The incidence of Hashimoto's disease in nodular goitre: the concordance in serological and cytological findings

OBJECTIVE

To determine the incidence of Hashimoto's disease in nodular goitre and to ascertain the degree of the concordance between serological and cytological findings.

METHODS

We retrospectively reviewed data from 188 patients who underwent a fine needle aspiration biopsy of the thyroid for uninodular or multinodular goitre with a documented serological level of antithyroid peroxidase (TPO) antibodies. AntiTPO antibodies were measured by immunochemiluminescent assay (Quest Diagnostics, Madison, NJ, USA).

RESULTS

The study cohort consisted of 170 female and 18 male patients with a mean (+/- SD) age of 47.8 +/- 14.9 years. AntiTPO antibodies were positive in 74 (39.36%) of the individuals and negative in 114 (60.63%). The cytodiagnoses were as follows: 5 (2.6%) cancerous, 18 (9.5%) suspicious, 12 (6.3%) inadequate, 92 (48.9%) benign and 61 (32.4%) consistent with chronic lymphocytic thyroiditis (CLT). For further analysis, we excluded all inadequate specimens. Based on the final sample of 176 patients, the sensitivity and specificity of antiTPO antibody test to detect CLT in nodular goitre were estimated to be 76.38% and 94.23% respectively. The prevalence of CLT in nodular goitre based on cytological criteria was (35.46%) compared with (31.97%) goitre based on positive antiTPO titres only.

CONCLUSION

There is a high degree of concordance between serological and cytological findings of CLT in people with nodular goitres. The high prevalence of CLT in nodular goitre justifies the use of antiTPO antibodies as part of the workup in this population.

Prognostic Effect of Sesrum 25 Hydroxyvitamin D Levels in Breast Cancer Patients

BackgroundThere is increasing evidence that vitamin D has been linked to breast cancer risk, but prognosis effect are unknown. We investigated the possible association between vitamin D and breast cancer prognosis by comparing serum vitamin D levelMethodsFrom June to December 2006, serum 25 OHD were measured in 310 Korean women with breast cancer at the Asan Medical Center. Clinical, Pathologic, and dietary data were accessed to examine prognostic effects of serum 25 OHDResultsMean age was 48.7 years, mean serum 25OHD was 31.4±16.1ng/ml. 25OHD levels were deficient(<20ng/ml) in 24.2%, insufficient (20-29ng/ml) in 30.6%, and sufficient(30-150ng/ml) in 24.0%. Mean follow up was 30 months: 31 had recurrences. Women with deficient 25 OHD levels had an increased risk of recurrence(HR=2.93;95% CI=1.27 to 6.77) compared with those with sufficient levels. 25OHD levels were inversely associated with prognosis of hormone receptor positive tumors, but not with hormone receptor negative tumors(HR=5.73 95CI=1.82 to 18.06 for hormone receptor positive tumor, HR=1.142, 95%CI =0.33 to 3.92 for hormone receptor negative tumor). The association remained after individual adjustment for age, tumor size, nodal status, estrogen receptor status (HR=4.13 95%CI=1.77 to 9.61) .ConclusionVitamin D deficiency may be associated with poor outcomes in hormone receptor positive breast cancer patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1052.

Triple Negative Breast Cancer Has a Worse Prognosis within 3 Years after Treatment Compared to Non-Triple Negative Breast Cancer

BackgroundTriple negative breast cancers (TNBC) become known as poor prognosis generally. Our purpose was to compare the clinical features and outcomes for TNBC with other subtypes of breast cancers in Korea.MethodsWe included 2,907 patients who diagnosed breast cancer and treated at Asan Medical Center from 2003 to 2005. Clinical and pathologic parameters, disease-free survival (DFS) and overall survival (OS) were compared between patients with TNBC and non-TNBC. All features were reviewed throughout medical records retrospectively.Results622 patients (21.4%) had TNBC. TNBC patients was associated with younger age, larger size, positive nodal involvement, overweight, family history, elevation of CaAg15-3, high tumor grade, positive p53 compared non-TNBC. The patients were followed for a median of 54 months (range 1-76 months). Relapse-free survival was 86.3% and 92.6% for TNBC and non-TNBC, respectively, with significant difference (P<0.0001). Overall survival was also 88.9% and 96.1% for TNBC and non-TNBC (P<0.0001). Compared with non-TNBC patients, TNBC had an increased likelihood of recurrence and death within 3 years after diagnosis but not thereafter. In non-TNBC, the recurrence risk and death risk seemed to be relatively constant. In univariate analysis for worse prognostic factors of TNBC associated with DFS and OS revealed that statistically significant in large tumor size, nodal status, CA15-3, Lymphovascular invasion. In multivariate analysis, nodal status was a prognostic factor for DFS (P=0.06, HR=2.28; 95% CI, 0.92-3.04) and OS (P<0.0001, HR=5.22; 95% CI, 2.11-12.96) of TNBC. Lymphovascular invasion was only poor prognostic factor for DFS (P=0.026, HR=10.2, 95% CI, 1.31-76.8), not for OS.ConclusionsTNBC has a worse prognosis than non-TNBC patients, but this effect is limited within 3 years after diagnosis. The most competent prognostic factor of recurrence and death for TNBC is a nodal status. We plan that perform analysis for prognosis according to hormone receptor and HER-2 receptor status sooner.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4044.

