Relationship between changes in pulmonary function and patient-reported outcomes of lung cancer surgery.

PURPOSE: To investigate the relationship between changes in pulmonary function (PF) and patient-reported outcomes (PROs) of lung cancer surgery. METHODS: We recruited 262 patients who underwent lung resection for lung cancer, to evaluate the PROs, using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30 and the Lung Cancer 13-question supplement (LC13). The patients underwent PF tests and PRO assessments preoperatively (Pre) and 1 year after surgery (Y1). Changes were calculated by subtracting the value at Pre from the value at Y1. We set two cohorts: patients under the ongoing protocol (Cohort 1) and patients who were eligible for lobectomy with clinical stage I lung cancer (Cohort 2). RESULTS: Cohorts 1 and 2 comprised 206 and 149 patients, respectively. In addition to dyspnea, changes in PF were also correlated with scores for global health status, physical and role function scores, fatigue, nausea and vomiting, pain, and financial difficulties. Absolute correlation coefficient values ranged from 0.149 to 0.311. Improvement of emotional and social function scores was independent of PF. Sublobar resection preserved PF more than lobectomy did. Wedge resection mitigated dyspnea in both cohorts. CONCLUSION: The correlation between PF and PROs was found to be weak; therefore, further studies are needed to improve the patient's postoperative experience.

Sex-specific emphysematous changes evaluated by a three-dimensional computed tomography volumetric analysis among patients with smoking histories who underwent resection for lung cancer.

PURPOSE: The present study evaluated the sex-specific susceptibility to the development of emphysema in patients with smoking histories who underwent lung cancer surgeries. METHODS: Lung cancer patients with smoking histories who underwent lung resection at the University of Tsukuba Hospital, Japan, were enrolled. Radiologic emphysematous changes were analyzed using three-dimensional computed tomography (3D-CT). The volume proportion of emphysematous lung per unit of smoking and the relationship between emphysematous change and clinicopathologic factors were evaluated. RESULTS: Radiologic emphysematous changes analyzed using 3D-CT per pack-year smoked, defined as the Smoking-Emphysema Index (SEI), were greater in females than males. The difference was more profound in adenocarcinoma patients than in non-adenocarcinoma patients (0.70 ± 2.30 vs. 0.21 ± 0.28, P = 0.037). CONCLUSION: Female lung cancer patients are more susceptible to smoking-induced emphysema than males. The SEI may be an effective indicator for evaluating smoking-induced emphysema.

Three-dimensional analysis reveals a high incidence of lung adenocarcinoma in the upper region.

PURPOSE: The lung is a unique organ with a ventilation-perfusion mismatch, which can cause inhomogeneous incidence rates of lung cancer depending on the location in the lung. We aimed to evaluate the incidence of lung adenocarcinoma in each lobe by analyzing the incidence per unit volume, to evaluate the incidence without being affected by differences in the size of each lobe or in the size of the lungs between individuals. METHODS: The number of adenocarcinomas in each lobe was counted. Lung volumes were measured using a three-dimensional computer workstation. The tumor incidence per unit volume was analyzed based on the number of tumors in each lobe. RESULTS: The number of tumors per unit volume was 0.467 in the right upper lobe (RUL), 0.182 in the right middle lobe, 0.209 in the right lower lobe, 0.306 in the left upper segment (LUS), 0.083 in the left lingular segment, and 0.169 in the left lower lobe. The tumor incidence rate of RUL + LUS was 2.269 times that of the other lobes, a value that was significantly higher when using the bootstrap method (p < 0.001). CONCLUSIONS: The incidence of adenocarcinoma per unit volume in both upper lobes was higher than that in other lobes.

Consolidation volume and integration of computed tomography values on three-dimensional computed tomography may predict pathological invasiveness in early lung adenocarcinoma.

