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Aims/hypothesis: Glycaemic control and clinical outcomes in diabetes are improved by continuous subcutaneous insulin infusion (CSII). Atmospheric pressure changes during flights may affect insulin delivery from pumps and cause unintended metabolic consequences, including hypoglycaemia, in people with type 1 diabetes. The present report evaluates both hypobaric flight simulation and real-world data in pilots using insulin pumps while flying., Methods: In the flight simulation part of this study, an in vitro study of insulin pumps was conducted in a hypobaric chamber, de-pressurised to 550 mmHg to mimic the atmospheric pressure changes in airliner cabins during commercial flights. Insulin delivery rates and bubble formation were recorded for standard flight protocol. Insulin infusion sets, without pumps, were tested in a simulated rapid decompression scenario. The real-world observational study was a 7.5-year retrospective cohort study in which pre- and in-flight self-monitored blood glucose (SMBG) values were monitored in pilots with insulin-treated diabetes. Commercial and private pilots granted a medical certificate to fly within the European Union Aviation Safety Agency approved protocol and receiving insulin either by pump or multiple daily injections (MDI) were included., Results: In the flight simulation study, full cartridges over-delivered 0.60 U of insulin during a 20 min ascent and under-delivered by 0.51 U during descent compared with ground-level performance. During emergency rapid decompression, 5.6 U of excess insulin was delivered. In the real-world study, seven pilots using CSII recorded 4656 SMBG values during 2345 h of flying across 1081 flights. Only 33 (0.7%) values were outside an acceptable safe range (5.0-15.0 mmol/l [90-270 mg/dl]). No clinically significant fall in the median SMBG concentration was observed after aircraft ascent and no in-flight SMBG values were within the hypoglycaemic range (<4.0 mmol/l [<72 mg/dl]). Compared with pilots receiving MDI therapy, pilots using CSII recorded more SMBG values within the acceptable range (99.3% vs 97.5%), fewer values in the low red range (0.02% vs 0.1%), fewer in-flight out-of-range values (0.2% vs 1.3%) and maintained stricter glycaemic control during flight., Conclusions/interpretation: Ambient pressure reduction during simulated flights results in bubble formation and expansion within insulin cartridges. This causes unintended delivery of small insulin doses independent of pre-determined delivery rates and represents the maximum amount of insulin that could be delivered and retracted. However, in vivo, pilots using CSII in-flight did not experience a fall in blood glucose or episodes of hypoglycaemia during these atmospheric pressure changes and the use of insulin pumps can be endorsed in view of their clinical benefits., (© 2024. The Author(s).)

Aims: Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE., Methods: This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE., Results: A total of 13,569 patients were included from 68 sites. Overall, 11,363 patients were available for analysis: 44.79% were elective (n = 5,090), 42.16% were trauma excluding TA ruptures (n = 4,791), 3.50% were acute diabetic procedures (n = 398), 2.44% were TA ruptures undergoing surgery (n = 277), and 7.10% were TA ruptures treated nonoperatively (n = 807). In total, 11 chemical anticoagulants were recorded, with the most common agent being low-molecular-weight heparin (n = 6,303; 56.79%). A total of 32.71% received no chemical prophylaxis. There were 99 cases of VTE (incidence 0.87% (95% CI 0.71 to 1.06)). VTE-related mortality was 0.03% (95% CI 0.005 to 0.080). Univariable analysis showed that increased age and American Society of Anesthesiologists (ASA) grade had higher odds of VTE, as did having previous cancer, stroke, or history of VTE. On multivariable analysis, the strongest predictors for VTE were the type of foot and ankle procedure and ASA grade., Conclusion: The 90-day incidence of symptomatic VTE and mortality related to VTE is low in foot and ankle surgery and TA management. There was notable variability in the chemical prophylaxis used. The significant risk factors associated with 90-day symptomatic VTE were TA rupture and high ASA grade., Competing Interests: J. Mangwani reports support from the Leicester Hospitals Charity, related to this study. J. Mangwani reports payment or honoraria for lectures, presentations, educational events from Orthosolutions, and royalties from Meshworks, unrelated to this study. K. Malhotra reports payment or honoraria for lectures, presentations, speaker bureaus, manuscript writing or educational events from NewClip Technics, unrelated to this study. L. W. Mason reports royalties or licenses, consulting fees, and patents planned, issued or pending from Orthosolutions, unrelated to this study., (© 2024 The British Editorial Society of Bone & Joint Surgery.)

Hybrid closed-loop (HCL) systems remain underexplored within aviation, and as atmospheric pressure changes can independently affect insulin pumps and continuous glucose monitoring readings, this preliminary study assessed the feasibility of HCL safety evaluation, in both fasting and post-prandial states, by using hypobaric chamber to simulate flights. Participants with type 1 diabetes and on HCL were studied: Medtronic Guardian 4-Medtronic 780G-SmartGuard ( n = 4), Dexcom G6-Omnipod DASH-Android APS ( n = 1), and Dexcom G6-Ypsomed Pump-CamAPS ( n = 1). Flight cabin pressures of 550 mmHg and 750 mmHg were simulated in a hypobaric chamber. Seven-hundred-50 glucose measurements were taken, with glucose levels demonstrating a stable decline to 4 mmol/L during fasting. To maintain a tight fasting and post-prandial glucose range across the different pressure settings, the HCL administered insulin as expected. While not demonstrating any apparent issues, repeating flight simulation protocol with other systems, examining longer flights, and undertaking larger, powered randomised controlled trials can confirm their safety in aviation.

Competing Interests: None declared.

