REALizing and improving management of stable COPD in China: results of a multicentre, prospective, observational study (REAL)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) management in China is far from adequate; underdiagnosis and undertreatment are major barriers to optimal care and improved patient outcomes.

OBJECTIVE

To generate reliable information on COPD management, outcomes, treatment patterns and adherence, and disease knowledge in China in a real-world setting.

DESIGN

A 52-week multicentre, prospective, observational study.

METHODS

Outpatients (⩾40 years old) diagnosed with COPD were enrolled from 50 secondary and tertiary hospitals across six geographical regions. Data were collected in routine clinical practice.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled and 4978 included in the analysis. Mean [standard deviation (SD)] age was 66.2 (8.9) years, 79.5% were male and 90% had moderate-to-very-severe airflow limitation. Annual rates of overall and severe exacerbation were 0.56 and 0.31, respectively. During 1 year, 1536 (30.8%) patients experienced ⩾1 exacerbation and 960 (19.3%) patients had ⩾1 exacerbation requiring hospitalization/emergency visit. Mean (SD) COPD assessment test score was 14.6 (7.6) at baseline and 10.6 (6.8) at follow-up; however, 42-55% of patients had persistent dyspnoea, chest tightness and wheezing at 1 year. The most prescribed treatments were inhaled corticosteroid (ICS)/long-acting β2-agonist (LABA) (36.0%), ICS/LABA + long-acting muscarinic antagonist (LAMA) (17.7%) and LAMA monotherapy (15.3%). Among patients with high exacerbation risk (GOLD Groups C and D), 10.1% and 13.1%, respectively, did not receive any long-acting inhalers; only 53.8% and 63.6% of Group C and D patients with ⩾1 exacerbation during follow-up were prescribed ICS-containing therapy, respectively. Mean (SD) adherence for long-acting inhalers was 59.0% (34.3%). Mean (SD) score for the COPD questionnaire was 6.7 (2.4).

CONCLUSION

These results indicate a high burden of severe exacerbations and symptoms in Chinese outpatients with COPD, and low adherence with treatment guidelines, highlighting the need for more effective management nationwide.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov identifier: NCT03131362).

Treatment patterns in patients with stable COPD in China: analysis of a prospective, 52-week, nationwide, observational cohort study (REAL)

BACKGROUND

Underdiagnosis and undertreatment pose major barriers to optimal management of chronic obstructive pulmonary disease (COPD) in China.

OBJECTIVE

The REAL trial was performed to generate reliable information on real-world COPD management, outcomes and risk factors among Chinese patients. Here, we present study outcomes related to COPD management.

DESIGN

It is a 52-week, prospective, observational, multicentre study.

METHODS

Outpatients (aged ⩾40 years) enrolled from 50 secondary and tertiary hospitals across six geographic regions of China were followed up for 12 months, with two onsite visits and by telephone every 3 months following baseline.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled and 4978 included in the analysis. Mean [standard deviation (SD)] age was 66.2 (8.9) years, the majority of patients were male (79.5%) and mean (SD) time since COPD diagnosis was 3.8 (6.2) years. The most common treatments at each study visit were inhaled corticosteroids/long-acting beta-agonists (ICSs/LABAs; 28.3-36.0%), long-acting muscarinic antagonists (LAMAs; 13.0-16.2%) and ICS/LABA + LAMA (17.5-18.7%), but up to 15.8% of patients at each visit received neither ICS nor long-acting bronchodilators. The use of ICS/LABA, LAMA and ICS/LABA + LAMA differed across regions and hospital tiers; up to fivefold, more patients received neither ICS nor long-acting bronchodilators in secondary (17.3-25.4%) versus tertiary hospitals (5.0-5.3%). Overall, rates of nonpharmacological management were low. Direct treatment costs increased with disease severity, but the proportion of direct treatment costs incurred due to maintenance treatment decreased with disease severity.

CONCLUSION

ICS/LABA, LAMA and ICS/LABA + LAMA were the most frequently prescribed maintenance treatments for patients with stable COPD in China, although their use differed between region and hospital tier. There is a clear need for improved COPD management across China, particularly in secondary hospitals.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov identifier: NCT03131362; https://clinicaltrials.gov/ct2/show/NCT03131362).

PLAIN LANGUAGE SUMMARY

Treatment patterns in patients with COPD in ChinaBackground: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory lung disease characterized by progressive and irreversible airflow limitation. In China, many patients with this disease do not receive a diagnosis or appropriate treatment.Objective: This study aimed to generate reliable information on the treatment patterns among patients with COPD in China to help inform future management strategies.Study design and methods: Patients (aged ⩾40 years) were enrolled from 50 hospitals across 6 regions of China and physicians collected data over the course of 1 year during routine outpatient visits.Results: The majority of patients were receiving long-acting inhaled treatments, which are recommended to prevent worsening of the disease. Up to 16% of patients in this study, however, did not receive any of these recommended treatments. The proportion of patients who received long-acting inhaled treatments differed across regions and hospital tiers; there were about five times more patients in secondary hospitals (about 25%) who did not receive these treatments compared with those in tertiary hospitals (about 5%). Guidelines recommend that pharmacological treatment should be complemented by nondrug treatment, but this was only received by a minority of patients in this study. Patients with higher disease severity incurred greater direct treatment costs compared with those with milder disease. Maintenance treatment costs made up a smaller proportion of overall direct costs for patients with higher disease severity (60-76%) compared with patients with milder disease (81-94%).Conclusion: Long-acting inhaled treatments were the most frequently prescribed maintenance treatments among patients with COPD in China, but their use differed between region and hospital tier. There is a clear need to improve disease management across China, especially in secondary hospitals.

Exacerbation in patients with stable COPD in China: analysis of a prospective, 52-week, nationwide, observational cohort study (REAL)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) management in China is inadequate and there is a need to improve care and outcomes for patients nationwide.

OBJECTIVES

The REAL study was designed to generate reliable information on COPD management from a representative sample of Chinese patients with COPD. Here, we present study outcomes related to acute exacerbations.

DESIGN

A 52-week, multicentre, prospective, observational study.

METHODS

Outpatients (aged ⩾ 40 years) enrolled from 25 tertiary and 25 secondary hospitals across six geographic regions in China were followed for 12 months. Risk factors for COPD exacerbation and disease severity by exacerbation were assessed using multivariate Poisson and ordinal logistic regression models, respectively.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled, with 4978 included in the analysis. Mean (standard deviation) age was 66.2 (8.9) years. More patients presented with exacerbations in secondary versus tertiary hospitals (59.4% versus 40.2%) and in rural versus urban areas (53.2% versus 46.3%). Overall exacerbation rates differed across regions (range: 0.27-0.84). Patients from secondary versus tertiary hospitals had higher rates of overall exacerbation (0.66 versus 0.47), severe exacerbation (0.44 versus 0.18) and exacerbation that resulted in hospitalisation (0.41 versus 0.16). Across regions and hospital tiers, the rates of overall exacerbation and exacerbations that resulted in hospitalisation were highest in patients with very severe COPD (based on the severity of airflow limitation or GOLD 2017 combined assessment). Strong predictors of exacerbation included demographic and clinical characteristics, modified Medical Research Council scores, mucus purulence, exacerbation history and the use of maintenance mucolytic treatment.

CONCLUSION

COPD exacerbation rates varied across regions and were higher in secondary compared with tertiary hospitals in China. Understanding the factors associated with COPD exacerbation may facilitate improved management of COPD exacerbations in China.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov: NCT03131362; https://clinicaltrials.gov/ct2/show/NCT03131362).

PLAIN LANGUAGE SUMMARY

Exacerbations in patients with chronic obstructive pulmonary disease in ChinaBackground: Chronic obstructive pulmonary disease (COPD) causes progressive and irreversible airflow limitation. As the disease progresses, patients often experience a flare up of symptoms referred to as an exacerbation. There is inadequate management of COPD in China and, therefore, there is a need to improve care and outcomes for patients across the country.Objective: This study aimed to generate reliable information on exacerbations among Chinese patients with COPD to help inform future management strategies.Study design and methods: Patients (aged ⩾ 40 years) were enrolled from 25 secondary and 25 tertiary hospitals across six regions of China. Physicians collected data over 1 year during routine outpatient visits.Results: There were more patients who experienced an exacerbation in secondary versus tertiary hospitals (59% versus 40%) and in rural versus urban areas (53% versus 46%). Patients in different geographic regions experienced varying frequencies of exacerbations over 1 year. Compared with patients from tertiary hospitals, patients from secondary hospitals experienced exacerbations (including exacerbations that were severe and those that resulted in hospitalisation) at a higher frequency over 1 year. Patients with very severe disease experienced exacerbations (including exacerbations that resulted in hospitalisation) at the highest frequency over 1 year, regardless of the patient's geographic region or hospital tier. Patients who had certain characteristics and symptoms, had exacerbation(s) over the previous year, or received medication that aids in the clearance of mucus were more likely to experience exacerbations.Conclusion: The frequency of exacerbations among Chinese patients with COPD varied between patients living in different geographic regions and between patients presenting to different hospital tiers. Understanding the factors related to the occurrence of an exacerbation may help physicians better manage the disease.

Severity distribution and treatment of chronic obstructive pulmonary disease in China: baseline results of an observational study

Background

Chronic obstructive pulmonary disease (COPD) receives low awareness and is undertreated in China. Understanding the burden and treatment of COPD across the nation is important for improving quality of care for this disease. This study aims to reveal the current situation of COPD severity distribution and management across China.

Methods

Baseline data from REALizing and Improving Management of Stable COPD in China, a multicentre, prospective, longitudinal, observational study, were analysed. Patients diagnosed with COPD as per Global Initiative for Chronic Obstructive Lung Disease 2016 (GOLD 2016) criteria were enrolled from 50 randomly selected hospitals (tertiary, 25; secondary, 25) across six geographical regions. Data were collected in routine clinical settings.

