Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy.

BACKGROUND: Postoperative pulmonary complications (PPCs) are associated with poor outcomes following thoracotomy and lung resection. Video-assisted thoracoscopic surgery (VATS) for lobectomy is now frequently utilised as an alternative to thoracotomy, however patients remain at risk for development of PPC. There is little known of the short-term outcome associated with PPC following VATS lobectomy and if there are any potential risk factors that could be modified to prevent PPC development; our study aimed to investigate this. METHODS: A prospective observational study of consecutive patients undergoing VATS lobectomy for lung cancer over a 4-year period in a regional centre was performed (2012-2016). Exclusion criteria included re-do VATS or surgery for pulmonary infection. All patients received physiotherapy as necessary from postoperative day 1 (POD1) and PPC was determined using the Melbourne Group Scale. Outcomes included hospital LOS, intensive therapy unit (ITU) admission and hospital mortality. RESULTS: Of the 285 patients included in the study, 137 were male (48.1%), the median (IQR) age was 69 (13) years and the mean (±SD) FEV1% predicted was 87% (±19). Patients that developed a PPC (n = 21; 7.4%) had a significantly longer hospital LOS (4 vs. 3 days), higher frequency of ITU admission (23.8% vs. 0.5%) and higher hospital mortality (14.3% vs. 0%) (p < 0.001). PPC patients also required more physiotherapy contacts/time, emergency call-outs and specific pulmonary therapy (p < 0.05). Current smoking and COPD diagnosis were significantly associated with development of PPC on univariate analysis (p < 0.05), however only current smoking was a significant independent risk factor on multivariate analysis (p = 0.015). CONCLUSIONS: Patients undergoing VATS lobectomy remain at risk of developing a PPC, which is associated with an increase in physiotherapy requirements and a worse short-term morbidity and mortality. Current smoking is the only independent risk factor for PPC after VATS lobectomy, thus vigorous addressing of preoperative smoking cessation is urgently needed.

Patients want more information after surgery: a prospective audit of satisfaction with perioperative information in lung cancer surgery.

BACKGROUND: Receiving information about their disease and treatment is very important to patients with cancer. There is an association between feeling appropriately informed and better quality of life. This audit aimed to estimate patient satisfaction with perioperative information in those undergoing surgery for lung cancer and any change in satisfaction over time. METHODS: A questionnaire (EORTC-Info-25) was administered prospectively to patients preoperatively and up to six months postoperatively. The preoperative questionnaire was completed by 292 patients and 88 free text comments were completed. Intrapersonal responses were compared over time. RESULTS: Patients were highly satisfied with information prior to surgery. The overall helpfulness of information did not change over time but satisfaction with the amount of information decreased. Patients who received more information about 'the disease' and 'things you can do to help yourself get well' were less likely to report a drop in satisfaction (Odds Ratio 0.858, 95% Confidence interval 0.765 to 0.961, p = 0.008 and OR 0.102, 95% CI 0.018 to 0.590, p = 0.011 respectively). Free text responses revealed patients most frequently wanted more information on the disease, aftercare and self-care. Suffering complications from surgery was not associated with a change in satisfaction with information postoperatively. CONCLUSIONS: Patients want to know more about their diagnosis, but also how to recover and cope with issues once they have gone home after surgery. Postoperative satisfaction with information may improve if patients are given more information on these topics.

Smoking and timing of cessation on postoperative pulmonary complications after curative-intent lung cancer surgery.

