Transoral endoscopic and robotic thyroidectomy for thyroid cancer: the mid-term oncological outcome.

BACKGROUND: Traditional open thyroidectomy is the surgical standard for thyroid cancer; however, it inevitably leaves a visible scar on the neck and affects the patient's quality of life. Therefore, to avoid making a neck incision, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) have been developed recently, and the surgical outcomes of these techniques are as favorable as open surgery for benign disease. Additionally, positive short-term surgical outcomes have also been achieved in a few patients with thyroid cancer. However, no data on the mid-to-long-term recurrence and survival rates of transoral thyroidectomy in thyroid cancer are available. Therefore, in this study, we analyzed the surgical outcomes and mid-term oncological results of the TOETVA and TORT in patients with thyroid cancer. METHODS: We reviewed patients who had received TOETVA or TORT between July 2017 and November 2021 and followed up on their oncological outcomes until December 2022. Perioperative surgical and mid-term oncological outcomes were analyzed. RESULTS: The 115 patients underwent 122 operations (57 TOETVAs and 65 TORTs), including seven complete thyroidectomies for differentiated thyroid cancer (DTC), Stage I-II, including T1-T3, N0-N1a, and initial low- to high-risk groups. There was no conversion from transoral to open surgery. TORT required a longer operating time (median [interquartile range]) than TOETVA (lobectomy: 279 [250, 318] vs. 196 [173, 253] min, p < 0.001; bilateral total thyroidectomy: 375 [309, 433] vs. 279 [238, 312] min, p < 0.001); however, no difference was found between the two groups regarding perioperative complications. Complete thyroidectomy with a second transoral approach was safe. TOETVA and TORT achieved favorable oncological outcomes with 100% survival and 98.2% acceptable response (excellent and indeterminate response) during a mean 37.88 ± 12.42 months mid-term follow-up. CONCLUSIONS: Transoral endoscopic and robotic thyroidectomy was safe and achieved favorable mid-term oncological outcomes in a selected cohort of patients with early-stage DTC.

PPI-HotspotDB: Database of Protein-Protein Interaction Hot Spots.

Single-point mutations of certain residues (so-called hot spots) impair/disrupt protein-protein interactions (PPIs), leading to pathogenesis and drug resistance. Conventionally, a PPI-hot spot is identified when its replacement decreased the binding free energy significantly, generally by ≥2 kcal/mol. The relatively few mutations with such a significant binding free energy drop limited the number of distinct PPI-hot spots. By defining PPI-hot spots based on mutations that have been manually curated in UniProtKB to significantly impair/disrupt PPIs in addition to binding free energy changes, we have greatly expanded the number of distinct PPI-hot spots by an order of magnitude. These experimentally determined PPI-hot spots along with available structures have been collected in a database called PPI-HotspotDB. We have applied the PPI-HotspotDB to create a nonredundant benchmark, PPI-Hotspot+PDBBM, for assessing methods to predict PPI-hot spots using the free structure as input. PPI-HotspotDB will benefit the design of mutagenesis experiments and development of PPI-hot spot prediction methods. The database and benchmark are freely available at https://ppihotspot.limlab.dnsalias.org.

Reduced-port robotic radical gastrectomy for gastric cancer: a single-institute experience.

BACKGROUND: Reduced-port laparoscopic gastrectomy can potentially reduce postoperative pain and improve recovery time. However, the inherent difficulty caused by the narrow manipulation angle makes this operation difficult, especially during lymph node dissection. The intrinsic advantage of the da Vinci® robotic system might offset this difficulty, maintaining adequate surgical quality with risks of surgical complications equal to those by the conventional four-port robotic approach. The aim of this study was to compare the reduced-port robotic approach and the conventional four-port approach in terms of postoperative pain and short-term surgical outcomes. METHODS: All patients who underwent radical gastrectomy with D2 lymph node dissection using the da Vinci Xi robotic system, including reduced-port or conventional four-port approach, were analyzed retrospectively. The primary outcome was postoperative pain assessed using the numerical rating scale (NRS). The secondary outcomes were the number of harvested lymph nodes, operation time, length of hospital stay, and postoperative 30-day complications. RESULTS: Forty-eight patients were enrolled in the study, 10 cases in the reduced-port and 38 in the conventional four-port group. Postoperative NRS revealed no significant difference between the reduced-port and conventional four-port groups [postoperative day (POD) 1: 4.5 vs. 3, p = 0.047, POD 3: 4 vs. 3, p = 0.178]. After propensity score matching, there were no significant differences in the median number of harvested lymph nodes, operation time, and length of hospital stay between the groups. The postoperative 30-day complications were more frequent in the conventional four-port group, but there was no significant difference compared with the reduced-port group after propensity score matching. CONCLUSIONS: Reduced-port robotic gastrectomy with D2 lymph node dissection might be comparable to the conventional four-port robotic operation in terms of postoperative pain, surgical quality, and short-term outcomes. However, further studies are required to confirm our results and clarify the advantages of the robotic reduced-port approach.

