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Introduction and objectives: Tracheal stenosis is a rare and challenging disease. Bronchoscopy is the gold standard for diagnosis and assessment but brings inherent risks. Spirometry is commonly used to access obstructions but is not always feasible due to patient related factors. We therefore considered impulse oscillometry (IOS) as a non-invasive method to quantify airway obstruction and its potential use for diagnosis and follow-up of tracheal stenosis. Materials and methods: Patients with confirmed tracheal stenosis were recruited between January 1st, 2015 and December 31st, 2016. Before bronchoscopy, all subjects underwent IOS and spirometry; for patients submitted to interventional bronchoscopy the same techniques were also performed after the procedure. We assessed the correlation between IOS measurements and airway narrowing as well as between IOS and spirometry values. Results: Twenty-one patients were included. Tracheal narrowing was inversely correlated with X5% (r −0.442, p 0.045) and positively correlated with FEV1/PEF (r 0.467, p 0.033). The stenosis length was inversely correlated with PEF and PEF% (r −0.729, p = 0.001 and r −0.707, p = 0.002, respectively). There was a strong correlation between spirometric and IOS values. We did not find any significant differences between pre- and post-intervention IOS values for patients assessed after interventional bronchoscopy. Conclusions: Our study showed a weak correlation between X5% and tracheal narrowing making it unclear whether IOS can be used for physiological assessment of patients with tracheal stenosis. Stenosis length correlated with PEF making it a potential predictor of successful surgical approach. The correlation between IOS and spirometric values makes IOS a potential alternative in patients with suspected tracheal stenosis who are not able to perform spirometry. Larger scale studies should clarify the role of IOS in this pathology. Keywords: Impulse oscillometry, Spirometry, Bronchoscopy, Tracheal stenosis

Introduction: Transbronchial lung cryobiopsy (TBC) has emerged as a diagnostic alternative to surgical lung biopsy in interstitial lung disease (ILD). Despite its less invasive nature, some associated complications have been described. Objective: To evaluate complications of TBC and associated factors. Methods: Prospective evaluation of all patients with ILD submitted to TBC in our centre. Clinicodemographic variables and factors associated to TBC complications were analyzed. The effect of the variables on the complication risk was evaluated by a logistic regression model. Results: Ninety patients were included (mean age 60 ± 13 years; 58.9% male). Twenty-two patients presented pneumothorax, 18 (81.8%) of which were treated with chest tube drainage [median air leak time: 1 day (IQR = 2)]. Grade 2 and 3 bleeding was observed in 13 (14.4%) cases. Presence of visceral pleura in the sample accounted for almost more than 10 times the odds of pneumothorax (OR = 9.59, 95% CI 2.95–31.17, p

Characteristics of never-smokers with lung cancer are still not fully clarified. The aim of this study was to compare never-smokers and ever-smokers with non-small cell lung cancer (NSCLC) regarding patient and tumor characteristics.All consecutive newly NSCLC patients with known smoking status diagnosed between 2011 and 2015 were included in this retrospective cohort study. Clinical, histological, and molecular characteristics were compared between ever-smokers and never-smokers.Of the 558 included patients, 125 (22.4%) were never-smokers. These patients were more likely to be female (74% vs. 7%, p .001), older (67 vs. 66 years-old, p = .019), and have adenocarcinoma (93% vs. 65%, p .001). Never-smokers took longer to seek medical care after the symptoms onset (3 vs. 2 months, p .001), regardless of the symptoms, histological type, or gender (OR: 1.2 [1.4-2.0]). The metastatic pattern was different in never-smokers: pleural metastases were more frequent (OR: 2.1 [1.1-4.0]), regardless of the histological type and gender. Never-smokers had a higher prevalence of ALK translocations (26% vs. 4%, p .001) and EGFR mutations (36% vs. 8%, p .001). The type of EGFR mutation was also significantly different between groups.Never-smokers with NSCLC present distinct demographic and clinical characteristics. The characteristics of tumor also differ between never-smokers and ever-smokers, which may suggest different carcinogenic pathways.