Can We Skip Sentinel Lymph Node Biopsy in Patients Who Have Microinvasive Breast Cancer?

Background: Sentinel lymph node(SLN) biopsy in patients with ductal carcinoma in situ(DCIS) was controversial. We may skip SLN biopsy when we performed conserving operation with small sized DCIS. But sometimes we can find DCIS with micro-invasive breast cancer (MIC) after operation. Should another operation be performed? We determined the incidence of positive axillary lymph node (ALNs) in patients with MIC, and the predictive factors of ALNs metastasis in these patients. Methods: Between July 1989 and January 2008, 9046 patients had operations performed on invasive breast cancers at Asan Medical Center. From July1989 to February 2003, ALND was performed to surgically stage the axilla. Since May 2003, SNB has been routinely performed for all cases. Patients who were treated with neoadjuvant chemotherapy and those who had no identifiable ALNs at surgery were excluded from the study. We retrospectively checked clinical and pathologic variables including diagnosis, patient demographics, size of DCIS, grade, multi-focal lesion, hormone receptor status, lymphatic invasion status etc. Results: 265 patients were identified with microinvasive (pathologic stage T1mic) breast cancer. Among these patients, 12 patients didn't have ALN study. 2 patients had bilateral MIC. The research was conducted on the remaining 255 cases. There were 13 cases of ALN metastases identified in this group of patients(5%). Young age (p=0.006), multifocal lesion (p=0.040) and lymphatic invasion (p<0.0001) were predictive factors for ALN metastases. There was no incidence of metastatic ALNs among the old age (≥50) patients of this group. Conclusion: As the incidence of ALN metastases in MIC patients is very small, particularly in those who had no lymphatic invasion, single lesion and among old age patients. So we think conservative treatment is one of the available options for these patients. However, due to the size of the subject group in this study, it needs to be validated through extensive prospective research.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1019.

Nipple areola skin-sparing mastectomy with TRAM flap reconstruction: Single-center study

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Background: Cosmetic aspect of breast cancer treatment becomes important. The originally described technique of Skin sparing mastectomy (SSM) included the removal of gland, nipple areola complex (NAC), and biopsy scar. However, the risk of tumor involvement of NAC in patients with breast cancer has been overestimated. The purpose of this study is to evaluate the oncological safety and technical outcomes of nipple areola skin sparing mastectomy (NA-SSM) compared with SSM. Methods: This retrospective study includes 522 patients who underwent immediate breast reconstruction using pedicled transverse rectus abdominis musculocutaneous (TRAM) flap between July 2001 and December 2006. The indication of NA-SSM in this study was defined as being for any stage, any tumor size and any tumor areola distance. Briefly, NAC was preserved when palpation and the outlook of the nipple was normal. 364 patients underwent SSM with immediate TRAM flap reconstruction and 152 underwent NA-SSM with immediate TRAM flap reconstruction. We compared complication rate, local recurrence rate (LRR), disease-free survival (DFS), and overall survival (OS) Between NA-SSM and SSM with immediate TRAM reconstruction cases. Results: Median follow up of NA-SSM and SSM was 60 and 67 months respectively. Complete or partial nipple areola necrosis developed in 26 (17.1%; complete, partial 15). The 5 year DFS was 89% for NA SSM and 87.4% for SSM (log rank p = 0.20), The 5 year OS was 99.3% for NA SSM and 98.3 % (log rank p = 0.33) The local failure occurred in 3 (2%) of 152 underwent NA SSM, 3 (0.8%) of 364 patients underwent SSM (p = 0.27). There were 2 (1.3%) nipple areola recurrence. Cosmetic outcome of NA SSM was better than that of SSM in the majority of patients. Conclusions: Our study demonstrates that NA-SSM with immediate TRAM reconstruction is oncologically as safe as SSM with immediate TRAM reconstruction and provides a good cosmetic outcome.

No significant financial relationships to disclose.

Characteristics of bone mineral density at the time of diagnosis in postmenopausal breast cancer patients

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Background: Bone mass has been proposed as a marker of cumulative exposure to estrogen in women. We have studied the association between bone mass and breast cancer in postmenopausal women. Methods: We investigated the association between bone mineral density(BMD), as measured at the lumbar spine and femoral neck and the breast cancer in women age 50 or older, who were received an initial diagnosis of stage 0-III breast cancer, confirmed by pathologic assessment of breast tissue. We recruited 718 women with newly diagnosed breast cancer in a Asan Medical Center from 1, Jun. 2006 to 31, Dec. 2007. BMD was measured by lunar EXPERT-XL for breast cancer patients Results: Median age at diagnosis was 58 (range 47–82). Patients with higher BMD at lumbar spine were found to have low grade disease (p<0.005). The patients with hormone receptor positive breast tumor showed higher BMD at lumbar spine and lower serum 25(OH)D than hormone receptor negative tumor. Serum estradiol level did not show a relation to BMD. There were no significant differences between breast cancer stage and serum 25(OH)D and BMD. Conclusions: The patients who have hormone receptor positive breast cancer had higher Lumbar spine BMD and lower 25(OH)D than hormone receptor negative patients.

