Sputum induction is a safe procedure to use in prisoners and MGIT is the best culture method to diagnose tuberculosis in prisons: a cohort study.

OBJECTIVES: To evaluate the concordance and safety of induced sputum (IS) and spontaneous sputum (SS), and estimate concordance and time to detection of M. tuberculosis between Lowenstein-Jensen (LJ), thin-layer agar (TLA), and the Mycobacteria Growth Indicator Tube system (MGIT). METHODS: This was a cohort study. Prisoners with pulmonary tuberculosis (PTB) were followed for 2 years. At baseline and every follow-up visit, three sputum samples were taken on consecutive days (one IS and two SS) and adverse events occurring before, during, and 30 min after IS were registered. All sputum samples were stained with auramine and cultured in LJ, TLA (to test resistance), and MGIT. RESULTS: Five hundred eighty-six IS and 532 SS were performed on 64 PTB patients. Breathlessness (1.6%), cough (1.2%), hemoptysis (0.3%), and cyanosis (0.2%) were the only complications. Concordance between IS and SS was 0.78 (95% confidence interval 0.69-0.87); 11 positive cultures from IS samples were negative in SS, and 11 positive cultures from SS samples were negative in IS. One hundred seventy-eight cultures were positive by any technique: MGIT 95%, LJ 73%, and TLA 57%. Time to detection of M. tuberculosis in LJ, TLA, and MGIT was 31, 18, and 11 days, respectively. CONCLUSIONS: The IS procedure is safe in prisons. The MGIT system is better and faster than LJ and TLA in the diagnosis of M. tuberculosis.

[Follow-up of subjects occupationally exposed to asbestos, what are the objectives, the benefits, and the possible risks?]. / Quels sont les objectifs du suivi post-professionnel, les bénéfices attendus et les risques possibles? Objectifs médicaux en termes de morbidité, mortalité et qualité de vie.

The follow-up of workers occupationally exposed to asbestos has two possible beneficial effects: (1) individually, both medical by screening for diseases related to asbestos and social by notification of occupational disease and/or compensation from the indemnity funds for asbestos victims; (2) collectively, by the establishment of epidemiological surveillance (follow-up of cohorts) and evaluation of the impact of follow-up in terms of health benefits and compensation. The respiratory disorders related to asbestos are: cancer (malignant pleural mesothelioma and bronchial carcinoma), asbestos-related pulmonary fibrosis, and pleural disease (plaques, pleural fibrosis and benign pleurisy). In the light of the data currently available and the effectiveness of the tools used, medical and public health benefits of screening for mesothelioma have not been demonstrated. The early diagnosis of primary bronchial carcinoma can theoretically improve the prognosis of the subjects screened, particularly by identification of stage I disease on CT (pulmonary nodules). This is a common finding but there are a large number of false-positives. While we await the results of several international randomised trials, the benefits of a screening programme for bronchial carcinoma in the population at risk have not been demonstrated. There is no effective treatment for asbestosis but this is an independent risk factor for bronchial carcinoma and it is evidence of heavy asbestos exposure. Stopping smoking in subjects suffering from asbestosis will reduce the incidence of bronchial carcinoma. There is no effective treatment for asbestos-related benign pleural diseases but these are markers of exposure. The presence of pleural plaques has not been shown to be an aetiological factor for thoracic cancers. Post-occupational follow-up may involve risks to health, particularly repeated irradiation and invasive diagnostic procedures. It is also necessary to consider the psychological consequences inherent in all screening programmes. In conclusion, post-occupational follow-up might reduce the mortality of lung cancer by screening for localised disease and its incidence by a targeted anti-smoking programme. The theoretical benefits, that have not yet been demonstrated, have to be seen in perspective with the risks to physical and psychological health related to both screening and diagnostic procedures.

Risk factors for Burkholderia cepacia complex bacteremia among intensive care unit patients without cystic fibrosis: a case-control study.

BACKGROUND: The Burkholderia cepacia complex is associated with colonization or disease in patients with cystic fibrosis (CF). For patients without CF, this complex is poorly understood apart from its presence in occasional point source outbreaks. OBJECTIVE: To investigate risk factors for B. cepacia bacteremia in hospitalized, intensive care unit patients without CF. METHODS: We identified patients with 1 or more blood cultures positive for B. cepacia between May 1, 1996, and March 31, 2002, excluding those with CF. Control patients were matched to case patients by ward, duration of hospitalization, and onset date of bacteremia. Matched analyses were used to identify risk factors for B. cepacia bacteremia. RESULTS: We enrolled 40 patients with B. cepacia bacteremia into the study. No environmental or other point source for B. cepacia complex was identified, although horizontal spread was suspected. Implementation of contact precautions was effective in decreasing the incidence of B. cepacia bacteremia. We selected 119 matched controls. Age, sex, and race were similar between cases and controls. In multivariable analysis, renal failure that required dialysis, recent abdominal surgery, 2 or more bronchoscopic procedures before detection of B. cepacia bacteremia, tracheostomy, and presence of a central line before detection of B. cepacia bacteremia were independently associated with development of B. cepacia bacteremia, whereas presence of a percutaneous feeding tube was associated with a lower risk of disease. CONCLUSIONS: B. cepacia complex is an important emerging group of nosocomial pathogens in patients with and patients without CF. Nosocomial spread is likely facilitated by cross-transmission, frequent pulmonary procedures, and central venous access. Infection control measures appear useful for limiting the spread of virulent, transmissible clones of B. cepacia complex.

