Ramucirumab plus FOLFIRI as second-line treatment for patients with RAS wild-type metastatic colorectal cancer previously treated with anti-EGFR antibody: JACCRO CC-16.

BACKGROUND: Chemotherapy in combination with anti-epidermal growth factor receptor (EGFR) antibody is considered a first-line treatment regimen for RAS wild-type and left-sided metastatic colorectal cancer (mCRC), whereas second-line treatment regimens have not yet been established. Few studies have prospectively evaluated second-line treatment with anti-vascular endothelial growth factor antibody after first-line anti-EGFR antibody therapy for RAS wild-type mCRC. PATIENTS AND METHODS: This non-randomized phase II trial investigated the clinical outcomes of second-line ramucirumab (RAM) plus fluorouracil, levofolinate, and irinotecan (FOLFIRI) after first-line anti-EGFR antibody in combination with doublet or triplet regimen in patients with RAS wild-type mCRC. The primary endpoint was the 6-month progression-free survival (PFS) rate. The secondary endpoints were PFS, overall survival (OS), objective response rate (ORR), rate of early tumor shrinkage (ETS), and safety. We hypothesized a threshold 6-month PFS rate of 30% and an expected 6-month PFS rate of 45%. Treatment was considered effective if the lower limit of the 90% confidence interval (CI) of the 6-month PFS rate was >0.30. RESULTS: Ninety-two patients were enrolled in the study. The primary tumor was located on the left side in 86 (95.6%) patients. Twenty (22.0%) patients had received triplet plus cetuximab as previous therapy. Six-month PFS rate was 58.2% (90% CI 49.3% to 66.2%) with a median PFS of 7.0 months (95% CI 5.7-7.6 months). Median OS was 23.6 months (95% CI 16.5-26.3 months). The ORR and ETS rate were 10.7% and 16.9%, respectively, in 83 patients with measurable lesions. The 6-month PFS rate was comparable between patients previously treated with doublet and triplet regimens; however, median PFS was longer for the doublet regimen (7.4 versus 6.4 months, P = 0.036). CONCLUSIONS: Our study demonstrated prospectively that RAM plus FOLFIRI is an effective second-line treatment after anti-EGFR antibody-containing first-line therapy in RAS wild-type and left-sided mCRC. Furthermore, the results were similar for patients who were previously treated with triplet regimen.

Predicting the Readmission and Mortality in Older Patients Hospitalized with Pneumonia with Preadmission Frailty.

BACKGROUND: In older people, frailty has been recognized as an important prognostic factor. However, only a few studies have focused on multidimensional frailty as a predictor of mortality and readmission among inpatients with pneumonia. OBJECTIVE: The present study aimed to assess the association between preadmission frailty and clinical outcomes after the hospitalization of older patients with pneumonia. DESIGN: Single-center, retrospective case-control study. SETTING: Acute phase hospital at Kobe, Japan. PARTICIPANTS: The present study included 654 consecutive older inpatients with pneumonia. MEASUREMENTS: Frailty status before admission was assessed using total Kihon Checklist (KCL) score, which has been used as a self-administered questionnaire to assess comprehensive frailty, including physical, social, and cognitive status. The primary outcome was a composited 6-month mortality and readmission after discharge. RESULTS: In total, 330 patients were analyzed (median age: 79 years, male: 70.4%, median total KCL score: 10 points), of which 68 were readmitted and 10 died within 6 months. After multivariate analysis, total KCL score was associated with a composited 6-month mortality and readmission (adjusted hazard ratio, 1.07; 95% confidence interval, 1.02-1.12; p = 0.006). The cutoff value for total KCL score determined by receiver operating characteristic curve analysis was 15 points (area under the curve = 0.610). The group with a total KCL score ≥ 15 points had significantly higher readmission or mortality rates than the groups with a total KCL score < 15 points (p < 0.001). CONCLUSIONS: Preadmission frailty status in older patients with pneumonia was an independent risk factor for readmission and survival after hospitalization.

Frequency-domain interferometry for the determination of time delay between two extreme-ultraviolet wave packets generated by a tandem undulator.

