Needle aspiration techniques in the diagnosis of pneumonia

There is a need for improved diagnostic methods in pneumonia in view of the low bacteriological yield from conventional diag nostic methods (Gram stain and culture of bronchial secretions, pleural fluid and blood culture), the difficulty of identifying the cause of common pulmonary infections on clinical grounds, the increasing number of bacteria that are resistant to commonly used broad spectrum antibiotics (which complicates an empirical approach to treatment), and the clinical importance of correctly identifying the causative organisms of pulmonary infection and favourable cost-benefit ratio.

Estudio comparativo entre el cepillado bronquial mediante catéter telescópico y la punción transtorácica aspirativa con aguja ultrafina en el diagnóstico de la neumonía de alto riesgo

[spa] El diagnóstico etiológico de la infección pulmonar mediante el empleo de los métodos diagnósticos tradicionales (MDT) -esputo, hemocultivo, líquido pleural y serología- sólo es posible en una minoría de casos. Determinados tipos de infección pulmonar son de tratamiento empírico difícil, por lo que la obtención de un diagnóstico etiológico fiable de gran importancia. La utilización de técnicas diagnósticas más o menos invasivas permite diagnosticar a un elevado porcentaje de casos. Sin embargo, la yatrogenia asociada a estas técnicas ha limitado considerablemente su empleo rutinario.En la presente tesis se estudian dos nuevas técnicas invasivas para el diagnóstico de la infección pulmonar grave: la punción transtorácica aspirativa (PTA) con aguja ultrafina y el cepillado bronquial con catéter telescópico (CBCT), en tres tipos concretos de infección pulmonar: la neumonía adquirida en la comunidad (NAC) catalogada como de alto riesgo, la neumonía nosocomial (NN) y la infección pulmonar anaerobia (IPA).El objetivo primordial de esta tesis ha sido el establecer las indicaciones de las técnicas estudiadas: PTA y CBCT, en cada uno de los tres modelos de infección pulmonar elegidos: NAC, NN e IFA. Para ello se han comparado su eficacia diagnóstica, yatrogenia, mejoría que representan con respecto a los MDT, utilidad práctica de su resultado, grado de aplicabilidad, y coste económico, en cada modelo estudiado, con el fin de elegir a la más adecuada.La PTA fue aplicada en 173 casos inicialmente valorados considerados como NAC de alto riesgo, lOS supuestas NN y 60 casos considerados como IPA. El CBCT fue llevado a cabo en 63 NAC, 220 NN Y 35 IPA. Además, ambas técnicas fueron llevadas de modo simultáneo en el mismo paciente en 91 casos: 31 NAC, 32 NN Y 25 IPA.La sensibilidad de la PTA fue del 56.6% en la NAC, del 64.9% en la NN y del 80.6% en la IPA. La especificidad y el valor predictivo positivo (VPP) fue del 100% en los tres modelos tras la exclusión de los contaminantes cutáneos habituales. El valor predicitivo negativo (VPN) fue menor: 50% en la NAC, 44.9% en la NN y 80% en la IPA.La sensibilidad del CBCT fue del 69.7% en la NAC, 91.3% en la NN y 76.2% en la IPA. La especificidad en cada uno de estos tres modelos fue del 78.3%, 84.9% Y 100% respectivamente, muy similar al VPP. El VPN por su parte fue del 64.3% en la NAC, 88% en la NN y 68.8% en la IPA. La yatrogenia total asociada a la PTA fue de un 8.3%, pero la yatrogenia importante (que precisó algún tipo de tratamiento) fue sólo del 1.2%. El CECT se confirmó como una técnica muy inocua con una yatrogenia total de sólo un 0.3%. Sin embargo, en ausencia de vía aérea artificial, la PTA fue mucho mejor tolerada que el CBCT.Comparadas con el conjunto de los MDT, ambas técnicas (PTA y CBCT) mostraron una sensibilidad muy superior, permitiendo diagnosticar a un 32.7 - 48.4% más de NAC, un 49.3 - 79.1% más de NN y un 80.6 - 76.2% de IPA respectivamente.La influencia del resultado aportado por PTA y CECT sobre la conducta terapéutica ulterior fue valorada de dos modos distintos: cambios en el tratamiento antibiótico empírico (suspensión tratamiento ineficaz, simplificación tratamiento efectivo, suspensión tratamiento innecesario), e hipotética influencia sobre el índice de mortalidad por neumonia (diagnósticos efectuados exclusivamente por la técnica invasiva en vida del paciente, que permitieron su curación tras la corrección del tratamiento antibiótico). La PTA generó cambios terapéuticos en el 29.5% de las NAC, 26.9% de las NN y 33.3% de las IPA. Por su parte el CBCT lo hizo en un 23.8%, 48.2% y 22.9% respectivamente. El hipotético impacto de la PTA sobre el índice de mortalidad fue valorado como de un 2.5% en la NAC, 10.7% en la NN y 0% en la IPA. En el caso del CBCT fue del 7.3%, 9.0% y 0% respectivamente.La aplicabilidad (porcentaje de casos en que la técnica no estaba potencialmente contraindicada) de la PTA fue del 79% en la NAC, 38.9% en la NN y 91.4% en la IPA. El CBCT por su parte ofreció una aplicabilidad del 100% en los tres modelos.El coste económico de la PTA en concepto de material fungible fue cuatro veces menor que el del CBCT. Aquella técnica fue asimismo de aplicación más simple y rápida que el CBCT.Como conclusiones de esta tesis puede afirmarse que el empleo de técnicas como la PTA y el CBCT es útil, aunque no imprescindible, en la NAC de alto riesgo, y claramente necesaria para una correcto tratamiento de la NN y de la IPA que no responde al tratamiento empírico. Según la experiencia recogida, la técnica idónea para el estudio de la NAC de alto riesgo es la PTA, siendo especialmente destacables su mínima yatrogenia, excelente tolerancia del paciente, bajo coste y rapidez de aplicación, y una eficacia diagnóstica no inferior a la del CBCT. En la NN, el CBCT es la técnica da elección por su elevada eficacia diagnóstica, ínfima yatrogenia, universal aplicabilidad y elevado impacto sobre la conducta terapéutica. Finalmente, en la IPA, ambas técnicas ofrecen resultados parecidos, por lo que la elección entra ambas viene condicionada por el hecho de que la broncoscopia esté indicada por otras razones. Cuando ello ocurra la técnica idónea es el CECT, dado que en este caso es de aplicación muy rápida. En caso contrario es aconsejable recurrir a la PTA.[eng] In order to establish their indications, two invasive diagnostic techniques -transthoracic needle aspiration (TNA) and bronchoscopic protected specimen brush (PSB)- have been compared in three kinds of lung infection: high risk community acquired pneumonia (CAP), nosocomial pneumonia (NP), and anaerobic lung infection (ALI).The indications have been based on the consideration of the following factors: diagnostic efficacy, comparative improvement of the yield of classical diagnostic techniques, influence of the technique result on the empirical treatment, coaplications rate, importance of potential contraindications, and economic cost of the studied technique.TNA was carried out in 173 suspected CAP, 108 NP, and 60 ALI. PSB was performed in 63 CAP, 220 NP, and 35 ALI. In 91 cases the patient was studied simultaneously by both techniques.According to this experience, TNA and PSB are useful in high risk CAP, and absolutely necessary in NP. In the case of ALI, they appear to be clearly needed when the case fails to respond to the empirical treatment. The comparison of all analyzed factors permits to consider TNA as the ideal technique for high risk CAP, while PSB seems to be specially indicated in NP. In the case of ALI, both techniques offered similar results, and PSB seems the technique of choice when bronchoscopy is needed by other reasons. If not, TNA will be preferable

