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Background@#In Korea, during the early phase of the coronavirus disease 2019 (COVID-19) pandemic, we responded to the uncertainty of treatments under various conditions, consistently playing catch up with the speed of evidence updates. Therefore, there was high demand for national-level evidence-based clinical practice guidelines for clinicians in a timely manner. We developed evidence-based and updated living recommendations for clinicians through a transparent development process and multidisciplinary expert collaboration. @*Methods@#The National Evidence-based Healthcare Collaborating Agency (NECA) and the Korean Academy of Medical Sciences (KAMS) collaborated to develop trustworthy Korean living guidelines. The NECA-supported methodological sections and 8 professional medical societies of the KAMS worked with clinical experts, and 31 clinicians were involved annually. We developed a total of 35 clinical questions, including medications, respiratory/critical care, pediatric care, emergency care, diagnostic tests, and radiological examinations. @*Results@#An evidence-based search for treatments began in March 2021 and monthly updates were performed. It was expanded to other areas, and the search interval was organized by a steering committee owing to priority changes. Evidence synthesis and recommendation review was performed by researchers, and living recommendations were updated within 3–4 months. @*Conclusion@#We provided timely recommendations on living schemes and disseminated them to the public, policymakers and various stakeholders using webpages and social media.Although the output was successful, there were some limitations. The rigor of development issues, urgent timelines for public dissemination, education for new developers, and spread of several new COVID-19 variants have worked as barriers. Therefore, we must prepare systematic processes and funding for future pandemics.
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Background/Aims@#Although the incidence and mortality of tuberculosis are decreasing in South Korea, the number of applications for financial assistance with the cost of tuberculosis treatment made by individuals from vulnerable groups was 3.8 times higher in 2019 compared to 2017 (Tuberculosis Relief Belt Project, 2019). @*Methods@#We analyzed the data of patients who received financial aid for tuberculosis treatment (in the period 2014-2018) from the Tuberculosis Relief Belt Project, which was designed to assist vulnerable groups. This study analyzed 137 subjects, and the independent variables included patient factors (age, gender, nationality, tuberculosis type, number of comorbidities, and place of residence) and treatment type (outpatient or inpatient). The dependent variable was the treatment outcome. @*Results@#The likelihood of treatment success was significantly lower for patients with one (odds ratio [OR] 0.202), two (OR 0.147), or three or more (OR 0.070) comorbidities compared to those with no comorbidities. This was also the case for patients living alone (OR 0.097), and for those classified as homeless (OR 0.053). Korean patients (OR 8.512) had a significantly higher probability of a successful treatment outcome than foreigners. @*Conclusions@#Appropriate community-based management of individuals with tuberculosis from vulnerable groups, including foreigners, people with comorbidities, people living alone, and people with an unstable residential situation or homeless status, is important.
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Background/Aims@#Although it is near concluded that renin-angiotensin system inhibitors do not have a harmful effect on coronavirus disease 2019 (COVID-19), there is no report about whether angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) offer any protective role. This study aimed to compare the association of ARBs and ACEIs with COVID-19-related mortality. @*Methods@#All patients with COVID-19 in Korea between January 19 and April 16, 2020 were enrolled. The association of ARBs and ACEIs with mortality within 60 days were evaluated. A comparison of hazard ratio (HR) was performed between COVID-19 patients and a retrospective cohort of pneumonia patients hospitalized in 2019 in Korea. @*Results@#Among 10,448 COVID-19 patients, ARBs and ACEIs were prescribed in 1,231 (11.7%) and 57 (0.6%) patients, respectively. After adjusting for age, sex, and history of comorbidities, the ARB group showed neutral association (HR, 1.034; 95% CI, 0.765 to 1.399; p = 0.8270) and the ACEI groups showed no significant associations likely owing to the small population size (HR, 0.736; 95% CI, 0.314 to 1.726; p = 0.4810). When comparing HR between COVID-19 patients and a retrospective cohort of patients hospitalized with pneumonia in 2019, the trend of ACEIs showed similar benefits, whereas the protective effect of ARBs observed in the retrospective cohort was absent in COVID-19 patients. Meta-analyses showed significant positive correlation with survival of ACEIs, whereas a neutral association between ARBs and mortality. @*Conclusions@#Although ARBs or ACEIs were not associated with fatal outcomes, potential beneficial effects of ARBs observed in pneumonia were attenuated in COVID-19.
