Automation of etch pit analyses on solid-state nuclear track detectors with machine learning for laser-driven ion acceleration

Solid-state nuclear track detectors (SSNTDs) are often used as ion detectors in laser-driven ion acceleration experiments and are considered to be the most reliable ion diagnostics since they are sensitive only to ions and measure ions one by one. However, ion pit analyses require tremendous time and effort in chemical etching, microscope scanning, and ion pit identification by eyes. From a laser-driven ion acceleration experiment, there are typically millions of microscopic images, and it is practically impossible to analyze all of them by hand. This research aims to improve the efficiency and automation of SSNTD analyses for laser-driven ion acceleration. We use two sets of data obtained from calibration experiments with a conventional accelerator where ions with known nuclides and energies are generated and from actual laser experiments using SSNTDs. After chemical etching and scanning the SSNTDs with an optical microscope, we use machine learning to distinguish the ion etch pits from noises. From the results of the calibration experiment, we confirm highly accurate etch-pit detection with machine learning. We are also able to detect etch pits with machine learning from the laser-driven ion acceleration experiment, which is much noisier than calibration experiments. By using machine learning, we successfully identify ion etch pits ∼105 from more than 10 000 microscopic images with a precision of ≳95%. A million microscopic images can be examined with a recent entry-level computer within a day with high precision. Machine learning tremendously reduces the time consumption on ion etch pit analyses detected on SSNTDs.

Prediction of survival time after terminal extubation: the balance between critical care unit utilization and hospice medicine in the COVID-19 pandemic era

BACKGROUND

We established 1-h and 1-day survival models after terminal extubation to optimize ventilator use and achieve a balance between critical care for COVID-19 and hospice medicine.

METHODS

Data were obtained from patients with end-of-life status at terminal extubation from 2015 to 2020. The associations between APACHE II scores and parameters with survival time were analyzed. Parameters with a p-value ≤ 0.2 in univariate analysis were included in multivariate models. Cox proportional hazards regression analysis was used for the multivariate analysis of survival time at 1 h and 1 day.

RESULTS

Of the 140 enrolled patients, 76 (54.3%) died within 1 h and 35 (25%) survived beyond 24 h. No spontaneous breathing trial (SBT) within the past 24 h, minute ventilation (MV) ≥ 12 L/min, and APACHE II score ≥ 25 were associated with shorter survival in the 1 h regression model. Lower MV, SpO2 ≥ 96% and SBT were related to longer survival in the 1-day model. Hospice medications did not influence survival time.

CONCLUSION

An APACHE II score of ≥ 25 at 1 h and SpO2 ≥ 96% at 1 day were strong predictors of disposition of patients to intensivists. These factors can help to objectively tailor pathways for post-extubation transition and rapidly allocate intensive care unit resources without sacrificing the quality of palliative care in the era of COVID-19. Trial registration They study was retrospectively registered. IRB No.: 202101929B0.

Serial Increases in Human Leukocyte Antigen-DR Expression and Decreases in Interleukin-10 Expression in Alveolar Monocytes of Survivors of Pneumonia-Related Acute Respiratory Distress Syndrome

ARDS is a potentially lethal syndrome. HLA-DR expression in monocytes reflects their activation and antigen-presenting capacity. However, the correlation between clinical outcomes and HLA-DR expression in alveolar monocytes/macrophages in patients with pneumonia-related ARDS remains unclear. Thus, we determined the trends of HLA-DR and cytokine expressions in alveolar monocytes using repeated measurements to answer this question. Thirty-one pneumonia patients with respiratory failure and ARDS without coronavirus disease 2019 between November 2019 and November 2021 were enrolled in our intensive care unit and three without complete data were excluded. Interleukin (IL)-10, IL-12, and HLA-DR expression in bronchoalveolar lavage (BAL) monocytes were determined on days one and eight. Monocyte HLA-DR expression (mHLA-DR) and CD4 T lymphocytes percentages in BAL cells of survivors increased remarkably after seven days. Monocyte IL-10 expression and monocytes percentages in BAL cells of survivors decreased substantially after seven days. The mHLA-DR was negatively correlated with disease severity scores on day one and eight. In conclusion, serial increases in HLA-DR expression and decreases in IL-10 expression were observed in BAL monocytes of survivors of pneumonia-related ARDS. More studies are needed to confirm this point of view, and then development of a therapeutic agent restoring mHLA-DR and preventing IL-10 production can be considered.

Stress Hyperphenylalaninemia Is Associated With Mortality in Cardiac ICU: Clinical Factors, Genetic Variants, and Pteridines

OBJECTIVES

Hyperphenylalaninemia predicts poor outcomes in patients with cardiovascular disease. However, the prognostic value and factors associated with stress hyperphenylalaninemia (SHP) were unknown in critical patients in the cardiac ICU.

DESIGN

Prospective observational study.

SETTING

Single-center, cardiac ICU in Taiwan.

PATIENTS

Patients over 20 years old with Acute Physiology And Chronic Health Evaluation II scores greater than or equal to 15 and/or ventilatory support in the cardiac ICU.

INTERVENTIONS

We measured plasma phenylalanine levels serially during patients' stays in the ICU to investigate their prognostic value for 90-day mortality. Gene array was performed to identify genetic polymorphisms associated with SHP (phenylalanine level ≥ 11.2 μmol/dL) and to develop a Genetic Risk Score (GRS). We analyzed the associations between SHP and clinical factors and genetic variants and identified the correlation between pteridines and genetic variants.

MEASUREMENTS AND MAIN RESULTS

The study enrolled 497 patients. Increased phenylalanine concentration was independently associated with increased mortality risk. Patients with SHP had a higher mortality risk compared with those without SHP (log rank = 41.13; p < 0.001). SHP was associated with hepatic and renal dysfunction and with genetic polymorphisms on the pathway of tetrahydrobiopterin (BH4) synthesis (CBR1 and AKR1C3) and recycling (PCBD2). Higher GRSs were associated with lower BH4 bioavailability in response to stress ( p < 0.05). In patients without SHP at baseline, those with GRSs gretaer than or equal to 2 had a higher frequency of developing SHP during the ICU stay (31.5% vs 16.1%; p = 0.001) and a higher mortality risk ( p = 0.004) compared with those with GRSs less than 2. In patients with SHP at baseline, genetic variants did not provide additional prognostic value.

CONCLUSIONS

SHP in patients admitted to the ICU was associated with a worse prognosis. In patients without SHP, genetic polymorphisms associated with SHP measured using a GRS of greater than or equal to 2 was associated with the subsequent SHP and higher mortality risk.

