OA. Further investigations of the health and socio-economic impacts of upper airways symptoms in WEA are required to improve the understanding and management of this common condition.

Vocal cord dysfunction: Beyond severe asthma

2009-12-07

Summary: Background: Vocal cord dysfunction (VCD) is the abnormal adduction of the vocal cords during inspiration causing extrathoracic airway obstruction. VCD has been described as a confounder of severe asthma. The influence of VCD among less severe asthmatics has not been previously defined.Methods: We retrospectively reviewed the medical records of 59 patients with pulmonologist-diagnosed asthma who were referred for videolaryngostroboscopy (VLS) testing from 2006 to 2007.Results: A total of 44 patients had both asthma and VCD. 15 patients had asthma without concomitant VCD. Females were predominant in both groups. Overall, the majority of patients referred for VLS testing had mild-to-moderate asthma (78%) and 72% of these patients had VCD. Few patients from either group had “classic” VCD symptoms of stridor or hoarseness. Gastroesophageal reflux disease (GERD) and rhinitis were common in both groups.Conclusions: Vocal cord dysfunction occurs across the spectrum of asthma severity. There was a lack of previously described “classic” VCD symptoms among asthmatics. Symptoms were diverse and not easily distinguished from common symptoms of asthma, highlighting the need for a high index of suspicion for VCD in patients with asthma. Failure to consider and diagnose VCD may result in misleading assumptions about asthma control, and result in unnecessary adjustments of asthma medications. The high prevalence of GERD raises the question of the role of acid reflux in the pathogenesis of VCD in asthmatics.

Low-dose fluticasone propionate with and without salmeterol in steroid-naïve patients with mild, uncontrolled asthma

2009-11-30

Summary: Background: The role of combination ICS/LABA as initial controller therapy in mild, persistent asthma is uncertain. Therefore, the objective of this study was to compare the efficacy of initial controller therapy with fluticasone propionate (FP) 100μg twice daily to the efficacy of fluticasone propionate/salmeterol xinafoate (FSC) 100/50μg twice daily in patients with persistent asthma symptoms while using as-needed SABA alone.Methods: This randomized, double-blind, parallel-group study was conducted at 45 general practice and 15 specialist centers. A total of 526 adult patients were randomized to receive FP or FSC for 24weeks. The primary efficacy endpoint was change in morning peak expiratory flow (PEF) from baseline. Secondary efficacy endpoints included symptom- and rescue-free days; asthma exacerbation rate; asthma-related health-care utilization; and the onset of effect. Safety was assessed by monitoring adverse events.Results: Mean morning PEF was significantly greater in the FSC versus the FP group (P<0.001); this greater effect was evident as early as the first week of treatment (P<0.001). The percentages of symptom-free days and rescue-free days in the FSC group were 7.7% (P=0.009) and 8.4% (P=0.001) higher than the FP group, respectively. Trends toward lower exacerbation-related health care-utilization for FSC versus FP were not statistically significant and exacerbation rates were not significantly different. The incidence of adverse events was low with both treatments.Conclusions: :Treatment with FSC was a more effective initial controller therapy than FP monotherapy in ICS-naïve patients who had uncontrolled asthma while using as-needed SABA alone.

Temazepam 10mg does not affect breathing and gas exchange in patients with severe normocapnic COPD

