Deep learning-based facial analysis for predicting difficult videolaryngoscopy: a feasibility study

While videolaryngoscopy has resulted in better overall success rates of tracheal intubation, airway assessment is still an important prerequisite for safe airway management. This study aimed to create an artificial intelligence model to identify difficult videolaryngoscopy using a neural network. Baseline characteristics, medical history, bedside examination and seven facial images were included as predictor variables. ResNet-18 was introduced to recognise images and extract features. Different machine learning algorithms were utilised to develop predictive models. A videolaryngoscopy view of Cormack-Lehane grade of 1 or 2 was classified as 'non-difficult', while grade 3 or 4 was classified as 'difficult'. A total of 5849 patients were included, of whom 5335 had non-difficult and 514 had difficult videolaryngoscopy. The facial model (only including facial images) using the Light Gradient Boosting Machine algorithm showed the highest area under the curve (95%CI) of 0.779 (0.733-0.825) with a sensitivity (95%CI) of 0.757 (0.650-0.845) and specificity (95%CI) of 0.721 (0.626-0.794) in the test set. Compared with bedside examination and multivariate scores (El-Ganzouri and Wilson), the facial model had significantly higher predictive performance (p < 0.001). Artificial intelligence-based facial analysis is a feasible technique for predicting difficulty during videolaryngoscopy, and the model developed using neural networks has higher predictive performance than traditional methods.

The effects of gastric cancer interstitial fluid on tumors based on traditional Chinese medicine 'phlegm' theory and the investigation on the mechanism through microRNA-21 regulation

This study aimed to investigate the effects of gastric cancer interstitial fluid (GCIF) on tumors and explore the possible mechanism of Xiaotan Sanjie decoction (XTSJ) on treatment of gastric cancer from the view of regulating microRNA-21 (miR-21) expression. The GCIF was extracted and identified by measuring the levels of interleukin-8 (IL-8), intercellular adhesion molecule 1 (ICAM-1) and miR-21. The effects of GCIF on the proliferation of SGC-7901 cells and tumor growing were assessed by cell counting kit-8 (CCK-8) assay and subcutaneously transplanted tumor-bearing nude mice model, respectively. Additionally, inhibition effect of XTSJ decoction on proliferation of SGC-7901 cells intervened by GCIF were assessed in vitro and anti-cancer effect of it was further assessed using orthotopic transplanted tumor-bearing nude mice model. The concentration of SGC-7901 gastric cancer cells were dependent on the concentration of the added GCIF. After 72 hours of continuous culture, the interstitial fluid had an obvious proliferative effect on the SGC-7901 tumor cells, which was the most significant in the high concentration group. XTSJ decoction could inhibit the growth-promoting effect (P < 0.01) of GCIF on gastric cancer cells. Intervention of the GCIF might promote the growth (P < 0.05) of the subcutaneously transplanted tumors in nude mice and decrease the net weight of the tumor-bearing nude mice (P < 0.05) after tumor removal. The GCIF was able to up-regulate the expression (P < 0.001) of miR-21 in the subcutaneously transplanted tumors. XTSJ decoction could downregulate the expression (P < 0.05) of miR-21 in SGC-7901 orthotopically transplanted tumors. XTSJ decoction can inhibit the multiplicative effect of GCIF on gastric cancer cells, growth of gastric tumor and promotion effect of GCIF on tumors, probably due to the down-regulating miR-21 expression in tumor tissues.

[Effects of tetrahydrobiopterin on the angiogenesis in hepatocellular carcinoma]

