A Case of Pulmonary Langerhans Cell Sarcoma Simultaneously Diagnosed with Cutaneous Langerhans Cell Histiocytosis Studied by Whole-Exome Sequencing.

Langerhans cell histiocytosis (LCH) and Langerhans cell sarcoma (LCS) are clonal proliferations of Langerhans-type cells. Unlike in LCH, the pathophysiology and clinical course of LCS are unclear due to its rarity. Here, we report the case of a 73-year-old male patient who was diagnosed with cutaneous LCH and pulmonary LCS at the same time. Pathological review of these 2 tumors revealed similar immunohistochemical findings. However, the tumor cells in LCS had more aggressive cytological features than those in LCH. Results of BRAF mutation analysis using real-time PCR were negative for both tumors. In whole-exome sequencing (WES), stop-gain mutations in TP53 gene were discovered only in LCS cells. The mechanism of development of LCS from various progenitor cells is currently unclear. According to the results of the WES study, changes in TP53 gene might have contributed to the malignant features of LCS.

Unintended Pulmonary Artery Ligation during PDA Ligation.

A 10-day-old boy was transferred to our hospital due to tachypnea. Patent ductus arteriosus (PDA), 4.8 mm in diameter, with small ASD was diagnosed on echocardiography. Surgical ligation of the ductus was performed after failure of three cycles of ibuprofen. However, the ductus remained open on routine postoperative echocardiography on the second postoperative day, and chest CT revealed inadvertent ligation of the left pulmonary artery (LPA) rather than the PDA. Emergent operation successfully reopened the clipped LPA and ligated the ductus on the same (second postoperative) day.Mechanical ventilator support was weaned on postoperative day 21, and the baby was discharged on postoperative day 47 with a normal left lung shadow.

Virulence and transmissibility of H1N2 influenza virus in ferrets imply the continuing threat of triple-reassortant swine viruses.

Efficient worldwide swine surveillance for influenza A viruses is urgently needed; the emergence of a novel reassortant pandemic H1N1 (pH1N1) virus in 2009 demonstrated that swine can be the direct source of pandemic influenza and that the pandemic potential of viruses prevalent in swine populations must be monitored. We used the ferret model to assess the pathogenicity and transmissibility of predominant Korean triple-reassortant swine (TRSw) H1N2 and H3N2 influenza viruses genetically related to North American strains. Although most of the TRSw viruses were moderately pathogenic, one [A/Swine/Korea/1204/2009; Sw/1204 (H1N2)] was virulent in ferrets, causing death within 10 d of inoculation, and was efficiently transmitted to naive contact ferrets via respiratory droplets. Although molecular analysis did not reveal known virulence markers, the Sw/1204 virus acquired mutations in hemagglutinin (HA) (Asp-225-Gly) and neuraminidase (NA) (Ser-315-Asn) proteins during the single ferret passage. The contact-Sw/1204 virus became more virulent in mice, replicated efficiently in vitro, extensively infected human lung tissues ex vivo, and maintained its ability to replicate and transmit in swine. Reverse-genetics studies further indicated that the HA(225G) and NA(315N) substitutions contributed substantially in altering virulence and transmissibility. These findings support the continuing threat of some field TRSw viruses to human and animal health, reviving concerns on the capacity of pigs to create future pandemic viruses. Apart from warranting continued and enhanced global surveillance, this study also provides evidence on the emerging roles of HA(225G) and NA(315N) as potential virulence markers in mammals.

Localized thymic amyloidosis presenting with myasthenia gravis: case report.

A mediastinal mass was incidentally found on chest radiography in a 46-yr-old woman who had had myasthenia gravis (MG) for 2 months. Computed tomography revealed a 4-cm in size, well-defined, and lobulating mass with nodular calcification that was located in the thymus. Microscopically, the mass consisted of diffuse amorphous eosinophilic materials. These deposits exhibited apple-green birefringence under polarized light microscopy after Congo red staining. Immunohistochemical analysis revealed that they were positive for both kappa and lambda light chains and negative for amyloid A. A diagnosis of localized primary thymic amyloidosis was finally made. After thymectomy, the symptoms of MG were controlled with reduced corticosteroid requirements. Localized thymic amyloidosis associated with MG has not been reported to date.

Correlation between 10-meter walking speed and exercise capacity in patients with surgical resection for lung cancer.

