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Published articles support the effect of chemotherapy in the immune environment of tumors, including lung carcinomas. The role of CD4 + T-cells is crucial for expansion and accumulation of other antigen-specific immune cells, and the participation of CD8 + cells in tumor killing activity has been confirmed by many studies. However, little is known about the effect of chemotherapy on the healthy lung parenchyma from lung cancer patients, and whether there are differences between the different chemotherapy compounds used to treat this patient population. The aim of our study was to explore the effect of chemotherapy on CD4 + and CD8 + cells in the bronchoalveolar lavage fluid (BALF) of the healthy lung in patients treated with standard chemotherapy regimens. Fifteen patients underwent BAL, in the healthy lung before and after six chemotherapy courses. Platinum-based regimens included vinolerbine (VN) in 6 patients, gemcitabine (GEM) in 4 patients and etoposide (EP) in 5 patients. All patients but one were males and smokers (93%). The median age of patients was 56 years (42–75). No significant difference was noted in the patients’ age between the three treated groups. Furthermore, between the three groups, no significant changes in the means of CD4 + and CD8 + cells were noted. However, when we compared the mean CD4 + cells before and after chemotherapy within each group, changes were noted when comparing VN before versus after (p = 0.05), GEM before versus after (p = 0.03), and EP before versus after (p = 0.036). In our pilot study, changes were noted in BALF CD4 + cells for the three most applied regimens at the normal lung parenchyma.

Background Thoracoscopy, either "medical" or "surgical", is the gold standard to reveal the cause of pleural effusion by taking large biopsies. However, in some cases, the histology of pleural biopsies is inconclusive for a specific cause, describing a variable process of inflammation, encompassing for non-specific pleuritis (NSP). Questions are raised whether the surgical (or video-assisted thoracoscopic surgery, VATS) is doing better than the medical thoracoscopy (MT or pleuroscopy), but no direct comparison between the two techniques exist in the current bibliography. The aim of our retrospective study was to compare these two techniques to find whether there is any difference in the false negative cases of NSP. Methods We included in our study 295 patients with NSP, 179 patients who underwent VATS comparing to 116 patients who underwent MT for pleural effusion of initially undetermined cause, having a follow-up of at least one year. Analysis of patients' files, history, clinical examinations, further tests, and follow-up were recorded. Results The mean age of our patients was 58.5±19.1 and M/F gender was 216/79; no difference was observed between the two groups. The mean follow-up period was 47.3±20.7 months. After VATS, only one patient (0.55%) was finally diagnosed with pleural malignancy (false negative) while after MT 2 patients (1.7%). Negative predictive value for pleura-related malignancy for VATS was 0.994 and for MT 0.982. Conclusions In patients with histological diagnosis of NSP both VATS and MT showed similar and excellent results of false negative cases and negative predictive value in excluding malignant pleural disease.

Positron emission tomography/computed tomography (PET/CT) has shown prognostic significance in head and neck cancer patients. The underlying pathologic features that could explain the mechanisms associated with this observation are not clear. To analyze the correlation between 18-F-fluoro-2-deoxy-D-glucose (18F-FDG) uptake assessed by PET/CT in head and neck cancer and histopathologic prognostic factors. Ninety-nine patients with laryngeal and pharyngeal squamous cell carcinoma were retrospectively reviewed for pretreatment PET/CT measurements, namely standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). The corresponding histologic material was evaluated for tumor stroma-related prognostic factors such as the amount and type of stroma, lymphocytic response, tumor budding activity, and size of tumor cell nests in the tumor core area and tumor front. TLG and MTV were associated with tumor localization, as they were higher in oropharyngeal tumors. These values were also associated with tumor cell nest size in the tumor core with higher values corresponding to tumors with smaller nests. MTV40% was marginally associated with fibroblastic stroma type and higher budding activity. SUVmax was not associated with the histological factors in the whole sample, but higher values trended with higher tumor budding activity and stroma-rich tumors of the oropharynx. 18F-FDG PET measurements in head and neck squamous cell carcinomas are associated with prognostic histopathologic factors and suggest a possible correlation of glucose metabolism to epithelial-to-mesenchymal transition.

Simple Summary Non-small cell lung cancer (NSCLC) accounts for approximately 85% of lung cancer cases, with few patients carrying driver mutations in the gene encoding for epidermal growth factor receptor (EGFR). Advances in translational research have established EGFR tyrosine kinase inhibitors (TKIs) as the standard first-line therapy for NSCLC patients with activating EGFR mutations. The aim of our observational study was to assess the frequency of T790M acquired resistance and predictors of its presence, in patients with EGFR-mutated locally advanced or metastatic NSCLC who have progressed in the first-line EGFR-TKI treatment setting with first- or second-generation TKIs and have undergone molecular testing in tissue and/or plasma biopsy. The study highlights the challenges of performing tissue re-biopsy in routine care settings, which can lead to patients considered non-eligible for certain therapies from which they can benefit, and merits further actions from the healthcare community, in order to establish re-biopsy as a standard procedure. Abstract Background: Real-world data on the molecular epidemiology of EGFR resistance mutations at or after progression with first- or second-generation EGFR-TKIs in patients with advanced NSCLC are lacking. Methods: This ongoing observational study was carried out by 23 hospital-based physicians in Greece. The decision to perform cobas® EGFR Mutation Test v2 in tissue and/or plasma at disease progression was made before enrollment. For patients with negative/inconclusive T790M plasma-based results, tissue re-biopsy could be performed. Results: Ninety-six (96) eligible patients were consecutively enrolled (median age: 67.8 years) between July-2017 and September-2019. Of the patients, 98% were tested upon progression using plasma and 2% using tissue/cytology biopsy. The T790M mutation was detected in 16.0% of liquid biopsies. Tissue re-biopsy was performed in 22.8% of patients with a T790M-negative plasma result. In total, the T790M positivity rate was 21.9%, not differing between patients on first- or second-generation EGFR-TKI. Higher (≥2) ECOG performance status and longer (≥10 months) time to disease progression following EGFR-TKI treatment initiation were associated with T790M positivity. Conclusions: Results from plasma/tissue-cytology samples in a real-world setting, yielded a T790M positivity rate lower than previous reports. Fewer than one in four patients with negative plasma-based testing underwent tissue re-biopsy, indicating the challenges in routine care settings.

