Biomedical subjects

S Kesten

Publications and source records attributed to S Kesten.

At least 55 records · Page 3Linked to original sources

PubMed1997

Asthma and allergy avoidance knowledge and behavior in postpartum women.

OBJECTIVE: Based on family history, infants may be classified as "high risk" or "low risk" for the development of allergy or asthma. Failure to breast-feed and early exposure to cigarette smoke or aeroallergens increase the risk of developing asthma or allergy. Since we suspect that physicians seldom educate mothers on reducing environmental exposures in the postnatal period, we sought to determine the level of maternal knowledge as well as actual avoidance behaviors with respect to these risk factors in high risk and low risk families. DESIGN: Questionnaire administered by a research assistant. SETTING: Obstetrics unit of two tertiary care general hospitals. PATIENTS: A sample of 194 postpartum women with uncomplicated pregnancies, interviewed after 24-hours postpartum. MAIN OUTCOME MEASURES: (1) Parental history of asthma, allergy or eczema; (2) potential for infant exposure to environmental risk factors for asthma and allergy, as indicated by history of avoidance practices in the home; (3) parental knowledge of risk factors for asthma or allergy; and (4) physician advise on avoidance. RESULTS: Of 194 women interviewed, a history of doctor-diagnosed asthma, allergy/allergic rhinitis or eczema in either parent was reported by 122 (high risk group). The remaining 72 patients had no history of atopy (low risk group). Of those in the high risk group, 10% of mothers smoked during pregnancy, and about 25% were exposed to second hand smoke on a daily basis. Most of the mothers in the high risk group planned to breast feed (89%). A large number of patients in the high risk group reported potential risk factors for allergy/asthma in their home environments. These included animals in the household (36%), dusty environments (10%) carpeting (47%), cigarette smoke (18%), and others. Despite these risks, only 13% of patients reported being educated by their physicians on improving their home environment. Exposures to environmental risk factors were not different between low and high risk groups. Similarly, knowledge of environmental risk factors and avoidance behaviors were not significantly different between low and high risk groups. CONCLUSIONS: Many mothers whose infants are at high risk of developing asthma or allergies are not aware of and do not practice avoidance of risk factors. Physicians involved in prenatal care of women with a family history of atopy and asthma should offer advice on reducing exposure to potential risk factors and how to modify their environment in ways that can potentially decrease the risk of asthma or allergy prevalence and severity.

Adult↗

PubMed1997

Factors associated with emergency department dependence of patients with asthma.

BACKGROUND: Dependence on crisis-oriented care rather than continuous ambulatory care for asthma is thought to contribute to asthma morbidity and mortality. We contrasted the characteristics of patients who depend on emergency department (ED) care for the management of their asthma exacerbations to the characteristics of patients employing self-management plans in an ambulatory setting. METHODS: In prospective fashion, we used a structured interview and charted information to survey two cohorts of patients suffering from an acute exacerbation of asthma; those seen in a hospital ED (n = 80) and those seen in an ambulatory asthma care facility (Asthma Center [AC]) (n = 40) at the same hospital. We looked for differences in socioeconomic characteristics, asthma severity, asthma knowledge, and asthma self-management skills between groups. RESULTS: There were no significant differences in mean age (SD) (ED vs AC: 36.65 [13.8] vs 40 [13.8] years) or female to male ratio (ED vs AC: 2/1 vs 2.5/1) between the two groups. There were no major differences in ethnic origin, educational status, marital status, smoking history, employment status, number of children in the household, possession of an extended health insurance plan, sick leave benefits, and child care availability between the two groups. Patients seeking ED care were more likely to have resided in the city for < 5 years (34% vs 8%; p < 0.05), and more likely to be living alone (35% vs 15%; p < 0.05). Significantly more patients from the ED group had a below average gross annual income (55% vs 3%; p < 0.05). There were several significant differences between groups in their knowledge of asthma and its therapy. Most striking, 79% of AC patients reported having a predetermined crisis plan vs just 23% of ED patients (p < 0.001). Although measurements of airflow (percent predicted FEV1) were significantly lower in the ED group than the AC group (mean, 50% vs 78.4%; p < 0.001), other indexes reflecting the degree of asthma severity over the long term such as past use of oral steroids, history of hospitalization, or ICU admission for asthma and the mean total days of disability within the preceding year were not significantly different between the two groups. Most of the ED patients had more than one previous visit to the ED for asthma exacerbation within the preceding year while most exacerbations of AC patients had been treated in the ambulatory care setting. Only 17% of ED patients initiated or increased inhaled or oral steroids before seeking medical care vs 89% of AC patients (p < 0.001). CONCLUSION: We conclude that a subgroup of asthmatics depends primarily on crisis-oriented care for the management of asthma. These patients are more likely to have lower income, to live alone, and to have resided at their current address for less time than patients seeking less urgent ambulatory care. Moreover, such patients are less knowledgeable about asthma and its management and are less likely to have a predetermined crisis plan.

