Duration of length of stay in pneumonia: influence of clinical factors and hospital type.

Length of stay (LOS) in hospital for community-acquired pneumonia depends on the characteristics of the patient and hospital. The present study sought to identify these variables within the first 24 h of hospitalisation. Patients hospitalised for pneumonia in four hospitals (one teaching and three general hospitals) had their data analysed by univariate and multivariate statististics. The variables entered were LOS, demographical characteristics, referral source, comorbidity, initial severity of illness, laboratory analyses, initial radiograph findings and antibiotic treatment regimens. The study sample included 425 patients. The overall mortality was 8.2% and the median LOS was 9 days. Using LOS as a dependent variable, three multivariate linear regression analyses were performed with: 1) the whole cohort; 2) the low-risk classes (categories I and II of Fine); and 3) the high-risk classes (categories III, IV and V of Fine). The mathematical model identified hypoxemia, low diastolic pressure, pleural effusion, multi-lobe involvement and hypoalbuminaemia as associated with longer stays in risk classes III-V, while in the low-risk patients (I-II) only hypoxemia and pleural effusion appeared in the equation. Following adjustment for these clinical variables, the LOS remained lower in some hospitals. Several independent clinical factors increased the pneumonia-associated length of stay with significant differences between hospitals. Hypoxemia and pleural effusions were the predictive variables of length of stay in low-risk patients and, additionally, diastolic blood pressure, multi-lobe involvement and hypoalbuminaemia were significant in the higher-risk classes III-V.

Ganancia, pérdida y concordancia en el diagnóstico de asma entre neumólogos y no neumólogos / Gain, loss and agreement between respiratory specialists and generalists in the diagnosis of asthma

OBJETIVO: Conocer y analizar el grado de acuerdo y desacuerdo en diagnosticar asma bronquial (AB) entre neumólogos y no neumólogos en el ámbito de atención primaria y especializada en un hospital comarcal. MATERIAL Y MÉTODOS: Se estudian 96 pacientes ( 16 y 70 años) de consulta externa en los que se diagnostica AB por parte del médico que remite al paciente o del neumólogo. Se recogen: a) datos clínicos, determinando la probabilidad diagnóstica inicial (PDI) de asma en alta, media o baja; b) espirometría, test broncodilatador (TBD), variabilidad de flujo espiratorio máximo y prueba de provocación bronquial con metacolina, y c) prick test y determinación de eosinófilos e IgE total en suero. Se registraron tres diagnósticos: el inicial (DI), del médico que remitía al paciente, quien desconocía el desarrollo del estudio; el del neumólogo, obtenido sólo con los datos clínicos (DCN), y el final (DF). En este último caso, para diagnosticar AB se exigió una PDI alta o media y un test broncomotor positivo. Se estudia el grado de concordancia entre los tres diagnósticos mediante el test de Kappa (K), y mediante la prueba de la 2 y análisis de la variancia se analizan las características de los grupos con mayor o menor concordancia. RESULTADOS: Se observó concordancia aceptable entre DCN y DF (K = 0,63) y muy baja entre DI-DCN y DI-DF. En estos dos casos, el grupo de pacientes con concordancia diagnóstica en AB presentaba mayor procedencia hospitalaria e IgE (p < 0,05), así como PDI alta, tiempo de evolución y antecedentes de asma (p < 0,01) (odds ratio: 59,8). Los pacientes discordantes lo eran fundamentalmente por ganancia en AB, con un infradiagnóstico del 39 por ciento. Éstos consultan sólo por algún síntoma relacionado con el asma (odds ratio: 119) y para su diagnóstico se requirió de pruebas broncomotoras distintas del TBD (p < 0,01). CONCLUSIONES: a) El grado de acuerdo a la hora de diagnosticar AB es bajo; b) el perfil clínico funcional de los pacientes en los que hay concordancia en AB difiere de aquellos en los que existe ganancia diagnóstica, y c) en las condiciones de nuestro estudio, se constata una amplia proporción de infradiagnóstico (AU)

Value of the polymerase chain reaction assay in noninvasive respiratory samples for diagnosis of community-acquired pneumonia.

