Passive smoking and respiratory allergies in adolescents.

OBJECTIVE: The aim of our study was to investigate impact of active and passive smoking on total and specific serum IgE levels and on incidence of developing allergic diseases (i.e. asthma, rhinitis) in a group of Croatian adolescents. METHODS: Our study consisted of random sample of one hundred fifty-five (155) voluntary pupils (80 males and 75 females), with mean age of 16.72 +/- 1.25 years, from one high school in the city of Varazdin (north-west part of Croatia). Their smoking habits were examined by interview administered by a single trained survey worker while diagnosis of allergic disease (i.e. asthma and allergic rhinits) had to be previously confirmed by physician. Total and specific serum IgE levels were determined using enzyme-linked immunosorbent assay (ELISA) method in Central Laboratory of Clinic for lung diseases Jordanovac, Zagreb (Croatia). RESULTS: Statistically significant higher prevalence of allergic diseases was found in the group of passive smokers as opposed to nonsmokers (chi2=9.29, p=0.002) as well as in active smokers compared to nonsmokers (chi2=4.45, p=0.034). Also, total IgE (IU/ml) was significantly higher in passive smokers when compared to non-smokers (t=13.039, p<0.01), and in passive smokers as opposed to active smokers as well (t=4.960, p<0.01), while difference in its level between active smokers and non-smokers was not statistically significant. The level of specific IgE to Dermatophagoides pteronyssinus between active smokers, passive smokers and non-smokers resulted to be not statistically significant. CONCLUSIONS: Results of the study indicate that clinical manifestations of allergic diseases are more frequent in smokers (both active and passive) than in nonsmokers. Our investigation leads us to a presumption of a possibly more harmful effect of passive than active smoking in the adolescent high school population. Statistically highest IgE level in passive smokers as opposed to non-smokers or smokers could be attributed to longer duration of exposure to tobacco smoke in passive smokers and tobacco's potential cumulative effect on allergic senzitisa-tion, although investigations with more precised and detailed mesures including higher number of participants are warranted.

Antibiotic therapy for exacerbations of chronic obstructive pulmonary disease (COPD).

Chronic obstructive pulmonary disease (COPD) is already the world's fourth most common cause of mortality and likely to become the third in a few year's time. Because it is an inflammatory airway disease with altered host immune response, infectious complications are frequent. Acute exacerbations of COPD (AECOPD) significantly worsen the patient's general health, accelerating disability. Each exacerbation leads progressively to further deterioration of lung function. Among the various causes of AECOPD, including viruses, bacteria and air pollution, a bacterial etiology is most common (50-69%). The management of AECOPD remains extremely challenging and places a heavy economic burden on health care institutions. The decision to administer antibiotics in AECOPD is multifactorial, the most important considerations being severity of the COPD stage and patient performance status, clinical symptoms (increased dyspnea, sputum volume and sputum purulence), severity of current and previous exacerbations, comorbidity and current smoking. Exacerbations which require hospital admission are associated with significant in-patient mortality. AECOPD patients presenting with worsening dyspnea, increased sputum volume and purulence should be offered antimicrobial therapy. If treating with antibiotics, treatment must include coverage for Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis in all cases, but other bacteria (such as Gram-negatives) may need to be covered depending on the condition of the patient. Antibiotics, particularly macrolides and fluoroquinolones, when administered under suitable conditions, shorten the clinical course and prevent severe deterioration. possible complications resulting from untreated severe AECOPD surpass the potential risks from the use of antibiotic therapy. Additional anti-inflammatory and immunomodulatory actions of some antibiotics may contribute to their efficacy in AECOPD.

Exsanguinating tuberculosis-related hemoptysis: bronchial blocker introduced through percutaneous tracheostomy.