Adult↗

PubMed1997

Prehospitalization inhaled corticosteroid use in patients with COPD or asthma.

BACKGROUND: Guidelines for the treatment of obstructive lung diseases suggest a primary role of inhaled corticosteroids (ICs) in asthma, but only a minor role in COPD. However, surveys of physicians' prescribing habits have suggested that there is little difference in the use of ICs between these two conditions. OBJECTIVES: To determine the prevalence of IC use before and during hospitalization among patients with COPD or asthma. DESIGN: Retrospective chart review. SETTING: Tertiary care university teaching hospital. PATIENTS: Adult inpatients, aged 18 or older, with physician-diagnosed COPD or asthma. MEASUREMENTS: Patient-reported prescription drug use at hospital admission, and medical chart record of in-hospital and discharge prescriptions. RESULTS: Of 350 charts reviewed, 102 patients were admitted to the hospital for unstable COPD, 133 patients had stable COPD, 36 patients were admitted with unstable asthma, and 79 patients had stable asthma. At hospital admission, 48% of unstable COPD patients, 26% of stable COPD patients, 56% of unstable asthma patients, and 44% of stable asthma patients reported having a current prescription for ICs. The proportion of all asthmatic patients reporting a current prescription for ICs at admission (48%) was significantly higher than the proportion of all COPD patients receiving an IC at admission (35%). However, there was no significant difference in the proportion of COPD and asthma patients with a current prescription of any form of corticosteroid (oral or inhaled). The proportion of COPD patients likely to respond to IC therapy is significantly different from the observed use at hospital admission. CONCLUSIONS: The proportion of patients found to be using ICs is much higher than the proportion expected to respond. There was little difference in the use of ICs for asthma and COPD patients at hospital admission. Most COPD patients using an IC were receiving the regimen on admission to hospital, indicating that there is need for education in the community and in the hospital regarding use of ICs in COPD patients.

Administration, Inhalation↗

PubMed1997

Lack of left ventricular dysfunction associated with sustained exposure to hyperlipidemia following lung transplantation.

OBJECTIVES: Hyperlipidemia due to standard immunosuppressive agents occurs commonly following solid organ transplantation. A decision to treat hyperlipidemias would be based on the assumption that such disorders lead to accelerated atherogenesis and ultimately to cardiac dysfunction. We therefore sought to examine whether hyperlipidemias following lung transplantation were associated with a decline in left ventricular (LV) function. STUDY DESIGN: We retrospectively reviewed serial echocardiograms, radionucleotide angiograms (RNAs), and serum lipid levels following lung transplantation. Results of cardiac studies were defined as abnormal if a decline in LV grade occurred from the best result at any time postoperatively to the most recent study. PATIENTS: A total of 184 patients with transplants between November 1983 and June 1995 were reviewed. Eighty patients were excluded owing to incomplete data. One patient was excluded because of severe perioperative myocardial dysfunction. RESULTS: Approximately 80% of patients had elevated cholesterol levels and 60% had elevated low-density lipoprotein levels. Triglyceride levels were raised in 34% of patients while only 4% had an abnormal serum high-density lipoprotein level. More than 80% of patients had no evidence of LV abnormalities in either RNA or echocardiographic studies (group 1). One patient had a change in echocardiographic LV function but no change in grade of RNA (group 2). Twenty patients had a decline in grade based on RNA but no change in the echocardiogram (group 3). There were no patients with changes in both RNA and echocardiogram (group 4). All changes in LV function were from grade I to II. The mean period of follow-up exceeded 30 months for patients in groups 1 to 3. Follow-up data at 3, 4, and 5 years were available on 47, 23, and 12 patients, respectively. There were no differences between the proportions of subjects with normal and abnormal serum lipid levels in each group. CONCLUSIONS: In the initial 5 years after lung transplantation, dyslipidemias affect the majority of patients but are not associated with evidence of deteriorating LV function.

