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Rationale: Airway remodeling in asthma comprises increased airway smooth muscle (ASM), an alteration linked to airway hyperresponsiveness and disease severity. Experimental studies showed that T cells adhere to ASM through vascular cell adhesion molecule-1 (VCAM-1) and drive ASM growth through direct contact between the T cells and smooth muscle alpha-actin (alpha-SMA)(+) cells. Objectives: To support the hypothesis of a T-cell/alpha-SMA(+) cell contact mechanism of ASM remodeling in asthma, using bronchial biopsies. Methods: We performed quantitative morphology on T cells, proliferating cell nuclear antigen (PCNA), alpha-SMA, and VCAM-1 on biopsies from subjects with moderate and severe asthma and healthy control subjects. Measurements and Main Results: We demonstrate ASM cell proliferation and infiltration by T cells in proportion to severity in the subjects with asthma. T cells localized with alpha-SMA(+)PCNA(+) cells, suggesting direct intercellular contact and a relationship with alpha-SMA(+) cell proliferation. Furthermore, the subjects with asthma developed a proliferating compartment of subepithelial alpha-SMA(+), nonorganized airway contractile elements (NOACE), suggesting a phenotype gradient from undifferentiated cells to smooth muscle-like cells. T-cell juxtaposition events were also observed in this compartment and correlated to its mass. The subjects with asthma showed VCAM-1 expression in postcapillary venules and clusters of VCAM-1 immunoreactivity in ASM and NOACE, consistent with a role of VCAM-1 in T-cell/alpha-SMA(+) cell interaction. Conclusions: T cells may induce alpha-SMA(+) cell proliferation through direct intercellular contact. NOACE may in part contribute to ASM growth through differentiation and translocation of alpha-SMA(+) cells. The findings support the role of the T cell in ASM remodeling in asthma. [ABSTRACT FROM AUTHOR]

Background: Fuel oil-derived volatile organic compounds (VOCs) inhalation is associated with accidental marine spills. After the Prestige petroleum tanker sank off northern Spain in 2002 and the Deepwater Horizon oil rig catastrophe in 2009, subjects involved in environmental decontamination showed signs of ongoing or residual lung disease up to 5 y after the exposure., Objectives: We aimed at investigating mechanisms driving persistent respiratory disease by developing an animal model of inhalational exposure to fuel oil-derived VOCs., Methods: Female Wistar and Brown Norway (BN) rats and C57BL mice were exposed to VOCs produced from fuel oil mimicking the Prestige spill. Exposed animals inhaled the VOCs 2 h daily, 5 d per week, for 3 wk. Airway responsiveness to methacholine (MCh) was assessed, and bronchoalveolar lavage (BAL) and lung tissues were analyzed after the exposure and following a 2-wk washout., Results: Consistent with data from human studies, both strains of rats that inhaled fuel oil-derived VOCs developed airway hyperresponsiveness that persisted after the washout period, in the absence of detectable inflammation in any lung compartment. Histopathology and quantitative morphology revealed the development of peripherally distributed pulmonary emphysema, which persisted after the washout period, associated with increased alveolar septal cell apoptosis, microvascular endothelial damage of the lung parenchyma, and inhibited expression of vascular endothelial growth factor (VEGF)., Discussion: In this rat model, fuel oil VOCs inhalation elicited alveolar septal cell apoptosis, likely due to DNA damage. In turn, the development of a peculiar pulmonary emphysema pattern altered lung mechanics and caused persistent noninflammatory airway hyperresponsiveness. Such findings suggest to us that humans might also respond to VOCs through physiopathological pathways different from those chiefly involved in typical cigarette smoke-driven emphysema in chronic obstructive pulmonary disease (COPD). If so, this study could form the basis for a novel disease mechanism for lasting respiratory disease following inhalational exposure to catastrophic fuel oil spills. https://doi.org/10.1289/EHP4178.

