Challenges to genetic testing for germline mutations associated with breast cancer among African Americans

Inequities in preventive cancer screening, diagnosis, treatment, and inferior cancer outcomes continue to pose challenges across the cancer continuum. While the exact reasons for these inferior outcomes are unknown, multiple barriers to various domains of social determinants of health (SDOH) play a vital role, leading to inequities in cancer care. These include barriers to transportation, housing, and food insecurities, contributing to delays in preventive screening and treatment. Furthermore, aggressive biologies also exist across various racial profiles with accompanying germline mutations. For example, African Americans (AAs) have a higher incidence of triple-negative breast cancer subtype and a high prevalence of BRCA1/2 gene mutations, increasing the risk of multiple cancers, warranting high-risk screening for these populations. Unfortunately, other barriers, such as financial insecurities, low health literacy rates, and lack of awareness, lead to delays in cancer screening and genetic testing, even with available high-risk screening and risk reduction procedures. In addition, physicians receive minimal interdisciplinary training to address genetic assessment, interpretation of the results, and almost no additional training in addressing the unique needs of racial minorities, leading to suboptimal delivery of genetic assessment provision resources among AAs. In this review, we discuss the confluence of factors and barriers limiting genetic testing among AAs and highlight the prevalence of germline mutations associated with increased risk of breast cancer among AAs, reflecting the need for multi-panel germline testing as well as education regarding hereditary cancer risks in underserved minorities.

56 Fe ion exposure increases the incidence of lung and brain tumors at a similar rate in male and female mice

The main deterrent to long-term space travel is the risk of Radiation Exposure Induced Death (REID). The National Aeronautics and Space Administration (NASA) has adopted Permissible Exposure Levels (PELs) to limit the probability of REID to 3% for the risk of death due to radiation-induced carcinogenesis. The most significant contributor to current REID estimates for astronauts is the risk of lung cancer. Recently updated lung cancer estimates from Japan's atomic bomb survivors showed that the excess relative risk of lung cancer by age 70 is roughly four-fold higher in females compared to males. However, whether sex differences may impact the risk of lung cancer due to exposure to high charge and energy (HZE) radiation is not well studied. Thus, to evaluate the impact of sex differences on the risk of solid cancer development post-HZE radiation exposure, we irradiated Rb ^fl/fl ; Trp53 ^fl/+ male and female mice infected with Adeno-Cre with various doses of 320 kVp X-rays or 600 MeV/n ⁵⁶ Fe ions and monitored them for any radiation-induced malignancies. We observed that lung adenomas/carcinomas and esthesioneuroblastomas (ENBs) were the most common primary malignancies in X-ray and ⁵⁶ Fe ion-exposed mice, respectively. In addition, 1 Gy ⁵⁶ Fe ion exposure compared to X-rays led to a significantly higher incidence of lung adenomas/carcinomas (p=0.02) and ENBs (p<0.0001). However, we did not find a significantly higher incidence of any solid malignancies in female mice as compared to male mice, regardless of radiation quality. Furthermore, gene expression analysis of ENBs suggested a distinct gene expression pattern with similar hallmark pathways altered, such as MYC targets and MTORC1 signaling, in X-ray and ⁵⁶ Fe ion-induced ENBs. Thus, our data revealed that ⁵⁶ Fe ion exposure significantly accelerated the development of lung adenomas/carcinomas and ENBs compared to X-rays, but the rate of solid malignancies was similar between male and female mice, regardless of radiation quality.

Covered stent placement for gastroduodenal artery stump hemorrhage after pancreaticoduodenectomy: long-term patency and risk factor of stent failure

OBJECTIVE

To evaluate the long-term outcomes of covered stent placement in patients with gastroduodenal artery (GDA) stump hemorrhage after pancreaticoduodenectomy (PD) and to identify risk factors of stent failure.

METHODS AND MATERIALS

Covered stent was placed in total of 21 patients for GDA stump hemorrhage after PD from September 2012 to March 2021. Technical and clinical success, complications, and stent patency were retrospectively evaluated. Nine relevant variables were analyzed to determine risk factors for stent failure.

