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Atteintes pleurales non tuberculeuses versus atteintes pleurales tuberculeuses

Publication year: 2012
Source:Revue des Maladies Respiratoires, Volume 29, Issue 3

K. Horo, A. N’Gom, B. Ahui, C. Brou-Gode, J.-C. Anon, A. Diaw, P. Bemba, K. Foutoupouo, H. Djè Bi, P. Ouattara, B. Kouassi, N. Koffi, E. Aka-Danguy

Introduction Dans les pays d’endémicité tuberculeuse, le premier diagnostic différentiel d’une atteinte pleurale infectieuse à germes banales est la tuberculose pleurale. Objectif Le but de notre étude était de déterminer les différences entre l’atteinte pleurale à germes banals et l’atteinte pleurale tuberculeuse. Méthodologie Notre étude a été une analyse rétrospective et comparative entre les atteintes pleurales non tuberculeuses d’allure bactérienne (APNTB) et les atteintes pleurales tuberculeuses (APT). Résultats Au cours des APNTB, les signes évoluaient depuis 2,4±1,4 semaines versus 5,6±2,2 semaines au cours des APT (p =0,01). En analyse multivariée en cas d’APNTB, le début des signes était plus brutal (OR=3,8 [1,5 ; 9,9] ; p =0,01), l’asthénie était moins fréquente (OR=0,3 [0,1 ; 0,9] ; p =0,03), le liquide pleural était plus purulent à la macroscopie (OR=40,0 [15,0 ; 106,7] ; p <0,01). L’hyperleucocytose sanguine à polynucléaire neutrophile était plus fréquente en cas d’APNTB (OR=2,5 [1,2 ; 5,4] ; p =0,02). Le pneumothorax/hydropneumothorax était moins fréquent au cours des APNTB (OR=0,3 [0,1 ; 1,0] ; p =0,04). Conclusion Des différences cliniques et paracliniques entre les APT et les APNTB existent. Cependant, elles sont peu discriminantes. La recherche du bacille tuberculeux doit être systématique en attendant la mise en place des nouveaux tests diagnostiques de la tuberculose. Introduction In countries where tuberculosis is endemic, the main differential diagnosis for pleural infection by common bacteria is pleural tuberculosis. Objective The purpose of our study was to determine the differences between pleural infection by common bacteria and that caused by pleural tuberculosis. Methodology Our study was a retrospective analysis and compared the characteristics of confirmed pleural infection by common bacteria (PIB) and that due to pleural tuberculosis (PT). Results For the PIB, the signs evolved for 2.4±1.4 weeks versus 5.6±2.2 weeks for the PT (P =0.01). In multivariate analysis, for PIB the onset of symptoms was more abrupt (OR=3.8 [1.5; 9.9]; P =0.01), asthenia was less frequent (OR=0.3 [0.1; 0.9]; P =0.03), pleural liquid was more purulent (OR=40.0 [15.0; 106.7]; P <0.01). The blood neutrophil count was more frequently raised in cases of PIB (OR=2.5 [1.2; 5.4]; P =0.02). Pneumothorax/hydropneumothorax was less frequent in PIB (OR=0.3 [0.1; 1.0]; P =0.04). Conclusion Clinical differences exist between pleural effusions caused by tuberculosis (TB) and those due to other bacterial infections. However, they are not sufficiently sensitive and therefore the search for the tuberculous bacillus must be systematic while waiting for implementation of new diagnostic tests for the organism.




Out-of-pocket medication costs and use of medications and health care services among children with asthma.

Out-of-pocket medication costs and use of medications and health care services among children with asthma.

JAMA. 2012 Mar 28;307(12):1284-91

Authors: Karaca-Mandic P, Jena AB, Joyce GF, Goldman DP

Abstract
CONTEXT: Health plans have implemented policies to restrain prescription medication spending by shifting costs toward patients. It is unknown how these policies have affected children with chronic illness.
OBJECTIVE: To analyze the association of medication cost sharing with medication and hospital services utilization among children with asthma, the most prevalent chronic disease of childhood.
DESIGN, SETTING, AND PATIENTS: Retrospective study of insurance claims for 8834 US children with asthma who initiated asthma control therapy between 1997 and 2007. Using variation in out-of-pocket costs for a fixed "basket" of asthma medications across 37 employers, we estimated multivariate models of asthma medication use, asthma-related hospitalization, and emergency department (ED) visits with respect to out-of-pocket costs and child and family characteristics.
MAIN OUTCOME MEASURES: Asthma medication use, asthma-related hospitalizations, and ED visits during 1-year follow-up.
RESULTS: The mean annual out-of-pocket asthma medication cost was $154 (95% CI, $152-$156) among children aged 5 to 18 years and $151 (95% CI, $148-$153) among those younger than 5 years. Among 5913 children aged 5 to 18 years, filled asthma prescriptions covered a mean of 40.9% of days (95% CI, 40.2%-41.5%). During 1-year follow-up, 121 children (2.1%) had an asthma-related hospitalization and 220 (3.7%) had an ED visit. Among 2921 children younger than 5 years, mean medication use was 46.2% of days (95% CI, 45.2%-47.1%); 136 children (4.7%) had an asthma-related hospitalization and 231 (7.9%) had an ED visit. An increase in out-of-pocket medication costs from the 25th to the 75th percentile was associated with a reduction in adjusted medication use among children aged 5 to 18 years (41.7% [95% CI, 40.7%-42.7%] vs 40.3% [95% CI, 39.4%-41.3%] of days; P = .02) but no change among younger children. Adjusted rates of asthma-related hospitalization were higher for children aged 5 to 18 years in the top quartile of out-of-pocket costs (2.4 [95% CI, 1.9-2.8] hospitalizations per 100 children vs 1.7 [95% CI, 1.3-2.1] per 100 in bottom quartile; P = .004) but not for younger children. Annual adjusted rates of ED use did not vary across out-of-pocket quartiles for either age group.
CONCLUSION: Greater cost sharing for asthma medications was associated with a slight reduction in medication use and higher rates of asthma hospitalization among children aged 5 years or older.

