First Report of Postharvest Rot of Chestnuts Caused by Mucor racemosus f. sphaerosporus in Korea

The Republic of Korea (South Korea) is the second largest chestnut producer in the world. Major cultivars planted in Korea, including cv. Daebo, Hyogo57, and Okkwang, are hybrids of Japanese chestnut (Castanea crenata) and Chinese chestnut (C. mollissima). Because of high perishability, most chestnuts harvested in September and October are preserved in cold rooms (0°C) for marketing. During a survey of postharvest diseases in April to August 2013, chestnut rots were continuously observed in cold rooms located in Buyeo County, Korea. Preliminary studies revealed that the most common agent of rot appeared to be a species of Mucor. When cut open, infected chestnuts showed partial interior discoloration varying from chalky white to dark brown. About 3 to 10% of chestnuts showed symptoms. Hyogo57 seemed to be the most susceptible variety with higher infection rates, up to 30% in some piles. Isolation was done by placing infected tissues on potato dextrose agar. A representative isolate was deposited in the Korean Agricultural Culture Collection (Accession No. KACC47727). Sporangiophores were mostly erect, branched sympodially, and hyaline. Sporangia were globose, pale yellow at first, then grayish brown at maturity. Columellae were obovoid to globose, subhyaline to pale brown, and usually with truncate base and collars. Sporangiospores were globose to irregular, and 4 to 10 μm in diameter. Chlamydospores were cylindrical to globose with oil drops. The fungus was identified as Mucor racemosus f. sphaerosporus (Hagem) Schipper based on the morphological characteristics and growth at low temperature (3). To conduct molecular analyses, genomic DNA was extracted with DNeasy Plant Mini Kits (Qiagen Inc., Valencia, CA). The primers ITS1/ITS4 and NL1/LR3 were used to amplify the internal transcribed spacer (ITS) region of rDNA and the D1/D2 region of the large subunit (4). The resulting 595-bp ITS sequences and 678 bp D1/D2 sequences were deposited in GenBank (Accession Nos. KJ769665 and KF769666). BLAST searches revealed that both the ITS sequences and D1/D2 sequences showed more than 99% similarity with those of M. racemosus f. sphaerosporus, respectively (JN939201 and AJ878775). To perform a pathogenicity test, a suspension of sporangiospores (1 × 10⁵ spores/ml) was sprayed over 10 chestnuts cv. Hyogo57 wounded with a sewing needle and kept in plastic containers (0°C, 100% RH). Another 10 chestnuts wounded with a sewing needle and treated with sterile water served as controls. After 5 days, typical rots appeared on the inoculated chestnuts, whereas no symptoms were observed on controls. Koch's postulates were fulfilled with the re-isolation of M. racemosus from inoculated chestnuts. The pathogenicity test was carried out twice with similar results. M. hiemalis and M. mucedo have been recorded on chestnuts as postharvest pathogens in Switzerland (2) and Chile (1). To our knowledge, this is first report of postharvest rot of chestnut caused by M. racemosus f. sphaerosporus worldwide as well as in Korea. Further studies are necessary for control measures during cold storage of fresh chestnuts. References: (1) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., online publication, ARS, USDA, Retrieved May 23, 2014. (2) M. Jermini et al. J. Sci. Food Agric. 86:877, 2006. (3) M. A. A. Schipper. Stud. Mycol. 12:1, 1976. (4) G. Walther et al. Persoonia 30:11, 2013.

First Report of Leaf Spot Caused by Phoma dictamnicola on Dictamnus dasycarpus in Korea

