Association between lung function and dyspnoea and its variation in the multinational Burden of Obstructive Lung Disease (BOLD) study

BACKGROUND

Dyspnoea is a common symptom of respiratory disease. However, data on its prevalence in general populations and its association with lung function are limited and are mainly from high-income countries. The aims of this study were to estimate the prevalence of dyspnoea across several world regions, and to investigate the association of dyspnoea with lung function.

METHODS

Dyspnoea was assessed, and lung function measured in 25,806 adult participants of the multinational Burden of Obstructive Lung Disease study. Dyspnoea was defined as ≥2 on the modified Medical Research Council (mMRC) dyspnoea scale. The prevalence of dyspnoea was estimated for each of the study sites and compared across countries and world regions. Multivariable logistic regression was used to assess the association of dyspnoea with lung function in each site. Results were then pooled using random-effects meta-analysis.

RESULTS

The prevalence of dyspnoea varied widely across sites without a clear geographical pattern. The mean prevalence of dyspnoea was 13.7 % (SD=8.2 %), ranging from 0 % in Mysore (India) to 28.8 % in Nampicuan-Talugtug (Philippines). Dyspnoea was strongly associated with both spirometry restriction (FVC

CONCLUSION

The prevalence of dyspnoea varies substantially across the world and is strongly associated with lung function impairment. Using the mMRC scale in epidemiological research should be discussed.

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Key Words

• Breathlessness
• Dyspnoea
• Lung function
• Spirometry

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MESH Headings Collapse

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SUBUNGUAL HEMATOMA OVERLAPPING WITH SUBUNGUAL LOCATED FOCAL MELANOCYTIC HYPERPLASIA: DERMATOSURGICAL APPROACH AS OPTIMAL TREATMENT CHOICE

Subungual lesions present a serious challenge for clinicians. The following factors can cause certain problems in interpreting the data: 1) Changes in lesion morphology over time: It may indicate the presence of a malignant lesion (increased pigmentation over time and lack of distal growth) but may actually be a benign lesion (chronic persistent subungual hematoma). 2) Patient's medical history can be misleading or difficult to verify, especially in problematic patients, or those with mental health problems or communication disorders (e.g., Asperger's syndrome, autism, schizoid psychosis, etc.). 3) The morphology of the lesion itself can be difficult to determine in the presence of simultaneously overlapping lesions. These patient dilemmas primarily concern the differentiation between subungual hematomas from subungual melanomas. The clinicians's concerns are based on the potential for metastasis and the risk of significantly worse prognosis for patients affected by nail biopsy. We present a 19-year-old patient with a subungual pigmented lesion with a clinical/dermatoscopic suspicion for subungual melanoma. Primary complaints for about 3-4 months. Intensified pigmentation and increase in size within two months led to a partial surgical resection of the nail plate and nail bed, followed by adaptation of the wound edges with single interrupted sutures. The histopathological finding was indicative of a subungual hematoma located above a focal melanocytic hyperplasia of the nail bed, clear resection lines. After a literature review, we believe that this is the first case of a patient with simultaneously present subungual benign focal melanocytic hyperplasia overlapping with a chronic persistent subungual hematoma.

CONGRESS REPORT OF THE 5TH NATIONAL CONGRESS OF THE BULGARIAN SOCIETY FOR DERMATOLOGIC SURGERY, SOFIA, 11TH MARCH 2023 WITH MAIN TOPICS: NITROSAMINES AS MOST POWERFUL TRIGGER FOR SKIN CANCER DEVELOPMENT AND PROGRESSION/PERSONALISED ONE STEP MELANOMA SURGERY AS POSSIBLE SKIN CANCER TREATMENT OPTION

