Clinical characteristics and prognosis of incidentally detected lung cancers.

OBJECTIVE: To evaluate clinical characteristics and outcomes in incidentally detected lung cancer and in symptomatic lung cancer. MATERIAL AND METHODS: We designed a retrospective study including all patients undergoing pulmonary resection with a curative intention for NSCLC. They were classified into two groups according to the presence or absence of cancer-related symptoms at diagnosis in asymptomatic (ASX)­incidental diagnosis­or symptomatic. RESULTS: Of the 593 patients, 320 (53.9%) were ASX. In 71.8% of these, diagnosis was made by chest X-ray. Patients in the ASX group were older (P = 0.007), had a higher prevalence of previous malignancy (P = 0.002), presented as a solitary nodule more frequently (P < 0.001), and were more likely to have earlier-stage disease and smaller cancers (P = 0.0001). A higher prevalence of incidental detection was observed in the last ten years (P = 0.008). Overall 5-year survival was higher for ASX (P = 0.001). Median survival times in pathological stages IIIB-IV were not significantly different. CONCLUSION: Incidental finding of NSCLC is not uncommon even among nonsmokers. It occurred frequently in smokers and in those with history of previous malignancy. Mortality of incidental diagnosis group was lower, but the better survival was related to the greater number of patients with earlier-stage disease.

Examining patients' preferences for participation in clinical decision-making: the experience in a Latin American chronic obstructive pulmonary disease and cancer outpatient population.

BACKGROUND AND AIMS: It is generally accepted that patients prefer to be told the truth by their physicians; however, the practice of partial truth-telling is frequent with an existing 'norm of nondisclosure.' Our primary objective was to determine what patients wanted to be told about their illness, and whether there might be differences between patients with either cancer or advanced chronic obstructive pulmonary disease (COPD). A second objective was to determine how these patients envisioned their participation, or lack thereof, in the treatment decision-making process. METHODS: Subjects were eligible for this prospective study if they were attending the oncology or pulmonary outpatient consultation services at the British Hospital or the Sanatorio Güemes Private Hospital in Buenos Aires, Argentina between June 2009 and May 2010. RESULTS: Ninety-nine patients were recruited. Forty-four had a diagnosis of COPD, and 55 patients had cancer. Seventeen of the patients expected their health to improve in the future, but a significantly higher proportion of patients with malignant disorders expected to get better in the near future as compared with those with COPD (98.2% vs 62.8%, P < 0.001). Most study participants expressed a desire to receive all the information available about their condition. A majority of the participants expressed a preference for making treatment decisions in collaboration with their physician (40.4%) CONCLUSIONS: While they considered the role of their families relevant and wanted information to be shared so that family members might participate in decision-making, they did not want their families to have a right to withhold information, make final decisions.

Calidad de vida en pacientes con fibrosis pulmonar idiopática / Quality of life in patients with idiopathic pulmonary fibrosis

La fibrosis pulmonar idiopática (FPI) es una enfermedad crónica que afecta principalmente a adultos a partir de la quinta década de la vida. Se caracteriza por la presencia de disnea progresiva, declinación funcional sostenida y una supervivencia media al diagnóstico menor de tres años. Hasta ahora, el foco del tratamiento ha sido la mejoría de la supervivencia, pero para muchos pacientes, una mejoría en la calidad de vida (QoL) es un objetivo más realista. A pesar del importante impacto que la enfermedad tiene sobre los aspectos físicos, emocionales y sociales, la investigación enfocada en la QoL es muy limitada. Actualmente, no existe ningún instrumento que esté totalmentevalidado como apropiado en la evaluación de la QoL específicamente en pacientes con FPI. Los instrumentos de medición genéricos que se han utilizado en los pacientes con FPI incluyen el instrumento de 100 ítems de la OMS (WHOQoL-100), la escala de calidad debienestar (QWB) y el instrumento de 36 ítems (SF-36), ninguno de los cuales fue diseñado específicamente para pacientes con FPI. En los estudios revisados, los pacientes con FPIpresentaron afectación de la HRQoL en casi todos los dominios de la vida, pero los más afectados fueron los relacionados con el funcionamiento físico, los síntomas y niveles de independencia. Se requiere de más investigaciones para aprender sobre cómo esta enfermedad afecta a nuestros pacientes, si se adaptan a su enfermedad a lo largo del tiempo y, si lo hacen, de qué manera. Además, se necesita demostrar si alguno de losinstrumentos de medición de QoL existentes es confiable y válido para evaluar la HRQoL a lo largo del tiempo en la población de pacientes con FPI.