Dictamnus dasycarpus Turcz, known as densefruit pittany, is a perennial herbal plant belonging to the Rutaceae. In Oriental medicine, this plant is used for treatment of various ailments (4). Since the white and purple striped flowers and glossy leaves are of aesthetic value, the plant is popular in gardens throughout Korea. In July 2012, a leaf spot was observed on hundreds of D. dasycarpus with nearly 100% incidence in a garden in Gapyeong County, Korea. Lesions on leaves reaching up to 20 mm in diameter were circular to irregular, brown to dark brown, then becoming zonate with age, and finally fading to grayish brown in the center with a reddish brown margin. The disease caused premature defoliation and reduced plant vigor as well as aesthetic value. In June 2014, the same symptoms were found on D. dasycarpus in a nursery in Jinju City, Korea. Representative samples were deposited in the Korea University Herbarium (KUS). Pycnidia on lesions were epiphyllous, immersed or semi-immersed in host tissue, light brown to olive brown, and 90 to 210 μm in diameter. Ostioles were 15 to 30 μm wide and surrounded by a ring of darker cells. Conidia were hyaline, smooth, ellipsoidal to nearly reniform, straight to mildly curved, aseptate or rarely medianly 1-septate with age, 5.5 to 9.6 × 1.8 to 3.6 μm, and contained small oil drops. These characteristics were consistent with the previous descriptions of Phoma dictamnicola Boerema, Gruyter & Noordel. (1,2). A monoconidial isolate was cultured on potato dextrose agar plates and deposited in the Korea Agricultural Culture Collection (Accession No. KACC46948). Morphological identification of the fungus was confirmed by molecular data. Genomic DNA was extracted using a DNeasy Plant Mini Kit (Qiagen Inc., Valencia, CA). The internal transcribed spacer (ITS) region of rDNA was amplified using the ITS1/ITS4 primers and sequenced. The resulting sequence of 505 bp was deposited in GenBank (Accession No. KM047023). A BLAST search showed that the ITS sequence shared >99% similarity with that of P. dictamnicola (GU237877). For the pathogenicity tests, inoculum was prepared by harvesting conidia from 30-day-old cultures of KACC46948 and a conidial suspension (2 × 10⁶ conidia/ml) was sprayed onto leaves of five healthy seedlings. Five seedlings were sprayed with sterile distilled water, serving as controls. The plants were covered with transparent plastic bags for 48 h in a 25°C glasshouse with a 12-h photoperiod. After 10 days, typical leaf spot symptoms started to develop on the leaves of the inoculated plants. The fungus, P. dictamnicola, was re-isolated from those lesions, confirming Koch's postulates. No symptoms were observed on control plants. Previously, Phoma leaf spot on Dictamnus spp. has been reported in the Netherlands and North America (3) and recently in China (1). To our knowledge, this is the first report of leaf spot on D. dasycarpus caused by P. dictamnicola in Korea. Our observations suggest that low humidity with good ventilation as well as removal of infected leaves and plant debris might be main strategies for preventing this disease. References: (1) Q. Bai et al. Plant Dis. 95:771, 2011. (2) G. H. Boerema et al. Phoma Identification Manual: Differentiation of Specific and Infra-Specific Taxa in Culture. CABI Publishing. Wallingford, UK, 2004. (3) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., Online publication, USDA ARS, Retrieved June 19, 2014. (4) J. L. Yang et al. Planta Med. 77:271, 2011.

First Report of Powdery Mildew Caused by Phyllactinia actinidiae on Hardy Kiwi in Korea

