Middle Lobe Research Articles

Clinical validation of an AI-based automatic quantification tool for lung lobes in SPECT/CT

BackgroundLung lobar ventilation and perfusion (V/Q) quantification is generally obtained by generating planar scintigraphy images and then imposing three equally sized regions of interest on the data of each lung. This method is fast but not as accurate as SPECT/CT imaging, which provides three-dimensional data and therefore allows more precise lobar quantification. However, the manual delineation of each lobe is time-consuming, which makes SPECT/CT incompatible with the clinical workflow for V/Q estimation. An alternative may be to use artificial intelligence-based auto-segmentation tools such as AutoLung3D (Siemens Healthineers, Knoxville, USA), which automatically delineate the lung lobes on the CT data acquired with the SPECT data. The present study assessed the clinical validity of this approach relative to planar scintigraphy and manual quantification in SPECT/CT.MethodsThe Autolung3D software was tested on the retrospective SPECT/CT data of 43 patients who underwent V/Q scintigraphy with 99mTc-macroaggregated albumin and 99mTc-labeled aerosol. It was compared to planar scintigraphy and SPECT/CT using the manual quantification method in terms of relative lobar V/Q quantification values and interobserver variability.ResultsThe three methods provided similar V/Q estimates for the left lung lobes and total lungs. However, compared to the manual SPECT/CT method, planar scintigraphy yielded significantly higher estimates for the middle right lobe and significantly lower estimates for the superior and inferior right lobes. The estimates of the manual and automated SPECT/CT methods were similar. However, the post-processing time in the automated method was approximately 5 min compared to 2 h for the manual method. Moreover, the automated method associated with a drastic reduction in interobserver variability: Its maximal relative standard deviation was only 5%, compared to 23% for planar scintigraphy and 19% for the manual SPECT/CT method.ConclusionsThis study validated the AutoLung3D software for general clinical use since it rapidly provides accurate lobar quantification in V/Q scans with markedly less interobserver variability than planar scintigraphy or the manual SPECT/CT method.

Distinct serum GDNF coupling with brain structural and functional changes underlies cognitive status in Parkinson's disease.

Aberrations in brain connections are implicated in the pathogenesis of Parkinson's disease (PD). We previously demonstrated that Glial cell-derived neurotrophic factor (GDNF) reduction is associated with cognition decline. Nonetheless, it is elusive if the pattern of brain topological connectivity differed across PD with divergent serum GDNF levels, and the accompanying profile of cognitive deficits has yet to be determined. We collected data on the participants' cognition, demographics, and serum GDNF levels. Participants underwent 3.0T magnetic resonance imaging, and we assessed the degree centrality, brain network topology, and cortical thickness of the healthy control (HC) (n = 25), PD-high-GDNF (n = 19), and PD-low-GDNF (n = 19) groups using graph-theoretic measures of resting-state functional MRI to reveal how much brain connectivity varies and its clinical correlates, as well as to determine factors predicting the cognitive status in PD. The results show different network properties between groups. Degree centrality abnormalities were found in the right inferior frontal gyrus and right parietal lobe postcentral gyrus, linked with cognition scores. The two aberrant clusters serve as a potentially powerful signal for determining whether a patient has PD and the patient's cognition level after integrating with GDNF, duration, and dopamine dosage. Moreover, we found a significant positive relationship between the thickness of the left caudal middle frontal lobe and a plethora of cognitive domains. Further discriminant analysis revealed that the cortical thickness of this region could distinguish PD patients from healthy controls. The mental state evaluation will also be more precise when paired with GDNF and duration. Our findings reveal that the topological features of brain networks and cortical thickness are altered in PD patients with cognitive deficits. The above change, accompanied by the serum GDNF, may have merit as a diagnosis marker for PD and, arguably, cognition status.

Endotracheal tube, by the venturi effect, reduces the efficacy of increasing inlet pressure in improving pendelluft.

