Predictors of Long-term Mortality after Hospitalization for Severe COPD Exacerbation.

Introduction:Chronic obstructive pulmonary disease (COPD) is a global health problem resulting in significant morbidity. Acute exacerbation of COPD (AECOPD) is a severe complication associated with increased short- and long-term mortality. Identifying predictors of long-term mortality after a severe AECOPD may improve management and long-term outcome of this disease. Materials and methods:A two-year prospective cohort study was undertaken in an academical medical center between 2016 and 2018. Patients with severe AECOPD who required non-invasive ventilation (NIV) were included. Baseline characteristics at inclusion, comorbidities (kidney dysfunction, left heart disease, diabetes), number of prior episodes of AECOPD and indication for long-term oxygen therapy (LTOT) or non-invasive ventilation (LTNIV) were recorded. Patients were monitored for a two-year period after initial admission. Outcomes were six-month, one-year and two-year mortality, irrespective of cause. Outcomes:51 patients (31 male, mean age 68.1) were included in the study. Mortality rates at six months, one year and two years were 20, 26 and 36%, respectively. Patients receiving LTOT and LTNIV at discharge had lower mortality at two years versus patients with no indication for LTOT and LTNIV at discharge. Absence of LTOT increased six-month mortality (OR .2, 95% CI, .04 to .90) and one-year mortality (p<.05). FEV1 and BMI were also correlated with long-term mortality in univariate analysis, p<.05. Age, number of prior episodes of AECOPD or the presence of comorbidities had no influence on long-term mortality. Conclusion:After an episode of severe AECOPD, LTOT is associated with lower long-term mortality when compared to patients with no severe hypoxemia at discharge. A decreased lung function and body mass index increase long-term mortality.

An overview of resistance profiles ESKAPE pathogens from 2010-2015 in a tertiary respiratory center in Romania.

Lower respiratory tract infections (LRTIs) is an umbrella term that covers a wide spectrum of diseases, comprising mild and severe, acute and chronic conditions. A wide spectrum of pathogens can be implicated, from viruses to pyogenic and atypical bacteria. A special place should be reserved for slow growing bacteria (Mycobacteria spp., Nocardia spp.) and parasites (i.e., hydatic cysts caused by Echinococcus granulosus). OBJECTIVE: The objective of this study is to observe, analyze and establish the drug susceptibility patterns for Enterococcus spp., Staphylococcus aureus, Klebsiella spp., Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp. (the ESKAPE pathogens) in the "Marius Nasta" Institute for Pulmonary Medicine (MNIPM), Bucharest, Romania. MATERIALS AND METHODS: A retrospective healthcare record based study was undertaken to establish the drug susceptibility patterns. We assessed all antibiograms of the ESKAPE pathogens isolated from respiratory samples from adult inpatients hospitalized between 2010-2015 at the MNIPM. RESULTS: We analyzed 2859 isolates (61% of the 4683 ESKAPE isolates). P. aeruginosa was the most frequent pathogen, while Enterococcus spp. and Enterobacter spp. were practically non-present. The antibiotic profile of P. aeruginosa isolates presented more resistance in the Intensive Care Unit (ICU)÷Surgery wards, probably resulting from antibiotic pressure. The other non-fermenter, A. baumannii, while less frequent (and the only pathogen more frequent in the surgery department) had an even more resistant profile, to almost all antibiotics, with the exception of Colistin. Methicillin-resistant S. aureus (MRSA) accounted for about 60% of all isolates, more in the ICU÷Surgery ward. K. pneumoniae presents a less resistance and shows more stability when analyzing the antibiogram pattern in the Medical wards. DISCUSSION: For methodological or procedural reasons, Enterococcus spp. and Enterobacter spp. were underrepresented in the study. Interventional programs comprising antibiotic stewardship and active surveillance need to be implemented to alleviate the antibiotic profile. Further research needs to focus on more detailed characterization of the molecular mechanisms leading to the high resistance detailed herein. CONCLUSIONS: This study adds to the body of literature reporting the antibiotic resistance landscape in Romania, for these highly resistant pathogens.