Actinidia arguta (Siebold & Zucc.) Planch. ex Miq., known as hardy kiwi, is a perennial vine native to Japan, Korea, northern China, and Russian Siberia. It produces a small fruit resembling the kiwifruit. The fruits, referred to as hardy kiwifruit, are edible and often sweeter than kiwifruit. Picking of wild hardy kiwifruits in autumn is a popular ecotourism activity in Korea. In 2000, a powdery mildew disease on the abaxial surface of hardy kiwi leaves was found in Korea. Additional findings of the powdery mildew between 2000 and 2013 showed that the disease of hardy kiwi commonly occurs in Korea. The infected leaves were frequently distorted when young, then becoming prematurely chlorotic and defoliated. Chasmothecia were abundantly formed by September. Voucher specimens (n = 21) were deposited in the Korea University Herbarium (KUS). Mycelia were hypophyllous, thinly effuse, initially forming patches, finally covering the whole abaxial leaf surface. Hyphal appressoria were hook-shaped or often branched, and single or opposite in pairs. Conidiophores were erect, cylindrical, 160 to 300 × 5 to 7.5 μm with straight foot-cells (65 to 115 μm long), basal septum elevated up to 15 μm, and produced conidia singly. Conidia were obpyriform to clavate, papillate at the apex, 55 to 75 × 20 to 32 μm, and devoid of fibrosin bodies. Germ tubes were produced at the terminal and lateral positions of conidia. Chasmothecia were blackish brown, depressed globose, and 190 to 250 μm in diameter. Appendages arising around the equatorial zone of chasmothecia were 9 to 15 in number, acicular with a bulbose base, 1 to 1.3 times as long as the chasmothecial diameter, hyaline throughout, and aseptate. Penicillate cells crowded on the upper part of the chasmothecia were ampulliform, numerous, 50 to 87.8 μm long, and 12.5 to 17.5 μm wide. Asci were 13 to 20 in a chasmothecium, olivaceous brown, 60 to 90 × 22.5 to 40 μm, and short stalked. Ascospores were 2 in an ascus, ellipsoid-ovoid, pale olivaceous, and 32.5 to 40 × 16.5 to 20 μm. On the basis of the morphological characteristics, this fungus was identified as Phyllactinia actinidiae (Jacz.) Bunkina (1). To confirm the identification, the complete internal transcribed spacer (ITS) regions of rDNA of three specimens (KUS-F23673, F26240, and F26308) were amplified using primers ITS5/P3 and sequenced (4). The resulting sequences were deposited in GenBank (Accession Nos. KJ703014, KJ703015, and KJ703016). GenBank BLAST search with the three isolates showed >99% similarity with the results for P. actinidiae on hardy kiwi from Japan (AB080489, AB080500, and AB080508). Actinidia-Phyllactinia associations were recorded in China, Japan, Taiwan, Korea, Russia, and Turkey (2,3). However, P. actinidiae on A. arguta was known only from Japan (3). To our knowledge, this is the first record of P. actinidiae on hardy kiwi in Korea. There has been no finding of powdery mildews on commercial varieties of golden kiwi (A. chinensis) and fuzzy kiwi (A. deliciosa) in Korea. Common occurrence of Phyllactinia powdery mildew on hardy kiwi in Korea can be a potential threat to the commercial kiwi industry. References: (1) U. Braun and R. T. A. Cook. Taxonomic Manual of the Erysiphales (Powdery Mildews), CBS Biodiversity Series No.11. CBS, Utrecht, 2012. (2) I. Erper et al. Scand. J. Forest Res. 27:432, 2012. (3) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., Online publication. ARS, USDA, March 10, 2014. (4) S. Takamatsu et al. Mycol. Res. 113:117, 2009.

First Report of Powdery Mildew Caused by Erysiphe elevata on Catalpa bignonioides in Korea

