[Pneumonia in the elderly population over 70 years with limited functional condition: case-control study of institutionalized patients]

OBJECTIVE

Community acquired pneumonia (CAP) of the elderly is an increasingly important growing health problem due to its prevalence and mortality. Among the factors that are usually related with poor evolution are advanced age, poor functional status and coming from a socio-health care institution such as residential homes for the elderly. In this study, we have chosen a population over 70 years of age with limited functional capacity (Barthel Index < 50) in order to know if coming from a residential home for the elderly is an isolated factor that is associated to worse prognosis of CAP.

PATIENTS AND METHODS

We selected 87 patients over 70 years from a prospective and multicenter study of the hospitalized CAPs during one year. We analyzed the evolution and course of the CAP based on place or origin and then conducted a case-control study of the elderly over 70 years with the Barthel under 50, including 21 elderly from residences and 21 from the own home.

RESULTS

In elderly patients over 70 years with CAP, those coming from the residence have a confusional picture more often and come to emergency with lower values of systolic and diastolic blood pressure, lower arterial oxygen saturation, greater involvement on the x-ray, Fine Index is worse and die more often. When we limit the population to those over 70 years with Barthel under 50, we do not find differences in institutionalized patients versus the others.

CONCLUSION

In the elderly over 70 years with CAP, patients from assisted living residences have greater mortality. However, when functional capacity is bad (Barthel < 50), place or origin (community or elderly residence) loses importance and becomes a variable that has no more influence than others in the clinical evolution and course of the CAP.

Empiric treatment in hospitalized community-acquired pneumonia. Impact on mortality, length of stay and re-admission

OBJECTIVE

To evaluate adherence to guidelines when choosing an empirical treatment and its impact upon the prognosis of community-acquired pneumonia (CAP).

METHODS

A prospective multicentre study was conducted in 425 CAP patients hospitalized on ward. Initial empirical treatment was classified as adhering or not to Spanish guidelines. Adherent treatment was defined as an initial antimicrobial regimen consisting of beta-lactams plus macrolides, beta-lactam monotherapy and quinolones. Non-adherent treatments included macrolide monotherapy and other regimens. Initial severity was graded according to pneumonia severity index (PSI). The end point variables were mortality, length of stay (LOS) and re-admission at 30 days.

RESULTS

Overall 30-day mortality was 8.2%, the mean LOS was 8+/-5 days, and the global re-admission rate was 7.6%. Adherence to guidelines was 76.5%, and in most cases the empirical treatment consisted of beta-lactam and macrolide in combination (57.4%). Logistic regression analysis showed that other regimens were associated with higher mortality OR=3 (1.2-7.3), after adjusting for PSI and admitting hospital. Beta-lactam monotherapy was an independent risk factor for re-admission. LOS was independently associated with admitting hospital and not with antibiotics.

CONCLUSIONS

A high adherence to CAP treatment guidelines was found, though with considerable variability in the empirical antibiotic treatment among hospitals. Non-adherent other regimens were associated with greater mortality. Beta-lactam monotherapy was associated with an increased re-admission rate.

Estado actual de la neumonía intersticial aguda

Acute interstitial pneumonia (AIP) is a rare lung disease recently included into the classification of idiopathic interstitial pneumonias as a distinctive disease, even though the clinical description was made more than 80 years ago, and the characteristic pathological findings were reported two decades ago. The diagnostic features have been established based on case series with limited number of patients enrolled with to different inclusion criteria,. This is an important bias when defining the clinical outcome and prognosis of the disease. The hospitalized mortality rate has been estimated higher than 50%, relapse and progressive fibrosis being most reported outcome. Recent studies describe a better prognosis in relation to HR-CT findings and to an early intervention, according to our own experience.