Inferior Vena Cava Volume Is an Independent Predictor of Massive Transfusion in Patients With Trauma.

OBJECTIVES: Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality. METHODS: We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality. RESULTS: Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66). CONCLUSIONS: The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED.

Transoral robotic thyroidectomy versus transoral endoscopic thyroidectomy: a propensity-score-matched analysis of surgical outcomes.

BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been shown to be safe and has similar outcomes as open thyroidectomy for selected patients. It is not clear if transoral robotic thyroidectomy (TORT) may extend transoral endoscopic thyroidectomy to more complex thyroid operations. The study aimed to compare the safety and outcomes of TORT with those of TOETVA. METHODS: We retrospectively reviewed all patients who had TORT and TOETVA performed by a single surgeon from June 2017 to May 2019. Intrathoracic goiter and combined operations were excluded. Surgical outcomes were compared after propensity score matching. Learning curves, as measured by operating time, were evaluated. RESULTS: A total of 150 patients underwent 154 transoral (55 TORT and 99 TOETVA) thyroidectomy. Of the 154 operations, 28 (18.2%) were bilateral total thyroidectomy and 126 (81.8%) were unilateral thyroid lobectomy. After propensity score matching, we found a longer operative time (median [interquartile range]) for TORT (n = 53) than for the TOETVA (308 [284-388] vs 228 [201-267] min, P < 0.001). Blood loss and visual analog scale scores for pain were not significantly different between the two groups. Central neck lymph node dissection was performed more frequent in the TORT group (28 of 53 [52.8%] vs 10 of 53 [18.9%], P = 0.001), and when performed, the numbers of total and positive lymph nodes did not differ significantly between the two groups. The rates of hypoparathyroidism and recurrent laryngeal nerve injury did not differ significantly between the two groups. There was no conversion to open thyroidectomy, mental nerve injury, or surgical site infection. The learning curve for TORT was 25 cases, but no obvious learning curve was observed for TOETVA. CONCLUSIONS: TORT requires a longer operative time, but is as safe as TOETVA and may be useful for more complex thyroid operations.

Predictive Analytics for Care and Management of Patients With Acute Diseases: Deep Learning-Based Method to Predict Crucial Complication Phenotypes.

BACKGROUND: Acute diseases present severe complications that develop rapidly, exhibit distinct phenotypes, and have profound effects on patient outcomes. Predictive analytics can enhance physicians' care and management of patients with acute diseases by predicting crucial complication phenotypes for a timely diagnosis and treatment. However, effective phenotype predictions require several challenges to be overcome. First, patient data collected in the early stages of an acute disease (eg, clinical data and laboratory results) are less informative for predicting phenotypic outcomes. Second, patient data are temporal and heterogeneous; for example, patients receive laboratory tests at different time intervals and frequencies. Third, imbalanced distributions of patient outcomes create additional complexity for predicting complication phenotypes. OBJECTIVE: To predict crucial complication phenotypes among patients with acute diseases, we propose a novel, deep learning-based method that uses recurrent neural network-based sequence embedding to represent disease progression while considering temporal heterogeneities in patient data. Our method incorporates a latent regulator to alleviate data insufficiency constraints by accounting for the underlying mechanisms that are not observed in patient data. The proposed method also includes cost-sensitive learning to address imbalanced outcome distributions in patient data for improved predictions. METHODS: From a major health care organization in Taiwan, we obtained a sample of 10,354 electronic health records that pertained to 6545 patients with peritonitis. The proposed method projects these temporal, heterogeneous, and clinical data into a substantially reduced feature space and then incorporates a latent regulator (latent parameter matrix) to obviate data insufficiencies and account for variations in phenotypic expressions. Moreover, our method employs cost-sensitive learning to further increase the predictive performance. RESULTS: We evaluated the efficacy of the proposed method for predicting two hepatic complication phenotypes in patients with peritonitis: acute hepatic encephalopathy and hepatorenal syndrome. The following three benchmark techniques were evaluated: temporal multiple measurement case-based reasoning (MMCBR), temporal short long-term memory (T-SLTM) networks, and time fusion convolutional neural network (CNN). For acute hepatic encephalopathy predictions, our method attained an area under the curve (AUC) value of 0.82, which outperforms temporal MMCBR by 64%, T-SLTM by 26%, and time fusion CNN by 26%. For hepatorenal syndrome predictions, our method achieved an AUC value of 0.64, which is 29% better than that of temporal MMCBR (0.54). Overall, the evaluation results show that the proposed method significantly outperforms all the benchmarks, as measured by recall, F-measure, and AUC while maintaining comparable precision values. CONCLUSIONS: The proposed method learns a short-term temporal representation from patient data to predict complication phenotypes and offers greater predictive utilities than prevalent data-driven techniques. This method is generalizable and can be applied to different acute disease (illness) scenarios that are characterized by insufficient patient clinical data availability, temporal heterogeneities, and imbalanced distributions of important patient outcomes.

