Targeting metastasis-initiating cancer stem cells in gastric cancer with leukaemia inhibitory factor

Gastric cancer's (GC) bad prognosis is usually associated with metastatic spread. Invasive cancer stem cells (CSC) are considered to be the seed of GC metastasis and not all CSCs are able to initiate metastasis. Targeting these aggressive metastasis-initiating CSC (MIC) is thus vital. Leukaemia inhibitory factor (LIF) is hereby used to target Hippo pathway oncogenic members, found to be induced in GC and associated with CSC features. LIF-treated GC cell lines, patient-derived xenograft (PDX) cells and/or CSC tumourspheres underwent transcriptomics, laser microdissection-associated proteomics, 2D and 3D invasion assays and in vivo xenograft in mice blood circulation. LIFR expression was analysed on tissue microarrays from GC patients and in silico from public databases. LIF-treated cells, especially CSC, presented decreased epithelial to mesenchymal transition (EMT) phenotype and invasion capacity in vitro, and lower metastasis initiation ability in vivo. These effects involved both the Hippo and Jak/Stat pathways. Finally, GC's high LIFR expression was associated with better clinical outcomes in patients. LIF treatment could thus represent a targeted anti-CSC strategy to fight against metastatic GC, and LIFR detection in primary tumours could constitute a potential new prognosis marker in this disease.

Spatial characterisation of β-catenin-mutated hepatocellular adenoma subtypes by proteomic profiling of the tumour rim

Background & Aims

Hepatocellular adenomas (HCAs) are rare, benign, liver tumours classified at the clinicopathological, genetic, and proteomic levels. The β-catenin-activated (b-HCA) subtypes harbour several mutation types in the β-catenin gene (CTNNB1) associated with different risks of malignant transformation or bleeding. Glutamine synthetase is a surrogate marker of β-catenin pathway activation associated with the risk of malignant transformation. Recently, we revealed an overexpression of glutamine synthetase in the rims of exon 3 S45-mutated b-HCA and exon 7/8-mutated b-HCA compared with the rest of the tumour. A difference in vascularisation was found in this rim shown by diffuse CD34 staining only at the tumour centre. Here, we aimed to characterise this tumour heterogeneity to better understand its physiopathological involvement.

Methods

Using mass spectrometry imaging, genetic, and proteomic analyses combined with laser capture microdissection, we compared the tumour centre with the tumour rim and with adjacent non-tumoural tissue.

Results

The tumour rim harboured the same mutation as the tumour centre, meaning both parts belong to the same tumour. Mass spectrometry imaging showed different spectral profiles between the rim and the tumour centre. Proteomic profiling revealed the significant differential expression of 40 proteins at the rim compared with the tumour centre. The majority of these proteins were associated with metabolism, with an expression profile comparable with a normal perivenous hepatocyte expression profile.

Conclusions

The difference in phenotype between the tumour centres and tumour rims of exon 3 S45-mutated b-HCA and exon 7/8-mutated b-HCA does not depend on CTNNB1 mutational status. In a context of sinusoidal arterial pathology, tumour heterogeneity at the rim harbours perivenous characteristics and could be caused by a functional peripheral venous drainage.

Impact and implications

Tumour heterogeneity was revealed in β-catenin-mutated hepatocellular adenomas (b-HCAs) via the differential expression of glutamine synthase at tumour rims. The combination of several spatial approaches (mass spectrometry imaging, genetic, and proteomic analyses) after laser capture microdissection allowed identification of a potential role for peripheral venous drainage underlying this difference. Through this study, we were able to illustrate that beyond a mutational context, many factors can downstream regulate gene expression and contribute to different clinicopathological phenotypes. We believe that the combinations of spatial analyses that we used could be inspiring for all researchers wanting to access heterogeneity information of liver tumours.

Loss of RND3/RHOE controls entosis through LAMP1 expression in hepatocellular carcinoma

Entosis is a process that leads to the formation of cell-in-cell structures commonly found in cancers. Here, we identified entosis in hepatocellular carcinoma and the loss of Rnd3 (also known as RhoE) as an efficient inducer of this mechanism. We characterized the different stages and the molecular regulators of entosis induced after Rnd3 silencing. We demonstrated that this process depends on the RhoA/ROCK pathway, but not on E-cadherin. The proteomic profiling of entotic cells allowed us to identify LAMP1 as a protein upregulated by Rnd3 silencing and implicated not only in the degradation final stage of entosis, but also in the full mechanism. Moreover, we found a positive correlation between the presence of entotic cells and the metastatic potential of tumors in human patient samples. Altogether, these data suggest the involvement of entosis in liver tumor progression and highlight a new perspective for entosis analysis in medicine research as a novel therapeutic target.

The E3 ubiquitin ligase FBXL6 controls the quality of newly synthesized mitochondrial ribosomal proteins

In mammals, about 99% of mitochondrial proteins are synthesized in the cytosol as precursors that are subsequently imported into the organelle. The mitochondrial health and functions rely on an accurate quality control of these imported proteins. Here, we show that the E3 ubiquitin ligase F box/leucine-rich-repeat protein 6 (FBXL6) regulates the quality of cytosolically translated mitochondrial proteins. Indeed, we found that FBXL6 substrates are newly synthesized mitochondrial ribosomal proteins. This E3 binds to chaperones involved in the folding and trafficking of newly synthesized peptide and to ribosomal-associated quality control proteins. Deletion of these interacting partners is sufficient to hamper interactions between FBXL6 and its substrate. Furthermore, we show that cells lacking FBXL6 fail to degrade specifically mistranslated mitochondrial ribosomal proteins. Finally, showing the role of FBXL6-dependent mechanism, FBXL6-knockout (KO) cells display mitochondrial ribosomal protein aggregations, altered mitochondrial metabolism, and inhibited cell cycle in oxidative conditions.

Quantitative vestibular function tests in posterior circulation stroke patients: A review

While specific bedside examinations are known to be sensitive in identifying stroke among acute vestibular syndrome patients, complementary quantitative vestibular function testing can be helpful to quantify vestibular loss due to stroke. In contrast to peripheral vestibular dysfunction, diagnosis of central vestibular dysfunction can be challenging for unskilful clinicians. This article presents a comprehensive overview of quantitative vestibular function test findings such as the video head impulse test (vHIT), cervical vestibular evoked myogenic potentials (cVEMPs), ocular vestibular evoked myogenic potentials (oVEMPs), videonystagmography (VNG) and caloric test among stroke patients. Vestibulo-ocular reflex (VOR) gain is usually found normal among posterior inferior cerebellar artery (PICA) stroke patients but varies among anterior inferior cerebellar artery (AICA) stroke patients. Abnormal contralesional posterior semicircular canal VOR gain can be observed due to lesions in the medial longitudinal fasciculus (MLF). AICA and PICA stroke can impair cVEMPs, oVEMPs, and VNG (i.e., smooth pursuit and saccade functions). Strokes, particularly those involving the vestibular nucleus, including both upper, lower brainstem and cerebellum, can result in various abnormalities of smooth pursuit, saccade or calorics testing. The combined evaluations of VNG, vHIT, and VEMPs can be accurately used to complement and quantify bedside vestibular evaluation in diagnosing central vestibular dysfunction. In addition, as most studies were conducted amongst acute vestibular syndrome (AVS) patients, future studies that investigate the prevalence of vestibular dysfunction in recovering stroke patients are required.