2009-11-13

Summary: Background: Benzodiazepines can improve sleep quality, but are also thought to cause respiratory depression in patients with chronic obstructive pulmonary disease (COPD). The aims of this study were to assess the effects of temazepam on indices of circadian respiratory function, dyspnea, sleep quality, and sleepiness in patients with severe COPD and insomnia.Methods: In a double-blind, randomized, placebo-controlled, cross-over study in 14 stable patients with COPD (mean FEV1 0.99±0.3L) with insomnia, polysomnography with continuous transcutaneous capnography and oximetry, arterial gas sampling, hypercapnic ventilatory response, multiple sleep latency test, Epworth Sleepiness Scale, dyspnea and sleep visual analogue scales (VAS) were performed at baseline, after one week of temazepam 10mg at bedtime and after one week of placebo.Results: Temazepam did not cause statistically significant changes in mean transcutaneous carbon dioxide tension during sleep compared to placebo (5.9±1.0kPa vs. 6.3±1.4kPa, p-value 0.27), nor in mean oxygen saturation (92±3% vs. 92±2%, p-value 0.31), nor in any of the other investigated variables, except for the total sleep time and sleep latency VAS, which improved with temazepam.Conclusions: One week usage of temazepam 10mg does not influence circadian respiratory function, dyspnea, and sleepiness in patients with stable, severe, normocapnic COPD and insomnia and it improves total sleep time and subjective sleep latency. However, this is a preliminary explorative study for assessing the feasibility to perform a larger study on this topic. The clinical implications of this study are very limited.

The clinical utility of long-term humidification therapy in chronic airway disease

2010-02-10

Summary: Aim: Persistent airway inflammation with mucus retention in patients with chronic airway disorders such as COPD and bronchiectasis may lead to frequent exacerbations, reduced lung function and poor quality of life. This study investigates if long-term humidification therapy with high flow fully humidified air at 37 °C through nasal cannulae can improve these clinical outcomes in this group of patients.Method: 108 patients diagnosed with COPD or bronchiectasis were randomised to daily humidification therapy or usual care for 12 months over which exacerbations were recorded. Lung function, quality of life, exercise capacity, and measures of airway inflammation were also recorded at baseline, 3 and 12 months.Results: Patients on long-term humidification therapy had significantly fewer exacerbation days (18.2 versus 33.5 days; p = 0.045), increased time to first exacerbation (median 52 versus 27 days; p = 0.0495) and reduced exacerbation frequency (2.97/patient/year versus 3.63/patient/year; p = 0.067) compared with usual care. Quality of life scores and lung function improved significantly with humidification therapy compared with usual care at 3 and 12 months.Conclusion: Long-term humidification therapy significantly reduced exacerbation days, increased time to first exacerbation, improved lung function and quality of life in patients with COPD and bronchiectasis.Clinical trial registered with www.actr.org.au; Number ACTRN2605000623695

Responsiveness of the cough and sputum assessment questionnaire in exacerbations of COPD and chronic bronchitis

2009-11-17

Summary: Background: To assess the responsiveness of the Cough and Sputum Assessment Questionnaire (CASA-Q) in COPD and chronic bronchitis patients recovering from an acute exacerbation. The 20-item questionnaire with a 7-day recall assesses the frequency and severity of cough and sputum and their impact on everyday life in clinical (trial) settings. The four domains (cough/sputum symptom and impact) use scales from 0 to 100, with lower scores indicating higher symptom/impact levels.Methods: Outpatients were enrolled within 48h of symptom onset of their exacerbation. Treatment was initiated at the discretion of the investigator, and patients observed for 6 weeks. During study visits, 59 eligible patients completed the CASA-Q at enrolment, week 1, 2 and 6. Responsiveness was assessed by calculating standardized effect sizes.Results: Of the 19 male and 40 female patients with a mean (standard deviation, SD) age of 61.1 (10.5) years, all were classified by their physician to have improved or recovered after six weeks. The mean (SD) CASA-Q sores for the cough symptom, cough impact, sputum symptom and sputum impact domains increased from 32.6 (21.0), 40.7 (22.4), 37.4 (20.1), 47.1 (24.2) at enrolment to 54.0 (19.8), 63.7 (21.3), 55.1 (19.0), 65.5 (20.5) at week 6, respectively. Standardized effect sizes for patients improved or recovered from their exacerbation at week 6 were above 1.0 for the cough domains and at least 0.77 for the sputum domains.Conclusions: The CASA-Q was responsive to symptom changes in patients recovering from an exacerbation.

