Chih Hsin Lee

Pulmonary Tuberculosis and Delay in Anti-Tuberculous Treatment Are Important Risk Factors for Chronic Obstructive Pulmonary Disease

Objective Tuberculosis (TB) remains the leading cause of death among infectious diseases worldwide. It has been suggested as an important risk factor of chronic obstructive pulmonary disease (COPD), which is also a major cause of morbidity and mortality. This study investigated the impact of pulmonary TB and anti-TB treatment on the risk of developing COPD. Design, Setting, and Participants This cohort study used the National Health Insurance Database of Taiwan, particularly the Longitudinal Health Insurance Database 2005 to obtain 3,176 pulmonary TB cases and 15,880 control subjects matched in age, sex, and timing of entering the database. Main Outcome Measures Hazard ratios of potential risk factors of COPD, especially pulmonary TB and anti-TB treatment. Results The mean age of pulmonary TB cases was 51.9±19.2. The interval between the initial study date and commencement of anti-TB treatment (delay in anti-TB treatment) was 75.8±65.4 days. Independent risk factors for developing COPD were age, male, low income, and history of pulmonary TB (hazard ratio 2.054 [1.768–2.387]), while diabetes mellitus was protective. The impact of TB persisted for six years after TB diagnosis and was significant in women and subjects aged >70 years. Among TB patients, delay in anti-TB treatment had a dose-response relationship with the risk of developing COPD. Conclusions Some cases of COPD may be preventable by controlling the TB epidemic, early TB diagnosis, and prompt initiation of appropriate anti-TB treatment. Follow-up care and early intervention for COPD may be necessary for treated TB patients.

Risk factors for pulmonary tuberculosis in patients with chronic obstructive airway disease in Taiwan: a nationwide cohort study.

BackgroundAn association between chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) has been described, mainly due to smoking and corticosteroid use. Whether inhaled corticosteroid (ICS) therapy is associated with an increased risk of TB remains unclear.MethodsWe selected COPD cases by using six diagnostic scenarios and control subjects from a nationwide health insurance database, and applied time-dependent Cox regression analysis to identify the risk factors for TB.ResultsAmong 1,000,000 beneficiaries, 23,594 COPD cases and 47,188 non-COPD control subjects were selected. Cox regression analysis revealed that age, male gender, diabetes mellitus, end-stage renal disease, and cirrhosis, as well as COPD (hazard ratio = 2.468 [2.205–2.762]) were independent risk factors for TB. Among the COPD cases, those who developed TB received more oral corticosteroids and oral β-agonists. Time-dependent Cox regression analysis revealed that age, male gender, diabetes mellitus, low income, oral corticosteroid dose, and oral β-agonist dose, but not ICS dose, were independent risk factors for TB. The identified risk factors and their hazard ratios were similar among the COPD cases selected using different scenarios.ConclusionKeeping a high suspicion and regularly monitoring for the development of pulmonary TB in COPD patients are necessary, especially for those receiving higher doses of oral corticosteroids and other COPD medications. Although ICS therapy has been shown to predispose COPD patients to pneumonia in large randomized clinical trials, it does not increase the risk of TB in real world practice.

Optimal Duration of Anti-TB Treatment in Patients With Diabetes: Nine or Six Months?

