Why do users override alerts? Utilizing large language model to summarize comments and optimize clinical decision support

OBJECTIVES

To evaluate the capability of using generative artificial intelligence (AI) in summarizing alert comments and to determine if the AI-generated summary could be used to improve clinical decision support (CDS) alerts.

MATERIALS AND METHODS

We extracted user comments to alerts generated from September 1, 2022 to September 1, 2023 at Vanderbilt University Medical Center. For a subset of 8 alerts, comment summaries were generated independently by 2 physicians and then separately by GPT-4. We surveyed 5 CDS experts to rate the human-generated and AI-generated summaries on a scale from 1 (strongly disagree) to 5 (strongly agree) for the 4 metrics: clarity, completeness, accuracy, and usefulness.

RESULTS

Five CDS experts participated in the survey. A total of 16 human-generated summaries and 8 AI-generated summaries were assessed. Among the top 8 rated summaries, five were generated by GPT-4. AI-generated summaries demonstrated high levels of clarity, accuracy, and usefulness, similar to the human-generated summaries. Moreover, AI-generated summaries exhibited significantly higher completeness and usefulness compared to the human-generated summaries (AI: 3.4 ± 1.2, human: 2.7 ± 1.2, P = .001).

CONCLUSION

End-user comments provide clinicians' immediate feedback to CDS alerts and can serve as a direct and valuable data resource for improving CDS delivery. Traditionally, these comments may not be considered in the CDS review process due to their unstructured nature, large volume, and the presence of redundant or irrelevant content. Our study demonstrates that GPT-4 is capable of distilling these comments into summaries characterized by high clarity, accuracy, and completeness. AI-generated summaries are equivalent and potentially better than human-generated summaries. These AI-generated summaries could provide CDS experts with a novel means of reviewing user comments to rapidly optimize CDS alerts both online and offline.

Leveraging large language models for generating responses to patient messages-a subjective analysis

OBJECTIVE

This study aimed to develop and assess the performance of fine-tuned large language models for generating responses to patient messages sent via an electronic health record patient portal.

MATERIALS AND METHODS

Utilizing a dataset of messages and responses extracted from the patient portal at a large academic medical center, we developed a model (CLAIR-Short) based on a pre-trained large language model (LLaMA-65B). In addition, we used the OpenAI API to update physician responses from an open-source dataset into a format with informative paragraphs that offered patient education while emphasizing empathy and professionalism. By combining with this dataset, we further fine-tuned our model (CLAIR-Long). To evaluate fine-tuned models, we used 10 representative patient portal questions in primary care to generate responses. We asked primary care physicians to review generated responses from our models and ChatGPT and rated them for empathy, responsiveness, accuracy, and usefulness.

RESULTS

The dataset consisted of 499 794 pairs of patient messages and corresponding responses from the patient portal, with 5000 patient messages and ChatGPT-updated responses from an online platform. Four primary care physicians participated in the survey. CLAIR-Short exhibited the ability to generate concise responses similar to provider's responses. CLAIR-Long responses provided increased patient educational content compared to CLAIR-Short and were rated similarly to ChatGPT's responses, receiving positive evaluations for responsiveness, empathy, and accuracy, while receiving a neutral rating for usefulness.

CONCLUSION

This subjective analysis suggests that leveraging large language models to generate responses to patient messages demonstrates significant potential in facilitating communication between patients and healthcare providers.

The 21st Century Cures Act Information Blocking Rule in Post-Acute Long-Term Care

Included as part of the 21st Century Cures Act, the information blocking rule entered the first compliance phase in April 2021. Under this rule, post-acute long-term care (PALTC) facilities must not engage in any activity that interferes with accessing, using, or exchanging electronic health information. In addition, facilities must respond to information requests in a timely fashion and allow records to be readily available to patients and their delegates. Although hospitals have been slow to adapt to these changes, skilled nursing and other PALTC centers have been even slower. With a Final Rule enacted in recent years, awareness of the information-blocking rules became more crucial. We believe this commentary will help our colleagues interpret the rule for the PALTC setting. In addition, we provide points of emphasis to help guide those providers and administrative staff workers toward compliance and avoid potential penalties.

Fact Check: Assessing the Response of ChatGPT to Alzheimer's Disease Statements with Varying Degrees of Misinformation

Background

There are many myths regarding Alzheimer's disease (AD) that have been circulated on the Internet, each exhibiting varying degrees of accuracy, inaccuracy, and misinformation. Large language models such as ChatGPT, may be a useful tool to help assess these myths for veracity and inaccuracy. However, they can induce misinformation as well. The objective of this study is to assess ChatGPT's ability to identify and address AD myths with reliable information.

Methods

We conducted a cross-sectional study of clinicians' evaluation of ChatGPT (GPT 4.0)'s responses to 20 selected AD myths. We prompted ChatGPT to express its opinion on each myth and then requested it to rephrase its explanation using a simplified language that could be more readily understood by individuals with a middle school education. We implemented a survey using Redcap to determine the degree to which clinicians agreed with the accuracy of each ChatGPT's explanation and the degree to which the simplified rewriting was readable and retained the message of the original. We also collected their explanation on any disagreement with ChatGPT's responses. We used five Likert-type scale with a score ranging from -2 to 2 to quantify clinicians' agreement in each aspect of the evaluation.

Results

The clinicians (n=11) were generally satisfied with ChatGPT's explanations, with a mean (SD) score of 1.0(±0.3) across the 20 myths. While ChatGPT correctly identified that all the 20 myths were inaccurate, some clinicians disagreed with its explanations on 7 of the myths.Overall, 9 of the 11 professionals either agreed or strongly agreed that ChatGPT has the potential to provide meaningful explanations of certain myths.

Conclusions

The majority of surveyed healthcare professionals acknowledged the potential value of ChatGPT in mitigating AD misinformation. However, the need for more refined and detailed explanations of the disease's mechanisms and treatments was highlighted.

Leveraging Large Language Models for Generating Responses to Patient Messages

Objective

This study aimed to develop and assess the performance of fine-tuned large language models for generating responses to patient messages sent via an electronic health record patient portal.

Methods

Utilizing a dataset of messages and responses extracted from the patient portal at a large academic medical center, we developed a model (CLAIR-Short) based on a pre-trained large language model (LLaMA-65B). In addition, we used the OpenAI API to update physician responses from an open-source dataset into a format with informative paragraphs that offered patient education while emphasizing empathy and professionalism. By combining with this dataset, we further fine-tuned our model (CLAIR-Long). To evaluate the fine-tuned models, we used ten representative patient portal questions in primary care to generate responses. We asked primary care physicians to review generated responses from our models and ChatGPT and rated them for empathy, responsiveness, accuracy, and usefulness.

Results

The dataset consisted of a total of 499,794 pairs of patient messages and corresponding responses from the patient portal, with 5,000 patient messages and ChatGPT-updated responses from an online platform. Four primary care physicians participated in the survey. CLAIR-Short exhibited the ability to generate concise responses similar to provider's responses. CLAIR-Long responses provided increased patient educational content compared to CLAIR-Short and were rated similarly to ChatGPT's responses, receiving positive evaluations for responsiveness, empathy, and accuracy, while receiving a neutral rating for usefulness.

Conclusion

Leveraging large language models to generate responses to patient messages demonstrates significant potential in facilitating communication between patients and primary care providers.

