Physical exercise rescues cocaine-evoked synaptic deficits in motor cortex.

Drug exposure impairs cortical plasticity and motor learning, which underlies the reduced behavioral flexibility in drug addiction. Physical exercise has been used to prevent relapse in drug rehabilitation program. However, the potential benefits and molecular mechanisms of physical exercise on drug-evoked motor-cortical dysfunctions are unknown. Here we report that 1-week treadmill training restores cocaine-induced synaptic deficits, in the form of improved in vivo spine formation, synaptic transmission, and spontaneous activities of cortical pyramidal neurons, as well as motor-learning ability. The synaptic and behavioral benefits relied on de novo protein synthesis, which are directed by the activation of the mechanistic target of rapamycin (mTOR)-ribosomal protein S6 pathway. These findings establish synaptic functional restoration and mTOR signaling as the critical mechanism supporting physical exercise training in rehabilitating the addicted brain.

AMPK activation attenuates inflammatory pain through inhibiting NF-κB activation and IL-1ß expression.

BACKGROUND: Chronic pain is a major clinical problem with limited treatment options. Previous studies have demonstrated that activation of adenosine monophosphate-activated protein kinase (AMPK) can attenuate neuropathic pain. Inflammation/immune response at the site of complete Freund's adjuvant (CFA) injection is known to be a critical trigger of the pathological changes that produce inflammatory pain. However, whether activation of AMPK produces an analgesic effect through inhibiting the proinflammatory cytokines, including interleukin-1ß (IL-1ß), in inflammatory pain remains unknown. METHODS: Inflammatory pain was induced in mice injected with CFA. The effects of AICAR (5-aminoimidazole-4-carboxyamide ribonucleoside, an AMPK activator), Compound C (an AMPK inhibitor), and IL-1ra (an IL-1 receptor antagonist) were tested at day 4 after CFA injection. Inflammatory pain was assessed with von Frey filaments and hot plate. Immunoblotting, hematoxylin and eosin (H&E) staining, and immunofluorescence were used to assess inflammation-induced biochemical changes. RESULTS: The AMPK activator AICAR produced an analgesic effect and inhibited the level of proinflammatory cytokine IL-1ß in the inflamed skin in mice. Moreover, activation of AMPK suppressed CFA-induced NF-κB p65 translocation from the cytosol to the nucleus in activated macrophages (CD68+ and CX3CR1+) of inflamed skin tissues. Subcutaneous injection of IL-1ra attenuated CFA-induced inflammatory pain. The AMPK inhibitor Compound C and AMPKα shRNA reversed the analgesic effect of AICAR and the effects of AICAR on IL-1ß and NF-κB activation in inflamed skin tissues. CONCLUSIONS: Our study provides new information that AMPK activation produces the analgesic effect by inhibiting NF-κB activation and reducing the expression of IL-1ß in inflammatory pain.

Prevalence and Risk Factors of Acute Pulmonary Embolism in Patients with Lung Cancer Surgery.

Acute pulmonary embolism (PE) is one of the serious complications with high mortality after thoracic surgery. The authors aimed to determine the prevalence of PE events and evaluate additional risk factors for PE in patients with lung cancer surgery. Patients underwent lung cancer resections during January 2012 to July 2015 and had 30-day postoperative follow-up were included. Those with incomplete or miscoded data were excluded. The number of postoperative PE events was recorded retrospectively. Analyses were used to evaluate risk factors of PE during the hospitalization. The authors reviewed 11,474 patients who underwent surgery for lung cancer. The overall 30-day incidence of PE after thoracic surgery at their institution was 0.53%. The 30-day PE incidence without chemical prophylaxis was 0.57% (55/9,726) and the mortality rate was 10%. Multivariate analyses revealed that age over 66 (odds ratio [OR]: 1.09, 95% confidence interval [CI]: 1.05-1.12, p < 0.001), more extensive surgery than lobectomy (OR: 2.34, 95% CI: 1.28-4.25, p = 0.006) and stage IV of lung cancer (OR: 4.22, 95% CI: 1.50-11.9, p = 0.007) were associated with an increased risk of PE. Using these additional risk factors, based on readily available clinical characteristics, can help to risk-stratify patients and warrant extended chemical prophylaxis for patients to reduce the incidence of acute PE.