INTRODUCTION Accumulating evidence suggests that cardiovascular disease (CVD) is highly prevalent among patients with concurrent obstructive sleep apnoea syndrome (OSAS) and chronic obstructive pulmonary disease, otherwise known as overlap syndrome (OS). OBJECTIVES The aim of this study was to investigate the 10-year risk for CVD in OS patients compared with OSAS patients and controls. METHODS Consecutive patients, referred for symptoms suggestive of OSAS, were evaluated with polysomnography and pulmonary function testing. Cardiovascular risk was assessed using the Framingham risk score (FRS) and systematic coronary risk evaluation (SCORE). RESULTS Overall, 244 participants (184 males) without CVD and diabetes were divided into 3 groups: controls (n = 63), OSAS (n = 139) and OS (n = 42). Both FRS and SCORE were found to be elevated in the OS group compared with the OSAS and control groups (P

Background: Real-world data on the molecular epidemiology of EGFR resistance mutations at or after progression with first- or second-generation EGFR-TKIs in patients with advanced NSCLC are lacking. Methods: This ongoing observational study was carried out by 23 hospital-based physicians in Greece. The decision to perform Cobas® EGFR Mutation Test v2 in tissue and/or plasma at disease progression was made before enrollment. For patients with negative/inconclusive T790M plasma-based results, tissue re-biopsy could be performed. Results: Ninety-six (96) eligible patients were consecutively enrolled (median age: 67.8 years) between July-2017 and September-2019. Of the patients, 98% were tested upon progression using plasma and 2% using tissue/cytology biopsy. The T790M mutation was detected in 16.0% of liquid biopsies. Tissue re-biopsy was performed in 22.8% of patients with a T790M-negative plasma result. In total, the T790M positivity rate was 21.9%, not differing between patients on first- or second-generation EGFR-TKI. Higher (≥2) ECOG performance status and longer (≥10 months) time to disease progression following EGFR-TKI treatment initiation were associated with T790M positivity. Conclusions: Results from plasma/tissue-cytology samples in a real-world setting, yielded a T790M positivity rate lower than previous reports. Fewer than one in four patients with negative plasma-based testing underwent tissue re-biopsy, indicating the challenges in routine care settings.

Background: Thoracoscopy, either “medical” or “surgical”, is the gold standard to reveal the cause of pleural effusion by taking large biopsies. However, in some cases, the histology of pleural biopsies is inconclusive describing a variable process of inflammation, encompassing for non-specific pleuritis (NSP). Questions are raised whether the surgical (or VATS) is doing better than the medical thoracoscopy (MT), but no direct comparison between the two techniques exist in the current bibliography. The Aim: of our retrospective study was to compare these two techniques to find whether there is any difference in the false negative cases of NSP. Methods: We included in our study 295 patients with NSP, 179 patients who underwent VATS comparing to 116 patients who underwent MT for pleural effusion of initially undetermined cause, having a follow-up of at least one year. Analysis of patients’ files, history, clinical examinations, further tests, and follow-up were recorded. Results: The mean age of our patients was 58.5±19.1 and M/F gender was 216/79; no difference was observed between the two groups. A previous history of cancer was noted in 36 patients (12.2%). The mean follow-up period was 47.3±20.7 months. 3 patients were diagnosed with mesothelioma during the follow-up: with VATS, only one patient (0.55%) (false negative), while with MT 2 patients (1.7%). Negative predictive value for pleura-related malignancy for VATS was 0.994 and for MT 0.982. Conclusion: In patients with histological diagnosis of NSP both VATS and MT showed similar and excellent results of false negative cases and negative predictive value in excluding malignant pleural disease.

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.

Pericardial and pleural cavities produce effusions with important clinical consequences. Metastases are one of the most common etiologies of both serosal effusions. However, data regarding the type of metastatic involvement of the pleura and the pericardium are lacking. This study investigated the histologic patterns of tumors involving the two cavities to better define their pathophysiology and possible consequences in molecular diagnostics.This was a retrospective study of patients diagnosed with pericardial (n = 75) and pleural (n = 70) metastases. Patterns of metastasis were characterized as (1) tumor cells floating inside the cavity (2) as lymphatic emboli and (3) as tumor cells frankly invading underlying fibrous tissue. Molecular analysis (EGFR, KRAS, BRAF, ALK, HER2) was performed in 44 metastases of lung adenocarcinomas.The two serosal membranes differed significantly (p0.0001) in the pattern of metastasis. The pleura showed predominantly an invasive pattern (67 [95.7%]), whereas most pericardial metastases consisted of tumor cells floating inside the cavity or as lymphatic emboli (44 [58.6%]). The origin of the primary differed marginally between the two organs. Time to diagnosis of metastasis differed between the two organs, with pleural metastases presenting later than the pericardial ones. Molecular analysis failed more often in pericardial biopsy specimens and in specimens with emboli or surface involvement.Although pericardium and pleura share common embryologic and histologic features and are often regarded as giving similar effusions, they differ significantly in the type of metastases involving them. This can have important consequences in histologic, cytologic, and molecular diagnostics.

