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PubMed1993

Cholelithoptysis. A complication following laparoscopic cholecystectomy.

A 59-year-old woman who underwent laparoscopic cholecystectomy for symptomatic cholecystitis presented four months later with fever, malaise, anorexia, hemoptysis and lithoptysis. Chemical analysis of the expectorated lithes revealed them to be gallstones. Ultrasound studies of the right upper quadrant demonstrated both supradiaphragmatic and subdiaphragmatic fluid collections containing echogenic fragments. ERCP failed to demonstrate retained ductal stones or fistula formation. To our knowledge, this is the first reported case of cholelithoptysis and demonstrates an unusual complication of gallstone retention following laparoscopic cholecystectomy.

Bronchi↗
PubMed1994

Bronchorrhea from diffuse lymphangitic metastasis of colon carcinoma to the lung.

Bronchorrhea, defined as watery sputum of 100 ml or more per day, was seen in a 52-year-old female patient with diffuse lymphangitic metastasis of colon carcinoma to the lung. For 5 months before the visit to our clinic, she complained of progressive worsening of the cough, watery sputum, and shortness of breath. On admission to our hospital, she expectorated large amounts of nonpurulent watery sputum (150 to 300 ml/d), and showed diffuse reticular and linear shadows in both lungs on chest radiograph and severe obstructive impairment (FEV1 percent, 35 percent) in lung function tests. Histologic findings obtained from both surgical specimens at abdominal operation for ileus and lungs at the autopsy revealed lymphangitic metastasis of ascending colon carcinoma to the lung. At autopsy, histologically the lungs showed diffuse infiltrations of mucus-secreting adenocarcinoma cells to both lung parenchyma and airway submucosa.

Adenocarcinoma, Mucinous↗
PubMed1994

Regional mucus transport following unproductive cough and forced expiration technique in patients with airways obstruction.

It has previously been shown that unproductive coughing in both healthy subjects and patients with airways obstruction is not effective in clearing lung secretions. This study investigates the regional mucus transport in a group of subjects with airways obstruction who failed to expectorate following instructed cough and forced expiration technique. Fourteen patients (mean +/- SEM age: 68 +/- 2 years) with airways obstruction (mean +/- SEM percent predicted. FEV1: 54 +/- 5; daily wet weight sputum: 9.1 +/- 2.0 g) took part in the study which was a randomized, three-way crossover within-patient design. Each patient underwent three treatment maneuvers: control, cough (30 coughs over a 10-min period), and forced expiration (30 forced expirations over a 10-min period). An objective radioaerosol technique was used to monitor regional mucus movement within the lungs of the patients. The lungs were divided arbitrarily into four regions of interest: tracheal, inner, intermediate, and outer. Peak expiratory flow rate during cough and forced expiration was measured at the mouth. There was no correlation between the radioaerosol clearance from all regions and (1) mean peak flow during cough and forced expiration, and (2) mean 24-h sputum production prior to the study day. There were no differences in regional radioaerosol clearance between cough and forced expiration. However, both cough and forced expiration resulted in significant clearance compared with control for all regions with the exception of the forced expiration in the outer region. To our knowledge, this study is the first to demonstrate that unproductive cough and forced expiration result in movement of secretions proximally from all regions of the lung in patients with airways obstruction.

Cough↗
PubMed1996

Incidence and significance of acid-fast bacilli in sputum smears at the end of antituberculous treatment.

