Mendelian randomization analysis reveals the impact of physical and occupational activities on the risk of gastroesophageal reflux disease and Barrett's esophagus.

BACKGROUND: Recent studies have indicated that participating in physical activity may provide a safeguard against gastroesophageal reflux disease (GERD). Nevertheless, the precise links between physical and occupational activity and the occurrence of GERD and Barrett's esophagus (BE) are still uncertain. METHODS: Conducting univariate and multivariate Mendelian randomization investigations to examine the causal relationship between exposures and outcomes. Genetic variation simulation was used in randomized experiments. Data on physical and occupational activity were obtained from the UK Biobank and GWAS catalog. In the meantime, data on GERD and BE were extracted from a high quality meta-analysis. RESULTS: The results of univariate Mendelian randomization analysis using multiple methods suggest a causal relationship between strenuous sports or other forms of exercise (as a protective factor) and GERD/BE. At the same time, three types of occupational related physical activities, including heavy manual or physical work, shift work and walking or standing work, are risk factors for GERD/BE and have a causal relationship with them. These results were reconfirmed through multivariate Mendelian randomization analysis, which excluding the influence of other potential confounding factors. CONCLUSIONS: The findings indicated that strenuous sports or other forms of exercise could lower the likelihood of GERD/BE, while excessive physical strain in the workplace, prolonged periods of standing or walking, and shift work could raise the risk of GERD/BE. Acknowledging this risk and implementing suitable measures can contribute to the prevention of GERD and BE, thus mitigating the associated health burden.

Three New Species of Diaporthe Causing Leaf Blight on Acer palmatum in China.

Diaporthe spp. are often reported as plant pathogens, endophytes, and saprobes. In this study, three new species (Diaporthe foliicola, D. monospora, and D. nanjingensis) on Acer palmatum were described and illustrated based on morphological characteristics and phylogenetic analyses. Phylogenetic relationships of the new species were determined by multilocus phylogenetic analyses based on partial sequences of the internal transcribed spacer (ITS) region, translation elongation factor 1-α (TEF), ß-tubulin (TUB), histone H3 (HIS), and calmodulin (CAL) genes. Genealogical concordance phylogenetic species recognition with a pairwise homoplasy index test was used to verify the conclusions of the phylogenetic analyses. All species were illustrated and their morphology and phylogenetic relationships with other related Diaporthe spp. are discussed. In addition, the tests of Koch's postulates showed that the three new species were pathogens causing leaf blight on A. palmatum.

Two new species of Fistulina (Agaricales, Basidiomycota) from the Northern Hemisphere.

Phylogenetic and morphological analyses on samples of Fistulina from East Asia and North America were carried out, and two new species were described, namely, Fistulina americana and Fistulina orientalis, both previously known as Fistulina hepatica. The former is characterized by lateral stipitate basidiocarps, relatively small pores (7-8 per mm), a monomitic hyphal system with both clamp connections and simple septa, and ellipsoid basidiospores of 4-4.8 × 3-3.3 µm, and the species has been found on Quercus in North-East USA. F. orientalis is characterized by lateral stipitate basidiocarps, very small pores (11-12 per mm) with pruinose dissepiments, a monomitic hyphal system with both clamp connections and simple septa, and ovoid to subglobose basidiospores of 3-4 × 2.7-3 µm, and the species has been found on Castanopsis in East Asia. Phylogenetically, samples of F. americana and F. orientalis form two new lineages nested in the Fistulina clade.

Two new forest pathogens in Phaeolus (Polyporales, Basidiomycota) on Chinese coniferous trees were confirmed by molecular phylogeny.

Phaeolus schweinitzii (Fr.) Pat. was originally described in Europe and is considered a common forest pathogen on conifers in the Northern Hemisphere. Our molecular phylogeny based on samples from China, Europe, and North America confirms that P. schweinitzii is a species complex, including six taxa. P. schweinitzii sensu stricto has a distribution in Eurasia; the samples from Northeast and Southwest China are distantly related to P. schweinitzii sensu stricto, and two new species are described after morphological, phylogenetic, and geographical analyses. The species growing on Larix, Picea, and Pinus in Northeast China is described as Phaeolus asiae-orientalis. Another species mostly occurring on Pinus yunnanensis in Southwest China is Phaeolus yunnanensis. In addition, three taxa distributed in North America differ from P. schweinitzii sensu stricto. Phaeolus tabulaeformis (Berk.) Pat. is in Southeast North America, "P. schweinitzii-1" in Northeast North America, and "P. schweinitzii-2" in western North America.