Responses to inhaled long-acting beta-agonist and corticosteroid according to COPD subtype

2009-11-18

Summary: Rationale: Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous disorder in which a number of different pathological processes lead to recognition of patient subgroups that may have individual characteristics and distinct responses to treatment.Objectives: We tested the hypothesis that responses of lung function to 3 months of combined inhalation of long-acting beta-agonist and corticosteroid might differ among patients with various COPD subtypes.Methods: We classified 165 COPD patients into four subtypes according to the severity of emphysema and airflow obstruction: emphysema-dominant, obstruction-dominant, mild-mixed, and severe-mixed. The emphysema-dominant subtype was defined by an emphysema index on computed tomography of more than 20% and FEV1 more than 45% of the predicted value. The obstruction-dominant subtype had an emphysema index≤20% and FEV1≤45%, the mild-mixed subtype had an emphysema index≤20% and FEV1>45%, and the severe-mixed subtype had an emphysema index>20% and FEV1≤45%. Patients were recruited prospectively and treated with 3 months of combined inhalation of long-acting beta-agonist and corticosteroid.Results: After 3 months of combined inhalation of long-acting beta-agonist and corticosteroid, obstruction-dominant subtype patients showed a greater FEV1 increase and more marked dyspnea improvement than did the emphysema-dominant subgroup. The mixed-subtype patients (both subgroups) also showed significant improvement in FEV1 compared with the emphysema-dominant subgroup. Emphysema-dominant subtype patients showed no improvement in FEV1 or dyspnea after the 3-month treatment period.Conclusion: The responses to 3 months of combined inhalation of long-acting beta-agonist and corticosteroid differed according to COPD subtype.

How often is diagnosis of COPD confirmed with spirometry?

2009-11-20

Summary: Background: Chronic obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality worldwide. Diagnosis is customarily confirmed with spirometry, but there are few studies on documented spirometry use in everyday clinical practice.Methods: In a cross-sectional survey and study of the medical records of primary and secondary care COPD patients aged 18–75 in a Swedish region, patients with COPD were randomly selected from the registers of 56 primary care centres and 14 hospital outpatient clinics. Spirometry data at diagnosis ±6 months were analyzed.Results: From 1114 patients with COPD, 533 with a new diagnosis of COPD during the four-year study period were identified. In 59% (n=316), spirometry data in connection with diagnosis were found in the medical records. Spirometry data with post-bronchodilator forced expiratory volume in 1s (FEV1)/ vital capacity (VC) ratios were available in 45% (n=241). FEV1/VC ratio <0.70 were found in 160 patients, which corresponds to 30% of the patients with a new diagnosis. Lower age, female gender, current smoking, higher body mass index (BMI) and shorter forced exhalation time were related to COPD diagnosis despite an FEV1/VC ratio of ≥0.70. The most common problem in the quality assessment was an insufficient exhalation time.Conclusions: Only a third of Swedish patients with COPD had their diagnosis confirmed with spirometry. Our data indicate that female gender, current smoking, higher BMI and short exhalation time increase the risk of being diagnosed with COPD without fulfilling the spirometric criteria for the disease.

A profile of volatile organic compounds in breath discriminates COPD patients from controls

2009-11-11

Summary: Background: Chronic obstructive pulmonary disease (COPD) is an inflammatory condition characterized by oxidative stress and the formation of volatile organic compounds (VOCs) secreted via the lungs. We recently developed a methodological approach able to identify profiles of VOCs in breath unique for patient groups. Here we applied this recently developed methodology regarding diagnosis of COPD patients.Methods: Fifty COPD patients and 29 controls provided their breath and VOCs were analyzed by gas chromatography–mass spectrometry to identify relevant VOCs. An additional 16 COPD patients and 16 controls were sampled in order to validate the model, and 15 steroid naïve COPD patients were sampled to determine whether steroid use affects performance.Findings: 1179 different VOCs were detected, of which 13 were sufficient to correctly classify all 79 subjects. Six of these 13 VOCs classified 92% of the subjects correctly (sensitivity: 98%, specificity: 88%) and correctly classified 29 of 32 subjects (sensitivity: 100%, specificity: 81%) from the independent validation population. Fourteen out of 15 steroid naïve COPD patients were correctly classified thus excluding treatment influences.Interpretation: This is the first study distinguishing COPD subjects from controls solely based on the presence of VOCs in breath. Analysis of VOCs might be highly relevant for diagnosis of COPD.