OBJECTIVE: A group of patients with pulmonary tuberculosis (PT) who received and correctly completed antituberculous therapy were studied to determine the incidence and significance of positive acid-fast bacilli (AFB) in sputum smears at the end of this treatment. DESIGN: Retrospective chart review of persons with bacteriologically proved PT. PATIENTS: Of 1,052 patients diagnosed as having PT between 1988 and 1992, 453 who fulfilled the following criteria were included in the study: (1) diagnosis established by positive AFB and positive culture in sputum smears; (2) no previous antituberculous treatment had been received; (3) HIV serologic test results were negative; (4) treatment was correctly completed; (5) they were followed up throughout the period of treatment; and (6) expectoration was still present at the end of treatment and at least two spontaneous sputum samples could be obtained. RESULTS: Positive AFB of sputum smears were found at the end of treatment in 10 (2.2%) of the 453 patients studied. Five patients had only one positive smear, and the other five had more than one. Of these ten cases, sputum culture was negative in eight, which were considered to be unviable bacilli, and positive for nontuberculous mycobacteria in two. Clinical symptoms or worsening on chest radiograph were observed only in one patient with unviable bacilli, but they were caused by a concomitant nonspecific respiratory tract infection. CONCLUSIONS: Positive AFB smear results at the end of completed treatment regimens analyzed in this study have occurred because of unviable bacilli and nontuberculous mycobacteria colonization. The presence of more than one positive smear seems not to increase the probability of treatment failure and is more frequently due to nontuberculous mycobacteria. Results of culture can thus be awaited without the need to prolong or modify antituberculous therapy.

Humans↗
PubMed1996

Noninvasive positive pressure ventilation in status asthmaticus.

OBJECTIVE: In asthmatic patients with acute respiratory failure (ARF), placing an endotracheal tube is associated with a high rate of complications and results in increased airway resistance. In acute asthma, mask-continuous positive airway pressure (CPAP) decreases airway resistance and the work of breathing (WOB), but does not improve gas exchange. In COPD with ARF, adding intermittent positive pressure ventilation to mask-CPAP results in an additional improvement in WOB and is highly effective in correcting gas exchange abnormalities. In our medical ICU, noninvasive positive pressure ventilation (NPPV) is used as first-line interventional therapy in eligible patients with hypercapnic ARF. We report our experience with NPPV in 17 episodes of asthma and ARF over a 3-year period. METHODS: A face mask was secured with head straps, avoiding a tight fit, and connected to a ventilator (PB-7200). Initial ventilatory settings included CPAP at 4 +/- 2 cm H2O to offset intrinsic positive end-expiratory pressure and pressure support ventilation (PSV) at 14 +/- 5 cm H2O aiming at a respiratory rate less than 25 breaths/min and an exhaled tidal volume of 7 mL/kg or more. PSV was then adjusted following arterial blood gas results. RESULTS: Mean age was 35.4 +/- 11.3 years; 10 patients were female. The mean (+/- SE) for different physiologic values are reported at initiation, less than 2 h, 2 to 6 h, and 12 to 24 h into NPPV. pH was 7.25 +/- 0.01, 7.32 +/- 0.02 (p = 0.0012), 7.36 +/- 0.02 (p < 0.0001), and 7.38 +/- 0.02; PaCO2 was 65 +/- 2, 52 +/- 3(p = 0.002), 45 +/- 3(p < 0.0001), and 45 +/- 4; PaO2 fraction of inspired oxygen was 315 +/- 41, 403 +/- 47, 367 +/- 47, and 472 +/- 67 (p = 0.06); and respiratory rate was: 29.1 +/- 1, 22 +/- 1 (p < 0.0001), 20 +/- 1, and 17 +/- 1. NPPV was well tolerated, and only two patients required sedation. Initial delivered minute ventilation was 16 +/- 4 L/min. The mean (+/- SD) peak inspiratory pressure to ventilate in the NPPV-treated patients was 18 +/- 5 cm H2O and always less than 25 cm H2O. There was no complication or problem with expectorating of secretions. Oral intake (liquid diet) was preserved. Two patients required intubation (35 min and 89 h into NPPV) for worsening PaCO2. Duration of NPPV was 16 +/- 21 h. All patients survived. Length of hospital stay was 5 +/- 4 days. CONCLUSIONS: In asthmatic patients with ARF, NPPV via a face mask appears highly effective in correcting gas exchange abnormalities using a low inspiratory pressure (< 25 cm H2O). A randomized study is in progress to assess fully the role of NPPV in status asthmaticus.

Adult↗
PubMed1997

Hemoptysis as the presenting symptom in bronchiolitis obliterans organizing pneumonia.

Bronchiolitis obliterans organizing pneumonia (BOOP) is an uncommon but increasingly recognized pulmonary entity that usually presents with symptoms of dyspnea, cough, and fever. The medical literature describes rare cases of hemoptysis in BOOP, with very small quantities of blood expectorated. We describe two cases of BOOP, one idiopathic and one in association with rheumatoid arthritis, in which large-quantity hemoptysis was the primary presenting symptom.

