Clinical course and outcome of rheumatoid arthritis-related usual interstitial pneumonia

BACKGROUND

Although the prognosis of interstitial pneumonia in connective tissue disorders is better than that of idiopathic pulmonary fibrosis (IPF), the prognosis of rheumatoid arthritis (RA) related usual interstitial pneumonia (UIP) is controversial.

OBJECTIVES

To determine prognosis, clinical course and prognostic factors of the patients with RA-UIP and compare them to IPF.

DESIGN

Retrospective review of 84 patients with RA-UIP (biopsy-proven: 30) from two tertiary referral centers.

RESULTS

The median follow-up period was 33 months. One half of the patients were stable, one third progressed, 17% had acute exacerbation and 6% improved. TLC % predicted was the only significant predictor for the stable group. Among non-AEx patients, 41% was treated due to poor initial lung function or progression of the disease and one half of them improved or had stable lung function. Despite of worse initial lung function, the survival of treated group was similar to untreated group. Age, FVC and change in DLco during 6 months were significant predictors for mortality. The prognosis of RA-UIP was significantly better than that of IPF matched with age, sex, smoking and baseline lung function (median survival, 53 vs. 41 months respectively, p = 0.015).

CONCLUSIONS

In spite of variable clinical course of RA-UIP, overall prognosis of RA-UIP was significantly better compared to IPF. Our data supported the treatment of the patients with significant functional impairments or progression.

First Report of Oak Anthracnose Caused by Apiognomonia errabunda on Oriental White Oak in Korea

Oriental white oak, Quercus aliena Blume, is native to East Asia including Korea. It is one of the major deciduous tree species in natural forests in Korea. In May 2012, several hundred trees were found to be heavily damaged by a previously unknown leaf disease in a forest near Songjiho Lake in Goseong County of central Korea. Leaf symptoms began as small, water-soaked, pale greenish to grayish lesions, which enlarged to follow the veins or midribs and to be bounded by them, often killing part of the leaf. Leaf distortion and blight resulted in the later stage of disease development. A number of grayish brown to nearly black acervuli were formed on the lesions, especially on the midribs and veins. Acervuli were mostly hypophyllous, intraepidermal, erumpent, circular to ellipsoid in outline, cushion-like, and 70 to 220 μm in diameter. Conidia (n = 30) were elliptical to fusiform-elliptical, occasionally obclavate, aguttulate or guttulate, hyaline, aseptate, and 7.5 to 20 × 5 to 7.5 μm (mean 14.6 × 6.1 μm). These morphological characteristics of the fungus were consistent with the description of conidial state of Apiognomonia errabunda (Roberge ex Desm.) Höhn. (3,4). Voucher specimens were deposited in the Korea University Herbarium (KUS). An isolate obtained from KUS-F26690 was deposited in the Korean Agricultural Culture Collection (Accession No. KACC46842). Fungal DNA was extracted with DNeasy Plant Mini DNA Extraction Kits (Qiagen Inc., Valencia, CA). The complete internal transcribed spacer (ITS) region of rDNA was amplified with the primers ITS1/ITS4 and sequenced. The resulting 549-bp sequence was deposited in GenBank (KC426947). This showed >99% similarity with sequences of A. errabunda (AJ888475 to 888477). For pathogenicity test, inoculum was prepared by harvesting conidia from 4-week-old cultures on potato dextrose agar. A conidial suspension (1 × 10⁶ conidia/ml) was sprayed onto young leaves of three potted seedlings. Three seedlings treated with sterile distilled water served as controls. Plants were covered with plastic bags to maintain 100% relative humidity for 24 h and then kept in a greenhouse (20 to 26°C and 60 to 80% RH). After 26 days, typical leaf spot symptoms, identical to the ones observed in the field, developed on the inoculated leaves. No symptoms were observed on controls. A. errabunda was reisolated from the lesions of inoculated plants, fulfilling Koch's postulates. Oak anthracnose associated with A. errabunda (including A. quercina) has been recorded in Europe and North America (1,4). Oak anthracnose of evergreen Quercus glauca Thunb. (syn. Cyclobalanopsis glauca (Thunb.) Oerst.) associated with A. supraseptata in Japan is not related to this disease (2). To our knowledge, this is the first report of oak anthracnose of Q. aliena globally and also the first finding of A. errabunda in Asia as well as in Korea. This pathogen is known as one of the major forest pathogens in oak stand in Europe and North America (3). Pending further studies, including a risk assessment, A. errabunda may be considered as a potentially new and serious threat in native and planted ranges of Q. aliena in Korea. References: (1) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., Online publication, ARS, USDA, retrieved February 18, 2013. (2) S. Kaneko and T. Kobayashi. Trans. Mycol. Soc. Japan 25:11, 1984. (3) A. Ragazzi et al. Phytopathol. Mediterr. 46:295, 2007. (4) M. V. Sogonov et al. Mycol. Res. 111:693, 2007.