Elevated 1, 25-dihydroxyvitamin D levels are associated with protracted treatment in sarcoidosis

Dashant Kavathia, John D. Buckley, Dhanwada Rao, Benjamin Rybicki, Robert Burke — 2010-01-13

Summary: Background: Active vitamin D metabolite, 1, 25-dihydroxyvitamin D, has pleomorphic effects on both innate and acquired immunity. Sarcoid granuloma derived 1, 25-dihydroxyvitamin D leads to hypercalcemia, but the association of 1, 25-dihydroxyvitamin D with the clinical phenotype of the disease is currently unknown.Objective: To determine the relationship between serum 1, 25-dihydroxyvitamin D levels and the degree of sarcoidosis disease chronicity.Design: Serum 1, 25-dihydroxyvitamin D levels were measured and associated with sarcoidosis activity and phenotypes as assessed by Sarcoidosis Severity Score and Sarcoidosis Clinical Activity Classification respectively.Results: Fifty nine patients were recruited with 44% having a sub-acute onset, and the chronic disease phenotype. There was no significant difference in serum 1, 25-dihydroxyvitamin D levels by chest radiograph stage (p = 0.092) nor did the levels correlate with the Sarcoidosis Severity Score (r = −0.16; p = 0.216). Serum 1, 25-dihydroxyvitamin D levels were associated with patients requiring repeated regimens of systemic immunosuppressive therapy or >1 year of therapy (SCAC Class 6). Increasing quartiles of serum 1, 25-dihydroxyvitamin D level was associated increased odds of the chronic phenotype (OR 1.82, 95% CI, 1.11, 2.99, p = 0.019). The majority (71%) of the patients with levels >51 pg/mL required chronic immunosuppressive therapy as defined by SCAC class 6.Conclusions: In patients with sarcoidosis, elevated 1, 25-dihydroxyvitamin D levels are associated with chronic treatment needs.

Deficiency of pulmonary Vα24 Vβ11 natural killer T cells in corticosteroid-naïve sarcoidosis patients

2009-12-02

Summary: Invariant natural killer T (NKT) cells might contribute to the amplified and prolonged T-cell immune response that characterizes sarcoidosis. Therefore, we want to investigate the frequency and distribution of pulmonary invariant NKT cells in corticosteroid-naïve patients with sarcoidosis. We used multi-parameter flow cytometry with antibodies against CD3, CD4, CD8, CD14, CD19, CD45, CD16/56, TCR Vα24, and TCR Vβ11, on bronchoalveolar lavage fluid (BALF), to examine the frequency and distribution of pulmonary invariant NKT cells in 47 newly diagnosed sarcoidosis patients and in 8 control subjects. The frequencies of BALF Vα24 Vβ11 invariant NKT cells were significantly lower in patients with sarcoidosis in comparison to control subjects. Moreover, lower invariant NKT cell frequencies in patients with sarcoidosis significantly correlated with exaggerated BALF lymphocytosis and CD4 T cell responses. This study demonstrated a pulmonary deficiency in the frequency of a subset of T cells with immunoregulatory function in patients with sarcoidosis.

Predictors for clinical trial participation in the rare lung disease lymphangioleiomyomatosis

2009-12-07

Summary: Background: Lymphangioleiomyomatosis (LAM) is a rare, progressive and frequently lethal cystic lung disease that almost exclusively affects women and has no proven therapies. An improved understanding of the pathogenesis has identified promising molecular targets for clinical trials. Although barriers, modifiers, and benefits for clinical trial participation in common diseases such as cancer have been studied, we are unaware of such evaluations concerning rare diseases.Methods: We performed a survey of a population-based registry of 780 LAM subjects in North America to identify predictors of trial participation. Logistic regression analysis evaluated the association of demographic and clinical features with trial participation.Results: 41 of 263 (16%) LAM patient respondents in North America had participated in a clinical trial. Age, disease duration, lack of any college education, use of oxygen therapy, and presentation without chest pain were associated with trial participation in unadjusted analyses. Multivariate analyses indicate that patient age was the strongest independent predictor for trial participation (OR=2.07, p=0.004 per decade greater of patient age). Common reasons reported against trial participation included not meeting enrollment criteria (44%), drug toxicity (25%), and stable disease (20%). The most frequent reason reported for trial participation was to help future patients (85%).Conclusions: Study entry criteria, drug toxicity, and stability of disease are barriers to trial enrollment among subjects with LAM. Older LAM patients and those with more advanced disease are more likely to have participated in clinical trials. Altruism is commonly a motivating factor.