Decreased Monocyte HLA-DR Expression in Patients with Sepsis and Acute Kidney Injury

Background and objectives: Acute kidney injury (AKI) is common in critically ill patients, especially those with sepsis. Persistently low human leukocyte antigen (HLA)-DR expression in monocytes reflects the decreased function of antigen-presenting cells, contributing to poor outcomes in sepsis. This study aimed to establish an association between AKI and HLA-DR expression in monocytes of patients with sepsis. Materials and Methods: We detected HLA-DR expression in monocytes and measured plasma levels of S100A12, high-mobility group box 1 (HMGB1), advanced glycation end products (AGE), and soluble receptor for AGE (sRAGE) from septic patients and healthy controls. Results: HLA-DR expression in monocytes was decreased in patients with AKI than in those without AKI (29.8 ± 5.0% vs. 53.1 ± 5.8%, p = 0.005). Compared with AKI patients, the mean monocyte HLA-DR expression in patients with end-stage renal disease was increased without statistical significance. There were no differences in the AGE/sRAGE ratio and plasma levels of S100A12, HMGB1, AGE, and sRAGE between patients with and without AKI. Conclusions: Compared with septic patients without AKI, patients with AKI had significantly lower HLA-DR expression in monocytes. The role of hemodialysis in monocyte HLA-DR expression needs further studies to explore.

Increased Production of Interleukin-10 and Tumor Necrosis Factor-Alpha in Stimulated Peripheral Blood Mononuclear Cells after Inhibition of S100A12

Sepsis may induce immunosuppression and result in death. S100A12 can bind to the receptor for advanced glycation end-products (RAGE) and Toll-like receptor (TLR)4 following induction of various inflammatory responses. It is unclear whether S100A12 significantly influences the immune system, which may be associated with sepsis-related mortality. We measured plasma S100A12 levels and cytokine responses (mean ± standard error mean) of lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs) after S100A12 inhibition in healthy controls and patients with sepsis on days one and seven. Day one plasma soluble RAGE (sRAGE) and S100A12 levels in patients with sepsis were significantly higher than those in controls (2481.3 ± 295.0 vs. 1273.0 ± 108.2 pg/mL, p < 0.001; 530.3 ± 18.2 vs. 310.1 ± 28.1 pg/mL, p < 0.001, respectively). Day seven plasma S100A12 levels in non-survivors were significantly higher than those in survivors (593.1 ± 12.7 vs. 499.3 ± 23.8 pg/mL, p = 0.002, respectively). In survivors, plasma sRAGE levels were significantly decreased after 6 days (2297.3 ± 320.3 vs. 1530.1 ± 219.1 pg/mL, p = 0.009, respectively), but not in non-survivors. Inhibiting S100A12 increased the production of tumor necrosis factor (TNF)-α and interleukin (IL)-10 in stimulated PBMCs for both controls and patients. Therefore, S100A12 plays an important role in sepsis pathogenesis. S100A12 may competitively bind to TLR4 and RAGE, resulting in decreased IL-10 and TNF-α production.

Reduction in Ventilation-Induced Diaphragmatic Mitochondrial Injury through Hypoxia-Inducible Factor 1α in a Murine Endotoxemia Model

Mechanical ventilation (MV) is essential for patients with sepsis-related respiratory failure but can cause ventilator-induced diaphragm dysfunction (VIDD), which involves diaphragmatic myofiber atrophy and contractile inactivity. Mitochondrial DNA, oxidative stress, mitochondrial dynamics, and biogenesis are associated with VIDD. Hypoxia-inducible factor 1α (HIF-1α) is crucial in the modulation of diaphragm immune responses. The mechanism through which HIF-1α and mitochondria affect sepsis-related diaphragm injury is unknown. We hypothesized that MV with or without endotoxin administration would aggravate diaphragmatic and mitochondrial injuries through HIF-1α. C57BL/6 mice, either wild-type or HIF-1α-deficient, were exposed to MV with or without endotoxemia for 8 h. MV with endotoxemia augmented VIDD and mitochondrial damage, which presented as increased oxidative loads, dynamin-related protein 1 level, mitochondrial DNA level, and the expressions of HIF-1α and light chain 3-II. Furthermore, disarrayed myofibrils; disorganized mitochondria; increased autophagosome numbers; and substantially decreased diaphragm contractility, electron transport chain activities, mitofusin 2, mitochondrial transcription factor A, peroxisome proliferator activated receptor-g coactivator-1α, and prolyl hydroxylase domain 2 were observed (p < 0.05). Endotoxin-stimulated VIDD and mitochondrial injuries were alleviated in HIF-1α-deficient mice (p < 0.05). Our data revealed that endotoxin aggravated MV-induced diaphragmatic dysfunction and mitochondrial damages, partially through the HIF-1α signaling pathway.

Effects of Curcuma longa L., Eucommia ulmoides Oliv. and Gynostemma pentaphyllum (Thunb.) Makino on Cytokine Production in Stimulated Peripheral Blood Mononuclear Cells in Patients with Tuberculosis

BACKGROUND

Tuberculosis (TB) infection triggers the innate and adaptive immune responses. Eucommia ulmoides Oliv., Gynostemma pentaphyllum (Thunb.) Makino, and Curcuma longa L. extracts exhibit various immunomodulatory effects.

OBJECTIVE

This study aimed to determine the effects of 3 extracts used in Traditional Chinese Medicine (TCM) on cytokine production in peripheral blood mononuclear cells (PBMCs) obtained from patients with TB.

DESIGN

The research team performed an in vitro study with self controls.

SETTING

The study took place at the Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Taiwan.

PARTICIPANTS

18 patients diagnosed with pulmonary TB were enrolled in the study.

INTERVENTION

Purified protein derivative (PPD)-stimulated PBMCs were cultured for 48 h in the presence and absence of 0.05 or 0.1 mg/mL of herbal extracts.

OUTCOME MEASURES

Cytokine levels of interferon (IFN)-γ, interleukin (IL)-10, IL-12, tumor necrosis factor (TNF)-α and transforming growth factor (TGF)-β1 in the culture supernatant were measured.

RESULTS

C longa L., E ulmoides Oliv. and G pentaphyllum (Thunb.) Makino extracts decreased IFN-γ production in PPD-stimulated PBMCs. C longa L. extract did not exhibit a marked and consistent effect on the production of IL-10, IL-12, TNF-α and TGF-β1. E ulmoides Oliv. extract increased the production of IL-10, TNF-α and TGF-β1. G pentaphyllum (Thunb.) Makino extract increased the production of IL-10, IL-12, TNF-α and TGF-β1.

CONCLUSION

These results show that G pentaphyllum (Thunb.) Makino might enhance cell immunity since it increased the production of IL-12 and TNF-α with dose effect.

The Determination of Efficacy of CircuCare on Blood Circulation and Metabolism: An Animal Model Study

OBJECTIVES

To determine whether feeding CircuCare to rats improves blood circulation, metabolism, immune regulation, endocrine activity, and oxidative stress.

METHODS

28 eight-week-old male Sprague-Dawley rats were evenly randomized into control and experimental groups. The control group was fed with ordinary drinking water, while the experimental group was fed with CircuCare at a daily dose of 93.75 mg per 300 g of body weight over eight weeks. Both groups were subjected to a swimming test, and blood samples were taken to observe any variations in various biochemical parameters before and after the test. Key Findings. The experimental group's mean swimming exhaustion duration was 53.2% longer and had a significantly higher lactic acid removal ratio. Their mean prostaglandin E2 level and mean glucose, cortisol, and glutathione level (30 minutes after swimming test) were also significantly higher. No undesirable impacts from CircuCare relating to general blood biochemistry values and bone mineral density were reported.

