Smoking cessation in patients: two further studies by the British Thoracic Society. Research Committee of the British Thoracic Society.

The effects of various smoking cessation strategies were studied in two multicentre trials with new patients attending hospital or a chest clinic because of a smoking related disease. In the first trial (study A, 1462 patients) the effect of the physician's usual advice to stop smoking was compared with the effect of the same advice reinforced by a signed agreement to stop smoking by a target date within the next week, two visits by a health visitor in the first six weeks, and a series of letters of encouragement from the physician. The second trial (study B, 1392 patients) compared (1) advice only, (2) advice supplemented by a signed agreement, (3) advice supplemented by a series of letters of encouragement, and (4) advice supplemented by a signed agreement and a series of letters of encouragement. Patients were reviewed at six months and those claiming to have stopped smoking were seen again at 12 months. Claims of abstinence were checked by carboxyhaemoglobin measurement. In study A 9% of the intervention group had succeeded in stopping smoking at six months compared with 7% of the "advice only" patients (p = 0.17). In study B success rates were 5.2%, 4.9%, 8.5%, and 8.8% respectively. The signed agreement did not influence outcome, whereas postal encouragement increased the effect of the physician's advice. In both studies patients reviewed clinically between the initial and the six month visit were more likely to stop smoking than those not reviewed. Success rates increased with age and men tended to do better than women. The studies suggest that physician's advice alone will persuade 5% of outpatients with a smoking related disease to stop smoking. Subsequent postal encouragement will increase the cessation rate by more than half as much again. Such small improvements in success rates are worth while, especially if they can be achieved cheaply and on a wide scale.     

Pulmonary Mycobacterium kansasii infection: comparison of the clinical features,treatment and outcome with pulmonary tuberculosis.

BACKGROUND: In the United Kingdom Mycobacterium kansasii is the most common pulmonary non-tuberculous mycobacteria to cause disease in the non-HIV positive population. METHODS: The clinical features, treatment, and outcome of 47 patients (13 women) of mean (SD) age 58 (17) years with culture positive pulmonary M kansasii infection were compared with those of 87 patients (23 women) of mean (SD) age 57 (16) years with culture positive pulmonary M tuberculosis infection by review of their clinical and laboratory records. Each patient with M kansasii infection was matched for age, sex, race and, where possible, year of diagnosis with two patients with M tuberculosis infection. RESULTS: All those with M kansasii infection were of white race. Haemoptysis was more common in patients infected with M kansasii but they were less likely to present as a result of an incidental chest radiograph or symptoms other than those due to mycobacterial infection. Patients with M kansasii were also less likely to have a history of diabetes, but the frequency of previous chest disease and tuberculosis was similar. An alcohol intake of > 14 units/week was less frequent in those with M kansasii, but there were no significant differences in drug history, past and present smoking habit, occupational exposures, social class, or marital status. Patients with M kansasii received a longer total course of antimycobacterial therapy and, in particular, extended treatment with ethambutol and rifampicin was given. There was no significant difference in outcome between pulmonary M kansasii or M tuberculosis infection. CONCLUSIONS: There are group differences between the clinical features of the two infections but, with the possible exception of diabetes and alcohol intake, these features are unlikely to be diagnostically helpful. Treatment of M kansasii infection with ethambutol, isoniazid, and rifampicin in these patients was as effective as standard regimens given to patients infected with M tuberculosis.     

British Thoracic Society study of cryptogenic fibrosing alveolitis: current presentation and initial management. Fibrosing Alveolitis Subcommittee of the Research Committee of the British Thoracic Society

