Image findings of anti-neutrophil cytoplasmic antibody-associated vasculitis involving the skull base

AIM

To investigate computed tomography (CT) and magnetic resonance imaging (MRI) features of skull bases involving anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV).

MATERIALS AND METHODS

A retrospective review was undertaken to identify an institutional historical cohort of 17 patients with confirmed AAV who underwent CT or MRI and had skull base involvement between 2002 and 2021. Two radiologists reviewed the extent and features of the lesions, bone changes, and other MRI findings.

RESULTS

A total of 17 patients (12 men; mean age ± standard deviation, 46.5 ± 17.1 years) were selected. AAV presented as infiltrative lesions with involvement at various sites. Most cases involved the paranasal sinuses (PNS; 88%, 15/17), nasopharynx (88%, 15/17), pterygopalatine fossa (82%, 14/17), and parapharyngeal space (82%, 14/17), frequently accompanied by mucosal irregularity of the PNS and nasopharynx (71%, 12/17). Central skull base and temporal bone involvement were seen in 53% (9/17) and 38% (6/16) of cases, respectively. On T1-weighted imaging (WI) and T2WI MRI, all lesions (15/15) showed predominant signal iso-intensity to grey matter.

CONCLUSIONS

Although radiological findings of AAV are non-specific and skull base involvement is less common, AAV may be considered if infiltrative lesions predominantly involving the PNS, nasopharynx, pterygopalatine fossa, and parapharyngeal space with combined bone changes of skull base are seen.

Classification of Alzheimer's disease stage using machine learning for left and right oxygenation difference signals in the prefrontal cortex: a patient-level, single-group, diagnostic interventional trial

OBJECTIVE

Recent evidence shows that indicators testing conventional olfactory function have a high degree of similarity to cognitive function tests and the potential to diagnose early-stage Alzheimer's disease (AD). In this study, the efficacy of functional near-infrared spectroscopy time-series data obtained through olfactory stimulation was investigated as an early diagnostic tool for mild cognitive impairment in AD using random forest, a machine learning algorithm.

PATIENTS AND METHODS

We conducted a patient-level, single-group, diagnostic interventional trial using near-infrared signals measured during olfactory stimulation in the prefrontal cortex of 178 older adults ranging from normal to participants with AD as markers to discriminate AD stages. We first divided the participants into normal older adults, AD mild cognitive impairment, and AD groups using dementia diagnostic criteria such as the Mini-Mental State Examination and Seoul Neuropsychological Screening Battery. We compared the left and right oxygenation difference by calculating the relative oxygenation difference from the change in relative oxygen concentration.

RESULTS

A total of 168 participants met the eligibility criteria: 70 (41.6%) had normal cognitive function; 42 (25%) mild cognitive impairment; 21 (12.5%) mild AD; and 35 (20.8%) moderate AD. A random forest machine learning model was developed to predict the AD stage, with an area under the receiver operating characteristic curve of 90.7% for mild cognitive impairment and AD, 90.99% for mild cognitive impairment, and 93.34% for AD only.

CONCLUSIONS

Based on the classification of the oxygenation difference index of the left and right prefrontal cortices during olfactory stimulation through machine learning, we found that it was possible to detect early-stage mild cognitive impairment in AD. Our results highlight the potential for early AD diagnosis using near-infrared signals from the prefrontal cortex obtained upon olfactory stimulation. Moreover, the results showed high similarity to the existing cognitive function tests and high accuracy in AD stage classification.

Effect of doping and loading Parameters on photocatalytic degradation of brilliant green using Sn doped ZnO loaded CSAC

Sn doped ZnO loaded cotton stalk activated carbon (Sn-ZnO/CSAC) was prepared by chemical precipitation method, and the products were characterized. The XRD resultants confirm that the presence of hexagonal wurtzite phase of the bare ZnO. Furthermore, particular particle size gradually decreases (21.49 nm) due to doping and loading. UV-Vis absorption intensity of doped/loaded sample was red-shifted and then PL intensity is reduced. The photocatalytic performances of bare, Sn-doped ZnO and Sn-ZnO/CSAC was estimated by photodegradation of brilliant green (BG) under sunlight. The photodegradation of BG dye in 120 min over Sn-doped ZnO/CSAC is nearly 96.52%, which is considerably improved than bare ZnO (72.60%), respectively.

Effect of Prehospital Epinephrine Use on Survival from Out-of-Hospital Cardiac Arrest and on Emergency Medical Services

This study was to identify the effect of epinephrine on the survival of out-of-hospital cardiac arrest (OHCA) patients and changes in prehospital emergency medical services (EMSs) after the introduction of prehospital epinephrine use by EMS providers. This was a retrospective observational study comparing two groups (epinephrine group and norepinephrine group). We used propensity score matching of the two groups and identified the association between outcome variables regarding survival and epinephrine use, controlling for confounding factors. The epinephrine group was 339 patients of a total 1943 study population. The survival-to-discharge rate and OR (95% CI) of the epinephrine group were 5.0% (p = 0.215) and 0.72 (0.43–1.21) in the total patient population and 4.7% (p = 0.699) and 1.15 (0.55–2.43) in the 1:1 propensity-matched population. The epinephrine group received more mechanical chest compression and had longer EMS response times and scene times than the norepinephrine group. Mechanical chest compression was a negative prognostic factor for survival to discharge and favorable neurological outcomes in the epinephrine group. The introduction of prehospital epinephrine use in OHCA patients yielded no evidence of improvement in survival to discharge and favorable neurological outcomes and adversely affected the practice of EMS providers, exacerbating the factors negatively associated with survival from OHCA.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

Management of isolated recurrence after surgery for pancreatic adenocarcinoma

BACKGROUND

Recurrence of pancreatic cancer after primary pancreatectomy occurs in the vast majority of patients. The role of surgical treatment for recurrent pancreatic cancer is not well established.

METHODS

Patients who underwent primary pancreatectomy with curative intent from 2000 to 2014 at a single large-volume centre were evaluated retrospectively. CT or PET was used to select patients with an isolated recurrence. The clinicopathological features and survival outcomes were compared according to treatment modalities.

RESULTS

Of the 1610 patients with pancreatic cancer who underwent resection, 1346 (83·6 per cent) were diagnosed with recurrent pancreatic cancer. Recurrence was locoregional in 366 patients (27·2 per cent), distant multifocal in 251 (18·6 per cent), distant isolated in 188 (14·0 per cent), locoregional plus distant in 153 (11·4 per cent) and peritoneal seeding in 388 (28·8 per cent). Of the 1346 patients with recurrence, 197 (14·6 per cent) had isolated recurrence; of these, 48 (24·4 per cent of all isolated recurrences; 3·6 per cent of all recurrences) underwent resection. Median survival of the 197 patients after diagnosis of isolated recurrence was 14·7 months; it was longer in patients who underwent surgical resection than among those treated non-surgically (23·5 versus 12·0 months; P = 0·014). Multivariable analysis showed that chemotherapy and resection for recurrence were associated with better prognosis. Median survival after recurrence was longest in the 23 patients with isolated pulmonary recurrence (33·3 months). Survival after recurrence was better in patients who underwent resection of isolated recurrence in the remnant pancreas (median 28·0 versus 12·0 months, P = 0·010) and lung (median 36·5 versus 9·5 months; P = 0·010) than in those who did not undergo resection.

CONCLUSION

Surgical resection may be considered an option for treatment of patients with isolated recurrent pancreatic cancer.

