Triage admission protocol with a centralized quarantine unit for patients after acute care surgery during the COVID-19 pandemic: A tertiary center experience in Taiwan.

BACKGROUND: During the COVID-19 surge in Taiwan, the Far East Memorial Hospital established a system including a centralized quarantine unit and triage admission protocol to facilitate acute care surgical inpatient services, prevent nosocomial COVID-19 infection and maintain the efficiency and quality of health care service during the pandemics. MATERIALS AND METHODS: This retrospective cohort study included patients undergoing acute care surgery. The triage admission protocol was based on rapid antigen tests, Liat® PCR and RT-PCT tests. Type of surgical procedure, patient characteristics, and efficacy indices of the centralized quarantine unit and emergency department (ED) were collected and analyzed before (Phase I: May 11 to July 2, 2021) and after (Phase II: July 3 to July 31, 2021) the system started. RESULTS: A total of 287 patients (105 in Phase I and 182 in Phase II) were enrolled. Nosocomial COVID-19 infection occur in 27 patients in phase I but zero in phase II. More patients received traumatological, orthopedic, and neurologic surgeries in phase II than in phase I. The patients' surgical risk classification, median total hospital stay, intensive care unit (ICU) stay, intraoperative blood loss, operation time, and the number of patients requiring postoperative ICU care were similar in both groups. The duration of ED stay and waiting time for acute care surgery were longer in Phase II (397 vs. 532 minutes, p < 0.0001). The duration of ED stay was positively correlated with the number of surgical patients visiting the ED (median = 66 patients, Spearman's ρ = 0.207) and the occupancy ratio in the centralized quarantine unit on that day (median = 90.63%, Spearman's ρ = 0.191). CONCLUSIONS: The triage admission protocol provided resilient quarantine needs and sustainable acute care surgical services during the COVID-19 pandemic. The efficiency was related to the number of medical staff dedicated to the centralized quarantine unit and number of surgical patients visited in ED.

Surgical outcome evaluation of perforated gastric cancer: from the aspects of both acute care surgery and surgical oncology.

BACKGROUND: Perforated gastric cancer (PGC) is a rare condition of gastric cancer (GC). In this study, we sought to assess the outcome of PGC from the aspects of both acute care surgery and surgical oncology at a single institute, Chang Gung Memorial Hospital (CGMH). METHODS: From 1997 to 2013, 6864 patients were diagnosed with GC and 2738 were diagnosed with gastroduodenal perforation at CGMH. In total, 29 patients with PGC were identified. Immediate surgical and long-term oncologic outcomes were evaluated after an appropriate matching process was performed. RESULTS: The immediate surgical outcome of PGC, i.e., the hospital mortality rate within 30 d after surgery, did not significantly differ from that of non-cancer related gastroduodenal perforation. The long-term oncologic outcome, with matching by age, gender, year of surgery and AJCC 7th stage grouping, also did not significantly differ from that of GC without perforation. CONCLUSIONS: Aggressive surgical treatment, including an initial emergency procedure for containing peritonitis and radical surgery for GC, may benefit PGC patients in terms of both the immediate and oncologic outcomes.

A nomogram for predicting the probability of recurrence in patients with carcinomas located in the ampulla of Vater.

Background and Objectives: The standard treatment for carcinomas of the ampulla of Vater (CAV) is surgical resection. Nevertheless, recurrence is observed in half of the patients within five years after cancer surgery. In this study, we aimed to identify predictive factors and develop a nomogram capable of predicting the risk of recurrence in post-resection CAV patients. Methods: Our study cohort was composed of two hundred and twelve patients who had undergone radical surgery for CAV between 2000 and 2012. Clinicopathological variables predictive of recurrence were identified using univariate analysis. A Cox proportional hazards model was used to select the predictive factors used for the nomogram. Results: The 5-year overall survival, cancer-specific survival and disease-free survival rates were 44.3%, 51.1%, and 42.8%, respectively. The five most predictive variables for tumor recurrence were chosen to develop the nomogram. The nomogram had a highly predictive performance, with a bootstrap-corrected concordance index of 0.72 (95% confidence interval, 0.67-0.79). Furthermore, the performance of the nomogram was found to be better than the American Joint Committee on Cancer (AJCC) staging system due to better homogeneity, higher ability of discrimination and higher risk stratification of the model. Conclusions: We developed a predictive nomogram for estimating tumor relapse probability in CAV patients after radical surgery. This nomogram might be more informative than the AJCC staging system and may allow for better estimation of the probability of relapse after surgical resections.