Life-threatening hemoptysis is very rare and, fortunately, not many physicians have experienced it. The unpredictability of massive hemoptysis is often underestimated in seemingly stable patients and becomes fatal within a few minutes. The current definitions of massive and/or life-threatening hemoptysis in the medical literature are inadequate and the specific recommendations for the management of such conditions, based on sporadic case reports, are inadequate as well. We report herein a case of active tuberculosis-related exsanguinating hemoptysis (>1500 mL of blood within minutes) in a 26-year-old male, which illustrates the essential issues in the management of this condition; the pertinent literature is also reviewed. After a cardiac arrest with successful resuscitation, in an effort to reduce the risk of recurrent hemoptysis, we introduced a bronchial blocker (i.e., a Fogarty catheter), as guided by a fiberoptic bronchoscope, into the right main bronchus through several days earlier performed percutaneous tracheostomy because of patient's respiratory insufficiency. Several factors played a crucial role in the patient's survival. The main purpose of this case report is to contribute to the management of hemoptysis that leads to exsanguination within minutes and the originality of this report entails the introduction of bronchial blocker through the percutaneous tracheal cannula.

Tuberculosis knowledge among patients in out-patient settings in Split, Croatia.

SETTING: Patients of five randomly selected general practitioners in Split, Croatia. OBJECTIVE: To investigate knowledge about tuberculosis (TB) and to identify target groups for information, education and communication activities. DESIGN: Cross-sectional survey based on a structured questionnaire using a convenience sampling among subjects aged > or =18 years. Data were stratified by sex, age group, educational background, personal monthly income and contact with TB patients. TB knowledge scores were determined from the number of correct answers to 12 selected questions. RESULTS: The questionnaires were completed by 386 subjects. No statistically significant differences were observed between females and males with respect to age, educational background or contact with TB patients, except for personal income, which was higher in males (P < 0.001). The mean TB knowledge score was 9.4 +/- 1.98 (range 1-12, median 10). A low score was associated with the youngest age group, 18-29 years (P = 0.018), and with <12 years of education (P = 0.002). CONCLUSION: Educational background and age groups of respondents were important determinants of TB knowledge. Although the study sample showed a satisfactory level of knowledge, the results demonstrated several misconceptions that need to be clarified. Uncertainties in core TB knowledge need to be addressed choosing less educated and young people as specific target groups.

COPD: magnesium in the plasma and polymorphonuclear cells of patients during a stable phase.

Magnesium is one of the most important factors for regulation of inflammatory response as well as muscle function, and COPD is a multicomponent disease characterized by abnormal inflammatory response of the lungs with systemic muscle dysfunction. Because polymorphonuclear (PMN) cells are significantly represented in the pathogenesis of COPD, concentrations of total (tMg) and ionised magnesium (iMg) were determined in plasma and isolated PMN cells in 46 patients in stable phase of COPD (past smokers, current smokers, and non-smokers), 24 healthy smokers and 37 healthy non-smokers. In the same samples concentrations of total (tCa) and ionised calcium (iCa) were determined, due to the antagonism of magnesium towards calcium. We found decreased biological active iMg in PMN compared to the group of healthy non-smokers (5.42, 1.98-17.31 micromol/10(9) cells vs. 7.50, 3.27-15.15 micromol/10(9) cells, p < 0.05). In the plasma and isolated PMN of the patients the ratio of total calcium/total magnesium (tCa/tMg) was significantly increased (2.89, 2.15-3.86 and 1.19, 0.07-9.87) compared to the group of healthy non-smokers (2.65, 2.19-3.44 and 0.67, 0.14-2.40, p < 0.05) and to the group of healthy smokers (2.58, 2.26-3.24 and 0.66, 0.14-2.85, p < 0.05). In the group of patients the concentration of tCa was significantly increased in all samples compared to the healthy group of non-smokers and healthy smokers. The results of univariant logistic regression analysis for smoking, concentration of tCa and ratio of tCa/tMg in PMN showed high odds ratio for COPD status. These results raise a possibility that intracellular polymorphonuclear value of magnesium could be a distinctive marker for COPD risk disclosure among smokers.

Clinical validation of bronchial hyperresponsiveness, allergy tests and lung function in the diagnosis of asthma in persons with dyspnea.

