Journal of thoracic disease最新文献

Background: Endobronchial ultrasound (EBUS)-guided mediastinal/hilar cryobiopsy (MedCryoBx) is a relatively new modality, being combined with EBUS-transbronchial needle aspiration (TBNA) to improve yield in the diagnosis of intrathoracic adenopathy. This meta-analysis aims to investigate the diagnostic yield of MedCryoBx versus EBUS-TBNA for intrathoracic adenopathy.

Methods: We conducted a systematic search using Google Scholar, Embase, and PubMed/MEDLINE for studies about a diagnosis of intrathoracic adenopathy using MedCryoBx and EBUS-TBNA. Two authors separately reviewed studies for inherent bias using the Quality Assessment Data Abstraction and Synthesis-2 (QUADAS-2) tool. Inverse Variance weighting for random effects methodology was used for meta-analysis. Pooled diagnostic yields overall and for subgroups were estimated. Complications of MedCryoBx were reviewed.

Results: Ten studies with 844 patients undergoing either biopsy procedure were in the final analysis. A total of 554 patients underwent MedCryoBx and 704 patients EBUS-TBNA. Meta-analysis showed a pooled diagnostic yield of 91% (504 of 554) for MedCryoBx and 81% (567 of 704) for EBUS-TBNA, with odds ratio (OR) of 2.5 [95% confidence interval (CI): 1.6 to 3.91; P<0.001], with I² of 20%. Subgroup analysis for benign conditions showed increased diagnostic yield with OR of 7.95 (91% MedCryoBx versus 58% EBUS-TBNA, P<0.001) with an I² of 25%. Subgroup analysis for lymphoma showed a statistically significant increase in pooled diagnostic yield with OR of 11.48 (87% MedCryoBx versus 29% EBUS-TBNA, P=0.001). Mild bleeding (36.5%) without any intervention was the most common complication. Bleeding requiring intervention (0.7%) was noted in patients. Pneumothorax (0.4%) and pneumomediastinum (0.4%) were less common in this analysis.

Conclusions: MedCryoBx is a very promising tool for the diagnosis of intrathoracic adenopathy. It has improved diagnostic yield over EBUS-TBNA in benign and possibly lymphoproliferative diseases, but less so in lung cancer. The complication rates with MedCryoBx are comparable to EBUS-TBNA.

Background: Interstitial lung diseases (ILDs) are a group of pulmonary disorders affecting the lung's structure. Acute exacerbation of ILD (AE-ILD) following medical procedures is a significant clinical concern. Lung cryoprobe transbronchial biopsy (cryobiopsy) is a relatively new diagnostic technique for ILD, but data on AE-ILD post-cryobiopsy is limited. This study aims to fill this gap by examining the prevalence, risk factors, and outcomes of AE-ILD following cryobiopsy.

Methods: This multicenter retrospective study analyzed data from patients who underwent cryobiopsy for ILD diagnosis at three U.S. institutions between January 2014 and August 2022. The study included patients over 18 years with confirmed or suspected ILD, categorized into those who experienced AE-ILD post-cryobiopsy and those who did not.

Results: Out of 111 patients, 3.6% experienced AE-ILD, with a 50% mortality rate in these cases. The study cohort was predominantly white, with a median age of 69.0 years. Common comorbidities included tobacco use and hypertension. Patients who developed AE-ILD had an increased median number of biopsies. The overall 30-day mortality was 1.8%. Overall complication rate was 32%, including pneumonia, pneumothorax, AE-ILD, and bleeding requiring intervention. The study findings suggest that bronchoscopic cryobiopsy may be associated with lower overall mortality, particularly in patients with compromised lung function.

Conclusions: This study provides significant insights into AE-ILD following cryobiopsy, underscoring the need for careful patient selection and procedural assessment. While cryobiopsy may offer a safer alternative to surgical lung biopsy in specific patient cohorts, the elevated risk of AE-ILD necessitates further research to optimize patient outcomes and procedural safety.

Background: The role of corticosteroids in acute respiratory distress syndrome (ARDS) remains contentious. This study aims to investigate the prognostic significance of immune deficiency in patients with ARDS and its response to varying doses of corticosteroids.

