Pneumologia

<div><bold>EDITORIAL</bold><bold>Comorbidities, COPD and COVID 19 -</bold> Ana Constantin, Florin Mihălțan<bold>REVIEWS</bold><bold>Challenges in the diagnosis, treatment and management of asthma during COVID-19 pandemic -</bold> Rohozneanu Oana Elena, Crișan-Dabija Radu Adrian, Vicol Cristina, Țurcanu Adina Magdalena, Trofor Antigona Carmen, Buculei Ioana<bold>ORIGINAL PAPERS</bold><bold>Systemic inflammation, TNM staging and survival in patients with lung cancer -</bold> Ionela Erhan, Stefan Dumitrache-Rujinski, ClaudiaToma, Miron Bogdan<bold>INSPIRO project – Educational intervention against non-adherence to inhalation therapy for Romanian asthma and COPD patients -</bold> Ruxandra Ulmeanu, Alina Croitoru, Floarea Mimi Nitu, Florin Mihaltan, Cristian Oancea, Ramona Nedelcu, Daniela Boldeanu, Ruxandra Rajnoveanu, Petronela Fildan, INSPIRO team<bold>Management of neoplastic pericarditis–overview of 156 patients -</bold> Elena Jianu, Natalia Motas, Mihnea Davidescu, Ovidiu Rus, Corina Bluoss, Veronica Manolache, Madalina Iliescu, Teodor Horvat<bold>CLINICAL CASES</bold><bold>Pulmonary artery thrombosis in home patient with a mild COVID 19 disease -</bold> Alessandro Graziani, Marco Domenicali, Grazia Zanframundo, Francesco Palmese, Barbara Caroli, Pierluigi Cataleta, Ludovico Graziani<bold>An Atypical Case:RT-PCR-negative, Sero-positive COVID-19 Patient -</bold> William Suriady, Andika Chandra Putra Wiwien Heru Wiyono Mohammad Fahmi Alatas, Bettia Bermawi, Ratna Moniqa, Hendra Koncoro, Laurentius Aswin Pramono, Fransiska, Maria Edith Sulistio, Ramzi, Robert Sinto, Rachmat Hamonangan, Adi Surya Komala, C. Krismini Dwi Irianti, JB Endrotomo Sumargono<bold>SMOKING PROBLEMS</bold><bold>COVID 19 - a new threat for smokers and vapers? -</bold> Florin Mihălţan, Corina Oprea, Valentin Coşei, Ancuţa Constantin<bold>No Tobacco Day 2020 - another ancient „COVID DAY”? -</bold> Florin Mihălțan, Monica Marc<bold>ROMANIAN SOCIETY OF PNEUMOLOGY ACTIVITIES</bold><bold>Romanian Society of Pneumology respect his traditional activities -</bold> Florin Mihălțan, Ruxandra Ulmeanu<sec id="j_pneum-2020-0022_s_001_w2aab3b7c52b1b6b1ab1c16Aa"><div>Sumar</div><bold>EDITORIAL</bold><bold>Impactul comorbidităților asupra pacienților diagnosticați cu BPOC și COVID 19 -</bold> Ana Constantin, Florin Mihălțan<bold>REVIEWS</bold><bold>Provocări în diagnosticul, tratamentul și managementul astmului bronșic în pandemia COVID-19 -</bold> Rohozneanu Oana Elena, Crișan-Dabija Radu Adrian, Vicol Cristina, Țurcanu Adina Magdalena, Trofor Antigona Carmen, Buculei Ioana<bold>Original Papers</bold><bold>Relația dintre inflamația sistemică, stadializarea TNM și suprviețuire la pacienții cu diagnostic de cancer bronhopulmonar -</bold> Ionela Erhan, Stefan Dumitrache-Rujinski, ClaudiaToma, Miron Bogdan<bold>Proiect INSPIRO - Intervenție educațională împotriva nonaderenţei la terapia inhalatorie a pacienților români cu astm și BPOC -</bold> Ruxandra Ulmeanu, Alina Croitoru, Floarea Mimi Nitu, Florin Mihaltan, Cristian Oancea, Ramona Nedelcu, Daniela Boldeanu, Ruxandra Rajnoveanu, Petronela Fildan, INSPIRO team<bold>Managementul pericarditelor neoplazice – evaluarea a 156 de pacienti -</bold> Elena Jianu, Natalia Motas, Mihnea Davidescu, Ovidiu Rus, Corina Bluoss, Veronica Manolache, Madalina Iliescu, Teodor Horvat<bold>CLINICAL CASES</bold><bold>Tromboza arterei pulmonare la pacient cu boala COVID 19 forma usoara aflat la domiciliu -</bold> Alessandro Graziani, Marco Domenicali, Grazia Zanframundo, Francesco Palmese, Barbara Caroli, Pierluigi Cataleta, Ludovico Graziani<bold>Un caz atipic: pacient COVID 19 seropozitiv, RT-PCR negativ -</bold> William Suriady, Andika Chandra Putra Wiwien Heru Wiyono Mohammad Fahmi Alatas, Bettia Bermawi, Ratna Moniqa, Hendra Koncoro, Laurentius Aswin Pramono, Fransiska, Maria Edith Sulistio, Ramzi, Robert Sinto, Rachmat Hamonangan, Adi Surya Komala, C. Krismini Dwi Irianti, JB Endrotomo Sumargono<bold>SMOKING PROBLEMS</bold><bold>COVID 19 - o nouă amenințare pentru fumători și “vapers”? -</bold> Florin Mihălţan, Corina Oprea, Valentin Coşei, Ancuţa Constantin</sec></div>

<article-title>Summary</article-title>

{"article-title":"Summary"}

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title>Boala Coronavirus 2019 cauzată de noua tulpină de coronavirus (SARS-COV-2) este una dintre cele mai presante probleme de sănătătate publică ale anului 2020. Numărul de cazuri noi în continuă creștere, extinderea globală a virusului și severitatea bolii au determinat Organizația Mondială a Sănătății să declare boala o pandemie.20% dintre pacienți prezintă forme severe și critice care necesită frecvent suplimentarea oxigenului și internarea în unități de terapie intensivă. De aceea, pentru a oferi îngrijiri optime, este necesar să se identifice pacienții cu risc.Pacienții cu boli cronice asociate sunt mai predispuși să dezvolte forme severe și critice ale infecției. Deși boala obstructivă pulmonară cronică este prezentă doar la un număr limitat de pacienți diagnosticați cu boala Coronavirus 2019, este cea mai frecventă boală pulmonară asociată și este comorbiditatea cel mai frecvent asociată cu o evoluție nefavorabilă.</trans-abstract>

Rezumat

<abstract><title style='display:none'>Abstract</title>Coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 is one of the most pressing health care concerns in 2020. The continually growing number of new cases, the global outspread of the virus and the severity of the disease determined the World Health Organization to declare the outbreak a pandemic.Twenty per cent of the patients present severe and critical forms that frequently require oxygen supplementation and intensive care unit admission. That is why, to provide optimal care, it is imperative to identify at-risk patients.Patients with associated chronic diseases are more prone to develop severe and critical forms of the infection. Although the chronic pulmonary obstructive disease is present only in a limited number of coronavirus disease 2019 patients, it is most commonly associated with lung disease and a poor outcome than other comorbidities.</abstract>

