The Role of Emphysema on Postoperative Prognosis in Early-Stage Nonsmall Cell Lung Cancer.

BACKGROUND: Emphysema is generally considered a poor prognostic factor for patients with nonsmall cell lung cancer; however, whether the poor prognosis is due to highly malignant tumors or emphysema itself remains unclear. This study was designed to determine the prognostic value of emphysema in patients with early-stage nonsmall cell lung cancer. METHODS: A total of 721 patients with clinical stage IA nonsmall cell lung cancer who underwent complete resection between April 2007 and December 2018 were retrospectively analyzed regarding clinicopathological findings and prognosis related to emphysema. RESULTS: The emphysematous and normal lung groups comprised 197 and 524 patients, respectively. Compared with the normal lung group, lymphatic invasion (23.9% vs. 14.1%, P = 0.003), vascular invasion (37.6% vs. 17.2%, P < 0.001), and pleural invasion (18.8% vs. 10.9%, P = 0.006) were observed more frequently in the emphysema group. Additionally, the 5-year overall survival rate was lower (77.1% vs. 91.4%, P < 0.001), and the cumulative incidence of other causes of death was higher in the emphysema group (14.0% vs. 3.50%, P < 0.001). Multivariable Cox regression analysis of overall survival revealed that emphysema (vs. normal lung, hazard ratio 2.02, P = 0.0052), age > 70 years (vs. < 70 years, hazard ratio 4.03, P < 0.001), and SUVmax > 1.8 (vs. ≤ 1.8, hazard ratio 2.20, P = 0.0043) were independent prognostic factors. CONCLUSIONS: Early-stage nonsmall cell lung cancer with emphysema has a tendency for the development of highly malignant tumors. Additionally, emphysema itself may have an impact on poor prognosis.

Effectiveness of Messenger RNA Coronavirus Disease 2019 Vaccines Against Symptomatic Severe Acute Respiratory Syndrome Coronavirus 2 Infections During the Delta Variant Epidemic in Japan: Vaccine Effectiveness Real-time Surveillance for SARS-CoV-2 (VERSUS).

BACKGROUND: Although high vaccine effectiveness of messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccines has been reported in studies in several countries, data are limited from Asian countries, especially against the Delta (B.1.617.2) variant. METHODS: We conducted a multicenter test-negative case-control study in patients aged ≥16 years visiting hospitals or clinics with signs or symptoms consistent with COVID-19 from 1 July to 30 September 2021, when the Delta variant was dominant (≥90% of SARS-CoV-2 infections) nationwide in Japan. Vaccine effectiveness of BNT162b2 or mRNA-1273 against symptomatic SARS-CoV-2 infections was evaluated. Waning immunity among patients aged 16-64 years was also assessed. RESULTS: We enrolled 1936 patients, including 396 test-positive cases and 1540 test-negative controls for SARS-CoV-2. The median age was 49 years, 53.4% were male, and 34.0% had underlying medical conditions. Full vaccination (receiving 2 doses ≥14 days before symptom onset) was received by 6.6% of cases and 38.8% of controls. Vaccine effectiveness of full vaccination against symptomatic SARS-CoV-2 infections was 88.7% (95% confidence interval [CI], 78.8%-93.9%) among patients aged 16-64 years and 90.3% (95% CI, 73.6%-96.4%) among patients aged ≥65 years. Among patients aged 16-64 years, vaccine effectiveness was 91.8% (95% CI, 80.3%-96.6%) within 1-3 months after full vaccination, and 86.4% (95% CI, 56.9%-95.7%) within 4-6 months. CONCLUSIONS: mRNA COVID-19 vaccines had high effectiveness against symptomatic SARS-CoV-2 infections in Japan during July-September 2021, when the Delta variant was dominant nationwide.

High prevalence of multiple serotypes of pneumococci in patients with pneumonia and their associated risk factors.

