Is severe re-expansion pulmonary edema still a lethal complication of closed thoracostomy or thoracic surgery?

BACKGROUND: Re-expansion pulmonary edema (REPE) is a lethal complication that can occur after inserting a chest tube. However, no clinical research reports have analyzed the progress and treatment of REPE, except for a single case report review. We retrospectively analyzed the common clinical characteristics, clinical progress, and treatment outcome of REPE with respiratory failure. METHODS: We retrospectively reviewed the clinical features, treatment, and outcomes of eight patients with REPE who required ventilator care from March 2004 to March 2018. RESULTS: The mean PaO2/FiO2 ratio of the patients immediately after intubation was 106.5±20.2 (range, 75-128), which indicated severe hypoxia in all cases. On the first day of treatment, most of the patients showed improvement in hypoxia symptoms, and most improved to the extubation level on day 3. The mean duration of ventilator use was 2.5±0.8 days (range, 1-4 days), and the mean duration of inotropic drug use was 1.1±0.7 days (range, 0-2 days). The mean intensive care unit (ICU) stay was 4.4±1.5 days (range, 3-8 days). No deaths were recorded during the study period, and no cases of permanent complications due to REPE were observed. CONCLUSIONS: REPE requiring ventilator care is a lethal disease. However, continued development of ICU care has dramatically decreased mortality. Low positive end-expiratory pressure (PEEP), low tidal and high O2 ventilator care represents the most appropriate treatment for REPE.

Concomitant Avulsion Injury of the Subclavian Vessels and the Main Bronchus Caused by Blunt Trauma.

Concomitant rupture of the subclavian vessels and the left main bronchus caused by blunt trauma is a serious condition. Moreover, the diagnosis of a tracheobronchial injury with rupture of the subclavian vessels can be difficult. This report describes the case of a 33-year-old man who suffered from blunt trauma that resulted in the rupture of the left subclavian artery and vein. The patient underwent an operation for vascular control. On postoperative day 3, the left main bronchus was found to be transected on a computed tomography scan and bronchoscopy. The transected bronchus was anastomosed in an end-to-end fashion. He recovered without any notable problems. Although the bronchial injury was not detected early, this case of concomitant rupture of the great vessels and the airway was successfully treated after applying extracorporeal membrane oxygenation.

The usefulness of Wi-Fi based digital chest drainage system in the post-operative care of pneumothorax.

BACKGROUND: Chest drainage systems are usually composed of chest tube and underwater-seal bottle. But this conventional system may restrict patients doing exercise and give clinicians obscure data about when to remove tubes because there is no objective indicator. Recently developed digital chest drainage systems may facilitate interpretation of the grade of air leak and make it easy for clinicians to decide when to remove chest tubes. In addition, with combination of wireless internet devices, monitoring and managing of drainage system distant from the patient is possible. METHODS: Sixty patients of primary pneumothorax were included in a prospective randomized study and divided into two groups. Group I (study) consisted of digital chest drainage system while in group II (control), conventional underwater-seal chest bottle system was used. Data was collected from January, 2012 to September, 2013 in Eulji University Hospital, Daejeon, Korea. RESULTS: There was no difference in age, sex, smoking history and postoperative pain between two groups. But the average length of drainage was 2.2 days in group I and 3.1 days in group II (P<0.006). And more, about 90% of the patients in group I was satisfied with using new device for convenience. CONCLUSIONS: Digital system was beneficial on reducing the length of tube drainage by real time monitoring. It also had advantage in portability, loudness and gave more satisfaction than conventional system. Moreover, internet based digital drainage system will be a good method in thoracic telemedicine area in the near future.

Leukotriene enhanced allergic lung inflammation through induction of chemokine production.

