Elucidating prioritized factor for mainstream partial nitritation between C/N ratio and dissolved oxygen: Response surface methodology and microbial community shifts.

Recently, C/N ratio is suggested as a promising control factor with dissolved oxygen (DO) achieving mainstream partial nitritation (PN); however, their combined effects on mainstream PN are still limited. This study evaluated the mainstream PN with respect to the combined factors, and investigated the prioritized factor affecting the community of aerobic functional microbes competing with NOB. Response surface methodology was performed to assess the combined effects of C/N ratio and DO on the activity of functional microbes. Aerobic heterotrophic bacteria (AHB) played the greatest role in oxygen competition among functional microbes, which resulted in relative inhibition of nitrite-oxidizing bacteria (NOB). The combination of high C/N ratio and low DO had a positive role in the relative inhibition of NOB. In bioreactor operation, the PN was successfully achieved at ≥ 1.5 of C/N ratio for 0.5-2.0 mg/L DO conditions. Interestingly, aerobic functional microbes outcompeting NOB were shifted with C/N ratio rather than DO, suggesting C/N ratio is more prioritized factor achieving mainstream PN. These findings will provide insights into how combined aerobic conditions contribute to achieve mainstream PN.

Chronic Hepatitis B Infection Is Significantly Associated with Chronic Kidney Disease: a Population-based, Matched Case-control Study.

BACKGROUND: Hepatitis B virus (HBV) infection leads to hepatic and extrahepatic manifestations including chronic kidney disease (CKD). However, the association between HBV and CKD is not clear. This study investigated the association between chronic HBV infection and CKD in a nationwide multicenter study. METHODS: A total of 265,086 subjects who underwent health-check examinations in 33 hospitals from January 2015 to December 2015 were enrolled. HBV surface antigen (HBsAg) positive cases (n = 10,048), and age- and gender-matched HBsAg negative controls (n = 40,192) were identified. CKD was defined as a glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 or proteinuria as at least grade 2+ of urine protein. RESULTS: HBsAg positive cases showed a significantly higher prevalence of GFR < 60 mL/min/1.73 m2 (3.3%), and proteinuria (18.9%) than that of the controls (2.6%, P < 0.001, and 14.1%, P < 0.001, respectively). In the multivariate analysis, HBsAg positivity was an independent factor associated with GFR < 60 mL/min/1.73 m2 along with age, blood levels of albumin, bilirubin, anemia, and hemoglobin A1c (HbA1c). Likewise, HBsAg positivity was an independent factor for proteinuria along with age, male, blood levels of bilirubin, protein, albumin, and HbA1c. A subgroup analysis showed that HBsAg positive men but not women had a significantly increased risk for GFR < 60 mL/min/1.73 m2. CONCLUSION: Chronic HBV infection was significantly associated with a GFR < 60 mL/min/1.73 m2 and proteinuria (≥ 2+). Therefore, clinical concern about CKD in chronic HBV infected patients, especially in male, is warranted.

Utility of the simplified Wells and revised Geneva scores to exclude pulmonary embolism in femur fracture patients.

OBJECTIVES: The diagnosis of acute pulmonary embolism (PE) in trauma patients is challenging. This study evaluated the diagnostic value of simplified Wells and simplified revised Geneva scores to predict PE in femur fracture patients in emergency department (ED). METHODS: All consecutive adult patients with femur fractures and elevated D-dimer levels (>0.5µg/mL) who underwent CTPA within 72h of injury from January 2010 to December 2014 were included. The simplified Wells and simplified revised Geneva scores were applied to evaluate the clinical probability of PE. RESULTS: Among 519 femur fracture patients, 446 patients were finally included, and 23 patients (5.2%) were diagnosed with acute PE. The median values of simplified Wells and simplified revised Geneva scores [0 (IQR: 0-1) vs. 0 (IQR: 0-0), P=0.23; 3 (IQR: 2-4) vs. 3 (IQR: 2-3), P=0.48] showed no differences between the PE (n=23) and non-PE (n=423) groups. Using the simplified Wells score, 98% of the patients were categorized into the "PE unlikely" group. The sensitivity, specificity, positive predictive value, and negative predictive value of the simplified revised Geneva score (≥3 points) for the diagnosis of PE were 74%, 35%, 6%, and 96%, respectively. CONCLUSION: In femur fracture patients with elevated D-dimer levels, the simplified Wells and simplified revised Geneva scores have limited predictive value. However, the simplified revised Geneva score of <3 points may be possibly used as a diagnostic tool.