Objective: To investigate the effect and mechanism of tetrahydrobiopterin (BH4) on the angiogenesis in hepatocellular carcinoma (HCC). Methods: BALB/c-nu mice were subcutaneously injected with HepG-2 cells and randomly divided into control and BH4 groups. The BH4 group and control group received 20 mg/kg BH4 or saline by intraperitoneal injection daily for two weeks, respectively. The level of BH4 was measured by high performance liquid chromatography (HPLC), the level of nitric oxide (NO) was measured by Griess test array, the transcriptional level of K-ras was measured by quantitative RT-PCR, and the protein expressions of guanosine triphosphate cyclohydrolase Ⅰ(GTPCH), endothelial nitric oxide synthase (eNOS), phospho-Akt and Akt were determined by Western blot. Results: BH4 level in the tumor tissues of BH4 group was (0.24±0.02) μg/ml, significantly higher than the (0.17±0.01) μg/ml in the control group (P<0.01). The level of NO in the tumor tissues of BH4 group was (51.44±2.90) mmol/L, significantly higher than the (24.77±0.54) mmol/L in the control group (P<0.01). The tumor volume of BH4 group was (191.05±8.70) mm3, significantly higher than the (103.10±5.03) mm3 in the control group (P<0.01). The expressions of CD34, K-ras, phospho-eNOS, phospho-Akt and GTPCH were significantly up-regulated in the tumor tissues of BH4 group when compared with those of the control group (P<0.01). Conclusions: BH4 recognized as an essential cofactor of eNOS can increase tumor-produced NO by activating the wild-type Ras-PI3K/Akt pathway, thus induces angiogenesis. This might provide a novel and promising way to control the progression of hepatocellular carcinoma through targeting BH4 synthesis pathway and inhibiting angiogenesis.

Aggravation of spinal cord compromise following new osteoporotic vertebral compression fracture prevented by teriparatide in patients with surgical contraindications

Patients with spinal cord deficits following new unstable osteoporotic compression fracture and surgical contraindications were considered to receive conservative treatment. Teriparatide was better than alendronate at improving bone mineral density and bone turnover parameters, as well as preventing aggravation of spinal cord compromise.

INTRODUCTION

This study compared the preventive effects of teriparatide and alendronate on aggravation of spinal cord compromise following new unstable osteoporotic vertebral compression fracture (OVCF) in patients with surgical contraindications.

METHODS

This was a 12-month, randomized, open-label study of teriparatide versus alendronate in 49 patients with new unstable OVCF and surgical contraindications. Neurological function was evaluated using modified Japanese Orthopedic Association (mJOA) score (11-point scale, the maximum score of 11 implies normalcy). Visual analog scale (VAS) scores, kyphotic angles, anterior-border heights and diameters of the spinal canal of the fractured vertebrae, any incident of new OVCFs (onset of OVCF during follow-up), spine bone mineral density (BMD), and serum markers of bone resorption and bone formation were also examined at baseline and 1, 3, 6, and 12 months after initiation of the medication regimen.

RESULTS

At 12 months, mean mJOA score had improved in the teriparatide group and decreased in the alendronate group. Mean concentrations of bone formation and bone resorption biomarkers, mean spine BMD, and mean anterior-border height and spinal canal diameter of the fractured vertebrae were significantly greater in the teriparatide group than in the alendronate group. Mean VAS score, mean kyphotic angle of the fractured vertebrae, and incidence of new OVCFs were significantly smaller in the teriparatide group than in the alendronate group.

CONCLUSIONS

In patients with neurological deficits following new unstable OVCF and with surgical contraindications, teriparatide was better than alendronate at improving the BMD and the bone turnover parameters, as well as preventing aggravation of spinal cord compromise.

The effect of methadone on the QTc interval in advanced cancer patients

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Background: Methadone (ME) has been used increasingly for pain control and for maintenance in drug addiction programs. Its use is increasing in cancer patients (pts), mainly as part of opioid rotation. Some recent reports suggest that ME may prolong QTc interval and cause torsade de pointes in pts on high dose ME. The purpose of our study was to determine the effect of initiation of ME on QTc interval in pts with cancer pain. Methods: We enrolled 101 pts in this prospective study. These pts had never been on ME before. Pts were followed clinically and electrocardiographically for QTc changes from baseline. EKG was obtained at baseline (QTc0), 2 (QTc2), 4 (QTc4), and 8 (QTc8) weeks. We recorded other contributing factors for QTc prolongation such as medication interactions with ME and electrolyte disturbances. QTc is prolongation is defined as > 430 ms in males and > 450 ms in females. In our study, significant QTc prolongation was defined as = 10% increase from baseline or QTc = 500 msec. Results: 74 pts (73%) had normal QTc (group A) and 27 pts (27%) had prolonged QTc (group B) at baseline. Significant increase in QTc in group A males occured in 1 of 16 (6%) at week 2, 2 of 10 (20%) at week 4, and 0 of 8 (0%) at week 8. Significant increase in QTc in group A females occured in 3 of 32 (10%) at week 2, 1 of 21 (5%) at week 4, and 0 of 12 (0%) at week 8. These pts had multiple contributing factors for QTc prolongation. QTc > reference for males occured in 6 of 16 (37%) at week 2, 4 of 10 (40%) at week 4, and 1 of 8 (12%) at week 8; in females, 1 of 32 (3%) at week 2, 3 of 21 (14%) at week 4, and 1 of 12 (8%) at week 8 ( Table 1 ). 2 of 27 pts (7%) from group B had a significant prolongation at week 2: one of them had an increase from 498 to 509 ms, then to 512 at week 4 and 486 at week 8. Conclusions: Baseline prolonged QTc is a common finding. QTc prolongation = 500 ms is rare in pts receiving ME for cancer pain. No data exists for other opioids. There was one case of temporary increase in QTc > 500 ms. There was no evidence of severe arrhythmias or torsade de pointes clinically or on EKG. ME dose was = 50 mg/day in the majority of these pts.

