The Implementation of ISO 9001:2015 to Improve the Supportive Care Services for the Cancer Survivors

Background and context: Cancer has been the leading cause of death in Taiwan since 1982. According the most updated cancer registry published by the Ministry of Health and Welfare, a total of 105,156 new cases (302/100,000 population) were diagnosed and 46,829 people (128/100,000 population) died of cancer which accounted for 28.6% of all deaths. Currently, around 500,000 people live with cancers in Taiwan. The Formosa Cancer Foundation (FCF) operates two Cancer Survivor Supportive Care Centers in Taipei and Kaohsiung cities which provide comprehensive, professional services to cancer survivors and their families. These centers regularly offer free medical, nutritional and psychological counseling, nutrition and transportation subsidies for low-income survivor households, critical emergency relief as well as hold a regular courses of body and mind rehabilitation to help cancer survivors successfully navigate their road to optimal recovery. As the number of cancer survivors needed supportive care services are rapidly increasing, the resources allocated for the services is not proportionately increased. Therefore, how to improve both the quantity and quality for the survivors' supportive care services becomes an essential issue. Aim: To ensure service standardization as well as to improve the quantity and quality of the supportive care services for the cancer survivors. Strategy/Tactics: FCF began the process necessary to certify its Survivor Supportive Care Service Quality Management System under ISO 9001 since 2015. Program/Policy process: To certify the FCF Survivor Supportive Care Service Quality Management System under ISO 9001:2015 by (1) Clearly defining the assessment and service goals (2) Systemized management and control of service delivery procedures (3) Regular collection and utilization of client-satisfaction data and comments (4) Systemized tracking and management of documents (5) Standard method for records storage and maintenance (6) Standardized procedures for managing and maintaining service facilities; and (7) Standardized procedures for evaluating and training staff. Outcomes: After implementation of the ISO 9001:2015 quality management system, FCF's overall service capacity has increased by 18-20%. Each service now covered by a standardized procedure, high levels of service quality and teamwork have been well maintained even under reduced staffing conditions. Survivors’ satisfaction with FCF services has risen significantly from an average of 4.0 prior to implementation of the quality management system to 4.7 afterward (full score: 5). The survivor´s family members also indicate strong satisfaction with FCF services. What was learned: Implementing the ISO 9001:2015 quality management system in the cancer survivor supportive care service has assisted FCF not only to increase the quality and quantity of its service deliveries but also to enhance the effectiveness of its professional team.

Cryo-EM analysis of the T3S injectisome reveals the structure of the needle and open secretin

The bacterial type III secretion system, or injectisome, is a syringe shaped nanomachine essential for the virulence of many disease causing Gram-negative bacteria. At the core of the injectisome structure is the needle complex, a continuous channel formed by the highly oligomerized inner and outer membrane hollow rings and a polymerized helical needle filament which spans through and projects into the infected host cell. Here we present the near-atomic resolution structure of a needle complex from the prototypical Salmonella Typhimurium SPI-1 type III secretion system, with local masking protocols allowing for model building and refinement of the major membrane spanning components of the needle complex base in addition to an isolated needle filament. This work provides significant insight into injectisome structure and assembly and importantly captures the molecular basis for substrate induced gating in the giant outer membrane secretin portal family.

The Redox-Sensing Regulator Rex Contributes to the Virulence and Oxidative Stress Response of Streptococcus suis Serotype 2

Streptococcus suis serotype 2 (SS2) is an important zoonotic pathogen responsible for septicemia and meningitis. The redox-sensing regulator Rex has been reported to play critical roles in the metabolism regulation, oxidative stress response, and virulence of various pathogens. In this study, we identified and characterized a Rex ortholog in the SS2 virulent strain SS2-1 that is involved in bacterial pathogenicity and stress environment susceptibility. Our data show that the Rex-knockout mutant strain Δrex exhibited impaired growth in medium with hydrogen peroxide or a low pH compared with the wildtype strain SS2-1 and the complementary strain CΔrex. In addition, Δrex showed a decreased level of survival in whole blood and in RAW264.7 macrophages. Further analyses revealed that Rex deficiency significantly attenuated bacterial virulence in an animal model. A comparative proteome analysis found that the expression levels of several proteins involved in virulence and oxidative stress were significantly different in Δrex compared with SS2-1. Electrophoretic mobility shift assays revealed that recombinant Rex specifically bound to the promoters of target genes in a manner that was modulated by NADH and NAD⁺. Taken together, our data suggest that Rex plays critical roles in the virulence and oxidative stress response of SS2.

