COPD profiles and treatable traits using minimal resources: identification, decision tree and stability over time.

BACKGROUND AND OBJECTIVE: Profiles of people with chronic obstructive pulmonary disease (COPD) often do not describe treatable traits, lack validation and/or their stability over time is unknown. We aimed to identify COPD profiles and their treatable traits based on simple and meaningful measures; to develop and validate a decision tree and to explore profile stability over time. METHODS: An observational, prospective study was conducted. Clinical characteristics, lung function, symptoms, impact of the disease (COPD Assessment Test-CAT), health-related quality of life, physical activity, lower-limb muscle strength and functional status were collected cross-sectionally and a subsample was followed-up monthly over six months. A principal component analysis and a clustering procedure with k-medoids were applied to identify profiles. A decision tree was developed and validated cross-sectionally. Stability was explored over time with the ratio between the number of timepoints that a participant was classified in the same profile and the total number of timepoints (i.e., 6). RESULTS: 352 people with COPD (67.4 ± 9.9 years; 78.1% male; FEV1 = 56.2 ± 20.6% predicted) participated and 90 (67.6 ± 8.9 years; 85.6% male; FEV1 = 52.1 ± 19.9% predicted) were followed-up. Four profiles were identified with distinct treatable traits. The decision tree included CAT (< 18 or ≥ 18 points); age (< 65 or ≥ 65 years) and FEV1 (< 48 or ≥ 48% predicted) and had an agreement of 71.7% (Cohen's Kappa = 0.62, p < 0.001) with the actual profiles. 48.9% of participants remained in the same profile whilst 51.1% moved between two (47.8%) or three (3.3%) profiles over time. Overall stability was 86.8 ± 15%. CONCLUSION: Four profiles and treatable traits were identified with simple and meaningful measures possibly available in low-resource settings. A decision tree with three commonly used variables in the routine assessment of people with COPD is now available for quick allocation to the identified profiles in clinical practice. Profiles and treatable traits may change over time in people with COPD hence, regular assessments to deliver goal-targeted personalised treatments are needed.

Current Practices in Home Mechanical Ventilation for Chronic Obstructive Pulmonary Disease: A Real-Life Cross-Sectional Multicentric Study.

Purpose: Home mechanical ventilation (HMV) use in chronic obstructive pulmonary disease (COPD) is becoming increasingly widespread. The aim of this study was to provide an accurate description of the current practices and clinical characteristics of COPD patients on HMV in Portugal. Methods: The study was designed as a cross-sectional, multicenter real-life study of COPD patients established on HMV for at least 30 days. Data related to clinical characteristics, adaptation and ventilatory settings were collected. Results: The study included 569 COPD patients on HMV from 15 centers. The majority were male, with a median age of 72 years and a high prevalence of obesity (43.2%) and sleep apnea (45.8%). A high treatment compliance was observed (median 8h/day), 48.7% with inspiratory positive airway pressure ≥20 cmH2O and oronasal masks were the preferred interface (91.7%). There was an equal distribution of patients starting HMV during chronic stable condition and following an exacerbation. Patients in stable condition were initiated in the outpatient setting in 92.3%. Despite the differences in criteria and setting of adaptation and a slightly lower BMI in patients starting HMV following an exacerbation, we found no significant differences regarding age, gender, ventilation pressures, time on HMV, usage, severity of airflow obstruction or current arterial blood gas analysis (ABGs) in relation to patients adapted in stable condition. Conclusion: Patients were highly compliant with the therapy. In agreement with most recent studies and recommendations, there seems to be a move towards higher ventilation pressures, increased use of oronasal masks and an intent to obtain normocapnia. This study shows that chronic hypercapnic and post exacerbation patients do not differ significantly regarding patient characteristics, physiological parameters or ventilatory settings with one exception: chronic hypercapnic patients are more often obese and, subsequently, more frequently present OSA.

Papillary adenocarcinoma of the thymus: case report and review of the literature.

A 44-year-old male with a mediastinal mass measuring 3.5 × 3.5 × 3 cm was diagnosed with papillary adenocarcinoma of the thymus. Other origins of papillary adenocarcinoma were excluded by clinical, imaging, and immunocytochemical methods before assuming this diagnosis. Residual thymus was seen under the microscope. Focal CD5 immunoreactivity was present. There was no associated thymoma. The patient underwent surgery, radiotherapy, and chemotherapy. He disclosed systemic recurrence at 18 months (subcutaneous nodule). He is alive after 24 months of follow-up with active disease. There had been only 7 cases of this rare entity published before.

Treatment of pulmonary actinomycosis with levofloxacin.

Actinomycosis is a chronic suppurative bacterial infection characterized by multiple abscesses, fistulous pathways, and fibrosis involving the face, neck, chest, and abdomen. It is caused by an anaerobic Gram-positive saprophytic bacterium (Actinomyces). Primary actinomycosis of the lung is a rare disease that probably results from aspiration of oropharyngeal secretions. It can present as a chronic respiratory disease. The treatment of choice is antibiotic therapy with penicillin. The authors report the case of a 55-year-old female diagnosed with pulmonary actinomycosis and successfully treated with levofloxacin.

