Deep-learning model associating lateral cervical radiographic features with Cormack-Lehane grade 3 or 4 glottic view.

Unanticipated difficult laryngoscopy is associated with serious airway-related complications. We aimed to develop and test a convolutional neural network-based deep-learning model that uses lateral cervical spine radiographs to predict Cormack-Lehane grade 3 or 4 direct laryngoscopy views of the glottis. We analysed the radiographs of 5939 thyroid surgery patients at our hospital, 253 (4%) of whom had grade 3 or 4 glottic views. We used 10 randomly sampled datasets to train a model. We compared the new model with six similar models (VGG, ResNet, Xception, ResNext, DenseNet and SENet). The Brier score (95%CI) of the new model, 0.023 (0.021-0.025), was lower ('better') than the other models: VGG, 0.034 (0.034-0.035); ResNet, 0.033 (0.033-0.035); Xception, 0.032 (0.031-0.033); ResNext, 0.033 (0.032-0.033); DenseNet, 0.030 (0.029-0.032); SENet, 0.031 (0.029-0.032), all p < 0.001. We calculated mean (95%CI) of the new model for: R2 , 0.428 (0.388-0.468); mean squared error, 0.023 (0.021-0.025); mean absolute error, 0.048 (0.046-0.049); balanced accuracy, 0.713 (0.684-0.742); and area under the receiver operating characteristic curve, 0.965 (0.962-0.969). Radiographic features around the hyoid bone, pharynx and cervical spine were associated with grade 3 and 4 glottic views.

A randomised controlled trial of 7.5-mm and 7.0-mm tracheal tubes vs. 6.5-mm and 6.0-mm tracheal tubes for men and women during laparoscopic surgery.

Sore throat after tracheal intubation impairs postoperative recovery. We randomly allocated 172 ASA physical status 1-2 participants, scheduled for laparoscopic lower abdominal surgery, to tracheal intubation with larger tubes (n = 88) or smaller tubes (n = 84), with internal diameters 7.5-mm vs. 6.5-mm for men and 7.0-mm vs. 6.0-mm for women. Primary outcome was the rates of no, mild, moderate or severe sore throat 1 h after surgery, which were 60, 10, 17 and 1 with larger tracheal tubes and 79, 5, 0 and 0 with smaller tubes, p < 0.001. The equivalent rates 24 h after surgery were 64, 16, 8 and 0 vs. 74, 6, 3 and 1, p = 0.037. Intra-operative ventilatory variables were unaffected by tube diameter, including peak inspiratory pressure, plateau pressure and end-tidal carbon dioxide partial pressure. In summary, smaller tracheal tubes benefitted patients having laparoscopic operations.

Urinary Tissue Inhibitor of Metalloproteinase and Insulin-like Growth Factor-7 as Early Biomarkers of Delayed Graft Function After Kidney Transplantation.

BACKGROUND: Recently, urinary tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor-7 (IGFBP-7), markers for G1 cell cycle arrest, have been identified and validated in predicting the development of acute kidney injury in critically ill patients. It is unknown, however, whether these two biomarkers could predict the development of delayed graft function (DGF) after kidney transplantation (KT). METHODS: This is a single-center, prospective, observational study. We enrolled 74 patients who underwent KT between August 2013 and December 2016. Urine sample were collected immediately after the operation. The primary outcome was development of DGF as defined by need for dialysis of more than 1 session within 7 days of KT. RESULTS: Twenty-three patients (31%) were diagnosed with DGF. In univariate analysis, kidneys from expanded criteria donors, higher donor serum creatinine, lower donor estimated glomerular filtration rate, antithymoglobulin exposure, neutrophil gelatinase associated lipocalin, and urinary [TIMP-2]·[IGFBP7] were significantly different between early graft function and DGF. However, in multivariate analysis adjusting other factors, deceased donor and urinary [TIMP-2]·[IGFBP7] at 0 hours post-transplantation could predict the development of DGF. The receiver operating characteristic curve for prediction of DGF showed an area under the curve of 0.867 (sensitivity 0.86, specificity 0.71) for a cutoff value of 1.39. CONCLUSIONS: Our results indicate that urine [TIMP-2]·[IGFBP7] immediately after transplantation could be an early, predictive biomarker of DGF in kidney transplantation.