In mechanically ventilated severe acute respiratory distress syndrome patients, spontaneous inspiratory effort generates more negative pressure in the dorsal lung than in the ventral lung. The airflow caused by this pressure difference is called pendelluft, which is a possible mechanisms of patient self-inflicted lung injury. This study aimed to use computer simulation to understand how the endotracheal tube and insufficient ventilatory support contribute to pendelluft. We established two models. In the invasive model, an endotracheal tube was connected to the tracheobronchial tree with 34 outlets grouped into six locations: the right and left upper, lower, and middle lobes. In the non-invasive model, the upper airway, including the glottis, was connected to the tracheobronchial tree. To recreate the inspiratory effort of acute respiratory distress syndrome patients, the lower lobe pressure was set at -13 cmH2O, while the upper and middle lobe pressure was set at -6.4 cmH2O. The inlet pressure was set from 10 to 30 cmH2O to recreate ventilatory support. Using the finite volume method, the total flow rates through each model and toward each lobe were calculated. The invasive model had half the total flow rate of the non-invasive model (1.92 L/s versus 3.73 L/s under 10 cmH2O, respectively). More pendelluft (gas flow into the model from the outlets) was observed in the invasive model than in the non-invasive model. The inlet pressure increase from 10 to 30 cmH2O decreased pendelluft by 11% and 29% in the invasive and non-invasive models, respectively. In the invasive model, a faster jet flowed from the tip of the endotracheal tube toward the lower lobes, consequently entraining gas from the upper and middle lobes. Increasing ventilatory support intensifies the jet from the endotracheal tube, causing a venturi effect at the bifurcation in the tracheobronchial tree. Clinically acceptable ventilatory support cannot completely prevent pendelluft.

Bronchoscopy for management and identification of etiology of right middle lobe syndrome: Analysis of 66 cases.

Right middle lobe (RML) syndrome is a recurrent or chronic obstruction of the RML causing atelectasis of the right middle lobe due to mechanical and nonmechanical etiologies. The consequences of untreated RML syndrome range from chronic cough to post-obstructive pneumonia and bronchiectasis. We report here our bronchoscopy experience in patients with RML syndrome. We conducted a retrospective study of adult patients who underwent bronchoscopy for RML syndrome at Rabin Medical Center from 2008 through 2022. Demographic data and medical history, bronchoscopy findings and procedures, and follow-up results were collected. A total of 66 patients (57.6% male, mean age 63 ± 13 years) underwent bronchoscopy for RML syndrome during the study period. Bronchoscopy revealed a mechanical etiology in 49 (74.2%) cases, including endobronchial mass (21, 31.8%) and external compression (7, 10.6%). Malignancy was identified in 20 (30.3%) cases. In 62 patients (93.9%), the bronchoscopy resulted in partial or complete reopening of the RML bronchus. The therapeutic bronchoscopic procedures were balloon dilatation (19), laser ablation (17), mechanical debridement (12), endobronchial stent insertion (11), and cryoablation (6). Malignancy was identified as the etiology of RML syndrome in approximately 25% of cases, suggesting bronchoscopy should be performed in every case of RML atelectasis. To our knowledge, this is the first reported series of endobronchial stenting of the RML bronchus in the context of RML syndrome.

Resting-state electroencephalographic characteristics related to mild cognitive impairments.

Alzheimer's disease (AD) causes a rapid deterioration in cognitive and physical functions, including problem-solving, memory, language, and daily activities. Mild cognitive impairment (MCI) is considered a risk factor for AD, and early diagnosis and treatment of MCI may help slow the progression of AD. Electroencephalography (EEG) analysis has become an increasingly popular tool for developing biomarkers for MCI and AD diagnosis. Compared with healthy elderly, patients with AD showed very clear differences in EEG patterns, but it is inconclusive for MCI. This study aimed to investigate the resting-state EEG features of individuals with MCI (n = 12) and cognitively healthy controls (HC) (n = 13) with their eyes closed. EEG data were analyzed using spectral power, complexity, functional connectivity, and graph analysis. The results revealed no significant difference in EEG spectral power between the HC and MCI groups. However, we observed significant changes in brain complexity and networks in individuals with MCI compared with HC. Patients with MCI exhibited lower complexity in the middle temporal lobe, lower global efficiency in theta and alpha bands, higher local efficiency in the beta band, lower nodal efficiency in the frontal theta band, and less small-world network topology compared to the HC group. These observed differences may be related to underlying neuropathological alterations associated with MCI progression. The findings highlight the potential of network analysis as a promising tool for the diagnosis of MCI.

