Diagnostic Accuracy for Acute Rib Fractures: A Cross-sectional Study Utilizing Automatic Rib Unfolding and 3D Volume-Rendered Reformation

RATIONALE AND OBJECTIVES

The aim of this study was to compare the use of computed tomography (CT) with automatic rib unfolding and three-dimensional (3D) volume-rendered imaging in the detection and characterization of rib fractures and flail chest.

MATERIALS AND METHODS

A total of 130 patients with blunt chest trauma underwent whole-body CT, and five independent readers assessed the presence and characterization of rib fractures using traditional CT images, automatic rib unfolding, and 3D volume-rendered images in separate readout sessions at least 2 weeks apart. A gold standard was established by consensus among the readers based on the combined analysis of conventional and reformatted images.

RESULTS

Automatic rib unfolding significantly reduced mean reading time by 47.5%-74.9% (P < 0.0001) while maintaining a comparable diagnostic performance for rib fractures (positive predictive value [PPV] of 82.1%-93.5%, negative predictive value [NPV] of 96.8%-98.2%, and 69.4%-94.2% and 96.9%-99.1% for conventional axial images and 70.4%-85.1% and 95.2%-96.6% for 3D images) and better interobserver agreement (kappa of 0.74-0.87). For flail chest, automatic rib unfolding showed a PPV of 85.7%-100%, NPV of 90.4%-99.0%, and 80.0%-100% and 89.7%-100% for conventional axial images and 76.9%-100% and 89.0%-92.1% for 3D images.

CONCLUSION

Automatic rib unfolding demonstrated equivalent diagnostic performance to conventional images in detecting acute rib fractures and flail chest, with good interobserver agreement and time-saving benefits.

Prehospital ultrasound scanning for abdominal free fluid detection in trauma patients: a systematic review and meta-analysis

INTRODUCTION

Focused assessment with sonography for trauma helps detect abdominal free fluid. Prehospital ultrasound scanning is also important because the early diagnosis of hemoperitoneum may reduce the time to definitive treatment in the hospital. This study investigated whether prehospital ultrasound scanning can help detect abdominal free fluid.

MATERIALS AND METHODS

In this systematic review, relevant databases were searched for studies investigating prehospital ultrasound examinations for abdominal free fluid in trauma patients. The prehospital ultrasound results were compared with computed tomography, surgery, or hospital ultrasound examination data. The pooled sensitivity and specificity values were analyzed using forest plots. The overall predictive power was calculated by the summary receiver operating characteristic curve. The quality of the included studies was assessed using the quality assessment of diagnostic accuracy studies tool. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was performed to assess the certainty of evidence.

RESULT

This meta-analysis comprised six studies that included 1356 patients. The pooled sensitivity and specificity values were 0.596 (95% confidence interval [CI] = 0.345-0.822) and 0.970 (95% CI = 0.953-0.983), respectively. The pooled area under the summary receiver operating characteristic curve was 0.998. The quality assessment tool showed favorable results. In the GRADE analysis, the quality of evidence was very low for sensitivity and high for specificity when prehospital ultrasound was used for hemoperitoneum diagnosis.

CONCLUSION

The specificity of abdominal free fluid detection using prehospital ultrasound examinations in trauma patients was very high.

Reconstructing Signaling Networks Using Biosensor Barcoding

Understanding how signaling networks are regulated offers valuable insights into how cells and organisms react to internal and external stimuli and is crucial for developing novel strategies to treat diseases. To achieve this, it is necessary to delineate the intricate interactions between the nodes in the network, which can be accomplished by measuring the activities of individual nodes under perturbation conditions. To facilitate this, we have recently developed a biosensor barcoding technique that enables massively multiplexed tracking of numerous signaling activities in live cells using genetically encoded fluorescent biosensors. In this chapter, we detail how we employed this method to reconstruct the EGFR signaling network by systematically monitoring the activities of individual nodes under perturbations.

The Coronary Reperfusion Effect and Safety of Prehospital P2Y12 Inhibitor in Primary-PCI STEMI Patients: A Systematic Review and Meta-Analysis

BACKGROUND

The concept of early administration of P2Y12 inhibitor in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) is widely accepted, but whether prehospital administration results in greater coronary reperfusion remains unclear. Our study aims to analyze the benefit and safety of prehospital P2Y12 inhibitor compared to in-hospital P2Y12 inhibitor administration.

METHOD

Three databases (PubMed, EMBASE, and Cochrane Library) were searched from database inception to June 2023. We included all types of studies except for conference publications, abstract presentations, reviews, and case reports. The primary outcomes were pre-PCI TIMI flow grade 2-3 (TIMI = Thrombolysis in Myocardial Infarction) and major bleeding. The secondary outcomes included post-PCI TIMI flow grade 2-3, major adverse cardiac events (MACE), recurrent myocardial infarction (MI), and short-term (30-day) mortality.

RESULT

Eight individual studies with a total of 10823 patients were included in our meta-analysis. Compared with in-hospital P2Y12 inhibitor, prehospital P2Y12 inhibitor were associated with significantly higher rates of pre-PCI TIMI flow grade 2-3 (OR 1.32, 95% CI: 1.09-1.61, p = 0.005) and post-PCI TIMI flow grade 2-3 (OR 1.43, 95% CI: 1.04-1.97, p = 0.03), and a significantly lower risk of recurrent MI (OR 0.69, 95% CI: 0.49-0.96, p = 0.03). There were no significant difference in the risk of major bleeding (OR 1.00, 95% CI: 0.75-1.32, p = 0.98), MACE (OR 0.94, 95% CI: 0.70-1.25, p = 0.65), or short-term mortality (OR 0.87, 95% CI: 0.50-1.51, p = 0.61).

CONCLUSION

Prehospital P2Y12 inhibitor compared to in-hospital P2Y12 inhibitor is associated with a significantly higher rate of pre-PCI and post-PCI TIMI flow grade 2-3, a reduced risk of recurrent MI, and no increase in major bleeding in STEMI patients undergoing primary PCI.

Clinical Outcomes of Sidewall/Parametrial Simultaneous Integrated Boost for Patients with Cervical Cancer

PURPOSE/OBJECTIVE(S)

In the treatment of cervical cancer, simultaneous integrated boost (SIB) is a common technique to deliver increased dose to gross disease in the para-aortic and pelvic nodal basins. However, SIB to the pelvic sidewall/parametria is not well characterized in the literature. We hypothesized that sidewall simultaneous integrated boost (SIB) in the treatment of cervical cancer is associated with acceptable levels of toxicity.

MATERIALS/METHODS

From 1/2009-12/2018, patients who received concurrent chemoradiation with external beam radiation therapy, utilizing a sidewall SIB technique, followed by low dose rate or high dose rate brachytherapy treatment were retrospectively identified. Sidewall SIB was defined as treatment at 2.1-2.4Gy/fraction to the parametria-usually performed for those with disease width >4cm at time of treatment start. Acute and late toxicity grading was defined by the Common Terminology Criteria for Adverse Events Version 5.0. Overall survival (OS), local control, progression-free survival (PFS), and toxicity were analyzed utilizing the Kaplan Meier method. Potential associations between cumulative D2cc for bladder and rectum and time to toxicity were investigated using Cox regression.

RESULTS

Fifty-six patients with IB2-IVB cervical cancer treated with sidewall SIB were identified, with a median follow up of 7.0 years (95% CI: 6.3, 8.3). Patients had a median age of 43 years (range: 26-68); 2 (3.6%) had FIGO stage I, 7 (12.5%) stage II, 46 (82.1%) stage III, and 1 (1.8%) stage IV disease. A majority had squamous cell histology (83.9%). Nearly all patients (96.4%) received concurrent cisplatin chemotherapy. Rates of acute grade ≥3 gastrointestinal (GI), genitourinary (GU), vaginal, and hematologic toxicity were 1.8%, 1.8%, 0%, and 15.9% respectively. Rates of late grade ≥3 GI, GU, and vaginal toxicity were 11.3%, 18.5%, and 11.1% respectively. OS and local control rates at five years were 0.61 (95% CI: 0.46, 0.73) and 0.95 (95% CI: 0.84, 0.98), respectively. Median PFS was 7.8 years (95% CI: 2.4, Not reached). Cumulative D2cc bladder was not significantly associated with time to Grade 2 or greater (HR 1.04, p = 0.33) or Grade 3 or greater (HR 1.02; p = 0.64) GU toxicity. Cumulative D2cc rectum was not significantly associated with time to Grade 2 or greater (HR 1.06, p = 0.06) or Grade 3 or greater (HR 1.08; p = 0.09) GI toxicity.

CONCLUSION

Sidewall SIB is a feasible technique for dose escalation in the treatment of cervical cancer with rates of acute and late toxicity consistent with other reports.

Hyperbaric Oxygen Therapy Attenuates the Whole Brain Radiotherapy-Induced Progressive Cognitive Dysfunction via Promoting Hippocampal Neurogenesis in Rats

PURPOSE/OBJECTIVE(S)

Radiation therapy is a widely used brain tumor treatment; however, it can cause significant effects on the central nervous system, including neurogenesis impairment, microglia activation, and oxidative stress, leading to brain injury. Hyperbaric oxygen therapy (HBOT) has been shown to benefit various neurological conditions, but its effect on radiation-induced brain injury damage remains limited. This study aims to investigate the impact of HBOT on radiation-induced neurogenesis impairment, microglia activation, and lipid peroxidation levels, and also aim to assess the therapeutic potential of HBOT on preventing irradiation-induced brain injury.

