Deep Learning-Based Diagnostic System for Velopharyngeal Insufficiency Based on Videofluoroscopy in Patients With Repaired Cleft Palates.

Velopharyngeal insufficiency (VPI), which is the incomplete closure of the velopharyngeal valve during speech, is a typical poor outcome that should be evaluated after cleft palate repair. The interpretation of VPI considering both imaging analysis and perceptual evaluation is essential for further management. The authors retrospectively reviewed patients with repaired cleft palates who underwent assessment for velopharyngeal function, including both videofluoroscopic imaging and perceptual speech evaluation. The final diagnosis of VPI was made by plastic surgeons based on both assessment modalities. Deep learning techniques were applied for the diagnosis of VPI and compared with the human experts' diagnostic results of videofluoroscopic imaging. In addition, the results of the deep learning techniques were compared with a speech pathologist's diagnosis of perceptual evaluation to assess consistency with clinical symptoms. A total of 714 cases from January 2010 to June 2019 were reviewed. Six deep learning algorithms (VGGNet, ResNet, Xception, ResNext, DenseNet, and SENet) were trained using the obtained dataset. The area under the receiver operating characteristic curve of the algorithms ranged between 0.8758 and 0.9468 in the hold-out method and between 0.7992 and 0.8574 in the 5-fold cross-validation. Our findings demonstrated the deep learning algorithms performed comparable to experienced plastic surgeons in the diagnosis of VPI based on videofluoroscopic velopharyngeal imaging.

Association Between Postoperative Body Temperature and All-Cause Mortality After Off-Pump Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study.

BACKGROUND: Inadvertent perioperative hypothermia is common in patients undergoing off-pump coronary artery bypass grafting (OPCAB). We investigated the association between early postoperative body temperature and all-cause mortality in patients undergoing OPCAB. METHODS: We reviewed the electronic medical records of 1714 patients who underwent OPCAB (median duration of follow-up, 47 months). Patients were divided into 4 groups based on body temperature at the time of intensive care unit admission after surgery (moderate-to-severe hypothermia, <35.5°C; mild hypothermia, 35.5°C-36.5°C; normothermia, 36.5°C-37.5°C; and hyperthermia, ≥37.5°C). Cox proportional hazards models were used to assess the association between body temperature and all-cause mortality. The association between early postoperative changes in body temperature and all-cause mortality was also assessed by dividing the patients into 4 categories according to the body temperature measured at postoperative intensive care unit admission and the average body temperature during the first 3 postoperative days. RESULTS: Compared to the normothermia group, the adjusted hazard ratios of all-cause mortality were 2.030 (95% confidence interval, 1.407-2.930) in the moderate-to-severe hypothermia group and 1.445 (95% confidence interval, 1.113-1.874) in the mild hypothermia group. Patients who were hypothermic at postoperative intensive care unit admission but attained normothermia thereafter were at a lower risk of all-cause mortality compared to patients who did not regain normothermia (adjusted hazard ratio, 0.631; 95% confidence interval, 0.453-0.878), while they were still at a higher risk of all-cause mortality than those who were consistently normothermic (adjusted hazard ratio, 1.435; 95% confidence interval, 1.090-1.890). CONCLUSIONS: Even mild early postoperative hypothermia was associated with all-cause mortality after OPCAB. Patients who regained normothermia postoperatively were at lower risk of all-cause mortality compared to those who did not.

Intraoperative glucose variability, but not average glucose concentration, may be a risk factor for acute kidney injury after cardiac surgery: a retrospective study.

PURPOSE: Altered perioperative glycemic control may contribute to the development of renal dysfunction in cardiac surgery patients. Nevertheless, whether it is intraoperative hyperglycemia or increased glucose variability that affects postoperative outcomes is not yet clear. The aim of this study was to assess the association of intraoperative glucose concentration and variability with acute kidney injury (AKI) after cardiac surgery. METHODS: We retrospectively reviewed the electronic medical records of 3,598 patients who underwent cardiac surgery between November 1, 2006 to December 31, 2016. The time-weighted average glucose (TWAG) and coefficient of variation of glucose measurements were both used as measures of intraoperative glucose control with multivariable logistic regression to evaluate their relationship to postoperative AKI. RESULTS: The intraoperative glucose coefficient of variation was an independent risk factor for AKI after cardiac surgery (highest quartile odds ratio, 1.38; 95% confidence interval, 1.09 to 1.75; P = 0.01). Nevertheless, the intraoperative TWAG did not remain in the final multivariable model of postoperative AKI. CONCLUSION: Intraoperative glucose variability, but not the average glucose concentration itself, may be a risk factor for AKI after cardiac surgery.

