Eye Accommodation Sensing for Adaptive Focus Adjustment.

Over 2 billion people across the world are affected by some visual impairment - mostly related to optical issues, and this number is estimated to grow. Often, particularly in the elderly, more than one condition can affect the eyes at the same time, e.g., myopia and presbyopia. Bifocal or multifocal lenses can be used, these however may become uncomfortable or disturbing and are not adapted to the user. There is therefore a need and opportunity for a new type of glasses able to adaptively change the lenses' focus. This paper explores the feasibility of recording the eye accommodation process in a non-invasive way using a wearable device. This can provide a way to measure eye convergence in real-time to determine what a person's eye is focused on. In this study, Electro-oculography (EoG) is used to observe eye muscle activity and estimate eye movement. To assess this, a group of 11 participants we each asked to switch their gaze from a near to far target and vice versa, whilst their EoG was measured. This revealed two distinct waveforms: one for the transition from a far to near target, and one for the transition from a near to far target. This informed the design of a correlation-based classifier to detect which signals are related to a far to near, or near to far transition. This achieved a classification accuracy of 97.9±1.37% across the experimental results gathered from our 11 participants. This pilot data provides a basic starting point to justify future device development.

Use of the hybrid room for thoracic surgery procedures: single-stage localization and removal of non-palpable nodules.

With the widespread availability of lung cancer screening programs, the number of small lung nodules requiring histological characterization has dramatically increased. Because computed tomography-guided fine-needle aspiration may frequently yield false-negative results, excisional biopsy using thoracoscopy is frequently required. Although thoracoscopic procedure has been known to be ideal for nodule resection, the identification of very small, subsolid and deep pulmonary nodules may still be challenging. Precise lesion localization is a key prerequisite to avoid conversion to an unplanned thoracotomy. In the traditional workflow, the localization procedure is performed in the radiology suite, after which the patient is moved to an operating room. With the availability of hybrid operating rooms, a new approach encompassing simultaneous localization and removal of non-palpable lung nodules has become feasible. In this article, we review the procedural workflow of this new technique and discuss its indications and results.

Role of endobronchial ultrasound-guided transbronchial needle aspiration in staging of lung cancer: a thoracic surgeon's perspective.

In potentially resectable non-small cell lung cancer (NSCLC) accurate mediastinal staging is crucial not only to offer the optimal management but also to avoid unnecessary surgery. Mediastinal staging is generally performed by the use of imaging techniques (computed tomography and positron emission tomography). However, the accuracy of radiological imaging in mediastinal staging is suboptimal. Therefore, additional invasive mediastinal staging is frequently required to select patients who can benefit from a neoadjuvant treatment. In recent years, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has progressively replaced mediastinoscopy as a test for invasive mediastinal staging. The considerable potential of EBUS-TBNA as minimally invasive staging method has been understood by pulmonologists since the early 2000s but only recently by thoracic surgeons. The clinical impact of this diagnostic technology has been broadly highlighted in the literature and EBUS-TBNA is currently considered the test of first choice in preoperative nodal staging of NSCLC. We analyze the actual role of EBUS-TBNA in invasive mediastinal staging of NSCLC patients from the thoracic surgeon point of view, with particular emphasis on the performance characteristics of this endoscopic diagnostic method as well as its clinical use within the published guidelines.

Single-Stage Localization and Thoracoscopic Removal of Nonpalpable Pulmonary Nodules in a Hybrid Operating Room.

OBJECTIVE: We report our experience with simultaneous localization and thoracoscopic removal for nonpalpable undiagnosed pulmonary nodules. METHODS: All patients with nonpalpable lesions requiring video-assisted thoracoscopic surgery (VATS) wedge resection underwent localization of the targets and surgical removal in a hybrid operating room. Lesions were considered nonpalpable if they were small (<1 cm), deep (>1 cm from the surface), subsolid, or located within a dystrophic area. In all cases, intraoperative cone-beam computed tomography was performed for nodule localization and targeting, metal hookwires, or coils were alternatively used for intraoperative marking. RESULTS: From April 2016 to November 2019, 39 image-guided VATS (iVATS) were performed. The mean lesion size was 12 ± 6 mm. The mean distance from the deep edge of the lesion to the pleural surface was 24 ± 9 mm. The localization was performed with 20 hookwires and 19 coils. iVATS localization was successful in 36 patients (92.3%). Thirty-seven wedge resections were completed by VATS, 2 (5%) required conversion to thoracotomy. In 9 patients with intraoperative diagnosis of lung cancer, a lobectomy was performed (7 VATS and 2 thoracotomies). Mean length of iVATS localization was 30 ± 13 minutes. Median postoperative length of stay was 4 days (IQR 3 to 5). CONCLUSIONS: iVATS seems to be a helpful tool for simultaneous localization and removal of nonpalpable nodules. A versatile approach using different devices seems advisable for the removal of targets in every clinical scenario reducing VATS conversion rate. Future research is required to compare iVATS with traditional preoperative localization techniques.