Aged↗
PubMed1998

An unusual presentation of metastatic colon cancer to the lung.

A 75-year-old man with a history of resected colon carcinoma presented to his primary care physician because of a new onset of coughing. The patient had expectorated a small piece of solid tissue; pathologic examination of the tissue found it to be consistent with metastatic colon adenocarcinoma. After further work-up, a right upper lobectomy was performed. The surgical specimen removed during the lobectomy showed a tumor that was histologically identical to the patient's prior colonic primary tumor.

Adenocarcinoma↗
PubMed1998

Standards for the optimal management of COPD: a summary.

Tobacco smoking is the main cause of COPD, and encouragement and support in smoking cessation is the best way to help the patient with COPD. The three major goals of COPD management are to lessen airflow limitation, to prevent and treat secondary medical complications, and to decrease respiratory symptoms and improve quality of life. Outpatient pharmacotherapy should be organized in a stepwise manner according the severity of disease, the aims being to induce bronchodilation, reduce inflammation, and facilitate expectoration, although the role of anti-inflammatory and mucolytic treatment of COPD has not been clearly established. Patients whose conditions are not well controlled with optimal pharmacotherapy are candidates for enrollment in a pulmonary rehabilitation program. Correction or prevention of hypoxemia is a priority, and long-term oxygen therapy supplementation prolongs survival in hypoxemic patients. With only limited data on criteria for hospital admission and the objectives of hospitalization, the published standards on the management of COPD include an expert consensus statement on these aspects of hospital care. Surgery, special considerations such as sleep, nutrition, and air travel, and ethical issues are discussed.

Combined Modality Therapy↗
PubMed1998

Comparative study of the clinical presentation of Legionella pneumonia and other community-acquired pneumonias.

The aim of this study was to compare the clinical, biological, and radiologic features of presentation in the emergency ward of community-acquired pneumonia (CAP) by Legionella pneumophila (LP) and other community-acquired bacterial pneumonias to help in early diagnosis of CAP by LP. Three hundred ninety-two patients with CAP were studied prospectively in the emergency department of a 600-bed university hospital. Univariate and multivariate analyses were performed to compare epidemiologic and demographic data and clinical, analytical, and radiologic features of presentation in 48 patients with CAP by LP and 125 patients with CAP by other bacterial etiology (68 by Streptococcus pneumoniae, 41 by Chlamydia pneumoniae, 5 by Mycoplasma pneumoniae, 4 by Coxiella burnetii, 3 by Pseudomonas aeruginosa, 2 by Haemophilus influenzae, and 2 by Nocardia species. Univariate analysis showed that CAP by LP was more frequent in middle-aged, male healthy (but alcohol drinking) patients than CAP by other etiology. Moreover, the lack of response to previous beta-lactamic drugs, headache, diarrhea, severe hyponatremia, and elevation in serum creatine kinase (CK) levels on presentation were more frequent in CAP by LP, while cough, expectoration, and thoracic pain were more frequent in CAP by other bacterial etiology. However, multivariate analysis only confirmed these differences with respect to lack of underlying disease, diarrhea, and elevation in the CK level. We conclude that detailed analysis of features of presentation of CAP allows suspicion of Legionnaire's disease in the emergency department. The initiation of antibiotic treatment, including a macrolide, and the performance of rapid diagnostic techniques are mandatory in these cases.

Adult↗
PubMed1999

Safety of long-term treatment with HFA albuterol.