CONCLUSIONS

The present results show that CircuCare can be safely used to increase stamina and exercise capability, expedite the metabolism of lactic acid, accelerate muscle repair, and promote the antioxidant activity of cells in rats.

Emergency physicians' role in telemedicine care during the coronavirus disease pandemic: Experiences from Taiwan

Taiwan's response to the coronavirus disease pandemic received international recognition. Among various epidemic control measures, telemedicine services are provided for people under home quarantine. Although this service presents no policy, cost or equipment problems, the medical needs of people under home quarantine are diverse. Further, there are no clear guidelines regarding which specialists should be included in a multidisciplinary team. Moreover, many physicians are unwilling to participate in telemedicine, creating a big challenge for hospitals providing these services. Emergency physicians (EPs) have unique experiences in crisis management and can provide a number of effective public health measures. We advocate that EPs should be the first specialists to contact patients in a multidisciplinary team. Currently, there is a lack of literature on this subject, and Taiwan's epidemic control experience is used as an example to prove our viewpoint and provide recommendations for future EPs.

An Actinobacterial Isolate, Streptomyces sp. YX44, Produces Broad-Spectrum Antibiotics That Strongly Inhibit Staphylococcus aureus

The need for new antibiotics is increasing due to their overuse, and antibiotic resistance has become one of the major threats worldwide to public health, food safety, and clinical treatment. In this study, we describe an actinobacterial isolate, YX44, which belongs to the genus Streptomyces. This Streptomyces was isolated from a drinking pipe located in Osaka, Japan, and has the ability to inhibit Gram-positive bacteria, Gram-negative bacteria, and various fungi. YX44 fermentation broth shows strong activity against Escherichia coli and Staphylococcus aureus, as well as also inhibiting clinical isolates of multidrug-resistant Staphylococcus aureus. The YX44 antibacterial substances in the broth are relatively heat-stable, show high stability from the pH range 1 to 11, and have good solubility in both organic and non-organic solvents. Size-exclusion chromatography revealed that the YX44 antibacterial compounds are less than 1000 Da in size. LC-MS was able to identify three possible candidate molecules with molecular weights of 308, 365, 460, and 653 g/mol; none of these sizes correspond to any well-known antibiotics. Our results show that Streptomyces sp. YX44 seems to produce a number of novel antibiotics with high pH stability and good solubility that have significant activity against S. aureus, including multidrug-resistant strains.

Suppression of Hypoxia-Inducible Factor 1α by Low-Molecular-Weight Heparin Mitigates Ventilation-Induced Diaphragm Dysfunction in a Murine Endotoxemia Model

Mechanical ventilation (MV) is required to maintain life for patients with sepsis-related acute lung injury but can cause diaphragmatic myotrauma with muscle damage and weakness, known as ventilator-induced diaphragm dysfunction (VIDD). Hypoxia-inducible factor 1α (HIF-1α) plays a crucial role in inducing inflammation and apoptosis. Low-molecular-weight heparin (LMWH) was proven to have anti-inflammatory properties. However, HIF-1α and LMWH affect sepsis-related diaphragm injury has not been investigated. We hypothesized that LMWH would reduce endotoxin-augmented VIDD through HIF-1α. C57BL/6 mice, either wild-type or HIF-1α–deficient, were exposed to MV with or without endotoxemia for 8 h. Enoxaparin (4 mg/kg) was administered subcutaneously 30 min before MV. MV with endotoxemia aggravated VIDD, as demonstrated by increased interleukin-6 and macrophage inflammatory protein-2 levels, oxidative loads, and the expression of HIF-1α, calpain, caspase-3, atrogin-1, muscle ring finger-1, and microtubule-associated protein light chain 3-II. Disorganized myofibrils, disrupted mitochondria, increased numbers of autophagic and apoptotic mediators, substantial apoptosis of diaphragm muscle fibers, and decreased diaphragm function were also observed (p < 0.05). Endotoxin-exacerbated VIDD and myonuclear apoptosis were attenuated by pharmacologic inhibition by LMWH and in HIF-1α–deficient mice (p < 0.05). Our data indicate that enoxaparin reduces endotoxin-augmented MV-induced diaphragmatic injury, partially through HIF-1α pathway inhibition.

Elevated plasma phenylalanine predicts mortality in critical patients with heart failure

Aims

Previous studies found a relationship between elevated phenylalanine levels and poor cardiovascular outcomes. Potential strategies are available to manipulate phenylalanine metabolism. This study investigated whether increased phenylalanine predicted mortality in critical patients with either acute heart failure (HF) or acute on chronic HF, and its correlation with inflammation and immune cytokines.

Methods and results

This study recruited 152 subjects, including 115 patients with HF admitted for critical conditions and 37 normal controls. We measured left ventricular ejection fraction (LVEF), plasma concentrations of phenylalanine, C‐reactive protein, albumin, pre‐albumin, transferrin, and pro‐inflammatory and immune cytokines. Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and maximal vasoactive–inotropic scores (VIS_max) were calculated. Patients were followed up until death or a maximum of 1 year. The primary endpoint was all‐cause death. Of the 115 patients, 37 (32.2%) were admitted owing to acute HF, and 78 (67.8%) were admitted owing to acute on chronic HF; 64 (55.7%) had ST elevation/non‐ST elevation myocardial infarction. An LVEF measured during the hospitalization of <40%, 40–50%, and ≥50% was noted in 51 (44.3%), 15 (13.1%), and 49 (42.6%) patients, respectively. During 1 year follow‐up, 51 (44.3%) patients died. Death was associated with higher APACHE II, SOFA, and VIS_max scores; higher levels of C‐reactive protein and phenylalanine; higher incidence of atrial fibrillation and use of inotropic agents; lower cholesterol, albumin, pre‐albumin, and transferrin levels; and significant changes in pro‐inflammatory and immune cytokines. Phenylalanine levels demonstrated an area under the receiver operating characteristic curve of 0.80 for mortality, with an optimal cut‐off value set at 112 μM. Phenylalanine ≥ 112 μM was associated with a higher mortality rate than was phenylalanine < 112 μM (80.5% vs. 24.3%, P < 0.001) [hazard ratio = 5.07 (2.83–9.05), P < 0.001]. The Kaplan–Meier curves revealed that phenylalanine ≥ 112 μM was associated with a lower accumulative survival rate (log rank = 36.9, P < 0.001). Higher phenylalanine levels were correlated with higher APACHE II and SOFA scores, higher C‐reactive protein levels and incidence of using inotropic agents, and changes in cytokines suggestive of immunosuppression, but lower levels of pre‐albumin and transferrin. Further multivariable analysis showed that phenylalanine ≥ 112 μM predicted death over 1 year independently of age, APACHE II and SOFA scores, atrial fibrillation, C‐reactive protein, cholesterol, pre‐albumin, transferrin, and interleukin‐8 and interleukin‐10.

Conclusions

Elevated phenylalanine levels predicted mortality in critical patients, phenotypically predominantly presenting with HF, independently of traditional prognostic factors and cytokines associated with inflammation and immunity.