BACKGROUND Diabetes mellitus (DM) increases the risk of TB recurrence. This study investigated whether 9-month anti-TB treatment is associated with a lower risk of TB recurrence within 2 years after complete treatment than 6-month treatment in patients with DM with an emphasis on the impact of directly observed therapy, short course (DOTs). METHODS Patients with pulmonary but not extrapulmonary TB receiving treatment of 173 to 277 days between 2002 and 2010 were identified from the National Health Insurance Research Database of Taiwan. Patients with DM were then selected and classified into two groups based on anti-TB treatment duration (9 months vs 6 months). Factors predicting 2-year TB recurrence were explored using Cox regression analysis. RESULTS Among 12,688 patients with DM and 43,195 patients without DM, the 2-year TB recurrence rate was 2.20% and 1.38%, respectively (P < .001). Of the patients with DM, recurrence rate decreased from 3.54% to 1.19% after implementation of DOTs (P < .001). A total of 4,506 (35.5%) were classified into 9-month anti-TB treatment group. Although a 9-month anti-TB treatment was associated with a lower recurrence rate (hazard ratio, 0.76 [95% CI, 0.59-0.97]), the benefit disappeared (hazard ratio, 0.69 [95% CI, 0.43-1.11]) under DOTs. Other predictors of recurrence included older age, male sex, malignancy, earlier TB diagnosis year, culture positivity after 2 months of anti-TB treatment, and anti-TB treatment being ≤ 80% consistent with standard regimen. CONCLUSIONS The 2-year TB recurrence rate is higher in a diabetic population in Taiwan and can be reduced by treatment supervision. Extending the anti-TB treatment by 3 months may also decrease the recurrence rate when treatment is not supervised.

Use of high-dose inhaled corticosteroids is associated with pulmonary tuberculosis in patients with chronic obstructive pulmonary disease.

The use of high-dose inhaled corticosteroids (ICS) in patients with chronic obstructive pulmonary disease (COPD) has recently been shown to increase the incidence of pneumonia. However, to our knowledge, the impact of high-dose ICS on pulmonary tuberculosis (TB) has never been investigated. To study that impact, we conducted a retrospective study including patients aged more than 40 years old with irreversible airflow limitation between August 2000 and July 2008 in a medical center in Taiwan. Of the 36,684 patients who underwent pulmonary function testing, we included 554 patients. Among them, patients using high-dose ICS (equivalent to >500 &mgr;g/d of fluticasone) were more likely to have more severe COPD and receive oral corticosteroids than those using medium-dose, low-dose, or no ICS. Sixteen (3%) patients developed active pulmonary TB within a follow-up of 25,544 person-months. Multivariate Cox regression analysis revealed that the use of high-dose ICS, the use of 10 mg or more of prednisolone per day, and prior pulmonary TB were independent risk factors for the development of active pulmonary TB. Chest radiography and sputum smear/culture for Mycobacterium tuberculosis should be performed before initiating high-dose ICS and regularly thereafter. Abbreviations: COPD = chronic obstructive pulmonary disease, FEV1 = forced expiratory volume in the first second, FVC = forced vital capacity, HD = high dose, ICS = inhaled corticosteroids, LD = low dose, MD = medium dose, TB = tuberculosis.

Trends and predictors of changes in pulmonary function after treatment for pulmonary tuberculosis

OBJECTIVES: The present study aimed to investigate the trends in changes in pulmonary function and the risk factors for pulmonary function deterioration in patients with pulmonary tuberculosis after completing treatment. INTRODUCTION: Patients usually have pulmonary function abnormalities after completing treatment for pulmonary tuberculosis. The time course for changes in pulmonary function and the risk factors for deterioration have not been well studied. METHODS: A total of 115 patients with 162 pulmonary function results were analyzed. We retrieved demographic and clinical data, radiographic scores, bacteriological data, and pulmonary function data. A generalized additive model with a locally weighted scatterplot smoothing technique was used to evaluate the trends in changes in pulmonary function. A generalized estimating equation model was used to determine the risk factors associated with deterioration of pulmonary function. RESULTS: The median interval between the end of anti-tuberculosis treatment and the pulmonary function test was 16 months (range: 0 to 112 months). The nadir of pulmonary function occurred approximately 18 months after the completion of the treatment. The risk factors associated with pulmonary function deterioration included smear-positive disease, extensive pulmonary involvement prior to anti-tuberculosis treatment, prolonged anti-tuberculosis treatment, and reduced radiographic improvement after treatment. CONCLUSIONS: After the completion of anti-tuberculosis TB treatment, several risk factors predicted pulmonary function deterioration. For patients with significant respiratory symptoms and multiple risk factors, the pulmonary function test should be followed up to monitor the progression of functional impairment, especially within the first 18 months after the completion of anti-tuberculosis treatment.