[Table: see text]

No significant financial relationships to disclose.

Interval between first palliative care consultation and death in patients with advanced cancer

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Background: Most referrals to acute palliative care (PC) services occur late in the trajectory of the disease, although an earlier intervention can decrease patients’ (pts) symptoms distress. The purpose of this study was to determine the time interval between first palliative care consultation (PC1) and death (D) in pts diagnosed with advanced cancer (aCA) at our comprehensive cancer center and whether such interval has increased over time. Methods: The study group was 2,868 consecutive pts who had their PC1 during a 30-month period. We reviewed the charts for information about demographics, cancer type, date of cancer diagnosis, aCA diagnosis, PC1, and D. aCA was defined as locally recurrent or metastatic. Results: 1,404 pts (49%) were female, 1,791 (62%) were < 65 years old, 2,563 (89%) had solid cancer, and 2,004 (70%) were white. The median PC1-D, aCA- PC1, and aCA-D intervals were 40, 114, and 243 days respectively. The median PC1-D interval (days) was: 47 for pts with solid cancer vs 14 for pts with hematological malignancy (p < 0.0001); 44 for pts < 65 years old vs 36 for pts = 65 years old (p = 0.002); 45 for females vs 37 for males (p = 0.004); 40 for white pts vs 41 for pts from other ethnicities (p = 0.42). The median PC1-D interval in 5 consecutive half-years was 46, 56, 42, 41, and 34 days respectively (p = 0.02). The total number of pts referred for PC1 in this period increased 20%, from 544 to 654. The ratio of PC involvement period in the aCA-D interval (PC1-D/aCA-D) decreased from 0.30 to 0.26 over the 5 half-year periods (p = 0.0004) ( Table ). Conclusions: Patients with solid cancers, younger pts, and females pts were referred earlier to acute PC. Referral timing was not affected by ethnicity. The interval between first palliative care consult and death has decreased over time. Education is needed among referring physicians to increase this interval. Further research on increasing acute PC access and its impact on PC1-D interval is needed.

[Table: see text]

No significant financial relationships to disclose.

Donepezil for cancer-related fatigue: A double-blind, randomized, placebo-controlled study

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Background: Fatigue is the most frequent symptom in advanced cancer. No standard treatment is available. We previously found that open-label donepezil significantly improved fatigue by day 3 and 7 in patients (pts) on opioids for cancer pain (Fisch et al, ASCO 2003). The purpose of this study was to compare donepezil (D) with placebo (P) for fatigue in pts with advanced cancer. Methods: In this randomized, double-blind, placebo-controlled trial, pts with fatigue score = 4 on a 0 to 10 scale (10 = worst fatigue) for > 1 week, hemoglobin = 10g/dl for = 4 weeks, and no major contraindication to D were randomized to receive D 5 mg or P orally every morning for 7 days. All pts were offered open-label D during week 2. Assessment included: research nurse daily phone call for fatigue and toxicity evaluation, Edmonton Symptom Assessment System (ESAS), Functional Assessment for Chronic Illness Therapy-Fatigue (FACIT-F), Sleeping Pattern Assessment, and overall effectiveness of the treatment. The FACIT-F fatigue subscale score on day 8 was considered the primary endpoint. Results: 103 pts were evaluable for final analysis. Mean difference in scores for symptoms intensity between baseline and day 8 are shown in Table 1 . FACIT-F fatigue subscale score at day 8 decreased a mean of 6 (10.6 SD) in the D arm (p < 0.001) and 7.2 (9.5 SD) in the P arm (p < 0.001). There was no significant difference in fatigue improvement between both arms according to the FACIT-F subscale (p = 0.57) and ESAS fatigue (p = 0.18) scores, and no significant difference in sleep quality score between D and P. On day 15 of the open-label phase, mean fatigue intensity remained significantly improved as compared to baseline on FACIT-F fatigue subscale (p < 0.001) and ESAS fatigue (p < 0.001) scores. No significant toxicities were observed. Conclusions: Both donepezil and placebo resulted in significant fatigue improvement. Donepezil was not significantly superior to placebo after one week. Our pilot findings are probably due to placebo effect.

