Airway Hyperresponsiveness, Inflammation, and Pulmonary Emphysema in Rodent Models Designed to Mimic Exposure to Fuel Oil-Derived Volatile Organic Compounds Encountered during an Experimental Oil Spill.

BACKGROUND: Fuel oil-derived volatile organic compounds (VOCs) inhalation is associated with accidental marine spills. After the Prestige petroleum tanker sank off northern Spain in 2002 and the Deepwater Horizon oil rig catastrophe in 2009, subjects involved in environmental decontamination showed signs of ongoing or residual lung disease up to 5 y after the exposure. OBJECTIVES: We aimed at investigating mechanisms driving persistent respiratory disease by developing an animal model of inhalational exposure to fuel oil-derived VOCs. METHODS: Female Wistar and Brown Norway (BN) rats and C57BL mice were exposed to VOCs produced from fuel oil mimicking the Prestige spill. Exposed animals inhaled the VOCs 2 h daily, 5 d per week, for 3 wk. Airway responsiveness to methacholine (MCh) was assessed, and bronchoalveolar lavage (BAL) and lung tissues were analyzed after the exposure and following a 2-wk washout. RESULTS: Consistent with data from human studies, both strains of rats that inhaled fuel oil-derived VOCs developed airway hyperresponsiveness that persisted after the washout period, in the absence of detectable inflammation in any lung compartment. Histopathology and quantitative morphology revealed the development of peripherally distributed pulmonary emphysema, which persisted after the washout period, associated with increased alveolar septal cell apoptosis, microvascular endothelial damage of the lung parenchyma, and inhibited expression of vascular endothelial growth factor (VEGF). DISCUSSION: In this rat model, fuel oil VOCs inhalation elicited alveolar septal cell apoptosis, likely due to DNA damage. In turn, the development of a peculiar pulmonary emphysema pattern altered lung mechanics and caused persistent noninflammatory airway hyperresponsiveness. Such findings suggest to us that humans might also respond to VOCs through physiopathological pathways different from those chiefly involved in typical cigarette smoke-driven emphysema in chronic obstructive pulmonary disease (COPD). If so, this study could form the basis for a novel disease mechanism for lasting respiratory disease following inhalational exposure to catastrophic fuel oil spills. https://doi.org/10.1289/EHP4178.

Discordance of physician clinical judgment vs. pneumonia severity index (PSI) score to admit patients with low risk community-acquired pneumonia: a prospective multicenter study.

BACKGROUND: The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP. METHODS: An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]. RESULTS: One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P<0.005). CONCLUSIONS: Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients.

Effects of a muscular training program on chronic obstructive pulmonary disease patients with moderate or severe exacerbation antecedents.

BACKGROUND: Muscular training is the corner stone of pulmonary rehabilitation programs. AIM: To evaluate the effects of a muscular training program - carried out on chronic obstructive pulmonary disease (COPD) subjects with antecedents of moderate or severe exacerbation - on exercise tolerance, Health Related Quality of Life (HRQoL) and illness prognosis. DESIGN: A quasi-experimental study. SETTING: University Hospital. POPULATION: Twenty-five subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) degrees II, III and IV); with moderate or severe exacerbations and functional deterioration due to respiratory disability; with commitment and capacity to participate in the program. Subjects were selected by consecutive sampling. METHODS: Subjects underwent 20 muscular training sessions consisting of 30 minutes of inspiratory muscle training, 15 minutes of warm-up protocol of upper limb exercises, 30 minutes of muscle training in ergometric cycle, 5 minutes of stretching protocol of lower limbs plus illness awareness. The main outcome measures were six minute walking test (6MWT), specific HRQoL questionnaires (St. Georges Respiratory Questionnaire (SGRQ), Chronic Respiratory Disease Questionnaire (CRDQ) and Airways Questionnaire 20 (AQ20)) and the BODE Index. RESULTS: All subjects improved significantly (P<0.001) their HRQoL in the SGRQ, the CRDQ and the AQ20, and this was demonstrated in each one of the evaluated dimensions. A positive response in relation to exercise tolerance and illness prognosis was observed. Following the program subjects walked an average of 56 meters more (P<0.001) and the BODE index was a mean of 1.5 less regarding the initial value (P<0.001). CONCLUSIONS: A 20-session muscular training program contributes to an improvement in HRQoL, exercise tolerance and illness prognosis in COPD subjects with moderate or severe exacerbations. CLINICAL REHABILITATION IMPACT: The intervention program could be easily implemented since it needs a minimum of human and technological resources.