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Background/Aims@#Although it is near concluded that renin-angiotensin system inhibitors do not have a harmful effect on coronavirus disease 2019 (COVID-19), there is no report about whether angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) offer any protective role. This study aimed to compare the association of ARBs and ACEIs with COVID-19-related mortality. @*Methods@#All patients with COVID-19 in Korea between January 19 and April 16, 2020 were enrolled. The association of ARBs and ACEIs with mortality within 60 days were evaluated. A comparison of hazard ratio (HR) was performed between COVID-19 patients and a retrospective cohort of pneumonia patients hospitalized in 2019 in Korea. @*Results@#Among 10,448 COVID-19 patients, ARBs and ACEIs were prescribed in 1,231 (11.7%) and 57 (0.6%) patients, respectively. After adjusting for age, sex, and history of comorbidities, the ARB group showed neutral association (HR, 1.034; 95% CI, 0.765 to 1.399; p = 0.8270) and the ACEI groups showed no significant associations likely owing to the small population size (HR, 0.736; 95% CI, 0.314 to 1.726; p = 0.4810). When comparing HR between COVID-19 patients and a retrospective cohort of patients hospitalized with pneumonia in 2019, the trend of ACEIs showed similar benefits, whereas the protective effect of ARBs observed in the retrospective cohort was absent in COVID-19 patients. Meta-analyses showed significant positive correlation with survival of ACEIs, whereas a neutral association between ARBs and mortality. @*Conclusions@#Although ARBs or ACEIs were not associated with fatal outcomes, potential beneficial effects of ARBs observed in pneumonia were attenuated in COVID-19.
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Background@#To compare the chest computed tomography (CT) images of children and adults in families with clusters of humidifier disinfectant-related lung injury (HDLI) after cessation of exposure to humidifier disinfectant (HD). @*Methods@#We reviewed medical records of 19 families with 43 patients (21 adults, 22 children) among families, which had at least one adult and one child with HDLI. Each family was exposed to the same HD exposure environment. @*Results@#In adults, centrilobular nodules were predominant (95.2%) in chronic HDLI findings after cessation of exposure to HD, however, in children, normal pattern was most prevalent on chest CT (45.5%), followed by centrilobular nodule (36.4%), bizarre lung cysts (36.4%), and reticulation (13.6%). @*Conclusion@#Unlike the known chronic HDLI finding of adults, centrilobular nodules were only present in 36.4% of children. The frequency of bizarre lung cysts were significantly greater in children than that in adults after cessation of similar exposure to HD. Thus, bizarre lung cysts may be useful as another novel finding of chronic HDLI in children who have no history of pulmonary infection or other perinatal disorder such as hyaline membrane disease or other interstitial lung disease.
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BACKGROUND: The “Tuberculosis Relief Belt Supporting Project (Tuberculosis Patient Management Project for Poverty Groups)” is a national program for socioeconomically vulnerable tuberculosis (TB) patients. We sought to evaluate the clinical and socioeconomic characteristics of poverty-stricken TB patients, and determined the need for relief. METHODS: We examined in-patients with TB, who were supported by this project at the National Medical Center from 2014 to 2015. We retrospectively investigated the patients' socioeconomic status, clinical characteristics, and project expenditures. RESULTS: Fifty-eight patients were enrolled. Among 55 patients with known income status, 24 (43.6%) had no income. Most patients (80%) lived alone. A total of 48 patients (82.8%) had more than one underlying disease. More than half of the enrolled patients (30 patients, 51.7%) had smear-positive TB. Cavitary disease was found in 38 patients (65.5%). Among the 38 patients with known resistance status, 19 (50%) had drug-resistant TB. In terms of disease severity, 96.6% of the cases had moderate-to-severe disease. A total of 14 patients (26.4%) died during treatment. Nursing expenses were supported for 12 patients (20.7%), with patient transportation costs reimbursed for 35 patients (60%). In terms of treatment expenses for 31 people (53.4%), 93.5% of them were supported by uninsured benefits. CONCLUSION: Underlying disease, infectivity, drug resistance, severity, and death occurred frequently in socioeconomically vulnerable patients with TB. Many uninsured treatment costs were not supported by the current government TB programs, and the “Tuberculosis Relief Belt Supporting Project” compensated for these limitations.
