Journal of thoracic disease最新文献

Background: Chronic obstructive pulmonary disease (COPD) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD) pose global challenges, with oxygen saturation (SpO₂) levels crucial in evaluating mortality. This study explored the correlation between admission SpO₂ levels and all-cause hospital mortality in patients with AECOPD, assessing whether SpO₂ can serve as an independent risk factor for predicting in-hospital mortality in these patients.

Methods: This study involved 996 AECOPD patients sourced from the Medical Information Mart for Intensive Care (MIMIC) III database (version 1.3), with 134 fatalities. Patients were categorized into a death group (n=134) and a survival group (n=862). The average admission SpO₂ value was recorded for all 996 AECOPD patients. Subsequently, a generalized additive model (GAM) curve was employed to examine the association between admission SpO₂ levels and all-cause hospital mortality. Following this, Cox regression analysis and survival analysis were conducted to further investigate the link between admission SpO₂ and all-cause hospital mortality.

Results: The GAM curve demonstrated a non-linear, U-shaped relationship between admission SpO₂ and all-cause hospital mortality in AECOPD patients. The nadir of all-cause hospital mortality was associated with an SpO₂ of 89.5%. Notably, an SpO₂ of 89.5% served as the optimal cutoff for predicting all-cause hospital mortality. Cox regression analysis identified SpO₂ as a risk factor for all-cause hospital mortality in AECOPD patients. Patients with SpO₂ ≥89.5% exhibited independently lower death risk compared to those with SpO₂ <89.5% (hazard ratio: 0.52; 95% confidence interval: 0.37-0.74; P<0.001).

Conclusions: Admission SpO₂ level is an independent risk factor for predicting all-cause hospital mortality in AECOPD patients and can serve as a prognostic indicator. A U-shaped relationship was observed, with an admission SpO₂ level of 89.5% associated with the lowest mortality, suggesting an optimal range for improved prognosis.

Background: The open anastomosis technique is a classic procedure for treating extended ascending aortic aneurysms, but hypothermic circulatory arrest is unavoidable, which increases the risk of organ injury. The aortic arch-clamping (AAC) technique is an alternative treatment. This study aimed to evaluate the efficacy of the AAC technique in patients with ascending aortic aneurysms extending to the proximal arch.

Methods: From January 2015 to February 2022, 230 patients with ascending aneurysms extending to the proximal arch underwent surgical intervention. Based on the type of distal ascending aorta surgery, the patients were divided into the AAC group (n=117 cases) and the open distal anastomosis (ODA) group (n=113 cases). The prognosis of 67 matched pairs was compared after 1:1 propensity score matching (PSM).

Results: After PSM, the baseline data were similar between the AAC and ODA groups. In the AAC group, the cardiopulmonary bypass duration was significantly lower (median 120 vs. 156 min, P<0.001). The incidences of acute kidney injury (AKI), transient neurological dysfunction, and ventilation time >24 h increased significantly in the ODA group (32.8% vs. 7.5%, P=0.001; 9% vs. 0%, P=0.04; 19.4% vs. 6%, P=0.04, respectively). Multivariable logistic regression analysis showed that the AAC approach was an independent protective factor for composite adverse events [odds ratio (OR): 0.05, 95% confidence interval (CI): 0.01-0.39, P=0.005], ventilation time >24 h (OR: 0.33, 95% CI: 0.12-0.92, P=0.03), and AKI (OR: 0.21, 95% CI: 0.08-0.54, P=0.001). There was no significant difference in midterm mortality (3.0% vs. 4.5%, P=0.44) or reintervention rates (3.0% vs. 3.0%, P=0.91) between the two groups.

Conclusions: Considering its short- and mid-term efficacy, the AAC technique is an alternative technique for extended ascending aneurysms.

Background: Lung cancer is the leading cause of cancer-related death worldwide, of which anaplastic lymphoma kinase fusion positive (ALK ⁺) non-small cell lung cancer (NSCLC) accounts for 3-7. Here, we identified a new fusion gene PLCXD3-ALK (P1, A19) from a patient with advanced lung squamous cell carcinoma (LUSC) by next-generation sequencing (NGS). We aimed to evaluate its oncogenic potential by performing functional studies in vitro and tumorigenicity in vivo of this fusion protein.

Methods: We performed functional experiments in NIH-3T3 cells with stable expression of PLCXD3-ALK including soft agar colony formation assay, cell proliferation and viability assays, and transwell assay. The activation of downstream pathways and the response to ALK inhibitors crizotinib and alectinib were demonstrated by western blotting (WB). In addition, we further evaluated the tumorigenicity of the PLCXD3-ALK mutants in nude mice.

Results: Similar to EML4-ALK, the PLCXD3-ALK fusion promoted proliferation and the capacity for non-anchorage-dependent growth of NIH-3T3 cells. We demonstrated that PLCXD3-ALK can activate ALK self-phosphorylation and downstream pathways, which could be inhibited by the addition of ALK inhibitors. Moreover, we observed that this gene could provoke oncogenic transformation in nude mice. Meanwhile, the patient was monitored for disease progression with computed tomography (CT) scanning during treatment with alectinib, and a benefit was observed.

