Coping, Anxiety, and Pain Intensity in Patients Requiring Thoracic Surgery.

Stress, anxiety, and post-surgical chest pain are common problems among patients with thoracic surgical pathology. The way in which psychological distress is managed-the coping style-can influence the postsurgical evolution and quality of life of patients. In our study, we monitored the influence of coping style on patients' anxiety and the intensity of post-operative chest pain. We conducted a cross-sectional study on 90 subjects with thoracic surgical pathology. One month after their surgeries, patients completed the following scales and questionnaires, translated, adapted, and validated for the Romanian population: COPE scale inventory, Generalized Anxiety Disorder-7 Questionnaire, McGill Pain Questionnaire, and Numeric Pain Rating Scale. Anxiety (evaluated using the Generalized Anxiety Disorder-7 Questionnaire) and postoperative thoracic pain intensity (evaluated by means of the Numeric Pain Rating Scale, Number of Words Chosen, and McGill Pain Questionnaire) were significantly higher in patients exhibiting social-focused coping than in patients presenting emotion-focused or problem-focused coping as their main coping style (Kruskal-Wallis, p = 0.028, p = 0.022, p = 0.042, p = 0.007). In our study, there were no differences observed in pain intensity relative to level of anxiety. Coping style is an important concept in the management of anxiety and pain experienced by patients undergoing chest surgery. Therefore, a multidisciplinary approach should be considered in clinical practice.

Ultrasound mapping of lung changes in idiopathic pulmonary fibrosis.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is the most common and severe form of idiopathic interstitial pneumonia, accounted for 20% of cases of interstitial lung disease (ILD). In this study, we sought to compare the lung changes of IPF using a lung ultrasound (LUS) protocol of 12 zones with "current standard" high resolution computed tomography (HRCT) diagnostic method and overlap it with the functional pulmonary test as a complete clinical and imaging evaluation. METHODS: Thirty-one patients were included in the study and performed HRCT and pulmonary functional tests (PFT). A 12-lung zones' LUS protocol was used and compared with HRCT and PFT. RESULTS: The HRCT total fibrotic score had a correlation coefficient of 0.454 (P < 0.005) with predicted FVC and 0.713 with predicted DLCO (P < 0.001). Both the median of the number of B-lines and the average of the thickness of the pleural line obtained in the LUS assessment had a positively and statistically significant correlation with the HRCT fibrotic score P < 0.001. The pleural thickness of 2.4 mm is the cut-off value of the mild form of fibrosis with a sensitivity of 0.958 and a specificity of 0.994. CONCLUSION: B-lines and the average thickness of the pleural line as LUS markers of the fibrotic interstitial syndrome are highly and positively correlated with HRCT score, FVC and DLCO. LUS as a complementary method in the clinical management of IPF could be used more often by skilled clinicians to assess patients in terms of possible diagnosis and monitoring of IPF.

Impact of moderate to severe obstructive sleep apnea on the cognition in idiopathic pulmonary fibrosis.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a relentlessly progressive lung disease with a fatal prognosis to whose rapid evolution multiple comorbidities may contribute, one of the most common being obstructive sleep apnea (OSA). There are several potential factors and conditions for the emergence of a cognitive deficit in relation to IPF or associated morbidities. OBJECTIVES: The goals of this study were to assess cognition in patients with IPF in stable phase and to identify clinical cognition modifiers. METHODS: In a cross-sectional study, 23 patients with IPF were evaluated using Montreal Cognitive Assessment (MoCA), an instrument for detecting mild cognitive impairments and were screened for OSA through overnight cardiorespiratory polygraphy and for anxiety and depression with three specific scale (Generalized Anxiety Disorder 7-item scale: GAD-7; the Patient Health Questionnaire: PHQ-9; Hospital Anxiety and Depression Scale: HADS). RESULTS: MoCA score was lower in patients with IPF when compared to controls subjects (24 [21,26] vs. 27 [26,28], p = 0.003) but not as significantly as in COPD patients (21 [18.8,23.3], p<0.0001). OSA was diagnosed in 19 (82.6%) IPF patients, 12 patients showed the presence of moderate-severe forms (63.15%). IPF patients with cognitive impairment (MoCA<23) exhibit a higher severity of OSA (apneea hypopnea index-AHI: 33.0±19.1 vs. 12.44±8.2, p = 0.018), and a higher Epworth score (7.1±3.3 vs. 4.3±1.8, p = 0.013). Anxiety and depression scores were not correlated with MoCA results. CONCLUSIONS: Impaired cognition in patients with IPF is mild and affect the areas of visuospatial abilities, language and working memory. OSA could be a possible predictor of IPF cognition deficit. Given the high prevalence of multiple types of sleep disorders in IPF patients, these should be investigated at least by cardiorespiratory polygraphy.

