The Relationship Between Nodal Metastases and Primary Location in Stage I Non-Small Cell Lung Cancer.

INTRODUCTION: This study examines the relationship between location of the primary tumor and specific nodal metastases in clinical stage 1 non-small cell lung cancer (NSCLC) patients undergoing lobectomy. METHODS: We retrospectively analyzed all lobectomies performed at a single institution, between January 2005 and December 2019, for clinical stage I NSCLC patients. Patients selected for this study were clinically node negative (cN0) by positron emission tomography-computed tomography scan and selectively by endobronchial ultrasound or mediastinoscopy. Cases of postoperative pathologic nodal upstaging were identified among these patients. For each patient upstaged, the specific lymph node stations found to be positive were recorded. Descriptive statistics, chi-squared tests, and Fisher's exact test were utilized to identify independent risk factors for upstaging to specific N1 and N2 lymph node stations. All clinical and pathologic staging information was retrospectively normalized to the International Association for the Study of Lung Cancer 8th Edition TNM Classification. RESULTS: The research cohort included 645 patients. The mean age was 68 years (standard deviation ± 9.2), 54% were female, and 88% were White, 11% Black, and 1% other. Twelve percent (n = 75) were upstaged from cN0 to pN1 or pN2 upon final pathologic examination: 41 to pN1 (54.7%) and 34 to pN2 (45.3%). The primary tumor location with the highest rate of nodal upstaging was the left upper lobe (LUL) (12.8%). Tumors in the right middle lobe had the lowest rate of unsuspected nodal metastases (8.8%). Out of all upstaged patients, there were no positive level eight lymph nodes, and only 1 patient with a positive level nine lymph node. Lymph node levels five and six were only positive in LUL primary tumors, a relationship that approached statistical significance (P = 0.0797). No patients with a LUL primary tumor had a positive level seven lymph node. Upstaging at station 12 was significantly associated with the location of the primary tumor, occurring less often in tumors originating in the right upper lobe in comparison to other lobes (P = 0.0288). CONCLUSIONS: We identified relationships between the location of a primary tumor and specific nodal upstaging in patients with clinical stage I NSCLC who undergo lobectomy. We found the following: 1) only 1 patient had a positive level eight or nine lymph node out of 645 patients; 2) only LUL primary tumors demonstrated upstaging to level five or six lymph nodes; and 3) right upper lobe tumors were significantly less likely to be associated with a positive level 12 lymph node.

Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis.

INTRODUCTION: Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis. METHODS: We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change. RESULTS: A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035). CONCLUSIONS: Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

NCCN Guidelines® Insights: Lung Cancer Screening, Version 1.2022.

The NCCN Guidelines for Lung Cancer Screening recommend criteria for selecting individuals for screening and provide recommendations for evaluation and follow-up of lung nodules found during initial and subsequent screening. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for Lung Cancer Screening.

Access to Telepharmacy Services May Reduce Hospital Admissions in Outpatient Populations During the COVID-19 Pandemic.

Introduction: Avoidable hospital admissions put increased pressure on already strained health care resources, causing emotional and financial distress for patients and their families while taxing the health system. Pharmacist involvement in patient care has been shown to improve health care outcomes. Telepharmacy allows for personalized interaction and access to pharmacy services in a flexible format. The primary aim of this report is to explore the impact that access to a personalized telepharmacy service has on the hospital admission rate in an outpatient population before and during the COVID-19 pandemic. Materials and Methods: A retrospective, double-arm cohort study was performed. Hospital admission rates were analyzed in two similarly aged groups; one group (n = 2,242) had access to telepharmacy services through their primary care provider and another group did not (n = 1,540), from 2019 to 2020. Statistical analysis was performed to explore hospitalization rates in both groups. Results: An increase in hospitalization rates was observed in both groups of patients from 2019 to 2020. The patient group that had access to the telepharmacy service demonstrated a reduced rise in hospitalization rates versus the group without access to the telepharmacy service (access group +12.9% vs. nonaccess group +40.2%, p < 0.05, Student's t-test). Discussion: The patient group with access to telepharmacy services demonstrated a reduced increase in hospitalizations versus the group without access in 2020. While this represents a preliminary investigation into the potential impacts of telepharmacy on hospitalization rates, telepharmacy services may have a role in improving patient outcomes and cost savings.

Incremental value of three-dimensional transthoracic echocardiography over the two-dimensional modality in the assessment of right heart compression and dysfunction produced by pectus excavatum.