Tratamento da actinomicose pulmonar com levofloxacina / Treatment of pulmonary actinomycosis with levofloxacin

A actinomicose é uma infecção bacteriana supurativa crônica caracterizada por múltiplos abcessos, trajetos fistulosos e fibrose envolvendo a face, o pescoço, o tórax e o abdômen. É causada por uma bactéria anaeróbia, Gram-positiva e saprófita (Actinomyces). A actinomicose pulmonar primária é uma doença rara que resulta provavelmente da aspiração de secreções da orofaringe. Pode apresentar-se como uma doença respiratória crônica. O tratamento de escolha é a antibioticoterapia com penicilina. Os autores apresentam o caso clínico de uma mulher de 55 anos com diagnóstico de actinomicose pulmonar tratada com sucesso com levofloxacina.

Actinomycosis is a chronic suppurative bacterial infection characterized by multiple abscesses, fistulous pathways, and fibrosis involving the face, neck, chest, and abdomen. It is caused by an anaerobic Gram-positive saprophytic bacterium (Actinomyces). Primary actinomycosis of the lung is a rare disease that probably results from aspiration of oropharyngeal secretions. It can present as a chronic respiratory disease. The treatment of choice is antibiotic therapy with penicillin. The authors report the case of a 55-year-old female diagnosed with pulmonary actinomycosis and successfully treated with levofloxacin.

Treatment of advanced non small cell lung cancer with erlotinib. Two clinical cases. / Erlotinib no tratamento do carcinoma pulmonar de não pequenas células, doença avançada. A propósito de dois casos clínicos.

Early studies with tirosine kinase inhibitors (TKI), namely Erlotinib and Gefitinib, in patients with non small cell lung cancer (NSCLC), showed that although most patients did not respond radiologically, a small percentage of those patients (about 10%) had an excellent response to treatment, with radiological regression and clinical response duration. Four patient populations are known as having better response to TKI as opposed to other patients: adenocarcinoma patients, non-smokers, women and asians. Nevertheless, a good general status remains a predictive factor for treatment response. The discovery of the EGFR mutation in NSCLC patients' tumors and its association with clinical response to Erlotinib and Gefitinib, confirmed by a considerable number of retrospective and prospective studies, showed that response rates are between 75-80% in patients carrying this mutation. Although several mutations have been identified, the two commonest (approximately 90%) are located in exons 19 and 21. The authors present two patients studied and treated at the Pulmonology Department's Lung Oncology Unit of CHVNGaia, where Erlotinib was used as 3(rd) line treatment: in one patient, which was part of the population with good response to TKI, a classic exon 19 was identified, and was treated with Erlotinib for twenty months with clinical stability; the other patient did not belong to the above mentioned population and an Exon 20 mutation was identified (a mutation not yet described in literature, being not clear its association with response to treatment with TKI) - treatment was stopped after 7.4months due to disease progression. Rev Port Pneumol 2008; XIV (Supl 3): S43-S51.

[Complete resection of endobronchial hamartomas via bronchoscopic techniques, electrosurgery by Argon plasma and laser]. / Ressecção completa de hamartomas endobrônquicos por técnicas broncoscópicas, electrocirurgia por argon plasma e laser Nd-YAG.

Hamartomas are benign neoplasms often located in lung and frequently asymptomatic. They are typically discovered incidentally with thorax radiographic stu- dies. About 1.4-20% of hamartomas have endobronchial location and can be symptomatic due to airway obstruction. Traditionally, surgical resection has been considered the standard of care for endobronchial hamartoma. However, there is increasing experience using endoscopic treatment and a paucity of reported complications. Endoscopic resection has comparable therapeutic efficacy with surgical resection but spares a major operation. We report two cases of endobronchial hamartomas, each diagnosed and definitively treated with bronchoscopic techniques. Persistent symptoms and abnormal radiological features were the impetus for initial diagnostic bronchoscopy. Endobronchial treatment was performed using electrosurgery by Argon plasma (APC) and Nd:YAG la- ser. This approach resulted in complete resolution of both patients' symptoms. Follow-up bronchoscopic examinations excluded residual or recurrent disease.

[Exacerbations in severe persistent asthma--impact of risk factors control]. / Exacerbações na asma persistente grave--Impacto do controlo dos factores de risco.

It is estimated that in developed countries between 1% and 2% of total healthcare expenditure goes on asthma treatment. The natural progression and causes of severe asthma are still not well defined. Severe persistent asthma is a less common situation, accounting for 5% of total asthma patients. Despite representing a small percentage of total patients, this group is largely responsible for the high health costs of asthma. Consequently, the improvement of risk factors can lead to both socioeconomic and health gains. The aim of this study was to examine risk factors for exacerbations in a group of patients with severe persistent asthma. It was a retrospective study, based on patient case histories that included subjects with severe persistent asthma with follow-up in an allergy unit between 1984 and 2005. A total 27 patients were included (mean age=50.64+/-12.7 years), 81.5% female. Main risk factors for exacerbations analysed were atopy, respiratory infections, premenstrual asthma, nasal symptoms, gastroesophageal reflux disease (GERD), psychological factors and obesity. Correction of these risk factors improved asthma control. The most significant impact was achieved with polypectomy and oral contraceptives in a teenager. In conclusion, correct identification of all risk factors for exacerbation in asthma, selection of those that can be controlled and their correction can improve asthma control.

