Search

OBJECTIVE: Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair. METHODS: From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database. RESULTS: Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged more than 80 years being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes. CONCLUSIONS: Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.

Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates.Serum creatinine-based criteria were used to identify adult cardiac surgical patients having postoperative AKI in the Perfusion Measures and Outcomes (PERForm) Registry (July 1, 2014, to June 30, 2019). Patient characteristics, operative details, and outcomes were compared by race (Black vs White) after excluding patients with preoperative dialysis, missing preoperative or postoperative creatinine, or other races. A mixed effects model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict postoperative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses.The study cohort included 34 520 patients (8% Black). More Black patients than White patients were female (43% vs 27%, P.001), and had hypertension (93% vs 87%, P.001) and diabetes mellitus (51% vs 41%, P.001). Acute kidney injury of stage 2 or greater occurred in 1697 patients (5%), more often among Black than White patients (8% vs 5%, P.001). Intraoperatively, Black patients had lower nadir hematocrits (23 vs 26, P.001), and were more likely to be given transfusions (22% vs 14%, P.001). After adjustment, Black race (compared with White) independently predicted odds for postoperative AKI (adjusted odds ratio 1.50; 95% confidence interval, 1.26 to 1.78). The multivariable findings were similar in propensity score analyses.Despite accounting for differences in risk factors and intraoperative practices, Black patients had a 50% increased odds for having moderate-severe postoperative AKI compared with White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes.

BACKGROUND: There is little evidence on managing the proximal aorta of 4.0-4.5 cm during aortic valve replacement (AVR) in bicuspid aortic valve (BAV) patients. METHODS: A total of 431 patients between 1993-2019 underwent either an isolated AVR, AVR + concomitant ascending aorta replacement, or aortic root replacement. We divided patients into native root dilation [4.0-4.5 cm, n=121] vs. root control groups [

To determine long-term survival and reoperation rate in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV) after stentless aortic valve replacement (AVR)/aortic root replacement (ARR).Between 1992 and 2014, 1293 patients underwent first AVR/ARR with a stentless aortic valve using the modified inclusion operating technique, including 741 patients with a TAV and 552 with a BAV. Using propensity scoring with 26 variables, 330 matched pairs were identified with AVR with or without ascending aorta/arch replacement. Data were obtained through chart review, surveys, and the National Death Index.Patient demographics were similar in the propensity score-matched groups. Both groups had similar cardiopulmonary bypass, cross-clamp, and hypothermia circulatory arrest times, cerebral protection strategies, and rate of aortic arch replacement. The median size of implanted valves was similar (BAV: 27 mm [range, 25-29 mm] vs TAV: 27 mm [range, 25-27 mm]). Compared with the TAV group, the BAV group had a shorter hospital stay (6 days vs 7 days;The BAV patients had better long-term survival but a higher reoperation rate compared with TAV patients after stentless AVR. Our findings suggest caution in the use of bioprostheses for BAV patients.

Background Familiarity among cardiac surgery team members may be an important contributor to better outcomes and thus serve as a target for enhancing outcomes. Methods Adult cardiac surgical procedures (n = 4,445) involving intraoperative providers were evaluated at a tertiary hospital between 2016 and 2020. Team familiarity (mean of prior cardiac surgeries performed by participating surgeon/nonsurgeon pairs within 2 years before the operation) were regressed on cardiopulmonary bypass duration (primary—an intraoperative measure of care efficiency) and postoperative complication outcomes (major morbidity, mortality), adjusting for provider experience, surgeon 2-year case volume before the surgery, case start time, weekday, and perioperative risk factors. The relationship between team familiarity and outcomes was assessed across predicted risk strata. Results Median (interquartile range) cardiopulmonary bypass duration was 132 (91–192) minutes, and 698 (15.7%) patients developed major postoperative morbidity. The relationship between team familiarity and cardiopulmonary bypass duration significantly differed across predicted risk strata (P = .0001). High (relative to low) team familiarity was associated with reduced cardiopulmonary bypass duration for medium-risk (–24 minutes) and high-risk (–27 minutes) patients. Increasing team familiarity was not significantly associated with the odds of major morbidity and mortality. Conclusion Team familiarity, which was predictive of improved intraoperative efficiency without compromising major postoperative outcomes, may serve as a novel quality improvement target in the setting of cardiac surgery.

BACKGROUND. Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. METHODS. From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. RESULTS. Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%) and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .0001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality. CONCLUSIONS. Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

Images captured behind glass are often contaminated by the undesired reflection that hinders other computer vision tasks. Due to ubiquitous glasses, the removal of undesired reflection becomes more important. Reflection is determined by imaging system parameters such as the transparency, color of the glasses, the position of the camera. In this letter, we propose a novel generative model based on a generative adversarial network (GAN), where an Encoder extracts system parameters from input images and encodes them succinctly as a distribution and a Generator emulates the optical process of reflection. Separating the optical process of the system parameters allows our model to cope with diversified real-life scenarios and avoid the mode collapse phenomenon. Based on the generative model, we introduce a reflection removal model that simultaneously extracts the original image, the reflection layer, and the encoded parameters from single image input. Computational results of real data show that our approach outperforms existing approaches.

BACKGROUND Patients with gastric cancer experience severe psychological distress as a result of their cancer diagnosis and chemotherapy. Resilience is a defense mechanism that enables one to thrive amid distress. However, little research has been done to explore the formation and development mechanism of resilience among patients with gastric cancer before their first chemotherapy treatment. OBJECTIVE The mediating roles of self-efficacy and hope on the relationship between positive coping and resilience among patients with gastric cancer before their first chemotherapy treatment were examined to inform the future resilience intervention. METHODS A total of 253 patients with gastric cancer before their first chemotherapy treatment were investigated using the Simplified Coping Style Questionnaire, the General Self-efficacy Scale, the Herth Hope Index, and the 14-Item Resilience Scale. Structural equation modeling was conducted using Mplus version 7.03 to test the hypothesized mediational model. RESULTS Structural equation modeling analysis showed self-efficacy and hope completely mediated the relationship between positive coping and resilience; the indirect effects were 0.242 (P < .01) and 0.258 (P < .01), respectively; indirect effects accounted for 81% of the total effect. CONCLUSIONS Positive coping is not the independent predictor that may contribute to resilience among patients with gastric cancer before their first chemotherapy treatment, but it can indirectly affect resilience through self-efficacy and hope. IMPLICATIONS Self-efficacy and hope may increase the positive influence of positive coping on resilience among patients with gastric cancer before their first chemotherapy treatment. Resilience intervention might be enhanced by addressing the impact of positive coping on self-efficacy and hope.

