Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by th...Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by the presence of systemic inflammation, infection and resultant multiorgan failure. The importance of immune dysregulation and acquisition of infection in the pathogenesis of acute liver failure and its associated complications is now recognised. In this review we discuss current thinking regarding the role of infection and inflammation in the pathogenesis of and outcome in human acute liver failure, the implications for the management of such patients and suggest directions for future research.展开更多
AIM:To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.METHODS:Retrospective observational study in a Tertiary Referral Centre.Between January 1999-October 2005,we iden...AIM:To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.METHODS:Retrospective observational study in a Tertiary Referral Centre.Between January 1999-October 2005,we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices.Patient details including age,gender and aetiology of liver disease/segmental portal hypertension were documented.The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle.All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded.Initial haemostasis rates,rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy.The duration of follow up was also listed.The study was conducted according to the United Kingdom research ethics guidelines.RESULTS:Thirty-seven patients were included.33 patients(89%) had thrombin(250 U/mL) for gastric varices,2(5.4%) for duodenal varices,1 for rectal varices and 1 for gastric and rectal varices.(1) Gastric varices,an average of 15.2 mL of thrombin was used per patient.Re-bleeding occurred in 4 patients(10.8%),managed in 2 by a transjugular intrahepatic portosystemic shunt(TIPSS)(one unsuccessfully who died) and in other 2 by a distal splenorenal shunt;(2) Duodenal varices(or type 2 isolated gastric varices),an average of 12.5 mL was used per patient over 2-3 endoscopy sessions.Re-bleeding occurred in one patient,which was treated by TIPSS;and(3) Rectal varices,an average of 18.3 mL was used per patient over 3 endoscopy sessions.No re-bleeding occurred in this group.CONCLUSION:Human thrombin is a safe,easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.展开更多
We conducted a six-year epidemiological study on human coronaviruses（HCoVs） circulating in Hong Kong, using 8275 nasopharyngeal samples from patients with acute respiratory tract infections. HCoVs were detected in 7...We conducted a six-year epidemiological study on human coronaviruses（HCoVs） circulating in Hong Kong, using 8275 nasopharyngeal samples from patients with acute respiratory tract infections. HCoVs were detected in 77（0.93%） of the samples by a pan-HCoV RT-PCR assay. The most frequently detected HCoV species was HCoV-OC43（0.58%）, followed by HCoV-229E（0.15%）,HCoV-HKU1（0.13%） and HCoV-NL63（0.07%）. HCoVs were detected throughout the study period（September 2008–August 2014）, with the highest detection rate from September 2010 to August2011（22/1500, 1.47%）. Different seasonal patterns of each HCoV species in Hong Kong were noted.HCoV-OC43 was predominant in the fall and winter, whereas HCoV-HKU1 showed peak activity in winter, with a few cases occurred in spring and summer. HCoV-229 E mainly occurred in winter and spring, while HCoV-NL63 was predominant in summer and autumn. HCoVs most commonly infect the elderly and young children, with median age of 79.5 years（range, 22 days to 95 years）.Intriguingly, the detection rate of HCoV-OC43 in the age group of ＆gt; 80 years（26/2380, 1.09%） was significantly higher than that in the age group of 0–10 years（12/2529, 0.47%）（P 〈 0.05）. These data provides new insight into the epidemiology of coronaviruses.展开更多
BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversa...BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversal agents.More needs to be reported on rates of reversal across different outpatient settings.Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center(APC)for their procedure.Here,we report data on outpatient sedation reversal rates for endoscopy performed at an inhospital APC vs at a free-standing ambulatory endoscopy digestive health center(AEC-DHC)following risk stratification with a triage tool.AIM To observe the effect of risk stratification using a triage tool on patient outcomes,primarily sedation reversal events.METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019.Procedures were stratified to their respective sites using a triage tool.We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded.Demographics and characteristics recorded include patient age,gender,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,procedure type,and reason for sedation reversal.RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period.Of these,17 patients at AEC-DHC and 9 at the APC underwent sedation reversals(0.017%vs 0.04%;P=0.06).Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age(53.5±21 vs 60.4±17.42 years;P=0.23),ASA class(1.66±0.48 vs 2.22±0.83;P=0.20),BMI(27.7±6.7 kg/m^(2) vs 23.7±4.03 kg/m^(2);P=0.06),and female gender(64.7%vs 22%;P=0.04).The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam(5.9±1.7 mg vs 8.9±3.5 mg;P=0.01),fentanyl(147.1±49.9μg vs 188.9±74.1μg;P=0.10),flumazenil(0.3±0.18μg vs 0.17±0.17μg;P=0.13)and naloxone(0.32±0.10 mg vs 0.28±0.12 m展开更多