The leukotrienes (LTs) enhance allergen- and interleukin (IL)-13-dependent allergic lung inflammatory disease. However, the precise requirement of LTs and the mechanism by which they elicit allergic lung responses remain uncertain. To clarify the involvement of LTs in respiratory allergen- and IL-13-induced experimental asthma and elucidate the underlying mechanisms of LTs-mediated enhanced allergic asthma, we investigated the role of LTs in two models of allergic inflammation: intranasal Aspergillus protease allergen and recombinant IL-13-induced T helper type 2 (Th2) cell-mediated inflammation, and also examined Th2-related chemokines downstream of LTs signaling. 5-Lipoxygenase (5-LO)-deficient mice exposed to short-term intranasal Aspergillus protease allergen showed attenuated airway inflammation, decreased airway hyper-responsiveness and reduced bronchoalveolar eosinophilia when compared to wild-type mice. However, this phenotype was less apparent using long exposure to the same allergen. 5-LO-deficient mice exposed to intranasal rIL-13 also showed attenuated phenotypes of allergic asthma via significant reduction in Th2-specific chemokines, CCL7 and CCL17 production and decreased Th2 cells recruitment to the lungs. Addition of leukotriene B4 (LTB4) and LTC4 to the airways of 5-LO-deficient mice resulted in the rescue of rIL-13-induced experimental asthma. Furthermore, LTs addition to rIL-13 synergistically enhanced the production of Th2-specific chemokines in the lung and inflammatory responses. Therefore, our findings suggest that LTs complement allergens and their downstream cytokine (e.g., IL-13) induced Th2 inflammation by enhancing the induction of Th2 chemokines.

Modified blowhole skin incision using negative pressure wound therapy in the treatment of ventilator-related severe subcutaneous emphysema.

OBJECTIVES: A 2-3-cm blowhole incision in the supraclavicular or infraclavicular area is widely used to eliminate the presence of subcutaneous air in cases of life-threatening subcutaneous emphysema (SE). However, when the patient is supported by mechanical ventilation, it is difficult to eliminate completely such air because mechanical ventilation leads consistently to the formation of large amounts of air. To overcome this, we applied negative pressure wound therapy (NPWT) along with blowhole incisions for the treatment of severe SE. METHODS: To evaluate the feasibility of NPWT, we retrospectively analysed the clinical outcomes of 10 patients who developed severe SE during ventilator care and were treated with a modified blowhole incision using NPWT from January 2009 to November 2013. RESULTS: All patients showed immediate improvement in SE after NPWT, and no symptom aggravation occurred after NPWT. The mean duration of NPWT was 7.5 ± 5.1 (range, 3-14) days, and the mean number of dressing changes was 1.5 ± 0.7 (range, 1-2). There were no blowhole-incision-related wound infections or any other complications. CONCLUSIONS: While it is not necessary to apply a blowhole incision with NPWT in all cases of SE, this therapy can be helpful for patients with severe SE associated with mechanical ventilation requiring rapid decompression.

Vacuum-assisted closure therapy as an alternative treatment of subcutaneous emphysema.

Vacuum-assisted closure therapy is an alternative method for a massive subcutaneous emphysema treatment. It is easily applicable and shows rapid effectiveness in massive subcutaneous emphysema, intractable with chest tube drainage.

Innate type 2 immunity is associated with eosinophilic pleural effusion in primary spontaneous pneumothorax.

RATIONALE: Eosinophilic pleural effusion (EPE) is characterized by greater than 10% eosinophilia and is frequently associated with air and/or blood in the pleural cavity. Primary spontaneous pneumothorax (PSP), defined as the spontaneous presence of air in the pleural space, is one of the most common causes of EPE. Recent studies have shown that type 2 immune responses play important roles in eosinophilic airway inflammation resulting in pleural pathology. OBJECTIVES: To determine the predominant immune responses associated with PSP in humans, and to examine whether IL-33, thymic stromal lymphopoietin (TSLP), or type 2 innate lymphoid cell (ILC2)-mediated immune responses are associated factors. METHODS: Eosinophil-associated cytokines were measured in the pleural fluid of patients with PSP and control subjects. Th2 cell and ILC2 responses in the pleural cavity and peripheral blood were also evaluated by in vitro restimulation and intracellular cytokine staining of T cells and ILC2s in patients with PSP (n = 62) and control subjects (n = 33). IL-33-mediated IL-5 production by ILC2s was also evaluated. MEASUREMENTS AND MAIN RESULTS: Significantly higher concentrations of IL-5 and eotaxin-3 were detected in the pleural fluid of patients with PSP, in addition to significantly higher concentrations of IL-33 and TSLP. Although IL-5 production was induced by IL-33 treatment of ILC2s, other Th2 cell-mediated immune responses were not detected. CONCLUSIONS: Our results indicate that innate immune responses characterized by the production of IL-33, TSLP, and IL-5 are associated with the development of EPE in PSP by an ILC2-dependent and Th2-independent mechanism.