No significant financial relationships to disclose.

[Table: see text]

Spirituality, quality of life, and locus of control in a palliative care setting

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Background: A patient’s spirituality/religious beliefs have a profound role on how one copes with disease & on quality of life (QOL). Perceptions of control play an important role in coping not only with stressful experiences, but also in health outcomes. Therefore, the primary objective was to determine whether patients’ spirituality/ religiosity correlates with quality of life and locus of control. Methods: As part of a pilot study, pts presenting for initial outpatient evaluation in the Department of Symptom Control & Palliative Care were enrolled and completed self-report measures: Functional Assessment of Chronic Illness Therapy-General (FACT-G), FACT-Spiritual Well-Being Scale (FACT-Sp), Duke University Religion Index (DUREL), Locus of Control (LOC), Herth Hope Scale (HHS), Predestination (PDQ), and Hospital Anxiety & Depression Scale (HADS). LOC contained 3 subscales: perceived occurrence of chance, dependence on powerful others, and internal control. Pearson correlation coefficients were calculated to explore the relationship between measures. The Mann-Whitney t-test was used to compare patient scores. Results: One hundred patients (48 men & 52 women) completed the surveys & 90% reported a Christian affiliation. QOL was positively correlated with FACT-Sp (p ≤ 0.001, r = .614) and the DUREL which measures both external/internal religiosity (p ≤ .01, r = .291). Interestingly, there was no gender difference in spirituality as measured by FACT-Sp; however, by the DUREL women engaged more frequently in private religious activity when compared with men (p < 0.001). Men had more perceived internal control with less emphasis on the occurrence of chance events or dependence on powerful others on LOC (p = 0.07), as well as a positive correlation with controlling of one’s own fate as measured by the PDQ (p = 0.1). Conclusions: As oncologists committed to providing comprehensive care, we need to be receptive to the spiritual needs of our patients since it augments their QOL and to empower them to have a sense of control. Future studies need to further define these complex relationships and to recognize possible gender differences.

No significant financial relationships to disclose.

Switching from methadone to a different opioid: What is the equianalgesic dose ratio?

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Background: Methadone (ME) is a highly effective opioid agonist used for difficult pain syndromes. However, the rotation from ME to another opioid may be difficult because of the absence of a uniformly accepted conversion ratio. Methods: We retrospectively reviewed consecutive medical records of Pts undergoing an opioid rotation from ME to an alternative opioid. For inclusion, Pts were required to have received ME for at least 3 days prior to the switch and reach a stable dose of the alternative opioid(s) during 7 days following. Stable dose was defined as a 30% or less change in opioid dose from one day to the next. For purposes of analysis, on the day before the switch, doses, were divided into ME doses and the oral morphine equivalent daily dose (MEDD), based on medication and route of all other opioids taken on that day, using standard equinalgesic tables. All doses after the switch were converted to the MEDD. For Pts receiving ME and a second opioid prior to the switch, the MEDD of the second opioid was subtracted from the MEDD calculated for the day when stable dose was reached. The remainder was used to calculate the equianalgesic raio with the previous ME dose. Results: Records on 39 Pts met inclusion criteria. Excluded from analysis were 5 Pts who were restarted on ME in < 8 days, 2 whose opioid dose markedly decreased of post switch, and 3 due to concerns about reliability of multiple routes used for fentanyl. Data from 29 Pts, 10 female, mean age 48 ±14.4 were evaluable. The ratio for: oral ME to MEDD was 1:4.7 (CL 3.0–6.5)(n=16), IV ME to MEDD was 1:13.5 (CL6.6–20.5)(n=13), p=0.06. ME dose is significantly correlated to stable MEDD after switching opioids for both ME IV and oral (Spearman=0.86,p=0.0001 and Spearman=0.72, p=0.0024, respectively. Mean day of achieving stable dose was on day 2.5 ±0.2 for IV ME and day 2.6±0.3 for oral ME. Conclusions: These dose ratios are new findings that will assist in switching Pts more safely to alternative opioids, when side effects or pain problems occur.An important difference in analgesic potency appears to exist between IV and oral ME. Further research with prospective studies is required.

