Related Articles

Lobar Lung Transplantation: A Relevant Surgical Option in the Current Era of Lung Allocation Score.

Ann Thorac Surg. 2013 Jun 15;

Authors: Shigemura N, D'Cunha J, Bhama JK, Shiose A, Abou El Ela A, Hackmann A, Zaldonis D, Toyoda Y, Pilewski JM, Luketich JD, Bermudez CA

Abstract
BACKGROUND: With the implementation of the lung allocation score (LAS) system, an increased number of critically ill patients are considered for transplantation. However, LAS does not take size matching between donor and recipient lungs into consideration. Mortality on the waiting list is high (as high as 25%) for short-stature patients and for patients with restrictive lung disease. Here, we review our experience using cadaveric lobar lung transplantation as a surgical option in an attempt to decrease mortality while waiting. METHODS: We retrospectively reviewed patients with end-stage lung diseases and an LAS greater than 70 who underwent cadaveric lobar lung transplantation between 2010 and 2012 (n = 25) at our institution, a high-volume lung transplant center. Anatomic lobectomy was performed on all donor lungs before double lung transplantation. RESULTS: Median LAS was 85.6 (range, 72 to 94). Average waiting time after the patients' LAS was updated to greater than 70 was 10 days (range, 1 to 41). There were 2 in-hospital deaths. The 90-day and 1-year survivals were 88% and 76%, respectively. Patient major comorbidities included severe primary graft dysfunction requiring postoperative extracorporeal membrane oxygenation (7 patients), acute renal insufficiency (4 patients), and bleeding requiring reoperation (4 patients). No technical problems were identified, and repeated bronchoscopy demonstrated satisfactory healing of the bronchial stump after lobectomy. The average posttransplant peak for forced expiratory volume in 1 second was 85%. CONCLUSIONS: Our initial experience supports the option of lobar lung transplantation for critically ill patients whose opportunities for transplant are limited by their stature. Long-term functional studies are warranted.

PMID: 23773735 [PubMed - as supplied by publisher]

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Endosonography vs conventional bronchoscopy for the diagnosis of sarcoidosis: the GRANULOMA randomized clinical trial.

JAMA. 2013 Jun 19;309(23):2457-64

Authors: von Bartheld MB, Dekkers OM, Szlubowski A, Eberhardt R, Herth FJ, in 't Veen JC, de Jong YP, van der Heijden EH, Tournoy KG, Claussen M, van den Blink B, Shah PL, Zoumot Z, Clementsen P, Porsbjerg C, Mauad T, Bernardi FD, van Zwet EW, Rabe KF, Annema JT

Abstract
IMPORTANCE: Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis. Bronchoscopy with transbronchial lung biopsies, the current diagnostic standard, has moderate sensitivity in assessing granulomas. Endosonography with intrathoracic nodal aspiration appears to be a promising diagnostic technique.
OBJECTIVE: To evaluate the diagnostic yield of bronchoscopy vs endosonography in the diagnosis of stage I/II sarcoidosis.
DESIGN, SETTING, AND PATIENTS: Randomized clinical multicenter trial (14 centers in 6 countries) between March 2009 and November 2011 of 304 consecutive patients with suspected pulmonary sarcoidosis (stage I/II) in whom tissue confirmation of noncaseating granulomas was indicated.
INTERVENTIONS: Either bronchoscopy with transbronchial and endobronchial lung biopsies or endosonography (esophageal or endobronchial ultrasonography) with aspiration of intrathoracic lymph nodes. All patients also underwent bronchoalveolar lavage.
MAIN OUTCOMES AND MEASURES: The primary outcome was the diagnostic yield for detecting noncaseating granulomas in patients with a final diagnosis of sarcoidosis. The diagnosis was based on final clinical judgment by the treating physician, according to all available information (including findings from initial bronchoscopy or endosonography). Secondary outcomes were the complication rate in both groups and sensitivity and specificity of bronchoalveolar lavage in the diagnosis of sarcoidosis.
RESULTS: A total of 149 patients were randomized to bronchoscopy and 155 to endosonography. Significantly more granulomas were detected at endosonography vs bronchoscopy (114 vs 72 patients; 74% vs 48%; P < .001). Diagnostic yield to detect granulomas for endosonography was 80% (95% CI, 73%-86%); for bronchoscopy, 53% (95% CI, 45%-61%) (P < .001). Two serious adverse events occurred in the bronchoscopy group and 1 in the endosonography group; all patients recovered completely. Sensitivity of the bronchoalveolar lavage for sarcoidosis based on CD4/CD8 ratio was 54% (95% CI, 46%-62%) for flow cytometry and 24% (95% CI, 16%-34%) for cytospin analysis. CONCLUSION AND RELEVANCE: Among patients with suspected stage I/II pulmonary sarcoidosis undergoing tissue confirmation, the use of endosonographic nodal aspiration compared with bronchoscopic biopsy resulted in greater diagnostic yield.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00872612.

