A Randomized Trial of Initiation of Chronic Noninvasive Mechanical Ventilation at Home vs In-Hospital in Patients With Neuromuscular Disease and Thoracic Cage Disorder: The Dutch Homerun Trial.

BACKGROUND: There is an increasing demand for home mechanical ventilation (HMV) in patients with chronic respiratory insufficiency. At present, noninvasive ventilation is exclusively initiated in a clinical setting at all four centers for HMV in the Netherlands. In addition to its high societal costs and patient discomfort, commencing HMV is often delayed because of a lack of hospital bed capacity. RESEARCH QUESTION: Is HMV initiation at home, using a telemonitoring approach, noninferior to in-hospital initiation in a nationwide study? STUDY DESIGN AND METHODS: We conducted a nationwide, randomized controlled noninferiority trial, in which every HMV center recruited 24 patients (home [n = 12] vs hospital [n = 12]) with a neuromuscular disease or thoracic cage disorder, all with an indication to start HMV. Change in arterial CO2 (Paco2) over a 6-month period was considered the primary outcome, and quality of life and costs were assessed as secondary outcomes. RESULTS: A total of 96 patients were randomized, most of them diagnosed with neuromuscular disease. We found a significant improvement in Paco2 within both groups (home: from 6.1 to 5.6 kPa [P < .01]; hospital: from 6.3 to 5.6 kPa [P < .01]), with no significant differences between groups. Health-related quality of life showed significant improvement on various subscales; however, no significant differences were observed between the home and hospital groups. From a societal perspective, a cost reduction of more than €3,200 ($3,793) per patient was evident in the home group. INTERPRETATION: This nationwide, multicenter study shows that HMV initiation at home is noninferior to hospital initiation, as it shows the same improvement in gas exchange and health-related quality of life. In fact, from a patient's perspective, it might even be a more attractive approach. In addition, starting at home saves over €3,200 ($3,793) per patient over a 6-month period. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03203577; URL: www.clinicaltrials.gov.

The Interdisciplinary Management of Acute Chest Pain.

BACKGROUND: Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory. METHODS: This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed. RESULTS: History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention. CONCLUSION: Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.

Genetic variations in TGFß1, tPA, and ACE and radiation-induced thoracic toxicities in patients with non-small-cell lung cancer.

INTRODUCTION: We hypothesized that radiation-induced thoracic toxicity (RITT) of the lung, esophagus and pericardium share a similar mechanism, and aimed to examine whether genetic variation of transforming growth factor-beta1 (TGFß1), tissue plasminogen activator (tPA) and angiotensin converting enzyme (ACE), are associated with RITT in patients with non-small-cell lung cancer (NSCLC). METHODS: Patients with stage I-III NSCLC were enrolled and received radiotherapy (RT). Blood samples were obtained pre-RT and at 4 to 5 weeks during RT, and plasma TGF-ß1 was measured using an enzyme-linked immunosorbent assay. The DNA samples extracted from blood pre-RT were analyzed for the following frequent genetic variations: TGFß1 509C/T, tPA -7351 C/T, and ACE I/D. RITT score was defined as the sum of radiation-induced toxicity grades in esophagus, lung, and pericardium. RESULTS: Seventy-six NSCLC patients receiving definitive RT were enrolled. Patients with TGFß1 509CC had higher mean grade of esophagitis (1.4 ± 0.2 versus 0.8 ± 0.2, p = 0.019) and RITT score (2.6 ± 0.3 versus 1.6 ± 0.3, p = 0.009) than T allele carriers. Although no significant relationship was observed between RITT and the tPA or ACE variants individually, patients with any high-risk alleles (tPA CC or ACE D or TGFß1 509CC) had significantly higher grade of developing combined RITT (p < 0.001). Patients with TGFß1 509CC had greater increase of plasma TGF ß1 levels at 4 to 5 weeks during RT than T allele carriers did (CC 1.2 ± 0.2 versus T 0.7 ± 0.1, p = 0.047). CONCLUSION: This exploratory study demonstrated that sensitivity of radiation toxicity may be determined by genomic factors associated with TGFß1 and genes involved in TGFß1 pathway.