PURPOSE: To investigate the relationship between three-dimensional computed tomography (3D-CT) findings and pathological invasiveness in lung adenocarcinoma. METHODS: We retrospectively evaluated 95 patients who underwent surgical resection of lung adenocarcinoma of ≤ 20 mm. The diameters, volumes, and CT values of tumor consolidation were analyzed. We defined the modified CT value by setting air as 0 and water as 1000 and assumed a correlation with pathological invasiveness. Pre-invasive lesions and minimally invasive adenocarcinomas were classified as non-invasive adenocarcinoma. We compared the clinico-radiological features with pathological invasiveness. Receiver operator characteristic (ROC) curves and recurrence-free survival curves were constructed. RESULTS: Twenty-six non-invasive adenocarcinomas and 69 invasive adenocarcinomas were evaluated. The multivariate analysis revealed that the consolidation volume and the integration of modified CT values were the most important predictors of pathological invasion. The area under the ROC curve and the cut-off values of the consolidation volume were 0.868 and 75 mm3, respectively. The area under the ROC curve and the cut-off values of the integration of modified CT values were 0.871 and 80,000, respectively. There was no recurrence in cases with values below the cut-off across all parameters. CONCLUSION: The consolidation volume and integration of modified CT values were shown to be highly predictive of pathological invasiveness.

[Influence of Pleural Adhesions on Thoracoscopic Surgeries for Malignant Lung Tumors].

In the present study, influences of pleural adhesions on thoracoscopic lung surgeries were investigated. A total of 666 consecutive patients who had undergone thoracoscopic surgeries for lung malignant tumors were retrospectively analyzed. Pleural adhesions were present intraoperatively in 289 cases, of which 6 required conversion to thoracotomy due to the adhesions. The influences of pleural adhesions on the perioperative period were comparatively large under following conditions (level-A); the adhesion-type was tight which meant lung and pleural wall sticked closely even if lung collapse was encouraged, the strength was middle( required sharp-dissection) or strong( hard to dissect between visceral and parietal pleura), and the range was more than 10% of total pleural surface. Significant influences of the level-A of pleural adhesions were as follows;prolonged operation time in all procedures, frequent intraoperative lung fistula and prolonged pleural drainage period in wedge resections, and increased blood loss, intraoperative and postoperative lung fistula with prolonged pleural drainage time and postoperative hospitalization period in lobectomy. Other postoperative complications (pneumonia, empyema, exacerbation of interstitial pneumonitis, and arrhythmias) were not associated with pleural adhesions. Careful dissection procedure for pleural adhesions that minimize damage of visceral pleura would be the most important.

Factors related to physical and mental components of quality of life in the community-dwelling frail older persons.

[Purpose] The aim of this study was to investigate factors associated with changes in both the physical and mental components of quality of life (QOL) in of community-dwelling frail older persons in long-term care and to clarify which aspects are important to maintaining physical and mental components of QOL. [Participants and Methods] In this 1 year follow-up cohort study, participants were older persons from a single day care rehabilitation center in Japan. The Medical Outcome Study 8-Item Short-Form Health Survey (MOS-SF8), which gives both physical component summary (PCS) and mental component summary (MCS) scores, was used as the main QOL assessment. Participants were divided according to their level of QOL maintenance according to changes in PCS and MCS scores over the study period, and the variables were compared between the groups. [Results] PCS domain was significantly associated with forced vital capacity and the MCS domain was significantly associated with the Geriatric Depression Scale and Dysphagia Risk Assessment for the Community-Dwelling Elderly Test. [Conclusion] Depression, reduced pulmonary function, and reduced deglutition ability were independently related to low QOL. Assessment of these factors could be beneficial for maintaining the physical and mental components of QOL in community-dwelling frail older persons in long-term care.

Evaluation of adenovirus amplified detection of immunochromatographic test using tears including conjunctival exudate in patients with adenoviral keratoconjunctivitis.