Objective The purpose of this umbrella review was to assess the associations between sarcopenia and adverse health‐related outcomes. Design An umbrella review of meta‐analyses of observational studies. Setting and Participants Patients with sarcopenia and controls without sarcopenia were included. Measures The PubMed, Web of Science and Embase were searched for relevant systematic review and meta‐analysis. AMSTAR and GRADE system were used for methodological quality and evidence quality assessments, respectively. Results Totally 54 outcomes extracted from 30 meta‐analyses were analyzed. Twenty out of 21 prognostic outcomes indicated that sarcopenia was significantly associated with poorer prognosis of gastric cancer, hepatocellular cancer, urothelial cancer, head and neck cancer, hematological malignancy, pancreatic cancer, breast cancer, colorectal cancer, lung cancer, esophageal cancer, and ovarian cancer. Besides, 10 out of 16 postoperative outcomes suggested that sarcopenia significantly increased the risk of multiple postoperative complications and prolonged the length of hospitalization of patients with digestive cancer. In age‐related outcomes, sarcopenia significantly increased the risk of dysphagia, cognitive impairment, fractures, falls, hospitalization, and all‐cause mortality of elderly populations. Moreover, sarcopenia was also associated with higher level of albuminuria, risk of depression, and several metabolic diseases. Conclusions and Implications Sarcopenia significantly affected a wide range of adverse health‐related outcomes, particularly in patients of tumor and elderly populations. Because evidences of most outcomes were rated as “low” and “very low,” more prospective cohort studies are required in the future., Sarcopenia significantly affected a wide range of adverse health‐related outcomes, particularly in patients of tumor and elderly populations. Besides, associations between sarcopenia and risk of metabolic diseases, depression and albuminuria were also noticeable.

Delayed wound healing is commonly associated with diabetes. It may lead to amputation and death if not treated in a timely fashion. Limited treatments are available partially due to the poor understanding of the complex disease pathophysiology. Here, we investigated the role of leucine-rich α-2-glycoprotein 1 (LRG1) in normal and diabetic wound healing. First, our data showed that LRG1 was significantly increased at the inflammation stage of murine wound healing, and bone marrow–derived cells served as a major source of LRG1. LRG1 deletion causes impaired immune cell infiltration, reepithelialization, and angiogenesis. As a consequence, there is a significant delay in wound closure. On the other hand, LRG1 was markedly induced in diabetic wounds in both humans and mice. LRG1-deficient mice were resistant to diabetes-induced delay in wound repair. We further demonstrated that this could be explained by the mitigation of increased neutrophil extracellular traps (NETs) in diabetic wounds. Mechanistically, LRG1 mediates NETosis in an Akt-dependent manner through TGFβ type I receptor kinase ALK5. Taken together, our studies demonstrated that LRG1 derived from bone marrow cells is required for normal wound healing, revealing a physiological role for this glycoprotein, but that excess LRG1 expression in diabetes is pathogenic and contributes to chronic wound formation.

Background Pneumonia is the most prevalent healthcare-associated infection after coronary artery bypass grafting (CABG), but the relative effectiveness of strategies to reduce its incidence remains unclear. We evaluated the relationship between healthcare-associated infection recommendations and risk of pneumonia after CABG. Methods Pneumonia prevention practice recommendations were developed based on literature review and analysis of semistructured interviews with key health care personnel across centers with low ( 6.1%) rates of pneumonia. These practices were implemented among 2482 patients undergoing CABG from 2016 to 2017 across 18 centers. The independent effect of each practice in reducing pneumonia was assessed using multivariable logistic regression, adjusting for baseline risk and center. A composite (bundle) score was calculated as the number of practices (0 to 4) each patient received. Results Recommended pneumonia prevention practices included lung protective ventilation management, early extubation, progressive ambulation, and avoidance of postoperative bronchodilator therapy. Pneumonia occurred in 2.4% of patients. Lung protective ventilation (adjusted odds ratio [ORadj], 0.45; 95% confidence interval [CI], 0.22-0.92), ambulation (ORadj, 0.08; 95% CI, 0.04-0.17), and postoperative ventilation of less than 6 hours (ORadj, 0.47; 95% CI, 0.26-0.87) were significantly associated with lower odds of pneumonia. Postoperative bronchodilator therapy (ORadj, 4.83; 95% CI, 2.20-10.7) was significantly associated with higher odds. Risk-adjusted rates of pneumonia, operative mortality, and intensive care unit length of stay were lower in patients with higher bundle scores (all P-trend Conclusions These pneumonia prevention recommendations may serve as effective targets for avoiding postoperative healthcare-associated infections.

This paper presents a novel image compression-encryption scheme, which has the compression-confusion-diffusion Structure. Firstly, based on Chebyshev chaotic map, a Gauss measurement matrix is constructed and optimized, which is applied to compressive sensing. Then, an image compression-encryption algorithm is proposed by using a six-dimensional discrete chaotic map. In the proposed scheme, the original image is transformed into a sparse coefficient matrix by discrete wavelet transform, and the sparse coefficients are measured by using the optimized Gauss measurement matrix to get the measured values. Then, the measured values are quantized into integer values and the compressed image is obtained. Furtherly, the compressed image is encrypted by using a six-dimensional chaotic map. In the process of encryption, the plaintext image is divided into two parts, when encrypting the second part, the first part is used as part of the key. While encrypting the first part, the ciphertext of the second part is used as part of the key. Thus, the algorithm has strong confusion and diffusion effect and makes ciphertext sensitive to plaintext. Experimental results such as effects of compression-encryption, key space analysis, key sensitivity analysis, differential analysis, histograms analysis, information entropy analysis, and correlation coefficients analysis show that the proposed scheme is secure and has high application potential.

The longevity of a stentless valve in a younger population (20-60 years old) is unknown.From 1992 to 2015, 1947 patients underwent aortic valve/root replacement for aortic stenosis, insufficiency, root aneurysm, or aortic dissection with stentless bioprostheses (median size, 26 mm). At operation 105 patients were40 years old, 528 were 40 to 59, 860 were 60 to 74, and 454 were ≥75 years. The data were obtained through chart review, administered surveys, and the National Death Index.The 30-day mortality rate was 2.6%. During follow-up 807 patients (41%) died before reoperation, 993 (51%) were alive without reoperations because of deterioration, and 113 patients (5.8%) underwent reoperation for structural valve deterioration. After adjusting death and reoperation for non-structural valve deterioration causes as competing risks, the cumulative incidence of reoperation was significantly different between the younger groups (40, 40-59) and the older groups (60-74, ≥75; P.0001) but not inside the younger (40 vs 40-59) or older (60-74 vs ≥75) group. The significant hazard ratio of reoperation for40 versus ≥75 years of age was 12,40 versus 60 to 74 was 4, 40 to 59 versus 60 to 74 was 3, and 40 to 59 versus ≥75 was 9 (P ≤ .01). The 10- and 15-year survival in the entire cohort was 53% and 29%, respectively.The stentless aortic valve provides satisfactory durability as a conduit for aortic valve/root replacement for patients who prefer a bioprosthesis. However it should be judiciously considered for patients younger than 60 years because of an increased incidence of reoperation for structural valve deterioration.