Idiopathic pulmonary fibrosis (IPF) is a chronic disease that primarily affects adults from the fifth decade of life. It is characterized by progressive dyspnea, sustained functional decline and survival of less than three years after diagnosis. So far, the treatment has focused on improving survival, but for many patients, an improvement in quality of life (QoL) is a more realistic goal. Despite the significant impact the disease has on physical, emotional and social features of the patient’s life, research focused on QoL is very limited.Currently, there are no fully validated instruments appropriate for the specific evaluation of QoL in patients with IPF. Generic measurement tools used in patients with IPF include the WHO 100 items instrument (WHOQOL-100), the quality scale of well-being (QWB)and the 36 items instrument (SF-36), but none of them was designed specifically for patients with IPF. In the reviewed studies, patients with IPF showed impairment of the health related QoL in almost all aspects of life, but those related to physical functioning,symptoms and levels of independence were the most affected ones. More research is needed to learn about how this disease affects IPF patients, whether they adapt themselves to their disease over time, and if so, how. Furthermore, research needs to showwhether the QoL measurement tools available are reliable and valid measures for health related QoL over time among patients with IPF.

Calidad de vida en pacientes con fibrosis pulmonar idiopática / Quality of life in patients with idiopathic pulmonary fibrosis

La fibrosis pulmonar idiopática (FPI) es una enfermedad crónica que afecta principalmente a adultos a partir de la quinta década de la vida. Se caracteriza por la presencia de disnea progresiva, declinación funcional sostenida y una supervivencia media al diagnóstico menor de tres años. Hasta ahora, el foco del tratamiento ha sido la mejoría de la supervivencia, pero para muchos pacientes, una mejoría en la calidad de vida (QoL) es un objetivo más realista. A pesar del importante impacto que la enfermedad tiene sobre los aspectos físicos, emocionales y sociales, la investigación enfocada en la QoL es muy limitada. Actualmente, no existe ningún instrumento que esté totalmentevalidado como apropiado en la evaluación de la QoL específicamente en pacientes con FPI. Los instrumentos de medición genéricos que se han utilizado en los pacientes con FPI incluyen el instrumento de 100 ítems de la OMS (WHOQoL-100), la escala de calidad debienestar (QWB) y el instrumento de 36 ítems (SF-36), ninguno de los cuales fue diseñado específicamente para pacientes con FPI. En los estudios revisados, los pacientes con FPIpresentaron afectación de la HRQoL en casi todos los dominios de la vida, pero los más afectados fueron los relacionados con el funcionamiento físico, los síntomas y niveles de independencia. Se requiere de más investigaciones para aprender sobre cómo esta enfermedad afecta a nuestros pacientes, si se adaptan a su enfermedad a lo largo del tiempo y, si lo hacen, de qué manera. Además, se necesita demostrar si alguno de losinstrumentos de medición de QoL existentes es confiable y válido para evaluar la HRQoL a lo largo del tiempo en la población de pacientes con FPI. (AU)

Idiopathic pulmonary fibrosis (IPF) is a chronic disease that primarily affects adults from the fifth decade of life. It is characterized by progressive dyspnea, sustained functional decline and survival of less than three years after diagnosis. So far, the treatment has focused on improving survival, but for many patients, an improvement in quality of life (QoL) is a more realistic goal. Despite the significant impact the disease has on physical, emotional and social features of the patientÆs life, research focused on QoL is very limited.Currently, there are no fully validated instruments appropriate for the specific evaluation of QoL in patients with IPF. Generic measurement tools used in patients with IPF include the WHO 100 items instrument (WHOQOL-100), the quality scale of well-being (QWB)and the 36 items instrument (SF-36), but none of them was designed specifically for patients with IPF. In the reviewed studies, patients with IPF showed impairment of the health related QoL in almost all aspects of life, but those related to physical functioning,symptoms and levels of independence were the most affected ones. More research is needed to learn about how this disease affects IPF patients, whether they adapt themselves to their disease over time, and if so, how. Furthermore, research needs to showwhether the QoL measurement tools available are reliable and valid measures for health related QoL over time among patients with IPF. (AU)

Pulmonary involvement of systemic lupus erythematosus: analysis of 90 necropsies.