Skin, ear and testis--unusual sites of tuberculosis.

Pulmonary localization is the most common site of tuberculosis (TB)and the most contagious form. Extrapulmonary tuberculosis with the rarest and most unexpected localizations represents a significant proportion of all cases of tuberculosis and remains an important public health problem. We report three unusual TB locations: skin, ear and testis occurred in three immunocompetent patients. In the case of skin and testicular lesions, diagnosis was based on pathological confirmation of granulomas with caseous necrosis. In the third case the diagnosis was made possible by identification of positive Acid-Fast Bacilli smear and positive culture from othic drainage fluid. The outcome at all three patients was good with antituberculous treatment. These unusual localization of tuberculosis also highlight the possibility of extrapulmonary tuberculosis as a differential diagnosis in many common diseases.

Treatment options in stage III non-small cell lung cancer.

Lung cancer is responsible for over 1 million deaths annually, worldwide. The disease becomes symptomatic in advanced stages, so the diagnosis is delayed and 90% of cases cannot benefit from a curative treatment. In NSCLC surgical resection represents the best option for long term survival in resectable stage III and in clinical stage I/II. Patients with stage IIIB or IV usually receive chemotherapy or palliative treatment. For patients with no driver mutation detected platinum based combination chemotherapy is the first choice. Definitive radiotherapy is considered an lternative for patients who are not candidates for combined modality treatment. When a stage IV cancer is diagnosed based on an isolated metastasis, the patient's benefit from the removal of the etastasis and of the primary tumor if it is resectable. The prognosis in NSLC is mainly influenced by the TNM stage at diagnosis. The rate of survival decreases in opposing correlation with the stage of the cancer. Poor performance status, reduced lung capacity, weight loss, vascular invasion are indicators for a poor prognosis

Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea.

BACKGROUND: Positive pressure therapy (CPAP) in patients with cardiac arrhythmias and obstructive sleep apnea (OSAS) may have favorable effects by correcting intermittent hypoxemia and sympathetic activation. OBJECTIVE: To assess the effect of CPAP added to pharmacological treatment in the rate control and prevention of arrhythmias recurrence in patients with OSA. MATERIALS AND METHODS: Prospective, interventional study study which included patients diagnosed with OSAS (cardiorespiratorypolygraphy, AHI>5/hour), and arrhythmias (ECG, Holter ECG), divided in two groups: group A (pharmacological therapy only) and group B (pharmacological therapy and CPAP). The patients were evaluated at enrollment (T0), at 3 and 6 months (T3 and T6) regarding the type, severity and recurrence of cardiac arrhythmias. RESULTS: 36 patients (31 men), mean age: 63.2 ± 12 years were enroled. In group A: 7 patients with ventricular extrasystoles, 8 with permanent atrial fibrillation, 1 patient with atrial flutter and 2 patients with paroxystic supraventricular tachycardia. In group B: 8 patients with ventricular extrasystoles, 5 with permanent atrial fibrillation, 2 patients with recurrent episodes of atrial fibrillation and 3 with paroxystic supraventricular tachycardia. A positive correlation (r: 0.74, p < 0.001) between Oxygen Desaturation Index and AHI was found. At T6, 12 patients from group B, and 18 from group A were evaluated. In group B, the mean heart rate in patients with atrial fibrillation was 69/min., lower than in group A (82/min.), no cases with recurrent atrial fibrillation were found, and more patients with class II Lown ventricular extrasystoles passed in class I Lown, compared to group A. In group B, heart rate statistically correlated with AHI (r: 0.53, p < 0.005). CONCLUSION: In patients with OSAS, adding CPAP to pharmacological therapy has favorable effects on preventing recurrences, heart rate control in patients with atrial fibrillation and in reducing frequency and/or severity of ventricular extrasystoles.

