Genetic complexity of killer-cell immunoglobulin-like receptor genes in human pangenome assemblies.

The killer-cell immunoglobulin-like receptor (KIR) gene complex, a highly polymorphic region of the human genome that encodes proteins involved in immune responses, poses strong challenges in genotyping owing to its remarkable genetic diversity and structural intricacy. Accurate analysis of KIR alleles, including their structural variations, is crucial for understanding their roles in various immune responses. Leveraging the high-quality genome assemblies from the Human Pangenome Reference Consortium (HPRC), we present a novel bioinformatic tool, the structural KIR annoTator (SKIRT), to investigate gene diversity and facilitate precise KIR allele analysis. In 47 HPRC-phased assemblies, SKIRT identifies a recurrent novel KIR2DS4/3DL1 fusion gene in the paternal haplotype of HG02630 and maternal haplotype of NA19240. Additionally, SKIRT accurately identifies eight structural variants and 15 novel nonsynonymous alleles, all of which are independently validated using short-read data or quantitative polymerase chain reaction. Our study has discovered a total of 570 novel alleles, among which eight haplotypes harbor at least one KIR gene duplication, six haplotypes have lost at least one framework gene, and 75 out of 94 haplotypes (79.8%) carry at least five novel alleles, thus confirming KIR genetic diversity. These findings are pivotal in providing insights into KIR gene diversity and serve as a solid foundation for understanding the functional consequences of KIR structural variations. High-resolution genome assemblies offer unprecedented opportunities to explore polymorphic regions that are challenging to investigate using short-read sequencing methods. The SKIRT pipeline emerges as a highly efficient tool, enabling the comprehensive detection of the complete spectrum of KIR alleles within human genome assemblies.

Periodontal disease and risk of mortality and kidney function decline in advanced chronic kidney disease: a nationwide population-based cohort study.

OBJECTIVES: Periodontal disease is prevalent in patients with chronic kidney disease (CKD) and potentially associated with kidney function decline. However, it is uncertain whether periodontal disease affects the risk of mortality and morbidity in patients with advanced CKD. MATERIALS AND METHODS: Taiwan's National Health Insurance Research Database was used to conduct a nationwide population-based cohort study. Propensity score matching procedures were performed to select people with stage 5 CKD and to compare the long-term risk of mortality, end-stage renal disease, and major adverse cardiovascular events (MACE) between people with and without periodontal disease. Multivariable Cox regression analyses were conducted to calculate the adjusted hazard ratio (aHR) with 95% confidence interval (CI) for the outcome of interest. RESULTS: A total of 8119 subjects with stage 5 CKD were initially included. After matching to demographic and clinical covariates, 1254 subjects with 7099 person-years of follow-up were selected for analyses. Periodontal disease was not associated with long-term risks of all-cause mortality (aHR: 0.77, 95% CI: 0.49-1.22), progression to end-stage renal disease (aHR: 0.91, 95% CI: 0.75-1.10), or MACE (aHR: 1.18, 95% CI: 0.91-1.53). These findings were generally consistent across subgroups of age, sex, comorbid diabetes, uses of systemic antibiotic, and different dental procedures. CONCLUSIONS: Periodontal disease is not a predictor for long-term mortality or morbidity in patients with advanced CKD. CLINICAL RELEVANCE: These results provide important evidence to elucidate the relationship between periodontitis and critical clinical outcomes of advanced CKD.

Effect of Influenza Vaccination Against Postoperative Pneumonia and Mortality for Geriatric Patients Receiving Major Surgery: A Nationwide Matched Study.

Background: Limited information is available on the association between influenza vaccination and postoperative outcomes. Methods: Using Taiwan's National Health Insurance Research Database reimbursement claims data from 2008-2013, we conducted a matched cohort study of 16903 patients aged >66 years who received influenza vaccinations and later underwent major surgery. Using a propensity score matching procedure adjusted for sociodemographic characteristics, medical condition, surgery type, and anesthesia type, 16903 controls who underwent surgery but were not vaccinated were selected. Logistic regressions were used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative pneumonia and in-hospital mortality associated with influenza vaccination. Results: Patients who received preoperative influenza vaccination had a lower risk of postoperative pneumonia (OR, 0.60; 95% CI, .56-.64) and in-hospital mortality (OR, 0.46; 95% CI, .39-.56), compared with unvaccinated patients, in both sexes and every age group. Vaccinated patients who underwent surgery also had a decreased risk of postoperative intensive care unit admission (OR, 0.56; 95% CI, .53-.60), shorter hospital stays (P < .0001), and lower medical expenditures (P < .0001) than nonvaccinated controls. Conclusions: Vaccinated geriatric patients who underwent surgery had lower risks of pneumonia and in-hospital mortality, compared with unvaccinated patients who underwent similar major surgeries. Further studies are needed to explain how preoperative influenza vaccination improves perioperative outcomes.