Impact of biochar produced from post-harvest residue on the adsorption behavior of diesel oil on loess soil.

The primary objective of this study was to investigate the effect of biochar, produced from wheat residue at different temperatures, on the adsorption of diesel oil by loess soil. Kinetic and equilibrium data were processed to understand the adsorption mechanism of diesel by biochar-affected loess soil; dynamic and thermodynamic adsorption experiments were conducted to characterize this adsorption. The surface features and chemical structure of biochar, modified at varying pyrolytic temperatures, were investigated using surface scanning electron microscopy and Fourier transform infrared analysis. The kinetic data showed that the adsorption of diesel oil onto loess soil could be described by a pseudo-second-order kinetic model, with the rate-controlling step being intraparticle diffusion. However, in the presence of biochar, boundary layer control and intraparticle diffusion were both involved in the adsorption. Besides, the adsorption equilibrium data were well described by the Freundlich isothermal model. The saturated adsorption capacity weakened as temperature increased, suggesting a spontaneous exothermic process. Thermodynamic parameter analysis showed that adsorption was mainly a physical process and was enhanced by chemical adsorption. The adsorption capacity of loess soil for diesel oil was weakened with increasing pH. The biochar produced by pyrolytic wheat residue increased the adsorption behavior of petroleum pollutants in loess soil.

Electroacupuncture Reduces Visceral Pain Via Cannabinoid CB2 Receptors in a Mouse Model of Inflammatory Bowel Disease.

Inflammatory bowel disease (IBD) results in chronic abdominal pain in patients due to the presence of inflammatory responses in the colon. Electroacupuncture (EA) is effective in alleviating visceral pain and colonic inflammation associated with IBD. Cannabinoid CB2 receptor agonists also reduce colonic inflammation in a mouse model of IBD. However, whether EA reduces visceral pain and colonic inflammation via the CB2 receptor remains unknown. Here, we determined the mechanism of the antinociceptive effect of EA in a mouse model of IBD induced by rectal perfusion of 2,4,6-trinitrobenzenesulfonic acid solution (TNBS). EA or sham EA was performed at the bilateral Dachangshu (BL25) point for seven consecutive days. The von Frey and colorectal distension tests were performed to measure mechanical referred pain and visceral pain. Western blotting and immunohistochemistry assays were carried out to determine the expression of IL-1ß and iNOS and activation of macrophages in the colon tissues. We found that EA, but not sham EA, attenuated visceral hypersensitivity and promoted activation of CB2 receptors, which in turn inhibited macrophage activation and the expression of IL-1ß and iNOS. The effects of EA were blocked by AM630, a specific CB2 receptor antagonist, and by CB2 receptor knockout. Our findings suggest that EA attenuates mechanical allodynia and visceral hypersensitivity associated with IBD by activating CB2 receptors and subsequent inhibition of macrophage activation and expression of IL-1ß and iNOS.

Electroacupuncture Reduces Anxiety Associated With Inflammatory Bowel Disease By Acting on Cannabinoid CB1 Receptors in the Ventral Hippocampus in Mice.

The therapeutic effects of electroacupuncture (EA) on the comorbidity of visceral pain and anxiety in patients with inflammatory bowel disease (IBD) is well known. It has been known that the ventral hippocampus (vHPC) and the cannabinoid type 1 receptors (CB1R) are involved in regulating anxiety and pain. Therefore, in this study, we determined whether EA reduces visceral pain and IBD-induced anxiety via CB1R in the vHPC. We found that EA alleviated visceral hyperalgesia and anxiety in TNBS-treated IBD mice. EA reversed over-expression of CB1R in IBD mice and decreased the percentage of CB1R-expressed GABAergic neurons in the vHPC. Ablating CB1R of GABAergic neurons in the vHPC alleviated anxiety in TNBS-treated mice and mimicked the anxiolytic effect of EA. While ablating CB1R in glutamatergic neurons in the vHPC induced severe anxiety in wild type mice and inhibited the anxiolytic effect of EA. However, ablating CB1R in either GABAergic or glutamatergic neurons in the vHPC did not alter visceral pain. In conclusion, we found CB1R in both GABAergic neurons and glutamatergic neurons are involved in the inhibitory effect of EA on anxiety but not visceral pain in IBD mice. EA may exert anxiolytic effect via downregulating CB1R in GABAergic neurons and activating CB1R in glutamatergic neurons in the vHPC, thus reducing the release of glutamate and inhibiting the anxiety circuit related to vHPC. Thus, our study provides new information about the cellular and molecular mechanisms of the therapeutic effect of EA on anxiety induced by IBD.

