FDG-PET parameters predicting mediastinal malignancy in lung cancer.

BACKGROUND: Staging of mediastinal lymph nodes in non-small cell lung cancer (NSCLC) is mandatory. The maximum Standard Uptake Value (SUVmax) obtained using F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is the best non-invasive technique available for this evaluation, but its performance varies from center to center. The aim of the present study was to identify FDG-PET predictors of mediastinal malignancy that are able to minimize intercenter variability and improve the selection of subsequent staging procedures. METHOD: A multicenter study of NSCLC patients staged through FDG-PET and endobronchial ultrasonography with needle aspiration (EBUS-NA) was performed using therapeutic surgery with systematic nodal dissection as gold standard. Intercenter variability and predictive power for mediastinal malignancy of different FDG-PET measures were assessed, as well as the role of these measures for selecting additional staging procedures. RESULTS: One hundred and twenty-one NSCLC patients, of whom 94 (72%) had ≥1 hypermetabolic spots in the mediastinum, were included in the study. Mean SUVmax of the primary tumor was 12.3 (SD 6.3), and median SUVmax of the highest hypermetabolic spots in the mediastinum was 3.9 (IQR 2.4-7). Variability of FDG-PET measures between hospitals was statistically significant (p = 0.016 and p < 0.001 respectively), but lost significance when SUVmax in the mediastinum was expressed as a ratio or a subtraction from the primary tumor (SUVmax mediastinum/tumor, p = 0.083; and SUVmax mediastinum - tumor, p = 0.428 respectively). SUVmax mediastinum/tumor showed higher accuracy in the ROC analysis (AUC 0.77 CI 0.68-0.85, p < 0.001), and showed predictive power for mediastinal malignancy when using a 0.4 cutoff (OR 6.62, 95%CI 2.98-14.69). Sensitivities and negative predictive values of clinical staging through EBUS-NA attained values ranging between 57% and 92% after FDG-PET, which improved with additional techniques when the tumor had a diameter >3 cm and/or a SUVmax mediastinum/tumor ratio >0.4. CONCLUSION: The SUVmax mediastinum/tumor ratio is a good predictor of regional tumor extension in NSCLC. This measure is not influenced by intercenter variability and has an accuracy of over 70% for the identification of malignancy when using a 0.4 cutoff.

Bronchial microbiome of severe COPD patients colonised by Pseudomonas aeruginosa.

The bronchial microbiome in severe COPD during stability and exacerbation in patients chronically colonised by Pseudomonas aeruginosa (PA), has not been defined. Our objective was to determine the characteristics of the bronchial microbiome of severe COPD patients colonised and not colonised by P. aeruginosa and its changes during exacerbation. COPD patients with severe disease and frequent exacerbations were categorised according to chronic colonisation by P. aeruginosa. Sputum samples were obtained in stability and exacerbation, cultured, and analysed by 16S rRNA gene amplification and pyrosequencing. Sixteen patients were included, 5 of them showing chronic colonisation by P. aeruginosa. Pseudomonas genus had significantly higher relative abundance in stable colonised patients (p = 0.019), but no significant differences in biodiversity parameters were found between the two groups (Shannon, 3 (2-4) vs 3 (2-3), p = 0.699; Chao1, 124 (77-159) vs 140 (115-163), p = 0.364). In PA-colonised patients bronchial microbiome changed to a microbiome similar to non-PA-colonised patients during exacerbations. An increase in the relative abundance over 20 % during exacerbation was found for Streptococcus, Pseudomonas, Moraxella, Haemophilus, Neisseria, Achromobacter and Corynebacterium genera, which include recognised potentially pathogenic microorganisms, in 13 patients colonised and not colonised by P. aeruginosa with paired samples. These increases were not identified by culture in 5 out of 13 participants (38.5 %). Stable COPD patients with severe disease and PA-colonised showed a similar biodiversity to non-PA-colonised patients, with a higher relative abundance of Pseudomonas genus in bronchial secretions. Exacerbation in severe COPD patients showed the same microbial pattern, independently of previous colonisation by P. aeruginosa.

