Diffusion Capacity Of Lung For Carbon Monoxide Research Articles

Long-term sequelae are highly prevalent one year after hospitalization for severe COVID-19

Many coronavirus disease 2019 (Covid-19) survivors show symptoms months after acute illness. The aim of this work is to describe the clinical evolution of Covid-19, one year after discharge. We performed a prospective cohort study on 238 patients previously hospitalized for Covid-19 pneumonia in 2020 who already underwent clinical follow-up 4 months post-Covid-19. 200 consented to participate to a 12-months clinical assessment, including: pulmonary function tests with diffusing lung capacity for carbon monoxide (DLCO); post-traumatic stress (PTS) symptoms evaluation by the Impact of Event Scale (IES); motor function evaluation (by Short Physical Performance Battery and 2 min walking test); chest Computed Tomography (CT). After 366 [363–369] days, 79 patients (39.5%) reported at least one symptom. A DLCO < 80% was observed in 96 patients (49.0%). Severe DLCO impairment (< 60%) was reported in 20 patients (10.2%), related to extent of CT scan abnormalities. Some degree of motor impairment was observed in 25.8% of subjects. 37/200 patients (18.5%) showed moderate-to-severe PTS symptoms. In the time elapsed from 4 to 12 months after hospital discharge, motor function improves, while respiratory function does not, being accompanied by evidence of lung structural damage. Symptoms remain highly prevalent one year after acute illness.

Chemotherapy-Associated Pulmonary Toxicity—Case Series from a Single Center

Background Pulmonary toxicity due to chemotherapeutic agents can occur with many established and new drugs. Strong clinical suspicion is important as the clinical presentation is usually with nonspecific symptoms like cough, dyspnea, fever, and pulmonary infiltrates. Timely discontinuation of the offending agent alone can improve the condition. Methods A prospective observational study on patients receiving chemotherapy at an 800-bedded tertiary care hospital was performed from 2014 to 2016. Consecutive patients on chemotherapy, presenting with nonresolving respiratory symptoms were evaluated with contrast-enhanced computerized tomography of chest, diffusion lung capacity for carbon monoxide (DLCO), fiberoptic bronchoscopy with lavage, and biopsy, after excluding all causes for pulmonary infections. Descriptive data has been depicted. Results A total of 18 patients were evaluated for persistent symptoms of dry cough, dyspnea, and fever among 624 who received chemotherapy during the study period. Ground-glass opacities on high-resolution CT was the most common imaging finding, others being patchy subpleural consolidation and pleural effusion. Lymphocyte-predominant bronchoalveolar lavage was detected in nine. Eight of the 15 patients who underwent DLCO, had abnormal results. Seven had significant histopathological findings on bronchoscopic lung biopsy, which revealed organizing pneumonia as the most common pattern. Paclitaxel, fluorouracil, gemcitabine, and tyrosine kinase inhibitors were the common culprit drugs. Discontinuation alone of the culprit drug was effective in 15 and 3 needed oral corticosteroids for relief of symptoms. None of the patients died due to the toxicity. Conclusion An incidence of 2.8% for chemotherapy-induced lung injury was seen in our observational study of 3 years, with parenchymal, interstitial, and pleural involvement due to various chemotherapeutic agents. Oral steroids maybe required in a subset of patients not responding to discontinuation of the culprit agent.

Preliminary Study: Immediate Effect of the Slow Deep Breathing Exercise and Sustained Maximal Inspiration with Volume-Oriented Incentive Spirometry on the Diffusing Lung Capacity in Healthy Young Participants