Results

Between 15 December 2017 and 6 August 2020, 5013 patients were enrolled and 4978 included in the full analysis set. Of these, 2459 (49.4%) reported ≥ 1 exacerbation within 12 months prior to study enrolment, with a mean annual rate of 0.9/patient, including 0.2/patient and 0.5/patient leading to emergency room visits and hospitalisation, respectively. Spirometry graded 458 (10.1%), 1886 (41.7%), 1558 (34.5%), and 616 (13.6%) were GOLD stage I–IV, and 536 (11.4%), 1034 (22.0%), 563 (12.0%), and 2566 (54.6%) were classified as GOLD 2016 Group A–D, respectively, without evident regional variations. Inhaled corticosteroids plus long-acting beta₂-agonist (ICS/LABA, 1316 [26.4%]), ICS/LABA plus long-acting muscarinic antagonist (ICS/LABA + LAMA, 871 [17.5%]), and LAMA (754 [15.1%]) were prescribed at high rates across all groups and regions. Medications not recommended by GOLD were commonly prescribed (TCM, 578 [11.6%]; others, 951 [19.1%]), and 681 (13.7%) were not given ICS or long-acting bronchodilators.

Conclusions

Disease burden among Chinese COPD outpatients is high. Improved guideline adherence for COPD treatment is needed.

Trial registration ClinicalTrials.gov identifier, NCT03131362.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02021-w.

[Diagnostic value of surgical lung biopsies for diffuse parenchymal lung disease: the change of disease spectrum in the past 28 years in a single institution in China]

Objective: To investigate the changes of disease spectrum in diffuse parenchymal lung disease (DPLD) diagnosed by surgical lung biopsy, and to explore the diagnostic value of surgical lung biopsy in DPLD. Methods: Four hundred and fifty-five consecutive DPLD patients, who underwent surgical lung biopsy in Peking Union Medical College Hospital during the past 28 years, were analyzed retrospectively. Results: There were 211 males and 244 females. The average age at biopsy was (45±14) years. Four hundred and eleven cases (90.3%) were diagnosed by pathologic findings. Four hundred and forty-one cases (96.9%) were diagnosed by clinical-radiologic-pathologic multidisciplinary discussion. The 30-day mortality and 90-day mortality were 2.4% and 3.3% respectively. The disease spectrum included interstitial pneumonia in 209 cases (45.9%) (nonspecific interstitial pneumonia in 105 cases, usual interstitial pneumonia in 33 cases), other miscellaneous DPLD in 166 cases (36.5%) (including hypersensitivity pneumonitis in 49 cases), tumor in 39 cases (8.6%), and infectious diseases in 27 cases (5.9%). In the three consecutive periods (1993-2002, 2003-2012 and 2013-2020), the number of biopsies was 76 (16.7%), 297 (65.3%) and 82 (18%) respectively. The disease spectrum changes over time: in the above three periods, the percentage of interstitial pneumonia in DPLD was 68.4%, 45.1% and 28%, other miscellaneous DPLDs were 22.4%, 39.4% and 39.0%, the tumors were 2.6%, 7.4% and 18.3%, the infectious diseases were 5.3%, 5.1% and 9.8%. Conclusions: This study presented the changes of disease spectrum in DPLD diagnosed by surgical lung biopsy through single center real-world data, reflecting the progress of clinicians' understanding of DPLD and interstitial pneumonia. Surgical lung biopsy is still valuable for some difficult and complicated DPLD cases.

[Analysis of the clinical characteristics and species distribution of non-tuberculous mycobacteria in a general hospital]

Objective: To summarize the clinical characteristics and species distribution of nontuberculous mycobacteria(NTM). Methods: We conducted a retrospectively chart review of 453 adult patients with 532 positive cultures with NTM diagnosed and treated in Peking Union Medical College Hospital from January 2014 to December 2018. The information including clinical findings, imaging and etiological data were obtained from clinical examination system. Among these 453 patients, 75 cases met the diagnostic criteria for NTM, with detailed clinical data, culture results and radiological images. Of these patients, 38 were males and 37 were females, with an average age of (50.8±16.2) years. Clinical manifestations, imaging features, NTM species and treatment were analyzed. Results: Among 75 NTM patients, 43 cases (57.3%, 43/75) were infected with Mycobacterium avium Complex (MAC)/intracellular, 18 cases (24.0%, 18/75) with Mycobacterium turtle/abscess, and 7 cases (9.3%, 7/75) with Mycobacterium kansasii. Comorbidities existed in 64.0% patients (48/75). The top two common comorbidities were previous tuberculosis (25.3%, 19/75) infection and clinical bronchiectasis (18.7%, 14/75). After the respiratory disease (82.7%, 62/75), we identified bloodstream as the most frequent manifestation of NTM infection (25.3%, 19/75). MAC was often associated with infection in respiratory system and bloodstream, while rapidly growing mycobacteria (RGM) was more commonly detected in lymph nodes and skin and soft tissues. Cough/expectoration (77.4%, 48/62) was the most common clinical symptom of NTM disease, followed by fever and dyspnea. The frequent imaging findings were nodules (41.9%, 26/62), bronchiectasis (37.1%, 23/62), and fibrous cavities (24.2%, 15/62). In disseminated NTM disease, 94.7% (18/19) patients had underlying diseases and 89.5% (17/19) patients had long-term immunosuppression. Conclusion: The most common NTM species was Mycobacterium avium/intracellular in our series. The predominant infected organ was the respiratory system. Previous tuberculosis history likely increased the risk of infection.

[The differential diagnosis for novel coronavirus pneumonia and similar lung diseases in general hospitals]

Novel coronavirus pneumonia was a novel coronavirus infection that has dominated pulmonary infection since December 2019. The main manifestations were fever, dry cough, shortness of breath, normal or leukopenia in peripheral blood and changes in chest CT and in severe cases, multiple organ failure might occur. The National Health Commission, PRC has revised the consensus on diagnosis and treatment seven times in a short period of time, indicating the growing understanding of the disease. Patients with novel coronavirus pneumonia usually had history of travelling or living in the epidemic area including Wuhan within 14 days before onset, or have been exposed to patients who had fever or respiratory symptoms from the epidemic area, or had clustering diseases. However, novel coronavirus pneumonia was becoming more and more blurred after vanishing epidemic. The diagnosis and differential diagnosis of novel coronavirus pneumonia were challenges not only because of large number of tourists increasing dramatically after the relieving of epidemic, but also patients with other diseases from different areas to search for medical care. In this article, the clinical and chest imaging features of the novel coronavirus pneumonia were reviewed and compared with other infections and non-infectious diffuse pulmonary diseases. We try to find the similarities and differences among them, and to identify clues to the diagnosis of novel coronavirus pneumonia, so as to ensure accurate diagnosis and treatment.

REALizing and improving management of stable COPD in China: a multi-center, prospective, observational study to realize the current situation of COPD patients in China (REAL) - rationale, study design, and protocol

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of death in China with a reported prevalence of 8.2% people aged ≥40 years. It is recommended that Chinese physicians follow Global Initiative for Chronic Obstructive Lung Disease (GOLD) and national guidelines, yet many patients with COPD in China remain undiagnosed. Furthermore, missed diagnoses and a lack of standardized diagnosis and treatment remain significant problems. The situation is further complicated by a lack of large-scale, long-term, prospective studies of real-world outcomes, including exacerbation rates, disease severity, efficacy of treatment, and compliance of COPD patients in China.

METHODS/DESIGN

The REALizing and improving management of stable COPD in China (REAL) study is a 52-week multi-center, prospective, observational trial. REAL aims to recruit approximately 5000 outpatients aged ≥40 years with a clinical diagnosis of COPD per GOLD 2016. Outpatients will be consecutively recruited from approximately 50 tertiary and secondary hospitals randomly selected across six geographic regions to provide a representative population. Patients will receive conventional medical care as determined by their treating physicians. The primary objective is to evaluate COPD patient outcomes including lung function, health status, exacerbations, hospitalization rate, and dyspnea following 1 year of current clinical practice. Secondary objectives are to assess disease severity, treatment patterns, adherence to medication, and associated risk factors. Data will be collected at two study visits, at patients' usual care visits, and by telephone interview every 3 months.

DISCUSSION

Knowledge of COPD among physicians in China is poor. The REAL study will provide reliable information on COPD management, outcomes, and risk factors that may help improve the standard of care in China. Patient recruitment began on 30 June 2017 and the estimated primary completion date is 30 July 2019.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03131362. Registered on 20 March 2017.

Current situation of asthma-COPD overlap in Chinese patients older than 40 years with airflow limitation: a multicenter, cross-sectional, non-interventional study

BACKGROUND AND AIMS

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is poorly recognized in China. Our study determined the distribution of ACO and its clinical characteristics among patients (aged ⩾40 years) with airflow limitation at Chinese tertiary hospitals.

METHODS

This cross-sectional, non-interventional study (NCT02600221), conducted between December 2015 and October 2016 in 20 Tier-3 Chinese hospitals, included patients aged ⩾40 years with post-bronchodilator (BD) FEV1/FVC <0.7. The primary variable was distribution of ACO in adults with post-BD forced expiratory volume /forced vital capacity (FEV1/FVC) <0.7 based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2015 and 2017 reports. Other variables included determination of characteristics of ACO and its clinical recognition rate.

