Impaired contractility of the diaphragm can occur secondary to diaphragm paralysis. Signs and symptoms of diaphragm paralysis vary among patients. Some may be asymptomatic and present incidentally, while others experience dyspnea secondary to impaired ventilation. Patients who are symptomatic from diaphragm paralysis may benefit from surgical intervention with diaphragm plication. Many surgical approaches are available for diaphragm plication, including open, thoracoscopic, laparoscopic, and robotic-assisted procedures. In this paper, we discuss our step-by-step approach to a robotic, transabdominal diaphragm plication. This was performed in a 60-year-old female presenting with dyspnea secondary to left hemidiaphragm paralysis. The technique includes inducing an iatrogenic pneumothorax to create a pressure equilibrium between the thoracic and peritoneal spaces. Subsequently, a diaphragm plication is performed in a 2-layer approach, using an initial running suture and subsequent reinforcing interrupted sutures in two separate axes, namely the posterior and anterior axes. Lastly, the plication repair is verified through the use of a thoracic port, which is subsequently used for tube thoracostomy placement.

Interstitial lung disease (ILD) encompasses a complex group of disorders primarily characterized by inflammation and fibrosis of the pulmonary interstitium. Affected individuals often present with dyspnea and cough, and their quality of life is markedly reduced. Given the limitations of current health management strategies, there is growing interest in exploring adjunctive supportive approaches based on functional foods. Ginseng, a traditional medicinal and edible plant, has a long history of consumption in East Asia. Studies have shown that ginseng and its major bioactive constituents, such as ginsenosides, exert beneficial regulatory effects on lung health by modulating key signaling pathways, including TGF-β/Smad, NF-κB, Nrf2/HO-1, and MAPK. These effects primarily involve health-promoting properties such as anti-inflammatory, antioxidant, and immunomodulatory activities. From the perspective of food science and nutrition, this article systematically reviews the regulatory mechanisms through which ginseng and its active components influence pathological processes related to ILD. It also discusses its traditional use as a functional food, dietary exposure, safety, and intake considerations. Current evidence from preclinical studies and early-stage population-based investigations supports the potential of ginseng as a supportive dietary component for maintaining lung health. Future research should include well-designed nutritional studies to clarify its specific role in health management and to establish appropriate intake regimens.

Spontaneous hemothorax, defined as bleeding into the pleural cavity without trauma or coagulopathy, is rare. Especially, it is uncommon in patients with primary epithelial lung cancer. We report a rare autopsy case of lung adenocarcinoma harboring both an anaplastic lymphoma kinase (ALK) rearrangement and a tumor protein p53 (TP53) mutation, in which hemothorax led to the formation of a giant pleural hematoma.A 75-year-old man with stage IVB lung adenocarcinoma presented with mediastinal and cervical lymph node metastases and right pleural effusion at diagnosis. Molecular testing revealed an ALK rearrangement and a TP53 mutation. He was treated sequentially with alectinib, lorlatinib, and brigatinib. After disease progression and treatment-related complications, he presented to the emergency department with acute dyspnea and a rapid decrease in hemoglobin level. Contrast-enhanced computed tomography showed encapsulated fluid retention with faint high attenuation in the right pleural cavity, and magnetic resonance imaging findings were consistent with a hematoma. Given his poor performance status and the absence of active bleeding on imaging, invasive intervention was not performed. Despite supportive management, he died one week after admission from respiratory failure and hemodynamic deterioration.Autopsy revealed a giant pleural hematoma above the diaphragm, surrounded by pleural metastases. Although no definite source vessel was identified, active bleeding from a metastatic pleural lesion was observed, suggesting persistent tumor-related hemorrhage as the cause of the hemothorax.This case represents an extremely rare presentation of ALK-rearranged lung adenocarcinoma complicated by spontaneous hemothorax. Neither ALK rearrangement nor TP53 mutation has been directly linked to hemothorax, but the aggressive biological behavior associated with this molecular profile may have contributed to the catastrophic pleural bleeding. In lung cancer patients, rapid pleural fluid accumulation with hyperdense imaging findings should raise suspicion for hemothorax.

A 25-year-old woman with progressive dyspnea underwent multimodality cardiovascular imaging, establishing the diagnosis of interrupted aortic arch with a giant pulmonary artery aneurysm. The combined strengths of echocardiography, cardiac computed tomography, cardiovascular magnetic resonance, and 4D flow imaging guided therapeutic decision-making in complex congenital heart disease.