Aspiration via congenital broncho-esophageal fistula after lobectomy.

Aspiration via a congenital broncho-esophageal fistula in an adult thoracotomy patient has not been previously reported. Repeated aspiration and subsequent respiratory failure if the fistula is not recognized could be life-threatening in these postoperative patients. We describe one such critical case, in which a broncho-esophageal fistula was discovered weeks after aspiration and the onset of respiratory failure after left lower lobectomy. This unusual case suggests that repeated localized pulmonary infections can indicate a broncho-esophageal fistula and that further investigations should be performed, including detailed history.

100 Hz Electroacupuncture Alleviated Chronic Itch and GRPR Expression Through Activation of Kappa Opioid Receptors in Spinal Dorsal Horn.

BACKGROUND: Clinical studies have shown that electroacupuncture (EA) alleviates chronic itch. Gastrin-releasing peptide receptor (GRPR) and dynorphin (DYN) in the spinal dorsal horn positively or negatively regulate itch, respectively. However, which frequency of EA is effective on relieving chronic itch and reducing the expression of GRPR, whether DYN-A in the spinal cord is involved in the underlying mechanism of the antipruritus effect of EA remains unknown. METHODS: The mixture of acetone and diethyl ether (1:1) [designated as AEW (acetone/diethyl ether and water) treatment] was used to induce the dry skin model of chronic itch. EA was applied to Quchi (LI11) and Hegu (LI4). Western blot was used to detect the expression of GRPR and DYN-A. Immunofluorescence was used to detect the expression of DYN-A. RESULTS: The AEW administration induced remarkable spontaneous scratching, enhanced the expression of GRPR, and reduced the expression of DYN-A. Compared with the sham EA, 2 Hz EA, or 15 Hz EA group, 100 Hz EA was the most effective frequency for relieving chronic itch, reducing the expression of GRPR, and increasing the expression of DYN-A in the cervical dorsal horn. Furthermore, intraperitoneal injection of kappa opioid receptors (KORs) antagonist nor-Binaltorphimine dihydrochloride (nor-BNI) significantly reversed the effect of 100 Hz EA on the inhibition of both itching behavior and GRPR expression. CONCLUSION: EA at 100 Hz is the most effective frequency that inhibits chronic itch and GRPR expression through activation of KORs in the spinal dorsal horn, which can effectively guide the clinical treatment and improve the antipruritic effect of acupuncture.

[Investigation of long-term outcome for lung cancer of patients with neoadjuvant chemotherapy].

OBJECTIVE: To evaluate and analyze prognostic factors for surgical treatment of patients with neoadjuvant chemotherapy. METHODS: Records of 256 patients who underwent operation after chemotherapy for lung cancer from June 1995 to May 2007 were reviewed retrospectively. Potential prognostic factors which were univariately and multivariately analyzed by COX proportional hazard regression model, included gender, age, p-TNM stage, size of tumor, metastasis of lymph node, histological type and operation extent. Kaplan-Meier method was used for survival curve and rate. However, survival difference was calculate by Log-rank test. RESULTS: Eleven patients (4.3%) developed postoperative complications. Two hundred and thirty-six patients (92.2%) underwent radical resection (169 for lobectomies, 53 for pneumonectomies and 14 for extended resections). On the contrary, 20 cases had palliative resection. The overall 1-, 3- and 5-year survival rate was 79.3%, 38.7% and 27.0% respectively. Age, p-TNM stage, size of tumor, metastasis of lymph node and type of operation were valued as prognostic factors in COX univariate analysis, p-TNM stage (OR = 1.323, 95% CI: 1.068 to 1.641, P = 0.017) and age (OR = 1.562, 95% CI: 1.148 to 2.125, P = 0.005) were identified independent prognostic factors in COX multivariate analysis. CONCLUSIONS: Long-term outcome for lung cancer of patients with neoadjuvant chemotherapy are encouraging, p-TNM stage and surgical type are the crucial prognostic factors for surgical treatment of patients with neoadjuvant chemotherapy.

