Μελέτη στάσεων και συμπεριφορών για την εποχική γρίπη και τη φυματίωση των επαγγελματιών υγείας σε πνευμονολογικά τμήματα δημόσιων νοσοκομείων

Εισαγωγή: Οι ιατροί και νοσηλευτές των δημόσιων νοσοκομείων πιθανόν να έχουν υιοθετήσει συγκεκριμένες στάσεις και συμπεριφορές όσον αφορά τον έλεγχο και την ενδονοσοκομειακή αντιμετώπιση της εποχικής γρίπης και της πνευμονική φυματίωσης. Σκοπός: Η διερεύνηση και η καταγραφή των στάσεων και αντιλήψεων των ιατρών και των νοσηλευτών οι οποίοι εργάζονται σε δημόσια πνευμονολογικά τμήματα σε νοσοκομεία της Αθήνας και σχετίζονται με την εφαρμογή στρατηγικών πρόληψης, καθώς και διαχείρισης πασχόντων με εποχική γρίπη και φυματίωση. Υλικό και Μέθοδος: Η μελέτη εκπονήθηκε από τον Δεκέμβριο 2019-Φεβρουάριο 2020 στο ιατρονοσηλευτικό προσωπικό πνευμονολογικών τμημάτων τριών δημόσιων νοσοκομείων. Οι συμμετέχοντες συμπλήρωσαν ένα ανώνυμο ερωτηματολόγιο με ερωτήσεις που αφορούσαν την αντιγριπική εμβολιαστική κάλυψη, τη βαρύτητα νόσησης από γρίπη και το φόβο έλλειψης κλινών στις κλινικές λόγω κρουσμάτων, το βαθμό εμπιστοσύνης στους κρατικούς μηχανισμούς, καθώς και την πιθανή λήψη αγωγής για λανθάνουσα ή ενεργό φυματική λοίμωξη. Αποτελέσματα: Συνολικά 210 άτομα (95 άντρες), μέσης ηλικίας 43.5 ± 13.8 έτη, 91 ιατροί και 119 νοσηλευτές, 134 απόφοιτοι ΑΕΙ, 91 έγγαμοι και 111 με τέκνα συμμετείχαν στη μελέτη. Το δείγμα παρουσίασε υψηλή εμβολιαστική κάλυψη στο 63%, ενώ στο 55% θεωρεί το εμβόλιο της γρίπης ασφαλές. Όσον αφορά τη φυματίωση, περίπου οι μισοί νοσηλευτές δεν έχουν εξεταστεί για πιθανή φυματική μόλυνση, ενώ η συντριπτική πλειοψηφία δεν έχει λάβει αγωγή για λανθάνουσα ή ενεργό φυματίωση. Οι συμμετέχοντες διαφωνούν ότι η γρίπη είναι μια ελαφριά ασθένεια, ενώ θεωρούν ότι αποτελεί μεγάλο κίνδυνο για την υγεία του ασθενούς (p<0.01), εκφράζοντας φόβους για έλλειψη κλινών στις κλινικές λόγω αυξημένων αριθμών κρουσμάτων (p<0.01). Όσον αφορά τη φυματίωση, στο νοσοκομείο τηρούνται οι βασικοί κανόνες υγιεινής, αποστείρωσης και αερισμού των χώρων (p<0.03), ενώ καταγράφηκε αδυναμία του ΕΟΔΥ να αντιμετωπίσει με επιτυχία τα κρούσματα φυματίωσης στη χώρα(p<0.01). Συμπεράσματα: Τα πνευμονολογικά τμήματα φέρουν αυξημένο βάρος εργασίας και απαιτούν εφαρμογή συγκεκριμένων πρωτοκόλλων προς αποφυγή ενδονοσοκομειακής διασποράς φυματίωσης και εποχιακής γρίπης. Πιθανή μη εφαρμογή των πρωτοκόλλων, μη επάρκεια μέτρων ατομικής προστασίας, ανάπτυξη αισθήματος εργασιακής ανασφάλειας και επαγγελματικής εξουθένωσης δύναται να οδηγήσουν σε μειωμένο επίπεδο παροχής φροντίδας υγείας στους πάσχοντες.Introduction: Physicians and nurses in public hospitals may have adopted certain attitudes and behaviors regarding control and in-hospital management of seasonal influenza and pulmonary tuberculosis. Purpose: To investigate and document attitudes and perceptions of physicians and nurses working in public pulmonary departments of hospitals located in Athens, with respect to implementation of prevention strategies and management of seasonal flu and tuberculosis. Materials and Methods: Between December 2019 and February 2020, a survey was conducted among physicians and nurses of pulmonary departments in 3 tertiary hospitals. An anonymous questionnaire was filled out, with items inquiring about flu immunization, workload, confidence in public health services, and potential treatment for latent or active tuberculosis. Results: A total number of 210 participants (95 men) responded to the survey, with a mean age of 43.5 ± 13.8 years. Ninety-one were physicians and 119 were nurses, with 134 having a university degree, 91 being married and 111 having children during the period studied. We found a high flu immunization rate (63%); 55% of responders considers the flu vaccine safe. Regarding tuberculosis, about half of the nurses have never been examined for potential tuberculous infection, whereas the majority have never taken any treatment for latent of active tuberculosis. The participants disagree that flu is a mild disease (p<0.03); instead, they believe that it represents a grave danger for patients’ health (p<0.01), expressing fears for shortage of available hospital beds due to the increased number of cases (p<0.01). For tuberculosis, all 3 hospitals were reported to abide by the hygiene, sterilization, and room ventilation standards (p<0.03). However, the participants reported an inability of the National Public Health Organization to successfully manage all cases of tuberculosis documented in the country (p<0.01). Conclusions: Pulmonary departments of tertiary hospitals have increased workloads and require implementation of specific protocols in order to prevent in-hospital dissemination of tuberculosis and seasonal flu. A potential failure to implement these protocols, inadequate personal protective equipment, occupational insecurity, and burn-out may lead to suboptimal patient care