Use of Long Short-Term Memory for Remaining Useful Life and Degradation Assessment Prediction of Dental Air Turbine Handpiece in Milling Process.

The complexity of the internal components of dental air turbine handpieces has been increasing over time. To make operations reliable and ensure patients' safety, this study established long short-term memory (LSTM) prediction models with the functions of learning, storing, and transmitting memory for monitoring the health and degradation of dental air turbine handpieces. A handpiece was used to cut a glass porcelain block back and forth. An accelerometer was used to obtain vibration signals during the free running of the handpiece to identify the characteristic frequency of these vibrations in the frequency domain. This information was used to establish a health index (HI) for developing prediction models. The many-to-one and many-to-many LSTM frameworks were used for machine learning to establish prediction models for the HI and degradation trajectory. The results indicate that, in terms of HI predicted for the testing dataset, the mean square error of the many-to-one LSTM framework was lower than that that of a logistic regression model, which did not have a memory framework. Nevertheless, high accuracies were achieved with both of the two aforementioned approaches. In general, the degradation trajectory prediction model could accurately predict the degradation trend of the dental handpiece; thus, this model can be a useful tool for predicting the degradation trajectory of real dental handpieces in the future.

miR-122-mediated translational repression of PEG10 and its suppression in human hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC), a primary liver malignancy, is the most common cancer in males and fourth common cancer in females in Taiwan. HCC patients usually have a poor prognosis due to late diagnosis. It has been classified as a complex disease because of the heterogeneous phenotypic and genetic traits of the patients and a wide range of risk factors. Micro (mi)RNAs regulate oncogenes and tumor suppressor genes that are known to be dysregulated in HCC. Several studies have found an association between downregulation of miR-122, a liver-specific miRNA, and upregulation of paternally expressed gene 10 (PEG10) in HCC; however, the correlation between low miR-122 and high PEG10 levels still remains to be defined and require more investigations to evaluate their performance as an effective prognostic biomarker for HCC. METHODS: An in silico approach was used to isolate PEG10, a potential miR-122 target implicated in HCC development. miR-122S binding sites in the PEG10 promoter were evaluated with a reporter assay. The regulation of PEG10 by miR-122S overexpression was examined by quantitative RT-PCR, western blotting, and immunohistochemistry in miR-122 knockout mice and liver tissue from HCC patients. The relationship between PEG10 expression and clinicopathologic features of HCC patients was also evaluated. RESULTS: miR-122 downregulated the expression of PEG10 protein through binding to 3'-untranslated region (UTR) of the PEG10 transcript. In miR-122 knockout mice and HCC patients, the deficiency of miR-122 was associated with HCC progression. The expression of PEG10 was increased in 57.3 % of HCC as compared to paired non-cancerous tissue samples. However, significant upregulation was detected in 56.5 % of patients and was correlated with Okuda stage (P = 0.05) and histological grade (P = 0.001). CONCLUSIONS: miR-122 suppresses PEG10 expression via direct binding to the 3'-UTR of the PEG10 transcript. Therefore, while PEG10 could not be an ideal diagnostic biomarker for HCC but its upregulation in HCC tissue still has predictive value for HCC prognosis.