The reliability of lung ultrasound in assessment of idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is the severest form of idiopathic interstitial pneumonia, with a median survival time estimated at 2-5 years from the time of diagnosis. It occurs mainly in elderly adults, suggesting a strong link between the fibrosis process and aging. Although chest high-resolution computed tomography (HRCT) is currently the method of choice in IPF assessment, diagnostic imaging with typical usual interstitial pneumonia (UIP) provides definitive results in only 55%, requiring an invasive surgical procedure such as lung biopsy or cryobiopsy for the final diagnostic analysis. Lung ultrasound (LUS) as a noninvasive, non-radiating examination is very sensitive to detect subtle changes in the subpleural space. The evidence of diffuse, multiple B-lines defined as vertical, hyperechoic artifacts is the hallmark of interstitial syndrome. A thick, irregular, fragmented pleura line is associated with subpleural fibrotic scars. The total numbers of B-lines are correlated with the extension of pulmonary fibrosis on HRCT, being an LUS marker of severity. The average distance between two adjacent B-lines is an indicator of a particular pattern on HRCT. It is used to appreciate a pure reticular fibrotic pattern as in IPF compared with a predominant ground glass pattern seen in fibrotic nonspecific interstitial pattern. The distribution of the LUS artifacts has a diagnostic value. An upper predominance of multiple B-lines associated with the thickening of pleura line is an LUS feature of an inconsistent UIP pattern, excluding the IPF diagnosis. LUS is a repeatable, totally radiation-free procedure, well tolerated by patients, very sensitive in detecting early changes of fibrotic lung, and therefore a useful imaging technique in monitoring disease progression in the natural course or after initiation of treatment.

Clinical profile of unclassifiable interstitial lung disease: Comparison with chronic fibrosing idiopathic interstitial pneumonias.

Objective Unclassifiable interstitial lung disease (ILD) is a common problem in clinical practice. These patients pose a distinct challenge with regard to appropriate evaluation and management. We investigated the clinical features and prognosis of unclassifiable ILD and compared its clinical profile with that of idiopathic pulmonary fibrosis (IPF) and idiopathic nonspecific interstitial pneumonia (NSIP). Methods Patients with IPF (n = 40), NSIP (n = 14), and unclassifiable ILD (n = 27) were selected from an ongoing database. Baseline clinical features, pulmonary function, and the extent of fibrosis on high-resolution computed tomography (HRCT) were evaluated. Mortality was estimated based on the ILD-Gender, Age, Physiology (ILD-GAP) index and composite physiologic index (CPI). Results IPF was associated with the worst survival (hazard ratio [HR] = 4.361 compared with NSIP), followed by unclassifiable cases (HR = 1.251 compared with NSIP). Increasing mortality was significantly impacted by age (HR = 1.04 per 1-year increase), lower carbon monoxide diffusing capacity of the lung (HR = 0.97), HRCT interstitial score (HR = 1.119 per 1-point increase), ILD-GAP score (HR = 1.570 per 1-point increase), and CPI (HR = 1.039 per 1-point increase). Conclusions Patients with unclassifiable ILD had an intermediate prognosis between that of IPF and NSIP. Patients at high risk of mortality can be identified using baseline clinical, physiological, and radiological features.

European screening for alpha1 -antitrypsin deficiency in subjects with lung disease.