RéSUMé: OBJECTIF: Un contrôle glycémique périopératoire déficient pourrait contribuer à l'apparition d'une dysfonction rénale chez les patients de chirurgie cardiaque. Toutefois, nous ne savons pas si c'est une hyperglycémie peropératoire ou l'augmentation de la variabilité glycémique qui affecte les pronostics postopératoires. L'objectif de cette étude était d'évaluer l'association entre la concentration et la variabilité glycémiques peropératoires et l'insuffisance rénale aiguë (IRA) après une chirurgie cardiaque. MéTHODE: Nous avons rétrospectivement passé en revue les dossiers médicaux électroniques de 3598 patients ayant subi une chirurgie cardiaque entre le 1er novembre 2006 et le 31 décembre 2016. La moyenne glycémique pondérée dans le temps et le coefficient de variation des mesures glycémiques ont été utilisés comme mesures de la régulation glycémique peropératoire, et la régression logistique multivariée a été utilisée pour évaluer leur relation à l'IRA postopératoire. RéSULTATS: Le coefficient de variation peropératoire de la glycémie était un facteur de risque indépendant d'IRA après une chirurgie cardiaque (rapport de cotes du quartile le plus élevé, 1,38; intervalle de confiance 95 %, 1,09 à 1,75; P = 0,01). Toutefois, la moyenne glycémique peropératoire pondérée dans le temps n'est pas demeurée dans le modèle multivarié final de l'IRA postopératoire. CONCLUSION: La variabilité peropératoire de la glycémie, et non la concentration glycémique moyenne, pourrait être un facteur de risque d'IRA après une chirurgie cardiaque.

Single-stage reconstruction of skin-involving nasal paraffinoma with pericraniosubgaleal flap.

BACKGROUND: The removal of a paraffinoma over the nasal bridge may result in thinning and even loss of involved skin as well as a saddle nose deformity. For nasal reconstruction, a variety of techniques using a free graft of autogenous tissue such as fascia, dermofat, or cartilage have been used, either in immediate, single-stage or in delayed, multiphase treatment. However, such reconstructions can be challenging largely due to absorption of the grafted tissue and poor blood supply to the surrounding nasal tissue infiltrated with paraffin. This article reports the successful clinical outcomes of immediate, single-stage reconstructions by wrapping a pericraniosubgaleal flap over the nasal implant after removing a paraffinoma. METHODS: Eleven patients with a paraffinoma showing a palpable lump, redness, or telangiectasia over the nasal skin were treated between November 1998 and March 2011. The mean follow-up period was 20.1 months. As much of the paraffinoma as possible was removed via a bidirectional approach (open rhinoplasty and frontal hairline incision), and the resulting deformity was reconstructed simultaneously using a pericraniosubgaleal flap and turning it over the sculpted nasal implant (ePTFE; GORE-TEX(®) in nine cases and silicone in two cases). RESULTS: Nine patients (81.8%) were treated successfully without complications and were satisfied with their results. However, the other two patients complained of incomplete removal of the paraffinoma requiring additional removal. Telangiectasia over the nose improved in four out of six patients after surgery. CONCLUSION: Nasal reconstruction using a pericraniosubgaleal flap is one of the most reliable surgical options for treating skin-involving nasal paraffinomas. The advantage of such a method is that a well-vascularized and durable flap, which is resistant to infection, is wrapped over the sculpted nasal implant in a single step. It also reinforces the thinned skin, which makes it easier to form various shapes, producing excellent cosmetic results. Finally, it can also serve as a tolerable graft bed in the case of overlying skin loss.

Clinical outcome of percutaneous lumbar foraminoplasty using a safety-improved device in patients with lumbar foraminal spinal stenosis.