Electro-acupuncture at ST37 and ST25 induce different effects on colonic motility via the enteric nervous system by affecting excitatory and inhibitory neurons

BACKGROUND

On the basis of the importance of the enteric nervous system (ENS) in gastrointestinal motility, we hypothesized that the ENS may mediate the therapeutic efficacy of electro-acupuncture (EA) in constipation by regulating the mechanisms underlying the effects of EA on gastrointestinal function.

METHODS

Model mice with constipation were generated by gastric instillation of 0-4°C normal saline. Defecation time and stool (form and wet and dry weight) were assessed. The effect of EA at ST37 or ST25 on colorectal motility and proximal colonic motility was assessed using a water-filled balloon. The expression of protein gene product 9.5 (PGP9.5), the cholinergic neuron marker acetyltransferase (ChAT) and the anticholinergic neuron marker nitric oxide synthase (nNOS) was detected by immunohistochemistry, real-time quantitative polymerase chain reaction (qPCR) and western blot analysis.

KEY RESULTS

ST37 and ST25 improved colorectal pressure; however, ST37 but not ST25 improved proximal colonic pressure. In the proximal colon, the expression of PGP9.5 returned to normal after EA at ST 37, while EA at ST25 did not have this effect. In addition, qPCR and western blot analysis showed that ST37 could downregulate the expression of nNOS and upregulate the expression of ChAT to normal levels, while ST25 could only downregulate the expression of nNOS to normal levels.

CONCLUSIONS AND INFERENCES

Electro-acupuncture at specific acupoints can improve intestinal motility in constipation by altering the ENS and differentially affecting excitatory and inhibitory neurons, restoring the coordination between contraction and relaxation muscles, and working in concert with the central nervous system and peripheral neural pathways.

Clinical and molecular insights into Glanzmann's thrombasthenia in China

Glanzmann's thrombasthenia (GT) is a rare bleeding disorder characterized by spontaneous mucocutaneous bleeding. The disorder is caused by quantitative or qualitative defects in integrin αIIbβ3 (encoded by ITGA2B and ITGB3) on the platelet and is more common in consanguineous populations. However, the prevalence rate and clinical characteristics of GT in non-consanguineous populations have been unclear. We analyzed 97 patients from 93 families with GT in the Han population in China. This analysis showed lower consanguinity (18.3%) in Han patients than other ethnic populations in GT-prone countries. Compared with other ethnic populations, there was no significant difference in the distribution of GT types. Han females suffered more severe bleeding and had a poorer prognosis. We identified a total of 43 different ITGA2B and ITGB3 variants, including 25 previously unidentified, in 45 patients. These variants included 14 missense, 4 nonsense, 4 frameshift, and 3 splicing site variants. Patients with the same genotype generally manifested the same GT type but presented with different bleeding severities. This suggests that GT clinical phenotype does not solely depend on genotype. Our study provides an initial, yet important, clinical and molecular characterization of GT heterogeneity in China.

Targeted Delivery of GP5 Antigen of PRRSV to M Cells Enhances the Antigen-Specific Systemic and Mucosal Immune Responses