[Thoracic endometriosis: A difficult diagnosis]. / Endométriose thoracique : un diagnostic difficile.

Thoracic endometriosis is a rare disease, which presents in women at a mean age of 35 years, later than for pelvic endometriosis. There are no known predisposing factors for the condition and its pathogenesis is not yet clearly established. The symptoms always appear in connection with the periods of the person affected by the condition, occurring within 24-48 h after the start of menstruation. Catamenial pneumothorax is the most common clinical entity. It is associated with pelvic endometriosis in 30-50% of cases. Thoracoscopy, preferably performed during menstruation, allows full inspection of the diaphragm and the pleural cavity for defects in the diaphragm, endometrial nodules and bullae. The level of CA 125 is often elevated but this is not a reliable or specific marker. Medical treatment is aimed at blocking the action of estrogen on the endometrium and ectopic endometrial implants. GnRH analogues or danazol are the preferred treatments. Surgery to repair and strengthen the diaphragm and/or resect nodules or bullae also has a role, supplemented by pleurodesis to prevent further pneumothorax or effusions. The main risk is recurrence, and thus the current usual practice is to combine surgery, immediately followed by hormone therapy focusing on GnRH analogues.

Impact of ventilation parameters and duration of ventilator use on non-invasive home ventilation in restrictive thoracic disorders.

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) is an accepted treatment option for chronic ventilatory failure due to restrictive thoracic disorders. OBJECTIVE: The impact of ventilation setting and the duration of ventilator use on changes in physiological and functional parameters has not yet been evaluated. METHODS: Effects of NPPV on body plethysmographic parameters, blood gas tension and inspiratory muscle function up to 12 months were analyzed in 44 patients with thoracic cage abnormalities in a clinical stable condition. Furthermore, the influence of ventilator parameters and the duration of ventilator use on these changes was determined. RESULTS: A significant improvement in blood gas parameters (PaCO(2), PaO(2) and base excess; p < 0.001), lung volumes (VC, TLC and FEV(1); p < 0.001) and inspiratory muscle function (PI(max), P(0.1); p < 0.01 and p < 0.05) was found after 3.8 +/- 0.8 months of treatment. As shown by a subgroup analysis, changes were already achieved within the first 3 months of NPPV and then remained stable over time. Improvements in VC were positively correlated with IPAP (r = 0.55; p < 0.001). Reduction in PaCO(2) was positively correlated with the quotient (IPAP - EPAP)/weight (r = 0.55; p < 0.001). No correlation could be detected between changes in functional parameters and the duration of ventilator use. CONCLUSIONS: NPPV can improve blood gas parameters, lung volume and inspiratory muscle function in thoracic restrictive disorders. To best utilize the potential of NPPV treatment, it seems to be more effective to optimize pressure levels than to extend the duration of ventilation.

Thoracic manifestation of myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA)-related disease. CT findings in 51 patients.

OBJECTIVE: To assess the pulmonary CT findings of patients with serum evidence of the myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA). METHODS: The pulmonary CT scans of 62 patients with serum evidence of MPO-ANCA (51 with microscopic polyangiitis, 11 with Churg-Strauss syndrome) were retrospectively assessed with regard to parenchymal, pleural, and mediastinal abnormalities. RESULTS: On the CT scans, abnormal findings were seen in 51 of the patients (82%, n = 62). Of the patients, the CT findings consisted of ground-glass attenuation in 48 of the patients (94%, n = 51), consolidation in 40 (78%), and thickening of bronchovascular bundles in 26 (51%). Pathologically, these findings corresponded to alveolar hemorrhages, interstitial chronic inflammation in the alveolar septa, vasculitis, or fibrosis. These abnormalities were predominantly seen in peripheral lung parenchyma (n = 37). CONCLUSION: The CT findings in patients with MPO-ANCA consisted mainly of ground-glass attenuation and consolidation in the peripheral lung. These findings, although nonspecific, are considered as pulmonary involvement in patients with MPO-ANCA.

Endogenous glycosides in critically ill patients.