Background: The relationship between clinical judgment and the pneumonia severity index (PSI) score in deciding the site of care for patients with community-acquired pneumonia (CAP) has not been well investigated. The objective of the study was to determine the clinical factors that influence decision-making to hospitalize low-risk patients (PSI ≤2) with CAP., Methods: An observational, prospective, multicenter study of consecutive CAP patients was performed at five hospitals in Spain. Patients admitted with CAP and a PSI ≤2 were identified. Admitting physicians completed a patient-specific survey to identify the clinical factors influencing the decision to admit a patient. The reason for admission was categorized into 1 of 6 categories. We also assessed whether the reason for admission was associated with poorer clinical outcomes [intensive care unit (ICU) admission, 30-day mortality or readmission]., Results: One hundred and fifty-five hospitalized patients were enrolled. Two or more reasons for admission were seen in 94 patients (60.6%), including abnormal clinical test results (60%), signs of clinical deterioration (43.2%), comorbid conditions (28.4%), psychosocial factors (28.4%), suspected H1N1 pneumonia (20.6%), and recent visit to the emergency department (ED) in the past 2 weeks (7.7%). Signs of clinical deterioration and abnormal clinical test results were associated with poorer clinical outcomes (P<0.005)., Conclusions: Low-risk patients with CAP and a PSI ≤2 are admitted to the hospital for multiple reasons. Abnormal clinical test results and signs of clinical deterioration are two specific reasons for admission that are associated with poorer clinical outcomes in low risk CAP patients., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Muscular training is the corner stone of pulmonary rehabilitation programs., Aim: To evaluate the effects of a muscular training program - carried out on chronic obstructive pulmonary disease (COPD) subjects with antecedents of moderate or severe exacerbation - on exercise tolerance, Health Related Quality of Life (HRQoL) and illness prognosis., Design: A quasi-experimental study., Setting: University Hospital., Population: Twenty-five subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) degrees II, III and IV); with moderate or severe exacerbations and functional deterioration due to respiratory disability; with commitment and capacity to participate in the program. Subjects were selected by consecutive sampling., Methods: Subjects underwent 20 muscular training sessions consisting of 30 minutes of inspiratory muscle training, 15 minutes of warm-up protocol of upper limb exercises, 30 minutes of muscle training in ergometric cycle, 5 minutes of stretching protocol of lower limbs plus illness awareness. The main outcome measures were six minute walking test (6MWT), specific HRQoL questionnaires (St. Georges Respiratory Questionnaire (SGRQ), Chronic Respiratory Disease Questionnaire (CRDQ) and Airways Questionnaire 20 (AQ20)) and the BODE Index., Results: All subjects improved significantly (P<0.001) their HRQoL in the SGRQ, the CRDQ and the AQ20, and this was demonstrated in each one of the evaluated dimensions. A positive response in relation to exercise tolerance and illness prognosis was observed. Following the program subjects walked an average of 56 meters more (P<0.001) and the BODE index was a mean of 1.5 less regarding the initial value (P<0.001)., Conclusions: A 20-session muscular training program contributes to an improvement in HRQoL, exercise tolerance and illness prognosis in COPD subjects with moderate or severe exacerbations., Clinical Rehabilitation Impact: The intervention program could be easily implemented since it needs a minimum of human and technological resources.

Objective: To study the impact of ventilatory management and treatment on the survival of patients with amyotrophic lateral sclerosis (ALS)., Method: Retrospective analysis of 114 consecutive patients admitted to a general hospital, evaluating demographic data, type of presentation, clinical management, treatment with mechanical ventilation and survival., Statistics: descriptive and Kaplan-Meier estimator., Results: Sixty four patients presented initial bulbar involvement. Overall mean survival after diagnosis was 28.0 months (95%CI, 21.1-34.8). Seventy patients were referred to the pulmonary specialist (61.4%) and 43 received non-invasive ventilation (NIV) at 12.7 months (median) after diagnosis. Thirty seven patients continued to receive NIV with no subsequent invasive ventilation. The mean survival of these patients was 23.3 months (95%CI, 16.7-28.8), higher in those without bulbar involvement, although below the range of significance. Survival in the 26 patients receiving programmed NIV was higher than in the 11 patients in whom this was indicated without prior pulmonary assessment (considered following diagnosis, P<.012, and in accordance with the start of ventilation, P<.004). A total of 7 patients were treated invasively; mean survival in this group was 72 months (95%CI, 14.36-129.6), median 49.6±17.5 (95%CI, 15.3-83.8), and despite the difficulties involved in home care, acceptance and tolerance was acceptable., Conclusions: Long-term mechanical ventilation prolongs survival in ALS. Programmed pulmonary assessment has a positive impact on survival of ALS patients and is key to the multidisciplinary management of this disease., (Copyright © 2014 SEPAR. Published by Elsevier Espana. All rights reserved.)

