Evidence Suggesting the End of Universal Domestic Asbestos Exposure in Metsovo, NW Greece.

BACKGROUND: Inhabitants of Metsovo, NW Greece, had been domestically exposed to asbestos from a gradually abandoned whitewash ("luto") that resulted in a declining epidemic of malignant mesothelioma. OBJECTIVES: We aimed to evaluate whether other sources of asbestos exposure exist following "luto" abandonment. METHODS: Chest computed tomography (CT) and bronchoalveolar lavage (BAL) were used to evaluate residual asbestos exposure in younger Metsovites through the identification of pleural calcifications and asbestos bodies, respectively. In order to provide a historical universally exposed group for comparison, we used the accumulated chest CTs and chest roentgenograms of our previous studies, performed in Metsovites with confirmed exposure but negative chest roentgenogram. As an additional external comparison group, we also assessed CT scans and chest roentgenograms of Metsovites being older than our target group obtained from the records of the Radiology Department between 2009 and 2011. In order to be able to compare our BAL findings, we sought historical controls among BAL studies performed in Metsovites with known exposure to "luto," in the 1980s-1990s, mainly to evaluate alveolitis. Those belonging to individuals of the same age range were used for further comparison. RESULTS: Twenty-two Metsovites born between 1960 and 1980 consented to undergo a chest CT scan, while another 14 CTs were retrieved from the records of the Radiology Department (among 86 of all ages), thus increasing the number of individuals studied to 36. Five of the 36 Metsovites studied were former "luto" users for a short period of time. Minimal pleural calcifications were present in 2 of them, while all chest CTs of nonusers were negative. All 8 BAL studies were negative for asbestos bodies. CONCLUSION: "Luto" use seems to have been the only source of considerable asbestos exposure in Metsovo.

Long-Term Oxygen Therapy in COPD: Factors Affecting and Ways of Improving Patient Compliance.

Long-term oxygen therapy (LTOT) is the cornerstone mode of treatment in patients with severe chronic obstructive pulmonary disease (COPD) associated with resting hypoxaemia. When appropriately prescribed and correctly used, LTOT has clearly been shown to improve survival in hypoxemic COPD patients. Adherence to LTOT ranges from 45% to 70% and utilization for more than 15 hours per day is widely accepted as efficacious. Although several studies have addressed the level of patients' adherence to LTOT, few have suggested or evaluated interventions that conduce to compliance enhancement. The lack of sufficient data regarding COPD patients following oxygen prescription is an enormous void that must be duly confronted to augment clinical effectiveness and cost containment for the long term use. The present review article highlights factors influencing the compliance of patients using LTOT and emphasizes novel strategies and interventions that may prove to be of significant benefit given the remarkably little current research appraising this issue. Therefore, additional research should be promptly performed to verify the efficacy of newly designed approaches in improving the outcomes of patients receiving LTOT.

The Challenging Evaluation of Patients with Severe Psoriasis for Latent Tuberculosis: An Important Indication for IGRA.

It is well-established that tumour necrosis factor (TNF)-α-antagonist regimens are advisable for the control of moderate to severe psoriasis; however the application of these agents is associated with increased risk of TB reactivation. Screening for latent tuberculosis infection (LTBI) is indispensable prior to treatment inception in order to diminish the risk of active TB. Although tuberculin skin test (TST) still represents a useful tool for LTBI detection, it is difficult to be performed and read in patients with extensive psoriatic lesions. In this paper, we report the case of a 65-year-old male with severe psoriasis, who was evaluated by an interferon-gamma release assay (IGRA) for LTBI diagnosis prior to anti-TNF-α therapy. Furthermore, the physiological aspects of interferon-gamma release assays are discussed emphasizing the value of these novel immunodiagnostic tests (IGRAs) for presumable LTBI in all patients with extensive skin disorders.

Use of interferon-gamma release assay for latent tuberculosis infection screening in older adults exposed to tuberculosis in a nursing home.

OBJECTIVES: To assess the additive value of a newly marketed interferon-gamma release assay, QuantiFERON-TB Gold In-Tube (QFT-GIT), to a single tuberculin skin test (TST) for the detection of latent tuberculosis infection (LTBI) in older adults who have been exposed to TB in a nursing home. DESIGN: Contact tracing included clinical examination, chest radiography, TST, and QFT-GIT in TST-negative people (TST< 5 mm). SETTING: A private nursing home. PARTICIPANTS: Seventy-seven individuals (63 elderly residents, 14 young employees) who had been exposed to an active TB case in a private nursing home. MEASUREMENTS: Comparison of TST and QFT-GIT in older adults who have been exposed to TB. RESULTS: For the TST, the positive response rate was 31.7% (n=20) of elderly residents and 43% (n=6) of staff. Positive QFT-GIT results were obtained in seven (16.3%) elderly residents with negative TST, six of whom were aged 80 and older. QFT-GIT increased the percentage of possible LTBI in this group from 31.7% to 42.9%. CONCLUSION: QFT-GIT has a significant additive value to single TST for detecting LTBI in institutionalized older adults, identifying infected subjects anergic to the TST.

