Predictors of survival in a group of patients with chronic airflow obstruction.

This article shows the results of a 10-year follow-up study conducted on a cohort of 870 patients affected by severe chronic airflow obstruction (CAO) on spirometric tests. The main aims of the study were to identify those factors associated with reduced survival in CAO patients and to evaluate the effectiveness of a care program on patients' survival. The analysis compared the survival time and causes of death between patients who showed adherence and patients who did not show adherence to the care program. The most important results can be summarized as follows: (1) CAO patients have a high mortality rate for acute respiratory failure, cor-pulmonale, and lung cancer; (2) patient's age at the time of selection to enter follow-up influences the death hazard; (3) patients who need long-term oxygen treatment (LTOT) have a higher death hazard than those who don't need it; (4) the higher is FEV1 or PaO2 value at the time of selection, the lower the death hazard; (5) patients who need, and regularly take, long-term oxygen treatment have a lower death hazard compared to those who need it, but do not take it properly; and (6) patients with a partial reversible airway obstruction (pRAO) who regularly attend the clinic for planned check-ups, have a lower death hazard compared to those who have the same characteristics, but do not show adherence to the care program. These results indicate that an organized program to treat severe CAO patients may improve their survival.

Tuberculin reactivity in adult BCG-vaccinated subjects: a cross-sectional study.

INTRODUCTION: Interpretation of the tuberculin skin test (TST) may be complicated by prior bacille Calmette-Guérin (BCG) vaccination. The skin reaction to the vaccination interferes with the management of individuals who may be infected with Mycobacterium tuberculosis. OBJECTIVE: To discriminate between TST reactions due to infection and those due to vaccination in subjects with unknown BCG status. METHODS: Among 60200 subjects tested with 5TU PPD for screening purposes, 4987 contacts of infectious TB cases (Group A), 4962 BCG-vaccinated subjects (Group B) and 5000 subjects from the general population (Group C) were sampled. The frequencies of TST cut-off diameters were calculated for the three groups using a logistic regression model. The frequency of positive subjects in each group and the sensitivity, specificity and predictive values were also computed by means of these cut-offs. RESULTS: The risk of being a contact versus BCG-vaccinated increases 2.43-fold with every mm of TST diameter. The 11 mm cut-off point seems to be the best discriminating value. CONCLUSIONS: Using the traditional 10 mm cut-off, we can consider all vaccinated subjects with a positive TST to be infected. The TST remains a valuable tool for the evaluation of household contacts and suspected cases of tuberculosis in BCG-vaccinated subjects and in populations with high vaccination coverage.

Effects of tobacco smoke exposure on lung growth in adolescents.

A longitudinal study on exposure to tobacco smoke among adolescents was carried out in Turin (North-Western Italy) in January-February 1992 and in January-February 1993. In 1992, 394 schoolchildren aged 14-16 years were enrolled in a study protocol which consisted in answering a standardized questionnaire, measurement of urinary cotinine and testing of lung function (flow-volume curve--[FVC] and forced expiratory volume in I sec.--[FEV1]). In 1993, 333 schoolchildren from the same group repeated the survey. By comparison to urinary cotinine, findings obtained showed a reduction of increase, from 1992 to 1993, of -0.57% (p = 0.082) for FVC, and -0.66% (p = 0.05) for FEV1. Assuming that the systematic selection bias did not seem to have occurred, findings, obtained from a multiple regression analysis, showed that active and passive exposure to tobacco smoke, as measured by urinary cotinine, had a significant effect on lung growth (as measured by FEV1) in adolescents; this effect, though small, was dose-related.

Dose-related effect of inhaled magnesium sulfate on histamine bronchial challenge in asthmatics.

The effects of various doses of inhaled MgSO4 on the histamine bronchoprovocation test were studied in nine asthmatics in clinical remission (FEV1 greater than 80% of predicted). The minimal effective dose of MgSO4 was 0.20 mmol, which increased the dose of histamine which produced a 20% decrease in control FEV1 (PD20) from 2.88 +/- 1.4 to 5.62 +/- 1.38 mumol, p less than 0.05. A greater increase of histamine PD20 was observed after inhalation of MgSO4 at 0.40 mmol (6.90 +/- 1.6 mumol of histamine, p less than 0.05 in comparison with baseline PD20). The decrease in bronchial hyper-reactivity produced by MgSO4 suggests that it influences smooth muscle contractility and may prove to be clinically important in the treatment of asthma.

