Chronic bronchitis in COPD patients is associated with increased risk of exacerbations: a cross-sectional multicentre study

BACKGROUND AND AIMS

Chronic bronchitis (CB) in chronic obstructive pulmonary disease (COPD) patients is associated with increased mortality, frequent exacerbations and faster disease progression. This study investigates the prevalence of CB in a large population of COPD patients to identify features associated with CB.

METHODS

Cross-sectional multicentre study in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages 2-4 from Belgium and Luxembourg.

RESULTS

The 974 patients included were on average 67.8 ± 9.6 years old; 72% were male, FEV1 was 52.5 ± 15.8% of predicted. The prevalence of CB was 64% (622/974). In patients with CB, the number of pack-years smoked and the prevalence of chronic respiratory failure, cachexia and skeletal muscle wasting were significantly higher, whereas FEV1 and FEV1 /VC were lower. The prevalence of CB increased with GOLD stage and was higher in patients with emphysema and those exposed to occupational risk factors. The CB group had more exacerbations, a higher percentage of patients with frequent exacerbations (37.3% vs. 14.2% of patients; p < 0.0001), increased COPD-related, non-intensive care unit hospitalisations and all-cause hospitalisation rates. In multiple logistic regression analysis, frequent exacerbation was the most important independent variable associated with CB, followed by current smoking, chronic respiratory failure, COPD duration and age.

CONCLUSIONS

CB prevalence in GOLD stage 2-4 COPD patients is high. CB is related to current tobacco smoking, and prevalence increases with COPD severity and duration, emphysema and age. CB could be the hallmark of a subtype of COPD easy to identify in clinical practice, associated with increased disease severity and increased risk of exacerbation.

Combined biological tests for suicide prediction

Disturbances in serotonin neuroregulation and in hypothalamic-pituitary-adrenal axis activity are both likely, and possibly independent, factors in the genesis of suicidal behavior. This analysis considers whether clinically accessible measures of these two disturbances have additive value in the estimation of risk for suicide. Seventy-four inpatients with RDC major or schizoaffective depressive disorders entered a prospective follow-up study from 1978-1981, underwent a dexamethasone suppression test (DST) and had fasting serum cholesterol levels available in the medical record. As reported earlier, patients who had had an abnormal DST result were significantly more likely to commit suicide during follow-up. Serum cholesterol concentrations did not differ by DST result and low cholesterol values were associated with subsequent suicide when age was included as a covariate. These results indicate that, with the use of age-appropriate thresholds, serum cholesterol concentrations may be combined with DST results to provide a clinically useful estimate of suicide risk.

[Treatment of pneumonia acquired in the community]

The community-acquired pneumonia is a common and serious illness. Pneumonia is said to be community acquired if it is contracted outside of hospital environment or if it is diagnosed within the first 48 hours of hospitalisation. The pathogen remains unknown after investigations in around 50%. The patient should initially be treated empirically, based on the likely pathogens according to the patient's risk-factors, underlying diseases, severity of pneumonia and place of therapy. If recent guidelines are compared (American Thoracic Society, British Thoracic Society and the Infectious Disease Advisory Board) there are differences concerning epidemiology, patients classification and the empiric antibiotic treatment. The appearance of resistances and the recent availability of new antibiotics account partially for these differences. In order to avoid further resistances but still achieving an efficient treatment, coherent antibiotic schemes considering local microbiological epidemiology and patients classifications must be applied as proposed by different guidelines.

The dexamethasone suppression test and suicide prediction

OBJECTIVE

Despite the substantial risks of eventual suicide associated with major depressive disorder, clinicians lack robust predictors with which to quantify these risks. This study compared the validity of demographic and historical risk factors with that of the dexamethasone suppression test (DST), a clinically practical measure of hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis.

METHOD

Seventy-eight inpatients with Research Diagnostic Criteria major depressive disorder or schizoaffective disorder, depressed type, entered a long-term follow-up study between 1978 and 1981, and, in addition, underwent a 1-mg DST. The number of suicides in this group during a 15-year follow-up period was determined, and the predictive validity of four demographic and historical risk factors reported in the literature to be consistently predictive of suicide in depressed patients was compared to the predictive validity of the DST results.

RESULTS

Thirty-two of the 78 patients had abnormal DST results. Survival analyses showed that the estimated risk for eventual suicide in this group was 26.8%, compared to only 2.9% among patients who had normal DST results. None of the demographic and historical risk factors examined in the study significantly distinguished those who later committed suicide from those who did not.

CONCLUSIONS

In efforts to predict and prevent suicidal behavior in patients with major depressive disorder, HPA-axis hyperactivity, as reflected in DST results, may provide a tool that is considerably more powerful than the clinical predictors currently in use. Research on the pathophysiology of suicidal behavior in major depressive disorder should emphasize the HPA axis and its interplay with the serotonin system.

