Analysis of the waitlist performance and post-transplant outcomes of lung transplant in elderly recipients in Korea: A nationwide cohort study.

BACKGROUND: There is a lack of information on the waitlist performance and post-transplant outcomes of lung transplants in elderly recipients in Korea. METHODS: We retrospectively reviewed and analyzed data from the Korean Network for Organ Sharing database between March 2010 and August 2023. RESULTS: In total, 2574 patients were listed for lung transplantation during the study period, with 511 (19.9%) of them being over 65 years of age. Among these, 188 patients (36.8%) underwent transplantation, while 184 patients (36%) passed away without undergoing transplantation at the time of data extraction. The most prevalent underlying disease on the waitlist was idiopathic pulmonary fibrosis, accounting for 68.1%. The 1-year survival rate was significantly lower in the elderly compared to that in the nonelderly (65.4 vs. 75.4%; p = .004). In the multivariate Cox analysis, elderly (hazard ratio [HR], 1.49; 95% CI, 1.14-1.97; p = .004) and a high urgent status at registration (HR, 1.83; 95% CI, 1.40-2.40; p < .001) were significantly associated with post-transplant 1-year mortality. Kaplan-Meier curves demonstrated a significant difference in post-transplant mortality based on the urgency status at enrollment (χ2 = 8.302, p = .016). Even with the same highly urgent condition at the time of transplantation, different prognoses were observed depending on the condition at listing (χ2 = 9.056, p = .029). CONCLUSION: The elderly exhibited worse transplant outcomes than nonelderly adults, with a highly urgent status at registration identified as a significant risk factor. Unprepared, highly urgent transplantation was associated with poor outcomes.

Erratum: Correction of Affiliations in the Article "Validity of Outcome Prediction Scoring Systems in Korean Patients with Severe Adult Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation Therapy".

This corrects the article on p. 932 in vol. 31, PMID: 27247503.

Upregulation of P21-Activated Kinase 1 (PAK1)/CREB Axis in Squamous Non-Small Cell Lung Carcinoma.

BACKGROUND/AIMS: p21-activated Ser/Thr kinase 1 (PAK1) is essential for the genesis and development of many cancers. The purpose of this study was to investigate the role of the PAK1-cyclic AMP response element-binding (CREB) axis in non-small cell lung cancer (NSCLC) tumorigenesis and its related mechanisms. METHODS: Western blot assay and immunohistochemical staining were employed to investigate the PAK1 and CREB expression in the tissue microarray of human squamous NSCLC. Co-immunoprecipitation and immunofluorescence confocal assays were performed to determine the link between PAK1 and CREB. NSCLC xenograft models were used to study oncogenic function of PAK1 in vivo. RESULTS: We observed that PAK1 and CREB expression levels were significantly elevated in human squamous NSCLC-tissue specimens, compared with those in adjacent normal bronchial or bronchiolar epithelial-tissue specimens, as well as their phosphorylated forms, based on western blotting. We showed in vitro that PAK1 knockdown by small-interfering RNA (siRNA) blocked CREB phosphorylation, whereas plasmid-based PAK1 overexpression resulted in CREB phosphorylation at Ser133, based on western blotting. In addition, PAK1 interacted with CREB in co-immunoprecipitation assays. Additionally, our in vitro findings detected by flow cytometry revealed that PAK1 silencing attenuated cell cycle progression, inducing apoptosis. Inhibition of PAK1 expression reduced tumor sizes and masses by modulating CREB expression and activation in xenograft models. CONCLUSION: These results suggest a novel mechanism whereby the PAK1-CREB axis drives carcinogenesis of squamous-cell carcinomas, and have important implications in the development of targeted therapeutics for squamous-cell lung cancer.

Highly Luminous and Thermally Stable Mg-Substituted Ca2-xMgxSiO4:Ce (0 ≤ x ≤ 1) Phosphor for NUV-LEDs.