BACKGROUND: Chlorofluorocarbons (CFCs) used as propellants in metered-dose inhalers deplete stratospheric ozone, which results in serious public health concerns. Albuterol has been reformulated in the non-ozone-depleting propellant, hydrofluoroalkane-134a (HFA albuterol). OBJECTIVES: The primary objective was to compare the safety of HFA albuterol to an albuterol product formulated in chlorofluorocarbon propellants (CFC albuterol) during 1 year of treatment in asthmatics. Bronchodilator efficacy of the two products was assessed as a secondary objective. METHODS: The results from two open-label, parallel-group trials of similar design in asthmatics requiring short-acting beta-agonists for symptom control were combined. Patients took two puffs bid of either HFA albuterol or CFC albuterol for 1 year. Additional puffs of study drug were allowed as needed to control asthma symptoms. Adverse events were recorded at clinic visits. Patients self-administered study drug at quarterly visits and underwent serial spirometry during a 6-h period postdose. Bronchodilator efficacy variables, based on FEV1 response to study drug, were proportion of responders, time to onset of effect, peak percent change, time to peak effect, duration of effect, and area under the curve. Differences between products and changes over time in efficacy variables were assessed using an analysis of variance model. Regression analyses with FEV1 as a covariate were performed post-hoc to analyze changes in bronchodilator efficacy over time. RESULTS: Demographic and baseline characteristics were similar for patients receiving HFA albuterol (n = 337) and CFC albuterol (n = 132). Total reported adverse events were similar for the two treatments. Differences in only four individual adverse events were noted: the HFA albuterol group reported more gastroenteritis and dizziness; the CFC albuterol group reported more epistaxis and expectoration. Adverse events attributed to study drug use were infrequent. No serious adverse events were related to study drug use. Predose FEV1 at quarterly visits increased to a small extent in both groups from month 0 to month 12. The bronchodilator efficacy of HFA albuterol was comparable to that of CFC albuterol at the quarterly visits, but decreased from baseline for both products over the 12 months of treatment. Use of inhaled corticosteroids, nasal corticosteroids, or theophylline did not explain the increase in predose FEV1 over time and did not protect patients from developing reduced bronchodilator efficacy by month 12. The change in predose FEV1 did not entirely account for the reduced bronchodilator efficacy over time. CONCLUSIONS: HFA albuterol has a safety profile similar to that of CFC albuterol during chronic, scheduled use, and both drugs are well tolerated. HFA albuterol and CFC albuterol provided comparable bronchodilator efficacy, but bronchodilator efficacy decreased for both products with 1 year of use.

Administration, Inhalation↗
PubMed2000

Comparison of the structural and inflammatory features of COPD and asthma. Giles F. Filley Lecture.

At least three conditions contribute to COPD. (1) Chronic bronchitis (mucous hypersecretion) is an inflammatory condition in which CD8+ T-lymphocytes, neutrophils, and CD68+ monocytes/macrophages predominate. The condition is defined clinically by the presence of chronic cough and recurrent increases in bronchial secretions sufficient to cause expectoration. There is enlargement of mucus-secreting glands and goblet cell hyperplasia, which can occur in the absence of airflow limitation. (2) Adult chronic bronchiolitis (small or peripheral airways disease) is an inflammatory condition of small bronchi and bronchioli in which there are predominantly CD8+ and pigmented macrophages. The functional defect is difficult to detect clinically but may be recognized by sophisticated tests of small airway function. There is mucous metaplasia, enlargement of the mass of bronchiolar smooth muscle, and loss of alveolar attachments. (3) Emphysema is an inflammatory condition of the alveoli in which T-lymphocytes, neutrophils, and pigmented alveolar macrophages are involved, associated with the release of excessive amounts of elastases. It is defined anatomically by permanent, destructive enlargement of airspaces distal to terminal bronchioli without obvious fibrosis. In contrast, asthma is a clinical syndrome characterized by allergic inflammation of bronchi and bronchioli in which CD4+ (helper) T-lymphocytes and eosinophils predominate. There is increased production and release of interleukin (IL)-4 and IL-5, which is referred to as a Th2-type response. There is usually increased tracheobronchial responsiveness to a variety of stimuli, and the condition is usually manifest as variable airflow obstruction. While differences between COPD and asthma have been highlighted, new data are emerging that indicate there may also be similarities.

Asthma↗
PubMed2000

Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD.

