The Effect of Pandemic on Lung Cancer Waiting Time - Tertiary Center Experience.

BACKGROUND: Early diagnosis and treatment of lung cancer are crucial to improve the survival and the outcomes in patients who are diagnosed with lung cancer. Many factors can affect the waiting time for lung cancer treatment, however, the corona virus disease 2019 (COVID-19) was one of the major factors that universally slowed down clinical activities in the last three years. We are aiming with this study to demonstrate how this pandemic and other factors affected the lung cancer waiting times for diagnosis and treatment. METHODS: This is a retrospective study including 670 patients who were diagnosed with lung cancer within the NHS Lothian region of Edinburgh - Scotland between March 2019 and November 2023. One hundred patients underwent curative lung resection. Patients were categorised into three groups for sub analysis. The first group included patients diagnosed before the COVID-19 pandemic, the second group included patients diagnosed during the pandemic in 2020, and the third group represents those diagnosed after the mass vaccination program was established and until November 2023. RESULTS: The average waiting time between the referral from the GP to the date of surgery in the three groups was 88.5 days, 81 days, and 83.5 days, respectively. On the other hand, the waiting times elapsing between the first surgical clinic appointment and the date of the surgery itself were 17.6 days, 18.6 days, and 21.5 days, respectively. CONCLUSION: Unexpectedly waiting times elapsing between the referral to surgery and the date of surgery amongst lung cancer patients showed improvement during the COVID-19 pandemic. This is likely due to prioritizing cancer patients. Nevertheless, actions should be considered to decrease the waiting times in general.

When teams disagree: Investigating the incidence and causes of dissent occurring in cancer multidisciplinary team meetings.

AIM: Multidisciplinary teams (MDT) are commonly involved in the care of patients with cancer. How frequently dissent occurs within MDT has not been studied. This study aimed to determine how frequently dissent was documented in cancer MDT meetings at our institution, the reasons for this, and the opinions of MDT members on how dissent should be documented and communicated. METHODS: A retrospective review of records from cancer MDT meetings at our institution from 2016 to 2020 was performed to identify cases where dissent was documented and the reasons for this. MDT members were invited to complete an online survey assessing their perceptions of how frequently dissent occurred, how comfortable they felt voicing dissenting opinions, and their opinions on how dissent should be documented and communicated. RESULTS: Dissent was recorded in 30 of 7737 MDT case discussions (0.39%). The incidence of dissent varied from 0 to 1.2% between cancer streams. The most common reason for dissent involved the role of surgery. 27% of survey respondents felt either very or somewhat uncomfortable voicing dissenting opinions. Only 3% felt that dissent should not be documented, and none that it should not be communicated in some way, although there were wide ranging of views on how this should occur. CONCLUSION: Dissent was rarely documented within cancer MDT meetings at our institution, likely due to underreporting. Measuring the incidence of dissent within an MDT may be a useful performance metric. MDT should develop policies for how dissent should be managed, documented, and communicated.

Sydney 'lockout' liquor licensing law restrictions have been associated with a sustained reduction in emergency department presentations from assaults over 5 years.

OBJECTIVES: The present study assessed the impact of changes to the New South Wales Liquor Act in 2014 on assault-related presentations to the ED of St Vincent's Hospital. This hospital is the primary receiving hospital for the area affected by these laws. METHODS: Patients presenting to the ED with an assault-related diagnosis were identified from the ED and trauma registry databases from 2009 to 2019 and retrospectively reviewed. The number of presentations in the 5 years prior to the introduction of the laws in 2014 was compared to the number occurring in the 5 years following this. Admission to the intensive care unit (ICU) and in-hospital death were used as markers for severe injury. RESULTS: From 2009 to 2019 there were 2983 assault-related presentations to the ED, with 153 requiring ICU admission and 12 deaths. The mean number of presentations annually fell from 342 to 255 after the introduction of the laws (P = 0.01). The reduction in presentations was sustained for the entire 5-year period after the introduction of the laws. Although the mean number of patients requiring ICU admission per year fell from 17 to 14, and the mean number of deaths annually fell from 1.6 to 0.8, neither of these were statistically significant. CONCLUSIONS: There has been a significant reduction in assault-related presentations to St Vincent's Hospital following the changes to the liquor licensing laws that has been sustained for 5 years with no significant decrease in the those with severe assault injuries.

