The impact of the COVID-19 pandemic on lung cancer presentation at a high-volume tertiary referral centre in South Africa.

Background: The COVID-19 pandemic had a significant impact on health services globally. Cancer diagnosis and treatment was one of the services most frequently reported to be disrupted. Several international studies showed a marked reduction in the number of new lung cancer cases. Objectives: To assess the impact of the COVID-19 pandemic on lung cancer diagnosis at a high-volume tertiary referral centre in South Africa. Methods: A retrospective audit was conducted of all patients with primary lung cancer who were presented at the multidisciplinary oncology meeting at Tygerberg Hospital, Cape Town, from January 2018 to December 2021, and the incidence of lung cancer was compared between two cohorts: one prior to and one during the COVID-19 pandemic. We collected data on patient demographics, as well as performance status. A combined panel staged all patients. Results: During the COVID-19 pandemic there was a relative reduction of 46% in the frequency of lung cancer, from a mean of 25.6 cases per month to 13.9. Patients referred during the COVID-19 pandemic had statistically better performance status (75.0% v. 25.0% with performance status 0 - 2; p=0.01) and were more likely to have adenocarcinoma (49.7% v. 41.1%; p=0.02) than those referred before the pandemic. The proportion of potentially curable lung cancer at presentation (i.e. stages I - IIIA) did not differ between the two cohorts. Conclusion: The COVID-19 pandemic resulted in a substantial decrease in the number of new lung cancers diagnosed. Patients who were diagnosed with lung cancer during the pandemic had better performance status and were more likely to have adenocarcinoma. No impact on the proportion of potential curable disease was noted. Study synopsis: What the study adds. Health services globally were substantially impacted by the COVID-19 pandemic. Cancer diagnosis and treatment was one of the services most frequently reported to be disrupted. This study highlights the significant impact of the COVID-19 pandemic on lung cancer presentation in a high-volume tertiary hospital in South Africa.Implications of the findings. Lung cancer is known to have high mortality. The reduction in lung cancer presentation during the COVID-19 pandemic is likely to result in an increase in lung cancer-related morbidity and mortality over the next few years.

The utility of artificial intelligence in identifying radiological evidence of lung cancer and pulmonary tuberculosis in a high-burden tuberculosis setting.

BACKGROUND: Artificial intelligence (AI), using deep learning (DL) systems, can be utilised to detect radiological changes of various pulmonary diseases. Settings with a high burden of tuberculosis (TB) and people living with HIV can potentially benefit from the use of AI to augment resource-constrained healthcare systems. OBJECTIVE: To assess the utility of qXR software (AI) in detecting radiological changes compatible with lung cancer or pulmonary TB (PTB). METHODS: We performed an observational study in a tertiary institution that serves a population with a high burden of lung cancer and PTB. In total, 382 chest radiographs that had a confirmed diagnosis were assessed: 127 with lung cancer, 144 with PTB and 111 normal. These chest radiographs were de-identified and randomly uploaded by a blinded investigator into qXR software. The output was generated as probability scores from predefined threshold values. RESULTS: The overall sensitivity of the qXR in detecting lung cancer was 84% (95% confidence interval (CI) 80 - 87%), specificity 91% (95% CI 84 - 96%) and positive predictive value of 97% (95% CI 95 - 99%). For PTB, it had a sensitivity of 90% (95% CI 87 - 93%) and specificity of 79% (95% CI 73 - 84%) and negative predictive value of 85% (95% CI 79 - 91%). CONCLUSION: The qXR software was sensitive and specific in categorising chest radiographs as consistent with lung cancer or TB, and can potentially aid in the earlier detection and management of these diseases.

A new understanding of clinical patterns in post-TB lung disease.