Catalpa bignonioides Walter, known as southern catalpa or Indian bean tree, is native to the southeastern United States and are planted as shade trees throughout the world. In August 2009, typical powdery mildew symptoms on several leaves of the plants below 5% disease incidence were observed in a public garden of Hongcheon County of Korea. In 2011 to 2013, hundreds of southern catalpa trees were found heavily damaged by a powdery mildew with 90 to 100% disease incidence in a park of Incheon City of Korea, about 140 km apart from Hongcheon County. Symptoms appeared as circular to irregular white patches, which subsequently showed abundant mycelial growth on both sides of leaves and herbaceous stems. Severe infections caused poor growth and premature loss of leaves, resulting in reduced aesthetic value. Voucher specimens (n = 6) were deposited in the Korea University Herbarium (KUS). Appressoria on the mycelium were well-developed, lobed, and solitary or in opposite pairs. Conidiophores composed of 3 to 4 cells were 70 to 100 × 7.5 to 10 μm, and produced conidia singly. Foot-cells of conidiophores were flexuous or nearly straight, and 20 to 40 μm long. Conidia were oblong to oblong-elliptical, measured 30 to 42 × 13 to 20 μm (n = 30) with a length/width ratio of 1.6 to 2.5, devoid of distinct fibrosin bodies, and showed angular/rectangular wrinkling of outer walls. Primary conidia were apically rounded, basally subtruncate, and generally smaller than the secondary conidia. Germ tubes were produced on the end of conidia. Chasmothecia were not observed. These structures are typical of the Pseudoidium anamorph of the genus Erysiphe. The specific measurements and characteristics were compatible with those of E. elevata (Burrill) U. Braun & S. Takam. (1,2). To confirm the identification, the complete internal transcribed spacer (ITS) region of rDNA from KUS-F27676 was amplified with primers ITS5 and P3 (4) and sequenced directly. The resulting 675-bp sequence was deposited in GenBank (Accession No. KF840721). A GenBank BLAST search of the ITS sequence showed >99% similarity with isolates of E. elevata on C. bignonioides (Accession Nos. AY587012 to AY587014). Pathogenicity was confirmed through inoculation by gently dusting conidia onto leaves of five healthy southern catalpa seedlings. Five non-inoculated plants served as controls. Inoculated and non-inoculated plants were maintained in a greenhouse at 24 to 28°C in isolation. Inoculated plants developed symptoms after 6 days, whereas the control plants remained symptomless. The fungus present on the inoculated plants was identical morphologically to that originally observed on diseased plants. E.elevata is a North American powdery mildew on Catalpa species which was recently introduced into Europe (1,2,3). To our knowledge, this is the first report of powdery mildew caused by E. elevata on C. bignonioides in Asia as well as in Korea. The disease would be a serious threat to the widespread ornamental plantings of C. bignonioides in Korea. References: (1) N. Ale-Agha et al. Mycol. Prog. 3:291, 2004. (2) U. Braun and R. T. A. Cook. Taxonomic Manual of the Erysiphales (Powdery Mildews), CBS Biodiversity Series No.11. CBS, Utrecht, 2012. (3) D. F. Farr and A. Y. Rossman. Fungal Databases, Syst. Mycol. Microbiol. Lab., Online publication. ARS, USDA. Retrieved November 4, 2013. (4) S. Takamatsu et al. Mycol. Res. 113:117, 2009.

Abstract P1-08-14: HER2 extracellular domain (ECD): A predictive marker of lapatinib treatment benefit in advanced breast cancer

Pretreatment serum HER2 ECD may be associated with clinical outcome to lapatinib therapy and may also have treatment-independent prognostic value. We performed a meta-analysis to examine the prognostic and predictive role of baseline ECD (bECD) levels for lapatinib therapy. We also compared and contrasted its role with tumor HER2 status.

We analyzed bECD and tumor HER2 data in 1902 of 2264 patients (84%) with advanced breast cancer who were randomly assigned to receive lapatinib-containing therapy or control treatment in three clinical trials: EGF30001 (lapatinib and paclitaxel vs paclitaxel), EGF30008 (lapatinib and letrozole vs letrozole), and EGF100151 (lapatinib and capecitabine vs capecitabine). bECD was centrally measured by enzyme linked immunoassay and tumor HER2 was centrally determined by immunohistochemistry and fluorescence in situ hybridization. bECD and tumor HER2 status were examined for associations with objective tumor response (ORR), progression-free survival (PFS) and overall survival (OS) in the treatment groups.

Of the patients with both bECD and tumor HER2 data, 31% had HER2 bECD≥15 ng/mL and 28% had HER2+ cancer. The effectiveness of lapatinib-containing therapy was significantly associated with bECD level (treatment-bECD interaction P<0.001 [ORR], P<0.001 [PFS]). In patients with bECD≥15 ng/mL, lapatinib-containing therapy, compared to control, significantly improved ORR (odds ratio [OR] for complete and partial response, 1.88; P = 0.001) and PFS (hazards ratio [HR] for progression or death, 0.69; P<0.001). Among patients with bECD<15 ng/mL, there was no significant difference between treatment groups for ORR (OR, 1.17; P = 0.19) or PFS (HR, 0.93; P = 0.30). The effectiveness of lapatinib-containing therapy was also significantly associated with HER2 tumor status for ORR (OR [HER2+] 2.39, P<0.001; OR [HER2-] 1.10, P = 0.43; treatment-HER2 interaction P = 0.001) and PFS (HR [HER2+] 0.63, P<0.001; HR [HER2-] 0.95, P = 0.46; treatment-HER2 interaction P<0.001). When bECD and HER2 tumor status were examined together, the effectiveness of lapatinib-containing therapy was significantly associated with both bECD and HER2 tumor status for PFS (treatment-biomarker interaction P = 0.02[HER2], P = 0.001[bECD]) but only for bECD for ORR (treatment-biomarker interaction P = 0.07 [HER2], P = 0.003 [bECD]). The effectiveness of lapatinib-containing therapy was not significantly associated with OS for both biomarkers (treatment-biomarker interaction P = 0.30 [bECD] and P = 0.80 [HER2]). In the control groups, bECD≥15 ng/mL (HR 1.35, P = 0.003) and HER2+ (HR 1.67, P<0.001) were associated with shorter PFS after adjusting for other baseline characteristics. bECD≥15 ng/mL (HR 1.89, P<0.001) but not HER2+ (HR 0.97, P = 0.81) was associated with shorter OS after adjusting for other baseline characteristics.

