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BackgroundThe Thymectomy Trial in Non-Thymomatous Myasthenia Gravis Patients Receiving Prednisone (MGTX) showed that thymectomy combined with prednisone was superior to prednisone alone in improving clinical status as measured by the Quantitative Myasthenia Gravis (QMG) score in patients with generalised non-thymomatous myasthenia gravis at 3 years. We investigated the long-term effects of thymectomy up to 5 years on clinical status, medication requirements, and adverse events.MethodsWe did a rater-blinded 2-year extension study at 36 centres in 15 countries for all patients who completed the randomised controlled MGTX and were willing to participate. MGTX patients were aged 18 to 65 years at enrolment, had generalised non-thymomatous myasthenia gravis of less than 5 years' duration, had acetylcholine receptor antibody titres of 1·00 nmol/L or higher (or concentrations of 0·50-0·99 nmol/L if diagnosis was confirmed by positive edrophonium or abnormal repetitive nerve stimulation, or abnormal single fibre electromyography), had Myasthenia Gravis Foundation of America Clinical Classification Class II-IV disease, and were on optimal anticholinesterase therapy with or without oral corticosteroids. In MGTX, patients were randomly assigned (1:1) to either thymectomy plus prednisone or prednisone alone. All patients in both groups received oral prednisone at doses titrated up to 100 mg on alternate days until they achieved minimal manifestation status. The primary endpoints of the extension phase were the time-weighted means of the QMG score and alternate-day prednisone dose from month 0 to month 60. Analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00294658. It is closed to new participants, with follow-up completed.FindingsOf the 111 patients who completed the 3-year MGTX, 68 (61%) entered the extension study between Sept 1, 2009, and Aug 26, 2015 (33 in the prednisone alone group and 35 in the prednisone plus thymectomy group). 50 (74%) patients completed the 60-month assessment, 24 in the prednisone alone group and 26 in the prednisone plus thymectomy group. At 5 years, patients in the thymectomy plus prednisone group had significantly lower time-weighted mean QMG scores (5·47 [SD 3·87] vs 9·34 [5·08]; p=0·0007) and mean alternate-day prednisone doses (24 mg [SD 21] vs 48 mg [29]; p=0·0002) than did those in the prednisone alone group. 14 (42%) of 33 patients in the prednisone group, and 12 (34%) of 35 in the thymectomy plus prednisone group, had at least one adverse event by month 60. No treatment-related deaths were reported during the extension phase.InterpretationAt 5 years, thymectomy plus prednisone continues to confer benefits in patients with generalised non-thymomatous myasthenia gravis compared with prednisone alone. Although caution is appropriate when generalising our findings because of the small sample size of our study, they nevertheless provide further support for the benefits of thymectomy in patients with generalised non-thymomatous myasthenia gravis.FundingNational Institutes of Health, National Institute of Neurological Disorders and Stroke.

Anatomic lung resections are the most commonly performed thoracic surgical procedure. These resections are typically performed as the primary, curative treatment for non-small cell lung cancer. The technical difficulty of [...], Background: An incomplete major pulmonary fissure can make anatomic lung resection technically more difficult and may increase the risk of complications, such as prolonged postoperative air leak. The objective of this study was to determine if preoperative computed tomography (CT) of the chest could accurately predict the completeness of the major pulmonary fissure observed at the time of surgery. Methods: From October 2008 to June 2009, patients at a single university institution were enrolled if they underwent surgery for a pulmonary nodule, mass or known cancer. At the time of surgery, completeness of the major pulmonary fissure was graded 1 if pulmonary lobes were entirely separate, 2 if the visceral cleft was complete with an exposed pulmonary artery at the base with some parenchyma fusion, 3 if the visceral cleft was only evident for part of the fissure without a visible pulmonary artery and 4 if the fissure was absent. The preoperative CT scan of each patient was graded by a single, blinded chest radiologist using the same scale. We used the Pearson [chi square] test with 2-tailed significance to test the independence of the operative and radiologic grading. Results: In 48% (29 of 61) of patients, the radiologic and operative grading were the same. Of those graded differently, 94% (30 of 32) were within 1 grade. Despite this agreement, we observed no statistically significant correlation between the operative and radiologic grading (p = 0.24). Conclusion: The major fissure can often be well-visualized on a preoperative CT scan, but preoperative CT cannot accurately predict the completeness of the major pulmonary fissure discovered at surgery. Contexte : Une scissure pulmonaire majeure incomplete peut rendre la resection pulmonaire anatomique plus difficile sur le plan technique et accroitre le risque de complications, notamment la fuite d'air prolongee apres l'intervention. Cette etude visait a determiner si une tomodensitometrie (TDM) pulmonaire preoperatoire pourrait predire avec precision le caractere complet de la scissure pulmonaire observee au moment de l'intervention chirurgicale. Methodes : D'octobre 2008 a juin 2009, les patients d'un meme etablissement universitaire ont ete inscrits a l'etude s'ils subissaient une intervention chirurgicale pour un nodule, une masse ou un cancer connu au poumon. Au moment de l'intervention, le caractere complet de la scissure pulmonaire a ete cote 1 si les lobes pulmonaires etaient entierement separes, 2 si le sillon branchial etait complet et conjugue a une exposition de l'artere pulmonaire a la base et a une fusion du parenchyme, 3 si le sillon branchial etait evident dans une partie seulement de la scissure sans que l'artere pulmonaire soit visible, et 4 s'il n'y avait pas de scissure. Le resultat de la TDM preoperatoire de chaque patient a ete cote par 1 seul radiologiste travaillant a l'insu et utilisant la meme echelle. Nous avons utilise le test [chi square] de Pearson avec signification bilaterale pour verifier l'independance de l'evaluation operatoire et radiologique. Resultats : Chez 48 % des patients (29 sur 61), les evaluations radiologique et operatoire ont ete identiques. Parmi ceux qui ont fait l'objet d'une evaluation differente, l'ecart de cote ne depassait pas 1 chez 94 % (30 sur 32). En depit de cette convergence, nous n'avons observe aucun lien statistiquement significatif entre l'evaluation operatoire et radiologique (p = 0,24). Conclusion : Une TDM preoperatoire permet souvent de bien visualiser la scissure majeure, mais elle ne peut predire avec exactitude le caractere complet de la scissure pulmonaire majeure au moment de l'intervention chirurgicale.