Evidence suggests that there is platelet activation in obstructive sleep apnea syndrome (OSAS) and chronic obstructive pulmonary disease (COPD). Our objective is to evaluate mean platelet volume (MPV) and platelet distribution width (PDW) in patients with overlap syndrome (OS), that is, concurrent COPD with OSAS. Mean platelet volume and PDW were assessed in consecutive patients who had undergone polysomnography and pulmonary function testing. They were divided into the following groups: controls (apnea–hypopnea index [AHI] 1]/forced vital capacity [FVC] >70%), OSAS group (AHI ≥5/hour and FEV1/FVC >70%), and OS group (AHI ≥5/hour and FEV1/FVC

Numerous studies have indicated that obstructive sleep apnea syndrome (OSAS), may contribute to the development of metabolic syndrome (MetS) and diabetes. Moreover, OSAS has been associated with lowered vitamin D (Vit D) levels, but reports are inconclusive. Aim of the study was to compare Vit D levels according to the presence of MetS and its components in OSAS patients.The presence of MetS was evaluated and serum 25-hydroxy vitamin D [25(OH)D] levels were measured in consecutive newly diagnosed, by polysomnography, subjects with OSAS.A total of 107 subjects (88 men) with OSAS were included in the study. Patients were divided into group A (OSAS with MetS group: 55 subjects) and group B (OSAS without MetS: 52 subjects). There were no differences between the two groups in terms of age, body mass index, and sleep parameters. Patients in group A exhibited higher levels of daytime sleepiness, as expressed by Epworth Sleepiness Scale score (12 ± 5.5 vs. 9.3 ± 4.8 for groups A vs. B, p = 0.008). Serum 25(OH)D levels were significantly decreased in group A, as compared with group B (18 ± 8.6 ng/mL vs. 23.9 ± 14.1 ng/mL, respectively, p = 0.012). Group A was then subdivided in two smaller groups, according to patients' metabolic index: OSAS patients with metabolic score = 3 and OSAS patients with metabolic score3. Serum 25(OH)D levels were higher in OSAS patients with metabolic score = 3 compared with OSAS patients with metabolic score3 (19.8 ± 8.9 ng/mL vs. 15.1 ± 7.3 ng/mL respectively, p = 0.038).OSAS patients with concurrent MetS exhibit lower serum Vit D levels, as compared with those without MetS.

Objectives. Obstructive sleep apnea syndrome (OSAS) is associated with increased cardiovascular morbidity and mortality. The aim of this study was to assess whether the 10-year risk for cardiovascular disease in newly diagnosed patients with OSAS is increased. Materials and Methods. Recently diagnosed, with polysomnography, consecutive OSAS patients were included. The Systematic Coronary Risk Evaluation (SCORE) and the Framingham Risk Score (FRS) were used to estimate the 10-year risk for cardiovascular disease. Results. Totally, 393 individuals (73.3% males), scheduled to undergo a polysomnographic study with symptoms indicative of OSAS, were enrolled. According to apnea-hypopnea index (AHI), subjects were divided in four groups: mild OSAS (AHI 5–14.9/h) was diagnosed in 91 patients (23.2%), moderate OSAS (AHI 15–29.9/h) in 58 patients (14.8%), severe OSAS (AHI > 30/h) in 167 patients (42.5%), while 77 individuals (19.6%) had an AHI p<0.001 and FRS values p<0.001. More specifically, a significant correlation was observed both between AHI and SCORE r=0.251, p<0.001 and AHI and FRS values r=0.291, p<0.001. Furthermore, a negative correlation was observed between FRS values and sleep efficiency r=−0.224, p=0.006. Conclusions. The 10-year risk for cardiovascular morbidity and mortality seems to increase with severity of OSAS. Physicians should bear this finding in mind, in order to seek for and consecutively eliminate risk factors for cardiovascular disease and to prevent future cardiovascular events in OSAS patients.

Background: Obstructive sleep apnoea syndrome (OSAS) has been linked with abnormal glucose metabolism, insulin resistance (IR) and development of diabetes mellitus. Methods: Non-diabetic patients (n=69) with OSAS, diagnosed by polysomnography, were prospectively recruited. To evaluate IR among OSAS patients, the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) and Insulin sensitivity by Quantitative Insulin sensitivity Check Index (QUICKI) were used. Results: HOMA-IR was positively associated with body-mass index (BMI) (ρ=0.364, p=0.002), time with oxyhaemoglobin saturation Conclusions: An independent association between OSAS and IR in patients without pre-existing diabetes mellitus was observed. Recurrent hypoxia and sleep fragmentation in OSAS are associated with IR in these patients.