Selpercatinib is a selective RET inhibitor with established efficacy in RET-altered malignancies; however, data regarding its long-term safety and pharmacokinetic behavior remain limited. We report a case of fatal hepatic failure occurring during prolonged selpercatinib therapy and describe associated clinical and pharmacokinetic findings. A 78-year-old man with RET-mutant medullary thyroid carcinoma received selpercatinib (160 mg twice daily) as second-line therapy following disease progression during vandetanib treatment. After dose interruption and subsequent dose adjustments, the patient achieved a sustained partial response during long-term treatment. Approximately 27 months after selpercatinib initiation, he developed progressive dyspnea, pleural effusion, and severe hepatic dysfunction, ultimately resulting in death. Plasma selpercatinib concentrations were measured during stable disease and later during hepatic decompensation. Pharmacokinetic analysis indicated that drug exposure during the stable treatment period was within the anticipated range, suggesting that elevated drug concentrations observed at the time of hepatic decompensation represented a consequence of impaired clearance rather than a primary cause. These findings implicate circulatory compromise as a potential mediating mechanism and highlight the importance of cardiovascular as well as hepatic monitoring during prolonged selpercatinib therapy. This case highlights a potential indirect mechanism of severe hepatic failure during long-term selpercatinib therapy, in which circulatory compromise-potentially mediated by selpercatinib-associated cardiovascular effects-may have contributed to congestive hepatic decompensation rather than direct drug-induced hepatotoxicity. These findings underscore the importance of integrating cardiovascular surveillance with hepatic monitoring during prolonged selpercatinib treatment.

COPD remains a leading cause of global morbidity and mortality, and a substantial minority of patients remain disabled by hyperinflation, chronic bronchitis, and exacerbations despite optimized inhaled pharmacotherapy and pulmonary rehabilitation. Over the past two decades, bronchoscopic interventions have matured from clinical trial investigation into guideline-endorsed treatments for patients with refractory symptoms despite optimal medical treatment. This state-of-the-art review synthesizes the mechanistic rationale, evidence-based clinical trial data, patient-selection criteria, key controversies, and future research needs for bronchoscopic lung volume reduction (BLVR) and airway-directed therapies. In rigorously selected patients with severe emphysema, hyperinflation, and absence of interlobar collateral ventilation, endobronchial valves deliver clinically meaningful, durable improvements in FEV1, 6-min walk distance, dyspnea, and quality of life with moderate-to-high certainty and carry the highest guideline rating (GOLD Evidence A). Pneumothorax, occurring in roughly 18-34% of valve recipients, is the principal early complication, necessitating several days of in-patient monitoring that add complexity and cost to care. Endobronchial coils and thermal vapor ablation offer fissure-independent but more modest benefit; airway scaffolds are an emerging, tissue-sparing option that may extend candidacy to patients ineligible for existing bronchoscopic approaches; targeted lung denervation may stabilize lung function and symptoms but did not reduce exacerbations in its pivotal trial; and bronchial rheoplasty and metered cryospray are emerging options for the chronic bronchitis phenotype. The field is now advancing toward expanding candidacy for endobronchial valve therapy through collateral ventilation conversion, individualized complication prediction, and phenotype-matched airway therapies. Multidisciplinary, imaging-driven patient selection that addresses the key features of a patient's symptoms while avoiding significant comorbidity remains the cornerstone of successful outcomes.

Oropharyngeal stenosis is a rare condition that can develop following head and neck cancer treatment, leading to progressive dyspnea, dysphagia, and dysphonia. Patients with symptomatic dyspnea may benefit from endoscopic surgery. However, head and neck cancer survivors can have severe trismus, limited neck extension, and altered laryngeal landmarks, which make rigid endoscopic surgery under general anesthesia high-risk or potentially not feasible without a tracheostomy tube. We describe an awake approach for the management of oropharyngeal stenosis for 2 head and neck cancer survivors with high-risk airways. Briefly, under monitored anesthesia care in the operating room, a flexible channeled nasolaryngoscope was utilized to perform awake blue light laser excision of stenosis followed by balloon dilation. Postoperatively, both patients reported symptomatic improvement, and objective increases in airway patency were noted at clinic follow-up. This operative technique represents a feasible, well-tolerated approach for high-risk airway patients with oropharyngeal stenosis.