No significant financial relationships to disclose.

Harm Avoidance as an Endophenotype of Schizophrenia: Comparative Study of First-degree Relatives, Schizophrenia Probands, and Healthy Controls

Objective:

Schizophrenia is highly familial neuropsychiatric disorder with heritability estimated at 60-90%. Even unaffected first-degree relatives of schizophrenia manifested some neuropsychological abnormalities as well as neurologic soft sign and morphologic anomalies. the aim of this study was to evaluate personality profile in first-degree relatives of schizophrenia compared to their schizophrenia probands and healthy controls and whether personality profile might be endophenotype of schizophrenia.

Methods:

The subjects were 97 first-degree relatives of schizophrenia, 48 their schizophrenia probands, and 106 healthy controls, who completed Temperament and Character Inventory (TCI) scale. Relatives were further divided into presumed carriers and pesumed non-carriers by schizophrenia genetic loading. Group difference in TCI scores were compared by general linear model using age and gender as covariates.

Results:

1.

Conclusion:

We found that HA scores of first-degree relatives of schizophrenia is intermediate level between schizophrenia probands and healthy controls. Considering increase of HA with schizophrenia genetic loading, HA may be potential endophenotype of schizophrenia. Further research with longitudinal follow up is needed to elucidate the clinical implication of high HA observed in schizophrenia family.

Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis

BACKGROUND

The effect of anticoagulant prophylaxis on the prevention of deep vein thrombosis (DVT) should include an investigation of both clinical and subclinical DVT. We conducted a systematic review to determine whether anticoagulant prophylaxis reduces the risk of asymptomatic DVT compared to no prophylaxis in at-risk hospitalized medical patients.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched through March 2007 for randomized trials of anticoagulant prophylaxis for the prevention of asymptomatic DVT, assessed by venogram or ultrasound. We assessed four outcomes: all asymptomatic DVT, asymptomatic proximal DVT, major bleeding and mortality. Random effects meta-analyses were performed and results were expressed using relative risk (RR) and 95% confidence intervals (95% CIs).

RESULTS

Four trials including 5516 patients were eligible. Our pooled analysis demonstrated that compared to placebo, anticoagulant prophylaxis was associated with a significantly lower risk of any asymptomatic DVT (RR 0.51; 95% CI 0.39-0.67) and asymptomatic proximal DVT (RR 0.45; 95% CI 0.31-0.65). Anticoagulant prophylaxis was associated with a significantly increased risk of major bleeding compared to placebo (RR 2.00; 95% CI 1.05-3.79). There was no significant difference in the pooled estimate for all-cause mortality. Anticoagulant prophylaxis conferred an absolute risk reduction of any DVT and proximal DVT of 2.6% and 1.8%, respectively, and was associated with a 0.5% absolute risk increase in major bleeding.

CONCLUSIONS

Anticoagulant prophylaxis is effective in preventing asymptomatic DVT in at-risk hospitalized medical patients but is associated with an increased bleeding risk. The therapeutic benefits of anticoagulant prophylaxis appear to outweigh the risks of bleeding.

Comparison of nasopharyngeal flocked swabs and aspirates for rapid diagnosis of respiratory viruses in children

BACKGROUND

The quality of clinical specimens is a crucial determinant for virological diagnosis.

OBJECTIVES

We compared the viral diagnostic yield for influenza A and respiratory syncytial virus (RSV) from the recently developed nasopharyngeal flocked swabs (NPFS) with nasopharyngeal aspirates (NPA) collected in parallel from 196 hospitalized children with acute respiratory infection during the peak period of influenza A and RSV activity in Hong Kong. Specimens were tested by RT-PCR for influenza A and RSV and viral load determined. They were also tested by direct immunofluorescence (DIF) for influenza A and B, RSV, parainfluenza types 1-3 and adenovirus.

RESULTS

Both NPA and NPFS had excellent sensitivity (100%) for detecting influenza A by RT-PCR but NPA was slightly more sensitive than NPFS for detecting RSV by both RT-PCR (100% vs. 92.3%) and DIF (87.2% vs. 84.6%) and for detecting influenza A by DIF (90.2% vs. 82.9%). Viral load for influenza A in NPA and NPFS was not significantly different but that for RSV was higher in NPA.

CONCLUSION

NPA remains the optimal specimen for diagnosis of respiratory infections by RT-PCR and DIF. However, collection of NPFS is easier to perform in an out-patient setting, was more acceptable to parents and less likely to generate aerosols than NPA engendering potentially less infection control hazard.

STK11 status and intussusception risk in Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is caused by germline STK11 mutations and characterised by gastrointestinal polyposis. Although small bowel intussusception is a recognised complication of PJS, risk varies between patients.

OBJECTIVE

To analyse the time to onset of intussusception in a large series of PJS probands.