Differentiating Imaging Features of Post-lobectomy Right Middle Lobe Torsion.

The purpose of this study was to identify differences in imaging features between patients with confirmed right middle lobe (RML) torsion compared to those suspected yet without torsion. This retrospective study entailing a search of radiology reports from April 1, 2014, to April 15, 2021, resulted in 52 patients with suspected yet without lobar torsion and 4 with confirmed torsion, supplemented by 2 additional cases before the search period for a total of 6 confirmed cases. Four thoracic radiologists (1 an adjudicator) evaluated chest radiographs and computed tomography (CT) examinations, and Fisher exact and Mann-Whitney tests were used to identify any significant differences in imaging features (P<0.05). A reversed halo sign was more frequent for all readers (P=0.001) in confirmed RML torsion than patients without torsion (83.3% vs. 0% for 3 readers, one the adjudicator). The CT coronal bronchial angle between RML bronchus and bronchus intermedius was larger (P=0.035) in torsion (121.28 degrees) than nontorsion cases (98.26 degrees). Patients with torsion had a higher percentage of ground-glass opacity in the affected lobe (P=0.031). A convex fissure towards the adjacent lobe on CT (P=0.009) and increased lobe volume on CT (P=0.001) occurred more often in confirmed torsion. A reversed halo sign, larger CT coronal bronchial angle, greater proportion of ground-glass opacity, fissural convexity, and larger lobe volume on CT may aid in early recognition of the rare yet highly significant diagnosis of lobar torsion.

Evolution of cavity formation in nontuberculosis mycobacteriosis of the lungs

The results of a long – term observation from practice are presented, which showed the gradual formation of the destruction cavity in a patient with limited focal and peribronchial fibrosis of the lung tissue. Patient H., 54 years old for more than twenty years, was observed by a pulmonologist at the place of residence with a diagnosis of chronic bronchitis with frequent annual exacerbations. She was admitted to the clinic of the FSBSI "CRIT" with complaints of pronounced weakness, fatigue, shortness of breath, prolonged subfebrile temperature mainly at night, cough with difficult-to-separate mucus of a mucous nature. A retrospective analysis of computed tomography of the chest revealed a consistent transformation of local focal peribronchial compaction in the middle lobe of the right lung into a limited area of bronchiectasia and the formation of a small cystic cavity with widespread zones of bilateral pneumonic infiltration. This observation shows the practical significance of CT research in understanding the mechanisms of formation of bronchiectatic cystic cavity in non-tuberculosis mycobacteriosis of the lungs.

Anatomical Variations in Pulmonary Arterial Branches in Patients Undergoing Evaluation for Chronic Thromboembolic Pulmonary Hypertension.

Catheter-based interventions have emerged for both acute and chronic pulmonary thromboembolic disease. With this development and the need for segmental cannulation, anatomic understanding of pulmonary arterial segmental branch origination is important. We aim to describe the prevalence of different pulmonary arterial segmental branch origination patterns. This study included 179 consecutive patients who underwent bilateral nonselective invasive pulmonary angiography for the evaluation of chronic thromboembolic pulmonary hypertension. In our study population (age, 59.0 ± 14.8 years, 55.3% female, 71% White), we found several anatomic variations of branches to the different lobes. These included 7 branching patterns in the right upper lobe, 3 in the right middle lobe, and 10 in the right lower lobe (4 patterns for the origin of the superior segmental artery and 6 for the origin of the basilar segmental arteries). On the left side, we found 8 patterns in the left upper lobe, with 5 involving lingular branches, and 9 in the left lower lobe (5 for the origin of the superior segmental artery and 4 for the basilar segmental pulmonary arteries). Although there were many variations, only 2-3 variations for each individual lobe accounted for >90% of the angiograms. Up to 3 anatomic branching patterns per lobe were noted to account for >90% of pulmonary artery branching variations in this study. This knowledge is not only useful for the interventionalist performing catheter-directed therapies but also for future research efforts that aim to standardize reporting of pulmonary angiographic findings.