STUDY OBJECTIVES: To stratify COPD patients presenting with an acute exacerbation on the basis of sputum color and to relate this to the isolation and viable numbers of bacteria recovered on culture. DESIGN: Open, longitudinal study of sputum characteristics and acute-phase proteins. SETTING: Patients presenting to primary-care physicians in the United Kingdom. Patients were followed up as outpatients in specialist clinic. PATIENTS: One hundred twenty-one patients with acute exacerbations of COPD were assessed together with a single sputum sample on the day of presentation (89 of whom produced a satisfactory sputum sample for analysis). One hundred nine patients were assessed 2 months later when they had returned to their stable clinical state. INTERVENTIONS: The expectoration of green, purulent sputum was taken as the primary indication for antibiotic therapy, whereas white or clear sputum was not considered representative of a bacterial episode and the need for antibiotic therapy. RESULTS: A positive bacterial culture was obtained from 84% of patients sputum if it was purulent on presentation compared with only 38% if it was mucoid (p < 0.0001). When restudied in the stable clinical state, the incidence of a positive bacterial culture was similar for both groups (38% and 41%, respectively). C-reactive protein concentrations were significantly raised (p < 0.0001) if the sputum was purulent (median, 4.5 mg/L; interquartile range [IQR], 6. 2 to 35.8). In the stable clinical state, sputum color improved significantly in the group who presented with purulent sputum from a median color number of 4.0 (IQR, 4.0 to 5.0) to 3.0 (IQR, 2.0 to 4. 0; p < 0.0001), and this was associated with a fall in median C-reactive protein level to 2.7 mg/L (IQR, 1.0 to 6.6; p < 0.0001). CONCLUSIONS: The presence of green (purulent) sputum was 94.4% sensitive and 77.0% specific for the yield of a high bacterial load and indicates a clear subset of patient episodes identified at presentation that is likely to benefit most from antibiotic therapy. All patients who produced white (mucoid) sputum during the acute exacerbation improved without antibiotic therapy, and sputum characteristics remained the same even when the patients had returned to their stable clinical state.

Acute Disease↗
PubMed2000

Effect of a thromboxane A(2) antagonist on sputum production and its physicochemical properties in patients with mild to moderate asthma.

STUDY OBJECTIVE: To determine the effects of a specific thromboxane A(2) (TxA(2)) receptor antagonist, seratrodast, on asthma control and airway secretions. DESIGN: Multicenter, double-blind, randomized, placebo-controlled study. PATIENTS: Forty-five patients with mild to moderate asthma who had been continuously expectorating sputum of > 20 g/d. Patients with a current pulmonary infection or taking oral corticosteroids, antibiotics, or mucolytic agents were excluded from the trial. INTERVENTIONS: Following a 2-week run-in period, while pulmonary function, sputum production, and mucociliary function were assessed, patients were assigned to receive seratrodast, 40 mg/d, or placebo for 6 weeks. MEASUREMENTS AND RESULTS: During the treatment period, the changes in FEV(1) and peak expiratory flow (PEF) were not different between the two patient groups, but there were significant reductions in diurnal variation of PEF (p = 0.034), frequency of daytime asthma symptoms (p = 0.030), and daytime supplemental use of beta(2)-agonist (p = 0.032) in the seratrodast group. For sputum analysis, seratrodast treatment decreased the amount of sputum (p = 0.005), dynamic viscosity (p = 0. 007), and albumin concentration (p = 0.028), whereas it had no effect on elastic modulus or fucose concentration. Nasal clearance time of a saccharin particle was shortened in the seratrodast group at week 4 (p = 0.031) and week 6 (p = 0.025), compared with the placebo group. CONCLUSION: Blockade of TxA(2) receptor has minimal effects on pulmonary function, but may cause an improvement in mucociliary clearance by decreasing the viscosity of airway secretions.

Adult↗
PubMed2001

Identifying pulmonary tuberculosis in patients with negative sputum smear results.