Efficacy, Immunogenicity, and Safety of a 9-Valent Human Papillomavirus Vaccine: Subgroup Analysis of Participants From Asian Countries

Background

A 9-valent human papillomavirus-6/11/16/18/31/33/45/52/58 (9vHPV) vaccine extends coverage to 5 next most common oncogenic types (31/33/45/52/58) in cervical cancer versus quadrivalent HPV (qHPV) vaccine. We describe efficacy, immunogenicity, and safety in Asian participants (India, Hong Kong, South Korea, Japan, Taiwan, and Thailand) from 2 international studies: a randomized, double-blinded, qHPV vaccine-controlled efficacy study (young women aged 16–26 years; NCT00543543; Study 001); and an immunogenicity study (girls and boys aged 9–15 years; NCT00943722; Study 002).

Methods

Participants (N = 2519) were vaccinated at day 1 and months 2 and 6. Gynecological samples (Study 001 only) and serum were collected for HPV DNA and antibody assessments, respectively. Injection-site and systemic adverse events (AEs) were monitored. Data were analyzed by country and vaccination group.

Results

9vHPV vaccine prevented HPV-31/33/45/52/58–related persistent infection with 90.4%–100% efficacy across included countries. At month 7, ≥97.9% of participants seroconverted for each HPV type. Injection-site AEs occurred in 77.7%–83.1% and 81.9%–87.5% of qHPV and 9vHPV vaccine recipients in Study 001, respectively, and 62.4%–85.7% of girls/boys in Study 002; most were mild to moderate.

Conclusions

The 9vHPV vaccine is efficacious, immunogenic, and well tolerated in Asian participants. Data support 9vHPV vaccination programs in Asia.

Clinical Trials Registration

NCT00543543; NCT00943722.

Effects of emergency department boarding on mortality in patients with ST-segment elevation myocardial infarction

OBJECTIVE

Patients with ST-segment elevation myocardial infarction (STEMI) are sometimes boarded in the emergency department (ED) after percutaneous coronary intervention (PCI). We evaluated the effects of direct and indirect admission to the CCU on mortality and the effect on length of stay (LOS) in patients with STEMI.

METHOD

This was a retrospective observational study of patients with STEMI between Jan 2014 and Nov 2017. The patients were divided into the direct admission (DA) group, who were admitted into the CCU immediately after PCI, and the indirect admission (IA) group, who were admitted after boarding in the ED. The primary endpoint was in-hospital mortality. Secondary endpoints were 3-month mortality, LOS in CCU and hospital, and LOS under intensive care.

RESULTS

During the study period, 780 patients were enrolled and analyzed. The in-hospital mortality rate and 3-month mortality rate were 5.9% (46 patients) and 8.5% (66 patients). The DA group and IA group had similar in-hospital and 3-month mortality rates (P = .50, P = .28). The median CCU LOS and hospital LOS was similar for both groups (P = .28, P = .46). However, LOS under in intensive care for the IA group was significantly longer than that of the DA group (DA, 31.9 h; IA, 38.7 h; P < .001).

CONCLUSION

This study suggests that direct admission after PCI and indirect admission was not associated with mortality in patients with STEMI. In addition, the stay in ED also appears to be associated with the duration of stay under critical care.

Long-term survival of pig-to-rhesus macaque renal xenografts is dependent on CD4 T cell depletion

The shortage of available organs remains the greatest barrier to expanding access to transplant. Despite advances in genetic editing and immunosuppression, survival in experimental models of kidney xenotransplant has generally been limited to <100 days. We found that pretransplant selection of recipients with low titers of anti-pig antibodies significantly improved survival in a pig-to-rhesus macaque kidney transplant model (6 days vs median survival time 235 days). Immunosuppression included transient pan-T cell depletion and an anti-CD154-based maintenance regimen. Selective depletion of CD4⁺ T cells but not CD8⁺ T cells resulted in long-term survival (median survival time >400 days vs 6 days). These studies suggested that CD4⁺ T cells may have a more prominent role in xenograft rejection compared with CD8⁺ T cells. Although animals that received selective depletion of CD8⁺ T cells showed signs of early cellular rejection (marked CD4⁺ infiltrates), animals receiving selective CD4⁺ depletion exhibited normal biopsy results until late, when signs of chronic antibody rejection were present. In vitro study results suggested that rhesus CD4⁺ T cells required the presence of SLA class II to mount an effective proliferative response. The combination of low pretransplant anti-pig antibody and CD4 depletion resulted in consistent, long-term xenograft survival.

Comparison of Clinical Performance Between BacT/Alert Virtuo and BacT/Alert 3D Blood Culture Systems

BACKGROUND

BacT/Alert Virtuo (BioMérieux, Durham, NC, USA) is a recently developed blood culture system that includes functions of automatic registration, loading, and unloading of the blood culture bottles, as well as measurement of blood volume. We compared the performances between the BacT/Alert Virtuo and 3D (BioMérieux) blood culture systems.

METHODS

A total of 952 patients (1,904 sets) visiting an university-affiliated hospital in Korea for blood cultures were enrolled. Five milliliters of blood was added into each of the two aerobic (FA Plus) and two anaerobic (FN Plus) bottles of the Virtuo and 3D systems for a single set. Positive rate and time to detection (TTD) were compared between the two systems.

RESULTS

The positive rates were 8.3% and 8.4% in FA Plus bottles and 7.8% and 8.3% in FN Plus bottles, in the Virtuo and 3D systems, respectively (P>0.05). Median TTDs were shorter in the Virtuo than in the 3D system for all isolates (11.5 hours [N=305] vs 11.8 hours [N=318], P<0.001), Staphylococcus aureus (N=38; 14.3 hours vs 16.0 hours, P=0.021), and Escherichia coli (N=117; 10.4 hours vs 11.0 hours, P<0.001).

CONCLUSIONS

The Virtuo has the potential to detect pathogens early in all bottle types. This might improve the prognosis of sepsis by allowing for implementation of expeditious management.

Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department

AIM

The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED.

METHODS

In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique.

RESULTS

The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes.

CONCLUSION

The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.

Factors predicting the early mortality of trauma patients

BACKGROUND

The aim of this study was to identify factors predicting early mortality in trauma patients.

METHODS

This was a study of 6288 trauma patients admitted to the hospital between July 2011 and June 2016. Among the variables recorded for a prospective trauma registry, the following were selected for analysis: sex; age; a combination of the Glasgow Coma Scale score, age, and systolic blood pressure (SBP) (GAP); a combination of the mechanism of injury, the Glasgow Coma Scale score, age, and SBP (MGAP); SBP; respiratory rate; peripheral oxygen saturation (SpO2 value); the Glasgow Coma Scale score; laboratory variables; and presentation time. Logistic regression analysis was used to explore associations between these variables and early mortality.

RESULTS

In total, 296 (4.6%) patients died within 24 hours. Univariate regression analysis indicated that age, the GAP, the MGAP, SBP, SpO2, the Glasgow Coma Scale score, base excess, hemoglobin level, platelet count, INR, and presentation time predicted early mortality. Multivariate regression showed that the GAP, the MGAP, SpO2, base excess, platelet count, and INR were independently predictive. The areas under the receiver operator curve comparisons for the GAP and MGAP models revealed the superiority of the GAP-based model.

CONCLUSION

The GAP model, SpO2, base excess, platelet count, and INR predicted the early mortality of trauma patients.

Long-Term Ultrasound Follow-Up of Incidentally Detected Thyroglossal Duct Cysts in Adults

BACKGROUND AND PURPOSE

There has been no previous study that used ultrasonography for longitudinal changes of thyroglossal duct cysts, to our knowledge. We assessed the prevalence and interval changes in incidentally detected thyroglossal duct cysts in adults.