We studied the causes of community-acquired pneumonia (CAP) in 184 patients. Microbiologic evaluation included sputum examination, blood culture, assessment of acute and convalescent antibody titers for Legionella pneumophila, Mycoplasma pneumoniae, Chlamydia pneumoniae, Coxiella psitacci, Coxiella burnetii and respiratory viruses, polymerase chain reaction (PCR) assays for M. pneumoniae and C. pneumoniae in throat swab, and PCR assay based on the amplification of pneumolysin gene fragment in sera. The causative pathogen was identified in 78 patients (Streptococcus pneumoniae, 44; M. pneumoniae, 26; C. pneumoniae, 1; others, 7). S. pneumoniae was detected in serum by the PCR assay in 41 patients, five of whom also had a positive blood culture. PCR assay was negative in two patients with positive blood culture for S. pneumoniae. C. pneumoniae was detected by PCR in nine patients, but only one showed seroconversion. M. pneumoniae was detected by PCR in only three patients (two without seroconversion). The diagnosis of pneumonia caused by S. pneumoniae was five times greater using PCR in serum than with blood culture. Detection of C. pneumoniae by PCR without fulfilling criteria for acute infection may be considered a prior infection. The PCR assay for the diagnosis of M. pneumoniae has a lower sensitivity than serologic methods.

[Descriptive study of patients diagnosed with asthma in a regional respiratory medicine practice]. / Estudio descriptivo de los pacientes diagnosticados de asma en una consulta neumológica de ámbito comarcal.

OBJECTIVE: To describe the characteristics of patients diagnosed of bronchial asthma (BA) in a regional respiratory medicine practice. METHODS: Over a period of two years, 88 adult patients followed a prospective-diagnostic protocol for BA that included taking of patient history to determine the probability of initial diagnosis (PID) of asthma, assessment of atopy and a lung function test that included spirometry with a bronchodilator test, recording of forced expiratory volume, and a methacholine challenge test. BA was diagnosed when symptoms denoting high or moderate PID were present and there was a positive reversibility and/or bronchial hyperreactivity test. The severity of disease was evaluated using the consensus criteria of the Global Initiative for Asthma (GINA). A student-t test and a chi 2 test were performed to compare data. RESULTS: BA was diagnosed in 24 men (30%) and 56 women (70%) with a mean age of 43.0 +/- 17.6 years (range 16 to 68). Significant differences between men and women were detected only for function parameters and cigarette consumption (p < 0.05). Fifty-three patients (66%) were referred by general practitioners, 22 (27%) were referred by hospital, and 5 came from other sources. The first group had a shorter history of disease course (p = 0.05) upon first evaluation. Sixty-one patients (76%) had mild asthma; these patients were younger and had had symptoms for a shorter period of time than those with more serious degrees of disease (16 with moderate asthma and 3 with severe asthma) (p < 0.05). Symptoms indicated a high PID in 57 cases (71%), and this figure increased significantly to 89.5% for those with more severe asthma (p < 0.05). Asthma was intrinsic for 39 patients and extrinsic for 41, with significant differences in age and total IgE between the two groups (p < 0.01). CONCLUSIONS: 1. BA is more than twice as common among women as among men. 2. Two thirds of patients are referred by general practitioners. 3. Mild asthma clearly predominates. 4. Clinical symptoms point to asthma, the PID in most cases being high.

Diagnostic value of cytokeratin fragment 19 (CYFRA 21-1) in bronchoalveolar lavage fluid in lung cancer.

The aim of this study was to evaluate the diagnostic value of a new tumour marker, cytokeratin fragment 19 (CYFRA 21-1), in bronchoalveolar lavage fluid (BALF) for the diagnosis of lung cancer. The cross-sectional study included 36 patients with lung cancer, 19 with benign lung diseases and 13 control subjects. In the group with cancer, BAL was performed in the cancer-involved lung and in the opposite lung. Results in BALF were expressed both as absolute concentrations (ng ml-1) and referred to total protein (TP) (ng mg-1 TP), and results in plasma were expressed in ng ml-1. In BALF, there was no significant different between cancer and control groups. Using the 95th percentile of levels obtained in benign lung disease in BALF (specificity 95%) as the cut-off point, the sensitivity of CYFRA 21-1 was 13%. Positive and negative predictive values (PPV and NPV) at different pretest probabilities, and positive and negative gains were obtained applying a Bayesian analysis. Results showed low positive gains for PPV (maximal increase of 22%) and almost none for NPV (negative gains < 5%). In plasma, CYFRA 21-1 provided a sensitivity of 65%. The combination of BALF and plasma tumour marker levels showed a sensitivity of 69%. Therefore, measurement of CYFRA 21-1 in BALF has poor diagnostic value in lung cancer.