The incidence and characteristics of 3-month mortality after intraoperative cardiac arrest in adults.

BACKGROUND: There is little information about clinical outcomes after intraoperative cardiac arrest (IOCA). We determined the incidence and characteristics of 3-month mortality after IOCA. METHODS: The electronic medical records of 238,648 adult surgical patients from January 2005 to December 2014 were reviewed retrospectively. Characteristics of IOCA were documented using the Utstein reporting template. RESULTS: IOCA occurred in 50 patients (21/100,000 surgeries). Nineteen patients died in the operating room, and further 12 patients died within 3 months post-arrest (total mortality: 62%). Three survivors at 3 months post-arrest had unfavourable neurological outcome. Finally, 34 patients showed unfavourable clinical outcomes at 3 months post-arrest. The incidences of non-cardiac surgery, emergency, pre-operative intubation state, non-shockable initial cardiac rhythm, hypovolaemic shock, pre-operative complications-induced cardiac arrest, non-anaesthetic cause of cardiac arrest, intra- and post-arrest transfusion, and continuous infusion of inotrope or vasopressor in intensive care unit (ICU) were significantly higher in non-survivors at 3 months post-arrest. Total epinephrine dose administrated during arrest was higher, and the duration of cardiac compressions was longer in non-survivors at 3 months post-arrest. CONCLUSIONS: In this study, the incidence of IOCA was 21/100,000 surgeries and the 3-month mortality rate after IOCA was 62%. Several factors including surgical emergency, non-shockable initial cardiac rhythm, pre-operative complications, surgical complications, long duration of cardiac compressions, high total epinephrine dose, transfusion, and continuous infusion of inotropes or vasopressors in ICU seemed to be risk factors for 3-month mortality after IOCA. These risk factors should be considered in the light of relatively small sample size of this study.

Single monosomy as a relatively better survival factor in acute myeloid leukemia patients with monosomal karyotype.

Monosomal karyotype (MK) defined by either ⩾2 autosomal monosomies or single monosomy with at least one additional structural chromosomal abnormality is associated with a dismal prognosis in patients with acute myeloid leukemia (AML). It was detected in 174 of 3041 AML patients in South Korean Registry. A total of 119 patients who had received induction therapy were finally analyzed to evaluate the predictive factors for a positive prognosis. On multivariate analysis, single monosomy, the absence of abn(17p), ⩾10% of cells with normal metaphase and the achievement of a complete remission (CR) after induction therapy were significant factors for more favorable outcomes. Especially, single monosomy remained as a significantly independent prognostic factor for superior survival in both patients who received allogeneic hematopoietic stem cell transplantation (allo-HSCT) in CR and who did not. Allo-HSCT in CR improved overall survival significantly only in patients with a single monosomy. Our results suggest that MK-AML may be biologically different according to the karyotypic subtype and that allo-HSCT in CR should be strongly recommended to patients with a single monosomy. For other patients, more prudent treatment strategies should be examined. Furthermore, the biological mechanism by which a single monosomy influences survival should be investigated.

Incidence of infection according to intravenous immunoglobulin use in autologous hematopoietic stem cell transplant recipients with multiple myeloma.

