Establishment and assessment of mortality risk prediction model in patients with sepsis based on early-stage peripheral lymphocyte subsets.

This study is aimed to explore the value of lymphocyte subsets in evaluating the severity and prognosis of sepsis. The counts of lymphocytes, CD3+ T cells, CD4+ T cells, CD8+ T cells, CD19+ B cells, and NK cells significantly decreased between day 1 and day 3 in both the survivor and the non-survivor groups. The peripheral lymphocyte subsets (PLS) at day 1 were not significantly different between the survivor and the non-survivor groups. However, at day 3, the counts of lymphocytes, CD3+ T cells, CD4+ T cells, and NK cells were remarkably lower in the non-survivor group. No significant differences in CD8+ T cells, or CD19+ B cells were observed. The PLS index was independently and significantly associated with the 28-day mortality risk in septic patients (OR: 3.08, 95% CI: 1.18-9.67). Based on these clinical parameters and the PLS index, we developed a nomograph for evaluating the individual mortality risk in sepsis. The area under the curve of prediction with the PLS index was significantly higher than that from the model with only clinical parameters (0.912 vs. 0.817). Our study suggests that the decline of PLS occurred in the early stage of sepsis. The new novel PLS index can be an independent predictor of 28-day mortality in septic patients. The prediction model based on clinical parameters and the PLS index has relatively high predicting ability.

Analysis of the phytochemical components of Prunella vulgaris using high-performance liquid chromatography quadrupole time-of-flight mass spectrometry combined with molecular networking and assessment of their antioxidant and anti-α-glucosidase activities.

Prunella vulgaris has long been used in traditional medicine and is consumed as a tea in China. Here, the total phenolic and flavonoid concentrations of plants from different geographical regions were measured. It was found that the total phenolic acid concentration ranged from 4.15 to 8.82 g of gallic acid equivalent per 100 g of dry weight (DW), and the total flavonoid concentration was 4.67-7.33 g of rutin equivalent per 100 g DW. Antioxidant activities were measured using 2,2-diphenyl-1-picrylhydrazyl and 2,2'-azino-bis-(3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt, and the results ranged from 73.47% to 94.43% and 74.54% to 93.39%, respectively, whereas α-glucosidase inhibition was between 75.31% and 95.49%. Correlation analysis showed that the total flavonoids in P. vulgaris had superior antioxidant and anti-α-glucosidase activities compared to the total phenolic compounds. The active components of P. vulgaris were analyzed using high-performance liquid chromatography quadrupole time-of-flight mass spectrometry combined with both classical molecular networking and feature-based molecular networking on the Global Natural Products Social platform, identifying 32 compounds, namely 14 flavonoids, 12 phenolic compounds, and 6 other chemical components. These results could provide useful information on the use of P. vulgaris as a functional tea.

Intraoperative pain prediction of percutaneous kyphoplasty under local anesthesia by preoperative experimental pain assessment.

BACKGROUND: Percutaneous kyphoplasty (PKP) is the preferred treatment for osteoporotic vertebral compression fractures (OVCF) Currently, the preoperative anesthesia methods for PKP are mainly local anesthesia and tracheal intubation general anesthesia. OBJECTIVE: To assess whether patient sensitivity to pain measured preoperatively could predict the patients' pain response during PKP treatment under local anesthesia, to facilitate the development of an optimal preoperative anesthesia plan for patients. METHODS: Fifty-five female patients diagnosed with osteoporotic single vertebral fracture who were treated with PKP under local anesthesia were selected. The patients' pain sensitivities, including pain threshold and pain tolerance threshold, were evaluated with a pain test device on the day before the operation in the ward. Heart rate (HR), mean arterial pressure (MAP), and blood oxygen saturation (SpO2) were recorded before anesthesia, post-anesthesia, after needle puncture, and after balloon dilatation. At the same time, blood was drawn at the above time points to determine the level of norepinephrine (NA) as an indicator of intraoperative pain stress response. The numerical rating scale (NRS) during surgery was recorded at the end of the surgery. RESULTS: The preoperative pain tolerance threshold of 55 surgical patients was correlated with the intraoperative NRS score (r=-0.768, P< 0.001), as well as with the preoperative and intraoperative changes in HR (r=-0.791, P< 0.001), MAP (r=-0.819, P< 0.001), and NA (r=-0.553, P< 0.001). Thus, the lower the preoperative pain tolerance threshold, the more severe the patient's response to pain during PKP treatment under local anesthesia, and the greater the hemodynamic changes. Consequently, the intraoperative experience becomes worse. However, there was no correlation between preoperative pain threshold and NRS scores (r=-0.069, P= 0.616) nor between the preoperative and intraoperative changes in HR (r= 0.103, P= 0.453), MAP (r= 0.086, P= 0.535), and NA (r=-0.058, P= 0.674). CONCLUSION: The results indicated that preoperative pain assessment could predict the level of pain response in OVCF patients during PKP surgery under local anesthesia.

