Application and advantages of a joystick-controlled robotic scope holder in transoral endoscopic thyroidectomy vestibular approach: a comparative study

Transoral endoscopic thyroidectomy has gained popularity due to its scarless nature, but the use of a handheld endoscope can lead to an unstable visual field. Soloassist II, a robotic scope holder, enables precise control using a joystick, ensuring stable vision. This study aims to evaluate the application and the advantages of Soloassist II in transoral thyroidectomy. Patients who underwent transoral thyroidectomy with Soloassist II or human assistance between June 2019 and May 2021 were reviewed. Patient demographics and surgical outcomes were compared. The ergonomic stress of the assistant in both groups was also measured. A total of 100 consecutive patients were included: 32 were assisted by Soloassist II and 68 by humans. The Soloassist II group demonstrated significantly shorter operation times (median [IQR]) (165 [149,179] vs. 181 [165,204] min, P = 0.004) in unilateral lobectomy and less blood loss (median [IQR]) (2 [2,2] vs. 2 [2,3] ml, P = 0.002) than the human-assisted group. Postoperative course and complication rates were similar. The musculoskeletal pain of the assistant was significantly higher and involved more areas in the human-assisted group. The utilization of Soloassist II in transoral endoscopic thyroidectomy is easy to set up and leads to shorter operation times, reduced blood loss, and decreased musculoskeletal pain compared to human handheld endoscope. These findings support the potential of Soloassist II in improving surgical outcomes and minimizing physical strain during transoral thyroidectomy.

Deciphering Early-Stage Molecular Mechanisms of Negative Pressure Wound Therapy in a Murine Model

Negative Pressure Wound Therapy (NPWT) is a commonly employed clinical strategy for wound healing, yet its early-stage mechanisms remain poorly understood. To address this knowledge gap and overcome the limitations of human trials, we establish an NPWT C57BL/6JNarl mouse model to investigate the molecular mechanisms involved in NPWT. In this study, we investigate the intricate molecular mechanisms through which NPWT expedites wound healing. Our focus is on NPWT's modulation of inflammatory immune responses and the concurrent orchestration of multiple signal transduction pathways, resulting in shortened coagulation time and reduced inflammation. Notably, we observe a significant rise in dickkopf-related protein 1 (DKK-1) concentration during NPWT, promoting the differentiation of Hair Follicle Stem Cells (HFSCs) into epidermal cells, expediting wound closure. Under negative pressure, macrophages express and release DKK-1 cytokines, crucial for stimulating HFSC differentiation, as validated in animal experiments and in vitro studies. Our findings illuminate the inflammatory dynamics under NPWT, revealing potential signal transduction pathways. The proposed framework, involving early hemostasis, balanced inflammation, and macrophage-mediated DKK-1 induction, provides a novel perspective on enhancing wound healing during NPWT. Furthermore, these insights lay the groundwork for future pharmacological advancements in managing extensive wounds, opening avenues for targeted therapeutic interventions in wound care.

Surgical intervention may provides better outcomes for hip fracture in nonagenarian patients: A retrospective observational study

Background

Hip fracture is a common disease in the elderly. Among these patients, surgical intervention for hip fracture should be carefully considered because of old age and multiple comorbidities. There are still insufficient comparisons between nonagenarian patients treated with surgery and those treated non-surgically. We studied hip fracture nonagenarian patients to compare the different outcomes between surgical and non-surgical treatments.

Materials and methods

Nonagenarian patients visiting the emergency department with hip fractures between March 2010 and December 2020 were identified. Overall survival was estimated using multivariate Cox proportional hazards models. The mortality rates, the length of hospital stay, complication and readmission rates were also recorded.

Results

A total of 173 patients who underwent surgery and 32 who received conservative treatments were included. The median survival time was 58.47 months in the OP group, which was significantly higher than the 24.28 months in the non-OP group. After adjusting for covariates, including age, sex, Charlson Comorbidity Index (CCI), injury severity score, and fracture type, the risk of death was reduced by surgery (hazard ratio [HR] = 0.427; 95 % confidence interval [CI]: 0.207-0.882; p = 0.021). CCI was also an independent risk factor for poor survival rate (HR = 1.3; 95 % CI: 1.115-1.515; p = 0.001). After adjusting for several factors, surgery within 48 h improved overall survival (HR: 2.518; 95 % CI: 1.299-4.879; p = 0.006) in operative group.

Conclusion

Our study suggests that surgical treatment may provide better survival for nonagenarian patients with hip fractures than non-operation, especially patients with less concurrent comorbidities.

A hierarchical multilabel graph attention network method to predict the deterioration paths of chronic hepatitis B patients

OBJECTIVE

Estimating the deterioration paths of chronic hepatitis B (CHB) patients is critical for physicians' decisions and patient management. A novel, hierarchical multilabel graph attention-based method aims to predict patient deterioration paths more effectively. Applied to a CHB patient data set, it offers strong predictive utilities and clinical value.

MATERIALS AND METHODS

The proposed method incorporates patients' responses to medications, diagnosis event sequences, and outcome dependencies to estimate deterioration paths. From the electronic health records maintained by a major healthcare organization in Taiwan, we collect clinical data about 177 959 patients diagnosed with hepatitis B virus infection. We use this sample to evaluate the proposed method's predictive efficacy relative to 9 existing methods, as measured by precision, recall, F-measure, and area under the curve (AUC).

RESULTS

We use 20% of the sample as holdouts to test each method's prediction performance. The results indicate that our method consistently and significantly outperforms all benchmark methods. It attains the highest AUC, with a 4.8% improvement over the best-performing benchmark, as well as 20.9% and 11.4% improvements in precision and F-measures, respectively. The comparative results demonstrate that our method is more effective for predicting CHB patients' deterioration paths than existing predictive methods.

DISCUSSION AND CONCLUSION

The proposed method underscores the value of patient-medication interactions, temporal sequential patterns of distinct diagnosis, and patient outcome dependencies for capturing dynamics that underpin patient deterioration over time. Its efficacious estimates grant physicians a more holistic view of patient progressions and can enhance their clinical decision-making and patient management.

Laparoscopic vs. open feeding jejunostomy: a systemic review and meta-analysis

BACKGROUND

Feeding jejunostomy is a solid way for patients to maintain enteral nutrition. However, debate over the superiority of the laparoscopic vs. laparotomic method has raised concerns in recent years. This systemic review and meta-analysis aimed to compare the postoperative outcomes between these two approaches.

METHODS

We searched PubMed, Embase, and Scopus from the date of inception to April 2022 for studies comparing laparoscopic and open feeding jejunostomy. Study characteristics and outcomes were extracted from the included articles. The primary outcome was the relative risk (RR) of postoperative complications in each group. We also analyzed the major/minor complication rates and operations, excluding major concomitant procedures. The risk of bias of included studies were assessed using the ROBINS-I tool. The certainty of evidence was rated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of seven retrospective studies with 1195 patients in total were included in this systemic review and meta-analysis. Laparoscopic feeding jejunostomy carried a significantly lower postoperative complication rate (RR: 0.62; 95% CI, 0.42-0.91, p = 0.02, low certainty of evidence) compared with laparotomy, and the heterogeneity was moderate (I² = 34%, p = 0.18). After excluding major concomitant procedures, the RR between the laparoscopic and open group was 0.48 (95% CI, 0.33-0.70, p < 0.001, low certainty of evidence), suggesting that the laparoscopic approach was superior in terms of postoperative complications.

CONCLUSIONS

Our results indicate that laparoscopic feeding jejunostomy might reduce the postoperative overall complication rate compared with open feeding jejunostomy.

Reduced-port robotic radical gastrectomy for gastric cancer: a single-institute experience

Background

Reduced-port laparoscopic gastrectomy can potentially reduce postoperative pain and improve recovery time. However, the inherent difficulty caused by the narrow manipulation angle makes this operation difficult, especially during lymph node dissection. The intrinsic advantage of the da Vinci^® robotic system might offset this difficulty, maintaining adequate surgical quality with risks of surgical complications equal to those by the conventional four-port robotic approach. The aim of this study was to compare the reduced-port robotic approach and the conventional four-port approach in terms of postoperative pain and short-term surgical outcomes.

