Evaluation of patients' satisfaction with domiciliary biological treatment in severe asthma: a Portuguese survey.

Dear Editor, According to GINA, severe asthma is defined as uncontrolled asthma, despite therapy adherence with an optimized high dose of inhaled corticosteroid plus long-acting ß2-agonist coupled with management of modifiable factors/comorbidities, that worsens when this treatment is decreased. It affects a significant portion of asthmatic patients and imposes a high risk of exacerbations and mortality, which are associated with significant healthcare costs and psychosocial impact...

Classification of Chronic Obstructive Pulmonary Disease (COPD) according to the new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017: Comparison with GOLD 2011.

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality worldwide. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) project has been working to improve awareness, prevention and management of this disease. The aim of this study is to evaluate how COPD patients are reclassified by the 2017 GOLD system (versus GOLD 2011), to calculate the level of agreement between these two classifications in allocation to categories and to compare the performance of each classification to predict future exacerbations. Two-hundred COPD patients (>40 years, post bronchodilator forced expiratory volume in one second/forced vital capacity<0.7) followed in pulmonology consultation were recruited into this prospective multicentric study. Approximately half of the patients classified as GOLD D [2011] changed to GOLD B [2017]. The extent of agreement between GOLD 2011 and GOLD 2017 was moderate (Cohen's Kappa = 0.511; p < 0.001) and the ability to predict exacerbations was similar (69.7% and 67.6%, respectively). GOLD B [2017] exacerbated 17% more than GOLD B [2011] and had a lower percent predicted post bronchodilator forced expiratory volume in one second (FEV1). GOLD B [2017] turned to be the predominant category, more heterogeneous and with a higher risk of exacerbation versus GOLD B [2011]. Physicians should be cautious in assessing the GOLD B [2017] patients. The assessment of patients should always be personalized. More studies are needed to evaluate the impact of the 2017 reclassification in predicting outcomes such as future exacerbations and mortality.

Effect of Accessions and Environment Conditions on Coumarin, O-Coumaric and Kaurenoic Acids Levels of Mikania laevigata.

Coumarin, o-coumaric, and kaurenoic acid are bioactive compounds usually found in the leaves of Mikania laevigata. Genetic and environmental variations in the secondary metabolites of plants may have implications for their biological effects. Three different accessions of M. laevigata cultivated in four sites between the Equator and the Tropic of Capricorn in Brazil were evaluated aiming to present potential raw materials and discuss relationships among these three bioactive compounds. The results revealed effects of plant accessions and environmental factors and suggested two contrasting chemical phenotypes of M. laevigata. The first phenotype presented the highest levels of kaurenoic acid (2283 ± 316 mg/100 g) besides lower levels of coumarin (716 ± 61 mg/100 g), which was also stimulated by the environment and mild climate at the site nearest to the Tropic of Capricorn. The other phenotype presented the lowest levels of kaurenoic acid (137 ± 17 mg/100 g) besides higher levels of coumarin (1362 ± 108 mg/100 g), which was also stimulated by the environment and tropical climate at the site nearest to the Equatorial beach.

Rectal mixed adenoneuroendocrine carcinoma: Case report.

RATIONALE: Colorectal mixed neuroendocrine-nonneuroendocrine neoplasms constitute a rare group of gastrointestinal tumors composed by both neuroendocrine and nonneuroendocrine components. Nondiagnostic macroscopic features, specific histological features, and poor awareness of the disease are responsible for the underestimated incidence and conflicting data available. Due to lack of randomized clinical trials and validated clinical guidelines, diagnostic and therapeutic approach are based on the standard of care for pure colorectal neuroendocrine carcinomas or adenocarcinomas. PATIENT CONCERNS: A 76-year-old caucasian male, without relevant medical or familial history, presented a positive faecal occult blood test during colorectal cancer screening. DIAGNOSIS: Total colonoscopy identified a rectal lesion with biopsy showing a moderate rectal adenocarcinoma staged as cT2N0M0. INTERVENTIONS: Anterior resection of the rectum with right ileostomy followed by local radiotherapy with radio-sensitising chemotherapy and adjuvant chemotherapy with capecitabine 1000 mg bid plus oxaliplatin 130 mg/m2. Due to chronic nodular pulmonary aspergillosis and chemotherapy induced immunosuppression patient was on 400 mg/daily of oral voriconazole. OUTCOMES: Overall survival of 15 months after progression under first line treatment and under palliative chemotherapy with platinum plus etoposide regimen. LESSONS: The reported case illustrates the challenge associated to the management of mixed neuroendocrine-nonneuroendocrine carcinomas due to lack of validated guidelines and scientific evidence. From diagnosis and staging to treatment, all steps must be tailored to individual clinical and histological features.

Predictors of survival and technical success of bronchoscopic interventions in malignant airway obstruction.