MATERIALS/METHODS

This study used a rat model that delivered different doses (2, 4, 10 Gy) of whole-brain radiation therapy (WBRT). The rats were divided into two groups: one received HBOT, and the other acted as the control (normal baric air, NBA) group. HBOT was performed on day 8 of post-radiation once per day for five consecutive days a week for four weeks. The rats were subjected to different irradiation dosages as described, followed by administration of 5-chloro-2'-deoxyuridine (CldU) immediately at day 0 or day 0 to day 7 and 5-iodo-2'-deoxyuridine (IdU) at day 2 or day 14 to day 28 following WBRT to detect serially replicating cells. Then the rats underwent behavioral tests to assess their cognitive and motor function every week. Brain tissues were collected and analyzed to evaluate neurogenesis, microglia activation, lipid peroxidation, and antioxidant levels using immunofluorescence stain and ELISA on days 7 and 28 of post-WBRT.

RESULTS

The radial maze was used to measure spatial learning and memory in rats. Compared with the 0 Gy-WBRT group, the 2 Gy-, 4 Gy-, and 10 Gy-WBRT groups of rats displayed a significant increase in latency. Seven days of post-WBRT, the newly proliferation cells (IdU positive) and serial replicating cells (CldU+IdU double positive) in the hippocampal dentate gyrus were significantly increased but were coupled with apoptosis. The alterations in the cellular composition of the dentate gyrus area were observed on days 7 and 28 post-WBRT, including increased newborn neuroblast and neuron, but half underwent apoptosis, which is associated with microglia phagocytosis and results in cognitive impairment. The lipid peroxidation was significantly increased on day 28 of post-WBRT. HBOT improves cognitive function by attenuating the WBRT-induced lipid oxidation, newly-formed cell apoptosis, and microglia phagocytosis.

CONCLUSION

Our present study suggests that HBOT may have a potential role in mitigating the effects of irradiation-induced brain injury by maintaining neurogenesis and reducing lipid peroxidation.

Pretreatment Clinical Parameters Associated with Intracranial Progression Burden Following an Initial Stereotactic Radiosurgery Course in a Multi-Institutional Brain Metastases Cohort

PURPOSE/OBJECTIVE(S)

While brain metastasis (BM) velocity is a valuable prognostic metric at time of intracranial progression (ICP), pre-SRS risk factors for post-SRS high-burden intracranial progression (ICP) remain poorly characterized. We hypothesized that pre-SRS clinical parameters are associated with subsequent high-burden (ICP), defined as either ≥5 (ICP5) or new/progressive ≥11 BMs (ICP11).

MATERIALS/METHODS

All patients completing an initial SRS course for BMs at two institutions from 1/2015-12/2020 were retrospectively identified. Patients with prior whole brain radiation therapy (WBRT) and/or BM resection were eligible. Demographic and clinical parameters were collected. ICP was defined as any radiographic concern for distant and/or in-field progression per multidisciplinary consensus. Overall survival (OS) and freedom from ICP were estimated via the Kaplan Meier method. Cox models assessed association between parameters and freedom from ICP5 and ICP11.

RESULTS

We identified 1383 patients completed SRS, with a median follow up of 8.7 months. Patients were 54.8% female, 45.6% with KPS ≥90, and a median of 63.4 years old. Primary tumor types included non-small cell lung (48.7%), breast (14.7%), and melanoma (8.5%). 46.9% had oligometastatic disease (≤5 metastatic foci: including BMs) at SRS, and 53.4% underwent SRS for >1 BM. 10.3% of patients had undergone prior WBRT and 26.1% surgical resection. 555 patients (40.1%) experienced ICP following SRS, of whom 72.6% had 1-4, 11.5% had 5-10, and 15.9% had ≥11 new/progressive BMs. Among patients with ICP, 6-month freedom from ICP was 35.5% (95% CI: 31.1-40.5%) for those with 1-4 BMs at time of ICP, 29.7% (95% CI: 20.4-43.3%) for 5-10 BMs, and 20.5% (95% CI: 13.5-30.1%) for ≥11 BMs (p = 0.016). Respective 12-month OS rates were 56.8% (95% CI: 52.1-61.9%), 46.0% (95% CI: 35.1-60.1%), and 38.7% (95% CI: 29.4-50.9%; p<0.001). Neurologic symptoms at time of ICP were observed in 21.1% of patients with 1-4 BMs, 28.1% with 5-10 BMs, and 50.0% with new/progressive ≥11 BMs (p<0.001). On multivariable analysis, superior freedom from high-burden ICP was associated with the following pre-SRS parameters: oligometastatic burden (ICP5: HR 0.68, 95% CI: 0.47-0.99; ICP11: 0.59; 95% CI: 0.36-0.97), no prior immunotherapy (ICP11: HR 0.57, 95% CI: 0.34-0.57), and a single BM at time of initial SRS (1 vs 2 BM, ICP 5: HR 0.51, 95% CI: 0.31-0.82; ICP11: HR 0.45, 95% CI: 0.24-0.84), while primary tumor type was not associated with ICP5 or ICP11.

CONCLUSION

Pre-SRS parameters including polymetastatic burden, prior receipt of immunotherapy, and >1 BM were associated with post-SRS high-burden ICP. High burden ICP developed earlier following SRS completion and was associated with higher rates of neurologic decline and inferior OS.

ChatGPT is an Unreliable Tool for Reviewing Radiation Oncology Literature

PURPOSE/OBJECTIVE(S)

To assess whether ChatGPT, a popular deep learning text generation tool, can serve as a resource for in-training and practicing clinicians by accurately identifying and summarizing studies related to radiation oncology.

MATERIALS/METHODS

Three question templates (Q1-Q3, shown in Table 1) were applied to eight cancer types to compile 24 questions posed to ChatGPT. Cancer types were designated as either common (breast, non-small cell lung, prostate, p16 positive oropharyngeal, and rectal) or uncommon (hypopharyngeal, medulloblastoma, and vulvar). ChatGPT's responses to each question were then reviewed to quantify the number of studies referenced in the response, the percentage of studies listed that were real studies, and the percentage of studies listed that were correctly summarized. Outcomes were compared between cancer types (common vs uncommon) and question types using Wilcoxon rank sum tests. As a secondary analysis, we assessed internal consistency of ChatGPT's responses by querying ChatGPT with three identical iterations of Q1-Q3 for breast cancer and comparing its responses between iterations.

RESULTS

Across all 24 of ChatGPT's responses, there were 78 studies referenced, of which 37 (47.4%) were real studies and 7 (9.0%) were correctly summarized. On average, each response included 3.25 (standard deviation (SD): 0.74) studies, of which 44.0% (SD: 44.2%) were real studies and 7.8% (SD: 14.6%) were correctly summarized. The proportion of correctly summarized studies was not significantly different between common vs uncommon cancers [p = 0.29], between questions that specified randomized-control trials (Q3) vs not (Q1 or Q2) [p = 0.94], or between questions that specified intensity modulated radiotherapy (Q2) vs not (Q1 or Q3) [p = 0.31]. Across the three iterations of ChatGPT queries for breast cancer, the number of studies listed for Q1, Q2, and Q3 ranged from 3 to 5, 2 to 3, and 3 to 5, respectively; the number of correctly summarized studies listed for each question ranged from 0 to 2, 0 to 1, and 0 to 1, respectively.

CONCLUSION

ChatGPT's responses consistently included a large proportion of non-existent and incorrectly summarized studies. Furthermore, our secondary analysis suggests variability in the content and accuracy of ChatGPT responses to identical questions, raising further concerns regarding reliability. Overall, our findings argue against the use of ChatGPT as a tool for reviewing literature related to radiation oncology.

Multi-Institutional Outcomes Following Stereotactic Radiosurgery for Gastrointestinal Brain Metastases

PURPOSE/OBJECTIVE(S)

Outcomes following stereotactic radiosurgery (SRS) for gastrointestinal (GI) brain metastases (BM) are poorly defined. We analyzed our multi-institutional database of SRS patients, comparing outcomes between GI and non-GI BM patients after SRS.

MATERIALS/METHODS

We retrospectively identified all patients completing an initial SRS course across two institutions from 1/2015-12/2020. Demographic and clinical parameters were manually captured. Intracranial progression (ICP) was defined as any concern on post-SRS imaging for recurrence determined by multidisciplinary consensus. Overall survival (OS) and freedom from ICP (FFICP) were estimated via Kaplan Meier models. Cox proportional hazard models were used to assess associations between ICP and parameters.

RESULTS

Among 1383 total patients completing SRS for BM, 102 (7.4%) had GI BM. Among these, 46 (45.1%) were of colorectal (CRC) and 34 (33.3%) esophageal origin. Other GI sites (21.6%) included anal, pancreatic, gastric, GI of unknown origin, and hepatocellular carcinoma. Median follow up was 8.7 mos. GI BM patients were more likely to be younger (mean 59.1 vs 63.5 yrs, p = 0.001), male (56.9% vs 44.3%, p = 0.014 ), have more extracranial metastases (mean 1.9 vs 1.6, p = 0.003), have received systemic therapy (73.5% vs 63.9%, p = 0.049) or resection of BM (45.1% vs 25.0%, p < 0.001) prior to SRS, have larger planned target volumes of all BMs (mean 20.3 ccs vs 15.0 ccs, p = 0.013), and were less likely to receive whole brain radiation therapy (WBRT) prior to SRS (3.9% vs 10.8%, p = 0.028) or systemic therapy after SRS (54.9% vs 68.9%, p = 0.004). Among GI patients, median OS was 28.2 mos (95% CI 16.5-35.3), with no significant differences between GI and non-GI patients (p = 0.220) or among GI subgroups (CRC vs other GI: p = 0.731; esophageal vs other GI: p = 0.478). Median FFICP was significantly worse for GI patients (6.2 mos, 95% CI 4.0-9.6 mos) than for non-GI patients (12.4 mos, 95% CI 10.8-13.9 mos; p = 0.004). After accounting for age, sex, performance status, number of irradiated BMs, extracranial disease burden, extracranial disease control, interval from primary cancer diagnosis to BM diagnosis, resection status, receipt of prior WBRT, and receipt of post-SRS systemic therapy, GI origin was significantly associated with worse FFICP (HR 1.50, 95% CI 1.15-2.02, p = 0.007). FFICP was not significantly different between GI subgroups, with CRC and esophageal patients demonstrating median times to ICP of 5.0 mos (95% CI 3.4-9.6) and 7.2 mos (95% CI 2.7-14.1), respectively. Only 2 GI patients (2.0%) had ICP at site of prior SRS.