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Humans , Drug Resistance , Health Care Costs , Health Expenditures , Medically Uninsured , Nursing , Poverty , Retrospective Studies , Social Class , Transportation , TuberculosisABSTRACT
This nationwide, prospective cohort study evaluated pulmonary function and radiological sequelae according to infection severity in 73 survivors from the 2015 Middle East respiratory syndrome (MERS) outbreak in Korea. Patients with severe pneumonia in MERS-coronavirus infection had more impaired pulmonary function than those with no or mild pneumonia at the 1-year follow-up, which was compatible with the radiological sequelae. Severe pneumonia significantly impairs pulmonary function and makes long radiological sequelae in MERS.
Subject(s)
Humans , Cohort Studies , Coronavirus , Coronavirus Infections , Follow-Up Studies , Korea , Middle East , Pneumonia , Prospective Studies , SurvivorsABSTRACT
BACKGROUND: From May to July 2015, the Republic of Korea experienced the largest outbreak of Middle East respiratory syndrome (MERS) outside the Arabian Peninsula. A total of 186 patients, including 36 deaths, had been diagnosed with MERS-coronavirus (MERS-CoV) infection as of September 30th, 2015. MATERIALS AND METHODS: We obtained information of patients who were confirmed to have MERS-CoV infection. MERS-CoV infection was diagnosed using real-time reverse-transcriptase polymerase chain reaction assay. RESULTS: The median age of the patients was 55 years (range, 16 to 86). A total of 55.4% of the patients had one or more coexisting medical conditions. The most common symptom was fever (95.2%). At admission, leukopenia (42.6%), thrombocytopenia (46.6%), and elevation of aspartate aminotransferase (42.7%) were observed. Pneumonia was detected in 68.3% of patients at admission and developed in 80.8% during the disease course. Antiviral agents were used for 74.7% of patients. Mechanical ventilation, extracorporeal membrane oxygenation, and convalescent serum were employed for 24.5%, 7.1%, and 3.8% of patients, respectively. Older age, presence of coexisting medical conditions including diabetes or chronic lung disease, presence of dyspnea, hypotension, and leukocytosis at admission, and the use of mechanical ventilation were revealed to be independent predictors of death. CONCLUSION: The clinical features of MERS-CoV infection in the Republic of Korea were similar to those of previous outbreaks in the Middle East. However, the overall mortality rate (20.4%) was lower than that in previous reports. Enhanced surveillance and active management of patients during the outbreak may have resulted in improved outcomes.
Subject(s)
Humans , Antiviral Agents , Aspartate Aminotransferases , Coronavirus Infections , Disease Outbreaks , Dyspnea , Extracorporeal Membrane Oxygenation , Fever , Hypotension , Leukocytosis , Leukopenia , Lung Diseases , Middle East Respiratory Syndrome Coronavirus , Middle East , Mortality , Pneumonia , Polymerase Chain Reaction , Republic of Korea , Respiration, Artificial , ThrombocytopeniaABSTRACT
A 68-year old man diagnosed with Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) presented with multiple pneumonic infiltrations on his chest X-ray, and the patient was placed on a mechanical ventilator because of progressive respiratory failure. Urinary protein excretion steadily increased for a microalbumin to creatinine ratio of 538.4 mg/g Cr and a protein to creatinine ratio of 3,025.8 mg/g Cr. The isotope dilution mass spectrometry traceable serum creatinine level increased to 3.0 mg/dL. We performed a kidney biopsy 8 weeks after the onset of symptoms. Acute tubular necrosis was the main finding, and proteinaceous cast formation and acute tubulointerstitial nephritis were found. There were no electron dense deposits observed with electron microscopy. We could not verify the virus itself by in situ hybridization and confocal microscopy (MERS-CoV co-stained with dipeptidyl peptidase 4). The viremic status, urinary virus excretion, and timely kidney biopsy results should be investigated with thorough precautions to reveal the direct effects of MERS-CoV with respect to renal complications.
