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Background: We aimed to identify predictive factors for positron emission tomography (PET)-detected hepatocellular carcinoma (HCC) metastasis and a cost-effective approach to preoperative PET-computed tomography (CT) for detecting metastasis. Methods: Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose (FDG) and 11C-acetate (ACT) following contrast-enhanced CT/magnetic resonance imaging (MRI) for preoperative tumor staging were reviewed. Binary logistic regression was performed to identify predictive factors for PET-detected metastasis. A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied. Results: Totally 152 patients were analyzed. Dual-tracer PET-CT detected metastasis in 17 patients (11%). By multivariate analysis, alpha-fetoprotein (AFP) ≥400 ng/mL [relative risk (RR): 4.30, 95% confidence interval (CI): 1.41–13.15, P=0.011] and bilobar disease (RR: 3.94, 95% CI: 1.24–12.52, P=0.014) were independent predictive factors for PET-detected metastasis. PET-CT findings altered the treatment strategy for 12 patients (7.9%); three partial hepatectomies, eight episodes of transarterial chemoembolization (TACE) and one episode of ablation were avoided, with an estimated cost-saving of US $91,000, $150,000 and $10,600 respectively. Had the PET-CT been performed only for patients with AFP ≥400 ng/mL or bilobar disease (n=74), metastasis would have been confirmed in 14 patients (18.9%), and the cost-saving per patient was estimated at US $1,070. Conclusions: Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP ≥400 ng/mL or bilobar disease. Its routine use in preoperative workup for all HCC patients is not recommended. Unilobar disease with AFP

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management.

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Coronavirus disease 2019 (COVID-19) is a global health concern as it continues to spread within China and beyond. The causative agent of this disease, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), belongs to the genus Betacoronavirus, which also includes severe acute respiratory syndrome-related coronavirus (SARSr-CoV) and Middle East respiratory syndrome-related coronavirus (MERSr-CoV). Codon usage of viral genes are believed to be subjected to different selection pressures in different host environments. Previous studies on codon usage of influenza A viruses helped identify viral host origins and evolution trends, however, similar studies on coronaviruses are lacking. In this study, we compared the codon usage bias using global correspondence analysis (CA), within-group CA and between-group CA. We found that the bat RaTG13 virus best matched the overall codon usage pattern of SARS-CoV-2 in orf1ab, spike and nucleocapsid genes, while the pangolin P1E virus had a more similar codon usage in membrane gene. The amino acid usage pattern of SARS-CoV-2 was generally found similar to bat and human SARSr-CoVs. However, we found greater synonymous codon usage differences between SARS-CoV-2 and its phylogenetic relatives on spike and membrane genes, suggesting these two genes of SARS-CoV-2 are subjected to different evolutionary pressures.

BACKGROUND To test the hypothesis that prognostication of treatment outcome is feasible by biomarker response at midcourse of chemoradiotherapy (CRT)/radiotherapy (RT), with respect to the plasma load of Epstein-Barr viral (EBV) DNA in nasopharyngeal carcinoma (NPC). PATIENTS AND METHODS One hundred seven patients with stage IIB-IV NPC were prospectively studied. Plasma EBV DNA load was measured by quantitative PCR before therapy (pre-DNA), at completion of 4 weeks of CRT/RT (mid-DNA), and within 3 months of completion of therapy (post-DNA). The end points are post-DNA load, a recognized surrogate of survival, and clinical outcome. RESULTS Ninety-three percent of patients had detectable EBV DNA before therapy (median load = 972 copies/ml). EBV DNA became undetectable in 55 (51%) patients at the end of week 4 of therapy. Detectable mid-DNA was associated with worse clinical outcome (median follow-up time, 6.2 years), for distant failure [hazard ratio (HR) 12.02, 95% confidence interval (CI) 2.78-51.93; P < 0.0001], progression-free survival (PFS; HR 4.05, 95% CI 1.89-8.67, P < 0.0001), and overall survival (OS; HR 3.29, 95% CI 1.37-7.90, P = 0.0077). Seventy-four percent of all failures were associated with detectable mid-DNA, whereas 34% of all failures were associated with detectable post-DNA. Stratification by tumor stage (IIB, III, IV) has no significant prognostic effect. CONCLUSIONS Unfavorable EBV DNA response at midcourse of RT/CRT is an adverse prognosticator for treatment outcome, is linked to majority of all failures, and discriminates outcome better than tumor stage. The data could provide a basis for trial design that addresses alteration of therapy intensity during the latter phase of CRT, and adjuvant therapy. Validation studies are awaited.