OBJECTIVE: To determine the incidence of critically ill patients displaying endogenous digitalis-like-immunoreactive substances (DLIS) and to examine the relationship of these hormones to routine laboratory variables, the underlying disease, myocardial function, hemodynamic status, severity of illness, systemic inflammation, and mortality rate. DESIGN: Sera of 401 consecutive critically ill patients, not treated with cardiac glycosides, were analyzed for DLIS (digitoxin and digoxin, TDx; Abbott Diagnostics, North Chicago, IL) and endogenous ouabain. Normal values of endogenous ouabain were determined in 62 healthy volunteers. We measured pro- and anti-inflammatory mediators (L-selectin, tumor necrosis factor-alpha, interleukin-1beta, interleukin-2, interleukin-6, interleukin-10), C-reactive protein, and serum amyloid A protein as well as patients' Acute Physiology and Chronic Health Evaluation II and Goris scores. In a subgroup of patients with a pulmonary artery catheter (n = 95), we determined cardiac output, pulmonary artery occlusion pressure, systemic and pulmonary vascular resistance, left ventricular stroke volume, and right and left stroke work. SETTING: Two surgical intensive care units of an university hospital. SUBJECTS: Sera of 401 consecutive critically ill patients. INTERVENTIONS: Blood sampling. MEASUREMENTS AND MAIN RESULTS: Of the 401 patients tested, 343 had nonmeasurable DLIS concentrations (DLIS-negative), and 58 (14.5%) had positive digoxin (n = 18) or digitoxin (n = 34) concentrations (DLIS-positive) or were positive in both tests (n = 6). Mean endogenous ouabain concentrations were nine-fold increased in DLIS-positive (3.59 +/- 1.43 nmol/L) and three-fold increased in DLIS-negative (1.34 +/-.81 nmol/L) patients compared with controls (0.38 +/- 0.31 nmol/L). DLIS and ouabain concentrations closely correlated with the Acute Physiology and Chronic Health Evaluation II and Goris score and were associated with increased concentrations of transaminases, bilirubin, aldosterone, cortisol, serum creatinine, fractional sodium excretion, proinflammatory mediators, C-reactive protein, and serum amyloid A (p

Primary intestinal and thoracic lymphangiectasia: a response to antiplasmin therapy.

Lymphangiectasia is a congenital or acquired disorder characterized by abnormal, dilated lymphatics with a variable age of presentation. We describe a case of lymphangiectasia with intestinal and pulmonary involvement in an adolescent female, who presented with many of the classic features including chylous pleural effusions, lymphopenia, hypogammaglobinemia, and a protein-losing enteropathy. She also presented with recurrent lower gastrointestinal bleeding, which is infrequently described. The patient did not improve with bowel rest and a low-fat medium-chain triglyceride diet and had little improvement with octreotide acetate therapy. However, she had a clinical response to antiplasmin therapy, trans-4-aminothylcyclohexamine carboxylic acid (tranexamic acid) in terms of serum albumin and gastrointestinal bleeding. She continues to have exacerbations of her condition, as well as persistent lymphopenia and chronic pleural effusions.

Long term follow-up of ventilated patients with thoracic restrictive or neuromuscular disease.