[Respiratory functional decline after 5 years in patients with silicosis and asbestosis]. / Declino funzionale respiratorio a 5 anni nei soggetti affetti da silicosi e asbestosi.

A retrospective study of 561 patients with silicosis and 234 with asbestosis was performed to assess whether lung function decline in five years is related to the type (restrictive or obstructive) and/or to the degree of initial damage. Based on lung function tests, three groups of patients were identified: NC with normal lung function tests, CR with restrictive impairment and CO with airway obstruction. The degree of impairment was classified as mild, moderate and severe. Patients were considered worse if five years later they presented a higher degree of impairment. The prevalence of CR was significantly higher in asbestosis, that of NC and CO in silicosis (p less than 0.01). Among subjects with normal starting lung function, 9% only developed CR or CO 5 years later. The prevalence of subjects with worsened lung function in the CR groups was significantly higher (p less than 0.001) in asbestotics (36%) than in silicotics (14%) and was closely related to starting functional impairment. In the CO group the prevalence of worsened subjects was significantly higher than in CR (p less than 0.001), similar in the two diseases and independent of starting lung impairment.

[Functional compromise of the small airways in subjects exposed to SiO2]. / Compromissione delle piccole vie aeree nei soggetti esposti a SiO2.

Aims of our study were: to evaluate small airway function of subjects with past or present silica dust exposure and normal spirometric values; to investigate whether small airway disease is related to radiographic signs of silicosis, to cumulative dust exposure (ES) and to cigarette smoking. Maximal expiratory flow at 50% (MEF50) and 25% (MEF25) of forced expired vital capacity were measured in 112 subjects, 69 with radiographic signs of silicosis, group I, and the remaining 43 with normal chest X-rays. Even if age and ES were significantly higher in group I, no significant difference in respiratory function tests and in prevalence of small airway disease was found between the two groups. In both groups small airway function was significantly negatively related to smoking habits, while it was independent of the other variables considered. Multiple regression analysis with MEF50 and MEF25 as dependent variables did not show any significant relationship. We conclude that small airway disease due to encroachment of bronchiolar walls by SiO2 deposition is masqued by the damage produced by cigarette smoking, even in the presence of radiographic signs of silicosis.

Acute effect of intravenous magnesium sulfate on airway obstruction of asthmatic patients.

The bronchodilating effect of magnesium sulfate (MgSO4) was studied in ten asthmatic patients with moderate to severe airway obstruction. Two grams of MgSO4 or saline in double-blind crossover design was administered IV for 20 minutes (0.40 mmol/min) and forced expiratory capacity and forced expiratory volume in one second (FEV1) were studied at intervals. Only at the end of MgSO4 infusion did FEV1 increase significantly (109% of initial values). The bronchodilating effect was short lasting and far less than that observed after salbutamol.

Histamine hyperresponsiveness of the extrathoracic airway in patients with asthmatic symptoms.

Functional abnormalities of the extrathoracic airway (EA) may produce symptoms mimicking bronchial asthma. We assessed the bronchial (B) and EA responsiveness to inhaled histamine in 40 patients with asthmatic symptoms and in nine asymptomatic controls. FEV1 and maximal mid-inspiratory flow (MIF50) were used as index of bronchial and EA narrowing. Hyperresponsiveness of the intra-(BHR) or extra-(EA-HR) thoracic airway was diagnosed when the provocative concentrations of histamine (PC20FEV1 or PC25MIF50) were less than 8 mg/ml. Fiberoptic laryngoscopy was performed in nine patients and three controls. The glottal region was measured at mid-volume of maximal inspiration (AgMI) and expiration (AgME) before and after histamine. Predominant EA-HR was found in 13 patients, predominant BHR in 12, equivalent BHR and EA-HR in another 12; no significant airway narrowing was observed in three patients and in the nine controls. EA-HR was significantly associated with female sex, sinusitis, post-nasal drip, dysphonia; BHR with atopy, wheezing and lower MEF50. The percent change in AgMI after histamine was closely related to the PC25MIF50 (r = 0.87, P less than 0.001), that of AgME to the PC20FEV1 (r = 0.78, P less than 0.01). These findings suggest that the assessment of EA responsiveness may be useful in the evaluation of asthmatic symptoms, especially in patients with no BHR.

