[THE ROLE OF CLOSED PLEURAL BIOPSY IN THE DIAGNOSIS OF TUBERCULOUS PLEURISY IN A POPULATION AT-RISK].

BACKGROUND: Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis, and a common cause of exudative pleural effusion. Closed pleural biopsy can be used for diagnosis. In recent years, more invasive methods are used for the diagnostic process in the western world. Contrary to the global trend, physicians at the Pulmonary Institute of the Soroka University Medical Center still perform a closed pleural biopsy as the first diagnostic step. In this article, we report our experience in the diagnosis of tuberculous pleurisy by closed pleural biopsy. METHODS: A retrospective cohort analysis, conducted among patients, who were admitted for investigation of pleural effusion between 2008 and 2013, and underwent closed pleural biopsy with an Abrams needle in the evaluation of tuberculous pleurisy (n=25). Histopathological evidence of tuberculosis bacterium infection included a positive staining for acid-fast bacteria, identification of Langerhans giant cells, demonstration of chronic granulomatous inflammation or demonstration of granulomas with central necrosis in samples of pleural fluid or pleural biopsy. RESULTS: Closed pleural biopsy was performed in 22/25 (88%) of patients. In 15/22 subjects (68%) histopathotogical evidence of tuberculous pleurisy was found. No significant complications were evident after the procedure. In addition, it was found that acid-fast bacteria in sputum samples, gastric fluid and pleural fluid is of very low diagnostic yield for the diagnosis of tuberculous pleurisy, while in cultures of sputum, gastric fluid or pleural fluid infection it was diagnosed in 27, 28 and 28% of subjects respectively. CONCLUSIONS: In subjects with a high probability for tuberculous pleurisy, closed pleural biopsy using Abrams needle is available, inexpensive and has a good diagnostic yield and low complication rate. We believe that there is great importance in preserving the ability to perform a closed pleural biopsy in all. medical centers in Israel.

Thromboembolic events in patients with severe pandemic influenza A/H1N1.

BACKGROUND: The 2009 pandemic influenza A/H1N1 developed as a novel swine influenza which caused more diseases among younger age groups than in the elderly. Severe hypoxemic respiratory failure from A/H1N1 pneumonia resulted in an increased need for ICU beds. Several risk groups were identified that were at a higher risk for adverse outcomes. Pregnant women were a particularly vulnerable group of patients The CDC reported on the first ten patients with severe illness and acute hypoxemic respiratory failure associated with A/H1N1 infection, none of whom were pregnant, but they noticed that half of the patients had a pulmonary embolism. METHODS: During a four-month period from September to December 2009, 252 patients were admitted to our hospital with confirmed pandemic influenza H1N1 by real-time reverse transcriptase-polymerase chain reaction test (rRT-PCR). We cared for twenty patients (7.9%) admitted to MICU with severe A/H1N1. Results on Thrombotic events were identified in five (25%) of our critically ill patients. CONCLUSIONS: We recommend that patients with severe influenza A/H1N1 pneumonitis and respiratory failure be administered DVT prophylaxis in particular if there are additional risk factors for TVE. Further prospective studies on the relationship of influenza A/H1N1 and VTE are needed.

Major respiratory adverse events after laparascopic gastric banding surgery for morbid obesity.

BACKGROUND: Laparoscopic adjustable gastric banding surgery has become one of the most common restrictive surgical procedures for treatment of morbid obesity worldwide. Although short-term respiratory complications are well known, long-term data is scarce. We investigated the manifestations of major pulmonary complications showed at least six months after the procedure. METHODS: A retrospective cohort study was conducted at a tertiary university medical center in the five years period of 2006-2010. We included every patient who had had major respiratory complication who needed hospitalization, at least 6 months after laparoscopic adjustable gastric banding procedure. Demographic, pre-operative and post-operative clinical data were collected. We documented respiratory symptoms, results of physical examination, pulmonary function tests, and imaging as well as therapies given and outcome. RESULTS: Out of 2100 patients who underwent LAGB, thirty subjects, mean age of 45.7 (range 29-64) with an equal number of males and females were included. Mean interval between operation and onset of respiratory symptoms was 51.5 months (range 10-150 months). All had dyspeptic complaints which included: regurgitation, fullness after meals, dysphagia and food aspiration with esophageal dilatation. Major respiratory complications included aspiration pneumonia (19) including pulmonary abscess (4) and empyema (2), exacerbation of asthma (3) and hemoptysis (1). Additionally we documented the emergence of chronic diseases such as interstitial lung disease (5) and bronchiectasis (3). One patient developed acute respiratory distress syndrome due to aspiration pneumonia and eventually died in the intensive care unit. The main mode of therapy was deflation of the gastric band. Those who refused to deflate or remove the gastric banding continued to suffer from dyspeptic and respiratory symptoms including recurrent pulmonary abscess. CONCLUSION: Although laparoscopic adjustable gastric banding surgery has few short-term risks and is highly effective at achieving weight reduction, we found an increased risk for major respiratory complications in the long-term period. The obesity epidemic and the increased use of surgical techniques to treat obesity will most likely lead to an increase in the incidence of long-term post-operative respiratory complications. This entity is probably under-reported and needs further research into how to reduce its incidence and morbidity.