Methods

All patients who underwent radical gastrectomy with D2 lymph node dissection using the da Vinci Xi robotic system, including reduced-port or conventional four-port approach, were analyzed retrospectively. The primary outcome was postoperative pain assessed using the numerical rating scale (NRS). The secondary outcomes were the number of harvested lymph nodes, operation time, length of hospital stay, and postoperative 30-day complications.

Results

Forty-eight patients were enrolled in the study, 10 cases in the reduced-port and 38 in the conventional four-port group. Postoperative NRS revealed no significant difference between the reduced-port and conventional four-port groups [postoperative day (POD) 1: 4.5 vs. 3, p = 0.047, POD 3: 4 vs. 3, p = 0.178]. After propensity score matching, there were no significant differences in the median number of harvested lymph nodes, operation time, and length of hospital stay between the groups. The postoperative 30-day complications were more frequent in the conventional four-port group, but there was no significant difference compared with the reduced-port group after propensity score matching.

Conclusions

Reduced-port robotic gastrectomy with D2 lymph node dissection might be comparable to the conventional four-port robotic operation in terms of postoperative pain, surgical quality, and short-term outcomes. However, further studies are required to confirm our results and clarify the advantages of the robotic reduced-port approach.

Recurrent right hepatic artery pseudoaneurysm after robotic-assisted cholecystectomy in a patient with Mirizzi syndrome: a case report

Background

Iatrogenic hepatic artery pseudoaneurysm is a rare complication following laparoscopic cholecystectomy. Trans-arterial embolization (TAE) is an effective way to control bleeding after a ruptured aneurysm. But uncommonly, rebleeding may occur which will require a second embolization or even laparotomy.

Case presentation

We report a case of a 45-year-old woman who underwent robotic-assisted cholecystectomy after the diagnosis of type II Mirizzi syndrome. During the operation, the anterior branch of the right hepatic artery was damaged and Hem-o-lok clips were applied to control the bleeding. The postoperative course was smooth, and the patient was discharged 6 days after the procedure. However, one week after hospital discharge, she presented to the emergency department with right upper abdominal tenderness, melena, and jaundice. After examination, the computed tomography angiography (CTA) revealed a 3 cm pseudoaneurysm at the distal stump of the right hepatic artery anterior branch. TAE with gelfoam material was performed. Three days later, the patient had an acute onset of abdominal pain. A recurrent pseudoaneurysm was found at the same location. She underwent TAE again but this time with a steel coil. No further complication was noted, and she was discharged one week later.

Conclusions

Even with the assistance of modern technologies such as the robotic surgery system, one should still take extra caution while handling the vessels. Also, embolization of the pseudoaneurysm with steel coils may be suitable for preventing recurrence.

Impact of bisphosphonates and comorbidities on initial hip fracture prognosis

The aim of this study is to investigate the impact of bisphosphonate treatment on the prognosis of patients with initial hip fracture. Patients aged fifty years and older with initial hip fracture were identified from the Taiwan National Health Insurance Research Database between 2002 and 2011. A multi-state model was established to evaluate the transition between "first to second hip fracture", "first hip fracture to death", and "second hip fracture to death". Transition probability and cumulative hazards were used to compare the prognosis of initial hip fracture in a bisphosphonate treated cohort versus non-treated cohort. In addition, Deyo-Charlson comorbidities, both vertebral and non-vertebral fractures, and cataracts were also included for analysis. After 10-year follow-up, there is decreased cumulative transition probability for both second hip fracture and mortality after both first and second hip fracture in the bisphosphonate treated cohort. Multivariable, transition-specific time-dependent Cox model revealed that bisphosphonate treatment significantly reduced risk for second hip fracture in the first 5 years of the treatment (HR 0.88; 95% CI 0.79-0.99; P: 0.034), first hip fracture mortality (HR 0.88; 95% CI 0.83-0.93; P < 0.001), and second hip fracture mortality in the first 2 years of the treatment (HR 0.78; 95% CI 0.65-0.95; P = 0.011). Female sex, both vertebral and non-vertebral fractures, cataracts, dementia in the first 2 years, and DM with complication were all significantly associated with risk of a second hip fracture. Cerebrovascular disease and hemiplegia comorbidities had less risk of a second hip fracture. The risk of mortality after both first and second hip fracture was significantly associated with congestive heart failure, renal disease, myocardial infarction, and moderate to severe liver disease. Our study demonstrated that bisphosphonate treatment and strict management of comorbidities after the initial hip fracture significantly decrease the risk for a second hip fracture and mortality.

Partial Versus Total Omentectomy in Patients with Gastric Cancer: A Systemic Review and Meta-Analysis

Background: Surgical treatment is the key to cure localized gastric cancer. There is no strong evidence that supports the value of omentectomy. Thus, a meta-analysis was conducted to compare the safety and efficiency of partial and total omentectomy in patients with gastric cancer. Methods: PubMed, Embase, and Cochrane Library databases were searched. All studies that compared total and partial omentectomy as treatments for gastric cancer were included. The primary outcomes were patients' overall survival and disease-free survival, while the secondary outcomes were perioperative outcome and postoperative complications. Results: A total of nine studies were examined, wherein 1043 patients were included in the partial omentectomy group, and 1995 in the total omentectomy group. The partial omentectomy group was associated with better overall survival (hazard ratio: 0.80, 95% CI: 0.66 to 0.98, p = 0.04, I² = 0%), shorter operative time, and lesser blood loss than the total omentectomy group. In addition, no statistically significant difference was observed in the number of dissected lymph nodes, length of hospital stays, complication rate, and disease-free survival. Conclusions: Our results show that, compared with total omentectomy in gastric cancer surgery, partial omentectomy had non-inferior oncological outcomes and comparable safety outcomes.

Sac transection versus sac reduction during laparoscopic herniorrhaphy: A systematic review and meta-analysis

Hernia repair techniques have evolved recently; however sac handling remains a critical step. Transection of the herniated sac as opposed to total sac reduction may simplify the procedure. However, residual sac tissue may increase the risk for seroma formation. We performed a systemic review and meta-analysis to evaluate the safety and feasibility of transecting the hernia sac during laparoscopic herniorrhaphy. Relevant literature search was performed in PubMed, EMBASE, SCORPUS, and the Cochrane Library databases. Relevant studies that compared total reduction with transection of the herniated sac during laparoscopic herniorrhaphy were included. The primary outcome measure was the incidence of seromas. We also analyzed secondary outcomes including operative duration, postoperative pain scores, complications, and hernia recurrence rate. Of the 330 studies identified, four studies published between 2002 and 2020, with sample sizes ranging from 70 to 520 patients, met the inclusion criteria. Overall, 848 hernias were evaluated. We observed a high incidence of seroma formation in the sac transection group compared to that in the sac reduction group (OR 2.41; 95% CI 1.39 to 4.17, P = 0.002), but the groups did not differ significantly with respect to factor such as operative duration, postoperative complications, and pain score. Herniated sac transection during laparoscopic herniorrhaphy might be associated with a higher risk of seroma formation than that observed with sac reduction. The former approach did not show any significant benefits compared to the latter approach with respect to operative duration and postoperative complications.

