Abstract Background Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. However, there are little published data on ...risk factors and outcomes of LT for ACLF. Methods The objective of this study was to analyze preoperative, intraoperative, postoperative, and overall survival data on 100 consecutive cases with ACLF in order to try to determine for which patients LT are futile. Results One hundred consecutive patients with pathology-confirmed ACLF who underwent LT from June 2004 to September 2012 were enrolled. The preoperative data showed that all patients were in a serious condition with a median high model for end-stage liver disease (MELD) score of 32, total bilirubin of 440.20 umol/L, international normalized ratio (INR) of 3.012, and at least one organ dysfunction as assessed by a Sequential Organ Failure Assessment (SOFA) score of ≥9. The patients had either deceased or a living donor LT with an overall mortality of 20%. The 1-, 3-, and 5-year cumulative survival rates were 76.8%, 75.6%, and 74.1%, respectively, and graft 1-, 3-, and 5-y accumulative survival rates were 73.3%, 72.1%, and 70.6%, respectively. However, the area under receiver operating characteristic of SOFA score, MELD score, as well as Child-Pugh score were 0.552, 0.547, and 0.547, respectively. Conclusions Both deceased and living donor LT are effective therapeutic options for patients with ACLF and the short- and long-term survival rates are encouraging. It is important to conduct more prospective and multi-center studies to define preoperatively which patients would benefit from LT.
Abstract Objective The aim of this research was to compare the functional outcome and safety between supraorbital keyhole approach (SKA) and pterional keyhole approach (PKA) for clipping intracranial ...aneurysms. Methods This is a retrospective study involving 318 patients with a total 365 aneurysms who underwent keyhole surgery, comprising 195 cases in SKA group and 123 cases in PKA group. The outcome measures include Glasgow Outcome Scale (GOS), complete clipping rate, adverse events incidence, operation view angle, working distance, and surgical incision condition. Results Of a total 356 aneurysms were clipped and 9 were trapped, no significant difference was observed in GOS score, adverse events incidence, complete clipping rate between the SKA and PKA groups. The distance from skin incision to anterior clinoid process was 5.87 ± 0.24 cm in SKA, and 5.12 ± 0.27 cm in PKA. The operation view angle (from midline to the operating channel in sagittal plane) was 30°– 40° in SKA, and 60°– 68°in PKA group. Conclusion Our research demonstrates that both SKA and PKA are safe and effective for most anterior circulation aneurysms and parts of posterior circulation aneurysms. The SKA exposure aneurysm better on deep and sagittal directions, and is more suitable for clipping aneurysms by the contralateral approach due to the short distance. The PKA has a good exposure on the neck of aneurysm with dorsal direction of parent artery, and could evacuate hematoma in the temporal lobe when clipping the aneurysm. Integrating multi-modal 3D images could help neurosurgeon selecting an appropriate and effective approach.
Objective The aim of this study was to assess the levels of serum lipid and awareness, treatment, and control of dyslipidemia in type 2 diabetes mellitus (T2DM) patients from top-ranked endocrinology ...clinics in large cities of China. Materials and Methods A cross-sectional study in a representative sample of 4807 Chinese adults 40 to 75 years of age was conducted during 2010 to 2011 at 20 endocrinology clinics in top-ranked hospitals covering most of the major cities of China. Serum lipid levels were measured, and treatment of dyslipidemia was recorded and assessed. Results In the present study, the prevalence of dyslipidemia was 67.1% in T2DM subjects. Among those with dyslipidemia, the proportion of awareness and treatment was 68.7% and 55.9%. Among participants with lipid-lowering therapy, 686 subjects achieved the low-density lipoprotein cholesterol (LDL-C) control less than 2.60 mmol/L, with the rate being 39.4%. In those patients with previous cardiovascular disease, the percentage of participants who achieved LDL-C goal (1.80 mmol/L) was 15.3%. Conclusion The prevalence of dyslipidemia is high, and the awareness, treatment, and control of dyslipidemia are relatively low in Chinese T2DM patients. This calls for the awareness and intervention of dyslipidemia in these patients.