The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing va...The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease.In this review,relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension.The main areas covered are safety of endoscopy in patients with liver disease,the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound,esophageal capsule,argon plasma coagulation,spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology.It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices.As the technology in endoscopy expands,so does the role of the endoscopist in liver disease.展开更多
BACKGROUND Metabolic dysfunction-associated steatotic liver disease(MASLD),characterised by hepatic lipid accumulation,causes inflammation and oxidative stress accompanied by cell damage and fibrosis.Liver injury(LI)i...BACKGROUND Metabolic dysfunction-associated steatotic liver disease(MASLD),characterised by hepatic lipid accumulation,causes inflammation and oxidative stress accompanied by cell damage and fibrosis.Liver injury(LI)is also frequently reported in patients hospitalised with coronavirus disease 2019(COVID-19),while preexisting MASLD increases the risk of LI and the development of COVID-19-associated cholangiopathy.Mechanisms of injury at the cellular level remain unclear,but it may be significant that severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)which causes COVID-19,uses angiotensin-converting expression enzyme 2(ACE2),a key regulator of the‘anti-inflammatory’arm of the renin-angiotensin system,for viral attachment and host cell invasion.AIM To determine if hepatic ACE2 levels are altered during progression of MASLD and in patients who died with severe COVID-19.METHODS ACE2 protein levels and localisation,and histological fibrosis and lipid droplet accumulation as markers of MASLD were determined in formalin-fixed liver tissue sections across the MASLD pathological spectrum(isolated hepatocellular steatosis,metabolic dysfunction-associated steatohepatitis(MASH)+/-fibrosis,end-stage cirrhosis)and in post-mortem tissues from patients who had died with severe COVID-19,using ACE2 immunohistochemistry and haematoxylin and eosin and picrosirius red staining of total collagen and lipid droplet areas,followed by quantification using machine learning-based image pixel classifiers.RESULTS ACE2 staining is primarily intracellular and concentrated in the cytoplasm of centrilobular hepatocytes and apical membranes of bile duct cholangiocytes.Strikingly,ACE2 protein levels are elevated in non-fibrotic MASH compared to healthy controls but not in the progression to MASH with fibrosis and in cirrhosis.ACE2 protein levels and histological fibrosis are not associated,but ACE2 and liver lipid droplet content are significantly correlated across the MASLD spectrum.Hepatic ACE2 levels are also increased in COVID-19 pa展开更多
The Mesoproterozoic(1.11 Ga)Umkondo large igneous province(LIP)in southern Africa and Antarctica was emplaced in<5 Myr and is dominated by low-Ti tholeiitic doleritic-gabbroic sills.It is of particular interest bec...The Mesoproterozoic(1.11 Ga)Umkondo large igneous province(LIP)in southern Africa and Antarctica was emplaced in<5 Myr and is dominated by low-Ti tholeiitic doleritic-gabbroic sills.It is of particular interest because it is the least studied LIP in southern Africa with both sublithospheric and lithospheric mantle sources proposed and it coincides with the early assembly of Rodinia,so it has importance in understanding the nature of magmatism and tectonics in and around the Kalahari craton during the Mesoproterozoic.In this study,we compiled a large database of existing(~750)and new(~100)major and trace element data for the Umkondo province,as well as 42 new Sr-Nd isotopic measurements,to provide constraints on its magma sources and geochemical evolution.Major element compositional variations in the low-Ti tholeiites are explained by low-pressure(1 kbar)three-phase fractional crystallisation(olivine,clinopyroxene and plagioclase)of a parent magma with~10 wt.%MgO in oxidising conditions(QFM+1).Inverse models show that the low-Ti tholeiitic magmas were derived as residual melts after the crystallization of 12%-33%olivine from primary komatiitic-basaltic magmas(up to~20 wt.%MgO)in equilibrium with mantle olivine(Fo90).Low Sm/Yb and TiO2/Yb-Nb/Yb indicate that the primary magmas were derived by 2%-20%shallow(40-50 km)partial melting of spinel lherzolite.High Sm/Yb is restricted to dyke swarms and may imply limited magma production from deeper(up to~70 km)garnet lherzolite-like sources.The low-Ti tholeiites of the Umkondo province are enriched in large ion lithophile elements(Rb-Sr-Cs-K)and depleted in high-field strength elements(Zr-Hf-Nb-Ta),indicating the involvement of crustal material and/or the subcontinental lithospheric mantle.This is supported by covariations in Th/Nb,Nb/Yb,Nb/La and Ce/Sm with generally negativeΔNb.Sr-Nd isotopes lend support to the notion that the Umkondo magmas were derived from depleted and/or enriched sublithospheric mantle sources and subsequently contaminated by enriched lithospheric 展开更多