There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, (Equation is included in full-text article.)O2peak), and blood pressure.Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection.Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured (Equation is included in full-text article.)O2peak was36% predicted normative values (19.2 mL·kgmin vs 29.3 mLkgmin, P.0001); the most marked impairment in (Equation is included in full-text article.)O2peak was observed in the acute type A aortic dissection group (40% normative values), which was significantly different from other groups (P.05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups.We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. (Equation is included in full-text article.)O2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness.

It is controversial if extension of aortic dissection into arch branches should be an indication for replacement of the arch and its branches in acute type A aortic dissection.From 2008 to April 2018, 399 patients underwent open repair for an acute type A aortic dissection, and 190 patients had known innominate and/or left common carotid artery dissection without malperfusion syndrome, including no arch procedure (n = 1)/hemiarch replacement (n = 109) and zone 1/2/3 arch replacement (n = 80) with replacement of 1 to 4 arch branch vessels.Median patient age was 58 years. Preoperative comorbidities were similar between groups, except the hemiarch group had more coronary artery disease (22% vs 3%, P = .0002). Both groups underwent similar aortic root procedures and other concomitant procedures with equivalent cardiopulmonary bypass and aortic cross-clamp times. The zone 1/2/3 group had longer hypothermic circulatory arrest times with greater use of antegrade cerebral perfusion (all P.05). The perioperative and midterm outcomes were similar between the hemiarch and zone 1/2/3 arch groups, including 30-day mortality (7% vs 5%), rates of transient ischemic attack and stroke, incidence rates of reoperation for distal aortic pathology with a mean follow-up time of 3.5 years, and 5-year survival (79% [95% confidence interval, 69%-87%] vs 85% [95% confidence interval, 71%-93%]). However the hemiarch group had a trend of increased cumulative incidence of reoperation (8-year, 23% vs 9%; P = .33).In acute type A aortic dissection, dissection of arch branches alone should not be an indication for routine zone 1/2/3 arch replacement; however zone 1/2/3 arch replacement could be considered to prevent future reoperations in select patients.

Exercise training benefits the heart. The knowledge of post-transcription regulation, especially RNA editing, in hearts remain rare. ADAR2 is an enzyme that edits adenosine to inosine nucleotides in double-stranded RNA, and RNA editing is associated with many human diseases. We found that ADAR2 was upregulated in hearts during exercise training. AAV9-mediated cardiac-specific ADAR2 overexpression attenuated acute myocardial infarction (AMI), MI remodeling, and doxorubicin (DOX)-induced cardiotoxicity. In vitro, overexpression of ADAR2 inhibited DOX-induced cardiomyocyte (CM) apoptosis. but it could also induce neonatal rat CM proliferation. Mechanistically, ADAR2 could regulate the abundance of mature miR-34a in CMs. Regulations of miR-34a or its target genes (Sirt1, Cyclin D1, and Bcl2) could affect the pro-proliferation and anti-apoptosis effects of ADAR2 on CMs. These data demonstrated that exercise-induced ADAR2 protects the heart from MI and DOX-induced cardiotoxicity. Our work suggests that ADAR2 overexpression or a post-transcriptional associated RNA editing via ADAR2 may be a promising therapeutic strategy for heart diseases.

Objective We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. Methods An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed. Results Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications. Conclusions The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.

IntroductionAbdominal surgery is associated with common complications, including decreased or poor appetite, abdominal distension, abdominal pain caused by decreased or absent gastrointestinal motility, anal arrest with flatus and defecation, and nausea and vomiting resulting from the use of anaesthetics and opioid analgesics. These complications seriously affect postoperative recovery, prolong hospital stay and aggravate patient burden. This study aims to investigate for the first time the efficacy of transcutaneous electrical acupoint stimulation (TEAS) combined with electroacupuncture (EA) therapy for rapid recovery after laparotomy for gastrointestinal surgery. There have been no clinical studies of this combination therapy.Methods and analysisThis will be a prospective, single-centre, three-arm, randomised controlled trial. A total of 480 patients undergoing abdominal surgery will be stratified according to surgery type (ie, gastric or colorectal procedure) and randomised into three groups; namely, the EA, TEAS +EA and control groups. The control group will receive enhanced recovery after surgery (ERAS)-standardised perioperative management, including preoperative education, optimising the anaesthesia scheme, avoiding intraoperative hypothermia, restrictive fluid infusion and reducing surgical trauma. The EA group will receive EA stimulation at LI4, PC6, ST36, ST37 and ST39 based on the ERAS-standardised perioperative management. Moreover, the TEAS +EA group will receive ERAS-standardised perioperative management; EA stimulation at the LI4, PC6, ST36, ST37 and ST39; and TEAS stimulation at ST21 and SP15. The primary outcome will be the GI-2 (composite outcome of time to first defaecation and time to tolerance of a solid diet). Secondary outcomes will include the time of first passage of flatus, time to first defaecation, time to tolerance of a solid diet, time to first ambulation, hospital duration from operation to discharge, pain and nausea vomiting scores on the Visual Analogue Scale, medication use, incidence of postoperative complications and evaluation of treatment modality acceptability. All statistical analyses will be performed based on the intention-to-treat principle.Ethics and disseminationEthics approval has been granted by the Ethics Committee on Biomedical Research, West China Hospital of Sichuan University (approval number: 2021; number 52). The results are expected to be published in peer-reviewed journals.Trial registration numberChiCTR2100045646.

