Metachronous Pulmonary Neoplasms in Lung Transplantation-When They Arise in the Donor Lung: A Case Report.

Lung cancer (LC) is uncommon among lung transplant recipients, being most often described in the native lung of single-lung transplant recipients. Its appearance in the transplanted lung is a very uncommon phenomenon, in which donor and recipient factors appear to be involved. We present a case of 2 distinct metachronous lung neoplasms diagnosed in the transplanted lung of a non-smoker patient with progressive massive silicosis (PMS), who underwent left unipulmonary transplantation at 39 years. The donor was a smoker and thoracic computed tomography (CT) performed before the organ collection showed no abnormalities. Thirty months after transplantation, a new node with significant avidity in positron emission tomography (PET)-CT was diagnosed in the upper left lobe (ULL). The Thoracic Surgery team chose to proceed directly to surgery with atypical resection of the nodule. Anatomopathologic study revealed an epidermoid carcinoma (pT1aNx). Multidisciplinary group decided clinical surveillance; however, 2 years later, the appearance of 2 new nodules in the ULL (PET-CT positive) was observed. It was again decided to proceed to the surgery with a second atypical resection. The anatomopathologic study of one nodule revealed pulmonary adenocarcinoma (pT1aNx), and the other was compatible with epidermoid carcinoma (pT1aNx). One month later, the patient was hospitalized with a pulmonary abscess and posteriorly developed a probable acute allograft rejection, eventually dying at the age of 44, 51 months after transplantation. This case raises relevant questions regarding the donor selection criteria and the approach to LC diagnosed in the post-transplantation period.

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.

Novel role of pancreatic differentiation 2 in facilitating self-renewal and drug resistance of pancreatic cancer stem cells.

BACKGROUND: Cancer stem cells (CSCs) contribute towards disease aggressiveness and drug resistance. Specific identification of CSC maintenance genes and targeting can improve the efficiency of currently available treatment modalities. Pancreatic differentiation 2 (PD2) has a major role in the self-renewal of mouse embryonic stem cells. In the present study, we investigated the role of PD2 in pancreatic CSCs. METHODS: Characterisation of CSCs and non-CSCs from mouse models, pancreatic cancer cells and human tissues by CSC and self-renewal marker analysis using confocal assay. Effect of PD2 knockdown in CSCs (after gemcitabine treatment) was studied by immunoblot and apoptosis assays. RESULTS: A subpopulation of cells displayed PD2 overexpression in mouse (Kras(G12D); Pdx1-Cre and Kras(G12D); Trp53(R172H/+); Pdx1-Cre) and human pancreatic tumours, which co-express CSC markers. Cancer stem cells exhibited elevated expression of PD2 and self-renewal markers, such as Oct3/4, Shh and ß-catenin. Gemcitabine treatment maintained the CSC population with simultaneous maintenance of PD2 and CSC marker expression. Knockdown of PD2 in CSCs resulted in reduced viability of cells and enhanced apoptosis along with abrogated expression of CD133 and MDR2. CONCLUSIONS: Our results suggest that PD2 is a novel CSC maintenance protein, loss of which renders the CSCs more susceptible to drug-induced cell death.

Produção de açafrão em função de acessos e do peso de rizomas-semente / Influence of the weight of seed-rhizomes in the production of turmeric

