Pulmonary scar carcinoma in South Africa

Background. The association between lung scarring and the subsequent development of cancer remains controversial. South Africa has one of the highest incidences of tuberculosis in the world, and resultant scarring may predispose to malignancy. The country also carries a very high burden of smoking and smoking-related diseases that may be synergistic in malignant transformation.Objective. To assess the frequency of pulmonary scarring in patients with lung cancer.Methods. All patients with confirmed lung cancer and a staging computed tomography (CT) scan of the chest were included in this 2-year retrospective study. Pulmonary scarring was categorised according to location as present in: (i) the same lobe as the primary tumour, (ii) a different lobe of the same lung, or (iii) the contralateral lung; or (iv) as diffuse. Post-obstructive bronchiectasis and other changes secondary to cancer were considered not to represent scarring.Results. We identified 435 cases of primary lung cancer. In total, 95 patients (21.8%) had CT evidence of pulmonary scarring. Eighty-three of 85 patients (97.6%) had focal scarring in the same lobe as the primary tumour. Of these, 37 (43.5%) also had scarring involving a different lobe of the same lung, whereas only one (1.2%; p<0.001) had scarring isolated to a different lobe of the same lung. Moreover, 21 patients (24.7%) also had scarring of the opposite lung, but only one patient (1.2%; p<0.001) had scarring isolated to the contralateral lung. Ten patients had diffuse scarring, caused by bronchiectasis (n=5), idiopathic pulmonary fibrosis (n=4) and silicosis (n=1).Conclusion. At least one in five patients with lung cancer had scarring, which was significantly more likely to be present in the same lobe as the tumour, suggesting a predisposition to malignancy

Predictors of treatment success in smoking cessation with varenicline combined with nicotine replacement therapy v. varenicline alone

Background. Identification of the predictors of treatment success in smoking cessation may help healthcare workers to improve the effectiveness of attempts at quitting.Objective. To identify the predictors of success in a randomised controlled trial comparing varenicline alone or in combination with nicotine replacement therapy (NRT).Methods. A post-hoc analysis of the data of 435 subjects who participated in a 24-week, multicentre trial in South Africa was performed. Logistic regression was used to analyse the effect of age, sex, age at smoking initiation, daily cigarette consumption, nicotine  dependence, and reinforcement assessment on abstinence rates at 12 and 24 weeks. Point prevalence and continuous abstinence rates were self-reported and confirmed biochemically with exhaled carbon monoxide readings.Results. The significant predictors of continuous abstinence at 12 and 24 weeks on multivariate analysis were lower daily cigarette consumption (odds ratio (OR) 1.86, 95% confidence interval (CI) 1.21 - 2.87, p=0.005 and OR 1.83, 95% CI 1.12 - 2.98, p=0.02, respectively) and older age (OR 1.52, 95% CI 1.00 - 2.31, p=0.049 and OR 1.79, 95% CI 1.13 - 2.84, p=0.01, respectively). There was no difference in the predictors of success in the univariate analysis, except that older age predicted point prevalence abstinence at 12 weeks (OR 1.47, 95% CI 1.00 - 2.15, p=0.049). The findings were inconclusive for an association between abstinence and lower nicotine dependence, older age at smokinginitiation and positive reinforcement.Conclusion. Older age and lower daily cigarette consumption are associated with a higher likelihood of abstinence in patients using varenicline, regardless of the addition of NRT

Lymphomatoid granulomatosis A report of 4 cases

Only 1 case of lymphomatoid granulomatosis has previously been reported from South Africa. Experience with 4 such adult patients (2 blacks and 2 whites) is described. These patients were followed up for 15 - 48 months and none developed evidence of a lymphoma during this period. Fever, weight loss, cough and breathlessness were prominent symptoms in all patients. One patient, a black woman, with a diffuse interstitial paUern of lung involvement, had digital clubbing - a rare accompaniment that resolved after therapy. Dilated congestive cardiomyopathy was found in association with pulmonary nodules in a black male patient. All 4 patients were treated with cytotoxic regimens. The 2 patients treated with oral cyclophosphamide and prednisolone responded favourably. The possible explanation for paucity of reports of lymphomatoid granulomatosis from South Africa could be under-reporting, underdiagnosis or a true geographic/ethnic variation in the incidence of this condition

