Uncontrolled pilot studies demonstrated promising results of endoscopic lung volume reduction using emphysematous lung sealant (ELS) in patients with advanced, upper lobe predominant emphysema. We aimed to evaluate the safety and efficacy of ELS in a randomised controlled setting. Patients were randomised to ELS plus medical treatment or medical treatment alone. Despite early termination for business reasons and inability to assess the primary 12-month end-point, 95 out of 300 patients were successfully randomised, providing sufficient data for 3- and 6-month analysis. 57 patients (34 treatment and 23 control) had efficacy results at 3 months; 34 (21 treatment and 13 control) at 6 months. In the treatment group, 3-month lung function, dyspnoea, and quality of life improved significantly from baseline when compared to control. Improvements persisted at 6 months with >50% of treated patients experiencing clinically important improvements, including some whose lung function improved by >100%. 44% of treated patients experienced adverse events requiring hospitalization (2.5-fold more than control, p=0.01), with two deaths in the treated cohort. Treatment responders tended to be those experiencing respiratory adverse events. Despite early termination, results show that minimally invasive ELS may be efficacious, yet significant risks (probably inflammatory) limit its current utility.

Community-acquired pneumonia (CAP) has a high incidence and involves an important consumption of healthcare resources. The present authors analysed the influence of comorbidity, initial severity and complications upon the direct costs associated with hospitalised CAP patients.Direct hospitalisation costs (room cost, treatment, laboratory and diagnostic tests) were assessed in a prospective, observational study of 271 patients admitted to a hospital ward due to CAP.The mean¡SD patient age was 70¡15 yrs. The mortality rate was 11.1%. Complications were found in 72.3% and comorbidities in 74.9%. The median (interquartile range) total cost was J1,683 (J1,291-2,471) and the component costs were: room cost J1,286 (J857-1,714); laboratory tests J212 (J171-272); treatment J187 (J114-304); and diagnostic procedures J58 (J29-122). Complications and higher Pneumonia Severity Index increased the costs, but age and comorbidity did not. A logistic regression analysis to predict high cost (.J1,683) showed that infectious (odds ratio 6.8, 95% confidence interval 1.3-36), digestive (5.9 (1.5-22.8)), pulmonary (2.6 (1.4-4.7)) and other complications (3.9 (1.8-8.4)) were independent risk factors, as were previous hospitalisation (2.3 (1.2-4.3)) and hypoalbuminaemia (2 (1.1-3.6)).Complications, hypoalbuminaemia and previous hospitalisation were the main determinants of high direct costs of hospitalisation due to community-acquired pneumonia. Neither age nor comorbidities were independently associated with cost.

Neutrophil activation state and its relationship with an inflammatory environment in community-acquired pneumonia (CAP) remain insufficiently elucidated. We aimed to evaluate the neutrophil apoptosis and cytokine pattern in CAP patients after 72 h of treatment, and their impact on infection resolution.Apoptosis of blood and bronchoalveolar lavage (BAL) neutrophils was measured in nonresponding CAP (NCAP), in responding CAP (blood only) and in patients without infection (control). Proinflammatory (interleukin (IL)-6, IL-8) and anti-inflammatory (IL-10) cytokines were measured. Main outcomes were clinical stability and days of hospitalisation.Basal neutrophil apoptosis was higher in the BAL and blood of NCAP, whereas spontaneous apoptosis (after 24 h culture) was lower. Cytokines in NCAP were higher than in responding CAP and control: IL-6 was increased in BAL and blood, IL-8 in BAL and IL-10 in blood. An increased basal apoptosis (o20%) in BAL of NCAP was associated with lower systemic IL-10 (p,0.01), earlier clinical stability (p50.05) and shorter hospital stay (p50.02). A significant correlation was found for systemic IL-6 and IL-10 with days to reach stability and length of stay.After 72 h of treatment, an increased basal alveolar neutrophil apoptosis might contribute to downregulation of inflammation and to faster clinical stability.

Indwelling pleural catheter is useful for palliative management of recurrent malignant pleural effusion in that it benefits Quality of Life in outpatients with advanced malignancies. In lung cancer patients, scores indicated that indwelling pleural catheter also provides significant relief of dyspnea.

The objective of the study was to evaluate the effects of cryoanalgesia in patients undergoing posterolateral thoracotomy. A double-blind randomized and prospective study was performed in 100 patients undergoing thoracotomy. They were randomized into two groups: Group A, 55 patients, who had undergone an intercostal cryoanalgesia and group B, control, 45 patients treated only with pharmacological analgesia ad libitum. In both groups we assessed pain in the first 7 postsurgical days, the amount of analgesia required, electromyography of the intercostal muscles involved and recording of maximal static respiratory pressures. Postsurgical pain was significantly lower (p < 0.001) in group A. No patient in group A needed major analgesia and the amount of aminopyrines required was significantly lower (p < 0.001) than those used in group B. Maximal static inspiratory pressure (P_Imax) showed no significant changes and no significant differences were found between the two groups. Maximal static expiratory pressure (P_Emax) significantly decreased (p < 0.001) in the 1st and 2nd week and it was not related to the type of analgesia used. We advocate the use of cryoanalgesia since it significantly reduces pain as well as the doses of analgesia.