RESULTS

In 2003 patients (mean age 62.30 ± 9.86 years), distribution of ACO, COPD and asthma were 37.40%, 48.50% and 14.10%, respectively. Proportions of patients with A, B, C and D grouping were 11.70%, 31.00%, 6.90% and 50.30% as per GOLD 2017, whereas they were 15.10%, 51.10%, 3.60% and 30.20% as per GOLD 2015. Similar clinical symptoms were reported in all three groups. A higher percentage of ACO patients presented with dyspnea, wheezing and chest tightness. Compared with the COPD group, a greater proportion of ACO patients reported wheezing (74.6% and 65.40%), while a lower proportion in the ACO group reported cough (79.40% versus 82.70%) and expectoration (76.50% versus 81.60%). Blood eosinophil count ⩾0.3 × 109/L was observed in 34.6% of ACO patients. The clinical recognition rate of ACO was 31.4%.

CONCLUSION

Despite ACO affecting two-fifths of the study population, the initial diagnosis rate was low at 6% in China, thus warranting concerted efforts to improve ACO diagnosis.

CLINICALTRIALS.GOV

[ClinicalTrials.gov identifier: NCT02600221] registered 22 October 2015, https://clinicaltrials.gov/ct2/show/NCT02600221The reviews of this paper are available via the supplemental material section.

Clinical features of pulmonary mucormycosis in patients with different immune status

Background

Pulmonary mucormycosis (PM) is a relatively rare but often fatal and rapidly progressive disease. Most studies of PM are case reports or case series with limited numbers of patients, and focus on immunocompromised patients. We investigated the clinical manifestations, imaging features, treatment, and outcomes of patients with PM with a focus on the difference in clinical manifestations between patients with different immune status.

Methods

Clinical records, laboratory results, and computed tomography scans of 24 patients with proven or probable PM from January 2005 to December 2018 in Peking Union Medical College Hospital were retrospectively analyzed.

Results

Ten female and 14 male patients were included (median age, 43.5 years; range, 13-64 years). Common presenting symptoms were fever (70.8%), cough (70.8%), sputum production (54.2%), and hemoptysis (41.7%). Radiological findings included consolidation (83.3%), ground-glass opacities (58.3%), nodules (50.0%), masses (37.5%), cavities (33.3%), mediastinal lymphadenopathy (29.2%), and halo sign (12.5%); one patient had a reversed halo sign. Seven patients (29.2%) had no obvious predisposing risk factors, and 17 (70.8%) had underlying diseases including diabetes, hematological malignancy, and use of immunosuppressants. Compared with immunocompromised patients, immunocompetent patients with PM were younger {23 [13-46] vs. 48 [17-64] years, P=0.023}, comprised a higher proportion of men (100.0% vs. 41.2%, P=0.019), had a longer disease course {34 [8-47] vs. 9 [2-102] weeks, P=0.033}, had a higher eosinophil count [0.66 (0.07-2.00) ×10⁹/L vs. 0.04 (0.00-0.23) ×10⁹/L, P=0.001], and had a lower erythrocyte sedimentation rate {12 [1-88] vs. 74 [9-140] mm/h, P=0.032}.

Conclusions

PM can occur in heterogeneous patients with different immune status, and the clinical phenotype differs between immunocompetent and immunocompromised patients. Because of the lack of specific clinic and imaging manifestations, aggressive performance of invasive procedures to obtain histopathological and microbial evidence is crucial for a definitive diagnosis.

Chronic bronchitis is associated with severe exacerbation and prolonged recovery period in Chinese patients with COPD: a multicenter cross-sectional study

BACKGROUND

Chronic bronchitis (CB) is closely associated with the frequency and severity of chronic obstructive pulmonary disease (COPD) exacerbation. However, little is known about the impact of CB on COPD exacerbations, severe and non-severe, and on recovery from an exacerbation.

METHODS

We conducted a nation-wide multicenter cross-sectional survey in China between September 2007 and December 2008. Eleven hospitals participated in this study. Patients' demographic information, presence of CB, overall numbers of COPD exacerbation and severe exacerbation leading to emergency visit, hospitalization and intensive care unit (ICU) stay in the past year, recovery period following the last exacerbation, and well- or poor-recovery were recorded.

RESULTS

A total of 1,101 patients with COPD were enrolled and 890 (80.8%) had CB. Patients with CB reported more history of frequent exacerbations (≥2/patient/year) (59.6% vs. 50.7%, P=0.019) and severe exacerbation (% emergency visit ≥1: 28.0% vs. 16.6%, P=0.001; % hospitalization ≥1: 51.2% vs. 28.0%, P<0.001; %ICU stay ≥1: 6.5% vs. 1.9%, P=0.009). Recovery period following the last exacerbation was longer in patients with CB (19.0±16.2 vs. 15.2±14.7 days, P=0.003) and more patients with CB reported poor recovery (85.8% vs. 78.4%, P=0.003). Multivariate analyses showed that CB was independently associated with severe exacerbation requiring emergency visit (adjusted OR, 1.512, P=0.048) and hospitalization (adjusted OR, 2.031, P<0.001) and prolonged recovery period (adjusted regression coefficient 2.861, P=0.030).

CONCLUSIONS

CB is associated with frequent exacerbations of COPD in Chinese population, especially severe exacerbations requiring emergency visit and hospitalization admission. Additionally, CB significantly prolongs recovery period following COPD exacerbation.

Perception of circadian variation of symptoms in Chinese patients with chronic obstructive pulmonary disease

BACKGROUND

Although, the variable pattern of asthmatic symptoms is well recognized, little is known about the respiratory symptoms variability in patients of chronic obstructive pulmonary disease (COPD). The present study evaluated the variability of the respiratory symptoms in a day and their influence on the daily activities in a cohort of Chinese COPD patients.

METHODS

An observational cross-sectional study was conducted in 11 medical centers of China. Participants were outpatient ≥40 years old with stable COPD, post-bronchodilator forced expiratory volume in 1 second (FEV1) <80% predicted. Overall, data of 1,032 eligible patients were valid for final analysis.

RESULTS

Mean post bronchodilator FEV1 (predicted %) was 46.5%. Cough, expectoration and dyspnea were the most commonly observed symptoms (73.6%, 68.8% and 61.4%, respectively). Daily symptom variability was experienced by 50.2% of symptomatic patients. The wake up time in the morning was the worst and the most troublesome time during the day (39.3%), followed by the nighttime (21.3%). The morning activities were most affected by COPD symptoms. Multivariate analyses revealed that COPD assessment test (CAT) scores was the only factor correlated with patients' symptom variability [odds ratio (OR) =0.463, P<0.0001].

CONCLUSIONS

Patient-perceived symptoms vary during the day in Chinese COPD patients. They experience the greatest increase in respiratory symptoms early in the morning. This variation should be considered as a potential new target in the long-term COPD management.

Pulmonary hypertension associated with combined fibrosing mediastinitis and bronchial anthracofibrosis: A retrospective analysis in a single Chinese hospital

INTRODUCTION

Both fibrosing mediastinitis (FM) and bronchial anthracofibrosis (BAF) are unique diseases. The combined appearance of FM and BAF is extremely rare.

OBJECTIVES

The aim of this study was to investigate the clinical features of patients with coexisting FM and BAF.

METHOD

Between January 2003 and December 2015, a total of eight patients were diagnosed at the Peking Union Medical College Hospital as having combined FM and BAF. The clinical presentations, radiographic features and bronchoscopic findings of the eight patients were reviewed.

RESULTS

The patients were five women and three men with a median age of 64 years (range 56-86 years). Symptoms included dyspnea (eight patients), cough (seven patients), chest pain (two patients), hemoptysis (two patients) and so on. Chest CT of all eight patients showed mediastinal soft-tissue lesions, with multiple narrowed or obliterated lobar or segmental bronchi and arteries. Bronchoscopy showed that all of the patients had multiple stenoses of lobar or segmental bronchi with anthracotic pigmentation on the mucosa. Echocardiography showed that all of the patients had elevated pulmonary arterial systolic pressure (median 81 mm Hg, range 51-107 mm Hg). Each of the eight patients had a history of exposure to, or infection with, tuberculosis, although there was no evidence of active disease. All of the eight patients had long-term exposure to indoor coal or biomass fuel smoke.

CONCLUSIONS

FM can coexist with BAF, characterized by prominent pulmonary hypertension. The possible etiological factors are tuberculosis and coal or biomass fuel exposure.

Anomalous systemic arterial supply of pulmonary sequestration in adult patients

OBJECTIVES:

This study described the characteristics of the systemic arterial supply of pulmonary sequestration (PS) in an attempt to better distinguish PS from other acquired lesions.

METHODS:

We identified 25 patients hospitalized at the Peking Union Medical College Hospital during January 2013 to December 2015 with the assistance of medical catalogers. Twenty-three patients with a definite diagnosis of “pulmonary sequestration” clinically or pathologically were included in the study. The medical records, imaging information, and pathological data were reviewed retrospectively. The general characteristics of the patients and the features of the anomalous arteries were summarized.

RESULTS:

Aberrant arterial supply of PS was found in all 23 (100%) cases. Among them, twenty patients received surgery, including 14 (70%) with aberrant arterial supply found before surgery, and the other 6 (30%) found during surgery. Nineteen (82.6%) patients had a single systematic arterial supply, with a median diameter of 8 mm. More than one arterial supplies were found in four (17.4%) cases. In 21 (91.3%) cases, the anomalous systemic artery originated from the descending thoracic aorta just adjacent to the sequestrated lung which it supplied, without the presence of accompanying bronchi. In twenty (87.0%) patients who received the surgical intervention, samples of 12 (85.7%) were proved to have elastic vessel walls, out of the 14 samples in which the anomalous systemic arteries were available for analysis.

CONCLUSIONS:

There are no certain pathology diagnostic criteria for the diagnosis of PS. The detecting of the aberrant systematic artery and distinguishing it from the bronchial arteries corresponded to certain lung abnormalities are the keys to the accurate diagnosis of pulmonary sequestration in adult patients. We propose that the characteristic features of the anomalous arteries include: Originating from aorta and its main branches, adjacent to the sequestrated area, directly running into the sequestrated mass without accompanying bronchus branch, being large in diameter, and having elastic vessel wall.