Critical analysis of the utility of initial pleural aspiration in the diagnosis and management of suspected malignant pleural effusion

INTRODUCTION:Current guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a 'real world' population. METHODS:A retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration. RESULTS:A diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (χ2 1df=26.27, p<0.001) and insufficient samples (χ2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (χ2 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures. CONCLUSIONS:An initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered

Μη επεμβατική αξιολόγηση της φλεγμονής σε βρογχεκτασίες. Ομοιότητες και διαφορές σε ΧΑΠ και άσθμα.

Εισαγωγή: Η μη επεμβατική αξιολόγηση της φλεγμονής των αεραγωγών μπορεί να δώσει σημαντικές πληροφορίες για την θεραπευτική αντιμετώπιση ασθενών με νοσήματα του αναπνευστικού. Μέσω της μέτρησης φλεγμονωδών κυττάρων και μεσολαβητών στο υπερκείμενο των προκλητών πτυέλων (κυτταροκίνες, πρωτεΐνες, ηωσινοφιλικές πρωτεΐνες) δύναται να εκτιμηθεί ο βαθμός φλεγμονής και αναδιαμόρφωσης των αεραγωγών. Η ευρεία εφαρμογή της πρόκλησης πτυέλων στο άσθμα και ΧΑΠ έχει δώσει πληροφορίες για τη σχέση πνευμονικής λειτουργίας και φλεγμονής των αεραγωγών, ενώ παράλληλα έχει προτείνει νέους φαινότυπους με διαφορετική απάντηση στη θεραπεία. Παρόλα αυτά, λίγα δεδομένα υπάρχουν για τη χρησιμότητά της μη επεμβατικής αξιολόγησης της φλεγμονής σε ασθενείς με βρογχεκτασίες υπό σταθερές συνθήκες. Από την άλλη, τα επιδημιολογικά δεδομένα για τις βρογχεκτασίες ολοένα και αυξάνονται, ενώ το ενδιαφέρον των ερευνητικών τείνει συγκεντρώνεται συνεχώς στην κατανόηση των φλεγμονωδών παθοφυσιολογικών μηχανισμών. Οι βρογχεκτασίες είναι μια χρόνια παθολογική κατάσταση του πνεύμονα που χαρακτηρίζεται παθολογοανατομικά και ακτινολογικά από μόνιμη διάταση και πάχυνση του τοιχώματος των βρόγχων στο πλαίσιο επαναλαμβανόμενων κύκλων φλεγμονής και λοίμωξης. Κλινικά χαρακτηρίζεται από χρόνιο βήχα, αυξημένη απόχρεμψη και υποτροπιάζουσες λοιμώξεις. Ως «gold standard» της διάγνωσης των βρογχεκτασιών αποτελεί η αξονική τομογραφία θώρακος υψηλής ευκρίνειαςIntroduction: Bronchiectasis is a heterogeneous entity, taking into account clinical characteristics, inflammatory response,effectiveness of treatment and frequency of exacerbations. In stable state non-cystic fibrosis (non-CF) bronchiectasis, little is known about non-invasive techniques used for evaluating airway inflammation in obstructive airway diseases. Objectives: We sought to evaluate the associations between induced sputum and clinical/radiologic characteristics, and the differences between biomarkers expressing Th1 and Th2 response in patients with non-CF bronchiectasis and to compare our findings with a previously studied population of patients with asthma and COPD. Methods: We evaluated prospectively collected data from subjects with bronchiectasis. Comparisons were made between clinical, radiographic and physiologic characteristics, as well as induced sputum markers using appropriate statistical tools. We compared the levels of sputum markers with those of a previously studied cohort of asthma and COPD patients. Results: We enrolled 40 subjects (21 men, mean age 63.5 yrs) with bronchiectasis. Fifteen subjects (37.5%) had a neutrophilic phenotype, 7 (17.5%) had an eosinophilic phenotype, 3 (12.5%) had a mixed neutrophiliceosinophilic phenotype and 15 (37.5%) had a paucigranulocytic phenotype. Subjects with sputum neutrophilia had more severe bronchiectasis in HRCT and higher levels of IL-8 in sputum, whereas subjects with eosinophilia had higher levels of FeNO, greater bronchodilator reversibility and higher sputum IL-13. Sputum IL-8 levels were higher in subjects exhibiting frequent exacerbations and correlated with neutrophils in sputum (r=0.799), the extent of bronchiectasis in HRCT (r=0.765) and post-bronchodilator FEV1 (r=-0.416). Sputum IL-13 levels correlated with sputum eosinophils (r=0.656) and bronchodilator reversibility (r=0.441). Neutrophilic bronchiectasis exhibited comparable IL-8 levels to COPD, whereas eosinophilic bronchiectasis showed significantly lower IL-13 levels compared to asthma. Conclusions: Sputum cell counts and IL-8 and IL-13 correlate with distinct clinical and functional measurements of disease severity and therefore may have a role for non-invasively assessing inflammation in non-cystic fibrosis bronchiectasis

