FDG-PET parameters predicting mediastinal malignancy in lung cancer.

BACKGROUND: Staging of mediastinal lymph nodes in non-small cell lung cancer (NSCLC) is mandatory. The maximum Standard Uptake Value (SUVmax) obtained using F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is the best non-invasive technique available for this evaluation, but its performance varies from center to center. The aim of the present study was to identify FDG-PET predictors of mediastinal malignancy that are able to minimize intercenter variability and improve the selection of subsequent staging procedures. METHOD: A multicenter study of NSCLC patients staged through FDG-PET and endobronchial ultrasonography with needle aspiration (EBUS-NA) was performed using therapeutic surgery with systematic nodal dissection as gold standard. Intercenter variability and predictive power for mediastinal malignancy of different FDG-PET measures were assessed, as well as the role of these measures for selecting additional staging procedures. RESULTS: One hundred and twenty-one NSCLC patients, of whom 94 (72%) had ≥1 hypermetabolic spots in the mediastinum, were included in the study. Mean SUVmax of the primary tumor was 12.3 (SD 6.3), and median SUVmax of the highest hypermetabolic spots in the mediastinum was 3.9 (IQR 2.4-7). Variability of FDG-PET measures between hospitals was statistically significant (p = 0.016 and p < 0.001 respectively), but lost significance when SUVmax in the mediastinum was expressed as a ratio or a subtraction from the primary tumor (SUVmax mediastinum/tumor, p = 0.083; and SUVmax mediastinum - tumor, p = 0.428 respectively). SUVmax mediastinum/tumor showed higher accuracy in the ROC analysis (AUC 0.77 CI 0.68-0.85, p < 0.001), and showed predictive power for mediastinal malignancy when using a 0.4 cutoff (OR 6.62, 95%CI 2.98-14.69). Sensitivities and negative predictive values of clinical staging through EBUS-NA attained values ranging between 57% and 92% after FDG-PET, which improved with additional techniques when the tumor had a diameter >3 cm and/or a SUVmax mediastinum/tumor ratio >0.4. CONCLUSION: The SUVmax mediastinum/tumor ratio is a good predictor of regional tumor extension in NSCLC. This measure is not influenced by intercenter variability and has an accuracy of over 70% for the identification of malignancy when using a 0.4 cutoff.

Diagnosticar la EPOC leve: ¿para qué? / No disponible

No disponible

[Delays in the diagnosis of lung cancer]. / Demoras diagnósticas en el cáncer del pulmón.

OBJECTIVE: To study the clinical and demographic factors associated with delays in the diagnosis of lung cancer. PATIENTS AND METHODS: A 2-year prospective study of patients admitted to the respiratory medicine ward with a suspected diagnosis of lung cancer. We studied demographic factors, health care received, place of residence, and delays in carrying out diagnostic procedures. The following diagnostic time periods were defined: consultation (from first symptom to first medical visit), middle period (from first medical visit to hospital admission) and diagnostic (from hospital admission to histological diagnosis and clinical staging). RESULTS: One hundred thirteen patients with a mean age of 65 years (range, 36-90), 103 men and 10 women, were studied. The most frequent symptoms leading to consultation were coughing (10.6%), hemoptysis (19.5%), chest pain (26.5%), and shortness of breath (9.7%). First visits were to a primary care physician for 72%, to the hospital emergency room for 22%, or to a pulmonologist for 6%. Forty-four percent of the patients visited the doctor 2 or 3 times. The mean SD, numbers of days for the different time periods were as follows: consultation, 30.3 60; diagnosis, 18.6 19; middle period 37.9 63. The mean total time from first symptom to diagnosis was 85.7 87 days. The middle period, the time in hospital until diagnosis, and the total time were shorter when patients were referred by the primary care physician to the emergency room or were directly admitted to the hospital (P<.001). Only 25.7% of the staged lung cancers were operable. CONCLUSIONS: Delays in lung cancer diagnosis are long. The attitudes of primary care physicians and their relations with specialized care providers are crucial for reducing delays.