The Black Lives Matter Movement: A Call to Action for Couple and Family Therapists.

The frequent police killings during the COVID-19 pandemic forced a reckoning among Americans from all backgrounds and propelled the Black Lives Matter movement into a global force. This manuscript addresses major issues to aid practitioners in the effective treatment of African Americans via the lens of Critical Race Theory and the Bioecological Model. We place the impacts of racism on Black families in historical context and outline the sources of Black family resilience. We critique structural racism embedded in all aspects of psychology and allied fields. We provide an overview of racial socialization and related issues affecting the parenting decisions in Black families, as well as a detailed overview of impacts of structural racism on couple dynamics. Recommendations are made for engaging racial issues in therapy, providing emotional support and validation to couples and families experiencing discrimination and racial trauma, and using Black cultural strengths as therapeutic resources.

Las frecuentes muertes a manos de la policía durante la pandemia de la COVID-19 obligaron a los estadounidenses de todos los orígenes a hacer una evaluación e impulsaron el movimiento Black Lives Matter hasta convertirlo en una fuerza mundial. Este manuscrito aborda las cuestiones principales con el fin de ayudar a los profesionales en el tratamiento eficaz de los afroestadounidenses desde la perspectiva de la teoría crítica de la raza y el modelo bioecológico. Ubicamos los efectos del racismo en las familias negras en un contexto histórico y describimos las fuentes de resiliencia de estas familias. Analizamos el racismo estructural incorporado en todos los aspectos de la psicología y en áreas afines. Ofrecemos un resumen de la socialización racial y de cuestiones relacionadas que afectan las decisiones de crianza en las familias negras, así como un panorama detallado de los efectos del racismo estructural en la dinámica de pareja. Se dan recomendaciones para integrar las cuestiones raciales en la terapia, brindar apoyo emocional y validación a parejas y familias que sufren discriminación y trauma racial, y usar las ventajas culturales de las personas de color como recursos terapéuticos.

Effect of 18F-Fluciclovine Positron Emission Tomography on the Management of Patients With Recurrence of Prostate Cancer: Results From the FALCON Trial.

PURPOSE: Early and accurate localization of lesions in patients with biochemical recurrence (BCR) of prostate cancer may guide salvage therapy decisions. The present study, 18F-Fluciclovine PET/CT in biochemicAL reCurrence Of Prostate caNcer (FALCON; NCT02578940), aimed to evaluate the effect of 18F-fluciclovine on management of men with BCR of prostate cancer. METHODS AND MATERIALS: Men with a first episode of BCR after curative-intent primary therapy were enrolled at 6 UK sites. Patients underwent 18F-fluciclovine positron emission tomography/computed tomography (PET/CT) according to standardized procedures. Clinicians documented management plans before and after scanning, recording changes to treatment modality as major and changes within a modality as other. The primary outcome measure was record of a revised management plan postscan. Secondary endpoints were evaluation of optimal prostate specific antigen (PSA) threshold for detection, salvage treatment outcome assessment based on 18F-fluciclovine-involvement, and safety. RESULTS: 18F-Fluciclovine was well tolerated in the 104 scanned patients (median PSA = 0.79 ng/mL). Lesions were detected in 58 out of 104 (56%) patients. Detection was broadly proportional to PSA level; ≤1 ng/mL, 1 out of 3 of scans were positive, and 93% scans were positive at PSA >2.0 ng/mL. Sixty-six (64%) patients had a postscan management change (80% after a positive result). Major changes (43 out of 66; 65%) were salvage or systemic therapy to watchful waiting (16 out of 66; 24%); salvage therapy to systemic therapy (16 out of 66; 24%); and alternative changes to treatment modality (11 out of 66, 17%). The remaining 23 out of 66 (35%) management changes were modifications of the prescan plan: most (22 out of 66; 33%) were adjustments to planned brachytherapy/radiation therapy to include a 18F-fluciclovine-guided boost. Where 18F-fluciclovine guided salvage therapy, the PSA response rate was higher than when 18F-fluciclovine was not involved (15 out of 17 [88%] vs 28 out of 39 [72%]). CONCLUSIONS: 18F-Fluciclovine PET/CT located recurrence in the majority of men with BCR, frequently resulting in major management plan changes. Incorporating 18F-fluciclovine PET/CT into treatment planning may optimize targeting of recurrence sites and avoid futile salvage therapy.

