Lathraea squamaria, a holoparasitic plant from Orobanchaceae, clade Rhinantheae. We found that in this plant the degree of plastome reduction is the least among non-photosynthetic plants. Like other parasites, Lathraea possess a plastome with elevated absolute rate of nucleotide substitution. The only gene lost is petL, all other genes typical for the plastid genome are present, but some of them–those encoding photosystem components (22 genes), cytochrome b6/f complex proteins (4 genes), plastid-encoded RNA polymerase subunits (2 genes), ribosomal proteins (2 genes), ccsA and cemA–are pseudogenized. Genes for cytochrome b6/f complex and photosystems I and II that do not carry nonsense or frameshift mutations have an increased ratio of non-synonymous to synonymous substitution rates, indicating the relaxation of purifying selection. Our divergence time estimates showed that transition to holoparasitism in Lathraea lineage occurred relatively recently, whereas the holoparasitic lineage Orobancheae is about two times older.Plants from the family Orobanchaceae are widely used as a model to study different aspects of parasitic lifestyle including host–parasite interactions and physiological and genomic adaptations. Among the latter, the most prominent are those that occurred due to the loss of photosynthesis; they include the reduction of the photosynthesis-related gene set in both nuclear and plastid genomes. In Orobanchaceae, the transition to non-photosynthetic lifestyle occurred several times independently, but only one lineage has been in the focus of evolutionary studies. These studies included analysis of plastid genomes and transcriptomes and allowed the inference of patterns and mechanisms of genome reduction that are thought to be general for parasitic plants. Here we report the plastid genome of  Lindenbergia Lehm., and all types of parasitism: facultative, obligate hemiparasites, and holoparasites (plants that completely lack photosynthetic activity) [Orobancheae (~180 species), another on the branch to Lathraea (5–7 species), the third on the branch to Hyobanche (Harveya) (~70 species) [Photosynthesis has been lost independently numerous times in flowering plant lineages during the transition to a parasitic lifestyle. By recent estimates, approximately 4500 species ~1%) of flowering plants are parasitic % of flow and inclctivity) . The resspecies) , 7.Epifagus virginiana (L.) W.P.C.Barton, the first parasitic plant with a fully sequenced plastome [Schwalbea americana L., and holoparasites Boulardia latisquama F.W.Schultz, Cistanche phelypaea Cout., Conopholis americana (L.) Wallr., Myzorrhiza californica (Cham. & Schltdl.) Rydb., Orobanche crenata Forssk., Orobanche gracilis Sm., Phelipanche purpurea (Jacq.) Soják, Phelipanche ramosa (L.) Pomel [Cistanche deserticola Ma [Orobanche austrohispanica M.J.Y.Foley, Orobanche densiflora Salzm. Ex. Reut., Orobanche rapum-genistae Thuill., Orobanche cumana Wallr., Orobanche pancicii Beck [There are sixteen Orobanchaceae parasitic species for which complete sequences of the plastid genome are now available, including plastome , the hem.) Pomel , Cistancicola Ma , Orobanccii Beck . All of cii Beck . The redcii Beck , 13. Inccii Beck , 15. Fascii Beck , 17 (butcii Beck ), and incii Beck , 20.Lathraea squamaria L. (common toothwort)—a non-photosynthetic plant widespread in Europe; it parasitizes on the roots of hazel, alder and other trees. L. squamaria represents the second branch within the Orobanchaceae family where loss of photosynthesis occurred—the Rhinantheae clade . In conc plants , 11. Chaublished , and thuL. squamaria is not an endangered or protected species and no specific permissions were required for collection. A voucher specimen was deposited at the Herbarium of Moscow State University, Russia . One microgram of DNA was sheared by sonication using a Covaris S220 instrument . Further steps of library preparation were performed using a TruSeq DNA Sample Prep Kit  according to the manufacturer’s instructions. The library was sequenced using an Illumina HiSeq 2000 instrument with read length 101 bp from each end of the fragment. Resulting reads were processed using the CLC Genomics Workbench v. 5.5 software. The processing included trimming of low quality (q<30) nucleotides and adapters and assembly with the following parameters: bubble size 50 nt, word size 21 nt (automatic choice), minimal contig length 1000 nt, no scaffolding. Among the resulting contigs, we selected those that have high similarity to plastid genomes but do not contain any sequences with similarity to mitochondrial genomes. These contigs were aligned to the Lindenbergia plastome; since no rearrangements relative to Lindenbergia were found within contigs, we assumed that gene order in Lathraea is not changed in general. Based on this assumption, we ordered the contigs and designed primers that match the ends of the contigs for joining them using PCR . The assembled plastid genome sequence was annotated using the online tool CpGAVAS [Total DNA was extracted using the CTAB method  from a s CpGAVAS  with defrpoC1, rpoC2, rbcL), we extracted RNA and obtained cDNA of Lathraea. RNA was extracted from two parts–immature fruits and perianth. The cDNA was synthesized with a ThermoScript RT-PCR System for first-strand cDNA synthesis  with random hexamers used as primers. Then partial cDNA was amplified using gene-specific primers  and three genomes as an outgroup . We considered only plastid genes present both in Lathraea and in other plants. Nucleotide sequences were aligned according to the corresponding amino acid alignment produced by MUSCLE [P<0.0001) [et al. [6 steps, the first 2×105 steps being discarded as burn-in. Absolute substitution rate was calculated by dividing the ML tree branch length by the age of the branch.Phylogenetic analysis was performed using a set of sequences of two rRNA and 35 protein-coding genes from 14 Orobanchaceae plastid genomes  . ML bran<0.0001) . We usedLathraea, Bartsia, Lindenbergia, Tectona, Salvia). Relative rates in Lathraea and Bartsia versus Lindenbergia with Tectona as an outgroup were compared, as well as Lathraea versus Bartsia with Lindenbergia as an outgroup. Comparisons were performed using all concatenated data, as well as separately in groups of genes combined according to their function , and genes accD, clpP, matK, ycf1, and ycf2 were analyzed individually.The codon-based Z-test of neutrality  and TajidS and dN, respectively) and the ratio ω = dN /dS were assessed with the maximum likelihood approach as implemented in the CODEML program of the PAML package, “branch” models with the F3x4 codon frequency model being used. Evaluation of ω difference in parasitic and photosynthetic plant lineages was performed using the five-species set because of reduction of gene content in Orobancheae plastid genomes. Four hypotheses of different dN /dS ratios for Lathraea versus photosynthetic plants + Bartsia and Bartsia versus photosynthetic plants + Lathraea were tested. Branch models corresponding to the hypotheses were a “one-ratio” model that assumes that all the branches have the same ω-values (model M1), a “three-ratio” model that assumes different ω-values for photosynthetic, hemiparasitic, and holoparasitic branches (model M3), a “two-ratio” model in which the hemiparasitic branch (Bartsia) is allowed to have a separate ω-value (model M2B), and another “two-ratio” model in which the same is allowed in the holoparasitic branch . Likelihood ratio tests (LRT) M1 versus M2B and M2L versus M3 examined whether the ω-ratio for the Bartsia branch is different from the background ratio, and LRT M1 versus M2L and M2B versus M3 examined the Lathraea branch. Twice log-likelihood difference between models was tested against the χ2 distribution with one degree of freedom, and P values for multiple comparisons were Bonferroni corrected: the corrected significance level was calculated as α divided by the number of hypotheses being tested.The proportion of synonymous and nonsynonymous substitutions per synonymous and nonsynonymous site  with the CODEML program in the PAML package using “branch-site” models, which allow ω to vary both among sites in the sequence and across pre-specified branches or clades on the tree. We used a model A and performed test 2 as described in Zhang et al. [atp genes were used, both terminal and internal branches within the parasitic subtree of Orobanchaceae were tested with Bonferroni correction for multiple comparisons. The same test was applied solely to the Lathraea branch using accD, clpP, matK, ycf1, and ycf2 sequences.Evidence for positive selection acting on the g et al. . When atLindenbergia. The coverage of two of them, 251X and 293X, suggesting that they correspond to repeat region, and the coverage of the remaining six was 130X to 143X. The complete plastid genome of L. squamaria is a circular molecule 150,504 bp in length and possesses a typical architecture with a large single-copy (LSC) region of 81,981 bp separated from the 16,061 bp small single-copy (SSC) region by two inverted repeats (IRs), each of 26,231 bp. The GC content is heavily biased (38.13%)  .L. squamaria is shown in The annotated plastome was deposited in GenBank (accession number NC_027838). The gene map for the plastome of L. squamaria, a set of 46 protein-coding genes, 30 tRNA genes, and four rRNA genes were identified (Lindenbergia plastome. The petL gene was completely lost (no reads were mapped to petL of Lindenbergia), and 32 putative pseudogenes  were detected among the protein coding genes in the Lathraea plastome. Nine plastid genes encoding subunits of the NAD(P)H dehydrogenase complex (ndh genes) became pseudogenes, and ndhC and ndhE ORF persisted. Three genes of photosystem I , eight of the photosystem II subunit , four members of the cytochrome b6/f