Current situation of asthma-COPD overlap syndrome (ACOS) in Chinese patients older than 40 years with airflow limitation: rationale and design for a multicenter, cross-sectional trial (study protocol)

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are the frequently occurring chronic airway diseases, and the overlapping syndrome observed in the majority of patients has been recently defined as asthma-COPD overlap syndrome (ACOS) by the Global Initiative for Chronic Obstructive Lung (GOLD, 2014) and Global initiative for Asthma (GINA, 2015). The proportion, features, and clinical practice of ACOS still remain elusive in China. We are conducting this multicenter, cross-sectional, observational study (NCT02600221) to investigate the distributions of chronic obstructive diseases in patients >40 years of age with chronic airflow limitation in China along with determination of the main clinical practice and features of these diseases. The study will also explore the factors that may influence the exacerbations and severity of ACOS in Chinese patients (>40 years of age).

METHODS

A total of 2,000 patients (age, ≥40 years; either sex) who are clinically diagnosed as having asthma, COPD/chronic bronchitis/emphysema, or ACOS for at least 12 months with airflow limitation [post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV₁/FVC): <0.7] will be enrolled from approximately 20 sites in China between December 2015 and December 2016. The proportion of ACOS among patients older than 40 years based on GINA 2015 and GOLD 2014 definitions is the primary variable. Following were the secondary variables: the proportions of COPD and asthma among the patients, distributions of the severity of airflow limitation, distribution of groups according to GOLD 2011 group definition (A, B, C, D), and the distribution of medication by drug class in patients with ACOS, asthma, and COPD. Acute exacerbation history, hospitalization, and severity of ACOS as evaluated using COPD Assessment Test, Asthma Control Questionnaire-5, and Modified British Medical Research Council in patients with ACOS were also assessed.

IMPLICATIONS

This will be the first study to disseminate scientific knowledge on the current situation, main clinical practice, and features of ACOS, asthma, and COPD conditions in Chinese patients. The insights will be helpful in designing optimal management strategies for ACOS and redefining the healthcare development programs.

mTOR Overactivation and Compromised Autophagy in the Pathogenesis of Pulmonary Fibrosis

The mammalian target of rapamycin (mTOR) signaling pathway in pulmonary fibrosis was investigated in cell and animal models. mTOR overactivation in alveolar epithelial cells (AECs) was achieved in the conditional and inducible Tsc1 knock-down mice SPC-rtTA/TetO-Cre/Tsc1^fx/+ (STT). Doxycycline caused Tsc1 knock-down and consequently mTOR activation in AECs for the STT mice. Mice treated with bleomycin exhibited increased mortality and pulmonary fibrosis compared with control mice. In wild-type C57BL/6J mice, pretreatment with rapamycin attenuated the bleomycin-mediated mortality and fibrosis. Rapamycin-mediated mouse survival benefit was inhibited by chloroquine, an autophagy inhibitor. Autophagosomes were decreased in the lungs after bleomycin exposure. Rapamycin induced the production of autophagosomes and diminished p62. We concluded that mTOR overactivation in AECs and compromised autophagy in the lungs are involved in the pathogenesis of pulmonary fibrosis. The suppression of mTOR and enhancement of autophagy may be used for treatment of pulmonary fibrosis.

[Present status of medical treatment for patients with chronic obstructive pulmonary disease based upon different severity classifications]

OBJECTIVE

To survey the present status of medical treatment for Chinese outpatients with chronic obstructive pulmonary disease (COPD) based upon the guidelines for diagnosing and treating COPD (2007 Revised Edition and 2013 Revised Edition) and explore the impact of new guideline on treatment regimens.

METHODS

A retrospective study was conducted at 11 participating hospitals. Stable COPD patients were consecutively recruited from outpatient clinics in China between September 2007 and December 2008 and categorized into the Global Initiative for Chronic Obstructive Lung Disease (GOLD) I-IV classification and A-D groups according to the Chinese guidelines for diagnosing and treating COPD (2007 Revised Edition and 2013 Revised Edition). The authors compared the present status of medical treatment of two guidelines and analyze the impact of new guideline on treatment regimens.

RESULTS

Among a total of 749 patients, 79.2% (593/749) patients received medical treatment. The distribution of classification GOLD I-IV was 34 (4.5%), 211 (28.2%), 309 (41.3%) and 195 (26.0%). According to the guideline 2007, the patients on medical under-treatment based upon the guidelines in GOLD I-IV classification were 32.4% (11/34), 53.6% (113/211), 57.6% (178/309) and 55.4% (108/195); those on medical treatment: 23.5% (8/34), 3.8% (8/211), 28.8% (89/309) and 33.3% (65/195); those on medical over-treatment: 44.1% (15/34), 42.7% (90/211), 13.6% (42/309), 11.3% (22/195). The distribution of categories A-D was 93 (12.4%), 45 (6.0%), 196 (26.2%), and 415 (55.4%). According to guideline 2013, the patients on medical under-treatment were 34.4% (32/93), 62.2% (28/45), 67.9% (133/196) and 60.7% (252/415); those on medical treatment: 24.7% (23/93), 4.4% (2/45), 32.1% (63 /196) and 39.3% (163/415); those on medical over-treatment: 40.9% (38/93), 33.3% (15/45), 0 and 0. The concordance analysis comparing the judgments of treatment regimens by these two guideline yielded a weighted Kappa coefficient of 0.534 (P < 0.001), indicating that there was a moderate degree of judgments between two guidelines. Medical treatment regimens recommended by new guideline was different from old guideline in 143 COPD patients. Among them, 24 patients (16.8%) required a step-down therapy while 119 patients (83.2%) a step-up therapy.

CONCLUSIONS

There are more outpatients with COPD on medical treatment, but few of them have received standardized treatment. Compared with the old GOLD classification, more patients are recommended for a step-up therapy by new stratification.

[Smoking cessation among rural populations in Beijing]

OBJECTIVE

To survey the smoking cessation among rural populations in Beijing.

METHODS

One natural village in Beijing suburb was sampled and all the 1901 villagers were surveyed by face-to-face interview to collect information on smoking status and smoking cessation. The potential factors related with smoking prevalence and smoking cessation were analzyed.

RESULTS

The response rate was 91.2%. The ever-smoking rate was 35.8%. Among the 621 ever-smokers, 35.5% had tried or were trying to quit smoking. The vast majority (93.9%) of smoking cessation methods was self-service method. The overall rate of abstinence was 12.4%, and the success rate was higher in those groups of elder age, lower educational level, lower income level, having respiratory symptoms, and/or without nicotine dependence. There were 291 responders (46.9%) had the willingness to quit. Responders at older age, having respiratory symptoms, or with nicotine dependence had higher willingness to quit.

CONCLUSIONS

The tobacco control efforts in rural areas should be strengthened. In part of motivated intervention, the advice should be given from the family, friends, doctors to young, asymptomatic smokers.

Expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the People's Republic of China

Chronic obstructive pulmonary disease (COPD) is a common disease that severely threatens human health. Acute exacerbation of COPD (AECOPD) is a major cause of disease progression and death, and causes huge medical expenditures. This consensus statement represents a description of clinical features of AECOPD in the People's Republic of China and a set of recommendations. It is intended to provide clinical guidelines for community physicians, pulmonologists and other health care providers for the prevention, diagnosis, and treatment of AECOPD.

Tsc1 deficiency-mediated mTOR hyperactivation in vascular endothelial cells causes angiogenesis defects and embryonic lethality

This is a study on the role of tuberous sclerosis complex1 (TSC1) mutation and mTOR activation in endothelial cells during angiogenic and embryonic development. Past studies had shown that Tsc1/Tsc2 mutant genes lead to overactivation of mTOR in the regulating pathways in developing fetus. We used conditional Cre-loxp gene knockout approach to delete Tsc1 in mice's endothelial cells in our experimental models. Similarly, activation of mTOR signaling in endothelial cells of these embryos (Tie2-Cre/Tsc1(-/-)) was found. Majority of Tie2-Cre/Tsc1(-/-) embryos died at embryonic day 14.5 in utero. Cardiovascular defects, subcutaneous edema and hemorrhage were present among them. Whole-mount immunostaining in these embryos revealed a disorganized vascular network, defective sprouting of vessels in yolk sac and thickening of the labyrinth layer in the placenta. A thinner ventricular wall with disorganized trabeculae was present in the hearts of Tie2-Cre/Tsc1(-/-) embryos. Endothelial cells in Tsc1-deficient mice showed defective mitochondrial and endoplasmic reticular morphology, but no significant change was observed in cell junctions. The mutant embryos displayed significantly reduced cell proliferation, increased apoptosis and disturbed expression of angiogenic factors. A cohort of mice was treated prenatally with mTOR inhibitor rapamycin. The offspring of these mutant mice survived up to 22 days after birth. It was concluded that physiological TSC1-mTOR signaling in endothelial cells is crucial for vascular development and embryogenesis. We postulated that disruption of normal angiogenic pathways through hyperactive mTOR signaling maybe the mechanism that lead to deranged vascular pathogenesis in the tuberous sclerosis complex.

[Clinical characteristic analysis of 96 cases of hypersensitivity pneumonitis]

OBJECTIVE

To improve understanding of the clinical characteristics and diagnosis of hypersensitivity pneumonitis (HP).

METHODS

We retrospectively analyzed the clinical data, including clinical symptoms, laboratory tests, exposure, pulmonary function tests, chest CT imaging and cytological classification of bronchoalveolar lavage (BAL) of 96 patients with HP from Jan 2001 to Jun 2011 in Peking Union Medical College Hospital. We divided the patients into 2 groups: a pathologically-confirmed group and a clinically-suspected group.