CT-guided microcoil localization of pulmonary nodules before VATS: clinical experience in 1059 patients.

To retrospectively evaluate the efficacy and safety of CT-guided microcoil localization of pulmonary nodules before video-assisted thoracoscopic surgery (VATS). A total of 1059 consecutive patients with 1331 pulmonary nodules treated between July 2018 and April 2021 were included in this study. Of the 1331 nodules, 1318 were localized using the tailed method and 13 were localized using the non-tailed method. The localization technical success rate and complications of the microcoil localization procedure were assessed. Univariate and multivariate logistic regression analyses were used to determine potential risk factors for technical failure, pneumothorax, and pulmonary hemorrhage. The technical success rate of the localization procedure was 98.4% (1310/1331 nodules). Nodule location in the lower lobes (p = 0.015) and need for a longer needle path (p < 0.001) were independent predictors of technical failure. All localization procedure-related complications were minor (grade 1 or 2) adverse events, with the exception of one grade 3 complication. The most common complications were pneumothorax (302/1331 nodules [22.7%]) and pulmonary hemorrhage (328/1331 nodules [24.6%]). Male sex (p = 0.001), nodule location in the middle (p = 0.003) and lower lobes (p = 0.025), need for a longer needle path (p < 0.001), use of transfissural puncture (p = 0.042), and simultaneous multiple localizations (p < 0.001) were independent risk factors for pneumothorax. Female sex (p = 0.015), younger age (p = 0.023), nodules location in the upper lobes (p = 0.011), and longer needle path (p < 0.001) were independent risk factors for pulmonary hemorrhage. CT-guided microcoil localization of pulmonary nodules before VATS using either the tailed or non-tailed method is effective and safe. CT-guided microcoil localization of pulmonary nodules before VATS resection is effective and safe when using either the tailed or non-tailed method. Nodules requiring transfissural puncture and multiple nodules requiring simultaneous localizations can also be successfully localized with this method. • Pre-VATS CT-guided microcoil localization of pulmonary nodules by tailed or non-tailed method was effective and safe. • When the feasible puncture path was beyond the scope of wedge resection, localization could be performed using the non-tailed method. • Although transfissural puncture and simultaneous multiple localization were independent risk factors for pneumothorax, they remained clinically feasible.

Covid-19’lu Pediatrik Vakalardaki Toraks Tomografisi Bulgularının Yaşlara Göre Dağılımı , Thoracic computed tomography findings of pediatric COVID-19 cases according to age groups

Objective: In this study, we aimed to evaluate thoracic computed tomography (CT) findings of pediatric patients with novel coronavirus disease 2019 (COVID-19) pneumonia according to age groups. Methods: A total of 105 patients aged between 0 and 18 years who were admitted to our clinic between April 2020 and September 2020 were retrospectively analyzed. The definitive diagnosis was established by reverse transcriptase-polymerase chain reaction (RT-PCR) testing of the combined nasopharyngeal/oropharyngeal swabs. The patients were divided into three groups according to age: 0-6, 6-12, and 12-18 years. Thoracic CT findings at the time of initial admission were evaluated. Results: Of the patients, 51 had RT-PCR positivity for COVID-19, while 54 had RT-PCR negativity. Of the RT-PCR-positive patients, 30 (58.8%) had normal CT, while lung involvement was observed in 21 patients (41.2%). The most common thoracic CT findings were bilateral lung involvement (27.5%), lower lobe involvement (31.4%), nodular involvement (31.4%), and ground-glass opacity (37.3%). In the 6-12 age group, middle lobe involvement was significantly more frequent (p=0.041). The rate of consolidation significantly decreased with the increasing age (p=0.045). Conclusion: The most common CT findings were bilateral, peripheral lower lobe involvement in pediatric COVID-19 cases. Consolidation was the most frequent lesion in the 0-6 age group, which can be attributed to the high incidence of bacterial co-infection. In the 12-18 age group, the distribution, morphology, and opacity of the lesions were comparable with those seen in adults. The lesions presented with nodular and ground-glass opacity patterns in the 6-12 and 12-18 age groups.

