[Application and evaluation of artificial intelligence TPS-assisted cytologic screening system in urine exfoliative cytology]

Objective: To explore the application of manual screening collaborated with the Artificial Intelligence TPS-Assisted Cytologic Screening System in urinary exfoliative cytology and its clinical values. Methods: A total of 3 033 urine exfoliated cytology samples were collected at the Henan People's Hospital, Capital Medical University, Beijing, China. Liquid-based thin-layer cytology was prepared. The slides were manually read under the microscope and digitally presented using a scanner. The intelligent identification and analysis were carried out using an artificial intelligence TPS assisted screening system. The Paris Report Classification System of Urinary Exfoliated Cytology 2022 was used as the evaluation standard. Atypical urothelial cells and even higher grade lesions were considered as positive when evaluating the recognition sensitivity, specificity, and diagnostic accuracy of artificial intelligence-assisted screening systems and human-machine collaborative cytologic screening methods in urine exfoliative cytology. Among the collected cases, there were also 1 100 pathological tissue controls. Results: The accuracy, sensitivity and specificity of the AI-assisted cytologic screening system were 77.18%, 90.79% and 69.49%; those of human-machine coordination method were 92.89%, 99.63% and 89.09%, respectively. Compared with the histopathological results, the accuracy, sensitivity and specificity of manual reading were 79.82%, 74.20% and 95.80%, respectively, while those of AI-assisted cytologic screening system were 93.45%, 93.73% and 92.66%, respectively. The accuracy, sensitivity and specificity of human-machine coordination method were 95.36%, 95.21% and 95.80%, respectively. Both cytological and histological controls showed that human-machine coordination review method had higher diagnostic accuracy and sensitivity, and lower false negative rates. Conclusions: The artificial intelligence TPS assisted cytologic screening system has achieved acceptable accuracy in urine exfoliation cytologic screening. The combination of manual screening and artificial intelligence TPS assisted screening system can effectively improve the sensitivity and accuracy of cytologic screening and reduce the risk of misdiagnosis.

[Application of near-infrared autofluorescence imaging-based convolution neural network in recognition of parathyroid gland]

Objective: To investigate the application value of near-infrared autofluorescence imaging-based convolution neural network (CNN) for automatic recognition of parathyroid gland. Methods: The data of 83 patients who underwent thyroid papillary cancer surgery in the Department of Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University from August 2020 to March 2022 were retrospectively analyzed, and a total of 725 autofluorescence images of parathyroid gland were collected during the surgery. Meanwhile, non-parathyroid fluorescence imaging videos in the operation area of 10 patients were also collected, and 928 non-parathyroid fluorescence images were captured from those videos. The fluorescence images of parathyroid and non-parathyroid glands were directly used as input features for deep learning to construct ResNet 34, VGGNet 16 and GoogleNet models for automatic parathyroid identification. The ability of different models to identify parathyroid glands was tested by indicators such as accuracy, specificity, sensitivity, precision, receiver operating characteristic curve and area under the curve (AUC). In addition, 30 fluorescence images of parathyroid and 35 fluorescence images of non-parathyroid glands in 13 patients with papillary thyroid cancer from March to May 2022 were collected to prospectively test the best performing CNN model. Results: Among the 83 patients, there were 25 males and 58 females, with the mean age of (46.7±12.4) years. In the binary classification (parathyroid gland and non-parathyroid gland), the ResNet 34 model performed the best in different CNN models, the accuracy, specificity, sensitivity and precision of the identification test set were 97.6%, 96.3%, 99.3% and 95.5%, and the AUC reached 0.978 (95%CI: 0.956-0.991). In the prospective test, the prediction accuracy of the ResNet 34 model reached 93.8%, and the AUC was 0.938 (95%CI: 0.853-0.984). Conclusion: The near-infrared autofluorescence imaging-based deep CNN has good application value in the automatic recognition of parathyroid gland, and can be used to assist the recognition and protection of parathyroid gland in thyroid cancer surgery.

[Use of indocyanine green fluorescence navigation in laparoscopic anatomical hepatectomy]

Objective: To examine the clinical value of fluorescence-guided indocyanine green (ICG) laparoscopic anatomical hepatectomy in the treatment of primary hepatocellular carcinoma. Methods: Data from patients diagnosed with hepatocellular carcinoma and who underwent laparoscopic hepatectomy with ICG fluorescence navigation in the Department of Liver Surgery and Liver Transplantation Center of West China Hospital between September 2020 and May 2022 were retrospectively collected. There were 53 males and 19 females, with an age of (55.5±12.9)years(range:42.6 to 68.4 years). Among them, 13 of the cases underwent laparoscopic anatomical liver resection(LALR) guided by tans-arterial ICG,43 of the cases received LAIR guided by portal vein negative ICG, and 16 of the cases received LALR positive by portal vein. Comparison among the three groups was performed by one-way ANOVA; and the rank sum test was used for comparison between groups. The counting data was expressed as percentage,and the χ² test or Fisher's exact probability method was used for comparison between groups. Results: (1) Postoperative pathology: Resection R0 was achieved in all operations. The maximum tumor diameter of the patients in the arterial staining group, the reverse staining group, and the positive staining group(M (IQR)) was 2.5 (2.4) cm, 3.0 (2.5) cm and 3.0(2.4) cm,respectively. There were no statistically significant differences in the maximum tumor diameter between the three groups (P=0.364). The minimum tumor margin was 1.1 (1.1) cm, 1.0 (1.0) cm, 1.1 (1.6) cm in the the arterial staining group, reverse staining group and the positive staining group, respectively. There was no significant difference in the margin among the three groups (P=0.878). (2) Operation conditions: the operation time of the arterial staining group, the negative staining group, and the positive portal staining group was (348±93)minutes,(277±112)minutes,and (295±116)minutes,respectively. There were no significant differences in operation time among the three groups (P=0.134). The intraoperative blood loss of the three groups was 80(150)ml,200(350)ml,and 100(150)ml,respectively. There was no statistically significant difference in intraoperative bleeding volume between the three groups(P=0.743). All cases were not transfused during the operation and were not converted to laparotomy. ALT in the arterial staining group was higher than in the negative staining group in the first two days after the operation ((559±398)IU/L307(257) IU/L, q=235.5,P=0.004;(611±389)IU/L(331±242) IU/L, q=265.2, P=0.002). There was only one case of a grade III complication (Clavien-Dindo grading system) postoperative complication in the negative and positive staining group of the portal vein, respectively. Tumor markers in all patients decreased to the normal range after 2 months of operation. Conclusion: Laparoscopic anatomical hepatectomy guided by ICG fluorescence through arterial staining and portal vein staining is safe and feasible for primary hepatocellular carcinoma treatment.

["Graded early warning system" of RET germline mutation carriers in MEN2A/MEN2B families and total thyroidectomy (report of 7 cases)]

Objective: To explore the reasonable time of prophylactic thyroidectomy for RET gene carriers in multiple endocrine neoplasia(MEN) 2A/2B families. Methods: From May 2015 to August 2021, RET gene carriers in MEN2A/MEN2B families were dynamically followed up at the Department of Thyroid Head and Neck Surgery, Beijing Tongren Hospital of Capital Medical University. The high-risk patients were encouraged to undergo prophylacitc total thyroidectomy according to the principle of "graded early warning system", namely the evaluation of gene detection, calcitonin value and ultrasound examination successively. Seven cases underwent the surgery, including 3 males and 4 females, aged from 7 to 29 years. According to the risk stratification listed in the guidelines of the American Thyroid Association in 2015, there were 2 cases of the highest risk, 2 cases of the high risk and 3 cases of the modest risk. Calcitonin index remained within the normal range in 3 cases and elevated in 4 cases before operation. All 7 patients underwent thyroidectomy with lymph node dissection of the level Ⅵ performed in 4 patients. Results: The time from suggestion to operation was 2 to 37 months, with an average of 15.1 months. The 6 patients were medullary thyroid carcinoma and 1 case with C-cell hyperplasia. The follow-up time was 2 to 82 months, with an average of 38.4 months. Postoperative serum calcitonin levels of all cases decreased to normal level, with biochemical cure. There was no sign of recurrence on ultrasound examination. All 7 patients had no serious complications, no obvious thyroid dysfunction. Their height, weight and other indicators of pediatric patients were similar to those of their peers, with normal growth and development. Conclusion: For healthy people with MEN2A/MEN2B family history, prophylactic thyroidectomy can be carried out selectively based on the comprehensive evaluation of "graded early warning system" with strict screening and close monitoring.