complex , and two genes for ribosomal proteins  were detected as pseudogenes. Two of four genes of the plastid-encoded RNA polymerase (PEP), rpoA and rpoC2, were also found to be pseudogenes due to multiple frameshifts in the former and an internal stop codon in the latter. The sequence of the RUBISCO large subunit gene rbcL contains an internal stop codon. Lathraea also has pseudogenes for cytochrome C biogenesis protein ccsA, envelope membrane protein cemA, and the putative photosystem I protein ycf4. No pseudogenes were detected in encoding subunits of the ATP synthase complex (atp genes).Among the 78 unique genes present in entified . No majorpoC1, rpoB, psaA, psaB, cemA, ycf2, ndhB, and ndhG being the most abundant. Interestingly, within the rbcL sequence one of three single nucleotide variants affected the premature stop codon so that a CGA triplet was restored whereas others did not change amino acids but always restored conserved codons  and the putatively functional (minor) sequence were transcribed in a proportion similar to a major-to-minor DNA variants ratio suggesting no RNA editing in the Lathraea rbcL sequence  100%.Phylogenetic analyses of the coding genes yielded a completely resolved Orobanchaceae tree  with theSchwalbea is a sister to the remaining broomrape clades (BS 100%). The next split within the plastid tree occurs between the Bartsia and Lathraea clades on one hand and the clade including the other holoparasitic genera (BS 100%) on the other. The latter clade groups Cistanche species with Conopholis and Epifagus, as well as Phelipanche species and Myzorrhiza with Orobanche species and Boulardia (BS 97%-100%). The estimated time of split of Bartsia and Lathraea lineages was 13.88 MYA  in all comparisons. However, the substitution rate acceleration is not uniform across compared genomes and functional groups of genes. Thus, there is no significant rate difference in rRNA sequences, but other groups of genes in Lathraea and Bartsia evolve faster than in photosynthetic plants. Relative rate tests show also insignificant rate difference in rpo, atp, and rpl/rps sequences between Bartsia and Lathraea, while psa/psb/pet genes and a group of miscellaneous genes (accD/clpP/matK/ycf1/ycf2) in Lathraea evolve faster than in Bartsia. In the latter case the difference is due to the matK gene, because in accD, ycf1, and ycf2 the rate difference is not significant (clpP from Bartsia is not available) when the genes are tested separately.The length of a dN /dS) can be considered uniform for all groups of genes when hemiparasitic Bartsia is pre-specified as a foreground branch: ω-value differences are not significant, and the null hypotheses (neither “one-ratio” nor “two-ratio” models) cannot be rejected at 1.25% level. The same is true for the rpo, atp, and rpl/rps genes when Lathraea is a branch of interest. However, for photosynthesis-related genes psa/psb/pet, models M2L and M3 fit the data significantly better than M1 and M2B (P<0.0001), suggesting individual ω-value for a holoparasitic lineage (Lathraea) being more than 7× that of other taxa . The LRT also indicates a better fit of a “two-ratio” model (models M3 and M2B were not tested) for the clpP gene (P<0.0001) with the ω estimate for Lathraea being equal to 1, i.e. reaching neutrality (ω = 0.05 for background branches). For accD, matK, ycf1, or ycf2, none of the tested branch models has a significantly better fit.Ratio ω (dN /dS) estimated using the “three-ratio” model M3 did not exceed 1 and exceeded 0.5  for a few fast evolving genes . The codon-based Z-test rejected the null hypothesis of neutrality in favor of negative selection in pairwise comparisons for individually analyzed genes and all groups except for the clpP gene. The branch-site test for evidence of positive selection acting on atp genes was applied to all eleven branches of the parasitic subtree of Orobanchaceae. The likelihood ratio statistic was non-zero for the Lathraea (1.126) and Myzorrhiza (3.99) branches, but in no case was the LRT statistic significant after Bonferroni correction  at α = 0.0045. Among other genes  tested with Lathraea lineage specified as a foreground branch, only clpP displayed statistically significant positive selection (P = 0.001) at α = 0.05, but no particular codons with high posterior probability (higher than 0.95) of being under positive selection were identified.Ratios ω  and two plastid  markers [Cistanche: in McNeal et al. [Cistanche species are closer to the Orobanche/Phelipanche clade than to Conopholis/Epifagus. In our tree parasitic species form a monophyletic group whereas holoparasites do not, and it is very unlikely that hemiparasitic Bartsia and holoparasitic Lathraea lineages could have a holoparasite as a common ancestor. Therefore, the topology obtained does not contradict a single transition to a parasitic lifestyle and independent transitions to obligate parasitism in Orobanchaceae as it was stated earlier in [The result of the phylogenetic analysis  is consi markers  except fl et al.  Cistanchrlier in , 36, 4.Lathraea lineage occurred relatively recently, whereas the holoparasitic lineage Orobancheae is about two times older, and support recent findings that parasitism in Orobanchaceae originated within 5 MY [Our divergence time estimates , S2 Fig hin 5 MY . Age estMyzorrhiza–Phelipanche , Boulardia–Orobanche  and Myzorrhiza–Orobanche  are close to those calculated with a clock calibrated with an ITS substitution rate taken from Gentianella (Gentianaceae) [Lathraea–Bartsia split at 21 MYA  [et al. [trnT–trnL intergenic spacer and the nuclear ITS region [et al. [Epifagus–Cistanche split age of 42 MY, the same node was calculated at 39.4 MY by Wolfe et al. [Conopholis and Epifagus, an age of 7.8 MY was estimated by Wolfe et al [et al. [et al. [et al. [et al. [et al. [et al. [et al. [Lathraea and photosynthetic lineages, the genome-wide rate of nucleotide substitution in plastid genome of Lathraea being elevated as in other parasitic plants.The age estimates of nodes anaceae)  and withanaceae) , while aS region . Focusinfe et al , but it  [et al. ; 35.91 M [et al. ; 38 MY,  [et al. , 32 MY,  [et al. ), thus aL. squamaria plastome is more similar to the plastid genome of autotrophic Lindenbergia than to that of the closely related holoparasite Lathraea clandestina. Hybridization experiments demonstrated that the plastome of L. clandestina was approximately 110-kb long and has a drastically reduced SSC region (which in land plants contains most of the ndh genes for subunits of a plastid NAD(P)H dehydrogenase), in addition to pseudogenization of atpB and atpE genes [L. squamaria plastome, atpB and atpE were maintained as functional genes and none of the ndh genes was lost, but nine out of the eleven ndh genes were pseudogenized. Degradation of the ndh complex is not attributed solely to heterotrophs and occurred independently in many angiosperm lineages, including bryophytes [ndh genes is typical for parasitic Orobanchaceae  were pseudogenized after the transition to obligate parasitism and mapped this event to a common ancestor of Schwalbea and other parasites [ndhA gene is present in facultative hemiparasite Bartsia [ndhD, ndhG and ndhF are not pseudogenized in another hemiparasite Castilleja miniata , as well as many members of the cytochrome b6/f complex (pet) of the Lathraea plastome, have been turned into pseudogenes. The remaining psa/psb/pet genes retained intact open-reading frames but clearly displayed signature of relaxed selective constraint: the estimated ω-ratio (dN /dS) is approximately seven times higher than that of non-holoparasite lineages , and this difference is statistically significant (P<0.0001). Contrary to Lathraea, the psa/psb/pet genes in Bartsia evolved under the same negative selection constraints as in the photosynthetic Lindenbergia and outgroups.The majority of subunit genes of photosystem I and II (Lathraea plastid genome only two of four plastid-encoded RNA-polymerase (PEP) genes (rpoB and rpoC1) have intact reading frames, the PEP seems to be nonfunctional, similarly to L. clandestina [Lathraea may be rendered redundant. The rpo genes themselves are transcribed, and at least two of them, rpoC1 and rpoC2, were amplified by RT-PCR and did not contain detectable RNA-editing sites. It is interesting to note a tissue-specificity of processing of the rpoC1 intron: spliced intron was found in fruits, but no intron processing was detectable in perianth  is also putatively functional. A similar situation has been reported for other non-photosynthetic plants–holoparasites [atp complex genes in the Lathraea plastome after the loss of photosynthesis.Not being associated with housekeeping processes, a set of ATP synthase complex genes . Howevendh sequences (including pseudogenes) was recently shown in Orchidaceae [Lathraea. In mycoheterotrophic Neottia nidus-avis at least three distinct rbcL sequences were found as pseudogenes and were likely located in the plastid genome [Hyobanche glabrata was shown to have five different rbcL transcripts and all also encoded pseudogenes [et al. [Lathraea complete mitochondrial genome sequence will help to distinguish between the possible causes of the observed polymorphism.Lastly, our mapping of the paired reads to the plastome assembly revealed the high level of nucleotide polymorphism, and polymorphic sites were recovered both in pseudogenes and coding sequences. Definitely, some of single nucleotide variants and indels are of mitochondrial origin, since the transfer of plastid DNA into the mitochondrial genome is a well-known phenomenon  and almohidaceae . On the d genome . Among budogenes . In rece [et al. ). We expS1 Appendix(PDF)Click here for additional data file.S1 Fig(PDF)Click here for additional data file.S2 Fig(PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.


