Publications by authors named "Stephen Yang"

271 Publications

Mobile physical activity planning and tracking: a brief overview of current options and desiderata for future solutions.

Mhealth 2021 20;7:13. Epub 2021 Jan 20.

State University of New York College at Cortland, Cortland, NY, USA.

Consistent and enjoyable physical activity (PA) can be a crucial component to improving or maintaining one's overall health status. Using advanced features on smartphones (GPS, Bluetooth, motion sensing, etc.) coupled with an app or game that is able to assist mobile users to not only track location, but also to interact socially with others based in real-life (IRL), virtual reality (VR), or alternate-reality (ARG), has the potential to give health experts better tools to encourage higher compliance to protocols, rehabilitation, behaviour change and health outcomes. This paper outlines the available mHealth apps that capitalize on pervasive smartphone features coupled with sensors, and suggests which features might impact future PA patterns. The authors argue that the ultimate mobile PA planning and tracking app/platform will be the one capable of supporting both precision and accuracy health (offering truly individualized PA advice and coaching while preserving user privacy) and precision and accuracy public health (providing public health decision makers with community-level PA indicators obtained from app data aggregates of user populations).
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http://dx.doi.org/10.21037/mhealth.2020.01.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7882264PMC
January 2021

Association of severe lymphopenia and disease progression in unresectable locally advanced non-small cell lung cancer treated with definitive chemoradiation and immunotherapy.

Lung Cancer 2021 Jan 27;154:36-43. Epub 2021 Jan 27.

Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. Electronic address:

Background: Definitive chemoradiation with consolidative immunotherapy offers the best chance for cure in patients with unresectable, locally advanced non-small cell lung cancer (NSCLC). However, treatment-related lymphopenia (TRL) may negatively impact outcomes.

Methods: Patients definitively treated with chemoradiation and immunotherapy from 2015 to 2019 at a single tertiary academic center were identified. Severe lymphopenia was defined as <0.5 × 10 cells/L. Progression-free survival (PFS) was calculated by Kaplan Meier methodology. Univariate and multivariate Cox Proportional Hazard modeling was used to correlate clinical variables with disease outcome. Immune-related adverse events (irAEs) were assessed according to CTCAE version 5.0 criteria.

Results: Seventy-eight patients were included in the final cohort. The median age was 66 years (IQR: 58-73), 55 % were males, and 88 % had a KPS of >70. At baseline, 90 % (n = 70/78) of patients had a normal ALC and one patient had severe lymphopenia. After chemoradiation, the median ALC decreased from 1.52 × 10cells/L (IQR: 1.23-1.98) to 0.72 × 10cells/L (IQR: 0.52-0.94) (p < 0.001), 22 % (n = 17/78) of patients had a normal ALC, and 23 % (n = 18/78) of patients developed severe lymphopenia. Patients who initiated consolidative immunotherapy with severe lymphopenia had worse PFS than those who did not (median 217 days [IQR: 120-434] vs. 570 days [IQR: 401-NR], p < 0.001). On multivariate modeling, severe lymphopenia at the time of immunotherapy initiation remained an independent predictor of worse PFS (HR 4.90, p < 0.001).

Conclusions: This is the first report to associate severe TRL with disease progression in patients with locally advanced NSCLC receiving consolidative immunotherapy. Factors associated with development of lymphopenia and strategies to mitigate lymphopenic effects should be considered.
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http://dx.doi.org/10.1016/j.lungcan.2021.01.022DOI Listing
January 2021

A performance comparison of the fully automated urine particle analyzer UF-5000 with UF-1000i and Gram staining in predicting bacterial growth patterns in women with uncomplicated urinary tract infections.

BMC Urol 2021 Feb 12;21(1):24. Epub 2021 Feb 12.

Division of Urology, Department of Surgery, Taipei Tzu Chi Hospital, New Taipei, Taiwan.

Background: The aim of this study was to compare the performance of the new flow cytometer UF-5000 with the UF-1000i and Gram staining for determining bacterial patterns in urine samples.

