2. • Advisor to Esteve Teijin in the area of
home respiratory therapy
• I have no other relevant financial
relationships to disclose
Conflict of interest
5. • Lower respiratory tract infection the third most common cause of death in
the world (3.5 million deaths/year)
• Streptococcus pneumoniae major cause of morbidity and mortality
worldwide (bacteremia, meningitis, pneumonia and acute otitis media)
• Serious disease mainly in children under two years of age and in elderly
• 1.6 million deaths / year estimated in 2005 (0.7–1 million children)
• PPSV23 less effective than expected
• Pneumococcal strains nonsusceptible to penicillin and erythromycin could
have reached 41% by 2004 in the absence of a PCV
PNEUMONIA: INTRODUCTION
WHO, 2013 (http://www.who.int/mediacentre/factsheets/fs310/en/index.html).
Jackson LA. An OficialPublication of the Infectious Diseases Society of America
2008;47:1328–38.
Richard G. et al. N Engl J Med 2014;370:543-51.
McCormick et al. AW Nat Med 2003;9:424-30.
PNEUMONIA
6. Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
PNEUMONIA
8. • PCV7 introduced in USA in 2000
• Major reduction in the incidence of invasive disease in all age
groups
• Aim: the early observed reductions in hospitalizations for pneumonia
were sustained throughout the first decade of PCV7 use?
PNEUMONIA
PNEUMONIA: BACKGROUND
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
9. • National Inpatient Sample (NIS)
• 1050 hospitals in 44 States
• ICD-9-CM/ pneumonia as 1st diagnosis or meningitis, septicemia or
empyema + pneumonia as 2nd
PNEUMONIA
PNEUMONIA: METHODS/DATA SOURCES
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
10. PNEUMONIA
Average Annual Rates of U.S. Hospitalizations for Pneumonia before and after the Introduction of PCV7, According to Age Group.
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
11. Hospitalizations for Pneumonia among U.S. Children.
PNEUMONIA
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
12. PNEUMONIA
The annual rates of hospitalization for pneumonia from 1997 through 2009.
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
14. PNEUMONIA
Differences in Rates of Hospitalization for Pneumonia from Any Cause 3 Years before and 7 to 9 Years after the
Introduction of PCV7.
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
15. Rates of In-Hospital Death Related to Pneumonia from Any Cause 3 Years before and 7 to 9 Years after the
Introduction of PCV7.
PNEUMONIA
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
16. PNEUMONIA: CONCLUSIONS
PNEUMONIA
• Declines in hospitalizations for childhood pneumonia were
sustained during the decade after the introduction of PCV7.
• Substantial reductions in hospitalizations for pneumonia among
adults were also observed.
Griffin et al. N Engl J Med Volume 369(2):155-163 July 11, 2013
17. PNEUMONIA: MESSAGES
PNEUMONIA
Hammit et al. J Infect Dis. Volume 193(11):1487-94 Apr 27,
2006
Weinberger, Lancet 2011; 378: 1962–73
Letters to the editor. NEJM 369;17 nejm.org october, 2013
Singleton, JAMA. 2007;297:1784-1792
• Probably the “herd” effect protects elderly people
– Hammit et al. J Infect Dis. Volume 193(11):1487-94 Apr 27, 2006
• Consequences of Serotype replacement There is not enough data
to evaluate the impact
– Weinberger, Lancet 2011; 378: 1962–73
• Species replacement Other pathogens like Staphylococcus aureus
is a concern
– Reed A. Siemieniuk M.D. Letters to the editor. NEJM 369;17 nejm.org october, 2013
• Pneumonia complications (Empyema) seems to arise
– Alessando Amaddeo. Letters to the editor. NEJM 369;17 nejm.org october, 2013
• We will have to wait to see the effects on mortality
• A decade of PVC13 is open
19. • Lung cancer 1.59 million deaths in 2012
• More individuals die from lung cancer than from colon, breast
and prostate cancer combined
• Rx radiographs and sputum screenings didn’t meet the
expectations, mortality?
• IELCAP results opened the door to RCTs
WHO Fact sheet N°297. Feb 2014. http://www.who.int/mediacentre/factsheets/fs297/en/
Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92S
Shlomi, Eur Respir J 2014; in press
LUNG CANCER: INTRODUCTION
LUNG CANCER
20. LUNG CANCER
RCT’S:
• DANTE A randomized study of lung cancer screening with spiral
computed tomography: three-year results from the DANTE trial.
• DLCST CT screening for lung cancer brings forward early disease. The
randomised Danish Lung Cancer Screening Trial: status after five
annual screening rounds with low-dose CT.
• NELSON Volumetric computed tomography screening for lung cancer:
three rounds of the NELSON trial.
• ITALUNG Four-year results of low-dose CT screening and nodule
management in the ITALUNG trial.
• NLST NLST Research Team
• >86.000 patients included in total
Am J Respir Crit Care Med. 2009 Sep 1;180(5):445-53.
