A Rare Case of Rib Fractures During Centrifuge Training.

There are several injuries potentially related to high-G exposure, including neck and back pain, spinal fractures, and pneumomediastinum. We present a young military pilot diagnosed with isolated fractures of the right 9th and 10th ribs via X-ray after high-G exposure (maximum G level: 9G). This patient presented with progressive and localized pain in the right anterior chest and flank region. After conservative treatment with rest and pain management, he recovered from the rib fractures and completed all profile challenges in the advanced high-G training program. A review of the annual health examination of the pilot did not show any rib lesions or other related illnesses. He was qualified for flying class II and considered fit for flight training. His medication history was unremarkable, and he did not have a family history of malignancy, osteoporosis, or osteopenia. He also denied having previously experienced trauma of the rib cage or participated in any strenuous military training program or exercise before centrifuge training. The potential explanations for the multiple rib fractures are repetitive stress from the anti-G straining maneuver and anti-G suit compression of the abdominal bladder. To our knowledge, consecutive rib fractures related to high-G exposure have never been documented. This report may increase the awareness of flight surgeons and training units regarding the risk of chest wall injuries during high-G exposure and encourage them to use multiple diagnostic tools to determine the correct diagnosis.

Benefit of Three-dimensional Image Simulation in Surgical Resection of Early-stage Lung Cancer.

BACKGROUND: The present study investigated the oncologic outcomes of clinical stage IA2 non-small cell lung cancer (NSCLC) treated using preoperative simulation and surgical resection. METHODS: Data of patients who underwent surgical resection for clinical stage IA2 NSCLC between January 2002 and June 2018 were reviewed. Preoperative simulations were indicated for patients with centrally located tumors who could undergo anatomic resection. Clinical features, imaging characteristics of the tumors, surgical approaches, and outcomes were analyzed. RESULTS: Of the 1086 identified patients, 281 patients with clinical stage IA2 NSCLC were enrolled and categorized into 2 groups, with and without preoperative simulation. Tumor location, maximum standard uptake value, histologic grade, disease-free survival, and disease recurrence were significantly different between the 2 groups. For patients with preoperative simulations, 70.7% underwent anatomic resection, whereas for patients without preoperative simulations, 79.7% underwent anatomic resection (P < .001). Patients with preoperative simulations had fewer relapses (2%) than patients without preoperative simulations (11.5%, P < .01). CONCLUSIONS: Preoperative simulation confirmed the relationship between the tumor and surrounding blood vessels and bronchus and ensured an oncologic safety margin. Three-dimensional simulations are a useful and feasible tool for planar operative procedures and satisfy the requirements for early-stage NSCLC. These results are promising but preliminary, and more extended follow-up is needed.

The prognostic factors of recurrence and survival in female patients with lung adenocarcinoma and breast cancer.

BACKGROUND: The aim of this study was to verify the predictors of recurrence and survival in lung adenocarcinoma patients with experiences of breast cancer therapies. METHODS: We retrospectively reviewed consecutive patients who were treated at our hospital for lung adenocarcinoma from 2004/01 to 2014/03. The patients were divided into groups of those with lung adenocarcinoma alone and those with lung and breast cancer. Kaplan-Meier plots and log-rank tests were used to estimate outcomes. RESULTS: 54 patients with lung adenocarcinoma and breast cancer were compared with 457 patients with single primary lung adenocarcinomas. After propensity score matching with control of age, operation type, smoking status and pathologic stage, tumor differentiation, recurrence rate and tumor size were significantly different between two groups. The significant predictors for recurrence included undergone chemotherapy (HR = 25, p < 0.001), moderate/poor differentiation (HR = 8.125, p = 0.012), tumor size ≧ 2 cm (HR = 15, p < 0.001), LVSI (HR = 13.67, p = 0.031) and GGO ratio < 50% (HR = 14.667, p = 0.014). The significant prognostic factors for survival were accepted chemotherapy (HR = 6.182, p = 0.021), LVSI (HR = 22, p = 0.012) and GGO ratio < 50% (HR = 9.143, p = 0.045). Kaplan-Meier analysis revealed that patients with lung adenocarcinoma and breast cancer had a better 5-year disease-free survival (p = 0.009), while the Her2-negative patients obtained a better overall survival (p = 0.038). CONCLUSIONS: In patients with breast cancer and lung adenocarcinoma, independent risk factors of recurrence were undergone chemotherapy, moderate/poor differentiation, tumor size ≧ 2 cm, LVSI and GGO ratio < 50%. Only undergone chemotherapy, LVSI and GGO ratio < 50% were significant poor predictors for survival. However, patients with metachronous lung adenocarcinoma and breast cancer had better disease-free survival and less tumor recurrence than patients with lung adenocarcinoma alone.