Soluble adhesion molecules E-cadherin, intercellular adhesion molecule-1, and E-selectin as lung cancer biomarkers.

BACKGROUND: Altered levels of circulating adhesion molecules found in several carcinomas, including lung cancer, reflect local loss of diffusion barriers and tumor volume and can be potentially used as biomarkers. In the present study, we investigated the role of soluble E-cadherin (sE-cad), soluble intercellular adhesion molecule-1 (sICAM-1), and soluble E-selectin (sE-sel) as biomarkers in lung cancer. METHODS: Sixty-two patients with recently diagnosed lung cancer, 42 with small cell lung cancer (SCLC), and 20 with non-small cell lung cancer (NSCLC), as well as 29 healthy volunteers were enrolled. Blood samples were collected at the time of diagnosis and measurement of soluble adhesion molecules in the serum samples was performed by enzyme-linked immunoassay using monoclonal antibodies against E-cadherin, E-selectin, and ICAM-1. RESULTS: Serum levels of sE-cad, sE-sel, and sICAM-1 in both SCLC and NSCLC were significantly elevated compared with control subjects (P < .001). In addition, patients with SCLC or NSCLC with distant metastasis had a marked increase of sE-Cad (P < .001), but no such correlation with sE-sel and sICAM-1 was found. CONCLUSIONS: Our findings suggest that sE-cad, sE-sel, and sICAM-1 have an adjunctive diagnostic role in lung cancer. Furthermore, sE-cad may also have a prognostic role and could be a useful biomarker in the prediction of lung cancer outcome.

Chronic eosinophilic pneumonia associated with neurofibromatosis type 1: an unusual complication.

Neurofibromatosis type 1 (formerly known as von Recklinghausen's disease) is an autosomal dominant disorder, which results from the proliferation of the neural crest cells, thus affecting any organ system. Several pulmonary manifestations have hitherto been reported, including chest wall deformities, diffuse lung disease, thoracic neoplasms, pulmonary arterial hypertension, central hypoventilation, diaphragmatic paralysis and meningocele. However, eosinophilic lung disorders have not been described. An unusual case of chronic eosinophilic pneumonia in a patient with neurofibromatosis type 1, is reported herein. He had a propitious outcome, following corticosteroid treatment. This is the first well-documented case of chronic eosinophilic pneumonia and neurofibromatosis type 1 in the same patient. These clinical entities might share common pathogenic mechanisms, as suggested by the present study, that could explain their co-existence.

Proteome analysis of bronchoalveolar lavage in individuals from Metsovo, nonoccupationally exposed to asbestos.

Inhabitants of Metsovo, NW Greece, have been exposed to an asbestos whitewash, resulting in malignant pleural mesothelioma (MPM) and pleural calcifications (PCs). Interestingly, those with PCs (PC(+)) are less prone to MPM. They also have lymphocytic alveolitis, and differences in bronchoalveolar lavage (BAL) proteins, compared with those without pleural calcifications (PC(-)). This may mean a different response to the fiber leading to different susceptibility to neoplasia. To further evaluate this, a proteomic analysis of BAL proteins was performed. Proteomic analysis (2D-electrophoresis/Mass Spectrometry) of BAL in Metsovites nonoccupationally exposed to asbestos revealed increased albumin fragments, alpha1-antitrypsin, S100-A9 and HSP27, suggesting ongoing inflammation. In those without pleural calcifications, increased expression of acid ceramidase, glutathione-S-transferase and presence of calcyphosin, all involved in cell cycle regulation and death as well as in the detoxification of mutagenic and toxic agents, lend further support to our thesis of possible "protection against neoplasia" in Metsovites with pleural calcifications.

Environmental mesothelioma associated with tremolite asbestos: lessons from the experiences of Turkey, Greece, Corsica, New Caledonia and Cyprus.