Metastatic lesions in the large bowel are rare. A case of single symptomatic colonic metastasis as first presentation of pulmonary mucoepidermoid carcinoma (MEC) is described. A 62-year-old male was admitted with constipation and rectal bleeding. Colonoscopy revealed extrinsic compression at sigmoid colon, and microscopy suggested a secondary origin. Subsequent chest computed tomography confirmed a right perihilar mass invading posterior mediastinum, carina and esophagus, and also a second consolidation on right lower lobe and ipsilateral mediastinal and subcarinal lymph nodes. After pathologic evaluation of a transthoracic biopsy specimen, the diagnosis of pulmonary high-grade MEC, stage IV (T4, N3, M1b - 7th ed. TNM), was established. Chemotherapy with carboplatin and paclitaxel was initiated, and disease progression occurred after two cycles with increasing colonic mass. Palliative surgery was rejected because of advanced stage, and the patient was submitted to palliative pelvic radiotherapy. Second-line chemotherapy with gemcitabine was initiated, but clinical status worsened and the patient died because of severe lung failure. Clinical, pathological and therapeutic aspects of this uncommon site of extrathoracic metastatic disease are discussed, emphasizing the important contribution of special stains and immunohistochemistry to the diagnosis.

Introduction: Immigrants may utilize health care services differently than other residents and may also have a greater risk for tuberculosis (TB). Objective: Identify barriers to healthcare access by immigrants, factors associated with these barriers, and discuss strategies that may reduce these barriers. Material and methods: Anonymous questionnaires were given to immigrants at National Immigrant Support Centres between 2015 and 2016. Barriers to healthcare were identified using logistic regression. Results: One-hundred and nineteen questionnaires were administered to immigrants, 9 of whom (8%) presented with TB while in Portugal. Twenty-one percent of immigrants reported barriers to healthcare access, and 69% had general practitioners (GPs). The presence of barriers to healthcare access was negatively associated with having a GP and with being married or in a de facto union. Conclusions: A considerable proportion of immigrants reported having difficulties accessing healthcare services in Portugal where legally these barriers are nonexistent. Certain factors were associated with these difficulties. Keywords: Tuberculosis, Immigration, Health services, Barriers

Introduction: In asthma, persistent symptoms and frequent exacerbations have a negative impact on quality of life, exercise tolerance and health status. Evidence of the benefit of pulmonary rehabilitation (PR) in asthma is less robust than in other chronic respiratory diseases such as COPD. Objectives: To evaluate the effects of PR in symptoms, exacerbations and pulmonary function. Methods: Retrospective study of all asthma patients (>18 years old) who participated in a PR program in 2013 and 2014 in our Unit of PR. The program comprised breathing and exercise training and patient education. Patients presenting other respiratory diseases and insufficient data were excluded. In patients who completed the training, dyspnoea, number of exacerbations and lung function were analysed and compared, one year before and after the program. Results: Twenty-six patients completed the program [mean age 65±12 years; 84.6% (n=22) female; 76.9% (n=20) non-smokers]. Following PR, 69.2% (n=18) of the patients showed improvement in dyspnoea (p=0.002) and 50.0% (n=13) showed a reduction of the total number of exacerbations (p=0.014). The number of emergency department admissions and the exacerbations without need of urgent healthcare use or hospitalization also decreased in, respectively, 23.1% (p=0.676) and 23.1% (p=0.059) of patients. Regarding pulmonary function there was an increase in FEV1%, PEF and FVC% after training, with statistical significance only for FVC (p=0.031). Conclusions: These results suggest a benefit of PR in patients with uncontrolled asthma. In these patients, PR improves symptoms, reduces the number of exacerbations and could improve pulmonary function.

Introduction: In the past, lung cancer was assumed to be a tobacco related disease. Studies about lung cancer in never-smokers (NS) are still limited. Aim: To compare ever-smokers (ES) and NS with non-small cell lung cancer (NSCLC) regarding patient and tumor characteristics. Methods: Retrospective study of patients with NSCLC diagnosed in our Lung Cancer Unit over 5 years. Patients were split in two groups: NS ( Results: 563 patients included: 78% men, mean age 66±11years. 126 (22%) were NS with mean age 69±12 years, mostly women (75%) with adenocarcinoma (93%). Regarding tumor mutations, EGFR mutations were tested in 100 NS (35% EGFR+) and ALK translocation in 43 patients (25% ALK+). Univariate analysis showed that NS with lung cancer were more often women (75% vs. 7%, p Conclusion: The prevalence of NS among patients with lung cancer (22% in our study) should increase our awareness of these patients. Lung cancer in NS seems to be a different disease compared to ES. Patients were mainly women, probably due to genetic, hormonal or ambient factors besides tobacco. EGFR and ALK mutations were significantly more frequent in NS, with obvious implications in treatment. EGFR mutations differ between groups, which may suggest different carcinogenic pathways.

