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Highlights from this issue

2017-08-21T06:25:33-07:00

The taming of the shrew

It may come as some surprise that the hedgehog is a distant relative of the shrew, and even more of a surprise that hedgehogs native to North America are now extinct and have never been present in Australia. However, hedgehog and its signalling pathways are increased in Idiopathic Pulmonary Fibrosis (IPF). In this issue of Thorax, Jia and colleagues describe how the chemokine CXCL14 is increased in mice in response to Hedgehog overexpression and is elevated in the plasma from patients with IPF (see page 780). In an effort to tame this shrew a hedgehog inhibitor has been developed and has been shown to inhibit CXCL14 in patients treated with cancer. Therefore, it is hoped CXCL14 can be used as a biomarker to demonstrate whether vismodegib can tame both the shrew and IPF.

The merry widows of windsor

Falstaff...




Thank you to our reviewers 2016

2017-08-21T06:25:33-07:00

The Editors would like to publicly acknowledge the people listed below who served as reviewers on the journal during 2016. Without their efforts, the quality of the journal could not be sustained.

Aaron, Shawn

Abbas, Abbas

Abman, Steven

Abouda, Maher

Accurso, Frank

Adams, Lewis

Adcock, Ian

Adhikari, Neill

Aggarwal, Neil R

Agostini, Carlo

Agrawal, Sanjay

Aguinagalde, Borja

Ahmed, Liju

Aitken, Leanne

Aitken, Moira

Al-Khairalla, Mudher

Alejandro, Rabinstein

Alison, Jennifer

Allen, Richard

Amaral, Andre

Ambalavanan, N

Ambroggio, Lilliam

Ambrosino, Nico

Ambrosino, Nicolino

Anders, Aneman

Ankersmit, Hendrik

Annema, Jouke

Antic, Nick

Antonini, James

Arias Arcos, Maria Beatriz

Armstrong-James, Darius

Arnold, Christina A

Asehnoune, Karim

Atkinson, Richard

Aurora, Paul

Aurora, Rashmi

Bach, John

BaHammam, Ahmed

Bajwah, Sabrina

Baker, Emma

Baldwin, David

Balfour-Lynn, Ian

Banac, Srdan

Bandeira, Teresa

Banks, Michael

Banzett, Robert

Barbé, Ferran

Barnes, Peter

Barr, David

Barreiro, Esther

Barrett, Nora

Bateman, Eric

Baughman, Robert

Baumann, Hans Joerg

Beasley, Richard

Becker, Allan

...



Ambient particulate matter and COPD in China: a challenge for respiratory health research

2017-08-21T06:25:33-07:00

Worldwide, COPD is an important cause of morbidity and mortality. The condition is increasing in prevalence, it is a major public health problem and it will remain a challenge for clinicians within the 21st century.1 COPD has become the third leading cause of death,2 resulting in 2.9 million deaths globally in 2013.3 The Global Burden of Diseases Study estimated that around 1.2 million premature deaths and 25 million disability-adjusted life-years annually in China alone could be attributed to air pollution.3 In recent years, evidence is growing that the exposure to ambient air pollution may contribute to the growing global burden of COPD.4 In many Western countries, levels of ambient air pollution have been improved with the setting of upper limits and better urban planning. However, air pollution in low/middle-income countries with rapid industrialisation, such as China, has become a...




Short course treatment for MDR TB: jumping the gun?

2017-08-21T06:25:33-07:00

Multidrug-resistant (MDR)-TB is threatening TB control worldwide. The conventional treatment lasts 20–24 months, is often toxic and half of the treated patients have poor outcomes. WHO has recently recommended a shorter regimen with treatment duration of 9–12 months, aiming for higher effectiveness, tolerability, adherence and completion rates.1 This shorter regimen is recommended for patients with pulmonary TB who have not been previously exposed to second-line drugs for more than 1 month and have no confirmed or suspected resistance to drugs in the regimen, except high-dose isoniazid. Recommendations were based on the promising results of large observational cohorts in Asia and Africa.

