1,721,033 research outputs found
Pneumopatie da agenti ambientali (professionali ed immunomediate)
No full textPneumopatie da agenti ambientali professionali ed immunomediate
Interstitial Lung Disease Associated With Autoimmune Rheumatic Diseases: Checklists for Clinical Practice
Full text linkBackground: Interstitial lung diseases (ILDs) are often associated with rheumatic diseases. Their early diagnosis and management are not only difficult, but also crucial, because they are associated with major morbidity and mortality and can be the first cause of death in autoimmune rheumatic diseases (ARDs).Objectives: By using methodologies, such as Nominal Group Technique (NGT) and Delphi Survey, the aims of this study were (1) to measure consensus between pulmonologists, radiologists, and rheumatologists experienced in the management of ARD-ILD; (2) to highlight the importance of a multidisciplinary approach; and (3) to provide clinicians with a practical tool aimed at improving the prompt recognition and follow-up of ILD associated with ARDs and of any possible rheumatic conditions underlying ILD.Results: During the NGT round, the Steering Committee defined 57 statements to be used in the Delphi survey. A total of 78 experts participated in the Delphi survey, namely 28 pulmonologists, 33 rheumatologists, and 17 radiologists. During this round, consensus on agreement was reached in 47 statements, while disagreement was not reached in any statements. A secondary questionnaire was drafted by the Steering Committee to obtain clearer indications on ILD-ARD "red-flags" and follow-up. Delphi Panelists took part also in the second-questionnaire survey. Answers from both surveys were used to draft two checklists of "red flags" sign or symptom suggestive of ILD and ARD, respectively, and two checklists on identification and monitoring of rheumatoid arthritis (RA) and systemic sclerosis (SSc) ILD.Limitations: This study is a consensus work, which cannot produce empiric data, and is limited to the Italian scenario.Conclusions: This work showed a high level of agreement, but also shows some divergent opinions between different experts. This underlines the importance of a multidisciplinary approach. Eventually, we believe the drafted checklists can help clinicians in the diagnosis and follow-up of ILD-ARD
The technique of endoscopic airway tumor treatment
No full textMore than half of primary lung cancers are not resectable at diagnosis and 40% of deaths may
be secondary to loco-regional disease. Many of these patients suffer from symptoms related to airways
obstruction. Indications for therapeutic endoscopic treatment are palliation of dyspnea and other obstructive
symptoms in advanced cancerous lesions and cure of early lung cancer. Bronchoscopic management is
also indicated for all those patients suffering from benign or minimally invasive neoplasm who are not
suitable for surgery due to their clinical conditions. Clinicians should select cases, evaluating tumor
features (size, location) and patient characteristics (age, lung function impairment) to choose the most
appropriate endoscopic technique. Laser therapy, electrocautery, cryotherapy and stenting are well-described
techniques for the palliation of symptoms due to airway involvement and local treatment of endobronchial
lesions. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound
(EBUS), autofluorescence bronchoscopy (AFB), and narrow band imaging (NBI). Other techniques, such
as endobronchial intra-tumoral chemotherapy (EITC), EBUS-guided-transbronchial needle injection or
bronchoscopy-guided radiofrequency ablation (RFA), are in development for the use within the airways.
These endobronchial interventions are important adjuncts in the multimodality management of lung cancer
and should become standard considerations in the management of patients with advanced lung cancer,
benign or otherwise not approachable central airway lesions. We aimed at revising several endobronchial
treatment modalities that can augment standard antitumor therapies for advanced lung cancer, including
rigid and flexible bronchoscopy, laser therapy, endobronchial prosthesis, and photodynamic therapy (PDT)
Observational, Multicenter Study on the Efficacy, Tolerability, and Safety of Nintedanib in Patients with Idiopathic Pulmonary Fibrosis Older than 80 Years
No full textBackground: Idiopathic pulmonary fibrosis (IPF) primarily affects old patients. Old age is a predictor of mortality. Nintedanib, the only antifibrotic drug approved in Italy for patients aged >80 years, can slow the progression of IPF by reducing the rate of decline in forced vital capacity (FVC) and the risk of exacerbations. Objectives: The primary aim of the study was to compare the decline of FVC after 12 months of nintedanib in patients aged >80 years versus younger patients. Differences related to other functional data, safety, tolerability, hospitalizations, exacerbations, and mortality were evaluated. Methods: An observational, retrospective, multicenter study was carried out in Italy. Results: 159 (122 [76.7%] males) patients were recruited: 106 (66.7%) aged ≤80 years and 53 (33.3%) aged >80 years. FVC decline after 12 months of therapy was not significantly different (−45 mL [−170; 75] vs. −20 mL [−138; 110] mL; p: 0.51). No differences were found for other functional data. Diarrhea was the most frequent adverse event (AE). Rate and type of any AEs, permanent/temporary dose reduction, or drug discontinuation were not significantly different between patients aged ≤80 vs. >80 years. Furthermore, acute exacerbations, hospitalization, and mortality were not significantly different. Conclusions: Nintedanib is effective and safe in patients with IPF aged >80 years, and no significant differences were found when clinical outcomes were compared with those of younger patients. Thus, older age should not be a barrier for the early prescription of antifibrotic treatment in IPF patients
Pulmonary diffusing capacity for carbon monoxide: a marker of depressed hypercapnic drive in type 1 diabetes mellitus
No full textAbstract
AIMS:
Decreased chemosensitivity to hypercapnia, a common finding in Type 1 diabetes mellitus, seems related to autonomic neuropathy. We proposed to verify whether simple neuroautonomic cardiovascular tests or indexes of severity of diabetes and respiratory impairment can identify patients with such a dysfunction, but no clinical evidence of autonomic neuropathy.
