Prediction Model of Delayed Hemothorax in Patients with Traumatic Occult Hemothorax Using a Novel Nomogram.

Background: Delayed hemothorax (dHTX) can occur unexpectedly, even in patients who initially present without signs of hemothorax (HTX), potentially leading to death. We aimed to develop a predictive model for dHTX requiring intervention, specifically targeting those with no or occult HTX. Methods: This retrospective study was conducted at a level 1 trauma center. The primary outcome was the occurrence of dHTX requiring intervention in patients who had no HTX or occult HTX and did not undergo closed thoracostomy post-injury. To minimize overfitting, we employed the least absolute shrinkage and selection operator (LASSO) logistic regression model for feature selection. Thereafter, we developed a multivariable logistic regression (MLR) model and a nomogram. Results: In total, 688 patients were included in the study, with 64 cases of dHTX (9.3%). The LASSO and MLR analyses revealed that the depth of HTX (adjusted odds ratio [aOR], 3.79; 95% confidence interval [CI], 2.10-6.85; p<0.001) and the number of totally displaced rib fractures (RFX) (aOR, 1.90; 95% CI, 1.56-2.32; p<0.001) were significant predictors. Based on these parameters, we developed a nomogram to predict dHTX, with a sensitivity of 78.1%, a specificity of 76.0%, a positive predictive value of 25.0%, and a negative predictive value of 97.1% at the optimal cut-off value. The area under the receiver operating characteristic curve was 0.832. Conclusion: The depth of HTX on initial chest computed tomography and the number of totally displaced RFX emerged as significant risk factors for dHTX. We propose a novel nomogram that is easily applicable in clinical settings.

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.

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.

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.

Clinicopathological characteristics of costal hemangiomas: a case report and literature review.

Bone hemangioma accounts for approximately 1% of all bone neoplasms and commonly occurs in the vertebral body and skull. However, costal hemangiomas are extremely rare. We herein present a case involving a 52-year-old woman with a hemangioma in the third rib and review 29 cases of rib hemangiomas available in the literature. Rib hemangioma mainly affects women in their 50s and has expansile osteolytic features in radiographs and a weak maximum standardized uptake value in 18F-fluorodeoxyglucose positron emission tomography images. When these findings are displayed, clinicians should include rib hemangioma as a differential diagnosis and consider avoidance of preoperative biopsy because of the risk of life-threatening bleeding.

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.

A Single Center Analysis of the Positivity of Hepatitis B Antibody after Neonatal Vaccination Program in Korea.

The antibody to hepatitis B surface antigen (anti-HBs) seropositivity rate after 3 doses of hepatitis B virus (HBV) vaccination during infancy period is known to be higher than 90%. However, a considerable number of vaccines do not form protective anti-HBs or chronologic decrease of anti-HBs. We retrospectively collected data of HBV serologic test results in 20,738 individuals from 2000 to 2015. After exclusion criteria were applied, 19,072 individuals were included. We analyzed the anti-HBs seropositivity rate, anti-HBs disappearance rate, anti-HBs positive seroconversion rate after receiving a booster vaccine, and the difference in anti-HBs positivity between the 2 groups; group A (born before 2005, while both recombinant vaccines and plasma-derived vaccines were used) and group B (born after 2005, when only recombinant vaccines were used by national regulation). The anti-HBs seropositivity rate was 55.8%, but there was a significant difference in the rate of seropositivity for anti-HBs between the group A and B (53.0% vs. 78.1%, P < 0.001). There was no significant age-adjusted difference in the mean seropositivity rate between the 2 groups (P = 0.058). In addition, the anti-HBs positivity rate was significantly lower in the group A as compared with the group B during infancy (83.1% vs. 92.1%, P < 0.001). A total of 1,106 anti-HBs-positive subjects underwent serologic tests more than twice. Of these, 217 subjects (19.6%) showed anti-HBs disappearance. After booster vaccinations, 87.4% (83/95) achieved seroconversion from seronegative to seropositive. Our results highlight the importance of lifelong protection against HBV and the possible necessity of booster vaccination after adolescent period.

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.

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.

(-)-Epigallocatechin-3-O-gallate (EGCG) attenuates the hemodynamics stimulated by caffeine through decrease of catecholamines release.