Lapatinib therapy was associated with higher ORR and longer PFS in patients with elevated ECD levels. Elevated ECD was also associated with shorter PFS and OS in patients treated with non-lapatinib therapy. ECD provided additional predictive and prognostic information, in addition to tumor HER2 status, that if validated, could aid in treatment decisions. The predictive role of ECD in other anti-HER2 therapies requires further research.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-14.

Abstract P6-08-04: Prognostic significance of quality-of-life scores in early stage and relapsed breast cancer: Results from seven randomized trials of the International breast cancer study group

We performed an individual patient meta-analysis to investigate the prognostic value of patient self-reported quality-of-life (QL) scores at baseline, and at several times prior to and following disease relapse on subsequent overall survival (OS) in seven randomized trials of the International Breast Cancer Study Group.

Patients with early stage breast cancer who participated in randomized trials that compared adjuvant therapies, and who had subsequent disease relapse, completed QL assessments for physical well-being, mood, appetite, nausea and vomiting, arm swelling, flushing, coping effort, and utility at study entry, prior to and after disease relapse. We tested the relationships between baseline QL scores and OS using Cox regression analyses. We performed landmark analyses to assess the relationships between pre-relapse QL scores with OS using QL assessments at 1, 2 and 3 months prior to disease relapse, at the time of relapse and at two subsequent QL assessments where these were available. All Cox models were stratified by trial and included other factors related to QL and/or outcome.

Among 8,024 patients, 3,834 (48%) had disease relapse after a median follow-up time of 12 years. Amongst these patients, QL score at baseline, and at 1, 2, and 3 months prior disease relapse were not significantly prognostic for OS. At disease relapse, scores for physical well-being (hazards ratio [HR] per 10 unit increase of QL score for death, 1.05; P = 0.003), mood (HR 1.05; P = 0.007), appetite (HR 1.08; P<0.001), and utility (HR 1.13; P = 0.008) were prognostic for subsequent OS. Nausea and vomiting (HR 1.05; P = 0.11), arm swelling (HR 1.00; P = 0.20), flushing (HR 1.01; P = 0.73), and coping effort (HR 1.02; P = 0.29) were not prognostic for subsequent OS. At post-relapse assessments at median times of 1 (HR 1.07; P<0.001), 6 (HR 1.08; P<0.001) and 10 months (HR 1.13; P<0.001) after disease relapse, scores for physical well-being showed increasing prognostic significance. Scores for mood, nausea and vomiting, appetite, coping effort and utility showed patterns similar to those for physical wellbeing, but scores for arm swelling and flushing were not prognostic for subsequent OS.

These findings confirm and extend those of Coates et al. (J Clin Oncol 2000;18:3768 - 3774) based on two of the trials included in the present analysis. At baseline and prior to relapse, QL scores did not have any prognostic significance for subsequent OS. At and after disease relapse, QL scores substantially predicted for subsequent OS, with stronger association for QL scores later in the course of relapsed disease. Patient perception of the severity of underlying illness after relapse might be a potential reason that determines the reported QL scores and thus contributes to their prognostic significance.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-04.