The association between higher driving pressure and higher mortality in patients with pneumonia without acute respiratory distress syndrome

PURPOSE

Recent studies reported that driving pressure has been associated with increased mortality in acute respiratory distress syndrome (ARDS) patients. We aimed to explore the association between 28-day mortality and driving pressure in patients with severe pneumonia without ARDS.

METHODS

In total, 207 non-ARDS patients with severe pneumonia were enrolled. Serial driving pressures were recorded daily for either 21 days or until ventilator support was no longer required. The relationships between all variables and 28-day mortality were analyzed using binary logistic regression analyses.

RESULTS

Non-survivors (56 patients) demonstrated high incidences of shock (55.4% vs. 24.5%, p < 0.001), acute renal failure (55.4% vs. 31.1%, p = 0.001), gastrointestinal bleeding (21.4% vs. 9.9%, p = 0.029), thrombocytopenia (53.6% vs. 23.2%, p < 0.001), jaundice (12.5% vs. 1.3%, p = 0.002), and driving pressure on Day 1 (19.9 ± 4.1 vs. 17.4 ± 4.5 cmH₂O, p = 0.001). The ratio of arterial partial pressure of oxygen to fraction of inspired oxygen was lower in non-survivors than in survivors (281.5 ± 139.3 vs. 376.2 ± 211.9, p = 0.002). Regression analysis revealed that driving pressure was an independent factor associated with 28-day mortality (odds ratio, 1.110; 95% confidence interval, 1.013-1.217).

CONCLUSION

Driving pressure was associated with 28-day mortality in patients with severe pneumonia without ARDS.

P3129Rheumatic heart diseases screening in Bornean Malaysia: a pilot echocardiography study

Background

Rheumatic heart disease is a major public health issue in developing countries including Malaysia. RHD is a preventable disease. Early detection and appropriate treatment may decrease the disease burden to the society. Rheumatic heart disease screening using portable echocardiography may improve early detection among school children in vulnerable community. This is a pilot study of rheumatic heart disease screening using Vscan among primary school students in the Bornean state of Sabah Malaysia.

Purpose

To evaluate the resources required for RHD screening, prevalence of RHD among school children and awareness among the parents and teachers.

Methods

A cohort of 211 students from a primary school were recruited in 2017–2018. Parental consents were obtained. Seven sessions were conducted at the school. Echocardiography was performed by 2–3 experienced ultrasonographers. Image interpretation as per the 2012 WHF RHD echocardiographic diagnostic criteria.

Results

Of the 211 students, 50% female, age range 7–12 year-old. Ethnic groups include Kadazandusun (87%), Rungus (2.4%), Lundayeh (2%), Chinese (2%). Overall, the average number of student scanned was 4.6 students/device/hour. There was a learning curve observed, whereby initial session only scanned 2 students/device/hour which improved to a maximum of 5.9 students/device/hour. Preliminary findings noted probable RHD among 36% (n=76) of screened subjects. Incidental diagnosis of congenital heart disease among 5 students. The suspected RHD cases were referred for formal echocardiography in the tertiary centre for confirmation. Thus far, 12 students were diagnosed with borderline RHD; the main diagnostic criteria in these cases were at least two morphological features of RHD of the MV without pathological MR or MS. Secondary prophylaxis with antibiotic, dental hygiene and patient education were given.

Conclusion

This is a pilot RHD screening using portable Vscan echocardiography among primary school students in Malaysia. Our study showed it is feasible to conduct RHD screening in the field using portable Vscan. The number of students screened improved with practice. Our preliminary finding suggest RHD is prevalent in this population in Sabah, Malaysia.

Amino Acid-Based Metabolic Indexes Identify Patients With Chronic Obstructive Pulmonary Disease And Further Discriminates Patients In Advanced BODE Stages

Background

The BODE index is a multidimensional grading system for predicting the prognoses of patients with chronic obstructive pulmonary disease (COPD). This study investigated whether an amino acids-based metabolic profile developed for heart failure patients (including histidine, ornithine, phenylalanine, and leucine) could identify COPD patients and further discriminates COPD patients in advanced BODE stages.

Methods

Ultra-performance liquid chromatography was performed on 119 participants, including 75 COPD patients at different BODE stages and 44 normal controls. Albumin, pre-albumin, transferrin, high sensitivity C-reactive protein, and hand grip strength were also measured. Receiver operating characteristic curves and area under curves were used for estimation.

Results

The BODE points in our patients were 3.29 [95% confidence interval (CI) = 2.74-3.85]. Compared to normal controls, COPD patients had lower leucine but higher ornithine levels. A COPD score, developed based on leucine and ornithine, significantly discriminated COPD from normal controls [odds ratio (OR) = 2.71, 95% CI = 1.83-4.04, p <0.001]. A COPD score of ≥ 3.00 had an OR of 15.58 (95% CI = 5.96-40.73, p <0.001). In COPD patients from BODE 1 to BODE 4, the levels of histidine, ornithine and phenylalanine increased significantly. In multivariable analysis, histidine and phenylalanine were independently able to distinguish BODE stages 3 and 4 from BODE 1 and were adopted to develop a metabolic score. Metabolic scores identified patients at BODE 3 and 4 (OR = 2.74, 95% CI =1.41-5.29, p = 0.003) better than hand grip strength, high sensitive C-reactive protein, albumin, pre-albumin, and transferrin value. A metabolic score of ≥9.53 significantly discriminated BODE 3 and 4 from BODE 1 and 2 (OR = 8.56, 95% CI = 2.77-26.39, p <0.001).

Conclusion

Amino acid-based COPD score and metabolic score discriminate COPD patients from normal controls, and identify patients in advanced stages of COPD.

Use of a Modified Fishbone Diagram to Analyze Diagnostic Errors in Emergency Physicians

Introduction

Reilly et al. described a structured approach to the analysis of diagnostic errors by using a novel modifi ed fi shbone diagram. The application of this tool in emergency medicine had not previously been reported. The objective of this study is to use the modified fishbone diagram analysis method in examining the causes of common diagnostic errors committed by emergency physicians and the circumstances associating errors in cognitive processes.

Methods

Sixty-one cases of diagnostic errors involving ten board-certified emergency physicians (EPs) were identifi ed through a peer review process. Using a qualitative study approach, in-depth semi structured interviews with EPs was conducted. All interview audiotapes were transcribed verbatim. Content analysis was performed on all textual data to identify the factors underlying errors using the modified fishbone diagram.

Results

In 61 cases, 165 diagnostic errors were identified (2.7 per case). The underlying contributions to errors fell into 7 categories: cognitive process (54/61, 89%), specific presentation (32/61, 52%), clinical data gathering (24/61, 39%), organization issues (12/61, 20%), affective factors (9/61, 15%), context of care (9/61, 15%), and communication (5/61, 8%). Of these cognitive errors were the most common. However, only six cases occurred in isolation (6/54, 11%), with the remaining 48 cases (48/54, 89%) occurring with other types of errors, the most common being specific presentation (28/54, 52%) and clinical data gathering (24/54, 44%).

Conclusions

The modified fishbone diagram is a useful tool to identify various categories of errors on diagnostic process in emergency department (ED). These fi ndings provide a basis on which to build a framework for teaching EPs how to avoid misdiagnoses in the ED setting.