Non invsive methods of infammation in brochiectasis

Introduction: Bronchiectasis is a heterogeneous entity, taking into account clinical characteristics, inflammatoryresponse, effectiveness of treatment and frequency of exacerbations. In stable state non-cystic fibrosis (non-CF)bronchiectasis, little is known about non-invasive techniques used for evaluating airway inflammation in obstructiveairway diseases.Objectives: We sought to evaluate the associations between induced sputum and clinical/radiologic characteristics,and the differences between biomarkers expressing Th1 and Th2 response in patients with non-CFbronchiectasis and to compare our findings with a previously studied population of patients with asthma andCOPD.Methods: We evaluated prospectively collected data from subjects with bronchiectasis. Comparisons were madebetween clinical, radiographic and physiologic characteristics, as well as induced sputum markers using appropriatestatistical tools. We compared the levels of sputum markers with those of a previously studied cohort ofasthma and COPD patients.Results: We enrolled 40 subjects (21 men, mean age 63.5 yrs) with bronchiectasis. Fifteen subjects (37.5%) had aneutrophilic phenotype, 7 (17.5%) had an eosinophilic phenotype, 3 (12.5%) had a mixed neutrophilic-eosinophilicphenotype and 15 (37.5%) had a paucigranulocytic phenotype. Subjects with sputum neutrophilia hadmore severe bronchiectasis in HRCT and higher levels of IL-8 in sputum, whereas subjects with eosinophilia hadhigher levels of FeNO, greater bronchodilator reversibility and higher sputum IL-13. Sputum IL-8 levels werehigher in subjects exhibiting frequent exacerbations and correlated with neutrophils in sputum (r =0.799), theextent of bronchiectasis in HRCT (r =0.765) and post-bronchodilator FEV1 (r =−0.416). Sputum IL-13 levelscorrelated with sputum eosinophils (r= 0.656) and bronchodilator reversibility (r= 0.441). Neutrophilicbronchiectasis exhibited comparable IL-8 levels to COPD, whereas eosinophilic bronchiectasis showed significantlylower IL-13 levels compared to asthma.Conclusions: Sputum cell counts and IL-8 and IL-13 correlate with distinct clinical and functional measurementsof disease severity and therefore may have a role for non-invasively assessing inflammation in non-cystic fibrosisbronchiectasisΗ μη επεμβατική αξιολόγηση της φλεγμονής των αεραγωγών μπορεί να δώσει σημαντικές πληροφορίες για την θεραπευτική αντιμετώπιση ασθενών με νοσήματα του αναπνευστικού. Μέσω της μέτρησης φλεγμονωδών κυττάρων και μεσολαβητών στο υπερκείμενο των προκλητών πτυέλων (κυτταροκίνες, πρωτεΐνες, ηωσινοφιλικές πρωτεΐνες) δύναται να εκτιμηθεί ο βαθμός φλεγμονής και αναδιαμόρφωσης των αεραγωγών. Η ευρεία εφαρμογή της πρόκλησης πτυέλων στο άσθμα και ΧΑΠ έχει δώσει πληροφορίες για τη σχέση πνευμονικής λειτουργίας και φλεγμονής των αεραγωγών, ενώ παράλληλα έχει προτείνει νέους φαινότυπους με διαφορετική απάντηση στη θεραπεία. Παρόλα αυτά, λίγα δεδομένα υπάρχουν για τη χρησιμότητά της μη επεμβατικής αξιολόγησης της φλεγμονής σε ασθενείς με βρογχεκτασίες υπό σταθερές συνθήκες

