Cutoff point for exhaled nitric oxide corresponding to 3% sputum eosinophils.

BACKGROUND: The eosinophilic asthma phenotype (sputum eosinophils 3%) indicates a good response to corticosteroids and T(H)2 immunomodulators. Exhaled nitric oxide (FeNO) is rapidly measured by portable devices, and although it is not a selective marker of eosinophilic inflammation, several studies have demonstrated a strong correlation with it. We investigated which FeNO value was the best fit with 3% sputum eosinophils in asthma patients. METHODS: We included 129 consecutive, nonsmoking asthmatics who underwent skin tests, FeNO quantification (NIOX MINO), spirometry, and induced sputum analysis and completed the Asthma Control Test questionnaire. Receiver operating characteristic curves were constructed, and logistic regression analysis was performed. RESULTS: Symptoms were detected more frequently in the eosinophilic asthma group, as were higher airway obstruction and sensitivity to hypertonic saline. The FeNO cutoff point of 21 ppb was the best fit with 3% sputum eosinophilia. This value behaved better among corticosteroid-naïve patients (sensitivity, 97%; specificity, 58%; positive predictive value, 86%; negative predictive value, 88%) than among those receiving corticosteroids (sensitivity, 81%; specificity, 25%; positive predictive value, 74%; negative predictive value, 33%). CONCLUSION: FeNO ≥ 21 ppb is associated with airway eosinophilia. In corticosteroid-naïve patients, FeNO < 21 ppb enables us to rule out airway eosinophilia.

Mannitol versus hypertonic saline: Safety and efficacy of mannitol and hypertonic saline in sputum induction and bronchial hyperreactivity assessment.

Eosinophilic asthma phenotype predicts good response to corticosteroids and associates to asthmatic exacerbations. Sputum induction by hypertonic saline (HS) inhalation is technically demanding. Bronchial hyperresponsiveness (BHR) to osmotic agents indirectly mirrors active airway inflammation. We compared the safety and ability of HS and mannitol to induce sputum and measure BHR. We evaluated the stability of inflammatory phenotypes. We studied 35 non-smoking asthmatics randomized to undergo HS and mannitol challenges on 2 days 1 week apart. Sputum was sampled for cell analysis and phenotyped as eosinophilic (≥3% eosinophils) and non-eosinophilic (<3%) asthma. Nineteen subjects had BHR to mannitol and nine of them also had BHR to HS. Drops in forced expiratory volume in 1 s were higher from HS challenge than from mannitol challenge. Adequate sputum samples were obtained from 80% subjects (68% mannitol and 71% HS). Eosinophils and macrophages from both challenges correlated. Neutrophils were higher in sputum from HS. Ninety percent samples were equally phenotyped with HS and mannitol. Fractional exhaled nitric oxide, sputum eosinophils and BHR correlated in both challenges. HS and mannitol showed similar capacity to produce valuable sputum samples. BHR to both osmotic stimuli partially resembled airway eosinophilic inflammation but mannitol was more sensitive than HS to assess BHR. Eosinophilic phenotype remained stable in most patients with both stimuli.

[Eosinophils in induced sputum versus nitric oxide in exhaled air: clinical utility in bronchial asthma]. / Eosinofilia en esputo versus óxido nítrico en aire exhalado: aplicación clínica en el asma.

BACKGROUND: Assessment of eosinophils in induced sputum can help to optimize anti-inflammatory therapy in bronchial asthma, but this is a very demanding technique. The aim of the study is to compare nitric oxide in exhaled air (FeNO), an easy to measure inflammatory biomarker, with eosinophils in sputum in terms of relationship with clinical and functional parameters. METHODS: 106 asthmatic patients (50 in anti-inflammatory therapy [AB+] and 56 without it [AB-]) and 15 controls were included. After filling a clinical questionnaire, FeNO measurement, forced spirometry and sputum induction by bronchial challenge with hypertonic saline solution were performed. RESULTS: Adequate measurements of FeNO and eosinophils were obtained in 100% and 81% of the patients, respectively. FENO w were higher for AB- compared to AB+ and controls. The percentage of eosinophils in sputum was higher in asthmatic patients compared to controls but without differences between both asthmatics groups and was well correlated with the slope of the dose-response curve of bronchial challenge. In the AB- group, FeNO and eosinophils were well correlated with asthma control level. CONCLUSION: FENO measurement is readily available and well correlated with clinical and functional markers asthma expression. Anti-inflammatory therapy blunts FeNO levels compromising its utility in the long-term follow-up of asthma patients.

