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A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy [How-to-do-it]

Extrapleural pneumonectomy (EPP) is an established surgical treatment for malignant mesothelioma; this operation is, however, burdened by a high rate of perioperative morbidity, mostly related to the surgical procedure. Diaphragmatic patch dehiscence is a potentially serious complication often related to the difficulty in placement of the fixing stitches, especially in the costo-phrenic angle. We present our experience with the use of titanium-plate support for an easy and safe positioning of the diaphragmatic patch.

Clinical predictors of frequent exacerbations in subjects with severe chronic obstructive pulmonary disease (COPD)

Acute exacerbations are a significant source of morbidity and mortality associated with chronic obstructive pulmonary disease. Among individuals with COPD, some patients suffer an inordinate number of exacerbations while others remain relatively protected.

We undertook a study to determine the clinical factors associated with "frequent exacerbator" status within a population of subjects with severe COPD.

Methods: Case-control cohort recruited from two Boston-area practices. All subjects had GOLD stage 3 or 4 (FEV1 ≤ 50% predicted) COPD. "Frequent exacerbators" (n = 192) had an average of ≥2 moderate-to-severe exacerbations per year while "non-exacerbators" (n = 153) had no exacerbations in the preceding 12 months. Multivariate logistic regression was performed...

Lysyl oxidase: A lung adenocarcinoma biomarker of invasion and survival.

Lung adenocarcinoma invasion and metastasis arises from autocrine and paracrine signaling events between tumor epithelial cells and the stromal microenvironment that is mediated in part by transforming growth factor-β (TGF-β) signaling. The copper-dependent amine oxidase lysyl oxidase (LOX) plays a role in extracellular matrix structure and is up-regulated in invasive type II TGF-β receptor-deficient cells.The authors hypothesized that LOX expression is associated with extent of invasion and survival in patients with lung adenocarcinoma

METHODS:: LOX immunohistochemical staining was examined in 166 surgically resected lung adenocarcinomas and results were correlated with clinicopathological features and survival.

RESULTS:: High-intensity LOX staining was found to be associated with the linear extent of invasion (Spearman correlation coefficient = 0.2; P = .01). There was an association between high LOX staining and decreased 5-year survival observed within the entire cohort (log-rank P < .001) and among the patients with stage I disease (n = 119; P < .001). Cox proportional hazards regression analysis confirmed that LOX was a significant prognostic indicator of increased risk of 5-year mortality for all patients (hazard ratio [HR], 2.55; 95% confidence interval [95% CI], 1.51-4.30 [P < .001]) and for patients with Stage I disease (HR, 3.51; 95% CI, 1.77-6.99 [P < .001]). LOX expression was found to be independently associated with risk of death after adjustment for relevant covariates (HR, 2.29; 95% CI, 1.33-3.94 [P = .003]).

CONCLUSIONS:: Higher expression of LOX is associated with invasion and is an independent predictor of poor prognosis in patients with early stage lung adenocarcinoma. Cancer 2010. © 2010 American Cancer Society.

Exercise capacity in idiopathic pulmonary fibrosis: the effect of pulmonary hypertension.

Pulmonary hypertension (PH) results in exercise limitation in patients with IPF. Although resting pulmonary function measurements are minimally informative regarding the presence and impact of PH, exercise parameters indicative of circulatory impairment correlate significantly with systolic pulmonary arterial pressure in patients with IPF and PH.

Background and objective: Increased pulmonary arterial pressure (PAP) usually co-exists with impaired lung function in IPF. Data on the effect of pulmonary hypertension (PH) on cardiopulmonary responses during exercise in IPF patients is very limited. We sought to investigate the impact of PH on exercise capacity and the correlation between systolic PAP (sPAP) and pulmonary function testing, as well as cardiopulmonary exercise parameters, in patients with IPF and PH.

Methods: Eighty-one consecutive patients with IPF, who were evaluated over a six-year period, were retrospectively studied. Patients underwent pulmonary function testing, Doppler echocardiography and maximal cardiopulmonary exercise testing. PH was defined as sPAP>35 mm Hg.

Results: PH was diagnosed in 57% of the patients. Categorization of patients according to severity of PH indicated a significant reduction in maximum work rate, peak O(2) uptake, anaerobic threshold and peak O(2) pulse in those with sPAP >50 mm Hg. In IPF patients with PH, estimated sPAP correlated with peak O(2) uptake, anaerobic threshold, peak O(2) pulse, and end-tidal CO(2) at anaerobic threshold, while the strongest correlation was between sPAP and ventilatory equivalent for CO(2) at anaerobic threshold (r = 0.611, P < 0.001). There were no differences in pulmonary function or exercise parameters indicative of lung volume reduction, across the patient categories, and none of these parameters correlated with sPAP.

Conclusions: PH has a negative impact on exercise capacity in IPF patients. In IPF patients with PH, resting sPAP correlated with exercise parameters indicative of gas exchange and circulatory impairment, but not with defective lung mechanics.

Viral infection and aging as cofactors for the development of pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a disease of unknown origin and progression that primarily affects older adults. Accumulating clinical and experimental evidence suggests that viral infections may play a role, either as agents that predispose the lung to fibrosis or exacerbate existing fibrosis. In particular, herpesviruses have been linked with IPF.

This article summarizes the evidence for and against viral cofactors in IPF pathogenesis. In addition, we review mechanistic studies in animal models that highlight the fibrotic potential of viral infection, and explore the different mechanisms that might be responsible. We also review early evidence to suggest that the aged lung may be particularly susceptible to viral-induced fibrosis and make recommendations for future research directions.

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