Assessing community health among indigenous populations in Ecuador with a participatory approach: implications for health reform

Health reform is an important movement in countries throughout the region of the Americas, which could profoundly influence how basic health services are provided and who receives them. Goals of health sector reform include to improve quality, correct inefficiencies, and reduce inequities in current systems. The latter may be especially important in countries with indigenous populations, which are thought to suffer from excess mortality and morbidity related to poverty. The purpose of this paper is to report the results of a community health assessment conducted in 26 indigenous communities in the Province of Cotopaxi in rural Ecuador. It is hoped that this information will inform the health reform movement by adding to the current understanding of the health and socioeconomic situation of indigenous populations in the region while emphasizing a participatory approach toward understanding the social forces impacting upon health. This approach may serve as a model for empowering people through collective action. Recommended health reform strategies include: 1) Develop a comprehensive plan for health improvement in conjunction with stakeholders in the general population, including representatives of minority groups; 2) Conduct research on the appropriate mix between traditional medicine, primary health care strategies, and high technology medical services in relation to the needs of the general population; 3) Train local health personnel and traditional healers in primary health care techniques; 4) Improve access to secondary and tertiary health services for indigenous populations in times of emergency; and 5) Advocate for intersectoral collaboration among government institutions as well as non-governmental organizations and the private sector.

[Sleep apnea syndromes and traffic accidents]

The sleep apnea syndrome (SAS) is an independent and important risk factor of traffic accidents. The risk is further increased by cofactors such as alcohol intake or poor visibility driving conditions. It is still difficult to prospectively identify apneic patients at forseeable driving risk; previous accidents, reaction tests, steering simulation tests as different polysomnographic parametres appear to be the most promising markers. The initiation of nocturnal nasal continuous positive airway pressure treatment (nCPAP) normalizes patient's accident risk. Unfortunately there does not exist any accurate European nor national regulation dealing with issuing a driving licence for persons with sleep apnea disorder.

[Diagnosis of lung cancer]

Due to the frequent diagnosis at a late inoperable stage and the bad prognosis of metastatic disease, lung cancer has become the first cause of cancer mortality. Early detection is thus the only way to influence mortality as there is no good treatment available for advanced disease. In the eighties, large screening studies using standard chest X Ray and sputum cytology have not been able to show a significant reduction in global lung cancer mortality. However these studies are now largely criticized for their methodological flaws. Recently, a new technique using auto-fluorescence fibroscopy has been developed, which is able to detect dysplastic and in situ neoplastic lesions which are invisible to standard fibroscopic techniques. This technique holds great promise in the detection of early lesions. In addition, molecular biology techniques are being developed which aim at detecting early invasive lesions at a stage where surgical treatment is still curative. The addition of these two techniques will probably in the future increase the efficiency of lung cancer screening. Therefore we think that new large scale screening studies are needed.

Malignant pleural mesothelioma

The incidence of malignant pleural mesothelioma (MPM) has risen for some decades and is expected to peak between 2010 and 2020. Up to now, no single treatment has been proven to be effective and death usually occurs within about 12-17 months after diagnosis. Perhaps because of this poor prognosis, early screening has incited little interest. However, certain forms may have a better prognosis when diagnosed early and treated by multimodal therapy or intrapleural immunotherapy. Diagnosis depends foremost on histological analysis of samples obtained by thoracoscopy. This procedure allows the best staging of the pleural cavity with an attempt to detect visceral pleural involvement, which is one of the most important prognostic factors. Although radiotherapy seems necessary and is efficient in preventing the malignant seeding after diagnostic procedures in patients, there has been no randomized phase III study showing the superiority of any treatment compared with another. However, for the early-stage disease (stage I) a logical therapeutic approach seems to be neoadjuvant intrapleural treatment using cytokines. For more advanced disease (stages II and III) resectability should be discussed with the thoracic surgeons and a multimodal treatment combining surgery, radiotherapy and chemotherapy should be proposed for a randomized controlled study. Palliative treatment is indicated for stage IV. In any case, each patient should be enrolled in a clinical trial.