BACKGROUND AND AIMS: Alpha1 -antitrypsin deficiency (AATD) predisposes individuals to early-onset emphysema. Despite its prevalence, especially among patients with chronic obstructive pulmonary disease, AATD is still underdiagnosed. The aim of this study is to identify individuals with lung disease and severe AATD in central-eastern Europe. METHODS: Subjects with respiratory symptoms that could be indicative of AATD provided blood samples as dried blood spot. The alpha1 -antitrypsin (AAT) concentration was determined by nephelometry and, if lower than 1.70 mg/dL in dried blood spot (equivalent to 1.04 g/L in serum), polymerase chain reaction was used to detect the PiS and PiZ alleles. Isoelectric focusing was used for confirmation of doubtful genotype results. RESULTS: From 13 countries, 11 648 subjects were included. Genotyping of 1404 samples with AAT levels <1.70 mg/dL revealed 71 (5.06%) PiS, 151 (10.8%) PiZ, 1 (0.071%) PiSS, 8 (0.57%) PiSZ and 32 (2.28%) PiZZ. Phenotyping of 1363 samples negative for the S and Z alleles or with PiS and PiZ genotype showed two (0.147%) PiZ(rare) and two (0.147%) Pi(null)(null). The countries with the highest rate of severe AATD were Croatia, Russia and Slovakia. By regions, the Baltic countries area showed the highest rate of both PiZ and severe AATD (2.45% and 1.20%, respectively) while the lowest rates were observed in the Balkan Peninsula (0.48% and 0.31%, respectively). CONCLUSION: This study confirms the need for targeted testing of symptomatic patients and provides AATD genotype data from countries for which only some estimates of prevalence were available until now.

Chronic obstructive pulmonary disease phenotypes and balance impairment.

BACKGROUND/OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in airflow limitation and respiratory distress, also having many nonrespiratory manifestations that affect both function and mobility. Preliminary evidence suggests that balance deficits constitute an important secondary impairment in individuals with COPD. Our objective was to investigate balance performance in two groups of COPD patients with different body compositions and to observe which of these groups are more likely to experience falls in the future. METHODS: We included 27 stable COPD patients and 17 healthy individuals who performed a series of balance tests. The COPD patients were divided in two groups: emphysematous and bronchitic. Patients completed the activities balance confidence scale and the COPD assessment test questionnaire and afterward performed the Berg Balance Scale, timed up and go, single leg stance and 6-minute walking distance test. We analyzed the differences in the balance tests between the studied groups. RESULTS: Bronchitic COPD was associated with a decreased value when compared to emphysematous COPD for the following variables: single leg stance (8.7 vs 15.6; P<0.001) and activities balance confidence (53.2 vs 74.2; P=0.001). Bronchitic COPD patients had a significantly higher value of timed up and go test compared to patients with emphysematous COPD (14.7 vs 12.8; P=0.001). CONCLUSION: Patients with COPD have a higher balance impairment than their healthy peers. Moreover, we observed that the bronchitic COPD phenotype is more likely to experience falls compared to the emphysematous phenotype.

Interstitial lung disease as first clinical manifestation within the antisynthetase syndrome--dermatomyositis.

Diffuse interstitial pneumopathies within the diseases of the connective tissue are often a diagnosis challenge, sometimes being the initial or dominant manifestation of the underlying autoimmune disease. The case of a young man shall be presented with relatively quick dyspnoea which has appeared under the conditions of an efficient physical status and without any notable pathological history. The cause of the dyspnoea is found to be a interstitial lung disease with radiological and histopathological pattern of non-specific interstitial pneumonia. The disease screening system discovers Ac anti Ro-52 which commits research in the direction of an autoimmune disease, confirmed by highlighting Ac anti PL-7 as being an antisynthetase syndrome. Subgroup of idiopathic inflammatory myopathies, the antisynthetase syndrome is a rare chronic autoimmune disease, which is characterised by the presence of antibodies directed against aminoacyl-t-RNA-synthetases (family of intracytoplasmic enzymes with a vital role in the protein synthesis). Shortly after specifying the relevant immunological status, the consistent clinical expression with dermatomyositis is also configured. The treatment is commenced with systemic corticoid and azathioprine; despite the treatment we are witnessing a slowly progressive clinical and functional deterioration.

