Factors affecting survival of hospitalised patients with COPD.

Factors determining in-hospital mortality and long-term survival of patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are not precisely understood. The aim of the present study was to assess the parameters related to in-hospital mortality and long-term survival after hospitalisation of patients with AECOPD. Clinical and epidemiological parameters on admission in 205 consecutive patients hospitalised with AECOPD were prospectively assessed. Patients were followed-up for 3 yrs. Factors determining short- and long-term mortality were analysed. In total, 17 patients (8.3%) died in hospital. In-hospital mortality was significantly associated with lower arterial oxygen tension (P(a,O2)), higher carbon dioxide arterial tension, lower arterial oxygen saturation and longer hospital stay. The overall 6-month mortality rate was 24%, with 1-, 2- and 3-yr mortality rates of 33%, 39% and 49%, respectively. Cox regression analysis revealed that long-term mortality was associated with longer disease duration (relative risk (RR) = 1.158), lower albumin (RR = 0.411), lower P(a,O2) (RR = 0.871) and lower body mass index (RR = 0.830). When the model was run for the time elapsed since first hospitalisation, it also appeared as statistically significant (RR = 1.195). These findings show that patients hospitalised with acute exacerbations of chronic obstructive pulmonary disease have poor short- and long-term survival. Prediction of survival status may be enhanced by considering arterial oxygen tension, albumin, body mass index, disease duration and time elapsed since the first hospitalisation.

Utility of blind forceps biopsy of the main carina and upper-lobe carina in patients with non-small cell lung cancer.

BACKGROUND AND OBJECTIVE: Preoperative detection of non-small cell lung cancer (NSCLC) metastasis to the main carina and upper-lobe carina can alter the operative approach, preclude further staging procedures, and save many patients from thoracotomy. This study assessed whether bronchoscopic forceps biopsy of the normal-appearing main carina and upper-lobe carina (blind biopsy) ipsilateral to the primary NSCLC lesion improved the accuracy of cancer staging and helped guide the management of these patients. PATIENTS AND METHODS: A prospective study of 52 patients was carried out at the SSK Süreyyapasa Center for Chest Disease and Cardiothoracic Surgery. Over a 6-month period, we bronchoscopically evaluated 52 consecutive NSCLC patients who were radiologically classified as operable. At least five blind forceps biopsy specimens were obtained from the main carina and/or upper-lobe carina during each patient's initial fiberoptic bronchoscopic examination. Biopsy specimens were collected from the main carina and upper-lobe carina in 51 and 17 patients, respectively. Initially, all patients were staged and evaluated for operability in standard fashion, without histologic assessment of the blind biopsy specimens. We then restaged the disease and reassessed the patients' operability in light of the biopsy findings. RESULTS: Metastasis was histologically diagnosed in seven patients (13.7%) who underwent main carina biopsy and in four patients (23.5%) who underwent upper-lobe carina biopsy. Cancer-positive blind biopsy results changed the status of 25% (6 of 24) of patients from operable to inoperable, and changed the surgical approach in 11.1% (2 of 18) of patients who ultimately did undergo surgery. We found no statistical relationship between metastasis to either carina and tumor type, stage of disease, visibility of the tumor on fiberoptic bronchoscopy, primary tumor location, T status, or N status (p > 0.05). CONCLUSIONS: A blind forceps biopsy of the main carina and upper-lobe carina ipsilateral to the lesion site should be done routinely at initial bronchoscopic examination of all radiologically operable patients with suspected lung cancer. This type of screening can save a significant number of NSCLC patients from inappropriate or unnecessary thoracotomy and further staging procedures with their associated morbidity and risk.

Thoracic involvement in Behçet's disease and its correlation with multiple parameters.

In Behçet's disease (BD), controversy has existed over the incidence of thoracic involvement, which may be a direct threat to the patient's life. The aim of this study is to evaluate the incidence of thoracic involvement in BD and its correlation with the number of diagnostic BD criteria of The International Study Group (ISG), gender, disease duration, and the presence of symptoms. Forty-two BD patients, who had consecutively applied to different clinics in Turgut Ozal Medical Center Research Hospital, were included in the study. They were either newly diagnosed or already under treatment. All patients were examined by standard chest roentgenogram, spirometry, and thorax CT. Perfusion scintigraphies were obtained in patients with thoracic involvement. Thoracic pathologic conditions were found in five patients (11.9%). All thoracic pathologic conditions appeared in patients with at least four diagnostic criteria (26 patients) of the ISG for BD. In this subgroup, the rate of thoracic involvement was 19.2%. Also, 25% of the patients with pulmonary symptoms (12 patients) had thoracic lesions. Gender and the duration of the disease did not correlate with thoracic involvement. Our findings suggest that the rate of thoracic involvement in BD is greater than is generally believed. An increased number of diagnostic BD criteria of the ISG may indicate other organ system involvement and an increased risk of thoracic pathosis. All BD patients with at least four diagnostic criteria or any pulmonary symptoms should be evaluated for thoracic involvement, which is a major menace to life and necessitates early intervention.