O açafrão-da-terra (Curcuma longa L.) é originário do sudeste asiático e subcontinente indiano. É uma herbácea de caule subterrâneo, alaranjado, com vários rizomas secundários aproveitados na indústria alimentícia e farmacêutica devido às características de cor, sabor, odor, produção de óleos essenciais, e corantes. Na escolha do melhor material propagativo deve-se levar em consideração o material genético, o peso, tamanho, idade, capacidade de reserva acumulada, sanidade, dentre outros fatores. O objetivo neste experimento foi avaliar a influencia de diferentes acessos e pesos de rizomas-sementes na produção de açafrão. Empregou-se o delineamento em blocos casualizados em parcelas subdivididas com quatro repetições, tendo como tratamento principal os acessos (C-06, C-36 e C-38) e como tratamento secundário as classes de rizomas-sementes (peso): pequeno, médio e grande, ±5, ±10 e ±15 g/rizoma, respectivamente. Após a colheita, os rizomas foram distribuídos sobre tela suspensa para secagem à sombra com ventilação natural, por 20 dias. Posteriormente, para avaliar a produção, os rizomas foram classificados em 4 classes: A (> 15g ), B (±10 g), C (±5 g) e D(<5g). A interação entre os acessos e o tamanho do rizoma-semente foi significativa para todas as variáveis, com exceção da Classe D. Com o uso de rizoma-semente grande os acessos C-38 e o C-06 apresentaram maior produtividade total, 0,834 e 0,812kg/planta, respectivamente. O descarte gerado foi menor no acesso C-38 do que no C-06, representando 7,8 e 12,8% da produção total, respectivamente. O uso de rizomas-semente maiores aumentou significativamente a produção total. No acesso C-06 a produção passou de 0,481 para 0,812 kg/planta, ou seja, um aumento de 70%. O ganho relativo na produção de rizoma (kg/planta) no acesso C-06 para o plantio de rizomas com ±15 g, foi de 28%.

Turmeric (Curcuma longa L) originated in Southeast Asia and the Indian subcontinent. It is an herbaceous plant with underground, orange stem with several secondary rhizomes used in the food and pharmaceutical industries, because of its characteristics of color, taste, smell, production of essential oils and dyes. In cultivation, the best choice of propagation material must take account the genetic material, weight, age, accumulated reserve capacity, sanity, among other factors. In this study, seed-rhizomes of three weight categories - small, medium and large -, ± 05, ± 10 and ± 15 g / rhizome, respectively, of three genetic materials - C-06, C-36 and C-38 - from the Germplasm Bank of the ESALQ / USP were cultured from December 2009 to August 2010, at a spacing of 0.5 mx 0.2 m. After harvest, they were distributed on canvas suspended for drying in the shade and natural ventilation for 20 days. Later, to evaluate the production, they were classified into four categories: A (> 15g), B (± 10 g), C (± 5 g) and D (<5g) .The interaction between accessions and size of seed-rhizomes was significant for all variables, except for category D. With the use of large seed-rhizomes, C-38 and C-06 had a higher total yield, with 0.834 and 0.812 kg/plant, respectively. The use of large seed-rhizomes increased significantly the total production. In C-06, the production increased from 0.481 to 0.812 kg/plant, i.e. an increase of 70%. Also in C-06, the relative gain in the production of rhizome (kg / plant) for the planting of seed-rhizomes with ± 15 g was 28%.

Integrated PET/CT in non small cell lung cancer staging--clinical and pathological agreement.

INTRODUCTION: Integrated PET/CT has become a fundamental tool in the preoperative assessment of non small lung cancer (NSCLC) providing useful anatomical and metabolic information to characterize tumoral lesions and to detect unsuspected metastatic disease. AIM: To compare the agreement between clinical and pathological staging before and after the use of PET/CT. MATERIAL AND METHODS: Retrospective study of patients with NSCLC who underwent potentially curative surgery throughout 10.5 years. Cohen's kappa coefficient was used to evaluate staging agreement. RESULTS: One hundred and fifty patients were evaluated, 78% males, with a mean age of 65 (±9.6) years. Thirteen percent were submitted to neoadjuvant chemotherapy. PET/CT was performed in 41%. Global agreement between clinical and pathological staging was 51% (kappa=0.3639). There was a statistically significant difference between the staging results in patients who underwent PET/CT, when compared to the subgroup who did not (p=0.003). For those with PET/CT false negatives occurred in less 39%, false positives in more 12% and clinical and pathological staging coincided in more 27%. The overall results reflected an improvement in the agreement between clinical and pathological staging in the PET/CT subgroup (67%, kappa=0.5737 vs 40%, kappa=0.2292). PET/CT accuracy was enhanced when patients re-staged after neoadjuvant therapy were excluded and a substantial staging agreement was obtained for those who had the exam only for staging purposes (73%, kappa=0.6323). CONCLUSION: Inclusion of PET/CT in NSCLC preoperative assessment improved the accuracy of the clinical staging, with a good level of agreement with pathological staging.