[Incidence of hospitalizations among chronic obstructive pulmonary disease (COPD) patients with anemia].

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterized by progressive exertional and resting dyspnea and is associated with major co-morbidities. Hemoglobin level disorders (anemia and polycythemia) prevalence among patients and the relationship between them and the clinical expression are still not characterized unequivocally. The main purpose of this work is to test the association between anemia and hospitalizations. The presence of such a link may promote the diagnosis and treatment aimed at the patient's hemoglobin levels. HYPOTHESIS: Anemia in patients with COPD is associated with an increased number of hospitalizations. METHODS: A retrospective cohort study analysis, conducted on a group of COPD patients (n = 333) followed in the Pulmonology Institute of the Soroka University Medical Center in the years 2003-2009. Demographic physiological and clinical characteristics were compared between anemic, polycythemic and normal hemoglobin patients. Using statistical models, we examined the relationship between the presence of anemia and clinical outcome. RESULTS: Anemia was found in 79 patients (24%) and polycythemia among seven patients (2%). No difference was found between the groups in terms of number of hospitalizations, number of hospitalization days and ventilator events. There was a higher rate of co-morbidities (such as heart failure, chronic kidney disease) among anemic patients. There were also lower values of BMI and lung function and a higher proportion of men among anemic patients. CONCLUSIONS: Anemia in patients with COPD was not associated with an increase in the number of severe exacerbations. More studies are needed to clarify the threshold of a hemoglobin level below which there is an increase in the rate of hospitalizations.

Varicella pneumonia in southern Israel: clinical characteristics, diagnosis and therapeutic considerations.

BACKGROUND: The most common and most serious complication of varicella (chickenpox) in adults is pneumonia, which can lead to severe respiratory failure. Varicella pneumonia is associated with considerable morbidity and even death. OBJECTIVES: To summarize our experience with varicella pneumonia in terms of clinical, laboratory and radiological characteristics as well as risk factors, management and outcome. METHODS: We conducted a retrospective cohort survey in our facility from 1995 to 2008. RESULTS: Our cohort comprised 21 patients with varicella pneumonia, of whom 19 (90%) were men; their mean age was 35 +/- 10.5 years. Nineteen patients (90%) were Bedouins and 18 (86%) were smokers. Eleven (52%) were admitted to the Medical Intensive Care Unit; 3 of them required mechanical ventilation and the remaining 10 (48%) were admitted to the general medical ward. Median length of stay was 6 +/- 7.7 days. Hypoxemia and elevated lactate dehydrogenase on admission were associated with respiratory failure. Radiological manifestations were variable and nine patients exhibited characteristic findings. All but one patient were treated with acyclovir. All patients fully recovered. CONCLUSIONS: In southern Israel varicella pneumonia is primarily a disease ofyoung male Bedouins who are smokers. Severity ranges from mild disease to severe, resulting at times in respiratory failure requiring mechanical ventilation. Prognosis is favorable with complete recovery.

Pulmonary functions testing in patients with rheumatoid arthritis.