Deciphering the mutational pattern of skin tumours, remains a major challenge for clinicians and researchers. Over 80% of mutations in tumours are acquired, which in practice also means preventable. The surgical treatment of skin cancer and cancer in general is a worldwide, unsolved but at the same time not unsolvable problem. The problem concerning the dilemma of acquired mutations lies in the circumstance of their being allowed and subsequently treated. A more logical solution would be to eliminate the problem by making contact with mutagens in drugs public, clarifying it, studying it in detail and definitively stopping it. At present, there is an alarming and unexplained tendency worldwide : 1) Potential acquired mutations, caused in all probability by contact with known exogenous mutagens- the nitrosamines in most commonly prescribed drugs, are allowed to occur. 2) And subsequently, the diseases generated by them- treated (at a later stage) by multiple surgical interventions and unjustifiably expensive targeted therapy; 3) Mutagens - such as nitrosamines for example, to be in a permissive or possibly permissive availability regime. Moreover, this permissible availability turns out to be ubiquitous and affects the most common medicines worldwide: metformin, ranitidine, propranolol, rifampicin, irbesartan, olmesartan, valsartan, telmisartan, eprosartan, losartan, ACE inhibitors, thiazide diuretics, etc. In certain geographical regions, there is almost no patient taking this type of medication who has not had at least one tumour detected. These significant correlations (nitrosamines/cancer) are labeled by the regulatory institutions as possible, probable, or not currently relevant. But in spite of ˝this inconclusiveness˝, the drugs, containing nitrosamines, are withdrawn from the pharmaceutical market: quickly and quietly, despite the fact that ˝they did not pose a threat˝. The FDA was the only organization and the most important regulatory body worldwide, which lifted the veil from this ominous picture back in 2018: nitrosamines in blood medicines and cancer risk. Unfortunately, at the moment, the problems with this issue are proving to be more than the solutions, and at the same time it remains completely unclear who is to blame for this 'sporadic contamination': the packaging of the drug, the humidity in the rooms where the preparations are stored or the synthesis process itself - the explanations are divergent, the responsibility is blurred. This fuzzy liability does not affect the manufacturers and distributors of the preparations/nitrosamines themselves in the manner required by law for this (mis)act. The Bulgarian Society of Dermatological Surgery remains to be the only organization worldwide that for the 5th consecutive year continues to seek solutions to the above-mentioned problems by: 1) Officialising all cases of skin tumors (but not only) occurring after intake of nitrosamine-contaminated drugs, 2) also officialising a significant number of cases of patients with cutaneous melanomas treated by the one-stage surgical removal method within one surgical session (OSMS). The main priorities of the organization remain: 1) the complete elimination of nitrosamines from drugs worldwide, 2) the optimization of melanoma surgical treatment guidelines with the goal of treatment within 1 surgical session: for thin melanomas, dysplastic nevi and melanoma in situ, a surgical margin of safety of 1 cm in all directions and without detection and removal of the draining sentinel lymph node. Whereas for medium and thick melanomas, the focus should be directed to the following recommendation: 2 cm surgical margin of safety plus detection and removal of the draining lymph node within one surgical session. The indication for the surgical removal of these lesions should be made on the basis of radically different criteria from those used to date by the AJCC/EJC, namely: based on 1) clinical presentation/ clinical morphology, 2) dermatoscopic finding, and if there is a melanoma suspected lesion with possible tumour thickness greater than 1 mm , 3) ultrasonographic measurement for preoperative determination of tumor thickness should be additionally performed. The methodology is applicable in up to 80% of cases, excluding only some rare findings such as: amelanotic cutaneous melanomas, cutaneous melanomas with regression zones or those with localization in the neck and head. However, after careful individual assessment and a subsequent selected approach, even these exceptions could be included in the innovative algorithm for one step surgical removal of cutaneous melanomas. The resulting problems of not resolving these two dilemmas could lead to: 1) Generation of skin cancer (but not only), through the availability of nitrosamines in drugs. 2) Unnecessary and stressful /surgeries for the patients- 2 in number, which not infrequently lead to complication of their status (due to delay of histopathological analysis/ desire for second opinion/ delay regarding the timeframe for the second surgical intervention/ uncertainty regarding the resection lines within the first intervention/ failure to respect the recommended surgical security resection margins already within the first surgical session, etc.). 3) Huge additional costs to health care systems on the order of probably/roughly calculated about $50 billion per year. Resolution of these two dilemmas would likely result in a dramatic drop in cancer incidence worldwide and a significant improvement in the effectiveness/efficiency of surgical treatment for cutaneous melanoma.

