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Refractory cardiogenic shock (RCS) represents the extremely-ill patients with STEMI, whose mortality rate was >60%. Despite the efforts to decrease door-to-balloon (D2B) time in the past decade, recent studies reported little progress on mortality of these patients. Meanwhile, early mechanical

An empirical study that utilizes a mailed survey to assess the initiatives and key factors of implementing ISO programs in various governmental departments in Taiwan was carried out. The results of this study identify five critical factors of successful ISO implementation in public organizations and show that the certification of ISO 9000 is seen as a tool for improving organizational images and creating the structures to integrate changed responsibilities for public organizations in Taiwan. The results also reveal differences in ISO 9000 implementation practices associated with organization size, unionization, and service types.

Multiclass prediction remains an obstacle for high-throughput data analysis such as microarray gene expression profiles. Despite recent advancements in machine learning and bioinformatics, most classification tools were limited to the applications of binary responses. Our aim was to apply partial least square (PLS) regression for breast cancer intrinsic taxonomy, of which five distinct molecular subtypes were identified. The PAM50 signature genes were used as predictive variables in PLS analysis, and the latent gene component scores were used in binary logistic regression for each molecular subtype. The 139 prototypical arrays for PAM50 development were used as training dataset, and three independent microarray studies with Han Chinese origin were used for independent validation (n=535). The agreement between PAM50 centroid-based single sample prediction (SSP) and PLS-regression was excellent (weighted Kappa: 0.988) within the training samples, but deteriorated substantially in independent samples, which could attribute to much more unclassified samples by PLS-regression. If these unclassified samples were removed, the agreement between PAM50 SSP and PLS-regression improved enormously (weighted Kappa: 0.829 as opposed to 0.541 when unclassified samples were analyzed). Our study ascertained the feasibility of PLS-regression in multi-class prediction, and distinct clinical presentations and prognostic discrepancies were observed across breast cancer molecular subtypes.

Laparoscopic incisional and ventral hernia repair (LIVHR) has been advocated for short hospital stay, rapid ambulation, and low recurrence rates and has gained increasing popularity. We report here the outcomes of long-term follow-up of LIVHR.The series comprised 100 LIVHR procedures performed between June 2000 and February 2004. LIVHR was performed with the standard three-trocar configuration. Underlay expanded polytetrafluoroethylene mesh was placed in a tension-free manner and bridged the fascia defect with an adequate overlap of at least 4 cm. Enrolled patients were prospectively followed up at return visits.Two conversions due to densely scarred abdomen were inevitable. There were four true recurrences (4%) and three eventrations (loss of prosthetic elasticity) (3%). There was no difference in recurrence rate and eventrations among ventral, incisional, and recurrent incisional hernias. Patients with recurrent incisional hernias reported more seroma formations, and seroma formation was independently associated with adhesiolysis (adjusted odds ratio=4.57).Long-term follow-up of LIVHR was satisfactory both in complications and in recurrences. The efficacy of LIVHR was ascertained and reproducible for Taiwanese patients. The concerns with chronic pain necessitate preoperative counseling with patients indicated or planned for LIVHR.