Waldenström's macroglobulinemia (WM) is a lymphoid malignancy characterized by infiltration, mainly of the bone marrow and lymph nodes, by small mature lymphocytes showing plasmacytoid differentiation, associated with an IgM monoclonal band, and, in general, a low degree of aggressiveness. We present the first case reported in the Spanish literature of interstitial lung disease presenting as MW and we review the literature., (Copyright © 2013 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Team-focused intervention to improve the care of low-risk patients with community-acquired pneumonia (CAP) is a matter of controversy. Our aim was to determine if a community-acquired pneumonia team (CAPT) would shorten hospital length of stay (LOS) and improve health care utilization in low-risk patients with CAP compared with management by a general pulmonary team (GPT)., Methods: We performed a prospective cohort study of hospitalized, low-risk patients with CAP (Pneumonia Severity Index [PSI] score class I or II) at a single tertiary hospital from June 2007 to June 2008. Study patients were stratified to management by the CAPT treating group (n = 35), following the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) CAP guideline recommendations, or to management by the GPT (n = 30) following the standard of care. Primary outcome measure for comparison of the efficacy of the 2 different team-focused interventions was hospital LOS for patients with CAP. Secondary study outcome measures included patient 30- and 90-day all-cause readmission rate, rate of mortality at 30 and 90 days, antibiotic-treatment duration, time to switch patient from intravenous (IV) to oral antibiotic treatment, and time to achieve clinical stability for patients., Results: Hospitalized, low-risk patients with CAP, who were assisted by a CAPT were more likely to have a shorter hospital stay (9 days less; P < 0.001), shorter time to switch from IV to oral antibiotic therapy (8 days less; P <0.001), and total shorter duration of antibiotic treatment (6 days less; P <0.001), when compared with low-risk patients with CAP who were assisted by a GPT. In addition, for both groups of assisted patients, there were no differences in the time to achieve clinical stability, use of guideline-concordant antibiotic therapy, rate of mortality, or rate of readmissions at 30 and 90 days., Conclusions: Management by a dedicated CAPT reduced patient hospital LOS, time to switch from IV to oral antibiotic therapy, and duration of antibiotic treatment, without causing adverse events, compared with standard of care, in low-risk patients with CAP.

Background: There is some evidence that quality of life measured by long disease-specific questionnaires may predict exacerbations in asthma and COPD, however brief quality of life tools, such as the Airways Questionnaire 20 (AQ20) or the Clinical COPD Questionnaire (CCQ), have not yet been evaluated as predictors of hospital exacerbations., Objectives: To determine the ability of brief specific health-related quality of life (HRQoL) questionnaires (AQ20 and CCQ) to predict emergency department visits (ED) and hospitalizations in patients with asthma and COPD, and to compare them to longer disease-specific questionnaires, such as the St George´s Respiratory Questionnaire (SGRQ), the Chronic Respiratory Disease Questionnaire (CRQ) and the Asthma Quality of Life Questionnaire (AQLQ)., Methods: We conducted a two-year prospective cohort study of 208 adult patients (108 asthma, 100 COPD). Baseline sociodemographic, clinical, functional and psychological variables were assessed. All patients completed the AQ20 and the SGRQ. COPD patients also completed the CCQ and the CRQ, while asthmatic patients completed the AQLQ. We registered all exacerbations that required ED or hospitalizations in the follow-up period. Differences between groups (zero ED visits or hospitalizations versus ≥ 1 ED visits or hospitalizations) were tested with Pearson´s X(2) or Fisher´s exact test for categorical variables, ANOVA for normally distributed continuous variables, and Mann-Whitney U test for non-normally distributed variables. Logistic regression analyses were performed to estimate the predictive ability of each HRQoL questionnaire., Results: In the first year of follow-up, the AQ20 scores predicted both ED visits (OR: 1.19; p = .004; AUC 0.723) and hospitalizations (OR: 1.21; p = .04; AUC 0.759) for asthma patients, and the CCQ emerged as independent predictor of ED visits in COPD patients (OR: 1.06; p = .036; AUC 0.651), after adjusting for sociodemographic, clinical, and psychological variables. Among the longer disease-specific questionnaires, only the AQLQ emerged as predictor of ED visits in asthma patients (OR: 0.9; p = .002; AUC 0.727). In the second year of follow-up, none of HRQoL questionnaires predicted exacerbations., Conclusions: AQ20 predicts exacerbations in asthma and CCQ predicts ED visits in COPD in the first year of follow-up. Their predictive ability is similar to or even higher than that of longer disease-specific questionnaires.

