Comparison between Antegrade versus Retrograde Ureteral Stent Placement for Malignant Ureteral Obstruction

PurposeTo compare the technical success of antegrade uteral stent (AUS) and retrograde ureteral stent (RUS) placements in patients with malignant ureteral obstruction (MUO) and to determine the predictors of technical failure of RUS.Materials and MethodsThis study retrospectively included 61 AUS placements (44 patients) performed under fluoroscopic guidance and 76 RUS placements (55 patients) performed under cystoscopic guidance in patients with MUO from January 2019 to December 2020. Technical success rates of the 2 techniques were compared using inverse probability of treatment weighting (IPTW) analysis. Logistic regression was used to identify predictive factors for technical failures.ResultsTechnical success was achieved in 98.4% of the AUS group and 47.4% of the RUS group. After stabilized IPTW, the technical success rate was higher in the AUS group than in the RUS group (adjusted risk difference, 49.4%; 95% confidence interval [CI], 35.4%–63.1%). The independent predictors for technical failure of the RUS procedure were age of ≥65 years (odds ratio [OR], 5.56; 95% CI, 1.73–21.27), ureteral orifice invasion (OR, 4.21; 95% CI, 1.46–13.46), and extrinsic cancer (OR, 15.58; 95% CI, 2.92–111.81).ConclusionsThe technical success rate of AUS placement was higher than that of RUS placement in patients with MUO. RUS failure was associated with age of ≥65 years, cancer with ureteral orifice invasion, and extrinsic ureteral obstruction.     

基于IgG抗A（B）效价梯度及动态差值探讨ABO-HDN病情相关性

目的探讨动态监测IgG抗A(B)效价梯度与ABO-HDN病情严重程度临床指标的相关性。方法选取2017年1~5月间47例ABO溶血病患儿临床资料进行统计分析,记录患儿出生后32 h的血清总胆红素(serum total bilirubin,STB_(32h))、血红蛋白(hemoglobin,Hb)、网织红细胞百分比(the percentage of reticulocyte,Ret%)及孕妇第16和37周IgG抗A(B)效价梯度。比较各组新生儿临床指标和lgG抗A(B)效价的相关性。结果 STB_(32h)与37周IgG抗A(B)效价梯度、IgG抗A(B)_(37-16)梯度差呈正相关(P0.001);Hb与第37周IgG抗A(B)效价梯度呈负相关(r~2=0.2074,P=0.0013);Hb与IgG抗A(B)_(37-16)梯度差值呈负相关(r~2=0.1831;P=0.0027);Ret%与37周IgG抗A(B)效价梯度、IgG抗A(B)_(37-16)梯度差值呈正相关(P0.001)。结论产前37周IgG抗A(B)效价梯度、IgG抗A(B)_(37-16)效价梯度差值与新生儿ABO-HDN的病情严重程度具有一定相关性。     

不同性别不同年龄成年人体成分测量指标的检测分析

目的探讨安徽省不同性别、不同年龄成年人体成分检测指标的差异,为安徽省成年人的健康指导及慢性疾病预防提供数据参考。方法选取2018年1～12月在安徽医科大学第一附属医院体检的4 944位体检者,按性别不同分为男性组2 556人和女性组2 388人;再对不同性别组按不同年龄(y)分为5组[18≤y <30岁组; 30≤y <40岁组; 40≤y <50岁组; 50≤y <60岁组;y≥60岁组(在男性中为60≤y≤83岁组,在女性中为60≤y≤81岁组)];比较男性组和女性组体成分测量指标(体质指数、体脂肪含量、体脂百分比、腰臀比、内脏脂肪面积、去脂体质量、骨骼肌肉量、骨矿物质含量、蛋白质含量及浮肿指数)差异,同时分析不同性别人群上述各项体成分测量指标在不同年龄层的变化。结果①女性组体脂肪含量、体脂百分比及浮肿指数均高于男性组,其余各项指标男性组均高于女性组,差异均有统计学意义(P <0. 05);②男性体质指数、体脂肪含量和腰臀比在30≤y <60岁各年龄组均高于18≤y <30岁组,差异有统计学意义(P <0. 05);体脂百分比、内脏脂肪面积和浮肿指数在y≥30岁各年龄组均高于18≤y <30岁组,差异有统计学意义(P <0. 05);去脂体质量、骨骼肌肉量、骨矿物质含量及蛋白质含量在y≥50岁各年龄组均低于18≤y <30岁组,差异有统计学意义(P <0. 05)。女性体质指数、腰臀比及内脏脂肪面积在y≥30岁各年龄组均高于18≤y <30岁组,差异有统计学意义(P <0. 05);体脂肪含量、体脂百分比及浮肿指数在y≥40岁各年龄组均高于18≤y <30岁组,差异有统计学意义(P <0. 05);去脂体质量、骨骼肌肉量、骨矿物质含量及蛋白质含量在y≥60岁组均低于18≤y <30岁组,差异有统计学意义(P <0. 05)。结论安徽省成年人体成分存在性别差异,女性体脂肪含量高于男性,男性内脏脂肪面积及骨骼肌肉量高于女性;成年人体成分在不同年龄间亦存在差异,脂肪组织含量及浮肿指数在高年龄段增加,而其他非脂肪组织含量在高年龄段减低。     

Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis

ObjectiveNew-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery.MethodsWe performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted.ResultsPOAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66).ConclusionsThe results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.     

