Bronchoalveolar lavage in interstitial lung diseases: does the recovery rate affect the results?

BACKGROUND: Bronchoalveolar lavage (BAL) is an established diagnostic tool in interstitial lung diseases. BAL frequently yields findings of diagnostic value and at times even confirmatory diagnostic results. OBJECTIVES: The present study has been designed to investigate whether the recovery rate affects BAL results relative to the instilled volume. METHODS: Six hundred and eighteen patients with the following diagnoses were included into the study: 236 with sarcoidosis, 85 with idiopathic pulmonary fibrosis, 83 with cryptogenic organizing pneumonitis, 64 with connective tissue disease affecting the lungs, 54 with respiratory bronchiolitis with interstitial lung disease, 51 with extrinsic allergic alveolitis and 45 control patients. BAL was performed during flexible bronchoscopy with an irrigation volume of 100 ml 0.9% saline solution in 5 aliquots of 20 ml each. Only patients with a recovery of at least 30 ml were evaluated. Initially, the entire patient population was analysed, followed by an analysis within the different diagnostic groups and a comparison between patients with a high (>50 ml) and low (< or =50 ml) recovery rate. RESULTS: The recovery rate varied between the diagnostic groups (p < 0.001) and was negatively correlated with age (r = -0.21, p < 0.001) and smoking history (r = -0.11, p < 0.035). There were no correlations with inspiratory vital capacity (%pred.; p = 0.26) and forced expiratory volume in 1 s (%pred.; p = 0.15), but a positive correlation with the index (forced expiratory volume in 1 s/inspiratory vital capacity) x 100 (r = 0.23, p < 0.001). The cellular and non-cellular constituents of BAL were not affected by the recovery: cells/millilitre BAL (p = 0.71), relative proportion of macrophages (p = 0.92), lymphocytes (0 = 0.33), neutrophils (p = 0.14) and eosinophils (p = 0.11), albumin concentration (p = 0.13), and proportion of albumin in total protein (p = 0.06). The same applied for the lymphocyte surface markers CD4 (p = 0.72) and CD8 (p = 0.53). In the group with a high recovery rate, patients with sarcoidosis had a lower proportion of eosinophils (p = 0.04) and patients with cryptogenic organizing pneumonitis a higher concentration of albumin (p = 0.02) and lymphocytes (p = 0.007). Otherwise, no further differences were detected. CONCLUSIONS: The recovery rate hardly affected the cellular and non-cellular constituents of BAL at a lower limit of 30% of the instilled volume.     

How helpful are meta-analyses in determining the best therapy of blood diseases?

Meta-analyses of data from randomized clinical trials (RCTs) are often used by hematologists to compare the efficacy of therapies of blood diseases. This is especially so when results of RCTs are not decisive. This situation in RCTs arises when the magnitude of differences in treatment outcomes between therapies tested is small, when trials are unpowered to detect differences (these are confounded) and/or when RCTs reach, or seem to reach, contradictory conclusions. Contributing to these limitations of RCTs are the relative rarity of many blood diseases, poor recruitment into RCTs and the greater interest of many hematologists in therapy strategy than in a direct comparison of alternate therapies. These limitations of RCTs are solvable, but only in part, by meta-analyses. Adding data from high-quality observational database studies(ODBs) to meta-analyses is sometimes useful in resolving controversies, but this approach also has limitations: biases may be difficult or impossible to identify and/or to adjust for. However, ODBs have large numbers of diverse subjects receiving diverse therapies and adding these data to meta-analyses sometimes gives answers more useful to clinicians than meta-analyses of RCTs alone. Side-by-side comparisons suggest analyses from high-quality ODBs often give similar conclusions as meta-analyses of high-quality RCTs. Quantification of expert opinion of high quality is also sometimes useful: experts rarely disagree under precisely defined circumstances and their consensus conclusions are often concordant with results of meta-analyses of high-quality RCTs with and without ODBs. We conclude that meta-analyses are often helpful to determine the best therapy of blood diseases. Accuracy can be improved by including data from high-quality ODBs, when appropriate, and by resolving discordances, if any, with conclusions from high-quality ODBs and from quantification of expert opinion.     