Background:  The evolution of artificial intelligence has introduced new ways to disseminate health information, including natural language processing models like ChatGPT. However, the quality and readability of such digitally generated information remains understudied. This study is the first to compare the quality and readability of digitally generated health information against leaflets produced by professionals., Methodology:  Patient information leaflets from five ENT UK leaflets and their corresponding ChatGPT responses were extracted from the Internet. Assessors with various degrees of medical knowledge evaluated the content using the Ensuring Quality Information for Patients (EQIP) tool and readability tools including the Flesch-Kincaid Grade Level (FKGL). Statistical analysis was performed to identify differences between leaflets, assessors, and sources of information., Results:  ENT UK leaflets were of moderate quality, scoring a median EQIP of 23. Statistically significant differences in overall EQIP score were identified between ENT UK leaflets, but ChatGPT responses were of uniform quality. Nonspecialist doctors rated the highest EQIP scores, while medical students scored the lowest. The mean readability of ENT UK leaflets was higher than ChatGPT responses. The information metrics of ENT UK leaflets were moderate and varied between topics. Equivalent ChatGPT information provided comparable content quality, but with reduced readability., Conclusion:  ChatGPT patient information and professionally produced leaflets had comparable content, but large language model content required a higher reading age. With the increasing use of online health resources, this study highlights the need for a balanced approach that considers both the quality and readability of patient education materials., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Dupilumab effectively treats atopic dermatitis (AD); however, its role in halting the atopic march remains uncertain., Objective: To investigate dupilumab's effect on atopic march in pediatric AD patients versus conventional immunomodulators., Methods: This retrospective cohort study utilized data from the TriNetX US Collaborative Network (2011-2024). Pediatric AD patients (≤18 years) were categorized into DUPI-cohort (newly prescribed dupilumab) or CONV-cohort (prescribed conventional immunomodulators without dupilumab). After 1:1 propensity-score matching, we analyzed atopic march progression, defined by the incident asthma or allergic rhinitis (AR). Cumulative incidence was plotted using Kaplan-Meier, with risk assessment via Cox regression., Results: The study included 2192 patients in each cohort. The 3-year cumulative incidence of atopic march progression was lower in the DUPI-cohort than the CONV-cohort (20.09% vs 27.22%; P < .001). The DUPI-cohort demonstrated significant risk reduction in atopic march progression (hazard ratio [HR] 0.68, 95% CI 0.55-0.83), individual asthma (HR 0.60, 0.45-0.81), and individual AR (HR 0.69, 0.54-0.88). Younger patients on dupilumab exhibited a greater risk reduction for atopic march progression and individual asthma, contrasting with the opposite age-related pattern for individual AR., Limitations: Observational study., Conclusion: Among pediatric AD patients, dupilumab was associated with reduced risk of atopic march progression compared with conventional therapies., Competing Interests: Conflicts of interest None declared., (Copyright © 2024 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Foreign body (FB) inhalation, ingestion, and insertion account for 11% of emergency admissions for ear, nose, and throat conditions. Children are disproportionately affected, and urgent intervention may be needed to maintain airway patency and prevent blood vessel occlusion. High-quality, readable online information could help reduce poor outcomes from FBs., Objective: We aim to evaluate the quality and readability of available online health information relating to FBs., Methods: In total, 6 search phrases were queried using the Google search engine. For each search term, the first 30 results were captured. Websites in the English language and displaying health information were included. The provider and country of origin were recorded. The modified 36-item Ensuring Quality Information for Patients tool was used to assess information quality. Readability was assessed using a combination of tools: Flesch Reading Ease score, Flesch-Kincaid Grade Level, Gunning-Fog Index, and Simple Measure of Gobbledygook., Results: After the removal of duplicates, 73 websites were assessed, with the majority originating from the United States (n=46, 63%). Overall, the quality of the content was of moderate quality, with a median Ensuring Quality Information for Patients score of 21 (IQR 18-25, maximum 29) out of a maximum possible score of 36. Precautionary measures were not mentioned on 41% (n=30) of websites and 30% (n=22) did not identify disk batteries as a risky FB. Red flags necessitating urgent care were identified on 95% (n=69) of websites, with 89% (n=65) advising patients to seek medical attention and 38% (n=28) advising on safe FB removal. Readability scores (Flesch Reading Ease score=12.4, Flesch-Kincaid Grade Level=6.2, Gunning-Fog Index=6.5, and Simple Measure of Gobbledygook=5.9 years) showed most websites (56%) were below the recommended sixth-grade level., Conclusions: The current quality and readability of information regarding FBs is inadequate. More than half of the websites were above the recommended sixth-grade reading level, and important information regarding high-risk FBs such as disk batteries and magnets was frequently excluded. Strategies should be developed to improve access to high-quality information that informs patients and parents about risks and when to seek medical help. Strategies to promote high-quality websites in search results also have the potential to improve outcomes., (©Tsz Ki Ko, Denise Jia Yun Tan, Ka Siu Fan. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.08.2024.)

Background: Nasopharyngeal carcinoma (NPC) is a rare disease that is strongly associated with exposure to the Epstein-Barr virus and is characterized by the formation of malignant cells in nasopharynx tissues. Early diagnosis of NPC is often difficult owing to the location of initial tumor sites and the nonspecificity of initial symptoms, resulting in a higher frequency of advanced-stage diagnoses and a poorer prognosis. Access to high-quality, readable information could improve the early detection of the disease and provide support to patients during disease management., Objective: This study aims to assess the quality and readability of publicly available web-based information in the English language about NPC, using the most popular search engines., Methods: Key terms relevant to NPC were searched across 3 of the most popular internet search engines: Google, Yahoo, and Bing. The top 25 results from each search engine were included in the analysis. Websites that contained text written in languages other than English, required paywall access, targeted medical professionals, or included nontext content were excluded. Readability for each website was assessed using the Flesch Reading Ease score and the Flesch-Kincaid grade level. Website quality was assessed using the Journal of the American Medical Association (JAMA) and DISCERN tools as well as the presence of a Health on the Net Foundation seal., Results: Overall, 57 suitable websites were included in this study; 26% (15/57) of the websites were academic. The mean JAMA and DISCERN scores of all websites were 2.80 (IQR 3) and 57.60 (IQR 19), respectively, with a median of 3 (IQR 2-4) and 61 (IQR 49-68), respectively. Health care industry websites (n=3) had the highest mean JAMA score of 4 (SD 0). Academic websites (15/57, 26%) had the highest mean DISCERN score of 77.5. The Health on the Net Foundation seal was present on only 1 website, which also achieved a JAMA score of 3 and a DISCERN score of 50. Significant differences were observed between the JAMA score of hospital websites and the scores of industry websites (P=.04), news service websites (P<.048), charity and nongovernmental organization websites (P=.03). Despite being a vital source for patients, general practitioner websites were found to have significantly lower JAMA scores compared with charity websites (P=.05). The overall mean readability scores reflected an average reading age of 14.3 (SD 1.1) years., Conclusions: The results of this study suggest an inconsistent and suboptimal quality of information related to NPC on the internet. On average, websites presented readability challenges, as written information about NPC was above the recommended reading level of sixth grade. As such, web-based information requires improvement in both quality and accessibility, and healthcare providers should be selective about information recommended to patients, ensuring they are reliable and readable., (©Denise Jia Yun Tan, Tsz Ki Ko, Ka Siu Fan. Originally published in JMIR Formative Research (https://formative.jmir.org), 27.11.2023.)

We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm 3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management., (© 2023. The Author(s).)