African American Couples in the 21st Century: Using Integrative Systemic Therapy (IST) to Translate Science into Practice.

The complexity of the African American community in the United States continues to evolve. The growing number of professional African Americans who grew up in the postcivil rights era combined with the persistent reminders of inequity paints a complex backdrop for understanding African American relationships. The majority of our knowledge about African American couples disproportionately comes from nonclinical social science fields such as sociology and demography. Unfortunately, the scholarly literature on how to work with African American couples is relatively scant. This paper seeks to add to this limited literature by providing clinicians and scholars with a proposed set of issues to consider when conceptualizing and treating African American couples. In particular, the complexity and nuance needed to work with African American couples are best done by using an integrative model. Thus, this paper will discuss how the Integrative Systemic Therapy (IST) model is particularly well suited for working with African American couples. This paper will summarize the science on African American marriages with a focus on salient factors such as gender, SES, and trust, which will then be translated into clinical practice by utilizing a case example. The case example will be of a middle-class couple in order to delineate the challenges and the growing heterogeneity of African Americans. The article will conclude with a commentary on the evolving heterogeneity of African Americans, which sheds light on how an integrative perspective is important for disentangling and embracing the growing complexity of African American couples.

La complejidad de la comunidad afroamericana de los Estados Unidos continúa evolucionando. El número cada vez mayor de afroamericanos profesionales que crecieron en la era posterior a los derechos civiles combinado con los recordatorios constantes de inequidad pinta un telón de fondo complejo para comprender las relaciones afroamericanas. La mayoría de nuestro conocimiento acerca de las parejas afroamericanas proviene desproporcionadamente de ámbitos de las ciencias sociales no clínicas, como la sociología y la demografía. Desafortunadamente, la bibliografía científica sobre cómo trabajar con parejas afroamericanas es relativamente escasa. Este artículo tiene como finalidad incrementar esta bibliografía limitada proporcionando a los clínicos y a los académicos un conjunto de asuntos propuestos para tener en cuenta al conceptualizar y tratar a las parejas afroamericanas. En particular, la complejidad y los matices necesarios para trabajar con las parejas afroamericanas se logran mejor usando un modelo integrativo. Por lo tanto, en este artículo se debatirá cómo el modelo de terapia sistémica integrativa (TSI) (Pinsof et al., 2017) se adapta perfectamente para trabajar con parejas afroamericanas. En este artículo se resumirá la ciencia sobre los matrimonios afroamericanos haciendo hincapié en factores prominentes, como el género, el nivel socioeconómico y la confianza, que luego se trasladarán a la práctica clínica utilizando un caso ilustrativo. El caso ilustrativo será de una pareja de clase media a fin de describir los desafíos y la heterogeneidad creciente de los afroamericanos. El artículo concluye con un comentario sobre la creciente heterogeneidad de los afroamericanos, donde se aclara cómo una perspectiva integrativa es importante para desenmarañar y aceptar la complejidad creciente de las parejas afroamericanas.

Confirming, Validating, and Norming the Factor Structure of Systemic Therapy Inventory of Change Initial and Intersession.