We examined cardiac features associated with residual mitral regurgitation (MR) following continuous-flow left ventricular assist device (cfLVAD) implant. From 2003 to 2017, 134 patients with severe MR underwent cfVLAD implant without mitral valve (MV) intervention. Echocardiographic (echo) assessment occurred pre-cfLVAD, early post-cfLVAD, and at last available echo. Ventricular and atrial volumes were calculated from established formulas and normalized to be predicted. Cluster analysis based on preoperative normalized left ventricular and atrial volumes, and MV height identified grades 1, 2, and 3 with progressively larger cardiac chamber sizes. Median early echo follow-up was 0.92 (0.55, 1.45) months and the last follow-up was 15.12 (5.28, 38.28) months. Mitral regurgitation improved early after cfLVAD by 2.10 ± 1.16 grades (p < 0.01). Mitral regurgitation severity at the last echocardiogram positively correlated with the preoperative left ventricular volume (p = 0.014, R = 0.212), left atrial volume (p = 0.007, R = 0.233), MV anteroposterior height (p = 0.032, R = 0.185), and MV mediolateral diameter (p = 0.043, R = 0.175). Morphologically, smaller grade 1 hearts were correlated with MR resolution at the late follow-up (p = 0.023). Late right ventricular failure (RVF) at the last clinical follow-up was less in grade 1 (4/48 [8.3%]) compared with grades 2 and 3 (26/86 [30.2%]), p = 0.004). Grade 1 cardiac dimensions correlates with improvement in severe MR and had less late RVF.

Objective To determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). Methods Between 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. Results Compared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P Conclusions BAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.

Objectives We examined for differences in pre–left ventricular assist device (LVAD) implantation myocardial transcriptome signatures among patients with different degrees of mitral regurgitation (MR). Methods Between January 2018 and October 2019, we collected left ventricular (LV) cores during durable LVAD implantation (n = 72). A retrospective chart review was performed. Total RNA was isolated from LV cores and used to construct cDNA sequence libraries. The libraries were sequenced with the NovaSeq system, and data were quantified using Kallisto. Gene Set Enrichment Analysis (GSEA) and Gene Ontology analyses were performed, with a false discovery rate Results Comparing patients with preoperative mild or less MR (n = 30) and those with moderate-severe MR (n = 42), the moderate-severe MR group weighted less (P = .004) and had more tricuspid valve repairs (P = .043), without differences in demographics or comorbidities. We then compared both groups with a group of human donor hearts without heart failure (n = 8). Compared with the donor hearts, there were 3985 differentially expressed genes (DEGs) for mild or less MR and 4587 DEGs for moderate-severe MR. Specifically altered genes included 448 DEGs for specific for mild or less MR and 1050 DEGs for moderate-severe MR. On GSEA, common regulated genes showed increased immune gene expression and reduced expression of contraction and energetic genes. Of the 1050 genes specific for moderate-severe MR, there were additional up-regulated genes related to inflammation and reduced expression of genes related to cellular proliferation. Conclusions Patients undergoing durable LVAD implantation with moderate-severe MR had increased activation of genes related to inflammation and reduction of cellular proliferation genes. This may have important implications for myocardial recovery.

BACKGROUND: The biological role and clinical significance of transfer RNA-derived small RNAs (tsRNAs) remain largely unclear. The purpose of this study was to investigate the biological function, molecular mechanism, and clinical significance of tsRNA-5001a in lung adenocarcinoma. METHODS: The function of tsRNA-5001a on the growth of tumor cells was accessed by cell function experiments. Real-time quantitative polymerase chain reaction (RT-qPCR) was used to detect the expression of tsRNA-5001a in paired samples of lung adenocarcinoma. Cell localization of tsRNA-5001a was performed by nuclear-cytoplasmic separation assay. Transcriptome sequencing was used to screen the molecules involved in the regulatory network of tsRNA-5001a. Independent samples t-test was used to compare the two groups. Prism software (Prism 7.0) was used to analyze the statistical results. P

Background Constitutional mismatch repair deficiency (CMMRD) is a rare autosomal recessive condition, which is caused by biallelic mutations in mismatch repair genes: MSH2, MLH1, MSH6, and PMS2. Case presentation We reported a unique case of an 11-year-old Chinese girl with colorectal polyposis and café-au-lait macules who had no obvious family history of Lynch syndrome-associated tumors, followed by brain gliomas and colorectal carcinoma five years later. The diagnosis of CMMRD was based on gene sequencing analysis showing a homozygous deletion NM_00535.5:c.1577delA (p.Asp526fs) in exon 11 of the PMS2 gene. Although the patient underwent surgery and radiation therapy, and close surveillances including radiological, endoscopic and hematological screening have been recommended, she died of the exacerbation of neurological symptoms at the age of 18. Conclusions We identified a novel homozygous deletion in the PMS2 gene in a CMMRD patient with complex clinical features.

Treatment of chronic hepatitis B with pegylated-interferon-α-2a (PegIFNα) in pediatric patients can lead to a higher rate of hepatitis B virus (HBV) surface antigen (HBsAg) loss than in adults. However, the mechanism of underlying immune response is not clear. The aim of this study was to explore innate and adaptive immunity, especially HBV-specific T cell responses in hepatitis B e antigen (HBeAg)-positive pediatric patients, who have experienced HBsAg loss. Isolated lymphocytes of 20 HBeAg-positive pediatric patients were collected every 12 weeks until treatment was stopped. The phenotype of T/natural killer (NK) cells and function of HBV-specific T cells were analyzed by flow cytometry. The frequency of CD69 and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) expressed on T cells and TRAIL on CD56hi NK cells in patients with HBsAg loss was remarkably higher compared with nonresponse patients. Furthermore, in vitro peptide stimulation of HBV-specific T cell responses was increased in patients with HBsAg loss when compared with week 0 and 48, and correlated with decline of viral load. The PegIFNα therapy in pediatric patients triggered T/NK cell activation and HBV-specific T cell responses, thereby contributing to successful viral control.

As surgical mortality decreases and endovascular utilization increases, it is unknown whether volume-outcome relationships exist in thoracic aortic dissection repair. We characterized volume-outcome relationships for surgical and endovascular management of thoracic aortic dissection.Patients aged more than 18 years undergoing repair of thoracic aortic dissection in the United States between 2010 and 2014 were identified in seven all-payer state inpatient administrative databases. Patients were divided into groups based on type of repair: surgical repair of type A dissection (TAAD), surgical repair of type B dissection (TBAD), and endovascular repair (TEVAR). Hierarchical logistic regression models evaluated the association between hospital volume and in-hospital mortality.Overall in-hospital mortality rate was 13.4% (890 of 6650), highest after TAAD (463 of 2918, 15.9%), followed by TBAD (270 of 1934, 14.0%) and TEVAR (157 of 1798, 8.7%). Volume-outcome relationships for adjusted in-hospital mortality were demonstrated for TAAD and TBAD (P-trend.001), but not TEVAR (P-trend = .11). Adjusted in-hospital mortality differed most for TAAD (fewer than 3 cases per year: 21%, 95% confidence interval, 18% to 24%; vs 11 or more cases per year: 12%, 95% confidence interval, 8% to 16%; P.001) and TBAD (fewer than 2 cases per year: 18%, 95% confidence interval, 15% to 22%; vs 11 or more cases per year: 9%, 95% confidence interval, 5% to 12%; P.001), whereas TEVAR did not differ between quartiles. Adjusted mortality was lower at centers with 26 or more overall annual thoracic dissection repairs, compared with any of the three lower-volume quartiles (P.001).This study demonstrated lower mortality at high-volume hospitals for overall repair of aortic dissection, persisting separately for surgical repair of TAAD and TBAD, but not TEVAR. As endovascular technology advances and practice patterns consequently change, analyses should focus on understanding the balance between procedural volume, mortality, and access to care for thoracic aortic dissection.

