Kamlesh Mohan

Long-Term Effect of Insulin Treatment in Cystic Fibrosis-Related Diabetes

Background: Although insulin treatment confers short-term benefit in cystic fibrosis-related diabetes (CFRD), few studies have compared its long-term effect on the clinical outcome. Objectives: In this study, we aimed to investigate the long-term impact of insulin treatment on pulmonary function, nutritional status and hospital admissions in patients with CFRD. Methods: We reviewed pulmonary function, body mass index (BMI) and hospital admissions 5 years before and 3 years after insulin therapy in 42 adult CFRD patients. Results: Prior to treatment, over a period of 5 years, the annual rate of change in forced expiratory volume in 1 s (FEV1) was –3.2%, forced vital capacity (FVC) –2.5%, and BMI –0.07%. At treatment of CFRD (baseline), the mean FEV1 was 51.6% predicted (range 24–96), FVC 66.4% (range 29–103) and BMI 19.5 (range 15.3–29.5). At 3 months following insulin treatment, there was a significant improvement in all parameters, which was maintained at 1 year for FEV1 (55.1%; p < 0.002), 2 years for FVC (72.1%; p < 0.01) and at 3 years for BMI (20.4%; p < 0.002). After 3 months, FEV1 declined at a rate similar to that before treatment (–3.2 vs. –3.1% per year; p = 0.77), such that the mean FEV1 after treatment returned to pretreatment baseline values at 34 months. There was no difference in the number of hospital admissions with insulin treatment. Conclusions: Insulin enhances the nutritional state and temporarily improves pulmonary function in CFRD patients, on average delaying the decline in FEV1 by 34 months.

Impact of chronic obstructive pulmonary disease severity on surgical outcomes in patients undergoing non-emergent coronary artery bypass grafting †

OBJECTIVES Although the association between chronic obstructive pulmonary disease (COPD) and adverse surgical outcomes has been previously demonstrated, the impact of COPD severity on postoperative mortality and morbidity remains unclear. Our objective was to analyse the prognostic implication of COPD stages as defined by the Global Initiative for Chronic Obstructive Lung Disease. METHODS Between September 1997 and April 2010, 13,638 patients undergoing first time isolated CABG were retrospectively reviewed, of whom 2421 patients were excluded due to lack of spirometry records or restrictive pattern on spirometry. The remaining 11,217 patients were divided into three groups: group 1 (including patients with normal spirometry and patients with mild COPD (FEV1/FVC ratio<70%, FEV1≥80% predicted), group 2 (moderate COPD: FEV1/FVC ratio<70%, 50%≤FEV1<80% predicted) and group 3 (severe COPD: FEV1/FVC ratio<70%, FEV1<50% predicted). Logistic regression was used to examine the effect of COPD severity on early mortality and morbidity, after adjusting for differences in patient characteristics. RESULTS Early mortality in the three groups was 1.4, 2.9 and 5.7% respectively (P<0.001). Similarly, a consistent trend of increasing frequency of postoperative complications with advanced COPD stage was noted. On multivariate analysis, severe COPD was found to be significantly associated with early mortality [adjusted OR, 2.31 (95% CI) (1.23-4.36)], P=0.01. CONCLUSIONS The severity of COPD as defined by spirometry can be a prognostic marker in patients undergoing CABG. Spirometric criteria may help refining currently used operative risk scores.

Transmission of Pseudomonas aeruginosa epidemic strain from a patient with cystic fibrosis to a pet cat

Chronic infection with Pseudomonas aeruginosa is common in cystic fibrosis (CF) and certain strains are more transmissible and virulent than others. Of these, the Liverpool Epidemic Strain (LES) is highly transmissible and cross infection has been reported between patients with CF and healthy non-CF relatives. However, the risk of transmission from humans to animals is unknown. The first report of interspecies transmission of the LES strain of P aeruginosa from an adult patient with CF to a pet cat is described. This development further complicates the issue of infection control policies required to prevent the spread of this organism.

Management of cystic fibrosis related diabetes: A survey of UK cystic fibrosis centers

Cystic fibrosis related diabetes (CFRD), a poor prognostic factor in cystic fibrosis (CF), is an increasing problem and guidelines regarding its management have recently been published. However, the evidence base for CFRD screening and diagnosis is not comprehensive and its current management in the UK is unknown. We therefore conducted a questionnaire survey of all recognized UK CF centers to assess clinical practice and determine adherence to these recent recommendations.

Long-term survival of patients with pulmonary disease undergoing coronary artery bypass surgery.

