Journal of Thoracic Disease

Current Issue Highlights

The value of serum biomarkers in the management of interstitial lung disease in patients with connective tissue disease: a protocol for an observational study
July 31, 2026: 18(7)
Background
Three key points in managing interstitial lung disease (ILD) in patients with connective tissue disease (CTD) are: First, identifying risk markers or factors for ILD in CTD patients without ILD. Second, diagnosing ILD in CTD patients poses uncertainty about the diagnosis of ILD. Third, predicting treatment response and outcomes of CTD patients with ILD. The current management approaches largely depend on lung biopsy or high-resolution computed tomography (HRCT), both of which have limitations in terms of invasiveness and radiation exposure. Serum biomarkers offer the advantages of non-invasiveness, low cost, radiation-free exposure, and thus represent a potential tool for managing ILD.
Methods
Here, we plan to conduct a prospective study to evaluate the value of serum biomarkers for predicting ILD risk, diagnosing ILD, assessing ILD prognosis, and predicting ILD treatment responsiveness in patients with CTD. We named this study “The value of serum biomarkers in diagnosing interstitial lung disease in connective tissue disease: a prospective diagnostic accuracy study” (VELD study). We will prospectively enroll CTD patients with uncertainty regarding ILD who visit the Departments of Rheumatology and Immunology at The Affiliated Hospital of Inner Mongolia Medical University between 2026 and 2028. Their serum specimens will be collected and stored at −80 ℃ for laboratory analyses, including biomarker screening and validation. The predictive and diagnostic values of serum biomarkers for ILD will be estimated using receiver operating characteristic (ROC) curve, decision curve analysis (DCA), logistic regression, net reclassification index (NRI), and integrated discrimination index (IDI).
Discussion
The VELD study will provide a novel insight into the clinical role of serum biomarkers in the management of CTD-associated ILD.
Trial Registration
chictr.org.cn (ChiCTR2600120197).
A randomized controlled trial protocol of herbal formulas for modifying susceptible body constitution to enhance COVID-19 resistance in Hong Kong residents
July 31, 2026: 18(7)
Background
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), triggers symptoms including fever, persistent cough, and respiratory distress. By the week ending May 10, 2025, the Centre for Health Protection of Hong Kong reported a COVID-19 sample positivity rate of 13.66%, with XDV and NB.1.8.1 as the dominant circulating strains. Despite widespread vaccination and hybrid immunity in Hong Kong, breakthrough and reinfections remain common in vulnerable populations. Despite the long history of traditional Chinese medicine (TCM) and its proven effectiveness in epidemic control, its preventive measures against COVID-19, which have been widely adopted in mainland China, have yet to be integrated into Hong Kong’s healthcare system. This study proposes a constitution-targeted preventive approach using TCM herbal formulas for Hong Kong residents at high risk of COVID-19 infection.
Methods
We plan to implement a randomized, forward-looking, quadruple-blind study. Participants with Qi-Yang deficiency or Qi-Yin deficiency will be stratified and allocated to one of four groups, and receive oral herbal granules/placebo at a dosage of 5 grams, twice daily, for a consecutive four-week intervention with TCM formulas customized to their specific TCM body constitution. The primary outcomes will be evaluated using TCM-based self-assessment tools, symptom questionnaires, and a fatigue scale. Secondary outcomes will consist of a detailed questionnaire survey to identify demographic and health factors related to increased vulnerability to COVID-19. The trial adopts a quadruple-blind design (participant, care provider, investigator, outcomes assessor) with allocation concealment implemented via sequentially numbered, opaque, sealed envelopes (SNOSE); the randomization sequence is generated by an independent statistician using random.org and stored in a password-protected central web-based system, with only the unblinded pharmacist having access to the allocation list for drug dispensing. Data management will prioritize confidentiality and data integrity, with statistical analyses conducted using R or SPSS software. Safety outcomes will be analyzed using descriptive statistics (incidence rate, severity grade) and the Chi-squared test/Fisher’s exact test for comparing adverse event rates between groups, while continuous safety indicators will be analyzed using the independent samples t-test.
Discussion
TCM offers a significant holistic paradigm for immune modulation and epidemic prevention. People with Qi-Yang deficiency and Qi-Yin deficiency are at a higher risk of SARS-CoV-2 infection due to impaired innate and adaptive immune function. We hypothesize that customized herbal formula interventions for Qi-Yang and Qi-Yin deficiency constitutions will significantly improve TCM constitution scores and reduce fatigue in Hong Kong residents, and potentially lower COVID-19 infection risk by modulating inflammatory and immune biomarkers, providing a localized TCM preventive strategy for COVID-19 in Hong Kong. The core TCM strategy for preventing COVID-19 is to “invigorate Qi and Yang, as well as to invigorate Qi and Yin” to enhance the body’s resistance to pathogenic factors.