Effects of vitamin C on airway responsiveness to inhaled histamine in heavy smokers.

Histamine bronchial threshold, the provocation concentration of histamine causing a 25% fall in maximal expiratory flow at 50% of forced vital capacity from the control value (PC25MEF50), was measured in seven heavy smokers and in seven sex- and age-matched nonsmokers before and one hour after ingestion, double-blind, of vitamin C (2 g) or placebo. Smokers had significantly lower baseline values of serum ascorbate, maximal expiratory flow at 50% of forced vital capacity (MEF50) and PC25MEF50: the latter was negatively related to serum ascorbate (r = -0.85; p less than 0.001). Acute treatment with vitamin C produced a significant decrease in PC25MEF50 in smokers (95% confidence limit (CL) from 4.87-3.36 to 2.91-2.01 mg.ml-1; p = 0.017), whilst it had no effect in nonsmokers. A preliminary open study on the effect of prolonged administration of vitamin C (1 g daily) was performed in smokers. One week of treatment produced a further significant decrease in PC25MEF50 (p less than 0.0001). Our results suggest that in heavy smokers histamine bronchial responsiveness may be attenuated by chronic ascorbate deficiency. In these circumstances, acute and short-term treatment with vitamin C may increase the bronchoconstrictive response to inhaled histamine.

Bronchial responsiveness in patients with mitral valve disease.

Bronchial responsiveness has been evaluated in patients with chronic lung congestion secondary to mitral valve disease. Methacholine bronchial challenge was performed by intermittent aerosol generation in 31 patients with mitral valve disease, 18 in New York Heart Association (NYHA) Class II and 13 in NYHA Class III, non-atopic and with baseline forced expiratory volume in one second/vital capacity (FEV1/VC) greater than 85% of predicted and in 30 normal controls. Haemodynamic data were available in 17 patients. The methacholine bronchial provocation dose causing a 35% fall of airway conductance (PD35sGaw) was significantly lower in patients (507 +/- C.I. 205 micrograms) than in normals (2779 +/- C.I. 358 micrograms), (p less than 0.001). In patients log PD35sGaw was significantly correlated with mean pulmonary artery pressure (r = 0.53, p less than 0.05), mean pulmonary capillary wedge pressure (r = 0.67, p less than 0.01), but not with any spirometric parameters. Bronchial hyperresponsiveness seems to be common in patients with mitral valve disease and evidence of lung congestion.

Effect of ascorbic acid on increased bronchial responsiveness during upper airway infection.

We investigated the acute effect of ascorbic acid on histamine bronchial responsiveness (PC 20: concentration causing a 20% fall in FEV1) in 9 hospital staff members with upper respiratory tract infection (URI) and cough. Subjects were examined within 5 days from the start of illness and 6 weeks after. On day 1, the reproducibility of PC20 was assessed by 2 consecutive inhalation challenges 1 h apart; the two values were closely related (r = 0.96, p less than 0.001). Five subjects had bronchial hyperresponsiveness (PC20 less than 8 mg/ml histamine). On the following day, PC20 was measured before and 1 h after oral intake of 2 g ascorbic acid. Vitamin C produced a significant increase in average PC20 (p less than 0.01) from 7.8 +/- (SE) 1.2 to 25.1 +/- (SE) 1.2 mg/ml. None had airway hyperresponsiveness after treatment. Six weeks after the onset of URI, bronchial responsiveness was normal in all the subjects but one. The mean PC20 was 15.5 +/- (SE) 1.25 mg/ml, significantly higher than during URI (p less than 0.05); after ascorbic acid it increased nonsignificantly to 25.7 +/- (SE) 1.35 mg/ml. Our results indicate that vitamin C inhibits the transient increase in bronchial responsiveness occurring in otherwise normal subjects during URI.