METHODS

STK11 mutation status was evaluated in 225 PJS probands and medical histories of the patients reviewed.

RESULTS

135 (60%) of the probands possessed a germline STK11 mutation; 109 (48%) probands had a history of intussusception at a median age of 15.0 years but with wide variability (range 3.7 to 45.4 years). Median time to onset of intussusception was not significantly different between those with identified mutations and those with no mutation detected, at 14.7 years and 16.4 years, respectively (log-rank test of difference, chi(2) = 0.58, with 1df; p = 0.45). Similarly no differences were observed between patient groups on the basis of the type or site of STK11 mutation.

CONCLUSIONS

The risk of intussusception in PJS is not influenced by STK11 mutation status.

Exonic STK11 deletions are not a rare cause of Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant cancer predisposition syndrome characterised by oro-facial pigmentation and hamartomatous polyposis of the gastrointestinal tract. A causal germline mutation in STK11 can be identified in 30% to 80% of PJS patients.

METHODS

Here we report the comprehensive mutational analysis of STK11 in 38 PJS probands applying conventional PCR based mutation detection methods and the recently introduced MLPA (multiplex ligation dependent probe amplification) technique developed for the identification of exonic deletions/duplications.

RESULTS

Nineteen of 38 probands (50%) had detectable point mutations or small scale deletions/insertions and six probands (16%) had genomic deletions encompassing one or more STK11 exons.

CONCLUSIONS

These findings demonstrate that exonic STK11 deletions are a common cause of PJS and provide a strong rationale for conducting a primary screen for such mutations in patients.

Transcranial magnetic stimulation screening for cord compression in cervical spondylosis

OBJECTIVE

Cervical spondylosis (CS) often results in various degrees of cord compression, which can be evaluated functionally with transcranial magnetic stimulation (TMS). We investigate the use of TMS as a screening tool for myelopathy in CS.

METHODS

We prospectively studied 231 patients classified into Groups 1 to 4 based on MRI grading of severity of cord compromise. TMS elicited central motor conduction times and motor evoked potential (MEP) amplitudes in all 4 limbs. The results were compared with those from 45 healthy controls.

RESULTS

TMS showed 98% sensitivity and 98% specificity for cord abnormality using MRI as reference standard.

CONCLUSIONS

MEP abnormalities are useful for electrophysiological evaluation of cord compression in CS. While TMS is not a substitute for MRI, it is of value as a rapid, inexpensive and non-invasive technique for screening patients before MRI studies.

Endovascular and surgical management of vertebral artery dissecting aneurysms presenting with subarachnoid haemorrhage: medium-term experience

INTRODUCTION

Dissecting aneurysms of the vertebral artery are associated with a high incidence of rebleeding and mortality if untreated. Current endovascular alternatives to surgery are being evaluated.

MATERIALS AND METHODS

We conducted a retrospective review of our experience with endovascular as well as surgical treatments of dissecting vertebral artery aneurysms in 6 patients. Three patients were treated with a combination of coils in the proximal artery and aneurysm sac; 1 with a combination of coils and balloon; and 2 with aneurysm clipping surgery. All patients were treated with the primary intention of coil deposition within the aneurysm sac and proximal vertebral artery. No proximal flow arrest was used. Anticoagulation was given during and after the procedure.

RESULTS

Technical success was achieved in all patients, and there was no postprocedural neurological deficit. Follow-up for a mean of 40 months (range, 7 to 64) confirmed the clinical stability of symptoms, as well as the cessation of flow to the aneurysm.

CONCLUSIONS

Endovascular treatment of vertebral artery dissections is a viable alternative to surgery in the appropriate setting. It has the benefit of being minimally invasive, allowing concomitant balloon testing as well as retaining the option to convert to surgery.

Prevention of transfusion-transmitted hepatitis E by donor-initiated self exclusion

Safety in blood transfusion has all along been focused on blood borne viruses like HIV, hepatitis B and C. However, infective agents that are not usually transmitted through blood may also pose risk to transfusion if the donor gives blood in the early-viraemic phase. A case report of potential transfusion-transmitted hepatitis E (HEV) is described. It shows the virus can be transmissible via blood because of the presence of HEV RNA in the blood donated. Pre-donation health screening was unable to exclude this asymptomatic donor. But donor-initiated call back system which acts as an additional safety net prevented the release of the potential infective blood products.

An 11-year experience of enterocutaneous fistula

Background

Enterocutaneous fistula has traditionally been associated with substantial morbidity and mortality, related to fluid, electrolyte and metabolic disturbance, sepsis and malnutrition.

Methods

A retrospective review of enterocutaneous fistula in 277 consecutive patients treated over an 11-year period in a major tertiary referral centre was undertaken to evaluate current management practice and outcome.

Results

Most fistulas occurred secondary to abdominal surgery, and a high proportion (52·7 per cent) occurred in association with inflammatory bowel disease. A low rate of spontaneous healing was observed (19·9 per cent). The healing rate after definitive fistula surgery was 82·0 per cent, although more than one attempt was required to achieve surgical closure in some patients. Definitive fistula resection resulted in a mortality rate of 3·0 per cent. In addition, one patient died after laparotomy for intra-abdominal sepsis and an additional 24 patients died from complications of fistulation, giving an overall fistula-related mortality rate of 10·8 per cent.