Surgical resection for lung cancer adversely impacts exercise capacity. The 6-minute walk test (6MinWT) and cardiopulmonary exercise test (CPET) are commonly used to assess exercise capacity. However, these tests are difficult to use clinically because they must be performed by a trained technician using specialized equipment according to a prescribed method. This study aims to analyze correlations between walking speed in a 10-meter walk test and exercise capacity measured by the 6MinWT or CPET in patients with lung resection for lung cancer. A total of 50 patients who were diagnosed with lung cancer and underwent lung resection were included in the analysis. The 6MinWT and CPET were performed to measure exercise capacity, and the 10-meter walk test was used to evaluate the short-duration walking speed. The population was divided into 2 groups -low and high exercise capacity - based on threshold values (6MinWT, 500 m; CPET, 20 mL·kg-1·min-1); we analyzed the correlation according to the level of exercise capacity. In the correlation analysis between the 10-meter walking speed and exercise capacity, the 10-meter walking speed showed a strong correlation (R = 0.70, P < .001) with the 6MinWT and a moderate correlation (R = 0.47, P < .001) with the CPET, respectively. The low exercise capacity group showed a significant correlation (6MinWT, ρ = 0.70; CPET, ρ = 0.54) between the 10-meter walking speed and exercise capacity, while the high exercise capacity group did not. In patients who underwent lung resection for lung cancer, the 10-meter walking speed was significantly correlated with exercise capacity, especially in subjects with low exercise capacity that require pulmonary rehabilitation.

Quantitative Measurement of Pneumothorax Using Artificial Intelligence Management Model and Clinical Application.

Artificial intelligence (AI) techniques can be a solution for delayed or misdiagnosed pneumothorax. This study developed, a deep-learning-based AI model to estimate the pneumothorax amount on a chest radiograph and applied it to a treatment algorithm developed by experienced thoracic surgeons. U-net performed semantic segmentation and classification of pneumothorax and non-pneumothorax areas. The pneumothorax amount was measured using chest computed tomography (volume ratio, gold standard) and chest radiographs (area ratio, true label) and calculated using the AI model (area ratio, predicted label). Each value was compared and analyzed based on clinical outcomes. The study included 96 patients, of which 67 comprised the training set and the others the test set. The AI model showed an accuracy of 97.8%, sensitivity of 69.2%, a negative predictive value of 99.1%, and a dice similarity coefficient of 61.8%. In the test set, the average amount of pneumothorax was 15%, 16%, and 13% in the gold standard, predicted, and true labels, respectively. The predicted label was not significantly different from the gold standard (p = 0.11) but inferior to the true label (difference in MAE: 3.03%). The amount of pneumothorax in thoracostomy patients was 21.6% in predicted cases and 18.5% in true cases.

Virtual randomized study comparing lobectomy and particle beam therapy for clinical stage IA non-small cell lung cancer in operable patients.

To the best of our knowledge there have been no randomized controlled trials comparing lobectomy-a standard treatment for patients with early-stage non-small cell lung cancer (NSCLC)-and particle beam therapy (PBT), the best performing existing radiotherapy. We conducted a virtual randomized trial in medically operable patients with stage IA NSCLC to compare lobectomy and PBT effectiveness. A Markov model was developed to predict life expectancy after lobectomy and PBT in a cohort of patients with stage IA NSCLC. Ten thousand virtual patients were randomly assigned to each group. Sensitivity analyses were performed as model variables and scenarios changed to determine which treatment strategy was best for improving life expectancy. All estimated model parameters were determined using variables extracted from a systematic literature review of previously published articles. The preferred strategy differed depending on patient age. In young patients, lobectomy showed better life expectancy than that of PBT. The difference in life expectancy between lobectomy and PBT was statistically insignificant in older patients. Our model predicted lobectomy as the preferred strategy when operative mortality was under 5%. However, the preferred strategy changed to PBT if operative mortality post lobectomy was over 5%. For medically operable patients with stage IA NSCLC, our Markov model revealed the preferred strategy of lobectomy or PBT regarding operative mortality changed with varying age and comorbidity. Until randomized controlled trial results become available, we hope the current results will provide a rationale background for clinicians to decide treatment modalities for patients with stage IA NSCLC.

Contained local compression on peri-ascending aortic area for postoperative bleeding control: a case report.