Pancreatic fistula (PF) remains the most challenging complication after pancreaticoduodenectomy (PD). The purpose of this study was to identify the risk factors of PF and delineate its impact on patient outcomes.We retrospectively reviewed clinical data of 532 patients who underwent PD and divided them into PF group and no PF group. Risk factors and outcomes of PF following PD were examined.PF was found in 65 (12.2%) cases, of whom 11 were classified into ISGPF grade A, 42 grade B, and 12 grade C. Clinically serious postoperative complications in the PF versus no PF group were mortality, abdominal bleeding, bile leak, intra-abdominal abscess and pneumonia. Univariate and multivariate analysis showed that blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreaticojejunostomy type were independent risk factors of PF after PD.Blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreatico-jejunostomy type were independent risk factors of PF after PD. PF was related with higher mortality rate, longer hospital stay, and other complications. Pancreaticoduodenectomy (PD) is the classic surgical approach for both malignant and benign disease of pancreatic head, duodenum and periampullary region. PD was associated with high mortality and morbidity since introduced as a treatment approach. Recently, both the mortality and morbidity following PD were significantly reduced for the improvement of surgical skills and perioperative care. The mortality rate after PD was kept even as low as 5% in many specialized centers -4. AlthoTo identify patients at high risk for PF and avoid the accompanying complications, it is important to predict its occurrence so that prompt treatment can be administered. The purpose of this study was to analyze the risk factors and outcomes of PF from a prospective database of 532 patients undergoing PD.Five hundred thirty-two patients undergoing elective PD in the first Affiliated Hospital of Sun Yat-sen University between April 2000 and November 2011 were included in this study. Clinical data including demographics, intraoperative procedures and postoperative complications were reviewed. Prior approval from the committee for Ethical Review of research involving Human Subject of the first Affiliated Hospital of Sun Yat-sen University  and informed consent from patients were obtained before study. One hundred and forty-one patients  accepted preoperative biliary drainage.All patients were divided into 2 groups, according to the presence of PF or not: PF group and no PF group. PF, delayed gastric emptying (DGE), and post-pancreatectomy hemorrhage (PPH) were defined according to the International Study Group on Pancreatic Fistula (ISGF) -11. BileOf the 532 patients, 7 cases had a pylorus-preserving pancreaticoduodenectomy (PPPD) and the others had a classical pancreaticoduodenectomy (PD). The pancreaticojejunostomy was performed using a traditional 2-layer anastomosis (n = 304), an invaginated anastomosis (n = 125), and a duct-mucous anastamosis (n = 103) based on surgeon’s preference. No pancreaticogastrostomy was used in our study. Four hundred and seventeen anastomoses (78.4%) were constructed using pancreatic duct stents. The biliary stent was not routinely placed. Drains were placed routinely in the Winslow’s foramen for draining peritoneal fluid in all patients. Prophylactic octreotide or somatostatin was not routinely used.t test was used to compare continuous variables. The Chi-square test or Fisher exact test was used to compare categorical variables. Of all the variables tested in univariate analysis, only those with P < .05 were put into multivariate analysis. Logistic regression (forward selection) was performed to determine the independent risk factors of PF. P < .05 was considered statistically significant.All statistical analyses were performed with SPSS version 21.0 software . Quantitative data are expressed as mean ± SD. Independent sample Student’s The indications for PD included duodenal neoplasm, pancreatic cancer, bile duct neoplasm, ampullary neoplasm, chronic pancreatitis, gastric antrum cancer, cystadenoma, pancreatic cyst, and so on. Three major indications for PD were duodenal neoplasm in 164 patients (30.8%), pancreatic cancer in 140 patients (26.3%) and ampullary neoplasm in 102 patients (19.2%). Sixty-five patients (12.2%) developed PF after PD, A grade 11 cases , B grade 42 cases  and C grade 12 cases .P = .003), pancreatic duct diameter ≤ 3 mm  and pancreaticojejunostomy type  were independent risk factors for PF after PD  patients didn’t develop any complication, while 229  patients had at least one complication: 60  patients had grade Icomplications, 50  patients had grade II complications, 93  patients had grade III complications, 3 patients had grade IV complications. Grade V (death) occurred in 23 patients . Besides PF, other postoperative complications included PPH , bile leak , delayed gastric emptying , intraabdominal abscess (IAA) , pneumonia , wound infection , deep venous thrombosis (DVT)  and chyle leak . Mortality, IAB, bile leak, IAA and pneumonia were significantly higher in the PF group when compared with the no PF group. The length of hospital stay significantly increased in those patients who developed PF compared with those that did not  stent showed an increased risk of PF formation [et al. found that no difference in the incidence of PF versus no-PF in those patients having ERCP or PTC and an increase in PF in those patients who did not have preoperative stents compared with those patients who did [et al. indicated that no difference in the incidence of PF versus no-PF in those patients having preoperative stent (either endoscopic or PBD) [The formation of PF is associated with many variables involving demographic, preoperative, intraoperative and pathological factors. Previous studies had reported that pancreaticogastrostomy was associated with significantly lower pancreatic fistula rate than pancreaticojejunostomy. Pancreaticogastrostomy was more efficient than pancreatico-jejunostomy in reducing the incidence of postoperative pancreatic fistula -23. In oormation . However who did . Lin et  or PBD) . Our reset al. demonstrated increased intraoperative blood loss was an independent risk factor for PF after PD by univariate and multivariate analysis [P = .003) was an independent risk factor for PF after PD. Kawai et al. showed that the preoperative CT image-assessed ligation of inferior pancreaticoduodenal artery (IPDA) method (CLIP) was a useful and reliable operative technique for reducing intraoperative bleeding in PD [et al. reported early ligation of the inferior pancreatoduodenal artery (IPDA) not only reduced intraoperative blood loss during PD but also alleviated postoperative morbidity and mortality [As expected, increased intraoperative blood loss appeared to be an important risk factor of PF. Yeh analysis . The facanalysis . In our ng in PD . Ishizakortality . Therefoet al. reported considerably fewer fistulas with invagination compared with duct to mucosapancreaticojejunostomy after pancreaticoduodenectomy by a randomized, prospective, dual-institution trial [et al. and Bartoli et al. reported that lowest incidence of PF in patients who had a duct to mucous anastomosis than other anastomoses [P < .001). Since the diameter of major pancreatic duct played an important role in selection of PJ types, some studies have concluded that major pancreatic duct diameter was also an independent risk factor of PF after PD [P < .001). Soft pancreatic tissue has been regarded as a potent contributor for PF formation [Type of pancreaticojejunostomy anastomosis has also been cited as a predictor of PF after PD. Berger on trial . Howeverstomoses ,29. We aafter PD ,23. Geneormation ,7,14, whormation  and performation .PF is associated with a greater many of other complications and prolonged hospital stay ,8,14,28.In conclusion, blood loss and the pancreatic duct diameter and pancreaticojejunostomy type were independent risk factors for PF after PD. Outcomes in patients with PF were remarkable for a higher rate of mortality, abdominal bleeding and septic complications, an increased incidence of reoperations, and a longer hospital stay.


Large intracranial occlusive vascular disease is a major contributor to the incidence of stroke worldwide, especially when it involves the middle cerebral artery (MCA). The data on the prognosis of symptomatic atherosclerotic MCA occlusions (MCAO) with concomitant intracranial arterial disease (MCAO-AIS) are limited. MCAO-AIS may reflect the extent of the atherosclerotic intracranial disease, we hypotheses that coexisting intracranial arterial disease influenced the prognosis of MCAO.Patients having survived at least one month after the initial ischemic stroke who suffered from atherosclerotic occlusion of the MCA were enrolled. According to their concomitant atherosclerotic intracranial arterial disease, the patients were assigned to one of two groups: the MCAO or the MCAO-AIS. All of the patients’ cerebrovascular risk factors were recorded. Recurrent ischemic stroke and death were the end-point events during the follow-up.p = 0.016), as well as gender and diabetes mellitus. The MCAO-AIS were more likely to experience ipsilateral ischemic strokes, but the difference was not statistically significant.A total of 232 patients  were analyzed. The mean follow-up time was 17.65 months. The end-point events occurred in 35 (15.09%) patients, resulting in an annual rate of 10.26%. The presence of MCAO- AIS was an independent risk factor associated with the patient’s prognosis in the cohort (OR = 3.426, 95% CI 1.261 to 9.308; Concomitant intracranial arterial disease may influence the prognosis of patients with atherosclerotic MCAO. The result warrants further research in larger sample population. Intracranial atherosclerotic occlusion or stenosis is an important cause of ischemic stroke in both Asians and African Americans -3. The mPrevious studies have reported that diabetes mellitus, stroke symptoms, and gender may influence the prognosis of patients with symptomatic MCAO ,9,10. HoWe therefore conducted this retrospective analysis to evaluate the further progression of MCAO-AIS and its potential risk factors for stroke recurrence and mortality in these patients.We consecutively recruited patients who were admitted to our hospital and had cerebral angiographic records from January 2006 to January 2010. The data were documented prospectively in the Nanjing Stroke Registry Program. Patients were included if they met the following criteria: 1) occlusion in the M1 segment of the MCA that was proven by magnetic resonance angiography (MRA) or cerebral digital subtraction angiography (DSA), 2) an initial ischemic stroke or transient ischemic stroke (TIA) within the occluded MCA distribution territory, 3) at least one risk factor of atherosclerosis, 4) survival for at least one month after the onset, and 5) an age greater than 40 years old.We excluded: 1) patients with a history of stroke or TIA, 2) those who died during one month after the one of symptoms, 3) patients with atrial fibrillation (AF) which included chronic or paroxysmal AF. Paroxysmal atrial fibrillation was defined as episodic AF on an electrocardiogram, or transient AF (<24 hours) on a 24-hour ambulatory electrocardiographic recording. 4) patients with MCAO due to non-atherosclerotic etiology such as vasculitis, vasospasm, dissection, aneurysm, basilar meningitis, or Moyamoya disease, 5) patients with recanalization of the occluded MCA after endovascular therapy, 6) and patients who presented with cancer, severe liver disease, renal failure, or hematological disease.In this study, all patients were performed MRA. One hundred twenty-eight patients were performed DSA. The magnetic resonance imaging was performed with a 1.5-T superconductive magnetic resonance system, and all of the MRA examinations were obtained using three-dimensional (3D) gadolinium (Gd)-enhanced technique. A DSA was performed in all patients in whom MCA occlusion was suspected from the MRA. The DSA were performed after the vital signs were stabilized. The location and severity of the stenosis was determined using an MRA or DSA and the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial criteria in all of the patients ,13. The This study was approved by the ethics committee of Jinling Hospital, and written informed consent was obtained from all patients.We reviewed the patients’ baseline demographic factors and the medical records. The main risk factors for MCAO were also recorded, such as hypertension , diabetes mellitus , hyperlipidemia , a history of coronary heart disease, cigarette smoking (at least 10 cigarettes per day during the past 5 years or more), and alcohol intake . Previous use of antiplatelet agents, anticoagulants, or statins was also evaluated.We followed the patients who survived the acute phase of stroke discharged after 1, 3, 6, 12 months by interviews or telephone to determine whether any events had occurred. Asymptomatic patients had subsequent yearly follow-up visits. The patients were asked whether they had experienced any sudden episode of weakness, blindness, numbness, speech difficulty and any other new symptoms and documented in Nanjing Stroke Registry Program. If a stroke was suspected, the patients were invited to our Neurology Clinic and were evaluated by study neurologists who were blinded to the treatment assignment and also underwent brain computerized tomography (CT) or magnetic resonance imaging (MRI). The interviewers were blinded to the patient’s group allocation. The composite outcome of the stroke recurrence or any-cause death was evaluated during the follow-up period to elucidate the long-term prognosis of symptomatic MCAO patients.An ischemic stroke was defined as a new focal neurological deficit of sudden onset ≥ 24 hours in duration that, was not associated with a hemorrhage on neuroimaging. An ipsilateral stroke was considered to have occurred in the same location of the symptomatic artery when the neurological signs correlated with a new infarct on a CT or MRI in an area of the brain supplied by that artery.p < 0.05 was considered to indicate statistically significant differences.The statistical analysis was performed with SPSS version 13.0 software . A chi-square or Fisher’s exact test was used to compare the rate and proportions of the discrete variables, and Student’s-t tests were performed for the continuous variables. We used the Cox proportional hazards models for the univariate and multivariate analyses to identify the potential factors associated with stroke recurrence or any-cause death. A Kaplan-Meier curve was generated for the cumulative probabilities of stroke recurrence and the composite outcome, and the two groups (MCAO and MCAO-AIS) were compared using the log-rank test. The patients who were lost to follow-up were censored at the last contact date in the analysis. The results were expressed as the adjusted odds ratio (OR) and corresponding 95% confidence intervals (95% CI). For all statistical tests, values are 2-sided and During the study, 3460 patients were enrolled from the databank. Three hundreds and six (8.8%) patients were recruited, all of them were first-ever stroke. Among them, 35 patients died in the acute phase 11.4%) and, 39 patients (14.39%) underwent a surgical revascularization procedure and were excluded. Therefore, we included 232 first-ever stroke patients with complete occlusion of the MCA in this study, and followed them for an average of 17.65 ± 10.81 months . Seven (3.02%) patients