Blue-emitting Ca2-xMgxSiO4:Ce (0.0 ≤ x ≤ 1.0) phosphors were successfully synthesized and characterized. Rietveld refinement revealed that four main phases exist within the solid-solution range of CaO-MgO-SiO2, namely, ß-Ca2SiO4 (Mg (x) = 0.0), Ca14Mg2(SiO4)8 (Mg (x) = 0.25), Ca3Mg(SiO4)2 (Mg (x) = 0.5), and CaMgSiO4 (Mg (x) = 1.0). The variation of the IR modes was more prominent with increasing Mg2+ content in the Ca2-xMgxSiO4 materials. The sharing of O atoms of the SiO4-tetrahedra by the MgO6-octahedra induced weakening of the Si-O bonds, which resulted in the red shift of the [SiO4] internal modes and appearance of a Mg-O stretching vibration at ∼418 cm-1. Raman measurement revealed that the change of the Ca-O bond lengths because of the Mg2+-substitution directly reflected the frequency shift of the Si-O stretching-Raman modes. Notably, the thermal stability of Ca2-xMgxSiO4:Ce (Mg (x) > 0.0) phosphors was superior to that of ß-Ca2SiO4:Ce (Mg (x) = 0.0) as confirmed by temperature-dependent photoluminescence (PL) measurements. This indicated that Mg2+ ions play an important role in enhancement of the thermal stability. In combination with the results from PL and electroluminescence (EL), it was elucidated that the luminous efficiency of Ca2-xMgxSiO4:Ce (Mg (x) = 0.1) was approximately twice as much as ß-Ca2SiO4:Ce (Mg (x) = 0.00), directly indicating a "Mg2+-substitution effect". The large enhancements of PL, EL, and thermal stability because of Mg2+-substitution may provide a platform in the discovery of more efficient phosphors for NUV-LEDs.

Impact of bloodstream infections on catheter colonization during extracorporeal membrane oxygenation.

There are concerns about secondary extracorporeal membrane oxygenation (ECMO) catheter infections in bacteremic patients. We investigated the association between blood stream infection (BSI) and ECMO catheter colonization. From January 2012 to August 2014, 47 adults who received ECMO support were enrolled. The ECMO catheter tip was cultured at the end of the ECMO procedure. The enrolled patients were classified into two groups according to the presence of BSI during ECMO support and analyzed with respect to ECMO catheter colonization. Of 47 cases, BSI during ECMO was identified in 13 patients (27.7 %). ECMO catheter colonization was identified in 6 (46.2 %) patients in the BSI group and 3 (8.8 %) in the non-BSI group. BSI during ECMO support was independently associated with ECMO catheter colonization [odds ratio (OR) 5.55; 95 % confidence interval (CI) 1.00-30.73; p = 0.049]. The organisms colonizing ECMO catheters in the setting of primary BSI were predominantly Gram-positive cocci and Candida species. Acinetobacter baumannii was the most common colonizing pathogen in the setting of secondary BSI. All the organisms colonizing ECMO catheters were multi-drug resistant organisms, including methicillin-resistant S. aureus, Candida glabrata, and carbapenem-resistant A. baumannii. ECMO catheters may become contaminated with multi-drug resistant pathogens in the presence of BSI. Therefore, ECMO should be applied cautiously in septic patients with bacteremia caused by multi-drug resistant pathogens.

Validity of Outcome Prediction Scoring Systems in Korean Patients with Severe Adult Respiratory Distress Syndrome Receiving Extracorporeal Membrane Oxygenation Therapy.

Recently, several prognostic scoring systems for patients with severe acute respiratory distress syndrome (ARDS) requiring extracorporeal membrane oxygenation (ECMO) have been published. The aim of this study was to validate the established scoring systems for outcome prediction in Korean patients. We retrospectively reviewed the data of 50 patients on ECMO therapy in our center from 2012 to 2014. A calculation of outcome prediction scoring tools was performed and the comparison across various models was conducted. In our study, the overall hospital survival was 46% and successful weaning rate was 58%. The Predicting Death for Severe ARDS on V-V ECMO (PRESERVE) score showed good discrimination of mortality prediction for patients on ECMO with AUC of 0.80 (95% CI 0.66-0.90). The respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and simplified acute physiology score (SAPS) II score also showed fair prediction ability with AUC of 0.79 (95% CI 0.65-0.89) and AUC of 0.78 (95% CI 0.64-0.88), respectively. However, the ECMOnet score failed to predict mortality with AUC of 0.51 (95% CI 0.37-0.66). When evaluating the predictive accuracy according to optimal cut-off point of each scoring system, RESP score had a best specificity of 91.3% and 66.7% of sensitivity, respectively. This study supports the clinical usefulness of the prognostic scoring tools for severe ARDS with ECMO therapy when applying to the Korean patients receiving ECMO.

