Pulmonary scar carcinoma in South Africa

Background. The association between lung scarring and the subsequent development of cancer remains controversial. South Africa has one of the highest incidences of tuberculosis in the world, and resultant scarring may predispose to malignancy. The country also carries a very high burden of smoking and smoking-related diseases that may be synergistic in malignant transformation.Objective. To assess the frequency of pulmonary scarring in patients with lung cancer.Methods. All patients with confirmed lung cancer and a staging computed tomography (CT) scan of the chest were included in this 2-year retrospective study. Pulmonary scarring was categorised according to location as present in: (i) the same lobe as the primary tumour, (ii) a different lobe of the same lung, or (iii) the contralateral lung; or (iv) as diffuse. Post-obstructive bronchiectasis and other changes secondary to cancer were considered not to represent scarring.Results. We identified 435 cases of primary lung cancer. In total, 95 patients (21.8%) had CT evidence of pulmonary scarring. Eighty-three of 85 patients (97.6%) had focal scarring in the same lobe as the primary tumour. Of these, 37 (43.5%) also had scarring involving a different lobe of the same lung, whereas only one (1.2%; p<0.001) had scarring isolated to a different lobe of the same lung. Moreover, 21 patients (24.7%) also had scarring of the opposite lung, but only one patient (1.2%; p<0.001) had scarring isolated to the contralateral lung. Ten patients had diffuse scarring, caused by bronchiectasis (n=5), idiopathic pulmonary fibrosis (n=4) and silicosis (n=1).Conclusion. At least one in five patients with lung cancer had scarring, which was significantly more likely to be present in the same lobe as the tumour, suggesting a predisposition to malignancy

Predictors of treatment success in smoking cessation with varenicline combined with nicotine replacement therapy v. varenicline alone

Background. Identification of the predictors of treatment success in smoking cessation may help healthcare workers to improve the effectiveness of attempts at quitting.Objective. To identify the predictors of success in a randomised controlled trial comparing varenicline alone or in combination with nicotine replacement therapy (NRT).Methods. A post-hoc analysis of the data of 435 subjects who participated in a 24-week, multicentre trial in South Africa was performed. Logistic regression was used to analyse the effect of age, sex, age at smoking initiation, daily cigarette consumption, nicotine  dependence, and reinforcement assessment on abstinence rates at 12 and 24 weeks. Point prevalence and continuous abstinence rates were self-reported and confirmed biochemically with exhaled carbon monoxide readings.Results. The significant predictors of continuous abstinence at 12 and 24 weeks on multivariate analysis were lower daily cigarette consumption (odds ratio (OR) 1.86, 95% confidence interval (CI) 1.21 - 2.87, p=0.005 and OR 1.83, 95% CI 1.12 - 2.98, p=0.02, respectively) and older age (OR 1.52, 95% CI 1.00 - 2.31, p=0.049 and OR 1.79, 95% CI 1.13 - 2.84, p=0.01, respectively). There was no difference in the predictors of success in the univariate analysis, except that older age predicted point prevalence abstinence at 12 weeks (OR 1.47, 95% CI 1.00 - 2.15, p=0.049). The findings were inconclusive for an association between abstinence and lower nicotine dependence, older age at smokinginitiation and positive reinforcement.Conclusion. Older age and lower daily cigarette consumption are associated with a higher likelihood of abstinence in patients using varenicline, regardless of the addition of NRT

An Endotracheal Plasmablastic Lymphoma

We describe an exceptionally rare case of a male patient with newly diagnosed advanced human immunodeficiency virus (HIV) infection, who presented with a plasmablastic lymphoma involving the right maxillary alveolar ridge with associated cervical lymphadenopathy. On a staging positron emission tomography computed tomography (PET-CT) scan, he was incidentally found to have an endotracheal tumour involving the anterolateral aspect of the mid-trachea. The tumour appeared to be well-vascularised at bronchoscopy and was confirmed as well-differentiated plasmablastic lymphoma. Plasmablastic lymphoma is a rare form of non-Hodgkin lymphoma and is associated with HIV. Tracheal involvement to the extent seen in our patient is exceptionally rare, and, to the best of our knowledge, has never been described

Parapneumonic pleural effusion and empyema

At least 40% of all patients with pneumonia will have an associated pleural effusion, although a minority will require an intervention for a complicated parapneumonic effusion or empyema. All patients require medical management with antibiotics. Empyema and large or loculated effusions need to be formally drained, as well as parapneumonic effusions with a pH <7.20, glucose <3.4 mmol/l (60 mg/dl) or positive microbial stain and/or culture. Drainage is most frequently achieved with tube thoracostomy. The use of fibrinolytics remains controversial, although evidence suggests a role for the early use in complicated, loculated parapneumonic effusions and empyema, particularly in poor surgical candidates and in centres with inadequate surgical facilities. Early thoracoscopy is an alternative to thrombolytics, although its role is even less well defined than fibrinolytics. Local expertise and availability are likely to dictate the initial choice between tube thoracostomy (with or without fibrinolytics) and thoracoscopy. Open surgical intervention is sometimes required to control pleural sepsis or to restore chest mechanics. This review gives an overview of parapneumonic effusion and empyema, focusing on recent developments and controversies. Copyright © 2008 S. Karger AG.Revie