Conclusion

Early recognition and control of sepsis, management of fluid and electrolyte imbalances, meticulous wound care and nutritional support appear to reduce the mortality rate, and allow spontaneous fistula closure in some patients. Definitive surgical management is performed only after restitution of normal physiology, usually after at least 6 months.

Attenuation of a human H9N2 influenza virus in mammalian host by reassortment with an avian influenza virus

In order to develop a surrogate virus strain for production of an inactivated influenza vaccine against a human H9N2 virus, A/Hong Kong/1073/99 (HK1073: H9N2) was co-infected in embryonated chicken eggs with an apathogenic avian influenza virus, A/Duck/Czechoslovakia/56 (Dk/Cz: H4N6), for gene segment reassortment. Multiple-gene reassortants obtained were examined for replication in mammalian hosts in vitro and in vivo by infecting MDCK cells and by intranasal administration to hamsters, respectively. A 2-6 gene reassortant with both surface glycoproteins of HK1073 origin and the rest of Dk/Cz origin, HK/CZ-13, was shown to replicate poorly in the mammalian hosts both in vivo and in vitro comparing with HK1073, although this reassortant replicated as efficiently as each parental strain in embryonated eggs. No sequence difference was observed in the HA1 region between HK1073 and HK/CZ-13, indicating that the reassortant would be equivalent in its immunogenicity to the parental HK1073 strain when it is used as an inactivated vaccine. A virus strain with attenuation in mammalian hosts is preferable for production of an H9 vaccine, since it should reduce the risk of manufacturing-related infections of employees during the vaccine production. HK/CZ-13 can therefore be a surrogate strain for production of an inactivated vaccine as well as diagnostic antigens in case of a possible future pandemic caused by an HK1073-like H9 influenza virus.

H5N1 influenza: a protean pandemic threat

Infection with avian influenza A virus of the H5N1 subtype (isolates A/HK/212/03 and A/HK/213/03) was fatal to one of two members of a family in southern China in 2003. This incident was preceded by lethal outbreaks of H5N1 influenza in waterfowl, which are the natural hosts of these viruses and, therefore, normally have asymptomatic infection. The hemagglutinin genes of the A/HK/212/03-like viruses isolated from humans and waterfowl share the lineage of the H5N1 viruses that caused the first known cases of human disease in Hong Kong in 1997, but their internal protein genes originated elsewhere. The hemagglutinin of the recent human isolates has undergone significant antigenic drift. Like the 1997 human H5N1 isolates, the 2003 human H5N1 isolates induced the overproduction of proinflammatory cytokines by primary human macrophages in vitro, whereas the precursor H5N1 viruses and other H5N1 reassortants isolated in 2001 did not. The acquisition by the viruses of characteristics that enhance virulence in humans and waterfowl and their potential for wider distribution by infected migrating birds are causes for renewed pandemic concern.

Systematic correlation of transcranial magnetic stimulation and magnetic resonance imaging in cervical spondylotic myelopathy

STUDY DESIGN

A prospective study over a 3.5-year period involving transcranial magnetic stimulation and magnetic resonance imaging.

OBJECTIVES

To assess the correlation of transcranial magnetic stimulation and magnetic resonance imaging in cervical spondylotic myelopathy qualitatively and statistically.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic myelopathy presents with different degrees of cord compression, which can be assessed by magnetic resonance imaging. There are no large studies correlating transcranial magnetic stimulation and magnetic resonance imaging findings in this condition.

METHODS

A total of 141 patients with a clinical diagnosis of cervical spondylotic myelopathy were prospectively studied over a 3.5-year period. They were classified into Groups 1 to 4 based on severity of cervical cord changes on magnetic resonance imaging. All had transcranial magnetic stimulation and central motor conduction time measurements within 2 months of the magnetic resonance imaging study.

RESULTS

Twenty-eight, 49, 28, and 36 patients were classified into Groups 1 to 4, respectively. Mean upper limb and lower limb central motor conduction times correlated with the severity of magnetic resonance cord compression. The absence of central motor conduction time abnormalities correlated reliably with the absence of cervical cord impingement as in Group 1. Statistically significant right left difference in central motor conduction time in the lower limbs was seen between Groups 1 (no cord changes) and Group 2 (mild cord impingement). Eight other patients with diagnoses other than cervical spondylotic myelopathy all showed central motor conduction time abnormalities. The sensitivity and specificity for transcranial magnetic stimulation for differentiating the presence from absence of magnetic resonance imaging cord abnormality were 100% and 84.8%, respectively.

CONCLUSIONS

Transcranial magnetic stimulation showed excellent correlation with magnetic resonance imaging findings and can be considered as an effective technique for screening patients for cervical cord abnormalities before magnetic resonance imaging in the clinical setting. The findings in this study have relevant implications in the pathophysiology, management, and health costs of cervical spondylotic myelopathy.