Community-acquired pneumonia and nursing home-acquired pneumonia in the very elderly patients

2010-01-11

Summary: The rapid increase in the elderly population is leading to a corresponding increase in the number of people requiring medical care. To date no comparative study between community-acquired pneumonia (CAP) and nursing home-acquired pneumonia (NHAP) has been reported in the very elderly non-intubated patients. The present study was undertaken to compare the clinical characteristics and microbial etiology between CAP and NHAP in elderly patients ≥85-years old. There were 54 patients with NHAP and 47 with CAP. Performance status was significantly worse in the NHAP than in the CAP group. Among all patients, the most frequent pathogens were Chlamydophilia pneumoniae followed by Streptococcus pneumoniae, Mycoplasma pneumoniae influenza virus and Staphylococcus aureus. The frequency of S. peumoniae was significantly higher in NHAP patients than in CAP patients after adjusting for age and sex. Physical activity, nutrition status and dehydration were significant prognostic factors of pneumonia among all patients. In-hospital mortality was significantly higher in NHAP than in CAP after adjusting for age and sex. This study demonstrated that the etiology and clinical outcome differ between CAP and NHAP patients in the very elderly non-intubated population.

Usefulness and safety of double endoscopy in children with gastroesophageal reflux and respiratory symptoms

2009-12-02

Summary: Background: Management of children with gastroesophageal reflux disease (GORD) and difficult-to-treat (D-T-T) respiratory symptoms may include double fiberoptic, airway and oesophago-gastro-duodenoscopies (DE). A study was performed to evaluate the usefulness and safety of DE in children with severe GORD and D-T-T respiratory symptoms.Methods: A 3-year retrospective review of records of children who underwent DE under general anaesthesia was performed: the relevant clinical information obtained and the occurrence of complications in the 72h following the DE.Results: Inflammatory changes of the airways were found at bronchoscopy in 40 out of the 60 children: bronchoalveolar lavage (BAL) demonstrated positive lipid-laden alveolar macrophages (LLAM), neutrophilic inflammation or both, respectively in 9, 12 and 16 patients. BAL bacterial cultures were positive in 2 patients with elevated airway neutrophilia. Structural airway abnormalities, explaining not GOR-related D-T-T respiratory symptoms were identified in 11 patients. Oesophagoscopic findings supporting GORD were detected in 32/60 children and confirmed by consistent histological changes in oesophageal mucosal biopsies (OEB) in 27.The frequency of complications, all minor, was low during the procedure and in the following 72h. They included mild desaturation, stridor or bronchospasm, vomiting, dysphagia and hyperthermia requiring antibiotic treatment in 1 patient. No “new onset” complication was observed after 48h following DE. The time-dependent hazard of complications was significantly higher for patients with a history of onset of respiratory symptoms early in life (≤2 years of age) (p=0.038).Conclusion: DE can be useful in the clinical evaluation of children with D-T-T respiratory symptoms and GORD and is associated with low frequency of mild complications when performed by appropriately trained and experienced personnel.

