Is the burden of metastatic lymph node stations a prognostic factor in patients with resected lung cancer?

OBJECTIVES: The burden of metastatic lymph node (LN) stations might reflect a distinct N subcategory with a more aggressive biology and behaviour than the traditional N classification. METHODS: Between 2008 and 2018, we analyzed 1236 patients with pN1/2 lung cancer. Survival was analyzed based on LN station metastasis, determining the optimal threshold for the number of metastatic LN stations that provided additional prognostic information. N prognostic subgrouping was performed using thresholds for the number of metastatic LN stations with the maximum chi-square log-rank value, and validated at each pT-stage. RESULTS: Survival showed stepwise statistical deterioration with an increase in the number of metastatic LN stations., Threshold values for the number of metastatic LN stations were determined and N prognostic subgroupswas created as sN-alpha; one LN station metastases (n = 632), sN-beta; two-three LN stations metastases (n = 505), and sN-gamma; ≥4 LN stations metastasis (n = 99). The 5-year survival rate was 57.7% for sN-alpha, 39.2% for sN-beta, and 12.7% for sN-gamma (chi-square log rank = 97.906, p < 0.001). A clear tendency of survival deterioration was observed from sN-alpha to sN-gamma in the same pT stage, except for pT4 stage. Multivariate analysis showed that age (p < 0.001), sex (p = 0.002), tumour histology (p < 0.001), IASLC-proposed N subclassification (p < 0.001), and sN prognostic subgroups (p < 0.001) were independent risk factors for survival. CONCLUSION: The burden of metastatic LN stations is an independent prognostic factor for survival in patients with lung cancer. It could provide additional prognostic information to the N classification.

Could the probability of surgical indication be determined after first episode of primary spontaneous pneumothorax?

OBJECTIVES: To develop a risk score model for primary spontaneous pneumothorax surgery (prolonged air leak or ipsilateral recurrence). The model was internally validated for risk estimation. METHODS: We analyzed 453 patients with primary spontaneous pneumothorax between 2014 and 2018. Patients were randomly assigned a 2:1 ratio to the development dataset (n = 302, study cohort) or the internal validation dataset (n = 151, validation cohort). The final outcomes of patients with primary spontaneous pneumothorax, the presence or absence of surgical indications, were tracked. Multivariable logistic regression models were prepared to estimate the probability of surgical indication and a scoring model was created. It was internally validated using the validation cohort. Calibration was ascertained using the Hosmer-Lemeshow method and Brier score. RESULTS: The surgery indication rate was 47.8% (n = 217) (prolonged air leak, n = 130; ipsilateral recurrence, n = 87). There were no demographic or radiological differences between the validation and the study cohorts. Logistic regression analysis showed that the presence of bullae or blebs (p < 0.001, odds ratio = 3.340, 95%CI = 1.753-6.363) and pneumothorax volume (p < 0.001, odds ratio = 1.033, 95%CI = 1.019-1.048) were independent risk factors for surgical indication. The scoring model significantly predicted surgical indications (area under the curve, AUC = 0.768, 95%CI = 0.714-0.821, p < 0.001). Our model showed acceptable discrimination with an AUC > 0.75 in the validation set (AUC = 0.777, 95%CI = 0.702-0.852, p < 0.001) and had an adequate calibration (Hosmer-Lemeshow test p = 0.249, Brier score = 0.25). CONCLUSION: The internally validated primary spontaneous pneumothorax scoring model was a good predictor of the need for surgery in patients with primary spontaneous pneumothorax. Prospective external validation studies with larger patient cohorts are required.

Exploiting On-Chip Voltage Regulators for Leakage Reduction in Hardware Masking.

A design space exploration of the countermeasures for hardware masking is proposed in this paper. The assumption of independence among shares used in hardware masking can be violated in practical designs. Recently, the security impact of noise coupling among multiple masking shares has been demonstrated both in practical FPGA implementations and with extensive transistor level simulations. Due to the highly sophisticated interactions in modern VLSI circuits, the interactions among multiple masking shares are quite challenging to model and thus information leakage from one share to another through noise coupling is difficult to mitigate. In this paper, the implications of utilizing on-chip voltage regulators to minimize the coupling among multiple masking shares through a shared power delivery network (PDN) are investigated. Specifically, different voltage regulator configurations where the power is delivered to different shares through various configurations are investigated. The placement of a voltage regulator relative to the masking shares is demonstrated to a have a significant impact on the coupling between masking shares. A PDN consisting of two shares is simulated with an ideal voltage regulator, strong DLDO, normal DLDO, weak DLDO, two DLDOs, and two DLDOs with 180∘ phase shift. An 18 × 18 grid PDN with a normal DLDO is simulated to demonstrate the effect of PDN impedance on security. The security analysis is performed using correlation and t-test analyses where a low correlation between shares can be inferred as security improvement and a t-test value below 4.5 means that the shares have negligible coupling, and thus the proposed method is secure. In certain cases, the proposed techniques achieve up to an 80% reduction in the correlation between masking shares. The PDN with two DLDOs and two-phase DLDO with 180∘ phase shift achieve satisfactory security levels since t-test values remain under 4.5 with 100,000 traces of simulations. The security of the PDN improves if DLDO is placed closer to any one of the masking shares.

