A Real-World Observational Study Examining the Impact of Aclidinium Bromide Therapy on the Quality of Life, Symptoms, and Activity Impairment of Patients with Chronic Obstructive Pulmonary Disease: The Greek ON-AIR Study.

Purpose: This multicenter, prospective, observational study aimed to supplement real-world evidence on the effects of aclidinium bromide on the quality of life (QoL), symptoms, and activity impairment of patients with COPD. Patients and Methods: Eligible patients were ≥40 years of age, newly initiated on aclidinium bromide as monotherapy or add-on therapy according to the product's approved label. Patient-reported COPD assessment test (CAT), the severity of symptoms and their impact on daily activities, and the features of the Genuair® inhaler device were assessed at enrollment and at 12 weeks post-treatment onset. Results: Between 13 March 2015 and 29 January 2016, 285 eligible consenting patients (76.3% males; median age: 69.0 years; 26.0% newly diagnosed with COPD) were enrolled by 15 hospital-based respiratory medicine specialists in Greece. Aclidinium bromide was initiated as add-on therapy to other inhaled maintenance medications in 73.1% of evaluable patients. The median (interquartile range [IQR]) baseline CAT score decreased from 14.0 (9.0-20.0) to 10.0 (6.0-15.0) points (p<0.001) after 12 weeks of treatment, with 76.5% of the patients achieving a ≥2-point decrease. The severity of night-time and early-morning symptoms, assessed using a 5-point Likert-type scale, decreased from a median (IQR) of 1.0 (0.0-2.0) to 0.0 (0.0-1.0), and from 2.0 (1.0-2.0) to 1.0 (1.0-2.0), respectively (p<0.001 for both). In patients with paired data, the prevalence of at least moderate night-time symptoms, early-morning symptoms, and daily activity impairment decreased from 28.2% to 19.1%, from 63.6% to 34.2%, and from 59.5% to 38.7%, respectively (p<0.001 for all). Inhaler device features were assessed as "very good"/"good" by more than 90% of the patients. The adverse drug reaction rate was 1.4%. Conclusion: The study provides real-world evidence on the beneficial effects of aclidinium bromide on the patients' QoL, symptom severity, and daily activity impairment, which are complemented by a favorable safety profile and high patient satisfaction with the inhaler device.

Left Lateral Cervical Mass with Draining Sinuses.

The aim of the present study is to describe an uncommon case of tuberculous lymphadenitis (TL) in a symptomless 89-year-old male smoker patient, who presented at the emergency department of our hospital with left lateral cervical swelling with draining sinuses. No other clinical symptoms or physical findings were observed at admission. An elevated erythrocyte sedimentation rate (ESR) and a small calcified nodule in chest CT were the only abnormal findings. Pus samples from sinuses were examined and confirmed tuberculosis which was in agreement with surgical pathology of lymph nodes. A four- (4-) drug antituberculous regimen was administered. After an initial remission of his symptoms, the patient presented an exacerbation of the cervical swelling with draining sinuses necessitating addition of oral steroids. TL can be symptomless presenting a paradoxical reaction during treatment. The uniqueness of our case lies in the patient's advanced age, which is uncommon with cervical lymphadenopathy as a form of extrapulmonary tuberculosis, as well as in the administration of oral steroids to resolve the neck's clinical deterioration. The patient had a complete recovery and was free of disease after completion of his six-month antituberculous chemotherapy.

Quantitative INTERSPECIMEN variability during biphasic pleural fluid cytological sampling in adenocarcinoma effusions.

