[Important step of weaning from mechanical ventilation: accurate assessment of respiratory muscle strength].

Mechanical ventilation (MV) is a powerful mean to rescue patients with respiratory failure. In view of the different etiology and basic respiratory function of patients with respiratory failure, weaning failure often occurs. Prolonged MV time is often accompanied by many complications. Thus, deeply understanding the pathophysiological changes of respiratory failure and strengthen monitoring of respiratory mechanics are helpful to optimize MV parameter settings, reduce ventilator-induced lung injury and wean from MV as early as possible. A successful weaning from MV depends on many factors, the most important factors are respiratory muscle strength, respiratory load and respiratory drive. Spontaneous breathing trial (SBT) is an important part of weaning process. The main purpose of implementing SBT is to screen patients and opportunities to weaning from MV, and find reversible reasons for not passing SBT. Because the accuracy of SBT in assessing weaning prognosis is about 85%, it is not adequate for difficult weaning patients. Standardized measurement of weaning indicators for patients with difficulty weaning is conducive to accurate assessment of respiratory muscle strength and improve the success rate of weaning from MV.

Chromosome Doubling Enhances Biomass and Carotenoid Content in Lycium chinense.

Lycium chinense, a type of medicinal and edible plant, is rich in bioactive compounds beneficial to human health. In order to meet the market requirements for the yield and quality of L. chinense, polyploid induction is usually an effective way to increase plant biomass and improve the content of bioactive components. This study established the most effective tetraploid induction protocol by assessing various preculture durations, colchicine concentrations, and exposure times. The peak tetraploid induction efficacy, 18.2%, was achieved with a 12-day preculture and 24-h exposure to 50 mg L-1 colchicine. Compared to diploids, tetraploids exhibited potentially advantageous characteristics such as larger leaves, more robust stems, and faster growth rates. Physiologically, tetraploids demonstrated increased stomatal size and chloroplast count in stomata but reduced stomatal density. Nutrient analysis revealed a substantial increase in polysaccharides, calcium, iron, and zinc in tetraploid leaves. In addition, seventeen carotenoids were identified in the leaves of L. chinense. Compared to the diploid, lutein, ß-carotene, neoxanthin, violaxanthin, and (E/Z)-phytoene exhibited higher levels in tetraploid strains T39 and T1, with T39 demonstrating a greater accumulation than T1. The findings suggest that the generated tetraploids harbor potential for further exploitation and lay the foundation for the selection and breeding of novel genetic resources of Lycium.

Intrapulmonary migration of a fractured acupuncture needle: a case report.

BACKGROUND: Acupuncture, a traditional Chinese medical treatment, has been gaining popularity over the years. However, it also presents certain risks. We report a case of a patient who discovered a foreign body in their lung several years after undergoing acupuncture. CASE PRESENTATION: A middle-aged woman presented to our hospital with chest pain. An X-ray revealed a needle-like foreign body in the middle lobe of her right lung. The patient had previously undergone acupuncture treatment for local pain in her lower back and lower extremities many years prior. Based on the imaging findings and her medical history, we hypothesized that the foreign body in her lung was a result of a dislodged acupuncture needle. Through preoperative 3-dimensional reconstruction and indocyanine green localization, we were able to locate the foreign body in the lateral segment of the right middle lobe. We successfully removed the foreign body via wedge resection, and the patient made a smooth recovery post-surgery. CONCLUSION: Acupuncturists and surgeons should remain vigilant about the potential risks associated with acupuncture.

[Respiratory muscle strength should be continuously monitored for patients on mechanical ventilation].

Mechanical ventilation (MV) is an effective treatment for respiratory failure. In recent years, it has been found that MV can not only cause ventilation-associated lung injury (VALI), but also cause ventilation-induced diaphragmatic dysfunction (VIDD). Although the injury site and etiology are not the same, they are interrelated and mutually causal, and eventually lead to weaning failure. Studies have indicated that diaphragmatic function protection strategy should be implemented in patients on MV. That is, the entire process from assessing the ability of spontaneous breathing before MV, to the initiation of spontaneous breathing and to weaning during MV. For patients on MV, continuous monitoring of respiratory muscle strength should be conducted. Early prevention, early intervention and timely detection of VIDD may reduce the occurrence of difficult weaning, resulting in improved prognosis. This study mainly discussed the risk factors and pathogenesis of VIDD.