BACKGROUND: Clinicians need to decide whether to begin empiric therapy for patients who are suspected of having tuberculosis (TB) but have negative sputum smear results. Culture results may take weeks, and delaying treatment may allow further transmission of disease. STUDY OBJECTIVE: To identify the clinical, demographic, and radiographic characteristics that identify smear-negative patients who have TB, and to create a TB prediction rule. DESIGN: Retrospective chart review. SETTING: University-affiliated public hospital in San Francisco, CA, between 1993 and 1998. PATIENTS: Forty-seven patients with TB and 141 control patients who were hospitalized with a suspicion of pulmonary TB; all had negative sputum smear results. MEASUREMENTS AND RESULTS: Demographic, clinical, and radiographic variables were determined by chart review. In multivariate analysis, a positive tuberculin skin test result (odds ratio [OR], 4.8; 95% confidence interval [CI], 2.0 to 11.9) was independently associated with an increased risk of a positive TB culture finding. A radiographic pattern not typical of pulmonary tuberculosis (OR, 0.3; 95% CI, 0.1 to 0.7) and expectoration with cough (OR, 0.3; 95% CI, 0.1 to 0.6) were predictive of a decreased risk. An interaction between HIV seropositivity and mediastinal lymphadenopathy on the chest radiograph was also associated with a positive TB culture result (OR, 7.2; 95% CI, 1.4 to 36.0). The TB prediction score (TPS) was created with widely ranging likelihood ratios that could affect the posterior probability of TB by 30-fold. CONCLUSION: The TPS put into context with the overall prevalence of TB in a given area may help clinicians decide if a patient with negative sputum smear results should start empiric antituberculous therapy or wait for culture results. These results need prospective validation.

Adult↗
PubMed2002

An intervention to improve antibiotic delivery and sputum procurement in patients hospitalized with community-acquired pneumonia.

STUDY OBJECTIVES: To determine if an educational intervention targeting emergency department (ED) and medicine staff could successfully decrease the time to antibiotic delivery (door-to-drug delivery time [DDD]) for patients admitted through the ED with community-acquired pneumonia (CAP). DESIGN: Prospective, multidisciplinary team-based educational project. Demographics, outcomes, and processes of care including DDD and sputum procurement for patients with CAP were determined during a baseline period and compared to the same parameters for patients with CAP presenting after the educational intervention was administered to ED and medicine staff. SETTING: Barnes-Jewish Hospital, a large Midwest teaching institution affiliated with the Washington University School of Medicine. PATIENTS: Consecutive adult patients admitted through the ED with CAP. INTERVENTION: Multidisciplinary in-service education administered to ED physicians and nurses, and medicine housestaff, which emphasized the importance of rapid antibiotic delivery and procurement of preantibiotic expectorated sputum. RESULTS: Mean DDD improved from 413 to 291 min (p = 0.02), with more patients receiving antibiotics in the ED (46% vs 69%; adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0 to 4.9). Sputum procurement improved from 11.5 to 25.4% (adjusted OR, 3.3; 95% CI, 1.1 to 9.9). There were no observed differences for inpatient mortality or length of stay. CONCLUSION: This multidisciplinary team intervention significantly improved the time to initiation of antibiotics and procurement of sputum for patients with CAP.

Adult↗
PubMed2003

Efficiency of pulmonary administration of tobramycin solution for inhalation in cystic fibrosis using an improved drug delivery system.

STUDY OBJECTIVES: To determine whether tobramycin solution for inhalation (TSI) can be administered safely and more efficiently with a new-generation aerosol device, the AeroDose 5.5 RP inhaler (Aerogen; Mountain View, CA) than with the approved PARI LC PLUS nebulizer (PARI Respiratory Equipment; Monterey, CA) with Pulmo-Aide compressor (DeVilbiss Corp; Somerset, PA). Second, we wanted to ascertain which AeroDose-delivered tobramycin dose is equivalent to the standard 300-mg dose administered with the PARI LC PLUS. DESIGN: Open-label, randomized, multicenter, single-dose, three-period, four-treatment, active- control, crossover trial. SETTING: Nine US cystic fibrosis (CF) centers. PATIENTS: Fifty-three patients >or= 12 years of age with a confirmed diagnosis of CF, the ability to expectorate sputum, and FEV(1) of >or= 40% of predicted. METHODS: Subjects inhaled three single doses of TSI at 1-week intervals, as follows: conventional control treatment, 300 mg via the PARI LC PLUS; and two of three experimental treatments, 30, 60, or 90 mg via the AeroDose. FEV(1) was measured before and after dosing. After each dose, sputum and serum samples were collected at various intervals for 8 h, and urine was collected for 24 h to estimate lung and systemic tobramycin delivery. RESULTS: There were no significant differences between treatments in the change in FEV(1) 30 min after dosing or in the frequency of adverse events. Sputum and serum levels of tobramycin produced by the AeroDose 90-mg dose treatment approximated those achieved with the PARI LC PLUS 300-mg dose treatment. Nebulization times using the AeroDose inhaler were < 50% those of the PARI LC PLUS. CONCLUSIONS: Compared with the standard nebulizer, the AeroDose safely achieved an approximately threefold greater efficiency in the delivery of TSI to the lungs in less than half the time.