Background Breast cancer is a heterogeneous disease in terms of transcriptional aberrations; moreover, microarray gene expression profiles had defined 5 molecular subtypes based on certain intrinsic genes. This study aimed to evaluate the prediction consistency of breast cancer molecular subtypes from 3 distinct intrinsic gene sets (Sørlie 500, Hu 306 and PAM50) as well as clinical presentations of each molecualr subtype in Han Chinese population. Methods In all, 169 breast cancer samples (44 from Taiwan and 125 from China) of Han Chinese population were gathered, and the gene expression features corresponding to 3 distinct intrinsic gene sets (Sørlie 500, Hu 306 and PAM50) were retrieved for molecular subtype prediction. Results For Sørlie 500 and Hu 306 intrinsic gene set, mean-centring of genes and distance-weighted discrimination (DWD) remarkably reduced the number of unclassified cases. Regarding pairwise agreement, the highest predictive consistency was found between Hu 306 and PAM50. In all, 150 and 126 samples were assigned into identical subtypes by both Hu 306 and PAM50 genes, under mean-centring and DWD. Luminal B tended to show a higher nuclear grade and have more HER2 over-expression status than luminal A did. No basal-like breast tumours were ER positive, and most HER2-enriched breast tumours showed HER2 over-expression, whereas, only two-thirds of ER negativity/HER2 over-expression tumros were predicted as HER2-enriched molecular subtype. For 44 Taiwanese breast cancers with survival data, a better prognosis of luminal A than luminal B subtype in ER-postive breast cancers and a better prognosis of basal-like than HER2-enriched subtype in ER-negative breast cancers was observed. Conclusions We suggest that the intrinsic signature Hu 306 or PAM50 be used for breast cancers in the Han Chinese population during molecular subtyping. For the prognostic value and decision making based on intrinsic subtypes, further prospective study with longer survival data is needed.

Background Circular Binary Segmentation (CBS) is a permutation-based algorithm for array Comparative Genomic Hybridization (aCGH) data analysis. CBS accurately segments data by detecting change-points using a maximal-t test; but extensive computational burden is involved for evaluating the significance of change-points using permutations. A recent implementation utilizing a hybrid method and early stopping rules (hybrid CBS) to improve the performance in speed was subsequently proposed. However, a time analysis revealed that a major portion of computation time of the hybrid CBS was still spent on permutation. In addition, what the hybrid method provides is an approximation of the significance upper bound or lower bound, not an approximation of the significance of change-points itself. Results We developed a novel model-based algorithm, extreme-value based CBS (eCBS), which limits permutations and provides robust results without loss of accuracy. Thousands of aCGH data under null hypothesis were simulated in advance based on a variety of non-normal assumptions, and the corresponding maximal-t distribution was modeled by the Generalized Extreme Value (GEV) distribution. The modeling results, which associate characteristics of aCGH data to the GEV parameters, constitute lookup tables (eXtreme model). Using the eXtreme model, the significance of change-points could be evaluated in a constant time complexity through a table lookup process. Conclusions A novel algorithm, eCBS, was developed in this study. The current implementation of eCBS consistently outperforms the hybrid CBS 4× to 20× in computation time without loss of accuracy. Source codes, supplementary materials, supplementary figures, and supplementary tables can be found at http://ntumaps.cgm.ntu.edu.tw/eCBSsupplementary.

Throughout the past 25 years, the interest in global health on the part of higher education in general has increased substantially. Medical education is no exception. The medical literature now contains dozens of descriptions of international health clerkships or experiences offered to medical students. In 1984, only 6% of graduating U.S. medical students had participated in international health electives. In 2004, 22% had done so.ABOUT THE AUTHORSBonita Stanton, MD, is Professor and Schotanus Family Endowed Chair of Pediatrics, and Pediatrician-in-Chief, Carmen and Ann Adams Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University School of Medicine; and is with the Federation of Pediatric Organizations (FOPO) Global Health Working Group. Chi-Cheng Huang, MD, is with Boston Medical Center, Boston University School of Medicine. Robert W. Armstrong, MD, PhD, is with the FOPO Global Health Working Group; and University of British Columbia and British Columbia Children’s Hospital. Theodore C. Sectish, MD; and Judith Palfrey, MD, are with the FOPO Global Health Working Group; Children’s Hospital Boston; and Harvard University. Brett D. Nelson, MD, MPH; and Julie M. Herlihy, MD, MPH, are with Children’s Hospital Boston; and Harvard University. Errol Alden, MD, is with the FOPO Global Health Working Group; and the American Academy of Pediatrics. William Keenan, MD, is with the FOPO Global Health Working Group and Children’s Hospital Boston. Peter Szilagyi, MD, is with the FOPO Global Health Working Group; and the University of Rochester School of Medicine, Rochester, New York.Address correspondence to: Bonita Stanton, MD, Children’s Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Blvd., Detroit, MI 48201; fax 313 993-0390; or e-mail bstanton@dmc.org.Dr. Stanton; Dr. Huang; Dr. Armstrong; Dr. Sectish; Dr. Palfrey; Dr. Nelson; Dr. Herlihy; Dr. Alden; Dr. Keenan; and Dr. Szilagyi have disclosed no relevant financial relationships. The authors appreciate the enthusiasm of the many residents and host institutions who are participating in global training. They thank Madeline Balice for her help in preparing this manuscript.

