Management of infusion-related reactions in cancer therapy: strategies and challenges.

Several anticancer therapies have the potential to cause infusion-related reactions (IRRs) in the form of adverse events that typically occur within minutes to hours after drug infusion. IRRs can range in severity from mild to severe anaphylaxis-like reactions. Careful monitoring at infusion initiation, prompt recognition, and appropriate clinical assessment of the IRR and its severity, followed by immediate management, are required to ensure patient safety and optimal outcomes. Lack of standardization in the prevention, management, and reporting of IRRs across cancer-treating institutions represents not only a quality and safety gap but also a disparity in cancer care. The present article, supported by recently published data, was developed to standardize these procedures across institutions and provide a useful tool for health care providers in clinical practice to recognize early signs and symptoms of an IRR and promptly and appropriately manage the event.

Predicting lung nodules malignancy.

BACKGROUND: It is critical to developing an accurate method for differentiating between malignant and benign solitary pulmonary nodules. This study aimed was to establish a predicting model of lung nodules malignancy in a real-world setting. METHODS: The authors retrospectively analysed the clinical and computed tomography (CT) data of 121 patients with lung nodules, submitted to percutaneous CT-guided transthoracic biopsy, between 2014 and 2015. Multiple logistic regression was used to screen independent predictors for malignancy and to establish a clinical prediction model to evaluate the probability of malignancy. RESULTS: From a total of 121 patients, 75 (62%) were men and with a mean age of 64.7 years old. Multivariate logistic regression analysis identified six independent predictors of malignancy: age, gender, smoking status, current extra-pulmonary cancer, air bronchogram and nodule size (p<0.05). The area under the curve (AUC) was 0.8573. CONCLUSIONS: The prediction model established in this study can be used to assess the probability of malignancy in the Portuguese population, thereby providing help for the diagnosis of lung nodules and the selection of follow-up interventions.

The Vacinómetro® initiative: an eleven-year monitorization of influenza vaccination coverage rates among risk groups in Portugal.

Annual vaccination is fundamental for individual and group protection against seasonal influenza infection. International and Portuguese healthcare organizations have established influenza vaccination coverage rate (VCR) targets for risk groups, namely 75% in people ≥ 65 years old. The Vacinómetro® initiative has been monitoring influenza VCR among target risk groups in Portugal since 2009,: Group 1, ≥ 65 years old; Group 2, patients with chronic conditions; Group 3, healthcare workers in direct contact with patients; and Group 4, 60-64 years old. Besides VCR, social-demographic and health-related variables have been evaluated. During the study period (2009/2010 - 2019/2020), the VCR increased in the 4 target risk groups: from 58.6% to 76.0% in Group 1 (reaching the WHO target); 33.3% to 72.0% in Group 2; 25.0% to 58.9% in Group 3; and 36.6% to 42.8% in Group 4. "Physician recommendation" was the main driver for vaccination whereas "lack of habit" was the main barrier to vaccination. Vacinómetro® data demonstrate that free-of-charge vaccination has a positive impact on VCR. The observed positive trends in influenza VCR demonstrate that public health measures implemented in Portugal to facilitate access to influenza vaccine result in increased vaccine uptake. Strategies to promote population literacy and the physician's awareness should be continued and reinforced. Free-of-charge vaccination criteria extended to more risk groups would also contribute to higher influenza VCR in Portugal.

Chronic obstructive pulmonary disease exacerbations' management in Portuguese hospitals - EvaluateCOPDpt, a multicentre, observational, prospective study.

