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Objective: To estimate the diagnostic accuracy of signal intensity of the lesion-to-spinal cord ratio (LSR) and apparent diffusion coefficient (ADC) in diffusion-weighted (DW) magnetic resonance imaging of pulmonary nodules suspicious for lung cancer in granulomatous lung disease-endemic regions., Methods: Forty-nine patients with indeterminate solitary pulmonary nodules detected by chest computed tomography and histopathologically confirmed diagnoses were included in the study. DW images were analysed semiquantitatively by focusing regions of interest on the lesion and spinal cord at the same level (for LSR calculation). ADCs were estimated from ratios of the two image signal intensities. Ratios of T1 and T2 signal intensity between nodules and muscle were calculated for comparison., Results: Mean ADCs ± standard deviations for lung cancer and benign lesions were 0.9 ± 0.2 and 1.3 ± 0.2 × 10(-3) mm(2)/s, respectively. Mean LSRs were 1.4 ± 0.3 for lung cancer and 1 ± 0.1 for benign lesions. ADCs and LSRs differed significantly between malignant and benign lesions (P < 0.001). Mean T2 signal intensity ratios also differed significantly between benign and malignant lesions (0.8 ± 0.2 vs. 1.6 ± 0.2; P < 0.05)., Conclusions: DWI can help to differentiate malignant from benign lesions according to ADC and the LSR with good accuracy., Key Points: • DW imaging can help differentiate malignant from benign pulmonary nodules. • ADC and LSR signal intensities had only small overlap between malignant and benign pulmonary nodules. • Mean T2 signal intensity ratios differed significantly between benign and malignant lesions.

Objective: To evaluate the changes in lung function in the first year after single lung transplantation in patients with idiopathic pulmonary fibrosis (IPF)., Methods: We retrospectively evaluated patients with IPF who underwent single lung transplantation between January of 2006 and December of 2012, reviewing the changes in the lung function occurring during the first year after the procedure., Results: Of the 218 patients undergoing lung transplantation during the study period, 79 (36.2%) had IPF. Of those 79 patients, 24 (30%) died, and 11 (14%) did not undergo spirometry at the end of the first year. Of the 44 patients included in the study, 29 (66%) were men. The mean age of the patients was 57 years. Before transplantation, mean FVC, FEV1, and FEV1/FVC ratio were 1.78 L (50% of predicted), 1.48 L (52% of predicted), and 83%, respectively. In the first month after transplantation, there was a mean increase of 12% in FVC (400 mL) and FEV1 (350 mL). In the third month after transplantation, there were additional increases, of 5% (170 mL) in FVC and 1% (50 mL) in FEV1. At the end of the first year, the functional improvement persisted, with a mean gain of 19% (620 mL) in FVC and 16% (430 mL) in FEV1., Conclusions: Single lung transplantation in IPF patients who survive for at least one year provides significant and progressive benefits in lung function during the first year. This procedure is an important therapeutic alternative in the management of IPF.

Patients with preexisting lung cavities are at risk of developing intracavitary fungal colonization. Because Aspergillus spp. are the most commonly implicated fungi, these fungal masses are called aspergillomas. Their characteristic "ball-in-hole" appearance, however, may be found in a variety of other conditions that can produce radiologic findings mimicking aspergilloma. In this paper, we review the main diseases that may mimic the radiographic findings of aspergilloma, with brief descriptions of clinical, radiologic, and histopathologic findings.

Objective: To report the long-term follow-up of the first living-donor lobar lung transplantation performed in Latin America., Description: The patient was a 12-year-old boy with post-infectious obliterative bronchiolitis with end-stage pulmonary disease. He was on continuous oxygen support, presenting with dyspnea even during minimal activity. He underwent bilateral lobar lung transplantation with living donors. The procedure was performed with the left and right lower lobes of two different related donors. In the second side cardiopulmonary bypass was required. The transplant was uneventful, and the patient was extubated after 14 hours and discharged with 44 days, after resolution of infectious, immunological and drug-related complications. After 12 years of follow-up, he presents with adequate lung function and has resumed his habitual activities., Comments: Living-donor lobar lung transplantation is a complex procedure feasible for the treatment of selected pediatric end-stage pulmonary disease. This particular population might benefit from this approach since the availability of pediatric donors is very scarce and the clinical course of pediatric advanced pulmonary disease may be unpredictable.

Objective: To report the cases of 6 patients with fungus ball caused by Aspergillus fumigatus (aspergilloma) in the pleural cavity., Methods: Between 1980 and 2009, 391 patients were diagnosed with aspergilloma at the Santa Casa Hospital Complex in Porto Alegre, Brazil. The diagnosis of aspergilloma in the pleural cavity was made through imaging tests revealing effusion and pleural thickening with air-fluid level; direct mycological examination revealing septate hyphae, consistent with Aspergillus sp.; and positive culture for A. fumigatus in the surgical specimen from the pleural cavity., Results: Of the 391 patients studied, 6 (2%) met the established diagnostic criteria. The mean age of those 6 patients was 48 years (range, 29-66 years), and 5 (83%) were male. The most common complaints were cough, expectoration, and hemoptysis. Four patients (67%) had a history of tuberculosis that had been clinically cured. All of the patients were submitted to surgical removal of the aspergilloma, followed by intrapleural instillation of amphotericin B, in 4; and 2 received systemic antifungal treatment p.o. There was clinical improvement in 5 patients, and 1 died after the surgery., Conclusions: In adult patients with a history of cavitary lung disease or pleural fistula, a careful investigation should be carried out and fungal infection, especially aspergilloma, should be taken into consideration. In such cases, laboratory testing represents the most efficient use of the resources available to elucidate the diagnosis.

