A cluster-randomized controlled trial of a nurse-led artificial intelligence assisted prevention and management for delirium (AI-AntiDelirium) on delirium in intensive care unit: Study protocol.

BACKGROUND: Delirium is a common complication among intensive care unit (ICU) patients that is linked to negative clinical outcomes. However, adherence to the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS guidelines), which recommend the use of the ABCDEF bundle, is sub-optimal in routine clinical care. To address this issue, AI-AntiDelirium, a nurse-led artificial intelligence-assisted prevention and management tool for delirium, was developed by our research team. Our pilot study yielded positive findings regarding the use of AI-AntiDelirium in preventing patient ICU delirium and improving activities of daily living and increasing intervention adherence by health care staff. METHODS: The proposed large-scale pragmatic, open-label, parallel-group, cluster randomized controlled study will assess the impact of AI-AntiDelirium on the incidence of ICU delirium and delirium-related outcomes. Six ICUs in two tertiary hospitals in China will be randomized in a 1:1 ratio to an AI-AntiDelirium or a PADIS guidelines group. A target sample size of 1,452 ICU patients aged 50 years and older treated in the ICU for at least 24 hours will be included. The primary outcome evaluated will be the incidence of ICU delirium and the secondary outcomes will be the duration of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, patient activities of daily living, and ICU nurse adherence to the ABCDEF bundle. DISCUSSION: If this large-scale trial provides evidence of the effectiveness of AI-AntiDelirium, an artificial intelligence-assisted system tool, in decreasing the incidence of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, and patient activities of daily living while increasing ICU nurse adherence to the ABCDEF bundle, it will have a profound impact on the management of ICU delirium in both research and clinical practice. CLINICAL TRIAL REGISTRATION: ChiCTR1900023711 (Chinese Clinical Trial Registry).

Posttreatment Non-Improved Vocal Cord Mobility Indicates the Need of Salvage Surgery for Hypopharyngeal Carcinomas.

INTRODUCTION: We aimed to analyze the relationship between the changed status of vocal cord mobility and survival outcomes. METHODS: Seventy-eight patients with dysfunctional vocal cords and hypopharyngeal carcinomas accepted non-surgical treatment as the initial therapy between May 2009 and December 2016. Vocal cord mobility was assessed before and after the initial non-surgical treatment. The cord mobility status was classified as normal, impaired, and fixed. Patients with improved mobility (IM) (n =56) were retrospectively analyzed for disease-free survival (DFS), recurrence-free survival (RFS), and overall survival (OS) and compared with 22 patients with non-improved mobility (non-IM). RESULTS: Fifty-six (71.8%) patients had improved cord mobility after the initial non-surgical treatment. The non-improved cord mobility was significantly associated with shortened DFS (P=0.005), RFS (P=0.002), and OS (P<0.001). If non-improved cord mobility was regarded as an indicator for local-regional recurrence within 1 year, the sensitivity and the specificity were 60.9%, 87.5% respectively. The multivariate analysis showed that improved cord mobility (P=0.006) and salvage surgery (P=0.015) were both independent protective factors for OS. CONCLUSION: Changes in cord mobility are a key marker for predicting prognosis. Non-improved cord mobility may indicate a high possibility of a residual tumor, therefore, patients whose cord mobility remains dysfunctional or worsens after non-surgical treatment might need an aggressive salvage strategy.

Predictors of Occult Lymph Node Metastasis and Prognosis in Patients with cN0 T1-T2 Supraglottic Laryngeal Carcinoma: A Retrospective Study.

BACKGROUND: This work aimed to explore the predictors of lymph node metastasis (LNM) and analyze the prognosis of patients with clinically node-negative (cN0) T1-T2 supraglottic laryngeal carcinoma (SGLC). METHODS: Data for 130 patients with cN0 T1-T2 SGLC who initially underwent surgery were retrospectively reviewed. Occult LNM incidence, relevant factors, and prognosis were analyzed. RESULTS: Of the 130 patients with cN0 T1-T2 SGLC, 21 (16.2%) had occult LNM. Based on univariate and multivariable regression analyses, male sex and poor tumor differentiation predicted the incidence of occult LNM. The incidence of occult LNM was 20.9% in males and 5.1% in females (p = 0.035). Patients with poorly differentiated tumors had a higher incidence of occult LNM (42.9%) than patients with well-differentiated (10.3%) and moderately differentiated tumors (14.3%; p < 0.05). Thirteen patients (10%) had cervical recurrence, and all had T2 tumors (p = 0.02). The 5-year disease-specific survival rates were 70 and 90% for patients with and without LNM, respectively (p = 0.000). CONCLUSIONS: Sex and tumor differentiation are potential predictors of occult nodal disease. Female patients with cN0 T1-T2 SGLC are less likely than male patients to have neck metastasis. Poorly differentiated tumors are associated with the frequency of neck metastasis, and selective neck dissection is strongly recommended for these tumors.

