Surgical Site Infections and their economic significance in hepatopancreatobiliary surgery: A retrospective incidence,cost, and reimbursement analysis in a German centre of the highest level of care

Surgical site infections (SSI) in open Hepatopancreatobiliary (HPB) surgery are common complications. They worsen patients’ outcomes and prolong hospital stays. Their economic significance in the German diagnosis related groups (DRG) system is mostly unknown. To investigate their economic importance, we evaluated all cases for SSIs as well as clinical and financial parameters undergoing surgery in our centre from 2015 and 2016. Subsequently, we carried out a cost‐revenue calculation by assessing our billing data and the cost matrix of the InEK (German Institute for the Payment System in Hospitals). A total of 13.5% of the patients developed a superficial, 9% a deep incisional, and 2.4% of the patients an organ space SSI. Compared with Patients without SSI, Patients with SSI had more comorbidities, were older, and their average length of stay was extended by 19 days (P < .001). The financial loss per SSI‐case was €‐7035.65 despite increased reimbursement, which resulted in a calculated total loss for the hospital of €‐802 064.62 in 2015 and 2016. Surgical site infections are common complications of open HPB surgery, which lead to a significant increase in the cost per case. Further prevention strategies need to be developed. Besides, an adjustment of revenues must be demanded.     

Evaluation of lung and chest wall mechanics during anaesthesia using the PEEP-step method

Background

Postoperative pulmonary complications are common. Between patients there are differences in lung and chest wall mechanics. Individualised mechanical ventilation based on measurement of transpulmonary pressures would be a step forward. A previously described method evaluates lung and chest wall mechanics from a change of ΔPEEP and calculation of change in end-expiratory lung volume (ΔEELV). The aim of the present study was to validate this PEEP-step method (PSM) during general anaesthesia by comparing it with the conventional method using oesophageal pressure (PES) measurements.

内皮细胞因子TM、vWF、凝血因子Ⅶ、Ⅷ和D-二聚体在肝移植排斥反应变化的研究

目的　为了解肝移植出现排斥反应患者内皮细胞因子、凝血因子和纤溶功能的变化 ,了解这些因素在监测排斥反应、疗效和判断预后的作用。方法　随机观察肝移植 4 1例 ,其中出现排斥反应 1 6例 (急性排斥 1 2例、慢性排斥 4例 )。在术前、术后检测血浆血栓调节蛋白 (STM)、血管性血友病因子 (v WF)、因子 V (FV )、V (FV )和 D-二聚体 (D- D)含量。结果　 1有排斥者术前 FVII含量减少 (6 9.2± 7.2 % ) ,D- D含量则升高 (1 .1 9± 0 .2 0 ng/ L) ;2有排斥者术后、排斥前 2天 FVII进一步减少 (分别为 75 .7± 3.1 ,6 0 .7± 4 .5 ) ,而 STM(分别为 5 .5 8± 0 .4 2 m g/ m l,5 .93± 0 .4 5 ng/ m l)、v WF(分别为 1 0 1 .2± 4 .6 % ,1 0 4 .3± 5 .8% ) ;D- D(分别为 2 .89± 0 .75 ,5 .2 8± 0 .81 )则明显升高 ;3急性排斥较慢性排斥 ,冲击治疗无效组与有效组 ,治疗后死亡组与生存组比较 ,STM和 D- D均明显升高。结论　本研究结果初步显示 :1血浆 STM　 v WF、D- D含量增高和FVII含量减少 ,可作为肝移植排斥早期预报指标 ,其中 STM的特异性最高 ;2血 STM、v WF、D- D和 FVII可作为监测肝移植排斥的实验室检测项目和指标 ;3血 STM和 D- D可作为区分急性与慢性排斥、监测冲击治疗疗效和判断预后的指标     