The aim of the study was to determine the most useful tests for decision making in the diagnosis of asthma in patients with dyspnea assessed by commonly used terms: sensitivity, specificity, positive and negative predictive values and diagnostic accuracy. In a group of 195 patients with dyspnea data were analyzed with respect to case histories and different diagnostic procedures: bronchial hyperresponsiveness (BHR), skin prick tests (SPT), total IgE, spirometry (FEV1), sputum eosinophils (SE) and blood eosinophilia (BE). Asthma was diagnosed in 141 subjects. The control group comprised 18 subjects. Sensitivity for BHR in asthma in subjects with dyspnea amounted to 97%, for SPT to 62%, while all other diagnostics were lower than 50%. Specificity was highest for SE (94%), and BHR (85%). Positive predictive value (PPV) in asthma was for BHR 94%, for SE 86%, for SPT 81%, for decreased FEV1 79%, total IgE 72% and BE 64%. The highest negative predictive value (NPV) was found for BHR (92%). Diagnostic accuracy was highest for BHR 93% and for SPT 62%, while all other tests were comparable or lower than 50%. It is not possible to conclude whether or not a person has asthma merely on the basis of data on skin sensitization to aeroallergens, total IgE, eosinophils or lung function tests. Bronchial hyperresponsiveness showed the highest values for sensitivity (97%), PPV (94%), NPV (92%) and accuracy (93%). The second most efficient test is the skin prick test, with PPV 81% and diagnostic accuracy 62%.

[Respiratory allergy to house dust: Dermatophagoides pteronyssinus versus Dermatophagoides farinae] ]. / Alergija disnog sustava na kucnu prasinu: Dermatophagoides pteronyssinus versus Dermatophagoides farinae.

House dust is one of the most common allergens that cause allergic respiratory diseases. It is a composed allergen, although the most important antigens are the mites Dermatophagoides pteronyssinus (Der p) and Dermatophagoides farinae (Der f). These mites have different geographic and climatic distribution. The aim of the study was to determine the sensitisation to Der p and Der f in our population of patients with respiratory allergic disorders. The investigation included 93 patients with perennial rhinitis and/or asthma and positive skin reactions to dust mites. Concomitant sensitisation to Der f was found in 81% of the tested patients sensitised to Der p. The same size reactions to both mites was found in 34% of patients. A larger diameter of the urtica to Der p was found in 39% of patients. In 10% a greater reaction was found to Der f than to Der p, while 3% of the subjects only had positive reaction to Der f. Patients with respiratory allergic diseases and skin sensitisation to dust mites in the investigated population were sensitised to Der p and Der f 97%:84%. In conclusion, most of our subjects were sensitised to both mites, although in some patients the correct diagnosis would not have been established if they had not been tested with Der p and Der f (in our investigation 19% of subjects). It is therefore suggested that both mites are used in the standard allergic skin prick test.

The value of Doppler echocardiography in cardiac output detection.

In the present study simultaneous measurements of cardiac output by thermodilution method and Doppler echocardiography were obtained 105 times in five persons with congestive cardiomyopathy. A significant degree of correlation (r = 0.79) was verified between the values of cardiac output measured by the two methods. To estimate the accuracy of echocardiography for consecutive measurements of cardiac output, all of the patients were given a positive inotropic drug: 5 mg milrinone per os. After that the cardiac output was measured, first by thermodilution and immediately after that by the Doppler method, in successive time periods: 15 minutes after the drug, then 30, 45, 60 and 90 minutes later, and then 2, 3, 4 and 5 hours after the drug. The same procedure was repeated with all subjects after application of 10 mg milrinone per os. By statistical analysis of differences between the cardiac output measured by both methods, a low connection was found (r = 0.43). In addition, when the increase of cardiac output was registered, the Doppler method showed a decrease of cardiac output, both methods had similar directional changes, but the numeric data was not correct. This performed study demonstrated that the measurement of cardiac output by thermodilution and continuous Doppler echocardiography had good correlation. However, Doppler echocardiography cannot replace classic invasive methods in consecutive measurements and monitoring of cardiac output in seriously ill cardiac patients.

[Evaluation of ventilatory function of the small airways]. / Prilog evaluaciji funkcije ventilacije malih disnih putova.

The results of functional tests and the values of flow-volume and spirometric parameters were reevaluated in 1174 randomly selected patients with no evidence of heart disease. There were 533 patients with normal ventilation and 327 patients with no restrictive disorders. In the latter group 11% of the patients had normal FEV1 and lowered FEF50 and FEF75 values. In those patients obstructive changes would not have been found if expiratory flow rates had not been taken into account as one of the criteria for evaluating airway obstruction. In further 13% of the patients a mild airway obstruction would have been found had only FEV1 been evaluated without taking account of expiratory flow rates. It is concluded that expiratory flow rates along with anamnestic data and clinical status are important indicators of obstructive changes of ventilation, especially as they serve to identify functional disorders while these are still reversible and therapy can be useful.