Methods: This single-center, retrospective cohort study enrolled 657 ARDS patients from January 24, 2008, to September 12, 2022, at Zhongshan Hospital of Fudan University, Shanghai, China. The patients were categorized into a discovery dataset (n=357) and a validation dataset (n=300), based on admission date. Further validation of the results in the validation dataset was used to enhance the credibility of the study conclusions. The study examined the association between immune deficiency and the patients' clinical characteristics, treatment measures, and prognosis. The primary outcome was 28-day mortality post disease onset. Data analysis was conducted from June 15, 2023 to August 15, 2023.

Results: The initial risk factor analysis in the discovery dataset was primarily based on the clinical characteristics, and the results suggested that immune deficiency likely impacted overall survival among patients receiving different doses of corticosteroid treatment. Multivariate analysis identified immune deficiency as an independent prognostic factor for overall survival in both the discovery and validation datasets. The final analysis revealed that patients with mild to moderate ARDS [discovery dataset: hazard ratio (HR) =1.719; 95% confidence interval (CI): 1.229-2.406; log-rank test P=0.001; validation dataset: HR =1.874; 95% CI: 1.238-2.837; log-rank test P=0.002] or severe ARDS (discovery dataset: HR =1.874; 95% CI: 1.007-3.488; log-rank test P=0.04; validation dataset: HR =1.698; 95% CI: 1.042-2.768; log-rank test P=0.03) with immune deficiency exhibited lower overall survival rates. Patients with mild to moderate ARDS and immune deficiency showed greater benefits from low-dose corticosteroid treatment (HR =0.409; 95% CI: 0.249-0.671; P<0.001 for interaction), whereas those with severe ARDS and immune deficiency benefitted from both low and high-dose treatments (low corticosteroid: HR =0.299; 95% CI: 0.136-0.654; high corticosteroid: HR =0.458; 95% CI: 0.214-0.981; P=0.005 for interaction).

Conclusions: Immune deficiency is an independent risk factor in ARDS. Incorporating it into the disease severity grading system based on the Berlin criteria may enhance personalized treatment approaches for ARDS patients. These findings warrant further validation through prospective, large-scale, multicenter randomized controlled trials (RCTs).

Background: Previously, stage-IIIB non-small cell lung cancer (NSCLC) has been considered inoperable. In recent years, neoadjuvant immunotherapy has shown encouraging efficacy in the treatment of advanced stage NSCLC in several trials. However, the effectiveness and safety of neoadjuvant immunotherapy in treating stage-IIIB NSCLC are still unknown. Therefore, we conducted this retrospective study to examine the outcomes of surgery after neoadjuvant immunotherapy combined with chemotherapy for stage-IIIB NSCLC.

Methods: Thirty patients with stage-IIIB NSCLC who were treated at the Department of Thoracic Surgery of Renji Hospital from January 2019 to September 2021 were analyzed retrospectively. Neoadjuvant immunotherapy combined with chemotherapy was administered prior to surgery. The curative effect was evaluated by imaging and pathological examinations.

Results: The objective response rate (ORR) and disease control rate (DCR) of the patients after neoadjuvant therapy evaluated by imaging studies were 70% and 86.7%, respectively. Of the 30 patients, 19 (63%) underwent surgical resection, in which all achieved a complete R0 resection. The median operative time was 168 minutes (range, 75-295 minutes), and the average intraoperative blood loss was 215.3±258.4 mL. The median postoperative hospital stay was 8 days (range, 4-59 days). The major pathological response (MPR) rate was 73.7% (14/19), and the pathological complete response rate was 47.4% (9/19); 2/30 patients (6.7%) had postoperative complications, including two who developed bronchopleural fistulas and one mortality, from a postoperative pulmonary infection. The treatment-related adverse reactions were mainly grades 1-2. Only two patients had grade 3 anemia, and no grade 4 adverse reactions were observed.

Conclusions: Neoadjuvant immunotherapy and chemotherapy combined with surgery in patients with stage-IIIB NSCLC is safe and feasible. The patient outcomes and optimal number of neoadjuvant treatment cycles need to be explored and studied further.

Background: Neoadjuvant therapy has become a mainstay of treatment for locally advanced resectable esophageal cancer. The objective of this research was to investigate the effectiveness and safety of neoadjuvant immunotherapy combined with chemotherapy in treating surgically removable esophageal squamous cell carcinoma (ESCC).