Aerobic and anoxic utilization of organic matter for flexible nitrite supply in nutrient conversion pathways based on anaerobic ammonium oxidation: Microbial interactive mechanism.

This study investigated nutrient conversion pathways and corresponding interactive mechanisms in a mainstream partial-nitritation (PN)/anaerobic ammonium oxidation (anammox)/partial-denitrification-(PD)-enhanced biological phosphorus-removal (EBPR) (PN/A/PD-EBPR) process. A laboratory-scale sequencing batch reactor was operated for 301 days under different operational strategies. Mainstream PN/A/PD-EBPR was successfully operated with aerobic and anoxic utilization of organic matter. Aerobic utilization of organic matter was an effective strategy for conversion to denitrifying polyphosphate-accumulating organism-based phosphorus removal, referring to a biological reaction that outperformed nitrite-oxidizing bacteria. Aerobically adsorbed organic matter could be used as a carbon source for PD, which further enhanced nitrogen removal by PN/A. Ultimately, the interaction between complex nutrient conversion pathways served to achieve stable performance. High-throughput sequencing results elucidated the core microbe functioning in the mainstream PN/A/PD-EBPR process with respect to various nutrients. The outcomes of this study will be beneficial to those attempting to implement mainstream PN/A/PD-EBPR.

Odor reduction using hydrogen sulfide-removing bacteria in sludge filtration systems: Ferrous-oxidizing bacteria and sulfur-oxidizing bacteria.

The preconditioning of digested sludge in sludge filtration systems produces hydrogen sulfide (H2S), a major odor-causing source. This study evaluated the effects of adding H2S-removing bacteria to sludge-filtration systems. Ferrous-oxidizing bacteria (FOB) and sulfur-oxidizing bacteria (SOB) were mass-cultivated in a hybrid bioreactor equipped with an internal circulation system. In this bioreactor, FOB and SOB effectively removed >99% of H2S; however, the acidic conditions created by adding a coagulant during digested sludge preconditioning were more favorable for FOB than for SOB. In batch tests, SOB and FOB removed 94 ± 1.1% and 99 ± 0.1% of H2S, respectively; therefore, digested sludge preconditioning proved more suitable for FOB activity than SOB activity. The results revealed that the optimal FOB addition ratio was 0.2%, validated using a pilot filtration system. Moreover, the 57.5 ± 2.9 ppm H2S generated in the sludge preconditioning step was reduced to 0.01 ± 0.01 ppm after adding 0.2% FOB. Therefore, the results of this study will be useful because they provide a process for biologically removing odor-causing sources without affecting the dewatering efficiency of the filtration system.

Phloretin Ameliorates Succinate-Induced Liver Fibrosis by Regulating Hepatic Stellate Cells.

BACKGRUOUND: Hepatic stellate cells (HSCs) are the major cells which play a pivotal role in liver fibrosis. During injury, extracellular stimulators can induce HSCs transdifferentiated into active form. Phloretin showed its ability to protect the liver from injury, so in this research we would like to investigate the effect of phloretin on succinate-induced HSCs activation in vitro and liver fibrosis in vivo study. METHODS: In in vitro, succinate was used to induce HSCs activation, and then the effect of phloretin on activated HSCs was examined. In in vivo, succinate was used to generated liver fibrosis in mouse and phloretin co-treated to check its protection on the liver. RESULTS: Phloretin can reduce the increase of fibrogenic markers and inhibits the proliferation, migration, and contraction caused by succinate in in vitro experiments. Moreover, an upregulation of proteins associated with aerobic glycolysis occurred during the activation of HSCs, which was attenuated by phloretin treatment. In in vivo experiments, intraperitoneal injection of phloretin decreased expression of fibrotic and glycolytic markers in the livers of mice with sodium succinate diet-induced liver fibrosis. These results suggest that aerobic glycolysis plays critical role in activation of HSCs and succinate can induce liver fibrosis in mice, whereas phloretin has therapeutic potential for treating hepatic fibrosis. CONCLUSION: Intraperitoneal injection of phloretin attenuated succinate-induced hepatic fibrosis and alleviates the succinate-induced HSCs activation.