Abstract

<div>On 31 December 2019, China reported the World Health Organization (WHO) a cluster of patients with pneumonia caused by an unknown virus. On 12 March 2020 the genetic sequence of the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) responsible for the disease called coronavirus disease 2019 (COVID-19) became public, and on 11 March 2020 WHO declared the outbreak a pandemic. The constantly growing number of new cases, the global outspread of the virus, the severity of the disease and the lack of an effective response were all arguments in making the decision (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_001_w2aab3b7b9b1b6b1ab2b1b1Aa">1</a>).At present, the disease affects more than 200 countries, with more than 50,000 new cases reported every day and more than 290,000 reported deaths (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_001_w2aab3b7b9b1b6b1ab2b1b1Aa">1</a>). The rapid outspread of the disease and the significant mortality rate make it necessary to focus on identifying at-risk patients.There are a few particularities of this disease worth mentioning in regards to the topic.COVID-19 is a polymorphous infectious disease caused by SARS-COV-2. Most of the patients develop mild forms of the disease (81%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_002_w2aab3b7b9b1b6b1ab2b1b2Aa">2</a>), some of whom are fairly asymptomatic (with a ratio of 41.6%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_003_w2aab3b7b9b1b6b1ab2b1b3Aa">3</a>). In these cases, radiological images may be inconsistent with pneumonia or may indicate lung infiltrates with limited extension. In comparison, the severe and critical forms represent approximately 19% and more frequently associate with respiratory failure, intensive care unit (ICU) admission, septic shock and death (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_002_w2aab3b7b9b1b6b1ab2b1b2Aa">2</a>).The positive diagnosis of COVID-19 entails a positive viral nucleic acid test. Since this type of testing is mostly limited, a diagnosis based on epidemiological, clinical and radiological criteria is also accepted. COVID-19 mainly affects patients in the age group of 30–79 years, with only a few patients in the age groups of 0–29 years (10%) and &gt;79 years (3%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_002_w2aab3b7b9b1b6b1ab2b1b2Aa">2</a>). Regarding sex distribution, most of the studies describe men as more frequently affected by the disease (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>). On admission, the patients may present fever (83%–98.6%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>) cough (59.4%–82%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>), fatigue (44%–69.6%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>), anorexia, myalgia, dyspnoea, diarrhoea, dizziness, headache and nausea (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>).Since the disease is highly contagious in the absence of an effective set of preventive measures, we would most likely be facing a large number of severe and even critical cases. Providing optimal care to these patients may become a major challenge as they require especially dedicated personnel, oxygen supplementation and, not seldom, admission to the ICU and ventilator support. Reports show that 15%–20% of the patients diagnosed with COVID-19 need at least a form of oxygen supplementation during the hospital stay (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>).Some patients are more predisposed to develop a severe or critical form than others. Recent studies proved that age, smoking status, associated comorbidities, secondary infections and elevated serum inflammatory parameters are risk factors for developing a severe form of COVID-19 (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_008_w2aab3b7b9b1b6b1ab2b1b8Aa">8</a>). Moreover, patients with at least two comorbidities have a higher risk of requiring intensive care admission, invasive ventilation and associated higher mortality rates as opposed to those with only one associated disease (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>).In this context, it is essential to assess which are the most frequently described comorbidities in patients diagnosed with COVID-19 and whether they have a different impact on the evolution of the disease.In some studies, hypertension (OR: 2.29, <italic>P</italic> &lt; 0.001), diabetes (OR: 2.47, <italic>P</italic> &lt; 0.001), chronic obstructive pulmonary disease (COPD) (OR: 5.97, <italic>P</italic> &lt; 0.001), cardiovascular disease (OR: 2.93, <italic>P</italic> &lt; 0.001) and cerebrovascular disease (OR: 3.89, <italic>P</italic> = 0.002) were independent risk factors associated with COVID-19 patients (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_009_w2aab3b7b9b1b6b1ab2b1b9Aa">9</a>).Generally, the comorbidities were reported based on patients’ statements making it possible to underestimate certain diseases. Commonly described associated pathologies are hypertension (15%–31%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_010_w2aab3b7b9b1b6b1ab2b1c10Aa">10</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_011_w2aab3b7b9b1b6b1ab2b1c11Aa">11</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_012_w2aab3b7b9b1b6b1ab2b1c12Aa">12</a>), cardiovascular diseases (8.4%–53.7%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_010_w2aab3b7b9b1b6b1ab2b1c10Aa">10</a>), diabetes (9.75%–20%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_007_w2aab3b7b9b1b6b1ab2b1b7Aa">7</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_010_w2aab3b7b9b1b6b1ab2b1c10Aa">10</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_011_w2aab3b7b9b1b6b1ab2b1c11Aa">11</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_013_w2aab3b7b9b1b6b1ab2b1c13Aa">13</a>), malignancy (1%–7.2%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>), cerebrovascular diseases (1.9%–5.1%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>), COPD (0.95%–3.2%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_010_w2aab3b7b9b1b6b1ab2b1c10Aa">10</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_013_w2aab3b7b9b1b6b1ab2b1c13Aa">13</a>), chronic kidney disease (1.4%–2.9%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_012_w2aab3b7b9b1b6b1ab2b1c12Aa">12</a>) and immunological diseases (1%–4%) (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_004_w2aab3b7b9b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_005_w2aab3b7b9b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_012_w2aab3b7b9b1b6b1ab2b1c12Aa">12</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_013_w2aab3b7b9b1b6b1ab2b1c13Aa">13</a>,<a ref-type="bibr" href="#j_pneum-2020-0014_ref_014_w2aab3b7b9b1b6b1ab2b1c14Aa">14</a>).Wei-Jie G et al. published a study that describes comorbidities in patients with COVID-19 and their impact on outcomes. The need for invasive ventilation or admission to ICU and death are expressions of a poor outcome. The study included 1,590 patients, of whom 25.1% reported having one comorbidity, and 8.2% reported having multiple comorbidities. COPD, chronic kidney disease, cerebrovascular diseases, immunodeficiency, hepatitis B, hypertension, cardiovascular diseases and malignancy are more common in patients with severe COVID-19 than patients with non-severe COVID-19 (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>). Moreover, COPD is associated with the highest risk in terms of the need for invasive ventilation and mortality. Out of the patients with COVID-19 and COPD, 50% is associated with a poor outcome, two times more than those with COVID-19 and diabetes. Furthermore, 29.2% of patients require admission to ICU and 20.8% need invasive ventilation, and the mortality rate is 25% (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_006_w2aab3b7b9b1b6b1ab2b1b6Aa">6</a>). At the same time, data from multiple individual studies did not prove an association between COPD and severe forms of COVID-19. The small prevalence of COPD in COVID-19 patients may explain the discrepancy. A meta-analysis that pooled the data from the same studies concluded that a COPD patient has more than five times higher risk of developing a severe form of COVID-19 (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_015_w2aab3b7b9b1b6b1ab2b1c15Aa">15</a>).There are several reasons why COPD patients may develop severe forms of COVID-19.First, some studies identify the pulmonary endothelium’s angiotensin-converting enzyme 2 (ACE-2) receptor as the primary gateway for the virus. After analysing samples obtained through bronchoscopic techniques, Leung et al. concluded that smokers and patients suffering from COPD present a higher expression of the <italic>ACE-2</italic> gene, possibly making them more susceptible to the disease. The same mechanism applies to smokers (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_008_w2aab3b7b9b1b6b1ab2b1b8Aa">8</a>).Second, patients with COPD are 16 times more likely to develop pneumonia (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_016_w2aab3b7b9b1b6b1ab2b1c16Aa">16</a>). Multiple factors, such as chronic bronchitis, persistent mucus production, microbiome imbalances, inflammation, impaired host immunity and structural damage, may explain the increased risk of developing pneumonia in COPD patients. Besides being more susceptible to pneumonia, COPD patients require more extended hospital stays and exhibit higher ICU admission rates, when diagnosed with pneumonia (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_017_w2aab3b7b9b1b6b1ab2b1c17Aa">17</a>) in general and may also apply to SARS-COV-2 infection.As many of the COVID-19 patients have multiple comorbidities, the relationship between them is of great importance.In general, COPD patients have significantly more associated diseases than non-COPD patients (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_018_w2aab3b7b9b1b6b1ab2b1c18Aa">18</a>). Among patients with moderate to severe COPD, 99.75% reported having one comorbidity, while over half of them, i.e. 55.5%, have four or more associated diseases (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_019_w2aab3b7b9b1b6b1ab2b1c19Aa">19</a>).Divo et al. described, using lines and knots, the interconnections between the comorbidities of COPD patients and revealed them to be frequent and multiple. The study proves that in the case of COPD patients, coronary artery disease, congestive heart failure, atrial fibrillation, flutter, anxiety and diabetes significantly influence mortality, while systemic hypertension and coronary artery disease influence the patients’ response to pulmonary rehabilitation (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_018_w2aab3b7b9b1b6b1ab2b1c18Aa">18</a>).Recently, there has been a tendency to organise associated diseases into clusters, hoping to evaluate their prognostic value and to facilitate managing these patients. Usually, studies sort comorbidities using five clusters. The first one includes patients with fewer comorbidities. The second one, the cluster of cardiovascular diseases, includes patients diagnosed with hypertension and atherosclerosis. Cachectic patients, who usually suffer from chronic renal diseases and osteoporosis, constitute the third cluster. The metabolic disease cluster includes patients with multiple comorbidities, often diagnosed with obesity, dyslipidaemia, diabetes and hypertension. Last, but of great importance, is the fifth cluster that defines psychological impairment. Patients included in this cluster may suffer from anxiety and depression (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_019_w2aab3b7b9b1b6b1ab2b1c19Aa">19</a>).Studies published on the same topic used other sorting strategies. Some studies describe the same number of clusters but sort the diseases differently. Raherison et al. established among the five clusters, one for patients with COPD and bronchiectasis (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_020_w2aab3b7b9b1b6b1ab2b1c20Aa">20</a>). Others define only three clusters. All aim to find the most relevant formula for arranging comorbidities to predict better the outcome, hospitalisation lengths, costs, the necessity of invasive ventilation and the best treatment courses.When treating a COVID-19 patient with COPD, especially one with moderate to severe COPD, it is crucial to consider that it is highly likely that the patient has at least one other disease and thus presents an increased risk for a poor outcome.While COPD is associated with numerous comorbidities, it is also prevalent in patients suffering from other diseases. Although insufficiently studied, it seems that patients suffering from other illnesses may also have COPD. COPD is present in 5.9% of patients suffering from an acute coronary syndrome, making them more susceptible to heart failure (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_021_w2aab3b7b9b1b6b1ab2b1c21Aa">21</a>), and in 26%–29% of the patients who have atherosclerosis (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_021_w2aab3b7b9b1b6b1ab2b1c21Aa">21</a>, <a ref-type="bibr" href="#j_pneum-2020-0014_ref_022_w2aab3b7b9b1b6b1ab2b1c22Aa">22</a>). More than exposure to higher than normal glycaemic serum levels may lead in time to a diminuation in lung function, making the association diabetes–COPD probable (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_023_w2aab3b7b9b1b6b1ab2b1c23Aa">23</a>).Although prospective studies are still necessary, it is fair to say that probably some of the patients diagnosed with COVID-19 that have underlying conditions might also be undiagnosed COPD patients.Concerning therapy, it seems that these COPD patients could benefit from quarantine. The adherence to controller therapy increased between January and March 2020 with 14.5% (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_024_w2aab3b7b9b1b6b1ab2b1c24Aa">24</a>) reflecting probably the patients’ concern and the increased motivation of asthma and COPD patients. There is a post-COVID recommendation for COPD survivors described by Celli and Fabbri (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_025_w2aab3b7b9b1b6b1ab2b1c25Aa">25</a>). They proposed a management plan that pays special attention to the prompt recognition of cardiovascular complications, especially in 30 days following the resolution of the acute phase of the event. It is another modality to avoid the deaths of survivors after pneumonia from a relatively preventable consequence. Smoking cessation for COPD remains another important recommendation. The chronically increased <italic>ACE-2</italic> gene expression in airways of current smokers (but not former smokers) and patients with COPD, predisposes individuals to increased risk of coronavirus infections. (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_008_w2aab3b7b9b1b6b1ab2b1b8Aa">8</a>). For the other main therapeutic medications, the Global Initiative for Chronic Obstructive Lung Disease (<a ref-type="bibr" href="#j_pneum-2020-0014_ref_026_w2aab3b7b9b1b6b1ab2b1c26Aa">26</a>) recommends not to avoid inhaled (or oral) corticosteroids, during COVID-19 epidemic, to maintain their regular use and also to provide oxygen therapy if needed (following standard recommendations).<sec id="j_pneum-2020-0014_s_001_w2aab3b7b9b1b6b1ab1c23Aa"><div>Conclusions</div>COPD patients remain a fragile and at-risk cohort of patients. The fragility is induced by multiple risk factors such as smoking and pollution, and also by cumulative number of comorbidities and age of this sample of patients.</sec></div>

Keywords

Cuvinte-cheie

<article-title>Comorbidities, COPD and COVID 19</article-title>

Comorbidities, COPD and COVID 19

Impactul comorbidităților asupra pacienților diagnosticați cu BPOC și COVID 19

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title>Persoanele cu vârsta peste 65 de ani și cele care suferă de boli cronice, precum astmul bronșic, fac parte din grupul de risc pentru infecția cu SARS-CoV-2. În trecut, s-a demonstrat existența unei conexiuni între infecțiile virale și astm. Pacienții cu astm par să aibă un risc crescut de a contracta infecții virale, iar virusurile pot provoca exacerbări ale astmului. O altă preocupare în această perioadă a fost reprezentată de administrarea cronică a corticosteroizilor la pacienții astmatici, datorită ideii că aceștia ar scade imunitatea acestor pacienți crescând astfel riscul de infecții, inclusiv cu virusul SARS-COV-2. Au apărut astfel mai multe întrebări cu privire la rolul corticoterapiei în dezvoltarea COVID-19 la pacienții aflați sub tratament cu corticosteroizi, iar majoritatea ghidurilor recomandă continuarea administrării tratamentului cronic la această categorie de pacienți. Totodată sistemul de sănătate a trebuit să se adapteze la situația cauzată de pandemia COVID-19 și să se abată de la metodele standard de gestionare a majorității bolilor cronice, iar aceste modificări au avut impact asupra acestei categorii de pacienți.</trans-abstract>

<abstract><title style='display:none'>Abstract</title>People over the age of 65 and those suffering from chronic diseases, such as asthma, are part of the risk group for severe acute respiratory syndrome-COV-2 (SARS-CoV-2) infection. In the past, a connection between viral infections and asthma has been presented. Patients with asthma appear to be at risk of contracting viral infections, and also viruses can cause asthma exacerbations. Another concern during this period was about the chronic administration of corticosteroids in asthmatic patients, because of the consideration that corticosteroid therapy would decrease the immunity of these patients, thus increasing the risk of infections, including the infection with SARS-CoV-2. Thus, several questions have emerged about the role of corticosteroid therapy in the development of COVID-19 in patients undergoing corticosteroid treatment. Most guidelines recommend continuing the administration of chronic treatment to this category of patients. At the same time, the health system had to adapt to the situation caused by the COVID-19 pandemic and deviate from the standard methods of managing most chronic diseases and these changes had an impact on these category of patients.</abstract>

University of Medicine and Pharmacy “Grigore T. Popa”

<article-title>Challenges in the diagnosis, treatment and management of asthma during COVID-19 pandemic</article-title>

Challenges in the diagnosis, treatment and management of asthma during COVID-19 pandemic

Provocări în diagnosticul, tratamentul și managementul astmului bronșic în pandemia COVID-19