Eosinofilia en esputo versus óxido nítrico en aire exhalado: aplicación clínica en el asma / Eosinophils in induced sputum versus nitric oxide in exhaled air: clinical utility in bronchial asthma

Fundamento. La eosinofilia en esputo inducido permiteoptimizar el tratamiento antiinflamatorio en el asma perosus requerimientos técnicos hacen poco viable su aplicaciónclínica. Evaluamos si el óxido nítrico (FENO), un marcadorinflamatorio de fácil medición, podía suplir a la eosinofiliaen esputo, así como la relación que ambos índicesmostraban con aspectos clínicos y funcionales del asma.Métodos. Se estudiaron 106 asmáticos (50 con tratamientoantiinflamatorio [AB+] y 56 sin él [AB-]) y 15controles. Tras completar un cuestionario clínico, seles realizó medición de FENO, espirometría forzada e inducciónde esputo. Se calculó el valor de pendiente dela curva concentración-respuesta (CCR) obtenida trasla inhalación de salino hipertónico.Resultados. Los resultados de FENO y de eosinofilia enesputo fueron valorables en 100% y 81% de los casosrespectivamente. Los valores de FENO fueron superioresen AB- que en AB+ y en éstos respecto a controles. Laeosinofilia, mayor en asmáticos que en controles aunquesin diferencias entre AB+ y AB-, se correlacionó conla FENO y se comportó de forma paralela a la pendienteCCR. Había correlación entre el nivel de control delasma y los índices inflamatorios (eosinofilia y FENO) enel grupo AB- pero no en el AB+.Conclusión. La obtención de FENO es rápida, sencilla yda resultados inmediatos que se correlacionan con laactividad del asma. Puede desempeñar un papel relevanteen el diagnóstico y manejo terapéutico inicial deasma, aunque se necesitan más estudios para evaluarsu aplicación en la monitorización a largo plazo de laenfermedad, por la influencia tan notable que tiene sobresus niveles el tratamiento antiinflamatorio(AU)

Background. Assessment of eosinophils in inducedsputum can help to optimize anti-inflammatory therapyin bronchial asthma, but this is a very demanding technique.The aim of the study is to compare nitric oxidein exhaled air (FeNO), an easy to measure inflammatorybiomarker, with eosinophils in sputum in terms of relationshipwith clinical and functional parameters.Methods. 106 asthmatic patients (50 in anti-inflammatorytherapy [AB+] and 56 without it [AB-]) and 15 controlswere included. After filling a clinical questionnaire,FeNO measurement, forced spirometry and sputum inductionby bronchial challenge with hypertonic salinesolution were performed.Results. Adequate measurements of FeNO and eosinophilswere obtained in 100% and 81% of the patients,respectively. FENO w were higher for AB- compared toAB+ and controls. The percentage of eosinophils in sputumwas higher in asthmatic patients compared to controlsbut without differences between both asthmaticsgroups and was well correlated with the slope of thedose-response curve of bronchial challenge. In the ABgroup,FeNO and eosinophils were well correlated withasthma control level.Conclusion. FENO measurement is readily available andwell correlated with clinical and functional markersasthma expression. Anti-inflammatory therapy bluntsFeNO levels compromising its utility in the long-termfollow-up of asthma patients(AU)

[Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)]. / Neumonitis por hipersensibilidad (alveolitis alérgica extrínseca).