Short telomeres in pulmonary fibrosis: from genetics to clinical significance.

Pulmonary fibrosis has been linked molecularly and pathophysiologically by abnormal telomere maintenance. Short telomere lengths are commonly found in both the familial and sporadic forms, telomerase mutations being the most common identifiable genetic cause of the disease. Telomeres are repeated nucleotide sequences that cap the ends of chromosomes and protect them from damage. Telomeres are eroded with cell division and shorten with age. Telomere integrity is mediated by the telomerase complex, a specialized polymerase that adds sequences to the ends of chromosomes. Mutations in the genes encoding telomerase (TERT and TERC) cause pulmonary fibrosis through low telomerase activity, accelerated telomere shortening and exhaustion of lung stem cells. Mutations in TERTor TERC account for only 19% of familial pulmonary fibrosis cases, and it is likely that additional environmental, genetic and epigenetic factors contribute to telomere erosion and to disease phenotype. Identification of short telomeres has potential clinical implications in pulmonary fibrosis: it may be a marker for an increased predisposition toward the development of the disease, it might affect risk stratification as it has been associated with lower survival rates and post-transplant complications that reflect the syndromic nature of this molecular defect.

Impact of medical education program on COPD patients: a cohort prospective study.

BACKGROUND: The main objective of this study was to assess the effects of intensive medical education courses on chronic obstructive pulmonary disease (COPD)-related rehospitalizations and emergency department visits and the secondary aim was to monitor quality of life. METHODS: This cohort prospective study included 76 group D COPD patients (pts.). Patients from the intervention group (IG, 52 pts.) underwent a program comprising two components: a comprehensive medical education program (1h/day for 5 days) and a specific drug therapy. Control group (CG, 24 pts.) received only drug therapy. Patients underwent spirometry and completed St. George's Respiratory Questionnaire (SGRQ) at the time of inclusion and at periodical evaluations performed every three months for a year. RESULTS: Patients included in a medical education program showed significant decrease of exacerbation rate compared with the CG. Patients from the IG group had fewer emergency department visits within a year compared with the CG. Patients from the IG had significantly better quality of life scores (both at 3 and 6 months) compared with the CG. CONCLUSIONS: This study reveals that an adequate medical education program is associated with a decreased rate of COPD-related hospitalizations. The implementation of a medical education program as an integrated part of therapy could lead to a more accurate self-management of the disease.

Balance impairment in patients with COPD.

BACKGROUND/PURPOSE: Chronic obstructive pulmonary disease (COPD) is a respiratory disease that results in progressive airflow limitation and respiratory distress. Physiopathological features of COPD suggest that people who suffer from this disease have many risk factors for falls that have been identified in older individuals. The aim of the study was to compare and quantify functional balance between COPD patients and healthy subjects; to investigate the risk of falls in acute stages of the disease and to identify risk factors that could lead to falls. METHODS: We studied 46 patients with moderate-severe COPD (29 stable and 17 in acute exacerbation--AECOPD) and 17 healthy subjects (control group) having similar demographic data. We analyzed the difference in Berg Balance Scale (BBS), Single Leg Stance (SLS) and Timed Up and Go test (TUG) between these three groups and the correlation of these scores with a number of incriminatory factors. RESULTS: The presence of COPD was associated with significant worsening of balance tests: BBS (55 control, vs. 53 COPD, vs. 44 AECOPD points p<0.001), TUG (8.6 control vs. 12.3 COPD vs. 15.9 AECOPD seconds. p<0.001), SLS (31.1 control vs. 17.7 COPD vs. 7.2 AECOPD seconds p<0.001) which may be associated with an increased risk of falls. Anxiety and depression were significantly associated with decreased balance test scores; anxiety (2 control vs. 6 COPD vs. 9 AECOPD points p<0.001) depression (2 control vs. 7 COPD vs. 12 AECOPD points p<0.001). CONCLUSIONS: According to our results COPD patients in moderate-severe stages and especially those in exacerbation have a high risk of falls.