Psychiatric diagnoses, emotional-behavioral symptoms and functional outcomes in adolescents born preterm with very low birth weights.

Children born preterm with very low birth weight (VLBW; birth weight ≤1,500 g) run risks of neurodevelopmental disorders. Studies of adolescent outcome are relatively few. In this follow-up survey, we examined the emotional-behavioral symptoms, psychiatric diagnoses and functional status in a geographically-based birth cohort of VLBW adolescents (average 13.4 years) as registered in a level III center of a recently developed Asian country. Psychiatric interviews were conducted. Parents were asked to fill out the Child Behavioral Checklist and the Current Status Survey. Results revealed that neonatal survival rate was 75.7% (112/148). In the follow-up, 26.2% of the adolescents required individualized educational plan; 52.5% were with at least one neuropsychiatric diagnosis (e.g. cerebral palsy 24.6%, intellectual disabilities 21.3%, attention deficit/hyperactivity disorder 19.7%), and 32.8% of the participants were disabled. Logistic regression found that neonatal sepsis and grade III/IV intraventricular hemorrhage were most predictive of a disabled status in adolescence.

Comparison of Surgical Outcomes of Transoral Versus Open Thyroidectomy for Graves Disease.

INTRODUCTION: The transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a safe alternative to thyroidectomy for thyroid goiter and provides the benefit of being scarless. However, the data on the use of TOETVA in patients with Graves disease are limited. This retrospective study compared the outcomes of Graves disease patients who underwent TOETVA versus those who underwent open thyroidectomy (OT). MATERIALS AND METHODS: Patients with Graves disease who received TOETVA or OT for bilateral total thyroidectomy between September 2017 and October 2022 were included. Patient demographics and surgical outcomes, including operation time, blood loss, length of stay, and complications, were compared. RESULTS: There were 15 patients in each group. The mean age in the TOETVA group was 35.80±8.13 years, which was significantly younger than that in the OT group, which was 51.53±14.22 years. Females predominated in both groups. The other demographic characteristics were similar in both groups. The operation time and intraoperative blood loss were also comparable. The postoperative stay and complications, including hypoparathyroidism, recurrent laryngeal nerve injury, surgical site infection, postoperative hemorrhage, and recurrence of hyperthyroidism, were not different between the 2 groups. There were 11 patients in the TOETVA group and 10 in the OT group who had thyroglobulin levels <0.1 ng/dL, indicating the completeness of total thyroidectomy in the 2 groups. There was no conversion of TOETVA to an open procedure. CONCLUSIONS: For carefully selected Graves patients, TOETVA offers a safe, scarless, and feasible alternative to conventional open thyroidectomy.

Application and advantages of a joystick-controlled robotic scope holder in transoral endoscopic thyroidectomy vestibular approach: a comparative study.

Transoral endoscopic thyroidectomy has gained popularity due to its scarless nature, but the use of a handheld endoscope can lead to an unstable visual field. Soloassist II, a robotic scope holder, enables precise control using a joystick, ensuring stable vision. This study aims to evaluate the application and the advantages of Soloassist II in transoral thyroidectomy. Patients who underwent transoral thyroidectomy with Soloassist II or human assistance between June 2019 and May 2021 were reviewed. Patient demographics and surgical outcomes were compared. The ergonomic stress of the assistant in both groups was also measured. A total of 100 consecutive patients were included: 32 were assisted by Soloassist II and 68 by humans. The Soloassist II group demonstrated significantly shorter operation times (median [IQR]) (165 [149,179] vs. 181 [165,204] min, P = 0.004) in unilateral lobectomy and less blood loss (median [IQR]) (2 [2,2] vs. 2 [2,3] ml, P = 0.002) than the human-assisted group. Postoperative course and complication rates were similar. The musculoskeletal pain of the assistant was significantly higher and involved more areas in the human-assisted group. The utilization of Soloassist II in transoral endoscopic thyroidectomy is easy to set up and leads to shorter operation times, reduced blood loss, and decreased musculoskeletal pain compared to human handheld endoscope. These findings support the potential of Soloassist II in improving surgical outcomes and minimizing physical strain during transoral thyroidectomy.

Hypoxia-induced long non-coding RNA HIF1A­AS2 regulates stability of MHC class I protein in head and neck cancer.