CONCLUSION

Across a modern, multi-institutional SRS cohort comparing GI to non-GI primary patients, BMs of GI origin demonstrated inferior FFICP to those of non-GI origin. OS did not vary significantly across GI and non-GI cases. Among GI subtypes, no significant differences were identified across FFICP or OS. These data may help inform treatment decisions and post-SRS surveillance.

Clinical Outcomes Following an Initial Stereotactic Radiosurgery Course for Brain Metastases from Melanoma

PURPOSE/OBJECTIVE(S)

Brain metastases (BM) are common in melanoma patients. The effect of gene mutations is not well characterized since first-line metastatic therapy has shifted from chemotherapy (CHT) to molecularly targeted therapies (TT) and immunotherapy (IO). We report outcomes of melanoma BM patients stratified by molecular subtype and pre-stereotactic radiosurgery (SRS) systemic therapy.

MATERIALS/METHODS

We identified all patients completing an initial SRS course for BM at two institutions between 1/2015 and 12/2020. Patients who had prior WBRT and/or resection were eligible. Demographic and clinical parameters were collected, along with melanoma tumor molecular characteristics. Intracranial progression (ICP) was defined as any radiographic distant and/or in-field progression per multidisciplinary consensus. Overall survival (OS) and freedom from ICP (FFICP) were estimated via the Kaplan Meier method.

RESULTS

From a total of 1383 SRS BM patients, we identified 118 (8.5%) with melanoma. Median follow up was 8.7 months, median age 64 years (IQR 51-72), 81% had cutaneous origin, and 55% had a KPS of 90-100. Molecular subtypes included BRAF (45%), NRAS (9.3%), and c-KIT (3.4%). Overall, 61% received IO prior to SRS, while 25% and 9.3% received TT and CHT prior to SRS respectively. 60% of patients harboring a mutation received IO as first line therapy, 10% received TT, and 30% received both TT and IO prior to SRS. BRAFmut patients more likely to have received TT prior to SRS (43% vs 9.2%, p<0.001) compared to BRAFwt patients. Median OS was 9.7 months (95% CI 7.8-13) and was not significantly different from non-melanoma patients (p = 0.6). Median FFICP was worse for melanoma patients (5.9 mos, 95% CI 3.5-8.5) than non-melanoma patients (8.96 mos, 95% CI 8.2-9.7, p = 0.009). A total of 72 ICP events occurred, with 56 (77.8%) distant ICP cases, 3 (4.2%) in-field ICP, and 13 (18%) ICP events that were radionecrosis (RN) only. RN was associated with the presence of a targetable mutation (18% vs 2%, p = 0.006) and receipt of TT pre-SRS (36% vs 9.8%, p = 0.001). BRAFmut patients had significantly worse FFICP (3.8 mos, 95% CI 3.0-6.8) compared to BRAFwt patients (8.5 mos, 95% CI 5.8-30.2, p = 0.006), although median OS was not significantly different (9.6 mos, 95% CI 6.9-16 vs 10.7 mos, 95% CI 6.7-15.5, p = 0.8). NRASmut was associated with better FFICP (29 mos, 95% CI 2.94-NA, p = 0.02).

CONCLUSION

In this modern, multi-institutional cohort of SRS patients, melanoma BM patients had worse FFICP compared to non-melanoma BM patients, and BRAFmut patients had worse FFICP than BRAFwt patients. RN was associated with mutational status and receipt of TT pre-SRS. OS did not vary significantly across groups. This analysis may help inform systemic therapy decisions and future genomic studies for patients with BMs from melanoma.

Evaluating the Reliability of Chat-GPT Model Responses for Radiation Oncology Patient Inquiries

PURPOSE/OBJECTIVE(S)

To determine if ChatGPT, a popular deep learning text generation tool, accurately and comprehensively answers patient questions related to radiation oncology.

MATERIALS/METHODS

A total of 28 common patient-centered questions were selected across various radiation oncology content domains, including diagnosis (4), workup (3), treatment (8), toxicity (4), and survivorship (9). To assess whether ChatGPT could detect inaccurate assumptions and/or respond negatively, we included two "negative control" questions in the treatment and toxicity domains. All questions were applied to common cancer types (breast, non-small cell lung, prostate, p16+ oropharyngeal, and rectal), uncommon cancer types (hypopharyngeal, medulloblastoma, and vulvar), and colon cancer as an additional "negative control." The ChatGPT responses were graded as 0 for any incorrect information, 1 for missing essential content, and 2 for correct and appropriately comprehensive for the length of the response. Each response was graded by two blinded MD reviewers, with discordant answers resolved by a third MD reviewer. Score distribution was compared across content domains, question type ("negative control" vs other), cancer type, and cancer commonality using the Chi-squared test.

RESULTS

Overall, a total of 252 questions were submitted to ChatGPT. A total of 86 (34.1%) answers were found to contain inaccurate information, 66 (26.2%) contained correct information but were found to be missing essential context, and 100 (39.7%) responses to questions were graded as correct and comprehensive. There was no significant difference in response score by question domains (p = 0.07). However, there was significant difference in response score across cancer type (p<0.001). The top scoring cancer types were breast (grade 0 = 10%; grade 1 = 21%, grade 2 = 68%) and prostate (grade 0 = 18%, grade 1 = 25%, grade 2 = 57%), while the two lowest scoring cancer types were colon (grade 0 = 61%, grade 1 = 21%, grade 2 = 18%) and vulvar (grade 0 = 50%, grade 1 = 25%, grade 2 = 25%). ChatGPT responses were also significantly different among common, uncommon and negative control questions, with the model performing best with responses to common cancer types (p = 0.003). ChatGPT performed significantly worse when responding to "negative control" questions (p<0.001).

CONCLUSION

ChatGPT failed to consistently generate accurate and comprehensive responses to the majority of radiation oncology patient centered questions, particularly across less common cancers and with "negative control" questions that included incorrect assumptions. This raises concern for the possible ChatGPT mediated reinforcement of patient misperceptions regarding radiotherapy.

Culture-negative TB: clinical characteristics, risk factors and treatment outcomes

BACKGROUND: Although culture remains the standard for TB diagnosis, 15-20% of patients diagnosed and treated for TB are culture-negative. We explored clinical characteristics, risk factors and treatment outcomes for culture-negative TB in a Peruvian cohort.METHODS: We recruited 4,500 index TB patients and 10,160 household contacts in Lima, Peru, and enrolled 692 secondary patients diagnosed with TB during follow-up of household contacts. We analyzed smear and culture status, sociodemographic factors, clinical characteristics and TB treatment outcomes to compare culture-negative and positive patients.RESULTS: Of the 4,880 adult patients, 915 (18.8%) were culture-negative. Culture-negative patients were less likely to report symptoms of TB disease and disease of longer duration. A multivariate analysis showed no statistically significant difference in loss to follow-up, treatment failure or recurrence between the culture-negative and -positive groups but a higher rate of death among culture-negative patients with an adjusted OR of 1.65 (95% CI 1.05-2.60). In a multivariate analysis of determinants of culture negativity, older age, substance use and being a secondary case were associated with culture status.CONCLUSIONS: More recognition and awareness of culture-negative TB is key for early and correct diagnosis to reduce transmission and improve treatment outcomes.

The adjusted impact of different severities of acute exacerbations and medications on the risk of developing dementia in COPD patients

BACKGROUND

Although a relationship between chronic obstructive pulmonary disease (COPD) and dementia has been reported, the initial severity upon emergency department (ED) visits and the medications used have not been well evaluated as risk factors for increased dementia occurrence. We aimed to analyze the risks of dementia development over 5 years among patients with COPD compared to matched controls (primary) and the impact of different severities of acute exacerbations (AEs) of COPD and medications on the risk of dementia development among COPD patients (secondary).

METHOD

This study used the Taiwanese government deidentified health care database. We enrolled patients during the 10-year study period (January 1, 2000, to December 31, 2010), and each patient was followed up for 5 years. Once these patients received a diagnosis of dementia or died, they were no longer followed up. The study group included 51,318 patients who were diagnosed with COPD and 51,318 matched (in terms of age, sex, and the number of hospital visits) non-COPD patients from the remaining patients as the control group. Each patient was followed up for 5 years to analyze the risk of dementia with Cox regression analysis. Data on medications (antibiotics, bronchodilators, corticosteroids) and severity at the initial ED visit (ED treatment only, hospital admission, or ICU admission) were collected for both groups, as well as demographics and baseline comorbidities, which were considered confounding factors.

RESULTS

In the study and control groups, 1,025 (2.0%) and 423 (0.8%) patients suffered from dementia, respectively. The unadjusted HR for dementia was 2.51 (95% CI: 2.24-2.81) in the study group. Bronchodilator treatment was associated with the HRs, especially among those who received long-term (> 1 month) treatment (HR = 2.10, 95% CI: 1.91-2.45). Furthermore, among 3,451 AE of COPD patients who initially visited the ED, patients who required ICU admission (n = 164, 4.7%) had a higher risk of dementia occurrence (HR = 11.05, 95% CI: 7.77-15.71).