RESULTS

In 20 of 21 patients (95.2%), the GDA stump was completely excluded with covered stent placement. Immediate hemostasis was achieved in the 20 patients and rebleeding from jejunal artery occurred in one patient which was successfully embolized one day after the stent placement. There was no procedure-related complication or early mortality (<30 days). During follow-up period (median 655.5 days), stent thrombosis was found on CT in 10 patients (50.0%, 10/20) without any laboratory or CT abnormalities. One thrombosed stent migrated into the jejunum 20 months after placement. The six-month, one-year, and two-year stent patency were 81.9%, 52.9%, and 37.8%, respectively (median 620 days). The recurrence of primary malignancy was associated with stent failure (HR 5.70; 95% CI 1.18-27.76, p = 0.03).

CONCLUSIONS

Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage. Stent failure occurred frequently (50%) but did not cause liver ischemia. Stent failure was associated with recurrence of primary malignancy.

ADVANCES IN KNOWLEDGE

1. Covered stent placement is an effective and safe management of postoperative GDA stump hemorrhage.2. Stent failure occurred frequently (50%) but did not cause liver ischemia.3. Stent failure was associated with recurrence of primary malignancy.

Coagulation parameters and Apgar score are associated with severity in preterm infants

OBJECTIVE

Coagulation parameters are used to diagnose hematological diseases. The correlation between the coagulation parameters and Apgar score at 5 min is yet to be elucidated. The present study aimed at describing the neonatal coagulation parameters in preterm infants with a low Apgar score at 5 min.

PATIENTS AND METHODS

In this case-control study, 32 serious preterm infants were compared with 20 preterm infants, according to the Apgar score at 5 min. The prothrombin time (PT), thrombin time (TT), fibrinogen (Fbg), activated partial thromboplastin time (APTT), calculated international normalized ratio (INR), D-dimer (D2), fructose diphosphate sodium (FDP), and procalcitonin (PCT) values were recorded. The linear correlation between coagulation parameters and Apgar score at 5 min was analyzed by linear regression. The two groups were compared using GraphPad Prism 8 (LaJolla, CA, USA).

RESULTS

In the study, the mean coagulation parameters were significantly higher in the serious preterm infants with low the Apgar score at 5 min compared to the preterm infants with normal Agar scores at 5 min (p<0.05). The correlation between coagulation parameters and Apgar score at 5 min was recorded (PT: R=0.3984; APTT: R=0.3165; INR: R=0.4139).

CONCLUSIONS

The coagulation parameters were significantly higher in serious preterm infants with a low Apgar score at 5 min. Also, the coagulation parameters and Apgar score at 5 min are associated with severity in preterm infants.

Association between bone mineral density and nonalcoholic fatty liver disease in Korean adults

PURPOSE

Nonalcoholic fatty liver disease (NAFLD) is associated with various metabolic abnormalities that can increase the risk of an osteoporotic fracture. Across the few previous studies of the association between NAFLD and bone mineral density (BMD), the association was not consistent. We examined the association between BMD and NAFLD in generally healthy adults.

METHODS

The subjects who visited the Seoul National University Hospital for health checkup between 2005 and 2015 were included. Men aged more than 40 and postmenopausal women were included. Lumbar spine and femoral neck (FN) BMD were measured using dual-energy X-ray absorptiometry. Liver ultrasonography was conducted to evaluate the extent of fatty changes. After excluding subjects with a secondary cause of liver disease such as heavy drinking or viral hepatitis, multivariable linear regression analysis adjusted for possible cofactors was performed to investigate the association between BMD and NAFLD.

RESULTS

A total of 6634 subjects was included in this study (men:women = 3306:3328). Multivariate regression analysis revealed a significant negative association between FN BMD and NAFLD in men (β = -0.013, p = 0.029). However, there was a positive correlation between lumbar spine BMD and NAFLD in postmenopausal women (β = 0.022, p = 0.005).

CONCLUSIONS

Moderate or severe NAFLD exerted a detrimental effect on FN BMD in men. However, moderate or severe NAFLD had a positive effect on lumbar spine BMD in postmenopausal women. Potential sex-specific differences of the effect of NAFLD on BMD need to be elucidated further.