Is response evaluation criteria in solid tumors (RECIST) effective in patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC?

BACKGROUND: Neoadjuvant immunotherapy combined with chemotherapy has been used to treat locally advanced non-small cell lung cancer (NSCLC). Several systems have been developed for response evaluation. The aim of this study was to evaluate the predictive value of response evaluation criteria in solid tumors (RECIST) and propose modified RECIST (mRECIST). METHODS: Eligible patients received chemotherapy combined with personalized neoadjuvant immunotherapy. Radical resection was subsequently performed for potentially resectable tumors evaluated by RECIST. The resected specimens were evaluated to determine the response to neoadjuvant therapy. RESULTS: A total of 59 patients received radical resection following neoadjuvant immunotherapy combined with chemotherapy. According to RECIST, four patients had complete remission, 41 had partial remission, and 14 had progressive disease. Postoperative pathological examination showed 31 patients achieved complete pathological remission, and 13 achieved major pathological remission. The final pathological results were uncorrelated with RECIST assessment (p = 0.086). The ycN stage and pN stage were irrelevant (p < 0.001). When the cutoff of sum of diameters (SoD) is 17%, the Youden's index reached its highest value. A correlation was found between mRECIST and final pathological results. Patients with squamous cell lung cancer showed higher proportions in objective response (OR) (p < 0.001) and complete pathological remission (CPR) (p = 0.001). A shorter time to surgery (TTS) was correlated with a better OR (p = 0.014) and CPR (p = 0.010). The decrease in SoD was correlated with better OR (p = 0.008) and CPR (p = 0.002). CONCLUSIONS: mRECIST was effective for patient selection for radical resection after neoadjuvant immunotherapy with advanced NSCLC. Two modifications were suggested for RECIST: (1) the cutoff value was adjusted to 17% for partial remission. (2) Changes in lymph nodes on computed tomography were eliminated. A shorter TTS, a larger decrease in SoD and squamous cell lung cancer (vs. adenocarcinoma) were correlated with better pathological responses.

The JASMONATE ZIM-domain-OPEN STOMATA1 cascade integrates jasmonic acid and abscisic acid signaling to regulate drought tolerance by mediating stomatal closure in poplar.

Drought, which directly affects the yield of crops and trees, is a natural stress with a profound impact on the economy. Improving water use efficiency (WUE) and drought tolerance are relatively effective strategies to alleviate drought stress. OPEN STOMATA1 (OST1), at the core of abscisic acid (ABA) signaling, can improve WUE by regulating stomatal closure and photosynthesis. Methyl jasmonate (MeJA) and ABA crosstalk is considered to be involved in the response to drought stress, but the detailed molecular mechanism is insufficiently known. Here, Populus euphratica, which naturally grows in arid and semiarid regions, was selected as the species for studying MeJA and ABA crosstalk under drought. A yeast two-hybrid assay was performed using PeOST1 as bait and a nucleus-localized factor, JASMONATE ZIM-domain protein 2 (PeJAZ2), was found to participate in MeJA signaling by interacting with PeOST1. Overexpression of PeJAZ2 in poplar notably increased water deficit tolerance and WUE in both severe and mild drought stress by regulating ABA signaling rather than ABA synthesis. Furthermore, a PeJAZ2 overexpression line was shown to have greater ABA-induced stomatal closure and hydrogen peroxide (H2O2) production. Collectively, this evidence establishes a mechanism in which PeJAZ2 acts as a positive regulator in response to drought stress via ABA-induced stomatal closure caused by H2O2 production. Our study presents a new insight into the crosstalk of ABA and jasmonic acid signaling in regulating WUE and drought stress, providing a basis of the drought tolerance mechanism of P. euphratica.

Surgical therapy and outcome of descending necrotizing mediastinitis in Chinese: a single-center series.