Methods: From January 1, 2016 to April 1, 2023, we conducted a retrospective analysis of patients diagnosed with resectable esophageal cancer who underwent neoadjuvant immunotherapy combined with chemotherapy at The First Affiliated Hospital of Nanchang University. The primary endpoints of this study were pathologic complete response (pCR), major pathologic response (MPR) and disease-free survival (DFS). The secondary endpoints of this study were overall survival (OS), objective response rate (ORR) and safety.

Results: A total of 122 patients with ESCC receiving neoadjuvant immune-chemotherapy (nICT) were included. Fifty-four patients achieved partial response (PR) and two patients achieved complete response (CR), with an ORR of 45.9%. Of the 106 patients who underwent surgery, a total of 28 patients achieved pCR (26.4%) and a total of 37 patients achieved MPR (34.9%). Grade 3 or higher adverse events occurred in 26 patients (21.3%). The most common postoperative complication was pneumonitis (25.5%).

Conclusions: Neoadjuvant immunotherapy combined with chemotherapy demonstrates satisfactory efficacy in the treatment of locally advanced ESCC, with manageable treatment-related adverse events and postoperative complications.

Background and objective: Sepsis, characterized by an aberrant immune response to infection leading to acute organ dysfunction, impacts millions of individuals each year and carries a substantial risk of mortality, even with prompt care. Despite notable medical advancements, managing sepsis remains a formidable challenge for clinicians and researchers, with treatment options limited to antibiotics, fluid therapy, and organ-supportive measures. Given the heterogeneous nature of sepsis, the identification of distinct clinical phenotypes holds the promise of more precise therapy and enhanced patient care. In this review, we explore various phenotyping schemes applied to sepsis.

Methods: We searched PubMed with the terms "Clinical phenotypes AND sepsis" for any type of article published in English up to September 2023. Only reports in English were included, editorials or articles lacking full text were excluded. A review of clinical phenotypes of sepsis is provided.

Key content and findings: While discerning clinical phenotypes may seem daunting, the application of artificial intelligence and machine learning techniques provides a viable approach to quantifying similarities among individuals within a sepsis population. These methods enable the differentiation of individuals into distinct phenotypes based on not only factors such as infectious diseases, infection sites, pathogens, body temperature changes and hemodynamics, but also conventional clinical data and molecular omics.

Conclusions: The classification of sepsis holds immense significance in improving clinical cure rates, reducing mortality, and alleviating the economic burden associated with this condition.

Background: Model for end-stage liver disease (MELD) is an effective predictive marker for renal, hepatic, and cardiac dysfunctions. In this study, we explore the correlation between MELD scores and the outcomes of patients undergoing cardiac valve surgery.

Methods: We conducted a retrospective analysis of clinical data from patients who underwent cardiac valve surgery, encompassing procedures on the aortic valve, mitral valve, and tricuspid valve, using the Informative Surgical Patient dataset for Innovative Research Environment (INSPIRE) database, we conducted receiver operating characteristic (ROC) analyses on the study participants and chose MELD as the primary scoring tool for our study due to its optimal area under the curve (AUC), patients were stratified into high (MELD ≥18) and low (MELD <18) groups based on the determined cutoff value. The perioperative clinical data of the two groups were compared.

Results: The analysis revealed 751 patients in the low MELD group (75.5%) and 244 patients (24.5%) in the high MELD group. Patients in the high MELD group exhibited a lower body mass index (BMI) compared to those in the low MELD group. In comparison to the low MELD group, the high MELD group exhibited a higher rate of emergency surgery (10.66% vs. 5.99%, P=0.01), along with prolonged anesthesia time, surgery time, and cardiopulmonary bypass (CPB) time. Regarding clinical prognosis, the high MELD group demonstrated a higher 28-day mortality rate (10.66% vs. 0.8%, P<0.001), as also observed in the analysis of three valve subgroups. Additionally, the high MELD group experienced longer hospitalization and intensive care unit (ICU) stay, and a higher proportion of patients requiring mechanical circulatory support, including intra-aortic balloon pump (IABP) assist (14.75% vs. 3.86%, P<0.001), extracorporeal membrane oxygenation (ECMO) assist (7.38% vs. 0.8%, P<0.001), and continuous renal replacement therapy (CRRT) (27.87% vs. 1.46%, P<0.001) post-surgery. The Kaplan-Meier survival curves illustrated a significantly lower mortality rate in the low MELD group compared to the high MELD group, with highly significant statistical differences (P<0.001).