Methods: Women who attended our clinic with symptoms suggestive of urinary tract infection were enrolled in the study. Mid-stream urine samples were collected for gram staining, urine analysis and urine cultures. Bacterial patterns were classified using the UF-1000i (none, cocci bacteria or rods/mixed growth), the UF-5000 (none, cocci, rods or mixed growth) and Gram staining.

Results: Among the 102 included samples, there were 10 g-positive cocci, 2 g-positive bacilli, 66 g-negative rods, and 24 mixed growth. The sensitivity/specificity of the UF-1000i was 81.8/91.1% for gram-negative rods and 23.5/96.9% for cocci/mixed. The sensitivity/specificity of the UF-5000 was 80.0/88.2% for gram negative rods and 70.0/86.5% for gram-positive cocci.

Conclusions: The UF-5000 demonstrated good sensitivity and specificity for Gram-negative bacilli and demonstrated an improved sensitivity for detecting Gram-positive cocci compared with the UF-1000i.
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http://dx.doi.org/10.1186/s12894-021-00791-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881468PMC
February 2021

Re: 'Clinical course and outcomes of critically ill patients with COVID-19 infection: a systematic review' by Serafim et al.

Clin Microbiol Infect 2021 Jan 21. Epub 2021 Jan 21.

Division of Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.cmi.2021.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7826130PMC
January 2021

Life and Limb: a Case of COVID-19-Associated Multisystem Thrombosis and Review of the Literature.

J Gen Intern Med 2021 Jan 5. Epub 2021 Jan 5.

Department of Anesthesia, Division of Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada.

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http://dx.doi.org/10.1007/s11606-020-06496-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784618PMC
January 2021

Letter to the Editor: Prehabilitation Before Major Abdominal Surgery-A Systematic Review and Meta-Analysis.

World J Surg 2021 03 25;45(3):909-910. Epub 2020 Nov 25.

Faculty of Medicine, McGill University, Montreal, QC, Canada.

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http://dx.doi.org/10.1007/s00268-020-05855-xDOI Listing
March 2021

Outcomes and clinical practice in patients with COVID-19 admitted to the intensive care unit in Montréal, Canada: a descriptive analysis.

CMAJ Open 2020 Oct-Dec;8(4):E788-E795. Epub 2020 Nov 24.

Departments of Anesthesia (Yang, Baldry, McMillan), Medicine (Lipes, Dial, Schwartz, Laporta, Warshawsky, Hornstein, de Marchie, Jayaraman) and Surgery (Wong), and Division of Critical Care (Yang, Lipes, Dial, Schwartz, Laporta, Wong, Baldry, Warshawsky, McMillan, Hornstein, de Marchie, Jayaraman), Jewish General Hospital, McGill University, Montréal, Que.

Background: The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada.

Methods: A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality.

Results: A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids.

Interpretation: Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.
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http://dx.doi.org/10.9778/cmajo.20200159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721255PMC
January 2021

The Virtual Residency Fair: A Legacy of the COVID-19 Era and an Opportunity for the Future.

J Oral Maxillofac Surg 2021 02 2;79(2):275-276. Epub 2020 Oct 2.

Assistant Professor and Program Director, Department of Oral and Maxillofacial Surgery, University of California, San Francisco, San Francisco, CA.

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http://dx.doi.org/10.1016/j.joms.2020.09.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7531429PMC
February 2021

Challenges and Future Directions of Big Data and Artificial Intelligence in Education.

Front Psychol 2020 19;11:580820. Epub 2020 Oct 19.

Institute for Research Excellence in Learning Sciences, National Taiwan Normal University, Taipei, Taiwan.