Conclusions: We identified and functionally validated PLCXD3-ALK as a novel rare fusion in NSCLC that has not been previously reported. It can serve as a meaningful therapeutic target for ALK inhibitors of ALK ⁺ NSCLC.

Background: Postoperative coagulation dysfunction is one of the common complications after coronary artery bypass grafting (CABG), especially in elderly patients. The aim of this study was to establish a risk prediction model for coagulation disorders in elderly patients after CABG, effectively identify high-risk patients who are prone to coagulation disorders, and strengthen postoperative treatment monitoring for these patients.

Methods: Patients who underwent CABG were retrospectively included between February 2019 and December 2020, and were randomly divided into a derivation set and a validation set at a ratio of 7:3. The disseminated intravascular coagulation (DIC) score of ≥2 was defined as coagulation disorder. The least absolute shrinkage and selection operator (LASSO) regression was used for variable selection and the establishment of a regression model. The confusion matrix and receiver operating characteristic (ROC) curve were used to evaluate the model prediction effect.

Results: The risk factors associated with postoperative coagulation dysfunction, selected by LASSO regression, including patient weight, preoperative baseline estimated glomerular filtration rate (eGFR), B-type natriuretic peptide (BNP), platelet count (PLT), preoperative use of heparin and angiotensin receptor-neprilysin inhibitor (ARNI), as well as intraoperative utilization of epinephrine, norepinephrine, dopamine, cephalosporins, cardiopulmonary bypass (CPB), intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), operation duration, and total intraoperative fluid input. The area under curve (AUC) of the derivation set was 0.818 [95% confidence interval (CI): 0.775-0.862], while the AUC of the validation set was 0.827 (95% CI: 0.755-0.898). The sensitivity and specificity of the model in the derivation set were 80.0% and 70.0%. In the validation set, the sensitivity was 76.6% and the specificity was 81.7%, indicating that the model has good predictive performance.

Conclusions: The LASSO regression model for predicting coagulation disorders after CABG showed a good predictive performance in both the derivation set and the validation set, which is helpful for early identification of high-risk patients with coagulation disorders after CABG.

Background: Sublobar surgeries involving the left anterior segment of the lung can be challenging due to its central location within the left upper lobe (LUL) and among multi-segments. However, there have been no reports specifically analysing the anatomical patterns of this segment. Therefore, this study aimed to comprehensively investigate the subsegmental bronchovascular patterns and relationship between variations and surgical strategies.

Methods: The branching patterns of the left anterior segment bronchi and pulmonary vessels were assessed retrospectively and categorised using three-dimensional reconstruction images of 647 consecutive patients.

Results: Anatomical distribution patterns of the left anterior segmental bronchus, artery, and vein analysed in 635 valid cases were 6, 38, and 6, respectively. For the first time, branches of the sub-subsegmental level were demonstrated and reclassified in the anterior segment. Additionally, all 102 cases (16.06%) of interlobar (IL) arterial variations were found in the lateral subsegmental artery. Interestingly, only the lateral subsegmental artery patterns were not independent of the types associated with the anterior segmental bronchus, artery, and vein in the left upper division. Based on the observed anatomical variant patterns of the artery and bronchus, we developed a decision-making theory to assist in selecting surgical approaches for nodules located within the lateral subsegment of the anterior segment of the lung.

Conclusions: The study elucidated the sub-subsegmental level of the left anterior segmental bronchovascular distribution patterns. This study also indicated a correlation between the lateral subsegmental arterial patterns and the patterns observed in the anterior bronchus and the left upper division vein (LUDV). By taking these findings on arterial and bronchial variations into account preoperatively, we might contribute to formulating a more concise operation procedure and optimizing the selection of surgical approaches.

The standard technique for McKeown's minimally invasive esophagectomy (MIE) involves a three-stage procedure that requires repositioning and secondary skin disinfection within the transition. Prolonged surgical times such as lobectomy and hysterectomy may be associated with an increased incidence of post-surgical complications. We introduced a one-step disinfection technique designed to facilitate esophageal cancer resection of oesophageal cancer by retrospectively analyzing 63 patients with oesophageal cancer who underwent MIE by the same surgeon. In this modified procedure, the patient is initially placed in a left semiprone position, while the region designated for disinfection includes the neck, the right arm, the right side of the chest, and an abdominal area extending to the anterior left axillary line. Upon completion of thoracoscopic process, the sheet beneath the body is dragged toward the direction of the ventral side, and subsequently, the body is rotated into the supine position, after which abdominal manipulation continues. Re-disinfection and reapplication of sterile towels for the surgical area are not necessary during the repositioning. Patient demographics and perioperative clinical data, including a median total surgical time of 261 minutes (range, 241-289 minutes), anastomotic leaks in 3 (4.8%) patients, pneumonia in 7 (11.1%) patients, and incisional infections in 1 (1.6%) patient, demonstrated that one-step disinfection technique is safe and simplifies the transition between thoracic manipulation and abdominal manipulation in minimally McKeown esophagectomy, reducing the surgical time.

