Validation and modification of the AJCC 8th TNM staging system for pancreatic ductal adenocarcinoma in a Chinese cohort: A nationwide pancreas data center analysis.

OBJECTIVE: To validate the 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic ductal adenocarcinoma (PDAC) in a Chinese cohort of radically resected patients and to develop a refined staging system for PDAC. METHODS: Data were collected from the China Pancreas Data Center (CPDC) for patients with resected PDAC in 2016 and 2017, and cancer-specific survival (CSS) was evaluated using the Kaplan-Meier method and log-rank test. Univariate and multivariate analyses based on Cox regression were performed to identify prognostic factors. The recursive partitioning analysis (RPA), Kaplan-Meier method, and log-rank test were performed on the training dataset to generate a proposed modification for the 8th TNM staging system utilizing the preoperative carbohydrate antigen (CA)19-9 level. Validation was performed for both staging systems in the validation cohort. RESULTS: A total of 1,676 PDAC patients were retrieved, and the median CSS was significantly different between the 8th TNM groupings, with no significant difference in survival between stage IB and IIA. The analysis of T and N stages demonstrated a better prognostic value in the N category. Multivariate analysis showed that the preoperative serum CA19-9 level was the strongest prognostic indicator among all the independent risk factors. All patients with CA19-9 >500 U/mL had similar survival, and we proposed a new staging system by combining IB and IIA and stratifying all patients with high CA19-9 into stage III. The modified staging system had a better performance for predicting CSS than the 8th AJCC staging scheme. CONCLUSIONS: The 8th AJCC staging system for PDAC is suitable for a Chinese cohort of resected patients, and the N category has a better prognostic value than the T category. Our modified staging system has superior accuracy in predicting survival than the 8th AJCC TNM staging system.

[Risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy and its predictive score].

OBJECTIVE: To develop and test a scoring system to predict the risks of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy(PD). METHODS: Clinic data and postoperative complications of the 445 consecutive patients who underwent a PD procedure between January 2008 and April 2015 in Peking University First Hospital were retrospectively collected and analyzed.The patients were randomly selected to modelling and validation sets at a ratio of 3∶1, respectively.The patient data were subjected to univariate and multivariate analysis in the modelling set of patients.A score predictive of POPF was designed and tested in the validation set. RESULTS: POPF occurred in 88 of 334 patients(26.4%) in the modelling set.The multivariate analysis showed that body mass index (BMI, P<0.01) and pancreatic duct width(P=0.001) are associated with POPF independently.A risk score to predict POPF was constructed based on these factors and successfully tested.The area under the receiver operating characteristic curve were 0.829(95% CI: 0.777-0.881) on the modelling set and 0.885(95% CI: 0.825-0.945) on the validation set, respectively. CONCLUSIONS: BMI and pancreatic duct width were associated with POPF after PD. The preoperative assessment of a patient's risk for POPF is feasible.The present risk score is a valid tool to predict POPF in patients undergoing PD, to make the selection on anastomosis types, and to take precautions against POPF.

[The diagnosis and management strategies for gastrointestinal hemorrhage following pancreaticoduodenectomy].

OBJECTIVE: To analyze the causes and clinical features of gastrointestinal hemorrhage following pancreaticoduodenectomy (PD), and to provide the management strategies for this complication. METHODS: The clinic data of 412 patients who underwent PD from January 2000 to April 2010 was retrospectively reviewed. There were 232 male and 180 female patients, average age was (60 ± 12) years. The mode of procedure was standard PD and the Child's reconstruction of digestive tract, whose anastomosic steps encluded gastroenterostomy following chlangioenterostomy and pancreaticoenterostomy, was employed. Etiology of gastrointestinal haemorrhage, diagnostic methods and treatment strategy was recorded and analyzed. RESULTS: The postoperative mobidity was 37.1% (153/412), the rate of haemorrhagic complications was 6.6% (27/412), and gastrointestinal hemorrhage was recorded in 11 patients (2.7%). The bleeding rate of pancreaticointestinal anastomosis and gastricointestinal anastomosis were 5/11 and 4/11, respectively. Among these 11 patients, early hemorrhage occurred in 6 patients, 7 patients were due to technical failure. In order to control this kind of complication, open abdominal operation alone was performed on 4 patients, endoscopic management was performed on 3 patients and succeeded in 2 patients, vascular interventional therapy was performed on 5 patients and succeeded in 2 patients, and Re-laparotomy following vascular interventional therapy was performed on 2 patients successfully. CONCLUSIONS: Gastrointestinal hemorrhage following PD always occurred in early stage and reliable hemostasis during operation is the key points for prevention. Angiography is minimally invasive and holds the diagnostic value. Timely and decisive reoperation is an important method to management of postoperative gastrointestinal hemorrhage.