Methylated SEPT9 showed relatively low sensitivity in detecting early stage colorectal cancer (CRC) and advanced adenomas (AA) in plasma. Combination of multiple biomarkers was an effective strategy to improve sensitivity in early stage cancer diagnosis and screening. A new qPCR‐based assay combining the detection of methylated SEPT9 and SDC2 (ColoDefense test) was used. Methylation statuses of SEPT9 and SDC2 were examined in 40 sets of cancer tissues and paired adjacent tissues, 10 adenomatous polyps and 3 hyperplastic polyps (HP). Then evaluated with 384 plasma samples, including 117 CRC patients, 23 AA patients, 78 small polyps patients, and 166 normal individuals. The limit of detection of ColoDefense was about 25 pg per reaction. Both SEPT9 and SDC2 were shown by ColoDefense to be heavily methylated in CRC tissues when compared to paired paracancerous tissues and HP (P, Colorectal cancer (CRC) is the most common malignancy of gastrointestinal tract and methylated SEPT9 showed relatively low sensitivity in detecting early stage CRC and advanced adenomas (AA) in plasma. We evaluated the performance of the new qPCR‐based assay (ColoDefense test) combining the detection of multiple methylated circulating tumor DNA biomarkers. The ColoDefense test showed high sensitivity and specificity in detecting early stage CRC (stage I) and AA in plasma when compared with methylated SEPT9 alone.

Acute heart failure (AHF) is a life-threatening condition with poor prognosis. Gender differences have been increasingly recognized in diverse cardiovascular diseases. The present study aimed to evaluate gender-specific prognostic markers of all-cause death in AHF patients based on a prospective 18-month follow-up study. Data were collected from 419 patients with AHF hospitalization who were followed up for 18 months using all-cause death as primary endpoint. The mean age of all patients was 60.9 ± 15.7 years old, 277 were males, and 142 were females. Females had higher rate of valvular heart disease (37.3%) and atrial fibrillation (45.8%) but lower rate of cardiomyopathy (30.3%) than males in this cohort. Based on multiple COX stepwise regression and ROC curve analysis, diastolic blood pressure (DBP), serum sodium, serum creatinine, and pulmonary artery systolic pressure (PASP) were identified as independent predictors of all-cause death in male AHF patients, while systolic blood pressure (SBP), serum aspartate transaminase (AST), serum creatinine, and serum D-dimer as independent predictors in females. Kaplan-Meier analysis showed a higher probability of all-cause death over time in male AHF patients with DBP ≤ 77 mmHg, serum sodium ≤ 138.5 mM, serum creatinine ≥ 126.2 μM, or PASP ≥ 52 mmHg, and in female AHF patients with SBP ≤ 129 mmHg, serum AST > 29.3 U/L, serum creatinine ≥ 102.7 μM, or serum D-dimer ≥ 1.76 mg/L. In conclusion, these data provide novel insights into gender differences in prognostic markers of outcomes of AHF patients.

The long-term survival and reoperation rate in chronic renal failure (CRF) on hemodialysis (HD) patients after aortic valve/root replacement (AVR/ARR) with a stentless bioprosthesis is unknown. From 1992-2015, 1941 patients underwent AVR/ARR with stentless valve for primary indications of aortic stenosis/insufficiency, root aneurysm, and acute type A aortic dissection, including 93 CRF-HD (64 new-onset postoperative HD, and 29 preoperative HD) and 1848 non-CRF-HD. Data was obtained from the STS database, retrospective chart review, administered surveys and national death index data. Compared to the non-CRF-HD group, the CRF-HD group had significantly higher incidence of diabetes mellitus (28 vs 18%), CAD (49 vs 38%), COPD (31 vs 16%), NYHA class IV (12 vs 4%), atrial fibrillation (24 vs 12%), and previous cardiac surgery (27 vs 16%). Postoperatively, CRF-HD group had a higher reoperation for bleeding (10 vs 4%), length of hospital stays (20 vs 7 days), and operative mortality (23 vs 2.3%), all p0.01. The odds ratio of CRF-HD for operative mortality was 8.97. The long-term survival was worse in CRF-HD group than that in non-CRF-HD group [8-year survival: 31% vs 70%, p0.0001]. The hazard ratio of CRF-HD for long-term mortality was 2.4. The 10-year cumulative reoperation rate for structural valve deterioration in the CRF-HD group was 6.0% vs 5.0% in the non-CRF-HD group, p = 0.74. Surgeons should consider poor short- and long-term outcomes of patients with high risk of being on dialysis when offering aortic valve/root replacement. Bioprosthesis could be a good option in this patient population.

OBJECTIVES: This study aimed to determine how acute type A aortic dissection (ATAAD) impacts patients’ quality of life. METHODS: The 36-Item Short Form Survey (SF-36) was used to measure quality of life. The eight SF-36 scales were aggregated into a two-factor summary: physical and mental component summary scales (PCS and MCS). 114 patients were included in the ATAAD group and 81 patients in the aortic valve replacement (AVR) group. All patients underwent surgery between June 2007 and December 2018. Surveys were completed after the operation. RESULTS: The mean scaled score of the ATAAD group decreased significantly in all eight domains of the SF-36 survey after aortic dissection repair except mental health. Also, the post-surgery PCS score was significantly lower than the pre-surgery score (39 vs 49; p

Gastric cancer (GC) is one of the most common types of cancer worldwide. Previous studies have reported that phosphofructo-2-kinase/fructose-2,6-biphosphatase 4 (PFKFB4) functions as an oncoprotein in various types of cancer. However, the association between PFKFB4 and GC remains unclear. The present study analyzed the expression levels of PFKFB4 in 148 GC tissue samples, including 46 tumor tissues with matched adjacent normal tissues, using immunohistochemistry, compared the expression levels of PFKFB4 between GC and adjacent normal tissues, and determined the association between PFKFB4 expression levels and patient clinicopathological characteristics. In addition, survival curves were generated using the Kaplan-Meier (KM) plotter database to evaluate the association between PFKFB4 expression and GC prognosis. The results revealed that PFKFB4 expression was upregulated in GC tissues compared with in adjacent normal tissues. PFKFB4 expression was associated with patient age, tumor size, pathological tumor (pT) stage and tumor-node-metastasis (pTNM) stage, and upregulated expression levels of PFKFB4 were observed in tumor tissues from patients