Mediterranean regions such as Greece, Turkey, Cyprus, Corsica and New Caledonia have experienced epidemics of malignant mesothelioma as a result of non-occupational, "domestic" exposure to tremolite asbestos and fibrous erionite. This exposure to tremolite asbestos and fibrous erionite is typified "domestic" due to its prevalence in regions with natural deposits of tremolite asbestos (or fibrous erionite) where the material from tremolite asbestos or fibrous erionite is used for domestic applications such as whitewashing. However, these exposures may be useful in examining the potential consequences of even small amounts of amphibole asbestos fibers in the ambient air. It can also elucidate the effects of fibers that behave like amphibole asbestos. However, this type of exposure is not useful for studying the potential effects of small amounts of asbestos in the ambient air of big cities due to the differing nature of the fiber types and modes of exposure between the regions.

Mefloquine-induced eosinophilic pneumonia.

Mefloquine has been widely used for prophylaxis and treatment of patients with chloroquine-resistant malaria; the drug is usually well tolerated. Rarely, adverse effects may be severe, including gastrointestinal disturbances, neuropsychiatric reactions, cardiovascular manifestations, skin lesions, musculoskeletal symptoms, and bone marrow toxicity. We describe a 67-year-old woman with fever, dyspnea on exertion, peripheral blood eosinophilia, and diffuse pulmonary infiltrates on chest radiography. She had taken mefloquine for malaria prophylaxis for an 8-week trip to South Africa. A thorough work-up led to the diagnosis of eosinophilic pneumonia caused by the mefloquine. Her condition improved after the drug was discontinued. To our knowledge, this is the first report of mefloquine-induced eosinophilic pneumonia. Clinicians should be aware of this rare, potential adverse effect of mefloquine.

Echocardiographic evidence of posteromedial hypokinesis of the left ventricle in relation to mitral regurgitation in cardiac sarcoidosis.

We describe herein the case of a 49-year-old female patient with pulmonary sarcoidosis (stage II) with cardiac manifestation. This consisted of systolic dysfunction without dilatation of the left ventricle and severe mitral insufficiency, possibly due to thinning of the posteromedial left ventricular free wall, based on our echocardiographic observations.

Long-term oxygen therapy in chronic obstructive pulmonary disease: the use of concentrators and liquid oxygen systems in north-western Greece.

BACKGROUND: Long-term oxygen therapy (LTOT) is the cornerstone mode of treatment in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES: The present study aims to investigate the effect of two oxygen sources (concentrator and liquid oxygen) on quality of life, exercise tolerance and compliance to LTOT in patients with COPD. METHODS: The survey included 104 patients with COPD (31 on concentrator treatment and 73 on liquid oxygen). Patients were subjected to pulse oximetry, basic spirometry, measurement of health-related quality of life by the St. George's Hospital respiratory questionnaire instrument and assessment of dyspnoea severity by the modified Borg category scale. Exercise tolerance was evaluated by the S(a)O(2) value after 3 min of walking. S(a)O(2) was measured before and after treatment with each device. Compliance with therapy was defined by the daily duration of oxygen use. RESULTS: The two LTOT groups did not differ significantly concerning pulmonary function tests (p = 0.49 for FEV(1), 0.98 for FVC, 0.15 for FEV(1)/FVC% and 0.38 for FEF(50%)), S(a)O(2) before (p = 0.28) and after (p = 0.80) O(2) treatment and after the 3-min walking trial (p = 0.47), and St. George's Hospital respiratory questionnaire score (p = 0.45). The liquid oxygen group was less dyspnoeic before treatment (p = 0.02), but this difference disappeared after treatment (p = 0.95). A highly significant difference (p < 0.001) was noted concerning the daily oxygen use. Complete compliance to LTOT (> or =15 h/day) was observed in 12.9 and 42.5%, respectively (p < 0.005). Noise disturbance was noted only in the concentrator group (80%). CONCLUSIONS: We conclude that stationary liquid oxygen seems to be a satisfactory alternative mode for LTOT treatment in COPD patients, with higher patient compliance to therapy in comparison with concentrators.

Decreasing prevalence of pleural calcifications among Metsovites with nonoccupational asbestos exposure.

STUDY OBJECTIVES: Twenty years ago, we reported on a very high prevalence of pleural calcifications (PCs) and malignant mesothelioma among inhabitants of Metsovo, in northwestern Greece. It was shown that both abnormalities were related to asbestos exposure from a whitewash containing tremolite. The fading use of this material has resulted in a decreased incidence of mesothelioma (one third of the original incidence). The aim of the present study was to examine whether PCs among Metsovites has followed a similar trend. DESIGN: Retrospective study. SETTINGS: University Hospital of Ioannina, a tertiary teaching hospital, "G. Hadjikosta" Hospital, a tertiary hospital in Ioannina, and Metsovo Health Center, a primary care center in the town of Metsovo. PATIENTS: Chest roentgenograms of 307 Metsovites, obtained between from 1998 to 2002 were examined. The prevalence of PCs was compared to the one noted 20 years ago. RESULTS: A significantly lower prevalence of calcifications was observed now among younger Metsovites (< 60 years of age). In both studies, there was an increasing rate of PC with age. CONCLUSIONS: The findings of the present study strengthen the incrimination of the whitewash containing tremolite in the development of PCs in Metsovites. The withdrawal of its use in the area has resulted in a null prevalence of PCs in individuals < 40 years old.