Variability and effects of bronchial colonisation in patients with moderate COPD.

Sputum and lung function were periodically assessed in stable moderate chronic obstructive pulmonary disease (COPD) outpatients to determine relationships between bronchial colonisation and inflammation. Relationships between potentially pathogenic microorganism (PPM) typology, bronchial inflammation (neutrophilia, tumour necrosis factor-alpha, interleukin (IL)-1beta, IL-6, IL-8, IL-10 and IL-12) and post-bronchodilator decline in forced expiratory volume in 1 s (FEV(1)) were analysed. PPMs periodically showing the same molecular profile using pulse field gel electrophoresis were considered long-term persistent. Bronchial colonisation was observed in 56 out of 79 follow-up examinations (70.9%) and was mainly due to Haemophilus influenzae, Pseudomonas aeruginosa and enterobacteria (n = 47). These PPMs were all related to sputum neutrophilia (p< or =0.05, Chi-squared test), and H. influenzae was related to higher levels of IL-1beta (p = 0.005) and IL-12 (p = 0.01), with a dose-response relationship (Spearman's correlation coefficient of 0.38 for IL-1beta (p = 0.001), and of 0.32 for IL-12 (p = 0.006)). Haemophilus parainfluenzae was not associated with an identifiable inflammatory response. Long-term persistence of the same strain was observed in 12 examinations (21.4%), mainly due to P. aeruginosa or enterobacteria. A neutrophilic bronchial inflammatory response was associated with a statistically significant decline in FEV(1) during follow-up (OR 2.67, 95% CI 1.07-6.62). A load-related relationship to bronchial inflammation in moderate COPD was observed for colonisation by H. influenzae, but not for colonisation by H. parainfluenzae.

Endobronchial ultrasound-guided transbronchial needle aspiration for identifying EGFR mutations.

The presence of somatic mutations of the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) gene in patients with advanced nonsmall cell lung cancer (NSCLC) correlates with a good response to tyrosine kinase inhibitors. The usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the detection of EGFR mutations in cells recovered from malignant mediastinal nodes in patients with NSCLC was assessed. All patients with lung adenocarcinoma or unspecified NSCLC referred for staging with EBUS-TBNA were included. Nodes with a short-axis diameter of >5 mm were sampled, and genomic DNA from metastatic tumour cells was obtained for analysis of exons 19 and 21. The impact of sampling on management was assessed. EGFR gene analysis of the EBUS-TBNA sample was feasible in 26 (72.2%) out of the 36 patients with lymph node metastasis. Somatic mutations of the EGFR gene were detected in tissue obtained through EBUS-TBNA in two (10%) out of 20 patients with metastasic lung adenocarcinoma. Malignant tissue samples obtained by EBUS-TBNA from patients with nodal metastasis of NSCLC are suitable for the detection of EGFR mutations in most cases, and this technique demonstrates mutated neoplastic cells in a tenth of patients with adenocarcinoma.

Efficacy of moxifloxacin in the treatment of bronchial colonisation in COPD.

This study was designed to investigate the efficacy of moxifloxacin for the eradication of bacterial colonisation of the airways in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD). Out of 119 stable patients with COPD screened, 40 (mean age 69 yrs, mean forced expiratory volume in 1 s 50% predicted) were colonised with potentially pathogenic microorganisms (PPMs) and were included in a randomised, double-blind, placebo-controlled trial with moxifloxacin 400 mg daily for 5 days. Eradication rates were 75% with moxifloxacin and 30% with placebo at 2 weeks (p = 0.01). Bacterial persistence at 8 weeks was still higher (not significantly) in the placebo arm (five (25%) out of 20 versus one (5%) out of 20; p = 0.18). The frequencies of acquisition of a new PPM were high and similar in both treatment groups; consequently, the prevalence of colonisation at 8 weeks was also similar between treatment arms. No difference was found in the number of patients with exacerbations during the 5-month follow-up. Only the acquisition of a new PPM during follow-up showed a statistically significant relationship with occurrence of an exacerbation. Moxifloxacin was effective in eradicating PPMs in patients with positive sputum cultures. However, most patients were recolonised after 8 weeks of follow-up. Acquisition of a new strain of bacteria was associated with an increased risk of developing an exacerbation.

Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns.

BACKGROUND: Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established. AIMS: The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year. MATERIALS AND METHODS: COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care. RESULTS: Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0-1] vs 1 [0-2.5]; P=0.022) and in days of admission (0 [0-7] vs 7 [0-12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (ß coefficient -0.785, P=0.014, and R2=0.219). CONCLUSION: A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.

Reported occupational respiratory diseases in Catalonia.

OBJECTIVES: A voluntary surveillance system was implemented in Catalonia (Spain) to ascertain the feasibility, incidence, and characteristics of occupational respiratory diseases and compare them with those of the compulsory official system. METHODS: In 2002, in collaboration with the Occupational and Thoracic Societies of Catalonia, occupational and chest physicians and other specialists were invited to report, on a bimonthly basis, newly diagnosed cases of occupational respiratory diseases. Information requested on each case included diagnosis, age, sex, place of residence, occupation, suspected agent, and physician's opinion on the likelihood that the condition was work related. Compulsory official system data derived from statistics on work related diseases for possible disability benefits declared by insurance companies, which are responsible for declaring these diseases to the Autonomous Government of Catalonia. RESULTS: Of 142 physicians seeing patients with occupational respiratory diseases approached, 102 (74%) participated. Three hundred and fifty nine cases were reported, of which asthma (48.5%), asbestos related diseases (14.5%), and acute inhalations (12.8%) were the most common. Physicians rated 63% of suspected cases as highly likely, 28% as likely, and 8% as low likelihood. The most frequent suspected agents reported for asthma were isocyanates (15.5%), persulphates (12.1%), and cleaning products (8.6%). Mesothelioma (5.9%) was the most frequent diagnosis among asbestos related diseases. The number of acute inhalations reported was high, with metal industries (26%), cleaning services (22%), and chemical industries (13%) being the most frequently involved. The frequency of occupational respiratory diseases recorded by this voluntary surveillance system was four times higher than that reported by the compulsory official system. CONCLUSIONS: The compulsory scheme for reporting occupational lung diseases is seriously underreporting in Catalonia. A surveillance programme based on voluntary reporting by physicians may provide better understanding of the incidence and characteristics of these diseases. Persulphates and cleaning products, besides isocyanates, were the most reported causes of occupational asthma. Metal industries and cleaning services were the occupations most frequently involved in acute inhalations with a remarkably high incidence in our register.

Aberrant gene methylation and bronchial dysplasia in high risk lung cancer patients.

INTRODUCTION: The risk for lung cancer is incremented in high degree dysplasia (HGD) and in subjects with hypermethylation of multiple genes. We sought to establish the association between them, as well as to analyze the DNA aberrant methylation in sputum and in bronchial washings (BW). METHODS: Cross sectional study of high risk patients for lung cancer in whom induced sputum and autofluorescence bronchoscopy were performed. The molecular analysis was determined on DAPK1, RASSF1A and p16 genes using Methylation-specific PCR. RESULTS: A total of 128 patients were enrolled in the study. Dysplasia lesions were found in 79 patients (61.7%) and high grade dysplasia in 20 (15.6%). Ninety eight patients out of 128 underwent molecular analysis. Methylation was observed in bronchial secretions (sputum or BW) in 60 patients (61.2%), 51 of them (52%) for DAPK1, in 20 (20.4%) for p16 and in three (3.1%) for RASSF1A. Methylated genes only found in sputum accounted for 38.3% and only in BW in 41.7%, and in both 20.0%. In the 11.2% of the patients studied, HGD and a hypermethylated gene were present, while for the 55.1% of the sample only one of both was detected and for the rest of the subjects (33.6%), none of the risk factors were observed. CONCLUSIONS: Our data determines DNA aberrant methylation panel in bronchial secretions is present in a 61.2% and HGD is found in 15.6%. Although both parameters have previously been identified as risk factors for lung cancer, the current study does not find a significative association between them. The study also highlights the importance of BW as a complementary sample to induced sputum when analyzing gene aberrant methylation.