After type A acute aortic dissection (AAD) repair or modified Bentall procedure, uncontrollable bleeding from the anastomotic sites of the fragile dissected tissues or aortic root area is a critical situation to a cardiac surgeon. For postoperative care, lots of blood transfusion with strict monitoring on the patient all night and subsequent reoperation for the bleeding control is usually needed. We managed to make contained local compression of upper half of the heart, from upper part of the right ventricle to just above the innominate vein, using bovine pericardium with closing both sides of transverse sinus in two cases of uncontrolled postoperative bleeding (bleeding from distal anastomotic site in type-A AAD and valve sitting site in modified Bentall procedure). Even though reoperations for the removal of packed gauges were done in both cases 2 days later, postoperative courses at intensive care unit were very smooth with little need for transfusion. This kind of contained local compression trial could be a useful strategy for dealing with the malignant uncontrollable bleeding from the fragile aortic tissue or root area after acute dissection or aortic root repair.

The clinical effect of smoking and environmental factors in spontaneous pneumothorax: a case-crossover study in an Inland province.

BACKGROUND: The factors that trigger spontaneous pneumothorax have not been sufficiently evaluated. The purpose of this study is to analyze the relationship between the development of spontaneous pneumothorax and meteorological parameters, including air pollutants. METHODS: This is a retrospective study using the medical records of 379 patients who were admitted for spontaneous pneumothorax (SP) over a period of 4 years. Meteorological and air pollution data were obtained from the National Meteorological Office and the Ministry of Environment. We employed a case-crossover design to evaluate the short-term association between SP and meteorological factors including air pollutants. Conditional logistic regression was used to analyze bi-directional matched data. RESULTS: Increase of relative humidity (RH) and of carbon monoxide (CO) were associated with the risk of pneumothorax, with odds ratio (OR) for RH = 1.18 (1.02-1.36), CO = 1.23 (1.02-1.48). Moreover, as air pressure (AP) decreased, risk of pneumothorax increased, with OR = 1.30 (1.05-1.59) but others did not. In the stratified analysis, the effect of RH was positive in ex-smokers (OR = 3.31) and non-smokers (OR = 1.32), but negative in current smokers (OR = 0.72). The effect of AP was significant in younger patients (OR = 1.33), males (OR = 1.40), and non-smokers (OR = 1.36). CO was related only with non-smokers (OR = 1.35). CONCLUSION: The triggering factors for spontaneous pneumothorax were relative humidity, carbon monoxide, and air pressure. The effect of the trigger was prominent in patients who were younger (<45 years), non- or ex-smokers, and male.The reviews of this paper are available via the supplemental material section.

Diaphragmatic hernia with isolated shoulder pain evoked by surfeit.

Bochdalek hernia in adult is extremely rare, so symptoms or indications of surgery are not reported enough. Here we report a case of small-sized Bochdalek hernia with isolated shoulder pain that resolved after surgical reduction of hernia. A 25-year-old man with diaphragmatic mass was referred to out-patient clinic. Chief complaint was an isolated left shoulder pain evoked by surfeit. Diaphragmatic hernia was suggested on chest computed tomography (CT) but it was not certain. So, video-assisted thoracic surgery (VATS) exploration was planned to clarify the diagnosis. The mass was proven to be the Bochdalek hernia and successfully restored into abdominal cavity. There were no postoperative complications and isolated shoulder pain disappeared clearly.

Ipsilateral Hyperhidrosis: Atypical Symptom of Small Lung Adenocarcinoma Evaluated by 18F-FDG PET-CT.

A 45-year-old male visited our clinic due to right palmar anhidrosis and contralateral hyperhidrosis. Chest computed tomography (CT) showed a solitary pulmonary nodule with mediastinal lymph node enlargement, but a cause for atypical palmar anhidrosis was not identified. Subsequent fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed (PET/CT) revealed a localized pleural metastasis at the right apex with direct invasion of the paravertebral sympathetic chain. The pleural metastasis, which was not seen on chest CT, evoked ipsilateral anhidrosis independent of a mass effect or direct invasion by the primary lung tumor. 18F-FDG PET/CT can be helpful in identifying the cause of atypical symptoms in patient with small sized lung cancer.

Fate of spontaneous pneumothorax from middle to old age: how to overcome an irritating recurrence?