Slow-deep breathing exercise (SDBE) while using a volume-oriented type of incentive spirometry (VIS) device (SDBE/VIS) is one of the techniques in chest physical therapy designed to improve lung volume and oxygenation. However, the immediate effect of SDBE/VIS paired with a sustained maximal inspiration (SMI) on diffusing lung capacity (DLC), has not been documented. This preliminary study aimed to evaluate the immediate effect of SDBE/VIS paired with the SMI technique on DLC in healthy participants. Twenty healthy sedentary adults (11 males and 9 females) aged 20 to 23 years were recruited into this cross-over study and randomly assigned to one of 2 ordered groups; SDBE/VIS paired with SMI followed by SDBE/VIS alone or SDBE/VIS alone followed by SDBE/VIS with SMI. During each of the 2-testing sessions, the participants performed 3 sets of 5 SDBE/VIS trials which were controlled by ensuring that each participant reached their maximal vital capacity; derived from their pulmonary function test. The DLC for carbon monoxide (DLCO), alveolar volume (VA), and total lung capacity (TLC) was assessed prior to (baseline) and after each of the 5 experimental trials. A 3-min rest period was given between each set of 5 trials and 1 week between testing sessions.&#x0D; The results demonstrated that SDBE/VIS paired with the SMI technique significantly increased both the DLCO (mL/min/mmHg and %) and VA (L and %) when compared to the baseline values. Whereas, SDBE/VIS without using the SMI technique did not alter the DLCO, VA or the DLCO/VA. However, both SDBE/VIS with and without the SMI technique showed a significant increase the TLC (L and %), with the TLC from SDBE/VIS paired with SMI was significantly higher than when the SDBE /VIS was performed without using the SMI technique. Thus, it appears that performing SDBE/VIS exercised paired with the SMI technique has a significant and positive effect on DLC.

Pulmonary function in cured pulmonary tuberculosis cases

BackgroundIn clinical practice it has been observed that several patients of cured pulmonary tuberculosis (PTB) suffer with lung dysfunction and these problems are less documented routinely. Prevalence of these abnormalities remains unknown. Aim of this study is to estimate the lung function abnormality and exercise capacity including diffusion capacity of lung for carbon monoxide (DLCO) in cured PTB cases. MethodsA hospital based observational descriptive study was carried out among 100 patients with PTB, who had been declared cured. These patients were evaluated by spirometry and DLCO to assess their lung function and were classified as normal or abnormal. Modified medical research council (mMRC) dyspnea scale for symptom assessment and 6-minute walk test (6MWT) to determine the exercise capacity was also done. Borg's scale was used for dyspnea assessment in 6MWT. Results83 (83%) patients having abnormal spirometry, 17 (17%) had obstructive pattern, 32 (32%) had restrictive pattern and 34 (34%) had mixed pattern. 22 (22%) patients had mild decrease in DLCO, 43 (43%) patients had moderate decrease in DLCO, while only 4 (4%) had severe decrease in DLCO. More than half of the patients having normal spirometry had reduced in DLCO. ConclusionThe prevalence of abnormal lung functions is high even after complete anti-tubercular treatment. DLCO could be a better tool for evaluation of lung function in these patients. There is need to strengthen the National Programme to detect and treat TB patient earlier, also there is need to formulate guidelines for pulmonary rehabilitation of cured PTB patient.

COVID-19: persistence of symptoms and lung alterations after 3-6months from hospital discharge.

PurposeFew data are currently available on persistent symptoms and late organ damage in patients who have suffered from COVID-19. This prospective study aimed to evaluate the results of a follow-up program for patients discharged from a nonintensive COVID-19 ward.Methods3–6 months after hospital discharge, 59 of 105 COVID-19 patients (31 males, aged 68.2 ± 12.8 years) were recruited in the study. Forty-six patients were excluded because of nontraceability, refusal, or inability to provide informed consent. The follow-up consisted of anamnesis (including a structured questionnaire), physical examination, blood tests, ECG, lower limb compression venous ultrasound (US), thoracic US, and spirometry with diffusion lung capacity for carbon monoxide (DLCO).Results22% of patients reported no residual symptoms, 28.8% 1 or 2 symptoms and 49.2% 3 or more symptoms. The most frequently symptoms were fatigue, exertional dyspnea, insomnia, and anxiety. Among the inflammatory and coagulation parameters, only the median value of fibrinogen was slightly above normal. A deep vein thrombosis was detected in 1 patient (1.7%). Thoracic US detected mild pulmonary changes in 15 patients (25.4%), 10 of which reported exertional dyspnea. DLCO was mildly or moderately reduced in 19 patients (37.2%), 13 of which complained of exertional dyspnea.ConclusionThese results highlight that a substantial percentage of COVID-19 patients (77.8%) continue to complain of symptoms 3–6 months after hospital discharge. Exertional dyspnea was significantly associated with the persistence of lung US abnormalities and diffusing capacity alterations. Extended follow-up is required to assess the long-term evolution of postacute sequelae of COVID-19.

