Showing papers by "Peking Union Medical College Hospital published in 2014"

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Angiotensin-converting enzyme 2 protects from lethal avian influenza A H5N1 infections

Abstract: The potential for avian influenza H5N1 outbreaks has increased in recent years. Thus, it is paramount to develop novel strategies to alleviate death rates. Here we show that avian influenza A H5N1-infected patients exhibit markedly increased serum levels of angiotensin II. High serum levels of angiotensin II appear to be linked to the severity and lethality of infection, at least in some patients. In experimental mouse models, infection with highly pathogenic avian influenza A H5N1 virus results in downregulation of angiotensin-converting enzyme 2 (ACE2) expression in the lung and increased serum angiotensin II levels. Genetic inactivation of ACE2 causes severe lung injury in H5N1-challenged mice, confirming a role of ACE2 in H5N1-induced lung pathologies. Administration of recombinant human ACE2 ameliorates avian influenza H5N1 virus-induced lung injury in mice. Our data link H5N1 virus-induced acute lung failure to ACE2 and provide a potential treatment strategy to address future flu pandemics.

Pasireotide Versus Octreotide in Acromegaly: A Head-to-Head Superiority Study

Abstract: Context: Biochemical control reduces morbidity and increases life expectancy in patients with acromegaly. With current medical therapies, including the gold standard octreotide long-acting-release (LAR), many patients do not achieve biochemical control. Objective: Our objective was to demonstrate the superiority of pasireotide LAR over octreotide LAR in medically naive patients with acromegaly. Design and Setting: We conducted a prospective, randomized, double-blind study at 84 sites in 27 countries. Patients: A total of 358 patients with medically naive acromegaly (GH >5 μg/L or GH nadir ≥1 μg/L after an oral glucose tolerance test (OGTT) and IGF-1 above the upper limit of normal) were enrolled. Patients either had previous pituitary surgery but no medical treatment or were de novo with a visible pituitary adenoma on magnetic resonance imaging. Interventions: Patients received pasireotide LAR 40 mg/28 days (n = 176) or octreotide LAR 20 mg/28 days (n = 182) for 12 months. At months 3 and 7, titration to ...

A comparison of different diagnostic criteria of acute kidney injury in critically ill patients

Abstract: Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) proposed a new definition and classification of acute kidney injury (AKI) on the basis of the RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage renal failure) and AKIN (Acute Kidney Injury Network) criteria, but comparisons of the three criteria in critically ill patients are rare. We prospectively analyzed a clinical database of 3,107 adult patients who were consecutively admitted to one of 30 intensive care units of 28 tertiary hospitals in Beijing from 1 March to 31 August 2012. AKI was defined by the RIFLE, AKIN, and KDIGO criteria. Receiver operating curves were used to compare the predictive ability for mortality, and logistic regression analysis was used for the calculation of odds ratios and 95% confidence intervals. The rates of incidence of AKI using the RIFLE, AKIN, and KDIGO criteria were 46.9%, 38.4%, and 51%, respectively. KDIGO identified more patients than did RIFLE (51% versus 46.9%, P = 0.001) and AKIN (51% versus 38.4%, P <0.001). Compared with patients without AKI, in-hospital mortality was significantly higher for those diagnosed as AKI by using the RIFLE (27.8% versus 7%, P <0.001), AKIN (32.2% versus 7.1%, P <0.001), and KDIGO (27.4% versus 5.6%, P <0.001) criteria, respectively. There was no difference in AKI-related mortality between RIFLE and KDIGO (27.8% versus 27.4%, P = 0.815), but there was significant difference between AKIN and KDIGO (32.2% versus 27.4%, P = 0.006). The areas under the receiver operator characteristic curve for in-hospital mortality were 0.738 (P <0.001) for RIFLE, 0.746 (P <0.001) for AKIN, and 0.757 (P <0.001) for KDIGO. KDIGO was more predictive than RIFLE for in-hospital mortality (P <0.001), but there was no difference between KDIGO and AKIN (P = 0.12). A higher incidence of AKI was diagnosed according to KDIGO criteria. Patients diagnosed as AKI had a significantly higher in-hospital mortality than non-AKI patients, no matter which criteria were used. Compared with the RIFLE criteria, KDIGO was more predictive for in-hospital mortality, but there was no significant difference between AKIN and KDIGO.