Mortality of severe septic patients between physician's high and low care volumes

BACKGROUND

Patients with severe sepsis frequently require intensive care unit (ICU) admission and different ICU care models may influence their outcomes. The mortality of severe septic patients between physician's high and low care volume remains unclear.

METHODS

We analyzed the data from a three-year prospective observation study, which was performed in an adult medical ICU of Chung Gung Memorial Hospital, Keelung. The data included initial bundle therapies based on the Surviving Sepsis Campaign (SSC) guidelines for patients with severe sepsis.

RESULTS

Clinical data of total 484 patients with severe sepsis were recorded. Cox regression model showed that physician's care volume was an independent factor for lowering mortality in ICU patients with severe sepsis (hazard ratio 0.708; 95% confidence interval 0.514-0.974; p = 0.034). Patients treated by high care volume physician had four out of nine bundle therapies that were significantly higher in percentage following the SSC guidelines. These four therapies were renal replacement therapy, administration of low-dose steroids for septic shock, prophylaxis of gastro-intestinal bleeding, and control of hyperglycemia.

CONCLUSION

High care volume physician may decrease mortality in ICU patients with severe sepsis through fitting bundle therapies for sepsis.

High Interleukin-10 Expression in Type 2 T Helper Cells in Septic Patients

Interleukin (IL)-10 response is associated with mortality in patients with sepsis. IL-10 is primarily produced by monocytes and type 2 T helper (Th2) cells. The aim of this study was to investigate differences in IL-10 production between monocytes and Th2 cells in patients with sepsis. Forty patients with sepsis and 35 healthy controls were enrolled. Cytokine expressions in peripheral blood mononuclear cells (PBMCs) were measured by flow cytometry. The IL-10 expression in the Th2 cells of the septic patients was higher than in the healthy controls, but the expression of IL-10 in the monocytes of the septic patients was lower than in the healthy controls. After regression analysis, IL-10 expression in Th2 cells was positively associated with sepsis, but IL-10 expression in monocytes was not associated with sepsis or shock. In conclusion, the production of IL-10 in Th2 cells was higher in the patients with sepsis.

Effect of preceding medications on resuscitation outcome of out-of-hospital cardiac arrest

As evidence regarding the impact of preceding medications on resuscitation outcomes has been inconsistent, this study aimed to analyze the association between preceding medications and resuscitation outcomes in patients experiencing out-of-hospital cardiac arrest (OHCA). This retrospective study included patients with OHCA presenting to a tertiary care hospital by emergency medical service (EMS) between January 2006 and June 2011. Using the Utstein template, data were collected from EMS and hospital medical records for prehospital care, in-hospital care, and medications which were taken continuously for at least 2 weeks preceding OHCA. Primary outcome was the proportion of patients with a survived event. Multivariable logistic regression analyses were performed to evaluate the predictors of survived events. Among the 1381 included patients with OHCA, 552 (40.0%) patients achieved sustained return of spontaneous circulation and 463 (33.5%) patients survived after resuscitation, 96 (7.0%) patients survived until discharge, and 20 (1.4%) patients had a favorable neurological outcome at discharge. The multivariable analyses revealed that use of statins preceding OHCA was independently associated with a greater probability of a survived events (OR=2.09, 95% CI 1.08 to 4.03, p=0.028).Use of digoxin was adversely associated with survived events (OR=0.39, 95% CI 0.16 to 0.90, p=0.028) in patients with OHCA. The continuous use of statins preceding OHCA was positively associated with survived events, while use of digoxin was adversely related. It deserves more attention on medications preceding OHCA because of their potential effect on resuscitation outcomes.

Radiofrequency ablation compared with laparoscopic adrenalectomy for aldosterone-producing adenoma

BACKGROUND

Radiofrequency ablation (RFA) is an emerging treatment for primary aldosteronism owing to aldosterone-producing adenoma. Whether RFA could be an alternative treatment to laparoscopic adrenalectomy is unknown.

METHODS

This was a retrospective comparative study in patients with aldosterone-producing adenoma undergoing either laparoscopic adrenalectomy or CT-guided percutaneous RFA between 2004 and 2012. Short-term outcomes and long-term resolution rates of primary aldosteronism (normalized aldosterone to renin ratio), hypokalaemia and hypertension (BP lower than 140/90 mmHg without antihypertensive medical therapy) were evaluated.

RESULTS

Some 63 patients were included, 27 in the laparoscopic adrenalectomy group and 36 in the RFA group. RFA was associated with shorter duration of operation (median 12 versus 124 min; P < 0·001), shorter hospital stay (2 versus 4 days; P < 0·001), lower analgesic requirements (13 of 36 versus 23 of 27 patients; P < 0·001) and earlier resumption of work (median 4 versus 14 days; P = 0·006). Morbidity rates were similar in the two groups. With median follow-up of 5·7 (range 1·9-10·6) years, resolution of primary aldosteronism was seen in 33 of 36 patients treated with RFA and all 27 patients who had laparoscopic adrenalectomy (P = 0·180). Hypertension was resolved less frequently after treatment with RFA compared with laparoscopic adrenalectomy (13 of 36 versus 19 of 27 patients; P = 0·007). Hypokalaemia was resolved in all patients.

CONCLUSION

For patients with aldosterone-producing adenoma the efficacy of resolution of primary aldosteronism and hypertension was inferior after treatment with RFA compared with laparoscopic adrenalectomy.

Clinical outcomes after spontaneous and nucleos(t)ide analogue-treated HBsAg seroclearance in chronic HBV infection

BACKGROUND

Both spontaneous and nucleos(t)ide analogue (Nuc)-treated hepatitis B surface antigen (HBsAg) seroclearance are associated with excellent clinical outcomes.

AIM

To conduct a case-control study to explore whether there is difference of clinical outcomes between these two groups.

METHODS

A total of 312 chronic hepatitis B patients with spontaneous HBsAg seroclearance and 110 patients with Nuc-treated HBsAg seroclearance were recruited retrospectively. Propensity score (PS) matching method produced 98 patients in each group for comparison. The development of hepatocellular carcinoma (HCC), hepatic complications and cumulative incidence of antibody to HBsAg (anti-HBs) was compared.

RESULTS

During a mean follow-up period of 107 months after HBsAg seroclearance, five patients developed HCC after a mean period of 75.3 months (four and one patients with spontaneous and Nuc-treated HBsAg seroclearance, respectively) in overall population. One died of pneumonia with sepsis and one experienced variceal bleeding in Nuc-treated patients but none in spontaneous group. The incidence of anti-HBs seroconversion was comparable between spontaneous and Nuc-treated HBsAg seroclearance (69.6% vs. 66.4%, respectively, P = 0.617). There were no significant differences in HCC development (2% vs. 1.1%), overall mortality (0% vs. 1%), variceal bleeding (0% vs. 4.2%) and 6-year cumulative incidence of anti-HBs seroconversion (62.3% vs. 61.5%) among PS-matched patients with spontaneous and Nuc-treated HBsAg seroclearance.