Cloud Computing Synthetic Syndromic Surveillance Systems: Opioid Epidemic in Illinois

With an increasing number of overdose cases yearly, the city of Chicago is facing an opioid epidemic. Many of these overdose cases lead to 911 calls that necessitate timely response from our limited emergency medicine services. This paper demonstrates how data from these calls along with synthetic and geospatial data can help create a syndromic surveillance system to combat this opioid crisis. Chicago EMS data is obtained from the Illinois Department of Public Health with a database structure using the NEMSIS standard. This information is combined with information from the RTI U.S. Household Population database, before being transferred to an Azure Data Lake. Afterwards, the data is integrated with Azure Synapse before being refined in another data lake and filtered with ICD-10 codes. Afterwards, we moved the data to ArcGIS Enterprise to apply spatial statistics and geospatial analytics to create our surveillance system.

[Phenotype-genotype analysis of the autosomal recessive hereditary hearing loss caused by OTOA variations]

Objective: To analyze the phenotypic-genotypic characteristics of hereditary deafness caused by OTOA gene variations. Methods: Family histories, clinical phenotypes and gene variations of six pedigrees were analyzed, which were diagnosed with hearing loss caused by OTOA gene variations at the PLA General Hospital from September 2015 to January 2022. The sequence variations were verified by Sanger sequencing and the copy number variations were validated by multiplex ligation-dependent probe amplification (MLPA) in the family members. Results: The hearing loss phenotype caused by OTOA variations ranged from mild to moderate in the low frequencies, and from moderate to severe in the high frequencies in the probands, which came from six sporadic pedigrees, among which a proband was diagnosed as congenital deafness and five were diagnosed as postlingual deafness. One proband carried homozygous variations and five probands carried compound heterozygous variations in OTOA gene. Nine pathogenic variations (six copy number variations, two deletion variations and one missense variation) and two variations with uncertain significance in OTOA were identified in total, including six copy number variations and five single nucleotide variants, and three of the five single nucleotide variants were firstly reported [c.1265G>T(p.Gly422Val),c.1534delG(p.Ala513Leufs*11) and c.3292C>T(p.Gln1098fs*)]. Conclusions: OTOA gene variations can lead to autosomal recessive nonsyndromic hearing loss. In this study, the hearing loss caused by OTOA defects mostly presents as bilateral, symmetrical, and postlingual, and that of a few presents as congenital. The pathogenic variations of OTOA gene are mainly copy number variations followed by deletion variations and missense variations.

[Epidemiological characteristics of pulmonary tuberculosis in Guangdong province from 2016 to 2020]

Objective: To analyze the epidemiological characteristics of pulmonary tuberculosis (TB) in Guangdong province from 2016 to 2020 and provide evidence for the prevention and control of pulmonary TB. Methods: Descriptive epidemiological methods were used to analyze the incidence data of pulmonary TB reported in Guangdong from 2016 to 2020. Dynamic geometric series averaging and circular distribution methods were used to reveal the epidemic pattern. Results: A total of 356 748 pulmonary TB cases were reported in Guangdong from 2016 to 2020. The reported incidence of pulmonary TB decreased from 71.82/100 000 to 50.40/100 000 (trend χ²=6 905.57,P<0.001) , with an annual decline rate of 8.47%. Results from the circular distribution methods showed that the incidence peak would occur on May 4^th-5^th (Z=1 176.96,P<0.05), and the incidence was relatively higher in May compared with other months. The area distribution of the pulmonary TB epidemic was uneven, and the reported average annual incidence was in the order of the eastern area (72.15/100 000), the northern area (68.14/100 000), the western area (65.31/100 000) and the Pearl River Delta area (60.05/100 000). Results of dynamic geometric series averaging analysis showed a declining trend in the reported incidence of pulmonary TB in all areas, except Dongguan, with the average growth rate less than 0.00. The decline rate in the eastern area (-10.90%) and northern area (-10.63%) was higher than the provincial average (-8.47%). The male to female ratio of the cases was 2.63∶1 (258 562∶98 186). The reported average annual pulmonary TB incidence in men (88.37/100 000) was higher than that in women (36.86/100 000), the difference was significant (χ²=75.19, P<0.001). The reported incidence of pulmonary TB generally increased with age (trendχ²=123 849.44, P<0.001), and reached peak in age group ≥65 years (164.54/100 000). Dynamic geometric series averaging analysis showed an increasing trend of the reported pulmonary TB incidence in age groups 5-14 years and 15-24 years, with the average growth rate of 0.05% and 3.60%. Conclusions: The reported annual incidence of pulmonary TB showed a declining trend year by year in Guangdong from 2016 to 2020. However, an increasing incidence was reported in children and adolescents. Active case finding should be strengthened in the elderly and other key populations. With comprehensive TB prevention and control measures, it is still necessary to pay attention to the prevention and control of pulmonary TB in men, low-income groups and less developed areas in Guangdong and strengthen the comprehensive prevention and control in winter and spring.

P15.11.A 18F-Fluciclovine PET/CT to distinguish radiation necrosis from tumour progression in brain metastases treated with stereotactic radiosurgery: results of a prospective pilot study

Background

Amino acid PET radiopharmaceutical, 18F-fluciclovine, shows increased uptake in brain tumors relative to normal tissue and may be a useful tool for detecting recurrent brain metastases. Here, we report results from a prospective pilot study evaluating the use of 18F-fluciclovine PET/CT to distinguish radiation necrosis from tumour progression among patients with brain metastases treated with stereotactic radiosurgery (SRS).

Material and Methods

The primary objective was to estimate the accuracy of 18F-fluciclovine PET/CT in distinguishing radiation necrosis from tumour progression. The trial included adults with brain metastases who underwent SRS and presented with a follow up MRI brain (with DSC MR perfusion) which was equivocal for radiation necrosis versus tumour progression. Within 30 days of equivocal MRI brain, patients underwent an 18F-fluciclovine PET/CT (Siemens mCT) acquired 5-15 min post-injection with images generated by PSF reconstruction. Quantitative metrics for each lesion were documented and lesion to normal brain SUVmean ratios were calculated. The reference standard for diagnosis of radiation necrosis vs tumour progression was clinical follow up with MRI brain every 2-4 months until multidisciplinary consensus or tissue confirmation.

Results

Of 16 patients enrolled between 7/2019-11/2020, 1 patient died prior to diagnosis, allowing 15 evaluable subjects with 20 lesions. Primary histology was NSCLC in 9 (45%) lesions, breast in 7 (35%), melanoma in 3 (15%), and endometrial in 1 (5%). The final diagnosis was radiation necrosis in 16 (80%) lesions and tumour progression in 4 (20%). SUVmax was a statistically significant predictor of tumour progression (P = 0.011), with higher SUVmax values indicative of tumour progression. The area under the ROC curve was 0.833 (95% CI: 0.590, 1.0). A cutoff of 4.3 provided a sensitivity to identify tumour progression of 1.0 (4/4) and specificity to rule out tumour progression of 0.63 (10/16). SUVmean (P = 0.018), SUVpeak (P = 0.007), and SUVpeak/normal (P = 0.002) also reached statistical significance as predictors of tumour progression, with higher SUVmax values indicative of tumour progression. SUVmax/normal (P = 0.1) and SUVmean/normal (P = 0.5) were not statistically significant. The AUC for SUVmax was not significantly higher than the AUCs for the other quantitative variables (P-values &gt; 0.2).

Conclusion

In this prospective pilot study, 18F Fluciclovine PET/CT demonstrated promising accuracy to distinguish radiation necrosis from tumour progression among patients with brain metastases previously treated with SRS. Using SUVmax, a cutpoint of 4.3 provided a sensitivity of 1.0 and specificity of 0.63. Confirmatory phase II and III studies are ongoing.