Effects of inhaled platelet activating factor on bronchial responsiveness in patients with symptomatic and asymptomatic pulmonary embolism.

To determine the possible role of platelet-activating factor (PAF) in pulmonary embolism (PE), the reactivity of the airways to inhaled PAF, using doses ranging from 6.25 to 400 micrograms, was examined in 24 patients with a past episode of PE. Twelve of these patients had experienced acute respiratory insufficiency during the episode (with or without additional symptoms). None of the remaining 12 patients had experienced any respiratory symptoms during the PE episode. Diagnosis was established by means of a ventilation-perfusion lung scan performed when admitted to the hospital because of deep venous thrombosis (DVT) in the lower limbs. Nonspecific bronchial reactivity as measured by the response to bronchoprovocation testing with methacholine showed no significant differences between both groups. PAF caused a dose-dependent bronchoconstriction defined by at least a 35 percent decrease in specific airway conductance (SGaw) in all patients. The average dose of PAF needed to decrease SGaw 35 percent was significantly lower in patients who had had a symptomatic PE than in those with asymptomatic PE (p = 0.011). This finding suggests that patients who suffered from symptomatic PE may present a greater airway reactivity to inhaled PAF. This different behavior might explain the existence of some of the respiratory symptoms of PE, which could be attributed to PAF-related effects. However, additional studies are needed to evaluate the role of PAF in PE.

Detection of mycobacterium tuberculosis in paraffin-embedded pleural biopsy specimens by commercial ribosomal RNA and DNA amplification kits.

STUDY OBJECTIVES: To evaluate the utility of two gene amplification systems in historical paraffin-embedded pleural biopsy (PEB) tissues from patients with pleural tuberculosis, and to compare the results to those obtained with conventional histologic and microbiological methods. DESIGN: A retrospective study. PATIENTS AND METHODS: Seventy-four formalin-fixed PEB tissues collected and stored over 12 years (1984 through 1995) were retrieved. Gene amplifications were performed in 57 tissues from patients with diagnoses of pleural tuberculosis and in 17 from patients with carcinoma as controls, using the first version of the Amplified Mycobacterium tuberculosis Direct Test (AMTDT; Gen-Probe; San Diego, CA) and the LCx Mycobacterium tuberculosis Assay (LCxMTB; Abbott Laboratories; Abbott Park, IL). RESULTS: The sensitivities of the AMTDT and LCxMTB were 52.6% and 63.2%, respectively (p = not statistically significant). The specificity of both tests was 100%. Twenty tissue samples (35.1%) were positive by both systems, and 10 tissues (17.5%) were positive only by the AMTDT, while 16 tissues (28.1%) were positive only by the LCxMTB. Both tests gave negative results for 11 specimens (19.3%). When both tests were used, a positive diagnosis was achieved in 80.7% of the samples. Diagnosis of 73.7% of patient conditions had previously been made by smear examination of pleural biopsy and sputum, pleural liquid, or biopsy culture. The overall diagnostic yield with both culture and amplification techniques was 96.5% (55 of 57 patients) for pleural tuberculosis, with amplification techniques adding 22.8% of the diagnoses. CONCLUSIONS: Amplification techniques are useful in archival PEB tissues, providing additional diagnoses beyond culturing, although the sensitivity should be improved, possibly by standardizing protocols.

Spirometry and maximal respiratory pressures in patients with facial paralysis.