Background: Descending Necrotizing Mediastinitis (DNM) is an acute and often fatal infection that affects the neck and mediastinum. DNM treatment consists of broad-spectrum antibiotics, early diagnosis, and surgical debridement with multidisciplinary cooperation. However, owing to the rarity and complexity of this disease, the mortality rate is high. This retrospective study analyzed a single-center experience of managing DNM in Chinese patients over the last 10 years. Methods: A single-center, retrospective, observational, and descriptive study was conducted on 31 patients with DNM at Peking Union Medical College Hospital from 2012 to 2022. Case report forms were used to collect data which were then analyzed with a focus on surgical management and outcomes. Results: This study examined the outcomes of 31 patients diagnosed with DNM at our hospital. The most common comorbidities on admission were hypertension (48%) and diabetes mellitus (42%). The degree of diffusion of DNM according to Endo's classification was classified as follows: type I in 7 patients (22.6%), type IIA in 5 (16.1%), and type IIB in 19 patients (61.3%). Among these patients, 13 (41.9%) were found to have a single microbial infection, while 16 (51.6%) were found to have polymicrobial infections. In all cases, neck drainage was performed via cervicotomy, with multiple drains (64.5%) and vacuum sealing drainage (VSD) (35.5%). Mediastinal drainage was performed via a cervical mediastinotomy (51.6%), video-assisted thoracic surgery (VATS) (41.9%), or thoracotomy (6.5%). The 30-day mortality rate was 25.8% and 24.0 days of the average length of hospital stay. Conclusion: Early accurate diagnosis and timely intervention have been shown to be correlated with a positive prognosis. Cervicothoracic CT (computed tomography) is essential for the diagnosis, staging, and evaluation of the optimal surgical treatment. Cervicotomy and video-assisted thoracoscopic surgery with percutaneous drainage is effective, even in advanced cases. Additionally, the application of VSD in cervical incision did not improve prognosis but may shorten the length of ICU (intensive care unit) and hospital stays.

Promoting azo dye decomposition in natural molybdenite activated peroxymonosulfate process by low concentration of ferrous ions.

In this study, low concentration of ferrous ions (Fe2+) was added into natural molybdenite (MDN) activated peroxymonosulfate (PMS) process to degrade a typical azo dye, orange G (OG). It was found that the addition of Fe2+ promoted OG degradation and simultaneously reduced the leaching of toxic Mo ions significantly. Further, the utilization efficiency of MDN was improved immensely, which was estimated from reuse experiment. MDN mainly acted as the reductant to promote cycling of Fe3+/Fe2+ redox couple through reducible sulfur and Mo(IV) on its surface. Sulfate radicals (SO4•-), hydroxyl radical (•OH) and singlet oxygen (1O2) were verified as the main reactive oxygen species responsible for OG degradation by scavenging tests and electron paramagnetic resonance. Some experiment parameters, such as MDN dosage, Fe2+ concentration, PMS concentration, initial solution pH and coexisting anion, all affected OG degradation efficiency. In a word, this work provides a new method of enhancing PMS activation by MDN using low concentration of Fe2+ for degradation of organic pollutants in water.

[Volume dynamics and volume management in intensive care unit patients].

Volume dynamics is a two-compartment dynamical model using hemoglobin (Hb) derived plasma diluted level as input data and urine output as input variable through consecutive repeated measurements of Hb concentration in the blood during infusion. It could be applied to evaluate and guide crystalloid fluid rehydration for patients with dehydration or hypovolemia and during anesthesia or surgery. Volume dynamics could be also used to quantificate of strains, hypovolume, and the change of fluid distribution and elimination caused by anesthesia or surgery. The factors which influence the volume resuscitation are complex, including gender, age, hemodynamic state [mean arterial pressure (MAP)], health and stress state, renal function, consciousness, surgical or anesthesia state and so on, which may affect the half-life, distribution, and volume of the fluid. This article summarizes and analyzes the pathophysiological changes of crystalloids fluid in vivo, in order to provide reference for volume management in critically ill patients.

Surgical treatment of lung metastasis in patients with refractory gestational trophoblastic neoplasia: A retrospective study.