were lost during the follow-up. The mean age was 57.68 ± 9.50 years, and 69% of the patients were male. All of the patients were continuously treated with both antiplatelet agents and statins if the patients had not any adverse events. Eighty-four patients were well controlled their lipid level  <3.6 mmol/L, LDL-C < 1.8 mmol/l). The distribution of the baseline characteristics and the composite outcome (stroke recurrence or any-cause death) is listed in Table 1.4% and,p = 0.007), and a poor composite outcome  than their counterparts MCAO . The patients in MCAO-AIS were more likely to have high blood pressure at enrollment  of the 232 patients died (three women (1.29%) and eight men (3.45%)). Three patients (1.29%) died from the initial stroke, two (0.86%) died from a recurrent stroke, one (0.43%) died from cardiovascular disease, and five (2.16%) died from pulmonary causes (pneumonia or pulmonary embolisms).p = 0.009, Figure We documented 35 15.09%) composite outcomes during the observation. The Kaplan-Meier curves showed that a significantly lower proportion of patients in the MCAO-AIS group survived without a composite outcome when compared with the MCAO group . Moreover, diabetes mellitus was related to the recurrence of both overall (p < 0.01) and ipsilateral ischemic vascular events (p < 0.01).The variables that were potentially associated with the MCAO prognosis are listed in Table p = 0.016), we further analyzed this subgroup, as shown in Table p = 0.016), diabetes mellitus (p = 0.007), and coronary artery disease (p = 0.033) were significantly associated with stroke recurrences or any-cause death in the univariate analysis. These 3 variables were included in the logistic regression model. Diabetes mellitus was the only factor independently associated with the recurrence of cerebral vascular events or any-cause death during the follow-up . The Kaplan-Meier curves showed that a significantly lower proportion of patients presenting with AIS survived free of a stroke recurrence or any-cause death compared with the MCAO group  , resulting in an overall annual rate of 6.45%. Seventeen events (77.27%) occurred in the location of the symptomatic occlusive MCA. Strokes located beyond the symptomatic MCAO occurred in 5 (22.73%) of the 22 patients. Of these 17 ipsilateral events, 11 were ischemic strokes  and 6 were TIAs . Among the patients in MCAO-AIS, 14 subjects experienced ipsilateral cerebrovascular events , with an occurrence rate of 7.00% in the first year, 10.2% in the second year, and 14.80% in the third year, compared with 3.30%, 5.40%, and 5.40% in the MCAO group respectively . The patients in MCAO-AIS tended to have ipsilateral ischemic strokes more frequently than those without AIS (9.40% vs. 3.60%), but this trend was not statistically significant in the Kaplan-Meier plots (p = 0.017) and diabetes mellitus (p = 0.000) were significantly associated with ipsilateral ischemic vascular event in the univariate analysis (Table p = 0.002).Both hypertension (is Table . Both ofp < 0.01).This follow-up study provides evidence about the dynamic nature of symptomatic MCA atherosclerotic occlusive disease with coexisting AIS. We found that the prevalence of concomitant AIS (50% to 99%) in our cohort of patients with symptomatic MCAO was high (63.79%). Our data suggests that the rate of stroke recurrence or any-cause death in MCAO-AIS is much higher than in MCAO  trial, aggressive medical therapy was superior to percutaneous transluminal angioplasty and stenting with the use of the Wingspan stent system . Therefo


The QUOROM and PRISMA statements were published in 1999 and 2009, respectively, to improve the consistency of reporting systematic reviews (SRs)/meta-analyses (MAs) of clinical trials. However, not all SRs/MAs adhere completely to these important standards. In particular, it is not clear how well SRs/MAs of acupuncture studies adhere to reporting standards and which reporting criteria are generally ignored in these analyses.To evaluate reporting quality in SRs/MAs of acupuncture studies.We performed a literature search for studies published prior to 2014 using the following public archives: PubMed, EMBASE, Web of Science, the Cochrane Database of Systematic Reviews (CDSR), the Chinese Biomedical Literature Database (CBM), the Traditional Chinese Medicine (TCM) database, the Chinese Journal Full-text Database (CJFD), the Chinese Scientific Journal Full-text Database (CSJD), and the Wanfang database. Data were extracted into pre-prepared Excel data-extraction forms. Reporting quality was assessed based on the PRISMA checklist (27 items).Of 476 appropriate SRs/MAs identified in our search, 203, 227, and 46 were published in Chinese journals, international journals, and the Cochrane Database, respectively. In 476 SRs/MAs, only 3 reported the information completely. By contrast, approximately 4.93% (1/203), 8.81% (2/227) and 0.00% (0/46) SRs/Mas reported less than 10 items in Chinese journals, international journals and CDSR, respectively. In general, the least frequently reported items (reported≤50%) in SRs/MAs were “protocol and registration”, “risk of bias across studies”, and “additional analyses” in both SRs/MAs of acupuncture studies have not comprehensively reported information recommended in the PRISMA statement. Our study underscores that, in addition to focusing on careful study design and performance, attention should be paid to comprehensive reporting standards in SRs/MAs on acupuncture studies. Systematic reviews (SRs) and meta-analyses (MAs) summarize large amounts of evidence and are a valuable tool for keeping clinicians up to date within their specialty Since 1987, numerous researchers have recognized the need to evaluate the quality of these types of reviews. For example, in 1987 Sacks and colleagues Acupuncture, a traditional medicine technique, has been widely used in clinical practice for thousands of years in China and many western countries. The number of published SRs/MAs of acupuncture studies has increased considerably in recent years. As the transparency and completeness of SRs/MAs in many fields is still not optimal The protocol for this study was written in Chinese and has not been published. The study was not a classical systematic review, but we tried to report it according to PRISMA Checklist We included all SRs or MAs of acupuncture published in Chinese journals, international journals, and the Cochrane Database of Systematic Reviews (CDSR) prior to 2014. The experimental group of SRs/MAs of acupuncture studies was also compared with a control group of SRs/MAs of studies of other interventions, such as herbal medicine, massage and western medicine. Participants: human in any conditions, not animal; Intervention: acupuncture; Comparisons: sham acupuncture or other interventions, such as herbal medicine, massage, western medicine, etc; Outcomes: no limitations; Study design: SRs/MAs. We excluded SRs/MAs that focused primarily on traditional Chinese medicine (TCM) other than acupuncture .We comprehensively and systematically searched the following literature archives for SRs/MAs published prior to 2014: CDSR, PubMed, EMBASE, Web of Science, Chinese Biomedical Literature Database (CBM), the TCM database, Chinese Journal Full-text Database (CJFD), Chinese Scientific Journal Full-text Database (CSJD), and the Wanfang database. Databases were searched three times: on March 24, 2011 for all entries submitted prior to March 2011, on June 12, 2012 for all entries submitted prior to January 2012 and on January 11, 2014 for all entries submitted prior to 2014. The search terms “acupuncture”, “needling”, “ear acupuncture”, “electroacupuncture”, “electro-acupuncture”, “acupuncture points”, “acupressure”, “moxibustion”, and “acupoint” were used with the terms “systematic review” or “meta-analysis”. The search strategy is presented in The titles and abstracts of the studies were independently screened by at least two reviewers  based on inclusion and exclusion criteria, and the full text of potentially suitable articles was retrieved for further assessment .t test. Dichotomous data were summarized with descriptive statistical analysis . Pearson's χ2 test and/or Fisher's exact test were used to assess differences in reporting among groups. P values less than 0.05 were considered significant. All statistical analyses were performed using Microsoft Excel (version 2007) and SPSS (version 13.0) software.Data were extracted independently by at least two reviewers  in accordance with the PRISMA checklist and the assessment checklist for SRs/MAs of acupuncture studies developed for this study. Inconsistencies were subsequently resolved by discussion between the two reviewers or final decisions were made by the third principal investigator . Data input utilized a standardized form and was done by trained data extractors . The form consisted of a general characteristics section  examined, diagnostic criteria, intervention, and outcome) and a 27-item PRISMA information section . Each item was assessed as “yes” if it was described in the paper or “no” if it was not . Data weOur initial literature search identified 3993 potential SRs/MAs of acupuncture-related studies. After closer examination, 476 were chosen for inclusion in our analysis . Of thesGeneral characteristics of the SRs/MAs analyzed are summarized in Acupuncture SRs/MAs in Chinese journals were conducted entirely by Chinese authors, whereas those published in international journals tended to be multinational collaborations, with Chinese first authors being most prevalent . Chinese authors were also most prevalent first authors in CDSR studies . The percentage of published acupuncture SRs/MAs in Chinese journals, international journals, and the CDSR that reported at least one funding source was 54.19% (110/203), 50.66% (115/227), and 89.13% (41/46), respectively, and the maximum number of funding sources reported was 5, 3, and 7, respectively.The majority of SRs/MAs  included at least one randomized controlled trial (RCT). Nervous system diseases, musculoskeletal system diseases, and mental illness were most frequently examined . Approximately 38% (180/476) of the SRs/MAs reported western diseases or TCM syndromes in their diagnostic criteria. All acupuncture SRs/MAs examined described the interventions in detail. 39.92% (190/476) and 19.54% (93/476) SRs/MAs included adverse events and quality-of-life in the outcome which were reported as primary and/or secondary outcomes.Comparison of PRISMA reporting among the three types of journals/databases Among 476 SRs/MAs, only 3 reported the information completely. By contrast, approximately 4.93% (1/203), 8.81% (2/227) and 0.00% (0/46) SRs/MAs reported less than 10 items on the checklist in Chinese journals, international journals, and CDSR, respectively. In general, the least frequently reported items (reported≤50%) in SRs/MAs were item 5 (“protocol and registration”), 15 and 22 (“risk of bias across studies”), and 16 and 23 . The remaining items on the checklist were adequately reported (i.e >90%), with the items listed in Comparison of PRISMA reporting before and after release of the PRISMA statement P>0.05) for item 2 (“structured summary”), 5 (“protocol and registration”), 6 (“eligibility criteria”), 8 (“search”), 10 (“data collection process”), 11 (“data items”), 12 , 16 , 17 (“study selection”), 18 (“study characteristics”), 23  and 27 (“funding”) between SRs/MAs published prior to release of the PRISMA statement and those published after its release. Unfortunately, the rate of reporting of two items (“objective” and “information sources”) had decreased in 2010–2013 compared with before 2010 (P<0.001).We found no statistical difference (Comparison of PRISMA reporting in Science Citation Index (SCI) and non-SCI journals P<0.001).We found that PRISMA reporting in SRs/MAs in SCI journals was more complete overall than in non-SCI journals, especially for items 4 (“objective”), 5 (“protocol and registration”), 7 (“information sources”), 8 (“search”), 9 (“study selection”), 11 (“data items”), 23 , and 27 (“funding”)  than in non-CDSR.Several studies have focused on the reporting quality of SRs/MAs covering the fields of TCM Both the QUOROM and PRISMA statements encourage the use of specific terms in the titles of SRs/MAs, which help to identify these studies. Because of the special title format requirements of the CDSR, however, SRs/MAs published in this database cannot conform to the QUOROM/PRISMA recommendation.Unequivocal descriptions of the scientific background and rationale for using acupuncture in the treatment of both western diseases and TCM syndromes provide the reader with a better understanding of the research context and rationale of SRs/MAs. In this respect, SRs/MAs in the CDSR were more explicit in their descriptions than those in international or Chinese journals.The importance of protocol consistency and registration of SRs/MAs to the transparency of reporting is underscored by the fact that they are considered key aspects of the “reporting guidelines for systematic review protocols” in the international prospective register of systematic reviews (PROSPERO) www.acubriefs.com), AcuBase (www.acubase.fr), Acudoc2 RCT (www.acubriefs.com/), and the TCM database are the most systematic and comprehensive sources for acupuncture information. Chinese RCTs make up the highest proportion of primary studies included in acupuncture SRs/MAs. If methods for sequence generation, allocation concealment, and study blindness are not adequately described, low-quality studies The PRISMA standards suggest that methodological details such as eligibility criteria, information sources, search strategies, study selection criteria, and data collection processes are necessary to judge the quality and accuracy of SRs/MAs. The majority of the SRs/MAs published in the CDSR adequately reported these items, whereas those published in Chinese and international journals did not. Eligibility criteria are an aspect of the PICOS criteria  central to the PRISMA approach. We propose that it is equally important that search strategies be uniformly reported. Many international journals require information about search strategies in at least one database, and the flexibility of the CDSR layout allows reporting of search strategies for multiple databases. Chinese journals, however, rarely request search strategy information. There is also considerable need for more consistency in the databases obtain acupuncture studies. We propose that, AcuBriefs  did not allow partial information to be used. Fourth, our study focused primarily on acupuncture rather than other TCM. We failed to distinguish acupuncture from herbal medicine massage, or western medicine because individual SRs/MAs we included in our analysis often contained several control groups rather than one group.In summary, SRs/MAs of acupuncture studies have not comprehensively reported the information recommended in the PRISMA statement. Our study underscores that, in addition to focusing on careful study design and performance, attention should be paid to comprehensive reporting standards when publishing SRs/MAs of acupuncture studies.Checklist S1PRISMA Checklist.(DOC)Click here for additional data file.Text S1The English and Chinese databases search strategy.(DOC)Click here for additional data file.Text S2Inclusion Exclusion Section.(DOC)Click here for additional data file.Text S3Definitions of reporting items.(DOC)Click here for additional data file.Text S4476 SRs/MAs of acupuncture.(DOC)Click here for additional data file.