Predicting early recurrence for resected pancreatic ductal adenocarcinoma: a multicenter retrospective study in China.

A precise classification of early recurrence (ER) after radical surgery of pancreatic ductal adenocarcinoma (PDAC) has not been standardized. We aim to develop an optimal cut-off based on scientific evidence to distinguish early and late recurrence (LR) for PDAC after radical surgery and develop a predictive model for ER of PDAC. The best threshold for recurrence-free survival (RFS) was assessed with a minimum P-value method, and patients were categorized into ER and LR groups. We used a logistic regression model to assess potential risk factors for ER and develop a predictive model for ER risk. The best threshold between high-risk and intermediate-high-risk groups was identified by using the receiver operating characteristic curve. Among 3,279 patients included, 1,234 (37.6%) experienced ER. The RFS of 9 months is the optimal threshold to distinguish ER and LR. Univariable and multivariable analysis identified four preoperative risk factors for ER, including larger tumor maximal diameter on computed tomography (CT), enlarged lymph nodes on CT, carbohydrate antigen (CA) 125 > 35 U/ml, and CA19-9 > 235 U/ml. The concordance index (C-index) for the predictive model in the training cohort and the validation cohort was 0.651 (95% confidence interval (CI): 0.624-0.678), and 0.636 (95% CI: 0.593-0.679), respectively, showing promising predictive ability. The high-risk group had a score above 203, and the corresponding risk of ER for this group was 56.7%. An RFS of 9 months is the best threshold to distinguish ER and LR. The model can accurately predict the risk of ER in PDAC after radical resection, and risk grouping can predict the patients who could benefit from upfront surgery.

[Surgical complications after pancreatoduodenectomy: risk factors and treatments].

OBJECTIVE: To explore the impact factors and treatment of post pancreatoduodenectomy complications. METHODS: The clinical data of 412 cases between January 1995 and April 2010 underwent pancreatoduodenectomy were analyzed retrospectively. There were 232 male, 180 female. Univariate and multivariate logistic regression model were used to identify the risk factors related to occurrence of postoperative complications. RESULTS: The overall postoperative morbidity rate was 37.1% (153/412), and mortality rate was 4.6% (19/412). Total uncinate process resection, type of pancreatic-enteric anastomosis, duct diameter and pancreatic texture had effects on postoperative pancreatic fistula statistically. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were identified as significant risk factors for post pancreatoduodenectomy hemorrhage by means of univariate analysis. Delayed gastric empting occurrence in the patients with pylorus-preserving pancreaticoduodenectomy was higher than those with standard pancreaticoduodenectomy significantly. The multivariate Logistic regression analysis revealed that duct diameter and pancreatic texture were the independent risk factors of pancreatic fistula. Total uncinate process resection, the amount of intra-operative blood loss ≥ 600 ml and pancreatic fistula were independent risk factors of bleeding. There were no statistically significant differences between the radical group and the standard group when postoperative complication rates were analyzed (P < 0.05). CONCLUSIONS: Pancreaticojejunal anastomoses by means of duct-to-mucosa is fit for the patients with dilated pancreatic duct and end-to-end invaginated pancreaticojejunostomy is fit for the patients with undilated pancreatic duct. The prevention of postoperative bleeding depends on total uncinate process resection and meticulous hemostatic technique during operation. The pancreatic fistula is one of the most important factors which can result in postoperative bleeding. Pancreaticoduodenectomy combines with SMV/PV resection and extended lymphadenectomy do not significantly increase the morbidity rates.