BACKGROUND: Mortality due to cryptogenic fibrosing alveolitis (CFA) is increasing, particularly in the elderly. Optimum management remains uncertain and previous studies of the disease have largely been from specialist centres. A national study was carried out of the presentation and initial management of CFA in the UK. METHODS: All respiratory physicians in England, Scotland and Wales were invited to enter patients with newly diagnosed CFA over a two year period. CFA was diagnosed on histological grounds or according to clinical criteria which included the absence of a defined connective tissue disorder or pneumoconiosis. Participating physicians (n = 150) completed a questionnaire at patient entry and at all subsequent follow up visits and death. RESULTS: A total of 588 patients (373 men, 63%) were studied of whom 441 (75%) were referrals from primary care. Their mean (SD) age was 67.4 (10.0) years and median duration of symptoms at presentation was 9.0 months. Clubbing was more common in men (203/373; 54%) than in women (86/ 215; 40%); 209 patients (36%) were graded as severely breathless at presentation. A history of dust exposure (organic or inorganic) was present in 274 patients (47%) of whom 87 had had some exposure to asbestos. Subjects exposed to dust were more likely to have smoked and had slightly higher mean lung volumes, but were otherwise indistinguishable from those not exposed in terms of clinical presentation, management, and outcome. Transbronchial biopsy specimens were taken in 164 patients (28%) and open lung biopsy specimens in 73 (12%), but 60% had no histological diagnostic procedure. Biopsy procedures were more likely to be performed in younger patients, those with better lung function, and those with a history of asbestos exposure. At presentation a decision not to initiate specific treatment was made in 284 cases (48%). The decision to initiate treatment was made predominantly on symptomatic grounds. Two years after the close of entry to the study 266 patients (45%) had died. CONCLUSIONS: CFA is predominantly a disease of elderly patients and has a poor prognosis. Physicians generally considered CFA to be a clinical diagnosis and did not initiate treatment in up to half of patients at presentation.


     

Ceftazidime compared with gentamicin and carbenicillin in patients with cystic fibrosis, pulmonary pseudomonas infection, and an exacerbation of respiratory symptoms. British Thoracic Society Research Committee.

An open randomised comparison of a new intravenous cephalosporin, ceftazidime, with the established regimen of gentamicin and carbenicillin was carried out in patients with cystic fibrosis who had persisting pulmonary infection with Pseudomonas species and who developed acute exacerbations of respiratory symptoms. Fifty patients received ceftazidime and 32 gentamicin and carbenicillin. The ceftazidime and gentamicin were given every eight hours and the carbenicillin every six hours. The mean total daily doses were 151 mg/kg for ceftazidime, 6.3 mg/kg for gentamicin and 450 mg/kg for carbenicillin. The mean duration of treatment was 10 days in patients receiving gentamicin and carbenicillin and 12 days in those receiving ceftazidime. Of the patients with pseudomonas in the initial sputum specimen in whom sputum was cultured after treatment, six (26%) of 23 receiving gentamicin and carbenicillin and seven (18%) of 39 receiving ceftazidime had sputum free from pseudomonas at the end of treatment, but recolonisation occurred subsequently. In those receiving ceftazidime all 10 coexisting organisms were eliminated, whereas only four of seven coexisting organisms in patients receiving gentamicin and carbenicillin were eliminated. Overall clinical improvement occurred in 25 (78%) of 32 patients treated with gentamicin and carbenicillin and 48 (96%) of 50 patients treated with ceftazidime. Nineteen (59%) of the patients receiving gentamicin and carbenicillin but only 15 (30%) of those receiving ceftazidime required admission to hospital or intravenous antibiotics, or both, or died during the three months after treatment. Side effects in both groups were similar, mild, and infrequent. Thrombophlebitis occurred in four patients treated with gentamicin and carbenicillin but in no patients treated with ceftazidime.     

Pulmonary Mycobacterium kansasii infection: comparison of radiological appearances with pulmonary tuberculosis.

