Trimodality therapy for patients with stage III non-small-cell lung cancer: A comprehensive surveillance, epidemiology, and end results analysis.

PURPOSE: Debate exists regarding the optimal management for patients with stage III non-small-cell lung cancer (NSCLC). Recent inclusion of chemotherapeutic data in the Surveillance, Epidemiology, and End Results (SEER) database has made it possible to identify patients with NSCLC who received chemotherapy. We hypothesized that patients with stage III NSCLC experience improved overall survival from trimodality therapy (TMT) versus definitive chemoradiation therapy (CRT) alone. MATERIALS AND METHODS: We analyzed the overall survival of stage III NSCLC patients based on the receipt of TMT versus CRT alone. This included crude and adjusted univariate models as well as crude and doubly robust adjusted multivariable analyses, both utilizing propensity score matching and inverse probability of treatment weighting. Factors included in the multivariable analyses included: age, sex, marital status, income, date of diagnosis, primary site, histology, grade, T stage, N stage, and intended treatment. Planned subset analyses were performed for stage III(N2) patients. RESULTS: Adult patients with stage III NSCLC (N = 9008) from the SEER database were included in our analyses. In our univariate analyses, an overall survival benefit was observed for TMT versus CRT (CrudeHR = 0.58, 95% CI = 0.55-0.61, p < 0.001; AdjHR = 0.58, 95% CI = 0.54-0.61, p < 0.001). This persisted in both crude and doubly robust multivariable analyses (CrudeHR = 0.57, 95% CI = 0.53-0.61, p < 0.001; AdjHR = 0.56, 95% CI = 0.53-0.59, p < 0.001). Patients with stage III(N2) disease also demonstrated a significant benefit to OS with TMT versus CRT alone. CONCLUSION: The significant difference in overall survival seen with TMT suggests this may be an effective treatment approach for select patients.

New Surgical Technique: Bidirectional Forehead Narrowing and Eyebrow Lifting Using Regional Flap Mobility.

We describe our experience with bidirectional forehead narrowing and eyebrow lifting (BiNaLi), a surgical technique we have been practicing for several years to correct facial esthetic issues of patients such as long forehead, high hairline, and low eyebrow level, which helps us achieve forehead height reduction with eyebrow lifting, using 1 incision line in a one-stage procedure. METHODS: We divided 576 patients who visited our institution between March 2014 and February 2019 into 4 groups: long forehead only (group I), low eyebrow level (groups II and IV), and M-shaped hairline (groups III and IV); BiNaLi operation was performed as appropriate for each group. RESULTS: The preoperative length of the median area of the forehead was 7.3 cm, and the mean postoperative change in the length of the same was 1.4 cm. The lateral forehead length was also measured for groups III and IV. The mean preoperative length was 7.7 cm, and the mean postoperative change in the length was 1.7 cm. Eyelid length was also measured for groups II and IV. The mean preoperative length was 0.7 cm, and the mean postoperative change in the length was 0.3 cm. More than 90% of the patients gave a score of 4.0 or higher for esthetic satisfaction. CONCLUSIONS: We designed a BiNaLi technique to satisfy patients' facial esthetic needs using changes in flap movement direction, adjustment in the range of skin excision, and differences in flap dissection. A single operation can have various effects, including achieving forehead shortening, clear double-fold line through eyebrow lifting, and correction of a mild M-shaped hairline.

The relationship among flow index, uroflowmetry curve shape, and EMG lag time in children.

