Treatment and outcomes of patients with chronic lung disease and acute myocardial infarction: Insights from the nationwide AMIS plus registry

BACKGROUND

Limited data are available on patients with chronic lung disease (CLD) presenting with acute myocardial infarction (AMI). We aimed to analyse baseline characteristics, treatment and outcome of those patients enrolled in the Swiss nationwide prospective AMIS Plus registry.

METHODS

All AMI patients enrolled between January 2002 and December 2021 with data on CLD, as defined in the Charlson Comorbidity Index, were included. The primary endpoints were in-hospital mortality and major adverse cardiac and cerebrovascular events (MACCE), defined as all-cause death, reinfarction and cerebrovascular events. Baseline characteristics, in-hospital treatments and outcomes were analysed using descriptive statistics and logistic regression.

RESULTS

Among 53,680 AMI patients enrolled during this time, 5.8% had CLD. Compared with patients without CLD, CLD patients presented more frequently with non-ST-elevation myocardial infarction (MI) and type 2 MI (12.8% vs. 6.5%, p < 0.001). With respect to treatment, CLD patients were less likely to receive P2Y12 inhibitors (p < 0.001) and less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p < 0.001). In-hospital mortality declined in AMI patients with CLD over time (from 12% in 2002 to 7.3% in 2021). Multivariable regression analysis showed that CLD was an independent predictor for MACCE (adjusted OR was 1.28 [95% CI 1.07-1.52], p = 0.006).

CONCLUSION

Patients with CLD and AMI were less likely to receive evidence-based pharmacologic treatments, coronary revascularization and had a higher incidence of MACCE during their hospital stay compared to those without CLD. Over 20 years, in-hospital mortality was significantly reduced in AMI patients, especially in those with CLD.

Treatment and outcome of patients with acute myocardial infarction and chronic lung disease: insights from the nationwide AMIS Plus registry

Introduction

Little is known about patients with acute myocardial infarction (AMI) and chronic lung disease (CLD). The aim of our study was to analyze risk factors, treatment, and outcome of AMI patients with CLD over the last 20 years using the nationwide AMIS Plus registry.

Methods

All AMI patients enrolled in the AMIS Plus registry with data on CLD between January 2002 and December 2021 were included. Chronic lung disease was determined according to the definition used in the Charlson Comorbidity Index. Data on baseline characteristics, regular medication, immediate therapy within 24 hours, in-hospital interventions and treatments, in-hospital outcome, complications and discharge medication were analyzed using descriptive statistics and logistic regression.

Results

Among 53,680 AMI patients, 5.8% had a CLD. The CLD group included 26.6% female and 73.4% male patients. Gender distribution was similar in patients with and without CLD. Patients with CLD were significantly older (71.2 vs. 65.8 y; p&lt;0.001), more frequently diagnosed with NSTEMI, had more comorbidities and were less frequently never smokers (17.4% vs. 35.3%; p&lt;0.001) compared to patients without CLD. In addition, CLD patients were less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors and statins (all p&lt;0.001), and were also less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p&lt;0.001). Median length of stay was 2 days longer for CLD patients. Patients with CLD had more major adverse cardiac and cerebrovascular events in-hospital (10.3% vs. 5.9%; p&lt;0.001) and higher crude in-hospital mortality (8.3% vs. 4.7%; p&lt;0.001). However, multivariable regression analysis showed that CLD was not an independent predictor for in-hospital mortality (OR 1.19 (95% CI 0.98–1.45), p=0.081).

Conclusion

Patients with CLD were less likely to receive evidence-based medicine and had a worse in-hospital outcome compared to those without CLD. However, after adjustment, CLD was not an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca AG, Biotronik (Schweiz) AG

Erlotinib has comparable clinical efficacy to chemotherapy in pretreated patients with advanced non-small cell lung cancer (NSCLC): A propensity-adjusted, outcomes research-based study

OBJECTIVES

Controversy exists about the integration of erlotinib in patients with EGFR wildtype, advanced NSCLC.

MATERIALS AND METHODS

We included patients with advanced NSCLC receiving at least two lines of palliative systemic treatment between January 2005 and December 2014 and not harbouring targetable driver mutations. Primary study endpoint was overall survival (OS), secondary endpoint progression-free survival (PFS). We used Kaplan-Meier statistics, multivariate Cox regression and Propensity score or Inverse Probability Weights (IPW) matching to compare clinical outcome between patients receiving erlotinib in second or further line and those receiving chemotherapy only. The study had a power of 90% to detect a survival superiority of 30%.