The vanadium redox flow battery (VRFB) can be used as a supporting technology for energy storage corresponding to wind and solar power generation. An aqueous vanadium compound solution can be used repeatedly. As the monomer is large, the flow uniformity of electrolytes in the battery is better, the service life is long, and the safety is better. Hence, large-scale electrical energy storage can be achieved. The instability and discontinuity of renewable energy can then be solved. If the VRFB precipitates in the channel, there will be a strong impact on the flow of vanadium electrolyte, and the channel could even be blocked as a result. The factors which influence its performance and life include electrical conductivity, voltage, current, temperature, electrolyte flow, and channel pressure. This study used micro-electro-mechanical systems (MEMS) technology to develop a flexible six-in-one microsensor which can be embedded in the VRFB for microscopic monitoring. The microsensor can perform real-time and simultaneous long-term monitoring of the physical parameters of VRFB, such as electrical conductivity, temperature, voltage, current, flow, and pressure to keep the VRFB system in the best operating condition.

Background: Aortic valve neocuspidization (AV Neo) using glutaraldehyde-treated autologous pericardium was first reported by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve in selected patients as long-term anticoagulation is not required and shows promising midterm results and durability., Method: A comprehensive search was performed on the major database using the search terms "Ozaki technique" AND "Aortic Valve Neocuspidization" AND "AV Neocuspidization" AND "Autologous pericardium" AND "glutaraldehyde-treated autologous pericardium." Articles up to August 1st, 2021 were included in this study., Results: A total of nine studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve (AV) and 31.37% of patients' native AV was bicuspid. Three studies reported their experience performing AV Neo via ministernotomy., Conclusion: AV Neo can be a suitable alternative to surgical AV replacement in selected patients. The short- and midterm outcomes are comparable without the need for long-term oral anticoagulation. Long-term follow-up data are required for this novel approach to be widely adopted., (© 2022 Wiley Periodicals LLC.)

Introduction: This bibliometric analysis evaluates the most influential studies in clinical research on melanoma., Methods: Based on the bibliometric theory, articles in the Thomson Reuters Web of Science database were analyzed. Full English-language articles were searched for using the terms melanoma, superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma, and acral lentiginous melanoma. The 100 most-cited articles were analyzed by topic, author, journal of publication, year of publication, institution, and country of origin., Results: The search returned 243,109 articles, with the majority from the past 3 decades: 1991-2000 (n = 29), 2001-2010 (n = 28), and 2011-2020 (n = 30). The top 100 cited articles had mean and median citations of 2,159 and 1,793, respectively. An article on the use of ipilimumab in metastatic melanoma, by Hodi et al., was most cited (8,150). The New England Journal of Medicine had the most citations (58,489), and Nature published the most articles (n = 21). The United States published the most articles (n = 81), led by the National Cancer Institute (n = 16). The majority of articles explored management (n = 68), prognosis (n = 57), and immunotherapy (n = 27)., Conclusions: This analysis serves as a guide for future research and highlights key areas of research, particularly in genetics and immunotherapy, that have influenced current knowledge of melanoma.

Introduction: Cardiothoracic surgery (CTS) has seen a decline in interest and application rates in recent years. As a relatively small speciality, teaching and placements in CTS are often not included during undergraduate study and postgraduate training. We aim to evaluate the exposure to CTS during both undergraduate study and postgraduate training., Methods: A ten-question online survey was designed and delivered to Foundation Year Two (FY2) doctors who graduated in 2017 and completed their two-year postgraduate foundation training in 2019. Medical schools with no graduates in 2017 and 2018 were excluded from our study. IBM® SPSS Statistics, version 25, and Microsoft Excel 365® were used for Student's t-test statistical analysis., Results: Three hundred and six FY2 doctors across 16 medical schools completed the survey, none of which included compulsory CTS attachments as their undergraduate curriculum. Thirty-two respondents (10.5%) underwent CTS attachments lasting between one to three weeks. Only 14 (43.8%) had worked in a cardiothoracic unit during their two-year Foundation Programme; 10 of which (71.2%) subsequently made an application for cardiothoracic speciality training. Most of the participants with previous exposure to CTS, during either undergraduate study or postgraduate Foundation Programme training or both, were significantly more likely to make an application to CTS training (P<0.05)., Conclusion: Our study suggests that doctors with increased exposure to CTS during undergraduate study and postgraduate training are more likely to pursue a career in CTS. Targeted interventions at both stages may improve interests in CTS and the number of prospective applicants.

