African Journal of Thoracic and Critical Care Medicine最新文献

Background: Bronchiectasis (BE) in children living with HIV (CLWH) remains a significant cause of morbidity and mortality, especially in tuberculosis (TB)-endemic low- and middle-income countries. Treatment modalities for BE in CLWH currently focus mainly on prevention of infections and management of symptoms, while surgical management is indicated for a select group. In contrast, surgical management in non-cystic fibrosis BE is well established.

Objectives: To describe the indications for and complications of surgical resection for BE in CLWH, and to identify variables influencing outcome.

Methods: A retrospective medical records review was conducted of all CLWH aged ≤14 years who underwent surgical resection for BE at Tygerberg Hospital, Cape Town, South Africa, between 1 January 2007 and 30 September 2014. The variables collected included immune status, antiretroviral treatment (ART), previous treatment for TB, operative and postoperative complications, and postoperative symptom relief.

Results: Twelve CLWH on ART with symptomatic BE underwent surgical resection. The mean age was 7 years and the mean CD4 count 970 cells/µL. Indications for surgery included recurrent infections, chronic cough and persistent lobar collapse. The most common procedures were left lower lobe lobectomy (42%), left pneumonectomy (17%) and right bilobectomy (17%). Complications were limited to persistent pneumothorax after surgery in one child. There were no deaths. Ten children (83%) showed significant improvement of symptoms at follow-up.

Conclusion: Surgical resection for BE in CLWH can be performed safely with a low complication rate, resulting in significant improvement of symptoms postoperatively.

Study synopsis: What the study adds. Bronchiectasis (BE) in children living with HIV (CLWH) is a significant cause of morbidity and mortality. Current treatment focuses on preventing infections and managing symptoms, while surgical management is rarely considered. A retrospective medical records review of 12 children aged ≤14 years in South Africa found that surgical resection for BE can be performed with a low complication rate, resulting in significant improvement of symptoms postoperatively. Variables influencing outcome include immune status, antiretroviral treatment and previous treatment for tuberculosis.Implications of the findings. This study demonstrates that surgery for BE can be performed safely in CLWH, with significant improvement of respiratory symptoms postoperatively.

Background: There has been a growing interest in nutritional/lifestyle factors, including vitamin D, that may affect chronic obstructive pulmonary disease (COPD). Most data are from Caucasian populations and temperate climates, with minimal African data.

Objectives: The primary objective was to determine the prevalence of vitamin D deficiency (25-hydroxyvitamin D (25(OH)D) ≤20 ng/mL) and insufficiency (25(OH)D 21 - 29 ng/mL) among patients with COPD. Secondary objectives were to investigate the association between vitamin D and demographic/lifestyle factors, lung function parameters, markers of COPD severity and corticosteroid use.

Methods: A prospective, cross-sectional study of 76 patients with COPD was conducted at a tertiary hospital in Johannesburg, South Africa. Patients were interviewed regarding demographic/lifestyle factors, COPD severity markers and corticosteroid therapy. The most recent spirometry result was recorded. Blood samples were taken for measurement of calcium, alkaline phosphatase and vitamin D levels. Patients were stratified according to vitamin D status (deficiency and non-deficiency (25(OH)D >20 ng/mL, i.e. combined insufficiency and adequate levels)), and statistical analysis was performed to assess for associations.

Results: The sample included 72% males and 63% black African patients. The prevalences of vitamin D deficiency and insufficiency were 48% (95% confidence interval (CI) 42 - 54) and 35% (95% CI 30 - 41), respectively. A Modified Medical Research Council (mMRC) dyspnoea score ≥2 was associated with a relative risk of 1.34 (95% CI 1.05 - 1.7) for vitamin D deficiency in univariate analysis. In multivariate regression analysis, only sunlight exposure (<1 hour/day) was an independent predictor of vitamin D deficiency (odds ratio 2.4; 95% CI 1.3 - 4.5).

Conclusion: There was a high prevalence of suboptimal vitamin D levels in this COPD sample population. A higher mMRC score was associated with an increased risk of vitamin D deficiency, while low sunlight exposure was the only independent predictor of vitamin D deficiency.

Study synopsis: What the study adds. This is the first study to provide prevalence data regarding vitamin D status in COPD patients in sub-Saharan Africa. The study highlights a relationship between vitamin D status and both symptom severity and sunlight exposure.Implications of the findings. Owing to the high prevalence of suboptimal vitamin D status among COPD patients, it may be useful to screen patients for vitamin D deficiency, especially those with a more severe phenotype. There may be scope for further studies to evaluate whether vitamin D supplementation corrects the deficiency and provides any clinical outcome benefit.

Background: Pulmonary complications cause significant morbidity and mortality in patients with idiopathic inflammatory myopathies (IIMs).

Objectives: To describe the frequency and spectrum of pulmonary complications in patients with IIMs in South Africa (SA).

Methods: A retrospective records review of adult patients with IIMs or clinically amyopathic dermatomyositis (CADM) presenting with respiratory complaints at a tertiary care facility in SA was performed. Clinical features, results of laboratory and pulmonary function tests (PFTs), radiological findings and treatment were recorded.