BACKGROUND: Malignant airway obstruction (MAO) leads to quality of life impairment and increased mortality. Interventional bronchoscopy allows airway patency restoring, leading to a better survival. We investigated predictors of survival and successful bronchoscopic intervention among MAO patients. METHODS: This observational prospective study enrolled 100 patients who were newly diagnosed with MAO. Survival was estimated with Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses were performed using Cox proportional hazard models. Univariate and multivariate logistic regression were used for odds ratio calculation. RESULTS: A proportion of 73% of the patients were male with a median age was 62.5 years (range, 21-88 years). Lung cancer was the most common primary malignancy (74%). The majority had single (61%), endoluminal (62%) lesions and were classified as grade III in Myer Cotton scale (57%). The most used techniques comprised mechanical debulking (n=81) and laser therapy (n=68). Twenty-two airway stents were placed. While eleven patients were considered untreatable, technical success was achieved in 78%. Haemorrhage was the most common acute complication (16%). No deaths occurred as a result of the procedure. Median global survival was 8 months. Adjusting for age and Eastern Cooperative Oncology Group Performance Status (ECOG), extrinsic compression or mixed airway obstructions [hazard ratio (HR) =2.075; P=0.012], successful bronchoscopic intervention (HR =0.468; P=0.025) and initiation of cancer treatment (HR =0.373; P=0.006) were independent predictors of survival. The absence of distal airway patency on thoracic CT was independently associated with failure of the intervention [odds ratio (OR) =0.013; P<0.001]. CONCLUSIONS: Interventional bronchoscopy has proven to be an efficient and safe strategy to manage MAO patients. The patients who benefit the most in terms of survival are those with purely endoluminal lesions, in whom technical success was achieved and those whose cancer-specific treatment was initiated. Distal airway patency on thoracic CT predicts the technical success of bronchoscopic intervention.

Interstitial lung disease and pre-capillary pulmonary hypertension in neurofibromatosis type 1.

Although previously reported, the existence of a neurofibromatosis (NF)-associated diffuse lung disease (DLD) still lacks solid evidence. We report a case of a 68-year-old non-smoking female with NF1, pre-capillary pulmonary hypertension (PH) and an interstitial lung pattern. Initial findings included progressive dyspnea, hypoxemia and sparse centrilobular ground-glass micronodules on high-resolution computed tomography (HRCT). Further study demonstrated a severe defect in diffusing capacity for carbon monoxide (DLCO), macrophages on bronchoalveolar lavage and pre-capillary PH on right cardiac catheterization. Surgical biopsy revealed macrophage accumulation along bronchovascular bundles and alveolar spaces and type II pneumocytes hyperplasia. Given the absence of environmental exposure or new drugs, a NF-DLD was hypothesized. Pre-capillary PH was disproportionate to interstitial findings, so it was attributed to a NF1-vasculopathy. Treatment with triple sequential combined therapy was unsuccessful culminating in death 18 months later. This case adds HRCT and anatomopathological data suggesting NF-DLD as a distinct manifestation of the disease.

Bacia hidrográfica do rio balsas: diagnóstico físico e avaliação qualitativa de áreas suscetíveis à erosão / Balsas river basin: physical diagnosis and qualitative presentation of erosion-susceptible areas

RESUMO Conhecer o comportamento geomorfológico de bacias hidrográficas é fundamental para a elaboração de políticas públicas de conservação dos recursos naturais, para subsidiar a ocupação humana de forma que os processos erosivos sejam minimizados. Considerando-se as escassas informações sobre a bacia hidrográfica do Rio das Balsas, no sul do estado do Maranhão, este estudo teve como objetivos realizar o diagnóstico físico e apresentar as áreas suscetíveis à erosão por meio de classificação qualitativa. Para tanto, utilizaram-se informações das bases de dados da Agência Nacional de Águas, Companhia de Pesquisa de Recursos Minerais e United States Geological Survey (modelo digital de elevação, hidrografia, solos e geologia). Por rotinas de geoprocessamento, foram delimitadas a bacia e as sub-bacias e obtidos os dados para o cálculo dos índices morfométricos. Além disso, foi feita a reclassificação das áreas suscetíveis a erosão, baseada no curve number, método que avalia o potencial de escoamento superficial por tipo de solo e respectivo uso. A reclassificação em quatro classes de suscetibilidade possibilitou elaborar o mapa de áreas suscetíveis à erosão. As características morfogenéticas encontradas na área mostram que são necessárias ações de manejo adequado, já que alguns tipos de solos combinados com 45% de declividade (44% da área) são as áreas mais vulneráveis aos processos erosivos. Com isso, conclui-se que o planejamento do uso e ocupação da bacia são extremamente importantes para que as características físicas da região não interfiram de maneira negativa no futuro da sua expansão, no que concerne tanto às atividades agrícolas quanto às urbanas.

