Serum IgG and IgA antibodies to Chlamydia pneumoniae and severity of emphysema

OBJECTIVE: Chronic Chlamydia pneumoniae infection has been identified serologically in patients with COPD. The aim of this study was to examine whether the severity of emphysema is related to elevated antibody titres against C. pneumoniae. METHODOLOGY: We measured antibody titres against C. pneumoniae using ELISA, and assessed the severity of emphysema by the percentage of low attenuation area (%LAA) using high resolution (HR) CT in patients with COPD and in non-smoking control subjects. RESULTS: The mean %LAA was 2.2% in non-smoking controls (n = 28) and 13.3% in COPD patients (n = 94). COPD patients with a high IgG antibody index to C. pneumoniae (> or =2.0, n = 42) had a significantly higher %LAA (16.8%) than those with a low IgG index (<2.0, n = 52) (10.6%, P = 0.01). In addition, COPD patients with a high IgA antibody index (> or =2.0, n = 46) had a significantly higher %LAA (15.9%) than those with a low IgA index (<2.0, n = 48) (10.9%, P = 0.048). COPD patients with a high IgA antibody index also had a significantly lower %DLco than that associated with a low IgA index (68.1% and 80.3%, respectively, P = 0.007). There were no significant differences in age, smoking index or FEV(1)/FVC between these groups. CONCLUSION: These results suggest that high antibody titres against C. pneumoniae are linked with the severity of emphysema on high resolution CT and decreased diffusing capacity to carbon monoxide.     

不同表型慢性阻塞性肺疾病治疗应答性差异比较

目的：分析不同表型的慢性阻塞性肺疾病( COPD)患者对长效β2受体激动剂/吸入型糖皮质激素的治疗应答性差异。方法纳入我院呼吸科门诊2013年1月至2015年1月连续使用沙美特罗/替卡松(50/500μg)12周的稳定期COPD患者。根据HRCT结果以低衰减区百分比( LAA%)≥15%定义为肺气肿型COPD,其余患者为慢性支气管炎型COPD。对患者进行常规体检、肺功能检测,使用改良英国医学研究委员会呼吸困难量表( MMRC)评价患者呼吸困难程度,使用圣乔治呼吸问卷( SGRQ)由患者自评呼吸问题给自身带来的困扰。结果纳入稳定期COPD患者297例,肺气肿型及慢性支气管炎型COPD患者在平均年龄、性别比例方面差异无统计学意义( P>0．05),两组患者BMI差异有统计学意义(P<0．05)。治疗前两组患者MMRC、SGRQ差异均无统计学意义(P>0．05),FEV1pre、FEV1/FVC、ICpre、RVpre差异有统计学意义(P<0．05)。治疗12周后,两组患者肺功能指标比较,△FEV1、△RV差异有统计学意义(P<0．05),△TLC、△IC差异无统计学意义(P>0．05)。结论①不同表型的COPD患者对长效β2受体激动剂/吸入型糖皮质激素的治疗应答性有明显差异。②肺气肿型与慢性支气管炎型相比分级更高,FEV 1下降的速度更快,治疗应答性更差。     

Endoscopic submucosal dissection for superficial esophageal neoplasms using the stag beetle knife

Endoscopic submucosal dissection (ESD) is an accepted standard treatment for early gastric cancer but is not widely used in the esophagus because of technical difficulties. To increase the safety of esophageal ESD, we used a scissors‐type device called the stag beetle (SB) knife. The aim of this study was to determine the efficacy and safety of ESD using the SB knife. We performed a single‐center retrospective, uncontrolled trial. A total of 38 lesions were excised by ESD from 35 consecutive patients who were retrospectively divided into the following two groups according to the type of knife used to perform ESD: the hook knife (hook group) was used in 20 patients (21 lesions), and the SB knife (SB group) was used in 15 patients (17 lesions). We evaluated and compared the operative time, lesion size, en bloc resection rate, pathological margins free rate, and complication rate in both groups. The operative time was shorter in the SB group (median 70.0 minutes [interquartile range, 47.5–87.0]) than in the hook group (92.0 minutes [interquartile range, 63.0–114.0]) (P = 0.019), and the rate of complications in the SB group was 0% compared with 45.0% in the hook group (P = 0.004). However, the lesion size, en bloc resection rate, and pathological margins free rate did not differ significantly between the two groups. In conclusion, ESD using the SB knife was safer than that using a conventional knife for superficial esophageal neoplasms.     

Tidal Expiratory Flow Limitation at Rest as a Functional Marker of Pulmonary Emphysema in Moderate-to-Severe COPD

Background: Tidal expiratory flow limitation (EFL) is a step of paramount importance in the functional decline in COPD. Among mechanisms contributing to EFL, loss of airway-parenchymal interdependence could mostly be involved. Aim: To assess if EFL is a functional marker more frequently linked to prevalent pulmonary emphysema rather than to prevalent chronic bronchiolitis in COPD patients with moderate-to-severe airflow obstruction. Methods: Forty consecutive stable COPD patients with FEV₁ between 59 and 30% of predicted were functionally evaluated by measuring spirometry, maximal flow-volume curve and lung diffusion capacity (DL_CO) and coefficient of diffusion (K_CO). EFL was assessed by the negative expiratory pressure (NEP) method both in sitting and supine position. Chronic dyspnea was also scored by modified Medical Research Council (mMRC) scale. Results: In sitting position 13 patients (33%) were flow limited (FL) and 27 were non-flow limited (NFL). Only FEV₁/FVC, FEV₁ and MEF_25–75% were different between FL and NFL patients (p < 0.01). In supine position, however, among NFL patients in sitting position those who developed EFL, had significantly lower values of DL_CO and K_CO (p < 0.05) and higher mMRC score (p < 0.01), but similar values of FEV₁ as compared to those who did not have EFL. Conclusions: In COPD EFL in sitting position is highly dependent by the severity of airflow obstruction. In contrast, the occurrence of EFL in supine position is associated with worse DL_CO and K_CO and greater chronic dyspnea, reflecting a prevalent emphysematous phenotype in moderate-to-severe COPD patients.     

