Prognosis of nodal micrometastasis in resectable pN0 non-small cell lung cancer

BackgroundNodal micrometastasis (NMM) is the presence of a small cluster of tumor cells in a regional lymph node. However, the prognostic value of NMM in resectable NSCLC is still debated.MethodsThis retrospective cohort study at Maharaj Nakorn Chiang Mai Hospital from 2006 to 2017 assesses the prognostic impact of nodal micrometastasis in resectable pN0 NSCLC patients, using immunohistochemistry staining for cytokeratin AE1/AE3, p53, and BerEp4. Patients are categorized into three groups: pN0 without nodal micrometastasis, pN0 with nodal micrometastasis, and pN+. Overall survival is the primary endpoint, with disease-free survival as the secondary endpoint.ResultsOut of 225 patients, 98 had pathological N0 (pN0) status and 127 had pathological N positive (pN+) status. Among pN0 patients, nodal micrometastasis was found in 21 cases (21.43%), distributed as follows: 2 (2.04%) in hilar and interlobar regions (N1), 17 (17.35%) in the mediastinal region (N2), and 2 in both hilar and mediastinal regions (N1+N2) (2.04%).Univariable analysis revealed that male sex and the presence of tumor necrosis increased both the recurrence rate of lung cancer and the mortality rate, whereas larger tumor size, intra-tumoral vascular invasion, and pleural invasion were associated solely with cancer recurrence. However, multivariable analysis showed no statistically significant difference in disease-free survival and overall survival between pN0 patients with and without NMM, with hazard ratios of 0.98 (95% CI: 0.31-3.08, P=0.973) and 1.11 (95% CI: 0.23-5.42, P=0.900), respectively.ConclusionNodal micrometastasis was identified in 21.43% of pN0 resectable NSCLC patients. However, the benefits of NMM detection in resectable cases remain controversial due to conflicting results from retrospective studies. Larger prospective cohort studies are needed to better understand disease prognosis and inform treatment strategies

Staplers versus hand-sewing for pulmonary lobectomy: randomized controlled trial

Abstract Background: division of the parenchymal lung for lobectomy is performed in patients who have an incomplete fissure. A stapler device can reduce postoperative air leak, but it is expensive. Objective: to investigate the advantage of using a stapler, in terms of postoperative air leak and cost, compared to handsewn techniques. Method: a non-blinded randomized controlled trial was conducted in Chiang Mai University Hospital, Thailand, from November 15, 2011 to September 30, 2012. Fifty-three adult patients were randomized to undergo a hand-sewn technique (27 patients) or stapler closure (26 patients). Results: postoperative air leak in the stapler group was less than that in the hand-sewn group (7.7% vs. 29.6%, p ¼ 0.044), and the duration of air leak in the stapler group was significantly shorter than that in the hand-sewn group (1.0 vs. 13.4 days, p ¼ 0.032). The cost of treatment was not significantly different between groups; however, the total cost in the stapler group was less than that in the hand-sewn group (mean difference 4454 Thai baht (US$144.75). Conclusion: a stapler reduces postoperative air leaks and the duration of air leaks. Furthermore, the total cost of treatment was comparable. Therefore, using staples may provide substantial financial benefits

Nodal involvement pattern in resectable lung cancer according to tumor location

The aim in this study was to define the pattern of lymph node metastasis according to the primary tumor location. In this retrospective cohort study, each of the operable patients diagnosed with lung cancer was grouped by tumor mass location. The International Association for the Study of Lung Cancer nodal chart with stations and zones, established in 2009, was used to define lymph node levels. From 2006 to 2010, 197 patients underwent a lobectomy with systematic nodal resection for primary lung cancer at Chiang Mai University Hospital. There were 123 male and 74 female patients, with ages ranging from 16– 85 years old and an average age of 61.31. Analyses of tumor location, histology type, and nodal metastasis were performed. The locations were the right upper lobe in 63 patients (31.98%), the right middle lobe in 18 patients (9.14%), the right lower lobe in 30 patients (15.23%), the left upper lobe in 55 patients (27.92%), the left lower lobe in 16 patients (8.12%), and mixed lobes (more than one lobe) in 15 patients (7.61%). The mean tumor size was 4.45 cm in diameter (range 1.2–16.5 cm). Adenocarcinoma was the most common histological type, which occurred in 132 cases (67.01%), followed by squamous cell carcinoma in 41 cases (20.81%), bronchiolo alveolar cell carcinoma in nine cases (4.57%), and large cell carcinoma in seven cases (3.55%). Eighteen cases (9.6%) had skip metastasis (mediastinal lymph node metastasis without hilar node metastasis). Adenocarcinoma and intratumoral lymphatic invasion were the predictors of mediastinal lymph node metastases. There were statistically significant differences between a tumor in the right upper lobe and the right lower lobe. However, there were no statistically significant differences between tumors in the other lobes. In conclusion, tumor location is not a precise predictor of the pattern of nodal metastasis. Systematic lymph node dissection is the only way to accurately determine lymph node status. Further studies are required for evaluation and conclusions

Prevalence and Risk Factors for Ocular Complications in New-Onset Uveitis:A Study From a Tertiary Referral Center in Northern Thailand