Trial Registration
ClinicalTrials.gov ID: NCT04668222, Registered on 28 April 2021.
Transsternal bronchial closure: a narrative review
July 31, 2026: 18(7)
Background and Objective
Bronchopleural fistula (BPF) after pneumonectomy remains a challenging and potentially life-threatening complication. The transsternal transpericardial approach has been described as an alternative route for selected central or postpneumonectomy BPFs, particularly when access through the previous thoracotomy is unsafe, technically difficult, or has failed. The objective of this review is to summarize the indications, technical principles, adjunctive strategies, outcomes, and limitations of the transsternal transpericardial approach for BPF repair.
Methods
A narrative review of the available literature was performed, focusing on studies, case series, and technical reports describing the transsternal transpericardial approach for BPF. Particular attention was given to patient selection, surgical technique, bronchial stump closure, use of reinforcement, endoscopic adjuncts, morbidity, mortality, recurrence, and the limitations of the current evidence.
Key Content and Findings
The transsternal transpericardial approach provides anterior access to the central airway and allows bronchial stump reamputation and closure while avoiding direct dissection through a chronically infected or hostile pleural cavity. Published series suggest that this technique may achieve durable closure with acceptable morbidity and mortality in selected patients. However, reported outcomes vary considerably across studies, reflecting differences in patient condition, fistula characteristics, timing of repair, presence of empyema, and previous failed treatment attempts. Recently, bronchoscopic and video-assisted techniques have been described as adjuncts to improve diagnosis, fistula localization, operative planning, and intraoperative guidance.
Conclusions
The transsternal transpericardial approach may represent a valuable surgical option for carefully selected patients with central or postpneumonectomy BPF, especially when conventional transthoracic repair is not feasible or has failed. Nevertheless, the available evidence is limited mainly to retrospective series, small cohorts, case reports, and technical descriptions. Therefore, definitive conclusions regarding superiority over other approaches cannot be drawn, and treatment should be individualized according to fistula anatomy, patient condition, pleural sepsis, and surgical expertise.
Endoluminal approaches to postoperative air leaks
July 31, 2026: 18(7)
Postoperative air leaks occur in up to 50% of patients following pulmonary resection, with 8–10% progressing to prolonged air leak (PAL) beyond postoperative day 5. PAL is associated with increased risk of empyema, reoperation, readmission, and prolonged hospitalization, imposing a substantial clinical and economic burden. This chapter provides a comprehensive review of the pathophysiology, risk stratification, diagnostic evaluation, and contemporary endoluminal treatment options for postoperative air leaks. Several preoperative prediction models—including the index of persistent air leak (IPAL), the prolonged air leak score (PALS), and the Gilbert score—have been developed to identify high-risk patients, though discriminatory performance remains moderate and no model-guided strategy has been shown to improve outcomes. Postoperative air leaks are classified temporally, physiologically as drainage-dependent PAL (DDPAL) or drainage-independent PAL (DIPAL), and by severity using analog or digital grading systems. Digital chest drainage systems offer objective airflow quantification and modestly reduce chest tube duration and hospital length of stay (LOS) compared with analog systems, though validated intervention thresholds are lacking. Accurate localization of the air leak source—distinguishing bronchopleural fistula (BPF) from alveolar-pleural fistula—is essential for guiding intervention. Sequential bronchoscopic balloon occlusion remains the most practical localization technique, while surgical methods including indocyanine green (ICG) fluorescence imaging offer complementary approaches. Endoluminal therapies encompass three mechanistic categories: one-way endobronchial valves (EBVs), bronchial occlusion devices (Watanabe spigots), and sealants [fibrin glue, cyanoacrylate, polyethylene glycol (PEG)-based hydrogel], supplemented by autologous blood patch (ABP) therapy. EBVs represent the most extensively studied modality, with a pooled success rate of 82% across 2,472 patients, though evidence is limited to observational studies. Emerging bioengineered approaches—including silk-elastin sponges, bio-three-dimensional (3D) printed cellular plugs, and lung-mimetic hydrofoam sealants—remain preclinical. With careful patient selection, physiologic classification, and appropriate device matching, endoluminal therapies offer minimally invasive alternatives that may reduce morbidity in patients with persistent postoperative air leaks who are not candidates for surgical re-exploration.