BACKGROUND: A high incidence of abnormal pulmonary function tests has been reported in cross-sectional studies among patients with rheumatoid arthritis. Few patients have been enrolled in longitudinal studies. OBJECTIVES: To perform PFT in rheumatoid arthritic patients without pulmonary involvement and to identify variables related to changes in PFT over 5 years of follow-up. METHODS: Consecutive RA patients underwent PFT according to recommendations of the American Thoracic Society. All surviving patients were advised to repeat the examination 5 years later. RESULTS: PFT was performed in 82 patients (21 men, 61 women). Their mean age was 55.7 (15.9) years and the mean RA duration was 11.1 (10) years. Five years later 15 patients (18.3%) had died. Among the 67 surviving patients, 38 (56.7%) agreed to participate in a follow-up study. The initial PFT revealed normal PFT in only 30 patients (36.6%); an obstructive ventilatory defect in 2 (2.4%), a small airway defect in 12 (17%), a restrictive ventilatory defect in 21 (25.6%), and reduced DLco in 17 (20.7%). Among the 38 patients participating in the 5 year follow-up study, 8 developed respiratory symptoms, one patient had a new obstructive ventilatory defect, one patient developed a restrictive ventilatory defect, and 5 patients had a newly developed small airway defect. The DLco had improved in 7 of the 8 patients who initially had reduced DLco, reaching normal values in 5 patients. Over the study period a new reduction in DLco was observed in 7 patients. Linear regression analyses failed to identify any patient or disease-specific characteristics that could predict a worsening in PFT. The absolute yearly decline in forced expiratory volume in 1 sec among our RA patients was 47 ml/year, a decline similar to that seen among current smokers. CONCLUSIONS: Serial PFT among patients with RA is indicated and allows for earlier identification of various ventilatory defects. Small airways disturbance was a common finding in our RA patients.

Acute interstitial pneumonia-Hamman-Rich syndrome: clinical characteristics and diagnostic and therapeutic considerations.

BACKGROUND: Acute interstitial pneumonia is a rapidly progressive disease frequently leading to respiratory failure and mechanical ventilation. The prognosis is usually poor despite aggressive diagnostic and treatment efforts. METHODS: In this retrospective cohort survey, we enrolled patients with hypoxemic respiratory failure who met predefined criteria of acute idiopathic interstitial pneumonia. Patients' records, radiologic studies, and pathologic specimens were reviewed. All data were recorded in each patient's study file and subsequently analyzed. RESULTS: Our cohort consisted of 5 men and 4 women with a mean age of 69.4 yr (55-80 yr). The chest radiograph in all patients progressed to diffuse bilateral infiltrates over a 12-day course. All nine patients had histological proof of diffuse alveolar damage consistent with acute interstitial pneumonia, obtained by either transbronchial biopsy or open lung biopsy. All patients required admission to the medical intensive care unit and mechanical ventilation. The mortality rate was 100%, and patients died within 5-26 days of their admission to the unit. CONCLUSIONS: Acute interstitial pneumonia (Hamman-Rich syndrome) is an idiopathic, rapidly progressive and, at times, fatal form of interstitial lung disease. A transbronchial biopsy is a logical first diagnostic step, to be followed by an open lung biopsy, if necessary. Response to corticosteroids in our series was minimal. In patients who fail to respond to conventional therapy and are otherwise appropriate candidates, lung transplantation may be considered as an additional alternative.

Repeated tuberculin skin testing following therapy with TNF-alpha inhibitors.

To determine the rate of true tuberculin skin test (TST) response in a cohort of patients with rheumatic disease treated with tumor necrosis factor inhibitors (TNFi). The study population included consecutive patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) treated with TNFi for at least 3 months. Patients with a positive TST at screening who began Tb prophylaxis before the beginning of TNFi therapy were excluded. All patients underwent a second TST. True TST response was defined as an increase of 6 mm of induration between the screening test and the second test. Forty patients (12 men and 28 women) were included. Mean age was 51.2 years. Of them, 27 (67.5%) had RA, eight (20%) had PsA, and five patients (12.5%) had AS. At pre-treatment TST, 15 patients had a TST > or = 5 mm. A significantly higher percent of patients with TST > or = 5 mm was seen among men compared with women (75% vs. 21%, p = 0.012) and patients with PsA compared with patients with RA (75% vs. 22%, p = 0.014). At the second test, eight (20%) had an increase of 6 mm between readings with four having an increase of 10 mm or more. Four patients received infliximab and the other four were treated with etanercept. Seven of these eight patients had RA and one was a patient with PsA. Patients with true TST response were significantly older and non-smokers with elevated sedimentation rate and a higher rate of anemia. Nationality, comorbid conditions, treatment with immunosuppressives, and BCG vaccination status had no significant influence on the TST response. Serial TST testing in patients receiving TNFi is indicated to identify patients with reactivation of latent tuberculosis infection or those exposed to mycobacterium.

Differences between Bedouin and Jewish populations in incidence and characteristics of patients hospitalized with community-acquired pneumonia.