OBJECTIVES: Given that cytology of adenocarcinoma-induced pleural effusions has a high diagnostic yield, we have comparatively evaluated the cytological information of smears during biphasic sampling of pleural fluid in patients with metastatic pleural adenocarcinoma from various primary sites. METHODS: We studied 25 male and 21 female patients, aged 59.4 ±17.2 years (mean ± SD) with unilateral malignant effusion of varying magnitude due to confirmed adenocarcinoma from various primary sites. At thoracocentesis we collected two 30-ml samples of pleural fluid, the first at the very beginning of fluid aspiration (S1) and the second just before termination of fluid removal (S2) and recorded the volume of fluid aspirated between the 2 samples. Cytological smears were examined under light microscopy by 3 independent cytologists after Papanicolaou stain. Quantitative assessment of cell types was averaged among 50 visual fields for each smear. RESULTS: In S1 versus S2 the mean number of mesothelial cells was 7.8 ± 4.8 versus 12.1 ± 5.4 (mean ± SD), of lymphocytes 64.6 ± 12.9 versus 85.9 ± 17.4, of neutrophils 8.5 ± 4.4 versus 11.7 ± 5.2, of eosinophils 1.5 ± 0.3 versus 1.7 ± 0.8, and the number of malignant cell aggregates(NMCA) was 11.9 ±4.9 versus 20.7 ± 5.1. The differences in numbers of all cell types including NMCA were statistically significant between S1 and S2 (P < .01). A strong significant linear association between S2/S1 ratio of NMCA and the volume of fluid aspirated between samples was also found (95% confidence interval [CI], 0.209-0.236, P-value < .001). CONCLUSION: Specimens aspirated before completion of fluid drainage are shown to contain significantly more diagnostic information than those aspirated at the beginning of fluid removal.

Does size matter concerning impact of position on oxygenation status in spontaneously breathing patients with unilateral effusion?

BACKGROUND: Inconsistent and contradictory findings have appeared in the literature concerning the impact of body position on oxygenation in pleural effusion. METHODS: We attempted to elucidate whether the size of the pleural effusion in patients with no parenchymal disease is the main determinant of posture-induced alterations in oxygenation parameters. We studied 62 spontaneously breathing patients aged 65.3±7.8 years (mean±SD), of whom 36 had large and massive-sized effusions (Group A) and 26 had small and moderate-sized effusions (Group B). Arterial blood gases were determined in four different body positions: sitting (SIT), supine (SUP), ipsilateral (IPS) and contralateral (CON) to the effusion side, after remaining relaxed for at least 20 min in each position. Separation into groups A and B was deliberately set from the position of the fluid meniscus line on a posteroanterior chest film just above the upper costal margin of the sixth anterior rib. A two-way ANOVA model with outcome variables PaO2, PaCO2 and [A-a] DO2 was used. RESULTS: In both groups the best oxygenation was found in SIT. The worst oxygenation (highest [A-a] DO2 value) occurred in group A in CON compared with IPS (59.4±7.6 vs 49.0±7.5 mm Hg, p<0.001) and in group B in IPS compared with CON (51.0±8.7 vs 39.5±9.2 mm Hg, p<0.001). Also, PaCO2 showed significant differences in both groups in IPS compared with CON (p=0.002). CONCLUSIONS: Patients with large-sized effusions exhibit the worst oxygenation when lying on the side contralateral to the effusion, while those with small-sized effusions exhibit the worst oxygenation when lying on the side ipsilateral to the effusion.

Initial size of unilateral pleural effusion determines impact of thoracocentesis on oxygenation.

BACKGROUND: There have been contradicting reports in the literature regarding the impact of pleural fluid aspiration on patients' oxygenation. The aim of this study was to assess the role of the initial size of effusion on post-drainage oxygenation. METHODS: We studied 122 patients, aged (mean±SD) 61.2±16.8 years, with unilateral pleural effusion and no remarkable parenchymal lesion, by determining PaO2, PaCO2 and [A-a] PaO2 just before thoracocentesis (T1), 30 min after its completion (T2) and 48 hours after the procedure (T3). Patients were divided into group A (75 patients) with small and moderate sized effusions and group B (47 patients) with large and massive effusions. The position of the meniscus line on the posteroanterior film, being arbitrarily set at just above the upper costal margin of the sixth anterior rib, was used to divide the two groups. Patients were studied at rest, breathing room air in the sitting position. Repeated measures ANOVA (related samples) and the Friedman test when the normality assumption was violated were used. RESULTS: In group A, at T3, PaO2(mm Hg) showed a statistically significant increase versus T1 (p<0.001) and T2 (p=0.002), while [A-a] PaO2 displayed a statistically significant decrease compared with T1 (p<0.001) and T2 (p=0.001). In group B, at T2, PaO2 presented significant decrease versus T1 (p<0.001) and T3 (p<0.001), while [A-a] PO2 was found to be significantly increased compared with both T1 and T3 (p<0.001). CONCLUSION: Patients with smaller effusions showed a small improvement in their oxygenation 48 hours post-thoracocentesis (T3). Patients with larger effusions exhibited a transient reduction in their oxygenation immediately after fluid removal (T2).