Markers of systemic inflammation predict survival in patients with advanced renal cell cancer

Background:

The host inflammatory response has a vital role in carcinogenesis and tumour progression. We examined the prognostic value of inflammatory markers (albumin, white-cell count and its components, and platelets) in pre-treated patients with advanced renal cell carcinoma (RCC).

Methods:

Using data from a randomised trial, multivariable proportional hazards models were generated to examine the impact of inflammatory markers and established prognostic factors (performance status, calcium, and haemoglobin) on overall survival (OS). We evaluated a new prognostic classification incorporating additional information from inflammatory markers.

Results:

Of the 416 patients, 362 were included in the analysis. Elevated neutrophil counts, elevated platelet counts, and a high neutrophil–lymphocyte ratio were significant independent predictors for shorter OS in a model with established prognostic factors. The addition of inflammatory markers improves the discriminatory value of the prognostic classification as compared with established factors alone (C-statistic 0.673 vs 0.654, P=0.002 for the difference), with 25.8% (P=0.004) of patients more appropriately classified using the new classification.

Conclusion:

Markers of systemic inflammation contribute significantly to prognostic classification in addition to established factors for pre-treated patients with advanced RCC. Upon validation of these data in independent studies, stratification of patients using these markers in future clinical trials is recommended.

Talon cusp affecting primary dentition in two siblings: a case report

The term talon cusp refers to a rare developmental dental anomaly characterized by a cusp-like structure projecting from the cingulum area or cement-enamel junction. This condition can occur in the maxillary and mandibular arches of the primary and permanent dentitions. The purpose of this paper is to report on the presence of talon cusps in the primary dentition of two southern Chinese siblings. The 4 years and 2 months old girl had a talon cusp on her maxillary right primary central incisor, while her 2 years and 9 months old brother had bilateral talon cusps on the maxillary primary central incisors. The presence of this rare dental anomaly in two siblings has scarcely been reported in the literature and this may provide further evidence of a hereditary etiology.

A prognostic nomogram to predict overall survival in patients with platinum-sensitive recurrent ovarian cancer

BACKGROUND

Patients with platinum-sensitive recurrent ovarian cancer have variable prognosis and survival. We extend previous work on prediction of progression-free survival by developing a nomogram to predict overall survival (OS) in these patients treated with platinum-based chemotherapy.

PATIENTS AND METHODS

The nomogram was developed using data from the CAELYX in Platinum-Sensitive Ovarian Patients (CALYPSO) trial. Multivariate proportional hazards models were generated based on pre-treatment characteristics to develop a nomogram that classifies patient prognosis based on OS outcome. We also developed two simpler models with fewer variables and conducted model validations in independent datasets from AGO-OVAR Study 2.5 and ICON 4. We compare the performance of the nomogram with the simpler models by examining the differences in the C-statistics and net reclassification index (NRI).

RESULTS

The nomogram included six significant predictors: interval from last platinum chemotherapy, performance status, size of the largest tumour, CA-125, haemoglobin and the number of organ sites of metastasis (C-statistic 0.67; 95% confidence interval 0.65-0.69). Among the CALPYSO patients, the median OS for good, intermediate and poor prognosis groups was 56.2, 31.0 and 20.8 months, respectively. When CA-125 was not included in the model, the C-statistics were 0.65 (CALYPSO) and 0.64 (AGO-OVAR 2.5). A simpler model (interval from last platinum chemotherapy, performance status and CA-125) produced a significant decrease of the C-statistic (0.63) and NRI (26.4%, P < 0.0001).

CONCLUSIONS

This nomogram with six pre-treatment characteristics improves OS prediction in patients with platinum-sensitive ovarian cancer and is superior to models with fewer prognostic factors or platinum chemotherapy free interval alone. With independent validation, this nomogram could potentially be useful for improved stratification of patients in clinical trials and also for counselling patients.