PURPOSE: To determine the relationship among flow index (FI), uroflowmetry curve shape, and electromyography (EMG) lag time in children. MATERIALS AND METHODS: A total of 294 children with lower urinary tract symptoms were included. The overall relationship between lag time and FI was investigated with curve estimation regression. Normal and primary bladder neck dysfunction was defined according to the previous classification, while patients with a lag time less than 2 seconds were grouped based on 2-second intervals. We also categorized cases into four groups (tower shaped, bell shaped, plateau shaped, and fractionated void) by FI and compared lag time. RESULTS: The overall distribution chart demonstrated that FI was the highest at lag time 0 second and decreased with the change in lag time both ways. The best fitting model for maximum FI and lag time was a cubic model (R2 = .282; P < .001). Children with lag times from 0 to less than 2 seconds showed the highest mean FI, while those with prolonged (>6 seconds) or delayed lag time (<-4 seconds) demonstrated lower mean FI values. EMG lag time of the tower-shaped curve was significantly close to 0 second, and plateau shaped and fractionated void had either prolonged or delayed. CONCLUSIONS: A lag time close to 0 second was associated with higher FI, representing hyperefficient voiding with a tower-shaped flow pattern. However, children with prolonged or delayed lag time showed a lower FI, implicating hypoefficient voiding and a plateau-shaped flow pattern. The relationship between FI and EMG lag time could be a cornerstone for a comprehensive understanding of voiding status.

Efficacy of modified radical prostatectomy technique for recovery of urinary incontinence in high-grade prostate cancer.

BACKGROUND: This study was conducted to evaluate predictive factors of urinary continence recovery after radical prostatectomy (RP) for high-grade prostate cancer (PCa). METHODS: A total of 241 patients with high-grade (Gleason Score 8 or 9) PCa who underwent RP in a single Korean center between January 2011 and May 2018 were retrospectively reviewed. Urinary continence was defined as no pads use. Urinary continence was evaluated at 1, 3, 6, and 12 months after RP. Univariate and multivariate analyses were performed to determine the predictive factors of urinary continence recovery after RP. RESULTS: The mean age was 67.6±6.4 years, and the mean PSA was 18.7±21.1 ng/dL. A total of 197 (81.7%) patients underwent nerve-sparing RP, and 198 patients (82.2%) were continent 1 year after RP. Multivariate analysis showed that the age (odds ratio [OR]=1.091 [1.015-1.172], P=0.018), Body Mass Index (BMI) (OR=1.227 [1.057-1.424], P=0.007), and modified surgical technique (OR=0.109 [0.044-0.267], P<0.001) were independent factors for predicting urinary continence recovery after RP. CONCLUSIONS: Younger age, low BMI, and modified surgery were independent predictors of urinary continence recovery after RP in patients with high-grade PCa. These findings may help surgeons to give pre- and postoperative advice to patients with high-grade PCa about urinary continence recovery after RP.

Pregnancy outcomes in women with inflammatory bowel disease: a 10-year nationwide population-based cohort study.

BACKGROUND: Data relating to the association between inflammatory bowel disease (IBD) and pregnancy outcomes are lacking in Korea. AIMS: To determine the incidence rates of pregnancy outcomes in women with IBD. METHODS: A nationwide population study was performed using the Korean National Health Insurance claims database. A total of 2058 women with IBD consisting of ulcerative colitis (UC, n = 1469) and Crohn's disease (CD, n = 589) were pregnant between 2007 and 2016. We compared their incidence of pregnancy outcomes with 20 580 age-matched controls without IBD. We also stratified the patients into those with quiescent to mild and moderate to severe IBD and compared the outcomes between them. RESULTS: The pregnancy rate of women with IBD was lower than that of women without (25.7% vs 32.3%, P < 0.001). Caesarean section (46.5% vs 38.8%, odds ratio [OR] 1.43, 95% confidence interval [CI]: 1.17-1.75), and intrauterine growth retardation (IUGR) (3.0% vs 1.0%, OR 2.89, 95% CI: 1.59-5.26) were increased in CD patients than the controls. In regards to disease severity, there were no significant differences in pregnancy outcomes between patients with quiescent to mild IBD and the controls. However, the live birth rate of patients with moderate to severe IBD was lower than that of the controls (65.0% vs 69.9%, OR 0.79, 95%CI: 0.66-0.94). In addition, moderate to severe IBD was significantly associated with spontaneous abortion (14.9% vs 11.9%, OR 1.33, 95% CI: 1.04-1.68), caesarean section (46.4% vs 38.8%, OR 1.41, 95% CI: 1.14-1.74) and IUGR (3.4% vs 1.0%, OR 3.20, 95% CI: 1.75-5.84). CONCLUSIONS: With the exception of moderate to severe disease, the incidences of adverse pregnancy outcomes in women with IBD are similar to that of the general population.

