Prevalence and risk factors for spontaneous bacterial pleuritis in cirrhotic patients with hydrothorax

Spontaneous bacterial pleuritis is a high mortality complication in cirrhotic patients with hydrothorax. To investigate the prevalence and risk factors for spontaneous bacterial pleuritis in cirrhotic patients with hydrothorax. Adult inpatients with liver cirrhosis and hydrothorax were enrolled. The severity of liver disease was assessed by the Model for End-Stage Liver Disease [MELD] score. Pleural fluid was analyzed [pH, polymorphonuclear [PMN] leucocyte count, total protein level, lactate dehydro-genase [LDH] level, glucose level, bacterial culture and cytology]. Spontaneous bacterial pleuritis was diagnosed by positive pleural fluid culture or, if negative, a pleural fluid PMN count > 500 cells/microL without radiographic evidence of pneumonia. Out of 98 cirrhotic patients with hydrothorax enrolled in the study; 14 [14.3%] fullfilled the criteria for the diagnosis of spontaneous bacterial pleuritis. Of those 14 patients; 9 were culture positive and 5 were culture negative. The other 84 did not have evidence of spontaneous bacterial pleuritis and were considered to have uncomplicated hydrothorax. Patients with spontaneous bacterial pleuritis had more severe liver diseases [MELD score], and higher rate of associated spontaneous bacterial peritonitis [SBP] and bacteraemia than patients with uncomplicated hydrothorax. Patients with spontaneous bacterial pleuritis had a significantly higher PMN count and a lower protein level in the pleural fluid. The prevalence of spontaneous bacterial pleuritis in the studied group of patients with hepatic hydrothorax was 14.3%. Patients with advanced liver disease, low pleural fluid protein, or SBP are at risk for spontaneous bacterial pleuritis

Utiity of tests used to diagnose asthma, gastroesophageal reflux and upper airway cough syndrome in patients with chronic cough and normal chest radiography

Despite the clinical significance of cough, research efforts aimed at improving diagnostic capabilities and developing more effective therapeutic agents have been, to date, disappointing in their limited scope and outcomes. Asthma, gastro-oesophageal reflux disease [GERD] and upper airway cough syndrome [UACS] are common causes for chronic cough with a normal chest X-ray [CXR]. To describe the frequency of these three causes in a cohort of outpatients with chronic cough and normal CXR and to identify the diagnostic tests best able to identify the aetiology in the vast majority of cases using the response to specific therapy as a gold standard. Nonsmoking outpatients of both genders who complained of cough for more than 8 weeks and had normal findings on CXR were studied prospectively. All patients were subjected to spirometery [including postbronchodilator reversibility], sinuses CT scan, rhinoscopy, and 24-h esophageal pH monitoring to get "an initial diagnosis". The assumed causes were confirmed by treating them sequentially. "The final diagnosis" depended on a successful response to therapy. Hundred patients were studied: the laboratory tests established initial diagnoses of asthma, UACS, GERD, or various combinations of these in 78 patients, of those; 35 patients [44.9%] had a single cause, 39 patients [50%] had two causes, and 4 patients [5.1%] had all three causes. After treatment of those 78 patients, the final diagnoses were established as follow: 47 patients [60.3%] has a single cause, 28 patients [35.9%] had two causes and 3 patients [3.8%] had all three causes. There was a good agreement between the laboratory tests and the definite causes [agreement in 65 patients [83%] and discrepancy in 13 patients [17%], k > 0.75]. Twelve patients had their diagnoses changed for two causes to a single cause and one patients had the diagnosis changed from three causes to two causes. Asthma, UACS, GERD, or some combination of these represent 78% of the causes of chronic cough in our sample. Therefore, these conditions should be considered first during diagnostic evaluation of patients with chronic cough and normal CXR. Inspite of some discrepancy between initial and final diagnoses, the study identifies the group of diagnostic methods best able to identify the cause in the vast majority of cases of chronic cough including sinuses CT scan, rhinoscopy, pulmonary function tests, and esophageal pH monitoring

Effect of upper limb, lower limb and combined training on exercise performance, quality of life and survival in COPD