Dyslipidemia is common in liver transplant recipients. This retrospective study investigates whether donors play a role. Prospectively collected data of donors and recipients of deceased-donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT) were reviewed. Total cholesterol, triglyceride, low-density lipoprotein, high-density lipoprotein (HDL) and fasting glucose were compared between groups. HDL ≥1.6 mmol/L at 2 years after transplant was considered the marker of a favorable post-transplant lipid profile in recipients. Univariate and multivariate analyses were performed to identify predictive factors for this marker. There were 85 DDLTs and 80 LDLTs. LDLT donors were younger (30 vs. 50 years, p

Biochemical hypothyroidism (BH) after hemithyroidectomy is an under-recognized complication with a reported incidence of 9% to 43%. This study aimed to identify potential clinicopathologic risk factors associated with early (12 months after hemithyroidectomy) and late-onset (≥12 months after hemithyroidectomy) BH.From 2005 to 2008 there were 263 postsurgical patients who were eligible for analysis. Serum thyroid stimulating hormone (TSH) level was checked regularly after surgery. Postoperative TSH reaching a level higher than 5.5 mIU/L was defined as BH. The overall median follow-up period was 21 months (range, 3-62 mo). Any clinicopathologic factors significantly associated with BH in the univariate analysis were entered into multivariate analysis. A further analysis was performed comparing factors between early and late-onset BH.There were 38 patients who developed subsequent BH, 33 of these cases developed within 2 years. Those patients with BH were significantly older (P = .037), had a higher preoperative TSH level (P.001), longer follow-up period (P.001), more frequent thyroiditis on histology (P = .043), lighter resected tissue weight (P = .001), and were more likely to have positive antimicrosomal antibodies (P = .043) than those without BH. However, in the multivariate analysis after adjusting for different follow-up periods in the 2 groups, only lighter resected tissue weight (P = .036) and concomitant thyroiditis on histology (P = .005) turned out to be independent factors for BH. Thyroiditis on histology was also the only significant risk factor for developing early onset BH.Patients with lighter resected tissue weight and concomitant thyroiditis on histology were particularly at risk for subsequent BH. Although not all patients with thyroiditis developed BH, in those who did develop BH it occurred within the first 11 months.

Hepatocellular carcinoma (HCC) is one of the commonest malignant tumours in the East. Although the management of HCC in the West is mainly based on the Barcelona Clinic for Liver Cancer staging, it is considered too conservative by Asian countries where the number of HCC patients is huge. Scientific and clinical advances were made in aspects of diagnosis, staging, and treatment of HCC. HCC is well known to be associated with cirrhosis and the treatment of HCC must take into account the presence and stage of chronic liver disease. The major treatment modalities of HCC include: (1) surgical resection; (2) liver transplantation; (3) local ablation therapy; (4) transarterial locoregional treatment; and (5) systemic treatment. Among these, resection, liver transplantation and ablation therapy for small HCC are considered as curative treatment. Portal vein embolisation and the associating liver partition with portal vein ligation for staged hepatectomy may reduce dropout in patients with marginally resectable disease but the midterm and long-term results are still to be confirmed. Patient selection for the best treatment modality is the key to success of treatment of HCC. The purpose of current review is to provide a description of the current advances in diagnosis, staging, preoperative liver function assessment and treatment options for patients with HCC in the east. © 2015 Baishideng Publishing Group Inc., published_or_final_version