CONCLUSIONS

The clinical outcomes between patients with spontaneous and Nuc-treated HBsAg seroclearance are comparable. HCC can develop at a low rate during long-term follow-up and periodic surveillance after HBsAg seroclearance is still mandatory.

Glucose increases interleukin-12 gene expression and production in stimulated peripheral blood mononuclear cells of type 2 diabetes patients

BACKGROUND

Lipopolysaccharide (LPS)-stimulated peripheral blood mononuclear cells (PBMCs) of type 2 diabetes patients produce more interleukin (IL)-12 under glucose treatment. The aim of this study was to determine whether increased IL-12 response in hyperglycemic LPS-stimulated PBMCs is due to increased gene expression or osmolarity.

METHODS

LPS-stimulated PBMCs of 13 type 2 diabetes patients and 8 healthy controls were used for culture in the presence or absence of glucose or mannitol for 24 h. The IL-12 gene expressions of PBMCs and IL-12 protein levels in supernatants were evaluated.

RESULTS

After 24 h, the stimulated PBMCs of diabetes patients expressed more IL-12 mRNA and produced more IL-12 protein following glucose treatment than those without glucose treatment and with mannitol treatment. Stimulated PBMCs of controls did not express more IL-12 mRNA and produce more IL-12 protein following glucose treatment than those without glucose treatment and with mannitol treatment.

CONCLUSIONS

Glucose increases the IL-12 production in stimulated PBMCs of diabetes patients through increased IL-12 gene expression.

Discotic liquid crystals as novel corrosion-resistant coatings

A discotic liquid crystal (DLC), HBC-C12, coating was successfully applied to improve the corrosion resistance of an iron surface.

Hybrid Antegrade Thoracic Aortic Stenting via a Temporary Ascending Aortic Graft Conduit for a Patient with Poor Peripheral Vascular Access

In patients with poor peripheral vascular access, thoracic aortic stenting procedures can be technically very challenging. Antegrade aortic stent deployments during concomitant open ascending and arch procedures are well described, but the issue of long endovascular catheters and wires may make such an approach difficult and awkward. We describe a novel hybrid method involving a temporary graft conduit to the ascending aorta which is brought caudal toward the foot of the table to facilitate antegrade deployment of the thoracic stent graft.

A phase I study of temsirolimus as novel therapeutic drug for patients with unresectable hepatocellular carcinoma (HCC)

e15048

Background: The oncogenic PI3K/Akt/mTOR pathway is frequently activated in hepatocellular carcinoma (HCC). Preliminary studies on mTOR inhibitors such as temsirolimus show promising results but there is limited data on the dose limiting toxicities (DLTs) in chronic liver disease, a co-morbidities commonly occurring in HCC pts. This phase I study aims to determine DLTs and maximum tolerated dose (MTD) of temsirolimus in advanced HCC. Methods: Patient (Pt) eligibilitie criteria include unresectable disease, ECOG <= 2, adequate organ functions. Temsirolimus was given i.v. in 250ml NS over 30 min on day 1, 8, and 15 every 3 weeks; dose levels were: 20 (level I), 25 (level II) and 30 mg (level III). DLTs are defined as grade 4 hematological toxicity or grade 3/4 non-haematological toxicity during cycle 1 (according to NCI CTC v3), or treatment delay >2 weeks. The MTD is defined as the dose below which > 2 of 3 or > 2 of 6 patients experiencing DLT. After determination of the MTD, additional pts to make up to 10 patients were treated at this dose to further define toxicity. The study has been registered in ClinicalTrials.gov (NCT00321594). Results: 19 pts were entered; level I (n=3), level II (n=10), and level III (n=6). 2 of the 6 pts in level 3 developed DLT; 1 developed grade 3 syncope and 1 had treatment delay for >2 weeks due to prolonged neutropenia. In cycle 1, grade 3/4/5 toxicities included: raised ALP 2/0/0, oral mucositis 2/0/0, neutropenia 1/0/0, syncope 1/0/0, dehydration 1/0/0 and dysphagia 1/0/0. A total of 77 cycles were administered; overall grade 3/4/5 toxicities: raised ALT 2/0/0, raised ALP 2/0/0, raised bilirubin 2/0/0, cough 1/0/0, dehydration 1/0/0, dysphagia 1/0/0, dyspnea 1/0/0, abdominal distension 1/0/0, anemia 1/0/0, hemorrhoids 1/0/0, hyperglycemia 1/0/0, hypokalemia 2/0/0, hyponatremia 1/0/0, infection 5/0/0 (1 dental, 2 pulmonary, upper airway 2), oral mucositis 2/0/0, neutropenia 1/0/0, thrombocytopenia 2/0/0, pleural effusion 1/0/0, pneumonitis 1/0/0, syncope 1/0/0. Clinical benefit rate (PR, CR or SD ≥12 weeks) was 36.8% (7 of 19 pts had confirmed SD). Conclusions: At the MTD of 25 mg weekly every 3 weeks, temsirolimus is well tolerated with no DLTs. Clinical trial information: NCT00321594.

The impact of image-guided radiotherapy (IGRT) for prostate cancer (PC) on radiotherapy (RT)-related acute toxicities and prostate-specific antigen (PSA) kinetics

e15110

Background: IGRT for PC could potentially improve the therapeutic ratio by enhancing accuracy of delivery of radiation to the prostate gland. Our aim is to compare the treatment outcomes in terms of RT-related acute toxicities and PSA kinetics of PC patients (pts) undergoing radical intensity-modulated radiotherapy (IMRT) with or without image-guidance. Methods: A cohort of 21 consecutive pts treated by IGRT (I) from January 2010, when the IGRT system was introduced in our institution, was compared with an immediately precedent cohort of 21 pts receiving IMRT without image-guidance (Non-I). The prescription dose (76Gy in 38 fractions) and the treatment margins were the same between the 2 groups (gps). In the I gp, daily online verification and correction of treatment position was performed with reference to image registration of the daily pre-treatment on-board imaging with the corresponding digitally reconstructed radiographs, based on three-dimensional matching of three intra-prostatic fiducial markers. Androgen deprivation therapy was not used in both gps. Acute toxicities were scored weekly during the course of RT according to the Common Terminology Criteria for Adverse Events Version 4.02. The pre- and the post-RT PSA within 6 months after completion of RT were obtained. The PSA halving time (PSAHT) was calculated by first order kinetics. Results: There was no statistically significant difference regarding the baseline clinical characteristics (age, PSA at diagnosis, Gleason score, T staging) between the gps. No grade 3 or 4 acute genitourinary (GU) or gastrointestinal (GI) toxicities was encountered in either gps. Acute grade 1 or 2 GI toxicities were significantly less frequent in the I gp (23.8% vs 81.0%, p=0.001), and their median duration of such toxicity were also significantly shorter (0.33 week vs 1.38 week, p=0.004).The frequencies of acute grade 1 or 2 GU toxicities were comparable between both gps (66.6% vs 81.0%, p=0.45).The I gp had a shorter median PSAHT than the non-I gp (3.36 week vs 5.49 week, p=0.09). Conclusions: IGRT is effective in reducing acute GI toxicities in treatment of PC, and may have more favorable PSA kinetics.