Lumbar foraminal spinal stenosis (LFSS) is defined as the narrowing of the nerve root exit associated with a herniated intervertebral disc, osteoarthritic changes in the facet joints, or a hypertrophied ligamentum flavum, which can provoke neurogenic claudication. To achieve effective and safe decompression of the lumbar spinal foramen, a specially designed instrument (Claudicare, SEAWON Meditech, Bucheon-si, Gyeonggi-do, Republic of Korea) for percutaneous lumbar foraminoplasty (PLF) was invented. The purpose of this study was to evaluate the clinical efficacy and safety of the newly devised instrument in patients with LFSS.PLF was performed for LFSS by a single pain physician. For each patient, an 11-point numerical rating scale (NRS) pain score-the Oswestry Disability Index (ODI)-and the duration of walking without radicular pain were evaluated at the 3-month follow-up. The successful responder percentage was defined as ≥50% reduction from the baseline NRS score with improvement in ODI and duration of walking.Among 24 patients who underwent PLF, 15 patients showed successful responses. The NRS pain score and duration of walking without radicular pain were improved significantly from baseline at the 3-month follow-up (P < .01). The ODI was also decreased, but the difference was not statistically significant (P = .09). The NRS pain score and walking duration without pain at 3 months were statistically significantly different between the groups (P < .001 and P = .01, respectively), whereas there was no statistically significant difference in improvement in ODI between the groups (P = .23). No serious adverse events occurred in the study.In conclusion, PLF using the Claudicare device may be an optimal and safe option for managing intractable LFSS on an outpatient basis.

Anaphylactic reaction after local lidocaine infiltration for retraction of retained teeth.

Although allergic reactions are not rare complications in drug use, anaphylaxis or anaphylactoid reactions to some widely used drugs can embarrass clinicians because anaphylaxis is not easily diagnosed at the time of the event and treatment is unfamiliar to many. Lidocaine is a very popular drug in dental procedures and anaphylactoid reaction to it has been rarely reported. Clinicians who use lidocaine daily should, however, be aware of the possibility of anaphylaxis after its use. Once it occurs, anaphylaxis can be fatal, but if it is quickly diagnosed or suspected, treatment is simpler than most clinicians believe. An 86-year-old woman experienced an anaphylactic reaction 30 min after local infiltration of lidocaine for retraction of retained teeth. The dentist called an anesthesiologist for assistance. Fortunately, an anaphylactic reaction was quickly suspected and after subsequent rapid treatment with the administration of fluid and drug therapy, the patient recovered completely.

Predictive Factors of Successful Percutaneous Cervical Nucleoplasty for the Treatment of Pain with Cervical Herniated Disk.

BACKGROUND: Percutaneous cervical nucleoplasty (PCN) is an effective treatment for cervical herniated intervertebral disc (C-HIVD). In this retrospective study, we evaluated clinical predictors that affect the successful outcome of PCN. METHODS: Fluoroscopically guided PCN was conducted for C-HIVD by one pain physician. Successful outcome was defined as a combination of greater than 50% pain relief on the numerical rating scale pain score, no increase in analgesics, and no cervical epidural steroid injection during the 3-month follow-up period. The relationship between outcomes and independent variables, including patient demographics, comorbid diseases, pain duration, type of disc herniation, presence of spinal stenosis, pain location, analgesics, and shape of the PCN needle tip, were investigated using multivariable analyses. RESULTS: Of 201 patients, 134 experienced a successful outcome after PCN. In the positive outcome group, shorter pain durations, rarer central canal stenosis, increased unilateral radiculopathy versus axial pain, and more frequent use of the curved tip technique, were reported. Multivariable analyses revealed that unilateral radiculopathy (P = 0.013) and use of the curved-tip technique (P = 0.027) were independent positive predictors of successful PCN outcomes; conversely, longer pain duration (P = 0.014) and concurrent spinal stenosis (P < 0.001) were negative predictors. No serious complications related to PCN occurred. CONCLUSIONS: In this study, the success rate of PCN was 66.7% in patients with C-HIVD. Shorter pain duration, the absence of cervical central canal stenosis, pain location (i.e., unilateral radiculopathy vs. axial pain), and the use of the curved-tip technique were positive predictors of successful PCN.

In vivo gene therapy of type I diabetic mellitus using a cationic emulsion containing an Epstein Barr Virus (EBV) based plasmid vector.

A cationic emulsion containing an insulin expression plasmid was prepared for the treatment of type 1 diabetic mellitus (DM) in vivo. A rat proinsulin-1 gene was inserted to EBV-based plasmid vectors containing CAG promoter. Cationic emulsion composed of DOTAP and squalene was complexed with the plasmid DNA. An intravenous injection of cationic emulsion containing proinsulin gene decreased blood glucose levels for 7 days within normal range. The cationic emulsion exerted more profound effect on blood glucose levels compared to naked DNA. RT-PCR results confirmed that the proinsulin was expressed in several organs containing liver, lung, spleen, and kidney. The refractory response was invoked by multiple injections of naked DNA or cationic emulsion/DNA complex, which was later proven to be an immune response against expressed proinsulin. Therefore, the cationic emulsion showed a promising result as a novel insulin gene therapy vehicle by decreasing blood glucose level for a month.

