Gonzalo Labarca

Pirfenidone for Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis

Idiopathic pulmonary fibrosis (IPF) is a progressive disease with poor prognosis. In the last decades pirfenidone an anti-inflammatory and anti-fibrotic agent has shown benefit in inhibit collagen production and has also demonstrated benefit in decline progression in IPF in physiological outcomes as Forced vital capacity (FVC), in clinical outcomes such as progression free survival (PFS) and a benefit in mortality but no in clinically relevant outcomes as exacerbations or worsening of IPF. Methods: We conducted a systematic review to evaluate the effectiveness of physiological and clinical outcomes of pirfenidone compared to placebo in IPF. We performed a search with no language restriction. Two researchers performed literature search, quality assessment, data extraction and analysis. And was performed a summary of findings table following the GRADE approach. Results: We included 5 RCTs (Randomized controlled trials) in analysis. The meta-analysis resulted in a decrease in all cause-mortality (RR 0.52 IC 0.32–0.88) and IPF related mortality (RR 0.32 IC 0.14–0.75); other outcomes evaluated were worsening of IPF (RR 0.64 IC 0.50–0.83) and acute exacerbation (RR: 0.72 IC 0.30–1.66 respectively). Also there was a decrease in progression free survival (PFS) (RR 0.83 IC 0.74–0.92) compared to placebo. Conclusions: We observed significant differences in physiologic and clinically relevant outcomes such as reduction in all-cause mortality, IPF related mortality, worsening and exacerbation of IPF and PFS. So pirfenidone treatment should be considered not only for its benefits in pulmonary function tests but also by its clinically relevant outcomes.

Diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal staging in lung cancer

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic test with a high diagnostic yield for suspicious central pulmonary lesions and for mediastinal lymph node staging. The main objective of this study was to describe the diagnostic yield of EBUS-TBNA for mediastinal lymph node staging in patients with suspected lung cancer. METHODS: Prospective study of patients undergoing EBUS-TBNA for diagnosis. Patients ≥ 18 years of age were recruited between July of 2010 and August of 2013. We recorded demographic variables, radiological characteristics provided by axial CT of the chest, location of the lesion in the mediastinum as per the International Association for the Study of Lung Cancer classification, and definitive diagnostic result (EBUS with a diagnostic biopsy or a definitive diagnostic method). RESULTS: Our analysis included 354 biopsies, from 145 patients. Of those 145 patients, 54.48% were male. The mean age was 63.75 years. The mean lymph node size was 15.03 mm, and 90 lymph nodes were smaller than 10.0 mm. The EBUS-TBNA method showed a sensitivity of 91.17%, a specificity of 100.0%, and a negative predictive value of 92.9%. The most common histological diagnosis was adenocarcinoma. CONCLUSIONS: EBUS-TBNA is a diagnostic tool that yields satisfactory results in the staging of neoplastic mediastinal lesions.

Compromiso multisistémico en apnea obstructiva del sueño

Obstructive Sleep Apnea (OSA) is characterized by repetitive upper airway collapse with apnea/hypopnea and recurrent hypoxia during sleep, which results in fragmented sleep and intermittent drops in arterial blood oxygen saturation (hypoxemia). Several dysfunctions of neurocognitive, endocrine, cardiovascular, and metabolic systems are recognized in patients with OSA. The most commonly reported associations are with obesity, increased cardiovascular risk, dyslipidemia, diabetes mellitus 2 and liver damage. However, there is a proven relationship between OSA and other diseases, such as polycystic ovary syndrome, gastroesophageal reflux, and chronic kidney disease. The aim of this review is to analyze clinical and experimental evidence linking OSA with other diseases.

