Pulse Oximeter-Derived Pleth Variability Index is a Reliable Indicator of Cardiac Preload in Patients Undergoing Liver Transplantation.

BACKGROUND: Accurate estimation of cardiac preload during liver transplantation is essential. The right ventricular end-diastolic volume index (RVEDVI) is recognized as a good preload indicator in patients undergoing liver transplantation. Recently, dynamic variation parameters including pleth variability index (PVI) have been used as predictors of fluid responsiveness. However, the correlation between PVI and preload status has not been well studied. We evaluated the relationship between PVI and RVEDVI during liver transplantation. METHODS: Eighteen patients undergoing liver transplantation were enrolled in this study. Data of hemodynamic parameters including PVI derived by Masimo Rainbow SET Pulse CO-Oximeter, central venous pressure (CVP), pulmonary arterial occlusion pressure (PAOP), and RVEDI were obtained at 10 defined time points throughout liver transplantation. The correlation between RVEDVI and CVP, PAOP, and PVI was analyzed using Spearman rank test. We also investigated the ability of PVI to accurately differentiate RVEDVI <123 or >142 mL/m(2) using receiver operating characteristic (ROC) analysis. RESULTS: There was fair to good correlation between PVI and RVEDVI (correlation coefficient = -0.492, P < .001). The correlation coefficient between CVP, PAOP, and RVEDVI was 0.345 and 0.463, respectively. A 13.5% cutoff value of PVI estimated the RVEDVI <123 mL/m(2) (area under the curve [AUC] = 0.762). A 12.5% cutoff value of PVI estimated the RVEDVI >142 mL/m(2) (AUC = 0.745). CONCLUSIONS: PVI presented as a reliable estimate of preload status and may be a useful predictor of fluid responsiveness in patients undergoing liver transplantation.

Accuracy and Trending of Continuous Noninvasive Hemoglobin Monitoring in Patients Undergoing Liver Transplantation.

BACKGROUND: Shift in large fluid volumes and massive blood loss during liver transplantation frequently leads to rapid changes in hemoglobin (Hb) concentration; thus, to ensure adequate tissue oxygenation, accurate and rapid determination of Hb concentration is essential in transplant recipients. The Radical-7 Pulse CO-Oximeter provides a noninvasive and continuous way to monitor Hb concentration (SpHb) in real time and is an ideal candidate for use during liver transplantation. In this study, we assessed the relationship between SpHb and total Hb (tHb) obtained from arterial blood samples during surgery. METHODS: Forty patients undergoing liver transplantation were enrolled in this study. tHb and time-matched SpHb were measured at 5 different phases throughout surgery. Paired SpHb and tHb levels were assessed using linear regression, Bland-Altman analysis, and the Critchley polar plot method. RESULTS: A total of 161 paired measurements with sufficient signal quality were analyzed. The correlation between SpHb and tHb was 0.59 (P < .001). Bland-Altman analysis revealed that a bias between SpHb and tHb was 2.28 g/dL, and limits of agreement (LoA) were from -0.78 to 5.34 g/dL. Trending analysis showed that 87% of data were located within the acceptable trending area, indicating that the trending ability was not satisfied. CONCLUSIONS: The Radical-7 Pulse CO-Oximeter was not sufficient to monitor Hb levels and trends during liver transplantation surgery in our cohort. In particular, in critical patients and in those with low Hb levels, invasive Hb measurement should be used for assessment.

Cardiac Output Assessed by the Fourth-Generation Arterial Waveform Analysis System Is Unreliable in Liver Transplant Recipients.

BACKGROUND: Liver transplant recipients often have violent hemodynamic fluctuation during surgery that may be related to perioperative and postoperative morbidity. Because there are some considerations for the risk of the pulmonary arterial catheter (PAC), the conventional invasive device for cardiac output (CO) measurement, a reliable and minimally invasive alternative is required. We validated the reliability of CO measurements with the use of a minimally invasive FloTrac system with the latest fourth-generation algorithm in liver transplant recipients. METHODS: Forty liver transplant recipients without atrial fibrillation, valvular pathology, or intracardiac shunt were recruited in this prospective, observational study. CO values measured by use of PAC with continuous thermodilution method (COTh) and FloTrac devices (COFT) were collected simultaneously throughout the operation for reliability validation. RESULTS: Four hundred pairs of CO data points were collected in total. The linear regression analysis showed a high correlation coefficient (73%, P < .001). However, the percent error between COTh and COFT was 42.2%, which is worse than the established interchangeability criterion of 30%. The concordance rates were calculated at 89% and 59% by 4-quadrant plot and polar plot analysis, respectively. Neither met the preset validation criteria (>92% for the 4-quadrant plot and >90% for polar plot analyses). CONCLUSIONS: Our study demonstrates that the CO measurements in liver transplant recipients by the latest FloTrac system and the PAC do not meet the recognized interchangeability criterion. Although the result showed improvement in linear regression analysis, it failed to display a qualified trending ability.