Demoras diagnósticas en el cáncer de pulmón / Delays in the Diagnosis of lung cancer

OBJETIVO: Estudio de los factores clínicos y demográficos asociados a las demoras diagnósticas del cáncer de pulmón (CP). PACIENTES Y MÉTODOS: Estudio prospectivo de dos años de evolución de pacientes ingresados en la planta de neumología por sospecha de CP. Se estudiaron variables demográficas, de atención sanitaria, hábitat y demoras en las exploraciones. Se definieron los tiempos diagnósticos siguientes: de consulta (desde el primer síntoma hasta la visita del primer médico), medio (el que va desde la visita médica hasta el ingreso) y diagnóstico (desde el ingreso hasta el diagnóstico histológico y la estadificación clínica). RESULTADOS: Se estudió a 113 pacientes con una edad media de 65 años (intervalo, 36-90), de los que 103 eran varones y 10, mujeres. Los síntomas más frecuentes por los que consultó el paciente fueron: tos (10,6 por ciento), hemoptisis (19,5 por ciento), dolor torácico (26,5 por ciento) y disnea (9,7 por ciento). El 72 por ciento de los pacientes consultaba por primera vez al médico de atención primaria (MAP), el 22 por ciento a urgencias del hospital y el 6 por ciento al neumólogo. El 44 por ciento realizó entre dos y tres visitas al médico. Las medias ñ desviaciones típicas, en días, de los diferentes tiempos fueron: consulta, 30,3 ñ 60; diagnóstico, 18,6 ñ 19; medio, 37,9 ñ 63, y total, 85,7 ñ 87. El tiempo medio, el tiempo hasta el diagnóstico y el tiempo total fueron inferiores cuando el paciente fue remitido, por el MAP, a urgencias o ingresado directamente en el hospital (p < 0,001). Sólo el 25,7 por ciento de los CP estadificados eran resecables quirúrgicamente. CONCLUSIONES: Los tiempos de demora diagnóstica en el CP son elevados. La actitud del MAP y su relación con la atención especializada es importante para su reducción (AU)

Utility of standardized exercise oximetry to predict cardiopulmonary morbidity after lung resection.

OBJECTIVES: To evaluate if desaturation, measured by finger oximetry on standardized exercise, accurately predicts cardiopulmonary morbidity after pulmonary resection. METHODS: A prospective observational clinical study was carried out on 81 consecutive lung carcinoma patients scheduled for pulmonary resection from February 1998 to March 1999. Finger oximetry was monitored during an incremental to exhaustion cycle exercise test. The presence or absence of desaturation (cut-off value 90%) during exercise was recorded. Other independent analyzed variables were: age of the patient (over 75th percentile), body-mass index (BMI) (over 75th percentile), presence of major cardiovascular co-morbidity, and calculated postoperative FEV1% (under 25th percentile) according to the number of resected segments (ppoFEV1%). Postoperative cardiopulmonary morbidity was the evaluated dependent outcome. Fisher's exact test and risk calculation on contingency tables were used for statistical analysis. RESULTS: A lobectomy was performed in 62 cases, a pneumonectomy was performed in 16 cases, and a segmentectomy was performed in three cases. The mean age of the patients was 63.6 years (SD 10.3, range 34-79 years, 75th percentile 72 years), the mean BMI was 25.9 (SD 4.9, range 16.9-38.1, 75th percentile 29.3), and the mean ppoFEV1% was 64.1 (SD 2016.1, range 29.5-98.6, 25th percentile 50.5). In 14 patients exercise desaturation was registered. Postoperative cardiopulmonary morbidity was presented in 32 cases (five deaths). No correlation was found between postoperative morbidity and any of the following variables: age of the patient, BMI, and co-morbidity. On univariate analysis only low ppoFEV1% (P<0.001) was associated with the outcome, so no multivariate analysis has been carried out. CONCLUSIONS: We have shown that desaturation during standardized exercise in this series adds no relevant information to predict postoperative cardiorespiratory morbidity after lung resection.

[The truthfulness of the answers of children, adolescents and young people to surveys on tobacco consumption conducted in schools]. / Veracidad en las respuestas de niños, adolescentes y jóvenes a las encuestas sobre el consumo de tabaco realizadas en los centros escolares.