Esclerosis lateral amiotrófica: impacto del seguimiento neumológico y ventilación mecánica en la supervivencia. Experiencia en 114 casos / Amyotrophic Lateral Sclerosis: Impact of Pulmonary Follow-Up and Mechanical Ventilation on Survival. A Study of 114 Cases

Objetivo: Conocer el impacto en la supervivencia del manejo y tratamiento ventilatorio de enfermos con esclerosis lateral amiotrófica (ELA). Método: Análisis retrospectivo de 114 pacientes con ingreso consecutivo en un hospital general, evaluandodatos demográficos, tipo de presentación, manejo clínico, tratamiento con ventilación mecánica y supervivencia. Estadística: descriptiva y análisis de Kaplan-Meier. Resultados: Sesenta y cuatro pacientes tenían afectación bulbar inicial. La supervivencia media global tras el diagnóstico fue 28,0 meses (IC 95%, 21,1-34,8). Setenta pacientes fueron derivados al neumólogo (61,4%) y 43 recibieron ventilación no invasiva (VMNI) a los 12,7 meses (mediana) del diagnóstico. Se mantuvieron con VMNI sin posterior ventilación invasiva 37 pacientes, cuya supervivencia media fue de 23,3 meses (IC 95%, 16,7-28,8), superior en los no bulbares, aunque en rango no significativo. En 26 en los que la VMNI se indicó de manera programada la supervivencia fue mayor que en 11 en que se indicó sin evaluación neumológica previa (considerando tras el diagnóstico, p < 0,012, y en función del comienzo de la ventilación, p < 0,004). Se trataron en modalidad invasiva 7 pacientes cuya supervivencia fue de 72 meses (IC 95%, 14,36-129,6), mediana de 49,6 ± 17,5 (IC 95%, 15,3-83,8), y pese a las dificultades de laatención en domicilio, la aceptación y la tolerancia fueron aceptables. Conclusiones: La ventilación mecánica prolonga la supervivencia de la ELA. La evaluación neumológica programada tiene un impacto favorable en la supervivencia de los pacientes con ELA y constituye un elemento esencial en el manejo multidisciplinario de esta enfermedad

Objective: To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS). Method: Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival. Statistics: descriptive and Kaplan-Meier estimator. Results: Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95% CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95% CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P < .012, and in accordance with the start of ventilation, P < .004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95% CI, 14.36-129.6), median 49.6 ± 17.5 (95% CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable. Conclusions: Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease

Amyotrophic lateral sclerosis: impact of pulmonary follow-up and mechanical ventilation on survival. A study of 114 cases.

OBJECTIVE: To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS). METHOD: Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival. STATISTICS: descriptive and Kaplan-Meier estimator. RESULTS: Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95%CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95%CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P<.012, and in accordance with the start of ventilation, P<.004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95%CI, 14.36-129.6), median 49.6±17.5 (95%CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable. CONCLUSIONS: Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease.

Enfermedad pulmonar intersticial difusa como primera manifestación de macroglobulinemia de Waldenström: descripción de un caso y revisión de la literatura / Diffuse Interstitial Lung Disease as a First Manifestation of Waldenström’s Macroglobulinemia: Case Report and Review of the Literature

La macroglobulinemia de Waldenström (MW) es una neoplasia linfoide caracterizada por una infiltración principalmente de la médula ósea y del ganglio linfático por linfocitos pequeños maduros o con diferenciación plasmocitoide, con banda monoclonal IgM asociada, y en general un bajo grado de agresividad. Presentamos el primer caso publicado en la literatura española de enfermedad pulmonar intersticial difusa como forma de presentación de una MW y realizamos una revisión de la literatura

Waldenström's macroglobulinemia (WM) is a lymphoid malignancy characterized by infiltration, mainly of the bone marrow and lymph nodes, by small mature lymphocytes showing plasmacytoid differentiation, associated with an IgM monoclonal band, and in general, a low degree of aggressiveness. We present the first case reported in the Spanish literature of interstitial lung disease presenting as MW and we review the literature

Diffuse interstitial lung disease as a first manifestation of Waldenström's macroglobulinemia: case report and review of the literature.