There is a large demand for online patient information for patients considering rhinoplasty. While there are many resources available, the quality and content of the information provided are unknown. This study aimed to assess the quality of the most popular information available online, using the "Ensuring Quality Information for Patients" (EQIP) tool to evaluate the content, structure, and readability of patient information on websites. Search terms including nose operation, nose job, nose reshaping, nose tip surgery, rhinoplasty, septorhinoplasty, were identified using Google AdWords and Trends. Unique links from the first 10 pages for each term were identified and evaluated with websites written in English and for general non-medical public use were included. 295 websites met the eligibility criteria with a median overall EQIP score of 17. Only 33% contained balanced information on the risks and benefits. Bleeding and infection risk was only mentioned in 29% and 27% of websites, respectively. Two percent described complication rates of the procedures and only 20% of articles explained further surgery may be required to achieve patient cosmetic or functional satisfaction. Information regarding rhinoplasty available online is currently of poor quality. The lack of effective risk counselling, possible outcome management, and complications may likely lead to unrealistic expectations of rhinoplasty. It is crucial the risks of surgery are communicated to the patient to ensure they can make an informed decision. Improved education through online resources would likely help to promote more realistic patient expectations., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: The optimal analgesic strategy for patients undergoing donor hepatectomy is not known and the potential short- and long-term physical and psychological consequences of complications are significant., Objectives: To identify whether a multimodal approach to pain of the donor intraoperatively enhances immediate and short-term outcomes after living liver donation, and to provide international expert panel recommendations., Data Sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central., Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. PROSPERO 2021 CRD42021260699., Results: Nine studies assessing multi-modal analgesia strategies were included in a qualitative assessment. Interventions included local, regional, and neuro-axial anesthetic techniques, pharmacological intervention (NSAIDs, COX-2 inhibitors, ketamine, dexmedetomidine, and lidocaine), and acupuncture. Overall, there was a significant (40%) reduction in opioid requirement on day 1 and a significant reduction in pain scores in the intervention vs control groups. Significant reductions in either length of stay or post-operative complications were demonstrated in four of nine studies., Conclusions: Opioid use for patients undergoing donor hepatectomy is likely to impact both their short- and long-term outcomes. To reduce post-operative pain scores, shorten length of hospital stay, and promote earlier post-operative return of bowel function, we recommend that multi-modal analgesia be offered to patients undergoing living donor hepatectomy. Further research is required to confirm which multi-modal techniques are most associated with enhanced recovery in living liver donors., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Tonsillitis is a common paediatric condition. The decision to seek medical attention and consent to treatment is usually made by parents or guardians. With increased accessibility of the internet, online medical information plays an increasingly significant role in the decision-making process. Little is known regarding the quality of online patient information on tonsillitis, as this has not been previously studied., Objective: The aim of our study was to identify the quality of information regarding tonsillitis on websites intended for the public., Methods: We conducted a systematic review of online information on tonsillitis using the following search terms: "Tonsillectomy", "Tonsillitis", "Adenotonsillectomy" and "Tonsil". The first three pages of returned websites were captured and each website was examined using the validated Ensuring Quality Information for Patients (EQIP) tool (score 0-36)., Results: A total of 92 websites met the inclusion criteria for analysis. The overall median EQIP score was 19 with an interquartile range of 17-22 and a maximum of 32. More than half of all websites originated from the USA (61%) and hospitals were the most common source of information (29%). Most websites failed to describe the quantitative benefits or address the medical intervention costs and insurance issues. Half of the websites included both tonsillectomy and antibiotics as treatments for tonsillitis. Only 68% included complications of tonsillitis or tonsillectomy., Conclusions: The assessment of the quality of online patient information websites regarding tonsillitis by the EQIP tool indicates that most websites were of poor credibility, with minimal information regarding treatment choices and complications. To improve awareness of tonsillitis, there is a need for more informative and patient-centred websites that are compatible with the international quality standard for patient information., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Web-based health information plays an increasingly vital role in spreading health information. Many patients interested in aesthetic surgery study the procedure on the Internet. This study aims to evaluate the quality of online health information on injectable fillers using the modified "Ensuring Quality Information for Patients" (EQIP) tool. Nine different search terms, including "fillers," "fuller cheeks," "wrinkle removal," and "antiwrinkle treatment" were identified and queried on Google. Unique links from the first three pages of each search term were identified and evaluated if the contents were in English language and were for general non-medical public use. A total of 172 websites were analyzed, with a median EQIP score of 20. In total 129 websites belonged to aesthetic practitioners, of which 81 were operated by medical doctors. Eighty-three percent of websites disclosed some forms of postoperative complications, most commonly edema (74%) and bruising (73%). Blindness and tissue necrosis were only mentioned by 12 and 10% of the websites, respectively. The current health information available on injectable fillers is of poor quality. While many do provide some information on risks, the majority of websites fail to disclose severe complications and quantifying risks. This poses a barrier against informed decision-making and may lead to unrealistic expectations. Patient satisfaction and expectations may be improved by developing better online education resources on fillers., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Male breast cancer is a considerably rare condition and only accounts for 1% of all breast cancer cases. Due to limited public awareness, the condition is likely to present late, leading to late diagnosis and treatment worsening morbidity and mortality. This article aims to identify the focus and most influential research on male breast cancer. Objective Identify the most influential papers in male breast cancer., Methods: Search on Web of Science using the search terms 'Male', 'Breast Cancer' and "Male breast cancer" to identify all full manuscripts in English language and were ranked by the total number of citations. The top 100 articles were then further analysed according to subject, author, journal, year and country of publications., Results: The mean number of citations per paper was 96. Most cited paper was by Thorlacius, S et al. evaluating the relationship between BRCA2 and female breast cancer, prostate cancer, pancreatic cancer and ovarian cancer. Cancer is the journal with the most published papers and received most citations in the male breast cancer research field. The USA contributed 49 of the manuscripts in the top 100. The most studied topic was risk factors for male breast cancer, with 20 articles., Conclusions: The most cited papers identified in this study described the advance in the knowledge of genetics and epidemiology in male breast cancer and has led to improvements in the 4 management of the disease. Most of the highly cited articles in this field were published in high impact journals and had accumulated at least 100 citations to date, reflecting their quality and impact. By collating the most influential publications in this field, this analysis can serve to identify knowledge gaps in male breast cancer research as well as to help identify what makes a paper impactful and citable.

Patients with rheumatic diseases, such as rheumatoid arthritis, ankylosing spondylitis, and systemic lupus erythematosus, have increased risk of receiving total knee replacement surgery or total hip replacement surgery. We speculated that psoriasis could also attack the joints of the knees and hips, leading to an increased risk of receiving total knee replacement surgery or total hip replacement surgery. The aim of this study was to investigate the risk of total knee replacement or total hip replacement surgery in patients with psoriasis using a nationwide, population-based health claims database in Taiwan. Using the Taiwan's National Health Insurance Research Database, we identified 10,819 patients with psoriasis between 2000 and 2012. A comparison cohort consisting of five patients without psoriasis for each patient with psoriasis was assembled, based on frequency matching for sex, 10-year age interval, and index year. Both groups were followed until a diagnosis of the study outcomes (total knee replacement or total hip replacement surgery) or the end of the follow-up period. Incidence rate ratios (IRRs) for the outcome variables were calculated using multiple Poisson regression models. Female patients with psoriasis exhibited a significantly higher incidence of receiving total knee replacement surgery [adjusted IRR = 1.44, p = 0.014)]. Analyses stratified by age groups showed that the risk of receiving total knee replacement surgery was significantly higher older (adjusted IRR = 1.31, p = 0.047) patients with psoriasis. There were no significant differences in the risk of receiving total hip replacement surgery in patients with psoriasis compared with controls, either with or without stratification by sex or age groups. In conclusion, patients with psoriasis were associated with an increased risk of receiving total knee. Clinicians should be vigilant in assessing the presence of arthritis in these patients, and initiate strategies to delay or prevent the need for joint replacement., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lu, Fan, Hsu, Koo and Lai.)

Background: Appendicitis is a common surgical problem among the young adult population, who are likely to use the internet to obtain medical information. This information may determine the health-seeking behavior of an individual and may delay medical attention. Little is known regarding the quality of patient information on appendicitis on the internet, as this has not been previously studied., Objective: The aim of our study was to identify the quality of information regarding appendicitis on websites intended for the public., Methods: We conducted a systematic review of information on appendicitis available online using the following 4 search terms in google: "appendicitis," "appendix," "appendectomy," and "appendicectomy". The top 100 websites of each search term were assessed using the validated Ensuring Quality Information for Patients (EQIP) tool (score 0-36)., Results: A total of 119 websites met the eligibility criteria for evaluation. The overall median EQIP score for all websites was 20 (IQR 18-22). More than half the websites originated from the USA (65/119, 54.6%), and 45.4% (54/119) of all websites originated from hospitals, although 43% (23/54) of these did not mention qualitative risks from surgery. Incidence rates were only provided for complications and mortality in 12.6% (15/119) and 3.3% (4/119) of all websites, respectively., Conclusions: The assessment of the quality and readability of websites concerning appendicitis by the EQIP tool indicates that most sites online were of poor credibility, with minimal information regarding complication rates and mortality. To improve education and awareness of appendicitis, there is an immediate need for more informative and patient-centered websites that are more compatible with international quality standards., (©Shahi Ghani, Ka Siu Fan, Ka Hay Fan, Lorenzo Lenti, Dimitri Raptis. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.03.2021.)