A novel device in parathyroid autotransplantation for 6 patients with secondary hyperparathyroidism - Case series.

BACKGROUND: Secondary hyperparathyroidism(sHPT) is one of the most serious complications in long-term hemodialysis patients. Patients may suffer from metabolic bone diseases, severe atherosclerosis and undesirable cardiovascular events. Endoscopic parathyroidectomy with autotransplantation is a treatment option for those who do not respond to clinical management. METHODS: 6 patients with secondary hyperparathyroidism were treated with endoscopic parathyroidectomy and autotransplantation. Pieces of parathyroid tissue were squeezed in our novel self-made device and injected into brachioradialis. RESULTS: Preoperative symptoms were alleviated, and the serum PTH and alkaline phosphatase levels, hyperphosphatemia, and hypercalcemia were improved or normalized in all 6 patients. The preparation time of parathyroid fragments for autotransplantation was less than 10 min in all 6 patients.Pathological examinations revealed parathyroid cells remains active. CONCLUSION: Application of the novel squeezing device is an economic, effective and safe way in endoscopic parathyroidectomy and autotransplantation for patients with secondary hyperparathyroidism.

Familial Nonmedullary Thyroid Carcinoma: A Retrospective Analysis of 117 Families.

BACKGROUND: The first and most important step in characterizing familial nonmedullary thyroid carcinoma (NMTC) is to distinguish the true familial patients, which is the prerequisite for all accurate analyses. This study aimed to investigate whether patients from families with ≥3 first-degree relatives affected with NMTC have different characteristics than patients from families with only two affected members, and to compare these patients with those with sporadic disease. METHODS:: We analyzed the clinicopathological features and prognosis of 209 familial and 1120 sporadic cases of NMTC. Familial patients were further divided into two subgroups: families with two affected members and families with ≥3 affected members. RESULTS:: The familial group had a significantly higher risk of bilateral growth, multifocality, extrathyroidal extension, and lateral lymph node metastasis than the sporadic group (P < 0.05). These main features were also different between the group with ≥3 affected members and the sporadic group. The only difference between the two affected members' group and the sporadic group was incidence of multifocality (P < 0.05). The probability of disease recurrence in patients from families with ≥3 affected members was significantly higher than that in sporadic cases (14.46% vs. 5.27%; P = 0.001), while the probability in patients from families with two affected members was similar to that in sporadic patients (6.35% vs. 5.27%; P = 0.610). The Kaplan-Meier survival analysis showed a statistically significant difference in disease-free survival between the two subgroups (85.54% vs. 93.65%; P = 0.045). CONCLUSIONS:: Patients from families with ≥3 members affected by NMTC have more aggressive features and a worse prognosis than those from families with only two affected members. Patients from families with ≥3 affected first-degree relatives may be considered to have true familial NMTC.

[Relationship between anogenital distance and cryptorchidism in human newborns].

OBJECTIVE: To explore the relation of the anogenital distance (AGD) with cryptorchidism in male newborns. METHODS: This study included 350 male infants delivered in two community hospitals between September 2013 and September 2014. Within 24 hours after birth, a pediatric surgeon measured the AGD of the neonates and determined whether they had cryptorchidism. According to the testicular position, we divided the undescended testes into three types: upper scrotal, inguinal, and non-palpable. RESULTS: Totally 39 cases of cryptorchidism were found in the 350 newborns. The AGD of the cryptorchidism infants was significantly shorter than that of the normal neonates ([2.01 ± 0.22] vs [2.35 ± 0.19] cm, P < 0.01), and statistically significant differences remained even when preterm and low birth-weight infants were excluded ([2.32 ± 0.14] vs [2.06 ± 0.19] cm; (2.37 ± 0.17) cm vs (2.12 ± 0.12) cm, all P < 0.01). The newborns with higher-position cryptorchidism had a shorter AGD, though with no significant difference (F = 0.434, P > 0.05). No significant differences were observed in the AGD between unilateral and bilateral cryptorchidism ([1.96 ± 0.13] vs [2.02 ± 0.17] cm, P > 0.05). CONCLUSION: Shorter AGD is associated with a higher incidence of cryptorchidism in male newborns. AGD could serve as a potential biomarker for disruption of androgen action during the male programming window period.