Effective Preventive Strategies to Prevent Secondary Transmission of COVID-19 in Hemodialysis Unit: The First Month of Community Outbreak in Taiwan

Background: Dialyzed patients are vulnerable to coronavirus infection disease 2019 (COVID-19). The incidence and outcome of COVID-19 in hemodialysis (HD) patients in Taiwan remain unclear. A series of preventive measures were executed to combat COVID-19 transmission among HD patients. Methods: We carried out a series of forward-looking and practical preventive strategies of COVID-19 control in our HD center. Incidences of COVID-19 of our HD unit were compared with those of national and local estimates from a community outbreak from 15 May to 30 June 2021. Prognostic factors associated with mortality were analyzed. Results: The national incidence of COVID-19 was 0.062%; being highest in Taipei City (0.173%), followed by New Taipei City (0.161%) and Keelung (0.083%). The overall incidence in Keelung HD patients was 0.666%. One patient of our HD center contracted COVID-19 from the household; however, we have contained secondary transmission in our HD center by implementing strict preventive measures. The mortality rate of HD patients in Keelung was 66.6%. The median Ct value of HD patients was 17.53 (11.75–27.90) upon diagnosis. The deceased patients had a higher cardiac/thoracic ratio than alive (0.61 vs. 0.55, p = 0.036). Conclusions: Taking aggressive and proactive infection preventive measures impedes the secondary transmission of COVID-19 in HD facilities. COVID-19-associated mortality was high in HD patients, being the high cardiac-thoracic ratio, an important prognostic factor for clinical outcome of infected HD patients.

Gut microbiota in the innate immunity against hepatitis B virus - implication in age-dependent HBV clearance

Hepatitis B virus (HBV) chronically infects 257 million people and is one of the most important liver diseases worldwide. A unique feature of HBV infection in humans is that viral clearance heavily depends on the age at exposure. Recent studies demonstrated that the virus takes advantage of immature innate immunity, especially hepatic macrophages, and not-yet-stabilized gut microbiota in early life to establish a chronic infection. The liver contains resident and infiltrating myeloid cells involved in immune responses to pathogens. They influence both innate and adaptive sectors of the immune system and their interplay with HBV has only been noticed recently. Here, we discuss how interactions between gut microbiota and hepatic macrophages influence the outcomes of HBV infection. Understanding the underlying mechanism would pave the way for the treatment of chronic HBV infection.

A Deep Learning-Based Unsupervised Method to Impute Missing Values in Patient Records for Improved Management of Cardiovascular Patients

Physicians increasingly depend on electronic health records (EHRs) to manage their patients. However, many patient records have substantial missing values that pose a fundamental challenge to their clinical use. To address this prevailing challenge, we propose an unsupervised deep learning-based method that can facilitate physicians' use of EHRs to improve their management of cardiovascular patients. By building on the deep autoencoder framework, we develop a novel method to impute missing values in patient records. To demonstrate its clinical applicability and values, we use data from cardiovascular patients and evaluate the proposed method's imputation effectiveness and predictive efficacy, in comparison with six prevalent benchmark techniques. The proposed method can impute missing values and predict important patient outcomes more effectively than all the benchmark techniques. This study reinforces the importance of adequately addressing missing values in patient records. It further illustrates how effective imputations can enable greater predictive efficacy with regard to important patient outcomes, which are crucial to the use of EHRs and health analytics for improved patient management. Supported by the complete data imputed by the proposed method, physicians can make timely patient outcome estimations (predictions) and therapeutic treatment assessments.

Predictive Analytics for Care and Management of Patients With Acute Diseases: Deep Learning-Based Method to Predict Crucial Complication Phenotypes

BACKGROUND

Acute diseases present severe complications that develop rapidly, exhibit distinct phenotypes, and have profound effects on patient outcomes. Predictive analytics can enhance physicians' care and management of patients with acute diseases by predicting crucial complication phenotypes for a timely diagnosis and treatment. However, effective phenotype predictions require several challenges to be overcome. First, patient data collected in the early stages of an acute disease (eg, clinical data and laboratory results) are less informative for predicting phenotypic outcomes. Second, patient data are temporal and heterogeneous; for example, patients receive laboratory tests at different time intervals and frequencies. Third, imbalanced distributions of patient outcomes create additional complexity for predicting complication phenotypes.

OBJECTIVE

To predict crucial complication phenotypes among patients with acute diseases, we propose a novel, deep learning-based method that uses recurrent neural network-based sequence embedding to represent disease progression while considering temporal heterogeneities in patient data. Our method incorporates a latent regulator to alleviate data insufficiency constraints by accounting for the underlying mechanisms that are not observed in patient data. The proposed method also includes cost-sensitive learning to address imbalanced outcome distributions in patient data for improved predictions.

METHODS

From a major health care organization in Taiwan, we obtained a sample of 10,354 electronic health records that pertained to 6545 patients with peritonitis. The proposed method projects these temporal, heterogeneous, and clinical data into a substantially reduced feature space and then incorporates a latent regulator (latent parameter matrix) to obviate data insufficiencies and account for variations in phenotypic expressions. Moreover, our method employs cost-sensitive learning to further increase the predictive performance.

RESULTS

We evaluated the efficacy of the proposed method for predicting two hepatic complication phenotypes in patients with peritonitis: acute hepatic encephalopathy and hepatorenal syndrome. The following three benchmark techniques were evaluated: temporal multiple measurement case-based reasoning (MMCBR), temporal short long-term memory (T-SLTM) networks, and time fusion convolutional neural network (CNN). For acute hepatic encephalopathy predictions, our method attained an area under the curve (AUC) value of 0.82, which outperforms temporal MMCBR by 64%, T-SLTM by 26%, and time fusion CNN by 26%. For hepatorenal syndrome predictions, our method achieved an AUC value of 0.64, which is 29% better than that of temporal MMCBR (0.54). Overall, the evaluation results show that the proposed method significantly outperforms all the benchmarks, as measured by recall, F-measure, and AUC while maintaining comparable precision values.

CONCLUSIONS

The proposed method learns a short-term temporal representation from patient data to predict complication phenotypes and offers greater predictive utilities than prevalent data-driven techniques. This method is generalizable and can be applied to different acute disease (illness) scenarios that are characterized by insufficient patient clinical data availability, temporal heterogeneities, and imbalanced distributions of important patient outcomes.

Association of age-related macular degeneration on fracture risks among osteoporosis population: a nationwide population-based cohort study

OBJECTIVES

Visual impairment is an important risk factor for fracture in the elderly population. Age-related macular degeneration (AMD) is the leading cause of irreversible visual impairment in elderly people. This study was conducted to explore the relationship between AMD and incident fractures in patients with osteoporosis (OS).

DESIGN

Retrospective analysis of Taiwan's National Health Insurance Research Database (NHIRD).

SETTING

A multicenter study conducted in Taiwan.

PARTICIPANTS AND CONTROLS

The current study used the NHIRD in Taiwan between 1996 and 2011. A total of 13 584 and 54 336 patients with OS were enrolled in the AMD group and the non-AMD group, respectively.

INTERVENTION

Patients with OS were included from the Taiwan's NHIRD after exclusion, and each patient with AMD was matched for age, sex and comorbidities to four patients with non-AMD OS, who served as the control group. A Cox proportional hazard model was used for the multivariable analysis.

PRIMARY OUTCOME MEASURES

Transitions for OS to spine fracture, OS to hip fracture, OS to humero-radio-ulnar fracture and OS to death.

RESULTS

The risks of spine and hip fractures were significantly higher in the AMD group (HR=1.09, 95% CI=1.04 to 1.15, p<0.001; HR=1.18; 95% CI=1.08 to 1.30, p=0.001, respectively) than in the non-AMD group. The incidence of humero-radio-ulnar fracture between AMD and non-AMD individuals was similar (HR=0.98; 95% CI=0.90 to 1.06; p=0.599). However, the risk of death was higher in patients with OS with older age, male sex and all types of comorbidity (p<0.05), except for hyperthyroidism (p=0.200).

CONCLUSION

Patients with OS with AMD had a greater risk of spine and hip fractures than did patients without AMD.

Inferior Vena Cava Volume Is an Independent Predictor of Massive Transfusion in Patients With Trauma

OBJECTIVES

Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality.

METHODS

We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality.

RESULTS

Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66).

CONCLUSIONS

The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED.

Retrocolic versus antecolic gastrointestinal reconstruction in robotic pancreaticoduodenectomy

BACKGROUND

With the advancement of robotic pancreaticoduodenectomy (RPD), several reconstruction methods have been advocated to make RPD more effective and safer. In this study, we investigated the safety and effectiveness of RPD using a left retrocolic (L-port) technique and compared it with those of RPD using an antecolic technique.