Under global climate change, drought has become one of the most serious natural hazards, affecting the ecological environment and human life. Drought can be categorized as meteorological, agricultural, hydrological or...Under global climate change, drought has become one of the most serious natural hazards, affecting the ecological environment and human life. Drought can be categorized as meteorological, agricultural, hydrological or socio-economic drought. Among the different categories of drought, hydrological drought, especially streamflow drought, has been given more attention by local governments, researchers and the public in recent years. Identifying the occurrence of streamflow drought and issuing early warning can provide timely information for effective water resources management. In this study, streamflow drought is detected by using the Standardized Runoff Index, whereas meteorological drought is detected by the Standardized Precipitation Index. Comparative analyses of frequency, magnitude, onset and duration are conducted to identify the impact of meteorological drought on streamflow drought. This study focuses on the Jinghe River Basin in Northwest China, mainly providing the following findings. 1) Eleven meteorological droughts and six streamflow droughts were indicated during 1970 and 1990 after pooling using Inter-event time and volume Criterion method. 2) Streamflow drought in the Jinghe River Basin lagged meteorological drought for about 127 days. 3) The frequency of streamflow drought in Jinghe River Basin was less than meteorological drought. However, the average duration of streamflow drought is longer. 4) The magnitude of streamflow drought is greater than meteorological drought. These results not only play an important theoretical role in understanding relationships between different drought categories, but also have practical implications for streamflow drought mitigation and regional water resources management.展开更多
The California Simulation of Evapotranspiration of Applied Water （CaI-SIMETAW） model is a new tool developed by the California Department of Water Resources and the University of California, Davis to perform daily s...The California Simulation of Evapotranspiration of Applied Water （CaI-SIMETAW） model is a new tool developed by the California Department of Water Resources and the University of California, Davis to perform daily soil water balance and determine crop evapotranspiration （ETo）, evapotranspiration of applied water （ETaw）, and applied water （AW） for use in California water resources planning. ETaw is a seasonal estimate of the water needed to irrigate a crop assuming 100% irrigation efficiency. The model accounts for soils, crop coefficients, rooting depths, seepage, etc. that influence crop water balance. It provides spatial soil and climate information and it uses historical crop and land-use category information to provide seasonal water balance estimates by combinations of detailed analysis unit and county （DAU/County） over Califomia. The result is a large data base of ETc and ETaw that will be used to update information in the new California Water Plan （CWP）. The application uses the daily climate data, i.e., maximum （Tx） and minimum （Tn） temperature and precipitation （Pcp）, which were derived from monthly USDA-NRCS PRISM data （PRISM Group 2011） and daily US National Climate Data Center （NCDC） climate station data to cover California on a 4 kmx4 km change grid spacing. The application uses daily weather data to determine reference evapotranspiration （ETo）, using the Hargreaves-Samani （HS） equation （Hargreaves and Samani 1982, 1985）. Because the HS equation is based on temperature only, ETo from the HS equation were compared with CIMIS ETo at the same locations using available CIMIS data to determine correction factors to estimate CIMIS ETo from the HS ETo to account for spatial climate differences. CaI-SIMETAW also employs near real-time reference evapotranspiration （ETo） information from Spatial CIMIS, which is a model that combines weather station data and remote sensing to provide a grid of ETo information. A second database containing the available展开更多
BACKGROUND The debate regarding diagnostic classification systems in psychiatry(categorial vs dimensional systems)has essential implications for the diagnosis,prevention and treatment of stress reactions.We previously...BACKGROUND The debate regarding diagnostic classification systems in psychiatry(categorial vs dimensional systems)has essential implications for the diagnosis,prevention and treatment of stress reactions.We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries,and termed it the Complex Stress Reaction Syndrome(CSRS).AIM To investigate CSRS,Type A(psychiatric symptoms,spanning anxiety,depression,stress symptoms,and posttraumatic stress disorder(PTSD)),with or without long-coronavirus disease(COVID)residuals(CSRS,Type B,neuropsychiatric symptoms spanning cognitive deficits and fatigue,excluding systemic symptoms).Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population(Type A)or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals(Type B).METHODS 977 individuals in four continents(North America,Europe,Australia and the Middle East)completed the online study questionnaire in six languages using the Qualtrics platform.The study was managed by six teams in six countries that promoted the study on social media.The questionnaire assessed anxiety,depression,stress symptoms and PTSD(CSRS,Type A),cognitive deficits and fatigue(CSRS,Type B).The data were analyzed using Proportion Analyses,Multivariate Analysis of Co-Variance(MANCOVA),linear regression analyses and validated clinical cutoff points.RESULTS The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety,depression,stress symptoms,and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents,age groups,and gender.This supports the transdiagnostic argument embedded in the CSRS(Type A).The same pattern of results was found in infected/recovered individuals.The prevalence of the 4 psychiatric symptoms combination was signific展开更多
BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis(DC).AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.ME...BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis(DC).AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.METHODS Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention(INT) or standard of care(SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.RESULTS Calculated sample size was not achieved due to coronavirus disease 2019;240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm(P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy(HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT(21%) vs SOC arm(45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up(n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).CONCLUSION Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.展开更多
In 2014 we began the first systematic study of water quality, specifically fecal contamination of drinking water in the Khumbu Valley, Sagarmatha National Park (SNP, Mt. Everest region), Nepal. Our goal was to identif...In 2014 we began the first systematic study of water quality, specifically fecal contamination of drinking water in the Khumbu Valley, Sagarmatha National Park (SNP, Mt. Everest region), Nepal. Our goal was to identify coliform bacteria and E. coli in drinking water and groundwater-fed springs to generate a data set that will function as a base for potable water supplies and further monitoring. Sampling occurred in May (pre-monsoon summer) and early November (post-monsoon early winter) 2014. Sample sites were selected based on proximity to villages and primary use as a drinking water source. Overall, the data presented a predictable correlation between fecal contamination and both elevation and increasing population/tourist traffic. Drinking water within the study area met current World Health Organization drinking water standards for the physical properties of temperature (2.8°C - 13°C), pH (5.27 - 7.24), conductivity (14.5 - 133 mS) and TDS (7.24 - 65.5 ppm). Samples from the more populated, lower altitude areas had higher levels of E. coli. Samples collected and analyzed in May (pre-monsoon summer) had a higher level of E. coli and coliform bacteria than samples collected in November (post-monsoon early winter) suggesting a seasonal dependence overlaid on the population signature. Surface water typically had higher E. coli values than groundwater-fed springs. Temperature, total dissolved solids and conductivity generally decreased with increasing elevation, whereas pH increased with increasing elevation. There appears to be significant presence of fecal contamination of water sources due to a combination of tourism, elevation and seasons.展开更多
By assuming the cosmological principle includes the Pauli Exclusion Principle (PEP) and that the initial singularity existed within Planck time and length scales, a model for inflationary expansion is argued using onl...By assuming the cosmological principle includes the Pauli Exclusion Principle (PEP) and that the initial singularity existed within Planck time and length scales, a model for inflationary expansion is argued using only standard model physics without any changes to general relativity. All Fermionic matter is forced by the PEP to make a quantum transition to minimally orthogonal states in sequential Planck time intervals. This results in an initial inflation effect due to nearest neighbor quantum transitions which is then exacerbated by matter and antimatter creation effects due to collisions giving rise to the observational effects of universal inflation. The model provides a mechanistic explanation for primordial expansion using only physics from the standard model, specifically utilizing the PEP as a repulsion force between indistinguishable fermions. The present theory offers the benefit of not requiring any particles or fields outside of the standard model nor utilizing changes to general relativity. More succinctly, this theory goes beyond simply offering a mathematical representation (or fit) of the functional dependence but rather offers a mechanistic model to drive inflation using only standard model physics.展开更多
文摘Acute liver failure is a rare and devastating clinical condition. At present, emergency liver transplantation is the only life-saving therapy in advanced cases, yet the feasibility of transplantation is affected by the presence of systemic inflammation, infection and resultant multiorgan failure. The importance of immune dysregulation and acquisition of infection in the pathogenesis of acute liver failure and its associated complications is now recognised. In this review we discuss current thinking regarding the role of infection and inflammation in the pathogenesis of and outcome in human acute liver failure, the implications for the management of such patients and suggest directions for future research.
