PET-CT SUVmax and Endobronchial Ultrasound Features for Prediction of Malignancy: A Prospective Study.

INTRODUCTION: Accurate and early staging of lung cancer has a critical impact on its prognosis. EBUS-TBNA is often the procedure of choice for mediastinal staging. Comprehension of the likelihood of malignancy of each lymph node (LN) can assist puncture decision-making during EBUS and offer insight of the procedure expected diagnostic yield. METHODS: Prospective analysis of mediastinal LN of patients undergoing EBUS-TBNA from April 2021 to May 2022. The relationship between PET-CT SUVmax levels, EBUS features, and malignancy on LN was investigated. For statistical analysis, patients were assigned to 3 groups: suspected malignancy (diagnosis and/or staging), confirmed malignancy (staging) or suspected benign disease. RESULTS: A total of 363 LN from 132 patients (71% male, mean 62 years old) were analyzed. Among those with suspected benign disease, no LN puncture resulted in a diagnosis of malignancy. PET-CT SUVmax and short axis size were independent factors for malignancy in LN of patients who underwent EBUS for suspected (p < .001 and p = .047, respectively) or confirmed malignancy (p < .001 and p < .001, respectively). All malignant LN presented SUVmax≥1.85 (≥2.85 for staging EBUS cases) and/or short axis size ≥4.28mm. Vascularized LN were more often malignant in either those with suspected (p = .087) or confirmed (p = .095) malignancy, although not statistically significant. LN that were simultaneously vascularized and lacked central hilar structure were also more commonly malignant (p = .013). CONCLUSION: LN that has higher SUVmax and are larger should be prioritized for puncture, followed by those vascularized and lacking central hilar structure. In staging EBUS cases, a systematic sampling (N3-N2-N1) is required and must precede any malignancy yield rationale.

Role of the one-minute sit-to-stand test in the diagnosis of post COVID-19 condition: a prospective cohort study / Papel do teste de se sentar e levantar durante um minuto no diagnóstico de síndrome pós-COVID-19: estudo prospectivo de coorte

ABSTRACT Objective: To analyze the relationship between one-minute sit-to-stand test (1MSTST) parameters and a diagnosis of post COVID-19 condition in a cohort of patients who previously had COVID-19. Methods: This was a prospective cohort study of patients with post COVID-19 condition referred for body plethysmography at a tertiary university hospital. Post COVID-19 condition was defined in accordance with the current WHO criteria. Results: Fifty-three patients were analyzed. Of those, 25 (47.2%) met the clinical criteria for post COVID-19 condition. HR was lower in the patients with post COVID-19 condition than in those without it at 30 s after initiation of the 1MSTST (86.2 ± 14.3 bpm vs. 101.2 ± 14.7 bpm; p < 0.001) and at the end of the test (94.4 ± 18.2 bpm vs. 117.3 ± 15.3 bpm; p < 0.001). The ratio between HR at the end of the 1MSTST and age-predicted maximal HR (HRend/HRmax) was lower in the group of patients with post COVID-19 condition (p < 0.001). An HRend/HRmax of < 62.65% showed a sensitivity of 78.6% and a specificity of 82.0% for post COVID-19 condition. Mean SpO2 at the end of the 1MSTST was lower in the patients with post COVID-19 condition than in those without it (94.9 ± 3.6% vs. 96.8 ± 2.4%; p = 0.030). The former group of patients did fewer repetitions on the 1MSTST than did the latter (p = 0.020). Conclusions: Lower SpO2 and HR at the end of the 1MSTST, as well as lower HR at 30 s after initiation of the test, were associated with post COVID-19 condition. In the appropriate clinical setting, an HRend/HRmax of < 62.65% should raise awareness for the possibility of post COVID-19 condition.