Anticholesteremic Agents↗

PubMed1997

Defining the asthma phenotype for the purpose of genetic analysis.

In 1991, we began a project to search for the genetic basis of asthma using linkage analysis. We encountered discord between a history of asthma and physiological measures of variable airflow obstruction and sought to examine the frequency of such occurrences and the issues surrounding phenotyping of patients with asthma. We reviewed our experience in ascertaining the asthma phenotype in 50 nuclear families comprised of 219 subjects (110 male, 109 female). Three respiratory physicians reviewed data including a questionnaire, skin testing, objective measures of variable airflow obstruction [increase in FEV1 > or = 15% following salbutamol 400 micrograms of PC20 (methacholine) < or = 4 mg/ml], and serum for IgE. Thirty-eight percent of subjects had both objective and questionnaire data consistent with asthma (++) whereas 39% had negative objective and negative questionnaire findings (--) (i.e., no asthma). A positive history but negative objective findings occurred in 7% of subjects, 2% had a negative history and positive objective findings. Retesting was requested in 13% of subjects; review of historical data was requested in 1% (i.e., childhood asthma but no present asthma). Retesting was requested for either (a) positive history, negative objective if symptoms were seasonal or the subject was using medications known to affect the challenge study, (b) viral infection within 6 weeks of a positive methacholine study, or (c) technically inadequate study. Overall, after the initial assessment, all members of only 22 families could be catagorized as either ++ or --. The diagnostic group requested at least 1 retest in 19 families and a review of historical records in 2 families. We conclude that discordance between self-reported questionnaire data and laboratory measures of variable airflow limitation is common and will increase the numbers of asthmatic subjects in studies that seek to determine the genetic basis of asthma.

Adolescent↗

PubMed1997

The six-minute walk test: a guide to assessment for lung transplantation.

BACKGROUND: A window of opportunity exists with regard to optimal timing for lung transplantation. Performance of a transplantation too early may rob the patient of months to years of survival, whereas waiting too long increases the risk of death before transplantation. Several studies have examined specific lung function tests as predictors of death, but none have been shown to be useful across the various disorders leading to end-stage lung disease. We therefore sought to examine the usefulness of the 6-minute walk test as a guide to assessment for transplantation. METHODS: We conducted a retrospective chart review of patients who were assessed and either were accepted or died waiting acceptance by the Toronto Lung Transplant Program between January 1991 and June 1995. One hundred forty-five patients with the following lung diseases were included: emphysema (n = 38), alpha-1-antitrypsin deficiency (n = 20), idiopathic pulmonary fibrosis (n = 26), primary pulmonary hypertension (n = 10), Eisenmenger's syndrome (n = 9), and cystic fibrosis (n = 41). The sensitivity, specificity, and positive and negative predicted values for a 6-minute walk distance of 300 and 400 m as a predictor of death were calculated. RESULTS: Mortality rates were as follows: emphysema (7.9%), alpha-1-antitrypsin deficiency (15%), idiopathic pulmonary fibrosis (42.3%), primary pulmonary hypertension (50%), Eisenmenger's syndrome (11%), and cystic fibrosis (24.4%). A 6-minute walk distance of less than 400 m had the following characteristics for prediction of death: sensitivity 0.80, specificity 0.27, positive predictive value 0.27, and negative predictive value 0.91. Similar findings for a 6-minute walk distance of less than 300 m were as follows: 0.52, 0.80, 0.38, and 0.88, respectively. CONCLUSION: The 6-minute walk test is a useful tool in the assessment of when to list patients for transplantation. A 6-minute walk test result of less than 400 meters appears to be a reasonable marker with regard to when a patient should be listed for transplantation.