CONCLUSION

Bronchodilator administration might be associated with a decreased risk of dementia development. More importantly, patients who suffered AEs of COPD and initially visited the ED and required ICU admission had a higher risk of developing dementia.

[Association of lean tissue index with arteriovenous fistula dysfunction in maintenance hemodialysis patients]

The clinical data of maintenance hemodialysis (MHD) patients from twenty hemodialysis centers in Guizhou province from June to September 2020 were collected by cross-sectional study. The patients were divided into AFD group and non-AFD group according to whether AFD had occurred. LTI was measured by body composition monitor. The results showed that the incidence of AFD in 2 781 MHD patients was 30.0% (835/2 781). Median LTI level was 15.2 (13.2, 17.5) kg/m². The LTI level in the AFD group was higher than that in the non-AFD group (P < 0.05). According to the tertiles of LTI, low LTI group (LTI ≤ 13.9 kg/m²) had the highest incidence of AFD (35.5%, 334/940), and the high LTI group had the lowest incidence of AFD (26.3%, 241/916), and the difference among the three groups was statistically significant (χ²=20.182,P < 0.001). Multivariate logistic regression analysis showed that low LTI group as the reference, the risk of AFD in moderate LTI group (13.9 kg/m² < LTI ≤ 16.6 kg/m²) and high LTI group were associated with the 20.0% (OR=0.800, 95% CI 0.650-0.986, P=0.036) and 22.8% (OR=0.772, 95% CI 0.616-0.966, P=0.024) decrease, respectively. These results suggest that low LTI level is independently associated with an increased risk of AFD in MHD patients.

Identifying a sphenoid sinus fungus ball using a nomogram model

Background: Sphenoid sinus fungus ball (SSFB) is a rare entity and usually presents with non-specific symptoms. SSFB could potentially lead to serious orbital and intracranial complications. Computed tomography (CT) scan is usually the first imaging test of the diagnostic workup in patients with specific clinical symptoms. This study aimed to compare the clinical characteristics and CT features between SSFB and unilateral (non-fungus ball) chronic sphenoid rhinosinusitis (USRS) and help differentiate between these two most common inflammatory diseases of the sphenoid sinus. Methods: By retrospective database review, 66 patients with a histopathologic diagnosis of isolated SSFB were recruited for analysis. Fifty-four patients who underwent endoscopic sinus surgery with clinical and histopathological diagnoses of USRS were enrolled as the control group. Clinical characteristics and CT features were evaluated. Results: Headache, rhinorrhoea, nasal obstruction, postnasal dripping, and hyposmia were the most common symptoms in both groups. In the univariate analysis, older age, lower white blood cell counts, irregular surface, bony dehiscence, lateral wall sclerosis, and intralesional hyperdensity (IH) were significant predictors for SSFB. Older age, irregular surface, and IH remained statistically significant in the multivariate analysis. Based on the results of the regression analysis, a nomogram for predicting the probability of SSFB was plotted. Conclusions: We developed a nomogram model as a novel preoperative diagnostic tool for identifying SSFB according to the predictors both in clinical characteristics and on CT features. This could help the clinicians in predicting the probability of SSFB, to reduce ineffective or delayed treatment and occurrence of complications.

Profiled polyethylene terephthalate filaments that incorporate collagen and calcium phosphate enhance ligamentisation and bone formation

Polyethylene terephthalate (PET) artificial ligaments offer an unlimited source of ligaments without donor-site-related morbidity and with good mechanical properties for a rapid return to sporting activities. Developing PET artificial ligaments with excellent ligamentisation and ligament-bone healing is still a considerable challenge. This study aimed to investigate the effects of the profiled PET/collagen/calcium phosphate (PET/C/CaP) ligament upon cell growth, ligamentisation and ligament-bone healing in vitro and in vivo. Profiled PET/C/CaP filaments were made by melt-spinning process with 2 % CaP hybrid spinning and collagen coating. Rat mesenchymal stem cells (MSCs) were cultured on the profiled PET/C filaments for cytotoxicity, viability, scanning electron microscopy (SEM) and ligament-related gene expression analysis. MSCs' osteogenic capacity on the profiled PET/CaP filaments was identified by detecting osteogenic gene expression and alizarin red S staining. For in vivo verification, an animal study was performed to evaluate the effect of the profiled PET/C/CaP ligament in a rabbit knee medial collateral ligament reinforcement reconstruction model. The graft ligamentisation and bone formation were investigated by SEM, histology, microcomputed tomography and mechanical tests. The profiled PET/C filaments enhanced MSC proliferation and ligament-related gene expression. Furthermore, they enhanced osteogenic gene expression, alkaline phosphatase activity and mineralisation of MSCs. The in vivo study indicated that the profiled PET/C/CaP ligament enhanced ligamentous matrix remodelling and bone formation. Therefore, their use is an effective strategy for promoting MSCs' ligamentous and osteogenic potential in vitro and enhancing ligamentous matrix remodelling and bone formation in vivo.

The effect of the head-up position on cardiopulmonary resuscitation: a systematic review and meta-analysis

OBJECTIVE

Experimental studies of head-up positioning (HUP) during cardiopulmonary resuscitation (CPR) have had some degree of conflicting published results. The current study aim was to analyze and reconcile those discrepancies in order to better clarify the effects of HUP CPR compared to conventional supine (SUP) CPR.

METHODS

Three databases (PubMed, EMBASE and Cochrane Library) were searched comprehensively (from each respective database's inception to May 2021) for articles addressing HUP CPR. The primary outcome to be observed was cerebral perfusion pressure (CerPP), and secondary outcomes were mean intracranial pressure (ICP), mean arterial pressure (MAP), coronary perfusion pressure (CoPP) and frequencies of return of spontaneous circulation (ROSC).

RESULTS

Seven key studies involving 131 animals were included for analysis. Compared to SUP CPR, CerPP (MD 10.37; 95% CI 7.11-13.64; p < 0.01; I² = 58%) and CoPP (MD 7.56; 95% CI 1.84-13.27, p = 0.01; I² = 75%) increased significantly with HUP CPR, while ICP (MD - 13.66; 95% CI - 18.6 to -8.71; p < 0.01; I² = 96%) decreased significantly. Combining all study methodologies, there were no significant differences detected in MAP (MD - 1.63; 95% CI - 10.77-7.52; p = 0.73; I² = 93%) or frequency of ROSC (RR 0.9; 95% CI 0.31-2.60; p = 0.84; I² = 65%). However, in contrast to worse outcomes in studies using immediate elevation of the head in a reverse Trendelenburg position, study outcomes were significantly improved when HUP (head and chest only) was introduced in a steady, graduated manner following a brief period of basic CPR augmented by active compression-decompression (ACD) and impedance threshold (ITD) devices.

CONCLUSION

In experimental models, gradually elevating the head and chest following a brief interval of circulatory priming with ACD and ITD devices can enhance CoPP, lower ICP and improve CerPP significantly while maintaining MAP. This effect is immediate, remains sustained and is associated with improved outcomes.

O-086 End-to-end deep learning for recognition of ploidy status using time-lapse videos

Study question

Our Retrospective study is to investigate an end-to-end deep learning model in identifying ploidy status through raw time-lapse video.

Summary answer

Our deep learning model demonstrates a proof of concept and potential in recognizing the ploidy status.

What is known already

Since the time-lapse system has been introduced into the IVF lab, the relationship between morphogenetic and ploidy status has been often discussed. However, the result has not yet reached a united conclusion due to some limitations such as human labeling. Besides the statistical approach, deep learning models have been utilized for ploidy prediction. As such approaches are single image-based, the performance remains unpromising as previous statistical-based research. Therefore, in order to move further toward clinical application, better research design and approach are needed.

Study design, size, duration

A retrospective analysis of the time-lapse videos and chromosomal status from 690 biopsied blastocysts cultured in a time-lapse incubator (EmbryoScope+, Vitrolife) between January 2017 and August 2018 in the Lee Women’s Hospital were assessed. The ploidy status of the blastocyst was derived from the PGT-A using high-resolution next-generation sequencing (hr-NGS). Embryo videos were obtained after normal fertilization through the intracytoplasmic sperm injection or conventional insemination.

Participants/materials, setting, methods

By randomly dividing the data into 80% and 20%, we developed our deep learning model based on Two-Stream Inflated 3D ConvNets(I3D) network. This model was trained by the 80% time-lapse videos and the PGT-A result. The remaining 20% has been tested by feeding the time-lapse video as input and the PGT-A prediction as output. Ploidy status was classified as Group 1 (aneuploidy) and Group 2 (euploidy and mosaicism).

Main results and the role of chance

Time-lapse videos were divided into 3-time partitions: day 1, day 1 to 3, and day 1 to 5. Deep learning models have been fed by RGB and optical flow. Combining 3 different time partitions with RGB, optical flow, and fused result from RGB and optical flow, we received nine sets of test results. According to the results, the longest time partition with the fusion method has the highest AUC result as 0.74, which appeared higher than the other eight experimental settings with a maximum increase of 0.17.

Limitations, reasons for caution

The present study is retrospective and future prospective research would help us to identify more key factors and improve this model. In addition, expanding sample size combined with cross-centered validation will also be considered in our future approach.

Wider implications of the findings

Group 1 and Group 2 approach provided deselection of aneuploidy embryos, while future deep learning approaches toward high mosaicism, low mosaicism, and euploidy will be needed, in order to provide a better clinical application.

Trial registration number

CS18082

P–009 A modified sperm chromatin dispersion test, LensHooke® R10, for quick and accurate determination of human sperm DNA fragmentation

Study question

The performance and efficiency of the LensHooke® R10 test kit were evaluated by the clinical examination for precision, accuracy, and time.