Brain death (BD) alters the pathophysiology of patients and may damage the kidneys, the lungs, the heart and the liver. To obtain better quality transplant organs, intensive care physicians in charge of the maintenance of deceased donors should attentively monitor these organs. Careful hemodynamic, ventilatory and bronchial clearance management minimizes the loss of kidneys and lungs. The evaluation of cardiac function and morphology supports the transplant viability assessment of the heart. The monitoring of liver function, the management of the patient's metabolic status and the evaluation of viral serology are fundamental for organ selection by the transplant teams and for the care of the transplant recipient.

Background: Lung transplantation (LT) has been established as a current therapy for selected patients with end-stage lung disease. Different prognostic factors have been reported by transplant centers. The objective of this study is to report our recent results with LT and to search for prognostic factors., Methods: We performed a retrospective analysis of 130 patients who underwent LT at our institution from January 2004 to July 2009. Donor, recipient, intraoperative, and postoperative variables were collected., Results: The mean age was 53.14 years (ranging from 8 to 72 years) and 80 (61.5%) were male. The main causes of end-stage respiratory disease were pulmonary fibrosis 53 (40.7%) and chronic obstructive pulmonary disease 52 (40%). The actuarial 1-year survival was 67.7%. Variables correlated with survival were age (P=0.004), distance in the 6-min walk test (P=0.007), coronary heart disease (P=0.001), cardiopulmonary bypass (P=0.02), intraoperative transfusion of red blood cells (P=0.016), increasing central venous pressure at 24th postoperative hour (P=0.001), increasing pulmonary capillary wedge pressure at 24th postoperative hour (P=0.01); length of intubation (P<0.01), reintubation (P=0.001), length of intensive care unit stay (P<0.001), abdominal complication (P=0.003), acute renal failure requiring dialysis (P<0.001), native lung hyperinflation (P=0.02), and acute rejection in the first month (P=0.03). In multivariate analysis, only dialysis (P=0.004, hazards ratio [HR] 2.68), length of intubation (P=0.004, HR 1.002 for each hour), and reintubation (P=0.003, HR 2.88) proved to be independent predictors., Conclusion: Analysis of variables in our cohort highlighted dialysis, longer mechanical ventilation requirement, and reintubation as independent prognostic factors in LT.

This paper describes the concentrations of polycyclic aromatic hydrocarbons (PAHs) and aliphatic hydrocarbons (AHs) derived from petroleum in bottled drinking water samples that were collected over 1 year from Mexico City in two bottle sizes (1.5 and 19 L), all brought in supermarkets. The analysis was by gas chromatography with flame ionization detection. -Concentrations of AHs (9.26-1.74 μg/L) were greater than PAHs (20.15-12.78 ng/L). Individual concentrations of PAHs such as fluoranthene, benzo(b)fluoranthene, benzo(k)fluoranthene, indeno(1,2,3-cd)pyrene and benzo(ghi)perylene were comparable with data reported by the World Health Organization (WHO). Total concentrations of PAHs for all samples (BDW1: 12.78 μg/L, BDW2: 16.72 μg/L, BDW3: 14.62 μg/L, BDW4: 20.15 μg/L and BDW5: 13.23 ng/L) were below the maximum permissible European level of 100 ng/L; no regulations exist for AHs although their values were greater than PAHs (BDW1: 3.11 μg/L, BDW2: 8.45 μg/L, BDW3: 1.74 μg/L, BDW4: 4.75 μg/L and BDW5: 9.26 μg/L).

Background: Bronchial carcinoid is an infrequent neoplasm with a neuroendocrine differentiation. Surgical treatment is the gold standard therapy, with procedures varying from sublobar resections to complex lung sparing broncoplastic procedures. This study evaluates the results of surgical treatment of bronchial carcinoids and its prognostic factors., Patients and Methods: Retrospective review of 126 consecutive patients who underwent surgical treatment for bronchial carcinoid tumors between December 1974 and July 2007., Results: There were 70 females (55%) and the mean age was 46 years, ranging from 17 to 81 years. Upon clinical presentation, 38 patients (30%) have had recurrent respiratory tract infection, 31 (24%) cough, 16 (12%) chest pain and 25 (20%) were asymptomatic. Preoperative bronchoscopic diagnosis was obtained in 74 cases (58.7%). The procedures performed were: 19 sublobar resections (14,9%), 58 lobectomies (46%), 8 bilobectomies (6.3%), 6 pneumonectomies (4.7%), 2 sleeve segmentectomies (1.5%), 26 sleeve lobectomies (20.6%) and 9 bronchoplastic procedures without lung resection (7.1%). Operative mortality was 1.5% (n = 2) and morbidity was 25.8% (n=32), including 12 respiratory tract infections and 4 reinterventions due to bleeding (3) and pleural empyema (1). Among the 112 patients available for follow-up, the overall survival at 3, 5 and 10 years was 89.2%, 85.5% and 79.8%, respectively. Five and 10-year survival for typical and atypical carcinoids were 91, 89% and 56, 47%, respectively. Overall disease-free survival at 5 years was 91.9% Statistical analysis showed that overall disease-free survival correlated with histology--typical vs. atypical--(p = 0.04) and stage (p = 0.02)., Conclusion: Surgery provides safe and adequate treatment to bronchial carcinoid tumors. Histology and stage were the main prognostic factors., (Copyright © 2010. Published by Elsevier Ireland Ltd.)

