A. Bugalho de Almeida

Four years’ follow up at a smoking cessation clinic

UNLABELLED Smoking is an important cause of pulmonary pathology and this addiction can be regarded as a chronic, recurrent disease. The benefits of smoking cessation are unquestionable and all physicians should become more active and assertive in recommending it. AIM To characterise the population seeking medical support for smoking cessation and understand why some successfully stop smoking and others do not. MATERIAL AND METHODS Retrospective analysis of medical records of outpatients in follow-up between January 2003 and June 2006. Age, gender, age at smoking initiation, smoking burden (number of pack-years), associated diseases, degree of dependence (Fagerström test for nicotine addiction), prior attempts at and motivation for smoking cessation, need for cognitive/behavioural support and success and abandonment rates were evaluated. RESULTS Five hundred and twenty six patients were studied, 50% male with an average age of 45.5+/-11.4 years. Almost half (43.1 %; n=227) of the patients started smoking before the age of 15. Average smoking burden was 35.8+/-20 pack-years although 21.4% (n=113) smoked more than 50 pack-years. Respiratory disease was present in 52.1% (COPD, 39.9% and others, 12.2%) and cardiovascular disease in 14.6% of the patients. In 46% of patients (n=242) a relevant psychiatric disorder was identified; depression (21.4%), anxiety disorder (19.4%), other dependencies (2.1%) bipolar disorder (1.5%) and schizophrenia (0.6%). The evaluation of degree of addiction revealed maximum level in 69.7% of the patients (n=380). Many patients (72.2%; n=380) reported prior attempts to quit smoking. The strongest reasons for giving up smoking were concern over health (83.5%), financial issues (8.2%) and search for better quality of life (5.7%). Most patients (81.7%; n=430) had undergone nicotine replacement therapy; skin patches (53.3%), chewing gum (1.1%) or both (45.6%). Psychopharmacological treatment included administration of sedative-hypnotics (86.5%), bupropion hydrochloride (2.3%) and antidepressants (0.6%). Seventy six patients (14%) benefited from cognitive/ behavioural support. Two hundred and twenty three patients (42.4%) were successful in giving up smoking while 219 (41.6%) abandoned follow up, the majority after the first appointment. Most patients that abandoned follow up reported lack of motivation and the price of therapy. CONCLUSIONS The population under study had a high rate of psychiatric disorders and a high level of dependence and lack of motivation that might justify the drop-out rate. Successful treatment was associated with close follow up, behavioural support and pharmacological therapy.

Asthma hospital admission and mortality in mainland Portugal 2000–2007

We conducted a review of asthma hospital admissions in mainland Portugal 2000-2007 to evaluate if one of the aims of the National Asthma Control Programme, a 20% reduction in hospital admissions in children and adolescents in 2007, had been achieved. Using the Health Services Central Administration data base we reviewed 24271 admissions and saw that 48.7% of patients admitted were aged under 19 years old and that 61.8% were aged 40 years old or under. Mean global annual asthma hospital admission rate was 30.79 per 100,000 inhabitants. Mean global hospital stay was 5.94 days, range 2.93 - 9.73 days, depending on the age group. We saw a drop in admission in both the northern and the Lisbon and Tagus Valley regions over the 8 year period. 189 patients died, 25 of who were aged 40 years old or under. The mortality rate ranged from 0.162 in 2002 to 0.324 per 100,000 inhabitants in 2005, with a mean patient death of 0.77 patients per 100 admissions. Mean annual costs were in excess of euro3.3 million, meaning an estimated annual financial asthma burden of around euro117.5 million in Portugal. We concluded that many asthma sufferers in Portugal do have sufficient disease controlled. Improved management would equal better quality of life and reduced disease costs.