Multifunctional trade-off and compensation mechanism of arable land under the background of rural revitalization: a case study in the West Mountain Regions of Hubei Province.

Exploring the spatial relationship and ecological compensation mechanism of each function of arable land in poor mountainous areas is important to promote rural revitalization and enhance arable land protection. Taking the mountainous region of Western Hubei (MRWH) as an example, this study quantified the "three living" functions of arable land and its secondary functions. Using the root mean square deviation method to calculate the trade-off index, a quantitative method can more scientifically reflect the trade-off relationship between arable land functions and measure the overall ecological compensation. Studies have shown that (1) the value of the production function exhibits a growing and subsequently a falling trend, whereas the value of living function and ecological function exhibits an increasing trend over time, with an average functional value of 5310, 220 and 6496 million yuan, respectively. The spatial pattern of the "three living" functional values decreases from west to east. Among them, water conservation and soil conservation function values show a high distribution in the south and low in the north, gas purification and agricultural pollution functional values show a scattered spatial pattern, and the value of other functions shows an increasing trend from southeast to northwest; (2) among the primary functions, the trade-off between production and ecological functions is the strongest, decreasing, and then increasing over time, with an average trade-off index of 0.89. Among the secondary functions, there is the most obvious trade-off between the food supply function and the five ecological functions, which requires coordination; (3) overall, the total amount of ecological compensation has shown an upward trend, with priority areas for level I ecological compensation increasing year by year. Optimized compensation zones and potential compensation zones are concentrated in the northwest, ecological balance zones are located in the central part, and optimized development compensation zones and key development compensation zones are located in the southeast. According to the research, MRWH is oriented to ecological function, followed by the production function, supplemented by the living function. Green agriculture should be vigorously developed and ecological function space should be compressed by strictly limiting the excessive expansion of production activities. Promoting the improvement of production function through ecological function, while exploring the potential value of living function. Ecological compensation in strict accordance with the priority of ecological compensation, zoning. Realizing cross-regional cooperation, low compensation areas drive high compensation areas to achieve sustainable development of arable land.

Plasma cell-free DNA promise monitoring and tissue injury assessment of COVID-19.

Coronavirus 2019 (COVID-19) is a complex disease that affects billions of people worldwide. Currently, effective etiological treatment of COVID-19 is still lacking; COVID-19 also causes damages to various organs that affects therapeutics and mortality of the patients. Surveillance of the treatment responses and organ injury assessment of COVID-19 patients are of high clinical value. In this study, we investigated the characteristic fragmentation patterns and explored the potential in tissue injury assessment of plasma cell-free DNA in COVID-19 patients. Through recruitment of 37 COVID-19 patients, 32 controls and analysis of 208 blood samples upon diagnosis and during treatment, we report gross abnormalities in cfDNA of COVID-19 patients, including elevated GC content, altered molecule size and end motif patterns. More importantly, such cfDNA fragmentation characteristics reflect patient-specific physiological changes during treatment. Further analysis on cfDNA tissue-of-origin tracing reveals frequent tissue injuries in COVID-19 patients, which is supported by clinical diagnoses. Hence, our work demonstrates and extends the translational merit of cfDNA fragmentation pattern as valuable analyte for effective treatment monitoring, as well as tissue injury assessment in COVID-19.

Evaluation of Landslide Susceptibility Based on CF-SVM in Nujiang Prefecture.