[The effect of cigarette smoking on pulmonary diffusing capacity in asymptomatic smokers]. / Utjecaj pusenja cigareta na difuzijski kapacitet pluca u asimptomatskih pusaca.

Ninety-seven subjects of which 72 smokers and 25 nonsmokers attending the Laboratory for Respiratory Functional Diagnostics of the University Hospital for Lung Diseases, Jordanovac, Zagreb were examined. The selection criteria were normal standard spirometric test values (FEV1, FVC, FEV1/FVC) in asymptomatic healthy, young smokers/nonsmokers who showed no signs of hematological, cardiovascular and chronic or acute pulmonary symptoms or diseases (according to a standardized questionnaire), and were not exposed to harmful environmental factors. The single-breath carbon monoxide diffusing capacity was measured in all patients. The results of our study confirm the findings of those authors who report reduced values of DLCO and DL/VA in smokers in comparison with the nonsmokers. A linear value diminution has been noticed in smokers and nonsmokers with increasing age, with the values being much lower in smokers. Our results also demonstrate a significant correlation between DLCO and DL/VA in young healthy smokers vs the duration of smoking and the number of cigarettes smoked per day (p < 0.01). The possibility to detect early reversible damages of lung function in young healthy smokers is an important contribution to the prevention of all diseases in which causal consecutive relation with cigarette smoking is confirmed.

[How should pharmacodynamic tests for respiratory tract obstruction be evaluated?]. / Kako procijeniti farmakodinamski test pri opstrukciji disnih putova?

The factors that could influence the results of pharmacodynamic testing with beta 2 agonists in lung function diagnostics are discussed. These are: hypersecretion of the mucus, acute respiratory infection, tachyphylaxis of the adrenoceptors, therapy in the past 48 hours, patient's cooperation, and ambient or environmental pollution. The correct application, by inhalation, of selective sympathomimetics is described and differences between the basic values of lung function parameters and those following the salbutamol test are discussed.

[Pharmacokinetic testing of patients with bronchial asthma]. / Farmakodinamsko testiranje bolesnika s bronhalnom astmom.

The study represents the investigation on pharmacodynamic lung function testing in 40 patients (21 with extrinsic asthma and 19 with intrinsic asthma). Skin prick tests on common inhalation allergens, IgE antibodies, spirometry, flow-volume curve, body plethysmography and pharmacodynamic testing with salbutamol spray were performed in each person. The greatest changes after beta 2 agonist were established by plethysmographic parameters SGaw (mean increase 117%) and Raw (mean decrease 45%), than by the expiratory flow rates from flow-volume curve: FEF25%-75% and FEF50% (mean increase 26%), than the FEV1 (+ 15%), the PEF (also + 15%), the RV (mean decrease 17%) and the FVC (mean increase 8%). The aim of this study was to represent the necessity of the complex analysis and interpretation of the results of pharmacodynamic testings because of many factors that might change the values of the tests.

[Neurocutaneous melanosis and melanoma of the brain]. / Neurokutana melanoza i melanomi mozga.

A case of neuro-cutaneous melanoma, in the course of which a bifocal melanoma of the cerebral hemisphere had developed, was used as a natural model for the study of the relation between tumorous and non-tumorous elements. The need is pointed out for the definition of such a cutaneous-meningeal syndrome before the development of a neoplasm. As tumours develop from the cells defining leptomeningeal melanosis, the possibility of a neuroradiological diagnosis of this process is accentuated, primarily by a minute examination of the sites characteristic of the disease. A premorbid detection of all such cases is imperative in order to introduce an early anti-tumour treatment.

[A computer program for the interpretation of the acid-base status and respiratory gases]. / Kompjutorski program za interpretaciju acido-baznog statusa i respiratornih plinova.