Isolation and characterization of viruses related to the SARS coronavirus from animals in southern China

A novel coronavirus (SCoV) is the etiological agent of severe acute respiratory syndrome (SARS). SCoV-like viruses were isolated from Himalayan palm civets found in a live-animal market in Guangdong, China. Evidence of virus infection was also detected in other animals (including a raccoon dog, Nyctereutes procyonoides) and in humans working at the same market. All the animal isolates retain a 29-nucleotide sequence that is not found in most human isolates. The detection of SCoV-like viruses in small, live wild mammals in a retail market indicates a route of interspecies transmission, although the natural reservoir is not known.

Further observations on LKB1/STK11 status and cancer risk in Peutz-Jeghers syndrome

Germline mutations in the LKB1/STK11 tumour suppressor gene cause Peutz-Jeghers syndrome (PJS), a rare dominant disorder. In addition to typical hamartomatous gastrointestinal polyps and pigmented perioral lesions, PJS is associated with an increased risk of tumours at multiple sites. Follow-up information on carriers is limited and genetic heterogeneity makes counselling and management in PJS difficult. Here we report the analysis of the LKB1/STK11 locus in a series of 33 PJS families, and estimation of cancer risks in carriers and noncarriers. Germline mutations of LKB1/STK11 were identified in 52% of cases. This observation reinforces the hypothesis of a second PJS locus. In carriers of LKB1/STK11 mutations, the risk of cancer was markedly elevated. The risk of developing any cancer in carriers by age 65 years was 47% (95% CI: 27-73%) with elevated risks of both gastrointestinal and breast cancer. PJS with germline mutations in LKB1/STK11 are at a very high relative and absolute risk of multiple gastrointestinal and nongastrointestinal cancers. To obtain precise estimates of risk associated with PJS requires further studies of genotype-phenotype especially with respect to LKB1/STK11 negative cases, as this group is likely to be heterogeneous.

Coronavirus as a possible cause of severe acute respiratory syndrome

BACKGROUND

An outbreak of severe acute respiratory syndrome (SARS) has been reported in Hong Kong. We investigated the viral cause and clinical presentation among 50 patients.

METHODS

We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters. We defined the clinical presentation and risk factors associated with severe disease and investigated the causal agents by chest radiography and laboratory testing of nasopharyngeal aspirates and sera samples. We compared the laboratory findings with those submitted for microbiological investigation of other diseases from patients whose identity was masked.

FINDINGS

Patients' age ranged from 23 to 74 years. Fever, chills, myalgia, and cough were the most frequent complaints. When compared with chest radiographic changes, respiratory symptoms and auscultatory findings were disproportionally mild. Patients who were household contacts of other infected people and had older age, lymphopenia, and liver dysfunction were associated with severe disease. A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus.

INTERPRETATION

A coronavirus was isolated from patients with SARS that might be the primary agent associated with this disease. Serological and molecular tests specific for the virus permitted a definitive laboratory diagnosis to be made and allowed further investigation to define whether other cofactors play a part in disease progression.

Molecular changes associated with the transmission of avian influenza a H5N1 and H9N2 viruses to humans

In order to identify molecular changes associated with the transmission of avian influenza A H5N1 and H9N2 viruses to humans, the internal genes from these viruses were compared to sequences from other avian and human influenza A isolates. Phylogenetically, each of the internal genes of all sixteen of the human H5N1 and both of the H9N2 isolates were closely related to one another and fell into a distinct clade separate from clades formed by the same genes of other avian and human viruses. All six internal genes were most closely related to those of avian isolates circulating in Asia, indicating that reassortment with human strains had not occurred for any of these 18 isolates. Amino acids previously identified as host-specific residues were predominantly avian in the human isolates although most of the proteins also contained residues observed previously only in sequences of human influenza viruses. For the majority of the nonglycoprotein genes, three distinct subgroups could be distinguished on bootstrap analyses of the nucleotide sequences, suggesting multiple introductions of avian virus strains capable of infecting humans. The shared nonglycoprotein gene constellations of the human H5N1 and H9N2 isolates and their detection in avian isolates only since 1997 when the first human infections were detected suggest that this particular gene combination may confer the ability to infect humans and cause disease. J. Med. Virol. 66:107-114, 2002. Published 2002 Wiley-Liss, Inc.

Analysis of the CTLA4 gene in Swedish coeliac disease patients

BACKGROUND

A genetic susceptibility to coeliac disease is well established, involving HLA and non-HLA components. CTLA4 is an important regulator of T-cell function and some studies have suggested that sequence variation in the gene might be a determinant of disease susceptibility, although the evidence is conflicting.

METHODS

Sixty-two children with biopsy-proven coeliac disease attending a single centre in Sweden were studied. All were genotyped for presence of the HLA-DQA1*0501, B 1*0201 alleles. Those who carried the HLA-DQ heterodimer (58/62) were genotyped for the +49 (A/G) exon I polymorphism. The transmission disequilibrium test (TDT) was used to test for association between coeliac disease and the A allele. The entire CTLA4 gene was screened for other sequence variants using a combination of conformation-sensitive gel electrophoresis and direct sequencing.