RESULTS

There were 58 females and 41 males. The median age at the diagnosis was 53 years. The most common exposures were low-molecular-weight chemicals (42.7%) and animal proteins (37.5%). Common clinical symptoms included dyspnea on exertion (90.6%) and cough (76.0%). Pulmonary function test showed diffusion abnormality (73.5%) and restrictive ventilatory impairment (59.7%). Chest CT scan revealed patchy or diffuse bilateral ground-glass opacities (64.6%), centrilobular nodules (21.9%), and air trapping (15.6%). Reticulation (45.8%), traction bronchiectasis (21.9%) and honeycombing(9.4%) were present in chronic HP. BAL lymphocyte counts > 0.2 and CD4/CD8 < 0.9 were more commonly seen in patients with a disease course of less than 1 year. The pathologically-confirmed group and the clinically-suspected group shared many similar characteristics including age at diagnosis, gender, clinical manifestation, pulmonary function impairments and imaging findings, but significant differences existed in certain parameters. In the pathologically- confirmed group, the duration of disease was longer (24 months vs 6 months, Z = -2.492, P = 0.013) and clubbed fingers were more common (23.4% vs 8.2%, χ(2) = 4.227, P = 0.040). Diffusion abnormality was present in more patients of this group (90.7% vs 44.0%, χ(2) = 35.219, P < 0.01). By CT scan, reticulation, traction bronchiectasis and honeycombing (57.5% vs 26.5%, χ(2) = 9.434, P < 0.01) were more evident as compared to the clinically-suspected group. The value of transbronchial lung biopsy for diagnosing HP was limited, with a positive result of only 8.2%. Surgical lung biopsy was needed in uncertain cases.

CONCLUSION

The diagnosis of HP was difficult. In some cases a clinical diagnosis can be made by combination of history of exposure, CT manifestations and cell classification of BAL. For atypical cases a multi-disciplinary approach including pathologists, radiologists and pulmonologists is needed.

SPC-Cre-ERT2 transgenic mouse for temporal gene deletion in alveolar epithelial cells

Although several Cre-loxP-based gene knockout mouse models have been generated for the study of gene function in alveolar epithelia in the lung, their applications are still limited. In this study, we developed a SPC-Cre-ER^T2 mouse model, in which a tamoxifen-inducible Cre recombinase (Cre-ER^T2) is under the control of the human surfactant protein C (SPC) promoter. The specificity and efficiency of Cre-ER^T2 activity was first evaluated by crossing SPC-Cre-ER^T2 mouse with ROSA26R mouse, a β-galactosidase reporter strain. We found that Cre-ER^T2 was expressed in 30.7% type II alveolar epithelial cells of SPC-Cre-ER^T2/ROSA26R mouse lung tissues in the presence of tamoxifen. We then tested the tamoxifen-inducible recombinase activity of Cre-ER^T2 in a mouse strain bearing TSC1 conditional knockout alleles (TSC1^fx/fx). TSC1 deletion was detected in the lungs of tamoxifen treated SPC-Cre-ER^T2/TSC1^fx/fx mice. Therefore this SPC-Cre-ER^T2 mouse model may be a valuable tool to investigate functions of genes in lung development, physiology and disease.

[The in-vitro effects of arbidol hydrochloride against 2009 new influenza virus A (H1N1)]

OBJECTIVE

To detect the in-vitro effects of arbidol hydrochloride against 2009 new influenza virus A (H1N1).

METHODS

The activity of arbidol hydrochloride against 2009 new influenza virus A (H1N1) was determined in MDCK cell cultures. Hemagglutination assay, observation of cytopathic effects, RT-PCR and quantitative RT-PCR tests were performed for determination of virus titers. Inhibition concentration 50% and cytotoxic concentration 50% were calculated with Chou's Menu of Dose-Effect Program.

RESULTS

Arbidol hydrochloride showed low cytotoxicity (cytotoxic concentration 50%>100 μmol/L)and significant anti-2009 new influenza virus A (H1N1) activity in cell cultures. Inhibition concentration 50% were (5.5 ± 0.9), (3.4 ± 0.8), and (1.5 ± 0.2) μmol/L in hemagglutination assay, cytopathic effect test, and quantitative RT-PCR assay, respectively.

CONCLUSION

Arbidol has low cytotoxicity and high anti-virus activity and can effectively trigger the activities of interferon and immune response, and therefore can be a valuable anti-influenza virus drug.

Comparative study of patients in correct usage of and preference for the Swinghaler and Turbuhaler multidose inhalers

OBJECTIVE

Current dry powder inhalers (DPIs), introduced to overcome problems associated with pressurized metered dose inhalers (pMDIs), possess not only difficulties originating from their designs but also other barriers that prevent their correct usage. The authors of this study investigated the ease and correctness of use of Swinghaler, a new device in the form of multidose DPI, as well as the preference of the study participants for either a Swinghaler or a Turbuhaler.

METHODS

A total of 260 patients from Korea, China, Indonesia, the Philippines, Taiwan, and Thailand were prospectively recruited. Patients who had stable asthma, were more than 12 years old, had no experience with DPIs, and provided informed consents were included, whereas those with limited physical or intellectual ability and prior experience with any DPIs were excluded.

RESULTS

There were no group or time effects between the patients who were assigned to use a Swinghaler or a Turbuhaler first. Forty-one (16.1%) participants correctly performed the inhalation maneuver with a Swinghaler, whereas 28 (10.9%) did so with a Turbuhaler; the difference was not statistically significant. The overall assessment on the precise use of the devices indicated that there were no differences between Swinghaler and Turbuhaler usage. Comparing the preference scales between the two devices, the participants gave higher scores to the Swinghaler for all assessment items and were more satisfied with the Swinghaler compared with the Turbuhaler (78.5% vs. 55.0%, p < .001).

CONCLUSIONS

The participants showed no difference in their ability to correctly use a Swinghaler when compared with a Turbuhaler and preferred the Swinghaler. These results suggest that the Swinghaler may be an effective and valuable tool for the management of airway diseases.

[The diagnostic value of CT-guided percutaneous needle lung biopsy in diffuse parenchymal lung diseases]

OBJECTIVE

This study was to evaluate the efficacy and limitation of CT-guided percutaneous cutting needle lung biopsy in the diagnosis of diffuse parenchymal lung diseases (DPLD).

METHODS

A total of 481 patients admitted in Peking Union Medical College Hospital from January 2000 to December 2008 underwent CT-guided percutaneous cutting needle lung biopsy. The patients were evaluated by clinical history, physical examination and lung HRCT. Those with localized opacity or lesions in a single lung in the CT scan were excluded. Finally, 248 patients with DPLD in HRCT were enrolled for this study.

RESULTS

The study patients included 114 males and 134 females, and the mean (± SD) age at diagnosis was 50 ± 16 (range from 13 - 78) years. Confirmed diagnosis by percutaneous needle lung biopsy was obtained in 130 patients (52.4%), including pulmonary infection (35.4%, 46/130), pulmonary malignant diseases (25.4%, 33/130), bronchiolitis obliterans organizing pneumonia/organizing pneumonia (22.3%, 29/130), pulmonary vasculitis (6.2%, 8/130), granulomatous lesions (4.6%, 6/130), pulmonary sarcoidosis (2.3%, 3/130), acute interstitial pneumonia (1.5%, 2/130), pulmonary amyloidosis (1.5%, 2/130), and pulmonary alveolar proteinosis (0.8%, 1/130). Open lung biopsy/video-assisted thoracoscopic surgery was performed in 37 out of 118 cases for which the diagnosis was undetermined by percutaneous lung biopsy. Confirmed diagnosis was obtained in 36 patients, including non-specific interstitial pneumonia (NSIP, 33.3%, 12/36), usual interstitial pneumonia (UIP, 8.3%, 3/36), pulmonary infection (16.7%, 6/36), neoplasm (8.3%, 3/36), lymphoid interstitial pneumonia, pulmonary vasculitis (5.6% 2/36), hypersensitivity pneumonitis (5.6%, 2/36), and pulmonary sarcoidosis, allergic bronchopulmonary aspergillosis, pulmonary hyalinizing granuloma, pneumoconiosis, Castleman's disease, and lymphoproliferative disorder (1 case respectively).

CONCLUSION

CT-guided percutaneous cutting needle lung biopsy can provide confirmed diagnosis in half of patients with DPLD, and has a high diagnostic yield in patients with infectious or neoplastic diseases, but it is not a good method for diagnosis of interstitial lung diseases such as NSIP and UIP.

[Clinical analysis of 25 cases of allergic granulomatous vasculitis]

OBJECTIVE

To improve the understanding of allergic granulomatous vasculitis, also called Churg-Strauss syndrome (CSS).

METHODS

The clinical data, including clinical manifestations, laboratory findings, and pathology, of 25 patients with CSS were retrospectively investigated.

RESULTS

There were 15 males and 10 females, aging 18 to 72 years (mean 45 ± 16). The clinical manifestations of CSS featured involvement of multiple systems or organs including respiratory system, nervous system, skin, digestive system, heart, and kidney. Eighty percent (20/25) of CSS patients had asthma as their first symptom, whereas 96.0% (24/25) had asthma in the whole course of CSS. The involvement of nasosinusitis of CSS was multi-group and the maxillary sinuses were the most frequently involved, which accounted for 61.1% (11/18). The peripheral nerves were involved in 72.7% (16/22) of patients and the most common manifestation was cerebrovascular event. Skin disease occurred in 60.0% (15/25), whereas heart involvement in 48.0% (12/25), renal involvement in 48.0% (12/25) and digestive system involvement in 32.0% (8/25) of the patients. The positive rate of IgE was 90.0% (18/20), and that of ANCA was 32.0% (8/25), with P-ANCA as the predominant. The main presentation of chest CT scan was patchy infiltration, mostly bilateral, which amounted for 71.4% (15/21). The change in electromyography was mononeuritis multiplex, of which the peroneal nerves and popliteal nerves were the most frequently involved. Electrocardiography of the CSS patients was always normal whereas the echocardiograms showed abnormal finds in 70.0% (14/20) of the patients. The pathological manifestations were necrotizing vasculitis, eosinophilic tissue infiltration, and extravascular granulomas.