PMID: 23780458 [PubMed - indexed for MEDLINE]

Montelukast improves air trapping, not airway remodeling, in patients with moderate-to-severe asthma: a pilot study.

Chin Med J (Engl). 2013 Jun;126(12):2229-34

Authors: Gao JM, Cai F, Peng M, Ma Y, Wang B

Abstract
BACKGROUND: Evidence has demonstrated that the distal lung, which includes airways of < 2 mm in diameter and lung parenchyma, constitutes an important component of asthma pathology. Cysteinyl leukotrienes (CysLTs) are potent proinflammatory mediators and bronchoconstrictors involved in the asthmatic process. Guidelines recommend the leukotriene-modifying agents for asthma treatment. We hypothesized that a leukotriene receptor antagonist with an inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) combination would improve small airways function in moderate-to- severe asthmatics evaluated by physiological tests and high-resolution computed tomography (HRCT) analysis. This study was performed at a tertiary university hospital in Beijing.
METHODS: This was a randomized, double-blind, parallel study performed in 38 patients with moderate-to-severe asthma treated with salmeterol/futicasone (SFC) plus montelukast (SFC+M) or SFC plus placebo over 24 weeks. Small airway function was assessed by physiological studies and HRCT image analysis.
RESULTS: Montelukast significantly improved air trapping as expressed by the residual volume (RV)/total lung capacity (TLC). Over 24 weeks of treatment, RV/TLC was improved by (15.41 ± 6.67)% in patients receiving SFC+M while RV/TLC was decreased by (8.57 ± 10.26)% in patients receiving SFC alone, the difference between the two groups was significant (P = 0.02). There was a trend towards a significant difference in forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) in the SFC+M group compared to that in the SFC group ((17.87 ± 8.17)% vs. (12.28 ± 9.20)%, P = 0.056). There was no significant change in percentage wall area (WA%) after 24 weeks of add-on treatment with montelukast. Patients receiving SFC+M showed significant improvement in the ratio of CT-determined values at full expiration to those at full inspiration (E/I ratio) (0.894 ± 0.005 vs. 0.871 ± 0.003, P = 0.002).
CONCLUSION: We have shown, using lung function tests and HRCT image technique, that add-on therapy with montelukast improves distal lung function reflected by air trapping, but not airway wall thickness in moderate-to-severe asthma.

PMID: 23786930 [PubMed - in process]

Health-Related Quality of Life and Utility in Patients with Advanced Non-Small-Cell Lung Cancer: A Prospective Cross-Sectional Patient Survey in a Real-World Setting.

J Thorac Oncol. 2013 Jun 19;

Authors: Chouaid C, Agulnik J, Goker E, Herder GJ, Lester JF, Vansteenkiste J, Finnern HW, Lungershausen J, Eriksson J, Kim K, Mitchell PL

Abstract
BACKGROUND:: Non-small-cell lung cancer (NSCLC) has a significant impact on patients' health-related quality of life (HRQOL). This study aimed to measure health state utility values representing the individual's preferences for specific health-related outcomes in advanced NSCLC patients and to assess predictive parameters.
METHODS:: We conducted a prospective quality-of-life survey on advanced NSCLC patients in 25 hospitals in Europe, Canada, Australia, and Turkey. HRQOL was assessed using the EuroQol (EQ-5D) questionnaire and EQ-5D utility and EQ-visual analog (EQ-VAS) scores were estimated.
RESULTS:: Three hundred nineteen patients were recruited of which 263 had evaluable data. Mean utility for progression-free (PF) patients on first-, second-, and third-/fourth-line treatment was 0.71 (SD = 0.24), 0.74 (SD = 0.18), and 0.62 (SD = 0.29), respectively. Mean utility for patients with progressive disease (PD) while on first-, second- and third-/fourth-line treatment was 0.67 (SD = 0.2), 0.59 (SD = 0.34), and 0.46 (SD = 0.38), respectively. Overall, patients with PD had lower mean utility scores than PF patients (0.58 versus 0.70). The results of the EQ-VAS showed that the score decreased with later treatment lines. Patients with PD had a 10-point decrease in VAS scores compared with PF patients (53.7 versus 66.6). The regression analysis revealed that stage IV disease, higher lines of treatment, and health state were significant predictors of utility at the 10% level.
CONCLUSION:: The results presented indicate a substantial impact of lung cancer on patients' HRQOL, with stage IV disease, line of treatment, and PD, resulting in considerable deterioration of utility. The values obtained here will inform evaluations of cost-utility for NSCLC therapies.

PMID: 23787802 [PubMed - as supplied by publisher]