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Thymic small cell carcinoma (TSCC) is an exceptionally rare and aggressive extrapulmonary neuroendocrine malignancy. We report a man in his 60s presenting with acute respiratory distress while receiving antibiotics for presumed aspiration pneumonia.Chest CT excluded pulmonary embolism but revealed anterior and paracardiac mediastinal masses. Thoracoscopic resection of the paracardiac mass unexpectedly confirmed small cell carcinoma of thymic origin. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT scan showed a hypermetabolic anterior mediastinal lesion and a suspicious right upper lobe nodule, without distant metastases. The disease was staged Masaoka–Koga IIB (cT3N1M1b). Combined chemoradiotherapy led to radiological regression after 3 months.TSCC is a high-grade, aggressive neoplasm that is frequently misdiagnosed because of its non-specific presentation. This case underlines the importance of considering rare thoracic malignancies in acute settings. It illustrates the key role of early histological diagnosis, multidisciplinary evaluation and multimodal therapy in the management of extrapulmonary small cell carcinomas (EPSCC).

Chronic obstructive pulmonary disease (COPD) is a prevalent condition characterized by persistent airflow obstruction and respiratory symptoms. Single-Inhaler Triple Therapy (SITT) has been shown to improve patient adherence, reduce exacerbations, and lower healthcare resource utilization in patients who are not controlled despite being on dual therapy or Multiple-Inhaler Triple Therapy (MITT). Despite evidence supporting SITT, payer-driven access rules across Europe sometimes limit its use in primary care, creating barriers to optimal COPD management. Through expert consensus, the study seeks to generate a shared understanding of the unintended consequences of payer-driven access criteria for SITT in managing moderate-to-severe COPD in primary care. A targeted literature review (TLR) was conducted to assess SITT initiation in primary care across Europe and examine the impact of access criteria. Semi-structured interviews were held with 14 experts from nine European countries, including clinicians, health economists, and patient advocacy representatives. A consensus generation workshop was conducted, where experts evaluated the findings and developed position statements to highlight the challenges posed by payer-driven access criteria. The TLR identified variability in access to SITT in Europe, with several countries restricting its initiation to specialists, thus limiting primary care physicians' (PCPs) ability to prescribe SITT. The expert panel generated seven consensus points stating that enabling PCPs to step up or switch eligible patients to SITT has the potential to support care continuity, enhance clinical autonomy for PCPs, reduce reliance on potentially less effective treatment options, improve patient and healthcare system outcomes, avoid unnecessary referrals to specialists, enable prompt initiation of guideline-directed medical therapy for COPD in primary care and reduce access inequalities. Restrictions for SITT initiation in primary care may need to be revisited to mitigate their unintended health and cost consequences and improve equitable access to treatment. This should take into consideration each country's unique healthcare system.

Chronic obstructive pulmonary disease (COPD) represents a major health and economic challenge in Belgium, affecting approximately 800,000 individuals, half of whom remain undiagnosed. Beyond respiratory morbidity, COPD patients face substantial cardiopulmonary (CP) risk-encompassing severe exacerbations and cardiovascular (CV) events-that is often under-recognized and insufficiently addressed due to limited clinical awareness, fragmented care, and the absence of national guidance. A multidisciplinary Belgian taskforce (general practitioners, pulmonologists, cardiologists, pharmacists, epidemiologists) convened through structured workshops and iterative consensus-building to develop a pragmatic, evidence-informed care pathway. The recommendations focus on COPD patients with at least one moderate or severe exacerbation, who are at heightened CP risk. This consensus introduces an integrated, stepwise framework that positions CP risk as a central component of COPD management after exacerbation and operationalizes it across primary care, hospitalization, and post-exacerbation follow-up. Core elements include systematic and proactive CP risk identification in primary care, standardized diagnostic workups during hospitalization, and multidisciplinary discharge planning. Pharmacological strategies combine eosinophil-guided inhaler therapy with guideline-directed CV treatment, while non-pharmacological measures reinforce smoking cessation, vaccination, physical activity, and pulmonary rehabilitation. Clear referral thresholds between primary care, pulmonology, and cardiology are defined, supported by patient education and digital monitoring tools. This Belgian consensus complements international guidelines by consolidating fragmented recommendations into coherent, actionable algorithms that bridge gaps in routine practice. Its contribution lies in translating emerging evidence into structured, real-world pathways that integrate respiratory and cardiac care. Adoption of this framework may help reduce exacerbations, improve CV outcomes, and support multidisciplinary COPD care in Belgium.