Should Pneumothorax Developing During the Recovery Period After COVID-19 in Patients with Previously Healthy Lungs be Considered a Primary Spontaneous Pneumothorax or a Secondary Spontaneous Pneumothorax?

OBJECTIVE: It is still unknown how to call the pneumothorax that develops during the recovery period after coronavirus disease 2019. Patients who developed pneumothorax during the recovery period after coronavirus disease 2019 were compared with those who had a primary or secondary spontaneous pneumothorax without a coronavirus disease 2019 history. MATERIAL AND METHODS: Between 2020 and 2021, 160 patients with pneumothorax were retrospectively analyzed. Twenty-three patients had a history of coronavirus disease 2019 (coronavirus disease recovery) confirmed by real-time reverse transcriptase-polyme rase chain reaction, whereas the remaining 137 patients did not have a history of coronavirus disease 2019 (18 of the patients with secondary spontaneous pneumothorax group and 119 patients with primary spontaneous pneumothorax group). RESULTS: The median time between discharge and readmission to the hospital because of pneumothorax was 9 days in the coronavirus disease recovery group. There were statistically significant differences in regards to age (P < .001), gender (P = .02), the presence of bullae (P = .02), and dystrophic severity lung score (P = .04) between the coronavirus disease recovery and primary spontaneous pneumothorax groups, whereas no difference was found between the coronavirus disease recovery and the secondary spontaneous pneumothorax groups (P > .05). The prolonged air leak was observed in 17.6% (n = 25). Patients who had prolonged air leak were statistically higher in the coronavirus disease recovery group than the primary spontaneous pneumothorax group (56.5% vs. 10.1%), although it was almost similar between the coronavirus disease recovery and secondary spontaneous pneumothorax groups (P = .951). On logistic regression analysis, the coronavirus disease recovery group was the independent factor for prolonged air leak (odds ratio = 9.900, 95% CI = 1.557- 62.500, P = .01). CONCLUSION: Pneumothorax may be developed during the recovery period after coronavirus disease 2019 in patients with previously healthy lungs, and it should be called as secondary spontaneous pneumothorax.

Bilateral PECS II Block is Associated with Decreased Opioid Consumption and Reduced Pain Scores for up to 24 hours After Minimally Invasive Repair of Pectus Excavatum (Nuss Procedure): A Retrospective Analysis.

OBJECTIVE(S): Compared to the open surgical technique, the minimally invasive repair of pectus excavatum (MIRPE; Nuss procedure) is a thoracoscopic technique designed to minimize intraoperative tissue damage. It still causes severe postoperative pain due to the insertion and pressure of the retrosternal bar used to raise the sternum and stabilize the chest. This study aimed to identify associations between ultrasound-guided PECS-II block and postoperative analgesia after the Nuss procedure. DESIGN: A retrospective cohort study SETTING: Single-center, training and research hospital affiliated with a university PARTICIPANTS: From Jan 1, 2018 to Nov 15, 2021, 171 consecutive patients were identified who underwent MIRPE surgery under general anesthesia. All patients received intravenous (I) patient-controlled analgesia (PCA) with or without PECS-II blocks for postoperative analgesia. One hundred twenty-five patients who met the inclusion criteria were evaluated. INTERVENTIONS: Demand-only morphine intravenous PCA was used for postoperative pain management in the PECS and control groups. Bilateral PECS-II block with 0.25% bupivacaine was performed in to the PECS group. MEASUREMENTS AND MAIN RESULTS: The primary outcome was postoperative opioid consumption, calculated as mg/kg of IV morphine. Secondary outcomes included Numeric Rating Scale (NRS) pain scores at rest (static) and with movement (dynamic) recorded 1, 4, 8, 12, 24 h after surgery. Postoperative morphine consumption was significantly lower in the PECS group than in the control group over the first 24 hours postoperatively: 0.325 mg/kg vs. 0.425 mg/kg (p<0.001). Static and dynamic NRS values were significantly lower in the PECS group for the first 12 postoperative hours (p <0.05). CONCLUSIONS: Bilateral PECS-II block is associated with decreased pain scores for up to 12 hours, and with decreased opioid consumption for up to 24 hours, following minimally invasive repair of pectus excavatum (Nuss procedure) in adolescents. PECS-II block in this context has not been previously described.

