Clinical significance of diabetes on symptom and patient delay among patients with acute myocardial infarction——an analysis from China Acute Myocardial Infarction(CAMI) registry

Background Diabetes is frequently associated with poor prognosis among acute myocardial infarction(AMI)patients.Patients with these comorbidities often have atypical symptoms and subsequent delay in treatment.Few studies have reported detailed AMI symptoms in patients with diabetes.This study compared AMI symptoms and presentation characteristics between diabetics and non-diabetics.Methods We included patients from the China AMI registry diagnosed with AMI between January 2013 and September 2014.Baseline characteristics,symptomology,and delay in treatment were compared between diabetics and non-diabetics.Multivariable logistic regression analysis was used to explore independent predictors of atypical symptoms.Results A total of 4450(20.2%)patients had diabetes.They were older,more often women,higher in body mass index,and more likely to have non-ST segment elevation myocardial infarction.Fewer diabetic patients presented with persistent precordial chest pain(63.1%vs.68%,P<0.0001),diaphoresis(60.1%vs.65.6%,P<0.0001),fatigue(16.7%vs.18.3%,P=0.0123),and incontinence(0.4%vs.0.7%,P=0.0093).Time to hospital presentation was longer among patients with diabetes than those without.In multivariable analysis,diabetes was identified as an independent predictor of atypical symptoms(OR:1.112,95%CI:1.034?1.196).Conclusions Our study is the first large-scale study providing evidence that diabetics are less likely to present with typical chest pain and more likely to experience treatment delay when suffering from an AMI.Our results may increase clinician awareness of recognizing AMI patients rapidly to reduce diagnosis and treatment delay,particularly in the context of diabetes.

Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods

Background: Augmented reality(AR) technology is used to reconstruct three-dimensional(3D) images of hepatic and biliary structures from computed tomography and magnetic resonance imaging data, and to superimpose the virtual images onto a view of the surgical field. In liver surgery, these superimposed virtual images help the surgeon to visualize intrahepatic structures and therefore, to operate precisely and to improve clinical outcomes.Data Sources: The keywords "augmented reality", "liver", "laparoscopic" and "hepatectomy" were used for searching publications in the Pub Med database. The primary source of literatures was from peer-reviewed journals up to December 2016. Additional articles were identified by manual search of references found in the key articles.Results: In general, AR technology mainly includes 3D reconstruction, display, registration as well as tracking techniques and has recently been adopted gradually for liver surgeries including laparoscopy and laparotomy with video-based AR assisted laparoscopic resection as the main technical application. By applying AR technology, blood vessels and tumor structures in the liver can be displayed during surgery,which permits precise navigation during complex surgical procedures. Liver transformation and registration errors during surgery were the main factors that limit the application of AR technology.Conclusions: With recent advances, AR technologies have the potential to improve hepatobiliary surgical procedures. However, additional clinical studies will be required to evaluate AR as a tool for reducing postoperative morbidity and mortality and for the improvement of long-term clinical outcomes. Future research is needed in the fusion of multiple imaging modalities, improving biomechanical liver modeling,and enhancing image data processing and tracking technologies to increase the accuracy of current AR methods.

Molecular Dynamics Simulation on Scale Inhibition Mechanism of Polyepoxysuccinic Acid to Calcium Sulphate

分子的动力学模拟被执行了模仿在 PESA 之间的相互作用并且(001 ) 在不同温度硬石膏晶体 CaSO4 面对 H2O 分子的各种各样的数字的存在。结果证明 PESA 能有效地在 323343 K 阻止 CaSO4 规模的生长。在一样的温度，在 PESA 之间的有约束力的精力并且(001 ) 为有 H2O 的各种各样的数字的系统的 CaSO4 的脸有 Ebind (0H2O ) 的顺序 > Ebind (200400H2O )> Ebind (100H2O ) 。为在不同温度的一样的系统，有约束力的精力是靠近的并且主要从库仑相互作用被贡献，包括离子的契约。契约在硬石膏规模水晶的钙原子和 PESA 的 carboxyl 组的氧原子之间被形成。氢契约在 PESA 的 carboxyl 组的 O 原子和 H2O 的 H 原子之间被形成。货车 der Waals 相互作用对 PESA， H2O，和 CaSO4 的系统的稳定性导致。O (PESA 的羰基) 的光线的分发函数 -H(H2O), O (CaSO4 )-H(H2O), 和 O (CaSO4 )-H(PESA) 暗示溶剂在 PESA 的反规模性能上有效果到 CaSO4。

Extrahepatic bile duct reconstruction in pigs with heterogenous animal-derived artificial bile ducts:A preliminary experience