Ischemic reperfusion injury-induced oxidative stress and pro-inflammatory mediators in liver transplantation recipients.

OBJECTIVE: Liver ischemic reperfusion injury is harmful to transplant recipients, and is associated with postoperative morbidity and mortality. Our study was designed to investigate the oxidative stress and pro-inflammatory mediators in liver transplant recipients. METHODS: We prospectively analyzed 14 recipients who underwent liver transplantation by measuring their blood levels of malondialdehyde (MDA) and cytokines, such as tumor necrosis factor-α (TNF-α), interleukin-1ß (IL-1ß), and IL-6, at nine time points perioperatively. We also evaluated the correlations between oxidative stress (MDA levels) and the characteristics of the recipient or the donated graft. RESULTS: These parameters significantly increased from 1 minute before reperfusion, and the values peaked within 3 to 30 minutes after reperfusion. On the time point at 5 minutes after reperfusion, the MDA levels which were the highest in the recipients correlated with the values of preoperative direct/and total bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), model for end-stage liver disease (MELD) score, international normalized ratio (INR), and surgical blood loss. CONCLUSION: The levels of MDA, TNF-α, IL-1ß, and IL-6 greatly increased with the ischemic reperfusion insult. Recipients with higher values of preoperative direct/and total bilirubin, AST, ALT, MELD score, INR, and surgical blood loss tended to have higher levels of MDA and may suffer more injury from this insult.

The ratio of plasma interleukin-18 is a sensitive biomarker for acute kidney injury after liver transplantation.

BACKGROUND: Acute kidney injury (AKI) is common after liver transplantation (OLT) and is associated with high morbidity and mortality. Previous studies have shown that interleukin-18 (IL-18) levels are associated with AKI. The purpose of this study was to determine whether plasma IL-18 levels were early predictors for AKI after liver transplantation. METHODS: Plasma samples were obtained from 26 patients who underwent OLT at induction of anesthesia (T1), 1 hour after the surgical incision (T2), the time of reperfusion (T3), as well as 1 (T4), 2 (T5), and 4 hours (T6) after reperfusion. Samples were also obtained at 24 hours after surgery (T7). The AKI criteria were taken according to the Acute Kidney Injury Network criteria. RESULTS: Twelve patients (46%) developed AKI after OLT. The area under the receiver operating curve of plasma IL-18 concentrations (T4/T1) to predict AKI occurrence was 0.842 at T5, 0.905 at T6, 0.726 at T7, and 0.726 at T5 to T7. CONCLUSION: Plasma IL-18 concentrations taken 1 hour after reperfusion were predictive of AKI. Therefore, changing IL-18 ratio may be an early predictor for AKI after OLT.

Recommendations for ICT use in Alzheimer's disease assessment: Monaco CTAD Expert Meeting.

Alzheimer disease (AD) and other related dementia represent a major challenge for health care systems within the aging population. It is therefore important to develop better instruments for assessing disease severity and disease progression to optimize patient's care and support to care providers, and also provide better tools for clinical research. In this area, Information and Communication Technologies (ICT) are of particular interest. Such techniques enable accurate and standardized assessments of patients' performance and actions in real time and real life situations. The aim of this article is to provide basic recommendation concerning the development and the use of ICT for Alzheimer's disease and related disorders. During he ICT and Mental Health workshop (CTAD meeting held in Monaco on the 30th October 2012) an expert panel was set up to prepare the first recommendations for the use of ICT in dementia research. The expert panel included geriatrician, epidemiologist, neurologist, psychiatrist, psychologist, ICT engineers, representatives from the industry and patient association. The recommendations are divided into three sections corresponding to 1/ the clinical targets of interest for the use of ICT, 2/ the conditions, the type of sensors and the outputs (scores) that could be used and obtained, 3/ finally the last section concerns specifically the use of ICT within clinical trials.

Should spikes be treated with equal weightings in the generation of spectro-temporal receptive fields?