LRP-1 Matricellular Receptor Involvement in Triple Negative Breast Cancer Tumor Angiogenesis

Background: LRP-1 is a multifunctional scavenger receptor belonging to the LDLR family. Due to its capacity to control pericellular levels of various growth factors and proteases, LRP-1 plays a crucial role in membrane proteome dynamics, which appears decisive for tumor progression. Methods: LRP-1 involvement in a TNBC model was assessed using an RNA interference strategy in MDA-MB-231 cells. In vivo, tumorigenic and angiogenic effects of LRP-1-repressed cells were evaluated using an orthotopic xenograft model and two angiogenic assays (Matrigel^® plugs, CAM). DCE-MRI, FMT, and IHC were used to complete a tumor longitudinal follow-up and obtain morphological and functional vascular information. In vitro, HUVECs’ angiogenic potential was evaluated using a tumor secretome, subjected to a proteomic analysis to highlight LRP-1-dependant signaling pathways. Results: LRP-1 repression in MDA-MB-231 tumors led to a 60% growth delay because of, inter alia, morphological and functional vascular differences, confirmed by angiogenic models. In vitro, the LRP-1-repressed cells secretome restrained HUVECs’ angiogenic capabilities. A proteomics analysis revealed that LRP-1 supports tumor growth and angiogenesis by regulating TGF-β signaling and plasminogen/plasmin system. Conclusions: LRP-1, by its wide spectrum of interactions, emerges as an important matricellular player in the control of cancer-signaling events such as angiogenesis, by supporting tumor vascular morphology and functionality.

Proteomic Profiling of Hepatocellular Adenomas Paves the Way to Diagnostic and Prognostic Approaches

BACKGROUND AND AIMS

Through an exploratory proteomic approach based on typical hepatocellular adenomas (HCAs), we previously identified a diagnostic biomarker for a distinctive subtype of HCA with high risk of bleeding, already validated on a multicenter cohort. We hypothesized that the whole protein expression deregulation profile could deliver much more informative data for tumor characterization. Therefore, we pursued our analysis with the characterization of HCA proteomic profiles, evaluating their correspondence with the established genotype/phenotype classification and assessing whether they could provide added diagnosis and prognosis values.

APPROACH AND RESULTS

From a collection of 260 cases, we selected 52 typical cases of all different subgroups on which we built a reference HCA proteomics database. Combining laser microdissection and mass-spectrometry-based proteomic analysis, we compared the relative protein abundances between tumoral (T) and nontumoral (NT) liver tissues from each patient and we defined a specific proteomic profile of each of the HCA subgroups. Next, we built a matching algorithm comparing the proteomic profile extracted from a patient with our reference HCA database. Proteomic profiles allowed HCA classification and made diagnosis possible, even for complex cases with immunohistological or genomic analysis that did not lead to a formal conclusion. Despite a well-established pathomolecular classification, clinical practices have not substantially changed and the HCA management link to the assessment of the malignant transformation risk remains delicate for many surgeons. That is why we also identified and validated a proteomic profile that would directly evaluate malignant transformation risk regardless of HCA subtype.

CONCLUSIONS

This work proposes a proteomic-based machine learning tool, operational on fixed biopsies, that can improve diagnosis and prognosis and therefore patient management for HCAs.

A review of idiopathic inflammatory myopathy cases in Terengganu, Malaysia: A single centre experience

INTRODUCTION

The purpose of this study was to analyse the clinical characteristics of patients with idiopathic inflammatory myopathy (IIM) in Hospital Sultanah Nurzahirah (HSNZ), Terengganu, Malaysia. It also aimed to describe the disease manifestations in association with malignancy and other CTD.

METHODS

This was a retrospective descriptive study involving all IIM patients who were managed by the Rheumatology Unit HSNZ from January 2010 to December 2019.

RESULTS

In this review we described 15 cases wherein malignancy was detected in 4 patients after the diagnosis of IIM was made and 4 patients with overlap syndrome. One third of patients with malignancy and overlap syndrome had poor treatment response and succumbed to complications of the disease. Almost all of patients received corticosteroid as the first line therapy and nearly two thirds of them responded well to either corticosteroid alone or with combination therapy.

CONCLUSION

Although this study did not represent the whole population in Malaysia, it does provide a better understanding of the disease manifestation, treatment and disease complications in our cohort of patients.

Hepatocyte proteomes reveal the role of protein disulfide isomerase 4 in alpha 1-antitrypsin deficiency

Background & Aims

A single point mutation in the Z-variant of alpha 1-antitrypsin (Z-AAT) alone can lead to both a protein folding and trafficking defect, preventing its exit from the endoplasmic reticulum (ER), and the formation of aggregates that are retained as inclusions within the ER of hepatocytes. These defects result in a systemic AAT deficiency (AATD) that causes lung disease, whereas the ER-retained aggregates can induce severe liver injury in patients with ZZ-AATD. Unfortunately, therapeutic approaches are still limited and liver transplantation represents the only curative treatment option. To overcome this limitation, a better understanding of the molecular basis of ER aggregate formation could provide new strategies for therapeutic intervention.

Methods

Our functional and omics approaches here based on human hepatocytes from patients with ZZ-AATD have enabled the identification and characterisation of the role of the protein disulfide isomerase (PDI) A4/ERP72 in features of AATD-mediated liver disease.

Results

We report that 4 members of the PDI family (PDIA4, PDIA3, P4HB, and TXNDC5) are specifically upregulated in ZZ-AATD liver samples from adult patients. Furthermore, we show that only PDIA4 knockdown or alteration of its activity by cysteamine treatment can promote Z-AAT secretion and lead to a marked decrease in Z aggregates. Finally, detailed analysis of the Z-AAT interactome shows that PDIA4 silencing provides a more conducive environment for folding of the Z mutant, accompanied by reduction of Z-AAT-mediated oxidative stress, a feature of AATD-mediated liver disease.

Conclusions

PDIA4 is involved in AATD-mediated liver disease and thus represents a therapeutic target for inhibition by drugs such as cysteamine. PDI inhibition therefore represents a potential therapeutic approach for treatment of AATD.

Lay summary

Protein disulfide isomerase (PDI) family members, and particularly PDIA4, are upregulated and involved in alpha 1-antitrypsin deficiency (AATD)-mediated liver disease in adults. PDI inhibition upon cysteamine treatment leads to improvements in features of AATD and hence represents a therapeutic approach for treatment of AATD-mediated liver disease.

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PDIA4 is upregulated and involved in alpha 1-antitrypsin deficiency (AATD)-mediated liver disease in adults.

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Knockdown of PDIA4 by siRNA or inhibition upon cysteamine treatment leads to improvements in features of AATD.

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RNA interference against PDIA4 or cysteamine represent approaches for treatment of AATD-mediated liver disease.

Abstract PO020: The matricellular receptor LRP-1 acts as a pro-tumorigenic receptor by supporting tumor angiogenesis in a triple negative breast cancer model

LRP-1 (low-density lipoprotein receptor-related protein-1) receptor is a multifunctional endocytosis receptor that is part of the LDL receptor family. Due to its capacity to control the pericellular level of various growth factors and proteases, LRP-1 plays a crucial role in controlling the dynamics of the membrane proteome. [1] LRP-1 overexpression in breast cancer and in particular in triple negative breast cancer (TNBC), prompted us to take an interest in its involvement in tumor progression and more specifically to the role it could play in controlling angiogenesis. For that purpose, an RNA interference strategy in a TNBC model (MDA-MB-231 line) in vivo was used, based on shRNA stable expression. 42 days following an orthotopic injection of shLRP-1 MDA-MB-231 cells (in which LRP-1 expression is repressed by 70%) and shCtrl MDA-MB-231 cells (comparable to wild type MDA-MB-231 cells) in BALB/c nude mice, a delay of 40% in tumor growth was observed (257 mm3 vs 432 mm3, p <0.05) (n = 15 per group). The concomitant use of complementary preclinical imaging modalities, namely magnetic resonance imaging (DCE-MRI) and fluorescence molecular tomography (FMT), allowed us to complete a longitudinal follow-up of tumor development and, especially, tumor angiogenesis. Morphological and functional information obtained on the tumor and its vascularization, supplemented and confirmed by immunohistochemical analyzes, allowed us to highlight that LRP-1 act as a pro-tumorigenic receptor in TNBC progression in vivo by, among other things, upholding tumor angiogenesis. In vitro, using tumor conditioned media (TCM) from MDA-MB-231 shLRP-1 compared to shCtrl, we showed that the secretome of these cancer cells can differentially modulate three-dimensional tubular network formation as well as migrative and proliferative capacities of human umbilical vein endothelial cells (HUVECs). A proteomic analysis (in collaboration with the CGFB plateform proteome (Bordeaux, France)) of these TCM allowed us to identify numerous angiogenesis molecular targets significantly modulated by LRP-1 repression. This revealed unstable angiogenic balance of growth factors, cytokines and proteases orchestrated by the lack of LRP1 expression strengthen LRP-1 non-negligible role in tumor angiogenesis and constitute a wealth of information to provide a better understanding of its regulatory action within the TNBC microenvironment. [1] Lillis AP, Van Duyn LB, Murphy-Ullrich JE, and Strickland DK. LDL Receptor-Related Protein 1: Unique Tissue- Specific Functions Revealed by Selective Gene Knockout Studies. Physiol Rev. 2008; 88: 887918