[Nasopharyngeal carcinoma with non-squamous immunophenotype: a clinicopathological analysis of 23 cases]

Objective: To investigate the pathological subtypes and clinicopathological characteristics of the non-squamous immunophenotype nasopharyngeal carcinoma (NSNPC). Methods: The clinicopathological features of the non-squamous immunophenotype nasopharyngeal carcinoma diagnosed between 2011 and 2019 at the First Affiliated Hospital of Zhengzhou University were analyzed using hematoxylin and eosin staining, immunohistochemistry, in situ hybridization, transmission electron microscopy and PCR gene rearrangement. Follow-up data were also collected. Results: There were 14 males and 9 females with a median age of 46 years (ranging from 16 to 76 years) with an average age of 45 years. Microscopically, patterns were similar to the classic nasopharyngeal carcinoma. Immunohistochemistry showed that most NSNPC cases expressed low molecular weight keratin (CK8/18, CK8 and CKL) and expressed pathway proteins in a low level (EGFR, PI3K, p-AKT and p-mTOR), which had significant difference from classic nasopharyngeal carcinoma group (P<0.05). Other proteins including CK5/6, CKpan, CK7, Syn, CD56, CgA, SOX-10, AKT, mTOR, Notch, STAT3 and p-STAT3 showed no statistical difference between the two groups. Pathogen detection showed that EBER was positive (18/23, 78.3%) and HPV positive(2/23, 8.7%)which were HPV35 and HPV38. The cancer suppressor gene BLU was highly expressed in NSNPC; RASSF1 and Rbms3 were less expressed in NSNPC, in line with classic NPC. As a whole, NSNPC was characterized by ultrastructures of low-differentiated squamous cell carcinoma. Compared with classic nasopharyngeal carcinoma, NSNPC had a lower recurrence rate and earlier clinical stage(P<0.05),but there was no significant correlation with age, sex, distant metastasis and death (P>0.05). Conclusions: The histological morphology, etiology and gene changes of NSNPC are similar to those of classical nasopharyngeal carcinoma and ultrastructural findings show that NSNPC still belongs to undifferentiated type in non-keratinized squamous cell carcinoma. The malignant degree of NSNPC is low and the prognosis is good.

[Interleukin 33 inhibits lipopolysaccharide-induced high permeability of cardiac microvascular endothelial cells]

Objective: To investigate the effect of interleukin-33 (IL-33) on lipopolysaccharide (LPS)-induced permeability of rat cardiac microvascular endothelial cells (RCMECs). Methods: RCMECs were cultured in vitro to be divided into control group, LPS group, IL-33 group and LPS+IL-33 group. The effect of IL-33 on the proliferation of RCMECs was detected by cell counting reagent (CCK8). Fluorescein isothiocyanate (FITC)-dextran assay was used to evaluate the permeability of RCMECs. The expression of vascular endothelial calmodulin, ras homologous gene family (Rho) member A (RhoA) and phosphorylated Rho-associated coiled-coil-containing protein kinase (p-ROCK2) proteins were tested by western blot. High-throughput sequencing and gene ontology (GO) were performed for gene expression in LPS and LPS+IL-33 groups. Results: No significant effect of IL-33 at 10-50 ng/ml on the proliferation of RCMECs was observed (P>0.05). Compared with the control group, the permeability of RCMECs (permeability coefficient ratio 1.404±0.029 vs. 1.000±0.200, P<0.05) was significantly increased in LPS group and the expression of vascular endothelial calmodulin (relative gray value 0.429 5±0.012 9 vs. 0.594 9±0.014 2, P<0.05) was down-regulated, while the permeability of monolayers (permeability coefficient ratio, 0.948±0.013, P<0.01) was decreased in LPS+IL-33 group and the expression of vascular endothelial calmodulin (relative grayscale value 0.549 1±0.012 0, P<0.005) was up-regulated compared with the LPS group. High-throughput sequencing data revealed that the differential genes downregulated in the LPS and LPS+IL-33 groups were associated with cytoskeleton and Rho signaling pathway. Compared with the control group, RhoA (relative gray value 0.211 4±0.009 9 vs. 0.135 0±0.007 6, P<0.000 1) and p-ROCK (relative gray value 0.656 3±0.013 2 vs. 0.503 6±0.036 2, P<0.000 1) protein expression was upregulated in the LPS group. When compared with LPS group, RhoA (relative gray value 0.157 7±0.010 7, P=0.000 2), p-ROCK (relative gray value 0.427 7±0.003 8, P<0.000 1) protein expression was decreased in LPS+IL-33 group. Conclusion: IL-33 may improve LPS-induced hyperpermeability of RCMECs by inhibiting RhoA and p-ROCK protein expression in Rho/Rho-associated coiled-coil-containing protein kinase signaling pathway.

[Analysis of COL1A1 gene variation and clinical prevention and treatment in patients with Van der Hoeve syndrome]

Objective: To investigate the clinical phenotype, treatment and prevention of Van der Hoeve syndrome, and analyze the variation characteristics of its related gene COL1A1. Methods: Hearing and sequencing data of syndromic deafness patients who had undergone genetic testing for deafness at the Chinese People's Liberation Army General Hospital since January 2008 to October 2020 were retrospectively reviewed. The variation of the COL1A1 gene and return visits to traceable patients and families were summarized, the disease progress and clinical treatment effects were analyzed, and the prevention strategies were discussed. Results: A total of 7 patients with COL1A1 gene mutation underwent clinical intervention. The mutation sites were c.1342A>T (p.Lys448*), c.124C>T (p.Gln42*), c.249insG(p.Ala84*), c.668insC(p.Gly224*), c.2829+1G>C, c.1081C>T (p.Arg361*), c.1792C>T (p.Arg598*), of which c.1081C>T and c.1792C>T had been previously reported, and the remaining 5 were novo mutations that have not been reported. All the 7 probands underwent stapes implantation and received genetic counseling and prevention guidance. Conclusions: Van der Hoeve syndrome belongs to osteogenesis imperfecta type Ⅰ. The disease has high penetrance. Timely surgical intervention for hearing loss can improve the life quality in patients. Accurate genetic counseling and preimplantation genetic diagnosis can achieve the primary prevention for the disease.

[Risk stratified management of cervical adenocarcinoma in situ based on cone margin state]

Objective: To investigate the hierarchical management scheme of cervical adenocarcinoma in situ (AIS) based on cervical conization margin state. Methods: All medical records of 249 patients diagnosed as AIS by loop electrosurgical excision procedure (LEEP) conization from Jan. 2010 to Dec. 2015 in Obstetrics and Gynecology Hospital of Fudan University were retrospectively reviewed, to explore the relationship between the status of the resection margin and the residual lesion after LEEP, and the multivariate logistic regression method was used to analyze the related factors that affect the residual lesion after LEEP in cervical AIS patients. Results: (1) The age of 249 cervical AIS patients was (40±8) years old (range: 23-71 years old). Of the 249 patients, 19 (7.6%, 19/249) had residual lesions; 69 cases were pathologically diagnosed as AIS after LEEP, and the residual lesion rate was 13.0% (9/69), which was significantly higher than that of AIS + high-grade squamous intraepithelial lesion [5.6% (10/180); χ²=3.968,P=0.046]; 33 cases were multifocal lesions, the residual rate of lesions was 21.2% (7/33), which was significantly higher than that of single focal lesions patients [5.6% (12/216); χ²=7.858, P=0.005]; 181 patients underwent endocervical curettage (ECC) before surgery, the residual rate of lesions in ECC-positive patients was 14.0% (14/100) , significantly higher than that of ECC-negative patients [4.9% (4/81); χ²=4.103, P=0.043]. (2) Among 249 cases of AIS patients, the positive rate of resection margins after LEEP was 35.3% (88/249); the residual rate of lesions in patients with positive resection margins (14.8%, 13/88) was significantly higher than those with negative margins [3.8%(6/156); χ²=9.355, P=0.002]. The age of patients underwent total hysterectomy after LEEP was (43±7) years old, which was significantly higher than that of patients who did not undergo total hysterectomy [(37±8) years old; t=6.518, P<0.01].Among the patients underwent total hysterectomy after LEEP, 3 cases (2.0%, 3/152) had fertility requirements, while 38 cases (39.2%, 38/97) did not underwent total hysterectomy, the difference between the two groups was statistically significant (χ²=59.579, P<0.01). Among the 152 patients who underwent total hysterectomy after LEEP, the residual rate of lesions was 11.8% (18/152); the residual rate of lesions in patients with positive resection margins was significantly higher than that of patients with negative resection margins [18.8% (12/64) vs 7.0% (6/86); χ²=4.861, P=0.028]. The median follow-up time of 97 patients who did not undergo total hysterectomy after LEEP was 32 months (range: 4-70 months). During the follow-up period, 3 cases of cervical AIS recurrence (3.1%, 3/97) and were followed by hysterectomy,no invasive adenocarcinoma were seen. (3) Multivariate logistic regression analysis showed that the positive resection margin (OR=4.098, 95%CI: 1.235-13.595, P=0.021), multifocal lesions (OR=5.464, 95%CI: 1.494-19.981, P=0.010) were independent risk factors that affected the residual lesions in patients with cervical AIS after LEEP. Conclusions: The cervical AIS patients after LEEP conization suggested be stratified by cone margin state as the first-line stratified index, age and fertility needs as the second-line stratified management index. The individualized management plan should be developed based on comprehensive assessment of high-risk factors of residual lesions.

