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Ischemia-reperfusion injury is associated with serious clinical manifestations, including myocardial hibernation, acute heart failure, cerebral dysfunction, gastrointestinal dysfunction, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. Ischemia-reperfusion injury is a critical medical condition that poses an important therapeutic challenge for physicians. In this review article, we present recent advances focusing on the basic pathophysiology of ischemia-reperfusion injury, especially the involvement of reactive oxygen species and cell death pathways. The involvement of the NADPH oxidase system, nitric oxide synthase system, and xanthine oxidase system are also described. When the blood supply is re-established after prolonged ischemia, local inflammation and ROS production increase, leading to secondary injury. Cell damage induced by prolonged ischemia-reperfusion injury may lead to apoptosis, autophagy, necrosis, and necroptosis. We highlight the latest mechanistic insights into reperfusion-injury-induced cell death via these different processes. The interlinked signaling pathways of cell death could offer new targets for therapeutic approaches. Treatment approaches for ischemia-reperfusion injury are also reviewed. We believe that understanding the pathophysiology ischemia-reperfusion injury will enable the development of novel treatment interventions.

The Nuss procedure is a minimally invasive repair used to treat pectus excavatum. A bilateral thoracoscopy-assisted approach has been reported as a safe method for Nuss repair. The aim of this observational cohort study is to evaluate the application of the bilateral thoracoscopy-inspection to assist in the selection of the number of bars for correction of the pectus deformity in adolescents and adults. A retrospective chart review was performed on all adolescent and adult patients (296 patients: 257 male, 39 female; aged of 23.9 ± 7.7 years) with pectus excavatum primarily corrected with the modified Nuss repair from August 2014 to January 2018. The patients were divided into three age groups (A: 12 years ≦ age < 19 years, n = 73; B: 19 years ≦ age < 30 years, n = 175; C: age ≧ 30 years, n = 48). Advanced repair of deformed chest walls using more than one bar depended on the change detected via gross and perioperative thoracoscopy-inspection. The results showed that two or three pectus bars were used in 268 patients (90.5%). The overall complication rate after a postoperative follow-up of 28.6 ± 11 months was 6.8% (20/296), without mortality, major bleeding, or serious infectious complications. A multivariate logistic regression analysis showed that the complications were only associated with Haller index (adjusted OR = 1.2935, p = 0.0317) under controlling confounding factors. The postoperative sternovertebral distance was significantly improved from 7.3±1.6 to 10.1± 2.8 cm (p<0.001). The thoracoscopy-assisted approach of Nuss repair for correction of pectus excavatum was safe and effective approach and could also be used as an alternative approach for the selection of placed bars in adolescent and adult patients. Further studies regarding long-term outcomes are required.

Acute respiratory distress syndrome is an inflammatory disease characterized by dysfunction of pulmonary epithelial and capillary endothelial cells, infiltration of alveolar macrophages and neutrophils, cell apoptosis, necroptosis, NETosis, and fibrosis. Inflammatory responses have key effects on every phase of acute respiratory distress syndrome. The severe inflammatory cascades impaired the regulation of vascular endothelial barrier and vascular permeability. Therefore, understanding the relationship between the molecular regulation of immune cells and the pulmonary microenvironment is critical for disease management. This article reviews the current clinical and basic research on the pathogenesis of acute respiratory distress syndrome, including information on the microenvironment, vascular endothelial barrier and immune mechanisms, to offer a strong foundation for developing therapeutic interventions.

Distant metastases are the major cause of mortality in cancer patients. Bone metastases may cause bone fractures, local pain, hypercalcemia, bone marrow aplasia, and spinal cord compression. Therefore, the management of bone metastases is important in cancer treatment. Normal bone remodeling is regulated by osteoprotegerin ligand (OPGL), receptor activator of NF-κB ligand (RANKL), parathyroid hormone-related protein (PTHrP), and other cytokines. In the tumor microenvironment, tumor cells induce a vicious cycle that promotes osteoblastic and osteolytic lesions. Studies support the idea that distant metastases may occur due to the immunosuppressive function of myeloid-derived suppressor cells (MDSCs). These cells inhibit T cells and natural killer (NK) cells and differentiate into tumor-associating macrophages (TAMs), monocytes, and dendritic cells (DCs). In this review, we summarize studies focusing on the role of MDSCs in bone metastasis and provide a strong foundation for developing anticancer immune treatments and anticancer therapies, in general.

