Persistent Sputum Production Research Articles

Association between Vitamin D Deficiency and Disease Severity in Bronchiectasis

Abstract Background: Bronchiectasis is a chronic respiratory condition characterized by irreversible bronchial dilation, leading to persistent cough, sputum production, and recurrent infections. Despite advancements in management, the severity and progression of the disease remain poorly understood. Objectives: This study investigates the association between Vitamin D deficiency and bronchiectasis severity, focusing on its impact on lung function, exacerbation rates, and radiological findings. Materials and Methods: This retrospective study reviewed medical records of adults (20–85 years) with confirmed bronchiectasis diagnosed via high-resolution computed tomography. Exclusions were patients with cystic fibrosis, traction bronchiectasis, autoimmune disorders, or those on vitamin D supplements. Serum vitamin D levels were measured, with levels <20 ng/mL indicating deficiency. Disease severity was assessed using the bronchiectasis severity index (BSI) and the Bhalla score. Lung function was evaluated through forced expiratory volume in 1 s (FEV1) and forced vital capacity. Results: The study included 50 patients (15 males and 35 females; median age = 55 years). The mean BSI was 7.0, the average Bhalla score was 17, and patients reported an average of three exacerbations per year. The median serum vitamin D level was 14.7 ng/mL, with 66% classified as deficient. A significant negative correlation between vitamin D levels and both the BSI (r = −0.56, P = 0.024 and the Bhalla score (r = −0.70, P = 0.040) was found. Conclusion: Vitamin D deficiency is significantly associated with increased severity of bronchiectasis. These findings suggest the need for further research into therapeutic interventions targeting vitamin D levels to improve patient outcomes.

Streptococcus salivarius pneumonia-associated pneumomediastinum: a case report and literature review

BackgroundStreptococcus salivarius is an opportunistic pathogen, and there have been no reported cases of Streptococcus salivarius pneumonia to date. Pneumomediastinum is usually secondary to tracheal or esophageal injury and is very rare as a complication of pneumonia. We report a case of Streptococcus salivarius pneumonia complicated by pneumomediastinum, aiming to enhance clinicians’ awareness of rare pathogens and uncommon complications in pneumonia.Case presentationThe patient, a 36-year-old male, presented with a persistent cough and sputum production for one week, accompanied by a sore throat that had developed just one day prior. Chest computed tomography (CT) disclosed pneumomediastinum alongside obstructive atelectasis in the left lower lobe. Streptococcus salivarius infection was conclusively identified through bronchoalveolar lavage metagenomic next-generation sequencing (mNGS), as well as smear and culture analyses. The patient was administered intravenous amoxicillin-clavulanate potassium for a duration of seven days as part of the anti-infection regimen. Given the stability of the patient’s respiratory and circulatory systems, a tube drainage procedure was deemed unnecessary. Post-treatment, the patient’s clinical symptoms notably improved. A subsequent chest CT scan revealed the re-expansion of the left lower lung and near-complete resolution of pneumomediastinum.ConclusionThere are numerous pathogens that can cause pneumonia. While focusing on common pathogens, it is important not to overlook rare ones. When considering infections from rare pathogens, it is recommended to promptly perform a bronchoscopy and submit bronchoalveolar lavage fluid for mNGS to improve pathogen detection rates. During the diagnosis and treatment of pneumonia, it is crucial to be vigilant for rare complications. When a patient presents with symptoms such as dyspnea or subcutaneous emphysema, it is advisable to immediately perform a chest CT scan to rule out pneumomediastinum.

Medical management of post-sublobar resection pulmonary granulomatous lesion: a report of two cases

BackgroundAutomatic stapling devices are commonly utilized in pulmonary resections, including sublobar segmentectomy. Large tumors can develop around the staple line, posing challenges in distinguishing them from cancer recurrence or inflammatory changes. In this report, we present two cases of symptomatic staple granulomatous lesion effectively managed with medications.Case presentationA 74-year-old man presented with a persistent cough and sputum production six years post-segmentectomy for a hamartoma in the left upper lobe. Chest computed tomography (CT) revealed a large tumor around the staple line. Laboratory investigations and bronchoscopic examination revealed no malignancy. The patient received corticosteroids and a cyclooxygenase-2 inhibitor; despite experiencing adverse reactions to steroids, both tumor size and respiratory symptoms were significantly reduced. The second case involved a 78-year-old woman who underwent pulmonary resection for suspected lung cancer. Despite a non-malignant tumor diagnosis, she reported a cough six months post-surgery. Chest CT revealed extensive shadow around the surgical staple, which was diagnosed as mycobacterium granuloma. Low-dose erythromycin induced inflammatory changes but effectively reduced the lesion.ConclusionsGranulomatous lesions around the staple can be effectively managed with medication, and monitoring the treatment response proves valuable in distinguishing them from tumor recurrence post-pulmonary resection.