What Factors Influence Dental Faculty's Willingness to Treat Pregnant Women?

BACKGROUND

Despite evidence-based guidelines advocating for the provision of oral health care throughout pregnancy, dentists remain hesitant to provide dental treatment for pregnant women. However, little is known about attitudes toward treating pregnant women among dental school faculty, who may transmit their attitudes and treatment preferences to their students.

METHODS

We collected cross-sectional survey data at the New York University College of Dentistry, which produces 10% of all US dentists and is the largest US dental school, to understand faculty attitudes and knowledge regarding providing dental treatment to pregnant women. This study was part of an educational effort to improve dental care access by pregnant women and to examine what factors influence willingness to treat pregnant patients among dental faculty members.

RESULTS

We found that concerns about professional liability outweighed inadequate knowledge regarding treatment of pregnant patients in determining dental faculty's willingness to treat pregnant women.

CONCLUSIONS

Educational interventions delivered to dental faculty regarding current dental treatment guidelines for pregnant women may not be sufficient to increase faculty's provision of dental care to women during pregnancy. Future work to design effective interventions to increase dental treatment of pregnant women among dental faculty should address liability concerns.

KNOWLEDGE TRANSFER STATEMENT

Interventions addressing dental clinician and faculty knowledge about dental treatment for pregnant women may be insufficient to increase dental treatment among pregnant women. Instead, policy makers should consider designing, implementing, and evaluating interventions addressing malpractice and liability concerns.

[Phenotype and genotype analysis of recessive hereditary moderate sensorineural hearing loss caused by new mutations in OTOGL gene]

Objective: To perform the phenotype and genetic analysis on two families with moderate sensorineural hearing impairment and determine the cause of deafness. Methods: The phenotype and genetic analysis was performed on the two hearing impairment pedigrees coming to Chinese PLA General Hospital from January 2014 to August 2020. DNA samples of the proband from family 1 and the parents from family 2 were collected and tested through next generation sequencing on all deafness genes, and Sanger sequencing was performed to verify the mutation sites. The reported pathogenic variants of the otogelin-like (OTOGL) gene, the autosomal recessive inherited deafness genes that cause moderate sensorineural hearing loss and the clinical manifestations of the deafness genes that have the similar expression location as the OTOGL gene were summarized and analyzed. Results: The pathogenic variants in the families were compound heterozygous variants in the OTOGL gene c.2773C>T/c.2826C>G (p.Arg925*/p.Tyr942*) and c.4455G>A/c.875C>G (Trp1485*/p.Ser292*), respectively. c.2773C>T was an already reported pathogenic variant causing hearing impairment in the literature, while c.2826C>G, c.4455G>A and c.875C>G were novel reported variant sites. The above four variants were classified as pathogenic variants according to the variant interpretation standards and guideline of the Amercian College of Medical Genetics and Genomics. Conclusions: Pathogenic variants in OTOGL gene is an important genetic factor leading to moderate sensorineural hearing loss. The newly discovered variant sites c.2826C>G, c.4455G>A and c.875C>G enrich the variant spectrum of OTOGL gene. The results of the current study provide a basis for genetic counseling of the related families and a new target for the treatment of hereditary hearing loss in the future.

Irradiation resistance mechanism of the CoCrFeMnNi equiatomic high-entropy alloy

When face-centered cubic (FCC) metals and alloys with low stacking fault energy (SFE) are irradiated by high-energy particles or deformed at high speed, stacking fault tetrahedra (SFTs), which are a type of vacancy cluster defect, are often formed. Therefore, SFTs were expected to form in the CoCrFeMnNi equiatomic high-entropy alloy (HEA). However, no SFT was observed in the CoCrFeMnNi HEA with high-speed plastic deformation even after annealing at 873 K. To elucidate this mechanism, the binding energy of vacancy clusters in the CoCrFeMnNi HEA was calculated based on first principles. The binding energy of the di-vacancy cluster was positive (average of 0.25 eV), while that of the tri-vacancy cluster was negative (average of - 0.44 eV), suggesting that the possibility of formation of a tri-vacancy cluster was low. The inability to form a cluster containing three vacancies is attributed to the excellent irradiation resistance of the CoCrFeMnNi HEA. However, if an extra vacancy is added to a tri-vacancy cluster (with negative binding energy), the binding energy of the subsequent tetra-vacancy cluster may become positive. This suggests that it is possible to form vacancy clusters in the CoCrFeMnNi HEA when high-energy ion or neutron irradiation causes cascade damage.

The invasion status of lymphovascular space and lymph nodes in cervical cancer assessed by mono-exponential and bi-exponential DWI-related parameters

AIM

To investigate whether mono-exponential and bi-exponential diffusion-weighted imaging (DWI)-related parameters of the primary tumour can evaluate the status of lymphovascular space invasion (LVSI) and lymph node metastasis (LNM) in patients with cervical carcinoma preoperatively.

MATERIALS AND METHODS

Eighty patients with cervical carcinoma were enrolled, who underwent preoperative multi b-value DWI and radical hysterectomy. They were classified into LVSI(+) versus LVSI(-) and LNM(+) versus LNM(-) according to postoperative pathology. The apparent diffusion coefficient (ADC), pure molecular diffusion (D), pseudo-diffusion coefficient (D∗), and perfusion fraction (f) were calculated from the whole tumour (__whole) and tumour margin (__margin). All parameters were compared between LVSI(+) and LVSI(-) and between LNM(+) and LNM(-). Logistic regression analysis and receiver operating characteristic (ROC) curve analysis were performed to evaluate the diagnostic performance of these parameters.

RESULTS

f__margin and D∗__whole showed significant differences in differentiating LVSI(+) from LVSI(-) tumours (p=0.002, 0.008, respectively), while LNM(+) tumours presented with significantly higher ADC__margin than that of LNM(-) tumours (p=0.009). The other parameters were not independent related factors with the status of LVSI or LNM according to logistic regression analysis (p>0.05). The area under the ROC curve of f__margin combined with D∗__whole in discriminating LVSI(+) from LVSI(-) was 0.826 (95% confidence interval [CI]: 0.691-0.961), while ADC__margin in differentiating LNM(+) from LNM(-) was 0.788 (95% CI: 0.648-0.928).

CONCLUSIONS

The parameters generated from mono-exponential and bi-exponential DWI of the primary cervical carcinoma could help discriminate its status regarding LVSI (f__margin and D∗__whole) and LNM (ADC__margin).

