A propensity score-matched comparison of the efficacies of OK-432 and talc slurry for pleurodesis for malignant pleural effusion induced by lung adenocarcinoma.

BACKGROUND: The choice of an optimal sclerosant for pleurodesis for malignant pleural effusion remains controversial. This retrospective clinical study compared the efficacy and safety of two sclerosants; talc slurry (talc-s) and OK-432. METHODS: We compared the characteristics, 30/90-day success rates, and adverse events in patients with lung adenocarcinoma who underwent pleurodesis by using either OK-432 or talc-s. Propensity score matching was used to compare the two scelrosants. RESULTS: Ninety-four patients (mean age=71.6±9.6 years) were included in this retrospective study, of whom 64 received OK-432 and 30 received talc-s. Seventy-three patients (77.6%) were initially diagnosed with clinical stage IV lung cancer, with a 28.7% epidermal growth factor receptor mutation frequency. The propensity score-matched cohort included 26 patients from each group. The 30-day success rates for OK-432 and talc-s were 80.7% and 76.9%, respectively (odds ratio: 1.26, 95% confidence interval: 0.33-4.77, p=0.73). Neither the overall incidence of adverse events nor the 90-day success rates differed significantly. Multivariate logistic regression revealed that the predictors of 30-day success were lower drainage volume on the previous day, particularly <250mL/day, the presence of full lung expansion, and pre-therapy with an epidermal growth factor receptor-tyrosine kinase inhibitor. The median post-pleurodesis survival time was 6.9 months, which was not significantly different between the study groups. CONCLUSIONS: Propensity score-matched analyses showed that pleurodesis using OK-432 and talc-s demonstrated comparable efficacy and safety profiles in patients with lung adenocarcinoma. This indicated that OK-432 could be a viable alternative to talc-s in this procedure.

Predictors and impact of time to clinical stability in community-acquired pneumococcal pneumonia.

BACKGROUND: A clinical stability (CS) evaluation is thought to be important in community-acquired pneumonia (CAP) treatment, but evidence concerning the time to CS (TCS) remains lacking. METHODS: Among consecutive patients hospitalized with pneumococcal pneumonia, relationships between TCS and other clinical outcomes were examined, and predictors and a predictive TCS score were derived from patient characteristics on admission. RESULTS: A total of 144 patients were enrolled, including 46% and 27% with moderate and severe pneumonia, respectively, defined by the pneumonia severity index (PSI). The median TCS was 2 days, and was significantly correlated with the length of hospital stay (r = 0.595); a longer TCS was significantly associated with the more presence of poor clinical outcomes and ICU stays (adjusted odds ratios: 1.359 and 1.366, respectively). A multivariate Cox proportional hazard model revealed an absence of bilateral pneumonia (hazard rate (HR): 2.107) or bacteremia (HR: 2.520), and mild or moderate pneumonia (HR: 2.798 and 2.515, respectively, versus severe) as predictors of CS. A predictive score had moderate discriminating power for the prolonged TCS (area under the curve: 0.76), and provided similar predictive values for poor clinical outcomes and ICU stays. A score of 3 or more points indicated the prolonged TCS, with a sensitivity and specificity of 73.3% and 70.9%, respectively. CONCLUSIONS: Because TCS has a significant relationship with other clinical outcomes of pneumococcal CAP, the prediction of TCS might lead to the prevention of complications or an earlier transition to oral therapy. Future studies are warranted to validate these results.

Prospective evaluation of the relationship between acute exacerbations of COPD and gastroesophageal reflux disease diagnosed by questionnaire.

BACKGROUND: Little is known about the relationship between acute exacerbations of COPD (AECOPD) and gastroesophageal reflux disease (GERD). The aim of this study was to investigate the effects on AECOPD of GERD diagnosed by a questionnaire. METHODS: The subjects were 221 consecutive patients with stable COPD who were evaluated using the Frequency Scale for Symptoms of GERD (FSSG) and a prospective survey of AECOPD for one year. Patients taking drugs for acid suppression were excluded. The association between the frequency of AECOPD and the presence of GERD or FSSG score was examined. RESULTS: Based on the FSSG, the prevalence of GERD was 26.7%. AECOPD and hospitalization due to AECOPD were significantly more frequent in patients with GERD than in those without GERD, with crude relative risks of 3.42 and 3.66, respectively. Multivariate analyses showed that GERD and COPD stage IV were significant predictors of hospitalization due to AECOPD, independent of respiratory therapies or patient characteristics. The severity of GERD symptoms, as measured by the FSSG score, was significantly correlated with the frequencies of AECOPD and hospitalization due to AECOPD. Similar correlations were seen for the FSSG subscores for acid reflux and gastric dysmotility. CONCLUSIONS: This prospective cohort study showed that GERD appears to be a predictive factor for hospitalization due to AECOPD and that severer GERD symptoms may be associated with more frequent AECOPD. Thus, further studies are warranted to evaluate the preventive effect of the therapy for GERD on AECOPD.

[A case of six metachronous primary malignancies].

