Patrícia Dionísio

Hypoxia challenge test and retinal circulation changes - a study using ocular coherence tomography angiography

Previous studies report that the response of retinal vessels to a decrease in oxygen (hypoxia) is vasodilation, thus increasing blood flow. We aimed to characterize the changes in retinal microvasculature induced by a mild hypoxia stress test in a healthy population, using ocular coherence tomography angiography (OCT‐A) technology.

An Unusual Association in an Uncommon Disease: Two Cases of Spontaneous Pneumomediastinum Associated with Pneumorrhachis

Pneumomediastinum, the presence of free air in the mediastinum, is described as spontaneous pneumomediastinum when there is no apparent cause such as trauma, surgery, interventional procedures, or intrathoracic infections. Pneumorrhachis is a rare clinical condition, consisting of intraspinal air. The main causes are iatrogenic, traumatic, and nontraumatic. Spontaneous mediastinum is usually associated with subcutaneous emphysema and, occasionally, with pneumothorax; however, its association with pneumorrhachis is extremely rare. Here, we present two rare cases of spontaneous pneumomediastinum associated with pneumorrhachis caused by vigorous coughing.

Pemetrexed continuation maintenance in patients with advanced lung adenocarcinoma

Background: Recent studies demonstrated that pemetrexed continuation maintenance therapy (PCMT) is a new treatment paradigm for advanced nonsquamous NSCLC. Aims: Describe demographic, efficacy and safety data from patients on PCMT, not progressing after first-line induction chemotherapy with a platinum/pemetrexed doublet for advanced lung adenocarcinoma. Methods: A retrospective descriptive study was conducted with patients on this regimen who were treated in the last four years at an outpatient clinic, in a tertiary hospital. Results: We identified 69 patients (58,0% male); median age of 60 years (range 36-84); 73,9% had actual or past smoking habits. Performance status (PS) was between 0-2, being PS 1 in 66,7% of cases. Almost all patients were stage IV (98,6%). All patients were initially submitted to 4 cycles or 6 cycles of induction therapy with pemetrexed plus carboplatin or cisplatin. The median progression-free survival (induction and maintenance) was 7,6 months (range 3,5-74,8). The best overall response for the entire treatment period was complete response in one case (1,4%), partial response in 66,7% and stable disease in 31,9% of cases. The overall response rate was 68,1%. Regarding safety, adverse events grade ≥3 were seen in 29,0% of patients and in 2 cases were grade 5 (febrile neutropenia). The most common were acute renal injury in 8,7% of all patients, anemia in 7,2%, febrile neutropenia in 5,8%, vomiting in 5,8% and hipocellular bone marrow in 4,3%. Conclusion: From our experience, for patients with good PS, diagnosed with advanced lung adenocarcinoma, PCMT shows clinically meaningful survival benefits and important response rates, while maintaining a reasonable safety profile.

Morgagni Hernia as a Reversible Cause of Hypercapnic Respiratory Failure

The three basic types of congenital diaphragmatic hernia (CDH) include hiatus hernia, posterolateral Bochdalek hernia and anterior Morgagni hernia (MH), the last being the rarest type (2–3% of all cases).1,2 The diagnosis of MH in adults is very rare and usually is incidental or presents with non-specific chronic respiratory or gastrointestinal symptoms.2,3 It can also be present with acute bowel obstruction or intestinal strangulation.3 Late-presenting CDH is often difficult to diagnose, and delays in treatment are common.4 Few cases have been described in the literature. A 64-year-old non-smoker caucasian woman, with previous diagnosis of morbid obesity (BMI of 50 kg/m2), arterial hypertension, hypertensive heart disease, hypothyroidism and depression was first admitted to our department in 2007 with a one-month history of progressive exertional dyspnoea, paroxysmal nocturnal dyspnoea and lower limb oedema, with no other symptoms. There was no history of recent trauma or surgery. On admission, she was started on non-invasive ventilation (NIV) for hypercapnic respiratory failure (pH 7.35, PaCO2 72.4 and PaO2 40.2 mmHg). The initial chest radiographs showed an hypotransparency on the right pulmonary lower lobe. The chest CT scan identified a large Morgagni hernia on the right side, with the compromise of the right lung volume and contralateral mediastinal deviation, as well as signs of pulmonary hypertension. The echocardiogram confirmed mild pulmonary hypertension (PSAP 49 mmHg). She was referred to Cardiothoracic Surgery but was refused because of her surgery-related risk. She was discharged on long-term supplemental oxygen therapy and domiciliary NIV. Between 2008 and 2012 she was admitted three times for decompensated hypercapnic respiratory failure and for oxygen and ventilatory parameters adjustment. Diaphragmatic hernia was also bigger on the chest radiographs. In 2013 she was admitted five times in the context of emesis and gastroparesis. Despite a significant weight loss (BMI 50 to 41 kg/m2), she maintained the need for both long-term supplemental oxygen therapy and NIV. At that time her lung function test showed a moderately severe obstructive pattern (FVC 1.05 mL (67%); FEV1 0.64 mL (52%); FEV1/FVC ratio 61.14%; TLC 2.87 mL (82%); RV 1.76 mL (106%); ITGV 2.50 (112%)). A new CT scan showed increased volume of the Morgagni hernia, which contained part of the transverse colon, all the ascending colon, loops of ileum and distal jejunum, with the insinuation of gastric antrum, leading to passive atelectasis of the middle lobe

Thoracoscopy: Diagnostic and therapeutic applications

Introduction: The technique and clinical applications of medical thoracoscopy (MT) have substantially evolved over the last decades. Aim: We sought to evaluate the diagnostic and therapeutic yield and safety of MT at our unit. Methods: The reports of all MT undergone from 2010 to 2014 were reviewed and analysed as regards to indication, side, endoscopic findings, procedures and immediate complications. Results: In our study, 268 patients underwent MT, 8 of which were excluded because of lost data. One hundred fifty-one patients were male (58,08%) and 109 female (41,92%) with a mean age of 55,76 ± 20,4 years. Sixty of the MT (23,08%) were diagnostic, 140 (53,84%) therapeutic and 60 (23,08%) simultaneously diagnostic and therapeutic. Undiagnosed or malignant pleural effusions were the main indications (66,92%), followed by pneumothorax (26,92%), nodules and masses (4,23%), hydropneumothorax (1,15%), abscess (0,39%) and pleural thickening (0,39%). Thoracoscopic pleural biopsies were performed in 113 patients. One hundred twenty-one (69,54%) of the pleural effusions and 68 (97,14%) of the pneumothorax were submitted to talc poudrage. No death related to thoracoscopy was registered. Conclusions: The role of medical thoracoscopy in the diagnosis and treatment of pleural disease is as relevant today as it was when Jacobeus pioneered this important procedure.