OBJECTIVE. Our goal was to describe current resident interest, participation, curricula, resources, and obstacles related to global health training within pediatric residency programs. METHODS. We conducted a cross-sectional survey of the 201 accredited pediatric residency programs in the United States, Puerto Rico, and the Caribbean from October 2006 to January 2007. Survey topics included resident interest and participation in electives, training opportunities, program support, and educational curricular content related to global health. RESULTS. Of the 201 surveyed pediatric residency programs, 106 (53%) responded. Fifteen percent of responding programs reported that a majority of their residents were interested in global health. Fifty-two percent offered a global health elective within the previous year, and 47% had formally incorporated global health into their training curricula. Six percent of the programs reported a formalized track or certificate in global health. The median number of residents per program participating in global health electives within the previous year was 0 during postgraduate year 1, 1 during postgraduate year 2, and 2 during postgraduate year 3. The median number of all residents per program participating in a global health elective in the previous year was 3 (7.4% of program size). Among programs that offered a global health elective, support to participating residents included prerequisite clinical training (36%), cultural orientation (36%), language training (15%), faculty mentorship (82%), and postelective debriefing (77%). Fourteen percent of the programs provided full funding for resident electives. Characteristics of pediatric residency programs that were significantly associated with higher resident participation in a global health elective were larger program size, university affiliation, greater reported resident interest, and faculty involvement in global health. CONCLUSIONS. More than half of the pediatric residency programs surveyed offered a global health elective in the previous year. An American Academy of Pediatrics survey 10 years earlier had shown 1 of 4 programs with global health electives. Observance of American Academy of Pediatrics consensus guidelines for global health electives varied widely among programs, and additional efforts should focus on resident preparation, mentorship, and funding.

Experience collected from 5200 cases of laparoscopic cholecystectomy (LC) and 29 patients (6 ours, 23 referred) with major common bile duct (CBD) injury during LC in our institute between December 1990 and July 2004 was reported to demonstrate that the system approach we applied in performing LC prevents CBD injury and enhances surgical performance. Each case of CBD injury was meticulously analyzed to identify causative factors. We developed preventive strategies focusing on 4 dimensions: patient, environment, procedure, and operator. Surgical performance was then evaluated to demonstrate improvements. Incidence of CBD injury was calculated for early and latter halves of the series to compare 5 parameters of surgical performance: patient selection, operation time, indwelling drainage tube, surgeon, and conversion rate. Results of accident analysis demonstrated that CBD injury followed definite mechanisms; several warning signs appearing before and during injury were identified and classified. According to these results, we designed strategies to prevent injury, including: setting up patient-selection program, controlling surgical environment, developing error-proof procedures, and constructing training programs. Incidence of CBD injury in the whole series was 0.12% (6/5200), 0.27% in early half (6/2224), and zero (0/2967) in latter half. Attending doctors had significantly shorter operation times in latter period for both elective and emergent LC. Rate of using drainage tubes for elective surgery by attending doctors was significantly decreased in latter period. Operation time for elective surgery by residents was similar in both early and latter periods. However, residents in latter period had longer operation times (around 23 min long, P