Evaluation of operating parameters affecting the two-stage nitritatin/anammox process in mainstream flows: From lab-scale to pilot-scale.

Operating parameters for the two-stage nitritation/anammox (PN/A) process in mainstream flows from lab-scale to pilot-scale were investigated. In the batch experiment, the specific activities of ammonia oxidizing bacteria (AOB) and nitrite oxidizing bacteria (NOB) were fitted with a Monod model, and the oxygen affinity of NOB was higher than that of AOB. Nevertheless, dissolved oxygen concentrations higher than 2.0 mgO2/L were effectively applied for selective inhibition of NOB. In addition, organic matter was evaluated as the operating parameter that inhibited the activity of NOB more selectively than AOB under mainstream conditions. The operating parameters determined in the batch experiment were verified in a continuous experiment, and it was shown that the shortening of hydraulic retention time with increasing aeration time in the sequencing batch reactor cycle has the potential to selectively enhance the activity of AOB over NOB. The effect on the C/N ratio and temperature in a lab-scale anammox reactor was investigated. The denitrification with the addition of organic matter contributed to the improvement of nitrogen removal efficiency, but a C/N ratio of more than 1.0 severely deteriorated the sludge settleability. The operating factors for the mainstream PN/A determined in the lab scale were applied to the pilot plant. As a result, a nitrogen removal efficiency of 79 ± 11% was stably achieved with effluent total nitrogen of 2.6 ± 1.5 mg/L. However, unpredictable fluctuations in environmental factors revealed that residual ammonium was another critical factor affecting mainstream PN/A.

Activation of N-acyl-homoserine lactone-mediated quorum sensing system improves long-term preservation of anammox microorganisms by vacuum lyophilization.

The long-term preservation of anaerobic ammonium oxidation (anammox) microorganisms via vacuum lyophilization process would help commercialize the technique. In this study, vacuum lyophilization was evaluated for the cost-effective long-term preservation of such microorganisms. Skim milk was found to be the most effective cryoprotectant for maintaining the physiological properties (heme c, EPS, and the PN/PS ratio) of anammox microorganisms. Conversely, the vacuum lyophilization technique was shown to cause serious damage to the quorum sensing (QS) system of anammox, so that anammox activity was not adequately recovered afterwards. To overcome this limitation, activation of the AHL-mediated QS system were applied to the vacuum lyophilization process. Endogenous (i.e., fresh anammox sludge of 10%) and exogenous (i.e., C6-HSL of 60 mg/L) QS autoinducers significantly increased anammox activity to 88.2 ± 12.2 and 130.0 ± 12.2 mgTN/gVSS/d, respectively, after 56 d of reactivation. In addition, nitrogen removal potentials were estimated to be 123.5 and 87.5 gTN/m3/d, respectively. The effect of the exogenous QS autoinducer on anammox reactivation was reconfirmed through the comparison experiment. The results of this study will be greatly significant to this field since they improve the feasibility of the once-underestimated vacuum lyophilization technique.

Evaluation of long-term preservation and reactivation efficiency of anaerobic ammonium oxidation (anammox) microorganisms based on activation energy.

The preservation efficiency of mainstream (M-ANA) and sidestream anaerobic ammonium oxidation (anammox) (S-ANA) were evaluated based on their activation energy (Ea). The Ea of M-ANA cultivated under low nitrogen loads was lower than that of S-ANA, which greatly contributed to enhancing the viability of anammox during preservation at 4 °C. After preservation for 140 d, the decay rate (bAN) of M-ANA ranged from 0.0012 to 0.0013/d; the bAN of S-ANA was 0.0036-0.0041/d. The addition of hydrazine, which requires minimal energy to activate anammox metabolism, is highly beneficial for the viability of microorganisms. The low Ea of anammox contributes to efficient reactivation with rapid reactivation of heme c, and the addition of hydrazine makes the process more beneficial. Although the specific nitrogen removal rate of the M-SNA seed sludge was much lower than that of S-ANA, the rate of M-ANA became higher after 48 days of reactivation.