Prognostic value of adenosine stress myocardial perfusion by cardiac magnetic resonance imaging in patients with known or suspected coronary artery disease

BACKGROUND

Cardiac magnetic resonance imaging (CMR) has been intensely researched in recent years, and its high diagnostic accuracy for myocardial ischemia has been demonstrated. However, its prognostic information is very limited.

AIM

We sought to assess the value of adenosine stress myocardial perfusion by CMR in predicting cardiac events in patients with known or suspected coronary artery disease (CAD).

DESIGN

Retrospective study.

METHODS

From January 2003 to December 2008, we retrospectively reviewed consecutive patients with or without history of CAD referred for evaluation of suspected myocardial ischemia who had undergone adenosine stress CMR in our hospital. End points were cardiac death or non-fatal myocardial infarction (MI).

RESULTS

After a mean follow-up of 3.2 ± 1.6 years in 203 patients, 15 (7.4%) cardiac events occurred. The 4-year event-free survival was 96.2% for patients with normal stress CMR perfusion and 71.5% for those with abnormal stress CMR perfusion. Univariate analysis showed that both adenosine-induced reversible perfusion defect and delayed gadolinium enhancement by CMR were significant predictors of cardiac events [Hazard ratio (HR) 9.31; 95% Confidence Interval (95% CI) 3.18-27.3; and HR 9.24; 95% CI 3.27-26.08; P < 0.001, respectively). By multivariate analysis, adenosine-induced reversible perfusion defect remained an independent predictor of cardiac events (HR 7.77; 95% CI 2.50-24.18; P < 0.001). In a stepwise multivariate model (Cox regression), an abnormal stress CMR perfusion result had significant incremental predictive value over clinical risk factors and resting regional wall motion abnormality (RWMA) (P < 0.001).

CONCLUSION

In patients with known or suspected CAD, adenosine stress CMR could be used to identify patients at high risk for subsequent cardiac death or nonfatal MI. A normal CMR perfusion was associated with a very low long-term event rate and excellent long-term prognosis. In addition, stress CMR perfusion provided important incremental prognostic information over clinical risk factors and RWMA.

Appropriate liver resection type for patients with the American joint committee on cancer classification T1 and T2 hepatocellular carcinoma

SYNOPSIS

Major liver resection prevents intrahepatic tumor recurrence in T2 hepatocellular carcinoma patients with microvascular invasion or daughter nodules.

BACKGROUND AND OBJECTIVES

There is no consensus on whether major or minor hepatectomy is better for hepatocellular carcinoma (HCC) patients. We investigated the outcomes of liver resection type in resectable HCC patients.

METHODS

Two hundred sixty-three HCC patients with Child-Pugh class A liver function who underwent curative hepatectomy were enrolled. Among them, 186 patients had pathologic stage T1 HCC and 77 had stage T2 HCC. Patients were also classed according to the type of resection (major or minor). Clinicopathologic characteristics and outcomes were compared.

RESULTS

Patients with T1 HCC who underwent major resection had a higher rate of blood transfusion than those who underwent minor resection (P < 0.001). The disease-free survival rate of T2 patients who underwent major resection was better than that of patients who underwent minor resection (P = 0.004). The overall survival rates of T1 and T2 HCC patients did not differ significantly between those with major or minor resection.

CONCLUSIONS

Major liver resection is recommended for T2 HCC patients with adequate remnant liver function because it results in a better disease-free survival rate than does minor resection in these patients. Minor liver resection is suggested for T1 HCC patients, except for those with a tumor sitting close to vessels, because it is associated with a low incidence of blood transfusion and a good survival rate.

Clinical presentations and imaging findings of neuroblastoma beyond abdominal mass and a review of imaging algorithm

Neuroblastoma is one of the most common malignant neoplasms in childhood. The most common clinical presentation of this tumour is abdominal mass. However, affected children may have various clinical presentations as a result of disseminated metastatic disease or associated paraneoplastic syndromes at the time of diagnosis. In this article we have outlined the imaging findings in seven patients with "extra-abdominal" presentation of neuroblastoma and the pitfalls in making the correct diagnosis. The purpose of this pictorial review is to alert the general radiologist to the possible presentations of this common childhood malignancy to derive early detection and diagnosis.

Prevalence of allergic rhinitis and its associated morbidity in adults with asthma: a multicentre study

OBJECTIVES

To assess the prevalence of allergic rhinitis in adult patients with asthma in Hong Kong, and to compare the morbidity endured by asthma patients with and without allergic rhinitis.

DESIGN

Cross-sectional study.

SETTING

Respiratory clinics of four major public hospitals in Hong Kong.

PATIENTS

A total of 600 adults with asthma were recruited from March to May 2007.

MAIN OUTCOME MEASURES

Doctors and patients completed separate questionnaires evaluating symptoms, treatment, and health care utilisation. Spirometry data were obtained for a subgroup of patients at the time of survey completion.

RESULTS

The patients consisted of 267 males and 333 females, with 251 having spirometry data. The mean pre-bronchodilator 1-second forced expiratory volume predicted among those who had spirometry performed was 88% (standard deviation, 28%). In all, 50% of the patients had intermittent and 50% had persistent asthma. Over three quarters (463/600; 77%) of patients had experienced allergic rhinitis symptoms in the past 12 months, of whom 96% had a previous diagnosis of allergic rhinitis. Asthmatics without allergic rhinitis symptoms had higher rates of visits to doctors, pharmacy visits, emergency department attendances, and hospitalisations for asthma than those with both conditions. Among subjects with asthma and allergic rhinitis, those taking nasal steroid (226/463; 49%) had lower rates of emergency department visits (13 vs 25%, P=0.002) and hospitalisations (7 vs 13%, P=0.045) for asthma than those who were not.

CONCLUSION

Allergic rhinitis is a common co-morbid condition of asthma in this hospital clinic cohort. Treatment of allergic rhinitis with intra-nasal steroid was associated with less health care utilisation for asthma.

Functional haplotypes in the promoter region of transcription factor Nrf2 in chronic obstructive pulmonary disease

Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) protects against oxidative stress which is important in the pathogenesis of chronic obstructive pulmonary disease (COPD). Three single nucleotide polymorphisms and 1 triplet repeat polymorphism are found in the promoter region of the Nrf2 gene. Molecular haplotyping of the Nrf2 promoter region was performed using DNA obtained from the peripheral blood of 69 COPD patients. The luciferase activities of Nrf2 promoter constructs containing all possible combinations of the 4 polymorphisms were determined and found to differ among the 16 haplotypes.The haplotypes isolated from the subjects were divided into 3 groups (L: low; M: medium; H: high) on the basis of luciferase activities. The proportions of subjects belonging to global initiative for chronic obstructive lung disease stage 3 or 4 decreased from the group with the LL haplotype to that with the HH haplotype. Presence of the LH or MM haplotype (hazard ratio, 3.36; 95% confidence interval, 1.16-9.69), gender (0.13; 0.02-0.67), and post-bronchodilator FEV1 value of predicted (0.95; 0.91-0.99) are significant predictors of respiratory failure development.The haplotype of the Nrf2 gene promoter affects its activity, and is associated with the severity and the development of respiratory failure in COPD.