Thorax. 2012 Apr;67(4):296-301.Singleton, JAMA. 2007;297:1784-1792
Eur Respir J. 2013 Dec;42(6):1659-67.
J Thorac Oncol. 2013 Jul;8(7):866-75.
N Engl J Med. 2011 Aug 4;365(5):395-409.
21. Inclusion criteria:
• 55–74 years
• ≥30 pack-years
• Former smokers (within the previous 15 years)
• LDCT vs. chest radiography – 3 annual rounds: T0, T1, T2
• For LDCT, noncalcified nodules of ≥4 mm (maximum diam.) -
positive
NLST Research Team, N Engl J Med 2011;365:395-409.
LUNG CANCER
24. PUBMED search March 2014. Number of publications related to the topic.
LUNG CANCER
25. • LDCT diagnosed more cancer (1,1% vs 0,7%)
• More stage I Ca in LDCT group
• Tendency of stage-shift
• Sensibility of LDCT 93,8% and Specificity 73,4%
• In LDCT group more positive screenings and more Dg
procedures
NLST Research Team, N Engl J Med 2013;368:1980-91.
LUNG CANCER
28. LUNG CANCER
NLST Research Team, N Engl J Med 2013;368:1980-91.
Sensitivity, specificity and positive predictive value for LDCT in T1 and T2.
Data extracted from original
29. LUNG CANCER
NLST Research Team, N Engl J Med 2013;368:1980-91.
T0; Number of patients diagnosed of lung cancer according to Stage.
Data extracted from original
30. LUNG CANCER
Aberle, N Engl J Med 2013;369:920-31.
T1; Number of patients diagnosed of lung cancer acording to Stage.
Data extracted from original
31. LUNG CANCER
Aberle, N Engl J Med 2013;369:920-31.
T2; Number of patients diagnosed of lung cancer acording to Stage.
Data extracted from original
32. LUNG CANCER
NLST Research Team, N Engl J Med 2013;368:1980-91.
T1; PPV according to lung nodule size.
Data extracted from original
33. LUNG CANCER
Aberle, N Engl J Med 2013;369:920-31.
T2; PPV according to lung nodule size.
Data extracted from original
34. LUNG CANCER
Aberle, N Engl J Med 2013;369:920-31.
T0; PPV according to lung nodule size.
Data extracted from original
35. • Low-dose CT detects more lung cancers than radiography
• Stage shift toward early-stage in non–small-cell lung cancers
• Performance characteristics of low-dose CT may be
enhanced
LUNG CANCER
LUNG CANCER: CONCLUSIONS
Aberle, N Engl J Med 2013;369:920-31.
36. • Selection criteria
–Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92S
–Kovalchik, N Engl J Med 2013;369:245-54
• Results may improve with the volumetric study
–Horeweg, Eur Respir J 2013; 42: 1659–1667
• Results may also improve with pet-ct (>8mm)
–Shlomi, Eur Respir J. 2014 Feb 13.
• Awareness of concept of slow-growing lung cancer!
–Infante, Eur Respir J 2013; 42: 1706–1722
• Biomarkers as additional screening tool
–Sozzi, J Clin Oncol 2014 32:768-773.
LUNG CANCER: MESSAGES 1
LUNG CANCER
Detterbeck, CHEST 2013; 143(5)(Suppl):e78S–e92S
Horeweg, Eur Respir J 2013; 42: 1659–1667
Shlomi, Eur Respir J. 2014 Feb 13.
Infante, Eur Respir J 2013; 42: 1706–1722
Kovalchik, N Engl J Med 2013;369:245-54
37. Benefits
• Effect on mortality
• Effect on smoking
behavior
Harms
• False positives
• Diagnostic procedure
complications
• Overdiagnosis
• Radiation exposure
• Quality of life
Screening could be performed such
that benefits outweigh the harms.
LUNG CANCER
Bach, JAMA. 2012;307(22):2418-2429
LUNG CANCER: MESSAGES 2
46. Natural history of FWL disease. Adapted from original
PULMONARY FIBROSIS
Turcotte, CHEST 2013; 143(6):1642–1648
47. • In summary, the natural history of FWL includes complete resolution;
persistent, but stable ILD with a restrictive pulmonary function deficit;
mixed obstructive/restrictive pulmonary function deficits; and
progressive fibrosis leading to respiratory failure, pulmonary
hypertension, and death.
PULMONARY FIBROSIS
PULMONARY FIBROSIS: CONCLUSIONS
Turcotte, CHEST 2013; 143(6):1642–1648
48. PULMONARY FIBROSIS
• Natural history of the interstitial lung diseases is not uniform and even
can be reversed
• It is important, when possible, to determine the cause of the disease
–Am J Respir Crit Care Med. 2014 Jan 1;189(1):48-56.
PULMONARY FIBROSIS: MESSAGES