The study included 17 patients with facial paralysis (FP) (10 male, 7 female) aged 47.6 +/- 21.0 years. Twelve of the 17 patients had Bell's palsy. The other causes of FP were as follows: one, polyradiculoneuritis; one, war injury; one, cerebrovascular accident; one, sarcoidosis; and one, dermatomyositis. Spirometry and maximal respiratory pressures (PImax and PEmax) were performed with three different techniques: without holding the lips, with patient holding lips, and with technician holding lips. We observed significant differences for PImax and PEmax among the three methods. There were no differences for spirometric values. In nine of the patients with Bell's palsy, PImax, PEmax, and spirometry tests were repeated two months after the first determination. With respect to the first determination, the values of Pmax-w/v holding lips increased, yet spirometric values were similar. In conclusion, PImax and PEmax can be an index of clinical FP evolution. Spirometric maneuvers can be performed with either patient or technician holding lips to ensure a perfect seal between lips and mouthpiece.

Quality of life in severe chronic obstructive pulmonary disease: correlation with lung and muscle function.

UNLABELLED: Chronic obstructive pulmonary disease (COPD) patients suffer from significant impairment in quality of life (QL), but the variables related to this impairment are not well known. The aim of this study has been to identify physiological parameters related to QL in severe COPD patients undergoing long-term oxygen therapy. MATERIALS AND METHODS: We studied 47 COPD patients using long-term oxygen therapy (43 men/four women, 65.17 SD 8.21 years, 3.17 SD 2.61 years on oxygen). The Nottingham Health Profile (NHP) and activities of daily living (ADL) questionnaire were used to measure QL. Subjective assessment of dyspnoea was performed using a visual analogue scale. The physiological parameters determined were lung function (spirometry, arterial blood gases, lung volumes and carbon monoxide diffusing capacity), muscle function (maximum inspiratory and expiratory pressures, deltoid muscle and handgrip strength), and nutrition status (tricipital skin fold and mid-arm muscle circumference). RESULTS: High ADL (8.32 SD 6.97) and NHP scores (energy 63.3 SD 40.43, pain 35.11 SD 31.56, emotional reactions 43.03 SD 25.13, sleep 51.91 SD 32.75, social isolation 30.64 SD 26.98, physical mobility 49.73 SD 24.93) demonstrated clinically significant QL impairment in the severe COPD patients studied. Stepwise multiple regression analysis found a correlation between lung function and QL. Low FEV1% was associated with impairment in energy, physical mobility and social isolation NHP scores and ADL score (r = -0.3, P < 0.05). RV/TLC also correlated with ADL and social isolation scores (r = 0.3, P < 0.05). Lung function explained 39-45% of the variation in these QL dimensions. QL did not correlate with other lung function parameters, muscle function or nutrition status. CONCLUSION: COPD patients using long-term oxygen suffer from severe QL impairment affecting not only energy and mobility but also emotional reactions, social isolation and sleep. Lung function is related to energy, mobility and social isolation dimensions, but muscle function is unrelated to QL in these patients.

[Occupational asthma due to amines]. / Asma ocupacional por aminas.

A case of occupational asthma due to ethylenediamine, commonly used in different industrial fields, appearing in a man 56 years old who worked in the laundry powder industry is presented. The diagnosis was confirmed by specific bronchial challenge and appeared as a late bronchoconstrictive response. The appearance of inespecific bronchial responsiveness after the bronchial challenge is emphasized.

[Oxygen therapy and other pneumological tools for home use in Barcelones Nord i Maresme. A descriptive study]. / Oxigenoterapia crónica y otros utillajes neumológicos de uso domiciliario en el Barcelonès Nord i Maresme. Estudio descriptivo.

Against a background of differences in prevalence of chronic home oxygen therapy (CHO) and other pneumological tools (nasal continuous positive airway pressure, aerosol therapy, monitoring, assisted ventilation) found in studies of the various regions of Catalonia (Spain), we carried out a descriptive study to determine how these tools were being used in the northern Barcelona and coastal plain health region (population 657,376). Three hundred sixty-six (49.8%) patients used CHO, 39 (5.3%) used aerosol therapy, 52 (7.1%) used nasal continuous positive airway pressure, 3 (0.4%) were monitored at home and 1 (0.1%) was mechanically ventilated at home. Two hundred seventy-three patients about whom we had insufficient data did not keep their appointments with the doctor. Use of CHO was considered appropriate in 302 (82.5%) of the 366 patients reviewed; 6.5% of these were active smokers as indicated by measurement of CO in expired air. The number of patients resistant to treatment (273) is very high in the northern Barcelona and coastal plain region and should be followed up more carefully. Our finding allow us to estimate that CHO is appropriately prescribed in the northern Barcelona and coastal area for 87.5 patients per 100,000 inhabitants, a prevalence that is higher than that observed for other health regions in Catalonia.