Chest low-dose computed tomography in neutropenic acute myeloid leukaemia patients

2009-12-17

Summary: Background: We aimed to compare chest low-dose computed tomography (LDCT) with chest radiography (CXR) in the assessment of febrile acute myeloid leukaemia neutropenic patients.Methods: A prospective non-randomized study was carried out between 30 May, 2003 and 3 June, 2004 in consecutive neutropenic patients who required imaging of the thorax and were treated for acute myeloid leukaemia. Each patient had a baseline 2-view chest radiograph followed by LDCT. Both the CXR and the LDCT studies were blindly and independently reviewed by two chest radiologists.Results: Forty patients were enrolled: 24 male and 16 female, mean age 53.5years (range 18–83) and an average neutrophil count of 0.78×109/L. Patients had CXR within a mean of 40min from the LDCT. Overall, 31 (77.5%) of 40 CXR were abnormal, whereas LDCT detected abnormalities in 38 (95%) of 40 patients. LDCT demonstrated three times the number of lung nodules as CXR and twice as many ground-glass opacities. Lung consolidation was detected similarly using both techniques, but LDCT demonstrated more extensive and multi-focal consolidation. The majority of nodules detected only on LDCT were subcentimetre in diameter. The additional information provided by LDCT led to an alteration in the clinical management of 11 (27.5%) of 40 patients.Conclusion: LDCT is a useful tool in the initial investigation of suspected pulmonary complication in neutropenic patients. This is supported by the additional information it provides to the CXR with reduced radiation when compared to conventional CT.

Adenosine for vasoreactivity testing in pulmonary hypertension: A head-to-head comparison with inhaled nitric oxide

Edmundo C. Oliveira, Antonio Luiz P. Ribeiro, Carlos Faria Santos Amaral — 2009-12-04

Summary: Background: APVT is an invasive method recommended for symptomatic patients with PAH that permits the identification of the minority of patients (<20%) that may benefit from long-term calcium channel blockers. Adenosine has been indicated in guidelines as a vasodilator agent of choice for APVT, although it has not been directly compared with iNO, the gold standard for this test. The objective of the study was to compare adenosine with inhaled nitric oxide (iNO) for acute pulmonary vasoreactivity testing (APVT) in pulmonary arterial hypertension (PAH), in order to determine the efficacy and safety of the first in the clinical setting.Methods: The measurements of cardiac output, pulmonary and systemic resistance were done in the basal state and with a stepwise increase of the dose of each drug until either maximum dosage (adenosine: 500 μg/kg/min or iNO: 80 ppm) or side effects observed or a positive response were reached, according to current guidelines. The order of drugs used in each test was consecutively alternated during the study.Results: Six of the 39 studied patients (15%) presented a positive response to iNO; none to adenosine (p = 0.047, McNemar's test). Twenty-three patients (59%) did not reach the maximum dose of adenosine due to side effects, including bronchospasm, thoracic pain and bradycardia.Conclusions: APVT testing with adenosine was not able to detect PAH patients responsive to iNo and provoked frequent adverse effects. Adenosine should not be used as a vasodilator drug in APVT.

Thoracic ultrasound for pleural effusion: Delays and cost associated with departmental scanning

K. Bateman, D.G. Downey, T. Teare — 2010-01-25

Summary: Pleural effusion is a common clinical condition on medical wards and the majority of cases undergo pleural aspiration or chest drain insertion as a diagnostic or therapeutic procedure. The use of a thoracic ultrasound scan (USS) improves diagnostic yield for pleural fluid aspiration and reduces complications and USS is increasingly recommended prior to all pleural aspirations or drains and ‘real time’ scanning which, as well as potentially reducing delays, enhances the safety of the procedure. In many U.K hospitals a thoracic USS is still routinely performed in the radiology department. We reviewed radiology records and case notes from hospital in-patients to assess potential delays and associated costs with departmental thoracic USS and to identify cases where physician-led portable USS would potentially have improved the patient's journey.We demonstrated delays resulting in significant financial costs to the hospital of an estimated £17, 880 per annum. However, the cost to the patient is also significant, both in terms of patient experience (many of whom will have an underlying diagnosis of metastatic carcinoma and with a limited life expectancy) but also patient safety. Respiratory physicians are increasingly recognising the importance of portable thoracic USS to guide pleural procedures and there has been increasing use of physician-led portable thoracic USS. Hospitals should be encouraged to fund both portable thoracic USS equipment but it is also crucial that training in this area is properly supported.