INTRODUCTION AND OBJECTIVES: In order to improve the quality of chronic obstructive pulmonary disease (COPD) patients' care, better knowledge of clinical practice and the factors associated with patient outcomes are needed. This study aimed to evaluate the relation between clinical practice and the outcomes of patients admitted for COPD exacerbations in Portuguese hospitals. MATERIALS AND METHODS: Observational, multicentre, prospective study with a 60-days follow-up period, in 11 hospitals, including patients aged ≥ 30 years, admitted to hospital for at least 24 hours due to an acute exacerbation of COPD. Demographic and clinical data were collected, including sex, age, smoking habits, hospitalisations, pulmonary function, comorbidities, COPD symptoms, and treatment. Sixty days after discharge, COPD exacerbations management, outcome measures, and readmission data were evaluated through a structured phone follow-up interview. RESULTS: 196 patients were included (85.7% male, mean age 71.2 years), the majority admitted through the emergency service. Ex-smokers and current smokers accounted for 51% and 36%, respectively. On admission, 72.4% were on LAMA, 54.6% on LABA, and 45.5% were on LABA/LAMA. Inhaled corticosteroids (ICS) were used in 37.3% and systemic steroids (SCS) in 10.3%. 35.7 % had had at least one exacerbation, with hospitalisation, in the previous year. There was no spirometry data for 23.2%. On hospitalisation, 98.5% of patients were treated with oxygen and 38.3% with non-invasive ventilation. Additionally, 93.4% used SCS and 60.2% ICS. Antibiotics were administered to 85.2%. 95.4% of patients were discharged; 9 died, 5 of whom had a COPD-related death. The median length of stay was 12 days for discharged patients and 33 days for patients who died. At discharge, 79.1% were prescribed with LAMA, 63.6% SCS, 61.5% LABA and 55.6% LAMA+LABA. 26,2% were prescribed with ICS+LABA+LAMA. At follow-up, 44.4% had a scheduled medical appointment within the 60 days after being discharged, and 28.3% were later readmitted due to exacerbation, of whom 52.8% were hospitalised. CONCLUSIONS: The severity of COPD, particularly in exacerbations, is directly related to impaired lung function and quality of life, mortality, and significant health system costs. Knowledge about COPD exacerbations' management in acute hospital admissions in Portugal may help stimulate a national discussion and review of existing data to engage clinicians, policymakers, managers, and patients, raising awareness and promoting action on COPD.

Predictors of immune-related adverse events and outcomes in patients with NSCLC treated with immune-checkpoint inhibitors.

OBJECTIVE: To identify predictors of immune-related adverse events (IRAEs) in patients with non-small cell lung cancer (NSCLC) treated with immune checkpoint inhibitors (ICIs). Assess associations between outcomes and the development of IRAEs. METHODS: Retrospective analysis of patients with NSCLC treated with ICIs between 2016 and 2020 in the Pulmonology Department of our hospital. Patients with and without IRAEs were compared. A logistic regression analysis was performed to determine predictors of IRAEs. Progression-free survival (PFS) and overall survival (OS) curves were calculated using the Kaplan-Meier method, and the long-rank test was used to assess survival differences between groups. Univariate and multivariate Cox proportional-hazards regression models were used to identify factors associated with PFS and OS. The value considered statistically significant was p≤0.05. RESULTS: A total of 184 patients (77.7% men, mean age 66.9±9.5 years) treated with ICIs were analyzed. During follow-up, 49 (26.6%) patients developed IRAEs and 149 (81.0%) died. According to the multivariate logistic regression analysis, treatment with statins (OR:3.15; p = 0.007), previous systemic corticosteroid therapy (OR:3.99; p = 0.001), disease controlled as response to ICI (OR:5.93; p < 0.001) and higher hemoglobin values (OR:1.28; p = 0.040) were independent predictors for the development of IRAEs. Patients who developed IRAEs had significantly longer medians of PFS (41.0 vs 9.0 weeks, p < 0.001) and OS (89.0 vs 28.0 weeks; p < 0.001). CONCLUSIONS: Patients treated with statins, pre-ICI systemic corticosteroids, higher baseline hemoglobin value and controlled disease as initial response to ICI had a higher risk of developing IRAEs. The development of IRAEs was associated with better outcomes.

COPD: Analysing factors associated with a successful treatment.

