Scientific evidence supports that the combination of psychological counseling and pharmacological treatment is the most effective healthcare intervention to help smokers quit. Four types of medications have been shown to be safe and effective: nicotine replacement therapy (NRT), bupropion, varenicline, and cytisinicline. Nevertheless, based on the results of new studies, we can point out several opportunities for development clinical research in this field: a) finding the most effective doses for cytisinicline, b) finding the effectiveness and safety of cytisinicline in smokers with chronic disorders, c) comparing the effectiveness and safety of cytisinicline at higher doses with varenicline at standard doses, d) investigating the effectiveness and safety of varenicline and cytisinicline used at standard doses but in different pharmaceutical formulations, e) comparing the effectiveness and safety of cytisinicline at higher doses with nicotine replacement combined treatment, f) determining the effectiveness and safety of smoking cessation medications as a treatment for new tobacco and nicotine products users (Electronic cigarettes and heated tobacco users), g) to determine the effectiveness and safety of combining pharmacological treatment for smoking cessation with non-invasive brain stimulation, h) to optimize the efficacy and safety of smoking cessation medications based on Nicotine Metabolite Ratio (NMR) and probably the most recent suggestion to determine the efficacy and safety of glucagon-like peptide-1 (GLP-1) receptor agonists.All these aspects will be discussed in this paper.
Clinical remission is an emerging treatment goal in severe asthma, although real-world data on its long-term maintenance remain limited. We retrospectively evaluated 50 patients who initiated first-line biologic therapy with omalizumab, mepolizumab, or reslizumab between 2015 and 2019. Clinical remission at 12 months was defined as no moderate or severe exacerbations, an asthma control test (ACT) score of ≥20, post-bronchodilator forced expiratory volume in 1 second of ≥80% predicted, and no use of maintenance oral corticosteroid. Of these patients, 13 (26.0%) met the criteria for remission. They had significantly higher unadjusted baseline forced vital capacities (FVC; 103.6% vs. 85.7%, p = 0.002) and ACT scores (17.5 vs. 11.0, p < 0.001), and 6 (46.2%) maintained remission over a median follow-up of 63.0 months. Although remission was achieved in approximately one-quarter of patients, it was maintained in fewer than half. Our baseline FVC and ACT findings require confirmation in larger studies.
Background: Medical thoracoscopy (MT) is an important diagnostic and therapeutic procedure for pleural diseases, particularly unexplained exudative pleural effusions. Although widely used internationally, data describing MT outcomes from southern Iran remain limited.Methods: This retrospective descriptive study evaluated 93 patients who underwent MT at a large tertiary referral hospital in southern Iran between 2017 and 2023. Data regarding patient characteristics, anesthesia methods, procedural details, complications, and pathological findings were collected and analyzed using descriptive statistics.Results: The study included 93 patients (59% male and 41% female) with a mean age of 60.7 ± 15.07 years. Conscious sedation was the most commonly used anesthesia method (72%). Pathological examination revealed malignant pleural involvement in 63 patients, including newly diagnosed primary lung malignancies and metastatic pleural disease. Thoracoscopic talc poudrage was performed in 17 patients with recurrent symptomatic pleural effusions. Non-specific inflammatory findings were identified in 27 patients, and three cases of granulomatous inflammation, including tuberculosis, were also observed. Complications occurred in 13 patients, mainly including chest pain, mild intraprocedural bleeding, and respiratory complications. Five patients died during hospitalization; however, none of these deaths were attributed to procedure-related complications.Conclusion: In this study, MT was associated with a high proportion of definitive pathological diagnoses and a low frequency of severe procedure-related complications. These findings support the utility of MT in the evaluation of selected patients with complex pleural diseases, particularly unexplained exudative pleural effusions. Further studies focusing on patient selection, therapeutic outcomes, and long-term follow-up are warranted.
Introduction: Cystic fibrosis transmembrane conductance regulator (CFTR) modulators have transformed cystic fibrosis (CF) treatment. Elexacaftor/tezacaftor/ivacaftor (ETI) is approved for patients with F508del, but individuals with rare mutations or uncharacterized genotypes often lack therapeutic options. We evaluated ETI efficacy over 12 months in this population at a time when CFTR modulator therapy was not approved for use in these mutations, although some variants have since been included in updated clinical indications.Material and methods: Prospective multicenter real-world study including 13 patients from 6 Spanish CF units treated under a compassionate use program. Inclusion criteria were age ≥ 12 years, rare CFTR mutations or inconclusive sweat test with single F508del mutation, and advanced lung disease. ETI was administered at standard doses with quarterly follow-up over 12 months. Outcomes included percent predicted forced expiratory volume in 1 second (ppFEV1), sweat chloride (SWCl), exacerbations, sputum microbiology, body mass index (BMI), and concomitant therapies.Results: Mean age was 34 years; 53.8% were female; baseline ppFEV1 was 42.3% and SWCl 92.5 mmol/L; 61.5% had chronic Pseudomonas aeruginosa infection. After 12 months, SWCl decreased in most patients except those carrying N1303K. ppFEV1 improved by 13% (95% CI, 5.5 to 32), with fewer exacerbations and hospitalizations. Pathogen prevalence decreased from 84.6% to 53.8%. Antibiotic and inhaled therapy use decreased, while BMI increased and respiratory symptoms improved.Conclusion: ETI therapy in CF patients with rare mutations showed clinical, functional, and microbiological benefits. These findings support the potential benefit of ETI in selected patients with severe disease carrying previously ineligible CFTR variants. The safety profile was consistent with that previously described for ETI.
