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In ship detection by means of Polarimetric SAR imagery, a very promising feature is the characterization of the pixels of the ship based on the elementary scattering mechanisms that can be extracted using different decomposition algorithms. Elementary scattering mechanisms provide information regarding the physical, electrical and geometrical properties of the scatterers in each Polarimetric SAR pixel. In this work, the newly established algorithm of the Double Scatterer Model is applied to interpret each pixel of the Polarimetric SAR image with the contributions of two elementary scattering mechanisms, namely, primary and secondary. The main idea is to construct a binary image while preserving the rich information content in order to proceed in simple and fast image processing for target detection. The present algorithm is applied to datasets with different inherent characteristics acquired by Radarsat-2 and ALOS-PALSAR. The results presented by this new perspective on ship monitoring are remarkable.

In this paper, a supervised land cover classification is presented based on the extracted information from polarimetric synthetic aperture radar (PolSAR) images. The analysis of the polarimetric scattering matrix is accomplished according to the Double Scatterer Model which interprets each PolSAR cell by a pair of elementary scattering mechanisms. Subsequently, by utilizing the contribution rate of the two fundamental scatterers, a novel data representation is accomplished, providing great informational content. The main component of the research is to highlight the robust new feature-tool and afterwards to present a classification scheme exploiting a fully connected artificial neural network (ANN). The PolSAR images used to verify the proposed method were acquired by RADARSAT-2 and the experimental results confirm the effectiveness of the presented methodology with an overall classification accuracy of 93%, which is considered satisfactory since only four feature-vectors are used.

Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups:18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p 0.001) in multivariable analysis.In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.

A land cover classification procedure is presented utilizing the information content of fully polarimetric SAR images. The Cameron coherent target decomposition (CTD) is employed to characterize each pixel, using a set of canonical scattering mechanisms in order to describe the physical properties of the scatterer. The novelty of the proposed classification approach lies on the use of Hidden Markov Models (HMM) to uniquely characterize each type of land cover. The motivation to this approach is the investigation of the alternation between scattering mechanisms from SAR pixel to pixel. Depending on the observations-scattering mechanisms and exploiting the transitions between the scattering mechanisms we decide upon the HMM-land cover type. The classification process is based on the likelihood of observation sequences been evaluated by each model. The performance of the classification approach is assessed my means of fully polarimetric SLC SAR data from the broader area of Vancouver, Canada and was found satisfactory, reaching a success from 87% to over 99%.

Background Current guidelines recommend laparoscopic cholecystectomy be offered for patients with acute cholecystitis except those deemed as high risk. Few studies have examined the impact of frailty on outcomes for patients undergoing laparoscopic cholecystectomy. Therefore, the aim of this study was to determine the association of frailty with postoperative morbidity and mortality in patients undergoing laparoscopic cholecystectomy for acute cholecystitis. Methods Patients undergoing laparoscopic cholecystectomy for acute cholecystectomy were identified from 2005 to 2010 in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP). The Modified Frailty Index (mFI) was used a surrogate for frailty, and patients were stratified as non-frail (mFI 0), low frailty (mFI 1–2), intermediate frailty (mFI 3–4) and high frailty (mFI ≥ 5). Univariable and multivariable analyses were performed. Receiver operator curves (ROC) and an area under the curve (AUC) were generated to determine accuracy of mFI in predicting postoperative morbidity and mortality. Results Of the 6898 patients undergoing laparoscopic cholecystectomy, 3245 (47%) patients were non-frail. There were 2913 (42%) patients with low-frailty, 649 (9%) patients with intermediate frailty, and 91 (2%) with high frailty. Clavien IV complications were higher for intermediate frail patients (OR 1.81, 95% CI 1.00–3.28, p = 0.050) and high-frail patients (OR 4.59, 95% CI 1.98–10.7, p

Hepatopancreatoduodenectomies (HPD) are historically associated with high morbidity and mortality. Currently, no data with hepatopancreatobiliary-specific complications have been available for HPD in North America. The aim of this retrospective analysis was to compare the outcomes of HPD to those of major hepatectomy (MH) and pancreatoduodenectomy (PD) in North America.The 2014-16 American College of Surgeons-National Surgical Quality Improvement Program database was queried for MH, PD, and HPD. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to match 23 HPDs to 92 MHs and 138 PDs by 28 demographic, comorbidity, laboratory, operative and pathologic variables. Outcomes were compared among these three groups.The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p 0.01) compared to both MH (51%, 7.6%) and PD (52%, 1.4%). Post-hepatectomy liver failure (PHLF) was more common (p 0.01) in HPD patients, but pancreatic fistula rates were similar.The morbidity and mortality after HPD are significantly higher than after MH or PD alone and may explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.

