Pulmonary artery size as a predictor of pulmonary hypertension and outcomes in patients with chronic obstructive pulmonary disease.

RATIONALE: The relationship between pulmonary artery size with underlying pulmonary hypertension and mortality remains to be determined in COPD. We sought to evaluate the relationships in a cohort of patients with advanced COPD. METHODS: A retrospective study of advanced COPD patients evaluated between 1998 and 2012 was conducted at a tertiary care center. Patients with chest computed tomography images and right heart catheterizations formed the study cohort. The diameters of the pulmonary artery and ascending aorta were measured by independent observers and compared to pulmonary artery pressures. Intermediate-term mortality was evaluated for the 24-month period subsequent to the respective studies. Cox proportional hazards model was used to determine independent effects of variables on survival. RESULTS: There were 65 subjects identified, of whom 38 (58%) had pulmonary hypertension. Patients with and without pulmonary hypertension had mean pulmonary artery diameters of 34.4 mm and 29.1 mm, respectively (p = 0.0003). The mean PA:A ratio for those with and without pulmonary hypertension was 1.05 and 0.87, respectively (p = 0.0003). The PA:A ratio was an independent predictor of mortality with a reduced survival in those with a PA:A >1 (p = 0.008). CONCLUSIONS: The PA:A ratio is associated with underlying pulmonary hypertension in patients with COPD and is an independent predictor of mortality. This readily available measurement may be a valuable non-invasive screening tool for underlying pulmonary hypertension in COPD patients and appears to impart important independent prognostic information.

Dynamic patient counseling: a novel concept in idiopathic pulmonary fibrosis.

BACKGROUND: The characteristics of long-term survivors with idiopathic pulmonary fibrosis (IPF) have never been fully elucidated. We sought to illustrate the attenuated mortality and describe the characteristics of patients with IPF who survived at least 5 years beyond their initial presentation. METHODS: Patients with IPF evaluated between 1997 and 2006 were identified through the clinic database. Patients who survived beyond 5 years from the time of their evaluation were compared with those who died or underwent lung transplantation within 5 years. Survival analyses were performed from the time of initial evaluation and contingent on annualized survival thereafter. RESULTS: Eighty-seven patients who survived at least 5 years formed the comparator group to whom other patients were contrasted. These patients had a higher BMI, FVC % predicted, FEV1 % predicted, total lung capacity % predicted, and diffusing capacity of lung for carbon monoxide % predicted, but a lower FEV1/FVC ratio and lower mean pulmonary artery pressures. More than one-half of these patients had moderate or severe disease at the time of presentation. Our annualized contingent survival analyses revealed a progressively increasing median survival dependent on the duration of the disease. CONCLUSIONS: Although we were able to demonstrate differences in our 5-year survivors, rather than being a distinct group, these patients appear to exist within a continuum of improving survival dependent on prior disease duration. This progressively improving time-dependent prognosis mandates the serial reevaluation of an individual patient's projected outcomes. The implementation of dynamic counseling is an important concept in more accurately predicting life expectancy for patients with IPF who are frequently haunted by the prospects of a dismal survival.

Fallas y marcas en la estructuración de un psiquismo: una incógnita: Nahuelito, el monstruo del lago / Faults and brands in the structuring of a psyche: one unknown

Transitar por la historia de Nahuel nos permitió profundizar la problemática de la psicosis desde una perspectiva más amplia y diferente; centrando la mirada en el complejo proceso de construcción sujetiva que atraviesa todo sujeto, para poder así llegar a comprender las diversas variantes de configuraciones psíquicas con las que nos podemos encontrar en la clínica. El papel arrasador de la pulsión de muerte, al servicio de la negativización, del desmantelamiento de las investiduras; se hace evidente en la historia de Nahuel. Asimismo, su historia familiar y escolar nos llevó a pensar en las consecuencias aniquiladoras de la violencia primaria y la violencia que podemos llamar secundaria, ejercida por las instituciones, quienes, mediante diagnósticos apresurados y simplistas, no hacen otra cosa que reforzar esa primer violencia padecida y acallar la posibilidad de escuchar el verdadero padecer del niño.

Fallas y marcas en la estructuración de un psiquismo: una incógnita: Nahuelito, el monstruo del lago / Faults and brands in the structuring of a psyche: one unknown

Transitar por la historia de Nahuel nos permitió profundizar la problemática de la psicosis desde una perspectiva más amplia y diferente; centrando la mirada en el complejo proceso de construcción sujetiva que atraviesa todo sujeto, para poder así llegar a comprender las diversas variantes de configuraciones psíquicas con las que nos podemos encontrar en la clínica. El papel arrasador de la pulsión de muerte, al servicio de la negativización, del desmantelamiento de las investiduras; se hace evidente en la historia de Nahuel. Asimismo, su historia familiar y escolar nos llevó a pensar en las consecuencias aniquiladoras de la violencia primaria y la violencia que podemos llamar secundaria, ejercida por las instituciones, quienes, mediante diagnósticos apresurados y simplistas, no hacen otra cosa que reforzar esa primer violencia padecida y acallar la posibilidad de escuchar el verdadero padecer del niño. (AU)