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

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

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

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

An efficient copper-catalyzed reductive defluorination of β-trifluoromethylated enones via an oxidative homocoupling of Grignard reagents is reported. The reaction proceeded smoothly with a wide range of substrates, including the ones bearing aromatic heterocycles, such as furyl and thienyl ring systems in high yields (80–92%, except one example) under mild conditions. This provides a practical method for synthesis of gem-difluoroolefin ketones. It is also worth noting that this homocoupling process of Grignard reagents using β-trifluoromethylated enones as “oxidizing reagents” is effective for both the Csp2–Csp2 and Csp3–Csp3 bond formations, including for substrates whose β-hydride elimination of the corresponding transition metal alkyl complex is particularly facile, affording coupling products with high yields (83–95%), simultaneously.

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

A solar heating system with the absorption heat pumps (AHPs) and oil/water heat exchanger (OWHE) was set up for space heating. The system was driven by parabolic trough solar collectors (PTCs). In this study, heat transfer models were built and experiments were conducted to evaluate the performance of PTCs. Collector efficiencies of 40-55% were obtained under different weather conditions. For the solar driven AHP system and OWHE system, primary energy ratio (PER) values were calculated and compared. The results showed that in overcast days with low direct normal insolation (DNI), the operation of the PTC system was not cost-effective. In cloudy days with high DNI lasting for a short period (e.g. 2 hours), the operation of OWHE system was better than the operation of AHP system as the AHP system needed more preheating energy before the system operation. While in sunny days with high DNI lasting for a longer period (e.g. 8 hours), the AHP system was suggested to be operated for it owned higher PER values.

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

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

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

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

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

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

Background: Systemic inflammation plays an important part in tumorigenesis and progression. The predictive values of the preoperative lymphocyte to monocyte ratio (LMR) and prognostic nutritional index (PNI) in colon cancer remained unclear. Methods: A total of 308 patients with colon cancer undergoing radical resection were enrolled and analyzed. The receiver operating curves were applied to identify the thresholds for these biomarkers. Kaplan-Meier method and multivariate analysis were used to identify independent prognostic factors. Results: The univariate analysis showed that elevated LMR and PNI were significantly correlated with better overall survival and progression-free survival. The multivariate analysis showed that LMR and PNI were the independent prognostic factors for overall survival. Conclusions: Preoperative LMR and PNI could serve as useful prognostic factor in patients with colon cancer undergoing radical resection.

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

Background: Cancer-related fatigue (CRF) is one of the most common and painful symptoms in patients with lung cancer undergoing treatment with operation, affecting patients’ physical, psychological, family and social functions as well as their quality of life. However, there is very little evidence for treatment guidelines at home and abroad. Traditional Chinese Medicine (TCM) has been proved to improve the symptoms of general weakness and shown to be beneficial to cancer patients’ recovery. TCM treatment should be based on syndrome differentiation. Aiming at the CRF, we should focus on bolstering the deficiency while simultaneously attacking and reinforcing it. This trial preliminarily evaluated the efficacy and safety of Zhengyuan capsule for CRF in lung cancer patients undergoing operation. Methods/design: The single center clinical study is a two-group, double-blind, prospective, placebo-controlled, randomized controlled trial (RCT) designed to assess the efficacy and safety of Zhengyuan capsule for CRF in lung cancer patients undergoing operation. Eligible participants will randomly divided into two groups: a treatment group receiving a 8-week Zhengyuan capsule regimen therapy and a control group receiving a 8-week placebo capsule regimen therapy. The main efficacy indicator is fatigue, assessed using severity scores from the Cancer Fatigue Scale(CFS) measurement system. Secondary efficacy measures include fatigue which assessed using severity scores from the Multidimensional Fatigue Symptom Inventory-Short Form(MFSI-SF) measurement system, TCM syndrome pattern differentiation, levels of immunologic indicators(TNF-α, IL-6, IL-1, T lymphocytes subsets and B lymphocyte subsets), patient’s pulmonary functionality and adverse events (AEs). Evaluation will be carried out at the screening period, baseline, the middle of the intervention and the end of the intervention, respectively. Discussion: Experimental results of Zhengyuan capsule can guide the improvement of CRF and provide evidences that Zhengyuan capsule is effective and safe in lung cancer patients undergoing operation. The data can be imported into the management and treatment guidelines of CRF for patients with lung cancer undergoing operation throughout China nationwide. Trial registration: Chinese Clinical Trial Registry (chictr.org.cn), ChiCTR1900022712/YZJ-TCM-ZYJN-02. Registered on 23 April 2019.