Wound healing is a complex and highly regulated process that is susceptible to a variety of failures leading to delayed wound healing or chronic wounds. This is becoming an increasingly global burden on the healthcare system. Treatment of wounds has evolved considerably to overcome barriers to wound healing especially within the field of regenerative medicine that focuses on the replacement of tissues or organs. Improved understanding of the pathophysiology of wound healing has enabled current advances in technology to allow better optimization of microenvironment within wounds. This approach may help tackle wounds that are difficult to treat and help reduce the global burden of the disease. This article provides an overview of the physiology in wound healing and the application of gene therapy using nanotechnology in the management of wounds., (© 2020 The Wound Healing Society.)

Bibliometric analysis identifies the most influential manuscripts that shape our understanding of various congenital gastrointestinal pathologies. This study sets out to analyse the 100 most cited manuscripts on congenital gastrointestinal surgery. The Thomson Reuters Web of Science database was searched for all manuscripts relevant to paediatric congenital gastrointestinal surgery. The number of citations, authorship, publication date, journal of publication, institution and country were recorded for each paper. Eigenfactor and impact factor rankings were obtained for each journal of publication. 971 eligible manuscripts were returned by the search. Within the top 100 manuscripts, the most cited paper (by Metkus et al .) investigated fetal diaphragmatic hernia and was cited 413 times. University of Indianapolis had the most publications ( n =5) and Journal of Pediatric Surgery had the most citations ( n =3231). The country with the most publications in top 100 were the USA ( n =39). The most commonly published topics were diaphragmatic hernia ( n =23), abdominal wall defect ( n =20) and atresia ( n =6). The most cited manuscripts include various topics with a primary focus on the aetiology, diagnosis, management and outcome of diaphragmatic hernia and abdominal wall defects. Additionally, by collecting the most influential works, this study serves to reference what makes a manuscript 'citable'., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Indian Association of Pediatric Surgeons.)

This bibliometric analysis aims to identify publications and highlight the key areas that have shaped modern clinical practices for aortic valve replacement (AVR). In this paper, the top 100 most cited manuscripts for AVR are analyzed. The Thomson Reuters Web of Science database was searched using the terms "aortic valve replacement," "AVR," "sAVR," "tAVR," or "TAVI." The results were ranked by citation number and the top 100 articles were further analyzed by evaluating the subject, author, journal, year of publication, institution, and country of origin. Thirty-thousand and eight hundred eligible papers were examined, with an accumulation of 81 851 citations in total and a mean citation of 819 per manuscript (ranged: 344-4180). The New England Journal of Medicine had the most manuscripts whereas Circulation had the most citations. The number of citations has also significantly increased for articles published after 2000.The most cited manuscript highlighting the management of valvular heart disease, was written by Baumgartner et al By providing the most influential references, this work serves as a comprehensive guide to topics of interest in the field of AVR., (© 2020 Wiley Periodicals LLC.)

Objective: To evaluate the quality of information regarding the prevention and treatment of COVID-19 available to the general public from all countries., Design: Systematic analysis using the 'Ensuring Quality Information for Patients' (EQIP) Tool (score 0-36), Journal of American Medical Association ( JAMA ) benchmark (score 0-4) and the DISCERN Tool (score 16-80) to analyse websites containing information targeted at the general public., Data Sources: Twelve popular search terms, including 'Coronavirus', 'COVID-19 19', 'Wuhan virus', 'How to treat coronavirus' and 'COVID-19 19 Prevention' were identified by 'Google AdWords' and 'Google Trends'. Unique links from the first 10 pages for each search term were identified and evaluated on its quality of information., Eligibility Criteria for Selecting Studies: All websites written in the English language, and provides information on prevention or treatment of COVID-19 intended for the general public were considered eligible. Any websites intended for professionals, or specific isolated populations, such as students from one particular school, were excluded, as well as websites with only video content, marketing content, daily caseload update or news dashboard pages with no health information., Results: Of the 1275 identified websites, 321 (25%) were eligible for analysis. The overall EQIP, JAMA and DISCERN scores were 17.8, 2.7 and 38.0, respectively. Websites originated from 34 countries, with the majority from the USA (55%). News Services (50%) and Government/Health Departments (27%) were the most common sources of information and their information quality varied significantly. Majority of websites discuss prevention alone despite popular search trends of COVID-19 treatment. Websites discussing both prevention and treatment (n=73, 23%) score significantly higher across all tools (p<0.001)., Conclusion: This comprehensive assessment of online COVID-19 information using EQIP, JAMA and DISCERN Tools indicate that most websites were inadequate. This necessitates improvements in online resources to facilitate public health measures during the pandemic., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Coronary artery disease and its associated clinical sequelae are a significant medical burden to clinicians and patients. Severe coronary artery disease presenting in the context of acute myocardial ischaemia, or stable plaques causing chronic symptoms despite best conservative and pharmacological intervention, are often amenable to further intervention such as coronary artery bypass grafting. This procedure has been extensively compared to newer and less invasive techniques, such as percutaneous coronary intervention, and other minimally invasive procedures such as robotic or endoscopic techniques. This review summarises the current evidence on revascularisation of the left coronary artery system, with particular emphasis on key clinical endpoints of mortality, myocardial infarction, stroke and repeat revascularisation.

Objective: To examine the current literature behind the evolution of mitral valve surgery techniques and their impact on patient outcomes., Methods: An electronic literature search among major databases was performed (PubMed, Embase, Scopus, Cochrane, and Google scholar). All the relevant articles were screened and identified to be included in this narrative review. The main outcomes were postoperative morbidity, length of in-hospital stay, and long-term mortality., Results: Minimally invasive and robot-assisted approach to mitral valve repair and replacements has shown great potential in improving surgical outcomes when compared against traditional midline sternotomy. Selected patients can benefit from percutaneous mitral valve surgery; however, more evidence is required to ascertain its long-term outcomes., Conclusion: Current evidence suggests that robotic and minimal invasive mitral valve surgeries are increasing in practice with satisfactory perioperative and mortality rates. However, long-term data is yet to be published to support current practice.

Coronary artery bypass graft (CABG) is one of the most commonly performed cardiac surgeries in the world. CABG using the internal mammary artery (IMA) remains the gold standard intervention for myocardial intervention in multivessel coronary artery disease. IMA harvesting can be performed with various techniques and approaches: pedicled vs skeletonized harvesting technique as well as approaches such as conventional sternotomy, robotic and endoscopic approaches. While each technique and approach have their respective advantages and disadvantages, evidence remains varied between cohorts. Traditionally, IMA has been used as an in situ conduit; however, IMA free grafts also provide satisfactory outcomes in certain situations. This literature review aims to explore the efficacy of different techniques and approaches of IMA harvesting and grafting. With evidence compiled, this will provide an overview of the complexity of CABG and locate gaps in current literature to direct future research., (© 2020 Wiley Periodicals, Inc.)