Combination of CA19-9 and the Neutrophil-to-Lymphocyte Ratio for the Differential Diagnosis of Gallbladder Carcinoma.

PURPOSE: This study aimed to evaluate the efficiency of several parameters, including the neutrophil-to-lymphocyte ratio (NLR) obtained from preoperative routine blood examination, either alone or as an adjunct to the carbohydrate antigen 19-9 (CA19-9), for the diagnosis of gallbladder carcinoma (GBC). PATIENTS AND METHODS: Data from 123 patients with gallbladder cholesterol polyps (GCP), 80 with gallbladder adenoma (GA), and 103 with GBC were reviewed retrospectively. Receiver operating characteristic analysis was used to assess the sensitivity, specificity, and clinical value of the NLR, CA19-9, and their combination. RESULTS: Values of measured indicators were significantly higher in GBC patients than in GCP or GA patients but there were no significant differences between GCP and GA patients. The combination of NLR and CA19-9 had the best diagnostic efficiency for differentiating GBC from benign lesions with 74.8% sensitivity and 89.7% specificity. However, the NLR showed no significant difference between mid-to-advanced stage and early-to-mid stage GBC. The combination of NLR and CA19-9 (53.7% sensitivity and 88.9% specificity) did not reveal any advantages over CA19-9 alone (63.0% sensitivity and 89.0% specificity) in distinguishing different stages of GBC. CONCLUSION: NLR and CA19-9, and their combination-parameters that are easily obtained preoperatively-have potential as diagnostic markers for GBC.

Surgical options for control of abdominal pain in chronic pancreatitis patients.

BACKGROUND: Long lasting and unbearable abdominal pain is the most common symptom of chronic pancreatitis (CP). This study aimed to evaluate surgical options for the control of chronic pancreatic pain based on anatomical morphological changes. METHODS: A retrospective review of patients who underwent surgery for treatment of chronic pancreatic pain in Peking University First Hospital between January 2000 and December 2017 was performed. The surgical options included modified Puestow procedure, Frey procedure, Beger procedure, pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD), distal pancreatectomy and total pancreatectomy. RESULTS: Among 116 patients, pain relief rate after surgery was 82.6% (95/115) while 22 (23.2%) cases suffered recurrent chronic pancreatic pain during follow-up. Pain relief rate was 83.1% (54/65) after modified Puestow procedure, 63.6% (7/11) after distal pancreatectomy, 83.3% (10/12) after PD/PPPD, 86.7% (13/15) after Frey procedure, and 90% (9/10) after Beger procedure. Pain recurrence rate was 27.8% (15/54) after modified Puestow procedure, 42.9% (3/7) after distal pancreatectomy, 10% (1/10) after PD/PPPD, 15.4% (2/13) after Frey procedure, and 11.1% (1/9) after Beger procedure. CONCLUSION: The surgical options for the control of chronic pancreatic pain according to the anatomical morphological changes of CP is reasonable and effective. The procedure of distal pancreatectomy alone should be cautiously used for pain relief.

[The diagnosis and surgical management for patients with variants of hepatic arteries in the procedure of pancreaticoduodenectomy].