Surgical approach for complete resection of giant retroperitoneal liposarcoma with diaphragmatic hernia via ninth rib thoracotomy.

Resection of a giant retroperitoneal liposarcoma is difficult and technically demanding, especially for large retroperitoneal tumors accompanied by a diaphragmatic hernia. Technically, the open abdominal approach can be time-consuming and difficult to perform, with possible intraoperative complications and other factors bringing psychological and physical difficulties to the patient. This study reports a safe and feasible approach for the complete resection of a large retroperitoneal tumor complicated by a diaphragmatic hernia. A 58-year-old male patient with persistent upper abdominal pain and distension was treated at a local hospital on 4 July 2022. Computed tomography showed a mixed-density mass on the right retroperitoneum, and liposarcoma was considered. On 6 July 2022, the patient was transferred to our hospital for further treatment. Computed tomography showed a mass with low-density fatty shadow in the right adrenal region. The boundary with the right adrenal gland was unclear. The mass was 102mm × 74mm, and the right lobe of the liver was compressed. Insufficiency of the right middle lobe of the liver was seen due to a right diaphragmatic hernia and left mediastinal deviation. We considered the traditional approach for tumor resection via laparotomy, but we opted to perform a comprehensive evaluation first. The tumor was close to the back of the right kidney and liver, causing the diaphragm to rise because of its proximity to these organs. Exposing the tumor through laparotomy would be difficult, making it challenging to remove. The patient had a diaphragmatic hernia and moderate pulmonary dysfunction; therefore, we decided to enter the abdomen through a thoracotomy of the ninth rib. Using our technique, the tumor was easily visualized and completely removed in approximately 30min. The intraoperative blood loss was 100ml, and no postoperative bleeding, pneumothorax, intestinal fistula, infection, or other complications occurred. The transthoracic approach may be a safer and more feasible resection method than the traditional open approach for patients with giant retroperitoneal liposarcoma with a diaphragmatic hernia.

Functional brain activity in patients with amnestic mild cognitive impairment: an rs-fMRI study.

Amnestic mild cognitive impairment (aMCI) is an early stage of Alzheimer's disease (AD). Regional homogeneity (ReHo) and amplitude of low-frequency fluctuation (ALFF) are employed to explore spontaneous brain function in patients with aMCI. This study applied ALFF and ReHo indicators to analyze the neural mechanism of aMCI by resting-state functional magnetic resonance imaging (rs-fMRI). Twenty-six patients with aMCI were included and assigned to the aMCI group. The other 26 healthy subjects were included as a healthy control (HC) group. Rs-fMRI was performed for all participants in both groups. Between-group comparisons of demographic data and neuropsychological scores were analyzed using SPSS 25.0. Functional imaging data were analyzed using DPARSF and SPM12 software based on MATLAB 2017a. Gender, age, and years of education were used as covariates to obtain ALFF and ReHo indices. Compared with HC group, ALFF decreased in the left fusiform gyrus, left superior temporal gyrus, and increased in the left cerebellum 8, left inferior temporal gyrus, left superior frontal gyrus (BA11), and right inferior temporal gyrus (BA20) in the aMCI group (p < 0.05, FWE correction). In addition, ReHo decreased in the right middle temporal gyrus and right anterior cuneiform lobe, while it increased in the left middle temporal gyrus, left inferior temporal gyrus, cerebellar vermis, right parahippocampal gyrus, left caudate nucleus, right thalamus, and left superior frontal gyrus (BA6) (p < 0.05, FWE correction). In the aMCI group, the ALFF of the left superior frontal gyrus was negatively correlated with Montreal Cognitive Assessment (MoCA) score (r = -0.437, p = 0.026), and the ALFF of the left superior temporal gyrus was positively correlated with the MoCA score (r = 0.550, p = 0.004). The ReHo of the right hippocampus was negatively correlated with the Mini-Mental State Examination (MMSE) score (r = -0.434, p = 0.027), and the ReHo of the right middle temporal gyrus was positively correlated with MMSE score (r = 0.392, p = 0.048). Functional changes in multiple brain regions rather than in a single brain region have been observed in patients with aMCI. The abnormal activity of multiple specific brain regions may be a manifestation of impaired central function in patients with aMCI.