Stable to improved cardiac and pulmonary function in children with high-risk sickle cell disease following haploidentical stem cell transplantation.

Children with sickle cell disease (SCD) are at high-risk of progressive, chronic pulmonary and cardiac dysfunction. In this prospective multicenter Phase II trial of myeloimmunoablative conditioning followed by haploidentical stem cell transplantation in children with high-risk SCD, 19 patients, 2.0-21.0 years of age, were enrolled with one or more of the following: history of (1) overt stroke; (2) silent stroke; (3) elevated transcranial Doppler velocity; (4) multiple vaso-occlusive crises; and/or (5) two or more acute chest syndromes and received haploidentical transplants from 18 parental donors. Cardiac and pulmonary centralized cores were established. Pulmonary function results were expressed as percent of the median of healthy reference cohorts, matched for age, sex, height and race. At 2 years, pulmonary functions including forced expiratory volume (FEV), FEV1/ forced vital capacity (FVC), total lung capacity (TLC), diffusing capacity of lung for carbon monoxide (DLCO) were stable to improved compared to baseline values. Importantly, specific airway conductance was significantly improved at 2 years (p < 0.004). Left ventricular systolic function (fractional shortening) and tricuspid regurgitant velocity were stable at 2 years. These results demonstrate that haploidentical stem cell transplantation can stabilize or improve cardiopulmonary function in patients with SCD.

A new ventilatory efficiency index and accuracy for early lung diffusion impairment in non-COPD smokers

In smokers without manifest airway obstruction, early emphysema and endothelial dysfunction has been related to minute-ventilation/carbon dioxide output ratio (V′E/V′CO2). Thus, smokers with reduced lung carbon monoxide diffusion capacity (DLco) have a heightened V′E/V′CO2 ratio. We hypothesized that ventilatory inefficiency could contribute to the suspicion of impaired diffusive capacity in the absence of significant airway obstruction. Thus, 15 smokers with impaired DLco were compared to 15 smokers with normal DLco. Accuracy through sensibility and specificity for V′E/V′CO2 slope and nadir was compared with a new index for ventilatory efficiency (ηV′E,%), to uncover early diffusive changes in smokers without COPD.

Different Faces of Idiopathic Pulmonary Fibrosis With Preserved Forced Vital Capacity

IntroductionIdiopathic pulmonary fibrosis (IPF) is progressive and irreversible. Some discrepancies about IPF staging exists, especially in mild phases. Forced vital capacity (FVC) higher than 80% has been considered early or mild IPF even for the design of clinical trials. MethodsSpanish multicentre, observational, retrospective study of IPF patients diagnosed between 2012 and 2016, based on the ATS/ERS criteria, which presented FVC greater or equal 80% at diagnosis. Clinical and demographic characteristics, lung function, radiological pattern, treatment, and follow-up were analyzed. Results225 IPF patients were included, 72.9% were men. The mean age was 69.5 years. The predominant high-resolution computed tomography (HRCT) pattern was consistent usual interstitial pneumonia (UIP) (51.6%). 84.7% of patients presented respiratory symptoms (exertional dyspnea and/or cough) and 33.33% showed oxygen desaturation below 90% in the 6min walking test (6MWT). Anti-fibrotic treatment was initiated at diagnosis in 55.11% of patients. Median FVC was 89.6% (IQR 17) and 58.7% of patients had a decrease of diffusion lung capacity for carbon monoxide (DLCO) below 60% of theoretical value; most of them presented functional progression (61.4%) and higher mortality at 3 years (20.45%). A statistically significant correlation with the 3-years mortality was observed between DLCO <60% and consistent UIP radiological pattern. ConclusionsPatients with preserved FVC but presenting UIP radiological pattern and moderate–severe DLCO decrease at diagnosis associate an increased risk of progression, death or lung transplantation. Therefore, in these cases, preserved FVC would not be representative of early or mild IPF.