A predictive model incorporating inflammation markers for high-grade surgical complications following liver resection for hepatocellular carcinoma.

BACKGROUND: Systemic inflammation and immune deficiency predispose surgical patients to infection and adversely affect postoperative recovery. We aimed to evaluate the prognostic ability of inflammation and immune-nutritional markers and to develop a predictive model for high-grade complications after resection of hepatocellular carcinoma (HCC). METHODS: This study enrolled 1431 patients undergoing liver resection for primary HCC at a medical center. Preoperative neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, prognostic nutritional index, Model for End-Stage Liver Disease score, Albumin-Bilirubin score, Fibrosis-4 score, and Aspartate Aminotransferase to Platelet Ratio Index score were assessed. Stepwise backward variable elimination was conducted to determine the factors associated with Clavien-Dindo grade III to V complications within 30-day postoperative period. The predictive model was internally validated for discrimination performance using area under the receiver operating characteristic curve (AUC). RESULTS: A total of 106 (7.4%) patients developed high-grade complications. Four factors independently predicted a high-grade postoperative complication and were integrated into the predictive model, including NLR (adjusted odds ratio: 1.10, 95% confidence interval [CI], 1.02-1.19), diabetes mellitus, extent of hepatectomy, and intraoperative blood loss. The AUC of the model was 0.755 (95% CI, 0.678-0.832) in the validation dataset. Using the cutoff value based on Youden's index, the sensitivity and specificity of the risk score were 59.0% and 76.3%, respectively. CONCLUSION: Preoperative NLR independently predicted a high-grade complication after resection of HCC. The predictive model allows for identification of high-risk patients and appropriate modifications of perioperative care to improve postoperative outcomes.

Overview of education system for oral hygienists in Taiwan.

Background/purpose: Currently, Taiwan has a very complete education system of oral hygiene, but there is still no licensing system for oral hygienists. This study explored mainly the profile of education system for oral hygienists in Taiwan from 2017 to 2021. Materials and methods: This study used the documentary analysis and secondary data analysis to survey mainly the development of oral hygiene education system in Taiwan, and the changes of oral hygiene students and graduates from 2017 to 2021. Results: In Taiwan, currently, there are 8 oral hygiene schools which offer associate, bachelor, and master degrees in oral hygiene. The oral hygiene enrollment quotas determined by the Ministry of Education increased from 343 quotas in 9 programs in 2017 to 500 quotas in 13 programs in 2021, while new oral hygiene students who completed registration increased from 282 students in 2017 to 353 students in 2021. The registration rate of the five-year training program of junior college was significantly higher than the other programs. The number of oral hygiene students with official student status increased from 604 students in 2017 to 1349 students in 2021. The total increase was 745 students from 2017 to 2021 with a total increase rate of 123.34%. Conclusion: In Taiwan, although the manpower of oral hygienists is important for public oral health, they usually work as dental assistants or change their careers. It is imperative to continue to promote the certification system for oral hygienists to improve the professionalism of this occupation.

A comparison of high-flow nasal cannula and standard facemask as pre-oxygenation technique for general anesthesia: A PRISMA-compliant systemic review and meta-analysis.

BACKGROUND: Current practice guidelines recommend the use of nasal cannula as an alternative pre-oxygenation method for tracheal intubation. However, the efficacy of high-flow nasal oxygenation versus standard facemask oxygenation has not been fully evaluated. METHODS: We searched PubMed, Cochrane Library, and ClinicalTrials.gov for English-language studies published from January 1, 2000 to November 30, 2021. We included randomized controlled trials which compared high-flow nasal oxygenation and facemask oxygenation as the pre-oxygenation maneuver. Primary outcome was arterial partial pressure of oxygen (PaO2) after pre-oxygenation. Secondary outcomes were safe apnea time, arterial desaturation during intubation, lowest peripheral capillary oxygen saturation during intubation, and patient comfort score. Random-effects models and Mantel-Haenszel method were used for data synthesis. RESULTS: A total of 16 randomized controlled trials and 1148 patients were included. High-flow nasal oxygenation achieved a higher PaO2 compared with facemask, mean difference: 64.86 mm Hg (95% confidence interval [CI]: 32.33-97.40, P < .0001). Safe apnea time was longer in high-flow nasal oxygenation, mean difference: 131.03 seconds (95% CI: 59.39-202.66, P < .0001). There was no difference in the risk of peri-intubation desaturation or lowest peripheral capillary oxygen saturation between groups. Patient comfort score was higher in high-flow nasal oxygenation, mean difference: 1.00 (95% CI: 0.46-1.54, P = .0003). CONCLUSION: High-flow nasal oxygenation better enhanced PaO2 and extended safe apnea time and is not inferior to facemask oxygenation in preventing desaturation during tracheal intubation. High-flow nasal oxygenation may be considered as an alternative method, especially for patients with a potential difficult airway.