First Report of Corynespora Leaf Spot on Beach Vitex Caused by Corynespora cassiicola in Korea

Beach vitex, Vitex rotundifolia L. fil., is a perennial that grows in temperate and tropical areas of the Pacific. In areas where it has been introduced outside of its native range, beach vitex has proven to be an invasive species. This plant dominates dune ecosystems leading to a reduction in the prevalence of native species (1). In October 2010, previously unknown leaf spots were observed on the beach vitex growing on sand dunes in Incheon City of Korea. The same symptoms were repeated in 2011 and 2012. In September 2012, the same leaf spots were found on the beach vitex in Samcheok and Gyeongju in Korea. The symptoms usually started as small, dark brown to purplish leaf spots with more or less concentric rings, eventually causing leaf blights or yellowing with 50% or more defoliation by the end of September. Representative samples (n = 6) were deposited in the Korea University Herbarium (KUS). Conidiophores of the fungus observed microscopically on the leaf spots were erect, brown to dark brown, single or occasionally in clusters, 80 to 500 × 5 to 9 μm, and mostly arose on the abaxial surface of symptomatic leaves. Conidia were borne singly or in short chains of 2 to 4, ranging from cylindrical to broadest at the base and tapering apically, straight to slightly curved, pale olivaceous brown, 1 to 12 pseudoseptate, 50 to 250 × 8 to 18 μm, each with a conspicuous thickened hilum. On potato dextrose agar (PDA), single-spore cultures of two isolates were identified as Corynespora cassiicola (Berk. & M.A. Curtis) C.T. Wei on the basis of morphological and cultural characteristics (3). Two monoconidial isolates were preserved at the Korean Agricultural Culture Collection (Accession Nos. KACC45712 and KACC46953). Isolate KACC45712 was used for molecular works and pathogenicity test. Genomic DNA was extracted using the DNeasy Plant Mini DNA Extraction Kit (Qiagen Inc., Valencia, CA). The complete internal transcribed spacer (ITS) region of rDNA was amplified with the primers ITS1/ITS4 and sequenced. The resulting sequence of 520 bp was deposited in GenBank (Accession No. KC987359). A BLAST search in GenBank revealed that the sequence showed 100% identity with those of C. cassiicola (e.g., JQ801302). To conduct a pathogenicity test, a conidial suspension (ca. 2 × 10⁴ conidia/ml) was prepared by harvesting conidia from 2-week-old cultures, and the suspension was sprayed onto the leaves of three healthy seedlings. Inoculated plants were kept in humid chambers for 48 h in a glasshouse. After 5 days, typical leaf spot symptoms started to develop on the leaves of all three inoculated plants. C. cassiicola was reisolated from the lesions, confirming Koch's postulates. Control plants treated with sterile water remained symptomless. C. cassiicola is cosmopolitan with a very wide host range (2,4). To our knowledge, C. cassiicola has not been reported on Vitex spp. anywhere in the world. According to field observations in Korea, Corynespora leaf spot was most severe in August and September, especially following a prolonged period of moist weather. C. cassiicola may be a potential biocontrol agent for this highly invasive species. References: (1) M. C. Cousins et al. Invasive Plant Sci. Manag. 3:340, 2010. (2) L. J. Dixon et al. Phytopathology 99:1015, 2009. (3) M. B. Ellis. Dematiaceous Hyphomycetes. Commonw. Mycol. Inst.: Kew, UK, 1971. (4) D. F. Farr and A. Y. Rossman. Fungal Databases. Syst. Mycol. Microbiol. Lab., Online publication, ARS, USDA, Retrieved April 30, 2013.

Serum biomarkers and transient elastography as predictors of advanced liver fibrosis in a United States cohort: the Boston children's hospital experience

OBJECTIVE

To evaluate and compare the ability of serum hyaluronic acid (HA) and human cartilage glycoprotein-39 (YKL-40) values, as well as transient elastography (TE) findings, to predict advanced hepatic fibrosis in a cohort from a single pediatric center.

STUDY DESIGN

Subjects who underwent liver biopsy analysis within 12 months before enrollment were eligible for this prospective study. HA and YKL-40 measurements were obtained within 1 month of TE. A METAVIR score of F3 or F4 was considered to indicate advanced fibrosis.

