The Diagnostic Contribution of Systematic Lung Ultrasonography in Patients Admitted to a Conventional Pulmonology Hospitalization Unit.

OBJECTIVE: Although the evidence to date remains limited, we hypothesized that performing protocolized lung ultrasound (LUS) in patients, admitted to a conventional pulmonology hospitalization unit, could improve diagnostic precision. The main objectives of this study were to evaluate the diagnostic contribution and changes in the treatments administered after performing a protocolized LUS in patients hospitalized in a Pulmonology Department ward. METHODOLOGY: This was a prospective, observational study, which included patients admitted from the Emergency Department to a conventional Pulmonology Department hospitalization unit, after first being evaluated by a pulmonologist. LUS was performed within the first 48 hours of admission. The diagnosis at the time of discharge was used as the reference diagnosis. RESULTS: A total of 180 patients were included in this study. The admitting diagnoses were the decompensation of an underlying obstructive disease in 60 patients (33.3%), respiratory infection in 93 (51.7%), pulmonary thromboembolism (PE) in 9 (5%), exacerbation of an interstitial lung disease in 14 (7.8%), and other causes in 4 cases (2.2%). Ultrasonography provided new information, unsuspected at the patient's admission, in 117 (65%) of the patients by capturing images suggestive of infection in 63 patients (35%), 1 new case of ILD, 23 (12.7%) cases of cardiogenic edema, and pleural pathology in 19 (10.5%), as well as two tumors and indirect data related to a PE. The use of LUS resulted in the decision to change the already established treatment in 17.2% of the cases. CONCLUSIONS: LUS provided additive information in more than half of patients that ended up reclassifying or potentially changing diagnosis or treatment. Thus, including LUS in management algorithms could reduce the need for other complementary tests or unnecessary treatments.

Predictive value of a series of inflammatory markers in COPD for lung cancer diagnosis: a case-control study.

BACKGROUND: There is a relationship between Chronic Obstructive Pulmonary Disease (COPD) and the development of lung cancer (LC). The aim of this study is to analyse several blood markers and compare their concentrations in patients with only COPD and LC + COPD. METHODS: Case-control study with cases presenting combined LC and COPD and two control groups (patients presenting only COPD and patients presenting only LC). We also included LC patients with descriptive purposes. In both groups, peripheral blood analyses of TNF-α, IL-6, IL-8, total leukocyte, lymphocyte and neutrophil counts, neutrophil-to-lymphocyte ratio, total platelet count, mean platelet volume, platelet-to-lymphocyte ratio, alpha 1-antitripsin (A1AT), IgE, C-reactive protein, fibrinogen, cholesterol and bilirubin were performed. We developed univariate and multivariate analyses of these markers, as well as a risk score variable, and we evaluated its performance through ROC curves. RESULTS: We included 280 patients, 109 cases (LC + COPD), 83 controls (COPD) and 88 LC without COPD. No differences were observed in the distribution by sex, age, BMI, smoking, occupational exposure, lung function, GOLD stage or comorbidity. Patients with LC + COPD had significantly higher levels of neutrophils [OR 1.00 (95%CI 1.00-1.00), p = 0.03] and A1AT [OR 1.02 (95%CI 1.01-1.03), p = 0.003] and lower cholesterol levels [OR 0.98 (95%CI 0.97-0.99), p = 0.009] than COPD controls. We developed a risk score variable combining neutrophils, A1AT and cholesterol, achieving a sensitivity of 80%, a negative predictive value of 90.7% and an area under the curve of 0.78 (95%CI 0.71-0.86). CONCLUSIONS: COPD patients who also have LC have higher levels of neutrophils and A1AT and lower of cholesterol. These parameters could be potentially predicting biomarkers of LC in COPD patients.

Chronic Obstructive Pulmonary Disease in Lung Cancer Patients: Prevalence, Underdiagnosis, and Clinical Characterization.

BACKGROUND: Lung cancer (LC) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. The differential clinical and functional features among LC patients with or without COPD have not been defined. OBJECTIVES: The aims of this study were to examine the prevalence and underdiagnosis rate of COPD in LC patients and to compare the clinical and functional features of LC patients with and without COPD. METHODS: We designed a multicenter hospital-based study including all LC cases diagnosed from January 2014 to August 2016. We assessed epidemiological, clinical, radiological, functional, and histological variables in all cases. RESULTS: We recruited 602 patients with LC, most of them men (77.9%), with a median age of 67 ± 15 years. The COPD prevalence among LC patients was 51.5%, with a underdiagnosis rate of 71.6%. The LC+COPD patients were older and the proportion of men was higher compared with the LC-only patients. The LC+COPD patients had more pack-years, more squamous LC, a lower monoxide transfer coefficient (KCO), and higher Charlson index scores than patients with LC only. The median survival of LC-only patients was 37% longer than that of LC+COPD patients (22 vs. 16 months), but this difference was not statistically significant. CONCLUSIONS: Among LC patients, COPD is prevalent and underdiagnosed. Patients with LC+COPD more often have squamous LC, have greater comorbidities, and have a lower KCO. More effort should be made for an early diagnosis of COPD to select patients at higher risk of developing LC.