There is general agreement that spontaneous pneumothorax (SP) results from rupture of blebs or emphysematous bullae beneath the visceral pleura. (1,2) It is believed that rupture occurs when a large [...], Background: Spontaneous pneumothorax (SP) results from the rupture of blebs or emphysematous bullae. Rapid changes in weather may precipitate this process. The city of Calgary is well suited to examine the effects of weather and specifically the rapid changes in weather associated with a chinook event and the occurrence of SP. Methods: We performed a retrospective chart review of all cases of SP in the Calgary Health Region from 2001 to 2005. We obtained local hourly weather data over the same period from Environment Canada. We then compared the rates of SP on chinook and nonchinook days. Further, we compared mean daily temperature, humidity, wind speed and atmospheric pressure on chinook and nonchinook days. Results: In all, 220 SP events from 149 patients occurred during the 4.5-year study period. There was no significant difference in the rate of SP on chinook days versus nonchinook days (p = 0.80). Similarly, there was no significant difference in the rate of SP in each of the 4 seasons (p = 0.30). We observed significantly higher average wind speed and lower mean atmospheric pressure on days with SP versus days without (p = 0.009, p = 0.020, respectively). There was no difference in mean temperature or mean relative humidity when comparing days with SP versus days without. Conclusion: We found no association between SP and chinook events. We observed significantly higher wind speeds and lower atmospheric pressures on days with SP versus days without. Contexte : Le pneumothorax spontane (PS) est cause par la rupture de boursouflures ou de bulles emphysemateuses. Les changements rapides de temperature peuvent precipiter ce phenomene. La ville de Calgary est un bon endroit ou etudier les effets de la temperature, et plus precisement des changements rapides de temperature associes a un chinook, et l'occurrence de PS. Methodes : Nous avons procede a une etude retrospective des dossiers de tous les cas de PS survenus dans la region sanitaire de Calgary de 2001 a 2005. Nous avons obtenu d'Environnement Canada les donnees sur la temperature horaire locale pendant la meme periode. Nous avons ensuite compare le taux de PS les jours de chinook et les autres jours. Nous avons de plus compare la temperature quotidienne moyenne, l'humidite, la vitesse du vent et la pression atmospherique les jours de chinook et les autres jours. Resultats : Au total, il y a eu 220 PS chez 149 patients au cours de l'etude de 4,5 ans. Il n'y avait pas de difference importante au niveau du taux de PS les jours de chinook par rapport aux autres jours (p = 0,80). De meme, il n'y avait pas de difference importante au niveau du taux de PS au cours de chacune des 4 saisons (p = 0,30). Par ailleurs, nous avons observe une vitesse du vent tres superieure a la moyenne et une pression atmospherique moyenne inferieure les jours ou il y a eu des PS par rapport aux autres jours (p = 0,009, p = 0,020, respectivement). Il n'y avait pas de difference au niveau de la temperature moyenne ou de l'humidite relative moyenne si l'on comparait les jours ou il y a eu PS par rapport aux autres. Conclusion : Nous n'avons trouve aucun lien entre le PS et le chinook. Nous avons observe des vitesses du vent beaucoup plus elevees et des pressions atmospheriques plus basses les jours ou il y a eu PS par rapport aux autres jours.