Synchrotron radiation, emitted by relativistic electrons traveling in a magnetic field, has poor temporal coherence. However, recent research has proved that time-domain interferometry experiments, which were thought to be enabled by only lasers of excellent temporal coherence, can be implemented with synchrotron radiation using a tandem undulator. The radiation generated by the tandem undulator comprises pairs of light wave packets, and the longitudinal coherence within a light wave packet pair is used to achieve time-domain interferometry. The time delay between two light wave packets, formed by a chicane for the electron trajectory, can be adjusted in the femtosecond range by a standard synchrotron technology. In this study, we show that frequency-domain spectra of the tandem undulator radiation exhibit fringe structures from which the time delay between a light wave packet pair can be determined with accuracy on the order of attoseconds. The feasibility and limitations of the frequency-domain interferometric determination of the time delay are examined.

Time domain double slit interference of electron produced by XUV synchrotron radiation.

We present a new realization of the time-domain double-slit experiment with photoelectrons, demonstrating that spontaneous radiation from a bunch of relativistic electrons can be used to control the quantum interference of single-particles. The double-slit arrangement is realized by a pair of light wave packets with attosecond-controlled spacing, which is naturally included in the spontaneous radiation from two undulators in series. Photoelectrons emitted from helium atoms are observed in the energy-domain under the condition of detecting them one by one, and the stochastic buildup of the quantum interference pattern on a detector plane is recorded.

Highly stretchable and sensitive silicone composites with positive piezoconductivity using nickel powder and ionic liquid.

Conductive rubber composites are mixtures of stretchable rubber and conductive materials. They can achieve conductivity and high elasticity and are used in soft robots and wearable devices. In general, these composites exhibit high electrical resistance owing to their bonds between the fillers breaking during elongation. However, there are several types of composite materials that decrease resistance by increasing contact between the conductive materials during elongation through optimization of the shape and size of the filler. These composite materials can rapidly decrease the resistance and are expected to be applicable to switch in electric circuits and sensors. However, to use such composite materials in circuits, the electrical resistance at the time of resistance reduction must be sufficiently low to not affect the electric circuit. To achieve this, a considerable amount of filler must be mixed; however, this reduces the elasticity of the composite. Simultaneously achieving elasticity of the composite and a sufficient decrease in the resistance is challenging. This study developed a conductive rubber composite gel by mixing silicone rubber, ionic liquid, and metal filler. Consequently, the composite achieved an elongation rate of over six times and a decrease in the resistance of less than 1/105. In addition, this composite material was used as a switch circuit wherein an electric circuit is turned on and off according to elongation through a connection to a DC power source.

Hearing Vital Signs: Mobile Audiometry in the Emergency Department for Evaluation of Sudden Hearing Loss.

Emergency departments (EDs) are a common location for patients to present with sudden hearing loss (SHL). Unfortunately, high-quality, rapid quantitative measurement of hearing loss is challenging. Herein, we aim to evaluate the accuracy of tablet-based audiometry in patients complaining of SHL. Prospective tablet-based testing was completed in the ED in patients complaining of SHL. Air conduction thresholds (ACTs) obtained via tablet-based audiometry were compared to same-day measurements with a clinical-grade audiometer. Hearing loss (HL) was defined as >20 dB ACT for any frequency. In participant-level analysis, 30+ dB HL in 3 consecutive frequencies was used to define SHL. In the ED, mobile audiogram ACTs were within 5 dB (77%) and 10 dB (89.6%) of those determined by conventional audiometry. The sensitivity and specificity for mobile audiometry to detect 3 or more consecutive thresholds with 30+ dB HL were 100% and 62.5%, respectively. Findings have implications for increasing access to high-quality audiometry.

Post-occlusional hyperemia for fractional flow reserve assessment and pull-back curve analysis.

Balloon occlusion is a potential method for inducing hyperemia to measure post-percutaneous coronary intervention (PCI) fractional flow reserve (FFR). The objective of this study was to determine the clinical usefulness of post-occlusional hyperemia. FFRs measured using post-occlusional hyperemia caused by 30 (FFRoccl30) and 60 s (FFRoccl60) of balloon occlusion after PCI were compared in 60 lesions from 60 patients. The duration of hyperemia was also measured. There was a strong correlation between FFRoccl30 and FFRoccl60 (r = 0.969, p < 0.01). The duration of hyperemia was significantly longer with FFRoccl60 than with FFRoccl30 (68 ± 23 vs. 37 ± 15 s, p < 0.01). The time required for pullback curve analysis was around 45 s. However, in 7 (12%) cases, the duration of hyperemia with FFRoccl60 was < 45 s, which was not enough for pull-back curve analysis. To predict the duration of hyperemia with FFRoccl60 ≥ 45 s, the receiver operating characteristic curve analysis revealed a cut-off value of 25 s of hyperemia with FFRoccl30. FFRoccl30 is sufficient for diagnostic purposes. FFRoccl60 is suitable for pull-back curve analysis in select cases based on predictions made using the duration of hyperemia with FFRoccl30.