Is bronchoalveolar lavage obsolete in the diagnosis of interstitial lung disease?

This review considers the literature on bronchoalveolar lavage in the diagnosis of interstitial lung disease published during the last 12 months with the aim of clarifying the role bronchoalveolar lavage can have in diagnostic work-up on the basis of current knowledge and expert opinion. Recent research findings with possible future clinical applications are presented. Various information, useful for research and clinical applications, can be obtained from performing bronchoalveolar lavage in patients with interstitial lung diseases. Indeed, evaluation of cell pattern associated with cell phenotype is used widely in clinical practice to distinguish the various forms and may be of diagnostic value in some interstitial lung diseases, as already known, when the clinical picture is compatible. Bronchoalveolar lavage may also be complementary to high-resolution CT or at least useful for diagnosis by exclusion. A major advance in the last year is recognition of a role for bronchoalveolar lavage in the diagnostic workup of idiopathic interstitial pneumonias, albeit as an auxiliary procedure. It may be useful to exclude infections and tumors, may help to decide whether to do surgical biopsy, and may aid in distinguishing different forms of interstitial lung disease. Although it is not diagnostic for idiopathic interstitial pneumonias, in the presence of cell patterns considered "typical" of the various forms, it can support clinical diagnosis in the absence of biopsy. Because further studies following standardized protocols and guidelines will presumably find new parameters for bronchoalveolar lavage in the diagnostics of interstitial lung diseases, it would be a mistake to consider bronchoalveolar lavage an obsolete tool.     

What are the advances for surgical therapy of inflammatory diseases of the spine?

Surgery for rheumatoid arthritis (RA) and spondyloarthropathies is a palliative surgery, and testifies to the failure of conservative treatment. In RA, surgery is generally used to deal with upper cervical instability and peridens pannus compression. These complications can have dramatic neurological consequences and can even be life threatening. Every effort must be made to avoid unnecessary surgery but, if needed, the indication must be precise and timely to be efficient. Instrumented fusion is indicated but the need for pannus excision is discussed. In ankylosing spondylitis (AS), major deformity will be the indication for corrective surgery if this deformity induces a marked decrease in the field of vision, thoracicy or abdominal problems or respiratory and mandibular troubles in the cervical spine. Different types of osteotomies with instrumented fixation are described. In AS. surgery is also indicated in fractures that are potentially unstable. At the cervical level these fractures are a surgical emergency. Neurological compressions and spondylodiscitis are other reasons for surgery in AS. Complications of other spondyloarthropathies, which include accompanying psoriasis, reactive arthritis, enteropathic arthritis or Behcet's syndrome are occasionally treated surgically along the same lines as RA or AS. Surgery for spinal inflammatory disorders involves major procedures with a high rate of severe complications. The indications for this type of surgery must be extremely precise and both the surgeon's and the patient's expectations must be clear and realistic. The surgery should only be performed by a surgeon who is experienced with this type of patient and procedure but, furthermore, it should also only be camed out in a centre with a team of neurologists, anaesthetists, nurses and physical therapists who have the expertise to work with these pathologies and these often severely debilitated patients. Only under these conditions will the outcome justify the burden and the risks.     

How many components for the metabolic syndrome? Results of exploratory factor analysis in the FIBAR study