We discuss the new challenges and directions facing the use of big data and artificial intelligence (AI) in education research, policy-making, and industry. In recent years, applications of big data and AI in education have made significant headways. This highlights a novel trend in leading-edge educational research. The convenience and embeddedness of data collection within educational technologies, paired with computational techniques have made the analyses of big data a reality. We are moving beyond proof-of-concept demonstrations and applications of techniques, and are beginning to see substantial adoption in many areas of education. The key research trends in the domains of big data and AI are associated with assessment, individualized learning, and precision education. Model-driven data analytics approaches will grow quickly to guide the development, interpretation, and validation of the algorithms. However, conclusions from educational analytics should, of course, be applied with caution. At the education policy level, the government should be devoted to supporting lifelong learning, offering teacher education programs, and protecting personal data. With regard to the education industry, reciprocal and mutually beneficial relationships should be developed in order to enhance academia-industry collaboration. Furthermore, it is important to make sure that technologies are guided by relevant theoretical frameworks and are empirically tested. Lastly, in this paper we advocate an in-depth dialog between supporters of "cold" technology and "warm" humanity so that it can lead to greater understanding among teachers and students about how technology, and specifically, the big data explosion and AI revolution can bring new opportunities (and challenges) that can be best leveraged for pedagogical practices and learning.
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http://dx.doi.org/10.3389/fpsyg.2020.580820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604529PMC
October 2020

Interleukin-6 Antagonist Tocilizumab to Treat Critically Ill Coronavirus Disease 2019 Patients With Cytokine Release Syndrome: A Case Series.

J Cardiothorac Vasc Anesth 2020 Oct 24. Epub 2020 Oct 24.

Division of Critical Care, Jewish General Hospital, Montreal, QC, Canada; Department of Medicine, Jewish General Hospital, Montreal, QC, Canada.

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http://dx.doi.org/10.1053/j.jvca.2020.10.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7584922PMC
October 2020

Current Status of Instagram Utilization by Oral and Maxillofacial Surgery Residency Programs: A Comparison With Related Dental and Surgical Specialties.

J Oral Maxillofac Surg 2020 Dec 27;78(12):2128.e1-2128.e7. Epub 2020 Aug 27.

Assistant Professor and Program Director, Department of Oral and Maxillofacial Surgery, University of California, San Francisco, San Francisco, CA.

Purpose: The utility of social media in oral and maxillofacial surgery (OMS) residency programs has never been investigated, despite the increasing popularity of such platforms in academic medicine. As a specialty that strives for constant innovation, it is important for OMS programs to participate in the emerging concept of incorporating social media into medical and surgical education. Therefore, this study aimed to evaluate the use of Instagram in OMS residency programs in the United States.

Methods: A cross-sectional study of Instagram search data was performed. The Instagram accounts of OMS residency programs were searched, and their metrics were retrieved from June 1 to June 5, 2020. Factors correlated with the total number of followers were identified. The use of Instagram in OMS residency programs was compared with that in other related dental and surgical residency programs.

Results: Only 17 (18.7%) of 91 OMS residency programs had an Instagram account. The number of programs with Instagram accounts exhibited linear growth (R = 0.98) since December 2018. The median number of followers was 326 (range, 94 to 2,152), and the median number of posts was 9 (range, 2 to 40). The number of Instagram followers was positively correlated with the number of accounts followed, the number of total posts, and the number of educational posts, and it was negatively correlated with the Instagram engagement rate. Instagram presence did not differ among residency programs for orthodontics (18.2%), periodontics (5.5%), and OMS (P = .067). However, Instagram presence in OMS residency programs was significantly lower than that in plastic surgery (74.7%; P < .001) and otolaryngology residency programs (35.0%; P = .011).

Conclusions: Instagram use in OMS residency programs is growing but is significantly lower than that in related surgical fields. This may represent a missed opportunity for promoting collaboration and efficiently delivering useful information to trainees.
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http://dx.doi.org/10.1016/j.joms.2020.08.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449933PMC
December 2020

Neoadjuvant nivolumab plus ipilimumab in resectable non-small cell lung cancer.

J Immunother Cancer 2020 09;8(2)

Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins, Baltimore, Maryland, USA

Background: We conducted the first trial of neoadjuvant PD-1 blockade in resectable non-small cell lung cancer (NSCLC), finding nivolumab monotherapy to be safe and feasible with an encouraging rate of pathologic response. Building on these results, and promising data for nivolumab plus ipilimumab (anti-CTLA-4) in advanced NSCLC, we expanded our study to include an arm investigating neoadjuvant nivolumab plus ipilimumab.