Background The management of severe pectus excavatum (PEx) in patients with multiple prior sternal reconstructions presents unique challenges for safe median sternotomy for cardiac surgery and concomitant sternal reconstruction. Promising outcomes using various approaches have been reported; however, limited literature is available for urgent scenarios. Case presentation We report our surgical approach in a young female patient with Marfan syndrome and PEx status after multiple sternal reconstruction procedures who presented with acute congestive heart failure due to mitral valve insufficiency caused by chordae rupture. A thoracic surgeon first removed the previously implanted Nuss bars. Subsequently, the cardiac procedure was performed, including a standard midline incision with median sternotomy preceded by peripheral cannulation for cardiopulmonary bypass via the right common femoral artery and vein. Dense adhesions were expected, and adequate mitral valve exposure was achieved after meticulous dissection and usual left atriotomy. Valve analysis revealed a classic Barlow-type mitral valve prolapse with A1-A2 chordae rupture. Two sets of CV-4 sutures attached to both papillary muscles were used to restore chordal attachments, followed by secondary chordae transfer and 36 mm Physio-2 annuloplasty ring implantation. A piece of bovine pericardium was used to cover the heart. Postprocedural transesophageal echocardiography revealed trace mitral regurgitation without systolic anterior motion. The patient was weaned off the cardiopulmonary bypass, and hemostasis was achieved in preparation for sternal reconstruction and closure. The thoracic surgery team rejoined for Nuss bar re-implantation to complete the procedure. The patient’s recovery was uneventful, and she was discharged on postoperative day 19. Conclusions Our case report on complex mitral valve repair with concomitant Nuss bar reimplantation demonstrates the feasibility and safety of this procedure in challenging scenarios. The median sternotomy approach is safe for urgent open-heart surgery, even in patients with a previously corrected sternum due to PEx.

Background Pectus excavatum (PE) is the most common congenital abnormality of the chest wall. Most patients with PE have slim bodies. Some studies have been conducted on the physical growth of children and adolescents who underwent the Nuss procedure. This study aimed to evaluate body measurement changes in adult patients with PE after the Nuss procedure. Methods A total of 272 adult PE patients, who underwent the Nuss procedure and pectus bars removal from August 2014 to December 2020, were evaluated retrospectively. Body measurement [body height (BH), body weight (BW), and body mass index (BMI)] of the patients were collected before Nuss repair and after bar removal. We used the interquartile range (IQR) to identify and exclude outliers. Associations between changes in body measurement and clinical and radiological features were evaluated. Results The BH, BW and BMI showed significantly increased after pectus bar removal, compared to pre-Nuss procedure parameters (BH 173.8 ± 5.9 cm vs. 173.9 ± 5.9 cm, P  < 0.001; BW 60.3 ± 8.1 kg vs. 61.1 ± 8.8 kg, P  = 0.005; BMI 19.9 ± 2.2 kg/m2 vs. 20.1 ± 2.4 kg/m2, P  = 0.02). The same result were observed in the male subgroup, the HI ≥ 4 group and the male subgroup within the HI ≥ 4 group. Conclusions The BH, BW and BMI were significantly increased after completing surgical correction of PE using the Nuss procedure, particularly in young males and patients with more pronounced deformities.

We aimed to implement a fully automatic computed tomography (CT) image-detection programming algorithm as a pectus excavatum (PE) diagnostic tool, facilitating comprehensive chest wall deformity evaluation. We developed our algorithm using MATLAB, leveraging the Hounsfield unit threshold and region growing methods. The MATLAB graphical user interface enables the direct use of our program. We validated the model using CT images of anthropomorphic phantoms and one normal individual. The measurement values obtained by our algorithm demonstrated very small differences compared to the known anthropomorphic phantom model data and manual measurement. For algorithm testing, 17,214 chest CT scans obtained from 57 PE patients were processed by the algorithm and independently reviewed by a radiologist and a thoracic surgeon. The measurements of transverse, anteroposterior, and sternum-to-vertebral distance of the thoracic cavity, along with the calculated data of four indices, exhibited high positive correlations (0.94–0.99). The asymmetry index and maximum anteroposterior hemithorax distance exhibited moderate correlation (0.40–0.83). Our automatic PE diagnostic tool demonstrated high accuracy; four chest wall deformity indices were obtained simultaneously without any initial manual marking, correlating well with manual measurements.