OBJECTIVES We sought to investigate the long-term survival of patients with obstructive, restrictive and chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). METHODS A prospective database was retrospectively analysed and cross-correlated with the UK strategic tracking service to evaluate survival after primary coronary artery bypass grafts (CABG). Univariate and multivariate Cox regression analyses were performed. Three separate multivariate analyses were performed: COPD GOLD criteria for obstructive and/or restrictive lung disease, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and the FEV1/FVC ratio to investigate the effect of FEV1 and FVC individually. RESULTS We analysed 13 337 primary CABG procedures. The median follow-up was 7 years. Univariate analysis demonstrated that obstructive (P < 0.0001), restrictive (P < 0.0001) and mixed obstructive and restrictive pulmonary disease (P < 0.0001), and COPD as defined by the GOLD criteria (P < 0.0001), are all significant factors determining long-term survival. Cox regression analysis identified age, diabetes, moderate LV, poor LV, peripheral vascular disease, dialysis, left internal mammary artery (LIMA) usage, EuroSCORE, cardiopulmonary bypass and creatinine kinase muscle-brain isoenzyme as significant factors in addition to pulmonary disease that determine long-term survival. Moderate and severe COPD defined by GOLD criteria were significant factors determining long-term survival, but mild COPD had no significant effect. Obstructive and restrictive lung disease were both significant factors determining long-term survival. Restrictive lung disease, however, carried a greater prognostic significance (higher hazard ratio 2.2 vs 1.6) than obstructive. LIMA utilization in patients with COPD was not associated with an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate. CONCLUSIONS Pulmonary disease is a significant factor determining long-term survival. Patients with severe COPD still have a relatively good long-term survival and should not be denied surgery. LIMA utilization in patients with COPD results in a significantly increased long-term survival, without an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate.

Impact of 18F-FDG PET scan on the prevalence of benign thoracic lesions at surgical resection

OBJECTIVE: The main utility of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) lies in the staging of lung cancer. However, it can also be used to differentiate indeterminate pulmonary lesions, but its impact on the resection of benign lesions at surgery is unknown. The aim of this study was to compare the prevalence of benign lesions at thoracotomy carried out for suspected lung cancer, before and after the introduction of PET scanning in a large thoracic surgical centre. MATERIALS AND METHODS: We reviewed our prospectively recorded surgical database for all consecutive patients undergoing thoracotomy for suspected or proven lung cancer and compared the prevalence of benign lesions in 2 consecutive 2-year groups, before (group I) and after (group II) the introduction of FDG-PET scan respectively. RESULTS: Surgical resection was performed on 1233 patients during the study period. The prevalence of benign lesions at surgery in groups I and II was similar (44/626 and 41/607, both 7%), and also in group II between those who underwent FDG-PET scan and the remainder (21/301 and 20/306 respectively, both 7%). In group II, of the 21 patients with benign lesions, who underwent FDG-PET, 19 had a false positive scan (mean standardised uptake value 5.3 [range 2.6-12.7]). Of these, 13 and 4 patients respectively had non-diagnostic bronchoscopy and percutaneous transthoracic lung biopsy pre thoracotomy. There was no difference in the proportion of different benign lesions resected between group I and those with FDG-PET in group II. CONCLUSION: The introduction of FDG-PET scanning has not altered the proportion of patients undergoing thoracotomy for ultimately benign lesions, mainly due to the avidity for the isotope of some non-malignant lesions. Such false positive results need to be considered when patients with unconfirmed lung cancer are contemplated for surgical resection.

Simultaneous bilateral spontaneous pneumothorax in an adult patient with cystic fibrosis

Pneumothorax is a common complication in cystic fibrosis and is associated with worsening of lung function. However, bilateral simultaneous pneumothorax in cystic fibrosis is a rare condition. We describe the case of a 17-year-old female with cystic fibrosis who presented with spontaneous pneumothorax. Clinically, she presented right-sided chest pain and progressive breathlessness. The pneumothorax failed to resolve after the initial treatment (chest drainage). However, the patient was later successfully treated with additional chest drainage and talc pleurodesis. We also discuss the etiology and management of pneumothorax in patients with cystic fibrosis, since pneumothorax is associated with increased morbidity and mortality among such patients.

Empyema due to a highly transmissible Pseudomonas aeruginosa strain in an adult cystic fibrosis patient.

Chronic pulmonary infection with Pseudomonas aeruginosa occurs in up to 85 % of individuals with cystic fibrosis (CF) by the time they reach adulthood, and is the major cause of morbidity and mortality: nearly all patients die from progressive respiratory failure due to repeated pulmonary exacerbations. However, despite the predilection of this organism for the lungs of CF people, infection of the pleura is much less common and is not well described in the CF population. We describe what is believed to be the first case of pleural empyema due to a particularly pathogenic transmissible strain of P. aeruginosa (the Liverpool epidemic strain) in an adult CF patient.