Fibronectin in bronchoalveolar lavage fluid in lung cancer: tumor or inflammatory marker?

OBJECTIVE: To evaluate the potential value of the level of fibronectin (FN) in the bronchoalveolar lavage fluid (BALF) as a lung tumor marker. METHOD: We compare the results of determinations in the tumor-bearing and tumor-free lungs of 38 patients with lung cancer, in 19 patients with benign lung diseases and in 13 healthy control subjects. FN was determined in BALF by a competitive ELISA and was also measured in plasma with a nephelometric assay. FN levels in BALF are expressed also referred to total protein content (ng FN/mg TP). RESULTS: The distribution of FN levels in BALF was not gaussian, and the levels in cancer patients were significantly greater than in healthy controls or in the contralateral lung. There was no significative difference in the levels in cancer compared with several benign conditions. In this study we observed a positive correlation between FN levels and total protein and polymorphonuclear leukocytes in BALF in the lung cancer and benign diseases group. CONCLUSION: These results do not support the possibility that FN levels in BALF were a general marker of lung cancer, and suggest that FN may mark the existence of pathologic lung processes associated with inflammation and, perhaps tissue repair after bronchopulmonary injury.

Repeated pulmonary infection by Nocardia asteroides complex in a patient with bronchiectasis.

A rare case of pulmonary nocardiosis was presented in a nonimmunocompromised patient who had chronic airway obstruction and bronchiectasis without corticoid treatment. The microbial diagnosis was established after isolating Nocardia in bronchial aspirate and sputum samples. An in vitro study showed sensitivity only to imipenem, netilmicine, amikacin and ofloxacin. The evolution was chronic, with multiple clinical recurrences in spite of prolonged antibiotic treatment. Finally, the eradication of Nocardia was achieved with the combination of imipenem and amikacin.

Prognostic factors in restoration of pulmonary flow after submassive pulmonary embolism: a multiple regression analysis.

Defects as evaluated by lung perfusion scans may persist even 6 months after pulmonary embolism (PE), when treatment is withdrawn. The aim of this study was to evaluate the effect of several potential factors on the resolution of lung perfusion defects, both during the first days and at 6 months, when patients were discharged. In a retrospective follow-up cohort study we included 102 patients with PE, diagnosed lung from a ventilation/perfusion (V'/Q') scan, following Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) criteria, together with a phlebographic study of lower extremities or angiography. Lung perfusion scan was performed at diagnosis, and in two follow-up evaluations, at 7-10 days and at 6 months. Potential factors studied were: age; sex; presence of underlying cardiac or pulmonary disease; venous insufficiency; alveolar-arterial pressure difference for oxygen; delay in diagnosis; abnormalities in electrocardiogram or chest radiograph; and the size of defects as shown in lung perfusion scans. All factors were studied with regards to the size of the defects at the two follow-up evaluations, through a univariate statistical analysis and two multiple stepwise regression analysis. Multivariate statistical analysis selected four factors: size of defects at diagnosis; prior cardiopulmonary disease; delay in diagnosis; and sex, as synergistic variables to predict defect size at 7-10 days. On the other hand, the defect size at 7-10 days was the only variable selected as a predictor of the size of defects at 6 months. Resolution of pulmonary defects during the first days after diagnosis of pulmonary embolism is influenced by the initial defect size, prior cardiopulmonary diseases and sex. The size of residual defects at 6 months depends mainly on the size of defects at 7-10 days.

Diagnostic value of SCC, CEA and CYFRA 21.1 in lung cancer: a Bayesian analysis.