BACKGROUND: We evaluated a novel silver amplification immunochromatography test for rapid detection of adenovirus (AdV) antigen equipped with an automated reader system using tears including conjunctival exudate in patients with adenoviral keratoconjunctivitis. METHODS: Two kinds of immunochromatographic (IC) kits, a conventional IC kit for conjunctival scrapings (control kit) and an IC kit using tears including conjunctival exudate collected by pressing a filter paper strip on the conjunctiva (test kit), were tested on 90 patients who attended Migita Eye Clinic with suspected adenoviral conjunctivitis. The results of the test kits were automatically obtained by a specific reader, which was based on silver amplification immunochromatography system, in 15 min. The detection of AdV was confirmed by real-time polymerase chain reaction (PCR) method, and typing was performed by direct sequencing. Comparative dilution assay was carried out with the two kits, using AdV type 3 and type 54 strains. RESULTS: The sensitivity of the control kit and test kit was 89.8% and 98.3%, respectively. The specificity of both kits was 100%. A significant difference in the sensitivities of the two IC kits against PCR positivity was observed (P < 0.01). A significant correlation was found between AdV DNA copy numbers on a logarithmic scale obtained with the two tests (P < 0.01). The sensitivity of the test kit was 32-64-fold higher than that of the control kit without silver amplification for both AdV types. CONCLUSIONS: These results suggest that this novel amplified AdV detection kit using tears including conjunctival exudate is useful, because it decreases patients' discomfort from specimen collection and its sensitivity is significantly higher than that of the conventional IC kit.

Human adenoviral type 54 keratoconjunctivitis accompanied by stellate keratitis and keratic precipitates: two cases.

BACKGROUND: Of the 10 patients with adenoviral type 54 keratoconjunctivitis examined at Nojima Hospital, 2 developed stellate keratitis and mutton-fat keratic precipitates (KPs) following acute symptoms. CASE PRESENTATION: We encountered 10 cases of epidemic keratoconjunctivitis from August to October 2017. All patients were adults with a mean age of 60.9 ± 10.0 years. The species D human adenovirus (HAdV)-54 was detected in the conjunctival scrapings of these patients. Fluorometholone instillation was administered during the first week for acute symptomatic relief. Case 1: A 64-year-old female was prescribed with fluorometholone instillation, which was discontinued after 1 week when her symptoms alleviated. One week after discontinuation of the instillation, she presented with blurred vision in her left eye with KPs and multiple stellate keratitis. The anterior chamber had no apparent cells. Her symptoms disappeared after 1 week of betamethasone instillation. Case 2: A 66-year-old female was prescribed with 0.1% fluorometholone instillation, which was discontinued within10 days. Three months after the appearance of initial symptoms, multiple subepithelial corneal infiltrates (MSI) appeared in her eyes. Stellate keratitis and dark-brown pigmentation were observed in the centres of MSI, with several cells in the anterior chamber. Betamethasone was prescribed, and MSI and stellate keratitis improved within 1 week. However, KPs were observed in the left eye. The instillation was continued for 3 more weeks until symptoms improved. CONCLUSIONS: MSI is an immune reaction that occurs after the disappearance of acute symptoms. Here, corneal findings and KPs were observed after improvement in eye redness and discontinuation of steroids. These symptoms were presumed to be secondary inflammation due to immune response to the adenoviral antigen. The clinical features of HAdV-54 keratoconjunctivitis on the ocular surface are initially moderate, but become active in the subacute to chronic phases. This may develop atypical findings, including stellate keratitis with KPs. Although early steroid administration can relieve acute symptoms, it may facilitate chronic corneal immunological reaction.

Three-dimensional computed tomographic volumetry precisely predicts the postoperative pulmonary function.

PURPOSE: It is important to accurately predict the patient's postoperative pulmonary function. The aim of this study was to compare the accuracy of predictions of the postoperative residual pulmonary function obtained with three-dimensional computed tomographic (3D-CT) volumetry with that of predictions obtained with the conventional segment-counting method. METHODS: Fifty-three patients scheduled to undergo lung cancer resection, pulmonary function tests, and computed tomography were enrolled in this study. The postoperative residual pulmonary function was predicted based on the segment-counting and 3D-CT volumetry methods. The predicted postoperative values were compared with the results of postoperative pulmonary function tests. RESULTS: Regarding the linear correlation coefficients between the predicted postoperative values and the measured values, those obtained using the 3D-CT volumetry method tended to be higher than those acquired using the segment-counting method. In addition, the variations between the predicted and measured values were smaller with the 3D-CT volumetry method than with the segment-counting method. These results were more obvious in COPD patients than in non-COPD patients. CONCLUSIONS: Our findings suggested that the 3D-CT volumetry was able to predict the residual pulmonary function more accurately than the segment-counting method, especially in patients with COPD. This method might lead to the selection of appropriate candidates for surgery among patients with a marginal pulmonary function.