Validity of Lung Ultrasound: Is an Image Worth More Than a Thousand Sounds?

INTRODUCTION: There is debate as to whether lung-ultrasound (LUS) can replace lung-auscultation (LA) in the assessment of respiratory diseases. METHODOLOGY: The diagnostic validity, safety, and reliability of LA and LUS were analyzed in patients admitted in a pulmonary ward due to decompensated obstructive airway diseases, decompensated interstitial diseases, and pulmonary infections, in a prospective study. Standard formulas were used to calculate the diagnostic sensitivity, specificity, and accuracy. The interobserver agreement with respect to the LA and LUS findings was evaluated based on the Kappa coefficient (ᴋ). RESULTS: A total of 115 patients were studied. LUS was more sensitive than the LA in evaluating pulmonary infections (93.59% vs. 77.02%; p = 0.001) and more specifically in the case of decompensated obstructive airway diseases (95.6% vs. 19.10%; p = 0.001). The diagnostic accuracy of LUS was also greater in the case of pulmonary infections (75.65% vs. 60.90%; p = 0.02). The sensitivity and specificity of the combination of LA and LUS was 95.95%, 50% in pulmonary infections, 76.19%, 100% in case of decompensated obstructive airway diseases, and (100%, 88.54%) in case of interstitial diseases. (ᴋ) was 0.71 for an A-pattern, 0.73 for pathological B-lines, 0.94 for condensations, 0.89 for pleural-effusion, 0.63 for wheezes, 0.38 for rhonchi, 0.68 for fine crackles, 0.18 for coarse crackles, and 0.29 for a normal LA. CONCLUSIONS: There is a greater interobserver agreement in the interpretation of LUS-findings compared to that of LA-noises, their combined use improves diagnostic performance in all diseases examined.

Diagnostic delay of associated interstitial lung disease increases mortality in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a systemic autoimmune disease whose main extra-articular organ affected is the lung, sometimes in the form of diffuse interstitial lung disease (ILD) and conditions the prognosis. A multicenter, observational, descriptive and cross-sectional study of consecutive patients diagnosed with RA-ILD. Demographic, analytical, respiratory functional and evolution characteristics were analyzed to evaluate the predictors of progression and mortality. 106 patients were included. The multivariate analysis showed that the diagnostic delay was an independent predictor of mortality (HR 1.11, CI 1.01-1.23, p = 0.035). Also, age (HR 1.33, 95% CI 1.09-1.62, p = 0.0045), DLCO (%) (HR 0.85, 95% CI 0.73-0.98, p = 0.0246), and final SatO2 (%) in the 6MWT (HR 0.62, 95% CI 0.39-0.99, p = 0.0465) were independent predictor variables of mortality, as well as GAP index (HR 4.65, 95% CI 1.59-13.54, p = 0.0051) and CPI index (HR 1.12, 95% CI 1.03-1.22, p = 0.0092). The withdrawal of MTX or LFN after ILD diagnosis was associated with disease progression in the COX analysis (HR 2.18, 95% CI 1.14-4.18, p = 0.019). This is the first study that highlights the diagnostic delay in RA-ILD is associated with an increased mortality just like happens in IPF.

Social and clinical predictors of short- and long-term readmission after a severe exacerbation of copd.

INTRODUCTION AND OBJECTIVES: The aim of this study was to evaluate the predictive ability of multiple social, and clinical factors for readmission after a severe acute exacerbation of COPD (AECOPD) during various time periods. METHODS: We performed a prospective cohort study in which recruited patients with AECOPD. We systematically collected numerous clinical (symptoms, pulmonary function, comorbidities, and treatment) and social (financial situation, housing situation, family support, caregiver overload, ability to perform activities, and risk of social exclusion) variables using several questionnaires and indices. The patients were followed closely for one year and readmissions at 30, 60, and 365 days were analysed. RESULTS: 253 patients were included, aged 68.9±9.8years, FEV1 = 42.1%±14.2%, and a Charlson's index = 1.8±0.9. Of these patients, 20.2%, 39.6%, and 63.7% were readmitted within the first 30, 90, and 365 days after discharge, respectively. In the multivariate model applied, the variables that were independently associated with readmission over all three periods of the analysis were dependence to perform basic activities of daily living (BADLs) (odds ratio [OR] = 2.10-4.10) and a history of two or more admissions within the previous year (OR = 2.78-3.78). At 90 days, a history of bacterial isolates in a previous sputum culture (OR = 2.39) and at 365 days, a high grade of dyspnoea (OR = 2.51) and obesity (OR = 2.38) were also identified as predictors of hospital readmission. CONCLUSIONS: The patients' limitation to perform BADLs and their history of admissions for AECOPD were the best predictive variables for the likelihood of readmission when adjusted for many other social and clinical variables, regardless of the time period considered for such prediction.