[Uptodate in the management and treatment of ANCA-associated vasculitis]. / Noutati în managementul si tratamentul vasculitelor asociate cu ANCA.

The antineutrophil cytoplasm antibody (ANCA)-associated vasculitis are heterogeneous, multisystem, autoimmune diseases characterized by necrotizing small and medium vessel vasculitis and the association with ANCA. The diagnosis and management of these patients may be challenging due to the variability of clinical features, the possibility of life-threatening events (acute renal failure or pulmonary hemorrhage) and the relative rarity of these syndromes. ANCA-associated vasculitis include granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. The treatment requires significant immunosuppression and there are frequent treatment related side effects. Although the standard protocol with cytotoxic agents and glucocorticoids has dramatically improved patient outcome, its toxic profile remains a major problem. Recent progress in evidence base and consensus in understanding the pathogenic mechanism and the quantification of disease activity further improved patient's life. Special attention was paid in refining immunosuppressive treatment to minimize his toxicity. This review will focus on evidence based treatment of ANCA-associated vasculitis.

[Evidences related to pulmonary rehabilitation in the respiratory pathology]. / Evidente legate de reabilitarea pulmonara în patologia respiratorie.

Pulmonary rehabilitation represents a modern therapeutic approach of respiratory diseases, with a multidisciplinary character, including: physical training, therapeutic education, psychosocial counseling, and nutritional approach. Pulmonary rehabilitation addresses to any patient suffering from pulmonary pathology whose quality of life is affected by the respiratory symptoms, regardless of the degree of functional impairment. This article is an analysis of evidences from the medical literature on outcomes of rehabilitation programs conducted in various lung diseases. The main indication of pulmonary rehabilitation is the chronic obstructive pulmonary disease - COPD (stable state and exacerbation) in which most studies were carried out. Pulmonary rehabilitation in patients with other respiratory pathology has its reason in the pathophysiological changes that they undergo (impaired lung function and gas exchange, muscle atrophy and deconditioning etc.) leading to symptoms, lower exercise tolerance and decrease daily physical activity, all of which ultimately result in impaired quality of life. The role of rehabilitation is reviewed in the following diseases: post-surgical lung volume reduction for emphysema, asthma, bronchiectasis, interstitial lung disease, cystic fibrosis, lung cancer, neuromuscular disease, intensive care, obstructive sleep apnea, pulmonary hypertension, post-tuberculous sequelae, lung transplantation.