BACKGROUND: A study was undertaken to determine if there are differences in the radiological appearances at presentation between pulmonary infections caused by Mycobacterium kansasii and Mycobacterium tuberculosis. Correct recognition of the organism has important implications with regard to initial therapy and contact tracing. METHODS: The initial chest radiographs of 28 patients with pulmonary M kansasii infection were compared with those of 56 age, sex, and race matched patients with M tuberculosis infection. All patients in both groups were culture positive and none was known to be HIV positive. The radiographs were analysed independently by two radiologists who were unaware of the causative organism. RESULTS: Radiographic abnormalities in patients with M kansasii infection were more frequently unilateral and right side predominant, while those with tuberculosis more frequently involved a lower lobe. Air space shadowing involving more than one bronchopulmonary segment and pleural effusions were seen less frequently in M kansasii infection (four of 28 (14%) versus 30 of 56 (54%) and none of 28 versus 15 of 56 (27%)). Cavitation (21 of 28 (75%) versus 34 of 56 (61%) was seen to a similar extent in patients with M kansasii infection and in those with tuberculosis. Cavities tended to be smaller in patients with M kansasii infection (p < 0.01). CONCLUSIONS: Differences are seen in the radiographic appearances of pulmonary infection caused by M kansasii and M tuberculosis. These differences are not sufficient to allow a positive diagnosis on the basis of radiographic findings alone, but the presence of a pleural effusion or lower lobe involvement makes M kansasii infection very unlikely.     

Mycobacterium tuberculosis resistance to rifampicin and ethambutol: a clinical survey.

Ninety-seven cultures of Myco, tuberculosis referred to the Tuberculosis Reference Laboratory, Cardiff during 1972-73 and found to be resistant to rifampicin or ethambutol were studied. Resistance to each drug appeared equally common. Few lower grades of rifampicin resistance occurred, cultures tending to be either fully sensitive or highly resistant. Intermediate grades of ethambutol resistance, however, were common, and a majority of highly resistant cultures were preceded by cultures showing lower grades of resistance. Case-notes were obtained on 84 patients (87%) and revealed no cases of primary resistance. In the three years since first developing resistance 36% of patients died: in the majority tuberculosis was a major cause of death. Half the patients had been prescribed unsatisfactory drug regimens containing rifampicin or ethambutol by their physicians, and only a small minority were considered to have co-operated well. One-third had discharged themselves from hospital against medical advice and only 21% attended clinics regularly. These two factors probably accounted for the development of resistance in most cases.     

Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee.

BACKGROUND--Peak flow based asthma self-management plans have been strongly advocated in consensus statements, but convincing evidence for the effectiveness of this approach has been largely lacking. METHODS--A randomised controlled trial was conducted in 25 general practices comparing an asthma self-management programme based on home peak flow monitoring and surgery review by a general practitioner or practice nurse with a programme of planned visits for surgery review only over a six month period. RESULTS--Seventy two subjects (33 in the self-management group and 39 in the planned visit group) completed the study protocol, but diary card data for at least three months were available on a total of 84 (39 in the self-management group and 45 in the planned visit group). Teaching self-management took longer than the planned visit review. In the self-management group home peak flow monitoring was felt to be useful by doctors and patients in 28 (85%) and 27 (82%) cases, respectively. There were no between group differences during the study period in terms of lung function, symptoms, quality of life, and prescribing costs. Only within the self-management group were improvements noted in disturbance of daily activities and quality of life. Possible explanations for these negative results include small numbers of subjects, the mild nature of their asthma, and inappropriate self-management strategies for such patients. CONCLUSIONS-- Rigid adherence to long term daily peak flow measurement in the management of mild asthma in general practice does not appear to produce large changes in outcomes. Self-management and the use of prescribed peak flow meters need to be tailored to individual circumstances.     

British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment.

BACKGROUND: Corticosteroids suppress disease activity in pulmonary sarcoidosis and their use produces symptomatic, radiographic, and functional improvement. There is, however, uncertainty regarding their effects on the overall natural history of the condition and long term benefit is unproven. METHODS: Patients with pulmonary radiographic shadowing due to sarcoidosis were recruited in a multicentre study. Those who, in the first six months after entry to the study, neither required prednisolone for symptoms nor showed radiographic improvement were allocated at six months to receive either long term steroid treatment (group L) or selective treatment (group S), with regular assessment over the subsequent five years. Patients in group L were scheduled to receive steroid treatment for at least 18 months with the policy of achieving and maintaining maximal radiographic clearing, while in group S treatment was reserved for use only if warranted by later development of symptoms or deteriorating lung function. Symptoms, radiographic appearances, and respiratory function were assessed periodically during the study. RESULTS: One hundred and forty nine patients were followed: 33 required prednisolone for troublesome symptoms within six months of entry and 58 showed radiographic improvement over this period. The remaining 58 patients were allocated to groups L (n = 27) and S (n = 31). Patients in group L showed greater improvements in symptoms, respiratory function, and radiographic appearances than those in group S, although the differences were not large. After adjusting for differences at the time of allocation, the average difference in vital capacity between groups L and S at final assessment was 9% of the predicted value. Side effects of treatment were frequent but usually mild, necessitating withdrawal in only two individuals. CONCLUSIONS: After excluding those individuals who required steroids for control of symptoms, approximately half of the remaining patients with sarcoidosis and pulmonary shadowing showed spontaneous radiographic improvement during six months of observation. In those in whom the radiograph failed to improve, prolonged steroid treatment with the aim of optimising radiographic appearances resulted in a significantly better long term functional outcome.     

