Paul Zarogoulidis

Asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS): current literature review

Asthma and chronic obstructive pulmonary disease (COPD) are chronic diseases, very common in general population. These obstructive airway illnesses are manifested with chronic inflammation affecting the whole respiratory tract. Obstruction is usually intermittent and reversible in asthma, but is progressive and irreversible in COPD. Asthma and COPD may overlap and converge, especially in older people [overlap syndrome-asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS)]. Although ACOS accounts approximately 15-25% of the obstructive airway diseases, is not well recognised because of the structure of clinical trials. COPD studies exclude asthma patients and asthma studies exclude COPD patients, respectively. It is crucial to define asthma, COPD and overlap syndrome (ACOS), as notable clinical entities, which they share common pathologic and functional features, but they are characterized from differences in lung function, acute exacerbations, quality of life, hospital impact and mortality.

Inhaled chemotherapy in lung cancer: future concept of nanomedicine.

Regional chemotherapy was first used for lung cancer 30 years ago. Since then, new methods of drug delivery and pharmaceuticals have been investigated in vitro, and in animals and humans. An extensive review of drug delivery systems, pharmaceuticals, patient monitoring, methods of enhancing inhaled drug deposition, safety and efficacy, and also additional applications of inhaled chemotherapy and its advantages and disadvantages are presented. Regional chemotherapy to the lung parenchyma for lung cancer is feasible and efficient. Safety depends on the chemotherapy agent delivered to the lungs and is dose-dependent and time-dependent. Further evaluation is needed to provide data regarding early lung cancer stages, and whether regional chemotherapy can be used as neoadjuvant or adjuvant treatment. Finally, inhaled chemotherapy could one day be administered at home with fewer systemic adverse effects.

Treatment of non-small cell lung cancer (NSCLC)

Radical surgery is the standard of care for fit stage I non-small cell lung cancer (NSCLC) patients. Adjuvant treatment should be offered only as part of an investigation trial. Stage II and IIIA adjuvant cisplatin-based chemotherapy remains the gold standard for completely resected NSCLC tumors. Additionally radiotherapy should be offered in patients with N2 lymph nodes. In advanced stage IIIB/IV or inoperable NSCLC pts, a multidisciplinary treatment should be offered consisted of 4 cycles of cisplatin-based chemotherapy plus a 3(rd) generation cytotoxic agent or a cytostatic (anti-EGFR, anti-VEGFR) drug.

Right heart failure post left ventricular assist device implantation

Right heart failure (RHF) is a frequent complication following left ventricular assist device (LVAD) implantation. The incidence of RHF complicates 20-50% (range, 9-44%) of cases and is a major factor of postoperative morbidity and mortality. Unfortunately, despite the fact that many risk factors contributing to the development of RHF after LVAD implantation have been identified, it seems to be extremely difficult to avoid them. Prevention of RHF consists of the management of the preload and the afterload of the right ventricle with optimum inotropic support. The administration of vasodilators designed to reduce pulmonary vascular resistance is standard practice in most centers. The surgical attempt of implantation of a right ventricular assist device does not always resolve the problem and is not available in all cardiac surgery centers.

Interleukin-8 and interleukin-17 for cancer.

Pro-inflammatory cytokines have been associated with chronic inflammation and inflammatory diseases. Increased levels of interleukins (ILs) have been associated with inflammatory disease exacerbation. ILs levels have been observed to be associated with advance stage cancer for several types of cancer and a poor prognostic maker for malignant disease. Moreover; increased levels of cytokines induce tumorigenesis. There are several paradigms such as the hepatocellular carcinoma induced from chronic inflammation of an underlying hepatitis. In the current review, we will focus on IL-8 and -17. These two ILs as in the case of others, induce neo-angiogenesis through activation of the vascular endothelial growth (VEGF) factor pathway. Additionally, they enhance the activity of matrix metalloproteinase-2 and –9 (MMP-2,-9) which in turn increase the metastatic activity of the underlying malignancy. Inhibition of cytokine production could be a potential treatment both for chronic inflammatory diseases and tumor modulation. Local microenvironment modulation could be applied in surgery resected patients as in the case of lung cancer in order to enhance the local immune activity.

Catamenial pneumothorax: a rare entity? Report of 5 cases and review of the literature