PURPOSE: The lungs are the most common site of metastasis in patients with gestational trophoblastic neoplasia. We investigated surgical management and prognostic factors of patients with refractory gestational trophoblastic neoplasia to assess the value of lung metastasis resection. PATIENTS AND METHODS: The clinical data of patients with refractory gestational trophoblastic neoplasia and lung metastasis treated at Peking Union Medical College Hospital from January 2005 to December 2020 were retrospectively analyzed. Surgical characteristics and survival outcomes were analyzed. RESULTS: In total, 213 patients with refractory gestational trophoblastic neoplasia and lung metastasis were screened, and 148 patients who underwent unilateral lung resection were analyzed. Patients' median age was 32 years. Lobectomy was performed in 65.5% of patients, while wedge resection was performed in 34.5%. The rate of postoperative complications was 12.2%. The pathological rate was 66.2%. Video-assisted thoracoscopic surgery showed better surgical characteristics than thoracotomy did. Compared with lobectomy, wedge resection had a shorter operative time, shorter duration of chest tube placement, shorter postoperative hospital stay, and fewer postoperative complications. The median follow-up period was 36 months. During follow-up, 90.5% of patients achieved complete remission. The 5-year disease-free and overall survival rates were 80.4% and 92.6%, respectively. More previous chemotherapy courses and failure to achieve normal ß-human chorionic gonadotropin levels postoperatively were predictors of poor prognosis. CONCLUSIONS: Surgical treatment of lung metastasis is valuable and safe for patients with refractory gestational trophoblastic neoplasia. The minimally invasive video-assisted thoracoscopic approach and wedge resection are recommended.

Multi-organs perioperative immune-related adverse events and postoperative bronchial anastomotic fistula in a patient receiving neoadjuvant immunotherapy with NSCLC.

The safety of neoadjuvant chemoimmunotherapy before surgery in patients with non-small cell lung cancer (NSCLC) remains unclear in the perioperative stage. We describe a case of a 63-year-old man with IIIC stage NSCLC who received neoadjuvant chemoimmunotherapy and radical lobectomy. After the second cycle of pembrolizumab and chemotherapy (paclitaxel + carboplatin), the patient was diagnosed with immunologic enterocolitis and relieved by glucocorticoid therapy. Radical lobectomy of the right upper lobe was then performed. On postoperative day 4 (POD 4), the patient suddenly suffered suffocated wheezing during sleep. Interstitial lung disease was, therefore, identified by chest computed tomography scan. Glucocorticoids and mechanical ventilation were applied and the symptoms were relieved. On POD 10, the patient developed a bronchial fistula and underwent emergent repair surgery. This is the first case of multi-organs, multi-time point immune-related adverse events (irAE) in perioperative NSCLC patients who received neoadjuvant chemoimmunotherapy. Clinicians should be on high alert for signs of irAEs in neoadjuvant chemoimmunotherapy patients, promptly requiring multidisciplinary management.

Neoadjuvant immunotherapy followed by surgery with curative intent in 35 patients with advanced NSCLC: the retrospective experiences of a multidisciplinary team.

Background: In recent years, neoadjuvant immunotherapy combined with chemotherapy has been used to treat locally advanced non-small cell lung cancer (NSCLC); however, no data are available to guide the selection of patients suitable for radical resection. In this paper, we report a clinical mode based on a multidisciplinary team (MDT). Methods: We retrospectively analyzed the clinical data of patients with advanced NSCLC who were treated in our center between 26 December, 2019 and 1 October, 2021. These cases received an MDT assessment first. Eligible patients then received chemotherapy combined with personalized neoadjuvant immunotherapy. Adverse events were recorded. Chest computed tomography (CT) was performed every other cycle for tumor assessment. Radical resection was subsequently performed for potentially resectable tumors. Intraoperative conditions and surgical complications were recorded. The resected specimens were evaluated to determine the response to neoadjuvant therapy. Results: The MDT team selected a total of 35 patients (squamous cell carcinoma: n=26, adenocarcinoma: n=8, adenosquamous carcinoma: n=1) for radical resection following neoadjuvant immunotherapy combined with chemotherapy. According to the Response Evaluation Criteria in Solid Tumors (RECIST) findings, 1 patient had complete remission, 27 had partial remission, 6 had progressive disease, and 1 had stable disease. All participants underwent radical resection, including video-assisted thoracoscopic surgery [VATS; 32 (91.4%)], sleeve resection [7 (20.0%)], and multilobar resection [7 (20.0%)]. A total of 17 patients (48.6%) achieved complete pathological remission, and 10 (28.6%) achieved major pathological remission. After surgery, the pathological grade was reduced in 33 patients (94.2%); the RECIST findings were unrelated to postoperative pathological remission (P=0.15). Conclusions: The MDT mode helps to select suitable patients for radical resection and results in satisfactory pathological remission.