Purpose: To determine the prevalence and identify risk factors of ocular complications in patients with uveitis. Methods: This retrospective study reviewed of 340 consecutive patients with a first episode of active uveitis from January 2015 to December 2019. Demographic and clinical data, including ocular complications were analyzed. Results: The mean age of the cohort was 47 years. Among them, 75 patients were HIV-positive (74% male), and 265 were HIV-negative (53% male). An Infectious etiology was identified in 52% of cases. Ocular complications, developed in 151 patients (44%), with their type strongly correlate to the anatomical location of uveitis. Multivariate analysis revealed chronic inflammation (risk ratio [RR]=18.9; 95% confidence interval [CI] 6.1–58.8), recurrent inflammation (RR=20.4; 95%; CI 6.5–64.3), and poor visual acuity (VA) at presentation (RR=3.6; 95% CI 1.4–9.2) as significant risk factors for complications. Conclusion: Nearly half of the patients with uveitis developed ocular complications, highlighting the importance of identifying risk factors. Understanding the relationship between the location of inflammation and specific complication patterns is essential for early detection and targeted prevention strategies.</p

Parapapillary choroidal microvascular density in acute primary angle-closure and primary open-angle glaucoma: an optical coherence tomography angiography study

Back ground/aims To determine whether parapapillary choroidal microvasculature (PPCMv) density, measured by optical coherence tomography angiography, differed between acute primary angle-closure (APAC), primary open-angle glaucoma (POAG) and controls.Methods This is a prospective, cross-sectional, observational study. Data from 149 eyes from two academic referral centres were analysed. Automated PPCMv density was calculated in inner and outer annuli around the optic nerve region in addition to the peripapillary superficial vasculature, using customised software. A generalised estimating equation was used to compare vessel densities among groups, adjusted for confounders.Results Data from 40 eyes with APAC, 65 eyes with POAG and 44 eyes in healthy controls were gathered and analysed. Global radial peripapillary capillary densities were reduced in eyes with APAC and POAG compared with controls (p=0.027 and 0.136, respectively). Mean outer annular PPCMv density in the POAG group was lower vs the APAC group by 3.6% (95% CI 0.6% to 6.5%) (p=0.018) in the multivariable model adjusted for confounders. The mean difference in inner and outer superior PPCMv between the POAG and APAC groups was 5.9% and 4.4% (95% CI 1.9% to 9.9% and 1.0% to 7.7%, respectively; both p<0.010). Furthermore, POAG and APAC groups both had significantly lower PPCMv compared with controls (both, p<0.001).Conclusions While superficial peripapillary vessels were affected to similar degrees in POAG and APAC, PPCMv drop-out was greater with POAG versus APAC, suggesting that choroidal vessel density may be affected to a lesser extent following an acute increase in intraocular pressure before glaucoma develops

Association of myopia and parapapillary choroidal microvascular density in primary open-angle glaucoma

Background/Aims: To compare parapapillary choroidal microvascular (PPCMv) densities between myopic eyes with and without glaucoma. Methods: In this retrospective study, OCTA images (4.5 × 4.5 mm) were obtained using a commercial spectral-domain OCTA system. PPCMv density was calculated in inner and outer annuli using customized software. Marginal model of generalized estimating equations was established to adjust for confounding factors and intraclass correlations. Results: This study included 35 myopic eyes with glaucoma (MG), 96 non-myopic eyes with glaucoma (NMG) matched for visual field mean deviation, 37 myopic eyes without glaucoma (MNG), and 73 control eyes from three tertiary centers. The participant ages were (mean [standard deviation, SD]) 57.43 [11.49], 60.40 [10.07], 52.84 [9.35], and 54.74 [12.07] years. Inner and outer annular PPCMv densities (mean [SD]) decreased in the following order: control (0.15 [0.04] and 0.12 [0.04]), MNG (0.14 [0.08] and 0.12 [0.08]), NMG (0.09 [0.05] and 0.07 [0.04]), and MG (0.09 [0.04] and 0.07 [0.03]). The mean differences in PPCMv density between glaucoma groups (NMG and MG) and the control group (mean difference [95% confidence interval]) were −0.06 (−0.08 to −0.04, P 0.112). Conclusions: Parapapillary choroidal microvascular density attenuation tends to be greater in eyes with glaucoma than in eyes with myopia

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Additional effects of topical tranexamic acid in on-pump cardiac surgery

Objective Postoperative bleeding after cardiac surgery is commonly associated with hyperfibrinolysis. This study was designed to evaluate the efficacy of topical tranexamic acid in addition to intravenous tranexamic acid in reducing bleeding in cardiac surgery cases. Methods From July 1, 2014 to September 30, 2015, 82 patients who underwent elective on-pump cardiac surgery were randomized into a tranexamic acid group and a placebo group. In the tranexamic acid group, 1 g of tranexamic acid dissolved in 100 mL of normal saline solution was poured into the pericardium during sternal closure; the placebo group had 100 mL of saline only. Two patients were excluded from the study due to obvious surgical bleeding. The primary endpoint was total blood loss 24 h after surgery. Repeated measures with mixed models was used to analyze bleeding over time. Results There was no significant difference in demographic and intraoperative data except for a significantly lower platelet count preoperatively in the tranexamic acid group ( p = 0.030). There was no significant difference in postoperative drainage volumes at 8, 16, and 24 h, postoperative bleeding over time (coefficient = 0.713, p = 0.709), or blood product transfusion between the groups. There were no serious complications. Conclusions Topical tranexamic acid is safe but it adds no additional efficacy to the intravenous application in reducing postoperative blood loss. Intravenous tranexamic acid administration alone is sufficient antifibrinolytic treatment to enhance the hemostatic effects during on-pump cardiac surgery. </jats:sec