Characterizing IgG4-related disease with 18F-FDG PET/CT: a prospective cohort study

Abstract: Purpose IgG4-related disease (IgG4-RD) is an increasingly recognized clinicopathological disorder with immune-mediated inflammatory lesions mimicking malignancies. A cohort study was prospectively designed to investigate the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in characterizing IgG4-RD.

The roles of mesenchymal stem cells in tumor inflammatory microenvironment.

Abstract: Tumor behavior is not entirely determined by tumor cells. Studies have demonstrated that a variety of non-tumor cells in the tumor microenvironment affect tumor behavior; thus, a new focus of cancer research has been the development of novel cancer treatment ideas and therapeutic targets based on the effects of these cells. Mesenchymal stem cells (MSCs) are an important component of the tumor microenvironment; however, previous studies have produced controversial results regarding whether MSCs promote or inhibit tumor growth and progression. In particular, Naive MSCs and tumor-derived MSCs (T-MSCs) have different functions. Naive MSCs could exert bidirectional effects on tumors because these cells can both promote and inhibit tumor progression while T-MSCs promote tumor progression due to influences from the tumor itself and from the inflammatory tumor microenvironment. As an unhealed wound, tumor produces a continuous source of inflammatory mediators and causes aggregation of numerous inflammatory cells, which constitute an inflammatory microenvironment. Inflammatory factors can induce homing of circulating MSCs and MSCs in adjacent tissues into tumors, which are then being “educated” by the tumor microenvironment to support tumor growth. T-MSCs could recruit more immune cells into the tumor microenvironment, increase the proportion of cancer stem cells and promote tumor angiogenesis, further supporting tumor progression. However, as plasti city is a fundamental feature of MSCs, MSCs can also inhibit tumors by activating various MSC-based signaling pathways. Studies of the mechanisms by which interactions among tumors, MSCs, and the inflammatory microenvironment occur and methods to disrupt these interactions will likely reveal new targets for cancer therapy.

Coexistence of EGFR with KRAS , or BRAF , or PIK3CA somatic mutations in lung cancer: a comprehensive mutation profiling from 5125 Chinese cohorts

Abstract: Determining the somatic mutations of epidermal growth factor receptor (EGFR)-pathway networks is the key to effective treatment for non-small cell lung cancer (NSCLC) with tyrosine kinase inhibitors (TKIs).The somatic mutation frequencies and their association with gender, smoking history and histology was analysed and reported in this study. Five thousand one hundred and twenty-five NSCLC patients’ pathology samples were collected, and EGFR, KRAS, BRAF and PIK3CA mutations were detected by multiplex testing. The mutation status of EGFR, KRAS, BRAF and PIK3CA and their association with gender, age, smoking history and histological type were evaluated by appropriate statistical analysis. EGFR, KRAS, BRAF and PIK3CA mutation rates revealed 36.2%, 8.4%, 0.5% and 3.3%, respectively, across the 5125 pathology samples. For the first time, evidence of KRAS mutations were detected in two female, non-smoking patients, age 5 and 14, with NSCLC. Furthermore, we identified 153 double and coexisting mutations and 7 triple mutations. Interestingly, the second drug-resistant mutations, T790M or E545K, were found in 44 samples from patients who had never received TKI treatments. EGFR exons 19, 20 and 21, and BRAF mutations tend to happen in females and non-smokers, whereas KRAS mutations were more inclined to males and smokers. Activating and resistant mutations to EGFR-TKI drugs can coexist and ‘second drug-resistant mutations’, T790M or E545K, may be primary mutations in some patients. These results will help oncologists to decide candidates for mutation testing and EGFR-TKI treatment.