Post-TB lung disease (PTLD) can be categorised based on physiological, radiological, and clinical abnormalities, delineating distinct clinical patterns; however, thus far the importance of this is unknown. People with PTLD have a high morbidity and increased mortality, but predictors of long-term outcomes are poorly understood.We conducted an observational study of PTLD patients attending a tertiary hospital in South Africa between 1 October 2021 and 30 September 2022. Patient demographics, risk factors, symptoms, lung function tests and outcomes were captured.A total of 185 patients were included (mean age: 45.2 years, SD ±14.3). Half of patients reported only one previous episode of Mycobacterium tuberculosis infection (n = 94, 50.8%). There was a statistically significant association between TB-associated obstructive lung disease (OLD) and dyspnoea (P = 0.002), chest pain (P = 0.014) and smoking (P = 0.005). There were significant associations between haemoptysis and both cavitation (P = 0.015) and fungal-associated disease (P < 0.001). Six patients (3.2%) died by study end.PTLD can affect young people even with only one previous episode of TB, and carries a high mortality rate. For the first time, clinical patterns have been shown to have meaningful differences; TB-related OLD is associated with dyspnoea, chest pain and smoking; while haemoptysis is associated with cavitary and fungal-associated disease..

Pulmonary hypertension in adults completing tuberculosis treatment.

Background: Pulmonary hypertension (PH) after tuberculosis (TB) is typically not included among the chronic lung diseases causing PH (group 3 PH), with few data available to support the inclusion. Objectives: To determine the prevalence of PH in an adult population completing TB treatment. Methods: This single-centre, cross-sectional study only included patients with their first documented episode of TB, and who were in the second half of treatment or had recently completed treatment. PH was assessed using transthoracic echocardiography. Questionnaires were completed, and spirometry and a 6-minute walk test were performed. Results: One hundred patients were enrolled, with a mean age of 37.1 years, of whom 58% were male and 46% HIV positive. The median time since initiation of TB treatment was 22 weeks. The mean (standard deviation) measured right ventricular systolic pressure (RVSP) was 23.6 (6.24) mmHg. One participant had PH (defined as RVSP ≥40 mmHg; 95% confidence interval (CI) 0.0 - 3.0) and a further 3 had possible PH (RVSP ≥35 and <40 mmHg), with a combined PH prevalence of 4% (95% CI 0.2 - 7.8). Airflow obstruction on spirometry was found in 13.3% of 98 patients, while 25.5% had a reduced forced vital capacity. There was no association between RVSP or PH/possible PH and sex, age, HIV status, systemic hypertension, spirometry measurements or 6-minute walking distance. Smoking status was associated with RVSP, but not with the presence of PH/possible PH. Conclusion: There was a significant prevalence of PH in this preliminary study of predominantly young patients completing treatment for a first episode of TB. Larger and more detailed studies are warranted. Study synopsis: What the study adds. Of 100 adult patients with their first episode of tuberculosis (TB) who underwent echocardiograms near the end of treatment completion to determine the prevalence of pulmonary hypertension (PH), 1 (1%) had PH and a further 3 (3%) had possible PH. There was no association between sex, age, HIV status, lung function or 6-minute walking distance and the presence of PH. The study adds to the growing awareness of the association of TB with pulmonary vascular disease. It shows that even in a young population with a first episode of TB treated in an ambulatory setting, there is a significant prevalence of PH on treatment completion.Implications of the findings. Given that 10.6 million people acquire TB annually, the absolute global burden of cases with PH is likely to be high, but is underappreciated to date. Further work is urgently needed in this field.

The utility of chest ultrasound-guided fine-needle biopsy in the diagnosis of plasmacytoma.