A computer program for analysing the parameters of the acid-base status and respiratory gases has been designed. The program separates cases which are included into classical picture of certain respiratory, metabolic and mixed disorders. Out of a test series of 200 findings, 93% findings have been accurately interpreted. The program is written in BASIC, translated into machine code and occupies about 25 Kbyte computer memory. The main parts of the program use commands which do not favorize any version of BASIC increasing the program portability to other systems. The classification of respiratory gases and acid-base status was based on the already known facts.

[Evaluation of allergologic diagnosis in patients with bronchial asthma]. / Evaluacija alergoloske dijagnostike u bolesnika s bronhialnom astmom.

The present paper deals with 16 patients who were referred to the Clinical Hospital for Lung Disease "Jordanovac", Zagreb. On admission they were supposed to have or had already been diagnosed to have bronchial asthma. Numerous data from the patients' history were evaluated as well as the results of allergy tests (skin tests, RIST, RAST, eosinophils in the blood and sputum) and parameters of the functional lung diagnostics (blood gas analysis during rest and exercise, spirometry, flow-volume, body plethysmography). It was established that allergy diagnostics is not carried out as required, even though it is necessary in all chronic obstructive lung diseases. Skin tests, inspite of the problems on the standardization of allergens and the average number of positive reactions in healthy volunteers, represent a significant diagnostic method for the determination of the role of allergic reaction in bronchial asthma. It is necessary to combine them with the determining level for specific IgE in serum (RAST), which would, if the other conditions are satisfactory, be a basis for specific immunotherapy. The value of skin tests is greater since a good correlation between them and bronchial sensibility was found established by specific broncho-provocative testing. The correlation between eosinophils in the blood and the sputum with allergic sensibilization in asthma was not confirmed in this work. For evaluation the localisation and degree of obstruction as well as the effect of therapy in asthma patients the best functional test was found to be the flow-volume.

[Functional diagnosis of pulmonary sarcoidosis]. / Funkcionalna dijagnostika plucne sarkoidoze.

Restrictive disturbances of ventilation of various degree and disorders in diffusing capacity of the lung have been reported as the most frequent disorders in pulmonary sarcoidosis. Recently, however, several authors have found the obstructive disorders of ventilation being present as well, especially in the second stage of disease, and pointed out a possibility of the airways being affected very early at the onset of disease. Present study shows the results of functional tests carried out in 70 patients with histologically verified pulmonary sarcoidosis at all three stages of the disease (classification by Würm). All of them were nonsmokers, aged 20 to 55 years, and had no symptoms of chronic bronchitis, asthma or emphysema, either in case history or clinical findings. They included spirometry, flow-volume loop, body-plethysmography, blood gas analyses at rest and after exercise and pulmonary diffusing capacity for carbon monoxide obtained by single-breath method. Results from the study show the obstructive disorders of ventilation to be dominant in the early stage, while restrictive disturbances dominate in the third stage in pulmonary sarcoidosis. Diffusing capacity of the lung should be measured in the early stage of the disease as well as in those more advanced because of a possibility that interstitial space is being affected, although there is no visible damage on a radiograph. Measurement of pulmonary diffusing capacity together with radiological findings provide a highly valuable data which is of great importance in monitoring the dynamics of this disease.

[Correlation of the size of the residual volume measured by whole body plethysmography and the single breath helium dilution method]. / Korelacija velicina rezidualnih volumena mjerenih pletizmografijom cijelog tijela i dilucijom helija metodom jednog udaha.

The value of residual volume, intrathoracic gas volume, functional residual capacity and total lung capacity obtained by the method of body plethysmography and helium dilution method was correlated by single-breath diffusing capacity. These parameters were correlated in 22 patients who had had complete functional diagnostics of the lung: spirometry, flow volume curve, body plethysmography and single-breath diffusing capacity. All findings were within normal limits, which was a condition for selection of patients for our group. Statistically significant differences (p = 0.01) of t-test were established between residual volumes by the plethysmographic and helium dilution method of single-breath diffusing capacity. The residual volume obtained by body plethysmography showed higher values for 526 ml, or 30%. The intrathoracic gas volume showed higher values for 682 ml, or 17%. Inspite of the fact that values of RV obtained by two methods had statistically significant differences, they were still within normal limits, if presented as percent of the predicted value.