Abstract Knowledge of the geomorphological behavior of watersheds is fundamental for the elaboration of public policies for the conservation of natural resources, to subsidize human occupation in a way that minimizes erosion processes. Considering the lack of information about the Balsas river basin, located in the south of the state of Maranhão, Brazil, this study aimed to make a physical diagnosis and indicate areas susceptible to erosion through qualitative classification. To that end, it drew on information from National Water Agency (ANA), the Geological Survey of Brazil (CPRM) and the United States Geological Survey (USGS) databases (digital elevation model, hydrography, soils and geology). Through geoprocessing routines, the basin and sub-basins were mapped and data was obtained for the calculation of morphometric indices. In addition, the areas susceptible to erosion were reclassified based on the curve number method, which assesses surface runoff potential by soil type and use. Reclassification into four susceptibility classes made it possible to map erosion susceptible areas. The morphogenetic characteristics found in the area show the need for appropriate management actions, since some types of soils, combined with 45% slope (about 44% of the area), are the most vulnerable to erosive processes. The conclusion reached was that planning of the use and occupation of the basin is extremely important to prevent the physical characteristics of the basin interfering negatively in the future of the region, as its agricultural as well as urban activities expand.

Photoperiod and temperature effects on in vitro growth and flowering of P. pusilla, an epiphytic orchid.

Psygmorchis pusilla Dodson and Dressler, an epiphytic orchid, has been shown to be an interesting model to study in vitro flower formation. In the present study, the effects of photoperiod and temperature on vegetative and reproductive development were investigated. Although photoperiod had limited effects on leaf number, an etiolating process was verified in darkness and a higher growth was detected under long days. A positive relationship was observed between long days and floral spike formation. However, plant incubation under 20 h photoperiod or longer days negatively affected floral bud development, inhibiting anthesis and reducing flower longevity. Higher soluble sugar and starch levels were detected in plants cultivated under long days, while chlorophyll and carotenoids contents were negatively affected under these conditions. Plants showed great sensitivity to temperature variations; 27 degrees C being the most adequate for growth, leaf and floral spike formation. Temperatures of 22 and 32 degrees C were not appropriate for in vitro development of P. pusilla.

A rare cause of lower abdominal and pelvic mass, primary tuberculous psoas abscess: a case report.

INTRODUCTION: Tuberculous psoas abscess was usually associated to complicate Pott's disease, but it can also be secondary to direct extension from other adjacent structures or haematogenous spread from an occult source. However, the occurrence of this entity as the presenting manifestation of tuberculosis, without evidence of active infection elsewhere, has been seldom reported. CASE PRESENTATION: We report a clinical case of a 64-year-old immunocompetent female that presented with left lower abdominal pain and a soft tissue mass over the left iliac fossa and inguinal regions due to a primary tuberculous psoas abscess. Early diagnosis and prompt treatment with percutaneous drainage guided by ultrasound along with antituberculous drugs, lead to a satisfactory outcome. CONCLUSION: The purpose of this case report is to point out attention to the diagnostic challenge of tuberculous psoas abscess in the absence of tuberculosis in other organs or a predisposing condition. A brief review of the literature about its epidemiology, etiology, clinical features and management is discussed over the text.

Lung and renal transplantation.

UNLABELLED: Renal transplantation is the most common type of solid organ transplantation and kidney transplant recipients are susceptible to pulmonary complications of immunosuppressive therapy, which are a diagnostic and therapeutic challenge. AIM: To evaluate patients admitted to the Renal Transplant Unit (RTU) of Hospital de S. João with respiratory disease. SUBJECT AND METHODS: We performed a retrospective study of all patients admitted to RTU with respiratory disease during a period of 12 months. RESULTS: Thirty-six patients were included. Mean age 55.2 (+/-13.4) years; 61.1% male. Immunosuppressive agents most frequently used were prednisolone and mycophenolate mofetil associated with ciclosporin (38.9%) or tacrolimus (22.2%) or rapamycin (13.9%). Thirty-one patients (86.1%) presented infectious respiratory disease. In this group the main diagnoses were 23 (74.2%) pneumonias, 5 (16.1%) opportunistic infections, 2 (6.5%) tracheobronchitis, and 1 case (3.2%) of lung abscesses. Microbiological agent was identified in 7 cases (22.6%). Five patients (13.9%) presented rapamycin-induced lung disease. Fibreoptic bronchoscopy was performed in 15 patients (41.7%), diagnostic in 10 cases (66.7%). Mean hospital stay was 17.1 (+/-18.5) days and no related death was observed. CONCLUSION: Respiratory infections were the main complications in these patients. Drug-induced lung disease implies recognition of its features and a rigorous monitoring of drug serum levels. A more invasive diagnostic approach was determinant in the choice of an early and more specific therapy.