Waldenström's macroglobulinemia (WM) is a lymphoid malignancy characterized by infiltration, mainly of the bone marrow and lymph nodes, by small mature lymphocytes showing plasmacytoid differentiation, associated with an IgM monoclonal band, and, in general, a low degree of aggressiveness. We present the first case reported in the Spanish literature of interstitial lung disease presenting as MW and we review the literature.

Community-acquired pneumonia team decreases length of stay in hospitalized, low-risk patients with pneumonia.

BACKGROUND: Team-focused intervention to improve the care of low-risk patients with community-acquired pneumonia (CAP) is a matter of controversy. Our aim was to determine if a community-acquired pneumonia team (CAPT) would shorten hospital length of stay (LOS) and improve health care utilization in low-risk patients with CAP compared with management by a general pulmonary team (GPT). METHODS: We performed a prospective cohort study of hospitalized, low-risk patients with CAP (Pneumonia Severity Index [PSI] score class I or II) at a single tertiary hospital from June 2007 to June 2008. Study patients were stratified to management by the CAPT treating group (n = 35), following the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) CAP guideline recommendations, or to management by the GPT (n = 30) following the standard of care. Primary outcome measure for comparison of the efficacy of the 2 different team-focused interventions was hospital LOS for patients with CAP. Secondary study outcome measures included patient 30- and 90-day all-cause readmission rate, rate of mortality at 30 and 90 days, antibiotic-treatment duration, time to switch patient from intravenous (IV) to oral antibiotic treatment, and time to achieve clinical stability for patients. RESULTS: Hospitalized, low-risk patients with CAP, who were assisted by a CAPT were more likely to have a shorter hospital stay (9 days less; P < 0.001), shorter time to switch from IV to oral antibiotic therapy (8 days less; P <0.001), and total shorter duration of antibiotic treatment (6 days less; P <0.001), when compared with low-risk patients with CAP who were assisted by a GPT. In addition, for both groups of assisted patients, there were no differences in the time to achieve clinical stability, use of guideline-concordant antibiotic therapy, rate of mortality, or rate of readmissions at 30 and 90 days. CONCLUSIONS: Management by a dedicated CAPT reduced patient hospital LOS, time to switch from IV to oral antibiotic therapy, and duration of antibiotic treatment, without causing adverse events, compared with standard of care, in low-risk patients with CAP.

Utility of brief questionnaires of health-related quality of life (Airways Questionnaire 20 and Clinical COPD Questionnaire) to predict exacerbations in patients with asthma and COPD.

BACKGROUND: There is some evidence that quality of life measured by long disease-specific questionnaires may predict exacerbations in asthma and COPD, however brief quality of life tools, such as the Airways Questionnaire 20 (AQ20) or the Clinical COPD Questionnaire (CCQ), have not yet been evaluated as predictors of hospital exacerbations. OBJECTIVES: To determine the ability of brief specific health-related quality of life (HRQoL) questionnaires (AQ20 and CCQ) to predict emergency department visits (ED) and hospitalizations in patients with asthma and COPD, and to compare them to longer disease-specific questionnaires, such as the St George´s Respiratory Questionnaire (SGRQ), the Chronic Respiratory Disease Questionnaire (CRQ) and the Asthma Quality of Life Questionnaire (AQLQ). METHODS: We conducted a two-year prospective cohort study of 208 adult patients (108 asthma, 100 COPD). Baseline sociodemographic, clinical, functional and psychological variables were assessed. All patients completed the AQ20 and the SGRQ. COPD patients also completed the CCQ and the CRQ, while asthmatic patients completed the AQLQ. We registered all exacerbations that required ED or hospitalizations in the follow-up period. Differences between groups (zero ED visits or hospitalizations versus ≥ 1 ED visits or hospitalizations) were tested with Pearson´s X(2) or Fisher´s exact test for categorical variables, ANOVA for normally distributed continuous variables, and Mann-Whitney U test for non-normally distributed variables. Logistic regression analyses were performed to estimate the predictive ability of each HRQoL questionnaire. RESULTS: In the first year of follow-up, the AQ20 scores predicted both ED visits (OR: 1.19; p = .004; AUC 0.723) and hospitalizations (OR: 1.21; p = .04; AUC 0.759) for asthma patients, and the CCQ emerged as independent predictor of ED visits in COPD patients (OR: 1.06; p = .036; AUC 0.651), after adjusting for sociodemographic, clinical, and psychological variables. Among the longer disease-specific questionnaires, only the AQLQ emerged as predictor of ED visits in asthma patients (OR: 0.9; p = .002; AUC 0.727). In the second year of follow-up, none of HRQoL questionnaires predicted exacerbations. CONCLUSIONS: AQ20 predicts exacerbations in asthma and CCQ predicts ED visits in COPD in the first year of follow-up. Their predictive ability is similar to or even higher than that of longer disease-specific questionnaires.