Because there are differences between the upper limb [UL] and lower limb [LL] muscles in terms of the morphological and functional adaptations in COPD patients, specific protocols for strength training and endurance should be developed and tested for the corresponding muscle groups. To elucidate the potential effects of unsupported UL and/or LL exercise training in patients with COPD. The 6-min walking distance [6-MWD], unsupported upper limb endurance [UULE] time, St. George's Respiratory questionnaire [SGRQ], BODE index and pulmonary function tests are used as outcome measures. A prospective, randomized controlled study of patients with COPD. Patients were randomly assigned to one of 4 groups, group A received UL training, group B received LL training, group C received both UL and LL training and group D received no training [controls]. Patients in group A, B, and C underwent exercise training 3 times weekly for 8 weeks. The outcome measures were carried out at study entry and after 8 weeks. 78 patients completed the study: 20 patients in group A, 21 in group B, 19 in group C and 18 in group D. Upper limb training significantly increased UULE time without affecting 6-MWD while LL training significantly increased 6-MWD without changing UULE time. Combined UL and LL training significantly increased both UULE time and 6-MWD. Significant reductions in the scores of SGRQ and BODE index were observed in groups A, B and C but not group D [control]. No changes were found in pulmonary function in all groups at the end of the study. In patients with COPD, combined UL and LL training significantly enhanced the exercise tolerance and quality of life and reduced the risk of death [BODE index] without any change in the pulmonary function

Effect of Aspergillus fumigatus sensitization and colonization on lung function and airways inflammation in asthma

The sensitization and exposure to fungal allergens have been reported to be associated with asthma. The importance of Aspergillus fumigatus [AF] sensitization and colonization of the airways in patients with asthma is unclear. To clarify the effect of sensitization and airways colonization of AF on lung function and airways inflammation in asthma. We studied 66 patients with asthma. Patients were classified into two groups according to AF sensitization: [1] AF-sensitized [immediate cutaneous reactivity >3 mm]; and [2] AFnonsensitized. A positive sputum culture for AF confirmed airways colonization by AF. Routine spirometry was performed for all patients. Airways inflammation was assessed by sputum differential inflammatory cell count. Asthma duration was significantly longer in AF-sensitized asthmatics. Significantly higher rates of positive AF-culture were detected in sputum from AF-sensitized asthmatics [63%] in comparison to AF-nonsensitized asthmatics [31%]. FEV1 and FEV1/FVC were more reduced in AF-sensitized asthmatics in comparison to AF-nonsensitized asthmatics. Sputum neutrophils count was significantly higher in AF-sensitized asthmatics in comparison to AF-nonsensitized asthmatics. Sputum eosinophils did not differ between AF-sensitized and AF-nonsensitized asthma groups, concordant with peripheral blood eosinophils, which did not differ significantly between groups. Multilinear regression analysis predicting FEV1% showed that AF sensitization and sputum neutrophil count were the most important predictors of FEV1 [p= 0.016 for both], followed by positive sputum culture for AF and sputum eosinophil count [p= 0.024 and 0.046 respectively]. [p = 0.105]. AF detection in sputum is associated with AF-sensitization, neutrophilic airway inflammation, and reduced lung function. This supports the concept that development of fixed airflow obstruction in asthma is consequent upon the damaging effects of airway colonization with AF

Prognostic value of plasma brain natriuretic peptide in patients with stable chronic obstructive pulmonary disease

Early detection of pulmonary hypertension or cor pulmonale could be beneficial in managing patients with chronic obstructive pulmonary disease [COPD] because the prognosis of these conditions is poor. Plasma brain natriuretic peptide [BNP] levels are elevated in patients with PH secondary to chronic lung diseases. The aim of the present study was to investigate the use of plasma BNP levels as a prognostic marker in patients with stable COPD. Plasma BNP was measured in controls and patients with stable COPD stage II, III and IV [according to the Global Initiative for Chronic Obstructive Lung Disease classification]. Echocardiography, arterial blood gas analysis, and spirometry were also performed for COPD patients. The study included 57 male patients with stable COPD; 19 had stage II COPD, 21 had stage III COPD, and 17 had stage IV COPD. Twenty age-matched healthy male smokers were enrolled as a control group. The plasma BNP levels were significantly higher in COPD patients compared to controls. The plasma BNP levels in COPD patients increased with disease severity. Plasma BNP levels significantly correlated with FEV1%, PaCO2, PaO2 and pulmonary artery systolic pressure. Plasma BNP levels increased significantly with disease severity, progression of chronic respiratory failure, and secondary pulmonary hypertension in patients with stable COPD. These results suggest that plasma BNP can be a useful prognostic marker to monitor COPD progression and identify cases of secondary pulmonary hypertension in patients with stable COPD