Endovascular therapy for occlusive lesion might reduce cardiac afterload and improve cardiac function potentially, but there is limited evidence regarding its effects on heart failure, particularly in patients with poorly controlled symptoms. One month earlier, this 80-year-old woman with paroxysmal atrial fibrillation had undergone left axillo-bifemoral bypass for acute aortoiliac occlusion and was transferred to a rehabilitation hospital. After that, she was returned to our hospital after developing palpitations, dyspnea, and hypoxia during post-operative rehabilitation. Laboratory tests showed anemia, mild renal dysfunction, and markedly elevated B type natriuretic peptide. Chest radiography demonstrated bilateral pulmonary congestion. She was diagnosed to acute heart failure, and treatment with intravenous furosemide at a dose of 40 mg/day and oral amiodarone at a dose of 100 mg/day was initiated. Because sinus rhythm could not be maintained despite medical therapy and pulmonary vein isolation, atrioventricular node radiofrequency catheter ablation and cardiac resynchronization therapy pacemaker implantation were performed on hospital Day 12. However, exertional oxygen desaturation persisted, BNP remained elevated, and rehabilitation was limited by bilateral intermittent claudication. On hospital Day 22, endovascular therapy for aortoiliac occlusive disease was performed. Subsequently, additional endovascular therapy was undertaken for chronic total occlusion of the left superficial femoral artery. She was able to ambulate 20 m with support without any intermittent claudication (ankle-brachial index increased from 0.67 to 0.91 on the right and from 0.81 to 0.98 on the left). Oxygen demand also gradually decreased (from 1 L/min to room air), and B type natriuretic peptide levels declined. Both systolic and diastolic blood pressure improved, and the patient was transferred back to the rehabilitation hospital on hospital Day 54 (32 days after endovascular therapy) without recurrence of heart failure symptoms. This case highlights two clinically relevant points. First, endovascular therapy for aortoiliac occlusive disease led to improvement in heart failure status. Second, B type natriuretic peptide levels showed a clear improvement following endovascular therapy.

Turner syndrome (TS) is associated with congenital heart disease, most commonly a bicuspid aortic valve and coarctation of the aorta; however, partial anomalous pulmonary venous return (PAPVR) remains an underrecognized cardiovascular anomaly. PAPVR, in which one or more pulmonary veins drain into the systemic venous circulation, can cause left-to-right shunting, right-sided chamber dilation, and pulmonary hypertension (PH). We report the case of a 51-year-old woman with TS and hypertension who presented with dyspnea and an estimated right ventricular systolic pressure of 55 mmHg on echocardiography. Right heart catheterization (RHC) showed severe PH, with a mean pulmonary artery pressure of 53 mmHg, a pulmonary capillary wedge pressure of 16 mmHg, and a pulmonary vascular resistance of 2.1 Wood units, along with unexpectedly high pulmonary artery oxygen saturations suggestive of a left-to-right shunt. Cardiac MRI demonstrated right-sided enlargement with a pulmonary-to-systemic flow ratio (Qp:Qs) of approximately 3.0 but no intracardiac defect. CT confirmed PAPVR, with the right superior and middle pulmonary veins draining into the superior vena cava and the left superior pulmonary vein draining into the brachiocephalic vein. She improved clinically with tadalafil and furosemide and was referred for surgical evaluation. In patients with TS and unexplained PH, an unexpectedly high pulmonary artery oxygen saturation on RHC should raise suspicion for an occult left-to-right shunt. When no intracardiac defect is identified, multimodality imaging with cardiac MRI and CT can reveal extracardiac shunt lesions such as PAPVR and guide timely referral for definitive management.

Sarcoidosis is a multisystem granulomatous disease that can involve multiple organ systems, present with varied clinical features, and overlap diagnostically with malignancy and immune-mediated disorders. We report the case of a 39-year-old woman who presented with mild dyspnea, generalized weakness, and unintentional weight loss, accompanied by marked hypereosinophilia. Laboratory evaluation revealed a cholestatic pattern of liver injury, elevated total serum IgG, markedly elevated serum IgG4, elevated serum IgE, polyclonal hypergammaglobulinemia, and elevated serum angiotensin-converting enzyme levels. Cross-sectional imaging demonstrated marked hepatosplenomegaly with multiple nodular lesions, extensive abdominal and mediastinal lymphadenopathy, and bilateral subpleural pulmonary nodules. Given these findings, an infiltrative or malignant process was initially suspected. Excisional lymph node biopsy revealed non-necrotizing granulomatous inflammation consistent with sarcoidosis. Bone marrow aspiration and biopsy demonstrated preserved hematopoiesis without abnormal cellular infiltration, while acid-fast bacilli staining and mycobacterial cultures were negative, effectively excluding hematologic malignancy, tuberculosis, and primary hypereosinophilic syndromes. This case expands the limited literature on hepatic sarcoidosis presenting with marked hypereosinophilia and elevated serum IgG4, emphasizing the importance of histopathological confirmation and systematic exclusion of alternative diagnoses.