BACKGROUND: The prevalence of tobacco consumption in scholars has been determined by self-governed inquiries, methodology that presents limitations of reliability and validity. This obstacle has been endeavoured to overcome through methodological inspections such as the test-retest valuation. On the contrary, the available analytical methods (i.e., determination of cotinine in urine or determination of carbon monoxide [CO] in exhaled air) have not been used up to now in this type of studies. Their use together with the inquiries could complement the results of the questionnaires and verify their reliability. POPULATION AND METHODS: 814 scholars took part in the survey, being valid the results of 809, 385 male students and 424 female students, 13 to 24 years old (mean 15.90, SD 1.73) from an urban high school and another in the rural area. The survey included a survey and the measurement of CO levels in exhaled air in the same scholar centre. RESULTS: 257 scholars stated that they had never tried tobacco and in 15 of them (5.8%) levels of CO were equal or higher than 10 ppm (14.26, SD 4.35 ppm). 589 students stated that were not regular smokers; in 46 of them (7.8%) levels of CO were superior to 10 ppm (13.87, SD 4.68). The morning when the survey was held 629 students assured that they had not smoked: in 52 of them (8.3%) levels of CO higher than 10 ppm were observed. The mean level of CO observed in these students was 13.5 (SD 4.4) ppm. In our survey, the measurement of CO in exhaled air allowed us to show percentage between 5.8 and 8.3% of students whose answers to the different questions were not reliable. CONCLUSIONS: The reliability of the results, observed through the carrying out of surveys, can be determined with the use of analytical methods that, owe to their simplicity, can be used massively. We have not found any relation between the shortage of reliability and the variants studied (age, sex or habitat), which reaffirms the difficulty in identifying variants that can determine those "deceives" and demands for its identification the need of practicing analytical determinations.

[Personalized minimal treatment of smoking addiction. Results of a multicenter study. Study Group of the Treatment of Tobacco Addiction. Spanish Society of Pneumology and Thoracic Surgery]. / Intervención mínima personalizada en el tratamiento del tabaquismo. Resultados de un estudio multicéntrico. Grupo de Trabajo de Tratamiento del Area de Tabaquismo. Sociedad Española de Neumología y Cirugía Torácica (SEPAR).

The aim of this study was to evaluate the efficacy of a minimal-intervention smoking cessation program tailored to meet the needs of patients in a pneumology practice. Six-months open study was designed, multicenter, involving four pneumology practices in different Spanish cities. Smokers with or without respiratory disease who consulted a pneumologist were included. Patients were grouped according to their phase in the self-change process toward smoking cessation: precontemplation or contemplation. The level of physical dependence on nicotine was assessed using a revised version of the Fagerström test. CO in exhaled air was also measured. Precontemplators were advised to quit smoking and given a booklet about smoking addiction. Contemplators were additionally given a practical guide to quitting. Advice on quitting was different for the two different phases. Smokers were reexamined twice: 8 weeks and 6 months later. We evaluated the success of the physician's intervention of encouragement to abstain (a level of CO in exhaled air [10 ppm was required]) and we recorded change of phase in the cessation process. Three hundred thirteen subjects were enrolled: 222 men (70.9%) and 91 women (29.1%). After 6 months, 40 (43%) of the precontemplators had changed phase and 21 of them (23%) had stopped smoking; 61 (28%) of the 221 contemplators had changed phase and 20 of them (9%) had quit smoking. Personalized minimal intervention in subjects with or without disease gives good results in terms of success in quitting as well as progress toward cessation.

[Usefulness of CO measurement in expired air in the study of tobacco consumption by youths and adolescents]. / Utilidad de la medida de CO en aire espirado en el estudio del consumo de tabaco por jóvenes y adolescentes.

The objective of our work was to know the relationship between carbon monoxide (CO) levels in expired air and smoking habits among school youths and the relationships that can be established between CO level and some peculiar attitudes regarding consume by youths, such as the number of cigarettes, inhaling technique and time elapsed since the last cigarette was smoked. The study, of cross-sectional design, was performed in two high school centres and a total of 777 students who answered a questionnaire and had an expired air CO sample in their own schoolroom tested were enrolled. CO determination in the schoolroom was a simple and attainable technique for the pupils, as only 32 cases (4.1%) had to be excluded due to poor collaboration or poor technique. The mean (mean and SD) CO level in the control group (n = 247), made up by non-smokers nor tobacco tasters was 4.75 (2.46) ppm, statistically lower than among smokers (p < 0.001), but with no differences compared with non smokers (n = 563), who had a CO level of 5.23 (3.4) ppm. This figure was also lower (p < 0.001) than that obtained in the smokers (12.6 [6.3] ppm), made up of 214 pupils, with a mean consume of 2.7 (1.69) cigarettes/day. Among smokers the mean abstinence time since the last cigarette was smoked was 26 (44) minutes and 54% of them admitted to have smoked in the last 10 minutes. CO in expired air correlated significantly with the number of smoked cigarettes (r = 0.58; p < 0.001). Likewise, it correlated significantly with abstinence minutes (r = -0.38; p < 0.001). The time required for CO level to decrease below 10 ppm was 140 minutes in four cases and 120 minutes in 33 cases.