Subject(s)
Aged , Humans , Male , Biopsy , Coronavirus Infections/diagnosis , Creatinine/blood , Dipeptidyl Peptidase 4/metabolism , In Situ Hybridization, Fluorescence , Kidney/metabolism , Microscopy, Confocal , Microscopy, Electron , Middle East Respiratory Syndrome Coronavirus/genetics , RNA, Viral/genetics , Reverse Transcriptase Polymerase Chain Reaction , Serum Albumin/analysisABSTRACT
Some cases of Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) infection presented renal function impairment after the first MERS-CoV patient died of progressive respiratory and renal failure. Thus, MERS-CoV may include kidney tropism. However, reports about the natural courses of MERS-CoV infection in terms of renal complications are scarce. We examined 30 MERS-CoV patients admitted to National Medical Center, Korea. We conducted a retrospective analysis of the serum creatinine (SCr), estimated glomerular filtration rate (eGFR), urine dipstick tests, urinary protein quantitation (ACR or PCR), and other clinical parameters in all patients. Two consecutive results of more than trace (or 1+) of albumin and blood on dipstick test occurred in 18 (60%) (12 [40%]) and 22 (73.3%) (19 [63.3%]) patients, respectively. Fifteen (50.0%) patients showed a random urine ACR or PCR more than 100 mg/g Cr. Eight (26.7%) patients showed acute kidney injury (AKI), and the mean and median durations to the occurrence of AKI from symptom onset were 18 and 16 days, respectively. Old age was associated with a higher occurrence of AKI in the univariate analysis (HR [95% CI]: 1.069 [1.013-1.128], P = 0.016) and remained a significant predictor of the occurrence of AKI after adjustment for comorbidities and the application of a mechanical ventilator. Diabetes, AKI, and the application of a continuous renal replacement therapy (CRRT) were risk factors for mortality in the univariate analysis (HR [95% CI]: diabetes; 10.133 [1.692-60.697], AKI; 12.744 [1.418-114.565], CRRT; 10.254 [1.626-64.666], respectively). Here, we report renal complications and their prognosis in 30 Korean patients with MERS-CoV.
Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Acute Kidney Injury/etiology , Coronavirus Infections/complications , Creatinine/blood , Glomerular Filtration Rate , Hematuria/etiology , Hospitals , Prognosis , Proteinuria/etiology , Republic of Korea/epidemiology , Retrospective Studies , Risk FactorsABSTRACT
Recently, the incidence of pulmonary cryptococcosis is gradually increasing in rheumatoid arthritis (RA) patients. Pulmonary rheumatoid nodules (PRN) are rare manifestations of RA. Eighteen months ago, a 65-year old woman was admitted to hospital due to multiple nodules (2.5x2.1x2 cm) with cavitations in the right lower lobe. She was diagnosed with RA three year ago. She had been taking methotrexate, leflunomide, and triamcinolone. A video-assisted thoracoscopic surgery biopsy was performed and PRN was diagnosed. However, a newly growing huge opacity with cavitation was detected in the same site. Pulmonary cryptococcal infection was diagnosed through a transthoracic computed tomograpy guided needle biopsy. Cryptococcus antigen was detected in serum but not in cerebrospinal fluid. The patient was treated with oral fluconazole which resulted clinical improvement and regression of the nodule on a series of radiography. Herein, we report the case of pulmonary cryptococcosis occurring in the same location as that of the PRN.
Subject(s)
Female , Humans , Arthritis, Rheumatoid , Biopsy , Biopsy, Needle , Cerebrospinal Fluid , Cryptococcosis , Cryptococcus , Fluconazole , Incidence , Methotrexate , Radiography , Rheumatoid Nodule , Thoracic Surgery, Video-Assisted , TriamcinoloneABSTRACT
Bronchial invasion of tuberculous lymphadenitis in children has been reported in areas of high tuberculosis (TB) prevalence as a complication due to primary pulmonary tuberculosis. However, it is rare in immunocompetent adults. When it appears, it often presents as a consequence of the reactivation of TB in the lung parenchyma. Primary TB occurs more frequently in patients with human immunodeficiency virus (HIV), with a history of organ transplants, or undergoing immunosuppressive treatments such as steroids. Furthermore, bronchial invasion of the bronchus by tuberculous lymphadenitis is considered to be very rare even among immunocompromised adults with primary TB, and has never before been reported in Korea. The authors report a case of bronchial invasion of the bronchus by tuberculous lymphadenitis, confirmed by bronchoscopy, in an Acquired Immunodeficiency Syndrome (AIDS) patient.