Inhibition of GABAergic Neurons and Excitation of Glutamatergic Neurons in the Ventrolateral Periaqueductal Gray Participate in Electroacupuncture Analgesia Mediated by Cannabinoid Receptor.

Although electroacupuncture (EA) has become a worldwide practice, little is understood about its precise target in the central nervous system (CNS) and the cell type-specific analgesia mechanism. In the present study, we found that EA has significant antinociceptive effects both in inflammatory and neuropathic pain models. Chemogenetic inhibition of GABAergic neurons in the ventrolateral periaqueductal gray (vlPAG) replicated the effects of EA, whereas the combination of chemogenetic activation of GABAergic neurons and chemogenetic inhibition of glutamatergic neurons in the vlPAG was needed to reverse the effects of EA. Specifically knocking out CB1 receptors on GABAergic neurons in the vlPAG abolished the EA effect on pain hypersensitivity, while specifically knocking out CB1 receptors on glutamatergic neurons attenuated only a small portion of the EA effect. EA synchronously inhibits GABAergic neurons and activates glutamatergic neurons in the vlPAG through CB1 receptors to produce EA-induced analgesia. The CB1 receptors on GABAergic neurons localized in the vlPAG was the basis of the EA effect on pain hypersensitivity. This study provides new experimental evidence that EA can bidirectionally regulate GABAergic neurons and glutamatergic neurons via the CB1 receptors of the vlPAG to produce analgesia effects.

Electroacupuncture decreases Netrin-1-induced myelinated afferent fiber sprouting and neuropathic pain through µ-opioid receptors.

Purpose: We determined whether electroacupuncture (EA) reduces Netrin-1-induced myelinated primary afferent nerve fiber sprouting in the spinal cord and pain hypersensitivity associated with postherpetic neuralgia (PHN) through activation of µ-opioid receptors. Methods: PHN was induced by systemic injection of resiniferatoxin (RTX) in rats. Thirty-six days after RTX injection, a µ-opioid receptor antagonist, beta-funaltrexamine (ß-FNA) or a κ-opioid receptor antagonist, nor Binaltorphimine (nor-BNI), was injected intrathecally 30 mins before EA, once every other day for 4 times. Mechanical allodynia was tested with von Frey filaments. The protein expression level of Netrin-1 and its receptors (DCC and UNC5H2) were quantified by using western blotting. The myelinated primary afferent nerve fiber sprouting was mapped with the transganglionic tracer cholera toxin B-subunit (CTB). Results: Treatment with 2 Hz EA at "Huantiao" (GB30) and "Yanglingquan" (GB34) decreased the mechanical allodynia at 22 days and the myelinated primary afferent nerve fiber preternatural sprouting into the lamina II of the spinal dorsal horn at 42 days after RTX injection. Also, treatment with 2 Hz EA reduced the protein levels of DCC and Netrin-1 and promoted the expression of UNC5H2 in the spinal dorsal horn 42 days after RTX injection. Furthermore, the µ-opioid receptor antagonist ß-FNA, but not the κ-opioid receptor antagonist nor-BNI, reversed the effect of EA on neuropathic pain caused by RTX. In addition, morphine inhibited the Netrin-1 protein level induced by RTX in SH-SY5Y cells. Conclusions: Through activation of µ-opioid receptors, treatment with EA reduces the expression level of DCC and Netrin-1 and changes a growth-permissive environment in spinal dorsal horn into an inhibitory environment by increasing UNC5H2, thus decreasing RTX-caused primary afferent nerve sprouting in the spinal dorsal horn and neuropathic pain.