Patients at risk of nontuberculous mycobacterial pulmonary disease who need testing evaluated using a modified Delphi process by European experts.

Identifying patients at risk of nontuberculous mycobacterial pulmonary disease (NTM-PD) is challenging. Delays in NTM-PD identification and management are associated with declining lung function and increased morbidity and mortality. European NTM-PD experts (n=12) participated in a three-round modified Delphi process to score symptoms and comorbidities potentially associated with NTM-PD as reasons to test for nontuberculous mycobacteria. Experts reached a consensus on the symptoms and comorbidities that should and should not prompt testing for nontuberculous mycobacteria. Requirements for testing were scored as high (mean ≥7), medium (mean ≥4-<7) or low (mean <4). Nontuberculous mycobacteria testing should be undertaken when multiple suggestive symptoms are present simultaneously in all patients except those with cancer (7.3-8.8), or when radiology is indicative of NTM-PD (≥8.9). Symptoms of persistent sputum production, recurrent respiratory infection and haemoptysis should prompt testing for nontuberculous mycobacteria, particularly in those with underlying respiratory diseases. Symptomatic patients with bronchiectasis or previous tuberculosis/NTM-PD or those being prescribed or undergoing long-term macrolide therapy for a respiratory condition should also be tested. Testing is not warranted in patients without an underlying respiratory disorder or in those without a history of respiratory disorders unless presenting with multiple symptoms. Assessing patients' risk of NTM-PD is challenging. This Delphi consensus process provides insight into symptoms and clinical characteristics that should prompt NTM-PD assessment. Timely testing and diagnosis would enable initiation of appropriate management.

Evaluation of an implementation package to deliver the COPD CARE service

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide and is estimated to be the leading cause of death in the next 15 years. Patients with...

Multimodal Approach to Acquired Bronchobiliary Fistula Secondary to Hepaticojejunostomy Stricture Following Yttruim-90 Therapy

Introduction: Bronchobiliary fistula (BBF) is an abnormal connection between the bronchial system and biliary tree. Bilioptysis (bilious-tinged sputum) is pathognomic of BBF. Mortality rate of BBF is as high as 12.7%. Method: A 56-year-old male who presented with stage IV pancreatic neuroendocrine tumor, underwent pancreaticoduodenectomy with partial hepatectomy, followed by Yttrium-90, and microwave ablation. Surveillance imaging, 2.5 years later, noted increase in hepatic lesions. Additional Yttrium-90 was poorly tolerated and patient was referred for peptide receptor radionuclide therapy. Ten months later patient presented with abdominal pain, cough with yellow-tinged sputum and history of recurrent pneumonia. Imaging demonstrated intrahepatic biliary dilation, peri-hepatic abscess and right-sided pleural effusion. Results: Patient underwent percutaneous drainage of abscess and chest tube placement. Persistent cough and sputum production prompted evaluation with HIDA (hepatobiliary iminodiacetic acid) and bronchoscopy, confirming BBF. Cholescintigraphy with single-photon emission computed tomography (NM-SPECT) localized the fistula tract to the right upper lobe of liver (Figure-1). Initially attempted biliary decompression with percutaneous transhepatic cholangiogram was unsuccessful due to failed cannulation of the hepaticojejunostomy, indicating complete stenosis at the anastomosis. Finally, the patient underwent resection of the hepaticojejunostomy with mobilization of the pancreaticobiliary limb and Kasai-type porto-enteric anastomosis between the pancreaticobiliary limb and hepatic duct. Complete resolution of symptoms and the bronchopulmonary fistula on follow up imaging, was noted. Conclusion: BBFs are rare, misdiagnosed, and difficult to treat. Although treatment with minimally invasive approach has favorable results, history of previous biliary reconstruction, may warrant multimodal treatments including percutaneous and complex surgical intervention.