Citation Format: Océane Campion, Jessica Thevenard-Devy, Nicolas Etique, Anne-Aurélie Raymond, Jean-William Dupuy, Stéphane Dedieu, Jérôme Devy. The matricellular receptor LRP-1 acts as a pro-tumorigenic receptor by supporting tumor angiogenesis in a triple negative breast cancer model [abstract]. In: Proceedings of the AACR Virtual Special Conference on the Evolving Tumor Microenvironment in Cancer Progression: Mechanisms and Emerging Therapeutic Opportunities; in association with the Tumor Microenvironment (TME) Working Group; 2021 Jan 11-12. Philadelphia (PA): AACR; Cancer Res 2021;81(5 Suppl):Abstract nr PO020.

HDAC inhibition induces expression of scaffolding proteins critical for tumor progression in pediatric glioma: focus on EBP50 and IRSp53

BACKGROUND

Diffuse midline glioma (DMG) is a pediatric malignancy with poor prognosis. Most children die less than one year after diagnosis. Recently, mutations in histone H3 have been identified and are believed to be oncogenic drivers. Targeting this epigenetic abnormality using histone deacetylase (HDAC) inhibitors such as panobinostat (PS) is therefore a novel therapeutic option currently evaluated in clinical trials.

METHODS

BH3 profiling revealed engagement in an irreversible apoptotic process of glioma cells exposed to PS confirmed by annexin-V/propidium iodide staining. Using proteomic analysis of 3 DMG cell lines, we identified 2 proteins deregulated after PS treatment. We investigated biological effects of their downregulation by silencing RNA but also combinatory effects with PS treatment in vitro and in vivo using a chick embryo DMG model. Electron microscopy was used to validate protein localization.

RESULTS

Scaffolding proteins EBP50 and IRSp53 were upregulated by PS treatment. Reduction of these proteins in DMG cell lines leads to blockade of proliferation and migration, invasion, and an increase of apoptosis. EBP50 was found to be expressed in cytoplasm and nucleus in DMG cells, confirming known oncogenic locations of the protein. Treatment of glioma cells with PS together with genetic or chemical inhibition of EBP50 leads to more effective reduction of cell growth in vitro and in vivo.

CONCLUSION

Our data reveal a specific relation between HDAC inhibitors and scaffolding protein deregulation which might have a potential for therapeutic intervention for cancer treatment.

miR-4510 blocks hepatocellular carcinoma development through RAF1 targeting and RAS/RAF/MEK/ERK signalling inactivation

BACKGROUND

Therapeutic outcomes using the multikinase inhibitors, sorafenib and regorafenib, remain unsatisfactory for patients with advanced hepatocellular carcinoma (HCC). Thus, new drug modalities are needed. We recently reported the remarkable capacity of miR-4510 to impede the growth of HCC and hepatoblastoma through Glypican-3 (GPC3) targeting and Wnt pathway inactivation.

METHODS

To identify new targets of miR-4510, we used a label-free proteomic approach and reported down-regulation of RAF proto-oncogene serine/threonine-protein kinase (RAF1) by miR-4510. Because the tumourigenic role of RAF1 in HCC is controversial, we further studied RAF1:miR-4510 interactions using cellular, molecular as well as functional approaches and a chicken chorioallantoic membrane (CAM) xenograft model.

RESULTS

We found an increase in RAF1 protein in 59.3% of HCC patients and a specific up-regulation of its transcript in proliferative tumours. We showed that miR-4510 inactivates the RAS/RAF/MEK/ERK pathway and reduces the expression of downstream targets (ie c-Fos proto-oncogene [FOS]) through RAF1 direct targeting. At a cellular level, miR-4510 inhibited HCC cell proliferation and migration and induced senescence in part by lowering RAF1 messenger RNA (mRNA) and protein expression. Finally, we confirmed the pro-tumoural function of RAF1 protein in HCC cells and its ability to sustain HCC tumour progression in vitro and in vivo.

CONCLUSIONS

In this work, we confirm that RAF1 acts as an oncogene in HCC and further demonstrate that miR-4510 acts as a strong tumour suppressor in the liver by targeting many proto-oncogenes, including GPC3 and RAF1, and subsequently controlling key biological and signalling pathways among which Wnt and RAS/RAF/MEK/ERK signals.

The invasive proteome of glioblastoma revealed by laser-capture microdissection

Background

Glioblastomas are heterogeneous tumors composed of a necrotic and tumor core and an invasive periphery.

Methods

Here, we performed a proteomics analysis of laser-capture micro-dissected glioblastoma core and invasive areas of patient-derived xenografts.

Results

Bioinformatics analysis identified enriched proteins in central and invasive tumor areas. Novel markers of invasion were identified, the genes proteolipid protein 1 (PLP1) and Dynamin-1 (DNM1), which were subsequently validated in tumors and by functional assays.

Conclusions

In summary, our results identify new networks and molecules that may play an important role in glioblastoma development and may constitute potential novel therapeutic targets.

Antigenic Mimicry in Paraneoplastic Immune Thrombocytopenia

The association of immune thrombocytopenia (ITP) with cancer has been reported, but the causality of tumor cells in paraneoplastic ITP pathogenesis and maintenance has never been established. We analyzed the unusual case of refractory ITP and coincident urothelial tumor of the kidney with circulating high titer anti-GPIIBIIIA autoantibodies. Intriguingly, after nephrectomy, the patient recovered fully and her anti-GPIIBIIIA autoantibodies disappeared. Proteomic and immunohistochemistry analyses revealed erratic GPIIB expression by the tumor cells, suggesting possible antigenic mimicry chronically stimulating the immune system and leading to this patient's refractory ITP. Such previously unreported findings provide proof-of-concept that requires further confirmation with the prospective study of a larger number of patients.

New insights into diagnosis and therapeutic options for proliferative hepatoblastoma

Surgery and cisplatin-based treatment of hepatoblastoma (HB) currently guarantee the survival of 70%-80% of patients. However, some important challenges remain in diagnosing high-risk tumors and identifying relevant targetable pathways offering new therapeutic avenues. Previously, two molecular subclasses of HB tumors have been described, C1 and C2, with C2 being the subgroup with the poorest prognosis, a more advanced tumor stage, and the worst overall survival rate. An associated 16-gene signature to discriminate the two tumoral subgroups was proposed, but it has not been transferred into clinical routine. To address these issues, we performed RNA sequencing of 25 tumors and matched normal liver samples from patients. The transcript profiling separated HB into three distinct subgroups named C1, C2A, and C2B, identifiable by a concise four-gene signature: hydroxysteroid 17-beta dehydrogenase 6, integrin alpha 6, topoisomerase 2-alpha, and vimentin, with topoisomerase 2-alpha being characteristic for the proliferative C2A tumors. Differential expression of these genes was confirmed by quantitative RT-PCR on an expanded cohort and by immunohistochemistry. We also revealed significant overexpression of genes involved in the Fanconi anemia (FA) pathway in the C2A subgroup. We then investigated the ability of several described FA inhibitors to block growth of HB cells in vitro and in vivo. We demonstrated that bortezomib, a Food and Drug Administration-approved proteasome inhibitor, strongly impairs the proliferation and survival of HB cell lines in vitro, blocks FA pathway-associated double-strand DNA repair, and significantly impedes HB growth in vivo.