Objectives: Nowadays, despite the advances of the low-pressure high-volume cuffs, post-intubation tracheo-oesophageal fistula (TEF) still poses a major challenge to thoracic surgeons. The original technique includes interposition of muscle flaps between suture lines to avoid recurrence. It is not clear if this manoeuvre is indispensable and, in fact, we and others have faced problems with it. Our aim is to present our experience with TEF management in a consecutive group with no muscle interposition., Methods: From June 1992 to November 2007, we evaluated 14 patients presenting with TEF, with a mean age of 44 years (from 18 to 79 years). Thirteen patients had a prolonged intubation history. The remaining case was a 40-year-old male with congenital TEF. Three patients had been previously submitted to failed repairs in other institutions. Ten patients had associated tracheal stenosis, which was subglottic in three of them. Regarding surgical technique, in all cases, we performed a single-staged procedure, which consisted of tracheal resection and anastomosis with double-layer oesophageal closure. In none of our cases was a muscle flap interposed between suture lines., Results: All operations were performed through a cervical incision; however, in one case, an extension with partial sternotomy was required. There was no operative mortality. Thirteen patients were extubated in the first 24h after the procedure, while one patient required 48 h of mechanical ventilation. Four complications were recorded: one each of pneumonia and left vocal cord paralysis and two small tracheal dehiscences managed with a T-tube and a tracheostomy tube. After discharge, three patients returned to their native cities and were lost to follow-up. The remaining 11 patients have been followed up by a mean of 32 months (from three to 108 months), with 10 presenting excellent and one good anatomic and functional results., Conclusions: The single-staged repair with tracheal resection and anastomosis with oesophageal closure provides good short- and mid-term results for TEF management. The interposition of a muscle flap between suture lines may not be crucial to prevent recurrence., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Due to the increasing number and improved survival of lung transplant recipients, radiologists should be aware of the imaging features of the postoperative complications that can occur in such patients. The early treatment of complications is important for the long-term survival of lung transplant recipients. Frequently, HRCT plays a central role in the investigation of such complications. Early recognition of the signs of complications allows treatment to be initiated earlier, which improves survival. The aim of this pictorial review was to demonstrate the CT scan appearance of pulmonary complications such as reperfusion edema, acute rejection, infection, pulmonary thromboembolism, chronic rejection, bronchiolitis obliterans syndrome, cryptogenic organizing pneumonia, post-transplant lymphoproliferative disorder, bronchial dehiscence and bronchial stenosis.

Context: Round pneumonia is a condition usually described in children, with few reports addressing adult patients. It is an oval-shaped consolidation that, due to its radiological appearance, simulates bronchogenic carcinoma. Its evolution tends to be benign, although diagnostic dilemmas have sometimes required exploratory thoracotomy. Deaths caused by this condition have even been reported. To the best of our knowledge, there have been 31 previous cases of round pneumonia in adults reported in the English and Portuguese-language literature, of which only one was completely asymptomatic., Case Report: The case of a 54-year-old female patient presenting a lung mass found on routine imaging evaluation is reported. Respiratory symptoms and signs were absent, but the patient had a significant history of smoking. Her physical examination gave normal results. On chest radiographs, a mass located in the middle third of the right lung was observed. Three weeks after the initial evaluation, the patient was admitted for a complete evaluation and for staging of a pulmonary malignancy, but repeated chest radiographs showed complete resolution.

Objective: To investigate the relation between decentralization and equity of resource allocation in Colombia and Chile., Methods: The "decision space" approach and analysis of expenditures and utilization rates were used to provide a comparative analysis of decentralization of the health systems of Colombia and Chile., Findings: Evidence from Colombia and Chile suggests that decentralization, under certain conditions and with some specific policy mechanisms, can improve equity of resource allocation. In these countries, equitable levels of per capita financial allocations at the municipal level were achieved through different forms of decentralization--the use of allocation formulae, adequate local funding choices and horizontal equity funds. Findings on equity of utilization of services were less consistent, but they did show that increased levels of funding were associated with increased utilization. This suggests that improved equity of funding over time might reduce inequities of service utilization., Conclusion: Decentralization can contribute to, or at least maintain, equitable allocation of health resources among municipalities of different incomes.