Living with bronchiectasis during the COVID-19 pandemic

Living with bronchiectasis during the COVID-19 pandemic

Gastroesophageal reflux disease is a risk factor for sputum production in the general population: the Nagahama study

BackgroundChronic sputum production in the general population is historically associated with clinical indices including male sex and smoking history. However, its relationship with gastroesophageal reflux disease (GERD), which may prove an underlying factor in sputum production, is unclear. We aimed to clarify factors associated with sputum production in the general population in cross-sectional and longitudinal manners.MethodsIn the Nagahama study, a community-based cohort study, 9804 subjects were recruited between 2008 and 2010 (baseline assessment), 8293 of whom were followed from 2013 to 2015 (follow-up assessment). This study contained a self-completed questionnaire which included medical history, assessment of sputum production, and a frequency scale for symptoms of GERD. A Frequency Scale for Symptoms of Gastroesophageal Reflux Disease score of ≥ 8 was defined as GERD. In addition to the frequency of sputum production at each assessment, frequency of persistent sputum production defined as sputum production at both assessments was examined.ResultsFrequency of sputum production was 32.0% at baseline and 34.5% at follow-up. Multivariable analysis demonstrated that sputum production at baseline was significantly associated with GERD [odds ratio (OR), 1.92; 95% confidence interval (CI) 1.73–2.13] and post-nasal drip (PND) (OR, 2.40; 95% CI 2.15–2.68), independent of other known factors such as older age, male sex and smoking history. These associations between sputum production and GERD or PND were also observed at follow-up. In longitudinal analysis, 19.4% had persistent sputum production and 12.3% had transient sputum production, i.e., at baseline only. Multivariable analysis for risk of persistence of sputum production revealed that persistent sputum production was associated with GERD and PND, in addition to the known risk factors listed above. The proportion of subjects with GERD at both assessments was highest among subjects with persistent sputum production.ConclusionsCross-sectional and longitudinal analysis demonstrated an association in the general population between sputum production and GERD, as well as PND, independent of known risk factors. The presence of GERD should be assessed in patients complaining of sputum production.

Short review on the diagnosis and treatment of bronchiectasis.

Bronchiectasis refers to the permanent dilation of the bronchi. It is often a sequel of insufficiently treated lung disease that develops into a pathological pattern of dilated bronchi, which heightens susceptibility to further lung infections. Modernization of diagnostic procedures (computed tomography scan) and definition of a clinical picture (repeated lung infections with a chronic cough and persistent sputum production) have raised international awareness of the prevalence of the disease, leading to increasing interest in reviewing and renewing the treatment guidelines.We selectively conducted a research on PubMed using the following keywords: “bronchiectasis”, “diagnosis”, “treatment”, “management”, “antibiotics”. This review focuses solely on bronchiectasis not due to cystic fibrosis. All relevant articles published after the year of 2000 were included.The aim of this review is to provide an analytical update on the management of bronchiectasis, focusing on etiological factors as well as existing and developing treatment options for the disease.

Practical considerations when prescribing a long-acting muscarinic antagonist for patients with COPD.

COPD is characterized by persistent airflow limitation, progressive breathlessness, cough, and sputum production. Long-acting muscarinic antagonists (LAMAs) are one of the recommended first-choice therapeutic options for patients with COPD, and several new agents have been developed in recent years. A literature search identified 14 published randomized, placebo-controlled studies of the efficacy and safety of LAMAs in patients with COPD, with improvements seen in lung function, exacerbations, breathlessness, and health status. A greater weight of evidence currently exists for glycopyrronium (GLY) and tiotropium than for umeclidinium and aclidinium, especially in terms of exacerbation reductions. To date, there have been few head-to-head clinical studies of the different LAMAs. Available data indicate that GLY and aclidinium have similar efficacy to tiotropium in terms of improving lung function, dyspnea, exacerbations, and health status. Overall, evidence demonstrates that currently available LAMAs provide effective and generally well-tolerated therapy for patients with COPD. Delivery devices for the different LAMAs vary, which may affect individual patient’s adherence to and preference for treatment. Subtle differences between individual therapeutic options may be important to individual patients and the final treatment choice should involve physician’s and patient’s experiences and preferences.

