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Background Indeterminate strictures pose a therapeutic dilemma. In recent years, cholangioscopy has evolved and the availability of cholangioscopy has increased. However, the position of cholangioscopy in the diagnostic algorithm to diagnose malignancy have not been well established. We aim to develop a consensus statement regarding the clinical role of cholangioscopy in the diagnosis of indeterminate biliary strictures. Methods The international experts reviewed the evidence and modified the statements using a three-step modified Delphi method. Each statement achieves consensus when it has at least 80% agreement. Results Nine final statements were formulated. An indeterminate biliary stricture is defined as that of uncertain etiology under imaging or tissue diagnosis. When available, cholangioscopic assessment and guided biopsy during the first round of ERCP may reduce the need to perform multiple procedures. Cholangioscopy are helpful in diagnosing malignant biliary strictures by both direct visualization and targeted biopsy. The absence of disease progression for at least 6 months is supportive of non-malignant etiology. Direct per-oral cholangioscopy provides the largest accessory channel, better image definition, with image enhancement but is technically demanding. Image enhancement during cholangioscopy may increase the diagnostic sensitivity of visual impression of malignant biliary strictures. Cholangioscopic imaging characteristics including tumor vessels, papillary projection, nodular or polypoid mass, and infiltrative lesions are highly suggestive for neoplastic/malignant biliary disease. The risk of cholangioscopy related cholangitis is higher than in standard ERCP, necessitating prophylactic antibiotics and ensuring adequate biliary drainage. Per-oral cholangioscopy may not be the modality of choice in the evaluation of distal biliary strictures due to inherent technical difficulties. Conclusion Evidence supports that cholangioscopy has an adjunct role to abdominal imaging and ERCP tissue acquisition in order to evaluate and diagnose indeterminate biliary strictures.

Background and aims This study explores the relationship between systolic blood pressure during the acute period of stroke and poor functional outcome in patients with lacunar stroke, emphasizing a possible time-dependent nature of the relationship. Methods Based on multicenter stroke registry data, patients with acute lacunar stroke were identified, and systolic blood pressure levels at eight time points (1, 2, 4, 8, 16, 24, 48, and 72 h) after stroke onset were extracted at the 15 participating centers in South Korea. Poor functional outcome was defined as a three-month modified Rankin Scale score of 2–6. Non-linear restricted cubic spline and linear models were used for assessing the relationship at each time point. Results A total of 97,349 systolic blood pressure measurements of 3,042 patients were analyzed. At 1 h and 4 h after stroke onset, the relationship between systolic blood pressure and poor outcome showed a non-linear association. The nadir was 155 mmHg at 1 h and 124 mmHg at 4 h. After this time period, a higher systolic blood pressure was associated with a poorer outcome. This linear relationship weakened over time after 12 h (coefficient values of the adjusted linear models: 0.0081 at 8 h, 0.0105 at 12 h, 0.0102 at 24 h, 0.0082 at 48 h, 0.0054 at 72 h). Conclusions Based on our cohort of large number of lacunar stroke patients, our findings suggest that systolic blood pressure levels may follow a time-dependent course in relation to prediction of outcome at three months. The findings may be valuable for hypothesis generation in association with clinical trial development for blood pressure control in acute stroke patients.

Convolutional neural networks (CNNs) have achieved significant progress in computer vision systems, helping to efficiently obtain feature information by sliding filters on the input images. However, CNNs have difficulty capturing specific properties when the images are affected by various noises. This paper proposes an attention based convolutional pooling neural network (ACPNN) where an attention-mechanism is applied to feature maps to obtain key features, and max pooling is replaced with convolutional pooling to improve recognition accuracy in harsh environments. The ACPNN with attention mechanism and convolutional pooling structure is robust against external noises and maintains classification performance under such conditions. The proposed ACPNN was validated on the German traffic sign recognition benchmark with various cases. Considering the traffic signs are suffered from various noises, the recognition performances were demonstrated with conventional CNN and state-of-the art CNNs such as multi-scale CNN, committee of CNN, hierarchical CNN, and multi-column deep neural network. Under such harsh conditions, the proposed ACPNN shows 66.981% and 83.198% respectively, which are the best performances compared to other CNNs.

Radiation dose intensification improves outcome in men with high-risk prostate cancer (HR-PCa). A prospective trial was conducted to determine safety, feasibility, and maximal tolerated dose of multilevel magnetic resonance imaging (MRI)-based 5-fraction SABR in patients with HR-PCa.This phase I clinical trial enrolled patients with HR-PCa with grade group ≥4, prostate-specific antigen (PSA) ≥20 ng/mL, or radiographic ≥T3, and well-defined prostatic lesions on multiparametric MRI (mpMRI) into 4 dose-escalation cohorts. The initial cohort received 47.5 Gy to the prostate, 50 Gy to mpMRI-defined intraprostatic lesion(s), and 22.5 Gy to pelvic lymph nodes in 5 fractions. Radiation doses were escalated for pelvic nodes to 25 Gy and mpMRI lesion(s) to 52.5 Gy and then 55 Gy. Escalation was performed sequentially according to rule-based trial design with 7 to 15 patients per cohort and a 90-day observation period. All men received peri-rectal hydrogel spacer, intraprostatic fiducial placement, and 2 years of androgen deprivation. The primary endpoint was maximal tolerated dose according to a 90-day acute dose-limiting toxicity (DLT) rate33%. DLT was defined as National Cancer Institute Common Toxicity Criteria for Adverse Events ≥grade 3 treatment-related toxicity. Secondary outcomes included acute and delayed gastrointestinal (GI)/genitourinary (GU) toxicity graded with Common Toxicity Criteria for Adverse Events.Fifty-five of the 62 enrolled patients were included in the analysis. Dose was escalated through all 4 cohorts without observing any DLTs. Median overall follow-up was 18 months, with a median follow-up of 42, 24, 12, and 7.5 months for cohorts 1 to 4 respectively. Acute and late grade 2 GU toxicities were 25% and 20%, while GI were 13% and 7%, respectively. Late grade 3 GU and GI toxicities were 2% and 0%, respectively.SABR dose for HR-PCa was safely escalated with multilevel dose painting of 47.5 Gy to prostate, 55 Gy to mpMRI-defined intraprostatic lesions, and 25 Gy to pelvic nodal region in 5 fractions. Longer and ongoing follow-up will be required to assess late toxicity.