When all else fails: a narrative review of surgical options for intercostal neuralgia from a plastic surgery perspective
July 31, 2026: 18(7)
Background and Objective
Intercostal neuralgia (ICN) is a debilitating neuropathic pain syndrome with heterogeneous etiologies, including post-thoracotomy pain, and iatrogenic nerve injury. Despite its significant functional and psychosocial burden, management remains challenging, and literature on surgical interventions is limited. This review aims to synthesize current evidence on surgical options for ICN, with a focus on techniques relevant to plastic and peripheral nerve surgery.
Methods
A narrative review was conducted from database inception through March 2026 using MEDLINE and Embase via Ovid, and PubMed. Search terms included “intercostal neuralgia”, “intercostal nerve injury”, “post-thoracotomy pain”, “neurectomy”, “neurolysis”, “targeted muscle reinnervation (TMR)”, and “regenerative peripheral nerve interface (RPNI)”. Eligible studies included primary research, systematic reviews, and meta-analyses evaluating surgical management, operative techniques, and clinical outcomes of ICN.
Key Content and Findings
Surgical management is typically reserved for refractory ICN after failure of pharmacologic and interventional therapies. Intercostal neurectomy remains the most widely studied technique, demonstrating substantial and durable pain reduction, with success rates exceeding 80% in several case series. Neurolysis and nerve decompression offer benefit in selected patients with compressive etiologies. Minimally invasive approaches, including percutaneous endoscopic neurectomy and radiofrequency ablation (RFA), provide effective pain relief with lower procedural morbidity. Emerging reconstructive techniques such as TMR and RPNI represent a paradigm shift by addressing the underlying pathophysiology of neuroma formation. Early evidence suggests significant pain reduction and improved quality of life; however, data remain limited to small cohorts.
Conclusions
Surgical interventions offer promising and potentially durable relief for refractory ICN, particularly when guided by accurate diagnosis and patient selection. While traditional approaches focus on interrupting nociceptive signaling, emerging nerve reconstruction techniques may provide more definitive solutions by preventing maladaptive nerve regeneration. Further high-quality studies are needed to establish standardized treatment algorithms and clarify the role of these novel techniques in ICN management.

Latest Articles

Idiopathic pulmonary fibrosis and interleukins: a bibliometric analysis [1999–2025]
Journal of Thoracic Disease. July 31, 2026: 18(7)
Background
Idiopathic pulmonary fibrosis (IPF) is a long-term lung condition, with limited therapeutic options and an overall poor prognosis. Accumulating evidence indicates that interleukins (ILs) are essential for the initiation and course of IPF, with certain IL signaling pathways contributing to disease pathogenesis while simultaneously emerging as potential therapeutic targets. This study aims to highlight the progress and current research priorities in the field of IPF and ILs, thereby laying the foundations for the development of targeted therapies for IPF.
Methods
In this study, research articles and clinical studies related to IPF and ILs were retrieved from the Web of Science Core Collection (WOSCC) and PubMed databases. Bibliometric and visual analyses were performed using CiteSpace 6.3.R3, VOSviewer 1.6.20, the R package bibliometrix, and SCImago Graphica to systematically characterize the research landscape and identify emerging hotspots in this field.
Results
A total of 832 publications and 15 clinical studies were included. The results demonstrate a steadily increasing research interest in the IPF-IL field, with analyses of references and keywords highlighting disease mechanism elucidation and therapeutic strategy development as the dominant research themes. Keyword burst analysis further indicates sustained prominence of topics such as pirfenidone, diagnosis, and fibrosis, suggesting their relevance to current and near-future research directions.
Conclusions
Overall, this study constructs a structured knowledge map of the IPF-IL research landscape, identifies potential avenues for future investigation, and offers priority guidance for subsequent mechanistic validation, clinical stratification, and therapeutic efficacy prediction in IPF.
On-call work schedules, sleep knowledge, and sleep quality in medical trainees: results from a UK pilot study
Journal of Thoracic Disease. July 31, 2026: 18(7)
Background
Evidence suggests that shift work and nocturnal on-call rotations have negative effects on the health of medical trainees. Data regarding the optimal frequency and duration of shifts that benefit the health of medical trainees, patient safety, and medical education are inconclusive. Additionally, the extent of medical trainees’ knowledge about sleep medicine and its impact on their well-being during on-call periods remains unclear. The aim of this study was to evaluate the knowledge of trainees around sleep when on call and further elicit the impact of on-call periods on their sleep.