Temporal evolution of thoracocentesis-induced changes in spirometry and respiratory muscle pressures.

BACKGROUND: Several studies investigated the effects of thoracocentesis on aspects of respiratory function without generally ensuring absence of coexistent lung pathology or homogeneity in initial size of the effusion. METHODS: We studied 90 patients aged 61.6±15.9 years (mean±SD) separated into a group A with small-sized or medium-sized effusion (A=56 patients) and a group B with large and massive one (B=34 patients). There was no significant lung lesion or cardiovascular pathology. The basic spirometric parameters and maximal respiratory pressures were recorded on three instances: just before thoracocentesis (T1), 30 min after completion of the procedure (T2) and after 48 hours (T3). RESULTS: At T2 vs T1, groups A and B respectively presented significant change (mean±SD) (increase) in forced vital capacity (FVC) of 0.071±0.232 and 0.139±0.224 L, in forced expiratory volume in 1 s (FEV1) of 0.127±0.231 and 0.201±0.192 L, in FEV1/FVC of 2.8% and 4.9%, in peak expiratory flow rate (PEFR) of 0.342±0.482 and 0.383±0.425 L/s, in maximal expiratory pressure (MEP) of 0.049±0.037 and 0.049±0.039 kPa and in maximal inspiratory pressure (MIP) of 0.040±0.041 kPa only in group A while decrease in MIP with significant change of 0.055±0.051 kPa in group B. At T3 vs T2 in groups A and B, there was significant change (decrease) in FEV1/FVC of 2.7% and 4.6% as well as significant change (increase) in MIP of 0.036±0.046 and 0.115±0.060 and in MEP of 0.049±0.043 and 0.070±0.048 kPa. CONCLUSIONS: Thoracocentesis is associated with progressive-small relative to the volume of fluid removed-increases in lung volumes. In larger effusions at T2, a transient decrease in MIP is observed presumably due to temporary geometric distortion of the diaphragm immediately after fluid removal.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis.

BACKGROUND: Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients. METHODS: Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. RESULTS: The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability. CONCLUSIONS: Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Right Upper Lobe Shadow and Tracheobronchopathia Osteochondroplastica Confined to Right Main Bronchus: A Case Report and Literature Review.

Tracheobronchopathia osteochondroplastica (TO) is a well documented benign entity of endoscopic interest. We describe a case of 76-year-old patient who presented with fever, cough, purulent sputum during the past four days, and presence of an ovoid shadow in right upper zone of his chest X-ray. Medical history included diagnosis of colon diverticuli identified by colonoscopy 3 months ago. Chest CT revealed a compact elongated lesion containing air-bronchogram stripes. Bronchoscopy showed normal upper airways and trachea but presence of unequal sized mucosal nodules, protruding into the lumen, along the entire length of the right main bronchial mucosa. No other abnormal findings were detected. Moreover, brushing and washing smears from the apical segment of right upper lobe (RUL), where the compact lesion was located, were negative for malignancy. Biopsy from the mucosal nodules of right main bronchus showed presence of cartilaginous tissue in continuity through thin pedicles with submucosal cartilage. This finding posed the diagnosis of TO while RUL lesion was cleared by antibiotic treatment. Case is reported because, to our knowledge, it represents a unique anatomic location of TO which was confined exclusively in the right main bronchus mucosa without affecting trachea.