The effects of multiple mitochondrial dysfunction (MMD) on heart, a highly mitochondria-dependent tissue, is still unclear. This study was the first to verify the effect of ISCA1 gene deficiency, which has been shown to cause multiple mitochondrial dysfunction syndromes type 5 (MMDS5), on cardiac development in vivo, that is cardiomyocytes suffer from energy shortage due to abnormal metabolism of iron ion, which leads to oncosis and eventually HF and body death. Subsequently, we determine a new interacting molecule for ISCA1, six-transmembrane epithelial antigen of prostate 3 (STEAP3), which acts as a reductase in the reduction of Fe3+ to Fe2+. Forward and reverse validation experiments demonstrated that STEAP3 plays an important role in iron metabolism and energy generation impairment induced by ISCA1 deficiency. This result provides theoretical basis for understanding of MMDS pathogenesis, especially on heart development and the pathological process of heart diseases, and finally provides new clues for searching of clinical therapeutic targets.

Previous studies analyzed risk factors for postoperative pancreatic fistula (POPF) and developed risk prediction tool using scoring system. However, no study has built a nomogram based on individual risk factors. This study aimed to evaluate individual risks of POPF and propose a nomogram for predicting POPF.From 2007 to 2016, medical records of 1771 patients undergoing pancreaticoduodenctomy were reviewed retrospectively. Variables with p 0.05 in multivariate logistic regression analysis were included in the nomogram. Internal performance validation was executed using a repeated cross validation method.Of 1771 patients, 222 (12.5%) experienced POPF. In multivariable analysis, sex (p = 0.004), body mass index (BMI) (p 0.001), ASA score (p = 0.039), preoperative albumin (p = 0.035), pancreatic duct diameter (p = 0.002), and location of tumor (p 0.001) were identified as independent predictors for POPF. Based on these six variables, a POPF nomogram was developed. The area under the curve (AUC) estimated from the receiver operating characteristic (ROC) graph was 0.709 in the train set and 0.652 in the test set.A POPF nomogram was developed. This nomogram may be useful for selecting patients who need more intensified therapy and establishing customized treatment strategy.

Background: The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians’ impressions that ICU care may be nonbeneficial. Methods: Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit. Results: There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians’ impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score. Conclusions: Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

Removing haze or rain is one of the difficult problems in computer vision applications. On real-world road images, haze and rain often occur together, but traditional methods cannot solve this imaging problem. To address rain and haze problems simultaneously, we present a robust network-based framework consisting of three steps: image decomposition using guided filters, a frequency-based haze and rain removal network (FHRR-Net), and image restoration based on an atmospheric scattering model using predicted transmission maps and predicted rain-removed images. We demonstrate FHRR-Net’s capabilities with synthesized and real-world road images. Experimental results show that our trained framework has superior performance on synthesized and real-world road test images compared with state-of-the-art methods. We use PSNR (peak signal-to-noise) and SSIM (structural similarity index) indicators to evaluate our model quantitatively, showing that our methods have the highest PSNR and SSIM values. Furthermore, we demonstrate through experiments that our method is useful in real-world vision applications.

Our purpose was to evaluate cosmetic changes after 5-fraction adjuvant stereotactic partial breast irradiation (S-PBI).Seventy-five women with in situ or invasive breast cancer stage 0, I, or II, with tumor size ≤3 cm, were enrolled after lumpectomy in a phase 1 dose escalation trial of S-PBI into cohorts receiving 30, 32.5, 35, 37.5, or 40 Gy in 5 fractions. Before S-PBI, 3 to 4 gold fiducial markers were placed in the lumpectomy cavity for tracking with the Synchrony respiratory tracking system. S-PBI was delivered with a CyberKnife robotic radiosurgery system. Patients and physicians evaluated global cosmesis using the Harvard Breast Cosmesis Scale. Eight independent panelists evaluated digital photography for global cosmesis and 10 subdomains at baseline and follow-up. McNemar tests were used to evaluate change in cosmesis, graded as excellent/good or fair/poor, from baseline to year 3. Wilcoxon signed rank tests were used to evaluate change in subdomains. Cohen's kappa (κ) statistic was used to estimate interobserver agreement (IOA) between raters, and Fleiss' κ was used to estimate IOA between panelists.Median cosmetic follow-up was 5, 5, 5, 4, and 3 years for the 30, 32.5, 35, 37.5, and 40 Gy cohorts. Most patients reported excellent/good cosmesis at both baseline (86.3%) and year 3 (89.8%). No dose cohort had significantly worsened cosmesis by year 3 on McNemar analysis. No cosmetic subdomain had significant worsening by year 3. IOA was fair for patient-physician (κ = 0.300, P.001), patient-panel (κ = 0.295, P.001), physician-panel (κ = 0.256, P.001), and individual panelists (Fleiss κ = 0.327, P.001).Dose escalation of S-PBI from 30 to 40 Gy in 5 fractions for early stage breast cancer was not associated with a detectable change in cosmesis by year 3. S-PBI is a promising modality for treatment of early stage breast cancer.

Introduction: Post-contrast acute kidney injury (PC-AKI) develops in a significant proportion of patients with CKD after invasive cardiology procedures and is strongly associated with adverse outcomes. Objective: We sought to determine whether increased intrarenal nitric oxide (NO) would prevent PC-AKI. Methods: To create a large animal model of CKD, we infused 250 micron particles into the renal arteries in 56 ± 8 kg pigs. We used a low-frequency therapeutic ultrasound device (LOTUS – 29 kHz, 0.4 W/cm2) to induce NO release. NO and laser Doppler probes were used to assess changes in NO content and blood flow. Glomerular filtration rate (GFR) was measured by technetium-diethylene-triamine-pentaacetic acid (Tc-99m-DTPA) radionuclide imaging. PC-AKI was induced by intravenous infusion of 7 cm3/kg diatrizoate. In patients with CKD, we measured GFR at baseline and during LOTUS using Tc-99m--DTPA radionuclide imaging. Results: In the pig model, CKD developed over 4 weeks (serum creatinine [Cr], mg/dL, 1.0 ± 0.2–2.6 ± 0.9, p < 0.01, n = 12). NO and renal blood flow (RBF) increased in cortex and medulla during LOTUS. GFR increased 75 ± 24% (p = 0.016, n = 3). PC-AKI developed following diatrizoate i.v. infusion (Cr 2.6 ± 0.7 baseline to 3.4 ± 0.6 at 24 h, p < 0.01, n = 3). LOTUS (starting 15 min prior to contrast and lasting for 90 min) prevented PC-AKI in the same animals 1 week later (Cr 2.5 ± 0.4 baseline to 2.6 ± 0.7 at 24 h, p = ns, n = 3). In patients with CKD (n = 10), there was an overall 25% increase in GFR in response to LOTUS (p < 0.01). Conclusions: LOTUS increased intrarenal NO, RBF, and GFR and prevented PC-AKI in a large animal model of CKD, and significantly increased GFR in patients with CKD. This novel approach may provide a noninvasive nonpharmacological means to prevent PC-AKI in high-risk patients.