Background. There is a considerable dissimilarity in the survival duration of the patients with gastric cancer. We aimed to assess the systemic inflammatory response (SIR) and nutritional status of these patients before the commencement of chemotherapy to find the appropriate prognostic factors and define a new score for predicting metastasis. Methods. SIR was assessed using Glasgow Prognostic Score (GPS). Then a score was defined as prealbumin/CRP based prognostic score (PCPS) to be compared with GPS for predicting metastasis and nutritional status. Results. 71 patients with gastric cancer were recruited in the study. 87% of patients had malnutrition. There was a statistical difference between those with metastatic (n = 43) and those with nonmetastatic (n = 28) gastric cancer according to levels of prealbumin and CRP; however they were not different regarding patient generated subjective global assessment (PG-SGA) and GPS. The best cut-off value for prealbumin was determined at 0.20 mg/dL and PCPS could predict metastasis with 76.5% sensitivity, 63.6% specificity, and 71.4% accuracy. Metastatic and nonmetastatic gastric cancer patients were different in terms of PCPS (P = 0.005). Conclusion. PCPS has been suggested for predicting metastasis in patients with gastric cancer. Future studies with larger sample size have been warranted. The majority of patients with gastric cancer have a poor overall survival. Therefore, finding the appropriate prognostic factors will help to improve clinical approach on patients that will lead to accurate decision making and planning for supportive care. This will possibly increase the rate of survival .Weight loss and performance status are usually used to predict survival and treatment outcomes in patients with inoperable gastric adenocarcinoma , but theRecently, the host nutritional and immune status have been evaluated by the Glasgow Prognostic Score (GPS), which is a combination of serum C-reactive protein (CRP) as an index for systemic inflammatory response and an important factor for the development and progression of neoplasms  along wiOn the other hand, prealbumin is a remarkable prognostic factor for treatment outcomes and/or nutritional status of colon , esophagA convenient sample of 71 patients with inoperable gastric adenocarcinoma was recruited in this prospective study before the onset of chemotherapy between February 2013 and March 2014 . The Hum2 i.v. (one-hour infusion) on day 1; cisplatin, 75 mg/m2 i.v. (one-hour infusion) on day 1; and 5-fluorouracil (5-FU) i.v. (continuous infusion) on days 1–5, to be repeated every 3 weeks for 6 cycles.The chemotherapy regimen was as follows: docetaxel, 75 mg/mVenus blood samples were taken after an overnight fasting and the serum was separated and stored at −70°C for future analysis. Hitachi 917 automated equipment was used for measuring albumin concentration and serum CRP, prealbumin, and transferrin were analyzed using the Minineph Human kits .The systemic inflammatory response was measured using a combination of serum C-reactive protein and albumin as follows: patients with C-reactive protein ≤10 mg/L and albumin ≥3.5 mg/dL were allocated a score of 0; patients with one of these parameters abnormalities were allocated a score of 1; and those with both abnormalities, C-reactive protein >10 mg/L and albumin <3.5 g/dL, were allocated a score of two . Then a 2). The scored PG-SGA was completed by all the patients with the help of a trained oncology nurse. PG-SGA consists of the history of weight changes, food intakes, and the contributing factors, activities, physical examination, and the metabolic stress which affects the nutritional requirements. Based on scored PG-SGA, patients were scored at 0-1  and there was a progressive need for nutritional support, so that those who scored ≥9 required immediate symptom management and/or nutritional support. PG-SGA also provided a categorical assessment as PG-SGA A (well-nourished), PG-SGA B , and PG-SGA C  [BMI was computed as weight (kg)/height (mtrition) .Quantitative variables were presented as mean (standard deviation [SD]) or median (percentile 25–percentile 75) based on the normality of the distribution, and qualitative variables were reported as frequency (%). The best cut-off point value for prealbumin was determined using receiver operating characteristic (ROC) analysis, considering the optimal sensitivity and specificity to calculate the Youden Index ((specificity + sensitivity) − 1). The likelihood ratios (LRs) and area under curve (AUC) were shown as a measure of metastasis prediction adequacy using prealbumin concentration. Then regression tree analysis was used to measure sensitivity, specificity, and accuracy of the new score, PCPS, for prediction of metastasis in IGA patients.The association between categorized variables was examined using Chi-square test or Fisher exact test. Independent-samples Kruskal-Wallis test was used to determine the association between scored PG-SGA and categorized variables.The significance level was considered 0.05 by doing a two-tailed analysis. SPSS software  was used for performing statistical analyses.n = 56) of the patients were male and 21% (n = 15) were female with an average of 62.13 ± 14.39 and 21.08 ± 3.99 for age and BMI, respectively. Twenty-eight patients (39%) had locally advanced unresectable gastric cancer (stage 3)   and 43 pstage 3) . AccordiP = 0.012 and P = 0.004, respectively .There was no statistical association between GPS, PCPS, and categorized PG-SGA, although 72% of the patients with severe malnutrition had a score of 2 for PCPS . MoreoveP = 0.009), while they were not different in terms of GPS .There was a statistical difference in PCPS score between metastatic and nonmetastatic gastric cancer patients  and the prognosis in patients with advanced cancer receiving total parenteral nutrition. They found that there was a significant association between RTPs' concentration and survival in cancer patients and among RTPs and prealbumin had the most correct prognosis rate with 91.9% compared to transferrin and retinol binding protein . The shoOn the other hand, CRP is an indicator of systemic inflammatory response and studies have shown the independent prognostic value of elevated serum levels of CRP in solid tumors including gastroesophageal cancer . Given tThe small sample size was one of the possible limitations, as it was a single center study and a large number of eligible patients declined inclusion as a result of their critical conditions. Moreover, there was no official registration system, so the patients could not be followed to determine the survival rate. However, this study presented a composite score of prealbumin and CRP suggesting that it may be a strong prognostic score in patients with inoperable gastric adenocarcinoma. Although it is early to propose the replacement of GPS with PCPS, assessment of the host inflammatory response and nutritional status with PCPS and evaluation of its association with response to treatment, prognosis, complications, and survival in patients with different kinds of cancer is warranted.