High-flow nasal oxygenation reduces the risk of desaturation in adults receiving procedural sedation: a meta-analysis of randomized controlled trials.

BACKGROUND: Procedural sedation reduces patients' discomfort and anxiety, facilitating performance of the examination and intervention. However, it may also cause adverse events, including airway obstruction and hypoxia. We conducted this systematic review and meta-analysis to evaluate the efficacy of high-flow nasal oxygenation (HFNO) compared with that of standard oxygen therapy in adult patients undergoing procedural sedation. METHODS: We identified randomized controlled trials published before November 2020 based on PubMed, Embase, and Cochrane Library databases and ClinicalTrials.gov registry. Intraprocedural desaturation [peripheral oxygen saturation (SpO2) < 90%] was evaluated as the primary outcome. The secondary outcomes were the lowest SpO2, need for airway intervention, oxygen therapy-related complications, and patient, operator, and anesthetist's satisfaction. RESULTS: Six trials with a total of 2633 patients were reviewed. Patients using HFNO compared with standard oxygen therapy had a significantly lower risk of intraprocedural desaturation [risk ratio 0.18, 95% confidence interval (CI) 0.04-0.87]. The lowest intraprocedural SpO2 in HFNO group was significantly higher than that in standard oxygen therapy group (mean difference 4.19%, 95% CI 1.74-6.65). CONCLUSIONS: Compared with standard oxygen therapy, HFNO may reduce the risk of desaturation and increase the lowest SpO2 in adult patients undergoing sedation for medical procedures.

Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study.

Migraine headaches can be provoked by surgical stress and vasoactive effects of anesthetics of general anesthesia in the perioperative period. However, it is unclear whether general anesthesia increases the migraine risk after major surgery. Incidence and risk factors of postoperative migraine are also largely unknown. We utilized reimbursement claims data of Taiwan's National Health Insurance and performed propensity score matching analyses to compare the risk of postoperative migraine in patients without migraine initially who underwent general or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for migraine risk. A total of 68,131 matched pairs were analyzed. The overall incidence of migraine was 9.82 per 1000 person-years. General anesthesia was not associated with a greater risk of migraine compared with neuraxial anesthesia (aORs: 0.93, 95% CI: 0.80-1.09). This finding was consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Influential factors for postoperative migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43) or depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery. There was no difference in the risk of postoperative migraine between surgical patients undergoing general and neuraxial anesthesia. This study identified the risk factors for postoperative migraine headaches, which may provide an implication in facilitating early diagnoses and treatment.

Association between Dental Scaling and Reduced Risk of End-Stage Renal Disease: A Nationwide Matched Cohort Study.

Periodontitis is prevalent in patients with chronic kidney disease (CKD) and is also associated with kidney function decline. It is unclear whether dental scaling treatment prevents the progression of CKD. In a nationwide cohort study, Taiwan's National Health Insurance Research Database was used to select people with CKD. Propensity score-matching procedures were performed to compare the long-term risk of end-stage renal disease (ESRD) between CKD patients with and without the receipt of dental scaling. A total of 33,637 matched pairs with CKD were included, with 503,373 person-years of follow-up for analyses. Dental scaling was significantly associated with a lower risk of ESRD (adjusted hazard ratio (aHR): 0.83, 95% confidence interval (CI): 0.77-0.90). In addition, there was a dose-dependent relationship between the frequency of dental scaling and a reduced risk of ESRD. Dental scaling was also linked to reduced risks of major adverse cardiovascular events (aHR: 0.91, 95% CI: 0.87-0.95), sepsis (aHR: 0.81, 95% CI: 0.77-0.85), and all-cause mortality (aHR: 0.81, 95% CI: 0.76-0.87). Dental scaling was significantly associated with lower risks of progression to ESRD in patients with CKD. Regular dental scaling may serve as a prophylactic measure for kidney function decline.