Combinatorial Treatment of Bone Marrow Transplantation and Regulatory T Cells Improves Glycemia in Streptozotocin-diabetic Mice

Autologous hematopoietic stem cell transplantation (HSCT) has limited benefits in patients with a long-duration of diabetes. To test whether a T regulatory cells (Tregs) and syngeneic bone marrow transplantation (syn-BMT) co-transplantation regimen will be effective, BMT±Tregs infusion was performed in streptozotocin-diabetic mice with a long-duaration of diabetes. Diabetic status, pancreata morphometry and Tregs/Th17 balancing were tested on day 100 after transplantation. While hyperglycemia relapsed in mice receiving BMT monotherapy about 6 weeks after transplantation, combined therapy with BMT+Tregs improved hyperglycemia and C-peptides, preserved islet cell mass within 100 days after BMT. Although both groups BMT and BMT+Tregs induced Tregs/Th17 rebalancing, combined treatment of BMT+Tregs synergistically elevated TGF-β1 and FoxP3 expression compared with BMT monotherapy. The sustained rebalance of Tregs/Th17 may be one possible explanation for the longer benefits of the combined treatment of BMT+Tregs over BMT monotherapy to mice with a long-duaration of diabetes. This observation of the therapeutic potential of BMCs+Tregs treatment may have important implications for clinical therapy for patients with a long-duration of diabetes.

HIF-1 Alpha Regulates the Response of Primary Sarcomas to Radiation Therapy through a Cell Autonomous Mechanism

Hypoxia is a major cause of radiation resistance, which may predispose to local recurrence after radiation therapy. While hypoxia increases tumor cell survival after radiation exposure because there is less oxygen to oxidize damaged DNA, it remains unclear whether signaling pathways triggered by hypoxia contribute to radiation resistance. For example, intratumoral hypoxia can increase hypoxia inducible factor 1 alpha (HIF-1α), which may regulate pathways that contribute to radiation sensitization or radiation resistance. To clarify the role of HIF-1α in regulating tumor response to radiation, we generated a novel genetically engineered mouse model of soft tissue sarcoma with an intact or deleted HIF-1α. Deletion of HIF-1α sensitized primary sarcomas to radiation exposure in vivo. Moreover, cell lines derived from primary sarcomas lacking HIF-1α, or in which HIF-1α was knocked down, had decreased clonogenic survival in vitro, demonstrating that HIF-1α can promote radiation resistance in a cell autonomous manner. In HIF-1α-intact and -deleted sarcoma cells, radiation-induced reactive oxygen species, DNA damage repair and activation of autophagy were similar. However, sarcoma cells lacking HIF-1α had impaired mitochondrial biogenesis and metabolic response after irradiation, which might contribute to radiation resistance. These results show that HIF-1α promotes radiation resistance in a cell autonomous manner.

Automated measurement of microcirculatory blood flow velocity in pulmonary metastases of rats

Because the lung is a major target organ of metastatic disease, animal models to study the physiology of pulmonary metastases are of great importance. However, very few methods exist to date to investigate lung metastases in a dynamic fashion at the microcirculatory level, due to the difficulty to access the lung with a microscope. Here, an intravital microscopy method is presented to functionally image and quantify the microcirculation of superficial pulmonary metastases in rats, using a closed-chest pulmonary window and automated analysis of blood flow velocity and direction. The utility of this method is demonstrated to measure increases in blood flow velocity in response to pharmacological intervention, and to image the well-known tortuous vasculature of solid tumors. This is the first demonstration of intravital microscopy on pulmonary metastases in a closed-chest model. Because of its minimized invasiveness, as well as due to its relative ease and practicality, this technology has the potential to experience widespread use in laboratories that specialize on pulmonary tumor research.

Assessing cardiac injury in mice with dual energy-microCT, 4D-microCT, and microSPECT imaging after partial heart irradiation

PURPOSE

To develop a mouse model of cardiac injury after partial heart irradiation (PHI) and to test whether dual energy (DE)-microCT and 4-dimensional (4D)-microCT can be used to assess cardiac injury after PHI to complement myocardial perfusion imaging using micro-single photon emission computed tomography (SPECT).

METHODS AND MATERIALS

To study cardiac injury from tangent field irradiation in mice, we used a small-field biological irradiator to deliver a single dose of 12 Gy x-rays to approximately one-third of the left ventricle (LV) of Tie2Cre; p53(FL/+) and Tie2Cre; p53(FL/-) mice, where 1 or both alleles of p53 are deleted in endothelial cells. Four and 8 weeks after irradiation, mice were injected with gold and iodinated nanoparticle-based contrast agents, and imaged with DE-microCT and 4D-microCT to evaluate myocardial vascular permeability and cardiac function, respectively. Additionally, the same mice were imaged with microSPECT to assess myocardial perfusion.