Smoking withdrawal in hospital patients: factors associated with outcome. Subcommittee of the Research Committee of the British Thoracic Society.

Factors associated with outcome were investigated in the British Thoracic Society's study of smoking withdrawal in 1550 patients attending hospital with smoking related diseases. A long term abstinence rate of 9.7% was found. Men did better than women, 12.2% of them succeeding in stopping smoking compared with 5.3% of the women. Success rate increased with age, and people with heart disease did better than those with any other diagnosis. The success rate of the best group, men with heart disease, was 21%. Sex, age, and diagnosis appeared to act independently. If the most important other person in the patient's life was a non-smoker success was more likely. Weight increased by an average of 5.9 kg over a year in those who stopped smoking.     

Pulmonary infection with Mycobacterium kansasii in Wales, 1970-9: review of treatment and response.

Thirty-five patients (88% male) with pulmonary infection caused by Mycobacterium kansasii have been reviewed. Sixty-six per cent had pre-existing lung disease, chronic bronchitis and emphysema accounting for half of the disorders. Unilateral lesions were present in 69% of patients whose chest radiographs were reviewed and 90% had cavitating disease. The development of unilateral or bilateral disease appeared to be independent of any delay in starting treatment. Five patients died while receiving treatment, but none of these deaths was due to M kansasii infection. The remaining 30 patients were successfully treated with drug regimens, all of which included rifampicin and 86% of which included ethambutol. There was 100% sputum conversion, with no relapses after a mean follow-up period of five-and-a-half years. Rifampicin and ethambutol given for a mean period of 15 months appeared to be a non-toxic, effective combination.     

Oral N-acetylcysteine and exacerbation rates in patients with chronic bronchitis and severe airways obstruction. British Thoracic Society Research Committee.

The influence of oral N-acetylcysteine on the exacerbation rate in patients with chronic bronchitis and severe airways obstruction has been studied. Two hundred and forty four patients entered the study during October and November 1983 and took placebo sachets for a run in month. One hundred and eighty one who completed this month satisfactorily were randomised to receive either active (acetylcysteine 200 mg three times a day) or matching placebo sachets for five months in a double blind parallel group study. The two groups were well matched. Patients kept detailed daily symptom diaries and were assessed monthly. At the end of the five months' study the outcome in the group taking acetylcysteine appeared a little better, but the differences did not reach conventional levels of statistical significance for the mean (SD) number of exacerbations (2.1 (0.2) for acetylcysteine, 2.6 (0.2) for placebo; p = 0.08); total days taking an antibiotic (13.5 (1.7), 18.0 (2.8); p = 0.17); total days spent in bed (4.8 (0.8), 5.1 (1.1); p = 0.9); number of withdrawals (13 (15%), 20 (21%); p = 0.4); incidence of side effects (which were few); drug compliance (which was good); and the patients' assessment of the treatment.     

Tuberculous pleural effusion: experience with six months of treatment with isoniazid and rifampicin.