In Thorax, Yanina Balabanova and colleagues assessed the proportion of adult smear-positive pulmonary MDR-TB cases who might have been eligible for the shorter regimen. The patients were initially recruited in 2007 and 2009 and followed up till 2012 in four eastern European countries, who participated in the European Union-funded...




Ventilator-associated pneumonia: when is a pathogen not a pathogen?

2017-08-21T06:25:33-07:00

The context of respiratory microbiology is changing. 16S rRNA gene sequencing is a workhorse method in the field of environmental microbiology, established for over 30 years.1 Rather than requiring growth of organisms on agar plates it targets the DNA of all the microorganisms present, revealing bacteria irrespective of their particular growth requirements. Together with metagenomics, the untargeted shotgun sequencing of DNA extracted from a sample, these techniques have been applied to the respiratory tract. These approaches have revealed a characteristic respiratory community of microorganisms, a respiratory microbiota that varies in different diseases.2–6 The most prevalent organisms in the healthy respiratory tract are Streptococcus spp., Veillonella spp. and Prevotella spp.; the latter two genera being anaerobic bacteria, intolerant of oxygen and not commonly isolated by classic microbiology approaches.

At times studies that use these techniques might seem to be...




Radiation exposure during lung cancer diagnostic work-up: how important in the wider picture?

2017-08-21T06:25:33-07:00

The paper by Rintoul et al1 has highlighted the radiation burden for patients undergoing imaging investigations for lung cancer and calculated the lifetime attributable risk of developing a further malignancy as a result of that radiation exposure. Patients who underwent curative-intent surgery or radical (chemo)radiotherapy received an average radiation dose of approximately 28 mSv in their work-up. As might be expected, those patients with more advanced disease, in whom radical treatment was not possible and underwent best supportive care, received approximately half the radiation dose (approximately 15 mSv).

Using standard conversion factors, the authors have derived the lifetime risk of developing a second cancer as a consequence of the radiation exposure as approximately 1:1700 for all cancers and 1:5000 specifically for lung cancer in patients undergoing curative-intent surgery or radical (chemo)radiotherapy. It is important for the physician, radiologist and, of course, the patient to determine whether this...




Defining the path: lung cancer CT screening in Europe

2017-08-21T06:25:33-07:00

Since the publication of the National Lung Screening Trial (NLST) in 2011 demonstrating a 20% reduction in lung cancer-specific mortality by annual low-dose CT (LDCT),1 implementation of screening has continued apace in the USA. Other developed nations, perhaps mindful of the potential cost implications of national screening programmes, have been more reticent, with many awaiting the final outcome data from the largest European randomised trial—the Dutch-Belgian Lung Cancer Screening trial (NELSON)  study which remains in follow-up.2

Despite the convincing mortality reduction in NLST, questions remain about implementation of LDCT screening for lung cancer. Unresolved issues include how to best identify high-risk individuals for screening, what is the most appropriate screening interval to achieve an optimal balance between mortality reduction and cost-effectiveness and how to minimise possible harms associated with screening—particularly overdiagnosis. This issue of Thorax includes two papers which provide important additions to accumulating evidence in this...




CXCL14 is a candidate biomarker for Hedgehog signalling in idiopathic pulmonary fibrosis

2017-08-21T06:25:33-07:00

Background

Idiopathic pulmonary fibrosis (IPF) is associated with aberrant expression of developmental pathways, including Hedgehog (Hh). As Hh signalling contributes to multiple pro-fibrotic processes, Hh inhibition may represent a therapeutic option for IPF. However, no non-invasive biomarkers are available to monitor lung Hh activity.

Methods

We assessed gene and protein expression in IPF and control lung biopsies, mouse lung, fibroblasts stimulated in vitro with sonic hedgehog (SHh), and plasma in IPF patients versus controls, and cancer patients before and after treatment with vismodegib, a Hh inhibitor.

Results

Lung tissue from IPF patients exhibited significantly greater expression of Hh-related genes versus controls. The gene most significantly upregulated in both IPF lung biopsies and fibroblasts stimulated in vitro with SHh was CXCL14, which encodes a soluble secreted chemokine whose expression is inhibited in vitro by the addition of vismodegib. CXCL14 expression was induced by SHh overexpression in mouse lung. Circulating CXCL14 protein levels were significantly higher in plasma from IPF patients than controls. In cancer patients, circulating CXCL14 levels were significantly reduced upon vismodegib treatment.