The relatively high incidence of gastric cancer in Taiwan warranted the need of a disease-specific quality of life (QOL) instrument. We translated the EORTC QLQ-C30 and QLQ-STO22 according to the guidelines from the EORTC. A total of 100 patients were interviewed. Convergent and discriminant validity, Cronbach's alpha coefficient and known-groups comparisons were used to examine the reliability and validity. We found good reliability for multi-item subscales of the QLQ-C30 and QLQ-STO22 (Cronbach's alpha coefficient: 0.70-0.94) except cognitive functioning of the QLQ-C30 and eating restriction of the QLQ-STO22. Patients in the active treatment group experienced compromised functional status and worse treatment-associated symptoms than those in the follow-up group. Similar results were found in comparisons based on Eastern Cooperative Oncology Group (ECOG) Performance Status and dysphagia grades. The study has ascertained the cross-cultural validity, reliability and clinical applicability of the Taiwan Chinese version of the EORTC QLQ-C30 and QLQ-STO22.

Inflammatory myofibroblastic tumour is a rare solid tumour mimicking malignancy with locally aggressive growth and recurrence even after complete resection. We report the case of a 10-year-old girl with an intra- abdominal inflammatory myofibroblastic tumour. This clinical and pathological entity should be differentiated from other malignant sarcomatous lesions when encountered intraoperatively. It is almost impossible to differentiate inflammatory myofibroblastic tumour from other malignancies preoperatively; the diagnosis is often confirmed by careful microscopic examination or immunohistochemical markers after surgical resection. Total excision of the tumour with life-time follow-up is needed because of the risk of recurrence.

Laparoscopy, both diagnostic and therapeutic, has been used in the management of pediatric non-palpable testes. We report a case of left non-palpable testis at the unusual age of 18 years. Laparoscopic exploration revealed an intra-abdominal testis lying between the internal inguinal ring and external iliac vessels. The testis was visually in good condition and, in contrast to the accepted procedure of orchiectomy performed in late adolescent cryptorchidism, we decided to preserve this intra-abdominal testis, which was located too far from the scrotum for a primary orchidopexy. The first stage of the Fowler-Stephens procedure was performed laparoscopically. The second-stage orchidopexy was performed successfully through an inguinal approach 3 months later, after sonographic ascertainment of non-decreased testicular volume. Laparoscopy allows thorough exploration for an intra-abdominal testis, with simultaneous therapeutic options. Our experience highlights the feasibility of laparoscopic assessment and treatment of cryptorchidism in adolescents and young adults.

The aim of the study is to evaluate gene component analysis for microarray studies. Three dimensional reduction strategies, Principle Component Regression (PCR), Partial Least Square (PLS) and Reduced Rank Regression (RRR) were applied to publicly available breast cancer microarray dataset and the derived gene components were used for tumor classification by Logistic Regression (LR) and Linear Discriminative Analysis (LDA). The impact of gene selection/filtration was evaluated as well. We demonstrated that gene component classifiers could reduce the high-dimensionality of gene expression data and the collinearity problem inherited in most modern microarray experiments. In our study gene component analysis could discriminate Estrogen Receptor (ER) positive breast cancers from negative cancers and the proposed classifiers were successfully reproduced and projected into independent microarray dataset with high predictive accuracy.

The interplay between copy number variation (CNV) and differential gene expression may be able to shed light on molecular process underlying breast cancer and lead to the discovery of cancer-related genes. In the current study, genes concurrently identified in array comparative genomic hybridization (CGH) and gene expression microarrays were used to derive gene signatures for Han Chinese breast cancers. We performed 23 array CGHs and 81 gene expression microarrays in breast cancer samples from Taiwanese women. Genes with coherent patterns of both CNV and differential gene expression were identified from the 21 samples assayed using both platforms. We used these genes to derive signatures associated with clinical ER and HER2 status and disease-free survival. Distributions of signature genes were strongly associated with chromosomal location: chromosome 16 for ER and 17 for HER2. A breast cancer risk predictive model was built based on the first supervised principal component from 16 genes (RCAN3, MCOLN2, DENND2D, RWDD3, ZMYM6, CAPZA1, GPR18, WARS2, TRIM45, SCRN1, CSNK1E, HBXIP, CSDE1, MRPL20, IKZF1, and COL20A1), and distinct survival patterns were observed between the high- and low-risk groups from the combined dataset of 408 microarrays. The risk score was significantly higher in breast cancer patients with recurrence, metastasis, or mortality than in relapse-free individuals (0.241 versus 0, P