Chronic thromboembolic pulmonary hypertension is optimally treated by pulmonary thromboendarterectomy (PEA). Treatment effectiveness has been evaluated principally using single-center series. Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were used to evaluate a volume-outcomes relationship for PEA.Circulatory arrest procedures performed between 2012 and 2018 were identified through a Society of Thoracic Surgeons Adult Cardiac Surgery Database Participant User File. For descriptive purposes, total center procedural volume categories were computed: low (0-75th percentile,16); medium (76-95th percentile, 16-100); high (95th percentile,100). Mixed effect modeling was used to evaluate the effect of center procedural volume (modeled continuously) on operative mortality, adjusting for preoperative risk factors, with centers as a random effect.There were 1358 cases performed across 64 centers (low volume: n = 49 of 172; medium volume: n = 12 of 527; high volume: n = 3 of 659), with 42 centers performing less than 10 operations during the period. Procedural volume increased 2.6-fold between 2012 and 2018 (94 vs 339), with 79% of the change in volume accounted for by 4 centers. The median preoperative pulmonary artery systolic value was 74 (interquartile range, 57-88) mm Hg, with no difference (P = .55) by center volume categories. In unadjusted analysis, patients at high-volume centers required fewer transfusions, had shorter ventilator and intensive care unit duration, had a lower frequency of postoperative extracorporeal membrane oxygenation, and trended toward lower mortality (2.1% vs 5.2%; P = .051). Operative mortality was lower at higher-volume centers (adjusted odds ratio [1-case increase], 0.997; 95% confidence interval, 0.994-1.0; P = .025).Most PEA procedures are performed among a small number of centers, with high-volume hospitals having favorable outcomes. These data suggest a potential role for PEA regionalization.

Introduction: It’s unknown if patients with Bicuspid Aortic Valve (BAV) endocarditis behave differently compared to Tricuspid Aortic Valve (TAV), and if BAV patients are more susceptible to aortic valve endocarditis. Hypothesis: We aimed to distinguish BAV and TAV infectious endocarditis, including the short and long-term outcomes after surgical treatment. Methods: From 1997-2017, 336 patients underwent surgical treatment for aortic valve endocarditis, including 63(19%) BAV, which is 10-20 times higher than the BAV incidence in the general population (1-2%), and 273(81%) TAV endocarditis. Results: Postoperatively, the BAV group had significant shorter intubation time, and less renal failure on dialysis compared to TAV group. There was no compelling difference in postoperative stroke, sepsis, pacemaker requirement and in-hospital mortality [3/65(4.6%) vs. 19/283(6.7%)] between groups. The 10-year survival was better in the BAV group than the TAV group (62% vs. 33%, p=0.004) (Figure). The significant risk factors for late mortality were renal failure on dialysis [hazard ratio (HR)=2], intravenous drug user (HR=2.4), congestive heart failure (HR=1.6), previous coronary artery bypass (HR=1.8) and liver disease (HR=2.4), all p Conclusions: In conclusion, BAV patients have a higher likelihood of infectious endocarditis requiring surgery at a younger age than TAV patients, but similar outcomes. Strong consideration of utilizing prophylactic antibiotics and early surgical treatment for BAV patients, to lower the likelihood of aortic valve endocarditis.

Background: Cancer-associated cachexia is characterized by ongoing loss of skeletal muscle and has a high incidence in gastric cancer. Although studies have focused on the effect of inflammatory cytokines on skeletal muscle loss, it is not clear whether inflammatory cytokines affect other physiological functions, particularly immunity in gastric cancer. Thus, we aim to investigate the relationships between circulating TNF-α, skeletal muscle and peripheral immune status in gastric cancer.Methods: Totally 392 gastric cancer patients in cohort A and 60 gastric cancer patients in cohort B were selected from the prospective cohort study NCT03115931 and ChiCTR1900026578 in West China Hospital, Sichuan University, respectively. Besides, human skeletal muscle myoblasts (HSMMs) and peripheral CD8+ T cells completed about 7 to 9 days successive TNF-α intervention with different concentrations. Results: From data in cohort A, multivariate analysis showed that preoperative weight loss ≥5% was associated with circulating TNF-α (P =0.001) and TNM stage (P =0.002). ROC curve indicated that cut-off point of 9.96 pg/ml for circulating TNF-α was an important warning of weight loss ≥5% in patient with gastric cancer. Before surgery, high circulating TNF-α (≥ 9.96 pg/ml) was associated with significantly lower body weight, skeletal muscle mass and handgrip strength but not fat mass. After radical surgery, high circulating TNF-α was also associated with significantly more loss of body weight and skeletal muscle mass instead of fat mass. In cohort B and vitro experiments, immunohistochemistry, western blot and flow cytometry identified that high TNF-α led to myofiber change, decreased expression of AMP-dependent protein kinase (AMPK) and phosphate-AMPK in skeletal muscle and increased myoblast apoptosis. Flow cytometry found that circulating TNF-α was not correlated with PD-1, LAG-3, TIM-3 and TIGIT expressed on peripheral CD8+ T cells, and TNF-α not only promoted the proliferation of CD8+ T cells but also increased their apoptosis ratio at higher concentration.Conclusions: In our study, we found that TNF-α could result in myofiber change, interfered glycometabolism of skeletal muscle, whereas promoted the proliferation of CD8+ T cells in gastric cancer during cachexia, and preoperative circulating TNF-α of more than 9.96 pg/ml could indicate a high risk of weight loss.

Aims Complement C3 (C3) has been shown to be involved in the aging process. However, the role of C3 in kidney aging has not been fully elucidated. This study aimed to investigate the effect of C3 on senescence related kidney disorders in mice. Materials and methods Two-, 8-, and 16-month-old C3-deficient male mice (KO) (n = 6) and age-, gender-, and strain- matched wild type (WT) C57BL/6 mice (n = 6) were selected to represent young, middle-aged and aging mice. Renal, blood and urine samples were collected. Hematoxylin-eosin (HE), Masson, and immunohistochemistry (IHC) staining as well as ELISA and Western blotting were used to explore the mechanisms involved in renal aging. Key findings The level of C3 was upregulated during aging in WT mice. The glomerular sclerosis index and tubulointerstitial fibrosis index were increased significantly in WT mice during aging. Renal function was not significantly different between the young and aged groups. Compared with those in WT mice, the levels of inflammation and fibrosis were decreased, while the expression of CD31 was significantly increased in the KO group. Significance Our data demonstrated that age-related changes in renal structure occur earlier than functional changes and that complement C3 is involved in aging-related kidney disorder.