RESULTS

A significant association between the exon I polymorphism and coeliac disease was observed (P = 0.02). No other sequence variants in CTLA4 were detected.

CONCLUSIONS

This study provides further evidence that variation in CTLA4 is a determinant of coeliac disease susceptibility. If not mediated through the +49 (A/G) dimorphism directly, then the effect is likely to be mediated through linkage disequilibrium.

Malignant evolution of Schnitzler's syndrome--chronic urticaria and IgM monoclonal gammopathy: report of a new case and review of the literature

Schnitzler's syndrome, initially described in 1974 is an uncommon condition defined by chronic urticaria and monoclonal IgM gammopathy. Additional features include fever of unknown origin, elevated ESR, bone pain and frequently a benign clinical course. We conducted a literature search of Medline, EMBASE and Cancerlit and found 56 cases of Schnitzler's syndrome reported to date. The absence of lymphoproliferative disease in this condition is typical, but nine patients have progressed to develop lymphoplasmacytic neoplasias, particularly Waldenstrom's macroglobulinemia (WM). Malignant evolution of Schnitzler's syndrome is a rare complication, but emphasizes the importance of long term follow-up and the need for these patients to undergo periodic assessment of the bone marrow and lymph nodes. Treatment of this condition is difficult, with varying response to corticosteroids and largely unsuccessful results with standard chemotherapy used for WM. We describe a case of Schnitzler's syndrome in a 50-year old man with lymphocytic aggregates in the bone marrow after 9 years of chronic urticaria, fever, arthralgias and bone pain. We review the clinical features and treatment, with emphasis on the hematologic aspects of this unusual condition.

Universal antenatal human immunodeficiency virus testing in Hong Kong: consensus statement

Following the recommendations of the Advisory Council on AIDS, Hong Kong, the Hospital Authority announced plans to introduce universal antenatal screening for human immunodeficiency virus infection and hence, a consensus conference was held to discuss strategies for implementing such screening in Hong Kong. This paper reports the discussions of the consensus conference. The consensus meeting group consisted of 15 clinicians and scientists from Hong Kong, Macau, and Thailand. Seven commonly asked questions concerning mother-to-child transmission of human immunodeficiency virus were selected for discussion by the participating panellists. Information on the laboratory diagnosis of human immunodeficiency virus infection and the efficacy of preventive measures in reducing mother-to-child transmission of human immunodeficiency virus were reviewed. Data from local studies was also presented and discussed. The timing, potential problems, and cost issues involved in testing all pregnant women in Hong Kong for human immunodeficiency virus were then considered.

Characterization of a human H9N2 influenza virus isolated in Hong Kong

Two H9N2 viruses were isolated, for the first time, from humans in Hong Kong in 1999. Isolation of influenza viruses with a novel subtype of the hemagglutinin (HA) drew attention of health care authorities worldwide from the view of pandemic preparedness. Sequence analysis of the HA genes reveals that HA of A/Hong Kong/1073/99 (H9N2) is most closely related to that of A/quail/HK/G1/97 (H9N2) that contains the internal genes similar to those of Hong Kong/97 (H5N1) viruses. Phylogenetic and antigenic analyses demonstrated the diversity among H9 HA. A/Hong Kong/1073/99 was shown to cause a respiratory infection in Syrian hamsters, suggesting that the virus can replicate efficiently in mammalian hosts. We developed a whole virion test vaccine with a formalin-inactivated egg-grown HK1073. Intraperitoneal administration of the vaccine twice to hamsters conferred a complete protection against challenge infection by the MDCK cell-grown homologous virus. Receptor specificity of HK1073 appeared different from that of other avian influenza viruses of H9 subtype which recognize preferentially alpha-2,3 linked sialic acid. Hemagglutination of HK1073 with guinea pig erythrocytes was inhibited by both alpha-2,3 and alpha-2,6 linked sialic acid containing polymers. These data suggested that HK1073 had acquired a broader host range, including humans. Together with data so far available, the present study suggested that isolation of the H9 influenza viruses from humans requires precaution against the emergence of a novel human influenza.

Effect of asymmetry on the loss of chaos synchronization

We investigate the effect of asymmetry of coupling on the bifurcation mechanism for the loss of synchronous chaos in coupled systems. It is found that only when the symmetry-breaking pitchfork bifurcations take part in the process of the synchronization loss for the case of symmetric coupling, the asymmetry changes the bifurcation scenarios of the desynchronization. For the case of weak coupling, pitchfork bifurcations of asynchronous periodic saddles are replaced by saddle-node bifurcations, while for the case of strong coupling, pitchfork bifurcations of synchronous periodic saddles transform to transcritical bifurcations. The effects of the saddle-node and transcritical bifurcations for the weak asymmetry are similar to those of the pitchfork bifurcations for the symmetric-coupling case. However, with increasing the "degree" of the asymmetry, their effects change qualitatively, and eventually become similar to those for the extreme case of unidirectional asymmetric coupling.