[Personalized minimal treatment of smoking addiction. Results of a multicenter study. Study Group of the Treatment of Tobacco Addiction. Spanish Society of Pneumology and Thoracic Surgery]

The aim of this study was to evaluate the efficacy of a minimal-intervention smoking cessation program tailored to meet the needs of patients in a pneumology practice. Six-months open study was designed, multicenter, involving four pneumology practices in different Spanish cities. Smokers with or without respiratory disease who consulted a pneumologist were included. Patients were grouped according to their phase in the self-change process toward smoking cessation: precontemplation or contemplation. The level of physical dependence on nicotine was assessed using a revised version of the Fagerström test. CO in exhaled air was also measured. Precontemplators were advised to quit smoking and given a booklet about smoking addiction. Contemplators were additionally given a practical guide to quitting. Advice on quitting was different for the two different phases. Smokers were reexamined twice: 8 weeks and 6 months later. We evaluated the success of the physician's intervention of encouragement to abstain (a level of CO in exhaled air [10 ppm was required]) and we recorded change of phase in the cessation process. Three hundred thirteen subjects were enrolled: 222 men (70.9%) and 91 women (29.1%). After 6 months, 40 (43%) of the precontemplators had changed phase and 21 of them (23%) had stopped smoking; 61 (28%) of the 221 contemplators had changed phase and 20 of them (9%) had quit smoking. Personalized minimal intervention in subjects with or without disease gives good results in terms of success in quitting as well as progress toward cessation.

[Scimitar sign in a partially anomalous pulmonary venous drainage]

The scimitar sign is an uncommon finding, that shows an anomalous pulmonary vein coursing to the right cardiac border, that drains to the inferior vena cava. Usually it is associated to other cardiovascular or pulmonary anomalies, within the hypogenetic lung syndrome. We present a rare case of a few symptomatic man 46 years-old, with partial anomalous pulmonary venous drainage, diagnosed upon finding the scimitar sign in a roentgenogram of the chest, in absence of the hypogenetic lung syndrome. We comment the role of CT in the diagnosis.

[Lung diseases due to opportunistic environmental Mycobacteria in patients uninfected with human immunodeficiency virus. Risk factors, clinical and diagnostic aspects and course]

Diseases caused by opportunistic ambient mycobacteria (OAM) are common in HIV-positive patients, although they also occur in immunocompetent individuals. The objective of the present study was to describe the risk factors, clinical signs, course and microbiological spectrum of OAM that cause pulmonary diseases in non HIV-infected individuals in our community. We reviewed 29 consecutive patients with OAM-caused pulmonary disease between 1989-1994 (26 men and 3 women, mean age 58 +/- 14 years). Infections were by Mycobacterium kansasii, 19 (66%) cases; M. avium complex, 7 (24%) cases; M. chelonei, 2 (7%) cases, and M. flavescens, one (3%) case. Risk factors most often associated to infection were smoking and a history of pulmonary disease (chronic obstructive pulmonary disease or residual tuberculosis). Clinical signs were non specific, although toxic syndrome and unproductive cough predominated. Chest films were indistinguishable from those for infection by M. tuberculosis, with cavitated alveolar fibrosis being the main pattern. In vitro drug sensitivity tests showed that all strains were resistant to isoniazid, and that M. avium complex and M. chelonei strains were resistant to rifampicin, streptomycin and, to a lesser degree, to ethambutol. With prolonged medical treatment lasting from 12 to 24 months with first line drugs, outcome was good for the 17 patients for whom full follow-up information was available. Therapy failed to eradicate the bacteria in only 2 patients.

[Coexistence of bronchogenic carcinoma and active pulmonary tuberculosis]

We describe 9 patients with coincident active tuberculosis of the lung and bronchogenic carcinoma who were all diagnosed within a 5-year period. All were men, with a mean age of 55 +/- 10 years. The principal symptom was toxic syndrome lasting 1-3 months and the most common X-ray sign was alveolar consolidation. Analysis of tissue samples revealed squamous carcinoma (4 cases), adenocarcinoma (4 cases, one of which was bronchioloalveolar) and non-small cell carcinoma (1 case). Tumoral stage was often advanced: IV (44%) and III (33%). The tuberculosis bacillus was isolated in sputum (100%) and in bronchial aspirate (50%); no in vitro resistance was observed. Three patients were treated with radical surgery and three with radiotherapy. Average survival was 3 months in this series.