Early aortic valve replacement in asymptomatic severe aortic stenosis with preserved ejection fraction

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. Specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic AS patients with preserved ejection.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severeAS with preserved ejection fraction criteria. Random-effects meta-analysis was performed.

Results

Eight studies were included in which two were randomized clinical trials. A total of 2672 patients were included, providing a 642 pooled death events (327 in early-AVR and 941 in watchful waiting). In our meta-analysis, early-AVR revealed a significant lower all-cause mortality (pooled OR, 0.39; 95% CI [0.30, 0.51], P<0.01; I2=47%). Additionally, the early-AVR group presented a lower rate of cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I2=64%). Both strategies had similar rate of stroke (pooled OR, 1.30; 95% CI [0.39, 4.27], P=0.67; I2=0%) and myocardial infarction (pooled OR, 0.49; 95% CI [0.14, 1.78], P=0.28; I2=0%). Heart Failure hospitalizations presented a lower trend early-AVR group (pooled OR, 0.22; 95% CI [0.05, 1.08], P=0.36; I2=36%).

Conclusion

Our pooled data suggests that early-AVR strategy is preferable for asymptomatic severe AS patients with preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

Early intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. However, the specific timing of intervention for asymptomatic patients with severe AS remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic patients with AS.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for both interventional or observational studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

Results

Thirteen studies were included in which two were randomised clinical trials. A total of 4,679 patients were included, providing a 1,268 pooled death events (327 in early AVR and 941 in WW). Our meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group, although with a moderate amount of heterogeneity between studies in the magnitude of the effect (pooled odds ratio [OR], 0.41; 95% confidence interval [CI] 0.34, 0.50, P<0.01; I2=60%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P<0.01; I 2=64%) and heart failure hospitalisations (pooled OR 0.19; 95% CI [0.10, 0.39], P<0.01, I2=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI [0.73, 2.29], P=0.36, I2=0%) and myocardial infarction (pooled OR 0.49; 95% CI [0.19, 1.27], P=0.14, I2=0%).

Conclusions

Our pooled data suggest that an early-AVR strategy is preferable for asymptomatic patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.

Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

Background

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation.

Purpose

To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed.

Results

Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P<0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P<0.01; I2=27%).

Conclusions

Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention.

Funding Acknowledgement

Type of funding sources: None.

The psychological determinants of internet gaming disorder: Vulnerability to stress, psychological well-being, and comorbidity

Introduction

A variety of psychological determinants, such as vulnerability to stress, low levels of psychological well-being and several comorbidities, have been hypothesized to play a role in the development, and maintenance of Internet Gaming Disorder (IGD). However, evidence has been insufficient to sustain an overarching model of the causal pathways leading to IGD.

Objectives

. This study aimed to depict a model of the causal links between vulnerability to stress, psychological well-being, and symptoms of common mental disorders (e.g., depression, generalized anxiety, phobic anxiety, obsessive-compulsive disorder, somatization, and hostility).

Methods

. A community-based sample of Portuguese gamers (N = 153; Mage = 21.92; 15.29% female) completed measures of IGD (IGDS9-SF), mental health (SCL-90-R), psychological well-being (EBEP), and vulnerability to stress (23QVS). A machine learning algorithm – Greedy Fast Causal Inference – was used to infer a model of the causal pathways linking those psychological determinants to IGD.

Results

. Hostility and psychological well-being were directly involved with a subgroup of IGD symptoms (i.e., gaming used as escape, tolerance, withdrawal, and loss of control). Stress vulnerability and symptoms of mental disorders were only indirectly implicated in the causal pathways leading to IGD.

Conclusions

. It is likely that several psychological factors implicated in the causal pathways leading to IGD, have not been yet identified. Future research should directly test specific models of the causal pathways involved in the development and maintenance of IGD symptoms.

Disclosure

No significant relationships.

Machine learning and glioma imaging biomarkers

AIM

To review how machine learning (ML) is applied to imaging biomarkers in neuro-oncology, in particular for diagnosis, prognosis, and treatment response monitoring.

MATERIALS AND METHODS

The PubMed and MEDLINE databases were searched for articles published before September 2018 using relevant search terms. The search strategy focused on articles applying ML to high-grade glioma biomarkers for treatment response monitoring, prognosis, and prediction.