Summary Background : Colorectal cancer screening by guaiac faecal occult blood test has been shown to reduce the incidence and mortality of colorectal cancer in Western populations. The optimal faecal occult blood test, whether guaiac or immunochemical, for colorectal cancer screening in the Chinese population remains to be defined. Aim : To compare the performance characteristics of a sensitive guaiac-based faecal occult blood test (Hemoccult SENSA) and an immunochemical faecal occult blood test (FlexSure OBT) in a Chinese population referred for colonoscopy. Methods : One hundred and thirty-five consecutive patients who were referred for colonoscopy and who met the study inclusion criteria took samples for the two faecal occult blood tests simultaneously from three successive stool specimens, with no dietary restrictions. All tests were developed and interpreted by a single experienced technician who was blind to the clinical diagnosis. The sensitivity, specificity and positive predictive value for the detection of colorectal adenomas and cancers were estimated for the two tests. Results : The sensitivity, specificity and positive predictive value for the detection of significant colorectal neoplasia (adenomas ≥ 1.0 cm and cancers) were 91%, 70% and 18% for Hemoccult SENSA and 82%, 94% and 47% for FlexSure OBT. The specificity and positive predictive value were significantly higher for FlexSure OBT than for Hemoccult SENSA (P

The pseudoparticle virus neutralisation test (ppNT) and a conventional microneutralisation (MN) assay are specific for detecting antibodies to Middle East respiratory syndrome coronavirus (MERS-CoV) when used in seroepidemiological studies in animals. Genetically diverse MERS-CoV appear antigenically similar in MN tests. We confirm that MERS-CoV was circulating in dromedaries in Saudi Arabia in 1993. Preliminary data suggest that feral Australian dromedaries may be free of MERS-CoV but larger confirmatory studies are needed.

At our center, living donor liver transplantation (LDLT) is the main workload supported by a strong, mature service. Deceased donor liver transplantation (DDLT) is performed but in small volume. This study aimed to review the results of a low-volume DDLT service alongside a strong LDLT service. Consecutive DDLTs for adults performed from 1991 to 2009 were reviewed. The 1st to the 50th DDLTs were categorized as Era I cases, and the rest were Era II cases. The outcomes of the DDLTs were analyzed and compared with those achieved overseas. Eras I and II consisted of 59 and 183 DDLTs, respectively. All donors were brain-dead and heart-beating with a median age of 49 years (range 7–76 years). Among the 242 DDLTS, 30.2 % were on a high-urgency basis and 15.3 % were for hepatocellular carcinoma. The patients had a median model for end-stage liver disease score of 21 (range 6–40), and most (67.8 %) were hepatitis B virus carriers. Before transplantation, 16.1 % of the patients were in the intensive care unit and 30.2 % were in the hospital. The hospital mortality rate dropped from 13.6 % (8/59) during Era I to 3.8 % (7/183) during Era II (p = 0.012). For Era I, the 1-, 3-, and 5-year survival rates were 84.7, 79.7, and 76.3 %, respectively, which improved to 92.9, 89.0 and 87.2 % for Era II (p = 0.026). The recipient survival of this series compares favorably with contemporary series. It is shown that a low-volume DDLT service alongside a strong LDLT service can have excellent results.

Routine preoperative laryngeal examination remains controversial. We aimed to assess the utility of preoperative routine flexible laryngoscopy (FL) by looking at the incidence, clinical significance and predictors for preoperative vocal cord paresis (VCP) and incidental laryngopharyngeal conditions (LPC) in our consecutive cohort. A total of 302 patients underwent laryngeal examination by an independent otorhinolaryngologist and were specifically asked about voice/swallowing symptoms suggestive of VCP 1 day before surgery. As well as vocal cord (VC) mobility, the naso-pharynx and larynx were examined using FL. Any VCP and/or LPC was recorded. VCP was defined as reduced or absent movement in one or more VC. An LPC was considered clinically significant if the ensuing thyroidectomy was changed or deferred. Seven (2.3 %) patients had preoperative VCP, while an additional seven patients had an incidental LPC. Of the seven VCPs, five were caused by previous thyroidectomy, while two were caused by a benign goitre. The incidence of asymptomatic VCP in a previously non-operated cohort was 1/245 (0.41 %). Voice/swallowing symptoms (p = 0.033) and previous thyroidectomy (p