Pleuropulmonary manifestations of systemic lupus erythematosus (SLE) have been reported to be of variable prevalence, depending on the diagnostic methods used. The objective of this study was to determine the anatomopathological prevalence and the nature of lung involvement associated with SLE and to define if there were differences in the grade and type of pulmonary involvement in patients who had died at different time periods, before or after 1996. Complete autopsy studies of 90 patients with SLE diagnosis carried out between 1958 and 2006 and their clinical records were studied. All patients fulfilled the American College of Rheumathology (ACR) diagnostic criteria for SLE. Two groups of patients were analyzed: patients who had died before 1996 and those deceased in 1996-2006. Some pleuropulmonary involvement was detected in 97.8% of the autopsies. The most frequent findings were pleuritis (77.8%), bacterial infections (57.8%), primary and secondary alveolar haemorrhages (25.6%), followed by distal airway alterations (21.1%), opportunistic infections (14.4%) and pulmonary thromboembolism (7.8%), both acute and chronic. No cases of acute or chronic lupus pneumonitis were found. Opportunistic lung infections were invasive aspergillosis, disseminated strongyloidiasis, mucormicosis and Pneumocystis carinii. Only three of 23 patients with alveolar haemorrhage showed capillaritis. The four patients with primary pulmonary hypertension (PHT) had plexiform lesions. Deceased patients' age at death (46.09 +/- 11.01 vs 30.3 +/- 11.5 years, P < 0.0001) as well as survival time from diagnosis date (11.8 +/- 11.2 vs 4.4 +/- 4.9 years, P < 0.0001) in the second time period evaluated were significantly higher. However, there were no statistically significant differences in the prevalence of any of the pulmonary manifestations. Sepsis was considered the major cause of death without significant differences in both groups. Our results show that pulmonary manifestations directly caused by systemic lupus erythematosus are very uncommon and that their prevalence has not changed in the past 10 years. Pulmonary infection is still the most frequent affection, and it is an important cause of death in patients with lupus.

Carcinoma broncoalveolar: sobrevida a cinco años / Bronchioalveolar carcinoma: five year survival

The epidemiology and prognosis of bronchioalveolar carcinoma (BAC) is different from adenocarcinoma. We studied 28 patients who underwent surgical resection and in whom a final histologic diagnosis of bronchioalveolar carcinoma was made. Sixty one percent of patients were asymptomatic at the time of diagnosis. The most usual radiological presentations were pulmonary nodule (11), pulmonary mass (6) and diffuse infiltrate (6). Nine patients (9/25) were never smokers. Bronchoscopy provided the diagnosis only in 4/26 patients. Patients were classified as stage IA 11/24, IB 5/24 IIIB in 2/24 and IV in 6/24. Five-year survival for the entire group was 65%. Patients with focal lesions had a longer survival. The survival in patients who underwent potentially curative resections was 62.8 +/- 44.0 months. When surgery was considered non-curative, survival was 21.2 +/- 19.5 months (p = 0.0064). Five-year survival in stage IA patients was 80%. Survival of patients with non-mucinous histology was longer than those with mucinous type carcinomas (54.9 +/- 25.0 months vs. 5.33 +/- 4.04, p < 0.0001) but the 5-year-survival was not statistically different. In conclusion, BAC has a favourable prognosis. The best survival rate was found in focal forms, represented by early tumor, nodes, metastasis (TNM) stages and non-mucinous BAC among the histological groups.

Carcinoma broncoalveolar: sobrevida a cinco años / Bronchioalveolar carcinoma: five year survival

The epidemiology and prognosis of bronchioalveolar carcinoma (BAC) is different from adenocarcinoma. We studied 28 patients who underwent surgical resection and in whom a final histologic diagnosis of bronchioalveolar carcinoma was made. Sixty one percent of patients were asymptomatic at the time of diagnosis. The most usual radiological presentations were pulmonary nodule (11), pulmonary mass (6) and diffuse infiltrate (6). Nine patients (9/25) were never smokers. Bronchoscopy provided the diagnosis only in 4/26 patients. Patients were classified as stage IA 11/24, IB 5/24 IIIB in 2/24 and IV in 6/24. Five-year survival for the entire group was 65%. Patients with focal lesions had a longer survival. The survival in patients who underwent potentially curative resections was 62.8 +/- 44.0 months. When surgery was considered non-curative, survival was 21.2 +/- 19.5 months (p = 0.0064). Five-year survival in stage IA patients was 80%. Survival of patients with non-mucinous histology was longer than those with mucinous type carcinomas (54.9 +/- 25.0 months vs. 5.33 +/- 4.04, p < 0.0001) but the 5-year-survival was not statistically different. In conclusion, BAC has a favourable prognosis. The best survival rate was found in focal forms, represented by early tumor, nodes, metastasis (TNM) stages and non-mucinous BAC among the histological groups.(AU)