RESUMO Objetivo: Analisar a relação entre parâmetros do teste de se sentar e levantar durante um minuto (TSL1) e o diagnóstico de síndrome pós-COVID-19 em uma coorte de pacientes que anteriormente apresentaram COVID-19. Métodos: Estudo prospectivo de coorte de pacientes com síndrome pós-COVID-19 encaminhados para realizar pletismografia corporal em um hospital universitário terciário. A síndrome pós-COVID-19 foi definida conforme os critérios atuais da OMS. Resultados: Foram analisados 53 pacientes. Destes, 25 (47,2%) preencheram os critérios clínicos de síndrome pós-COVID-19. A FC foi menor nos pacientes com síndrome pós-COVID-19 do que naqueles sem a síndrome 30 s após o início do TSL1 (86,2 ± 14,3 bpm vs. 101,2 ± 14,7 bpm; p < 0,001) e no fim do teste (94,4 ± 18,2 bpm vs. 117,3 ± 15,3 bpm; p < 0,001). A relação entre a FC no fim do TSL1 e a FC máxima prevista para a idade (FCfim/FCmáx) foi menor nos pacientes com síndrome pós-COVID-19 (p < 0,001). A relação FCfim/FCmáx < 62,65% apresentou sensibilidade de 78,6% e especificidade de 82,0% para síndrome pós-COVID-19. A média da SpO2 no fim do TSL1 foi menor nos pacientes com síndrome pós-COVID-19 do que naqueles sem a síndrome (94,9 ± 3,6% vs. 96,8 ± 2,4%; p = 0,030). Os pacientes com síndrome pós-COVID-19 realizaram menos repetições durante o TSL1 do que os sem a síndrome (p = 0,020). Conclusões: SpO2 e FC mais baixas no fim do TSL1 e FC mais baixa 30 s após o início do teste apresentaram relação com síndrome pós-COVID-19. No contexto clínico apropriado, a relação FCfim/FCmáx < 62,65% deve alertar para a possibilidade de síndrome pós-COVID-19.

Comparative analysis of the bronchoalveolar microbiome in Portuguese patients with different chronic lung disorders.

The lung is inhabited by a diverse microbiome that originates from the oropharynx by a mechanism of micro-aspiration. Its bacterial biomass is usually low; however, this condition shifts in lung cancer (LC), chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). These chronic lung disorders (CLD) may coexist in the same patient as comorbidities and share common risk factors, among which the microbiome is included. We characterized the microbiome of 106 bronchoalveolar lavages. Samples were initially subdivided into cancer and non-cancer and high-throughput sequenced for the 16S rRNA gene. Additionally, we used a cohort of 25 CLD patients where crossed comorbidities were excluded. Firmicutes, Proteobacteria and Bacteroidetes were the most prevalent phyla independently of the analyzed group. Streptococcus and Prevotella were associated with LC and Haemophilus was enhanced in COPD versus ILD. Although no significant discrepancies in microbial diversity were observed between cancer and non-cancer samples, statistical tests suggested a gradient across CLD where COPD and ILD displayed the highest and lowest alpha diversities, respectively. Moreover, COPD and ILD were separated in two clusters by the unweighted UniFrac distance (P value = 0.0068). Our results support the association of Streptoccocus and Prevotella with LC and of Haemophilus with COPD, and advocate for specific CLD signatures.

Profiling of lung microbiota discloses differences in adenocarcinoma and squamous cell carcinoma.

The lung is a complex ecosystem of host cells and microbes often disrupted in pathological conditions. Although bacteria have been hypothesized as agents of carcinogenesis, little is known about microbiota profile of the most prevalent cancer subtypes: adenocarcinoma (ADC) and squamous cell carcinoma (SCC). To characterize lung cancer (LC) microbiota a first a screening was performed through a pooled sequencing approach of 16S ribosomal RNA gene (V3-V6) using a total of 103 bronchoalveaolar lavage fluid samples. Then, identified taxa were used to inspect 1009 cases from The Cancer Genome Atlas and to annotate tumor unmapped RNAseq reads. Microbial diversity was analyzed per cancer subtype, history of cigarette smoking and airflow obstruction, among other clinical data. We show that LC microbiota is enriched in Proteobacteria and more diverse in SCC than ADC, particularly in males and heavier smokers. High frequencies of Proteobacteria were found to discriminate a major cluster, further subdivided into well-defined communities' associated with either ADC or SCC. Here, a SCC subcluster differing from other cases by a worse survival was correlated with several Enterobacteriaceae. Overall, this study provides first evidence for a correlation between lung microbiota and cancer subtype and for its influence on patient life expectancy.

Endobronchial Ultrasound under Moderate Sedation versus General Anesthesia.