Coordinación de la asistencia entre un hospital comarcal y su centro de referencia: evaluación de dos modelos de atención neumológica / Coordination Between a District Hospital and a Reference Hospital: Evaluation of Chest Disease Care Models

No está bien definida el tipo de asistencia especializada que deben dar los hospitales comarcales. Paraevaluar diferentes opciones, se analizó retrospectivamente la atención neumológica en el año 2008 endos áreas comarcales de Galicia: Barbanza y Cee, con características poblacionales similares. El hospitalde Barbanza dispone de consulta de neumología atendida por especialistas del hospital de referencia 3días/semana, mientras que en Cee la atienden internistas del propio centro. En ambos casos, la hospitalizaciónestá a cargo del servicio de Medicina Interna. Los datos fueron proporcionados por los serviciosadministrativos de los hospitales y autonómicos.Las estancias medias para el agrupador CDM4 fueron similares en los dos comarcales, pero inferioresa las de los centros de referencia. No hubo diferencias en comorbilidad (Charlson) ni en reingresos almes de alta. Se realizaron más exploraciones funcionales en pacientes del Barbanza, tanto en el propiocentro (957 espirometrías vs 21; p < 0,0001) como en el hospital de referencia (214 determinaciones devolúmen/difusión vs 99; p < 0,001). La prevalencia de tratamientos con CPAP fue más elevada en el áreade Barbanza (3,9 vs 2/1.000 habitantes; p < 0,0001). No encontramos diferencias en la prevalencia deoxigenoterapia ni en ventilación mecánica domiciliaria. La mortalidad por patología respiratoria el año2007 fue similar en las dos áreas.Estos datos sugieren que en un modelo de hospital comarcal con neumólogos consultores, la consultaambulatoria facilita el acceso a una asistencia más especializada, más completa y, probablemente, de máscalidad, que los comarcales sin este tipo de consultoría(AU)

Specialised medical care at district hospitals has not been thoroughly defined. Respiratory care data from2008 in Barbanza and Cee hospitals (Galicia, Spain), were analysed to evaluate different approaches,as they are both similar. Barbanza hospital has a chest diseases clinic run by specialist doctors fromthe reference hospital three days per week, while Cee hospital is operated by the staff on site. In bothcases hospitalisation is the responsibility of the Internal Medicine department. Data was provided by theadministrative departments of each hospital and the regional government.Average CDM4 stays were similar for both district hospitals; however, they were lower than in thereference hospital. Charlson scores and re-admissions a month after discharge were similar in both.Barbanza’s hospital carried out more functional explorations, both at the centre (957 spirometries vs21; P<.0001) and at the reference hospital (214 volume/diffusion tests vs 99; P<.001). CPAP treatments were more prevalent in the Barbanza area (3.9 vs 2/1,000 habitants; P<.0001). No differences were foundin oxygen therapy and home mechanical ventilation. Mortality due to respiratory disease in 2007 wassimilar in both regions.Data suggests that in a district hospital scheme supported by chest disease consultants and outpatientclinics gives easier access to specialised, comprehensive and probably, higher quality care than districthospitals without them(AU)

Coordination between a district hospital and a reference hospital: evaluation of chest disease care models.

Specialised medical care at district hospitals has not been thoroughly defined. Respiratory care data from 2008 in Barbanza and Cee hospitals (Galicia, Spain), were analysed to evaluate different approaches, as they are both similar. Barbanza hospital has a chest diseases clinic run by specialist doctors from the reference hospital three days per week, while Cee hospital is operated by the staff on site. In both cases hospitalisation is the responsibility of the Internal Medicine department. Data was provided by the administrative departments of each hospital and the regional government. Average CDM4 stays were similar for both district hospitals; however, they were lower than in the reference hospital. Charlson scores and re-admissions a month after discharge were similar in both. Barbanza's hospital carried out more functional explorations, both at the centre (957 spirometries vs 21; P<.0001) and at the reference hospital (214 volume/diffusion tests vs 99; P<.001). CPAP treatments were more prevalent in the Barbanza area (3.9 vs 2/1,000 habitants; P<.0001). No differences were found in oxygen therapy and home mechanical ventilation. Mortality due to respiratory disease in 2007 was similar in both regions. Data suggests that in a district hospital scheme supported by chest disease consultants and outpatient clinics gives easier access to specialised, comprehensive and probably, higher quality care than district hospitals without them.