Role of Holmium laser enucleation of the prostate to increase cancer detection rate in patients with gray-zone PSA level.

BACKGROUND: Even though the safety of the treatment for prostate cancer diagnosed by HoLEP has been reported, the diagnostic value of HoLEP for prostate cancer detection has not been confirmed. Therefore, we investigated the diagnostic potential of HoLEP for detecting prostate cancer. METHODS: Between December 2009 and October 2015, 359 patients (median age, 70.9 years; range, 66.2-74.8) were treated simultaneously with HoLEP and transrectal prostate needle biopsy (TPNB). Of these, 199 patients with a normal digital rectal examination and serum PSA concentration between 3.5 and 10.0 ng/mL were included in the study. Univariate and multivariate logistic regression analyses were performed to identify the predictive factor for prostate cancer detected by HoLEP. RESULTS: Median PSA, prostate volume and PSA density were 4.97 ng/mL (range, 4.20-6.70), 57.40 gm (range, 43.67-77.80) and 0.09 ng/mL2 (range, 0.07-0.12), respectively. Prostate cancer (Gleason score ≥6) was detected in 46 cases (23.1%). Of these, 26 (56.5%) were detected by HoLEP pathology, 11 (23.9%) by TPNB pathology, and 9 (19.6%) by both. Univariate and multivariate logistic regression analyses were performed in 179 patients, including benign prostatic hyperplasia patients (N=153, 76.9%) and patients with cancer detected by HoLEP pathology. PSA density was identified as an independent predictor of prostate cancer detected by HoLEP in gray-zone PSA. CONCLUSIONS: HoLEP is a viable modality for detecting prostate cancer in selected cases. PSA density was an independent predictor of prostate cancer detected by HoLEP in gray-zone PSA.

Mapping the malaria parasite druggable genome by using in vitro evolution and chemogenomics.

Chemogenetic characterization through in vitro evolution combined with whole-genome analysis can identify antimalarial drug targets and drug-resistance genes. We performed a genome analysis of 262 Plasmodium falciparum parasites resistant to 37 diverse compounds. We found 159 gene amplifications and 148 nonsynonymous changes in 83 genes associated with drug-resistance acquisition, where gene amplifications contributed to one-third of resistance acquisition events. Beyond confirming previously identified multidrug-resistance mechanisms, we discovered hitherto unrecognized drug target-inhibitor pairs, including thymidylate synthase and a benzoquinazolinone, farnesyltransferase and a pyrimidinedione, and a dipeptidylpeptidase and an arylurea. This exploration of the P. falciparum resistome and druggable genome will likely guide drug discovery and structural biology efforts, while also advancing our understanding of resistance mechanisms available to the malaria parasite.

Determining the 2-Dimensional Threshold for Perception of Artificial-Appearing Lips.