METHODS:
Forty patients with Type 1 diabetes, 20 with autonomic neuropathy according to the results of a standardized test battery, were studied and compared with 40 normal subjects matched by age and sex. Spirometry and pulmonary diffusing capacity for carbon monoxide were performed. The chemosensitivity to hypercapnia was tested by the rebreathing method.
RESULTS:
There was no significant difference between patients with and without autonomic neuropathy in chemosensitivity to hypercapnia, as expressed by the ventilation response to increasing end-tidal pressure of carbon dioxide; however, it was lower in the whole group of patients with diabetes than in control subjects (1.71 ± 0.80 vs. 2.45 ± 1.11 l−1 min−1 mmHg, respectively, P=0.002). No significant correlation was found between ventilation response to increasing end-tidal pressure of carbon dioxide and the results of autonomic tests. In patients with diabetes mellitus, the ventilatory response to hypercapnia significantly correlated with pulmonary diffusing capacity for carbon monoxide (Spearman's rho=0.387, P=0.013) and this was the only variable significantly associated with ventilation response to increasing end-tidal pressure of carbon dioxide in a multiple regression model.
CONCLUSIONS:
Chemosensitivity to hypercapnia was depressed in patients with diabetes mellitus, irrespective of autonomic neuropathy, in comparison with control subjects. The correlation with pulmonary diffusing capacity for carbon monoxide suggests that microcirculatory damage might contribute to depress the central chemosensitivit
Ultrasonography of the Mediastinum: Techniques, Current Practice, and Future Directions
No full textIn the everyday practice of respiratory physicians, ultrasound techniques play a key role by enabling
several diagnostic and interventional procedures. The application of ultrasound to endoscopic
procedures allows both a visualization and a guided sampling of mediastinal and hilar lymph
nodes. Endobronchial ultrasound can be combined with transbronchial needle aspiration, and,
similarly, endoscopic ultrasound can be combined with fine-needle aspiration to sample virtually all
mediastinal nodal stations from the airways and the esophagus. Endobronchial ultrasound–transbronchial
needle aspiration and endoscopic ultrasound–fine needle aspiration showed a complementary
diagnostic yield, and, recently, endoscopic ultrasound with bronchoscope was introduced
in clinical practice to perform a transesophageal needle aspiration by using an ultrasound bronchoscope.
This technique allows a single operator to perform both transbronchial and transesophageal
needle sampling with the same instrument during a single bronchoscopic procedure. Mediastinal
staging impacts the management of patients affected by lung cancer, and the most recent
guidelines clearly state that endobronchial ultrasound and endoscopic ultrasound should be the
initial tissue sampling procedure over surgical staging. In addition, endoscopic ultrasound techniques
demonstrated an excellent yield in diagnosing lymphoma and benign diseases, for example,
sarcoidosis. The aim of this review was to discuss the current role and future perspectives of
endosonography techniques available for the evaluation of the mediastinum. Special emphasis was
placed on equipment and technical aspects, the diagnostic role, and future directions of development
Influence of the Learning Effect on the Diagnostic Yield of Endobronchial Ultrasound-guided Transbronchial Needle Aspiration of Mediastinal and Hilar Lymph Nodes
No full textThe diagnostic yield of conventional
transbronchial needle aspiration (TBNA) is characterized
by a learning effect. The aim of this retrospective
study was to verify whether a learning curve
similarly affected the yield of endobronchial
ultrasound-guided (EBUS)-TBNA. To this end, we
evaluated the sensitivity and diagnostic accuracy of
EBUS-TBNA during the first 3 years of activity.