文摘AIM:To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.METHODS:Retrospective observational study in a Tertiary Referral Centre.Between January 1999-October 2005,we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices.Patient details including age,gender and aetiology of liver disease/segmental portal hypertension were documented.The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle.All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded.Initial haemostasis rates,rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy.The duration of follow up was also listed.The study was conducted according to the United Kingdom research ethics guidelines.RESULTS:Thirty-seven patients were included.33 patients(89%) had thrombin(250 U/mL) for gastric varices,2(5.4%) for duodenal varices,1 for rectal varices and 1 for gastric and rectal varices.(1) Gastric varices,an average of 15.2 mL of thrombin was used per patient.Re-bleeding occurred in 4 patients(10.8%),managed in 2 by a transjugular intrahepatic portosystemic shunt(TIPSS)(one unsuccessfully who died) and in other 2 by a distal splenorenal shunt;(2) Duodenal varices(or type 2 isolated gastric varices),an average of 12.5 mL was used per patient over 2-3 endoscopy sessions.Re-bleeding occurred in one patient,which was treated by TIPSS;and(3) Rectal varices,an average of 18.3 mL was used per patient over 3 endoscopy sessions.No re-bleeding occurred in this group.CONCLUSION:Human thrombin is a safe,easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.
基金partly supported by the Theme-Based Research Scheme, University Grant CouncilStrategic Research Theme Fund and University Development Fund, The University of Hong KongHealth and Medical Research Fund of the Food and Health Bureau of HKSAR
文摘We conducted a six-year epidemiological study on human coronaviruses（HCoVs） circulating in Hong Kong, using 8275 nasopharyngeal samples from patients with acute respiratory tract infections. HCoVs were detected in 77（0.93%） of the samples by a pan-HCoV RT-PCR assay. The most frequently detected HCoV species was HCoV-OC43（0.58%）, followed by HCoV-229E（0.15%）,HCoV-HKU1（0.13%） and HCoV-NL63（0.07%）. HCoVs were detected throughout the study period（September 2008–August 2014）, with the highest detection rate from September 2010 to August2011（22/1500, 1.47%）. Different seasonal patterns of each HCoV species in Hong Kong were noted.HCoV-OC43 was predominant in the fall and winter, whereas HCoV-HKU1 showed peak activity in winter, with a few cases occurred in spring and summer. HCoV-229 E mainly occurred in winter and spring, while HCoV-NL63 was predominant in summer and autumn. HCoVs most commonly infect the elderly and young children, with median age of 79.5 years（range, 22 days to 95 years）.Intriguingly, the detection rate of HCoV-OC43 in the age group of ＆gt; 80 years（26/2380, 1.09%） was significantly higher than that in the age group of 0–10 years（12/2529, 0.47%）（P 〈 0.05）. These data provides new insight into the epidemiology of coronaviruses.
文摘BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings.A known risk of performing endoscopy under moderate sedation is the potential for over-sedation,requiring the use of reversal agents.More needs to be reported on rates of reversal across different outpatient settings.Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center(APC)for their procedure.Here,we report data on outpatient sedation reversal rates for endoscopy performed at an inhospital APC vs at a free-standing ambulatory endoscopy digestive health center(AEC-DHC)following risk stratification with a triage tool.AIM To observe the effect of risk stratification using a triage tool on patient outcomes,primarily sedation reversal events.METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019.Procedures were stratified to their respective sites using a triage tool.We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded.Demographics and characteristics recorded include patient age,gender,body mass index(BMI),American Society of Anesthesiologists(ASA)classification,procedure type,and reason for sedation reversal.RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period.Of these,17 patients at AEC-DHC and 9 at the APC underwent sedation reversals(0.017%vs 0.04%;P=0.06).Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age(53.5±21 vs 60.4±17.42 years;P=0.23),ASA class(1.66±0.48 vs 2.22±0.83;P=0.20),BMI(27.7±6.7 kg/m^(2) vs 23.7±4.03 kg/m^(2);P=0.06),and female gender(64.7%vs 22%;P=0.04).The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam(5.9±1.7 mg vs 8.9±3.5 mg;P=0.01),fentanyl(147.1±49.9μg vs 188.9±74.1μg;P=0.10),flumazenil(0.3±0.18μg vs 0.17±0.17μg;P=0.13)and naloxone(0.32±0.10 mg vs 0.28±0.12 m
文摘The management of complications in liver disease is often complex and challenging.Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease.In this review,relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension.The main areas covered are safety of endoscopy in patients with liver disease,the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound,esophageal capsule,argon plasma coagulation,spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology.It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices.As the technology in endoscopy expands,so does the role of the endoscopist in liver disease.