Background: Plasmacytoma is a plasma cell dyscrasia originating from a single clone of plasma cells of B-lymphocyte lineage and produces a monoclonal immunoglobulin. Transthoracic fine-needle aspiration (TTNA) under ultrasound (US) guidance is a well-validated technique for the diagnosis of many neoplasms and has been shown to be safe and cost effective, with diagnostic yields comparable to more invasive techniques. However, the role of TTNA in the diagnosis of thoracic plasmacytoma is not well established. Objectives: The aim of this study was to assess the utility of TTNA and cytology in confirming a diagnosis of plasmacytoma. Methods: All cases of plasmacytoma diagnosed from January 2006 to December 2017 by the Division of Pulmonology, Tygerberg Hospital, were retrospectively identified. All patients who underwent an US-guided TTNA and of whose clinical records could be retrieved were included in this cohort. The International Myeloma Working Group's definition of a plasmacytoma was used as the gold standard. Results: A total of 12 cases of plasmacytoma were identified and 11 patients included (one patient was excluded owing to missing medical records). Six of the 11 patients (mean age 59.5 ± 8.5 years) were male. Radiologically, most had multiple lesions (n=7), most commonly bony (n=6) with vertebral body involvement (n=5) and pleural-based lesions (n=2). Rapid onsite evaluation (ROSE) was performed and documented in 6 of the 11 cases, and a provisional diagnosis of plasmacytoma was suggested in 5 of the 6 patients (83.3%). The final laboratory cytological diagnoses of all 11 cases were compatible with plasmacytoma which was further confirmed via a bone marrow biopsy (n=4) and by serum electrophoresis (n=7). Conclusion: US-guided fine-needle aspiration is feasible and is useful to confirm a diagnosis of plasmacytoma. Its minimally invasive nature may be the ideal investigation of choice in suspected cases.

Correlation between lung function tests and peak oxygen consumption in post-TB lung disease.

BACKGROUND: After TB treatment, many patients have post-TB lung disease (PTLD), associated with increased mortality and morbidity. Nevertheless, relationships between lung function testing and exercise capacity in people with PTLD are poorly understood.METHODS: This single-centre study investigated the association between lung function testing and peak oxygen consumption (VO2peak) and percentage-predicted VO2peak (VO2peak (%pred)) in adults with PTLD investigated for surgery.RESULTS: Eighty-two patients (52 males, 30 females) with a mean age of 43.2 years (SD 11.3) were included. Spirometric values of forced vital capacity (FVC) percentage predicted (%pred) and forced expiratory volume in 1 sec (FEV1) %pred suggested significant correlations with VO2peak (%pred) (P < 0.001 and P < 0.001), whereas FEV1/FVC did not. Diffusing capacity for carbon monoxide (DLCO) %pred also correlated significantly with VO2peak (%pred) (P = 0.002). However, the magnitude of all significant correlation coefficients were weak. No significant correlations for any plethysmographic values with VO2peak (%pred) could be robustly concluded. Correlations with VO2peak (ml/kg/min) for most physiological variables were less robust than for VO2peak (%pred).CONCLUSIONS: Although statistically significant, the correlations between any measure of lung function and VO2peak or VO2peak (%pred) were weak, with only FVC correlation coefficient surpassing 0.50.

A severity-of-illness score in patients with tuberculosis requiring intensive care.

BACKGROUND: We previously retrospectively validated a 6-point severity-of-illness score aimed at identifying patients at risk of dying of tuberculosis (TB) in the intensive care unit (ICU). Parameters included septic shock, HIV infection with a CD4 count <200 cells/µL, renal dysfunction, a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (P/F) <200 mmHg, a chest radiograph demonstrating diffuse parenchymal infiltrates, and no TB treatment on admission. OBJECTIVES: To prospectively validate the severity-of-illness scoring system in patients with TB requiring intensive care, and to refine and simplify the score in order to expand its clinical utility. METHODS: We performed a prospective observational study with a planned post hoc retrospective analysis, enrolling all adult patients with confirmed TB admitted to the medical ICU of a tertiary hospital in Cape Town, South Africa, from 1 February 2015 to 31 July 2018. The admission data of all adult patients with TB requiring admission to the ICU were used to calculate the 6-point severity-of-illness score and a refined 4-point score (based on the planned post hoc analysis). Descriptive statistics and χ2 or Fisher's exact tests (where indicated) were performed on dichotomous categorical variables, and t-tests on continuous data. Patients were categorised as hospital survivors or non-survivors. RESULTS: Forty-one of 78 patients (52.6%) died. The 6-point scores of non-survivors were higher than those of survivors (mean (standard deviation (SD)) 3.5 (1.3) v. 2.7 (1.2); p=0.01). A score ≥3 v. <3 was associated with increased mortality (64.0% v. 32.1%; odds ratio (OR) 3.75; 95% confidence interval (CI) 1.25 - 10.01; p=0.01). Post hoc, a P/F ratio <200 mmHg and no TB treatment on admission failed to predict mortality, whereas any immunosuppression did. A revised 4-point score (septic shock, any immunosuppression, acute kidney injury and lack of lobar consolidation) demonstrated higher scores in non-survivors than survivors (mean (SD) 2.8 (1.1) v. 1.6 (1.1); p<0.001). A score ≥3 v. ≤2 was associated with increased mortality (78.4% v. 29.3%; OR 8.76; 95% CI 3.12 - 24.59; p<0.001). CONCLUSIONS: The 6-point severity-of-illness score identified patients at increased risk of death. We were able to derive and retrospectively validate a simplified 4-point score with superior predictive power.