No significant financial relationships to disclose.

Characterization of cancer pain syndromes (PS) seen at a Comprehensive Cancer Center (CCC) and pain response (PR) to palliative care consultation (PCC)

8551

Background: Comparison of cancer PS across settings is challenging due to differences in prognostic features. Data from 1 CCC participating in a multi-site international study of a pain classification system is presented to characterize cancer PS & response to PCC. Methods: The Edmonton Classification System for Cancer Pain was completed by prospective chart review to characterize PS of 100 consecutive hospitalized patients (pts) seen in PCC. Pts were followed until major PR, hospital discharge or death. Major PR was defined as <2 p.r.n. opioid doses/d & pain intensity (PI) <3/10 for 3 consecutive days (d). Results: 85% of pts had pain (n=85), with age 62.9+13.3, 47.1% male & KPS 44.5+23.1. The most common tumor diagnoses were lung (24.7%) & GU (21.2%). Pts were followed for a median of 4 d (0–27). 39% achieved a major PR. Except for steroids (49.4%) & anticonvulsants (29.4%), other adjuvant analgesic use was all <10%. Pain-associated features: *Numeric Rating Scale 0–10, 10=worst suggestivie of alcoholism + Mean morphine equivalent dailydose On univariate analysis, older age (p=.006), lower initial PI (p=.003), lower final PI (p=.001) & lower final MEDD (p=.002) were significantly associated with achieving major PR. On multivariate analysis, lower initial PI (p=.03) & lower final MEDD (p=.02) retained significance for achieving major PR. Conclusions: Only 39%of pts with cancer pain seen in PCC achieve a major PR by discharge or death. Despite aggressive opioid titration, 61% do not achieve a major PR & require better pain management. Potential strategies for achieving improved PR include earlier PCC, identification of more sensitive prognostic variables &critical evaluation of targeted therapies.

[Table: see text]

No significant financial relationships to disclose.

[Clinical application of sural nerve island flap pedicled with collateral vessels]

OBJECTIVE

To sum up the application experience of the sural nerve island flap pedicled with the collateral vessels.

METHODS

From 1997, the retrograde-flow sural nerve island flaps pedicled with collateral vessels were performed to repair the soft tissues defects of the shank in 3 cases, ankle in 3 cases and foot in 8 cases.

RESULTS

Twelve flaps were survived, one flap was partially necrosed and one flap was necrosed. Among them, 10 wounds healed by first intention, 3 cases were healed after changing dressing and the one necrosed flap was repaired by free flap transplantation. Nine cases were followed up for 3 to 21 months and had fine appearance and function. The flap texture was similar to normal skin, the sensation of flap partially recovered after 6 months.

CONCLUSION

The flap has more reliable blood supply and great rotation arc, it is easy to resect with little injury. It is excellent for repairing the soft tissues defect in the anterior leg, ankle and proximal half of foot. It is more significant while the main blood vessels are damaged.

[An epidemiological investigation of eperythrozoon infection in human and animals (II)]

This paper reported an epidemiological investigation on human and animals infection of eperythrozoon in 1 provinces. The results showed that eperythrozoon infection appeared in human as well as in swines, sheep, cats, donkeis and chickens. Due to geographical variations, the infection rates showed a significant difference, both in human and animals. The infection rate was not associated with sex, age or occupation in human, but was associated with seasons in animals. High peak of infection rates in animals was in May, June, July and August.