Elevated procalcitonin levels in the absence of infection in procalcitonin-secretin hepatocellular carcinoma: A case report.

BACKGROUND: Serum procalcitonin (PCT) is widely used to diagnose bacterial infection and sepsis. However, PCT may be elevated in some neoplasms. It is important to distinguish infection from no infection in such neoplasms. The relationship between hepatocellular carcinoma (HCC) and PCT is unknown. CASE SUMMARY: A 62-year-old male was admitted due to a hepatic lesion of unknown origin. The patient had an elevated PCT level. Infectious diseases were excluded after appropriate examination. He then underwent exploratory laparotomy and a left lateral hepatectomy was performed. The patient recovered with an uneventful postoperative course and PCT level decreased gradually and was normal on day 16. HCC was diagnosed by histopathology and no evidence of infection was observed. Furthermore, immunohistochemical analyses revealed that tumor cells were positive for PCT. CONCLUSION: HCC cells can secrete PCT in the absence of infection and PCT may be used as a marker to monitor the efficacy of tumor therapy.

Low Tumor Infiltrating Mast Cell Density Reveals Prognostic Benefit in Cervical Carcinoma.

Objectives: Research on the role of mast cells (MCs) in cervical tumor immunity is more limited. Therefore, our study aimed to evaluate the prognostic value of MCs and their correlation with the immune microenvironment of cervical carcinoma (CC). Methods: The Cancer Genome Atlas (TCGA) data was utilized to obtain the degree of immune infiltration of MCs in CC. Meanwhile, this study retrospectively collected patient clinical characteristic data and tissue specimens to further verify the relevant conclusions. Mast cell density (MCD) was measured by the CIBERSORT algorithm in TCGA data and immunohistochemical staining of tryptase in CC tissues. Finally, differentially expressed genes (DEGs) of TCGA data were performed using "limma" packages and key gene modules were identified using the MCODE application in Cytoscape. Results: The results showed MCs were diffusely distributed in CC tissues. Moreover, we found that low tumor-infiltrating MCD was beneficial for overall survival (OS) in the TCGA cohort. Consistent conclusions were also obtained in a clinical cohort. In addition, a total of 305 DEGs were analyzed between the high tumor-infiltrating MCD and low tumor-infiltrating MCD group. Seven key modules, a total of 34 genes, were screened through the MCODE plug-in, which was mainly related to inflammatory response and immune response and closely correlated with cytokines including CSF2, CCL20, IL1A, IL1B, and CXCL8. Conclusion: In short, high tumor-infiltration MCs in CC tissue was associated with worse OS in patients. Furthermore, MCs were closely related to cytokines in the tumor microenvironment, suggesting that they collectively played a role in the immune response of the tumor. Therefore, MCD may be a potential prognostic indicator and immunotherapy target of CC.

Severe gastric insufflation and consequent atelectasis caused by gas leakage using AIR-Q laryngeal mask airway: A case report.

BACKGROUND: The airways of patients undergoing awake craniotomy (AC) are considered "predicted difficult airways", inclined to be managed with supraglottic airway devices (SADs) to lower the risk of coughing or gagging. However, the special requirements of AC in the head and neck position may deteriorate SADs' seal performance, which increases the risks of ventilation failure, severe gastric insufflation, regurgitation, and aspiration. CASE SUMMARY: A 41-year-old man scheduled for AC with the asleep-awake-asleep approach was anesthetized and ventilated with a size 3.5 AIR-Q intubating laryngeal mask airway (LMA). Air leak was noticed with adequate ventilation after head rotation for allowing scalp blockage. Twenty-five minutes later, the LMA was replaced by an endotracheal tube because of a change in the surgical plan. After surgery, the patient consistently showed low tidal volume and was diagnosed with gastric insufflation and atelectasis using computed tomography. CONCLUSION: This case highlights head rotation may cause gas leakage, severe gastric insufflation, and consequent atelectasis during ventilation with an AIR-Q intubating laryngeal airway.