An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery

INTRODUCTION

Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy.

METHODS

We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results.

RESULTS

Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective.

CONCLUSION

Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.

[Diagnostic performance of pathology, culture and ROSE of lung biopsy for suspected pulmonary infectious diseases]

Objective: To explore the diagnostic performance of CT guided percutaneous lung biopsy (PTLB) with pathology, culture and rapid on-site evaluation (ROSE) in patients with pulmonary infectious diseases. Methods: From January 2016 to June 2018, a retrospective study was implemented in the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University. Patients who received PTLB, suspected with lung infection were included. The basic information, clinical symptoms, imaging findings, diagnostic methods, complications, and changes in treatment of cases were collected. The diagnostic sensitivity of histopathology, microbial culture, and ROSE were evaluated at the same time. Results: A total of 529 cases were enrolled, including 354 males and 175 females, (59±14) years old in average. Tuberculosis was identified in 197 cases, non-tuberculosis mycobacteria (NTM) pulmonary disease in 8, cryptococcosis in 95, pulmonary aspergillosis in 27, filamentous fungal pneumonia in 3, talaromyces marneffei pulmonary infection in 3 and pulmonary candidiasis in 1, bacterial pneumonia in 39, and pathogen were unknown in 156 cases. A total of 417 cases were submitted for histopathology and microbial culture at the same time, the diagnostic value of pathology and microbial culture were 35.0% (146/417) and 45.6% (190/417), respectively. Combined pathology with microbial culture, the diagnostic value increased to 62.8% (262/417). The diagnostic accuracy of ROSE was 51.8% (71/137). The most common complication of PTLB was pneumothorax 26.1% (138/529). 56.1% (297/529) of the patients received targeted treatment after the diagnosis was confirmed, and 43.9% (232/529) maintained the original treatment. Conclusion: The pathology, microbial culture, and ROSE of PTLB have relative high diagnostic value for pulmonary infectious diseases.

[High serum cholesterol: a novel risk factor for thyroid associated ophthalmopathy?]

This study was aimed to investigate the association between dyslipidemia and thyroid associated ophthalmopathy (TAO). We evaluated the relationship between dyslipidemia and TAO in 218 patients with Graves' disease (GD) and found that the serum total cholesterol (TC) and low density lipoprotein cholesterol (LDL-C) in the GD subjects with TAO (n=110) were significantly increased [(5.32±1.39) mmol/L vs. (3.18±2.12) mmol/L, (2.98±0.75) mmol/L vs. (1.25±0.98) mmol/L] than those in the GD subjects without TAO (n=108). TC and LDL-C were positively correlated with the Clinical disease activity score (CAS) [TC (r=0.7, P=0.03),LDL-C (r=0.82, P=0.03)], and the levels of TC (OR=2.56, P=0.02) and LDL-C(OR=2.01, P=0.015) were positively associated with TAO. These suggested that high serum cholesterol level is a novel risk factor for TAO, and management of blood lipids should be included in the treatment of TAO.

Chlorhexidine-based decolonization to reduce healthcare-associated infections and multidrug-resistant organisms (MDROs): who, what, where, when, and why?

Body surface decolonization with chlorhexidine bathing and nasal mupirocin has become a simple solution for prevention of healthcare-associated infections. The clinical trial evidence for this practice will be reviewed to understand who benefits from this practice, for what reasons, and at what times. The method of bathing and nasal decolonization will also be discussed as proper application is needed for maximal effectiveness. Finally, the conflict between current effectiveness and future potential for fueling resistance is considered.

[Case report and diagnosis of Noonan syndrome with multiple lentigines with deafness as its main clinical feature]

Summary Noonan syndrome with multiple lentigines（NSML） is a disorder with syndromic hearing loss. Abnormalities of other systems in NSML have received increasing attention, but hearing loss is rarely concerned. And due to the incomplete phenotype, some patients with NSML maybe missed or maybe confused with other syndromic deafness such as Waardenburg syndrome. Our study will familiarize more otolaryngologists with Leopard syndrome. A 5-year-old boy with bilateral sensorineural hearing loss and numerous symmetrically distributed dark brown macules that had good effect of cochlear implantation was collected in this study. And his father had bilateral sensorineural hearing loss and numerous symmetrically distributed dark brown macules. Waardenburg syndrome was initially diagnosed by clinical phenotype and its molecular etiology was confirmed by gene diagnosis. Waardenburg syndrome-related deafness genes and 131 known deafness genes were not identified by second-generation sequencing. Whole-exon sequencing was performed for 4 individuals in the family and the results were confirmed by Sanger sequencing. This study confirmed the diagnosis by identifying a disease-causing mutation in the PTPN11 gene, which was a heterozygous missense mutation at p. Tyr279Cys（c. 836A>G）. The mutation co-segregated with hearing loss in the family. Our results demonstrated that hearing loss in this family was caused by heterozygous mutations in PTPN11. These cases will familiarize more otolaryngologists with NSML, and they emphasize the importance of considering NSML as a possible cause of hearing problems.

An Economic Evaluation of a Comprehensive School-Based Caries Prevention Program

INTRODUCTION

Current economic evaluations of school-based caries prevention programs (SCPPs) do not compare multiple types of SCPPs against each other and do not consider teeth beyond permanent first molars.

OBJECTIVES

To assess the cost-effectiveness of a comprehensive SCPP relative to an SCPP focused on delivering sealants for permanent first molars only and to a default of no SCPP. Based on a societal perspective, a simulation model was used that compared the health and cost impacts on 1) permanent first molars only and 2) all posterior teeth.

METHODS

To calibrate the model, we used data from CariedAway, a comprehensive SCPP that used glass ionomer to prevent and arrest active decay among children. We then evaluated the incremental cost-effectiveness of implementing 3 alternate school-based approaches (comprehensive, sealant only, and no program) on only first molars and all posterior teeth. Probabilistic, 1-, and 2-way sensitivity analyses are included for robustness. Cost-effectiveness is assessed with a threshold of $54,639 per averted disability-adjusted life year (DALY).

RESULTS

We first compared the 3 programs under the assumption of treating only first molars. This assessment indicated that CariedAway was less cost-effective than school-based sealant programs (SSPs): the resulting incremental cost-effectiveness ratio (ICER) for CariedAway versus SSPs was $283,455 per averted DALY. However, when the model was extended to include CariedAway's treatment of all posterior teeth, CariedAway was not only cost-effective but also cost-saving relative to SSPs (ICER, -$943,460.88 per averted DALY; net cost, -$261.45) and no SCPP (ICER, -$400,645.52 per averted DALY; net cost, -$239.77).

CONCLUSIONS

This study finds that economic evaluations assessing only cost and health impacts on permanent first molars may underestimate the cost-effectiveness of comprehensive SCPPs 1) preventing and arresting decay and 2) treating all teeth. Hence, there is an urgent need for economic evaluations of SCPPs to assess cost and health impacts across teeth beyond only permanent first molars.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by policy makers to understand how to evaluate economic evaluations of school-based caries prevention programs and what factors to consider when deciding on what types of programs to implement.