基金Supported by University of Edinburgh Hepatology Laboratory Internal Fundingthe Liver Endowment Funds of the Edinburgh&Lothian Health Foundation.
文摘BACKGROUND Metabolic dysfunction-associated steatotic liver disease(MASLD),characterised by hepatic lipid accumulation,causes inflammation and oxidative stress accompanied by cell damage and fibrosis.Liver injury(LI)is also frequently reported in patients hospitalised with coronavirus disease 2019(COVID-19),while preexisting MASLD increases the risk of LI and the development of COVID-19-associated cholangiopathy.Mechanisms of injury at the cellular level remain unclear,but it may be significant that severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)which causes COVID-19,uses angiotensin-converting expression enzyme 2(ACE2),a key regulator of the‘anti-inflammatory’arm of the renin-angiotensin system,for viral attachment and host cell invasion.AIM To determine if hepatic ACE2 levels are altered during progression of MASLD and in patients who died with severe COVID-19.METHODS ACE2 protein levels and localisation,and histological fibrosis and lipid droplet accumulation as markers of MASLD were determined in formalin-fixed liver tissue sections across the MASLD pathological spectrum(isolated hepatocellular steatosis,metabolic dysfunction-associated steatohepatitis(MASH)+/-fibrosis,end-stage cirrhosis)and in post-mortem tissues from patients who had died with severe COVID-19,using ACE2 immunohistochemistry and haematoxylin and eosin and picrosirius red staining of total collagen and lipid droplet areas,followed by quantification using machine learning-based image pixel classifiers.RESULTS ACE2 staining is primarily intracellular and concentrated in the cytoplasm of centrilobular hepatocytes and apical membranes of bile duct cholangiocytes.Strikingly,ACE2 protein levels are elevated in non-fibrotic MASH compared to healthy controls but not in the progression to MASH with fibrosis and in cirrhosis.ACE2 protein levels and histological fibrosis are not associated,but ACE2 and liver lipid droplet content are significantly correlated across the MASLD spectrum.Hepatic ACE2 levels are also increased in COVID-19 pa
文摘The Mesoproterozoic(1.11 Ga)Umkondo large igneous province(LIP)in southern Africa and Antarctica was emplaced in<5 Myr and is dominated by low-Ti tholeiitic doleritic-gabbroic sills.It is of particular interest because it is the least studied LIP in southern Africa with both sublithospheric and lithospheric mantle sources proposed and it coincides with the early assembly of Rodinia,so it has importance in understanding the nature of magmatism and tectonics in and around the Kalahari craton during the Mesoproterozoic.In this study,we compiled a large database of existing(~750)and new(~100)major and trace element data for the Umkondo province,as well as 42 new Sr-Nd isotopic measurements,to provide constraints on its magma sources and geochemical evolution.Major element compositional variations in the low-Ti tholeiites are explained by low-pressure(1 kbar)three-phase fractional crystallisation(olivine,clinopyroxene and plagioclase)of a parent magma with~10 wt.%MgO in oxidising conditions(QFM+1).Inverse models show that the low-Ti tholeiitic magmas were derived as residual melts after the crystallization of 12%-33%olivine from primary komatiitic-basaltic magmas(up to~20 wt.%MgO)in equilibrium with mantle olivine(Fo90).Low Sm/Yb and TiO2/Yb-Nb/Yb indicate that the primary magmas were derived by 2%-20%shallow(40-50 km)partial melting of spinel lherzolite.High Sm/Yb is restricted to dyke swarms and may imply limited magma production from deeper(up to~70 km)garnet lherzolite-like sources.The low-Ti tholeiites of the Umkondo province are enriched in large ion lithophile elements(Rb-Sr-Cs-K)and depleted in high-field strength elements(Zr-Hf-Nb-Ta),indicating the involvement of crustal material and/or the subcontinental lithospheric mantle.This is supported by covariations in Th/Nb,Nb/Yb,Nb/La and Ce/Sm with generally negativeΔNb.Sr-Nd isotopes lend support to the notion that the Umkondo magmas were derived from depleted and/or enriched sublithospheric mantle sources and subsequently contaminated by enriched lithospheric
基金Under the auspices of National Natural Science Foundation of China(No.41171403,41301586)China Postdoctoral Science Foundation(No.2013M540599,2014T70731)Program for New Century Excellent Talents in University(No.NCET-08-0057)