Severity of Pectus Excavatum is a Risk Factor for Primary Spontaneous Pneumothorax.

BACKGROUND AND OBJECTIVE: This study aimed to investigate the relationship between bleb formation, primary spontaneous pneumothorax (PSP) and pectus excavatum (PE). METHODS: From July 2005 to December 2016, the records of 514 patients with PE who underwent the Nuss procedure were obtained from a prospectively collected database and reviewed. Clinical features, images and treatments were analyzed retrospectively. RESULTS: The incidence rate of bleb formation was 26.5% in PE patients. The bleb group had a greater body height (174.4 cm vs. 170.4 cm, p < 0.001), a higher Haller index (HI; 4.2 vs. 3.43, p < 0.001) and a higher risk of developing PSP than the non-bleb group (risk ratio 9.8, p = 0.002). HI values larger than 3.615 had good discriminatory power for predicting bleb formation in patients with PE. With each increase in the HI, PE patients had a 2.2-fold greater odds ratio of bleb formation (odds ratio 2.221, CI 1.481-3.330, p < 0.001). CONCLUSION: We discovered that a high percentage of PE patients have bleb formation and a higher risk of PSP, especially those with an HI >3.615. High-resolution computed tomography of the chest may be useful for evaluating both the HI and the presence of blebs in the lungs before performing a corrective surgical procedure.

Feasibility and Clinical Effectiveness of Three-Dimensional Printed Model-Assisted Nuss Procedure.

BACKGROUND: The Nuss procedure is a minimally invasive technique for correcting pectus excavatum. We hypothesized that three-dimensional (3D) simulation may shorten operation time and provide better morphologic outcome. This study aimed to demonstrate the feasibility of the 3D model-assisted Nuss procedure and to compare its potential benefits with those of the traditional Nuss procedure. METHODS: We simulated the targeted curvature, length, and planned intercostal space of a metallic bar, based on the preoperative chest computed tomographic images. After the use of a 3D printing technique, a plastic template bar was produced and sterilized. The metallic bar was bent and placed at the planned intercostal space accordingly. The patients' characteristics, total number of pectus bar placement, total operation time, and improvement percentage of Haller indices were compared with patients who underwent the traditional Nuss procedure. RESULTS: A total of 419 patients underwent the Nuss procedure from January 2010 to July 2017 in our hospital, and 357 patients were eligible and enrolled for the following analysis. Fifteen patients underwent 3D simulation. After performing propensity-score matching analysis, the 3D printing group had a shorter operative time (60.36 versus 74.34 minutes, p < 0.001), fewer metallic bar placements (1.00 versus 1.36 bars, p < 0.001), and better improvement percentages in the Haller indices (20.34% versus 10.06%, p < 0.001) compared with the traditional Nuss procedure. CONCLUSIONS: In this preliminary study, 3D-printed model-assisted Nuss procedure may provide benefits of shorter operative time, fewer metallic bar insertions, and comparable morphologic outcome by preoperative simulation.

The Role of Three-Dimensional Printing in the Nuss Procedure: Three-Dimensional Printed Model-Assisted Nuss Procedure.

BACKGROUND: The Nuss procedure is a minimally invasive surgery for pectus excavatum. Success of the Nuss procedure is dependent on a previously bent pectus bar that is shaped to the desired curvature of the chest wall. Traditionally, the size and curvature of the metallic pectus bar are determined by trial and error. Herein, we introduce a novel design method for the metallic pectus bar to optimize the bar curvature and outcome after the Nuss procedure. METHODS: From August 2016 through March 2017, 10 consecutive patients with pectus excavatum underwent the three-dimensional (3D) printed model-assisted Nuss procedure. The computed tomography images were used to generate a 3D thorax model of pectus excavatum. The 3D models of personalized pectus bar curvature were completed by computer-aided design. Herein, we report the demographic data, treatment outcomes, and radiographic findings. RESULTS: All patients with pectus excavatum received one pectus bar insertion. The mean age was 19.80 ± 4.73 years (range, 12 to 26). The mean preoperative Haller index was 3.48 ± 0.35 (range, 3.06 to 3.95). We advantageously utilized preoperative planning; the mean interval change of the Haller index was 20.71% ± 4.63%. With the benefit of 3D printed model simulation, the surgical duration was 59.8 ± 23.2 minutes (range, 32 to 107). No patient had adverse events after operation. CONCLUSIONS: Our initial results revealed that the 3D printed model-assisted Nuss procedure reduces the surgical duration and facilitates an optimal morphological outcome.