RESULTS

From a total of 827 patients, we excluded 171 patients with potentially curative treatment, 189 receiving treatment outside of our institute, 206 receiving no or only one line of systemic treatment, 6 with ALK translocations and 28 with EGFR mutations. From 227 patients in the final efficacy analysis, 125 patients received erlotinib in second (89 patients), third (28) or further-line (8), and 102 patients received chemotherapy only. Women and never smokers were significantly overrepresented in the erlotinib group. Both OS (hazard ratio (HR)=1.14, 95% CI 0.80-1.63, P=0.448) and PFS (HR=1.20, 95% CI 0.95-1.52, P=0.119) were similar in the erlotinib compared to the chemotherapy group using IPW-adjusted Cox regression analysis treating the use of erlotinib as a time-dependent covariate starting from second-line treatment and stratified for ECOG performance status and treatment line. ECOG performance status was the most powerful covariate to select patients for erlotinib treatment.

CONCLUSION

The present study suggests erlotinib to have similar clinical efficacy compared to chemotherapy in patients with pretreated advanced NSCLC and no known molecular targetable alterations.

[The role of chronic or transient hypoxia on the retinal nerve fiber layers]

BACKGROUND

In a clinical study, the role of chronic hypoxia in patients with chronic obstructive pulmonary disease or the role of transient hypoxia in patients with obstructive sleep apnea syndrome were examined for the peripapillary retinal nerve fiber layers.

PATIENTS AND METHODS

10 patients with chronic obstructive pulmonary disease GOLD stages 3 or 4 (4 men and 6 women, age 47 to 71 years, mean 60.6 years) and 10 patients with obstructive sleep apnea syndrome with an apnea-hypopnea index of 15 or more (8 men and 2 women, age 39 to 76 years, mean 60.7 years) were included in the study. The thickness of the retinal nerve fiber layers was measured with an optical coherence tomography.

RESULTS

In the group with chronic obstructive pulmonary disease and in the group with obstructive sleep apnea syndrome, the measurements of the retinal nerve fiber layers were in normal range.

CONCLUSIONS

By using optical coherence tomography, no lesions to the retinal nerve fiber layers were detectable in patients with chronic or transient hypoxia. The findings of the study could be limited by the too short duration of the disease and/or to the too small number of patients.

Circulating microRNA profiling in patients with advanced non-squamous NSCLC receiving bevacizumab/erlotinib followed by platinum-based chemotherapy at progression (SAKK 19/05)

OBJECTIVES

Molecular subclassification of non small-cell lung cancer (NSCLC) is essential to improve clinical outcome. This study assessed the prognostic and predictive value of circulating micro-RNA (miRNA) in patients with non-squamous NSCLC enrolled in the phase II SAKK (Swiss Group for Clinical Cancer Research) trial 19/05, receiving uniform treatment with first-line bevacizumab and erlotinib followed by platinum-based chemotherapy at progression.

MATERIALS AND METHODS

Fifty patients with baseline and 24 h blood samples were included from SAKK 19/05. The primary study endpoint was to identify prognostic (overall survival, OS) miRNA's. Patient samples were analyzed with Agilent human miRNA 8x60K microarrays, each glass slide formatted with eight high-definition 60K arrays. Each array contained 40 probes targeting each of the 1347 miRNA. Data preprocessing included quantile normalization using robust multi-array average (RMA) algorithm. Prognostic and predictive miRNA expression profiles were identified by Spearman's rank correlation test (percentage tumor shrinkage) or log-rank testing (for time-to-event endpoints).

RESULTS

Data preprocessing kept 49 patients and 424 miRNA for further analysis. Ten miRNA's were significantly associated with OS, with hsa-miR-29a being the strongest prognostic marker (HR=6.44, 95%-CI 2.39-17.33). Patients with high has-miR-29a expression had a significantly lower survival at 10 months compared to patients with a low expression (54% versus 83%). Six out of the 10 miRNA's (hsa-miRN-29a, hsa-miR-542-5p, hsa-miR-502-3p, hsa-miR-376a, hsa-miR-500a, hsa-miR-424) were insensitive to perturbations according to jackknife cross-validation on their HR for OS. The respective principal component analysis (PCA) defined a meta-miRNA signature including the same 6 miRNA's, resulting in a HR of 0.66 (95%-CI 0.53-0.82).

CONCLUSION

Cell-free circulating miRNA-profiling successfully identified a highly prognostic 6-gene signature in patients with advanced non-squamous NSCLC. Circulating miRNA profiling should further be validated in external cohorts for the selection and monitoring of systemic treatment in patients with advanced NSCLC.

Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

Determinants of change in airway reactivity over 11 years in the SAPALDIA population study

We investigated determinants of change in bronchial reactivity in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA), a population-based cohort with wide age range (29-72 yrs at follow-up). The role of sex, age, atopic status, smoking and body mass index (BMI) on percentage change in bronchial reactivity slope from the baseline value was analysed in 3,005 participants with methacholine tests in 1991 and 2002, and complete covariate data. Slope was defined as percentage decline in forced expiratory volume in 1 s from its maximal value per micromole of methacholine. Bronchial hyperreactivity prevalence fell from 14.3 to 12.5% during follow-up. Baseline age was nonlinearly associated with change in reactivity slope: participants aged <50 yrs experienced a decline and those above an increase during follow-up. Atopy was not associated with change, but accentuated the age pattern (p-value for interaction = 0.038). Smoking significantly increased slope by 21.2%, as did weight gain (2.7% increase per BMI unit). Compared with persistent smokers, those who ceased smoking before baseline or during follow-up experienced a significant decrease in slope (-27.7 and -23.9%, respectively). Differing, but not statistically different, age relationships and effect sizes for smoking and BMI between sexes were found. Mean bronchial reactivity increases after 50 yrs of age, possibly due to airway remodelling or ventilation-perfusion disturbances related to cumulative lifetime exposures.