The Stewart-Figge acid–base model has been criticized for being mathematically complex. We aimed to develop simpler formalisms, which can be used at the bedside. The following simplifications were used: (1) [Ca2+] and [Mg2+] are replaced by their mid-reference concentrations (2) pH is set to 7.4. In the new model [SIDa] is replaced by its adjusted form, [SIDa, adj] = [Na+] + [K+] − [Cl−] + 6.5 and [SIG] is replaced by “bicarbonate gap”, [BICgap] = [SIDa, adj] − (0.28⋅[Albumin]) − (1.82⋅[Phosphatei])- [HCO3]. The diagnostic performance of the model was tested in 210 patients with acute respiratory diseases and 17 healthy volunteers. [BICgap] was also compared to albumin-corrected anion gap ([AGc]). The concordant correlation coefficient between [SIDa, adj] and [SIDa] and between [BICgap] and [SIG] was 0.98 in both comparisons. The mean bias (limits of agreement) of [SIDa, adj] − [SIDa] and of [BICgap] − [SIG] were 0.53 meq/l (− 0.46 to 1.53) and 0.50 meq/l (− 0.70 to 1.70), respectively. A [SIDa, adj] 52.5 meq/l had an accuracy of 0.997 (p 11.6 meq/l predicted unmeasured ion (UI) acidosis with an accuracy of 0.997 (p 19.88 meq/l predicted UI acidosis with an accuracy of 0.994 (p

The 21st-century challenges have established changes in education's prospects. In this vein, the current action-research followed the three steps (planning, implementation, evaluation) of an interdisciplinary project which explores the pedagogical impact of its application in the field of STEM education. The three stages of the project are an overview of an internet-of-things platform called Fielduino – Digital Farming. This platform constitutes a prototype for a do-it-yourself (DIY) construction and maintenance of a system which is capable of applying new technologies. The research was conducted in a provincial Institute of Vocational Education. The participants were a group of five trainees. The research tool employed was participatory observation. The research results highlighted that the current project positively influenced computational thinking, soft skills development, and the trainees' engagement with STEM education.

BackgroundWell-annotated, high-quality biorepositories provide a valuable platform to support translational research and discovery. However, most biorepositories have poor representation of minority groups, limiting the ability to address cancer health disparities and improve disease outcomes. This report describes the establishment of the Florida Pancreas Collaborative (FPC), the first state-wide prospective longitudinal cohort study and biorepository specifically designed to address the higher burden of pancreatic cancer (PaCa) in African Americans (AA) compared to Non-Hispanic Whites (NHW) and Hispanic/Latinx (H/L).MethodsWe describe rationale for establishing the FPC and provide an overview of key stakeholders; study eligibility and design; ascertainment and recruitment strategies; and standard operating procedures (SOPs) developed to collect, process, store, and transfer biospecimens, medical images, and data. We also describe the customized cloud-based, secure data management platform built to facilitate recruitment, track study-related workflow, house data, and perform queries. We also present progress to date regarding recruitment and biobanking.ResultsThe FPC consists of multidisciplinary teams from fifteen Florida medical institutions. From March 2019 through August 2020, 350 patients were assessed for study eligibility, 323 met inclusion/exclusion criteria, and 305 (94%) enrolled, including 228 NHW, 30 AA, and 47 H/L, with 94%, 100%, and 94% participation rates, respectively. A high percentage of participants have donated blood (87%), pancreatic tumor tissue (41%), computed tomography scans (76%), and baseline questionnaire data (62%).ConclusionsThis biorepository addresses a critical gap in PaCa research with the potential to advance basic, clinical, population-based, and translational studies intended to minimize disparities, increase quality of life, and reduce PaCa-related morbidity and mortality.ImpactThis multi-institutional infrastructure can serve as a prototype for development of similar resources across the country and disease sites.