At present, landslide susceptibility assessment (LSA) based on landslide characteristics in different areas is an effective measure for landslide management. Nujiang Prefecture in China has steep mountain slopes, a large amount of water and loose soil, and frequent landslide disasters, which have caused a large number of casualties and economic losses. This paper aims to understand the characteristics and formation mechanism of regional landslides through the evaluation of landslide susceptibility so as to provide relevant references and suggestions for spatial planning and disaster prevention and mitigation in Nujiang Prefecture. Based on the grid cell, this study selected 10 parameters, namely elevation, slope, aspect, lithology, proximity to faults, proximity to road, proximity to rivers, normalized difference vegetation index (NDVI), land-use type, and precipitation. Support vector machine (SVM), certainty factor method (CF), and deterministic coefficient method-support vector machine (CF-SVM) were used to evaluate the landslide susceptibility in Nujiang Prefecture. According to these three models, the study area was divided into five landslide susceptibility grades, including extremely high susceptibility, high susceptibility, moderate susceptibility, low susceptibility, and very low susceptibility. Receiver operating characteristic curve (ROC) was applied to verify the accuracy of the model. The results showed that CF model (ROC = 0.865), SVM model (ROC = 0.892), CF-SVM model (ROC = 0.925), and CF-SVM model showed better performance. Therefore, CF-SVM model results were selected for analysis. The study found that the characteristics of high and extremely high landslide-prone areas in Nujiang Prefecture have the following characteristics: intense human activities, large density of buildings and arable land, rich water resources, good economic development, perfect transportation facilities, and complex topography and landform. In addition, there is a finding inconsistent with our common sense that the distribution of landslide disasters in the study area does not decrease with the increase of NDVI value. This is because the Nujiang River basin is a high mountain canyon area with low rock strength, barren soil, and underdeveloped vegetation and root system. In an area with large slope, the probability of landslide disaster will increase with the increase of NDVI. The CF-SVM coupling model adopted in this study is a good first attempt in the study of landslide hazard susceptibility in Nujiang Prefecture.

Qualitative and quantitative assessment of pendelluft: a simple method based on electrical impedance tomography.

BACKGROUND: Pendelluft, defined as asynchronous alveolar ventilation, is caused by different regional time constants or dynamic pleural pressure variations. The aim of the present study was to propose a simple method to evaluate pendelluft based on electrical impedance tomography (EIT). The efficacy of this method was demonstrated in well-known pendelluft scenarios in 6 patients. METHODS: Two patients with flail chest after accidents, two patients with acute respiratory distress syndrome (ARDS) and two patients with acutely exacerbated obstructive lung disease were prospectively included. EIT measurements were performed before and after surgery (in patients with flail chest, who had video-assisted thoracoscopic surgery with ribs fixation), or at two different levels of positive end-expiratory pressure (PEEP; ARDS patients), or two different time points (obstructive lung disease). Pendelluft was assessed by regional phase shift (defined as time difference between global and regional impedance-time curves) and amplitude differences (defined as the impedance difference between sum of all regional tidal variation and the global tidal variation). RESULTS: In patients with flail chest, pendelluft diminished several days after surgery (pendelluft amplitude normalized to tidal impedance variation reduced from 88% to 2% in one patient, 12% to 2% in the other). Increased PEEP reduced the amplitude of pendelluft (from 3% to 0% in one patient, 20% to 2% in the other) but not necessarily the phase shifts (average time differences were <0.1 second for both patients for both ins- and expiration) in ARDS patients. Pendelluft assessment in obstructive lung diseases reflected the change in airway resistance (from 5% to 1% in one patient after broncholytic medication administration, as airway resistance fell from 15 to 11 cmH2O/L/s; from 9% to 35% in the other patient with acute exacerbation, the corresponding airway resistance increased from 15 to 22 cmH2O/L/s). CONCLUSIONS: The proposed EIT-based method can be used to evaluate the degree of pendelluft in dimension of phase shift and amplitude difference.

Validation of a Chinese Version of the Parental Burnout Assessment.