[Effects of mesenchymal stem cells on primary culture and secretion function of parathyroid cells in vitro]

Objective: To investigate the effects of adipose-derived mesenchymal stem cells (ADMSCs) on proliferation and hormone secretion of parathyroid cells in votro. Methods: The parathyroid cells and ADMSCs were obtained from 10 SD rats by cell separation and culture. The phenotype of P3 generation for ADMSCs was detected by flow cytometry. The co-culture of parathyroid cells and ADMSCs was conducted in the ratios of 2∶1, 1∶1, 1∶2 and 1∶5, respectively. The level of parathyroid hormone in cell supernatant was determined. The results were compared with the parathyroid hormone in the supernatant of parathyroid cells cultured separately in the corresponding number. The effects of ADMSCs on the hormone secretion of parathyroid cells were evaluated. SPSS 11.0 software was used for statistical analysis. Results: The primary culture of either parathyroid cells or ADMSCs and the co-culture of these cells in vitro were performed successfully, and the in vitro culture of different proportions of the two cells showed different effects on parathyroid hormone secretion. The co-culture of parathyroid cells and ADMSCs, especially in the ratio of 1∶5, facilitated the secretion of parathyroid hormone ((1.3±0.0) vs. (0.8±0.1), (1.3±0.0) vs. (0.9±0.0), (1.7±0.5) vs. (0.9±0.0), (1.7±0.0) vs. (1.2±0.2))ng/L with t value of 25.46, 64.30, 3.32, 7.16, P<0.05 on the 2nd, 4th, 6th and 8th days respectively. Secondly, when the ratio was 1∶2, the PTH level showed an upward trend. Conclusion: Parathyroid cells and ADMSCs can be co-cultured in vitro, facilitating the secretion of parathyroid hormone under the appropriate cell proportion such as the ratio of by parathyroid cells to ADMSCs at 1∶5.

Severe duodenal ulcer behaves like gastroduodenal intussusception

Intestinal intussusception is uncommon in adults. As a retroperitoneal structure, gastroduodenal intussusception is extremely rare. The leading cause of intussusception is reported to be a tumour, either benign or malignant. The case presented may be the first of gastroduodenal intussusception resulting from severe peptic ulcer. A 64-year-old man was admitted with epigastralgia, appetite loss and melena for 1 week. He had history of peptic ulcer and reflux esophagitis for 9 years, caused by Helicobacter pylori infection; eradication therapy had been performed 5 years previously. This time, an abdominal computed tomography scan showed duodenogastric intussusception and gastric outlet obstruction. Preoperative biopsy failed for complete obstruction; thus, the patient underwent Whipple procedure for complete resection under impression of malignancy. The postoperative course was uneventful. Pathological findings for the specimen showed gastric and duodenal ulcer. Progressive peptic ulcer after eradication therapy is rarely seen, and eradication therapy is used widely to treat H. pylori infection. The eradication rate is extremely high in Taiwan for lower first-line antibiotic as clarithromycin resistance is low due to a policy restricting antimicrobial usage. Early eradication therapy is highly recommended for patients with H. pylori infection. We emphasise the importance of regular follow-up for the non-significant correlation of severity of gastric ulcer with clinical symptoms. When ulceration progresses or non-invasive treatments fail early surgical interventions should be applied to these anatomic alterations.

Ultrafast X-Ray Diffraction Visualization of B1-B2 Phase Transition in KCl under Shock Compression

The classical B1(NaCl)↔B2(CsCl) transitions have been considered as a model for general structural phase transformations, and resolving corresponding phase transition mechanisms under high strain rate shock compression is critical to a fundamental understanding of phase transition dynamics. Here, we use subnanosecond synchrotron x-ray diffraction to visualize the lattice response of single-crystal KCl to planar shock compression. Complete B1-B2 orientation relations are revealed for KCl under shock compression along ⟨100⟩_{B1} and ⟨110⟩_{B1}; the orientation relations and transition mechanisms are anisotropic and can be described with the standard and modified Watanabe-Tokonami-Morimoto model, respectively, both involving interlayer sliding and intralayer ion rearrangement. The current study also establishes a paradigm for investigating solid-solid phase transitions under dynamic extremes with ultrafast synchrotron x-ray diffraction.

Genetic Structure Analysis of Y Chromosome STR and SNP in Population of Changshu

Abstract

Objective To provide a theoretical basis for building a Y chromosome database in specific regions by analyzing the pedigree specific core haplogroup and region specific genetic structure in Changshu. Methods One thousand seven hundred and two samples from unrelated Han male individuals in Changshu were collected. Then 27 Y-STR were genotyped through YfilerTM Plus PCR Amplification Kit, Y-SNP haplogroup of each sample was speculated using Y-Predictor software and some samples were verified by amplification refractory mutation system-polymerase chain reaction （ARMS-PCR）. Results A total of 1 556 haplotypes were found on the 27 Y-STR genetic markers of the 1 702 samples. The haplotype diversity （HD） value was 0.999 827. DYS385 （0.933） had the highest gene diversity （GD） value while DYS438 （0.409） had the lowest. By the Y-Predictor software, all samples were confirmed to be from 162 sub-haplogroups of C, D, N, O, Q and R. Samples were randomly selected to verify the prediction results by the software and the prediction accuracy of Y-Predictor software was as high as 95.74%. Conclusion This study found that 27 Y-STR genetic markers have relatively high polymorphisms in the Changshu population, and have good forensic individual identification and paternity testing ability.

[Acute lymphoblastic leukemia complicated with cerebral venous thrombosis in 14 children]

Objective: To explore the clinical characteristics and management of childhood acute lymphoblastic leukemia (ALL) complicated with cerebral venous thrombosis (CVT). Methods: The clinical data of 14 ALL children complicated with CVT who were admitted to Department of Pediatrics of Sun Yat-sen Memorial Hospital and underwent chemotherapy from January 2011 to October 2019 were collected retrospectively. The clinical manifestations, coagulation function, imaging findings, treatment plan and prognosis of patients were analyzed. Results: CVT was diagnosed in 14 (2.8%, 14/505) cases, with a median age of 10 (3-14) years at onset, 11 cases occurred in the stage of induction remission, and the acute onsets were mainly characterized by convulsions (9 cases), consciousness disorders (6 cases) and headache (4 cases). Coagulation function test showed that, before the CVT, antithrombin Ⅲ activity was lower than 60% in 8 cases, D-dimer elevated on the day of onset in 8 cases. Arteriovenous angiography showed filling defects in single (9 cases) or multiple (5 cases) venous sinuses. The most common site of venous sinus enlargement was superior sagittal sinus (10 cases). Secondary cerebral hemorrhage was found in 5 cases. Anticoagulation therapy included combination of low-molecular-weight heparin (LMWH) and warfarin in 9 cases, sequential application of LMWH and warfarin in 2 cases, and LMWH alone in 3 cases. Patients accepted further asparaginase and no CVT recurrence or progression was found. Conclusions: The secondary coagulation dysfunction during induction remission chemotherapy is the major risk factor for CVT in ALL, which needs active monitoring and early prevention. Arteriovenous angiography can diagnose accurately, and the prognosis of anticoagulant therapy with LMWH and warfarin is optimistic.