Association between sarcopenia and metabolic syndrome in chronic obstructive pulmonary disease: the Korea National Health and Nutrition Examination Survey (KNHANES) from 2008 to 2011.

AIM: It is not clear whether the restrictive or obstructive pattern of spirometry is associated with metabolic syndrome. We investigated the associations between restrictive and obstructive spirometric patterns and metabolic risk factors using data from the Korea National Health and Nutrition Examination Survey (KNHANES). Additionally, we investigated whether sarcopenia is associated with metabolic syndrome in patients with chronic obstructive pulmonary disease (COPD). METHODS: Using data from KNHANES between 2008 and 2011, we enrolled 8,145 subjects (normal lung function: 6,077, obstructive spirometric pattern: 1,039, restrictive pattern: 1,029) aged ≥40 years who underwent anthropometric measurement, laboratory tests, spirometry and estimation of appendicular muscle mass. Sarcopenia was defined as an appendicular skeletal muscle mass divided by body weight squared <2 SD below the sex-specific mean for the young reference group. RESULTS: Sarcopenia was found in 32.8% of male and 12.2% of female patients with COPD. The odds ratio (OR) of metabolic syndrome for the restrictive spirometric pattern in male was 1.29 (95% confidence interval [CI], 1.02-1.65), and that for obstructive pattern in males was 0.99 (95% CI, 0.79-1.26) after adjustments for covariables (female restrictive pattern (ORs, 1,45; 95% CI, 1.09-1.91) and female obstructive pattern (ORs 0.73; 95% CI, 0.49-1.09). After adjustment for other confounding factors, the risk of metabolic syndrome was higher in sarcopenic male (OR, 1.88; 95% CI, 1.27-2.77) with COPD than in those without sarcopenia. CONCLUSIONS: The restrictive spirometric pattern is associated with metabolic syndrome, and sarcopenia may contribute to the risk of metabolic syndrome in male patients with COPD.

Unique Changes in the Lung Microbiome following the Development of Chronic Lung Allograft Dysfunction.

The importance of lung microbiome changes in developing chronic lung allograft dysfunction (CLAD) after lung transplantation is poorly understood. The lung microbiome-immune interaction may be critical in developing CLAD. In this context, examining alterations in the microbiome and immune cells of the lungs following CLAD, in comparison to the lung condition immediately after transplantation, can offer valuable insights. Four adult patients who underwent lung retransplantation between January 2019 and June 2020 were included in this study. Lung tissues were collected from the same four individuals at two different time points: at the time of the first transplant and at the time of the explantation of CLAD lungs at retransplantation due to CLAD. We analyzed whole-genome sequencing using the Kraken2 algorithm and quantified the cell fractionation from the bulk tissue gene expression profile for each lung tissue. Finally, we compared the differences in lung microbiome and immune cells between the lung tissues of these two time points. The median age of the recipients was 57 years, and most (75%) had undergone lung transplants for idiopathic pulmonary fibrosis. All patients were administered basiliximab for induction therapy and were maintained on three immunosuppressants. The median CLAD-free survival term was 693.5 days, and the median time to redo the lung transplant was 843.5 days. Bacterial diversity was significantly lower in the CLAD lungs than at transplantation. Bacterial diversity tended to decrease according to the severity of the CLAD. Aerococcus, Caldiericum, Croceibacter, Leptolyngbya, and Pulveribacter genera were uniquely identified in CLAD, whereas no taxa were identified in lungs at transplantation. In particular, six taxa, including Croceibacter atlanticus, Caldiserium exile, Dolichospermum compactum, Stappia sp. ES.058, Kinetoplastibacterium sorsogonicusi, and Pulveribacter suum were uniquely detected in CLAD. Among immune cells, CD8+ T cells were significantly increased, while neutrophils were decreased in the CLAD lung. In conclusion, unique changes in lung microbiome and immune cell composition were confirmed in lung tissue after CLAD compared to at transplantation.