METHODS

Between October 2015 and August 2016, we retrospectively reviewed consecutive cases of RPD before and after introducing the L-port technique for gastrointestinal reconstruction. The L-port technique was mainly performed for retrocolic gastrojejunal reconstruction and some cases of duodenojejunal reconstruction. The perioperative and postoperative outcomes were compared in the two groups.

RESULTS

Eighty-three cases of RPD were retrieved for statistical analysis. Compared with the antecolic group, the L-port group was significantly associated with a shorter operative time (median time [IQR] 345 [307-384] min vs. 390 [370-455] min, P < 0.001), reconstruction time (54 [48-59] min vs. 84 [75-98] min, P < 0.001) and lower incidence of delayed gastric emptying. There were no cases of re-operation due to internal herniation, colonic ischemia, or bowel volvulus in the L-port group during the 1-year follow-up period.

CONCLUSIONS

Our results demonstrated that the L-port technique of RPD is a safe and feasible technique for gastrointestinal reconstruction.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Diabetes poses a higher risk of hepatocellular carcinoma and mortality in patients with chronic hepatitis B: A population-based cohort study

Diabetes mellitus may be a risk factor of HCC development in chronic hepatitis B infected patients and affect the all-cause mortality. This study aimed to examine whether DM was associated with the development of HCC with CHB and affected the all-cause mortality. A total of 2966 CHB patients newly diagnosed with DM in 2000 were retrieved from the Longitudinal Cohort of Diabetes Patients database and used propensity scores matching based on age, sex-gender, alcohol-related liver disease and baseline liver cirrhosis to compare with the non-DM patients from the Taiwanese National Health Insurance Research Database. The CHB patients with DM compared to the non-DM had significantly increased (3.3%) risk for HCC development and significantly increased (2.8%) risk of HCC-related mortality. Interestingly, the all-cause mortality was significantly higher in the DM cohort (16.9%) compared to the non-DM cohort (8.2%). In a multivariable transition-specific Cox model to investigate the adjusted hazard ratio of CHB patients with DM or non-DM during the transitions from start to HCC was 1.35; 95% CI (1.16-1.57) and from HCC to death was 1.31; 95% CI (1.06-1.62). All-cause mortality between CHB patients with DM or non-DM during the transitions from start to death was 2.32; 95% CI (1.84-2.92). Taken together, DM is an independent risk factor associated with increasing disease development of HCC, HCC-related mortality and all-cause mortality in CHB patients. This study may provide a clinical strategy for strict DM control in order to reduce the risk of disease development in CHB patients.

Impact of comorbidities on the prognoses of trauma patients: Analysis of a hospital-based trauma registry database

Here we conducted a retrospective analysis of hospital-based trauma registry database for evaluating the impacts of comorbidities on the prognosis for traumatized patients using Index of Coexistent Comorbidity Disease (ICED) scores. We analyzed the data of patients with blunt trauma who visited emergency department between January 1, 2011, and December 31, 2015 in Chang-Gung Memorial Hospital, Keelung branch, a single level I trauma center in the Northern Taiwan. All consecutive patients with blunt trauma who admitted to the intensive care unit or ordinary ward after initial managements in the emergency department were included. We measured the hospital mortality of blunt traumatized patients using alive discharge as a competing risk. To investigate conditional independence of mortality and ICED scores given Injury Severity Score (ISS), we used log-linear models for modeling independence structures. Overall, we included 4997 patients (median age [IQR], 59 years old (44–75 years); 55.3% male). The mortality rate of blunt traumatized patients was higher in the higher ICED scores group compared to lower ICED scores group (4.7% vs 1.8%, p < 0.001). Meanwhile, the higher ICED scores group were associated with older age, higher ISS, and longer hospital stay than lower ICED scores group. Higher ICED group had higher probability of transition-to-death and lower probability of transition-to-discharge under the competing risk model. In the multivariable analysis of transition-specific Cox models, higher ICED group were associated with higher risk for hospital mortality compared to lower ICED group (HR 1.60; [95% CI 1.04–2.47]; p = 0.032). Also, higher ICED group were associated with lower probability of transition-to-discharge (HR 0.79; [95%CI 0.73–0.86]; p < 0.001). Additionally, higher ICED scores accounted for hospital mortality among patients with ISS < 25. In conclusion, our study suggested that severity of comorbidity was associated with higher hospital mortality among traumatized patients, particularly lower ISS.

Effects of Antiplatelet Medication on Arteriovenous Fistula Patency After Surgical Thrombectomy

OBJECTIVES

To study the effect of antiplatelet agents on preventing arteriovenous (AV) fistulae thrombosis in hemodialysis (HD) patients after surgical thrombectomy (ST) for acute AV fistulae occlusion. Whether post-operative antiplatelet drugs have similar effects on the patency of AV fistula after surgical thrombectomy in patients with end-stage renal disease who undergo HD has not been investigated.

DESIGN, MATERIALS AND METHODS

We employed the Taiwan National Health Insurance Research Database (NHIRD) from 1999 to 2010 to assess the recurrent occlusion requiring ST and longevity of AV fistula after ST in 1049 patients on regular HD, with or without antiplatelet drugs.

RESULTS

From the propensity-score (PS)-matched NHIRD, Multivariate Cox model demonstrated that concomitant antiplatelet medication in the HD patients who received the first ST significantly reduced the duration of recurrent ST (adjusted hazard ratio (HR) 1.69; 95% confidence interval (CI) 1.22-2.35, p=0.002) and the longevity of the fistula (adjusted HR 1.79; 95% CI 1.31-2.46, p<0.001).

CONCLUSION

Treatment with antiplatelet drugs in HD patients did not prevent recurrent thrombosis requiring further ST, but significantly jeopardized the longevity of AV fistula after ST.

Diabetes, hepatocellular carcinoma, and mortality in hepatitis C-infected patients: A population-based cohort study

BACKGROUND AND AIM

The effect of diabetes mellitus (DM) on the development of hepatocellular carcinoma (HCC) and all-cause mortality after HCC development in chronic hepatitis C virus (HCV)-infected patients remains inconclusive. This cohort study aimed to investigate these issues using the Taiwanese National Health Insurance Research Database.

METHODS

We retrieved and enrolled newly diagnosed DM patients with HCV from the Longitudinal Cohort of Diabetes Patients database. Propensity score matching-including age, sex, alcohol-related liver disease, and baseline liver cirrhosis-was used to identify and enroll HCV patients without DM from the Longitudinal Health Insurance Database (n = 1686). A multi-state model was used to investigate transitions from "start-to-HCC," "start-to-death," and "HCC-to-death."

RESULTS

The multi-state model showed higher cumulative hazards for "start-to-HCC," "start-to-death," and "HCC-to-death" transitions in the DM (vs non-DM) cohort. The cumulative probability of death with or without HCC after 10 years of follow-up was higher in the DM cohort than in the non-DM cohort. Multivariable transition-specific Cox models demonstrated that DM significantly increased the risk for transition from "start-to-HCC" (adjusted hazard ratio [aHR] 1.36; 95% confidence interval [CI] 1.16-1.59; P < 0.001), "start-to-death" (aHR 2.61; 95% CI: 2.05-3.33; P < 0.001), and "HCC-to-death" (aHR 1.36; 95% CI 1.10-1.68; P = 0.005). The effect of liver cirrhosis on "start-to-HCC" and "start-to-death" transitions decreased over time, particularly within 2 years.

CONCLUSIONS

Diabetes mellitus increased the risk of HCC development in HCV-infected patients and the risk of all-cause mortality in patients with or without HCC.

Envenoming by Viridovipera stejnegeri snake: a patient with liver cirrhosis presenting disruption of hemostatic balance

Background

In most cases of envenoming by the green habu Viridovipera stejnegeri in Taiwan coagulopathy is not observed.