UNLABELLED: Progress or feedback research tracks and feeds back client progress data throughout the course of psychotherapy. In the effort to empirically ground psychotherapeutic practice, feedback research is both a complement and alternative to empirically supported manualized treatments. Evidence suggests that tracking and feeding back progress data with individual or nonsystemic feedback systems improves outcomes in individual and couple therapy. The research reported in this article pertains to the STIC(®) (Systemic Therapy Inventory of Change)-the first client-report feedback system designed to empirically assess and track change within client systems from multisystemic and multidimensional perspectives in individual, couple, and family therapy. Clients complete the STIC Initial before the first session and the shorter STIC Intersession before every subsequent session. This study tested and its results supported the hypothesized factor structure of the six scales that comprise both STIC forms in a clinical outpatient sample and in a normal, random representative sample of the U.S. POPULATION: This study also tested the STIC's concurrent validity and found that its 6 scales and 40 of its 41 subscales differentiated the clinical and normal samples. Lastly, the study derived clinical cut-offs for each scale and subscale to determine whether and how much a client's score falls in the normal or clinical range. Beyond supporting the factorial and concurrent validity of both STIC forms, this research supported the reliabilities of the six scales (Omegahierarchical ) as well as the reliabilities of most subscales (alpha and rate-rerate). This article delineates clinical implications and directions for future research.

Cognitive impairment associated with carcinoid syndrome.

OBJECTIVES: To evaluate the cognitive performance of patients with carcinoid syndrome (CS) compared with population norms and cancer patients with non-neuroendocrine (non-NET) liver metastases. BACKGROUND: The release of serotonin into the systemic circulation from metastatic small bowel neuroendocrine tumors (SB NET) causes CS. Many patients with CS followed in a multidisciplinary NET clinic seemed to exhibit a unique cognitive impairment. Because serotonin is known to influence a range of cognitive function, the question arouse as to whether cognitive impairment is another manifestation of CS. METHODS: Patients were recruited from the multidisciplinary NET and the hepatobilary cancer clinics at the cancer center. The CS group consisted of patients with proven SB NETs metastatic to liver; the cancer comparison group consisted of patients with liver metastases from non-NET cancer. All completed a self-reported cognitive questionnaire and a battery of 6 standardized neurocognitive tests. Both groups were compared to age/sex/educational-matched norms. RESULTS: Thirty-six patients with CS and 20 with non-NET metastases were enrolled. Patients with CS reported greater cognitive dysfunction in all cognitive domains than both norms and the comparison cancer group. On cognitive testing, patients with CS demonstrated weakness in initiation, processing speed, visual memory, cognitive efficiency, and delayed verbal recall compared with norms. Although the patients with non-NET cancer also demonstrated some cognitive dysfunction compared with norms, the patients with CS did significantly worse on delayed recall (P = 0.03) and marginally slower on speeded mental flexibility (P = 0.097) compared with patients with non-NET cancer. CONCLUSION: This study confirmed our clinical observation that patients with CS suffer from cognitive impairment that is different from the non-NET cancer group and population norms.

Research on the treatment of couple distress.

This article reviews the research on couple therapy over the last decade. The research shows that couple therapy positively impacts 70% of couples receiving treatment. The effectiveness rates of couple therapy are comparable to the effectiveness rates of individual therapies and vastly superior to control groups not receiving treatment. The relationship between couple distress and individual disorders such as depression and anxiety has become well established over the past decade. Research also indicates that couple therapy clearly has an important role in the treatment of many disorders. Findings over the decade have been especially promising for integrative behavioral couples therapy and emotion-focused therapy, which are two evidence-based treatments for couples. Research has also begun to identify moderators and mediators of change in couple therapy. Finally, a new and exciting line of research has focused on delineating the principles of change in couple therapy that transcends approach.

Invasive melanoma of the face: Management, outcomes, and the role of sentinel lymph node biopsy in 260 patients at a single institution.