OBJECTIVES: To evaluate if non-adherence to inhaled medications, inhalers mishandling or the prescribers' non-adherence to GOLD strategy are associated with mMRC grade, CAT score, COPD acute exacerbations or FEV1%. METHODS: A cross-sectional study on COPD was conducted in the ambulatory pulmonary clinic of Hospital de Guimarães. Patients ≥40 years diagnosed according to GOLD criteria were recruited consecutively. A survey of demographic and clinical data was used. Adherence was assessed by using the Measure of Treatment Adherence (MTA) questionnaire. Inhalation technique was evaluated by using checklists of correct steps and critical errors, and inhalers' misuse was defined when one or more critical errors were made, whatever the number or types of inhalers in use. To evaluate the prescriber non-adherence to GOLD strategy, the patients' current medication was compared with therapeutic standards proposed by the GOLD 2017 strategy for the same ABCD groups. A statistical analysis was performed with IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp. RESULTS: We studied 303 participants, 79.5% males, mean age=67.5 years. A total of 285 completed the MTA questionnaire. Non-adherence was referred by 47 (16.5%) patients, and a significant negative association was found between adherence and CAT score and FEV1%. 285 patients performed 499 inhalations manoeuvres with 10 different IDs. Inhaler misuse was observed in 113 (39.6%) patients, and was not associated with CAT score, mMRC grade, ECOPD or FEV1%. We found deviations from the GOLD strategy in 133 (44.3%) patients, which were negatively related to CAT score, mMRC grade and ECOPD. CONCLUSIONS: In the present study we failed to prove a positive association between non-adherence to medication, inhalers mishandling or prescribers' non-adherence to GOLD strategy with symptoms, exacerbations and airflow limitation. Conversely, more symptomatic and more obstructed patients were more adherent to medication, previous ECOPD seems to improve prescribers' adherence to treatment guidelines, and symptoms, ECOPD and FEV1% were not significantly associated with inhaler technique.

Coexistence of DIPNECH and carotid body paraganglioma: is it just a coincidence?

SUMMARY: We describe the case of a 56 year-old woman with the almost simultaneous appearance of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and a carotid body paraganglioma. Of interest, 6 years earlier, the patient underwent total thyroidectomy due to papillary thyroid carcinoma and, in the meantime, she was submitted to mastectomy to treat an invasive ductal carcinoma of the breast. In order to explain these lesions, an extensive genetic study was performed. Results showed positivity for the presence of the tumor suppressor gene PALB2, whose presence had already been detected in a niece with breast cancer. The patient underwent different procedures to treat the lesions and currently she is symptom-free over 2 years of follow-up. LEARNING POINTS: The presence of two rare neoplasms in a single person should raise the suspicion of a common etiology. To the best of our knowledge, this is the first case that shows the coexistence of DIPNECH and paraganglioma. The contribution of the PALB2 gene in the etiology of these rare neoplasms is a possibility.

Real-world data from the Portuguese Nivolumab Expanded Access Program (EAP) in previously treated Non Small Cell Lung Cancer (NSCLC).

OBJECTIVE: The main aim of the study was to evaluate the efficacy and safety profile of Nivolumab, an immune-checkpoint-inhibitor antibody, in advanced, previously treated, Non-Small Cell Lung Cancer (NSCLC) patients, in a real world setting. METHODS: We performed a retrospective, multicentre data analysis of patients who were included in the Portuguese Nivolumab Expanded Access Program (EAP). Eligibility criteria included histologically or citologically confirmed NSCLC, stage IIIB and IV, evaluable disease, sufficient organ function and at least one prior line of chemotherapy. The endpoints included Overall Response Rate (ORR), Disease Control Rate (DCR), Progression Free Survival (PFS) and Overall Survival (OS). Safety analysis was performed with the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 4.0, and immune-related Adverse Events (irAEs) were treated according to protocol treatment guidelines. Tumour response was assessed using the Response Evaluation Criteria in Solid Tumours (RECIST) version 1.1. Data was analysed using SPSS, version 21.0 (IBM Statistics). RESULTS: From June 2015 to December 2016, a total of 229 patients with advanced NSCLC were enrolled at 30 Portuguese centres. Clinical data were collected up to the end of July 2018. The baseline median age was 64 years (range 37-83) and the majority of patients were males (70.3%) and former/current smokers (69.4%). Patients with non-squamous histology predominated (88.1%), and 67.6% of the patients had received 2 or more prior lines of chemotherapy. Out of 229 patients, data was available for 219 patients (3 patients did not start treatment, while data was unavailable in 7 patients); of the 219 patients, 15.5% were not evaluated for radiological tumour assessment, 1.4% had complete response (CR), 21% partial response (PR), 31% stable disease (SD) and 31.1% progressive disease (PD). Thus, the ORR was 22.4% and DCR was 53.4% in this population. At the time of survival analysis the median PFS was 4.91 months (95% CI, 3.89-6.11) and median OS was 13.21 months (95% CI, 9.89-16.53). The safety profile was in line with clinical trial data. CONCLUSIONS: Efficacy and safety results observed in this retrospective analysis were consistent with observations reported in clinical trials and from other centres.