Proceedings: AACR 104th Annual Meeting 2013; Apr 6-10, 2013; Washington, DC We performed genome-wide characterization of Han Chinese breast cancer at molecular level by integrating two microarray technologies: comparative genomic hybridization (CGH) for DNA copy number variations (CNV) and expression arrays. Concurrent gains and losses from the same subject across genomic and transcriptional levels may be a better approach to explore potential biomarkers for breast cancer and to identify possible candidates for target therapy. Oncogenesis of breast cancer could originate from chromosome level manifesting as CNV and persist through transcription in gene expression profiles. Genes with coherent patterns at chromosomal and transcriptional level are more likely to serve as potential biomarkers for Han Chinese breast cancer and deserve meticulous evaluation. A total of 23 array CGH and 81 gene expression microarrays (21 samples with data from both platforms) were performed. Potential targets of cancer therapy were revealed by Genomic Identification of Significant Targets in Cancer (GISTIC) from 23 array CGH. Genes with coherent patterns between CNV and gene expression profiles were identified from 21 samples with both platforms assayed. We used these concurrent genes as well as genes with significant GISTIC scores to derive signatures associated with ER, HER2 and event-free survival. Distributions of signature genes were strongly associated with chromosomal locations: chromosome 16 for ER and 17 for HER2. 37 and 13 genes were differentially expressed between distinct ER and HER2 status and were used for classifier development in our 81 samples. Predictive accuracy as high as 90% for ER and 80% for HER2 was reported during leave-one-out cross-validation while much compromised performance was observed in an independent test dataset ([GSE5460][1]). Consensus genes between our dataset and 125 Chinese breast cancers ([GSE5460][1]) were identified, and a 28 genes and a 9 genes signature for ER and HER2 was developed in combined dataset of 206 microarrays with the best predictive accuracy of 92% and 94% for ER and HER2 respectively. Breast cancer risk predictive model was built based on supervised principle components from two genes (RWDD3 and ZBTB44) and distinct survival patterns were observed between high- and low-risk groups from a combined dataset of 408 microarrays (combination of our 81 samples with [GSE20685][2]). The risk score was significantly higher in breast cancers with recurrence, metastasis or mortality than those remained event-free (0.438 versus 0.17, p

Technology development programs have proven to be useful strategies for governments to encourage private firms to undertake R&D projects. Due to limited budgets, a government must select proper R&D projects for funding. R&D project selection is full of uncertainty and can be viewed as a multiple-criteria decision that is normally made by a review committee. In this study, we propose a fuzzy analytic network process method to handle interdependency among evaluation criteria and integrate the divergent judgements of experts in a R&D project selection committee. Our findings suggest that ‘scientific and technological merit’ and ‘project execution’ are the most important criteria and, moreover, indicate that the relative importance of evaluation criteria changes in different degrees of uncertainty.

We demonstrate that indium nitride (InN) can be used as ion selective electrode (ISE) for anion concentration measurements. The InN ISE reveals remarkable selectivity, response time, signal stability, and repeatability for chlorine and hydroxyl ions. The selective interaction of Lewis bases in solutions with the N-polarity InN epitaxial layer grown on silicon is confirmed by potentiometric responses. The Helmholtz potential of the InN ISE, generated at the InN/solution interface, satisfies the Nernst equation. The observation of anion attraction to the InN surface further demonstrates the existence of donor-type surface states on InN.