Efficient delivery of antigens through oral immunization is a first and critical step for successful induction of mucosal immunity, which can provide protection against pathogens invading the mucosa. Membranous/microfold cells (M cells) within the mucosa can transcytose internalized antigen without degradation and thus play an important role in initiating antigen-specific mucosal immune responses through inducing secretory IgA production. In this research, we modified poly (D, L-lactide-co-glycolide) (PLGA) nanoparticles (NPs) with Ulex europaeus agglutinin 1 (UEA-1) and successfully prepared an oral vaccine delivery system, UEA-1/PLGA NPs. PLGA NPs were prepared using a standard double emulsion solvent evaporation technique, which can protect the entrapped PRRSV DNA vaccine [pcDNA3.1-SynORF5 (synthetic ORF5)] or subunit vaccine ORF5-encoded glycoprotein (GP5) from exposure to the gastrointestinal (GI) tract and release the plasmids in a controlled manner. With UEA-1 modification, the UEA-1/PLGA NPs can be effectively transported by M-cells. We investigated immune response induced by UEA-1/PLGA-SynORF5 or UEA-1/PLGA-GP5 following inoculation in mice and piglets. Compared with PLGA-SynORF5 or PLGA-GP5 NPs, UEA-1/PLGA-SynORF5, or UEA-1/PLGA-GP5 NPs stimulated significantly increased serum IgG levels and augmented intestinal IgA levels in mice and piglets (P < 0.05). Our findings indicate UEA-1/PLGA NPs can be applied as a promising and universally robust oral vaccine delivery system.

Short communication: Does early-life administration of a Megasphaera elsdenii probiotic affect long-term establishment of the organism in the rumen and alter rumen metabolism in the dairy calf?

Megasphaera elsdenii is a bacterial species of the rumen that can utilize lactate to produce butyrate, a key volatile fatty acid often implicated in driving calf rumen development. Because lactate is abundant in the rumen of young calves, administration of M. elsdenii to increase butyrate production and thus promote calf rumen development is an appealing possibility. The main objective of this study was to determine whether M. elsdenii administration to calves via oral drench at 14 d of age affected its long-term establishment at 70 d postadministration. Ruminal volatile fatty acid and lactate profiles and blood glucose and β-hydroxybutyrate concentrations were also examined to determine potential influence on rumen metabolism. Six neonatal Holstein heifer calves were blocked on d 1 by body weight (41.3 ± 1.8 kg) and total serum protein (5.23 ± 0.16 g/dL) and assigned to either the M. elsdenii (n = 3) or control (n = 3) treatment groups. On d 14, calves in the M. elsdenii group orally received 25 mL of a commercially available M. elsdenii suspension, whereas calves in the control group received 25 mL of the same product that had been autoclaved. Rumen contents and blood samples were collected weekly from each animal until 84 d of age. The oral administration of M. elsdenii at 14 d did not increase the abundance of M. elsdenii 70 d postdosing, alter rumen fermentation, or change blood metabolites associated with butyrate. These results suggest that a single administration of the M. elsdenii probiotic may not affect the rumen establishment of the organism.

Poly (d,l-lactide-co-glycolide) nanoparticle-entrapped vaccine induces a protective immune response against porcine epidemic diarrhea virus infection in piglets

Porcine epidemic diarrhea (PED) causes 80-100% mortality in neonatal piglets, and its causative agent, the porcine epidemic diarrhea virus (PEDV), poses an important threat to the swine industry worldwide. In this study, we prepared biodegradable poly (d,l-lactide-co-glycolide) (PLGA) nanoparticle-entrapped PEDV killed vaccine antigens (KAg) (PLGA-KAg). Late-term pregnant sows were intranasally inoculated with PLGA-KAg, and the mortality resulting from challenge with highly virulent PEDV was investigated in their passively immunized suckling piglets. PEDV-specific IgG and IgA antibody titers were enhanced in pregnant sows immunized with PLGA-KAg relative to the titers in sows inoculated with KAg. Similar results were seen in the passively immunized suckling piglets of these sows. Improved lymphocyte proliferation responses and IFN-γ levels were induced in pregnant sows immunized with PLGA-KAg compared with those vaccinated with KAg or with Montanide™ ISA 201 VG emulsified killed PEDV vaccine (201-KAg). Importantly, there was less piglet mortality in the group vaccinated with PLGA-KAg than in the groups vaccinated with KAg or 201-KAg. These results demonstrate that PLGA-KAg is a promising candidate vaccine that can provide protective immunity against PEDV infection in suckling piglets.