MicroRNA-34a promotes MICB expression in hepatocytes.

MicroRNA-34a (miR-34a) behaves as a tumor suppressor by decreasing the expression of oncogenes involved in multiple carcinogenic pathways. Intravenous delivery of miR-34a mimics has been investigated in clinical trials as a potential treatment for advanced cancers; however, the effect of miR-34a on cancer immune surveillance is controversial. In the current study, we found that miR-34a plays a dual role in the regulation of major histocompatibility complex class I-related sequence B (MICB) protein, a ligand of the NKG2D receptor. MiR-34a could both induce and reduce MICB expression by upregulating ataxia telangiectasia and Rad3-related (ATR) protein kinase and downregulating the transcription factor E2F1, respectively. The net effect of miR-34a on MICB expression depended on endogenous E2F1 levels. Overexpression of miR-34a promoted MICB expression in hepatocytes and hepatocellular carcinoma (HCC) cells that have low E2F1 levels but not in HCC cells that have high E2F1 levels. In HCC patients, the expression of miR-34a and MICB showed positive correlation in paratumor liver tissues, which have low E2F1 levels, but not in HCC tissues, which have high E2F1 levels. We showed that miR-34a overexpression in non-transformed liver cells enhanced cytolysis and interferon-γ production by NK-92MI cells. Furthermore, higher miR-34a expression in tumor and paratumor tissues was associated with positive and negative outcomes, respectively, in HCC patients. Our findings suggest that miR-34a induces MICB expression in paratumor liver tissues, which may cause liver damage and serious cytokine release syndrome, thus disclosing potential side effects of systemic administration of miR-34a in anticancer therapy.

Combined Preoperative ALBI and FIB-4 Is Associated with Recurrence of Hepatocellular Carcinoma After Curative Hepatectomy.

BACKGROUND AND PURPOSE: Chronic inflammatory response is a risk factor for hepatocarcinogenesis and recurrence. This study aimed to develop a nomogram incorporating the combined albumin-bilirubin (ALBI) and fibrosis-4 (FIB-4) scores and the peritumoral inflammation score (PIS) to predict postoperative recurrence-free survival (RFS) of hepatocellular carcinoma (HCC). METHODS: The prognostic roles of preoperative ALBI and FIB-4 scores for HCC recurrence were investigated, and a nomogram was developed. The predictive ability of the nomogram was compared with the American Joint Commission on Cancer (AJCC) and Barcelona Clinic Liver Cancer (BCLC) staging systems for HCC. Necroinflammatory activity in the peritumoral liver tissues was evaluated by hematoxylin and eosin (H&E) staining. RESULTS: Combined ALBI and FIB-4 was associated with PIS in the training and validation cohorts (r = 0.342 and 0.473, both P < 0.001), and all of the scores exhibited predictive value for RFS of HCC. The independent predictive factors of RFS such as AFP, tumor number, tumor size, microvascular invasion, PIS, and combined ALBI and FIB-4 were included in the corresponding nomogram. In the training cohort, the C-index of the RFS nomogram was 0.722. ROC analyses showed that the RFS nomogram had a larger AUC (0.739) than the AJCC and BCLC staging systems. These results were verified by the validation cohort. CONCLUSIONS: The proposed nomogram incorporating PIS and combined ALBI and FIB-4 was associated with recurrence for HCC following curative hepatectomy.

Comparison and validation of the prognostic value of preoperative systemic immune cells in hepatocellular carcinoma after curative hepatectomy.