Specialised medical care at district hospitals has not been thoroughly defined. Respiratory care data from 2008 in Barbanza and Cee hospitals (Galicia, Spain), were analysed to evaluate different approaches, as they are both similar. Barbanza hospital has a chest diseases clinic run by specialist doctors from the reference hospital three days per week, while Cee hospital is operated by the staff on site. In both cases hospitalisation is the responsibility of the Internal Medicine department. Data was provided by the administrative departments of each hospital and the regional government. Average CDM4 stays were similar for both district hospitals; however, they were lower than in the reference hospital. Charlson scores and re-admissions a month after discharge were similar in both. Barbanza's hospital carried out more functional explorations, both at the centre (957 spirometries vs 21; P<.0001) and at the reference hospital (214 volume/diffusion tests vs 99; P<.001). CPAP treatments were more prevalent in the Barbanza area (3.9 vs 2/1,000 habitants; P<.0001). No differences were found in oxygen therapy and home mechanical ventilation. Mortality due to respiratory disease in 2007 was similar in both regions. Data suggests that in a district hospital scheme supported by chest disease consultants and outpatient clinics gives easier access to specialised, comprehensive and probably, higher quality care than district hospitals without them., (Copyright © 2010 SEPAR. Published by Elsevier Espana. All rights reserved.)

Objective: To describe the psychometric properties of the Spanish version of the Airways Questionnaire 20 (AQ20S) for asthma and COPD separately., Study Design: Two hundred and eight patients (108 asthma, 100 COPD) filled in the AQ20S, the St. George's Respiratory Questionnaire (SGRQ), the Asthma Quality of Life Questionnaire (AQLQ) and the Chronic Respiratory Disease Questionnaire (CRQ). Clinical and physiological measurements were assessed concurrently. Clinically stable patients were asked to fill in again the AQ20S after 14 days. The same assessment as on baseline visit was repeated after 3 months., Results: The AQ20S showed a satisfactory score distribution, with minimal floor and ceiling effects, high internal consistency (Cronbach's α > 0.80), and good test-retest reliability (ICC ≥ 0.87). The AQ20S showed a high correlation with the SGRQ in both asthma and COPD (r (s) > 0.75; P < 0.001), as well as with the AQLQ (r (s) = -0.72, P < 0.001) in asthma and with the CRQ (r (s) = -0.59; P < 0.001) in COPD. The AQ20S showed significant correlation with clinical and functional variables, similar to the SGRQ and the AQLQ in asthmatics, but weaker than the SGRQ in COPD patients. Changes in AQ20S scores correlated quite well with changes in other HRQoL questionnaires, both in asthma and COPD., Conclusion: The AQ20S showed psychometric properties similar to the original questionnaire. It was equally useful compared with the SGRQ and the AQLQ in asthma patients and slightly less useful than the SGRQ in COPD patients. Considering its simplicity, the AQ20S may be an alternative to more complex traditional questionnaires.