Electroacupuncture potentiates peripheral CB2 receptor-inhibited chronic pain in a mouse model of knee osteoarthritis.

PURPOSE: Knee osteoarthritis (KOA) is a highly prevalent, chronic joint disorder, with chronic pain as its typical symptom. Although studies have shown that an activated peripheral CB2 receptor can reduce acute pain, whether the CB2 receptor is involved in electroacupuncture (EA) inhibiting chronic pain and the involved mechanism remains unclear. The aim of this study was to investigate whether EA may strengthen peripheral CB2 receptor-inhibited chronic pain in a mouse model of KOA. MATERIALS AND METHODS: KOA was induced by intra-articular injection of monosodium iodoacetate (MIA) into the left knee joint of mice. Thermal hyperalgesia was tested with the hot plate test, and mechanical allodynia was quantified using von Frey filaments. The expression of CB2 receptor and IL-1ß were quantified by using immunofluorescence labeling. RESULTS: EA treatment at 2 Hz+1 mA significantly increased the expression of CB2 receptor in fibroblasts and decreased the expression of IL-1ß in the menisci compared with that in the KOA group. However, EA had no effect on the expression of IL-1ß in CB2-/- mice. At 2 Hz+1 mA, EA significantly increased mechanical threshold, thermal latency, and weight borne after KOA modeling. However, knockout of the CB2 receptor blocked these effects of EA. After 2 Hz+1 mA treatment, EA significantly reduced the Osteoarthritis Research Society International (OARSI) score after KOA modeling. However, EA had no significant effect on the OARSI score in CB2-/- mice. CONCLUSION: EA reduced the expression of IL-1ß by activating the CB2 receptor, thus inhibiting the chronic pain in the mouse model of KOA.

Nonintubated-Awake Anesthesia for Uniportal Video-Assisted Thoracic Surgery Procedures.

Nonintubated video-assisted thoracic surgery (VATS) strategies are gaining popularity. This review focuses on noninutbated VATS, and discusses advantages, indications, anesthetic techniques, and approaches to intraoperative crisis management. Advances in endoscopic, endovascular, and robotic techniques have expanded the range of surgical procedures that can be performed in a minimally invasive fashion. The nonintubated thoracoscopic approach has been adapted for use with major lung resections. The need for general anesthesia and endotracheal intubation has been reexamined, such that regional or epidural analgesia may be sufficient for cases where lung collapse can be accomplished with spontaneous ventilation and an open hemithorax.

Surgery following neoadjuvant chemotherapy for non-small-cell lung cancer patients with unexpected persistent pathological N2 disease.

Patients with mediastinal lymph node (LN) downstaging following neoadjuvant chemotherapy exhibit improved outcomes compared with patients with persistent N2 disease. The aim of this study was to compare clinicopathological characteristics and survival between patients with unexpected and expected persistent N2 disease following surgery for non-small-cell lung cancer (NSCLC). This retrospective analysis included 348 patients with NSCLC who underwent surgery following chemotherapy at the Shanghai Pulmonary Hospital, Tongji University School of Medicine, between 1995 and 2012. According to the results of the imaging examinations and postoperative pathology, the patients were divided into three groups, namely groups I (nodal downstaging, pN0-1), II (expected persistent N2 disease) and III (unexpected persistent N2 disease). The rates of overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for OS and DFS. The mortality rate was 1.1% during the postoperative period. Perioperative complications occurred in 45 patients (12.9%). The 5-year OS rate was 32.2, 6.3 and 25.9% in groups I, II and III, respectively (group I vs. III, P=0.023; and group III vs. II, P<0.001). The 5-year DFS rate was 30.1, 5.1 and 22.4% in groups I, II and III, respectively (group I vs. III, P=0.012; and group III vs. II, P<0.001). Grouping, predicted forced expiratory volume in 1 sec, N downstaging and skip N2 metastasis were identified as independent predictive factors associated with OS, whereas the independent risk factors associated with DFS were grouping and N downstaging. Patients with unexpected persistent N2 disease exhibited better survival compared with those with expected persistent N2 disease. Surgery following chemotherapy remains the optimal approach for a proportion of patients with persistent N2 disease.