In this study, we aimed to compare and validate the prognostic abilities of preoperative systemic immune cells in hepatocellular carcinoma (HCC) after curative hepatectomy. We developed two nomograms to predict the postoperative recurrence-free survival (RFS) and overall survival (OS) after comparisons of the systemic immune cell prognostic scores. The two nomograms were constructed based on 305 patients who underwent curative hepatectomy for HCC. The predictive accuracy and discriminative ability of the nomograms were compared with six commonly used staging systems for HCC. The results were validated using bootstrap resampling and an internal validation cohort of 142 patients and an external validation cohort of 169 patients. Necroinflammatory activity in peritumoral liver tissues in the primary cohort was evaluated by hematoxylin and eosin (H&E) staining. Neutrophil, monocyte, and lymphocyte ratio (NMLR) had a higher area under the receiver operating characteristic curves (AUROC) value at both RFS (AUC = 0.603) and OS (AUC = 0.726) compared to that of other systemic immune cell prognostic scores. The independent predictors of RFS or OS, including α-fetoprotein (AFP), tumor size, tumor number, microvascular invasion, and NMLR, were incorporated into the two nomograms. In the primary cohort, the C-indexes of the RFS and OS nomograms were 0.705 and 0.797, respectively. The ROC analyses showed that the two nomograms had larger AUC values (0.664 for RFS and 0.821 for OS) than those of the American Joint Commission on Cancer seventh edition, Barcelona Clinic Liver Cancer, Cancer of the Liver Italian Program, Japan Integrated Staging Score, Okuda stage, and the Vauthey's system. These results were verified by internal and external validations. The nomogram-predicted probability of RFS was associated with peritumoral necroinflammatory activity scores (r = 0.304, P < 0.001). The proposed nomograms had accurate prognostic prediction in patients with HCC after curative hepatectomy.

Phylogenetic relationships of Chlamydomyces, Harzia, Olpitrichum, and their sexual allies, Melanospora and Sphaerodes.

Phylogenetic analyses using internal transcribed spacer (ITS), large subunit rRNA (LSU), and small subunit (SSU) sequence data showed that Harzia, Chlamydomyces, and Olpitrichum are con-generic. Thus, Chlamydomyces, and Olpitrichum were reduced to synonymy of Harzia. The generic concept was amended and expanded accordingly. Eight new combinations were proposed. Melanospora and Sphaerodes are phylogenetically related to Harzia. However, several members of Melanospora and Sphaerodes are polyphyletic and belong to Hypocreales or Microascales in Sordariomycetes. The Proteophiala morph is not only a crucial morphological character, but also has a phylogenetical significance in defining Melanosporales. It is hypothesized that the taxa with synanamorphic or asexual Proteophiala all belong to Ceratostomataceae, Melanosporales.

Metavir and FIB-4 scores are associated with patient prognosis after curative hepatectomy in hepatitis B virus-related hepatocellular carcinoma: a retrospective cohort study at two centers in China.

Although Metavir and Fibrosis-4 (FIB-4) scores are typically used to assess the severity of liver fibrosis, the relationship between these scores and patient outcome in hepatocellular carcinoma (HCC) is unclear. The aim of this study was to evaluate the prognostic value of the severity of hepatic fibrosis in HBV-related HCC patients after curative resection. We examined the prognostic roles of the Metavir and preoperative FIB-4 scores in 432 HBV-HCC patients who underwent curative resection at two different medical centers located in western (Chongqing) and eastern (Shanghai) China. In the testing set (n = 108), the Metavir, FIB-4, and combined Metavir/FIB-4 scores were predictive of overall survival (OS) and recurrence-free survival (RFS). Additionally, they were associated with several clinicopathologic variables. In the validation set (n = 324), the Metavir, FIB-4, and combined Metavir/FIB-4 scores were associated with poor prognosis in HCC patients after curative resection. Importantly, in the negative alpha-fetoprotein subgroup (≤ 20 ng/mL), the FIB-4 index (I vs. II) could discriminate between patient outcomes (high or low OS and RFS). Thus Metavir, preoperative FIB-4, and combined Metavir/FIB-4 scores are prognostic markers in HBV-HCC patients after curative hepatectomy.

Systemic and intratumoral balances between monocytes/macrophages and lymphocytes predict prognosis in hepatocellular carcinoma patients after surgery.