OBJECTIVE Spontaneous recurrent pneumothorax during menstruation is reported as catamenial pneumothorax. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women. The percentage among women referred for surgery is significantly higher (25-30%). Although it usually involves the right-side (85-95%) it can be left-sided or bilateral. It is associated with diaphragmatic perforations and/or thoracic endometriosis. There is pelvic endometriosis in up to 30-51% of cases. The lesions that are not always found may present as small or larger holes at the central tendon of the diaphragm, as red, blueberry, brown spots or larger nodules at the diaphragm, the visceral or parietal pleura. Lesion histology may reveal endometriosis. We present 5 cases of catamenial pneumothorax treated surgically during the last 6 years. PATIENTS AND METHODS Five women, with a mean age of 34+/-9.9 years (median 38, range, 19-45 years) presented with right-sided recurrent catamenial pneumothorax. In 3 patients diaphragmatic perforation(s) were found; perforation suturing (n=1), and diaphragmatic plication reinforced with bovine pericardial patch (n=1) were performed. All patients underwent atypical resection of upper and/or middle lobe segments of lung parenchyma that appeared abnormal (haemorrhagic/emphysematous or blebs). Four patients underwent pleurodesis and 1 patient underwent pleurectomy. Four interventions were performed through video assisted thoracoscopic surgery, while diaphragmatic plication was performed through a video assisted mini-thoracotomy. Histology did not reveal endometriosis tissue. RESULTS The postoperative course was uneventful. The patients were extubated in theatre and were discharged home at a mean of 7+/-4 days (median 6 days, range, 4-14 days). Two of them received hormonal therapy [Gonadotropin Releasing Hormone (GnRH) analogue] postoperatively. At a follow-up of 14.16 patient-years (mean 2.83+/-1.08 years, range, 1.33-3.83 years) there was recurrence, 6.5 months postoperatively, in one patient that had not undergone closure of a tiny diaphragmatic hole and had not received hormonal treatment postoperatively. She was treated medically (amenorrhea for 6 months with GnRH analogue) and had no further recurrences (in 3.3 years). CONCLUSIONS Surgery is the treatment of choice of catamenial pneumothorax. It should aim to complete management of all lesions. The most common complication is recurrence. Early diagnosis and multidisciplinary treatment including hormonal therapy may be beneficial in high risk patients.

Extrapelvic endometriosis: a rare entity or an under diagnosed condition?

Endometriosis is a clinical entity characterized by the presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity. Endometriosis can be either endopelvic or extrapelvicdepending on the location of endometrial tissue implantation. Despite the rarity of extrapelvic endometriosis, several cases of endometriosis of the gastrointestinal tract, the urinarytract, the upper and lower respiratory system, the diaphragm, the pleura and the pericardium, as well as abdominal scars loci have been reported in the literature. There are several theories about the pathogenesis and the pathophysiology of endometriosis. Depending on the place of endometrial tissue implantation, endometriosis can be expressed with a wide variety of symptoms. The diagnosis of this entity is neither easy nor routine. Many diagnostic methods clinical and laboratory have been used, but none of them is the golden standard. The multipotent localization of endometriosis in combination with the wide range of its clinical expression should raise the clinical suspicion in every woman with periodic symptoms of extrapelvic organs. Finally, the therapeutic approach of this clinical entity is also correlated with the bulk of endometriosis and the locum that it is found. It varies from simple observation, to surgical treatment and treatment with medication as well as a combination of those.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1968087883113362.

Inhaled Insulin: Too Soon To Be Forgotten?

Inhalation is a potentially viable route of administration for numerous agents. In diabetes mellitus, the need for frequent injections to achieve ideal glycemic control remains a significant limitation for initiating and complying with insulin therapy in a large number of patients. To overcome this barrier, inhaled insulin was developed. The inhalation form of regular human insulin has been tested and administered in a large number of trials. Respiratory capacity was evaluated in patients with normal lung parenchyma in whom inhaled insulin was administered without complications. However, issues like cost, bulky device, fear for lung safety, and the small number of studies in subjects with underlying respiratory disease prevented widespread use of this new mode of delivery. In the present review, we will suggest a number of methods that could be applied in this form of administration to maximize drug absorption and fully exploit the advantages of this route of administration.

Review of mitral valve insufficiency: repair or replacement

Mitral valve (MV) dysfunction is the second-most common clinically significant form of valvular defect in adults. MV regurgitation occurs with the increasing frequency of degenerative changes of the aging process. Moreover, other causes of clinically significant MV regurgitation include cardiac ischemia, infective endocarditis and rhematic disease more frequently in less developed countries. Recent evidence suggests that the best outcomes after repair of severe degenerative mitral regurgitation (MR) are achieved in asymptomatic or minimally symptomatic patients, who are selected for surgery soon after diagnosis on the basis of echocardiography. This review will focus on the surgical management of mitral insufficiency according to its aetiology today and will give insight to some of the perspectives that lay in the future.

Pneumothorax and asthma.

This review is focused on the relationship between asthma, pneumothorax and pneumomediastinum while presenting a number of case reports that include these conditions. The association between pneumothorax and asthma is not widely known. While asthma includes a common disorder and is prevalent worldwide, its morbidity and mortality is high when is associated with pneumothorax. Furthermore, the delayed diagnosis of pneumothorax while focusing on asthma includes the higher risk of coincidental pneumothorax in asthmatic patients. In addition, pneumomediastinum is considered benign and self-limiting condition that responds to conservative therapy. Although it is rare, the concurrence of pneumomediastinum with pneumothorax may prove fatal during a serious asthma attack. In conclusion, the symptoms of chest pain, dyspnea or focal chest findings when presented in asthmatic patients, must always create suspicion of pneumothorax or pneumomediastinum to the physician.