Effect of exposure to PM2.5 on blood pressure: a systematic review and meta-analysis.

Abstract: Background:Comprehensive studies have confirmed that particulate matter air pollution could trigger myocardial infarction, heart failure and reduce heart rate variability; however, its effect on blood pressure (BP) remains controversial. Therefore, we did a systematic review and meta-analysis to inv

Does pulse pressure variation predict fluid responsiveness in critically ill patients? A systematic review and meta-analysis.

Abstract: Fluid resuscitation is crucial in managing hemodynamically unstable patients. The last decade witnessed the use of pulse pressure variation (PPV) to predict fluid responsiveness. However, as far as we know, no systematic review and meta-analysis has been carried out to evaluate the value of PPV in predicting fluid responsiveness specifically upon patients admitted into intensive care units. We searched MEDLINE and EMBASE and included clinical trials that evaluated the association between PPV and fluid responsiveness after fluid challenge in mechanically ventilated patients in intensive care units. Data were synthesized using an exact binomial rendition of the bivariate mixed-effects regression model modified for synthesis of diagnostic test data. Twenty-two studies with 807 mechanically ventilated patients with tidal volume more than 8 ml/kg and without spontaneous breathing and cardiac arrhythmia were included, and 465 were responders (58%). The pooled sensitivity was 0.88 (95% confidence interval (CI) 0.81 to 0.92) and pooled specificity was 0.89 (95% CI 0.84 to 0.92). A summary receiver operating characteristic curve yielded an area under the curve of 0.94 (95% CI 0.91 to 0.95). A significant threshold effect was identified. PPV predicts fluid responsiveness accurately in mechanically ventilated patients with relative large tidal volume and without spontaneous breathing and cardiac arrhythmia.

Epidemiology and outcome of severe sepsis and septic shock in intensive care units in mainland China.

Abstract: Introduction Information about sepsis in mainland China remains scarce and incomplete. The purpose of this study was to describe the epidemiology and outcome of severe sepsis and septic shock in mixed ICU in mainland China, as well as the independent predictors of mortality.

PI3K/AKT/mTOR signaling pathway as a therapeutic target for ovarian cancer

Abstract: Ovarian cancer is one of the major causes of death in women worldwide. Despite improvements in conventional treatment approaches, such as surgery and chemotherapy, a majority of patients with advanced ovarian cancer experience relapse and eventually succumb to the disease; the outcome of patients remains poor. Hence, new therapeutic strategies are urgently required. The phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) is activated in approximately 70 % of ovarian cancers, resulting in hyperactive signaling cascades that relate to cellular growth, proliferation, survival, metabolism, and angiogenesis. Consistent with this, a number of clinical studies are focusing on PI3K pathway as an attractive target in the treatment of ovarian cancer. In this review, we present an overview of PI3K pathway as well as its pathological aberrations reported in ovarian cancer. We also discuss inhibitors of PI3K pathway that are currently under clinical investigations and the challenges these inhibitors face in future clinical utility. PubMed was searched for articles of relevance to ovarian cancer and the PI3K pathway. In addition, the ClinicalTrials.gov was also scanned for data on novel therapeutic inhibitors targeting the PI3K pathway. Genetic aberrations at different levels of PI3K pathway are frequently observed in ovarian cancer, resulting in hyperactivation of this pathway. The alterations of this pathway make the PI3K pathway an attractive therapeutic target in ovarian cancer. Currently, several inhibitors of PI3K pathway, such as PI3K/AKT inhibitors, rapamycin analogs for mTOR inhibition, and dual PI3K/mTOR inhibitors are in clinical testing in patients with ovarian cancer. PI3K pathway inhibitors have shown great promise in the treatment of ovarian cancer. However, further researches on selection patients that respond to PI3K inhibitors and exploration of effective combinatorial therapies are required to improve the management of ovarian cancer.