[Metabolic profile in obese patients with obstructive sleep apnea. A comparison between patients with insulin resistance and with insulin sensitivity]. / Profilul metabolic al pacientilor cu sindrom de apnee obstructiva în somn si obezitate. Comparatie între pacienti cu insulinorezistenta si pacienti cu insulinosensibilitate.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) may induce metabolic abnormalities through intermittent hypoxemia and simpathetic activation. It is difficult to demonstrate an independent role of OSAS in the occurrence of metabolic abnormalities, as obesity represents an important risk factor for both OSAS and metabolic abnormalities. AIM: to assess the relations between insulin resistance (IR), insulin sensitivity (IS), OSAS severity and nocturnal oxyhaemoglobin levels in obese, nondiabetic patients with daytime sleepiness. MATERIAL AND METHODS: We evaluated 99 consecutive, obese, nondiabetic patients (fasting glycemia < 126 mg/dL, no hypoglycemic or hypolipemiant medication) diagnosed with OSAS (AHI > 5/hour and daytime sleepiness) by an ambulatory six channel cardio-respiratory polygraphy. Hight, weight serum triglycerides (TG), high density lipoprotein-cholesterol (HDL-C) levels were evaluated. Correlations between Apneea Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), average and lowest oxyhaemoglobin saturation (SaO), body mass index (BMI) and insulin resistance or sensitivity were assesed. IR was defined as a TG/ HDL-Cratio > 3, and insulin sensitivity (IS) as a TG/HDL-C ratio < 2. RESULTS: 64 patients (out of 99) had lR and 18 IS. In the IR group (44 men and 20 women), the mean age was 52 +/- 10.6 years, mean BMI: 38.54 +/- 6.67 Kg/m2 (30-60), TG/HDL-C:5, 27 +/- 2.03 (3.02-11.1), mean AHI: 49.65 +/- 25.55/hour (7-110), mean ODI: 4769 +/- 24.95/hour (4-98), mean average SaO2 89.42 +/- 4.6 and mean lowest SaO2 68.4% +/- 13.8% (32-88%). 48 patients had severe, 7 moderate and 9 mild OSAS. In the IS group (10 men and 8 women), the mean age was 58.4 +/- 8.2years, mean BMI: 35.4 +/- 4.29 Kg/m2 (30-46), TG/ HDL-C: 1.64 +/- 0.29 (1.13-1.95), mean AHI: 45.8 +/- 30.3/hour (9-131), mean ODI: 39.9 +/- 32.2/hour (2-133), mean average SaO2 90.8 +/- 8.2 (81-95) and mean lowest SaO2: 74% +/- 10.8% (52-87%). 12 patients had severe, 3 moderate and 3 mild OSAS. Insulin sensitivity positively correlated with mean average SaO2 (r: 0.49; p: 0.037) and negatively with ODI (r: - 0,56; p: 0.014). Insulin resistance negatively correlated with mean lowest SaO2 (r: -0,25; p: 0.045). Mean lowest SaO2 values were significant lower in patients with IR than in those with IS (p: 0.042). No statistically significant difference was found for BMI, AHI or ODI between IR and IS patients. CONCLUSIONS: nocturnal oxyhaemoglobin levels rather than OSAS severity (expressed as AHI or ODI) may be involved in the occurrence of metabolic abnormalities in obese nondiabetic patients. Preserving insulin sensitivity is more likely when oxyhaemoglobin levels are higher and ODI is lower. Mean lowest nocturnal SaO2 levels seems to be independently involved in the development of insulin resistance as no statistically significant differences were found for BMI between the two groups.

[Operability in chronic thromboembolic pulmonary hypertension]. / Operabilitate în hipertensiunea pulmonara cronica postembolica.

UNLABELLED: We present the case of a 86-year-old male patient diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) with proximal bilateral obstructions of the pulmonary arteries. The history included systemic hypertension, benign prostate adenoma and in situ colonic adenocarcinoma, cured by local radiotherapy; no prior history of thromboembolic disease was noted. The work-up comprised of a detailed analysis of pulmonary hemodynamics and right ventricular function by echocardiography and right heart catheterization, imagistic evaluation of the pulmonary circulation by contrast tomography, but also a complete evaluation of the left heart, respiratory function, neurologic status, liver and kidney function. A new colonoscopy confirmed the absence of relapse of the colonic carcinoma. The only curative therapy in proximal CTEPH is pulmonary endarterectomy, a very complex surgical procedures available in only a few centres worldwide. The case was discussed in a multidisciplinary meeting and the indications for surgery were based on exercise tolerance impairment, surgically accessible thrombi, absence of comorbidities and patient informed consent. The limits for the intervention were considered the extreme age and oncological history. The procedure was performed in Cardiovascular surgical department Timisoara, by prof. dr. Walter Klepetko and prof. dr. Marian Gappar, with good clinical and hemodinamic outcome. We present the post surgical side effects and the most important functional parameters of the follow-up. CONCLUSION: pulmonary endarterectomy should be evaluated initially in all patients diagnosed with CTEPH and the old age should not be considered an absolute contraindication if no other significant comorbidities are identified.

Complete therapeutical approach in pulmonary arterial hypertension: from vasodilators to lung transplantation - case report.