RESULTS

Magnetic resonance imaging (MRI) is typically used throughout the patient pathway because routine structural imaging provides detailed anatomical and pathological information and advanced techniques provide additional physiological detail. Using carefully chosen image features, ML is frequently used to allow accurate classification in a variety of scenarios. Rather than being chosen by human selection, ML also enables image features to be identified by an algorithm. Much research is applied to determining molecular profiles, histological tumour grade, and prognosis using MRI images acquired at the time that patients first present with a brain tumour. Differentiating a treatment response from a post-treatment-related effect using imaging is clinically important and also an area of active study (described here in one of two Special Issue publications dedicated to the application of ML in glioma imaging).

CONCLUSION

Although pioneering, most of the evidence is of a low level, having been obtained retrospectively and in single centres. Studies applying ML to build neuro-oncology monitoring biomarker models have yet to show an overall advantage over those using traditional statistical methods. Development and validation of ML models applied to neuro-oncology require large, well-annotated datasets, and therefore multidisciplinary and multi-centre collaborations are necessary.

COPD and Cardiovascular Disease

COPD is one of the major public health problems in people aged 40 years or above. It is currently the 4th leading cause of death in the world and projected to be the 3rd leading cause of death by 2020. COPD and cardiac comorbidities are frequently associated. They share common risk factors, pathophysiological processes, signs and symptoms, and act synergistically as negative prognostic factors. Cardiac disease includes a broad spectrum of entities with distinct pathophysiology, treatment and prognosis. From an epidemiological point of view, patients with COPD are particularly vulnerable to cardiac disease. Indeed, mortality due to cardiac disease in patients with moderate COPD is higher than mortality related to respiratory failure. Guidelines reinforce that the control of comorbidities in COPD has a clear benefit over the potential risk associated with the majority of the drugs utilized. On the other hand, the true survival benefits of aggressive treatment of cardiac disease and COPD in patients with both conditions have still not been clarified. Given their relevance in terms of prevalence and prognosis, we will focus in this paper on the management of COPD patients with ischemic coronary disease, heart failure and dysrhythmia.

Asthma-COPD overlap: A Portuguese survey

INTRODUCTION

The overlap between asthma and chronic obstructive pulmonary disease (COPD) (ACO) has been discussed for many years but clinical recommendations for this entity have been diverse. This study is intended to reach a consensus on diagnosis, treatment and patient orientation for ACO, within the Portuguese medical community.

METHODS

This study was conducted by a multidisciplinary panel of experts from three distinct medical specialties (Pulmonology, Family Medicine and Immunoallergology). This panel selected a total of 190 clinicians, based on their expertise in obstructive airway diseases, to participate in a Delphi structured survey with three rounds of questionnaires. These results were ultimately discussed, in a meeting with the panel of experts and some of the study participants, and consensus was reached in terms of classification criteria, treatment and orientation of ACO patients.

RESULTS

The majority of clinicians (87.2%) considered relevant the definition of an overlap entity between asthma and COPD. A consensus was achieved on the diagnosis of ACO - presence of simultaneous clinical characteristics of asthma and COPD together with a fixed airflow obstruction (FEV1/FVC<0.7) associated with 2 major criteria (previous history of asthma; presence of a previous history of smoking exposure and/or exposure to biomass combustion; positive bronchodilation test (increase in FEV1 of at least 200mL and 12%) on more than 1 occasion) plus 1 minor criteria (history of atopy; age ≥40 years; peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes); elevation of specific IgEs or positive skin tests for common allergens). A combination of inhaled corticosteroid (ICS) with long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA) was considered as first line pharmacological treatment. Triple therapy with ICS plus LABA and LAMA should be used in more severe or symptomatic cases. Non-pharmacological treatment, similar to what is recommended for asthma and COPD, was also considered highly important. A hospital referral of ACO patients should be made in symptomatic or severe cases or when there is a lack of diagnostic resources.

CONCLUSIONS

This study highlights the relevance of defining ACO, within the Portuguese medical community, and establishes diagnostic criteria that are important for future interventional studies. Recommendations on treatment and patient's orientation were also achieved.