Capture Deformation Twinning in Mg during Shock Compression with Ultrafast Synchrotron X-Ray Diffraction

Deformation twinning plays a vital role in accommodating plastic deformation of hexagonal-close-packed (hcp) metals, but its mechanisms are still unsettled under high strain rate shock compression. Here we investigate deformation twinning in shock-compressed Mg as a typical hcp metal with in situ, ultrafast synchrotron x-ray diffraction. Extension twinning occurs upon shock compression along ⟨112[over ¯]0⟩ and ⟨101[over ¯]0⟩, but only upon release for loading along ⟨0001⟩. Such deformation mechanisms are a result of the polarity of deformation twinning, which depends on directionality and relative magnitude of resolved shear stress and may be common for Mg and its alloys in a wide range of strain rates.

[Surgical management for local retroperitoneal recurrence of 33 renal cell carcinoma patients underwent radical nephrectomy]

Objective: To investigate the therapeutic effects of surgical management for local retroperitoneal recurrence of renal cell carcinoma after radical nephrectomy. Methods: Clinical and follow-up data of 33 cases of local recurrence after radical nephrectomy in Renji Hospital from January 2010 to April 2018 were retrospectively analyzed. Results: In these 33 patients, 25 was male and 8 was female; The median age was 54 years old. The pathological stage of radical nephrectomy included 14 cases of pT1-2N0M0 stage, 16 cases of pT3-4 N0M0 stage, and 3 cases of pN1 stage. Only 4 relapsing patients had symptoms, the others were all found to have recurrence by imaging examination during follow up period of postoperation.The median recurrence time for all patients was 30 months, and the median diameter of recurrent tumors was 4.5 cm.Twenty-nine patients underwent complete resection of local recurrent lesions, and 4 patients whose recurrent lesions could not be completely resected converted receive palliative surgery. The median intraoperative blood loss was 500 ml and the median hospital stay after surgery was 4 days. Clavien grade Ⅰ-Ⅱ complications occurred in 5 patients after surgery, and no serious complications of Clavien grade Ⅲ-Ⅴ complications occurred. Six patients received postoperative adjuvant target therapy and distant metastasis occurred in one patient.In the 27 patients without adjuvant target therapy, postoperative distant metastases occurred in 12 patients. The median survival time for all patients after local recurrence surgery was 31 months. The 1-year and 3-year survival rates were 86.8% and 36.9%, respectively. Conclusions: The rigorous imaging examination after radical nephrectomy can detect local recurrent lesions as early as possible in most relapsing patients and imaging examination can predict the integrity of surgical resection of local recurrence.Although intraoperative bleeding of resection of local recurrence is relatively high, the operation is safe and the postoperative complications are controllable. Postoperative adjuvant therapy may also provide better survival benefit for patients with local recurrence.

[Effect of vascular changes on prognosis after induced chemotherapy for advanced hypopharyngeal carcinoma]

Objective: To analyze the clinical characteristics of two groups(vascular classification declines or not in narrow band imaging (NBI) of patients with advanced hypopharyngeal carcinoma after induced chemotherapy, to follow-up and compare the survival differences between the two groups, and to explore the effect of vascular changes on clinical prognosis after induced chemotherapy in patients with advanced hypopharyngeal carcinoma. Methods: Clinical data of 56 patients with advanced hypopharyngeal carcinoma from August 2014 to September 2016 in Beijing Tongren Hospital, Capital Medical University were collected. The patients were divided into two groups according to NBI vascular classification declines or not after induced chemotherapy. The survival of patients and the impact of different factors on the prognosis were retrospectively analyzed. SPSS 24.0 statistical software was used for analysis. Frequency data were compared between the two groups using χ(2) test. Kaplan-Meier method and Cox regression analysis were employed for survival analysis and Log-Rank test was used for inter-group comparison, P<0.05 was statistically significant. Results: There was significant difference in overall survival rate(OS) between two groups of patients with advanced hypopharyngeal carcinoma after induced chemotherapy (P<0.05). Multivariate analysis showed that NBI vascular classification changes after induced chemotherapy was the impact factor for prognosis of advanced hypopharyngeal carcinoma after induced chemotherapy. Conclusion: In addition to recurrence and metastasis, NBI vascular classification changes is the important impact factor for prognosis of advanced hypopharyngeal carcinoma after induced chemotherapy. Patients with NBI vascular classification declines have significant survival benefit. The patients with advanced hypopharyngeal carcinoma should be checked with NBI examination before and after induced chemotherapy. NBI should be included in the routine screening indicators for prognosis of advanced hypopharyngeal carcinoma.

Ultrasound-guided percutaneous rib biopsy: a safe procedure with high diagnostic yield

AIM

To assess the diagnostic yield and complication rate of image-guided percutaneous rib biopsy, comparing ultrasonography (US) to fluoroscopy and computed tomography (CT)-guided biopsy techniques.

MATERIALS AND METHODS

A retrospective review was conducted of patients who underwent image-guided percutaneous rib biopsy at a single tertiary-care academic centre between January 2007 and June 2017. The diagnostic yield and complication rates were calculated and compared between the three imaging methods.

RESULTS

A total of 70 consecutive, image-guided percutaneous rib biopsies were performed in 67 patients (48 in males, 22 in females, mean age of 68.2 years, age range 31-92 years). The image guidance method utilised for biopsy was US in 64.3% (45/70), CT in 18.6% (13/70), and fluoroscopy in 17.1% (12/70). The diagnostic yield for all cases combined was 97.1% (68/70) and 97.8% (44/45) for US-guided biopsies specifically. A complication of pneumothorax was encountered in 4.3% (3/70) of all cases combined and in 4.4% (2/45) of US-guided biopsies specifically.

DISCUSSION

US-guided percutaneous rib biopsy has a high diagnostic yield and low complication rate, comparable to fluoroscopy or CT-guided biopsy.

[Correlation between N-terminal probrainnatriuretic peptide and prognosis of acute exacerbations of chronic obstructive pulmonary disease]

Objective: To evaluate the correlation between N-terminal probrainnatriuretic peptide (NT-proBNP) and the prognosis of death in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease(COPD). Methods: A cohort study of 169 patients with acute exacerbations COPD. According to the age and NT-proBNP value measured on admission, cases were divided into 3 groups. The risk ratio of mortality among the three group were analyzed. Results: Thirty-two patients died within 1 year. There are 93 cases in group A (NT-proBNP < 300 ng/L), 45 cases in group B (aged 75 and below with NT-proBNP 300-900 ng/L, older than 75 with NT-proBNP 300-1 800 ng/L), 31 cases in group C (aged 75 and below with NT-proBNP>900 ng/L, older than 75 with NT-proBNP>1 800 ng/L); The in-hospital mortalities were 3.2%, 11.1% and 32.3%respectively, and mortalities within a year were 5.4%, 17.8% and 61.3% . The risk ratio (RR) and 95%CI for dying in hospital of group C to group A and B were 10.00 (3.61-56.50) and 2.90 (1.15-12.60), RR and 95%CI for dying within 1 years after hospitalization were 11.40 (8.78-88.46) and 3.45 (2.56-20.97, P<0.05). Conclusion: The NT-proBNP values measured at admission were associated with the short-term and long-term prognosis of patients with AECOPD.