BACKGROUND: Multiple serotypes of pneumococci have epidemiological and clinical implications, such as the emergence of non-vaccine serotypes and the acquisition of antimicrobial resistance. Prevalence of multiple serotypes of pneumococci in adults and their risk factors are not known. METHODS: We enrolled adult patients from age ≥15 years with radiologically confirmed pneumonia in four hospitals across Japan. Pneumococcal pneumonia was defined with a pneumococcal bacterial density of ≥104/mL in sputum by lytA quantitative PCR, and serotypes were determined. Pneumonias with a single serotype were categorised as single-serotype pneumococcal pneumonia and with two or more serotypes as multiple-serotype pneumococcal pneumonia. Multivariable logistic regression was used to assess the risk factors. RESULTS: 3470 patients (median age 77 years, IQR 65-85) were enrolled. Pneumococcal pneumonia was identified in 476 (18.3%, n=2605) patients. Multiple serotypes were detected in 42% of them. Risk of having multiple serotypes was low among patients who had received 23-valent pneumococcal polysaccharide vaccine (PPSV23) vaccines (adjusted OR 0.51 (95% CI 0.27 to 0.94)). Proportion of non-PCV7 PPSV23 serotypes in overall distribution of multiple serotypes was 67.4% (n=324/481) compared with 46.4% (n=128/276) in that of single serotypes (p=0.001). Serotypes 5, 9N/9L, 10A, 12/22/46, 17F and 35F were associated with multiple-serotype pneumonia, and serotypes 6A/6B, 23F, 11 and 6C/6D were associated with single-serotype pneumonia. Proportion of more invasive serotypes (serotypes 1, 5, 7F, 8) was significantly higher in multiple-serotype pneumonia (p=0.001). CONCLUSIONS: Multiple serotypes of pneumococci are common in sputum of adult patients with pneumonia. The risk of multiple-serotype pneumococcal pneumonia is lower than that of single-serotype pneumococcal pneumonia among PPSV23-vaccinated patients. TRIAL REGISTRATION NUMBER: UMIN000006909.

Implementation of a standardised pharmacist check of medical orders prior to preparation of anticancer drugs to reduce drug wastage.

BACKGROUND: The increasing cost of anticancer drugs is now being recognised as a global problem, and measures against drug wastage are among the most important cost containment strategies for anticancer drugs. OBJECTIVE: When blood examination results or changes to a patient's condition necessitate dose reduction or discontinuation of anticancer drugs after their preparation, the compounded anticancer drugs are discarded. To reduce anticancer drug wastage after preparation, we developed a protocol that set the eligibility, start of treatment, dose reduction and discontinuation criteria for injectable anticancer drugs and assessed the effect of pharmacists' checks of these criteria based on the present protocol prior to preparation of injectable anticancer drugs. METHOD: Observations before and after introduction of the protocol were conducted at Gifu University Hospital. We recorded the number, type and cost of anticancer drugs discarded after preparation and the reason for discarding these drugs in our dedicated database. RESULTS: Checking the criteria for anticancer drug administration before preparation significantly reduced the rate at which anticancer drugs within a chemotherapy cycle were discarded after preparation compared with that prior to the protocol's introduction (0.367% [18/4909] vs 0.032% [2/6248], P < .001). Additionally, the total cost of anticancer drugs discarded after preparation was reduced from JPY 2 041 786 (USD 18 562) to JPY 398 414 (USD 3622). CONCLUSION: Pharmacists' checks of the eligibility, start of treatment, dose reduction and discontinuation criteria for anticancer drugs based on the present protocol prior to preparation of injectable anticancer drugs was useful for reducing drug wastage after preparation.

[Shewanella algae bacteremia in patients with biliary tract malignancy: report of three cases].

We encountered three cases of Shewanella algae bacteremia in patients with biliary tract malignancy. Shewanella species are mainly found in seawater and other watery environments. Human infections caused by Shewanella species have been rare. However, reports of Shewanella infections are increasing, although only a few have been from Japan. The three patients we encountered had common features, including hepatobiliary malignancy, male sex, and age over 60 years. These features are similar to those in reports from elsewhere. Shewanella infection bears consideration in patients with those characteristics who have a history of exposure to sea or fresh water or ingestion of seafood. Prompt treatment is needed as the mortality rate of this infection is high.

The efficacy and safety of cefepime or meropenem in the treatment of febrile neutropenia in patients with lung cancer. A randomized phase II study.