Adult↗

PubMed1997

Status of lung transplant recipients surviving beyond five years.

BACKGROUND: Prolonged survival after lung transplantation is now commonplace as a result of advances in surgical techniques and postoperative management protocols. Although 1- and 5-year functional and survival data after lung transplantation are well known, sparse information is available regarding functional status of recipients surviving beyond 5 years. METHODS: The medical records and pulmonary function study results of lung transplant recipients who had survived at least 5 years as of September 1995 were retrospectively reviewed. RESULTS: Of the 76 transplantations performed between November 1983 and September 1990, 30 (39.5%) were double lung transplantations, and 46 (60.5%) were single lung transplantations. Thirty-one recipients were alive 5 years after transplantation (12 double lung transplantations, 19 single lung transplantations). The 5-, 6-, and 7-year survival rates were 44%, 34%, and 29%, respectively. There was no association or difference in cytomegalovirus status, sex, and blood group between those who died within 5 years and those who survived beyond 5 years. The median percent predicted FEVs for single and double lung transplant recipients were as follows: 5 yrs-75%, 75%; 6 years-73%, 75%; 7 years-68%, 73%. The proportion of recipients with bronchiolitis obliterans syndrome according to published criteria was as follows: stage 0, 32%; stage I, 19%; stage II, 16%; and stage III, 19%. The functional status (i.e., active, working, disabled) 5 years after transplantation was as follows: active/working, 74%; active but not working, 13%; some limitation/independent, 10%; and disabled, 3%. CONCLUSION: Bronchiolitis obliterans syndrome is a frequent occurrence in long-term survivors. Nevertheless, in spite of this condition, most recipients have acceptable lung function, are active, and are generally working.

Activities of Daily Living↗

PubMed1997

Tacrolimus as rescue therapy for bronchiolitis obliterans syndrome.

BACKGROUND: Chronic lung allograft rejection manifested by sustained declines in lung function is the most common cause of late death after lung transplantation. Numerous strategies have shown variable results. We sought to evaluate the effect of FK506 (tacrolimus) on bronchiolitis obliterans syndrome (BOS) after lung transplantation. METHODS: A single-center open study was conducted of 15 patients whose treatment was converted to tacrolimus from cyclosporine. Of the 15, 12 patients had BOS characterized by sustained loses in lung function while receiving cyclosporine. Rate of decline of forced expiratory volume in 1 second (FEV1) for the 12 patients was calculated before and after administration of tacrolimus. Biochemical changes before and after conversion were compared for the entire group. RESULTS: Median monthly rate of decline in FEV1 was significantly reduced after administration of tacrolimus (5.3% vs 1.1%; p = 0.002). Forced vital capacity did not change significantly. No subjects experienced at least a 10% improvement in FEV1. At least a 10% further decline in FEV1 was noted in five subjects, and seven subjects had no change (i.e., within 10% of baseline). A minor nonsignificant increase in creatinine occurred after administration of tacrolimus. Blood cell count, electrolytes, and liver enzymes remained unchanged. The median change in fasting blood glucose was +0.7 mmol/L (p = 0.02). CONCLUSION: Although tacrolimus does not reverse changes in FEV1 with BOS, in this nonrandomized study it seemed to be associated with a decrease in the rate of decline in lung function and no significant sustained toxicity. Further studies are necessary to substantiate this observation.

Adult↗

PubMed1996

Aspergillus infection in single and double lung transplant recipients.