This study reports predictive dosimetric and physiologic factors for fat necrosis after stereotactic-partial breast irradiation (S-PBI).Seventy-five patients with ductal carcinoma-in situ or invasive nonlobular epithelial histologies stage 0, I, or II, with tumor size3 cm were enrolled in a dose-escalation, phase I S-PBI trial between January 2011 and July 2015. Fat necrosis was evaluated clinically at each follow-up. Treatment data were extracted from the Multiplan Treatment Planning System (Cyberknife, Accuray). Univariate and stepwise logistic regression analyses were conducted to identify factors associated with palpable fat necrosis.With a median follow-up of 61 months (range: 4.3-99.5 months), 11 patients experienced palpable fat necrosis, 5 cases of which were painful. The median time to development of fat necrosis was 12.7 months (range, 3-42 months). On univariate analyses, higher V32.5-47.5 Gy (P.05) and larger breast volume (P.01) were predictive of any fat necrosis; higher V35-50 Gy (P.05), receiving 2 treatments on consecutive days (P = .02), and higher Dmax (P = .01) were predictive of painful fat necrosis. On multivariate analyses, breast volume larger than 1063 cmEarly-stage breast cancer patients treated with breast conserving surgery and S-PBI in our study had a fat necrosis rate comparable to other accelerated partial breast irradiation modalities, but S-PBI is less invasive. To reduce risk of painful fat necrosis, we recommend not delivering fractions on consecutive days; limiting V42.550 cm

Convolutional Neural Network is one of state-of-the-arts and demonstrated its superior performance in various computer visions systems recently. The conventional convolutional neural network has one-way structure to train image information with fixed sizes of filters in general. However, this structure only learns image information followed by one fixed sizes of filters and this is not the best to achieve high performance of the network. In order to achieve high performance of the network, this paper suggests a novel convolutional neural network which consists of spatial transformer network and multi-structure convolutional neural network. Spatial transformer network is robust against distorted images. Multi-structure convolutional neural network uses different sizes of filters for global and local information from the given images. The proposed algorithm, spatial transformer with multi-structure convolutional neural network (SPMCNN) demonstrates its classification performance on German traffic sign recognition benchmark.

IMPORTANCE: For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit. OBJECTIVE: To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care. DESIGN, SETTING, AND PARTICIPANTS: This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage. INTERVENTIONS: Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers. MAIN OUTCOMES AND MEASURES: Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure). RESULTS: A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P

Aiming at the problem of the springback in the CNC incremental forming, a method for predicting the springback and generating the compensated forming trajectory was proposed based on the explicit and implicit finite element analysis. First, the middle surface of the simulated sheet metal part was reconstructed after the springback simulation with the coordinates of all nodes obtained from the numerical simulations, and the reconstructed middle surface was compared with the middle surface of the theory model to calculate the normal deviation values. Second, the theory model was offset with the unequal distances of the deviation values to generate the compensated facet and the forming path. Once more, the finite element analysis was done until the compensatory effect met the required precision. Meanwhile, aiming at the roughness of the compensated facet caused by the multi-compensation process, the smoothing method was given to guarantee the smooth of the forming path. According to the predicted result of the numerical simulations, three times compensation meets the required precision and the normal deviation value is decreased from 0.696 mm to 0.194 mm. The forming experiments indicate that the springback of the target part in Z direction is decreased from 1.107 mm to 0.427 mm. Therefore, the predicting and compensating method of the springback proposed in the paper is available, which can improve the forming precision of the sheet metal part.

Racial and ethnic minorities are at risk for disparities in quality of care after out-of-hospital cardiopulmonary arrest (OHCA). As such, we examined associations between race and ethnicity and use of guideline-recommended and life-sustaining procedures during hospitalizations for OHCA.This was a retrospective study of hospitalizations for OHCA in all acute-care, non-federal California hospitals from 2009 to 2011. Associations between the use of (1) guideline-recommended procedures (cardiac catheterization for ventricular fibrillation/tachycardia, therapeutic hypothermia), (2) life-sustaining procedures (percutaneous endoscopic gastrostomy (PEG)/tracheostomy, renal replacement therapy (RRT)), and (3) palliative care and race/ethnicity were examined using hierarchical logistic regression analysis.Among 51,198 hospitalizations for OHCA, unadjusted rates of cardiac catheterization were 34.9% in Whites, 19.8% in Blacks, 27.2% in Hispanics, and 30.9% in Asians (P0.01). Rates of therapeutic hypothermia were 2.3% in Whites, 1.1% in Blacks, 1.3% in Hispanics, and 1.9% in Asians (P0.01). Rates of PEG/tracheostomy and RRT were 2.2% and 9.8% in Whites, 5.7% and 19.9% in Blacks, 4.2% and 19.9% in Hispanics, and 3.4% and 18.2% in Asians, respectively (P0.01). Rates of palliative care were 14.8% in Whites, 9.6% in Blacks, 10.1% in Hispanics, and 14.3% in Asians (P0.01). Differences in utilization of procedures persisted after adjustment for patient and hospital-related factors.Racial and ethnic minorities are less likely to receive guideline-recommended interventions and palliative care, and more likely to receive life-sustaining treatments following OHCA. These findings suggest that significant disparities exist in medical care after OHCA.

Intraductal papillary mucinous neoplasm (IPMN) is an broad-spectrum disease from benign to malignant. Inflammatory markers are known as prognostic predictors in various diseases. The purpose of this study was to determine the predictive value of inflammatory markers for prognosis in IPMN.From April 1995 to December 2016, patients who underwent pancreatectomy with pathologically confirmed IPMN at four tertiary centers were enrolled. Patients with a history of pancreatitis or cholangitis, and other malignancies were excluded. Neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and advanced lung cancer inflammation index (ALI) were calculated.Of all, ninety-eight patients (26.8%) were diagnosed as invasive IPMN. The NLR and PLR were significantly elevated in invasive IPMN than in non-invasive disease (2.0 vs 1.8, p = 0.004; 117.1 vs 107.4, p = 0.009, respectively). ALI was significantly higher in non-invasive IPMN than in invasive disease (58.1 vs 45.9, p 0.001). In multivariate analysis, only NLR showed significant association among the inflammatory markers studied (p = 0.044). In invasive IPMN, the five-year recurrence-free survival rate for NLR less than 3.5 was superior to the rest (59.1 vs 42.2, p = 0.023).NLR may help to rightly select IPMN patients who will require surgery and may serve as a useful prognostic factor.