Methods: Patients with resectable stage IB (≥4 cm)-IIIA (American Joint Committee on Cancer Tumor Node Metastases seventh edition), histologically confirmed, treatment-naïve NSCLC received nivolumab 3 mg/kg intravenously plus ipilimumab 1 mg/kg intravenously 6 weeks prior to planned resection. Nivolumab 3 mg/kg was given again approximately 4 and 2 weeks preoperatively. Primary endpoints were safety and feasibility with a planned enrollment of 15 patients. Pathologic response was a key secondary endpoint.

Results: While the treatment regimen was feasible per protocol, due to toxicity, the study arm was terminated early by investigator consensus after 9 of 15 patients were enrolled. All patients received every scheduled dose of therapy and were fit for planned surgery; however, 6 of 9 (67%) experienced treatment-related adverse events (TRAEs) and 3 (33%) experienced grade ≥3 TRAEs. Three of 9 patients (33%) had biopsy-confirmed tumor progression precluding definitive surgery. Of the 6 patients who underwent resection, 3 are alive and disease-free, 2 experienced recurrence and are actively receiving systemic treatment, and one died postoperatively due to acute respiratory distress syndrome. Two patients who underwent resection had tumor pathologic complete responses (pCRs) and continue to remain disease-free over 24 months since surgery. Pathologic response correlated with pre-treatment tumor PD-L1 expression, but not tumor mutation burden. Tumor co-mutations were identified in 5 of 9 patients (59%), of whom two with disease progression precluding surgery had tumor co-mutations.

Conclusions: Though treatment was feasible, due to toxicity the study arm was terminated early by investigator consensus. In light of this, and while the long-term disease-free status of patients who achieved pCR is encouraging, further investigation of neoadjuvant nivolumab plus ipilimumab in patients with resectable NSCLC requires the identification of predictive biomarkers that enrich for response.
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http://dx.doi.org/10.1136/jitc-2020-001282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488786PMC
September 2020

Re-visiting preoperative SARS-CoV-2 testing using a Bayesian approach.

Can J Anaesth 2020 11 16;67(11):1690-1691. Epub 2020 Jul 16.

Division of Infectious Disease, St-Mary's Hospital, Montreal, QC, Canada.

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http://dx.doi.org/10.1007/s12630-020-01767-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365519PMC
November 2020

Cardiothoracic surgery educational research and training innovation: A review of 2018-2019.

J Thorac Cardiovasc Surg 2020 Oct 23;160(4):1133-1137. Epub 2020 Apr 23.

Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.049DOI Listing
October 2020

Corticosteroids for critically ill COVID-19 patients with cytokine release syndrome: a limited case series.

Can J Anaesth 2020 10 11;67(10):1462-1464. Epub 2020 May 11.

Department of Internal Medicine, Jewish General Hospital, Montreal, QC, Canada.

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http://dx.doi.org/10.1007/s12630-020-01700-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7212834PMC
October 2020

Effect of thoracic versus cervical anastomosis on anastomotic leak among patients who undergo esophagectomy after neoadjuvant chemoradiation.

J Thorac Cardiovasc Surg 2020 Oct 20;160(4):1088-1095. Epub 2020 Feb 20.

Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.

Objective: To assess the rate and effect of anastomotic leak among patients who undergo esophagectomy with either thoracic or cervical anastomosis after neoadjuvant chemoradiation.

Methods: We conducted a retrospective cohort study using data from the National Surgical Quality Improvement Program Esophagectomy Data File. We included adult patients who underwent esophagectomy for esophageal cancer (2016-2017) after neoadjuvant chemoradiation. We used inverse probability of treatment weighted regression adjustment to compare 30-day anastomotic leak and mortality rates among patients with cervical or thoracic anastomoses. We accounted for confounding due to patient-, surgeon-, and procedure-related variables.

Results: Of the 908 patients who met inclusion criteria, 528 (58%) had a thoracic anastomosis and 119 (13%) experienced anastomotic leak. There was no statistically significant difference in leak rate for patients who underwent thoracic (12%) compared with cervical anastomoses (14%) in the inverse probability of treatment weighted regression adjustment analysis (P = .09). Although overall 30-day mortality was low (2.3%), it was significantly higher among patients who had an anastomotic leak (8.4% vs 1.4%; P < .01). Among patients with a leak, there was no significant difference in length of stay, mortality, or type of required intervention for patients with cervical versus thoracic anastomoses.