文摘Under global climate change, drought has become one of the most serious natural hazards, affecting the ecological environment and human life. Drought can be categorized as meteorological, agricultural, hydrological or socio-economic drought. Among the different categories of drought, hydrological drought, especially streamflow drought, has been given more attention by local governments, researchers and the public in recent years. Identifying the occurrence of streamflow drought and issuing early warning can provide timely information for effective water resources management. In this study, streamflow drought is detected by using the Standardized Runoff Index, whereas meteorological drought is detected by the Standardized Precipitation Index. Comparative analyses of frequency, magnitude, onset and duration are conducted to identify the impact of meteorological drought on streamflow drought. This study focuses on the Jinghe River Basin in Northwest China, mainly providing the following findings. 1) Eleven meteorological droughts and six streamflow droughts were indicated during 1970 and 1990 after pooling using Inter-event time and volume Criterion method. 2) Streamflow drought in the Jinghe River Basin lagged meteorological drought for about 127 days. 3) The frequency of streamflow drought in Jinghe River Basin was less than meteorological drought. However, the average duration of streamflow drought is longer. 4) The magnitude of streamflow drought is greater than meteorological drought. These results not only play an important theoretical role in understanding relationships between different drought categories, but also have practical implications for streamflow drought mitigation and regional water resources management.
基金supported and funded by the California Department of Water Resources(DWR)
文摘The California Simulation of Evapotranspiration of Applied Water （CaI-SIMETAW） model is a new tool developed by the California Department of Water Resources and the University of California, Davis to perform daily soil water balance and determine crop evapotranspiration （ETo）, evapotranspiration of applied water （ETaw）, and applied water （AW） for use in California water resources planning. ETaw is a seasonal estimate of the water needed to irrigate a crop assuming 100% irrigation efficiency. The model accounts for soils, crop coefficients, rooting depths, seepage, etc. that influence crop water balance. It provides spatial soil and climate information and it uses historical crop and land-use category information to provide seasonal water balance estimates by combinations of detailed analysis unit and county （DAU/County） over Califomia. The result is a large data base of ETc and ETaw that will be used to update information in the new California Water Plan （CWP）. The application uses the daily climate data, i.e., maximum （Tx） and minimum （Tn） temperature and precipitation （Pcp）, which were derived from monthly USDA-NRCS PRISM data （PRISM Group 2011） and daily US National Climate Data Center （NCDC） climate station data to cover California on a 4 kmx4 km change grid spacing. The application uses daily weather data to determine reference evapotranspiration （ETo）, using the Hargreaves-Samani （HS） equation （Hargreaves and Samani 1982, 1985）. Because the HS equation is based on temperature only, ETo from the HS equation were compared with CIMIS ETo at the same locations using available CIMIS data to determine correction factors to estimate CIMIS ETo from the HS ETo to account for spatial climate differences. CaI-SIMETAW also employs near real-time reference evapotranspiration （ETo） information from Spatial CIMIS, which is a model that combines weather station data and remote sensing to provide a grid of ETo information. A second database containing the available
文摘BACKGROUND The debate regarding diagnostic classification systems in psychiatry(categorial vs dimensional systems)has essential implications for the diagnosis,prevention and treatment of stress reactions.We previously found a unique pattern of stress reaction in a study executed during the coronavirus disease 2019 pandemic using large representative samples in two countries,and termed it the Complex Stress Reaction Syndrome(CSRS).AIM To investigate CSRS,Type A(psychiatric symptoms,spanning anxiety,depression,stress symptoms,and posttraumatic stress disorder(PTSD)),with or without long-coronavirus disease(COVID)residuals(CSRS,Type B,neuropsychiatric symptoms spanning cognitive deficits and fatigue,excluding systemic symptoms).Our two-tailed hypothesis was that CSRS is a condition related to an unrecognized type of stress reaction in daily life in the general population(Type A)or that it is related to the severe acute respiratory syndrome coronavirus 2 infection and its long-COVID residuals(Type B).METHODS 977 individuals in four continents(North America,Europe,Australia and the Middle East)completed the online study questionnaire in six languages using the Qualtrics platform.The study was managed by six teams in six countries that promoted the study on social media.The questionnaire assessed anxiety,depression,stress symptoms and PTSD(CSRS,Type A),cognitive deficits and fatigue(CSRS,Type B).The data were analyzed using Proportion Analyses,Multivariate Analysis of Co-Variance(MANCOVA),linear regression analyses and validated clinical cutoff points.RESULTS The results of the Proportion Analyses showed that the prevalence of 4 symptoms spanning anxiety,depression,stress symptoms,and PTSD was significantly higher than the most prevalent combinations of fewer symptoms across 4 continents,age groups,and gender.This supports the transdiagnostic argument embedded in the CSRS(Type A).The same pattern of results was found in infected/recovered individuals.The prevalence of the 4 psychiatric symptoms combination was signific
基金GASTR29:Prospective validation of readmission risk score and interventions to prevent readmission in patients with decompensated cirrhosis(CCTS ID#:6018).