BACKGROUND: The causes and treatment of pneumothorax in older patients are different from those in younger patients. However, studies on this topic are limited thus; pneumothorax in older patients is often inadequately managed. The purpose of this research was to investigate the characteristics of pneumothorax in patients over 45 years old, understand patterns of management and factors of recurrence, and propose reasonable guidelines for the treatment of older patients. METHODS: Of 438 consecutive patients with spontaneous pneumothorax between 2013 and 2017, 120 patients were enrolled and divided into two groups: (I) 45-64 years and (II) ≥65 years. Basic demographics, treatment modality, and patterns of surgery/recurrence were described. Clinical variables were compared between groups, and risk factors of recurrence were analyzed using logistic regression. RESULTS: The study population was divided into group A (younger, n=61) and B (older, n=59). Chest tube drainage was the most common procedure for both groups and chemical pleurodesis was applied more often in B (27% vs. 11%, P=0.03). The length of hospital stay was longer in B (8.8 vs. 5.9 days, P<0.01) but complications and recurrence rate did not differ between groups (P=0.09 and 0.93). The choice of procedures in recurrent pneumothorax was different (P=0.02). Specifically, invasive procedures such as surgery occurred more often in A, but non-invasive procedures occurred more often in B. Multivariate analysis revealed that bullae/blebs (odds ratio=5.57) and emphysema (odds ratio=3.83) showed a positive association with recurrence whereas surgery (odds ratio=0.11) was negative. CONCLUSIONS: Radiological findings of emphysema or bullae/blebs are risk factors for recurrence of pneumothorax in elderly patients. Surgery in selected patients is an effective method for decreasing the recurrence rate.

Comparison of the pathogenic potential of highly pathogenic avian influenza (HPAI) H5N6, and H5N8 viruses isolated in South Korea during the 2016-2017 winter season.

Highly pathogenic avian influenza (HPAI) A(H5N6) and A(H5N8) virus infections resulted in the culling of more than 37 million poultry in the Republic of Korea during the 2016/17 winter season. Here we characterize two representative viruses, A/Environment/Korea/W541/2016 [Em/W541(H5N6)] and A/Common Teal/Korea/W555/2017 [CT/W555(H5N8)], and evaluate their zoonotic potential in various animal models. Both Em/W541(H5N6) and CT /W555(H5N8) are novel reassortants derived from various gene pools of wild bird viruses present in migratory waterfowl arising from eastern China. Despite strong preferential binding to avian virus-type receptors, the viruses were able to grow in human respiratory tract tissues. Em/W541(H5N6) was found to be highly pathogenic in both chickens and ducks, while CT/W555(H5N8) caused lethal infections in chickens but did not induce remarkable clinical illness in ducks. In mice, both viruses appeared to be moderately pathogenic and displayed limited tissue tropism relative to HPAI H5N1 viruses. Em/W541(H5N6) replicated to moderate levels in the upper respiratory tract of ferrets and was detected in the lungs, brain, spleen, liver, and colon. Unexpectedly, two of three ferrets in direct contact with Em/W541(H5N6)-infected animals shed virus and seroconverted at 14 dpi. CT/W555(H5N8) was less pathogenic than the H5N6 virus in ferrets and no transmission was detected. Given the co-circulation of different, phenotypically distinct, subtypes of HPAI H5Nx viruses for the first time in South Korea, detailed virologic investigations are imperative given the capacity of these viruses to evolve and cause human infections.

What is difficult about doing video-assisted thoracic surgery (VATS)? A retrospective study comparing VATS anatomical resection and conversion to thoracotomy for lung cancer in a university-based hospital.

BACKGROUND: To analyze causes and clinical outcomes of conversion to thoracotomy during video-assisted thoracic surgery (VATS) anatomical resection for patients with non-small cell lung cancer. METHODS: A total of 245 consecutive pulmonary resections were performed from January 2013 to July 2016 at Chungbuk National University Hospital. Patients who underwent curative, anatomical resection for lung cancer were included in the study. Preoperative basal characteristics, functional factors, radiologic findings and clinical outcomes were compared between converted and non-converted patients. RESULTS: Of the 245 patients, 91 (benign disease) and 17 (non-anatomical resection) were excluded from the study. Of the 137 remaining patients, 51 (37%) who received anatomical resection via VATS and 38 (28%) via conversion to thoracotomy were included in the study, but 48 (35%) with planned thoracotomy were excluded. Gender, previous medical history, American Society of Anesthesiologists (ASA) score, body mass index (BMI) and forced expiratory volume for 1 second (FEV1) were not different between the two groups. However, age (P<0.01), enlarged lymph node by chest computed tomography (P=0.04), lesion fluorodeoxyglucose (FDG) uptake except main mass by positron emission tomography with computed tomography (P=0.01) (P<0.01), and tumor location (P=0.03) were significantly different between groups. Multivariate analysis showed patient age [odds ratio (OR), 1.06; P=0.04] and tumor location (OR, 2.71; P=0.03) were predicted conversion to thoracotomy. Converted patients showed a trend for longer duration of thoracic drainage, longer hospital stays and higher blood loss, but operation time (P<0.01) was the only statistically different factor between patient groups. CONCLUSIONS: Elderly patients, in particular if their lung mass was located in the middle or lower lobe, may be likely to convert to thoracotomy during VATS anatomical resection for lung cancer. These factors can help determine surgical approach, especially when surgeons are not familiar with VATS.