COPD-related Bronchiectasis; Independent Impact on Disease Course and Outcomes

Background: COPD and radiographic bronchiectasis frequently coexist but the effect of this on the clinical course of COPD is not fully understood. We determined the impact of bronchiectasis on clinical outcomes in COPD patients, independent of coexisting emphysema and bronchial wall thickening (BWT). Methods: COPD patients admitted with first exacerbation 1998–2008 were identified retrospectively using ICD10 codes J44.0,1,8,9. Patients with suitable CT scans were graded for severity of bronchiectasis, emphysema and BWT on a 5 point scale (0-absent, 1-minor, 2-mild, 3-moderate, 4-severe). Results: 406 patients (71 ± 11 years, 56% male, FEV₁ 52 ± 23% predicted) were included; 278 (69%) patients had bronchiectasis: minor, 112 (40%); mild, 81 (29%); moderate, 62 (22%); severe 23 (8%). Bronchiectasis severity correlated with severity of BWT (p < 0.001) but not emphysema (p = 0.090). Bronchiectasis independently determined sputum isolation of Pseudomonas aeruginosa (Odds ratio (OR) 1.39 (95% CI 1.07 to 1.80), p = 0.013) and atypical mycobacteria (OR 2.44 (95% CI 1.04 to 5.69), p = 0.040), annual respiratory admissions (p = 0.044) and inpatient days (p < 0.001), but did not predict survival (p = 0.256). Conclusions: Radiographic bronchiectasis in COPD patients is associated with increased respiratory infection and hospitalisation, independent of coexisting emphysema and BWT. COPD-related bronchiectasis is therefore an important diagnosis with potential implications for treatment.     

Conservative management of post-intubation tracheal tears—report of three cases

Iatrogenic tracheal rupture is a rare complication after intubation. We present three patients with tracheal tears. In all of these patients, a common finding was a lesion of the posterior tracheal wall with postoperative subcutaneous and emphysema as the first clinical sign of the rupture. Diagnosis and follow-up were based on clinical and endoscopic findings and chest computed tomography (CT) scans. In our cases with progressive subcutaneous and mediastinal emphysema or dyspnea, we performed a tracheotomy and bypassed the lesion with a tracheostomy tube to avoid an increase in air leakage into the mediastinum. Under broad-spectrum antibiotic therapy, no mediastinitis occurred and all patients survived without sequelae. Closure of tracheostomy was scheduled for 1-2 months after tracheal injury. Analysis of surgical and anesthesiological procedures revealed no abnormalities and the accumulation of tracheal injuries was considered as accidental. We found that in clinically stable patients with spontaneous breathing and with no mediastinitis, a conservative management of tracheal tears is a safe procedure.     

Radiological evidence of subcutaneous emphysema leading to a diagnosis of retroperitoneal perforated diverticulum

INTRODUCTIONThis case report outlines the investigation and management of a young patient presenting with left iliac fossa pain and sepsis. A CT was performed which was initially reported as not showing a perforation, however closer analysis provided evidence of subcutaneous emphysema in the anterior abdominal wall. This evidence justified urgent operative intervention. We review the evidence with regard to this presentation.PRESENTATION OF CASEA previously fit 24-year-old male presented with left iliac fossa pain and features of sepsis. A CT provided subtle but distinctive evidence of retroperitoneal perforation secondary to diverticulitis, in the form of surgical emphysema in the anterior abdominal wall. In view of this, urgent operation was considered justified on suspicion of visceral perforation. A diverticular perforation was confirmed intra-operatively, and a sigmoid colectomy with primary anastomosis was performed, together with a covering ileostomy. The patient made a good post-operative recovery.DISCUSSIONDiverticular disease and its complications are becoming more common in a younger age group, in whom perforation may present late or may not be suspected. In this context special attention must be paid to any radiological evidence of perforation.CONCLUSIONSurgical emphysema in the abdominal wall is an indicator of retroperitoneal perforation, and its presence should be excluded before the possibility of perforation is dismissed. This may be of especial value in younger age groups amongst whom perforation may be less clinically obvious.     

头孢呋辛钠治疗老年肺气肿感染的临床分析

目的：探讨头孢呋辛钠在老年肺气肿感染中的应用价值。方法：以近两年来在我院住院接受治疗的98例老年肺气肿感染患者作为研究对象,以患者自愿原则将98例患者分为观察组和对照组,两组均49例,对照组患者行青霉素抗感染治疗,观察组则行头孢呋辛钠抗感染治疗,比较两组患者的临床疗效。结果：观察组行头孢呋辛钠治疗的总有效率明显高于行青霉素治疗的对照组（P〈O．05）,观察组的临床症状、胸部x线表现、体温血象恢复正常时间和对照组相比均有明显差异（P〈0．05）;两组患者经不同药物治疗后药物不良反应发生率比较无明显差异（P〉0．05）。结论：将头孢呋辛钠应用于老年肺气肿感染的治疗具有较高临床价值,可提高治疗效果,值得临床推广。     

Other conditions of the lung (abscesses,inhaled foreign bodies,bullous lung disease,hydatid)

Lung abscess remains a common complication of pneumonia and aspiration, particularly in immunosuppressed patients, and must be differentiated from a cavitary form of lung cancer. The conservative treatment with antibiotics is still the main therapeutic approach; however, percutaneous drainage may be employed in selected cases.