[Neurosyphilis and HIV co-infection with the initial symptom of sudden deafness and optic atrophy: a case report]

A 46-year-old male presented with left ear hearing loss,vertigo,tinnitus and left eye blurred vision. Pure tone audiometry showed left ear had been total deafness. Treponema pallidum particle agglutination (TPPA) assay was reactive. The serum rapid plasma regain (RPR) was 1∶16. Human immunodeficiency virus(HIV) 1/2 antibody immunoassay was positive，and the CD4 cell count was low at 100 cells/μl. Cerebrospinal fluid (CSF) TPPA was positive,with a white blood cell count of 53×10 ⁶ /L and protein level of 1.08 g/L.The diagnosis was:①left ear sudden deafness(total deafness type);②neurosyphilis;③acquired immune deficiency syndrome(AIDS).

BNIP3 induces apoptosis and protective autophagy under hypoxia in esophageal squamous cell carcinoma cell lines: BNIP3 regulates cell death

Bcl-2/adenovirus E1B 19-kDa interacting protein (BNIP3), a pro-apoptosis protein regulated by the methylation status of its promoter, has been implicated in inducing autophagy. However, the roles of BNIP3 and BNIP3-induced autophagy under hypoxia remain uncertain in esophageal squamous cell carcinoma (ESCC). Two esophageal squamous cancer cell lines, CAES17 and KYSE140, were selected on the basis of the expression and methylation status of BNIP3 to investigate the features of BNIP3 under hypoxia. Hypoxia increased cell death and the expression of BNIP3, whose promoter status was lower methylation, in a time-dependent manner. BNIP3 knockdown by RNA interference downregulated cell death. These studies demonstrated that the exposure of ESCC cells to hypoxia increased the autophagic punctate distribution of MDC staining and GFP-LC3 and that autophagy rate could be inhibited by BNIP3-siRNA. In addition, under hypoxia, cells transfected with BNIP3-siRNA exhibited a lower apoptosis rate than the control, and the apoptosis induced by BNIP3 exhibited a caspase-independent manner. Furthermore, the administration of the autophagic inhibitor 3-methyladenine (3-MA) could augment BNIP3-induced cell apoptosis and death, suggesting that autophagy plays a protective role under hypoxia. Together, our studies indicated that BNIP3 exerts prodeath effects through the induction of caspase-independent apoptosis under hypoxia in ESCC, though BNIP3-induced autophagy acting as a survival mechanism.

Salinomycin enhances doxorubicin sensitivity through reversing the epithelial-mesenchymal transition of cholangiocarcinoma cells by regulating ARK5

Chemotherapy response rates in patients with cholangiocarcinoma remain low, primarily due to the development of drug resistance. Epithelial-mesenchymal transition (EMT) of cancer cells is widely accepted to be important for metastasis and progression, but it has also been linked to the development of chemoresistance. Salinomycin (an antibiotic) has shown some potential as a chemotherapeutic agent as it selectively kills cancer stem cells, and has been hypothesized to block the EMT process. In this study, we investigated whether salinomycin could reverse the chemoresistance of cholangiocarcinoma cells to the chemotherapy drug doxorubicin. We found that combined salinomycin with doxorubicin treatment resulted in a significant decrease in cell viability compared with doxorubicin or salinomycin treatment alone in two cholangiocarcinoma cell lines (RBE and Huh-28). The dosages of both drugs that were required to produce a cytotoxic effect decreased, indicating that these two drugs have a synergistic effect. In terms of mechanism, salinomycin reversed doxorubicin-induced EMT of cholangiocarcinoma cells, as shown morphologically and through the detection of EMT markers. Moreover, we showed that salinomycin treatment downregulated the AMP-activated protein kinase family member 5 (ARK5) expression, which regulates the EMT process of cholangiocarcinoma. Our results indicated that salinomycin reversed the EMT process in cholangiocarcinoma cells by inhibiting ARK5 expression and enhanced the chemosensitivity of cholangiocarcinoma cells to doxorubicin. Therefore, a combined treatment of salinomycin with doxorubicin could be used to enhance doxorubicin sensitivity in patients with cholangiocarcinoma.

Effects of Teriparatide on Joint Erosions in Rheumatoid Arthritis: A Randomized Controlled Trial

OBJECTIVE

Articular erosions correlate with disability in rheumatoid arthritis (RA). Biologic agents reduce erosion progression in RA, but erosion healing occurs infrequently. This study was undertaken to assess the effects of the anabolic agent teriparatide on joint erosion volume in RA patients treated with a tumor necrosis factor inhibitor (TNFi).