Effect of aerobic microbes' competition for oxygen on nitrogen removal in mainstream nitritation-anammox systems.

The effects of C/N ratio in mainstream partial nitritation (PN)-anaerobic ammonia oxidation (ANAMMOX) considering competitive relationship of aerobic microbes competing for oxygen were investigated. Thy system was operated for 501 d with various C/N ratio. Competitive growth of aerobic heterotrophic bacteria (AHB) at ≥ 1 of C/N ratio acted effectively on the selective inhibition of nitrite-oxidizing bacteria (NOB) while contributing to stable PN-A. In-depth kinetic analysis indicated oxygen affinity of aerobic microbes was in the order of AHB > ammonia-oxidizing bacteria (AOB) > NOB. In addition, potential of denitritation by AHB could contributed to improving nitrogen removal up to 87.5 ± 4.3%. AHB was comparatively clustered into two groups with a C/N ratio of 1. Nitrosomonas sp. PY1 became predominant while Nitrospira spp. were the major NOB. The potential of AHB in establishing selective inhibition of NOB was identified, which could be a novel approach to stabilze the mainstream PN-A.

Gemigliptin Alleviates Succinate-Induced Hepatic Stellate Cell Activation by Ameliorating Mitochondrial Dysfunction.

BACKGRUOUND: Dipeptidyl peptidase-4 inhibitors (DPP-4Is) are used clinically as oral antidiabetic agents. Although DPP-4Is are known to ameliorate liver fibrosis, the protective mechanism of DPP-4Is in liver fibrosis remains obscure. In this study, gemigliptin was used to investigate the potential of DPP-4Is to alleviate the progression of liver fibrosis. METHODS: To clarify the effects and mechanisms of gemigliptin, we conducted various experiments in LX-2 cells (immortalized human hepatic stellate cells [HSCs], the principal effectors of hepatic fibrogenesis), which were activated by succinate and exhibited elevated expression of α-smooth muscle actin, collagen type 1, and pro-inflammatory cytokines and increased cell proliferation. In vivo, we examined the effects and mechanisms of gemigliptin on a high-fat, high-cholesterol-induced mouse model of nonalcoholic steatohepatitis (NASH). RESULTS: Gemigliptin decreased the expression of fibrogenesis markers and reduced the abnormal proliferation of HSCs. In addition, gemigliptin reduced the succinate-induced production of mitochondrial reactive oxygen species (ROS), intracellular ROS, and mitochondrial fission in HSCs. Furthermore, in the mouse model of NASH-induced liver fibrosis, gemigliptin alleviated both liver fibrosis and mitochondrial dysfunction. CONCLUSION: Gemigliptin protected against HSC activation and liver fibrosis by alleviating mitochondrial dysfunction and ROS production, indicating its potential as a strategy for preventing the development of liver disease.

Outcome of Intermittent Thoracentesis versus Pigtail Catheter Drainage for Hepatic Hydrothorax.

Background/Aims: The management of hepatic hydrothorax (HH) remains a challenging clinical scenario with suboptimal options. We investigated the effect and safety of pigtail catheter drainage compared to intermittent thoracentesis. Methods: This multicenter, retrospective study included 164 cirrhotic patients with recurrent pleural effusion from March 2012 to June 2017. Patients with neoplasms, cardiopulmonary disease, and infectious conditions were excluded. We compared the clinical outcomes of pigtail catheter drainage versus thoracentesis for variables including complications related to procedures, overall survival, and re-admission rates. Results: A total of 164 patients were divided into pigtail catheter (n = 115) and thoracentesis (n = 49) groups. During the follow-up period of 6.93 months after discharge, 98 patients died (pigtail; n = 47 vs. thoracentesis; n = 51). The overall survival (p = 0.61) and 30-day mortality (p = 0.77) rates were similar between the pigtail catheter and thoracentesis groups. Only MELD scores were associated with overall survival (adjusted HR, 1.08; p < 0.01) in patients with HH. Spontaneous pleurodesis occurred in 59 patients (51.3%) in the pigtail catheter group. Re-admission rates did not differ between the pigtail catheter and thoracentesis groups (13.2% vs 19.6% p = 0.7). A total of five complications occurred, including four total cases of bleeding (one patient in the pigtail catheter group and three in the thoracentesis group) and one case of empyema in the pigtail catheter group. Conclusions: Pigtail catheter drainage is not inferior to that of intermittent thoracentesis for the management of HH, proving it may be an effective and safe clinical option.