Conclusions

CXCL14 is a systemic biomarker that could be used to identify IPF patients with increased Hh pathway activity and monitor the pharmacodynamic effects of Hh antagonist therapy in IPF.

Trial registration number

Post-results, NCT00968981.




Association between exposure to ambient particulate matter and chronic obstructive pulmonary disease: results from a cross-sectional study in China

2017-08-21T06:25:33-07:00

Objective

The association between exposure to ambient particles with a median aerodynamic diameter less than 10/2.5 µm (particulate matter, PM10/2.5) and COPD remains unclear. Our study objective was to examine the association between ambient PM10/2.5 concentrations and lung functions in adults.

Methods

A cross-sectional study was conducted in southern China. Seven clusters were randomly selected from four cities across Guangdong province. Residents aged ≥20 years in the participating clusters were randomly recruited; all eligible participants were examined with a standardised questionnaire and spirometry. COPD was defined as a post-bronchodilator FEV1/FVC less than 70%. Atmosphere PM sampling was conducted across the clusters along with our survey.

Results

Of the subjects initially recruited, 84.4% (n=5993) were included for analysis. COPD prevalence and atmosphere PM concentration varied significantly among the seven clusters. COPD prevalence was significantly associated with elevated PM concentration levels: adjusted OR 2.416 (95% CI 1.417 to 4.118) for >35 and ≤75 µg/m3 and 2.530 (1.280 to 5.001) for >75 µg/m3 compared with the level of ≤35 µg/m3 for PM2.5; adjusted OR 2.442 (95% CI 1.449 to 4.117) for >50 and ≤150 µg/m3 compared with the level of ≤50 µg/m3 for PM1. A 10 µg/m3 increase in PM2.5 concentrations was associated with a 26 mL (95% CI –43 to –9) decrease in FEV1, a 28 mL (–49 to –8) decrease in FVC and a 0.09% decrease (–0.170 to –0.010) in FEV1/FVC ratio. The associations of COPD with PM10 were consistent with PM2.5 but slightly weaker.

Conclusions

Exposure to higher PM concentrations was strongly associated with increased COPD prevalence and declined respiratory function.

Trial registration number

ChiCTR-OO-14004264; Post-results.




Socio-environmental correlates of physical activity in patients with chronic obstructive pulmonary disease (COPD)

2017-08-21T06:25:33-07:00

Background

Study of the causes of the reduced levels of physical activity in patients with COPD has been scarce and limited to biological factors.

Aim

To assess the relationship between novel socio-environmental factors, namely dog walking, grandparenting, neighbourhood deprivation, residential surrounding greenness and residential proximity to green or blue spaces, and amount and intensity of physical activity in COPD patients.

Methods

This cross-sectional study recruited 410 COPD patients from five Catalan municipalities. Dog walking and grandparenting were assessed by questionnaire. Neighbourhood deprivation was assessed using the census Urban Vulnerability Index, residential surrounding greenness by the satellite-derived Normalized Difference Vegetation Index, and residential proximity to green or blue spaces as living within 300 m of such a space. Physical activity was measured during 1 week by accelerometer to assess time spent on moderate-to-vigorous physical activity (MVPA) and vector magnitude units (VMU) per minute.

Findings

Patients were 85% male, had a mean (SD) age of 69 (9) years, and post-bronchodilator FEV1 of 56 (17) %pred. After adjusting for age, sex, socio-economic status, dyspnoea, exercise capacity and anxiety in a linear regression model, both dog walking and grandparenting were significantly associated with an increase both in time in MVPA (18 min/day (p<0.01) and 9 min/day (p<0.05), respectively) and in physical activity intensity (76 VMU/min (p=0.05) and 59 VMUs/min (p<0.05), respectively). Neighbourhood deprivation, surrounding greenness and proximity to green or blue spaces were not associated with physical activity.

