Frequency of use and acceptability of clinical prediction rules for pulmonary embolism among Swiss general internal medicine residents.

INTRODUCTION: Whether clinical prediction rules for pulmonary embolism are accepted and used among general internal medicine residents remains uncertain. We therefore evaluated the frequency of use and acceptability of the Revised Geneva Score (RGS) and the Pulmonary Embolism Severity Index (PESI), and explored which factors were associated with rule use. MATERIALS/METHODS: In an online survey among general internal medicine residents from 10 Swiss hospitals, we assessed rule acceptability using the Ottawa Acceptability of Decision Rules Instrument (OADRI) and explored the association between physician and training-related factors and rule use using mixed logistic regression models. RESULTS: The response rate was 50.4% (433/859). Overall, 61% and 36% of the residents reported that they always or regularly use the RGS and the PESI, respectively. The mean overall OADRI score was 4.3 (scale 0-6) for the RGS and 4.1 for the PESI, indicating a good acceptability. Rule acceptability (odds ratio [OR] 6.19 per point, 95% confidence interval [CI] 3.64-10.51), prior training in emergency medicine (OR 5.14, CI 2.20-12.01), and availability of internal guidelines recommending RGS use (OR 4.25, CI 2.15-8.43) were associated with RGS use. Rule acceptability (OR 6.43 per point, CI 4.17-9.92) and rule taught at medical school (OR 2.06, CI 1.24-3.43) were associated with PESI use. CONCLUSIONS: The RGS was more frequently used than the PESI. Both rules were considered acceptable. Rule acceptability, prior training in emergency medicine, availability of internal guidelines, and rule taught at medical school were associated with rule use and represent potential targets for quality improvement interventions.

Physical activity and the frequency of acute exacerbations in patients with chronic obstructive pulmonary disease.

PURPOSE: Acute exacerbations (AE) in patients with COPD are associated with a decline in lung function, increased risk of hospitalization, and mortality. In this cross-sectional study we tested whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations. METHODS: In 210 patients with COPD (67 % men; mean (SD) age: 63 (8) years) enrolled in The Obstructive Pulmonary Disease Outcomes Cohort of Switzerland (TOPDOCS) physical activity (PA) (steps per day, physical activity level, (PAL)), exercise capacity (6-min walking distance, (6MWD)), comorbidities, lung function, and medication were assessed. Differences between COPD patients with frequent (≥2 year) and infrequent (0-1 year) exacerbations were assessed. Univariate and multivariate analyses were performed to investigate whether the level of objectively measured daily physical activity and exercise capacity are associated with the number of COPD exacerbations. RESULTS: Patients with frequent AE had a significantly lower FEV1 and 6MWD compared to patients with infrequent AE. In univariate analysis, the number of exacerbations was inversely associated with FEV1, 6MWD, BMI, and smoking status while there was a positive association with RV/TLC and combined inhaled medication. However, there was no significant association with PAL and steps per day. In multivariate analysis, FEV1 and the use of combined inhaled medication were independently associated with the number of AE, after correction for covariates. CONCLUSIONS: The findings of this study imply that FEV1, independent of inhaled medication, is significantly associated with COPD exacerbations. Neither physical activity nor exercise capacity was independently associated with COPD exacerbations.

[A smoking cessation intervention in the Swiss Armed Forces]. / «Feuer einstellen!¼ - eine kontrollierte Rauchstoppintervention bei Rekrutenschulen der Schweizer Armee.

Smoking is a major health risk in young adults. We undertook a study in young Swiss military recruits to determine the impact of intensive training and of help offered on smoking cessation during Basic Military Training (BMT). A questionnaire including questions according to their smoking status, sporting activities and, alcohol use was administered to 999 conscripts at beginning and at the end of the BMT. The results were compared to a control group of BMT schools where no such intervention took place. The study shows that the prevalence of smokers in the intervention group decreased (start BMT 31.9%, end BMT 25.5%; p = 0.021), while the prevalence of smokers increased in the control group (start BMT 26.4%, end BMT 32.6%; p = 0.038). A motivation to serve in the armed forces, as well as the willingness to stop smoking in the next month were the factors associated with a subsequent cessation of smoking during BMT. A smoke stop intervention during BMT is viable and can lead to a decrease in the prevalence of smoking at the end of BMT.

The use of the Asthma Control Test in general practice and its correlation with asthma control according to the GINA guidelines.