Risk factors for early postoperative complications after pneumonectomy for benign lung disease.

BACKGROUND: Pneumonectomy is associated with a significant incidence of postoperative complications. The purpose of this study is to identify the risk factors associated with adverse outcomes. METHODS: One hundred thirty-six patients with benign lung disease who underwent pneumonectomy were included in this retrospective analysis. Postoperative complications were observed during the 30-day follow-up. Univariate and multivariate analysis was performed to investigate the risk factors of pneumonectomy among the patients. RESULTS: Postoperative complications were observed in 33 patients (24.26%). The rate of bronchopleural fistula was 6.1% (9 of 136). Five perioperative deaths (3.68%) were noted. Univariate analysis and multivariate analysis indicated that type of disease (hazard ratio [HR], 3.158; 95% confidence interval [CI], 1.248 to 7.992; p = 0.015) and operation duration (HR, 2.508; 95% CI, 1.035 to 6.080; p = 0.042) were independent risk factors of postoperative complications, and that type of disease (HR, 6.409; 95% CI, 1.669 to 6.021; p = 0.011) and pulmonary function (HR, 6.159; 95% CI, 0.018 to 0.625; p = 0.013) were independent risk factors of bronchopleural fistula for patients with benign lung disease after pneumonectomy. CONCLUSIONS: A high incidence of complications was reported among patients with benign lung disease after pneumonectomy. The type of disease and operation duration were the best independent predictors of morbidity after this surgery. With careful patient selection and operative technique, morbidity and mortality rates could be comparable to those for pneumonectomy in cancer patients. Pneumonectomy is still a satisfactory treatment method for benign lung disease.

A clinical risk model for the evaluation of bronchopleural fistula in non-small cell lung cancer after pneumonectomy.

BACKGROUND: There are no reliable risk factors to predict bronchopleural fistula (BPF) formation in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC). This study aims to create a validated clinical model based on the risk factors for BPF after pneumonectomy. The model to estimate the risk of BPF may help select patients for intervention therapy to reduce the rate of BPF after pneumonectomy. METHODS: This retrospective analysis included 684 patients with NSCLC who underwent pneumonectomy at our institution from 1995 to 2012. The rates of BPF were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for the BPF and based on which a clinical model for the prediction of the incidence of BPF was formed. RESULTS: The incidence of BPF was 4.4% (30 of 684 patients). Three factors were independently associated with BPF after pneumonectomy for NSCLC: neoadjuvant therapy (hazard ratio, 2.479), diabetes mellitus (hazard ratio, 1.061), and age 70 years or older (hazard ratio, 1.175). A scoring system for BPF was developed by assigning 2 points for a major risk factor (neoadjuvant therapy) and 1 point for each minor risk factor (diabetes mellitus and age ≥ 70 years). The 684 patients were divided into a low-risk group (score, 0 to 1), moderate-risk group (score, 2), and high-risk group (score, ≥ 3), with respective incidences of early BPF after pneumonectomy of 2.4%, 18.2%, and 58.3% CONCLUSIONS: This model, based on readily available clinical characteristics, can estimate the risk of BPF after pneumonectomy in the NSCLC patients, independent of early BPF and late BPF classifications. This model could be used to select patients for intervention therapy (parenteral alimentation, control of blood glucose level, oxygen therapy, and strengthening the antibiotic treatment) if validated in independent data sets.

Re-appraisal of N2 disease by lymphatic drainage pattern for non-small-cell lung cancers: by terms of nodal stations, zones, chains, and a composite.