BACKGROUND: Although intravenous immunoglobulin (IVIG) is not routinely recommended, many centers still use IVIG during the post-hematopoietic stem cell transplant (HSCT) period. METHOD: A total of 162 multiple myeloma (MM) patients who underwent autologous (auto-) HSCT between January 2008 and June 2013 were retrospectively reviewed. Primary objective was determination of the impact of IVIG on post-transplant infection, and secondary objectives included identification of overall incidence of infection, type of infection, and risk factors for infection after auto-HSCT in MM patients. RESULTS: After auto-HSCT, 53 of 162 patients (32.7%) experienced 104 infectious events. Upper respiratory infection was most common (n = 31, 29.8%) and pneumonia (n = 27, 26.0%) and herpes zoster (n = 15, 14.4%) came next. Among the identifiable organisms causing respiratory infection, influenza virus (n = 10) and Pneumococcus (n = 9) were predominant. Incidence of infection was not statistically different according to IVIG use (34.8% in IVIG (-) vs. 31.3% in IVIG (+), P = 0.631). Incidence of infection requiring hospitalization and multiple episodes of infection showed no difference between the groups (P = 0.147, P = 0.156). In a Cox proportional hazard model, none of the factors including age, gender, type of disease, stage, tandem (vs. single) transplantation,and IVIG was prognostic for infectious event after auto-HSCT (P = 0.955, hazard ratio 0.980 with 95% confidence interval 0.481-1.997 for IVIG). CONCLUSION: In auto-HSCT recipients with MM, incidence of post-transplant infection was not different according to prophylactic IVIG use.

Simultaneous pancreas-kidney transplantation from living donor using hand-assisted laparoscopic donor surgery: single-center experience.

BACKGROUND: Simultaneous pancreas-kidney (SPK) transplantation has been the fundamental treatment and has shown significant results in selected patients diagnosed with type 1 diabetes with renal insufficiency. Most pancreas transplantations are dependent on deceased donors, yet the waiting time for SPK transplantation from deceased donors is significantly long in Asian countries. METHODS: In 3 cases, living-donor SPK transplantation was performed with the use of hand-assisted laparoscopic donor surgery (HALS). Three cases of patients who underwent SPK transplantation from living donors (LDSPK) with the use of HALS at Korea University Anam Hospital from 2012 to 2013 were retrospectively reviewed regarding patient characteristics and clinical outcomes of donors and recipients. For the donors, the pancreas and renal function had been well preserved postoperatively. RESULTS: One donor had a pancreatic fistula, which was controlled with conservative management. Of the 3 cases of recipient operation, 1 case was performed by ABO incompatibility donor. The levels of creatinine, serum insulin, and C-peptide of recipients were normalized and remained stable at the last follow-up. CONCLUSIONS: LDSPK can be an efficient alternative in cases in which the deceased donor is not present at the proper time, depending on the degree of completion in the operator's skill.

Generic piperacillin/tazobactam is not associated with galactomannan false-positivity in adult patients with cancer: a case-control study.

Recent products of piperacillin/tazobactam (PTZ) from the original manufacturer, previously considered a major cause of galactomannan (GM) false-positivity, are reported not to be related to it. However, data regarding generic PTZ are limited and controversial. To evaluate the effect of generic PTZ on GM false-positivity in Korea, we performed a case-control study in adult patients with cancer. A case-control study was designed. Electronic medical records of cancer patients who were admitted and tested for serum GM between March and June 2014 at a tertiary care university hospital were reviewed. During the study period, a single generic PTZ (C manufacturer, Korea) was used. Patients who received PTZ within 24 h prior to serum GM testing were enrolled. Age- and GM test date-matched non-PTZ patients were selected as controls. A total of 110 patients received PTZ within 24 h prior to serum GM testing during the study period. The GM optical density index (ODI) of the PTZ group did not vary significantly from that of the control group (p = 0.251). The percentage of false-positive patients in the PTZ group was also similar to that of the control group (p = 0.538). There was no statistical relationship between GM ODI titer and time interval from PTZ administration (p = 0.095) or cumulative PTZ dose (p = 0.416). In a case-control study that evaluated 220 patients, a generic PTZ in Korea was not related to GM false-positivity.

Incidence and risk factors of poor mobilization in adult autologous peripheral blood stem cell transplantation: a single-centre experience.

