Efficacy and cost effectiveness of rapid on site examination (ROSE) in management of patients with mediastinal lymphadenopathies.

BACKGROUND: The diagnostic and staging approach for the mediastinal lymphadenopathies, with or whithout pulmonary lesions endoscopically visible, is based on transbronchial needle aspiration (TBNA) during fiberoptic bronchoscopy and on mediastinoscopy. One important factor impacting on TBNA sensitivity is the rapid on site cytological examination (ROSE). AIM: The aim of this study was to evaluate the economic impact of TBNA and TBNA + ROSE, in the diagnosis of these lesions. PATIENTS AND METHODS: 120 patients, affected by mediastinal lymphadenopathies suspected for lung cancer, underwent TBNA during fiberoptic bronchoscopy: 60 patients without ROSE (group A) and other 60 with ROSE (group B). Whenever needle aspirations failed to provide diagnosis, the patient underwent mediastinoscopy. The economic impact of the diagnostic process was performed. RESULTS: In group A, 39 patients (65%) obtained a diagnosis with TBNA while 21 patients (35%) required mediastinoscopy. In group B, 48 patients (80%) obtained a diagnosis with TBNA + ROSE, while 12 patients (20%) required mediastinoscopy. With regards to the costs of the procedures performed in the diagnostic process, the use of TBNA with ROSE as first diagnostic approach has saved a considerable amount of euros (19,413) compared to the use of TBNA without ROSE and the combined procedure increased (p < 0.02; chi square test) the sensitivity of TBNA by 15%. CONCLUSIONS: ROSE significantly impacts on the diagnostic yield, as well as on the overall management costs of patients with mediastinal lymphadenopathy, suspected for lung cancer.

Severe pneumonia caused by Nocardia farcinica and complicated by Staphylococcus haemoliticus superinfection.

It is reported the case of a subject 54 years old, painter, drinker and smoker who after an episode of cooling and the occurrence of widespread pain was taking its own initiative, cortisone and analgesics from approximately 30 days. The symptoms worsened and the patient was hospitalized. Chest X-ray and CT scan showed an extensive opacity in the left upper lobe with excavations in the context and also some nodular opacities excavated in the contralateral lung. In the first eight days after admission, the clinical picture despite empirical antibiotic therapy worsened towards adult respiratory distress syndrome (ARDS). On the ninth day after the admission, strains of Nocardia farcinica and Staphylococcus haemoliticus were isolated from the sputum. The targeted therapy (trimethoprim-sulfamethoxazole, amikacin, etc.) induced a rapid improvement of the clinical picture that was resolved in 6 months. Pneumonia caused by Nocardia farcinica is rare but its identification is necessary to set an appropriate therapy.

Influenza A H1N1 and severe asthma exacerbation.

The pandemic influenza A H1N1 will affect millions of subjects. This influenza can cause respiratory complications with possible death. We have described two case reports of acute severe asthma exacerbation combined to influenza A H1N1, caracterized by severe respiratory failure. The diagnosis of influenza A H1N1 was confirmed with the multiplex reverse transcription-polymerase chain reaction (RT-PCR) assay. These patients, apart from asthma, do not have other diseases; but they did not take adequate therapy. In addition to conventional therapy (corticosteroids, bronchodilator and antibiotics) oseltamivir 75 mg bid was immediately added. After few days the patients improved and therefore in a short time they were discharged. During this period, in the case of severe asthma exacerbations, one must always think of influenza A H1N1 as the possible cause. It is necessary to use oseltamivir precociously to avoid severe complications. All asthmatic patients must regularly take their therapy especially during pandemic influenza A H1N1.

Serum CA 15-3 is increased in pulmonary fibrosis.

BACKGROUND AND AIM OF THE WORK: Carbohydrate antigen CA 15-3 is a glycoprotein whose expression, aberrant intracellular localization and changes in glycosylation have been associated with a wide range of cancers. Pulmonary fibrosis represents the final evolution of a chronic inflammation and is defined by the overgrowth of fibroblasts and exaggerated extracellular matrix deposition. The aim of the present study was to evaluate the possible diagnostic role of CA 15-3 in fibrosis in different idiopathic interstitial pneumonias. METHODS: CA 15-3 was measured in serum samples from healthy subjects (n=25) and patients affected with idiopathic pulmonary fibrosis (IPF/UIP) (n=20), sarcoidosis (n=22) at different stages (I, II, and III) and systemic sclerosis (n=25). CA 15-3 protein expression was also evaluated by immunohistochemistry in 21 lung biopsies and in 6 primary lung fibroblasts cell lines. RESULTS: The CA 15-3 serum levels were significantly higher in patients with IPF/UIP and with clinically advanced sarcoidosis (stage III). Serum CA 15-3 levels were slightly increased in patients with systemic sclerosis. No difference was observed between serum CA 15-3 levels in patients with sarcoidosis at stages I and II compared with control subjects. In IPF/UIP and in sarcoidosis at stage III elevated CA 15-3 serum levels significantly correlated with decreased total lung capacity, decreased diffusing capacity of carbon monoxide and high resolution computed tomography findings. Immunohistochemical analysis showed an intense specific CA 15-3 staining in fibroblasts within fibroblastic foci, surrounding sarcoid granulomas and in all cell cultures of lung fibroblasts from IPF/UIP lungs. CONCLUSIONS: Our results indicate that increased CA 15-3 levels are associated with pulmonary interstitial damage, fibroblast activity and progression to fibrosis of the lung. Therefore, CA-15-3 may be considered a sensitive marker useful in the identification of patients with advanced fibrosis and more severe prognosis.