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

Background: Thoracic aortic dissection is an emergent life-threatening condition. Routine screening for genetic variants causing thoracic aortic dissection is not currently performed for patients or family members. Methods: We performed whole exome sequencing of 240 patients with thoracic aortic dissection (n=235) or rupture (n=5) and 258 controls matched for age, sex, and ancestry. Blinded to case-control status, we annotated variants in 11 genes for pathogenicity. Results: Twenty-four pathogenic variants in 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, and TGFBR2) were identified in 26 individuals, representing 10.8% of aortic cases and 0% of controls. Among dissection cases, we compared those with pathogenic variants to those without and found that pathogenic variant carriers had significantly earlier onset of dissection (41 versus 57 years), higher rates of root aneurysm (54% versus 30%), less hypertension (15% versus 57%), lower rates of smoking (19% versus 45%), and greater incidence of aortic disease in family members. Multivariable logistic regression showed that pathogenic variant carrier status was significantly associated with age Conclusions: Clinical genetic testing of known hereditary thoracic aortic dissection genes should be considered in patients with a thoracic aortic dissection, followed by cascade screening of family members, especially in patients with age-of-onset

Objectives To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically. Methods From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data. Results Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%). Conclusions Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.

The study objective was to evaluate whether 5-m gait speed, an established marker of frailty, is associated with postoperative events after elective proximal aortic surgery.We performed a retrospective review of 435 patients aged more than 60 years who underwent elective proximal aortic surgery, defined as surgery on the aortic root, ascending aorta, or aortic arch through median sternotomy. Patients completed a 5-m gait speed test within 30 days before surgery. We evaluated the association between categoric (slow, ≤0.83 m/s and normal,0.83 m/s) and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for European System for Cardiac Operative Risk Evaluation II. The composite outcome included in-hospital mortality, renal failure, prolonged ventilation, and discharge location. Secondary outcomes were 1-year mortality and 5-year survival.Of the study population, 30.3% (132/435) were categorized as slow. Slow walkers were significantly more likely to have in-hospital mortality, prolonged ventilation, and renal failure, and were less likely to be discharged home (all P .05). The composite outcome was 2 times more likely to occur for slow walkers (gait speed categoric adjusted odds ratio, 2.08; 95% confidence interval, 1.27-3.40; P = .004). Moreover, a unit (1 m/s) increase in gait speed (continuous) was associated with 73% lower risk of experiencing the composite outcome (odds ratio, 0.27; 95% confidence interval, 0.11-0.68; P = .006).Slow gait speed is a preoperative indicator of risk for postoperative events after elective proximal aortic surgery. Gait speed may be an important tool to complement existing operative risk models, and its application may identify patients who may benefit from presurgical and postsurgical rehabilitation.