BACKGROUND: Different anesthetic protocols may influence endobronchial ultrasound-guided needle aspiration (EBUS-TBNA) outcomes, patient comfort, and even safety. In this study, two anesthesia techniques were assessed and compared for EBUS-TBNA. METHODS: A prospective, multicenter study was carried out. Patients were allocated to Group 1 (general anesthesia with neuromuscular blockade and controlled ventilation) and Group 2 (intravenous sedation). EBUS-TBNA accuracy was the primary outcome. Safety, patient comfort and satisfaction, and operators' difficulties were defined as secondary outcomes. RESULTS: Of the 115 patients enrolled (Group 1 = 59, Group 2 = 56), EBUS-TBNA was performed for hilar or mediastinal lesion diagnosis and lung cancer staging in, respectively, 77 (67%) and 38 (33%) patients. The numbers of lymph nodes stations (1.8 ± 1.0 vs. 1.7 ± 1.0, p = 0.472) and punctures per station (6.9 ± 3.1 vs. 6.0 ± 2.5, p = 0.084) were similar between groups. Adequate samples were obtained from 109 patients (97.3%) with similar diagnostic accuracy. Procedure duration was not significantly different (p = 0.348). Hemodynamic parameters and systolic and diastolic blood pressures were higher in Group 1 at the beginning and at the end of the procedure. Adverse events were equally distributed, and no significant differences were found regarding patient satisfaction and bronchoscopist/anesthesiologist difficulties. CONCLUSIONS: The type of anesthesia used did not influence EBUS-TBNA outcomes. EBUS-TBNA performed under sedation or general anesthesia did not affect the diagnostic yield, complication rate, and patients' comfort and satisfaction.

Health-Related Quality of Life in Patients With α1 Antitrypsin Deficency: A Cross Sectional Study. / Calidad de vida relacionada con la salud en pacientes con déficit de α1 antitripsina: estudio transversal.

BACKGROUND: Measures of health related quality of life (HRQoL) in patients with α1-antitrypsin deficiency (AATD) can help to determine the impact of the disease and provide an important insight into the intervention outcomes. There is few data regarding this issue in the literature. The aim of this study is to assess the relationship between HRQoL and gender, functional parameters and history of hospitalizations in patients with AATD. METHODS: This is a cross-sectional study of 26 patients with severe AATD recruited in the pulmonology outpatient clinic at a tertiary care medical center. Social-demographic, clinical and functional parameters were recorded and HRQoL was assessed with the Portuguese version of the medical outcome study short form-36 (SF-36) self-administered questionnaire. RESULTS: Older patients, females and patients with at least one hospitalization in the previous year due to respiratory disease had statistical lower scores in some dimensions of the SF-36 questionnaire. Superior FEV1 and higher distance mark in the 6-min walking test distance influenced positively several dimensions of the questionnaire. Higher scores in the mMRC scale influenced negatively the HRQoL. CONCLUSIONS: These data suggests that older and female patients with AATD have worse HRQoL. Hospitalizations and functional markers of respiratory disease progression influenced negatively the HRQoL, suggesting that the SF-36 questionnaire could be useful as an outcome for AATD patients with lung involvement.

[Lung cancer--What has changed in two decades].

Lung cancer (LC) is a major public health problem and it is the most common form of cancer in men. It remains the most common cause of cancer death in men and women. In the initial decades of the smoking-caused epidemic, squamous cell carcinoma was the most frequent type. Recently there was a shift toward predominance of adenocarcinoma. The aim of our retrospective study was to compare the demographic factors and factors connected with the disease in patients whose LC was diagnosed in two distinct periods in H.S. João (1979-1982 and 1999-2002). A total of 750 LC were diagnosed. Between 1979-1982 a total of 236 patients were diagnosed LC (84.3% male; mean age 60.0 +/- 10.0). The most common histological type was squamous cell (46.2%). A total of 514 LC were diagnosed during the period 1999-2002 (83.9% male; mean age 64.7 +/- 10.8) and adenocarcinoma was the most frequent (47.1%). There were significant differences, between the two periods analysed concerning smoking (increase in the number of smokers; 73.7% vs 82.4%), age (increase in the mean age of patients) and histology (higher percentage of ade notnocarcinoma and reduction of squamous cell and small-cell lung cancer). The percentage of patients treated symptomatically decreased significantly in 20 years (26% vs 19%). As a conclusion we can say that there was an evolution of histological types in the last two decades and a reduction in the number of patients submitted to symptomatic treatment alone.

[Endobronchial tuberculosis -- clinical and bronchoscopic features]. / Tuberculose endobrônquica -- alterações clínicas e broncoscópicas.