OBJECTIVE: To evaluate the long term effects of home mechanical ventilation (HMV) on pulmonary function, nighttime gas exchange, daytime arterial blood gases, sleep architecture and functional exercise capacity (6 min walk). Patients with respiratory failure attributable to thoracic restrictive disease (TRD) (kyphoscoliosis) or neuromuscular disease (NMD) were assessed, ventilated, trained and followed in a dedicated unit for the care of patients requiring long term ventilation. DESIGN: All patients admitted for home ventilation training since 1988 were reviewed. Measurements of lung function, gas exchange during wakefulness and sleep, as well as functional exercise capacity, were recorded before and immediately after the establishment of HMV. Measurements were repeated one to two years, five years and eight to 10 years later. PATIENTS: Seventy-four individuals with TRD or NMD who completed the home ventilation training program and continued with HMV during all or part of the day for at least one year were studied. RESULTS: Forty patients had TRD. The characteristics of these patients were (mean SE) as follows: age 58 2.4 years; vital capacity (VC) 27% 1.6% predicted, forced expiratory volume in 1 s (FEV1) 25% 1.5% predicted; FEV1/forced VC (FVC) 78% 1.8%. Thirty-four patients had NMD. The characteristics of these patients were as follows: age 44 3.1 years; VC 41% 4.9% predicted, FEV1 44 5.3% predicted; FEV1/FVC 83% 4.2%. There was a significant improvement in distance walked in 6 min (maximum change 51.2 m in patients with NMD and 93.0 m in patients with TRD), daytime partial pressure of arterial carbon dioxide (maximum change 12.9 mmHg in patients with NMD and 10.4 mmHg in patients with TRD) and nighttime partial pressure of arterial carbon dioxide (maximum change 11.7 mmHg in patients with NMD and 18.0 mmHg in patients with TRD) over time (P 0.004). Ventilation resulted in an improvement in partial pressure of arterial oxygen in patients with TRD (68.1 2.8 mmHg to 80.1 3.5 mmHg) and in patients with NMD (52.9 1.7 mmHg to 65.3 2.1 mmHg), although the change was not statistically significant in patients with NMD (P=0.001 in patients with TRD; P=0.105 in patients with NMD). The improvement after ventilation was maintained over several years. Sleep efficiency (75% 18%, 79% 2.2%), the arousal index (13.4 13 events/h, 28.2 17 events/h) and the apnea-hypopnea index (10.1 11.3 events/h, 13.9 9.5 events/h) did not change with time in either patients with TRD or patients with NMD, respectively (P 0.5). CONCLUSIONS: HMV was associated with sustained, long term improvements in nighttime and daytime gas exchange in patients with TRD and NMD. Function exercise capacity increased in patients with TRD and in a subgroup of ambulatory patients with NMD. In patients with TRD, these improvements were maintained for up to 10 years after HMV was established.

Elevated serum pro-mMP2 levels in patients with advanced lung cancer are not suitable as a prognostic marker.

Using the one-step sandwich enzyme immunoassay for pro-MMP2, we investigated whether the serum pro-MMP2 levels could be used as predictors of the development and extension of lung cancer. The study included 52 lung cancer patients and 26 nonmalignant thoracic disease patients. Serum samples were collected before clinical treatment. The serum pro-MMP2 levels were found to be elevated in patients with lung cancer (1006.3+/-37.4 ng/ml) in comparison with nonmalignant controls (767.7+/-41.6 ng/ml) (P = 0.0002). In addition, stage IIIb lung cancer patients (1167.2+/-124.2 ng/ml) had significantly higher pro-MMP2 levels compared with stage I patients (936.0+/-44.8 ng/ml, P = 0.0431). The serum pro-MMP2 levels were similar in the samples between the pathological subtypes. As a result, the serum pro-MMP2 levels may serve as a marker that can be used as a diagnostic indicator of higher stages in lung cancer. There was no difference in the prognosis between the group with normal pro-MMP2 levels (<850 ng/ml) and the group of elevated pro-MMP2 levels (>850 ng/ml), thus indicating that serum analyses of the pro-MMP2 levels were of limited value in the prognosis of lung cancer.

Determination of hemoglobin saturation in patients with acute sickle chest syndrome: a comparison of arterial blood gases and pulse oximetry.