P165 Surgical lung biopsy in the diagnosis of interstitial lung disease – where are we now?

Introduction With the advent of multidisciplinary team (MDT) working and new therapies in interstitial lung disease (ILD), diagnostic accuracy is increasingly important, and international guidelines1 have reaffirmed the importance of surgical lung biopsy (SBx) where necessary. However, SBx has associated risks: to assess this further we looked at the diagnostic yield and complication rate of SBx carried out at our regional thoracic centre for patients with ILD. Methods We looked at all 104 SBxs carried out for ILD over 24 months between 2014–16, collecting data on the nature of the procedure, number of lobes sampled, complications encountered and mortality, and also whether the cases had been discussed at a regional ILD or local radiology MDT meeting prior to SBx. Results Seventy cases (67%) had been discussed prior to SBx (18 at an ILD MDT). Overall, mean age was 56 years, mean FEV1 79% predicted, FVC 84% predicted, RV 79% predicted, TLC 77% predicted, TLCO 56% predicted, and KCO 77% predicted. All but 3 procedures were carried out by VAT: the median number of lobes sampled was 2 (>1 lobe in 86%), and diagnostic specimens were obtained in 97% (UIP 29%, RB-ILD and DIP 23%, HSP 12%, Sarcoid 10%, NSIP 7%, others 19%). For complications see Table. The mean length of stay was 5.2 days (range 1–44): in-hospital mortality and 30-day mortality were 1% and 3% respectively. Conclusion Although SBx is here to stay, it has significant morbidity and mortality. Transbronchial cryobiopsy may in the future sit alongside SBx in the diagnostic pathway for ILD, but in addition to offering low morbidity and mortality it must also offer a high diagnostic yield. Abstract P165 Table 1 Major complications % of cases HDU/ITU admission 6 Required re-intubation 3 Required tracheostomy 1 Acute renal failure 3 Empyema 1 Ileus 1 Minor complications % of cases Pneumothorax 6 Persistent air leak 4 Atrial fibrillation 1 Lower respiratory tract infection 11 Urinary retention 1 Wound infection 2 Reference Travis WD, Costabel U, Hansell DM, et al. An official American Thoracic Society/European Respiratory Society Statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med 2013;188:733–748.

P164 Changing patterns of the use of lung biopsy in interstitial lung disease

Introduction Radiological and international guidelines have improved the diagnosis of interstitial lung disease (ILD) subtype in the absence of a surgical lung biopsy (SBx). However, it may still be needed since up to 38% of cases1 cannot be diagnosed on clinical and radiological grounds alone, and new antifibrotic therapies require more diagnostic certainty for idiopathic pulmonary fibrosis (IPF). We wished to ascertain whether SBx rates and diagnostic outcomes had changed at our regional thoracic centre. Methods We looked at 104 consecutive patients undergoing SBx between May 2014 to April 2016, and compared their mode of referral and outcome with a previous study (210 cases) in the same centre conducted between 2001 and 2008. Results There was no evidence of multidisciplinary team (MDT) input prior to SBx in 31 cases (30%), but 18 (17%) were discussed at an ILD MDT and 55 (53%) in local radiology meetings. For SBx outcome see Table. Prior diagnosis was uncertain in 28% of ILD MDT cases and 27% of local radiology meeting cases, whereas SBx confirmed the suspected diagnosis in 22% of ILD MDT cases but only 9% of radiology meeting cases. Conclusion Overall, there appears to be increase in the ILD cases referred for SBx. Despite the small proportion of cases discussed at the ILD MDT prior to SBx, there appears to be a trend in the reduction of UIP/NSIP and significant increase in HSP, RBILD and DIP cases. Histological diagnosis remains important in ILD, and the use of other techniques with lower complication rates (e.g. transbronchial cryobiopsy) needs to be established. Abstract P164 Table 1 Diagnosis Percentage of cases 2001–2008 (n = 210) Percentage of cases 2014–2016 (n = 104) P= Usual interstitial pneumonia (UIP) 37% 29% 0.17 Non-specific interstitial pneumonia (NSIP) 12% 7% 0.17 Organising pneumonia 10% 3% 0.025 Sarcoidosis 8% 10% 0.53 Smoking related (RB-ILD, DIP) 9% 23% 0.0014 Hypersensitivity pneumonitis 4% 12% 0.0072 Vasculitis/Connective tissue disease 2% 1% >0.99 Other 18% 15% 0.43 Reference Raghu G, Mageto YN, Lockhart D, et al. The accuracy of the clinical diagnosis of new-onset idiopathic pulmonary fibrosis and other interstitial lung disease. A prospective study. Chest 1999;116:1168–1174.