Case presentation

Herein, we describe the case of a patient with liver cirrhosis who developed venom-induced consumptive coagulopathy after V. stejnegeri bite. Laboratory investigation revealed the following: prothrombin time > 100 s (international normalized ratio > 10), activated partial thromboplastin time > 100 s, fibrinogen < 50 mg/dL, and fibrin degradation product > 80 μg/mL. The patient recovered after administration of bivalent hemorrhagic antivenom, vitamin K, fresh frozen plasma and cryoprecipitate.

Conclusion

The liver, directly involved in the acute phase reaction, is the main responsible for neutralization of animal toxins. Any patient with history of liver cirrhosis bitten by a venomous snake, even those whose venoms present low risk of coagulopathy, should be very carefully monitored for venom-induced consumptive coagulopathy (VICC), since the hemostatic balance may be disrupted.

Association between macular degeneration and mild to moderate chronic kidney disease: A nationwide population-based study

Chronic kidney disease (CKD) and macular degeneration (MD) are 2 grave diseases leading to significant disability secondary to renal failure and blindness. The 2 diseases share not only common risk factors but also similar pathogenic mechanisms to renal and retinal injuries. Previous epidemiological studies indicated association between these 2 diseases. However, this concept is challenged by recent investigations. Patients with mild to moderate CKD (n = 30,696) between January 1, 1995 and December 31, 2005 were selected from the Taiwan National Health Insurance Database. Controls (n = 122,784) were matched by age, gender, diabetes mellitus type 2, and hypertension status (1:4 ratios). The risk of MD was compared between the 2 groups. The mean age of patients was 54.9 ± 15.7 years. The proportion of MD was 2.7% in mild to moderate CKD patients and 1.9% in normal controls (P < 0.001); and, 0.39% and 0.26% (P < 0.001) in advanced MD. Mild to moderate CKD patients had higher risk for MD [adjusted odds ratio (OR), 1.301; 95% confidence interval (CI), 1.200-1.411; P < 0.001] than normal renal function subjects. The association was more pronounced for advanced MD. From all age strata (10 years increase), the presence of CKD in those patients aged less than 40 years had highest OR for all MD (OR = 2.125, 95% CI: 1.417-3.186, P < 0.001). The results were consistent in interaction terms, highlighting the importance of CKD in young age patient for risk of MD. The high risk for MD in mild to moderate CKD patients remains significant after adjustment for personal habits (alcohol drinking and smoking, model 1; OR: 1.371; 95% CI: 1.265-1.486; P < 0.001), comorbidities (dyslipidemia, cerebrovascular disease, and peripheral vascular disease, model 2; OR: 1.369; 95% CI: 1.264-1.484; P < 0.001) and all these factors (model 3; OR: 1.320, 95% CI: 1.218-1.431, P < 0.001). This association was consistent in the subanalysis, excluding those patients with diabetic retinopathy. Proper diagnosis and timely intervention should be warranted to retard visual loss of these patients.

The number of displaced rib fractures is more predictive for complications in chest trauma patients

Background

Traumatic rib fractures can cause chest complications that need further treatment and hospitalization. We hypothesized that an increase in the number of displaced rib fractures will be accompanied by an increase in chest complications.

Methods

We retrospectively reviewed the trauma registry between January 2013 and May 2015 in a teaching hospital in northeastern Taiwan. Patients admitted with chest trauma and rib fractures without concomitant severe brain, splenic, pelvic or liver injuries were included. The demographic data, such as gender, age, the index of coexistence disease, alcohol consumption, trauma mechanisms were analyzed as potential predictors of pulmonary complications. Pulmonary complications were defined as pneumothorax, hemothorax, flail chest, pulmonary contusion, and pneumonia.

Results

In the 29 months of the study period, a total of 3151 trauma patients were admitted to our hospital. Among them, 174 patients were enrolled for final analysis. The most common trauma mechanism was road traffic accidents (58.6%), mainly motorbike accidents (n = 70, 40.2%). Three or more displaced rib fractures had higher specificity for predicting complications, compared to three or more total rib fractures (95.5% vs 59.1%). Adjusting the severity of chest trauma using TTSS and Ribscore by multivariable logistic regression analysis, we found that three or more rib fractures or any displaced rib fracture was the most significant predictor for developing pulmonary complication (aOR: 5.49 95% CI: 1.82–16.55). Furthermore, there were 18/57 (31.6%) patients with fewer than three ribs fractures developed pulmonary complications. In these 18 patients, only five patients had delayed onset complications and four of them had at least one displaced rib fracture.

Discussion

In this retrospective cohort study, we found that the number of displaced or total rib fractures, bilateral rib fractures, and rib fractures in more than two areas were associated with the more chest complications. Furthermore, three or more rib fracture or any displacement were found to be the most sensitive risk factor for chest complications, independent of other risk factors or severity index.

Conclusion

The number of displaced rib fractures could be a strong predictor for developing pulmonary complications. For patients with fewer than three rib fractures without rib displacement and initial lung or other organ injuries, outpatient management could be safe and efficient.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0368-y) contains supplementary material, which is available to authorized users.

Application of the World Health Organization Fracture Risk Assessment Tool to predict need for dual-energy X-ray absorptiometry scanning in postmenopausal women

OBJECTIVE

To evaluate the efficacy of the World Health Organization Fracture Risk Assessment Tool, excluding bone mineral density (pre-BMD FRAX), in identifying Taiwanese postmenopausal women needing dual-energy X-ray absorptiometry (DXA) examination for further treatment.

MATERIALS AND METHODS

The pre-BMD FRAX score was calculated for 231 postmenopausal women who participated in public health education workshops in the local Keelung community, Taiwan. DXA scanning and vertebral fracture assessment (VFA) were arranged for women classified as intermediate or high risk for fracture using the pre-BMD FRAX fracture probability.

RESULTS

Pre-BMD FRAX classified 26 women as intermediate risk and 37 as having high risk for fracture. Subsequent DXA scans for these 63 women showed that 36 were osteoporotic, 19 were osteopenic, and eight had normal bone density. Concurrent VFA revealed 25 spine factures in which 14 were osteoporotic, seven were osteopenic, and four had normal bone density. The efficacy of the pre-BMD FRAX score to identify those patients with low bone mass by DXA was 87.3% (55/63). When VFA was combined with BMD to identify those patients with high risk (osteopenia, osteoporosis, or spinal fracture), the efficacy of the pre-BMD score increased to 93.7% (59/63). According to the National Osteoporosis Foundation, the overall concordance between pre-BMD FRAX and BMD, expressed through the kappa index, was 0.967. Compared with the evaluation when BMD was used alone, there was a significant increase in efficacy in identifying women who need treatment using BMD plus VFA or FRAX plus BMD. Furthermore, the highest efficacy was achieved when FRAX with BMD and VFA was used.

CONCLUSION

The pre-BMD FRAX score not only efficiently predicts postmenopausal patients who are potentially at risk and might require treatment but also reduces unnecessary DXA use. Concurrent VFA during DXA use increases spine fracture detection. This improvement in diagnostic efficacy allows clinicians to provide the most appropriate therapeutic recommendation.

Initiation and Persistence of Pharmacotherapy for Youths with Attention Deficit Hyperactivity Disorder in Taiwan

BACKGROUND

Pharmacotherapy is an effective therapeutic option for attention deficit hyperactivity disorder (ADHD). Understanding the patterns of medication treatment is crucial for clinical practice. This study employed nationwide population-based data to elucidate the initiation and persistence of pharmacotherapy (immediate-release methylphenidate [IR-MPH], osmotic controlled-release formulations of methylphenidate [OROS-MPH] and atomoxetine [ATX]) for youths with ADHD in Taiwan.

METHODS

Patients first receiving an ADHD diagnosis at age 18 or younger between January 2000 and December 2009 (n = 112,140; mean age at ADHD diagnosis: 7.7 years) were selected from Taiwan's National Health Insurance database. All patients were monitored through December 31, 2011, with an average follow-up time of 5.8 years. The initiation of ADHD drug therapy was defined as the first patient prescription, and discontinuation was defined as the cessation of ADHD medication for 180 days or longer.