Angiogram based fractional flow reserve in patients with dual/triple vessel coronary artery disease.

OBJECTIVE: To assess the performance of angiography derived Fractional Flow Reserve (FFRangio) in multivessel disease (MVD) patients undergoing angiography. BACKGROUND: FFR is the reference standard for physiologic assessment of coronary stenosis and guidance of revascularization, especially in patients with MVD, yet it remains grossly underutilized. The non-wire based FFRangio performs well in non-MVD patients, but its accuracy in MVD is unknown. METHODS: A prospective clinical study was conducted at Gifu Heart Centre, Japan. Patients underwent physiologic assessment of all relevant coronary lesions using wire-based FFR (wbFFR) and FFRangio. Primary outcome was diagnostic performance (sensitivity, specificity, accuracy) for FFRangio with wbFFR as reference. Other outcomes were the correlation between wbFFR/FFRangio, time required for wbFFR/FFRangio measurements, and the effect of wbFFR/FFRangio on the reclassification of coronary disease severity. RESULTS: Fifty patients (118 lesions in total) were included. Mean age was 72 ±â€¯9 years, 72% were male, 36% had triple vessel disease and the average SYNTAX score was 13. The mean measurement of wbFFR and FFRangio were 0.83 ±â€¯0.12 and 0.81 ±â€¯0.11, respectively. Accuracy, sensitivity and specificity for FFRangio were 92.3% (95% CI 79.1-98.4%), 92.4% (95% CI 84.3-97.2%) and 92.4% (95% CI 87.4-97.3%), respectively. Pearson's r between wbFFR and FFRangio was 0.83. FFRangio measurement was faster than wbFFR (9.6 ±â€¯3.4 vs. 15.0 ±â€¯8.9 min, p < 0.001). CONCLUSIONS: In patients with MVD, FFRangio shows good correlation and excellent diagnostic performance compared to wbFFR, and measuring FFRangio is faster than wbFFR. These results highlight the potential clinical benefits of utilizing FFRangio among patients with MVD.

VALIDATION OF MONTE CARLO DOSE CALCULATION FOR PAEDIATRIC CT EXAMINATIONS USING TUBE CURRENT MODULATION BASED ON IN-PHANTOM DOSIMETRY.

The aim of this study is to estimate tube current modulation (TCM) profiles in paediatric computed tomography (CT) examinations with a TCM scheme (Volume-EC) and evaluate the estimation accuracy of TCM profiles. Another aim is to validate organ doses calculated using Monte Carlo-based CT dosimetry software and estimated TCM profiles by comparing them with those measured using 5-year-old and 10-year-old anthropomorphic phantoms and radio-photoluminescence glass dosemeters. Dose calculations were performed by inputting detailed descriptions of a CT scanner, scan parameters and CT images of the phantoms into the software. Organ doses were evaluated from the calculated dose distribution images. Average relative differences (RDs) between the estimated and actual TCM profiles ranged from -3.6 to 5.6%. RDs between the calculated and measured organ doses ranged from -4.2 to 13.0% and -18.1 to 4.9% for 5-year-old and 10-year-old phantoms, respectively. These results validate dose calculations for paediatric CT scans using TCM.

EP2 receptor plays pivotal roles in generating mechanical hyperalgesia after lengthening contractions.