Alarming drug-resistance rates for tuberculosis in Süreyyapasa Hospital, Turkey.

The susceptibility patterns to 'classic' tuberculous pleuritis can reflect the circulating strains in a society. The records of patients with 'classic' tuberculous pleuritis were reviewed retrospectively. Eighty-six patients were selected who were hospitalized between January 1990 and April 1994. Pleural fluid and tissue samples of patients were cultured in Lowenstein-Jensen medium. The isolated strains were subjected to drug susceptibility testing based on the absolute concentration method. We obtained 40 positive cultures in 86 patients with 'classic' tuberculous pleuritis. The resistance rate was 75% to one or more drugs, 27.5% to two drugs, 15% to three drugs, and 10% to four drugs. The resistance rates to isoniazid, rifampicin, streptomycin, and ethambutol were 32.5, 55,42.5 and 32.5%, respectively. The resistance to isoniazid + rifampicin was 7.5%. Our findings indicate that the resistance rates for 'classic' tuberculous pleuritis are considerably high, reflecting the currently circulating resistance patterns in our region. The best regimen for new tuberculous cases and the appropriate regimens for drug-resistant cases should be designed and conducted by a nationwide institution.

Intrathoracic tuberculous lymphadenopathy: clinical and bronchoscopic features in 17 adults without parenchymal lesions.

BACKGROUND: Whilst intrathoracic lymphadenitis is a characteristic sign of primary tuberculosis in children, its presence without parenchymal lesions in adults is unusual and makes the diagnosis using noninvasive techniques difficult. The diagnostic role of bronchoscopy in adults with intrathoracic tuberculous lymphadenitis is reported. METHODS: Seventeen patients with intrathoracic lymphadenopathy seen during 1993 who had all undergone bronchoscopy and had been found to have tuberculosis in the absence of any parenchymal lung lesions were evaluated retrospectively. RESULTS: Right paratracheal lymphadenopathy was observed on the plain chest radiograph in all the patients. Fifteen of the 17 patients had an endobronchial abnormality and samples taken at bronchoscopy gave a definitive diagnosis in nine (53%) of the 17. Four patients had ulcerating endobronchial granuloma and all had biopsy samples positive for tuberculosis. Transbronchial or transcarinal needle aspiration samples were diagnostic in five of 11 patients (45%) subjected to the procedure. Peripheral lymph node biopsy diagnosed tuberculosis in two cases and in the remaining six patients the diagnosis wa achieved by mediastinoscopy or thoracotomy. CONCLUSIONS: Bronchoscopy has an important role in the diagnosis of intrathoracic tuberculous lymphadenopathy in adults and should be considered before other invasive procedures.

High initial and acquired drug resistance in pulmonary tuberculosis in Turkey.

SETTING: Süreyyapasa Center for Chest Diseases and Thoracic Surgery, Istanbul, Turkey between January 1992 and December 1992. OBJECTIVE: To evaluate the prevalances of initial and acquired resistance to antituberculosis drugs in our center. DESIGN: 785 patients with pulmonary tuberculosis (both old = 525/785 and new = 260/785 cases) referred to our center were evaluated with respect to their drug resistance patterns. RESULTS: The overall resistance rate (1 or more drugs) was 35.5%, with initial resistance 26.6% (140 of 525) and acquired resistance 53.4% (139 of 260). Initial resistance to streptomycin was the most frequent (20.6%), followed by rifampicin (10.8%), isoniazid (5.1%) and ethambutol; (4.2%). Initial resistance was noted as 16.4% to 1 drug, 7.7% to 2 drugs, 1.2% to 3 drugs and 1.3% to 4 drugs. Acquired resistance to rifampicin was the most frequent (36.2%) followed by streptomycin 31.9%, and isoniazid 30%. Acquired resistance was found as 18.7% to 1 drug, 19.3% to 2 drugs, 9.6% to 3 drugs and 5.8% to 4 drugs. CONCLUSION: High initial drug resistance in Turkey may well threaten the success rates of antituberculosis treatment and it is therefore mandatory to begin antituberculosis treatment in routine practice in our country with at least 4 first-line drugs, replacing streptomycin with ethambutol due to high resistance to streptomycin. In conclusion there is an urgent need for a nationwide tuberculosis control programme in Turkey, where the treatment of old cases is still challenging, in order to combat the grave situation of high initial and acquired drug resistance.