The decomposition of toxic flotation reagents upon UV 185+254 nm irradiation was attractive due to operational simplicity and no dosage of oxidants. In this work, the degradation of typical thiol collectors (potassium ethyl xanthate (PEX), sodium diethyl dithiocarbamate (SDD), O -isopropyl- N -ethyl thionocarbamate (IET) and dianilino dithiophoshoric acid (DDA)) was investigated by UV 185+254 nm photolysis. The degradation efficiencies and mineralization extents of collectors were assessed. The formation of CS 2 and H 2 S byproducts was studied, and the mechanisms of collector degradation were proposed under UV 185+254 nm irradiation. The PEX, SDD and IET were decomposed with nearly 100% removal upon 75 min of UV 185+254 nm irradiation. The decomposition rate constants decreased in the order SDD > PEX > IET ≫ DDA, and the DDA was the refractory collector. After 120 min of UV 185+254 nm irradiation, 15−45% of carbon and 25−75% of sulfur of collectors were completely mineralized, and the mineralization extent decreased in the order PEX > SDD > IET > DDA. The percentage of gaseous sulfur (CS 2 and H 2 S) ranged from 0.48 to 4.85% for four collectors, showing the fraction of emitted sulfur byproducts was small. The aqueous CS 2 concentration increased in the first 10−20 min, and was decreased to a low level of 0.05–0.1 mg l −1 at 120 min. Two mechanisms, i.e. direct UV 254 nm photolysis and indirect oxidation with free radicals, were responsible for collector decomposition in the UV 185+254 nm photolysis.

Objective: Despite the growth in thoracic aortic repair surgery, there remain concerns about the clinical and financial impact of complications secondary to these procedures. Therefore, we leveraged Medicare administrative claims to estimate the incidence, outcomes, and spending associated with complications during 90-day episodes of thoracic aortic repair surgery. Methods and Results: Using a previously validated claims-based algorithm, we identified 11,240 Medicare fee-for-service beneficiaries hospitalized for thoracic aortic repair surgery [open type A (n=4,538), open type B (n=4,091), and thoracic endovascular aortic repair procedures (TEVAR, n=2,611)] from April 2014 to March 2015. We identified any (and total number) of the following complications within 30-day of surgery: renal failure, stroke/transient ischemic attack, respiratory failure, bleeding, pneumonia, deep vein thrombosis or pulmonary embolism, surgical site infection, paralysis, or acute myocardial infarction. Overall, 5,525 patients (49.2%) developed any complication (zero complications: 50.9%, one: 28.4%, two: 13.0%, three: 5.3%, or four or more: 2.4%). For the entire sample, 90-day episode mortality was 15.4%, which was higher in patients with any complication (23.0%) compared to patients without complications (8.1%). Adjusting for patient demographics, admission status, comorbidities, and hospital random effects, the relative odds of mortality comparing patients with and without complications was 2.41 (95% CI: 2.11-2.76) (Table). On average, 90-day episode spending was $54,668±$43,287, which was also higher among patients with any complication ($69,243 vs. $40,578, p Conclusions: Complications after thoracic aortic repair were common and associated with worse outcomes and higher episode spending. Identifying and intervening upon patient and provider factors predictive of complications is essential to improving the value of thoracic aortic repair procedures.

Background The use of transcatheter aortic valve replacement (TAVR) has grown rapidly. The purpose of this study was to assess whether hospital market competition was associated with the use of TAVR. Methods We used 5 Healthcare Cost and Utilization Project state inpatient databases (Arizona, Florida, Iowa, Massachusetts, Washington) to identify patients undergoing TAVR (n = 5563) or surgical aortic valve replacement (n = 30,672) across 154 hospitals from 2011 to 2014. Using the Herfindahl-Hirschman Index (HHI) to calculate market competition, hospitals were categorized into commonly used categories of low (HHI >0.25), moderate (HHI 0.15-0.25), and high (HHI Results After adjustment, patients treated at high-competition hospitals had higher odds of receiving TAVR, relative to patients at low-competition hospitals (adjusted odds ratio [ORadj], 5.31; 95% confidence interval [CI], 2.10-13.4). TAVR use increased each year (ORadj, 1.73; 95% CI, 1.38-2.17) but was similar across HHI categories. Competition was not associated with in-hospital mortality or length of stay. Patients at high-competition hospitals were more likely to be discharged home (ORadj, 2.39; 95% CI, 1.23-4.66) compared with patients at low-competition hospitals. Conclusions Market competition was positively associated with a hospital's adoption of TAVR. Future studies should further examine the impact of competition on quality and appropriateness.