Background: Although immigration flows continue in Greece, there has been a gradual change in the country of origin of the refugees/immigrants that arrived in the country, in the last years. Aims: To compare the epidemiological and clinical characteristics of the refugees/immigrants who were examined for potential active or latent tuberculosis (TB) infection in a major chest Greek hospital, during 2 time periods. Methods: All refugees/immigrants who were examined between 2016-2017 (1st period) and 2018-2019 (2nd period) constituted the study population. Most participants had a prior screening at primary care settings and found to be of risk for TB infection. Demographic and clinical characteristics were recorded and group comparisons were conducted, as appropriate. Results: 116 (82,8% males) in the 1st period and 147 (85% males) patients in the 2nd period were examined. During the 2nd period, immigrants were older (27.6±11.8 years vs. 22.9±10.7 years; p=0.001) and they came more frequently from African (34.9% vs. 17.4%) and Asian (34.2% vs. 27.8%) countries and less frequently from Syria (19.9% vs. 38.3%; p=0.001), compared to the 1st period. TST was positive in higher rates (81% vs 54.5%; p Conclusions: Although several epidemiological characteristics of immigrants/refugees changed, the percentage of active TB infection remained the same.

Introduction: Patients with ILD and IPF are often reported to suffer from depression (D) and/or anxiety (A). The aim of the study was to examine the prevalence of D and A in a northern greek cohort of outpatients. Methods: Consecutive patients attending the clinic were examined with PFT9s, six minute walk test (6mwt) and completed the mMRC, the University of California San Diego Shortness of Breath Questionnaire (UCSDSoBQ) and the Hospital Anxiety and Depression Scale (HADS). Results: A hundred and thirty one (131) patients with ILD were examined (IPF:62, Sarcoidosis:19, CTD-ILD:17, Non-IPF ILD:32). Patient characteristics:male:59%, age:73.8±5.2, former/current smokers:70%, FVC:83.8±15.8%, Dlco:57.3±20%, 6mwt:450±113, ΔSpO2:3.7±4.3 Median[IQR] for anxiety and depression scores were 3[1-6] and 2[0-5.5] respectively. Possible (HADS 8-10) or clinically significant (HADS≥11) anxiety was present in 20,6% and depression in 21.4% of the cohort. There was no difference in the prevalence of D and A between the ILD and IPF group. Depression and anxiety were significantly correlated with dyspnea (mMRC Sprearman9s rho: 0.37 and 0.32, UCSDSoBQ:0.52 and 0.47) and fitness(6mwt:-0.32 and -0.25) (p Conclusions: The presence of ILD per se rather than IPF seems to be the driving factor for the occurence of depression or anxiety. Dyspnea levels and fitness are strongly correlated with both disorders. In the present cohort the frequency of both afflictions was lower than reference publications. This could be due to the tool used or the population examined or both. The research was sponsored by the Hellenic Chest Diseases Society.

In this paper we report our experiences from a University outreach program with primary and secondary education teachers of various specialties. Our goal was to improve the coding abilities of teachers through Scratch activities. The participants can in turn teach their students, multiplying that way the benefitted population. To increase the participation and the completion percentage, the activities are designed as a course in Moodle realized in discrete runs with manageable groups, in a blended learning approach. The educational material was a combination of learning objects with specific objectives, video material and try-out activities. The course has been completed by 559 teachers from various Greek districts, mainly of regional areas, with a high completion rate of 65%. The participants found the experience highly satisfying, interesting and agreed that they had been supported effectively throughout the process. In the paper we describe the rational of our approach, the design and implementation phases of the project, the outcomes and the main findings of the evaluation of the user opinions.