OBJECTIVE: To study the principle and surgical managements for the patients with anatomic variants of hepatic artery in the procedure of pancreaticoduodenectomy (PD). METHODS: One hundred and seventy-six patients who underwent PD between January 2000 and July 2007 were investigated retrospectively. Hepatic arterial variants were analyzed according to the intraoperative finding and CT imaging were reviewed postoperatively. RESULTS: Hepatic arterial variants were found intraoperatively in 20 cases of all 176 patients. Accessory right heptic artery, replaced right heptic artery and common heptic artery arising from the superior mesenteric artery (SMA) were present in 9 (5.1%), 5 (2.8%), 4 (2.3%) cases respectively,and replaced right heptic artery coming from the gastroduodenal artery was present in 2 cases (2.9%). All the variants of hepatic arteries arising from the superior mesenteric artery could be observed in spiral CT imaging. Most of the variant arteries were dissected intact intraoperatively except 2 cases with accessory right heptic artery arising from SMA. CONCLUSIONS: Performing CT scan preoperatively, especially CTA,is effective to diagnose these disorders. Skillful surgical techniques can manage the anatomic variants safely.

Long non-coding RNA MEG3 functions as a tumour suppressor and has prognostic predictive value in human pancreatic cancer.

Long non-coding RNA (lncRNA) MEG3 has been demonstrated to be a tumour suppressor in many malignancies. However, the functional role of MEG3 in pancreatic cancer (PC) is unclear. In this study, the expression pattern of MEG3 was evaluated in 25 samples of microdissected PC tissues and 8 PC cell lines and was compared to the expression in adjacent non­cancerous tissues and a human pancreatic normal epithelial cell line. Loss of MEG3 expression was observed in both the cancerous tissues and cancer cell lines. Although the absence of expression of MEG3 was not statistically correlated to either histological grade or TNM stage in the 25 cases, the prognosis was significantly worse. MEG3 knockdown enhanced cell proliferation, promoted cell migration and invasion, induced epithelial­mesenchymal transition (EMT), increased the sphere­forming ability and cancer stem cell (CSC) properties, and decreased the chemosensitivity to gemcitabine in vitro. In contrast, forced expression of MEG3 resulted in a reverse effect. In conclusion, MEG3 functions as a tumour suppressor in human PC. The underlying cause of the poor prognosis induced by low levels of MEG3 expression in PC patients might involve EMT induction, enhanced CSC phenotypes and reduced chemoresistance, all of which might be associated with Snail activation.

Long noncoding RNA H19 derived miR-675 regulates cell proliferation by down-regulating E2F-1 in human pancreatic ductal adenocarcinoma.

The long noncoding RNA (lncRNA) H19 has been proven to be overexpressed in human pancreatic ductal adenocarcinoma (PDAC). H19-induced PDAC cell proliferation is cell cycle-dependent by modulating E2F-1. However, the mechanism of how H19 regulates E2F-1 remains unclear. In this study, we investigated the expression of miR-675 in PDAC tumours and cells, the biological function of miR-675 in PDAC cell proliferation and the possible relationship among H19, miR-675 and E2F-1. As a transcript of the first exon of H19, the level of miR-675 was negatively correlated with H19 expression in microdissected PDAC tissues (r=-0.0646, P=0.001). The serum miR-675 expression was significantly down-regulated in patients with PDAC compared to those in healthy individuals. Moreover, an evaluation of five PDAC cases showed that there was a remarkable increase of serum miR-675 levels after resection of the primary tumours. Ectopic overexpression of miR-675 in AsPC-1 and PANC-1 cells decreased cell viability, the colony-forming ability and the percentage of cells in S phase; contrarily, miR-675 knockdown resulted in enhanced cell proliferation. Furthermore, the suppressed cell proliferation caused by H19 knockdown could be rescued by inhibiting miR-675 expression. Additionally, intratumoural injection of either miR-675 agomir or antagomir could significantly affect tumour growth in vivo. Both the bioinformatic prediction and luciferase activity assay confirmed that E2F-1 was a direct target of miR-675. And the decrease of E2F-1 protein expression caused by siH19 could be partially reversed by miR-675 knockdown. We concluded that there might be a H19/miR-675/E2F-1 regulatory loop in cell cycle modulation. Serum miR-675 might serve as a potential biomarker for not only early diagnosis but also outcome prediction in PDAC.

[Influencing factor analysis of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy].