Achieving stable nitrogen removal performance of mainstream PN-ANAMMOX by combining high-temperature shock for selective recovery of AOB activity.

This paper describes the new concept of the mainstream partial nitritation (PN)-anaerobic ammonium oxidation (ANAMMOX) combined with a high-temperature shock strategy for the selective recovery of ammonia-oxidizing bacteria (AOB) activity. In the preliminary test, the temperature shock condition for PN was optimized (60 °C and > 20 min). Based on this, the implementation strategy in a continuous stirred tank reactor (CSTR) system was studied further, and the polyvinyl alcohol (PVA)/sodium alginate carrier exposure ratio (ER) and dissolved oxygen (DO) concentration were considered as primary variables. The AOB activity was recovered selectively when the ER of the carrier ranged from 20 to 40%, and the DO was higher than 2.3 mg O2/L. This was not the case for nitrite-oxidizing bacteria (NOB) (AOB: 1.17±0.1 gNH4+-N/LCarrier/d, NOB: 0.34±0.1 gNO3--N/LCarrier/d). As a result, the activity of AOB was recovered selectively with a decrease in Nitrospira spp., which was verified by kinetic and microbial analyses for the AOB (KS, DO = 3.89 mgO2/L) and NOB (KS, DO = 1.14 mgO2/L). Eventually, the mainstream PN-ANAMMOX was achieved with a nitrogen removal efficiency of 81.5±3.3% for 95 days. The findings provide insight to establishing a stable mainstream PN-ANAMMOX process using a high-temperature shock strategy.

Innovative start-up strategies for single-stage deammonification with conventional activated sludge: Results of a pilot-scale demonstration.

This study investigated innovative start-up strategies of a pilot-scale sequencing batch reactor (SBR) for single-stage deammonification using activated sludge as the sole inoculum source. In 24 m3 aerobic oxidizing bacteria cultivation plant, nitrogen loss efficiency was suggested to be an indicator for determining duration of cultivation. In 12 m3 ANAMMOX (ANaerobic AMMonium OXidation) cultivation plant, combined strategy (sequential fed-batch and continuous modes) was adopted to promote ANAMMOX activity from activated sludge. Both the cultivated sludge were inoculated in 24 m3 pilot-plant for single-stage SBR with deammonification. The feed distribution strategy was used to cultivate ANAMMOX bacteria selectively resulting in nitrogen removal rate of 0.73 kg/m3/d and nitrogen removal efficiency of 86.5 ± 1.9% within 254 days. Candidatus Brocadia sp. 40 was enriched from undetectable to 22.7% relative abundance. These findings indicated that fast start-up of the deammonification process was possible without ANAMMOX seed sludge in pilot-scale reactor with various variables.

Irisin Regulates the Functions of Hepatic Stellate Cells.

BACKGROUND: Hepatic stellate cells (HSCs) are known to play a fundamental role in the progression of liver fibrosis. Once HSCs are activated, they are involved in proliferation, migration, and contractility which are characteristics of liver fibrogenesis. Recent studies have shown that irisin, a myokine secreted during physical exercise, has a protective effect in various metabolic diseases, especially in renal fibrosis. However, whether irisin is involved in HSC activation and other processes associated with liver fibrosis has not yet been investigated. In this study, we reveal the role of irisin in HSC activation as well as in proliferation, migration, and contractile properties of HSCs in vitro. METHODS: LX-2 cells, immortalized human HSCs, were treated with transforming growth factor beta 1 (TGF-ß1), a core regulator of HSC fibrosis, with or without irisin, and markers of the aforementioned processes were analyzed. Further, an inflammatory response was stimulated with TGF-ß1 and lipopolysaccharide (LPS) in combination with irisin and the expression of cytokines was measured. RESULTS: Recombinant irisin significantly suppressed the expression of TGF-ß1-stimulated fibrosis markers including alpha-smooth muscle actin and collagen type 1 alpha 1 and prevented the TGF-ß1-induced proliferation, migration, and contractility of LX-2 cells. Additionally, irisin ameliorated the production of interleukin-6 (IL-6) and IL-1ß induced by TGF-ß1 and LPS treatments. CONCLUSION: These findings suggested that irisin potently improved the progression of hepatic fibrosis by regulating HSC activation, proliferation, migration, contractility, and HSC-mediated production of inflammatory cytokine.