Introduction: Continued smoking after lung cancer (LC) diagnosis is linked to adverse effects on treatment efficacy, life quality and survival. Objectives: To evaluate smoking patterns after LC diagnosis and its relation with clinical-demographic variables. Methods: All diagnosed LC patients followed in a Pulmonology Department between 1th and 31th December 2014, of a Portuguese tertiary hospital, which agreed to participate in our study, were selected. A questionnaire about smoking patterns was distributed to them. Clinical information was added by the attending physician. Results: Forty-seven patients were included (mean age 63±13 years; 33 male). At time of the inquiry 3 LC patients had active smoking habits (mean 44pack/year). Among variables analyzed (age, gender, comorbidities, histology, stage) only COPD was associated with continued smoking (p=0,014). Despite none of them were aware that continuing to smoke would decrease the effectiveness of the therapy, there was no significant statistical association (p=0,068). Among 32 ex-smokers at the time of inquiry, 15 smoked after LC diagnosis for a mean of 4±5 months, 3 of which after chemotherapy initiation (mean 1±0,8 month). Among the 15, 9 knew about consequences of maintaining smoking habits concomitant to therapy, but there was no impact in their decision (p>0,05). Of 12 non-smokers, 6 lived/worked with smokers. Conclusions: This population-based study indicated that smoking can persist long after initial diagnosis and even after treatment initiation. Continued smoking after LC diagnosis was associated with concomitant COPD. Characteristics associated with quitting remained uncertain in our population, due to a small population sample.

Introduction: Staging of lung cancer is an important predictor of survival. The last review of the TNM staging divides the M1 descriptor into M1a (pulmonary contralateral metastases or pleural/pericardial effusion) and M1b (extrapulmonary metastases). Despite this division, patients staged M1a or M1b are categorized as stage IV. Aims: To analyze the survival of patients with non-small cell lung cancer (NSCLC) with and without metastases and to compare the survival of patients classified as M1a and M1b. Methods: Retrospective study in patients diagnosed with NSCLC in a Lung Oncology Unit between 2010 and 2011. Patients were divided into 3 groups (M0, M1a, M1b). The median survival was estimated by Kaplan-Meier method and other prognostic factors were evaluated by Cox regression analysis. Results: 216 patients included, mean age 65±11 years, 73% men. The most common histological type was adenocarcinoma (64%). 104 (48%) were in stage IV; 17% were M1a, 31% M1b. There were no statistically significant differences between M0, M1a and M1b groups regarding age, gender, smoking history and histological type. At the time of the study, 47 (22%) patients were alive. The median survival of patients M0, M1a and M1b was 22, 11, and 6 months, respectively (p Other factors associated with reduced survival were older age (HR=1.036, p Conclusions: NSCLC prognosis of M1a and M1b patients is different. M1a patients have a median survival almost twice longer than M1b patients (11 vs. 6 months). We suggest that stage IV may be divided into IVa and IVb in order to improve the predictive accuracy of TNM staging. In addition, male gender and older age seems to be associated with worse prognosis.

Introduction: In non-small cell lung cancer (NSCLC), translocation ALK/EML4 (ALK+) seems to be more frequent in young women, non-smokers, non-squamous tumors and advanced stages. ALK+ studies are rare in Portuguese patients. Aims: To study the rate of ALK+ in Portuguese patients and to find predictors of ALK+. Methods: Retrospective study with non-squamous NSCLC patients in a Lung Oncology Unit (2012 to 2014). Sequencing of 18-21 EGFR exons was done followed by FISH analysis of ALK/EML4 in wild-type EGFR (EGFR-). Patients were divided into 2 groups: ALK+ and ALK-. Rate of ALK+ was determined and groups were compared. Results: 304 patients included, EGFR sequenced in 270, 215 EGFR-. Of these, ALK/EML4 was analyzed in 115 patients: 12 (10%) ALK+, 91 ALK-, 12 (10%) inconclusive. Of 103 patients ALK+/ALK-, mostly were men (80%), smokers/ex-smokers (78%), stage IIIb or IV at diagnosis (67%); mean age: 68±12 years. Patients: ALK+ were mostly men (67%), non-smokers (50%), mean age 58±14 years. There was a statistically significant association between ALK+ and younger age (58±14 vs. 70±11 years, p=0.013) and a negative association with smoking (18% vs. 50%, p=0.027). No statistical differences in gender, performance status and stage at diagnosis. Conclusion: In literature, prevalence of ALK+ is 4% and may reach 30% in non-smokers EGFR- patients. In this study, 10% of EGFR- patients tested for ALK/EML4 were ALK+ and this was more frequent in younger non-smokers. The inadequacy of samples was a problem, hindering ALK/EML4 results in 10% of cases. If possible, AKL/EML4 analysis should be done to all non-squamous NSCLC in advanced stage and considered in early stages, for better molecular characterization and therapeutic orientation.