Comparison between the Airgo™ Device and a Metabolic Cart during Rest and Exercise.

The aim of this study is to compare the accuracy of Airgo™, a non-invasive wearable device that records breath, with respect to a gold standard. In 21 healthy subjects (10 males, 11 females), four parameters were recorded for four min at rest and in different positions simultaneously by Airgo™ and SensorMedics 2900 metabolic cart. Then, a cardio-pulmonary exercise test was performed using the Erg 800S cycle ergometer in order to test Airgo™'s accuracy during physical effort. The results reveal that the relative error median percentage of respiratory rate was of 0% for all positions at rest and for different exercise intensities, with interquartile ranges between 3.5 (standing position) and 22.4 (low-intensity exercise) breaths per minute. During exercise, normalized amplitude and ventilation relative error medians highlighted the presence of an error proportional to the volume to be estimated. For increasing intensity levels of exercise, Airgo™'s estimate tended to underestimate the values of the gold standard instrument. In conclusion, the Airgo™ device provides good accuracy and precision in the estimate of respiratory rate (especially at rest), an acceptable estimate of tidal volume and minute ventilation at rest and an underestimation for increasing volumes.

Artificial intelligence and radiomics enhance the positive predictive value of digital chest tomosynthesis for lung cancer detection within SOS clinical trial.

OBJECTIVE: To enhance the positive predictive value (PPV) of chest digital tomosynthesis (DTS) in the lung cancer detection with the analysis of radiomics features. METHOD: The investigation was carried out within the SOS clinical trial (NCT03645018) for lung cancer screening with DTS. Lung nodules were identified by visual analysis and then classified using the diameter and the radiological aspect of the nodule following lung-RADS. Haralick texture features were extracted from the segmented nodules. Both semantic variables and radiomics features were used to build a predictive model using logistic regression on a subset of variables selected with backward feature selection and using two machine learning: a Random Forest and a neural network with the whole subset of variables. The methods were applied to a train set and validated on a test set where diagnostic accuracy metrics were calculated. RESULTS: Binary visual analysis had a good sensitivity (0.95) but a low PPV (0.14). Lung-RADS classification increased the PPV (0.19) but with an unacceptable low sensitivity (0.65). Logistic regression showed a mildly increased PPV (0.29) but a lower sensitivity (0.20). Random Forest demonstrated a moderate PPV (0.40) but with a low sensitivity (0.30). Neural network demonstrated to be the best predictor with a high PPV (0.95) and a high sensitivity (0.90). CONCLUSIONS: The neural network demonstrated the best PPV. The use of visual analysis along with neural network could help radiologists to reduce the number of false positive in DTS. KEY POINTS: • We investigated several approaches to enhance the positive predictive value of chest digital tomosynthesis in the lung cancer detection. • Neural network demonstrated to be the best predictor with a nearly perfect PPV. • Neural network could help radiologists to reduce the number of false positive in DTS.

Enhanced recovery after surgery: adherence and outcomes in elderly patients undergoing VATS lobectomy.

OBJECTIVES: To evaluate whether ERAS is feasible and beneficial in elderly patients undergoing VATS lobectomy for lung cancer. METHODS: From February 2016 to March 2019, 182 patients were included into a 17-items ERAS pathway. Patients were divided into two groups according to age: Group A (< 75 years) 138 patients and Group B (≥ 75 years) 44 patients. End points were: length of stay (LoS), 30-day morbidity, 90-day mortality, 30-day re-admittance rate, and ERAS-score (number of ERAS objectives achieved). RESULTS: Elderly patients had significantly more chronic renal failure (p = 0.039) and a worse pulmonary function. Mean FEV1% was 101.6% (± 21.0% SD) and 90.8% (± 19.1% SD) and mean FEV1/FVC was 0.75 (± 0.10 SD) and 0.68 (± 0.12 SD) for group A and B, respectively (p = 0.02 and p = 0.01). Median LoS was longer in Group B (6 days) than in Group A (5 days; p = 0.006). Morbidity was higher for elderly patients (A 32.6% vs B 56.8%; p = 0.007), major complication rates were similar (p = 0.782). No post-operative mortality was observed, re-admittance rates were similar (A 7.8% vs B 11.5%; p = 0.548). Mean ERAS-scores were 13.8 (± 1.83 SD) for Group A and 13.4 (± 1.98 SD) for Group B (p = 0.240). Multivariable analysis showed previous major surgery (p = 0.028), COPD (p = 0.027), history of arrhythmic disease (p = 0.015), post-operative complications (p < 0.001), and ERAS-score (p < 0.001) as independent predictive factors of LoS, age did not significantly influence LoS. CONCLUSIONS: Elderly patients adhere to an ERAS protocol similarly to younger ones. ERAS pathway in VATS lobectomy patients seems to be beneficial regardless the age.

Tailored intraoperative localization of non-palpable pulmonary lesions for thoracoscopic wedge resection using hybrid room technology.