CONCLUSION

The clinical manifestations of CSS are diverse and complex, with a lack of pathognomonic symptoms. Clinical manifestations, auxiliary examinations and pathology are often required to make a diagnosis. Early diagnosis and treatment will be helpful for a better prognosis.

Churg-Strauss syndrome presented as paraneoplastic syndrome with thymic neuroendocrine carcinoma: a case report

Churg-Strauss syndrome (CSS) is rarely presented as paraneoplastic syndrome. We reported here a 47-year-old man with refractory asthma for 3 years, and his CT scan showed an anterior mediastinal mass, pulmonary reticular opacities and bilateral maxillary sinusitis. He also presented with elevated peripheral blood eosinophils (EOS). Thoracoscopic resection of the mediastinal mass and a lung biopsy were performed, and thymic neuroendocrine carcinoma (TNC) and pulmonary eosinophilic vasculitis were pathologically diagnosed. The laboratory and clinical findings fulfilled the criteria of the diagnosis of CSS (Masi et al. in Arthritis Rheum 33(8):1094-1100, 1990). Asthma was improved, and elevated EOS was recovered to normal range after surgery and four courses of chemotherapy. This was the first report of CSS manifested as a paraneoplastic syndrome of TNC.

[Evaluation of clinical significance of chronic obstructive pulmonary disease assessment test]

OBJECTIVE

To determine the reliability and validity of the COPD assessment test (CAT) Chinese version in patients with chronic obstructive pulmonary disease (COPD), and to study its value in evaluating quality of life in Chinese patients.

METHODS

One hundred and thirty-five patients with COPD in stable condition from Peking Union Medical College Hospital were assessed by interview with CAT Chinese version, and underwent pulmonary function test on the same day. The validity was documented by performing correlation analysis, and Pearson's correlation coefficients were calculated. The stages of COPD determined by CAT score and lung function were compared to observe the value of CAT in determining disease severity.

RESULTS

Cronbach's alpha of CAT Chinese version was 0.805. CAT score increased with the severity of the disease, and was negatively correlated to FEV(1)% of predicted (r = -0.567, P < 0.01). CAT score varied significantly in patients (10 ± 5, 16 ± 6, 21 ± 7 and 23 ± 6), with different severity of COPD (χ(2) = 48.437, P < 0.01). There was a high degree of consistency between the stages of COPD determined by CAT score and lung function.

CONCLUSIONS

The Chinese version of the CAT had good internal consistency reliability and validity, and can be used to assess the quality of life for Chinese COPD patients. It provided a simple, valid and standardized measurement of COPD health status.

[Combined pulmonary fibrosis and emphysema syndrome]

OBJECTIVE

To retrospectively analyze clinical presentations, pulmonary function parameters and radiological appearance in patients with combined pulmonary fibrosis and emphysema (CPFE) syndrome.

METHODS

We reviewed the clinical features, imaging, and lung function indices from 8 patients diagnosed with CPFE according to the findings by high resolution computerized tomography (HRCT) since 2006 to 2009 at Peking Union Medical College Hospital.

RESULTS

All patients were male, aged 65 (59 - 75) years, and 7 of them were smokers. Dyspnea on exertion was presented in 7 patients. Basal crackles were heard in 6 patients and finger clubbing was observed in 4 patients. Pulmonary function demonstrated that forced expiratory volume in one second/forced vital capacity (FEV₁/FVC) was slightly lower with a median of 76% (range 60% to 86%), forced vital capacity (FVC) was 73% (51% - 92%), and total lung capacity (TLC) was 80% (59% - 114%). However, carbon monoxide diffusion capacity (D(L)CO) was significantly impaired (44%, 16% - 65%). HRCT findings included emphysema predominantly at the upper zone, while reticular opacities, honeycombing and traction bronchiectasis were in the lower lobes. Pulmonary hypertension was seen in 6 patients.

CONCLUSIONS

The co-existence of lower lung fibrosis and upper lung emphysema was found in some smokers. Patients with CPFE syndrome can present with a normal or nearly normal lung volume but a remarkable impairment in gas exchange. A high prevalence of pulmonary hypertension is seen in CPFE syndrome. Further studies to elucidate the pathogenesis and to explore the treatment and prognosis are warranted.

[A new health-related quality of life questionnaires-chronic obstructive pulmonary disease assessment test]

Chronic obstructive pulmonary disease (COPD) is a major public health problem with high prevalence and mortality. A simple and effective tool for COPD assessment is urgently needed in clinical practice. The COPD Assessment Test is a newly developed questionnaire for assessing and monitoring COPD. This simple, highly sensitive, and highly reliable in assessing the patients quality of life and providing information concerning the severity of disease, and therefore can be widely applied.

[Role of glucocorticoid receptor and nuclear factor-kappaB in patients with stable chronic obstructive pulmonary disease]

OBJECTIVE

To explore the expressions of glucocorticoid receptor (GCR) and nuclear factor-kappaB (NF-kappaB) in patients with stable chronic obstructive pulmonary disease (COPD).

METHODS

Bronchial biopsies and blood specimens were obtained from 8 smokers with stable COPD (COPD group) and 8 nonsmokers with normal lung function (control group). The expressions of NF-kappaB and GCR in nucleus protein of bronchial biopsies and peripheral blood lymphocyte from these two groups were examined by Western blot.

RESULTS

The expressions of GCR in nuclear protein of peripheral blood lymphocyte and the bronchial biopsies, especially in bronchi, were significantly lower in COPD group than in control group (P<0.05, P <0.01). Also, the expressions of NF-kappaB in nuclear proteins of the bronchial biopsies and peripheral blood lymphocyte were significantly higher in COPD group than in control group (P<0.05). The expressions of NF-kappaB and GCR were significantly higher in bronchial biopsies than in peripheral blood lymphocyte in both groups (P<0.05, P<0.01).

CONCLUSION

Chronic inflammation, especially airway inflammation, still exists in patients with stable COPD, as suggested by the different expressions of GCR and NF-kappaB between COPD patients and normal controls.

[Exploration of vibration response imaging in evaluating airway resistance of asthmatics]

OBJECTIVE

To explore the value of vibration response imaging (VRI) system in evaluating airway resistance of asthmatics.

METHODS

The asthmatic group had 64 patients with a FEV1 of (56 +/- 18)% predicted before bronchodilator, and a FEV1 of (69 +/- 18)% predicted after bronchodilator. The control group had 20 patients with COPD with a FEV1 of (64 +/- 17)% predicted before bronchodilator, and a FEV1 of (66 +/- 19)% predicted after bronchodilator. All patients underwent VRI examination in close proximity of each spirometric recording before and after bronchodilator. VRI outcomes were evaluated to determine whether the VRI technology could detect changes in airway resistance in asthmatics. The statistical analysis in comparison between VRI outcomes before and after bronchodilator was performed using a matched pairs signed rank test. Linear regression was used to describe the relation between the improvements of VRI parameters and the increase in FEV1. ROC curve was used to evaluate the accuracy of this examination.

RESULTS

After bronchodilator, VRI outcomes including flow graph characteristics, dynamic appearance, shape of the maximal energy frame and rale counts had significant improvements after bronchodilator (M = 7.5, 14.5, 12.5, 7.5, respectively, all P<0.05). Outcomes in the control group showed no significant improvements (M = 0.5, 2.0, 0.5, 1.0, respectively, all P>0.05). y = 0.12784 + 0.06767x1 + 0.04723x2 + 0.04919x3 + 0.00391x4 was the model of the linear regression between improvements of VRI parameters (x1, x2, x3, x4) and the observed changes in FEV1 (y), F = 10.16, P<0.01. According to the bronchodilation test, the sensitivity was 81.3%, and the specificity was 55.0%. The area under the ROC curve was 0.704.

CONCLUSION

VRI outcomes including graph characteristics, dynamic appearance, shape of the MEF and rale counts may be a promising method to evaluate changes of airway resistance in asthmatics.

Causative agent distribution and antibiotic therapy assessment among adult patients with community acquired pneumonia in Chinese urban population

BACKGROUND

Knowledge of predominant microbial patterns in community-acquired pneumonia (CAP) constitutes the basis for initial decisions about empirical antimicrobial treatment, so a prospective study was performed during 2003-2004 among CAP of adult Chinese urban populations.

METHODS

Qualified patients were enrolled and screened for bacterial, atypical, and viral pathogens by sputum and/or blood culturing, and by antibody seroconversion test. Antibiotic treatment and patient outcome were also assessed.

RESULTS

Non-viral pathogens were found in 324/610 (53.1%) patients among whom M. pneumoniae was the most prevalent (126/610, 20.7%). Atypical pathogens were identified in 62/195 (31.8%) patients carrying bacterial pathogens. Respiratory viruses were identified in 35 (19%) of 184 randomly selected patients with adenovirus being the most common (16/184, 8.7%). The nonsusceptibility of S. pneumoniae to penicillin and azithromycin was 22.2% (Resistance (R): 3.2%, Intermediate (I): 19.0%) and 79.4% (R: 79.4%, I: 0%), respectively. Of patients (312) from whom causative pathogens were identified and antibiotic treatments were recorded, clinical cure rate with beta-lactam antibiotics alone and with combination of a beta-lactam plus a macrolide or with fluoroquinolones was 63.7% (79/124) and 67%(126/188), respectively. For patients having mixed M. pneumoniae and/or C. pneumoniae infections, a better cure rate was observed with regimens that are active against atypical pathogens (e.g. a beta-lactam plus a macrolide, or a fluoroquinolone) than with beta-lactam alone (75.8% vs. 42.9%, p = 0.045).