Wedge extended bronchoplasty with caliber adjustment by membranous suture.

Extended bronchoplasty for the left lower lobe lung tumors with interlobar lymph node involvement is a useful surgical technique for avoiding pneumonectomy. Typically, sleeve bronchoplasty, in which the superior division bronchus and the left main bronchus are separated and anastomosed, is chosen due to the difference in caliber of the anastomosis; herein, we report a wedge extended bronchoplasty in which the superior division bronchus and the left main bronchus were not completely separated. The main point of this technique is to adjust the difference in caliber by suturing the main bronchial membranes.

[Examination of Optimal Frequency Processing in X-ray Images for Occult Femoral Neck Fractures].

PURPOSE: Osteosclerotic images are known as an image appearance of occult femoral neck fractures in X-ray images. The aim of this study is to investigate frequency enhancement processing that improves the visibility of the osteosclerotic image. METHODS: We acquired three sclerotic bone images with different thicknesses, and self-made bone equivalent phantoms were set up on a pelvic phantom. The frequency processing type and high-density enhancement coefficients were applied to the X-ray images taken at RF-A(1.0, 2.0), C(2.0, 4.0), D(1.0), and H(2.0, 4.0). For the physical index, we compared the difference in signal values between the sclerotic and background normal bone. We evaluated the preference using Scheffé's paired comparison methods for the visual index. RESULTS: For the physical index, RF-C(4.0) had the most significant signal value difference for all 3 bone stiffness images. For the visual index, RF-C(4.0) showed the highest preference. CONCLUSION: Using frequency-enhanced processing, RF-C(4.0) was suggested to improve the visibility of the osteosclerosis image.

Lung cancer detection in perioperative patients' exhaled breath with nanomechanical sensor array.

INTRODUCTION: Breath analysis using a chemical sensor array combined with machine learning algorithms may be applicable for detecting and screening lung cancer. In this study, we examined whether perioperative breath analysis can predict the presence of lung cancer using a Membrane-type Surface stress Sensor (MSS) array and machine learning. METHODS: Patients who underwent lung cancer surgery at an academic medical center, Japan, between November 2018 and November 2019 were included. Exhaled breaths were collected just before surgery and about one month after surgery, and analyzed using an MSS array. The array had 12 channels with various receptor materials and provided 12 waveforms from a single exhaled breath sample. Boxplots of the perioperative changes in the expiratory waveforms of each channel were generated and Mann-Whitney U test were performed. An optimal lung cancer prediction model was created and validated using machine learning. RESULTS: Sixty-six patients were enrolled of whom 57 were included in the analysis. Through the comprehensive analysis of the entire dataset, a prototype model for predicting lung cancer was created from the combination of array five channels. The optimal accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 0.809, 0.830, 0.807, 0.806, and 0.812, respectively. CONCLUSION: Breath analysis with MSS and machine learning with careful control of both samples and measurement conditions provided a lung cancer prediction model, demonstrating its capacity for non-invasive screening of lung cancer.

Identification of the Separation Range of an Incomplete Interlobar Fissure in Segmentectomy Using Near Infrared.

In segmentectomy for patients with incomplete interlobar fissures, insufficient dissection of the interlobar parenchyma may result in incomplete segmentectomy, while excessive dissection may lead to excessive bleeding and air leaks. Here, we report a case of left apicoposterior (S1+2) segmentectomy with incomplete interlobar fissure in which near-infrared thoracoscopy with indocyanine green was used to identify the separation range of interlobar fissure by dissecting the relevant vessels beforehand.

Sphericity of lymph nodes using 3D-CT predicts metastasis in lung cancer patients.