Prevalence of airflow obstruction in smokers and never-smokers in Switzerland

The aim of the present study was to measure age-specific prevalence of airflow obstruction in Switzerland in smokers and never-smokers using pulmonary function tests and respiratory symptoms from 6,126 subjects participating in the Swiss Cohort Study on Air Pollution and Lung Diseases in Adults. The lower limit of normal of the forced expiratory volume in 1 s/forced vital capacity ratio was used to define airflow obstruction. Severity of airflow obstruction was graded according to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Prevalence of airflow obstruction ranged from 2.5% in subjects aged 30-39 yrs to 8.0% in those aged ≥ 70 yrs. In multivariate analysis, age (OR 2.8, ≥ 70 yrs versus 30-39 yrs), smoking (OR 1.8) and asthma (OR 6.7) were associated with airflow obstruction. Never-smokers constituted 29.3% of subjects with airflow obstruction. Never-smokers with airflow obstruction were younger, more likely to be male and reported asthma more frequently than obstructive smokers. Obstructive smokers and never-smokers had similar level of symptoms and quality of life impairment. The prevalence of airflow obstruction in Switzerland is similar to other developed countries. Never-smokers account for a third of the prevalence, which is higher proportion than elsewhere. Airflow obstruction in never-smokers deserves attention because of its frequency and its similar health impact to that in smokers.

Longitudinal change of prebronchodilator spirometric obstruction and health outcomes: results from the SAPALDIA cohort

BACKGROUND

Understanding the prognostic meaning of early stages of chronic obstructive pulmonary disease (COPD) in the general population is relevant for discussions about underdiagnosis. To date, COPD prevalence and incidence have often been estimated using prebrochodilation spirometry instead of postbronchodilation spirometry. In the SAPALDIA (Swiss Study on Air Pollution and Lung Disease in Adults) cohort, time course, clinical relevance and determinants of severity stages of obstruction were investigated using prebronchodilator spirometry.

METHODS

Incident obstruction was defined as an FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio >or=0.70 at baseline and <0.70 at follow-up, and non-persistence was defined inversely. Determinants were assessed in 5490 adults with spirometry and respiratory symptom data in 1991 and 2002 using Poisson regression controlling for self-declared asthma and wheezing. Change in obstruction severity (defined analogously to the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification) over 11 years was related to shortness of breath and health service utilisation for respiratory problems by logistic models.

RESULTS

The incidence rate of obstruction was 14.2 cases/1000 person years. 20.9% of obstructive cases (n = 113/540) were non-persistent. Age, smoking, chronic bronchitis and non-current asthma were determinants of incidence. After adjustment for asthma, only progressive stage I or persistent stage II obstruction was associated with shortness of breath (OR 1.71, 95% CI 0.83 to 3.54; OR 3.11, 95% CI 1.50 to 6.42, respectively) and health service utilisation for respiratory problems (OR 2.49, 95% CI 1.02 to 6.10; OR 4.17 95% CI 1.91 to 9.13, respectively) at follow-up.

CONCLUSIONS

The observed non-persistence of obstruction suggests that prebronchodilation spirometry, as used in epidemiological studies, might misclassify COPD. Future epidemiological studies should consider both prebronchodilation and postbronchodilation measurements and take specific clinical factors related to asthma and COPD into consideration for estimation of disease burden and prediction of health outcomes.

Glutathione S-transferase genotype increases risk of progression from bronchial hyperresponsiveness to asthma in adults

BACKGROUND

Bronchial hyperresponsiveness (BHR) and variation in glutathione S-transferase (GST) genes have been associated with asthma risk. The relationship of these two risk factors with adult onset asthma in the general population was investigated.

METHODS

GSTP1 Ile105Val single nucleotide polymorphism and GSTM1 and GSTT1 gene deletion polymorphisms were genotyped in the population-representative SAPALDIA cohort. BHR was assessed at baseline by methacholine challenge and defined as a fall of > or =20% in forced expiratory volume in 1 s. Independent effects of GST polymorphisms and BHR on new onset of asthma after 11 years of follow-up were estimated by multiple logistic regression analysis, adjusting for relevant baseline measures. Effect modification was assessed by including interaction terms in the model.