BACKGROUND: The GINA guidelines have redefined the primary goal of asthma treatment as achieving optimum control. OBJECTIVES: To document the level of asthma control in Switzerland, the correlations between the international guidelines by GINA and the ACT's rating of asthma control, current treatment in adolescent and adult Swiss asthma patients and factors associated with asthma control. METHODS: General practitioners and specialists (pulmonologists, allergologists and paediatricians) were invited to participate in the cross-sectional survey. Asthma control was assessed in 1093 asthma patients using both the ACT and the GINA classification for asthma control. RESULTS: According to the GINA guidelines controlled asthma was found in 290 (27%) patients, when measured with the ACT 124 (11.5%) patients showed sufficient asthma control. Of the test results 65% were in accordance with each other, whereas in 85% of the non-matching results the ACT underestimated control according to GINA classification. An ACT cut-off score of ≤17 best identified uncontrolled asthma according to GINA guidelines. A total of 956 (87.7%) patients received controller medication and 849 (77.9%) patients received reliever medication. The following parameters were consistently identified to be significantly associated with insufficient asthma control in both GINA and ACT measurements: presence of exacerbation, use of reliever medication, switch of therapy and smoking. STUDY LIMITATION: For this study only the ACT version for adults was used. CONCLUSION: Asthma control remains insufficient in the majority of patients, despite prescription of regular controller medication. This survey confirms the validated ACT to be useful and important in everyday practice as an objective measure for asthma control according to GINA guidelines in order to monitor control and adjust treatment.

[Intermittent or persistent rhinitis in children and adolescents with Asthma: «the Swiss LARA paediatrics survey¼]. / Intermittierende oder Persistierende Rhinitis bei Kindern und Jugendlichen mit Asthma: «The Swiss LARA paediatrics survey¼

Asthma and allergic rhinitis are chronic inflammatory airway diseases which often occur concomitantly. The objective of the LARA program was to identify the comorbidities and characteristics of asthma (A), intermittent or persistent rhinitis (IPR) and physician defined atopic dermatitis (AD) in 6- to 16-year old asthmatic Swiss children and adolescents. Overall, 126 general practitioners and paediatricians collected the data of 670 asthmatics. Approximately one third of the asthmatic children in Switzerland had well-controlled asthma. Almost two thirds of these asthmatics suffered from concomitant IPR. The latter presented with significantly less symptoms while the treatment rates with inhaled corticosteroids (approximately 90%) and leukotriene-receptorantagonists (approximately 50%) were comparable. However, there were almost twice as many passive smokers in the less well-controlled group. The prevalence of AD was similar in both groups. IPR and AD may play an important role as risk factors in the future development of asthma.

[Smoking behaviour and willingness to stop smoking in patients admitted in an internal medicine ward]. / Untersuchung der Rauchgewohnheiten und der Bereitschaft zum Rauchstopp bei Patienten einer internistischen Abteilung.

Smoking is one of the leading preventable risk factors for the development of lung-, cardio-vascular diseases and cancer. We report results of a prospective survey regarding smoking behaviour and willingness to stop smoking in patients of an internal medicine clinic. Twenty percent of participants admitted smoking cigarettes in the previous 7 days. Smokers were more often males and were younger than non- or ex-smokers. Every second smoker reported being told to stop smoking by a physician before but only about a third was offered active support in doing so. About half of the smoking participants were interested to quit smoking and to participate in a hospital-based smoking cessation program. In patients admitted to the hospital, smoking behaviour and willingness to quit smoking should be recorded and help in quitting smoking should be offered actively. Beside recording smoking behaviour and willingness to quit, patients who are admitted in the hospital should be offered help to quit smoking or to join a proactive structured smoking cessation program.

Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study.