The peripheral neutrophil-monocyte/lymphocyte ratio (NMLR) and intratumoral CD16/CD8 ratio (iMLR) may have prognostic value in hepatocellular carcinoma (HCC) patients after curative resection. In this study, the circulating NMLR was examined 387 HCC patients who underwent curative resection between 2006 and 2009. Intratumoral levels of CD4, CD8, CD16 and CD68 and the CD16/CD8 ratio were determined immunohistologically. The prognostic values of clinicopathological parameters, including NMLR and iMLR, were evaluated. NMLR was predictive of overall survival (OS) and recurrence-free survival (RFS) when patients in the training cohort (n = 256) were separated into high (> 1.2) and low (≤ 1.2) NMLR subgroups. NMLR was also an independent predictor of low alpha-fetoprotein (AFP) expression and early recurrence. High NMLR was associated with increases in clinicopathological variables, including alanine aminotransferase (ALT), tumor number, tumor size and BCLC stage. In addition, iMLR strongly predicted risk of recurrence and patient survival, and was positively correlated with NMLR. These findings were confirmed in an independent validation patient cohort (n = 131). Peripheral NMLR and iMLR may thus be useful prognostic markers, and anti-inflammatory treatment may be beneficial in HCC patients after curative hepatectomy.

Preoperative neutrophil-to-lymphocyte ratio predicts recurrence of patients with single-nodule small hepatocellular carcinoma following curative resection: a retrospective report.

BACKGROUND: Preoperative neutrophil-to-lymphocyte ratio (NLR) has been identified as a predictor for the recurrence of hepatocellular carcinoma (HCC), but the cut-off of NLR is inconsistent in various studies. Thus, we detected the prognostic value of preoperative NLR in the single-nodule small HCC (SHCC) patients using X-tile for cutpoint. METHODS: Between January 2007 and December 2010, a total of 222 single-nodule SHCC patients underwent curative resection and were examined for the prognostic roles of preoperative NLR by X-tile. RESULTS: In this study, all patients were divided into the low-NLR subgroup (NLR ≤ 2.1) and the high-NLR subgroup (NLR > 2.1) by X-tile. Preoperative NLR showed predictive value for time to recurrence (TTR) and overall survival (OS). Moreover, NLR was associated with total bilirubin, white blood cell counts, and HBsAg, respectively (P = 0.012, <0.001, and 0.011, respectively). Especially, NLR could discriminate the outcome of patients in the subgroup with alpha-fetoprotein (AFP) levels of ≤400 ng/mL. Importantly, postoperative transcatheter arterial chemoembolization (TACE) had close relationship with OS (P = 0.001) and TTR (P ≤ 0.001). CONCLUSIONS: Therefore, this study indicates that preoperative NLR, divided by X-tile for the cutpoint, is a simple prognostic marker for the patients with single-nodule SHCC after curative resection.

Conditional survival of pancreatic ductal adenocarcinoma in surgical and nonsurgical patients: a retrospective analysis report from a single institution in China.

BACKGROUND: Conditional survival (CS) could offer reliable prognostic information for patients who survived beyond a specified time since diagnosis when the impact of late effects have the greatest influence on prognosis. We aim to investigate CS for pancreatic ductal adenocarcinoma (PDAC) patients with surgery and nonsurgery. METHODS: Chinese PDAC patients between January 2002 and September 2012 were reviewed for analyses. CS rates were calculated for survivors after surgery and nonsurgery at different time points. RESULTS: Several clinicopathologic features were associated with overall survival (OS) in each subgroup including curative resection, palliative surgery, and nonsurgery. Both univariate and multivariate analyses showed that chemotherapy was a critical predictor for OS regardless of treatment status. CS rates were higher in the curative resected patients than other cases at the same time points. Importantly, stratification of 1-year CS by carcinoembryonic antigen (CEA), (carbohydrate antigen) CA19-9, and tumor stage showed lower CEA, CA19-9, and tumor stage associated with favorable 1-year CS over time (P = 0.016, 0.009 and 0.003). CONCLUSIONS: Dynamic CS estimates could be an accurate assessment for the prognosis of PDAC patients, allowing patients and clinicians to project subsequent survival based on time change.