Conclusions

Dog walking and grandparenting are associated with a higher amount and intensity of physical activity in COPD patients.

Trial registration number

Pre-results, NCT01897298.




The dynamics of the pulmonary microbiome during mechanical ventilation in the intensive care unit and the association with occurrence of pneumonia

2017-08-21T06:25:33-07:00

Rationale

Ventilator-associated pneumonia (VAP) is the most common nosocomial infections in patients admitted to the ICU. The adapted island model predicts several changes in the respiratory microbiome during intubation and mechanical ventilation.

Objectives

We hypothesised that mechanical ventilation and antibiotic administration decrease the diversity of the respiratory microbiome and that these changes are more profound in patients who develop VAP.

Methods

Intubated and mechanically ventilated ICU-patients were included. Tracheal aspirates were obtained three times a week. 16S rRNA gene sequencing with the Roche 454 platform was used to measure the composition of the respiratory microbiome. Associations were tested with linear mixed model analysis and principal coordinate analysis.

Measurements and main results

111 tracheal aspirates were obtained from 35 patients; 11 had VAP, 18 did not have VAP. Six additional patients developed pneumonia within the first 48 hours after intubation. Duration of mechanical ventilation was associated with a decrease in α diversity (Shannon index; fixed-effect regression coefficient (β): –0.03 (95% CI –0.05 to –0.005)), but the administration of antibiotic therapy was not (fixed-effect β: 0.06; 95% CI –0.17 to 0.30). There was a significant difference in change of β diversity between patients who developed VAP and control patients for Bray-Curtis distances (p=0.03) and for Manhattan distances (p=0.04). Burkholderia, Bacillales and, to a lesser extent, Pseudomonadales positively correlated with the change in β diversity.

Conclusion

Mechanical ventilation, but not antibiotic administration, was associated with changes in the respiratory microbiome. Dysbiosis of microbial communities in the respiratory tract was most profound in patients who developed VAP.




Ultrasound evaluation of diaphragm function in mechanically ventilated patients: comparison to phrenic stimulation and prognostic implications

2017-08-21T06:25:33-07:00

Rationale

In intensive care unit (ICU) patients, diaphragm dysfunction is associated with adverse clinical outcomes. Ultrasound measurements of diaphragm thickness, excursion (EXdi) and thickening fraction (TFdi) are putative estimators of diaphragm function, but have never been compared with phrenic nerve stimulation. Our aim was to describe the relationship between these variables and diaphragm function evaluated using the change in endotracheal pressure after phrenic nerve stimulation (Ptr,stim), and to compare their prognostic value.

Methods

Between November 2014 and June 2015, Ptr,stim and ultrasound variables were measured in mechanically ventilated patients <24 hours after intubation (‘initiation of mechanical ventilation (MV)’, under assist-control ventilation, ACV) and at the time of switch to pressure support ventilation (‘switch to PSV’), and compared using Spearman's correlation and receiver operating characteristic curve analysis. Diaphragm dysfunction was defined as Ptr,stim <11 cm H2O.

Results

112 patients were included. At initiation of MV, Ptr,stim was not correlated to diaphragm thickness (p=0.28), EXdi (p=0.66) or TFdi (p=0.80). At switch to PSV, TFdi and EXdi were respectively very strongly and moderately correlated to Ptr,stim, (r=0.87, p<0.001 and 0.45, p=0.001), but diaphragm thickness was not (p=0.45). A TFdi <29% could reliably identify diaphragm dysfunction (sensitivity and specificity of 85% and 88%), but diaphragm thickness and EXdi could not. This value was associated with increased duration of ICU stay and MV, and mortality.

Conclusions

Under ACV, diaphragm thickness, EXdi and TFdi were uncorrelated to Ptr,stim. Under PSV, TFdi was strongly correlated to diaphragm strength and both were predictors of remaining length of MV and ICU and hospital death.




Risk stratification based on screening history: the NELSON lung cancer screening study

2017-08-21T06:25:33-07:00

Background

Debate about the optimal lung cancer screening strategy is ongoing. In this study, previous screening history of the Dutch-Belgian Lung Cancer Screening trial (NELSON) is investigated on if it predicts the screening outcome (test result and lung cancer risk) of the final screening round.