STUDY OBJECTIVES: To evaluate three different methods of measuring oxygen saturation in patients suffering from acute sickle chest syndrome. DESIGN: A prospective, descriptive study of 9 months' duration. SETTING: A tertiary care university hospital. PATIENTS: Adult patients with acute sickle chest syndrome scheduled to undergo RBC exchange transfusion. INTERVENTIONS: None. MEASUREMENTS: Baseline hemoglobin oxygen saturation was determined simultaneously by (1) calculation based on PaO2 and an oxyhemoglobin dissociation curve algorithm, (2) co-oximetry, and (3) pulse oximetry. These same measures were repeated after exchange transfusion. Baseline and postexchange hemoglobin electrophoresis was performed in all patients. RESULTS: Baseline calculated saturation overestimated true saturation (determined by co-oximetry) with a baseline mean bias (co-oximetry minus calculated saturation) of -6.78 +/- 2.63% (95% confidence interval for bias: -8.37% to -5.19%). Pulse oximetry was not different than co-oximetry at baseline with a baseline bias of +1.86 +/- 3.25% (95% confidence interval: -0.1% to 3.82%). After exchange transfusion, there was no bias between either co-oximetry and calculated saturation (mean difference: -0.17 +/- 1.31% [95% confidence interval: -0.95% to 0.61%]), or co-oximetry and pulse oximetry (mean difference: +0.3 +/- 1.53% [95% confidence interval: -0.62% to 1.22%]). CONCLUSIONS: Calculated saturation overestimates true saturation during acute sickle chest syndrome. This discrepancy abates after exchange transfusion. Pulse oximetry more closely follows co-oximetry than does calculated saturation during acute sickle chest syndrome.

[Biochemical mechanisms of thoracic fibrosis development after pneumonectomy in patients operated for progressive pulmonary tuberculosis]. / Biokhimicheskie mekhanizmy formirovaniia fibrotoraksa posle pul'moéktomii u bol'nykh, operirovannykh po povodu progressiruiushchego tuberkuleza legkikh.

Forty three patients undergone pulmonectomy/pleuropulmonectomy were studied 1-3 days to 1.5 months after surgery. The content of total protein (TP), fibronectin (FN), medium-weight molecules, fibrinogen and fibrin degradation products (FFDP). In the absence of complications within the first 3 weeks after surgery, exudate was concentrated along with intensive cavitary proteolytic clearance, then there was deposited fibrin lysis concurrently with increased local FN synthesis. The magnitude of the two latter processes was directly relate to the rates of residual cavitary fragmentation and obliteration. In patients with empyema, fluid drainage from the residual cavity and exudate was impaired in the early postoperative period and the exudate was characterized by very low concentrations of TP, FN, FFDP. Subsequently, the phenomena of exudate dilution remained, which was associate with a decrease in the rate of proteolytic processes and a slow increase in local FN synthesis.

[Content of haptoglobin in blood serum in patients after thoracic surgery for various indications]. / Zawartosc haptoglobiny w surowicy krwi u chorych po operacjach torakochirurgicznych wykonywanych z róznych wskazan.

Initial results are presented on the usefulness of haptoglobin content monitoring in blood serum of patients after thoracic operations performed for various indications. 57 patients were analysed and divided into 3 groups based on the type of disease. Group 1 consisted of patients operated for malignant neoplasm. Group 2 consisted of patients with inflammatory changes and purulent complications within the thorax. Group 3 consisted of patients operated from other indications. The experimental samples of further 30 operated patients have not been analysed yet due to a delay in shipment of plates from Boehringer. The control group consisted of 31 healthy volunteers. In the experimental groups blood was taken 1 day before and 1, 3, 7, 10 and 14 days after the surgical intervention and in the case of complications-21 and 30 days after surgery. Erythrocyte sedimentation, leucocyte level, serum haptoglobin content, clinical and radiological data were analysed. Haptoglobin content was measured using the radial immunodiffusion method according to Manchini. Results were analysed statistically. The increase in serum haptoglobin content in patients after thoracic surgeries and after purulent complications, shows that haptoglobin is a sensitive acute phase indicator and its monitoring may be useful in evaluating the disease process. In advanced neoplastic processes haptoglobin content is a reflection of the progression of the disease process.

Pre- and postoperative sequential study on the serum gastrin level in patients with lung cancer.