We present the case of a 37 years old patient with idiopathic pulmonary arterial hypertension (PAH). After initial treatment with calcium channel blockers (CCB), based on a positive vasoreactive response at right heart catheterization, due to disease progression, major vasodilator therapies were introduced in a sequential strategy: sildenafil, bosentan and treprostinil. Finally, the patient received double-lung transplantation with eventually favourable evolution despite immediate postoperative significant complications. Markers of disease progression were monitored before the transplant, and after the intervention the patient was screened according to a specific protocol for bronchiolitis obliterans and infections. According to our knowledge, this case represents a premiere in Romanian medicine, being the first lung transplant in a PAH patient. This case represents a model of PAH with a documented evolution of 8 years. We present the progression of the disease and the effective therapeutic strategies according to the current guidelines. This case reinforces the need for upgrading the Romanian National PAH Program with the inclusion of prostanoid therapy, as an option for severe patients.

Body composition in patients with chronic obstructive pulmonary disease.

OBJECTIVES: Body composition assessment in chronic obstructive pulmonary disease (COPD) is important, as weight loss and muscular wasting are responsible for low exercise capacity in these patients, and low body mass index (BMI) and fat free mass index (FFMI) are important prognostic factors. Our study aims were: (a) to describe body composition in COPD patients referred to a pulmonary rehabilitation center in Bucharest; (b) to examine the relationships between body composition and disease severity (bronchial obstruction, exercise capacity, quality of life); (c) to test if segmental wasting of lower limbs muscle mass (measured by segmental body composition analysis) correlates with decreased exercise capacity. MATERIAL AND METHODS: We studied 36 consecutive COPD patients referred to our clinic for pulmonary rehabilitation. Patients performed pulmonary function tests, six minutes walking test (6MWT), and health status was evaluated with COPD Assessment Test (CAT). Body composition measurements were performed by direct segmental multi-frequency bioelectrical impedance analysis (BIA). OUTCOMES: This study offers the first data on body composition of Romanian COPD patientsThe prevalence of nutritional depletion (defined by low BMI and/or low FFMI) among our COPD patients was 22.2%. Mean FFMI was significantly lower in normal or underweight patients versus overweight or obese patients. Patients with low FFMI had lower exercise capacity at the 6MWT and higher CAT scores than patients with normal FFMI.Depending on the BMI and FFMI values the patients were divided in four categories: normal, semistarvation, sarcopenia and cachexia. The group of patients with sarcopenia (low FFMI and normal BMI) had the lowest mean MIP (Maximal Inspiratory Pressure), the lowest mean 6MWD (six minutes walking distance) and the higher CAT mean scores among all groups. Exercise capacity was significantly lower in muscular depleted patients (with low skeletal muscle mass index - SSMI). MIP correlated significantly with FFMI and SMMI. No correlations were found between parameters of body composition and FEV1 or CAT. Segmental body composition assessment revealed that unbalanced upper/lower skeletal muscle mass is associated with a lower exercise capacity as measured by 6WMT. CONCLUSIONS: This study offers the first data on body composition of Romanian COPD patients. The prevalence of nutritional depletion is similar to that found in other European studies. No significant correlations were found between FFMI and severity of the disease (bronchial obstruction, distance walked, CAT score). FFMI and SSMI correlated significantly with MIP. Sarcopenic patients had the lowest mean 6MWD, the lowest mean MIP and the highest CAT mean scores. SMMI significantly correlated with 6MWD. Segmental body composition assessment of revealed that "unbalanced" patients had lower results at 6MWT. These results show that body composition evaluation is useful for the assessment of COPD patients referred to pulmonary rehabilitation and should be routinely performed.

New Echocardiographic Tehniques in Pulmonary Arterial Hypertension vs. Right Heart Catheterization - A Pilot Study.