[Comparison of efficacy between sorafenib and sunitinib as first-line therapy for metastatic renal cell carcinoma and analyze prognostic factors for survival]

Objective: To investigate the efficacy and drug related adverse reactions of sorafenib and sunitinib as first-line tyrosine-kinase inhibitors (TKIs) for patients with metastatic renal cell carcinoma (mRCC) and analyze the clinical prognostic factor for survival. Methods: The data of 271 patients with metastatic renal cell carcinoma who had complete clinicopathological data were retrospectively analyzed, including 174 cases in sorafenib group and 97 cases in sunitinib group, to access patients' overall survival (OS) and progression-free survival (PFS). Prognostic values of all characteristics were determined by using univariate and multivariate Cox regression models. Results: The objective response rates (ORR) of the sorafenib and sunitinib groups were 14.9% and 19.6%, respectively, and the disease control rates (DCR) were 85.1% and 88.6%, respectively. No significant difference was found between the sorafenib and sunitinib group in ORR (P=0.325) or DCR (P=0.408). The most common grade 3 to 4 adverse events in the sorafenib group were hand-foot syndrome (6.7%), diarrhea (2.3%), and rash (2.3%). The most common grade 3 to 4 adverse events in the sunitinib group were neutropenia (6.2%), hand-foot syndrome (6.2%), and thrombocytopenia (4.6%). During the follow-up, 97 cases death occurred and 81 cases disease progression occurred in sorafenib group. The median PFS was 12 months (95% CI: 9-15 months), and the median OS was 25 months (95% CI: 21-29 months) in sorafenib group. While 74 cases death occurred and 40 cases disease progression occurred in sunitinib group, the median PFS was 12 months (95% CI: 10-12 months) and the median OS was 23 months (95% CI: 20-32 months) in sunitinib group. No significant difference was found between the sorafenib and the sunitinib group in PFS (P=0.771) or OS (P=0.548). Multivariate analysis showed Fuhrman grades (HR=1.358, 95%CI: 1.004-1.835), number of metastatic sites (HR=1.550, 95%CI: 1.143-2.101) and MSKCC risk grade (Intermediate risk group: HR=1.621, 95%CI: 1.117-2.232; Poor risk group: HR=2.890, 95%CI: 1.942-4.298) were independent prognostic factors for PFS. Fuhrman grades (HR=2.135, 95%CI: 1.533-2.974), number of metastatic sites (HR=1.774, 95%CI: 1.279-2.461) and MSKCC risk grade (Intermediate risk group: HR=1.415, 95%CI: 1.002-1.998; Poor risk group: HR=3.161, 95%CI: 2.065-4.838) were independent prognostic factors for OS. Conclusions: The results of this study indicate that sorafenib and sunitinib are both effective as the first-line TKIs for mRCC patients and sorafenib has comparable efficacy to sunitinib. But they have differences in the incidence of adverse effects. Fuhrman grades, number of metastatic sites and MSKCC risk grade are independent prognostic factors for mRCC patients.

[Preference on screening frequency and willingness-to-pay for multiple-cancer packaging screening programs in urban populations in China]

Objective: From an actual cancer screening service demanders' perspective, we tried to understand the preference on screening frequency and willingness-to-pay for the packaging screening program on common cancers and to evaluate its long-term sustainability in urban populations in China. Methods: From 2012 to 2014, a multi-center cross-sectional survey was conducted among the actual screening participants from 13 provinces covered by the Cancer Screening Program in Urban China (CanSPUC). By face-to-face interview, information regarding to preference to screening frequency, willingness-to-pay for packaging screening program, maximum amount on payment and related reasons for unwillingness were investigated. Results: A total of 31 029 participants were included in this survey, with an average age as (55.2±7.5) years and median annual income per family as 25 000 Chinese Yuan. People's preference to screening frequency varied under different assumptions ( " totally free" and "self-paid" ). When the packaging screening was assumed totally free, 93.9% of residents would prefer to take the screening program every 1 to 3 years. However, the corresponding proportion dropped to 67.3% when assuming a self-paid pattern. 76.7% of the participants had the willingness-to-pay for the packaging screening, but only 11.2% of them would like to pay more than 500 Chinese Yuan (the expenditure of the particular packaging screening were about 1 500 Chinese Yuan). The remaining 23.3% of residents showed no willingness-to-pay, and the main reasons were unaffordable expenditure (71.7%) and feeling'no need'(40.4%). Conclusions: People who participated in the CanSPUC program generally tended to choose high-frequency packaging screening program, indicating the high potential acceptance for scale-up packaging screening, while it needs cautious assessments and rational guidance to the public. Although about seven in ten of the residents were willing to pay, the payment amount was limited, revealing the necessity of strengthening individual's awareness of his or her key role in health self-management, and a reasonable payment proportion should be considered when establishing co-compensation mechanism.

[Willingness and preferences of actual service suppliers regarding cancer screening programs: a multi-center survey in urban China]

Objective: From the perspective of actual service suppliers regarding cancer screening, this study aimed to assess the long-term sustainability of cancer screening programs in China. Methods: Based on a Cancer Screening Program in Urban China (CanSPUC), our survey focused on all the hospitals, centers for disease control and prevention (CDC) and community service centers across 16 provinces in China which participated in the programs between 2013 and 2015. All the managers (institutional/department level) and professional staff involved in the program were interviewed using either paper-based questionnaire or online approach. Results: A total of 4 626 participants completed the interview. It showed that the main gains from providing screening service emphasized promotion in social value (63.6%), local reputation (35.9%), and professional skills (30.6%), whereas difficulties encountered included inadequate compensation (30.9%) and discordance among information systems (28.3%). When the service remuneration amounts to about 50 Chinese Yuan per screening item, those professional staff self-reported that they would like to work overtime. More than half (63.7%) of the staff expressed willingness to provide routine screening service, the main expectations were to promote their reputation to the local residents (48.7%) and to promote professional skills (43.1%). Those who were not willing to provide screening services were worried about the potential heavy workload (59.8%) or being interfered with their routine work (49.8%). Further detailed results regarding the different organization types and program roles were presented in the following detailed report. Conclusions: Findings of gains and difficulties showed that if cancer screening is expected to become a long-term running, incentive mechanism from the program, external promotion and advocacy as well as capacity building should be strengthened; furthermore, rewards to staff's screening services should be raised according to the local situations. Results regarding the "willingness to provide service" showed that management of the program should also be strengthened, including information system building and inter-agency and inter-department coordination at the government levels.

Cancer Screening Recommendations for Solid Organ Transplant Recipients: A Systematic Review of Clinical Practice Guidelines

Solid organ transplant recipients (SOTRs) are at increased risk of developing and dying from cancer. However, controversies exist around cancer screening in this population owing to reduced life expectancy and competing causes of death. This systematic review assesses the availability, quality and consistency of cancer screening recommendations in clinical practice guidelines (CPGs). We systematically searched bibliographic databases and gray literature to identify CPGs and assessed their quality using AGREE II. Recommendations were extracted along with their supporting evidence. Thirteen guidelines were included in the review. CPGs for kidney recipients were the most frequent source of screening recommendations, and recommendations for skin cancer screening were most frequently presented. Some screening recommendations differed from those for the general population, based on literature demonstrating higher cancer incidence among SOTRs versus direct evidence of screening effectiveness. Relevant stakeholders such as oncology specialists, primary care providers and public health experts were not involved in the formulation of the screening recommendations. In conclusion, although several guidelines make recommendations for cancer screening in SOTRs, the availability of cancer screening recommendations varied considerably by transplanted organ. More studies are required to inform cancer screening recommendations in SOTRs, and guideline development should involve transplant patients, oncologists and cancer screening specialists.

Adult diaphyseal both-bone forearm fractures: A clinical and biomechanical comparison of four different fixations

BACKGROUND

Although there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains.

HYPOTHESIS

Hybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk.

MATERIALS AND METHODS

Forty cadavers (20 males, 20 females; mean age 68.06, SD 1.58years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age 38.03±0.88years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius.

RESULTS

In the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (All P>0.05), suggesting the more stable fixation compared with the other two groups (All P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (Both P<0.05).

CONCLUSION

The hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes.

LEVEL OF EVIDENCE

Level II, prospective randomised study.

Simultaneous, single-pulse, synchrotron x-ray imaging and diffraction under gas gun loading

We develop a mini gas gun system for simultaneous, single-pulse, x-ray diffraction and imaging under high strain-rate loading at the beamline 32-ID of the Advanced Photon Source. In order to increase the reciprocal space covered by a small-area detector, a conventional target chamber is split into two chambers: a narrowed measurement chamber and a relief chamber. The gas gun impact is synchronized with synchrotron x-ray pulses and high-speed cameras. Depending on a camera's capability, multiframe imaging and diffraction can be achieved. The proof-of-principle experiments are performed on single-crystal sapphire. The diffraction spots and images during impact are analyzed to quantify lattice deformation and fracture; fracture is dominated by splitting cracks followed by wing cracks, and diffraction peaks are broadened likely due to mosaic spread. Our results demonstrate the potential of such multiscale measurements for studying high strain-rate phenomena at dynamic extremes.