RESULTS

Among 4426 asthma-free participants at baseline, 14% had BHR. At follow-up, 3.3% reported new onset of physician-diagnosed asthma. BHR (p<0.001) and GSTP1 Ile105Val genotype (p = 0.005) were independently associated with incident asthma, but no association was seen for GSTT1 and GSTM1 gene deletion polymorphisms. Among subjects free of respiratory symptoms at baseline, the effect of BHR on the risk of physician-diagnosed asthma at follow-up was restricted to GSTP1 105 Ile/Ile carriers (OR 4.57, 95% CI 2.43 to 8.57 vs 1.40, 95% CI 0.58 to 3.39; p for interaction = 0.023).

CONCLUSIONS

If confirmed by independent studies, our results suggest that GSTP1 Ile105Val genotype strongly determines the progression of BHR to physician-diagnosed asthma in the general population.

[A rare cause of dyspnea on exertion. A 76-year-old retired woman]

Es wird eine 76-jährige Nichtraucherin mit Gesichtshämangiomen und Anstrengungsdyspnoe vorgestellt. Krankheitsbild, Diagnose und Behandlung der pulmonalen AV-Malformation werden diskutiert und ein kurzer Überblick über den Morbus Osler vermittelt.

[Combination of asthma and COPD: more frequent as considered to be?]

Evidence-based national and international guidelines are largely aimed to guide in the diagnosis and treatment of asthma or COPD, but none addresses sufficiently mixed disease states of both disorders, which are ill-defined but very common in the daily routine clinic. This is a consensus report of a workshop on mixed disease. Asthma is characterized by a classical clinical history and physical exam, reversible airflow limitation and a high degree of bronchial hyperresponsiveness. In contrast, history (mostly smoker) and findings in typical COPD are different: COPD patients have little if any bronchial hyperresponsiveness and reversibility of the airflow limitation, respectively. However, beyond the full reversible airflow limitation which excludes COPD or mixed disease, none of these criteria are fully discriminatory. Patients with some of the characteristics of both diseases should be classified as mixed disease. A definitive diagnosis however, should only be assigned in a dynamic process. Once diagnosed the patient should be continuously re-evaluated according to the strength of the diagnosis, since the consequent treatment is important: COPD patients with asthmatic phenotype need early inhaled corticosteroids, even if their FEV1 > 50 %. Moreover, allergen avoidance can be indicated. On the other hand, asthma patients with COPD phenotype could benefit from anticholinergics or--if indicated--pulmonary rehabilitation. Mixed disease should be diagnosed as the coexistence of two distinct entities, i. e. asthma (allergic or intrinsic asthma, whichever is appropriate) and COPD.

Cytokine gene polymorphisms and atopic disease in two European cohorts. (ECRHS-Basel and SAPALDIA)

BACKGROUND

Atopy and allergic phenotypes are biologically characterized by an imbalanced T helper cell response skewed towards a type 2 (TH2) immune response associated with elevated serum immunoglobulin E (IgE) levels. Polymorphisms in cytokine genes might modulate regulation of the TH1/TH2 balance. We thus aimed at reproducing our previous findings from a European study population on the association of various cytokine polymorphisms with self-reported hay fever as well as increased total and specific IgE levels in two comparable study populations.

METHODS

Two prospective Caucasian cohorts were used. In the Basel center of the European Community Respiratory Health Survey (ECRHS, n = 418) ten distinct cytokine polymorphisms of putative functional relevance were genotyped. In the Swiss cohort Study on Air Pollution And Lung Disease In Adults (SAPALDIA, n = 6003) two cytokine polymorphisms were genotyped. The associations of these polymorphisms with atopy were estimated by covariance and logistic regression analysis.

RESULTS

We confirmed IL4, IL10, IL6 and IL18 as candidate genes for atopic health outcomes. In the large, well-characterized SAPALDIA cohort the IL6(-174G>C) and IL18(-137G>C) polymorphisms were associated with circulating total IgE concentrations in subjects with hay fever. The IL18(-137G>C) polymorphism was also associated with the prevalence of hay fever.

CONCLUSION

Comprehensive characterization of genetic variation in extended cytokine candidate gene regions is now needed. Large study networks must follow to investigate the association of risk patterns defined by genetic predisposing and environmental risk factors with specific atopic phenotypes.

Cough suppression during flexible bronchoscopy using combined sedation with midazolam and hydrocodone: a randomised, double blind, placebo controlled trial

BACKGROUND

Current British Thoracic Society guidelines do not recommend routinely the combined use of a benzodiazepine and opiate during flexible bronchoscopy (FB). A randomised, placebo controlled, double blind study was undertaken to determine whether hydrocodone in combination with midazolan improves cough suppression during FB without increasing the risk of desaturation.

METHODS

120 patients were randomised to receive midazolam and 5 mg i.v. hydrocodone or midazolam and placebo with topical anaesthesia. Pulse oximetry was recorded continuously during FB. Bronchoscopists and nurses charted their perception of cough and the patients rated their discomfort during the procedure on a 10 cm visual analogue scale (VAS).