[Sex differences in experimentation and tobacco consumption by children, adolescents and young adults]. / Diferencias entre sexos en la experimentación y consumo de tabaco por niños, adolescentes y jóvenes.

Studies carried out in the past ten years have found the prevalence or smoking among children and adolescents to be high, with the greatest increase observed for girls and young women, indicating increasing gender-related differences. The aim of our study was to determine the prevalences and differences among children and adolescents of both sexes with regard to experimentation and use of tobacco products and to determine any possible influence related to urban or rural environment. Eight hundred fourteen students participated, with 809 providing valid data for study: 385 males and 424 females ranging in age from 13 to 24 years old (15.90 +/- 1.73 years). The subjects studied in either an urban or a rural school. Data was collected on campus by questionnaire and carbon monoxide in expired air was measured. Smoking had been tried by 68.2%: 241 males (62.5%) and 31 females (73.3%) (p < 0.001). Habitual smoking was reported by 27.2%: 78 males (20.2%) and 142 females (33.4%) (p < 0.001). Mean ages of experimenters (16.18 +/- 1.78 years) and smokers (16.55 +/- 1.85 years) were higher than the mean age of non-experimenters (15.29 +/- 1.43) (p < 0.001). Habitual smokers consumed a mean 2.71 +/- 1.68 cigarettes/day and consumption was similar for both sexes. CO in expired air was 12.61 +/- 6.39 ppm in these smokers, significantly higher (p < 0.001) than that found in experimenters and non smokers (p 0.001). One hundred eighty students (22.2%), 119 females and 61 males (p < 0.001), reported having smoked on the morning of the study. In total, 81.8% of the students who described themselves as smokers had smoked that morning: 78.2% of the males and 83.9% of the females. CO in this group was 13.95 +/- 1.69 ppm, significantly higher than that found for the other groups (non smokers or experimenters). We found no significant differences between number of cigarettes/day smoked by students who reported being habitual smokers and the number consumed the morning of data collection by students who had smoked the day of the study. Changes can be observed in patterns of tobacco use among children and young people. We found that nearly all aspects related to experimentation and consumption of tobacco are significantly higher in females.

[Compliance with antismoking laws in official institutions]. / Cumplimiento de la legislación antitabaco en instituciones oficiales.

The prevention of nicotine addiction involves a wide range of measures, including writing laws to preserve public health by protecting nonsmokers from smoke and discouraging smokers from consumption. Also important are campaigns to educate both parties (smokers and nonsmokers) about the negative effects of tobacco. The main antismoking law in Spain is the Health and Consumer Ministry's Royal Decree 192/1988 limiting the sale and use of tobacco with the aim of protecting public health. Other regulations have since been enacted by public administrations to complement that law. Research finding published in recent years have been the basis for major legal changes leading in two directions; toward standardizing laws existing in different countries and toward increasing restrictions on the advertising and sale of tobacco. Various scientific and social groups have demanded that current laws be made stricter. Little has been done, however, to assess the degree of vigilance and compliance, and consequently the efficacy, of current legislation. The aim of this study was to determine the level of compliance with the law in governmental institutions in Salamanca. We visited 30 centers and saw that while notices prohibiting smoking were visible in 80%, the number of smokers was high: 43% among workers (none of whom was in educational or medical centers) and 37% among the public. No posters warning of the dangers of tobacco were seen in any of the centers visited. It appears necessary to further restrict the sale and use of tobacco in public places, to enforce compliance with existing regulations and to increase the amount of information on the toxic effects of tobacco in order to gain the cooperation of both smokers and nonsmokers toward achieving smoke-free environments.

[Carboxyhemoglobin levels in relation with home heating]. / Niveles de carboxihemoglobina en relación con la calefacción doméstica.

To study carboxyhemoglobin levels (HbCO) associated with use of different types of home heating and to evaluate the usefulness of measuring hemoglobin oxygen saturation. Nonsmoking patients with chronic respiratory insufficiency who were initially prescribed home oxygen therapy were enrolled in the study. One hundred four patients were studied in winter and summer (when heating was not used). The control group consisted of 92 hospitalized patients not exposed to carbon monoxide. Of the 104 patients 74.1% were men. Mean age was 72.33 (range 17 to 97 years) and 57.9% lived in rural areas. Mean HbCO in the control group was 1.53 +/- 0.96% (p = 0.01). Among the 39% who burned slack coal for heat, the mean HbCO was 4.63 +/- 2.87%. The 23.7% with central heating had HbCO levels of 2.15 +/- 0.87% (p < 0.0001). Pulse oximetry (SpO2) estimated higher hemoglobin oxygen than direct measurement (SaO2): 87.12 +/- 6% and 83.3 +/- 8%, respectively (p < 0.001). High HbCO concentrations are related to chronic exposure to slack coal fumes. Pulse oximetry, as opposed to SaO2, overestimates hemoglobin oxygen saturation in such cases.