BACKGROUND AND OBJECTIVES: The face is a common site of melanoma occurrence. The purpose of this study was to examine the management and outcomes of patients with invasive melanoma of the face. METHODS: Patients with invasive melanoma of the face managed at our institution from 1997 to 2008 were retrospectively reviewed. Details of sentinel lymph node biopsy (SNB), disease recurrence, and deaths were recorded. RESULTS: Two hundred sixty patients were reviewed (mean age 68, mean tumor thickness 0.87 mm). Of 100 patients eligible for SNB (tumor thickness ≥ 1 mm, Clark level ≥ IV, or ulceration) this was performed in only 29 (29%), and those who underwent SNB were younger than those who did not (mean age 59 vs. 79 years, P < 0.0001). SNB was successful in 28 (97%), and no complications occurred. SNB was positive in 3 (11%). After mean follow-up of 30 months, nodal recurrence occurred in 9 (3.5%) and distant recurrence in 20 (7.7%). There were 60 deaths (overall mortality 23%); attributed to melanoma in only 16 cases (disease specific mortality 6.2%). CONCLUSIONS: Facial melanoma is associated with low rates of regional recurrence despite underutilization of SNB. Older patients are less likely to undergo SNB. Due to the advanced age of patients with facial melanoma, most deaths occurring are from unrelated causes.

Role of imaging in the preoperative staging of small bowel neuroendocrine tumors.

BACKGROUND: Imaging studies are important in the preoperative staging of patients with small bowel neuroendocrine tumors (NET) and when selecting patients for cytoreduction procedures for metastatic disease. The purpose of this study was to assess the accuracy of preoperative imaging compared with operative findings in the staging of small bowel NET. STUDY DESIGN: Sixty-four patients with small bowel NET undergoing laparotomy and who had preoperative imaging with combinations of CT, MR, and radionuclide scintigraphy were reviewed. Results of imaging studies were compared with operative findings to assess the ability of these investigations to detect mesenteric, peritoneal, and hepatic metastases. RESULTS: Mesenteric nodal metastases were seen on imaging in 47 (73%) patients and were present at laparotomy in 56 (88%) patients. Peritoneal metastases were seen on preoperative imaging in 4 (6%) patients and found at laparotomy in 16 (25%) patients. Hepatic metastases were seen on imaging in 42 patients (66%) and found at laparotomy in 49 (77%). Sensitivity and specificity for detection of hepatic metastases were 77% and 100% for CT, 82% and 100% for MR, 63% and 100% for (123)I-meta-iodobenzylguanadine scintigraphy, and 63% and 100% for (111)In-octreotide. Imaging studies failed to detect hepatic metastases in 7 patients and underestimated the extent of hepatic metastatic disease in 17 patients. CONCLUSIONS: Imaging of small bowel NET, even with combinations of CT, MR, and radionuclide studies, underestimates the extent of peritoneal, mesenteric, and hepatic metastatic disease. Accurate staging of small bowel NET might be best performed at the time of laparotomy.

Does surgery have a role in T4N0 and T4N1 lung cancer?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether [surgery] has a role in [treatment of T4N0 and T4N1 lung cancer]. Altogether more than 151 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that upfront surgery for locally invasive T4 tumours without mediastinal lymph node involvement (T4N0 and T4N1 non-small cell lung cancer) is of benefit in terms of survival rates in carefully selected patients. Overall five-year survival rates following resection of T4N0-N2 tumours vary from 19.1% to 57% (from six studies), within which, involvement of certain structures were found to greatly affect prognosis. Pulmonary artery invasion has a good prognosis (five-year survival; 52.8%) relative to other mediastinal structures [five-year survival: left atrium; N0; 28.94%, N1; 27.92%, N2; 17.95% (three-year survival), aorta; N0; 100%, N1; 37.1%, N2; 0%, superior vena cava (SVC); 11%, -29.4% (from four studies), carina; 28-42.5% (two studies), veterbral bodies; 16%, oesophagus; 12%, pleural dissemination; 0%]. When considering isolated invasion of the pulmonary great vessels there are mixed outcomes, one study reporting reduced mortality (reduced risk -0.483, P=0.004) in contrast to another that found five-year survival of 35.7% with great vessel invasion vs. 58.3% for invasion of all other structures excluding the pulmonary great vessels. The prognostic variables found to be of greatest determinacy were; first, the completeness of resection, wherein five-year survival rates ranged from 37.5 to 46.2% (from three studies) with complete tumour removal, and 15.9-22.4% (from three studies) with incomplete resection, and second, nodal status of the patients, N0/N1 having five-year survival of 43-74% and N2 of 15.1-17.5% (P=0.022 and P=0.007, for two studies). Multiple intralobar lesions represent either multilobar metastasis or NSCLC with multifocal origin and have been found to behave differently to invasive T4 tumours. Reported five-year survival in NSCLC with satellite nodules is 48.2-57% compared with 18-30% from T4 invasive tumours (three studies), respectively (P=0.011) corroborating the change in TNM ipsilobar multifocal T4 disease to be recoded as T3.