Angiotensin II plasma levels are linked to disease severity and predict fatal outcomes in H7N9-infected patients

Abstract: A novel influenza A (H7N9) virus of avian origin emerged in eastern China in the spring of 2013. This virus causes severe disease in humans, including acute and often lethal respiratory failure. As of January 2014, 275 cases of H7N9-infected patients had been reported, highlighting the urgency of identifying biomarkers for predicting disease severity and fatal outcomes. Here, we show that plasma levels of angiotensin II, a major regulatory peptide of the renin-angiotensin system, are markedly elevated in H7N9 patients and are associated with disease progression. Moreover, the sustained high levels of angiotensin II in these patients are strongly correlated with mortality. The predictive value of angiotensin II is higher than that of C-reactive protein and some clinical parameters such as the PaO2/FiO2 ratio (partial pressure of arterial oxygen to the fraction of inspired oxygen). Our findings indicate that angiotensin II is a biomarker for lethality in flu infections.

Defective PTEN regulation contributes to B cell hyperresponsiveness in systemic lupus erythematosus

Abstract: PTEN regulates normal signaling through the B cell receptor (BCR). In systemic lupus erythematosus (SLE), enhanced BCR signaling contributes to increased B cell activity, but the role of PTEN in human SLE has remained unclear. We performed fluorescence-activated cell sorting analysis in B cells from SLE patients and found that all SLE B cell subsets, except for memory B cells, showed decreased expression of PTEN compared with B cells from healthy controls. Moreover, the level of PTEN expression was inversely correlated with disease activity. We then explored the mechanisms governing PTEN regulation in SLE B cells. Notably, in normal but not SLE B cells, interleukin-21 (IL-21) induced PTEN expression and suppressed Akt phosphorylation induced by anti-immunoglobulin M and CD40L stimulation. However, this deficit was not primarily at the signaling or the transcriptional level, because IL-21-induced STAT3 (signal transducer and activator of transcription 3) phosphorylation was intact and IL-21 up-regulated PTEN mRNA in SLE B cells. Therefore, we examined the expression of candidate microRNAs (miRs) that could regulate PTEN: SLE B cells were found to express increased levels of miR-7, miR-21, and miR-22. These miRs down-regulated the expression of PTEN, and IL-21 stimulation increased the expression of miR-7 and miR-22 in both normal and SLE B cells. Indeed, a miR-7 antagomir corrected PTEN-related abnormalities in SLE B cells in a manner dependent on PTEN. Therefore, defective miR-7 regulation of PTEN contributes to B cell hyperresponsiveness in SLE and could be a new target of therapeutic intervention.

Identification of long noncoding RNA associated with osteoarthritis in humans.

Abstract: Objective Long noncoding RNAs (lncRNAs) are an important class of genes involved in various biological functions; however, knowledge about lncRNAs in osteoarthritis (OA) is limited. Therefore, the present study aimed to identify which lncRNAs are expressed in OA versus normal cartilage. Methods To identify lncRNAs specifically expressed in OA cartilage, expression of lncRNAs in OA cartilage was compared with that in normal cartilage using microarray analysis. The identified differences in expression of lncRNAs were validated by real time polymerase chain reaction (RT-PCR). Furthermore, expression of several key mRNAs associated with OA, including those for matrix metalloproteinase (MMP)-9, MMP-13, bone morphogenetic protein (BMP)-2, COL2A1 and ADAMTS5, was investigated by RT-PCR in OA and normal cartilage. Results Microarray analysis identified 121 lncRNAs that were up- or down-regulated in OA compared with normal tissue, 73 being upregulated and 48 downregulated compared with normal cartilage. Twenty-one of the above differently expressed lncRNAs were up-regulated twofold. Expression of six lncRNAs, including HOTAIR, GAS5, PMS2L2, RP11-445H22.4, H19 and CTD-2574D22.4, was up-regulated in OA compared with normal tissue as validated by RT-PCR after microarray analysis. Expression of mRNA for MMP-9, MMP-13, BMP-2, and ADAMTS5 in OA was significantly greater than in normal cartilage. However, expression of mRNA for COL2A1 was lower in OA than in normal cartilage. Conclusion The differently expressed lncRNAs may be associated with the pathogenesis of OA. Further functional studies are critical to confirming the function of lncRNAs in OA and to exploring new potential targets for therapy.