BACKGROUND--Tuberculous pleurisy is associated with small numbers of bacteria. Due to the low rate of primary resistance to antituberculous drugs a two-drug regimen was used to treat the condition. METHODS--Patients received isoniazid 5 mg/kg and rifampicin 10 mg/kg daily for six months. Clinical, radiological, and haematological assessments were performed during treatment and patients were followed up for a median period of 41 (range 6-96) months. RESULTS--One hundred and thirty patients were studied with a mean age of 27 (range 11-53) years. Seven were withdrawn due to parenchymal disease and eight were lost to follow up during the treatment period. Side effects during treatment were frequent (20.7%), but only three patients required a change in medication. No treatment failures were observed. One hundred and fifteen patients completed therapy and were followed up for 41 (range 6-96) months with no evidence of a relapse. CONCLUSIONS--Tuberculous pleurisy responds well to a two-drug regimen of antituberculous therapy given for six months.     

Control and prevention of tuberculosis in the United Kingdom: Code of Practice 1994. Joint Tuberculosis Committee of the British Thoracic Society.

BACKGROUND--The guidelines on control and prevention of tuberculosis in the United Kingdom have been reviewed and updated. METHODS--A subcommittee was appointed by the Joint Tuberculosis Committee (JTC). Each member of this group drafted one or more sections of the guidelines, and drafts were made available to all members of the group. In the course of several meetings drafts were altered and incorporated into a final text. The guidelines were approved by the full JTC and by the Standards of Care Committee of the British Thoracic Society. In revising the guidelines the authors took account of new published evidence and recent concerns about drug resistance and possible effects of HIV on tuberculosis. CONCLUSIONS--(1) All cases of tuberculosis must be notified. (2) A few patients need hospital admission. (3) Patients with positive sputum smears and sensitive organisms should be considered infectious until they have received two weeks' chemotherapy. (4) Treatment of all tuberculosis patients should be supervised by a respiratory physician employing standard medication guidelines and monitoring compliance at least monthly. (5) Health care workers at risk should be protected by BCG vaccination and appropriate infection control measures, and evidence of infectious tuberculosis should be sought among prospective NHS staff, school teachers, and others. (6) Prison staff should be protected. (7) Tuberculosis should be considered in the elderly in long stay care with persistent chest symptoms. (8) Contact tracing should be vigorously pursued with chemoprophylaxis, BCG vaccination, or follow up where applicable. (9) Entrants to the UK from high risk countries (tuberculosis incidence more than 40/100,000 population per year) should be screened. (10) BCG vaccination should be offered where appropriate but not in subjects with known or suspected HIV infection. (11) The local organisation of tuberculosis services should be strengthened and should include adequate nursing and support staff. (12) Contracts between purchasers and providers should specify management of tuberculosis in line with this and other JTC guidelines.     

Control and prevention of tuberculosis in the United Kingdom: code of practice 2000. Joint Tuberculosis Committee of the British Thoracic Society

BACKGROUND—Theguidelines on control and prevention of tuberculosis in the UnitedKingdom have been reviewed and updated.
METHODS—A subcommitteewas appointed by the Joint Tuberculosis Committee (JTC) of the BritishThoracic Society to revise the guidelines published in 1994 by the JTC,including representatives of the Royal College of Nursing, PublicHealth Medicine Environmental Group, and Medical Society for Study ofVenereal Diseases. In preparing the revised guidelines the authors tookaccount of new published evidence and graded the strength of evidencefor their recommendations. The guidelines have been approved by the JTC and the Standards of Care Committee of the British Thoracic Society.
RECOMMENDATIONS—Tuberculosisservices in each district should have staffing and resources to fulfilboth the control and prevention recommendations in this document and toensure adequate treatment monitoring. Notification of tuberculosis isrequired for surveillance and to initiate contact tracing (whereappropriate). The following areas are discussed and recommendationsmade where appropriate: (1) public health law in relation totuberculosis; (2) the organisational requirements for tuberculosisservices; (3) measures for control of tuberculosis in hospitals,including segregation of patients; (4) the requirements for health careworker protection, including HIV infected health care workers; (5)measures for control of tuberculosis in prisons; (6) protection forother groups with potential exposure to tuberculosis; (7) awareness ofthe high rates of tuberculosis in the homeless together with localplans for detection and action; (8) detailed advice on contact tracing; (9) contact tracing required for close contacts of bovine tuberculosis; (10) management of tuberculosis in schools; (11) screening of newimmigrants and how this should be performed; (12) outbreak contingencyinvestigation; and (13) BCG vaccination and the management of positivereactors found in the schools programme.