Physiologic Characterization of the Chronic Bronchitis Phenotype in GOLD Grade IB COPD

Smokers with persistent cough and sputum production (chronic bronchitis [CB]) represent a distinct clinical phenotype, consistently linked to negative clinical outcomes. However, the mechanistic link between physiologic impairment, dyspnea, and exercise intolerance in CB has not been studied, particularly in those with mild airway obstruction. We, therefore, compared physiologic abnormalities during rest and exercise in CB to those in patients without symptoms of mucus hypersecretion (non-CB) but with similar mild airway obstruction. Twenty patients with CB (≥ 3 months cough/sputum in 2 successive years), 20 patients without CB but with GOLD (Global Initiative for Chronic Obstructive Lung Disease) grade IB COPD, and 20 age- and sex-matched healthy control subjects underwent detailed physiologic testing, including tests of small airway function and a symptom-limited incremental cycle exercise test. Patients with CB (mean ± SD postbronchodilator FEV1, 93% ± 12% predicted) had greater chronic activity-related dyspnea, poorer health-related quality of life, and reduced habitual physical activity compared with patients without CB and control subjects (all P < .05). The degree of peripheral airway dysfunction and pulmonary gas trapping was comparable in both patient groups. Peak oxygen uptake was similarly reduced in patients with CB and those without compared with control subjects (% predicted ± SD, 70 ± 26, 71 ± 29 and 106 ± 43, respectively), but those with CB had higher exertional dyspnea ratings and greater respiratory mechanical constraints at a standardized work rate than patients without CB (P < .05). Patients with CB reported greater chronic dyspnea and activity restriction than patients without CB and with similar mild airway obstruction. The CB group had greater dynamic respiratory mechanical impairment and dyspnea during exercise than patients without CB, which may help explain some differences in important patient-centered outcomes between the groups.

The Relationship of Mucus Concentration (Hydration) to Mucus Osmotic Pressure and Transport in Chronic Bronchitis.

Chronic bronchitis (CB) is characterized by persistent cough and sputum production. Studies were performed to test whether mucus hyperconcentration and increased partial osmotic pressure, in part caused by abnormal purine nucleotide regulation of ion transport, contribute to the pathogenesis of CB. We tested the hypothesis that CB is characterized by mucus hyperconcentration, increased mucus partial osmotic pressures, and reduced mucus clearance. We measured in subjects with CB as compared with normal and asymptomatic smoking control subjects indices of mucus concentration (hydration; i.e., percentage solids) and sputum adenine nucleotide/nucleoside concentrations. In addition, sputum partial osmotic pressures and mucus transport rates were measured in subjects with CB. CB secretions were hyperconcentrated as indexed by an increase in percentage solids and total mucins, in part reflecting decreased extracellular nucleotide/nucleoside concentrations. CB mucus generated concentration-dependent increases in partial osmotic pressures into ranges predicted to reduce mucus transport. Mucociliary clearance (MCC) in subjects with CB was negatively correlated with mucus concentration (percentage solids). As a test of relationships between mucus concentration and disease, mucus concentrations and MCC were compared with FEV1, and both were significantly correlated. Abnormal regulation of airway surface hydration may slow MCC in CB and contribute to disease pathogenesis.

Clinical characteristics and airway inflammation profile of COPD persistent sputum producers

COPD patients with chronic bronchitis include a subgroup with persistent sputum production on most or every day. We hypothesized that COPD patients with persistent sputum production have a different profile of airway inflammation, and more severe clinical characteristics. To compare the airway inflammation profile and clinical characteristics of COPD persistent and non-persistent sputum producers. COPD persistent sputum producers (n = 26) and non-persistent sputum producers (n = 26) underwent sputum induction and pulmonary function tests. Exacerbation history was recorded; the St. George's Respiratory Questionnaire, Modified Medical Research Council Dyspnoea scale and COPD Assessment Tool were completed. 33 COPD patients provided sputum for bacteriology. Persistent sputum producers had lower post-bronchodilator FEV1% predicted (p = 0.01), diffusion capacity (p = 0.04), 6 min walk test distance (p = 0.05), and higher closing volume (p = 0.01), BODE index (p = 0.01), rate of bacterial colonization (p = 0.004) and exacerbations (p = 0.03) compared to non-persistent sputum producers. The mean SGRQ and CAT scores were higher in persistent sputum producers (p = 0.01 and 0.03 respectively). Sputum neutrophil and eosinophil total cell counts were higher in persistent sputum producers (p = 0.02 and 0.05 respectively). Sputum levels of eotaxin (p = 0.02), MCP-1 (p = 0.02), TNF-α (p = 0.03) and IL-6 (p = 0.05) were higher in persistent sputum producers. COPD persistent sputum producers have more severe clinical characteristics and increased concentrations of some inflammatory mediators in the airways.