BACKGROUND: Smoking is a risk factor for postoperative pulmonary complications (PPC) following non-small cell lung cancer (NSCLC) surgery. The optimal timing for preoperative smoking cessation has not been identified. Our study aimed to observe the impact of preoperative smoking cessation on PPC incidence and other postoperative outcomes including long-term survival. METHODS: A prospective study included consecutive patients following resection for NSCLC in a regional thoracic centre over a 4-year period (2010-2014). Patients were stratified according to self-reported preoperative smoking status. The primary endpoint was PPC incidence, which was assessed from postoperative day one onwards using the Melbourne Group Scale. Secondary endpoints included short-term outcomes (hospital length of stay [LOS], intensive therapy unit [ITU] admission, 30-day hospital readmission rate) and long-term survival. RESULTS: Four hundred and sixty-two patients included 111 (24%) current smokers, 55 (12%) ex-smokers <6 weeks, 245 (53%) ex-smokers ≥6 weeks and 51 (11%) never smokers. PPC occurred in 60 (13%) patients in total. Compared to never smokers, current smokers had a higher frequency of PPC (22% vs. 2%, p = 0.004), higher frequency of ITU admission (14% vs. 0%; p = 0.001) and a longer median (IQR) hospital LOS (6 [5] vs. 5 [2]; p = 0.001). In the ex-smokers there was a trend for a lower frequency of PPC (<6 weeks, 10.9% vs. ≥6 weeks, 11.8%) and ITU admission (<6 weeks, 5.5% vs. ≥6 weeks, 4.5%), but there was no difference between the <6 weeks or ≥6 weeks ex-smoking groups prior to surgery. There was no significant difference in long-term survival found between the groups of differing smoking status (median follow-up 29.8 months, 95%CI 28.4-31.1). CONCLUSION: Current smokers have higher postoperative morbidity; this risk reduces following smoking cessation but 6 weeks does not appear to identify a time-point where differences in outcomes are noted.

Postoperative pulmonary complications and rehabilitation requirements following lobectomy: a propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy†.

OBJECTIVES: : Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this. METHODS: Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging. RESULTS: Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P < 0.001), shorter median LOS (4 days vs 6; P < 0.001), and a shorter median HDU LOS (1 day vs 2; P = 0.002). Patients undergoing VATS required less physiotherapy contacts (3 vs 6; P < 0.001) and reduced therapy time (80 min vs 140; P < 0.001). More patients mobilized on POD1 (84% vs 81%; P = 0.018), and significantly less physiotherapy to treat sputum retention and lung expansion was required ( P < 0.05). CONCLUSIONS: This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, and required half the physiotherapy resources having fewer pulmonary and mobility issues.

A 20-year review of pectus surgery: an analysis of factors predictive of recurrence and outcomes.

OBJECTIVES: Only a few studies report the long-term outcomes following repair of pectus excavatum (PE) and pectus carinatum (PC). Predictors of recurrence after surgery are important in this group of young patients. The purpose of this study was to assess the short- and long-term outcomes of both PE and PC and identify factors associated with postoperative complications and pectus recurrence. METHODS: This was a retrospective observational study that included all patients who underwent primary or recurrent repair of PC and PE in a regional thoracic centre over 20 years. Patients' demographics, type of surgery, complications and recurrence were recorded. Logistic regression analysis was performed to identify factors predictive of pectus recurrence. RESULTS: A total of 297 patients were included (262 men and 35 women). The mean age was 19.8 years (95% CI 19.3-20.5). A total of 169 patients had surgery for PE and 127 for PC. A total of 243 patients had a modified Ravitch procedure (166 without a bar) and 53 patients underwent the Nuss repair. The main postoperative complications were wound infection and bleeding or haematoma. The recurrence rate over the mean follow-up period of 8.6 years was 10%. In PE, patients treated with the Ravitch procedure with the bar experienced more complications. Univariate and multivariate analyses showed that PE patients who developed a complication had a significantly increased chance of recurrence. No risk factors were linked with recurrence of PC. CONCLUSIONS: Life-transforming pectus surgery can be performed with low morbidity and good long-term outcomes. Recurrence of PE deformity is associated with the development of postoperative complications.

A case of a retained drain tip following intercostal drain insertion: avoiding a 'never event'.

Pleural effusions are commonly drained with Seldinger intercostal drains. One uncommon but serious risk of drain insertion is that of a foreign body being retained in the pleural cavity following removal. We report a case in which the tip of the drain was retained in the pleural space following difficult insertion of a Seldinger intercostal drain in a district general hospital. Prompt recognition and clear patient communication are important at the occurrence of an unusual complication. Surgical removal of the foreign body was performed following transfer. We report this case to raise awareness that insertion and withdrawal of drains over the guidewire during insertion may damage the drain and highlight the need for doctors who insert chest drains to perform a count of instruments during ward or clinic-based procedures as well as those performed in theatres. We now include removable parts of chest drains in our theatre instrument count.

Pectus patient information website has improved access to care and patient reported outcomes.