RESULTS

After PHI with tangent fields, DE-microCT scans showed a time-dependent increase in accumulation of gold nanoparticles (AuNp) in the myocardium of Tie2Cre; p53(FL/-) mice. In Tie2Cre; p53(FL/-) mice, extravasation of AuNp was observed within the irradiated LV, whereas in the myocardium of Tie2Cre; p53(FL/+) mice, AuNp were restricted to blood vessels. In addition, data from DE-microCT and microSPECT showed a linear correlation (R(2) = 0.97) between the fraction of the LV that accumulated AuNp and the fraction of LV with a perfusion defect. Furthermore, 4D-microCT scans demonstrated that PHI caused a markedly decreased ejection fraction, and higher end-diastolic and end-systolic volumes, to develop in Tie2Cre; p53(FL/-) mice, which were associated with compensatory cardiac hypertrophy of the heart that was not irradiated.

CONCLUSIONS

Our results show that DE-microCT and 4D-microCT with nanoparticle-based contrast agents are novel imaging approaches complementary to microSPECT for noninvasive assessment of the change in myocardial vascular permeability and cardiac function of mice in whom myocardial injury develops after PHI.

Developmental hypothyroxinaemia induced by maternal mild iodine deficiency delays hippocampal axonal growth in the rat offspring

Iodine is essential for the biosynthesis of thyroid hormones, including triiodothyronine and thyroxine. Thyroid hormones are important for central nervous system development. Mild maternal iodine deficiency (ID)-induced hypothyroxinaemia causes neurological deficits and mental retardation of the foetus. However, the detailed mechanism underlying these deficits is still largely unknown. Given that the growth-associated protein of 43 kDa (GAP-43), semaphorin 3A (Sema3A) and the glycogen synthase kinase 3β (GSK3β)/collapsin response mediator protein 2 (CRMP2) pathway are essential for axonal development, we hypothesise that hippocampal axonal growth-related proteins may be impaired, which may contribute to hippocampal axonal growth delay in rat offspring exposed to maternal hypothyroxinaemia. To test this hypothesis, maternal hypothyroxinaemia models were established in Wistar rats using a mild ID diet. Besides a negative control group, two maternal hypothyroidism models were created with either a severe ID diet or methimazole in the water. Our results showed that maternal hypothyroxinaemia exposure delayed offspring axonal growth on gestational day 19, postnatal day (PN) 7, PN14 and PN21. Consistent with this, the mean intensity of hippocampal CRMP2 and Tau1 immunofluorescence axonal protein was reduced in the mild ID group. Moreover, maternal hypothyroxinaemia disrupted expressions of GAP-43 and Sema3A. Furthermore, the phosphorylation of GSK3β and CRMP2 was also affected in the treated offspring, implying a potential mechanism by which hypothyroxinaemia-exposure affects neurodevelopment. Taken together, our data support the hypothesis that maternal hypothyroxinaemia may impair axonal growth of the offspring.

Clinical effects of transvaginal vesicovaginal fistula repair surgery mediated by the Foley catheter (64 cases)

OBJECTIVE

To investigate the clinical effects and superiority of transvaginal vesicovaginal fistula (VVF) repair surgery mediated by the Foley catheter.

PATIENTS AND METHODS

We retrospectively reviewed the case notes of 129 patients with vesicovaginal fistulas who received surgery in our hospital; 68 patients received VVF repair surgery mediated by the Foley catheter (modified group), and 61 patients received traditional transvaginal VVF repair surgery (traditional group).

RESULTS

The success rate of the primary operation, mean operation time, mean intraoperative blood loss, mean postoperative hospitalization time, and rate of patients with postoperative urine leakage were significantly different between the modified group and traditional group. However, the mean bladder capacity, postoperative recovery time of self-miction, and postoperative wound infection rate were not significantly different between the groups.

CONCLUSIONS

Transvaginal VVF repair surgery mediated by the Foley catheter had a higher success rate, shorter operation time, less blood loss and sooner recovery time postoperatively. Therefore, it should be applied in clinics generally.

