Volume 07

Issue 01

January 2019

Inside This Issue

Opinion/Editorial, 2, 3

Technology Corner, 4,5

Tips from the Experts, 6,7

Humanitarian News, 8-12

Upcoming Events, 19

Sally C. Lau, MD

Upon T cell receptor

The PD-1

Durvalumab consolidaon signicantly improved

Median progression free survival (PFS) in the durvalumab group was more than

Of the 22 paents who received treatment, 45% of paents achieve a major pathologic response (MPR), ≤10%

The subsequent phase II NEOSTAR study randomized 33 paents with resectable NSCLC to

References:

with PSP, bleb rupture along the visceral pleura is a popular theory for the pathogenesis of PSP. However, other theories like visceral pleural

porosity have been proposed, so the exact cause of air leakage in PSP is not enrely clear.

Management of the rst episode of PSP

One thing that is agreed upon is that paents with this disorder rarely present with tension physiology or respiratory distress unlike those

with secondary spontaneous pneumothoraces (SSPs) who have less pulmonary reserve. Even though most paents with PSP present with an

abrupt onset of pleuric chest pain with or without breathlessness, many paents will have minimal to no symptoms. The Brish Thoracic

Society (BTS) Guidelines from 2010 remind us that we have me and we should adopt a more conservave approach with greater reliance

on clinical symptoms to dictate management and minimize painful procedures when possible. In contrast, the earlier American College of

Chest Physicians (ACCP) guidelines from 2001 recommended tube thoracostomy for any pneumothorax greater than 20% of the hemi thorax

for hospitalizaon. Considering the litany of user friendly small bore thoracostomy tubes on the market, one could argue that an eight

french pleural drain could be used rst line as well as simple aspiraon. It should not add signicant discomfort and could prevent the need

for a second procedure if simple aspiraon fails (i.e., air leak persists even aer 2.5 liters is aspirated). If the air leak resolves and follow up

imaging shows lung re-expansion, then the paent may be discharged the same day without need for hospitalizaon. Simple aspiraon for

PSP fails 25-50% of the me and there is no evidence to support a second aspiraon rather than chest drain inseron. Alternavely, dis-

charge with a one-way Heimlich valve aached to the chest drain is another opon to prevent hospitalizaon.

Prevenon and Management of PSP recurrence

Medical University of South Carolina

Division of Pulmonary and Crical Care

Tips from the Experts

absence of a large body of evidence, this topic is one for debate. It should be considered that the recurrence rate for PSP is less than that of

secondary spontaneous pneumothoraces (30% vs. 50%, respecvely) and paents will generally tolerate recurrent PSP more favorably with

less risk of pulmonary decompensaon than paents with SSP. So, unless the paent engages in high risk professions (e.g., scuba diving, air-

cra personnel), has a persistent air leak for longer than 3 to 5 days, has a hemopneumothorax, or has bilateral pneumothoraces, a preventa-

ve pleurodesis procedure can be delayed aer the rst episode of PSP. Surgical management (bleb or bullectomy with paral or complete

A more complicated issue is the management of recurrent PSP aer mechanical pleurodesis. Repeat VATS would be indicated for a complete-

ly failed pleurodesis (when a sizable pneumothorax is clearly idened). However, on occasion, these paents have small, loculated recurrent

pneumothoraces that are not easily accessible to drain but yet are responsible for recurrent chest pain. Pain medicaon, reassurance and

monitoring may be the most reasonable approach in these scenarios.

In conclusion, the literature supports simple aspiraon in symptomac individuals with a rst presentaon of PSP. Other management con-

sideraons may include small bore chest drains and consideraon for the use of Heimlich valves. In high risk groups at rst presentaon or in

paents with recurrent PSP, denive management with a thoracoscopic pleurodesis procedure should be pursued. As chest physicians, we

should also counsel paents on the need for smoking cessaon to reduce the chance of PSP recurrence.

Figure 1: While a conservave approach is generally favored for the

Figure 2: CT scan of the chest on the same paent with PSP showing

Humanitarian News

The Ethics of Migraon

Ethical quesons regarding human migraon are a topic of hot public debate, parcularly in recent years. The consequences

of human migraon have received much aenon in polical theory, internaonal law, internaonal relaons theory and

expatriates. A United Naons report states that the number of internaonal migrants reached 244 million in 2015, with ap-

proximately 20 million being refugees and the rest considered as economic migrants. Although migrant workers are vital to a

country's economy, many of them, especially low-wage laborers, generally have limited rights in their receiving countries

and are vulnerable to discriminaon and abuse.

Migraon is the basic story of the human race from its origins to the present. People have always moved, in search of food

or escaping from the dangers of the war. Or simply looking for beer opportunies for their families. Almost every single

human being all over the world is a descendent of a migrant. Some sciensts esmate that the migraon could have begun

as early as 100,000 years ago and that contact with more archaic populaons like the Neanderthals could have produced

changes in what became the modern humans. But beyond some academic dierences between scholars, no sciensts have

disputed that ancestors of the human species (all of us) originated in Africa.