A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation.

PURPOSE: Clamshell incision offers excellent exposure and access to the pleural spaces and is a standard incision for lung transplantation. However, due to its high sternal complication rate, the clamshell incision is considered a procedure that requires improvement. In this study, we aimed to investigate the outcomes of transverse sternotomy with clamshell incision in comparison to sternum-sparing bilateral anterolateral thoracotomy (BAT). MATERIALS AND METHODS: In total, 134 bilateral sequential lung transplants were performed from May 2013 to June 2022. The clamshell incision was used between May 2013 and December 2017, and the BAT was introduced in January 2018. Thirty-four patients underwent clamshell surgery, and 100 patients underwent BAT. We retrospectively compared patient characteristics and perioperative and postoperative outcomes between the two groups. RESULTS: The clamshell group required an operation time of 745.18±101.76 min, which was significantly longer than that of the BAT group at 669.90±134.09 min (p=0.003). The mechanical ventilation period after surgery was 17.26±16.04 days in the clamshell group, significantly longer than the 11.35±12.42 days in the BAT group (p=0.028). Intensive care unit stay was also significantly longer in the clamshell group (21.54±15.23 days vs. 15.03±14.28 days; p=0.033). In-hospital mortality rates were 26.5% in the clamshell group and 22.0% in the BAT group. CONCLUSION: Less-invasive lung transplantation via sternum-sparing BAT is a safe procedure with low morbidity and favorable outcomes. Preventing sternal instability enables more stable breathing after surgery, earlier weaning from mechanical ventilation, and faster recovery to routine activities.

Clinical outcomes of esophageal granular cell tumors with different endoscopic resection methods.

Esophageal granular cell tumors (GCTs), the second most common subepithelial tumors (SETs) of the esophagus, are potentially malignant with no definite management guidelines available. We retrospectively enrolled 35 patients with endoscopically resected esophageal GCTs between December 2008 and October 2021 and evaluated the clinical outcomes from the various methods performed. Several modified endoscopic mucosal resections (EMRs) were performed for treating esophageal GCTs. Clinical and endoscopic outcomes were evaluated. Mean age of patients was 55.8 ± 8.2, with majority being men (57.1%). Mean tumor size was 7.2 ± 2.6 mm, most (80.0%) were asymptomatic and present in the distal third of the esophagus (77.1%). Endoscopic characteristics predominantly included broad-based (85.7%) and whitish-to-yellowish color changes (97.1%). Endoscopic ultrasound (EUS) of 82.9% of the tumors revealed homogeneous hypoechoic SETs originating from the submucosa. The five endoscopic treatment methods used were: ligation-assisted (77.1%), conventional (8.7%), cap-assisted (5.7%), and underwater (5.7%) EMRs and ESD (2.9%). Mean procedure time was 6.6 ± 2.1 min, and no procedure-associated complications were noted. The en-bloc and complete histologic resection rates were 100% and 94.3%, respectively. No recurrences were noted during follow-up, and no significant differences in the clinical outcomes of the different methods of endoscopic resection were found. Based on tumor characteristics and therapeutic outcomes, modified EMR methods can be effective and safe. However, there were no significant differences in the clinical outcomes of the different methods of endoscopic resection.

Association of positive pre-transplant angiotensin II type 1 receptor antibodies with clinical outcomes in lung transplant recipients.