MATERIALS AND METHODS

From January 2010 to December 2016, we identified 796 ultrasonography radiologic reports from 513 subjects that contained the words "thyroglossal" or "TGDC" among 54,369 participants. Of 513 subjects, 172 (M/F = 103:69, mean age, 53 ± 11 years) who underwent ≥2 sonography studies were enrolled. Two reviewers determined ultrasonography features, including maximal diameter, location, internal echogenicity, wall thickness, and the presence of posterior enhancement, internal septa, and solid components.

RESULTS

The mean follow-up time of total 172 lesions was 2.01 ± 1.13 years. Thyroglossal duct cysts ranged from 2 to 32 mm (mean, 8.77 ± 3.83 mm) on the initial ultrasonography examination. On follow-up ultrasonography studies, 14 lesions (8.2%) increased by >2 mm, while most thyroglossal duct cysts (133 lesions, 77.3%) remained stable in size. During the follow-up period, 31 lesions (18.0%) showed interval changes in ultrasonography features. There was no significant relationship between the presence of ultrasonography feature changes and size changes (P = .12).

CONCLUSIONS

On ultrasonography, 0.9% of adults had incidental thyroglossal duct cysts. Most did not increase in size with time despite changes in various ultrasonography features. Therefore, we recommend performing an observation at long intervals of 2-3 years for asymptomatic thyroglossal duct cysts, and we suggest that fine-needle aspiration can be suspended unless suspicious findings of malignancy are detected.

Harmful effects of early hyperoxaemia in patients admitted to general wards: an observational cohort study in South Korea

OBJECTIVES

We evaluated the association between hyperoxaemia induced by a non-invasive oxygen supply for 3 days after emergency department (ED) arrival and the clinical outcomes at day 5 after ED arrival.

DESIGN

Observational cohort study.

SETTING AND PATIENTS

Consecutive ED patients ≥16 years of age with available arterial blood gas analysis results who were admitted to our hospital were enrolled from January 2010 to December 2016.

INTERVENTIONS

The highest (PaO_2MAX), average (PaO_2AVG) and median (PaO_2MED) PaO₂ (arterial oxygen pressure) values within 72 hours and the area under the curve divided by the time elapsed between ED admittance and the last PaO₂ result (AUC₇₂) were used to assess hyperoxaemia. The AUC₇₂ values were calculated using the trapezoid rule.

OUTCOMES

The primary outcome was the 90-day in-hospital mortality rate. The secondary outcomes were intensive care unit (ICU) transfer and respiratory failure at day 5 after ED arrival, as well as new-onset cardiovascular, coagulation, hepatic and renal dysfunction at day 5 after ED arrival.

RESULTS

Among the 10 141 patients, the mortality rate was 5.8%. The adjusted ORs of in-hospital mortality for PaO_2MAX, PaO_2AVG, PaO_2MED and AUC₇₂ were 0.79 (95% CI 0.61 to 1.02; p=0.0715), 0.92 (95% CI 0.69 to 1.24; p=0.5863), 0.82 (95% CI 0.61 to 1.11; p=0.2005) and 1.53 (95% CI 1.25 to 1.88; p<0.0001). All of the hyperoxaemia variables showed significant positive correlations with ICU transfer at day 5 after ED arrival (p<0.05). AUC₇₂ was positively correlated with respiratory failure, as well as cardiovascular, hepatic and renal dysfunction (p<0.05). PaO_2MAX was positively correlated with cardiovascular dysfunction. PaO_2MAX and AUC₇₂ were negatively correlated with coagulation dysfunction (p<0.05).

CONCLUSIONS

Hyperoxaemia during the first 3 days in patients outside the ICU is associated with in-hospital mortality and ICU transfer at day 5 after arrival at the ED.

Impact of early hyperoxia on 28-day in-hospital mortality in patients with myocardial injury

INTRODUCTION

Despite relevant evidence that supplemental oxygen therapy can be harmful to patients with myocardial injury, the association between hyperoxia and the clinical outcome of such patients has not been evaluated. We assessed whether early hyperoxia negatively affects outcomes in hospitalized patients with myocardial injury.

METHODS

This was a retrospective study conducted at a tertiary referral teaching hospital. Between January 2010 and December 2016, 2,376 consecutive emergency department patients with myocardial injury, defined as a peak troponin-I level ≥ 0.2 ng/mL, within the first 24 hours of presentation were included. The metrics used to define hyperoxia were the maximum average partial pressure of oxygen (PaO2MAX), average partial pressure of oxygen (PaO2AVG), and area under the curve during the first 24 hours (AUC24). The association between early hyperoxia within 24 hours after presentation and clinical outcomes was evaluated using multiple imputation and logistic regression analysis. The primary outcome was 28-day in-hospital mortality. The secondary outcomes were new-onset cardiovascular, coagulation, hepatic, renal, and respiratory dysfunctions (sequential organ failure sub-score ≥ 2).

RESULTS

Compared with normoxic patients, the adjusted odds ratios (ORs) for PaO2MAX, PaO2AVG, and AUC24 were 1.55 (95% confidence interval (CI) 1.05-2.27; p = 0.026), 2.13 (95% CI 1.45-3.12; p = 0.001), and 1.73 (95% CI 1.15-2.61; p = 0.008), respectively, in patients with mild hyperoxia and 6.01 (95% CI 3.98-9.07; p < 0.001), 8.92 (95% CI 3.33-23.88; p < 0.001), and 7.32 (95% CI 2.72-19.70; p = 0.001), respectively, in patients with severe hyperoxia. The incidence of coagulation and hepatic dysfunction (sequential organ failure sub-score ≥ 2) was significantly higher in the mild and severe hyperoxia group.

CONCLUSIONS

Hyperoxia during the first 24 hours of presentation is associated with an increased 28-day in-hospital mortality rate and risks of coagulation and hepatic dysfunction in patients with myocardial injury.

Anion gap and base deficit are predictors of mortality in acute pesticide poisoning

BACKGROUND:

Acute pesticide poisoning has long been a serious problem as a method of suicide worldwide. This poisoning is a highly fatal condition that requires a rapid and precise diagnosis for adequate treatment. However, various studies on mortality predictor factors have been insufficient for whole pesticide treatments. We hypothesized that the initial plasma anion gap (AG) and base deficit (BD) are reliable prognostic factors.

METHODS:

A retrospective study analyzed 561 patients with a diagnosis of acute pesticide poisoning between January 1, 2014 and June 30, 2017. The initial AG and BD values were divided into quartiles according to the number of patients. Survival at 30 days from admission was estimated using the Kaplan-Meier survival analysis. Receiver-operator characteristic (ROC) curves were drawn, and the areas under the curve for AG and BD for mortality were calculated.

RESULTS:

Fifty-eight (10.3%) of 561 patients died within 30 days. The highest AG quartile (>22 mEq/L) was associated with an increased risk of 30-day hospital mortality. Compared to patients with an AG less than 14.7 mEq/L, these patients had a 4.18-fold higher risk of 30-day hospital mortality and the highest BD quartile (>7.9 mEq/L) was associated with an increased risk of 30-day hospital mortality. Compared to patients with a BD less than 1.4 mEq/L, these patients had 2.23-fold higher risk of 30-day hospital mortality. The areas under the ROC for AG and BD curve were 0.699 and 0.744, respectively.

CONCLUSIONS:

Initial high AG and BD values could predict mortality and require precise intensive care.

The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V)

Objectives

Laser-engineered net shaping (LENS) of coated surfaces can overcome the limitations of conventional coating technologies. We compared the in vitro biological response with a titanium plasma spray (TPS)-coated titanium alloy (Ti6Al4V) surface with that of a Ti6Al4V surface coated with titanium using direct metal fabrication (DMF) with 3D printing technologies.