Background Hepatectomy is the main curative treatment for hepatocellular carcinoma (HCC), but postoperative long-term survival is poor. Preoperative radiological features of HCC displayed by computed tomography or magnetic resonance imaging could serve as additional prognostic factors. This study aimed to identify preoperative radiological features of HCC that may be of prognostic significance in hepatectomy. Methods Ninety-two patients who underwent hepatectomy for HCC were included in this study. Preoperative radiological features including tumor number, size, location (peripheral, middle, central), portal vein invasion, hepatic vein invasion, and presence of pseudo-capsule were analyzed in relation to survival. Results With a median follow-up period of 41.7 months, the 1-, 3- and 5-year overall survival rates were 85%, 65% and 58%, respectively. Univariate analysis showed that portal vein invasion and absence of pseudo-capsule were significant prognostic factors for overall survival, while all the examined radiological features were prognostic factors for disease-free survival. Multivariate analysis for overall survival found no significant factor. On multivariate analysis for disease-free survival, patients who had tumors with portal vein invasion had poorer survival with a hazard ratio of 2.26 (95% CI, 1.05-4.91; P =0.038) and patients with single nodular HCC or pseudo-capsulated HCC had better survival with a hazard ratio of 0.50 (95% CI, 0.27-0.94; P =0.032) and 0.38 (95% CI, 0.14-0.99; P =0.048), respectively. Conclusions Demonstrable pseudo-capsule of HCC and solitary HCC on imaging and absence of portal vein invasion are features associated with better disease-free survival after hepatectomy. These features may guide treatment planning for HCC.

Bleeding angiodysplasia of the gastrointestinal tract poses frustrating challenges to clinicians because these minute vascular lesions are difficult to diagnose pre-operatively and to locate intra-operatively. During the past 12 years, 24 patients were treated for histopathologically confirmed bleeding angiodysplasia of the gastrointestinal tract. Pre-operative investigations and intra-operative localization followed a fixed protocol for patients with gastrointestinal bleeding of obscure origin. The median follow-up of these 24 patients was 51 months and the results of treatment for 22 patients were excellent. Two patients had recurrent bleeding but investigations failed to determine the bleeding source.

Loss of DNA copy number at the short arm of chromosome 3 is one of the most common genetic changes in human lung cancer, suggesting the existence of one or more tumor suppressor genes (TSG) at 3p. To identify most frequently deleted regions and candidate TSGs within these regions, a recently developed single-nucleotide polymorphism (SNP)-mass spectrometry-genotyping (SMSG) technology was applied to investigate the loss of heterozygosity (LOH) in 30 primary non–small-cell lung cancers. A total of 386 SNP markers that spanned a region of 70 Mb at 3p, from 3pter to 3p14.1, were selected for LOH analysis. The average intermarker distance in the present study is ∼180 kb. Several frequently deleted regions, including 3p26.3, 3p25.3, 3p24.1, 3p23, and 3p21.1, were found. Several candidate TSGs within these frequently detected LOH regions have been found, including APG7L at 3p25.3, CLASP2 at 3p23, and CACNA2D3 at 3p21.1. This study also showed that SMSG technology is a very useful approach to rapidly define the minimal deleted region and to identify target TSGs in a given cancer. (Cancer Res 2006; 66(8): 4133-8)

