Previous outpatient antibiotic use in patients admitted to hospital for COPD exacerbations: room for improvement.

PURPOSE: Several studies have analyzed factors associated to hospitalization in chronic obstructive pulmonary disease (COPD) patients. However, data are lacking on the quality of treatment received by patients prior to hospital admission. The present study analyzed how often patients requiring hospitalization for a COPD exacerbation had received previous treatment for the exacerbation, particularly antibiotics. METHODS: This was a multicenter, cross-sectional, observational study conducted in 30 Spanish hospitals among COPD patients aged >40 years who were hospitalized for an acute exacerbation. Patients were grouped according to whether or not they had received treatment prior to admission and, subsequently, according to whether or not they had received antibiotics. Patient eligibility for antibiotic therapy was assessed using both national and European guidelines. RESULTS: The study population consisted of 298 patients, of which 277 (93 %) were men, with a mean [standard deviation (SD)] age of 69.1 (9.5) years. One hundred and thirty-three patients (45 %) had received treatment prior to admission; among these, 76/133 (57 %) had received antibiotic therapy. However, 81-91 % of these patients fulfilled criteria for this therapy. Antibiotic use was significantly associated with yellow or green-yellow sputum prior to the exacerbation, a higher number of exacerbations in the previous year, more visits to emergency departments, and bronchiectasis. On the other hand, 10-20 % of patients who did receive antibiotics were not eligible for this therapy according to guidelines. CONCLUSIONS: This study demonstrates a low rate of previous outpatient treatment and antibiotic use among patients with a COPD exacerbation requiring hospital admission.

[Reliability of the presurgical anatomopathologic diagnosis in primary bronchogenic carcinoma]. / Fiabilidad del diagnóstico anatomopatológico prequirúrgico en el carcinoma broncogénico primario.

BACKGROUND: The specific cell type in primary lung cancer (LC) has important consequences, both for treatment and prognosis. Our objective has been to evaluate the degree of accuracy of several preoperative techniques in the LC diagnosis. PATIENTS AND METHODS: We have studied 442 diagnostic techniques realized in 360 patients who underwent thoracotomy for LC in our hospital (1988-1994). Twelve sputum cytologies, 93 transthoracic needle biopsies (TNB), 73 bronchial aspirated cytologies, 30 bronchial brushing, 205 bronchial biopsies (BB) and 29 transbronchial biopsies were included. In each case the cellular type of LC, obtained through these techniques, was compared with the result derived from the study of surgical piece (reference diagnosis). To calculate the degree of concordance between both diagnoses we used the kappa coefficient (K). RESULTS: The overall concordance between the cellular type observed in the different preoperative techniques and the definitive result obtained by thoracotomy was 0.61. The worst test was TNB (K = 0.41). Sputum cytology and BB presented a good histopathological precision (K = 0.75 and 0.70 respectively). The rest of techniques showed moderate results. On the different histologies, the best result was obtained in squamous carcinoma (K = 0.68) and the worst in undifferentiated large cell carcinoma (LCC) (K = 0.39). Small-cell lung cancer only showed a moderate concordance (K = 0.58). The coexistence and coincidence of two or more tests with the same cellular type were associated with a higher proportion of accuracy (0.97 vs 0.73; p = 0.00002; odds ratio: 12.02). CONCLUSIONS: The preoperative histopathological diagnoses should be interpreted with caution, especially those obtained by TNB and those where it is implied the LCC. In these two circumstances and in cases in which the knowledge of the cellular type have relevance, we think that the initial diagnosis should be reinforced with a second result. The precision of the preoperative diagnoses in small-cell lung cancer must be reevaluated.

[Factors related to diagnostic reliability of bronchial biopsy in primary bronchogenic carcinoma]. / Factores relacionados con la rentabilidad diagnóstica de la biopsia bronquial en el carcinoma broncogénico primario.

To analyze the diagnostic reliability of bronchial biopsy (BB) in bronchogenic carcinoma and the impact of several factors, among them patient symptoms and condition, tumor characteristics and the endoscopist's and pathologist's experience. One hundred eighty-four BB from 151 patients diagnosed of bronchogenic carcinoma in our hospital in the years 1993 and 1994 were reviewed. We first performed single variable analysis, and later logistical regression analysis taking BB positivity or negativity as the dependent variable. The independent variables were age, tumor stage, histological type, lesion necrosis, number of biopsy fragments collected, size of the largest fragment, the endoscopist who performed the BB and the pathologist who studied the specimen. The diagnosis sensitivity of BB was 69.6%. The variables that significantly influenced diagnostic accuracy, in both the single variable and multiple factorial analyses, were clinical status (p < 0.0004) and necrosis (p < 0.0057) with odds ratios of 4.6088 and 0.3766, respectively. The patient's clinical status and the presence or absence of necrosis are the factors that most influence diagnostic accuracy in BB for bronchogenic carcinoma. The likelihood of obtaining a diagnosis is 4.6 greater when clinical status is severe, and 2.7 times greater in the absence of necrosis. The experience of the bronchoscopist, after a learning period, and of the examining pathologist, do not appear to have a decisive effect on diagnostic reliability in this technique.

Cell type accuracy of bronchial biopsy specimens in primary lung cancer.