BACKGROUND: Pectus is the most common congenital disorder. Awareness amongst primary care physicians and the general public is poor. NHS commissioning bodies plan to withdraw funding for this surgery because they deem a lack of sufficient evidence of benefit. The purpose of this study is to assess the effects of introducing a patient information website on referral and activity patterns and on patients reported outcomes. METHODS: We produced an innovative information website, www.pectus.co.uk , accessible to the general public, providing information about pectus deformities; management options and advice about surgery. Referral patterns and number of cases where studied before and after the introduction of the website in 2010. Patients' satisfaction post-op was assessed using the Brompton's single step questionnaire (SSQ). RESULTS: The website had considerable traffic with 2179 hits in 2012, 4983 in 2013 and 7416 in 2014. This has led to 1421 contacts and 372 email enquiries. These emails have resulted in an increased number of patients who have been assessed and go on to have surgery. We asked 59 pectus excavatum patients who were operated from 2008 to 2014 to complete the SSQ. We received 32 replies. Eighty-four percent (16/19) of patients who visited the website and then underwent surgery, found the website useful. All patients scored satisfactorily in SSQ. Even though those who visited the website tended to be more satisfied with the surgical outcomes this did not reach statistical significance. This group of patients said that would have the operation again given the option compared to 76.9 % of the group who did not visit the website before surgery (p=0.031). Despite the fact that patients who visited the website experienced more post-operative complications were equally or more satisfied with post-operative outcomes. The overall SSQ obtainable score was not different for the two subgroups, being more widespread in the group that did not visit the website. CONCLUSIONS: The introduction of a pectus patient information website has significantly improved access to specialised services. Patients are overall highly satisfied with the surgical outcomes.

Chest wall mechanics before and after diaphragm plication.

BACKGROUND: Following diaphragmatic plication for unilateral paralysis, the effect on global chest wall function are unknown. Our hypothesis was that chest wall function would improve in both sides of the chest after plication of the paralysed side. CASE PRESENTATION: Using Optoelectronic Plethysmography, total and regional chest wall volumes were measured in one patient before and after left diaphragmatic plication. Volumes were recorded at quiet breathing. Respiratory capacity improved during quiet breathing when measured before and 6 months after surgery. These improvements occur at the abdominal-rib cage level in both operated and contralateral. Prior to surgery the abdominal rib cage motion was out of phase to the upper rib cage and abdominal compartment in both sides of the chest. Synchrony of all three compartments was restored after plication. CONCLUSION: This physiological study is the first published data in humans to show improvement in chest wall motion both in operated and contralateral side following diaphragmatic plication for unilateral paralysis.

Long-term impact of developing a postoperative pulmonary complication after lung surgery.

INTRODUCTION: Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors. METHODS: A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality. RESULTS: 86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5-14.9 vs 6.3, 95% CI 5.9 to 6.7; p<0.001) and higher rates of ITU admissions (28% vs 1.9%; p<0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p<0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p<0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006). CONCLUSIONS: Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome.

Survival following Pulmonary Metastasectomy for Sarcoma.

OBJECTIVES: The aim of this study is to report the overall survival after pulmonary metastasectomy in patients with metastatic sarcoma and prognostic factors for survival. METHODS: This is a retrospective observational study of consecutive patients having pulmonary metastasectomy for sarcoma over a 5-year period. Survival was calculated by Kaplan-Meier method. RESULTS: Between August 2007 and January 2014, a total of 80 pulmonary metastasectomies were performed on 66 patients with metastatic sarcoma. There were no postoperative in-hospital deaths. The median age was 51 years (range, 16-79) and 39 (59%) patients were male. Fourteen patients had bilateral lung operations and surgical access was by video-assisted thoracoscopic surgery in 48 (73%) cases. The median number of metastases resected was 3 (range, 1-9). The median disease-free interval was 25 months (range, 0-156). Median overall survival was 25.5 months (range, 1-60). At follow-up, 19 patients (29%) were dead with a median follow-up of 31 months (range, 1-60). Recurrence of metastases significantly affected survival: median of 25.5 months (95% confidence interval [CI], 17.7-33.4) versus 48.4 months (95% CI, 42.5-54.4) in patients with no recurrent metastases (p = 0.004). There was no significant difference in survival between patients with high-grade versus low-grade tumors (p = 0.13), histological type (osteosarcoma vs. other soft tissue sarcoma types, p = 0.14), unilateral versus bilateral lung metastases (p = 0.48), or lung metastases alone versus lung and other sites of metastases (p = 0.5). CONCLUSION: In selected patients, pulmonary metastasectomy for sarcoma is safe and may confer a good medium-term survival. Recurrent metastasis after resection confers a poor prognosis.