INTRODUCTION: Autoantibodies against the angiotensin II type 1 receptor (AT1R-Ab) have been previously associated with de novo donor-specific antibody (DSA) formation in lung transplantation. However, data regarding the clinical significance of AT1R-Ab in long-term graft function after lung transplantation are lacking. METHODS: Seventy-one patients who underwent lung transplantation between July 2016 and January 2020 were enrolled in this study. We examined the relationship between pre-transplant AT1R-Ab levels and graft function, clinical outcomes, and human leukocyte antigen (HLA) DSA levels during the first 3 years post-transplantation. RESULTS: Seventeen (23.9%) patients were AT1R-Ab-positive, and 54 (76.1%) were AT1R-Ab-negative. The median antibody value of the AT1R-Ab-positive group was 18 [18-22.5] U/mL, while that of the AT1R-Ab-negative group was 5.1 [3.5-8.0] U/mL (p < 0.001). There was no significant difference in the median acute cellular rejection (ACR) scores between the two groups (median [interquartile range] 1 [0.8-3] vs. 0.7 [0-1]; p = 0.145). However, there was a significant difference in the distribution of the ACR scores between the two groups (p = 0.015). Most (41.2%) patients in the pre-transplant AT1R-positive group scored above 1. The incidence of de novo DSA was also higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (52.9% vs. 20.4%, p = 0.009). The incidence of chronic lung allograft dysfunction (CLAD) within 3 years was significantly higher in AT1R-Ab-positive than in AT1R-Ab-negative patients (58.3% vs. 11.8%; p < 0.001). In the multivariate Cox regression analysis, AT1R-Ab positivity (hazard ratio, 9.46; 95% confidence interval, 2.89-30.94; p < 0.001) was significantly associated with early CLAD. Furthermore, Kaplan-Meier analysis showed that AT1R-Ab-positive patients had a shorter survival time (χ2 = 39.62, p < 0.001). CONCLUSION: High AT1R-Ab levels in the pre-transplant serum of lung recipients were associated with the development of de novo HLA-DSA, ACR, early CLAD, and short survival.

Morphological Adaptation after Bilateral Lung Transplantation in a Patient with Kartagener Syndrome: A Case Report.

Kartagener syndrome (KS) is a rare disease with an incidence of 1 in 20,000 to 30,000 births. There is no cure for KS, and conservative medical treatments are used to relieve symptoms and prevent disease progression. Lung transplantation (LT) is the only treatment option for end-stage KS. Since patients with KS have anatomical abnormalities such as situs inversus totalis, which often require surgery to correct, most reports are related to surgical techniques. Reports about morphological adaptations and changes in transplanted lung structure after LT in patients with KS are rare. We performed LT in a patient with KS and observed morphological adaptation of the lungs for 6 months on chest computed tomography using a quantitative evaluation tool (Chest Image Platform; Harvard University Disability Resources, Cambridge, MA, USA).

Clinical impact of preoperative diaphragm dysfunction on early outcomes and ventilation function in lung transplant: a single-center retrospective study.

BACKGROUND: Clinical impact of preoperative diaphragm dysfunction on lung transplantation has not been studied. We aimed to evaluate how preoperative diaphragm dysfunction affects clinical outcomes and ventilation function after transplantation. METHODS: We retrospectively enrolled 102 patients. Ultrasound for diagnosis of diaphragm dysfunction was performed on all patients both before and after lung transplantation. The primary outcome was to compare prolonged mechanical ventilation after transplantation according to the preoperative diaphragm dysfunction. Secondary outcomes compared global inhomogeneity index and lung volume after transplantation. Multivariate regression analysis were used to evaluate the association between preoperative diaphragm dysfunction and prolonged mechanical ventilation after transplantation. RESULTS: A total of 33 patients (32.4%) had preoperative diaphragm dysfunction, and half of them (n = 18) recovered their diaphragm function after transplantation. In contrast, 15 patients (45.5%) showed postoperative diaphragm dysfunction. The ratio of prolonged mechanical ventilation after transplantation was significantly higher in the preoperative diaphragm dysfunction group (p = 0.035). The postoperative durations of mechanical ventilation, intensive care unit and hospital stays were higher in the preoperative diaphragm dysfunction group, respectively (p < 0.05). In the multivariate regression analysis, preoperative diaphragm dysfunction was significantly associated with prolonged mechanical ventilation after transplantation (Odds ratio 2.79, 95% confidence interval 1.07-7.32, p = 0.037). As well, the preoperative diaphragm dysfunction group showed more inhomogeneous ventilation (p < 0.05) and lower total lung volume (p < 0.05) after transplantation. In addition, at 1 month and 3 months after transplantation, FVC was significantly lower in the preoperative diaphragm dysfunction group (p < 0.05). CONCLUSIONS: Preoperative diaphragm dysfunction was associated with prolonged mechanical ventilation after lung transplantation.