Background Neoadjuvant therapy is recommended for patients with borderline-resectable pancreatic cancer (BRPC). In this study, we compare survival outcomes of neoadjuvant therapy with upfront surgery. Methods From January 2011 to June 2016, 1415 patients underwent treatments for pancreatic cancer in Samsung Medical Center. Among them, 112 (7.9%) patients were categorized as BRPC by the NCCN 2016 guideline. They were classified by type of initial treatments into neoadjuvant group (NA, N.=26) and upfront surgery group (US, N.=86). Results The median survival duration of all patients was 18.3 months. Patients in the NA group had more T4 disease than those in the US group (38.5% in NA versus 15.1% in the US group; P=0.010). Arterial involvement was more frequent in the NA group (42.3% versus 15.1%; P=0.003). In the NA group, ten (38.5%) patients underwent surgery, and seven of them had complete R0 resection. In the US group, 83 (96.5%) patients received radical surgery, and 42 (48.8%) had R0 resection. In survival analysis according to intent to treat, the overall two-year survival rate was 51.1% in the US group and 36.7% in the NA group (P=0.001). However, among patients who underwent surgery (N.=96), the two-year overall survival rate was not significantly different between the two groups (P=0.089). According to involved vessels, the survival rate was not different between patients with arterial or both arterial and venous involvement and in patients with only venous involvement (P=0.649). Conclusions It is necessary to demonstrate the efficacy of neoadjuvant therapy and to standardize the regimens through large-scale, multicenter, randomized controlled studies.

We propose a local feature descriptor based on moment. Although conventional scale invariant feature transform (SIFT)-based algorithms generally use difference of Gaussian (DoG) for feature extraction, they remain sensitive to more complicated deformations. To solve this problem, we propose MIFT, an invariant feature transform algorithm based on the modified discrete Gaussian-Hermite moment (MDGHM). Taking advantage of MDGHM&rsquo, s high performance to represent image information, MIFT uses an MDGHM-based pyramid for feature extraction, which can extract more distinctive extrema than the DoG, and MDGHM-based magnitude and orientation for feature description. We compared the proposed MIFT method performance with current best practice methods for six image deformation types, and confirmed that MIFT matching accuracy was superior of other SIFT-based methods.

Background Recently, several studies have reported that sarcopenia and sarcopenic obesity (SO) could worsen postoperative complications after PD. This study aims to evaluate the effects of preoperative sarcopenia and SO following PD in pancreatic head cancer (PHD). Methods Preoperative sarcopenia and SO were assessed in 548 patients undergoing PD for PHC at Samsung Medical Centre between 2007 and 2016. The visceral adipose tissue-to-skeletal muscle ratio was calculated from cross-sectional visceral fat and muscle areas on preoperative CT images. The overall survival (OS) and rate of clinically relevant postoperative pancreatic fistula (CR-POPF) among postoperative complications were extracted from prospectively maintained databases. Results Preoperative sarcopenia was present in 252 patients (45.9%). The 5-year survival rates of patients with non-sarcopenia and sarcopenia were 28.4% and 23.4% (p = 0.046). Preoperative SO was present in 202 patients (36.9%). After multivariable analysis, the presence of SO was the only independent risk factor for CR-POPF (p = 0.018). Conclusion Sarcopenia can be a risk factor affecting decreased OS after PD in patients with PHC. SO is the only predictive factor for CR-POPF after PD in patients with PHC. More observational studies are needed to evaluate the effects of sarcopenia and SO on survival after PD.

Ubiquitous and traditional service-provider platforms and frameworks are non-flexible and standardized. But ubiquitous environments are dynamic and variable. New service-provider platforms should be capable of handling such changing conditions. Specifically, a flexible and reliable network framework that adapts to various service components is necessary. Towards achieving this goal, this paper proposes a network-based intelligent humanoid robot (NBIHR) consisting of intelligent software components. The framework of an NBIHR requires reliable and stable network connection with real-time response between software components. In the developed service platform, intelligent software components work on the resources that are distributed in the network, and the NBIHR uses the results from the resources. In this way, the NBIHR is able to provide high-quality and intelligent service to users. In this framework, TCP/IP-based interface and middleware CORBA (Common Object Request Broker Architecture) are designed to integrate software components into an NBIHR system. The performance of the developed system is studied to demonstrate its effectiveness.

Purpose: Readmission after hospitalization for malignant pleural effusion (MPE) may represent gaps in the quality of health care delivery. The goal of this study was to determine the frequency of 30-day readmission for MPE and identify clinical factors associated with rehospitalization. Patients and Methods: A retrospective cohort of adults hospitalized for MPE from 2009 to 2011 was analyzed using an administrative database. The primary outcome was all-cause 30-day readmission rate. Hierarchic mixed-effects logistic regression models were used to examine associations between patient- and hospital-level factors and 30-day readmission and assess variation in readmission rates across hospitals. Results: The 7-, 14-, 30-, 60-, and 90-day readmission rates for MPE were 16.1%, 25.9%, 38.3%, 52.5%, and 63.8%, respectively. The most common primary diagnoses for 30-day readmission were MPE (69.5%) and other clinical issues related to malignancy (21.1%). Clinical factors associated with 30-day readmission were female sex (odds ratio [OR], 0.78; 95% CI, 0.63 to 0.95), greater number of medical comorbidities (OR, 1.51; 95% CI, 1.15 to 1.99), and having a do-not-resuscitate order (OR, 1.37; 95% CI, 1.03 to 1.84). Hospitals in the 90th percentile were only 1.1 times more likely to have a 30-day readmission for MPE than those in the lowest 10th percentile (40.9% v 37%). Conclusion: Readmission for MPE is common and frequently results from progression of malignancy. Readmission rates were similar across all hospitals, suggesting they are unlikely to be mutable using conventional approaches to reduce rehospitalizations. Instead, interventions may need to focus on addressing care planning at the end of life.