We previously demonstrated that nerve growth factor (NGF) and glial cell line-derived neurotrophic factor (GDNF) were upregulated after lengthening contractions (LC) in exercised muscle through B2 bradykinin receptor activation and cyclooxygenase (COX)-2 upregulation, respectively, and that these trophic factors sensitized nociceptors resulting in mechanical hyperalgesia (delayed-onset muscle soreness, DOMS). Here, we examined the prostaglandin receptor subtype involved in DOMS. The mechanical withdrawal threshold of the exercised muscle was measured before and after LC in rats administered prostaglandin E2 receptor (EP) antagonists before LC, or in wild-type (WT), EP2 knockout (EP2-/- ), and IP knockout (IP-/- ) mice. The change in expression of NGF, GDNF, or COX-2 mRNA was examined using real-time RT-PCR in the muscle in EP2-/- and WT mice. None of the antagonists to EP1, EP3, and EP4 receptors (ONO-8713, ONO-AE5-599, and ONO-AE3-208, respectively) induced a significant difference in DOMS compared with controls in rats. WT and IP-/- mice developed mechanical hyperalgesia after LC, but EP2-/- mice did not. Upregulation of NGF, GDNF, and COX-2 mRNA was observed after LC in WT mice but not in EP2-/- mice. Injecting an EP2 agonist (ONO-AE1-259-01) into the mouse muscle increased expression of COX-2 mRNA. These results suggest that EP2 contributes to generating mechanical hyperalgesia through positive feedback upregulation of COX-2 expression in muscle after LC.

Clavicle fracture with osteomyelitis after neck dissection and post-operative radiotherapy: case report.

BACKGROUND: Non-traumatic bone fractures in cancer patients are usually pathological fractures due to bone metastases. In head and neck cancer patients, clavicle stress fractures may occur as a result of atrophy of the trapezius muscle after neck dissection in which the accessory nerve becomes structurally or functionally damaged. CASE REPORT: A 71-year-old man underwent modified radical neck dissection with accessory nerve preservation and post-operative radiotherapy for submandibular lymph node metastases of tongue cancer. Four weeks after the radiotherapy, a clavicle fracture, with osteomyelitis and abscess formation in the pectoralis major muscle, occurred. Unlike in simple stress fracture, long-term antibiotic administration and drainage surgery were required to suppress the inflammation. CONCLUSION: As seen in the present patient, clavicle stress fractures may occur even after neck dissection in which the accessory nerve is preserved, and may be complicated by osteomyelitis and abscess formation owing to risk factors such as radiotherapy, tracheostomy and contiguous infection.

Contingent Valuation Analysis of an Otolaryngology and Ophthalmology Emergency Department: The Value of Acute Specialty Care.

Importance: Specialty emergency departments (EDs) provide a unique mechanism of health care delivery, but the value that they add to the medical system is not known. Evaluation of patient preferences to determine value can have a direct impact on resource allocation and direct-to-specialist care. Objective: To assess the feasibility of contingent valuation (CV) methodology using a willingness-to-pay (WTP) survey to evaluate specialty emergency services, in the context of an ophthalmology- and otolaryngology-specific ED. Design, Setting, and Participants: Contingent valuation analysis of a standalone otolaryngology and ophthalmology ED. Participants were English-speaking adults presenting to a dedicated otolaryngology and ophthalmology ED. The WTP questions were assessed using a payment card format, with reference to an alternative modality of treatment (ie, general ED), and were analyzed with multivariate regression. Intervention: Validated WTP survey administered from October 14, 2014, through October 1, 2015. Main Outcomes and Measures: Sociodemographic data, level of distress, referral data, income, and WTP. Results: A total of 327 of 423 (77.3%) ED patients responded to the WTP survey, with 116 ophthalmology and 211 otolaryngology patients included (52.3% female; mean [range] age, 46 [18-90] years). The most common reason for seeking care at this facility was a reputation for specialty care for both ear, nose, and throat (80 [37.9%]) and ophthalmology (43 [37.1%]). Mean WTP for specialty-specific ED services was $377 for ophthalmology patients, and $321 for otolaryngology patients ($340 overall; 95% CI, $294 to $386), without significant difference between groups (absolute difference, $56; 95% CI, $-156 to $43). Self-reported level of distress was higher among ear, nose, and throat vs ophthalmology patients (absolute difference, 0.47 on a Likert scale of 1-7; 95% CI, 0.10 to 0.84). Neither level of distress, income, nor demographic characteristics influenced WTP, but patients with higher estimates of total visit cost were more likely to have higher WTP (ß coefficient, 0.27; SE, 0.05; adjusted R2 = 0.17 for model). Conclusions and Relevance: Patients with eye and ear, nose, and throat complaints place a mean explicit value on specialty emergency services of $340 per visit, relative to general emergency care. Ultimately, CV data using WTP methodology are useful in valuing patient preferences in monetary terms and can help inform state-wide resource allocation and the availability of direct-to-specialist care.