Carcinoma broncoalveolar: sobrevida a cinco años / Bronchioalveolar carcinoma: five year survival

The epidemiology and prognosis of bronchioalveolar carcinoma (BAC) is different from adenocarcinoma. We studied 28 patients who underwent surgical resection and in whom a final histologic diagnosis of bronchioalveolar carcinoma was made. Sixty one percent of patients were asymptomatic at the time of diagnosis. The most usual radiological presentations were pulmonary nodule (11), pulmonary mass (6) and diffuse infiltrate (6). Nine patients (9/25) were never smokers. Bronchoscopy provided the diagnosis only in 4/26 patients. Patients were classified as stage IA 11/24, IB 5/24 IIIB in 2/24 and IV in 6/24. Five-year survival for the entire group was 65%. Patients with focal lesions had a longer survival. The survival in patients who underwent potentially curative resections was 62.8 +/- 44.0 months. When surgery was considered non-curative, survival was 21.2 +/- 19.5 months (p = 0.0064). Five-year survival in stage IA patients was 80%. Survival of patients with non-mucinous histology was longer than those with mucinous type carcinomas (54.9 +/- 25.0 months vs. 5.33 +/- 4.04, p < 0.0001) but the 5-year-survival was not statistically different. In conclusion, BAC has a favourable prognosis. The best survival rate was found in focal forms, represented by early tumor, nodes, metastasis (TNM) stages and non-mucinous BAC among the histological groups.(AU)

Features of asthma in the elderly.

Asthma has been considered a rare disease in the elderly, but recent studies have shown that it is as common in the elderly as in the middle-aged population. Diagnosis of asthma is often overlooked in older patients, leading to undertreatment. Spirometry, determination of expiratory flow lability, and histamine challenge tests are tools that are as usefulfor the evaluation of elderly asthmatics as they areforyoungerpatients. Asthma is more severe in the elderly, especially in long-standing asthmatics. Treatment of asthma in the elderly should follow the same stepwise guidelines that are recommended for all age groups, though it will require more intense monitoring. An aggressive treatment approach to mild and moderate asthma in young people is the best hope of changing the future trends of asthma in the elderly.

[Bronchodilator response in elderly patients]. / Respuesta a broncodilatadores en pacientes ancianos.

Asthma in the elderly is more severe and a decreased bronchodilating response has been suggested as a contributing factor. There is no agreement on the best way of expressing reversibility. The aim of this study was to evaluate bronchodilator response in elderly patients with asthma with different levels of airway obstruction and expressing reversibility by different indices. A total of 72 asthmatic patients were studied: (FEV1/FVC < 1.64 SEE below predicted). Two groups were considered: Group I: > or = 65 years (71.0 +/- 11.7 years; FEV1 54.0 +/- 16.7% of predicted) and Group II: < 40 years (23.0 +/- 7.7 years, FEV1 67.6 +/- 16.1%). Response to bronchodilators expressed as delta absolute, delta%predicted or delta%maximal was not different between the two groups. Reversibility expressed as delta%initial, however, was lower in younger patients (> 65 years: 22.2 +/- 16.6% vs 40 years: 11.8 +/- 9.9%, p = < 0.005). A covariance analysis was performed using baseline FEV1 as covariate and bronchodilator response was not different between the two groups. Neither delta absolute (r = 0.13, p = NS), delta%predicted (r = 0.06, p = NS) nor delta maximal (r = 0.09, p = NS) showed correlation with age. delta%initial showed weak but significant correlation with age (r = 0.28, p = < 0.05) and marked dependence on baseline FEV1 (r = 0.47, p = < 0.001). Bronchodilator reversibility in the elderly asthmatics is preserved. Expressing reversibility as delta%initial produces differences depending on baseline airway obstruction.