Farmer's lung was first described in 1932. We can define hypersensitivity pneumonitis as a pulmonary and systemic disease that is accompanied by dyspnoea and coughing; it is caused by an immunological type of inflammation of the alveolar walls and the terminal airways and it is secondary to the repeated inhalation of a variety of antigens by a susceptible host. It can be said that it is an underdiagnosed disease and only a high degree of clinical manifestations and a detailed history of exposure can lead to an early diagnosis and satisfactory treatment. A combination among clinical-radiological, functional, cytological or pathological findings leads in some cases to a diagnosis. Treatment is based on avoiding further exposure to the causal agent and in the more serious cases the administration of systemic corticoid treatment.

Neumonitis por hipersensibilidad (alveolitis alérgica extrínseca) / Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)

El pulmón del granjero se describió por primeravez en 1932. Podemos definir la neumonitis por hipersensibilidadcomo una enfermedad pulmonar y sistémicaque cursa con disnea y tos, y que se produce porla inflamación de tipo inmunológico de las paredesalveolares y vías aéreas terminales y que es secundariaa la inhalación repetida de una variedad de antígenospor un huésped susceptible. Puede decirse que es unaenfermedad infradiagnosticada y sólo un alto grado desospecha clínica y una historia detallada de la exposiciónpueden llevar a un diagnóstico precoz y un tratamientosatisfactorio. Una combinación entre los hallazgosclínico-radiológicos, funcionales, citológicos o anatonomopatológicos,en algunos casos, nos llevarán aldiagnóstico

Farmer’s lung was first described in 1932. We candefine hypersensitivity pneumonitis as a pulmonaryand systemic disease that is accompanied by dyspnoeaand coughing; it is caused by an immunological type ofinflammation of the alveolar walls and the terminalairways and it is secondary to the repeated inhalationof a variety of antigens by a susceptible host. It can besaid that it is an underdiagnosed disease and only ahigh degree of clinical manifestations and a detailedhistory of exposure can lead to an early diagnosis andsatisfactory treatment. A combination among clinicalradiological,functional, cytological or pathologicalfindings leads in some cases to a diagnosis

Recovery of impaired muscle function in severe sciatica.

This is a prospective cohort study of patients with acute treated severe sciatica. The objectives of the study are, firstly, to describe the recovery of muscle performance by manual and isokinetic muscle testing in patients with acute severe sciatica over 1 year, and secondly, to discuss the potential clinical relevance of the isokinetic testing of the ankle for patients with acute sciatica. In clinical daily practice, muscle performance is evaluated by means of isometric manual tests. Different authors using manual muscle tests have reported the long-term outcome of the muscle function in patients with sciatica. Overall, the results are good in terms of the recovery of muscle strength. However, it is not clear whether the isometric strength is sufficiently relevant to evaluate the more complete muscle performance of the affected muscles in patients with sciatica. This study presents data on the muscle recovery measured with manual testing and isokinetic testing of patients with severe sciatica. Consecutive patients admitted to the Cantonal Hospital for conservative management of severe acute sciatica were eligible for inclusion in the study. Patients were evaluated at admission, discharge, and follow-up at 3, 6, and 12 months. All the visits included a standardized clinical examination and the completion of questionnaires. Imaging and electromyography were conducted at the first visit. Isokinetic muscle tests at 30 degrees/s and 120 degrees/s were performed at discharge and follow-up visits. Manual and isokinetic tests were performed on foot and ankle flexor and extensor muscles. Eighty-two consecutive patients (66% men), with a mean age of 43 (+/-10.3) years, entered the study. The prevalence of major muscle weakness was low, with 7% of patients unable to perform toe walking and 11% unable to walk on the heel at visit one. Moreover, motor deficit defined as a score of 4 or less (out of 5) was found in 15% of subjects at the first evaluation. Such severe deficits were not found during the last three visits. The isokinetic tests showed a higher prevalence of muscle function impairment. At visit 5, the isokinetic test showed impaired muscle function recovery from 23% to 32%, while the manual test showed almost full recovery. The issues of agreement between manual and isokinetic muscle testing are discussed. In this selected and homogeneous cohort of patients, the prevalence of motor deficit was rather low and the outcome excellent according to the results of the manual testing. Isokinetic muscle tests showed a higher prevalence of deficit and a much slower recovery. The manual muscle test is a crude clinical test. For more indepth muscle performance evaluation, additional testing may be necessary, especially for those patients with physically demanding jobs or activities.