BACKGROUND AND OBJECTIVES: Collection of sufficient CD34+ cells for autologous peripheral blood stem cell (PBSC) transplantation is frequently failed in patients with lymphoma or multiple myeloma (MM). We investigated the incidence and the predictive factors for poor mobilization. MATERIALS AND METHODS: A total of 205 adult patients (101 lymphoma and 104 MM) were retrospectively included for identifying the incidence of mobilization failure and the predictive factors for poor mobilization in conventional G-CSF-based mobilization regimen. Another 17 patients who used plerixafor for mobilization were included. RESULTS: Overall, 14·1% of patients (21·8% of patients with lymphoma, 6·7% of patients with MM) were poor mobilizers. Univariate analysis and multivariate analysis revealed an interval from G-CSF administration to PBSC collection exceeding 10 days and peripheral blood mononuclear cells count on the first day of collection were predictive factors for poor mobilization in lymphoma, but not in MM. Among plerixafor-treated patient group, 9 of 11 poor mobilizers who received second-cycle plerixafor mobilization were able to collect higher number of CD34+ cells than that of CD34+ cells during the G-CSF-based first mobilization. All patients who had received initial plerixafor mobilization reached 2·0 × 10(6) CD34+ cells/kg during the four leukaphereses. CONCLUSION: In conventional G-CSF-based mobilization, early PBSC collection after G-CSF administration might enhance CD34+ cell yield. A combination of a new mobilizing agent, plerixafor, would be helpful to harvest sufficient number of CD34+ cells for successful transplantation outcome while reducing the effort of collection procedures in poor mobilizers.

Incidence of venous thromboembolism following major surgery in Korea: from the Health Insurance Review and Assessment Service database.

BACKGROUND: Data on the incidence of venous thromboembolism (VTE) following major surgery in Asian populations are limited. METHODS: Using the Korean Health Insurance Review and Assessment Service database, we performed a nationwide population-based epidemiologic study to estimate the incidence of VTE after major orthopedic, cancer, and benign surgeries. VTE cases were identified from all patients undergoing major surgery between 2007 and 2011 using both diagnostic and drug codes as treatment evidence of VTE within 5 weeks of surgery. We also calculated the relative risk of VTE in major orthopedic and cancer surgery compared to benign surgery. RESULTS: The overall rates of postoperative VTE were 1.24%, 0.67%, and 0.05% for major orthopedic, cancer, and benign surgeries, respectively. Hip fracture (1.60%) and colorectal cancer surgeries (1.67%) were associated with the highest rates of VTE, and the rates steadily increased during the study period. Advanced age, female sex, and general anesthesia were independent risk factors for VTE. Patients undergoing surgery for colorectal, pancreatic, ovarian, and esophageal cancer, and major orthopedic surgery had a > 20-fold higher risk of VTE than those undergoing benign surgery. CONCLUSIONS: This is the largest epidemiologic study to investigate the incidence of VTE after major surgery in Asia, demonstrating that the rates of postoperative VTE are lower than in Caucasian populations. This study contributes to a better understanding of the differences in postoperative VTE development between Korean and Caucasian populations; the data also suggest that perioperative prophylactic strategies in Asians should be based on studies of such populations.

Risk factors for cytomegalovirus gastrointestinal diseases in adult patients with cancer.