Pulmonary manifestations of IgG4­related disease in a South African patient.

Immunoglobin 4-related disease (IgG4-RD) is an auto-immune, multisystem inflammatory disorder characterised by storiform fibrosis, lymphoplasmacytic infiltration and obliterative phlebitis on histology. Its pathophysiology is not well understood, but is thought to occur due to complex interactions between T helper 2 cells, their cytokines, chemokines, and B lymphocytes that become dysregulated and produce dysfunctional immunoglobulins. Here, we present a case report of a 54-year-old man who was initially suspected of having lung cancer on imaging, but was ultimately diagnosed with IgG4-RD on histological analysis of a pneumonectomy specimen. Treatment with glucocorticoids can establish disease remission, with a small proportion of patients relapsing, if the diagnosis is made before significant fibrosis occurs.

Respiratory presentations to acute services at a tertiary hospital in South Africa.

BACKGROUND: Respiratory diseases account for >10% of the global burden of disease when measured in disability-adjusted life-years. The burden of chronic respiratory diseases (CRDs) increases as the world's population ages, with a much greater increase in low- to middle-income countries. OBJECTIVES: To characterise and quantify the reasons for acute respiratory presentations to the acute care services at a tertiary hospital in Cape Town, South Africa. METHODS: A cross-sectional descriptive study was conducted. Casualty registers and electronic record databases were reviewed to determine the diagnoses of consecutive patients attending the casualty unit from May 2019 to January 2020. RESULTS: A total of 1 053 individual patients presented with a primary respiratory diagnosis. Fewer than 10% of admissions were from outside the Cape Town metropole, while >60% were from the subdistrict immediately adjacent to the hospital. Of all patients, 8.3% were readmitted at least once within the 9-month study period. Six hundred and forty-three (61.1%) of the patients presented with non-CRDs. The main reasons for presentation in these patients were pulmonary tuberculosis (PTB) (n=224; 21.3%), other infections including lower respiratory tract infections, pneumonia and bronchitis (n=272; 25.8%), and cancer (n=140; 13.3%). Haemoptysis was seen in 9.8% of all patients, mainly explained by post-tuberculosis lung disease (PTLD) (37.9%) and PTB (36.9%). Of the patients, 410 (38.9%) had an underlying CRD, with chronic pulmonary obstructive disease (COPD) being the most common (n=192; 18.2%), followed by PTLD (n=88; 8.5%) and asthma (n=52; 5.1%). CONCLUSIONS: Over a 9-month period, acute respiratory presentations to a tertiary hospital were mainly for primary/secondary level of care indications, highlighting disparity in accessing tertiary services. COPD and PTLD predominated among CRDs, while infections and cancers were common. A high readmission rate was found for several diseases, suggesting the potential for targeted interventions to prevent both admissions and readmissions and reduce acute hospital utilisation costs.

Comparison of patients with severe COVID-19 admitted to an intensive care unit in South Africa during the first and second wave of the COVID-19 pandemic.