Oral corticosteroids can improve nocturnal isolated hypoxemia in stable COPD patients with diurnal PaO2 > 60 mmHg.

The aim of this study was to evaluate whether a short therapy cycle of oral methylprednisolone plus conventional therapy might improve isolated nocturnal hypoxemia evidenced through pulse-oxymetry in 28 patients (19 M/9 F; mean age 71 +/- 8.31) with stable moderate to severe COPD (average FEV1 of 43.33 +/- 9.38 of theoretical) and daytime PaO2 > 60 mmHg. All patients showed oxygen desaturation during the night and apnoea/hypoapnoea index < or = 10, measured by means of a nocturnal polysomnography and were successfully on conventional treatment for COPD. The patients were randomly divided into two groups: 14 (steroid group) were administered methylprednisolone for three weeks at progressively decreasing doses (16 mg/die for the first 7 days, then 8 mg die for another 7 days, and finally 4 mg die for another 7 days) plus conventional therapy (bronchodilators and inhaled corticosteroids). The remaining 14 patients (control group) instead were on conventional therapy only. After 3 weeks for the steroid group, but no for the control group, was improved next parameters (p < 0.0001): VC (L) dropped from 2.53 +/- 0.85 measured at baseline to 2.82 +/- 0.84, FEV1 dropped from 1.07 +/- 0.31 L to 1.23 +/- 0.31 L, the IC dropped from 1.71 +/- 0.48 to 2 +/- 0.37 L, the average nocturnal SpO2% from 90.4 +/- 1.79 to 92.3 +/- 1.72 and the Nocturnal Time % of SpO2 < 90% went from 31.19 +/- 18.12 to 10.88 +/- 11.56 after 3 weeks of therapy. Also dyspnoea, sleep duration and mean heart rate significantly improved (p < 0.0001). There was also a significant correlation between average increase in mean nocturnal SpO2% and in Lowest SpO2% and the variation in inspiratory capacity (IC) and in Sleep Duration % in the steroid group (p < 0.0001). In conclusion, methylprednisolone in combination with conventional medical therapy not only improved lung function values but also mean nocturnal oxyhemoglobin saturation and sleep duration in clinically stabilized COPD patients who experience nocturnal oxyhemoglobin desaturation.

The influence of ipratropium bromide in the recovery phase of methacholine induced-bronchospasm.

BACKGROUND: The protective effect of Ipratropium Bromide (IB) in the methacholine-induced bronchospasm is well known from some time. The objective of the present study was to assess whether a pretreatment with IB may influence the subsequent phase of methacholine-induced bronchospasm relief. METHODS: Sixteen patients with bronchial hyper-reactivity (PD20 FEV1 < 200 microg) were randomly assigned to three methacholine challenge tests at a 48 to 72 hours interval apart. In the first test IB was inhaled before the challenge (pre-IB), in the second IB was administered soon after the PD20 FEV1 (post-IB), and in the third no treatment was given (control). RESULTS: The pre-IB PD20 FEV1 (695 +/- 587.6 microg) was significantly greater (p < 0.0001) than that of post-IB (82.2 +/- 49.18 microg) and of control (73.9 +/- 41.8 microg). The dose response slope (DRS) (decline percentage of FEV1/cumulative methacholine dose), in pre-IB was greatly lower (p < 0.0001) than that in post-IB and in control. During the bronchospasm relief phase, the increase of FEV1 measured after 5, 10, 15, 30 and 60 minutes from the PD20 FEV1 was significantly greater in post-IB (p < 0.05) compared with the other two conditions. Conversely, the recovery slope (RS) (increase percentage of FEV1 at 60 minutes after PD20 FEV1 x cumulative methacholine dose) was significantly more efficient (p < 0.001) in pre-IB than in post-IB and in control. CONCLUSION: In conclusion, ipratropium bromide confirmed to have a good protective activity against methacholine-induced bronchospasm; the pre-administration of ipratropium bromide showed also a positive effect on the recovery phase.

