Trends and an Online Survey on the Use of Rigid Bronchoscopy in Korea.

BACKGROUND: Although almost all interventional pulmonologists agree that rigid bronchoscopy is irreplaceable in the field of interventional pulmonology, less is known about the types of diseases that the procedure is used for and what difficulties the operators face during the procedure. The purpose of this study is to evaluate what diseases rigid bronchoscopy is used for, whether it is widely used, and what challenges the operators face in Korea. METHODS: We enrolled 14 hospitals in this retrospective cohort of patients who underwent rigid bronchoscopy between 2003 and 2020. An online survey was conducted with 14 operators to investigate the difficulties associated with the procedure. RESULTS: While the number of new patients at Samsung Medical Center (SMC) increased from 189 in 2003-2005 to 468 in 2018-2020, that of other institutions increased from 0 to 238. The proportion of SMC patients in the total started at 100% and steadily decreased to 59.2%. The proportion of malignancy as the indication for the procedure steadily increased from 29.1% to 43.0%, whereas post-tuberculous stenosis (25.4% to 12.9%) and post-intubation stenosis (19.0% to 10.9%) steadily decreased (all P for trends < 0.001). In the online survey, half of the respondents stated that over the past year they performed less than one procedure per month. The fewer the procedures performed within the last year, the more likely collaboration with other departments was viewed as a recent obstacle (Spearman correlation coefficient, rs = -0.740, P = 0.003) and recent administrative difficulties were encountered (rs = -0.616, P = 0.019). CONCLUSION: This study demonstrated that the number of patients undergoing rigid bronchoscopy has been increasing, especially among cancer patients. For this procedure to be used more widely, it will be important for beginners to systematically learn about the procedure itself as well as to achieve multidisciplinary consultation.

Effect of chlorhexidine Mouthrinse on prevention of microbial contamination during EBUS-TBNA: a randomized controlled trial.

BACKGROUND: Although endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure, fatal infectious complications have been reported. However, adequate preventive strategies have not been determined. We aimed to investigate the effect of chlorhexidine mouthrinse on the prevention of microbial contamination during EBUS-TBNA. METHODS: In this single-center, assessor-blinded, parallel-group randomized controlled trial, we randomly assigned adult participants undergoing EBUS-TBNA using a convex probe to gargle for 1 minute with 100 mL of 0.12% chlorhexidine gluconate before EBUS-TBNA or to receive usual care (no chlorhexidine mouthrinse). Aspiration needle wash samples were collected immediately after completion of EBUS-TBNA by instilling sterile saline into the used needle. The primary outcome was colony forming unit (CFU) counts per mL of needle wash samples in aerobic cultures. Secondary outcomes were CFU counts per mL of needle wash samples in anaerobic cultures, fever within 24 hours after EBUS-TBNA, and infectious complications within 4 weeks after EBUS-TBNA. RESULTS: From January 2021 to June 2021, 106 patients received either chlorhexidine mouthrinse (n = 51) or usual care (n = 55). The median CFU counts of needle wash samples in aerobic cultures were not significantly different in the two groups (10 CFU/mL vs 20 CFU/mL; P = 0.70). There were no significant differences between the groups regarding secondary outcomes, including median CFU counts in anaerobic cultures (P = 0.41) and fever within 24 hours after EBUS-TBNA (11.8% vs 5.6%, P = 0.31). There were no infectious complications within 4 weeks in both groups. CONCLUSIONS: Chlorhexidine mouthrinse did not reduce CFU counts in needle wash samples of EBUS-TBNA. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04718922 . Registered on 22/01/2021.

Association of Adipopenia at Preoperative PET/CT with Mortality in Stage I Non-Small Cell Lung Cancer.