To investigate the clinical manifestations of Aspergillus infections in lung transplant recipients, we reviewed the mycology and autopsy reports of all double (DLT=93) and single (SLT=48) lung transplant recipients from November 1983 to May 1993. Positive Aspergillus cultures were identified in 22% of the recipients (DLT=21, SLT=10). Colonization alone was present in 19 recipients (DLT=16, SLT=3). Complicated Aspergillus infection included Aspergillus bronchitis (DLT=1, SLT=1), aspergilloma (SLT=2), pulmonary invasive aspergillosis (DLT=1, SLT=2), disseminated aspergillosis (DLT=1, SLT=2), empyema (DLT=1), and a retroperitoneal abscess (DLT=1). Symptoms were seen only in patients with complicated lung infections and CXR abnormalities began in the native lung of four SLT recipients. Twenty patients survived (DLT=17, SLT=3) and 11 died (DLT=4, SLT=7) of disseminated aspergillosis (SLT=2), pulmonary invasive disease (DLT=1), bronchiolitis obliterans (DLT=2, SLT=2, CMV pneumonitis (SLT=1), diffuse alveolar damage (SLT=2), and hyperacute rejection (DLT=1). Complicated infection and mortality were more common in SLTs than DLTs (P<0.05). We conclude that infection with Aspergillus is not infrequent in the lung transplantation population. Single lung recipients develop more complicated infection than double lung recipients after Aspergillus infection with native lung being a potential source of infection.

Adult↗

PubMed1996

Cytolytic therapy for the treatment of bronchiolitis obliterans syndrome following lung transplantation.

Bronchiolitis obliterans syndrome (BOS) is a common occurrence following lung transplantation and is one of the most important impediments to long-term graft viability. Cytolytic therapy has been used as treatment for BOS, but there is little data documenting efficacy. Furthermore, these agents have been associated with significant adverse effects. Charts of 15 patients who received an antilymphocyte preparation (ALP) for BOS were reviewed. Forced expiratory volume-1 second (FEV1) and stage of BOS were compared before and after treatment. Complications of ALP were recorded from the charts. Two of 15 patients had an improvement in FEV1, 5/15 exhibited no change, and 8/15 continued to decline. There was no pattern associating stage of BOS with likelihood of response to ALP. All patients received antimicrobial prophylaxis and did not experience infectious complications following administration of the ALP. ALP for the treatment of BOS results in an arrest or improvement of FEV1 in approximately 50% of patients. Infectious complications are uncommon when antimicrobial prophylaxis is administered.

Adult↗

PubMed1996

Diaphragmatic paralysis: a complication of lung transplantation.

BACKGROUND: Damage to the phrenic nerve, either unilaterally or bilaterally, is a well-documented complication of cardiac operation, but less commonly reported after lung transplantation. METHODS: A retrospective review of 185 single and sequential single lung transplant procedures was performed at The Toronto Hospital. Objective confirmation (fluoroscopy or ultrasound) of diaphragmatic paralysis was found in 6 patients. Paralysis was unilateral in 5 patients (all were left sided) and bilateral in 1 patient. RESULTS: The average length of ventilation was 8.2 +/- 9.2 days with an average intensive care unit stay of 11.2 +/- 10.6 days. Mean duration in the hospital was 37.5 +/- 11.1 days. The average length of intensive care unit stay and hospitalization were compared with all other sequential single transplantations performed from approximately the time of the first documented case of diaphragmatic paralysis. Intensive care unit stay and hospitalization for the other (no diaphragmatic paralysis) transplant recipients were significantly shorter (5.3 +/- 2.7 and 29.1 +/- 12.9 days, respectively; p < 0.05). One patient required noninvasive ventilatory assistance via bilevel positive airway pressure in the hospital. One other patient used bilevel positive airway pressure in the hospital and overnight for 6 months after discharge. All patients obtained acceptable lung function and were ambulatory upon discharge from the hospital. CONCLUSIONS: Clinically detectable diaphragmatic paralysis is an infrequent complication of lung transplantation and is associated with longer intensive care unit stay and hospitalization, but is not associated with significant adverse outcomes.