Objective The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis. Methods From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n = 97, 37%) or a stentless valve (n = 168, 63%) with further breakdown into inclusion technique (n = 142, 85%) or total root replacement (n = 26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data. Results The median age of patients was 53 years (43-56) in the stented group and 57 years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups. Conclusions Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P.05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P.05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P.001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

In this paper, we propose a meta-learning based semi-supervised explicit dialogue state tracker (SEDST) for neural dialogue generation, denoted as MEDST. Our main motivation is to further bridge the chasm between the need for high accuracy dialogue state tracker and the common reality that only scarce annotated data is available for most real-life dialogue tasks. Specifically, MEDST has two core steps: meta-training with adequate unlabelled data in an automatic way and meta-testing with a few annotated data by supervised learning. In particular, we enhance SEDST via entropy regularization, and investigate semi-supervised learning frameworks based on model-agnostic meta-learning (MAML) that are able to reduce the amount of required intermediate state labelling. We find that by leveraging un-annotated data in meta-way instead, the amount of dialogue state annotations can be reduced below 10% while maintaining equivalent system performance. Experimental results show MEDST outperforms SEDST substantially by 18.7% joint goal accuracy and 14.3% entity match rate on the KVRET corpus with 2% labelled data in semi-supervision.

A Dialogue State Tracker (DST) is a core component of a modular task-oriented dialogue system. Tremendous progress has been made in recent years. However, the major challenges remain. The state-of-the-art accuracy for DST is below 50% for a multi-domain dialogue task. A learnable DST for any new domain requires a large amount of labeled in-domain data and training from scratch. In this paper, we propose a Meta-Reinforced Multi-Domain State Generator (MERET). Our first contribution is to improve the DST accuracy. We enhance a neural model based DST generator with a reward manager, which is built on policy gradient reinforcement learning (RL) to fine-tune the generator. With this change, we are able to improve the joint accuracy of DST from 48.79% to 50.91% on the MultiWOZ corpus. Second, we explore to train a DST meta-learning model with a few domains as source domains and a new domain as target domain. We apply the model-agnostic meta-learning algorithm (MAML) to DST and the obtained meta-learning model is used for new domain adaptation. Our experimental results show this solution is able to outperform the traditional training approach with extremely less training data in target domain.

This study aimed to investigate the applicability of the solar heating system in different geographical regions with different meteorological conditions, of which parabolic trough solar collectors (PTCs) were operated with the absorption heat pumps (AHP) and oil/water heat exchanger (OWHE) at medium and low operating temperature respectively. The heat transfer model for PTCs was constructed with a lumped parameter method and validated by experimental results. The thermal performance of the system was evaluated by the index of primary energy ratio (PER). The results showed that on overcast days with low direct normal irradiance (DNI), the operation of the PTC + AHP/OWHE system was not cost-effective. On cloudy days with high DNI lasting for a short period (e.g. 2 h), the operation of the PTC + OWHE system was better than that of the PTC + AHP system as the latter needed more preheating energy before the system operation. While on sunny days with high DNI lasting for a longer period (e.g. 8 h), the PTC + AHP system was suggested to be operated as it owned higher PER values. Besides, the solar energy distributions in China could be divided into four categories, i.e. rich (S1), relatively rich (S2), available (S3) and absent (S4). In S1 region the PTC + AHP system was suggested to be operated. In S4 region the PTC + AHP/OWHE system was not suggested to be operated. While in S2 and S3 region, whether the operation of the PTC + AHP/OWHE system was suggested depending on the meteorological conditions. With these findings the developing strategy of the solar heating system in different geographical regions can be devised and the operating strategy on a specific day with different weather conditions can be developed, which is helpful to guide the application of solar energy and improve the energy structure in domestic heating.

Background Electroencephalography at hospital presentation may offer important insights regarding prognosis that can inform understanding of cerebral malaria (CM) pathophysiology and potentially guide patient selection and risk stratification for future clinical trials. Electroencephalogram (EEG) findings in children with CM in Uganda and Malawi were compared and associations between admission EEG findings and outcome across this diverse population were assessed. Demographic, clinical and admission EEG data from Ugandan and Malawian children admitted from 2009 to 2012 with CM were gathered, and survivors assessed for neurological abnormalities at discharge. Results 281 children were enrolled (Uganda n = 122, Malawi n = 159). The Malawian population was comprised only of retinopathy positive children (versus 72.5% retinopathy positive in Uganda) and were older (4.2 versus 3.7 years; p = 0.046), had a higher HIV prevalence (9.0 versus 2.8%; p = 0.042), and worse hyperlactataemia (7.4 versus 5.2 mmol/L; p

Objective Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes. Methods Patients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs. Results Age was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26). Conclusions No long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.

In this paper, a novel type of all-optical logic device based on graphene surface plasmon polaritons (GSP) is proposed. By utilizing linear interference between the GSP waves propagating in the different channels, this new structure can realize six different basic logic gates including OR, XOR, NOT, AND, NOR, and NAND. The state of “ON/OFF” of each input channel can be well controlled by tuning the optical conductivity of graphene sheets, which can be further controlled by changing the external gate voltage. This type of logic gate is compact in geometrical sizes and is a potential block in the integration of nanophotonic devices.