外源性CC10基因表达对肝癌细胞增殖、 凋亡、迁移和侵袭的影响

目的 探究外源性Clara细胞分泌蛋白10（CC10）的基因表达对肝癌细胞增殖、凋亡、迁移和 侵袭的影响,并探讨其可能的作用机制。方法 采用RT-qPCR和Western blotting检测人正常肝细胞LO2和 肝癌细胞HepG2、Hep3B中CC10的内源表达水平;将HepG2细胞系分为pcDNA 3.1组和pcDNA 3.1-CC10 组,用LipofectionTM分别转染pcDNA 3.1空载体质粒和重组质粒pcDNA 3.1-CC10。用CCK-8法、TUNEL 法和Transwell小室实验分别检测两组细胞增殖、凋亡情况及迁移、侵袭能力。采用RT-qPCR和Western blotting检测两组细胞中CC10和细胞周期蛋白D1（Cyclin D1）的表达水平。结果 与正常肝细胞LO2相 比,CC10在肝癌细胞HepG2、Hep3B中呈明显低表达（P<0.05）;转染 pcDNA 3.1-CC10后的HepG2细胞内 CC10 mRNA和蛋白水平均显著增高（P<0.05）。与 pcDNA 3.1组相比,pcDNA 3.1-CC10组细胞活力受到抑 制,细胞活力以时间依赖性方式降低（P<0.05）,细胞迁移和侵袭实验中的过膜细胞数均低于pcDNA 3.1组 （P<0.05）,细胞凋亡率高于pcDNA 3.1组（P<0.05）。同时,Cyclin D1的mRNA和蛋白表达水平均明显降低 （P<0.05）。 结论? 外源性CC10基因表达可抑制肝癌细胞增殖、迁移和侵袭,促进其凋亡,其机制可能与 下调Cyclin D1表达有关。     

Mineral loss in cortical and trabecular bone during high-dose prednisone treatment

Summary To evaluate the effect of prednisone and triple treatment (sodium fluoride, calcium, and vitamin D) on trabecular and cortical bone serial bone mineral content (BMC) measurements were made at a metaphyseal (BMC_D) and diaphyseal (BMC_P) site on the forearm on 31 consecutive and previously bone-healthy patients scheduled for at least 24 weeks high-dose prednisone treatment. The patients were randomized into two further treatment groups: group I (n=16) received prednisone plus triple treatment and group II (n=15) received only prednisone. The two groups were similar with regard to age, sex, prednisone dose, and initial BMC. During 24 weeks treatment, BMC_D (partially representing trabecular bone) and BMC_P (mainly representing cortical bone) fell significantly and similarly, demonstrating that there is no preventive effect on bone mineral loss on the triple regimen. The BMC fall after 12 weeks was significantly more pronounced for metaphyseal (partially trabecular) than for diaphyseal (cortical) bone, whereas the values did not differ significantly after 24 weeks; this indicates a greater sensitivity to the hormone treatment of trabecular bone. In the entire group, the fall in BMC correlated positively with individual prednisone dose, significant at the diaphyseal site (r=0.39,P<0.05), but not at the metaphyseal site (r=0.31, P=0.08). It is concluded that corticosteroid-induced osteopenia is a diffuse bone disease which affects trabecular as well as cortical bone, suggesting that BMC measured on the forearm reflects changes in bone mineral at other locations.     

液相色谱-质谱联用法（LC-MS/MS）和酶联免疫法(ELISA)对体内25（OH）D3水平的测定

目的 同时用液相色谱-质谱联用法（LC-MS/MS）和酶联免疫法（ELISA）检测患者体内25（OH）D3水平,分析两者结果的差异。方法 随机选取50例住院患者,对同一血清样本分别用LC-MS/MS法和ELISA法测定25（OH）D3水平,同时用LC-MS/MS法测定25（OH）D2的水平。结果 LC-MS/MS法测定的维生素D3的均数为14.99±6.51ng/ml,酶联免疫法测定的均数为20.91±9.70ng/ml,两者的相关系数为0.725（P＜0.01）,线性相关方程为维生素D3（LC-MS/MS法）=4.829+0.486×维生素D3(ELISA法)。LC-MS/MS法组25（OH）D3浓度高于20ng/ml的比例17%,酶联免疫法组为52%,LC-MS/MS法组的25（OH）D2和25（OH）D3总浓度高于20ng/ml的为24%。25（OH）D2占25（OH）D总量的8.4%。 结论 LC-MS/MS法测定的维生素D3的数值明显低于ELISA法,两者正相关性较高,可经方程互换。酶联免疫法低估了体内维生素D的缺乏,检测25（OH）D3的同时需测定25（OH）D2浓度。     