[Screening for hotspot mutations associated with genetic hearing impairment in pregnant women and subsequent prenatal diagnosis in high risk pregnancies]

Objective: To screen for hotspot gene mutations associated with genetic deafness in Chinese pregnant women, and to perform risk assessment and prenatal diagnosis in high-risk families. Methods: Between November 2012 and October 2017, 26 117 pregnant women were screened by molecular hybridization microarray for 9 hot-spot mutations in 4 hereditary deafness related genes (GJB2 c. 35 del G, c. 176_191 del 16 bp, c. 235 del G, c. 299_300 del AT, GJB3 c. 538 C>T, SLC26A4 c. 2168 A>G, IVS 7-2 A>G, mitochondrial DNA 12S rRNA m. 1494 C>T, m. 1555 A>G). Genotype analysis was carried out in husbands of women carrying mutations, and prenatal diagnosis was carried out in the fetuses with high risk of deafness. Results: Among all women tested, 1 208(4.63%) were carriers of genetic deafness mutations, 7 with hearing impairment were affected by homozygous or compound heterozygous mutations, 51 were mitochondrial gene mutation carriers, 103 were carriers of GJB3 c. 538 C>T heterozygous mutation, 1 026 were carriers of GJB2 or SLC26A4 heterozygous mutations, and 21 carried heterozygous mutations in two genes simultaneously. In 394 families, the husbands accepted gene sequence testing, and 27 in which were determined as carriers of mutations in identical genes as their wives. Among which, 18 families received prenatal diagnosis, and 5 fetuses were diagnosed as hereditary deafness. In 9 families who did not receive prenatal diagnosis, 1 neonate was diagnosed as compound heterozygote after delivery. Conclusion: In order to prevent birth defects with congenital hearing problems, it is effective to provide screening for hotspot mutations in pregnant women and to perform prenatal diagnosis on high risk pregnancies.

Eculizumab Dosing in Infants

Eculizumab is the therapy of choice for patients with atypical hemolytic uremic syndrome (aHUS). Dosing recommendations stem from two trials: one retrospective trial (19 children and 5 infants) and one prospective trial (22 patients and 5 infants). This case report highlights the need for more precise dosing recommendations in children, particularly in infants, and for smaller vials of the medication to facilitate more precise dosing. Such changes would ensure that adverse events are minimized and that the children with aHUS who are treated with eculizumab experience an optimal clinical response.

An initial cost-effectiveness analysis of intraoperative magnetic resonance imaging (iMRI) in pediatric epilepsy surgery

PURPOSE

Previous studies have illustrated the clinical utility of the addition of intraoperative magnetic resonance imaging (iMRI) to conventional microsurgical resection. While iMRI requires initial capital cost investment, long-term reduction in costly follow-up management and reoperation costs may prove economically efficacious. The objective of this study is to investigate the cost-effectiveness of the addition of iMRI utilization versus conventional microsurgical techniques in focal cortical dysplasia (FCD) resection in pediatric patients with medically refractory epilepsy.

METHODS

We retrospectively reviewed the medical records of pediatric subjects who underwent surgical resection of FCD at the Children's National Health System between March 2005 and April 2015. Patients were assigned to one of three cohorts: iMRI-assisted resection, conventional resection with iMRI-assisted reoperation, or conventional resection. Direct costs included preoperative, operative, postoperative, long-term follow-up, and antiepileptic drug (AED) costs. The cost-effectiveness was calculated as the sum total of all direct medical costs over the quality-adjusted life years (QALYs). We also performed sensitivity analysis on numerous variables to assess the validity of our results.

RESULTS

Fifty-six consecutive pediatric patients underwent resective surgery for medically intractable FCD. Ten patients underwent iMRI-assisted resection; 7 underwent conventional resection followed by iMRI-assisted reoperation; 39 patients underwent conventional microsurgical resection. Taken over the lifetime of the patient, the cumulative discounted QALY of patients in the iMRI-assisted resection cohort was about 2.91 years, versus 2.61 years in the conventional resection with iMRI-assisted reoperation cohort, and 1.76 years for the conventional resection cohort. Adjusting for inflation, iMRI-assisted surgeries have a cost-effectiveness ratio of $16,179 per QALY, versus $28,514 per QALY for the conventional resection with iMRI-assisted reoperation cohort, and $49,960 per QALY for the conventional resection cohort. Sensitivity analysis demonstrated that no one single variable significantly altered cost-effectiveness across all three cohorts compared to the baseline results.

CONCLUSION

The addition of iMRI to conventional microsurgical techniques for resection of FCD in pediatric patients with intractable epilepsy resulted in increased seizure freedom and reduction in long-term direct medical costs compared to conventional surgeries. Our data suggests that iMRI may be a cost-effective addition to the surgical armamentarium for epilepsy surgery.

Taxes, bankruptcy costs, and capital structure in for-profit and not-for-profit hospitals

About 60% of the US hospitals are not-for-profit and it is not clear how traditional theories of capital structure should be adapted to understand the borrowing behavior of not-for-profit hospitals. This paper identifies important determinants of capital structure taken from theories describing for-profit firms as well as prior literature on not-for-profit hospitals. We examine the differential effects these factors have on the capital structure of for-profit and not-for-profit hospitals. Specifically, we use a difference-in-differences regression framework to study how differences in leverage between for-profit and not-for-profit hospitals change in response to key explanatory variables (i.e. tax rates and bankruptcy costs). The sample in this study includes most US short-term general acute hospitals from 2000 to 2012. We find that personal and corporate income taxes and bankruptcy costs have significant and distinct effects on the capital structure of for-profit and not-for-profit hospitals. Specifically, relative to not-for-profit hospitals: (1) higher corporate income tax encourages for-profit hospitals to increase their debt usage; (2) higher personal income tax discourages for-profit hospitals to use debt; and (3) higher expected bankruptcy costs lead for-profit hospitals to use less debt. Over the past decade, the capital structure of for-profit hospitals has been more flexible as compared to that of not-for-profit hospitals. This may suggest that not-for-profit hospitals are more constrained by external financing resources. Particularly, our analysis suggests that not-for-profit hospitals operating in states with high corporate taxes but low personal income taxes may face particular challenges of borrowing funds relative to their for-profit competitors.

[Histologic classification and prognosis factors in phyllodes tumors of breast]

Objective: To study the relationship between morphological characteristics, grading, diagnosis and prognosis in phyllodes tumors (PT) of the breast. Methods: A retrospective study was carried out on 83 PTs diagnosed between 1999 and 2003 that were classified semi-quantitatively according to the WHO recommendation. Follow-up data was available for some cases, and Cox regression analysis was used to evaluate factors affecting metastasis and recurrence. Results: All cases were classified into the benign (57.8%), borderline (28.9%) and malignant (13.3%). The overall recurrence rate for the 72 cases with follow-up data was 20.8% (15/72), and was 17.5% (7/40) in benign, 22.7% (5/22) in borderline and 3/10 in malignant PT, respectively, with no significant difference (P>0.05). The median interval between the initial diagnosis and the first recurrence was 24 months. Lung or bone metastases occurred in 1/22 borderline and 3/10 malignant PT patients 5 years post-surgery. The mitotic count and the degree of stromal cell atypia were significantly correlated with recurrence (P=0.001 and P=0.006). Multivariate analysis showed that severe stromal cell atypia was an independent predictor of recurrence-free survival in PT [HR=6.40 (95% CI=1.378 to 29.732), P=0.018]. Conclusions: Each parameter in the histological grading of PT may have different prognostic value, and markedly increased mitotic count and were predictive of relapse.

Potential economic burden of carbapenem-resistant Enterobacteriaceae (CRE) in the United States

OBJECTIVES

The Centers for Disease Control and Prevention considers carbapenem-resistant Enterobacteriaceae (CRE) an urgent public health threat; however, its economic burden is unknown.

METHODS

We developed a CRE clinical and economics outcomes model to determine the cost of CRE infection from the hospital, third-party payer, and societal, perspectives and to evaluate the health and economic burden of CRE to the USA.