Pulmonary rehabilitation improves exercise capacity and quality of life in underweight patients with chronic obstructive pulmonary disease

Background and objective:  An estimated 20–40% of COPD patients are underweight. We sought to confirm the physiological and psychosocial benefits of pulmonary rehabilitation programmes (PRP) in underweight compared with non‐underweight patients with COPD.

Benefits of Pulmonary Rehabilitation in Patients With COPD and Normal Exercise Capacity

BACKGROUND: Pulmonary rehabilitation (PR) is beneficial for patients with COPD, with improvement in exercise capacity and health-related quality of life. Despite these overall benefits, the responses to PR vary significantly among different individuals. It is not clear if PR is beneficial for patients with COPD and normal exercise capacity. We aimed to investigate the effects of PR in patients with normal exercise capacity on health-related quality of life and exercise capacity. METHODS: Twenty-six subjects with COPD and normal exercise capacity were studied. All subjects participated in 12-week, 2 sessions per week, hospital-based, out-patient PR. Baseline and post-PR status were evaluated by spirometry, the St Georges Respiratory Questionnaire, cardiopulmonary exercise test, respiratory muscle strength, and dyspnea scores. RESULTS: The mean FEV1 in the subjects was 1.29 ± 0.47 L/min, 64.8 ± 23.0% of predicted. After PR there was significant improvement in maximal oxygen uptake and work rate. Improvements in St Georges Respiratory Questionnaire scores of total, symptoms, activity, and impact were accompanied by improvements of exercise capacity, respiratory muscle strength, maximum oxygen pulse, and exertional dyspnea scores (all P < .05). There were no significant changes in pulmonary function test results (FEV1, FVC, and FEV1/FVC), minute ventilation, breathing frequency, or tidal volume at rest or exercise after PR. CONCLUSIONS: Exercise training can result in significant improvement in health-related quality of life, exercise capacity, respiratory muscle strength, and exertional dyspnea in subjects with COPD and normal exercise capacity. Exercise training is still indicated for patients with normal exercise capacity.

Lung Cancer with Unusual Presentation as a Thin-Walled Cyst in a Young Nonsmoker

A 27-year-old female nonsmoker ever had received a healthy examination of chest radiography (CXR) with normal result 1 year ago. She consulted our institute because of prolonged cough for the past 3 months. She underwent CXR and this showed a thin-walled cyst in the right lower lung with ipsilateral hilar enlargement (Figure 1A). The chest CT showed a 30 30-mm cystic lesion in the right lower lung with hilar lymphadenopathy. Mycobacterial smears and cultures of obtained sputum were negative. Her carcinoembryonic antigen level was in the normal range. However, given that the appearance of the large cyst with hilar enlargement was atypical, the bronchoscopic examination was performed and revealed an endobronchial mass at the orifice of the right lower lobe (Figure 1B). The histologic examination of transbronchial biopsy specimens confirmed lung adenocarcinoma. Positron emission tomography revealed heterogeneous uptake of the cystic lesion, right hilar, mediastinal, and left neck lymph nodes, suggestive of metastasis. The patient was diagnosed as having stage IIIb lung cancer, T2N3M0. She underwent chemotherapy and external irradiation to the mediastinal and left neck lymph nodes. Her disease course was rapid. She succumbed to her tumor within 6 months of diagnosis. The most common radiologic manifestation in lung cancer is solitary or multiple nodules. This report describes a case of lung adenocarcinoma presenting as a cystic lesion in a young nonsmoker, which is extremely rare. However, this atypical presentation of lung cancer should be kept in mind in the differential diagnosis.1 It should be possible to make a definite diagnosis of benign or malignant cystic masses. There are many hypotheses of cyst formation in malignancy including a check-valve obstruction at the conducting bronchus, central necrosis within the tumor, and development in preexisting cystic lesions.2,3 This is the first case reported with tumor imaging at the conducting bronchus that supports the hypothesis of cyst formation due to a check-valve obstruction at the conducting bronchus.