We successfully synthesized a strontium-doped tricalcium silicate (Sr x Ca 3 - x SiO 5 , Sr = 0 to 2 mol%) bone cement using the sol-gel process. The material properties including crystallinity, setting time, mechanical strength, and hydration products were characterized. Release of ions and pH values of simulated body fluid soaked with the bone cement were measured. In vitro biocompatibility of different concentrations of the material was evaluated by the viability of L929 cells. The setting times of as-prepared slurries were all <70 min. Doping with 0.5 mol% Sr reduced the final setting time by 20 min. After 14 days curing, 0.25 mol% Sr-doped Sr x Ca 3 - x SiO 5 possessed the highest compressive strength of 45 MPa among all the Sr-doped groups with no statistical difference to Ca 3 SiO 5 . The bioactivity of the materials was confirmed with the formation of an apatite layer on the surface of the materials after immersion in simulated body fluid. In addition, the proliferation of L929 cells exposed to 1 mol% Sr was significantly promoted as compared to no Sr doping. Sr x Ca 3 - x SiO 5 is a novel and advanced material that has the potential to serve as a bone cement in bone restoration with appropriate mechanical strength and favorable biocompatibility., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: Acute appendicitis is a common surgical emergency, with a prevalence of 112 per 100,000 people per year in Europe. Negative appendicectomy is defined as a pathologically normal appendix removed from patient suspected with appendicitis. Negative appendectomy rate (NAR) has been reported to be around 15-25%. We aimed to evaluate our unit's negative appendectomy rate and the effect of pre-operative imaging on NAR., Method: A retrospective study including all patients who underwent both open and laparoscopic emergency appendicectomy in a single district general hospital from 2017-2018. Clinical information including cost was calculated based on the 2017/18 national tariff payment system. Patients under 18 years old were excluded from this study., Results: Two hundred thirty-two patients were included in this study, of which 69 (29.74%) had a pre-operative CT scan. The mean length of stay was 2.57 days. The sensitivity, specificity, positive predictive value and negative predictive value for CT were 77.8%, 100%, 87.5% and 100%. The negative appendicectomy rate with and without pre-operative CT scan were 7.25% and 22.09% respectively. Based on the 2017/18 national tariff payment system, a CT abdomen and pelvis with contrast and emergency appendicectomy with CC score of 0 cost 92 and 2370 pounds respectively. The total cost of patients who underwent appendicectomy without imaging was £ 322,320. If all patients undergo pre-operative CT, with a reduction of 15% in negative appendicectomy rate, the overall total cost would significantly lower to £ 36,212., Conclusion: Our study demonstrated that the negative appendicectomy rate could be improved by preoperative imaging. The study also showed that implementation of preoperative imaging for suspected appendicitis cases could save costs, allowing better allocation of resources., Competing Interests: Provenance: externally peer reviewed, (Copyright © 2020 Ulster Medical Society.)

Thoracic aortic aneurysms and aortic dissections (TAAD) are highly fatal emergencies within cardiothoracic surgery. With increasing age, thoracic aneurysms become more prevalent and pose an even greater threat when they develop into aortic dissections. Both diseases are multifactorial and are influenced by a multitude of physiological and biomechanical processes. Structural stability of aorta can be disrupted by genes, such as those for extracellular matrix and contractile protein, as well as telomere dysfunction, which leads to senescence of smooth muscle and endothelial cells. Biomechanical changes such as increased luminal pressure imposed by hypertension are also very prevalent and lead to structural instability. Furthermore, ageing is associated with a pro-inflammatory state that exacerbates degeneration of vessel wall, facilitating the development of both aortic aneurysms and aortic dissection. This literature review provides an overview of the aetiology and pathophysiology of both thoracic aneurysms and aortic dissections. With an improved understanding, new therapeutic targets may eventually be identified to facilitate treatment and prevention of these diseases., Competing Interests: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this review., (© 2019 The authors.)

Spinal cord injury (SCI) often leads to permanent loss of motor, sensory, and autonomic functions. We have previously shown that neurotrophin3 (NT3)-loaded chitosan biodegradable material allowed for prolonged slow release of NT3 for 14 weeks under physiological conditions. Here we report that NT3-loaded chitosan, when inserted into a 1-cm gap of hemisectioned and excised adult rhesus monkey thoracic spinal cord, elicited robust axonal regeneration. Labeling of cortical motor neurons indicated motor axons in the corticospinal tract not only entered the injury site within the biomaterial but also grew across the 1-cm-long lesion area and into the distal spinal cord. Through a combination of magnetic resonance diffusion tensor imaging, functional MRI, electrophysiology, and kinematics-based quantitative walking behavioral analyses, we demonstrated that NT3-chitosan enabled robust neural regeneration accompanied by motor and sensory functional recovery. Given that monkeys and humans share similar genetics and physiology, our method is likely translatable to human SCI repair., Competing Interests: The authors declare no conflict of interest.

Introduction: Patients with chronic obstructive pulmonary disease (COPD) frequently experience concurrent comorbidities; therefore, risk assessment for major adverse cardiovascular events (MACEs) is very important., Objectives: We explored the association between COPD and risk of MACEs with three common clinical events: acute myocardial infarction (AMI), ischemic stroke (IS), and cardiovascular death (CVD)., Methods: We evaluated the predictive value of the CHA2DS2-VASc score (congestive heart failure [C], hypertension [H], age [A], diabetes [D], stroke [S], and vascular disease [VASc]) for MACEs in COPD patients. In this observational study, we retrospectively reviewed the records of 29 258 patients with COPD between 2005 and 2009 in relation to MACE risk using the CHA2DS2-VASc score. We calculated the hazard ratios (HR) and 95% confidence intervals (CI) using a significance level of .05., Results: Patients with COPD had significantly (P < .001) increased risk of MACEs, and a high prevalence of CHA2DS2-VASc scores ≥ 6, predicting MACEs (16.1%), AMI (3.3%), IS (8.7%), and CVD (4.0%). A good discrimination was found for MACEs, IS events, and CVD events (AUC = 0.740, 0.739, and 0.778, respectively) but poorer discrimination for AMI events (AUC = 0.697)., Conclusion: Early lifestyle modifications and antithrombotic therapy may be essential for COPD patients at a high risk of MACEs, that is, those with CHA2DS2-VASc scores ≥ 6., (© 2017 John Wiley & Sons Ltd.)