BACKGROUND: Pulmonary arterial hypertension (PAH) represents an emerging pathology in modern medicine. Transthoracic echocardiography is an inexpensive and reproducible method and it is the most commonly used non-invasive diagnostic tool to asses pulmonary artery pressure (PAP) and the function of the right ventricle. Although, the right heart catheterization is still considered as the standard for the diagnosis, according to the last guidelines, the new echocardiographic methods may offer an improved value in the PAH evaluation. AIM: To evaluate if cardiac ultrasonography data correlate with catheterization results in patients with PAH (Group I Dana Point 2008), and to compare the ultrasonography evaluation of PAH patients with that of normal. METHODS: 15 consecutive patients (pts) (52±15 yrs, 5 men, time from onset of symptoms 1.6±1.7 years) with PAH of different aetiologies (12 pts with idiopathic PAH, 2 pts with PAH associated with scleroderma and one with persistent PAH after atrial septal defect (ASD) closure) were evaluated through: 1. clinical examination (NYHA class); 2. exercise capacity (6 minute walking test - 6MWT); 3. conventional echocardiography (diameter of right ventricle - RVD and right atrium, fractional area shortening - FAS, TAPSE, pulmonary ascension time - PA, systolic and mean PAP -sPAP, mPAP, tricuspid E/A ratio, cardiac index-CI) and 4. Tissue Doppler Imaging - TDI (systolic and diastolic myocardial velocities at the tricuspid annulus - S, D, A); 5. right heart catheterization (sPAP, mPAP, CI, pulmonary vascular resistance - PVR)We compared classical and TDI echo parameters with those obtained from 15 normal subjects, matched in age and sex. RESULTS: PAH patients had high sPAP and mPAP with right heart dilation (RV - 44.8±7.3 mm), depressed TAPSE (16.2±5.9 mm) and cardiac index and low TDI systolic velocities at tricuspid level (7.3±2.9 cm/s). All parameters differed statistically significant from normal. There were no significant correlations between ultrasonography and catheterization (cath) parameters (sPAP 92±28.2 echo vs. 106.4±25.8 mmHg cath; mPAP 47.9±8.4 echo vs. 65.8±17.3 mmHg cath), excepting for CI 2.3±1.2 l/min/m(2) vs. 2.08±0.3 ml/min/m(2)) and PVR (16.5 ± 15.3 Wood U echo, vs. 19.6 ± 7.9 cath). CONCLUSION: Classic and TDI cardiac ultrasonography represents a good screening and monitoring tool for PAH patients, but tends to underestimate the severity of the disease, leaving right heart catheterization as the essential diagnostic method for this rare disease.

Prevalence and Characteristics of Pulmonary Hypertension Associated with COPD - A Pilot Study in Patients Referred to a Pulmonary Rehabilitation Program Clinic.

OBJECTIVES: Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmo-nary disease (COPD); its prevalence is currently unknown. The objectives of the study were: (a) to provide data on the prevalence of PH among the COPD patients referred to a pulmonary rehabilitation program; (b) to evaluate possible correlations of PH with the severity of COPD, the presence of hypoxemia and polycythemia. MATERIAL AND METHODS: We retrospectively studied 31 consecutive patients with the diagnosis of COPD hospitalised in our clinic in which echocardiography was performed. Spirometry, peripheral oxygen saturation, haematocrit, echocardiography data, history of exacerbations and cardiac comorbidities were obtained from patients records. PH was defined as systolic pulmonary arterial pressure (sPAP) greater than 35 mmHg or by the presence of right ventricle (RV) abnormalities. OUTCOMES: The prevalence of PH was 38.7%. Resting hypoxemia was significantly more frequent in the PH group than in the non PH patients (p=0.019). Other differences were not statistically significant (severity of bronchial obstruction and polycythemia, cardiac comorbidities). The impact of PH on RV was found in only 5 patients with RV enlargement; no patient had RV hypertrophy or RV systolic dysfunction. Suspected "out of proportion" PH (sPAP greater than 50 mmHg) was encountered in 2 out of 12 patients with PH. CONCLUSIONS: The prevalence of PH in patients with COPD was 38.7%. Resting hypoxemia was significantly more frequent in PH patients. As PH has an important role in the prognosis of COPD patients, it should be evaluated in as many COPD patients as possible.

[Respiratory muscle training in pulmonary rehabilitation]. / Antrenamentul muschilor respiratori în reabilitarea pulmonara.