A study of the predonation hemoglobin and iron status among Hong Kong Chinese blood donors

BACKGROUND

Predonation hemoglobin (PDH) is used to safeguard donors' welfare, and low hemoglobin (Hb) is known to be the most frequent reason for donor deferral. A study was initiated to assess the PDH and iron status of blood donors in Hong Kong.

STUDY DESIGN AND METHODS

This observational study was designed with four groups of whole blood donors invited (group 1-eligible first time donors, group 2-eligible repeat donors with zero or one donation in preceding 12 months, group 3-eligible repeat donors with at least two donations in preceding 12 months, group 4-repeat donors being deferred for low PDH). Predonation blood samples were obtained for blood counts and iron status. Mann-Whitney test, Kruskal-Wallis test, and chi-square test for trend were applied for statistical analysis.

RESULTS

A total of 836 donors were recruited, of which 35 were excluded because of hemoglobinopathy. An inverse relationship between serum ferritin level and number of donations in the preceding 12 months was observed in both sexes. Iron deficiency was significantly seen in 35.1% of male and 65.3% of female deferred donors. More importantly, up to 7.2, 5.8, and 29.5% of the female donors in groups 1, 2, and 3 were found to be iron deficient despite having a high enough PDH.

CONCLUSION

This is the first study to assess PDH and iron status in Chinese blood donors. Iron depletion is noted with increasing number of blood donations in the preceding 12 months. Advice on iron repletion is a necessary step for donor welfare and strategies should be developed to ensure that donors have adequate PDH.

Effectiveness and cost-effectiveness of sentinel lymph node biopsy compared with axillary node dissection in patients with early-stage breast cancer: a decision model analysis

Background:

Sentinel lymph node biopsy (SLNB) is less invasive than axillary lymph node dissection (ALND) for staging early breast cancer, and has a lower risk of arm lymphoedema and similar rates of locoregional recurrence up to 8 years. This study estimates the longer-term effectiveness and cost-effectiveness of SLNB.

Methods:

A Markov decision model was developed to estimate the incremental quality-adjusted life years (QALYs) and costs of an SLNB-based staging and management strategy compared with ALND over 20 years’ follow-up. The probability and quality-of-life weighting (utility) of outcomes were estimated from published data and population statistics. Costs were estimated from the perspective of the Australian health care system. The model was used to identify key factors affecting treatment decisions.

Results:

The SLNB was more effective and less costly than the ALND over 20 years, with 8 QALYs gained and $883 000 saved per 1000 patients. The SLNB was less effective when: SLNB false negative (FN) rate >13% 5-year incidence of axillary recurrence after an SLNB FN>19% risk of an SLNB-positive result >48% lymphoedema prevalence after ALND <14% or lymphoedema utility decrement <0.012.

Conclusion:

The long-term advantage of SLNB over ALND was modest and sensitive to variations in key assumptions, indicating a need for reliable information on lymphoedema incidence and disutility following SLNB. In addition to awaiting longer-term trial data, risk models to better identify patients at high risk of axillary metastasis will be valuable to inform decision-making.

Clinically significant red blood cell antibodies in chronically transfused patients: a survey of Chinese thalassemia major patients and literature review

BACKGROUND

Red blood cell (RBC) alloimmunization is reported to occur at an incidence of 5.2% to 23.5% among patients with thalassemia requiring chronic transfusion. With very limited data on alloimmunization among the Chinese population, a territory-wide study has been performed to look at its prevalence among Chinese thalassemia major patients.

STUDY DESIGN AND METHODS

A retrospective study was conducted by reviewing RBC request records for patients with thalassemia major in Hong Kong from 2006 to 2009. Demographic information and serologic data were retrieved for analysis.