Malignant airway-oesophageal fistulas (AEF) are a serious complication of advance oesophageal or lung cancer. The aim of this study was to assess the quality of life before and after stent insertion, and to examine the role of treatment and location of AEF as factors influencing survival in AEF patients managed with airway and/or oesophageal stent insertion. 112 patients with AEF were included prospectively. 83 (74%) patients had advanced lung cancer and 29 (26%) patients had oesophageal cancers. Airway stents were inserted in 65 (58%) patients, oesophageal stents in 37 (33%) patients, and both airway and oesophageal stents in 10 (9%) patients. Seven (6%) patients developed respiratory failure and required transient ventilator support in the intensive care unit (four patients with airway stenting, two patients with double stents and one patient in the oesophageal stenting group). None of the patients developed stent migration or needed stent repositioning. Overall, mean survival was 236.6 days (airway stent 219.1 days, oesophageal stent 262.8 days and combined airway-oesophageal stent 252.9 days). Backward, stepwise regression revealed the site of stent placement (airway and/or oesophagus; p < 0.028), exact location of the fistula in airway (p = 0.011) and additional treatment with chemotherapy and/or radiation (p < 0.001) as independent risk factors predicting increased survival. The mean quality of life score (QoL) was 81 prior to stent insertion and 72 post-stent insertion (p < 0.001). Airway and/or oesophageal stent insertion provides an effective approach to improve the QoL in patients with malignant AEF.

General practitioner's adherence to the COPD GOLD guidelines: baseline data of the Swiss COPD Cohort Study.

PRINCIPLES: Chronic obstructive pulmonary disease (COPD) is a major burden on patients and healthcare systems. Diagnosis and the management of COPD are often administered by general practitioners (GPs). This analysis investigated the adherence of GPs in Switzerland to the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) guidelines. METHODS: As part of an ongoing investigation into the effect of GPs prescriptions on the clinical course of COPD, 139 GPs submitted a standardised questionnaire for each COPD patient recruited. Information requested included spirometric parameters, management and demographic data. Participating GPs were provided with and received instruction on a spirometer with automatic feedback on quality. Patients were grouped by the investigators into the GOLD COPD severity classifications, based on spirometric data provided. Data from the questionnaires were compared between the groups and management was compared with the recommendations of GOLD. RESULTS: Of the 615 patients recruited, 44% did not fulfil GOLD criteria for COPD. Pulmonary rehabilitation was prescribed to 5% of all patients and less than one-third of patients exercised regularly. Less than half the patients in all groups used short-acting bronchodilators. Prescribing long-acting bronchodilators or inhaled corticosteroids conformed to GOLD guidelines in two-thirds of patients with GOLD stage III or IV disease, and approximately half of the less severe patients. Systemic steroids were inappropriately prescribed during stable disease in 6% of patients. CONCLUSIONS: Adherence to GOLD (COPD) guidelines is low among GPs in Switzerland and COPD is often misdiagnosed or treated inappropriately. This is probably due to poor knowledge of disease definitions.

Quality of spirometry in primary care for case finding of airway obstruction in smokers.

BACKGROUND: Diagnosis of chronic obstructive pulmonary disease (COPD) and its severity determination is based on spirometry. The quality of spirometry is crucial. OBJECTIVES: Our aim was to assess the quality of spirometry performed using a spirometer with automated feedback and quality control in a general practice setting in Switzerland and to determine the prevalence of airflow limitation in smokers aged > or =40 years. METHOD: Current smokers > or =40 years of age were consecutively recruited for spirometry testing by general practitioners. General practitioners received spirometry training and were provided with an EasyOne spirometer. Spirometry tests were assigned a quality grade from A to D and F, based on the criteria of the National Lung Health Education Program. Only spirometry tests graded A-C (reproducible measurements) were included in the analysis of airflow limitation. RESULTS: A total of 29,817 spirometries were analyzed. Quality grades A-D and F were assigned to 33.9, 7.1, 19.4, 27.8 and 11.8% of spirometries, respectively. 95% required < or =5 trials to achieve spirometries assigned grade A. The prevalence of mild, moderate, severe and very severe airway obstruction in individuals with spirometries graded A-C was 6, 15, 5 and 1%, respectively. CONCLUSION: Spirometries in general practice are of acceptable quality with reproducible spirometry in 60% of measurements. Airway obstruction was found in 27% of current smokers aged > or =40 years. Office spirometry provides a simple and quick means of detecting airflow limitation, allowing earlier diagnosis and intervention in many patients with early COPD.

Asthma tests in the assessment of military conscripts.