Endobronchial tuberculosis (ET) is a serious complication of pulmonary tuberculosis and is a major cause of morbidity. The aim of our retrospective study was to characterize the clinical, radiological, microbiological and bronchoscopic features of ET. Between January 1999 and June 2002 a total of 14 patients were diagnosed as having ET in our hospital. There were 8 (57%) men and 6 women with a median age of 39.6 +/- 18.1 years (range from 20 to 78 years). Cough was the most common complain and it was present in 71.4% of patients. Only 5 patients were sputum smear positive. Five patients (35.7%) had parenchymal infiltration and this was the most common roentgenographic appearance. Forms of ET were classified into subtypes: actively caseating (n=4), granular (n=3), tumorous (n=3), edematous-hyperemic (n=2) and ulcerative (n=2). The upper lobes were affected in 9 (64.3%) patients. Nine patients had involvement of the left bronchial tree, 3 of the right and in 2 there were bilateral lesions. The diagnosis could be established in 11 (78.6%) cases by bronchial biopsy. All patients had positive bronchial lavage cultures for acid-fast bacilli. Clinical manifestations and roentgenographic appearance of ET are not specific and so bronchoscopy is mandatory for the prompt diagnosis and follow-up of its evolution.

[Plasma concentration of lidocaine during bronchoscopy]. / Concentração plasmática de lidocaína durante a broncofibroscopia.

Lidocaine is commonly used for local anesthesia during fiberoptic bronchoscopy (FOB). It has been suggested that the total dose of lidocaine should be limited to 300-400 mg (or < 8.2 mg/kg). Lidocaine toxicity is directly correlated with its concentration in the blood and a threshold above which the side effects become more likely has been put at a plasma level of 5 microg/ml. The aim of our study was to determine plasmatic lidocaine concentrations (PLC), how often the PLC fall into the potentially toxic range and its correlation with adverse reactions. PLC were recorded in 30 patients undergoing FOB. Lidocaine was administered as a 2% gel, 10% spray and 2% solution. Venous blood samples were taken before the beginning of local anesthesia and at 20, 30 and 40 min thereafter. The mean total amount of lidocaine administered was 746.3 +/- 159.5 mg (11.6 +/- 3.1 mg/kg). Before the beginning of anesthesia, no significant levels of lidocaine were measurable in the patients. PLC were 3.2 +/- 1.7 (g/ml at 20 min., 3.3 +/- 1.7 microg/ml at 30 min. and 3.0 +/- 1.5 microg/ml at 40 min. The PLC exceeded toxic levels in 6 patients, but no complications were observed. Our data show that although the amount of lidocaine used in this study exceeded the recommended highest dose, no subjects had signs of toxicity. A maximum dose of lidocaine for topical anesthesia should be determined despite the fact that an average total dose superior to 400 mg appears to be safe in patients undergoing FOB.

[Pleural disease and acquired immunodeficiency syndrome]. / Doença pleural e síndroma de imunodeficiência adquirida.

Respiratory infections are among the most common complications in patients infected with human immune deficiency virus (HIV) and can occur at all CD4 level. Pleural complications are uncommon but they have some distinctive aspects from HIV-negative patients. The PTX occurrence in HIV-positive patients was described for the first time in 1984. The total incidence of pneumothorax (PTX) in patients with acquired immune deficiency syndrome (AIDS) varies from 2.7% to 4.9%. The great majority occurs in patients with current or previous Pneumocystis carinii infection, who present subpleural pulmonary cavities with necrosis. The treatment of spontaneous PTX in patients with AIDS is difficult, with an increased tendency to bronchopleural fistula persistence. The use of tube thoracostomy, with or without pleural sclerose, can be insufficient to resolve PTX. Other therapeutic options are attachment of a Heimlich valve or surgical intervention. The prevalence and the etiology of pleural effusion (PE) among hospitalized patients with AIDS varies widely. One reason that can contribute to this variability is the difference on risk factors associated with HIV infection, in the studied population. Parapneumonic effusions, tuberculosis and Kaposi's sarcoma are the most common causes. Empyemas are a rare pleural complication. Although Pneumocystis carinii pneumonia is a common cause of pneumonias in AIDS patients, it is an unusual cause of pleural effusion. Other possible causes of pleural effusion are non-Hodgkin's lymphoma, namely body cavity-based lymphoma.