Age-related changes of the noradrenergic innervation of rat tracheo-bronchial tree and pulmonary vasculature.

Age-related changes of the noradrenergic innervation of the tracheo-bronchial tree and of pulmonary vasculature were investigated in male Wistar rats of 3 months (young), 12 months (adult) and 24 months (old/aged), using catecholamine histofluorescence techniques associated with image analysis and by high pressure liquid chromagraphy with electrochemical detection. In young rats, blue-green fluorescent nerve fibres supply tracheo-bronchial smooth muscle and tracheal and bronchial glands, which are innervated by a delicate network of nerve fibres rich in varicosities. Pulmonary artery and vein are sparsely innervated. They are supplied with nerve fibres distributed in the vasa vasorum or the adventitia and the outer tunica media. The higher noradrenaline concentrations were found in the trachea and extraparenchymal bronchi, followed by pulmonary vein and pulmonary artery. The density and pattern of noradrenergic innervation of the tracheo-bronchial tree, or of the pulmonary vasculature, were similar in young and adult rats. In aged rats, a loss of noradrenergic innervation involving primarily the supply to the smooth muscle of the tracheo-bronchial tree was observed. Histofluorescence techniques demonstrated a higher sensitivity than noradrenaline assay in detecting changes of the sympathetic innervation of the tracheo-bronchial tree and of the pulmonary vasculature. The possible significance of reduced noradrenergic innervation of the tracheo-bronchial tree in aged rats is discussed.

Influence of age on L-type Ca2+ channels in the pulmonary artery and vein of spontaneously hypertensive rats.

The influence of age on the density and localization of L-type Ca2+ channels was studied during development of hypertension in the pulmonary artery and vein of spontaneously hypertensive rats (SHR) and age-matched normotensive Wistar-Kyoto (WKY) rats by radioligand binding assay and light microscope autoradiography. SHR were examined at 6 weeks (juvenile, pre-hypertensive stage), 12 weeks (young, developing hypertension) and 24 weeks (mature, established hypertension). The dihydropyridine-type Ca2+ antagonist [3H]nicardipine was used as a radioligand. It was bound specifically to sections of rat pulmonary artery and vein. Dissociation constant (Kd) values were similar in WKY rats and SHR, whereas maximum density of binding sites (Bmax) values increased in SHR in comparison with WKY rats. This increase was noticeable from the pre-hypertensive phase. The pharmacological profile of [3H]nicardipine binding was similar in different age groups of either normotensive and hypertensive rats. Quantitative analysis of autoradiographs from SHR revealed a progressive increase of silver grains in smooth muscle of tunica media and to a lesser extent in the adventitia of pulmonary artery but not of pulmonary vein from pre-hypertensive stage to developing hypertension. No further changes were observed in established hypertension. The above data indicate that the density of L-type Ca2+ channels of pulmonary arteries is increased in SHR. This augmentation after the pre-hypertensive phase suggests the occurrence of dysregulation of Ca2+ handling in the pulmonary vasculature of developing SHR.

Airway stenosis after tracheo-bronchial tuberculosis.

Primary endobronchial localization of tuberculosis without change on chest X-ray is a rare clinical entity, and bronchoscopic examination is most appropriate to reveal such an occurrence. A 38-year-old man and a 52-year-old woman underwent fibre-optic bronchoscopy many months after the onset of cough with poor sputum and dyspnoea on exercise, chest X-ray being normal. In both cases, a widespread granulomatous involvement of the tracheo-bronchial tree was found and cultures of bronchial wash grew Mycobacterium tuberculosis. Patients recovered after 6 months of combined anti-tuberculous and steroid therapy; the granulomatous lesions disappeared but stenoses were found in the trachea and/or main bronchi. In one case, CO2 laser therapy was performed with no improvement.

Strongyloides stercoralis hyperinfection in a case of idiopathic pulmonary fibrosis.

The Strongyloides stercoralis infection is a prominent cause of death in many areas of the world. A 64-year-old man with pulmonary fibrosis was admitted to the hospital because of progressive shortness of breath and increasing cough. The patient had been previously admitted for his illness and had a remarkable immunosuppression due to the use of steroids (CD4+ lymphocytes = 200 x 10(6)/l). Repeated sputum and stool studies were diagnostic for strongyloidiasis. The patient died suddenly from severe cardiorespiratory failure while he was under mebendazole treatment (100 mg b.i.d.). Strongyloidiasis occurs mostly in immunocompromised hosts, as in patients with chronic pulmonary diseases on long-term treatment with corticosteroids, oncology patients under treatment and patients with AIDS.