Interstitial lung diseases: an observational study in patients admitted in "Marius Nasta" Institute of Pulmonology Bucharest, Romania, in 2011

Interstitial lung diseases (lLD) are a large group of rare diseases, with difficult diagnosis and management. Very little is known about prevalence, diagnosis and management of ILDs in Romania. This study aims to gather information on how ILDs are diagnosed and managed in Romania, focusing on a tertiary hospital with expertise and equipment needed for accurate diagnosis. We analyzed retrospectively the files of patients admitted with ILD in 2011 in "Marius Nasta" Institute of Pulmonology Bucharest. There were 178 eligible patient files with ILDs and 186 sarcoidosis cases. The ILD diagnosis were: 41 cases idiopathic pulmonary fibrosis (IPF), collagen disease associated ILD (29 cases), hypersensitivity pneumonia (19 cases), alveolar proteinosis (9 cases), cryptogenic organizing pneumonia (9 cases), undefined ILD (46 cases), other (25 cases). The investigations used for the diagnosis were: chest X-ray (100%), spirometry (157pts, 88.21%), diffusion capacity (127 pts, 71.43%, broncho-alveolar lavage (92 pts, 51.69%), CT scan (141 pts, 79.22%), lung biopsy (26 pts, 14.6%), similar to other European centers, but fewer lung biopsies are performed. There is need for a prospective registration of ILD cases in a national registry, for creating local guidelines for diagnosis of ILDs, to improve the suspicion of ILD and referring of patients to specialized centers. Diagnosis can be improved by a multidisciplinary approach of each case, involving the clinician, the radiologist, the pathologist and the thoracic surgeon.

Benefits of a 7-week outpatient pulmonary rehabilitation program in COPD patients

BACKGROUND

Respiratory rehabilitation programs (RR) are essential tools in the management of COPD.

AIM

We present the results of a 7-week outpatient rehabilitation program in terms of dyspnea, exercise tolerance and quality of life.

MATERIAL AND METHOD

The following parameters were evaluated before and after RR: dyspnea (mMRC scale), pulmonary function (FEVI, RV- residual volume), exercise tolerance (6MWT- 6 minutes walk test, CPET - cardiopulmonary exercise test), quality of life (SGROQ questionnaire). The RR program was outpatient, hospital based (7 weeks, 3 sessions/ week) and included: exercise training, therapeutic education, and psychological support.

RESULTS

25 patients, COPD stage II-IV GOLD (mean FEVI 44.5 +/-13% predicted), mean age 60.4 +/-12 years, 7 females, average BMI 27.14+/-4 kg/m2, average RV residual volume 221.55+/-86% predicted. Mean 6MWTdistance: 407.48 +/- 84 m and mean maximum power (Pmax) obtained on CPET: 75.67+/-30 Watts. All patients were symptomatic with significant dyspnea (3.06+/-0.7 on mMRC scale) and showed a significant impairment of quality of life: SGRO score 46.23+/- 14. At the end of RR program: dyspnea decreased with 0.67points on mMRC scale (p = 0.000), 6MWT distance increased with 58.5 m (p = 0.0071), Pmax obtained during CPET increased with 11.2 W, without reaching statistical significance (p> 0.05). SGRO score decreased by 5.59 points (p = 0.02). There were no significant improvements in FEV1 and RV values (p> 0.05).

CONCLUSION

In our COPD patients, the 7 week outpatient rehabilitation program was effective, leading to improvement ofsymptoms, exercise tolerance and quality of life.

[Romanian national registry for interstitial lung diseases and sarcoidosis (REGIS): rationale and methods]

Interstitial lung diseases (ILD) are a group of extremely heterogeneous conditions (over 200), with low prevalence, but in most cases with severe impact on the quality of life and survival of the patients. The ILD group comprises: idiopathic pulmonary fibrosis, sarcoidosis, hypersensitivity pneumonitis, colagen diseases, vasculitis, eosinophilic pneumonia etc. The prevalence of these diseases is unknown in Romania; the accurate diagnosis needs access to special investigations and expertise with this group of diseases. The authors propose the initiation of a National Registry for Interstitial Lung Diseases and Sarcoidosis (REGIS), based on the lessons learned from other national ILD) registries, which should allow building-up an extended clinical expertise in ILD, evaluating epidemiological data, creating an educational platform for young physicians, better understanding of the outcome and prognosis of these diseases, shaping Romanian Guidelines for the diagnosis and management of ILD, using the data base for clinical research. The registry is started as a pilot in two Romanian centres: "Marius Nasta" Institute of Pneumology in Bucharest and Pneumology Clinic, "Victor Babey" Infectious Diseases Hospital Timişoara. After refining the inclusion criteria for the data base, editing guidelines for ILD diagnosis and launching the registry website, other Romanian centres with interest in ILD will also be able to feed information.