Gender trends in applicants to general surgery residency programs in Canada

BackgroundSurgical disciplines lag behind non-surgical disciplines in attracting female trainees. Female representation of Canadian General Surgeons has not been evaluated in recent years in the literature. The objectives of this study were to assess gender trends in applicants to Canadian General Surgery residency programs and practicing general surgeons and subspecialists.MethodsThis retrospective cross-sectional study analyzed gender data for residency applicants ranking General Surgery as their first-choice discipline from publicly-available annual Canadian Residency Matching Service (CaRMS) R-1 match reports from 1998 to 2021. Aggregate gender data for practicing female physicians in General Surgery and related subspecialties, including Pediatric Surgery, obtained from annual Canadian Medical Association (CMA) census from 2000 to 2019 was also analysed.ResultsThere was a significant increase in the proportion of female applicants from 34% in 1998 to 67% in 2021 (p < 0.001) and of successfully matched candidates from 39% to 68% (p = 0.002) from 1998 to 2021. Success rates between male and female candidates were significantly different in 1998 (p < 0.001), but not in 2021 (p = 0.29). The proportion of practicing female General Surgeons also significantly increased from 10.1% in 2000 to 27.9% in 2019 (p = 0.0013), with variable trends in subspecialties.ConclusionGender inequality in General Surgery residency matches has normalized since 1998. Despite females representing more than 40% of applicants and successfully matched candidates to General Surgery since 2008, a gender gap still exists amongst practicing General Surgeons and subspecialists. This suggests the need for further cultural and systemic change to mitigate gender disparities.Type of studyOriginal research article, clinical research.Level of evidenceLevel III (Retrospective cross-sectional study).     

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation.ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.Level of EvidenceII.     

Impact of gender on treatment and outcome of ICU patients

BACKGROUND: Gender modifies immunologic responses caused by severe trauma or critical illness. The aim of this study was to investigate the impact of gender on hospital mortality, length of intensive care unit (ICU) stay, and intensity of care of patients treated in ICUs. METHODS: Data on 24,341 ICU patients were collected from a national database. We measured severity of illness with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and intensity of care with Therapeutic Intervention Scoring System (TISS) scores. We used logistic regression analysis to test the independent effect of gender on hospital mortality. We compared the lengths of ICU stay and the intensity of care of men and women. RESULTS: Male gender was associated with increased hospital mortality among postoperative ICU patients [adjusted odds ratio 1.33 (95% confidence interval 1.12-1.58, P = 0.001)] but not among medical patients [adjusted odds ratio 1.02 (95% confidence interval 0.92-1.13, P = 0.74)]. Male gender was associated with an increased risk of death particularly in the oldest age group (75 years or older) and among the patients with relatively low APACHE II scores (<16). Mean length of ICU stay was 3.2 days for men and 2.6 days for women (P < 0.001). Male patients comprised 61.7% of the study population but consumed 66.0% of days in intensive care. CONCLUSION: Male gender contributes to poor outcome in postoperative ICU patients. Approximately two-thirds of ICU resources are consumed by male patients.     

Chaotic dynamics and convergence analysis of temporal difference algorithms with bang‐bang control

Reinforcement learning is a powerful tool used to obtain optimal control solutions for complex and difficult sequential decision making problems where only a minimal amount of a priori knowledge exists about the system dynamics. As such, it has also been used as a model of cognitive learning in humans and applied to systems, such as humanoid robots, to study embodied cognition. In this paper, a different approach is taken where a simple test problem is used to investigate issues associated with the value function's representation and parametric convergence. In particular, the terminal convergence problem is analyzed with a known optimal control policy where the aim is to accurately learn the value function. For certain initial conditions, the value function is explicitly calculated and it is shown to have a polynomial form. It is parameterized by terms that are functions of the unknown plant's parameters and the value function's discount factor, and their convergence properties are analyzed. It is shown that the temporal difference error introduces a null space associated with the finite horizon basis function during the experiment. The learning problem is only non‐singular when the experiment termination is handled correctly and a number of (equivalent) solutions are described. Finally, it is demonstrated that, in general, the test problem's dynamics are chaotic for random initial states and this causes digital offset in the value function learning. The offset is calculated, and a dead zone is defined to switch off learning in the chaotic region. Copyright © 2015 John Wiley & Sons, Ltd.     

Kinetic comparison of older men and women during walk-to-stair descent transition

Stair walking is one of the most challenging tasks for older adults, with women reporting higher incidence of falls. The purpose of this study was to investigate the gender differences in kinetics during stair descent transition. Twenty-eight participants (12 male and 16 female; 68.5 and 69.0 years of mean age, respectively) performed stair descent from level walking in a step-over-step manner at a self-selected speed over a custom-made three-step staircase with embedded force plates. Kinematic and force data were combined using inverse dynamics to generate kinetic data for gender comparison. The top and the first step on the staircase were chosen for analysis. Women showed a higher trail leg peak hip abductor moment (−1.0 N m/kg), lower trail leg peak knee extensor moment and eccentric power (0.74 N m/kg and 3.15 W/kg), and lower peak concentric power at trail leg ankle joint (1.29 W/kg) as compared to men (p < 0.05; −0.82 N m/kg, 0.89 N m/kg, 3.83 W/kg, and 1.78 W/kg, respectively). The lead leg knee eccentric power was also lower in women (p < 0.05). This decreased ability to exert knee control during stair descent transition may predispose women to a higher risk of fall.