Background Pectus excavatum is a prevalent congenital chest wall deformity that is often treated using surgical methods such as the Ravitch or Nuss procedures. Although both techniques are effective, recurrence is possible. We present two cases of recurrent pectus excavatum in patients who had undergone Ravitch procedures during childhood, with retained struts identified during evaluation > 15 years later. These patients underwent repair using the Nuss procedure. Case presentation Two adult patients with a history of pectus excavatum treated using the Ravitch procedure in their childhood experienced deformity recurrence. Evaluation revealed that the struts from their original Ravitch surgeries remained in place. Corrective surgery was performed using the modified Nuss procedure. Preoperative imaging and careful intraoperative planning were critical in addressing the existing struts and ensuring the correct placement of the replacement Nuss bars. Both patients underwent the procedure successfully without any intraoperative complications. Their postoperative recovery was smooth, with marked improvement in their chest wall deformities and enhanced quality of life. Conclusions These cases underscore the viability of the Nuss procedure in treating recurrent pectus excavatum in patients who have previously undergone the Ravitch procedure, even if retained struts are present. Meticulous preoperative planning and surgical techniques are essential to managing the challenges posed by previous surgeries and hardware retention. The Nuss procedure can provide effective solutions in complex cases. However, further research is required to investigate the long-term outcomes of this approach.

Nuss surgery is effective in correcting pectus excavatum (PE), with a recurrence rate of 1.2–27%. Re-do surgery is successful but still has a 6% failure rate. Patients with obstructive sleep apnea (OSA) experience repetitive PE-associated sternal depression during sleep. As the prevalence of OSA among PE patients is higher than the average, co-existing OSA in PE patients might negatively affect the efficacy of Nuss surgery. This study aimed to evaluate the impact of co-existing OSA on Nuss surgery in patients with PE. In total, 20 adult patients with PE only and 9 patients with PE and OSA were analyzed. Polysomnography was performed before Nuss surgery to evaluate OSA. Sternovertebral distance (SVD) and radiographic Haller index (RHI) were recorded before surgery and at 3, 6, and 24 months postoperatively. The results showed that percentage changes in SVD in patients with PE only at 3, 6, and 24 months postoperatively were significantly increased compared with those in the patients with PE and OSA (31.1% vs. 14.1% at 3 months; 37.5% vs. 21.4% at 6 months; 42.5% vs. 19.2% at 24 months). Meanwhile, percentage changes in RHI were significantly lower in patients with PE alone than in the patients with PE and OSA (-22.9% vs. -9.3% at 3 months; -27.9% vs. -18.7% at 6 months; -30.6% vs. -16.7% at 24 months). This study showed that co-existing OSA might reduce the efficacy of Nuss surgery for patients with PE. We recommend that patients with PE should be evaluated and treated for OSA before surgery to prevent surgical failure after bar removal.

Background Usually, pectus bars are removed 3 years after the Nuss procedure in patients with pectus excavatum. However, the optimal timing for postoperative pectus bar removal remains undefined. Our study investigated the effects of delayed pectus bar removal after Nuss repairs. Methods Retrospective data were collected on patients who underwent Nuss procedures for pectus excavatum and had their bars removed from August 2014 to December 2020. Patients with correction periods > 3 years were divided into group A (< 6 years) and group B (≥ 6 years). Propensity score matching was used to compare complications and radiological outcomes associated with bar removal. Results Of the 542 patients who underwent bar removal, 451 (Group A: 419 patients, Group B: 32) had correction duration > 3 years. The average correction duration was 4.5 ± 1.4 years. After propensity score matching analysis, group B [median duration: 8.0 (6.0–16.2) years] exhibited significantly longer median operative times (85 vs. 55 min; P  = 0.026), higher callus formation rates (68.8% vs. 46.9%; P  = 0.029), and greater median intraoperative blood loss (35 vs. 10 mL; P  = 0.017) than group A [median duration: 4.2 (3.0–5.9) years]. However, following bar removal, the groups showed no statistical differences in the surgical complication rates (group A: 6.3% vs. group B: 9.4%; P  = 0.648) or median ratio of radiological improvement (an improvement on the Haller index on chest radiography; 21.0% vs. 22.2%; P  = 0.308). Conclusions Delaying pectus bar removal after Nuss repair presents certain challenges but does not compromise overall outcomes. These findings suggest that a longer correction period may be unnecessary. However, further multicenter studies with long-term follow-up are warranted to assess long-term outcomes.