Background Body mass index (BMI) and sarcopenia status are well-established prognostic factors in patients with lung cancer. However, the relationship between the amount of adipose tissue and survival remains unclear. Purpose To investigate the association between baseline adipopenia and outcomes in patients with early-stage non-small cell lung cancer (NSCLC). Materials and Methods Consecutive patients who underwent surgical resection for stage I NSCLC between 2011 and 2015 at a single tertiary care center were retrospectively identified. The primary outcome was the 5-year overall survival (OS) rate, and secondary outcomes were the 5-year disease-free survival (DFS) rate and the major postoperative complication rate. The abdominal total fat volume at the waist and the skeletal muscle area at the L3 level were obtained from preoperative PET/CT data and were normalized by the height squared to calculate the fat volume index (FVI) and skeletal muscle index. Adipopenia was defined as the sex-specific lowest quartile of the FVI for the study sample, and sarcopenia was determined using the skeletal muscle index reference value (men, <55 cm2/m2; women, <39 cm2/m2). The association between body composition and outcomes was evaluated using Cox regression analysis. Results A total of 440 patients (median age, 65 years [interquartile range, 58-72 years]; 243 men) were evaluated. Most underweight patients (<20 kg/m2) had adipopenia (97%, 36 of 37 patients), but overweight patients (25-30 kg/m2, n = 138) and obese patients (>30 kg/m2, n = 14) did not have adipopenia (3%, four of 152 patients). In the group with a normal BMI (20-25 kg/m2), 28% (70 of 251 patients) had adipopenia and 67% (168 of 251 patients) had sarcopenia. After adjusting for age, sex, smoking history, surgical procedure, stage, histologic type, BMI, and sarcopenia, adipopenia was associated with reduced 5-year OS (hazard ratio [HR] = 2.2; 95% CI: 1.1, 3.8; P = .02) and 5-year non-cancer-specific OS rates (HR = 3.2; 95% CI: 1.2, 8.7; P = .02). There was no association between adipopenia and postoperative complications (P = .45) or between adipopenia and the 5-year DFS rate (P = .18). Conclusion Baseline adipopenia was associated with a reduced 5-year overall survival rate in patients with early-stage non-small cell lung cancer and may indicate risk for non-cancer-related death. © RSNA, 2021 Online supplemental material is available for this article.

Impact of Sleep Duration on Mortality and Quality of Life in Chronic Kidney Disease: Results from the 2007-2015 KNHANES.

INTRODUCTION: In the general population, short and long sleep durations have been associated with adverse health outcomes. However, this association remains unclear in patients with chronic kidney disease (CKD). We examined the relationship of sleep duration to mortality and health-related quality of life (HRQOL) in individuals with CKD. METHODS: A total of 1,783 adults with CKD who participated in the 2007-2015 Korea National Health and Nutrition Examination Survey were analyzed. CKD was defined as an estimated glomerular filtration rate of <60 mL/min per 1.73 m2. Participants were categorized into 3 groups according to self-reported sleep duration: <6 h (short sleepers), 6-8 h, and >8 h (long sleepers). The outcome variables were all-cause mortality and HRQOL. HRQOL was assessed using the European Quality of Life-5 Dimensions (EQ-5D) index. RESULTS: During a median of 6.4 years, 481 (27%) deaths occurred. In unadjusted Cox regression analysis, long sleepers with CKD had an increased risk of death (hazard ratio [HR], 1.62; 95% confidence interval [CI]: 1.26-2.09). This significant association remained after adjusting for age, sex, and BMI (HR, 1.36; 95% CI: 1.05-1.75); however, it was lost after adjusting for CKD stage, social and lifestyle factors, and presence of comorbidities (HR, 1.15; 95% CI: 0.89-1.49). Compared with 6- to 8-h sleepers with CKD, long sleepers with CKD had significantly worse HRQOL in multivariable linear regression models. The adjusted means of the EQ-5D index were 0.80 (95% CI: 0.77-0.82) for short sleepers, 0.81 (95% CI: 0.80-0.82) for 6- to 8-h sleepers, and 0.76 (95% CI: 0.73-0.79) for long sleepers (p = 0.01). DISCUSSION/CONCLUSION: Long sleep duration is associated with poor HRQOL in Korean adults with CKD. The weak association between long sleep duration and mortality was attenuated after multivariable adjustment in this study.

Sleep Duration and Its Associations with Mortality and Quality of Life in Chronic Obstructive Pulmonary Disease: Results from the 2007-2015 KNAHNES.