Methods

15 792 participants were randomised (1:1) of which 7900 randomised into a screening group. CT screening took place at baseline, and after 1, 2 and 2.5 years. Initially, three screening outcomes were possible: negative, indeterminate or positive scan result. Probability for screening outcome in the fourth round was calculated for subgroups of participants.

Results

Based on results of the first three rounds, three subgroups were identified: (1) those with exclusively negative results (n=3856; 73.0%); (2) those with ≥1 indeterminate result, but never a positive result (n=1342; 25.5%); and (3) with ≥1 positive result (n=81; 1.5%). Group 1 had the highest probability for having a negative scan result in round 4 (97.2% vs 94.8% and 90.1%, respectively, p<0.001), and the lowest risk for detecting lung cancer in round 4 (0.6% vs 1.6%, p=0.001). ‘Smoked pack-years’ and ‘screening history’ significantly predicted the fourth round test result. The third round results implied that the risk for detecting lung cancer (after an interval of 2.5 years) was 0.6% for those with negative results compared with 3.7% of those with indeterminate results.

Conclusions

Previous CT lung cancer screening results provides an opportunity for further risk stratifications of those who undergo lung cancer screening.

Trial registration number

Results, ISRCTN63545820.




Mortality, survival and incidence rates in the ITALUNG randomised lung cancer screening trial

2017-08-21T06:25:33-07:00

Background

ITALUNG is contributing to the European evaluation of low-dose CT (LDCT) screening for lung cancer (LC).

Methods

Eligible subjects aged 55–69 years, smokers or ex-smokers (at least 20 pack-years in the last 10 years), were randomised to receive an annual invitation for LDCT screening for 4 years (active group) or to usual care (control group). All participants were followed up for vital status and cause of death (at the end of 2014) and LC incidence (at the end of 2013). Pathological and clinical information was collected from the Tuscan Cancer Registry data.

Results

1613 subjects were randomly assigned to the active group and 1593 to the control group. At the end of the follow-up period 67 LC cases were diagnosed in the active group and 71 in the control group (rate ratio (RR)=0.93; 95% CI 0.67 to 1.30). A greater proportion of stage I LC was observed in the active group (36% vs 11%, p<0.001). Non-significant reductions of 17% (RR=0.83; 95% CI 0.67 to 1.03) for overall mortality and 30% (RR=0.70; 95% CI 0.47 to 1.03) for LC-specific mortality were estimated.

Conclusions

Despite the lack of statistical significance, the ITALUNG trial outcomes suggest that LDCT screening could reduce LC and overall mortality. Moreover, the comparison of the number of LC cases diagnosed in the two groups does not show overdiagnosis after an adequate follow-up period. A pooled analysis of all European screening trials is advocated to assess the benefit-to-harm ratio of LDCT screening and its implementation in public health settings.

Trial registration number

Results, NCT02777996.




Validation of a health-related quality of life instrument for primary ciliary dyskinesia (QOL-PCD)

2017-08-21T06:25:33-07:00

Background

Quality of life (QOL)-primary ciliary dyskinesia (PCD) is the first disease-specific, health-related QOL instrument for PCD. Psychometric validation of QOL-PCD assesses the performance of this measure in adults, including its reliability, validity and responsiveness to change.

Methods

Seventy-two adults (mean (range) age: 33 years (18–79 years); mean (range) FEV1% predicted: 68 (26–115)) with PCD completed the 49-item QOL-PCD and generic QOL measures: Short-Form 36 Health Survey, Sino-Nasal Outcome Test 20 (SNOT-20) and St George Respiratory Questionnaire (SGRQ)-C. Thirty-five participants repeated QOL-PCD 10–14 days later to measure stability or reproducibility of the measure.