The usefulness of two-dimensional transthoracic echocardiography (2DTTE) in the assessment of right heart compression and dysfunction produced by pectus excavatum chest wall deformity has been well described in the literature by several investigators. However, there is a paucity of reports describing incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional technique in the evaluation of right heart function in these patients. We present a severe case of pectus excavatum chest wall deformity in a young male, in whom 3DTTE provided incremental value over standard 2DTTE in assessing compression of the right heart before surgery and marked improvement in right heart function parameters following surgical repair. In addition, an updated summary of salient features of this deformity, including 2D and 3DTTE findings as well as right heart echocardiographic parameters by both 2D and 3DTTE in normal/healthy subjects summarized from the literature have been provided in a tabular form for comparison.

Lung Cancer Screening, Version 3.2018, NCCN Clinical Practice Guidelines in Oncology.

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.

Mimics of pramanicin derived from pyroglutamic acid and their antibacterial activity.

Mono and dihydroxypyrrolidinones are readily available by direct oxygenation of a pyroglutamate-derived bicyclic lactam with high diastereoselectivity, and these may be manipulated further in protected or unprotected form by Grignard addition to a pendant Weinreb amide to give acylhydroxypyrrolidinones, which are analogues of the natural product, pramanicin. Preliminary bioassay against S. aureus and E. coli indicated that some compounds exhibit selective Gram-negative antibacterial activity, and may offer promise for the development of novel systems suitable for antibacterial drug development.

Synthesis of mimics of pramanicin from pyroglutamic acid and their antibacterial activity.

Epoxypyrrolidinones are available by epoxidation of carboxamide-activated bicyclic lactam substrates derived from pyroglutamate using aqueous hydrogen peroxide and tertiary amine catalysis. In the case of an activating Weinreb carboxamide, further chemoselective elaboration leads to the efficient formation of libraries of epoxyketones. Deprotection may be achieved under acidic conditions to give epoxypyroglutaminols, although the ease of this process can be ameliorated by the presence of internal hydrogen bonding. Bioassay against S. aureus and E. coli indicated that some compounds exhibit antibacterial activity. These libraries may be considered to be structural mimics of the natural products pramanicin and epolactaene. More generally, this outcome suggests that interrogation of bioactive natural products is likely to permit the identification of "privileged" structural scaffolds, providing frameworks suitable for optimization in a short series of chemical steps that may accelerate the discovery of new antibiotic chemotypes. Further optimization of such systems may permit the rapid identification of novel systems suitable for antibacterial drug development.

Tobacco Use and Body Mass Index as Predictors of Outcomes in Patients Undergoing Breast Reduction Mammoplasty.

BACKGROUND: Breast reduction mammoplasty accounts for more than 60,000 procedures annually, but the literature is still sparse on outcomes, especially beyond the single institution perspective. The aim of this study was to seek a broader view by study breast reduction outcomes in the National Surgical Quality Improvement Program database. METHODS: The National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010. The principal outcomes measured were wound complications, surgical site infections, and reoperations. Univariate and multivariate analysis was performed to identify significant relationships. RESULTS: A total of 2779 patients were identified. The mean age was 42.7 (14.1) years and the mean body mass index (BMI) was 31.6 (7.0) kg/m2. Tobacco use was associated with a higher rate of reoperation (P = 0.02). Body mass index was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). Patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (P = 0.02). CONCLUSIONS: This study represents the largest sample on breast reduction in the literature. Age and surgeon specialty did not correlate with negative results. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes.

Synthesis of 3-acyltetramates by side chain manipulation and their antibacterial activity.

An efficient approach for the introduction of 3-acyl side chain groups onto a core tetramate system, which are suitable for further manipulation by nucleophilic displacement or Horner-Wadsworth-Emmons coupling, provides access to a diverse library of substituted tetramates related to two distinct classes of natural products, equisetin and pramanicin. Assessment against S. aureus and E. coli indicated that some compounds exhibit significant antibacterial activity, providing unusual leads for further optimisation in the drug discovery process.

The effects of MyD88 deficiency on disease phenotype in dysferlin-deficient A/J mice: role of endogenous TLR ligands.

An absence of dysferlin leads to activation of innate immune receptors such as Toll-like receptors (TLRs) and skeletal muscle inflammation. Myeloid differentiation primary response gene 88 (MyD88) is a key mediator of TLR-dependent innate immune signalling. We hypothesized that endogenous TLR ligands released from the leaking dysferlin-deficient muscle fibres engage TLRs on muscle and immune cells and contribute to disease progression. To test this hypothesis, we generated and characterized dysferlin and MyD88 double-deficient mice. Double-deficient mice exhibited improved body weight, grip strength, and maximum muscle contractile force at 6-8 months of age when compared to MyD88-sufficient, dysferlin-deficient A/J mice. Double-deficient mice also showed a decrease in total fibre number, which contributed to the observed increase in the number of central nuclei/fibres. These results indicate that there was less regeneration in the double-deficient mice. We next tested the hypothesis that endogenous ligands, such as single-stranded ribonucleic acids (ssRNAs), released from damaged muscle cells bind to TLR-7/8 and perpetuate the disease progression. We found that injection of ssRNA into the skeletal muscle of pre-symptomatic mice (2 months old) resulted in a significant increase in degenerative fibres, inflammation, and regenerating fibres in A/J mice. In contrast, characteristic histological features were significantly decreased in double-deficient mice. These data point to a clear role for the TLR pathway in the pathogenesis of dysferlin deficiency and suggest that TLR-7/8 antagonists may have therapeutic value in this disease.