Adult↗

PubMed1996

Analysis of the T cell receptor Vgamma region gene repertoire in bronchoalveolar lavage (BAL) and peripheral blood of atopic asthmatics and healthy subjects.

We analyzed the T cell receptor (TCR) Vgamma repertoire in BAL and peripheral blood (PBL) of three mild stable atopic asthmatics and two non-asthmatic controls. We used the polymerase chain reaction (PCR) to establish the expression of the four Vgamma families, and to detect oligo or monoclonal expansion of gammadelta+ T cells, we resolved the PCR projects on denaturing and non-denaturing gels to find the extent of junctional diversity arising from differences in the lengths of the V(D)J junctions. We also subcloned and sequenced the PCR products to characterize fully the sequence diversity. BAL T lymphocytes from two asthmatic patients (treated with inhaled steroids) expressed only VgammaII and, in one of them, VgammaIIJgamma usage was restricted to JgammaP and JgammaP1 gene segments, contrasting with the VgammaJgamma repertoire found in his respective PBL. Analyses in denaturing and non-denaturing gels showed that the BAL VgammaIIJgammaP and VgammaIIJgammaP1 PCR products resolved into few bands, suggesting deletions at the juctions due to oligoclonal expansion. BAL T lymphocytes from the third asthmatic (not receiving inhaled steroids) expressed VgammaI, II and III, and the sequences of the in-frame TCR transcripts from this asthmatic and one healthy volunteer who expressed a similar BAL VgammaTCR repertoire showed clonal expansion of T cells expressing all three Vgamma families. Our analyses showed that much of the GammaDeltaT cell population found in BAL fluid of humans derives from clonally expanded T cells.

Adult↗

PubMed1996

Extrathoracic angiomyolipomas in lymphangioleiomyomatosis.

Pulmonary lymphangioleiomyomatosis (LAM) is a rare disorder that affects women and can lead to serious respiratory impairment. Since Bourneville's tuberous sclerosis (TS) was first reported, the striking similarities between the two entities have led many to believe that LAM is a forme fruste of TS. This is suggested by reports that angiomyolipomas, rare tumours in themselves, are reported in 40-80% of TS patients and occur in 15-30% of LAM patients. A retrospective chart review was conducted of 14 patients that presented to our institution with a diagnosis of LAM. We sought to document the clinical manifestations, particularly the incidence and location of extrathoracic tumours, in order to further support the hypothesis that LAM is a forme fruste of TS. Twelve patients had premenopausal onset of symptoms and two postmenopausal. The diagnosis was confirmed histologically (n = 12) and/or by computed tomography (CT) scan of the thorax (n = 12). Imaging investigations revealed extrathoracic tumours in 12 of 14 patients (86%). Eight of the 14 patients (57%) had renal tumours consistent with angiomyolipomas (bilateral in five patients). Only one patient had renal symptoms (flank pain and haematuria). All had normal serum creatinine, one had a reduced creatinine clearance. Extrathoracic nonrenal tumours were discovered in the pancreas, adrenals and uterus, findings previously unreported in LAM. In summary, the incidence of extrathoracic tumours in lymphangioleiomyomatosis patients is much higher than previously reported in the literature. This increased association supports the theory that lymphangioleiomyomatosis and tuberous sclerosis represent part of a spectrum of a similar disease process.

Adrenal Gland Neoplasms↗

PubMed1996

Bronchodilator response at low lung volumes predicts bronchiolitis obliterans in lung transplant recipients.