Conclusions: Anastomosis type does not affect leak rates or mortality after esophagectomy in patients who have undergone neoadjuvant chemoradiation. Patient risk factors and surgeon experience should determine the ideal surgical approach for each patient.
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http://dx.doi.org/10.1016/j.jtcvs.2020.01.089DOI Listing
October 2020

Management and treatment of nocturnal enuresis-an updated standardization document from the International Children's Continence Society.

J Pediatr Urol 2020 Feb 30;16(1):10-19. Epub 2020 Jan 30.

Department of Pediatrics, Skejby Sygehus, Aarhus University Hospital, Aarhus N, 8200, Denmark.

Background: Enuresis is an extremely common condition, which, although somatically benign, poses long-term psychosocial risks if untreated. There are still many misconceptions regarding the proper management of these children.

Aim: A cross-professional team of experts affiliated with the International Children's Continence Society (ICCS) undertook to update the previous guidelines for the evaluation and treatment of children with enuresis.

Methods: The document used the globally accepted ICCS terminology. Evidence-based literature served as the basis, but in areas lacking in primary evidence, expert consensus was used. Before submission, a full draft was made available to all ICCS members for additional comments.

Results: The enuretic child does, in the absence of certain warning signs (i.e., voiding difficulties, excessive thirst), not need blood tests, radiology or urodynamic assessment. Active therapy is recommended from the age of 6 years. The most important comorbid conditions to take into account are psychiatric disorders, constipation, urinary tract infections and snoring or sleep apneas. Constipation and daytime incontinence, if present, should be treated. In nonmonosymptomatic enuresis, it is recommended that basic advice regarding voiding and drinking habits be provided. In monosymptomatic enuresis, or if the above strategy did not make the child dry, the first-line treatment modalities are desmopressin or the enuresis alarm. If both these therapies fail alone or in combination, anticholinergic treatment is a possible next step. If the child is unresponsive to initial therapy, antidepressant treatment may be considered by the expert. Children with concomitant sleep disordered breathing may become dry if the airway obstruction is removed.
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http://dx.doi.org/10.1016/j.jpurol.2019.12.020DOI Listing
February 2020

Postoperative Remote Automated Monitoring and Virtual Hospital-to-Home Care System Following Cardiac and Major Vascular Surgery: User Testing Study.

J Med Internet Res 2020 03 18;22(3):e15548. Epub 2020 Mar 18.

Population Health Research Institute, Hamilton, ON, Canada.

Background: Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure.

Objective: As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip's Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively.

Methods: Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews.

Results: A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems.

Conclusions: User testing indicated a high degree of user acceptance of Philips' Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.
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http://dx.doi.org/10.2196/15548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113803PMC
March 2020

Scholarships in cardiothoracic surgery-a guide for surgical trainees.

J Thorac Cardiovasc Surg 2020 Feb 21. Epub 2020 Feb 21.

Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.

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http://dx.doi.org/10.1016/j.jtcvs.2020.02.053DOI Listing
February 2020

A Deep-Learning Algorithm (ECG12Net) for Detecting Hypokalemia and Hyperkalemia by Electrocardiography: Algorithm Development.

JMIR Med Inform 2020 Mar 5;8(3):e15931. Epub 2020 Mar 5.

Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.

Background: The detection of dyskalemias-hypokalemia and hyperkalemia-currently depends on laboratory tests. Since cardiac tissue is very sensitive to dyskalemia, electrocardiography (ECG) may be able to uncover clinically important dyskalemias before laboratory results.

Objective: Our study aimed to develop a deep-learning model, ECG12Net, to detect dyskalemias based on ECG presentations and to evaluate the logic and performance of this model.