Evidence and guidelines are becoming increasingly clear about imbalance between the risks and benefits of inhaled corticosteroids (ICSs) in patients with COPD. While selected patients may benefit from ICS-containing regimens, ICSs are often inappropriately prescribed with - according to Belgian market research data - up to 70% of patients in current practice receiving ICSs, usually as a fixed combination with a long-acting β -adrenoreceptor agonist. Studies and recommendations support withdrawal of ICSs in a large group of patients with COPD. However, historical habits appear difficult to change even in the light of recent scientific evidence. We have built a collaborative educational platform with chest physicians and primary care physicians to increase awareness and provide guidance and support in this matter.

Patients with chronic airway disease may present features of both asthma and COPD, commonly referred to as asthma-COPD overlap syndrome (ACOS). Recommendations on their diagnosis are diffuse and inconsistent. This survey aimed to identify consensus on criteria for diagnosing ACOS. A Belgian expert panel developed a survey on ACOS diagnosis, which was completed by 87 pulmonologists. Answers chosen by ≥70% of survey respondents were considered as useful criteria for ACOS diagnosis. The two most frequently selected answers were considered as major criteria, others as minor criteria. The expert panel proposed a minimal requirement of two major criteria and one minor criterion for ACOS diagnosis. Respondents were also asked which criteria are important for considering inhaled corticosteroids prescription in a COPD patient. To diagnose ACOS in COPD patients, major criteria were \"high degree of variability in airway obstruction over time (change in forced expiratory volume in 1 second ≥400 mL)\" and \"high degree of response to bronchodilators (>200 mL and ≥12% predicted above baseline)\". Minor criteria were \"personal/family history of atopy and/or IgE sensitivity to ≥1 airborne allergen\", \"elevated blood/sputum eosinophil levels and/or increased fractional exhaled nitric oxide\", \"diagnosis of asthma <40 years of age\"; \"symptom variability\", and \"age (in favor of asthma)\". To diagnose ACOS in asthma patients, major criteria were \"persistence of airflow obstruction over time (forced expiratory volume in 1 second/forced vital capacity ratio <0.7)\" and \"exposure to noxious particles/gases, with ≥10 pack-years for (ex-)smokers\"; minor criteria were \"lack of response on acute bronchodilator test\"; \"reduced diffusion capacity\"; \"limited variability in airway obstruction\"; \"age >40 years\"; \"emphysema on chest computed tomography scan\". Specific criteria were identified that may guide physicians to a more uniform diagnostic approach for ACOS in COPD or asthma patients. These criteria are largely similar to those used to prescribe inhaled corticosteroids in COPD.

COPD is a chronic disease, typically accompanied by multiple comorbid conditions. The need to apply several, and sometimes conflicting, disease-specific treatment guidelines, complicates the management of individual patients. Moreover, national and international recommendations evolve rapidly but provide limited guidance on the integrated approach in the multimorbid patient. Particularly bothersome is the fact that the presence of comorbidities may deteriorate the course of COPD, and inversely COPD may affect the outcome of the comorbid diseases. In addition, some effects of commonly prescribed COPD inhaler medications, including beta -agonists, long-acting antimuscarinics and especially inhaled corticosteroids, mimic or worsen COPD-related comorbidities. Therefore, the authors combined their perspectives to formulate advice that may help physicians to improve COPD patient care in daily practice when comorbidities are present. Diabetes, atrial fibrillation, osteoporosis/fractures, infections (pneumonia and tuberculosis) and asthma were identified as areas where practicing clinicians should give special attention to the risk-benefit ratio of the inhaled medication. Overall, the presence of multimorbidity in a COPD patient should act as a signal to carefully reconsider the treatment choices.