Febrile neutropenia frequently develops after chemotherapy. There is little evidence to indicate the type of antimicrobial agents that should be used in the treatment of febrile neutropenia in patients with solid tumors. The objective is to determine the efficacy and safety of cefepime (CFPM) and meropenem (MEPM) in the treatment of febrile neutropenia in lung cancer patients in a prospective randomized study. FN patients with lung cancer were randomly divided into CFPM or MEPM groups. The primary end-point was the response rate. The secondary end-points were the defervescence rates at 72 h, 7 days, 14 days and the incidence of adverse events. Twenty-one patients were treated with CFPM and 24 patients were treated with MEPM. One patient died of FN. The CFPM treatment completion rate was 17.65% (95% CI; 0.00-35.77%), while the MEPM treatment completion rate was 38.10% (95% CI; 17.33-58.87%). The defervescence rates at 72 h, 7 days, and 14 days were 70.59%, 86.67%, and 100.00%, respectively in the CFPM group; and 65.00%, 84.21%, and 92.31% in the MEPM group. Adverse events were observed in 33.33% of the CFPM group and 45.83% of the MEPM group. The response rate of the CFPM group was 94.12% (95% CI; 73.02-98.95%), while that of the MEPM group was 85.71% (95% CI; 65.36-95.02%). No differences were found in the efficacy or safety of CFPM and MEPM in the treatment of febrile neutropenia in patients with lung cancer.

Preparation and evaluation of highly drug-loaded fine globular granules using a multi-functional rotor processor.

The manufacture of highly drug-loaded fine globular granules eventually applied for orally disintegrating tablets has been investigated using a unique multi-functional rotor processor with acetaminophen, which was used as a model drug substance. Experimental design and statistical analysis were used to evaluate potential relationships between three key operating parameters (i.e., the binder flow rate, atomization pressure and rotating speed) and a series of associated micromeritics (i.e., granule mean size, proportion of fine particles (106-212 µm), flowability, roundness and water content). The results of multiple linear regression analysis revealed several trends, including (1) the binder flow rate and atomization pressure had significant positive and negative effects on the granule mean size value, Carr's flowability index, granular roundness and water content, respectively; (2) the proportion of fine particles was positively affected by the product of interaction between the binder flow rate and atomization pressure; and (3) the granular roundness was negatively and positively affected by the product of interactions between the binder flow rate and the atomization pressure, and the binder flow rate and rotating speed, respectively. The results of this study led to the identification of optimal operating conditions for the preparation of granules, and could therefore be used to provide important information for the development of processes for the manufacture of highly drug-loaded fine globular granules.

Evaluation of the physicochemical properties of fine globular granules prepared by a multi-functional rotor processor.

Multiple regression analysis (MRA) and principal component analysis (PCA) have been used in the present study to examine the relationships between the operational conditions of a unique multi-functional rotor processor, material attributes such as water content during granulation, and a series of associated micromeritics, including the flowability, granule mean size and granule density values. A variety of different operational conditions were tested, including the binder flow rate, atomization pressure, slit air flow rate, rotating speed and temperature of the inlet air. The results of MRA revealed several trends, including (1) the granule mean size was negatively affected by the atomization pressure, and positively affected by the binder flow rate; (2) the granule flow property, Carr's index was positively affected by the atomization pressure, and negatively affected by the slit air flow rate; and (3) the granule density was positively affected by the rotating speed. Taken together, these results suggested that the binder flow rate, atomization pressure and slit airflow rate were critical process parameters for the preparation of fine globular granules. Using PCA, it was possible to examine each relationship of all 19 batches and 10 variables, as well as determine which process parameters or material attributes impacted on the quality of the final product. The PCA results revealed that the roundness was positively correlated with the water content. Therefore, we believe this fundamental information will be important for the development of processes for the facile manufacture of fine globular granules.

Utility of 4 K three-dimensional endoscopic system in performing video-assisted thoracoscopic surgery lobectomy: initial results of the first year after installation.