     

Recurrence of pulmonary embolism during anticoagulant treatment: a prospective study.

The risk of early recurrence of pulmonary embolism in patients with venous thromboembolic disease treated by anticoagulants is not well established. To determine the risk linked to contemporary proximal deep venous thrombosis, a prospective study was organised to give clinical and scintigraphic surveillance to 50 patients with angiographically proved pulmonary embolism plus phlebographically proved proximal deep vein thrombosis during the first 15 days of anticoagulant treatment. Perfusion lung scans were performed initially and on days 3, 7, and 15. Only two patients had a recurrence of pulmonary embolism during this period; both episodes were revealed by new symptoms, and one recurrence was fatal. The systematic performance of angiography in four patients found to have new scintigraphic defects led to the diagnosis of "spurious scintigraphic recurrence" in three of them. It is concluded that (a) adjusted anticoagulant treatment showed an effectiveness of 96% for preventing early recurrence of pulmonary embolism in this group of supposed high risk patients, and (b) in patients with recent pulmonary embolism new defects on systematic perfusion lung scans are not specific indicators of recurrent pulmonary embolism.     

First randomised trial of treatments for pulmonary disease caused by M avium intracellulare, M malmoense, and M xenopi in HIV negative patients: rifampicin, ethambutol and isoniazid versus rifampicin and ethambutol

BACKGROUND—Thetreatment of pulmonary disease caused by opportunist mycobacteria iscontroversial. It is uncertain whether in vitro sensitivity testingpredicts clinical response in the way it does forMycobacterium tuberculosis. The literaturesuggests that the combination of rifampicin (R) and ethambutol (E) isimportant whereas isoniazid (H) may not be, but to date there have beenno published reports of randomised controlled trials in the treatmentof these conditions. The British Thoracic Society has conducted thefirst such trial, a randomised study of two regimens in HIV negativepatients with pulmonary disease caused by Mavium intracellulare (MAC),M malmoense, and Mxenopi.
METHODS—When twopositive cultures were confirmed by the Mycobacterium ReferenceLaboratories for England, Wales and Scotland, the coordinatingphysician invited the patient's physician to enrol the patient.Patients were also recruited from Scandinavia. Randomisation to 2 yearsof treatment with RE or REH was performed from lists held in thecoordinator's office. Clinical, bacteriological, and radiologicalprogress was monitored at set intervals up to 5years.
RESULTS—FromOctober 1987 to December 1992, 141 physicians entered 223 patients (106 with M malmoense, 75 with MAC, 42 withM xenopi). At entry the RE and REH groupswere comparable over a range of demographic and clinical features. Foreach species there was no significant difference between RE and REH inthe number of deaths, but when the three species were combined therewere fewer deaths from the mycobacterial disease with RE (1%v 8%, p=0.018, odds ratio 0.10, exact 95%CI 0.00 to 0.76). For M malmoense the failure of treatment/relapse rates did not differ appreciably betweenthe regimens, but for MAC there were fewer failures of treatment/relapses with REH (16% v 41%,p=0.033) With M xenopi there was anon-significant trend in the same direction (5%v 18%, p=0.41) and when all three specieswere combined there was a significant difference in favour of REH (11%v 22%, p=0.033). There was no correlationbetween failure of treatment/relapse and in vitro resistance.M xenopi was associated with the greatest mortality (57% at 5 years), MAC was the most difficult to eradicate, and M malmoense had the most favourableoutlook (42% known to be alive and cured at 5years).
CONCLUSIONS—Theresults of susceptibility tests performed by the modal resistancemethod do not correlate with the patient's response to chemotherapy.RE and REH are tolerated better than previous regimens containingsecond or third line anti-mycobacterial drugs. Treatment ofM malmoense with RE for 2 years ispreferable to REH. The addition of H reduces the failure oftreatment/relapse rates for MAC and has a tendency to do so also forM xenopi, but there is a suggestion that REHis associated with higher death rates overall. Better regimens are required.