Is blood pleurodesis effective for determining the cessation of persistent air leak?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether blood pleurodesis is effective for cessation of persistent air leak (PAL). Altogether more than 43 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that autologous blood pleurodesis has superior outcomes when compared with conservative management for treatment of postoperative PAL. In addition, for PAL causing pneumothorax, blood pleurodesis [optimal volume 100 ml (from two studies)] should be considered in patients who are unsuitable for surgery, talc pleurodesis is ineffective or not viable (including cases complicated by acute respiratory distress syndrome) and a prompt resolution is required. Some 70-81% of patients treated for postoperative air leak resolved within 12 h and 95-100% within 48 h vs. a mean of 3-6.3 days (from two studies) with simple drainage. Resolution of pneumothorax with blood pleurodesis was also significantly shorter (P<0.01). Overall success rates (from all studies) were 92.7% (n=133) from patients having undergone pulmonary surgery (76.6% in one injection, n=111), and 91.7% (n=109) of patients with pneumothorax. Recurrence rates were between 0 and 29% compared with 35-41% for simple drainage, although one controlled study in which the recurrence rate was improved from 16% in controls to 0% in the blood pleurodesis group (at 12-48 months). Minor complication (empyema/fever/pleural effusion) rates varied between studies (0-18%), although they show reduced incidence in line with improving technique over time. A controlled study looking at acute respiratory distress syndrome complicated by pneumothorax showed a significant reduction in mortality (odds ratio 0.6), time to cessation of air leak (P<0.01), weaning time (P<0.01) and intensive treatment unit (ITU) stay (P<0.01) whilst another randomized control study showed significant reduction in hospital stay following pulmonary resection (P<0.001).

Arteriovenous malformation in the anterior mediastinum.

Arteriovenous malformations of the mediastinum are exceedingly rare. A literature search found fewer than 10 reported cases of congenital, posterior mediastinal arteriovenous malformations in adults. We describe a giant anterior mediastinal arteriovenous malformation in a 29-year-old man.

Is video-assisted thoracoscopic surgical decortication superior to open surgery in the management of adults with primary empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracoscopic surgical decortication (VATSD) might be superior to open decortication (OD) (or chest tube drainage) for the management of adults with primary empyema? Altogether 68 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that VATSD has superior outcomes for the treatment of persistent pleural collections in terms of postoperative morbidity, complications and length of hospital stay, and gives equivalent resolution when compared with OD. One study comparing VATSD and chest tube drainage of fibrinopurulent empyema found video-assisted thoracoscopic surgery (VATS) had higher treatment success (91% vs. 44%; P<0.05), lower chest tube duration (5.8+/-1.1 vs. 9.8+/-1.3 days; P=0.03), and lower number of total hospital days (8.7+/-0.9 vs. 12.8+/-1.1 days; P=0.009). Eight studies comparing early and late empyema report conversion rates to OD of 0-3.5% in early, 7.1-46% in late stage and significant reductions in length of stay with VATSD compared with OD both postoperatively (5 vs. 8 days; P=0.001) and in total stay (15 vs. 21; P=0.03). Additionally VATS resulted in reduced postoperative pain (P<0.0001) and complications including atelectasis (P=0.006), prolonged air-leak (P=0.0003), sepsis (P=0.03) and 30-day mortality (P=0.02). Five studies considered only chronic persistent empyema of which two directly compared VATSD to tube thoracostomy (TT). VATS resolved 88% of cases and had mortality rates of 1.3% compared with 62% and 11%, respectively, for TT. Moreover, conversion to OD was 10.5-17.1% with VATS and 18-37% with TT (P<0.05). In agreement with mixed stage empyema, hospital stay was reduced both postoperatively (8.3 vs. 12.8 days; P<0.05) and in total (14+/-1 vs. 17+/-1 days; P<0.05), and when compared with OD (one study), pain (P<0.0001), postoperative air-leak (P=0.004), hospital stay (P=0.020) and time to return to work (P<0.0001) were all reduced with VATS. Additionally, re-operation (4.8% vs. 1%; P=0.09) and mortality (4/123% vs. 0%) were lower in VATS vs. OD.