Background and aimsFactor analysis can be used as a basis for the determination of diagnostic criteria for the metabolic syndrome (MS). This approach can be used as a basis for the determination of diagnostic criteria for MS.Methods and resultsExploratory factor analysis of Adult Treatment Panel (ATP)-III and International Diabetes Federation (IDF) criteria for MS, entered as dichotomic variables, was performed on 2945 patients enrolled in a screening programme for diabetes. The ability of calculated factors to identify patients with MS-related conditions (glucose intolerance, hyperuricaemia, and elevation of alanine aminotransferase; ALT) was assessed through Receiver Operator Characteristics (ROC) curve analysis. Alternative sets of criteria based on ATP-III and IDF definitions of MS were also assessed. A two-factor structure was found for both ATP-III and IDF criteria. Factor 1 (associated with fasting hyperglycaemia, hypertension, and elevated waist circumference) was capable of identifying subjects with MS-related conditions to a greater extent than factor 2 (low HDL-cholesterol and hypertriglyceridaemia). When a composite variable (low HDL-cholesterol and/or hypertriglyceridaemia) was used for dislipidaemia, a single factor structure was obtained both for ATP-III and IDF definitions; this factor structure was retained when hyperuricaemia was added as a fifth component of MS. Such a modified definition of MS was not inferior to original ATP-III and IDF criteria in the identification of subjects with glucose intolerance and elevated ALT.ConclusionsA modification of current ATP-III or IDF criteria is necessary in order to obtain a single-factor structure. Alternative definitions of MS, including additional features, such as hyperuricaemia, can maintain a monofactorial structure, and an association with related conditions not inferior to that of original criteria.     

What are the risk factors for extraintestinal manifestations in inflammatory bowel diseases?

Extraintestinal manifestations (EIMs) are common in patients with inflammatory bowel disease (IBD); however, studies surrounding EIMs are lacking, particularly in Asia. This study aimed to identify risk factors by analyzing the characteristics of patients with EIMs. From January 2010 to December 2020, the medical records of 531 patients diagnosed with IBD (133 with Crohn disease [CD] and 398 with ulcerative colitis [UC]) were reviewed. The patients’ baseline characteristics and risk factors were analyzed by dividing them into 2 groups according to EIMs presence. The prevalence of EIMs in all patients with IBD was 12.4% (n = 66), of which CD and UC prevalences were 19.5% (n = 26) and 10.1% (n = 40), respectively. The articular (7.9%, n = 42), cutaneous (3.6%, n = 19), ocular (1.5%, n = 8), and hepatobiliary types (0.8%, n = 4) of EIMs were observed. Two or more EIMs occurred in only 1.2% of all IBD patients (n = 6). Multivariate analysis revealed that the risk factors for the occurrence of EIMs were a follow-up period ≥ 10 years (odds ratio, 2.106; 95% confidence interval, 1.187–3.973; P = .021) and treatment with biologics (odds ratio, 1.963; 95% confidence interval, 1.070–3.272; P = .037). The EIMs prevalence in patients with IBD was 12.4%, and the particular type was the most common, with EIMs occurring more frequently in patients with CD than in those with UC. Patients who have been treated for IBD for more than 10 years or who are using biologics should be carefully monitored as they are at high risk for EIMs.     

How useful are combinations of blood tests in “Rheumatic panels” in diagnosis of rheumatic diseases?

Laboratory tests are sometimes combined into "panels," presumably to facilitate a swift and accurate diagnosis. "Rheumatic panels" were available from 16 of 17 members of the American Clinical Laboratory Association. Panels included an average of five tests (range three to 11). Panel prices ranged from $25 to $189. The three tests most common in the available panels were those for rheumatoid factor, antinuclear antibody, and uric acid level. A panel combining these three tests would have a positive predictive value of only 34.6% in identifying rheumatoid arthritis, systemic lupus erythematosus, or gout in a population with joint pain, in which the combined prevalence of these diseases is estimated to be 10%. Therefore, 65.4% of persons with a "positive" test would not have one of these three rheumatic diseases. Lack of independence between diseases and second tests (for example, positive antinuclear antibodies in rheumatoid arthritis) increases misclassification errors. A careful history and physical examination along with serial ordering of a few selected tests appear optimal to establish a clinical diagnosis of a rheumatic disease.     