Differentiating whether disparities in outcomes for sepsis among racial groups are due to differences in hospital care versus pre-hospitalization factors is an important step in developing effective strategies to reduce these disparities. As such, we examined the association between race and case fatality rates among hospitalizations for sepsis. This was a case-control study of hospitalizations for sepsis in all acute-care, non-federal California hospitals during 2011. The association between hospital mortality and race was examined using hierarchical logistic regression analysis. Among 131,831 hospitalizations for sepsis, the unadjusted case fatality rates were 15.1 % in whites, 14.0 % in blacks, 13.8 % in Hispanics, and 16.2 % in Asians (P

Although recent studies have shown that 30-day readmissions following sepsis are common, the overall fiscal impact of these rehospitalizations and their variability between hospitals relative to other high-risk conditions, such as congestive heart failure and acute myocardial infarction, are unknown. The objectives of this study were to characterize the frequency, cost, patient-level risk factors, and hospital-level variation in 30-day readmissions following sepsis compared with congestive heart failure and acute myocardial infarction.A retrospective cohort analysis of hospitalizations from 2009 to 2011.All acute care, nonfederal hospitals in California.Hospitalizations for sepsis (n = 240,198), congestive heart failure (n = 193,153), and acute myocardial infarction (n = 105,684) identified by administrative discharge codes.None.The primary outcomes were the frequency and cost of all-cause 30-day readmissions following hospitalization for sepsis compared with congestive heart failure and acute myocardial infarction. Variability in predicted readmission rates between hospitals was calculated using mixed-effects logistic regression analysis. The all-cause 30-day readmission rates were 20.4%, 23.6%, and 17.7% for sepsis, congestive heart failure, and acute myocardial infarction, respectively. The estimated annual costs of 30-day readmissions in the state of California during the study period were $500 million/yr for sepsis, $229 million/yr for congestive heart failure, and $142 million/yr for acute myocardial infarction. The risk- and reliability-adjusted readmission rates across hospitals ranged from 11.0% to 39.8% (median, 19.9%; interquartile range, 16.1-26.0%) for sepsis, 11.3% to 38.4% (median, 22.9%; interquartile range, 19.2-26.6%) for congestive heart failure, and 3.6% to 40.8% (median, 17.0%; interquartile range, 12.2-20.0%) for acute myocardial infarction. Patient-level factors associated with higher odds of 30-day readmission following sepsis included younger age, male gender, Black or Native American race, a higher burden of medical comorbidities, urban residence, and lower income.Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions. Interventions at clinical and policy levels should prioritize identifying effective strategies to reduce sepsis readmissions.

The importance of the web is increasing, not only as a communication channel but also in enhancing the quality of life for many. Accordingly, there is a growing interest in web accessibility (WA), which involves the creation of an environment in which everyone can equally access and use the web. WA is especially important to those who have disability as it can directly influence their quality of life. This study explores the factors that hinder WA for persons with disabilities and how can they be alleviated. Using a Delphi method, study showed that the main factors hindering web accessibility are lack of the following: publicity and awareness; management's interest; institutional or financial support from the government; objective evaluations of accessibility compliance; availability of experts; accessibility education and relevant educational institutions; the understanding of accessibility compliance. Being one of few pioneering WA studies, this research contributes to both theory and practice.

Vehicle detection is the most basic and important technology in advanced driver assistant system. Conventional methods do not reflect characteristic information of vehicle images, so they were vulnerable to noise. In order to improve the performance of vehicle detection, this paper proposes a vehicle detection framework using selective multi-stage features in convolutional neural networks. We design the convolutional neural network (CNN) model with 10 layers and use a visualization technique to selectively extract features from the activation feature map in CNN. Our proposed features have the characteristic information of vehicle images and are more robust to noise than traditional appearance based features. We train the Adaboost algorithm using these features to implement a vehicle detector. The result of the experiments proves that our proposed vehicle detection framework has a better performance than other frameworks.

Objectives/Hypothesis To evaluate the effect of oral prednisolone on recovery from tonsillectomy. Study Design Prospective, randomized, controlled trial of 198 consecutive patients, aged 4 years and older, with no previous or known contraindications to steroid therapy. Methods All 198 patients scheduled for elective tonsillectomy with or without adenoidectomy from April 2013 to April 2014 were included. The participants were then randomly assigned to receive a postoperative course of prednisolone 0.25 mg/kg/d or no prednisolone over 7 days. During the first postoperative day, pain, type of diet (none, fluid, soft, normal), type of activity (none, bed rest, quiet, restricted, normal), presence of nausea and vomiting, postoperative bleeding rate, and sleep disturbance were assessed using questionnaires. All patients were followed up on days 7 and 14 by endoscopic photographic examination of both tonsillar fossa and by completion of questionnaires. Results No statistically significant differences in pain, diet, activity, rate of minor bleeding, nausea/vomiting, fever, or sleep disturbance were observed between the groups on day 1. On day 7, however, in pediatric patients, differences in pain (P = .001), diet (P = .001), activity (P = .004), mean area of re-epithelialization (P = .000), fever (P = .04), and sleep disturbance (P = .04) were observed. On day 14, differences in the mean area of re-epithelialization (P = .000, .001) remained in both pediatric and adult patients. Conclusions Oral prednisolone may be beneficial during recovery from tonsillectomy without causing any serious complications. Level of Evidence 1b. Laryngoscope, 125:111–117, 2015

Identifying factors associated with do-not-resuscitate (DNR) orders is an informative step in developing strategies to improve their use. As such, a descriptive analysis of the factors associated with the use of DNR orders in the early and late phases of hospitalizations for sepsis was performed.A retrospective cohort of adult patients hospitalized for sepsis was identified using a statewide administrative database. DNR orders placed within 24 h of hospitalization (early DNR) and after 24 h of hospitalization (late DNR) were the primary outcome variables. Multivariable logistic regression analysis was used to identify patient, hospital, and healthcare system-related factors associated with the use of early and late DNR orders.Among 77,329 patients hospitalized for sepsis, 27.5 % had a DNR order during their hospitalization. Among the cases with a DNR order, 75.5 % had the order within 24 h of hospitalization. Smaller hospital size and the absence of a teaching program increased the likelihood of an early DNR order being written. Additionally, greater patient age, female gender, White race, more medical comorbidities, Medicare payer status and admission from a skilled nursing facility were all significantly associated with the likelihood of having an early DNR. The strength of association between these factors and the use of late DNR orders was weaker. In contrast, the greater the burden of medical comorbidities, the more likely a patient was to receive a late DNR order.Multiple patient, hospital, and healthcare system-related factors are associated with the use of DNR orders in sepsis, many of which appear to be independent of a patient's clinical status. Over the course of the hospitalization, the burden of medical illness shows a stronger association relative to other variables. The influence of these multi-level factors needs to be recognized in strategies to improve the use of DNR orders. .