Linfangioma quístico retroperitoneal tratado durante la gestación / Retroperitoneal cystic lymphangioma treated during gestation

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Linfohistiocitosis hemofagocítica con afectación parenquimatosa del sistema nervioso central / Hemophagocytic lymphohistiocytosis with parenchymatous affectation of the central nervous system

Los síndromes histiocíticos más frecuentes en la infancia se pueden agrupar en histiocitosis de Langerhans e histiocitosis de fagocitos mononucleares, de los cuales el más frecuente es la linfohistiocitosis hemofagocítica. Ésta agrupa formas familiares de herencia autosómica recesiva y formas esporádicas que pueden aparecer tras un proceso infeccioso o en neoplasias. La linfohistiocitosis hemofagocítica es un importante diagnóstico diferencial en niños con fiebre prolongada, pancitopenia y hepatolesplenomegalia. La afectación neurológica es frecuente en esta enfermedad. La gravedad de las lesiones des sistema nervioso central son variables: desde la mera infiltración histiocitaria hasta la necrosis y hemorragia paarenquimatosa. Presentamos el caso de una niña de seis meses de edad que falleció por las complicaciones neurológicas de esta enfermedad (AU)

Recovery of severe sciatica.

STUDY DESIGN: A prospective study of patients with acute severe sciatica. OBJECTIVES: To 1) describe the characteristics of patients with acute severe sciatica and the agreement among different diagnostic tests, 2) describe overall recovery during 1 year in terms of perceived disability, and pain, and 3) explore acute-phase predictors of failure to recover at 1 year. SUMMARY OF BACKGROUND DATA: The development of imaging techniques has been very impressive during recent decades. However, different authors have highlighted the prevalence of abnormal images among asymptomatic subjects. These findings increase the difficulty of interpreting the results from the diagnostic techniques used with each individual patient. Furthermore, other clinical and biopsychosocial variables need to be explored for their associations with recovery or failure to recover. This study aimed to explore those associations. METHODS: Consecutive patients admitted to the hospital for conservative management of severe acute sciatica were eligible for inclusion in the study. Patients were evaluated at admission, discharge, and 3, 6, and 12 months. All the visits included a standardized clinical examination and the completion of questionnaires that included items on demographics, pain, perceived disability, and quality of life. Imaging and blood samples were collected at the first visit, and an electromyogram was taken for sciatica lasting at least 3 weeks. RESULTS: The study included 82 consecutive patients (66% men) with a mean age of 43 +/- 10.3 years. The mean intensity of pain, on a visual analog scale of 0 to 100 (VAS) at Visit 1, was 73. The straight leg raising test was positive in 78% of the patients, with a mean value of 59 degrees +/- 18 degrees. The contralateral straight leg raising test was positive in 20% of the patients. Imaging was positive for disc herniation in 74% and electromyogram was positive in 62% of cases. These two diagnostic tests showed a good to excellent total agreement (58-87%) with the straight leg raising tests and the presence of radiating pain below the knee. The recovery of clinical symptoms and signs was observed mainly within the first 3 months. However, clinical recovery and perceived recovery was not complete in most cases. CONCLUSIONS: In most cases, there was good to excellent agreement among the different diagnostic tests. None of the tests was predictive of recovery. The presence of blood antibodies against 3'LM1 (IgM + IgG) and GD1a (IgM) was significantly associated (P < 0.023) with neurologic symptoms and signs. However, the meaning of these antibodies remains unclear. Only a minority of the patients (29%) had fully recovered after 12 months. Within the 1-year follow-up, one third of the patients had surgery.