BACKGROUND: Respiratory diseases such as asthma may affect individuals' fitness for military service. In order to assess fitness for military service in subjects with asthma symptoms at conscription, objective and reliable tests are needed. OBJECTIVE: To prospectively determine the diagnostic value of the mannitol and methacholine bronchial provocation test (BPT) as well as exhaled nitric oxide in assessing physician-diagnosed asthma in a group of Swiss Armed Forces conscripts. METHODS: Questionnaire, spirometry, BPT with methacholine and mannitol, exhaled nitric oxide (FeNO) and skin prick testing were conducted in 18-20-year-old male conscripts. Asthma was diagnosed by a military physician not involved in this study according to the medical record, results of BPT, current respiratory symptoms and use of asthma medication. RESULTS: Two hundred and eighty four subjects participated in the study. Complete data for the BPT with methacholine, mannitol and measurement of FeNO were available on 235 subjects. Forty-two conscripts (17.9%) had physician-diagnosed asthma. The sensitivity/specificity of mannitol to identify physician-diagnosed asthma was 41%/93% and for methacholine it was 43%/92%. Using a cut-off point of 36.5 p.p.b., FeNO had a similar negative predictive value to rule out physician-diagnosed asthma as BPT with mannitol or methacholine. CONCLUSION: BPT with mannitol has a sensitivity and specificity similar to methacholine for the diagnosis of physician-diagnosed asthma in military conscripts but is less costly to perform without the need to use and maintain a nebulizer.

["Real-life"-data on asthma control using budesonide/formoterol for both maintenance and relief: the Swiss experience]. / "Real-life"-Daten zur Asthmakontrolle mit Budesonid/Formoterol als Erhaltungs- und Bedarfstherapie: die Erfahrung in der Schweiz.

BACKGROUND: Asthma is not adequately controlled in many patients. A new approach in asthma treatment, known as Budesonide/Formoterol Maintenance and Reliever Therapy has shown improvement in asthma control compared to conventional therapy regimens. As Switzerland was the first European country to formally approve budesonide/formoterol maintenance and reliever therapy, a patient follow-up programme was commenced in January 2006 to investigate its efficacy and safety in a "real-life" environment. METHODS: A non randomized uncontrolled post-marketing survey involving 420 physicians in all language regions in Switzerland was carried out. 2035 patients with asthma were enrolled. Data on current asthma treatment, asthma control and unscheduled visits due to worsening asthma were recorded. Asthma control was assessed subjectively by both the patients and the physicians as well as by means of the validated 5-item Asthma Control Questionnaire (ACQ5). An ACQ score of 0.75 or less indicates well-controlled asthma. RESULTS: Data from 2006 out of 2035 patients were analysed (mean age 44.9 +/- 19.6 years, 50.5% female). With budesonide/formoterol maintenance and reliever therapy the mean ACQ5 score improved by more than 3-fold the defined minimal important difference (MID). The percentage of patients with an ACQ score < or =0.75 increased from 4.8% at baseline to 58.0% at the end of the follow-up programme. Patient satisfaction with budesonide/formoterol for both maintenance and relief was high. CONCLUSIONS: Budesonide/formoterol maintenance and reliever therapy improves asthma control in a non randomised real-life setting.

Use of B-type natriuretic peptide in the risk stratification of community-acquired pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is the leading infectious cause of death in developed countries. Risk stratification has previously been difficult. METHODS: Markers of cardiac stress (B-type natriuretic peptide, BNP) and inflammation (C-reactive protein, white blood cell count, procalcitonin) as well as the pneumonia severity index (PSI) were determined in 302 consecutive patients presenting to the emergency department (ED) with CAP. The accuracy of these parameters to predict death was evaluated as the primary endpoint. Prediction of treatment failure was considered as the secondary endpoint. RESULTS: B-type natriuretic peptide levels increased with rising disease severity as classified by the PSI (P = 0.015). BNP levels were significantly higher in nonsurvivors compared to survivors [median 439.2 (IQR 137.1-1384.6) vs. 114.3 (51.3-359.6) pg mL(-1), P < 0.001]. In a receiver operating characteristic analysis for the prediction of survival the area under the curve (AUC) for BNP was comparable to the AUC of the PSI (0.75 vs. 0.71, P = 0.52). Importantly, the combination of BNP and the PSI significantly improved the prognostic accuracy of the PSI alone (AUC 0.78 vs. 0.71; P = 0.02). The optimal cut-off for BNP was 279 pg mL(-1). The accuracy of BNP to predict treatment failure was identical to the accuracy to predict death (AUC 0.75). CONCLUSIONS: In patients with CAP, BNP levels are powerful and independent predictors of death and treatment failure. When used in conjunction with the PSI, BNP levels significantly improve the risk prediction when compared with the PSI alone.