Background: Alexithymia is a personality trait characterized by difficulties in perceiving and expressing emotions. The relationship between alexithymia and health outcomes in asthma has been shown in a scarce number of studies, in which alexithymia has been considered as an homogeneous construct and the confounding potential effect of anxiety and depression has not been controlled for., Objectives: To determine the relationship between each of the three dimensions of alexithymia as assessed with the Twenty-Item Toronto Alexithymia Scale--Difficulty Identifying Feelings, Difficulty Describing Feelings, and Externally Oriented Thinking--and health-related quality of life and utilization of health care services, controlling anxiety and depression., Methods: Patients with moderate to severe asthma between 18 and 65 years old filled in the Twenty-Item Toronto Alexithymia Scale, the Short-Form 36 Health Survey, the St. George's Respiratory Questionnaire, the Trait Anxiety Inventory, and the Cognitive Depression Index. Sociodemographic and clinical data were collected and the frequency of emergency room visits and hospitalizations due to asthma during the following 24 months was recorded. Data were analyzed using the ?2 test, the Mann-Whitney U test, Spearman correlations and multiple linear regression analyses., Results: A total of 76 patients took part in the study (42.67 ± 15.33 years; 59.2% female; 81.6% severe asthma). Data on emergency room visits during the 24-month follow-up were collected for 42 patients; 13 of them (30.95%) with at least one emergency room visit during the follow-up. After controlling for sociodemographic variables, clinical variables, anxiety, and depression, the Difficulty Describing Feelings factor was related to dimensions of the Short-Form 36 Health Survey: Physical Functioning (p = .021), Role-Physical (p = 0.025), and the Physical Component Score (p = .012). The Difficulty Identifying Feelings factor was associated with a higher frequency of emergency room visits (p = .005). The Externally Oriented Thinking factor was not related to any of the dependent measures., Conclusions: Two dimensions of alexithymia, Difficulty Identifying Feelings and Difficulty Describing Feelings, are complicating factors in the management of asthma, but they operate via different mechanisms and over different outcomes and the effects of alexithymia remain even while controlling for the confounding effect of anxiety and depression.

Amyotrophic neuralgia is an inflammatory and idiopathic neuropathy which is characterised by neuropathic pain. It was described for the first time in 1948 as condition that only affected the brachial plexus and was called Parsonage-Turner syndrome. Although this syndrome is more common in the brachial plexus, it can concomitantly, or in isolation affect the phrenic nerve, and in this case the diagnosis is very difficult if there is no high clinical suspicion. We present a case of a patient with amyotrophic neuralgia in which the only sign was left phrenic involvement, and we highlight the resistance of the pain to analgesics, as well as the persistence of the symptoms and diaphragm problems for over 6 months., (Copyright 2009 SEPAR. Published by Elsevier Espana. All rights reserved.)

Primary thoracic sarcomas are very rare. The most common intrathoracic variants are synovial sarcoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma, and sarcomatoid mesothelioma. Although thoracic Ewing sarcoma/primitive neuroectodermal tumor (PNET) usually develops on the chest wall, there have been reports of primary Ewing sarcoma/PNET of the lung. We present the case of a 22-year-old woman with Ewing sarcoma/PNET diagnosed following histologic, immunohistochemical, and in situ hybridization studies of a bronchial biopsy specimen. Radiography, ventilation-perfusion scintigraphy, and a bone marrow biopsy confirmed that the tumor was not metastatic. The patient was started on a chemotherapy regimen of vincristine, actinomycin, cyclophosphamide, doxorubicin, ifosfamide, and etoposide and responded well. She is now being seen regularly at our outpatient clinic., (Copyright (c) 2009 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background and Objectives: The routine use of health-related quality-of-life questionnaires in patients with chronic respiratory disease is limited due to the time required to complete them. The Airways Questionnaire 20 (AQ20) contains 20 easy-to-answer questions, making it ideal for use in routine practice. However, a Spanish version is not available. Our aim was to create a version of the AQ20 for use in Spain that would be equivalent to the original English questionnaire., Method: The original questionnaire was adapted using the translation-backtranslation method. We evaluated the conceptual equivalence of the translation to the original questionnaire, classifying items as type A if they were fully equivalent, type B if they contained questionable wording, and type C if there were doubts about their equivalence. The items in categories B and C were re-examined by the researchers and translators, with input from the author of the original questionnaire and a group of patients. The final version was piloted among 30 patients., Results: Low difficulty ratings were given to both the translation (3.45) and backtranslation (3.52). Sixty-five percent of the backtranslated items were considered to be fully equivalent to the original English items (type A), 15% were classified as type B, and 20% as type C. The final Spanish version, produced after discussion of items B and C, was administered to 15 patients with asthma (66% women; mean [SD] age, 53.13 [19.6] y) and 15 patients with chronic obstructive pulmonary disease (13% women; mean age, 67.8 [8.94] y). A Cronbach alpha of 0.92 was obtained., Conclusion: The adaptation process produced a Spanish questionnaire that is conceptually equivalent to the English original, easy to understand, and satisfactory in terms of internal consistency.