Platypnea-orthodeoxia syndrome (POS) is an uncommon and underrecognized cause of positional hypoxemia, usually related to dynamic right-to-left shunting. We report the case of a 74-year-old man with obesity and unexplained presyncopal episodes associated with severe positional oxygen desaturation. Initial transthoracic echocardiography with agitated saline contrast performed in the supine position was negative. However, contrast-enhanced transesophageal echocardiography performed in the sitting position revealed a patent foramen ovale with a dynamic right-to-left shunt associated with aortic root dilatation and interatrial septal distortion. Percutaneous closure using a NobleStitch system resulted in immediate improvement in oxygenation. Subsequent respiratory polygraphy identified moderate obstructive sleep apnea, interpreted as a possible contributing factor rather than a proven mechanism. This case highlights the importance of considering POS in unexplained positional hypoxemia and emphasizes that a negative supine transthoracic contrast study does not exclude a dynamic intracardiac shunt.
Introduction:Chronic obstructive pulmonary disease (COPD) is a major public health problem. Research over the past few years has shown that COPD is the result of dynamic and cumulative gene-environment interactions starting early in life. This opens new opportunities for the Prediction, Prevention, Personalized and Precise management (P4) of COPD in young adults. The P4COPD study sought to: (1) investigate the genomic and environmental/lifestyle determinants of COPD in young adults (18-50 years); (2) contrast them with those determined in children, adolescent and older individuals; and (3) explore the feasibility and cost of implementing a P4 strategy for COPD in young adults in clinical practice. Materials and methods:The P4COPD study leverages from already existing cohorts (EarlyCOPD, INMA, LEVANTE, Aduheart) of young subjects (18-50 years) and de novo recruitment from primary care centers, in whom we: (1) analyzed demographic, epidemiological, clinical and physiologic information; (2) measured genetic, epigenetic and proteomic markers; (3) used analytical methods to identify endotypes, biomarkers and potential therapeutic targets associated with the presence of COPD, pre-COPD and/or low peak lung function. Results in young individuals: (4) were contrasted with healthy controls from the general population (IMPACT cohort) and COPD cohorts in older patients (BIOMEPOC, CHAIN and ECLIPSE). Besides, we (5) explored how to implement results in clinical practice; and (6) estimated its potential health cost implications. Results:First results are expected in the third and fourth quarters of 2026. Conclusions:Identifying young individuals at risk of COPD, in whom to establish a P4 strategy is highly relevant to promote healthy aging.
Pulmonary rehabilitation (PR) is a fundamental treatment of COPD. Since it remains underutilized, home-based programs and telemedicine may be useful. In this study, the authors wanted to test if a novel home-based, step-guided PR program centered on self-efficacy promotion and telehealth, was feasible and safe. This quasi-experimental feasibility study included 14 patients with COPD, two consecutive pillars (education and exercise training) and three consecutive exercise training steps of progressive intensity, for 12 weeks. There was a significant reduction in the BODE Index (6 ± 3 to 5 ± 3) and in symptoms and quality-of-life questionnaires. Five patients improved the 6-min walk test with clinical and statistical significance (270 ± 124 to 338 ± 97). Three patients improved FEV1 and CPET, with clinical significance. There was significant improvement in hand-grip strength (29.5 ± 16.5 to 32.9 ± 17). No adverse events reported. This home-based step-guided PR centered on self-efficacy in COPD is feasible, improves BODE Index and is safe. Randomized controlled studies with larger samples are required.
Chronic bronchial infection by Stenotrophomonas maltophilia in non-cystic fibrosis (non-CF) bronchiectasis poses a major therapeutic challenge due to multidrug resistance and biofilm-forming capacity. We report a 19-year-old athlete with a one-year history of productive cough, dyspnea, and hemoptysis, whose CT scan revealed bibasilar cylindrical bronchiectasis. Following the failure of oral levofloxacin monotherapy and a subsequent sputum culture showing intermediate susceptibility to cotrimoxazole, a combination regimen was initiated. The patient received systemic trimethoprim-sulfamethoxazole combined with intermittent 28-day cycles of inhaled levofloxacin to leverage drug synergy and achieve high local concentrations capable of penetrating the bacterial biofilm. This dual approach achieved complete symptomatic remission, stable lung function, and microbiological clearance. To our knowledge, this is the first report documenting successful S. maltophilia eradication using inhaled levofloxacin in non-CF bronchiectasis, suggesting that this combination may be an alternative therapeutic strategy deserving further evaluation in future studies.