Selecting patients for a second hepatectomy for colorectal metastases: an systemic review and meta-analysis

BACKGROUND

Opinions on the suitability of repeat hepatectomy for patients with recurrent colorectal liver metastases (CRLMs) vary among studies. We conducted a meta-analysis to establish the criteria for selecting the best candidates for a second hepatectomy.

METHODS

Database and manual searches were performed to identify comparative or prognostic studies published up to October 2013. Outcomes of interest included disease characteristics, perioperative outcomes, and long-term survival after initial and second hepatectomies for patients with CRLM. Study quality was appraised using the Newcastle-Ottawa scale and a modified Hayden's score.

RESULTS

A total of 7226 patients from 27 studies were included. Recurrent CRLMs after initial hepatectomy were more likely to be solitary (RR = 0.86, P = 0.045), unilobar (RR = 0.60, P < 0.001), and smaller (WMD = -0.66, P < 0.001). Postoperative morbidity and mortality were comparable between initial and second hepatectomies (RR = 1.10, P = 0.191; RR = 0.78, P = 0.678, respectively). In high-quality studies, patients showed better survival after a second hepatectomy than those after a single hepatectomy (HR = 0.68, P = 0.022). Patients meeting the following six predictors survived longer after second hepatectomy: disease-free survival after initial hepatectomy >1 y (P = 0.034); solitary CRLM at second hepatectomy (P < 0.001); unilobar CRLM at second hepatectomy (P = 0.009); maximal size of CRLM at second hepatectomy ≤ 5 cm (P = 0.035); lack of extrahepatic metastases at second hepatectomy (P < 0.001); and R0 resection at second hepatectomy (P < 0.001).

CONCLUSIONS

Second hepatectomy is a safe and feasible procedure for patients with recurrent CRLM. In fact, in well-selected patients it improves overall survival. The established criteria can help clinicians to select the best candidates for second hepatectomy and to achieve better long-term outcomes after resection.

BLMP-1/Blimp-1 regulates the spatiotemporal cell migration pattern in C. elegans

Spatiotemporal regulation of cell migration is crucial for animal development and organogenesis. Compared to spatial signals, little is known about temporal signals and the mechanisms integrating the two. In the Caenorhabditis elegans hermaphrodite, the stereotyped migration pattern of two somatic distal tip cells (DTCs) is responsible for shaping the gonad. Guidance receptor UNC-5 is necessary for the dorsalward migration of DTCs. We found that BLMP-1, similar to the mammalian zinc finger transcription repressor Blimp-1/PRDI-BF1, prevents precocious dorsalward turning by inhibiting precocious unc-5 transcription and is only expressed in DTCs before they make the dorsalward turn. Constitutive expression of blmp-1 when BLMP-1 would normally disappear delays unc-5 transcription and causes turn retardation, demonstrating the functional significance of blmp-1 down-regulation. Correct timing of BLMP-1 down-regulation is redundantly regulated by heterochronic genes daf-12, lin-29, and dre-1, which regulate the temporal fates of various tissues. DAF-12, a steroid hormone receptor, and LIN-29, a zinc finger transcription factor, repress blmp-1 transcription, while DRE-1, the F-Box protein of an SCF ubiquitin ligase complex, binds to BLMP-1 and promotes its degradation. We have therefore identified a gene circuit that integrates the temporal and spatial signals and coordinates with overall development of the organism to direct cell migration during organogenesis. The tumor suppressor gene product FBXO11 (human DRE-1 ortholog) also binds to PRDI-BF1 in human cell cultures. Our data suggest evolutionary conservation of these interactions and underscore the importance of DRE-1/FBXO11-mediated BLMP-1/PRDI-BF1 degradation in cellular state transitions during metazoan development.

The migratory path of DTCs determines the shape of the C. elegans gonad. How the spatiotemporal migration pattern is regulated is not clear. We identified a conserved transcription factor BLMP-1 as a central component of a gene regulatory circuit required for the spatiotemporal control of DTC migration. BLMP-1 levels regulate the timing of the DTC dorsal turn, as high levels delay the turn and low levels result in an early turn. We identify and characterize upstream regulators that control BLMP-1 levels. These regulators function in two ways, i.e. by destabilization of BLMP-1 through ubiquitin-mediated proteolysis and by transcriptional repression of the blmp-1 gene to down-regulate BLMP-1. Interestingly, blmp-1 also negatively controls these regulators. Our data suggest that a dietary signal input acts together with a double-negative feedback loop to switch DTCs from the “blmp-1-on” to the “blmp-1-off” state, promoting their dorsal turn. Furthermore, we show that some protein interactions in the circuit are conserved in C. elegans and humans. Our work defines a novel function of the conserved blmp-1 gene in the temporal control of cell migration, and establishes a gene regulatory circuit that integrates the temporal and spatial inputs to direct cell migration during organogenesis.

Intermediate pre-tilt angle control by a composite alignment thin film structure for liquid crystal displays

We designed a patterned composite alignment thin film structure using a horizontal alignment polyimide (PI) layer and vertical alignment liquid crystal polymer (LCP) pillars. The LCP polymer precursor concentration was varied at 0-10% and the pillars were introduced by a photolithography process. Both single-sided and double-sided liquid crystal display cells were assembled for a series of electro-optical characterization techniques. The horizontal PI alignment layer alone had a designated control of the pre-tilt angle of 7 degrees after the prescribed mechanical rubbing process. The pre-tilt angle was improved to 24 degrees when the LCP precursor concentration was 5%. It was further increased to 61 degrees at the concentration of 10%. In addition, the study on the electrical response time and gray level variation demonstrated promising results for potential applications. The field-on response time was only 2.79 ms and the field-off response time was 0.35 ms for the double-sided liquid crystal display cells using a ramping voltage of 5.5 V. The effective control of the cell pre-tilt angle suggested that the display power consumption and response time would be greatly improved.

The effect of Al/Si ratio on the transport properties of the layered intermetallic compound CaAl(2)Si(2)

We report the results of the electrical resistivity and Seebeck coefficient as well as thermal conductivity measurements on the stoichiometric CaAl(2)Si(2) and non-stoichiometric CaAl(1.75)Si(2.25), CaAl(1.9)Si(2.1), CaAl(2.1)Si(1.9), and CaAl(2.25)Si(1.75) compounds in the temperature range 10-300 K. It has been found that the magnitude of electrical resistivity decreases for the non-stoichiometric samples, attributed to the shift of Fermi energy from the dip of the density of states as a consequence of the changed Si/Al content. In addition, a systematic change in the magnitude of Seebeck coefficient as a function of Al/Si concentration has been observed. The results have been associated with the effect of hole/electron doping on the Fermi level density of states. A detailed analysis of the electrical resistivity and Seebeck coefficient suggests the presence of two types of charge carrier and the temperature dependent changes in their mobility. From the thermal conductivity results, we correlated the extent of disorder and Al/Si ratio with various thermal scattering mechanisms in the investigated temperature range.

Impact of feeding 2-hydroxy-4-(methylthio)butanoic acid and DL-methionine supplemented maize-soybean-rapeseed meal diets on growth performance and carcase quality of broilers

1. This experiment was conducted to compare the effectiveness of DL-2-hydroxy-4-(methylthio)butanoic acid (HMTBA) and DL-methionine (DLM) on growth performance and carcase quality of broilers in a 2 x 3 x 2 factorial experimental design including two methionine (Met) sources, three equimolar levels of Met supplementation and two sexes. 2. No difference was observed between the two Met sources in growth performance and muscle deposition from 10 to 49 d. With increasing Met levels, average daily gain was increased in the starter, grower and overall phases, average daily feed intake was increased in the starter phase, and feed:gain ratio was decreased in the grower and overall phases. Met supplementation increased breast muscle content and decreased abdominal fat content. Broilers given HMTBA had breast and thigh muscle coloration that was characterised as superior to those fed DLM. 3. These results indicated that Met supplementation improved growth performance and carcase quality irrespective of the Met sources. Compared to DLM, HMTBA has the same molar bioefficacy for improving the growth performance and carcase quality; however, HMTBA-fed birds had superior meat colour to DLM-fed birds.