Methods: EBUS-TBNA was performed by 2 operators
with no previous experience in this technique. Cytologic
samples were obtained from mediastinal and hilar
lymph nodes enlarged at a chest computed tomography
scan and/or with increased fluorodeoxyglucose uptake
at computed tomography/positron emission tomography
scan in patients with suspected lung cancer. The
cytologic diagnosis of EBUS-TBNA samples has been
compared with the final diagnosis obtained from further
diagnostic procedures, surgery, or clinical-radiologic
follow-up.
Results: From October 2012 to October 2015, we
collected 408 EBUS-TBNA cytologic samples from
313 patients: 223 samples were positive for metastatic
involvement and 185 were nonmetastatic. The latter
included 137 true-negative and 48 false-negative
results. The final diagnosis comprised 271
metastatic and 137 nonmetastatic lymph nodes.
The overall sensitivity for cancer was 82% and
diagnostic accuracy was 88%. Sensitivity and accuracy
per year were as follows: first year, 78% and
82% in 90 nodal samples; second year, 83% and 89%
in 144 nodal samples; third year, 85% and 91% in
174 nodal samples.
Conclusions: EBUS-TBNA can be considered as a reliable
tool even if performed by operators without
previous experience in this procedure, and the diagnostic
yield continues to increase progressively over a
long time
Long-term treatment with nintedanib and pirfenidone in idiopathic pulmonary fibrosis: a comparative, real-world cohort study
No full textRationale: Limited data exists on the long-term comparative efficacy and tolerability of pirfenidone and nintedanib, the two approved treatments for idiopathic pulmonary fibrosis (IPF). Methods: We retrospectively enrolled IPF patients treated with either pirfenidone or nintedanib at our centre between 2017 and 2023. Progression-free survival (PFS), defined as time to death or ≥ 10% decline in % predicted forced vital capacity (FVC) and continuous FVC decline were compared between groups defined by antifibrotic type or treatment intensity (full or reduced). Time to drug dose reduction was also compared. Statistical analysis included Kaplan-Meier curves with Log-Rank tests, Cox proportional hazards models and linear mixed-effects models. Results: A total of 292 IPF patients treated with pirfenidone (n = 142) or nintedanib (n = 150) were included with a mean follow-up time of 32.3 months (SD = 14.5). No significant differences in efficacy were observed between groups by antifibrotic type. Dose reduction was more frequent in the nintedanib group (59.3%) than pirfenidone group (16.9%, p < 0.001). Multivariate analysis showed that patients on nintedanib had a 4-fold higher risk of dose reduction compared to those on pirfenidone (p < 0.001). There were no significant differences in clinical outcomes between patients with dose reduction and those maintaining the full dose, both in the overall population and when stratified by antifibrotic type. Conclusion: Nintedanib and pirfenidone exhibited similar long-term efficacy. Dose adjustment was more frequent with nintedanib, however it did not have impact on clinical outcomes
Predictors of Stability/Improvement of Forced Vital Capacity in Patients With Idiopathic Pulmonary Fibrosis After One Year of Treatment With Nintedanib
No full textNon
Treating heart failure with preserved ejection fraction: learning from pulmonary fibrosis
No full textHeart failure with preserved ejection fraction (HFpEF) has a poor prognosis, and an effective treatment is currently lacking. Increasing evidence suggests a prevailing pathogenic role of cardiac fibrosis in HFpEF, which generates the possibility of a mechanistic overlap with pulmonary fibrosis. Indeed, cardiac and pulmonary fibrosis share some characteristics and molecular pathways, such as that of transforming growth factor-β. If pulmonary and cardiac fibrosis share common pathways, we can hypothesize a beneficial effect of anti-fibrotic drugs used in idiopathic pulmonary fibrosis on cardiac outcomes. Of note, pirfenidone has been tested in animal models of cardiac fibrosis and was found to be effective in reducing ventricular remodelling. Yet, no results are hitherto available for humans. In this review article, we discuss the potential benefit of anti-fibrotic treatment in HFpEF. In particular, we propose to reappraise safety data collected in placebo-controlled trials of anti-fibrotic drugs in idiopathic pulmonary fibrosis, to explore the hypothesis that these might reduce cardiac fibrosis
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