Modernmultislice computed tomography (CT) scanners produce isotropic CT images with a thickness of 0.6 mm. These CT images offer detailed information of lung cavities, which could be used for better surgical planning of treating lung cancer. The major challenge for developing a surgical planning system is the automatic segmentation of lung lobes by identifying the lobar fissures. This paper presents a lobe segmentation algorithm that uses a two-stage approach: 1) adaptive fissure sweeping to find fissure regions and 2) wavelet transform to identify the fissure locations and curvatures within these regions. Tested on isotropic CT image stacks from nine anonymous patients with pathological lungs, the algorithm yielded an accuracy of 76.7%-94.8% with strict evaluation criteria. In comparison, surgeons obtain an accuracy of 80% for localizing the fissure regions in clinical CT images with a thickness of 2.5-7.0 mm. As well, this paper describes a procedure for visualizing lung lobes in three dimensions using software--amira--and the segmentation algorithm. The procedure, including the segmentation, needed about 5 min for each patient. These results provide promising potential for developing an automatic algorithm to segment lung lobes for surgical planning of treating lung cancer. Index Terms--Computed tomography (CT) images, isotropic, lobar fissures, lungs, segmentation, wavelet transform.

Objectives/Hypothesis: Cricotracheal resection (CTR) is an effective treatment for refractory idiopathic subglottic stenosis (iSGS) but is associated with persistent dysphonia. Outcomes were measured longitudinally to characterize how patients' voices and self‐perceived voice handicaps changed after CTR. Study Design: Retrospective case‐series. Methods: We conducted a retrospective cohort study of patients with refractory iSGS treated by CTR from 2006 to 2017. Voice Handicap Index (VHI), Consensus Auditory‐Perceptual Evaluation of Voice (CAPE‐V), and acoustic analysis were prospectively collected preoperatively and postoperatively at 1, 3, 6, 12, and 24‐month intervals. A linear mixed model was used to evaluate temporal change. Results: Thirty‐three patients (97% female) were included. VHI scores increased significantly from baseline preoperative score (27.2 ± 22.7) to a mean value of 44.3 ± 25.6 (P <.001) 1‐month postoperatively but decreased below preoperative scores after 2 years (18.8 ± 11.9, P =.795). Mean fundamental frequency (F0) values in speech decreased significantly from 192.0 ± 24.9 Hz preoperatively to 167.1 ± 19.8 Hz at a 2‐year follow‐up (P =.002), with a nadir value at 1‐month postoperatively (148.4 ± 20.5, P <.001). CAPE‐V scores increased significantly from preoperative to 1‐month postoperative (3.0 ± 2.3 vs. 21.9 ± 17.3, P <.001) but returned toward baseline values at 24 months after CTR (6.9 ± 4.8, P =.027). CAPE‐V measurements postoperatively were correlated with VHI and F0 (Pearson coefficient = 0.54 (VHI), −0.46 (F0), P <.001). Conclusions: Following CTR, mean F0 values were significantly and consistently lower but did increase over time, correlating with patients' improving VHI and CAPE‐V scores. VHI values indicate that patient's perception of their voice is not significantly impacted in long term. These results provide a framework to counsel patients about long term voice expectations. Level of Evidence: 4 Laryngoscope, 132:1054–1060, 2022 [ABSTRACT FROM AUTHOR]

Modernmultislice computed tomography (CT) scanners produce isotropic CT images with a thickness of 0.6 mm. These CT images offer detailed information of lung cavities, which could be used for better surgical planning of treating lung cancer. The major challenge for developing a surgical planning system is the automatic segmentation of lung lobes by identifying the lobar fissures. This paper presents a lobe segmentation algorithm that uses a twostage approach: 1) adaptive fissure sweeping to find fissure regions and 2) wavelet transform to identify the fissure locations and curvatures within these regions. Tested on isotropic CT image stacks from nine anonymous patients with pathological lungs, the algorithm yielded an accuracy of 76.7 %-94.8% with strict evaluation criteria. In comparison, surgeons obtain an accuracy of 80% for localizing the fissure regions in clinical CT images with a thickness of 2.5-7.0 mm. As well, this paper describes a procedure for visualizing lung lobes in three dimensions using software-amira-and the segmentation algorithm. The procedure, including the segmentation, needed about 5 mm for each patient. These results provide promising potential for developing an automatic algorithm to segment lung lobes for surgical planning of treating lung cancer. [ABSTRACT FROM AUTHOR]

The article reports on the case of a 30-year-old man with a 6-year history of recurrent hemoptysis presented with massive hemoptysis. Attempts had been made to control hemoptysis by using a variety of embolic agents including silk threads, microcoils, and gel foam. Pneumonectomy was considered because of the risk of life-threatening hemoptysis.