Objective To identify early Klebsiella pneumoniae(KP)infection after liver transplantation and its impact on prognosis.Methods Clinical data of 171 liver transplant recipients were retrospectively analyzed,and they were divided into the non-infection(n=52)and infection groups(n=119)according to the bacterial culture results at postoperative 2 weeks.In the infection group,KP was not detected in 86 cases(non-KP infection group),and KP was cultured in 33 cases(KP infection group).Preoperative,intraoperative and postoperative data were statistically compared between the non-infection and infection groups,and between the non-KP infection and KP infection groups.The risk factors of early KP infection after liver transplantation and the influencing factors of long-term survival of the recipients were analyzed.Results Compared with the non-infection group,model for end-stage liver disease(MELD)score and total bilirubin level were higher,the operation time was longer,the length of postoperative intensive care unit(ICU)stay and the length of hospital stay were longer,the amount of intraoperative red blood cell transfusion was higher,the hospitalization expense was higher,the incidence of severe complications was higher,white blood cell count,absolute neutrophil cell count and neutrophil-to-lymphocyte ratio at postoperative 14 and 30 d were higher,absolute lymphocyte count at postoperative 14 d was lower and hemoglobin level at postoperative 30 d was lower in the infection group.The differences were statistically significant(all P＜0.05).Compared with the non-KP infection group,MELD score,total bilirubin level and aspartate aminotransferase(AST)level were higher,the operation time and the length of postoperative ICU stay were longer,the hospitalization expense was higher,the 90-d fatality was higher,the albumin level at postoperative 14 d was lower,and total bilirubin level at postoperative 30 d was higher in the KP infection group.The differences were statistically significant(all P＜0.05).Among 33 recipients with KP infection,16 cases were resistant to carbapenem antibiotics,and 7 of them died within postoperative 90 d.Seventeen cases were intermediate or sensitive to carbapenem antibiotics,and 4 of them died within postoperative 90 d.Preoperative MELD score ≥17 and operation time≥415 min were the independent risk factors for KP infection after liver transplantation(both P＜0.05).The length of postoperative ICU stay ≥44 h and KP infection were the independent risk factors for long-term prognosis of liver transplantation(both P＜0.05).Conclusions KP infection is an independent risk factor for death after liver transplantation.High preoperative MELD score and long operation time are the independent risk factors for early KP infection after liver transplantation.

With the dramatically increasing detection rate of ground-glass nodules (GGN), exact understanding and treatment strategy of them has become the hottest issue currently. More and more studies have begun to explore the underlying mechanisms of their indolent characteristics and favorable prognosis from the perspectives of molecular evolution and immune microenvironment. GGN has different dominating gene mutations at different evolutional stages. The pure GGN has a lower tumor mutation burden and genomic instability, while a gradually evolutionary feature of genomic mutation along with the pathological progression can be observed. GGN has less infiltration of immune cells, and they are under the pressure of immune surveillance with weakened immune escape. With the increase of solid components, an inhibitory immune microenvironment is gradually established and immune escape is gradually enhanced, leading to rapid tumor growth. Further exploration of the molecular characteristics of GGN will help to more precisely distinguish these highly heterogeneous lesions, which could be helpful to make personalized treatment plans.

Objective:To examine the efficiacy of a machine learning diagnostic model specifically for solid nodules in multiple pulmonary nodules constructed by combining patient clinical information and CT features.Methods:Totally 446 solid nodules resected from 287 patients with multiple pulmonary nodules in Department of Thoracic Surgery, Peking University People′s Hospital from January 2010 to December 2018 were included. There were 117 males and 170 females, aging (61.4±9.9) yeras (range: 33 to 84 years). The nodules were randomly divided into training set (228 patients with 357 nodules) and test set (59 patients with 89 nodules) by a ratio of 4∶1. The extreme gradient boosting (XGBoost) algorithm was used to generate a predictive model (PKU-ML model) on the training set. The accuracy was verified on the test set and compared with previous published models. Finally, an independent single solid nodule set (155 patients, 95 males, aging (62.3±8.3) years (range: 37 to 77 years)) was used to evaluate the accuracy of the model for predictive value of single solid nodules. Area of receiver operating characteristic curve (AUC) was used to evaluate diagnostic values of models.Results:In the training set, the AUC of the PKU-ML model was 0.883 (95% CI: 0.849 to 0.917). In the test set, the performance of the PKU-ML model (AUC=0.838, 95% CI: 0.754 to 0.921) was better than the models designed for single pulmonary nodules (Brock model: AUC=0.709, 95% CI: 0.603 to 0.816, P=0.04; Mayo model: AUC=0.756, 95% CI: 0.656 to 0.856, P=0.01; VA model: AUC=0.674, 95% CI: 0.561 to 0.787, P<0.01), similar with PKUPH model (AUC=0.750, 95% CI: 0.649 to 0.851, P=0.07). In the independent single solid nodules set, the PKU-ML model also achieved good performance (AUC=0.786, 95% CI: 0.701 to 0.872). Conclusion:The machine learning based PKU-ML model can better predict the malignancy of solid nodules in multiple pulmonary nodules, and also achieved a good performance in predicting the malignancy of single solid pulmonary nodules compared to mathematical models.