A case of bilateral aldosterone-producing adenomas differentiated by segmental adrenal venous sampling for bilateral adrenal sparing surgery.

Primary aldosteronism due to unilateral aldosterone-producing adenoma (APA) is a surgically curable form of hypertension. Bilateral APA can also be surgically curable in theory but few successful cases can be found in the literature. It has been reported that even using successful adrenal venous sampling (AVS) via bilateral adrenal central veins, it is extremely difficult to differentiate bilateral APA from bilateral idiopathic hyperaldosteronism (IHA) harbouring computed tomography (CT)-detectable bilateral adrenocortical nodules. We report a case of bilateral APA diagnosed by segmental AVS (S-AVS) and blood sampling via intra-adrenal first-degree tributary veins to localize the sites of intra-adrenal hormone production. A 36-year-old man with marked long-standing hypertension was referred to us with a clinical diagnosis of bilateral APA. He had typical clinical and laboratory profiles of marked hypertension, hypokalaemia, elevated plasma aldosterone concentration (PAC) of 45.1 ng dl(-1) and aldosterone renin activity ratio of 90.2 (ng dl(-1) per ng ml(-1 )h(-1)), which was still high after 50 mg-captopril loading. CT revealed bilateral adrenocortical tumours of 10 and 12 mm in diameter on the right and left sides, respectively. S-AVS confirmed excess aldosterone secretion from a tumour segment vein and suppressed secretion from a non-tumour segment vein bilaterally, leading to the diagnosis of bilateral APA. The patient underwent simultaneous bilateral sparing adrenalectomy. Histopathological analysis of the resected adrenals together with decreased blood pressure and PAC of 5.2 ng dl(-1) confirmed the removal of bilateral APA. S-AVS was reliable to differentiate bilateral APA from IHA by direct evaluation of intra-adrenal hormone production.

Cost-Benefit Analysis of an Otolaryngology Emergency Room Using a Contingent Valuation Approach.

OBJECTIVES: Dedicated otolaryngology emergency rooms (ERs) provide a unique mechanism of health care delivery. Relative costs and willingness to pay (WTP) for these services have not been studied. This study aims to provide a cost-benefit analysis of otolaryngology-specific ER care. STUDY DESIGN: Cost-benefit analysis based on contingent valuation surveys. SETTING: An otolaryngology-specific ER in a tertiary care academic medical center. SUBJECTS AND METHODS: Adult English-speaking patients presenting to an otolaryngology ER were included. WTP questions were used to assess patient valuations of specialty emergency care. Sociodemographic data, income, and self-reported levels of distress were assessed. State-level and institution-specific historical cost data were merged with WTP data within a cost-benefit analysis framework. RESULTS: The response rate was 75.6%, and 199 patients were included in the final analysis. Average WTP for otolaryngology ER services was $319 greater than for a general ER (95% CI: $261 to $377), with a median value of $200. The historical mean cost per visit at a general ER was $575, and mean cost at the specialty ER was $551 (95% CI: $529 to $574). Subtracting incremental cost from incremental WTP yielded a net benefit of $343. CONCLUSION: Dedicated otolaryngology ER services are valued by patients for acute otolaryngologic problems and have a net benefit of $343 per patient visit. They appear to be a cost-beneficial method for addressing acute otolaryngologic conditions. This study has implications for ER-based otolaryngologic care and direct-to-specialist services.

MRI findings of radiation-induced myocardial damage in patients with oesophageal cancer.

AIM: To evaluate radiation-induced myocardial damage after mediastinal radiotherapy using MRI. MATERIALS AND METHODS: Between May 2010 and April 2011, delayed contrast-enhanced MRI was performed for patients who had maintained a complete response to curative radiotherapy for oesophageal cancer for more than 6 months. The patients received radiotherapy with a median total dose of 66 Gy (60-70 Gy) for the primary tumour and metastatic lymph nodes. Images of MRI were analysed by a 17-segment method recommended by the American Heart Association. A segment included mainly in the 40 Gy dose line was defined as Segment 40 Gy, a segment included mainly in the 60 Gy dose line as Segment 60 Gy, and a segment out of the radiation fields as Segment OUT. The percentage of late gadolinium enhancement (LGE) was examined in those categories. The layer in which LGE was predominantly distributed was evaluated for each patient. RESULTS: Four hundred and eight segments in 24 patients were analysed. The median interval from completion of radiotherapy to MRI was 23.5 months (range 6-88 months). LGE was detected in 12 of the 24 patients. LGE was detected in 15.38% of Segment 40 Gy cases, 21.21% of Segment 60 Gy cases, and 0% of Segment OUT cases. LGE in mid-myocardial and subendocardial layers was detected in 11 patients and one patient, respectively. CONCLUSION: LGE suggesting radiation induced myocardial fibrosis was observed by performing delayed contrast-enhanced MRI. Care should be taken when planning radiotherapy to avoid late cardiac damage.