Background: Hospital-acquired infections (HAI) can be defined as those occurring after 48 hours of hospital admission, 30 days of discharge or 30 days of an operation without prosthesis and 1 year if placement of prosthesis. They affect 1 in 10 patients admitted to hospital. Purpose: The aim of this study was to characterize, find predictors and evaluate the impact of HAI. Methods: We carried out an observational prospective study that included all patients admitted in the Pulmonology Department of a portuguese central hospital between October and December 2014. Socio-demographic variables, comorbidities, cause of admission, presence of infection and its nature (HAI or community acquired-CAI), microbiologic findings and mortality were recorded. Results: There were 235 patients included: mean age 63±1.7 years, 59.6% men. Infection prevalence was 81%: 11.1% HAI and 87.4% CAI. An aetiological agent was found in 15.3% of all infections, 52.3% of HAI, and 11% of CAI. The most frequent agents were Haemophilus influenzae and Legionella pneumophila in CAI and Staphylococcus aureus , Pseudomonas aeruginosa and Acinetobacter baumann ii in HAI. Predictors of HAI were reduced mobility (p=0.032), malnutrition (OR 5.37; p=0.047), neoplastic disease (OR 5.65; p=0.001) and immunosuppression (OR 5.65; p=0.005). Comparing with CAI HAI was associated with higher mortality (OR 4.65; p=0.032) and length of hospitalization (p=0.004). Conclusions: HAI is associated with a higher mortality and increased hospitalization duration. Risk factors for HAI such as malnutrition, immunosuppression, and presence of neoplastic disease should be evaluated at admission and infection control measures should be taken.

RATIONALE Carcinoid tumors are derived from neuroendocrine cells and are most frequently found in the gastrointestinal tract and bronchopulmonary system. They are generally characterized by an indolent clinical course but may in some instances spread to regional lymph nodes or to distant sites. Subcutaneous metastases of carcinoid tumors are extremely rare; there are only few cases reported in the literature and the site of the primary tumor was mainly the gastrointestinal tract. Also, the diagnosis of this type of lesions many years after the surgical resection of the pulmonary carcinoid (PC) could be a challenge for clinicians. PATIENT CONCERNS A nonsmoker woman diagnosed with a atypical carcinoid stage IA2 maintained follow-up at our institution. Seven years later she incidentally detected a subcutaneous nodular lesion in the lumbar region. DIAGNOSES A positron emission tomography-computed tomography (PET/CT) was performed and showed pathological uptake of the refered lesion. An excisional biopsy was performed and with the support of immunohistochemistry the diagnosis of a subcutaneous metastasis from a pulmonary atypical carcinoid was made. INTERVENTIONS The patient initiated chemotherapy with carboplatin plus etoposide and complied 4 cycles of treatment. OUTCOMES She maintained tight follow-up at our center and for 12 months there were no signs of relapse. LESSONS This extremely rare case highlights the difficulties in the differential diagnosis and the importance of diagnostic tests as PET/CT and immunohistochemistry in the establishment of a diagnosis. Physicians should be aware of signs of skin metastasis from lung malignancies even if the prognosis is good or many years have passed since the surgical resection.

Metastatic lesions in the large bowel are rare. A case of single symptomatic colonic metastasis as first presentation of pulmonary mucoepidermoid carcinoma (MEC) is described. A 62-year-old male was admitted with constipation and rectal bleeding. Colonoscopy revealed extrinsic compression at sigmoid colon, and microscopy suggested a secondary origin. Subsequent chest computed tomography confirmed a right perihilar mass invading posterior mediastinum, carina and esophagus, and also a second consolidation on right lower lobe and ipsilateral mediastinal and subcarinal lymph nodes. After pathologic evaluation of a transthoracic biopsy specimen, the diagnosis of pulmonary high-grade MEC, stage IV (T4, N3, M1b - 7th ed. TNM), was established. Chemotherapy with carboplatin and paclitaxel was initiated, and disease progression occurred after two cycles with increasing colonic mass. Palliative surgery was rejected because of advanced stage, and the patient was submitted to palliative pelvic radiotherapy. Second-line chemotherapy with gemcitabine was initiated, but clinical status worsened and the patient died because of severe lung failure. Clinical, pathological and therapeutic aspects of this uncommon site of extrathoracic metastatic disease are discussed, emphasizing the important contribution of special stains and immunohistochemistry to the diagnosis.