Objectives To describe the technique of pleuroscopy, its clinical uses such as diagnosis of exudative pleural effusion, treatment of pleural infection, treatment of pneumothorax, and diagnosis and pleurodesis of malignant pleural mesothelioma. Also to describe the newer techniques developed such as minothoracoscopy, semirigid thoracoscopy, narrow band imaging pleuroscopy, infrared pleuroscopy, autofluorescence pleuroscopy. Data source We searched the pubmed the last decade for publications with the key words pleuroscopy, medical thoracoscopy, pneumothorax and pleuroscopy, malignant pleural mesothelioma, minothoracoscopy, semirigid thoracoscopy, autofluorescence pleuroscopy. Conclusion Medical thoracoscopy is the method of choice for investigation of the undiagnosed exudative pleural effusions. Newer techniques, such as narrow band imaging thoracoscopy, infrared thoracoscopy, autofluorescence thoracoscopy are offering a promising future for medical thoracoscopy.

Background: Knowledge of pleural malignancy can lead to immediate pleurodesis during thoracoscopy. However, the accuracy of pleural frozen sections is largely unknown. Objectives: To investigate the accuracy of frozen sections in pleural tumor pathology. Methods: A total of 156 frozen pleural sections performed with the question of malignancy were retrospectively reviewed. The original frozen sections were compared to the permanent section slides which were considered as the gold standard. The influence of the following parameters on the frozen section response was evaluated: specimen size, clinical information, as well as the processing by a specialized pulmonary pathologist or not. The reasons of discrepancies were categorized as sampling errors or interpretation errors. Results: Frozen sections made up 16.4% of 951 pleural biopsies performed in the same time period. Accurate diagnosis was feasible in 92.3% of the cases. There were 7 (4.5%) deferred (inconclusive) cases and 5 (3.2%) discrepant cases. Sensitivity of the method was 96.26%, specificity 97.87%, the positive predictive value was 99.04%, and the negative predictive value was 92%. There was no association between the responses given during frozen section and specimen size, clinical information, or the evaluation by a specialized pulmonary pathologist. Four of the 12 cases were sampling errors, while 8 cases were interpretation errors mostly made in the absence of fat tissue invasion. Thus, paucicellular lesions without prominent invasion - fat invasion or haphazardly invading cellular proliferation - were those posing most of the difficulties during frozen section. Conclusions: Frozen sections are a highly accurate tool in pleural pathology. Thus, they can be used when an immediate pleurodesis is requested.

Background and objectives: Obstructive sleep apnea syndrome (OSAS) is associated with cardiovascular and metabolic risk factors, such as insulin resistance. Furthermore, OSAS has been associated with decreased levels of vitamin D (Vit D). The aim of the study was to assess the association between Vit D levels (expressed as 25(OH)D serum levels) and insulin resistance in patients with OSAS. Materials and Methods: Serum 25(OH)D levels were measured in consecutive subjects who had undergone polysomnography and pulmonary function testing. OSAS patients were divided into those with (homeostatic model assessment [HOMA-IR] &ge, 2) and without insulin resistance (HOMA-IR &lt, 2). Results: Overall, 92 patients (81 males) were included in the study. OSAS patients with insulin resistance significantly differed from those without insulin resistance in terms of the body-mass index (BMI) (36.3 &plusmn, 5.8 compared to 32 &plusmn, 5.6 kg/m2, respectively, p = 0.001), apnoea-hypopnoea index (AHI) (57.4 &plusmn, 28.9 compared to 40.9 &plusmn, 27.9 events/h, respectively, p = 0.009) and indices of hypoxia during sleep. Patients with OSAS and insulin resistance had lower levels of serum 25 (OH) D compared with OSAS but without insulin resistance (19.3 &plusmn, 11.5 vs 26.7 &plusmn, 12.2 ng/mL, respectively, p = 0.005). Regression analysis demonstrated a negative association of 25(OH)D levels (&beta, = &minus, 0.048, odds ratio [OR]: 0.953, 95% confidence interval [CI]: 0.913&ndash, 0.995, p = 0.030) and a positive association of BMI (&beta, = 0.110, OR: 1.116, 95% CI: 1.007&ndash, 1.237, p = 0.036) with insulin resistance. Conclusions: Vit D insufficiency was significantly more frequent among OSAS patients with insulin resistance. Both low 25(OH)D levels and high BMI were associated with the risk of insulin resistance in this population.

A pleural biopsy without granulomatous inflammation or tumour cells is interpreted as 'non-specific pleuritis' (NSP), a diagnosis without any specificity, often frustrating for physicians. However, varying histological features are found in NSPs with unknown significance. The aim of this study was to describe the detailed microscopic features of NSP and correlate them with the underlying aetiology. One hundred patients diagnosed with NSP after pleural biopsy were retrospectively evaluated. A benign cause of pleural effusion was attributed. Histological features evaluated were inflammation, fibrosis, vascular proliferation, haemorrhage, fibrin, oedema and mesothelial hyperplasia. A semi-quantitative scoring was applied. Bacterial-caused and autoimmune disease-associated NSPs showed a higher score followed by viral and drug-induced conditions, while pneumothorax and cardiac-induced NSPs showed a lower score (p

Background Metastatic spread to the tracheobronchial tree from other than bronchopulmonary tumors is a common clinical problem. However, malignant melanoma, a highly metastatic potential tumor, is rarely metastasing in the airways. Therefore little is known about survival of patients with endobronchial metastasis from melanoma. Objectives The aim of our study was to assess survival of patients with endobronchial metastasis of melanomas according to clinical and radiological features, to determine any possible factor affecting survival. Methods This retrospective study included 19 patients who underwent a bronchoscopy from 11 different hospitals. Data about patients' demographics, symptoms, radiographic, endoscopic findings and treatment were investigated to evaluate any possible impact on survival. Results Endobronchial metastases occurred at a median of 48 months (range 0-120) following the diagnosis of the primary tumor. About 73.7% of patients had other proven metastases when the endobronchial involvement was diagnosed. Symptoms are not specific as well as radiological features. Median overall survival of the studied population was 6 months (range 1-46). Factors of poor survival were multiple metastatic sites (P = 0.019), pleural (P = 0.0014) and soft tissue metastasis (P = 0.024). Different treatment modalities applied in our patients showed no effect on survival. Conclusion Patients with endobronchial metastasis have overall poor survival, affected by multiple organ involvement, the presence of pleural and soft tissue disease, while no impact on survival has been shown by any treatment applied.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications.

