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Background: Medical thoracoscopy (MT) is an important procedure in the management of patients with pleural diseases. Objectives: We designed a survey to explore whether the participants of our courses implement MT at their hospital after attending the course as no real-life data exist. Methods: We distributed by e-mail a questionnaire to the participants of the courses. The questionnaire included general information about the participants, the precourse experience on MT, the postcourse implementation of the technique, and the reasons for failure. Results: Responses were obtained from 104 of 324 (32.3%) identified emails. Responders were males (76%), seniors (59.7%), respiratory physicians (91.3%), working in a public/university hospital (78.8%), and mostly beginners (65.3%) from 41 countries. Following the course, 58.6% of responders either created or modified a MT program in their workplace. The reasons for not performing MT before the course were as follows: patients’ referral to a thoracic surgeon, not enough training, lack of funding, department understaffed, and refusal by the hospital/department. Overall, these reasons were significantly decreased (p = 0.002) after the course. Conclusions: Real-life data of our survey suggest that more than half of the responders have implemented the technique or modified their practice according to the skills they got from the course.

Background: Medical thoracoscopy is the gold standard for the diagnosis of pleural diseases. To date, no consensus exists regarding the choice of sedative and analgesic agents in patients undergoing local anesthetic thoracoscopy (LAT), and questions are raised as to whether sedatives may add to respiratory side effects. Objective: The aim of the study was to test the hypothesis that administration of midazolam associated with lidocaine versus lidocaine alone in patients with LAT adds to respiratory side effects. Methods: We randomly assigned 80 patients to a 1:1 study to 2 groups: local anesthesia by lidocaine (n = 40) versus lidocaine and midazolam (n = 40), with the primary end point being the mean lowest oxygen saturation. The secondary end points were cardiovascular parameters, complications, days of drainage, hospital stay, and patients’ quality of life (QoL) as assessed by a visual analog scale (VAS). Results: The mean age of all patients was 66.6 ± 13.1 years. The study comprised 50 males (62.5%). No difference was observed in the demographics between the 2 groups. No significant difference was observed between the 2 groups in oxygen saturation (primary end point). A significant difference was observed in favor of the midazolam group regarding the QoL assessed by VAS. Conclusion: Midazolam does not add to respiratory side effects when it is used with lidocaine for LAT, while patients’ QoL is actually improved in this group. Therefore, in our department, we changed our startegy in favor of the association of lidocaine and midazolam.

ation of the fluid and adhesiolysis during thoracoscopy, showed excellent immediate (>90%) and 1-year (85%) results [6] , with few side effects, producing better quality and quantity of pleural symphysis compared to talc slurry [7] . Talc seems to have another interesting local antitumor effect, the induction of apoptosis of cancer cells [4, 8] . Iodopovidone is an interesting alternative to talc for pleurodesis as it is cheap, safe and showed high efficacy rates (90%) [9] . Many chemotherapeutic agents, such as bleomycin, cisplatin and taxanes, which have lower efficacy but at the same time highest costs, have been tested [10] . New molecules such as cytokines (transforming growth factor-β), which are involved in the coagulation cascade [11] , are expensive, and data in humans are still lacking. To date, thoracoscopy with Luzenac talc poudrage remains the most effective low-cost method of pleurodesis in patients with MPE, a good performance status and long life expectancy [12–14] . Studies reporting data from patients with recurrent non-MPE are mainly retrospective or include only a small number of patients with many different causes of their disease (inhomogeneous population) [15–17] . Frequently, benign diseases necessitating an intervention in case of refractory pleural effusion are congestive heart failure, renal failure and hepatic cirrhosis [15, 16] . Patients with Pleural effusion is a common manifestation of malignancies, which either reveals the disease or occurs during the course of the disease. Overall, 150,000 new cases of malignant pleural effusions (MPE) are reported every year in the USA. Any neoplasm may lead to this manifestation: in primary tumors of the pleura (mesothelioma), it occurs in up to 95% of the cases, whereas in metastatic neoplasms in males lung carcinomas account for 40% and in females breast carcinomas account for 30% [1, 2] . Although the survival of patients with MPE is globally reported to be poor, we have to differentiate between patients with MPE as an initial manifestation of the disease, who are naive to any treatment, and patients with MPE occurring during disease progression, who are relapsing and/or resisting to treatment [3] . Pleurodesis is a process involving multiple inflammatory cells recruited by cytokines, which leads to a coagulation-fibrinolysis imbalance and finally a development of adhesions between visceral and parietal pleurae in order to obliterate the pleural space to palliate effusion and symptoms [4] . Relief of dyspnea may be obtained regardless of radiographic findings. For pleurodesis, many compounds have been tested. The cheapest compound providing long-lasting pleurodesis is sterile, asbestos-free, calibrated Luzenac talc [5] . Talc insufflation, after evacuPublished online: May 6, 2014

Thoracoscopy is currently the gold standard for the diagnosis and treatment of pleural diseases. Its diagnostic yield is 95% in patients with malignant pleural disease, with approximately 90% successful pleurodesis for malignant pleural effusion and 95% for pneumothorax. At the same time, thoracoscopy constitutes an important tool in the research of pleural pathophysiology and molecular biology. The improvement of technology has provided important tools to thoracoscopy, such as autofluorescence, narrow band imaging, and infrared light, used in clinical and basic research in many disorders involving the pleura. For these reasons, training in thoracoscopy should be considered equally important as training in bronchoscopy for residents in respiratory medicine.

