BackgroundThe objective of this prospective study was to assess the prevalence of anxiety and depression disorders and their association with quality of life (QoL), clinical parameters and survival in patients with pulmonary hypertension (PH).MethodsWe prospectively assessed 158 patients invasively diagnosed with pulmonary arterial hypertension (n = 138) and inoperable chronic thromboembolic PH (n = 20) by clinical measures including quality of life (QoL, SF-36 questionnaire), cardiopulmonary exercise testing and six minute walking distance and by questionnaires for depression (PHQ-9) and anxiety (GAD-7). According to the results of the clinical examination and the questionnaires for mental disorders (MD) patients were classified into two groups, 1) with moderate to severe MD (n = 36, 22,8%), and 2) with mild or no MD (n = 122). Patients were followed for a median of 2.7 years. Investigators of QoL, SF-36 were blinded to the clinical data.ResultsAt baseline the 2 groups did not differ in their severity of PH or exercise capacity. Patients with moderate to severe MD (group 1) had a significantly lower QoL shown in all subscales of SF-36 (p < 0.002). QoL impairment significantly correlated with the severity of depression (p < 0.001) and anxiety (p < 0.05). During follow-up period 32 patients died and 3 were lost to follow-up. There was no significant difference between groups regarding survival. Only 8% of the patients with MD received psychopharmacological treatment.ConclusionAnxiety and depression were frequently diagnosed in our patients and significantly correlated with quality of life, but not with long term survival. Further prospective studies are needed to confirm the results.

which becomes increasingly frequent as the number of CT examinations rises. The workup of these nodules is rather expensive and emotionally burdensome, especially when the patient has risk factors for bronchial carcinoma. SPN are noted in up to 0.2% of chest radiographs [4,5] , whereas 27.3% of patients undergoing the National Lung Screening Trial (NLST) had at least one SPN with a diameter >4 mm on their CT examination [6] . Differential diagnosis is extensive, but the majority of the identified nodules are comprised of granulomas, lung cancers and hamartomas [7,8] . Against the background of potential malignancy and the poor prognosis of advanced lung cancer, rapid identification and resection of malignant SPN is crucial, leading to a 5-year survival rate of 60-80% in stage I [9, 10] non-small-cell lung carcinoma (NSCLC). Nonetheless, even in a population at high-risk for lung cancer, the vast majority of small SPN are benign. In the lung screening study of the National Cancer Institute, the lung cancer diagnosis rates were <5, 21.3 and 34.5% for nodules <10, 11-19 and >20 mm in diameter, respectively [11] . The management of an SPN should aim to identify malignancy as fast as possible in order to provide the option of potentially curative surgical treatment whilst avoiding invasive diagnostic procedures in the case of benign lesions. Numerous articles have been published addressing the optimal strategy of evaluating individuals with lung nodules, including the most recently published ACCP guideline for the diagnosis and management of lung cancer [12] . Those strategies are generally based on the individual's risk of developing lung cancer, the pulmonary nodule characteristics and the capability of the current diagnostic and therapeutic approaches. Key WordsSolitary pulmonary nodule · Lung cancer · Screening · Management · Biopsy · Surgical approaches Abstract Due to the high etiological diversity and the potential for malignancy, pulmonary nodules represent a clinical challenge, becoming increasingly frequent as the number of CT examinations rises. The topic gains even more importance as clear evidence for the effectiveness of CT screening was provided by the National Lung Screening Trial (NLST). Yet, the results were tempered by the high false-positive rate and the requirement of performing further diagnostic procedures. The management of those detected solitary pulmonary nodules is currently based on the individuals' risk of developing lung cancer, the pulmonary nodule characteristics and the capability of diagnostic and therapeutic approaches.

Background: The minimal invasive investigation of solitary pulmonary nodules becomes increasingly important with the emergence of lung cancer screening. Objectives: We report the results of the first utilization of a recently developed procedure in a bronchoscopy suite, which approaches solitary pulmonary nodules via a transparenchymal path. Methods: This study was a prospective, single-arm interventional study. We investigated patients with a solitary pulmonary nodule detected on CT imaging, which was suspicious for malignancy. The subject's CT was employed to calculate an airway wall point of entry (POE) as well as an avascular path through lung tissue from the POE to the solitary pulmonary nodule. Using a set of catheter-based tools under fused fluoroscopy guidance, a tunnelled tract was created from the POE to the nodule. The patients were surveyed for at least 72 h in our hospital. The primary end point of the study was to evaluate the feasibility to access and biopsy solitary pulmonary nodules outside of an operation theatre. Results: Six patients were recruited, and a tunnel pathway was created in 5 patients. There were no adverse events during the procedures. Two pneumothoraces were diagnosed by chest X-ray 2 h after the procedure, with one pneumothorax requiring drainage. Adequate biopsies were obtained from all 5 patients in whom a tunnel path was created. Conclusions: This study demonstrates that bronchoscopic transparenchymal access of solitary pulmonary nodules is feasible outside an operation theatre.