OBJECTIVES: With the evolution of technology in the field of thoracoscopy, three-dimensional (3D) endoscopic systems with 4 K resolution have recently come into use. This study aimed to determine perioperative outcomes of video-assisted thoracoscopic surgery (VATS) lobectomy performed a year after the 4 K three-dimensional (3D) endoscopic system installation and compare them with those of the high-definition (HD) 3D endoscopic system. METHODS: We included patients who underwent complete VATS (cVATS) lobectomy for primary lung cancer using an HD3D endoscopic system (HD3D group, June 2015-September 2021, n = 251) or 4K3D endoscopic system (4K3D group, October 2021-September 2022, n = 47). The perioperative outcomes were compared between the two groups. RESULTS: The operation time was significantly shorter in the 4K3D group (mean, 189.5 min) than in the HD3D group (208.5 min; p = 0.021), and the 4K3D group did not require conversion to thoracotomy or transfusion. The 4K3D group had less blood loss volume (4K3D group: mean, 24.0 mL vs. HD3D group: 43.3 mL; p = 0.105) and shorter chest drainage duration (4K3D group: mean, 2.3 days vs. HD3D group: 3.1 days; p = 0.115) and hospitalization period (4K3D group: mean, 7.9 days vs. HD3D group:10.0 days; p = 0.226) than the HD3D group, with no significant difference. No difference was observed in the incidence of ≥ Grade IIIa complications (p = 0.634). CONCLUSION: The 4K3D endoscopic system significantly shortened the duration of cVATS lobectomy. It is useful for lung resection and may replace other endoscopy systems.

Completion lobectomy under 4K three-dimensional endoscopy for surgical margin recurrence after segmentectomy.

As the adoption of segmentectomy for small-sized lung cancers expands, the need for more challenging completion lobectomy (CL) may arise to address surgical margin recurrence. Herein, we present a case of successful CL using a 4K three-dimensional (3D) (4K3D) endoscopy after segmentectomy. A 77-year-old male patient with lung cancer in the anterior segment (S3) of the left upper lobe underwent S3 segmentectomy. One year later, the patient experienced a recurrence at the surgical margin. CL was successfully performed under 4K3D endoscopy, same as the initial surgery. CL after segmentectomy requires meticulous preoperative planning and precise surgical maneuvering, and 4K3D endoscopy provides safe and reliable outcomes.

Lessons from short chest drain management for primary spontaneous pneumothorax.

OBJECTIVES: Video-assisted thoracic surgery (VATS) bullectomy is the mainstay treatment for primary spontaneous pneumothorax (PSP) but we encounter patients with pain due to chest tube. This study investigated the postoperative outcomes of shortened silicone drain as a chest tube after VATS bullectomy to reduce pain. METHODS: The current study included patients aged < 30 years who underwent VATS bullectomy for PSP. Patients with normal intrathoracic lengths of the silicone drain placed in a loop at the apex toward the diaphragm were categorized as Group L, whereas those with the silicone drain shortened to approximately 10 cm and placed toward the apex were classified as Group S. Postoperative pain evaluated using a numerical rating scale (NRS) and other perioperative outcomes were compared between the groups. RESULTS: Altogether, 43 patients were included, with 22 in Group L and 21 in Group S, respectively. The NRS before chest tube removal was significantly lower in Group S (mean, 2.1) than in Group L (4.4; p = 0.001). In Group L, 4 patients (p = 0.017) required early chest tube removal than expected due to severe pain whereas none in Group S required this intervention; additionally, more patients needed additional analgesics than in Group S (p = 0.003). CONCLUSION: In VATS bullectomy for PSP, the pain intensity could be reduced by shortening the intrathoracic length of the silicone drain, compared to a longer intrathoracic length of the silicon drain. Our findings contribute to the establishment of optimal postoperative management of general thoracic surgery.

Application of microwave surgical instrument to lung segmentectomy for small-sized lung cancer.

Objectives: For lung segmentectomy of small lung cancers, we used a microwave surgical instrument for lung parenchymal dissection mainly at the pulmonary hilum, which is difficult to handle with surgical staplers. This technique facilitated the insertion of staples. Methods: In total, 116 patients with cStage 0-1A3 non-small cell lung cancer who underwent lung segmentectomy were included in this study. We compared the perioperative factors of the group in which a microwave surgical instrument was used for dissection procedures, including lung parenchymal dissection at the pulmonary hilum, and peripheral intersegmental dissection was performed with surgical staplers (group M+S: N = 69), with those of the group in which parenchymal dissection was performed mainly with surgical staplers without using the microwave surgical instrument (group S: N = 47). Results: Although more complex segmentectomies were performed in the M+S group (P = .001), the number of staple cartridges (7 staple cartridges vs 8 staple cartridges, P = .005), the surgical times (179 vs 221 minutes, P < .0001), and the blood loss (5 mL vs 30 mL, P = .012) were significantly lower in the M+S group. The duration of chest tube placement was significantly shorter in the M+S group (P = .019), and postoperative complications of grade 2 or greater were significantly lower in the M+S group (P = .049). Conclusions: The effective use of the microwave surgical instrument combined with surgical staplers can simplify pulmonary hilar and intersegmental plane dissections not only for simple segmentectomy but also for complex segmentectomy, leading to favorable intraoperative and postoperative outcomes.