Methods

The in vitro ability of human osteoblasts to adhere to TPS-coated Ti6Al4V was compared with DMF-coating. Scanning electron microscopy (SEM) was used to assess the structure and morphology of the surfaces. Biological and morphological responses to human osteoblast cell lines were then examined by measuring cell proliferation, alkaline phosphatase activity, actin filaments, and RUNX2 gene expression.

Results

Morphological assessment of the cells after six hours of incubation using SEM showed that the TPS- and DMF-coated surfaces were largely covered with lamellipodia from the osteoblasts. Cell adhesion appeared similar in both groups. The differences in the rates of cell proliferation and alkaline phosphatase activities were not statistically significant.

Conclusions

The DMF coating applied using metal 3D printing is similar to the TPS coating, which is the most common coating process used for bone ingrowth. The DMF method provided an acceptable surface structure and a viable biological surface. Moreover, this method is automatable and less complex than plasma spraying.

Cite this article: T. Shin, D. Lim, Y. S. Kim, S. C. Kim, W. L. Jo, Y. W. Lim. The biological response to laser-aided direct metal-coated Titanium alloy (Ti6Al4V). Bone Joint Res 2018;7:357–361. DOI: 10.1302/2046-3758.75.BJR-2017-0222.R1.

International Bullous Diseases Group: consensus on diagnostic criteria for epidermolysis bullosa acquisita

BACKGROUND

Epidermolysis bullosa acquisita (EBA) is a complex autoimmune bullous disease disease with variable clinical presentations and multiple possible diagnostic tests, making an international consensus on the diagnosis of EBA essential.

OBJECTIVES

To obtain an international consensus on the clinical and diagnostic criteria for EBA.

METHODS

The International Bullous Diseases Group (IBDG) met three times to discuss the clinical and diagnostic criteria for EBA. For the final voting exercise, 22 experts from 14 different countries voted on 50 different items. When > 30% disagreed with a proposal, a discussion was held and re-voting carried out.

RESULTS

In total, 48 of 50 proposals achieved consensus after discussion. This included nine diagnostic criteria, which are summarized in a flow chart. The IBDG was unable to determine one procedure that would be applicable worldwide. A limitation of the study is that differential diagnosis of bullous systemic lupus erythematosus has not been addressed.

CONCLUSIONS

This first international consensus conference established generally agreed-upon clinical and laboratory criteria defining the clinical classification of and diagnostic testing for EBA. Holding these voting exercises in person with the possibility of discussion prior to voting has advantages in reaching consensus over Delphi exercises with remote voting.

Predictor of Isolated Trauma in Head: A New Simple Predictor for Survival of Isolated Traumatic Brain Injury

BACKGROUND

Mortality prediction in patients with brain trauma during initial management in the emergency department (ED) is essential for creating the foundation for a better prognosis.

OBJECTIVE

This study aimed to create a simple and useful survival predictive model for patients with isolated blunt traumatic brain injury that is easily available in the ED.

METHODS

This is a retrospective study based on the trauma registry data of an academic teaching hospital. The inclusion criteria were age ≥ 15 years, blunt and not penetrating mechanism of injury, and Abbreviated Injury Scale (AIS) scores between 1 and 6 for head and 0 for all other body parts. The primary outcome was 30-day survival probability. Internal and external validation was performed.

RESULTS

After univariate logistic regression analysis based on the derivation cohort, the final Predictor of Isolated Trauma in Head (PITH) model for survival prediction of isolated traumatic brain injury included Glasgow Coma Scale (GCS), age, and coded AIS of the head. In the validation cohort, the area under the curve of the PITH score was 0.970 (p < 0.0001; 95% confidence interval 0.960-0.978). Sensitivity and specificity were 95% and 81.7% at the cutoff value of 0.9 (probability of survival 90%), respectively.

CONCLUSIONS

The PITH model performed better than the GCS; Revised Trauma Score; and mechanism of injury, GCS, age, and arterial pressure. It will be a useful triage method for isolated traumatic brain injury in the early phase of management.

Preparation of “Open/closed” pores of PLGA-microsphere for controlled release of protein drug

Poly(D,L-lactic-co-glycolic acid)  has been extensively used as a controlled release carrier for drug delivery due to its good biocompatibility, biodegradability, and mechanical strength. In this study, porous PLGA microspheres were fabricated by an emulsion-solvent evaporation technique using poly ethylene glycol (PEG) as an extractable porogen and loaded with  protein (lysozyme) by suspending them in protein solution. For controlled release of protein, porous microspheres containing lysozyme were treated with water-miscible solvents in aqueous phase for production of pore-closed microspheres. The surface morphology of microspheres were investigated using scanning electron microscopy (SEM) for confirmation of its porous microstructure structure. Protein property after release was observed by enzymatic activity assay. The pore-closing process resulted in nonporous microspheres which exhibited sustained release patterns over an extended period.

Serum lactate upon emergency department arrival as a predictor of 30-day in-hospital mortality in an unselected population

BACKGROUND

Despite of numerous evidences that elevated serum lactate levels were associated with unfavorable outcomes, there have been no study demonstrated an optimal cutoff of serum lactate in unselected patients. This study was aimed to evaluate the prognostic property of lactate, and to identify a cutoff of serum lactate level for predicting 30-day in-hospital mortality among unselected patients presenting to the emergency department (ED).

METHODS

We performed a retrospective observational study from January 2010 to December 2016. 61,151 patients were used for propensity score analysis after exclusion. 14,015 patients who underwent lactate test at ED arrival were enrolled for final analysis.

RESULTS

The average treatment effect (ATE) of carrying out a lactate test on 30-day in-hospital mortality was 0.53% (adjusted odds ratio (OR) = 1.013, p = 0.19; 95% confidence interval (CI), 0.997-1.013). Adjusted OR of serum lactate calculated from multivariable analysis was 1.09 (p < 0.001; 95% CI, 1.07-1.10). The area under a ROC curve (AUC) of serum lactate was 0.711 (p < 0.001; 95% CI, 0.703-0.718). The sensitivity, specificity, and positive and negative predictive values for the cutoff > 2.6 mmol/L were 56.7%, 74.3%, 20.8%, and 93.5%, respectively. Mortality of the high-lactate group (> 2.6 mmol/L) was significantly higher than that of the low lactate group (≤ 2.6 mmol/L) (20.8% vs. 6.5%, difference = 14.3%, p < 0.01; 95% CI, 13.0% - 15.7%).

CONCLUSIONS

A serum lactate level > 2.6 mmol/L predicted 30-day in-hospital mortality in unselected patients who arrived to the ED and were admitted to the hospital. Additionally, serum lactate test in the ED could be an effective screening method for identifying low risk patients.

Usability verification of the Emergency Trauma Score (EMTRAS) and Rapid Emergency Medicine Score (REMS) in patients with trauma: A retrospective cohort study

Early estimation of mortality risk in patients with trauma is essential. In this study, we evaluate the validity of the Emergency Trauma Score (EMTRAS) and Rapid Emergency Medicine Score (REMS) for predicting in-hospital mortality in patients with trauma. Furthermore, we compared the REMS and the EMTRAS with 2 other scoring systems: the Revised Trauma Score (RTS) and Injury Severity score (ISS).We performed a retrospective chart review of 6905 patients with trauma reported between July 2011 and June 2016 at a large national university hospital in South Korea. We analyzed the associations between patient characteristics, treatment course, and injury severity scoring systems (ISS, RTS, EMTRAS, and REMS) with in-hospital mortality. Discriminating power was compared between scoring systems using the areas under the curve (AUC) of receiver operating characteristic (ROC) curves.The overall in-hospital mortality rate was 3.1%. Higher EMTRAS and REMS scores were associated with hospital mortality (P < .001). The ROC curve demonstrated adequate discrimination (AUC = 0.957 for EMTRAS and 0.9 for REMS). After performing AUC analysis followed by Bonferroni correction for multiple comparisons, EMTRAS was significantly superior to REMS and ISS in predicting in-hospital mortality (P < .001), but not significantly different from the RTS (P = .057). The other scoring systems were not significantly different from each other.The EMTRAS and the REMS are simple, accurate predictors of in-hospital mortality in patients with trauma.

