Organizing pneumonia and non-necrotizing granulomata on transbronchial biopsy: coexistence or bronchiolitis obliterans organizing pneumonia secondary to Mycobacterium kansasii disease.

Mycobacterium kansasii disease was diagnosed in an 85-year-old woman admitted to the hospital for cough and gradually worsening breathlessness. Transbronchial biopsy indicated either non-necrotizing granulomata or bronchiolitis obliterans organizing pneumonia (BOOP). She was cured with combined therapy of specific anti-mycobacterial medications and systemic steroids. To our knowledge, this is the first report of M. kansasii non-tuberculous mycobacterium disease with a BOOP-like pattern on lung biopsy.

Efficacy of nebulized fluticasone propionate in adult patients admitted to the emergency department due to bronchial asthma attack.

BACKGROUND: Locally delivered steroids by inhalers or nebulizers have been shown in small trials to be effective in acute asthma attack, but evidence-based data are insufficient to establish their place as routine management of adult asthma attacks. OBJECTIVES: To determine the efficacy of nebulized compared to systemic steroids in adult asthmatics admitted to the emergency department following an acute attack. METHODS: Adult asthmatics admitted to the ED were assigned in random consecutive case fashion to one of three protocol groups: group 1--nebulized steroid fluticasone (Flixotide Nebules), group 2--intravenous methylprednisolone, group 3--combined treatment by both routes. Objective and subjective parameters, such as peak expiratory flow, oxygen saturation, heart rate and dyspnea score, were registered before and 2 hours after ED treatment was initiated. Steroids were continued for 1 week following the ED visit according to the protocol arm. Data on hospital admission/discharge rate, ED readmissions in the week after enrollment and other major events related to asthma were registered. RESULTS: Altogether, 73 adult asthmatics were assigned to receive treatment: 24 patients in group 1, 23 in group 2 and 26 in group 3. Mean age was 44.4 +/- 16.8 years (range 17-75 years). Peak expiratory flow and dyspnea score significantly improved in group 1 patients compared with patients in the other groups after 2 hours of ED treatment (P = 0.021 and 0.009, respectively). The discharge rate after ED treatment was significantly higher in groups 1 and 3 than in group 2 (P = 0.05). All 73 patients were alive a week after enrollment. Five patients (20.8%) in the Flixotide treatment arm were hospitalized and required additional systemic steroids. Multivariate analysis of factors affecting hospitalization rate demonstrated that severity of asthma (odds ratio 8.11) and group 2 (OD 4.17) had a negative effect, whereas adherence to chronic anti-asthma therapy (OD 0.49) reduced the hospitalization rate. CONCLUSIONS: Our study cohort showed the advantage of nebulized steroid fluticasone versus systemic corticosteroids in adult asthmatics managed in the ED following an acute attack. Both these and previous results suggest that nebulized steroids should be used, either alone or in combination with systemic steroids, to treat adults suffering acute asthma attack.

Asthma control and compliance in a cohort of adult asthmatics: first survey in Israel.

BACKGROUND: Asthma control and treatment compliance are widely investigated issues around the world. Studies have demonstrated relatively low asthma compliance and control in 40-90% of asthma patients in different countries. There are no available data on the Israeli adult asthmatic population OBJECTIVES: To investigate the level of asthma control and compliance in adult asthmatic patients. METHODS: This cross-sectional study of consecutive adult asthmatic patients visiting the pulmonary clinic used a combined questionnaire that included demographics, data on asthma severity and management, and asthma control and compliance scores. Each patient was interviewed and questionnaires were filled out during a routine visit. RESULTS: The study group comprised 142 males (35.4%) and 259 females (64.6%). Compliance was found optimal in 8 patients (2%), fair in 146 (36%), partial in 156 (39%) and poor in 92 (23%) of the participating asthmatic patients. Asthma control was found optimal in 26 (7%), fair in 124 (31%), partial in 122 (30%) and poor in 129 (32%). Sephardic and Ashkenazi Jewish origin, higher level of education, and treatment protocol including either single fixed-dose inhalers or short-acting beta-agonist bronchodilators significantly improved compliance in our cohort. Socioeconomic status and compliance were found to positively affect asthma control, whereas active smoking negatively affected asthma control in the study patients. CONCLUSIONS: The figures of optimal asthma control and compliance to treatment in Israeli adult asthmatics are low and worse than reported in other studies abroad.

[Ocular manifestation of bronchogenic carcinoma: simultaneous occurrence of diffuse uveal melanocytic proliferation and uveal metastases].

Systemic cancer may affect the eye and orbit as metastatic disease or paraneoplastic retinal degeneration. This is a case report of a 55-year-old man with unilateral visual loss as the presenting symptom of metastatic adenocarcinoma of lung in one eye and diffuse uveal melanocytic proliferation in the other. Fundoscopy, B-scan ultrasonography, fluorescein angiography and the workup for inflammatory, infectious and neoplastic diagnoses are presented. In heavy smokers, bronchogenic carcinoma should be highly suspected.

Minocycline induced lupus with yellow colored chylous exudative pleural effusion.

Ninety years old male was admitted to hospital due to breathlessness. The prominent findings were extensive blue-grey skin pigmentation and large left chylothorax. Drug induced lupus was diagnosed due to either minocycline chronic treatment or no alternative illness to explain his sub-acute disease. Minocycline therapy was stopped with gradual improvement of pleural effusion and skin discoloration. This case is the first presentation of minocycline induced lupus with chylothorax.