Background Nasal polyposis (NP) is a comorbidity of type 2 severe asthma (SA) which could influence response to SA biologics. Methods We evaluated (super-) response in SA patients with (NP +) and without NP (NP−) enrolled in the Belgian Severe Asthma Registry (BSAR). Results 914 patients, of whom 31% NP + , were included. At enrollment, NP + patients had higher annual exacerbation rates, higher number of emergency room visits and more elevated type 2 biomarkers. In the longitudinal subanalysis of 104 patients, both groups had significant and similar asthma responses to asthma biologics, except for a greater increase in FEV 1 in the NP + group. Super-response was achieved in 33 patients (32%), irrespective of NP status or type of biologic. Conclusion In conclusion, both NP + and NP − patients had positive treatment responses, with some able to achieve super-response. In SA patients with NP, a greater FEV 1 improvement as compared to SA patients without NP was observed.

Selecting the most appropriate inhalation device from the wide range available is essential for the successful management of patients with chronic obstructive pulmonary disease. Although choice is good for healthcare professionals, knowing which inhaler to prescribe is a complex consideration. Among the key factors to consider are quality of disease control, inhaler technique, inhaler resistance and inspiratory flow, inhaler design and mechanisms of drug delivery, insurance and reimbursement restrictions, and environmental impact. In this article, we offer a simple, practical tool that brings together all these factors and includes hyperlinks to other published resources from the United Kingdom, Belgium, and The Netherlands.

Hypocomplementemic urticarial vasculitis syndrome is a rare small-vessel vasculitis characterized by the combination of vasculitis and chronic urticaria. The hypocomplementemic form is distinguished by a more severe clinical presentation than the normocomplementemic form, with prognosis influenced by respiratory involvement. Due to its rarity and the similarities in presentation to systemic lupus erythematosus (SLE), diagnosis may be delayed and treatment may be inappropriate. We report the case of a young non-smoking female patient with a history of SLE refractory to standard treatments, whose progression was marked by severe and irreversible obstructive ventilatory disorder. This case aims to highlight the potential for severe and irreversible obstructive disorders that may occur in this condition in young non-smoking patients.

Background In the BACE trial, a 3-month (3 m) intervention with azithromycin, initiated at the onset of an infectious COPD exacerbation requiring hospitalization, decreased the rate of a first treatment failure (TF); the composite of treatment intensification (TI), step-up in hospital care (SH) and mortality. Objectives (1) To investigate the intervention’s effect on recurrent events, and (2) to identify clinical subgroups most likely to benefit, determined from the incidence rate of TF and hospital readmissions. Methods Enrolment criteria included the diagnosis of COPD, a smoking history of ≥10 pack-years and ≥ 1 exacerbation in the previous year. Rate ratio (RR) calculations, subgroup analyses and modelling of continuous variables using splines were based on a Poisson regression model, adjusted for exposure time. Results Azithromycin significantly reduced TF by 24% within 3 m (RR = 0.76, 95%CI:0.59;0.97, p  = 0.031) through a 50% reduction in SH (RR = 0.50, 95%CI:0.30;0.81, p  = 0.006), which comprised of a 53% reduction in hospital readmissions (RR = 0.47, 95%CI:0.27;0.80; p  = 0.007). A significant interaction between the intervention, CRP and blood eosinophil count at hospital admission was found, with azithromycin significantly reducing hospital readmissions in patients with high CRP (> 50 mg/L, RR = 0.18, 95%CI:0.05;0.60, p  = 0.005), or low blood eosinophil count (<300cells/μL, RR = 0.33, 95%CI:0.17;0.64, p  = 0.001). No differences were observed in treatment response by age, FEV1, CRP or blood eosinophil count in continuous analyses. Conclusions This post-hoc analysis of the BACE trial shows that azithromycin initiated at the onset of an infectious COPD exacerbation requiring hospitalization reduces the incidence rate of TF within 3 m by preventing hospital readmissions. In patients with high CRP or low blood eosinophil count at admission this treatment effect was more pronounced, suggesting a potential role for these biomarkers in guiding azithromycin therapy. Trial registration ClinicalTrials.gov number. NCT02135354 .