Gallbladder cancer (GBC) and cholangiocarcinoma (CCA) are rare entities with relatively poor prognoses. We compared treatment outcomes of definitive resection with or without neoadjuvant therapy in GBC and CCA patients.All non-metastatic GBC and CCA patients at a single institution who underwent definitive resection from 1992-2016 were analyzed. We compared overall survival (OS), locoregional failure (LRF) and distant failure (DF) in patients who received neoadjuvant therapy (chemotherapy and/or radiation) versus those who did not receive neoadjuvant treatment. OS was analyzed using the Kaplan-Meier method and log rank tests. Cox proportional hazard models were used to analyze time to recurrence.Out of 128 patients, 90 had GBC and 38 had CCA, 25 patients (27%) among GBC and 8 patients (21%) with CCA were T3, T4 or node positive. Overall, 52 (40%) GBC and 25 (20%) CCA patients received neoadjuvant treatment, chemotherapy alone 60 patients (47%) or radiation with or without chemotherapy 17 patients (13%). Chemotherapy was single agent in 44 patients (34%) and multi-agent in 25 (20%). The median OS for GBC patients was 3.1 years with 2.6 years for no neoadjuvant group and 3.1 years for neoadjuvant group (P=0.6786). Median OS was 2.6 years for CCA patients, 3.6 years for no neoadjuvant therapy versus 2.0 years for neoadjuvant group (P=0.1613). There was a trend towards increased DF in patients with CCA and GBC receiving neoadjuvant therapy: HR 2.74, 95% CI, 0.73-10.3, P=0.14 and 0.92, 95% CI, 0.44-1.93, P=0.82 respectively. The hazard ratio for time to LRF in CCA patients receiving neoadjuvant treatment was 3.17, 95% CI, 0.62-16.31, P=0.16 whereas HR was 0.15, 95% CI, 0.10-1.76, P=0.23 for GBC patients. Among GBC patients, the pattern of first failure was locoregional in 8 (10%) having 3 LRF in neoadjuvant group (2 with chemotherapy, 1 with CRT, 0 with RT alone) as compared to 5 in adjuvant group. Among 28 (35%) patients with DF first, 15 patients received neoadjuvant therapy versus 13 patients in non-neoadjuvant group. In CCA patients, LRF occurred first in 6 patients receiving neoadjuvant treatment (3 with chemotherapy, 1 with CRT, 2 with RT alone) as compared to 2 patients who were treated with non-neoadjuvant CRT. DF was the first site of failure in 9 patients treated with neoadjuvant CRT (8 with chemotherapy, 0 with CRT and 1 with RT alone) as compared to 4 patients without neoadjuvant treatment.In this retrospective data set, a trend towards better survival was seen in adjuvantly treated CCA patients, but not in GBC patients. Recurrence patterns also appear different among the two, which might be attributed to treatment modality used, patient selection or unmeasured factors.Gallbladder cancer (GBC); cholangiocarcinoma (CCA); neoadjuvant; resection; chemoradiation; chemotherapy.

Paragangliomas are rare neuroendocrine tumors that can vary in size and metabolic activity. We report a case of giant bilateral malignant retroperitoneal paragangliomas (PGL) in a patient with germline succinate dehydrogenase B (SDHB) mutation. This patient, who presented in an emaciated and debilitated state, was managed with adrenergic blockade followed by radical primary surgery. After being metabolically and radiographically disease free for 4 years, he underwent salvage resection for recurrent retroperitoneal disease and palliative radiation to a site of solidary vertebral metastasis. We review incidence and prognosis of metastatic PGL.

International audience; The present paper presents a systematic review of the last 30 years that concerns records on Smart Toys and focuses on toys regarding early childhood and primary education children (3–12 years old). This paper aims to analyse and categorise smart toys (50 articles) in terms of their technological and educational affordances. The results show that the toys are designed based on four main technological affordances and their combinations. The educational affordances of smart toys are studied in terms of different use modes and their learning objectives aimed to identify specific objectives in different subjects and objectives based on transversal competencies such as problem solving, spatial thinking, computational thinking, collaboration and symbolic thinking. Finally, with the multiple correspondence analysis, the correlations between smart toys’ individual technological and educational affordances are grouped with the evolution of affordances related to their development date. In conclusion, in recent years, smart toys concern special sciences (programming) and some 21st-century skills (STEM and computational thinking). In contrast, in the first 20 years, the interest focused more on transverse skills, such as collaboration, emotional thinking, symbolic thinking, story-telling and problem solving.