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title><sec><title style='display:none'>Premize</title>Inflamația sistemică are un rol important în apariția, proliferare, invazia, metastazarea, răspunsul la tratament și prognosticul cancerului bronhopulmonar. Raportul neutrofile/limfocite(NLR), raportul trombocite/limfocite(PLR), viteza de sedimentare a hematiilor(VSH), fibrinogenul și lațimea distribuției eritrocitare(RDW) reprezintă modalități de evaluare a inflamației sistemice în cancerul bronhopulmonar.</sec><sec><title style='display:none'>Scop</title>Evaluarea relației dintre NLR, PLR si VSH ca biomarkeri ai inflamației sistemice, stadiile TNM ale cancerului bronhopulmonar și impactul asupra supraviețuirii pacienților.</sec><sec><title style='display:none'>Materiale și metode</title>Pacienți cu diagnostic de cancer bronhopulmonar, stadializat conform ediției a 7-a TNM, împărțiți conform stadiului bolii în două grupuri: Grupul A(stadii rezecabile: I-IIIA) și Grupul B (stadii nonrezecabile: IIIB-IV). Cele două grupuri au fost divizate în câte 2 subgrupuri: pacienți decedați (subgrupurile Ad, Bd) și supraviețuitori(subgrupurile As, Bs). S-au determinat: hemoleucograma (HLG), VSH, NLR, PLR. Rezultatele au fost comparate între cele două grupuri și subgrupurile lor.</sec><sec><title style='display:none'>Rezultate</title>Analiza a 102 pacienți consecutivi. În Grupul A (31): NLR:2,74(0,87-12,94), PLR:133,95 (21,61-416,66), ESR:35 mm/h (6-135). Subgrupul As: NLR:2,36 (0,87-8,36), PLR:138,82 (21,61-416,66), ESR:15 mm/h (6-110). Subgrupul Ad: NLR:2,77 (1,25-12,94), PLR:132,57 (41,11-371,17), ESR:62 mm/h (11-135). În Grupul B (71): NLR: 3,51(0,76-25,60), PLR: 170,37 (3,38-651,25), ESR:40 mm/h (3-120). Subgrupul Bs: NLR:1,40 (1,32-1,73), PLR:112,89 (91,14-140,54), ESR:31mm/h (9-90). Subgrupul Bd: NLR:3,59 (0,70-25,60), PLR:183,50 (3,38-651,25), ESR:44 mm/h (3-120). În Grupul B al pacienților cu stadii nonrezecabile, valorile rapoartelor NLR și PLR au fost semnificativ mai mari (p: 0.04, p: 0.05) decât în Grupul A (pacienți cu stadii rezecabile). Pacienții cu stadii nonrezecabile, decedați (subgrup Bd), au avut valori ale NLR si PLR semnificativ mai mari (p: 0.01, p: 0.03) comparativ cu pacienții supraviețuitori (Subgrup Bs). Nu același lucru s-a putut constata în cazul pacienților cu stadii rezecabile, decedați, la care doar valoarea VSH a fost semnificativ mai mare la decedați decât la cei supraviețuitori.</sec><sec><title style='display:none'>Concluzie</title>Inflamația sistemică evaluată prin biomarkeri accesibili precum raportul neutrofile limfocite (NLR) și raportul trombocite limfocite (PLR) este mai pronunțată în stadiile avansate, nonrezecabile ale cancerului bronhopulmonar și pare să influențeze negativ, alături de stadiul bolii, supraviețuirea pacienților. Atât raportul neutrofile limfocite (NLR) cât și raportul trombocite limfocite (PLR) ar putea avea aplicabilitate clinică în decizia terapeutică personalizată a pacienților cu stadii avansate ale cancerului pulmonar.</sec></trans-abstract>

<abstract><title style='display:none'>Abstract</title><sec><title style='display:none'>Background</title>It is recognised that systemic inflammation plays an important role in the development and progression of lung cancer. Several affordable biomarkers could be used to evaluate systemic inflammation: neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and erythrocyte sedimentation rate (ESR). These biomarkers may be linked with survival in lung cancer.</sec><sec><title style='display:none'>Aim</title>To assess the relation between systemic inflammation evaluated by NLR, PLR and ESR, tumour nodes metastasis (TNM) staging and negative outcome in lung cancer.</sec><sec><title style='display:none'>Materials and methods</title>Patients with lung cancer were classified (7th TNM lung cancer staging) into two groups: Group A (resectable stages) and Group B (nonresectable stages). Each group was divided into two subsets: survivors (As, Bs) and deceased (Ad, Bd) patients. Complete blood count (CBC) and ESR were determined. NLR and PLR were calculated. NLR, PLR and ESR values were compared between the two groups and their subsets.</sec><sec><title style='display:none'>Results</title>102 consecutive patients completed the protocol. In Group A (31 patients): NLR: 2.74 (0.87–12.94), PLR: 33.95 (21.61–416.66), ESR: 35 mm/h (6–135). Subgroup As: NLR: 2.36 (0.87–8.36), PLR: 138.82 (21.61–416.66), ESR: 15 mm/h (6–110). Subgroup Ad: NLR: 2.77 (1.25–12.94), PLR: 132.57 (41.11–371.17), ESR: 62 mm/h (11–135). In Group B (71 patients): NLR: 3.51(0.76–25.60), PLR: 170.37 (3.38–651.25), ESR:40 mm/h (3–120). Subgroup Bs: NLR: 1.40 (1.32–1.73), PLR: 112.89 (91.14–140.54), ESR: 31 mm/h (9–90). Subgroup Bd: NLR: 3.59 (0.70–25.60), PLR: 183.50 (3.38–651.25), ESR: 44 mm/h (3–120). NLR and PLR values were significantly higher (p: 0.04; p: 0.05) in Group B versus Group A. No significant difference was noted for ESR values between the two groups. In patients with nonresectable stages who were deceased (subgroup Bd), NLR and PLR values were significantly higher (p: 0.01; p: 0.03) versus survivals. In patients with resectable stages who were deceased (subgroup Ad), only the ESR value was significantly higher versus survivals.</sec><sec><title style='display:none'>Conclusions</title>Systemic inflammation assessed by affordable biomarkers as NLR and PLR is more prominent in advanced, nonresectable lung cancer. It may be a contributor, along with TNM staging, to the poor outcome of patients with nonresectable lung cancer.</sec><sec><title style='display:none'>Clinical implication</title>NLR and PLR may represent a valuable additional tool in the clinical management of patients with nonresectable lung cancer.</sec></abstract>

”Dr. Carol Davila” Central Military Emergency Universitary Hospital Bucharest

Carol Davila University of Medicine and Pharmacy

<article-title>Systemic inflammation, TNM staging and survival in patients with lung cancer</article-title>

Systemic inflammation, TNM staging and survival in patients with lung cancer

Relația dintre inflamația sistemică, stadializarea TNM și suprviețuire la pacienții cu diagnostic de cancer bronhopulmonar

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title><sec><title style='display:none'>Introducere</title>În gestionarea bolilor respiratorii cronice, cum ar fi astmul și boala pulmonară obstructivă cronică (BPOC), aderența la terapie reprezintă o cheie a succesului.</sec><sec><title style='display:none'>Obiectiv</title>Obiectivul a fost creșterea aderenței la tratament prin dezvoltarea intervenției educaționale (IE) pentru astm și BPOC, adresată pacienților și medicilor de familie. Programul educațional a inclus sesiuni educaționale de grup și materiale educaționale și s-a desfășurat în cinci spitale din România. Rezultatele au fost evaluate prin chestionarul Test de aderență la inhalatoare (TAI).</sec><sec><title style='display:none'>Rezultate</title>Au fost incluși 347 de medici de familie și 435 de pacienți. Șaizeci și șase la sută din medicii de familie au considerat că principalele cauze ale neaderării sunt neînțelegerea bolii, dificultatea utilizării medicamentelor inhalatorii, teama de efecte adverse, convingerea pacientului că niciun medicament nu este util pentru boala și latura financiară (20%). Cincizeci și cinci la sută dintre medicii de familie chestionați cred că pacienții lor respectă întotdeauna sau de cele mai multe ori terapia inhalatorie, dar 57% din aceiași medici de familie chestionați au verificat tehnica de inhalare a pacienților lor uneori, rar sau niciodată. Doar 44% dintre medicii de familie au discutat cu pneumologul despre boala pacientului lor. Înainte de IE, doar 32% dintre pacienți aveau un scor de aderență bun la terapie; acest procent a crescut la 57% după IE. Cele mai frecvente motive pentru neaderare au fost: pacientul uită să-și administreze zilnic medicamentele inhalatorii (49%), teama de efectele adverse (33%), credința că medicamentul este inutil (26%) și teama că medicamentul inhalator afectează viața de zi cu zi a pacientului (24%). Aproape jumătate dintre pacienți (47%) renunță la medicamente atunci când se simt mai bine. 40% din pacienți renunță la tratamentele inhalatorii din motive financiare. Cele mai influențate comportamente ca urmare a IE au fost componenta psihologică (85%), frica de evenimentele adverse (82%) și componenta socială (79%).</sec><sec><title style='display:none'>Concluzii</title>Neaderarea la terapie rămâne o problemă reală la pacienții cu astm și BPOC din grupul nostru de studiu, dar intervenția educațională a avut efecte pozitive. Extinderea programelor de educație medicală pentru pacienți axată pe principalele motive ale aderenței slabe, cum ar fi uitarea de a lua medicamente zilnic, utilizarea dispozitivelor inhalatorii, neînțelegerea bolii lor, poate crește semnificativ respectarea tratamentului inhalator.</sec></trans-abstract>

<abstract><title style='display:none'>Abstract</title><sec><title style='display:none'>Background</title>In the management of chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD), adherence to therapy represents a key to success.</sec><sec><title style='display:none'>Objective</title>The objective was to increase adherence to treatment through the development of educational intervention (EI) for asthma and COPD, addressed to patients and general practitioners (GPs). The educational programme includes group educational sessions and educational materials and was carried out in five Romanian hospitals. The results were assessed through Test of Adherence to Inhalers (TAI) questionnaire.</sec><sec><title style='display:none'>Results</title>Of note, 347 GPs and 435 patients were included. Seventy-six per cent of the GPs considered that the main causes of non-adherence are the disease misunderstanding, difficulty of using inhaled medication, fear of adverse effects, the patient’s conviction that no medicine is useful for his illness and financial nature (20%). Fifty-five per cent of surveyed GPs believed that their patients always or most of the time adhere to inhaled therapy but 57% of the same surveyed GPs checked the inhalation technique of their patients sometimes, rarely or never. Only 44% of the GPs discussed with the pulmonologist about their patient’s disease. Before the EI, only 32% of patients had a good adherence score to therapy; this percentage increases to 57% after EI. The most common reasons for non-adherence were: patient forgets to administer his inhalation medication daily (49%), fear of adverse effects (33%), belief that medication is useless (26%), and fear that inhalation medication affects everyday life of the patient (24%). Nearly half of the patients (47%) give up medication when they feel better. Forty per cent of patients drop off inhalation treatments due to financial reasons. The most influenced behaviours as a result of the EI were psychological component (85%), fear of the adverse events (82%) and social component (79%).</sec><sec><title style='display:none'>Conclusions</title>The non-adherence to therapy remains a real problem in asthma and COPD patients in our study group, but EI had positive effects. Extending medical education programmes for patients focused on main reasons of poor adherence, such as forgetting to take medication daily, use of inhalator devices, not understanding their disease, may significantly increase adherence to inhalation treatment.</sec></abstract>

University of Medicine and Pharmacy Carol Davila

University of Medicine and Pharmacy Victor Babes

University of Medicine and Pharmacy Iuliu Hatieganu

Faculty of Medicine – Ovidius University

<article-title>INSPIRO project – Educational intervention against non-adherence to inhalation therapy for Romanian asthma and COPD patients</article-title>

INSPIRO project – Educational intervention against non-adherence to inhalation therapy for Romanian asthma and COPD patients

Proiect INSPIRO - Intervenție educațională împotriva non-aderenţei la terapia inhalatorie a pacienților români cu astm și BPOC

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title><sec><title style='display:none'>Introducere</title>Pericardita neoplazica poate apare in orice tip de cancer, insa este mai frecventa in cancerul pulmonar, neoplasmul mamar si limfoame.</sec><sec><title style='display:none'>Material si metoda</title>Am studiat 156 de pacienti oncologici consecutivi care s-au prezentat cu pericardita in intervalul 2010 – 2015. Din acestia, 80 au fost stabili, fara indicatie de drenaj sau biopsie pericardica, iar 76 de pacienti au necesitat interventie chirurgicala pentru drenaj pericardic si biopsie.</sec><sec><title style='display:none'>Rezultate</title>Ecografia cardiaca si tomografia computerizata au fost esentiale in aprecierea topografiei lichidului pericardic si a efectului hemodinamic, in plus au ajutat la alegerea caii de abord chirurgical. Procedeele chirurgicale de drenaj pericardic au fost: pericardiocenteza, drenajul pericardic subxifoidian, drenajul pericardic paraxifoidian, fenestrarea pericardo-pleurala prin chirurgie toracica video-asistata CTVA sau prin chirurgie toracica clasica. Douazeci si trei de pacienti (14.7%) s-au prezentat cu tamponada cardiaca. Rata de recurenta dupa drenajul pericardic a fost 3.89%. Supravietuirea imediata la 48h a fost de 97.3%.</sec><sec><title style='display:none'>Concluzii</title>Supravietuirea pe termen lung la pacientii oncologici cu pericardita drenata este influentata majoritar de tipul neoplaziei subiacente. Am observat supravietuire mai buna la cei fara tamponada cardiaca. Supravietuirea imediata este influentata de aparitia socului pericardic, sau sindromul postoperator de debit cardiac scazut, sau sindromul de decompresie pericardica. Indicatia de drenaj pericardic depinde de cantitatea de lichid pericardic, de prezenta tamponadei, de asocierea pleureziei si de necesitatea obtinerii biopsiei, oferind astfel pacientilor maximul posibil de siguranta si beneficiu.</sec></trans-abstract>

