Age of onset and the characteristics of asthma.

OBJECTIVE: The aim of this study was to evaluate the characteristics of asthma in patients with different ages of disease onset. METHODOLOGY: Five hundred and four asthmatic patients (303 males and 201 females) were divided into five groups based on age of onset (group I, age of onset < 15 years old; group II, 15-24 years old; group III, 25-44 years old; group IV, 45-64 years old; and group V, > 64 years old). The relationship between age of onset and the characteristics of asthma, including lung function, reversibility, atopic status and the incidence of coexistent allergic rhinitis was assessed. Multivariate analysis, adjusted for the duration of disease, gender, educational level, smoking status, and degree of previous inhaled corticosteroid treatment, was performed. RESULTS: Thirty per cent of the patients developed asthma before they were 14 years old (group I), and the percentages of those developing asthma at other ages of onset were: group II, 12%; group III, 29%; group IV, 21% and group V, 8%. In all, 57.6% of the asthmatic patients had coexistent allergic rhinitis; younger patients tended to have this comorbidity. The pulmonary function of older onset asthma patients was worse than that of early onset patients. The multivariate analysis showed that there was a positive correlation between the reduction of pulmonary function and duration of the disease (P < 0.001), but there was no relationship between pulmonary function and gender (P = 0.502), educational level (P = 0.734), smoking pack-years (P = 0.902), or degree of use of inhaled corticosteroid treatment (P = 0.586). CONCLUSION: Asthma is a heterogeneous disease with a wide variety of presentations. This study provides information about the disease characteristics and their relationship with age of onset. Further study is necessary to determine why these differences exist.

The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures.

STUDY OBJECTIVES: We used invasive and noninvasive procedures to determine the causes of pneumonia in renal transplant recipients. SUBJECTS AND METHODS: We retrospectively surveyed 565 renal transplant recipients (transplants received March 1984 to August 2001) to find those with pneumonia. Noninvasive diagnostic methods included serologic testing, and blood and sputum cultures with stains. Invasive procedures included fiberoptic bronchoscopy and percutaneous transthoracic procedures. RESULTS: A total of 92 patients were enrolled. Of these, 71 patients had a definite etiologic diagnosis of pneumonia. The major infectious pathogens were bacterial (n = 21) and mixed bacterial infection (n = 10), Mycobacterium tuberculosis (TB) [n = 18], and fungi (n = 8). Noninvasive and invasive procedures led to the diagnosis of pneumonia in 31.5% (n = 29) and 45.6% (n = 42) of patients, respectively. Bronchoscopy was used in 64 patients, with a diagnostic yield of 38 cases (59.3%). Patients were 3.62 times more likely to contract pneumonia within 12 months of renal transplantation than they were > or =12 months thereafter (95% confidence interval, 1.33 to 9.84). Twenty-seven of the 92 patients (29.3%) died. The pneumonia mortality rate has dropped significantly since 1996 (41.8% vs 10.8%, p = 0.002). CONCLUSION: Both invasive and noninvasive procedures are useful in the diagnosis of pneumonia, with declining mortality, in renal transplant recipients. Bacterial and mixed bacterial infection, TB, and fungal infection are the most common pathogens; cases are most likely to occur within 1 year after renal transplantation.

Features of severe pneumonia in patients with undiagnosed pulmonary tuberculosis in an intensive care unit.

BACKGROUND AND PURPOSE: Early antituberculosis (anti-TB) therapy in hospitalized, severely ill patients with pulmonary tuberculosis (PTB) diminishes the mortality and morbidity rate and also reduces nosocomial transmission. However, delayed diagnosis of PTB is common in the respiratory intensive care unit (RICU), especially in patients with respiratory failure. This retrospective study evaluated the clinical features of RICU patients with severe pneumonia and undiagnosed active PTB, in order to determine which specific features might help in the screening of these patients. METHODS: Patients with severe pneumonia with undiagnosed active PTB and those without active PTB on admission to the RICU, from March 1, 2000 to August 31, 2002, were compared. The 2 groups of patients were matched for age, gender, and Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to the analysis. Data on clinical course, chest radiographic patterns, and laboratory findings were collected. RESULTS: Thirty five patients in the case group were matched with 35 controls who were similar with regard to age, gender, smoking history, acute lung injury score, and the presence of underlying disease. The duration of symptoms before admission was significantly longer in the case group than in the control group (15.1 +/- 13.9 vs 7.8 +/- 7.6 days, p = 0.012). The mean interval from admission to the RICU to the initiation of anti-TB therapy was 10.0 +/- 9.8 days. Small nodular lesions (p = 0.044) and cavitary lesions (p = 0.013) predominated on the chest radiograph in the case group. The mortality rates at discharge were not significantly different between the case group and the control group. CONCLUSIONS: These data suggest that when a patient developing severe pneumonia has a history of a sub-acute or chronic illness longer than 2 weeks in duration, and predominant small nodular or cavitary patterns on chest radiograph, active PTB should be considered.

Successful treatment of multifocal bronchioloalveolar cell carcinoma with ZD1839 (Iressa) in two patients.