Morbidity and mortality of lung resection candidates defined by the American College of Chest Physicians as 'moderate risk': an analysis from the European Society of Thoracic Surgeons database.

The American College of Chest Physicians functional guidelines classify patients with predicted postoperative forced expiratory volume in 1 s or predicted postoperative carbon monoxide lung diffusion capacity <60% and with maximal oxygen consumption (VO2max) between 10 and 20 ml/kg/min in a heterogeneous category broadly defined as 'moderate risk' with variable morbidity and mortality. Data to support this statement are lacking. Using the European Society of Thoracic Surgeons database, our goal was to test this definition by evaluating the morbidity and mortality of those patients falling into this class. All patients who had anatomical lung resection for lung cancer (2007-2019) and were deemed of moderate risk were identified in the European Society of Thoracic Surgeons database. Cardiopulmonary morbidity and 30-day mortality of these patients were assessed by the type of operation. A total 2016 patients were identified. The incidence of cardiopulmonary complications in this group was 21% after lobectomy (294/1435), 29% after bilobectomy (33/112), 22% after pneumonectomy (72/333) and 16% after segmentectomy (22/136) (analysis of variance P = 0.07). The 30-day mortality was 3.4% after lobectomy (49/1435), 8.9% after bilobectomy (10/112), 7.8% after pneumonectomy (26/333) and 3.7% after segmentectomy (5/136) (analysis of variance P = 0.0005). The 30-day mortality rate was 1.6-fold higher in patients with a VO2max between 10 and 15 ml/kg/min compared to those with a higher VO2max [49/861 (5.7%) vs 41/1155 (3.5%); P = 0.022]. For operations that were less extensive than a pneumonectomy and were performed by minimally invasive surgery, there was no difference in mortality between patients with a VO2max between 10 and 15 ml/kg/min and those with a higher VO2max [7/181 (3.8%) vs 11/272 (4.0%); P = 0.92]. On the other hand, after open surgery, the mortality of patients with a lower VO2max (10-15 ml/kg/min) was higher than that of those with a higher VO2max [26/501 (5.1%) vs 20/721 (2.8%); P = 0.034]. Linear regression adjusting for the extent and access of the operation confirmed that within the moderate-risk group a VO2max <15 ml/kg/min was associated with higher mortality (P = 0.028; odds ratio 1.61; 95% confidence interval 1.1-2.5). Morbidity and mortality rates found in this study are not negligible and reinforce the recommendation to ensure careful patient discussion and informed decision-making prior to lung cancer resection surgery.

Associations of Pretreatment Physical Status Parameters with Tolerance of Concurrent Chemoradiation and Survival in Patients with Non-small Cell Lung Cancer.

The aim of this study was to evaluate associations between pretreatment physical status parameters and tolerance of concurrent chemoradiation (cCHRT) and survival among patients with stage III non-small cell lung cancer (NSCLC). A retrospective cohort study was conducted among patients with stage III NSCLC who had received cCHRT between 2006 and 2015. Multivariate independent associations were analysed between the pretreatment parameters age, Charlson comorbidity index, World Health Organization performance status (WHO performance status), body mass index (BMI), fat-free mass index (FFMI), maximal handgrip strength, forced expiratory volume in one second and carbon monoxide lung diffusion capacity on the one hand with tolerance of cCHRT (defined as a received radiation dose at least equal to the prescribed radiation dose) and survival on the other hand. 527 of 577 patients (91.3%) tolerated cCHRT. A WHO performance status ≥ 2 (odds ratio (OR) 0.43) and BMI < 18.5kg/m2 (OR 0.36) were associated with poorer tolerance of cCHRT. In the total group, a WHO performance status ≥ 2 (hazard ratio (HR) 1.73), low FFMI (HR 1.23) and intolerance of cCHRT (HR 1.55) were associated with poorer survival. In patients with stage III NSCLC receiving cCHRT, poor WHO performance status and BMI < 18.5kg/m2 were independently associated with tolerance of cCHRT. Physical status parameters and intolerance of cCHRT were independently associated with poorer survival. Besides using this information for treatment decisions, optimizing physical status in patients at risk for intolerance of cCHRT might be a next step for improving treatment outcomes.