The impact of the improvement in internal medicine consultation process on ED length of stay

INTRODUCTION

Although consultations are essential for delivering safe, high-quality care to patients in emergency departments, they contribute to emergency department patient flow problems and overcrowding which is associated with several adverse outcomes, such as increases in patient mortality and poor quality care. This study aimed to investigate how time flow metrics including emergency department length of stay is influenced by changes to the internal medicine consultation policy.

METHOD

This study is a pre- and post-controlled interventional study. We attempted to improve the internal medicine consultation process to be more concise. After the intervention, only attending emergency physicians consult internal medicine chief residents, clinical fellows, or junior staff of each internal medicine subspecialty who were on duty when patients required special care or an admission to internal medicine.

RESULTS

Emergency department length of stay of patients admitted to the department of internal medicine prior to and after the intervention decreased from 996.94min to 706.62min. The times from consultation order to admission order and admission order to emergency department departure prior to and after the intervention were decreased from 359.59min to 180.38min and from 481.89min to 362.37min, respectively. The inpatient mortality rates and Inpatient bed occupancy rates prior to and after the intervention were similar.

CONCLUSION

The improvements in the internal medicine consultation process affected the flow time metrics. Therefore, more comprehensive and cooperative strategies need to be developed to reduce the time cycle metrics and overcrowding of all patients in the emergency department.

Belatacept-Resistant Rejection Is Associated With CD28+ Memory CD8 T Cells

Recently, newer therapies have been designed to more specifically target rejection in an effort to improve efficacy and limit unwanted toxicity. Belatacept, a CD28-CD80/86 specific reagent, is associated with superior patient survival and graft function compared with traditional therapy, but its adoption as a mainstay immunosuppressive therapy has been tempered by increased rejection rates. It is essential that the underlying mechanisms associated with this rejection be elucidated before belatacept is more widely used. To that end, we designed a study in a nonhuman primate kidney transplant model where animals were treated with either a belatacept- or a tacrolimus-based immunosuppressive regimen. Interestingly, we found that elevated pretransplant frequencies of CD28⁺ CD8⁺ T_EMRA cells are associated with rejection on belatacept but not tacrolimus treatment. Further analysis showed that the CD28⁺ CD8⁺ T_EMRA cells rapidly lose CD28 expression after transplant in those animals that go on to reject with the allograft infiltrate being predominantly CD28^- . These data suggest that CD28⁺ memory T cells may be resistant to belatacept, capable of further differentiation including loss of CD28 expression while maintaining effector function. The unique signaling requirements of CD28⁺ memory T cells provide opportunities for the development of targeted therapies, which may synergize with belatacept to prevent costimulation-independent rejection.

Patterns and predictors of persistent opioid use following hip or knee arthroplasty

OBJECTIVE

The relationship between arthroplasty and long-term opioid use in patients with knee or hip osteoarthritis is not well studied. We examined the prevalence, patterns and predictors of persistent opioid use after hip or knee arthroplasty.

METHOD

Using claims data (2004-2013) from a US commercial health plan, we identified adults who underwent hip or knee arthroplasty and filled ≥1 opioid prescription within 30 days after the surgery. We defined persistent opioid users as patients who filled ≥1 opioid prescription every month during the 1-year postoperative period based on group-based trajectory models. Multivariable logistic regression was used to determine preoperative predictors of persistent opioid use after surgery.

RESULTS

We identified 57,545 patients who underwent hip or knee arthroplasty. The mean ± SD age was 61.5 ± 7.8 years and 87.1% had any opioid use preoperatively. Overall, 7.6% persistently used opioids after the surgery. Among patients who used opioids in 80% of the time for ≥4 months preoperatively (n = 3023), 72.1% became persistent users. In multivariable analysis, knee arthroplasty vs hip, a longer hospitalization stay, discharge to a rehabilitation facility, preoperative opioid use (e.g., a longer duration and greater dosage and frequency), a higher comorbidity score, back pain, rheumatoid arthritis, fibromyalgia, migraine and smoking, and benzodiazepine use at baseline were strong predictors for persistent opioid use (C-statistic = 0.917).

CONCLUSION

Over 7% of patients persistently used opioids in the year after hip or knee arthroplasty. Given the adverse health effects of persistent opioid use, strategies need to be developed to prevent persistent opioid use after this common surgery.

The new trauma score (NTS): a modification of the revised trauma score for better trauma mortality prediction

Background

Since its introduction, the Revised Trauma Score (RTS) has been widely used to determine the prognosis of trauma patients. Recent studies have revealed a need to change the parameters of the RTS. We have designed a new trauma score (NTS) based on revised parameters, including the adoption of the actual Glasgow Coma Scale (GCS) score instead of a GCS code, the revision of the systolic blood pressure interval used for the code value and the incorporation of peripheral oxygen saturation (SpO₂) instead of respiratory rate. The purpose of this study was to evaluate the predictive performance of the NTS for in-hospital mortality compared with the RTS and other trauma scores.

Methods

This was a prospective observational study using data from the trauma registry of a tertiary hospital. The subjects were selected from patients who arrived at the ED between July 1, 2014, and June 30, 2016, and, for external validation purposes, those who arrived at the ED between July 1, 2011, and June 30, 2013. Demographic data and physiological data were analyzed. NTS models were calculated using logistic regression for GCS score, SBP code values, and SpO₂. The mortality predictive performance of NTS was compared with that of other trauma scores.

Results

A total of 3263 patients for derivation and 3106 patients for validation were included in the analysis. The NTS showed better discrimination than the RTS (AUC = 0.935 vs. 0.917, respectively, AUC difference = 0.018, p = 0.001; 95% CI, 0.0071–0.0293) and similar discrimination to that of mechanism, Glasgow Coma scale, age, and arterial pressure (MGAP) and the Glasgow Coma Scale, age, and systolic arterial pressure (GAP). In the validation cohort, the global properties of the NTS for mortality prediction were significantly better than those of the RTS (AUC = 0.919 vs. 0.906, respectively; AUC difference = 0.013, p = 0.013; 95% CI, 0.0009–0.0249) and similar to those of the MGAP and GAP.

Conclusions

The NTS predicts in-hospital mortality substantially better than the RTS.

The Revised Trauma Score plus serum albumin level improves the prediction of mortality in trauma patients

INTRODUCTION

The Revised Trauma Score (RTS) is used worldwide in prehospital practice and in the emergency department (ED) settings to triage trauma patients. The main purpose of this study was to evaluate the value of the RTS plus serum albumin (RTS-A) and to compare it with other existing trauma scores as well as to compare the predictive performance of the Trauma and Injury Severity Score with the RTS-A (TRISS-A) with the original TRISS.

METHODS

This was a single center, trauma registry based observational cohort study. Data were collected from consecutive patients with blunt or penetrating injuries who presented to the emergency department of a tertiary referral hospital, between January 2012 and June 2016. 3145 and 2447 patients were assigned to the derivation group and validation group, respectively. Main outcome was in-hospital mortality.

RESULTS

Among patients in the derivation group, the median [interquartile range] age was 59 [43-73] years, and 66.7% were male. The area under the receiver operating characteristic curves (AUC) of the RTS-A (0.948; 95% CI: 0.939-0.955) was higher than that of the RTS (0.919; 95% CI: 0.909-0.929). In patients with blunt trauma, the AUC of the TRISS-A (0.960; 95% CI: 0.952-0.967) was significantly higher than that of the original TRISS (0.949; 95% CI: 0.941-0.957).