The decomposition of toxic flotation reagents upon UV185+254 nm irradiation was attractive due to operational simplicity and no dosage of oxidants. In this work, the degradation of typical thiol collectors (potassium ethyl xanthate (PEX), sodium diethyl dithiocarbamate (SDD), O-isopropyl-N-ethyl thionocarbamate (IET) and dianilino dithiophoshoric acid (DDA)) was investigated by the UV185+254 nm photolysis. The degradation efficiencies and mineralization extents of collectors were assessed. The formation of CS2 and H2S byproducts was studied, and the mechanisms of collector degradation were proposed under UV185+254 nm irradiation. The PEX, SDD and IET were decomposed with nearly 100% removal upon 75 min of UV185+254 nm irradiation. The decomposition rate constants decreased in the order SDD > PEX > IET ≫ DDA, and the DDA was the refractory collector. After 120 min of UV185+254 nm irradiation, 15‒45% of carbon and 25‒75% of sulfur of collectors were completely mineralized, and the mineralization extent decreased in the order PEX > SDD > IET > DDA. The percentage of gaseous sulfur (CS2 and H2S) was ranged from 0.48 to 4.85% for four collectors, showing the fraction of emitted sulfur byproducts was small. The aqueous CS2 concentration increased in first 10‒20 min, and was decreased to a low level of 0.05‒0.1 mgl−1 at 120 min. Two mechanisms, i.e. direct UV254 nm photolysis and indirect oxidation with free radicals, were responsible for collector decomposition in the UV185+254 nm photolysis.

Automatic kinship verification using facial images is a relatively new and challenging research problem in computer vision. It consists in automatically predicting whether two persons have a biological kin relation by examining their facial attributes. While most of the existing works extract shallow handcrafted features from still face images, in this chapter, we approach this problem from deep learning point of view. Promising results, especially those of deep features, are obtained on the benchmark UvA-NEMO Smile database and KinFaceW-I and KinFaceW-II kinship face databases.

Since there are no public tagged corpora available for ancient Chinese word segmentation (CWS), the state-of-the-art CWS methods cannot be used for ancient Chinese. To address this problem, this paper proposes a word segmentation method based on word alignment (WSWA). Specifically, the method segments words according to the word alignment between modern Chinese words and ancient Chinese characters. If multiple consecutive characters in ancient Chinese align to the same modern Chinese word, they are considered as one word. Because many modern Chinese words are derived from ancient Chinese, the method also exploits the co-occurring characters between modern and ancient Chinese to extract words for CWS. Moreover, to reduce the effect of alignment errors, the method removes the word alignments easily leading to CWS errors. We quantitatively analyze the effects of modern CWS and word alignment on WSWA method using hand-annotated corpora. Our method outperforms the state-of-the-art methods on the WSA experiment on Shiji with a large margin, which demonstrates the effectiveness of using word alignment to perform ancient CWS.

Kinship verification is a challenging problem, where recognition systems are trained to establish a kin relation between two individuals based on facial images or videos. However, due to variations in capture conditions (background, pose, expression, illumination and occlusion), state-of-the-art systems currently provide a low level of accuracy. As in many visual recognition and affective computing applications, kinship verification may benefit from a combination of discriminant information extracted from both video and audio signals. In this paper, we investigate for the first time the fusion audio-visual information from both face and voice modalities to improve kinship verification accuracy. First, we propose a new multi-modal kinship dataset called TALking KINship (TALKIN), that is comprised of several pairs of video sequences with subjects talking. State-of-the-art conventional and deep learning models are assessed and compared for kinship verification using this dataset. Finally, we propose a deep Siamese network for multi-modal fusion of kinship relations. Experiments with the TALKIN dataset indicate that the proposed Siamese network provides a significantly higher level of accuracy over baseline uni-modal and multi-modal fusion techniques for kinship verification. Results also indicate that audio (vocal) information is complementary and useful for kinship verification problem.