Intratumoral hypoxia not only promotes angiogenesis and invasiveness of cancer cells, but also creates an immunosuppressive microenvironment that facilitates tumor progression. However, the mechanisms by which hypoxic tumor cells disseminate immunosuppressive signals remain unclear. In this study, we demonstrate that a hypoxia-induced long non-coding RNA (lncRNA) HIF1A Antisense RNA 2 (HIF1A-AS2) is upregulated in both hypoxic tumor cells and hypoxic tumor-derived exosomes (TEXs) in head and neck squamous cell carcinoma (HNSCC). Hypoxia-inducible factor 1 alpha 1 (HIF-1α) was found to directly bind to the regulatory region of HIF1A-AS2 to enhance its expression. HIF1A-AS2 reduced the protein stability of major histocompatibility complex class I (MHC-I) by promoting the interaction between the autophagy cargo receptor Neighbor of BRCA1 gene 1 protein (NBR1) and MHC-I, thereby increasing the autophagic degradation of MHC-I. In HNSCC samples, the expression of HIF1A-AS2 was found to correlate with hypoxic signatures and advanced clinical stages. Patients with high HIF-1α and low HLA-ABC expression showed reduced infiltration of CD8+ T cells. These findings define a mechanism of hypoxia-mediated immune evasion in HNSCC through downregulation of antigen-presenting machinery via intracellular or externalized hypoxia-induced lncRNA.

Removal and concurrent reduction of Cr(VI) by thermoacidophilic Cyanidiales: a novel extreme biomaterial enlightened for acidic and neutral conditions.

Thermoacidophilic Cyanidiales maintain a competitive edge in inhabiting extreme environments enriched with metals. Here, species of Cyanidioschyzon merolae (Cm), Cyanidium caldarium (Cc), and Galdieria partita (Gp) were exploited to remove hexavalent chromium [Cr(VI)]. Cm and Gp could remove 168.1 and 93.7 mg g-1 of Cr(VI) at pH 2.0 and 7.0, respectively, wherein 89% and 62% of sorbed Cr on Cm and Gp occurred as trivalent chromium [Cr(III)]. Apart from surface-sorbed Cr(VI), the in vitro Cr(III) bound with polysaccharide and in vivo chromium(III) hydroxide [Cr(OH)3] attested to the reduction capability of Cyanidiales. The distribution of Cr species varied as a function of sorbed Cr amount, yet a relatively consistent proportion of Cr(OH)3, irrespective of Cr sorption capacity, was found only on Cm and Cc at pH 2.0. In conjunction with TXM (transmission X-ray microscopy) images that showed less impaired cell integrity and possible intracellular Cr distribution on Cm and Cc at pH 2.0, the in vivo Cr(OH)3 might be the key to promoting the Cr sorption capacity (≥ 152 mg g-1). Cyanidiales are promising candidates for the green and sustainable remediation of Cr(VI) due to their great removal capacity, the spontaneous reduction under oxic conditions, and in vivo accumulation.

Unique Growth Pathway in Solution-Solid-Solid Nanowires: Cubic to Hexagonal Phase Transformation.

Solution-solid-solid (SSS) nanowires can be catalyzed by superionic Ag2S via ion diffusion. Here, we synthesize ZnS nanowires of the wurtzite crystal structure and heterostructures via a low-temperature growth pathway. Single-crystalline ZnS nanowires were produced by varying reaction time and temperature (120-200 °C) via thermal decomposition of a single-source precursor, Zn(DDTC)2. A phase transformation (zinc blende → wurtzite) was observed during the synthesis with a three-step growth pathway proposed. Temperature-controlled phase transformation facilitates oriented attachment into a 1D nanowire, followed by helical epitaxial and lateral growths during ripening. Additionally, the CdS-ZnS heterostructured nanowires can be obtained after introducing the Cd(DDTC)2 precursor. ZnS nanowires of defined diameters (5-10 nm) are served as backbones to grow heterostructures of ternary semiconductors with multicolor photoluminescence (450-800 nm). Structural and optical characterizations (PL, 2D PLE, and TCSPC) are investigated to confirm origins of broadband emission from multiple lifetimes (0.5-12 ns) for exciton recombination in heterostructures. Our study demonstrates this unique growth pathway for SSS nanowire synthesis under mild, facile, and atmospheric conditions.

International Multi-institutional Experience with the Transoral Endoscopic Thyroidectomy Vestibular Approach.