BACKGROUND: While extreme sleep duration negatively affects mortality and health-related quality of life (HRQOL) in general populations, the relationship remains uncertain in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES: To evaluate the association between sleep duration and mortality and HRQOL in patients with COPD. METHODS: We analyzed 3,349 participants with COPD enrolled in the 2007-2015 Korea National Health and Nutrition Examination Survey (KNHANES). Participants aged 40 years or older with a smoking history and prebronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) <0.7 were eligible. The participants were categorized as short sleepers (<6 h), 6-8 h, and long sleepers (>8) according to self-reported sleep duration. The outcome variables were all-cause mortality and HRQOL. HRQOL was measured using the European Quality of Life-5 Dimensions (EQ-5D) index. RESULTS: During a median of 6.5 years, 386 (11.5%) participants died. In unadjusted Cox regression analysis, short sleepers with COPD had an increased risk of death (hazard ratio, 1.35; 95% confidence interval [CI]: 1.07-1.71). However, this association was not significant after adjusting for sociodemographic factors, BMI, FEV1, and comorbidities. In unadjusted and adjusted multiple linear regression, short sleepers had significantly worse HRQOL. The adjusted means of the EQ-5D index were 0.88 (95% CI: 0.87-0.89) for short sleepers, 0.90 (95% CI: 0.90-0.91) for 6- to 8-h sleepers, and 0.89 (95% CI: 0.87-0.91) for long sleepers (p = 0.01). CONCLUSIONS: In patients with COPD, sleep duration was not associated with all-cause mortality. However, short sleep duration was significantly associated with worse HRQOL.

Dexmedetomidine versus midazolam for sedation during endobronchial ultrasound-guided transbronchial needle aspiration: A randomised controlled trial.

BACKGROUND: Desaturation is a common complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Dexmedetomidine (DEX), a commonly used sedative in intensive care, is associated with less respiratory depression compared with other sedatives. OBJECTIVE: We compared DEX with midazolam (MDZ) when used as a sedative during EBUS-TBNA. DESIGN: A randomised, parallel, double-blinded trial. SETTING: A university-affiliated teaching hospital between June 2014 and July 2015. PATIENTS: A total of 102 patients who underwent EBUS-TBNA were randomly allocated to two groups (48 DEX group, 54 MDZ group). INTERVENTIONS: DEX group received 0.25 to 0.75 µg kg-1 h-1 (start with 0.5 µg kg-1 h-1, modulated in three steps from 0.25 to 0.75 µg kg-1 h-1) of DEX after a loading dose of 0.25 µg kg-1 h-1 for 10 min to maintain a Ramsay Sedation Scale (RSS) of 3 to 5. If the patient was agitated, 1 mg of MDZ bolus was used as a rescue drug. Patients in the MDZ group initially received 0.05 mg kg-1 of MDZ as a bolus. For maintenance and rescue, 1 mg of MDZ bolus was used. MAIN OUTCOME MEASURES: The primary outcome was the presence of oxygen desaturation. Secondary outcomes were level of sedation (Ramsay Sedation Scale score), cough score, sedation and procedure satisfaction score. RESULTS: The baseline characteristics of the patients, duration of EBUS-TBNA procedures and the use of rescue MDZ were not different between the groups. There was no significant difference in desaturation events between the DEX and MDZ groups (56.3 and 68.5%, respectively; P = 0.20). The level of sedation and the sedation satisfaction scores were similar between the two groups. However, cough score was significantly lower in the DEX group (41.9 vs. 53.4; P = 0.02). CONCLUSION: The use of DEX during EBUS-TBNA was not superior to MDZ in terms of oxygen desaturation. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02157818.

Improved Oxygenation After Prone Positioning May Be a Predictor of Survival in Patients With Acute Respiratory Distress Syndrome.