[Accurate evaluation of mechanical ventilation and spontaneous respiratory activity].

Maintenance of spontaneous effort during mechanical ventilation has long been recognized to improve oxygenation. Such effort has been considered beneficial because oxygenation is a key management aim. However, accumulating evidence indicates that spontaneous effort during mechanical ventilation may cause or worsen acute lung injury. Recently, effort-dependent lung injury has been termed as patient-self inflicted lung injury (P-SILI). This paper describes pathophysiological changes of ventilation-induced lung injury (VILI) induced by mechanical ventilation and spontaneous breathing, and the role of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome (ARDS). Studies have shown that spontaneous breathing is a double-edged sword, depending on the intensity of spontaneous breathing activity and the severity of lung injury. Future studies are needed to determine ventilator strategies minimizing injury.

The impact of segmentectomy versus lobectomy on pulmonary function in patients with non-small-cell lung cancer: a meta-analysis.

OBJECTIVE: Segmentectomy has been reported as an alternative to lobectomy for small-sized NSCLC without detriment to survival. The long-term benefits of segmentectomy over lobectomy on pulmonary function have not been firmly established. This meta-analysis aims to compare postoperative changes in pulmonary function in NSCLC patients undergoing segmentectomy or lobectomy. METHODS: Medline, Embase, Web of Science and Scopus were searched through March 2021. Statistical comparisons were made when appropriate. RESULTS: Fourteen studies (2412 participants) out of 324 citations were included in this study. All selected studies were high quality, as indicated by the Newcastle-Ottawa scale for assessing the risk of bias. Clinical outcomes were compared between segmentectomy and lobectomy. ΔFEV1 [10 studies, P < 0.01, WMD = 0.40 (0.29, 0.51)], ΔFVC [4 studies, P < 0.01, WMD = 0.16 (0.07, 0.24)], ΔFVC% [4 studies, P < 0.01, WMD = 4.05 (2.32, 5.79)], ΔFEV1/FVC [2 studies, P < 0.01, WMD = 1.99 (0.90, 3.08)], and ΔDLCO [3 studies, P < 0.01, WMD = 1.30 (0.69, 1.90)] were significantly lower in the segmentectomy group than in the lobectomy group. Subgroup analysis showed that in stage IA patients, the ΔFEV1% [3 studies, P < 0.01, WMD = 0.26 (0.07, 0.46)] was significantly lower in the segmentectomy group. The ΔDLCO% and ΔMVV% were incomparable. CONCLUSION: Segmentectomy preserves more lung function than lobectomy. There were significantly smaller decreases in FEV1, FVC, FVC%, FEV1/FVC and DLCO in the segmentectomy group than in the lobectomy group.

Application of intraoperative nerve monitoring for recurrent laryngeal nerves in minimally invasive McKeown esophagectomy.