Obstructive sleep apnea syndrome (OSAS) has been recently proposed as an independent risk factor for chronic kidney disease. Cystatin C (Cyst C) and neutrophil gelatinase-associated lipocalin (NGAL) are novel biomarkers for the earlier detection of latent kidney disease. The aim of the study was to assess serum Cyst C and NGAL levels in otherwise healthy OSAS patients and to explore possible associations with sleep parameters. Consecutive subjects (n = 96, 79.2% males), without known comorbidities, with symptoms suggestive of OSAS were included. All of them underwent polysomnography (PSG) and blood examination for the measurement of serum Cyst C and NGAL levels. Based on apnea-hypopnea index (AHI), subjects were classified into two groups: 32 controls and 64 OSAS patients, with no significant differences in terms of age (50.1 ± 11.7 vs 51 ± 12.2 years, p = 0.747) and BMI (33.9 ± 8.8 vs 35.9 ± 13.1 kg/m2, p = 0.449). Serum Cyst C and NGAL mean levels were higher in OSAS patients compared to those in controls (1155.2 ± 319.3 vs 966.8 ± 173 ng/ml, p = 0.001, and 43.7 ± 23.2 vs 35.6 ± 13.8 ng/ml, p = 0.035, respectively). After adjustment for age and BMI in OSAS patients, serum NGAL levels were associated with AHI (β = 0.341, p = 0.015) and minimum oxyhemoglobin saturation during sleep (β = − 0.275, p = 0.032), while serum Cyst C levels were associated with percentage of time with oxyhemoglobin saturation

Eosinophilic pleural effusions (EPE) account for 5%-8% of all exudative pleural effusions. A pleural effusion is defined as eosinophilic if it contains 10% or more eosinophils. We present the case of a 70-year-old man with EPE, blood eosinophilia and pericardial effusion due to dabigatran, a novel anti-thrombin agent.

Inhaled foreign body, which remains unknown from the childhood until the mid-age is extremely rare. We report the case of a 58-year-old man who was addressed to our department to remove a pen cap, inhaled forty-one years earlier. It was discovered during a routine pre-op check-up for bronchiectasis, caused by the long period of retention into the bronchial tree. The successful removal of the cap changed completely the therapeutic strategy, as there was no indication for surgical resection any more.

BACKGROUND Vitamin D (Vit D) insufficiency has been implicated in the pathophysiology of numerous diseases. Obstructive sleep apnoea syndrome (OSAS), a disorder associated with increased cardiovascular and cerebrovascular morbidity, has been associated with decreased Vit D levels, but reports are inconclusive. AIM To evaluate the association between serum 25-hydroxyvitamin D [25(OH)D], a marker of Vit D status, with anthropometric and sleep characteristics of OSAS patients and to compare those levels between OSAS patients and non-apnoeic controls. METHOD Consecutive subjects who had undergone polysomnography and pulmonary function testing were divided into controls (apnoea-hypopnea index, AHI

Aim of the study was to evaluate anthropometric, clinical and sleep characteristics of Obesity Hypoventilation Syndrome (OHS) patients, in comparison to obese eucapnic Obstructive Sleep Apnea Syndrome (OSAS) patients and controls. Methods Included were 942 consecutive subjects with BMI≥30kg/m 2 (69.9% males, age 54.9±11.9 years), examined with polysomnography (PSG), due to suspected OSAS. All had undergone pulmonary function testing and ABGs examination and had completed the Epworth Sleepiness Scale (ESS) and Athens Insomnia Scale (AIS) for sleepiness and insomnia assessment, respectively. They were categorized as follows: OHS patients (n=177), obese, eucapnic OSAS patients (AHI≥5/h, n=615), and obese controls with AHI Results OHS patients had the highest BMI (p 1, SpO 2 , PaO 2 , PaCO 2 and HCO 3 values in awake (p 2 and averSpO 2 during sleep were more impaired in OHS patients (p Conclusions OHS patients were more obese, differed significantly in several sleep characteristics and reported insomnia and daytime sleepiness more frequently, compared with obese OSAS patients and controls.

International audience; IntroductionIn case of undiagnosed pleural effusions, it is necessary to conduct thoracentesis with pleural fluid (PF) cytology. Yet, sensitivity of PF cytology is widely variable as a result of sample size, experience, and preparation method. ObjectivesThe aim of this study was to assess whether pleural fluid (PF) cytology is correlated to visceral or parietal pleural invasion as assessed by thoracoscopy in metastatic pleural effusions. MethodsAll records of patients with pleural effusion were reviewed. The inclusion criteria were as follows: PF cytology, reported appearance of macroscopic pleural invasion during thoracoscopy and malignant diagnosis. Patients with mesothelioma were excluded. Finally, 287 patients who met all criteria were selected. According to the thoracoscopy findings, the extent of the disease on the pleura was analyzed in relation to the PF cytology. ResultsIn this study, 160 patients (55.7%) had a positive PF cytology (Group A) while 127 (44.3%) recorded negative PF cytology (Group B). From Group A, patients with visceral pleural invasion were 120 (75%) while only 49 patients (38.5%) were found from Group B and the difference was statistically significant (P