Overlooked but Serious Gallbladder Disease during Extracorporeal Membrane Oxygenation: A Retrospective Analysis.

Background: To date, there have been no reports assessing the incidence, risk factors, and clinical outcomes of GB disease in patients receiving ECMO for cardiorespiratory failure. Methods: The medical records of adults (aged > 18 years) who underwent ECMO between May 2010 and October 2019 were retrospectively reviewed. We investigated the prevalence and related factors of GB disease during ECMO therapy, compared clinical outcomes between patients with and without GB disease, and performed propensity-matched analysis. Results: In total, 446 patients were included, and symptomatic GB disease was found in 62 patients (13.9%, 76.2/1000 ECMO days). Complicated GB disease occurred in 42 patients (9.4%, 89.4/1000 ECMO days) and presented as acute cholecystitis, acute cholangitis, and biliary pancreatitis in 33 (7.4%), 7 (1.6%), and 5 (1.1%) patients, respectively. In multivariate Cox regression analysis, longer ECMO support (>2 weeks) (hazard ratio (HR), 2.95; 95% confidence interval (CI), 1.69−5.15) and elevated plasma hemoglobin (Hb, >50 mg/dL) (HR. 2.12; 95% CI, 1.18−3.78) were significantly associated with the development of GB disease. In the propensity-matched cohort, the intensive care unit (ICU) and hospital survival rates were significantly lower for patients with GB disease than for those without GB disease (ICU survival rate, 64.5% vs. 84.7%; hospital survival rate, 59.7% vs. 81.5%). Conclusion: The incidence of GB disease was higher in patients who received ECMO than in the general ICU patients. Furthermore, elevated plasma Hb and prolonged ECMO therapy were significant factors for the development of GB disease during ECMO therapy.

Combination conventional endoscopy and endoscopic ultrasound can differentiate between esophageal granular cell tumors and leiomyomas.

Esophageal leiomyomas and granular cell tumors (GCTs) are the 2 most common subepithelial tumors found in the esophagus. We attempted to differentiate the 2 tumors using endoscopic findings and endoscopic ultrasound (EUS) features. Between December 2008 and June 2021, a total of 38 esophageal GCTs and 11 esophageal leiomyomas originating from the muscularis mucosa were selected. Clinical characteristics and endoscopic features were retrospectively reviewed. Although esophageal GCTs are mainly located in the lower third of the esophagus (81.6%), esophageal leiomyomas are mainly located in the upper third of the esophagus (45.5%). Broad-based (84.2%, P = .002) and whitish-to-yellowish color changes (97.4%, P < .001) are significant endoscopic features of esophageal GCTs. The echogenicity of esophageal leiomyoma was similar to that of proper muscle echogenicity. However, the echogenicity of esophageal GCTs was hyperechoic compared to that of the proper muscle layer (90.0% vs 9.1%, respectively, P < .001). EUS revealed a clearer hyperechoic epithelial lining in the esophageal leiomyoma than in esophageal GCTs (100% vs 26.7%, respectively, P < .001). The 5 endoscopic factors (location of the lower third, broad base, whitish-to-yellowish color, hyper-echogenic, and unclear demarcated hyperechoic epithelial line) were counted to differentiate esophageal GCTs from esophageal leiomyomas. Tumors with 3 or more endoscopic factors were all esophageal GCTs. The characteristic endoscopic and EUS features of esophageal GCTs were broad-based, whitish-to-yellowish colored subepithelial tumors located in the lower third of the esophagus and hyperechoic tumor with an unclear demarcated hyperechoic epithelial line. A combination of these features can predict esophageal GCTs before endoscopic resection.

Biofilm microbiome in extracorporeal membrane oxygenator catheters.