RESULTS

Depending on the infection type, the median cost of a single CRE infection can range from $22 484 to $66 031 for hospitals, $10 440 to $31 621 for third-party payers, and $37 778 to $83 512 for society. An infection incidence of 2.93 per 100 000 population in the USA (9418 infections) would cost hospitals $275 million (95% CR $217-334 million), third-party payers $147 million (95% CR $129-172 million), and society $553 million (95% CR $303-1593 million) with a 25% attributable mortality, and would result in the loss of 8841 (95% CR 5805-12 420) quality-adjusted life years. An incidence of 15 per 100 000 (48 213 infections) would cost hospitals $1.4 billion (95% CR $1.1-1.7 billion), third-party payers $0.8 billion (95% CR $0.6-0.8 billion), and society $2.8 billion (95% CR $1.6-8.2 billion), and result in the loss of 45 261 quality-adjusted life years.

CONCLUSIONS

The cost of CRE is higher than the annual cost of many chronic diseases and of many acute diseases. Costs rise proportionally with the incidence of CRE, increasing by 2.0 times, 3.4 times, and 5.1 times for incidence rates of 6, 10, and 15 per 100 000 persons.

Common genetic risk factors of venous thromboembolism in Western and Asian populations

Venous thromboembolism (VTE) is a multifactorial disorder involving both acquired and genetic risk factors. The common genetic factors in Western populations have been studied and reported for several decades, while studies on Asian populations are relatively scarce. Evidence suggests that the prevalence and genetic risk factors of VTE vary significantly among ethnic populations. In this review, we summarize the common genetic risk factors of VTE in both Western and Asian populations. In addition to the development of DNA sequencing technology, genome-wide association studies have many advantages and are becoming more important in identifying new genetic risk factors and susceptible loci. They can therefore help in the prediction and prevention of VTE.

Acidic FGF promotes neurite outgrowth of cortical neurons and improves neuroprotective effect in a cerebral ischemic rat model

Acidic fibroblast growth factor (aFGF) is a neurotrophic factor which is a powerful neuroprotective and neuroregenerative factor of the nervous system. Prior study had shown that levels of FGFs significantly increase following ischemic injury, reflecting a physiological protection mechanism. However, few reports demonstrated the efficacy of applying aFGF in cerebral ischemia. A recent report showed that the intranasal aFGF treatment improved neurological functional recovery; however, it did not significantly reduce the lesion size in ischemic rats. The present study examines the neuroprotective effect of aFGF on cortical neuron-glial cultures under oxygen glucose deprivation (OGD)-induced cell damage and investigates whether epidural application of slow-released aFGF could improve benefit on ischemic stroke injury in conscious rats. We used a topical application of aFGF mixed in fibrin glue, a slow-release carrier, over the peri-ischemic cortex and examined such treatment on cerebral infarction and behavioral impairments of rats subjected to focal cerebral ischemia (FCI). Results demonstrate that aFGF effectively protected cortical neuron-glial cultures from OGD-induced neuronal damage. Neurite extension from cortical neurons was significantly enhanced by aFGF, mediated through activation of AKT and ERK. In addition, topical application of fibrin glue-mixed aFGF dose-dependently reduced ischemia-induced brain infarction and improved functional restoration in ischemic stroke rats. Slow-released aFGF not only protected hippocampal and cortical cell loss but reduced microglial infiltration in FCI rats. Our results suggest that aFGF mixed in fibrin glue could prolong the protective/regenerative efficacy of aFGF to the damaged brain tissue and thus improve the functional restorative effect of aFGF.

Molecular screening and predation evaluation of the key predators of Conopomorpha sinensis Bradley (Lepidoptera: Gracilariidae) in litchi orchards

Conopomorpha sinensis Bradley (Lepidoptera: Gracilariidae) is one of the major fruit borer pests of litchi and longan in Southern China. Although chemical control is effective, alternative, biorational strategies are preferable, and should be developed. Predators play an important role in the biological control of agricultural pests, but an accurate method for the evaluation of predation in agriculture has not yet been developed. Here, we report a new, specific primer pair to amplify a C. sinensis cytochrome c oxidase subunit I (COI) sequence fragment that can be used to detect consumption of C. sinensis by its predators. C. sinensis DNA was found in several arthropods collected in the field, including the important C. sinensis predators M enochilus sexmaculata (Coccinellidae), Leucauge magnifica (Tetragnathidae), Propylea japonica (Coccinellidae), and Oxyopes sertatus (Oxyopidae). The detection rates of C. sinensis COI DNA in these predators were 39.3, 36.4, 27.3, and 27.2%, respectively. Laboratory consumption and hunting capacity analysis of M. sexmaculata and P. japonica adults indicated that they exhibit a Holling type II functional response on C. sinensis eggs under field temperatures. A polymerase chain reaction digestion analysis of M. sexmaculata and P. japonica adults after consumption of a single C. sinensis egg indicated that positive detection decreased with the extension of digestion time, and estimated prey DNA half-lives were 16.3 h in M. sexmaculata and 6.0 h in P. japonica. These data serve to characterize two major predators of C. sinensis with potential for biological control of C. sinensis in litchi orchards.

Double-prism domain PPLN for simultaneous laser Q-switching and optical parametric oscillation in a Nd:YVO4 laser

We report a design and demonstration of an electro-optically Q-switched intracavity optical parametric oscillator (IOPO) based on a unique ramped duty-cycle periodically poled lithium niobate (PPLN) in a diode-pumped 1064-nm Nd:YVO(4) laser. The PPLN crystal, having a double-prism domain (DPD) structure with a domain period of 30 μm, can work simultaneously as an electro-optic (EO) beam deflector (and therefore an EO Q-switch in the laser cavity) and an optical parametric down converter. The characterized deflection sensitivity of the DPD PPLN device was 1.15°/kV-cm. At a 180-V Q-switching voltage and a 1-kHz switching rate, we measured a down-converted signal at 1550 nm with pulse energy of >8.1 μJ (or peak power of >2.3 kW) from the constructed IOPO at 7.5-W diode pump power. Continuous wavelength tuning of the IOPO signal was also demonstrated.

Effect of heat shock on ultrastructure and calcium distribution in Lavandula pinnata L. glandular trichomes

The effects of heat shock (HS) on the ultrastructure and calcium distribution of Lavandula pinnata secretory trichomes are examined using transmission electron microscopy and potassium antimonate precipitation. After 48-h HS at 40°C, plastids become distorted and lack stroma and osmiophilic deposits, the cristae of the mitochondria become indistinct, the endoplasmic reticulum acquires a chain-like appearance with ribosomes prominently attached to the lamellae, and the plasma and organelle membranes become distorted. Heat shock is associated with a decrease in calcium precipitates in the trichomes, while the number of precipitates increases in the mesophyll cells. Prolonged exposure to elevated calcium levels may be toxic to the mesophyll cells, while the lack of calcium in the glands cell may deprive them of the normal protective advantages of elevated calcium levels. The inequality in calcium distribution may result not only from uptake from the transpiration stream, but also from redistribution of calcium from the trichomes to the mesophyll cells.

The economic burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA)

The economic impact of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) remains unclear. We developed an economic simulation model to quantify the costs associated with CA-MRSA infection from the societal and third-party payer perspectives. A single CA-MRSA case costs third-party payers $2277-$3200 and society $7070-$20 489, depending on patient age. In the United States (US), CA-MRSA imposes an annual burden of $478 million to 2.2 billion on third-party payers and $1.4-13.8 billion on society, depending on the CA-MRSA definitions and incidences. The US jail system and Army may be experiencing annual total costs of $7-11 million ($6-10 million direct medical costs) and $15-36 million ($14-32 million direct costs), respectively. Hospitalization rates and mortality are important cost drivers. CA-MRSA confers a substantial economic burden on third-party payers and society, with CA-MRSA-attributable productivity losses being major contributors to the total societal economic burden. Although decreasing transmission and infection incidence would decrease costs, even if transmission were to continue at present levels, early identification and appropriate treatment of CA-MRSA infections before they progress could save considerable costs.