Respiratory symptoms, atopy and bronchial hyperreactivity in professional firefighters.

The aim of the present study was to assess respiratory health in professional firefighters. A total of 101 male professional firefighters from Basel, Switzerland, were included in the study. A control group consisting of 735 male subjects of the general population was composed of the Basel sample of the Swiss Study on Air Pollution and Lung Diseases in Adults. All subjects were administered a standardised questionnaire, spirometry, skin-prick tests and bronchial challenge testing to methacholine. Respiratory symptoms at work were more frequent in firefighters compared with the control group, including burning eyes (21 versus 3%), running nose (19 versus 2%), itchy throat (26 versus 3%), cough (28 versus 3%), dyspnoea (7 versus 2%) and headache (25 versus 3%), respectively. Atopy was present in 51% of firefighters compared with 32% in the control group. The odds ratio for hyperreactivity to methacholine was 2.24 (95% confidence interval 1.12-4.48) for firefighters compared with the control group. Firefighters reported more respiratory symptoms at work and suffered more often from atopy compared with the control group. Bronchial hyperreactivity was more pronounced in firefighters, but it was not related to acute exposure or duration of employment. It remains unclear whether these findings were present at recruitment or developed after joining the workforce.

Measurement of combined oximetry and cutaneous capnography during flexible bronchoscopy.

The aim of the present study was to assess the feasibility of measuring combined arterial oxygen saturation measured by pulse oximetry (Sp,O2) and cutaneous carbon dioxide tension (Pc,CO2) to monitor ventilation and quantify change in Pc,CO2 during bronchoscopy. Combined Sp,O2 and Pc,CO2 were measured at the ear lobe in 114 patients. In four patients, the ear-clip slipped and they were excluded. In total, 11 patients had artefacts with Sp,O2 recordings, thus, Sp,O2 was analysed in 99 patients. Spirometry data were available in 77 patients. Multivariate analysis of covariance and logistic regression were used for statistical analyses. Mean baseline Pc,CO2 was 4.78+/-1.06 kPa (36+/-8 mmHg) and mean rise in the Pc,CO2 during bronchoscopy was 1.26+/-0.70 kPa (9.5+/-5.3 mmHg), while mean Pc,CO2 at the end of bronchoscopy was 5.85+/-1.19 kPa (44+/-9 mmHg) . Baseline Pc,CO2 and the lowest Sp,O2 were significantly associated with peak Pc,CO2 and the change in Pc,CO2 during bronchoscopy. Risk of significant hypoxaemia (Sp,O2

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.

Symptoms of persistent allergic rhinitis during a full calendar year in house dust mite-sensitive subjects.

BACKGROUND: Little is known about the natural course of persistent rhinitis symptoms over a prolonged period. OBJECTIVE: To describe the frequency and severity of nasal symptoms and quality of life (QoL) in house dust mite-sensitive persistent rhinitic subjects and to determine if medication use was related to symptoms. METHODS: Rhinitics and controls were telephoned fortnightly for 1 year to monitor symptoms. QoL was measured every 3 months. RESULTS: Thirty-seven rhinitics and 19 controls completed the study. Total nasal symptom scores (TNSS) were 'high' for 65% (95% CI +/- 6%) of the year in rhinitic subjects. When TNSS increased by 1, the likelihood of nasal medication use increased by 25% (95% CI: 7-46%). General and specific QoL were worse in rhinitic subjects than controls (P < 0.04 and <0.0001). Rhinitics with pollen allergy (n = 21) had seasonal variation in the frequency of high nasal symptom scores (P = 0.02). CONCLUSION: Nasal symptom scores were consistently high in rhinitics, and their QoL was worse than controls, even in general QoL. An increase in nasal symptom score increased the likelihood of nasal medication use. These findings help to characterize the course of persistent rhinitis over a previously unstudied period of 1 year.

Increased prevalence of perennial allergic rhinitis in patients with obstructive sleep apnea.