STUDY OBJECTIVES: To evaluate the diagnostic accuracy of bronchial biopsy (BB) specimens in establishing the specific cell type in primary lung cancer (LC), and to study the influence of several factors on this accuracy. SETTING: Tertiary health-care center. PATIENTS: One hundred forty-six patients with LC diagnosed by BB specimens who underwent thoracotomy (T). MEASUREMENTS: We have studied the specific LC cell type observed in the BB specimen and compared it with the T specimen (reference diagnosis). Age, location and type of bronchial lesion, number and size of the biopsy fragments, tumoral size, sample necrosis, degree of cell differentiation, tumoral stage, pathologist's experience, and the presence of other diagnostic tests with the same cell type were analyzed to assess their influence on the concordance between the two diagnoses. RESULTS: The overall concordance between BB and T histologic diagnosis was 0.70 (kappa coefficient [K]). Of the different histologic types, the worst result was obtained in large cell carcinoma (LLC) (K, 0.49). Squamous carcinoma and adenocarcinoma gave similar results (0.74 and 0.77, respectively), while small cell lung cancer (SCLC) only reached a value of 0.60. The degree of cell differentiation, the absence of necrosis, and presence of other preoperative diagnoses were the variables that most influenced the histologic accuracy of BB specimens. Therefore, the probability of BB accuracy was 2.7, 7.7, and 25 times higher in well-differentiated, than in poorly differentiated, moderately differentiated, or undifferentiated carcinomas; 5.2 times higher when there was no necrosis in the sample; and 7.43 higher when there was another preoperative diagnosis. CONCLUSIONS: The histologic results of BB must be examined carefully, especially in cellular subtypes like LLC. The absence of differentiation and presence of necrosis in BB samples were the factors that require the greatest caution in ascertaining the cell type. When they are involved and also in all cases in which identifying the specific cell type has important implications, we prefer to classify the patients as having SCLC or non-small cell lung cancer, and then reclassify them later after using a second diagnostic technique.

[The clinical characteristics of pleural tuberculosis in patients with and without human immunodeficiency virus infection]. / Características clínicas de la tuberculosis pleural en el paciente con y sin infección por el virus de la inmunodeficiencia humana.

OBJECTIVE: To determine whether or not there are differences in the characteristics of pleural tuberculosis (PT) related to whether patients are or are not infected by human immunodeficiency virus (HIV). METHODS: We conducted a retrospective study of the medical histories of patients diagnosed of PT in our hospital between 1986 and 1993. RESULTS: We found no significant differences in the proportions of tuberculosis patients with or without HIV infection (8% versus 11%) who were diagnosed of PT. Of the 119 patients diagnosed of PT, 10% were also HIV positive. The HIV patients had more serious forms of PT, and among them there was a higher incidence of pleural discharge, more isolations of Mycobacterium tuberculosis in sputum and pleural fluid (42% and 45% versus 13% and 15%, p < 0.05), and more deaths before end of treatment (17% versus 1%, p < 0.05). The HIV patients had a lower rate of positive results in Mantoux's intradermal reaction test (17% versus 67%, p < 0.01), however, and fewer positive results for pleural biopsy (36% versus 84% positivity for granulomas, p < 0.01). CONCLUSIONS: The frequency of PT was similar for subjects with and without HIV infection in our study. In patients with both HIV and PT pleural fluid and sputum cultures are more useful diagnostic tools than pleural biopsy, and the former tests should therefore be stressed.

Parapneumonic effusions secondary to community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients.

The purpose of this study was to determine whether the clinical and microbiological characteristics of parapneumonic effusions in patients with community-acquired pneumonia (CAP) infected with the human immunodeficiency virus (HIV) were different from those observed in patients without HIV infection. One hundred and thirty seven patients with parapneumonic effusions were included and divided into two groups depending on whether they had HIV infection or not. The parapneumonic effusion rate was significantly higher in HIV-positive than in noninfected patients (21 vs 13%). Their clinical course was more severe, presenting a higher rate of bacteraemias (58 vs 18%). Pleural fluid in patients infected with HIV had significantly lower glucose levels than that of patients without HIV infection. Chest tube drainage was more frequent in parapneumonic effusions of patients infected with HIV than in those without HIV infection (71 vs 44%). Staphylococcus aureus was the most common microorganism found in the bacteriological samples of patients with CAP infected with HIV (53 vs 12%). We conclude that patients with community-acquired pneumonia and HIV infection have a higher rate of parapneumonic effusions and a more severe clinical course than non-HIV patients, and that Staphylococcus aureus predominates in their bacteriological samples.

[Individualized prognosis in non-small-cell carcinoma. A multivariate approach]. / Pronóstico individualizado en el carcinoma de pulmón no microcítico. Una aproximación multivariada.

With the aim of providing a system to give individualized initial prognosis for patients with non-small cell lung cancer (NSLC), we performed a multivariate discriminant analysis with combinations of various prognostic factors, studying 93 patients with diagnoses of stage II NSLC and complete followup information. All had undergone surgery at our hospital. Survival longer than or less than one year was defined as the dependent variable: independent variables more clinical, analytical, lung function, histological, anatomical and surgical data. Among the 31.2% of patients who died within one year, tumor size was noticeably greater (6.0 +/- 2.1 cm versus 4.8 +/- 2.0 cm; p = 0.11) and serum albumin was lower (3.7 +/- 0.7 g/dl versus 3.9 +/- 0.6 g/dl; p = 0.039); we found no significant differences among the remaining independent variables in the preliminary univariate analysis. The linear function obtained with discriminant analysis allowed us to classify the patients correctly in 87.1% of cases, with a diagnostic sensitivity of 79.3%, specificity of 90.6%, positive predictive value of 79.3% and negative predictive value of 90.6% for patients who died during the first year. The independent variables that were associated with poor prognosis were large tumor size, long duration of symptoms, low albumin level, high alkaline phosphate level, presence of 2 or more N1 affected nodes, pneumonectomy and presence of perioperative complications. Our findings allow us to conclude that the simultaneous analysis of a variety of prognostic factors can help to give an accurate prognosis for individual patients with the same anatomical stage classification.