BACKGROUND Extrahepatic biliary duct injury(BDI)remains a complicated issue for surgeons.Although several approaches have been explored to address this problem,the high incidence of complications affects postoperative recovery.As a nonimmunogenic scaffold,an animal-derived artificial bile duct(ada-BD)could replace the defect,providing good physiological conditions for the regeneration of autologous bile duct structures without changing the original anatomical and physiologic conditions.AIM To evaluate the long-term feasibility of a novel heterogenous ada-BD for treating extrahepatic BDI in pigs.METHODS Eight pigs were randomly divided into two groups in the study.The animal injury model was developed with an approximately 2 cm segmental defect of various parts of the common bile duct(CBD)for all pigs.A 2 cm long novel heterogenous animal-derived bile duct was used to repair this segmental defect(group A,ada-BD-to-duodenum anastomosis to repair the distal CBD defect;group B,ada-BD-to-CBD anastomosis to repair the intermedial CBD defect).The endpoint for observation was 6 mo(group A)and 12 mo(group B)after the operation.Liver function was regularly tested.Animals were euthanized at the above endpoints.Histological analysis was carried out to assess the efficacy of the repair.RESULTS The median operative time was 2.45 h(2-3 h),with a median anastomosis time of 60.5 min(55-73 min).All experimental animals survived until the endpoints for observation.The liver function was almost regular.Histologic analysis indicated a marked biliary epithelial layer covering the neo-bile duct and regeneration of the submucosal connective tissue and smooth muscle without significant signs of immune rejection.In comparison,the submucosal connective tissue was more regular and thicker in group B than in group A,and there was superior integrity of the regeneration of the biliary epithelial layer.Despite the advantages of the regeneration of the bile duct smooth muscle observed in group A,the effect on the patency of the ada-BD grafts in group B was not confirmed by macroscopic assessment and cholangiography.CONCLUSION This approach appears to be feasible for repairing a CBD defect with an ada-BD.A large sample study is needed to confirm the durability and safety of these preliminary results.

Portal inflow preservation during portal diversion in small-for-size syndrome

AIM:To investigate the impact of portal inflow on liver remnants in a stable pig model of small-for-size syndrome.METHODS:Twenty pigs underwent mesocaval shunt(MCS)surgery followed by 85%-90%hepatectomy.The control group had no shunt placement;the S1group had portal flow maintained at an average of 2.0times the baseline values;and the S2group had portal flow maintained at an average of 3.2 times the baseline flow.The effect of portal functional competition on the liver remnant was investigated for 48 h postoperatively.Data were presented as mean±SD.Statistical significance was determined using Student’s t test(SPSS,Chicago,IL,United States).Values of P<0.05 were considered statistically significant.RESULTS:At 24 h after hepatectomy,biochemical and histological changes were not significantly different between the S1and S2groups,but changes in both sets of variables were significantly less than in the control group.At 48 h,biochemical and histological changes were significantly less in the S2group than in the S1or control group.The regeneration index was significantly higher in the S2group than in the S1group,and was similar to that in the control group.Apoptosis index,serum lipopolysaccharide,and bacterial DNA levels were significantly lower in the S2group than in the other two groups.CONCLUSION:Diversion of portal inflow using MCS reduces portal overflow injury.Excessive diversion of portal inflow inhibits liver regeneration following major hepatectomy.Maintaining portal inflow at an average of 3.2 times above baseline helps promote hypertrophy of the liver remnant and reduce apoptosis.

Laparoscopic pancreaticoduodenectomy via a reverse-''V'' approach with four ports:Initial experience and perioperative outcomes

AIM:To evaluate the feasibility,safety,and efficacy of laparoscopic pancreaticoduodenectomy(LPD) using a reverse-"V" approach with four ports.METHODS:This is a retrospective study of selected patients who underwent LPD at our center between April 2011 and April 2012.The following data were collected and reviewed:patient characteristics,tumor histology,surgical outcome,resection margins,morbidity,and mortality.All patients were thoroughly evaluated preoperatively by complete hematologic investigations,triple-phase helical computed tomography,upper gastrointestinal endoscopy,and biopsy of ampullary lesions(when present).Magnetic resonance cholangiopancreatography was performed for doubtful cases of lower common bile duct lesions.RESULTS:There was no perioperative mortality.LPD was performed with tumor-free margins in all patients,including patients with pancreatic ductal adenocarcinoma(n = 6),ampullary carcinoma(n = 6),intra-ductal papillary mucinous neoplasm(n = 2),pancreatic cystadenocarcinoma(n = 2),pancreatic head adenocarcinoma(n = 3),and bile duct cancer(n = 2).The mean patient age was 65 years(range,42-75 years).The median blood loss was 240 m L,and the mean operative time was 368 min.CONCLUSION:LPD using a reverse-"V" approach can be performed safely and yields good results in elective patients.Our preliminary experience showed that LDP can be performed via a reverse-"V" approach.This approach can be used to treat localized malignant lesions irrespective of histopathology.

Exponential stability of nonlinear impulsive switched systems with stable and unstable subsystems

Exponential stability and robust exponential stability relating to switched systems consisting of stable and unstable nonlinear subsystems are considered in this study.At each switching time instant,the impulsive increments which are nonlinear functions of the states are extended from switched linear systems to switched nonlinear systems.Using the average dwell time method and piecewise Lyapunov function approach,when the total active time of unstable subsystems compared to the total active time of stable subsystems is less than a certain proportion,the exponential stability of the switched system is guaranteed.The switching law is designed which includes the average dwell time of the switched system.Switched systems with uncertainties are also studied.Sufficient conditions of the exponential stability and robust exponential stability are provided for switched nonlinear systems.Finally,simulations show the effectiveness of the result.