A novel evaluation method for building construction project based on integrated information entropy with reliability theory.

Selecting construction schemes of the building engineering project is a complex multiobjective optimization decision process, in which many indexes need to be selected to find the optimum scheme. Aiming at this problem, this paper selects cost, progress, quality, and safety as the four first-order evaluation indexes, uses the quantitative method for the cost index, uses integrated qualitative and quantitative methodologies for progress, quality, and safety indexes, and integrates engineering economics, reliability theories, and information entropy theory to present a new evaluation method for building construction project. Combined with a practical case, this paper also presents detailed computing processes and steps, including selecting all order indexes, establishing the index matrix, computing score values of all order indexes, computing the synthesis score, sorting all selected schemes, and making analysis and decision. Presented method can offer valuable references for risk computing of building construction projects.

[Significance of selective neck dissection in patients with cN0 thyroid carcinoma].

OBJECTIVE: To investigate the significance of selective neck dissection in patients with cN0 thyroid carcinoma who have a high-risk of lateral neck lymph node metastasis. METHODS: Sixty three patients with cN0 thyroid carcinoma who have a high-risk of lateral neck lymph node metastasis were prospectively studied at the Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between August 2006 and June 2011. The patients with cN0 thyroid carcinoma easy to occur neck lymph node metastasis include: The maximum diameter of primary tumor is ≥ 2 cm; The primary tumor invaded the thyroid capsule; Lymph node metastasis in level VI is found; Lymph node enlargement in level III or/and IV were detected preoperatively by ultrasonography, but not considered as metastasis. The surgical procedure is that the selective neck dissection in level III and IV is performed depending on the collar incision of thyroid surgery. The lymph node chosen from the specimen has a frozen section. If lymph node metastasis is found in the frozen section, a functional neck dissection should be performed through prolonging the collar incision. RESULTS: All cases were pathologically confirmed as thyroid papillary carcinoma. The occult metastasis rate of lateral neck lymph nodes was 39.7%. According to the univariate analysis, the patients with thyroid capsule invasion and lymph node metastasis in level VI were more likely to have lateral neck lymph node metastasis, and the occult metastasis rate was 46.9% and 54.3%, respectively (P = 0.028, P = 0.008), and there were statistically no significant difference in the primary tumor size and the preoperative neck lymph node status by ultrasonography with occult metastasis of lateral neck lymph nodes (P = 0.803 and P = 0.072). According to the multivariate analysis, there was a significant correlation only between the lymph node metastasis in level VI and occult metastasis of lateral neck lymph nodes (P = 0.017), but there was no significant correlation with the thyroid capsule invasion, primary tumor size and neck lymph node status by preoperative ultrasonography in prediction of occult metastasis of lateral neck lymph nodes (all P > 0.05). CONCLUSIONS: Selective neck dissection is feasible for the patients with cN0 thyroid carcinoma who have a high-risk lateral neck lymph node metastasis and the lateral occult metastatic lymph node can be promptly found and removed. We suggest that the selective neck dissection for level III and IV should be routinely performed in cN0 thyroid carcinoma patients with thyroid capsule invasion and lymph node metastasis in level VI.

Management with the insufficient proximal landing zone for endovascular repair in aortic dissection.

BACKGROUND: Sufficient length of the proximal landing zone (PLZ) is the key for a successful thoracic endovascular aortic repair (TEVAR) of an aortic lesion. The aim of this research was to investigate the safety, feasibility, efficacy, and problems of endovascular repair for aortic dissection with insufficient PLZ. METHODS: The clinical data between August 2005 and February 2010 from patients with insufficient PLZ for endovascular repair of aortic dissection were retrospectively reviewed. According to the classification proposed by Ishimaru, aortic zone 0 was involved in 3 cases, zone 1 in 10 cases, and zone 2 in 11 cases. A hybrid surgical procedure of supraortic debranching and revascularization, directly coverage the orifice of left subclavian artery, or a left common carotid artery chimney graft technique were performed to obtain an adequate proximal aortic landing zone. RESULTS: There was no significant difference in risk factors and diameter of the PLZ between Zone 0, Zone 1, and Zone 2. But the length of the PLZ was significantly different in the three groups (P < 0.01). There was no significant difference in technical and clinical success rate between the groups. CONCLUSIONS: The procedure for extending an insufficient PLZ for endovascular repair for aortic arch pathology is feasible and relatively safe. The applicability of TEVAR in such aortic disorders may be expanded.

