Catarina Dias

Transbronchial cryobiopsy in the diagnosis of desquamative interstitial pneumonia.

Desquamative interstitial pneumonia (DIP) is a rare interstitial pneumonia usually associated with cigarette smoke.1,2 It is characterized by the accumulation of intra-alveolar macrophages, sometimes associated with giant cells.1,3 The diagnosis may be suggested by patchy ground-glass opacification with a predilection for the mid and lower lung lobes on high-resolution computed tomography (HRCT); subpleural involvement is also typical. Irregular lines, traction bronchiectasis, cysts, emphysema, and nodules are other possible findings of DIP.4 Bronchoalveolar lavage fluid nearly always contains an increased number of alveolar macrophages.2,4 Histologically, DIP is characterized by the accumulation of macrophages in the alveolar spaces associated with interstitial inflammation and/or fibrosis. The macrophages usually contain light brown pigment. Lymphoid nodules and a sparse but distinct eosinophilic infiltrate are common.3 Surgical lung biopsy is still required to make a definitive diagnosis.1--3 Transbronchial lung cryobiopsy (TBLC) is a new endoscopic technique that has recently shown superior diagnostic yield to conventional transbronchial biopsy (TBB).5--7 The advantage of the cryoprobe, compared with conventional TBB or TBB using jumbo forceps is that larger pieces of tissue, without crush artifacts, can be extracted during the freeze-thaw cycle, allowing the identification of complex pathologic patterns. The technique permits visualization of peripheral structures of the secondary pulmonary lobule and facilitates immunohistochemical staining. In addition, TBLC can be performed on an outpatient basis and is both an easier and safer procedure for patients with comorbidities, as it reduces the complications and mortality associated with surgical lung biopsy.6 Most of the data available to date is on TBLC overall diagnostic yield and complication rates.5 However, it is also important for clinicians to know the diagnostic accuracy of TBLC in particular diffuse lung diseases, especially in cases in which histologic evaluation is an essential component of

CT-guided transthoracic lung diagnostic procedures: A 5 year experience

Computerized tomography (CT)-guided transthoracic diagnostic procedures are effective and safe techniques, and may help avoid thoracic surgery for the diagnosis of intrathoracic lesions. Fine needle aspiration (FNA) provides material for cytological analysis, core biopsy (CB) provides a sample for histologic examination. The aim of our study was to evaluate the diagnostic accuracy and complication rate of both FNA and CB in pulmonary lesions suspected of malignancy. A retrospective analysis of CT-guided transthoracic interventional procedures completed in the Radiology Department, between January 2008 and January 2013, was performed. Patients with a pulmonary lesion suspected of malignancy, on chest CT, were included in the study. All patients underwent a coagulation study. Anticoagulant and antiplatelet therapy had been previously interrupted. An axial acquisition prior to the procedure was obtained. The CT equipment was Philips ® Brilliance 16P. A 22G spinal needle was used for the FNA, and an 18G semi-automatic needle tru-cut gauge system for CB. The shortest intraparenchymal needle path was chosen. The usual number of needle passes was 2 (1--3). The occurrence of complications, including pneumothorax and bleeding was identified through CT images obtained immediately after needle removal. After the procedure, patients remained under observation in the Department of Pulmonology for 6 h, with clinical evaluation before discharge. The results of the procedures were compared with the diagnosis obtained from the integration of clinical evolution, radiological follow-up, and histological result (in patients submitted to surgery) for at least 12 months after the procedure. The relationship of procedural factors and risk of complications was analyzed separately for each variable. For qualitative variables Qhi-square test was used, for quantitative variables we used the Mann--Whitney test. Statistical analysis was performed using SPSS version 22.0. A

Titration with automatic continuous positive airway pressure in obstructive sleep apnea