RESULTS

Within the first year after ADHD diagnosis, 47.3%, 14.4%, and 0.8% of the patients were prescribed IR-MPH, OROS-MPH, and ATX, respectively. Regarding the patients prescribed IR-MPH, OROS-MPH, and ATX, 17.8%, 12.6%, and 18.8%, respectively, received the prescription only once and never returned for a drug refill, and 51.0%, 38.9%, and 58.8%, respectively, discontinued drug therapy within 1 year after the first prescription. Male sex and neuropsychiatric comorbidities were associated with higher probabilities of being prescribed one of the medications. An older age at first prescription and a higher daily dose of prescription were significant predictors of early discontinuation of ADHD medication.

CONCLUSIONS

The current findings suggest that IR-MPH is the most frequently prescribed drug for ADHD treatment in Taiwan. Patients treated with OROS-MPH possessed the highest persistence rate, whereas those treated with ATX had the lowest persistence rate. The results provide insight into the delivery of pediatric mental health services and have crucial implications for ADHD medication treatment in real clinical settings.

miR-122-mediated translational repression of PEG10 and its suppression in human hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC), a primary liver malignancy, is the most common cancer in males and fourth common cancer in females in Taiwan. HCC patients usually have a poor prognosis due to late diagnosis. It has been classified as a complex disease because of the heterogeneous phenotypic and genetic traits of the patients and a wide range of risk factors. Micro (mi)RNAs regulate oncogenes and tumor suppressor genes that are known to be dysregulated in HCC. Several studies have found an association between downregulation of miR-122, a liver-specific miRNA, and upregulation of paternally expressed gene 10 (PEG10) in HCC; however, the correlation between low miR-122 and high PEG10 levels still remains to be defined and require more investigations to evaluate their performance as an effective prognostic biomarker for HCC.

Methods

An in silico approach was used to isolate PEG10, a potential miR-122 target implicated in HCC development. miR-122S binding sites in the PEG10 promoter were evaluated with a reporter assay. The regulation of PEG10 by miR-122S overexpression was examined by quantitative RT-PCR, western blotting, and immunohistochemistry in miR-122 knockout mice and liver tissue from HCC patients. The relationship between PEG10 expression and clinicopathologic features of HCC patients was also evaluated.

Results

miR-122 downregulated the expression of PEG10 protein through binding to 3′-untranslated region (UTR) of the PEG10 transcript. In miR-122 knockout mice and HCC patients, the deficiency of miR-122 was associated with HCC progression. The expression of PEG10 was increased in 57.3 % of HCC as compared to paired non-cancerous tissue samples. However, significant upregulation was detected in 56.5 % of patients and was correlated with Okuda stage (P = 0.05) and histological grade (P = 0.001).

Conclusions

miR-122 suppresses PEG10 expression via direct binding to the 3′-UTR of the PEG10 transcript. Therefore, while PEG10 could not be an ideal diagnostic biomarker for HCC but its upregulation in HCC tissue still has predictive value for HCC prognosis.

Characterization and Mechanism for the Protection of Photolytic Decomposition of N-Halamine Siloxane Coatings by Titanium Dioxide

N-Halamine antibacterial materials have superior inactivation activities due to oxidative chlorine species. However, N-Cl bonds and bonds between N-halamine and substrates often decompose rapidly under UV irradiation, leading to unrecoverable loss of antimicrobial activity. In this study, titanium dioxide was covalently bonded onto N-halamine siloxane poly[5,5-dimethyl-3-(3'-triethoxysilylpropyl)hydantoin] (PSPH) via a sol-gel process. Experimental testing of the chlorinated cotton fabrics treated with TiO2/PSPH demonstrated that the residual oxidative chlorine in cotton-TiO2/PSPH-Cl was still effective for inactivating bacteria after 50 washing cycles and under UV light irradiation for 24 h. Quantum mechanical calculations found that TiO2 improves the UV stability of the PSPH-Cl system by increasing the activation barrier of the C-Si scission reaction responsible for the loss of the biocidal hydantoin moiety. SEM, XPS and FTIR spectra were used to characterize the coated cotton samples. Cotton-TiO2/PSPH-Cl samples exhibited good antibacterial activity against Staphylococcus aureus (ATCC 6538) and Escherichia coli O157:H7 (ATCC 43895). The storage stability and washing stability of treated cotton fabrics were also investigated.

Direct Revascularization With the Angiosome Concept for Lower Limb Ischemia: A Systematic Review and Meta-Analysis

The angiosome concept provides practical information regarding the vascular anatomy of reconstructive and vascular surgery for the treatment of peripheral arterial occlusive disease and, particularly, critical lower limb ischemia.The aim of the study was to confirm the efficacy of direct revascularization with the angiosome concept (DR) for lower limb ischemia.Complementary manual searches were performed through the Pubmed, Cochrane Library, and EMBASE databases.We searched all randomized and nonrandomized studies (NRSs) comparing DR with indirect revascularization (IR) (without the angiosome concept) for lower limb ischemia. Only 9 nonrandomized controlled retrospective cohort studies were found and included. Trials published in any language were included.Primary endpoints were time to limb amputation and time to wound healing. Data extraction and trial quality assessment were performed by two authors independently. A third author was consulted for disagreements settlement and quality assurance.Five NRSs involving 779 lower limbs revealed that DR significantly improved the overall survival of limbs (hazard ratio [HR] 0.61; 95% confidence interval [CI] = 0.46-0.80; P < 0.001; I = 0%). In addition, DR significantly improved time to wound healing (HR 1.38; 95% CI = 1.13-1.69; P = 0.002; I = 0%, in 5 studies including 605 limbs).All included studies were retrospective comparative studies, and no consensus was obtained in describing wound conditions in the included studies.Our results suggested that treatment of lower limb ischemia using DR is more effective in salvaging limbs and healing wounds than IR is. Additional randomized controlled studies are necessary to confirm these results.

Self-assembled antibacterial coating by N-halamine polyelectrolytes on a cellulose substrate

In this research, two N-halamine polymer precursors, a cationic homopolymer poly((3-acrylamidopropyl)trimethylammonium chloride) (CHP) and an anionic homopolymer poly(2-acrylamido-2-methylpropane sulfonic acid sodium salt) (AHP), have been successfully synthesized and coated onto cotton fabrics via a layer-by-layer (LbL) deposition technique. The coated cotton fabrics were characterized using scanning electron microscopy, X-ray photoelectron spectroscopy, and Fourier transform infrared spectroscopy. The biocidal efficacies of uncoated and coated cotton fabrics were evaluated against Staphylococcus aureus and Escherichia coli. The chlorinated swatches (CHP-Cl and AHP-Cl) inactivated 100% S. aureus and 99.73% E. coli O157:H7 in 30 min. Over 51% of the chlorine is retained after the equivalent of 50 machine washes. A skin stimulation test showed that CHP-Cl and AHP-Cl compounds have no irritation to rabbit skin, and so these swatches might be utilized for biomedical applications in the future. As an easy and efficient way of coating fabrics, the LbL deposition technique can broaden the use of N-halamine biocides in other polar substances as antimicrobial functional coatings.

Effects of estradiol and progestogens on human breast cells: regulation of sex steroid receptors

OBJECTIVES

To examine the effects of 17β-estradiol (E2) and progestogens, used in hormone therapy, on estrogen receptors (ER), progesterone receptors (PR), and human breast tumor cell growth.

MATERIALS AND METHODS

MCF-7 cells were incubated in pure E2 (1 nM and 10 nM) as well as in E2 in conjunction with 10 nM progestogens, including progesterone (P4), medroxyprogesterone acetate (MPA), norethisterone acetate (NET), and cyproterone acetate (CPA). Cell proliferation, apoptosis, expression of caspase-3, and both ER and PR isoforms were evaluated.