Patient -controlled epidural ropivacaine as a post-Cesarean analgesia: a comparison with epidural morphine.

OBJECTIVE: Conventional, intermittent, epidural morphine is widely applied as a post-Cesarean delivery analgesia. We compared the analgesic efficacy, motor weakness, and side effects of administering a patient-controlled epidural analgesia (PCEA) of pure ropivacaine versus the intermittent administration of epidural morphine after Cesarean delivery. MATERIALS AND METHODS: This randomized, double-blind study included 120 full-term parturients who underwent elective Cesarean delivery and received either PCEA with pure ropivacaine or an intermittent bolus epidural of 2 mg/10 mL morphine in normal saline twice per day. The efficacy of pain relief, post-Cesarean side effects, motor blockades, time to first ambulation, and global satisfaction scores were evaluated. RESULTS: Pain scores were recorded at the four evaluation times (2, 12, 24, and 48 hours post-Cesarean delivery), and the time to first ambulation did not statistically differ between the two groups. Patients in the ropivacaine group experienced more motor weakness at 2 and 12 hours, fewer side effects, and higher global satisfaction scores than those in the morphine group (p < 0.05). CONCLUSION: The analgesic efficacy after cesarean delivery was almost equivalent between two groups. PCEA with pure ropivacaine induced significant motor blockade during the first 12 hours, but without delaying the time to first ambulation. Patients in the ropivacaine group reported higher patient satisfaction scores due to the significant reduction of annoying side effects, such as pruritus, nausea, vomiting, and urinary retention.

Significant hypercapnia either in CO(2)-insufflated or air-insufflated colonoscopy under deep sedation.

BACKGROUND: previous reports showed that CO(2)-insufflated colonoscopy is safe and less discomfortable. However, hypercapnia remains a vital concernment if deep sedation is necessary for difficult colonoscopy with prolonged CO(2) insufflation. This observational study is to measure bodily CO(2) subjected to colonoscopy facilitated by CO(2)- and air- or air-insufflation in conscious-sedation, deep-sedation and awake patients. OBJECTIVE: to investigate if CO(2)-insufflated colonoscopy could increase the risk of hypercapnia in awake, conscious-sedation and deep-sedation patients. METHODS: 104 patients in our health center undergoing sequential esophagogastroscopy and colonoscopy screening were included. At patients' request, incremental intravenous sedatives were given in order that the air-insufflated esophagogastroscopy could be carried out without the molestation of gag and cough reflexes. The sedation levels were re-evaluated before proceeding colonoscopy and the patients were divided into conscious-sedation (respond purposefully to verbal commands) and deep-sedation groups and randomly allocated for air or CO(2) insufflation. Transcutaneous capnography (TcCO(2)) was recorded every minute throughout the colonoscopy procedure. RESULTS: the baseline TcCO(2) in the air- (50.9 ± 5.7 mmHg) and CO(2)-insufflated (53.1 ± 6.5 mmHg) groups under deep sedation was significantly higher than the groups under conscious-sedation and the awake groups (p < 0.01). In both air- and CO(2)-insufflation groups there were also a statistically significant (p < 0.01) correlation in TcCO(2) between the start, the peak and the end of colonoscopy. TcCO(2) did not significantly change throughout the colonoscopy in awake and conscious-sedation groups, either with air or CO(2) insufflation. With deep sedation, TcCO(2) significantly increased and peaked around the time when the scope touching the cecum, and then returned to original state with suction and withdrawl of the colonoscope without significant interaction of CO(2) insufflation and deep sedation. CONCLUSION: the TcCO(2) during colonoscopy was correlated to the data before inserting colonoscope but significantly different within awake, conscious-sedation and deep-sedation groups. TcCO(2) did not change significantly either with CO(2) insufflation or air insufflations in awake and conscious-sedation groups. However, in deep-sedation groups with significantly higher baseline TcCO(2), further increase of TcCO(2) were significant without interaction with CO(2) insufflation. We concluded that when patients need deep sedation for colonoscopic procedures facilitated by gas insufflation, hypercapnia is still considerably present, not only with CO(2) insufflation but also with air insufflation colonoscopy.

Right ventricular exclusion for hepatocellular carcinoma metastatic to the heart.

We used for the first time a right ventricular exclusion procedure for the treatment of hepatocellular carcinoma metastatic to the right ventricle. Our case report shows that this surgical option can be effective as rescue therapy for right ventricular outflow tract obstruction secondary to myocardial metastasis in critically ill patients. Most notably, this technique can prevent inadvertent dislodgement of tumor cells.