[Inflammatory pseudotumor of the lung. Case report]. / Pseudo-tumor inflamatório do pulmão. Caso clínico.

Inflammatory pseudotumor of the lung is a rare entity, of unknown etiology and variable clinical evolution. The histological variety of this entity makes the diagnosis difficult, which is generally obtained after surgical removal of the lesion. The authors report the clinical case of a 32 years old woman presenting with hemoptysis and radiologic appearance of aspergilloma. The lesion was surgically removed and the diagnosis of inflammatory pseudotumor of the lung was confirmed by pathologic and immunohistochemical analysis.

Positron emission tomography: indications in lung cancer - prospective experience of a department.

Positron emission tomography (PET) is a new technique in nuclear medicine. It uses biological radiotracers such as (18)F-fluoro-2-deoxyglucose (FDG) which permit the detection of suspected lesions with metabolic alterations that take up the glucose isotope too avidly, as is the case with neoplastic cells. PET has become an innovatory and important imaging tool for evaluating patients with lung cancer. The present recommended uses of PET include lung cancer diagnosis and the intrathoracic and extrathoracic staging in N-SCLC.

[Pulmonary manifestations of autoimmune diseases]. / Manifestações pulmonares de patologias auto-imunes.

The lung is a unique interface between the antigen and the circulating blood volume. It is submitted to extrinsic/intrinsic challenges and is particularly vulnerable to circulating insulting agents. It is a site of intense immune surveillance, allowing antigen sampling to expand the immunologic repertoire through lymphocyte recirculation. In addition, local inflammatory reactions to antigens are generated. Imaging has an important role in diagnosis of patients with immunologic lung diseases. This group includes autoimmune lung diseases. There are many advantages of plain chest radiography but also significant limitations. It was a revolution in imaging of lung diseases with Computed Tomography (CT), being high resolution an important help in pulmonary interstitium study. This technique has a higher diagnostic accuracy than the conventional chest X-ray both in the detection and the diagnosis of lung diseases, such as autoimmune lung diseases.

[Pulmonary arteriovenous malformations - association with hereditary hemorrhagic telangiectasia. Clinical cases and family screening]. / Malformações arteriovenosas pulmonares - Associação a telangiectasia hemorrágica hereditária. Casos clínicos e rastreio familiar.

Pulmonary arteriovenous malformations are a rare disorder associated to hereditary hemorrhagic telangiectasia in over 50 % of the cases. Clinical presentation, diagnostic work-up, therapeutic options and prognosis are reviewed by the authors. Pulmonary arteriovenous malformations are known to have considerable morbidity and mortality, their treatment being advisable as well as their screening among family members, especially if the index case is diagnosed with both pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia. To this moment prospective studies establishing the best diagnostic work-up for the patients and their families are lacking. The authors report two pulmonary arteriovenous malformations cases in a family with hereditary hemorrhagic telangiectasia. Patient's diagnosis led to family screening which resulted in the identification of pulmonary arteriovenous malformations in two family members and pulmonary disease exclusion in four patients previously known to have hereditary hemorrhagic telangiectasia.

Avaliação da capacidade inibitória de crescimento de S. mutans de diferentes materiais restauradores / Evaluation of inhibitory growth of S. mutans on different restorative materials

A adesão de bactérias ao dente e aos materiais restauradores apresentam correlação positiva com a cárie e Doença Priodontal, portanto deve-se levar em consideração às características químicas e a textura de superfície do material restaurador à ser selecionado pelo profissional durante o ato operatório. O presente estudo avaliou o potencial de inibição de crescimento de S. mutans de diferentes materiais restauradores, contribuinbdo ao profissional para a seleção do material restaurador que envolva um menor acúmulo e crescimento desse tipo de bactéria. Foi medido em milímetros, a formação de halos de inibição de crescimento ao redor de discos de diferentes materiais restauradores, em meio de ágar-mitis salivarius com cepa de S. mutans, onde ficaram em estufa bacteriológica por 48 horas, em jarra de anaerobiose. O único material que inibiu o crescimento de S. mutans, no presente estudo, foi o amálgama dental de alto teor de cobre, ao contrário dos cimentos de ionômero de vidro convencional e reforçado com resina, e as resinas compostas

Estudo in vivo do desempenho de dois sistemas de selantes de fóssulas e fissuras / In vivo study of the performance of two pit and fissure sealant systems

Foram selados, com duas marcas diferentes de selantes com carga, 107 dentes, pré-molares e molares hígidos, que foram avaliados quanto à retenção, desgaste e prevenção à cárie. Observou-se que após seis meses, 94,39% apresentavam retenção total e 5,6% retenção parcial. Quanto ao desgaste, 35,51% apresnetavam desgaste significativo. nenhum dos dentes apresentou indício de lesão cariosa, o que confirmou a eficácia de seu uso como medida preventiva à instalação de cárie