The latent regenerative potential of endogenous neural stem/progenitor cells (NSCs) in the adult mammalian brain has been postulated as a likely source for neural repair. However, the inflammatory and inhibitory microenvironment after traumatic brain injury (TBI) prohibits NSCs from generating new functional neurons to restore brain function. Here we report a biodegradable material, chitosan, which, when loaded with neurotrophin-3 (NT3) and injected into the lesion site after TBI, effectively engaged endogenous NSCs to proliferate and migrate to the injury area. NSCs differentiate and mature into functional neurons, forming nascent neural networks that further integrate into existing neural circuits to restore brain function. Three main actions of NT3-chitosan, i.e., pro-neurogenesis, anti-inflammation, and pro-revascularization, elicit significant regeneration after TBI. Our study suggests that through creating an optimal microenvironment, endogenous NSCs are capable of executing neural repair, thus widening the therapeutic strategies to treat TBI and perhaps stroke or other neurological conditions., (Copyright © 2017. Published by Elsevier Ltd.)

Spinal cord injury (SCI) is considered incurable because axonal regeneration in the central nervous system (CNS) is extremely challenging, due to harsh CNS injury environment and weak intrinsic regeneration capability of CNS neurons. We discovered that neurotrophin-3 (NT3)-loaded chitosan provided an excellent microenvironment to facilitate nerve growth, new neurogenesis, and functional recovery of completely transected spinal cord in rats. To acquire mechanistic insight, we conducted a series of comprehensive transcriptome analyses of spinal cord segments at the lesion site, as well as regions immediately rostral and caudal to the lesion, over a period of 90 days after SCI. Using weighted gene coexpression network analysis (WGCNA), we established gene modules/programs corresponding to various pathological events at different times after SCI. These objective measures of gene module expression also revealed that enhanced new neurogenesis and angiogenesis, and reduced inflammatory responses were keys to conferring the effect of NT3-chitosan on regeneration.

Exophiala jeanselmei, a saprobe in the environment, is an opportunistic pathogen. We present a rare case of subcutaneous phaeohyphomycosis caused by E jeanselmei in a man aged 66 years with a 3-month history of a tender swelling on the dorsal area of the left middle finger. Purulent fluid was aspirated from the area, and the culture yielded black colonies composed of conidiophores, phialides, and yeast cells. After sequencing of the rDNA ITS1-5.8S-ITS2 gene, the pathogen was confirmed as E jeanselmei. The patient was cured by surgical excision without any antifungal agents., (Copyright © 2012. Published by Elsevier B.V.)

Myxomas are uncommon primary cardiac tumours that usually affect the left atrium. We herein report the case of a patient who presented with right heart failure and proteinuria, leading to the diagnosis of atrial myxoma. Surgical resection resulted in resolution of the patient's symptoms.

Objectives: To determine the curative effect and complications of 23G vitrectomy via corneal approach for the treatment of pediatric cataract., Materials and Methods: We performed anterior circular capsulotomy, lentectomy and aspiration, posterior circular capsulotomy, and anterior vitrectomy via corneal approach in 40 eyes from 25 children with congenital cataract. In patients aged > 2 years, foldable intraocular lens (IOL) was implanted and frame glasses were prescribed at younger age. The intraoperative/postoperative complications, comfort level, and inflammatory reaction after surgery were observed., Results: No intraoperative complications occurred and 9 eyes were simultaneously implanted IOL. All patients could blink normally except one child who suffered from corneal epithelial abrasion for one day. All corneas were clear and only mild postoperative inflammation was observed. There was no hyphema, effusion, hypotony, and hypertension. A week later, the mild congestion also disappeared. All parents reported good vision of their babies allowing them free play during 3-50 months follow-up. This surgical technique provided a clear 4-6 mm diameter visual axis and circular pupil in all cases. The IOL positions were centered at the pupil area. No secondary cataract developed., Conclusions: The 23-gauge vitrectomy via corneal approach for the treatment of pediatric cataract involves only mild discomfort and fewer complications.

Purpose: The aim of this study was to test whether or not a strong static magnetic field (SMF) had a positive effect on the survival rate of frozen erythrocytes., Materials and Methods: Human erythrocytes were slow freezing at a rate of -1°C/min, to a final temperature of -20°C. During the freezing process, the cells were simultaneously exposed to an SMF with a magnetic induction of 0.2 or 0.4 T. After the cells were thawed, the survival rate, morphology, and function of the thawed erythrocytes were evaluated. Furthermore, tests of membrane fluidity were performed to assess the effect of the SMF on the cell membrane., Results: The slow freezing process coupled with an SMF increased the survival rate of frozen erythrocytes, without any negative effect on the cell morphology or function. The increases in relative survival rates of frozen erythrocytes were 5.7% and 9.1% when the cells were frozen in 0.2 T and 0.4 T groups, respectively. In addition, the 0.4 T group significantly increased the membrane rigidity of the erythrocytes., Conclusions: Slow freezing coupled with a strong SMF produced positive effects on the survival rate of thawed erythrocytes, without changing their normal function.

Choroidal metastasis is uncommon and usually identified in a relatively advanced cancer status. The median survival after diagnosing choroid metastasis in lung cancer patients was only 1.9 months. Once failed to systemic treatment, there was no effective local treatment for saving visual acuity. The off-label use of intravitreal bevacizumab was popular in treating VEGF-mediated chorioretinal diseases worldwide. We here demonstrate a dramatic and durable response to intravitreal bevacizumab. Unlike the previous similar reports, our patient had failed both first- and second-line therapies., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

It is essential to the achievement of zero waste that emphasis is concentrated on front-end preventions rather than end-of-pipe (EOP) treatment. Zero waste is primarily based on cleaner production, waste management, the reduction of unnecessary consumption and the effective utilization of waste materials. The aim of this study was to briefly review the tasks undertaken and future plans for achieving zero waste in Taiwan. Waste prevention, source reduction, waste to product, waste to energy, EOP treatment, and adequate disposal are the sequential principal procedures to achieve the goal of zero waste. Six strategies have been adopted to implement the zero waste policy in Taiwan. These are regulatory amendments, consumption education, financial incentives, technical support, public awareness, and tracking and reporting. Stepwise targets have been set for 2005, 2007, 2011, and 2020 for both the municipal solid waste (MSW) and industrial waste to reach the goal of zero waste. The eventual aim is to achieve 70% MSW minimization and 85% industrial waste minimization by 2020. Although tools and measures have been established, some key programmes have higher priority. These include the establishment of a waste recycling programme, promotion of cleaner production, a green procurement programme, and promotion of public awareness. Since the implementation of the zero waste policy started in 2003, the volume of MSW for landfill and incineration has declined dramatically. The recycling and/or minimization of MSW quantity in 2007 was 37%, which is much higher than the goal of 25%. Industrial waste reached almost 76% minimization by the end of 2006, which is 1 year before the target year.