Comparative changes in tissue oxygenation between laparoscopic and open cholecystectomy.

BACKGROUND: Previous studies examined the effect of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) on physiological variables of the respiratory system. In this study we compared changes in arterial blood gases-related parameters between LC and OC to assess their comparative influence on gas exchange. METHODS: We studied 28 patients, operated under identical anesthetic protocol (LC: 18 patients, OC: 10 patients). Measurements were made on the morning before surgery (BS), the second (AS2) and the eighth (AS8) postoperative day. Studied parameters, including alveolar-arterial difference in PO2 ((A-a)DO2) and oxygen content (Oct in vol%), were statistically compared. RESULTS: On AS2 a greater increase was found in ((A-a)DO2) for the OC compared to LC (4.673 ± 0.966 kPa versus 3.773 ± 1.357 kPa, respectively). Between BS and AS2, Oct in vol% decreased from 17.55 ± 1.90 to 15.69 ± 1.88 in the LC and from 16.99 ± 2.37 to 14.62 ± 2.23 in the OC, whilst a reduction (P = 0.093) between AS2 and AS8 was also found for the open method. Besides, on AS2, SaO2% decrease was greater in OC compared to LC (P = 0.096). CONCLUSIONS: On AS2, the greater increase in OC-((A-a)DO2) associated with Oct in vol% and SaO2% findings also in OC group suggest that LC might be associated with lower risk for impaired tissue oxygenation.

Effects of laparoscopic cholecystectomy on lung function: a systematic review.

AIM: To present and integrate findings of studies investigating the effects of laparoscopic cholecystectomy on various aspects of lung function. METHODS: We extensively reviewed literature of the past 24 years concerning the effects of laparoscopic cholecystectomy in comparison to the open procedure on many aspects of lung function including spirometric values, arterial blood gases, respiratory muscle performance and aspects of breathing control, by critically analyzing physiopathologic interpretations and clinically important conclusions. A total of thirty-four articles were used to extract information for the meta-analysis concerning the impact of the laparoscopic procedure on lung function and respiratory physiopathology. The quality of the literature reviewed was evaluated by the number of their citations and the total impact factor of the corresponding journals. A fixed and random effect meta-analysis was used to estimate the pooled standardized mean difference of studied parameters for laparoscopic (LC) and open (OC) procedures. A crude comparison of the two methods using all available information was performed testing the postoperative values expressed as percentages of the preoperative ones using the Mann-Whitney two-sample test. RESULTS: Most of the relevant studies have investigated and compared changes in spirometric parameters.The median percentage and interquartile range (IQR) of preoperative values in forced vital capacity (FVC), forced expiratory volume in 1 s and forced expiratory flow (FEF) at 25%-75% of FVC (FEF25%-75%) expressed as percentage of their preoperative values 24 h after LC and OC were respectively as follows: [77.6 (73.0, 80.0) L vs 55.4 (50.0, 64.0) L, P < 0.001; 76.0 (72.3, 81.0) L vs 52.5 (50.0, 56.7) L, P < 0.001; and 78.8 (68.8, 80.9) L/s vs 60.0 (36.1, 66.1) L/s, P = 0.005]. Concerning arterial blood gases, partial pressure of oxygen [PaO2 (kPa)] at 24 or 48 h after surgical treatment showed reductions that were significantly greater in OC compared with LC [LC median 1.0, IQR (0.6, 1.3); OC median 2.4, IQR (1.2, 2.6), P = 0.019]. Fewer studies have investigated the effect of LC on respiratory muscle performance showing less impact of this surgical method on maximal respiratory pressures (P < 0.01); and changes in the control of breathing after LC evidenced by increase in mean inspiratory impedance (P < 0.001) and minimal reduction of duty cycle (P = 0.01) compared with preoperative data. CONCLUSION: Laparoscopic cholecystectomy seems to be associated with less postoperative derangement of lung function compared to the open procedure.