COPD: misuse of inhaler devices in clinical practice.

Background and objectives: Inhalers mishandling remain an important clinical issue worldwide. The aim of this study was to evaluate inhalation technique in stable COPD out-patients. The variables under study were type of inhaler device (ID), patients' preference for an inhaler, number of IDs used by each patient, beliefs about inhaler medication and some demographic, clinical and functional patients' characteristics. We aim to assess how they are related to inhalation technique. Methods: A cross-sectional study was conducted in a hospital outpatient respiratory care. COPD patients over 40 years old, diagnosed according to GOLD criteria, and using IDs were included consecutively. The Beliefs about Medicines Questionnaire (BMQ), a demographic and a clinical survey were applied. The number of IDs used by each patient and the patients' preference for some IDs were recorded. Patients were asked to demonstrate the use of their prescribed inhalation devices, and inhaler technique was assessed by using previously defined checklists, including essential steps and critical errors. A statistics analysis was then performed. Results: We studied 300 subjects performing a total of 521 inhalation manoeuvers with 10 different IDs. At least one step incorrectly performed was found in 48.2% of demonstrations and in 29.9% critical errors were observed. Misuse was related to priming/loading in 6.9%, to inhalation manoeuver in 13.1% and to both in 10%. There was a statistically significant association between critical errors and type of ID (P<0.001). No significant relationship was found between correct performance of key manoeuvers and patients' preference or number of inhalers used per patient. Misuse due to critical errors was observed in 39.3% of patients and was positively related to female gender, age ≥65, lower education level and lower socioeconomic status (higher Graffar classification score), but not to patients' clinical or functional characteristics. In the sub-group of patients presenting critical errors when using IDs, there was a statistically significant inverse association between BMQ Necessity score and number of critical errors. Conclusions: Inhalers mishandling remains disappointingly common. A good inhalation technique depends on the type of ID, and failure of inhalation manoeuver was the main cause of ID misuse. It was not associated to multiple inhalers' use nor to patient's preference, but to the patient's beliefs about the necessity to use them. Elderly patients, women and those with lower education level or lower socioeconomic status demonstrate a worse inhalation technique.

Characterisation of morbidity in a COPD hospital cohort.

OBJECTIVES: To characterise the morbidity of COPD out-patients based on symptoms, acute exacerbations, FEV1 and comorbidities, and to explore the association between different patients' characteristics such as social, demographic, clinical history or exposure. METHODS: Stable COPD outpatients over 40 years old diagnosed according to GOLD criteria were included consecutively; the exclusion criteria were only refusal to participate and inability to understand clinical questionnaires. A survey of demographic and clinical data was conducted. Symptoms were evaluated using the CAT and mMRC questionnaires. The number of COPD acute exacerbations reported in the previous year was assessed, and spirometry performed on all participants according to ATS/ERS recommendations. Different variables were collected and then related to each other. RESULTS: We studied 303 COPD outpatients, all Caucasians, 79.5% males and mostly elderly. 65.7% of participants reported having low monthly income and 87.8% a low education level. Tobacco smoking was the most common exposure identified but a substantial proportion of COPD patients were non-smokers (26%). Frequent acute exacerbations were reported by 38.0% of patients. The mean post-bronchodilator FEV1 was 53.2%. The distribution of patients according to GOLD 2017 stage and classification was respectively 9.9%, 41.9%, 35.0% and 13.2% from 1 to 4 and 23.1%, 39.6%, 2.3% and 35.0% from GOLD A to D. Only 29 patients (9.5%) presented no comorbid conditions, and the most common were hypertension, heart diseases and dyslipidaemia. CONCLUSIONS: Our data confirms COPD as a complex and heterogeneous disorder, with a significant morbidity due to the nature of symptoms, frequent comorbidities and exacerbations. A substantial proportion of COPD patients were never-smokers, mainly women, calling attention to the need for COPD recognition in these cases. COPD in women, in never-smokers and in patients with a previous diagnosis of asthma presented some specific characteristics. Some patient characteristics are associated with frequent acute exacerbations. FEV1 was strongly related both to symptoms and exacerbations.