With the dramatically increasing detection rate of ground-glass nodules (GGN), exact understanding and treatment strategy of them has become the hottest issue currently. More and more studies have begun to explore the underlying mechanisms of their indolent characteristics and favorable prognosis from the perspectives of molecular evolution and immune microenvironment. GGN has different dominating gene mutations at different evolutional stages. The pure GGN has a lower tumor mutation burden and genomic instability, while a gradually evolutionary feature of genomic mutation along with the pathological progression can be observed. GGN has less infiltration of immune cells, and they are under the pressure of immune surveillance with weakened immune escape. With the increase of solid components, an inhibitory immune microenvironment is gradually established and immune escape is gradually enhanced, leading to rapid tumor growth. Further exploration of the molecular characteristics of GGN will help to more precisely distinguish these highly heterogeneous lesions, which could be helpful to make personalized treatment plans.

Objective:To examine the efficiacy of a machine learning diagnostic model specifically for solid nodules in multiple pulmonary nodules constructed by combining patient clinical information and CT features.Methods:Totally 446 solid nodules resected from 287 patients with multiple pulmonary nodules in Department of Thoracic Surgery, Peking University People′s Hospital from January 2010 to December 2018 were included. There were 117 males and 170 females, aging (61.4±9.9) yeras (range: 33 to 84 years). The nodules were randomly divided into training set (228 patients with 357 nodules) and test set (59 patients with 89 nodules) by a ratio of 4∶1. The extreme gradient boosting (XGBoost) algorithm was used to generate a predictive model (PKU-ML model) on the training set. The accuracy was verified on the test set and compared with previous published models. Finally, an independent single solid nodule set (155 patients, 95 males, aging (62.3±8.3) years (range: 37 to 77 years)) was used to evaluate the accuracy of the model for predictive value of single solid nodules. Area of receiver operating characteristic curve (AUC) was used to evaluate diagnostic values of models.Results:In the training set, the AUC of the PKU-ML model was 0.883 (95% CI: 0.849 to 0.917). In the test set, the performance of the PKU-ML model (AUC=0.838, 95% CI: 0.754 to 0.921) was better than the models designed for single pulmonary nodules (Brock model: AUC=0.709, 95% CI: 0.603 to 0.816, P=0.04; Mayo model: AUC=0.756, 95% CI: 0.656 to 0.856, P=0.01; VA model: AUC=0.674, 95% CI: 0.561 to 0.787, P<0.01), similar with PKUPH model (AUC=0.750, 95% CI: 0.649 to 0.851, P=0.07). In the independent single solid nodules set, the PKU-ML model also achieved good performance (AUC=0.786, 95% CI: 0.701 to 0.872). Conclusion:The machine learning based PKU-ML model can better predict the malignancy of solid nodules in multiple pulmonary nodules, and also achieved a good performance in predicting the malignancy of single solid pulmonary nodules compared to mathematical models.