BACKGROUND: Impaired nasal breathing is a risk factor for obstructive sleep apnea syndrome (OSAS). OBJECTIVES: The aim of this study was to determine whether atopy to perennial allergens and existence of perennial allergic rhinitis was a risk factor for OSAS. METHODS: In a case-control study, we compared the proportions of OSAS patients with atopy to perennial allergens and perennial allergic rhinitis to the proportions in patients with chronic obstructive pulmonary disease (COPD). Seventy-two OSAS patients (mean age 60.7 years; 79.4% male) and 44 COPD patients (mean age 63.6 years; 88.6% male) were selected from a hospital outpatients' clinic in Switzerland. All patients completed a respiratory symptom questionnaire, performed spirometry and had a skin prick test for atopy. RESULTS: OSAS patients were significantly heavier than COPD patients (BMI 32.4 +/- (SD) 6.6 vs. 29.2 +/- 6.6 kg/m2, p = 0.04) and had a better lung function than COPD patients (FEV1% predicted 91.3 +/- 19.2 vs. 51.6 +/- 18.9%, p < 0.001). Patients with OSAS were more likely to be sensitized to perennial allergens such as house dust mite (23.6 vs. 4.5%, p = 0.009) and dog (18 vs. 4.5%, p = 0.04) than the COPD patients. Perennial allergic rhinitis (having nose problems [nasal obstruction and/or runny nose and/or sneezing] all year and being atopic to at least one perennial allergen) was reported in 11% of OSAS patients but in only 2.3% of COPD patients (p = 0.15). CONCLUSION: We conclude that subjects with OSAS may have an increased risk of being allergic to perennial allergens and suffer from perennial rhinitis. Awareness of this risk may have important consideration in the clinical situation.

Association between nasal and bronchial symptoms in subjects with persistent allergic rhinitis.

BACKGROUND: The association between nasal and bronchial symptoms, and the course of bronchial responsiveness and airway inflammation in house dust mite sensitive persistent rhinitis over a prolonged time period has not been thoroughly explored. OBJECTIVE: To determine if nasal symptoms were associated with bronchial symptoms in persistent rhinitic subjects, and to assess their bronchial responsiveness and airway inflammation in comparison to nonrhinitic, nonatopic controls. The additional impact of pollen sensitivity on the lower airways in rhinitic subjects was also addressed. METHODS: Rhinitics and controls answered telephone symptom questionnaires once every 2 weeks for 1 year. Every 3 months, exhaled nitric oxide (eNO) and bronchial responsiveness to histamine were measured. RESULTS: Thirty-seven rhinitics and 19 controls completed the study. High nasal symptom scores in rhinitic subjects were associated with bronchial symptoms (OR = 1.7, 95% CI 1.2-2.5). Bronchial hyper-responsiveness was present in 32.4% of rhinitic subjects on at least one clinical visit during the year. Pollen allergy caused seasonal variation in eNO (P = 0.03). CONCLUSION: In persistent rhinitic subjects, high nasal symptom scores were associated with bronchial symptoms, and many subjects experienced bronchial hyper-responsiveness during the year. Persistent rhinitic subjects were more at risk than healthy adults of bronchial symptoms and airway inflammation, which are likely risk factors for asthma.

Ciprofloxacin-induced acute interstitial pneumonitis.

The current authors present the case of a 68-yr-old female patient who developed severe respiratory failure after medication with ciprofloxacin for acute urinary tract infection. A chronic subdural haematoma was surgical evacuated. Postoperatively, an acute urinary tract infection was treated with ciprofloxacin. Six days later, C-reactive protein was rising and the patient was suffering from intermittent high fever, dyspnoea and severe hypoxaemia. The high-resolution-computed tomography (HRCT) showed an interstitial lung disease in the anterior upper lobe on the left side as well as in the lingula. Assuming a bacterial infection amoxyl/clavulanic acid was started which did not improve the clinical symptoms. Bronchoalveolar lavage revealed a marked lymphocytosis (87%). Analysis for typical bacterial infections, Tuberculosis, Mycoplasma, Chlamydia and Legionella spp. were all negative. Another HRCT scan was made because of worsening of symptoms and this showed rapidly progressive infiltrates in most lobes. An open lingular biopsy showed an interstitial lymphoplasmocytotic infiltrate with some eosinophilic granulocytes and a few scattered giant cell granulomas, consistent with hypersensitivity pneumonitis. The patient's symptoms rapidly improved with systemic corticosteroid therapy and another HRCT scan revealed complete remission of pulmonary infiltrates. Ciprofloxacin can induce interstitial pneumonitis with acute respiratory failure. This is an important fact considering that ciprofloxacin is a widely used antibiotic agent in treatment of urinary tract infection.