Medicina Pulmonar e Respiratória

Background: Patients with inflammatory bowel disease (IBD) occasionally present with pulmonary involvement. Recently, a tumor necrosis factor-α (TNF-α) blocking agent was introduced for the treatment of IBD in Japan. We aimed to clarify the frequency and type of chest X-rays or computed tomography (CT) abnormalities associated with IBD in patients treated with infliximab (IFX).

Methods: We prospectively obtained, through interviews, information regarding respiratory symptoms, medical history, smoking history, occupational and environmental exposure, and medication history for patients with IBD treated with IFX at the IBD center of our hospital. We also examined percutaneous oxygen saturation (SpO2) and chest X-rays. Chest computed tomography and spirometry were also performed for patients with respiratory symptoms, abnormal SpO2, and/or abnormal chest X-rays.

Results: Subjects were 115 patients with Crohn’s disease (CD) and 8 with ulcerative colitis (UC). Of those with CD, 21 presented with respiratory symptoms. Among these, 4 (3.5%) had chest X-ray abnormalities. None of the patients with UC had respiratory symptoms or chest X-ray abnormalities. CT examination of 13 patients with CD revealed 5 with bronchiectatic changes, ground glass opacity (GGO), consolidation, nodular lesions, and/or granular shadows.

Conclusion: Chest X-rays or computed tomography abnormalities were detected in at least 3.5% of patients with CD treated with IFX.

Aim and Objectives: To find out the effectiveness of moxifloxacin prophylaxis in HIV patients having contact history of MDR-TB. Materials and Methods: This is an observational prospective cohort study of HIV patients divided in to two groups, moxifloxacin prophylaxis group and non-prophylaxis group. These groups are followed for four years from March 2012 to March 2016 to appraise the incidence of tuberculosis and mortality in these two cohorts. Results: The tuberculosis incidence in more in non-prophylaxis group when compared to prophylaxis group. Crude tuberculosis incidence is 275 per 1000 person/years in non-prophylaxis group when compared to 42 per 1000 person/years in prophylaxis group (p<0.005). Incidence of MDR-TB is more in non-prophylaxis group (26 vs 6; p=0.002) when compared to prophylaxis group. Crude mortality rate is more in non-prophylaxis group (774 vs 103; p=0.003) when compared to the other group which was further confirmed by Cox regression hazards model. Proportional hazards model in which moxifloxacin prophylaxis had a 60% decrease in mortality compared to non-prophylaxis (adjusted relative hazard). Conclusion: Prophylaxis with 6-months moxifloxacin is an effective alternative for HIV patients instead of isoniazid suspected to contact with multidrug resistant tuberculosis.

Objective: High flow nasal cannula (HFNC) is an evolving respiratory therapy whereby high flow rates of conditioned breathing gas are delivered into the nasal cavity to purge anatomical dead space of CO2 rich expired gas. The aim of this project was to create a computational fluid dynamics (CFD) model to evaluate the fluid patterns in the human nasal and pharyngeal cavities with HFNC application, and quantify time to purge for two cannula configurations. Methods: Three-dimensional geometry of the human airway was used to define the extrathoracic dead space and the two cannula designs tested incorporate large vs small bore nasal prong configurations (Vapotherm, Exeter, NH, USA). The fluid flow simulations were performed using FLOW-3D software, set up for a cannula flow rate of 20 L·min-1 and run until steady state. Results: Basic flow patterns were similar between cannulae, creating vortices around a central inward flow path. Flow velocity around the vortices was greater with the small prong cannula, resulting in a lower pressure in each region of the nasal and nasopharyngeal space. The calculation of purge time revealed that the small prong nasal cannula was able to clear the nasal, pharyngeal and oral cavities in 2.2 seconds, whereas the large bore cannula required 3.6 seconds (64% longer). Conclusion: The current CFD data validate that a smaller bore nasal prong facilitates the purge action, which is related to velocity and dynamic energy induced by the tighter prong nozzle as opposed to the lesser occlusion of the nares.

Introduction: In stable adult cystic fibrosis (CF) patients, we assessed the role of baseline high sensitivity C-reactive protein (hs-CRP) on CF clinical variables and frequency of intravenous (IV) treated pulmonary exacerbations (PExs) 1-year post- baseline. Methods: We recruited 51 clinically stable CF patients from our Adult CF Center. We incorporated collected parameters into Matouk CF clinical score and CF questionnaire-revised quality of life score (QOL). We used the clinical minus complications subscores as a clinical disease activity score (CDAS). We dichotomized our patients according to the cohort median baseline hs-CRP of 5.2 mg/L. Results: Patients in the high hs-CRP group (≥ 5.2 mg/L) demonstrated worse CDAS (r=0.67, p=0.0001) and QOL scores (r=0.57, p=0.0017) at a given FEV1 % predicted. In both hs-CRP groups, prior-year IV-treated PExs and baseline CDASs were significant predictors of future IV-treated PExs. Interestingly, the association between baseline CDAS and future PExs frequency was more robust in the high compared to the low hs-CRP group (r=–0.88, p<0.0001, r=–0.48, p=0.017, respectively) with a steeper regression slope (p=0.001). In addition, a significant interaction was demonstrated between elevated baseline hs-CRP levels and CDASs for the prediction of increased risk of future PExs (p=0.02). This interaction provided an additional indicator of clinical disease activity and added another dimension to the prior year PExs frequency phenotype to identify patients at increased risk for future PExs. Conclusion: Stable CF patients with elevated baseline hs-CRP (≥ 5.2 mg/L) demonstrated worse clinical disease activity and QOL scores at a given level of disease severity (FEV1 % predicted). Elevated baseline hs-CRP values combined with clinical disease activity scores are associated with increased risk for future IV-treated PExs even in those with mild clinical disease activity scores.