Chronic fatigue in long-term peritoneal dialysis patients

OBJECTIVE

Fatigue is a common symptom in long-term dialysis patients. This study investigated possible clinical factors which may cause the development of fatigue in patients receiving peritoneal dialysis (PD). We also investigated the relationship between total solute clearance (TSC) and fatigue symptoms in PD patients.

DESIGN

A cross-sectional study design was used to compare the clinical characteristics among groups of PD patients classified by different degrees of fatigue. The relationship among dialysis adequacy (including Kt/V(urea) and weekly creatinine clearance; C(cr)), clinical characteristics and fatigue symptoms were also assessed.

SETTING

The PD unit of a major university teaching hospital in Taipei, Taiwan.

PATIENTS

Consecutive patients who had received PD for a minimum duration of 4 months were recruited for participation in the study. Patients were excluded if they had a history of ischemic heart disease, severe heart failure (NYHA function III or IV), malignant neoplasm, active infection, major psychiatric problems, chronic obstructive pulmonary disease, or disturbed consciousness. Finally, a total of 64 patients, 31 of whom were receiving continuous ambulatory peritoneal dialysis and 33 who were receiving continuous cycling-assisted peritoneal dialysis, were enrolled in the study.

METHODS

Fatigue was evaluated using a specially designed questionnaire that includes fourteen items. Patients were divided into three groups according to their fatigue scores (FS): mild (FS, 0-3), moderate (FS, 4-8), and severe (FS, 9-14) fatigue. The demographic data, dialysis variables, and clinical parameters of patients were compared among these groups. The relationship between fatigue and TSC was also examined.

RESULTS

The FS were correlated with serum intact parathyroid hormone (iPTH) level and total cholesterol concentration (p < 0.05). A linear correlation was also noted between serum iPTH level and total cholesterol level. When the patients were divided into an adequate- and an inadequate-dialysis group according to values of TSC, Kt/V(urea) as well as weekly creatinine clearance, a significant correlation was found between weekly C(cr) and FS.

CONCLUSION

This study has demonstrated that dialysis adequacy plays a key role in the development chronic fatigue. In addition, weekly C(cr) was better correlated with fatigue than Kt/V(urea).

Dipyridamole inhibits TGF-beta-induced collagen gene expression in human peritoneal mesothelial cells

BACKGROUND

Peritoneal matrix accumulation is characteristic of peritoneal fibrosis (PF). Continuous ambulatory peritoneal dialysis (CAPD) patients who had persistent transforming growth factor-beta (TGF-beta) in their drained effluent had an increased risk of PF. We previously reported that TGF-beta stimulates the expression of types I and III collagen mRNA in cultured human peritoneal mesangial cells (HPMCs), which may predispose them to develop PF. Pharmacological interventions to attenuate TGF-beta-stimulated matrix accumulation in HPMC may have therapeutic potential for the treatment of PF. The SMAD family and the extracellular signal-regulated protein kinase (ERK1/2, p44/p42) pathways have been shown to participate in TGF-beta signaling. Our current study identified these signal pathways in HPMCs and investigated the molecular mechanisms involved in the inhibitory effects of dipyridamole on TGF-beta-induced collagen gene expression in HPMCs.

METHODS

HPMCs were cultured from human omentum by an enzyme digestion

METHOD

Expression of collagen alpha1(I) mRNA was determined by Northern blotting. The SMAD proteins and the ERK1/2 activity were determined by Western blotting.

RESULTS

TGF-beta-stimulated collagen alpha1(I) mRNA expression of HPMC was inhibited by dipyridamole in a dose-dependent manner. Smad2 and ERK1/2 were activated in response to TGF-beta; however, TGF-beta had little effect on the protein expression of Smad4. The addition of PD98059, which blocked activation of ERK1/2, suppressed TGF-beta-induced collagen alpha1(I) mRNA expression in a dose-dependent manner. At a concentration that inhibited collagen gene expression (17 microg/mL), dipyridamole suppressed ERK1/2 activation by TGF-beta. In contrast, the same concentration of dipyridamole had no effect on TGF-beta-induced activation of Smad2.

CONCLUSION

Dipyridamole inhibits TGF-beta-induced collagen gene expression in HPMC through modulation of the ERK pathway. Our study of dipyridamole may provide therapeutic basis for clinical applications in the prevention of PF.

Direct determination of sinigrin in mustard seed without desulfatation by reversed-phase ion-pair liquid chromatography

Reversed-phase ion-pair liquid chromatography has been investigated for directly analyzing sinigrin in mustard seed without desulfatation. After extraction by phosphate buffer (pH 7.0) from the grind-pastes of inactivated-myrosinase mustard seeds, sinigrin was first isolated through deproteinization and centrifugation, followed by filtration and injection into the chromatographic system. A reversed-phase C18 column was used to separate the sinigrin with an eluent of acetonitrile (ACN)-water (20:80) containing 0.02 M tetrabutylammonium (TBA) as the counter ion at pH 7.0. Detection was carried out with an UV detector operated at 227 nm. Factors affecting the chromatographic separation and quantitative determination, such as concentrations of TBA and ACN, and pH, were studied. The linear dynamic range is larger than three orders of magnitude and the detection limit is 0.045 mg/L. The RSD is around 3% and the recovery is 85% (3% RSD, n = 3).

Systemic lupus erythematosus and peritoneal dialysis: outcomes and infectious complications

OBJECTIVE

Systemic lupus erythematosus (SLE) is the most common secondary glomerulonephritis resulting in end-stage renal disease (ESRD) among young adults in Taiwan. Studies of the infectious complications and outcomes among such SLE patients undergoing peritoneal dialysis (PD) are limited.

DESIGN

A retrospective age- and gender-matched case control study.

SETTING

A university teaching hospital.

PATIENTS

There were 23 SLE patients with ESRD receiving PD for more than 3 months during the past 15 years. Another 46 age- and gender-matched non-SLE nondiabetic patients receiving PD were selected as the control group in this study.

INTERVENTION

All patients underwent PD as renal replacement therapy and were regularly followed up at this hospital.

MAIN OUTCOME MEASURES

Technique survival and incidences of exit-site infection (ESI) and peritonitis in these patients.

RESULTS

The SLE patients had a lower predialysis serum albumin than the control group (3.16 +/- 0.50 g/dL vs 3.52 +/- 0.50 g/dL, p < 0.01). The incidences of exit-site infection (ESI) and peritonitis were higher for SLE patients than for control patients (p < 0.01 and p < 0.001, respectively). Kaplan-Meier survival analysis indicated that SLE patients had shorter time intervals to first infectious complications, and poorer technique survival. Infection was the major cause of dropout and mortality in the SLE patients. The SLE patients had a reduced chance of receiving a renal transplant. The use of steroids by SLE patients was associated with a higher incidence of peritonitis (p = 0.04), but association with ESI was insignificant. In a Cox regression model, the underlying SLE was the only risk factor for technique failure and time interval to first infectious complication.

CONCLUSION

SLE patients undergoing PD are more susceptible to infection than age- and gender-matched non-SLE nondiabetic patients and have poorer technique survival. Systemic lupus erythematosus itself may further compromise the immunity of uremic patients.

Comparison of infectious complications in peritoneal dialysis patients using either a twin-bag system or automated peritoneal dialysis

BACKGROUND

Automated peritoneal dialysis (APD) and twin-bag (TB) systems are two major peritoneal dialysis (PD) modalities. Published data comparing the infectious complications of these modalities is limited. Subjects and methods. Ninety-five patients using APD (the APD group) and 117 patients using TB system (the TB group) were recruited. Among them, 35 patients used both modalities. The two groups' clinical characteristics, incidences of infectious complications, and the time intervals to first PD-related infection were compared.