Summary answer

The LensHooke® R10 based on sperm chromatin dispersion test offers not only quick testing for sperm DNA fragmentation but also reliable and accurate test results.

What is known already

Sperm chromatin dispersion (SCD) test, one of the most commonly used testing for sperm DNA fragmentation (SDF), can be conducted promptly and without the need for expensive laboratory instruments. However, the main disadvantage of the SCD test is inter-observer variability in categorizing the size of characteristics halos surrounding the core of sperm. Moreover, it takes more than one hour to accomplish whole assay procedures making this testing an inefficient diagnostic tool. These may hinder its broad availability among andrology laboratories or prevent it from being routinely used for the evaluation of male infertility.

Study design, size, duration

A total of 108 participants was included in this prospective study. Data was collected from the reproductive medicine center between June and December 2020.

Participants/materials, setting, methods

This study included 108 consecutive male partners of couples attending for assisted reproductive treatment. SDF was simultaneously tested by using LensHooke® R10 (R10) and Halosperm® G2 (G2) respectively. We evaluated the correlation and agreement between two SCD-based test kits. The repeatability and reproducibility of the SCD kits were assessed by intra-and inter-observer agreement experiments. The sensitivity, specificity, positive predictive value, negative predictive value for the R10 was determined by receiver operator characteristics (ROC) curve analysis.

Main results and the role of chance

The R10 produced more clear sperm core and dispersed chromatin, therefore highly recognizable images can be easily and accurately categorized when scoring of SDF. It took 50% less time for SDF testing by the R10 compared to the G2 (38.26 ± 9.85 minutes vs. 76.52 ± 19.7 minutes, P &lt; 0.0001). The SDF% results showed a strong correlation for the R10 and G2 with Spearman’s coefficients of rank correlation (rho) above 0.8 (P &lt; 0.0001, N = 108). The R10 showed 89.8% accuracy with 87.9% sensitivity, 90.8% specificity, 82.9% PPV, and 93.7% NPV on the measurement of SDF% at the threshold value of 22%. Intraclass correlation coefficients (ICC) &gt;0.9 showed a strong agreement between two observers on the testing of SDF using the R10. ICC &gt;0.9 showed a high intra-observer agreement within 4 repeated testing on SDF using the R10. The R10 showed an intra-observer’s precision of coefficient variation, CV &lt; 10% for SDF%. In addition, SDF% test results obtained by the R10 for asthenospermic (31.8% ± 16.7%), teratospermic (22.9% ± 14.4%), and oligoasthenoteratozoospermic samples (36.6% ± 14.4%) were significantly higher than that observed in normozoospermic samples (15.3% ± 10.2%, p &lt; 0.05), was comparable with the G2.

Limitations, reasons for caution

The sample size of 4 semen specimens used to evaluate the intra-and inter-observer agreement was a limitation. Besides, evaluating the relationship between the SDF and clinical outcome of ART is necessary for further study.

Wider implications of the findings: The new in vitro diagnostics reagent, LensHooke® R10, is a simple and quick test kit that offers reliable and accurate test results of sperm DNA fragmentation, can be routinely used in male infertility evaluation.

Trial registration number

CS2–20012

Clinical treatment and medication in decreasing the development of major depression caused by spinal fracture

Background

Chronic pain and limited activities of daily living after spinal fracture may induce the occurrence of major depression (MD); however, risk factors regarding medications, surgical intervention, and severity of fracture are unclear. We aimed to analyze risk factors of MD development after spinal fracture.

Methods

This was a retrospective database study, using the health care database of the Taiwan government. We included 11,225 patients with new spinal fracture (study group), and 33,675 matched patients without fracture (comparison group). We respectively reviewed data of each participant for 3 years to assess the development of MD. The Cox proportional hazards model was used to determine the prevalence of MD, after adjusting for patient demographics, medications, surgical interventions, spinal cord involvement, and postfracture comorbidities.

Results

In total, 187 fracture patients (1.7%) and 281 nonfracture patients (0.8%) developed new-onset MD (hazard ratio [HR]:1.96, (95% confidence interval [CI]: 1.63–2.36)). Spinal cord involvement (HR: 2.96, 95% CI: 2.54–3.42) and postfracture comorbidities (HR: 3.51, 95% CI: 2.86–3.97) obviously increased the risk of MD.

Conclusions

Patients with spinal fracture (spinal cord involvement and postfracture comorbidities) were more likely to develop MD. Early surgical interventions (vertebroplasty) and medications (narcotics) may decrease the risk of MD.

75Safety and efficacy of rivaroxaban in combination with anti-arrhythmic drugs in patients with non-permanent atrial fibrillation

Background

Rivaroxaban is useful for stroke prevention in atrial fibrillation (AF) patients. Most patients with non-permanent AF also treated with anti-arrhythmic drugs (AADs) to prevent the recurrence of arrhythmia. But there are limited data regarding drug-drug interactions between rivaroxaban and AADs despite its high clinical relevance.

Purpose

To compare the bleeding risks and ischemic events between the use of rivaroxaban alone and the concomitant use of AADs.

Methods

This is a multicenter retrospective study, which identified patients with a diagnosis of non-permanent AF who received rivaroxaban more than 1 month between December 1, 2011 and November 30, 2016. The study divided patients into 4 groups : rivaroxaban alone, combined with amiodarone, dronedarone and propafenone. We compared the clinical events and cumulative incidences to compare the endpoints including efficacy endpoint (new ischemic stroke, intracranial hemorrhage, or new

embolism), safety endpoints (Hb fall more than 2g/dL or transfusion more than 2U PRBC, critical site bleeding, or fatal bleeding.) and major adverse cardiovascular events (MACE), including cardiovascular death, myocardial infarction, new ischemic stroke, new embolism, or intracranial hemorrhage.

Results

Of 1777 enrolled patients, the rivaroxaban alone was 1205 cases, 177 in amiodarone group, 231 in dronedarone group and 164 in propafenone group. There was no statistically significant difference on efficacy endpoints, safety endpoints and MACE between the 4 groups. The average dosage of rivaroxaban was insignificantly the lowest in the group combined with dronedarone (12.3mg, p = 0.146). The rate of new embolism (0%, p = 0.029), recurrent heart failure admission rate (3.9%, p &lt; 0.001), and all-cause mortality (3.0%, p = 0.013) in dronedarone group showed a significant lower occurrence rate. The occurrence rate of new ischemic stroke (0.9%, p = 0.549), new hemorrhagic stroke (0.4%, p = 0.546), efficacy endpoints (1.7%, p = 0.369) and MACE (3.9%, p = 0.72) in dronedarone droup were the lowest but insignificant. The cumulative incidences of efficacy endpoints, safety endpoints and MACE during follow-up period were also similar in these four groups.(Picture 1)

Conclusions

In patients with non-permanent atrial fibrillation, this real-world study showed that there were no significant differences between using rivaroxaban alone or concomitant with an AAD (dronedarone/amiodarone/propafenone) on events such as new ischemic stroke, intracranial hemorrhage, GI bleeding and MACEs. The happening of new embolism was lower especially in the group combined with dronedarone. The safety and efficacy between rivaroxaban alone and combined with rhythm control using AADs proved to be the same.  Relative low dose rivaroxaban combined with dronedarone did not increase the bleeding risk, and may decrease the probability of thromboembolism.

Abstract Figure. Picture 1

P1064Using Data Mining to Predict Bleeding Events caused by Novel Oral Anticoagulants

Background

Novel oral anticoagulants (NOAC) is important in preventing thromboembolism in atrial fibrillation (AF) patients. Bleeding risk was evaluated by HAS-BLED score traditionally. Data mining is a relatively new discipline that has sprung up at the confluence of several other disciplines, driven primarily by the growth of large databases. 

Purpose

This study aimed to find a useful predictive model by data mining to assess the risk of rivaroxaban, an antithrombotic drug that causes bleeding in AF patients. The seven parameters of the HAS-BLED score were used to predict the effect of rivaroxaban on bleeding tendency in AF patients and may provide clinicians with appropriate treatments to avoid complications from bleeding events and reduce the incidence of health damage.

Methods

Through conducting a multicenter retrospective study, we identified patients with AF who were treated with rivaroxaban for more than 1 month between December 1, 2011 and November 30, 2016. After preprocessing, the established data were used for training and testing of data mining models. This study evaluated four models, including association rules, neural networks, Bayesian classification, and decision trees.

Result

Of the 872 enrolled cases, 432 were in any of the bleeding groups and 432 were in the non-bleeding randomized control group. After comparing the overall classification accuracy, omission error and over-prediction error, the decision tree proved to be the most accurate model for bleeding prediction. The overall classification accuracy is 77%, the omission error is 15%, the over-prediction error is 21.9%, and the AUC score is 0.84. The results show that the model has good discriminative ability and visibility of decision rules.

Conclusion

Among several data mining models, decision tree proved to be the most accurate model for bleeding prediction. The conclusion of this study can be used as a reference for supporting decision making before anticoagulation treatment and suggest future research to compare efficacy of bleeding prediction between HAS-BLED score and decision tree.

Data mining comparison Model Omission error Commission error Overall accuracy AUC score Ranking Decision tree 15.0% 21.90% 77.00% 0.84 1 Association rules 16.8% 27.20% 76.50% 0.81 2 Neural networks 12.0% 26.40% 78.20% 0.83 3 Bayesian classification 16.1% 27.50% 76.50% 0.83 4

Galectin-3 and S100A9: Novel Diabetogenic Factors Mediating Pancreatic Cancer-Associated Diabetes

OBJECTIVE

Pancreatic cancer-associated diabetes (PCDM) is a paraneoplastic phenomenon accounting for 1% of new-onset diabetes. We aimed to identify the mediators of PCDM and evaluate their usefulness in distinguishing PCDM from type 2 diabetes.