RESULTS

There was no significant difference between the two groups with regard to the indication for FB, duration of procedure (21 (11) min v 22 (10) min, p = 0.570), doses of supplemental lignocaine (171 (60) mg v 173 (66) mg, p = 0.766) and midazolam (4.5 (2.3) mg v 4.9 (2.7) mg, p = 0.309), lowest oxygen saturation (94.8 (2.7) v 94.9 (2.7), p = 0.433), and desaturations < or =90%. Perception of cough by both the bronchoscopist and the nurse was significantly lower in the hydrocodone group (3 (0-10) and 3 (0-10)) than in the placebo group (6 (0-10) and 6 (0-10)), respectively (p = 0.001). According to the VAS scale, patients' tolerance was also significantly better with hydrocodone than with placebo (2 (0-8) v 3 (0-9), p = 0.043).

CONCLUSION

The combination of midazolam and hydrocodone markedly reduces cough during FB without causing significant desaturation, especially when invasive diagnostic procedures are performed.

[Cough and dyspnea during exertion 14 days after nicotine use]

Eine 38-jährige Patientin präsentiert sich mit zunehmender Atemnot auf der Notfallstation, nachdem sie vor zwei Wochen angefangen hat zu rauchen. Anhand dieses Fallbeispiels wird die Diagnose, Differentialdiagnose und Therapie der akuten eosinophilen Pneumonie (AEP) erörtert.

Lymphoproliferative responses in cord blood and at one year: no evidence for the effect of in utero exposure to dust mite allergens

BACKGROUND

Maternal allergen exposure beyond the 22nd week of pregnancy may be important in foetal T cell priming. Allergen-specific cord blood mononuclear cell (CBMC) immunoproliferative responses without corresponding bacterial antigen responses (tetanus toxoid), have been suggested as evidence of in utero sensitization.

OBJECTIVES

To investigate the relationship between lymphoproliferative responses at birth and at 1 year with maternal and 1-year infants house dust mite allergen exposure.

METHODS

Home visits and dust sampling were performed by the 20th week of pregnancy, immediately after birth, and then at 1 years of age. Der p 1 was assayed using a two-site immunometric ELISA. CBMC immunoproliferative responses (AIM V serum-free medium; 1 x 105 cells/well) were measured for 225 neonates (171 had a high risk of atopy (HR)--both parents skin test positive; 59 had a low risk of atopy (LR) - both parents skin test negative, no history of atopy) by 3H-Thymidine (1microCi/well) incorporation after stimulation in primary culture with phytohaemagglutinin (PHA) (1 microg/mL), house dust mite [HDM] extract (30 microg/mL), immunopurified Der p 1 (30 microg/mL), Tetanus toxoid (TT) (aluma free, 30 Lf/mL) or vehicle. Blood was collected from 144 infants at the age of 1 years and stimulated proliferative responses were assessed using the same procedure.

RESULTS

PHA-stimulated lymphoproliferative response was significantly lower in HR compared to LR neonates (mean difference 38%, 95% CI 15%-54%; P = 0.003); significantly lower proportion of positive CBMC responses to HDM occurred in LR than in HR neonates (30.4% vs. 46.6%; P = 0.034). There was no relationship between Der p 1 levels in maternal bed and CBMC immunoproliferative responses, despite the 21 000-fold range of maternal Der p 1 exposure. No significant differences in magnitude, or in proportion of positive responses to any stimulant were observed between the neonates at low, medium or high tertile of allergen exposure. Immunoproliferative responses at birth were not predictive of 1-year PBMC responses. There was no relationship between maternal allergen exposure in pregnancy and 1-year PBMC proliferative responses. However, the proportion of positive proliferative responses at 1 years significantly increased with increasing infant Der p 1 exposure at 1 years.

CONCLUSION

These results indicate that the magnitude of immunoproliferative responses are unrelated to maternal mite allergen exposure and cannot be used as evidence for in utero sensitization to inhalant allergens. The immunoproliferative responses at 1 year seem to shift away from the genetically influenced responses at birth towards responses to specific stimulants which correlate with environmental exposure to those specific stimulants. These data support the concept of sensitization to inhalant allergens occurring in early life, but not in utero.