Cationic lipid emulsions containing heavy oils for the transfection of adherent cells.

A new cationic emulsion system with high density was prepared increasing in vitro transfection efficiencies of adherent cells. Lipiodol with a density of 1.3 (g/ml) was selected to increase the density of the DNA/emulsion complex. Cationic lipid emulsions were formulated with mixtures of lipiodol and squalene as the oil phase and 1,2-dioleoyl-sn-glycero-3-trimethylammonium-propane (DOTAP) as a cationic lipid. These emulsions were used to find the correlation between the density and the in vitro transfection efficiency. The physical characteristics of the new emulsion formulations were also determined. Heavier DNA/cationic lipid emulsion complex showed higher in vitro transfection efficiency on adherent cell lines in the presence of 10% serum compared to lighter ones. The cationic lipid emulsion formulated with lipiodol and DOTAP was more stable and showed better in vitro transfection efficiency than other carriers without lipiodol. Due to the high density of the carrier, the DNA/carrier complex sank to the bottom of the wells, thereby increasing the contact between the complex and adherent cells. The new lipiodol emulsion with high density showed superior transfection activities on adherent cells in the presence of serum.

Cellular uptake mechanism and intracellular fate of hydrophobically modified glycol chitosan nanoparticles.

Polymeric nanoparticle-based carriers are promising agents for the targeted delivery of therapeutics to the intracellular site of action. To optimize the efficacy in delivery, often the tuning of physicochemical properties (i.e., particle size, shape, surface charge, lipophilicity, etc.) is necessary, in a manner specific to each type of nanoparticle. Recent studies showed an efficient tumor targeting by hydrophobically modified glycol chitosan (HGC) nanoparticles through the enhanced permeability and retention (EPR) effect. As a continued effort, here the investigations on the cellular uptake mechanism and the intracellular fate of the HGC nanoparticles are reported. The HGC nanoparticle, prepared by a partial derivatization of the free amino groups of glycol chitosan (GC) with 5beta-cholanic acid, had a globular shape with the average diameter of 359 nm and the zeta potential of ca. 22 mV. Interestingly, these nanoparticles showed an enhanced distribution in the whole cells, compared to the parent hydrophilic GC polymers. In vitro experiments with endocytic inhibitors suggested that several distinct uptake pathways (e.g., clathrin-mediated endocytosis, caveolae-mediated endocytosis, and macropinocytosis) are involved in the internalization of HGC. Some HGC nanoparticles were found entrapped in the lysosomes upon entry, as determined by TEM and colocalization studies. Given such favorable properties including low toxicity, biocompatibility, and fast uptake by several nondestructive endocytic pathways, our HGC nanoparticles may serve as a versatile carrier for the intracellular delivery of therapeutic agents.

In vivo time-dependent gene expression of cationic lipid-based emulsion as a stable and biocompatible non-viral gene carrier.

To make stable and biocompatible non-viral gene carriers for therapeutic gene therapy, we developed a cationic lipid-based emulsion (CLE) prepared by an oil-in-water (O/W) emulsion method, wherein squalene oil was used as an oil core and the cationic lipid, 1,2-dioleoyl-sn-glycero-3-trimethylammonium-propane (DOTAP), was employed as an emulsifier. To evaluate in vivo characteristics such as toxicity and time-dependent gene expression, a bioluminescence reporter gene in pCMV-luc plasmid DNA was simply mixed with CLE in aqueous condition, resulting in a CLE/DNA complex. The CLE/DNA complex was optimized to form a compact and stable nano-sized particle by adding different amounts of plasmid DNA, and an optimal cationic lipid-to-DNA (C/D) weight ratio of 4 was identified. Freshly prepared CLE/DNA complex, with a C/D of 4, showed a high transfection efficiency and minimal cytotoxicity in vitro, compared to controls of a liposome (DOTAP)/DNA complex and a branched poly(ethyleneimine) (Mw=25 kDa) (bPEI)/DNA complex, respectively. The in vivo characteristics of the CLE/DNA complex were evaluated after intravenous injection into Balb/c mice. Time-dependent gene expression data in vivo were obtained using a non-invasive, whole animal bioluminescence imaging system. These data showed that the CLE/DNA complex offered prolonged high-level gene expression for 1 week, particularly in the liver and spleen. On the other hand, the controls of DOTAP/DNA complex and bPEI/DNA complex showed a relatively lower gene expression, because of the unstable and toxic properties of the control carriers. Our in vivo gene expression data demonstrate the potential of the CLE/DNA complex as a non-viral gene carrier for in vivo gene delivery.