Long COVID Syndrome Following Infection with SARS-CoV-2- A Devastating Influence on Health Status in Some Affected Individuals

Almost a year since the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) began causing COVID-19, our knowledge about its manifestations continues to expand. As more people become fatally ill with COVID-19, it is now clear that many patients who developed a mild illness, recovered from a serious illness, or had an asymptomatic infection are also beginning to suffer from a newly described entity called Long COVID. Studies show that show COVID-19 influences the cardiovascular framework, yet the general effects stay obscured. Impaired diffusion capacity, lower respiratory muscle strength, and lung imaging abnormalities are seen in COVID-19 patients in the early recovery stage. As compared to non-severe cases, severe patients had a higher incidence of Diffusion capacity of lung for carbon monoxide (DLCO) impairment and are more prone to total lung capacity decrease and 6-Minute Walk Test (6MWT) decline. The degree and seriousness of long-term well-being outcomes remain unclear, yet increasing information points in the direction of poorer physiological outcomes. Long-term sequelae of COVID-19 will have enduring implications on those afflicted’s physical, mental, and social health while having a substantial monetary impact on society.

Mortality prediction in chronic interstitial lung diseases (ILDs): ILD-GAP (gender age physiology) and (the new modified classification) TNMC-ILD-GAP

Abstract Introduction: The interstitial lung disease-gender age physiology (ILD-GAP) model has been proposed on the lines of GAP-idiopathic pulmonary fibrosis (IPF) to predict mortality in chronic ILDs, other than IPF. We replaced diffusion capacity of lung for carbon monoxide (DLCO) with the easy to perform 6-minute walk distance (6 MWD) in the ILD-GAP and proposed the new modified classification (TNMC)-ILD-GAP model. Our aim was to demonstrate the usefulness of the TNMC-ILD-GAP as a predictor of mortality in all chronic ILDs and compare the results with the ILD-GAP. Methods: It was a retrospective observational study conducted at a tertiary care centre. Baseline characteristics of the patients among different ILD groups were analysed. A 3-year follow-up was recorded. The results were compared with the original ILDGAP model. Chi-square and paired t-test was used for comparison of qualitative and quantitative data, respectively. Results: Mean ages were 62.34 (±9.85), 57.9 (±11.6), 46.1 (±14.6) and 55.5 (±14.7) in IPF, non-specific interstitial pneumonitis (NSIP), connective tissue disease (CTD) and unclassifiable groups, respectively. There were 50%, 18%, 26% and 55% males in the four categories respectively. Mean 6 MWD was 227 m, 302 m, 342 m, and 332 m. Mean PaO2 was 64 mmHg, 70 mmHg, 75 mmHg, 69 mmHg. Mean forced vital capacity (FVC) (percentage predicted) was 52, 49, 51 and 54. Most of the patients had comorbidities, among which pulmonary hypertension was the most common. Mortality with ILD-GAP model and TNMC-ILD-GAP showed concordant results as the difference in mortality predicted by ILD-GAP and the TNMC-ILD-GAP models was statistically insignificant (P &gt; 0.050). Conclusion: 6 MWD can serve as a reliable replacement for DLCO in the ILD-GAP model, especially in resource limited settings.

Effects of left ventricular assist device on pulmonary functions and pulmonary hemodynamics: A meta-analysis. waqasullah.dr@gmail.com.