In Healthy Adults,Biological Activity of Vitamin D,as Assessed by Serum PTH,Is Largely Independent of DBP Concentrations

Vitamin D insufficiency, as measured by 25‐hydroxyvitamin D (25[OH]D) levels, has been associated with important health outcomes. The majority of vitamin D in circulation is bound to vitamin D–binding protein (DBP) and albumin, and recent genetic studies have demonstrated that serum DBP is a major determinant of 25(OH)D concentrations in adults. The impact of circulating DBP levels on vitamin D's biologic action, is unclear, but is of particular relevance to vitamin D epidemiology, because a lack of control for DBP levels could strongly influence the association of vitamin D with disease. Serum parathyroid hormone (PTH) levels can act as a biological readout of 25(OH)D activity. We therefore assessed the relationship between serum total and free 25(OH)D and PTH with and without adjusting for DBP, in 2073 subjects of European descent. Total 25(OH)D levels correlated positively (r = 0.19, p = 1.8 × 10^?17) with DBP, whereas the free 25(OH)D correlated negatively (r = ?0.14, p = 5.0 × 10^?12). Total and free 25(OH)D levels correlated negatively with PTH (r = ?0.29, p = 1.3 × 10^?39; r = ?0.26, p = 1.9 × 10^?33, respectively). Including age, body mass index (BMI), sex, estimated glomerular filtration rate, calcium, and season of blood draw as covariates, total 25(OH)D levels were significantly associated with log‐transformed PTH (lnPTH) levels (linear term: β = ?0.010, p < 0.0001, squared term: β = 0.00004, p < 0.0001) and this association was not changed by adjusting for DBP. These findings provide evidence that in a largely vitamin D–sufficient cohort, the biological effect of vitamin D on PTH levels is mainly independent of DBP concentration. Accordingly, this study may provide useful information for studies investigating the relationship between vitamin D, DBP, and disease. © 2014 American Society for Bone and Mineral Research.     

Calorie restriction increases serum parathyroid hormone and decreases serum calcitonin levels in patients with maturity onset diabetes mellitus

Calorie restriction is important in managing patients with maturity onset diabetes mellitus (NIDDM). The effect of such restriction on calcium metabolism is not known. The objective of this study was to determine whether patients on calorie restricted diets would show any modification of parathyroid hormone (PTH) and calcitonin (CTN). The serum levels of PTH and CTN were measured by radioimmunoassays in 269 patients with NIDDM. The patients were divided into two groups depending on the intake of calorie, and PTH and CTN were monitored for 2 years. Plasma levels of vitamin D were measured by competitive protein binding assays before and after each program. The level of PTH (520.8±266.0 pg/ml) (mean±S.D.) was significantly (P<0.01) higher in 109 diabetic patients whose calorie intake was restricted for 2 years (diet (D) group) as compared with that (256.6±103.8 pg/ml) of 160 diabetic patients whose calorie intake was not restricted (non-diet (ND) group). The daily oral calcium intake of the two groups did not differ significantly. We found no significant difference in the serum PTH level in the ND groupVS. normal control subjects (248.8±98.4, N=78). The serum calcium concentration and the amount of calcium excreted in urine were slightly but significantly (P<0.01) lower in the D than in the ND group. The rate of tubular reabsorption of phosphate (% TRP) was significantly lower in the D group than that in the ND group (P<0.01). The serum CTN level was significantly (P<0.01) lower in the D group (33.9±11.3 pg/ml) than in the ND group (64.9±21.2 pg/ml) 2 years after each treatment. The plasma 1,25-(OH)₂-vitamin D level was significantly (P<0.01) lower in the D group (22.2±6.6 pg/ml) than in the ND group (50.6±4.2 pg/ml). When the restriction of calorie intake in the D group was canceled, their PTH levels decreased, which was accompanied by increase in the 1,25-(OH)₂-vitamin D levels, whereas their CTN levels were unchanged. These observations suggested that a restricted calorie intake is a risk factor for secondary hyperparathyroidism as well as for a low serum level of CTN in patients with NIDDM.     