Parenting is a meaningful endeavor but it also induces stress, which can cause parental burnout. In China, the assessment and study of parental burnout are still in their formative stages. To contribute to advancing this field, the present study aimed to develop and validate a Chinese version of the Parental Burnout Assessment (PBA). Questionnaires were distributed to 614 families (comprising students in the eighth grade and both of their parents; one questionnaire for each person) on two separate occasions (Time 1 and Time 2). The students were asked to self-report their loneliness and life satisfaction at Time 1 and their anti-social behavior at Time 2. Meanwhile, parents were asked to self-report their parental burnout and job burnout at both Time 1 and Time 2, their marriage satisfaction at Time 1, and their levels of agreeableness and neuroticism at Time 2. Using the data obtained, we performed exploratory and confirmatory factor analyses, which indicated that this version of the PBA had a single-factor structure. The α of the PBA was 0.938 at Time 1 and 0.952 at Time 2. At Time 1, parental burnout was positively related to their job burnout in emotional exhaustion and depersonalization, and negatively related to their marriage satisfaction. In addition, parental burnout was positively related to students' life satisfaction, and mothers' parental burnout was positively related to students' loneliness. At Time 2, parental burnout showed positive relations with neuroticism and job burnout in emotional exhaustion and depersonalization, and was negatively related to agreeableness. In addition, mothers' parental burnout was positively related to students' anti-social behavior. Furthermore, parental burnout at Time 1 also showed positive relations with job burnout through emotional exhaustion and depersonalization measured at Time 2, and parental burnout at Time 1 was positively related to students' anti-social behavior at Time 2. Overall, the present study confirmed the reliability and validity of the Chinese version of the PBA.

Perineal Assessment Tool (PAT-C): Validation of a Chinese Language Version and Identification of a Clinically Validated Cut Point Using ROC Curve Analysis.

PURPOSE: The purpose of this study was to evaluate content validity and feasibility of the Chinese language perineal assessment tool (PAT-C), to assess its use in the clinical setting, and establish an optimal cut point for identifying patients at high risk for incontinence-associated dermatitis (IAD). DESIGN: Psychometric evaluation of existing instrument. SUBJECTS AND SETTING: The sample comprised 440 patients managed in intensive care units of 3 hospitals across the island of Taiwan and an affiliated home care service. One hundred three nurses practicing throughout Taiwan participated in the workshops in the third phase of the experiment. METHODS: The content validity of the PAT-C was evaluated by 3 experienced nurses using the content validity index statistic. We calculated a receiver operating characteristics (ROC) curve to determine a cut point of high-risk IAD. The curve was based on assessment of patients from receiving care from the intensive care unit and home care service of Cathay General Hospital (located in Taipei, New Paipei and Hsinchu). Nurse perceptions on the feasibility of PAT-C were assessed using an investigator-developed survey. RESULTS: Three experienced nurses rated the PAT-C and gave a robust overall content validity index score of 97.22%. The cut point for identifying patients at high risk for developing IAD via ROC curve analysis of 440 patients was 7.5 (sensitivity: 0.85; specificity: 0.79, area under curve: 0.82, P value < .001). One hundred three enrolled nurses attended the workshops and evaluated the feasibility using the PAT-C. Most of the participants considered the PAT-C as necessary (97.90%), 49.7% of participants suggested IAD risk assessment should be implemented by first-line (generalist) nurses, and 40% of participants recommended assessment on a daily basis. CONCLUSIONS: Study findings indicate robust content validity, and results of the investigator survey of nurse perceptions of the PAT-C indicate the potential for its widespread use in the clinical setting. We found that a cut point score 8 or more indicates a high risk for developing IAD.

Critical Care Resources in Guangdong Province of China: Three Surveys from 2005 to 2015.

OBJECTIVES: Data about the critical care resources in China remain scarce. The purpose of this study was to investigate the variation and distribution of critical care resources in Guangdong province from 2005 to 2015. DESIGN: Data in regard to critical care resources were collected through questionnaires and visits every 5 years from 2005. SETTING: All hospitals in Guangdong province were screened and hospitals that provide critical care services were enrolled. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: One hundred eleven, 158, and 284 hospitals that provide critical care services were enrolled in the three consecutive surveys respectively. The number of ICUs, ICU beds, intensivists, and nurses increased to 324, 3,956, 2,470, and 7,695, respectively, by 2015. Adjusted by population, the number of ICU beds per 100,000 (100,000) population increased by 147.7% from 2005 to 2015, and the number of intensivists and nurses per 100,000 population increased by 35.3% and 55.1% from 2011 to 2015. However, the numbers in the Pearl River Delta, a richer area, were higher than those in the non-Pearl River Delta area (ICU beds: 4.64 vs 2.58; intensivists: 2.90 vs 1.61; nurses: 9.30 vs 4.71 in 2015). In terms of staff training, only 17.85% of intensivists and 14.29% of nurses have completed a formal accredited critical care training program by 2015. CONCLUSIONS: Our study was the first one to investigate the trend and distribution of critical care resources in China. The quantity of ICU beds and staff has been increasing rapidly, but professional training for staff was inadequate. The distribution of critical care resources was unbalanced. Our study can be beneficial for healthcare policymaking and the allocation of critical care resources in Guangdong province and other provinces in China.