<abstract><title style='display:none'>Abstract</title><sec><title style='display:none'>Introduction</title>Neoplastic pericarditis may develop in any type of cancer, but it is found more frequently in lung cancer, breast cancer and lymphoma.</sec><sec><title style='display:none'>Methods</title>We studied 156 consecutive oncological patients presented with pericardial fluid between 2010 and 2015. Among them, 80 patients were stable, with no indication for pericardial drainage or biopsy, and 76 patients needed surgery to evacuate the pericardium and obtain biopsy.</sec><sec><title style='display:none'>Results</title>Echocardiography and computed tomography were essential in evaluating the topography of the pericardial fluid and the haemodynamic effect, and these investigations helped us choose the appropriate surgical procedure. We performed pericardiocentesis, subxiphoid pericardial drainage, left paraxifoidian pericardial drainage, pericardio-pleural window through intercostal video-assisted thoracic surgery (VATS) or through classical thoracic surgery. Twenty-three patients (14.7%) were admitted and treated for cardiac tamponade. The rate of recurrence after pericardial drainage was 3.89%. The immediate survival at 48 h was 97.3%.</sec><sec><title style='display:none'>Conclusion</title>Long-term survival in patients with malignancy and drained pericardial effusion is influenced mainly by the type of underlying malignant disease. We observed a better survival in patients without cardiac tamponade. Immediate survival depends on the pericardial shock complication – postoperative low cardiac output syndrome (LCOS) or pericardial decompression syndrome (PDS). The indication for pericardial drainage depends on the quantity of pericardial fluid, presence of tamponade, associated pleural effusion and need for biopsy, offering the maximum possible benefit and safety for the patient.</sec></abstract>

<div><sec id="j_pneum-2020-0020_s_001_w2aab3b7c48b1b6b1ab1aAa"><div>Introduction</div>The pericardium is composed of a fibrous parietal membrane and a thin visceral membrane. The space between them usually contains &lt;50 ml of plasma ultrafiltrate (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_001_w2aab3b7c48b1b6b1ab2b1b1Aa">1</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_002_w2aab3b7c48b1b6b1ab2b1b2Aa">2</a>). The parietal pericardium is non-compliant – if the fluid accumulates rapidly, the pressure in the pericardial space increases, which can compromise the diastolic filling of the right heart and lead to tamponade (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_003_w2aab3b7c48b1b6b1ab2b1b3Aa">3</a>). However, if the fluid accumulates slowly, the pericardium can enlarge and may accumulate &gt;2,000 ml fluid.Patients with cancer usually accumulate pericardial fluid slowly (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_002_w2aab3b7c48b1b6b1ab2b1b2Aa">2</a>). This may develop in any type of cancer, but this condition is found with increased frequency in lung cancer, followed by breast cancer and lymphoma (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_005_w2aab3b7c48b1b6b1ab2b1b5Aa">5</a>). The incidence of increased pericardial fluid in patients with cancer has been proven in 15%–20% during autopsies (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_006_w2aab3b7c48b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_007_w2aab3b7c48b1b6b1ab2b1b7Aa">7</a>).</sec><sec id="j_pneum-2020-0020_s_002_w2aab3b7c48b1b6b1ab1b1Aa"><div>Materials and methods</div>We studied 156 oncological patients consecutively presenting with pericardial fluid between 2010 and 2015. There were 74 women and 82 men. Patients ranged in age from 28 to 83 years, with a predilection in the sixth and seventh decades of life.The electrocardiogram (ECG) of patients with intrapericardial fluid was either normal or with low QRS voltage, ST/T-wave changes, as described in the literature (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_005_w2aab3b7c48b1b6b1ab2b1b5Aa">5</a>). The chest X-ray showed enlarged cardiac silhouette when the quantity of the pericardial fluid was high (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_005_w2aab3b7c48b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_008_w2aab3b7c48b1b6b1ab2b1b8Aa">8</a>).Echocardiography (<a ref-type="fig" href="#j_pneum-2020-0020_fig_001_w2aab3b7c48b1b6b1ab1b1b4Aa">Figure 1</a>) is the most important method of evaluating the presence, location and haemodynamic effect of pericardial fluid on the right heart (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_002_w2aab3b7c48b1b6b1ab2b1b2Aa">2</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_009_w2aab3b7c48b1b6b1ab2b1b9Aa">9</a>).<fig id="j_pneum-2020-0020_fig_001_w2aab3b7c48b1b6b1ab1b1b4Aa" position="float" fig-type="figure"><label>Figure 1</label><caption>Echocardiography showing the presence of massive pericardial fluid. The thickness of pericardial fluid at the apex is 4.6 cm (upper left corner).</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_001.jpg"/></fig>Computed tomography (<a ref-type="fig" href="#j_pneum-2020-0020_fig_002_w2aab3b7c48b1b6b1ab1b1b6Aa">Figure 2</a>) evaluates the presence, topography and thickness of the pericardial fluid. Especially in oncological patients, thoracic CT scan offers information about other modifications inside the thorax due to the underlying malignancy (tumours, pleurisy, and so on). The CT scan helps the surgeon to choose the appropriate surgical procedure (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_010_w2aab3b7c48b1b6b1ab2b1c10Aa">10</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_011_w2aab3b7c48b1b6b1ab2b1c11Aa">11</a>).<fig id="j_pneum-2020-0020_fig_002_w2aab3b7c48b1b6b1ab1b1b6Aa" position="float" fig-type="figure"><label>Figure 2</label><caption>Computed tomography scan shows the circumferential pericardial fluid without pericardial adhesions, significant left pleurisy with lung collapse and medium right pleurisy.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_002.jpg"/></fig>Among all 156 patients with pericardial effusion, 80 were asymptomatic and clinically stable – cardiac follow-up was indicated (clinical symptoms, ECG and cardiac ultrasonography), and they received treatment for the underlying malignancy. Seventy-six patients were symptomatic and needed surgery to evacuate the pericardial fluid. Surgical interventions were performed based on the clinical, biological and oncological status of the patient.</sec><sec id="j_pneum-2020-0020_s_003_w2aab3b7c48b1b6b1ab1b2Aa"><div>Results</div>Pericardial effusion appeared most frequently in lung cancer (93 patients), followed by breast cancer (34 patients), lymphoma (eight patients) and other types of neoplasia (<a ref-type="fig" href="#j_pneum-2020-0020_fig_003_w2aab3b7c48b1b6b1ab1b2b2Aa">Figure 3</a>): five cases of cervical cancer, two cases of melanoma and one each of the following types: renal, endometrial, vulvar, colonic, ovarian, gastric, prostatic, thymic and basal cell carcinomas, lip neoplasm, fibrosarcoma, teratoma and mesothelioma.<fig id="j_pneum-2020-0020_fig_003_w2aab3b7c48b1b6b1ab1b2b2Aa" position="float" fig-type="figure"><label>Figure 3</label><caption>Distribution of the 156 patients according to the primary neoplasia.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_003.jpg"/></fig>More than half of our patients were smokers (88 patients, 56.4%) (<a ref-type="fig" href="#j_pneum-2020-0020_fig_004_w2aab3b7c48b1b6b1ab1b2b4Aa">Figure 4</a>), probably because of the high number of lung neoplasia cases.<fig id="j_pneum-2020-0020_fig_004_w2aab3b7c48b1b6b1ab1b2b4Aa" position="float" fig-type="figure"><label>Figure 4</label><caption>Distribution of patients with malignant pericardial effusion according to smoking status.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_004.jpg"/></fig>Among the 156 patients, 23 were admitted with cardiac tamponade and managed in emergency.The surgical interventions for the 76 patients were chosen based on their clinical status, the presence of the tamponade and the possibility to receive general anaesthesia, the topography and quantity of pericardial fluid and the presence of pleural fluid. In addition, the need for pericardial biopsy (expressed by the clinical oncologist) played an important role in choosing the surgical procedure. The surgical procedures performed in our patients were pericardiocentesis (needle-based partial evacuation of the pericardial fluid), subxiphoid pericardial drainage, left paraxifoidian pericardial drainage, pericardiopleural window through intercostal video-assisted thoracic surgery (VATS) or through classical thoracic surgery (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_012_w2aab3b7c48b1b6b1ab2b1c12Aa">12</a>) (<a ref-type="fig" href="#j_pneum-2020-0020_fig_005_w2aab3b7c48b1b6b1ab1b2b7Aa">Figures 5</a> and <a ref-type="fig" href="#j_pneum-2020-0020_fig_006_w2aab3b7c48b1b6b1ab1b2b8Aa">6</a>).<fig id="j_pneum-2020-0020_fig_005_w2aab3b7c48b1b6b1ab1b2b7Aa" position="float" fig-type="figure"><label>Figure 5</label><caption>Types of surgical interventions performed in the 76 cases with indication for pericardial drainage. VATS = video-assisted thoracic surgery.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_005.jpg"/></fig><fig id="j_pneum-2020-0020_fig_006_w2aab3b7c48b1b6b1ab1b2b8Aa" position="float" fig-type="figure"><label>Figure 6</label><caption>Pericardial fenestration by uniportal video-assisted thoracic surgery: (1) tensioned pericardium is incised with thoracoscopic cautery and haemorrhagic pericardial fluid is evacuated slowly and (2) after evacuation, the pericardium (thicker than usual) is fenestrated, the heart is directly visible and the pericardial fragment is sent to pathology.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_006.jpg"/></fig>The rate of recurrence after pericardial drainage was 3.89%. The immediate survival at 48 h was 97.3% (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_012_w2aab3b7c48b1b6b1ab2b1c12Aa">12</a>).The 80 patients without indication for pericardial drainage were monitored; they received non-steroidal anti-inflammatory drugs, according to cardiologist recommendation, and when indicated by the oncologist, the oncological treatment was continued.</sec><sec id="j_pneum-2020-0020_s_004_w2aab3b7c48b1b6b1ab1b3Aa"><div>Discussion</div>Pericardial effusion may appear in any type of cancer (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_013_w2aab3b7c48b1b6b1ab2b1c13Aa">13</a>). Clinical manifestation may vary from asymptomatic to haemodynamic collapse secondary to cardiac tamponade (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_001_w2aab3b7c48b1b6b1ab2b1b1Aa">1</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_008_w2aab3b7c48b1b6b1ab2b1b8Aa">8</a>). The most accurate prevalence data of pericardial effusion come from autopsies, with studies reporting prevalence up to 20% (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_007_w2aab3b7c48b1b6b1ab2b1b7Aa">7</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_012_w2aab3b7c48b1b6b1ab2b1c12Aa">12</a>).The long-term survival of cancer patients with pericardial effusions is not influenced by age or sex and is not affected by the surgical technique used. The type of cancer carries the long-time prognosis in patients with neoplastic pericarditis (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_008_w2aab3b7c48b1b6b1ab2b1b8Aa">8</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_011_w2aab3b7c48b1b6b1ab2b1c11Aa">11</a>). The worst survival rate is in lung cancer, and the best long-term survival is found in lymphomas and breast cancer, mainly because of their good response to chemotherapy (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_004_w2aab3b7c48b1b6b1ab2b1b4Aa">4</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_008_w2aab3b7c48b1b6b1ab2b1b8Aa">8</a>).In our study, lung cancer was the most frequent type of neoplasia, i.e. 93 out of 156 cases, almost 60%. In fact, the 16 open (through thoracotomy) pericardial fenestrations were performed in patients who intraoperatively proved to have unresectable tumours associated with pericardial fluid – the pericardium was opened for drainage but mainly for intrapericardial assessment of resectability of the tumour. Most of the patients (13 out of 16) had lung cancer, this pathology being the vast majority of presentations in our clinic, as we presented elsewhere (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_014_w2aab3b7c48b1b6b1ab2b1c14Aa">14</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_015_w2aab3b7c48b1b6b1ab2b1c15Aa">15</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_016_w2aab3b7c48b1b6b1ab2b1c16Aa">16</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_017_w2aab3b7c48b1b6b1ab2b1c17Aa">17</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_018_w2aab3b7c48b1b6b1ab2b1c18Aa">18</a>).The significance of the 48h survival period is that, following the pericardial drainage, the main specific complication is postoperative low cardiac output syndrome (LCOS), pericardial decompression syndrome (PDS) or pericardial shock, which remains the main cause of mortality and, therefore, influences the immediate survival (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_001_w2aab3b7c48b1b6b1ab2b1b1Aa">1</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_019_w2aab3b7c48b1b6b1ab2b1c19Aa">19</a>). To reduce the risk of pericardial shock, we must evacuate the pericardium slowly, monitor the heart and use inotropic support (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_001_w2aab3b7c48b1b6b1ab2b1b1Aa">1</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_019_w2aab3b7c48b1b6b1ab2b1c19Aa">19</a>).At 5 years after the last enrolled patient, we have 12 patients alive out of 156, i.e. 7.69%. Estimated survival at 5 years is presented in <a ref-type="fig" href="#j_pneum-2020-0020_fig_007_w2aab3b7c48b1b6b1ab1b3b6Aa">Figure 7</a>, comparing two groups of patients: with or without pericardial drainage. The differences are not statistically significant (<italic>p</italic> = 0.07). Analysing the graphs, we can observe a better survival for patients with pericardial drainage after 1 year.<fig id="j_pneum-2020-0020_fig_007_w2aab3b7c48b1b6b1ab1b3b6Aa" position="float" fig-type="figure"><label>Figure 7</label><caption>Kaplan–Meier survival curves for operated and conservatively treated patients. No statistically significant differences were observed between the survival rates of patients who underwent surgery and those treated conservatively (<italic>p</italic> = 0.07).</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_007.jpg"/></fig>In addition, comparing the calculated survival rate of patients with or without tamponade (<a ref-type="fig" href="#j_pneum-2020-0020_fig_008_w2aab3b7c48b1b6b1ab1b3b8Aa">Figure 8</a>), we observe the difference to be statistically non-significant, but from the graphs, the patients without tamponade present a better survival.<fig id="j_pneum-2020-0020_fig_008_w2aab3b7c48b1b6b1ab1b3b8Aa" position="float" fig-type="figure"><label>Figure 8</label><caption>Kaplan–Meier survival curves for patients with and without cardiac tamponade who received pericardial drainage.</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0020_fig_008.jpg"/></fig>These two findings support the idea that long-term survival is influenced mainly by the type of malignant disease, similar to the one presented earlier.Pericardiocentesis can be done rapidly, using only anatomic landmarks and/or echographic guidance, under local anaesthesia. However, it is associated with high rate of recurrence, up to 50%, and a significant mortality and cardiac complications, compared with any other pericardial approach (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_003_w2aab3b7c48b1b6b1ab2b1b3Aa">3</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_009_w2aab3b7c48b1b6b1ab2b1b9Aa">9</a>). In addition, in patients with malignancy, it cannot provide pericardial biopsy when needed.The lowest rate of recurrence is found for the pericardiopleural window done thoracoscopically or by VATS, followed by subxifoidian and left paraxifoidian drainages (<a ref-type="bibr" href="#j_pneum-2020-0020_ref_006_w2aab3b7c48b1b6b1ab2b1b6Aa">6</a>,<a ref-type="bibr" href="#j_pneum-2020-0020_ref_011_w2aab3b7c48b1b6b1ab2b1c11Aa">11</a>). The subxifoidian and left paraxifoidian approaches are, in fact, ways to evacuate the pericardium, drain it with a tube and obtain pericardial biopsy; after removal of the tube, the pericardium remains opened into the mediastinum – a pericardio-mediastinal fenestration. This is the reason why we perform the pericardial biopsy and fenestration as wide as we can. In our study, the rate of recurrence after pericardial drainage was 3.89%.</sec><sec id="j_pneum-2020-0020_s_005_w2aab3b7c48b1b6b1ab1b4Aa"><div>Conclusions</div>In conclusion, the overall prognosis of patients with malignant pericardial effusion remains poor, linked to their underlying malignancy, mainly depending on the response of the malignancy to oncological treatment. The immediate prognosis depends on the pericardial shock complication, also known as postoperative LCOS (low cardiac output syndrome) or PDS (pericardial decompression syndrome). The procedure of surgical drainage of pericardial effusion in each oncological patient must be chosen depending on the presence of tamponade, the quantity of pericardial fluid, the associated pleural effusion and the need for biopsy, offering the maximum possible benefit and safety from the surgical procedure.</sec></div>