Background: The second wave of coronavirus disease 2019 (COVID-19), dominated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Beta variant, has been reported to be associated with increased severity in South Africa (SA). Objectives: To describe and compare clinical characteristics, management and outcomes of COVID-19 patients admitted to an intensive care unit (ICU) in SA during the first and second waves. Methods: In a prospective, single-centre, descriptive study, we compared all patients with severe COVID-19 admitted to ICU during the first and second waves. The primary outcomes assessed were ICU mortality and ICU length of stay (LOS). Results: In 490 patients with comparable ages and comorbidities, no difference in mortality was demonstrated during the second compared with the first wave (65.9% v. 62.5%, p=0.57). ICU LOS was longer in the second wave (10 v. 6 days, p<0.001). More female admissions (67.1% v. 44.6%, p<0.001) and a greater proportion of patients were managed with invasive mechanical ventilation than with non-invasive respiratory support (39.0% v. 14%, p<0.001) in the second wave. Conclusion: While clinical characteristics were comparable between the two waves, a higher proportion of patients was invasively ventilated and ICU stay was longer in the second. ICU mortality was unchanged.

Factors associated with poor adherence to anti-retroviral therapy in patients attending a rural health centre in South Africa.

South Africa has a very high HIV disease burden and proper patient adherence to anti-retroviral therapy (ART) is crucial in achieving optimal treatment outcomes. Factors influencing adherence include demographic and psychosocial factors, medication-related issues and other patient-related matters. This study was carried out in order to determine factors associated with poor compliance to anti-retroviral (ARV) medications in a rural setting. This interview-based descriptive and analytical study was carried out in a health centre where 168 patients who received ARVs were interviewed with pre-structured questionnaires, which covered various important compliance-related aspects. The results showed that 37.5% of the patients were non-adherent. Amongst men, poor adherence was seen in those who were single (48.9%), with tertiary education (60%), in those who consumed alcohol regularly (47.1%) and in those who were unemployed (56.1%). Higher rates of non-adherence in women was associated with being single (36.5%) and in those who used alcohol (60.7%). Medication-related adverse effects were reported in 47% of patients, notably, neuropathy, headache, nausea, loss of memory, diarrhoea and fatigue. Common reasons for missing doses were: being away from home (57.1%), simply forgot (41.3%), side effects (50.8%) and being too busy (49.2%). Poor adherence to ART is an important concern relating to HIV management in our setting and needs to be addressed with more patient-oriented interventions.

Pulmonary scarring and its relation to primary lung cancer.

BACKGROUND: Lung scar carcinoma, so called 'scarcinoma', is a perceived entity that was originally described by Friedrich in 1939, in which a carcinoma originates from peripheral scarring of lung tissue. In a recent pilot study, there was a strong association between the geographic location of lung cancer and the presence of scarring of the lung. OBJECTIVES: To investigate this relationship in the largest cohort to date. METHODS: We reviewed all radiological images of patients (N=917) with confirmed lung cancer from 2013 - 2017 and included all who had at least a staging computed tomography (CT) of the chest and a tissue diagnosis of primary lung cancer. Two pulmonary specialists categorised all patients as no pulmonary scarring, scarring in the same lobe, scarring in the ipsilateral lung, but not lobe, scarring in the contralateral lung and diffuse scarring both lungs. RESULTS: Almost 1 in 3 patients had pulmonary scarring. In patients with lung cancer, if scarring was present, the pulmonary scarring was more likely to be found in the same lobe as the cancer compared with any other lobe, including the same lung (p<0.0001). CONCLUSION: Pulmonary scarring was common, and there was a strong association between the geographical location of scarring and primary lung cancer in those with scarring.

Thymoma: A case report and update.

Thymomas are slow growing, evolve with metastasis and commonly present as ipsilateral pleural involvement along with the primary tumour of the mediastinum. Early-stage recognition and treatment with surgical resection and postoperative chemoradiotherapy may offer a better 10-year survival rate.

Acinetobacter baumannii infection in a medical intensive care unit: The impact of strict infection control.