Despite the formation of biofilms on catheters for extracorporeal membrane oxygenation (ECMO), some patients do not show bacteremia. To elucidate the specific linkage between biofilms and bacteremia in patients with ECMO, an improved understanding of the microbial community within catheter biofilms is necessary. Hence, we aimed to evaluate the biofilm microbiome of ECMO catheters from adults with (n = 6) and without (n = 15) bacteremia. The microbiomes of the catheter biofilms were evaluated by profiling the V3 and V4 regions of bacterial 16s rRNA genes using the Illumina MiSeq sequencing platform. In total, 2,548,172 reads, with an average of 121,341 reads per sample, were generated. Although alpha diversity was slightly higher in the non-bacteremic group, the difference was not statistically significant. In addition, there was no difference in beta diversity between the two groups. We found 367 different genera, of which 8 were present in all samples regardless of group; Limnohabitans, Flavobacterium, Delftia, Massilia, Bacillus, Candidatus, Xiphinematobacter, and CL0-1 showed an abundance of more than 1% in the sample. In particular, Arthrobacter, SMB53, Neisseria, Ortrobactrum, Candidatus Rhabdochlamydia, Deefgae, Dyella, Paracoccus, and Pedobacter were highly abundant in the bacteremic group. Network analysis indicated that the microbiome of the bacteremic group was more complex than that of the non-bacteremic group. Flavobacterium and CL0.1, which were abundant in the bacteremic group, were considered important genera because they connected different subnetworks. Biofilm characteristics in ECMO catheters varied according to the presence or absence of bacteremia. There were no significant differences in diversity between the two groups, but there were significant differences in the community composition of the biofilms. The biofilm-associated community was dynamic, with the bacteremic group showing very complex network connections within the microbiome.

Is the pleating technique superior to the invaginating technique for plication of diaphragmatic eventration in infants?

BACKGROUNDS: The pleating technique is widely used in plication but is difficult to perform with thoracoscopy because of its complex procedure and the limited surgical space. Thus, the invaginating technique was introduced to facilitate thoracoscopic surgery and is now widely used in video-assisted thoracoscopic surgery (VATS) plication. However, the usefulness of the invaginating technique in children has not been established because of the lack of data on long-term outcomes after surgery using the technique. METHODS: From March 2007 to December 2017, 21 patients who were surgically treated for congenital diaphragmatic eventration and phrenic nerve palsy after congenital cardiac surgery were divided into 2 groups according to the surgical method used (pleating technique: 10 patients, invaginating technique: 11 patients). We evaluated the patients for postoperative outcomes and recurrence of diaphragmatic eventration over 5 years. Postoperative recurrence of diaphragmatic eventration was confirmed by calculating the ratio of the eventration level between the eventrated and normal diaphragms. RESULTS: In the 21 patients who underwent diaphragmatic plication, the pleating and invaginating techniques were used in 10 and 11 patients, respectively. The mean follow-up duration was 63.4 ±â€¯48.4 months (pleating group [P] vs invaginating group [I]: 89.1 ±â€¯52.4 vs 40.1 ±â€¯30.8 months, p = 0.022). The mean eventration rates in the 21 patients was 26.7% ±â€¯9.1% (P vs I: 26.6% ±â€¯6.1% vs 26.9% ±â€¯11.3%, p = 0.945) before operation and -2.1% ±â€¯7.3% (-2.8% ±â€¯7.5% vs -1.5% ±â€¯7.4%, p = 0.695) in the immediate postoperative period. From the first to the fifth postoperative year, no recurrence of diaphragmatic eventration was found in any of the groups during the follow-up. CONCLUSIONS: The invaginating technique was easier to perform but showed a similar long-term result as compared with the pleating technique in terms of the growth and development of the chest cavity in the pediatric patients in this study. Thus, we recommend that the invaginating technique be applied in VATS plication for children as an alternative to the pleating technique. LEVEL OF EVIDENCE: Level III.

Prone Positioning as a Bridge to Recovery From Refractory Hypoxemia After Oversized Lung Transplant.