INTRODUCTION: VATS wedge resection can require conversion to thoracotomy when pulmonary lesions cannot be identified. Hybrid operating rooms (HORs) provide real-time image acquisition capabilities allowing the intraoperative placement of markers to facilitate the removal of non-palpable nodules during VATS. OBJECTIVES: To present our workflow based on the alternative use of two different markers according to the location of the lung lesion and report our initial results. METHODS: All consecutive patients with non-palpable lesions requiring VATS wedge resection underwent localization of the targets in HOR. Lesions were considered non-palpable if they were small (<1 cm), deep (>1 cm from surface), subsolid, or located within a dystrophic area. Anesthetized patients were placed in lateral decubitus. Cone-beam CT (CBCT) was performed, and the needle trajectory was planned using Syngo iGuide Needle Guidance. Metal hook-wire or coil was placed, according to our workflow, close to the lesion and their position was verified by CBCT or fluoroscopy. RESULTS: Eleven VATS wedge resections were performed in 10 patients with 12 non-palpable lesions. The localization was performed with seven hook-wires and four coils in 30 minutes (range 17-56 minutes). The median estimated total effective dose was 11.6 mSv (range 1.9-24.7 mSv). Eleven lesions were removed by VATS, and one deep nodule required a thoracotomy. No complications were observed. CONCLUSIONS: Our experience confirms that HOR is suitable for simultaneous localization and VATS resection of 'difficult' pulmonary lesions. A versatile approach, using different devices, seems advisable for the removal of targets in every clinical scenario, reducing the VATS conversion rate.

Pulmonary middle lobectomy for non-small-cell lung cancer: effectiveness and prognostic implications.

OBJECTIVES: The therapeutic value of pulmonary middle lobectomy (PML) has been questioned. PML is currently regarded as a standard form of lobectomy, even so it shares some surgical features with segmentectomies (SEG) more than with lobectomies. The present study's aim was to assess the therapeutic value of PML with respect to other lobectomies (LOBs) and SEGs. METHODS: A total of 902 consecutive patients who underwent lobectomy or SEG with mediastinal lymph node dissection for Stage I-IIIa non-small-cell lung cancer were analysed. Patients with pT4 tumours and/or pathologically incomplete resection were excluded. RESULTS: PML was performed in 50 patients, SEG in 44 and LOBs were performed in 808. The three study groups were homogeneous, except for gender, pT and grade: females, pT1 and G1 tumours were more frequent in the PML and SEG groups. The lymph node dissection yield was poorer in PML (P < 0.007) and SEG (P < 0.001) groups when compared with LOB group. Five-year overall survival (OS) was 45.3% for PML, 54.0% for SEG and 60.2% for LOB (P = 0.793). When limiting the analysis to G2-3 right-sided tumours, 5-year survival was lower in the PML group than in the LOB group: 41.3 vs 59.0% (P = 0.057). Similar results were found when analysing pT2-3 right-sided tumours: 27.3 vs 57.3% (P = 0.049). Multivariable analysis showed four independent prognostic factors: age (P = 0.001), pathological stage (P < 0.001), gender (P = 0.005) and the type of surgical resection (P = 0.029). PML (hazard ratio, HR = 1.63) and SEG (HR = 1.64) were detrimental in comparison with LOB. After adjusting for baseline differences between groups (propensity score), a trend towards a worse OS in PML group when compared with LOB group was observed (HR = 1.38, P = 0.150). CONCLUSIONS: Both the lymphadenectomy yield and prognosis make PML more similar to SEG than lobectomy, especially for pT2-3 or G2-3 tumours.

Pleural lavage cytology predicts recurrence and survival, even in early non-small cell lung cancer.

PURPOSE: The TNM staging remains the best prognostic descriptor of lung cancer; however, new independent prognostic factors are needed, particularly for early stage disease. METHODS: An evaluation of the pleural lavage cytology (PLC) was performed in 436 consecutive NSCLC patients who underwent surgical resection; clinical, pathological and follow-up data were available for 414 patients. RESULTS: The PLC was positive in 15 patients (3.6 %). The overall five-year survival was 35.9 % in PLC-positive and 57.8 % in PLC-negative patients (p = 0.004). To compare groups with the same prognostic characteristics, the analysis was restricted to p-stage I patients, but the survival remained worse in the PLC-positive patients (42.9 vs 69.4 %; p = 0.001). Recurrence was also observed more frequently in PLC-positive cases: 69.2 vs 34.5 %, OR 4.28 (95 % CI 1.29-14.18; p = 0.01). Among the PLC-positive patients, no difference between the local (44.4 %) and distant (55.6 %) relapse patterns was found (p = 0.82). The multivariate analysis identified four independent prognostic factors: age (p < 0.001), disease stage (p < 0.001), gender (p = 0.025) and PLC status (p = 0.012). CONCLUSIONS: PLC is an independent prognostic factor for NSCLC. PLC-positive NSCLC patients have a worse overall survival and a higher recurrence rate, even in stage I disease. PLC-positive patients should be considered a high risk category, who should potentially be eligible for adjuvant therapy regardless of their p-stage.