BACKGROUND: Bronchiolitis obliterans syndrome (BOS) is the major obstacle to long-term lung allograft viability. The diagnosis often occurs after significant organ dysfunction is present, and BOS is often unresponsive to standard immunosuppressive agents. We have observed bronchodilator responses (BRs) at low lung volumes in many of our patients who have developed BOS. We therefore assessed whether BR could predict the development of BOS. METHODS: We conducted a retrospective review of the clinical and pulmonary function laboratory records of 146 patients who underwent transplantation between March 1983 and November 1993. BR was defined as 25% or more increase in forced expiratory flow at 50% of vital capacity or 30% or more increase in forced expiratory flow at 75% of vital capacity. BOS was defined according to recently published FEV1 criteria. Bronchiolitis obliterans was defined histologically according to criteria of the Lung Rejection Study Group. RESULTS: Of the total population, 52 were excluded because of death or insufficient information. BRs of the small airways were seen in 31 patients (33%), 25 of whom developed BOS (83%). Approximately half of those with BR who developed BOS had evidence of acute rejection in the month prior to the onset of BR. Two thirds (four of six) of patients with BR not developing BOS had acute rejection in the previous month. The sensitivity of BR in predicting BOS was 51% with a specificity of 87%. The positive predictive value was 81%. CONCLUSIONS: BR appears to be useful as an early marker of BOS. The development of BR in selected patients should lead to closer monitoring and possibly a trial of augmented immunosuppression to arrest the establishment of BOS.

Adolescent↗

PubMed1996

Prior diagnosis and treatment of patients with normal results of methacholine challenge and unexplained respiratory symptoms.

OBJECTIVE: Previous research indicates that asthma has been underdiagnosed. However, we suspect that recent widespread attention to the underdiagnosis of asthma has led to an overdiagnosis of asthma in some settings. We therefore sought to examine prior diagnosis and treatment of patients referred to our facility and subsequently found to have no objective evidence of variable airflow limitation. DESIGN: Retrospective chart review. SETTING: Hospital-based asthma center. PATIENTS: A referred sample of 263 patients in whom a methacholine challenge (MCC) was conducted after evaluation by our pulmonologists; complete medical histories were available. MAIN OUTCOME MEASURES: Prior respiratory diagnoses, duration of treatment with asthma medications, and diagnosis following assessment by our pulmonologists in 175 patients with a provocative concentration of the substance causing a 20% fall in FEV1 (PC20) greater than 8.0 mg/mL and 88 with a PC20 of 8.0 mg/mL or less. RESULTS: Of those with a PC20 greater than 8 mg/mL, a diagnosis of asthma or possible asthma prior to the challenge study was recorded by their primary care physician in 129 patients (74%). One hundred sixty of 172 patients (88%) with a PC20 greater than 8 mg/mL were diagnosed as not having asthma by our pulmonologists; 109 of 172 patients (62%) had been previously treated with asthma medication(s). The mean duration of asthma treatment was 25.9+/- 56.3 months, and there was no significant difference in the duration of treatment between this group and those who had a PC20 of 8 mg/mL or less. Most of those treated received inhaled beta2-agonists and inhaled corticosteroids. Approximately 61% received two or more classes of medications. CONCLUSIONS: The misdiagnosis of asthma occurs commonly in the referral practice of a tertiary care asthma center. The more frequent use of objective pulmonary function testing in primary practice might reduce the problem of delayed diagnosis and inappropriate therapy for respiratory symptoms.

Asthma↗

PubMed1996

Bronchiolitis obliterans organizing pneumonia (BOOP) in lung transplant recipients.

We reviewed all tissue specimens from 163 transplant patients (108 double lung transplant [DLT], 55 single lung transplant [SLT]) between November 1983 and January 1994 for abnormalities indicating bronchiolitis obliterans organizing pneumonia (BOOP) and found 17 cases (14 DLT and 3 SLT). Of the three SLTs, BOOP was diagnosed by open lung biopsy (OLB) in two and one was found at autopsy. Of the 14 DLTs, BOOP was diagnosed by transbronchial biopsy (TBB) specimens (9), OLB specimens (2), autopsy (1), TBB and OLB specimens (1), and OLB specimens and autopsy (1). BOOP was found between 1 and 43 months posttransplantation; time of survival from diagnosis was between 2 and 36 months with 9 patients presently alive. Concurrent pathologic diagnosis at the time of BOOP findings were as follows: acute rejection (7) (grade 1 [4] and grade 2 [3]), BO and grade 1 rejection (2), BO and grade 2 rejection (2), BO and Aspergillus infection (1), acute alveolar injury (1), acute alveolar injury and pulmonary embolus (1), acute rejection (grade 1) and Burkholderia cepacia pneumonia (1). No other pathologic diagnosis was found in 1 patient. In total, 11 of 17 patients (65%) had associated acute rejection. Of the 17 patients, 7 subsequently developed BO and 3 had BO before the finding of BOOP. Death occurred in 8 patients (5 DLT and the 3 SLT) between 2 and 6 months after the diagnosis. We conclude that BOOP is an important complication after lung transplantation; it was present in 13% of DLTs and 5% of SLTs. BOOP was most often associated with acute rejection.