IMPORTANCE: Recognizing the perceptual threshold for artificial-appearing lips is important to avoid an undesirable outcome of treatment. OBJECTIVE: To characterize the quantitative measurements for the perceptual threshold of artificial- and unnatural-appearing lips. DESIGN, SETTING, AND PARTICIPANTS: Photographs of a female model's lips were digitally altered incrementally in 5 sets of features (the upper lip, lower lip, upper and lower lips, and shape of the Cupid's bow). From December 1, 2013, to January 30, 2014, participants viewed the photographs in random sequence using an online survey and responded to 2 questionnaires after each photograph. The participants were prompted to respond whether each altered photograph of the lips appeared to have received any cosmetic treatment, and whether the lips looked attractive and natural or artificial and unnatural. The measurement of each lip at which 50% of the observers perceived the lips as being treated and 50% of the observers perceived the lips as being artificial was determined. The difference in these 2 measurements was defined as dTA50, which represents the threshold differential between the perception of treated lips and artificial lips for 50% of the observers. MAIN OUTCOMES AND MEASURES: Survey responses of the participants to the appearance of the lips in the photographs. RESULTS: A total of 98 participants (76 females and 22 males; mean age, 42 years) provided usable responses to the survey. Each area of the lips had a unique quantitative measurement at which the observers perceived the lips as being treated and artificial. Enhancement of the upper lip alone had a narrower margin for artificial appearance (dTA50, 0.9 mm) compared with enhancement of both the upper and lower lips (dTA50, 1.5 mm). Any alteration to the Cupid's bow resulted in the narrowest margin for artificial appearance (dTA50, 0.3 mm). The difference in the perceptual threshold between the age of the observers was the most significant for the upper lip. CONCLUSIONS AND RELEVANCE: The perceptual threshold for treated and/or artificial appearance is unique for each area of the lips. LEVEL OF EVIDENCE: NA.

A review of medical and surgical treatment options for androgenetic alopecia.

IMPORTANCE: Androgenetic alopecia is a highly prevalent condition that can profoundly impair the quality of life in both men and women. OBJECTIVE: To provide the up-to-date medical and surgical treatment options for patients with androgenetic alopecia. EVIDENCE REVIEW: A Medline search of scientific literature was conducted from 1997 to 2013. Search terms included androgenetic alopecia, hair restoration, follicular unit transplantation, and follicular unit extraction. FINDINGS: Oral finasteride and topical minoxidil are the 2 mainstream medical treatments for androgenetic alopecia. These medications have different mechanisms of action and should be combined to have an additive effect in men. Follicular unit transplantation is the gold standard for surgical management. There are 2 types of graft harvest technique: donor strip and follicular unit extraction. Each technique has its own advantages and disadvantages and should be tailored to the individual patient. Understanding of the anterior hairline design is essential to achieving a natural-appearing result. CONCLUSIONS AND RELEVANCE: Medical treatment should be used in conjunction with surgery to achieve a synergistic effect. For the right candidate, follicular unit hair transplantation can lead to a long-lasting, natural result with appearance of dense scalp hair.

Different cut-off values of the insulin tolerance test, the high-dose short Synacthen test (250 µg) and the low-dose short Synacthen test (1 µg) in assessing central adrenal insufficiency.

OBJECTIVE: The short Synacthen test (SST) is widely used as alternative test to the insulin tolerance test (ITT) to investigate central adrenal insufficiency (CAI), but the methodology and cut-off values of the SST are controversial. Our aim was to evaluate the cut-off value of the ITT in normal subjects and to assess the different cut-off values of the high-dose SST (250 µg, HDT) and the low-dose SST (1 µg, LDT) in subjects with suspected CAI. SUBJECTS AND METHODS: We conducted ITTs in 208 normal subjects to establish the cut-off value for the ITT, and 28 of those subjects underwent the HDT and LDT. From 1999 to 2007, 182 patients with suspected CAI were recruited and underwent ITTs, LDTs and HDTs to establish cut-off values and compare the diagnostic accuracy between the LDT and HDT. RESULTS: The 95th percentile of the peak cortisol level during the ITT in the normal control subjects was 14·8 µg/dl. Receiver operator characteristics (ROC) analysis revealed that the optimal cut-off values of peak cortisol in the LDT and HDT in patients with suspected CAI were 15·8 and 17·4 µg/dl, respectively. However, the cut-off values from normative data (mean - 2 SD) were 18·3 µg/dl for the LDT and 20·5 µg/dl for the HDT in normal control. CONCLUSIONS: The optimal cut-off values of SSTs needed to be individualized according to the type of SST and tested patient population.

New technologies in robotic surgery: the Korean experience.