Respiratory muscles are essential in maintaining normal ventilation and adequate gas exchanges. Any imbalance in their function can lead to clinical symptoms: dyspnea, hypercapnia, exercise intolerance, ineffective cough. In the pulmonary rehabilitation a particular area is represented by the respiratory muscle training in various lung diseases. Inspiratory muscles training, particularly in COPD patients, has a beneficial effect, resulting in increased strength and endurance of respiratory muscles, decreased dyspnea level, improved quality of life and exercise tolerance. It is a therapy that can be used alone or in combination with generalized physical training, especially in patients with inspiratory muscle weakness.

Unilateral pulmonary hilar tumor mass: is it always lung cancer?

Sarcoidosis is a multisystem inflammatory disease of unknown etiology, characterized by noncaseating epithelioid cell granulomas. In sarcoidosis, the most common radiological findings are mediastinal and bilateral hilar lymph node enlargement. We present a case of sarcoidosis with a rare radiological aspect of pulmonary hilar tumor mass.A 54-year-old female patient, active smoker (40 packs/year), with a history of cutaneous lupus, was admitted in our institute for progressive dyspnea and dry cough. At admission physical examination and laboratory tests were normal. Pulmonary function tests diagnosed an obstructive syndrome. Chest X-ray showed a tumor mass of the right pulmonary hilum. Transbronchial biopsy was nondiagnostic. HRCT-scan showed a tumor mass in the right hilum, which raised the suspicion of a lung cancer. PET-CT scan revealed a high metabolic activity of the tumor mass and of a paratracheal right lymphadenopathy. Lymph node biopsy by mediastinoscopy showed noncaseating epithelioid-cell granulomas, sustaining the diagnosis of sarcoidosis. The outcome was favorable, with spontaneous remission without treatment, but with a relapse that responded after systemic corticotherapy.In conclusion, even if a tumor mass in the pulmonary hilum is highly suggestive of lung cancer, a positive diagnosis should be made only after histological examination, because other benign conditions, like sarcoidosis, could have such an aspect.

A rare case of lung tumor -- pulmonary inflammatory pseudotumor.

Pulmonary inflammatory pseudotumor (PIP) is a rare condition of unknown etiology. It is still a matter of debate if it represents an inflammatory lesion characterized by uncontrolled cell growth or a true neoplasm. Although mostly benign, these tumors are diagnosis and therapeutic challenges. Preoperative diagnosis can rarely be established. The treatment of choice is surgical resection which has both diagnostic and therapeutic value. We report the case of a 63-year-old male presented with clinical and imagistic picture suggestive of malignancy in the thorax. Lobectomy was performed with histological diagnosis of PIP. No evidence of tumor recurrence.

[Therapeutical approach in severe exacerbation of COPD associating obstructive sleep apnoea and obesity]. / Atitudine terapeutica în exacerbarea severa a BPOC care asociaza sindrom de apnee în somn si obezitate.

COPD exacerbations with respiratory acidosis are difficult to manage, especially when OSA and obesity are associated. The solution is the use of noninvasive ventilation associated with oxygenotherapy in order to correct the hypercapnia, hypoxemia and respiratory acidosis and to prevent the invasive mechanical ventilation. Early respiratory rehabilitation and the use of a domiciliary ventilatory support after the acute episode could be a part of the management for these patients. We present a modality of therapeutical approach through a clinical case.

[Radiation induced lung injuries secondary to radiotherapy for breast cancer]. / Tipuri de leziuni pulmonare secundare radioterapiei pentru cancer mamar.