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Adult , Child , Humans , Acquired Immunodeficiency Syndrome , Bronchi , Bronchoscopy , Fistula , HIV , Korea , Lung , Lymph Nodes , Prevalence , Steroids , Transplants , Tuberculosis , Tuberculosis, Lymph Node , Tuberculosis, PulmonaryABSTRACT
Much controversy surrounds the issue of whether HIV infection is a risk factor for developing multidrug-resistant tuberculosis (MDR-TB). In this study, we evaluated the prevalence of and risk factors for MDR-TB in HIV-infected patients at the National Medical Center of Korea. We reviewed the medical records of HIV/TB co-infected patients from January 2005 to May 2011; the drug susceptibility profiles were available for 55 patients. Of these, 32.7% had MDR-TB, which was approximately 3.6 times higher than the prevalence among the general population. Additionally, there were more additional AIDS-defining clinical illnesses in the MDR-TB group than in the non-MDR-TB group (27.8% vs 5.4%, P = 0.032). These results suggest that HIV infection and HIV-related immunosuppresion may contribute to the development of MDR-TB.
Subject(s)
Adult , Aged , Female , Humans , Male , Middle Aged , Coinfection , HIV Infections/complications , Immunosuppression Therapy , Mycobacterium tuberculosis/isolation & purification , Prevalence , Republic of Korea/epidemiology , Retrospective Studies , Risk Factors , Tuberculosis, Multidrug-Resistant/complicationsABSTRACT
Diffuse alveolar damage (DAD) is a histological change in lung tissue, and is generally caused by an acute lung injury, which is characterized by bilateral and widespread damages. Localized DAD occurs very rarely. The causes for DAD are numerous, but the chief cause is acute interstitial pneumonia or acute exacerbation of idiopathic interstitial pneumonia, in cases of idiopathic manifestation. The 82-year-old patient, in this case study, showed a DAD lesion in only 1 lobe. The patient was otherwise healthy, with no previous symptoms of DAD. He was admitted to our medical center owing to localized infiltration, observed on his chest radiograph. Laboratory studies showed no signs of infections. DAD was confirmed by a surgical lung biopsy. The patient received corticosteroid treatment and had gradually improved. We report the case of a patient with localized, idiopathic DAD that cannot be classified as acute interstitial pneumonia or acute exacerbation of idiopathic interstitial pneumonia.
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Aged, 80 and over , Humans , Acute Lung Injury , Biopsy , Idiopathic Interstitial Pneumonias , Idiopathic Pulmonary Fibrosis , Lung , Lung Diseases, Interstitial , Lung Injury , ThoraxABSTRACT
BACKGROUND/AIMS: Chronic obstructive pulmonary disease (COPD) often coexists with co-morbid conditions that significantly affect the prognosis. Although depression frequently coexists with COPD, little about how to screen for depression in COPD patients is known. We report the effectiveness of depression screening in patients with COPD and of the instruments used for this purpose. METHODS: We performed a systematic literature review of the domestic (Research Information Sharing Service, KoreaMed, and Kmbase) and international (Medline, Embase, Cochrane library) databases using "COPD AND depression AND screening tools" as key words. RESULTS: No study directly evaluated the effectiveness of screening for depression in COPD patients. However, depression was present more frequently in patients with COPD. COPD patients with depression were also more likely to be in poor health. A total of eight screening instruments for depression were translated into Korean. All had similar reliabilities and internal consistencies. CONCLUSIONS: Screening of COPD patients for depression is necessary because individuals with this condition are more likely to suffer from depression, which has a negative impact on health. The choice of depression screening instruments may need to be based on considerations of simplicity.
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Humans , Depression , Information Dissemination , Mass Screening , Prognosis , Pulmonary Disease, Chronic ObstructiveABSTRACT
Streptomycin is currently utilized to treat advanced tuberculosis in Korea. However, the usefulness of intravascular streptomycin is not fully understood. In this study, streptomycin was administered intravenously in 30 patients. Intravenous administration of streptomycin may be a useful route of administration without undesirable toxicities.