RESULTS

Caspase-3 was significantly diminished in cultures with only E2, whereas ERα significantly increased. A significant increase of caspase-3 in addition to the entire abolishment of E2-induced augmentation of ERα was observed in 1 nM E2 plus MPA and 10 nM E2 plus NET, whereas PR isoform B (PRB) was significantly increased. The ratios of apoptosis: proliferation significantly increased in 1 nM E2 plus progestogens (except P4) and 10 nM E2 plus NET. The changes of the PRA/PRB ratio were inversely related to the changes of the apoptosis to proliferation ratio. Significant increase of ERβ and PRB was noted in the E2 plus MPA or NET, in addition to a significant increase of ERα and decrease of PRA in the E2 plus CPA, as well as an increase of ERα and decrease of PRA and PRB in the E2 plus P4.

CONCLUSIONS

The combination of E2 and various progestogens resulted in diverging effects on ERs and PRs expressions, which induced different effects on MCF-7 cell growth. Compared with P4, aberrant hormone and biological activity of synthetic progestin, by way of altered receptor expression, may be an important factor in affecting breast cell growth.

A procalcitonin-based algorithm to guide antibiotic therapy in secondary peritonitis following emergency surgery: a prospective study with propensity score matching analysis

Background

Procalcitonin (PCT)-based algorithms have been used to guide antibiotic therapy in several clinical settings. However, evidence supporting PCT-based algorithms for secondary peritonitis after emergency surgery is scanty. In this study, we aimed to investigate whether a PCT-based algorithm could safely reduce antibiotic exposure in this population.

Methods/Principal Findings

From April 2012 to March 2013, patients that had secondary peritonitis diagnosed at the emergency department and underwent emergency surgery were screened for eligibility. PCT levels were obtained pre-operatively, on post-operative days 1, 3, 5, and 7, and on subsequent days if needed. Antibiotics were discontinued if PCT was <1.0 ng/mL or decreased by 80% versus day 1, with resolution of clinical signs. Primary endpoints were time to discontinuation of intravenous antibiotics for the first episode and adverse events. Historical controls were retrieved for propensity score matching. After matching, 30 patients in the PCT group and 60 in the control were included for analysis. The median duration of antibiotic exposure in PCT group was 3.4 days (interquartile range [IQR] 2.2 days), while 6.1 days (IQR 3.2 days) in control (p < 0.001). The PCT algorithm significantly improves time to antibiotic discontinuation (p < 0.001, log-rank test). The rates of adverse events were comparable between 2 groups. Multivariate-adjusted extended Cox model demonstrated that the PCT-based algorithm was significantly associated with a 87% reduction in hazard of antibiotic exposure within 7 days (hazard ratio [HR] 0.13, 95% CI 0.07–0.21, p < 0.001), and a 68% reduction in hazard after 7 days (adjusted HR 0.32, 95% CI 0.11–0.99, p  =  0.047). Advanced age, coexisting pulmonary diseases, and higher severity of illness were significantly associated with longer durations of antibiotic use.

Conclusions/Significance

The PCT-based algorithm safely reduces antibiotic exposure in this study. Further randomized trials are needed to confirm our findings and incorporate cost-effectiveness analysis.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12612000601831

Diagnostic performance of alpha-fetoprotein, lens culinaris agglutinin-reactive alpha-fetoprotein, des-gamma carboxyprothrombin, and glypican-3 for the detection of hepatocellular carcinoma: a systematic review and meta-analysis protocol

BACKGROUND

Diagnosis of early-stage hepatocellular carcinoma (HCC) followed by curative resection or liver transplantation offers the best chance for long-term patient survival. Clinically, ultrasonography has suboptimal sensitivity for detecting early-stage HCC. Several serological tests including alpha-fetoprotein (AFP), the ratio of lens culinaris agglutinin-reactive alpha-fetoprotein to total AFP (AFP-L3/AFP), des-gamma carboxyprothrombin (DCP), and glypican-3 (GPC-3) have been widely investigated as diagnostic biomarkers for early-stage HCC in at-risk populations. However, these tests are not recommended for routine HCC screening. Our objective is to determine the diagnostic performance of AFP, AFP-L3/AFP, DCP, and GPC-3 for the detection of HCC, particularly early-stage tumors meeting the Milan criteria.

METHODS/DESIGN

We will include cross-sectional studies that consecutively or randomly recruit target populations. We will search the Cochrane Library, Medline, Embase, Science Citation Index, and the Chinese National Knowledge Infrastructure. We will also search the MEDION and ARIF databases to identify diagnostic systematic reviews that include primary studies. Reference lists of relevant reviews will be searched for additional trials. Language restrictions will not be applied. Two reviewers will independently screen study eligibility and extract data. Methodological quality will be assessed according to the revised tool for the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Two authors will apply the QUADAS-2 assessment to all the included studies, and any discrepancies will be resolved by the third author. The following test characteristics will be extracted into 2 × 2 tables for all included studies: true positives, false positives, true negatives, and false negatives. Study-specific estimates of sensitivity and specificity with 95% confidence intervals will be displayed in forest plots. When possible, we will use the bivariate random-effects model or the Rutter and Gatsonis hierarchical summary receiver operating characteristic model for statistical analysis. To investigate heterogeneity, we will include study designs, population characteristics, test characteristics, and types of reference standard as the study-level variables.

DISCUSSION

Our systematic review will allow patients, clinicians, and researchers to determine the diagnostic performance of AFP, AFP-L3/AFP, DCP, and GPC-3 for the detection of early-stage HCC and the potential roles of these diagnostic biomarkers in the existing diagnostic pathways.Systematic Review Registration: PROSPERO 2013; CRD42013003879.

Effect of parenteral selenium supplementation in critically ill patients: a systematic review and meta-analysis

BACKGROUND

It is currently unclear whether parenteral selenium supplementation should be recommended in the management of critically ill patients. Here we conducted a systematic review and meta-analysis to assess the efficacy of parenteral selenium supplementation on clinical outcomes.

METHODS/PRINCIPAL FINDINGS

Randomized trials investigating parenteral selenium supplementation administered in addition to standard of care to critically ill patients were included. CENTRAL, Medline, EMBASE, the Science Citation Index, and CINAHL were searched with complementary manual searches. The primary outcome was all-cause mortality. Trials published in any language were included. Two authors independently extracted data and assessed trial quality. A third author was consulted to resolve disagreements and for quality assurance. Twelve trials were included and meta-analysis was performed on nine trials that recruited critically ill septic patients. These comprised 965 participants in total. Of these, 148 patients (30.7%) in the treatment groups, and 180 patients (37.3%) in control groups died. Parenteral selenium treatment significantly reduced all-cause mortality in critically ill patients with sepsis (relative risk [RR] 0.83, 95% CI 0.70-0.99, p = 0.04, I(2) = 0%). Subgroup analyses demonstrated that the administration schedule employing longer duration (RR 0.77, 95% CI 0.63-0.94, p = 0.01, I(2) = 0%), loading boluses (RR 0.73, 95% CI 0.58-0.94, p = 0.01, I(2) = 0%) or high-dose selenium treatment (RR 0.77, 95% CI 0.61-0.99, p = 0.04, I(2) = 0%) might be associated with a lower mortality risk. There was no evidence of adverse events.

CONCLUSIONS/SIGNIFICANCE

Parenteral selenium supplementation reduces risk of mortality among critically ill patients with sepsis. Owing to the varied methodological quality of the studies, future high-quality randomized trials that directly focus on the effect of adequate-duration of parenteral selenium supplementation for severe septic patients are needed to confirm our results. Clinicians should consider these findings when treating this high-risk population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2011; CRD42011001768.

High sensitivity, low noise Mirnov coil array on Prairie View rotamak

An array of 32 Mirnov coils with novel features of high sensitivity and low noise has been installed on the outside chamber surface of Prairie View rotamak. This B(R)-oriented coil array has proven to be very reliable in the plasma driven by rotating magnetic field; it can resolve magnetic perturbation signals of 0.1 G. With this new diagnostic, the n = 1 tilt, radial shift, and kink modes are observed for the first time in rotamak plasmas.