Vitamin D deficiency in mothers of rachitic infants

Summary The existence of nutritional deficiency rickets among infants in sunny Riyadh was confirmed radiologically. Most of the rachitic infants were breast-fed, some received unsupplemented infant feeding formulae, and all live in an environment that is devoid of sunlight. Their mean age at the time of onset was 10.5 months. 25-Hydroxyvitamin D (25OHD) levels were found to be low in mothers of the rachitic infants. This maternal deficiency as a factor in pathogenesis of rickets in the infant is discussed. Proposals are made to prevent the occurrence of rickets on this scale.     

肝脏血管与胆道系统的MR图像三维重建与融合的初步研究

目的探索利用MR后处理工作站进行肝脏血管与胆管系统融合的方法及意义。方法12例手术病人术前同时行三维动态增强磁共振血管成像(three dimensional contrast enhanced magnetic resonance angiography,3D DCE MRA)及磁共振胰胆管成像(MR cholangiopancreatogra- phy,MRCP),包括6例肝硬化、4例肝癌、2例发生在胆总管的胆管细胞癌。两种序列采取一致的扫描范围、视野及层厚。利用MR后处理工作站分别进行血管与胆管系统的重建,然后将两者融合并形成三维动画。结果三种重建方法中.肝动脉、门静脉和肝静脉最大密度投影(maximum intensity projection,MIP)法重建观察的血管级数高于(surface shaded display,SSD)和容积重建(volume recon- struction,VR),胆管三种方法之间无统计学差别。重建和融合可同时显示肝内血管、胆管的解剖与异常及两者之间的关系。结论利用MR后处理工作站可在活体达到肝脏血管系统与胆管系统的融合,其解剖关系的显示有助于临床治疗方式的选择。     

Serum bone gla protein (BGP) and other markers of bone mineral metabolism in postmenopausal osteoporosis

Summary Bone gla protein, the vitamin K-dependent protein synthesized by osteoblasts and measured in blood by radioimmunoassay, has been used as an index of the rate of bone turnover. The relationship of bone gla protein with other markers of bone mineral metabolism was determined in 31 untreated postmenopausal women with the osteoporotic syndrome. In addition to serum osteocalcin (BGP) we measured parathyroid hormone (PTH) (carboxyl and mid-molecule fragments), 25(OH)D, alkaline phosphatase, estradiol (E₂), estrone (E₁), dietary calcium intake, 24 hour urinary calcium excretion, and bone mineral density by CT scan of the lumbar vertebrae. Significant osteopenia was present on CT in untreated postmenopausal osteoporotic women (bone density in 18 out of 31 was below the critical value of 60 mg/cm³). Serum BGP correlated positively with CT scan (r+0.647,P<0.001). CT and age were negatively correlated (r−0.661,P<0.001) while CT and E₂ showed a positive correlation (r+0.554,P<0.01). Unexpectedly, BGP and age revealed a significant negative correlation (r−0.421,P<0.05). These findings suggest a state of low bone turnover in this group with untreated postmenopausal osteoporosis.     