Pulmonary hamartoma is the most common benign lung tumour and is usually detected as a peripheral pulmonary lesion. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a minimally invasive technique for mediastinal staging and diagnosis of thoracic lesions. We report the case of a 72-year-old man with an incidental right hilar lesion identified on computed tomography during follow-up after coronary surgery. Imaging revealed a partially calcified lesion with fatty density adjacent to the right main bronchus. Bronchoscopic examination showed no endobronchial abnormalities, while EBUS demonstrated a well-defined heterogeneous lesion with hyperechoic punctate areas and posterior acoustic shadowing. EBUS-TBNA was performed without complications. Cytological and cell block analysis demonstrated the diagnosis of pulmonary hamartoma. This case highlights the utility of EBUS-TBNA as a safe and effective diagnostic tool for centrally located pulmonary hamartomas.
Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare interstitial lung disease characterized by upper-lobe-predominant fibrosis and thoracic cage deformity. However, its electrocardiographic (ECG) features remain poorly defined. We retrospectively analyzed ECG, echocardiography, and chest computed tomography (CT) findings in 20 patients with IPPFE and 18 with idiopathic pulmonary fibrosis (IPF). Patients with IPPFE showed a more rightward QRS axis than those with IPF (median +70.5° [interquartile range (IQR) 55.3-77.3] vs. +32.5° [IQR 1.3-63.5], p = 0.007). The PR interval was shorter in IPPFE but within normal limits. CT showed greater upward displacement of the pulmonary hila. No significant correlations were found between QRS axis and hilar elevation, flat chest index, or echocardiographic indices. These findings suggest that the rightward QRS axis shift may reflect altered cardiac orientation associated with thoracic deformity rather than overt pulmonary hypertension. ECG abnormalities may aid recognition of IPPFE, particularly when radiological findings are subtle.
A 75-year-old male, former smoker (50 pack-years), with a history of squamous cell lung carcinoma treated with right lower lobectomy 20 years earlier, presented with progressive dyspnea at rest (mMRC IV) and hypoxemic respiratory failure. Chest computed tomography revealed a 14 mm nodular lesion in the left main bronchus. Bronchoscopy showed a lesion at the carina between the left upper and lower lobes, causing near-complete obstruction. Biopsy and partial endoscopic resection were performed, but follow-up demonstrated slight progression. Histopathology confirmed squamous cell carcinoma. Due to prior lobectomy, surgery was ruled out, and radical high-dose-rate endobronchial brachytherapy with Iridium-192 (30 Gy in six weekly fractions) was administered. Complete endobronchial resolution was achieved and maintained at six months. Endobronchial brachytherapy is a well-tolerated technique that delivers high radiation doses with minimal damage to surrounding tissue and may represent a radical therapeutic option in selected patients with localized endobronchial tumors not eligible for surgery or external radiotherapy.
Tezepelumab is a human monoclonal antibody directed against thymic stromal lymphopoietin that inhibits initiation of the type 2 inflammatory cascade. Several pivotal studies demonstrating tezepelumab effectiveness and leading to regulatory and marketing authorization have since been complemented by further evidence, most notably from the following studies: (a) for severe uncontrolled asthma, the PASSAGE phase 4 clinical trial, conducted in a routine clinical practice setting, found that tezepelumab significantly reduced exacerbations, including in underrepresented populations (African-Americans, adolescents, smokers, individuals with chronic obstructive pulmonary disease), and improved lung function, disease control, and quality of life. (b) For corticosteroid-dependent asthma, the WAYFINDER phase 3b clinical trial reported tezepelumab's effectiveness in reducing both dependency and the number of exacerbations as well as clinical remission in around a quarter of patients. (c) For chronic rhinosinusitis with nasal polyps, the WAYPOINT phase 3 clinical trial found that tezepelumab, after therapeutic optimization, decreased nasal polyp size and nasal congestion, improved clinical impact and sense of smell, and reduced the need for surgery. (d) For moderate-to-very severe chronic obstructive pulmonary disease, the COURSE phase 2a clinical trial reported a non-significant reduction in exacerbations, but also that reductions were greater for the type 2 phenotype (eosinophils ≥150 cells/μL). In conclusion, up-to-date evidence confirms tezepelumab safety and efficacy in treating severe uncontrolled asthma in routine clinical practice and in managing corticosteroid-dependent asthma and chronic rhinosinusitis with nasal polyps.