Efficacy evaluation of educational sessions for patients with asthma and COPD.

INTRODUCTION: Asthma and COPD are respiratory diseases in which a better knowledge and understanding of the pathology allows the patients to be more involved, which is crucial in their treatment. Holding educational sessions is a good way of imparting information to the patients. AIM: To determine the efficacy of educational sessions in helping patients with Asthma and COPD to acquire a better understanding of their condition. METHODS: Following a Portuguese Lung Foundation initiative to improve knowledge about respiratory health, educational sessions for patients suffering from Asthma or COPD were organized. 25 randomized patients with the disease were invited to participate. Each session lasted 60 minutes. Patient knowledge was tested by means of a multiple choice questionnaire before and after the session. RESULTS: Fifteen patients with asthma attended the sessions, they had an average age of 36 years, of which 60% were female. Within the group 60% were able to name their pathology correctly. Seventeen patients with COPD attended the sessions, they had an average age of 69 years, of which 70% were males and only 3 (17,6%) patients were able to correctly name their pathology. In both groups, there was a statistically positive improvement (p<0,05) of correct answers to the questionnaire the end of each educational session. CONCLUSION: Patient knowledge increased in each educational session. Patients with COPD were less well informed about their disease than patients with asthma and they also had more difficulty in correctly naming their disease.

[Azithromycin as an adjuvant therapy in cryptogenic organizing pneumonia]. / Azitromicina como terapêutica adjuvante na pneumonia organizativa criptogénica.

There are literature data about the immunomodulatory properties of some macrolides in cryptogenic organizing pneumonia (COP) as an alternative to corticosteroids in mild disease or as adjuvant to standard therapy. A sixty-year-old female, with a controlled intrinsic asthma, presented with COP and recurrent respiratory exacerbations despite corticosteroid and immunossupressant therapy. Azithromycin (500mg, on alternate days) as an adjuvant to steroids was then started, with clinical and functional improvement and regression of lung infiltrates. Withdrawal of steroids was possible in one year, without evidence of relapse in the next six months. Azithromycin was maintained (three times per week) with no documentation of adverse side effects. This clinical case reinforces the potential role of macrolides anti-inflammatory properties in COP as corticosteroids adjuvant therapy.

[Primary endobronchial leiomyoma--endoscopic laser resection]. / Leiomioma endobrônquico primário--ressecção laser endoscópica.

Leiomyomas account for less than 2% of all benign lung tumors. Only one third is endobronchial in location, usually presenting as primary solitary lesions and airway obstruction findings. Literature on primary endobronchial leiomyomas is therefore scarce, with a few more than 100 cases being reported. We describe a case of a 44-year-old female that presented with bronchial asthma like symptoms and an obstructive pneumonia, due to a right main bronchus primary leiomyoma that was successfully resected using Nd:YAG laser through rigid bronchoscopy. Purpose of this case is to enhance the rarity of primary endobronchial leiomyoma diagnosis and report the relevance of laser resection in its definitive treatment. A brief review on lung leiomyomas is discussed over the text.

[Positive bronchoalveolar lavage and quantitative cultures results in suspected late-onset ventilator associated penumonia evaluation--retrospective study]. / Resultados positivos do lavado broncoalveolar e das culturas quantitativas na suspeita da pneumonia tardia associada ao ventilador--estudo retrospectivo.