Traumatic tracheobronchial injury: delayed diagnosis and treatment outcome.

BACKGROUND: Most traumatic tracheobronchial injuries are fatal and result in death. Some milder cases are not life threatening and are often missed at the initial presentation. Tracheobronchial rupture is difficult to diagnose in the evaluation of severe multiple trauma patients. We reviewed the traumatic tracheobronchial injuries at Konyang University and Eulji University Hospital and analyzed the clinical results. MATERIALS AND METHODS: From January 2001 to December 2011, 23 consecutive cases of traumatic tracheobronchial injury after blunt trauma were reviewed retrospectively. We divided them into two groups by the time to diagnosis: group I was defined as the patients who were diagnosed within 48 hours from trauma and group II was the patients who diagnosed 48 hours after trauma. We compared the clinical parameters of the two groups. RESULTS: There was no difference in the age and gender between the two groups. The most common cause was traffic accidents (56.5%). The Injury Severity Score (ISS) was 19.6 in group I and 27.5 in group II (p=0.06), respectively. Although the difference in the ISS was not statistically significant, group II tended toward more severe injuries than group I. Computed tomography was performed in 22 cases and tracheobronchial injury was diagnosed in 5 in group I and 6 in group II, respectively (p=0.09). Eighteen patients underwent surgical treatment and all four cases of lung resection were exclusively performed in group II (p=0.03). There were two mortality cases, and the cause of death was shock and sepsis. CONCLUSION: We believe that close clinical observation with suspicion and rigorous bronchoscopic evaluation are necessary to perform diagnosis earlier and preserve lung parenchyma in tracheobronchial injuries from blunt trauma.

Extended aortic arch replacement through the L-incision approach.

There are various methods for approaching the aortic arch, such as median sternotomy or lateral thoracotomy. However, accessing the site of distal anastomosis is problematic when the distal arch is extensively involved. We report a case of extended aortic arch replacement and coronary artery bypass through the L-incision approach.

The use of neutrophil elastase inhibitor in the treatment of acute lung injury after pneumonectomy.

BACKGROUND: The prognosis of acute lung injury (ALI) after pneumonectomy is poor, with reported mortality rates of 30-100%. Neutrophil elastase inhibitor (NEI) is known to prevent lung injury caused by neutrophil elastase and improve lung function in ALI. We evaluated the effect of NEI on ALI after pneumonectomy. METHODS: We analyzed nine patients who required ventilator care due to ALI after pneumonectomy. Five of these patients underwent conventional ventilator care (group I), and four patients underwent ventilator care and were administrated NEI (group II). We retrospectively analyzed the lung injury score (LIS) for 10 days after intubation. RESULTS: The LIS before intubation satisfied the diagnostic criteria of ALI or acute respiratory distress syndrome (ARDS) in all patients. After intubation, the LIS improved in both groups. But, as times went on, the mean value of the LIS in group II was lower compared to group I. In group I, only one patient underwent extubation. In group II, extubation was possible in three patients. Mortality rates were 80% in group I and 25% in group II. CONCLUSIONS: We conclude that NEI may improve the lung function, shorten the duration of mechanical ventilation, and reduce mortality in patients with ALI after pneumonectomy.

A comparison between two types of limited sympathetic surgery for palmar hyperhidrosis.

PURPOSE: Endoscopic thoracic sympathetic surgery is effective for treating palmar hyperhidrosis, although compensatory sweating (CS) is a significant and annoying side effect. The purpose of this study was to compare the results of limited resection at two different locations. METHODS: From May 2004 to June 2009, T3 sympathicotomy (group I) was performed in 46 patients and T3,4 ramicotomy (group II) was performed in 43 patients during the same period. T3 sympathicotomy (group I) and T3,4 ramicotomy (group II) were performed during the same period. Using questionnaires, completed by the patients, the satisfaction rates and grades of CS were analyzed. RESULTS: No significant differences in age distribution or sex ratios were observed between the two groups. The satisfaction rate was 91.3 % in group I and 79.1 % in group II. The operation time was 19.8 (±6.6) min in group I, and 51.6 (±18.8) min in group II, showing a statistically significant difference (p < 0.002). The incidence of persistent hand sweating in group II (16.3 %) was higher than that observed in group I (2.2 %). The incidence of compensatory sweating on the lower extremities was higher in group II (37.2 %) than in group I (10.9 %). CONCLUSIONS: Although ramicotomy is considered to be an effective method for treating hyperhidrosis and has a theoretical advantage of allowing greater anatomical resection, it requires longer operation time and induces more severe compensatory sweating in the lower limbs resulting in reduced satisfaction rates.