BACKGROUND AND OBJECTIVE Autotitrating positive airway pressure (APAP) is an accepted titration method to determine the optimal positive airway pressure (PAP), for the treatment of obstructive sleep apnea (OSA). The required duration of APAP monitoring to determine a fixed continuous positive airway pressure level still remains to be established. We aimed to evaluate the variation in PAP level, delivered by APAP devices, at different periods of treatment, to determine the APAP treatment duration required to reach an effective and stable PAP level. METHODS A cross-sectional study of 62 patients newly diagnosed with OSA were evaluated after 3 months of APAP therapy. APAP data corresponding to the first day (D1), first week (W1), seventh week (W7) and twelfth week (W12) under APAP therapy was collected. For the analysis of the pressure behaviour, the difference of P95th pressure level between W12 and W7 (P W12-W7), W12 and W1 (P W12-W1) and W12 and D1 (P W12-D1) was calculated. RESULTS There was a high correlation in P95th pressure level between D1 and W12 (r=0.771; p>0.0001), W1 and W12 (r=0.817; p>0.0001), and W7 and W12 (r=0.926; p>0.0001). This correlation progressively increased with APAP use. A significance difference was found in concordance between P W12-W7 and P W12-D1 (p=0.046) within the pressure range ±2cmH2O. However there was no significant difference in concordance between P W12-W7 and P W12-W1. CONCLUSIONS One week of APAP therapy seems sufficient to determine an effective and stable PAP level, within the pressure range ±2cmH2O.

Lung cancer patients harbouring epidermal growth factor receptor mutation

Introduction: EGFR mutation status is associated with the response to targeted therapy and survival.Data regarding this subject in the Portuguese population is scarce. Methods: 333 NSCLCs patients were tested for EGFR mutations, between 2010 and 2013,and patients with EGFRmutation were included. Clinical, pathological parameters, treatment and survival were analysed. Results: EGFR mutations (exons 18 to 21) were detected in 61 (18,3%)of 333NSCLCs. Patients with EGFR mutation included 39 female, median age of 67,2 years, 11% smokers,21,8%ex-smokers and 67,3% non-smokers.The majority (91,8%) were adenocarcinoma. Thirty-one(31,1%)patientshad an exon 19 deletion, 20 (32,7%) had an exon 21 mutation, 6 (9,8%) had an exon 20 mutation and 4 (6,5%) had an exon 18 mutation.For the patients with stage IV disease themedian overall survival was12 months for the 19EGFR mutation and 9 months for the 21 EGFR mutation. For the rare mutations, the overall survival was 21 months and 1 month, respectively for the 18 and20exons. The overall survival was not different according to the mutation exon (p>0,05).In thestage IV, the overall survival was not significantly affected (p>0,05) by the first line treatment, conventional chemotherapy(n=11)versus tyrosine kinase inhibitors (n=31). The overall survival was significantly longer for the 19 and 21 exons than 18 and 20 exons (p Conclusion: In this population, EGFR mutation frequency was 18,3%. The most frequent mutations were in accordance with literature. Among the rare mutations found,exon 20 seems to be the more aggressive type, however without a significant statistical difference.Theoverall survival was not influenced by the choice of first line therapy.

Catathrenia: A 10 year revision

Introduction: Catathrenia is a rare sleep disorder characterized by a deep inspiration followed by a prolonged expiration and a vocalization. Predominates in males, usually occurring in REM sleep. The pathogenesis remains unclear and is currently considered a sleep-disordered breathing. Methods: Revision of patients with the diagnosis of Catathrenia at a Sleep Medicine Center between 2003 and 2013. Patients underwent a clinical evaluation, questionnaire of Epworth Sleepiness Scale (ESS), physical examination and a level I polysomnography. Results: Eleven patients were considered. The population included 8 female, a mean age of 33,2 years, a mean body mass index 27.7 kg/m 2 . The most common symptoms were an expiratory groaning during sleep, excessive daytime sleepiness and morning headache (n=7). The majority (n=6) of patients had manifestations compatible with an anxiety disorder. Two patients had a family history of the disease. The ESS and RDI average were 11/24, and 3.42 events/hour of sleep, respectively. Two patients had obstructive apnea syndrome, in one case associated with periodic limb movement in sleep (PLMS). The episodes of Catathrenia occurred in REM, N1 and N2 stages. Some patients were treated with mandibular advancement device and clonazepam, there was no clinical improvement in any of the cases. Conclusion: The majority of our patients were females, episodes occurred in NREM and REM sleep, in opposition to what is generally described. Several patients reported excessive daytime sleepiness, despite only three patients had concomitant sleep pathology. It stands out the elevated number of patients with anxiety disorder.