Parálisis diafragmática unilateral dolorosa como única manifestación de la neuralgia amiotrófica / Unilateral Painful Diaphragm Paralysis as the Only Sign of Amyotrophic Neuralgia

La neuralgia amiotrófica es una neuropatía inflamatoria e idiopática que se caracteriza por dolor neuropático. Se describió por primera vez en 1948 como una afectación sólo del plexo braquial y se denominó síndrome de Parsonage-Turner. Aunque este síndrome es más frecuente en el plexo braquial, puede afectar de forma concomitante o aislada al nervio frénico, y en esta circunstancia el diagnóstico es muy difícil si no hay alta sospecha clínica.Presentamos el caso de un paciente con neuralgia amiotrófica cuya única manifestación fue la afectación frénica izquierda, y destacamos la refractariedad del dolor a los analgésicos, así como la persistencia de los síntomas y de la alteración diafragmática durante más de 6 meses(AU)

Amyotrophic neuralgia is an inflammatory and idiopathic neuropathy which is characterised by neuropathic pain. It was described for the first time in 1948 as condition that only affected the brachial plexus and was called Parsonage-Turner syndrome. Although this syndrome is more common in the brachial plexus, it can concomitantly, or in isolation affect the phrenic nerve, and in this case the diagnosis is very difficult if there is no high clinical suspicion.We present a case of a patient with amyotrophic neuralgia in which the only sign was left phrenic involvement, and we highlight the resistance of the pain to analgesics, as well as the persistence of the symptoms and diaphragm problems for over 6 months(AU)

Validation of a Spanish version of the Airways Questionnaire 20: a short and simple instrument.

OBJECTIVE: To describe the psychometric properties of the Spanish version of the Airways Questionnaire 20 (AQ20S) for asthma and COPD separately. STUDY DESIGN: Two hundred and eight patients (108 asthma, 100 COPD) filled in the AQ20S, the St. George's Respiratory Questionnaire (SGRQ), the Asthma Quality of Life Questionnaire (AQLQ) and the Chronic Respiratory Disease Questionnaire (CRQ). Clinical and physiological measurements were assessed concurrently. Clinically stable patients were asked to fill in again the AQ20S after 14 days. The same assessment as on baseline visit was repeated after 3 months. RESULTS: The AQ20S showed a satisfactory score distribution, with minimal floor and ceiling effects, high internal consistency (Cronbach's α > 0.80), and good test-retest reliability (ICC ≥ 0.87). The AQ20S showed a high correlation with the SGRQ in both asthma and COPD (r (s) > 0.75; P < 0.001), as well as with the AQLQ (r (s) = -0.72, P < 0.001) in asthma and with the CRQ (r (s) = -0.59; P < 0.001) in COPD. The AQ20S showed significant correlation with clinical and functional variables, similar to the SGRQ and the AQLQ in asthmatics, but weaker than the SGRQ in COPD patients. Changes in AQ20S scores correlated quite well with changes in other HRQoL questionnaires, both in asthma and COPD. CONCLUSION: The AQ20S showed psychometric properties similar to the original questionnaire. It was equally useful compared with the SGRQ and the AQLQ in asthma patients and slightly less useful than the SGRQ in COPD patients. Considering its simplicity, the AQ20S may be an alternative to more complex traditional questionnaires.

The role of alexithymia in quality of life and health care use in asthma.