Subject(s)
Humans , Administration, Intravenous , Korea , Mycobacterium tuberculosis , Streptomycin , TuberculosisABSTRACT
Approximately 5% of patients infected with Herpes zoster experience motor complications, such as muscle atrophy or paresis, caused by motor neuron involvement. The majority of paretic cases are associated with involvement of cranial nerves or of spinal nerves that innervate the muscles of extremities. We report the case of an 82-year-old female patient with cutaneous Herpes zoster involving the T10-11 sensory dermatomes, complicated by ipsilateral abdominal protrusion. Electromyography on the left external oblique muscle revealed marked denervation potentials, implying motor neuron involvement. One month after the onset of abdominal protrusion, the patient's motor symptoms markedly improved. Clinicians should consider the possibility of motor neuron involvement with Herpes zoster, even in cases of zoster involving thoracic branches of spinal nerves.
Subject(s)
Aged, 80 and over , Female , Humans , Cranial Nerves , Denervation , Electromyography , Extremities , Herpes Zoster , Motor Neurons , Muscles , Muscular Atrophy , Paresis , Spinal NervesABSTRACT
Approximately 5% of patients infected with Herpes zoster experience motor complications, such as muscle atrophy or paresis, caused by motor neuron involvement. The majority of paretic cases are associated with involvement of cranial nerves or of spinal nerves that innervate the muscles of extremities. We report the case of an 82-year-old female patient with cutaneous Herpes zoster involving the T10-11 sensory dermatomes, complicated by ipsilateral abdominal protrusion. Electromyography on the left external oblique muscle revealed marked denervation potentials, implying motor neuron involvement. One month after the onset of abdominal protrusion, the patient's motor symptoms markedly improved. Clinicians should consider the possibility of motor neuron involvement with Herpes zoster, even in cases of zoster involving thoracic branches of spinal nerves.
Subject(s)
Aged, 80 and over , Female , Humans , Cranial Nerves , Denervation , Electromyography , Extremities , Herpes Zoster , Motor Neurons , Muscles , Muscular Atrophy , Paresis , Spinal NervesABSTRACT
We report a rare case of a primary mediastinal synovial sarcoma. A 44-year-old man had a well-defined tumor in the left posterior mediastinum involving the left lower lobe of the lung, as detected on chest computed tomography, and underwent an en bloc excision and a left lower lobectomy. Grossly, the tumor measured 8.0 cm in the greatest diameter, with a solid and tan-white cut surface. Histologically, the tumor was mainly composed of spindle-shaped cells with a few foci of epithelial differentiation. Immunohistochemical studies were focally positive for cytokeratin, and diffusely positive for vimentin and bcl-2. Epithelial membrane antigen, S-100 protein, desmin, smooth muscle actin, calretinin, and CD34 were all negative. The SYT-SSX1 gene fusion transcript was detected by a reverse transcription- polymerase chain reaction, which was diagnostic of primary synovial sarcoma of the mediastinum. We also reviewed the literature with regard to the clinicopathologic, immunohistochemical, and molecular studies of primary intrathoracic synovial sarcoma
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Adult , Humans , Actins , S100 Calcium Binding Protein G , Desmin , Gene Fusion , Keratins , Lung , Mediastinum , Mucin-1 , Muscle, Smooth , Oncogene Proteins, Fusion , Polymerase Chain Reaction , S100 Proteins , Sarcoma, Synovial , Thorax , VimentinABSTRACT
In 1865, Armand Trousseau recognized the first relationship between a neoplastic disease and a thromboembolic disorder. Since then, many cases have been reported and have been termed as Trousseau's syndrome. One mechanism of hypercoagulability was considered to be the activation of coagulation systems by a tissue factor secreted by neoplastic cells, but accurate pathophysiology still remains unknown. We report a case of a multiple and recurrent thromboembolism in a patient with adenocarcinoma of the lung. A woman aged 68 years with an acute thromboembolism at her right distal calf artery was diagnosed as having adenocarcinoma of the lung. She underwent a thromboembolectomy two times, but had to receive surgery for a below knee amputation. Multiple and recurrent thromboembolic events then attacked her cerebral and coronary arteries, which led to cerebral and myocardial infarctions. She expired by a progression of the adenocarcinoma of the lung after about six months.