Objective    To emphasize the important role of video-assisted thoracoscopic surgery (VATS) in treatment of mediastinal bronchogenic cysts (MBCs). Methods    We retrospectively reviewed the clinical data of 112 patients (53 males and 59 females) of mediastinal bronchogenic cysts who underwent VATS in our institution between April 2001 and Aprial 2016. Median age was 4–75 (45.6±15.0) years. All patients underwent chest CT preoperatively. The patients were divided into two groups: an anterior mediastinum group, 47 patients; a middle and posterior mediastinum group, 65 patients including 35 patients in the middle mediastinum, 30 patients in the posterior mediastinum. The average diameter was 0.5–22.0 (3.50±2.33) cm. The average CT attenuation was 0–67 (35.5±15.3) Hu on unenhanced CT. We began each operation with the VATS technique. Results    The CT diagnostic accuracy for group middle and posterior mediastinum with CT value≤20 Hu was higher than others (61.5% vs. 13.1%, χ2=17.675, P<0.001). A total of 111 patients underwent VATS, only one patient converted to open thoracotomy. Cyst resection and thymectomy were conducted in 45 patients, cyst resection and extended thymectomy were conducted in 2 patients in the anterior mediastinum group. Simply cyst resection were performed in the middle and posterior mediastinum group (n=65). The average operative time was 40–360 (104.5±43.1) min. The average intraoperative blood loss was 5–600 (57.9±88.9) mL. The intraoperative complication rate was 3.6% and the incomplete resection rate was 6.3%. The main reason for these was severe adhesion between the cyst and mediastinal structure. No serious postoperative complication was found. Follow-up was done in 99 patients, and the mean follow-up time was 42 (12–191) months. There was no local recurrence. Conclusion    VATS resection of MBCs is a safe and efficacious procedure, and minimally invasive and  surgical resection should be performed as early as possible for MBCs.

Objective To assess the value of multi-modal image-guided transrectal ultrasonography in the diagnosis of prostatic nodules in elderly patients.Methods Sixty-four elderly patients suspected of prostate cancer (PCA) were enrolled from December 2015 to December 2016.Sixty-four patients with 72 nodules underwent transrectal ultrasound (TRUS),contrast-enhanced transrectal ultrasound (CETRUS) and transrectal real-time tissue elastography (TRTE).A combination of systematic biopsy and suspicious sitetargeted biopsy was conducted.The accuracies of different detection methods for prostate cancer were assessed against the gold standard of histological examination of prostate biopsy samples.Results Among the 72 nodules,31 were prostatic hyperplasia,5 were chronic prostatitis,35 were prostatic cancer,and one was prostatic lymphoma.There were significant differences in enhancement strength,enhancement time fast-in and degree of elasticity on TRTE and CETRUS between the malignant and benign groups (x2 =28.794,10.889,52.898;P =0.000,0.001,0.000,respectively).When the 35 PCA nodules were divided into two subgroups based on the Gleason score,there were statistically significant differences in enhancement strength,homogeneity of enhancement,and enhancement time fast-in and fast-out between them (x2=6.073,12.315,4.717,18.093;P =0.048,0.001,0.030,0.000,respectively).The combination of CETRUS and TRTE in diagnosing prostate nodules produced a sensitivity of 83.3 ％,a specificity of 86.1 ％,an accuracy of 84.7 ％,a positive predictive value of 85.7％,and a negative predictive rate of 83.8％,better than either method alone.Conclusions Multi-modal image-guided transrectal ultrasonography has an advantage in providing information on the perfusion and elasticity of prostate nodules in the elderly patients and thus has important clinical value for the diagnosis of prostate nodules.

Objective:To estimate the probability of N2 lymph node metastasis and to assist physicians in making diagnosis and treatment decisions.Methods:We reviewed the medical records of 739 patients with computed tomography-defined stage Ⅰ non-small cell lung cancer ( NSCLC ) that had an exact tumor-node-metastasis stage after surgery.A random subset of three fourths of the patients ( n =554 ) were selected to develop the prediction model.Logistic regression analysis of the clinical characteristics was used to estimate the independent predictors of N2 lymph node metastasis.A prediction model was then built and externally validated by the remaining one fourth ( n=185 ) patients which made up the validation data set.The model was also compared with 2 previously described models.Results:We iden-tified 4 independent predictors of N2 disease:a younger age, larger tumor size, central tumor location, and adenocarcinoma or adenosquamous carcinoma pathology.The model showed good calibration ( Hos-mer-Lemeshow test:P=0.923) with an area under the receiver operating characteristic curve (AUC) of 0.748 (95%confidence interval, 0.710-0.784) .When validated with all the patients of group B, the AUC of our model was 0.781 (95% CI: 0.715 -0.839) and the VA model was 0.677 (95% CI:0.604-0.744) (P =0.04).When validated with T1 patients of group B, the AUC of our model was 0.837 (95%CI:0.760 -0.897) and Fudan model was 0.766 (95% CI: 0.681 -0.837) (P <0.01) .Conclusion:Our prediction model estimated the pretest probability of N2 disease in computed tomography-defined stageⅠNSCLC and was more accurate than the existing models.Use of our model can be of assistance when making clinical decisions about invasive or expensive mediastinal staging procedures.