Prolonged Mycoplasma pneumoniae infection in an elderly patient with community-acquired pneumonia

An 81-year-old woman with no underlying systemic illness was hospitalized with fever, muscle weakness, and sputum without cough for 2 days. Chest imaging showed consolidation in the left lower lobe. Real-time polymerase chain reaction (PCR) for six respiratory bacteria and 12 respiratory viruses performed on sputum obtained on admission showed Mycoplasma pneumoniae DNA, with no evidence of other pathogens. M. pneumoniae was confirmed to be the causative agent by serologic data. Variation of mycoplasma quantity in subsequent sputa was analyzed because of persistent sputum production despite treatment with minocycline. Mycoplasma DNA gradually decreased, becoming undetectable 1 week after the completion of 2 weeks of minocycline therapy. Two weeks after the completion of the minocycline therapy, mycoplasma DNA in sputum was strongly detectable again, and oral treatment with clarithromycin was initiated. No pathogen DNA was detected during 2 weeks of clarithromycin therapy or at 2 weeks after completion of this therapy. Although susceptibility tests on three isolates (on admission, 1 week after starting minocycline, and 2 weeks after minocycline cessation), showed no resistance to minocycline or clarithromycin, the infection was, nonetheless, prolonged. Some elderly subjects with mycoplasma pneumonia may show a longer course than that in young persons with pneumonia.

Coccidioidomycosis

Coccidioidomycosis is a common infectious disease in the southwestern United States. Although Coccidioides species are not endemic in other areas of the country, the rapid population growth in the southwestern United States in recent decades and the increase in tourism mean that many people travel to the Southwest and return home before developing the clinical syndrome of coccidioidomycosis. In this respect, coccidioidomycosis is a disease of national importance. It can occur in various manifestations: acute pneumonia, chronic progressive pneumonia, pulmonary nodules and cavities, extrapulmonary nonmeningeal disease, and meningitis. The diagnosis is often made on the basis of serologic findings. Treatment is usually with an azole or amphotericin B, depending on the clinical manifestations and the immune status of the host. We discuss the most common clinical manifestations, the best way to make the diagnosis, and the treatment of common infections.

Efficacy and safety of formoterol fumarate delivered by nebulization to COPD patients

Nebulized solutions of long-acting bronchodilators provide an alternative to DPI and MDI delivery, particularly for COPD patients unable to use hand-held devices easily or correctly. The long-acting beta2-agonist, formoterol fumarate, is differentiated by its onset of significant bronchodilation within 5 min of administration. In a randomized, double-blind, double-dummy trial, COPD subjects (n=351, mean forced expiratory volume FEV1=1.3 L, 44% predicted) received nebulized formoterol fumarate (Perforomist inhalation solution; FFIS 20 microg) or DPI (Foradil Aerolizer; FA 12 microg), or placebo twice daily for 12 weeks. Efficacy was assessed with 12-h pulmonary function tests, and quality of life was assessed before and after treatment with the St. George's Respiratory Questionnaire (SGRQ). At the 12-week endpoint, FFIS significantly increased FEV1 AUC0-12h relative to placebo (p<0.0001). No evidence of tachyphylaxis was observed as indicated by maintained FEV1 AUC and reduced rescue albuterol use throughout treatment. FFIS also significantly increased peak FEV1, trough FEV1, and standardized FVC AUC0-12h compared with placebo. SGRQ assessment at Week 12 demonstrated significant and clinically meaningful improvements in total score (FFIS vs placebo, -4.9, p=0.0067), symptom, and impact scores. No significant differences in efficacy were observed between the two active treatments. Drug related AEs in the FFIS arm with a frequency > or = 1% and exceeding placebo were dry mouth, nausea, and insomnia. Nebulized FFIS provided significant improvement in respiratory status and quality of life in subjects with COPD relative to placebo and was well tolerated. The efficacy and safety profile of FFIS was comparable to FA DPI.

