Chou Chin Lan

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.

Pulmonary rehabilitation improves heart rate variability at peak exercise, exercise capacity and health-related quality of life in chronic obstructive pulmonary disease

OBJECTIVE Patients with chronic obstructive pulmonary disease (COPD) appear to have impaired cardiac autonomic modulation with depressed heart rate variability (HRV). Pulmonary rehabilitation (PR) is recommended as an integral part of the management. However, the effect of PR on HRV at peak exercise remains unclear. METHODS Sixty-four patients with COPD participated in a 12-week, 2 sessions-per-week, hospital-based PR program. Baseline and post-PR status were evaluated by spirometry, HRV, health-related quality of life (HRQL, St. Georges Respiratory Questionnaire, SGRQ), cardiopulmonary exercise test, respiratory muscle strength, and dyspnea Borgs scale. RESULTS After PR, there were significant improvements in the time and frequency domains of HRV with increased standard deviation of the normal R-R intervals, difference between adjacent normal R-R intervals within a given time minus one, high-frequency and decreased low-frequency, as well as concurrent improvements in HRQL, exercise capacity, dyspnea score, and respiratory muscle strength (all p < 0.05). CONCLUSIONS PR results in significant improvements in autonomic function, with concurrent improvements in HRQL and exercise capacity.

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.

Prolonged mechanical ventilation in a respiratory- care setting: a comparison of outcome between tracheostomized and translaryngeal intubated patients

IntroductionMechanical ventilation of patients may be accomplished by either translaryngeal intubation or tracheostomy. Although numerous intensive care unit (ICU) studies have compared various outcomes between the two techniques, no definitive consensus indicates that tracheostomy is superior. Comparable studies have not been performed in a respiratory care center (RCC) setting.MethodsThis was a retrospective observational study of 985 tracheostomy and 227 translaryngeal intubated patients who received treatment in a 24-bed RCC between November 1999 and December 2005. Treatment and mortality outcomes were compared between tracheostomized and translaryngeal intubated patients, and the factors associated with positive outcomes in all patients were determined.ResultsDuration of RCC (22 vs. 14 days) and total hospital stay (82 vs. 64 days) and total mechanical ventilation days (53 vs. 41 days) were significantly longer in tracheostomized patients (all P < 0.05). The rate of in-hospital mortality was significantly higher in the translaryngeal group (45% vs. 31%;P < 0.05). No significant differences were found in weaning success between the groups (both were >55%) or in RCC mortality. Because of significant baseline between-group heterogeneity, case-match analysis was performed. This analysis confirmed the whole cohort findings, except for the fact that a trend for in-hospital mortality was noted to be higher in the translaryngeal group (P = 0.08). Stepwise logistic regression revealed that patients with a lower median severity of disease (APACHE II score <18) who were properly nourished (albumin >2.5 g/dl) or had normal metabolism (BUN <40 mg/dl) were more likely to be successfully weaned and survive (all P < 0.05). Patients who were tracheostomized were also significantly more likely to survive (P < 0.05)ConclusionsThese findings suggest that the type of mechanical ventilation does not appear to be an important determinant of weaning success in an RCC setting. Focused care administered by experienced providers may be more important for facilitating weaning success than the ventilation method used. However, our findings do suggest that tracheostomy may increase the likelihood of patient survival.

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.

Increased Survivin mRNA in Malignant Pleural Effusion is Significantly Correlated with Survival

OBJECTIVE The sensitivity of cytologic examination of pleural effusions is variable and not predictive of prognosis. Survivin is an inhibitor of apoptosis that may be a novel diagnostic/prognostic marker of cancers. This study aimed to determine the diagnostic and prognostic value of measuring survivin mRNA levels in pleural effusions. METHODS Eighty-eight consecutive pleural effusion samples were examined for both cytology and survivin mRNA level. The accuracy of diagnosis and the correlation between survivin mRNA level and survival in malignant pleural effusion (MPE) were determined. Pleural effusions were divided into three groups: Group I, malignancy-associated (n = 44); Group II, inflammatory (n = 27); and Group III, transudative (n = 17). RESULTS Survivin mRNA levels in Group I (1.03 +/- 0.61, range 0-2.96) were significantly higher than those in Groups II (0.45 +/- 0.69, range 0-3.30) and III (0.08 +/- 0.22, range 0-0.71) (P < 0.001). Survivin mRNA level was significantly higher in MPE than in non-MPE. The cut-off value for survivin mRNA levels in pleural effusions was 0.074 for the diagnosis of malignancies, with sensitivity, specificity, and positive and negative predictive values of 96%, 45%, 45% and 96%, respectively. Survivin mRNA level in pleural effusions of cancer patients significantly correlated with poor survival. CONCLUSIONS Survivin mRNA level is significantly higher in MPEs. Over-expression of survivin mRNA correlates with poor prognosis in cancer patients.

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.

Risk factors of pneumothorax after CT-guided coaxial cutting needle lung biopsy through aerated versus nonaerated lung

PURPOSE To compare the risk factors of developing a pneumothorax after computed tomography-guided lung biopsy in cases in which aerated lung is traversed and in cases in which aerated lung is not traversed. MATERIALS AND METHODS The records of 381 patients from July 2005-December 2009 were retrospectively reviewed. Multivariable analysis of patient demographic characteristics, lung lesion characteristics, and biopsy procedure details was performed with respect to the development of pneumothorax. RESULTS Among 381 patients, 249 biopsies traversed aerated lung tissue, and 132 biopsies did not traverse aerated lung tissue. Patients in whom aerated lung tissue was traversed had a significantly higher rate of pneumothorax. When aerated lung was not traversed, lesion size (≤ 2 cm vs > 2 cm; P = .025) and pleural-lesion angle (odds ratio = 1.033/degree; P = .004) were associated with pneumothorax. When aerated lung was traversed, location (middle vs upper; P = .009) and a transfissure approach (yes vs no; P = .001) were associated with pneumothorax. CONCLUSIONS When aerated lung was not traversed, lesion size and pleural-lesion angle were associated with pneumothorax, and when aerated lung was traversed, location and a transfissure approach were associated with pneumothorax.

The impact of diabetes mellitus and its control on the development of tuberculosis: A nationwide longitudinal study in Taiwan

Diabetic mellitus (DM) is a well‐known risk factor of tuberculosis (TB). However, there is paucity of reports on the impact of diabetic control and adherence to anti‐diabetic treatment on the risk of TB. This nationwide cohort study aimed to address these issues.

Spontaneous Rupture of Gastroduodenal Artery Pseudoaneurysm Following Vigorous Cough

To the Editor: Acute abdominal pain is one of the most common conditions confronted in daily practice of general practitioners. However, in some instances, it is difficult to be certain about the exact intra-abdominal lesion that has given rise to the symptoms, even for an experienced gastroenterology specialist. It is especially dangerous to jump to spot diagnosis, when a serious uncommon underlying pathology somewhat mimics the clinical presentations of a common disease. We report, here, a patient of abdominal apoplexy because of a ruptured gastroduodenal artery pseudoaneurysm that has abdominal computed tomography (CT) findings characteristic of acute hemorrhagic pancreatitis.