Acute Disease↗

PubMed1996

Yield of surveillance transbronchial biopsies performed beyond two years after lung transplantation.

BACKGROUND: Acute lung rejection after transplantation may lead to significant graft dysfunction. Hence surveillance protocols which include transbronchial biopsies have been established to monitor for early findings suggestive of acute rejection. However, the frequency of acute rejection diminishes as time from the transplant procedure increases. We therefore sought to examine the incidence of acute rejection seen on surveillance transbronchial biopsy performed at least 2 years after transplantation. METHODS: A retrospective review of all transbronchial biopsy was conducted. Forced expiratory volume in 1 second at the time of transbronchial biopsy and in the preceding 6 months was recorded. RESULTS: A total of 102 transbronchial biopsy procedures were assessed. Histologic evidence of at least grade 2 rejection (including three judged as grade 1 to 2) occurred in biopsy samples from 10 procedures (9.8%). Five of the episodes occurred at 2 years, three occurred at 3 years, and two occurred at 4 years. Inadequate biopsies occurred on 22 occasions (21.6%). A corresponding significant change in forced expiratory volume in 1 second ( >or= 10% decline) compared with the preceding 6 months was seen in 4 of 10 episodes of grade 2 acute rejection. Only one of five episodes occurring at least 3 years after transplantation was associated with a decline in forced expiratory volume in 1 second. No evidence of acute rejection was found in any of 15 transbronchial biopsy procedures beyond 4 years after transplantation where adequate material for histologic interpretation was obtained. However, no statistically significant change was found in the proportion of transbronchial biopsy procedures showing acute rejection as a function of time. CONCLUSIONS: We conclude that transbronchial biopsy-proven acute rejection may occur in patients with asymptomatic, stable conditions who have survived at least 2 years, but the yield of transbronchial biopsy performed beyond 4 years is exceedingly low.

Biopsy↗

PubMed1996

Previous intrapleural procedures do not adversely affect lung transplantation.

BACKGROUND: Initially a previous intrapleural procedure causing a partially or completely fused pleural space represented a contraindication to lung transplantation. However, as experience with transplantation increased, particularly in patients with septic lung diseases who frequently have pleural adhesions, a previous intrapleural procedure became a relative rather than an absolute contraindication. The "clam shell" incision, which allows better control of the pleural spaces than a median sternotomy, contributed to this change. METHODS: The outcome of 18 patients with a previous intrapleural procedure was compared with 18 paired controls without previous surgery involving the transplanted pleural space. RESULTS: Five study patients had a predictably fused pleural space from their previous surgery, and four had extensive adhesions (major previous intrapleural procedures). The nine patients with minor previous intrapleural procedures had undergone more limited intrapleural procedures (open lung biopsy or chest tube drainage of a pneumothorax). There was no statistically significant trend for the operating time, blood loss, transfusion requirements, time intubated, and intensive care unit stay to be greater in the study population than in the controls. However, the major previous intrapleural procedure patients were younger, required longer cardiopulmonary bypass, and had a longer intensive care unit stay. The 6- and 12-month forced expiratory volumes in 1 second from the patients with major previous intrapleural procedures were not different from those of either the patients with minor previous intrapleural procedures or the controls. CONCLUSIONS: A previous intrapleural procedure, even when resulting in a fused pleural space, did not have a significant detrimental impact on outcome. Therefore a previous intrapleural procedure should neither preclude listing a patient for transplantation nor significantly influence the choice of recipient when lungs become available for transplantation.

Adult↗