OBJECTIVETo analyze the clinical characteristics and follow up record of patients with synchronous multiple lung cancers (SMLC).

METHODSThe medical records of 1 868 lung cancer patients who underwent surgical treatments From January 2007 to December 2014 were reviewed, in which 103 patients were diagnosed SMLC by Martini and American College of Chest Physicians modified guideline. The average age was 60.5 years, including 34 male and 69 female patients. According to consolidation/tumor ratio (CTR) on thin-section computed tomography, 103 cases were classified into three groups: group A (multiple ground-glass opacities, CTR ≤ 50%), group B (with one solid dominant nodules, CTR > 50%), group C (with two solid dominant nodules). The surgical procedure was determined according to CT findings and respiratory function. The Kaplan-Meier method was used to analyze the duration of recurrence-free survival (RFS) and over-all survival (OS), and differences were assessed using the Log-rank test. Multivariate analysis using the Cox proportional hazards models was used to assess the potential independent effects on RFS or OS.

RESULTSThere were 38 patients in group A (36.9%), 40 patients in group B (38.8%) and 25 patients (24.3%) in group C. More female (73.7% vs. 48.0%, χ² = 4.291, P = 0.038), less smoker (21.1% vs. 44.0%, 2 = 3.770, P = 0.052), younger (56.2 years old vs. 65.9 years old, t = -4.172, P = 0.000) and less tumor size (1.24 cm vs. 2.31 cm, t = -4.573, P = 0.000) patients in group A than in group C. The 3, 5-year RFS were 80.3% and 64.9% for all patients, respectively. The 3, 5-year OS were 87.3% and 68.6% for all patients, respectively. The 3, 5-year RFS were 100% and 100% in group A, 77.7% and 51.8% in group B, 59.6% and 44.7% in group C (P = 0.029). No significance were found in OS between the three groups (P = 0.214). Multivariate Cox analysis demonstrated that size of dominant nodule larger than 2 cm (HR = 4.475, 95% CI: 1.138 to 17.604, P = 0.032) is associated with poor prognosis, whereas postoperative chemotherapy did not affect RFS.

CONCLUSIONSMultifocal ground-glass opacities and multiple solid lung cancers are different in nature. RFS of patients with SMLC is strongly affected tumor size. Surgical resection is effective and should be performed specifically to patients.

Female ; Humans ; Lung ; pathology ; surgery ; Lung Neoplasms ; diagnosis ; pathology ; surgery ; Male ; Middle Aged ; Multivariate Analysis ; Proportional Hazards Models ; Tomography, X-Ray Computed ; Treatment Outcome

Objective To determine the value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of intrapulmonary tumors located adjacent to the central airway.MethodsThe study was retrospective,from September 2009 to September 2011,33 patients with pulmonary masses located close to the central airways suspected to be lung cancer were accessed by EBUS-TBNA.Conventional bronchoscopic biopsy before EBUSTBNA was nondiagnostic in all cases.If EBUS-TBNA did not result in a formal pathological diagnosis of malignancy,patients were subsequently referred for a surgical procedure.ResultsOf the 33 patients,EBUS-TBNA confirmed lung cancer in 29 cases (4 small cell lung cancer,25 non-small cell lung cancer).Four patients were not confirmed by EBUS-TBNA,3 cases were diagnosed as squamous cell carcinoma by thoracoscoopy or thoracotomy,the other one was a pulmonary inflammatory lesion diagnosed by thoracoscopy.The sensitivity,specificity,accuracy,negative predictive value and positive predictive value of EBUS-TBNA for the diagnosis of intrapulmonary lesions was 90.2％,100％,90.9％,25％,and 100％,respectively.The procedure was uneventful,and there were no complications.ConclusionEBUS-TBNA is an effective tool with a high yield for the diagnosis of intrapulmonary lesions located adjacent to the central airway.