Background and Aims Image quality can be guaranteed with the conventional dosage of fluorescein sodium in probe-based confocal laser endomicroscopy (pCLE). However, yellow discoloration of the skin ...seriously affects daily life and simultaneously increases the risk of adverse events such as allergic reactions. The aim of this study was to test whether a lower dosage of fluorescein sodium can provide satisfactory image quality and to compare the diagnostic accuracy of gastric intestinal metaplasia (GIM) through a randomized blind controlled trial. Methods Consecutive patients were randomly assigned to different doses of fluorescein sodium. Image quality was determined by the endoscopists’ subjective assessments and signal-to-noise ratio (SNR) assessment systems. Skin discoloration was tested using a neonatal transcutaneous jaundice detector. In addition, consecutive patients with a known or suspected diagnosis of GIM were examined by pCLE with the lower dose and the traditional dose. Results Only 0.01 mL/kg dose of 10% fluorescein sodium led to a significant decrease in image quality ( P < .05), and a dose of 0.02 mL/kg had the highest SNR value ( P < .05). There were no significant differences in skin discoloration between the 0.01 mL/kg and 0.02 mL/kg doses ( P = .148) and no statistical difference in the diagnostic accuracy of pCLE for GIM between the 0.02 mL/kg and 0.10 mL/kg doses ( P > .05). The kappa values for the correlation between pCLE and histopathology were 0.867 (95% confidence interval, 0.782–0.952) and 0.891 (95% confidence interval, 0.811–0.971). Conclusions The 0.02 mL/kg dose of 10% fluorescein sodium seems to be the best dose for pCLE in the upper GI tract, with comparable image quality with the conventional dose and insignificant skin discoloration. This dose is also very efficient for the diagnosis of GIM.
Abstract Background Endoscopic submucosal tunneling dissection (ESTD) has been proved to be safe and effective for removal of esophageal submucosal tumors (SMTs) and can maintain the mucosal ...integrity compared with other endoscopic methods. The aim of the study was to estimate the safety and efficacy of ESTD as well as compare its efficacy with thoracoscopic enucleation for esophageal SMTs, which is used increasingly as a minimally invasive approach. Methods We retrospectively collected the clinical data of the patients with esophageal SMTs smaller than 40 mm who underwent ESTD or thoracoscopic enucleation at Nanfang hospital between January 2008 and August 2016. Epidemiological data (gender, age), tumor location, tumor size, en bloc resection rate, adverse events, pathological results, length of postoperative hospital stay and cost were compared between ESTD and thoracoscopic enucleation. Results A total of 126 patients were included, and 74 patients underwent ESTD and the other 52 received thoracoscopic enucleation. There was no significant difference between the 2 groups in gender, age, tumor size, hospitalization expense, infection, adverse events and en bloc resection rate ( p <0.05). However, patients in the ESTD groups had a shorter operating time, a less estimated blood loss, a shorter length of postoperative hospital stay and a lower chest pain level ( p <0.05). Kaplan-Meier curves for disease-free survival also shows no statistically significant difference between ESTD and thoracoscopic enucleation groups during the median follow-up of 19.5 and 42 months, respectively. Conclusions The treatment efficacy was comparable between the ESTD and thoracoscopic enucleation for esophageal SMTs smaller than 40 mm. However, there is a significant advantage in ESTD group for a shorter operating time, reduced postoperative chest pain and shorter hospitalization.
Accurate assessment of left atrial appendage (LAA) morphology is crucial in determining an LAA occlusion strategy. The aim of this study was to develop a novel echocardiographic volume-rendered ...imaging technique to visualize LAA morphology.
This was a retrospective study. Forty patients with atrial fibrillation who underwent three-dimensional (3D) transesophageal echocardiography (TEE) and cardiac computed tomographic angiography (CCTA) before catheter ablation were enrolled. Full-volume 3D data were acquired and displayed in gray values-inverted (GVI) mode. Threshold segmentation and interactive segmentation were used to create 3D digital replicas of the LAA chambers. The morphologic classification, number of lobes, and dimensions of the LAA were analyzed and compared with the data obtained with CCTA.
LAA morphology and measurements were successfully acquired via CCTA and 3D GVI TEE in all 40 cases. In terms of LAA morphologic classifications, 19 cases of chicken wing, eight of windsock, nine of cauliflower, and four of cactus morphology were determined using 3D GVI TEE, and 20 cases of chicken wing, eight of windsock, eight of cauliflower, and four of cactus morphology were determined using CCTA. The κ value between these two methods was 0.963. Measurements of maximal diameter, minimal diameter, and area of the ostia and the depth of the LAAs were larger when based on the 3D GVI transesophageal echocardiographic data than when using cardiac computed tomographic angiographic data (P < .01); however, there was agreement between the results. Formed thrombi were well displayed by both computed tomography and 3DGVI TEE.
Three-dimensional GVI TEE can be used to acquire LAA morphologic volume-rendered images that are similar to computed tomographic volume-rendered images, and it shows promise as a feasible and valuable modality for planning individual LAA occlusion procedures.