Knowledge on the trigger features of central auditory neurons is important in the understanding of speech processing. Spectro-temporal receptive fields (STRFs) obtained using random stimuli and spike-triggered averaging allow visualization of trigger features which often appear blurry in the time-versus-frequency plot. For a clearer visualization we have previously developed a dejittering algorithm to sharpen trigger features in the STRF of FM-sensitive cells. Here we extended this algorithm to segregate spikes, based on their dejitter values, into two groups: normal and outlying, and to construct their STRF separately. We found that while the STRF of the normal jitter group resembled full trigger feature in the original STRF, those of the outlying jitter group resembled a different or partial trigger feature. This algorithm allowed the extraction of other weaker trigger features. Due to the presence of different trigger features in a given cell, we proposed that in the generation of STRF, the evoked spikes should not be treated indiscriminately with equal weightings.

Computerized diagnosis of Helicobacter pylori infection and associated gastric inflammation from endoscopic images by refined feature selection using a neural network.

BACKGROUND AND STUDY AIM: We investigated whether analysis of endoscopic images using a refined feature selection with neural network (RFSNN) technique could predict Helicobacter pylori-related gastric histological features. PATIENTS AND METHODS: A total of 104 dyspeptic patients were prospectively enrolled for panendoscopy and gastric biopsy for histological evaluation using the updated Sydney system. The endoscopic images of each patient were analyzed to obtain 84 image parameters. The significant image parameters from 30 randomly selected patients (15 with and 15 without H. pylori infection) associated with histological features were used to develop the RFSNN model. This was then used to test the sensitivity and specificity of the image parameters obtained from the remaining 74 patients for the prediction of the presence of H. pylori infection and related histological features. RESULTS: The RFSNN technique had a sensitivity of 85.4 % and a specificity of 90.9 % for the detection of H. pylori infection. Moreover, RFSNN was highly accurate (> 80 %) in predicting the presence of gastric atrophy, intestinal metaplasia and the severity of H. pylori-related gastric inflammation. CONCLUSIONS: RFSNN is an effective computerized technique for assessing the presence of H. pylori infection and related gastric inflammation and precancerous lesions. By using RFSNN to analyze endoscopic images, a comprehensive evaluation of the stomach may be done, thus avoiding the need for invasive but localized biopsy sampling for histological examination.

KDBI: Kinetic Data of Bio-molecular Interactions database.

Understanding of cellular processes and underlying molecular events requires knowledge about different aspects of molecular interactions, networks of molecules and pathways in addition to the sequence, structure and function of individual molecules involved. Databases of interacting molecules, pathways and related chemical reaction equations have been developed. The kinetic data for these interactions, which is important for mechanistic investigation, quantitative study and simulation of cellular processes and events, is not provided in the existing databases. We introduce a new database of Kinetic Data of Bio-molecular Interactions (KDBI) aimed at providing experimentally determined kinetic data of protein-protein, protein-RNA, protein-DNA, protein-ligand, RNA-ligand, DNA-ligand binding or reaction events described in the literature. KDBI contains information about binding or reaction event, participating molecules (name, synonyms, molecular formula, classification, SWISS-PROT AC or CAS number), binding or reaction equation, kinetic data and related references. The kinetic data is in terms of one or a combination of the following quantities as given in the literature of a particular event: association/dissociation or on/off rate constant, first/second/third/. order rate constant, equilibrium rate constant, catalytic rate constant, equilibrium association/dissociation constant, inhibition constant and binding affinity constant. Each entry can be retrieved through protein or nucleic acid or ligand name, SWISS-PROT AC number, ligand CAS number and full-text search of a binding or reaction event. KDBI currently contains 8273 entries of biomolecular binding or reaction events involving 1380 proteins, 143 nucleic acids and 1395 small molecules. Hyperlinks are provided for accessing references in Medline and available 3D structures in PDB and NDB. This database can be accessed at http://xin.cz3.nus.edu.sg/group/kdbi/kdbi.asp.

Orthogonal subspace projection-based approaches to classification of MR image sequences.

Orthogonal subspace projection (OSP) approach has shown success in hyperspectral image classification. Recently, the feasibility of applying OSP to multispectral image classification was also demonstrated via SPOT (Satellite Pour 1'Observation de la Terra) and Landsat (Land Satellite) images. Since an MR (magnetic resonance) image sequence is also acquired by multiple spectral channels (bands), this paper presents a new application of OSP in MR image classification. The idea is to model an MR image pixel in the sequence as a linear mixture of substances (such as white matter, gray matter, cerebral spinal fluid) of interest from which each of these substances can be classified by a specific subspace projection operator followed by a desired matched filter. The experimental results show that OSP provides a promising alternative to existing MR image classification techniques.

Sensitivity of diffusion-weighted magnetic resonance imaging in the diagnosis of acute lacunar infarcts.