Background Idiopathic eosinophilic pleural effusions (IEPEs) comprise the eosinophilic pleural effusions for which a specific aetiology cannot be established. There are no reports investigating IEPE on the basis of a systematically applied pleuroscopy approach and entailing an appropriate patient follow-up till the final outcome is established; existing series rather combine clinical and thoracocentesis criteria to establish the idiopathic character of the diagnosis. Objectives The aim of our study was to assess the clinical outcome of patients with IEPE, who underwent a systematic diagnostic approach by pleuroscopy. Methods We studied 10 patients with IEPE among 175 consecutive patients who underwent pleuroscopy for undiagnosed pleural effusion. Pleural biopsies were obtained from observed lesions. All patients were followed up by means of clinical examination and imaging. Results The diagnosis of IEPE was established in 10 patients (median age was 50.5 years, range 35–91). Macroscopic examination of the pleura showed diffuse thickening with pleural plaques in eight patients, consistent with diffuse pleural eosinophilic inflammation histologically proven. In two patients, macroscopic examination showed scattered nodules associated with non-caseating granulomas histologically. In all 10 patients, a specific aetiology could not be established. Follow-up was available for all patients ranging from 24–102 months (median 60 months). No patient received a specific treatment during the follow-up period. No relapse of a pleural effusion was documented during this period. Conclusion Pleuroscopy is mandatory in diagnosing IEPE. Negative histology and a long follow-up showed a benign course. These findings suggest that we should call these effusions ‘indeterminate’.

Background: The survival of patients with malignant pleural effusion is considered generally poor. Most of the studies reporting results of prognostic factors are retrospective, using pleural thoracentesis for diagnosis. The objectives of our study were to reveal possible prognostic factors in patients initially presenting with undiagnosed pleural effusion proven to be malignant by diagnostic thoracoscopy. Methods: Ninety consecutive patients, 48 of whom were male (53%), with a median age of 69 years (range 37-93) and a performance status (PS) of 0/1 (63%) and with initially undiagnosed pleural effusion that was proven to be malignant by thoracoscopy were evaluated. Survival time was defined as the time from thoracoscopic diagnosis to death or the last follow-up. A regression analysis was used to determine significant clinical and biological prognostic factors. Results: Lung carcinoma (44.4%), breast carcinoma (24.4%), and mesothelioma (12.2%) were the most frequent tumors diagnosed. The median overall survival was 11 months (range 0.5-55). The survival of the patients was related to the following factors: histology of the primary tumor (p = 0.008), PS (p < 0.001), white blood cells (p = 0.018), and the blood neutrophil-to-lymphocyte (N/L) ratio (p = 0.002). Multiple regression showed PS, histology, and the N/L ratio. Conclusion: The factors affecting survival in our patients were PS, primary tumor histology, and the N/L ratio. These factors may help physicians select patients for treatment and/or interventional procedures.

BACKGROUND: Total Lung Lavage (TLL) is considered as standard of care in Pulmonary Alveolar Proteinosis (PAP). Yet, new therapies have emerged in the treatment of PAP and therefore there is a real need to evaluate the efficacy of TTL in this rare disease. OBJECTIVES: The aim of this study was to assess the efficacy of TTL in patients with PAP. METHODS : We have included 33 patients who underwent TTL from 11 centers, members of the French-Speaking Endoscopy Group (GELF) for analysis. Data collection concerned patient9s and disease characteristics, pulmonary function tests (PFTs) before and after the procedure, and technical informations on the procedure. RESULTS: Patients with respiratory insufficiancy at presentation were 22 (68.75%). All patients underwent lung lavage by general anesthesia and selective lung ventilation, except one who underwent flexible bronchoscopy. We noted differences in the technique as 12 (36.36%) patients had percussion during the procedure and only 7(21.2%) underwent two-lungs lavage during one anesthesia. A median of 16.8 L were used to performed TLL (1.0L to 40L). Complications occured in 11 (33.3%) patients and 18(56.25%) of them relapsed in a median period of 16.9 months. No significant changes were found in all PFTs parameters studied, in exception to PaO2 which was after the procedure higher of 6.375 mmHg (p=0.0213 ; [95%CI: 1.03-11.7]) in comparison to before. CONCLUSION: Although the technique of TLL has a variability in its application, due probably to patient9s condition, it improves significantly patients9 short-term respiratory condition, by improving PaO2. However, long-term effect needs to be confirmed, as many of our patients relapsed.

Background. Obstructive sleep apnea syndrome (OSAS) is associated with systemic inflammation and increased risk of cardiovascular and chronic kidney disease. Cystatin C (Cyst C) is a novel biomarker of both latent renal damage and cardiovascular disease. Aim of the study was to measure serum levels of Cyst C, as well as IL-8 and CRP, in otherwise healthy OSAS patients.Methods. 84 individuals examined with polysomnography for OSAS symptoms without known comorbidities were prospectively recruited.Results. According to apnea hypopnea index (AHI) subjects were divided in two groups: OSAS group (AHI > 5/hour,n=64) and controls (AHI < 5/hour,n=20), which were age- and BMI-matched. Cyst C levels were higher in OSAS patients versus controls (1176.13±351.33versus938.60±245.83 ng/mL, resp.;p=0.017) while serum IL-8 and CRP levels did not differ significantly. Positive correlation was found between Cyst C levels and respiratory disturbance index (RDI) (r=0.240,p=0.039) and percentage of time with oxygen saturation r=0.290,p=0.02) and negative correlation was found between Cyst C levels and average oxygen saturation during sleep (r=-0.291,p=0.012). After adjustment for age and BMI, RDI was the only independent predictor of Cyst C levels (β= 0.256,p=0.039).Conclusion. Cyst C serum levels are increased in OSAS patients without comorbidities, suggesting an increased renal and cardiovascular disease risk.