BACKGROUND: Alexithymia is a personality trait characterized by difficulties in perceiving and expressing emotions. The relationship between alexithymia and health outcomes in asthma has been shown in a scarce number of studies, in which alexithymia has been considered as an homogeneous construct and the confounding potential effect of anxiety and depression has not been controlled for. OBJECTIVES: To determine the relationship between each of the three dimensions of alexithymia as assessed with the Twenty-Item Toronto Alexithymia Scale--Difficulty Identifying Feelings, Difficulty Describing Feelings, and Externally Oriented Thinking--and health-related quality of life and utilization of health care services, controlling anxiety and depression. METHODS: Patients with moderate to severe asthma between 18 and 65 years old filled in the Twenty-Item Toronto Alexithymia Scale, the Short-Form 36 Health Survey, the St. George's Respiratory Questionnaire, the Trait Anxiety Inventory, and the Cognitive Depression Index. Sociodemographic and clinical data were collected and the frequency of emergency room visits and hospitalizations due to asthma during the following 24 months was recorded. Data were analyzed using the ?2 test, the Mann-Whitney U test, Spearman correlations and multiple linear regression analyses. RESULTS: A total of 76 patients took part in the study (42.67 ± 15.33 years; 59.2% female; 81.6% severe asthma). Data on emergency room visits during the 24-month follow-up were collected for 42 patients; 13 of them (30.95%) with at least one emergency room visit during the follow-up. After controlling for sociodemographic variables, clinical variables, anxiety, and depression, the Difficulty Describing Feelings factor was related to dimensions of the Short-Form 36 Health Survey: Physical Functioning (p = .021), Role-Physical (p = 0.025), and the Physical Component Score (p = .012). The Difficulty Identifying Feelings factor was associated with a higher frequency of emergency room visits (p = .005). The Externally Oriented Thinking factor was not related to any of the dependent measures. CONCLUSIONS: Two dimensions of alexithymia, Difficulty Identifying Feelings and Difficulty Describing Feelings, are complicating factors in the management of asthma, but they operate via different mechanisms and over different outcomes and the effects of alexithymia remain even while controlling for the confounding effect of anxiety and depression.

T Cells localize with proliferating smooth muscle alpha-actin+ cell compartments in asthma.

RATIONALE: Airway remodeling in asthma comprises increased airway smooth muscle (ASM), an alteration linked to airway hyperresponsiveness and disease severity. Experimental studies showed that T cells adhere to ASM through vascular cell adhesion molecule-1 (VCAM-1) and drive ASM growth through direct contact between the T cells and smooth muscle alpha-actin (alpha-SMA)(+) cells. OBJECTIVES: To support the hypothesis of a T-cell/alpha-SMA(+) cell contact mechanism of ASM remodeling in asthma, using bronchial biopsies. METHODS: We performed quantitative morphology on T cells, proliferating cell nuclear antigen (PCNA), alpha-SMA, and VCAM-1 on biopsies from subjects with moderate and severe asthma and healthy control subjects. MEASUREMENTS AND MAIN RESULTS: We demonstrate ASM cell proliferation and infiltration by T cells in proportion to severity in the subjects with asthma. T cells localized with alpha-SMA(+)PCNA(+) cells, suggesting direct intercellular contact and a relationship with alpha-SMA(+) cell proliferation. Furthermore, the subjects with asthma developed a proliferating compartment of subepithelial alpha-SMA(+), nonorganized airway contractile elements (NOACE), suggesting a phenotype gradient from undifferentiated cells to smooth muscle-like cells. T-cell juxtaposition events were also observed in this compartment and correlated to its mass. The subjects with asthma showed VCAM-1 expression in postcapillary venules and clusters of VCAM-1 immunoreactivity in ASM and NOACE, consistent with a role of VCAM-1 in T-cell/alpha-SMA(+) cell interaction. CONCLUSIONS: T cells may induce alpha-SMA(+) cell proliferation through direct intercellular contact. NOACE may in part contribute to ASM growth through differentiation and translocation of alpha-SMA(+) cells. The findings support the role of the T cell in ASM remodeling in asthma.

Sarcoma de Ewing pulmonar/tumor neuroectodérmico primitivo (PNET): aportación de un caso y revisión de la bibliografía / Pulmonary Ewing sarcoma/primitive neuroectodermal tumor: a case report and a review of the literature

Los sarcomas primarios de tórax son muy poco frecuentes. Sarcoma sinovial, angiosarcomas, leiomiosarcomas, rabdomiosarcomas y mesoteliomas sarcomatoides son las variantes intratorácicas más comunes. Aunque el sarcoma de Ewing/tumor neuroectodérmico primitivo (PNET) torácico se desarrolla habitualmente en la pared torácica, se ha descrito en la literatura médica algún caso de localización pulmonar primaria. Presentamos el caso de una mujer de 22 años diagnosticada de sarcoma de Ewing/PNET pulmonar mediante muestra broncoscópica por sus características histológicas, inmunohistoquímicas y técnicas de hibridación in situ. Se excluyó el origen metastásico mediante radiografía, gammagrafía y biopsia de médula ósea. Se inició quimioterapia según el esquema VACD-IE (vincristina, actinomicina D, ciclofosfamida, doxorrubicina, ifosfamida y etopósido), con buena respuesta. En la actualidad acude de forma regular a consultas ambulatorias(AU)