Conclusions: The MELD score demonstrates a robust predictive value for clinical outcomes following cardiac valve surgery, underscoring its utility as a viable metric for disease stratification research.

Background: Bleeding following lung surgery can lead to reoperation and blood transfusions, potentially impairing outcomes. This study aimed to assess how bleeding complications affect long-term survival and postoperative complications in a nationwide contemporary group of patients undergoing lung resections.

Methods: Adult patients who underwent lung resections, for both malignant and nonmalignant diagnoses, between 2013-2021, were included from the Swedish national registry for thoracic surgery. Patients with bleeding complications, defined as requiring reexploration and/or transfusions, were compared to patients without bleeding complications regarding long-term survival and postoperative complications. We used propensity scores and optimal full matching to account for differences in baseline characteristics between the groups.

Results: The cohort comprised 15,617 adult patients, of which 646 patients (4.1%) had bleeding complications. The unadjusted 90-day mortality was 9.4% vs. 1.0% in the bleeding group vs. no bleeding group, respectively. After matching, the odds ratio (OR) for 90-day mortality in the bleeding group compared with the no bleeding group was 3.66 [95% confidence interval (CI): 2.17-6.17]. Long term overall survival was lower among patients in the bleeding group, adjusted hazard ratio (95% CI) for all-cause mortality was 1.47 (1.29-1.69). Postoperative complications were more common in the bleeding group (OR: 3.00, 95% CI: 2.38-3.79), including infections (OR: 2.80, 95% CI: 1.86-4.20). Bleeding complications were more frequent during the first third of the study time period as compared to the last third (P<0.001).

Conclusions: Patients with bleeding complications had reduced long-term survival and higher incidence of postoperative complications. A declining trend in bleeding rates over time was noted.

Background: The incidence of pulmonary embolism (PE) has been on the rise annually. Despite receiving regular sequential anticoagulation therapy, some patients with non-high-risk acute PE (APE) continue to experience residual pulmonary vascular obstruction (RPVO). This study sought to identify the risk factors for RPVO following 3 months of sequential anticoagulation therapy for non-high-risk PE. Machine learning techniques were utilized to construct a clinical prediction model for predicting the occurrence of RPVO.

Methods: A total of 254 acute non-high-risk PE patients were included in this study, all of whom were admitted to the Third People's Hospital of Yunnan Province between 2020 and 2023. After 3 months of regular anticoagulant treatment, computed tomography pulmonary angiography (CTPA) were reviewed to identify the presence of RPVO. Patients were then categorized into either the thrombolysis group or the thrombosis residue group. Throughout the study period, 49 patients were excluded due to missing data, irregular treatment, or loss to follow-up. Clinical symptoms, physical signs, and laboratory results of 205 PE patients were recorded. Correlation and collinearity analyses were conducted on relevant risk factors, and significance tests were performed. Heat maps illustrating the relationships between influencing factors were generated. Predictors were selected using least absolute shrinkage and selection operator (LASSO) regression, followed by multivariate logistic regression analysis to create a predictive model. Internal validation of the model was also carried out.

Results: By searching the literature to understand all the clinical indicators that may affect the efficacy of anticoagulation therapy. A total of 205 patients with non-high-risk acute pulmonary thromboembolism were evaluated for various risk factors. Five independent factors were identified by multivariable analysis-age, chronic obstructive pulmonary disease (COPD), acratia, pulmonary systolic blood pressure (PASP), and major arterial embolism-and their P value, odds ratio (OR) and confidence interval (CI) were as follows: (P=0.012, OR =1.123; 95% CI: 1.026-1.23), (P=0.002, OR =13.30; 95% CI: 2.673-66.188), (P=0.001, OR =14.009; 95% CI: 2.782-70.547), (P=0.003, OR =1.061; 95% CI: 1.020-1.103) and (P<0.001, OR =18.128; 95% CI: 3.853-85.293), which may indicate a poor prognosis after standard anticoagulant therapy. A nomogram was constructed using these variables and internally validated. The receiver operating characteristic (ROC) curves of the model demonstrated strong predictive accuracy, with an area under the curve (AUC) of 0.94 (95% CI: 0.89-0.96) for the training set and 0.93 (95% CI: 0.88-0.95) for the validation set. Calibration curves were utilized to assess the practicality of the nomogram.

Conclusions: A novel predictive model was developed based on a single-center retrospec