UNLABELLED: Modern radiotherapy decreased the number and severity of the effects of irradiation on the lung. Yet, the increased cancer incidence makes the related radiation injuries to remain actual, radiotherapy being frequently used in cancer treatment. Aim of the study consists in analysis of the radiological pattern of radiation induced lung disease due to radiotherapy for breast cancer. MATERIAL AND METHOD: Sixty-eight female patients were evaluated for clinical and radiological suspicion of radiation pneumonitis after radiotherapy for breast cancer between 2001 and 2009 in "Marius Nasta" Institute of Pneumophtiziology, Bucharest. The following procedures were performed: medical history, physical examination, chest radiography and CT-scan (in a subgroup of 27 patients). Radiotherapy toxicity was evaluated based on the RTOG/EORTC (Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer) classification and radiological lesions based on Arriagada classification. RESULTS: Fifty patients (73.5%) were symptomatic (fever, dry cough, dyspnea, chest pain, fatigability), the other 18 were asymptomatic. Symptoms were mild to moderate corresponding to grade 1 (27 patients, 39.7%) or grade 2 (23 patients, 33.8%) according to RTOG/EORTC scale. All patients had radiological lesions: 25 patients (36.7%) had grade 2 lesions (linear opacities), 25 patients (36.7%) had grade 3 lesions (patchy opacities) and 18 patients (26.5%) had grade 4 lesions (dense opacities), according to Arriagada classification. Symptoms were more frequent in patients with extensive lesions on chest radiography. CT-scan, performed in 27 patients, showed more accurate images. CONCLUSIONS: Chest radiography remains the simplest method in screening for radiation pneumonitis and monitoring its outcome. Adverse effects secondary to radiotherapy are usually mild and self-limited, and the most difficult task remains the differential diagnosis with infections and cancer relapse.

The bronchoalveolar lavage pattern in radiation pneumonitis secondary to radiotherapy for breast cancer.

BACKGROUND AND PURPOSE: Radiotherapy in breast cancer patients is limited by lung tissue tolerance. Two complications involving the lung are known: radiation pneumonitis (RP) and radiation fibrosis. The aim of the study was to evaluate the pattern of bronchoalveolar lavage (BAL) in patients with RP after radiotherapy for breast cancer in symptomatic and asymptomatic patients. MATERIAL AND METHODS: Sixty-five female patients (mean age 58.3 yrs) with RP after radiotherapy for breast cancer were included in the study. The majority of patients had previous breast surgery (mastectomy or lumpectomy and axillary dissection) and received doses of radiations of 45-50Gy. All patients had adjuvant chemotherapy with cyclophosphamide, 5-fluorouracil, and epirubicin or methotrexate. RESULTS: All patients had an infiltrate or consolidation on chest radiography confined to the upper lobe of the irradiated lung, as marker of RP. Based on the presence or absence of symptoms, we divided the patients in 2 groups: 49 patients (75.4%) with symptomatic RP (fever, cough, dyspnea, chest pain and fatigue) and 16 patients (24.6%) without any symptom. Symptomatic RP patients had a BAL with significant increase in total cells (18.0±12.2 x10(6) cells•100mL-1) when compared to BAL in asymptomatic patients (11.9±6.2 x10(6) cells•100mL-1), p=0.01. Lymphocytosis in BAL was significantly increased in symptomatic group, compared with asymptomatic one (35.4±18.7% vs. 26.1±14.3%, p=0.045), with predominance of T lymphocytes (CD3). It was also a predominance of CD4 lymphocytes in all patients, but the CD4/CD8 ratio was inside normal range in the majority of cases. Five patients had clinical features of bronchiolitis obliterans organizing pneumonia (BOOP) secondary to irradiation with increased percentages of lymphocytes, neutrophils, eosinophils, and mast cells in BAL and one patient without history of atopic disease had a percentage of 40% eosinophils. Only a mild reduction in diffusing capacity for carbon monoxide was seen in both groups on pulmonary function tests. The lung volumes were normal in all patients. CONCLUSIONS: Lymphocytic alveolitis was the marker of radiation pneumonitis in all patients. The degree of the inflammatory reaction of the lungs was correlated with the presence of symptoms. The lymphocytic alveolitis consisted mainly of T lymphocytes, with a predominance of CD4 subset in both groups, but the CD4/CD8 ratio remained mostly into normal range.