Results: Pulmonary complications were documented in 66 patients. Most patients (n=41; 62.1%) had dermatomyositis, 14 (21.2%) had polymyositis, and 3 (4.5%) had CADM. There were 8 patients with overlap syndromes. Dyspnoea and a dry cough were the most common presenting symptoms, in 52 (78.8%) and 36 (54.5%) patients, respectively. Bibasal crackles were noted in 38 patients (57.6%). Interstitial lung disease (ILD), followed by infection and pulmonary hypertension (PH), were documented in 46 (69.7%), 16 (24.2%) and 9 (13.6%) patients, respectively. Nine patients had microbiologically confirmed pulmonary tuberculosis. Patients who were anti-Jo1 antibody positive (n=16) had higher levels of acute inflammatory markers and muscle enzymes compared with the rest of the patients (p<0.0001). Dyspnoea and bibasal crackles were associated with significantly lower baseline and 12-month lung function parameters. Nonspecific interstitial pneumonia was the most common radiological pattern of ILD, present in 25 (62.5%) of the patients with ILD.

Conclusion: ILD was the most prevalent complication in this study of SA patients with IIMs. Pulmonary infections and PH were also significant contributors to morbidity. The presence of dyspnoea and crackles was predictive of lower baseline PFTs in this population.

Study synopsis: What the study adds. Pulmonary complications, including interstitial lung disease (ILD) and infections, are significant contributors to morbidity and mortality in patients with idiopathic inflammatory myopathies (IIMs). There is very little research currently available to describe the spectrum of pulmonary manifestations in these patients in an African setting, a lack that this study aimed to address.Implications of the findings. ILD was the most common pulmonary complication in patients with IIMs in this cohort. Signs and symptoms of ILD may be present before symptoms of myositis, and dyspnoea and a dry cough were shown to be predictive of reduced lung volumes. Patients with IIMs on immunosuppressive therapy in our setting are at high risk of infection, particularly tuberculosis.

Background: There is a paucity of evidence on the impact of mild COVID-19 on the respiratory system, particularly in non-healthcare seeking individuals.

Objectives: To investigate the effects of mild COVID-19 on respiratory function and to identify indicators of decreased lung function.

Methods: We conducted a cross-sectional study in 175 non-healthcare-seeking individuals with confirmed acute SARS-CoV-2 infection who did not require hospitalisation. Participants were divided into three groups: those who had pulmonary function tests (PFTs) within 6 months, between 6 and 12 months, and between 12 and 24 months after infection. Each participant underwent spirometry, measurement of the diffusing capacity of the lungs for carbon monoxide (DL_CO ), a 6-minute walking distance test (6MWD) and plethysmography.

Results: The mean age of the participants was 44.3 years, and the mean body mass index (BMI) 32.7 kg/m². Forty-six participants had PFTs within 6 months, 64 between 6 and 12 months, and 65 between 12 and 24 months. Lower than expected DL_CO was the most commonly detected abnormality (57%). Spirometry anomalies were noted in 23%, 10% showing an obstructive impairment and 13% a restrictive impairment, confirmed by a total lung capacity <80%. An increased BMI was the only variable that was significantly and independently linearly associated with lower than predicted (<80%) forced vital capacity, forced expiratory volume in the 1st second, DL_CO and 6MWD.

Conclusion: DL_CO was low in a considerable proportion of non-healthcare-seeking individuals 2 years after mild COVID-19. A high BMI was found to be significantly and independently associated with lower than predicted PFT results and 6MWD.

Study synopsis: What the study adds. We found that pulmonary function, particularly diffusing capacity, was lower than predicted in a significant proportion of non-healthcare-seeking individuals up to 2 years after mild COVID-19. A high body mass index (BMI) was found to be significantly and independently associated with decreased lung function.Implications of the findings. There is a paucity of evidence on the medium-term effects of mild COVID-19 on the respiratory system in non-healthcare-seeking individuals. We investigated the medium-term effects of mild COVID-19 on the respiratory system, showed lower than predicted lung function, and identified one independent predictor, BMI. Even individuals classified as having 'mild' COVID-19 could have medium-term respiratory sequelae.

Background: Connective tissue disease-associated interstitial lung disease (CTD-ILD) that progresses despite first-line immunosuppressive therapy is a clinical challenge. Rituximab (RTX) is a chimeric monoclonal antibody targeted to CD20+ B cells, resulting in B-cell depletion, and has been used as a salvage therapeutic modality in severe disease.

Objectives: To investigate the therapeutic effects and safety of RTX in patients with severe CTD-ILD.

Methods: A retrospective observational analysis of patients with severe CTD-ILD treated with salvage RTX therapy and various combinations of immunomodulatory therapy at Wits Donald Gordon Medical Centre, Johannesburg, South Africa, between January 2010 and December 2020 was performed. A total of 19 patients with progressive CTD-ILD, sufficient data, and 24-month follow-up were analysed. The effects of adding salvage RTX to standard drug therapy were investigated with serial pulmonary function testing, high-resolution computed tomography (HRCT) of the chest, and World Health Organization functional class (FC) assessment.

Results: At 24-month follow-up from baseline, there was no significant deterioration in forced vital capacity (0.01 L; 95% CI -0.13 - 0.14) (p=0.91) after commencing RTX salvage therapy. Serial HRCT of the chest showed radiological disease stability or improvement in 13 of the 19 patients (68%). FC assessment showed no significant deterioration compared with baseline (p=0.083). No serious adverse drug reactions or deaths were recorded.

Conclusion: Salvage RTX therapy, in combination with various immunomodulatory treatments, resulted in disease stability in the majority of patients with severe CTD-ILD over a 24-month period.

Study synopsis: What the study adds. Connective tissue disease-associated interstitial lung disease (CTD-ILD) is a challenging clinical entity. Rituximab (RTX), a chimeric monoclonal antibody targeted to CD20+ B cells, resulting in B-cell depletion, has been suggested as a potential therapeutic modality in refractory or severe disease. A single-centre experience of RTX salvage therapy in progressive CTD-ILD is presented.Implications of the findings. This small study suggests a possible role for RTX therapy in severe or refractory CTD-ILD.