During hospital quality improvement activities, statistical approaches are critical to help assess hospital performance for benchmarking. Current statistical approaches are used primarily for research and reimbursement purposes. In this multiinstitutional study, these established statistical methods were evaluated for quality improvement applications. Leveraging a dataset of 42,199 patients who underwent coronary artery bypass grafting surgery from 2014 to 2016 across 90 hospitals, six statistical approaches were applied. The non-shrinkage methods were: (1) indirect standardization without hospital effect; (2) indirect standardization with hospital fixed effect; (3) direct standardization with hospital fixed effect. The shrinkage methods were: (4) indirect standardization with hospital random effect; (5) direct standardization with hospital random effect; (6) Bayesian method. Hospital performance related to operative mortality and major morbidity or mortality was compared across methods based on variation in adjusted rates, rankings, and performance outliers. Method performance was evaluated across procedure volume terciles: small (< 96 cases/year), medium (96-171), and large (> 171). Shrinkage methods reduced inter-hospital variation (min-max) for mortality (observed: 0%-10%; adjusted: 1.5%-2.4%) and major morbidity or mortality (observed: 2.6%-35%; adjusted: 6.9%-17.5%). Shrinkage methods shrunk hospital rates toward the group mean. Direct standardization with hospital random effect, compared to fixed effect, resulted in 16.7%-38.9% of hospitals changing quintile mortality ranking. Indirect standardization with hospital random effect resulted in no performance outliers among small and medium hospitals for mortality, while logistic and fixed effect methods identified one small and three medium outlier hospitals. The choice of statistical method greatly impacts hospital ranking and performance outlier’ status. These findings should be considered when benchmarking hospital performance for hospital quality improvement activities.

In view of the most difficult problem of terminology translation in the translation of historical books, this paper extracts term translation pairs from bilingual parallel corpus as a reference to improve the quality and efficiency of the translation of historical books. However, the small size of the corpus of historical books leads to poor word alignment, which brings a large number of errors to term alignment. At the same time, the special grammar of ancient Chinese will also affect term alignment. In order to solve the above two problems, this paper proposes a method of term alignment of historical books based on pivot language and position correspondence. This method introduces modern Chinese as the pivot language, makes use of the position correspondence between modern Chinese and English terms in sentences, and uses the sliding window method to generate candidate term pairs, which avoids the influence of word alignment errors on term alignment. In addition, if we first align to modern Chinese, the ancient Chinese terminology will complete the omitted characters in modern Chinese and replace the false characters, so as to avoid the influence of the special usage in ancient Chinese on the term alignment. The experimental results in Historical Records show that the accuracy of this method is slightly better than that of the method based on word alignment, which verifies the effectiveness of this method without word alignment.

Objective The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion. Methods From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143). Results The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30). Conclusions Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.