Social Profile of Patients Admitted for COPD Exacerbations. A Gender Analysis. / Perfil social de los pacientes que ingresan por una agudización de EPOC. Un análisis desde una perspectiva de género.

OBJECTIVE: To describe and compare from a gender perspective the social profile of patients admitted to a respiratory unit for COPD exacerbations (COPDE). METHODOLOGY: A cross-sectional study in patients with serious COPDE in which demographic, clinical, and social data (economic situation, care, dependency for basic and instrumental activities, social risk, caregiver overload, use of social services) were collected using questionnaires and indices such as Barthel, Lawton-Brody, Zarit, Barber, and Gijón. A descriptive analysis was made of patients' social and healthcare situation, compared on the basis of gender. RESULTS: We included 253 patients, aged 68.9±9.8years, 58 (23%) women, FEV1 42.1±14.2%, and Charlson index 1.8±0.9; 37.9% were active smokers. In total, 55.2% had an income of less than €800/month, 46.2% had some dependency for basic activities, and 89.3% for instrumental activities, 89% presented social fragility, while 64% were in a situation of social problem/risk; 49% had a caregiver, 83% in a non-formal arrangement, 90.9% of whom were women, with some overload reported by 69.2%. A total of 21.4% lived alone, and 22.9% had contacted social services. Women with COPDE are younger, smoke more actively, and have fewer comorbidities. They have more scant economic resources and assistance and are in a poorer socio-familiar situation, but they are less dependent for some activities. CONCLUSIONS: The social profile of patients with serious COPDE admitted to respiratory units is very unfavorable, especially among women. These inequalities appear to go beyond differences in the expression of COPD, and are associated with gender.

Predicting delays in lung cancer diagnosis and staging.

BACKGROUND: Despite growing interest in increasing the efficiency and speed of the diagnosis, staging, and treatment of lung cancer (LC), the interval from signs and symptoms to diagnosis and treatment remains longer than recommended. The aim of this study was to analyze the factors that cause delays in the LC diagnosis/staging process and, consequently, delays in making therapeutic decisions. METHODS: We analyzed audit data from a prospective dataset of 1330 patients assessed at The Lung Cancer Rapid Diagnostic Unit from 26 June 2013 to 26 March 2016. The number and type of procedures and medical tests and the times of all procedures were recorded. Clinical and epidemiological variables and whether the diagnosis was performed on an inpatient or outpatient basis were also recorded. RESULTS: Malignancy was confirmed in 737 (55.4%) of the 1330 patients, with LC in 627 of these (85.2%). The mean interval to final diagnosis was 19.8 ± 13.9 days. Variables significantly related to a longer diagnostic time were the number of days until computed tomography (CT) was performed (odds ratio [OR], 95% confidence interval [CI] 1.347, 1.103-1.645; P = 0.003), until a histology sample was obtained (OR 1.243, 95% CI1.062-1.454; P = 0.007), and the total number of tests performed during the diagnostic and staging process (OR 1.823, 95% CI 1.046-3.177; P = 0.03). CONCLUSIONS: A greater number of tests and more days to CT and histology led to longer delay times. Optimization of these factors should reduce delays in the LC diagnosis process.

Reliability and usefulness of spirometry performed during admission for COPD exacerbation.