Patient factors related to patient engagement technology (PET) usage in thoracic surgery.

BACKGROUND: We evaluated using Patient Engagement Technology (PET) to capture Patient Reported Outcomes (PROs) in thoracic surgery patients. METHODSY: atients using a PET received surveys including the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) and a health literacy (HL) screen. The relationship of patient-level factors with survey completion was assessed through univariate and logistic regression analyses. RESULTS: 703 patients enrolled in a PET. 52 â€‹% were female and 83 â€‹% were white with a median age of 63.72 â€‹% had adequate HL. 81 â€‹% completed the PROMIS-10 survey. Univariate analysis found lower rates of PROMIS-10 completion in male patients and those with inadequate HL. Logistic regression analysis showed adequate HL (OR 1.76) and white race (OR 1.72) were associated with PROMIS-10 survey completion, while male gender (OR 0.65) had the opposite effect. CONCLUSIONS: PETs are an effective means of collecting PROs, but use is affected by gender, race, and health literacy.

Vein-first vs. artery-first robotic lobectomy outcomes in non-small cell lung cancer.

Background: Data remains limited as to whether the order of pulmonary vessel division during performance of a lobectomy for non-small cell lung cancer (NSCLC) affects survival outcomes. Some authors have suggested that ligation of the pulmonary veins should be conducted first in order to minimize the spread of tumor cells secondary to manipulation of the lung. This study examines whether there is a difference in outcomes between patients who undergo robotic lobectomies for NSCLC using a vein-first (V-first) vs. artery-first (A-first) technique. Methods: A retrospective review of electronic medical record data was performed for patients who underwent robotic lobectomies from January 2013 to May 2019. Patients were separated into two groups based on the sequence in which the pulmonary vessels were divided: V-first or A-first. Baseline characteristics and postoperative events were recorded and compared between groups using Chi-squared and Student's t-tests. Kaplan-Meier survival curves for overall and recurrence-free survival were constructed and compared with log-rank tests. Results: A total of 374 patients were identified: 94 V-first and 280 A-first patients. There was no significant difference between the V-first and A-first groups with regards to postoperative complications, length of stay, recurrence-free survival, or overall survival. Conclusions: Our study suggests that choosing a V-first vs. A-first technique for a robotic lobectomy does not significantly impact overall survival or cancer recurrence for patients with NSCLC. Further studies are needed to evaluate whether the order of pulmonary vessel resection affects outcomes for patients with NSCLC.

Minimally invasive versus open esophagectomy: Comparing the combined effects of smoking burden and operative approach on outcomes in esophagectomy.

OBJECTIVE: To evaluate the interaction between smoking status and operative approach following esophagectomy on perioperative outcomes. METHODS: Patients undergoing esophagectomy for esophageal cancer between January 1, 2009, and December 31, 2022, were identified from the STS-GTSD database and divided into 6 groups based on smoking status-never (NS), former (FS), or current (CS)-and surgical approach-minimally invasive (MIE) or open (OpenE). Primary outcomes were respiratory complications, operative mortality, major morbidity, and composite major morbidity and mortality. RESULTS: The final study population comprised 27,373 patients (28.3% NS, 68.0% FS, and 13.7% CS) from 295 hospitals. Most cases were OpenE (58.1%), but the proportion of MIE increased from 19.2% in 2009 to 56.3% in 2022. Multivariable analysis showed that (1) risk-adjusted operative mortality was decreased only in never-smokers who underwent MIE (MIE-NS: adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI], 0.45-0.82), and; (2) there were no significant differences in mortality among the groups compared to the reference OpenE-NS group. Respiratory complications, major morbidity, and composite mortality and morbidity outcomes showed similar smoking and surgical approach effects. All outcomes were worse in smokers irrespective of approach, and within the same smoking status group, AORs for respiratory complications and morbidity were slightly lower in MIE versus OpenE, but these differences were nonsignificant. CONCLUSIONS: Respiratory complications and other major morbidity outcomes following esophagectomy are substantially worsened by smoking history, particularly in current smokers. Among NS, MIE is associated with reduced operative mortality.

Steroids for idiopathic sudden sensorineural hearing loss.