Optimization of nitrogen removal performance in a single-stage SBR based on partial nitritation and ANAMMOX.

A partial nitritation (PN)/anaerobic ammonium oxidation (ANAMMOX) process in sequencing batch reactor (SBR) was successfully developed to treat high-strength ammonium wastewater. The feed distribution in the SBR cycle and sub-cycles was considered as the main operating strategy, and was optimized using a response surface methodology (RSM)-based optimization technique. In the SBR cycle, the maximum nitrogen removal rate (NRR) of 0.79 ± 0.01 kg m-3 d-1 was achieved by applying a feed distribution strategy that considered the kinetic characteristics of ANAMMOX and ammonia oxidizing bacteria (AOB). However, this strategy negatively affected the nitrogen removal efficiency (NRE) due to alkalinity loss. Therefore, the feed distribution in the SBR sub-cycles with respect to the NRE and the NRR was further studied. The nitrogen removal performance was optimized in the optimum region and an NRE of 88% and an NRR of 0.84 kg m-3 d-1 were achieved. The optimized model was verified in confirmation test. The RSM-based optimization results provide insights into the feed distribution strategy for achieving single-stage PN/ANAMMOX SBR operation.

Key operating parameters affecting nitrogen removal rate in single-stage deammonification.

The key operating parameters for improving the nitrogen removal rate (NRR) in a sequencing batch reactor (SBR) for deammonification were investigated. The major operating strategies were the coexistence between deammonification and denitrification with a carbon/nitrogen (C/N) ratio of 0.5 and the control of the number of sub-cycles based on substrate concentration for anaerobic ammonium oxidation (ANAMMOX) and ammonium oxidizing bacteria (AOB). In the study, denitrification with the addition of an organic source was beneficial for improving the NRR from 0.5 ±â€¯0.01 kg N m-3 d-1 to 0.53 ±â€¯0.01 kg N m-3 d-1 by removing the nitrate produced as a by-product of ANAMMOX. Unlike the gradual increase of the specific activity for AOB, the specific ANAMMOX activity (SAA) was maximized when an ammonium concentration supplied after sub-feeding phase was increased from 20 to 100 mg L-1, which increased the NRR from 0.53 ±â€¯0.01 kg N m-3 d-1 to 0.79 ±â€¯0.01 kg N m-3 d-1. This result suggested that the SAA is more important than the specific activity for AOB as a parameter for controlling the NRR in the single-stage deammonification. In the whole experimental period, the granule size smaller than 100 µm accounted for 52.5 ±â€¯0.9%, making the largest contribution to the activity for AOB and denitrifiers. However, the granule size larger than 100 µm made the greatest contribution (83.8 ±â€¯0.5%) to SAA. The feasibility of using the derivate of pH and OPR as indirect parameters to control the NRR was verified.

Comparison of Age of Onset and Frequency of Diabetic Complications in the Very Elderly Patients with Type 2 Diabetes.