Complicaciones asociadas a la broncoscopía flexible: análisis de registro post-procedimiento

Background: Flexible bronchoscopy is a useful diagnostic tool with a relative low rate of complications. Aim: To analyze post procedure risk of complications after flexible bronchoscopy with transbronchial or bronchial biopsy. Material and methods: The electronic database of a bronchoscopy unit at a general Hospital was analyzed. All procedures performed between 2009 and 2011 were reviewed and complications recorded. The primary outcome measure was the risk for complications defined as the percentage of procedures complicated by hemorrhage, pneumothorax, desaturation <80% and other complications. We used a logistic regression model to explore the association between each procedure characteristic and complication. Results: One thousand seventy nine procedures were included in the analysis. Eight percent had complications. Among these, the frequency of hemorrhage was 5.9% and pneumothorax was 0.3%. Factors associated with complications were exclusive use of topical anesthesia with an odds ratio (OR) of 1.72 (confidence intervals (CI): 1.04 – 2.86), regular or bad intolerance to the procedure with an OR 4.70 (CI: 3.00 –7.38) and performing biopsies of the upper lobes with an OR of 1.76 (CI: 1.04-2.97). Conclusions: Exclusive use of topical anesthesia, performing biopsies of the upper lobes and procedure tolerance were risk factors associated with complications Following bronchoscopic biopsies.

Correction: Pirfenidone for Idiopathic Pulmonary Fibrosis: A Systematic Review and Meta-Analysis.

There are errors in the ninth and tenth sentences of the Abstract. These sentences should read: Also there was a decrease in the risk of progression (RR of PFS: 0.82 IC 0.73–0.92) compared to placebo. Conclusions: We observed significant differences in physiologic and clinically relevant outcomes such as reduction in all-cause mortality, IPF related mortality, worsening of IPF and improvement of PFS. So pirfenidone treatment should be considered not only for its benefits in pulmonary function tests but also by its clinically relevant outcomes. There are multiple errors in the Results described below. The third and fourth sentences of the “Progression-free Survival (PFS)” section should read: The meta-analysis includes 786 patients in intervention group and 728 in placebo group (Fig 5). Pirfenidone decreased the risk of progression (RR of PFS: 0.82 IC 0.73–0.92, I2:22%) compared to placebo. We rated the quality of evidence as moderate, because of indirectness. Fig 5 Comparison 3. Risk of progression (RR of PFS). The third sentence of the “Worsening of IPF” section should read: The meta-analysis includes 858 patients in intervention group and 763 in placebo group (Fig 7). Pirfenidone improves worsening of IPF with a RR of 0.64 (IC 0.50–0.83, I2:23%) compared to placebo. The second sentence of the “Adverse events” section should read: The meta-analysis includes 859 patients in intervention group and 763 in placebo group (Fig 10). There is an error in the third sentence of the fourth paragraph of the Discussion. It should read: We also observed differences in clinically relevant outcomes such as reduction in all-cause mortality, IPF related mortality, worsening of IPF and risk of progression; but no benefit on acute exacerbation of IPF. There are errors in the fourth and fifth columns of Table 2. Please see the corrected Table 2 here. Table 2 Summary of finding form Pirfenidone for idiopathic pulmonary fibrosis. Fig 5 and its caption are incorrect. Please view Fig 5 and see its complete, correct caption here.

Minimally Invasive Methods for Staging in Lung Cancer: Systematic Review and Meta-Analysis

Introduction. Endobronchial ultrasound (EBUS) is a procedure that provides access to the mediastinal staging; however, EBUS cannot be used to stage all of the nodes in the mediastinum. In these cases, endoscopic ultrasound (EUS) is used for complete staging. Objective. To provide a synthesis of the evidence on the diagnostic performance of EBUS + EUS in patients undergoing mediastinal staging. Methods. Systematic review and meta-analysis to evaluate the diagnostic yield of EBUS + EUS compared with surgical staging. Two researchers performed the literature search, quality assessments, data extractions, and analyses. We produced a meta-analysis including sensitivity, specificity, and likelihood ratio analysis. Results. Twelve primary studies (1515 patients) were included; two were randomized controlled trials (RCTs) and ten were prospective trials. The pooled sensitivity for combined EBUS + EUS was 87% (CI 84–89%) and the specificity was 99% (CI 98–100%). For EBUS + EUS performed with a single bronchoscope group, the sensitivity improved to 88% (CI 83.1–91.4%) and specificity improved to 100% (CI 99-100%). Conclusion. EBUS + EUS is a highly accurate and safe procedure. The combined procedure should be considered in selected patients with lymphadenopathy noted at stations that are not traditionally accessible with conventional EBUS.