BACKGROUNDGiven current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.AIMTo better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.METHODSElectronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.RESULTSA total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23 L (95%CI: 0.11-0.34, P = 00002), 0.18 L (95%CI: 0.03-0.34, P = 0.02), and 3.16 mmol/min (95%CI: 2.17-4.14, P < 0.00001), respectively. The net post-LVAD mean value of the cardiac index was significantly higher by 0.49 L/min/m2 (95%CI: 0.31-0.66, P < 0.00001) compared to pre-LVAD value. The pulmonary capillary wedge pressure and pulmonary vascular resistance were significantly reduced after LVAD implantation by 8.56 mmHg (95%CI: 3.78-13.35, P = 0.0004), and 0.83 Woods U (95%CI: 0.11-1.55, P = 0.02), respectively. There was no significant difference observed in the right atrial pressure after LVAD implantation (0.61 mmHg, 95%CI: -2.00 to 3.32, P = 0.65). Overall findings appear to be driven by studies using HeartMateII devices.CONCLUSIONLVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.

Severity of radiation pneumonitis, from clinical, dosimetric and biological features: a pilot study

Background and objectiveRadiation pneumonitis (RP) could be a lethal complication of lung cancer treatment. No reliable predictors of RP severity have been recognized. This prospective pilot study was performed to identify early predictors of high grade lung toxicity and to evaluate clinical, biological or dosimetric features associated with different grades of toxicity.MethodSixteen patients with non-small cell lung cancer with indication of concurrent chemoradiotherapy using 60 Gy/2 Gy/fraction starting at cycle one of platinum based chemotherapy were included. Bronchoalveolar lavage (BAL), pulmonary function testing (PFT), and 18F-2-fluoro-2-deoxy-D-glucose positron-emission tomography was performed before radiotherapy (RT), after three weeks of treatment, and two months post-RT. For analysis, patients were grouped by grade (low [G1-G2] vs. high [G3-G5]). The two groups were compared to identify predictors of RP. Protein expression BAL and lung tissue metabolism was evaluated in two patients (RP-G1 vs. RP-G3). Categorical variables such as comorbidities, stages and locations were summarized as percentages. Radiation doses, pulmonary function values and time to RP were summarized by medians with ranges or as means with standard deviation. Longitudinal analysis PFT was performed by a T-test.ResultsAll 16 patients developed RP, as follows: G1 (5 pts; 31.3%); G2 (5 pts; 31.3%); G3 (5 pts; 31.3%); and G5 (1 pts; 6.1%). Patients with high grade RP presented significant decrease (p = 0.02) in diffusing lung capacity for carbon monoxide (DLCO) after three weeks of RT. No correlation between dosimetric values and RP grades was observed. BAL analysis of the selected patients showed that CXCL-1, CD154, IL-1ra, IL-23, MIF, PAI-1 and IFN-γ were overexpressed in the lungs of the RP-G3 patient, even before treatment. The pre-RT SUVmax value in the RP-G3 patient was non-significantly higher than in the patient with RP-G1.ConclusionsRT induces some degree of RP. Our data suggest that decrease in DLCO% is the most sensitive parameter for the early detection of RP. Moreover, we detect biological differences between the two grades of pneumonitis, highlighting the potential value of some cytokines as a prognostic marker for developing high grade lung toxicity. Further multicenter studies with larger sample size are essential to validate these findings.

Abatacept in interstitial lung disease associated with rheumatoid arthritis: national multicenter study of 263 patients.