RESULTS

A total of 128 patients (51% males) aged 1.4 months to 27.6 years (22% aged <2 years) were enrolled. Thirty-one subjects had data on only HA and YKL-40 measurements, and 97 subjects had data on both blood tests and TE. For the prediction of advanced fibrosis, the area under the receiver operating characteristic curve (AUC) values were 0.83 for TE, 0.72 for HA, and 0.52 for YKL-40. The AUC of 0.83 for TE was statistically significantly greater than the AUCs for HA (P = .03) and YKL-40 (P < .0001). Optimal cutpoints for predicting F3-F4 fibrosis were 8.6 kPa for TE (P < .0001), 43 ng/mL for HA (P < .0001), and 26.2 ng/mL for YKL-40 (P = .85). The combination of TE and HA was not better than TE alone for predicting advanced fibrosis (P = .15).

CONCLUSION

In this study, which evaluated TE, HA, and YKL-40 to predict liver fibrosis in children in the US, YKL-40 had no predictive value and TE was superior to HA, but the addition of HA did not improve the performance of TE. Our data suggest that TE and HA may be useful noninvasive tools for assessing liver fibrosis in children.

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.

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.

Long-term efficacy of entecavir therapy in chronic hepatitis B patients with antiviral resistance to lamivudine and adefovir

No studies have reported the long-term effects of entecavir switching in patients with multidrug resistance who developed resistance after lamivudine/adefovir sequential therapy. We evaluated the efficacy of 96 weeks of entecavir therapy in patients with resistance to lamivudine/adefovir sequential therapy. In total, 33 patients with chronic hepatitis B virus (HBV) infection with evidence of active viral replication (HBV DNA levels ≥ 10(5) copies/mL) or a history of treatment failure to lamivudine/adefovir sequential therapy between April 2007 and July 2009 were treated with entecavir (1.0 mg daily) for at least 48 weeks. The rates of alanine transaminase (ALT) normalization and HBV DNA negativity were 66.7% (14/21) and 24.2% (8/33) at 48 weeks, respectively. The initial HBV DNA level was the only factor that was inversely associated with serum HBV DNA negativity after 48 weeks of entecavir therapy (P < 0.023). At 96 weeks, the rates of ALT normalization and HBV DNA negativity were 77.8% (7/9) and 16.7% (3/18), respectively. Viral breakthrough occurred in 21.2% (7/33) and 78.9% (15/19) of patients at 48 and 96 weeks, respectively. Patients who achieved a HBV DNA level of <4 log(10) copies/mL at 48 weeks maintained a similar HBV DNA level and a normal ALT level until 96 weeks. Entecavir monotherapy for 96 weeks was not efficacious for patients with lamivudine/adefovir-resistant HBV. The initial HBV DNA level was the only predictive factor for antiviral efficacy. However, patients who achieved a HBV DNA level of <4 log(10) copies/mL with a normal ALT level at 48 weeks should maintain, rather than stop, entecavir therapy.

Missed diagnosis of influenza B virus due to nucleoprotein sequence mutations, Singapore, April 2011

A new influenza B variant was discovered in Singapore in April 2011 during diagnostic testing of a 3-year-old boy with respiratory symptoms. Influenza B virus was isolated from culture and confirmed by standard immunofluorescence testing, but was not detected by the routine, in-house influenza screening reverse-transcription polymerase chain reaction assay that targets the nucleoprotein (NP) gene. Subsequent sequencing investigations demonstrated that several other published assays targeting NP could also fail to detect this novel variant.

Missed diagnosis of influenza B virus due to nucleoprotein sequence mutations, Singapore, April 2011

A new influenza B variant was discovered in Singapore in April 2011 during diagnostic testing of a 3-year-old boy with respiratory symptoms. Influenza B virus was isolated from culture and confirmed by standard immunofluorescence testing, but was not detected by the routine, in-house influenza screening reverse-transcription polymerase chain reaction assay that targets the nucleoprotein (NP) gene. Subsequent sequencing investigations demonstrated that several other published assays targeting NP could also fail to detect this novel variant.