Trophoblastic disease review for diagnosis and management: a joint report from the International Society for the Study of Trophoblastic Disease, European Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic Cancer InterGroup.

Abstract: Objective The objective of this study was to provide a consensus review on gestational trophoblastic disease diagnosis and management from the combined International Society for the Study of Trophoblastic Disease, European Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic Cancer InterGroup. Methods A joint committee representing various groups reviewed the literature obtained from PubMed searches. Results and Conclusions Guidelines were constructed on the basis of literature review. After initial diagnosis in local centers, centralization of pathology review and ongoing care is recommended to achieve the best outcomes.

The impact of soluble dietary fibre on gastric emptying, postprandial blood glucose and insulin in patients with type 2 diabetes

Abstract: Dietary fibre plays an important role in controlling postprandial glycemic and insulin response in diabetic patients. The intake of dietary fibre has been shown to delay the gastric emptying in healthy subjects. The relationship between gastric emptying and postprandial blood glucose in diabetic patients with fibre-load liquids needs to be investigated. To investigate the impact of soluble dietary fibre (SDF) on gastric emptying, postprandial glycemic and insulin response in patients with type 2 diabetes. 30 patients with type 2 diabetes (DM) and 10 healthy subjects (HS) matched for gender and age were randomized to receive SDF-free liquid (500 mL, 500 Kcal) and isoenergetic SDF liquid (oat β-glucan 7.5 g, 500 mL, 500 Kcal) on two separate days based on a cross-over with 6-day wash-out period. Gastric emptying was monitored by ultrasonography at intervals of 30 min for 2 hours. Fasting and postprandial blood was collected at intervals of 30-60 min for 180 min to determine plasma glucose and insulin. Proximal gastric emptying was delayed by SDF-treatment both in DM (p = 0.001) and HS (p = 0.037). SDF resulted in less output volume in the distal stomach in DM (p ＜ 0.05). SDF decreased postprandial glucose (p = 0.001) and insulin (p = 0.001) in DM subjects. Postprandial glucose (r = -0.547, p = 0.047) and insulin (r = -0.566, p = 0.004) were negatively correlated with distal emptying of SDF in DM subjects. Distal gastric emptying was delayed significantly in DM subjects with HbA1c levels ≥ 6.5% (p = 0.021) or with complications (p = 0.011) by SDF, respectively. SDF improved postprandial glycaemia which was related to slowing of gastric emptying.

The impact of nurse empowerment on job satisfaction

Abstract: Title. The impact of nurse empowerment on job satisfaction. Aim. This paper is a report of a study conducted to test Kanter’s organizational empowerment theoretical model specifying the relationships among demographics, structural empowerment, and job satisfaction. Background. Empowerment has become an increasingly important factor in determining nurses’ job satisfaction in current restructured work environments in China. Methods. A correlational, cross-sectional design was used to test Kanter’s organizational empowerment model with a sample of 650 full-time nurses employed in six Chinese hospitals in 2007, with a response rate of 92% (n = 598). The instruments used were the Demographic Data Questionnaire, Conditions of Work Effectiveness Questionnaire-II, and Job Satisfaction Scale. Results. The three lowest scoring items for Conditions of Work Effectiveness Questionnaire-II were resources, opportunity and informal power. The job satisfaction items revealing most dissatisfaction were workload and compensation, professional promotion, amount of work responsibility, work environments, and organizational policies. A statistically significant positive correlation was found between empowerment and job satisfaction (r = 0·547, P < 0·01). The demographic factors influencing empowerment were work objectives and age. The influencing factors for job satisfaction were work objectives and education level. Conclusion. The results provide support for Kanter’s organizational empowerment theory in the Chinese nurse population. Nurses who view their work environments as empowering are more likely to provide high quality care. Enhancing empowerment in a supportive environment would allow nurses to experience satisfaction with their jobs.