To assess the efficacy of abatacept (ABA) in RA patients with interstitial lung disease (ILD) (RA-ILD). This was an observational, multicentre study of RA-ILD patients treated with at least one dose of ABA. ILD was diagnosed by high-resolution CT (HRCT). We analysed the following variables at baseline (ABA initiation), 12 months and at the end of the follow-up: Modified Medical Research Council (MMRC) scale (1-point change), forced vital capacity (FVC) or diffusion lung capacity for carbon monoxide (DLCO) (improvement or worsening ≥10%), HRCT, DAS on 28 joints evaluated using the ESR (DAS28ESR) and CS-sparing effect. We studied 263 RA-ILD patients [150 women/113 men; mean (s.d.) age 64.6 (10) years]. At baseline, they had a median duration of ILD of 1 (interquartile range 0.25-3.44) years, moderate or severe degree of dyspnoea (MMRC grade 2, 3 or 4) (40.3%), FVC (% of the predicted) mean (s.d.) 85.9 (21.8)%, DLCO (% of the predicted) 65.7 (18.3) and DAS28ESR 4.5 (1.5). The ILD patterns were: usual interstitial pneumonia (UIP) (40.3%), non-specific interstitial pneumonia (NSIP) (31.9%) and others (27.8%). ABA was prescribed at standard dose, i.v. (25.5%) or s.c. (74.5%). After a median follow-up of 12 (6-36) months the following variables did not show worsening: dyspnoea (MMRC) (91.9%); FVC (87.7%); DLCO (90.6%); and chest HRCT (76.6%). A significant improvement of DAS28ESR from 4.5 (1.5) to 3.1 (1.3) at the end of follow-up (P < 0.001) and a CS-sparing effect from a median 7.5 (5-10) to 5 (2.5-7.5) mg/day at the end of follow-up (P < 0.001) was also observed. ABA was withdrawn in 62 (23.6%) patients due to adverse events (n = 30), articular inefficacy (n = 27), ILD worsening (n = 3) and other causes (n = 2). ABA may be an effective and safe treatment for patients with RA-ILD.

Poor preoperative quality of life predicts prolonged hospital stay after VATS lobectomy for lung cancer.

The aim of this study was to assess whether quality of life (QoL) scales are associated with postoperative length of stay (LoS) following video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer. This is a single-centre retrospective analysis on 250 consecutive patients submitted to VATS lobectomies (233) or segmentectomies (17) over a period of 3 years. QoL was assessed in all patients by the self-administration of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 questionnaire. The individual QoL scales were tested for possible association with LoS along with other objective baseline and surgical parameters using univariable and multivariable analyses. Thirty-day cardiopulmonary and mortality rates were 22% and 2.4%. The median LoS was 4 days [interquartile range (IQR) 3-7]. Fifty-one (20%) patients remained in hospital longer than 7 days after surgery (upper quartile). General health [global health score (GHS)] (P = 0.019), physical function (P = 0.014) and role functioning (P = 0.016) scales were significantly worse in patients with prolonged stay. They were highly correlated between each other and tested separately in different logistic regression analyses. The best model resulted the one containing GHS (P = 0.032) along with age, low force expiratory volume in 1 s and carbon monoxide lung diffusion capacity and history of cerebrovascular disease. Fifty-nine patients had GHS <58 (lower interquartile value). Thirty-one percent of them experienced prolonged hospital stay (vs 17% of those with higher GHS, P = 0.027). Preoperative patient-reported QoL was associated with prolonged postoperative hospital stay. Baseline QoL status should be taken into consideration to implement psychosocial supportive programmes in the context of enhanced recovery after surgery.

Impact of Left Ventricular Assist Device on Pulmonary Functions and Pulmonary Hemodynamics: A Meta-analysis

Background Given current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests (PFT) remains controversial. Methods Electronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation (SD) on a random-effects model. Results A total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23L (95% (confidence interval) CI 0.11-0.34, p=00002), 0.18L (95% CI 0.03-0.34, p=0.02), and 3.16 mmol/min (95% CI 2.17-4.14, p Conclusion LVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.

Ninety-day hospital costs associated with prolonged air leak following lung resection.

Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

Rituximab and antimetabolite treatment of granulomatous and lymphocytic interstitial lung disease in common variable immunodeficiency