Occupational risk factors of carpal tunnel syndrome (CTS) are popular current research targets, with main emphasis put on wrist posture and dynamics. In this study, we do not intend to pinpoint individual occupations, but aim to identify high risk wrist postures and actions which may occur across various occupations. It is hoped that prevention can thus be instituted in a general population by directing at the particular causative wrist actions rather than exclusively targeting isolated occupations. We performed a case-control study with 166 cases and 111 controls recruited from different hospitals in Hong Kong in 2004. All cases and controls completed the survey on their general health condition, smoking status, wrist posture and motion as well as psychosocial status at the time of diagnosis of CTS. Frequent flexion OR = 4.436 (95% CI: 1.833–10.734), frequent extension OR = 2.691 (95% CI: 1.106–6.547) of the wrist were found to be associated with CTS. Frequent sustained forceful motion of the wrist OR = 2.588 (95% CI: 1.144–5.851) was also found to be associated with CTS. Neutral wrist position and repetitive wrist motion were not associated with CTS. Adjustment was made for age, sex, BMI, smoking and psychosocial stress. Our study confirms that frequent flexion, extension and sustained force of the wrist increase the risk of developing CTS.

A total of 203 patients were randomized into a prospective trial to compare short (SC) versus long courses (LC) of systemic antibiotic for acute cholecystitis treated by early cholecystectomy. The initial pre-operative management was the same and all patients received 2 g of cefamandole intravenously just before operation. Two further doses of cefamandole 500 mg were given 6 and 12 h later for patients on SC while the antibiotic was continued at 500 mg at 6 h intervals for 7 days for patients on LC. Seven patients developed wound infection on SC compared with five patients with wound infection and an additional patient with a subphrenic abscess on LC (P greater than 0.05). Thrombophlebitis related to intravenous antibiotic injections was more common in patients on LC (P less than 0.05). Also, patients on LC had to stay statistically longer in hospital in order to complete the course of antibiotic (P less than 0.05). We therefore recommend a SC to be used, as it is more cost-effective and causes fewer complications.

In the past six years, 37 patients with gastrointestinal bleeding of obscure origin had their bleeding sites localised preoperatively or intraoperatively. Preoperative investigations followed a regime consisting of endoscopy, barium meal and follow through, small bowel enema, 99mTc pertechnetate scan, 99mTc-labelled red blood cell scan and selective coeliac and mesenteric angiography. Bleeding lesions were localised preoperatively in 36 patients. In one patient, diagnostic laparotomy had to be carried out immediately before any investigation because the bleeding was severe. At operation, angiosarcoma of ileum was found. Unless preoperative investigations showed the lesions to be in anatomically fixed organs like the duodenum or colon, the lesions had still to be found at operation. Palpation and transillumination detected the lesion intraoperatively in 21 patients while only some lesions were found in three patients with multiple lesions. Sigmoidoscopy through enterotomies was required in one patient. Intraoperative enteroscopy was done for small lesions not found grossly at operation in nine patients, to detect additional lesions in three patients or to rule out suspicious lesion shown on preoperative tests in one patient. In another patient with diffuse lymphoma of small bowel with bleeding from only a small segment of jejunum, injection of methylene blue intraoperatively through a previously placed angiographic catheter stained the bleeding segment of jejunum blue. This segment was identified easily and resected. These preoperative and intraoperative localisation procedures were simple and effective and we recommend them to be used more freely.

For this study, a sample of 1,689 patients classified as “charity” and “bad debt” cases in 1986 were identified from 27 general acute care hospitals and one tertiary hospital in Indiana. Half of the hospitals were in rural areas and 57 percent were small (less than 150 beds). Most of the patients (87.2 percent) incurred uncompensated amounts under $2,500, and 40 percent of the cases were below $500. About 72 percent of the patients with uncompensated care were from the same county as the location of the hospital (range from 30.9% to 100.0%). The majority of the cases (79.4 percent) with over $5,000 in uncompensated care were treated in urban hospitals. The average age of these patients was 27.2 years. Fifty-four percent of the patients were single, 60.7 percent were female, and nearly all (83.0 percent) were discharged to home care. Only 44.6 percent of the patients with uncompensated care had no insurance; 46.8 percent had some form of commercial insurance which covered part of the charges for care. The most common diagnosis for these patients was pregnancy and childbirth (22.8 percent), with injury and poisoning second (10.7 percent). The cases with $5,000 or more in bad debt (about 4 percent of the cases) account for 28.3 percent of the total uncollected amount. Bad debt represents a cost of doing business. Any national effort to contain health care costs must address this problem.