Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla

Development of the Phosphorus Recovery System (PRS) Utilizing Ultrasonic Wave in Incinerated Sewage Sludge Ash (ISSA)

This study was performed to develop a Phosphorus Recovery System(PRS) for the recovery of phosphorus from incinerated sewage sludge ash using struvite precipitation. Fly ash generated at the Seonam Sewage Treatment Plant(SSTP) has a high P2O5 content (13.9%). We developed a PRS consisting of an ultrasonic extractor, solid-liquid separator, mixing tank, and phosphorus recovery tank. The ultrasonic extractor had a 28 kHz vibrator for high speed and efficiency, which could perform the extraction in one-quarter of the time required in the conventional stirring method. Results of tests on the ultrasonic extractor showed that up to 0.044 g of P per gram of ash could be extracted with 1 N NaOH at an L/S ratio of 10 mL/g and an ultrasonic output of 500 Wh for 0.5 hr. The PRS is needed to improve the operation method and economic analysis to commercialize the technology and its application through further studies

Prostate Specific Membrane Antigen mRNA in Blood as a Potential Predictor of Biochemical Recurrence after Radical Prostatectomy

We investigated whether the detection of prostate specific membrane antigen (PSMA) in blood preoperatively has predictive value for biochemical recurrence (BCR) after radical prostatectomy in patients with prostate cancer. All 134 patients scheduled to receive radical prostatectomy for prostate cancer were prospectively enrolled. The authors used nested reverse transcriptase-polymerase chain reaction (RT-PCR) assay to detect PSMA mRNA-bearing cells in peripheral blood, and analyzed the ability of PSMA mRNA positivity to predict BCR after surgery. PSMA-mRNA was detected in 24 (17.9%) patients by RT-PCR. Over a median follow-up of 20 months (range, 3 to 46 months), BCR developed in 15 patients (11.2%) and median time to BCR was 7 months (range, 3 to 25 months). Kaplan-Meier analysis revealed a significant difference between those positive or negative for PSMA in terms of recurrence-free actuarial probability (log rank P=0.0039). Multivariate analysis showed that positivity for PSMA mRNA (HR: 3.697, 95% CI 1.285-10.634, P=0.015) and a biopsy Gleason score of ≥7 (HR: 4.500, 95% CI 1.419-14.274, P=0.011) were independent preoperative predictors of BCR. The presence of PSMA mRNA in peripheral blood can be used to predict BCR after radical prostatectomy

Comparison of Artificial Neural Network and Logistic Regression Models for Predicting In-Hospital Mortality after Primary Liver Cancer Surgery

BACKGROUND: Since most published articles comparing the performance of artificial neural network (ANN) models and logistic regression (LR) models for predicting hepatocellular carcinoma (HCC) outcomes used only a single dataset, the essential issue of internal validity (reproducibility) of the models has not been addressed. The study purposes to validate the use of ANN model for predicting in-hospital mortality in HCC surgery patients in Taiwan and to compare the predictive accuracy of ANN with that of LR model. METHODOLOGY/PRINCIPAL FINDINGS: Patients who underwent a HCC surgery during the period from 1998 to 2009 were included in the study. This study retrospectively compared 1,000 pairs of LR and ANN models based on initial clinical data for 22,926 HCC surgery patients. For each pair of ANN and LR models, the area under the receiver operating characteristic (AUROC) curves, Hosmer-Lemeshow (H-L) statistics and accuracy rate were calculated and compared using paired T-tests. A global sensitivity analysis was also performed to assess the relative significance of input parameters in the system model and the relative importance of variables. Compared to the LR models, the ANN models had a better accuracy rate in 97.28% of cases, a better H-L statistic in 41.18% of cases, and a better AUROC curve in 84.67% of cases. Surgeon volume was the most influential (sensitive) parameter affecting in-hospital mortality followed by age and lengths of stay. CONCLUSIONS/SIGNIFICANCE: In comparison with the conventional LR model, the ANN model in the study was more accurate in predicting in-hospital mortality and had higher overall performance indices. Further studies of this model may consider the effect of a more detailed database that includes complications and clinical examination findings as well as more detailed outcome data

The impact of transferring patients with ST-segment elevation myocardial infarction to percutaneous coronary intervention-capable hospitals on clinical outcomes

Background: Primary percutaneous coronary intervention (PCI) is recommended for ST-segment elevation myocardial infarction (STEMI) patients even when the patient must be transported to a PCI-capable hospital. This study aimed to evaluate the long-term clinical outcomes of STEMI patients who were transferred for primary PCI compared to patients who arrived directly to PCI-capable hospitals. Methods: A total of 3,576 STEMI patients with less than 12 h of symptom onset-to-door time from the Korea Acute Myocardial Infarction Registry were divided into transfer (n = 2,176) and direct-arrival (n = 1,400) groups according to their status. The primary outcome was the composite of major adverse cardiac event (MACE), defined as death, non-fatal myocardial infarction, and revascularization at 1 year. Results: In the transfer vs. the direct-arrival group, the median symptom onset-to-firstmedical contact time was significantly shorter (60 vs. 80 min, p < 0.001), but the median symptom onset-to-door time was significantly longer (194 vs. 90 min, p < 0.001). The median door-to-balloon time was significantly shorter in the transfer group vs. the direct-arrival group (75 vs. 91 min, p < 0.001). Total death and the composite of MACE were not significantly different during hospitalization (5.1 vs. 3.9%, p = 0.980; 5.4 vs. 4.8%, p = 0.435, respectively) and at 1-year (8.2 vs. 6.6%, p = 0.075; 13.7 vs. 13.9%, p = 0.922, respectively). Conclusions: Transferring STEMI patients to PCI-capable hospitals with a time delay did not affect clinical outcomes after 1 year. This study suggests that inter-hospital transfer should be encouraged even with delay for STEMI patients who require primary PCI in areas with a similar geographic accessibility

Analysis of Changes in the Total Lymphocyte and Eosinophil Count during Immunotherapy for Metastatic Renal Cell Carcinoma: Correlation with Response and Survival

The aims of this study were to analyze lymphocyte and eosinophil counts in consecutive peripheral blood samples taken during immunotherapy for metastatic renal cell carcinoma (mRCC) and to correlate the findings with objective response and survival. A total of 40 patients with mRCC who received immunotherapy with interleukin-2, interferon-α, and 5-fluorouracil were analyzed. Objective responses were observed in 14 patients, including 2 (5%) who showed a complete response (CR) and 12 (30%) who showed a partial response (PR). Eleven patients (27%) achieved stable disease (SD), and 15 patients (38%) had progressive disease (PD). Changes from baseline in the total lymphocyte counts were significantly higher in the responding patients (CR+PR+SD) than in the non-responding patients (PD) (p=0.017), but no difference was seen in the total eosinophil counts (p=0.275). Univariate analysis identified the Eastern Cooperative Oncology Group (ECOG) performance status (p=0.017), the presence of a primary renal tumor (p<0.001) and the peripheral lymphocyte counts at week 4 (p=0.034) as prognostic factors, but a low ECOG performance status (p=0.003) and the presence of a primary renal tumor (p=0.001) were identified as independent poor prognostic factors by multivariate analysis. This study provides further evidence that changes in blood lymphocyte counts may serve as an objective indicator of objective responses