Efficacy of ultrasound-guided erector spinae plane block versus paravertebral block for postoperative analgesia in single-port video-assisted thoracoscopic surgery: a retrospective study.

BACKGROUND: Thoracic paravertebral block (TPVB) is an analgesic method recommended in the enhanced recovery after surgery (ERAS) protocol and proven successful in thoracoscopic surgery. The study aimed to investigate whether the erector spinae plane block (ESPB) administered single-injection in uniportal video-assisted thoracoscopic surgery (VATS) can be an alternative to TPVB as an analgesic method. METHODS: In this study, American Society of Anesthesiologists (ASA) physical status class I-II-III patients aged between 18-70 years who underwent thoracoscopic wedge resection surgery were analyzed retrospectively; 136 patients in the ESPB group and 114 patients in the TPVB group were included in the study. Postoperative cumulative morphine consumption numerical rating scale (NRS) scores were compared at 1, 6, 12, and 24 hours after surgery at rest and during coughing between the groups. Also, rescue analgesia requirements, postoperative nausea, vomiting and other complications were evaluated. RESULTS: The mean cumulative morphine consumption in the postoperative 24 hours was 20.06 mg in the ESPB group and 11.35 mg in the TPVB group. A statistically significant difference was observed between groups in terms of total morphine consumption in the postoperative 24 hours (P<0.001). NRS score was significantly lower in the TPVB group at postoperative 6th and 24th hours during coughing (P=0.003 and P=0.034, respectively) and at 24th hour at rest (P=0.008) than ESPB group. Median NRS scores at rest were low (<4) in both groups. There was no significant difference between the groups in terms of postoperative pulmonary complications as atelectasis and length of hospital stay (LOS) (P=0.643 and P=0.867 respectively). CONCLUSIONS: Ultrasound (US)-guided single-injection TPVB provided superior analgesia in patients undergoing single-port VATS than ESPB. In addition to this, TPVB showed more opioid sparing by reducing morphine consumption.

Evaluation of functions after surgical treatment in patients with arterial thoracic outlet syndrome using QuickDASH.

BACKGROUND: The aim of this study was to examine the validity and reliability of the Quick Disability of the Arm, Shoulder and Hand questionnaire in patients with arterial thoracic outlet syndrome. METHODS: A total of 106 patients (15 males, 91 females; mean age: 30.7±10.2 years; range, 13 to 60 years) with arterial thoracic outlet syndrome were included in this prospective study between January 2015 and December 2018. The questionnaire was administered to all patients before and six months after surgery. The patients were operated using a transaxillary or supraclavicular approach under general anesthesia. RESULTS: The Cronbach"s alpha value of the questionnaire was found to be 0.85 and the scale consisted of two factors. The change in both the functional status subscale scores (p<0.001) and the physical pain subscale scores (p<0.001) were statistically significantly different before and after surgery. At the end of six months, 53% of the patients with at least one mild difficulty continued to have complaints related to hand, arm and shoulder. CONCLUSION: Based on our study results, this questionnaire is a valid and reliable tool for measuring and monitoring disease symptoms in patients with arterial thoracic outlet syndrome.

The Outcomes of Chest Wall Stabilization in Flail Chest Patients in the Intensive Care Unit.

Objectives: In this study, the effect of multi-trauma on treatment results in flail chest patients who underwent chest wall stabilization was investigated. Methods: The data of thirty-six flail chest cases between the ages of 18-79 who were consulted for thoracic surgery were retrospectively analyzed in the study. The presence of flail chest in the patients was confirmed by thoracic surgeons, and the multi-traumas were confirmed through the diagnoses made by specialist physicians reexamining clinical methods. Results: It was found that 27 (75%) of flail chest cases evaluated had multi-trauma, and 3 (8.3%) of the cases had mortality in the study. It was found that the duration of the intensive care unit stay and the number of days on invasive mechanical ventilation of the cases were positively correlated with the number of surgical areas exposed to trauma (p<0.05). According to the univariate binary logistic regression analysis, it was found that the total number of rib fractures (OR = 1.44, p=0.055), the number of fixed ribs (OR = 0.76, p=0.558), the number of plates placed for fixation (OR = 0.70, p=0.368), and the number of additional trauma areas outside the thorax (OR = 6.76, p=0.076) were not statistically significant in increasing the mortality risk. Conclusion: Considering that multi-trauma is an effective factor in the prolongation of the duration of treatment, the management of traumas with different specialties can positively affect the treatment results and reduce the risk of mortality.