Probe-based confocal laser endomicroscopy (pCLE) is a relatively new technology in pulmonary medicine. Real time, in vivo visualization of elastin microstructure in the airway wall as well as alveoli is possible via flexible bronchoscopy under moderate sedation. This technique delivers high quality images without significant morbidity, and potentially enables non-invasive diagnosis. The images acquired have low intraobserver and intrapatient variability. The structure or normal airways and alveoli have already been elucidated. pCLE has been used in pilot studies for the diagnosis of various malignant lesions, airway diseases and diffuse parenchymal lung diseases. There may also be a role in monitoring of treatment response and disease progression. However, development is still needed both in the technology and standardization of endoscopic procedure to realize the full potential of pCLE.

Objective: To assess the impact of a telemedicine project that uses the Medtep platform in patients diagnosed with asthma. Method: An asthma consultation in the Integrated Care Management center of Albacete, in collaboration with the Pneumology department, which treat patients with possible asthma and/or acute asthma. In March of 2015 a group of 25 patients diagnosed with asthma, previously invited to participate in the study, were selected. Several training meetings were scheduled to assist them in using a web portal to control their asthma. They were also delivered a Peak-Flow and taught how it works. For 6 months clinical evolution and web portal entrances to follow. The data which was collected: smoking, how long they were diagnosed with asthma, asthma attacks, hospitalizations. Treatments- Evolution, According to patient level. Results: Out of the total 25 patients diagnosed, 17 (67%) were men and 8 (32%) women. The patient’s average age is of 34 years old. The total amount of smokers were 5 patients (20%), 3 of the remaining patients had never smoked. The average cigarette consumption of the smokers was of 2 packs a day. 42% had been diagnosed with asthma for less than 1 year; 20% between 1 and 5 years and the rest of patients had been diagnosed for over 5 years. Before entering the study, 50% had to attend emergency visits at least once (a year?), and some patients as much as 4 times in the last year. After entering the study, none of the patients had to attend ER visits. 80% of the total patients entered their health related data on a daily basis, as well as medication registers, which was above 95% in those who assiduously used the system. The total Peak flow of the patients saw an increase of 7% over baseline. More than 50% of patients increased their treatment before entering the study, and none and even 25% decreased their dose of treatment. 32% of patients have improved their level depending on the base treatment. Conclusions: Improvements in asthma control were achieved in patients who received Medtep Asthma support for 6 months, decreasing assistance in emergency services and, as a result, requiring less treatment.

Study objective: The objective of this study is to determine whether the BODE (body mass index, airflow obstruction, dyspnea and exercise capacity) index correlates with frequency of exacerbation and smoking (pack/year) in patients with COPD Saudi Arabia. Methods: Forty COPD patients were recruited from King Fahad University Hospital and two sets of outcome were measured: the BODE index parameters and the correlation between BODE index with the frequency of exacerbation events as well as the number of packs of cigarettes that a patient consumes in a year. All the statistical analyses were carried out using Statistical Package for the Social Sciences (SPSS) software, version 21.0. Results: There was a positive correlation found between the BODE index and exacerbation events (r=0.389, n=23, p<0.05). However, for smoking frequency, the result of the correlation analysis showed that its correlation with the BODE index was not statistically significant (r=0.021, n=23, p=0.461). Those involved in the study were 23 participants after the application of the inclusion and exclusion criteria, all are male with a mean age of 67.70 years. The results show that while a correlation was observed for exacerbation, the correlation with smoking frequency was not significant. The analysis also identified age as a factor that has significant correlation with the BODE index which is may be due to the lack of control and uniformity in the age range of the participants. Conclusion: This study results suggest that the BODE index could potentially be used in Saudi patients with COPD to assess disease progression. However, variable controls be emphasized and better gender representation be achieved in future study.