Cavitating lung lesion as a manifestation of inflammatory tumor (pseudotumor) of the lung: A case report and literature review.

PATIENT: Female, 60 FINAL DIAGNOSIS: Inflammatory pseudotumor of the lung Symptoms: Cough dry • fever MEDICATION: - Clinical Procedure: - Specialty: - OBJECTIVE: Rare disease. BACKGROUND: Inflammatory pseudotumor of the lung involves a benign, non-neoplastic lung lesion of unknown etiology. CASE REPORT: We present a case of a 60-year-old female smoker who had been under intermittent immunosuppressive medication for discoid lupus, who was admitted to hospital with fever of 39.5°C of 10-day duration, not responding to an oral cephalosporin. Chest CT examination showed a cavitating opacity in the upper zone of the left lung. It was not feasible to establish a diagnosis based on clinical and laboratory testing nor based on CT scanning and bronchoscopy. Thus, the patient underwent left thoracotomy and sphenoid resection of the lesion, which was sent for biopsy. The histopathologic features aided by immunohistochemical staining proved the lesion to be an inflammatory pseudotumor of the lung. CONCLUSIONS: The case is reported because of the extremely rare radiologic presentation of the development of a lung pseudotumor emerging as a cavitated lesion, which relapsed during the follow-up period while the patient was still under immunosuppressive medication.

Pericardial involvement as an atypical manifestation of giant cell arteritis: report of a clinical case and literature review.

PURPOSE: Pericardial effusion has been known to be a rare manifestation of giant cell arteritis. During the last six decades, only 24 cases have been cited in the literature. In this report, we describe the case of a patient presenting with nonspecific symptoms and development of pericardial effusion. PROCEDURES AND FINDINGS: A 71-year-old woman was admitted to the hospital with low-grade fever, exertion breathlessness, atypical diffuse muscular pain, and weight loss over a period of about 5 weeks. Pericardial effusion and giant cell arteritis were diagnosed by echocardiography and left temporal artery biopsy, respectively. Treatment with corticosteroids resulted in remarkable improvement of symptoms and complete remission of pericardial effusion. One year after admission, the patient remained in a stable good condition, under low steroid maintenance dosage. CONCLUSIONS: The diversity of clinical manifestations (such as pericardial effusion) in such a potentially severe disease should alert the physician to prompt diagnosis and treatment in view of impending irreparable vascular damages, even in cases in which the initial presentation is quite uncommon.

Changes in breathing control and mechanics after laparoscopic vs open cholecystectomy.

HYPOTHESIS: We hypothesized that there might be different effects on breathing control and respiratory mechanics after laparoscopic vs open cholecystectomy. DESIGN: Randomized clinical trial. SETTING: A general hospital in Greece. PATIENTS: Of 53 patients assessed for eligibility, 18 and 10 were randomly allocated to the laparoscopic and open cholecystectomy groups, respectively. These 28 patients had normal spirometry measurements and American Society of Anesthesiologists' class I physical status. MAIN OUTCOME MEASURES: Measurements of breathing control and mechanics variables. Tidal volume, inspiratory time, breathing frequency, mean inspiratory flow, duty cycle, central respiratory drive, and mean inspiratory impedance were recorded before surgery on the second and eighth postoperative days. Airway resistance was recorded before surgery and on the eighth postoperative day, with all measurements being performed under no influence of analgesia. RESULTS: Two days after surgery, inspiratory time, breathing frequency, and central respiratory drive were significantly changed compared with preoperative values for both methods, whereas mean inspiratory impedance was significantly increased (P<.001) for the laparoscopic procedure. Eight days after surgery, changes were seen only for the laparoscopic group: duty cycle and airway resistance were significantly reduced (P = .01) and increased (P = .04), respectively, compared with preoperative data. CONCLUSION: Laparoscopic cholecystectomy seems to be associated with small but sustained alterations in the control of breathing and mechanics, which might have an unfavorable clinical impact on patients with compromised lung function.