Cancer survival in Tianjin, China, 1991-1999

The Tianjin cancer registry was established in 1978, and registration of cases is done by the active method. The registry contributed data on 51 cancer sites or types registered during 1991-1999 for this survival study. Follow-up has been a mixture of both active and passive methods, with median follow-up ranging from 5-77 months. The proportion with histologically verified diagnosis for various cancers ranged from 21-95% and 97-100% of total registered cases were included for survival analysis. The top-ranking cancers by 5-year age-standardized relative survival (%) were renal pelvis (101%), lip (99%), corpus uteri (91%), penis and nonmelanoma skin (90%) and thyroid (89%). The corresponding survival for common cancers were lung (31%), stomach (41%), Liver (25%) and breast (82%). The 5-year relative survival by age group reveals an inverse relationship for a few cancers and fluctuated for most cancers. Period survival closely predicted the survival experience of cancer cases diagnosed in that period, with the 5-year relative survival in 1991-1995 by period approach being more or less similar to survival by cohort approach in 1996-1999 for most cancers.

Kinetics of Acetate Utilization by Two Thermophilic Acetotrophic Methanogens: Methanosarcina sp. Strain CALS-1 and Methanothrix sp. Strain CALS-1

The kinetics of acetate utilization were examined for washed concentrated cell suspensions of two thermophilic acetotrophic methanogens isolated from a 58 degrees C anaerobic digestor. Progress curves for acetate utilization by cells of Methanosarcina sp. strain CALS-1 showed that the utilization rate was concentration independent (zero order) above concentrations near 3 mM and that acetate utilization ceased when a threshold concentration near 1 mM was reached. Acetate utilization by cells of Methanothrix sp. strain CALS-1 was concentration independent down to 0.1 to 0.2 mM, and threshold values of 12 to 21 muM were observed. Typical utilization rates in the concentration-independent stage were 210 and 130 nmol min mg of protein for the methanosarcina and the methanothrix, respectively. These results are in agreement with a general model in which high acetate concentrations favor Methanosarcina spp., while low concentrations favor Methanothrix spp. However, acetate utilization by these two strains did not follow simple Michaelis-Menton kinetics.

A Phytoplasma Associated with an Outbreak of an Unusual Disease of Chrysanthemum in China in 2008

In August of 2008, a disease of chrysanthemum (Dendranthema morifolium (Ramat.) Tzvel) caused losses of 70 to 80% in one of the largest chrysanthemum gardens in Yangling, Shanxi Province, China. Chrysanthemum plants in nearby areas also were affected to various degrees. Symptoms included flattened stems, shortening of internodes, yellowing of leaf margins, root death, and dwarfing of plants. Affected plants eventually collapsed. On the basis of these symptoms, a phytoplasma was suspected. Total nucleic acids were extracted from 0.5 g of phloem tissue from stems of eight symptomatic and eight asymptomatic plants by the cetyltrimethylammoniumbromide (CTAB) method (1). To amplify phytoplasma DNA, primer pairs R16mF2/R16mR1, followed by R16F2n/R16R1 (2), were used in a nested PCR. A final amplicon product (1.2 kb) was obtained from all symptomatic plants but not from asymptomatic ones. Restriction fragment length polymorphism (RFLP) analyses of R16F2n/R16R1 amplicons with MseI, AluI, HhaI, HaeIII, KpnI, RsaI, and HpaII endonucleases indicated that all symptomatic plants, but none of the asymptomatic plants, contained a phytoplasma strain of group 16SrI, subgroup B (3). A search of rDNA sequences in GenBank revealed a similarity (>99%) to aster yellow phytoplasma, 16SrI group, thereby confirming strain identity based on RFLP analysis. These results indicate the disease of chrysanthemum is associated with a phytoplasma related to the aster yellow phytoplasma group. Sequences were deposited in GenBank (Accession No. FJ543467). A vector of this phytoplasma in chrysanthemum has not been identified. References: (1) E. Angelini et al. Vitis 40:79, 2001. (2) D. E. Gundersen and I.-M. Lee. Phytopathol. Mediterr. 35:144, 1996. (3) I. M. Lee et al. Int. J. Syst. Evol. Microbiol. 48:1153, 1998.