OBJECTIVES: Although not currently recommended, spirometry during hospitalization due to exacerbation of chronic obstructive pulmonary disease (COPD) is an opportunity to enhance the diagnosis of this disease. The aim of the present study was to assess the usefulness and reliability of spirometry before hospital discharge, comparing it to measurements obtained during clinical stability. METHODS: This prospective longitudinal observational study compares spirometry results before and 8 weeks after discharge in consecutive patients admitted for COPD exacerbation. Concordance between results was assessed by the Kappa index, intraclass correlation coefficient, and Bland-Altman graphs. RESULTS: From an initial population of 179 COPD patients, 100 completed the study (mean age 67.8 years, 83% men, 35% active smokers, FEV1 at clinical stability 40.3%). Forty-nine patients could not complete the study because they did not reach clinical stability. In three patients with obstructive spirometry during admission, the results were normal at follow-up. In the remaining patients, the COPD diagnosis was confirmed at stability with acceptable concordance. In 27 cases, spirometry improved more than 200 mL.No variables were found to be associated with this improvement or to explain it. CONCLUSIONS: This study provides information on the role of spirometry prior to hospital discharge in patients admitted for COPD exacerbation, demonstrating that it is a valid and reproducible method, representing an opportunity toimprove COPD diagnosis.

Influence of the type of emphysema in the relationship between COPD and lung cancer.

INTRODUCTION: There are no studies analyzing the relationship between emphysema and lung cancer (LC). With this aim and in order to make some comparisons between different clinical variables, we carried out the present study. METHODS: This is a case-control study, patients with COPD and LC being the cases and subjects with stable COPD being the controls. Clinical and functional parameters, as well as the existence of radiological emphysema, were evaluated in a qualitative and quantitative way, using a radiological density of -950 Hounsfield units as a cutoff point in the images. The existence of several different types of emphysema (centrilobular, paraseptal, panacinar, or bullae) was analyzed, allowing patients to have more than one simultaneously. The extent to which lobes were involved was evaluated and the extension of emphysema was graduated for each type and location, following a quantitative scale. Differences between cases and controls were compared by using bivariate and multivariate analyzes with results expressed as OR and 95% CI. RESULTS: We included 169 cases and 74 controls, 84% men with a FEV1 (%) of 61.7±18.5, with 90.1% non-exacerbators. Most of them (50%) were active smokers and 47.2% were ex-smokers. Emphysema was found in 80.2% of the subjects, the most frequent type being centrilobular (34.4%). The only significantly different factor was the presence of paraseptal emphysema (alone or combined; OR =2.2 [95% CI =1.1-4.3, P = 0.03]), with adenocarcinoma being significantly more frequent in paraseptal emphysema with respect to other types (67.2% vs 32.8%, P =0.03). CONCLUSION: Patients with COPD and paraseptal emphysema could be a risk group for the development of LC, especially adenocarcinoma subtype.

Validation of the portable Air-Smart Spirometer.

BACKGROUND: The Air-Smart Spirometer is the first portable device accepted by the European Community (EC) that performs spirometric measurements by a turbine mechanism and displays the results on a smartphone or a tablet. METHODS: In this multicenter, descriptive and cross-sectional prospective study carried out in 2 hospital centers, we compare FEV1, FVC, FEV1/FVC ratio measured with the Air Smart-Spirometer device and a conventional spirometer, and analyze the ability of this new portable device to detect obstructions. Patients were included for 2 consecutive months. We calculate sensitivity, specificity, positive and negative predictive value (PPV and NPV) and likelihood ratio (LR +, LR-) as well as the Kappa Index to evaluate the concordance between the two devices for the detection of obstruction. The agreement and relation between the values of FEV1 and FVC in absolute value and the FEV1/FVC ratio measured by both devices were analyzed by calculating the intraclass correlation coefficient (ICC) and the Pearson correlation coefficient (r) respectively. RESULTS: 200 patients (100 from each center) were included with a mean age of 57 (± 14) years, 110 were men (55%). Obstruction was detected by conventional spirometry in 73 patients (40.1%). Using a FEV1/FVC ratio smaller than 0.7 to detect obstruction with the Air Smart-Spirometer, the kappa index was 0.88, sensitivity (90.4%), specificity (97.2%), PPV (95.7%), NPV (93.7%), positive likelihood ratio (32.29), and negative likelihood ratio (0.10). The ICC and r between FEV1, FVC, and FEV1 / FVC ratio measured by the Air Smart Spirometer and the conventional spirometer were all higher than 0.94. CONCLUSION: The Air-Smart Spirometer is a simple and very precise instrument for detecting obstructive airway diseases. It is easy to use, which could make it especially useful non-specialized care and in other areas.

Deletion of GSTM1 and GSTT1 genes and lung cancer survival: a systematic review.