Background Despite pharmacological treatments, patients undergoing cardiac surgery experience severe anxiety and pain, which adversely affect outcomes. Previous work examining pediatric and nonsurgical adult patients has documented the effectiveness of inexpensive, nonpharmacological techniques to reduce anxiety and pain as well as health care costs and length of hospitalization. However, the impact of nonpharmacological interventions administered by a dedicated comfort coach has not been evaluated in an adult surgical setting. Objective This trial aims to assess whether nonpharmacological interventions administered by a trained comfort coach affect patient experience, opioid use, and health care utilization compared with usual care in adult cardiac surgery patients. This study has 3 specific aims: assess the effect of a comfort coach on patient experience, measure differences in inpatient and outpatient opioid use and postoperative health care utilization, and qualitatively evaluate the comfort coach intervention. Methods To address these aims, we will perform a prospective, randomized controlled trial of 154 adult cardiac surgery patients at Michigan Medicine. Opioid-naive patients undergoing first-time, elective cardiac surgery via sternotomy will be randomized to undergo targeted interventions from a comfort coach (intervention) versus usual care (control). The individualized comfort coach interventions will be administered at 6 points: preoperative outpatient clinic, preoperative care unit on the day of surgery, extubation, chest tube removal, hospital discharge, and 30-day clinic follow-up. To address aim 1, we will examine the effect of a comfort coach on perioperative anxiety, self-reported pain, functional status, and patient satisfaction through validated surveys administered at preoperative outpatient clinic, discharge, 30-day follow-up, and 90-day follow-up. For aim 2, we will record inpatient opioid use and collect postdischarge opioid use and pain-related outcomes through an 11-item questionnaire administered at the 30-day follow-up. Hospital length of stay, readmission, number of days in an extended care facility, emergency room, urgent care, and an unplanned doctor’s office visit will be recorded as the primary composite endpoint defined as total days spent at home within the first 30 days after surgery. For aim 3, we will perform semistructured interviews with patients in the intervention arm to understand the comfort coach intervention through a thematic analysis. Results This trial, funded by Blue Cross Blue Shield of Michigan Foundation in 2019, is presently enrolling patients with anticipated manuscript submissions from our primary aims targeted for the end of 2020. Conclusions Data generated from this mixed methods study will highlight effective nonpharmacological techniques and support a multidisciplinary approach to perioperative care during the adult cardiac surgery patient experience. This study’s findings may serve as the foundation for a subsequent multicenter trial and broader dissemination of these techniques to other types of surgery. Trial Registration ClinicalTrials.gov NCT04051021; https://clinicaltrials.gov/ct2/show/NCT04051021 International Registered Report Identifier (IRRID) DERR1-10.2196/21350

This study aimed to identify characteristics of elderly participants in the Michigan Home and Community-Based Waiver Program that are associated with high risk of long-term nursing home (LT-NH) placement. We identified 8172 waiver clients aged 65 and older during 10/1/2010-9/30/2014. A proportional cause-specific hazards regression model was used to analyze risk factors of waiver elderly for LT-NH placement. Waiver elderly participants who were white (HR (white vs. black): 2.76, with 95% CI (1.91, 4.00); HR (white vs. other races): 1.77, with 95% CI (1.05, 2.97)), had a history of long-term care use (HR: 1.42, 95% CI (1.14, 1.76)), mental disorders (HR: 1.51, 95% CI (1.23, 1.86)), bathing dependency (HR: 1.43, 95% CI (1.07, 1.89)), and finance management dependency (HR: 1.73, 95% CI (1.15, 2.60)) had greater hazards of LT-NH placement. Our study can be useful for policy makers to develop relevant support to reduce LT-NH placement.

Postoperative pneumonia is the most prevalent of all hospital-acquired infections after isolated coronary artery bypass graft surgery (CABG). Accurate prediction of a patient's risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision making and quality improvement, we developed a preoperative prediction model for postoperative pneumonia after CABG.We undertook an observational study of 16,084 patients undergoing CABG between the third quarter of 2011 and the second quarter of 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy, and the institution performing the procedure were investigated. Logistic regression through forward stepwise selection (p0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were used to assess the model's performance.Postoperative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 preoperative factors, including demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed through sensitivity analyses by center and clinically important subgroups.We identified 17 readily obtainable preoperative variables associated with postoperative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient's preoperative risk of pneumonia through prehabilitation.

A regio- and enantioselective copper-catalyzed 1,4-conjugate addition of trimethylaluminium to linear δ-aryl-substituted α,β,γ,δ-unsaturated alkyl ketones was developed. A series of γ,δ-unsaturated alkyl ketones were obtained in good yields with high regio- and enantioselectivity (up to 88% ee and 96:4 dr). Expansion of the reaction scope to substrates containing aromatic heterocycles also afforded good yields and enantioselectivities (up to 91% ee) with very high regioselectivities, exclusively providing the single 1,4-products.