Background: Surgical approaches to thyroidectomies have undergone a rapid evolution over the past three decades. Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is currently the latest remote access procedure for the treatment of benign and malignant thyroid disease. The purpose of this article is to present the results of TOETVA from five different international institutions. Materials and Methods: From 2016 to 2019, 152 TOETVA procedures were performed on 149 patients at five separate international institutions. Outcomes were analyzed from a prospectively maintained database. There were 12 (8%) men and 137 (92%) women with mean ages of 41.5 ± 10.3 (27-69) and 46.9 ± 1.8 (17-78), respectively. Results: There were 3 (2%) cases that required conversion from the endoscopic approach to an open procedure. A thyroid lobectomy was performed in 111 (73.0%) cases, total thyroidectomy in 38 (25.0%) cases whereas a completion thyroidectomy in 3 (2.0%) cases. Mean operative times were 161.8 ± 42.4 (83-304) minutes for the lobectomy, 213.4 ± 71.7 (120-430) minutes for the total thyroidectomy, and 136.7 ± 109.8 (64-263) minutes for the completion thyroidectomy. The final pathology report revealed 107 (70.4%) benign nodules, 44 (28.9%) nodules with underlying papillary thyroid carcinoma, and 1 (0.7%) case with Hurthle cell carcinoma. Of the 152 cases, 7 (4.7%) patients developed temporary hypoparathyroidism. There were 5 (3.3%) patients who developed transient recurrent laryngeal nerve (RLN) injury and 3 (2.0%) with persistent injury of the RLN. Temporary lower lip numbness was noted in 51 (33.6%) patients whereas 1 (0.7%) patient was noted to have persistent numbness. We reported 57 (38.5%) patients with temporary chin numbness, 9 (5.9%) patients with skin injuries, and 2 (1.3%) with tracheal perforation. Conclusion: To date, the literature and the outcomes from these 5 international institutions have determined that, in select patients, TOETVA can be as safe and efficacious as the traditional trans-cervical technique for the treatment of specific thyroid pathologies.

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO2 insufflation: Preclinical feasibility study.

BACKGROUND: Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision. METHODS: In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers. RESULTS: A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands. CONCLUSION: In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.

Impact of comorbidities on the prognoses of trauma patients: Analysis of a hospital-based trauma registry database.

Here we conducted a retrospective analysis of hospital-based trauma registry database for evaluating the impacts of comorbidities on the prognosis for traumatized patients using Index of Coexistent Comorbidity Disease (ICED) scores. We analyzed the data of patients with blunt trauma who visited emergency department between January 1, 2011, and December 31, 2015 in Chang-Gung Memorial Hospital, Keelung branch, a single level I trauma center in the Northern Taiwan. All consecutive patients with blunt trauma who admitted to the intensive care unit or ordinary ward after initial managements in the emergency department were included. We measured the hospital mortality of blunt traumatized patients using alive discharge as a competing risk. To investigate conditional independence of mortality and ICED scores given Injury Severity Score (ISS), we used log-linear models for modeling independence structures. Overall, we included 4997 patients (median age [IQR], 59 years old (44-75 years); 55.3% male). The mortality rate of blunt traumatized patients was higher in the higher ICED scores group compared to lower ICED scores group (4.7% vs 1.8%, p < 0.001). Meanwhile, the higher ICED scores group were associated with older age, higher ISS, and longer hospital stay than lower ICED scores group. Higher ICED group had higher probability of transition-to-death and lower probability of transition-to-discharge under the competing risk model. In the multivariable analysis of transition-specific Cox models, higher ICED group were associated with higher risk for hospital mortality compared to lower ICED group (HR 1.60; [95% CI 1.04-2.47]; p = 0.032). Also, higher ICED group were associated with lower probability of transition-to-discharge (HR 0.79; [95%CI 0.73-0.86]; p < 0.001). Additionally, higher ICED scores accounted for hospital mortality among patients with ISS < 25. In conclusion, our study suggested that severity of comorbidity was associated with higher hospital mortality among traumatized patients, particularly lower ISS.

The number of displaced rib fractures is more predictive for complications in chest trauma patients.