Primary thoracic sarcomas are very rare. The most common intrathoracic variants are synovial sarcoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma, and sarcomatoid mesothelioma. Although thoracic Ewing sarcoma/primitive neuroectodermal tumor (PNET) usually develops on the chest wall, there have been reports of primary Ewing sarcoma/PNET of the lung. We present the case of a 22-year-old woman with Ewing sarcoma/PNET diagnosed following histologic, immunohistochemical, and in situ hybridization studies of a bronchial biopsy specimen. Radiography, ventilation-perfusion scintigraphy, and a bone marrow biopsy confirmed that the tumor was not metastatic. The patient was started on a chemotherapy regimen of vincristine, actinomycin, cyclophosphamide, doxorubicin, ifosfamide, and etoposide and responded well. She is now being seen regularly at our outpatient clinic(AU)

[Unilateral painful diaphragm paralysis as the only sign of amyotrophic neuralgia]. / Parálisis diafragmática unilateral dolorosa como única manifestación de la neuralgia amiotrófica.

Amyotrophic neuralgia is an inflammatory and idiopathic neuropathy which is characterised by neuropathic pain. It was described for the first time in 1948 as condition that only affected the brachial plexus and was called Parsonage-Turner syndrome. Although this syndrome is more common in the brachial plexus, it can concomitantly, or in isolation affect the phrenic nerve, and in this case the diagnosis is very difficult if there is no high clinical suspicion. We present a case of a patient with amyotrophic neuralgia in which the only sign was left phrenic involvement, and we highlight the resistance of the pain to analgesics, as well as the persistence of the symptoms and diaphragm problems for over 6 months.

[Pulmonary Ewing sarcoma/primitive neuroectodermal tumor: a case report and a review of the literature]. / Sarcoma de Ewing pulmonar/tumor neuroectodérmico primitivo (PNET): aportación de un caso y revisión de la bibliografía.

Primary thoracic sarcomas are very rare. The most common intrathoracic variants are synovial sarcoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma, and sarcomatoid mesothelioma. Although thoracic Ewing sarcoma/primitive neuroectodermal tumor (PNET) usually develops on the chest wall, there have been reports of primary Ewing sarcoma/PNET of the lung. We present the case of a 22-year-old woman with Ewing sarcoma/PNET diagnosed following histologic, immunohistochemical, and in situ hybridization studies of a bronchial biopsy specimen. Radiography, ventilation-perfusion scintigraphy, and a bone marrow biopsy confirmed that the tumor was not metastatic. The patient was started on a chemotherapy regimen of vincristine, actinomycin, cyclophosphamide, doxorubicin, ifosfamide, and etoposide and responded well. She is now being seen regularly at our outpatient clinic.

[Cultural adaptation into Spanish of the Airways Questionnaire 20, a short health-related quality-of-life questionnaire for the clinical evaluation of asthma and chronic obstructive pulmonary disease]. / Adaptación transcultural al español del Airways Questionnaire 20 (AQ20), un cuestionario de calidad de vida abreviado para la evaluación clínica del asma y la EPOC.

BACKGROUND AND OBJECTIVES: The routine use of health-related quality-of-life questionnaires in patients with chronic respiratory disease is limited due to the time required to complete them. The Airways Questionnaire 20 (AQ20) contains 20 easy-to-answer questions, making it ideal for use in routine practice. However, a Spanish version is not available. Our aim was to create a version of the AQ20 for use in Spain that would be equivalent to the original English questionnaire. METHOD: The original questionnaire was adapted using the translation-backtranslation method. We evaluated the conceptual equivalence of the translation to the original questionnaire, classifying items as type A if they were fully equivalent, type B if they contained questionable wording, and type C if there were doubts about their equivalence. The items in categories B and C were re-examined by the researchers and translators, with input from the author of the original questionnaire and a group of patients. The final version was piloted among 30 patients. RESULTS: Low difficulty ratings were given to both the translation (3.45) and backtranslation (3.52). Sixty-five percent of the backtranslated items were considered to be fully equivalent to the original English items (type A), 15% were classified as type B, and 20% as type C. The final Spanish version, produced after discussion of items B and C, was administered to 15 patients with asthma (66% women; mean [SD] age, 53.13 [19.6] y) and 15 patients with chronic obstructive pulmonary disease (13% women; mean age, 67.8 [8.94] y). A Cronbach alpha of 0.92 was obtained. CONCLUSION: The adaptation process produced a Spanish questionnaire that is conceptually equivalent to the English original, easy to understand, and satisfactory in terms of internal consistency.