Background The purpose of this study was to clarify the post-operative prognosis of pancreatic head cancer with pathologic portal vein (PV) or superior mesenteric vein (SMV) invasion. Methods From May 1995 to December 2009, preoperative, intra-operative and post-operative data from 276 patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma were reviewed retrospectively. The long-term prognosis was compared between patients with a pathologic PV-SMV invasion and those without invasion. Results Fourty-six patients (16.7%) underwent PV-SMV resection during pancreaticoduodenectomy. Pathologic PV-SMV invasion was observed in 30 (65.2%). Post-operative severe morbidity (grade 3 or 4) was similar for patients with and without PV-SMV resection (8.7% with versus 7.0% without P = 0.754). The mortality rate was 2.2% with PV-SMV resection and 0.9% without PV-SMV resection (P = 0.423). Survival of PV-SMV resection and no resection group had no significant difference (median survival, 16 versus 12 months; P = 0.086). No significant difference in overall survival was seen between patients with and without pathologic PV-SMV invasion (median survival, 13 versus 16 months; P = 0.663). Tumour differentiation, R status, tumour size and type of operation were revealed as independent prognostic factors. Conclusions 34.8% of patients who underwent PV-SMV resection had no pathologic invasion. And PV-SMV resection did not increase the rate of severe complications and mortality. Furthermore, the prognosis for patients with pathologic PV-SMV invasion may be nearly the same as patients with no invasion. So, PV-SMV resection with reconstruction should be considered in pancreatic head cancer patients with suspected PV-SMV invasion.

Mobile robot has been studied for long time due to its simple structure and easy modeling. Regarding path planning of the mobile robot, we suggest real-time hybrid path planning algorithm which is the combination of optimal path planning and real-time path planning in this paper. Real-time hybrid path planning algorithm modifies, finds best route, and saves calculating time. It firstly plan the route with real-time path planning then robot starts to move according to the planned route. While robot is moving, update the route as the best outcome which found by optimal path planning algorithm. Verifying the performance of the proposed method through the comparing real-time hybrid path planning with optimal path planning will be done.Key Words : Hybrid path planning, Mobile robot, Real-time path planning, Optimal path planning† Corresponding Author : Dept. of Digital Electronics, INHA Technical College, South Korea E-mail : dwnkim@inhatc.ac.kr* ROBOTIS Inc, South Korea** Dept. of Electrical Engr., Soonchunhyang University, South Korea***Dept. of Digital Electronics, INHA Technical CollegeReceived : October 20, 2013; Accepted : December 3, 2013

As the mobile Internet has become widespread in recent years, communication based on mobile networks is increasing. As a result, security threats have been posed with regard to the abnormal tra ffic of mobile networks, but mobile security has been handled with focus on threats posed by mobile malicious codes, and researches on security threats to the mobile network itself have not attracted much attention. In this paper, we analyzes security threats that occurred to mobile networks recently, and checks the security threats likely to occur in actual commercial service networks and their results. We propose a countermeasure that can respond to such security threats, present results that can be applied to actual commercial networ ks, and thus make it possible to proactively respond to security threats described in this paper.

This paper addresses the vision based local path planning system for obstacle avoidance. To handle the obstacles which exist beyond the field of view (FOV), we propose a Panoramic Environment Map (PEM) using the MDGHM-SIFT algorithm. Moreover, we propose a Complexity Measure (CM) and Fuzzy logic-based Avoidance Motion Selection (FAMS) system to enable a humanoid robot to automatically decide its own direction and walking motion when avoiding an obstacle. The CM provides automation in deciding the direction of avoidance, whereas the FAMS system chooses the avoidance path and walking motion, based on environment conditions such as the size of the obstacle and the available space around it. The proposed system was applied to a humanoid robot that we designed. The results of the experiment show that the proposed method can be effectively applied to decide the avoidance direction and the walking motion of a humanoid robot.

In an autonomous multi-mobile robot environment, path planning and collision avoidance are important functions used to perform a given task collaboratively and cooperatively. This study considers these important and challenging problems. The proposed approach is based on a potential field method and fuzzy logic system. First, a global path planner selects the paths of the robots that minimize the potential value from each robot to its own target using a potential field. Then, a local path planner modifies the path and orientation from the global planner to avoid collisions with static and dynamic obstacles using a fuzzy logic system. In this paper, each robot independently selects its destination and considers other robots as dynamic obstacles, and there is no need to predict the motion of obstacles. This process continues until the corresponding target of each robot is found. To test this method, an autonomous multi-mobile robot simulator (AMMRS) is developed, and both simulation-based and experimental results are given. The results show that the path planning and collision avoidance strategies are effective and useful for multi-mobile robot systems.

For an autonomous multi-mobile robot system, path planning and collision avoidance are important functions used to perform a given task collaboratively and cooperatively. This study considers these important and challenging problems. The proposed approach is based on a potential field method and fuzzy logic system. First, a global path planner selects the paths of the robots that minimize the cost function from each robot to its own target using a potential field. Then, a local path planner modifies the path and orientation from the global planner to avoid collisions with static and dynamic obstacles using a fuzzy logic system. In this paper, each robot independently selects its destination and considers other robots as dynamic obstacles, and there is no need to predict the motion of obstacles. This process continues until the corresponding target of each robot is found. To test this method, an autonomous multi-mobile robot simulator (AMMRS) is developed, and both simulation-based and experimental results are given. The results show that the path planning and collision avoidance strategies are effective and useful for multi-mobile robot systems.

Background The duration of viral shedding is an important determinant of infectivity and transmissibility and provides vital information for effective infection prevention and control. However, few studies have evaluated viral shedding in patients admitted to hospital with 2009 H1N1 influenza and treated with oseltamivir. Objective To determine the incidence of prolonged 2009 H1N1 influenza viral shedding in patients treated for 5 days with oseltamivir and to identify factors that promote prolonged viral shedding. Methods This was a prospective, observational cohort study of 173 patients infected with 2009 H1N1 influenza (confirmed by RT-PCR) who were admitted to isolation rooms in the emergency department of our hospital between August 25, 2009 and December 31, 2009. All of the patients were treated according to institutional protocols and received routine follow-up RT-PCR testing after 5 days of oseltamivir therapy. Prolonged viral shedding was defined as a positive follow-up RT-PCR result. Result Of the 173 patients in our cohort, 88 (50·8%) showed persistent viral shedding after oseltamivir treatment. Viral shedding was significantly prolonged if antiviral therapy was started ≥2 days after symptom onset (OR 2·74, 95% CI 1·29–5·82), if there were major comorbidities (OR 3·07, 95% CI 1·29–7·32), and/or if respiratory symptoms were still present on the day 5 of antiviral treatment (OR 4·13, 95% CI 2·10–8·11). Conclusions The presence of major comorbidities, a delay in initiating antiviral treatment, and continuing respiratory symptoms after 5 days of antiviral treatment are associated with prolonged shedding of the 2009 H1N1 influenza virus.

Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs.To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality.Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions.The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs.The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ ≥ 0.90 for all comparisons; P .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions.For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.