Cognitive impairment in chronic obstructive pulmonary disease.

BACKGROUND/PURPOSE: Chronic obstructive pulmonary disease (COPD), especially in severe forms, is commonly associated with multiple cognitive problems. Montreal Cognitive Assessment test (MoCA) is used to detect cognitive impairment evaluating several areas: visuospatial, memory, attention and fluency. Our study aim was to evaluate the impact of stable COPD and exacerbation (AECOPD) phases on cognitive status using MoCA questionnaire. METHODS: We enrolled 39 patients (pts), smokers with COPD group D (30 stable and 9 in AECOPD) and 13 healthy subjects (control group), having similar level of education and no significant differences regarding the anthropometric measurements. We analyzed the differences in MoCA score between these three groups and also the correlation between this score and inflammatory markers. RESULTS: Patients with AECOPD had a significant (p<0.001) decreased MoCA score (14.6±3.4) compared to stable COPD (20.2±2.4) and controls (24.2±5.8). The differences between groups were more accentuated for the language abstraction and attention (p<0.001) and delayed recall and orientation (p<0.001) sub-topics. No significant variance of score was observed between groups regarding visuospatial and naming score (p = 0.095). The MoCA score was significantly correlated with forced expiratory volume (r = 0.28) and reverse correlated with C-reactive protein (CRP) (r = -0.57), fibrinogen (r = -0.58), erythrocyte sedimentation rate (ESR) (r = -0.55) and with the partial pressure of CO2 (r = -0.47). CONCLUSIONS: According to this study, COPD significantly decreases the cognitive status in advanced and acute stages of the disease.

Lymphangiogenesis as a prerequisite in the pathogenesis of lung fibrosis.

Despite increasing knowledge on the cellular and molecular mechanisms involved in pulmonary fibrosis, its therapeutic options are still limited. The study of lymphangiogenesis has contributed to a better understanding of tumor growth and metastasis, with a major impact upon changes in therapeutic strategies and this was followed by the research of lymphatic vessels in other pathological conditions. Some data support the possible role of lymphangiogenesis in the pathogenesis of lung fibrosis. However, at the time of diagnosis for each patient with a fibrotic interstitial lung disease, it is necessary to predict the prognosis and to choose for individual targeted-therapy. Our aim was the characterization of lymphangiogenesis as a useful tool to stratify patients with lung fibrosis. We evaluated the presence, morphology and density of D2-40-positive lymphatic vessels and co-localization of D2-40/Ki67 in pulmonary fibrosis with different degrees of severity and without a specific etiology. Lymphatic vessel density did not correlate with severity grade and ranged between 4.66 to 38.33 vessels/×40 field, with the highest value in degree III of fibrosis. An intense proliferative activity of lymphatic endothelial cells was found in 24% (6 out of 25) of cases. The morphology of lymphatics and the presence of splitting combined with the proliferative activity of endothelial cell pillars suggested two different mechanisms in the formation new lymphatic vessels. Our results support the hypothesis that the activity and ongoing evolution of fibrosis can be predicted through the characterization of lymphangiogenesis but its presence or absence cannot predict the severity of fibrosis.

Changes in physical activity in healthy people and COPD patients.

PURPOSE: Pedometry is an objective method to analyse part of physical activity. The aims of this study were to evaluate physical activity (by quantifying walking steps/day) in Romanian chronic obstructive pulmonary disease (COPD) patients and healthy subjects. METHODS: A total of 58 COPD patients (GOLD stages III and IV) and 273 healthy subjects, divided by decades of age, wore pedometers for 2 weeks. RESULTS: Significant decrease of physical activity level was observed in COPD patients vs. control group (3,414 ± 1,105 vs. 7,200 ± 2,452 steps/day). Walking performance of patients with COPD stage III was better than that of patients with COPD stage IV. For both groups, the lowest activity level was recorded during the weekend. Patients with COPD could not perform any aerobic movement. CONCLUSIONS: This study revealed a difference of physical activity in both healthy individuals and COPD patients, in the latter group the decrease being worse and in accordance with the disease severity.