Methods: Spanning from May 2011 to December 2016, 66,321 ECG records with corresponding serum potassium (K) concentrations were obtained from 40,180 patients admitted to the emergency department. ECG12Net is an 82-layer convolutional neural network that estimates serum K concentration. Six clinicians-three emergency physicians and three cardiologists-participated in human-machine competition. Sensitivity, specificity, and balance accuracy were used to evaluate the performance of ECG12Net with that of these physicians.

Results: In a human-machine competition including 300 ECGs of different serum K+ concentrations, the area under the curve for detecting hypokalemia and hyperkalemia with ECG12Net was 0.926 and 0.958, respectively, which was significantly better than that of our best clinicians. Moreover, in detecting hypokalemia and hyperkalemia, the sensitivities were 96.7% and 83.3%, respectively, and the specificities were 93.3% and 97.8%, respectively. In a test set including 13,222 ECGs, ECG12Net had a similar performance in terms of sensitivity for severe hypokalemia (95.6%) and severe hyperkalemia (84.5%), with a mean absolute error of 0.531. The specificities for detecting hypokalemia and hyperkalemia were 81.6% and 96.0%, respectively.

Conclusions: A deep-learning model based on a 12-lead ECG may help physicians promptly recognize severe dyskalemias and thereby potentially reduce cardiac events.
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http://dx.doi.org/10.2196/15931DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082733PMC
March 2020

Data for beta-blockade in ACLS - A trial sequential analysis.

Resuscitation 2020 05 27;150:191-192. Epub 2020 Feb 27.

Department of Anesthesia, McGill University, Montreal, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.

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http://dx.doi.org/10.1016/j.resuscitation.2020.02.019DOI Listing
May 2020

The aging effects on phenylephrine-induced relaxation of bladder in mice.

Ci Ji Yi Xue Za Zhi 2020 Jan-Mar;32(1):26-29. Epub 2019 Feb 18.

Division of Urology, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.

Objective: We have demonstrated that phenylephrine (PE) activates the capsaicin-sensitive nerves, and then activates capsaicin-sensitive nerves to release an unknown substance that facilitates the release of norepinephrine (NE) from adrenergic nerves. Subsequently, NE stimulates β-ARs in the detrusor muscle in mice, leading to neurogenic relaxation of the urinary bladder (UB).

Materials And Methods: We examined if there existed sensory-motor dysfunction in UB of aging mice. To investigate the change of PE-induced detrusor relaxation in aging male-C57BL/6 mice (12- vs. 24-month-old mice), UB strips from mice were isolated, cut into strips, and mounted in the organ bath.

Results: The UB strip contractility responding to various agents was estimated using tissue bath wire myography. Acetylcholine (ACh) and KCl-induced UB strips contraction was not significantly different between 24- and 12-month mice. NE-induced UB strips relaxation was significantly lower in 24-month than 12-month mice. Denuded bladder strips showed similar decreased relaxation response to NE. This NE-induced relaxation was inhibited by silodosin and lidocaine. PE did not induce contraction in UB strips of aging mice. In contrast, PE-induced relaxation was weaker in 24-month than 12-month mice.

Conclusion: Our results suggested that the PE-induced relaxation was age related. Aging seemed to lead the sensory-motor dysfunction. More animal and human studies are required to prove this concept and its clinical usefulness in the future.
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http://dx.doi.org/10.4103/tcmj.tcmj_178_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7015013PMC
February 2019

Epigenetic therapy inhibits metastases by disrupting premetastatic niches.

Nature 2020 03 26;579(7798):284-290. Epub 2020 Feb 26.

Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Cancer recurrence after surgery remains an unresolved clinical problem. Myeloid cells derived from bone marrow contribute to the formation of the premetastatic microenvironment, which is required for disseminating tumour cells to engraft distant sites. There are currently no effective interventions that prevent the formation of the premetastatic microenvironment. Here we show that, after surgical removal of primary lung, breast and oesophageal cancers, low-dose adjuvant epigenetic therapy disrupts the premetastatic microenvironment and inhibits both the formation and growth of lung metastases through its selective effect on myeloid-derived suppressor cells (MDSCs). In mouse models of pulmonary metastases, MDSCs are key factors in the formation of the premetastatic microenvironment after resection of primary tumours. Adjuvant epigenetic therapy that uses low-dose DNA methyltransferase and histone deacetylase inhibitors, 5-azacytidine and entinostat, disrupts the premetastatic niche by inhibiting the trafficking of MDSCs through the downregulation of CCR2 and CXCR2, and by promoting MDSC differentiation into a more-interstitial macrophage-like phenotype. A decreased accumulation of MDSCs in the premetastatic lung produces longer periods of disease-free survival and increased overall survival, compared with chemotherapy. Our data demonstrate that, even after removal of the primary tumour, MDSCs contribute to the development of premetastatic niches and settlement of residual tumour cells. A combination of low-dose adjuvant epigenetic modifiers that disrupts this premetastatic microenvironment and inhibits metastases may permit an adjuvant approach to cancer therapy.
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http://dx.doi.org/10.1038/s41586-020-2054-xDOI Listing
March 2020

Comparing the Efficacy of OnabotulinumtoxinA, Sacral Neuromodulation, and Peripheral Tibial Nerve Stimulation as Third Line Treatment for the Management of Overactive Bladder Symptoms in Adults: Systematic Review and Network Meta-Analysis.

Toxins (Basel) 2020 02 18;12(2). Epub 2020 Feb 18.

Division of Urology, Department of Surgery, Taipei Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, New Taipei 23142, Taiwan.

The American Urological Association guidelines for the management of non-neurogenic overactive bladder (OAB) recommend the use of OnabotulinumtoxinA, sacral neuromodulation (SNM), and peripheral tibial nerve stimulation (PTNS) as third line treatment options with no treatment hierarchy. The current study used network meta-analysis to compare the efficacy of these three modalities for managing adult OAB syndrome. We performed systematic literature searches of several databases from January 1995 to September 2019 with language restricted to English. All randomized control trials that compared any dose of OnabotulinumtoxinA, SNM, and PTNS with each other or a placebo for the management of adult OAB were included in the study. Overall, 17 randomized control trials, with a follow up of 3-6 months in the predominance of trials (range 1.5-24 months), were included for analysis. For each trial outcome, the results were reported as an average number of episodes of the outcome at baseline. Compared with the placebo, all three treatments were more efficacious for the selected outcome parameters. OnabotulinumtoxinA resulted in a higher number of complications, including urinary tract infection and urine retention. Compared with OnabotulinumtoxinA and PTNS, SNM resulted in the greatest reduction in urinary incontinence episodes and voiding frequency. However, comparison of their long-term efficacy was lacking. Further studies on the long-term effectiveness of the three treatment options, with standardized questionnaires and parameters are warranted.
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http://dx.doi.org/10.3390/toxins12020128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7077313PMC
February 2020

Does ketamine ameliorate the social stress-related bladder dysfunction in mice?

Neurourol Urodyn 2020 03 18;39(3):935-944. Epub 2020 Feb 18.

Division of Urology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.

Aims: The aim of this study is to investigate whether ketamine could relieve the social stress (SS)-related bladder dysfunction in mice.

Materials And Methods: The FVB mice were randomly assigned to either undergo SS exposure for 60 minutes per day on seven consecutive days for 4 weeks (SS1) or control without SS (SS0). The SS0 were then allocated to single or no injection of ketamine (SS0K1 and SS0K0). In the group of SS1, the SS1 mice were allocated to receive single injection of saline (SS1K0), single dose (SS1K1) or five daily dose of (SS1K5) ketamine injection (25 mg/kg/day/ip) since day 22. In vivo cystometry and tissue bath wire myography were performed on day 29. Serum and urine level of brain-derived neurotrophic factor (BDNF) were measured with enzyme-linked immunosorbent assay.

Results: In mice without social stress exposure, ketamine administration did not significantly affect voiding frequency (P > .05). SS K , SS K and SS K had significantly lower voiding frequency than that of control (SS K ) (each n = 15, P < .05). Ketamine administration reversed the trend of decreased voiding frequency in SS mice. Stressed mice had significant higher serum level of BDNF that reduced by short-term ketamine. Stressed mice had detrusor overactivity and impaired detrusor contractility which were not reversed by short-term ketamine.