Prediction of tumor necrosis fraction using combined volumetric and metabolic indices derived from FDG-PET/CT in osteosarcoma patients receiving neoadjuvant chemotherapy

10539

Background: Maximum standardized uptake values (mSUV) might not reliably reflect the chemotherapy response in osteosarcoma especially when treatment response within tumors is heterogenous. The purpose of this study was to compare the usefulnesses of various FDG PET/CT indices for predicting tumor response to neoadjuvant chemotherapy and to identify the most appropriate one in osteosarcoma. Methods: Thirteen patients with primary osteosarcoma (age 14±2.9 yrs, ranged 10–19 yrs) that had undergone FDG PET/CT scans before and after neoadjuvant chemotherapy were enrolled. The authors measured mSUV, metabolic tumor volumes (MTV), and total lesion glycolysis (TLG) in each PET/CT scan. MTVs were calculated by summing voxels with SUV greater than 1.5, 2, 2.5 and 3.0, and with % mSUV greater than 20%, 25%, 30% and 35%. Histopathologic necrosis fractions were compared with the above-mentioned PET/CT parameters and their pre- to post-treatment ratios (MTV ratio, rMTV; mSUV ratio, rSUV; TLG ratio, rTLG). Results: Histopathologic necrosis fractions ranged from 3% to 99% (62.2%±37.7%). rMTV and rTLG values were found to be correlated with histopathologic necrosis fractions (R2=0.45–0.65, p<0.05), whereas, mSUV and MR image volumes (MRV), both before and after treatment, rSUV values, and rMRV values were not. With regard to rMTV and rTLG values obtained using various MTV criteria, the highest correlation was observed for a rTLG value of 2.5 mg/ml (R2=0.65, p=0.001). Five patients were classified as responders and 8 as poor-responders to neoadjuvant chemotherapy defined as those with chemotherapy-induced necrosis fractions of ≥90% and <90%, respectively. The rSUVs of responders and poor-responders were not different, but rMTV and rTLG values showed a trend toward difference, although statistically not significant (p=0.110 and 0.106, respectively). The sensitivity and specificity of rTLG were 100% and 62.5%, respectively, at an SUV cut-off of 0.13. Conclusions: In our osteosarcoma patient population, TLG and MTV, which represent combined metabolic and volumetric indices, were found to predict tumor response better than pre- or post-treatment mSUV or rSUV.

No significant financial relationships to disclose.

Detection and Molecular Characterization of a 'Candidatus Phytoplasma asteris'-Related Strain Infecting Sasa fortunei in China

Bamboos are ecologically and economically valuable plants. Young shoots of almost all species are edible, either raw or cooked, and are major components of Asian cuisine while culms are used for furniture or handicrafts as well as fuel wood. Symptoms indicative of phytoplasma disease were observed on Sasa fortunei (van Houtte) Fiori during a survey in Yangling, Shaanxi Province, China during 2007. Symptoms included internode shortening, a mosaic pattern on leaves of diminished size, stunted growth, and death of entire plants. Total nucleic acids were extracted from leaf veins of 10 diseased plants and 6 symptomless plants with a modified cetyltrimethylammoniumbromide (CTAB) method (1). Phytoplasma infection of plants was demonstrated by a nested PCR assay employing primer pair R16mF2/R16mR1 followed by R16F2n/R16R2 (2), which generated a 16S rDNA product of approximately 1.2 kb from all symptomatic plants only. Restriction fragment length polymorphism analysis by digestion of nested PCR products with restriction enzymes AluI and MseI indicated that S. fortunei plants contained group 16SrI (aster yellows), subgroup B phytoplasmas. Sequencing and phylogenetic analysis of phytoplasma 16S rDNA from S. fortunei (GenBank Accession No. FJ501958) revealed this strain to be very similar (99.7 and 99.6%, respectively) to phytoplasmas previously associated with Henon bamboo (Phyllostachys nigra) witches'-broom (GenBank Accession No. AB242433) (4) and sasa (S. borealis) witches'-broom (GenBank Accession No. AB293421) in Korea but less so (98.6%) to bamboo (Phyllostachys spp.) witches'-broom (GenBank Accession No. AY635145) disease in China (3). To our knowledge, this is the first report of a 'Ca. Phytoplasma asteris'-related strain infecting S. fortunei in China. References: (1) E. Angelini et al. Vitis 40:79, 2001. (2) D. E. Gundersen and I.-M. Lee. Phytopathol. Mediterr. 35:144, 1996. (3) C. Hong et al. Plant Prot. 31:39, 2005. (4) H. Jung et al. J. Gen. Plant Pathol. 72:261, 2006.