BACKGROUND: The presence of mediastinal lymph node metastasis is important because it is related to the treatment and prognosis of lung cancer. Although prevalently used, evaluation of lymph nodes is not always reliable. We introduced sphericity as a criterion for evaluating morphologic differences between metastatic and nonmetastatic nodes. METHODS: We reviewed the cases of 66 patients with N2 disease and of 68 patients with N0-1 disease who underwent lobectomy with mediastinal dissection between January 2012 and December 2021. The sphericity of the dissected station lymph nodes, which represents how close the node is to being a true sphere, was evaluated along with the diameter and volume. Each parameter was obtained and evaluated for ability to predict metastasis. RESULTS: Metastatic lymph nodes had a larger short-axis diameter (average: 8.2 mm vs. 5.4 mm, p < 0.001) and sphericity (average: 0.72 vs. 0.60, p < 0.001) than those of nonmetastatic lymph nodes. Short-axis diameter ≥ 6 mm and sphericity ≥ 0.60 identified metastasis with 76.2% sensitivity and 70.2% specificity (AUC = 0.78, p < 0.001) and 92.1% sensitivity and 53.9% specificity (AUC = 0.78, p < 0.001), respectively. For lymph nodes with a short-axis diameter ≥ 5 mm, sphericity ≥ 0.60 identified metastasis with 84.1% sensitivity and 89.3% specificity. CONCLUSION: By using 3D-CT analysis to examine sphericity, we showed that metastatic lymph nodes became spherical. Our method for predicting lymph node metastasis based on sphericity of lymph nodes with a short-axis diameter ≥ 5 mm could do so with higher sensitivity than the conventional method, and with acceptable specificity.

Rapid clearance of supplemented tetrahydrobiopterin is driven by high-capacity transporters in the kidney.

Tetrahydrobiopterin (BH(4)) is an essential cofactor of aromatic amino acid hydroxylases and NO synthase. Supplementation of BH(4) potentially targets cardiovascular dysfunction as well as inherited BH(4) deficiencies and BH(4)-responsive phenylketonuria. However, the high cost/effect ratio of the recommended daily dose of BH(4) supplementation acts against further popularization of this therapy. The aim of this study was to attenuate urinary excretion with the intention of improving efficacy of BH(4) supplementation. The rapid excretion of BH(4) in the urine was confirmed to be the major route of supplemented BH(4) loss. In addition to glomerular filtration into the urine, a dominant rapid exclusion by renal secretion was observed in rats (T((1/2))=16 min) when the plasma BH(4) was higher than about 1 nmol/mL (more than 10 times higher than normal), due to BH(4) supplementation. The rapidity of the process was slowed by prior administration of cyclosporin A, a representative anti-excretory drug, and the excretion decelerated to a moderate rate (T((1/2))=53 min). By the combined administration of BH(4) plus cyclosporin A, the blood BH(4) levels were dramatically elevated. It was hypothesized that the drug interfered with kidney excretion of BH(4) rather than by attenuating organ tissue distribution by inhibiting biopterin uptake from the plasma. Consistent with this hypothesis, biopterin levels after BH(4) administration were elevated in major organs in the presence of anti-excretory drugs without notable change in their BH(4) fraction which was consistently 95% or higher regardless of combined administration with the drugs. Targeting these putative transporters would be a promising approach for improving the efficiency of BH(4) supplementation therapy.

Left thoracoscopic sympathectomy for refractory ventricular arrhythmias.

Left cardiac sympathetic denervation is a procedure used to prevent ventricular arrhythmias that remain refractory despite medical treatments. This procedure usually involves the resection of the lower side of the stellate ganglion, which is an uncommon surgical technique due to the limited situations in which it can be applied. Here, we report a case of refractory ventricular arrhythmias and a description of its successful treatment with the method of left cardiac sympathetic denervation using video-assisted thoracotomy.

Comparison of Postoperative Quality of Life and Pain with and without a Metal Rib Spreader in Patients Undergoing Lobectomy through Axillary Mini-Thoracotomy for Stage I Lung Cancer.