Psychological Problems of Pneumothorax According to Resilience, Stress, and Post-Traumatic Stress.

OBJECTIVE: The aims of the study were to investigate psychological distress in pneumothorax patients. METHODS: A cohort study was performed in 101 patients with spontaneous pneumothorax. They were divided into three groups: (A) under 19 years old, (B) those of an intermediate age, and (C) over 45 years old. General well-being [Psychological Wellbeing Index-Short Form (PWI-SF)], traumatic event [Impact of Event Scale (IES)], and resilience [Life Orientation Test-Revised (LOT-R)] were assessed. RESULTS: There were 35 patients in Group A, 51 in B, and 15 in C. The mean length of hospital stay was five days in all patients. The overall recurrence rate after surgery was 8%. All patients were under severe stress and reported an average PWI-SF score of 39. The IES score was 27, which did not meet the criteria for post-traumatic stress disorder but was higher in Group C than in the other groups (p=0.02). Age and operation were significant factors for a high IES, but age was the only significant factor according to multivariate analysis. CONCLUSION: Pneumothorax patients may be at high risk for severe stress. Moreover, post-traumatic stress was higher in elderly patients. Actions to reduce the psychological problems in these patients are required.

Management of long-term persistent air leakage developed after bullectomy for giant bullous lung disease associated with neurofibromatosis type 1.

Persistent air leakage is a serious and sometimes fatal complication of bullous lung disease surgery. A 32-year-old man with lung involvement of neurofibromatosis type I underwent bullectomy for huge bullae and recurrent pneumothorax. Persistent postoperative air leakage developed and the lung was totally collapsed. The initial surgery failed, but a second trial employing a novel suture technique on half-absorbed polyglycolic acid (PGA) felt successfully resolved the massive air leakage. Pneumothorax did not recur and the patient remained stable without dyspnea. Thus, a suture technique employing half-absorbed PGA felt was an effective option for managing persistent air leakage.

Diaphragmatic Hernia after Transhiatal Esophagectomy for Esophageal Cancer.

Diaphragmatic hernia was found in a patient who had undergone transhiatal esophagectomy for early esophageal cancer. Chest X-ray was not helpful, but abdominal or chest computed tomography was useful for accurate diagnosis. Primary repair through thoracotomy was performed and was found to be feasible and effective. However, long-term follow-up is required because hernia recurrence is common.

Primary Pulmonary Amyloidosis with Mediastinal Lymphadenopathy.

We report a case of inadvertent hoarseness after surgery for primary pulmonary amyloidosis. A 55-year-old male was transferred to our facility due to a lung mass. Chest computed tomography revealed a solitary pulmonary nodule. Positron emission tomography-computed tomography showed fluorodeoxyglucose uptake in the main mass and in the mediastinal lymph nodes. To confirm the pathology of the mass, wedge resection and thorough lymph node dissection were performed via video-assisted thoracic surgery (VATS). No complications except for hoarseness were observed; hoarseness developed soon after surgery and lasted for 3 months. The main mass was diagnosed as amyloidosis, but this was not found in the lymph nodes. In conclusion, VATS wedge resection for peripheral amyloidosis is a feasible and safe procedure. However, mediastinal lymph node dissection is not recommended unless there is evidence of a clear benefit.

Genetic diversity and pathogenic potential of low pathogenic H7 avian influenza viruses isolated from wild migratory birds in Korea.

To detect the circulation of H7 avian influenza viruses, we characterized H7 viruses found in migratory birds and live poultry markets of South Korea from 2005 to 2014. Phylogenic analysis revealed that while all viruses clustered into the Eurasian-lineage of H7 avian viruses, at least 12 distinct genotypes were represented. Most H7 viruses contained at least one gene segment from the highly-pathogenic A/Sck/Hong Kong/YU100/02(H5N1)-like avian virus, and they could be separated into at least two antigenic groups. Although we did not detect genetically identical strains, HI assay demonstrated close cross-reactivity of some isolates with the H7N9 viruses from China. Animal studies revealed that most of the genotypes could replicate in the lungs of mice and chickens without prior adaptation and some, particularly H7N4 and H7N7 subtypes, induced mortality in mice. These results reinforce growing pandemic concerns regarding recent H7 viruses and emphasize the importance of continued surveillance of avian influenza viruses in the wild.