The aim of this study was to evaluate the diagnostic value of three tumour markers, squamous cell carcinoma (SCC) antigen, carcinoembryonic antigen (CEA) and CYFRA 21.1, in lung cancer using a Bayesian analysis to obtain the predictive values for different pretest probabilities or prevalences. A cross-sectional study included 94 patients with lung cancer, 40 with benign lung disease, and 40 healthy controls. SCC antigen and CEA were measured in blood samples by microparticle enzyme immunoassay (MEIA), and CYFRA by enzyme-linked immunosorbent assay (ELISA). The results of tumour marker determinations were expressed as percentiles, and showed significantly higher levels in the cancer group than in the two control groups. Taking the 95th percentile of benign lung diseases as the cut-off point (specificity 95%), the following sensitivities were found: SCC 41%, CEA 31% and CYFRA 79%. After a Bayesian analysis, the best results for the three tumour markers were found in prevalences of 30-40%. The highest incremental gain was obtained by CYFRA (at prevalence of 36%, positive and negative predictive value approximately 90%). The three tumour markers were included in a stepwise regression analysis to predict lung cancer, and CYFRA was the only selected variable. We conclude that CYFRA 21.1 may be a useful marker in lung cancer when there is an intermediate pretest probability of disease.

[Profile of a pneumology regional health service]. / Perfil de una consulta de neumología de ámbito comarcal.

This study analyzes patient demand in a regional public health pulmonology practice. The following data were recorded for all first-visit patients for a period of two years: age, sex, referral source, initial diagnosis by the referring physician, final diagnosis by the pulmonologist, and destination. The service studied 1,486 patients (men/women: 1.5). Most (71%) were between 40 and 80 years old. Referrals were from the family doctor (60%), health center (9%), emergency service (10%), hospital (12%), other specialists (6%), and others (3%). The most frequent reasons for remission were upper airway disease (UAD) (36%), specifically chronic obstructive pulmonary disease (COPD) and asthma, and the presentation of symptoms (28%) such as dyspnea, cough, hemoptysis and chest pain. Analysis of the final diagnoses for the patients presenting with symptoms showed that no disease could be detected in one third of those with dyspnea and hemoptysis or in half of those who complained of chest pain; acute respiratory infection was diagnosed in 45% of those complaining of persistent cough. UAD was the most frequent cause of symptoms. The index of doctor's visit/inhabitant was 0.97% for patients referred by family doctors and 0.38% for those from health centers, but the initial and final diagnosis profiles of these patients were not statistically different. Patients referred by emergency services had significantly more (p < 0.001) in number of radiological findings and hemoptysis. Those sent from hospitals more often suffered pneumonia. In conclusion, this profile of a regional public health pulmonology practice shows that: 1) UAD and clinical symptoms are the most frequent reasons for patient remission; 2) family doctors generate three times mor demand for services than do health centers, and 3) 14% of patients can be considered normal.

Effect of cyclosporin on lung diffusing capacity in renal transplant patients.

A prospective lung function study pre- and postrenal transplantation was performed on 21 patients in order to evaluate whether cyclosporin decreased the lung diffusing capacity due to lung toxicity. Initial inclusion criteria were absence of respiratory symptoms and normal findings in both chest X-ray and pulmonary function tests. Participants had to be nonsmokers. We determined spirometry including lung volumes, arterial blood gases, carbon monoxide diffusing capacity by the single breath method (DLCOSB), and rate of CO uptake per unit of lung volume (KCO) before and 3, 6, and 12 months after transplantation. Immunosuppression consisted of prednisone and cyclosporin, maintaining total blood levels between 100 and 250 ng/ml. Spirometric and blood gases data remained within reference levels during the follow-up. Hemoglobin (Hb) pretransplant concentrations remained low, returning to their normal levels post-transplantation. Pretransplant DLCOSB levels were slightly decreased but fell within the therapeutic range after correction for Hb concentration, unlike the mean KCO levels which remained slightly diminished despite their correction. In post-transplant controls, the values obtained for both DLCOSB and KCO were significantly higher at the different post-transplant intervals (P < 0.005) than pretransplantation but only when compared without Hb correction. No significant differences for DLCOSB were found when corrected values were compared, and an improvement in the KCO appeared to be significant at 12 months posttransplantation. Based on these findings, we feel that when serum levels are within the therapeutic range, cyclosporin fails to alter the respiratory function or the pulmonary diffusing capacity of the lung.