Objective: To clarify the proliferation of bovine corneal endothelial cells (bCEC) by interference with the recombinant plasmid of short hairpin RNA (shRNA) against p27Kip1, a kind of cyclin-dependent kinase inhibitor (CKI)., Methods: It was an experimental study. Three p27Kip1-shRNA template DNA sequences containing small hairpin structure were designed and synthesized as experimental groups. Plasmid expressing irrelevant shRNA with a random combination was used as negative shRNA. The products were inserted into the Pgensil-1 plasmid and the recombinant plasmid of Pgenesil-P1, Pgenesil-P2, Pgenesil-P3 and Pgenesil-HK were constructed. The recombinant plasmids were transfected into bCEC cells with liposome and a blank group. The expression of mRNA and protein of p27Kip1 was detected by RT-PCR and Western blot after stable transfection, and the plasmid with the best inhibitory effect was selected. The growth of the experimental group, Pgenesil-HK group and blank group were assessed by MTT. The influence of shRNA-p27Kip1 on bCEC cell cycle was deteceted by flow cytometry (FCM). All statistical analyses were performed using one-way ANOVA., Results: Restrictive enzyme digestion and sequence analysis showed that four recombinant plamids were constructed successfully and the aim sequence was obtained. The expression of p27Kip1 mRNA and p27Kip1 protein of Pgenesil-P1 group, Pgenesil-P2 group and Pgenesil-P3 group were all lower than that in the control group, including blank group and negative siRNA group. The inhibitive rate of mRNA reached 32.71%, 67.76% and 80.28% (F = 453.102, P = 0.000 in each group) and the inhibitive rate of protein reached 29.27%, 64.73% and 76.13% (F = 75.385, P = 0.000 in each group) compared with the blank group. As the lowest expression among the three positive shRNA group, Pgenesil-P3 was selected for the next steps. There was no significant difference between blank group and negative Pgenesil-HK of the expression of p27Kip1 protein (P = 0.356) and the express of p27Kip1 mRNA (P = 0.246). Compared with the control group and the blank group, the growth of the bCEC transfected by Pgenesil-P3 was significantly promoted with increased cell percent of S-phrase (F = 334.957, P = 0.000) and decreased cell percent of G1-phrase (F = 134.224, P = 0.000)., Conclusions: shRNA-p27Kip1 can down-regulate the expression of bCEC effectively and increase the growth of bCEC. shRNA-p27Kip1 RNA interference may be an effective method to promote the proliferation of CEC.

Before implementing the self-monitoring model programme of the Basel Convention in the Asia, Taiwan has conducted a comprehensive 4-year follow-up project to visit the governmental authorities and waste-disposal facilities in the countries that import waste from Taiwan. A total of nine treatment facilities, six of which are reported in this paper, and the five countries where the plants are located were visited in 2001-2002. France, Belgium and Finland primarily handled polychlorinated biphenyl capacitors, steel mill dust and metal waste. The United States accepted metal sludge, mainly electroplating sludge, from Taiwan. Waste printed circuit boards, waste wires and cables, and a mixture of waste metals and electronics were the major items exported to China. Relatively speaking, most treatment plants for hazardous waste paid close attention to environmental management, such as pollution control and monitoring, site zoning, system management regarding occupational safety and hygiene, data management, permits application, and image promotion. Under the tight restrictions formulated by the central environment agency, waste treatment plants in China managed the environmental issues seriously. For example, one of the treatment plants had ISO 14001 certification. It is believed that with continuous implementation of regulations, more improvement is foreseeable. Meanwhile, Taiwan and China should also continuously enhance their collaboration regarding the transboundary management of hazardous waste.

The objective of this work was to evaluate the production of hydrogen in a continuous system as a function of hydraulic retention time (HRT). The intermediates accumulated and other parameters of pH, oxidation-reduction potential were quantified. The heat treatment (103 degrees C for 24 h) of the compost from a cattle dung composting facility was able to select H2-producing spores; this product was used as a seed for continuous systems. The brewery waste was used as substrate. For the eight runs with combinations of five HRTs and four pHs, the results indicate that at pH=5.5, a maximum H2 production of 47% H2 concentration, 43 ml H2/g COD(added), and 3.1 l H2/l reactor d was achieved at HRT=18 h. Nevertheless, at HRT=18 h, pH 5.5 was also the optimum pH for the maximum H2 production among four pHs evaluated from 5 to 6.5. There was a significant accumulation of volatile acid and alcohols during the entire study.

Mixed metal-containing waste, polychlorinated biphenyls (PCB) containing capacitors, printed circuit boards, steel mill dust and metal sludge were among the most common wastes exported from Taiwan. Before the implementation of the self-monitoring model programme of the Basel Convention (secretariat of the Basel Convention 2001) in the Asia region, Taiwan conducted a comprehensive 4-year follow-up project involving government authorities and the waste disposal facilities of the importing countries. A total of five countries and nine plants were visited in 2001-2002. The following outcomes can be drawn from these investigations. The Chinese government adopts the strategies of 'on-site processing' and 'relative centralization' on the waste management by tightening permitting and increasing site inspection. A three-level reviewing system is adopted for the import application. The United States have not signed the Basel Convention yet; the procedures of hazardous waste import rely on bilateral agreements. Importers are not required to provide official notification from the waste exporting countries. The operation, administration, monitoring and licensing of waste treatment plants are governed by the state environmental bureau. Finland, France and Belgium are members of the European Union. The procedures and policies of waste import are similar. All of the documents associated with transboundary movement require the approval of each government involved. Practically, the notification forms and tracking forms effectively manage the waste movement.

Taiwan's resource recycling program was formally established in 1989, starting with the mandatory recycling of polyethylene terephthalate bottles. The number of mandatory regulated materials was extended to 8 categories with 27 items by 2002. Because of false data reporting, financial scandal, lack of transparency of the system, and the demand from parliament, the recycling policy has gradually changed from entirely privatized to being nationalized. Currently, the structure is built on six main bodies: fund management committee, consumers, industries responsible, recyclers, fee reviewing committee, and auditing agents. The industries that are responsible submit a fee, which is set by the fee reviewing committee, to the waste recycling fund (WRF), which is operated by the fund management committee. The auditing agents routinely check the responsible industries by documentation review as well as on-site counting to ensure that the fee is correctly submitted. The WRF provides initiatives to collect and dispose of the end-of-life products. The fund is split into a trust fund and a nonbusiness fund to deal with the collection, disposal, and treatment of the listed materials. The latter deals with the supporting works and ensures that the system runs effectively. The ratio of trust fund to nonbusiness fund is 80-20%. It is no doubt that the current practice achieves some improvements. Household waste has been reduced by 22%. And, most importantly, the benefit-to-cost ratio was as high as 1.24. However, similar to other state-owned systems, the resource recycling program has been criticized for false reporting from the responsible industries, a rigid system, and complicated procedures. To build a sustainable enterprise, the recycling program should be privatized as the recycling market and operating procedures are well established and fully mature.