Patterns of waste generation: A gradient boosting model for short-term waste prediction in New York City.

Historical municipal solid waste (MSW) collection data supplied by the New York City Department of Sanitation (DSNY) was used in conjunction with other datasets related to New York City to forecast municipal solid waste generation across the city. Spatiotemporal tonnage data from the DSNY was combined with external data sets, including the Longitudinal Employer Household Dynamics data, the American Community Survey, the New York City Department of Finance's Primary Land Use and Tax Lot Output data, and historical weather data to build a Gradient Boosting Regression Model. The model was trained on historical data from 2005 to 2011 and validation was performed both temporally and spatially. With this model, we are able to accurately (R2>0.88) forecast weekly MSW generation tonnages for each of the 232 geographic sections in NYC across three waste streams of refuse, paper and metal/glass/plastic. Importantly, the model identifies regularity of urban waste generation and is also able to capture very short timescale fluctuations associated to holidays, special events, seasonal variations, and weather related events. This research shows New York City's waste generation trends and the importance of comprehensive data collection (especially weather patterns) in order to accurately predict waste generation.

Assessment of functional capacity in patients with chronic obstructive pulmonary disease: correlation between cardiopulmonary exercise, 6 minute walk and 15 step exercise oximetry test.

BACKGROUND: Different exercise tests are used to evaluate the functional capacity in chronic obstructive pulmonary disease. The cardiopulmonary exercise test is considered the gold standard, but the 6 minute walk and the 15 step exercise oximetry test are considerably less expensive. OBJECTIVES: To determine whether reliable data could be obtained at lower cost. METHODS: The study sample consisted of 50 patients with mild to severe stable COPD. All underwent pulmonary function test and the cardiopulmonary exercise test, 6 minute walk and 15 step exercise oximetry test as part of their regular follow-up visit. Functional capacity was graded according to each test separately and the functional capacities obtained were correlated. RESULTS: The results showed that most of the patients had severe COPD according to pulmonary function tests (mean forced expiratory volume in the first second 46.3 +/- 19.9% of predicted value). There was a good correlation between the cardiopulmonary exercise test and the 6 minute walk functional capacity classes (r = 0.44, P = 0.0013). We did not find such correlation between the 15 step exercise oximetry test and the cardiopulmonary exercise test (r = 0.07, P = 0.64). CONCLUSIONS: The study shows that the 6 minute walk is a reliable and accurate test in the evaluation of functional capacity in COPD patients.

Initial experience with a mechanical ventilation weaning unit.

BACKGROUND: While increasing numbers of patients require prolonged mechanical ventilation, resources for weaning are either limited (ICU beds) or inadequate (general wards). OBJECTIVES: To report on our initial experience over a 7 month period with an eight-bed mechanical ventilation weaning unit. METHODS: Sixty-nine patients requiring MV for > 10 days were admitted to the unit (nurse:patient ratio 1:4). Data collected included reason for MV, duration of hospital stay, and MVWU course. Outcome results (successful weaning and mortality) were compared to those in historic controls (patients ventilated in the general wards over a 4 month period prior to the MVWU; n = 100). RESULTS: The mean age of the patients was 68 +/- 16.6 years and hospital stay prior to MVWU admission 28.6 +/- 24.2 days (range 10-72). The main reasons for MV included acute exacerbation of chronic obstructive pulmonary disease (31%) and recent pneumonia (28%). Mean MVWU stay was 13.5 +/- 15.7 days (range 1-72 days). Thirty-four patients (49%) underwent tracheostomy. Fourteen patients required admission to the ICU due to deterioration in their status. Twenty-nine patients (42%) were successfully weaned and discharged to the wards. A further 20 patients were transferred to the chronic ventilation unit of a regional geriatric rehabilitation hospital, where 5 were subsequently weaned and 15 required prolonged ventilation. Compared to controls (matched for age and reason for mechanical ventilation), more MVWU patients underwent successful weaning (49% vs. 12%, P < 0.001) and their mortality rate (n = 12) was significantly lower (17% vs. 88%, P < 0.001). CONCLUSION: The higher level of care possible in a MVWU may result in a significantly improved rate of weaning and lower mortality. The assessment of long-term outcome in patients discharged to pulmonary rehabilitation centers requires further investigation.

Late-onset chylothorax after heart-lung transplantation.

Chylothorax has rarely been reported after heart and lung transplantation. We describe a case of a bilateral chylothorax that occurred in a 53-year-old man 4 months after heart-lung transplantation and review the three additional reports in the literature of chylothorax after heart transplantation. Chyle drainage may cause compromise of the transplant patient. The good nutritional status of our recipient, however, allowed conservative therapy with chest tube drainage and enteral low-fat diet, without the need for surgical intervention. We concluded that chylothorax can presents late after lung transplantation and that conservative treatment should be considered in patients with good nutritional status.

Large vessel aneurysms in Wegener's granulomatosis.

Large vessel aneurysm is not a classical finding in Wegener's granulomatosis. We describe a case report of WG complicated by subclavian artery aneurysm and review the literature on large-vessel and medium-vessel aneurysms in WG. The involved arteries included the aorta and the hepatic, renal, and left gastric arteries. In all but one case, abdominal pain was the presenting symptom. Treatment included medical and vascular interventions. In two patients, the involved vessel ruptured, leading to massive hemorrhage and death. We concluded that unexplained abdominal pain or extremity ischemia in patients with WG should alert the physician to the possibility of a large-vessel or medium-vessel aneurysm.