Efficacy of heat-inactivated Mycobacterium bovis vaccine delivered to European badgers (Meles meles) through edible bait

Badgers (Meles meles) are a major tuberculosis (TB) reservoir in Europe, with the potential to transmit infection to cattle. Here we assessed whether a recently described oral tuberculosis vaccine based on heat-inactivated Mycobacterium bovis (HIMB), delivered as edible baits, can protect badgers from infection. Eight badgers were given individually five baits, each one consisting of a ball of peanut butter, natural peanut and oat flakes including a dose of the vaccine containing 5 × 107 colony-forming units. In parallel, a control group of seven badgers did not receive the vaccine. One month and a half later a second dose of the vaccine was offered to the vaccinated group. Ninety-four days after the second dose, all badgers were challenged with M. bovis (103 colony-forming units per animal) delivered endobronchially to the right middle lung lobe. Clinical, immunological, pathological and bacteriological variables were measured throughout the whole study to assess the efficacy of the vaccine. Two vaccinated animals showed high bacterial load of M. bovis and worsening of pathological lesions of TB. Conversely, the other six vaccinated animals showed slight improvement in bacterial load and pathology with respect to the control group. These results suggest that delivering the TB vaccine via food bait can partially protect wild badger populations, although vaccination can lead to either protection or tolerization, likely depending on the animal's immune status and general condition at the time of vaccination. Further optimization of the vaccination trial/strategy is needed to reduce the rate of tolerization, such as altering vaccine dose, number of doses, type of bait, use of adjuvants or route of administration.

Pulmonary Actinomycosis, A Lesson Learned Story

The bacteria Actinomyces spp. a gram-positive bacteria responsible for the actinomycosis disease. Its 15–20% pulmonary presentation is generally chronic, progresses slowly, and might be misinterpreted as lung cancer or other long-term conditions. We describe a man in his 60s with weight loss and dyspnea. The presence of Actinomyces spp. was identified in a bronchial biopsy of the middle lobe, ruling out lung cancer as the initial diagnostic possibility. After a month of intravenously administered antibiotic treatment, the patient experienced bronchiectasis. Pulmonary actinomycosis should be considered since it is challenging to detect and sometimes mistaken for lung neoplasia or TB due to its comparable clinical and radiographic presentations. The prognosis of pulmonary actinomycosis (PA) is favorable, and it is feasible to avoid recurring complications with the correct antibiotic treatment.