Anti‐TNF‐α therapy for patients with sepsis: a systematic meta‐analysis

Abstract: SummaryObjective In humans, the role of anti-tumour necrosis factor (TNF)-α therapy in severe sepsis and septic shock is debatable. The aim of this meta-analysis was to determine the efficacy of anti-TNF-α therapies against placebo in patients with severe sepsis or septic shock. Methods A structured literature search was undertaken to identify randomised controlled trials (RCTs) conducted in patients with severe sepsis or septic shock receiving anti-TNF-α therapy or placebo. A meta-analysis on relative risk (OR) with a 95% confidence interval (95% CI) was performed. Results Seventeen studies with a total of 8971 patients were included. When all forms of anti-TNF-α therapy were pooled together, there was a significant reduction of 28-day all-cause mortality with respect to placebo (OR = 0.91, 95% CI: 0.83–0.99; p = 0.04). Subgroup analysis showed that anti-TNF-α antibodies (monoclonal and polyclonal) reduced mortality (OR = 0.90, 95% CI: 0.81–0.99; p = 0.04). Monoclonal antibodies enhanced survival (OR = 0.91, 95% CI: 0.82–1.00; p = 0.05), while polyclonal antibodies or receptor blockers did not enhance survival (OR = 0.71, 95% CI: 0.39–1.28, p = 0.25; OR = 0.95, 95% CI: 0.78–1.17, p = 0.65). There was a trend towards better survival in patients with high levels of IL-6 (> 1000 pg/ml) and patients with shock if they were treated with anti-TNF-α therapy (OR = 0.85, 95% CI: 0.72–1.00; OR = 0.80, 95% CI: 0.62–1.04). Publication bias and statistical heterogeneity (I2 0.1) were absent. Sensitivity analysis suggests that these results are highly stable. Conclusions This meta-analysis suggests that in patients with severe sepsis (before shock), immunotherapy with anti-TNF-α monoclonal antibodies reduces overall mortality. In patients with shock or high levels of IL-6 (> 1000 pg/ml), anti-TNF-α therapy may improve survival.

Long noncoding RNA plays a key role in metastasis and prognosis of hepatocellular carcinoma.

Abstract: Long noncoding RNAs (lncRNAs) have been attracting immense research interests. However, only a handful of lncRNAs had been thoroughly characterized. They were involved in fundamental cellular processes including regulation of gene expression at epigenetics as well as tumorogenesis. In this paper, we give a systematic and comprehensive review of existing literature about lncRNA involvement in hepatocellular carcinoma. This review exhibited that lncRNAs played important roles in tumorigenesis and subsequent prognosis and metastasis of hepatocellular carcinoma and elucidated the role of some specific lncRNAs such as MALAT1 and HOTAIR in the pathophysiology of hepatocellular carcinoma and their potential of being therapeutic targets.

Optimal Cutoff Scores for Dementia and Mild Cognitive Impairment of the Montreal Cognitive Assessment among Elderly and Oldest-Old Chinese Population

Abstract: Background All versions of the Montreal Cognitive Assessment (MoCA) lack population-based data of 80-plus individuals. The norms and cut-off scores for mild cognitive impairment (MCI) and dementia of the MoCA are different among five Chinese versions. Objective To provide the cut-off scores in detecting MCI and dementia of the Peking Medical Union College Hospital version of the MoCA (MoCA-P). Methods In a cross-sectional survey, Chinese veterans aged ≥60 years completed the MoCA-P and the Mini-Mental State Examination (MMSE). Results Among 7,445 elderly veterans, 5,085 (68.30%) were aged ≥80 years old, 2,621 (35.20%) had 6 years of education or less, 6,847 (91.97%) were male, and 2,311 (31.04%) and 984 (13.22%) veterans were diagnosed as having MCI and dementia, respectively. Adding two points and one point to the MoCA scores for the primary and middle school groups, respectively, can fully adjust for the notable impact of education but cannot compensate for the effect of age. In the three age groups (60-79, 80-89, and ≥90 years old), the optimal MoCA-P cut-off scores for detecting MCI were ≤25, ≤24, and ≤23, respectively, and for detecting dementia were ≤24, ≤21, and ≤19, respectively, which demonstrated relatively high sensitivities and specificities. The areas under the curves for the MoCA-P for detecting MCI and dementia (0.937 and 0.908, respectively) were greater than those for the MMSE (0.848 and 0.892, respectively). Conclusion Compared with the MMSE, the MoCA-P is significantly better for detecting MCI in the elderly, particularly in the oldest old population, and it also displays more effectiveness in detecting dementia.