Results

Multitrait analysis was used to evaluate how the items loaded on 10 hypothesised scales: physical, emotional, role and social functioning, treatment burden, vitality, health perceptions, upper respiratory symptoms, lower respiratory symptoms and ears and hearing symptoms. This analysis of item-to-total correlations led to 9 items being dropped; the validated measure now comprises 40 items. Each scale had excellent internal consistency (Cronbach's α: 0.74 to 0.94). Two-week test–retest demonstrated stability for all scales (intraclass coefficients 0.73 to 0.96). Significant correlations were obtained between QOL-PCD scores and age and FEV1. Strong relationships were also found between QOL-PCD scales and similar constructs on generic questionnaires, for example, lower respiratory symptoms and SGRQ-C (r=0.72, p<0.001), while weak correlations were found between measures of different constructs.

Conclusions

QOL-PCD has demonstrated good internal consistency, test–retest reliability, convergent and divergent validity. QOL-PCD offers a promising tool for evaluating new therapies and for measuring symptoms, functioning and QOL during routine care.




State of the art thoracic ultrasound: intervention and therapeutics

2017-08-21T06:25:33-07:00

The use of thoracic ultrasound outside the radiology department and in everyday clinical practice is becoming increasingly common, having been incorporated into standards of care for many specialties. For the majority of practitioners, their experience of, and exposure to, thoracic ultrasound will be in its use as an adjunct to pleural and thoracic interventions, owing to the widely recognised benefits for patient safety and risk reduction. However, as clinicians become increasingly familiar with the capabilities of thoracic ultrasound, new directions for its use are being sought which might enhance practice and patient care. This article reviews the ways in which the advent of thoracic ultrasound is changing the approach to the investigation and treatment of respiratory disease from an interventional perspective. This will include the impact of thoracic ultrasound on areas including patient safety, diagnostic and therapeutic procedures, and outcome prediction; and will also consider potential future research and clinical directions.




Multidrug-resistant TB in Eastern region of the EU: is the shorter regimen an exception or a rule?

2017-08-21T06:25:33-07:00

WHO recently recommended the use of a shorter multidrug-resistant TB (MDR-TB) regimen under programmatic conditions. We assessed eligibility for this regimen in a cohort of 737 adult patients with MDR-TB from Latvia, Lithuania, Estonia and Bucharest city recruited in 2007 and 2009. Only 4.2% of the patients were eligible for this regimen. Ethambutol (64%), pyrazinamide resistance (58%) and previous exposure to second-line TB drugs were major reasons for non-eligibility. High-level resistance to isoniazid is expected due to widespread prevalence of katG mutations. In Eastern Europe, the use of the shorter regimen might be an exception rather than a rule.




Exposure of patients to ionising radiation during lung cancer diagnostic work-up

2017-08-21T06:25:33-07:00

We examined the dose of radiation received during diagnosis of lung cancer as this may add to the risk of a second primary cancer. Patients undergoing surgery (n=40) or (chemo)radiotherapy (n=40) received comparable doses (28.6 and 25.8 mSv, respectively), significantly higher than that for supportive care (n=40; 15.1 mSv). The effective dose of radiation received was higher for early stage disease than for those with metastatic disease. The mean lifetime attributable risk of malignancy for those receiving treatment with curative intent in our cohort was 0.059%, and lung-specific risk 0.019%.




Peer support to improve recovery following critical care discharge: a case-based discussion

2017-08-21T06:25:33-07:00

Case presentation

We report the case of a self-employed builder aged 58-years, with a medical history of ischaemic heart disease and type II diabetes. He was transferred to our intensive care unit (ICU) from another local hospital for treatment of gallstone pancreatitis. He stayed in critical care for 19 days, with a total hospital stay of 9 weeks. He and his wife have consented to the presentation of their case.

This patient required level three care (ICU care) for 3 days. He required level two care (high dependency care) for a further 16 days due to complications related to his acute kidney injury and pancreatitis. He was mechanically ventilated for 3 days with a worst P/F ratio of 150 mmHg and underwent renal replacement therapy for 8 days. As per standard practice in the ICU at the time, he was visited by physical therapy on 17 of his 19 ICU days. This patient has...