Conclusions: Social stress leads to elevated serum BDNF, infrequent voiding, detrusor overactivity, and impaired contractility. Short-term administration of ketamine may improve SS-related infrequent voiding and elevated serum BDNF level. However, ketamine did not improve SS-related bladder dysfunction on urodynamic and myography studies.
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http://dx.doi.org/10.1002/nau.24324DOI Listing
March 2020

Intravenous lidocaine to prevent postoperative airway complications in adults: a systematic review and meta-analysis.

Br J Anaesth 2020 Mar 28;124(3):314-323. Epub 2020 Jan 28.

Department of Anesthesia, McGill University, Montreal, QC, Canada.

Background: In surgical patients undergoing general anaesthesia, coughing at the time of extubation is common and can result in potentially dangerous complications. We performed a systematic review and meta-analysis to assess the efficacy and safety of i.v. lidocaine administration during the perioperative period to prevent cough and other airway complications.

Methods: We searched Medical Literature Analysis and Retrieval System, Excerpta Medica database, and Cochrane Central Register of Controlled Trials for RCTs comparing the perioperative use of i.v. lidocaine with a control group in adult patients undergoing surgery under general anaesthesia. The RCTs were assessed using risk-of-bias assessment, and the quality of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results: In 16 trials (n=1516), the administration of i.v. lidocaine compared with placebo or no treatment led to large reductions in post-extubation cough (risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.48-0.86) and in postoperative sore throat at 1 h (RR: 0.46; 95% CI: 0.32-0.67). There was no difference in incidence of laryngospasm (risk difference [RD]: 0.02; 95% CI: -0.07 to 0.03) or incidence of adverse events related to the use of lidocaine.

Conclusions: The use of i.v. lidocaine perioperatively decreased airway complications, including coughing and sore throat. There was no associated increased risk of harm.
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http://dx.doi.org/10.1016/j.bja.2019.11.033DOI Listing
March 2020

Analyzing Outcomes of Nuss and Ravitch Repair for Primary and Recurrent Pectus Excavatum in Adults.

Ann Thorac Surg 2020 07 23;110(1):272-275. Epub 2020 Jan 23.

Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Electronic address:

Background: Limited data exist for pectus excavatum repair in adults. We reviewed outcomes in adult patients undergoing Ravitch or Nuss pectus excavatum repairs to determine whether there was a statistical difference in postoperative complications and recurrence between primary and redo operations.

Methods: Patients undergoing pectus excavatum repair between 2001 and 2018 were excluded if they were receiving a concurrent unrelated operation, aged younger than 18 years, or had less than 1 year of follow-up (for recurrence analysis). Postoperative complications were recorded based on procedure type (Ravitch/Nuss) and iteration of repair (primary/redo). Continuous patient data were compared using Student t tests for variables such as age, length of stay, estimated blood loss, body mass index, and number of bars inserted. Fisher exact or χ tests were performed for postoperative complications and recurrence rates between groups.

Results: Of 290 patients, there were no significant differences in postoperative complications or recurrence rates between all Nuss repairs (n = 237; P = .59) and all Ravitch repairs (n = 53; P = .48), redo Nuss repairs (n = 53; P = .26) and Ravitch repairs (n=26; P = .99), and primary (P = .26) and redo Nuss (P = .10) repairs or primary (P = .99) and redo Ravitch (P = .99) repairs. There were significant differences in age, length of stay, follow-up, bars inserted, and estimated blood loss between all Nuss and Ravitch repairs (P < .05).

Conclusions: Postoperative complication and recurrence rates were not statistically different between Nuss and Ravitch procedures of all types, suggesting either procedure may have utility in recurrent pectus excavatum. Further research may look to expand sample size and a prospective study investigating long-term outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.012DOI Listing
July 2020

Do erythropoietin and iron really decrease blood transfusion in surgical patients? A trial sequential analysis.

Can J Anaesth 2020 06 8;67(6):777-778. Epub 2020 Jan 8.

Department of Anesthesia, McGill University, Montreal, QC, Canada.

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http://dx.doi.org/10.1007/s12630-019-01564-9DOI Listing
June 2020