Mutation in D-loop region of mitochondrial DNA in gastric cancer and its significance.

AIM: To investigate the mutation in D-loop region of mitochondrial DNA in gastric cancer and its influence on the changes of reactive oxygen species (ROS) and cell cycle. METHODS: The D-loop region was amplified by PCR and sequenced. Reactive oxygen species and cell cycle were detected by flow cytometry in 20 specimens from gastric cancer and adjacent normal tissues. According to the sequence results, gastric cancer tissue was divided into mutation group and control group. Reactive oxygen species, apoptosis and proliferation in the two groups were compared. RESULTS: Among the 20 gastric cancer specimens, 18 mutations were identified in 7 patients, the mutation rate being 35%. There were four microsatellite instabilities in the mutations. No mutation was found in the adjacent tissues. Reactive oxygen species, apoptosis, and proliferation in the mutation group were all significantly higher than those in control group. CONCLUSION: Mutation in D-loop region plays a role in the genesis and development of gastric cancer.

Detection of micrometastasis in peripheral blood by multi-sampling in patients with colorectal cancer.

AIM: To evaluate the reverse transcriptase-PCR assay and multiple sampling for detection of cytokeratin-positive cells in peripheral blood of colorectal carcinoma patients and to investigate the clinical significance of micrometastasis in peripheral blood. METHODS: The expression of CK20 mRNA by RT-PCR was investigated in bone marrow, portal vein and peripheral blood in 58 colorectal cancer patients and 12 controls without known cancer. The peripheral blood was sampled twice at intervals of 3 d before operation. All the patients were followed up for one year. RESULTS: There was no positive expression of CK20mRNA in 12 volunteers. The positive expression of CK20mRNA was 77.6% (45/58) in bone marrow, and that in portal vein was 74.1% (43/58) of colorectal carcinoma patients. The positive expression of CK20mRNA cells in peripheral blood rose from 44.8% (26/58) to 69.0% (40/58) (P<0.01). The total positivity of CK20mRNA expression in peripheral blood was similar to the positivity of CK20mRNA in bone marrow and portal vein. The positive rates became higher in later clinical stages than in early stages. The CK20mRNA positive patients had a higher relapse rate within one year than the CK20mRNA negative patients. CONCLUSION: Multiple blood sampling can increase the detection of tumor cells in peripheral blood by RT-PCR for CK20mRNA in colorectal carcinoma patients and it is as sensitive and specific as that of bone marrow and portal vein. This technique may be reliable and convenient to diagnose micrometastasis of colorectal carcinoma and has an important significance in determining the prognosis of cancer patients.

[Significance of detecting disseminated tumor cells in peripheral blood of gastric and colorectal cancer patients].

OBJECTIVE: To evaluate the clinical significance of CK20 mRNA expression in detecting disseminated tumor cells in peripheral blood of gastric and colorectal cancer patients. METHODS: Expression of CK20 mRNA was investigated by RT-PCR in bone marrow, portal vein and peripheral blood in 47 gastric, 58 colorectal cancer patients and 6 non-cancer volunteers. All the patients were followed-up for one year. RESULTS: There was no positive expression of CK20 mRNA in 6 non-cancer volunteers. The positive rates of CK20 mRNA in bone marrow, portal vein were 87.2% (41/47) and 85.1% (40/47) in gastric cancer, and were 77.6% (45/58) and 74.1% (43/58) in colorectal cancer. The positive rates of CK20 mRNA in peripheral blood in gastric and colorectal cancer patients were 42.6% (20/47) and 44.8% (26/58) by one single test, and were 74.5% (35/47) and 69.0% (40/58) by two tests. The overall positive rate of CK20 mRNA in peripheral blood (two tests) was similar to that in bone marrow and portal vein. The overall positive rate of CK20 mRNA in peripheral blood was higher in two tests than in one single test (P < 0.05) and in advanced than early lesions. The relapse rate within one year was higher in CK20 mRNA positive patients than the negative ones (P < 0.05). CONCLUSION: Detection of cancer cells by RT-PCR for CK20 mRNA in peripheral blood, being as sensitive and specific as in bone marrow and portal vein, is reliable and convenient in diagnosing micrometastasis of gastric and colorectal cancer, which possesses clinical significance in assessing the prognosis and scheme of therapy.