PURPOSE: N2 non-small-cell lung cancer (NSCLC) is a heterogeneous disease with an extremely wide range of 5-year survival rates. A composite method of sub-classification for N2 is likely to provide a more accurate method to more finely differentiate prognosis of N2 disease. METHODS: A total of 720 pN2 (T1-4N2M0) NSCLC cases were enrolled in our retrospective analysis of the proposed composite method. Survival rates were respectively calculated according to the N2 stratification methods: singly by "nodal stations", "nodal zones", or "nodal chains", or by combination of all three. Statistical analysis was carried out by Kaplan-Meier and Cox regression models. RESULTS: A total of 10,199 lymph nodes (8059 mediastinal; 2140 hilar and intra-lobar) were removed. By nodal station, there were 173 cases of single-station involvement and 547 multi-stations. By nodal zone, there were 413 single-zone involvement and 307 with multiple zones. By nodal chain, there were 311 cases with single-chain and 409 multi-chain involvements. The overall 5-year survival was 20% and median survival time was 27.52 months. The 5-year survival was significantly better for cases of single-zone involvement, as compared to multi-zones (29% vs. 6%, p<0.0001). The 5-year survival rates of single- and multi-chains involvement were 36% and 8%, respectively (p<0.0001). When taking all of the above grouping methods into consideration, the N2 disease state could be further sub-classified into two subgroups with respective survival rates of 36% and 7% (p<0.0001). Subgroup I was composed of individuals with single-chain involvement and having either one or two station metastasis; individuals with any other metastasis combinations formed Subgroup II. Multivariate analysis revealed that the composite sub-classification method, number of positive lymph nodes, ratio of nodal metastasis, and pT information were the most important risk factors of 5-year survival. CONCLUSIONS: By combining the three N2 stratification methods based on "stations", "zones", and "chains" into one composite method, prognosis prediction was more accurate for N2 NSCLC disease. Single nodal chain involvement, which may be either one or two nodal stations metastasis, is associated with best outcome for pN2 patients.

Define relative incomplete resection by highest mediastinal lymph node metastasis for non-small cell lung cancers: rationale based on prognosis analysis.

PURPOSE: Present research aimed to explore the rationale of defining RIR operations by metastatic status of highest nodes. PATIENTS AND METHODS: 549 surgical patients, bearing pN2-NSCLCs, were enrolled in the current study. R1/R2 nodes on the right side and L4 nodes on the left were taken as the highest mediastinal lymph nodes. The operations were defined "Complete Resection (CR)" if the highest nodes were negative. Operations were otherwise "Relative Incomplete Resections (RIR)" if the nodes were positive. Exclusion criteria included: metastatic carcinomas or small cell lung cancer, prior history of induction therapy, exploratory thoracotomy, palliative resection, and massive pleural dissemination, as well as cases without "highest" mediastinal nodal pathology. The survival rate was calculated using the life-table and Kaplan-Meier method. Comparisons between groups were calculated using the Log-rank test. RESULTS: A total of 6865 lymph nodes (5705 mediastinal and 1160 regional, average 12.6±6.4 nodes for each patient) were removed. Total cases included 246 RIR (100 left and 146 right side) and 303 CR (108 left and 195 right). The overall 5-year survival rate was 22% and the median survival time was 28.29 months. Five-year survival rates of the CR and RIR group were statistically significant (29% and 13%, respectively p<0.0001). L4 and R1/R2 lymph nodes had similar position for defining RIR; no obvious survival difference was indicated between either side (p=0.464 in CR groups, p=0.647 in RIR groups). N2 subcategories and skip-metastasis were closely associated with highest nodal involvement (p<0.0001). Multivariate analysis showed CR/RIR assignment, tumor size, N2 disease stratification, pathological T status, and number of positive mediastinal nodes were risk factors for 5-year survival in the present case series. CONCLUSION: Involvement of the highest mediastinal lymph nodes is highly predictive of poor prognosis and indicates an advanced stage of the disease. Therefore, it may be appropriate to assign R1/R2 or L4 as criterion for defining RIR or CR cases in surgical NSCLC cases.

Complete lobar torsion simulating hemorrhagic shock after left upper lobectomy.

Lung torsion is a rare but serious complication after thoracic operations. We describe an unusual case of left lobar torsion after video-assisted thoracoscopic upper lobectomy. The profound symptom was impending hemorrhagic shock, which masqueraded as postoperative bleeding. The differentials between these 2 entities and treatment options for lung torsion are discussed.