Global diversity of the Ganoderma lucidum complex (Ganodermataceae, Polyporales) inferred from morphology and multilocus phylogeny.

Species of the Ganoderma lucidum complex are used in many types of health products. However, the taxonomy of this complex has long been chaotic, thus limiting its uses. In the present study, 32 collections of the complex from Asia, Europe and North America were analyzed from both morphological and molecular phylogenetic perspectives. The combined dataset, including an outgroup, comprised 33 ITS, 24 tef1α, 24 rpb1 and 21 rpb2 sequences, of which 19 ITS, 20 tef1α, 20 rpb1 and 17 rpb2 sequences were newly generated. A total of 13 species of the complex were recovered in the multilocus phylogeny. These 13 species were not strongly supported as a single monophyletic lineage, and were further grouped into three lineages that cannot be defined by their geographic distributions. Clade A comprised Ganoderma curtisii, Ganoderma flexipes, Ganoderma lingzhi, Ganoderma multipileum, Ganoderma resinaceum, Ganoderma sessile, Ganoderma sichuanense and Ganoderma tropicum, Clade B comprised G. lucidum, Ganoderma oregonense and Ganoderma tsugae, and Clade C comprised Ganoderma boninense and Ganoderma zonatum. A dichotomous key to the 13 species is provided, and their key morphological characters from context, pores, cuticle cells and basidiospores are presented in a table. The taxonomic positions of these species are briefly discussed. Noteworthy, the epitypification of G. sichuanense is rejected.

Outcomes of simple saline-coupled bipolar electrocautery for hepatic resection.

AIM: To evaluate the application of bipolar coagulation (BIP) in hepatectomy by comparing the efficacy of BIP alone, cavitron ultrasonic surgical aspirator (CUSA) + BIP and conventional clamp crushing (CLAMP). METHODS: Based on our database of patient records, a total of 380 consecutive patients who underwent hepatectomy at our hospital were retrospectively studied for the efficacy of BIP alone, CUSA + BIP and CLAMP. Of all the patients, 75 received saline-coupled BIP (Group A), 53 received CUSA + BIP (Group B), and 252 received CLAMP (Group C). The pre-, mid-, and postoperative clinical manifestations were compared, and the effects of those maneuvers were evaluated. RESULTS: There was no obvious difference among the preoperative indexes between the different groups. The operative time was longer in Groups A and B than in Group C (P < 0.001 for both). The amount of bleeding and the rate of transfusion during the operation were significantly higher in Group C than in Groups A and B (P < 0.001 for all). The incidence of postoperative complications in Group C (46.43%) was higher than that in Groups A (30.67%, P = 0.015) and B (28.30%, P = 0.016). The patients' liver function recovery and postoperative hospital stay were not significantly different. BIP could decrease intraoperative hemorrhage and postoperative complications compared to CLAMP. CONCLUSION: Simple saline-coupled BIP should be considered a safe and reliable technique for liver resection to decrease intraoperative hemorrhage and postoperative complications.

Controlled attenuation parameter for the detection of steatosis severity in chronic liver disease: a meta-analysis of diagnostic accuracy.

BACKGROUND AND AIM: Controlled attenuation parameter (CAP) is a novel ultrasound-based elastography method for detection of steatosis severity. This meta-analysis aimed to assess the performance of CAP. METHODS: PubMed, the Cochrane Library, and the Web of Knowledge were searched to find studies, published in English, relating to accuracy evaluations of CAP for detecting stage 1 (S1), stage 2 (S2), or stage 3 (S3) hepatic steatosis which was diagnosed by liver biopsy. Sensitivities, specificities, and hierarchical summary receiver operating characteristic (HSROC) curves were used to examine CAP performance. The clinical utility of CAP was also evaluated. RESULTS: Nine studies, with 11 cohorts were analyzed. The summary sensitivities and specificities values were 0.78 (95% confidence interval [CI], 0.69-0.84) and 0.79 (95% CI, 0.68-0.86) for ≥ S1, 0.85 (95% CI, 0.74-0.92) and 0.79 (95% CI, 0.71-0.85) for ≥ S2, and 0.83 (95% CI, 0.76-0.89) and 0.79 (95% CI, 0.68-0.87) for ≥ S3. The HSROCs were 0.85 (95% CI, 0.81-88) for ≥ S1, 0.88 (95% CI, 0.85-0.91) for ≥ S2, and 0.87 (95% CI, 0.84-0.90) for ≥ S3. Following a "positive" measurement (over the threshold value) for ≥ S1, ≥ S2, and ≥ S3, the corresponding post-test probabilities for the presence of steatosis (pretest probability was 50%) were 78%, 80% and 80%, respectively; if the values were below these thresholds ("negative" results), the post-test probabilities were 22%, 16%, and 17%, respectively. CONCLUSIONS: CAP has good sensitivity and specificity for detecting hepatic steatosis; however, based on a meta-analysis, CAP was limited in their accuracy of steatosis, which precluded widespread use in clinical practice.