Adaptación transcultural al español del Airways Questionnaire 20 (AQ20), un cuestionario de calidad de vida abreviado para la evaluación clínica del asma y la EPOC / Cultural Adaptation Into Spanish of the Airways Questionnaire 20, a Short Health-Related Quality-of-Life Questionnaire for the Clinical Evaluation of Asthma and Chronic Obstructive Pulmonary Disease

Introducción y objetivos el uso habitual de cuestionarios de calidad de vida relacionada con la salud en enfermedades respiratorias crónicas está limitado por el tiempo que requiere su cumplimentación. El Airways Questionnaire 20 (AQ20) consta de 20 ítems con un formato de respuesta sencillo, idóneo para aplicar en la práctica asistencial, pero aún no se dispone de una versión para su uso en España. Así pues, nuestro objetivo ha sido elaborar una versión del AQ20 en lengua española equivalente al original inglés.Métodopara la adaptación del cuestionario utilizamos el método de traducción-retrotraducción. Evaluamos la equivalencia de cada uno de los ítems con los de la versión original clasificándolos como totalmente equivalentes (tipo A), con alguna expresión dudosa (tipo B) o de equivalencia dudosa (tipo C). Se volvieron a evaluar los ítems de tipo B y C mediante la discusión entre investigadores y traductores, con las aportaciones del autor del cuestionario y la consulta a un grupo de pacientes. Con la versión final se realizó un estudio piloto en 30 pacientes.Resultadoslas puntuaciones de dificultad de traducción y retrotraducción fueron bajas (3,45 y 3,52, respectivamente). En cuanto a la equivalencia conceptual entre la versión retrotraducida y el cuestionario original, el 65% de los ítems se calificó de tipo A, el 15% de tipo B y el 20% de tipo C. Tras la discusión de los ítems B y C se elaboró la versión española final del AQ20, que se aplicó a 15 pacientes con asma (un 66% mujeres; edad media±desviación estándar: 53,13±19,6 años) y a otros 15 con enfermedad pulmonar obstructiva crónica (un 13% mujeres; edad media: 67,8±8,94 años), y se obtuvo un alfa de Cronbach de 0,92.Conclusiónel proceso de adaptación ha permitido obtener un instrumento en español conceptualmente semejante al original inglés, de fácil comprensión y con una consistencia interna adecuada(AU)

Background and objectives The routine use of health-related quality-of-life questionnaires in patients with chronic respiratory disease is limited due to the time required to complete them. The Airways Questionnaire 20 (AQ20) contains 20 easy-to-answer questions, making it ideal for use in routine practice. However, a Spanish version is not available. Our aim was to create a version of the AQ20 for use in Spain that would be equivalent to the original English questionnaire.MethodThe original questionnaire was adapted using the translation-backtranslation method. We evaluated the conceptual equivalence of the translation to the original questionnaire, classifying items as type A if they were fully equivalent, type B if they contained questionable wording, and type C if there were doubts about their equivalence. The items in categories B and C were re-examined by the researchers and translators, with input from the author of the original questionnaire and a group of patients. The final version was piloted among 30 patients.ResultsLow difficulty ratings were given to both the translation (3.45) and backtranslation (3.52). Sixty-five percent of the backtranslated items were considered to be fully equivalent to the original English items (type A), 15% were classified as type B, and 20% as type C. The final Spanish version, produced after discussion of items B and C, was administered to 15 patients with asthma (66% women; mean [SD] age, 53.13 [19.6] y) and 15 patients with chronic obstructive pulmonary disease (13% women; mean age, 67.8 [8.94] y). A Cronbach á of 0.92 was obtained.ConclusionThe adaptation process produced a Spanish questionnaire that is conceptually equivalent to the English original, easy to understand, and satisfactory in terms of internal consistency(AU)