OBJECTIVE: To investigate the influencing factors of delayed gastric emptying (DGE) after pylorus-preserving pancreaticoduodenectomy (PPPD) and its preventing managements. METHODS: Forty-two patients who underwent PPPD and 104 patients underwent standard Whipple procedure (SPD) between January 2000 and July 2006 were investigated retrospectively. The factors influencing the development of DGE following PPPD were analyzed statistically. RESULTS: There was no significant difference in mortality between PPPD and SPD (0/42 vs. 7/104, P = 0.193). Pancreatic fistula occurred much more frequently in SPD than in PPPD (29/104 vs. 1/42, P < 0.05). The occurrence of DGE after PPPD was higher significantly than that after SPD (35.7% vs. 18.3%, P = 0.024). More DGE occurred in patients with a operation time more than 6 hours than in patients whose operation lasted less than 6 hours (76.9% vs. 17.2%, P = 0.008). Meanwhile, DGE occurred in 20% of patients with the antero-colonic route for duodenojejunostomy and in 50% with retro-colonic route (P = 0.043). Multivariate analysis by logistic regression model showed postoperative intra-abdominal complications were not risk factors for DGE. Prophylactic use of somatostatin couldn't prevent DGE effectively. CONCLUSIONS: DGE is the most frequent postoperative complication after PPPD, it can be markedly reduced by shortening operative time and using antero-colonic duodenojejunostomy procedure. There is no medicine which could prevent DGE effectively.

Comparison of Uncinate Process Cancer and Non-Uncinate Process Pancreatic Head Cancer.

The special anatomical position accounts for unusual clinicopathological features of uncinate process cancer. This study aimed to compare clinicopathological features of patients with uncinate process cancer to patients with non-uncinate process pancreatic head cancer. Total 160 patients with pancreatic head cancer were enrolled and classified into two groups: uncinate process cancer and non-uncinate process pancreatic head cancer. We found that the ratio of vascular invasion was significantly higher in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In addition, the rate of R1 resection was significantly higher in patients with uncinate process cancer. Furthermore, the median disease-free survival (11 months vs. 15 months, p=0.043) and overall survival (15 months vs. 19 months, p=0.036) after R0 resection were lower for uncinate process cancer. Locoregional recurrence was more frequent (p=0.017) and earlier (12 months vs. 36 months; p=0.002) in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In conclusion, uncinate process cancer is more likely to invade blood vessel and has worse prognosis due to the earlier and more frequent locoregional recurrence.

Hedgehog Signaling Regulates Epithelial-Mesenchymal Transition in Pancreatic Cancer Stem-Like Cells.

Hedgehog (Hh) signaling is crucially involved in tumorigenesis. This study aimed to assess the role of Hh signaling in the regulation of epithelial-mesenchymal transition (EMT), stemness properties and chemoresistance of human pancreatic Panc-1 cancer stem cells (CSCs). Panc-1 cells were transfected with recombinant lentiviral vectors to silence SMO and serum-free floating-culture system was used to isolate Panc-1 tumorspheres. The expression of CSC and EMT markers was detected by flow cytometry, real-time RT-PCR and Western blot analysis. Malignant behaviors of Panc-1 CSC were evaluated by tumorigenicity assays and nude mouse lung metastasis model. We found that tumorspheres derived from pancreatic cancer cell line Panc-1 possessed self-renewal, differentiation and stemness properties. Hh pathway and EMT were active in Panc-1 tumorspheres. Inhibition of Hh signaling by SMO knockdown inhibited self-renewal, EMT, invasion, chemoresistance, pulmonary metastasis, tumorigenesis of pancreatic CSCs. In conclusion, Hh signaling contributes to the maintenance of stem-like properties and chemoresistance of pancreatic CSC and promotes the tumorigenesis and metastasis of pancreatic cancer. Hh pathway is a potential molecular target for the development of therapeutic strategies for pancreatic CSCs.

Locally advanced undifferentiated carcinoma with osteoclast-like giant cells of the pancreas.