Optimising asthma care

[No abstract available]Editoria

Chronic persistent asthma: A review of medicines in the step-up approach

The medications used in asthma have been the subject of intense study over the last three decades. We now have extensive insights into their structure, regulation, receptors and mechanisms of action. Their intersection with the complexity of asthma inflammation has also been well characterised. In parallel, good quality pharmaceutical trials have informed national guidelines and patient-centered outcomes have been explored. With this therapeutic armamentarium the practitioner should aim to achieve the goals of asthma therapy that are focused on clinical and lung function parameters. The concept of complete asthma control is the current benchmark. Airway inflammation is the fundamental problem in asthma and, logically, anti-inflammatory therapy in the form of inhaled corticosteroids is the single most important intervention. The importance of appropriate use of inhaler devices cannot be sufficiently emphasised. The clinician carefully titrates this treatment utilising additional medications for synergy and to modulate side-effects and costs. The contemporary standard of asthma care is a single inhaler with a combination of inhaled corticosteroids (ICS) and long-acting beta adrenoceptor agonists. The alternative is to add leukotriene modifiers to ICS therapy; there are special circumstances when this may be more appropriate. Poor inhaler use and concomitant allergic rhinitis are examples when supplementation with anti-leukotriene agents would be prudent. With whatever therapeutic strategy, regular education of the patient, tailoring of medication and monitoring of asthma are still crucial to ensure that the goals of asthma control are achieved and maintained in the long term.Revie

The corticosteroid dose-response curve in asthma and how to identify patients for adjunctive and alternate therapies

Asthma is an inflammatory disorder of the airways and inhaled corticosteroids are the most effective agents in controlling the disease process. The corticosteroid-dose response curve has traditionally been thought of as being flat, i.e. plateaus early, with no further therapeutic response with increasing dose of medication. This is only true for mild asthma and the improvement in airway calibre that occurs as inflammation subsides. For other parameters of asthma control, the dose- response curve is shifted to the right (i.e. control takes longer to achieve) and for severe asthma and bronchial hyper-responsiveness, the curve is much steeper (an almost linear relationship). Thus, for PEFR or FEV1, the curve plateaus at about 400-800 ug BDP equivalent per day (depending on asthma severity), whilst doses greater than 1000 ug per day control bronchial hyper-reactivity much better. In assessing the efficacy of asthma medication, the current literature is confusing in that response criteria are chosen arbitrarily (e.g. a 10% improvement in FEV 1) and can mislead if results are extrapolated to other components of asthma control that were not studied. Thus one needs to appreciate data in the appropriate research context. Asthma control should be gauged using composite measures of as many variables in the goals of therapy as possible. Failure to achieve these goals is an indication that the ICS dose should be increased or that an additional agent should be added when one needs to limit steroid side-effects. Co-administration of LABA/ICS remains the most effective strategy (especially in the combination product), that allows for superior asthma control, with leukotriene antagonists and theophylline being alternate choices.Articl

Hemoptysis and hypoxemia in an asthmatic

[No abstract available]Articl

Clinical and radiological grading of superior vena cava obstruction

Background: Superior vena cava obstruction (SVCO) is commonly caused by neoplastic venous compression and presents with typical symptoms and signs. Its clinical severity presumably depends on the degree of obstruction and the adequacy of venous collateral formation. Objectives: The development of novel clinical and radiological scoring systems based on the postulate that a reproducible relationship exists between the degree of SVCO, the presence of collateral circulation and the extent of clinical symptoms. Methods: We prospectively evaluated consecutive cases of acute and subacute SVCO with a newly developed clinical scoring system, which is based on easily detectable clinical symptoms and signs of SVCO. In parallel, we recorded and scored the degree of SVCO and the extent of collaterals visible on contrast-enhanced computed tomography (CT). Results: Thirty-four cases of SVCO were evaluated: 8 (23.5%) were clinically mild, 16 (47%) moderate and 10 (29.5%) severe. Lung cancer was the underlying histological diagnosis in 94% of cases. Radiologically, 53% had complete SVCO. A well-developed collateral system was found in 14 (41%). A scoring system subtracting a 'collateral score' from an 'obstruction score' showed a significant correlation with the clinical score (r = 0.75, p < 0.01). Conclusions: Clinical severity of SVCO depends upon the degree of SVCO and is ameliorated by collateral formation. The novel clinical scoring system can predict the underlying CT features in SVCO and may be valuable in the bedside assessment of SVCO severity. Copyright © 2007 S. Karger AG.Articl