To the Editor .— We applaud the efforts of Leslie et al and the Pediatric Leadership Alliance1 for placing the importance of leadership on the academic agenda ( Pediatrics , March 2005). Historically, medical schools and residency programs have fallen short in training physicians to become great managers and leaders for the 21st century. In contrast, other industries, particularly the business world, place high value in this area of professional development. Leaders alter operational systems and make definitive decisions that set their vision in …

Bolivian sex workers were more likely than other employed women to report tuberculosis screening only if they reported HIV screening. Of all women with household tuberculosis exposure

Background/Purpose: Breast cancer is the most common female malignancy in Taiwan; however, quality of life (QOL) following breast cancer therapy remains rarely studied. The aim of the present study was to evaluate QOL among Taiwanese breast cancer patients with and without breast-conserving therapy. Methods: A total of 130 women with breast cancer (37 with breast-conserving therapy and 93 with modified radical mastectomy) were enrolled between August, 2004 and December, 2007 in a single center. Patients who underwent breast-conserving therapy were younger, less likely to be married, had a higher educational level, and were at an earlier clinical stage than those who underwent modified radical mastectomy. The traditional Chinese version of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-BR23 questionnaires were used as measuring instruments. Structural equation modeling with mean structural analysis, which evaluates configuration invariance and compares groups for latent functional/symptomatic factors, was constructed using a multi-indicators approach. Results: Patients with breast-conserving therapy reported worse global QOL status and role function scores and higher symptomatic scores for fatigue, pain, dyspnea, insomnia, appetite loss, breast and arm problem subscales than those without conserving therapy. In addition, age, marital status, hormone manipulation and postoperative adjuvant therapy were significant confounders for QOL. Measurement invariance was ascertained and the same QOL construct could be applied to Taiwanese subjects with and without breast-conserving therapy. Conclusion: Our study suggests that breast-conserving therapy might be associated with worse perceived QOL for Taiwanese breast cancer survivors.

The growth arrest-specific 2 (GAS2) was cloned and found to be upregulated in the feces of recurrent CRC patients. This overexpressed GAS2 induced different patterns of gene expressions in CRC cells. Briefly, one cell proliferation marker, Ki-67 antigen (Ki-67), was upregulated in the cells with overexpressed GAS2, “Correlation between proliferation markers: PCNA, Ki-67, MCM-2 and antiapoptotic protein Bcl-2 in colorectal cancer” [1]. Whereas, the expression of another cell proliferation marker, proliferating cell nuclear antigen (PCNA), changed insignificantly [1]. In addition, the mRNA level of one cyclin involving in both cell cycle G1/S and G2/M transitions was also not affected by GAS2 overexpression, “Cdc20 and Cks direct the spindle checkpoint-independent destruction of cyclin A” [2]. The experimental design and procedures in this article can be helpful for understanding the molecular significance of GAS2 in SW480 and SW620 CRC cells.

Background Colorectal cancer (CRC) is one of the leading causes of malignant death worldwide. Because young age of onset is often considered a poor prognostic factor for CRC, it is important to identify the poor outcomes of CRC in a younger population and to consider an aggressive approach by implementing early treatment. Our aim was to specifically quantify the fecal cytokeratin 19 (CK19) transcript from CRC patients and investigate its correlation with clinical stage, tumor malignancy, and age. Methods The quantitation of fecal CK19 transcript was determined by a quantitative real-time reverse transcription polymerase chain in 129 CRC patients (45 younger than 60 years at diagnosis) and 85 healthy controls. The levels of CK19 protein were examined both in colonic cell lines and tissues. Results The analysis of 45 younger CRC patients (age ≤ 60 years) revealed that patients at the M1 stage had significantly higher expression levels of fecal CK19 mRNA when compared with healthy controls (p < 0.001) and patients at the M0 stage (p = 0.004). Additionally, the degree of consistency between the mean level of fecal CK19 mRNA and the distant metastatic rate in each age interval was up to 89% (p = 0.042). Conclusion These results indicate that high levels of fecal CK19 mRNA represent a potential marker for colorectal malignancy and for aggressive treatment of younger CRC patients.