A Macroscopic and Microscopic Study of Liver in Female Iraqi Green Freshwater Turtle (Chelonia mydas) Linnaeus,1758 during the Active Period

The study aims to provide anatomical and histological information about the liver in female Iraqi green freshwater turtles. Ten female green freshwater turtles (Chelonia mydas) were collected from Shatt Al-Hilla and used in this study. They were anesthetized by chloroform in closed chambers. The anatomical information was recorded and the histological sections of the liver were stained by using hematoxylin and Eosin stains. The result showed that the liver of a female green freshwater turtle (Chelonia mydas) is a large elongated organ. The mean weight of turtles is 735±0.04 gm, and the mean weight of the liver is 28±0.02 gm. The ratio between the weight of the liver to the weight of the body was 3.809 %. The liver of (Chelonia mydas) is formed from three lobes right, left and middle (central) lobes. The right lobe is the large one with an average weight of 13 ±0.022 gm. It looks like a square and has two surfaces ventral and dorsal (visceral) surface. The left lobe is smaller than the right with an average weight of 9±0.05gm, and its shape is rectangular. The middle lobe is rounded and small. Its mean weight is 7±0.01gm. Histologically, the liver is covered by mesothelium under its connective tissue layer as a hepatic capsule which divided the liver into lobules in the shape of hexagons with portal spaces, from the central to the walls of the hepatocyte.

Absence of Horizontal Fissure, Middle Lobe Fusion and Anomalous Appearance of Mediastinal Surface of Right Lungs: A Rare Case Report

Anatomical variations of lungs in the form of presence of any extra lobe or absence of anatomical lobe, fissures of lungs are important to know to avoid injuries during surgeries related to lungs and associated structures. In this case report absence of middle lobe and horizontal fissure in two right lungs extracted from male cadaver during routine dissection in the Anatomy department, Adesh institute of medical sciences and research, Bathinda, Punjab, India was noted and reported. Every anatomical structure in left side lung of same cadaver was found normal. Also in one abnormal right lung, gross appearance of right lung was looked like left lung. Anatomical knowledge and statistics of every type of variations are important for anatomists for teaching purposes and for surgeons while performing lobectomies, surgical resections of segments of lungs and for radiological interpretations.

Spontaneous middle lobe torsion: An institutional case series.

Lobar torsion is a rare occurrence in which a portion of the lung is twisted on its bronchovascular pedicle. The vast majority are observed in the acute postoperative period often following right upper lobectomy. Spontaneous middle lobe torsion independent of pulmonary resection is exceptionally rarer; fewer than 15 cases have been recorded. We present an institutional case series of 2 patients postorthotopic liver transplantation who developed spontaneous middle lobe torsion due to large pleural effusions. We provide the medical course as well as intraoperative techniques for our 2 patients along with a review of the literature. Both patients in this case series underwent orthotopic liver transplant complicated postoperatively by a large pulmonary effusion. Patient one developed an abdominal hematoma requiring evacuation and repair, after which he developed progressive shortness of breath. Bronchoscopy revealed a right middle lobe obstruction; upon thoracotomy, 180-degree torsion with widespread necrosis was evident and the middle lobe was removed. He is doing well to date. Patient 2 experienced postoperative pleural effusion and mucus plugging; computed tomography revealed abrupt middle lobe arterial occlusion prompting urgent operative intervention. Again, the middle lobe was grossly ischemic and dissection revealed a 360-degree torsion around the pedicle. It was resected. He is doing well to date. As the result of its rarity, radiographic and clinical diagnosis of spontaneous pulmonary lobar torsion is challenging; a high index of suspicion for spontaneous middle lobe torsion must be maintained to avoid delays in diagnosis. Prompt surgical intervention is essential to improve patient outcomes.

Removal of obstructive organized tracheo-bronchial clots under respiratory support using veno-venous extracorporeal membrane oxygenation in a patient with blunt thoracic trauma: a case report