CONCLUSION

The highly proliferating C2A subtype is characterized by topoisomerase 2-alpha gene up-regulation and FA pathway activation, and the HB therapeutic arsenal could include bortezomib for the treatment of patients with the most aggressive tumors. (Hepatology 2018;68:89-102).

Argininosuccinate synthase 1 (ASS1): A marker of unclassified hepatocellular adenoma and high bleeding risk

Hepatocellular adenomas (HCAs) are rare benign tumors divided into three main subgroups defined by pathomolecular features, HNF1A (H-HCA), mutated β-catenin (b-HCA), and inflammatory (IHCA). In the case of unclassified HCAs (UHCAs), which are currently identified by default, a high risk of bleeding remains a clinical issue. The objective of this study was to explore UHCA proteome with the aim to identify specific biomarkers. Following dissection of the tumoral (T) and nontumoral (NT) tissue on formalin-fixed, paraffin-embedded HCA tissue sections using laser capture methodology, we performed mass spectrometry analysis to compare T and NT protein expression levels in H-HCA, IHCA, b-HCA, UHCA, and focal nodular hyperplasia. Using this methodology, we searched for proteins which are specifically deregulated in UHCA. We demonstrate that proteomic profiles allow for discriminating known HCA subtypes through identification of classical biomarkers in each HCA subgroup. We observed specific up-regulation of the arginine synthesis pathway associated with overexpression of argininosuccinate synthase (ASS1) and arginosuccinate lyase in UHCA. ASS1 immunohistochemistry identified all the UHCA, of which 64.7% presented clinical bleeding manifestations. Interestingly, we demonstrated that the significance of ASS1 was not restricted to UHCA, but also encompassed certain hemorrhagic cases in other HCA subtypes, particularly IHCA.

CONCLUSION

ASS1 + HCA combined with a typical hematoxylin and eosin stain aspect defined a new HCA subgroup at a high risk of bleeding. (Hepatology 2017;66:2016-2028).

Reptin regulates DNA double strand breaks repair in human hepatocellular carcinoma

Reptin/RUVBL2 is overexpressed in most hepatocellular carcinomas and is required for the growth and viability of HCC cells. Reptin is involved in several chromatin remodeling complexes, some of which are involved in the detection and repair of DNA damage, but data on Reptin involvement in the repair of DNA damage are scarce and contradictory. Our objective was to study the effects of Reptin silencing on the repair of DNA double-strand breaks (DSB) in HCC cells. Treatment of HuH7 cells with etoposide (25 μM, 30 min) or γ irradiation (4 Gy) increased the phosphorylation of H2AX by 1.94 ± 0.13 and 2.0 ± 0.02 fold, respectively. These values were significantly reduced by 35 and 65 % after Reptin silencing with inducible shRNA. Irradiation increased the number of BRCA1 (3-fold) and 53BP1 foci (7.5 fold). Depletion of Reptin reduced these values by 62 and 48%, respectively. These defects in activation and/or recruitment of repair proteins were not due to a decreased number of DSBs as measured by the COMET assay. All these results were confirmed in the Hep3B cell line. Protein expression of ATM and DNA-PKcs, the major H2AX kinases, was significantly reduced by 52 and 61 % after Reptin depletion whereas their mRNA level remained unchanged. Phosphorylation of Chk2, another ATM target, was not significantly altered. Using co-immunoprecipitation, we showed an interaction between Reptin and DNA-PKcs. The half-life of newly-synthesized DNA-PKcs was reduced when Reptin was silenced. Finally, depletion of Reptin was synergistic with etoposide or γ irradiation to reduce cell growth and colony formation. In conclusion, Reptin is an important cofactor for the repair of DSBs. Our data, combined with those of the literature suggests that it operates at least in part by regulating the expression of DNA-PKcs by a stabilization mechanism. Overexpression of Reptin in HCC could be a factor of resistance to treatment, consistent with the observed overexpression of Reptin in subgroups of chemo-resistant breast and ovarian cancers.

Genome-wide screen identifies a novel p97/CDC-48-dependent pathway regulating ER-stress-induced gene transcription

The accumulation of misfolded proteins in the endoplasmic reticulum (ER) activates the Unfolded Protein Response (UPR(ER)) to restore ER homeostasis. The AAA(+) ATPase p97/CDC-48 plays key roles in ER stress by promoting both ER protein degradation and transcription of UPR(ER) genes. Although the mechanisms associated with protein degradation are now well established, the molecular events involved in the regulation of gene transcription by p97/CDC-48 remain unclear. Using a reporter-based genome-wide RNAi screen in combination with quantitative proteomic analysis in Caenorhabditis elegans, we have identified RUVB-2, a AAA(+) ATPase, as a novel repressor of a subset of UPR(ER) genes. We show that degradation of RUVB-2 by CDC-48 enhances expression of ER stress response genes through an XBP1-dependent mechanism. The functional interplay between CDC-48 and RUVB-2 in controlling transcription of select UPR(ER) genes appears conserved in human cells. Together, these results describe a novel role for p97/CDC-48, whereby its role in protein degradation is integrated with its role in regulating expression of ER stress response genes.

Aspirin resistance in patients with acute coronary events: risk factors and prevalence as determined by whole blood multiple electrode aggregometry

Objectives: To determine the prevalence of aspirin resistance and associated risk factors based on biochemical parameters using whole blood multiple electrode aggregometry.

Methods:The study was conducted at the outpatients cardiology clinic of the Universiti Kebangsaan Malaysia Medical Centre (UKMMC) from August 2011 to February 2012.

Subjects on aspirin therapy were divided into two groups; first-ever coronary event and recurrent coronary event. Aspirin resistance was measured by a Multiplate^® platelet analyser.

Results: A total of 74 patients (63 male, 11 female), with a mean age of 57.93 ± 74.1years were enrolled in the study. The patients were divided into two groups –first-ever coronary event group (n=52) and recurrent coronary event group (n=22). Aspirin resistance was observed in 12 out of 74 (16%) of the study patients, which consisted of 11 patients from the first-ever coronary event group and one patient from the recurrent coronary event group. There were significant correlations between aspirin resistance and age (r = -0.627; p = 0.029), total cholesterol (r = 0.608; p = 0.036) and LDL (r = 0.694; p = 0.012). LDL was the main predictor for area under the curve (AUC) for aspirin resistance. However, there was no association between aspirin resistance and cardiovascular events in both groups in this study.

Conclusions: Aspirin resistance was observed in 16% of the study population. LDL was the major predictor of aspirin resistance. No association was found in the study between aspirin resistance with recurrent coronary events.

Risk factors and predictors of levodopa-induced dyskinesia among multiethnic Malaysians with Parkinson's disease

Chronic pulsatile levodopa therapy for Parkinson's disease (PD) leads to the development of motor fluctuations and dyskinesia. We studied the prevalence and predictors of levodopa-induced dyskinesia among multiethnic Malaysian patients with PD.

METHODS

This is a cross-sectional study involving 95 patients with PD on uninterrupted levodopa therapy for at least 6 months. The instrument used was the UPDRS questionnaires. The predictors of dyskinesia were determined using multivariate logistic regression analysis.

RESULTS

The mean age was 65.6 ± 8.5 years. The mean onset age was 58.5 ± 9.8 years. The median disease duration was 6 (7) years. Dyskinesia was present in 44% (n = 42) with median levodopa therapy of 3 years. There were 64.3% Chinese, 31% Malays, and 3.7% Indians and other ethnic groups. Eighty-one percent of patients with dyskinesia had clinical fluctuations. Patients with dyskinesia had lower onset age ( p < 0.001), longer duration of levodopa therapy ( p < 0.001), longer disease duration ( p < 0.001), higher total daily levodopa dose ( p < 0.001), and higher total UPDRS scores ( p = 0.005) than patients without dyskinesia. The three significant predictors of dyskinesia were duration of levodopa therapy, onset age, and total daily levodopa dose.