BACKGROUND: Mediastinal lymphadenectomy is of great importance during esophagectomy for esophageal squamous cell carcinoma. However, recurrent laryngeal nerve (RLN) injury is a severe complication caused by lymphadenectomy along the RLN. Intraoperative nerve monitoring (IONM) can effectively identify the RLN and reduce the incidence of postoperative vocal cord paralysis (VCP). Here, we describe the feasibility and effectiveness of IONM in minimally invasive McKeown esophagectomy. METHODS: A total of 150 patients who underwent minimally invasive McKeown esophagectomy from 2016 to 2020 were enrolled in this study. We divided the patients into two groups: a neuromonitoring group (IONM, n = 70) and a control group (control, n = 80). Clinical data, surgical variables, and postoperative complications were retrospectively analyzed and compared. RESULTS: There was no significant difference in baseline data between the two groups. Postoperative VCP occurred in six cases (8.6%) in the IONM group, which was lower than that in the control group (21.3%, P = 0.032). Postoperative pulmonary complications were found in five cases (7.1%) and 14 in the control group (18.8%, P = 0.037). The postoperative hospital stay in the IONM group was significantly shorter than that in the control group (8 vs. 12, median, P < 0.001). The number of RLN lymph nodes harvested in the IONM group was higher than that in the control group (13.74 ± 5.77 vs. 11.03 ± 5.78, P = 0.005). The sensitivity and specificity of IONM monitoring VCP were 83.8% and 100%, respectively. A total of 66.7% of patients with a reduction in signal showed transient VCP, whereas 100% with a loss of signal showed permanent VCP. CONCLUSION: IONM is feasible in minimally invasive McKeown esophagectomy. It showed advantages for distinguishing RLN and achieving thorough mediastinal lymphadenectomy with less RLN injury. Abnormal IONM signals can provide an accurate prediction of postoperative VCP incidence.

A pulmonary nodule mislocated in "dorsal" segment due to tri-lobed left lung.

Background: The left lung has two lobes and one fissure, while the right lung has three lobes and two fissures. Accessory fissures are usually found in imaging examinations and autopsies; however, finding an actual accessory lobe is rare. Case presentation: In a lung nodule resection surgery, a 68-year-old male patient was found with three lobes and two fissures in his left lung. The lung nodule was misdiagnosed as being located in the lower lobe because the accessory fissure was misregarded as the oblique fissure. The lung nodule was found in the upper lobe, and this anatomical variation changed the surgical plan. The pathology of the lung nodule was granulomatous inflammation with caseous necrosis with the positive antacid stain. The patient was eventually diagnosed with tuberculosis. Literature review: Cases involving the lung accessory fissure and lung accessory lobe variants were reviewed. In 10 autopsy and dissection studies, the incidence of accessory fissure in the left lung was 13.5% (79/587, ranging from 2.7% to 50.0%), and in the right lung, it was 7.3% (42/575, ranging from 3.1% to 30.4%). The incidence of accessory lobes in the left lung was 2.0% (11/547, ranging from 0.0% to 7.4%), and in the right lung was 2.6% (14/539, ranging from 0.0% to 17.4%). The incidence of accessory fissures in bilateral lungs identified by chest x-ray or computed tomography ranged from 7.3% to 32.0%. Three surgical case reports inferred accessory lobes, including a left upper lobectomy, left lung transplantation, and an open thoracotomy. Conclusion: This is the first clinical case report that shows that lung accessory lobe caused the mislocation of a lung nodule. Therefore, radiologists and surgeons should be aware of the possibility of an accessory lobe in the lung.

circDENND4C Promotes Proliferation and Metastasis of Lung Cancer by Upregulating BRD4 Signaling Pathway.

OBJECTIVE: To investigate the effects of circDENND4C on the malignant biological behavior of lung cancer and its downstream target genes and molecular mechanisms. METHODS: The expression of circDENND4C in lung cancer tissues and cells was detected. After transfection with silenced circDENND4C, the expression levels of circDENND4C, miR-141-3p, and BRD4 in lung cancer cells were detected by qRT-PCR. The targeting relationship between circDENND4C and miR-141-3p as well as miR-141-3p and BRD4 was verified. Cell activity was detected by CCK-8 and EdU assay. Transwell assay was used to detect the invasiveness of A549 and NCI-H1299 in each group. Effects of circDENND4C on proliferation and metastasis of lung cancer in nude mice were studied. RESULTS: In vitro and in vivo results showed that circDENND4C silencing reduced the proliferation, invasion, and metastasis of lung cancer cells. Mechanism studies showed that circDENND4C has a targeting relationship with miR-141-3p. However, miR-141-3p has a targeting relationship with BRD4. circDENND4C indirectly upregulated BRD4 through sponge adsorption of miR-141-3p, thereby promoting metastasis and proliferation of NSCLC. CONCLUSION: circDENND4C, as an oncogene, promotes the proliferation, invasion, and metastasis of lung cancer cells.