University of Medicine and Pharmacy ‘Carol Davila’

<article-title>Management of neoplastic pericarditis – overview of 156 patients</article-title>

Management of neoplastic pericarditis – overview of 156 patients

Managementul pericarditelor neoplazice – evaluarea a 156 de pacienti

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title>COVID-19 a fost descris ca fiind responsabil de status proinflamator și hipercoagulant capabil să inducă leziuni trombotice vasculare, și în cazuri mai severe, coagulare intravasculară diseminată. Valorile crescute ale D-dimerilor se corelează cu o boală mai severă și un prognostic mai prost. Studiile efectuate în secțiile de terapie intensivă au raportat un risc mai mare de embolie pulmonară și tromboză venoasă profundă la pacienții cu COVID-19 comparativ cu grupul de control, chiar și la acei pacienți la care s-a efectuat anticoagulare profilactică. Pacienții cu COVID-19, stabili din punct de vedere clinic nu necesită spitalizare și sunt tratați acasă cu simptomatice. Heparinele cu greutate moleculară mică sunt rezervate pentru acei pacienții care nu se mobilizează. Acest articol descrie cazul unui pacient cu infecție COVID-19 tratat la domiciliu care a dezvoltat, tromboză arterială pulmonară.</trans-abstract>

<abstract><title style='display:none'>Abstract</title>COVID-19 has been described as the cause for a proinflammatory and hypercoagulable state that induces thrombotic vascular lesions and, in more severe cases, disseminated intravascular coagulation. Increased values of <sc>d</sc>-dimers are related to the severity of the disease and are associated with worst prognosis. Intensive care studies reported an increased risk of pulmonary embolism and venous thrombosis diseases in COVID-19 compared with the historical control group even in patients who underwent the low-molecular-weight heparin (LWMH) prophylaxis. Patients with COVID-19 who have a stable clinical condition do not require hospitalisation and are treated at home with symptomatic therapy. LWMH is reserved for those with reduced mobility. In this case report, we describe a COVID-19 patient with pulmonary artery thrombosis treated at home.</abstract>

<div><sec id="j_pneum-2020-0012_s_001_w2aab3b7b3b1b6b1ab1aAa"><div>Introduction</div>Arising in China in the winter of 2019, the infection with the novel coronavirus – severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was described in people who had been exposed to seafood market in Wuhan. Since then, there has been a quick spread of the disease, leading to a global pandemic of coronavirus disease (COVID-19) (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_001_w2aab3b7b3b1b6b1ab2b1b1Aa">1</a>). After an incubation period of 4–5 days, patients who become symptomatic have fever, cough, sore throat, malaise and myalgias. A minority of cases occur with gastrointestinal symptoms (anorexia, nausea and diarrhoea) or neurological symptoms (anosmia and ageusia). Most patients (80%) have mild or moderate disease (including those with mild pneumonia), 15% had severe disease (diffuse lung injury) and 5% had critical illness (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_002_w2aab3b7b3b1b6b1ab2b1b2Aa">2</a>). Patients with respiratory failure are usually monitored in hospital, while those with mild illness usually recover at home with supportive care and isolation. Self-monitoring of oxygen saturation is a useful tool for people who are at high risk for complications (lung diseases, cardiovascular diseases, diabetes and obesity) (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_003_w2aab3b7b3b1b6b1ab2b1b3Aa">3</a>). COVID-19 has been well described as the cause of a proinflammatory and hypercoagulable state. After 7–14 days from the onset of the symptoms, there is a systemic increase of inflammatory mediators and cytokines (CK) (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_004_w2aab3b7b3b1b6b1ab2b1b4Aa">4</a>). The inflammatory response induces a procoagulant effect and a diffuse endothelial damage that determine thrombotic vascular lesions and disseminated intravascular coagulation (DIC) in patients with critical illness (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_005_w2aab3b7b3b1b6b1ab2b1b5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0012_ref_006_w2aab3b7b3b1b6b1ab2b1b6Aa">6</a>). Increased values of <sc>d</sc>-dimers are related to the severity of the disease and are associated with the worst prognosis. Intensive care studies reported an increased risk of pulmonary embolism (PE) and venous thrombosis diseases (VTD) in COVID-19 compared with the historical control group even in patients who underwent the low-molecular-weight heparin (LMWH) prophylaxis (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_007_w2aab3b7b3b1b6b1ab2b1b7Aa">7</a>). Monitoring <sc>d</sc>-dimers blood value has to be useful in identifying cases with a poor prognosis and higher risk of thrombotic phenomena (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_008_w2aab3b7b3b1b6b1ab2b1b8Aa">8</a>). Stable patients infected with COVID-19 do not require hospitalisation and are treated at home (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_009_w2aab3b7b3b1b6b1ab2b1b9Aa">9</a>). LMWH is reserved for those with reduced mobility. Home-treated patients do not undergo laboratory exams or radiological investigations in any phases of the disease. In this case report, we describe a COVID-19 patient with pulmonary artery thrombosis, treated at home with hydroxychloroquine.</sec><sec id="j_pneum-2020-0012_s_002_w2aab3b7b3b1b6b1ab1b1Aa"><div>Case presentation</div>A 57-year-old male with a history of virus B hepatitis (VHB) was admitted to our hospital after 3 days history of fever and chest pain. He was an active person and did not have any history of chronic medication. The diagnosis of COVID-19 was based on the detection of SARS-CoV-2 by means of reverse transcriptase polymerase chain-reaction (RT-PCR) assay on nasopharyngeal swab 1 month before admission. After the diagnosis, he started hydroxychloroquine (400 mg/day) for 10 days.On examination, he was breathing regularly without dyspnoea with body temperature 37.7°C, heart rate 88 beats/min, blood pressure 145/65 mmHg, respiratory rate 16 breaths/min, oxygen saturation 96% at room air and body mass index (BMI) 26 kg/m2. Heart sounds were regular and lung auscultation was clear in both lungs. Laboratory test showed: white blood cell count (WBC) = 12.960 mmc, neutrophils 10.730 mmc, C-reactive protein (CRP) 53 mg/L (normal value (NV) &lt; 5), alanine aminotransferase (ALT) 214 U/L, <sc>d</sc>-dimers 3,742 mg/L (NV &lt; 500), HIV-negative. Arterial blood gases (ABG) in breathing air showed a pH of 7.45, PaCO2 40 mmHg, PaO2 89 mmHg, satO2 = 95%. Electrocardiography (EKG) was unremarkable. Doppler ultrasonography (DU) of the lower limbs was negative for deep venous thrombosis (DVT) while a computed tomography pulmonary angiography (CTPA) demonstrated a bilateral arterial thrombosis associated with ground glass opacity (GGO) in the lower lobes (<a ref-type="fig" href="#j_pneum-2020-0012_fig_001_w2aab3b7b3b1b6b1ab1b1b3Aa">Figure 1</a>). His nasal swab resulted positive for COVID-19. The patient started anticoagulation with LWMH 8,000 U twice a day. Abdominal ultrasonography did not demonstrate any signs of cirrhosis, hepatic focal lesions or portal hypertension.<fig id="j_pneum-2020-0012_fig_001_w2aab3b7b3b1b6b1ab1b1b3Aa" position="float" fig-type="figure"><label>Figure 1</label><caption>CT thorax with contrast (sagittal view) showing bilateral lower arterial thrombosis (red arrows).</caption><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0012_fig_001.jpg"/></fig>Echocardiogram showed normal left and right ventricular wall motion, left ventricle ejection fraction 60% and a normal pulmonary artery pressure (20 mmHg).After 5 days of hospitalisation, laboratory exams showed WBC 8,720 mmc, ALT 207 U/L and <sc>d</sc>-dimer 1,425 mg/L. The patient had stable clinical condition without dyspnoea and fever, and the chest pain gradually improved. During discharge (13 days later), he continued anticoagulation therapy with warfarin. His nasal–pharyngeal swab was negative for COVID-19.</sec><sec id="j_pneum-2020-0012_s_003_w2aab3b7b3b1b6b1ab1b2Aa"><div>Discussion</div>This article describes the case of a patient with mild COVID-19 and pulmonary artery thrombosis initially treated at home. Our patient never performed blood chemistry tests or radiological investigation during the home treatment period of COVID-19 infection. For this reason, it was not possible to determine when the thrombotic event occurred. CTPA showed a distal bilateral thrombosis of the lower pulmonary arterial branches where the pulmonary inflammation is most diffuse. It is noteworthy that Doppler ultrasound was negative for DVT. As current data suggest, coagulation disorders are significantly increased in COVID-19 patients, especially among those with severe disease. Indeed, it was observed that COVID-19 may predispose to both venous and arterial thrombosis due to inflammatory cascade, hypoxia and endothelial injury (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_010_w2aab3b7b3b1b6b1ab2b1c10Aa">10</a>). Post-mortem evidence shows microvascular platelet-rich thrombotic depositions in small vessels of the lungs and other organs (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_011_w2aab3b7b3b1b6b1ab2b1c11Aa">11</a>). The endothelial vascular damage inside the injured areas may predispose to the development of a primitive pulmonary artery thrombosis. A recent study reported the findings of 12 autopsies where the authors noted a high incidence of PE with or without underlying DVT (<a ref-type="bibr" href="#j_pneum-2020-0012_ref_012_w2aab3b7b3b1b6b1ab2b1c12Aa">12</a>,<a ref-type="bibr" href="#j_pneum-2020-0012_ref_013_w2aab3b7b3b1b6b1ab2b1c13Aa">13</a>).In conclusion, we described a patient with mild COVID-19 disease who developed a pulmonary vascular injury, strictly correlated with an elevation of <sc>d</sc>-dimer values, without any signs of respiratory failure. Based on these studies, elevation of <sc>d</sc>-dimer levels could identify patients at risk for concurrent thrombotic diseases. We suggest a periodical monitoring of coagulation parameters and prophylactic dose of LMWH even in home patients with mild COVID-19 disease. Further studies will be needed to address this issue.</sec></div>