Background Confocal laser endomicroscopy (CLE) is a novel endoscopic modality that allows subsurface analysis of the gastric mucosa during ongoing endoscopy. Several studies have reported that this ...technique is of value in the diagnosis of premalignant lesions in the GI tract, but as yet no investigations have reported its application in the analysis of gastric intraepithelial neoplasia (GIN). Objective To assess the feasibility of CLE for the identification and grading of GIN. Design Prospective double-blind feasibility study. Setting Qilu Hospital, Shandong University, Jinan, China. Patients CLE images of 33 patients were first evaluated to establish the diagnostic criteria for gastric lesions. Eligible patients were then prospectively investigated by CLE using the newly established criteria. Interventions All endoscopically suspicious lesions were examined by CLE, and CLE diagnoses were compared with corresponding histopathologic results. Main Outcome Measurements Sensitivity, specificity, and positive and negative likelihood ratios of CLE diagnosis of biopsy-proven intraepithelial neoplasia by per-lesion analysis. Results The sensitivity, specificity, and positive and negative likelihood ratios of CLE diagnosis of GIN were 77.8%, 81.8%, 4.28, and 0.27, respectively. The mean κ value for interobserver agreement for the diagnosis of GIN was 0.70 among endoscopists and 0.71 between endoscopist and GI pathologist. Intraepithelial neoplasia score ≥5 differentiated high-grade from low-grade intraepithelial neoplasia with a sensitivity of 66.7% and a specificity of 88.0%. Limitations Nonrandomized single-center study, limited number of patients. Conclusions CLE is an acceptable and potentially useful technology for the identification and grading of GIN in vivo. The diagnostic accuracy needs to be improved.
Summary Our aim was to investigate the expression of micro-RNA-200b (miR-200b) and cAMP-responsive element-binding protein 1 (CREB-1) in astrocytoma and its efficacy for predicting outcome. Both ...miR-200b and CREB-1 messenger RNA expression was measured in 122 astrocytomas and 30 nonneoplastic brain specimens by quantitative real-time polymerase chain reaction. Expression of miR-200b was significantly lower in astrocytoma than in nonneoplastic brain ( P < .001), whereas CREB-1 messenger RNA expression was significantly elevated in the tumors ( P < .001). Both miR-200b down-regulation and CREB-1 up-regulation were significantly associated with advanced pathologic grade ( P = .002 and P = .006, respectively). Low miR-200b expression correlated negatively with Karnofsky performance score ( P = .03), and high CREB-1 expression correlated positively with mean tumor diameter ( P = .03). By Kaplan-Meier analysis, low miR-200b, high CREB-1, and coexistence of abnormal miR-200b and CREB-1 expression (low miR-200b/high CREB-1) were predictive of shorter progression-free survival and overall survival in both grade III and grade IV astrocytoma. By multivariate analysis, only low miR-200b/high CREB-1 expression was an independent prognostic factor for poor prognosis in astrocytoma of advanced grade. Both miR-200b and CREB-1 may play important cooperative roles in the progression of human astrocytoma. The efficacy of miR-200b and CREB-1 together as a predictor of prognosis in astrocytoma patients is shown for the first time.
Objective This study aims at evaluating the safety and efficacy of a porous stent system consisting of multiple overlapping uncovered stents in the treatment of complex aortic aneurysms with vital ...branches. Methods Data of all patients with aortic aneurysms treated in our center with multiple overlapping uncovered stents between February 2010 and December 2011 were retrospectively reviewed. Preoperative characteristics, intraoperative details, and follow-up outcomes were documented. Technical success was defined as successful deployment of the stents to target locations without procedure-related complications. Clinical success was characterized by complete shrinkage or stabilization of the aneurysm, preservation of vital branches, and absence of major complications. Patients were grouped, according to rapidity of aneurysm thrombosis, into fast-thrombosis group (complete thrombosis of aneurysmal sac was achieved in ≤6 months) and a delayed-thrombosis group (>6 months required for complete thrombosis). Possible factors affecting the speed of thrombosis were analyzed statistically with the Fisher exact test and the t -test. Results This porous stent system was used to treat 34 patients (23 men, 11 women; mean age, 65.7 years). Technical success was achieved in all patients (100%). Regular follow-up over 6 months was achieved in 29 patients (mean length of follow-up, 11.4 months). Complete thrombosis of the aneurysm sac within 12 months was observed in 24 patients (83%). Aneurysm shrinkage was documented in seven patients (24%) and stabilization in 21 (72%). All branch arteries covered by bare stents stayed patent during follow-up. The overall clinical success rate reached 97% in the follow-up group. Risk factors for delayed thrombosis included fewer stents implanted ( P = .013), longer sac entrance ( P = .043), and use of antiplatelet medication ( P = .040). Conclusions An alternative method of management of complicated aortic aneurysm appears to be feasible using overlapping bare stents, which may prevent aneurysm growth while preserving vital branches. The short-term outcome of our study seems encouraging but is not sufficient to draw a robust conclusion. Further hemodynamic and clinical studies are warranted to evaluate long-term efficacy.
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