Altered expression of phosphatase of regenerating liver gene family in non-small cell lung cancer.

Protein tyrosine phophatases (PTPs) are implicated in the tumorigenesis and metastasis of human cancer. The phosphatase of regenerating liver (PRL) gene family, a subgroup of PTPs is also linked to these processes. In many solid cancers, high levels of PRL-3 expression are related with metastasis and poor prognosis. However, the expression patterns of PRL-1 and -2 have not been explored in lung cancer yet. Thus, we investigated the expression levels of PRL-1, -2 and -3 in the tissues of primary lung cancer patients. The protein expression levels of PRL-2, but not PRL-1 and -3 were increased in cancer tissues. However, there was no correlation between mRNA and protein expression levels of the PRLs. Reporter assays showed that PRLs suppressed the activity of the p21 promoter but promoted AP-1 activity. Furthermore, transfection of PRLs showed significantly increased cell proliferation. Therefore, these results suggest that PRL-2 plays an important role in lung cancer and can be a biomarker of lung cancer, substituting for the function of other PRLs.

Topographical considerations under video-scope guidance in the T3,4 levels sympathetic surgery.

INTRODUCTION: Anatomical variation of the sympathetic nervous system is known to be one of the main causes of failure and dissatisfaction after sympathetic surgery. However, there are only few reports on the descriptive analysis of sympathetic nerve variants. The purpose of this study is to investigate the anatomical variations of the sympathetic trunk at the levels of T3 and T4 ganglia considered in a topographic approach for sympathetic procedures and to further improve the postoperative outcome. MATERIALS AND METHODS: From June 2003 to January 2004, 44 patients with palmar hyperhidrosis underwent bilateral T3,4 ramicotomy via video-assisted thoracoscopic surgery. The anatomy of T3 and T4 sympathetic ganglia, pathway of sympathetic trunk, and rami-communicantes were recorded on video and still cut images for descriptive analysis. RESULTS: The thoracic sympathetic trunks were mostly lying against the heads of the ribs, but there were variants of sympathetic trunk running along the medial side of the rib heads of 3rd, 4th and 5th ribs, respectively in 9.0%, 18.0% and 37.5% of the cases. There were also variants running along the lateral side of rib heads near the neck portion in 12.5%, 10.2% and 8.0% of the cases. The 3rd ganglion was located within the intercostal space (59.1%) or at the level of the upper border of the 4th rib (36.4%) or upon the 4th rib (4.5%). The location of the 4th ganglion was in the intercostal space (18.2%), the upper border of the 5th rib (44.3%) or upon the 5th rib (37.5%). The ascending rami were found at the level of the 3rd ganglion in 48.8% and the 4th ganglion in 45.5% of the cases. The descending rami were located at the level of 3rd and the 4th ganglion in 8.0% and 6.8%, respectively. And the middle rami were found in all cases except one. CONCLUSIONS: It may be difficult to localize the sympathetic trunk in some cases of severe obesity; a careful inspection has to be performed from the medial side of the rib heads to the neck portion. The obvious 'downward shift of ganglion' in the position shown as the thoracic sympathetic trunk descends is to be deliberated in T4 sympathetic surgery. Many ascending and descending accessory pathways of sympathetic nerve were observed; therefore, a lateral extension of electrocoagulation at the level of upper and lower rib border is necessary to impose a complete blockage of sympathetic nerve stimulus.

Fine-scale map of encyclopedia of DNA elements regions in the Korean population.

The International HapMap Project aims to generate detailed human genome variation maps by densely genotyping single-nucleotide polymorphisms (SNPs) in CEPH, Chinese, Japanese, and Yoruba samples. This will undoubtedly become an important facility for genetic studies of diseases and complex traits in the four populations. To address how the genetic information contained in such variation maps is transferable to other populations, the Korean government, industries, and academics have launched the Korean HapMap project to genotype high-density Encyclopedia of DNA Elements (ENCODE) regions in 90 Korean individuals. Here we show that the LD pattern, block structure, haplotype diversity, and recombination rate are highly concordant between Korean and the two HapMap Asian samples, particularly Japanese. The availability of information from both Chinese and Japanese samples helps to predict more accurately the possible performance of HapMap markers in Korean disease-gene studies. Tagging SNPs selected from the two HapMap Asian maps, especially the Japanese map, were shown to be very effective for Korean samples. These results demonstrate that the HapMap variation maps are robust in related populations and will serve as an important resource for the studies of the Korean population in particular.