CONCLUSION

In Chinese adult CAP patients, M. pneumoniae was the most prevalent with mixed infections containing atypical pathogens being frequently observed. With S. pneumoniae, the prevalence of macrolide resistance was high and penicillin resistance low compared with data reported in other regions.

Economic analysis in admitted patients with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

The socio-economic burden of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) in Beijing is not fully understood. The study investigated the hospitalization cost in patients with AECOPD and the associated factors.

METHODS

A multi-center, retrospective study was conducted in the four hospitals in Beijing including two level III hospitals and two level II hospitals. Patients with AECOPD admitted to the hospitals between January and December in 2006 were enrolled. The hospitalization cost and its relationship with disease severity and treatment were analyzed.

RESULTS

Totally 439 patients were enrolled with 294 men (67.0%) and a mean age 73.4 years. The mean hospital stay was 20.7 days. A total of 204 patients (46.5%) had respiratory failure, 153 (34.9%) with cor pulmonale, 123 (28.0%) with coronary artery disease, 231 (52.6%) with hypertension, 70 (15.9%) with cerebrovascular disease and 32 (7.3%) with renal failure. The percentage of drug cost to total cost was the highest (71.2%), followed by laboratory cost (16.7%), therapy cost (9.7%), oxygen cost (7.3%), radiology cost (4.5%), examination cost (4.5%), bed cost (4.1%). Correlation analysis showed that cost was positively correlated with age, hospitalization days, co-morbidities such as respiratory failure and cor pulmonale, hypertension. Three hundred and twenty-one patients were further analyzed. The hospitalization cost increased in patients with non-invasive ventilation (P < 0.01), invasive mechanical ventilation (P < 0.01), ICU stay (P < 0.01), antibiotics (P < 0.05), systemic steroids (P < 0.01), and poor prognosis (P < 0.05). Correlation analysis showed that the hospitalization cost was negatively correlated with percentage forced expiratory volume in 1 second (FEV(1)%) (r = -0.149, P < 0.05), pH (r = -0.258, P < 0.01), and PaO(2) (r = -0.131, P < 0.05), positively correlated with PaCO2 (r = 0.319, P < 0.01), non-invasive positive pressure ventilation (r = 0.375, P < 0.01) and duration (r = 0.463, P < 0.01), invasive mechanical ventilation (r = 0.416, P < 0.01) and duration (r = 0.511, P < 0.01), ICU stay (r = 0.390, P < 0.01) and duration (r = 0.650, P < 0.01), antibiotics (r = 0.140, P < 0.05) and systemic steroids (r = 0.202, P < 0.01).

CONCLUSIONS

AECOPD had a great impact on healthcare resources utilization. Disease severity, use of non-invasive or invasive ventilation, ICU stay and usage of antibiotics and systemic steroids were the major determinants of hospitalization cost. Long-term regular treatment aimed at reducing the frequency of acute exacerbation will lower the social and economic burden of chronic obstructive pulmonary disease (COPD).

[The diagnostic value of transbronchial lung biopsy in diffuse parenchymal lung diseases]

OBJECTIVE

This study was to evaluate the efficacy and limitations of transbronchial lung biopsy (TBLB) in the diagnosis of diffuse parenchymal lung diseases (DPLD).

METHODS

TBLB was performed in 416 patients with diffuse lung diseases from January 2001 to October 2006 in Peking Union Medical College Hospital. The results of clinical data and pathologic diagnosis were retrospectively analyzed.

RESULTS

Confirmed diagnosis by TBLB was obtained in 124 patients, the total positive diagnostic rate was 29.8%. The diseases included pulmonary sarcoidosis (52/124, 41.9%), bronchiolitis obliterans organizing pneumonia/organizing pneumonia (BOOP/OP) (28/124, 22.6%), pulmonary alveolar proteinosis (19/124, 15.3%), lung cancer (12/124, 9.7%), pulmonary vasculitis (5/124, 4.0%), pulmonary tuberculosis (3/124, 2.4%), and pneumocystis carinii pneumonia, lung fungal infection, lymphangiomyomatosis, and pulmonary amyloidosis (each 1/124, 0.8%). Open lung or thoracoscopic biopsy was performed in 104 cases in whom the diagnosis was undetermined by TBLB. Confirmed diagnosis was obtained in 109 patients, including nonspecific interstitial pneumonia (37/104, 37.7%), usual interstitial pneumonia (18/104, 18.4%), pulmonary sarcoidosis (11/104, 11.2%), BOOP/OP (6/104, 6.1%), and lung cancer (5/104, 5.1%).

CONCLUSIONS

Pathologic diagnosis can be obtained by TBLB in about 30% of the cases with DPLD, and therefore it should be considered to be a routine diagnostic procedure before open lung or thoracoscopic biopsy.

[Radio-pathological manifestations of pulmonary sarcoidosis]

OBJECTIVE

To investigate the radio-pathological features of pulmonary sarcoidosis.

METHOD

Forty six consecutive patients from January 2000 to August 2005 in Peking Union Medical College Hospital with pathologic features of epithelioid cell granuloma were enrolled in the study.

RESULTS

All the cases were confirmed by pathological findings consistent with sarciodosis. Bronchoalveolar lavage (BAL) fluid analysis showed that, the differential count of lymphocytes was 0.47 +/- 0.18, and the CD(4)/CD(8) ratio was 6.63 +/- 4.51. Serum angiotensin converting enzyme level was (47 +/- 16) U/L. Chest computed tomography scan showed bilateral hilar adenopathy (33%, 12/46), well circumscribed pulmonary nodules (35%, 16/46) distributed randomly or along the bronchovascular bundle, patchy areas of alveolar consolidation (28%, 13/46), and bilateral ground glass infiltrations (11%, 5/46). Open lung biopsy, video-assistant thoracoscopic biopsy or mediastinoscopic biopsy were performed in 13 patients, and percutaneous lung biopsy or transbronchial lung biopsy in 33 patients. The characteristic pathologic finding was noncaseating epithelioid cell granulomas, which were embedded in the substance of hyalinization. The granulomas were distributed around blood vessels, lymphatics, or in the bronchial submucosa. Granulomatous vasculitis was noted in some cases.

CONCLUSION

The diagnosis of sarcoidosis can be proposed by clinico-radiologic and BAL fluid findings. However, histologic evidence of noncaseating epithelioid cell granulomas and the therapeutic efficacy of glucocorticoids are essential to the final diagnosis.

[Circulating leptin and ghrelin in patients with chronic obstructive pulmonary disease]

OBJECTIVE

To investigate the potential roles of leptin and ghrelin in malnutrition in patients with chronic obstructive pulmonary disease (COPD).

METHODS

Plasma leptin, total ghrelin and active ghrelin, TNF-alpha and IL-6 levels were determined in 53 patients with COPD and 26 control subjects. Body compositions were assessed by bioelectrical impedance analysis.

RESULTS

Plasma leptin levels were significantly lower in underweight patients than those in normal weight patients and in healthy controls [2.6 (2.0 - 4.4) vs. 6.1 (5.1 - 7.8) vs. 4.8 (3.3 - 6.1) ng/L]. The leptin level was associated positively with fat mass (r = 0.662, P = 0.000) and TNF-alpha (r = 0.431, P = 0.001) in the patients. By a stepwise multiple regression analysis, fat mass, TNF-alpha, presence of COPD, smoking and sex were found to affect leptin level (R(2) = 0.635). Both plasma total ghrelin levels and active ghrelin levels were significantly higher in underweight patients than those in normal weight patients and in healthy controls [total ghrelin: 1090 (860 - 2838) vs. 765 (651 - 941) vs. 844 (676 - 1045) ng/L; active ghrelin: 63 (50 - 97) vs. 47 (41 - 56) vs. 54 (41 - 60) ng/L]. Plasma total ghrelin and active ghrelin were associated negatively with BMI respectively (total ghrelin: r = -0.517, P = 0.000; active ghrelin: r = -0.417, P = 0.002).

CONCLUSIONS

Plasma leptin levels were decreased, while plasma total ghrelin and active ghrelin levels were elevated in underweight patients with COPD, and the levels were associated with nutritional parameters. The plasma levels of leptin and ghrelin may be a compensatory mechanism in malnutritional status of COPD. After adjustment for nutritional parameters, leptin levels were elevated in COPD patients and correlated to TNF-alpha. The result suggests that leptin may play a role in systemic inflammation of COPD.

[A clinical analysis of 23 cases of allergic bronchopulmonary aspergillosis]

OBJECTIVE

To describe the clinical characteristics of allergic bronchopulmonary aspergillosis (ABPA).

METHODS

The clinical presentations, serologic results, lung function data, chest radiology and the results of treatment of 23 patients with ABPA in Peking Union Medical College Hospital were retrospectively analyzed.