CONCLUSIONS

The prevalence of levodopa-induced dyskinesia in our patients was 44%. The most significant predictors were duration of levodopa therapy, total daily levodopa dose, and onset age.

Prevalence of depression in stroke patients with vascular dementia in universiti kebangsaan malaysia medical center

OBJECTIVE

Depression among patients with vascular dementia is frequently overlooked and potentially causes significant morbidity. There is limited data in Malaysia on the subject and this study was conducted to determine the prevalence of depression in vascular dementia (VaD) in UKMMC.

METHODS

This was a cross-sectional study involving diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria and who had a mini mental state examination (MMSE) score of less than 26. All patients were interviewed, examined clinically and their previous brain computer tomography (CT) were reviewed. The prevalence of depression was determined using the Cornell scale of depression.

RESULTS

A total of 76 patients were recruited with a mean age of 70.5 ± 9.5 years. The median duration of illness was 2.0 (1.0-4.8) years. The prevalence of depression in the study population was 31.6%. The patients with depression had a significant older mean age (74.5±8.7 years old) compared to those without depression (68.6±9.4 years old). Patients with large artery stroke of less than 3 years had significant higher frequency of depression (53.6%) compared to patients with small artery stroke (23.8%) and patients with right sided large artery stroke had significantly higher frequency of depression compared to left (70% vs. 44.4%). Median MMSE score (17.0) for depressed patients was significantly lower compared with median MMSE score (22.5) for non depressed patients. Median Barthel Index (30.0) for depressed patients was significantly lower compared with median Barthel score for non depressed patients.

CONCLUSIONS

Depression was prevalent among post stroke patients with VaD in UKMMC particularly for patients with older age, large artery stroke, right sided large artery stroke, low MMSE score and low Barthel Index. Early recognition of high risk patients is important in the holistic management of patients to prevent significant morbidity arising from depression.

Spinal cord compression following traditional confinement massage

We describe a case of tetraparesis in a 33-year-old woman following neck manipulation performed by a traditional confinement mid-wife. An MRI of the cervical spine revealed a fracture of the second cervical vertebra with atlanto-axial subluxation that resulted in cord compression.

Deimination of human filaggrin-2 promotes its proteolysis by calpain 1

Filaggrin-2 (FLG2), a member of the S100-fused type protein family, shares numerous features with filaggrin (FLG), a key protein implicated in the epidermal barrier functions. Both display a related structural organization, an identical pattern of expression and localization in human epidermis, and proteolytic processing of a large precursor. Here, we tested whether FLG2 was a substrate of calpain 1, a calcium-dependent protease directly involved in FLG catabolism. In addition, deimination being critical for FLG degradation, we analyzed whether FLG2 deimination interfered with its proteolytic processing. With this aim, we first produced a recombinant form of FLG2 corresponding to subunits B7 to B10 fused to a COOH-terminal His tag. Incubation with calpain 1 in the presence of calcium induced a rapid degradation of the recombinant protein and the production of several peptides, as shown by Coomassie Blue-stained gels and Western blotting with anti-FLG2 or anti-His antibodies. MALDI-TOF mass spectrometry confirmed this result and further evidenced the production of non-immunoreactive smaller peptides. The degradation was not observed when a calpain 1-specific inhibitor was added. The calpain cleavage sites identified by Edman degradation were regularly present in the B-type repeats of FLG2. Moreover, immunohistochemical analysis of normal human skin revealed colocalization of FLG2 and calpain 1 in the upper epidermis. Finally, the FLG2 deiminated by human peptidylarginine deiminases was shown to be more susceptible to calpain 1 than the unmodified protein. Altogether, these data demonstrate that calpain 1 is essential for the proteolytic processing of FLG2 and that deimination accelerates this process.

Lack of association of ABCB1 and PXR polymorphisms with response to treatment in epilepsy

It is proposed that overexpression of P-glycoprotein (P-gp), encoded by the ABC subfamily B member 1 (ABCB1) gene, is involved in resistance to antiepileptic drugs (AEDs) in about 30% of patients with epilepsy. Genetic variation and haplotype patterns are population specific which may cause different phenotypes such as response to AEDs. Although several studies examined the link between the common polymorphisms in the ABCB1 gene with resistance to AEDs, the results have been conflicting. This controversy may be caused by the effect of some confounders such as ethnicity and polytherapy. Moreover, expression of the ABCB1 gene is under the control of pregnane X receptor (PXR). Evidence showed that PXR gene contribute to the response to treatment. The aim of this study was to assess the association of ABCB1 and PXR genetic polymorphisms with response to the carbamazepine (CBZ) or sodium valproate (VPA) monotherapy in epilepsy. Genotypes were assessed in 685 Chinese, Indian, and Malay epilepsy patients for ABCB1 (C1236T, G2677T, C3435T) and PXR (G7635A) polymorphisms. No association between these polymorphisms and their haplotypes, and interaction between them, with response to treatment was observed in the overall group or in the Chinese, Indian, and Malay subgroups. Our data showed that these polymorphisms may not contribute to the response to CBZ or VPA monotherapy treatment in epilepsy.

ABCB1 C3435T polymorphism and the risk of resistance to antiepileptic drugs in epilepsy: a systematic review and meta-analysis

OBJECTIVE

The C3435T, a major allelic variant of the ABCB1 gene, is proposed to play a crucial role in drug-resistance in epilepsy. The C/C genotype carriers reportedly are at higher risk of pharmacoresistance to AEDs, but only in some studies. The hypothesis of the C-variant associated risk and resistance to antiepileptic drugs (AEDs) has been hampered by conflicting results from inadequate power in case-control studies. To assess the role of C3435T polymorphism in drug-resistance in epilepsy, a systematic review and meta-analysis was conducted.

METHODS

Databases were obtained from the Cochrane Library, MEDLINE, EMBASE, major American and European conference abstracts, and www.google.my for genetic association studies up to February 2010. All the case-control association studies evaluating the role of ABCB1 C3435T in pharmacoresistance to AEDs were identified. The new definition of treatment outcome from International League Against Epilepsy (ILAE) was used for including studies for sub-analysis. To measure the strength of genetic association for the gene variant, the odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using models of both fixed- and random-effects for comparisons of the alleles and genotypes with co-dominant (C/C vs. T/T, C/T vs. T/T), dominant (C/C+C/T vs. T/T), and recessive (C/C vs. C/T+T/T) models in overall and in ethnicity subgroups. The 19 studies were selected for the next sub-analysis based on the new definition of drug-responsiveness and drug-resistance from ILAE. The same analysis was also performed for treatment outcome and ethnicity subgroups.

RESULTS

A total of 22 association studies including 3231 (47.8%) drug-resistant patients and 3524 (52.2%) drug-responsive patients or healthy controls (genotyped for C3435T) were pooled in this meta-analysis. The allelic association of ABCB1 C3435T with risk of drug-resistance was not significant under fixed-effects model, 1.06 (95% CI 0.98-1.14, p=0.12) and random-effects model, 1.10 (0.93-1.30, p=0.28) in overall and in the subgroup analysis by ethnicity. Similar results were also obtained for all genetic models in the stratified analyses by new definition of drug-resistance by ILAE and ethnicity subgroups. There was no publication bias.

CONCLUSION

We failed to show an association between the ABCB1 C3435T polymorphism and the risk of drug-resistance suggesting a revision in contribution of this polymorphism in the multi-drug transporters hypothesis of pharmacoresistance to AEDs in epilepsy.

Sleep-disordered breathing in patients with Parkinson's disease

INTRODUCTION

There are limited studies reporting the frequency of sleep-disordered breathing (SDB) in Parkinson's disease (PD), and the figures quoted are variable, ranging from 2.5 to 66 percent. This study aimed to determine the prevalence and types of SBD in PD patients attending the Universiti Kebangsaan Malaysia Medical Centre neurology clinic, and the correlation between the subjective sleep symptoms using the Parkinson's disease sleep scale (PDSS) and the objective measurements using polysomnography (PSG).