This report introduced and evaluated our computer-assisted surgical method in the treatment of complex maxillofacial fractures. One patient with zygomatico-orbitomaxillary complex fracture underwent computed tomography to obtain DICOM data. Three-dimensional reconstruction and virtual surgical planning were carried out in the software MIMICS 10.01. Three reposition templates and 1 skull model were manufactured in our three-dimensional rapid prototyping machine. Reconstruction surgery was carried out according to the preoperative planning and with the guide of reposition templates. At 3-month follow-up, the treatment outcome was consistent with preoperative planning exactly, and the patient expressed high satisfaction with the surgery. Combination of reposition templates and rapid prototyping method demonstrated great practical value in complex maxillofacial fracture surgery.

The discrete Gaussian-Hermite moment (DGHM) is a global feature representation method that can be applied to square images. We propose a modified DGHM (MDGHM) method and an MDGHM-based scale-invariant feature transform (MDGHM-SIFT) descriptor. In the MDGHM, we devise a movable mask to represent the local features of a non-square image. The complete set of non-square image features are then represented by the summation of all MDGHMs. We also propose to apply an accumulated MDGHM using multi-order derivatives to obtain distinguishable feature information in the third stage of the SIFT. Finally, we calculate an MDGHM-based magnitude and an MDGHM-based orientation using the accumulated MDGHM. We carry out experiments using the proposed method with six kinds of deformations. The results show that the proposed method can be applied to non-square images without any image truncation and that it significantly outperforms the matching accuracy of other SIFT algorithms.

Please cite this paper as: Shin et al. (2012) Practices and predictors of 2009 H1N1 vaccination in cancer patients: a nationwide survey in Korea. Influenza and Other Respiratory Viruses 6(601), e120–e128. Background Because patients with cancer are considered to be at high-risk for influenza infection and related complications, annual vaccination is recommended. The emergence of the novel H1N1 influenza virus in 2009 complicated the medical care of patients with cancer. The present study examined H1N1 vaccination practices among patients with cancer during the pandemic season and investigated factors related to the vaccination. Methods A national multicenter cross-sectional survey of patient–doctor dyads was performed; A total of 97 oncologists (response rates of invited participants, 87·4%) and 495 patients (response rates of recruited participants, 86·5%) were included. Patients with cancer provided information concerning vaccination practices and reasons for/against it. Oncologists answered questions about their recommendations and knowledge of H1N1 vaccination. Mixed logistic regression was used to identify patient-level and physician-level predictors of H1N1 vaccination. Results Only 34·1% of the patients had received H1N1 vaccination, and 53·5% had not considered the need for vaccination. The H1N1 vaccine was proactively recommended by physicians in only a small fraction of patients (8·3%). Increasing age, higher educational status, longer time since the cancer diagnosis, comorbidities, and greater knowledge of H1N1 vaccination among oncologists were significant predictors of patients being vaccinated. Conclusions The present results showed low levels of utilization and poor interaction between patients and physicians with regard to the need for vaccination. In addition, the oncologist’s level of knowledge affected the adoption of preventive services. Intervention strategies are needed to maximize the rapid adoption of preventive methods to confront future pandemic threats in the cancer patient population.

This paper concerns ZMP-based control that is inspired by artificial neural networks for humanoid robot walking on varying sloped surfaces. Humanoid robots are currently one of the most exciting research topics in the field of robotics, and maintaining stability while they are standing, walking or moving is a key concern. To ensure a steady and smooth walking gait of such robots, a feedforward type of neural network architecture, trained by the back-propagation algorithm, is employed. The inputs and outputs of the neural network architecture are the ZMPx and ZMPy errors of the robot, and the x, y positions of the robot, respectively. The neural network developed allows the controller to generate the desired balance of the robot positions, resulting in a steady gait for the robot as it moves around on a flat floor, and when it is descending or ascending slopes. In this paper, experiments of humanoid robot walking are carried out, in which the actual position data from a prototype robot are measured in real-time situations, and fed into a neural network inspired controller designed for stable bipedal walking. In addition, natural walking motions on the different surfaces with varying slopes are obtained and the performance of the resulting controller is shown to be satisfactory.

Aloes have been widely used for a broad range of pharmacological activities, including parasitic problems. Avian coccidiosis is the most costly and wide-spread parasitic disease in the poultry industry, and has been mainly controlled by the use of chemotherapeutic agents. Due to the emergence of drug-resistant strains, alternative control strategies are needed. In this study, the protective effects of Aloe vera-based diets were assessed in broiler chickens following oral infection with Eimeria maxima. Chickens were fed a regular diet supplemented with ground Aloe vera throughout the duration of the experiment beginning 2 days prior to infection with 1 × 10(4) sporulated oocysts of E. maxima. No significant differences were found in body weight gain or loss between the Aloe vera-supplemented and unsupplemented groups with or without E. maxima infections. Fecal oocyst shedding decreased significantly (p < 0.05) in all of the treatment groups that were supplemented with Aloe vera as compared to the unsupplemented group. Furthermore, the Aloe vera-supplemented group showed significantly fewer intestinal lesions (p < 0.05) than the unsupplemented group following infection. The findings of this study suggest that Aloe vera could be used an alternative treatment for controlling avian coccidiosis.

This paper handles ZMP based control that is inspired by neural networks for humanoid robot walking on varying sloped surfaces. Humanoid robots are currently one of the most exciting research topics in the field of robotics, and maintaining stability while they are standing, walking or moving is a key concern. To ensure a steady and smooth walking gait of such robots, a feedforward type of neural network architecture, trained by the back propagation algorithm is employed. The inputs and outputs of the neural network architecture are the ZMPx and ZMPy errors of the robot, and the x, y positions of the robot, respectively. The neural network developed allows the controller to generate the desired balance of the robot positions, resulting in a steady gait for the robot as it moves around on a flat floor, and when it is descending slope. In this paper, experiments of humanoid robot walking are carried out, in which the actual position data from a prototype robot are measured in real time situations, and fed into a neural network inspired controller designed for stable bipedal walking.

An evolutionary design of Sugeno-type fuzzy systems for modelling humanoid robots is presented in this article, and issues related to the determination of the antecedent and consequent structures of the fuzzy model are addressed. In the design of the fuzzy model, determination of the type, the number of membership functions assigned to the input variables, the types of consequent equations for the fuzzy rules, the optimal number of input variables, and the dominant input variables among the input candidates are carried out using evolutionary algorithms. Using these algorithms, proper structures are evolved for the antecedent and the consequent of the Sugeno-type fuzzy model. Simulations are performed to show the effectiveness of the developed method when applied to a humanoid robot system with strong nonlinearities that have 10 input candidates.