Background: Reports describing the management of lung re-transplantation (Re-LTx) are lacking. Therefore, this study evaluated the characteristics of Re-LTx to guide perioperative management.

Methods: This study retrospectively analysed the clinical data of patients who underwent primary lung transplantation (primary-LTx) and Re-LTx in the First Affiliated Hospital of Guangzhou Medical University from 2016 to 2023. The key perioperative changes after Re-LTx (primary outcome) and the short-term postoperative rehabilitation characteristics (secondary outcome) were evaluated.

Results: The study included 26 patients who underwent primary LTx who were propensity score-matched (1:2) with 13 patients who underwent Re-LTx. The preoperative Acute Physiology and Chronic Health Evaluation (APACHE) score was higher in the Re-LTx group (P=0.001). The intraoperative conditions, incidence of postoperative extracorporeal membrane oxygenation (ECMO) support, intensive care unit (ICU) stay, duration of postoperative hospital stay, total hospital stay, and complications on postoperative day seven did not differ between the groups (P>0.05). However, the intraoperative haemoglobin and fibrinogen levels were lower (P=0.002 and P=0.03, respectively), and the blood urea nitrogen and serum creatinine levels were higher in the Re-LTx group (both P<0.001). The pH, arterial oxygen pressure, partial pressure of carbon dioxide, and haemodynamic values did not differ between the groups (P>0.05).

Conclusions: The perioperative management of Re-LTx may be similar to that of primary LTx based on comparable intraoperative conditions and postoperative rehabilitation characteristics. However, patients undergoing Re-LTx were prone to renal dysfunction and intraoperative anaemia.

Background: Non-small cell lung cancer (NSCLC) presents the most common type of lung cancer, accounting for 80-85% of cases. Combining immunotherapy with radiotherapy (RT) has emerged as a significant research area in recent years. However, the risk of radiation pneumonitis, especially in lung cancer patients, poses a significant concern. Iodine-125 (I¹²⁵) seed implantation offers a precise, less invasive alternative, minimizing damage to surrounding lung tissues and reducing side effects. This study aims to evaluate the safety and efficacy of I¹²⁵ seed implantation combined with immune checkpoint inhibitors (ICIs) and chemotherapy (CT) in treating driver gene-negative NSCLC patients.

Methods: Retrospective analysis of 95 patients with driver gene-negative NSCLC who presented to the First Affiliated Hospital of Army Medical University was conducted. Among them, 33 cases in the observation group were treated with I¹²⁵ seed implantation combined with CT and ICIs (ICIs + CT + I¹²⁵), and 62 cases in the control group were treated with extracorporeal RT combined with CT and ICIs (ICIs + CT + RT). The primary observational endpoint was median progression-free survival (mPFS), while the secondary observational endpoints included the 1- and 2-year PFS rate and the incidence of adverse events.

Results: mPFS was not reached in the observation group but 11.8 months [95% confidence interval (CI): 9.743-13.857] in the control group, a statistically significant difference (P<0.001). The restricted mean survival time (RMST) was 22.2 (95% CI: 18.257-26.101) and 13.8 (95% CI: 11.912-15.718) months in both groups at 31.7 months, PFS was better in the observation group than in the control group. In the observation group, two cases (6.1%) developed grade 3 pneumothorax or hemorrhage, and in the control group, 16 cases (25.8%) developed grade 3 radiation pneumonitis, which was higher in the control group than in the observation group (P=0.02).

Conclusions: Compared to RT in combination with CT and immunotherapy, patients with driver gene-negative NSCLC who received I¹²⁵ seed implantation had greater advantages with longer survival and fewer adverse effects.

Background: Unplanned early rehospitalization (UER) is common among lung transplant recipients, but its incidence varies among lung transplant centers. This study aimed to analyze the incidence, causes and predictors of UER in a lung transplant center in China and to explore the impact of preoperative nutritional risk status, postoperative duration of mechanical ventilation (MV) and extracorporeal membrane oxygenation support in the intensive care unit on unplanned readmission in lung transplant patients.

Methods: This study was conducted in one of the largest lung transplant centers in China. We collected demographic and clinical data from lung transplant recipients who underwent transplantation and were discharged in 2022. Predictors of UER within 30 days after discharge were analyzed through a retrospective cohort study.

Results: A total of 99 patients were included in this study. The incidence of UER was 29.3%. The three most common reasons were chest distress with shortness of breath (38%), cough with expectoration (21%), and fever (21%). Multivariate analysis revealed that the postoperative MV duration [odds ratio (OR) =1.027; 95% confidence interval (CI): 1.008-1.046; P=0.004] and preoperative Nutrition Risk Screening 2002 (NRS-2002) score (OR =1.615; 95% CI: 1.189-2.194; P=0.002) were significant risk factors for UER.

Conclusions: Patients with higher preoperative NRS-2002 scores and longer postoperative MV duration had a greater risk of UER within 30 days after initial discharge. More research is needed to determine whether improving preoperative nutritional risk status and shortening the duration of MV can reduce UER in patients.