OBJECTIVES: Prone position ventilation improves oxygenation and reduces the mortality of patients with severe acute respiratory distress syndrome. However, there is limited evidence about which patients would gain most survival benefit from prone positioning. Herein, we investigated whether the improvement in oxygenation after prone positioning is associated with survival and aimed to identify patients who will gain most survival benefit from prone positioning in patients with acute respiratory distress syndrome. DESIGN: A retrospective cohort study. SETTING: Medical ICU at a tertiary academic hospital between 2014 and 2020. PATIENTS: Adult patients receiving prone positioning for moderate-to-severe acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcomes were ICU and 28-day mortality. A total of 116 patients receiving prone positioning were included, of whom 45 (38.8%) were ICU survivors. Although there was no difference in PaO2:FIO2 ratio before the first prone session between ICU survivors and nonsurvivors, ICU survivors had a higher PaO2:FIO2 ratio after prone positioning than nonsurvivors, with significant between-group difference (p < 0.001). The area under the receiver operating characteristic curve of the percentage change in the PaO2:FIO2 ratio between the baseline and 8-12 hours after the first prone positioning to predict ICU mortality was 0.87 (95% CI, 0.80-0.94), with an optimal cutoff value of 53.5% (sensitivity, 91.5%; specificity, 73.3%). Prone responders were defined as an increase in PaO2:FIO2 ratio of greater than or equal to 53.5%. In the multivariate Cox regression analysis, prone responders (hazard ratio, 0.11; 95% CI, 0.05-0.25), immunocompromised condition (hazard ratio, 2.15; 95% CI, 1.15-4.03), and Sequential Organ Failure Assessment score (hazard ratio, 1.16; 95% CI, 1.06-1.27) were significantly associated with 28-day mortality. CONCLUSIONS: The PaO2:FIO2 ratio after the first prone positioning differed significantly between ICU survivors and nonsurvivors. The improvement in oxygenation after the first prone positioning was a significant predictor of survival in patients with moderate-to-severe acute respiratory distress syndrome.

Validation of age, PaO2/FlO2 and plateau pressure score in Korean patients with acute respiratory distress syndrome: a retrospective cohort study.

BACKGROUND: A predictive scoring system for acute respiratory distress syndrome (ARDS) patients, which incorporates age, PaO2/FlO2, and plateau pressure, APPS, was developed recently. It was validated externally in a Caucasian population but has not been studied in Asian populations. The aim of this study was to validate APPS in Korean ARDS patients. METHODS: We retrospectively reviewed the medical records of patients who were diagnosed with ARDS using the Berlin criteria and admitted to the medical ICU at Seoul National University Hospital from January 2015 to December 2016. The validation of the APPS was performed by evaluating its calibration and predictive accuracy. Its calibration was plotted and quantified using the Hosmer-Lemeshow test. Its predictive accuracy was assessed by calculating the area under the receiver operating characteristics (AUC-ROC) curve. RESULTS: A total of 116 patients were analyzed, 32 of whom survived. Of the 116 patients, 11 (9.5%) were classified as APPS grade 1 (score 3-4), 88 (75.9%) as grade 2 (score 5-7) and 17 (14.6%) as grade 3 (score 8-9). In-hospital mortality was 27.3% for grade 1, 73.9% for grade 2 and 94.1% for grade 3 (P for trend < 0.001). The APPS was well calibrated (Hosmer-Lemeshow test, P = 0.578) and its predictive accuracy was acceptable (AUC-ROC 0.704, 95% confidence interval 0.599-0.809). CONCLUSIONS: The APPS predicted in-hospital mortality in Korean patients with ARDS with similar power to its application in a Western population and with acceptable predictive accuracy. TRIAL REGISTRATION: Retrospectively registered.

Rapid Muscle Loss Negatively Impacts Survival in Critically Ill Patients With Cirrhosis.

PURPOSE: To assess the impact of rapid muscle loss before admission to intensive care unit (ICU) in critically ill patients with cirrhosis. MATERIALS AND METHODS: Patients with cirrhosis who had undergone 2 or more recent computed tomography scans before admission to the medical ICU were included. Muscle cross-sectional area at the level of the third lumbar vertebra was quantified using OsiriX software. The rate of muscle mass change and skeletal muscle index (SMI) were also calculated. Multivariable Cox proportional hazards regression was used to evaluate the association between muscle loss and mortality. RESULTS: Among 125 patients, 113 (90.4%) patients were classified as having sarcopenia. The mean body mass index was 22.6 (3.9) kg/m2. Thirty-nine (31.2%) patients were within the normal range for muscle mass change, while 86 (68.8%) patients demonstrated rapid decline in muscle mass before admission to the ICU. Patients with rapid muscle loss showed high ICU mortality (59.3%) and in-hospital mortality (77.9%). Multivariate Cox analysis showed that ICU mortality and in-hospital mortality were independently associated with malignancy, Acute Physiology and Chronic Health Evaluation (APACHE) II score, SMI, and rapid muscle loss. CONCLUSION: Rapid muscle decline is correlated with increased ICU mortality and in-hospital mortality in critically ill patients with cirrhosis.