RESULTS

Clinical characteristics, incidence of exit-site infection (ESI), and time intervals to first ESI were similar in the TB and APD groups. The incidence of peritonitis in the APD group (1.22 episodes/100 patient-months) was significantly (P < 0.001) lower than that of the TB group (2.28 episodes/100 patient-months). Using the Cox proportional hazard model, APD was found to have a lower risk of peritonitis relative to TB systems, with marginal significance (RR 0.58, P = 0.051).

CONCLUSION

APD was found to have a lower peritonitis rate than the TB system. Since reducing the peritonitis rate helps to maintain technical survival during PD, from this viewpoint, APD may be preferred for patients undergoing PD, unless contraindicated.

Trace Metals' abnormalities in hemodialysis patients: relationship with medications

A multicenter collaborative study was performed to investigate the prevalence of abnormal blood contents of 6 trace metals, copper (Cu), zinc (Zn), aluminum (Al), lead (Pb), cadmium (Cd), and mercury (Hg), in hemodialysis (HD) patients and to analyze their relationship with the medications, such as CaCO3, Ca acetate, Al containing phosphate-binding agents, 1,25-dihydroxy vitD3, 1-hydroxy vitD3, and erythropoietin (EPO), as well as hematocrit level, by chi-square statistics. From 6 medical centers in Taiwan, we included 456 patients in maintenance HD for more than 4 months for this study, and they had continued the previously mentioned medications for at least 3 months. Blood samples were collected before initiating HD, and atomic absorption spectrophotometry was used to measure plasma levels of Cu, Zn, and Al as well as whole blood levels of Pb, Cd, and Hg. Three hundred seventy-five (78%) of the HD patients had low plasma Zn levels, that is, <800 microg/L, and the mean (+/-SD) concentration was 705.8 (+/-128.23) microg/L in all subjects. One hundred forty-one (31%) of the HD patients had high plasma Al, that is, >50 microg/L, and the mean (+/-SD) was 44.30 (+/-28.28) microg/L in all subjects. Three hundred thirty-three (73%) of the dialysis patients had high Cd levels, that is, >2.5 microg/L, and the mean (+/-SD) was 3.32 (+/-1.49) microg/L in all subjects. The majority of HD patients had normal blood levels of Cu, PB, and Hg. Only 21 (4. 6%), 5 (1.1%), and 3 (0.06%) patients had elevated blood levels of Cu, Pb, and Hg, respectively. Their mean (+/-SD) blood concentration of Cu, Pb, and Hg were 1,049.78 (+/-233.25) microg/L, 7.45 (+/-3.95) microg/dL, and 3.17 (+/-25.56) microg/L, respectively. Three patients had elevated plasma Hg concentrations, that is, 546, 12.6, and 24.0 microg/L, respectively. In the 152 normal healthy age and sex matched control group, the blood levels of Al, Cd, and Pb were all significantly lower than the HD patients. However, the levels of Cu and Zn were higher in the control group. The Hg level was not significantly different in both groups. There was no statistical difference between patients with normal and abnormal blood levels of trace metals in various medications except Al containing phosphate binder. The Al containing phosphate binder users had significantly higher plasma Al levels (54.71 +/- 26.70 versus 41.15 +/- 28.03 microg/L, p < 0.001) and hematocrit levels (29.61 +/- 4.61 versus 27. 81 +/- 3.91, p < 0.0005). There was no statistical correlation between erythropoietin (EPO) dose and hematocrit level in these patients. In conclusion, the blood level of trace metals of these HD patients except Al was not related to their medications. However, caution must be exercised in interpreting this result as dose and duration of medication; efficiency of HD and water treatment may play an important role. Otherwise, environmental factors, diet, and the aging process may contribute to the trace metal burden in uremia. Thus, Zn and Cu are abundant in seafood, and Cd is abundant in contaminated plants such as rice.

Incidence of exit-site infection with various exchange systems in continuous ambulatory peritoneal dialysis

BACKGROUND AND PURPOSE

The disconnect twin-bag (TB) system was first introduced in Taiwan for use as an exchange system in continuous ambulatory peritoneal dialysis (CAPD) in 1995. Following its introduction, the incidence of CAPD-associated peritonitis declined, but the incidence of exit-site infection (ESI) increased. To determine the cause of the increase in ESI incidence after the introduction of the TB system, this study compared the incidence of ESI among patients using the O set, ultraviolet antiseptic (UV) device, and the TB system.

METHODS

A total of 170 patients who had received CAPD for more than 3 months were enrolled in this study. Poisson test and Kaplan-Meier survival analysis were used to compare the ESI incidence and ESI-free catheter survival among patients using the O set, UV device, or TB system. Cox stepwise forward proportional hazard analysis was used to assess the impact of sex, education, cause of uremia, age, and type of exchange system on ESI.

RESULTS

The incidences of ESI differed significantly among patients using the three exchange systems, with 20.9, 13.8, and 4.0 episodes per 100 patient-years for patients using the TB system, O set, and UV device, respectively. New patients using the TB system also had a shorter mean interval of ESI-free catheter survival than those using the UV device (26.9 vs 58.8 months, p = 0.002). In the Cox stepwise forward proportional hazard analysis, non-lupus patients had a lower risk of developing ESI than lupus patients (relative risk [RR] 0.40, p = 0.03). The RR of ESI in patients using the UV device was also lower than in those using the TB system (RR 0.15, p < 0.01).

CONCLUSION

In this study, use of the TB system was associated with a higher incidence of ESI. The increased ESI incidence may be related to the heavier mini-transfer set of the TB system. Therefore, special attention should be given to fastening the mini-transfer set tightly during the exchanging procedure to prevent traction on the exit-site, which is associated with an increased incidence of subsequent ESI.

Clinical features of and risk factors for fungal peritonitis in peritoneal dialysis patients

BACKGROUND AND PURPOSE

Fungal peritonitis (FP) is a serious complication for peritoneal dialysis (PD) patients and can result in technical failure and mortality. Catheter removal remains the mainstay of treatment. This study sought to identify the risk factors for FP in order to facilitate the prevention of this catastrophic complication.

METHODS

A total of 246 patients who received long-term PD from 1985 to 1998 were included in this retrospective study. Twenty episodes of FP occurred in 19 patients. The clinical characteristics, pathogens, treatment modalities, and outcomes of the FP episodes were retrospectively reviewed. The FP incidence in various demographic and clinical groups, classified according to sex, age, education, and underlying cause of uremia, were compared with the Poisson test.

RESULTS

Thirteen episodes of FP were caused by yeast, and the remaining episodes were caused by Aspergillus spp. Age, sex, and education did not affect the FP incidence. Lupus patients (969 patient-months) had a higher incidence of FP than patients with other underlying diseases (p < 0.05). The 19 FP patients also had a higher incidence of bacterial peritonitis than other PD patients (p < 0.01). Among the 20 FP episodes, 14 (70%) were preceded by antibiotic use, and eight (40%) developed during hospitalization. Steroids were used at the time of FP in five of six lupus patients. Seven patients (37%) died within 1 month after diagnosis of FP. Five patients were able to remain on PD after FP, but only three patients were able to maintain catheter placement.

CONCLUSION

The risk factors for FP identified in this study include the use of antibiotics and steroids, underlying lupus, frequent occurrence of bacterial peritonitis, and hospitalization. Antifungal therapy may allow the catheter to be kept in place in a few patients, but catheter removal should be considered in patients whose FP is refractory to medical treatment.