Multifocal bronchioloalveolar cell carcinoma (BAC) is a rare condition that often presents as bilateral lung infiltrates unsuitable for surgical and radiological treatment, with poor response to conventional chemotherapies. Epidermal growth factor receptor (EGFR) pathways are closely related to the proliferation and metastasis of cancer cells. ZD1839 (Iressa) is a quinazoline-derived, orally active, selective inhibitor of the EGFR tyrosine kinase that shows promising effects in the treatment of non-small cell lung cancer. We report 2 cases of multifocal BAC successfully treated with ZD1839. Both patients had advanced disease, and had productive cough for more than 1 year. After the diagnosis of BAC, the first patient received chemotherapy, but was unresponsive. Within 2 weeks of starting treatment with ZD1839 250 mg per day, the amount of bronchorrhea decreased. Two months after the start of ZD1839 treatment, image study showed a marked decrease of lung infiltrates. The second patient developed respiratory failure after an operation on the spine. He received ZD1839 250 mg daily via nasogastric tube. Two weeks after the start of treatment, his dyspnea had improved and he was weaned from the mechanical ventilator. The side effects of ZD1839 treatment in these 2 patients consisted only of dry skin and acne over the face, trunk, and periungual areas. Although the precise mechanisms of the antitumor effects of ZD1839 remain unclear, these results suggest a role for the agent in the management of patients with advanced multifocal BAC.

Serial-measured versus estimated creatinine clearance in patients with non-small cell lung cancer receiving cisplatin-based chemotherapy.

BACKGROUND AND PURPOSE: Cisplatin-based chemotherapy is the main therapy for patients with advanced stage non-small cell lung cancer (NSCLC). The dose of cisplatin is adjusted according to the patient's renal function. Calculation of creatinine clearance (CCr) by 24-hour urine collection is the most common method for estimating the glomerular filtration rate but is time-consuming and inconvenient. Estimation of CCr using the Cockcroft-Gault formula has been suggested to be accurate, reproducible, and less costly. This study compared CCr values obtained by measured and estimated methods during cisplatin-based chemotherapy in NSCLC patients in Taiwan. METHODS: A total of 92 patients (58 men, 34 women) with advanced NSCLC who completed 6 cycles of chemotherapy participated in the study. The dose of cisplatin per cycle was 80 mg/m(2) every 28 days, reduced to 50 mg/m(2) if CCr was 30 to 60 mL/min by the measured method. When urine collection was finished, serum and urine creatinine levels were measured simultaneously. Estimated values were calculated before each cycle of chemotherapy. RESULTS: The mean measured CCr was 85.2 mL/min, 25.7 mL/min higher than the mean estimated value. CCr values obtained by both methods were significantly reduced during the 6 cycles of chemotherapy. There was no significant difference in CCr values between patients aged < 65 years or >/= 65 years (-19.9 vs -15.1 mL/min, p = 0.15). Using a cut-off of measured CCr >/= 60 or < 60 mL/min, agreement on the dosage for both methods was 51% for all patients, 77.7% for patients < 65 years, and 26.7% for patients >/= 65 years. CONCLUSIONS: The Cockcroft-Gault formula underestimated measured CCr by about 25 mL/min in this study. Cisplatin-based chemotherapy reduced CCr, with no significant difference between older and younger patients. Use of the estimated method would result in significant under-dosing, especially for patients >/= 65 years old.

Bronchoalveolar interleukin-1 beta: a marker of bacterial burden in mechanically ventilated patients with community-acquired pneumonia.

OBJECTIVE: To assess the relationship between concentrations of bronchoalveolar cytokines and bacterial burden (quantitative bacterial count) in intubated patients with a presumptive diagnosis of community-acquired pneumonia. DESIGN: A cross-sectional and clinical investigation. SETTING Medical/surgical and respiratory intensive care unit of a tertiary 1,200-bed medical center. PATIENTS: According to the time course of community-acquired pneumonia at the time of study with bronchoalveolar lavage, 69 mechanically ventilated patients were divided into three subgroups: primary (n = 11), referral (n = 23), and treated (n = 35) community-acquired pneumonia. INTERVENTIONS: Bronchoalveolar lavage was performed in the most abnormal area on chest radiograph by fiberoptic bronchoscope. Bronchoalveolar lavage fluid was processed for quantitative bacterial culture. The concentrations of bronchoalveolar lavage cytokines (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6, interleukin-8, and interleukin-10) also were measured. MEASUREMENTS AND MAIN RESULTS: Thirty-two patients had a positive bacterial culture (bronchoalveolar lavage > or = 10 colony-forming units/mL)., and made up 76% of pathogens recovered at high concentrations. The concentrations of bronchoalveolar lavage interleukin-1 beta were 199.1 +/- 32.1 and 54.9 +/- 13.0 pg/mL (mean +/- se) in the patients with positive and negative bacterial culture, respectively (p < .001). Bronchoalveolar lavage interleukin- 1 beta was significantly higher in the patients with a high bacterial burden (p < .001), with mixed bacterial infection (p < .001), and with pneumonia (p < .001), compared with values in patients without these features. The relationship between bacterial load and concentrations of bronchoalveolar lavage interleukin-1 beta was very strong in the patients with primary and referral community-acquired pneumonia but was borderline in treated community-acquired pneumonia. CONCLUSIONS: The common pathogens were similar to the core pathogens of hospital-acquired pneumonia, probably due to antibiotic effects, delayed sampling, and superimposed nosocomial infection. Since the concentration of bronchoalveolar lavage interleukin-1 beta was correlated with bacterial burden in the alveoli, it may be a marker for progressive and ongoing inflammation in patients who have not responded to pneumonia therapy and who have persistence of bacteria in the lung.