Sleep duration and health-related quality of life in Korean adults: 2007-2015 Korea National Health and Nutrition Examination Survey.

PURPOSE: To evaluate the association of sleep duration with health-related quality of life (HRQOL) and examine the influence of age, sex, and common comorbidities on this association. METHODS: Using appropriate survey design, we analyzed 50,181 adults who participated in the 2007-2015 Korea National Health and Nutrition Examination Survey. Participants were categorized into five groups according to self-reported sleep duration ≤ 5 (short sleeper), 6, 7, 8, and ≥ 9 h (long sleeper). HRQOL was measured with the European Quality of Life-5 Dimensions (EQ-5D) index and visual analogue scale (VAS). RESULTS: In multiple linear regression, short sleep duration was associated with lower EQ-5D index (ß = - 0.024; 95% confidence interval [CI], - 0.027 to - 0.021) and lower EQ-VAS (ß = - 3.0; 95% CI, - 3.7 to - 2.3), and long sleep duration was associated with lower EQ-5D index (ß = - 0.016; 95% CI, - 0.021 to - 0.011) and lower EQ-VAS (ß = - 2.2; 95% CI, - 3.1 to - 1.3) compared with 7-h sleepers. Old-age (≥ 65 years old) short and long sleepers had significantly lower EQ-5D index than those of < 65 years old. When separated according to sex, men with long sleep and women with short sleep showed the lowest EQ-5D index. Short and long sleepers with hypertension, diabetes, hypercholesterolemia, cardiovascular disease, or depression showed significantly lower EQ-5D index than those without comorbidities. CONCLUSIONS: Extreme sleep duration was associated with poor HRQOL. Short and long sleepers with old age and comorbidities had significantly lower HRQOL than those without such conditions.

Mortality risk and causes of death in patients with non-cystic fibrosis bronchiectasis.

BACKGROUND: All-cause mortality risk and causes of death in bronchiectasis patients have not been fully investigated. The aim of this study was to compare the mortality risk and causes of death between individuals with bronchiectasis and those without bronchiectasis. METHODS: Patients with or without bronchiectasis determined based on chest computed tomography (CT) at one centre between 2005 and 2016 were enrolled. Among the patients without bronchiectasis, a control group was selected after applying additional exclusion criteria. We compared the mortality risk and causes of death between the bronchiectasis and control groups without lung disease. Subgroup analyses were also performed according to identification of Pseudomonas or non-tuberculous mycobacteria, airflow limitation, and smoking status. RESULTS: Of the total 217,702 patients who underwent chest CT, 18,134 bronchiectasis patients and 90,313 non-bronchiectasis patients were included. The all-cause mortality rate in the bronchiectasis group was 1608.8 per 100,000 person-years (95% confidence interval (CI), 1531.5-1690.0), which was higher than that in the control group (133.5 per 100,000 person-years; 95% CI, 124.1-143.8; P < 0.001). The bronchiectasis group had higher all-cause (adjusted hazard ratio (aHR), 1.26; 95% CI, 1.09-1.47), respiratory (aHR, 3.49; 95% CI, 2.21-5.51), and lung cancer-related (aHR, 3.48; 95% CI, 2.33-5.22) mortality risks than the control group. In subgroup analysis, patients with airflow limitation and ever smokers showed higher all-cause mortality risk among bronchiectasis patients. Therefore, we observed significant interrelation between bronchiectasis and smoking, concerning the risks of all-cause mortality (P for multiplicative interaction, 0.030, RERI, 0.432; 95% CI, 0.097-0.769) and lung cancer-related mortality (RERI, 8.68; 95% CI, 1.631-15.736). CONCLUSION: Individuals with bronchiectasis had a higher risk of all-cause, respiratory, and lung cancer-related mortality compared to control group. The risk of all-cause mortality was more prominent in those with airflow limitation and in ever smokers.

Serum Uric Acid Level as a Prognostic Marker in Patients With Acute Respiratory Distress Syndrome.