A human study of the effects on hemodynamics of caffeine and epigallocatechin-3-O-gallate (EGCG) was performed. Caffeine tablets (200 mg) were orally administered to healthy males aged between 25 and 35 years 30 min after oral administration of EGCG tablets (100 and 200 mg). The increase in BP induced by caffeine was inhibited when co-administrated with EGCG. We found that caffeine slightly decreased heart rate (HR) in the volunteers. Although EGCG enhanced HR reduction, the effect was not significant. In addition, caffeine increased blood catecholamine levels, but EGCG inhibited the increase in noradrenaline, adrenaline and dopamine levels induced by caffeine. Whether EGCG decreases the elevated HR and systolic perfusion pressure, and ventricular contractility induced by adrenergic agonists in the isolated rat heart was investigated. The modified Krebs-Henseleit solution was perfused through a Langendorff apparatus to the isolated hearts of rats. HR, systolic perfusion pressure, and developed maximal rates of contraction (+dP/dtmax) and relaxation (-dP/dtmax) were increased by epinephrine (EP) and isoproterenol (IP). In contrast, EGCG decreased the elevated HR, systolic perfusion pressure, and left ventricular ±dp/dtmax induced by EP and/or IP. In conclusion, EGCG could attenuate the hemodynamics stimulated by caffeine through decreasing catecholamine release.

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.

Therapeutic effect of anti CEACAM6 monoclonal antibody against lung adenocarcinoma by enhancing anoikis sensitivity.

Carcinoembryonic antigen-related cell adhesion molecule 6 (CEACAM6) plays a crucial role in tumorigenesis of lung cancer. However, the therapeutic potential for anti CEACAM6 monoclonal antibody (mAb) has only been limitedly explored. Here, we evaluate the therapeutic potential of naked anti CEACAM6 mAb against lung adenocarcinoma. Clone 8F5, recognizing B domain of CEACAM6, is established by immunizing A549 cells and screening for clones double positive for A549 and CEACAM6-Fc recombinant protein. We found that 85.7% of 70 resected lung adenocarcinoma tissue sections were positive for CEACAM6, whereas all squamous cell carcinoma examined were negative. A549 cells with high levels of CEACAM6 demonstrated more aggressive growth nature and showed increased paclitaxel chemosensitivity upon 8F5 binding. Treatment with 8F5 to A549 decreased cellular CEACAM6 expression and reversed anoikis resistance. 8F5 also decreased cellular status of Akt phosphorylation and increased apoptosis via caspase activation. In a mouse model of lung adenocarcinoma with xenotransplanted A549 cells, 8F5 treatment alone demonstrated 40% tumor growth inhibition. When combined with paclitaxel treatment, 8F5 markedly enhanced tumor growth inhibition, up to 80%. In summary, we demonstrate that anti CEACAM6 mAb is an effective therapeutic treatment for lung adenocarcinoma whose effect is further enhanced by combined treatment with paclitaxel.

A recurrent empyema with peripheral bronchopleural fistulas treated by retrograde bronchial sealing with Gore Tex plugs: a case report.

Bronchopleural fistulae (BPF) are communications between the bronchial tree and the pleural spaces. This anomaly is associated with significant morbidity and mortality, and its management in some patients remains a major therapeutic challenge for clinicians. Here we report a case involving a 62-year-old man with chronic empyema associated with multiple BPF caused by severe necrotizing pneumonia with parapneumonic effusion in the left lower lobe. His BPF were treated by decortication and retrograde surgical sealing with Gore-Tex plugs that were sutured to the parenchyma and bronchus and reinforced by glue and an intercostal muscle flap. The air leakage stopped immediately after surgery and the chronic empyema resolved. His subsequent postoperative course was uneventful, and he was discharged 14 days after surgery. At the 8-month follow-up visit, stable surgical outcomes with no BPF recurrence were observed. In summary, we described a novel and easy surgical technique for the repair of intractable peripheral BPF in select patients.

Rapid growing huge teratoma: complete surgical resection.

We report successful total resection of a huge mediastinal teratoma. An 11-year-old male underwent chest computed tomography that revealed a 14-cm mediastinal mass occupying the right thoracic cavity. The mass was successfully removed without any postoperative postoperative complication.

Acute aortic dissection in pregnancy with the marfan syndrome.

Acute aortic dissection (AAD) during pregnancy can be fatal to both the pregnant mother and the baby, particularly in patients with the Marfan syndrome. We report a case of the modified Bentall procedure in surgery for AAD in a 31-year-old pregnant woman at 24 weeks of gestation with the Marfan syndrome. The patient recovered well after the operation, but unfortunately, the fetus could not be saved.