BACKGROUND: The prevalence of type 2 diabetes in elderly people has increased dramatically in the last few decades. This study was designed to clarify the clinical characteristics of type 2 diabetes in patients aged ≥80 years according to age of onset. METHODS: We reviewed the medical records of 289 patients aged ≥80 years with type 2 diabetes at the outpatient diabetes clinics of Kangwon National University Hospital from September 2010 to June 2014. We divided the patients into middle-age-onset diabetes (onset before 65 years of age) and elderly-onset diabetes (onset at 65+ years of age). RESULTS: There were 141 male and 148 female patients. The patients had a mean age of 83.2±2.9 years and the mean duration of diabetes was 14.3±10.4 years. One hundred and ninety-nine patients had elderly-onset diabetes. The patients with elderly-onset diabetes had a significantly lower frequency of diabetic retinopathy and nephropathy, lower serum creatinine levels, lower glycated hemoglobin (HbA1c) levels, and similar coronary revascularization and cerebral infarction rates compared to those with middle-age-onset diabetes. There was no frequency difference in coronary revascularization and cerebral infarction and HbA1c levels between three subgroups (<5, 5 to 15, and ≥15 years) of diabetes duration in elderly onset diabetes. However, both in the elderly onset diabetes and middle-age-onset diabetes, the cumulative incidence of retinopathy was increasing rapidly according to the duration of diabetes. CONCLUSION: We report that individuals with elderly-onset diabetes have a lower frequency of diabetic retinopathy and nephropathy and similar cardiovascular complications compared to those with middle-age-onset diabetes.

Timing of pulmonary embolisms in femur fracture patients: Incidence and outcomes.

BACKGROUND: Femur fracture is a well-recognized risk factor for pulmonary embolism (PE). Despite recent reports of early PE after major trauma, the incidence and outcomes of PE in femur fracture patients are unknown. The aims of the study were to determine the incidence of PE after a femur fracture and to evaluate its timing and clinical significance. METHODS: We included all consecutive adult patients (≥18 years old) with femur fracture admitted to our emergency department from January 2010 to December 2014 who underwent subsequent PE computed tomography within 72 hours. Of 453 stable patients, 28 with a confirmed diagnosis of acute PE were compared against those without PE. RESULTS: Of 1,301 femur fracture patients who presented at our hospital, 453 were included in our present analysis, of whom 28 developed PE (2.2%). Proximal PE, defined as emboli located within the main or lobar arteries, constituted 78.6% and subsegmental PE constituted 21.4% of these 28 cases. The femur fracture sites were mainly intertrochanteric (50.3%) and the neck (43.9%). The median interval from injury to computed tomography was 13.0 hours (IQR, 9.0-24.0 hours). PE was detected in 57.1% (16 of 28) of patients in the first 24 hours after injury and in 89.3% (25 of 28) in the first 48 hours. Overall mortality was 0.7%, and no patient in the early PE group died of their injury. CONCLUSION: PE arises in femur fracture patients in the immediate period following injury and shows an incidence somewhat higher than commonly appreciated in other trauma events but is not fatal. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Extracorporeal cardiopulmonary resuscitation among patients with out-of-hospital cardiac arrest.

OBJECTIVE: Extracorporeal cardiopulmonary resuscitation (ECPR) may be considered as a rescue therapy for patients with refractory cardiac arrest. Identifying patients who might benefit from this potential life-saving procedure is crucial for implementation of ECPR. The objective of this study was to estimate the number of patients who fulfilled a hypothetical set of ECPR criteria and to evaluate the outcome of ECPR candidates treated with conventional cardiopulmonary resuscitation. METHODS: We performed an observational study using data from a prospective registry of consecutive adults (≥18 years) with non-traumatic out-of-hospital cardiac arrest in a tertiary hospital between January 2011 and December 2015. We developed a hypothetical set of ECPR criteria including age ≤75 years, witnessed cardiac arrest, no-flow time ≤5 minutes, low-flow time ≤30 minutes, refractory arrest at emergency department >10 minutes, and no exclusion criteria. The primary endpoint was the proportion of good neurologic outcome of ECPR-eligible patients. RESULTS: Of 568 out-of-hospital cardiac arrest cases, 60 cases (10.6%) fulfilled our ECPR criteria. ECPR was performed for 10 of 60 ECPR-eligible patients (16.7%). Three of the 10 patients with ECPR (30.0%), but only 2 of the other 50 patients without ECPR (4.0%) had a good neurologic outcome at 1 month. CONCLUSION: ECPR implementation might be a rescue option for increasing the probability of survival in potentially hopeless but ECPR-eligible patients.