PURPOSE:: Uric acid acts as both a pathogenic inflammatory mediator and an antioxidative agent. Several studies have shown that uric acid level correlates with the incidence, severity, and prognosis of pulmonary diseases. However, the association between uric acid level and acute respiratory distress syndrome (ARDS) has not been studied. This study was conducted to elucidate how serum uric acid level is related with clinical prognosis of ARDS. METHODS:: A retrospective cohort study with propensity score matching was conducted at a medical intensive care unit of a tertiary teaching hospital. The medical records of patients diagnosed with ARDS admitted from 2005 through 2011 were reviewed. RESULTS:: Two hundred thirty-seven patients with ARDS met the inclusion criteria. Patients with a serum uric acid level <3.0 mg/dL were classified into the low uric acid group, and those with a level ≥3 mg/dL were classified into the normal to high uric acid group. We selected 40 patients in each group using propensity score matching. A higher percentage of patients in the low uric acid group experienced clinical improvement in ARDS. More patients died from sepsis in the normal to high uric acid group. Kaplan-Meier analysis showed that a low serum uric acid level was significantly associated with better survival rate. CONCLUSION:: In patients with ARDS, a low serum uric acid level may be a prognostic marker of a low risk of in-hospital mortality.

Diagnostic and prognostic values of serum activin-a levels in patients with acute respiratory distress syndrome.

BACKGROUND: We aimed to evaluate whether serum activin-A levels are elevated and have any value in predicting severity and prognosis in acute respiratory distress syndrome (ARDS). METHODS: Retrospective cohort study was performed with patients who were admitted to MICU with diagnosis of ARDS and have serum samples stored within 48 h of Intensive care unit (ICU) admission between March 2013 and December 2016 at a single tertiary referral hospital. Serum activin-A levels were measured with ELISA kit, and were compared with those of normal healthy control and non-ARDS sepsis patients. RESULTS: Total 97 ARDS patients were included for the study. Levels of Activin-A were elevated in ARDS patients compared to those of healthy controls (Log-transformed activin-A levels 2.89 ± 0.36 vs. 2.34 ± 0.11, p < 0.001, absolute activin-A levels 1525.6 ± 1060.98 vs. 225.9 ± 30.1, p = 0.016) and non-ARDS sepsis patients (Log-transformed activin-A levels 2.89 ± 0.36 vs. 2.73 ± 0.34, p = 0.002, Absolute activin-A levels 1525.6 ± 1060.98 vs. 754.8 ± 123.5 pg/mL, p = 0.036). When excluding five outliers with extremely high activin-A levels, activin-A showed statistically significant correlation with in-hospital mortalities (In-hospital survivors 676.2 ± 407 vs. non-survivors 897.9 ± 561.9 pg/mL, p = 0.047). In predicting in-hospital mortality, serum activin-A concentrations showed superior area under curve compared to that of Acute physiologic and chronic health evaluation II scores (0.653; 95% CI [0541, 0.765] vs. 0.591, 95% CI [0.471, 0.710]). With cut-off level of 708 pg/mL, those with high serum activin-A levels had more than twofold increased risk of in-hospital mortalities. However, those relations were missing when outliers were in. CONCLUSIONS: Serum activin-A levels in ARDS patients are elevated. However, its levels are weakly associated with ARDS outcomes.

Relation of EGFR Mutation Status to Metabolic Activity in Localized Lung Adenocarcinoma and Its Influence on the Use of FDG PET/CT Parameters in Prognosis.

OBJECTIVE: The purposes of this study were to assess the relation between epidermal growth factor receptor (EGFR) mutation status and FDG PET/CT findings and to evaluate the influence of this relation on the use of FDG PET/CT parameters to establish a prognosis in cases of localized lung adenocarcinoma. MATERIALS AND METHODS: Patients with stage I and II lung adenocarcinomas were retrospectively enrolled. At the initial FDG PET/CT examination, maximum and peak standardized uptake, tumor-to-background ratio, and volumetric parameters of metabolic tumor volume and total lesion glycolysis were measured. RESULTS: The values of all the metabolic and volumetric FDG PET/CT parameters were significantly lower in EGFR mutant than in EGFR wild-type lung adenocarcinomas. All parameters were statistically significant for predicting recurrence-free survival. In multivariate analyses, peak standardized uptake and total lesion glycolysis were more significant prognostic factors than was TNM stage (p < 0.001). Optimal cutoff values of parameters for predicting recurrence-free survival were slightly different between the two groups. CONCLUSION: EGFR mutation is related to low metabolic activity of localized lung adenocarcinoma at FDG PET/CT. Because of differences in the metabolic activity of EGFR mutant and wild-type tumors, EGFR mutation status must be considered when FDG PET/CT parameters are used for prognosis.