Polymeric antimicrobial N-halamine epoxides

A new N-halamine copolymer has been prepared, characterized, and evaluated for antimicrobial efficacy, stability toward hydrolyses, and stability toward UVA degradation when covalently bound to cellulose fibers. A copolymer of 3-chloro-2-hydroxypropylmethacrylate and glycidyl methacrylate was coated onto cotton, and, after curing, was treated with an aqueous solution containing the potassium salt of 5,5-dimethylhydantoin to form a coating which became antimicrobial upon exposure to househod bleach (sodium hypochlorite). The coating inactivated S. aureus and E. coli O157:H7 within minutes of contact time and was quite stable toward washing and UVA photodegradation.

N-halamine copolymers for use in antimicrobial paints

A series of copolymers containing units of a novel hydantoinylacrylamide and the sodium salt of 2-(acrylamido)-2-methylpropanesulfonic acid have been synthesized. The homopolymer of the hydantoinylacrylamide compound was insoluble in water, while the copolymers with the sulfonic acid sodium salt were water-dispersible/soluble, with the solution becoming completely transparent when the feed ratio for the copolymer contained 7 parts of the hydantoin moiety to 3 parts of the sodium sulfonate moiety. The polymers were added into a commercial water-based latex paint, and upon drying, the painted surfaces treated with the water-miscible copolymers were rendered antimicrobial following chlorination with dilute household bleach. The chlorinated homopolymer failed to provide an antimicrobial property for the paint because of its tendency to isolate into aggregates in the paint, while the completely miscible copolymers were capable of 6-log inactivation of Staphylococcus aureus and Escherichia coli O157:H7 within 5 min of contact time.

N-halamine biocidal coatings via a layer-by-layer assembly technique

Two N-halamine copolymer precursors, poly(2,2,6,6-tetramethyl-4-piperidyl methacrylate-co-acrylic acid potassium salt) and poly(2,2,6,6-tetramethyl-4-piperidyl methacrylate-co-trimethyl-2-methacryloxyethylammonium chloride) have been synthesized and successfully coated onto cotton fabric via a layer-by-layer (LbL) assembly technique. A multilayer thin film was deposited onto the fiber surfaces by alternative exposure to polyelectrolyte solutions. The coating was rendered biocidal by a dilute household bleach treatment. The biocidal efficacies of tested swatches composed of treated fibers were evaluated against Staphylococcus aureus and Escherichia coli. It was determined that chlorinated samples inactivated both S. aureus and E. coli O157:H7 within 15 min of contact time, whereas the unchlorinated control samples did not exhibit significant biocidal activities. Stabilities of the coatings toward washing and ultraviolet light exposure have also been studied. It was found that the stability toward washing was superior, whereas the UVA light stability was moderate compared to previously studied N-halamine moieties. The layer-by-layer assembly technique can be used to attach N-halamine precursor polymers onto cellulose surfaces without using covalently bonding tethering groups which limit the structure designs. In addition, ionic precursors are very soluble in water, thus promising for biocidal coatings without the use of organic solvents.

A simple novel model to predict hospital mortality, surgical site infection, and pneumonia in elderly patients undergoing operation

BACKGROUND/AIMS

Predicting models of operative morbidity and mortality in the geriatric population are important in the prevention of adverse surgical outcomes.

METHODS

A retrospective review of medical records was performed for patients over 80 years of age who underwent gastrointestinal surgery from 1998 to 2008.

RESULTS

215 patients were identified with a mean age of 83.7 years. Overall morbidity and mortality rates were 48.8 and 14.4%, respectively. Multivariate logistic regression analysis revealed that serum albumin levels [odds ratio (OR) = 0.367, p = 0.0267], postoperative pneumonia (OR = 3.471, p = 0.0101), hollow organ perforation or anastomosis combined with leakage (OR = 7.600, p = 0.0126), and preoperative systemic inflammatory response syndrome (OR = 3.186, p = 0.0323) were significant predictors of hospital mortality. Moreover, albumin (OR = 0.270, p = 0.0002) and physical disability (OR = 3.802, p = 0.0009) were significant predictors of postoperative pneumonia, and albumin (OR = 0.491, p = 0.0212) and enterotomy (OR = 3.335, p = 0.0208) were significant predictors of surgical site infections.

CONCLUSION

This study provides novel predicting models to identify the elderly surgical patients at high risk, who should receive more intensive preventive and perioperative care.

Developmental silencing of human zeta-globin gene expression is mediated by the transcriptional repressor RREB1

The mammalian embryonic zeta-globin genes, including that of humans, are expressed at the early embryonic stage and then switched off during erythroid development. This autonomous silencing of the zeta-globin gene transcription is probably regulated by the cooperative work of various protein-DNA and protein-protein complexes formed at the zeta-globin promoter and its upstream enhancer (HS-40). We present data here indicating that a protein-binding motif, ZF2, contributes to the repression of the HS-40-regulated human zeta-promoter activity in erythroid cell lines and in transgenic mice. Combined site-directed mutagenesis and EMSA suggest that repression of the human zeta-globin promoter is mediated through binding of the zinc finger factor RREB1 to ZF2. This model is further supported by the observation that human zeta-globin gene transcription is elevated in the human erythroid K562 cell line or the primary erythroid culture upon RNA interference (RNAi)(2) knockdown of RREB1 expression. These data together suggest that RREB1 is a putative repressor for the silencing of the mammalian zeta-globin genes during erythroid development. Because zeta-globin is a powerful inhibitor of HbS polymerization, our experiments have provided a foundation for therapeutic up-regulation of zeta-globin gene expression in patients with severe hemoglobinopathies.

Suppression of n=1 tilt instability by magnetic shaping coils in Rotamak plasmas

Measurements from the array of Mirnov magnetic coils provide the first evidence for n=1 tilt and radial shift instabilities in a 40 ms field-reversed configuration (FRC) driven by rotating magnetic field. External plasma-shaping magnetic coils are utilized to suppress the n=1 instability modes. It is demonstrated that by energizing the middle shaping coil with 250-500 A current, the tilt mode is completely suppressed when a doublet FRC with an internal figure-of-eight separatrix is formed.

Dual thyroid ectopia with a normally located pretracheal thyroid gland: Case report and literature review

BACKGROUND

Only 1 case with dual thyroid ectopy and a normally located thyroid gland has been reported.

METHODS

We present the case of a 71-year-old woman who had 1-sided lateral neck swelling in the right submandibular space, which grew and doubled in size within 1 year. A CT scan demonstrated 2 right submandibular, lobulated, heterogeneously enhanced masses, an ectopic lingual thyroid, and bilateral thyroid goiter. A Tc-99m sodium pertechnetate thyroid scan revealed a cold area in the right lateral neck region below the submandibular gland, an ectopic lingual thyroid, and bilateral pretracheal thyroids. She underwent total thyroidectomy and en bloc excision of right neck masses. Thyroxin was prescribed following the surgery.

RESULTS

Pathological diagnoses were ectopic thyroid tissue with goitrous change and bilateral thyroid goiter.

CONCLUSION

This report demonstrates that dual ectopic thyroid tissue accompanying a normally located thyroid gland can exist and should be differentiated from head and neck malignancies.

Immune responses to foot-and-mouth disease virus in pig farms after the 1997 outbreak in Taiwan

This paper reports on a retrospective study of the antibody responses to structural and non-structural proteins of FMD virus O Taiwan 97 in six pig herds in Taiwan in the year after the 1997 Taiwanese FMD outbreak. All herds were vaccinated against FMD after the outbreak as part of the countrywide control program. Three of the herds had confirmed FMD infections (herds N, O and P) and three herds remained non-infected (herds K, L and M). The serum neutralizing antibody titers and the non-structural protein ELISA (NSP) antibody responses in sows and 1-month-old pigs in the infected herds were higher than in the non-infected herds, but over time a number of positive NSP reactors were detected. From the serological studies and the herd monitoring and investigations it was considered that the FMD NSP positive reactors may not have constituted a true reservoir of FMD virus infection especially in herds where susceptible pigs were no longer present post-exposure or post-vaccination. Pigs vaccinated with an unpurified FMD type O vaccines being used at that time also showed false positive responses for NSP antibodies.