Long-term effects of nocturnal continuous positive airway pressure therapy in patients with resistant hypertension and obstructive sleep apnea.

Obstructive sleep apnea (OSA) is often linked to high blood pressure and has a particularly high prevalence in patients with resistant hypertension. The effect of continuous positive airway pressure (CPAP) therapy on blood pressure (BP) values has been evaluated in several short-term clinical trials with conflicting results. Our aim was to investigate the role of long-term CPAP treatment in achieving BP control in patients who associate OSA and resistant hypertension. We have included in the study 33 patients with resistant hypertension, diagnosed with OSA in our sleep lab. Data was collected initially and after a mean follow-up period of 4 years. Patients were divided into 2 groups according to the use of CPAP therapy. Patients under CPAP therapy (n = 12) exhibited a higher reduction in both systolic and diastolic pressure and BP control was achieved in 75% of cases, while patients without CPAP treatment (n = 21) remained with refractory hypertension in proportion of 90.5%. A de-escalation of antihypertensive drug regimen by discontinuation of 1 or more drugs was observed in 41.6% (n = 5) of patients from CPAP group and in the other 33.4% (n = 4) the medication remained unchanged, but BP control was reached. Using a direct logistic regression model for examining the impact of different confounders on the probability of diagnosis of resistant hypertension at follow-up, the only statistically significant predictor found was the lack of CPAP usage.

The usefulness of pedometry in patients with chronic obstructive pulmonary disease.

BACKGROUND: Effort tolerance and daily physical activity (DPA) are predictive of quality of life and survival in COPD patients, but still remain difficult to assess based on their daily life.The aim of this study was: how to relate pedometry to other classic parameters commonly used in pulmonary rehabilitation (PR). METHODS: DPA was evaluated through pedometry. 74 patients with COPD, aged 63.55 ± 8.73 (12 stage II, FEV1 = 60.16 ± 7.78%), (29 stage III, FEV1 = 39.07 ± 6.30%), (33 stage IV, FEV1 = 23.1 ± 7.18%). The monitoring was conducted for a period of 7 days before and 6 months after a pulmonary rehabilitation program (PRP) of 3 weeks. A control group consisting of 21 patients with stable COPD was evaluated initially, but they did not undergo Pulmonary Rehabilitation Program (PRP). After 6 months the patients were re-evaluated using the same parameters. RESULTS AND DISCUSSION: The values are widely dispersed, with a maximum of 17,420 and minimum of 964 steps/24hrs. The average values acquired were: the lowest in COPD stage IV (2476→3112 steps/24 hrs, p < 0.0001), still with the highest increase over 6 months of PR + 636steps/24hrs; in COPD stage III the increase of DPA was + 597steps/24hrs over 6 months (5627→6224, p < 0.0001), COPD stage II registered the lowest increase + 540steps/24hrs (8724→9264, p < 0.13), probably because the subjects belonging to this stage had the best preserved DPA. The results show moderate correlation between pedometry and the 6MWT and the SGQ. (r = 0.5-0.7). However it demonstrated the positive effects of PRP, even after 6 months. CONCLUSIONS: DPA decreases with increasing COPD stage, it is fluctuant with every subject, dependent on clinical status, weather and daily schedule. Wearing pedometers is very easy and motivational, provided that patients realize that they are being "watched".

[Romanian national registry for interstitial lung diseases and sarcoidosis (REGIS): rationale and methods]. / Registrul National de Pneumopatii Interstitiale Difuze si Sarcoidoza (REGIS): justificare, metodologie de lucru.