BACKGROUND: Acinetobacter baumannii is a waterborne organism that preferentially colonises aquatic environments. Infections usually involve organ systems that have a high fluid content. Multidrug-resistant (MDR) A. baumannii is recognised to be among the most difficult antimicrobial-resistant Gram-negative bacilli to prevent and treat in the nosocomial setting. OBJECTIVES: To determine the utility of concomitant implementation of a strict antimicrobial stewardship programme and comprehensive infection control measures to control MDR A. baumannii in a medical intensive care unit (ICU). METHODS: We retrospectively compared the relative incidence of A. baumannii infections in our unit over a 1-year period before (2012) and after (2016) the implementation of strict infection control bundles. Patients with A. baumannii infections were identified using the microbiology database of the National Health Laboratory Service's central data warehouse. The total number of admissions and clinical data were derived from the ICU registry. RESULTS: A. baumannii was isolated from 43/263 patients (16.35%) in 2012 compared with 37/348 patients in 2016 (10.63%, p=0.03; relative risk reduction=35%). We found almost 100% sensitivity to colistin and tigecycline, but 90% resistance to carbapenem antibiotics. CONCLUSION: The introduction of strict infection control bundles had a statistically significant and clinically meaningful impact on the incidence of nosocomial A. baumannii infection in the medical ICU.

Histologically confirmed tuberculosis-associated obstructive pulmonary disease.

Although chronic airflow limitation (CAL) is an important long-term consequence of tuberculosis (TB), little is known about the disease process. We present what we believe to be the first case of histologically confirmed residual TB-associated obstructive pulmonary disease (TOPD) in a 23-year-old non-smoking man who developed severe CAL after one episode of TB, with no other plausible risk factors. Lung biopsies identified residual post-TB pathology affecting the small airways and vessels throughout his lung; this has not been reported previously. These findings strengthen the argument that TOPD may be a phenotype of CAL distinct from both smoking-related chronic obstructive pulmonary disease and bronchiectasis.

The utility of hand-held mobile spirometer technology in a resource-constrained setting.

BACKGROUND: Mobile phone-linked spirometry technology has been designed specifically for evaluating lung function at primary care level. The Air-Smart Spirometer is the first mobile spirometer accepted in Europe for the screening of patients with chronic respiratory diseases. OBJECTIVES: To prospectively assess the accuracy of the device in measuring forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) in a South African population, and to investigate the ability of the device to detect obstructive ventilatory impairment. METHODS: A total of 200 participants were randomly assigned to perform spirometry with either the mobile spirometer connected to a smartphone or the desktop spirometer first, followed by the other. The FEV1/FVC ratio as well as the absolute FEV1 and FVC measurements were compared, using each participant as their own control. A Pearson correlation and Bland-Altman analysis were performed to measure the agreement between the two devices. We defined obstructive ventilatory impairment as FEV1/FVC <0.7 measured by desktop spirometry in order to calculate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the Air-Smart Spirometer. RESULTS: There was a strong correlation between the absolute FEV1 and FVC values and FEV1/FVC ratio measured with the mobile Air-Smart Spirometer and more conventional pulmonary function testing, with r=0.951, r=0.955 and r=0.898, respectively. The Air-Smart Spirometer had a sensitivity of 97.6%, specificity of 74.4%, PPV of 73.0% and NPV of 97.8% for obstructive ventilatory impairment. CONCLUSIONS: The mobile Air-Smart Spirometer compared well with conventional spirometry, making it an attractive and potentially affordable tool for screening purposes in a primary care setting. Moreover, it had a high sensitivity and NPV for obstructive ventilatory impairment.

Clinical and radiological grading of superior vena cava obstruction.