Effectiveness of primary series, first, and second booster vaccination of monovalent mRNA COVID-19 vaccines against symptomatic SARS-CoV-2 infections and severe diseases during the SARS-CoV-2 omicron BA.5 epidemic in Japan: vaccine effectiveness real-time surveillance for SARS-CoV-2 (VERSUS).

BACKGROUND: This study aimed to evaluate VE of primary, first, and second booster ancestral-strain monovalent mRNA COVID-19 vaccination against symptomatic infections and severe diseases in Japan. METHODS: We conducted a test-negative case-control study. We included medically attended episodes and hospitalizations involving individuals aged ≥16 with signs and symptoms from July to November 2022, when Omicron BA.5 was dominant nationwide. To evaluate VE, we calculated adjusted ORs of vaccination among test-positive versus test-negative individuals using a mixed-effects logistic regression. RESULTS: For VE against symptomatic infections among individuals aged 16 to 59, VE of primary vaccination at > 180 days was 26.1% (95% CI: 10.6-38.8%); VE of the first booster was 58.5% (48.4-66.7%) at ≤90 days, decreasing to 41.1% (29.5-50.8%) at 91 to 180 days. For individuals aged ≥60, VE of the first booster was 42.8% (1.7-66.7%) at ≤90 days, dropping to 15.4% (-25.9-43.2%) at 91 to 180 days, and then increasing to 44.0% (16.4-62.5%) after the second booster. For VE against severe diseases, VE of the first and second booster was 77.3% (61.2-86.7%) at ≤90 days and 55.9% (23.4-74.6%) afterward. CONCLUSION: mRNA booster vaccination provided moderate protection against symptomatic infections and high-level protection against severe diseases during the BA.5 epidemic in Japan.

Pulmonary function and chest CT abnormalities 3 months after discharge from COVID-19, 2020-2021: A nation-wide multicenter prospective cohort study from the Japanese respiratory society.

BACKGROUND: No comprehensive analysis of the pulmonary sequelae of coronavirus disease 2019 (COVID-19) in Japan based on respiratory function tests and chest computed tomography (CT) has been reported. We evaluated post-COVID-19 conditions, especially focusing on pulmonary sequelae assessed by pulmonary function tests and chest CT. METHODS: For this prospective cohort study, we enrolled 1069 patients who presented pneumonia at the time of admission in 55 hospitals from February 2020 to September 2021. Disease severity was classified as moderateⅠ, moderate II, and severe, defined primarily according to the degree of respiratory failure. The data on post-COVID-19 conditions over 12 months, pulmonary function, and chest CT findings at 3 months were evaluated in this study. Additionally, the impact of COVID-19 severity on pulmonary sequelae, such as impaired diffusion capacity, restrictive pattern, and CT abnormalities, was also evaluated. RESULTS: The most frequently reported post-COVID-19 conditions at 3 months after COVID-19 were muscle weakness, dyspnea, and fatigue (48.4%, 29.0%, and 24.7%, respectively). The frequency of symptoms gradually decreased over subsequent months. In pulmonary function tests at 3 months, the incidence of impaired diffusion capacity and restrictive pattern increased depending on disease severity. There also were differences in the presence of chest CT abnormalities at the 3 months, which was markedly correlated with the severity. CONCLUSION: We reported a comprehensive analysis of post-COVID-19 condition, pulmonary function, and chest CT abnormalities in Japanese patients with COVID-19. The findings of this study will serve as valuable reference data for future post-COVID-19 condition research in Japan.

Impact of the Tohoku earthquake and tsunami on pneumonia hospitalisations and mortality among adults in northern Miyagi, Japan: a multicentre observational study.