Bilateral empyema associated to infectious pericarditis is an extremely rare, yet life-threatening condition. Pleuroscopy-medical thoracoscopy has proved its efficacy in series of patients with empyema. Yet, all reported cases treated by this technique, concerned patients with pleural infection located to a single hemithorax. We present the case of a 71-year-old man with bilateral empyema treated successfully by sequential pleuroscopy, associated to infectious pericarditis.

A wide range of diseases may be the cause of an accumulation of fluid in the pleural space. Pleural effusion is a major diagnostic problem, since the pleura is an inner cavity with no direct access. The aim of this review is to provide a practical approach to the investigation of the patient presenting with pleural effusion. This should help to accurately diagnose pleural effusion and keep time-consuming, but necessary, invasive investigations to the minimum.

SummaryPulmonary alveolar proteinosis (PAP) is a rare, heterogeneous diffuse lung disease in childhood. We report a case of an asymptomatic 13-year old girl with PAP. She had radiolographic findings suggesting the diagnosis, which was confirmed by the “milky” bronchoalveolar lavage fluid and the histology of transbronchial biopsy. Total lung lavage was performed by flexible fiberoptic bronchoscope under local anesthesia with success. This is the first reported case of a PAP in a child that was treated by being awake during bronchoscopy. After one-year of follow-up, the patient remains free of symptoms.

Malignant pleural effusion as presenting manifestation in lung cancer is of poor prognosis. Therefore, diagnostic approach in this patient population is important. Pleural cytology (PC) and chest computed tomography findings (CCT) might be helpful as first line approach in the diagnosis of pleural metastasis. The aim of this study was to evaluate whether there is a correlation between PC and CCT pleural findings. Methods: Selection criteria from our electronic files were patients with lung cancer and pleural effusion at initial presentation. Data of PC, pleural biopsy (PB) and CCT have been recorded and analyzed. Results: 47 consecutive patients (34 males, 72%) were selected. Their mean age was 68.5±11 years. Final histological diagnosis was adenocarcinoma in 28 patients (59%), squamous in 7 (15%), small-cell in 7 (15%) and large cell in 5 (11%). No findings were found in 29 patients (61%), nodules or masses were observed in 6 patients (13%) while pleural thickening in 12 (26%) at CCT. Nodules and thickening were more likely to be associated (chi square=20, p

Recent studies have reported fever as a side effect of talc poudrage during thoracoscopic pleurodesis. However, thoracoscopy itself is likely to induce systemic inflammatory reaction, as it is an interventional procedure. The aim of the study was to investigate whether systemic inflammatory response is due to talc poudrage or to thoracoscopy.We prospectively studied two groups of patients. The first group (18 patients) underwent thoracoscopic talc poudrage, and the second group (17 patients) underwent only diagnostic thoracoscopy. We measured body temperature, as well as WBC count and C-reactive protein (CRP) levels before the procedure (baseline), and at 24 and 48 h after the procedure. No antiinflammatory medication was permitted to be used before, during, or after the procedure. All patients had a 3-month follow-up.The baseline patient characteristics were similar in both groups. Temperature increased significantly in the thoracoscopic talc poudrage group (overall comparison, p = 0.005) especially at 9, 12, and 24 h after the procedure. Overall, the WBC count (p = 0.004), percentage of neutrophils (p = 0.03), and CRP levels (p0.0001) were significantly increased in the group of patients who underwent thoracoscopic talc poudrage. On the contrary, lymphocytes were significantly decreased (overall comparison, p = 0.01) in the thoracoscopic talc poudrage group during the same period. Mild side effects, such as pain during and after thoracoscopy and subcutaneous emphysema, were noted. No severe complication, such as infection or acute respiratory failure, was noted in either group during the hospitalization or during the follow-up period.According to our results, fever and systemic inflammatory reaction is due to talc poudrage and not to thoracoscopy.

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

Pneumoconiosis among dental technicians has recently emerged as an area of research in interstitial lung disease. This study was carried out to estimate the prevalence of pneumoconiosis in Greek dental technicians on the island of Crete. Fifty-one of the 58 dental technicians of the Heraklion Dental Technicians’ Association completed an exposure history questionnaire and underwent a clinical examination, including chest radiographs, and spirometric assessment of lung volume and diffusing capacity. Values were compared with 51 control subjects. Five dental technicians showed radiological evidence of pneumoconiosis. Mean lung function values of the dental technicians, even in those with pneumoconiosis, were not significantly different from controls. No significant changes in lung function parameters were associated with smoking, exposure to metals and other contaminants. Dental technicians, however, reported more respiratory symptoms than controls (p = 0.008). Symptoms were associated to the absence of a ventilation system. We concluded that occupational exposure in dental technicians in Crete did not affect lung function. The prevalence of pneumoconiosis in this study was 9.8%.