// Yihan Ma 1 , Xiaoyan Pan 1, 2 , Peiqi Xu 3 , Yanjun Mi 1 , Wenyi Wang 1 , Xiaoting Wu 1 , Qi He 1 , Xinli Liu 1 , Weiwei Tang 1 and Han-Xiang An 1 1 Xiamen Cancer Hospital the First Affiliated Hospital of Xiamen University, 361003 Fujian, China 2 Department of Medical Oncology, Linyi Cancer Hospital, 276000 Shandong, China 3 Reproduction Center, The Second Affiliated Hospital of Kunming Medical University, 650101 Yunnan, China Correspondence to: Han-Xiang An, email: anhanxiang@xmu.edu.cn Keywords: EGFR, EGFR-TKI, NSCLC, circulating miRNA, primary resistance Received: November 02, 2016 Accepted: July 18, 2017 Published: August 03, 2017 ABSTRACT Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have obtained excellent therapeutic effects against non-small cell lung cancer (NSCLC) harboring activating EGFR mutations. However, some patients have exhibited primary resistance which becomes a major obstacle in effective treatment of NSCLC. The mechanisms of EGFR-TKIs resistance involved are still poorly understood. Many studies suggest that miRNAs play an important role in regulating drug sensitivity of EGFR-TKIs. The aim of the present study was to examine differentially expressed miRNAs in plasma between EGFR-TKIs sensitive and EGFR-TKIs primary resistance patients. MiRNA microarray of plasma from patients’ blood identified 16 differentially expressed miRNAs of which 15 (hsv2-miR-H19, hsa-miR-744-5p, hsa-miR-3196, hsa-miR-3153, hsa-miR-4791, hsa-miR-4803, hsa-miR-4796-3p, hsa-miR-372-5p, hsa-miR-138-2-3p, hsa-miR-16-1-3p, hsa-miR-1469, hsa-miR-585-3p, ebv-miR-BART14-5p, hsa-miR-769-3p, hsa-miR-548aq-5p) were down regulated while only hsa-miR-503-3p was up regulated in primary resistant patients’ plasma. Volcano plot and hierarchical clustering were performed to examine the accuracy of the miRNAs. Then validation with quantitative real-time PCR was performed and the result was in accordance with the array data. Functional analysis of these differentially expressed miRNAs with Ingenuity Pathway Analysis (IPA) revealed a common signaling network including MYC, CCND1, IGF1 and RELA. In conclusion, our finding may play important role in understanding the mechanisms underlying the problem and should be further evaluated as potential biomarkers in primary resistance of NSCLC.

Background Although blood transfusions are common and have been associated with adverse sequelae after cardiac surgical procedures, few contemporaneous models exist to support clinical decision making. This study developed a preoperative clinical decision support tool to predict perioperative red blood cell transfusions in the setting of isolated coronary artery bypass grafting. Methods We performed a multicenter, observational study of 20,377 patients undergoing isolated coronary artery bypass grafting among patients at 39 hospitals participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative's PERFusion measures and outcomes (PERForm) registry between 2011 and 2015. Candidates' preoperative risk factors were identified based on previous work and clinical input. The study population was randomly divided into a 70% development sample and a 30% validation sample. A generalized linear mixed-effect model was developed to predict perioperative red blood cell transfusion. The model's performance was assessed for calibration and discrimination. Sensitivity analysis was performed to assess the robustness of the model in different clinical subgroups. Results Transfusions occurred in 36.8% of patients. The final regression model included 16 preoperative variables. The correlation between the observed and expected transfusions was 1.0. The risk prediction model discriminated well (receiver operator characteristic [ROC] development , 0.81; ROC validation , 0.82) and had satisfactory calibration (correlation between observed and expected rates was r = 1.00). The model performance was confirmed across medical centers and clinical subgroups. Conclusions Our risk prediction model uses 16 readily obtainable preoperative variables. This model, which provides a patient-specific estimate of the need for transfusion, offers clinicians a guide for decision making and evaluating the effectiveness of blood management strategies.

To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery.Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation.Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P .001), were women (41.5% vs 15.9%; P .001), and had a lower body surface area (1.93 mThe results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.

To improve surgical pain control through cryoablation of intercostal nerves and reduce narcotic usage in patients undergoing open thoracic or thoracoabdominal aortic aneurysm (TAA or TAAA) repair. From 2012 to 2018, 117 patients underwent open repair of TAA or TAAA. Of those patients, 25 (21%) received cryoablation (2016-2018) of their intercostal nerves and 92 (79%) did not (2012-2018). The primary outcome was pain scores and narcotic usage from extubation day 1 to 10 or the day of discharge. The median age (57 years), demographics, and preoperative comorbidities were not significantly different between the 2 groups. The cryoablation group had significantly more incidences of thoracoabdominal incisions (52% vs 28%), urgent operations (32% vs 11%), and longer duration of chest tubes compared to the noncryoablation group (all P0.05). T9-T12 intercostal arteries were selectively reimplanted. Left intercostal nerves were cryoablated from T3 to T9 if 2 thoracotomies were used; or 2 intercostal spaces above and below the thoracotomy if 1 thoracotomy was used. There were no significant differences between the noncryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was significantly reduced in the cryoablation group by 28 measured morphine equivalents (equal to four 5 mg Oxycodone)/patient/day in 10 days after extubation, P = 0.005. With cryoablation of intercostal nerves, the postoperative surgical pain was well controlled and narcotic usage was significantly decreased after TAA or TAAA repair. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.

Background: We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Methods: Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Results: Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs . 1%, P

The impact of the renal microenvironment on macrophage phenotype determination can contribute to the progression or resolution of renal fibrosis. Although the complement proteins affect macrophage polarization, whether complement component 3 (C3) can induce macrophage polarization and regulate renal interstitial fibrosis remains undetermined. In the present study, we investigated the contribution of C3 on macrophage polarization and renal fibrosis in C3-deficient mice with unilateral ureteral obstruction and bone marrow-derived macrophages. C3-deficient mice exhibited attenuated renal fibrosis and ameliorated peritubular capillary rarefaction. Lack of C3 contributed to M2 macrophage polarization, increased IL-10 and VEGF164, and decreased TNF-α and soluble VEGF receptor 1 expression in the obstructed kidneys at the early stages of unilateral ureteral obstruction. C3a facilitated LPS-induced M1 polarization and inflammatory factor production in bone marrow-derived macrophages in vitro, accompanied by increased ERK, NF-κB, and STAT1 phosphorylation. The ERK-specific inhibitor PD98059 inhibited the phosphorylation of ERK, NF-κB, and STAT1 and attenuated M1 polarization-related inflammatory factor production. Furthermore, the culture supernatant from M1 macrophages and C3a-treated M2 macrophages were more detrimental to angiogenesis compared with M2 macrophage supernatants. Thus, complement C3 exacerbates renal interstitial fibrosis by facilitating macrophage M1 polarization, promoting proinflammatory cytokine expression, and deteriorating peritubular capillary rarefaction in the kidney.

OBJECTIVE: To evaluate aortic disease progression and reintervention following an initial thoracic aortic dissection in pathogenic variant carriers. METHODS: Of 175 participants diagnosed with thoracic aortic dissection, 31 had a pathogenic variant (pathogenic group) across 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, TGFBR2) identified by whole exome sequencing. Those with benign or normal variants (benign/normal group, n=144) comprised the control group. Clinical data was collected through medical record review (1985-2018) and supplemented with the National Death Index database (December 2018). RESULTS: The entire cohort (n=175) consisted of 108 type A aortic dissections (TAAD) and 67 type B aortic dissections, similarly distributed between groups. The pathogenic group was significantly younger (43- vs. 56-years-old, p