Analysis of the Nuss procedure for pectus excavatum in different age groups.

BACKGROUND: The Nuss procedure is a newly developed operative method for minimally invasive repair of pectus excavatum in pediatric patients. However, the surgical indication for this procedure has been extended into adult patients. The aim of this study was to assess the surgical outcome of the Nuss procedure in different age groups and to analyze its feasibility in the adult population. METHODS: From December 1999 to March 2003, 51 patients (40 males and 11 females) with pectus excavatum underwent the Nuss procedure. We classified patients into three groups based on age (pediatric, adolescent, and adult), retrospectively analyzed demographic, intraoperative and postoperative data, and compared outcomes among each group. RESULTS: Mean operation time was 52.0 +/- 22.9 minutes, 80.4 +/- 27.4 minutes, and 127.3 +/- 44.9 minutes in the pediatric, adolescent, and adult groups, respectively (p < 0.001). Postoperative complications occurred in 3 of 27 patients (11.1%) in the pediatric group and in 7 of 12 patients (58.3%) in both the adolescent and adult groups (p = 0.002). Reoperations were performed due to complications in 1 of 27 patients (3.7%) in the pediatric group, 2 of 12 patients (16.6%) in the adolescent group, and 5 of 12 patients (41.7%) in the adult group (p = 0.001). CONCLUSIONS: The Nuss procedure is highly recommended in pediatric patients with pectus excavatum. However, in adults it is necessary to select patients carefully because of the longer operation time and higher incidence of complications associated with the procedure in this population.

Bridging expressed sequence alignments through targeted cDNA sequencing.

One of the major challenges in genome research is the identification of the complete set of genes in a genome. Alignments of expressed sequences (RNA and EST) with genomic sequences have been used to characterize genes. However, the number of alignments far exceeds the likely number of genes in a genome, suggesting that, for many genes, two or more alignments can be joined through overlapping sequences to yield accurate gene structures. High-throughput EST sequencing becomes less efficient in closing those alignment gaps due to its nonselective nature. We sought to bridge these alignments through a novel approach: targeted cDNA sequencing. Human expressed sequences from GenBank version 124 were aligned with the genomic sequence from NCBI build 24 using LEADS, Compugen's EST and RNA clustering and assembly software system. Nine hundred forty-eight pairs of alignments were selected based on EST clone information and/or their homology to the same known proteins. Reverse transcriptase PCR and sequencing yielded sequences for 363 of those pairs. These sequences helped characterize over 60 novel or otherwise incomplete genes in the recent UniGene build 153, which included over 1 million additional ESTs. These results indicate that this integrated and targeted strategy, combining computational prediction and experimental cDNA sequencing, can efficiently generate the overlapping sequences and enable the full characterization of genomes. Additional information about the contig pairs, the resultant overlapping sequences, tissue sources, and tissue profiles are available in a supplemental file.

Lung transplantation in patients with pulmonary emphysema.

Lung transplantation is a viable option for patients with chronic obstructive pulmonary disease (COPD), and emphysema is the most common indication to undergo lung transplantation. A total of seven lung and one heart-lung transplantations were performed between July 1996 and June 2004 at the Yongdong Severance Hospital, and herein, three emphysema patients who underwent single lung transplantations are reviewed. There were 2 males and 1 female, with a mean age of 50 years (35, 57 and 58 years). They all underwent an operation, without cardiopulmonary bypass, and there was no operative mortality. The mean survival was 12 months (4 months, 15 months and 17 months) and all succumbed to death due to activation of pulmonary tuberculosis, post-transplantation lymphoproliferative disease and cytomegalovirus (CMV) gastritis associated with asphyxia. Infection was the most common postoperative complication, resulting in longer hospital stays, higher medical expenses and shorter survival rates, necessitating aggressive prophylactic management. The accumulation of experience, modifications to operative procedures and perioperative care may lead to improved early and long-term survival in patients with emphysema undergoing single or bilateral lung transplantations.