BACKGROUND: Superior vena cava obstruction (SVCO) is commonly caused by neoplastic venous compression and presents with typical symptoms and signs. Its clinical severity presumably depends on the degree of obstruction and the adequacy of venous collateral formation. OBJECTIVES: The development of novel clinical and radiological scoring systems based on the postulate that a reproducible relationship exists between the degree of SVCO, the presence of collateral circulation and the extent of clinical symptoms. METHODS: We prospectively evaluated consecutive cases of acute and subacute SVCO with a newly developed clinical scoring system, which is based on easily detectable clinical symptoms and signs of SVCO. In parallel, we recorded and scored the degree of SVCO and the extent of collaterals visible on contrast-enhanced computed tomography (CT). RESULTS: Thirty-four cases of SVCO were evaluated: 8 (23.5%) were clinically mild, 16 (47%) moderate and 10 (29.5%) severe. Lung cancer was the underlying histological diagnosis in 94% of cases. Radiologically, 53% had complete SVCO. A well-developed collateral system was found in 14 (41%). A scoring system subtracting a 'collateral score' from an 'obstruction score' showed a significant correlation with the clinical score (r = 0.75, p < 0.01). CONCLUSIONS: Clinical severity of SVCO depends upon the degree of SVCO and is ameliorated by collateral formation. The novel clinical scoring system can predict the underlying CT features in SVCO and may be valuable in the bedside assessment of SVCO severity.

Inhaled corticosteroids in COPD: Personalising the therapeutic choice.

There has been a recent surge in interest in the role of inhaled corticosteroids (ICS) in the treatment of COPD, especially regarding patients with high eosinophil counts. Evidence has shown that despite the increase in localised adverse effects and a small increase in non-fatal pneumonia events with ICS use, ICS still have an important role to play in reducing exacerbation rates and addressing the inflammation that is at the heart of the pathogenesis of COPD. Current international guidelines recommend the use of ICS only in patients with severe disease. This review examines the potential role of ICS in all COPD patients.

A comparison of the functional parameters of operability in patients with post-inflammatory lung disease and those with lung cancer requiring lung resection.

BACKGROUND: It is a common, yet unproven, belief that patients with post-inflammatory lung disease have a better functional reserve than patients with lung cancer when compared with their respective functional parameters of operability - forced expiratory volume in one second (FEV1), maximum oxygen uptake in litres per minute (VO2 max) and the diffusion capacity for carbon monoxide (DLCO). OBJECTIVES: The aim of this study was to compare a group of patients with lung cancer with a group with post-inflammatory lung disease according to their respective functional parameters of operability. We also aimed to investigate any associations of FEV1 and/or DLCO with VO2 max within the two groups. METHODS: We retrospectively included 100 adult patients considered for lung resection. All patients were worked up using a validated algorithm and were then sub-analysed according to their parameters of functional operability. RESULTS: Two-thirds of patients had post-inflammatory lung diseases whilst the rest had lung cancer. The majority of the patients in the lung cancer group had coexistent chronic obstructive pulmonary disease (COPD) (n=18). Most (n=47) of the patients in the post-inflammatory group were diagnosed with a form of pulmonary TB (active or previous). Among the two groups, the lung cancer group had a higher median %FEV1 value (62.0%; interquartile range (IQR) 51.0 - 76.0) compared with the post-inflammatory group (52%; IQR 42.0 - 63.0; p=0.01). There was no difference for the %DLCO and %VO2 max values. The lung cancer group also had higher predicted postoperative (ppo) values for %FEV1 (41.0%; IQR 31.0 - 58.0 v. 34.0%; IQR 23.0 - 46.0; p=0.03, respectively) and %VO2 max (58.0%; IQR 44.0 - 68.0 v. 46.0%; IQR 35.0 - 60.0; p=0.02). There was no difference in the %DLCO ppo values between the groups. CONCLUSION: Patients with lung cancer had higher percentage values for FEV1 and ppo parameters for %FEV1 and %VO2 max compared with those who had post-inflammatory lung disease. Our findings suggest that lung cancer patients have a better functional reserve.

Complete resolution of apparently definite radiological and histological usual interstitial pneumonia.

Idiopathic pulmonary fibrosis is considered to be the most common form of pulmonary fibrosis. It is a progressive and irreversible disease with a reported median survival of ~3 years. The pathological correlate is usual interstitial pneumonia (UIP), and although antifibrotic agents can slow down lung function decline, they do not completely reverse the disease process. To date, there have been no case reports describing reversal of UIP. We present a case where both the imaging and histology were compatible with definite UIP, yet it reversed with immunosuppressive therapy without the use of antifibrotic agents.