Objective: The aim of this study was to describe 5 microepidemics of tuberculosis occurring in schools, establish the risk factors associated with the outbreaks, assess how well a concentric circles strategy for contact tracing predicts infection, and assess the usefulness of genotyping strains in the analysis of the outbreaks., Material and Methods: The study assessed 5 epidemic outbreaks of tuberculosis using a standard contact tracing procedure. The outbreaks occurred in 2 day nurseries and 2 high schools between 1998 and 2005. Contacts were stratified using a concentric circle system based on level of exposure. DNA fingerprints of the available strains were determined based on the restriction fragment length polymorphism (RFLP) IS6110 and compared with the contact study to interpret the transmission of the infection., Results: We analyzed 5 outbreaks. Eighty-five contacts were analyzed in the first outbreak, 519 in the second, 116 in the third, 655 in the fourth, and 102 in the fifth. The rate of infection was 31%, 29%, 66%, 37.6%, and 32%, respectively. Secondary cases of active disease were detected: 9 in the first outbreak, 16 in the second, 5 in the third, 6 in the fourth, and 13 in the fifth. RFLP analysis revealed that a single strain was involved in 3 of the outbreaks, and in a fourth, at least 2 strains were involved. In outbreaks 2, 3, and 5, there was a significant association between the degree of contact and the probability of infection (P< .05). In all of the outbreaks, the relative risk of developing the disease was associated with the level of exposure., Conclusions: Analysis of contacts based on concentric circles of risk predicts the likelihood of infection. RFLP facilitates analysis of complex transmission routes that are not detected using traditional methods of contact screening.

Objective: To assess the efficacy of treatment with sildenafil monotherapy in patients with pulmonary hypertension., Patients and Methods: An observational study was undertaken in 11 patients with pulmonary hypertension in functional class II or III who received treatment with sildenafil (150 mg/day). Seven of the patients had inoperable chronic thromboembolic pulmonary hypertension and 4 had pulmonary arterial hypertension. To assess treatment response, the following parameters were assessed during follow-up at 3, 6, and 12 months: exercise tolerance in the 6-minute walk test, change in functional class, and systolic pulmonary arterial pressure measured by echocardiography., Results: We observed a significant improvement in exercise tolerance, as shown by increased 6-minute walk distance after 3, 6, and 12 months of treatment (increases of 20, 67, and 95 m, respectively). All patients showed an improvement in functional class. The results of echocardiography did not reveal statistically significant differences in systolic pulmonary arterial pressure between baseline and 6 or 12 months of treatment. No significant adverse effects were observed, although sildenafil treatment was suspended in 1 patient due to persistent headache., Conclusions: The results of this study confirm that sildenafil is an effective drug for the management of pulmonary arterial hypertension and inoperable chronic thromboembolic pulmonary hypertension both in the short term and medium to long term, and that the drug is well tolerated and shows few side effects.

The antiphospholipid syndrome is defined by the association of vein and/or arterial thrombotic events and a high level of antiphospholipid antibodies. Pulmonary embolism and pulmonary hypertension are the most usual complications and recently some new cases of alveolar haemorrhage have been described. We present the case of an alveolar haemorrhage in a patient with a primary antiphospholipid syndrome. The first manifestation of this patient was a deep vein thrombosis on his left lower leg . After that he had persistent hemoptoic sputum and his chest x-ray showed alveolar infiltrates. The bronchoscopy ruled out another causes of haemoptysis and the bronchoalveolar lavage confirmed that it was an alveolar haemorrhage (80% of hemosiderophages ). The case is discussed and we do a literature review.

Background and Objectives: The aim of this study is to evaluate the relationship between the interval from first symptom to diagnosis (SDI) and the degree of invasion and survival in lung cancer., Methods: Three hundred seventy-eight patients with lung cancer were included. SDI was defined as the time calculated from the cytohistologic confirmation of the diagnosis of cancer and the first symptoms noted by the patient and attributed to cancer by the physician. The degree of invasion was determined by TNM classification., Results: The median SDI was 2.1 months, and did not correlate with stage. Survival decreased progressively according to TNM classification. Adjusting for age, sex, SDI and TNM, survival was influenced by age (RR=1.02) and by staging [Stage (Ib) RR=1.3; stage (IIIa) RR=2.6; stage (IIIb) RR=4.06; stage (IV) RR=7.5]. SDI was not found to affect survival (RR=1.01; 95% CI: 0.94-1.08). In the small cell group, SDI also failed to modify survival., Conclusions: The results of this study indicate that SDI has no effect on the stage or survival of patients with lung cancer.