Interventional bronchoscopy: 5-year experience at the Academic Hospital of the Vrije Universiteit Brussel (AZ-VUB)

Our experience with interventional bronchoscopic techniques in a University Hospital is described: in 93 patients during a 5-year period, 149 interventional procedures (i.e., Nd-YAG laser photoresection and/or airway stenting and/or balloon dilatation) have been performed. Laser resection was successful in relieving major symptoms (intractable dyspnea, hemoptysis or retro-obstructive complications) in 35/41 (85%) of malignant indications, and in 18/19 (94%) of benign obstructions. Major complications included one death (1.6%) early in the series, and major nonfatal hemorrhage in three patients (5%), all with malignant disease. In 31/35 (89%) of malignant central airway stenoses treated with stents, respiratory symptoms could be palliated successfully. Mean survival after stenting was 6 +/- 5.3 months. In 20/23 (87%) of benign tracheal stenoses, temporary or permanent stenting allowed for complete restoration of airway patency. The development of inexpensive and simplified insertion techniques for existing stents, and of a new (and even less expensive) type of tracheal stent has enabled the use of airway stenting in all categories of patients. Bronchoscopic balloon dilatation was helpful in the mechanical dilatation of stenoses, and in the unfolding of unopened stents. Finally, a plea for an organised referral system and for active collaboration between interventional bronchoscopy centers is made.

Bronchoscopic balloon dilatation in the combined management of postintubation stenosis of the trachea in adults

Bronchoscopic balloon dilatation (BBD) using angioplasty balloon catheters has been employed successfully in the treatment of tracheobronchial stenoses in children and has worked with variable success in adults with bronchial stenosis. In adults with tracheal stenosis, BBD only has been reported anecdotally. In this study, experience with BBD using a valvuloplasty balloon catheter in the combined treatment (with Nd-YAG laser photoresection and stenting) of severe benign postintubation tracheal stenoses in three adults is delineated. BBD was particularly successful in establishing tracheal patency when laser photoresection was contraindicated or was too dangerous; BBD allowed easy insertion of tracheal stents and the "opening" of folded silicone stents. BBD is a simple, inexpensive, safe, and efficient adjunct in the combined treatment of severe postintubation rigid tracheal stenosis in selected adults.

[Malignant mesothelioma. Diagnosis and treatment]

In over 90% of cases, mesothelioma initially presents as a banal pleural effusion, contributing no orientation to the diagnosis. The pleural fluid can even disappear after initial puncture. For early diagnosis, simple puncture, with or without biopsy, does not suffice. Thoracoscopy is 98% diagnostic. The course depends on the stage, the histological type and the general status. A new international TNM classification has been proposed to allow comparison of series and to choose a treatment appropriate to the stade: at stage I, intrapleural, local immuno-chemotherapy treatment gives good results; at stages II and III, surgery followed by radiation therapy are indicated; at stage IV, symptomatic treatment alone is justified.

Comparison of video-assisted thoracoscopic talcage for recurrent primary versus persistent secondary spontaneous pneumothorax

Thoracoscopic talcage (TT) is a safe and effective prophylactic treatment for patients suffering from recurrent primary spontaneous pneumothorax (PSP). Empirically, TT is considered equally effective in the treatment of persistent secondary spontaneous pneumothorax (SSP), although this has not yet been proved. In this study, the efficacy and safety of TT was prospectively evaluated in 28 patients (17 males and 11 females, mean age 27 +/- 8 yrs), with 31 episodes of recurrent PSP, and in 20 patients (13 males and 7 females, mean age 43 +/- 21 yrs) with persistent SSP. TT proved to be equally effective in achieving pleurodesis in both groups; there were 6.5% recurrences in the PSP group and 8.7% in the SSP group during a mean follow-up period of 18 months (p > 0.05). In the SSP group, there were significantly more prolonged postoperative air leaks (26 vs 0%; p = 0.004) and a longer postoperative chest tube drainage time (35.5 +/- 18 vs 24.9 +/- 3.2 hrs; p = 0.002) was necessary. All air leaks, however, ceased spontaneously during drainage. Duration of hospitalization was significantly longer in the SSP group (4.7 +/- 2 vs 3.2 +/- 0.5 days; p < 0.0001). Postoperative pain (90 vs 43%; p < 0.0001) and fever (65 vs 17%; p = 0.001) were more frequent in the PSP group than in the SSP group. There were no major peri- or postoperative complications in either group. We conclude that thoracoscopic talcage is as efficient and safe in achieving pleurodesis in persistent spontaneous pnuemothorax as in recurrent primary spontaneous pneumothorax.

[Role of transesophageal echocardiography in the diagnosis of pulmonary embolism]

The authors report a 72 year-old woman presenting with severe shock after ilio-femoral artery bypass surgery. The transesophageal echocardiography allowed the diagnosis of an unsuspected massive right pulmonary artery embolism. This case emphasizes the role of this procedure for the early bedside diagnosis of massive pulmonary embolism, especially in critically ill patients who require urgent therapeutic interventions.