PURPOSE: To evaluate postoperative patient-reported quality of life (QOL) and pain with and without a metal rib spreader (MRS) in patients with stage I lung cancer who underwent lobectomy through axillary mini-thoracotomy (AMT). METHODS: This single-institution prospective observational study enrolled patients between January 2015 and April 2018. Their QOL and pain were evaluated using the EQ-5D and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire 30 items (QLQ-C30). The EQ-5D was completed preoperatively (Pre) and on days 1/3/5/7 (D1/3/5/7), at 1 month (M1), and at 1 year postoperatively (Y1). The EORTC QLQ-C30 was completed at Pre, M1, and Y1. RESULTS: The data of 140 patients were analyzed (video-assisted without MRS: VA/noMRS: 67, AMT with MRS: AMT/MRS: 73). Although the AMT/MRS group had more preoperative comorbidities, longer operative times, and more blood loss than the VA/noMRS group, the EQ-5D visual analog scale scores were not significantly different at any assessment point (Pre/D1/D3/D5/D7/M1/Y1) (VA/noMRS: 82/48/60/67/73/77/85, AMT/MRS: 80/46/60/66/73/76/85). Postoperative pain in the EQ-5D descriptive system and the EORTC QLQ-C30 was comparable between the groups. CONCLUSION: VA/noMRS and AMT/MRS showed similar postoperative QOL and pain scores, indicating that MRS negligibly impacts the postoperative QOL and pain.

Effect of pulmonary training for community-dwelling frail older adults with chronic stroke: A randomized controlled pilot trial.

Background: Decreased pulmonary function and poor deglutition are a major risk factor for poststroke aspiration pneumonia. We analyzed the benefits of pulmonary training on pulmonary function, deglutition, and quality of life (QOL) in community-dwelling, frail elderly people with chronic stroke. Method: This study was designed as an open, randomized, controlled pilot trial. The participants, who were frail older adults with a history of stroke, were randomized to 2 rehabilitation groups: intervention group (n = 15) and control (n = 15). All participants (65-94 years) attended twelve 20-min sessions twice a week for 6 weeks of either standard rehabilitation (control group) or standard rehabilitation with pulmonary training including home pulmonary exercise (intervention group). The main outcome measures were pulmonary function (%MIP), deglutition (DRACE), and QOL (SF8ï½¥PCS), while secondary outcomes were muscle strength (grip and abdominal), thorax flexibility, 6-min walk distance, and activities in daily living. All outcomes were measured both prior to training and after the 12 sessions. Results: The intervention group showed significant improvement in %MIP (95% CI, 2.9-31.6; p < 0.01), DRACE (95% CI, -4.1-0.1; p < 0.01), and SF8ï½¥PCS (95% CI, 2.5-7.2; p < 0.01) compared with controls. There were no cognitive function decline and higher brain dysfunction. Conclusions: These results suggest that the addition of pulmonary training including home pulmonary exercise to a standard rehabilitation program could improve pulmonary function, deglutition, and QOL in frail elderly people with chronic stroke.

Efficacy of Alaska Pollock Gelatin Sealant for Pulmonary Air Leakage in Porcine Models.

BACKGROUND: Postoperative prolonged air leakage is a frequent complication after lung resection. We have developed a new sealant based on a hydrophobically modified Alaska pollock-derived gelatin (ApGltn) sealant. The purpose of this study was to evaluate the adhesive strength of the ApGltn sealant in comparison with a fibrin sealant using a new spray system in ex vivo and in vivo models. METHODS: Pleural defects in ex vivo and in vivo porcine models were created, to which the ApGltn sealant or the fibrin sealant was applied. The pressure resistance was assessed with a stepwise increase in airway pressure to confirm air leakage from the sealing site. Tissue samples covered with each sealant were obtained for histologic assessment. RESULTS: In the ex vivo experiment, the leak pressures of the ApGltn sealant were significantly greater than those of the fibrin sealant (102.94 ± 15.6 cm H2O and 28.37 ± 5.1 cm H2O, respectively) (P < .01). In the in vivo experiment, the leak pressures of the ApGltn sealant were also significantly greater than those of the fibrin sealant (68.82 ± 18.04 cm H2O and 43.33 ± 7.13 cm H2O, respectively) (P = .043). The histologic examination confirmed that the ApGltn sealant adhered tightly to both the pleura and the surface of the pleural defect. CONCLUSIONS: The ApGltn sealant has sufficiently high adhesive quality in ex vivo and in vivo porcine lungs, which could be considered suitable and effective for use in the prevention of air leakage from the lungs.