Unique radiological features of two cases of primary pulmonary diffuse large B-cell lymphoma

2017-08-21T06:25:33-07:00

Introduction 

Radiographic infiltration of the lungs by malignant lymphoma is often observed, with a reported frequency of approximately 25%. On the other hand, primary pulmonary lymphoma (PPL) is very rare. According to previous reports, PPL was observed in only 3% of patients with extranodal lymphoma, and in less than 1% of patients with non-Hodgkin's lymphoma. Most cases of PPL (58%–87%) are marginal zone lymphomas of the mucosa-associated lymphoid tissue (MALT) type.1 However, primary lung diffuse large B-cell lymphoma (DLBCL) is rare (10%).2 Here we present two cases of primary lung DLBCL displaying unique imaging.

Case reportCase 1

A 56-year-old woman complaining of dyspnoea and fever was admitted to our hospital. Consolidation in the bilateral upper fields on chest radiological examination and multiple pulmonary nodules on CT were the only abnormalities detected by radiography (Figure 1A).

Upper and lower endoscopy showed no evidence of gastrointestinal cancer....




Pulmonary microvascular architecture in hereditary haemorrhagic telangiectasia

2017-08-21T06:25:33-07:00

A 24-year-old Caucasian man was admitted with a known hereditary haemorrhagic telangiectasia (HHT) and heterozygous mutation of factor V Leiden following episodes of cerebral infarctions in occipital lobes, cerebellum and brainstem. In his case history, the patient underwent several interventional embolisation of arteriovenous (AV) malformations in the middle and lower lobes (figure 1). However, those were not completely successful as the malformations were diffuse. We performed video-assisted thoracoscopic surgery with a resection of the middle lobe and a wedge resection of segment 10.

HHT (Osler-Weber-Rendu disease) is an autosomal-dominant disease determined by multiple dilated vessels including mucocutaneous telangiectasias and vascular malformations of visceral organs resulting in recurrent epistaxis, gastrointestinal bleedings, paradoxical emboli, cerebral infarctions and abscesses.1 In about 55% of patients with HHT type 1 (HHT-1) and about 10% of patients with HHT type 2 (HHT-2), large pulmonary arteriovenous malformations (PAVMs) are found which...




Macroscopic inflammatory tracheal and endobronchial nodules in Sjögren's syndrome

2017-08-21T06:25:33-07:00

A 38-year-old woman with primary Sjögren's syndrome (SS) presented with a 1 month history of cough and chest pain. She had been treated with prednisolone for organising pneumonia and had been on prednisolone (5 mg/day). Flexible bronchoscopy revealed macroscopic multiple nodules mainly in trachea and in both main bronchus (figure 1A). Three-dimensional CT (3D-CT) also demonstrated multiple nodules in the same place (figure 1B). Endobronchial biopsy showed polyclonal lymphocyte infiltration in the bronchial submucosa and epithelium in part (figure 1C, H & E: upper, CD3: middle, CD20: lower). There were few IgG4-positive plasma cells in the lesion. Amyloid deposition was not detected by direct fast scarlet staining. Abnormal proliferations of squamous epithelium were not observed, and human papilloma virus DNA was not detected in the bronchial lavage fluid. These findings indicated that the inflammatory nodules were associated with SS. Selective cyclo-oxygenase-2 inhibitor, celecoxib, was...




Whats hot that the other lot got

2017-08-21T06:25:33-07:00

Ex-vivo lung perfusion as standard protocol

Perfusion of the lung after harvest was developed to assess the suitability of borderline organs, or those not fully assessed at the donor centre. In this randomised control trial Slama et al (J Heart Lung Transplant 2017;36:744–53) examine ex-vivo lung perfusion (EVLP) versus standard transplant. 76 single sequential lung transplants at Medical University of Vienna between October 2013 and May 2015 were included. CIT (duration from aortic clamp to reperfusion within the recipient minus the duration of EVLP) was significantly longer in the EVLP group (first side, 372 min vs 291 min, p<0.001; second side 437 min vs 370 min; p=0.001). All transplants were done on arterio-venous ECMO; two patients in the EVLP group and five in the control group required prolonged ECMO. At 24 hours primary graft dysfunction (PGD) score was >1 for two patients in the EVLP group, and seven in the control group, which is...