Natural changes in peritoneal equilibration test results in continuous ambulatory peritoneal dialysis patients: a retrospective, seven year cohort survey

We conducted a retrospective, 7 year cohort survey to examine the natural changes in peritoneal equilibration test (PET) results in patients with long-term uneventful continuous ambulatory peritoneal dialysis (CAPD). Thirty-two (17 males, 15 females) patients on CAPD with two or more standard PETs performed more than 6 months apart, in the absence of peritoneal insult, were included. Changes and pattern of PET results were evaluated by the dialysate to plasma ratio of creatinine (D:P-cre), the fourth h dialysate to instilled glucose ratio (D4:Do) and ultrafiltration volume (UF, ml). The subgroups included high (H), high-average (HA), low-average (LA), or low (L) transporters with the dividing ratios (D:P-cre) of >0.81, >0. 65 to 0.81, >0.5 to 0.65, and <0.5, respectively. The median D:P-cre significantly decreased (p = 0.04), but neither the D4:Do nor the final median UF significantly decreased. The change in D:P-cre was strongly and inversely correlated with the initial D:P-cre value (r = -0.68; p < 0.05). A similar relationship was found between the change in the final D4:Do and the initial D4:Do (r = -0.752; p < 0. 01) and between the change in the final UF and the initial UF (r = -0.875; p < 0.01). No correlation was found between the change in D:P-cre and the age of the patient, the time interval between PETs, monthly dialysate glucose exposure, or underlying diabetes/non-diabetes. The final peritoneal transport pattern was altered with 5 (15.6%) patients remaining in the extreme subgroups (H or L) and, by contrast, 84.4% (27/32) of the patients now in the averaged (HA or LA) groups (p < 0.01, chi2 test). We demonstrated a natural "centralization" migration of PET results after long-term uneventful CAPD, which may help to explain why patients with extreme PET characteristics, that is, H or L, continued to do well on CAPD.

Airway cross section strongly influences alveolar plateau slope of capnograms for smaller tidal volumes

We compared the predictions of the single path convection-diffusion model (SPM) and the well-mixed single acinus model (SAM) with the normalized slopes (NS) of experimentally measured volumetric capnograms in which VT was varied in three healthy spontaneously breathing adults. For values of VT greater than 15 ml/kg, the tidal volume penetrates deep into the acinar airways, mixing by molecular diffusion is rapid and the predictions of the SAM and SPM both agree with the experiment. The SPM however shows much better agreement with the experimental NS data than does the SAM for values of VT less than 10 ml/kg. The explanation for the departure of the SAM from the observed experimental data, at small VT, is that it represents the limiting case (of well-mixed alveolar gas) for the SPM, only at large VT, where the assumption of rapid mixing is most accurate. We conclude that in general, gas phase diffusivity and total acinar airway cross sectional area variation with cumulative volume into the lung are essential to realistically model airway gas exchange between VT and FRC and to obtain agreement with experimental data under the widest range of breathing conditions.

Necrotizing fasciitis caused by Serratia marcescens in two patients receiving corticosteroid therapy

Necrotizing fasciitis (NF), a devastating soft tissue infection, is rarely attributed to Serratia marcescens. We here report two patients with S. marcescens NF, both of whom had underlying renal disease and had been receiving corticosteroid therapy. The first patient, a 40-year-old man with systemic lupus erythematosus and uremia on prednisolone therapy, developed fulminant cellulitis and septic shock 1 month after a skin biopsy for cutaneous vasculitis of the left foot. The cellulitis evolved to NF, and blood and necrotic tissue cultures both grew S. marcescens. The patient completely recovered after debridement and ceftazidime therapy. The second patient, a 73-year-old man receiving prednisolone therapy for nephrotic syndrome, developed right leg cellulitis that evolved to NF. Blood and necrotic tissue cultures both grew S. marcescens. After aggressive debridement and ciprofloaxcin therapy, the NF improved. However, the patient died of aspiration pneumonia and massive gastrointestinal bleeding 1 month later. These findings illustrate that S. marcescens should be considered as a potential pathogen causing NF in susceptible hosts.

Control of a nonsquare drug infusion system: A simulation study

A model predictive control strategy was developed and tested on a nonlinear canine circulatory model for the regulation of hemodynamic variables under critical care conditions. Different patient conditions such as congestive heart failure, post-operative hypertension, and sepsis shock were studied in closed-loop simulations. The model predictive controller, which uses a different linear model depending on the patient condition, allowed constraints to be explicitly enforced. The controller was initially tuned on the basis of a linear plant model, then tested on the nonlinear physiological model; the simulations demonstrated the ability to handle constraints, such as drug dosage specifications, commonly desired by critical care physicians.

Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: difficulty in diagnosis

Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. He had been receiving nocturnal intermittent PD for 2 years and had ischemic heart disease and cirrhosis of the liver. Pneumoperitoneum and peritonitis were documented, but the symptoms were mild. The "board-like abdomen" sign was not noted. Air inflation and contrast radiography indicated a perforation in the upper gastrointestinal tract, and laparotomy disclosed a perforation in the prepyloric great curvature. Unfortunately, the patient died during surgery. This case illustrates that the "board-like abdomen" sign may be absent in PD patients with PPU because of dilution of gastric acid by the dialysate. Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.

Depth of anesthesia estimation and control

A fully automated system was developed for the depth of anesthesia estimation and control with the intravenous anesthetic, Propofol. The system determines the anesthesia depth by assessing the characteristics of the mid-latency auditory evoked potentials (MLAEP). The discrete time wavelet transformation was used for compacting the MLAEP which localizes the time and the frequency of the waveform. Feature reduction utilizing step discriminant analysis selected those wavelet coefficients which best distinguish the waveforms of those responders from the nonresponders. A total of four features chosen by such analysis coupled with the Propofol effect-site concentration were used to train a four-layer artificial neural network for classifying between the responders and the nonresponders. The Propofol is delivered by a mechanical syringe infusion pump controlled by Stanpump which also estimates the Propofol effect-site and plasma concentrations using a three-compartment pharmacokinetic model with the Tackley parameter set. In the animal experiments on dogs, the system achieved a 89.2% accuracy rate for classifying anesthesia depth. This result was further improved when running in real-time with a confidence level estimator which evaluates the reliability of each neural network output. The anesthesia level is adjusted by scheduled incrementation and a fuzzy-logic based controller which assesses the mean arterial pressure and/or the heart rate for decrementation as necessary. Various safety mechanisms are implemented to safeguard the patient from erratic controller actions caused by external disturbances. This system completed with a friendly interface has shown satisfactory performance in estimating and controlling the depth of anesthesia.

Immunoblot analysis of components of barley recognized by IgE antibodies in sera from pig farm workers

Components of the crude extract of barley, recognized by IgE antibodies in sera from 132 pig farm-workers in southern Taiwan, were investigated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblotting. Among the sera tested, 43 (32.6%) showed IgE reactivity to 15 components of barley with molecular mass ranging from 148000 to 14000 daltons (Da). Heterogeneity in the IgE-binding patterns of the samples tested was observed. However, the major antigen appears to be the component with about 37 kDa, in 32 (74.4%) of the 43 immunoblot-positive serum samples. Furthermore, components with about 55 and 67 kDa which reacted with 26 (60.5%) and 18 (41.9%) of the positive samples, respectively. These might also be considered as important allergens of the flour made from entire seeds of barley. The results suggest that barley may be considered to play a role in the IgE-mediated occupational respiratory disorders and the 37 kDa component has also been shown to be the major allergen.

Multiple-drug hemodynamic control using fuzzy decision theory

A fuzzy-logic-based, automated drug-delivery system has been developed and validated on a nonlinear canine circulatory model for managing hemodynamic states. This controller features: 1) a fuzzy decision analysis module for patient status determination by assessing cardiac index, systemic vascular resistance index, and pulmonary vascular resistance index and 2) a fuzzy hemodynamic management module utilizing dopamine, phenylephrine, nitroprusside, and nitroglycerin for regulating mean arterial pressure, mean pulmonary arterial pressure, and cardiac output. A rule-based drug delivery scheduling program has been devised and incorporated to execute the therapeutic strategy as recommended by the decision analysis module. Compared to the existing controllers, this system is able to achieve a faster response time with a more secured and effective regulation. The simulation results have demonstrated the feasibility of the decision analysis process for automated management of the arterial and venous circulation with an expanded arsenal of pharmacological agents.