The resumption of menses (ROM) is considered an important clinical marker in weight restoration for patients with anorexia nervosa (AN). The purpose of this study was to examine ROM in relation to expected body weight (EBW) and psychosocial markers in adolescents with AN.N = 225 females with AN). Eighty-four adolescents  with a DSM-IV diagnosis of AN, presenting with secondary amenorrhea were identified. All participants had received a course of outpatient family-based treatment (FBT), i.e., ~20 sessions over 12 months. Weight and menstrual status were tracked at each therapy session throughout treatment. The primary outcome measures were weight , and ROM.We conducted a retrospective chart review at The University of Chicago Eating Disorders Program from September 2001 to September 2011 (SD = 6.5). ROM was reported by 67.9% of participants (57/84), on average at 94.9 (SD = 9.3) percent EBW, and after having completed an average of 13.5 (SD = 10.7) FBT sessions (~70% of standard FBT). Compared to participants without ROM by treatment completion, those with ROM had significantly higher baseline Eating Disorder Examination Global scores (p = .004) as well as Shape Concern (p < .008) and Restraint (p < .002) subscale scores. No other differences were found.Mean percent EBW at baseline was 82.0 (Results suggest that ROM occur at weights close to the reference norms for percent EBW, and that high pre-treatment eating disorder psychopathology is associated with ROM. Future research will be important to better understand these differences and their implications for the treatment of adolescents with AN. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text revision (DSM-IV-TR)[DSM-IV-TR does not consider primary amenorrhea  as part of the criteria for females with AN [Anorexia nervosa (AN) is a serious disorder that is associated with numerous medical and psychiatric complications -6. AN tySM-IV-TR) and is cSM-IV-TR), especia with AN . Further with AN , while m with AN .Despite debate about its diagnostic utility, menstrual status as a measure of physiological health highlights the need for the early identification of serious medical issues , such asOverall, this study aimed to identify correlates of ROM that may assist clinicians with treatment planning. Our primary goal was to detect mean percent EBW and time point during a course of outpatient family-based treatment   at whichDSM-IV criteria for AN or partial AN were included in the current study. Partial AN was defined as <90% EBW and was included as many young patients with eating disorders do not fit criteria used for adults, while being at risk for developing significant health complications following less severe weight loss than might be typical among adult populations [Potential participants were 225 females with AN, aged 11–20 years, presenting for treatment at the Eating Disorders Program at The University of Chicago between September 2001 and September 2011. Of those, 47 were prepubertal or presented with primary amenorrhea, 56 had regular or irregular periods, 27 were taking oral contraceptives, and 11 did not provide this information. Therefore, 84 females with secondary amenorrhea, meeting ulations -28. EBW ulations . Calculaulations . For theulations , was useulations .The Eating Disorder Examination (EDE) is a semi-structured diagnostic interview assessing the frequency and severity of eating disorder behaviors and cognitions . The EDEThe Institutional Review Board at The University of Chicago approved this research. Written assent and/or consent were obtained from each patient and parent/guardian, where appropriate . All patients received manualized FBT administered by a trained clinician in our program. FBT has received robust research support , and is Descriptive statistics were used to examine percent EBW and FBT session at which ROM occurred. Independent samples t-tests were used to compare patients with full versus partial AN in age, illness duration, eating disorder psychopathology, and weight gained during treatment. AN cases were compared to partial AN to test whether (a) these two groups were broadly comparable, and (b) ensure that differences between patients with or without ROM were not due to diagnosis. Chi-square tests were used to examine differences between AN and partial AN in terms of previous medical and/or psychiatric hospitalizations and ethnicity. In addition, independent samples t-tests were conducted to determine baseline differences in age, percent EBW, BMI, LOI, average amount of weight gained during treatment, and eating disorder pathology between patients with or without ROM. Chi-square tests were used to compare patients with or without ROM in terms of previous medical and/or psychiatric hospitalizations and ethnicity, and to determine whether patients with bingeing and/or purging behaviors at baseline were any more or less likely to resume menses during treatment than patients with a restricting subtype.In an exploratory analysis, patients who achieved ROM were compared across a range of physiological and psychosocial variables to a subset of patients who gained the appropriate amount of weight to expect menses to return but failed to resume menses.SD = 2.2) years. Seventy-seven percent self-identified as Caucasian, 12% as Hispanic, 2% as African American, 4% as Asian, and 5% as ‘other’. Fifty-three (63%) patients met full DSM-IV-TR criteria for AN, while 31 (37%) were categorized as partial AN. There were no statistically significant differences between patients with AN and partial AN in age, ethnicity, LOI, and EDE subscale and global scores . As expected, baseline percent EBW was lower for patients with AN than for those with partial AN  = −3.31, p < .001), while patients with AN gained more weight (in lbs.) from baseline to ROM compared to partial AN, even after controlling for baseline percentage EBW  = 4.74, p = .01). There was no difference in terms of previous hospitalization for patients with AN compared to those with partial AN (χ2(1) = 4.05, p = .06).Mean age of participants was 15.1 (SD = 6.5), with 67.9% (57/84) having ROM. Average percent EBW at which ROM occurred was 94.9% (SD = 9.3) and average weight gain required for ROM during treatment was 14.7 lbs. (SD = 10.8). (A table with the exact percent EBW at which each participant experienced ROM is available from the corresponding author upon request). Mean session number at which ROM occurred was 13.5 (SD = 10.7), i.e., ~70% of standard FBT. There were no differences in baseline age, ethnicity, or LOI between patients with and without ROM. ROM was not associated with percent EBW at baseline (t(82) = −0.77, NS), meaning that patients who weighed less at baseline were no less likely to resume menses during treatment than patients at higher initial weights. Patients with partial AN were more likely than full AN to resume menses during treatment (χ2(1) = 3.82, p = .04). Patients with binge/purge behaviors were no more likely to resume menses than patients without those behaviors at initial presentation (χ2(1) = 0.90, NS). Patient characteristics for those with and those without ROM are summarized in Table Mean percent EBW at baseline was 82.0 . Patients with ROM had significantly higher EDE Global Scores (p < .004), as well as Shape Concern (p < .008) and Restraint (p < .002) subscale scores compared to those without ROM. No other differences were found between these two groups.Patients with ROM gained more weight during treatment than those without ROM, but this difference was not statistically significant  to those with ROM after reaching 95% of EBW on LOI, percent of EBW at baseline, amount of weight gained during treatment, and EDE subscale and global scores. Mann–Whitney U tests revealed significantly higher EDE Shape Concern, Restraint, and Global Scores for the group with ROM. There were no other differences between these two groups  at which ROM occurs after a course of a manual-based treatment modality (FBT). However, there was great variability in the number of treatment sessions at which menses returned, demonstrating that some patients recommenced menses after only a few sessions, while others required much more treatment. Another strength of this study is the examination of baseline psychological variables that correlate with ROM during FBT. Limitations include a modest sample size comprised mostly of Caucasian patients, thereby restricting the generalizability of our findings. In addition, there are limitations to using EBW based on the CDC reference norms in children and adolescents, which rely on cross-sectional data and do not take into account the timing of puberty . Girls wFindings from this study underscore the need for full weight restoration based on EBW as a primary treatment goal for the pediatric eating disorder populations. Several factors are important to consider in setting appropriate goal weights during weight restoration, e.g., past height and weight percentiles, premorbid weight using menstrual threshold or weight trajectory over time (if applicable), sexual maturity, and age. When information concerning the patient’s weight history is unavailable or conflicting, our results suggest that aiming for at least 95% EBW is an appropriate target for these patients in outpatient treatment. Menstrual status is a frequently used measure of severity of illness in eating disorders , making This is the first study to examine when ROM occurs during FBT, and although tentative, it does provide clinicians, and patients and families treated with FBT, a clinical benchmark in that ROM occurred at 70% of the standard number of sessions in this treatment. FBT is manualized, has robust research support ,34, and This study was supported by grants MH070620 and MH093768 (Dr Le Grange) from the National Institutes of Health. Dr. Le Grange receives royalties from Guilford Press and Drs. Le Grange and Loeb receive honoraria from the Training Institute for Child and Adolescent Eating Disorders, LLC.JF, KA, and DLG conceived of the study, and participated in its design, coordination, and helped draft the manuscript. JF performed the statistical analysis, while AG, KL, MB and DK participated in drafting the manuscript. All authors read and approved the final manuscript.


Purpose. To investigate the preventive effect of resveratrol (RES) on the formation of portal vein system thrombosis (PVST) in a rat fibrosis model. Methods. A total of 64 male SD rats, weighing 200–300 g, were divided into five groups: Sham operation, Splenectomy I, Splenectomy II, RES, and low molecular weight heparin (LMWH), with the former two groups as nonfibrosis controls. Blood samples were subjected to biochemical assays. Platelet apoptosis was measured by flow cytometry. All rats were euthanized for PVST detection one week after operation. Results. No PVST occurred in nonfibrosis controls. Compared to Splenectomy II, the incidences of PVST in RES and LMWH groups were significantly decreased (both p < 0.05). Two rats in LMWH group died before euthanasia due to intra-abdominal hemorrhage. In RES group, significant decreases in platelet aggregation, platelet radical oxygen species (ROS) production, and increase in platelet nitric oxide (NO) synthesis and platelet apoptosis were observed when compared with Splenectomy II , while in LMWH group only significant decrease in platelet aggregation was observed. Conclusion. Prophylactic application of RES could safely reduce the incidence of PVST after splenectomy in cirrhotic rat. Regulation of platelet function and induction of platelet apoptosis might be the underlying mechanisms. Hepatic cirrhosis was most commonly caused by viral hepatitis and alcohol abuse  with hepPortal vein system thrombosis (PVST) referred to thrombosis in the portal vein, splenic, and superior mesenteric veins or intrahepatic portal vein branches . It was Resveratrol , a natural polyphenol, was first isolated from the roots of white hellebore in 1940  and is nIn light of these, the present study aimed to investigate the preventive effect of RES on the formation of PVST in rats after splenectomy in the context of liver cirrhosis. The findings will provide some clues that RES can be a potential antithrombotic agent for reducing PVST formation after splenectomy for cirrhotic patients.4, Sinopharm Chemical Reagent Co. Ltd. Shanghai, China; 0.6 mL/kg of body weight) in olive oil, twice a week for six weeks, and was confirmed by liver biopsy when animals were euthanized. All animals were allowed free access to water and standard laboratory chow, except for an overnight fast before undergoing surgery. All experiments were performed in accordance with the Guide for the Care and Use of Laboratory Animals . All procedures were reviewed and approved by the Ethics Committee, Xi'an Jiaotong University Health Science Center.Male Sprague-Dawley (SD) rats weighing between 200 and 300 g 9 to 10 weeks old were purchased from the Laboratory Animal Center of Xi'an Jiaotong University Health Science Center . Liver fibrosis was induced by intraperitoneal injection of carbon tetrachloride . Dimethyl sulfoxide (DMSO) and RPMI-1640 were purchased from Wuhan Boster Biological Technology, Ltd. . The RES was dissolved and sterilized in DMSO and then diluted in RPMI-1640 to 5 mg/mL.