Objectives Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is characterised by neutrophil activation. An elevated prevalence of venous thromboembolic events has been reported in AAV. Because of the critical role of neutrophils in inflammation associated thrombosis, we asked whether neutrophil tissue factor (TF) may be implicated in the thrombotic diathesis in AAV. Methods Neutrophils from four patients and sera from 17 patients with ANCA associated vasculitis with active disease and remission were studied. TF expression was assessed by immunoblotting and confocal microscopy. Circulating DNA levels were evaluated. TF expressing microparticles (MPs) were measured by flow cytometry and thrombin–antithrombin complex levels by ELISA. Results Peripheral blood neutrophils from four patients with active disease expressed elevated TF levels and released TF expressing neutrophil extracellular traps (NETs) and MPs. TF positive NETs were released by neutrophils isolated from the bronchoalveolar lavage and were detected in nasal and renal biopsy specimens. Elevated levels of circulating DNA and TF expressing neutrophil derived MPs were further observed in sera from patients with active disease. Induction of remission attenuated the aforementioned effects. Control neutrophils treated with sera from patients with active disease released TF bearing NETs and MPs which were abolished after IgG depletion. Treatment of control neutrophils with isolated IgG from sera from patients with active disease also resulted in the release of TF bearing NETs. TF implication in MP dependent thrombin generation was demonstrated by antibody neutralisation studies. Conclusions Expression of TF in NETs and neutrophil derived MPs proposes a novel mechanism for the induction of thrombosis and inflammation in active AAV.

One century after the Swedish physician Hanz-Christian Jacobaeus introduced a cystoscope into the pleural cavity of a patient with pleural tuberculosis, thoracoscopy, the first interventional technique of modern pulmonology, has become an important tool in the diagnosis, treatment, and research of pleural disease. The development of new devices such as the single-port rigid thoracoscope and the flex-rigid pleuroscope helped a lot to spread the technique over the world. Its application as diagnostic and therapeutic technique has increased dramatically during the last decade. Also, the possibility to use new tools through the pleuroscopes, initially designed to flexible endoscopy, such as autofluoroscopy and narrow band imaging, has enlarged the field of research in pleural disease. The aim of this chapter is to develop all advances, performed the recent years in medical thoracoscopy – pleuroscopy.

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.

A number of epidemiological studies have shown that byssinosis is associated with exposure to high levels of cotton dust. In this first survey, the prevalence of respiratory symptoms in cotton workers under low concentration of cotton dust was investigated. A respiratory questionnaire consisting of 47 questions was given to 443 cotton workers. Their lung function was measured with spirometry. Breathing zone cotton dust concentration was measured by personal samplers and static sampling was used to define the level of the work area concentration. Workers with abnormalities in the pulmonary function parameters, including forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and peak expiratory flow rate (PEFR), were 5.9%. In this group of operatives 7.7% had symptoms compatible with byssinosis, 65.4% of them were smokers, 69.2% of them had symptoms of allergic rhinitis, while 72.2% of them were smokers. Asthma, which appeared after the age of 30, was reported by 57.7%, while 60% of them were smokers. Mean breathing zone cotton dust concentration was 0.16 mg/m3 and the mean work area cotton dust concentration 0.14 mg/m3. Despite the reduction in cotton dust concentration, byssinosis symptoms, allergic rhinitis, asthma and impaired pulmonary function are the most common findings in our cotton workers depending on the duration of exposure, whether they are smokers or not and the nature of the cotton dust.

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.

We report the case of a 56-year-old patient with malignant pleural mesothelioma of epithelial type, who responded to second-line chemotherapy with lipoplatin plus gemcitabine. Diagnosis and staging of the disease was done by medical thoracoscopy with biopsies of the right pleura in December 2003, when he was treated with talc pleurodesis. Eighteen months later, he presented with pleural effusion of the left side and underwent first-line chemotherapy with cisplatin plus vinorelbine. After 8 cycles, the patient presented renal toxicity limiting further cisplatinum chemotherapy and disease progression with peritoneal invasion of the tumor and ascites. Treatment with lipoplatin-gemcitabine was decided on in November 2006, and the patient showed important improvement in the clinical status and peritoneal effusion. He survived for 36 weeks, with symptom-free survival of 34 weeks.

Summary Background Talc is the most effective chemical pleurodesis agent for patients with malignant pleural effusion. However, concerns have arisen about the safety of intrapleural application of talc, after reports of development of acute respiratory distress syndrome in 1–9% of treated patients. Our aim was to establish whether use of large-particle-size talc is safe in patients with malignant pleural effusion. Methods We did a multicentre, open-label, prospective cohort study of 558 patients with malignant pleural effusion who underwent thoracoscopy and talc poudrage with 4 g of calibrated French large-particle talc in 13 European hospitals, and one in South Africa. The primary endpoint was the occurrence of acute respiratory distress syndrome after talc pleurodesis. Findings No patients developed acute respiratory distress syndrome (frequency 0%, one-sided 95% CI 0–0·54%). 11 (2%) patients died within 30 days. Additionally, seven patients had non-fatal post-thoracoscopy complications (1·2%), including one case of respiratory failure due to unexplained bilateral pneumothorax. Interpretation Use of large-particle talc for pleurodesis in malignant pleural effusion is safe, and not associated with the development of acute respiratory distress syndrome.

A 47 year old woman developed idiopathic bronchiolitis obliterans organizing pneumonia (BOOP) presenting with haemoptysis and diffuse multiple cavitary nodules. The disease was histologically confirmed by open lung biopsy after other entities had been excluded. The patient responded to a course of corticosteroids. This BOOP should be added to the list of diseases with multiple cavitary nodules.

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.