BACKGROUND: This is an update of a Cochrane review first published in The Cochrane Library in Issue 1, 2006 and previously updated in 2009.Idiopathic sudden sensorineural hearing loss (ISSHL) is a clinical diagnosis characterised by a sudden deafness of cochlear or retrocochlear origin in the absence of a clear precipitating cause. Steroids are commonly prescribed to treat this condition. There is no consensus on their effectiveness. OBJECTIVES: To determine whether steroids in the treatment of ISSHL a) improve hearing (primary) and b) reduce tinnitus (secondary).To determine the incidence of significant side effects from the medication. SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 22 April 2013. SELECTION CRITERIA: We identified all randomised controlled trials (with or without blinding) in which steroids were evaluated in comparison with either no treatment or a placebo. We considered trials including the use of steroids in combination with another treatment if the comparison control group also received the same other treatment. The two authors reviewed the full-text articles of all the retrieved trials of possible relevance and applied the inclusion criteria independently. DATA COLLECTION AND ANALYSIS: We graded trials for risk of bias using the Cochrane approach. The data extraction was performed in a standardised manner by one author and rechecked by the other author. Where necessary we contacted investigators to obtain the missing information. Meta-analysis was neither possible nor considered appropriate because of the heterogeneity of the populations studied and the differences in steroid formulations, dosages and duration of treatment. We analysed and reported the quality of the results of each study individually. A narrative overview of the results is presented. MAIN RESULTS: Only three trials, involving 267 participants, satisfied the inclusion criteria and all three studies were at high risk of bias. One trial showed a lack of effect of oral steroids in improving hearing compared with the placebo control group. The second trial showed a significant improvement of hearing in 61% of the patients receiving oral steroid and in only 32% of the patients from the control group (combination of placebo-treated group and untreated control group). The third trial also showed a lack of effect of oral steroids in improving hearing compared with the placebo control. However, this trial did not follow strict inclusion criteria for participant selection and analysis of data was limited by significant exclusion of participants from the final analysis and lack of participant compliance to the treatment protocol. No clear evidence was presented in two trials about any harmful side effects of the steroids. Only one study declared that no patients suffered from adverse effects of the steroid treatment. AUTHORS' CONCLUSIONS: The value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear since the evidence obtained from randomised controlled trials is contradictory in outcome, in part because the studies are based upon too small a number of patients.

Sublobar Resections: Indications and Approaches.

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Comparison of laparoscopic vs. robotic paraesophageal hernia repair: a systematic review.

Background: In both clinical practice and residency training, the use of robotic platforms in surgery is becoming more common. The aim of this study was to perform a systematic review of the perioperative outcomes of robotic and laparoscopic paraesophageal hernia (PEH) repair. Methods: The PRISMA statement guidelines were used to perform this systematic review. We conducted a database search which included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. There were 384 articles discovered in the initial search using various keywords. From those 384 articles, after duplicates were removed and publications were eliminated based on eligibility criteria, 7 publications were then chosen for analysis. Risk of bias was assessed using Cochrane Risk of Bias Assessment Tool. Narrative synthesis of results has been provided. Results: When compared to standard laparoscopic approaches, robotic surgery for large PEHs may offer benefits in terms of decreased conversion rate and shorter hospital stay. Some studies found a decrease in need for esophageal lengthening procedures and fewer long-term recurrences. The perioperative complication rate is similar between the two techniques in most studies; however, one large study of nearly 170,000 patients in the early years of robotics adoption demonstrated a higher rate of esophageal perforation and respiratory failure in the robotic group (2.2% increase in absolute risk). Cost is another disadvantage of robotic repair when compared to laparoscopic repair. Our study is limited by the non-randomized and retrospective nature of the studies. Conclusions: More studies into recurrence rates and long-term complications are needed to determine the efficacy of robotic versus laparoscopic PEHs repair.

Robotic Resection of Pulmonary Sequestration With Fluorescence Image Guidance.

We present the case of a 21-year-old woman with intralobar pulmonary sequestration in the right lower lobe. Minimally invasive robotic resection of the sequestration was performed to limit the loss of normal-functioning lung. This case also demonstrates the use of indocyanine green fluorescence guidance for demarcation of the sequestration.

An Unusual Cause of End-Tidal Carbon Dioxide Rise During One-Lung Ventilation.

A relatively common problem that may arise during one-lung ventilation is elevation of end-tidal carbon dioxide (ETCO2), which has several potential etiologies. This case report describes a 69-year-old woman with carcinoid tumor undergoing a robotic left lower lobectomy complicated by an acute rise in ETCO2 during one-lung ventilation, without an immediately identifiable cause. Thorough evaluation revealed CO2 leak through an open bronchial lumen resulting in an artificially high ETCO2 reading. This case report demonstrates the importance of performing a comprehensive assessment during acute changes in ETCO2 while also considering changes in the surgical field, which may contribute to these findings.