α = 0.05 and β = 0.20), when the forecasting incidences of PVST in nonfibrosis controls, fibrotic rats without anticoagulation, and fibrotic rats with anticoagulation were 1% [We estimated that a total of 64 rats would be needed to detect a difference between groups, with a one-tailed chi-square test  at a count of 1 × 108/mL.5 mL of PRP was added with equal volume of the washing buffer  and centrifuged at 800 ×g for 15 min. The pellet was resuspended in washing buffer and washed twice. Then the platelets were suspended in Krebs solution  as agonist to 0.5 mL platelet suspension and was determined using a computerized dual channel Chronolog Aggregometer  at 37°C as previously described [Platelet aggregation was initiated by adding 10 escribed . At the 8/mL) were loaded with 5 μM of 2′,7′-dichlorofluorescein diacetate  for 15 min at 37°C. Then the platelet samples were centrifuged at 800 ×g for 10 min and resuspended in 500 μL of Krebs solution. The ROS-generated fluorescence was read using a Becton Dickinson flow cytometer  equipped with a 488 nm wavelength argon laser, 510–540 nm band pass filter, as described [For the measurement of the generation of ROS by activated platelets, washed platelets in Krebs solution  as reported previously .For measuring platelet apoptosis, an Annexin-V Apoptosis Detection Kit FITC  was used according to manufacturer's instructions.t-test or chi-square test using SPSS 11.5 statistical software . A p value <0.05 was considered statistically significant.Continuous data were presented as mean ± SD and categorical data were presented as frequencies. Statistical differences were calculated by Student's p = 0.037 and p = 0.039, resp.).No PVST occurred in Sham group and Splenectomy group I. For the other three groups of rats with liver fibrosis, the incidence of PVST 1 week after operation was 43.75% (7/16) in Splenectomy group II, 6.25% (1/16) in RES group, and 7.14% (1/14) in LMWH group . Both pretreatment with RES (50 mg/d per nasogastric tube for 10 days) and a short term postoperative administration of Enoxaparin  showed a significant decrease in the incidence of PVST than in Splenectomy group II .p < 0.001). Both pretreatment with RES (50 mg/d per nasogastric tube for 10 days) and a short term postoperative administration of Enoxaparin  caused a significant reduction in collagen-induced platelet aggregation 1 week after splenectomy, compared with Splenectomy group II .Data on the effects of RES and Enoxaparin on platelet aggregation induced by collagen are presented in p < 0.001). However, this increase in ROS formation was significantly alleviated by in vivo pretreatment with RES (p < 0.001), but not by postoperative administration of Enoxaparin . However, this decrease in NO release was significantly alleviated by in vivo pretreatment with RES (p < 0.001) but not by postoperative administration of Enoxaparin , suggesting more platelet apoptosis occurring in rats pretreated with RES.As seen in Although the pathogenesis of PVST following splenectomy is still controversial, it is generally agreed that it is related to blood hypercoagulability , hemodynFor cirrhotic patients, preoperative platelet count was generally lower than normal due to concurrent hypersplenism. Under such condition, removal of spleen would lead to a platelet rebound phenomenon and the soaring count and augmented aggregation competence of platelet after operation would contribute to the hypercoagulable state, which, in combination with other underlying causes, may synergistically result in the formation of PVST.Currently, the prophylaxis of PVST after splenectomy in liver cirrhosis remains controversial. The main concern is that prophylactic anticoagulation might induce relevant complications, mainly related to bleeding. So far, the management of PVST after splenectomy is mainly based on individual experience . Severalp < 0.05 and p < 0.001, resp.). However, two rats in LMWH group died before euthanasia due to intra-abdominal hemorrhage, suggesting that the anticoagulants under such conditions should be used more carefully. We speculated that a possible reason might be the increased release of tissue plasminogen activator and consequent fibrinolysis induced by LMWH.The activation of thrombin is a crucial step in the formation of thrombosis. LMWH could suppress the activation of thrombin via suppressing coagulation active factor X. Moreover, LMWH could reduce platelet aggregation induced by thrombin and inhibit platelet aggregation in response to adenosine diphosphate (ADP) . In the 2+ influx into thrombin-stimulated platelets [κB/Rel-dependent transcription in both endothelial cells and monocytes [One of the most studied actions of RES was its antiplatelet aggregation property. RES exerted this function through multiple mechanisms. First, RES could inhibit both type I collagen mRNA expression and platelet adhesion to the collagen, which was the initiation of platelet activation ; second,latelets ; third, onocytes .Besides, RES was shown to reduce oxidative stress by different mechanisms including activation of antioxidant enzymes, inhibition of nicotinamide adenine dinucleotide phosphate (NADPH) oxidases, and chelation of metal catalysts , thus reOf late, there were reports of plant-derived molecules, such as RES, causing platelet apoptosis , 42. FurA previous study had reported that RES exerted protective effect on rats subjected to PVST via its antioxidant and antiaggregant properties . The autIn the present study, we investigate the preventive effect of RES on the formation of PVST after splenectomy in a rat fibrosis model. The reported interval between splenectomy and PVST development varied and in our previous study the interval was 4 days . Taking Taken together, our present study has provided evidence for the first time that RES exerts its preventive effect on PVST formation after splenectomy, through simultaneously inhibiting aggregation, decreasing ROS, and increasing NO production, as well as stimulating apoptosis effects on platelets, in a rat fibrosis model. RES, as a natural substance found in multiple plants, could be a promising candidate in the development of an effective antithrombotic therapy for the prevention of PVST after splenectomy for cirrhotic patients.


P = 0.0053). The severity of urinary pyuria and the UPC value were correlated with uNGAL concentration. The results of our study show that urinary NGAL concentration is correlated with WBCs number in urinary sediment of dogs with negative urinoculture. The present study suggests that noninfectious pyuria is significantly correlated with urinary NGAL values and might influence uNGAL values.Neutrophil gelatinase-associated lipocalin (NGAL) is a neutrophil-derived protein whose concentration increases in plasma and urine with ongoing renal damage. Urinary leucocytes can be a potential source of urinary NGAL. The aim of this study is to investigate the effects of urinary neutrophil count and other urinary parameters on urinary NGAL values in urine with negative culture. Urinalysis, urine culture, and determination of urinary NGAL were performed on 33 clinically healthy nonproteinuric dogs with negative urinoculture. The median uNGAL concentration in dogs in this study population was 9.74 ng/mL (IQR 1.93–25.43 ng/mL). In samples with WBCs > 5 hpf , median uNGAL value was significantly higher than that in samples with WBCs < 5 hpf , (4.96 pg/mL (0.29–11.34) and 23.65 pg/mL (20.04–29.80), resp.;  Neutrophil gelatinase-associated lipocalin (NGAL) is a protein expressed by neutrophils, monocytes, and a variety of tissues such as kidneys, liver, lungs, intestines, and adipose tissue , 2. NGALIn physiological condition, renal NGAL is filtered by glomerular and then reabsorbed by the proximal tubular cells. During kidney injury there is a decrease of NGAL reabsorption and an increase of its expression that contributes to an increase of NGAL concentration in both serum and urine , 4.In human patients NGAL has been investigated across a range of several studies , assessiIn veterinary studies urinary NGAL (uNGAL) has been proved to be a valuable biomarker for canine different renal diseases such as AKI and CKD , 9–11. UThe purpose of this study is to evaluate if urinary NGAL concentration is affected by noninfectious pyuria.This prospective study was conducted at the Veterinary Teaching Hospital of University of Milan. Blood samples analysis, urinalysis, urine culture, and determination of urinary NGAL were performed on 33 clinically healthy dogs.Dogs were considered healthy based on the clinical examination and normal results of complete blood count and serum chemistry profile. Urinary tract infection (UTI) was excluded based on the absence of signs of UTI, hematuria, pollakiuria, stranguria or dysuria, negative urine culture, and protein/creatine (UPC) ratio of <0.5. Considering pyuria to be clinically relevant when median WBC in urine sediment/hfp is >5 , dogs weBlood and urine samples were collected as part of routine diagnostic preoperative screening for sterilization surgery and dental scaling. After obtaining informed owner consent surplus urine samples were submitted to uNGAL determination and urine culture.Urine samples were collected by natural voiding and immediately cooled to 4°C. Routine urinalyses, urine sediment preparations, and quantitative bacteriologic culture of urine were performed in different sections within the Veterinary Teaching Hospital of University of Milan.Before analysis, urine samples were divided into tree aliquots. Routine urinalysis was performed on all fresh urine samples within 2 hours of submission. Specific gravity of urine samples was measured with a refractometer and urine chemical examination was measured by dipstick tests . One aliquot of each sample was centrifuged at 309 g for 5 minutes and the supernatant was removed, frozen, and stored at −20°C for urine protein, creatinine, and urinary NGAL determination. The remainder of aliquot was used for urine culture within 4 hours of sample collection. Microscopic examination (10 fields at 400x) of centrifuged urine stained sediment was used to identify and quantify the number of leukocytes (WBCs) and red blood cells (RBCs) in the high power field (hpf), crystals, epithelial cells, casts  and granular casts (GC)), and bacteria.Protein and creatinine concentrations were measured in the supernatant using a Cobas Mira Classic chemistry analyser . Urine protein concentration was determined with a Pyrogallol red colorimetric assay  and urine creatinine concentration was determined with the modified kinetic Jaffe method .The urine supernatant was diluted in a ratio of  1 : 100 with water before creatinine measurement.The UPC ratio was calculated automatically by dividing the urine protein concentration (mg/dL) by the creatinine concentration (mg/dL).Urinary neutrophil gelatinase-associated lipocalin (NGAL) was determined by a commercially available sandwich enzyme-linked immunosorbent assay (ELISA) kit validated for canine species . Assays were used in accordance with the manufacturer's instructions. Briefly, after thawing, urine samples aliquots were diluted and either samples or provided standards  were added in duplicate to 96-well plates and incubated at room temperature for 60 minutes; after incubation and washing, biotinylated Dog-NGAL antibody was dispensed into each microwell and incubated at room temperature for 60 minutes. After washing, the detection antibody HRP-conjugated streptavidin was added and incubated at room temperature for 60 minutes; finally, after washing, colour-forming TMB substrate was added and after 10-minute incubation period the reaction was stopped with sulfuric acid and immediately read. Absorbance was measured at 450 nm. The concentration of NGAL in each sample was calculated from a standard curve, obtained by a 4-parameter regression logistic curve. The detection limit of the ELISA test lies between 4 pg/mL and 400 pg/mL. For statistical calculations values below the detection limit were assigned a value of 0.2 pg/mL.Intra-assay variability was estimated by determining urinary NGAL concentrations in duplicate on 3 canine urine samples at 3 different concentrations . Duplicate analyses were run twice each day for 5 days. The coefficient of variation, CV, was calculated as mean/DSX100.Quantitative measurements were described using summary statistics .t-test or Mann-Whitney independent sample test . Significance was set at P < 0.05.All data were tested for their normal distribution with D'Agostino-Pearson normality test. Normally distributed data were expressed as mean ± standard deviation. Nonnormally distributed data were expressed as medians with interquartile range (IQR). Pearson's correlation or Spearman's coefficient of rank correlation (rho) were used to evaluate the relationship between uNGAL concentration and urinary parameters: UP/UC, WBCs, RBCs, epithelial cells, crystals, and casts. The statistical difference of uNGAL level between two groups of dogs with WBCs > 5 hpf and with WBCs < 5 hpf and mean between uNGAL concentration in both genders were valuated using independent samples The dogs group consisted of 33 dogs , with age ranging from 6 months to 14 years . The WBCAll parameters, except urinary epithelial cells, were not normally distributed.P = 0.0071).The median uNGAL concentration in dogs in this study population was 9.74 ng/mL (IQR 1.93–25.43 ng/mL). Median uNGAL value was significantly higher in male than in female  median uNGAL value was significantly higher than that in samples with WBCs < 5 hpf , 4.96 pg/mL (IQR 0.29–11.34) and 23.65 pg/mL (IQR 20.04–29.80), respectively; ntration . Intra-aPrevious studies have reported that increased uNGAL concentration precedes increase in serum creatinine as marker of acute renal injuries in dogs . NGAL isP = 0.0071).When uNGAL is used as biomarker to diagnose UTI , possiblFurthermore one of the limitations of this study is the use of urine obtained by spontaneous urination that may have interfered with the presence of leukocytes, as the WBCs, could result from contact with the genital mucosa or skin.As already described in human and veterinary medicine , 15 in tAlthough limited by the reduced number of cases, our results suggest that, as urinary neutrophils can be regarded as a potential source of uNGAL, also noninfectious pyuria could contribute to urinary NGAL concentration. Therefore the presence of noninfectious pyuria may affect interpretation of uNGAL results, causing misdiagnosis of UTI if uNGAL was used as marker disease. This result must be confirmed on a larger number of samples that should be collected in subjects in which disorders that may cause sterile pyuria were diagnosed.