Obesity hypoventilation syndrome (OHS) is a chronic hypoventilation disorder characterized by a body mass index (BMI) ≥ 30 kg/m2 and daytime hypercapnia (PaCO2 > 45 mmHg) in patients with no other possible causes of hypoventilation. Positive airway pressure (PAP) therapy is the mainstay of OHS respiratory management. PAP therapy improves gas exchange, quality of sleep and life, and survival in OHS patients with no difference in the effect size among different PAP modalities; PAP adherence appears to be a major predictor of outcome. Survival of OHS patients treated with noninvasive ventilation (NIV) is higher as opposed to several other NIV-treated patients with various hypoventilation syndromes. PAP modes other than CPAP and bi-level PAP may benefit OHS patients, but more evidence is required.

Recent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy.Patients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0-3) and routine (POD 4-7) drain removal and multivariable regressions were performed.Early drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p 0.001) and serious (9 vs 13%, p 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p 0.003). Length of stay was two days shorter (4 vs 6 days, p 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal.Early drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s discussion and updated recommendations regarding systemic therapy for first-line and subsequent-line treatment of patients with hepatocellular carcinoma.

The purpose of the study is to indicate the importance of inclusive education. This study focuses on the need for student’s voice to be heard and consid­ered during educa­tional planning. By doing this, the study intends to detect which students are marginalized, and use this method towards school improvement. The research was con­ducted in two kindergartens. In the first, twenty-two students and two teachers were interviewed (kindergarten teacher and headmistress), while in the second, we used the method of non-participant observa­tion with five children attending the integration class, as well as the teachers, during one month. Interviews were conducted in the second school, too, only with two teachers (qualified pedagogue and headmistress). During our study, margin­alized students have been identified due to the difficulties they face, and we have managed to strengthen children’s confidence, and help create a more empathetic school environment. These have been implemented through a school pro­ject in which students narrate their personal stories using digital storytelling software. Our aim has also been to encourage the creation of stories for the pro­duction of which Scratch digital storytelling software was used. Zadatak ove studije je naglasiti važnost inkluzivnog obrazovanja. Ova je studija usmjerena na potrebu za slusanjem i razmatranjem misljenja ucenika prilikom plani­ranja obrazovanja. Na taj nacin studija planira otkriti koji su ucenici marginalizirani i iskoristiti ovu metodu za poboljsanje skolske jedinice. Istraživanje je provedeno u dva vrtica. U prvom su intervjuirana dvadeset i dva polaznika i dvije odgojiteljice (tete u vrticu i ravnateljica), a u drugom smo se koristili metodom neaktivnog promatraca petero djece koja su pohađala integrirani razred, i odgojiteljice tijekom jednog mjeseca. Intervjui su provedeni i u drugom vrticu samo s dvoje odgojitelja (kvalificirani pedagog i ravnateljica). Marginalizirani ucenici se identificiraju zbog poteskoca s kojima se suocavaju. Tijekom provođenja studije uspjeli smo pojacati samopouz­danje ucenika i pomogli stvoriti suosjecanije skolsko okruženje. To se postiže u vrtickom projektu u kojem polaznici s pomocu digitalnog softvera za pripovijedanje pricaju svoje osobne price. Nas cilj bio je i potaknuti stvaranje prica za produkciju, za sto se koristio digitalni softver za pripovijedanje Scratch. Kljucne rijeci : suradnja; digitalno pripovijedanje; poboljsanje skolske jedinice; pluralisticki odgoj I obrazovanje; djeca predskolskog uzrasta

Cholangiocarcinomas are rare biliary tract tumors that are often challenging to diagnose and treat. Cholangiocarcinomas are generally categorized as intrahepatic or extrahepatic depending on their anatomic location. The majority of patients with cholangiocarcinoma do not have any of the known or suspected risk factors and present with advanced disease. The optimal evaluation and management of patients with cholangiocarcinoma requires thoughtful integration of clinical information, imaging studies, cytology and/or histology, as well as prompt multidisciplinary evaluation. The current review focuses on recent advances in the diagnosis and treatment of patients with cholangiocarcinoma and, in particular, on the role of endoscopy, surgery, transplantation, radiotherapy, systemic therapy, and liver-directed therapies in the curative or palliative treatment of these individuals. Cancer 2016;122:1349-1369. © 2016 American Cancer Society.