RESULTS

A total of 382 patients were identified and consisted of 190 males and 192 females with a median age of 23 ± 10.4 (range, 0.25 to 52) years. Eighty-eight patients (23.0%) were reported to have RBC antibodies. Of them, 114 alloantibodies, 18 autoantibodies, and 19 unidentified antibodies were identified. Anti-E (42, 39.3%), anti-Mi(a)/Mur (33, 30.85%), anti-c (14, 13.1%), and anti-Jk(a) (seven, 6.55%) were the commonest antibodies reported. However, one case of anti-K (0.9%) and two cases of anti-Fy(b) (1.9%) were reported. Seven of the 18 patients with autoantibodies contained a total of 13 alloantibodies. They were anti-E (five, 38.4%), anti-Mi(a)/Mur (four, 30.8%), anti-Jk(a) (two, 15.4%), anti-c (one, 7.7%), and anti-Fy(b) (one, 7.7%).

CONCLUSION

It is the first comprehensive study on Chinese thalassemia major patients. Clinically significant alloantibodies are different from those observed in the Western population, although antibodies developed against Rh antigens are still common. Chinese patients are less likely to have antibodies against Kell and Duffy blood group antigens, but are more prone to develop antibodies against the Miltenberger antigens.

Antimicrobial gauze as a dressing reduces pin site infection: a randomized controlled trial

BACKGROUND

Pin site infection is a common problem in external fixation. Plain gauze wetted with normal saline is commonly used for a pin site dressing owing to the simplicity and low cost. Evidence to support adding an antimicrobial agent in the dressing material is lacking.

QUESTIONS/PURPOSES

We compared the rate of pin tract infection using plain gauze and gauze impregnated with polyhexamethylene biguanide in patients undergoing limb lengthening procedures.

PATIENTS AND METHODS

We included 38 patients (40 limbs) undergoing limb lengthening or deformity correction using an external fixator between July 2009 and June 2010. There were 23 male patients and 15 female patients, with a mean age of 26.3 years (range, 5-68 years). The patients were randomized into two groups: a polyhexamethylene biguanide group (22 limbs) and a control group (18 limbs). The metal-skin interfaces were assessed by a researcher blinded to the type of gauze at 2, 4, 8, and 12 weeks after surgery for the pin site infection based on a predetermined grading system. There were a total of 483 metal-skin interfaces, with 1932 total observations. Infection rates were compared using the chi square test and relative risk with 95% confidence interval.

RESULTS

The infection rate was lower (χ(2) [1, n = 1932] = 23.00) and the risk for infection was lower (relative risk, 0.228; 95% confidence interval, 0.118, 0.443) for the polyhexamethylene biguanide group (n = 1068; 1.0%) than for the control group (n = 864; 4.5%).

CONCLUSIONS

Use of polyhexamethylene biguanide-impregnated gauze can reduce the risk of pin tract infection in external fixation.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

215 COMPARATIVE ANALYSIS OF PORCINE PLURIPOTENT CELL LINES DERIVED FROM SOMATIC CELLS AND VARIOUS EMBRYONIC ORIGINS

Since pluripotent cells were first derived from the inner cell mass (ICM) of mouse blastocysts, tremendous efforts have been made to establish embryonic stem cell (ESC) lines in several domestic species including the pig; however, authentic porcine ESCs have not yet been established. It has proven difficult to derive pluripotent cells of naïve state that represents full pluripotency, due to the frequent occurrence of spontaneous differentiation into an EpiSC-like state during culture in pigs. We have been able to derive EpiSC-like porcine embryonic stem cell (pESC) lines of a differentiated non-ES cell state from blastocyst stage porcine embryos of various origins, including in vitro fertilized (IVF), in vivo derived, IVF aggregated and parthenogenetic embryos. In addition, we have generated induced pluripotent stem cells (piPSCs) via plasmid transfection of reprogramming factors (Oct4, Sox2, Klf4 and c-Myc) into porcine fibroblast cells. In this study, we analysed characteristics such as marker expression, pluripotency and the X chromosome inactivation (XCI) status of our EpiSC-like pESC lines along with our piPSC line. Our results show that these cell lines demonstrate the expression of genes associated with the Activin/Nodal and FGF2 pathways along with the expression of pluripotent markers Oct4, Sox2, Nanog, SSEA4, TRA 1-60 and TRA 1-81. Furthermore all of these cell lines showed in vitro differentiation potential; female XCI activity and a normal karyotype. Here we provide preliminary results that suggest that, as a nonpermissive species, the porcine species undergoes reprogramming into a primed state during the establishment of pluripotent stem cell lines. This work was supported by the BioGreen 21 Program (#20070401034031, PJ0081382011), Rural Development Administration, Republic of Korea.