What's in the pipeline? Prospects for monoclonal antibodies (mAbs) as therapies for lung diseases

The striking clinical results from recent studies with Remicade (infliximab, a monoclonal anti-TNFalpha antibody) in rheumatoid arthritis, Crohn's disease and psoriasis demonstrate the disease-altering potential of monoclonal antibodies (mAbs) in chronic inflammation. Chronic obstructive pulmonary disease (COPD) and asthma represent two major chronic pulmonary inflammatory diseases with substantial unmet medical needs. Most of the cells and mediators implicated in the pathophysiology of COPD and asthma are excellent targets for mAb intervention. Indeed, clinical trials with mAbs directed against IL-5, IgE, and CD4 yielded results that are critical in dissecting the pathophysiology of asthma, and reinforce the potential for mAbs as therapeutic agents in treating pulmonary diseases. Furthermore, fundamental advances in the discovery, manufacture and safety of mAbs underscore the enormous therapeutic value of these agents for chronic pulmonary diseases. Indeed, a large number of mAbs are in pre-clinical and clinical development for treating these conditions. In this review, we discuss the scientific rationale for generating mAb therapies directed specifically toward COPD and asthma. We believe that as a therapeutic class, mAbs offer the opportunity to alter symptoms, progression and outcome of chronic pulmonary diseases.     

Histopathological assessment of the microscopic activity in inflammatory bowel diseases: What are we looking for?

Advances in diagnostics of inflammatory bowel diseases (IBD) and improved treatment strategies allowed the establishment of new therapeutic endpoints. Currently, it is desirable not only to cease clinical symptoms, but mainly to achieve endoscopic remission, a macroscopic normalization of the bowel mucosa. However, up to one-third of IBD patients in remission exhibit persisting microscopic activity of the disease. The evidence suggests a better predictive value of histology for the development of clinical complications such as clinical relapse, surgical intervention, need for therapy escalation, or development of colorectal cancer. The proper assessment of microscopic inflammatory activity thus became an important part of the overall histopathological evaluation of colonic biopsies and many histopathological scoring indices have been established. Nonetheless, a majority of them have not been validated and no scoring index became a part of the routine bioptic practice. This review summarizes a predictive value of microscopic disease activity assessment for the subsequent clinical course of IBD, describes the most commonly used scoring indices for Crohn's disease and ulcerative colitis, and comments on current limitations and unresolved issues.     

Laparoscopy for bowel obstruction—a contradiction? Results of a multi-institutional survey in Germany

Purpose

The purpose of the present study was to investigate on the acceptance and frequency of laparoscopic surgery for the management of acute and chronic bowel obstruction in a general patient population in German hospitals.

Methods

To receive an authoritative opinion on laparoscopic treatment of bowel obstruction in Germany, a cross-sectional online study was conducted. We designed an online-based survey, supported by the German College of Surgeons (Berufsverband der Deutschen Chirurgen, BDC) to get multi-institutional-based data from various level providers of patient care.

Results

Between January and February 2014, we received completed questionnaires from 235 individuals (16.7 %). The participating surgeons were a representative sample of German hospitals with regard to hospital size, level of center size, and localization. A total of 74.9 % (n?=?176) of all responders stated to use laparoscopy as the initial step of exploration in expected bowel obstruction. This procedure was highly statistically associated with the frequency of overall laparoscopic interventions and laparoscopic experience. The overall conversion rate was reported to be 29.4 %.

Conclusions

This survey, investigating on the use of laparoscopic exploration or interventions in bowel obstruction, was able to show that by now, a majority of the responding surgeons accept laparoscopy as an initial step for exploration of the abdomen in the case of bowel obstruction. Laparoscopy was considered to be at least comparable to open surgery in an emergency setting. Furthermore, data analysis demonstrated generally accepted advantages and disadvantages of the laparoscopic approach. Indications for or against laparoscopy are made after careful consideration in each individual case.

     

How useful are high vaginal swabs in general practice? Results of a multicentre study

Vulvovaginal symptoms are a common reason for consultation with a general practitioner (GP). High vaginal swabs (HVS) are used to investigate symptoms, but their usefulness is poorly evaluated and microbiological tests performed vary between laboratories. In this multicentre study of 797 women with genital symptoms attending GPs, diagnostic yield of HVS was poor except for Candida spp. (22%). There is an urgent need to establish the most cost-effective approach for the management of these women.