Prognostic Value of the Metastatic Lymph Node Ratio in Patients With Resectable Carcinoma of Ampulla of Vater.

Patients with carcinoma of the ampulla of Vater (CAV) have better outcomes among periampullary malignancies. However, little is known about the metastatic lymph node ratio (LNR) as a prognostic factor for resectable CAV. We retrospectively reviewed our CAV patients undergoing curative surgery and analyzed their prognostic factors.A total of 212 CAV patients who received radical surgery at Chang Gung Memorial Hospital, Linkou, between 2000 and 2010 were admitted in this study. The lymph node ratio was defined as the number of metastatic lymph nodes (LNs) divided by the total number of LNs removed. The patients' demographic data, comorbidities, operation type, and tumor features were analyzed retrospectively for survival prediction of patients.The median age of the patients was 62 years, and 57% of the patients were men. The surgical procedure was standard pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy in 53% and 47% of the patients, respectively. The median follow-up duration was 32.6 months, and 50% of the patients had died by the end of the study. The median overall survival time (OS) and disease-free survival time (DFS) were 65.8 and 33.7 months, respectively. In multivariate analysis, patients with a metastatic LNR >0.056 had a significantly poor prognosis in both OS and DFS.A metastatic LNR >0.056 predicted a poor DFS and OS in CAV patients after radical surgery. Greater awareness on the impact of metastatic LNR may help clinicians provide appropriate adjuvant treatment for high-risk CAV patients.

Structure-based and ligand-based drug design for HER 2 receptor.

Human epidermal growth factor receptor 2, HER2, is a commonly over-expressed tyrosine kinase receptor found in many types of carcinoma. Despite that there are several HER2 inhibitors, namely Iressa, Tarceva and Tykerb, currently in clinical trials, all can cause several side effects. In this study, both structure-based and ligand-based drug design were employed to design novel HER2 inhibitors from traditional Chinese medicine (TCM). The HER2 structure model was built in homology modeling based on known receptors of the same family. Docking and de novo evolution experiments were performed to identify candidates and to build derivatives. A training set of 32 compounds with inhibitory activities to HER2 was used to formulate the pharmacophore hypotheses that were subsequently used to examine candidates obtained from the docking study. Hydrogen bond interactions, salt-bridge formations and pi-stacking were observed between the ligands and Phe731, Lys753, Asp863 and Asp808 of HER2 protein. Combining results from both docking and pharmacophore mapping analysis, CLC015-5, CLC604-11 and CLC604-18 were well accepted and consistent in both approaches and were considered as the most potential HER2 inhibitors.

Clinical and molecular epidemiology of infective endocarditis in intravenous drug users.

BACKGROUND: Infective endocarditis (IE) in intravenous drug users has been increasing in incidence. The major pathogen used to be methicillin-susceptible Staphylococcus aureus, but resistant isolates have also been increasing. This study aimed to investigate the clinical characteristics of IE in intravenous drug users and to evaluate the molecular patterns of methicillin-resistant S. aureus (MRSA) that cause IE in these drug users. METHODS: A total of 37 episodes of IE in intravenous drug users hospitalized from 1980 to 2006 at a 1,250-bed teaching hospital in Southern Taiwan were evaluated retrospectively. The genetic relatedness of S. aureus strains was assessed using pulsed-field gel electrophoresis. Polymerase chain reaction was used to detect Panton-Valentine leukocidin (PVL) and staphylococcal gamma-hemolysin (Hlg), and to determine the staphylococcal chromosomal cassette carrying the mecA methicillin-resistant gene (SCCmec) type. RESULTS: The patients had a mean +/- standard deviation age of 31.5 +/- 9.25 years, with a male predominance of 76%. Hepatitis C was present in all patients. Methicillin-susceptible S. aureus accounted for 76% of infections, and the most common clinical symptoms were fever (97%) and embolic phenomenon (68%). There were 4 MRSA isolates, 3 of which were SCCmec type III. PVL and Hlg genes were found in 2 and 3 MRSA isolates, respectively. Eighty percent similarity was found among the MRSA isolates by pulsed-field gel electrophoresis. CONCLUSION: Our results suggest that coinfection with hepatitis C was common in intravenous drug users with IE, and that molecular patterns of MRSA isolates had high similarity. SCCmec type III, which is usually hospital-acquired, could have caused the community-associated MRSA endocarditis in our patients.