PURPOSE OF REVIEW: The development of the robotic systems has made surgery an increasingly technology-driven field. Since the introduction of the first robotic platform in 2005, surgical practice in South Korea has also been caught up in the global robotic revolution. Consequently, a market focused on improving the robotic systems was created and Korea has emerged as one of its frontrunners. This article reviews the Korean experience in developing various robotic technologies and then Korea's most recent contributions to the development of new technologies in robotic surgery. RECENT FINDINGS: The goal of new technologies in the field of robotic surgery has been to improve on the current platforms by eliminating their disadvantages. The pressing goal is to develop a platform that is less bulky, more ergonomic, and capable of providing force feedback to the surgeon. In Korea, the Lapabot and two new robotic systems for single-port laparoscopic surgery are the most recent advances that have been reported. SUMMARY: Robotic surgery is rapidly evolving and Korea has stayed in the forefront of its development. These new advancements in technology will eventually produce better robotic platforms that will greatly improve the manner in which surgical care is delivered.

Determining the threshold for asymmetry detection in facial expressions.

OBJECTIVES/HYPOTHESIS: To quantify the threshold for human perception of asymmetry for eyebrow elevation, eye closure, and smile, and to ascertain whether asymmetry detection thresholds and perceived severity of asymmetry differ in distinct facial zones. STUDY DESIGN: Online survey. METHODS: Photographs of a female volunteer performing eyebrow elevation, eye closure, and smile were digitally manipulated to introduce left-to-right asymmetry in 1-mm increments from 0 mm to 6 mm. One hundred and forty-five participants viewed these photographs using an online survey, measuring accuracy of asymmetry detection and perceived expression unnaturalness (on a scale of 1-5). RESULTS: Photographs of facial asymmetries were correctly judged as asymmetrical over 90% of the time for 2 mm or more of asymmetry in eyelid closure, and 3 mm or more of asymmetry during smiling. Identification of eyebrow elevation asymmetry gradually rose from 23% correct to 97% correct across the range of 1 mm to 6 mm of asymmetry. Greater degrees of asymmetry were ranked as significantly more unnatural across all expressions (3 tests; X(2) (6, N = 145) = 405.52 to 656.27, all P <0.001). CONCLUSION: Thresholds for asymmetry detection vary across different zones of the face; once detected, asymmetry in eyelid position is perceived as more unnatural than asymmetries in either brow elevation or smile. These data will inform counseling of patients with segmental facial weakness and may provide more objective goals for facial reanimation procedures. LEVEL OF EVIDENCE: 4.

Detection and perceptual impact of side-to-side facial movement asymmetry.

IMPORTANCE: In this study, we examined whether specific facial movements have different time-delay detection thresholds, and to what extent such side-to-side facial movement asymmetry affects subjective ratings of movement naturalness. Ratings of dynamic asymmetry in experimentally manipulated video recordings demonstrate that there are different side-to-side time-delay thresholds for distinct regions of the face, with a strong inverse correlation between naturalness rating and the length-of-time delay. These findings will be helpful for counseling patients with unilateral facial paralysis and guide the design of neural interfaces for facial reanimation. OBJECTIVE: To determine the detection threshold of side-to-side facial movement timing asymmetry and measure its effect on perceived movement naturalness. DESIGN, SETTING, AND PARTICIPANTS: Videos of 5 symmetrical facial movements (eye blink, rapid eyebrow raising, slow eyebrow raising, smiling, and lip depression) were edited to introduce 6 levels of side-to-side timing asymmetry, ranging from 33 to 267 milliseconds. Participants (N = 58) viewed video clips through an online survey service, indicating whether they noticed side-to-side asymmetry and judging movement naturalness on a 5-point scale. RESULTS: There was a significant difference among facial movements in asymmetry detection threshold. There was a strong correlation between naturalness ratings and amount of delay across movements (R = 0.823), with greater asymmetry being judged as progressively less natural. Blink was judged as less natural at 33, 67, 100, and 133 milliseconds of side-to-side delay compared with all other movements (P < .005). CONCLUSIONS AND RELEVANCE: Side-to-side asymmetry in blink timing is detected sooner and viewed as less natural compared with asymmetry of the eyebrow and lips. At 100 milliseconds of delay, nearly all movements are detected as asymmetric, although blink is judged as the least natural. These findings will help set timing goals for facial pacing technologies treating unilateral paralysis. LEVEL OF EVIDENCE: NA.