Respuesta a broncodilatadores en pacientes ancianos. / [Bronchodilator response in elderly patients]

Asthma in the elderly is more severe and a decreased bronchodilating response has been suggested as a contributing factor. There is no agreement on the best way of expressing reversibility. The aim of this study was to evaluate bronchodilator response in elderly patients with asthma with different levels of airway obstruction and expressing reversibility by different indices. A total of 72 asthmatic patients were studied: (FEV1/FVC < 1.64 SEE below predicted). Two groups were considered: Group I: > or = 65 years (71.0 +/- 11.7 years; FEV1 54.0 +/- 16.7

of predicted) and Group II: < 40 years (23.0 +/- 7.7 years, FEV1 67.6 +/- 16.1

). Response to bronchodilators expressed as delta absolute, delta

predicted or delta

maximal was not different between the two groups. Reversibility expressed as delta

initial, however, was lower in younger patients (> 65 years: 22.2 +/- 16.6

vs 40 years: 11.8 +/- 9.9

, p = < 0.005). A covariance analysis was performed using baseline FEV1 as covariate and bronchodilator response was not different between the two groups. Neither delta absolute (r = 0.13, p = NS), delta

predicted (r = 0.06, p = NS) nor delta maximal (r = 0.09, p = NS) showed correlation with age. delta

initial showed weak but significant correlation with age (r = 0.28, p = < 0.05) and marked dependence on baseline FEV1 (r = 0.47, p = < 0.001). Bronchodilator reversibility in the elderly asthmatics is preserved. Expressing reversibility as delta

initial produces differences depending on baseline airway obstruction.

[Evaluation and treatment of interstitial lung disease in Argentine]. / Evaluación y tratamiento de la enfermedad intersticial pulmonar en la Argentina.

To determine the availability and usual management of interstitial lung diseases (ILD) in our country, the Section of Interstitial Lung Diseases of the Argentine Association for Respiratory Medicine (AAMR) made a survey about diagnostic methodology and treatment of ILD. A total of 115 answers were obtained (38.5%), 43% of them among physicians living in the provinces. Availability of diffusing capacity of the lung for carbon monoxide test (DLCO) is limited: 25.4% never have access to it and 35.6% can seldom use it. Availability to thoracic CT scan is wider: 85% may use if often (32.4%) or always (52.6%). Bronchoscopy is commonly available in 87.7% of the physicians either often (21.9%) or always (65.8%). However, only 20.2% perform BAL and 13.1% transbronchial biopsy in every patient. Only 16.6% perform open lung biopsy or thoracoscopic biopsy in all or most of their patients. Sixty eight percent of physicians who always have availability of DLCO perform it in every patient but only 7.1% of those who seldom have access to DLCO do so (p = 0.0003). Availability of bronchoscopy does not have any influence on the decision of performing BAL or transbronchial biopsy. Frequency of use of surgical biopsy or treatment with immunosuppressive drugs was not influenced by any variable. We conclude that there is a current trend to underuse diagnostic resources for ILD in Argentina. Limitations in availability are relevant regarding DLCO. An effort from the health authorities to centralize the management of patients with ILD would allow to study and treat them according to international recommendations.

Evaluación y tratamiento de la enfermedad intersticial pulmonar en la Argentina. / [Evaluation and treatment of interstitial lung disease in Argentine]

To determine the availability and usual management of interstitial lung diseases (ILD) in our country, the Section of Interstitial Lung Diseases of the Argentine Association for Respiratory Medicine (AAMR) made a survey about diagnostic methodology and treatment of ILD. A total of 115 answers were obtained (38.5

), 43

of them among physicians living in the provinces. Availability of diffusing capacity of the lung for carbon monoxide test (DLCO) is limited: 25.4

never have access to it and 35.6

can seldom use it. Availability to thoracic CT scan is wider: 85

may use if often (32.4

) or always (52.6

). Bronchoscopy is commonly available in 87.7

of the physicians either often (21.9

) or always (65.8

). However, only 20.2

perform BAL and 13.1

transbronchial biopsy in every patient. Only 16.6

perform open lung biopsy or thoracoscopic biopsy in all or most of their patients. Sixty eight percent of physicians who always have availability of DLCO perform it in every patient but only 7.1

of those who seldom have access to DLCO do so (p = 0.0003). Availability of bronchoscopy does not have any influence on the decision of performing BAL or transbronchial biopsy. Frequency of use of surgical biopsy or treatment with immunosuppressive drugs was not influenced by any variable. We conclude that there is a current trend to underuse diagnostic resources for ILD in Argentina. Limitations in availability are relevant regarding DLCO. An effort from the health authorities to centralize the management of patients with ILD would allow to study and treat them according to international recommendations.

Evaluation of bronchodilator response in patients with airway obstruction.