The purpose of this study was to assess the possibility of screening and supervising influenza A (H7N9) virus infected patients via rapid point-of-care-test kit with upper or lower respiratory specimens. Here, we demonstrate that the POCT kits can detect H7N9 virus (Guangzhou strain) in different type of samples, which obtained from upper and lower respiratory tract, via the simulated experiment. The detection limit ranged from 4 to 6 log10TCID50/mL and 2.78 × 107 to 1.05 × 108 copies/mL in PBS and nasopharyngeal swab solution (NSS) solutions respectively. Furthermore, the detection ranges were enhanced by 0.5 or 1 log10TCID50/mL in BALF or sputum solution (SS) diluents for some parts of the POCT kits. Furthermore, we observed that there were higher replication and longer screening of H7N9 virus in lower respiratory tract (LRT) samples, such as endotracheal aspirate (ETA) and sputum, from the H7N9 virus-infected patients, although the detection results of POCT kits were negative for these clinical samples. So that, we think that POCT kits can be used to screen and supervise H7N9 virus-infected patients if in the accurate timing. And the LRT samples, special ETA and sputum, seem a good sample option for detecting H7N9 virus via POCT kits, so we need pay more attention to the LRT samples when the new POCT kits were developed.

COPD is a chronic progressive inflammatory lung disease. The key in treating COPD is to treat the inflammation. Current treatments of COPD are LABA, LAMA, and ICS. LABA and LAMA only treat the symptoms of COPD by dilating the small airway; they do not target the underlying mechanism of COPD (the inflammation). ICS only temporarily suppress the inflammation in COPD, cannot terminate the inflammatory reaction and therefore it cannot stop the progression of COPD. Corticosteroid resistant is a big issue in treating COPD. In order to effectively treat COPD, we must find new anti-inflammatory therapies or developing new anti-inflammatory drugs. The author is a clinician and found that the smoke (or the tar) of burning Artemisia argyi (an herb, also called moxa) had special anti-inflammatory effect, which is different to corticosteroid. It not only can effectively treat corticosteroid resistant chronic inflammation, but also can terminate chronic self-perpetuating inflammation. Treatment done for 25 COPD patients with inhalation of moxa smoke, 3/25 patients had no improvement in breathlessness and 22/25 patients became symptoms free after 1-2 months treatment and kept symptoms free without any further treatment.

Objective: To analyse the spirometry situation in primary care (PC), in terms of its use as well as its quality, one decade after our first analysis and to evaluate the effectiveness of the plans instituted since then. Methodology: In the first phase, a survey of all health centres (centros de salud, CSs, in Spanish), similar to the one used in 2005, was conducted in which information was requested regarding spirometric equipment, frequency of use, calibration, and personnel training. Subsequently, 96 patients were referred from PC after having a baseline spirometry conducted at a CS. The spirometry was repeated the same morning with a similar spirometer in the pneumology laboratory. Two expert pneumologists in functionalism analysed the quality of the tests according to the ATS/ERS and SEPAR regulations and compared the results with these obtained in 2005. Results: A spirometer is available in 100% of the CSs (90.9% in 2005). Spirometries are performed in 91.8%, and in 80.3%, daily calibration is performed (4% in 2005). However, the number of spirometries remains similar to that found in our previous study and lower than desired. With respect to their quality, only 40.5% of the 96 tests analysed had sufficient quality (A, B or C in a scale from A to F). The spirometric diagnosis was wrong in 43.7% of the cases (39.7% in 2005), corresponding to an absence of agreement in 29.1% and a discrepancy in the severity in 13.5%. Conclusions: Spirometry in PC continues to be an unresolved problem in our area, and we have ascertained that exclusively training and non-continuing programmes yield insufficient results. Given the magnitude of the problem and knowledge of the existence of projects that have demonstrated their effectiveness, we believe there should be no further delay in implementing any of these strategies adapted to each area.

Background: This study sought to analyze the results and prognosis of recurrent thymoma. Methods: Between 1991 and 2012, 32 patients that developed recurring thymoma after radical resection at initial treatment were reviewed. Results: The median follow-up duration after initial treatment and recurrence was 89 and 49.5 months, respectively. The median recurrence free internal (RFI) was 42 months, and the 5-year overall survival (OS) rates following recurrence was 65.5% for recurrent thymoma. Among 32 patients that relapsed, 7 underwent reoperation, 18 experienced nonsurgical management, 5 failed to receive treatment, and 2 remain unknown. The 5-year OS rates after recurrence of the surgery plus adjuvant chemotherapy/radiotherapy group and the non-surgery group were 100% and 73.1%, respectively (P=0.210). Histological WHO upgrading was frequently observed (57.1%) in patients with recurrent thymoma who received reoperation. In univariate analysis, age (<55 years, P=0.009), local and regional recurrence (P=0.022), and late recurrence (RFI ≥ 20 months, P=0.038) indicated good prognostic factors of recurrent thymoma. Conclusions: Reoperation plus adjuvant chemotherapy/radiotherapy may result in good outcomes for patients who can tolerate surgery when complete resection is possible, and may get better results than non-surgery treatment. Histological WHO upgrade was frequently observed in recurrent thymoma. Age <55 years, local and regional recurrence, and longer RFI (RFI ≥ 20 months) were associated with a positive prognosis.