Clinical diagnosis of current asthma: predictive value of respiratory symptoms in the SAPALDIA study. Swiss Study on Air Pollution and Lung Diseases in Adults

Bronchial asthma is a very common disease which often remains underdiagnosed. The aim of this study was to determine the predictive value of the most common respiratory symptoms and to explore the best symptom combinations to predict diagnosis of asthma. A questionnaire comprising common respiratory symptoms was submitted to 9,651 subjects aged 18-60 yrs, randomly selected from the Swiss population, of whom 225 subjects (2.3%) had current asthma as confirmed by their general practitioner. Based on these data the authors calculated the predictive values of single symptoms and symptom combinations to diagnose asthma. Wheezing was the most sensitive single symptom (sensitivity 75%). Simple symptoms such as wheezing with dyspnoea, chronic phlegm or chronic cough had specificity greater than 95%. Wheezing with dyspnoea (WD) or nocturnal dyspnoea (ND) had the best positive predictive value (PPV) as isolated symptoms (24% and 21%, respectively). When combining symptoms, wheezing associated with daily dyspnoea at rest or nocturnal dyspnoea showed the best PPV (42% and 39%, respectively), almost double single symptoms such as WD or ND. Wheezing associated with at least two of the three nocturnal symptoms (nocturnal dyspnoea, nocturnal cough or nocturnal chest tightness) had a sensitivity of 80% to diagnose asthma. In conclusion, respiratory symptoms obtained by medical history are reliable predictors of asthma. The findings suggest that particular combinations of symptoms are clinically useful in the differential diagnosis of asthma.

Manchester Asthma and Allergy Study: low-allergen environment can be achieved and maintained during pregnancy and in early life

BACKGROUND

Early exposure to dust mite allergens may be critical for primary sensitization. Reducing exposure may offer a realistic chance for primary prevention of sensitization and asthma, but it is essential to implement measures that can achieve and maintain the low-allergen environment.

OBJECTIVE

Our purpose was to assess the effectiveness of mite allergen avoidance measures in achieving and maintaining a low-allergen environment during pregnancy and in the first year of life.

METHODS

The Manchester Asthma and Allergy Study is a prospective, prenatally randomized study that follows the development of asthma and atopy in a cohort of infants at high risk (both parents atopic) who are randomly allocated to full mite allergen avoidance or to a normal regimen. Avoidance measures comprise (1) mite-proof covers (mattress, pillow, and quilt) for parental bed, (2) high-filtration vacuum cleaner, (3) vinyl flooring in infant's bedroom, (4) new crib and portable crib mattresses encased in mite-proof material, (5) benzyl benzoate (Acarosan) applied on carpets and soft furniture, (6) bed linens washed in hot water weekly, and (7) washable soft toys. Dust samples from the parental bed, bedroom floor, living room floor, infant's mattress, and nursery floor were collected between the 10th and 14th weeks of pregnancy, immediately after birth, and then at age 6 months and 1 year, and Der p 1 levels were determined by mAb-based ELISA.

RESULTS

Recovered Der p 1 from maternal mattress was reduced by 97. 25% (95% confidence interval [CI] 95.25%-98.41%) during the second and third trimesters of pregnancy, with the effect persisting for 6 months (98% reduction, 95% CI 97.25%-99.1%) and 12 months (97.6% reduction, 95% CI 95.7%-98.6%) after the birth (active vs control, P <.000001). Total Der p 1 from bedroom floor in the active group was reduced by 53.7% (95% CI 25.7%-71.2%) in samples collected within 4 weeks of the child's birth, with the percentage reduction being 62. 8% (95% CI 39.3%-77.2%) at 6 months and 26.5% (95% CI -24% to 57.1%) at 1 year (active compared vs control, P <.007). Der p 1 levels in crib mattress and nursery floor in the active group were extremely low (crib mattresses geometric mean [95% CI] 2.3 ng [1.6-3.4] at birth, 6.8 ng [4.5-10] at age 6 months, and 15.6 ng [9.8-24.8] at age 1 year [active vs control, P =.001]; nursery 1 ng [0.9-1.1] at birth, 1.7 ng [1.2-2.5] at age 6 months, and 2 ng [1.3-3.5] at age 1 year [active vs control, P <.00001]). The total amount of allergen recovered at age 1 year was 29-fold (95% CI 15.1- to 56.7-fold) higher in the control group than in the active group.

CONCLUSIONS

The avoidance measures used in this study achieved and maintained a low mite allergen environment during pregnancy and in the first year of life in homes of infants at risk of atopy.

Current allergic asthma and rhinitis: diagnostic efficiency of three commonly used atopic markers (IgE, skin prick tests, and Phadiatop). Results from 8329 randomized adults from the SAPALDIA Study. Swiss Study on Air Pollution and Lung Diseases in Adults