BACKGROUND: On 11 March 2011, the Tohoku earthquake and tsunami struck off the coast of northeastern Japan. Within 3 weeks, an increased number of pneumonia admissions and deaths occurred in local hospitals. METHODS: A multicentre survey was conducted at three hospitals in Kesennuma City (population 74 000), northern Miyagi Prefecture. All adults aged ≥18 years hospitalised between March 2010 and June 2011 with community-acquired pneumonia were identified using hospital databases and medical records. Segmented regression analyses were used to quantify changes in the incidence of pneumonia. RESULTS: A total of 550 pneumonia hospitalisations were identified, including 325 during the pre-disaster period and 225 cases during the post-disaster period. The majority (90%) of the post-disaster pneumonia patients were aged ≥65 years, and only eight cases (3.6%) were associated with near-drowning in the tsunami waters. The clinical pattern and causative pathogens were almost identical among the pre-disaster and post-disaster pneumonia patients. A marked increase in the incidence of pneumonia was observed during the 3-month period following the disaster; the weekly incidence rates of pneumonia hospitalisations and pneumonia-associated deaths increased by 5.7 times (95% CI 3.9 to 8.4) and 8.9 times (95% CI 4.4 to 17.8), respectively. The increases were largest among residents in nursing homes followed by those in evacuation shelters. CONCLUSIONS: A substantial increase in the pneumonia burden was observed among adults after the Tohoku earthquake and tsunami. Although the exact cause remains unresolved, multiple factors including population aging and stressful living conditions likely contributed to this pneumonia outbreak.

Significance of the Goddard Score in Predicting Complications Related to Air Leak After Lobectomy.

BACKGROUND: Postoperative air leakage is a frequent complication after lung resection, and emphysema is a risk factor. However, no study has investigated the relationship between emphysema severity and postoperative complications related to air leak by the Goddard score (GS), a visual evaluation method of radiologic emphysema using computed tomography. METHODS: This study included patients who underwent lobectomy for non-small cell lung cancer between April 2009 and March 2022. The utility of GS in predicting complications related to air leak (air leak prolonged for ≥5 days, pleurodesis, and reoperation for air leak) was investigated by receiver operating characteristic curve analysis and multivariable analysis with a logistic regression model. RESULTS: This study included 477 patients. The GS was a significant predictor of complications related to air leak (area under the curve, 0.696; P < .001). Based on the receiver operating characteristic curve analysis, GS of 6 points was used as the cutoff point for multivariable analysis. In the multivariable analysis, GS of ≥6 points was a significant predictor of complications related to air leak (odds ratio, 2.719; P = .007). In the subgroup analysis of patients with emphysema, GS of ≥6 points was a significant predictor of complications related to air leak (P = .014). CONCLUSIONS: The GS was useful in predicting complications related to air leak. Patients with radiologic findings of emphysema with GS of ≥6 points should be recognized as a high-risk group for complications related to air leak.

Pleural plaque identification in computed tomography and intraoperative thoracic findings: Correspondence and prognosis comparison in patients with resection of non-small cell lung cancer.

BACKGROUND: We previously reported that intraoperative findings of pleural plaques were worse prognostic factors of resected non-small cell lung cancer (NSCLC). However, differences in the presence of pleural plaques detected either intraoperatively or by CT findings have not been addressed. METHOD: We included 121 patients who underwent resection for NSCLC with intraoperatively detected pleural plaques. We investigated preoperative CT findings and compared the prognosis between patients with or without evidence of pleural plaque on CT. RESULTS: Only 43% of patients with pleural plaques on intrathoracic findings had pleural plaques detected on preoperative CT. There were no differences in prognosis between patients with or without pleural plaque evidences on preoperative CT. CONCLUSION: The rate of detection of pleural plaques on preoperative CT is low even if they are present intraoperatively, and patients with intraoperative findings of pleural plaques have equally poor prognosis regardless of their evidences on preoperative CT.

Pulmonary hypertension secondary to interstitial fibrosis with pulmonary venous lesions masquerading pulmonary veno-occlusive disease.

We present a 41-year-old man with idiopathic interstitial pneumonia and pulmonary hypertension (PH) in the setting of a non-autoimmune background whose clinical presentation masqueraded pulmonary veno-occlusive disease (PVOD). Because of no histological evidence of venous occlusion in his previous lung biopsy, phosphodiesterase type-5 inhibitor was given, resulting in sudden onset of pulmonary edema. At autopsy, there were histological features of interstitial fibrosis with occlusion of the lobular septal veins and venules. Clinical presentations of PH due to interstitial fibrosis with pulmonary venous lesions may simulate those of PVOD and careful diagnostic and therapeutic approaches are required.