Clinical manifestations of severe enterovirus 71 infection and early assessment in a Southern China population.

BACKGROUND: Enterovirus 71 (EV-A71) shows a potential of rapid death, but the natural history of the infection is poorly known. This study aimed to examine the natural history of EV-A71 infection. METHODS: This was a prospective longitudinal observational study performed between January 1st and October 31st, 2012, at three hospitals in Guangdong, China. Subjects with positive EV-A71 RNA laboratory test results were included. Disease progression was documented with MRI, autopsies, and follow-up. Symptoms/signs with potential association with risk of death were analyzed. RESULTS: Among the 288 patients, neurologic symptoms and signs were observed (emotional movement disorders, dyskinesia, involuntary movements, autonomic dysfunction, and disturbance of consciousness). Some of them occurred as initial symptoms. Myoclonic jerks/tremors were observed among >50% of the patients; nearly 40% of patients presented fatigue and 25% were with vomiting. Twenty-eight patients (9.7%) presented poor peripheral perfusion within 53.4 ± 26.1 h; 23 patients (8.0%) presented pulmonary edema and/or hemorrhage within 62.9 ± 28.6 h. Seventeen (5.9%) patients were in a coma. Seven (2.4%) patients died within 62.9 ± 28.6 h. Seventy-seven survivors underwent head and spinal cord MRI and 37.7% (29/77) showed abnormalities. Two fatal cases showed neuronal necrosis, softening, perivascular cuffing, colloid, and neuronophagia phenomenon in the brainstem. CONCLUSIONS: Patients with EV-A71 infection showed high complexity of symptoms and onset timing. Death risk may be indicated by autokinetic eyeball, eyeball ataxia, severe coma, respiratory rhythm abnormality, absent pharyngeal reflex, ultrahyperpyrexia, excessive tachycardia, pulmonary edema and/or hemorrhage, and refractory shock and ataxic respiration. Early assessment of these symptoms/signs is important for proper management.

Population Pharmacokinetics in China: The Dynamics of Intravenous Voriconazole in Critically Ill Patients with Pulmonary Disease.

Pharmacokinetic research in China on the use of voriconazole in critically ill adult patients with different pulmonary diseases remains to be explored. This study evaluated the population pharmacokinetics of the use of voriconazole (VRC) in critically ill patients to determine covariate effects on VRC pharmacokinetics by NONMEM, which could further optimize VRC dosing in this population. A one-compartment model with first-order absorption and elimination best fit the data, giving 4.28 L/h clearance and 93.4 L volume of distribution of VRC. The model variability, described as an approximate percentage coefficient of interindividual variability in clearance and volume of distribution, was 72.94% and 26.50%, respectively. A significant association between Cmin and drug response or grade 2 hepatotoxicity was observed (p=0.002, <0.001, respectively, 1.5-4.0 µg/mL) via logistic multivariate regression. Monte Carlo simulations at 100, 150, 200, and 250 mg dosage predicted effectiveness at 45.99%, 99.76%, 98.76%, and 67.75% within the 1.5-4.0 µg/mL range, suggesting that a 150 or 200 mg intravenous dose twice daily is best suited to achieve the target steady state trough concentration range in critically ill patients with pulmonary disease.

Quality Assessment of Clinical Practice Guidelines for Respiratory Diseases in China: A Systematic Appraisal.