Total serum IgE, Phadiatop, and the skin prick test (SPT) are commonly used to diagnose atopic diseases. However, no large study has ever been done to test their diagnostic efficiency. We studied the diagnostic value of these three atopic markers in 8329 well-randomized adults from the Swiss Population Registry. The prevalence of current allergic asthma (CAA) was 1.8% and of current allergic rhinitis (CAR) 16.3%. The prevalences of positive Phadiatop, positive SPT (at least, one out of eight SPT to common aeroallergens with a wheal of > or = 3 mm), and positive total IgE (IgE > or = 100 kU/l) were 29, 23, and 23%, respectively. To diagnose CAA and CAR, the sensitivity of Phadiatop was significantly higher than that of SPT (72.5% vs 65.4%, 77.1% vs 68.4% respectively; P < 0.01 and < 0.001) and IgE (72.5% vs 56.9%, 77.1% vs 43.9%, respectively; both P < 0.001). The sensitivity of SPT was significantly higher (68.4% vs 43.9% P < 0.001) than that of IgE to diagnose CAR. When CAA and CAR were excluded, the SPT specificity was significantly higher than that of Phadiatop (77.8% vs 71.9% and 85.9% vs 80.5%, respectively; both P < 0.001): when CAR was excluded, SPT was significantly higher than IgE (85.9 vs 81.4%; P < 0.001). SPT had significantly the best positive predictive value for CAA (5.2% for SPT vs 4.6% for both IgE and Phadiatop; both P < 0.001) and CAR (48.7% for SPT vs 43.5% for Phadiatop and 31.6% for IgE; both P < 0.001). The three markers of atopy had roughly the same negative predictive value (NPV) for CAA, but IgE had a significantly lower NPV for CAR than SPT and Phadiatop (88.1% vs 93.3% and 94.7%, respectively; both P < 0.001). The diagnostic efficiency of SPT was significantly higher than that of Phadiatop (83.1% vs 79.9% and 77.6 vs 71.9%, respectively; both P < 0.001) to diagnose CAR and CAA. IgE and SPT had equal efficiency (77.6%), which was significantly higher than that of Phadiatop, to diagnose CAA (71.9%; both P < 0.001). In conclusion, SPT have the best positive predictive value and the best efficiency to diagnose respiratory atopic diseases. Furthermore, SPT give information on sensitivity to individual allergens and should therefore be used primarily by clinicians to assess respiratory allergic diseases. Moreover, they are cheaper and provide immediate, educational information for both patient and physician.

[Value of thoracoscopy and talc pleurodesis in diagnosis and palliative treatment of malignant pleural mesothelioma]

Malignant pleural mesothelioma (MPM) remains a disease of very poor prognosis despite all new therapeutic approaches. We describe here 13 cases with MPM. The main symptoms at presentation were dyspnea (12/13) followed by weight loss (7/13), cough (3/13) and thoracic pain (2/13). On chest X-ray, all patients had pleural effusion associated with pleural thickening in 8/13 cases (62%). A definitive diagnosis was brought by thoracoscopy in 11/12 cases (diagnostic sensitivity 92%). In one patient, thoracoscopy was technically impracticable because of very important obesity. By thoracoscopic talc pleurodesis, we were able to control the pleural effusion in all patients with suppression of dyspnea (11). The mean survival after diagnosis was 6.8 +/- 5.0 months (range 1-16). At the present time, we believe that thoracoscopy is well indicated in any suspicion of MPM not only for diagnosis but also for palliative treatment of this pleural disease. However, there is a need for well controlled studies to improve the outcome of MPM.

Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anaesthesia

BACKGROUND

Complicated (recurring or persistent) spontaneous pneumothorax requires treatment either by talc pleurodesis with bullae electrocoagulation or, more aggressively, by thoracotomy or video-assisted thoracoscopic surgery. However, the relative merits of bullectomy, pleurectomy, and pleurodesis have not yet been established in the treatment of spontaneous pneumothorax.

METHODS

The complications, duration of drainage, length of hospital stay, and immediate and long term success rate of treating complicated spontaneous pneumothorax with talc pleurodesis under local anaesthesia supplemented with nitrous oxide were studied.

RESULTS

Talc pleurodesis was performed in 93 patients without serious complication (two benign arrhythmias, two subcutaneous emphysema, two pneumonia, one bronchospasm). The procedure was immediately successful in 90 patients (97%) with a median duration of drainage of five days (range 2-40) and a median length of hospital stay of 5.2 days (range 3-40). After a mean follow up duration of 5.1 (range 1-9.4) years in 84 cases the long term success rate was 95%, although six cases developed a small localised recurrence of spontaneous pneumothorax which did not require further surgery. Macroscopic staging at thoracoscopy was only carried out in the last 59 cases of whom 10 (17%) had bullae with a diameter of > 2 cm. In this group of patients the risk of definitive failure requiring surgery was significantly higher than in those patients without such bullae (odds ratio 7; confidence interval 3.7 to 13.3; p = 0.03), although eight of these patients did not require thoracotomy. Total lung capacity was reduced immediately after talc pleurodesis (mean (SD) 75 (23)% predicted at 10 days) but had improved to 95 (14)% predicted at 12 months.

CONCLUSIONS

This study shows that simple thoracoscopic talc pleurodesis under local anaesthesia is a safe and effective treatment for complicated spontaneous pneumothorax. However, patients with bullae of > 2 cm in diameter have a greater risk of treatment failure.