Torçäo de útero näo-grávido / Torsion of the non-pregnant uterus

A torçäo uterina é uma patologia bastante rara, de diagnóstico difícil e está geralmente associada ao aumento do volume uterino em combinaçäo com outras alteraçöes dos órgäos pélvicos. Este trabalho relata o caso de uma mulher idosa, desnutrida, com quadro de abdome agudo e diagnóstico intra-operário de miomatose e torçäo de 360º para a direita do útero que apresentava sinais de grave isquemia.

Esclerite causada pelo Mycobacterium leprae em paciente hanseniano supostamente curado com a monoterapia / Mycobacterium Leprae scleritis in a patient afetr many years of Dapsona therapy

Os autores descrevem um caso de esclerite bilateral causada diretamente pelo M. leprae em um paciente hanseniano dado como curado, após anos de tratamento com DAPSONA, inclusive com laudos baciloscópicos de anos anteriores. O quadro de esclerite foi, aparentemente, a primeira manifestaçäo clínica de recidiva da doença e, os autores destacam a possibilidade de alteraçöes nos olhos e anexos oculares virem a ser consideradas importantes na avaliaçäo dos quadros de recidiva da HANSENIASE. Comentam sobre as possíveis repercussöes que este caso pode trazer em relaçäo ao diagnóstico diferencial entre crises de esclerite por invasäo bacilar e das causadas por reaçöes imunológicas (estados reacionais).

Impregnaçäo sui generis conjuntivo-escleral por clofazimina em um paciente portador de hanseníase / Impregnation sui generis of the conjunctiva and sclera by clofazimine in a carrier Hansen's disease

Os autores apresentam o caso de um paciente de 40 anos de idade, portador de hanseníase forma virchoniana que recebeu, por via oral, durante 9 anos, clofazimina, numa dose total de 324 gramas. Apresentou intensa pigmentaçäo na conjuntiva e esclera por este medicamento. A biomicroscopia observavam-se com facilidade cristais policromáticos na conjuntiva e esclera de ombos os olhos. O estudo destes cristais também foi possível à microscopia óptica de fragmento da conjuntiva a fresco. O caso é discutido com os achados na literatura e os autores chamam a atençäo para os diagnóticos diferenciais

Iridociclite bilateral causada pelo "Mycobacterium leprae" diagnosticada através da punçäo de câmara anterior / Bilateral iridocyclitis caused by Mycobacterium leprae diagnosed through paracentesis

Os AAs realizaram Punçäo de Câmara Anterior em uma paciente portadora de Hanseníase, com quadro de iridociclite bilateral. A Punçäo foi realizada sob anestesia tópica, em regime ambulatorial, e o humor aquoso foi submetido à coloraçäo pelo método de Ziehl-Nielsen, tendo sido isolado o M. Leprae na Câmara Anterior. O trabaho mostra que o M.Leprae é uma das causas de uveítes na Hanseníase, merecendo ser procurado em casos de uveítes em pacientes portadores de Hanseníase

Uso de Clofazimina em pacientes com albinismo óculo-cutâneo portador de Hanseníase na forma Virchowiana / Use of clofazimina in patients with oculo-cutaneous albinism in Bearer's of Virchow's form o f Hansen disease

O presente trabalho mostra um caso de paciente com Albinismo óculo-cutâneo, tirosinase +, portador de Hanseníase na forma V., submetido à MDT. O paciente foi medicado por um período de 2 anos, mas näo se notou qualquer pigmentaçäo de pele e mucosas pela Clofazimina um dos componentes da multidrogaterapia (MDT). Já que o Albinismo é uma doença congênita, devido à deficiência na produçäo de Melanina, estaria o metabolismo da Clofazimina relacionado ao da Melaniana, explicando a falta de pigmentaçäo neste paciente?

Biópsia conjuntival em pacientes portadores de hanseníase / Conjunctival biopsy in patients bearing Hansen's Disease

Investigaçäo em 120 pacientes hansenianos, divididos igualmente entre as formas clínicas da doença: 30 pacientes da forma Tuberculóide, 30 pacientes da forma indeterminada, 30 pacientes da forma Virchowiana. A investigaçäo foi feita através de biópsia da conjuntiva bulbar, no quadrante temporal superior do olho direito, tanto em pacientes virgens de tratamento, como em pacientes em tratamento e em alta medicamentosa. O estudo procurou identificar a presença do M.leprae na conjuntiva destes pacientes e, conseguiu tal intento em 4 casos: 1 na forma Dimorfa, virgem de tratamento, e 3 na forma Virchowiana, sendo 1 virgem de tratamento e 2 em tratamento