Mucociliary clearance in patients with chronic asthma: Effects of β2 agonists

Chronic asthma is characterized by airway inflammation, mucus hypersecretion and impaired mucociliary clearance (MCC). We investigated baseline MCC and the acute effect of terbutaline in chronic asthmatics with sputum production while on long-term treatment with salmeterol in combination with inhaled corticosteroids (ICS). MCC was measured at baseline and in response to 1 mg terbutaline (or placebo) on three visits over 80 min in 16 asthmatics (52+/-13 years of age). Subjects who had greater than 10% absolute increase in MCC above baseline and placebo, after terbutaline, were categorized in group A and subjects who had less than 10% in group B. In group A subjects (n=6), MCC increased from 23.7+/-4.0% at baseline to 43.7+/-4.9% with terbutaline (P<0.0001) and to 34.4+/-5.7% with placebo (P<0.01). In group B subjects (n=10), MCC remained similar: 11.3+/-3.2% at initial baseline, 12.0+/-3.2% with terbutaline and 7.3+/-3.0% with placebo (P>0.05). Group B subjects withdrew from all beta(2) agonists for a week and MCC was remeasured. After withdrawal, baseline MCC (7.0+/-1.8%) was similar to the initial baseline value (P>0.1) and MCC with terbutaline (15.8+/-4.9%) was greater than baseline (P<0.005) but remained abnormal in most subjects. Baseline percentage predicted FEV(1) and FEF(25--75%) were 77.3+/-7.2 and 41.7+/-5.6 in group A and 59.9+/-8.1 and 29.5+/-8.4 in group B subjects, respectively. MCC was impaired in most of these asthmatics with persistent airway obstruction and sputum production, despite regular treatment with ICS and salmeterol. In addition, there was little or no stimulation of MCC acutely after terbutaline in most of these asthmatics.

Aetiological factors in persistent sputum production: a case-control study.

The aim was to explore the aetiological roles of smoking, occupational exposure, childhood respiratory illness, and atopy in persistent sputum production. This was a case-control study. Data were obtained using a questionnaire administered by two observers blind to the subjects' status. Information was sought on lifetime smoking, occupation, hospital admissions due to respiratory disease, and respiratory disease history. Four general practices in south east England in 1990, with a total population of about 30,000. Cases were subjects aged 5 to 54 years with sputum production; one control was selected per case, matched by general practice, age, and sex, forming 210 matched pairs (88% response rate). Cigarette smoking remains an important cause of persistent sputum production: the odds ratio (95% confidence interval) for current smoking was 7.9 (3.6-20.4). A dose-response relationship was confirmed, with falling risk estimates after stopping smoking. The association of sputum production with occupational exposure to respiratory irritants, which was independent of smoking, was confined to men (odds ratio 2.4, 1.0-6.0) and largely attributable to very heavy exposure. Examination of the relationship with early respiratory disease suggested that much, though not all, was attributable to wheezing illnesses first manifest in childhood. Aetiological fractions derived from the results suggest that in the general population of south east England approximately 68% of all cases of persistent sputum production can be independently attributed to current cigarette smoking, 17% to heavy occupational exposure to respiratory irritants, and 13% to wheezing illnesses first manifest in early childhood.

Acute bronchitis: Results of U.S. and European trials of antibiotic therapy

Acute bronchitis, an illness frequently encountered by primary-care physicians, is an inflammation of the tracheobronchial tree that results from a respiratory tract infection. It is characterized by persistent cough and sputum production and is occasionally accompanied by fever and/or chest pain. Acute bronchitis may have a viral or bacterial origin and is often treated with antibiotics. Four clinical trials were conducted to compare high and low doses of loracarbef, a new oral β-lactam antibiotic, with three agents commonly used to treat acute bronchitis: amoxicillin/clavulanate, cefaclor, and amoxicillin. Results of these studies indicated that loracarbef, 400 and 200 mg twice daily, had clinical and bacteriologic efficacy against the common respiratory pathogens Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella (Branhamella) catarrhalis that was comparable with that of the comparative agents. Loracabef was as well tolerated as cefaclor and amoxicillin; moreover, it produced a significantly lower incidence of diarrhea than did amoxicillin/clavulanate. Loracarbef may be considered a safe and effective alternative agent for the treatment of patients with acute bronchitis.

Persistent cough and sputum: prevalence and clinical characteristics in south east England

In order to measure the prevalence of chronic respiratory symptoms in the population and to identify subjects for a case-referent study of aetiologic factors, 10,000 persons registered with general practices in south east England were surveyed. Responses to an initial postal questionnaire were validated by telephone interview; clinical interviews and simple spirometry were subsequently carried out on a sample of persons aged 5-54 years, reporting persistent sputum production. Results indicated that the postal questionnaire was an effective and sensitive method of surveying respiratory symptoms in the population. Comparison with earlier surveys suggests that the prevalence of chronic cough and sputum in Great Britain has fallen in males but not in females. Of those adults reporting persistent sputum production, high proportions reported associated symptoms of wheezing (54%), breathlessness (45%) or upper respiratory tract symptoms (54%). Thirty percent recalled a serious respiratory infection in childhood and 52% were current cigarette smokers although 34% reported that they had never been regular smokers. Overall there was little evidence of serious airflow obstruction in this group.