// Yihan Ma 1 , Peiqi Xu 2 , Yanjun Mi 1 , Wenyi Wang 1 , Xiaoyan Pan 1 , Xiaoting Wu 1 , Qi He 1 , Hongming Liu 1 , Weiwei Tang 1 , Hanxiang An 1 1 Xiamen Cancer Hospital, The First Affiliated Hospital of Xiamen University, 361003, Fujian, China 2 Reproduction Center, The Second Affiliated Hospital of Kunming Medical University 650101, Yunnan, China Correspondence to: Hanxiang An, email: anhanxiang@xmu.edu.cn Keywords: circulating miRNA, microarray, NSCLC, EGFR, response Received: April 29, 2016 Accepted: July 10, 2016 Published: July 24, 2016 ABSTRACT Based on recognition of driver mutations, treatment paradigm for non-small-cell lung cancer (NSCLC) patients has been shifted. However, recently exon 19 deletion mutation (del19) of epidermal growth factor receptor (EGFR) clearly shows better clinical benefit over single-point substitution mutation L858R in exon 21 (L858R). The aim of this study was to investigate the difference by analyzing the expression of plasma microRNAs (miRNAs) of NSCLC patients with EGFR mutation del19 or L858R. MiRNA microarray of plasma from patients’ blood identified 79 mapped, network-eligible miRNAs (fold > 5), of which 76 were up regulated and 3 were down regulated. Genetic network was performed with Ingenuity Pathway Analysis (IPA). Among analysis, MYC, Argonaute2 (AGO2), Y-box binding protein 1 (YBX1), cyclin E1 (CCNE1) were involved in organismal abnormalities and cancer. Our findings provide information on the epigenetic signature of the two major sensitive mutations among NSCLC and add to the understanding of mechanisms underlying the different outcomes.

This paper based on the panel data of 31 provinces in China from 1999 to 2014. The three-stage least squares method is used in this paper to analysis the relationship between land management scale, rural labour migration and agricultural mechanization level. The analysis reveal that the rural labour migration and the scale of land management show a U-shaped relationship. The level of agricultural mechanization is positively affecting the transfer of rural labour. In addition, we find that the scale of land management, rural labour migration have promoted the level of agricultural mechanization. The proportion of the gross agricultural output value in the GDP has a negative impact on rural labour migration.

Objective To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair. Methods From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database. Results The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46. Conclusions In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.

Circular RNA (circRNA) has been classified as noncoding RNA with a covalent closed continuous loop, the 3'and 5' ends of which are normally joined together to increase its own stability. More recently, circRNA has been shown to encode proteins and may be involved in the regulation of gene transcription. This provides more evidence for the involvement of circRNA in disease progression. Accumulating investigations have found that the expression of many circRNAs is abnormal in plenty of skin diseases such as malignant melanoma, psoriasis, and abnormal wound healing. Herein, in addition to the summary of recent studies on the nuclear export, N6-methyladenosine (m6A) modification, degradation, and other biogenesis and properties of circRNA, we highlight the importance of circRNAin skin diseases. Although their exact roles and mechanisms in most skin disease remain preliminary, circRNAs have potential applications as diagnostic biomarkers and novel therapeutic targets for skin diseases due to its structural and functional properties (stability, specificity and sensitivity), which is worthy of deeper exploration and greater research efforts.