Interstitial lung diseases (ILD) are a group of extremely heterogeneous conditions (over 200), with low prevalence, but in most cases with severe impact on the quality of life and survival of the patients. The ILD group comprises: idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, colagen diseases, vasculitis, eosinophilic pneumonia etc. The prevalence of these diseases is unknown in Romania; the accurate diagnosis needs access to special investigations and expertise with this group of diseases. The authors propose the initiation of a National Registry for Interstitial Lung Diseases and Sarcoidosis (REGIS), based on the lessons learned from other national ILD) registries, which should allow building-up an extended clinical expertise in ILD, evaluating epidemiological data, creating an educational platform for young physicians, better understanding of the outcome and prognosis of these diseases, shaping Romanian Guidelines for the diagnosis and management of ILD, using the data base for clinical research. The registry is started as a pilot in two Romanian centres: "Marius Nasta" Institute of Pneumology in Bucharest and Pneumology Clinic, "Victor Babey" Infectious Diseases Hospital Timisoara. After refining the inclusion criteria for the data base, editing guidelines for ILD diagnosis and launching the registry website, other Romanian centres with interest in ILD will also be able to feed information.

[What is new in the interpretation of polysomnography according to the revised manual for sleep staging in adults? A comparative analysis]. / Ce aduce nou interpretarea polisomnografiei dupa manualul revizuit de stadializare a somnului la adult? Analiza comparativa.

Aim of this paper is to compare the new polysomnography staging manual according to American Academy of Sleep Medicine with Rechtschaffen & Kales rules, underlying the newly introduced aspects and illustrated with polysomnographic images. The new rules simplify the staging but increase the time of electrodes application. They were established on the base of low levels of evidence, without being included in the multicenter statistical validation. For the first time in literature are given details about the criteria for the interpretation of sleep in children, but there are problems still remain unanswered, such as those regarding the scoring of hypopnea. In Romania, the main problem is primarily limited access to investigation and the deficit of health professionals.

[Sleep apnea syndrome -- cause of resistance to treatment of arterial hypertension]. / Sindromul de apnee în somn -- factor de rezistenta la tratament a hipertensiunii arteriale.

The prevalence of sleep apnea syndrome is relatively high in population (5%). The mortality is significantly higher in those with apnea-hypopnea index >20. There is an increased rate of car accidents in the subjects with OSA compared to those who don't have this syndrome (31% versus 6%). The impact of OSA on mortality is also given by its association with a significant number of cardiovascular diseases. The association between OSA and hypertension has been much debated. The prevalence of hypertension among patients with OSA varies between 50-58%, while the prevalence of OSA in hypertensive patients is 30%. A particular association is OSA and resistant hypertension, i.e. blood pressure that remains above goal in spite of the concurrent use of three antihypertensive agents of different classes, one to be a diuretic and all pharmacological agents being prescribed at recommended doses. Secondary causes of hypertension are common in patients with resistant hypertension. Among these causes, one of the most frequent is sleep apnea syndrome. Some of the mechanisms by which sleep apnea contributes to the development of hypertension are intermittent hypoxia and/or increased upper airway resistance associated with sleep apnea that induces a sustained increase in sympathetic nervous system activity. Treatment of sleep apnea with continuous positive airway pressure devices (CPAP) improves blood pressure control, although the benefit of CPAP evaluated in clinical trials is variable.

[The role of radio-imaging techniques in the investigation of the pathophysiologic mechanisms in chronic obstructive bronchopneumonia. Part I. Role of imaging in the investigation of respiratory lesions caused by COPD]. / Aportul tehnicilor de radioimagistia întelegerea mecanismelor fiziopatologice din bronhopneumopatia obstructiva cronica. Partea I. Aportul imagisticii în investigarea leziunilor aparatului respirator caracteristice determinate de BPOC.

Chronic obstructive pulmonary disease (COPD) is a common disease (4-6% of adults), with insidious onset and slow progression, which is why the disease remains under diagnosed especially in early stages. Most patients get medical attention in stage III, IV of disease, according to GOLD classification (Global Obstructive Lung Diseases). According to GOLD, priority in staging the disease severity is the evaluation of respiratory function, the FEV1. However radiographic evaluation of patients with risk (smokers or those working in polluted environment) may represent a first step in marking the changes in the lung and especially comorbidities. Since this disease is causing disability and a major socioeconomic problem, modern investigations, such as spiral computerised tomography (CT), multidetector computerised tomography (MDCT) and magnetic resonance (MRI) may be alternatives in diagnosis and early detection of disease.