Exercise-induced bronchospasm (EIB) in relation to seasonal and perennial specific IgE in young adults

We investigated the relationship between exercise-induced bronchospasm (EIB) and specific IgEs for seasonal (S-IgE) and perennial (P-IgE) allergens. The study, outside the main pollen season, was conducted on 289 20-year-old soldiers, who completed a self-administered questionnaire. A total of 289 subjects had S-IgE and P-IgE measured. The population was divided into subjects with (n = 166) and without (n = 123) history of atopic diseases (HAD). Twenty-three of 289 subjects (8%) had asthma, 70/289 (24%) allergic rhinitis, and 92/289 (32%) atopic siblings. Measured EIB was found in 17/289 subjects (6%). They had significantly higher levels of S-IgE and P-IgE than those without measured EIB (respectively, P < 0.01 and P < 0.05). The odds ratios of having EIB were significantly increased in the entire population in relationship with an increase in both S-IgE and P-IgE (chi-square test for trend = 9.4 and 12.7, P < 0.002 and 0.001, respectively). Interestingly, this highly significant relationship remained true when considering only the no HAD group (chi-square test = 7.4 and 8.8, P < 0.006 and 0.003, respectively). Outside the pollen season, EIB was highly related to the level of both specific seasonal and perennial IgEs in the total population and in the subjects without HAD. This suggests that even in young adults who have been asymptomatic throughout their life EIB appears to be closely linked to seasonal or perennial allergic diathesis as measured by specific IgEs.

Passive smoking exposure in adults and chronic respiratory symptoms (SAPALDIA Study). Swiss Study on Air Pollution and Lung Diseases in Adults, SAPALDIA Team

The association between passive exposure to tobacco smoke and respiratory symptoms was examined in a sample of 4,197 never-smoking adults. They constituted the never-smoking subsample of a random sample of 9,651 adults (age, 18 to 60 yr) in eight areas in Switzerland. Information on passive smoking exposure and standardized questions on respiratory symptoms were obtained via a questionnaire administered by trained examiners. After controlling for age, sex, body mass index (BMI), study area, atopy, and parental and sibling history, passive smoking exposure was associated with an elevated risk of wheezing apart from colds (odds ratio [OR] = 1.94, 95% CI = 1.39 to 2.70), an elevated risk of bronchitis symptoms (OR = 1.59, 95% CI = 1.17 to 2.15), an elevated risk of symptoms of chronic bronchitis (OR = 1.65, 95% CI = 1.28 to 2.16), an elevated risk of dyspnea (OR = 1.45, 95% CI = 1.20 to 1.76), and an elevated risk of physician diagnosed asthma (OR = 1.39, 95% CI = 1.04 to 1.86). It was not associated with any increased risk of allergic rhinitis including hayfever. Adding a variable for low educational level, excluding subjects whose mother ever smoked or subjects with end-expiratory CO levels > or = 7 ppm, and controlling for paternal smoking during childhood or occupational exposure had little impact on the association. The association of passive smoking exposure with dyspnea, wheeze, and asthma showed evidence of a dose-dependent increase with hours per day of exposure, whereas association with symptoms of bronchitis was stronger with years of exposure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Campaign against smoking and the general practitioner. Evaluation of a simple method allowing immediate measurement of compliance with smoking cessation in the physicians office]

Recently, the Swiss Medical Association and the Swiss Federal Office for Public Health started a campaign against smoking. Portable carbon monoxide (CO) devices measuring alveolar CO concentration are now available. It is important to know how accurate they are in discriminating smokers (S) from nonsmokers (NS) in different environmental conditions. We administered a smoking questionnaire and measured alveolar CO concentration in 241 people living in an urban area (PU) and 112 people living in a mountain area (PM). Smoking prevalence was 39% in PU and 17% in PM. Alveolar CO concentration was significantly higher in S than in NS (27 +/- 11, 11 to 60, vs. 14 +/- 9, 4 to 52, p < 0.01 in PU and 23 +/- 13, 4 to 48, vs. 9 +/- 7, 4 to 46, p < 0.01 in PM). We found significantly higher CO-values in NF of PU than PM (p < 0.01). This test has a sensitivity of 80%, a specificity of 78%/79% (PU/PM) and a predictive positive value of 74%/80% (PU/PM). The cut-off point has to be adapted depending on the environmental exposure (PU: 15 ppm, PM: 10 ppm CO). Alveolar CO measurement is a cheap accurate method whose results are immediately available to the general practitioner in his fight against smoking. This method merits higher application.

[Diarrhea, erythema nodosum, arthralgia]

Following antibiotic treatment of febrile tonsillitis, a 20-year old man developed watery diarrhea during military service. He was admitted to the infirmary by the medical officer. During the last year the patient had traveled to Spain. The history of recent food intake was not remarkable. The clinical investigation revealed a slightly tender liver. A markedly elevated ESR, a consecutively developing erythema nodosum on both lower legs and arthralgias opened a broad spectrum of differential diagnoses that are discussed here. Stool cultures grew salmonella typhimurium. The clinical picture, the treatment and possible complications of this salmonellosis are discussed.