Immediate post-operative effects of tracheotomy on respiratory function during mechanical ventilation.

INTRODUCTION: Tracheotomy is widely performed in the intensive care unit after long-term oral intubation. The present study investigates the immediate influence of tracheotomy on respiratory mechanics and blood gases during mechanical ventilation. METHODS: Tracheotomy was performed in 32 orally intubated patients for 10.5 +/- 4.66 days (all results are means +/- standard deviations). Airway pressure, flow and arterial blood gases were recorded immediately before tracheotomy and half an hour afterwards. Respiratory system elastance (Ers), resistance (Rrs) and end-expiratory pressure (EEP) were evaluated by multiple linear regression. Respiratory system reactance (Xrs), impedance (Zrs) and phase angle (phirs) were calculated from Ers and Rrs. Comparisons of the mechanical parameters, blood gases and pH were performed with the aid of the Wilcoxon signed-rank test (P = 0.05). RESULTS: Ers increased (7 +/- 11.3%, P = 0.001), whereas Rrs (-16 +/- 18.4%, P = 0.0003), Xrs (-6 +/- 11.6%, P = 0.006) and phi rs (-14.3 +/- 16.8%, P = <0.001) decreased immediately after tracheotomy. EEP, Zrs, blood gases and pH did not change significantly. CONCLUSION: Lower Rrs but also higher Ers were noted immediately after tracheotomy. The net effect is a non-significant change in the overall Rrs (impedance) and the effectiveness of respiratory function. The extra dose of anaesthetics (beyond that used for sedation at the beginning of the procedure) or a higher FiO2 (fraction of inspired oxygen) during tracheotomy or aspiration could be related to the immediate elastance increase.

Long-term oxygen therapy in Ioannina.

BACKGROUND: Long-term oxygen treatment (LTOT) is very important, especially in patients with severe chronic obstructive pulmonary disease (COPD), but its efficacy is closely related to patient compliance. OBJECTIVES: The aim of the present study was to investigate the compliance of patients under LTOT in the Prefecture of Ioannina (north-western Greece) and to identify factors that might be involved. METHODS: The study included 249 patients treated with LTOT during a 1-year period. They were visited at home by the investigating staff (a chest specialist and a primary care nurse). Compliance to therapy was defined by the daily use of the O2 concentrator (in hours). Patients underwent pulse oximetry, basic spirometry, and trial inhalation of bronchodilators. RESULTS: Only 67 patients (26.9%) complied with therapy, while the daily concentrator use lasted 9.7 +/- 6.09 h. SaO2, FEV1 and FVC were negatively correlated to patient compliance. No significant differences concerning LTOT compliance were noted between men and women, urban and rural population, and between smokers, ex-smokers and non-smokers. A chest physician recommended LTOT for the majority of patients (86.3%), while COPD was the main reason for LTOT prescription (74.7%). Nevertheless, compliance to LTOT was not significantly higher when prescribed by a respiratory physician. No specific medical instructions and information was recorded for the majority of the study patients treated with LTOT. CONCLUSIONS: Our results suggest that an organized home care program establishing the relative guidelines is necessary for substantial improvement in patient compliance to LTOT in Greece.

Volume and flow dependence of respiratory mechanics in mechanically ventilated COPD patients.

Volume and flow dependencies of respiratory mechanics are examined in 10 COPD patients under mechanical ventilation (MV) at 3 levels of externally applied PEEP (PEEPe). Airways pressure (Paw), flow (V') and volume (V) data are analyzed according to (1) the linear and (2) a non-linear model, accounting for volume dependence of elastance and for flow and volume dependence of resistance. The models' fitness to data is assessed by the regression errors. Non-linear modelling fits significantly better to data, while the difference of fitness decreases with PEEPe. Linear mechanics are not significantly different between the 3 levels of PEEPe. A positive volume dependence of elastance observed at 0, decreases at 5 and increases again at 10 hPa of PEEPe. A seriously negative volume dependence of resistance at 0 turned to positive with PEEPe. These dependencies of respiratory mechanics during COPD under MV, show that the present non-linear respiratory mechanical monitoring may help for better and less risky adjustment of PEEPe.