Inflammatory response to sputum induction measured by exhaled markers.

BACKGROUND: Sputum induction is increasingly used to study both cellular and biochemical composition of the airways. However, there is a significant rise in the percentage of neutrophils at 8 h after inhalation with hypertonic saline. OBJECTIVE: The aim of this study was to assess whether markers of inflammation in exhaled air and exhaled air condensate change after sputum induction in normal and asthmatic subjects. METHODS: We measured leukotriene B(4) (LTB(4)) and a marker of oxidative stress, 8-isoprostane, (by enzyme immunoassay) in exhaled air condensate and exhaled nitric oxide (NO; by chemiluminescence analyzer) in 15 healthy subjects (8 females, mean age 35 +/- 4 years, FEV(1) 97.4% predicted) and in 8 mild asthmatic subjects (5 males, mean age 34 +/- 2 years, FEV(1) 70.5% predicted). RESULTS: LTB(4) was significantly higher compared with baseline at 6 h but did not remain increased at 24 h after sputum induction (134.3 +/- 30.15 and 75.4 +/- 14.32 vs. 64.6 +/- 11.6 pg/ml at baseline; p < 0.02 and p > 0.05, respectively) in healthy subjects. An inverse correlation between LTB(4) and exhaled NO at 6 h after sputum induction was observed in healthy subjects (r = -0.66, p < 0.03). No increase in LTB(4) levels was observed in asthmatic patients. Baseline 8-isoprostane levels were higher in asthmatic patients than in healthy subjects (47.3 +/- 37.1 vs. 17.5 +/- 8.8 pg/ml; p < 0.01). A trend towards increased levels of 8-isoprostane could be observed at 6 and 24 h after inhalation in healthy subjects (26.2 +/- 3.7 and 26.7 +/- 3.9 pg/ml; p = 0.09 and p = 0.07, respectively). In healthy subjects, exhaled NO was significantly higher compared with baseline at 6 h and remained increased 24 h after sputum induction (7.96 +/- 3.5 vs. 5.61 +/- 1.86 ppb; p < 0.01 and p < 0.05, respectively). Exhaled NO levels were increased in asthmatic patients but did not further increase after sputum induction. CONCLUSIONS: Sputum induction with hypertonic saline causes an inflammatory response which should be considered when using the technique to monitor airway inflammation.

Estudo das alterações espirométricas após broncofibroscopia / Study of spirometric alterations after bronchofiberscopy

Breve estudo das alterações espirométricas em 39 pacientes submetidos a broncofibroscopia (BFP), no período de 1993 a 1995, no Serviço de Pneumologia do Hospital Universitário de Brasília. Os exames foram efetuados sem oxigenoterapia; os pacientes estavam sob monitor de oxímetro digital. Observamos diminuição significativa e transitória de volumes (capacitade vital forçada) nos primeiros 10 minutos após os procedimentos broncoscópicos

Invasive diagnostic techniques for pneumonia: protected specimen brush, bronchoalveolar lavage, and lung biopsy methods.

We suggest the following strategy for managing patients with pneumonia. For nonventilated patients with either CAP or HAP, empiric antibiotic treatment should be started according to approved guidelines, and if the clinical evolution of the patient is not adequate, fiberoptic bronchoscopy including PSB and BAL could be considered, with modification of the antibiotic treatment accordingly. In ventilated patients with either CAP or HAP, respiratory secretion sampling using noninvasive techniques should be conducted upon clinical suspicion of VAP and before starting a new antibiotic treatment. Antibiotic therapy according to approved guidelines should be started as soon as possible and maintained during the first 48 hours if the patient's evolution is satisfactory and condition has stabilized. Then, initial antibiotic treatment should be adjusted according to cultures. If there is a clear diagnostic alternative to VAP and cultures are negative, this is the only case in which antibiotic treatment could be withdrawn. If the patient's clinical evolution is inadequate (persistence of fever, leukocytosis, increasing infiltrates, and respiratory failure), fiberoptic bronchoscopy with PSB and BAL and modification of the initial antibiotic regimen should be sought. Open lung biopsy may be indicated in patients with diffuse pulmonary infiltrates in whom a diagnosis has not been achieved by other methods, including bronchoscopy. Transbronchial lung biopsy should not be viewed as a diagnostic technique for pneumonia except in immunosuppressed patients with diffuse alveolar infiltrates.