SAN FRANCISCO--Evaluation and treatment at an asthma center improves care and reduces costs among patients with difficult-to-control asthma, suggest new data presented at CHEST 2000. Other highlights of the meeting included a study showing a 70% survival rate five years after lung volume reduction surgery (LVRS) and evidence that coronary artery bypass grafting (CABG) produces acceptable outcomes in patients with severely impaired left ventricular ejection fractions (LVEFs) and noncardiac comorbid conditions.

More than two thirds of patients who undergo LVRS are still alive five years postoperatively and have experienced significant clinical improvement. "Lung volume reduction surgery should be accepted as a therapeutic option for select patients with severe emphysema who are markedly symptomatic despite optimized medical therapy," said lead investigator Roger D. Yusen, MD, of Barnes-Jewish Hospital in St. Louis.

Dr. Yusen and colleagues prospectively followed the first 200 patients undergoing LVRS at their institution. The annual survival rates among these patients during the first five years after the operation were 93%, 87%, 82%, 74%, and 71%.

By about six months after surgery, lung function in survivors had improved by a mean of 50% from baseline, and the distance these patients could walk in six minutes had increased by a mean of 53 m.

In addition, one third of the patients who had needed supplemental oxygen before surgery were able to discontinue this treatment postoperatively. Furthermore, dyspnea was alleviated in 82% of the patients; in only 4% did the severity of dyspnea worsen.

Patient satisfaction with the surgical outcome was high: 84% reported good to excellent satisfaction with the results, and this level of patient satisfaction persisted through the five years of follow-up.

Mandatory asthma screening among schoolchildren may be warranted--new data show that a large percentage of children with asthma are not aware of their condition. The data also reveal that children who are frequently absent from school have significantly higher rates of asthma than do other children.

Uzma A. Rana, MPH, of MCP Hahnemann University, in Philadelphia, and colleagues screened 176 children with high rates of absenteeism and 404 children with low absenteeism rates. Asthma diagnosis was defined as a self-report of asthma or the report of at least one of the following three asthma symptoms: wheezing on exertion, wheezing at night, and wheezing at rest.

A self-reported diagnosis of asthma was found more frequently in the high-absentee group than in the low-absentee group (34.9% vs 25.2%). Wheezing was also more common in the high-absentee group (48.3% vs 36.7%). Both of these differences were statistically significant. Of asthmatic children with high absenteeism rates, 43% did not know they had the disease. A slightly higher percentage (52%) of the asthmatic children with low absenteeism rates were unaware that they had asthma.

Revascularization options for patients with severely impaired LVEFs and noncardiac comorbidities need not be limited to catheter-based techniques, results of a recent trial suggest. Researchers found favorable operative outcomes following bypass grafting in these high-risk patients.

The study involved 95 consecutive high-risk patients with a global LVEF of 25% or less who underwent CABG at the West Roxbury VA Medical Center, in Massachusetts. All of the patients had one of the following comorbidities: diabetes (33%), chronic obstructive pulmonary disease (31%), peripheral vascular disease (36%), or cerebrovascular disease (21%).

Only five patients died following the surgery, and only two experienced perioperative myocardial infarction, reported Vladimir Birjiniuk, MD, and colleagues. None of the patients developed perioperative renal failure or stroke. Six patients required ventilatory support for more than 48 hours.

For patients with difficult-to-control asthma, evaluation and treatment in an asthma center can reduce costs and improve care, according to data presented by Andrew G. Villanueva, MD, and colleagues.

The researchers examined data from 125 patients referred to the asthma clinic at the Lahey Clinic Medical Center in Burlington, Massachusetts, from October 1996 to April 2000. These patients were chosen because each had been treated in the emergency department at least two times within six months or had been hospitalized for asthma. Patients with chronic obstructive pulmonary disease were not included in the analysis.

Initial evaluation in the asthma clinic consisted of spirometry and allergy skin testing. Treatment and follow-up plans were devised, and the patients were given extensive education about their condition.

Patient satisfaction with the center was high; 90% of the subjects rated their visit as "very good" to "excellent." The number of emergency department visits fell from 74 before enrollment in the asthma clinic to 17 after treatment at the clinic. Similarly, the number of hospitalizations decreased from 38 to four. Among patients for whom pharmacy data were available, the ratio of inhaled ß-agonist prescriptions filled to the number of inhaled corticosteroid prescriptions filled decreased from 1.65 to 1.05.

The mean cost of the initial asthma clinic visit was $770. After enrollment in the clinic, the cost of emergency department and inpatient care fell by $26,733 and $172,618, respectively.

Although photodynamic therapy is approved for the treatment of microinvasive non-small-cell lung cancer (NSCLC), few prospective data exist on the efficacy of this treatment. New findings suggest that photodynamic therapy is "an effective, durable treatment for microinvasive NSCLC in high-risk patients who are not candidates for surgery or radiotherapy," reported Tracey L. Weigel, MD, of Memorial Sloan-Kettering Cancer Center in New York, and colleagues.

The study involved seven patients who were considered poor candidates for surgery because of poor pulmonary function, tumor location, and/or medical comorbidities. A total of 10 microinvasive lesions were treated. A cylindrical diffusing fiber and a 630-nm laser were used to deliver a mean of 403 J per lesion over two days. Nine of the lesions were stage I; the other lesion was stage IIB.

No complications were reported. Seven of the 10 lesions showed a durable complete response after a mean follow-up of 31 months. In one patient, lobectomy was performed because disease persisted after two courses of photodynamic therapy. Another patient has been treated with additional photodynamic therapy and brachytherapy for local recurrence. A patient who had a contralateral stage IIIA NSCLC died of metastatic disease 16 months after the photodynamic treatment.

--Kristin Della Volpe

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