OBJECTIVE: Southern Israel is inhabited by two ethnic groups: predominantly urban Jews and semi-nomad Bedouin Arabs. We evaluated the incidence of hospitalization and differences in clinical characteristics of community-acquired pneumonia (CAP) between these populations. DESIGN: A hospital-based prospective observational study at Soroka Medical Center, a 1200-bed tertiary care hospital, the single hospital in the region. PATIENTS: All patients admitted with CAP to the internal medicine division during a 5-month winter period. RESULTS: 262 patients were enrolled, of whom 58 (22.1%) were Bedouins. Age-standardized incidence rate for CAP hospitalization among Jews was 68 cases per 100,000 during one winter period, compared to 284 per 100,000 among Bedouins. Bedouin patients were younger than Jewish patients (60.0 +/- 20 vs. 66 +/- 17 years, P = .05). Jews had lower rates of smoking (19.1%, vs. 39.7% P = .001), chronic obstructive pulmonary disease (9.3% vs. 31.0%, P = .001) and diabetes (25.0% vs 41.4%, P = .01). Bedouin patients had a lower rate of pre-hospitalization antibiotic therapy (12.1% vs. 25.5%, P = .03) and influenza vaccination (14.0 vs. 26.8, P = .01). Despite these differences, severity of disease, (measured by Pneumonia Outcome Research Team score), length of hospitalization (median 4 days, P = .38) and 30-day mortality rate (3.4% vs. 8.8%, P = .18) were similar in both populations. CONCLUSIONS: We found a higher incidence of CAP hospitalizations in Bedouin Arabs compared to the Jews. Higher rates of smoking, chronic obstructive pulmonary disease, and lower rates of influenza vaccination most likely contribute to this difference. Despite socioeconomic and clinical differences between the two ethnic groups, no difference was found in the clinical outcomes.

[Tuberculosis among patients treated with TNF-alpha blockers].

Several reports have indicated a relationship between reactivation of latent tuberculosis infection (LTBI) and treatment with tumor necrosis factor alpha (TNF) blocking agents. These biologic drugs have demonstrated high efficacy in the treatment of chronic inflammatory diseases. Several guidelines have been published worldwide suggesting pretreatment screening strategies for latent tuberculosis in candidates for TNF-blocking treatment, as well as a regimen for prophylactic therapy if latent tuberculosis is indeed diagnosed. There are considerable variations among the different guidelines. This review summarizes currently available data on the risk of infection and particularly, the increased risk profile for tuberculosis in patients treated with TNF-blocking agents. The role of TNF alpha blockers in the pathogenesis of tuberculosis and the existing protocols that have been formulated in order to minimize the risk of tuberculosis reactivation during TNF blockade are also outlined.

Urinothorax: An unexpected cause of pleural effusion.

Urinothorax is an unexpected cause of transudative pleural effusion associated with obstructive uropathy. We present a case of urinothorax in a patient with congestive heart failure who had undergone percutaneous nephrolithotomy. The diagnosis was made after an unexpected enlargement of the pleural effusion after treatment with diuretics.

Disagreement in the interpretation of chest radiographs among specialists and clinical outcomes of patients hospitalized with suspected pneumonia.

BACKGROUND: Pneumonia is diagnosed by a combination of clinical symptoms and findings on chest X-ray (CXR). However, there is often disagreement, even among experts, upon the interpretation of the CXR. The purpose of this study was to compare the agreement rates in CXR interpretation of suspected community-acquired pneumonia (CAP) between a radiologist, a pulmonologist, an infectious disease specialist, and an internal medicine staff and to establish the correlation of such an agreement with the length of hospitalization and 30-day mortality rate. METHODS: We prospectively enrolled in our study all patients admitted to the Department of Medicine with suspected CAP, as defined by the admitting physician, within the first 24 h of hospitalization. A radiologist, pulmonologist, and infectious disease specialist who were aware of the suspected diagnosis independently interpreted the CXR. The final diagnosis was obtained from the discharge notes. RESULTS: A total of 262 patients participated in the study, 214 of whom (81.7%) were eventually discharged with a diagnosis of CAP. The agreement rates between the readers of the CXR ranged from a kappa of 0.09 to 0.44. There were no differences in terms of background illness, PORT (Pneumonia Patients Outcomes Research Team) score, length of hospitalization, or mortality rates between patients discharged with or without a diagnosis of CAP. In multivariate analysis, only the PORT score was a significant predictor of length of hospitalization and mortality rate. CONCLUSION: We found a low to moderate agreement rate of the diagnosis of CAP between CXR readers. Identification of an infiltrate on CXR, either by specialists or by the attending physician, did not impact the clinical outcomes.