RESEARCH DESIGN AND METHODS

Secreted proteins of MIA PaCa-2 cells were identified by proteomics, and those with ≥10-fold overexpression in transcriptome analysis were assessed by bioinformatics and glucose uptake assay to identify candidate factors. Expression of factors was compared between tumors with and without PCDM by immunohistochemistry. Serum levels were measured in a training set including PC with and without PCDM, type 2 diabetes, pancreatitis, other pancreatic/peripancreatic tumors, and control subjects (n = 50 each). Cutoff values for differentiation between PCDM and type 2 diabetes from the training set were validated in a test set (n = 41 each).

RESULTS

Galectin-3 and S100A9 were overexpressed in tumors with PCDM and dose-dependently suppressed insulin-stimulated glucose uptake in C2C12 myotubes. In the training set, serum galectin-3 and S100A9 levels were exclusively increased in patients with PCDM and distinguished PCDM from type 2 diabetes (area under the curve [AUC] galectin-3: 0.73 [95% CI 0.64-0.83]; S100A9: 0.79 [95% CI 0.70-0.87]). Similar results were observed in the test set (AUC galectin-3: 0.83 [95% CI 0.74-0.92]; S100A9: 0.77 [95% CI 0.67-0.87]), with sensitivity and specificity 72.1% and 86.1%, respectively, for galectin-3 and 69.8% and 58.1% for S100A9 in differentiating between PCDM and type 2 diabetes.

CONCLUSIONS

Galectin-3 and S100A9 are overexpressed in PCDM tumors and mediate insulin resistance. Galectin-3 and S100A9 distinguish PCDM from type 2 diabetes in subjects with new-onset diabetes.

Early Epinephrine Improves the Stabilization of Initial Post-resuscitation Hemodynamics in Children With Non-shockable Out-of-Hospital Cardiac Arrest

Background: In children with non-shockable out-of-hospital cardiac arrest, early epinephrine (EE) might help to establish the return of spontaneous circulation (ROSC) and be associated with survival. In the present study, we aimed to analyze the effects of EE on outcomes and post-resuscitation hemodynamics in children with non-shockable OHCA. Methods: This was a retrospective analysis of data from 216 children (<19 years) who had suffered non-traumatic and non-shockable OHCA and received epinephrine for resuscitation (Jan 1, 2006-Dec 31, 2014). Demographics, pre-/in-hospital information, and the time to the first dose of epinephrine were recorded. Early post-resuscitation hemodynamics (the first hour after sustained ROSC), survival and good neurological outcomes (Pediatric Cerebral Performance Category Scales 1 or 2) were analyzed by the time to epinephrine-classified as early (EE): <15 min, intermediate (IE): 15-30 min, or late (LE): >30 min. Results: Twenty-eight (13.0%) children survived to discharge, but only 17 (7.9%) had good neurological outcomes. In all, 41 (18.9%) children received EE; in comparison to IE and LE, this was significantly associated with tachycardia (73.9%) in the post-resuscitation period (p < 0.05). Tachycardia (OR: 7.41, 95% CI: 1.96-29.31) and hypertension (OR: 6.03, 95% CI: 1.85-13.77) were significantly associated with EE after adjusting for confounding factors. EE was also significantly associated with better overall outcomes than ME and LE (any ROSC, sustained ROSC, survival to the intensive care unit, admission, survival to discharge and good neurological outcomes, all p < 0.05). Conclusions: EE helped to establish ROSC but was also associated with more tachycardia and hypertension in the early post-resuscitation period. In children with non-traumatic and non-shockable OHCA, EE was associated with a higher survival rate and better neurological outcomes than were ME and LE.

Demographics of Pediatric OHCA Survivors With Postdischarge Diseases: A National Population-Based Follow-Up Study

Background: Postdischarge diseases (PDDs) have been reported for adult survivors of out-of-hospital cardiac arrest (OHCA). However, the detailed demographics of pediatric OHCA survivors with PDDs are not well-documented, and information regarding functional survivors is particularly limited. We aimed to report detailed information on the PDDs of survivors of traumatic and non-traumatic pediatric OHCA using a national healthcare database. Methods: We retrospectively obtained data from the Taiwan government healthcare database (2011-2015). Information on the demographics of traumatic and non-traumatic pediatric OHCA survivors (<20 years) was obtained and reported. The patients who survived to discharge (survivors) and those classified as functional survivors were followed up for 1 year for the analysis of newly diagnosed PDDs. The time from discharge to PDD diagnosis was also reported. Results: A total of 2,178 non-traumatic and 288 traumatic OHCA pediatric cases were included. Among the non-traumatic OHCA survivors (n = 374, survival rate = 17.2%), respiratory tract (n = 270, 72.2%), gastrointestinal (n = 187, 50.0%), and neurological diseases (n = 167, 49.1%) were the three most common PDD categories, and in these three categories, the majority of PDDs were atypical/influenza pneumonia, non-infective acute gastroenteritis, and generalized/status epilepsy, respectively. Among the traumatic OHCA survivors (n = 21, survival rate = 7.3%), respiratory tract diseases (n = 17, 81.0%) were the most common, followed by skin or soft tissue (n = 14, 66.7%) diseases. Most functional survivors still suffered from neurological and respiratory tract diseases. Most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge. Conclusions: Respiratory tract (pneumonia), neurological (epilepsy), and skin or soft tissue (dermatitis) diseases were very common among both non-traumatic and traumatic OHCA survivors. More importantly, most PDDs, except for skin or soft tissue diseases, were newly diagnosed within the first 3 months after discharge.

A Novel, Optimized Method to Accelerate the Preparation of Injectable Poly-L-Lactic Acid by Sonication

Current consensus for preparing injectable poly-L-lactic acid (PLLA) suggests adequate hydration (less than equal to 2-24 hours of reconstitution) of the lyophilized particles before injection, but the volume of reconstitution and the duration of hydration time varies. This study established a method to evaluate the distribution of PLLA particles after hydration and found that longer hydration time increased the effective portion (particles less than 60 μm) of PLLA products. Further investigation of the feasibility of reconstitution with sonication revealed that 2-hour hydration of PLLA powders with additional 5-minute-sonication could yield a comparable particle distribution with 48-hour-hydration of PLLA. Moreover, adding lidocaine into the diluent did not alter the distribution of PLLA particles. We proposed a new, feasible and efficient method of preparing PLLA injectable products: 2-hour hydration of the powders, sonication of the bottle or vial containing PLLA products for at least 5 minutes, and finalization with 1-2 mL of lidocaine immediately before injection. J Drugs Dermatol. 2018;17(8):894-898.

Predicting Vaginal Delivery in Nulliparous Women Undergoing Induction of Labor at Term

OBJECTIVE

We sought to develop a model to calculate the likelihood of vaginal delivery in nulliparous women undergoing induction at term.

STUDY DESIGN

We obtained data from the Consortium on Safe Labor by including nulliparous women with term singleton pregnancies undergoing induction of labor at term. Women with contraindications for vaginal delivery were excluded. A stepwise logistic regression analysis was used to identify the predictors associated with vaginal delivery by considering maternal characteristics and comorbidities and fetal conditions. The receiver operating characteristic curve, with an area under the curve (AUC) was used to assess the accuracy of the model.

RESULTS

Of 10,591 nulliparous women who underwent induction of labor, 8,202 (77.4%) women had vaginal delivery. Our model identified maternal age, gestational age at delivery, race, maternal height, prepregnancy weight, gestational weight gain, cervical exam on admission (dilation, effacement, and station), chronic hypertension, gestational diabetes, pregestational diabetes, and abruption as significant predictors for successful vaginal delivery. The overall predictive ability of the final model, as measured by the AUC was 0.759 (95% confidence interval, 0.749-0.770).

CONCLUSION

We identified independent risk factors that can be used to predict vaginal delivery among nulliparas undergoing induction at term. Our predictor provides women with additional information when considering induction.

Revealing the nature of low-temperature photoluminescence peaks by laser treatment in van der Waals epitaxially grown WS2 monolayers

Monolayers of transition metal dichalcogenides (TMD) are promising materials for optoelectronics devices. However, one of the challenges is to fabricate large-scale growth of high quality TMD monolayers with the desired properties in order to expand their use in potential applications. Here, we demonstrate large-scale tungsten disulfide (WS₂) monolayers grown by van der Waals Epitaxy (VdWE). We show that, in addition to the large structural uniformity and homogeneity of these samples, their optical properties are very sensitive to laser irradiation. We observe a time instability in the photoluminescence (PL) emission at low temperatures in the scale of seconds to minutes. Interestingly, this change of the PL spectra with time, which is due to laser induced carrier doping, is employed to successfully distinguish the emission of two negatively charged bright excitons. Furthermore, we also detect blinking sharp bound exciton emissions which are usually attractive for single photon sources. Our findings contribute to a deeper understanding of this complex carrier dynamics induced by laser irradiation which is very important for future optoelectronic devices based on large scale TMD monolayers.

Clinical analysis of submucosal Medpor implantation for empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates.The treatment of ENS is still debatable.

PURPOSE

To analyse clinical outcomes of submucosal Medpor® implantation for ENS.

METHODS

A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients' symptoms before and after surgery.

RESULTS

Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively.

CONCLUSIONS

The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.