Undifferentiated carcinoma with osteoclast-like giant cells of the pancreas (UCOGCP) is an unusual pancreatic neoplasm that represents < 1% of all pancreatic malignancies. Moreover, the giant cells of UCOGCP morphologically resemble the benign giant cells of bone tumors. Due to the rarity of this tumor type, the histogenesis and biologic behavior of UCOGCP remain controversial. Here, we report a case of UCOGCP that exhibited an invasive growth pattern involving infiltration of the adjacent bowel loop and portal vein, as well as superior mesenteric vein thrombosis. The patient underwent a distal pancreatectomy with splenectomy and partial colectomy, followed by four cycles of gemcitabine chemotherapy. No evidence of recurrence was detected after ten years. In addition to this case, clinical information on other UCOGCP cases reported in the English literature is summarized.

Surgical treatment and prognosis of 96 cases of intraductal papillary mucinous neoplasms of the pancreas: a retrospective cohort study.

INTRODUCTION: The indications, the extent and type of surgery for intraductal papillary mucinous neoplasm (IPMN) are still controversial. This study aimed to investigate clinical manifestation, individualized surgical treatment, and prognosis of IPMN of pancreas. METHODS: The clinical data of 96 IPMN cases treated in our hospital between January 2006 and December 2013 were retrospectively analyzed. Among the 96 patients (58 male and 38 female), 46 were main-duct type, 29 were branch-duct type, 21 were mixed type. Pancreatectomy was performed on 78 cases, including pancreaticoduodenectomy on 43 patients, distal pancreatectomy on 25, segmental pancreatectomy on 6, and total pancreatectomy on 4. A regular follow-up without surgical treatment was performed on 18 cases with asymptomatic side branch IPMN less than 3 cm in diameter. RESULTS: The overall postoperative morbidity rate was 33.3%, and there was no perioperative mortality. 46 cases were non-invasive IPMN, 32 cases were invasive IPMN including 14 cases with lymph node metastasis. The five-year survival rate for patients with non-invasive and invasive carcinomas was 96.2% and 35.2%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis. No progression was found during the follow-up in 18 asymptomatic small branch duct type IPMN patients. CONCLUSION: IPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive surgical treatment. Patients of branch duct type IPMN with lesion <3 cm in diameter and without clinical manifestations can be managed with close follow-up.

[Genotype of extended-spectrum beta-lactamases produced by antibiotic-resistant Escherichia coli and Klebsiella pneumoniae in surgical intensive care unit].

OBJECTIVE: To describe the antibiotic resistant mode of extended-spectrum beta-lactamases(ESBLs) producing Escherichia coli (E. coli.) and Klebsiella pneumoniae (KPn) in surgical intensive care unit(SICU), and to implore the molecular epidemiology of ESBLs coding genes of these strains. METHODS: The minimal inhibitory concentrations (MICs) at antibiotics were examined by agar dilution method. The ESBLs coding genes were amplified by TEM, SHV and CTX-M specific primers. Amplicons of such genes with conjugates' plasmids as templates were sequenced. RESULTS: In vitro susceptibility tests of ESBLs producing strains showed a high level of resistance to most of the beta-lactam biotics, especially cefotaxime. 93.5% of these ESBLs positive strains contained CTX-M group genes,and 38.7% of the strains contained SHV genes. By sequencing, some genotype were determined: TEM-1, CTX-M-1,3,14,22. CONCLUSION: ESBLs producing strains were resistant to most of the beta-lactam biotics. The most prevalent ESBLs genotype of ESBLs produced by E coli and KPn in SICU was CTX-M subgroup. The most probable reason might be the extensive use of cefotaxime.

WE-CARE: an intelligent mobile telecardiology system to enable mHealth applications.