Internamento e mortalidade intra-hospitalar por asma em Portugal continental (2000-2007)

Resumo Para avaliarmos um dos objectivos do Programa Nacional de Controlo da Asma que, no ano 2007, deveria ter uma reducao de 20% nos internamentos de criancas e jovens, decidimos analisar os internamentos hospitalares por asma, ocorridos em Portugal continental no periodo compreendido entre 2000 e 2007. Utilizando a base de dados da Administracao Central dos Servicos de Saude, avaliamos 24 271 internamentos, tendo-se verificado que 48,7% dos doentes tinham menos de 19 anos e 61,8% tinham 40 ou menos. A taxa media anual global de internamento por asma foi de 30,79 por 100 000 habitantes. A demora media global foi de 5,94 dias, com varia-coes entre os 2,93 e os 9,73 dias, de acordo com os varios grupos etarios. Ao longo destes oito anos observou-se uma tendencia para o decrescimo dos internamentos nas regioes Norte e Lisboa e Vale do Tejo. Faleceram 189 doentes, 25 dos quais com idade igual ou inferior a 40 anos. As taxas de mortalidade variaram entre os 0,162 em 2002 e os 0,324 por 100 000 habitantes em 2005, tendo falecido em media 0,77 doentes por cada 100 internamentos. O custo medio anual ultrapassou os €3,3 milhoes, possibilitando uma estimativa do custo anual da asma, em Portugal, de cerca de €117,5 milhoes. Conclui-se que, em Portugal, muitos asmaticos nao tem a sua doenca devidamente controlada e que este controlo se pode traduzir numa melhoria da qualidade de vida e reducao dos custos da doenca. Rev Port Pneumol 2009; XV (3): 367-383

Infliximab no tratamento da sarcoidose - Experiência de um hospital central

Despite aggressive treatment, sarcoidosis may be debilitating and progressive. The role of tumor necrosis factor (TNF)-α in the genesis of granulomas is ambiguous. It has proven to be critical in the formation and maintenance of granulomatous inflammation and its antagonist, Infliximab, has therefore been used with success in the treatment of patients with sarcoidosis. There are, however, reports of onset of sarcoidosis in patients in treatment for other conditions and that had no outbursts before submission to this therapy. We used Infliximab in the treatment of patients with sarcoidosis who either didn’t respond to corticosteroids and other conventional drugs or developed unacceptable side effects to these drugs. The initial dose was 5 mg/Kg body weight and subsequent doses were given at weeks 2, 4 and then every other 8 weeks for a total period of one year. We treated ten patients with biopsy proven sarcoidosis, five men and five women, with a mean age of 47.1 years ranging from 28 to 63 years of age. Three patients had severe neurological symptoms, two had hepatic cirrhosis, one had granulomatous inflammation of the lachrymal gland and had already been submitted to many surgeries, one had extensive pulmonary involvement (stage III), one had disfiguring lupus pernio and two presented disabling cutaneous nodules. In four patients the dosage of corticosteroids or other immunosuppressive drugs was suspended, in three the dosage was reduced and in one, corticosteroids were added to the Infliximab therapy. In five of the patients there was a significant improvement. One of the patients with neurological symptoms displayed a complete recovery, while another had significant improvement of vision deficit enabling her to read again. Two patients withdrew from therapy, one due to lack of improvement of neurological symptoms and the other due to the onset of organizing pneumonia spawned by Infliximab. Two patients developed anti-histone antibodies during treatment. Infliximab seems effective in treating patients who are either refractory or develop side effects to a standard regimen of corticosteroids and immunosuppressive agents. These patients, treated with Infliximab, should be under tight surveillance in order to quickly identify possible secondary effects.

Lavagem pulmonar total – A propósito de quatro casos de proteinose alveolar

Resumo A lavagem pulmonar e uma tecnica desenvolvida na decada de 60 do seculo xx com o intuito de remocao fisica de material proteinaceo dos bronquios, em doentes com proteinose alveolar, levando a uma melhoria clinica e funcional. A tecnica foi evoluindo e o que era inicialmente realizado com anestesia local a um segmento do pulmao e actualmente realizado sob anestesia geral, sequencialmente, a ambos os pulmoes. A presente revisao descreve a tecnica de lavagem pulmonar total, a sua principal indicacao, a proteinose alveolar e, a proposito, relatamos alguns dados relativos a experiencia do nosso servico, onde a realizam com regularidade desde 2002.