CT assessment-based direct surgical resection of part-solid nodules with solid component larger than 5 mm without preoperative biopsy: experience at a single tertiary hospital.

OBJECTIVES: To retrospectively evaluate the feasibility of CT assessment-based direct surgical resection of part-solid nodules (PSNs) with solid components > 5 mm without preoperative percutaneous transthoracic needle biopsies (PTNBs). METHODS: From January 2009-December 2014, 85 PSNs with solid components > 5 mm on CT were included. Preoperative PTNBs were performed for 41 PSNs (biopsy group) and CT assessment-based direct resections were performed for 44 PSNs (direct surgery group). Diagnostic accuracy and complication rates of the groups were compared. RESULTS: Pathological results of 83 PSNs excluding two indeterminate nodules included 76 adenocarcinomas (91.6%), two adenocarcinomas in situ (2.4%) and five benign lesions (6.0%). In the biopsy group, the overall sensitivity, specificity and accuracy for the diagnosis of adenocarcinoma were 78.9% (30/38), 100% (1/1) and 79.5% (31/39), respectively. Pneumothorax and haemoptysis occurred in 11 procedures (26.8%). In the direct surgery group, the respective values for the diagnosis of adenocarcinoma were 100% (38/38), 0% (0/6) and 86.4% (38/44), respectively. Seven pneumothoraces (15.9%); no haemoptysis occurred during localization procedures. There were no significant differences in diagnostic accuracy (P = 0.559) between the two groups. CONCLUSIONS: CT assessment-based direct resection can be reasonable for PSNs with solid part > 5 mm. KEY POINTS: • 91.6% of PSNs with solid component > 5 mm were adenocarcinomas. • PTNBs for PSNs with solid component > 5 mm had 79.5% accuracy. • CT-based resection for PSNs with solid component > 5 mm had 86.4% accuracy. • CT-based resection without biopsy can be a reasonable option in routine practice.

The additional role of Xpert MTB/RIF in the diagnosis of intrathoracic tuberculous lymphadenitis.

BACKGROUND: Diagnosis of intrathoracic tuberculosis (TB) lymphadenitis remains a challenge because of difficulties in obtaining adequate tissue and the lack of a sensitive test. Recently, Xpert MTB/RIF assay is being used for rapid diagnosis of pulmonary TB, but it has not yet been widely validated in intrathoracic TB lymphadenitis. The aim of this study was to assess the additional role of Xpert MTB/RIF in diagnosing intrathoracic TB lymphadenitis using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) specimen. METHODS: Consecutive patients who underwent Xpert MTB/RIF assay using EBUS-TBNA specimen from January 2012 and November 2013 at a tertiary referral hospital were recruited. Among them, the cases with malignant lymph nodes were excluded. RESULTS: Among 73 patients, 13 (17.8%) cases were diagnosed with intrathoracic TB lymphadenitis. In detail, 10 patients were diagnosed using conventional methods only (histology or AFB culture) and 3 patients were additionally diagnosed when adding Xpert MTB/RIF assay. The median time to diagnosis using Xpert MTB/RIF (1 day) was shorter than conventional methods (3 days for histology, 14 days for AFB culture). Rifampin resistance was not detected in any patients. CONCLUSION: In patients with enlarged intrathoracic lymph nodes and low suspicion of malignancy, combination of conventional diagnostic methods with Xpert MTB/RIF could lead to additional and rapid diagnosis of intrathoracic TB lymphadenitis.

Analysis of Fifty Hotspot Mutations of Lung Squamous Cell Carcinoma in Never-smokers.