Uric acid, anion gap and urea concentration in the diagnostic approach to hyponatremia

We analyzed the serum anion gap (AG = sodium plus potassium minus chloride plus bicarbonate, N = 11-21 mEq/l), serum uric acid and urea concentrations in hyponatremia of various origins. We found that characteristic chemical patterns emerged in association with different hypotonic states: Low uric acid concentration was typically observed in the SIADH and in hyponatremia related to hypopituitarism. The same observation was also frequently noted in hyponatremia secondary to diuretics or to polydypsia. In the SIADH, we observed a decrease in the AG but to a greater extent (-26%) than one would expect from the simple dilutional effect (-16%). Fifty percent of the patients presented an AG lower than 11 mEq/l. In patients with diuretic-related hyponatremia, one group presented an hypouricemia and a low AG as in SIADH (reflecting volume expansion), in the other group the AG was normal or increased as was uric acid concentration (reflecting volume depletion). In adrenocorticotropin deficiency, hyponatremia was typically associated with a low bicarbonate concentration, a normal AG and hypouricemia. In polydypsic patients with hyponatremia, the AG was usually normal or increased despite sometimes very low sodium levels. Uric acid levels were highly variable, most often decreased. We also noted in these patients that the serum urea levels were correlated with urine osmolality (R = +0.8; p < 0.001), and in 40% of them we observed very low blood urea concentration (0.5-2 mmol/l) at the admission time. In hyponatremia related to cardiac failure or cirrhosis, the AG was usually normal despite mild hypoproteinemia.

Raised urea clearance in cirrhotic patients with high uric acid clearance is related to low salt excretion

In cirrhotic patients without renal failure, salt retention could result from a decreased effective intravascular volume or could be a primary event leading to increased intravascular volume. Clearance of urea and uric acid depend on an effective intravascular volume. In the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)--a state of increased intravascular volume--uric acid clearance is increased and that of urea is increased only when salt excretion is low. The intravascular volume of 60 consecutive cirrhotic patients without renal failure was estimated indirectly by studying the relationship between fractional excretion of filtered (FE) sodium, urea, and uric acid. Forty five per cent had a high FE uric acid (> 12%), which could mean a high intravascular volume, and presented with an FE urea that was inversely correlated with FE sodium (r = 0, 62; p < 0.001) as in SIADH, while in the controls the FE urea was positively correlated with FE sodium (r = +0, 46; p < 0.01). In patients who had a normal FE uric acid and low FE sodium (< 0.2%), the FE urea was significantly lower (40 (13)%, n = 20) than in subjects with high FE uric acid and a low FE sodium (61 (9)%, n = 16, p < 0.001); this last group also presented with lower mean blood urea concentrations (3.1 (1.2) mmol/l and 4.0 (1.8) mmol/l; p < 0.05) and a lower supine renin activity (p < 0.01). As observed in the SIADH, cirrhotic patient with high FE uric acid have raised FE urea only when salt excretion is low. It is believed that the low salt excretion is not caused by a decrease in effective intravascular volume and that this is increased in cirrhotic patients with raised FE uric acid.

Provocative endocrine testing in recovered depressives

Twenty-eight patients underwent a series of provocative endocrine tests an average of one year after their last admission for depression. Hypersecretion of cortisol, early escape of cortisol from dexamethasone suppression, diminished growth hormone response to insulin-induced hypoglycemia and altered thyrotropin response to thyrotropin-releasing hormone reported in acute primary depression were not observed after recovery. There were no differences in these measures after recovery between previous suppressors and nonsuppressors to dexamethasone. The cortisol response to insulin-induced hypoglycemia was less than expected in 6 of 16 recovered patients tested. There were significant differences in post-dexamethasone urinary free cortisol and in basal and early post-insulin serum cortisol levels between patients who had been suppressors and those who had been nonsuppressors to dexamethasone during acute depression. Further studies need to be done to substantiate these findings. These data indicate that hormone responses in recovered depressives are largely normal, suggesting that abnormalities during depression are "state" related phenomena.

Dexamethasone suppression, protirelin stimulation, and insulin infusion in subtypes of recovered depressive patients

Twenty-eight patients (10 bipolar, 13 depressive spectrum disease, and 5 familial pure depressive), recovered from depression for an average of 1 year, underwent a series of basal and provocative endocrine tests. No significant differences were found among depressive subtypes in thyrotropin, cortisol, or growth hormone measurements either before or after provocative testing with the exception of growth hormone response to insulin-induced hypoglycemia. Patients with depressive spectrum disease showed a significantly different growth hormone response to insulin-induced hypoglycemia than patients with bipolar disorder, a finding which suggests differences in alpha-adrenergic receptor sensitivity between these groups.

Catatonia and systemic lupus erythematosus

Catatonia has generally been assumed by many physicians to be a subtype of schizophrenia. Numerous cases have been reported in the literature associating catatonia with other psychiatric and also medical illnesses. The present report describes a patient with Systemic Lupus Erythematosus (SLE) who presented in a catatonic state. A brief differential diagnosis of catatonia is also included.