BACKGROUND AND PURPOSE: Heightened interest in the early diagnosis and treatment of acute stroke challenges neuroimaging specialists to optimize available modalities and to develop new techniques for the evaluation of cerebrovascular disease. The purpose of this study was to evaluate the sensitivity of diffusion-weighted (DW) magnetic resonance (MR) imaging in detecting early small infarcts and in differentiating acute from nonacute small infarcts when conventional MR imaging demonstrates multiple small infarcts. METHODS: Thirty-eight consecutive patients with a clinical diagnosis of lacunar infarcts (20 men and 18 women, aged 50-79 yr) who underwent DW MR imaging within 3 days of symptom onset were enrolled in this study. All patients underwent both conventional fast spin-echo (FSE) MR imaging and DW MR imaging. Apparent diffusion coefficient (ADC) maps were also acquired. All patients had at least one of the following classic lacunar syndromes: pure motor hemiparesis, ataxic hemiparesis, dysarthria-clumsy hand, pure sensory stroke, and sensorimotor stroke. RESULTS: Thirty-six patients (40 acute lesions) had focal areas of high intensity on DW MR imaging associated with their clinical symptoms. Acute lacunar infarcts were seen on DW MR imaging as bright areas of decreased ADC ratio (range 0.31-0.85, mean 0.64). Lesion conspicuity with DW MR imaging was superior to that with FSE in 33 acute lesions. In four patients with small hyperacute (within 6 hours) infarcts, DW MR imaging was particularly sensitive for infarcts that were not visible on FSE sequences. The sensitivity of DW MR imaging and ADC map for acute lacunar infarcts was 95%, specificity 94%, positive predictive value 97%, negative predictive value 90%, and accuracy 95%. In 15 patients with both acute and nonacute old small infarcts, DW MR imaging and ADC map could easily distinguish the new infarct from adjacent old ones, although this distinction was difficult to make with FSE. CONCLUSIONS: DW MR imaging accompanied by ADC map is a sensitive diagnostic modality for hyperacute and acute lacunar infarcts. It is also sensitive in distinguishing fresh small infarcts from adjacent multiple old infarcts.

Endometrium estimation in a sequence of ultrasonic images.

In this paper a novel algorithm for motion estimation of the endometrium in a sequence of ultrasonic images is presented. The algorithm used is based on the criterion that a pixel of a motion object at different times has a different gray value. The motion estimation includes motion frequency and thickness; the former one is determined by the detection of change of a pixel value in a sequence of images during a given time period, and the latter is the result of the object's dimension divided by its extended width. The algorithm has been tested on synthetic and real images, and the results are encouraging.

Butachlor, a suspected carcinogen, alters growth and transformation characteristics of mouse liver cells.

Butachlor is a widely used herbicide in Asia and South America. Previous investigations have indicated that it is a suspected carcinogen. To understand more about the biological effects of butachlor on cultured cells and the mechanism(s) of its carcinogenicity, we studied the alteration of the growth characteristics that was induced by butachlor in normal mouse liver cells (BNL CL2). This study demonstrates that butachlor decreases the population-doubling time of BNL CL2 cells, suggesting that it stimulates cell proliferation. To support this finding, a thymidine incorporation assay was conducted and a similar result that butachlor stimulates cell proliferation was elucidated. In addition, we show that butachlor increases the saturation density of the BNL CL2 cells. When combined with the tumor initiator N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), butachlor transforms cells efficiently, as demonstrated by loss of contact inhibition. These findings indicate that butachlor alters the growth characteristics of BNL CL2 cells and suggest that butachlor may induce malignant transformation through stimulation of cell proliferation, alteration of cell cycle regulation, and suppression of cell density-dependent inhibition of proliferation.

Hand motion assessment and rehabilitation system.

Along with the rapid development of information technology, computers play an increasingly prominent and important role. One current trend is to use computers as instruments for physical rehabilitation. In this study, we introduce a new hand motion assessment and rehabilitation system. This system assesses a user's grip strength and records the sudden changes in air pressure through a circuit and A/D adapter. A PC interface transforms and saves the data in a data record file. The data is then compiled and combined with a patient's case history and keyed into a database as reference for clinical use. The system is highly efficient, cheap and convenient to use. Doctors can use it to monitor and analyze the progress of a rehabilitation program.

Robust radial basis function neural networks.