BACKGROUND: Size matching is an important challenge in lung transplantation. Although the survival rate after lung transplantation with an oversized allograft was improved, it is associated with substantial immediate postoperative morbidity and mortality. Prone positioning is a rescue therapy showing improved outcomes in acute respiratory distress syndrome. We present a case of immediate postoperative refractory hypoxemia after oversized lung transplantation treated by prone positioning. METHODS: A 62-year-old man was transferred to our hospital by our extracorporeal membrane oxygenation (ECMO) transport team because of acute exacerbation of idiopathic pulmonary fibrosis. He underwent bilateral lung transplantation through bilateral anterior thoracotomy. For size matching between donor and recipient, multiple wedge resection and lingular segmentectomy were performed, but an oversized lung was implanted. On the immediate postoperative day, chest radiography revealed haziness in the left lower quadrant and the patient had an increased O2 requirement; he could not be weaned from venovenous (VV) ECMO. Chest computed tomography revealed left lower lobar atelectasis and primary graft dysfunction. To revert the atelectatic portion, improve ventilation/perfusion mismatch, and avoid high ventilation pressure, we performed the recruitment maneuver. Despite this, his blood gas profile did not improve. Therefore, we applied prone positioning with VV ECMO. After conversion to the prone positioning, the hypoxia corrected and the tidal volume increased. After 20 hours, he was changed to the supine position. Thereafter, arterial blood gas analyses were stable and he could be weaned from ECMO. He was discharged on postoperative day 57 and maintained good respiratory function. CONCLUSIONS: This case demonstrated the safety and feasibility of prone positioning during the immediate postoperative period after lung transplant by bilateral anterior thoracotomy. Prone positioning successfully reversed postoperative atelectasis and improved primary graft dysfunction after oversized lung transplant.

Endoscopic vacuum therapy for cervical leakage following esophagectomy under monitored anesthesia care: a case report.

Although esophagectomy is a standard treatment for esophageal cancer, anastomotic leak after esophagectomy is a relatively common complication and its incidence is 10-25% for cervical anastomosis. Endoscopic vacuum therapy (EVT) is a feasible primary treatment of esophageal perforations and leaks. Currently, there are no anesthesia guidelines for EVT, however, it is usually performed under general anesthesia with endotracheal intubation, especially for cervical EVT. Here, we report a successful EVT under monitored anesthesia care (MAC) without any complication, which doesn't need to intubate the patient. A 64-year-old male with upper esophageal cancer underwent an Ivor-Lewis operation with cervical anastomosis. Vacuum assisted closure (VAC) was performed for cervical leak under general anesthesia, but there was no further improvement. Although EVT was attempted under sedation with midazolam in an endoscopy room, the procedure was discontinued because of desaturation. Furthermore, the thoracic surgeon was concerned about the possibility of dyspnea and hypoxia even after the procedure. EVT was scheduled under MAC at the request of a thoracic surgeon and medical doctor, as EVT was expected to lead to patient discomfort and difficult airway. EVT was performed successfully with no respiratory depression or patient movement using target controlled infusion with 2% propofol and remifentanil. The patient was discharged on the 78th POD without any other complications. EVT for cervical leak after esophagectomy can be successfully performed with MAC, and understanding the general condition of the patient, cooperation with the patient and the surgeon, and providing continuous oxygen supply to the patient are necessary for a successful procedure under MAC.

Total pleural coverage followed by lung transplantation in patient with lymphangioleiomyomatosis.

Tuberous sclerosis complex lymphangioleiomyomatosis (TSC-LAM) is a rare disease, which may develop an intractable pneumothorax. Chemical or mechanical pleurodesis is a general management to prevent recurrence of pneumothorax, rendering it difficult to later dissect the pleura and control intraoperative bleeding. Since total pleural coverage (TPC) alternative to pleurodesis has been firstly reported by Kurihara et al. (Jpn J Thorac Cardiovasc Surg 54:274, 2006), TPC was performed in case of a 46-year-old female with a secondary spontaneous pneumothorax caused by TSC-LAM and followed by lung transplantation. Final pathological report showed the reinforced visceral pleura in the absence of dense adhesions.