Quantitative analysis of muscle histologic method in rodent facial nerve injury.

OBJECTIVE: To describe denervation features of facial musculature following facial nerve injury in a rodent model. METHODS: Six Wistar-Hannover rats underwent unilateral transection and immediate repair of the facial nerve. After 8 weeks, muscular bundles consisting of dilator naris and levator labii superioris from both sides were analyzed for mean muscle cell diameter and the percentage of muscle cell cross-sectional area using image processing software. The atrophic features of facial muscles were quantified and compared with the contralateral, healthy side of the face. RESULTS: Weekly postoperative whisking assessment demonstrated the anticipated course of recovery. We observed significant differences between the normal side and the manipulated side, respectively, in the percentage of muscle specimen cross-sectional area attributable to muscle cell profiles (57% vs 29%; P = .006) and total fiber counts (1346 vs 794; P = .02). The mean cross-sectional area of individual muscle fibers was higher on the normal side (1129 vs 928 µm2; P = .39); however, this difference was statistically nonsignificant. CONCLUSION: The objective, quantitative measures of muscle microstructure used in this report provide a valuable point of comparison for whisking function and electrophysiologic measures and can be used in future studies to assess muscle atrophic features associated with facial nerve injury and repair techniques.

Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients.

OBJECTIVE: The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented. STUDY DESIGN: Prospective study from July 1, 2009, to February 1, 2011. SETTING: Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital. METHODS: Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed. RESULTS: A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients. CONCLUSION: There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

Long-term outcome of radiofrequency ablation for intraoral microcystic lymphatic malformation.

OBJECTIVE: To determine long-term outcome of radiofrequency (RF) ablation of microcystic lymphatic malformation (LM) of the oral cavity for control of recurrent infection and bleeding. DESIGN: Institutional review board-approved retrospective study, SETTING: Tertiary pediatric medical center, PATIENTS: Twenty-six patients with intraoral microcystic LM were treated with RF ablation from August 2002 through August 2010. INTERVENTION: Radiofrequency ablation of intraoral LM. MAIN OUTCOME MEASURES: Postoperative stay, diet, pain; control of bleeding and/or infection; recurrence; and indication for retreatment. RESULTS: The most common complaints necessitating initial RF ablation were recurrent infection (n=10 [37%]) and bleeding (n=9 [33%]). The most common problems requiring further ablation were bleeding (n=11 [41%]) and cosmetic deformity not affecting function (n=8 [31%]). Fourteen patients (55%) were discharged home on postoperative day (POD) 3; the remaining 11 (45%) were discharged home on POD 4. Thirteen patients (52%) resumed oral diet immediately on the day of the procedure. Ten patients (38%) began eating on POD 1, and virtually every patient was on full oral intake at discharge. Fourteen patients (55%) required only acetaminophen for pain control, 11 (41%) required acetaminophen with codeine, and 1 (4%) required oxycodone. The mean follow-up time was 47 months after treatment. At the most recent clinic evaluation, 13 patients (50%) were symptom free, 8 (31%) were stable and improved without need for future treatment, and 5 (19%) required further treatment. One-half of patients in the study group underwent more than 1 RF procedure for recurrence. The number of RF ablations in this series were 1 procedure (n = 13), 2 procedures (n = 7), 3 procedures (n = 2), 4 procedures (n = 2), and 6 or 7 procedures (n = 2). CONCLUSIONS: Radiofrequency ablation is an effective treatment for localized, superficial microcystic LM in the oral cavity. Pediatric patients tolerate the treatment with rapid postoperative recovery and minimal complications. The majority of patients required a short hospital stay for observation of the airway. Virtually every patient resumed oral diet by the time of discharge. Radiofrequency ablation is the treatment of choice at Children's Hospital Boston (CHB) for patients who present with symptomatic, superficial, and localized intraoral microcystic LM. For lesions involving deeper structures, multimodal treatments including surgical and sclerotherapy may be necessary.