Cytomegalovirus (CMV) gastrointestinal (GI) disease has been noticed frequently in cancer patients, causing abdominal pain, diarrhea, and GI bleeding. However, little is known about its actual incidence, clinical presentation, and the risk factors for its development among cancer patients. To answer these questions, we analyzed all cases that occurred during an 18-year period at our center. A case-control study was performed to identify risk factors for CMV GI disease. Electronic medical records were reviewed from individuals who were admitted and diagnosed with CMV GI disease during the period of January 1995 through March 2013 at a tertiary care center. Two CMV disease-free cancer patients were matched as controls. A total of 98 episodes of CMV GI disease were included in this study, and the overall incidence rate was 52.5 per 100,000 cancer patients, with an increasing trend throughout the study period. According to multivariate analysis, male sex, low body mass index, lymphopenia, hematological malignancy, and steroid use and red blood cell transfusion within 1 month prior to the CMV disease were identified to be independent risk factors. Among these factors, RBC transfusion showed the highest odds ratio (OR = 5.09). Male sex, low body mass index, lymphopenia, hematological malignancy, steroid use, and red blood cell transfusion within 1 month prior to the CMV disease diagnosis were independent risk factors for the development of CMV GI disease in adult patients with cancer.

Clinical outcomes in kidney transplantation patients from deceased donors with acute kidney injury.

BACKGROUND: This single-center study sought to examine the clinical outcomes of kidney transplant recipients from donors displaying acute kidney injury (AKI). METHODS: We analyzed retrospectively the medical records of the donors and recipients of 54 deceased-donor kidney transplantations performed in our center between March 2009 and March 2012. RESULTS: Among the 54 deceased donors, 36 (66.7%) experienced AKI as determined by the final mean serum creatinine levels measured before graft harvest of 2.66 ± 1.62 mg/dL versus 0.82 ± 0.28 mg/dL among non-AKI donors. The risks of delayed graft function and slow graft function were increased among the AKI versus non-AKI groups in the early post-transplantation period. However, the renal function status of recipients at 3, 6, and 12 months after transplantation was not significantly different between the two groups. Moreover, rejection-free survival rates during the study period were similar. Multivariate analysis revealed an acute rejection episodes (P = .047) and a lower body mass index in the donor relative to the recipient (P = .011) to be independent risk factors predicting poor graft function defined as a 1-year estimated glomerular filtration rate less than 50 mL/min/l.73 m(2). Donor AKI with either a high level (>4.0 mg/dL), an increasing trend of creatinine, or greater severity by the Risk, Injury, Failure, Loss, and End-stage kidney disease (RIFLE) classification was not a significant risk factor. CONCLUSION: Transplantation of kidneys from the AKI donors, namely, patients with severely decreased renal function, displayed excellent short-term outcomes. Accordingly, kidney transplantations from deceased donors with AKI should be considered more actively to expand the donor pool in Korea.

The effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube over a bronchoscope during oral fibreoptic intubation.

During fibreoptic intubation, it is often difficult to advance a tracheal tube over the fibreoptic bronchoscope. We performed a prospective randomised study to investigate the effect of the jaw-thrust manoeuvre on the ability to advance a tracheal tube during oral fibreoptic intubation. After placing the bronchoscope in the trachea, an assistant randomly applied a jaw-thrust manoeuvre (jaw-thrust group) or sham manoeuvre (control group) in 82 patients during tube advancement. The jaw-thrust group had a higher success rate on the first attempt (70.7% vs 34.1%, p = 0.002), required fewer attempts (median (IQR [range]) 1 (1-2 [1-3]) vs 2 (1-3 [1-4]), p < 0.001), and took less time [6 (4-8 [2-16]) s vs 10 (7-15 [3-40]) s, p < 0.001] for tube advancement compared with the control group. The jaw-thrust manoeuvre facilitates the advancement of a tracheal tube over the bronchoscope during oral fibreoptic intubation.

Influence of enzyme and transporter polymorphisms on trough imatinib concentration and clinical response in chronic myeloid leukemia patients.