The study objective was to determine the optimal treatment for patients with acute type A aortic dissection and previous cardiac surgery.A total of 545 patients underwent open repair of an acute type A aortic dissection (July 1996 to January 2017), including patients with (n = 50) and without previous cardiac surgery (n = 495). Data were collected through the University of Michigan Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.Compared with patients without previous cardiac surgery, patients with previous cardiac surgery were older (62 vs 59 years, P = .24) and had significantly more coronary artery disease (48% vs 14%, P .001), peripheral arterial disease (24% vs 11%, P = .01), connective tissue disorders (15% vs 4.5%, P = .004), and acute renal failure on presentation (28% vs 15%, P = .02); and significantly more concomitant mitral or tricuspid procedures, longer cardiopulmonary bypass time, and more intraoperative blood transfusions. There were no statistically significant differences in postoperative major complications between previous cardiac surgery and no previous cardiac surgery groups, including stroke, myocardial infarction, new-onset dialysis, and 30-day mortality (8.9% vs 6.3%, P = .55). Multivariable logistic model showed the significant risk factors for operative mortality were cardiogenic shock (odds ratio, 9.6; P .0001) and male gender (odds ratio, 3.7; P = .006). The 5- and 10-year unadjusted survivals were significantly lower in the previous cardiac surgery group compared with the no previous cardiac surgery group (66% vs 80% and 42% vs 66%, respectively, P = .02). However, previous cardiac surgery itself was not a significant risk factor for operative mortality (odds ratio, 1.6; P = .36) or all-time mortality (hazard ratio, 1.3; P = .33).Acute type A aortic dissection in patients with previous cardiac surgery can be repaired with favorable operative mortality and long-term survival, and should be treated surgically.

We prove that a conformal singular material is equivalent to a uniform and anisotropic material by transmutation. The trajectories before and after transmutation are compared for both attractive and repulsive cases, indicating the more accurate paths near singularities after transmutation. We further study the splitting effects when a beam impinges on the singular point, and observe different behaviors for attractive and repulsive cases.

Transcatheter aortic valve replacement (TAVR) approval in lower risk surgical aortic valve replacement (SAVR) populations led a marked increase in the number of TAVR procedures. Implanters must be mindful of “lifetime management” strategy in younger patients which will include SAVR after TAVR

Objective The study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection. Methods From 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology. Results Patients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan–Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group. Conclusions Aortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short- and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.

Findings from a large multicenter experience showed that sex influenced the relationship between low nadir hematocrit and increased risk of acute kidney injury after cardiac surgery. We explored whether sex-related differences persisted among patients undergoing isolated coronary artery bypass grafting.We undertook a prospective, observational study of 17,363 patients without dialysis (13,137 male: 75.7%; 4226 female: 24.3%) undergoing isolated coronary artery bypass grafting between 2011 and 2016 across 41 institutions in the Perfusion Measures and Outcomes registry. Odds ratios between nadir hematocrit and stage 2 or 3 acute kidney injury were calculated, and the interaction of sex with nadir hematocrit was tested. The multivariable, generalized, linear mixed-effect model adjusted for preoperative and intraoperative factors and institution.Median nadir hematocrit was 22% among women and 27% among men (P .001). Women were administered a greater median net prime volume indexed to body surface area (407 vs 363 mL/mWe found no sex-related differences in the effect of nadir hematocrit on acute kidney injury after isolated coronary artery bypass grafting. However, the strong inverse relationship between anemia and acute kidney injury across sexes suggests the importance of reducing exposure to low nadir hematocrit.

Background: Immediate open repair of acute type A aortic dissection is traditionally recommended to prevent death from aortic rupture. However, organ failure because of malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. Methods: From 1996 to 2017, among 597 patients with acute type A aortic dissection, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decades and observed mortalities with those expected with an “upfront OR for every patient” approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA [German Registry for Acute Aortic Dissection Type A] models). Results: Overall, in-hospital mortality improved between the 2 decades (21.0% versus 10.7%, P P =0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio=6.63; 95% CI, 1.5–29; P =0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the upfront OR for every patient models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all patients with acute type A aortic dissection were significantly lower ( P ≤0.03). Conclusions: Immediate OR is the strategy to prevent death from aortic rupture for the majority of patients with acute type A aortic dissection. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by aortic OR at resolution of organ failure.