First Report of Leaf Spot Caused by Ascochyta marginata on Aralia elata in Korea

Aralia elata (Miq.) Seem., known as Japanese angelica tree, is a deciduous shrub belonging to the Araliaceae, which is native to East Asia. The young shoots have long been used in various dishes in East Asia. Commercial cultivation of this shrub, especially in polytunnels, is expanding in Korea. Several diseases including Sclerotinia rot have been known to be present on this plant (1,2). In early September 2007, leaf spot symptoms were first observed on several trees in Hongcheon, Korea. Microscopic observations revealed that the leaf spots were associated with an Ascochyta sp. Further surveys of the Ascochyta leaf spot showed the occurrence of the disease in approximately 5 to 10% of the trees in the 3 ha of commercial fields surveyed in Chuncheon, Gapyeong, Inje, and Jinju, Korea. Initial symptoms on leaves were circular to irregular, brown to dark brown, becoming zonate, and finally fading to grayish brown in the center with a yellow halo. Representative samples were deposited in the herbarium of Korea University. Conidiomata on leaf lesions were pycnidial, amphigenous, but mostly epiphyllous, immersed or semi-immersed in host tissue, light brown to olive brown, and 60 to 200 μm in diameter. Ostioles were papillate, 20 to 35 μm wide, and surrounded by a ring of darker cells. Conidia were hyaline, smooth, cylindrical to clavate, straight to mildly curved, slightly constricted at the septa, medianly one-septate, sometimes aseptate, 8 to 16 × 2.5 to 3.5 μm, and contained small oil drops. These morphological characteristics were consistent with the previous reports of Ascochyta marginata J.J. Davis (3,4). A monoconidial isolate was cultured on potato dextrose agar (PDA) plates and accessioned in the Korea Agricultural Culture Collection (Accession KACC43082). The conidia were readily formed on PDA. Inoculum for the pathogenicity tests was prepared by harvesting conidia from 30-day-old cultures of KACC43082 and a conidial suspension (approximately 2 × 10⁶ conidia/ml) was sprayed onto leaves of three healthy seedlings. Three noninoculated seedlings served as controls. Inoculated and noninoculated plants were covered with plastic bags for 48 h in a glasshouse. After 7 days, typical leaf spot symptoms started to develop on the leaves of the inoculated plants. The fungus, A. marginata, was reisolated from those lesions, confirming Koch's postulates. No symptoms were observed on control plants. Previously, the disease was reported in Japan (4) and China (3). To our knowledge, this is the first report of A. marginata on Japanese angelica trees in Korea. According to our field observations in Korea, the Ascochyta leaf spot mostly occurred on plants growing in a humid environment, especially during the rainy season. The seedlings as well as the trees growing in sunny, well-ventilated plots were nearly free from this disease. Therefore, the growing conditions seemed to be the most important factor for the development and severity of the disease. References: (1) C. K. Lee et al. Plant Pathol. J. 26:426, 2010. (2) S. H. Lee et al. Diseases of Japanese Angelica Tree and Their Control. Research Report 08-10. Korea Forest Research Institute. Seoul, Korea, 2008. (3) J. Sun et al. Acta Mycol. Sin. 14:107, 1995. (4) M. Yoshikawa and T. Yokoyama. Mycoscience 36:67, 1995.

Risk factor analysis of hepatitis C virus infection among Chinese blood donors in Hong Kong

BACKGROUND

Hepatitis C virus (HCV) infection can result in serious hepatic complications and hence potentially significant burden to the society. Despite advances in technology, transfusion-transmitted HCV infection still exists. To further minimise the risk, a review on the epidemiology of HCV infection among Chinese blood donors in Hong Kong was conducted.

METHODS

All donations associated with HCV infection confirmed by positive serologic diagnosis with or without molecular confirmation during the period from 2003 to 2010 were studied. Demographic data were retrieved and risk factors were identified.

RESULTS

HCV infection was more commonly seen in first time donors and donors with blood transfusion history before the availability of HCV testing, whereas its association with intravenous drug use was noted to be decreasing. Interestingly, half of the HCV positive donors in 2008-2010 were young donors aged below 21, which was also the group with the highest rate of no known source of infection.

CONCLUSION

A subgroup of younger age donors was found to have no known risk factor. To develop better screening strategy, it is recommended that a more detailed analysis of this group of donors is required.