Recently, the early detection and the advances in therapy for malignant diseases have contributed to prolonged survival of patients, resulting in an increment of multiple primary malignancies. We describe a 55-year-old man, at the first presentation, with six malignancies over 14 years(malignant lymphoma, gastric cancer, ureteral cancer, small cell lung cancer, bladder cancer, and squamous cell lung cancer). A case of six primary malignancies is extremely rare and, as far as we know, this is the 16th case of its kind reported in Japan. The overlapping of many malignant diseases resulted in some difficulties with treatment. Whereas the ureteral cancer and small cell lung cancer were synchronous, considering the therapeutic duration of lung cancer, we proceeded with the operation for ureteral cancer and had to delay the start of chemotherapy for small cell lung cancer for more than one month. Moreover, dose intensity of the chemotherapy for the small cell lung cancer was limited by expectancy of augmented myelosuppression, due to the effect of prior chemotherapy for malignant lymphoma. However, a strong neutropenia-induced postoperative abdominal infection necessitated discontinuation of chemotherapy and treatment with radiotherapy alone. In addition, the therapies for the newly developed squamous cell lung cancer, the sixth malignancy, were also limited because of reduced lung function and myelopoiesis. In treatment or follow-up of patients with multiple primary malignancies, as opposed to those with a single malignant disease, the characteristics of other malignancies and the morbidities by preceding therapies must be considered.

[Relationship between chronic obstructive pulmonary disease and gastroesophageal reflux disease defined by the Frequency Scale for the Symptoms of gastroesophageal reflux disease].

Little is known about gastroesophageal reflux disease (GERD) in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to investigate the prevalence, clinical characteristics and risk factors for GERD in COPD patients, based on the Frequency Scale for the Symptoms of GERD (FSSG). In 228 COPD patients, the prevalence of GERD was 26.7%, independent of COPD stage. Logistic regression multivariate analysis revealed significant risk factors for accompanying GERD were age (p = 0.009; odds ratio (OR), 0.933; 95% confidence interval (CI) 0.885 to 0.983) and number of COPD exacerbation within one year (p = 0.043; OR, 1.675; 95% CI, 1.075 to 2.764). The risk factors of COPD exacerbation were total FSSG score (p = 0.031; OR, 1.079; 95% CI, 1.007 to 1.156) and inhaled corticosteroid use (p = 0.003; OR, 3.238; 95% CI, 1.482 to 7.076). Moreover, the Spearman rank correlation test showed that FSSG score was weakly but significantly correlated with the number of COPD exacerbations (rs = 0.317, p < 0.001). In conclusion, the incidence of GERD in COPD patients is high, and the incidence of GERD is closely related to COPD exacerbation.

Spontaneous pneumomediastinum: an algorithm for diagnosis and management.

Spontaneous pneumomediastinum (SPM) is a rare disorder most often affecting young males which is generally self-limiting. Despite the benign prognosis with few complications and little morbidity, it frequently confuses clinicians in primary settings, who may have difficulty differentiating SPM from other serious organ ruptures, especially oesophageal rupture (the so-called Boerhaave syndrome), which may lead to mediastinitis and may be fatal, even with appropriate interventions. An overview of adult SPM is provided, reviewing 17 studies (414 patients), including our clinical experience, and finally an algorithm for diagnosis and management of SPM is proposed, based on the characteristics of SPM.

[Predictors of survival in patients with chronic hypercapnic respiratory failure receiving domiciliary NPPV].

Fifty-four cases (36 men) with chronic hypercapnic respiratory failure were prescribed domiciliary NPPV during 9 years. COPD (26 patients) and sequelae of tuberclosis (16 patients) were the major primary diseases. At the initiation of NPPV, the age was 71.2 +/- 7.3 years-old (mean +/- standard deviation) and PaCO2 was 76.7 +/- 16.2Torr. Overall, the 1-year and 5-year survival rates were 63.8% and 26.0%, respectively. Multivariate analysis identified BMI (body mass index) (hazzard ratio : 0.837, p = 0.020) and the number of days of hospitalization during 1 year before NPPV (hazzard ratio: 1.013, p = 0.016) as predictors of survival. Patients with frequent hospitalization for exacerbation or with malnutrition had poor prognosis, so comprehensive supports aimed to improve general status are needed for patients with chronic respiratory failure received domiciliary NPPV.

Management of spontaneous pneumomediastinum based on clinical experience of 25 cases.

STUDY OBJECTIVES: Spontaneous pneumomediastinum (SPM) is a rare disorder that usually occurs in young individuals and has a self-limiting course and no recurrence in most cases. But actually in many cases, patients are undergo some examinations or some limitations. The purpose of this study was to evaluate the clinical characteristics and recommend appropriate management of SPM. DESIGN: Retrospective research of clinical records of a single institution. RESULTS: Over 11 years, we diagnosed 25 patients (18 males) with SPM. Their average age was 20.1 years (range 13-28 years). Chest pain or neck symptoms were most frequent, and 17 patients (68%) had subcutaneous emphysema. In all cases, blood counts and C-reactive protein (CRP) were measured, and their mean values were 10,100+/-4600/mm(3) and 1.0+/-1.5 mg/dL, respectively. In 20 patients (80%), either leucocytosis or elevated CRP was observed. Twenty-four patients (96%) were admitted (average 7.8+/-4.1 days) and 20 of them were prescribed antibiotics or limited oral intake. The symptoms were self-limiting in all cases and disappeared on average 1.8+/-0.9 days after diagnosis. No recurrence was noted in the approximately 2 years follow-up period. CONCLUSION: SPM is a self-limiting disease with mild inflammatory signs. For patients suspicious of SPM, shortened hospitalization for about 2 days with observation alone may be feasible, if their symptoms improve gradually. Otherwise, less invasive procedures, such as esophagram, should be performed immediately. Long-term follow-up is usually unnecessary. We propose a new algorithm for management of SPM based on clinical experience.