CONCLUSION

The value of the RTS-A predicts the in-hospital mortality of trauma patients better than the RTS, and the TRISS-A is a better mortality predictor compared to the original TRISS in patients with blunt trauma.

Efficient extraction of oil from droplet microfluidic emulsions

Droplet microfluidic techniques can perform large numbers of single molecule and cell reactions but often require controlled, periodic flow to merge, split, and sort droplets. Here, we describe a simple method to convert aperiodic flows into periodic ones. Using an oil extraction module, we efficiently remove oil from emulsions to readjust the droplet volume fraction, velocity, and packing, producing periodic flows. The extractor acts as a universal adaptor to connect microfluidic modules that do not operate under identical flow conditions, such as droplet generators, incubators, and merger devices.

Non-aneurysmal and non-traumatic subarachnoid hemorrhage after attempted suicide by incomplete hanging

Hanging is a common method of suicide that is being reported more frequently in many countries. Several complications including injuries to the cervical spine, neck vessels, and brain can occur after attempted suicide by hanging. There are only a few reports of brain computed tomography and magnetic resonance imaging of hanging victims. The most common abnormality was diffuse cerebral edema. A subarachnoid hemorrhage is an atypical complication by suicidal hanging. We report a case of a female patient who presented to an emergency department with altered mental status after attempting suicide by incomplete hanging. The patient was diagnosed with a non-aneurysmal and non-traumatic subarachnoid hemorrhage. This case shows that spontaneous subarachnoid hemorrhage can develop due to a sudden elevation of intracranial pressure, as occurs with hanging.

Base deficit is a predictor of mortality in organophosphate insecticide poisoning

OBJECTIVE

Organophosphate insecticide (OPI) self-poisoning is a major medical problem in many countries. Several studies have demonstrated that the base deficit (BD) is a prognostic tool that is correlated with the severity of injury and predicted mortality, particularly in trauma patients. Here, we aimed to investigate the prognostic significance of BD in OPI poisoning.

METHODS

This retrospective observational study was conducted between January 1, 2006, and January 31, 2015, at a single emergency department (ED). The BD values were divided into quartiles according to the number of patients: 3 mEq/L or less, 3-5.9 mEq/L, 6-9.9 mEq/L, and 10 mEq/L or greater. Survival at 30 days from ED admission was estimated using the Kaplan-Meier survival analysis.

RESULTS

Among 154 patients, 31 died, yielding a mortality of 20.1%. The highest BD quartile (≥ 10 mEq/L) and the 6-9.9 mEq/L group were associated with an increased risk of 30-day mortality. Patients with a BD of 10 mEq/L or greater had a 5.85-fold higher risk of 30-day mortality and patients with a BD of 6-9.9 mEq/L had a 5.40-fold higher risk of 30-day mortality compared to patients with a BD of 3 mEq/L or less. The area under the curves of the BD and the Acute Physiology and Chronic Health Evaluation II score for mortality were 0.748 (95% confidence interval (CI), 0.660-0.835) and 0.852 (95% CI, 0.789-0.915), respectively.

CONCLUSIONS

This study showed that the BD is a predictor of 30-day mortality in patients with OPI poisoning.

Risk of high-grade cervical dysplasia and cervical cancer in women with systemic lupus erythematosus receiving immunosuppressive drugs

Objective Prior studies suggest an increased risk of cervical cancer among women with systemic lupus erythematosus. However, the relationship with immunosuppressive drugs is not well studied in US nationwide cohorts. We compared the risk of high-grade cervical dysplasia and cervical cancer among women with systemic lupus erythematosus who started immunosuppressive drugs versus hydroxychloroquine. Methods We identified systemic lupus erythematosus patients initiating immunosuppressive drugs or hydroxychloroquine using claims data from two US commercial health plans and Medicaid (2000-2012). We used a validated claims-based algorithm to identify high-grade cervical dysplasia or cervical cancer. To account for potential confounders, including demographic factors, comorbidities, medication use, HPV vaccination status, and health care utilization, immunosuppressive drugs and hydroxychloroquine initiators were 1:1 matched on the propensity score. We used inverse variance-weighted, fixed effect models to pool hazard ratios from the propensity score-matched Medicaid and commercial cohorts. Results We included 2451 matched pairs of immunosuppressive drugs and hydroxychloroquine new users in the commercial cohort and 7690 matched pairs in Medicaid. In the commercial cohort, there were 14 cases of cervical dysplasia or cervical cancer among immunosuppressive drugs users and five cases among hydroxychloroquine users (hazard ratio 2.47, 95% CI 0.89-6.85, hydroxychloroquine = ref). In Medicaid, there were 46 cases among immunosuppressive drugs users and 29 cases in hydroxychloroquine users (hazard ratio 1.24, 95% CI 0.78-1.98, hydroxychloroquine = ref). The pooled hazard ratio of immunosuppressive drugs was 1.40 (95% CI 0.92-2.12). Conclusion Among women with systemic lupus erythematosus, immunosuppressive drugs may be associated with a greater, albeit not statistically significant, risk of high-grade cervical dysplasia and cervical cancer compared to patients receiving hydroxychloroquine alone.

Comparative cardiovascular safety of glucagon-like peptide-1 receptor agonists versus other antidiabetic drugs in routine care: a cohort study

AIMS

To evaluate the comparative cardiovascular disease (CVD) safety of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in head-to-head comparisons with dipeptidyl peptidase-4 (DPP-4) inhibitors, sulphonylureas or insulin, when added to metformin, as used in 'real-world' patients with type 2 diabetes mellitus (T2DM).

METHODS

Within a large US commercial health plan database linked to laboratory test results, we identified three pairwise 1 : 1 propensity-score-matched cohorts of patients with T2DM aged ≥18 years treated with metformin who initiated a GLP-1 RA or a comparator, i.e. DPP-4 inhibitor (n = 35 534), second-generation sulphonylureas (n = 28 138) or insulin (n = 47 068), between 2005 and 2013. We examined the association between drug initiation and a composite CVD endpoint, comprising hospitalizations for acute myocardial infarction, unstable angina, stroke or coronary revascularization.

RESULTS

During the course of 1 year, there were 13.9 and 13.7 CVD events per 1000 person-years among propensity-score-matched initiators of GLP-1 RAs versus DPP-4 inhibitors [hazard ratio (HR) 1.02; 95% confidence interval (CI) 0.84-1.24]; and 12.1 versus 14.0 events among initiators of GLP-1 RAs versus sulphonylureas (HR 0.86; 95% CI 0.69-1.08). The effect estimates for GLP-1 RAs versus insulin were sensitive to the adjustment for glycated haemoglobin, after which the HR was 1.01 (95% CI 0.73-1.41). Results were robust across several sensitivity analyses, including an as-treated analysis considering up to 8.7 years of follow-up.

CONCLUSIONS

This large study, performing head-to-head comparisons of GLP-1 RAs with other antidiabetic agents in real-world patients, provides estimates of relative safety precise enough to exclude large differences in CVD risk and adds further understanding to results from recent clinical trials.

On-scene factors that predict severe injury of patients involved in frontal crashes of passenger cars

PURPOSE

We sought to determine on-scene factors that predict severe injury to the occupants of passenger cars involved in frontal crashes.

METHODS

From January 2011 to December 2014, we collected data from patients who were taken to two emergency centres following a frontal motor vehicle crash. Binomial logistic regression was used to model the effects of occupant characteristics (sex, age, body mass index), vehicle damage (according to the collision deformation classification code), and safety devices on severe injuries (injury severity score >15).