<article-title>Pulmonary artery thrombosis in home patient with a mild COVID-19 disease</article-title>

Pulmonary artery thrombosis in home patient with a mild COVID-19 disease

Tromboza arterei pulmonare la pacient cu boala COVID 19 forma usoara aflat la domiciliu

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title>COVID-19 definește o patologie infectioasă cauzată de infecția cu noua tulpină de coronavirus (SARS-CoV-2), care a devenit în scurt timp o problemă de sănătate publică cu impact internațional. Primul caz de COVID-19 din Indonezia a fost anunțat pe 2 martie 2020, iar pe data de 3 fuseseră deja confirmate 11.192 de cazuri. Până în prezent, Organizația Mondială a Sănătății a declarat că diagnosticul standard pentru COVID-19 este detecția ARN viral prin Real-Time RT-PCR (reverse-transcription polymerase chain reaction). Se recoltează probele de la nivelul căilor respiratorii superioare și inferioare, cel mai des folosite fiind exudatele nazofaringean și orofaringiean. În Indonezia, se folosesc și alte teste pentru a diagnostica boala, cum ar fi testele rapide pentru anticorpii specifici SARS-CoV-2. Prezentăm un caz atipic de COVID-19; am descris modul în care s-a pus diagnosticul, evoluția clinică a pacientului cu progresie spre pneumonie severă în saptămâna 3 și modul în care a fost gestionat cazul. De asemenea am încercat să punem în evidență și posibilele rezultate fals-negative ale reacției RT-PCR.</trans-abstract>

<abstract><title style='display:none'>Abstract</title>The novel coronavirus disease-2019 (COVID-19), caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has become a public health emergency of international concern. The first confirmed COVID-19 case in Indonesia was announced on 2 March 2020, and later on, 11,192 confirmed cases were reported as of 3 May. The World Health Organization has stated that performing a real-time reverse transcription–polymerase chain reaction (RT-PCR) specific for SARS-CoV-2 on specimens from the upper and the lower respiratory tracts, especially nasopharyngeal and oropharyngeal swabs, is the standard diagnostic procedure for COVID-19. In Indonesia, we also use other diagnostic tests, such as rapid antibody tests specific for SARS-CoV-2. Herein, we report an atypical case of COVID-19 and describe the diagnostic process, the clinical course, with progression to severe pneumonia on Week 3 of illness and the case management. We also try to highlight the possibility of false-negative RT-PCR tests.</abstract>

Department of General Medicine, St. Carolus Hospital

Department of Pulmonology, St. Carolus Hospital

Department of Pulmonology and Respiratory Medicine

Department of Clinical Pathology, St. Carolus Hospital

Department of Radiology, St. Carolus Hospital

Department of Internal Medicine, St. Carolus Hospital

Department of Anesthesiology and Intensive Care, St. Carolus Hospital

<article-title>An atypical case: RT-PCR-negative, sero-positive covid-19 patient</article-title>

An atypical case: RT-PCR-negative, sero-positive covid-19 patient

Un caz atipic: pacient COVID 19 seropozitiv, RT-PCR negativ

<trans-abstract xml:lang="ro"><title style='display:none'>Rezumat</title>O nouă boală pandemică a obligat toți cercetătorii să cerceteze pentru identificarea timpurie a factorilor de risc potenţiali. Conexiunile fumatului la infecții sunt bine cunoscute. Autorii încearcă să vadă care sunt legăturile epidemiologice, mecanismele patogenice și, de asemenea, impactul acestui coronavirus asupra diferitelor boli cronice respiratorii, căutând ultimele date publicate despre consecințele fumatului și “vapingului” asupra consumatorilor.</trans-abstract>

<abstract><title style='display:none'>Abstract</title>The new pandemic disease Covid-19 compelled all the researchers to investigate for early identification of the potential risk factors. Further, the relation between smoking and infections are well known. The authors are trying to find the epidemiological links, the pathogenic mechanisms and also the impact of this coronavirus on different respiratory chronic diseases, based on the last published data about the consequences of smoking and vaping on consumers.</abstract>