Fatal lung abscess due to lactobacillus casei ss rhamnosus

We read with interest the short report of Dr Namnyak and others on lung abscess due to Lactobacillus casei (August 1992;47:666-7). In the discussion it is stated: .... Pneumonia with empyema due to Lactobacillus has been described in only three cases.

Defining the role of neutrophil-to-lymphocyte ratio in COPD: a systematic literature review

COPD is characterized by a pulmonary and systemic inflammatory process. Several authors have reported the elevation of multiple inflammatory markers in patients with COPD; however, their use in routine clinical practice has limitations. The neutrophil-to-lymphocyte ratio (NLR) is a useful and cost-effective inflammatory marker derived from routine complete blood count. We performed a systematic literature review using the PRISMA statement. Twenty-two articles were included, recruiting 7,601 COPD patients and 784 healthy controls. Compared with controls, COPD patients had significantly higher NLR values. We found a significant correlation between the NLR and clinical/functional parameters (FEV1, mMRC, and BODE index) in COPD patients. Elevation of the NLR is associated with the diagnosis of acute exacerbation of COPD (pooled data propose a cut-off value of 3.34 with a median sensitivity, specificity, and area under the curve of 80%, 86%, and 0.86, respectively). Additionally, increased NLR is also associated with the diagnosis of a bacterial infection in exacerbated patients, with a cut-off value of 7.30, although with a low sensitivity and specificity. The NLR is an independent predictor of in-hospital and late mortality after exacerbation. In conclusion, the NLR could be a useful marker in COPD patients; however, further studies are needed to better identify the clinical value of the NLR