Synaptic and non-synaptic immunolocalization of GABA and glutamate acid decarboxylase (GAD) in cerebellar cortex of rat.

The existence of a large number of GABA receptors in the cerebellar molecular layer, and the observation of numerous punctate immunoreactive deposits of GABA synthesizing enzyme (GAD) throughout this layer, could indicate the existence of numerous axon terminals that may be involved in neurotransmission modulated by GABA. These axon terminals may be different from those considered classically as cerebellar GABAergic axon terminals. Therefore, we have reinvestigated the localization of GABA- and GAD-immunoreactivities in the cerebellar cortex of the rat with the PAP method, using different antisera obtained from rabbits immunized with GABA, baclofen and GAD. The results observed in our investigation have demonstrated GABA- and GAD-immunoreactivities in the axon terminals considered classically as GABAergic, as well as in others which, until now, have not been considered GABAergic. This fact leads us to think that the distribution of GABA or molecules structurally similar to GABA is far more extended than previously thought in the cerebellum. We have also observed both GABA- and GAD-immunoreactivities within dendrites and glial cells. These facts suggest us a possible extrasynaptic release of GABA.

Presence of meprobamate-like molecules in rat neuromuscular junction. Immunohistochemical demonstration at light- and electron-microscopic levels.

The localization of meprobamate-like (MPB-like) molecules in the neuromuscular junction of rats has been investigated at light- and electron- microscopic levels with the peroxidase-antiperoxidase (PAP) immunohistochemical method, using a purified antiserum obtained from rabbits immunized with a meprobamate-bovine serum albumin (MPB-BSA) conjugate. The immunoreaction was found surrounding synaptic vesicles and in protuberant deposits situated in the post-synaptic membrane. These facts suggest the existence of endogenous MPB-like molecules in neuromuscular junction and that the immunostained protuberant deposits should mark the receptors of those molecules.

Ultrastructural peculiarities of the supraoptic nucleus of Mauremys caspica (turtle): its evolutionary interest in reptiles.

The hypothalamic Supraoptic Nucleus (SON) supposes an evolutionary achievement in the reptiles, zoological group in which this nucleus is first differentiated. Its scarce development in the chelonian, subject of the present study, is related to their primitive brain pattern. The peculiar location and the topographical configuration of the SON in the hypothalamus of the turtle Mauremys caspica allows to evidence morphologically the successive steps in the evolutionary process from lower to higher vertebrates. The marked neurosecretory character of the chelonian SON is the unequivocal proof of its philogenetic origin derived from the magnocellular preoptic nucleus of lower vertebrates.

Altered structures in the cytoplasm of the ependymal cells next to the periventricular nucleus of the turtle Mauremys caspica.

In the apical cytoplasm of some ependymal cells of the Hypothalamic Periventricular Nucleus of the turtle Mauremys caspica large amount of cell structures of difficult diagnose are found. Their morphology is variable seeming to correspond to cell organelles in a process of degeneration, characteristic feature of the high metabolic activity in the ventricular barrier. Their possible physiological significance is discussed in the present work.

Ventricular labyrinths of the ependyma adjacent to the hypothalamic paraventricular nucleus in the turtle Mauremys caspica.

Labyrinthic recesses projecting to the subependymal tissue have been observed in the ependyma of the III ventricle in close relation to the neurons of the hypothalamic paraventricular nucleus in the turtle Mauremys caspica. There seems to be evidence of a direct contact between the paraventricular nucleus neurons and the cerebrospinal fluid whose physiological significance is discussed in the present work.

Similarity between cytoplasmic inclusions in the paraventricular hypothalamic nucleus neurons of the turtle Mauremys caspica and the cytoplasmic structures as reaction to viral infections (hepatitis) and SIDA ultrastructural tracers.

Two types of "inclusions" observed in the neurons of the hypothalamic paraventricular nucleus of the turtle Mauremys caspica, "tubular systems" and "fingerprint-like" structures, may be added to the inventory of those described in apparently normal neurons. Despite their enigmatic significance, we are inclined to think that they could be a morphological expression of viral diseases in the neuron cytoplasm. These structures have a striking similarity with those observed on pathological cells (hepatitis and SIDA).