<div><sec id="j_pneum-2020-0017_s_001_w2aab3b7c22b1b6b1ab1aAa"><div>Introduction</div>The year 2020 started with a new pandemic disease COVID-19, spreading rapidly everywhere. More and more alarming signals and information reached the world from Wuhan, Hubei Province (China) in the last few months. After extensive research made by my Chinese colleagues, the first case (case zero) was reported in November 2019 and officially recognized in December (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_001_w2aab3b7c22b1b6b1ab2ab1Aa">1</a>). A wet market in this town is found to be and considered as the possible pandemic origin. The link between humans and the intermediate host is still unclear even though the researchers found a 96% DNA match between bat and human coronavirus or they suspected pangolins earlier for the disease (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_001_w2aab3b7c22b1b6b1ab2ab1Aa">1</a>). It is one of the important epidemic diseases of the last century. Other pandemic diseases in the last 40 years prior to this challenging disease were: Ebola virus disease in 1976 in the Democratic Republic of Congo and Sudan (fatality rate around 50%), Severe Acute Respiratory Syndrome (SARS) (caused by SARS coronavirus) in 2002–2003 (first case in China a mortality rate of 9.6%), Asian Flu (N1H1) in 2009 (first case in California, with 0.001–0.007% deaths of the world population) and Middle East Respiratory Syndrome (MERS) (caused by a coronavirus (MERS-CoV) in 2012 (first case in South Arabia, 35% of reported patients died) (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_002_w2aab3b7c22b1b6b1ab2ab2Aa">2</a>). Now, we have the initial statistics on COVID 19 infection and the researchers are working to evaluate the social, health and economic impact on every nation. On March 13, WHO said that Europe was the centre of the pandemic (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_003_w2aab3b7c22b1b6b1ab2ab3Aa">3</a>) but every European nation approached and tackled this contagious disease and its consequences with different strategies. On 29 March 2020, the pandemic statistics were: more than 6,84,000 are confirmed with infection, over 32,000 are dead and more than 1,45,000 are recovered (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_004_w2aab3b7c22b1b6b1ab2ab4Aa">4</a>). We have now started to learn many lessons from the obtained data.When risk factors are considered even with the available limited data taking into account risk and prognostic factors, smoking is found to be a recognized detrimental factor to the immune system as well as the responsiveness to a variety of infections. The outbreaks of influenza, MERS, and SARS brought more severe cases and increased mortality rates of smokers or the risk of infections (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_005_w2aab3b7c22b1b6b1ab2ab5Aa">5</a>,<a ref-type="bibr" href="#j_pneum-2020-0017_ref_006_w2aab3b7c22b1b6b1ab2ab6Aa">6</a>). But the following question ‘what are the links between smoking, vaping, and COVID 19’ is still remaining unanswered. We are trying to find the answers starting with the epidemiology of the disease, possible pathogenic interactions, or therapeutically aspects.<sec id="j_pneum-2020-0017_s_001_s_001_w2aab3b7c22b1b6b1ab1ab3Aa"><div>Epidemiology connections</div>Vardavas and Nikitara (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_007_w2aab3b7c22b1b6b1ab2ab7Aa">7</a>) conducted a research about the possibility of the association between smoking-severity of COVID 19 infections, the need for ventilation, need of ICU, and rate of hospitalisation or death. They screened 71 studies and finally, only 5 from China were selected by the authors. Their idea was following the first 2 months of the COVID 19 pandemic (December 2019 and January 2020) and registering the data, and found that the mortality rate of smokers is 9% (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_008_w2aab3b7c22b1b6b1ab2ab8Aa">8</a>). General mortality in China due to COVID 19, was 3.6% (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_009_w2aab3b7c22b1b6b1ab2ab9Aa">9</a>). Consistent with these 5 studies, analysis of deaths due to coronavirus in China shows that men are more likely to die than women, which may be probably related to the fact that many Chinese men smoke more than women (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_010_w2aab3b7c22b1b6b1ab2ac10Aa">10</a>). WHO report on the global tobacco epidemic, China Country Profile 2019, demonstrated that 52.1% of Chinese men smoke compared to just 2.7% of women. Another strong argument coming from these studies is about the factors and chances against and of disease progression (including death). Moreover, Chinese authors reported that there is a 14 times higher risk of having pneumonia among people with a history of smoking compared to those who did not smoke (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_011_w2aab3b7c22b1b6b1ab2ac11Aa">11</a>). Zhang and et al. (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_012_w2aab3b7c22b1b6b1ab2ac12Aa">12</a>), after analysing the mortality and the severity of diseases, found that among the severe vs. nonsevere patients, 3.4% were current smokers and 6.9% were former smokers, and on the other sample 0% and 3.7% (QR-2,3). In another study (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_013_w2aab3b7c22b1b6b1ab2ac13Aa">13</a>) the number of smokers with severe disease was much higher (12.6%). Further, it is mentioned by Liu et al. in his paper that smoking, as a risk factor, is responsible for adverse outcome in patients with a history of smoking (27.3%) than the group that showed improvement or stabilization (3.0%) (<italic>p</italic>=0.018 level) (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_011_w2aab3b7c22b1b6b1ab2ac11Aa">11</a>). Most of these studies were on small samples. The largest study was conducted by Guan et al. (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_013_w2aab3b7c22b1b6b1ab2ac13Aa">13</a>). They identified that higher percentages of current and former smokers among patients needed ICU support, mechanical ventilation or who had died, and a higher percentage of smokers among the severe cases. Further, they quantified the risk for smokers vs. non-smokers; for the first group, it is 1.4 times more likely to have severe symptoms of COVID-19 and 2.4 times more likely to be admitted to an ICU (on ventilators or to die).</sec><sec id="j_pneum-2020-0017_s_001_s_002_w2aab3b7c22b1b6b1ab1ab4Aa"><div>Hypothesis of susceptibility to COVID 19 of smokers</div>It is well known that smokers are vulnerable to virus and countless studies confirming the same. Angiotensin converting enzyme 2 (ACE2) has been identified as a receptor for HCoV-19. This generates the hypothesis that smoking is responsible for the differences in the expression pattern of ACE2 in the respiratory tract, with consequences related to the susceptibility to the virus. Three datasets (GSE994, GSE17913, and GSE18344) have been evaluated. Elevated ACE2 were found in intrapulmonary airways (GSE994) and oral epithelial cells (GSE17913) of smokers; it was not the same for non-smokers or former smokers (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_014_w2aab3b7c22b1b6b1ab2ac14Aa">14</a>). Data on human as well as experimental research on rats confirmed that smoking is increasing ACE2 in the respiratory tract and also the susceptibility to HCoV-19. Smoking can upregulate this angiotensin-converting enzyme-2 (ACE2) receptor which is recognized as a receptor for other coronavirus infections such as SARS, SARS-CoV, and the human respiratory coronavirus NL638 (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_015_w2aab3b7c22b1b6b1ab2ac15Aa">15</a>). ACE2 could be a novel adhesion molecule for SARS-CoV-2 causing COVID-19. So, it can be a potential therapeutic target for the prevention of fatal microbial infections and the same type of upregulation is possible for e-cigarette and heat-not-burn IQOS devices (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_015_w2aab3b7c22b1b6b1ab2ac15Aa">15</a>). Using RNAseq, Leung et al. (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_016_w2aab3b7c22b1b6b1ab2ac16Aa">16</a>) determined gene expression levels in bronchial epithelia obtained from cytological brushings of 6th to 8th generation airways in individuals with and without COPD. They found an increasing ACE2 expression in lower airways in patients with COPD and current smokers. Moreover, they suggest that these patients are at increased risk of serious COVID19 infection and highlight the importance of stopping smoking in reducing the risk.The other well-known effect of smoking is vasospasm and transient hypoxia of organs induced by a high level of blood nicotine. The depletion of oxygen in the viscera and the respiratory tract will reduce immunity significantly (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_017_w2aab3b7c22b1b6b1ab2ac17Aa">17</a>). Dissemination of COVID 19 infection depends also on the one’s smoking habits; that’s why in between the personal precocious recommendations coming from the specialist it’s also included quitting smoking</sec><sec id="j_pneum-2020-0017_s_001_s_003_w2aab3b7c22b1b6b1ab1ab5Aa"><div>E cigarette and COVID-19</div>Just like the discussion on vaping divided the medical schools between the defenders and opponents for 2 years, the discussion on the consequences of COVID 19 on the dangers of vaping and e-cigarette have split the community into two. For some authors (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_018_w2aab3b7c22b1b6b1ab2ac18Aa">18</a>) there is no evidence that vaping (intrinsically) increases the risk of infection or progression to severe condition of COVID-19; they consider it as an effect of COVID19 linked to previous conventional smoking. They sustained also that even propylene glycol is working as a disinfectant. That’s why these authors have only some plain recommendations like (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_018_w2aab3b7c22b1b6b1ab2ac18Aa">18</a>,<a ref-type="bibr" href="#j_pneum-2020-0017_ref_019_w2aab3b7c22b1b6b1ab2ac19Aa">19</a>):
<list list-type="bullet"><list-item>If you vape, do not revert to smoking (if you are a dual user try to become an exclusive vaper).</list-item><list-item>If you enjoy vaping and do not smoke, quitting vaping must be a personal choice and not an obligation.</list-item><list-item>Be discreet and do not call unwanted attention (bear in mind that these are difficult times and that a lot of nonvapers have been exposed to a lot of misinformation).</list-item><list-item>Avoid big clouds in public no matter what (even outdoors).</list-item><list-item>Use low powered devices whenever possible and when others are around. The risk of spreading the virus with discrete vaping in low powered devices is roughly equivalent to the risk of spreading it through normal sedentary breathing.</list-item><list-item>Avoid vaping in enclosed public spaces and try to keep at least 2 m distance from others when vaping outdoor.</list-item></list>Contrarily Prof Glantz (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_020_w2aab3b7c22b1b6b1ab2ac20Aa">20</a>), recognized as an objective researcher (without any sponsoring activities from the tobacco industry), stated that vaping like smoking may also harm lung health; his arguments are based on the well-known demonstrated effects of e-cigarette on the lung (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_021_w2aab3b7c22b1b6b1ab2ac21Aa">21</a>,<a ref-type="bibr" href="#j_pneum-2020-0017_ref_022_w2aab3b7c22b1b6b1ab2ac22Aa">22</a>) (impaired mucociliary clearance and neutrophil phagocytosis, damage of the lung by the effect of neutrophils lyse DNA and release it into the extracellular environment to help to immobilize bacteria and enhance of upper airway colonization and tissue damage by aerosol exposure). Because of these, including stopping smoking, vaping, and avoiding secondhand exposure are the lists of important preventive measures according to his opinion. Even the FDA stated in an email that e-cigarette use can damage lung cells (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_023_w2aab3b7c22b1b6b1ab2ac23Aa">23</a>).</sec><sec id="j_pneum-2020-0017_s_001_s_004_w2aab3b7c22b1b6b1ab1ab6Aa"><div>Smoking and different diseases. What we already know</div>In lung cells including bronchial epithelial cells, alveolar macrophages, pulmonary endothelial cells, and interstitial fibroblasts, nicotinic receptors are co-expressed with most components of the RAS (renin–angiotensin system) (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_024_w2aab3b7c22b1b6b1ab2ac24Aa">24</a>). Smoking is already known for increasing the risk for the development of acute respiratory distress syndrome (ARDS) on people associated with different risk factors like: severe infection, non-pulmonary sepsis (blood infection), or blunt trauma (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_025_w2aab3b7c22b1b6b1ab2ac25Aa">25</a>, <a ref-type="bibr" href="#j_pneum-2020-0017_ref_020_w2aab3b7c22b1b6b1ab2ac20Aa">20</a>). Regarding the cancer patients with smoking, the higher rate of smoking history can be one of the potential factors of higher risk of COVID-19, and with a poorer prognosis than those without cancer (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_026_w2aab3b7c22b1b6b1ab2ac26Aa">26</a>). The same authors describe these cancer patients in the sample are prone to severe conditions and events (admission to the intensive care unit requiring invasive ventilation, or death) due to COVID-19. For COPD patients after adjusting for age and smoking status, COPD hazards ratio (HR) was 2.681(95% confidence interval 1.424–5.048) (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_027_w2aab3b7c22b1b6b1ab2ac27Aa">27</a>). The number of comorbidities is also an important factor. Smoking is a trigger for asthma and at the same time smoking can weaken lung function. When you have asthma, if you smoke, your lung capacity will deteriorate very rapidly. Smoking when children with asthma are near to you will affect their lung function too (<a ref-type="bibr" href="#j_pneum-2020-0017_ref_028_w2aab3b7c22b1b6b1ab2ac28Aa">28</a>).</sec></sec><sec id="j_pneum-2020-0017_s_002_w2aab3b7c22b1b6b1ab1b1Aa"><div>Conclusions</div>Many relations are established at this moment by demonstrating the smoker’s vulnerability to COVID-19. If more cases are being examined in the coming months (from different ethnic and genetic backgrounds worldwide), probably this ACE2 expression variation can be better analysed and compared to establish whether and when it contributes to susceptibility to COVID-19 and it will be more simple to find some subgroups or phenotypes.(<a ref-type="bibr" href="#j_pneum-2020-0017_ref_029_w2aab3b7c22b1b6b1ab2ac29Aa">29</a>) But, it is certain for smokers with COVID 19 infections, there will be a greater impact on disease progression; association with smoking is most likely with the negative progression and adverse outcomes of COVID-19. Further, WHO and all countries should ensure for the next pandemic waves that the smoking status of patients identified with Covid-19, including deaths, is recorded and incorporated in data sets for determining this important relationship of the virus with an external risk factor. Data on vaping and COVID-19 are now collected and we are confident that the next articles will be able to analyse on deleterious effects of e-cigarette effectively and more convincingly.</sec></div>

<article-title>COVID 19 - a new threat for smokers and vapers?</article-title>

COVID 19 - a new threat for smokers and vapers?

COVID 19 - o nouă amenințare pentru fumători și “vapers”?

<div><fig id="j_pneum-2020-0018_fig_001_w2aab3b7c25b1b6b1ab1aAa" position="anchor" fig-type="figure"><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0018_fig_001.jpg"/></fig>Another No Tobacco Day on 31 May 2020 was promoted by the Romanian Society of Pneumology in full pandemic evolution of COVID-19. In 2020, the World Health Organisation (WHO) had a unique message: ‘No Secret Protecting youth from industry manipulation and preventing them from tobacco and nicotine use’. Why did they choose this campaign under this logo? Because for decades, the tobacco industry has deliberately employed strategic, aggressive and well-resourced tactics to attract the youth to tobacco and nicotine products (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_001_w2aab3b7c25b1b6b1ab2ab1Aa">1</a>). Internal industry documents reveal their strategies among which is the attractive new product design to market campaigns like the new ‘healthy’ products, which have only one objective: to replace the millions of people who died each year from tobacco-attributable diseases with new young consumers. There are some myths emanating from this industry, and we must understand their manipulation tactics. The WHO recommendations (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_001_w2aab3b7c25b1b6b1ab2ab1Aa">1</a>) are as follow:
<list list-type="bullet"><list-item>Debunk myths and expose manipulation tactics employed by the tobacco and related industries, particularly marketing tactics targeted at youth, including through the introduction of new and novel products, flavours and other attractive features;</list-item><list-item>Equip young people with knowledge about tobacco and related industries’ intentions and tactics to hook current and future generations on tobacco and nicotine products;</list-item><list-item>Empower influencers (in pop culture, on social media, in the home or in the classroom) to protect and defend youth and catalyse change by engaging them in the fight against Big Tobacco (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_001_w2aab3b7c25b1b6b1ab2ab1Aa">1</a>). There are a variety of modalities to manipulate the new generations like the World No Tobacco Day 2020 – WHO (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_001_w2aab3b7c25b1b6b1ab2ab1Aa">1</a>). A few more examples are as below:
<list list-type="custom"><list-item><label>○</label>Using of flavours that are attractive to youth in tobacco and nicotine products, like cherry, bubble gum and cotton candy, which encourage young people to underestimate the related health risks and to start using them;</list-item><list-item><label>○</label>Sleeking designs and attractive products, which can also be easy to carry and are deceptive (e.g. products shaped like a USB stick or candy);</list-item><list-item><label>○</label>Promoting of products as ‘reduced harm’ or ‘cleaner’ alternatives to conventional cigarettes in the absence of objective science substantiating these claims;</list-item><list-item><label>○</label>Using celebrity/influencer sponsorships and brand sponsored contests to promote tobacco and nicotine products (e.g. Instagram influencers);</list-item><list-item><label>○</label>Placing point-of-sale marketing at vendor outlets frequented by children, including positioning near sweets, snacks or soda and providing premiums for vendors to ensure their products are displayed near venues frequented by young people (includes providing marketing materials and display cases to retailers);</list-item><list-item><label>○</label>Selling of single stick cigarettes and other tobacco and nicotine products near schools, which makes it cheap and easy for school children to access tobacco and nicotine products;</list-item><list-item><label>○</label>Using indirect marketing of tobacco products in movies, TV shows and online streaming shows;</list-item><list-item><label>○</label>Placing tobacco vending machines at venues frequented by young people, covered in attractive advertising and pack displays, and undermining regulations on sales to minors;</list-item><list-item><label>○</label>Creating litigation to weaken all kinds of tobacco control regulations, including warning labels, display at point of sale and regulations that limit access and marketing to children (specifically, provisions to ban the sale and advertising of tobacco products near schools).</list-item></list></list-item></list>The consequences are visible worldwide and in Romania. There are many ‘painful’ data concerning tobacco evidences in our country. The latest global study ‘Global Youth Tobacco Survey’ (2017–2018) (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_002_w2aab3b7c25b1b6b1ab2ab2Aa">2</a>), where an analysis on tobacco consumption for Romania, implemented on a nationally representative sample of 5,409 children enrolled in grades VI–VIII, aged 13–15 years found that 30.1% of respondents had tried to smoke cigarettes at least once, and 8.6% of respondents had smoked cigarettes in the last 30 days. Smoking in these conditions remains the leading cause of illness in our country; over 36,600 Romanians die annually due to smoking. Also for the other ‘health products’ promoted by the tobacco industry, there are dangerous effects for Romanian children and youth. Thus, in 2017, the total percentage of students who smoked electronic cigarettes was almost equal to that of those who smoked regular cigarettes (8.2% and 8.6%, respectively). Moreover, several boys stated that they preferred to smoke e-cigarettes compared with regular cigarettes – 10.1% versus 9.8%. Article 13 of the Framework Convention on Tobacco Control, ratified by Romania in 2005, calls for a complete ban on tobacco advertising, promotion and sponsorship, and a study conducted in 23 developed and 30 developing countries showed that banning all forms of tobacco advertising reduces tobacco consumption by 23.5% (<a ref-type="bibr" href="#j_pneum-2020-0018_ref_003_w2aab3b7c25b1b6b1ab2ab3Aa">3</a>). The Romanian Society of Pneumology organised a webinar on this year’s ‘No Tobacco Day’ and responded with the hope that all these echoes and alarms would be taken into account by the authorities, government and health officials, and that all those long-awaited legislative changes would remove any source of direct and indirect publicity and promotion, for all tobacco products and e-cigarettes. Romanian lung physicians join the WHO efforts in urging influencers – in pop culture, on social media, in the home or in the classroom – to reach and connect with youth to expose the industries’ manipulative tactics for creating a new generation of tobacco users. Covid-19 is a challenging problem for humanity, but we have not the right to forget this ancient world problem generate by the tobacco industry with 8 million deaths annually induced by tobacco consumption.</div>