Granulomatous and lymphocytic interstitial lung disease (GLILD) is a life-threatening complication in patients with common variable immunodeficiency (CVID), but the optimal treatment is unknown. Our aim was to determine whether rituximab with azathioprine or mycophenolate mofetil improves the high-resolution computed tomography (HRCT) chest scans and/or pulmonary function test results in patients with CVID and GLILD. A retrospective chart review of clinical and laboratory data on 39 patients with CVID and GLILD who completed immunosuppressive therapy was performed. Chest HRCT scans, performed before therapy and after the conclusion of therapy, were blinded, randomized, and scored independently by 2 radiologists. Differences between pretreatment and posttreatment HRCT scan scores, pulmonary function test results, and lymphocyte subsets were analyzed. Whole exome sequencing was performed on all patients. Immunosuppressive therapy improved patients' HRCT scan scores (P< .0001), forced vital capacity (P= .0017), FEV1 (P= .037), and total lung capacity (P= .013) but not their lung carbon monoxide diffusion capacity (P= .12). Nine patients relapsed and 6 completed retreatment, with 5 of 6 of these patients (83%) having improved HRCT scan scores (P= .063). Relapse was associated with an increased number of B cells (P=.016) and activated CD4 T cells (P= .016). Four patients (10%) had pneumonia while undergoing active treatment, and 2 patients (5%) died after completion of therapy. Eight patients (21%) had a damaging mutation in a gene known to predispose (TNFRSF13B [n= 3]) or cause a CVID-like primary immunodeficiency (CTLA4 [n= 2], KMT2D [n= 2], or BIRC4 [n= 1]). Immunosuppression improved the HRCT scan scores in patients with (P= .0078) and without (P< .0001) a damaging mutation. Immunosuppressive therapy improved the radiographic abnormalities and pulmonary function of patients with GLILD. Amajority of patients had sustained remissions.

Identification of Subclinical Lung Involvement in ACPA-Positive Subjects through Functional Assessment and Serum Biomarkers.

Lung involvement is related to the natural history of anti-citrullinated proteins antibodies (ACPA)-positive rheumatoid arthritis (RA), both during the pathogenesis of the disease and as a site of disease-related injury. Increasing evidence suggests that there is a subclinical, early lung involvement during the course of the disease, even before the onset of articular manifestations, which can potentially progress to a symptomatic interstitial lung disease. To date, reliable, non-invasive markers of subclinical lung involvement are still lacking in clinical practice. The aim of this study is to evaluate the diagnostic potential of functional assessment and serum biomarkers in the identification of subclinical lung involvement in ACPA-positive subjects. Fifty ACPA-positive subjects with or without confirmed diagnosis of RA (2010 ARC-EULAR criteria) were consecutively enrolled. Each subject underwent clinical evaluation, pulmonary function testing (PFT) with assessment of diffusion lung capacity for carbon monoxide (DLCO), cardiopulmonary exercise testing (CPET), surfactant protein D (SPD) serum levels dosage and high-resolution computed tomography (HRCT) of the chest. The cohort was composed of 21 ACPA-positive subjects without arthritis (ND), 10 early (disease duration < 6 months, treatment-naïve) RA (ERA) and 17 long-standing (disease duration < 36 months, on treatment) RA (LSRA). LSRA patients had a significantly higher frequency of overall HRCT abnormalities compared to the other groups (p = 0.001). SPD serum levels were significantly higher in ACPA-positive subjects compared with healthy controls (158.5 ± 132.3 ng/mL vs 61.27 ± 34.11 ng/mL; p < 0.0001) and showed an increasing trend from ND subjects to LSRD patients (p = 0.004). Patients with HRCT abnormalities showed significantly lower values of DLCO (74.19 ± 13.2% pred. vs 131.7 ± 93% pred.; p = 0.009), evidence of ventilatory inefficiency at CPET and significantly higher SPD serum levels compared with subjects with no HRCT abnormalities (213.5 ± 157.2 ng/mL vs 117.7 ± 157.3 ng/mL; p = 0.018). Abnormal CPET responses and higher SPD levels were also associated with specific radiological findings. Impaired DLCO and increased SPD serum levels were independently associated with the presence of HRCT abnormalities. Subclinical lung abnormalities occur early in RA-associated autoimmunity. The presence of subclinical HRCT abnormalities is associated with several functional abnormalities and increased SPD serum levels of SPD. Functional evaluation through PFT and CPET, together with SPD assessment, may have a diagnostic potential in ACPA-positive subjects, contributing to the identification of those patients to be referred to HRCT scan.