RESULTS

Of 344 subjects, 75 (21.8 %) had severe injuries. Sex, seat belt status, extent of vertical crash, intrusion, and deformation extent (DE) were significantly different between severe and non-severe injuries. After adjusting for confounders, non-use of seat belt tripled the odds of severe injury [odds ratio (OR) 2.7, 95 % confidence interval (CI) 1.461-5.105]. DE ≥4 and intrusion increased the risk of severe injury (OR 2.4, 95 % CI 1.120-5.204 and OR 5.2, 95 % CI 2.525-10.780, respectively). A combination model to predict severe injury using intrusion, seat belt use, and DE ≥4 demonstrated 56.0 % sensitivity, 88.9 % specificity, and 58.4 % positive predictive value (AUC = 0.781, 95 % CI 0.734-0.824).

CONCLUSIONS

For passenger cars involved in a frontal crash, intrusion, unbelted status, and DE ≥4 are good predictors of severe injury. Sequential criteria using vehicle DE, seat belt use, and intrusion can be used by first responders to triage patients involved in a frontal collision.

CLIF-SOFA score and SIRS are independent prognostic factors in patients with hepatic encephalopathy due to alcoholic liver cirrhosis

Hepatic encephalopathy (HE) is a complication associated with worst prognosis in decompensated liver cirrhosis (LC) patients. Previous studies have identified prognostic factors for HE, and recent studies reported an association between systemic inflammatory response syndrome (SIRS) and liver disease. This study aimed to identify prognostic factors for 30-day mortality in alcoholic LC patients with HE who visited the emergency department (ED).This was a retrospective study of alcoholic LC patients with HE from January 1, 2010, to April 30, 2015. The baseline characteristics, complications of portal hypertension, laboratory values, Child-Pugh class, Model for End-stage Liver Disease (MELD) score, chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score, and SIRS criteria were assessed. The presence of 2 or more SIRS criteria was considered SIRS. The primary outcomes were 30-day mortality and prognostic factors for patients with HE visiting the ED.In total, 105 patients who met the inclusion criteria were analyzed. Overall, the 30-day mortality rate was 6.7% (7 patients).Significant variables were hepatorenal syndrome, international normalized ratio, white blood cell count, total bilirubin level, MELD score CLIF-SOFA score, and SIRS in univariate analysis. CLIF-SOFA score and SIRS were the significant factors in the multivariate analysis (hazard ratio 5.56, 15.98; 95% confidence interval 1.18-26.18, 1.58-161.37; P = 0.03, P = 0.02). The mortality rates differed according to the CLIF-SOFA score (P < 0.01).The CLIF-SOFA score and SIRS in alcoholic LC patients with HE visiting the ED are independent predictors of 30-day mortality.

Alcohol Intake and Reduced Mortality in Patients with Traumatic Brain Injury

BACKGROUND

The purpose of our study was to determine whether alcohol intake influences short-term mortality in patients with traumatic brain injury (TBI), using a comprehensive trauma database.

METHODS

We collected data from 7 emergency departments (EDs) between June 1, 2008 and May 31, 2010, using the same data form. Cases were included if they met the following criteria: (i) older than 15 and (ii) injuries including TBI. Demographics and outcomes were compared between patients with and without alcohol intake. We present the risk of mortality using hazard ratios and 95% confidence intervals.

RESULTS

A total of 76,596 trauma patients visited the EDs during the study period; 12,980 patients were older than 15 and had TBI. There were 4,009 (30.9%) patients in the alcohol-intake group, of whom 3,306 (82.5%) patients were male, 1,450 (36.2%) patients were moved by ambulance, and 1,218 (30.4%) patients' injuries were intentional. The most frequent injury mechanism was falling down with alcohol intake and blunt injury without alcohol intake. Mortality rate was 1.0% with alcohol intake and 2.0% without alcohol intake. After adjusting for all factors related to mortality, the hazard ratio of mortality was 0.72 in the alcohol-intake group.

CONCLUSIONS

Mortality rate due to TBI in the alcohol-intake group appears to be lower compared to that in the no-alcohol-intake group after adjusting for main confounding variables.

Optimization of a nanotip on a surface for the ultrafast probing of propagating surface plasmons

We theoretically analyze a method for characterizing propagating surface plasmon polaritons (SPPs) on a thin gold film. The SPPs are excited by few-cycle near-infrared pulses using Kretschmann coupling, and a nanotip is used as a local field sensor. This geometry removes the influence of the incident excitation laser from the near fields, and enhances the plasmon electric field strength. Using finite-difference-time-domain studies we show that the geometry can be used to measure SPP waveforms as a function of propagation distance. The effects of the nanotip shape and material on the field enhancement and plasmonic response are discussed.

Incarceration of gravid uterus by growing subserosal myoma: case report

Incarceration of gravid uterus is a rare condition, occurring in one in 3,000 to 10,000 pregnancies during second trimester. Incarceration of uterus can cause several complications, such as uterine rupture, labor dystocia, and uncontrollable postpartum hemorrhage. Early diagnosis is important to prevent these complications, but there are no standard treatments of incarceration of gravid uterus. The authors present a case report of incarceration of gravid uterus caused by growing subserosal myoma, which was treated with myomectomy during second trimester.

Comparison of mechanical artificial shrinkage methods in mouse blastocyst vitrification

PURPOSE OF INVESTIGATION

This study was designed to determine which mechanical artificial shrinkage (AS) method, conducted by puncture, pipetting, or aspiration, was effective in increasing the re-expansion rate of mouse blastocysts.

MATERIALS AND METHODS

In each group, 30 mouse blastocysts were used. Before vitrification, the blastocoelic cavity was collapsed by puncture with a micro-needle, pipetting with a micro-glass pipette, and direct aspiration with an ICSI pipette. After thawing, the re-expansion rate of blastocysts was examined for each AS method. Re-expansion rate was checked at three, five, and seven hours after thawing.

RESULTS

The number of re-expanded mouse blastocysts at five hours after thawing was 12 in the puncture with a micro-needle group, 11 in the pipetting with a micro-glass pipette group, and 24 in the direct aspiration with an ICSI pipette group. The cumulative number of re-expanded mouse blastocysts at seven hours after thawing was 20 in the puncture with a micro-needle group, 20 in the pipetting with a micro-glass pipette group, and 28 in the direct aspiration with an ICSI pipette group. There were statistically significant differences in the cumulative number of re-expanded mouse blastocysts between five and seven hours after thawing (p = 0.001 and 0.021, respectively).

CONCLUSIONS

Direct aspiration with an ICSI pipette resulted in a higher re-expansion rate than the puncture and pipetting methods. It can be considered that the direct aspiration method is more convenient and simpler than the other two methods.

Crumbled or mashed feed had no significant effect on the performance of lactating sows or their offspring

Background

Physical and chemical properties of feedstuffs can be changed by feed processing. Moreover, through various mechanisms, feed processing can affect growth performance and feed efficiency of swine, nutrition value of the feed. Weaning-to service-intervals (WSI), subsequent farrowing rates, and total-born litter sizes were determined by feed intake and metabolic state during lactation.

Methods

A total of 20 sows (Landrace × Yorkshire) with an average body weight (BW) of 266.1 kg 4 d before farrowing were used to determine the effect of feed processing on the performance of lactating sows and their offspring. The following two dietary treatments were used: 1) Crumble diet (C); and 2) Mash diet (M). Ten replications were used for each treatment. Back fat thickness of sows was measured 6 cm off the midline at the 10th rib using a real-time ultrasound instrument at 4 d before farrowing, 1 d after farrowing, and during weaning. Sow BW were also checked at 4 d before farrowing, 1 d after farrowing, and during weaning. Fecal score of sows were assessed on d 14. Fecal score of piglets were observed on d 7, 15, and 24. Data were analyzed using t-test procedure of SAS (2014) with sow as experimental unit.