[Functional evaluation before lung resection for cancer--international recommendations]

Complications and disability after radical therapy for lung cancer can be predicted by preoperative functional evaluation. Functional tests and threshold values of the parameters have been described and included in a well-validated algorithm, ensuring functional reserve evaluation of candidates for pulmonary resection. There are no defined tests or cut-off values to provide predictions of complications after chemo-radiotherapy or limited pulmonary resections.

[Tuberculosis in Romania. Problems and solutions]

The analysis of the Management Unit of the National TB Programme (NTP) database, together with the reports of the TB county managers, allowed to the authors to identify some weaknesses of TB control in Romania in the recent years and to propose the appropriate measures.

PROBLEMS

The marked decrease in the reduction of TB cases reported annually from 2,761 in 2005-2006, to 145 in 2007-2008 and the stagnation of mortality rate: 7.5 per ten thousand in 2007 and 7.6 per ten thousand in 2008. Deficiencies in data recording and reporting through informatic system of the NTP. Lack of financial resources for system maintenance and upgrade. Deficiencies in monitoring and control of mycobacterium resistance to antituberculous drugs phenomenon at national level. Sensitivity testing only for a small percentage of culture confirmed new TB cases (21%). Higher percentage of MDR in new TB cases compared to the results of national survey of mycobacterium drug resistance 2003-2004. Lack of personnel: 16 TB dispensaries without any pulmonologist, vacancies for 259 doctors, 436 nurses and 433 auxiliary personnel. Important deficiencies in the NTP network's infrastructure and logistics countrywide. Discontinuities in the supply with first and second line antituberculous drugs resulting in interruption of treatments. Lack of an officially endorsed protocol for the diagnosis, treatment and monitoring of cases with TB/HIV co-infection. Solutions: Revitalization of monitoring-supervision activities of the NTP running countrywide, provision with necessary financial resources to perform the scheduled visits in counties. Providing maintenance and upgrade of the informatic system for data collection. Implementation of the necessary measures in order to attract and maintain the personnel in the NTP network. Conduct the national survey of mycobacterium susceptibility to first and second line antituberculous drugs and drug susceptibility testing of the most culture confirmed TB cases. Restore the centralized procurement of TB drugs. Finalization and official endorsement of the protocol for TB/HIV co-infection initiated in 2004.

[Cancer of the head of pancreas--resection vs. palliative surgery]

Pancreatic cancer remains a disease with high mortality. The unspecific symptoms for a long time make the diagnostic difficult. Between 1995-2004, only 85 from 465 patients with this diagnosis, had pancreatic resection. To them, we performed Whipple pancreaticoduodenectomy (60), pylorus preserving pancreaticoduodenectomy (15), pancreatico-duodenectomy with preserving of duodenum (2), pancreaticoduodenectomy with associated resections (5), subtotal pancreatico-duodenectomy (30). The reconstruction after pancreatic resection was pancreatico-jejuno anastomosis (26) and pancreatico-gastro-anastomosis (59). Morbidity was about 34% and the mortality was about 9%.

[Bronchoalveolar lavage findings in the pulmonary impairment related to systemic sclerosis]

The main objective of the study was to evaluate the relationship between the findings of the bronchoalveolar lavage (BAL) and the lung function in patients with systemic sclerosis and subsequent pulmonary impairment. The study was retrospective and included 17 cases with systemic sclerosis and pulmonary involvement investigated at "Marius Nasta" Institute. Bucharest, between January 1999-August 2001. Lung function assessment found the following: VC (% of predicted) = 82.5 +/- 14; DLCO (% of predicted) = 67.5 +/- 23.2. Cell count in BAL fluid showed: total number of cells x 10(6) = 11.5 +/- 6; lymphocytes (%) = 22.9 +/- 15.4; neutrophils (%) = 15.2 +/- 13.4; eosinophils (%) = 1.9 +/- 0.9; macrophages (%) = 58.1 +/- 19.8. We also compared the cell pattern according to DLCO value: the patients with DLCO > 80% had increased levels of eosinophils (5.2 +/- 4.9 vs 0.9 +/- 0.2, p = 0.007) while the group with DLCO < 80% presented significantly higher levels of neutrophils (16.1 +/- 15.5 vs 12.6 +/- 2.8, p = 0.003) compared to the group with normal lung function.

CONCLUSIONS

Patients with systemic sclerosis and normal lung function present an increased level of eosinophils in BAL fluid, suggesting a transitory alveolitis. In change, those with DLCO < 80% have a higher level of neutrophils, usually associated to pulmonary fibrosis. The investigation by BAL appears to be a reliable tool for the assessment of the pulmonary impairment related to systemic sclerosis.