In elderly patients with lung cancer is resection justified in terms of morbidity, mortality and residual quality of life?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: In [patients over 70 years of age with lung cancer] is [lung resection] when compared with [non-surgical treatment] justified in terms of [postoperative morbidity, mortality and quality of life]? Altogether more than 297 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that patients over 70 years of age undergoing anatomical lung resection respond as well as younger patients in terms of morbidity, mortality and residual quality of life (QoL). Collective analysis of the papers reveals no significant difference in five-year survival rates following surgery for early stage disease (stage I non-small cell lung cancer: <70 years; 69-77%, >70 years; 59-78%), although, elderly patients currently receive far higher rates of palliative care (30-47% in patients 65-70 years vs. 8% in patients under 65 years). Additionally, 30-day mortality rates (5.7% <70 years vs. 1.3-3.3% >70 years), length of hospital stay [1.3 days vs. 1 day (video-assisted mini-thoracotomy) and 4.6 vs. 4.9-5.2 days (thoracotomy) for <70 years vs. >70 years, respectively] and postoperative lung function tests (FEV(1) decrease; 13% <70 years vs. 18% >70 years P=0.34, functional vital capacity decrease; 9% <70 years vs. 14% >70 years P=0.31) are equivalent between the two age groups. Residual QoL following lobectomy (evaluated by patient self-assessment) showed decreased social (P<0.001) and role (P<0.001) functioning but less pain at discharge (P<0.001) in those over 70 years. Global QoL, however, was not influenced by age (global QoL; <70 years 22.2+/-25.3 vs. >70 years 17.6+/-22.9). Pneumonectomy showed statistically significant decreases in physical functioning [six months postoperatively (MPO) P=0.045], role functioning (3 MPO P=0.035), social functioning (6 MPO P=0.006, 12 MPO P=0.001) and general pain (6 MPO P=0.037), but showed no age related differences (<70 years; 81.9+/-19.1, >70 years; 78.0+/-22.8).

Do patients undergoing lung biopsy need a postoperative chest drain at all?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether insertion of an intercostal chest drain prolongs the length of stay of patients undergoing lung biopsy. Altogether 210 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that where an intraoperative check reveals no air leak, chest drain should be avoided if possible in order to discharge patients earlier. Where chest drain is used following video-assisted thoracoscopic surgery lung biopsy, early removal results in reduced pain and earlier discharge. Four studies advocate early chest tube removal, allowing discharge of 95% within 24 h in one study, reduced hospital stay from 3.9+/-2.1 days to 2+/-1 days (P=0.001) in another, and a median stay of 1.2 days (range 0-7 days) in a third. Removal of chest drain within 1 h of the operation was possible in 92% of patients (one study), significantly reducing pain (P=0.03, P=0.005; two studies) and postoperative complications (P=0.01; one study) compared with conventional treatment. Five studies in which patients were managed without chest drain following intraoperative air leak checks, reduced hospital stay vs. conventional management (two studies; 2 vs. 3, P<0.001, 1 vs. 3, P<0.01) but results in no difference in complication rates (three studies: pneumothoraces requiring chest drain; 2 vs. 2, P=non-significant; 0 vs. 0; 0 vs. 0) or pain score (two studies; 0.77 vs. 0.76, P=0.894; 5 vs. 5, P=0.81).