Bronchoscopic management of patients with symptomatic airway stenosis and prognostic factors for survival.

BACKGROUND: Interventional bronchoscopy is effective in the management of patients with symptomatic airway obstruction for both malignant and benign conditions. The main aim of this study is to report our experience with emergency interventional bronchoscopy in patients with symptomatic airway obstruction and identify prognostic factors for survival. METHODS: This is a retrospective observational study of patients undergoing emergency interventional bronchoscopy over a 4-year period. Survival times were analyzed separately for patients with benign and malignant airway obstruction by the Kaplan-Meier method. RESULTS: Between June 2009 and July 2013, 168 emergency interventional bronchoscopies were performed in 112 patients for airway obstruction. The median age was 63 years (range, 20 to 86), and 91 patients (54%) patients were female. Seventy-two cases (43%) had airway obstruction due to malignant disease. There were 3 in-hospital deaths (2.7%). Median survival of the study population was 5.6 months (range, 0 to 51) with a median follow-up of 7.3 months (range, 0 to 51). Median survival for patients with malignant airway obstruction was 3.5 months (range, 0 to 21), and 9.8 months (range, 0.1 to 51) for those with benign disease. Airway intervention facilitated palliative chemotherapy in 32 patients (44%) of those with malignant airway obstruction. At multivariate analysis in patients with malignant airway obstruction, presence of stridor (hazard ratio 1.919, 95% confidence interval: 1.082 to 3.404, p = 0.026) and not receiving postprocedure chemotherapy (hazard ratio 2.05, 95% confidence interval: 1.156 to 3.636, p = 0.014) were independent prognostic factors for death. CONCLUSIONS: Emergency interventional bronchoscopy for airway obstruction is safe, relieved symptoms, and facilitated palliative chemotherapy, which improved survival.

Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study.

BACKGROUND: Early mobility is considered important in minimising pulmonary complication, length of stay (LOS) and enhancing recovery following major surgery. We aimed to observe and measure the reduction in early postoperative physical activity following major thoracic surgery, identifying any potentially limiting factors, and factors predictive of reduced activity. METHODS: Patients undergoing thoracotomy and lung resection were prospectively observed for the purposes of this study. All patients were routinely assisted to mobilise by physiotherapists from postoperative day 1, and continued daily with exercise and progression of mobility as per usual practice. Physical activity was measured with SenseWear Pro 3 armband physiologic motion sensors between postoperative day 1-4. The motion sensors recorded step count, time spent in 'sedentary'/ 'moderate' activity, and energy expenditure. Frequency of postoperative pulmonary complication (PPC) and postoperative LOS were also observed. Multivariate analyses were performed using forward stepwise logistic regression; results are displayed as odds ratio (95% confidence intervals). RESULTS: n = 99, median (interquartile range) steps 472 (908) over combined postoperative days 2/ 3, sedentary activity (< 3 METs) 99%. Less active subjects reported significantly more pain on day 2 and 3 (p = 0.013/ 0.00 respectively) (p < 0.001). On regression analysis age ≥ 75 years, predicted FEV1 < 70% and poor preoperative activity were predictive of lower postoperative activity. Factors limiting mobility on day 1 included pain and dizziness. Median LOS was longer (p = 0.013) (6 vs. 5 days) in less active patients and frequency of PPC was 20% vs 4% (p = 0.034). CONCLUSION: Physical activity following major thoracic surgery is generally very limited, with less active patients demonstrating longer LOS. Factors limiting immediate postoperative mobility were largely modifiable, some of the factors predictive of lower activity were also possibly modifiable/amenable to physiotherapy or pulmonary rehabilitation. Prompt assessment and recognition of these factors is needed in future, with timely and effective management incorporated into care pathways to maximise each patients potential to mobilise postoperatively. TRIAL REGISTRATION: ISRCTN52709424.

Exercise improvement after pectus excavatum repair is not related to chest wall function.