Transthoracic ultrasound for chest wall, pleura, and the peripheral lung

Thoracic ultrasonography can be performed by means of the most basic ultrasound (US) equipment. In healthy individuals, US can visualize the chest wall, the diaphragm and the pleura but not the lung parenchyma. The main domain of thoracic US is the investigation of chest wall abnormalities, pleural thickening and pleural tumours, and the qualitative and quantitative description of pleural effusions. US can visualize lung tumours, pulmonary consolidations and other parenchymal pulmonary processes provided they abut the pleura. US is the ideal tool to assist with thoracentesis and drainage of effusions. US-assisted fine needle aspiration and cutting needle biopsy of lesions arising from the chest wall, pleura and peripheral lung are safe and have a high yield in the hands of chest physicians. US may also guide aspiration and biopsy of diffuse pulmonary infiltrates, consolidations and lung abscesses, provided the pleura is abutted. Advanced applications of transthoracic US include the diagnosis of a pneumothorax and pulmonary embolism. Copyright © 2009 S. Karger AG, Basel.Articl

A patient with leonine facies and occult lung disease

[No abstract available]Articl

An unusual cause of hoarseness

[No abstract available]Articl

Transthoracic Ultrasonography for the Respiratory Physician.

Transthoracic ultrasonography is still not utilized to its full potential by respiratory physicians, despite being a well-established and validated imaging modality. It allows for an immediate and mobile assessment that can potentially augment the physical examination of the chest. Ultrasound (US)-assisted procedures can be performed by a single clinician with no sedation and with minimal monitoring, even outside of theatre. The main indications for the use of transthoracic US are: the qualitative and quantitative description of pleu-ral effusions, pleural thickening, diaphragmatic dysfunction and chest-wall and pleural tumours. It may also be used to visualise lung tumours and other parenchymal pulmonary processes provided they abut the pleura. It is at least as sensitive as chest radiographs as far as the detection of a pneumothorax is concerned. It is the ideal tool to assist with thoracocentesis and drainage of effusions. The US-assisted fine-needle aspiration and/or cutting-needle biopsy of extrathoracic lymph nodes, lesions arising from the chest wall, pleura, peripheral lung and mediastinum, are safe and have a high yield in the hands of chest physicians. US may also guide the aspiration and biopsy of diffuse pulmonary infiltrates, consolidations and lung abscesses, provided the chest wall is abutted. Advanced applications of transthoracic US include the diagnosis of pulmonary embolism. Copyright © 2012 S. Karger AG, Basel

Stair climbing in the functional assessment of lung resection candidates

Background: Algorithms for the pre-operative evaluation of lung resection candidates with impaired lung function invariably include maximum oxygen uptake (VO2MAX) as a critical parameter of functional reserves, with a VO2MAX ≥20 ml/kg/min generally considered sufficient for pneumonectomy. Stair climbing is a low-cost alternative to assess exercise capacity. Objectives: As stair climbing is not standardised, we aimed to compare the altitude reached and the speed of ascent with VO2MAX measured by cycle ergometry. Methods: We prospectively enrolled 44 pulmonary resection candidates (mean age: 47.6 ± 12.5 years) with an FEV1 &lt;80%. Patients were asked to climb as high and as fast as they could, to a maximum elevation of 20 m. The altitude reached and the average speed of ascent were compared to VO2MAX. Results: Forty-three patients reached a 20-metre elevation. Thirteen of them, as well as the patient who did not reach this height, had a VO2MAX &lt;20 ml/kg/min. There was a linear correlation between speed of ascent and VO2MAX/kg (R2 = 0.67), but not between altitude and VO2MAX/kg. All 24 patients with a speed ≥15 m/min had a VO2MAX ≥20 ml/kg/min. Thirty-nine of 40 patients with a speed ≥12 m/min had a VO2MAX ≥15 ml/kg/min. Conclusions: The average speed of ascent during stair climbing was an accurate semiquantitative predictor of VO2MAX/kg, whereas altitude was not. We were able to identify potential cut-off values for lobectomy or pneumonectomy. Pending validation with clinical endpoints, stair climbing may replace formal exercise testing at much lower costs in a large proportion of lung resection candidates. Copyright © 2008 S. Karger AG.Articl