PURPOSE: The mechanisms of lung carcinogenesis are not fully understood. Not all smokers develop lung cancer, indicating that genetic variations and other environmental factors may play an important role in its development. The human glutathione S-transferases (GSTs) have been associated with an increased risk of lung cancer. Glutathione S-transferases are phase II biotransformation enzymes that play a role in detoxifying a wide range of exogenous agents including carcinogens but also anticarcinogenic drugs. METHODS: We assessed the effect of allelic deletions in the GSTM1 and GSTT1 genotypes on lung cancer overall survival through a systematic review of the scientific literature after applying predefined inclusion and exclusion criteria. RESULTS: Most of the included studies found no effect or a tendency to worse survival for individuals with deletion of GSTs. CONCLUSIONS: Further studies are necessary to understand the magnitude of the effect of the deletion of both genes on lung cancer survival.

Ten Years of Linear Endobronchial Ultrasound: Evidence of Efficacy, Safety and Cost-effectiveness.

Real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is one of the major landmarks in the history of bronchoscopy. In the 10 years since it was introduced, a vast body of literature on the procedure and its results support the use of this technique in the study of various mediastinal and pulmonary lesions. This article is a comprehensive, systematic review of all the available scientific evidence on the more general indications for this technique. Results of specific studies on efficacy, safety and cost-effectiveness available to date are examined. The analysis shows that EBUS-TBNA is a safe, cost-effective technique with a high grade of evidence that is a valuable tool in the diagnosis and mediastinal staging of patients with suspected or confirmed lung cancer. However, more studies are needed to guide decision-making in the case of a negative result. Evidence on the role of EBUS-TBNA in the diagnosis of sarcoidosis and extrathoracic malignancies is also high, but much lower when used in the study of tuberculosis, lymphoma and for the re-staging of lung cancer after neoadjuvant chemotherapy. Nevertheless, due to its good safety record and lack of invasiveness compared to surgical techniques, the grade of evidence for recommending EBUS-TBNA as the initial diagnostic test in patients with these diseases is very high in most cases.

Lichtheimia ramosa: A Fatal Case of Mucormycosis.

Mucormycosis due to Lichtheimia ramosa is an infrequent opportunistic infection that can potentially be angioinvasive when affecting inmunocompromised hosts. We present a fatal case of mucormycosis, affecting a 56-year-old male with diabetes mellitus and siderosis, initially admitted to our hospital due to an H1N1 infection. The subject's clinical condition worsened and he finally died because of a necrotizing bilateral pneumonia with disseminated mycotic thromboses due to Lichtheimia ramosa, which is an emerging Mucoralean fungus. This is an infrequent case because of the extent to which it affected a subject without overt immunocompromise. This case underlines the importance of an early premortem diagnosis and treatment in order to prevent rapid progression of this disease, as well as the need of considering mucormycosis when facing subjects with multiple emboli and fever unresponsive to usual antimicrobials.

COPD, emphysema and the onset of lung cancer. A systematic review.

Chronic Obstructive Pulmonary Disease (COPD) and emphysema have been described as possible risk factors for lung cancer. We aim to assess the relationship between COPD, emphysema and the onset of lung cancer. We have developed a systematic review of the published literature in order to systematically analyze the scientific evidence available on this association, applying predefined inclusion and exclusion criteria. 11 Studies were included. Both COPD and emphysema seem to increase the risk of developing lung cancer, being this risk higher for smokers with heavier tobacco consumption. These results emphasize the need for physicians to perform spirometries in current and former smokers and lung image tests when needed in order to identify COPD and emphysema and thus select patients at higher risk of developing lung cancer.

Changes in clinical presentation and staging of lung cancer over two decades.

INTRODUCTION: Important clinical and epidemiological changes have been observed in lung cancer (LC) in our healthcare area compared to the previous decade. In the last 10 years, specific LC care circuits have been implemented and the active search for cases has been stepped up. The aim of this study was to analyze the progress of these changes over the last 20 years. METHODS: This is a retrospective study comparing clinical and epidemiological changes between 2 historical cohorts of LC patients (1992-1994 [group 1, 164 patients] and 2004-2006 [group 2, 250 patients]) and a current group from the period 2011-2012 (group 3, 209 patients) RESULTS: Two hundred and nine (209) LC patients were included in group 3 (2011-2012 period). After comparing groups 3 and 2, a non-significant rise in smoking was observed in women (59% vs 41%, p=.25), while the prevalence of adenocarcinoma was unchanged (45% vs 44%, p=.9). The main changes observed were the increase in cases with previous malignancies (23% vs 16%, p=.04), the rise in patients with no associated LC symptoms (33% vs 16%, p<.001), and an increased number of localized NSCLC (non-small cell LC) diagnoses (42% vs 24% in series 2, p<.001 and 14.2% in series 1, p<.001). CONCLUSIONS: The number of LC patients diagnosed in localized stages has increased significantly. Furthermore, the number of patients with no symptoms associated with LC and with a history of previous malignancy were significantly increased.