Serum 25-hydroxyvitamin D levels and activities of daily living in noninstitutionalized elderly Japanese requiring care

To date, no study has investigated the nutritional status of vitamin D in frail elderly people living at home. The purposes of this study were to assess serum 25-hydroxyvitamin D (25[OH]D) levels and associated factors in noninstitutionalized elderly people who had various levels of physical disability, and to propose an adequate vitamin D nutritional status for the elderly by interpreting the serum 25(OH)D levels in relation to serum parathyroid hormone (PTH) levels in this population. Health examinations were conducted in the winter and summer of 2003. The subjects were 143 elderly people in the winter, and 120 elderly people in the summer, who all used the long-term care insurance system at home. Serum 25(OH)D concentrations were determined with a chemiluminescence protein-binding assay, and serum intact PTH concentrations were determined with an immunoradiometric assay. The subjects' disease histories and lifestyle information were obtained through an interview. Activities of daily living (ADL) levels were evaluated using the Barthel index, and grip strength was measured with a digital hand dynamometer. Average serum 25(OH)D levels in the winter and summer were 54.2 nmol/l (SD 29.0) and 53.3 nmol/l (SD 32.3), respectively, and intact PTH concentrations in the winter and summer were 4.2 pmol/l (SD 1.8) and 4.3 pmol/l (SD 1.8), respectively. The proportion of people who had a low 25(OH)D (<30 nmol/l) and high intact PTH levels (>6.9 pmol/l) were 15%–20% and 8%, respectively. Significant predictors of low serum 25(OH)D concentrations were low ADL levels, female sex, and low fish consumption in both seasons. Serum 25(OH)D concentrations of less than 50 nmol/l were associated with elevated serum intact PTH concentrations. In conclusion, elderly people requiring care at home are at high risk of hypovitaminosis D, and their low serum 25(OH)D levels are mainly associated with low ADL levels. In addition, maintenance of serum 25(OH)D concentrations above 50 nmol/l may prevent hypovitaminosis D-induced hyperparathyroidism.     

小儿外周血骨碱性磷酸酶含量与钙营养关系的分析

目的 通过对我院儿保门诊就诊的40～55天的小儿骨碱性磷酸酶的测定结果 进行分析,了解此年龄段小儿钙营养状况及其相关影响因素.方法 对本院门诊就诊的650例小儿进行骨碱性磷酸酶测定,并对其测定结果 进行分析比较.结果 1～3月份出生的小儿骨碱性磷酸酶升高几率最高,7～9月份相对最低.母孕中晚期及生后未补充维生素D、钙小儿较补充者发生骨碱性磷酸酶升高的几率高.结论 1～3月份出生的小儿、母孕中晚期及生后未补充维生素D、钙小儿易发生缺钙而导致佝偻病.     

3D assessment of damaged bicycle helmets and corresponding craniomaxillo-mandibular skull injuries: A feasibility study

ObjectivesIn the Netherlands, cyclists continue to outnumber other road users in injuries and deaths. The wearing of bicycle helmets is not mandatory in the Netherlands even though research has shown that wearing bicycle helmets can reduce head and brain injuries by up to 88%. Therefore, the aim of this study was to assess the feasibility of using 3D technology to evaluate bicycle-related head injuries and helmet protection.MethodsThree patients who had been involved in a bicycle accident while wearing a helmet were subjected to multi-detector row computed tomography (MDCT) imaging after trauma. The helmets were separately scanned using the same MDCT scanner with tube voltages ranging from 80 kVp to 140 kVp and tube currents ranging from 10 mAs to 300 mAs in order to determine the best image acquisition parameters for helmets. The acquired helmet images were converted into virtual 3D surface hence Standard Tessellation Language (STL) models and merged with MDCT-derived STL models of the patients’ skulls. Finally, all skull fractures and corresponding helmet damage were visualized and related.ResultsImaging bicycle helmets on an MDCT scanner proved to be feasible using a tube voltage of 120 kVp and a tube current of 120 mAs. Merging the resulting STL models of the patients’ skull and helmet allowed the overall damage sustained by both skull and helmet to be related.ConclusionOur proposed 3D method of assessing bicycle helmet damage and corresponding head injuries could offer valuable information for the development and design of safer bicycle helmets.     