[Bilateral lung masses: the same aetiology?]. / Massas pulmonares bilaterais. mesma etiologia?

The authors describe the case of a 50 year old woman, smoker, healthy until September 2003 when she presented persistent dry cough, fatigue and weight loss. Chest x-ray showed two lung masses, one in the superior right lobe and the other in the lingula lobe of the left lung. The patient underwent TFNA (transthoracic fine needle aspiration) and the cytological result was compatible with small cell lung cancer. Staging procedures identified hepatic lesions, probably secondary. Presence of hepatic metastasis and contralateral lung lesions defined the stage of the disease as disseminate. Chemotherapy with carboplatin and etoposide was started. Six months later the right lesion had decreased but the left lesion had increased. TFNA of this lesion revealed adenocarcinoma. A new treatment was started with vinorelbine and gemcitabine. After four cycles of chemotherapy without any response patient underwent radiotherapy of the left lesion. After 28 months of follow up the patient was asymptomatic and able to manage her normal daily routine. Multiple lung cancers can be considered as synchronous or metachronous, depending on the time of diagnosis. Metachronous lesions are the most frequent (50-70% of all cases) and adenocarcinoma the more frequent histological pattern. In this case the disease was at a disseminate stage, which did not suggest a synchronous lung tumour. While the disease was at an advanced stage with poor prognosis at diagnosis, the evolution of the two different lung tumours did not seem to compromise patient's daily routine.

[Unusual diagnosis of tracheal obstruction]. / Diagnóstico pouco usual de obstrução da traqueia.

Male, 54 years old, with smoking habits. The patient complaints were cough, with bleeding secretions in the previous two months. Because of the persistence of the symptoms, a bronchoscopy was proposed. This exam showed multiple lesions in the trachea, nearly 2 cm above the vocal cords that compromised the airway and did not allow the progression of the bronchoscope. For this reason, it was decided to introduce a tracheal prosthesis. Because of instability, and the suspicion of malignancy we started thoracic irradiation. The histological specimen was compatible with anaplastic Lymphoma, CD 30+. Because of respiratory distress, with stridor, the prosthesis was removed. The trachea was permeable after this. The patient was discharged and oriented to Clinical Haematology. He is clinically stable and under monitoring, having now completed a chemotherapy treatment with CHOP (Ciclophosphamide, Adriamycin or Hydroxydorubicin, Vincristine or Oncovin and Prednisone). The primary mediastinal Large Cells Lymphoma represents 11.5% of the Large Cells Lymphomas (2% of the non-Hodgkin's Lymphomas). This neoplasm is in many studies considered incurable, but there are some positive results with the combination of radiotherapy and chemotherapy. If there is any airway compromise, the tracheal prosthesis may be one option for the resolution of the respiratory insufficiency.

[Non small cell lung cancer - comparison between clinical and pathological staging].

Lung cancer (LC) staging remains a clinical challenge as it determines the disease's prognosis and treatment. Surgery is the best option for controlling non-small cell lung cancer (NSCLC) and the only potential cure. In this setting, lung cancer staging helps select patients who will benefit from surgery, excluding inoperable patients and including patients with resectable lesions. The aim of this study is to compare clinical staging (TNMc) with pathological staging (TNMp) and to evaluate diagnosis, complementary treatment and survival of these patients. This is a retrospective study that included patients with non-small cell lung cancer or with highly suspicious lesions who had undergone surgery and were followed up in the Hospital de São João lung cancer unit between January 1999 and December 2003. It is based on clinical files and pathology reports. 73.3% of this group of 60 patients were male, with median age 59.2 years. The most frequent TNMc stages were 41.7% T1N0M0 and 36.7% T2N0M0. Thoracotomy for therapeutic purpose was per- formed in 80% and thoracotomy for diagnostic purpose also in the remaining 20%. In 6.7% the resection was incomplete. The most frequent TNMp stages were T2N0p in 33.3%, T2N1p in 15.0% and T2N2p in 13.3%. There was a significant difference between the two staging types, with upstaging in 65.0%, down staging in 67% and only 28.3% keeping the same stage. The most frequent differences were from T1N0c to T2N0p and from T2N0c to T2N1p. The global agreement between both staging methods was 21.7%. Median global survival was 43 months. In conclusion, while clinical staging was less accurate, it did not determine important changes in therapeutic strategy and survival. For the future, we should consider using other diagnostic tools and other biological factors to complement the anatomical information that we currently use.