Background: Medical thoracoscopy (MT) is a procedure considered as minimally invasive. The safety of the procedure has been questioned recently in fragile patients, but no explanation of the pathophysiologic mechanism has been given. Although MT is applied by respiratory physicians who are also dealing with patients with impairment of lung function, it is surprising that there are no data concerning lung mechanics and function in this patient population. Objectives: To assess respiratory muscle strength and lung function in patients undergoing MT, with or without talc pleurodesis. Methods: We measured prospectively the maximal inspiratory (MIP) and expiratory pressures (MEP) and lung function of 29 patients who underwent MT before (baseline) and on consecutive days following MT. Results: 29 patients participated with a mean age of 63.6 ± 13.8 (range 20–79) years. 15 of them underwent talc pleurodesis and 14 diagnostic thoracoscopy. Mean MIP and MEP values were significantly decreased on day (d) 1 after MT compared to baseline (p = 0.03 and p = 0.007, respectively) and recovered on d2. FEV1 and FVC mean values were also found significantly decreased on d1 after MT compared to baseline (p < 0.0001 and p = 0.0003, respectively) and recovered on d2. Patients with pleurodesis presented with lower mean values of the studied parameters than those with diagnostic thoracoscopy. No significant complication was associated with the procedure. Conclusion: Respiratory muscles and lung function can be temporarily affected from MT. Physicians should be alert, especially in patients with already impaired lung function, where any further impairment could be detrimental.

Primary pleural lymphoma is rare. It occurs in only 7% of lymphoma cases. We report herein two cases of primary pleural Hodgkin and non-Hodgkin follicular lymphomas diagnosed by thoracoscopy under local anesthesia. Both patients presented initially with dyspnea revealing pleural effusions. The pleural findings during thoracoscopy differed in the two cases and selective pleural biopsies under optical forceps led to the diagnosis of lymphoma. To date, primary pleural Hodgkin and non-Hodgkin follicular lymphomas have not been reported.

Background: Long-term oxygen treatment (LTOT) is very important, especially in patients with severe chronic obstructive pulmonary disease (COPD), but its efficacy is closely related to patient compliance. Objectives: The aim of the present study was to investigate the compliance of patients under LTOT in the Prefecture of Ioannina (north-western Greece) and to identify factors that might be involved. Methods: The study included 249 patients treated with LTOT during a 1-year period. They were visited at home by the investigating staff (a chest specialist and a primary care nurse). Compliance to therapy was defined by the daily use of the O2 concentrator (in hours). Patients underwent pulse oximetry, basic spirometry, and trial inhalation of bronchodilators. Results: Only 67 patients (26.9%) complied with therapy, while the daily concentrator use lasted 9.7 ± 6.09 h. SaO2, FEV1 and FVC were negatively correlated to patient compliance. No significant differences concerning LTOT compliance were noted between men and women, urban and rural population, and between smokers, ex-smokers and non-smokers. A chest physician recommended LTOT for the majority of patients (86.3%), while COPD was the main reason for LTOT prescription (74.7%). Nevertheless, compliance to LTOT was not significantly higher when prescribed by a respiratory physician. No specific medical instructions and information was recorded for the majority of the study patients treated with LTOT. Conclusions: Our results suggest that an organized home care program establishing the relative guidelines is necessary for substantial improvement in patient compliance to LTOT in Greece.

Background: The role of tumor markers in the diagnosis and prognosis of lung cancer is under investigation. Objectives: The aim of this study was to investigate the diagnostic and prognostic significance of pre-therapeutic levels of various serum tumor markers, CYFRA 21-1, neuron-specific enolase (NSE), tissue polypeptide antigen (TPA), carcinoembryonic antigen (CEA), CA 125 and squamous cell carcinoma antigen (SCCAg), in patients with lung cancer. Methods: We studied 102 consecutive patients (mean age 65.2 ± 11 years) with newly diagnosed lung cancer (96 males, 94%, with a mean age of 66.3 ± 10.5 years). All patients had a 5-year follow-up. Measurements of the serum tumor markers were performed on initial diagnosis. Results: Eighty-four patients (82%) had non-small-cell lung cancer (NSCLC) and 18 (18%) small-cell lung cancer (SCLC). From the 84 patients with NSCLC, 34 patients (33%) had squamous-cell lung cancer, 23 (22%) adenocarcinoma and 23 (22%) large-cell carcinomas. The overall median survival was 8.5 months. All SCLC patients had extensive disease with a median survival of 10.1 months and NSCLC patients of 8.4 months. Significant differences in the mean values of NSE and CYFRA 21-1 were observed between SCLC and NSCLC. In NSCLC, CYFRA 21-1, TPA, CA 125 and SCCAg serum levels were related to the stage of the disease at diagnosis, and CYFRA 21-1, NSE, TPA and CA-125 were related to a poor outcome. None of the above tumor markers was related to survival in the SCLC group. Conclusion: CYFRA 21-1 and NSE may help to differentiate cell types in lung cancer patients. Also, CYFRA 21-1 with TPA and CA 125 may provide useful information regarding the staging of the disease at diagnosis and the prognosis of patients with NSCLC.