Insertion/Deletion (I/D) Polymorphism of Angiotensin-Converting Enzyme Gene in Steroid-Resistant Nephrotic Syndrome for Children: A Genetic Association Study and Meta-analysis

Abstract

An assessment of the association of angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism with steroid-resistant nephrotic syndrome (SRNS) risk in children is still controversial. A meta-analysis was performed to evaluate the relation between ACE gene polymorphisms and SRNS susceptibility. The relevant studies were screened from electronic database and eligible investigations were synthesized using meta-analysis methods. Seven investigations were identified for the analysis of association between ACE I/D gene polymorphism and SRNS risk in children, including five in Asians, one in Caucasians, and one in Africans. There was not a markedly positive association between D allele or DD genotype and SRNS susceptibility in Asians (OR = 1.60, p = 0.26; OR = 1.90, p = 0.38) and for Caucasian population (OR = 0.92, p = 0.86; OR = 0.27, p = 0.22). However, an association of D allele with SRNS susceptibility was observed (OR = 4.67, p = 0.003) in Africans, but not for DD genotype (OR = 6.00, p = 0.05). Interestingly, II genotype seemed to play a positive role against SRNS onset for Asians and African children (OR = 0.51, p = 0.02; OR = 0.07, p = 0.02), but not for Caucasians (OR = 0.33, p = 0.30). In conclusion, our results indicate that D allele or DD homozygous might not be a significant genetic molecular marker for the development of SRNS in Asians and Caucasian children. However, D allele seemed be associated with SRNS risk for Africans but DD genotype did not.     

Associations of 25‐Hydroxyvitamin D and 1,25‐Dihydroxyvitamin D With Bone Mineral Density,Bone Mineral Density Change,and Incident Nonvertebral Fracture

Relationships between 1,25‐dihydroxyvitamin D (1,25(OH)₂D) and skeletal outcomes are uncertain. We examined the associations of 1,25(OH)₂D with bone mineral density (BMD), BMD change, and incident non‐vertebral fractures in a cohort of older men and compared them with those of 25‐hydroxyvitamin D (25OHD). The study population included 1000 men (aged 74.6 ± 6.2 years) in the Osteoporotic Fractures in Men (MrOS) study, of which 537 men had longitudinal dual‐energy X‐ray absorptiometry (DXA) data (4.5 years of follow‐up). A case‐cohort design and Cox proportional hazards models were used to test the association between vitamin D metabolite levels and incident nonvertebral and hip fractures. Linear regression models were used to estimate the association between vitamin D measures and baseline BMD and BMD change. Interactions between 25OHD and 1,25(OH)₂D were tested for each outcome. Over an average follow‐up of 5.1 years, 432 men experienced incident nonvertebral fractures, including 81 hip fractures. Higher 25OHD was associated with higher baseline BMD, slower BMD loss, and lower hip fracture risk. Conversely, men with higher 1,25(OH)₂D had lower baseline BMD. 1,25(OH)₂D was not associated with BMD loss or nonvertebral fracture. Compared with higher levels of calcitriol, the risk of hip fracture was higher in men with the lowest 1,25(OH)₂D levels (8.70 to 51.60 pg/mL) after adjustment for baseline hip BMD (hazard ratio [HR] = 1.99, 95% confidence interval [CI] 1.19–3.33). Adjustment of 1,25(OH)₂D data for 25OHD (and vice versa) had little effect on the associations observed but did attenuate the hip fracture association of both vitamin D metabolites. In older men, higher 1,25(OH)₂D was associated with lower baseline BMD but was not related to the rate of bone loss or nonvertebral fracture risk. However, with BMD adjustment, a protective association for hip fracture was found with higher 1,25(OH)₂D. The associations of 25OHD with skeletal outcomes were generally stronger than those for 1,25(OH)₂D. These results do not support the hypothesis that measures of 1,25(OH)₂D improve the ability to predict adverse skeletal outcomes when 25OHD measures are available. © 2015 American Society for Bone and Mineral Research.