BACKGROUND: Traumatic rib fractures can cause chest complications that need further treatment and hospitalization. We hypothesized that an increase in the number of displaced rib fractures will be accompanied by an increase in chest complications. METHODS: We retrospectively reviewed the trauma registry between January 2013 and May 2015 in a teaching hospital in northeastern Taiwan. Patients admitted with chest trauma and rib fractures without concomitant severe brain, splenic, pelvic or liver injuries were included. The demographic data, such as gender, age, the index of coexistence disease, alcohol consumption, trauma mechanisms were analyzed as potential predictors of pulmonary complications. Pulmonary complications were defined as pneumothorax, hemothorax, flail chest, pulmonary contusion, and pneumonia. RESULTS: In the 29 months of the study period, a total of 3151 trauma patients were admitted to our hospital. Among them, 174 patients were enrolled for final analysis. The most common trauma mechanism was road traffic accidents (58.6%), mainly motorbike accidents (n = 70, 40.2%). Three or more displaced rib fractures had higher specificity for predicting complications, compared to three or more total rib fractures (95.5% vs 59.1%). Adjusting the severity of chest trauma using TTSS and Ribscore by multivariable logistic regression analysis, we found that three or more rib fractures or any displaced rib fracture was the most significant predictor for developing pulmonary complication (aOR: 5.49 95% CI: 1.82-16.55). Furthermore, there were 18/57 (31.6%) patients with fewer than three ribs fractures developed pulmonary complications. In these 18 patients, only five patients had delayed onset complications and four of them had at least one displaced rib fracture. DISCUSSION: In this retrospective cohort study, we found that the number of displaced or total rib fractures, bilateral rib fractures, and rib fractures in more than two areas were associated with the more chest complications. Furthermore, three or more rib fracture or any displacement were found to be the most sensitive risk factor for chest complications, independent of other risk factors or severity index. CONCLUSION: The number of displaced rib fractures could be a strong predictor for developing pulmonary complications. For patients with fewer than three rib fractures without rib displacement and initial lung or other organ injuries, outpatient management could be safe and efficient.

Envenoming by Viridovipera stejnegeri snake: a patient with liver cirrhosis presenting disruption of hemostatic balance.

BACKGROUND: In most cases of envenoming by the green habu Viridovipera stejnegeri in Taiwan coagulopathy is not observed. CASE PRESENTATION: Herein, we describe the case of a patient with liver cirrhosis who developed venom-induced consumptive coagulopathy after V. stejnegeri bite. Laboratory investigation revealed the following: prothrombin time > 100 s (international normalized ratio > 10), activated partial thromboplastin time > 100 s, fibrinogen < 50 mg/dL, and fibrin degradation product > 80 µg/mL. The patient recovered after administration of bivalent hemorrhagic antivenom, vitamin K, fresh frozen plasma and cryoprecipitate. CONCLUSION: The liver, directly involved in the acute phase reaction, is the main responsible for neutralization of animal toxins. Any patient with history of liver cirrhosis bitten by a venomous snake, even those whose venoms present low risk of coagulopathy, should be very carefully monitored for venom-induced consumptive coagulopathy (VICC), since the hemostatic balance may be disrupted.

Contact heat evoked potentials in normal subjects.

Laser-evoked potentials are widely used to investigate nociceptive pathways. The newly developed contact heat stimulator for evoking brain response has the advantages of obtaining reliable scalp potentials and absence of cutaneous lesions. This study aimed to identify the most appropriate stimulation site with consistent cortical responses, and to correlate several parameters of the contact heat evoked potentials (CHEPs) with age, gender, and body height in normal subjects. CHEPs were recorded at Cz with a contact heat stimulator (Medoc, Israel) in 35 normal controls. The subjects were asked to keep eyes open and remain alert. The baseline temperature was 32 degrees C, and stimulation peak heat intensity of 51 degrees C was applied to five body sites: bilateral forearm, right dorsum hand, right peroneal area, and right dorsum foot. Reproducible CHEPs were recorded more frequently when stimulated at volar forearm (62.5%) than at the lower limbs (around 40%). The first negative peak latency (N1) was 370.1 +/- 20.3 ms, first positive peak latency (P1) was 502.4 +/- 33.0 ms, and peak to peak amplitude was 10.2 +/- 4.9 microV with stimulation of the forearm. Perceived pain intensity was not correlated with the presence or amplitude of CHEPs. No gender or inter-side differences were observed for N1 latency and N1-P1 amplitude. Also, no correlation was noted between N1 and age or body height. These results support future clinical access of CHEPs as a diagnostic tool.