METHODS

We conducted a randomized controlled trial in 24 patients with erosive RA, osteopenia, and disease activity controlled by TNFi treatment for at least 3 months. Half were randomized to receive teriparatide for 1 year and the others constituted a wait-list control group. Subjects and primary rheumatologists were not blinded with regard to treatment assignment, but all outcomes were assessed in a blinded manner. The primary outcome measure was change in erosion volume determined by computed tomography at 6 anatomic sites. Significance within each hand and anatomic site was based on a 2-tailed test, with P values less than 0.05 considered significant.

RESULTS

Baseline characteristics of the treatment groups were well balanced. After 52 weeks, the median change in erosion volume in the teriparatide group was -0.4 mm³ (interquartile range [IQR] -34.5, 29.6) and did not differ significantly from that in controls (median change +9.1 mm³ [IQR -29.6, 26.4]) (P = 0.28). No significant difference in change in erosion volume was noted at the radius, ulna, or metacarpophalangeal joints. Bone mineral density improved at the femoral neck and lumbar spine in the teriparatide group.

CONCLUSION

Our findings indicate that teriparatide treatment for 1 year does not significantly reduce erosion volume in the hands or wrists of patients with established RA with disease activity controlled by TNFi treatment.

Efficiency, effectiveness and treatment stability of clear aligners: A systematic review and meta-analysis

OBJECTIVES

The objective of this study was to perform a systematic review of the orthodontic literature with regard to efficiency, effectiveness and stability of treatment outcome with clear aligners compared with treatment with conventional brackets.

METHODS

An electronic search without time or language restrictions was undertaken in October 2014 in the following electronic databases: Google Scholar, the Cochrane Oral Health Group's Trials Register, Scopus, CENTRAL, MEDLINE via OVID, EMBASE via OVID and Web of Science. We also searched the reference lists of relevant articles. Quality assessment of the included articles was performed. Two authors were responsible for study selection, validity assessment and data extraction.

RESULTS

Four controlled clinical trials including a total of 252 participants satisfied the inclusion criteria. We grouped the trials into four main comparisons. One randomized controlled trial was classified as level 1B evidence, and three cohort studies were classified as level 2B evidence. Clear aligners appear to have a significant advantage with regard to chair time and treatment duration in mild-to-moderate cases based on several cross-sectional studies. No other differences in stability and occlusal characteristics after treatment were found between the two systems.

CONCLUSIONS

Despite claims about the effectiveness of clear aligners, evidence is generally lacking. Shortened treatment duration and chair time in mild-to-moderate cases appear to be the only significant effectiveness of clear aligners over conventional systems that are supported by the current evidence.

MicroRNA-30a-5p promotes replication of porcine circovirus type 2 through enhancing autophagy by targeting 14-3-3

Accumulating evidence demonstrates that autophagy and microRNAs (miRNAs) play key roles in regulating virus-host interactions and can restrict or facilitate viral replication. In the present study we examined whether a functional relationship exists between autophagy, miRNA and porcine circovirus type 2 (PCV2) infection, using several approaches. We demonstrated that there was a positive correlation between PCV2 infection and autophagy in 3D4/21 cells and autophagy induced by PCV2 infection triggered PCV2 replication. Four miRNA were selected by real-time PCR and further studied, but only miR-30a-5p mimic had a significant effect on PCV2 replication. Overexpression of miR-30a-5p significantly enhanced PCV2 infection and autophagy in a dose-dependent manner. Blockage of miR-30a-5p significantly decreased PCV2 replication. We provided further evidence that miR-30a-5p regulate the link between PCV2 infection and host immune system. Furthermore, miR-30a-5p targeted and regulated 14-3-3 gene, which is a regulator of autophagy. Flow cytometry data demonstrated that miR-30a-5p promotes cell cycle arrest at the G2 phase to regulate PCV2 replication and autophagy by interacting directly with 14-3-3, but not with the PCV2 genome. These data not only provide new insights into virus-host interactions during PCV2 infection but also suggest a potential new antiviral therapeutic strategy against PCV2 infection.