INTRODUCTION: Bronchoalveolar lavage (BAL) with quantitative cultures has been used in order to increase ventilator associated pneumonia (VAP) diagnosis specificity, although the accurate technique for this entity diagnosis remains controversial. OBJECTIVES: To evaluate the influence of using positive BAL and quantitative cultures results in microbiologic diagnosis and treatment of patients with suspected late VAP and prior antibiotherapy. MATERIAL AND METHODS: Retrospective analysis of intensive care unit (UCI) patients, during a one year period, with clinical suspicion of late VAP and prior use of antibiotics that presented a growth in BAL cultures. RESULTS: Of 243 BAL performed, there were 71 (29.2%) positive cultures (60 patients, 76.7% male, 54 ± 19 years). BAL was done after 13 days (median) of invasive mechanical ventilation, 11 days of ICU antibiotherapy and in the day in which a new antibiotic for VAP suspicion was started. Colony forming units (CFU)/ml count was performed in 71.8% and endotracheal aspirate (ETA) simultaneously collected for qualitative analysis in 85.9%. Therapeutic approach was changed in 38.0%: correction (16.9%), de-escalation (12.7%) and directed antibiotherapy start (8.4%). Therapeutic changes were made in the presence of CFU > 10(4) in 84.2% and in agreement with ETA in 70.8%. In cases in which antibiotherapy was maintained (62.0%), quantitative cultures would have allowed de-escalation in 9.1%. Changes in prescription were more frequent when CFU was > 10(4) (48.5%), comparing with situations in which counts were lower and BAL analysis was qualitative (28.9%), p = 0.091. There were no significant differences between patients submitted to different therapeutic approaches concerning to ICU mortality or length of stay. CONCLUSION: In late onset VAP, positive BAL and quantitative cultures allowed therapeutic changes, leading to antibiotic adequacy and consumption reduction, which can however be maximised.

Translation of Berlin Questionnaire to Portuguese language and its application in OSA identification in a sleep disordered breathing clinic.

BACKGROUND: Berlin Questionnaire (BQ), an English language screening tool for obstructive sleep apnea (OSA) in primary care, has been applied in tertiary settings, with variable results. AIMS: Development of BQ Portuguese version and evaluation of its utility in a sleep disordered breathing clinic (SDBC). MATERIAL AND METHODS: BQ was translated using back translation methodology and prospectively applied, previously to cardiorespiratory sleep study, to 95 consecutive subjects, referred to a SDBC, with OSA suspicion. OSA risk assessment was based on responses in 10 items, organized in 3 categories: snoring and witnessed apneas (category 1), daytime sleepiness (category 2), high blood pressure (HBP)/obesity (category 3). RESULTS: In the studied sample, 67.4 % were males, with a mean age of 51 ± 13 years. Categories 1, 2 and 3 were positive in 91.6, 24.2 and 66.3 %, respectively. BQ identified 68.4 % of the patients as being in the high risk group for OSA and the remaining 31.6 % in the low risk. BQ sensitivity and specificity were 72.1 and 50 %, respectively, for an apnea-hipopnea index (AHI) > 5, 82.6 and 44.8 % for AHI > 15, 88.4 and 39.1 % for AHI > 30. Being in the high risk group for OSA did not influence significantly the probability of having the disease (positive likelihood ratio [LR] between 1.44-1.49). Only the items related to snoring loudness, witnessed apneas and HBP/obesity presented a statistically positive association with AHI, with the model constituted by their association presenting a greater discrimination capability, especially for an AHI > 5 (sensitivity 65.2 %, specificity 80 %, positive LR 3.26). CONCLUSIONS: The BQ is not an appropriate screening tool for OSA in a SDBC, although snoring loudness, witnessed apneas, HBP/obesity have demonstrated being significant questionnaire elements in this population.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial.

OBJECTIVES: Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE). METHODS: Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale. RESULTS: Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60). CONCLUSION: In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.