Sex differences of high-risk carotid atherosclerotic plaque with less than 50% stenosis in asymptomatic patients: an in vivo 3T MRI study.

BACKGROUND AND PURPOSE: Men have a greater prevalence of high-risk carotid plaque features associated with stroke compared with women who have ≥50% stenosis, but little is known about these features in less significantly stenotic carotid arteries. This study aims to evaluate sex differences in complicated carotid plaque features in asymptomatic patients with <50% stenosis. MATERIALS AND METHODS: Ninety-six patients (50 men, 46 women) with <50% carotid stenosis on MRA who had been referred for analysis of contralateral >50% carotid stenosis were included. The associations between sex and plaque features as identified by 3T MR carotid plaque imaging were examined by using logistic and linear regression models controlling for demographic characteristics, MRA stenosis, and the presence of contralateral plaque features. RESULTS: The presence of a thin/ruptured fibrous cap (16% versus 2%, adjusted odds ratio = 8.57, P = .047), IPH (24% versus 6%, adjusted odds ratio = 4.53, P = .027), and American Heart Association type VI plaque (26% versus 6%, adjusted odds ratio = 5.04, P = .017) was significantly higher in men than in women. These associations remained significant following adjustment for contralateral plaque features. Men demonstrated a larger percentage volume of LR/NC (median, 1.66% versus -0.21%; P < .01). Calcification was not significantly associated with sex. CONCLUSIONS: There is a sex difference of higher risk carotid plaque features during the early stage of disease seen in patients recruited for MR imaging evaluation of contralateral moderate-to-severe stenosis. Given the potential of using LR/NC without or with IPH to monitor therapy, these results indicate the possible importance of sex-based management in patients with asymptomatic carotid atherosclerosis across all stages of carotid stenosis.

Neonatal Fc receptor for IgG (FcRn) expressed in the gastric epithelium regulates bacterial infection in mice.

Neonatal Fc receptors for immunoglobulin (Ig)G (FcRn) assume a central role in regulating host IgG levels and IgG transport across polarized epithelial barriers. We have attempted to elucidate the contribution of FcRn in controlling Helicobacter infection in the stomach. C57BL/6J wild-type or FcRn(-/-) mice were infected with Helicobacter heilmannii, and gastric lesions, bacterial load and the levels of antigen-specific IgG in serum and gastric juice were analyzed. The elevated levels of anti-H. heimannii IgG in gastric juice were observed exclusively in wild-type mice but not in FcRn(-/-) mice. In contrast, an increase in lymphoid follicles and bacterial loads along with deeper gastric epithelium invasion were noted in FcRn(-/-) mice. C57BL/6J wild-type or FcRn(-/-) mice were also infected with Helicobacter pylori SS1, and the results of the bacterial load in stomachs of these mice and the anti-H. pylori IgG levels in serum and gastric juice were similar to those from H. heilmannii infection. Our data suggest that FcRn can be functionally expressed in the stomach, which is involved in transcytosis of IgG, and prevent colonization by H. heilmannii and the associated pathological consequences of infection.

[Clinical effect of the cauterization for emphysematous bulla].

The purpose of performing pleural cauterization is developing heat denaturation, and we can induce pleural thickening and also reduce the bullae by shrinking the pleura It originates in a method of the cauterization whether there will be tissue damage. So a safe and reliable method of cauterization is required. Here, we investigated the indications for and effectiveness of cauterization techniques performed at our facility. We perform cauterization while dropping saline solution, so when using a Salient Monopolar Sealer, we can avoid excessive thermo-coagulation and more easily control cauterization. Furthermore, on the basis that only emphysematous pleura will turn white on cauterization, bullae can be distinguished, which is particularly effective in the case of lesions with unclear borders. In the case of a large emphysematous bulla, shrinkage of the bulla by cauterization can provide a sufficient surgical field, and a smaller lesion can then be stapled.