METHODS

This was a cross-sectional study involving 46 PD patients over a period of six months. The patients' demographic data, Hoehn and Yahr staging and PDSS scores were collected. The patients were then subjected to overnight PSG using the Somnomedic system.

RESULTS

There were 27 male and 19 female patients with a mean age of 64.0+/-9.7 years. 29 were Chinese, 15 Malay and 2 Indian. The mean duration of illness was 5.8+/-4.3 years. The mean PDSS score was 120.3+/-13.5. SDB was found in 54.6 percent of the patients (apnoeahypopnoea index [AHI] 5 and above), with 27.3 percent having moderate and severe SDB (AHI 15 and above). The median AHI was 6.7 (range 0-40.4). The prevalence of SDB in PD patients based on the AHI cutoffs were 27.3 percent for mild, 18.2 percent for moderate and 9.1 percent for severe. There were statistically significant positive correlations between the AHI and the neck circumference and between the AHI and the waist-hip ratio. There was no significant correlation between the AHI and PDSS, or the AHI and disease severity.

CONCLUSION

There was a high prevalence of SBD in our PD patients, which was comparable to other studies. Obstructive sleep apnoea was the dominant type of SBD. There was no correlation between the subjective sleep symptoms using the PDSS and the objective measurements using PSG.

Sleep disturbances in Malaysian patients with Parkinson's disease using polysomnography and PDSS

BACKGROUND

Sleep disturbances such as sleep fragmentation, sleep disordered breathing (SDB), periodic limb movements (PLM), excessive daytime somnolence (EDS) and insomnia are prevalent in Parkinson's disease (PD). However, studies in the Asian population are limited.

METHODS

This was a cross-sectional study involving 46 Malaysians with PD using polysomnography (PSG) and standardized translated Parkinson's disease sleep scale (PDSS). Overnight PSG recordings, UPDRS and PDSS scores, and baseline demographic data were obtained.

RESULTS

Data from 44 patients were analysed. Thirty-six patients (81.8%) had PSG-quantified sleep disorders. Twenty-three (52.3%) had sleep fragmentation, 24 (54.6%) had SDB and 14 (32%) had PLM. EDS was present in 9.1%. Insomnia was reported by 31.8%. Patients with sleep fragmentation had significantly higher UPDRS scores and lower PDSS insomnia sub-scores. The UPDRS scores correlated negatively with the TST and sleep efficiency. All patients with EDS had SDB (p=0.056). The PDSS insomnia sub-items correlated with sleep fragmentation on PSG.

CONCLUSION

: The prevalence of sleep disorders based on PSG and PDSS in our PD patients was high, the commonest being sleep fragmentation and SDB, while EDS was the least prevalent. Problem specific sub-items of the PDSS were more accurate in predicting the relevant PSG-related changes compared to the PDSS as a whole.

Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after stroke

Botulinum toxin is effective in reducing spasticity post stroke. As there are limited data on post stroke spasticity in Asia, we undertake this study to determine the effectiveness and safety of intramuscular injection of botulinum toxin type-A (BTX-A), in the treatment of chronic focal post-stroke hand spasticity, and the impact of BTX-A on the activities of daily living and quality of life, in comparison to placebo, in Malaysian stroke patients. This was a randomized, double-blind, placebo-controlled study to assess the efficacy and safety of BTX-A in 27 subjects with wrist and finger spasticity after a stroke. The outcome measures were assessed with the Modified Ashworth Scale (MAS) to assess spasticity of the flexor muscles, Barthel Index (BI) for activities of daily living and EQ-5D and EQ VAS for quality of life. Assessments were performed at baseline and 1 and 3 months after injection. Compared to placebo, the BTX-A group had greater improvement in the flexor tone of the wrist and fingers (p = 0.001 and p < 0.001, respectively), at first month follow-up visit and sustained the improvement through to three months. Although there was an improvement in the measures of global function and quality of life in the BTX-A group, there was no significant improvement in between the two groups. No serious BTX-A related adverse effects were reported. The results of this study demonstrate that intramuscular injection of botulinum toxin A is safe and effective in the treatment of chronic focal post-stroke spasticity of the hand.

Randomised, open label, controlled trial of celecoxib in the treatment of acute migraine

INTRODUCTION

Migraine is a common disabling condition that results in considerable socioeconomic loss. The role of non-steroidal anti-inflammatory drugs (NSAIDs) in acute migraine has been well-established. We compared the efficacy of the cyclooxygenase-2 inhibitor celecoxib with the NSAID, naproxen sodium, in the treatment of acute migraine.

METHODS

This was a randomised, open label, controlled trial. We selected patients with a diagnosis of migraine, based on the International Headache Society revised criteria. 60 patients were randomised to either celecoxib 400 mg (30 patients) or naproxen sodium 550 mg (30 patients). Patients took the study medicine for the first acute migraine episode that occurred during the study period and reported the headache reduction based on a visual analogue score (VAS). Patients were reviewed after a month to check on VAS at one and two hours, compared to the baseline. Any side effects of the medication were also recorded.

RESULTS

Of the 52 patients who completed the study, eight did not experience any headaches. The mean VAS in the celecoxib group improved significantly from baseline (6.48 +/- 1.53) to one hour (4.28 +/- 2.11) and two hours (2.24 +/- 2.57) (p-value is less than 0.0005). The mean VAS in the naproxen sodium group also improved significantly from baseline (7.30 +/- 1.66) to one hour (4.81 +/- 2.50) and two hours (2.63 +/- 2.65) (p-value is less than 0.0005). However, there was no significant difference between the magnitudes of improvement between the treatment groups. The incidence of gastric pain was significantly higher in the naproxen sodium group (p-value is equal to 0.029).

CONCLUSION

In comparison with naproxen sodium, celecoxib was equally effective in relieving pain in acute migraine and caused significantly less gastric pain.

Short QTc in epilepsy patients without cardiac symptoms

Epilepsy patients have a higher mortality rate than the general population. Sudden unexpected death in epilepsy (SUDEP) is a major cause of mortality for these patients. The possibility of cardiac involvement in the pathogenesis of SUDEP has been suggested by many previous studies. This study compared the QT interval in epilepsy patients and normal controls, and identified the factors that affected the QT interval. Standard 12-lead ECGs were recorded from 70 consecutive epilepsy patients from the neurology clinic of HUKM and 70 age, race and gender matched controls. The mean QT interval corrected for heart rate (QTc) was calculated and compared. The mean QTc among the epilepsy patients was 0.401 +/- 0.027s. It was significantly shorter than the QTc (0.420 +/- 0.027s) in the control group (p<0.0005). Thirty five epilepsy patients (50%) and 17 matched controls (24.3%) had a mean QTc shorter than 0.40s (p=0.001). Among the epilepsy patients, the mean QTc did not significantly differ between patients in the duration (F=0.836, p=0.438) of the epilepsy, frequency (F=0.273, p=0.845) and types of seizures (p=0.633). There was no significant difference in the mean QTc between the epilepsy patients on different number of antiepileptic agents (F=0.444, p=0.643). Patients with cryptogenic epilepsy had a mean QTc of 0.392 +/- 0.029s, which was significantly shorter than patients with symptomatic epilepsy (QTc = 0.410 +/- 0.027s, p = 0.015). The mean QTc of the same subjects showed no significant interobserver difference (p=0.661). This study, for the first time, demonstrates that epilepsy patients have a significantly shorter QTc than controls, particularly in the subgroup of patients with cryptogenic epilepsy.