Adult-onset Langerhans cell histiocytosis of the sternum.

Langerhans cell histiocytosis (LCH) is a rare disease with uncertain etiology that is more prevalent in children. LCH typically invades skeletal systems, but in rare cases, it has been reported in the ribs or sternum. Optimal treatment choices for single-site, skeletal LCH are still undefined. We report a case of adult-onset LCH of the sternum. The range of surrounding soft tissue invasion was confirmed by three-dimensional fusion and reconstruction of chest computed tomography and magnetic resonance images. Our patient was successfully treated by local surgical curettage and adjuvant radiation therapy. We concluded that postoperative adjuvant radiation therapy may be advantageous for single-site LCH of bones with soft tissue invasion.

Elevated serum tartrate-resistant acid phosphatase isoform 5a levels in metabolic syndrome.

BACKGROUND: Tartrate-resistant phosphatase isoform 5a is expressed in tumor-associated macrophages and is a biomarker of chronic inflammation. Herein, we correlated serum tartrate-resistant phosphatase isoform 5a levels with metabolic syndrome status and made comparisons with traditional markers of inflammation, including c-reactive protein and interleukin-6. METHODS: One hundred healthy volunteers were randomly selected, and cut-off points for metabolic syndrome related inflammatory biomarkers were determined using receiver operating characteristic curves. Linear and logistic regression models were subsequently used to correlate inflammatory markers with the risk of metabolic syndrome. RESULTS: Twenty-two participants met the criteria for metabolic syndrome, and serum tartrate-resistant phosphatase isoform 5a levels of >5.8 µg/L were associated with metabolic syndrome (c-statistics, 0.730; p = 0.001; 95% confidence interval, 0.618-0.842). In addition, 1 µg/L increases in tartrate-resistant phosphatase isoform 5a levels were indicative of a 1.860 fold increase in the risk of metabolic syndrome (p = 0.012). CONCLUSIONS: Elevated serum tartrate-resistant phosphatase isoform 5a levels are associated with the risk of metabolic syndrome, with a cut-off level of 5.8 µg/L.

Radiation Therapy for Invasive Breast Cancer Increases the Risk of Second Primary Lung Cancer: A Nationwide Population-Based Cohort Analysis.

INTRODUCTION: Although the risk factors for lung cancer are well documented, whether previous radiation therapy (RT) to treat breast cancer (BC) increases the incidence of second primary lung cancer remains unclear. We determined the overall incidence of second primary lung cancer after previous RT for all clinical stages of BC. METHODS: After an analysis of the Longitudinal Health Insurance Database, 986,713 individuals were randomly enrolled from 2000 to 2010 for cohort analysis. All women with newly diagnosed invasive BC, aged 18 years or older, and without other types of malignancy before 2000 or in the follow-up periods were enrolled and allocated to the RT or non-RT groups. Age, comorbidities, insurance premium, urbanization level, location, date of event, and hospital care level were analyzed. The hazard ratios of parameters were calculated by Cox regression analysis. RESULTS: A total of 7408 individuals met the inclusion criteria, including 5695 patients with BC who underwent RT and 128 (2.25%) in whom lung cancer developed. In contrast, lung cancer was diagnosed in only four of 1713 individuals in the non-RT group (0.23%) during the follow-up period. Cox regression analysis showed that the adjusted hazard ratio was 10.078 times higher in the RT group than in the non-RT group for individuals with previous BC. CONCLUSIONS: The incidence of second primary lung cancer was significantly higher in the RT group than in the non-RT group for individuals with previous BC. Patients with BC treated by RT should be extensively surveyed to assess the incidence of subsequent lung cancer.