BACKGROUND: There has been a significant increase in the publication of clinical practice guidelines (CPGs) for respiratory diseases in China. However, little is known about the quality and potential impacts of these CPGs. Our objective was to critically evaluate the quality of Chinese CPGs for respiratory diseases that were published in peer-reviewed medical journals. METHODS: A systematic search of scientific literature published between 1979 and 2013 was undertaken to identify and select CPGs that were related to respiratory diseases. Four Chinese databases (the Chinese Biomedical Literature database [CBM], the China National Knowledge Infrastructure [CNKI], the VIP database, and the WANFANG database) were used. The quality of eligible guidelines was assessed independently by four reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. The overall agreement among reviewers was evaluated using an intraclass correlation coefficient. RESULTS: A total of 109 guidelines published in 27 medical journals from 1979 to 2013 were evaluated. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.838; 95% CI, 0.812-0.862). The scores of the six AGREE domains were low: 57.3% for scope and purpose (range, 4.2%-80.5%), 23.8% for stakeholder involvement (range, 2.8%-54.2%), 7.7% for rigor of development (range, 0%-27.1%), 59.8% for clarity and presentation (range, 22.2%-80.6%), 10.9% for applicability (range, 0%-22.9%), and 0.6% for editorial independence (range, 0%-16.7%). Scores for all guidelines were below 60%, and only three guidelines (2.8%) were recommended for clinical practice with modifications. CONCLUSIONS: The quality of the guidelines was low, and stakeholder involvement, rigor of development, applicability, and editorial independence should be considered in the future development of CPGs for respiratory diseases in China.

Assessment of tear film stability in dry eye with a newly developed keratograph.

PURPOSE: To investigate the applicability of a newly developed corneal topographer in assessing tear film stability. METHODS: This is a prospective, case-control study. Forty-four Chinese dry eye patients and 41 normal subjects were recruited. Noninvasive tear film break-up time (NI-BUT) was measured using a new method based on a corneal topographer equipped with modified scan software. The reliability of the measurements was determined. Then, the correlations between the NI-BUT and the traditional fluorescein tear film break-up time, Schirmer I test values, and inferior tear meniscus height measurements were determined. The receiver operating characteristic curve technique was used to evaluate the NI-BUT examination in the diagnosis of dry eye. RESULTS: In total, a significant difference between the NI-BUT and the fluorescein tear film break-up time was found (3.2 ± 2.3 seconds vs. 5.2 ± 3.4 seconds; P < 0.001). The coefficient of variation and intraclass correlation coefficient values of NI-BUT were 12.8% and 0.93, respectively, for NI-BUT for intraobserver repeatability and 15.4% and 0.88, respectively for interobserver repeatability. The NI-BUT showed a good correlation with other dry eye examinations (all P < 0.05). In addition, the NI-BUT was significantly shorter in dry eye patients (2.0 ± 0.2 seconds) than in normal subjects (4.3 ± 0.3 seconds; P < 0.001). When the cutoff value was set at <2.65 seconds, the sensitivity and specificity of the test were 84.1% and 75.6%, respectively. CONCLUSIONS: Measurements of NI-BUT obtained with the newly developed corneal topographer may provide a simple, noninvasive screening test for dry eyes with acceptable sensitivity, specificity, and repeatability.

Assessment of limbus and central cornea in patients with keratolimbal allograft transplantation using in vivo laser scanning confocal microscopy: an observational study.

BACKGROUND: Keratolimbal allograft (KLAL) transplantation has been proved to be a useful surgical procedure for limbal stem cell deficiency patients. However, information about in vivo ocular surface changes in those patients is limited, due to the lack of a reliable and non-invasive technique for closely monitoring the changes of KLAL grafts. The aim of this study is to characterize the cellular changes in the limbus and central cornea after KLAL in patients with severe ocular chemical injury, using in vivo laser scanning confocal microscopy (LSCM). METHODS: This is a prospective, noncomparative, observational case series. Twenty-three patients (23 eyes) with total limbal stem cell deficiency due to ocular chemical injury were recruited. KLAL with or without other concurrent surgery were performed. LSCM and slit-lamp examination were performed on the limbus and the central cornea before surgery and at 6 and 12 months postoperatively. Presence of palisades of Vogt, limbal basal epithelial cell density within the palisades of Vogt (LEC), limbal dendritic cells (DC) density, and central corneal basal epithelial cell (CEC) density were assessed by LSCM. RESULTS: All patients completed 12 months of follow-up. Twenty-one patients were male and two were female, with a mean age of 39.5 ± 12.5 years. Six cases were due to acid burns, and the others were alkali burns. Palisades of Vogt were observed in all surviving grafts but were absent in graft failure. The epithelial cells in the central cornea of the failed graft had lost the classic polygonal morphology of the normal corneal basal epithelial cells. The cell density of LEC and CEC decreased significantly, whereas DC density increased in the failed grafts over time. CONCLUSIONS: In vivo LSCM is a useful tool for monitoring the cellular changes in KLAL grafts, and has the potential to diagnose the failure of KLAL grafts at the cellular level.