The purpose of this chapter is the overview of an educational robotic platform called e-ProBotLab (early Programming Robots Laboratory), which constitutes a laboratory prototype for the construction and programming of robotic devices, suitable for the development of computational thinking through the use of robotics in education. The e-ProBotLab platform constitutes a programming and robotics learning framework through practice. It was developed by the ICT in education research group (ICTE Group) of the department of Educational Sciences and Early Childhood Education of the University of Patras. The platform allows preschool students to program the robotic construction in a playful way, while the open-source technology used enables older students to construct the robotic device on their own, possibly with the aid of the instructor. Through the engagement with this platform, children are taught introductory concepts of mathematics, computer engineering, and programming.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

Objectives We evaluated dobutamine stress echocardiography as an initial screening test for a cardiac evaluation before a liver transplant. Materials and methods We retrospectively examined 111 liver transplant candidates who had undergone previous cardiac evaluation; 30 of whom had undergone a liver transplant. Results Eighty patients (72.1%) completed a dobutamine stress echocardiography (41 chronotropically competent, 39 incompetent), while 31 patients (27.9%) required us to terminate early. Overall, 68 patients (61%) were on β-blockers (21 required early dobutamine stress echocardiography termination, 30 chronotropically incompetent, and 17 competent). Patient results were normal. Thirty patients underwent a liver transplant. Among candidates requiring termination of early dobutamine stress echocardiography, posttransplant cardiac events included 1 fatal acute myocardial infarction, 1 nonfatal acute myocardial infarction, and 1 idiopathic cardiomyopathy. Among chronotropically incompetent patients, 2 patients had transient bradycardia, and among those who were chronotropically competent, 1 had refractory atrial fibrillation, and 1 had transient bradycardia. Conclusions Nearly 50% of patients with end-stage liver disease may not reach the target heart rate. Early termination of dobutamine stress echocardiography because of cardiac symptoms or significant echocardiographic changes have more effect in predicting postoperative cardiac events, but further evaluation is required even if their target heart rate is close to that desired. Lower target heart rate may be acceptable in chronotropically incompetent individuals provided they are asymptomatic, have no echocardiographic changes, or cardiovascular risk factors, especially if they are on β-blockers.

Background The serum tumor markers CA 19–9 and CA 125 are the serologic markers used for the monitoring of biliopancreatic and ovarian cancer, respectively. They are reported to be elevated in a variety of nonneoplastic clinical situations, including end-stage liver disease (ESLD). However, their prevalence and degree of elevation in patients with ESLD remained unclear. Aim To examine the prevalence and degree of elevation of CA 19–9 and CA 125 in patients with ESLD and to determine their association with severity of liver disease. Methods Retrospective analysis of 161 patients with ESLD that were evaluated for liver transplantation at our institution between March 2009 and December 2010. The mean age was 55.15 ± 8.75 years and 107 (66.4%) of the patients were men. Serum CA 19–9 and CA 125 levels were determined during evaluation of their candidacy for liver transplantation. Results Eighty-three (51.5%) patients had elevated CA 125 and 44 (53%) of them had a serum concentration >5 times the upper limit of normal (ULN). Elevated CA 125 was associated with alcoholic liver disease, high Model for End-Stage Liver Disease (MELD) score, and presence of ascites. Similarly, 37 (23%) patients had elevated CA 19–9 and 8 (21.6%) of them had a serum concentration >5 times ULN. Elevation of CA 19–9 was associated with high MELD score. Conclusions CA 125 and CA 19–9 concentrations were elevated in 51.5% and 23% of patients with ESLD, respectively. Although the definite etiology remained unclear, their elevation was associated with the pathological conditions associated with advanced liver disease. Further studies are needed to clarify the underlying mechanism(s) responsible for their increased levels.