The predictors of subclinical cerebral infarcts in ischaemic stroke patients

Subclinical cerebral infarcts (SCI) have been increasingly shown to cause a significant clinical impact. However, there are limited data available on Asian patients. The objectives of this study were to determine the prevalence of SCI in ischaemic stroke patients seen in the Hospital Universiti Kebangsaan Malaysia (HUKM) and to identify its associated risk factors. We evaluated the brain computed tomography (CT) evidence of subclinical infarcts in ischaemic stroke patients. The patients were selected from those who were on regular follow up in the neurology clinic following an ischaemic stroke. The risk factors associated with subclinical infarct were documented. The brain CTs were done during acute admission and reviewed for SCI. Sixty-one patients were enrolled in this study. Twenty-two (36.1%) out of the 61 patients had SCI. The risk factors for SCI in our study were hypertension (OR 14.16 CI 2.04-97.89), diabetes mellitus (OR 12.48; CI 1.95-79.77) and leukoaraiosis (OR 28.39; CI 2.33-284.16). Subclinical cerebral infarcts were present in about one third of our ischaemic stroke patients. This finding is higher than in previous studies done on Caucasians. Hypertension, diabetes mellitus and leukoaraiosis independently predict SCI.

Leukoaraiosis as a predictor for mortality and morbidity after an acute ischaemic stroke

INTRODUCTION

Leukoaraiosis (LA) is a term that defines an abnormal appearance of the subcortical white matter of the brain on neuroimaging. This study was done to evaluate the predictive value of LA in terms of mortality, disability and cognitive decline at three months post-stroke and also to identify the risk factors that are independently associated with LA in a stroke population.

METHODS

This was a prospective observational study of all patients with acute ischaemic stroke who were admitted to Hospital Universiti Kebangsaan Malaysia from June to November 2004. A single observer using the pre-defined diagnostic criteria recorded the information on demography, Barthel Index and mini-mental state examination. LA was diagnosed on brain computed tomography alone.

RESULTS

60 patients were recruited into the study. Three patients (five percent) died and LA was present in 29 patients (48 percent). There was no significant association between LA and mortality (p-value equals 0.89). The independent risk factors that were associated with LA were age (odds-ratio [OR] 4.43; 95 percent confidence interval [CI] 1.28-15.27) and hypertension (OR 14.3; 95 percent CI 1.40-147.42). There was a significant association between LA with early dementia (OR 3.53; 95 percent CI 1.19-10.49). However, LA did not significantly predict any functional disability (Barthel Index is less than 60) in the study population (p-value equals 0.45).

CONCLUSION

Development of LA correlates significantly with ageing and hypertension. The presence of LA can also predict early cognitive dysfunction but is not associated with functional disability at three months post-stroke.

The coexistence of anxiety and depressive personality traits in migraine

INTRODUCTION

Migraine is associated with a variety of personality traits. The objective of this study was to reevaluate the personality traits using Minnesota Multiphasic Personality Inventory-2 (MMPI-2) in migraine patients diagnosed by applying the new International Classification of Headache Disorders-2 criteria.

METHODS

This was a case control study involving 70 migraine patients and 70 age- and gender-matched controls. The personality traits in the two groups were analysed using the MMPI. Data was analysed using the chi-square test.

RESULTS

The migraine patients showed a higher MMPI score on the following personality traits: depression (39 versus 15, p-value is less than 0.0005), and anxiety (24 versus 11, p-value equals 0.011). Both depressive and anxiety personality traits were significantly higher in migraine patients.

CONCLUSION

All migraine patients should probably be screened for their personality traits and psychopathology using the MMPI.

The electroencephalogram changes in migraineurs

Migraine is associated with a variety of electroencephalographic (EEG) changes. Previous studies using analogue EEG and old diagnostic criteria may under or over report the prevalence of EEG changes in migraine. The objective of this study was to reevaluate the EEG changes in migraine patients diagnosed by applying the new International Classification of Headache Disorder -2 criteria. This was a case control study involving 70 migraine patients and 70 age and gender matched control who were subjected to scalp EEG. The EEG changes during hyperventilation (HV), which were significantly more common in the migraine group were theta activity (34 vs 22, p = 0.038) and frontal intermittent rhythmic delta activity (FIRDA) (10 vs 3, p = 0.042). Applying the new ICHD -2 diagnostic criteria and digital EEG, this study yielded previously unrecognized features including FIRDA during HV on EEG.

Risk factors and outcome of dysphagia after an acute ischaemic stroke

Dysphagia occurs frequently after a stroke. It is a major problem as patients are at risk of malnutrition and aspiration pneumonia. We aimed to identify the risk factors for and outcome of dysphagia over the first one month after an acute ischaemic stroke. Patients with acute first-ever ischaemic stroke admitted to the medical ward of Hospital Universiti Kebangsaan Malaysia (HUKM) between July 2004 and December 2004 were prospectively examined. Observation was done using pre-defined criteria. Demographic data, risk factors, and type of stroke were recorded on admission. The assessment of dysphagia was made using standardized clinical methods. All patients were followed up for three months. One hundred and thirty four patients were recruited in the study. Fifty-five patients (41%) had dysphagia at presentation. This number was reduced to 29 (21.6%) patients at one month. Logistic regression analysis revealed that age of more than 75 years [OR 5.20 (95% CI 1.89 - 14.30)], diabetes mellitus [OR 2.91 (95% CI 1.07 - 7.91)] and MCA infarct [OR 2.48 (95% CI 1.01-6.14)] independently predicts the occurrence of dysphagia after an acute stroke. Dysphagia at presentation was found to be an independent predictor of mortality at one-month [OR 5.28 (95% CI 1.51-18.45)] post ischaemic infarct. Dysphagia occurred commonly in ischaemic stroke. Advance age, diabetes mellitus and large infarcts were independently associated with the presence of dysphagia. Early stroke mortality can be independently predicted by the presence of dysphagia.

Case of severe refractory myasthenia gravis in HUKM

A 20-year-old girl first notice bilateral ocular muscle weakness in 2001. Two months later, she developed acute muscle paralysis and respiratory failure which required ventilation. Serum anti-acetylcholine receptor antibodies and repetitive nerve stimulation test was positive and consistent with myasthenia gravis (MG). CT scan thorax revealed thymic enlargement and she underwent a video assisted thymectomy (VATS). However, over the next three years, despite maximal doses of various immunosuppressive agents with plasmapheresis and intravenous immunoglobulin, she was admitted with recurrent myasthenic crisis without any obvious precipitant. She was then commenced on mycophenolate mofetil and together with regular plasmapheresis, cyclosporine and prednisolone, her symptoms have finally improved and brought under control.

The risk factors of gastrointestinal bleeding in acute ischaemic stroke

Gastrointestinal (GI) bleeding is one of the most serious complications after an acute ischaemic stroke and may affect stroke outcome. We identified predictors and the eventual outcome of gastrointestinal bleeding during the in-patient period following the commencement of aspirin. This was a study of patients with acute ischaemic stroke admitted to Universiti Kebangsaan Malaysia Hospital from June 2000 to January 2001. A single observer, using predefined diagnostic criteria recorded information on demography, risk factors and GI bleeding that occurred during the inpatient period. One hundred and fifteen patients with acute ischaemic stroke were enrolled in the study. Gastrointestinal bleeding was observed in 6 (5.2%) patients. Using univariate analysis, the independent predictors of gastrointestinal bleeding were age (OR 1.25; 95% CI 1.07 to 1.50), and middle cerebral artery (MCA) territory infarcts (OR 9.47; 95% CI 1.62 to 55.5). Using multivariate analysis, the presence of gastrointestinal bleeding increased mortality (OR 24.97; 95% CI 1.97 to 316.91). Older age, and large MCA infarct predict the development gastrointestinal bleeding. Stroke mortality was independently predicted by gastrointestinal bleeding. Prophylactic treatment in elderly patients with large cerebral infarcts may be an area for further investigation.

The prognostic value of tissue factor levels in acute ischaemic stroke

INTRODUCTION

There is no biological marker that can accurately predict the prognosis after an acute ischaemic stroke. The main objective of this study was to evaluate the prognostic value of tissue factor (thromboplastin) levels in first ischaemic stroke.

METHODS

This was a prospective study of all patients with first ischaemic stroke conducted from October 2003 to February 2004. Plasma for tissue factor levels was kept at -80 degrees Celsius and was analysed at the end of the study period by an independent person. The activities of daily living (ADL) were assessed by using the Barthel index (BI) on admission and at one month after the stroke onset. Any death or recurrent events were recorded.