The safe transition from open to thoracoscopic lobectomy: a 5-year experience.

BACKGROUND: We hypothesized that established thoracic surgeons without formal minimally invasive training can learn thoracoscopic lobectomy without compromising patient safety or outcome. METHODS: Data were retrospectively collected on patients who underwent pulmonary lobectomy at a single health system between August 1, 2003, and April 1, 2008. Age, sex, pulmonary function tests, preoperative and postoperative stages, pathologic diagnosis, anatomic resection, extent of lymph node sampling, surgical technique and duration, complications, blood loss, transfusion requirement, chest tube duration, length of hospital stay, 30-day readmission, and mortality rate were examined. The percentage of patients who underwent thoracoscopic lobectomy and their outcomes were then compared among three chronologic cohorts. RESULTS: Three hundred sixty-four patients underwent pulmonary lobectomy (239 open; 99 thoracoscopic; 26 thoracoscopic converted to open). Baseline characteristics, staging, pathologic diagnosis, and anatomic resections were similar in the early, middle, and late cohorts. The percentage of thoracoscopic lobectomies increased from 16% to 49%, whereas open lobectomy decreased from 81% to 42% (p < 0.0001). The complication rate remained constant with the exception of air leaks lasting more than 7 days (9% versus 10% versus 2%; p = 0.02). Hospital length of stay (6 versus 5 versus 4 days; p < 0.0001) and chest tube duration (4 versus 3 versus 3 days; p < 0.0001) decreased and operative duration increased as more thoracoscopic lobectomies were performed. Blood loss, transfusion requirement, 30-day readmission, and 1-year survival were not significantly different among chronologic cohorts. CONCLUSIONS: Established thoracic surgeons can safely incorporate thoracoscopic lobectomy with no increase in morbidity or mortality.

Intravascular ultrasound assessment of ruptured atherosclerotic plaques in left main coronary arteries.

Atherosclerotic plaque rupture is the main cause of acute coronary syndromes. There is no systematic description of ruptured plaques located in the left main coronary artery (LMCA). The aim of our study was to describe ruptured plaques in the LMCA with intravascular ultrasound. We identified 17 LMCA plaque ruptures in 16 patients. Two patients had a recent myocardial infarction, 13 had unstable angina, and 1 had stable angina. Two left main ruptures were clinically considered to be incidental findings and were left untreated; the remaining 14 were culprit lesions that were treated with emergency coronary artery bypass grafting (n = 3) or LMCA stenting (n = 11). One patient died in the hospital after left main stenting for unstable angina; all other patients who underwent stenting or surgical bypass did well. Almost all ruptured plaques that were identified by intravascular ultrasound had an angiographic complex appearance that was defined by the presence of ulceration (81%), intimal flap (38%), aneurysm (12%), or thrombus (6%). All ruptures were located in the distal half of the LMCA; 6 ruptures involved bifurcation and 11 were confined to the LMCA proper. The angle between the maximum plaque cavity and the left anterior descending/left circumflex artery flow divider was 162.3 degrees +/- 15.6 degrees in bifurcation versus 71.3 degrees +/- 41.6 degrees in nonbifurcation lesions (p <0.0001). The LMCA minimum lumen area measured 6.0 +/- 3.3 mm2 in nonbifurcation lesions and 7.4 +/- 4.7 mm2 in bifurcation lesions (p = 0.5). LMCA plaque ruptures mostly present as unstable angina, are located in the distal portion and/or bifurcation of the LMCA, often do not compromise the lumen, and have an angiographic complex appearance. When ruptured plaques involve the bifurcation, they occur opposite the distal flow divider.