Phenotyping established chronic lung allograft dysfunction predicts extracorporeal photopheresis response in lung transplant patients

Chronic lung allograft dysfunction (CLAD) remains the leading cause of mortality in lung transplant recipients after the first year. Treatment remains limited and unpredictable. Existing data suggests extracorporeal photopheresis (ECP) may be beneficial. This study aimed to identify factors predicting treatment response and the prognostic implications. A single center retrospective analysis of all patients commencing ECP for CLAD between November 1, 2007 and September 1, 2011 was performed. In total 65 patients were included, 64 of whom had deteriorated under azithromycin. Median follow-up after commencing ECP was 503 days. Upon commencing ECP, all patients were classified using proposed criteria for emerging clinical phenotypes, including "restrictive allograft syndrome (RAS)", "neutrophilic CLAD (nCLAD)" and "rapid decliners". At follow-up, 8 patients demonstrated ≥10% improvement in FEV1 , 27 patients had stabilized and 30 patients exhibited ≥10% decline in FEV1 . Patients fulfilling criteria for "rapid decliners" (n=21, p=0.005), RAS (n=22, p=0.002) and those not exhibiting neutrophilia in bronchoalveolar lavage (n=44, p=0.01) exhibited poorer outcomes. ECP appears an effective second line treatment in CLAD patients progressing under azithromycin. ECP responders demonstrated improved progression-free survival (median 401 vs. 133 days). Proposed CLAD phenotypes require refinement, but appear to predict the likelihood of ECP response.

[Epidemiology, diagnosis and treatment of adult patients with nosocomial pneumonia. S-3 Guideline of the German Society for Anaesthesiology and Intensive Care Medicine, the German Society for Infectious Diseases, the German Society for Hygiene and Microbiology, the German Respiratory Society and the Paul-Ehrlich-Society for Chemotherapy]

Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However infections on general wards are also increasing. A central issue are infections with multi drug resistant (MDR) pathogens which are difficult to treat particularly in the empirical setting potentially leading to inappropriate use of antimicrobial therapy. This guideline was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and therapy of HAP on the basis of quality of evidence and benefit/risk ratio. The guideline has two parts. First an update on epidemiology, spectrum of pathogens and antiinfectives is provided. In the second part recommendations for the management of diagnosis and treatment are given. Proper microbiologic work up is emphasized for knowledge of the local patterns of microbiology and drug susceptibility. Moreover this is the optimal basis for deescalation in the individual patient. The intensity of antimicrobial therapy is guided by the risk of infections with MDR. Structured deescalation concepts and strict limitation of treatment duration should lead to reduced selection pressure.

[Interdisciplinary AWMF guideline for the treatment of primary antibody deficiencies]

BACKGROUND

Currently, management of antibody deficient patients differs significantly among caregivers. Evidence and consensus based (S3) guidelines for the treatment of primary antibody deficiencies were developed to improve the management of these patients.

METHODS

Based on a thorough analysis of current evidence (systematic literature search in PubMed; deadline November 2011) 14 recommendations were finalized during a consensus meeting in Frankfurt in November 2011 using structured consensus methods (nominal group technique). Experts were nominated by their scientific societies/patient initiatives (Tab. 1).

RESULTS

The guidelines focus on indication, practical issues and monitoring of immunoglobulin replacement therapy as well as on different routes of administration. Furthermore recommendations regarding supportive measures such as antiinfective therapy, vaccinations and physiotherapy are given. Combining literature evidence and experience of caregivers within this evidence and consensus based guidelines offers the chance to improve the quality of care for anti-body deficient patients.

[Use of a lung function screening device for identifying patients at risk for COPD in general practice]

BACKGROUND

Screening measures can facilitate the diagnosis of chronic obstructive pulmonary disease (COPD) and help save costs and time. We examined whether use of a lung function screener (Vitalograph copd-6™) can help general practitioners to identify patients at risk for COPD.

METHODS

In 17,856 patients aged > 40 years (smokers/ex-smokers with cough and/or exertional dyspnoea) general practitioners measured prebronchodilator FEV1 [% of predicted] and FEV1/FEV6 with the lung function screening device. In addition, the general practitioners completed a questionnaire on symptoms, history and planned measures and estimated whether or not the patient was at risk for COPD.

RESULTS

In 2927 patients (16.7 %) an FEV1/FEV6 < 70 % was measured; 88.2 % of these were classed by the doctors as being at risk for COPD. The total number of all patients with suspected COPD was considerably greater (10,000; 56 % of the total population); in only 25.3 % was an FEV1/FEV6 < 70 % documented. Compared with patients without a suspicion of COPD, patients judged to be at risk for COPD in spite of an FEV1/FEV6 ≥ 70 % were more often male, had more cigarette pack years and more often had dyspnoea, but less often cough, as main symptom. They had more concomitant diseases and previous hospitalisations, more prescriptions for bronchodilators, glucocorticoids and antibiotics in the past year and lower FEV1 values. In 61.3 % of the patients with suspected COPD the general practitioners planned further evaluation by spirometry, in 39.9 % referral to a pulmonologist as alternative or additional procedures were suggested.

CONCLUSION

Most patients with an FEV1/FEV6 < 70 % measured with the lung function screener Vitalograph copd-6™ were classed by the general practitioners as being at risk for COPD. Even in patients with unremarkable FEV1/FEV6 values the diagnosis of suspected COPD was often made if clinical signs or symptoms or a reduced FEV1 pointed to such a suspicion.

[Meeting of experts on obstructive airway diseases: targets and methods]

New insights into the pathogenesis and clinical course of chronic obstructive pulmonary disease (COPD) and asthma have become available. Systematic analyses of well-defined and intensively monitored patient cohorts are being published, particularly from the ECLIPSE cohort in the U.S.A. and from the network COSYCONet in Germany. Important articles from 2011 on COPD and asthma put former concepts into question. There is a new understanding of the relationship between parenchymal destruction and bronchial obstruction in COPD as well as on the impact of cardiovascular comorbidity. Computed tomography allows high-resolution imaging of lung structures, and MRI delivers supplementary functional information. Researchers have also investigated the value of patient-reported outcomes, such as quality of life, dyspnoea, or the COPD assessment test (CAT). Members of the GOLD committee are trying to establish a feasible classification of the multiple facets of COPD. With respect to treatment, novel data on beta-adrenergic antagonists in COPD and on muscarinic antagonists in asthma have been published. These aspects were discussed during an expert meeting and are now summarised in the present review article.