BackgroundIt has been reported that veno-venous extracorporeal membrane oxygenation is useful for treating patients with acute respiratory failure following severe thoracic trauma. However, the removal of an obstructive organized tracheo-bronchial clot under respiratory support using extracorporeal membrane oxygenation in a patient with trauma has never been reported.Case presentationA teenage female was injured in a fall and experienced right open hemopneumothorax and bilateral lung contusions. Since she was in refractory shock due to bleeding into the right thoracic cavity, we performed right thoracotomy and resection of the lacerated right middle lobe. After hemorrhage control, her respiratory status could not be maintained under mechanical respiratory support. Therefore, we initiated veno-venous extracorporeal membrane oxygenation. Although her respiratory failure gradually improved, the removal of obstructing tracheo-bronchial organized blood clots using bronchoscopy was required daily. Because of the size and firm adherence of organized clots to the airway membrane, we performed a tracheostomy to remove organized clots directly through the incision under extracorporeal membrane oxygenation without any adverse events on day 9. The next day, she was successfully removed from extracorporeal membrane oxygenation.ConclusionsExtracorporeal membrane oxygenation could provide respiratory support not only for acute respiratory failure but also for removal of obstructing tracheo-bronchial organized clots in patients with severe lung injury following trauma.

A nomogram for predicting lateral lymph node metastasis in cN0 unifocal papillary thyroid microcarcinoma

BackgroundIdentifying risk factors for occult lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC) can provide valuable insights into the necessity of lateral neck dissection (LND). The objective of this study was to develop a nomogram for predicting the probability of LLNM in patients with cN0 unifocal PTMC.MethodsWe conducted a retrospective analyzed a total of 4872 patients with cN0 unifocal PTMC who were treated at our center from January 2013 to June 2018. Logistic regression analysis was used to determine the risk factors for LLNM, and a nomogram was constructed based on these risk factors.ResultsThe rate of LLNM was 3.2%. Tumors located in the upper lobe(odds ratio [OR] = 2.56, 95% confidence interval [CI] 1.80–3.62; p < 0.001) and size greater than 7 mm (OR = 2.59, 95% CI 1.85–3.62; p < 0.001) had a significantly higher risk of LLNM compared to tumors in the lower or middle lobe and size less than or equal to 7 mm. Tumors with extrathyroidal extension (ETE) had a significantly higher risk of LLNM (OR = 1.41, 95% CI 1.01–1.99; p = 0.044). The presence of three or more central lymph node metastases (CLNMs) (OR = 5.84, 95% CI 3.83–8.93; p < 0.001) or one or two CLNMs (OR = 2.91, 95% CI 1.93–4.42; p < 0.001) also increased the risk of LLNM compared to having no CLNMs. A nomogram incorporating these risk factors was developed, and the receiver operating characteristic (ROC) curve demonstrated an area under the curve (AUC) of 0.777, indicating a high degree of predictive accuracy.ConclusionTumor location in the upper lobe, greater than 7 mm in size, ETE, and CLNMs, especially three or more, were independent risk factors for LLNM in cN0 unifocal PTMC. The nomogram based on these factors exhibited favorable predictive value and consistency.

Typical carcinoid in right middle lobe of pulmonary hypoplasia

BackgroundPulmonary typical carcinoid occurring in hypoplasia of the right middle lobe is very rare.Case presentationA routine examination's chest X-ray revealed an abnormal shadow in the right middle lung field of an 82-year-old Japanese woman. A chest computed tomography scan showed a solid 2.5 × 2.0-cm nodule in the very small right middle lobe. A trans-bronchial lung biopsy of the mass in the right middle lobe was performed; it revealed atypical cells with round nuclei growing in multiple foci, and immunostaining was positive for chromogranin A, synaptophysin and CD56, suggesting pulmonary carcinoid. The preoperative clinical diagnosis of primary lung cancer, cT1cN0M0 stage IA3 was considered. A right middle lobectomy and mediastinal lymph node dissection were performed by video-assisted thoracic surgery. Intraoperatively, the middle lobe of the right lung was very small, with 1- to 2-mm-dia. pulmonary arteries and veins that were considered hypoplastic. The final histopathological diagnosis was typical carcinoid, pT2aN0M0 stage IB based on the presence of pleural invasion.ConclusionsIncluding the present patient, only nine cases of lung cancer occurring within pulmonary hypoplasia have been reported, most of which were typical carcinoid.