[Minimal intervention in smoking in the outpatient pneumonology consultation]. / Intervención mínima sobre el trabaquismo en la consulta neumológica extrahospitalaria.

Brief intervention (BI) in smoking has been shown to be an effective way of stopping smoking in the general population. BI involves medical advice given to each smoking patient, with complementary information on the effects of smoking on the body and methods of giving up the habit. Patients who come to the clinic with respiratory disease may be especially receptive to BI since the strong link between their symptoms and smoking may increase their motivation for cessation. A BI protocol on smoking was applied in 285 smokers seen in an outpatient pneumological clinic. Two hundred eight smokers (group A) received medical advice and health care education with the offer of follow up. Seventy-seven smokers (group B) received the same BI protocol, with the offer of support treatment with nicotine gum (2 mg) and an explanation as to its use. One year after BI the patients were contacted by telephone to determine the number of non-smokers, with the result adjusted according to the truth index (71.4%) known for telephone response in this context. A total of 71 (24.9%) smokers were not located by telephone due to change of address, wrong number, exitus or lack of telephone. The estimated number of non-smokers in group A was 31.5/160 (19.7%) and 8.6/54 (15.9%) (non significant difference, chi square test). Group B's use of nicotine gum was therapeutically significant in 11.0% of the cases. We conclude that the efficacy of BI in the outpatient pneumological clinic is high.(ABSTRACT TRUNCATED AT 250 WORDS)

[Identifying asbestos bodies in bronchoalveolar lavage fluid]. / Identificación de cuerpos de asbesto en el lavado broncoalveolar.

UNLABELLED: Asbestos bodies (AB) in respiratory secretions in bronchoalveolar lavage (BAL) identify subjects with lower airway AB content is a potential cause of pleural or pulmonary disease. The precision of this qualitative measure, however, has not been adequately analyzed. OBJECTIVE: To determine the sensitivity and specificity of finding AB in BAL fluid by conventional qualitative cytology in comparison with the quantification of AB in BAL fluid. METHOD: BAL samples from 40 subjects exposed to asbestos (mean age 59.2 years; men/women 36/4) were processed in the following ways: 1) qualitative cytology and 2) quantification of AB in BAL fluid expressed as AB/ml. The concentration of AB in BAL fluid was considered the gold standard (upper limit of normal 1 AB/ml) for determining the precision of qualitative cytology. RESULTS: In 9 of the 40 cases (22.5%) AB was found in BAL liquid cytology, but in only five of them were AB counts greater than 1 AB/ml. AB counts also showed concentrations greater than 1 AB/ml for four patients whose qualitative results were negative. The sensitivity of a qualitative AB-positive finding for identifying subjects with potentially disease-causing AB concentrations was 0.55, while specificity was 0.87. We conclude that a qualitative finding of AB in BAL fluid is adequately specific, but that sensitivity is very low, an indication that AB concentration in BAL should be determined to adequately screen for patients at high risk of developing disease.

[Second consensus report on the use of antimicrobial agents in exacerbations of chronic obstructive pulmonary disease]. / Segundo documento de consenso sobre uso de antimicrobianos en la exacerbación de la enfermedad pulmonar obstructiva crónica.