文摘BACKGROUND We previously reported national 30-d readmission rates of 27% in patients with decompensated cirrhosis(DC).AIM To study prospective interventions to reduce early readmissions in DC at our tertiary center.METHODS Adults with DC admitted July 2019 to December 2020 were enrolled and randomized into the intervention(INT) or standard of care(SOC) arms. Weekly phone calls for a month were completed. In the INT arm, case managers ensured outpatient follow-up, paracentesis, and medication compliance. Thirty-day readmission rates and reasons were compared.RESULTS Calculated sample size was not achieved due to coronavirus disease 2019;240 patients were randomized into INT and SOC arms. 30-d readmission rate was 33.75%, 35.83% in the INT vs 31.67% in the SOC arm(P = 0.59). The top reason for 30-d readmission was hepatic encephalopathy(HE, 32.10%). There was a lower rate of 30-d readmissions for HE in the INT(21%) vs SOC arm(45%, P = 0.03). There were fewer 30-d readmissions in patients who attended early outpatient follow-up(n = 17, 23.61% vs n = 55, 76.39%, P = 0.04).CONCLUSION Our 30-d readmission rate was higher than the national rate but reduced by interventions in patients with DC with HE and early outpatient follow-up. Development of interventions to reduce early readmission in patients with DC is needed.
文摘In 2014 we began the first systematic study of water quality, specifically fecal contamination of drinking water in the Khumbu Valley, Sagarmatha National Park (SNP, Mt. Everest region), Nepal. Our goal was to identify coliform bacteria and E. coli in drinking water and groundwater-fed springs to generate a data set that will function as a base for potable water supplies and further monitoring. Sampling occurred in May (pre-monsoon summer) and early November (post-monsoon early winter) 2014. Sample sites were selected based on proximity to villages and primary use as a drinking water source. Overall, the data presented a predictable correlation between fecal contamination and both elevation and increasing population/tourist traffic. Drinking water within the study area met current World Health Organization drinking water standards for the physical properties of temperature (2.8°C - 13°C), pH (5.27 - 7.24), conductivity (14.5 - 133 mS) and TDS (7.24 - 65.5 ppm). Samples from the more populated, lower altitude areas had higher levels of E. coli. Samples collected and analyzed in May (pre-monsoon summer) had a higher level of E. coli and coliform bacteria than samples collected in November (post-monsoon early winter) suggesting a seasonal dependence overlaid on the population signature. Surface water typically had higher E. coli values than groundwater-fed springs. Temperature, total dissolved solids and conductivity generally decreased with increasing elevation, whereas pH increased with increasing elevation. There appears to be significant presence of fecal contamination of water sources due to a combination of tourism, elevation and seasons.
文摘By assuming the cosmological principle includes the Pauli Exclusion Principle (PEP) and that the initial singularity existed within Planck time and length scales, a model for inflationary expansion is argued using only standard model physics without any changes to general relativity. All Fermionic matter is forced by the PEP to make a quantum transition to minimally orthogonal states in sequential Planck time intervals. This results in an initial inflation effect due to nearest neighbor quantum transitions which is then exacerbated by matter and antimatter creation effects due to collisions giving rise to the observational effects of universal inflation. The model provides a mechanistic explanation for primordial expansion using only physics from the standard model, specifically utilizing the PEP as a repulsion force between indistinguishable fermions. The present theory offers the benefit of not requiring any particles or fields outside of the standard model nor utilizing changes to general relativity. More succinctly, this theory goes beyond simply offering a mathematical representation (or fit) of the functional dependence but rather offers a mechanistic model to drive inflation using only standard model physics.