Hepato-biliary-enteric stent drainage as palliative treatment for proximal malignant obstructive jaundice.

The proximal malignant obstructive jaundice remains one of the most challenging problems for hepato-biliary surgeons. Particularly when the findings preclude surgical resection at exploration, the next decision seems hard to make. A novel palliative treatment called "hepato-biliary-enteric stent drainage" was designed for these proximal malignant obstructive jaundice patients. Hepato-biliary-enteric stent drainage was performed with silicone tube whose diameter was determined according to the degree of dilated biliary ducts, and the proximal end of the tube was placed to intrahepatic ducts as far as possible, the distal end was placed across the duodenal papilla. Between February 2011 and August 2012, 23 patients with the proximal malignant obstructive jaundice of unresectable tumors at exploration received hepato-biliary-enteric stent drainage. Patient's liver function results, symptoms, complications, and survival time were documented. The bilirubin levels of all 23 patients had a considerable and persistent decrease after operation and remained low or normal before death except for four cases of recurrent jaundice (two resulted from migration of tube and other two resulted from hepatocellular carcinoma extensively involving liver parenchyma). After effective drainage, clinical symptoms of cholangitis such as fever or pain were markedly relieved. No procedure-related bleeding, bile leakage, pancreatitis were observed. The median survival time was 212 days, half-year and 1-year survival rate were 56.5 and 21.7%, respectively. Hepato-biliary-enteric stent drainage with less expense, less complications, and easy operation may be an ideal option for patients with unresectable malignancy in the hilar region at exploration.

Performance of shear wave elastography for differentiation of benign and malignant solid breast masses.

OBJECTIVES: To perform a meta-analysis assessing the ability of shear wave elastography (SWE) to identify malignant breast masses. METHODS: PubMed, the Cochrane Library, and the ISI Web of Knowledge were searched for studies evaluating the accuracy of SWE for identifying malignant breast masses. The diagnostic accuracy of SWE was evaluated according to sensitivity, specificity, and hierarchical summary receiver operating characteristic (HSROC) curves. An analysis was also performed according to the SWE mode used: supersonic shear imaging (SSI) and the acoustic radiation force impulse (ARFI) technique. The clinical utility of SWE for identifying malignant breast masses was evaluated using analysis of Fagan plot. RESULTS: A total of 9 studies, including 1888 women and 2000 breast masses, were analyzed. Summary sensitivities and specificities were 0.91 (95% confidence interval [CI], 0.88-0.94) and 0.82 (95% CI, 0.75-0.87) by SSI and 0.89 (95% CI, 0.81-0.94) and 0.91 (95% CI, 0.84-0.95) by ARFI, respectively. The HSROCs for SSI and ARFI were 0.92 (95% CI, 0.90-0.94) and 0.96 (95% CI, 0.93-0.97), respectively. SSI and ARFI were both very informative, with probabilities of 83% and 91%, respectively, for correctly differentiating between benign and malignant breast masses following a "positive" measurement (over the threshold value) and probabilities of disease as low as 10% and 11%, respectively, following a "negative" measurement (below the threshold value) when the pre-test probability was 50%. CONCLUSIONS: SWE could be used as a good identification tool for the classification of breast masses.