Aware of the importance of chronic obstructive pulmonary disease (COPD), a panel of experts belonging to the Spanish Society of Respiratory Medicine and Thoracic Surgery (SEPAR), the Spanish Society of Chemotherapy (SEQ) and the Spanish Society of Family and Community Medicine (SEMFyC) issued a statement of consensus in 2000 to serve as the basis for adequate antibiotic control of the disease. Three years later, in accordance with significant scientific progress made in this area, the statement has been thoroughly revised. The new paper in fact constitutes a second consensus statement on the use of antibiotics in COPD exacerbations. When several scientific associations expressed interest in joining the project and contributing to it the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of General Medicine (SEMG) and the Spanish Society of Rural and General Medicine (SEMERGEN) their incorporation led SEPAR and SEMFyC to change the structure of the statement and certain aspects of its content. Additionally, a new group of antibiotics, the ketolides, has joined the therapeutic arsenal. Telithromycin, the single representative of the group for the moment, can be considered not only an alternative treatment but even the drug of choice in certain clinical settings that are analyzed in the new statement. Those developments, along with others, such as the increasingly recognized action of levofloxacin against Pseudomonas aeruginosa and the steady action of amoxicillin with clavulanic acid when administered at recommended doses every 8 hours, provide new antimicrobial therapeutic protocols for COPD. Finally, the statement includes a scientific analysis of other groups of antimicrobial agents (macrolides, oral cephalosporins, etc.) and guidelines for both primary care physicians and specialists to follow when prescribing them.

Mineralogical microanalysis of idiopathic pulmonary fibrosis.

A mineralogical analysis of lung tissue was conducted on 25 samples from patients who had been diagnosed as having idiopathic pulmonary fibrosis (IPF). Scanning electron microscopy (SEM) at low magnification and energy-dispersive x-ray analysis (EDXA) was used. In all samples, the surface silicon/sulfur (Si/S) ratio was calculated. The Si/S ratio for 25 samples of normal lung and 6 samples of pneumoconiotic lung was also determined (upper limit of normal Si/S ratio = 0.3). The difference between the Si/S ratio in the group with IPF and group with normal lung tissue was significantly significant (p less than .007, Wilcoxon test). Six of 12 patients with a previous diagnosis of IPF and a Si/S ratio greater than 0.3 had an exposure history that could imply inhalation of silica/silicates, and the correct diagnosis for these patients is most probably pneumoconiosis. The silica/silicate deposits detected in patients with IPF, and who had a ratio and no past exposure to dusts, could be either a cause or an effect of the disease.

Occupational asthma in the community: risk factors in a western Mediterranean population.

Risk factors and prevalence of occupational asthma in the general population were examined in a cross-sectional community study conducted in north Barcelona. A self-administered questionnaire that contained questions about bronchial asthma and occupation was mailed to a random sample of 4000 adults who lived in north Barcelona; the response rate was 31.0%. Investigators made phone calls to nonresponders to determine response bias. Risk factors for occupational asthma were assessed with logistic regression. Investigators, who sought a definite diagnosis of occupational asthma, offered a chest examination to all subjects who reported asthma in life and who experienced clinically relevant occupational exposures. The examination included skin tests to common allergens, forced spirometry with reversibility test, and peak expiratory flow rate at and away from work. Cumulative prevalences obtained from responders were good estimates for the general population: asthma in life, 9.0%; clinically relevant occupational exposure, 28.9%; and respiratory symptoms at work, 18.3%. Adjustments were made for age, sex, and smoking habits, and relevant exposure caused an increase in asthma risk (odds ratio [OR] = 1.9; 95% confidence interval [95% CI] = 1.1, 3.2); however, when investigators introduced specific occupations in the model as independent variables, only occupational exposure to leather (OR = 12.8 [95% CI = 4.4, 37.4]), animals (OR = 10.3 [95% CI = 1.6, 65.2]), dyes (OR = 5.6 [95% CI = 2.1, 15.3]), and flour (OR = 4.6 [CI = 1.3, 15.7]) persisted as significant risk factors. A 1.7/1000 minimum prevalence of occupational asthma for the north Barcelona population was estimated from chest examination results. Occupational risk for asthma appeared to be associated with exposure to leather, animals, dyes, or flour in the north Barcelona area.