BACKGROUND: This study explored the impact of genetic polymorphisms in cytochrome P450 (CYP) enzymes and transporters on the plasma trough concentration of imatinib mesylate (IM) and clinical response in chronic myeloid leukemia (CML). PATIENTS AND METHODS: In total, 82 patients with CML who had been administered 400 mg IM daily for over 6 months were genotyped for 11 single-nucleotide polymorphisms in nine genes (CYP3A4, CYP3A5, CYP2C9, CYP2C19, CYP2D6, ABCB1, SLC22A1, SLC22A2 and ABCG2) using blood samples. The trough imatinib concentration and clinical responses were assessed 6 months after the initiation of IM therapy. RESULTS: The CC, CA and AA genotypes in ABCG2 421C>A gave significantly different frequencies for the major molecular response (MMR) (P = 0.02). However, no significant differences were found between the genotypes of the CYP enzymes and transporters identified in this study and the imatinib plasma trough concentrations and clinical response frequencies, except for the correlation of ABCG2 with MMR. CONCLUSIONS: The results of the present study may indicate that the ABCG 421C>A genetic polymorphism influences the MMR of imatinib in patients with CML.

Nafamostat mesilate attenuates Postreperfusion Syndrome during liver transplantation.

Postreperfusion syndrome (PRS), an acute decrease in blood pressure after reperfusion of the liver graft, occurs frequently during liver transplantation surgery. We supposed that the activation of the kallikrein-kinin system leading to extensive systemic vasodilatation was a possible cause. The effect of pretreatment with nafamostat mesilate (NM), a broad spectrum serine protease inhibitor, on the occurrence of PRS was evaluated. Sixty-two adult liver recipients were randomized to receive an intravenous bolus of either 0.02 mg/kg of NM (NM group, n = 31) or an equal volume of normal saline (control group, n = 31) just before reperfusion of the liver graft. Occurrence of PRS and intraoperative use of vasoactive drugs were compared between the two groups. Postoperative recovery was also compared. PRS was significantly less frequent (48% vs. 81%, p = 0.016) requiring less vasopressors in the NM group compared to the control group. The NM group also showed faster recovery of the mean arterial pressure. Perioperative laboratory values were similar between the two groups. Pretreatment with 0.02 mg/kg of NM immediately before reperfusion decreases the frequency of PRS and vasopressor requirements during the reperfusion period in liver transplantation.

Low central venous pressure with milrinone during living donor hepatectomy.

Maintaining a low central venous pressure (CVP) has been frequently used in liver resections to reduce blood loss. However, decreased preload carries potential risks such as hemodynamic instability. We hypothesized that a low CVP with milrinone would provide a better surgical environment and hemodynamic stability during living donor hepatectomy. Thirty-eight healthy adult liver donors were randomized to receive either milrinone (milrinone group, n = 19) or normal saline (control group, n = 19) infusion during liver resection. The surgical field was assessed using a four-point scale. Intraoperative vital signs, blood loss, the use of vasopressors and diuretics and postoperative laboratory data were compared between groups. The milrinone group showed a superior surgical field (p < 0.001) and less blood loss (142 +/- 129 mL vs. 378 +/- 167 mL, p < 0.001). Vital signs were well maintained in both groups but the milrinone group required smaller amounts of vasopressors and less-frequent diuretics to maintain a low CVP. The milrinone group also showed a more rapid recovery pattern after surgery. Milrinone-induced low CVP improves the surgical field with less blood loss during living donor hepatectomy and also has favorable effects on intraoperative hemodynamics and postoperative recovery.

Clinical relevance of vascular endothelial growth factor (VEGFA) and VEGF receptor (VEGFR2) gene polymorphism on the treatment outcome following imatinib therapy.