Effect of tobacco smoke on hydrogen sulfide-induced rat thoracic aorta relaxation

Levels of hydrogen sulfide (H₂S), a gaseous signaling molecule, are reduced in the serum of individuals who smoke. We hypothesized that tobacco smoke influenced smooth muscle relaxation by decreasing H₂S levels and this effect could also influence expression of cystathionine γ-lyase (CSE) and sulfonylurea receptor-2 (SUR-2). The aim of this study was to explore the effect of tobacco smoke on H₂S-mediated rat thoracic aorta relaxation and its possible mechanism. Thirty-two Sprague-Dawley rats were divided into four groups: control (C) group, short-term smoker (SS) group, mid-term smoker (MS) group, and long-term smoker (LS) group. H₂S concentrations in serum, action of H₂S on rat aortic vascular relaxation, and expression of CSE and SUR-2 in thoracic aortic smooth muscle were measured. Although there was no significant difference in H₂S between the C and the SS groups, concentration of H₂S was significantly reduced in both the LS and MS groups compared to control (P<0.01). Furthermore, H₂S was significantly lower in the LS than in the MS group (P<0.05). Rat aortic vascular relaxation was lower in all three treatment groups compared to the control, with the most significant decrease observed in the LS group (P<0.05 compared to the MS group). Expression of CSE and SUR-2 was reduced in the LS and MS groups compared to control (P<0.05), with the lowest levels observed in the LS group (P<0.05). Therefore, tobacco smoke reduced expression of CSE and SUR-2 in rat thoracic aorta, which may inhibit H₂S production and vascular dilation.

Stevens-Johnson syndrome and toxic epidermal necrolysis in patients with malignancies

BACKGROUND

Malignancy is known to be associated with an increased mortality rate in patients with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, risk factors contributing to the poor prognosis of patients with SJS/TEN with malignancies remain undefined.

OBJECTIVES

To explore the potential involvement of malignancy and its related factors contributing to the poor outcome of SJS/TEN, in a retrospective study.

METHODS

In total 517 patients with SJS/TEN were enrolled. Forty-seven who sustained various types of malignancies were analysed for numerous malignancy-related factors, including cancer types, clinical stages and chemotherapies given or not before the onset of SJS/TEN.

RESULTS

We found that the mortality rate of patients with SJS/TEN with malignancies was higher than that of patients without malignancies (32%, 15/47 vs. 8·5%, 40/470, respectively) (P < 0·001). The use of phenytoin was significantly higher in the malignancy group. The presence of hepatocellular carcinoma (80%, four of five; P < 0·001; odds ratio 43) and colorectal cancer (67%, two of three; P = 0·022; odds ratio 21·5) significantly increased the death rate of patients with SJS/TEN, whereas lung cancer and urothelial carcinoma did not. Patients who had received ongoing or recent chemotherapy showed higher mortality than those without chemotherapy (P = 0·022; odds ratio 4·95). Furthermore, among the 47 patients with SJS/TEN with malignancies, lower serum albumin, haemoglobin and platelet count were detected in the deceased patients than in the surviving patients before the onset of SJS/TEN.

CONCLUSIONS

Our results suggest that several factors related to malignancies, such as specific cancer types, chemotherapy and malnutrition, may contribute to poor prognosis in patients with malignancies developing SJS/TEN.

Prenatal air pollutant exposure and occurrence of atopic dermatitis

BACKGROUND

Hereditary and environmental factors have been related to the occurrence of atopic dermatitis (AD) in early childhood. However, the role of prenatal and early postnatal exposure to air pollutants has not been totally elucidated.

OBJECTIVES

To evaluate the association between prenatal air pollutant exposure and occurrence of AD.

METHODS

In total 24 200 infant-mother pairs were recruited to participate in the Taiwan Birth Cohort Study in 2005 using multistage stratified sampling. Medical history, including physician-diagnosed AD, was inquired by questionnaire at the infant's age of 6 months. Monthly averages of five criteria air pollutants - NO2 , CO, O3 , SO2 and PM10 - were retrieved from 66 air-quality-monitoring stations, and interpolated to all administrative districts using the kriging method. Exposure data during each of the three gestational trimesters and three months after birth were calculated for each study subject, and odds ratios (ORs) of AD occurrence were calculated by logistic regression.

RESULTS

Among the participants, 16 686 mother-infant pairs were qualified for and included in the analysis. Among them, 1206 infants (7·2%) had been diagnosed as having AD before the age of 6 months, and the prevalence was higher in boys (8·3%) than in girls (6·1%). The occurrence of AD was significantly associated with CO exposure during the whole gestational period [adjusted OR (aOR) 1·37, 95% confidence interval (CI) 1·06-1·78] and the first trimester (aOR 1·51, 95% CI 1·16-1·97). We did not observe any significant association among the other air pollutants during either the whole gestational period or any period of the three trimesters and 3 months after birth.

CONCLUSIONS

Our study found a relationship between AD occurrence and gestational exposure to CO, where exposure during the first trimester seemed to be the most important.

Estrogen-dependent sushi domain containing 3 regulates cytoskeleton organization and migration in breast cancer cells

Aromatase inhibitors (AIs) are the standard endocrine therapy for postmenopausal breast cancer; however, currently used biomarkers, such as, estrogen receptor-alpha/progesterone receptor (ERα/PR), predict only slightly more than half of the potential responders to AI treatment. To identify novel markers of AI responsiveness, a genome-wide microarray analysis was performed using primary breast tumor samples from 50 postmenopausal women who later developed metastatic breast cancer. Sushi domain containing 3 (SUSD3) is a significantly differentially expressed gene, with 3.38-fold higher mRNA levels in AI-responsive breast tumors vs non-responders (P<0.001). SUSD3 was highly expressed in ERα-positive breast tumors and treatment with estradiol increased SUSD3 expression in ERα-positive breast cancer cells. Treatment with an antiestrogen or ERα knockdown abolished basal and estradiol-dependent SUSD3 expression. Recruitment of ERα upstream of the transcription start site of SUSD3 was demonstrated by chromatin immunoprecipitation-PCR. Flow cytometric analysis of SUSD3-knockdown cells revealed blunted estradiol effects on progression into S and M phases. SUSD3 was localized to the plasma membrane of breast cancer cells. SUSD3 knockdown decreased the appearance of actin-rich protrusions, stress fibers and large basal focal adhesions, while increasing the presence of cortical actin concomitant with a decrease in Rho and focal adhesion kinase activity. SUSD3-deficient cells demonstrated diminished cell spreading, cell-cell adhesion and motility. In conclusion, SUSD3 is a novel promoter of estrogen-dependent cell proliferation and regulator of cell-cell and cell-substrate interactions and migration in breast cancer. It may serve as a novel predictor of response to endocrine therapy and potential therapeutic target.

An isolated intracranial mucocoele herniated from the frontal sinus

Mucocoeles are chronic mucosa-lined retention cysts that occur due to sinus ostium obstruction and expand along the path of least resistance, most commonly involving the frontal sinus. A frontal mucocoele typically appears as a smooth and rounded expansile enlargement of a completely opacified frontal sinus, with or without thinning of the bony wall of the sinus. Here we report a rare case of isolated intracranial mucocoele that presented with posterior herniation to the anterior cranial fossa through a small bony defect on the posterior table of the frontal sinus. The findings upon imaging could easily be confused with intracranial abscess, potentially leading to craniotomy drainage. In the present case of mucocoele, the frontal intracranial lesion was completely resolved following endoscopic frontal sinusotomy.

YM155 down-regulates survivin and XIAP, modulates autophagy and induces autophagy-dependent DNA damage in breast cancer cells

BACKGROUND AND PURPOSE

The aim of this study was to determine the potency and molecular mechanism of action of YM155, a first-in-class survivin inhibitor that is currently under phase I/II clinical investigations, in various drug-resistant breast cancers including the oestrogen receptor positive (ER(+) ) tamoxifen-resistant breast cancer and the caspase-3-deficient breast cancer.

EXPERIMENTAL APPROACH

The potency of YM155 in SK-BR-3, MDA-MB-231, MCF7 and its tamoxifen-resistant sublines, TamR6, TamR7, TamR8, TamC3 and TamC6, were determined by MTT assay. Western blot analysis, flow cytometric analysis, reverse transcription-PCR, fluorescent microscopy and comet assay were used to determine the molecular mechanism of action of YM155 in different breast cancer cell lines.

KEY RESULTS

YM155 was equally potent towards the parental ER(+) /caspase-3-deficient MCF7 breast cancer cells and its tamoxifen-resistant sublines in vitro. The ER(-) /HER2(+) SK-BR-3 breast cancer cells and the triple-negative/caspase-3-expressing metastatic aggressive MDA-MB-231 breast cancer cells were also sensitive to YM155 with IC50 values in the low nanomolar range. Targeting survivin by YM155 modulated autophagy, induced autophagy-dependent caspase-7 activation and autophagy-dependent DNA damage in breast cancer cells. Interestingly, YM155 also induced XIAP degradation and the degradation of XIAP might play an important role in YM155-induced autophagy in breast cancer cells.

CONCLUSIONS AND IMPLICATIONS

YM155 is a potent survivin inhibitor that has potential for the management of various breast cancer subtypes regardless of the expression of ER, HER2 and caspase-3. Importantly, this study provides new insights into YM155's molecular mechanism of action and therapeutic potential in the treatment of tamoxifen-resistant breast cancer.

Resonant x-ray diffraction spectrum for possible structures of the smectic liquid crystal phase with a six-layer periodicity

With the discovery of the smectic-C(d6)(*) (SmC(d6)(*)) phase showing six-layer periodicity [S. Wang et al., Phys. Rev. Lett. 104, 027801 (2010)] and a recent report of the observation of a possible alternative structure, the need for a reliable and accurate method for distinguishing different possible structures is more urgent than ever. Through simulations using the tensorial structure factor method, we present the resonant x-ray diffraction (RXRD) spectra for different possible structures as proposed in several theoretical studies. Subtle distinctions between models are shown. The ability and limitations of RXRD as a technique for determining the structure of this particular phase is discussed.