RESULTS

There were 11 males and 12 females, with a mean age of (34.0 +/- 13.2) yrs. Tuberculosis, pneumonia, lung cancer and Wegener's granulomatosis were initially diagnosed in 12, 3, 2 and 1 cases respectively. Cough was present in all patients and sputum production in 22 cases, wheeze in 18, sputum plugs in 16, fever in 15 (high degree of fever in 4), hemoptysis in 12, chest pain/backache in 8 and weight loss in 7 cases. Forced expired volume in one second (FEV(1)) was (54.7 +/- 24.1)% predicted, and FEV(1)/forced vital capacity (FVC) was (62.5 +/- 11.9)%. The FEV(1) reversibility was found in 56% (9/16) of the patients. Chest CT were performed in 22 cases. Patchy infiltrations were present in 21, central bronchiectasis in 17, nodular opacities in 9, mucoid impaction (glover-finger/band linear opacities) in 6, consolidation in 5, and mediastinal adenopathy in 11 cases, while 17 cases presented fleeting infiltrations. Twenty-two patients were treated with prednisone plus itraconazole and 17 patients were followed. The median follow up time was 26.2 months (13 days -19 years). Pulmonary infiltrations relapsed in 9 patients and not appeared for more than 6 years in only one patient.

CONCLUSIONS

ABPA was mostly misdiagnosed as tuberculosis. Wheeze is present in almost all patients with ABPA, which can be useful in differentiation from tuberculosis. Obstructive ventilatory defect, peripheral blood eosinophilia, fleeting pulmonary infiltration and central bronchiectasis were features of ABPA. Measurement of total IgE, A.fumigatus-specific IgE levels and immediate cutaneous reaction to A.fumigatus are helpful for confirmation of the diagnosis.

[Bilateral sequential whole lung lavage in the same treatment session for pulmonary alveolar proteinosis]

OBJECTIVE

To study the safety and effectiveness of bilateral sequential whole lung lavage in the same treatment session for pulmonary alveolar proteinosis.

METHODS

Twelve times bilateral sequential whole lung lavage in the same treatment session were performed under general anaesthesia using a double lumen endotracheal tube for 10 cases of pulmonary alveolar proteinosis. The volume of lavage, return volume and the return rate were calculated. The efficacy was evaluated according to the improvement of symptoms, pulmonary function and arterial blood gas analysis data.

RESULTS

Twelve times bilateral sequential whole lung lavage in the same treatment session were performed successfully for the 10 cases of pulmonary alveolar proteinosis. The total volume of lavage was (26,417+/-7,064) ml, the return volume was (25,962+/-7,023) ml, the time of lavage was (192+/-26) minutes. The symptoms and chest radiograph were improved immediately after the procedure for all patients. The alveolar to arterial oxygen tension difference was decreased significantly. Arterial oxygen tensions were increased but no significant difference was reached. There was no significant immediate improvement for the pulmonary function. No complications were noted but pulmonary edema in one patient.

CONCLUSION

Bilateral sequential whole lung lavage in the same treatment session is a safe and effective procedure for treatment of pulmonary alveolar proteinosis.

[Comparison of tiotropium inhalation capsules and ipratropium metered dose inhaler in a randomized, double-blind, double-dummy, efficacy and safety study in patients with chronic obstructive pulmonary disease]

OBJECTIVE

To compare the efficacy and safety between tiotropium capsule and ipratropium MDI in a 4 week treatment in patients with chronic obstructive pulmonary disease (COPD).

METHODS

A multi-center, randomized, double blind, double dummy and parallel comparison clinical trial was conducted in 221 stable moderate to severe patients with COPD. They were randomized into tiotropium 18 microg once per day arm or ipratropium 2 puffs qid. arm for four weeks. The spirometry was conducted at 5 minutes pre-medication; and 30, 60, 120, and 180 minutes post-medication before; 2 weeks and 4 weeks after treatment.

RESULTS

The forced expiratory volume in one second (FEV(1)) trough response, the primary endpoint, was significantly higher in the tiotropium arm than that of the ipratropium with (0.063 +/- 0.024) L (95% CI 0.016 - 0.111 L, t = 2.63, P = 0.009) after 4 weeks of treatment. Meanwhile the clinical evidences indicated the continuous improvement of bronchodilation in the tiotropium arm. Forced vital capacity (FVC) trough response was also significantly higher in the tiotropium arm 4 weeks after treatment with (0.133 +/- 0.047) L (t = 2.83, P = 0.005). By comparison with baseline, no significant differences were found between these two arms in the average change of FEV(1) as well as FVC 0 - 3 hours after inhalation (all P > 0.05). There was no significant difference in rescue medication consumptions (t = 0.60, P = 0.548). Adverse events occurred in 12 (10.9%) patients in the tiotropium arm and 18 (16.2%) in the ipratropium arm, without statistical difference (chi(2) = 1.326, P = 0.249). The major adverse event in the tiotropium group was dry mouth (5, 4.5%). No cardiac disorder or abnormal electrocardiogram was reported.

CONCLUSION

The results indicated that tiotropium 18 microg once per day is more potent than ipratropium qid. in bronchodilation to COPD patients with the similar tolerance of ipratropium.

[The diagnosis and differential diagnosis of lymphocytic interstitial pneumonia]

OBJECTIVE

To explore the etiology, diagnosis and differential diagnosis of lymphocytic interstitial pneumonia (LIP).

METHOD

The clinical, radiographical and histological characteristics of three cases of LIP diagnosed in Peking Union Medical College Hospital were analyzed, and the literature was reviewed.

RESULTS

The precise cause of LIP was unknown. However, LIP was strongly associated with autoimmune diseases and immunodeficiency. Clinically, patients presented with chronic cough and progressive dyspnea. Pulmonary function tests showed restrictive ventilatory pattern. HRCT of chest revealed ground-glass attenuation, centrilobular nodules, subpleural small nodules, thickening of bronchovascular bundles, interlobular septal thickening and cystic dilated air spaces. Bronchoalveolar lavage showed an increase in lymphocytes. The key finding in histopathology was dense interstitial lymphoid infiltrate with a polyclonal pattern.

CONCLUSION

Idiopathic LIP is rare. Cases of LIP should be thoroughly investigated for any known causes and related disorders.

[A multicentre study on the pathogenic agents in 665 adult patients with community-acquired pneumonia in cities of China]

OBJECTIVE

To investigate the pathogenic causes of community-acquired pneumonia (CAP) in adult patients in China, the relation of previous antibiotic use and the Pneumonia Patient Outcome Research Team (PORT) classification to microbial etiology, and the prevalence of drug resistance of common CAP bacteria.

METHODS

A prospective study was performed on 665 consecutive adult patients with CAP at 12 centers in 7 Chinese cities during one year. The etiology of pneumonia was considered if one of the following criteria was met: (1) valid sputum sample yielding one or more predominant strains; (2) blood cultures yielding a bacterial pathogen; (3) seroconversion, a > or = 4-fold increase or decrease titers of antibodies to Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila. Minimum inhibitory concentration (MIC) of respiratory tract isolates was determined using the agar dilution method.

RESULTS

Pathogens were identified in 324/610 patients (53.1%) with valid serum samples and sputum cultures as follows: Mycoplasma pneumoniae (126, 20.7%), Streptococcus pneumoniae (63, 10.3%), Haemophilus influenzae (56, 9.2%), Chlamydia pneumoniae (40, 6.6%), Klebsiella pneumoniae (37, 6.1%), Legionella pneumophila (31, 5.1%), Staphylococcus aureus (23, 3.8%), Escherichia coli (10, 1.6%), Moraxella catarrhalis (8, 1.3%), Pseudomonas aeruginosa (6, 1.0%). Of 195 patients with a bacterial pathogen, an atypical pathogen was identified in 62 (10.2%) cases. The non-susceptibility rate of Streptococcus pneumoniae to penicillin, azithromycin, and moxifloxacin was 20.3%, 75.4% and 4.3% respectively.

CONCLUSIONS

Atypical pathogens have important role in CAP, with Mycoplasma pneumoniae being the most common pathogen, and mixed infection of atypical pathogens with bacteria was found in 10.2% of the cases. Streptococcus pneumoniae and Haemophilus influenzae remain the most important bacteria for CAP. More than 75.0% of Streptococcus pneumoniae was resistant to macrolides and 20.3% was resistant to penicillin.

Respiratory manifestations in amyloidosis

BACKGROUND

Amyloidosis is a collection of diseases in which different proteins are deposited. Amyloid deposits occur in systemic and organ-limited forms. In both systemic and localized forms of the disease, lung can be involved. The aim of this study was to explore the different respiratory manifestations of amyloidosis.

METHODS

Chest radiology, clinical presentations, bronchoscopic/laryngoscopic findings and lung function data of 59 patients with amyloidosis involving respiratory tract collected during January 1986 to March 2005, were analysed.

RESULTS

Of the 16 cases with localized respiratory tract amyloidosis, 8 had the lesions in the trachea and the bronchi, 2 in the larynx and the trachea, 5 in the larynx and/or the pharynx, and 1 in the lung parenchyma. Of 43 systemic amyloidosis with respiratory tract involvement, 3 had the lesions in bronchi, 13 in lung parenchyma, 33 in pleura, 8 in mediastina, 1 in nose and 1 in pharynx. Chest X-rays were normal in most cases of tracheobronchial amyloidosis. CT, unlike chest X-rays, showed irregular luminal narrowing, airway wall thickening with calcifications and soft tissue shadows in airway lumen. Localized lung parenchymal amyloidosis presented as multiple nodules. Multiple nodular opacities, patch shadows and reticular opacities were the main radiological findings in systemic amyloidosis with lung parenchymal involvement. In pleural amyloidosis, pleural effusions and pleural thickening were detected. Mediastinal and/or hilar adenopathy were also a form of lung involvement in systemic amyloidosis. The major bronchoscopic findings of tracheobronchial amyloidosis were narrowing of airway lumen, while nodular, 'tumour like' or 'bubble like' masses, with missing or vague cartilaginous rings, were detected in about half of the patients.

CONCLUSIONS

Localized respiratory tract amyloidosis mostly affects the trachea and the bronchi. Chest X-rays are not sensitive to detect these lesions. Systemic amyloidosis often involves lung parenchyma and the pleura. Open lung biopsy or pleural biopsy should be performed for the diagnosis.