Concomitant tracheal and subcutaneous glomus tumor: Case report and review of the literature

Glomus tumors are unusual and generally benign neoplasms mainly found in subungeal areas. We describe a case of concomitant subcutaneous and tracheal glomus tumor that underwent successful endoscopic resection. A 48-year old male with a left forearm subcutaneous mass presented with hemoptysis. A chest CT scan demonstrated a polypoid tracheal lesion. He underwent a bronchoscopic resection. A biopsy revealed a glomus tumor, which was the same type of neoplasm that was found on the forearm biopsy. Glomus tumors are rarely found in the respiratory tract. Only 49 cases have been described. The majority of the glomus tumors arise from the lower posterior tracheal wall with no extraluminal extension. Bronchoscopic resection has been successfully used. Glomus tumors should be included in the differential diagnosis of tracheobronchial lesions. Bronchoscopic resection and adjuvant radiotherapy are valid treatment options. This is the first report of concomitant subcutaneous and tracheal glomus tumor, as well as the first reported airway glomus tumor, in Latin America. As part of this study, we also perform a literature review.

Dendriform Pulmonary Ossification

Dendriform pulmonary ossification is a rare condition often diagnosed by either surgery or postmortem examination. We report a 43-y-old man with a history of nonproductive cough for 1 y. His physical examination was unremarkable. Chest computed tomography showed multiple bilateral micronodules in both lower lobes; however, the patients pulmonary function was normal. Flexible bronchoscopy with transbronchial biopsies revealed branching ossification. Pulmonary ossification is a chronic process characterized by progressive metaplastic ossification. We reviewed a total of 42 cases of dendriform pulmonary ossification reported in the medical literature: most of these cases were diagnosed by autopsy. Despite its rarity, dendriform pulmonary ossification should be considered in the differential diagnosis of diffuse lung disease. Bronchoscopy with transbronchial biopsies must be considered as a potential diagnostic procedure.

Un caso de neumopatía intersticial con engrosamiento pleural apical: fibroelastosis pleuroparequimatosa idiopática

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a very rare, recently described condition, characterised by fibrotic thickening of the pleural and subpleural parenchyma, predominantly in the upper lobes.1 Clinical manifestations and lung function tests are similar to those observed in restrictive interstitial pneumonias, and in some of the cases described, there was a history of recurrent infections, such as allergic bronchopulmonary aspergillosis or cystic fibrosis.2,3 Radiological findings include intense pleural thickening associated with signs of fibrosis, particularly in the upper lobes, with loss of volume and structural distortion, as observed in the case presented here. This is an 82-year-old female patient with suspected usual interstitial pneumonia on CT imaging, who consulted her pulmonologist due to worsening of dyspnoea on effort and non-productive cough. The patient stated that she was a non-smoker and had not had any previous exposure to environmental allergens, radiotherapy, drugs or history of contact with asbestos. On the physical examination, the patient had a healthy appearance, with nor-

CPAP in patients with obstructive sleep apnea and type 2 diabetes mellitus: Systematic review and meta-analysis

Obstructive sleep apnea hypopnea syndrome (OSAHS) is a prevalent condition across the world; it co‐exists with others metabolic diseases, such as central obesity, dyslipidemia, and arterial hypertension. These associations increase the cardiovascular risk and mortality. Observational studies have reported a strength association between OSA and type 2 Diabetes Mellitus (T2DM) and continuous positive airway pressure (CPAP) is recommended for moderate to severe OSAHS.