In the current world, 3.2% of the world’s populaon are internaonal migrants. Migrants are an heterogeneous populaon:

refugees escaping from persecuon, persons displaced by environmental factors, people seeking for employment and even

ly, emerging economies (Brazil, India, China) and oil-producing countries are now receiving the majority of migraon, that

consequently takes place mainly towards the Southern hemisphere. In spite of those uncontroversial facts, states in the

As a result of ever-increasing controls on migraon, the vulnerability of migrant persons to violaons of their human rights is

increasingly exacerbated.

Humanitarian News

the prize of cizenship and wealthy countries compete to aract them. Like it or not, global inequality is at the heart of the

debate of the ethics of internaonal migraon. We have to admit that it would be the height of hypocrisy to deny that the

problem are not immigrants but poor immigrants. The wealthy and/or polically powerful immigrants are always welcome in

most of the sociees.

Interesngly, migraon is generally viewed as an individual choice, without taking into account that most of the mes, fac-

tors out of the individual control, such as loss of land, natural or man-made disasters, polical instability, poverty and mainly

economic and polical policies and acons of the local government, neighboring governments, or super-powers may create

an eect that results in forced decisions to migrate that are far from the individual choice of the migrant.

One of the most used moral argument to support limits on immigraon assumes that any country has a limited pool of

goods, that if they are allowed to be consumed by immigrants from developing countries will be less available for cizens. It

the naon's producve potenal, increasing the available goods. Addionally, when immigrants turn into workers, they also

turn into new consumers and they contribute to the growing of economy.

On the other hand, most of the mes, immigrants do not use government services in a signicant degree. In most of the

countries, in order to access to social services provided by government, people have to pay the same income and social se-

curity taxes that cizens pay to support these services. In fact, in most of the wealthy economies immigrants subsidize

healthcare for locally born individuals by paying in more to the system than they withdraw as in most of the host countries

immigrants use far less healthcare resources than persons born there. A recent study has found that immigrants make up

12% of the populaon, but only account for 8.6% of total U.S. healthcare spending. (Flavin, L., Zallman, L., McCormick, D., &

Wesley Boyd, J. (2018). Medical Expenditures on and by Immigrant Populaons in the United States: A Systemac Review.

Internaonal Journal of Health Services, 48(4), 601–621).

migrant eect,” meaning that recent immigrants tend to be young and robust when they arrive. Currently, undocumented

Annual Board of Regents Meeng 2019

As the new business year is upon us, WABIP Regents (member society

representaves) shall meet and vote on WABIP acvity and nancial re-

ports for our annual lings as a non-prot organizaon in Japan. The

recipients. We are proud to announce two WABIP Vising

Deepak (India) and Dr. Mia Elhidsi (Indonesia). Dr. Deepak

shall be travelling to Maryland, USA and conduct a 3 week

observership program under supervisor Dr. Joseph S. Fried-

berg. Dr. Elhidsi shall undergo her observership in Marseille,

France under supervisor Dr. Hervé Dutau. Their learning ex-

periences shall be included in future WABIP Newsleer is-

sues.

New Member Sociees

ve regions of the world.

alent. Aer which, the natural next step would be the ability to ablate/treat them. Currently, there are several limitaons in reaching small and

ogy that would work with smaller scopes. Current navigaon systems have improved the yield of transbronchial biopsies to a great extent, How-

ever, among other issues, the human factor/operator’s skill and instrument size pose some limitaons.

Recently, innovave roboc bronchoscopic systems with built-in navigaon and sensor technology and constant tracking of the micro-

instruments may provide even more accuracy and consistency in higher yield. These devices are operated from a video-game like a console

once the scope is in the airway. The systems are equipped with sophiscated pressure/resistance feedback system similar to human tacle

study the system worked eciently and eecvely.

Another study (2) of roboc bronchoscopy system made by Intuive Surgical was tested

in its rst human study in Australia on 30 paents’. The diagnosc yield with this system

was 83% for all lesions and 89% for malignant lesions. The system appeared to be

ecient and safe.

Roboc bronchoscopy is yet another step towards our sincere desire to serve our

paents with pulmonary nodules beer and quicker. With the advent of such

technologies, we seem to be geng closer to our long-standing desire to ablate

malignant pulmonary lesions in paents who can’t tolerate surgical intervenons.

Associate editor: Dr. Sepmiu Murgu

Editor-in-Chief: Dr. Kazuhiro Yasufuku

The WABIP has started a new educaon project recently: THE WABIP ACADEMY. The WABIP Academy will pro-

vide free online webcasts with new and hot topics that will interest pulmonologists and intervenonalists.

Current webcast topic: Tissue acquision for biomarker directed therapy of NSCLC