Serial changes in serum gastrin level were detected by radioimmunoassay in 58 lung cancer patients before and after operation. In comparing these tests with those of 40 cases of noncancerous thoracic lesions and 151 normal adults, the serum gastrin from lung cancer patients is significantly higher than that of noncancerous thoracic lesions and normal individuals (P less than 0.01). The gastrin level is closely related to stage of cancer, size of primary tumor, presence of lymph node metastasis, and type of histological classification. The serum gastrin was found to decrease gradually after the removal of the tumor and to return to normal on the 14th postoperative day. Those patients whose serum gastrin level can return to normal on the 14th postoperative day will have a good prognosis; if not, their prognosis will be very poor. These results suggest that serum from patients with lung cancer contains a high concentration of gastrin that can help differentiate benign from malignant thoracic lesions and evaluate prognosis of patients with lung cancer. Therefore, the cause of high serum gastrin in patients with lung cancer is likely due to the gastrin-producing property of the lung cancer cells.

[Intrathoracic and generalized granulomatosis in chronic diffuse liver diseases caused by the hepatitis B virus]. / Vnutrigrudnoi i generalizovannyi granulematoz pri khronicheskikh diffuznykh zabolevaniiakh pecheni, obuslovlennykh virusom gepatita B.

In 7 patients suffering from chronic diffuse liver diseases, they were combined with intrathoracic (3 patients) and generalized (4 patients) granulomatosis. Acute viral hepatitis or risk factors of infecting hepatitis viruses revealed in the case reports of 5 patients preceded the appearance of the signs of both lung and pulmonary damage. In 2 patients (without any indications in the case report to acute viral hepatitis and risk factors of infecting by hepatitis viruses) both the processes were established at a time. HBV markers were detected in all the 7 patients: in the blood serum in 3 and in the blood serum and liver tissue in 4 patients. Besides, HBsAg was identified in the smears of the lavage fluid sediment in 3 patients examined for that purpose. The role of HBV in both etiology of chronic diffuse liver diseases and granulomatosis is under discussion.

[Clinical value of the blood lymphocyte count in thoracic sarcoidosis in adults. Apropos of 123 cases]. / Intérêt clinique de la numération des lymphocytes dans le sang au cours de la sarcoïdose thoracique de l'adulte. A propos de 123 cas.

Lymphocyte counts in the peripheral blood were performed in 123 patients with thoracic sarcoidosis and in 33 healthy subjects. A significant decrease in the number of lymphocytes as compared to controls was observed, at least in patients of Caucasian origin. This lymphopenia was more pronounced when the disease was of more than 10 years' duration, was accompanied by extrathoracic manifestations and belonged to radiological groups II or III. The only parameter of pathological activity with which it correlated was serum angiotensin converting enzyme activity. Patients from the french Caribbean had scattered lymphocyte counts which precluded any firms conclusion.

[Perioperative behavior of prostaglandin E2 (PGE2) and 13,14-dihydro-15-keto-PGF2 alpha (DHK-PGF2 alpha) in the serum in bronchial cancer]. / Untersuchungen zum perioperativen Verhalten von Prostaglandin E2 (PGE2) und 13,14-dihydro-15-keto-PGF2 alpha (DHK-PGF2 alpha) im Serum beim Bronchialkarzinom.

The perioperative behaviour of PGE2 and DHK-PGF2 alpha was studied in peripheral blood of patients undergoing lung surgery. The measurement of prostaglandins was performed by RIA after an extraction procedure. Common control criteria were observed. In 39 patients blood sampling was performed preoperatively and 2 weeks postoperatively. PGE2 and DHK-PGF2 alpha were significantly elevated in 8 patients with lung cancer before the operation. Postoperatively the concentrations decreased; 2 weeks later, DHK-PGF2 alpha was still slightly increased, PGE2 had normalized. 9 patients suffering from tuberculosis had normal serum concentrations of PGE2 and DHK-PGF2 alpha before and after resection procedures. In 8 cases the resection of benign lung diseases did not cause any abnormal reactions. In 2 special groups blood sampling was performed the following way: in 4 cancer patients and 3 tuberculosis patients blood was collected preoperatively, 5 times in the first hour after lung resection and 1 day and 2 weeks after operation. It could be demonstrated that PGE2 and DHK-PGF2 alpha almost completely normalized within the first postoperative hour in cancer patients, whereas no significant alterations could be found in tuberculosis. After discussion of technical problems in the measurement of prostaglandins the alterations of PG concentrations after lung cancer resection are emphasized.