Urinary tuberculosis is associated with the development of urothelial carcinoma but not renal cell carcinoma: a nationwide cohort study in Taiwan

Background:Obstructive uropathy and chronic urinary tract infection increase the risk of urinary tract cancer. Urinary tuberculosis (UTB) can cause chronic urinary tract inflammation, lead to obstructive uropathy, and potentially contribute to the development of urinary tract cancer. However, the association between UTB and urinary tract cancer has not been studied.Methods:This study enrolled 135 142 tuberculosis (TB) cases (male, 69%) from a nationwide health insurance research database in Taiwan and investigated the risk factors for urinary tract cancer, with emphasis on a history of UTB. The incidence of urinary tract cancer in the general population without TB was also calculated for comparison.Results:The TB patients had a mean age of 57.5±19.5 years. Of the 1287 UTB and 133 855 non-UTB patients, 15 (1.2%) and 396 (0.3%) developed urothelial carcinoma, respectively (P<0.001); and 2 (0.2%) and 96 (0.1%) developed renal cell carcinoma, respectively (P=0.240). Cox regression analysis revealed that age, male sex, end-stage renal disease, obstructive uropathy, arsenic intoxication, organ transplantation, and UTB (hazard ratio: 3.38 (2.01–5.69)) were independent risk factors for urothelial carcinoma. The hazard ratio of UTB was higher among female patients (5.26 (2.12–13.06)) than that among male patients (2.96 (1.57–5.60)).Conclusion:Urinary tuberculosis had a strong association with urothelial carcinoma, but not with renal cell carcinoma. In TB endemic areas, the urinary tract of TB patients should be scrutinised. It is also imperative that these patients be followed-up carefully in the post-treatment period, and urinalysis, ultrasonography or endoscopy should be an integral part of the follow-up.

Pulmonary Rehabilitation Improves Subjective Sleep Quality in COPD

BACKGROUND: Poor sleep quality is often reported among patients with COPD. Pulmonary rehabilitation (PR) is beneficial in improving exercise capacity and health-related quality of life (HRQOL). However, its benefit in terms of sleep quality in patients with COPD remains unclear. This study aimed to investigate the effects of PR on sleep quality of patients with COPD. METHODS: Thirty-four subjects with COPD were studied. All subjects participated in a 12-week (2 sessions/week) hospital-based out-patient PR study. Baseline and post-PR status were evaluated by spirometry, a sleep questionnaire (Pittsburgh Sleep Quality Index [PSQI]), a disease-specific questionnaire of HRQOL (St George Respiratory Questionnaire [SGRQ]), cardiopulmonary exercise testing, respiratory muscle strength, and the Borg dyspnea scale. RESULTS: Mean FEV1/FVC in the subjects was 0.49 ± 0.13, and the mean FEV1 was 1.06 ± 0.49 L/min (49.7 ± 18.0% of predicted). After PR, the PSQI score decreased from 9.41 ± 4.33 to 7.82 ± 3.90 (P < .001). The number of subjects with a PSQI score > 5 also decreased (85.3–64.7%, P = .006). There were significant improvements in HRQOL (SGRQ, P = .003), exercise capacity (peak oxygen uptake, P < .001; and work rate, P < .001), dyspnea score (P < .001), and respiratory muscle strength (inspiratory muscle strength, P = .005; and expiratory muscle strength, P = .004) after PR. There were no significant changes in pulmonary function test results (FEV1, P = .77; FVC, P = .90; FEV1/FVC, P = .90). CONCLUSIONS: PR results in significant improvement in sleep quality, along with concurrent improvements in HRQOL and exercise capacity. PR is an effective nonpharmacologic treatment to improve sleep quality in patients with COPD and should be part of their clinical management.