Recently, cardiovascular disease (CVD) has become one of the leading death causes worldwide, and it contributes to 41% of all deaths each year in China. This disease incurs a cost of more than 400 billion US dollars in China on the healthcare expenditures and lost productivity during the past ten years. It has been shown that the CVD can be effectively prevented by an interdisciplinary approach that leverages the technology development in both IT and electrocardiogram (ECG) fields. In this paper, we present WE-CARE , an intelligent telecardiology system using mobile 7-lead ECG devices. Because of its improved mobility result from wearable and mobile ECG devices, the WE-CARE system has a wider variety of applications than existing resting ECG systems that reside in hospitals. Meanwhile, it meets the requirement of dynamic ECG systems for mobile users in terms of the detection accuracy and latency. We carried out clinical trials by deploying the WE-CARE systems at Peking University Hospital. The clinical results clearly showed that our solution achieves a high detection rate of over 95% against common types of anomalies in ECG, while it only incurs a small detection latency around one second, both of which meet the criteria of real-time medical diagnosis. As demonstrated by the clinical results, the WE-CARE system is a useful and efficient mHealth (mobile health) tool for the cardiovascular disease diagnosis and treatment in medical platforms.

Design and tests of a smartphones-based multi-lead ECG monitoring system.

With the rapid development of wireless communications and sensor technologies, multi-lead electrocardiogram (ECG) monitoring systems can be implemented for real-time Cardiovascular Disease (CVD) tracking and prevention services by using mobile terminals. To meet this objective, we designed a 7-lead ECG monitoring system enabled by smartphones, which is a combination of user mobility requirement and clinical intelligent function. In the system, an application-layer protocol is conceived and tested for guaranteeing data transmission reliability between smartphones and portable sensors. In addition, the smartphone in the system can be customized as a personal health manager, which can control system function modes and device states, and also perform information management and deeper data analysis. Most significantly, we developed a health risk alarm algorithm to detect ECG signal abnormities, which could help professionals pick out the data with key clinical information. To test our system performance and validity, we carried out simulation tests and system experiments. The results show our system is helpful in CVD prevention services.

Influential factors and effect evaluation of the intra-operative puncture biopsy for pancreatic masses.

BACKGROUND: It is a challenge for the surgeons to accurately diagnose the pancreatic masses preoperatively, which decides the choice of surgical managements and subsequently results in different survivor outcomes, operative complications, and mortality rates. The purposes of this study were to evaluate the diagnostic role that intra-operative puncture biopsy may play in pancreatic masses and to explore the relevant factors influencing the diagnosis. METHODS: A retrospective study was performed on 94 in-patients admitted to Peking University First Hospital for pancreatic masses during the period from June 1994 to December 2007. They all underwent intra-operative puncture biopsy during exploratory laparotomy. The sensitivity and specificity of intra-operative puncture biopsy were calculated and the relevant factors to the diagnosis of biopsy were selected for the statistical analysis. RESULTS: The overall sensitivity, specificity, positive predictive value, and negative predictive value of intra-operative puncture biopsy were 76.0%, 94.7%, 98.3% and 50.0%, respectively. The analysis of bivariate correlations showed that the size of the pancreatic masses (P = 0.000), the number of puncture biopsies (P = 0.000), and the presence of pancreatic fibrosis (P = 0.012) had statistic significance for the diagnosis. But the multivariate analysis identified the size of the pancreatic masses (P = 0.004) and the number of puncture biopsies (P = 0.000) as independent predictive factors for intra-operative puncture biopsy. In addition, as the number of puncture biopsies increased, the sensitivity and specificity of diagnosis was improved (P = 0.000). The sensitivity and specificity of intra-operative puncture biopsy were found to be lower for the pancreatic masses less than 25 mm compared with the masses larger than 25 mm (P = 0.000). It was noted, however, that even if the masses were less than 25 mm, the sensitivity and specificity could be improved significantly as the number of puncture biopsies reached 3 to 6 (P = 0.007). CONCLUSIONS: Intra-operative puncture biopsy is simple and accurate for qualitatively differentiating various types of pancreatic masses. Three to 4 biopsies could significantly improve the diagnostic effect for pancreatic masses, even if the masses are less than 25 mm in size.