Rainfall is a risk factor for sporadic cases of Legionella pneumophila Pneumonia

It is not known whether rainfall increases the risk of sporadic cases of Legionella pneumonia. We sought to test this hypothesis in a prospective observational cohort study of non-immunosuppressed adults hospitalized for community-acquired pneumonia (1995-2011). Cases with Legionella pneumonia were compared with those with non-Legionella pneumonia. Using daily rainfall data obtained from the regional meteorological service we examined patterns of rainfall over the days prior to admission in each study group. Of 4168 patients, 231 (5.5%) had Legionella pneumonia. The diagnosis was based on one or more of the following: sputum (41 cases), antigenuria (206) and serology (98). Daily rainfall average was 0.556 liters/m2 in the Legionella pneumonia group vs. 0.328 liters/m2 for non-Legionella pneumonia cases (p = 0.04). A ROC curve was plotted to compare the incidence of Legionella pneumonia and the weighted median rainfall. The cut-off point was 0.42 (AUC 0.54). Patients who were admitted to hospital with a prior weighted median rainfall higher than 0.42 were more likely to have Legionella pneumonia (OR 1.35; 95% CI 1.02-1.78; p = .03). Spearman Rho correlations revealed a relationship between Legionella pneumonia and rainfall average during each two-week reporting period (0.14; p = 0.003). No relationship was found between rainfall average and non-Legionella pneumonia cases (−0.06; p = 0.24). As a conclusion, rainfall is a significant risk factor for sporadic Legionella pneumonia. Physicians should carefully consider Legionella pneumonia when selecting diagnostic tests and antimicrobial therapy for patients presenting with CAP after periods of rainfall

The effect of simvastatin on inflammatory cytokines in community-acquired pneumonia: a randomised, double-blind, placebo-controlled trial

Objectives: it has been suggested that statins have an effect on the modulation of the cytokine cascade and on the outcome of patients with community-acquired pneumonia (CAP). The aim of this prospective, randomised, double-blind, placebo-controlled trial was to determine whether statin therapy given to hospitalised patients with CAP improves clinical outcomes and reduces the concentration of inflammatory cytokines. Setting: a tertiary teaching hospital in Barcelona. Participants: thirty-four patients were randomly assigned and included in an intention-to-treat analysis (19 to the simvastatin group and 15 to the placebo group). Intervention: patients were randomly assigned to receive 20 mg of simvastatin or placebo administered in the first 24 h of hospital admission and once daily thereafter for 4 days. Outcome: primary end point was the time from hospital admission to clinical stability. The secondary end points were serum concentrations of inflammatory cytokines and partial pressure of arterial oxygen/fractional inspired oxygen (PaO2/FiO2) at 48 h after treatment administration. Results: the trial was stopped because enrolment was much slower than originally anticipated. The baseline characteristics of the patients and cytokine concentrations at the time of enrolment were similar in the two groups. No significant differences in the time from hospital admission to clinical stability were found between study groups (median 3 days, IQR 2-5 vs 3 days, IQR 2-5; p=0.47). No significant differences in PaO2/FiO2 (p=0.37), C reactive protein (p=0.23), tumour necrosis factor-α (p=0.58), interleukin 6 (IL-6; p=0.64), and IL-10 (p=0.61) levels at 48 h of hospitalisation were found between simvastatin and placebo groups. Similarly, transaminase and total creatine kinase levels were similar between study groups at 48 h of hospitalisation (p=0.19, 0.08 and 0.53, respectively). Conclusions: our results suggest that the use of simvastatin, 20 mg once daily for 4 days, since hospital admission did not reduce the time to clinical stability and the levels of inflammatory cytokines in hospitalised patients with CAP