Clonal replacement among 19A Streptococcus pneumoniae in Massachusetts, prior to 13 valent conjugate vaccination

As part of an ongoing study of the response of the Streptococcus pneumoniae population to conjugate vaccination, we applied multi-locus sequence typing (MLST) to 291 isolates sampled from nasopharyngeal carriage in Massachusetts children. We found 94 distinct sequence types (STs), including 19 that had not been previously recorded, and a xpt allele containing a large insertion. Comparison with a similar sample collected in 2007 revealed no significant overall difference in the ST composition (p=0.51) suggesting that the population has reached a new equilibrium following the introduction of 7 valent vaccination in 2000. Within serotypes, a large and statistically significant increase (p=0.014 Fisher's Exact test) was noted in the prevalence of the major multiresistant clone ST 320, which is apparently outcompeting ST 199 among serotype 19A strains. This sample will be used as a baseline to study the future evolution of the pneumococcal population in Massachusetts following introduction of vaccines with higher valency.

Resistive and capacitive response of nitrogen-doped TiO2 nanotubes film humidity sensor

Dielectric oxides are traditionally used to fabricate resistive surface humidity-sensing devices, as well as capacitive sandwich-structured sensors. In the present work, relative humidity (RH) sensors were fabricated by employing vertically aligned TiO(2) nanotubes array (TNA) film produced using electro-chemical anodization of Ti foil followed by a nitrogen-doping process, simultaneously showing resistive and capacitive humidity-sensing properties in the range of 11.3-93.6%. For the sample formed at optimized experimental conditions, the capacitance (C(S)) and resistance (R(S)) of the as-fabricated RH sensors made from nitrogen-doped TiO(2) nanotubes film could be simultaneously obtained. Both the resistive and capacitive sensitivity (K(R) and K(C)) of the as-fabricated TiO(2) nanotube RH sensors show distinct dependence on the frequency of alternating current (AC) voltage signal and RH. At higher water coverage, water-water interaction will result in lowering of the water dissociation barrier, leading to an increase of conductance. With the increase of RH, the polarization of as-adsorbed water molecules will also occur, causing a sharp increase of capacitance. For an explanation of the frequency response of both C(S) and R(S), ionic transport, as well as the polarization effect, should be comprehensively considered. The changes of capacitance and resistance at different temperatures are plausibly caused by thermal expansion and surface state modification by adsorption and desorption of oxygen and water.

Application of Fe2V4O13 as a new multi-metal heterogeneous Fenton-like catalyst for the degradation of organic pollutants

Iron tetrapolyvanadate (Fe2V4O13) was prepared and characterized by X-ray diffraction (XRD), Brunauer-Emmett-Teller (BET) measurement and scanning electron microscopy (SEM). It was found that Fe2V4O13 could effectively catalyse H2O2 to generate active OH; therefore, Fe2V4O13 was employed as a new two-metal heterogeneous Fenton-like catalyst. The decomposition of H2O2 and the degradation of Acid Orange II catalysed by Fe2V4O13 could be well described with a simple pseudo-first-order rate equation between the reaction temperatures of 15 degrees C and 30 degreesC. It was inferred from the reaction activation energy data that the generation of the hydroxyl radical was a control step in a series of reactions for the oxidation of Acid Orange II in the presence of H2O2 and Fe2V4O13. The catalytic activity of Fe2V4O13 towards degradation of Acid Orange II was not only much higher than that of alpha-Fe2O3, V2O5 and FeVO4 but also than that of their mixtures with an identical ratio of Fe and V, such as 2FeVO4 + V2O5 and Fe2O3 + 2V2O5. The high catalytic activity possibly involved a special two-way Fenton-like mechanism and the synergistic activation of Fe(III) and V(V) in Fe2V4O13 towards H2O2.

Desorption and ripening of low density InAs quantum dots

In this paper, combining low deposition rate with proper growth temperature, we have developed a way to prepare very low-density quantum dots (QDs) suited for the study of single QD properties without resorting to submicron lithography. Experiment results demonstrate that InAs desorption is significant during growing the low density QDs. Ripening of InAs QDs is clearly observed during the post-growth annealing. Photoluminescence spectroscopy reveals that the emission wavelength of low density InAs QDs arrives at 1332.4 nm with a GaAs capping layer.

Long-wavelength emission InAs quantum dots grown on InGaAs metamorphic buffers

In this work, InAs quantum dots (QDs) grown on a linear graded InGaAs metamorphic buffer layer by molecular beam epitaxy have been investigated. The growth of the metamorphic buffer layers was carefully optimized, yielding a smooth surface with a minimum root mean square of roughness of less than 0.98 nm as measured by atomic force microscopy (AFM). InAs QDs were then grown on the buffer layers, and their emission wavelength at room-temperature is 1.49 microm as measured by photoluminescence (PL). The effects of post-growth rapid thermal annealing (RTA) on the optical properties of the InAs QDs were investigated. After the RTA, the PL peak of the QDs was blue-shifted and the full width at half maximum decreased.

Role of growth factors in oncogenesis: growth factor-proto-oncogene pathways of mitogenesis

Cellular genes which encode proteins involved in the response of cells to stimulation by growth factors may be potential oncogenes. The factors involved in the signal transmission from growth factor-receptor interaction to DNA synthesis constitute a cascade system which we call the 'growth factor-proto-oncogene pathway(s) of mitogenesis'. For each growth factor, all the responsive cells, regardless of cell types and tissue source, have specific growth factor receptors which are similar, if not identical, in molecular weight and biological activity. Thus, we believe that the growth factor-proto-oncogene pathway(s) functions in the same manner in all responsive cells. Platelet-derived growth factor (PDGF), epidermal growth factor (EGF), and brain-derived growth factor (BDGF) are major growth factors for connective tissue cells and do not share a common pathway in mitogenesis in responsive cells. The gene product of c-myc may be involved in the cellular response of cells stimulated by PDGF or FGF, but not directly in the signal transmission which leads to DNA synthesis.

Survey of heavy metal pollution and assessment of agricultural soil in Yangzhong district, Jiangsu Province, China

We investigated concentrations of Hg, Cd, Pb, Zn, Cu, As, Ni, and Cr in samples of soil, cereal, and vegetables from Yangzhong district, China. Compared to subsoils, the sampled topsoils are enriched in Hg, Cd, Cu, Pb, Zn, and As. High levels of Cd and Hg are observed in most agricultural soils. Concentrations of Cr and Ni show little spatial variation, and high Cu, Pb, and Zn contents correspond well to areas of urban development. High As contents are primarily recorded at the two ends of the sampled alluvion. The contents of Cd, Hg, and total organic carbon (TOC) increase gradually to maximum values in the upper parts of soil profiles, while Cr and Ni occur in low concentrations within sampled profiles. As, Pb, Cu, and Zn show patterns of slight enrichment within the surface layer. Compared to data obtained in 1990, Cd and Hg show increased concentrations in 2005; this is attributed to the long-term use of agrochemicals. Cr and Ni contents remained steady over this interval because they are derived from the weathering of parent material and subsequent pedogenesis. The measured As, Cu, Pb, and Zn contents show slight increases over time due to atmospheric deposition of material sourced from urban anthropogenic activity. Low concentrations of heavy metals are recorded in vegetables and cereals because the subalkaline environment of the soil limits their mobility. Although the heavy metal concentrations measured in this study do not pose a serious health risk, they do affect the quality of agricultural products.

Congou tea drinking and oesophageal cancer in South China

The study from a large hospital-based case-control for 1248 cases with oesophageal cancer and the same number of controls in South China showed that Congou, a grade of Chinese black tea, may protect against cancers of the oesophagus and reduce the risk of a combination of alcohol drinking and smoking (especially smoking), regardless of temperature when drinking.