High dose versus low dose streptokinase infusion in patients with submassive pulmonary embolism and echocardiographic right ventricular dysfunction

Pulmonary embolism [PE] remains a major cause of morbidity and mortality in the general population, the established treatment for PE is anticoagulation. It has previously been demonstrated that thrombolytic therapy can be lifesaving in patients with massive PE [haemodynamic instability and right heart failure]. However, the use of thrombolytic therapy in patients with submassive PE [haemodynamically stable] remains a controversial topic. Recent clinical studies, however, support evidence that thrombolysis may favorably affect the outcomes in a wider spectrum of high risk PE patients presenting with right ventricular dysfunction [RVD] as evidenced by decreased right ventricular end diastolic diameter [RVEDD], disappearance of paradoxical septal motion [PSM], and tricuspid regurge [TR] as well as decrease in the pulmonary artery pressure. The aim of this study was to evaluate the effect high dose streptokinase [SK] in 1 hour versus low dose SK in 24 hours in patients with submassive PE and RVD. The study included 50 patients [25 males and 25 females, mean age 45.5 y] with submassive PE [positive spiral CT chest] and RVD [proved by echocardiography]. Those without contraindications to SK were randomly assigned to receive either high dose [group 1] or low dose [group 2] of SK. Those with contraindication [s] to SK received anticoagulation [group 3]. Echocardiography was done before and 72 h after treatment. Right ventricular dysfunction [RVEDD, PSM, and TR] and mean pulmonary artery pressure [PAP] improved significantly 72 h after treatment in group 1 and 2, while a slight improvement in PAP was observed after treatment in group 3. No significant difference was noticed between group 1 and 2 regarding the effect of treatment on RVD or PAP. No significant difference was found between group 1 and 2 regarding the complications of SK. No significant difference was found between the 3 groups regarding the mortality. These data suggest that SK can rapidly reverse the pulmonary hypertension and RVD in contrast to anticoagulation. Both protocols of SK are equieffective in rapid reversal of RVD and pulmonary hypertension. Both protocols were safe as proved by absence of difference in mortality over anticoagulant group

Role of medical thoracoscopy in the diagnosis of pleural malignancies

A malignant pleural effusion is diagnosed by finding exfoliated malignant cells in pleural fluid or by demonstrating these cells in pleural tissues obtained by closed pleural biopsy, thoracoscopy, or thoracotomy. Precise diagnosis is mandatory as different tumors have different managements. Unlike thoracocentesis and closed pleural biopsy [CPB]; medical thoracoscopy [MT] permits biopsy with direct visualization of the pleural surfaces. The aim of this study was to evaluate of the role of MT in the diagnosis of pleural malignancies in 2 situations: the 1[st] situation; patients with exudative pleural effusion [EPE], in whom thoracocentesis and CPB have failed to establish a diagnosis [15 patients; group I], the 2[nd] situation; patients with EPE, in whom these procedures have established a diagnosis of pleural malignancies [15 patients; group II]. Among the 15 patients of group I; MT established a diagnosis in 14 patients [93%]. Malignancy was the main diagnosis detectable on thoracoscopy; 9 of 15 patients [60%] proved to have pleural malignancies; five patients [33%] proved to have non-malignant conditions after thoracoscopy, MT failed to establish the diagnosis in one patient [7%] [non-specific pleurisy]. Out of the 15 patients in group II, MT confirmed the diagnosis established by thoracocentesis and CPB in 12 cases [80%] and corrected the diagnosis in 3 cases [20%]; a malignant mesothelioma [MM] was corrected to adenocarcinoma, an adenocarcinoma was corrected to MM, and an adenocarcinoma was corrected to squamous cell carcinoma. Few minor complications were reported in five patients [16.7%] including empyema, residual pneumothorax, subcutaneous emphysema and tumor implantation at the site of MT. No bleeding or mortality was reported. In conclusion, MT under local anesthesia and conscious sedation is a safe procedure and could be applied to a variety of indications especially when a pleural malignancy is suspected. Moreover, MT asserts its usefulness in modifying the diagnosis of prior malignancy and to overcome the problem in the distinction between MM and adenocarcinoma thus saving the patients from unnecessary thoracotomy especially in inoperable cases