Function approximation has been found in many applications. The radial basis function (RBF) network is one approach which has shown a great promise in this sort of problems because of its faster learning capacity. A traditional RBF network takes Gaussian functions as its basis functions and adopts the least-squares criterion as the objective function, However, it still suffers from two major problems. First, it is difficult to use Gaussian functions to approximate constant values. If a function has nearly constant values in some intervals, the RBF network will be found inefficient in approximating these values. Second, when the training patterns incur a large error, the network will interpolate these training patterns incorrectly. In order to cope with these problems, an RBF network is proposed in this paper which is based on sequences of sigmoidal functions and a robust objective function. The former replaces the Gaussian functions as the basis function of the network so that constant-valued functions can be approximated accurately by an RBF network, while the latter is used to restrain the influence of large errors. Compared with traditional RBF networks, the proposed network demonstrates the following advantages: (1) better capability of approximation to underlying functions; (2) faster learning speed; (3) better size of network; (4) high robustness to outliers.

Airway compression by a biplane pediatric transesophageal echocardiography probe: case report.

Transesophageal echocardiography (TEE) has been extensively used in cardiac surgery to assess cardiac function and anatomical relationships in both adults and children. Newer monitoring devices, despite being labeled "noninvasive", often present significant risks. Physicians should be cautious with the use of TEE in infants and small children, recognizing that oversized probes may inadvertently compress vital structures, resulting in airway or vascular compromise. If severe compression of the airway or vascular structures occurs, TEE monitoring may need to be discontinued. Although technological progress has yielded smaller ultrasonic probes, the TEE probe is significantly larger than most other devices placed in the esophagus. We present in this report a case of airway compression using a small-sized biplane pediatric TEE probe in a child undergoing Blalock-Taussig shunt surgery. Pediatric patients may be more at risk for airway obstruction because of the over-size of the probe-distended esophagus in relation to adjacent airway structures.

An automatic diagnostic system for CT liver image classification.

Computed tomography (CT) images have been widely used for liver disease diagnosis. Designing and developing computer-assisted image processing techniques to help doctors improve their diagnosis has received considerable interests over the past years. In this paper, a CT liver image diagnostic classification system is presented which will automatically find, extract the CT liver boundary and further classify liver diseases. The system comprises a detect-before-extract (DBE) system which automatically finds the liver boundary and a neural network liver classifier which uses specially designed feature descriptors to distinguish normal liver, two types of liver tumors, hepatoma and hemageoma. The DBE system applies the concept of the normalized fractional Brownian motion model to find an initial liver boundary and then uses a deformable contour model to precisely delineate the liver boundary. The neural network is included to classify liver tumors into hepatoma and hemageoma. It is implemented by a modified probabilistic neural network (PNN) [MPNN] in conjunction with feature descriptors which are generated by fractal feature information and the gray-level co-occurrence matrix. The proposed system was evaluated by 30 liver cases and shown to be efficient and very effective.

Shape from texture: estimation of planar surface orientation through the ridge surfaces of continuous wavelet transform.

In this correspondence, a method is proposed for estimating the surface orientation of a planar texture under perspective projection based on the ridge of a two-dimensional (2-D) continuous wavelet transform (CWT). We show that an analytical solution of the surface orientation can be derived from the scales of the ridge surface. A comparative study with an existing method is given.

An image capture and communication system for emergency computed tomography.

An image capture and communication system for emergency computed tomography (CT) is presented. The system, named ICCS, integrates CT scanners, personal computers (PC), network systems, an IBM API gateway and an IBM mainframe platform. The ICCS was implemented in the emergency unit in the Taichung Veterans General Hospital (TCVGH) and has received considerable support from the doctors, nurses and staff of the TCVGH emergency unit who have shown great interest in ICCS. This is because ICCS allows physicians in the emergency unit to examine patients' images on image viewing stations immediately after the patients are CT scanned. It also makes remote consultation possible for doctors who can stay where they are and consult with radiologists through the system and a hot line without leaving the emergency unit. This advantage greatly reduces the consultation time and saves many unnecessary trips between the emergency unit and the Department of Radiology.

A hierarchical model for PACS.

In this paper, a hierarchical model for Picture Archiving and Communication Systems (HPACS) is presented and implemented at Taichung Veterans General Hospital (TCVGH) in Taiwan. Despite the fact that the HPACS is built on the architecture of the second generation PACS, it offers many improved features and has advantages over the second generation PACS, such as the user security control, fast resource dispatch and efficient resource management. This HPACS can be used as a reference model for a hospital with any scale-size. The real implementation of HPACS is currently undertaken in the Taichung Veterans General Hospital (TCVGH), Taiwan, Republic of China and consists of four phases with the first two phases already completed. It is the first pilot system ever to be implemented successfully in a large-scale hospital in Taiwan. The experiences have illustrated the great promise of the HPACS in the future.