Results

No significant (p > 0.05) difference was observed in the reproduction performance of sows between the two treatments. In addition, there was no significant (p > 0.05) difference in the growth performance of piglets between the two treatments. Fecal score of sows or piglets showed no significant (p > 0.05) difference either.

Conclusions

In conclusion, different feed processing (mash or crumble) did not make any significant difference on the performance of lactation sow or their piglets.

The suprasternal notch as a landmark of chest compression depth in CPR

OBJECTIVE

This study was performed to determine a landmark for chest compression depth for adult cardiopulmonary resuscitation (CPR) using chest computed tomography and to evaluate the validity of the landmark.

METHODS

The external anteroposterior diameters (EAPDs) of each chest at the suprasternal notch (SN) and the lower half (LH) of the sternum were measured. We analyzed the differences in the EAPDs between the LH and the SN in each EAPD group in the LH of the sternum as follows: less than 20.00, 20.00 to 21.99, 22.00 to 23.99, greater than or equal to 24.00. We compared the differences in the EAPDs between the 2 points with 50 mm and the chest compression depth on simulated one-fourth external chest compressions for each EAPD group on the LH of the sternum.

RESULTS

The mean difference in the EAPDs between the SN and the LH was 5.16 ± 0.91 mm. The differences in the EAPDs between the SN and the LH of the sternum with 50 mm did not indicate a significant difference. The mean one-fourth EAPD at the LH of the sternum was 5.50 ± 0.53 mm. There was not a significant difference in the residual chest depth on one-fourth simulated chest compression for each EAPD group on the LH of the sternum.

CONCLUSIONS

The SN may have value as a functional landmark for chest compression depth in adult CPR. Our findings combined with the simulated one-fourth chest compressions were more consistent with the depth between 50 and 60 mm recommended by the 2015 CPR guidelines.

Patients' perception about risks and benefits of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after orthopedic surgery: a qualitative study

Background

The 9th edition of the American College of Chest Physicians’ Antithrombotic Therapy and Prevention of Thrombosis guidelines emphasize the importance of considering the risk–benefit ratio of “patient-important” outcomes. However, little is known about patients’ perception and understanding regarding the different outcomes of antithrombotic treatment after orthopedic surgery, and the factors that influence their decision to use these treatments. Using a series of semi-structured interviews, we explored patients’ understanding and perception concerning the benefits and risks of antithrombotic treatment for the prevention of venous thromboembolism (VTE) after joint replacement surgery.

Methods

A series of semi-structured interviews were conducted with patients who had undergone knee or hip replacement surgery at a tertiary care hospital (Brigham and Women’s Hospital, Boston, MA) in 2014. Discussions were recorded and transcribed. Two investigators independently coded and analyzed the data to identify important themes and concepts using the constant comparative method.

Results

Of 64 patients who were invited, 12 patients (19 %) completed the interviews. The majority of patients (92 %) were aware of the benefits of antithrombotic therapy for reducing the risk of blood clots, while less than half of them had a clear understanding of deep vein thrombosis and pulmonary embolism. While all patients were aware of risk of minor bleeding, only 6 patients (50 %) considered the risk of major bleeding as a possible side effect of antithrombotic treatment. Overall, patients perceived bleeding as a less important outcome than a thrombotic event. The lack of awareness about the risk of major bleeding, the assumption that a short-term exposure would not meaningfully affect bleeding risk, and the assumption that bleeding is a controllable event influenced their perception. Most patients (83 %) stated that their decision to use antithrombotic medications was mainly based on the trust in their physician’s expertise.

Conclusions

Patients perceived thrombotic events as more important outcomes than bleeding events. Patients’ understanding of thrombotic and bleeding events varies and may play a key role in their preferences. The majority of patients stated that trust in their physician’s expertise had a large influence on their decision to use antithrombotic medications.

Coulomb Impurity Problem of Graphene in Strong Coupling Regime in Magnetic Fields

We investigate the Coulomb impurity problem of graphene in strong coupling limit in the presence of magnetic fields. When the strength of the Coulomb potential is sufficiently strong the electron of the lowest energy boundstate of the n = 0 Landau level may fall to the center of the potential. To prevent this spurious effect the Coulomb potential must be regularized. The scaling function for the inverse probability density of this state at the center of the impurity potential is computed in the strong coupling regime. The dependence of the computed scaling function on the regularization parameter changes significantly as the strong coupling regime is approached.

Stability of Anomalous States of a Local Potential in Graphene

Graphene Landau levels have discrete energies consisting zero energy chiral states and non-zero energy states with mixed chirality. Each Landau level splits into discrete energies when a localized potential is present. A simple scaling analysis suggests that a localized potential can act as a strong perturbation, and that it can be even more singular in graphene than in ordinary two-dimensional systems of massful electrons. Parabolic, Coulomb, and Gaussian potentials in graphene may have anomalous boundstates whose probability density has a sharp peak inside the potential and a broad peak of size magnetic length l outside the potential. The n = 0 Landau level with zero energy has only one anomalous state while the n = ±1 Landau levels with non-zero energy have two (integer quantum number n is related to the quantized Landau level energies). These anomalous states can provide a new magnetospectroscopic feature in impurity cyclotron resonances of graphene. In the present work we investigate quantitatively the conditions under which the anomalous states can exist. These results may provide a guide in searching for anomalous states experimentally.

Effects of Palm Kernel Expellers on Productive Performance, Nutrient Digestibility, and White Blood Cells of Lactating Sows

This experiment was conducted to investigate the effects of palm kernel expellers on productive performance, nutrient digestibility, and changes in white blood cells (WBC) of lactating sows. A total of 14 sows (200±12 kg of average body weight [BW]; 2.5 of average parity) were used and moved from gestation room to farrowing room on d 109 of gestation. Sows were randomly assigned to 2 dietary treatments in a completely randomized design. The treatments were a diet based on corn and soybean meal (CON) and CON added with 20% of palm kernel expellers (PKE). Sows were fed the treatments for 28 days (weaning) after farrowing. Blood was collected from each sow and 4 randomly selected piglets from each sow before farrowing or on d 3, 7, or 14 of lactation. Sows were fed respective treatments containing 0.2% chromic oxide from d 15 to 21 of lactation. Fecal samples were collected daily for the last 3 days after the 4-d adjustment period. Measurements were performances and WBC changes of sows and litter, nutrient digestibility of sows, and daily diarrhea of litter. Sows fed PKE had greater average daily feed intake (7.38 vs 7.10 kg/d; p<0.05) and lost less BW (−6.85 vs −8.54 kg; p<0.05) and backfat depth (−0.42 vs −0.71 mm; p<0.05) than those fed CON. However, there were no differences on digestibility of dry matter, nitrogen, and energy and weaning to estrus interval of sows fed either CON or PKE. Piglets from sows fed PKE gained more BW (203 vs 181 g/d; p = 0.08) and had less frequency of diarrhea (6.80 vs 8.56%; p = 0.07) than those from sows fed CON. On the other hand, no difference was found on preweaning mortality of piglets from sows fed either CON or PKE. Sows fed PKE had lower number of WBC (9.57 vs 11.82 ×10³/μL; p = 0.09) before farrowing than those fed CON, but no difference on d 3 and 7. Similarly, piglets from sows fed PKE had also lower number of WBC (7.86 vs 9.80 ×10³/μL; p<0.05) on d 14 of lactation than those from sows fed CON, but no difference on d 3 and 7. In conclusion, addition of 20% palm kernel expellers to lactation diet based on corn and soybean meal had no negative effects on productive performance, nutrient digestibility, and WBC changes of lactating sows.