The first novel influenza A (H1N1) fatality despite antiviral treatment and extracorporeal membrane oxygenation in Hong Kong

We report the first fatality caused by novel influenza A (H1N1) infection despite having the diagnosis confirmed and being given antiviral treatment after hospitalisation. This patient was also the first with influenza A (H1N1) to be supported with extracorporeal membrane oxygenation in Hong Kong. Although extracorporeal membrane oxygenation is an effective means of supporting patients with refractory hypoxaemia on high mechanical ventilatory support, it is labour-intensive and technically demanding. We also discuss the challenges faced when managing this case.

Differential mRNA expression of Toll-like receptors and their adaptors in pleural effusions

BACKGROUND AND OBJECTIVE

Binding of Toll-like receptors (TLRs) to microbial or endogenous ligands activates and triggers the associated signalling pathway, which leads to the production of inflammatory cytokines and type I interferons. The extent of TLR pathway activation may vary with the ligands present in different pleural diseases.

METHODS

The relative mRNA expression levels of TLRs and their adaptors in pleural fluid were determined by PCR and gel electrophoresis in 36 transudative, 25 infectious and 39 malignant pleural effusions.

RESULTS

The relative mRNA expression levels of TLR8 and myeloid differentiation factor 88 were low in infectious effusions and that of ras-related C3 botulinum toxin substrate 1 was low in malignant pleural effusions. Different cellular components correlated significantly with the relative mRNA expression of TLRs or their adaptors in pleural effusions with different aetiologies.

CONCLUSIONS

The relative mRNA expression profiles of TLRs and their adaptors in pleural fluid differ among transudative, infectious and malignant pleural effusions.

Role of polymorphisms of the inflammatory response genes and DC-SIGNR in genetic susceptibility to SARS and other infections

1. A genetic risk-association study involving more than 1200 subjects showed individuals homozygous for L-SIGN tandem repeats are less susceptible to SARS infection. 2. This was supported by in vitro binding studies that demonstrated homozygous L-SIGN, compared to heterozygous, had higher binding capacity for SARS coronavirus (SARS-CoV), with higher proteasome-dependent viral degradation. In contrast, homozygous L-SIGN demonstrated lower binding capacity for HIV1-gp120.3. Genetic-association studies for single nucleotide polymorphisms of the inflammatory response genes, namely TNF-alpha, INF-alpha, INF-beta, INF-gamma, IL1-alpha, IL1-beta, IL-4, IL-6 and iNOS, failed to show a significant association with SARS clinical outcomes or susceptibility.

Polymorphisms and functional activity in superoxide dismutase and catalase genes in smokers with COPD

Increased oxidative stress has been implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). This study investigated the risk of COPD and the substitution of alanine 16 with valine (Ala16Val) polymorphism of manganese-superoxide dismutase (Mn-SOD) and the cytosine to thymidine transition of nucleotide -262 (-262C>T) polymorphism of the catalase gene, and the activity of erythrocyte SOD and catalase. The subjects were stable COPD patient ever smokers (n = 165) and healthy controls, matched for age and cigarette consumption. Genotyping of Mn-SOD at Ala16Val and the catalase gene at -262C>T was performed, and the functional activity of SOD and catalase in erythrocytes determined. There were no significant differences in the distribution of the different genotypes or allele frequencies between patients and controls for both the Mn-SOD and catalase genes. Among healthy controls or COPD patients, no differences were observed in erythrocyte SOD and catalase activity, irrespective of genotype. Significantly higher erythrocyte catalase activity was found in COPD patients than in healthy controls. The T/T catalase genotype and Ala/Ala Mn-SOD genotype were uncommon in the present Chinese population. The increase in erythrocyte catalase activity in Chinese patients with chronic obstructive pulmonary disease probably indicates dysfunction of the oxidant/antioxidant defence system, but it is unclear whether this increase is compensatory or a pathogenic factor.

Complicated parapneumonic effusion and empyema thoracis: microbiology and predictors of adverse outcomes

OBJECTIVES

To describe the microbiological characteristics of a cohort of patients with complicated parapneumonic effusion and empyema thoracis, and to identify the potential risk factors for adverse outcomes, with particular reference to the choice of empirical antibiotics, intrapleural fibrinolytics, adherence to management guidelines, and input from pulmonologists.

DESIGN

Retrospective review.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients with a diagnosis of complicated parapneumonic effusion/empyema thoracis admitted between January 2003 and June 2005.

MAIN OUTCOME MEASURES

Microbiological characteristics, mortality, and surgery-free survival. RESULTS. There were 63 patients, with a mean age of 64 (standard deviation, 16) years and a male-to-female ratio of 45:18. The pleural fluid culture positivity rate was 68%; Streptococcus milleri (19%), Bacteroides (14%), Klebsiella pneumoniae (12%), and Peptostreptococcus (7%) were the most common organisms. Thirteen (21%) patients died during their index admission. Use of intrapleural fibrinolytics according to the guideline was associated with survival (P=0.001) while discordant initial antibiotic use was associated with mortality (P=0.002). Discordant initial antibiotic use was also independently associated with reduced surgery-free survival (P<0.001). Subgroup analysis showed that early intrapleural fibrinolytic use (within 4 days of diagnosis) was associated with decreased mortality (P<0.001), increased surgery-free survival (P=0.005), and shorter hospital stay (P=0.039).

CONCLUSION

Organisms identified from complicated parapneumonic effusion and empyema thoracis differ from those giving rise to community-acquired pneumonia. In these patients, adherence to guidelines, early concordant antibiotic treatment, intrapleural fibrinolytics, and input from a pulmonologist were associated with improved outcomes.

Comparison of clinical staging systems in predicting survival of hepatocellular carcinoma patients receiving major or minor hepatectomy

AIM

To compare the utility of seven commonly used staging systems in the prediction of survival among patients with hepatocellular carcinoma (HCC) undergoing major or minor hepatectomy.

METHODS

All patients were classified by the Okuda, the TNM, the CLIP, the BCLC, the CUPI, the JIS and the MELD classifications to estimate the probabilities of survival. Survival curves were calculated using the Kaplan-Meier method and were examined using log-rank testing. The overall predictive power for patient survival with each staging system was evaluated using linear trend chi(2) tests and from the area under the receiver operating characteristic (ROC) curve.

RESULTS

In our patient cohort, the log-rank test and the linear trend chi(2) test of the CLIP and JIS systems gave better results than did the other staging systems. The discriminatory ability of the CLIP and JIS staging for death, evaluated by ROC curve areas, was also better. In the subgroups of major hepatectomy patients with a non-cirrhotic liver or minor hepatectomy patients with a cirrhotic liver, the CLIP and JIS systems showed similar better performances in these three tests. The discriminatory ability of the CLIP system was the best in major hepatectomy patients with a non-cirrhotic liver while JIS score discriminated best in minor hepatectomy patients with a cirrhotic liver.

CONCLUSION

Among the seven staging systems, the CLIP and JIS systems perform better than do the others. While the CLIP system should be considered to stage major hepatectomy patients, the JIS system could be chosen to stage minor hepatectomy patients.