Pleural cholesterol in differentiating transudates and exudates. A prospective study of 232 cases

Two hundred and four patients with pleural effusion were studied to investigate the utility of Light's criteria and pleural fluid cholesterol level (pCHOL) in the identification of exudative pleural effusion (EPE) and transudative pleural effusion (TPE). There were 48 TPE, 56 tumor, 47 tuberculous, 30 metapneumonic and 23 miscellaneous patients. A value > or = 54 mg/dl for pCHOL and > or = 0.32 for the pleura/serum cholesterol ratio (p/sCHOL) showed sensitivity (S) and specificity (Sp) of 95.5% and 91.6% for pCHOL, and 97.4% and 91.6% for p/sCHOL, respectively. Combined pCHOL and/or p/sCHOL showed a S of 98.7% and Sp of 89.5%. Light's criteria achieved a S of 100% and Sp of 64.5%. Combined pCHOL and p/sCHOL revealed a similar accuracy to Light's criteria in EPE diagnosis but was found to be more exact in TPE diagnosis.

[Endobronchial metastasis. Clinical aspects, diagnosis and course in a series of 27 cases]

Our 10-year experience is reviewed of 27 cases of endobronchial metastasis diagnosed by bronchoscopy. Primary tumors were breast (15 cases), kidney, bladder, rectum and melanoma (two cases each), and stomach, gingiva, amygdala and penis (one case each). Their presentation was prior to primary neoplasm in two patients, simultaneously in three, and posterior in the remaining patients (mean 64 +/- 52 months). Half of patients also had extrathoracic metastasis. In cases of breast cancer systemic chemotherapy was administered and the median survival rate was 24 months, significantly longer than in the remaining group (3 months); in the later, symptomatic therapy predominated due to the common involvement of lung parenchyma and functional deterioration of patients.

[Fiber bronchoscopy in lung cancer: relationship between radiology, endoscopy, histology and diagnostic value in a series of 1801 cases]

A retrospective analysis of 1,801 patients with primary pulmonary neoplasm diagnosed by fiber bronchoscopy between 1977 and 1992 was carried out in order to determine the relation between chest X-rays and endoscopic and histological findings, as well as to assess the diagnostic usefulness of the various endoscopic techniques used. Central tumors numbered 1,598 and peripheral ones 203. The largest tissue classification was squamous (39%) and the most common X-ray finding was pulmonary mass (40%). Endoscopy showed neoplastic infiltration in 49% of the cases and endobronchial tumor in 27%. X-rays showing pulmonary mass, hilar involvement and atelectasis were more often associated with infiltration, tumor and necrosis and with a small-cell tissue type. Bronchial biopsy gave the best diagnostic results in these cases. In cases of solitary pulmonary nodule and pleural effusion, on the other hand, normal endoscopic results with non-specific changes or extrapulmonary involvement, predominated, with adenocarcinoma and non-small cell tissue types. Transbronchial biopsy, especially with radioscopic monitoring, was most useful in these cases. We conclude that chest X-rays and endoscopic results can be used to predict the most likely tissue type in lung cancer and that they can serve as guides for the choice of diagnostic technique.

[Tetracycline pleurodesis for treatment of malignant pleural effusions. Retrospective study of 91 cases]

BACKGROUND

Malignant pleural effusions (MPE) are a common complication in patients with advanced neoplasms. Even though no large series confirming this exist, tetracycline pleurodesis has become the therapy of choice. The aim of this retrospective study was to evaluate its efficacy, adverse effects and possible factors predicting the success of the method.

METHODS

Between 1985 through 1991, 91 patients with cytologically or histologically confirmed MPE were treated with 1,000-1,500 mg tetracycline pleurodesis. There were 49 females and 42 males, with a mean age of 59 years. The most common malignancies were lung, breast and unknown primary carcinomas. 85% patients complained of dyspnea and the volume of the effusion was moderate in half the cases. 12 variables were analyzed in relation with the probability of response through chi 2 test; survival and recurrence times were calculated with Kaplan and Meier's method.

RESULTS

73 patients were evaluable, with a 67% response rate (22 complete, 27 partial). Time to relapse was significantly higher for partial responses (mean 112 days) than for failures (mean 33 days). 37 patients presented mild complications (pain and fever). Karnofsky performance status (70% or greater), size of the effusion (small or moderate), chest radiograph (only effusion) and pleural LDH (600 U/l or less) attained favourable prognostic significance. Median survival was reached at 6 months.

CONCLUSIONS

Tetracycline pleurodesis is an effective and well-tolerated paliative treatment for MPE. Along with other known parameters (pleural pH and glucose levels), Karnofsky performance status, size of the effusion, chest radiograph and pleural LDH allow to predict its results and optimize its indications.