Journal Club

10.07.2017

P. Sendi

Lady Windermere syndrome

• Victorian-era play

• “How do you do, Lord Darlington. No, I can't shake hands with you. My hands are all wet with the roses.”

Oscar Wilde’s play 1892

Lady Windermere's Fan, Act 1, scene 1, Routledge, Chapman, and Hall, London (1966)

http://walterdaletheatre.com/wp-content/uploads/2016/02/LWFProgram.jpg

• typically seen in elderly white women who chronically (voluntarily) suppress the normal cough reflex.

• Victorian upper class society “ladies don’t spit”.

Lady Windermere syndrome

The clinical and radiographic similarities of these 6 patients appear to comprise a distinct clinical syndrome

• initial involvement of the periphery of the lingula or of its counterpart the middle lobe.

• absence of clinically evident predisposing pulmonary disease.

• exclusivity female patients, tended to be older (mean 65 yr).

We offer the term, Lady Windermere's syndrome, from the Victorian-era play, Lady Windermere's Fan, to convey the fastidious behavior hypothesized.

The name is inappropriate: Lady Windermere was a vivacious 21-year old girl, who was married for two years

and had never coughed or showed any other illness.

Singapore Med J 2008; 49(2) : e49

Am J Respir Crit Care Med Vol 175. pp 367–416, 2007

Study Aim

→ evaluate the long-term outcomes of pulmonary resection for NTMPD

→ to determine the risk factors for microbiological recurrence and survival.

observational retrospective cohort study Minami Yokohama National or

Seirei Hospital

01/1994 – 08/2014

(1) NTMPD refractory to multiple drug therapy

(2) cavitary lesions and/or severe bronchiectasis

(3) development of complications such as massive

haemoptysis

(4) patients who had received ≥ 6 months of antimicrobial

therapy*

NTMPD treated by pulmonary resection

(only 1st instance of resection was considered for analysis)

125 patients

definitions – sputum after surgery Sputum conversion was defined as more than 3 consecutive negative sputum cultures over a period of 3 months. Sputum was considered to have converted to smear-negative if patients failed to cough up any sputum even upon sputum induction using hypertonic saline solution. In case of patients who achieved sputum conversion, microbiological recurrence was defined by 2 or more positive sputum cultures regardless of radiological findings.

Not defined

Lady Windermere Syndrome ?

54%

http://www.aboutcancer.com/lung_surgery.htm

78%

more than every 5th patient

http://www.aboutcancer.com/lung_surgery.htm

The complication rate of occurrence after pneumonectomy (42% [13/31]) was significantly higher compared to that after other types of pulmonary resection (15% [14/94].

OR 4.1 (95% CI, 1.6–10.3; P = .005)

Cumulative recurrence rates at

1 year 4.6% 3 years 10% 5 years 15% 10 years 20%

→ Pneumonectomy (cave see numbers) → Cavitary lesions after surgery were associated with microbiological recurrence

The median follow-up duration of the 125 patients was 7.1 years (IQR, 3.5–10.3 years). At the end of follow-up, 26 patients had died.

The survival rates at 1 year 94% 3 years 90% 5 years 84% 10 years 76%

→ Age ↓ → BMI ↑ → No pneumonectomy → No cavitary lesions after surgery were associated with better survival

→ Age ↓ → BMI ↑ → No pneumonectomy → No cavitary lesions after surgery were associated with better survival

score the paper

+ - high patient number with a distinct disease

- as precise as possible given the retrospective nature

- clear messages: consider age, BMI, type of surgery, lesions

-

- treatment duration after surgery

- patients selected from referral center

- microbiological testing of isolates (51 patients, 2 CAM – R)

- data on the decision making process «who and when»