Increased AGE-RAGE ratio in idiopathic pulmonary fibrosis

Background: the abnormal epithelial-mesenchymal restorative capacity in idiopathic pulmonary fibrosis (IPF) has been recently associated with an accelerated aging process as a key point for the altered wound healing. The advanced glycation end-products (AGEs) are the consequence of non-enzymatic reactions between lipid and protein with several oxidants in the aging process. The receptor for AGEs (RAGEs) has been implicated in the lung fibrotic process and the alveolar homeostasis. However, this AGE-RAGE aging pathway has been under-explored in IPF. Methods: lung samples from 16 IPF and 9 control patients were obtained through surgical lung biopsy. Differences in AGEs and RAGE expression between both groups were evaluated by RT-PCR, Western blot and immunohistochemistry. The effect of AGEs on cell viability of primary lung fibrotic fibroblasts and alveolar epithelial cells was assessed. Cell transformation of fibrotic fibroblasts cultured into glycated matrices was evaluated in different experimental conditions. Results: our study demonstrates an increase of AGEs together with a decrease of RAGEs in IPF lungs, compared with control samples. Two specific AGEs involved in aging, pentosidine and Nε-Carboxymethyl lysine, were significantly increased in IPF samples. The immunohistochemistry identified higher staining of AGEs related to extracellular matrix (ECM) proteins and the apical surface of the alveolar epithelial cells (AECs) surrounding fibroblast foci in fibrotic lungs. On the other hand, RAGE location was present at the cell membrane of AECs in control lungs, while it was almost missing in pulmonary fibrotic tissue. In addition, in vitro cultures showed that the effect of AGEs on cell viability was different for AECs and fibrotic fibroblasts. AGEs decreased cell viability in AECs, even at low concentration, while fibroblast viability was less affected. Furthermore, fibroblast to myofibroblast transformation could be enhanced by ECM glycation. Conclusions: all of these findings suggest a possible role of the increased ratio AGEs-RAGEs in IPF, which could be a relevant accelerating aging tissue reaction in the abnormal wound healing of the lung fibrotic process

Vascular disease in COPD: systemic and pulmonary expression of PARC (Pulmonary and Activation-Regulated Chemokine)

Introduction: The role of Pulmonary and Activation-Regulated Chemokine (PARC) in the physiopathology of Chronic Obstructive Pulmonary Disease (COPD) is not fully understood. The aim of the present study is to analyze the expression of PARC in lung tissue and its relationship with the vascular remodeling of the systemic and pulmonary arteries of COPD subjects. Methods: To achieve this objective, protein and gene expression experiments, together with ELISA assays, were performed on the lung tissue, intercostal arteries and serum samples from COPD patients, non-obstructed smokers (NOS) and never-smokers (NS). Results: A total of 57 subjects were included in the analysis (23 COPD, 18 NOS and 16 NS). In the comparisons between groups, a significantly increased lung protein expression of PARC was observed in the COPD group compared to the NOS group (1.96±0.22 vs. 1.29±0.27, P-adjusted = 0.038). PARC was located predominantly in the smooth muscle cells of the remodeled pulmonary muscular arteries and the macrophage-rich area of the alveolar parenchyma. No differences were detected in PARC gene expression analyses. The protein content of PARC in the intercostal arteries were similar between groups, though little remodeling was observed in these arteries. Circulating levels of PARC were numerically higher in patients with COPD compared to NOS and NS. Conclusion: The results of the present study suggest an increased lung protein expression of PARC in COPD subjects. This protein was mainly localized in the smooth muscle cells of the pulmonary muscular arteries and was associated with the severity of intimal thickening, indicating its possible role in this remodeling process

Comparing probe-based confocal laser endomicroscopy with histology. Are we looking at the same picture?

In conclusion, we found for the first time a positive relationship between a long sleep duration and some markers of melanoma aggressiveness. Future studies are needed to investigate the main pathophysiological mechanisms that could explain this association and the prognostic relevance of this findin

Clinical features, etiology and outcomes of community-acquired pneumonia in patients with chronic obstructive pulmonary disease

Background Community-acquired pneumonia (CAP) is a frequent complication of chronic obstructive pulmonary disease (COPD), but previous studies are often contradictory. Objectives We aimed to ascertain the characteristics and outcomes of CAP in patients with COPD as well as to determine the risk factors for mortality and Pseudomonas aeruginosa pneumonia in COPD patients with CAP. We also describe the etiology and outcomes of CAP in COPD patients receiving chronic oxygen therapy at home and those receiving inhaled steroids. Methods An observational analysis of a prospective cohort of hospitalized adults with CAP (1995-2011) was performed. Results We documented 4121 CAP episodes, of which 983 (23.9%) occurred in patients with COPD; the median FEV1 value was 50%, and 57.8% were classified as stage III or IV in the GOLD classification. Fifty-eight per cent of patients were receiving inhaled steroids, and 14.6% chronic oxygen therapy at home. Patients with COPD presented specific clinical features. S. pneumoniae was the leading causative organism overall, but P. aeruginosa was more frequent in COPD (3.4 vs. 0.5%; p<0.001). Independent risk factors for case-fatality rate in patients with COPD were multilobar pneumonia, P. aeruginosa pneumonia, and high-risk PSI classes. Prior pneumococcal vaccination was found to be protective. FEV1 was an independent risk factor for P. aeruginosa pneumonia. Conclusions CAP in patients with COPD presents specific characteristics and risk factors for mortality. Prior pneumococcal vaccine has a beneficial effect on outcomes. P. aeruginosa pneumonia is associated with low FEV1 values and poor prognosis