Prevalência da exposição ao fumo ambiental do tabaco em casa e do tabagismo na população Portuguesa – o estudo INAsma

BACKGROUND We aimed to: 1) estimate the prevalence of exposure to environmental tobacco smoke (ETS) at home in the Portuguese population; 2) estimate tobacco smoking prevalence in Portugal; 3) identify social and personal characteristics associated with smoking or exposure to ETS. METHODS Nationwide, cross-sectional, population-based telephone survey. Overall, 6003 individuals completed the interview. ETS exposure at home was defined as exposure to at least one current smoker at home. A smoker was defined as someone with 15 years or older, smoking at least 1 cigarette per day during a year; a current smoker (CS) smoked in the last month. RESULTS Exposure to ETS at home was reported by 26.6% (95%CI 25.5-27.7) of the participants. Living in households with ≥4 persons (OR=2.31; 95%CI[1.81-2.96]), being a current smoker (OR=7.29; 95%CI[5.74-9.26]) or having current asthma (OR=2.06; 95%CI[1.45-2.94]) were factors positively associated with ETS exposure. When analyzed by gender, the effect of current asthma was only relevant to females. Currently 19.0% (95%CI 18.0-20.0) of the Portuguese population smokes tobacco and 17.2% (95%CI 16.2-18.2) are ex-smokers. CS prevalence is higher in males than females (26.5%versus 12.2%, p<0,001). The odds of being a CS were higher for males, the more educated, and those exposed to ETS at home. When analyzed by gender, school education only affected females. CONCLUSION Exposure to ETS at home was higher than previously reported. Children/adolescents and asthma patients may have a higher risk of exposure. This report endorses a decreasing trend in the prevalence of tobacco smoking in Portuguese males, but a tendency to increase in females.

Revista Portuguesa de Pneumologia, Ano em Revisão 2009

The Portuguese Journal of Pulmonology is progressively achieving an important status in Portuguese medical literature. The present editors thought it would be an enriching task to revise the main topics published during 2009. The invited members of the Editorial Board covered and commented the most relevant articles and gave us an important picture of the quality of the science it was published in Portuguese Pulmonology.

Linfoma intravascular do pulmão: A propósito de um caso clínico com boa resposta à terapêutica

Intravascular lymphoma is a very rare form of large B cell non-Hodgkin’s lymphoma, characterised by the presence of lymphoma cells in the lumina of small vessels only, particulary in the capillaries. We report a 54 year-old female non-smoker, admitted to hospital for further examination of a four month long clinical condition involving high fever, night sweats, unqualified weight loss and progressive dyspnea. Patient’s temperature was 38.5 oC, pulse 100/min and respiratory 22 cycles/min. Patient’s haemoglobin was 9.4 g/dL, she had leukocytosis, elevated LDH and arterial blood gas analysis with moderate hypoxaemia (FiO2 1 l/m: PaO2-63.6 mm Hg). Chest X-ray revealed diffuse interstitial changes. All the possible causes of unknown origin fever were excluded. Diagnosis was made through lung biopsy and treatment with combined chemotherapy and rituximab was prescribed leading to a 48 hours clinical remission. We present this case to show how difficult this diagnosis can be and how a good response to therapy is possible. Rev Port Pneumol 2008; XIV (6): 857-868

Intravascular pulmonary lymphoma with good response to treatment. A case report

Intravascular lymphoma is a very rare form of large B cell non-Hodgkins lymphoma, characterised by the presence of lymphoma cells in the lumina of small vessels only, particularly in the capillaries. We report a 54 year-old female non-smoker, admitted to hospital for further examination of a four month long clinical condition involving high fever, night sweats, unqualified weight loss and progressive dyspnea. Patients temperature was 38.5 degrees C, pulse 100/min and respiratory 22 cycles/min. Patients haemoglobin was 9.4 g/dL, she had leukocytosis, elevated LDH and arterial blood gas analysis with moderate hypoxaemia (FiO2 1l/m: PaO2-63.6 mm Hg). Chest X-ray revealed diffuse interstitial changes. All the possible causes of unknown origin fever were excluded. Diagnosis was made through lung biopsy and treatment with combined chemotherapy and rituximab was prescribed leading to a 48 hours clinical remission. We present this case to show how difficult this diagnosis can be and how a good response to therapy is possible.

Inflamação e doença pulmonar obstrutiva crónica

Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality worldwide. Cigarette smoke and genetics are implicated in its pathogenesis. In the last few years, inflammation as been considered one of the most important causes of progression and irreversibility of the disease, with numerous cells and mediators implicated. In this paper, the role of different protagonists, their relations and contribute to worsening the disease are reviewed. In a brief way we try to explain why corticosteroids are ineffective in COPD. REV PORT PNEUMOL 2001; VII (1):