Univeristiy of Medicine and Pharmacy „Victor Babes” Timișoara

<article-title>No Tobacco Day 2020 – another ancient ‘COVID DAY’?</article-title>

No Tobacco Day 2020 – another ancient ‘COVID DAY’?

{"article-title":"No Tobacco Day 2020 \u2013 another ancient \u2018COVID DAY\u2019?"}

<div><fig id="j_pneum-2020-0015_fig_001_w2aab3b7c15b1b6b1ab1aAa" position="anchor" fig-type="figure"><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0015_fig_001.jpg"/></fig>Even though coronavirus disease-2019 (COVID-19) is coming with its second wave, the Romanian Society of Pneumology continues to respect the calendar of traditional events. The ninth edition of the Conference on Management of Chronic Diseases has been successfully conducted. COVID-19 has changed our private and scientific life. Therefore, this edition was conducted online. The programme was very attractive, with the presence of &gt;350 participants in this live session. The advantage of this type of webinar was the presence also of other specialties such as internal medicine, labour medicine, allergology and general practitioner (GP).We had a variety of topics and sessions. On the first day, we started with an asthma session, with many interesting topics offered, such as difficult to treat asthma or severe asthma (by Ruxandra Ulmeanu), profile of severe asthma (by Roxana Nemes) and characteristics of asthma treatment in the COVID-19 pandemic (by Claudia Toma). Another session covered topics on bronchoscopic techniques and the diagnosis of different respiratory diseases such as tracheal tumours (by Petronela Fildan), interstitial lung diseases (by Mihai Alexe), criobiopsy (by Marioara Simon) and autofluoroscopy (by Camelia Badescu). On the next day, we had a session on tuberculosis (TB) (connected to the following: smoking: Ioana Munteanu; COVID-19: Adriana Socaci; and therapies in multi-drug-resistant TB: Cristina Popa), chronic obstructive pulmonary disease (COPD) (reahibilitation: Mimi Nitu; COVID effects: Florin Mihaltan; auto management: Doina Todea) and sleep disorders (by Gabriela Jimboreanu). Other important sessions were on lung cancer (solitary nodule – Dorin Vancea; screening – Beatrice Mahler; COVID-19 pandemic consequences – Radu Crisan Dabija; and management in chest services – Cristian Oancea) and a ‘varia’ session with exposure to novelties in interstitial lung diseases (by Irina Strambu), pollution and smoking in COPD (by Antigona Trofor), functional investigation in the COVID-19 period (by Ovidiu Fira Mladinescu) and rehabilitation in this moment of coronavirus extension (by Alina Haulica). It was a well-organised online event, confirming that our lung physicians are prepared also for telemedicine practice.<fig id="j_pneum-2020-0015_fig_002_w2aab3b7c15b1b6b1ab1b3Aa" position="anchor" fig-type="figure"><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0015_fig_002.jpg"/><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0015_fig_003.jpg"/><graphic xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="graphic/j_pneum-2020-0015_fig_004.jpg"/></fig></div>

<article-title>Romanian Society of Pneumology respect its traditional activities</article-title>

Romanian Society of Pneumology respect its traditional activities

{"article-title":"Romanian Society of Pneumology respect its traditional activities"}

Pneumologia is covered by the following services: <ul> <li> Baidu Scholar </li> <li> CNKI Scholar (China National Knowledge Infrastructure) </li> <li> CNPIEC - cnpLINKer </li> <li> Dimensions </li> <li> EBSCO </li> <li> ExLibris </li> <li> Google Scholar </li> <li> J-Gate </li> <li> KESLI-NDSL (Korean National Discovery for Science Leaders) </li> <li> Naver Academic </li> <li> Naviga (Softweco) </li> <li> ReadCube </li> <li> SCOPUS </li> <li> Semantic Scholar </li> <li> TDNet </li> <li> WanFang Data </li> <li> WorldCat (OCLC) </li> <li> X-MOL </li> </ul>

Pneumologia ist in den folgenden Services indiziert: <ul> <li> Baidu Scholar </li> <li> CNKI Scholar (China National Knowledge Infrastructure) </li> <li> CNPIEC - cnpLINKer </li> <li> Dimensions </li> <li> EBSCO </li> <li> ExLibris </li> <li> Google Scholar </li> <li> J-Gate </li> <li> KESLI-NDSL (Korean National Discovery for Science Leaders) </li> <li> Naver Academic </li> <li> Naviga (Softweco) </li> <li> ReadCube </li> <li> SCOPUS </li> <li> Semantic Scholar </li> <li> TDNet </li> <li> WanFang Data </li> <li> WorldCat (OCLC) </li> <li> X-MOL </li> </ul>

<DIV align=left> Open Access Statement The journal is an Open Access journal that allows a free unlimited access to all its contents without any restrictions upon publication to all users. </DIV>

<DIV align=left> Pneumologia is the journal of the Romanian Society of Pneumology, being continuously edited since 1951. Pneumologia is an open-access journal, edited in English, 4 issues per year and is included in international databases. It publishes clinical and experimental research articles in the field of respiratory medicine, paediatrics, thoracic surgery, allergology, respiratory intensive care and oncology. Pneumologia aims to publish scientifically valid papers, related to the respiratory field, offering a good visibility of the published papers. It is also an educational platform for physicians, educators interested in this domain, and aims to promote research and good clinical practice. Pneumologia publishes original articles in the field of respiratory medicine, paediatrics, thoracic surgery, allergology, respiratory intensive care, and oncology. The following types of submissions are accepted: <UL> <LI>Original research papers </LI> <LI>Case reports </LI> <LI>Reviews </LI> <LI>Letters to the editor </LI> <LI>Educational materials: practice guidelines, new techniques description and use </LI> <LI>News, chronicles </LI></UL> All submitted papers are confidentially peer-reviewed in a timely manner, by at least two independent reviewers selected according to the topic of the article. The peer-review process aims to check the originality, scientific validity, and coherence of the submission. Pneumologia offers fast publication; the eligible submissions are typically published within 3 months. There is no publication fee, and the online version is available open access on the Journal’s web site. The printed journal is distributed to the members of the Romanian Society of Pneumology and several public libraries. Romanian and international authors are welcome to submit papers to Pneumologia, which is one of the few journals specifically dedicated to respiratory medicine in the region. Archiving Sciendo archives the contents of this journal in <A href="https://www.portico.org/">Portico</A> - digital long-term preservation service of scholarly books, journals and collections. Plagiarism Policy The editorial board is participating in a growing community of <A href="https://www.crossref.org/services/similarity-check/">Similarity Check System's</A> users in order to ensure that the content published is original and trustworthy. Similarity Check is a medium that allows for comprehensive manuscripts screening, aimed to eliminate plagiarism and provide a high standard and quality peer-review process. Back issues <A href="https://www.pneumologia.eu/en/all-articles">www.pneumologia.eu/en/all-articles</A> <A href="http://arhiva.pneumologia.eu/">arhiva.pneumologia.eu/</A> </DIV>

JOURNAL DIRECTOR: Tudor Toma - Lewisham Hospital, London, United Kingdom EDITOR IN CHIEF: Radu Crișan Dabija - Gr. T. Popa University of Medicine and Pharmacy, Iași, Romania SENIORS EDITORS: Irina Strâmbu - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Anca Macri - Marius Nasta Institute of Pneumoptysiology, Bucharest, Romania Alina Croitoru - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania EDITORS: Bianca Paraschiv - Sfantul Stefan Hospital, Bucharest, Romania Nicoleta Motoc - Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania Ovidiu Fira Mlãdinescu - Victor Babes University of Medicine and Pharmacy,Timișoara, Romania Ana Zaharie -Marius Nasta Institute of Pneumoptysiology, Bucharest, Romania Irina Pele - Marius Nasta Institute of Pneumoptysiology, Bucharest, Romania JUNIOR EDITOR: Ana Constantin, MD - Marius Nasta Institute of Pneumophtysiology, Bucharest SCIENTIFIC CONSULTANT THORACIC SURGERY: Ciprian Bolca - Marius Nasta Institute of Pneumoptysiology, Bucharest, Romania EDITORIAL ADVISORY BOARD: Voicu Tudorache - Victor Babes University of Medicine and Pharmacy,Timișoara, Romania Lorenzo Corbetta - University of Florence - University Hospital of Careggi, Florence, Italy Doina Todea - Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania Stephen Spiro - University College Hospital, London, United Kingdom Florin Mihãlþan - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Cristian Oancea - Victor Babes University of Medicine and Pharmacy, Timișoara, Romania Vincenzo Zagà - U.O. di Pneumotisiologia Territoriale, Azienda USL di Bologna, Italy Elena Danteș - Faculty of Medicine, Ovidius University, Constanta, Romania Sophia Papadakis - University of Otawa Heart Institute, Otawa, Canada Traian Mihãescu - Gr. T. Popa University of Medicine and Pharmacy, Iași, Romania Ruxandra Ulmeanu - Faculty of Medicine and Pharmacy, Oradea, Romania Victor Botnaru - „Nicolae Testemiþanu" State University of Medicine and Pharmaceutics, Chișinãu, Moldova Miron Bogdan - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Lilia Todoriko - Bukovinian State Medical University, Chernivitsy, Ukraine Ioan Cordoș - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Oana Arghir - Faculty of Medicine, Ovidius University, Constanta, Romania Manuel Lillo Crespo - Faculty of Health Sciences, University of Alicante, Spain Claudia Toma - Carol Davila University of Medicine and Pharmacy, Bucharest, Romania Gabriela Jimborean - University of Medicine and Pharmacy, Târgu Mureș, Romania Marco Mura - Division of Respirology, Western University, London, ON, Canada Ariadna Petronela Fildan - Faculty of Medicine, Ovidius University, Constanta, Romania Paraschiva Postolache - Gr. T. Popa University of Medicine and Pharmacy, Iași, Romania Constantine Vardavas - Institute of Public Health, Athens, Greece Mimi Niþu - University of Medicine and Pharmacy, Craiova, Romania Monica Pop - Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania EDITORIAL SECRETARY: Roxana Anastase - Marius Nasta Institute of Pneumophtysiology, Bucharest Publisher De Gruyter Poland Bogumiła Zuga 32A Str. 01-811 Warsaw, Poland T: +48 22 701 50 15

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Volume 69 (2020): Issue 2 (December 2020)

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Romanian Society of Pneumology Activities