Smoking is the major risk factor for lung squamous cell carcinoma (SCC), although a small number of lung SCCs occurs in never-smokers. The purpose of this study was to compare 50 hotspot mutations of lung SCCs between never-smokers and smokers. We retrospectively reviewed the medical records of patients newly diagnosed with lung SCC between January 1, 2011 and December 31, 2013 in the Seoul National University Hospital. Formalin-fixed, paraffin-embedded tumor samples were used for analysis of hotspot mutations. Fifty cancer-related genes in never-smokers were compared to those in ever-smokers. Of 379 lung SCC patients, 19 (5.0%) were never-smokers. The median age of these 19 patients was 67 years (interquartile range 57-73 years), and 10 of these patients were women (52.5%). The incidence rates of stage I, II, III, and IV disease in this group were 26.4%, 5.3%, 31.6%, and 36.8%, respectively, and sequencing was performed successfully in 14 cases. In the 26 lung SCC tumor samples (12 from never-smokers and 14 from ever-smokers) sequenced using personal genome machine, the most common mutations were in TP53 (75.0%), RAS (66.7%), and STK11 (33.3%), but mutations were also found in EGFR, KIT, and PTEN. The distribution of hotspot mutations in never-smokers was similar to that in ever-smokers. There was no significant difference in overall survival between the 2 groups. The 50 hotspot mutations of lung SCC in never-smokers were similar to those of ever-smokers.

Preoperative staging of non-small cell lung cancer: prospective comparison of PET/MR and PET/CT.

OBJECTIVES: To prospectively compare the accuracies of PET/MR and PET/CT in the preoperative staging of non-small cell lung cancer (NSCLC). METHODS: Institutional review board approval and patients' informed consents were obtained. 45 patients with proven or radiologically suspected lung cancer which appeared to be resectable on CT were enrolled. PET/MR was performed for the preoperative staging of NSCLC followed by PET/CT without contrast enhancement on the same day. Dedicated MR images including diffusion weighted images were obtained. Readers assessed PET/MR and PET/CT with contrast-enhanced CT. Accuracies of PET/MR and PET/CT for NSCLC staging were compared. RESULTS: Primary tumour stages (n = 40) were correctly diagnosed in 32 patients (80.0 %) on PET/MR and in 32 patients (80.0 %) on PET/CT (P = 1.0). Node stages (n = 42) were correctly determined in 24 patients (57.1 %) on PET/MR and in 22 patients (52.4 %) on PET/CT (P = 0.683). Metastatic lesions in the brain, bone, liver, and pleura were detected in 6 patients (13.3 %). PET/MR missed one patient with pleural metastasis while PET/CT missed one patient with solitary brain metastasis and two patients with pleural metastases (P = 0.480). CONCLUSIONS: This study demonstrated that PET/MR in combination with contrast-enhanced CT was comparable to PET/CT in the preoperative staging of NSCLC while reducing radiation exposure. KEY POINTS: • PET/MR can be comparable to PET/CT for preoperative NSCLC staging. • PET/MR and PET/CT show excellent correlation in measuring SUVmax of primary lesions. • Using PET/MR, estimated radiation dose can decrease by 31.1 % compared with PET/CT.

Serum activin-A as a predictive and prognostic marker in critically ill patients with sepsis.

BACKGROUND AND OBJECTIVE: There are limited data regarding serum activin-A as a biomarker for sepsis. We examined whether serum activin-A concentration could predict sepsis severity and prognosis in the management of critically ill patients with sepsis. METHODS: The subjects were adult patients suspected of having sepsis and admitted to intensive care unit (ICU) from January 2013 to March 2014. Serum activin-A concentration was measured in blood sampled within 48 h after ICU admission. The primary and secondary outcomes were the diagnostic value of serum activin-A concentration as a biomarker of sepsis and the prognostic value for predicting the clinical outcomes of sepsis, respectively. RESULTS: One hundred and thirty patients who had clinically suspected sepsis were included. Most (66.2%) were male; their median age was 65 years, and their Acute Physiology and Chronic Health Evaluation II score was 22.3. Serum activin-A concentration tended to increase with sepsis severity and differed significantly between those with non-sepsis and severe sepsis and between those with severe sepsis and septic shock. The risks of sepsis, severe sepsis and septic shock were significantly higher in patients with a serum activin-A concentration of 251, 319 and 432 pg/mL or greater, respectively. Serum activin-A concentration was significantly associated with the Acute Physiology and Chronic Health Evaluation II score, Sequential Organ Failure Assessment score, Charlson comorbidity index and ICU mortality. CONCLUSION: Serum activin-A was a predictor of sepsis severity and a prognostic marker in critically ill patients with sepsis. Serum activin-A concentration in the early phase of sepsis was associated with prognostic indexes on ICU admission and with ICU mortality.