High variability in baseline urinary free cortisol values in patients with Cushing's disease

Abstract: Summary Objective Twenty-four-hour urinary free cortisol (UFC) sampling is commonly used to evaluate Cushing’s syndrome. Because there are few data on UFC variability in patients with active Cushing’s disease, we analysed baseline UFC in a large patient cohort with moderate-to-severe Cushing’s disease and assessed whether variability correlates with hypercortisolism severity. These data will help clinicians establish the minimum number of UFC samples required to obtain reliable data. Design Observational study (enrolment phase of Phase III study). Methods Patients (n = 152) with persistent/recurrent or de novo Cushing’s disease and mean UFC (mUFC) ≥159ULN (normal: 30–145 nmol/24 h) were included. Mean UFC level was calculated from four 24-h urine samples collected over 2 weeks. Results Over 600 24-h UFC samples were analysed. The mUFC levels of samples 1 and 2 and samples 3 and 4 were 1000 nmol/ 24 h (SD 1872) and 940 nmol/24 h (SD 2148), respectively; intrapatient coefficient of variation (CV) was 38% for mUFC. The intrapatient CV using all four samples was 52% (95% CI: 48–56). The intrapatient CV was 51% (95% CI: 44–58) for samples 1 and 2, 49% (95% CI: 43–56) for samples 3 and 4 and 54% (95% CI: 49–59) for samples 1, 2 and 3. Variability in mUFC increased as UFC levels increased. There were no correlations between UFC and clinical features of hypercortisolism. Conclusions There is intrapatient variability of approximately 50% in 24-h UFC measurements, which is relevant to targets set to estimate any treatment effect. Analysing more than two 24-h collection periods in individual patients does not result in a relevant decrease in variability. Interestingly, UFC levels did not correlate with hypercortisolism severity.

Transversus abdominis-plane block versus local anesthetic wound infiltration in lower abdominal surgery: a systematic review and meta-analysis of randomized controlled trials

Abstract: Background: Postoperative pain management is of great importance in perioperative anesthetic care Transversus abdominis plane (TAP) block has been described as an effective technique to reduce postoperative pain and morphine consumption after open lower abdominal operations Meanwhile, local anesthetic infiltration (LAI) is also commonly used as a traditional method However, the effectiveness of these two methods has not been compared before Methods: A meta-analysis of all relevant randomized controlled trials (RCTs) was conducted to compare the efficacy of single shot TAP block with that of single shot LAI for postoperative analgesia in adults Major medical databases and trial registries were searched for published and unpublished RCTs The endpoints include postoperative visual analog scale (VAS) pain score, morphine requirement, and rate of postoperative nausea and vomiting (PONV) For continuous data, weighted mean differences (WMDs) were formulated; for dichotomous data, risk ratios (RR) were calculated Results were derived using a random-/fixed-effects model with 95% confidence interval (CI) Results: Four RCTs, encompassing 96 TAP-block and 100 LAI patients, were included in the final analysis Patients in the TAP-block group had lower VAS pain scores 24 hours postoperatively compared with the LAI group, both at rest (WMD [95% CI] =�067 [p < 001] and with movement (WMD =�089, p < 001) There were no significant between-group differences in 24-hour postoperative morphine requirements, the rates if PONV or VAS pain scores at 2 and 4 h postoperatively Conclusion: TAP block and LAI provide comparable short-term postoperative analgesia, but TAP block has better long-lasting effect