[Bronchospasm and hemoptysis. Could have the same cause?]. / Sibilância e hemoptises. Poderão ter uma causa comum?

The authors describe the case of a man, 46 years old, former smoker, former bird breeder, followed in the service of Imunoallergology for bronchospasm without response to the treatment. After experiencing an hemoptysis he was admitted in our service. He was submitted to many exams, which include a flexible bronchoscopy. This technique allows the identification of an endobronquial necrotic mass, which almost obstructed the main right bronchus. In order to obtain a bigger and more representative sample a rigid bronchoscopy was performed. This technique showed a broncholith, which was partially removed, and a bronchial fistula. Actually he is assimptomatic and under annual surveillance. First described for Aristoteles, the broncholithiasis is defined by the presence of stones in the bronchial tree. It is a very rare pathology, with a variable clinical expression, which must be considered whenever there is respiratory complaints in association with hilar or mediastinic calcifications.

Bronchiectasis: a retrospective study of clinical and aetiological investigation in a general respiratory department.

BACKGROUND: Bronchiectasis can result from many diseases, which makes the aetiological investigation a complex process demanding special resources and experience. The aetiological diagnosis has been proven to be useful for the therapeutic approach. OBJECTIVE: Evaluate how accurately and extensive the clinical and aetiological research was for adult bronchiectasis patients in pulmonology outpatient service which were not following a pre-existing protocol. METHODS: We retrospectively reviewed the records of 202 adult patients with bronchiectasis, including the examinations performed to explain the aetiology. RESULTS: The mean age of the patients was 54 ± 15 years, there was a predominance of female (63.9%) and non-smoker (70%) patients. Functional evaluation showed a mild airway obstruction. The sputum microbiological examination was available for 168 patients (43.1% had 3 or more sputum examinations during one year). Immunoglobulins and α1-antitrypsin were measured in around 50% of the patients. The sweat test and the CF genotyping test were performed in 18% and 17% of the patients, respectively. The most commonly identified cause was post-infectious (30.3%), mostly tuberculosis (27.2%). No definitive aetiological diagnosis was established in 57.4% of the patients. We achieved a lower aetiological diagnosis if we compare our series with studies in which a diagnostic algorithm was applied prospectively. CONCLUSIONS: The general characteristics of our patients were similar with other series. Detailed investigation of bronchiectasis is not a standard practice in our outpatient service. These results suggest that the use of a predefined protocol, based on current guidelines, could improve the assessment of these patients and facilitate the achievement of a definitive aetiology.

Survival predictors in advanced non-small cell lung cancer.

The authors studied the influence on survival of 21 clinical, anatomical, haematological and biochemical factors evaluated, at diagnosis, of 411 patients (pts) with advanced Non Small Cell Lung Cancer (NSCLC) followed in our department between 1984 and 1990. Most of the patients were male (347--84.4%) and only 64 (15.6%) were females. Median age was 62 years, but was slightly higher in females. Only 34 patients were aged under 45 years. Squamous cell carcinoma (215 pts--52%) and adenocarcinoma (152 pts--37%) were the most frequent histologic types. Performance status was poor--only 103 (25%) continued active; 120 (29%) spent at least half of the time in bed; 188 (46%) were severely limited. After staging, 179 (44%) presented locally advanced disease (stage IIIB) and 232 (56%) metastatic dissemination (stage IV). Therapy was defined by the oncologic group according to individual characteristics and based on clinical grounds. Anti-neoplastic therapy was performed in 225 (55%), chemotherapy alone in 121 (30%), radiation therapy alone in 67 (16%), and sequential combined treatment (chemotherapy and thoracic radiation) in 37 (9%). Until 1987, the main chemotherapy regimen was MACC (Metrotrexate + Adriamycine + Cyclophosphamide + Lomustin), afterwards VP(M) (Cisplatin + Vimblastin + Mitomycine). Radiation therapy was performed using Co60, 2 Gy/day, 5 days a week, for 4 weeks (approximately 45 Gy total). The response rate was poor--four complete responses (2%), 42 (19%) partial responses. The overall median survival was 4.3 months and only 5% of patients were alive after 18 months of follow up. Prognostic importance of each characteristic studied was initially done by unifactorial analysis, followed by multifactorial analysis according to two methods: Cox proportional hazards model and recursive partitioning amalgamation--RECPAM. Regardless of the method used, the main determinants of survival were found to be performance status (Zubrod), weight loss and serum albumin. Other factors such as the staging (presence or absence of metastasis), lymphocytes, lactic dehydrogenase, and hoarseness were also significant. It is noteworthy that age and histological type were irrelevant; sex and hoarseness only proved important when integrated within a multifactorial model. The overall prognostic evaluation and therapeutic decision of advanced NSCLC patients could be improved by combining the prognostic value of TNM with that of performance status, weight loss and serum albumin. These prognostic guidelines must be taken into account when designing new clinical trials.