Administration, Inhalation↗
PubMed2003

Lung retransplantation for bronchiolitis obliterans syndrome: long-term follow-up in a series of 15 recipients.

BACKGROUND: Although lung retransplantation is the only definitive therapeutic option in lung recipients with bronchiolitis obliterans syndrome (BOS), its value remains a considerable source of controversy. We report our experience of retransplantation for BOS performed in our center since 1988. METHODS: Between 1988 and 2002, 15 lung retransplantations for BOS were performed. Patient survival, causes of death, long-term functional status, and BOS recurrence rate were reviewed. RESULTS: The retransplantation procedure was single-lung transplantation (SLT) in all cases (ipsilateral SLT, n = 4; contralateral SLT, n = 9; SLT after previous double-lung transplantation, n = 2). The median time between primary lung transplantation and retransplantation was 31 months (range, 12 to 39 months). The median follow-up duration of the 10 patients surviving beyond 6 months was 49.5 months (range, 16.5 to 105 months), and 5 patients were followed up for > 5 years. Actuarial survival rates at 1 year, 2 years, and 5 years after retransplantation were 60%, 53%, and 45%, respectively. Ten patients died during long-term follow-up, 6 of them from infection (60%). The retained graft was the initial site of the fatal infection in four of these six patients (66%). Two other patients with a retained graft experienced disabling chronic purulent expectoration arising from the old graft. In the 10 patients surviving beyond 6 months, mean best FEV(1) was 58 +/- 13% of predicted (+/- SD), and actuarial freedom from BOS (stage 1, 2, or 3) at 1 year, 3 years, and 5 years was 90%, 72%, and 66%, respectively. CONCLUSION: Lung retransplantation offered a viable therapeutic option for selected lung recipients with BOS. Given the morbidity and mortality related to the retained graft, we now favor replacement of the primary graft when retransplantation is considered.

Adult↗
PubMed2004

Viral community-acquired pneumonia in nonimmunocompromised adults.

INTRODUCTION: Viral community-acquired pneumonia (CAP) has been poorly studied and clinically characterized. Using strict criteria for inclusion, we studied this type of infection in a large series of hospitalized adults with CAP. MATERIALS AND METHODS: All nonimmunocompromised adult patients with a diagnosis of CAP having paired serology for respiratory viruses (RVs) [338 patients] were prospectively included in the study from 1996 to 2001 at our 1,000-bed university teaching hospital, and subsequently were followed up. We compared patients with pure viral (PV), mixed viral (RV + bacteria), and pneumococcal CAP. RVs (ie, influenza, parainfluenza, respiratory syncytial virus, and adenovirus) were diagnosed by means of paired serology. RESULTS: Sixty-one of 338 patients (18%) with paired serology had an RV detected, and in 31 cases (9%) it was the only pathogen identified. Influenza was the most frequent virus detected (39 patients; 64%). Patients with chronic heart failure (CHF) had an increased risk of acquiring PV CAP (8 of 26 patients; 31%) when compared to a mixed viral/bacterial etiology (2 of 26 patients; 8%; p = 0.035) or CAP caused by Streptococcus pneumoniae (1 of 44 patients; 2%; p = 0.001). Multivariate analysis revealed that CHF (odds ratio [OR], 15.3; 95% confidence interval [CI], 1.4 to 163; p = 0.024) and the absence of expectoration (OR, 0.14; 95% CI, 0.04 to 0.6; p = 0.006) were associated with PV pneumonia compared to pneumococcal CAP. CONCLUSION: RVs are frequent etiologies of CAP (single or in combination with bacteria). Patients with CHF have an increased risk of acquiring a viral CAP.

Community-Acquired Infections↗