The prognosis for locally advanced breast cancer (LABC) patients continues to be poor, with an estimated five-year survival of only 50-60%. Preclinical data demonstrates enhanced therapeutic efficacy with liposomal encapsulation of doxorubicin combined with hyperthermia (HT). Therefore this phase I/II study was designed to evaluate the safety and efficacy of a novel neoadjuvant combination treatment of paclitaxel, liposomal doxorubicin, and hyperthermia.Eligible patients received four cycles of neoadjuvant liposomal doxorubicin (30-75 mg/m(2)), paclitaxel (100-175 mg/m(2)), and hyperthermia. They subsequently underwent either a modified radical mastectomy or lumpectomy with axillary node dissection followed by radiation therapy and then eight cycles of CMF (cyclophosphamide, methotrexate, 5-fluorouracil) chemotherapy.Forty-seven patients with stage IIB-III LABC were enrolled and 43 patients were evaluable. Fourteen patients (33%) had inflammatory breast cancer. Combined (partial + complete) clinical response rate was 72% and combined pathological response rate was 60%. Four patients achieved a pathologically complete response. Sixteen patients were eligible for breast-conserving surgery. The cumulative equivalent minutes (CEM 43) at T90 (tenth percentile of temperature distribution) was significantly greater for those with a pathological response. Four-year disease-free survival was 63% (95% CI, 46%-76%) and the four-year overall survival was 75% (95% CI, 58-86%).Neoadjuvant therapy using paclitaxel, liposomal doxorubicin and hyperthermia is a feasible and well tolerated treatment strategy in patients with LABC. The thermal dose parameter CEM 43 T90 was significantly correlated with attaining a pathological response.

This paper describes a multi-mobile robot system with fuzzy rule based structure in collision avoidance. Collision avoidance is an important function to perform a given task collaboratively and cooperatively in multi-mobile robot environments. So the important but challenging problem is handled in this paper. Considered obstacles for collision avoidance between multi mobile robots are static, dynamic, or both of them at the same time. Using the fuzzy rule based structure, distance and angle from a robot to obstacles are described as fuzzy linguistic values and steering angle for the robot are updated from the collision environments. As a result, the multi-mobile robot can modify a global path from a robot itself to its own target. In addition, avoiding collision with static or dynamic obstacles for the robot system can be achieved. Simulation based experimental results are given to show usefulness of this method.

There is a wide variation in risk factors for intrahepatic cholangiocarcinoma (ICC) among various populations. Several studies have suggested that hepatitis C virus (HCV) infection may play a role in the development of ICC, whereas the role of hepatitis B virus (HBV) infection is less clear.To determine whether HBV or HCV infection is a risk factor of ICC, we compared baseline demographic and clinical factors in 622 patients diagnosed between 2000 and 2004 with histologically confirmed ICC and 2,488 healthy controls, matched 4:1 with ICC patients for sex and year of birth.HBV infection (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.6-3.3), but not HCV infection, was significantly related to ICC. Other significant risk factors for ICC included liver cirrhosis (OR 13.6), heavy alcohol consumption (OR 6.6), diabetes (OR 3.2), Clonorchis sinensis infection (OR 13.6), hepatolithiasis (OR 50.0), and choledochal cysts (OR 10.7).Our results indicate that development of ICC seems to be more closely related to HBV infection than to HCV infection in Korea, where both HBV and ICC are endemic.

Despite recent advances in laparoscopic pancreatic surgery, few studies have compared laparoscopic distal pancreatic resection (LDPR) with open distal pancreatic resection (ODPR). This study aimed to compare clinical outcomes for LDPR and ODPR performed at a single institution.For this study, 93 patients with benign pancreatic disease underwent LDPR, and 35 patients with benign pancreatic disease underwent ODPR. Patient demographic characteristics, operative times, perioperative complications, length of hospital stay, and return to normal diet were compared retrospectively between the two groups.The LDPR and ODPR groups had the same demographic characteristics. The median operative time was 195 min in the LDPR group and 190 min in the ODPR group (p0.05). The rate of spleen preservation was higher in the LDPR group (40.8%) than in the ODPR group (5.7%) (p0.05) No operative mortality occurred in either group. The overall complication rate was 24.7% in the LDPR group and 29% in the ODPR group (p0.05). The rate of pancreas-related complications was 11.8% in the LDPR group and 17.2% in the ODPR group (p0.05). Pancreatic fistula developed in 8.6% of the LDPR group and in 14.3% of the ODPR group (p0.05). Bowel movement return to normal and resumption of normal diet were achieved 2.8+/-1.3 days after the operation in the LDPR group and 4.5+/-1.6 days after the operation in the ODPR group (p0.05). The median duration of hospital stay was 10 days for the LDPR group, which was significantly shorter than the 16 days for the ODPR group (p0.01).The use of LDPR for benign lesions of the distal pancreas is feasible and safe. The LDPR procedure is associated with operative times and complication rates similar to those for ODPR, but LDPR has the advantages of an earlier return to normal bowel movements and normal diet and shorter hospital stays than ODPR.

Appropriate surgical treatment strategies based on clinicopathological findings are unavailable for intraductal papillary mucinous neoplasm (IPMN) of the pancreas. We investigated the clinical features of pancreatic IPMN in a single-center database in order to design an optimal surgical strategy. The medical records of 118 consecutive patients who had undergone surgical resection between August 1994 and December 2004, in whom IPMN was histologically confirmed, were reviewed retrospectively for radiological and pathological findings. Most of the invasive carcinomas in these patients were detected as the main-duct type (88.5%). The type of tumor (main-duct type vs branched-duct type), the tumor size, and the dilated duct size were significant predictive factors associated with malignancy. The relative risk of malignancy was greatest at 13-mm or more ductal dilation in the main-duct type (Odds ratio, 4.1), at 35-mm or more tumor size (Odds ratio, 7.6), and for main-duct type (Odds ratio, 3.9). Major pancreatic resections such as total pancreatectomy and pancreatoduodenectomy were performed in 14.5% and 69% of the patients, respectively. There was a 19.5% rate of incomplete resection, with these patients having a positive resection margin. However, significant recurrence did not occur in patients with a benign IPMN lesion which remained at the resection margin. The overall postoperative survival rate at 5 years was 98.2% for benign IPMN and 65.3% for malignant IPMN. Function-preserving strategies, based on the clinical status of the patient, are necessary in order to avoid possible severe metabolic complications following extended pancreatectomy in patients with benign IPMN because of the low recurrence rate and good prognosis of this entity, irrespective of margin status.