[Prevalence of asthma in the city of Porto]. / Prevalência da asma na cidade do Porto.

It is possible that asthma epidemiology will contribute to the definition of asthma precipitant factors. This work is enrolled in an international study co-ordinated by COMAC-EPI. In Oporto, among 137.000 residents in the same town region, a standardised sample of 4.047 male and female individuals aged from 20 to 44 years was defined. A screening questionnaire was sent with a stamped envelope. Four months later the same questionnaire was sent to the individuals who did not answer it and finally those who do not answer the second letter were visited in their own residence. We got 2075 answers. Among the responders about half were women: 1075, 25.39% belonging (273) to the 20-29 years age group; 42.69% (459) 30-39 years; 31.90% (343) 40-44 years. In men the percentage of distribution by age groups was similar. Question nQ 5 was answered affirmatively by 60 individuals, corresponding to the prevalence of 2.89%. Seventy-one (3.42%) said they had been under asthma treatment during the last year. Among the symptoms that usually define the attack of asthma, those inquired in the group of question 1 show a prevalence close to that of the asthma diagnosis: 6.45%. The prevalence of being awakened by tightness in the chest, shortness of breath and coughing, with values of 16.17%, 10.69% and 25.68% is quite superior than in question nQ 5. The prevalence obtained with the Hay Fever question was 18.84%. Data obtained is similar to the data of other centers.

[Spirometric alterations caused by hemodialysis. Their relation to changes in the parameters commonly used to measure hemodialysis efficiency]. / Alterações espirométricas provocadas pela hemodiálise. Sua relação com a variação dos parâmetros vulgarmente utilizados na medição da eficácia hemodialítica.

The Forced Expiratory Volume in the 1st second (FEV1) and the Forced Vital Capacity (FVC) was determined before and after a hemodialysis (HD), in 61 patients suffering from chronic renal failure (CRF). Before and after the same HD the value of the following parameters were determined: Na; K; Cl; Urea; Creatinine, Ca; P and hematocrit. We found the following values: initial FEV1 91.68%, final FEV1 100.35%, (P less than 0.001); initial FVC 87.4%, final FVC 95.87% (P less than 0.001). The 61 patients were separated in two sub-groups. In the first the FEV1 variation less than or equal to 8%, while in the second it was greater than 8%. The mean variation of the other parameters was determined in both sub-group. No significant difference was found between them. On the other hand a significant correlation was found (r = 0.06, P less than 0.03) between the improvement of pulmonary function and the ponderal loss. The correction of the hydrosaline overload seems to be an important factor in the reported spirometric improvement.

Lung cancer during pregnancy: an unusual case.

The incidence of pregnancy-associated cancer is relatively low, complicating only 0.02-0.1% of all pregnancies. The authors describe a case of a 36-year-old woman, a light smoker, who was admitted to the hospital at 27 weeks of pregnancy, with respiratory symptoms since second trimester. Chest-X ray showed total left lung opacity with contralateral mediastinal deviation, suggestive of pleural effusion, and the pleural biopsy revealed invasion by lung adenocarcinoma. EGFR mutation test was negative. After a multidisciplinary meeting, it was decided to start fetal lung maturation and cesarean section at 29 weeks gestation. The patient received two lines of chemotherapy and bone metastasis radiotherapy, but there was progression of the disease. An EML4-ALK translocation was identified in an additional genetic test. Crizotinib 250mg BID was started. The patient showed a progression-free survival of 9 months and died 19 months after lung adenocarcinoma was diagnosed.