PMID: 22453569 [PubMed - indexed for MEDLINE]

Endemic mycoses: Overlooked causes of community acquired pneumonia

Publication year: 2012
Source:Respiratory Medicine, Volume 106, Issue 6

Chadi A. Hage, Kenneth S. Knox, Lawrence J. Wheat

The endemic mycoses are important but often overlooked causes for community acquired pneumonia. Delays in recognition, diagnosis and proper treatment often lead to disastrous outcomes. This topic is not usually discussed in reviews and guidelines addressing the subject of community acquired pneumonia. In this review we discuss the three major endemic mycoses in North America that present as community acquired pneumonias; Coccidioidomycosis, Histoplasmosis and Blastomycosis. We discuss their epidemiology, clinical presentations, methods of diagnosis and current treatment strategies.




Influence of inspiration level on bronchial lumen measurements with computed tomography

Publication year: 2012
Source:Respiratory Medicine, Volume 106, Issue 5

M. Els Bakker, Jan Stolk, Johan H.C. Reiber, Berend C. Stoel

Background Bronchial dimensions measured in CT images generally do not take inspiration level into consideration. However, some studies showed that the bronchial membrane is distensible with airway inflation. Therefore, re-examination of the elasticity of bronchi is needed. Purpose To assess the influence of respiration on bronchial lumen area (defined as distensibility) in different segmental bronchi and to explore the correlations between distensibility and both lung function and emphysema severity. Material and methods In 44 subjects with COPD related to alpha-1-antitrypsin deficiency (AATD), bronchial lumen area was measured in CT images, acquired at different inspiration levels. Measurements were done at matched locations in one apical and two basal segmental airways (RB1, RB10 and LB10). Airway distensibility was calculated as lumen area difference divided by lung volume difference. Results Bronchial lumen area in the lower lobes (RB10 and LB10) correlated positively with FEV1%predicted (p =0.027 for RB10; and p =0.037 for LB10, respectively). Lumen area is influenced by respiration (p =0.006, p =0.045, and, p =0.005 for RB1, RB10 and LB10, respectively). Airway distensibility was different between upper and lower bronchi (p <0.001), but it was not correlated with lung function. Conclusion Lumen area of third generation bronchi is dependent on inspiration level and this distensibility is different between bronchi in the upper and lower lobes. Therefore, changes in lumen area over time should be studied whilst accounting for the lung volume changes, in order to estimate the progression of bronchial disease while excluding the effects of hyperinflation.




Les abcès et nécroses pulmonaires à germes banals : drainage ou chirurgie ?

Publication year: 2012
Source:Revue de Pneumologie Clinique, Volume 68, Issue 2

P.-B. Pagès, A. Bernard

Les abcès pulmonaires et les nécroses pulmonaires sont des complications peu fréquentes des pneumopathies aiguës à germes communautaires depuis l’avènement des antibiotiques. Leurs prises en charge s’appuient en premier lieu sur le traitement antibiotique adapté aux germes documentés. Cependant dans 11 à 20 % des cas d’abcès pulmonaires, ce traitement est insuffisant, et un drainage soit endoscopique, soit percutané doit être envisagé. En première intention, on se dirigera vers une technique peu invasive : endoscopique ou percutanée radioguidée. En cas d’échec de ces deux techniques, le drainage chirurgical percutané par minithoracotomie sera réalisé. Dans les nécroses pulmonaires, du fait de l’obstruction conjointe de la bronche et des vaisseaux sanguins correspondant à un segment pulmonaire, le traitement antibiotique systémique sera peu efficace. On proposera donc en cas d’échec de celui-ci, un drainage chirurgical percutané, surtout si la nécrose se limite à un seul lobe. Le traitement chirurgical sera quant à lui réservé : aux échecs de la stratégie de drainage chirurgical, aux nécroses s’étendant à plusieurs lobes. Lung abscesses and necrotizing pneumonia are rare complications of community-acquired pneumonia since the advent of antibiotics. Their management leans first of all on the antibiotic treatment adapted on the informed germs. However, in 11 to 20% of the cases of lung abscesses, this treatment is insufficient, and drainage, either endoscopic or percutaneous, must be envisaged. In first intention, we shall go to less invasive techniques: endoscopic or percutaneous radio-controlled. In case of failure of these techniques, a percutaneous surgical drainage by minithoracotomy will be performed. In the necrotizing pneumonia, because of the joint obstruction of the bronchus and blood vessels corresponding to a lung segment, the systemic antibiotic treatment will be poor effective. In case of failure of this one we shall propose, a percutaneous surgical drainage, especially if the necrosis limits itself to a single lobe. The surgical treatment will be reserved: in the failures of the strategy of surgical drainage, in the necroses extending in several lobes.




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