Management of COVID-19 Patients in the Emergency Department

COVID-19 is an emerging disease of global public health concern. As the pandemic overwhelmed emergency departments (EDs), a restructuring of emergency care delivery became necessary in many hospitals. Furthermore, with more than 2000 papers being published each week, keeping up with ever-changing information has proven to be difficult for emergency physicians. The aim of the present review is to provide emergency physician with a summary of the current literature regarding the management of COVID-19 patients in the emergency department

Three cases of infection with pulmonary Mycobacterium Avium complex with resistance to macrolides secondary to prolonged prior use for bronchectasis

Summary: The activity of atypical or non tuberculous mycobacteria (NTM) as pulmonary pathogens has been recognized even in immunocompetent individuals. The Mycobaterium avium complex (MAC) is the commonest of the 130 NTMs and comprises two species, M. avium and M. intracellulare. For the treatment of pulmonary MAC infection combination of a macrolide (azithromycin or clarithromycin) with rifampicin and ethambutol is required. An aminoglucoside (streptomycin or amikacin) should be added in cavitational or severe disease. The treatment is long and expensive, of uncertain efficacy and with serious adverse effects. One quarter of patients either fail to become culture negative or relapse despite treatment. In addition, only 52% of appropriately treated patients show clinical improvement. Resistance to macrolides is a significant negative prognostic factor. As in the case of antituberculosis drugs, the main mechanism of resistance development is prior exposure to monotherapy. Three cases are presented of MAC pulmonary infection with resistance to macrolides, which probably developed secondary to prolonged use for the treatment of exacerbations or maintenance therapy of bronchiectasis. Because of the increasing prevalence of NTM infection, the presence of nodules and bronchiectasis in a patient with pulmonary symptoms should raise the suspicion of NTM disease. The administration of macrolides without sufficient evidence poses the danger of development of resistance in the case of undiagnosed NTM disease, and testing for acid-fast bacilli is imperative before initiation of treatment of bronchiectasis with macrolides. Pneumon 2013,26(2

Comparison of Two Gamma Interferon Release Assays and Tuberculin Skin Testing for Tuberculosis Screening in a Cohort of Patients with Rheumatic Diseases Starting Anti-Tumor Necrosis Factor Therapy

Gamma interferon release assays (IGRAs) are increasingly used for latent Mycobacterium tuberculosis infection (LTBI) screening in patients with rheumatic diseases starting anti-tumor necrosis factor (anti-TNF) therapies. We compared the performances of two IGRAs, an enzyme-linked immunospot release assay (T-SPOT. TB) and an enzyme-linked immunosorbent assay (QuantiFERON-TB Gold In Tube [QFT-GIT]), to that of tuberculin skin testing (TST) for LTBI screening of 157 consecutive rheumatic patients starting anti-TNF therapies. Among 155 patients with valid results, 58 (37%) were positive by TST, 39 (25%) by T-SPOT. TB assay, and 32 (21%) by QFT-GIT assay. IGRAs were associated more strongly with at least one risk factor for tuberculosis (TB) than TST. Risk factors for a positive assay included chest X-ray findings of old TB (TST), advanced age (both IGRAs), origin from a country with a high TB prevalence, and a positive TST (T-SPOT. TB assay). Steroid use was negatively associated with a positive QFT-GIT assay. The agreement rate between IGRAs was 81% (kappa rate = 0.47), which was much higher than that observed between an IGRA and TST. If positivity by either TST or an IGRA was required for LTBI diagnosis, then the rate of LTBI would have been 46 to 47%, while if an IGRA was performed only for TST-positive patients, the respective rate would have been 11 to 17%. In conclusion, IGRAs appear to correlate better with TB risk than TST and should be included in TB screening of patients starting anti-TNF therapies. In view of the high risk of TB in these patients, a combination of one IGRA and TST is probably more appropriate for LTBI diagnosis