OBJECTIVES: In patients undergoing corrective surgery for pectus excavatum, there is evidence of improvement in cardiopulmonary function. It is unclear how much of this improvement is attributable to improved chest wall function. Thus, we observed changes in chest wall function in response to an incremental load exercise pre- and postoperatively. METHODS: Using optoelectronic plethysmography, total and regional chest wall volumes were measured in 7 male patients with severe pectus excavatum who underwent a Nuss correction. Rib cage and abdominal volumes were recorded at rest and during exercise (incremental cycle ergometry), pre- and postoperatively in conjunction with spirometry. RESULTS: Tidal volume increases during exercise are blunted compared with baseline measurements at 6 days (-36 ± 7%) partially recovering at 6 months postoperatively (-18 ± 22%). This is mirrored by changes in spirometry. Tidal volume decreased during exercise initially in all compartments, but persisted in the rib cage compartment. An increase of 44% (P = 0.009) in exercise tolerance was found 6 months after surgical correction. CONCLUSIONS: Six months after Nuss correction in pectus patients, there was a decrease in rib cage mobility. Despite reduction, patients had a significant improvement in exercise tolerance. Therefore, we conclude that early postoperative improvement in exercise capacity is not due to changes in chest wall function. The longer term effects on chest wall function are yet to be defined.

Does the revised cardiac risk index predict cardiac complications following elective lung resection?

BACKGROUND: Revised Cardiac Risk Index (RCRI) score and Thoracic Revised Cardiac Risk Index (ThRCRI) score were developed to predict the risks of postoperative major cardiac complications in generic surgical population and thoracic surgery respectively. This study aims to determine the accuracy of these scores in predicting the risk of developing cardiac complications including atrial arrhythmias after lung resection surgery in adults. METHODS: We studied 703 patients undergoing lung resection surgery in a tertiary thoracic surgery centre. Observed outcome measures of postoperative cardiac morbidity and mortality were compared against those predicted by risk. RESULTS: Postoperative major cardiac complications and supraventricular arrhythmias occurred in 4.8% of patients. Both index scores had poor discriminative ability for predicting postoperative cardiac complications with an area under receiver operating characteristic (ROC) curve of 0.59 (95% CI 0.51-0.67) for the RCRI score and 0.57 (95% CI 0.49-0.66) for the ThRCRI score. CONCLUSIONS: In our cohort, RCRI and ThRCRI scores failed to accurately predict the risk of cardiac complications in patients undergoing elective resection of lung cancer. The British Thoracic Society (BTS) recommendation to seek a cardiology referral for all asymptomatic pre-operative lung resection patients with > 3 RCRI risk factors is thus unlikely to be of clinical benefit.

Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery.

OBJECTIVES: The aim of the study was to develop a multistranded pragmatic rehabilitation programme for operable lung cancer patients, that looks into feasibility, process indicators, outcome measures, local adaptability, compliance and potential cost benefit. METHODS: An outpatient-based complex intervention, rehabilitation for operated lung cancer (ROC) programme, was developed to optimize physical status, prepare for the inpatient journey and support through recovery after surgery. It includes exercise classes, smoking cessation, dietary advice and patient education and was tested in an enriched cohort study within a regional thoracic unit over 18 months. RESULTS: A multistranded pragmatic rehabilitation programme pre- and post-surgery is feasible. Fifty-eight patients received the intervention and 305 received standard care. Both groups were matched for age, lung function comorbidity and type of surgery. Patients in the intervention group attended exercise classes twice a week until surgery, which was not delayed. Patients attended four sessions presurgery (range 1-15), resulting in an improvement of 20 m (range -73-195, P = 0.001) in a 6-min walk test and 0.66 l in forced expiratory volume in 1 s (range -1.85 from 1.11, P = 0.009) from baseline to presurgery. Fifty-four percentage of smokers in the intervention group stopped smoking. Sixteen percentage of patients were identified as being at risk of malnourishment and received nutritional intervention. There was a trend in patients in the intervention group towards experiencing fewer postoperative pulmonary complications than those in the non-intervention group (9 vs 16%, respectively, P = 0.21) and fewer readmissions to hospital because of complications (5 vs 14% respectively, P = 0.12). CONCLUSION: Chronic obstructive pulmonary disease-type pulmonary rehabilitation before and after lung cancer surgery is viable, and preliminary results suggest improvement in physical measures. A multicentre, randomized controlled trial is warranted to confirm clinical efficacy. ISRCTN REGISTRATION NUMBER: ISRCTN00061628.

Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications.

BACKGROUND: Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. METHODS: 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. RESULTS: No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI -5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI -7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (-7.4% to 2.6%). CONCLUSIONS: Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

A rare association of pulmonary carcinoid, lymphoma, and sjögren syndrome.

Pulmonary carcinoid and pulmonary lymphoma are both rare cancers and are seldom seen together. Cases have been reported of their coexistence in the gastrointestinal tract, but our literature searches only found a single case of their coexistence in the lung. We discuss our case as well as the literature to try to find a connection and explanation for this occurrence.

Circulating DBP level and prognosis in operated lung cancer: an exploration of pathophysiology.

Vitamin D stimulates transcription of antiangiogenic and apoptotic factors that may suppress tumours, while vitamin D binding protein (DBP) may be a biomarker in murine lung cancer models. We sought to ascertain whether the vitamin D axis is altered in lung cancer or influences prognosis. 148 lung cancer patients, 68 other intrathoracic cancer patients and 33 noncancer controls were studied for up to 5 yrs. Circulating DBP and vitamin D levels were compared between groups and their effect on survival assessed by Cox regression analysis. Expression of DBP and vitamin D receptor (VDR) was examined in lung cancer cell lines and in normal and tumour lung tissue by Western blot and immunohistochemistry. Low serum DBP levels predicted lung cancer-specific death (p=0.04), and DBP was poorly expressed in lung cancer cells on Western blot and immunohistochemistry. Vitamin D did not predict cancer survival and VDR expression was variable in tumours. Preservation of serum DBP is a significant independent factor associated with better cancer outcome in operated lung cancer patients. Given the established role of DBP in macrophage activation and clearance of abnormal cells, further study on its involvement in lung cancer is merited.

Thoracoscore fails to predict complications following elective lung resection.

The Thoracoscore mortality risk model has been incorporated into the British Thoracic Society guidelines on the radical management of patients with lung cancer. The discriminative and predictive ability to predict mortality and post-operative pulmonary complications (PPCs) in this group of patients is uncertain. A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 42 months. 128 out of 703 subjects developed a PPC. 16 (2%) patients died in hospital. In a logistic regression analysis the Thoracoscore was not a significant predictor of mortality (OR 1.07, 95% CI 0.99-1.17; p=0.11) but was a significant predictor of PPCs (OR 1.08, 95% CI 1.03-1.13; p=0.002). However, the area under the receiver operator characteristic curve for the Thoracoscore was 0.68 (95% CI 0.56-0.80) for predicting mortality and 0.64 (95% CI 0.59-0.69) for PPCs, indicating limited discriminative ability. In a logistic regression analysis, another risk model, the European Society Objective Score, was predictive of mortality (OR 1.43, 95% CI 1.11-1.83; p=0.006) and PPCs (OR 1.48, 95% CI 1.30-1.68; p<0.0001). Therefore, Thoracoscore may have poor discriminative and predictive ability for mortality and PPCs following elective lung resection.

Proteomic analysis of resectable non-small cell lung cancer: post-resection serum samples may be useful in identifying potential markers.

Surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI-TOF-MS) can be used to analyse peptides and proteins in clinical samples. A prospective study was undertaken on patients undergoing curative resection for non-small cell lung cancer (NSCLC): we used SELDI-TOF-MS to compare the proteomic profiles of serum from these patients both before surgical resection and after resection (disease-free) to identify potential biomarkers. Student t-tests were used, and a P-value of <0.01 was considered significant. Twenty-five patients with NSCLC [76% male, mean age 69 (range 53-81) years] were analysed. There were 13 squamous cell carcinomas, 10 adenocarcinomas and 2 large cell carcinomas with a stage distribution of four stage IA, 11 stage IB, five stage IIB, three stage IIIA, one stage IIIB and one stage IV. SELDI spectra generated with immobilised metal affinity chromatography arrays produced 170 peaks. Of these, 35 showed significant differences in their intensities between the preoperative and post-resection states (P<0.01). Postoperative samples in the disease-free state may represent good controls to identify biomarkers in NSCLC, avoiding the difficulties associated with cross-sectional studies. These pilot data need to be validated with larger numbers of patients.