BACKGROUND: Imatinib could reverse marrow angiogenesis and decrease the plasma level of vascular endothelial growth factor (VEGF) in chronic myeloid leukemia (CML) patients. Methods, materials and patients: The current study investigated the impact of four vascular endothelial growth factor type A (VEGFA) and three vascular endothelial growth factor receptor type 2 (VEGFR2) gene polymorphisms on the outcomes of 228 CML patients following imatinib therapy. VEGFA genotypes such as -2578C>A (rs699947), -460T>C (rs833061), +405G>C (rs2010963) and +936C>T (rs3025039) loci and VEGFR2 genotypes (rs1531289, rs1870377 and rs2305948) were analyzed using matrix-assisted laser desorption/ionization time-of-flight-based method. RESULTS: In single marker analyses, strong correlations were noted between complete cytogenetic response (CCyR) and VEGFR2 genotypes (rs1531289/rs1870377), between treatment failure and VEGFR2 genotype (rs1870377) and between progression to advanced disease and VEGFA genotypes (rs699947/rs833061). Three haplotypes of VEGFR2 gene were generated as follows: GT (46.1%), AT (27.9%) and GA (25.7%). Haplotype analyses showed good correlations between VEGFR2 haplotype and CCyR and treatment failure to imatinib. Multivariate analyses confirmed strong correlations of VEGFR2 polymorphisms (especially rs1531289, rs1870377 or VEGFR2 haplotype) with CCyR, treatment failure and of VEGFA genotype (rs699947) with progression to advanced disease. CONCLUSION: The VEGFR2 gene polymorphism correlates with cytogenetic response, treatment failure following imatinib therapy for CML, while VEGFA genotype correlates with progression to advanced disease.

Reduction of pain during induction with target-controlled propofol and remifentanil.

BACKGROUND: Pain on injection of propofol is unpleasant. We hypothesized that propofol infusion pain might be prevented by infusing remifentanil before starting the propofol infusion in a clinical setting where target-controlled infusions (TCI) of both drugs were used. A prospective, randomized, double-blind, placebo-controlled trial was performed to determine the effect-site concentration (Ce) of remifentanil to prevent the pain without producing complications. METHODS: A total of 128 patients undergoing general surgery were randomly allocated to receive normal saline (control) or remifentanil to a target Ce of 2 ng ml(-1) (R2), 4 ng ml(-1) (R4), or 6 ng ml(-1) (R6) administered via TCI. After the target Ce was achieved, the infusion of propofol was started. Remifentanil-related complications were assessed during the remifentanil infusion, and pain caused by propofol was evaluated using a four-point scale during the propofol infusion. RESULTS: The incidence of pain was significantly lower in Groups R4 and R6 than in the control and R2 groups (12/32 and 6/31 vs 26/31 and 25/32, respectively, P<0.001). Pain was less severe in Groups R4 and R6 than in the control and R2 groups (P<0.001). However, both incidence and severity of pain were not different between Groups R4 and R6. No significant complications were observed during the study. CONCLUSIONS: During induction of anaesthesia with TCI of propofol and remifentanil, a significant reduction in propofol infusion pain was achieved without significant complications by prior administration of remifentanil at a target Ce of 4 ng ml(-1).

New clinical grading system for chronic GVHD predicts duration of systemic immunosuppressive treatment and GVHD-specific and overall survival.

We investigated outcomes according to a new clinical grading system for chronic graft-versus-host disease (chronic GVHD) in 38 patients who developed chronic GVHD after an allogeneic hematopoietic stem cell transplantation. We categorized the patients into three grade groups, namely, grade I, grade II and grade III, according to the presence of three risk factors: extensive skin involvement, thrombocytopenia (TP) and progressive type of onset. Sixteen patients were classified into grade 1, 19 into grade II and three into grade III. The probability of withdrawal of systemic immunosuppression (IST) at 1, 2 and 3 years was 61, 76 and 87%, respectively. Patients with grades 2 or 3 chronic GVHD had prolonged duration of systemic IST compared to grade 1 (P=0.043). The probability of GVHD-specific survival (GSS) at 5 years was 52%. Twenty-two of 38 patients with chronic GVHD were still alive and the estimated 3-year overall survival (OS) rate was 60%, whereas that for the group with chronic GVHD grade I and grade II+III was 64 and 48% (P<0.05). Multivariate analysis showed that prior occurrence of acute GVHD, chronic GVHD grade, serum bilirubin over 1.5 mg/dl, date of diagnosis of chronic GVHD (day 150) and transplantation-risk factor were independent prognostic factors for GSS and OS.