Polymorphic microsatellite loci isolated from Cervus unicolor (Cervidae) show inbreeding in a domesticated population of Taiwan Sambar deer

Primers for eight microsatellites were developed; they successfully amplified DNA from 20 domesticated Formosan Sambar deer (Cervus unicolor swinhoei). All loci were polymorphic, with 10-19 alleles per locus. The average observed heterozygosity across loci and samples was 0.310, ranging from 0 to 0.750 at each locus. All loci but one, CU18, deviated from Hardy-Weinberg equilibrium due to excessive homozygosity in these domesticated broodstocks, reflecting inbreeding. These microsatellite loci will be useful, not only for assessment of population structure and genetic variability, but also for conservation of wild deer populations in Taiwan.

Loss of speech after living-related donor liver transplantation: detection of the lesion by diffusion tensor image

INTRODUCTION

Loss of speech after living-related liver transplantation is uncommon. Either immunosuppressive agents, related sequelae, or a neurological event may cause it.

CASE REPORT

A 46-year-old man developed dysarthria and dysphagia on the 10th day after living-related donor liver transplantation for alcoholic cirrhosis with Child-Pugh class C. Brain magnetic resonance images and electroencephalograms could not detect any lesion, but the diffusion tensor image showed a subacute lacunar infarction at right midbrain. The patient's speech improved 1 month after rehabilitation.

CONCLUSIONS

Some unexpected neurological events, such as loss of speech, may occur after liver transplantation. The differential diagnosis becomes very important before active treatment. Magnetic resonance imaging supplemented with diffusion tensor imaging is an effective imaging study in establishing the diagnosis.

Spontaneous and field-induced mesomorphism of a silyl-terminated bent-core liquid crystal as determined from second-harmonic generation and resonant X-ray scattering

The polarity and structure of the phases of a liquid crystal constituted by thiophene-based bent-core molecules is investigated by means of optical second-harmonic generation (SHG), and resonant and conventional X-ray diffraction. The material studied is representative of a wide family of mesogens that contain silyl groups at the ends of the chains. These bulky terminal groups have been reported to give rise to smectic phases showing ferroelectric switching. However, the analysis of the SHG signal before and after application of electric fields has allowed us to establish unambiguously that the reported ferroelectricity is not intrinsic to the material but stabilized by the cell substrates once an electric field has been applied. In addition, the results obtained from resonant X-ray diffraction indicate that virgin samples have antiferroelectric undulated synclinic smectic structures.

DSPP contains an IRES element responsible for the translation of dentin phosphophoryn

The major phosphoprotein in dentin is the aspartic acid and serine-rich protein called dentin phosphophoryn (DPP). DPP appears to be synthesized as a part of a larger compound protein, dentin sialophosphoprotein (DSPP). DSPP has never been isolated or detected in dentin extracts. It is now evident that DSPP is a chimeric protein composed of 3 parts: dentin sialoprotein (DSP), DPP, and dentin glycoprotein (DGP). Previous reports have suggested that the BMP1 protease is responsible for processing DSPP. However, unequal amounts of these products are present in the dentin matrix. Here, we provide evidence for an internal ribosome entry site in the DSPP gene that directs the synthesis of DPP. This mechanism would account for unequal amounts of intracellular DSP and DPP. The internal ribosomal entry site (IRES) activity varied in different cell types, suggesting the presence of additional regulatory elements during the translational regulation of DPP. Further, we provide evidence that DPP is transported to the extracellular matrix (ECM) through exosomes. Using tissue recombination and lentivirus-mediated gain-of-function approaches, we also demonstrate that DPP is essential for the formation of well-defined tooth structures with mineralized dentin matrix.

First Report of Chrysoporthe deuterocubensis Causing Canker on Syzygium samarangense in Taiwan

Wax apple (Syzygium samarangense Merr. & Perry, syn. Eugenia javanica Lam.) belongs to the Myrtaceae family is an important economical tree fruit in Taiwan. The total production acreage of wax apple was 5,266 ha in which more than 77% were located in Pingtung County, southern Taiwan, in 2012. Since the winter of 2010, symptoms of withering leaves and cracking branches on wax apple trees were observed in some orchards in Nanjhou and Linbian Townships, Pingtung County. Diseased trees declined gradually and resulted in reduced fruit production. On the bark of diseased twigs and branches, black conidiamata with yellowish orange conidia were usually observed. For diagnosis, tissues from symptomatic branches were excised, surface sterilized with 0.5% sodium hypochlorite, and placed on 2% water agar in petri dishes. A total of four identical fungal isolates were obtained and maintained on potato dextrose agar (PDA). To fulfill Koch's postulates, three twigs of a wax apple tree were wounded with scalpel and inoculated with each of the four isolates, one tree per isolate. A 7-day-old hyphal mat (about 7 × 18 mm) of each fungal isolate was attached on the wound, wrapped with a wet absorbent cotton and Parafilm, and then covered with a layer of aluminum foil. For the control, the twigs of a wax apple tree were inoculated with PDA plugs. The pathogenicity test was repeated once. After 30 days, withering leaves and cracking twigs were observed on inoculated twigs and the same pathogen was reisolated. Conversely, all of the non-inoculated plants remained healthy. Identification of the pathogen was conducted using its morphological, physiological, and molecular characteristics. On malt extract agar, the colony was floccose and white with hazel hues. The optimal temperature for the mycelial growth was 30°C. Conidia were hyaline, and oblong, with the average size of 4.7 ± 0.6 × 2.7 ± 0.2 μm (100 conidia). Ascostromata were semi-immersed in the bark with fusoid asci, eight ascospores per ascus. Ascospores were hyaline, 2-celled, and tapered in both ends, with the average length of 6.8 ± 0.7 × 2.4 ± 0.3 μm (100 ascospores). For molecular identification, the internal transcribed spacer (ITS) of ribosomal DNA and β-tubulin genes was amplified using the ITS1/ITS4 (3), Bt1a/Bt1b, and Bt2a/Bt2b (1) primer pairs. The gene sequences were deposited in GenBank (Accessions KC792616, KC792617, KC792618, and KC792619 for the ITS region; KC792620, KC792621, KC792622, and KC792623 for Bt1 region, and KC812732, KC812733, KC812734, and KC812735 for Bt2 region) and showed 99 to 100% identity to the Chrysoporthe deuterocubensis isolate CMW12745 (DQ368764 for ITS region; GQ290183 for Bt1 region, and DQ368781 for Bt2 region). In addition, the Bt1 region of the β-tubulin gene consisted of two restriction sites for AvaI and one restriction site for HindIII. This is identical to the description of C. deuterocubensis, a cryptic species in C. cubensis, by Van Der Merwe et al. (2). According to these results, the pathogen was identified as C. deuterocubensis Gryzenh. & M. J. Wingf. To the best of our knowledge, this is the first report of canker disease caused by C. deuterocubensis on S. samarangense in Taiwan. References: (1) N. L. Glass and G. C. Donaldson. Appl. Environ. Microbiol. 61:1323, 1995. (2) N. A. Van Der Merwe et al. Fungal Biol. 114:966, 2010. (3) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, 1990.

Brucellosis in a renal transplant recipient

Brucellosis is one of the most common systemic zoonotic diseases transmitted by consumption of unpasteurized dairy products or by occupational contact with infected animals. Brucellosis is rare in renal transplant recipients. Only 3 cases have been reported in the literature. We report a case of brucellosis with hematologic and hepatobiliary complications in a patient 3 years after renal transplantation. The mean time from transplantation to the diagnosis of brucellosis in these 4 reported patients was 5.1 years (range 17 months to 13 years). All patients had fever and constitutional symptoms, and all attained clinical cure after combination antibiotic therapy. Given the small number of patients, further study is needed to identify the characteristics of brucellosis in renal transplant recipients. Drug interactions and acute renal failure developed in our patient during antibiotic treatment. Therefore, we should monitor the levels of immunosuppressive agents frequently. Several studies have shown in vitro susceptibilities of Brucella melitensis to tigecycline. In our patient, fever finally subsided after tigecycline administration. The minimum inhibitory concentration of tigecycline using Etest was 0.094 μg/mL. Tigecycline may be a potential option for treatment of brucellosis in the setting of transplantation.

Assessing patient safety culture in hospitals across countries

OBJECTIVE

It is believed that in order to reduce the number of adverse events, hospitals have to stimulate a more open culture and reflective attitude towards errors and patient safety. The objective is to examine similarities and differences in hospital patient safety culture in three countries: the Netherlands, the USA and Taiwan.

DESIGN

This is a cross-sectional survey study across three countries. A questionnaire, the Hospital Survey on Patient Safety Culture (Hospital SOPS), was disseminated nationwide in the Netherlands, the USA and Taiwan.

SETTING

The study was conducted in 45 hospitals in the Netherlands, 622 in the USA and 74 in Taiwan.

PARTICIPANTS

A total of 3779 professionals from the participating hospitals in the Netherlands, 196 462 from the USA and 10 146 from Taiwan participated in the study.

MAIN OUTCOME MEASURES

The main outcome measures of the study were 12 dimensions of patient safety culture, e.g. Teamwork, Organizational learning, Communication openness.

RESULTS

Most hospitals in all three countries have high scores on teamwork within units. The area with a high potential for improvement in all three countries is Handoffs and transitions. Differences between countries exist on the following dimensions: Non-punitive response to error, Feedback and communication about error, Communication openness, Management support for patient safety and Organizational learning--continuous improvement. On the whole, US respondents were more positive about the safety culture in their hospitals than Dutch and Taiwanese respondents. Nevertheless, there are even larger differences between hospitals within a country.

CONCLUSIONS

Comparison of patient safety culture data has shown similarities and differences within and between countries. All three countries can improve areas of their patient safety culture. Countries can identify and share best practices and learn from each other.