Methods
We sought to gather data on the effect of shift work and being on-call on sleep in medical trainees. The study was prospectively registered on ClinicalTrials.gov (NCT06706453; registered 11/09/2024). It was designed as a cross-sectional, online survey conducted through a secure online link (REDCap 14.0.42, Vanderbilt University, Nashville, TN, USA) to cover (I) demographics and place of work; (II) basic knowledge and perception of sleep; (III) sleep routine during “on-call” and “off-call”; and (IV) sleep-related questionnaires [Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI)]. A level of significance was indicated at P<0.05. Medical trainees were recruited through online distribution of the survey link via professional networks, institutional mailing lists, and trainee groups.
Results
The study was open between February and April 2025, with 107 respondents [mean ± standard deviation (SD): age 32±6 years; height 1.70±0.10 m; weight 69.3±14.6 kg; 41% male, 55% female, 4% identified as other; 28% were single, 73% lived in a relationship, and 32.0% had children; 82% were resident physicians]. The regular on-call working time per day was significantly higher than when not being on call, with a median of 13 [interquartile range (IQR), 12, 13] vs. 9 (IQR, 9, 10) hours, P<0.05. During on-call periods, respondents experienced shorter sleep duration with 6 (IQR, 5, 7) vs. 7 (IQR, 6.5, 8) hours, more difficulties falling asleep (70% vs. 27%) and maintaining sleep (63% vs. 23%), and required more daytime naps (50% vs. 12%) (P<0.05, respectively). Time on the commute (one way) was negatively correlated with self-rated current sleep (Spearman r=−0.492; P=0.01). Knowledge about obstructive sleep apnea (OSA) was positively correlated with the sense of well-being (Spearman r=0.426; P=0.03), negatively correlated with the ESS score (Spearman r=−0.429; P=0.046), and negatively correlated with early awakening (Spearman r=−0.378; P=0.043).
Conclusions
Medical trainees in the UK experience long on-call working hours with an impact on sleep quality and quantity. These findings have implications on work performance and social interactions. Sleep education may be used to improve sleep and well-being.
Local fluid application and needle insertion in gravity-dependent areas to reduce the risk of pneumothorax during lung nodule localization: a single-center observational study
Journal of Thoracic Disease. July 31, 2026: 18(7)
Background
Pneumothorax is a common and clinically significant complication during computed tomography (CT)-guided preoperative lung nodule localization. This study aimed to evaluate the clinical outcomes of a novel strategy—combining extrapleural local fluid application with gravity-dependent needle insertion—for reducing the risk of pneumothorax in an observational setting.
Methods
A total of 166 patients who underwent preoperative CT-guided percutaneous pulmonary nodule (PN) localization and completed thoracoscopic surgery at The First Affiliated Hospital of Kunming Medical University between June 1, 2024, and November 1, 2024, were included in this study. Patients were grouped based on whether they received the CT-guided injection of 2% lidocaine outside the parietal pleura and the area of the localization needle insertion point. Baseline information, nodule-related details, localization-related data, and complications were collected and compared between groups and subgroups.
Results
The pneumothorax incidence was analyzed among the four groups: FD (fluid application + gravity-dependent area) group: 1/33 case (3%) < FnD (fluid application + non-dependent area) group: 4/44 cases (9%) < nFD (non-fluid application + gravity-dependent area) group: 6/36 cases (17%) < nFnD (non-fluid application + non-dependent area) group: 19/37 cases (51%), with statistically significant differences (P<0.001). Multivariate analysis indicated that lidocaine injection beneath the pleura [P<0.001, odds ratio (OR) =0.07, 95% confidence interval (CI): 0.02–0.24] and needle insertion in gravity-dependent areas (P<0.001, OR=0.16, 95% CI: 0.05–0.48) were independent risk factors for pneumothorax. In the F group (FD + FnD), 53% of patients reported no pain (score 0), and 47% experienced mild pain (score 1–3). In the nF group (nFD + nFnD), 91% of patients experienced mild pain, and 9% reported moderate pain (score 4–6), with P<0.001. Complication-related analysis showed a positive correlation between pneumothorax and pain, as well as between pain and pleural reactions, with statistically significant differences.
Conclusions
Prior to percutaneous CT-guided lung nodule localization, the precise administration of 10 mL of lidocaine external to the parietal pleura, coupled with the selection of an appropriate needle insertion site within the gravity-dependent region, can reduce the incidence of pneumothorax during CT-guided localization of PNs. The use of lidocaine outside the parietal pleura can reduce the pain felt by patients during the localization process, increase comfort, and enhance the embodiment of humanistic care.