Infection of a child in Hong Kong by an influenza A H3N2 virus closely related to viruses circulating in European pigs

Influenza virus A/Hong Kong/1774/99, isolated from a young child with mild influenza, was shown to be similar in its antigenic and genetic characteristics to H3N2 viruses circulating in pigs in Europe during the 1990s and in particular to be closely related to viruses isolated from two children in the Netherlands in 1993. Similar viruses had previously not been identified outside Europe. Although there is little evidence as to how the child contracted the infection, it appears likely that pigs in southern China were the source of infection. Characteristics shared with the European swine viruses include resistance to the anti-influenza drugs amantadine and rimantadine. Thus not only does this incident once again highlight the potential of pigs as a source of novel human influenza viruses, but also indicates the potential for emergence of amantadine-resistant human viruses.

The p38 mitogen-activated kinase pathway regulates the human interleukin-10 promoter via the activation of Sp1 transcription factor in lipopolysaccharide-stimulated human macrophages

Interleukin-10 (IL-10), a pleiotropic cytokine that inhibits inflammatory and cell-mediated immune responses, is produced by a wide variety of cell types including T and B cells and monocytes/macrophages. Regulation of pro- and anti-inflammatory cytokines has been suggested to involve distinct signaling pathways. In this study, we investigated the regulation of the human IL-10 (hIL-10) promoter in the human monocytic cell line THP-1 following activation with lipopolysaccharide (LPS). Analysis of hIL-10 promoter sequences revealed that DNA sequences located between base pairs -652 and -571 are necessary for IL-10 transcription. A computer analysis of the promoter sequence between base pairs -652 and -571 revealed the existence of consensus sequences for Sp1, PEA1, YY1, and Epstein-Barr virus-specific nuclear antigen-2 (EBNA-2)-like transcription factors. THP-1 cells transfected with a plasmid containing mutant Sp1 abrogated the promoter activity, whereas plasmids containing the sequences for PEA1, YY1, and EBNA-2-like transcription factors did not influence hIL-10 promoter activity. To understand the events upstream of Sp1 activation, we investigated the role of p38 and extracellular signal-regulated kinase mitogen-activated protein kinases by using their specific inhibitors. SB202190 and SB203580, the p38-specific inhibitors, inhibited LPS-induced IL-10 production. In contrast, PD98059, a specific inhibitor of extracellular signal-regulated kinase kinases, failed to modulate IL-10 production. Furthermore, SB203580 inhibited LPS-induced activation of Sp1, as well as the promoter activity in cells transfected with a plasmid containing the Sp1 consensus sequence. These results suggest that p38 mitogen-activated protein kinase regulates LPS-induced activation of Sp1, which in turn regulates transcription of the hIL-10 gene.

Bicritical scaling behavior in unidirectionally coupled oscillators

We study the scaling behavior of period doublings in a system of two unidirectionally coupled parametrically forced pendulums near a bicritical point where two critical lines of period-doubling transition to chaos in both subsystems meet. When crossing a bicritical point, a hyperchaotic attractor with two positive Lyapunov exponents appears, i.e., a transition to hyperchaos occurs. Varying the control parameters of the two subsystems, the unidirectionally coupled parametrically forced pendulums exhibit multiple period-doubling transitions to hyperchaos. For each transition to hyperchaos, using both a "residue-matching" renormalization group method and a direct numerical method, we make an analysis of the bicritical scaling behavior. It is thus found that the second response subsystem exhibits a new type of non-Feigenbaum scaling behavior, while the first drive subsystem is in the usual Feigenbaum critical state. The universality of the bicriticality is also examined for several different types of unidirectional couplings.

Some problematic behaviors in Alzheimer's dementia

We examined 18 patients with problematic behaviors in relation to their individual characteristics and their possible relationship to certain aspects of dementia namely cognitive impairment, stage of illness, language impediment and functional disability. They formed part of an earlier assessment of 94 patients with dementia-related problems. Ten had altered eating habits and eight (8.5%) of them had hyperphagia. One exhibited an incomplete form of Kluver-Bucy Syndrome. Two had pathological stealing and one scatolia (smearing of faeces). The remaining had bizzare behaviors such as screaming and head banging. The majority of the patients were in the moderate category in relation to the four domains tested. The study revealed that behavioral problems in the more severe dementia becomes less of a problem to the caregivers and others. These behaviors could dramatically affect the social and interpersonal relationships resulting in community, family and caregiver burden.

Mechanism for the riddling transition in coupled chaotic systems

We investigate the loss of chaos synchronization in coupled chaotic systems without symmetry from the point of view of bifurcations of unstable periodic orbits embedded in the synchronous chaotic attractor (SCA). A mechanism for direct transition to global riddling through a transcritical contact bifurcation between a periodic saddle embedded in the SCA and a repeller on the boundary of its basin of attraction is thus found. Note that this bifurcation mechanism is different from that in coupled chaotic systems with symmetry. After such a riddling transition, the basin becomes globally riddled with a dense set of repelling tongues leading to divergent orbits. This riddled basin is also characterized by divergence and uncertainty exponents, and thus typical power-law scaling is found.