Pneumothorax in patients with coronavirus disease 2019 pneumonia with invasive mechanical ventilation.

OBJECTIVES: Our goal was to evaluate the prevalence of and risk factors for pneumothorax in patients with invasive mechanical ventilation in the intensive care unit (ICU) diagnosed with coronavirus disease 2019 pneumonia. METHODS: The prevalence of pneumothorax was retrospectively reviewed in 107 patients diagnosed with coronavirus disease 2019 pneumonia and treated in an ICU in Turkey between 11 March 2020 and 30 April 2020. RESULTS: The patients were aged 19-92 years; 37 (34.6%) were women. Pneumothorax developed in 8 (7.5%) of the intubated patients. Four (50%) of the patients with pneumothorax and 68 (68.7%) of those without it died. In the univariable logistic regression analysis of the presence of comorbid diseases (P = 0.91), positive end-expiratory pressure (P = 0.18), compliance (P = 0.93), peak pressure (P = 0.41) and the Horowitz index (P = 0.13) did not show statistically significant effects in increasing the risk of pneumothorax. CONCLUSIONS: There was no significant increase or decrease in the risk of pneumothorax in patients treated with invasive mechanical ventilation after the diagnosis of coronavirus disease 2019-related pneumonia/acute respiratory distress syndrome. However, consideration of the risk of pneumothorax in these individuals may have the potential to improve the prognoses in such settings.

Thoracic trauma and mortality in geriatric Turkish population: 6-month follow-up study.

AIM: The aim of this study was to evaluate survival rates in elderly individuals who have undergone thoracic trauma and to investigate the risk of mortality for 6 months. METHOD: In this study, the mortality rate was evaluated in 400 thorax trauma cases referred to thoracic surgery, between 65 and 101 years of age. Six-month survival rates in discharged cases of thoracic trauma were examined by using Turkey's Health Ministry Death Notification System. RESULTS: It was found that thoracic traumas evaluated in the study were due to 314 (78.5%) falls and 51 (12.8%) exterior vehicle traffic accident. It was found that the presence of hemopneumothorax (OR 5.82; 95% CI 1.31-25.98; p = 0.021), and the presence of multiple trauma (OR 16.49; 95% CI 3.13-86.91; p = 0.001) had statistically significant effects on the mortality risk from the moment of the event to the emergency treatment period. In addition, it was found that age (OR 1.06; 95% CI 1.01-1.11; p = 0.011), male gender (OR 2.55; 95% CI 1.15-5.68; p = 0.022), and the presence of comorbidities (OR 3.07; 95% CI 1.29-7.31; p = 0.011) statistically significantly increased mortality during the six months after trauma. CONCLUSION: It should be kept in mind that the presence of multiple trauma and the presence of hemopneumothorax increase the risk of death in elderly thoracic trauma cases consulted for thoracic surgery.

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Can we predict the compensatory hyperhidrosis following a thoracic sympathectomy?

BACKGROUND: Primary hyperhidrosis is a functionally and socially disabling condition resulting in social embarrassment and low quality of life. Thoracic sympathectomy is a definitive choice of treatment with favorable results. However, patients may face another embarrassing condition following surgery as compensatory hyperhidrosis which has no definitive treatment. The predictors of compensatory hyperhidrosis are controversial and remain unclear. PATIENTS AND METHODS: A total of 74 patients underwent a videothoracoscopic sympathectomy for primary hyperhidrosis. We statistically analyzed our patients with correlations and uni-multivariate logistic regression models to outline the possible predictors of compensatory hyperhidrosis. RESULTS: A total of 45 (60.8%) patients had compensatory hyperhidrosis. The correlations showed that patients, with age greater than 21 years (P = 0.018), with body mass index (BMI) greater than 22 kg / m2 (P = 0.045), with isolated facial hyperhidrosis (P = 0.044), and with smoking status (P = 0.015), had significantly greater rates of compensatory hyperhidrosis. Similarly, the significant univariate predictors of compensatory hyperhidrosis were age > 21 (P = 0.020), BMI > 22 kg / m2 (P = 0.048), and the presence of smoking status (P = 0.015). Multivariate analysis revealed only smoking as a predictor within the threshold of significance (P = 0.078). CONCLUSION: The clinical predictors of compensatory hyperhidrosis following a thoracic sympathectomy appear as older age, greater body mass index, and smoking.