The aim of this study was to define the most useful index of expressing bronchodilator response and to distinguish between asthma and COPD. A prospective study was carried out of bronchodilator response in 142 asthmatics and 58 COPD patients in a university hospital. Reversibility was expressed as: 1. absolute change (delta abs); 2. % of initial (delta %init); 3. % of predicted (delta %pred) and 4. % of maximum possible response (delta %max). Dependence on forced expirations volume in 1 sec (FEV1) as % of predicted and sensitivity and specificity for diagnosis of asthma were established. A relationship between delta abs and initial FEV1 was not found in asthma (delta abs vs. % initial FEV1. r = 0.07) or COPD (r = 0.02). delta %pred did not show a correlation in asthma (r = 0.10) or COPD (r = 0.06). delta %init was dependent on the baseline value in asthma (r = 0.38, P < or = 0.001) but not in COPD (r = 0.18, P = n.s.). delta max was dependent in both. The combination of best sensitivity and specificity to separate asthma and COPD was obtained with delta abs (70.4 or 70.6%). The worst specificity for asthma diagnosis was obtained with delta %init (50%). The best likelihood ratios were obtained with delta abs and delta %pred and the worst likelihood ratio with delta %init. delta %init is not recommended as an index for differential diagnosis between asthma and COPD; 2) delta %init overscores bronchodilator response in patients with low FEV1. The independence of each bronchodilator response index should be verified in clinical trials for each selected sample.

Assessment of respiratory function: influence of spirometry reference values and normality criteria selection.

The purpose of this study was to determine the impact upon classification of patients of the choice of reference equation and the criterion defining the lower limit of the normal range in clinical practice. One thousand consecutive spirometries were checked to calculate the predicted values [forced vital capacity (FVC) and forced expiratory volume in sec (FEV1)] in accordance with the equations by Morris, Cherniack, Crapo, Knudson and the Economic Community for Coal and Steel (ECCS). We quantified the difference between the predicted values obtained for each individual and each equation, determined the percentage of individuals whose classification might have changed from normal to abnormal when using a different equation and defined the lower limit of the normal range in accordance with the determination of 1. the 90% confidence interval or 2. 80% of predicted, comparing their differences. The greatest differences found were between the values given by Morris and Crapo's equations for male FEV1, between Morris and Cherniak for female FEV1 and male FVC and between Morris and Knudson for female FVC. Using 80% of predicted value for female FEV1, up to 35% of tests changed their classification from 'normal' to 'abnormal' upon changing the equation used. A high percentage of tests showed a lower limit of normal defined by the confidence interval under 80% and 70% of predicted value. This study emphasizes the importance of choosing the appropriate reference equation. We do not consider it acceptable to use a fixed percentage of the predicted value as the lower limit of normal because of the great number of patients found to be inappropriately classified.

[Beta-agonists: new perspective in the treatment of asthma?]. / Beta-agonistas una nueva perspectiva en el tratamiento del asma?

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Beta-agonistas una nueva perspectiva en el tratamiento del asma? / [Beta-agonists: new perspective in the treatment of asthma?]

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Is asthma in the elderly really different?

To examine the nature of asthma in the elderly, we compared older (group 1: 65 years or older, n = 50) with younger patients (group 2: <40 years, n = 99) and to determine the influence of long-standing disease, elderly asthmatics with early onset (group A: onset before 40, n = 22) were compared with patients developing symptoms later in their lives (group B: onset after 40, n = 22). Blood eosinophilia and IgE value >/=100 IU/l were more frequent in younger patients. Short symptom-free periods were more frequent among older asthmatics (78.5 vs. 45.4%, p < 0.001). Only 31.2% of older patients had only mild symptoms. Requirement of systemic steroids was higher in the elderly population. The worst FEV1 was lower in older patients (54.4 +/- 17.3 vs. 71.8 +/- 18.5%, p

[Non-invasive mechanical ventilation as treatment for severe pneumonia in an HIV positive patient]. / Ventilacion mecanica no invasiva como tratamiento de la neumonia severa en un paciente con serologia HIV positiva.

A 27 year-old HIV+ patient was admitted to the hospital for probable Pneumocystis carinii pneumonia (PCP). He was severely dyspneic, with respiratory rate of 44 x min and accessory respiratory muscle contraction. The alveolar-arterial quotient was 0.35. Ventilation by BiPAP was applied during 12 hours. After BiPAP a/AO2 was O.42, with amelioration of dyspnea, decrease of respiratory rate (25 x min) and without using of accessory respiratory muscles. No complications occurred. At the end of hospital stay a/AO2 was 0.68. CPAP application but not BiPAP has been reported in PCP. Our patient showed evident improvement after BiPAP, suggesting that this method of ventilation is useful and should be incorporated to the routine management of these patients.