At hospital arrival, early prognostication for children after out-of-hospital cardiac arrest (OHCA) might help clinicians formulate strategies, particularly in the emergency department. In this study, we aimed to develop a simple and generally applicable bedside tool for predicting outcomes in children after cardiac arrest.n = 3,693), and the data were validated using external data from 2010 .We analyzed data of 5,379 children who had undergone OHCA. The data were extracted from a prospectively recorded, nationwide, Utstein-style Japanese database. The primary endpoint was survival with favorable neurological outcome  scale categories 1 and 2) at 1 month after OHCA. We developed a decision tree prediction model by using data from a 2-year period . The next predictor for children with prehospital ROSC was an initial shockable rhythm. For children without prehospital ROSC, the next best predictor was a witnessed arrest. Use of a simple decision tree prediction model permitted stratification into four outcome prediction groups: good , moderately good , poor  and very poor . By using this model, we identified patient groups ranging from 0.2% to 66.2% for 1-month CPC 1 and 2 probabilities. The validated decision tree prediction model demonstrated a sensitivity of 69.7%  = 58.7% to 78.9%), a specificity of 95.2% (95% CI = 94.1% to 96.2%) and an area under the receiver operating characteristic curve of 0.88 (95% CI = 0.87 to 0.90) for predicting 1-month CPC 1 and 2.With our decision tree prediction model using three prehospital variables , children can be readily stratified into four groups after OHCA. This simple prediction model for evaluating children after OHCA may provide clinicians with a practical bedside tool for counseling families and making management decisions soon after patient arrival at the hospital. Pediatric out-of-hospital cardiac arrest (OHCA) is an uncommon event, and outcomes following OHCA are considerably worse than in-hospital cardiac arrest -4. DespiOutcomes in children after OHCA depend on a multitude of variables, including age, specific diseases , initial recorded cardiac rhythm and other circumstances related to cardiac arrest, such as prolonged periods of no blood flow or day of arrests ,2,5,6. PIn this study, we aimed to establish and validate a new prediction model for emergency physicians treating OHCA children that would allow them to decide on in-hospital strategies immediately after patient arrival at the emergency department (ED).The present investigation was a nationwide, population-based observational study of all children (age <18 years) for whom resuscitation had been performed in Japan after OHCA between 1 January 2008 and 31 December 2010. “Cardiac arrest” was defined as the cessation of cardiac mechanical activity confirmed by the absence of signs of circulation . The cau2, approximately two-thirds of which is uninhabited mountainous terrain. Details of the Japanese EMS system have been described previously [Japan has approximately 127 million residents in an area of 378,000 kmeviously -19. Brieeviously , which aeviously . Becauseeviously ,20. The The FDMA launches a prospective, population-based observational study that includes all OHCA patients who received EMS in Japan since January 2005 ,15. EMS The primary study endpoint was a 1-month favorable neurological outcome (defined as a CPC of 1 or 2) . The secP < 0.01). Therefore, the Wilcoxon and Kruskal–Wallis tests for continuous variables and the χ2 test for categorical variables were performed to compare the characteristics and outcomes between the cohorts. Multivariate logistic regression analyses including 11 variables were performed to assess the association between prehospital variables and 1-month survival or CPC category 1 or 2 at 1 month after OHCA in the group used for model development. We selected 11 variables obtained before hospitalization to develop a prediction model. These 11 variables, related to patient characteristics and resuscitation, were age, sex, witnessed arrest (yes or no), arrest witnessed by EMS personnel (yes or no), bystander CPR (yes or no), presumed cardiac etiology (yes or no), initial cardiac rhythm recorded (shockable or not), prehospital AED use (yes or no), call-to-response time interval, call-to-hospital arrival time interval and prehospital ROSC. Eight of the variables were considered dichotomous.The Kolmogorov–Smirnov–Lilliefors test was performed to evaluate the distributions of continuous variables, by which we found a nonnormal distribution of all continuous variables . Categorical variables are expressed as percentages. As an estimate of effect size and variability, we report odds ratios (ORs) with 95% confidence intervals (CIs). We assessed overall model discrimination by using sensitivity, specificity and the area under the receiver operating characteristic curve (AUC). All statistical analyses were performed with the JMP statistical package version 9 . All tests were two-tailed, and a value of P < 0.05 was considered statistically significant.Wilcoxon and Kruskal–Wallis tests for continuous variables and χn = 3,693), which we validated using external data from 2010 . The characteristics of all the subjects and the results of analyses between the two cohorts used for the development and validation of the models are shown in Table P < 0.0001), bystander CPR (P = 0.027), presumed cardiac etiology (P = 0.001), prehospital AED administration (P = 0.036), call-to-response time (P = 0.006) and call-to-hospital arrival time (P = 0.025). However, sizable differences were not frequent, except for the proportion of patients age <1 year. Although the validation cohort had a significantly higher prehospital ROSC rate than the development cohort (P = 0.039), there were no significant differences between the two cohorts in 1-month survival or 1-month CPC 1and 2 rates .During the 3-year study period, 5,659 patients were documented in the database. We considered 5,379 patients 95.1%) eligible for enrollment into this study. Figure % eligiblTable Figure In the present analysis of more than 5,000 Japanese children who experienced OHCA, we demonstrate that, by using the appropriate AUC values, neurological outcomes and survival at 1 month after cardiac arrest can be reliably estimated in the ED based on three routinely available prehospital variables: prehospital ROSC, initial shockable rhythm and witnessed arrest. This prediction model of a decision tree for children after OHCA might provide emergency physicians with a practical bedside tool for counseling families and making medical decisions in the ED.et al. [Michiels et al.  recentlyet al. [et al. [et al. [et al. [In the present study, five variables, determined by the multivariate logistic analysis, were significantly associated with increased odd of favorable neurological outcome: prehospital ROSC, witnessed arrest, shockable initial rhythm, bystander CPR and presumed cardiac etiology Table . Of theset al. . They deet al. ,30, Atki [et al.  demonstr [et al.  reported [et al.  observed [et al. , surviva [et al.  and favo [et al. ,33. Theret al. [The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care  provide et al.  demonstret al.  evaluateet al. [In Japan, Goto et al.  demonstret al. demonstrated that general emergency physicians were less likely than pediatric emergency physicians to halt futile resuscitation in pediatric patients [In recent years, TOR in the out-of-hospital setting has become more widespread in adults after OHCA following futile resuscitation . Althougpatients . This fipatients . Our decpatients ,36. CollNew treatments for cardiac arrest and improvements in prehospital system factors may improve outcomes following OHCA. To carry a self-fulfilling prophecy in implementing our prediction model, it should be challenged periodically as new treatments emerge or social systems evolve.The potential limitations of the current analysis are as follows. First, our database lacked detailed data with which to make further risk adjustments for outcomes, such as comorbid diseases, location of OHCA occurrence, quality of EMS personnel, degree of regional differences among EMS centers, in-hospital medications and the availability emergency care specialists. These data were not evaluated, owing to the retrospective design of our study. Second, although we used uniform data collection procedures based on the Utstein-style guidelines for reporting cardiac arrest and the study had a large sample size and a population-based design, we cannot exclude the possibility of the presence of uncontrolled confounders. Third, as with all epidemiological studies, the integrity, validity and ascertainment bias of the data are potential limitations. Fourth, the generalizability of our results to other countries could be limited because the data we analyzed were derived from only a Japanese nationwide population-based cohort of OHCA patients in Japan. Therefore, it may be necessary for researchers to validate the present prediction model in other countries. Finally, as we did not have precise data concerning the causes of cardiac arrest, there is a possibility that some of patients may have had sudden infant death syndrome.On the basis of our decision tree prediction model with three prehospital variables , children can be readily stratified into four groups after OHCA  that can help predict both 1-month survival and 1-month favorable neurological outcome. This prediction model demonstrated a sensitivity of 69.7%, a specificity of 95.2% and an AUC of 0.88 for predicting 1-month favorable neurological outcome in our validation study. This simple prediction model may provide clinicians with a practical bedside tool for counseling families and making management decisions soon after pediatric patient arrival in the ED.• We have developed and validated a simple and generally applicable decision tree prediction model for children in the ED after OHCA by using a prospectively recorded, nationwide, Utstein-style Japanese database.• The decision tree model consists of three prehospital variables: prehospital ROSC, initial shockable rhythm and witnessed arrest.• This model can readily stratify recovery in children after OHCA into groups of good, moderately good, poor and very poor prognosis by predicting a 1-month favorable neurological outcome and might help guide clinicians’ decision-making and risk assessment in these children.AED: Automated external defibrillator; AUC: Area under the receiver operating characteristic curve; CI: Confidence interval; CPC Scale: Cerebral Performance Categories Scale; CPR: Cardiopulmonary resuscitation; ED: Emergency department; ELST: Emergency lifesaving technician; EMS: Emergency medical services; FDMA: Fire and Disaster Management Agency; OHCA: Out-of-hospital cardiac arrest; OR: Odds ratio; ROSC: Return of spontaneous circulation; TOR: Termination of resuscitation.The authors declare that they have no competing interests.YG and TM designed the study. YG, TM and YN conducted data cleaning. YG and YN analyzed the data. YG drafted the manuscript, and YN and TM contributed substantially to its revision. YG takes responsibility for the article as a whole. All authors read and approved the final manuscript.