RESULTS

50 patients were recruited into the study. The median tissue factor level was 184.5 +/- 97.3 pg/ml. Only age (p-value is 0.027) and middle cerebral artery (MCA) infarcts (p-value is 0.038) were found to be significant independent predictors for severe disability at one month with BI equal to or less than 9. There was no correlation of tissue factor level with BI at one month post-stroke (r equals -0.028, p-value is 0.846) and there was also no significant relationship between levels of tissue factor and recurrent events (p-value is 0.41).

CONCLUSION

There is no correlation between tissue factor levels with acute ischaemic stroke outcome.

Risk factors for developing sleep-disordered breathing in patients with recent ischaemic stroke

INTRODUCTION

There are several studies that reported a higher frequency of sleep-disordered breathing (SDB) among ischaemic stroke patients with increasing evidence linking SDB and cardiovascular complications. Many showed prevalence between 43 percent and 72 percent, taking the apnoea-hypopnoea index (AHI) equal to or greater than ten. The main objective of this study was to determine the frequency of SDB in recent ischaemic stroke patients admitted to Hospital Universiti Kebangsaan Malaysia (HUKM) and the relationship between SDB and known risk factors of ischaemic stroke.

METHODS

This was a cross-sectional, prospective study involving 28 consecutive acute ischaemic stroke patients admitted to HUKM over three months. Sleep studies were done within one to four weeks after stroke onset. Demographical data and associated risk factors were recorded and data were analysed.

RESULTS

There were 20 men and eight women, with mean age of 60.3 +/- 8.9 years. There were eight Malay, 16 Chinese and four Indian patients. The prevalence of SDB in ischaemic stroke depending on the AHI cut-off was: 92.8 percent for AHI greater than or equal to five, 78.5 percent for AHI greater than or equal to ten, 44.5 percent for AHI greater than or equal to 15, and 37.7 percent for AHI greater than or equal to 20. We discovered that diabetes mellitus and smoking history were important factors predicting significant SDB (AHI greater than or equal to 15) in recent ischaemic stroke cases.

CONCLUSION

There was a high prevalence of SDB in recent ischaemic stroke patients in HUKM, comparable to other studies. Diabetes mellitus and smoking history were strong predictors of the occurrence of SDB after an ischaemic stroke.

A prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with acute dysphagic stroke

Dysphagia following stroke is common problem and is of particular concern because of its potental for malnutrition. Nasogastric (NG) and percutaneous endoscopic gastrostomy (PEG) tube feeding are recognized methods for nutritional support for patients with persistent neurologic dysphagia. However, the former is associated with tube dislodgement and blockage that might compromise the patients' nutritional status. There have been few randomized prospective studies to date comparing the efficacy and safety of these 2 modes of dysphagia management in stroke patients. The objective of this study was to compare PEG with NG tube feeding after acute dysphagic stroke in terms of nutritional status and treatment failure. This was a randomized prospective clinical trial. A total of 23 consecutive patients who fulfilled the criteria were recruited from the medical wards in Hospital Universiti Kebangsaan Malaysia. The diagnosis of stroke (acute cerebral infarct) was based on clinical and brain computed tomographic (CT scan) findings; and the diagnosis of dysphagia was done clinically by using the 'swallowing test'. At recruitment, upper-arm skin fold thickness (triceps and biceps) and mid-arm circumference were measured; and blood was drawn for serum albumin level. They were then followed up at 4 weeks where the above tests were repeated. A total of 22 patients completed the study (12 patients in the NG group and 10 patients in the PEG group). Serum albumin levels (p = 0.045) were significantly higher in the PEG as compared to the NG group at 4 weeks post-intervention. There were statistically significant improvements in serum albumin level (p = 0.024) in the PEG group; and statistically significant reductions in serum albumin level (p = 0.047) in the NG group 4 weeks after the intervention. However, there were no significant differences in anthropometric parameters between the two groups and no significant changes in these parameters for each group 4 weeks after the intervention. Treatment failure occurred in 5 out of 10 patients (50.0%) in the NG group, but none in PEG group (p = 0.036). PEG tube feeding is more effective than NG tube feeding in improving the nutritional status (in terms of the serum albumin level) of patients with dysphagic stroke. NG tube feeding, in fact, reduced the nutritional status (in terms of the serum albumin level) of the patients.

Haemophagocytic syndrome presenting as pyrexia of unknown origin

Haemophagocytic syndrome (HPS) should be included in the differential diagnosis of pyrexia of unknown origin (PUO). The hallmark of HPS is the accumulation of activated macrophages that engulf haematopoietic cells in the reticuloendothelial system. We describe a patient with unexplained fever in which a final diagnosis of HPS was established in a bone marrow study.

The prognostic value of C-reactive protein (CRP) levels in patients with acute ischaemic stroke

Increasing evidence suggests that inflammation plays an important role in the development of both cardiovascular and cerebrovascular events. Recently C-reactive protein (CRP) levels have been reported to be a prognostic factor for cerebrovascular and cardiovascular events. The main objective of the study was to evaluate the prognostic value of CRP levels in a first ever ischaemic stroke at one month. All ischaemic stroke patients who were admitted to Hospital Universiti Kebangsaan Malaysia (HUKM) between May 2002 and July 2002 were eligible for the study. CRP levels were taken within 72 hours after an acute ischaemic stroke. The functional ability was assessed using the Barthel Index (BI) after one month of stroke. During the study period 84 patients were admitted to HUKM with the diagnosis of ischaemic stroke; 49 patients were enrolled and 35 were excluded. Twenty-nine patients (59.2%) had elevated CRP levels (median 1.64+/-3.07 mg/dL, range 0.06 to 16.21 mg/dL). Elevated CRP levels were found to be a predictor of severe functional disability (BI<5) and were also associated with larger infarcts. In conclusion, elevated CRP levels are associated with poorer functional outcome and predict a larger infarct size.

Rheumatoid pachymeningitis

Symptomatic rheumatoid pachymeningitis is a rare extra-articular manifestation of rheumatoid arthritis. Clinical symptoms are non-specific and diagnosis is frequently made by exclusion. We present a 61-year-old woman with a 9-year history of rheumatoid arthritis presenting with deafness and progressive disability over a two month duration. She was diagnosed as having rheumatoid pachymeningitis based on the cerebral magnetic resonance imaging findings.

Acute disseminated encephalomyelitis (ADEM) presenting with seizures secondary to anti-tetanus toxin vaccination

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system (CNS) that is known to occur spontaneously in association with specific and non-specific viral illnesses and after vaccination against various pathogens. Although it is often a self-limited monophasic illness, the fatality rate is estimated to be as high as 20%, and many patients suffer residual neurologic impairment 1. The diagnosis is mainly based on clinical and radiological findings. The clinical presentation varies from merely, an asymptomatic condition to loss of consciousness, seizures, ataxia, optic neuropathy, cranial nerve palsies, and motor dysfunction. MRI of the brain is the single most important diagnostic radiological investigation and can facilitate early diagnosis and prompt treatment. This case report describes a patient with ADEM presenting with only seizures after vaccination with anti-tetanus toxin.

Risk factors and complications of acute ischaemic stroke patients at Hospital Universiti Kebangsaan Malaysia (HUKM)

In Malaysia, there is limited information on the mortality and morbidity after an acute stroke in hospitalised patients. The objective of the study was to identify the type, time of onset, and frequency of medical and neurological complications following an acute ischaemic stroke. Consecutive patients with acute ischaemic stroke who were admitted to Hospital Universiti Kebangsaan Malaysia from June 2000 to January 2001 were observed. The complication rate was 20.9%. The most common individual complication was pneumonia (12.3%), followed by septicaemia (11.0%), urinary tract infection (4.3%), and upper gastrointestinal haemorrhage (3.7%). The overall mean length of stay was 7.48 days. The independent risk factors for complications were diabetes mellitus (OR 2.87; 95%CI 1.06 to 7.78), middle cerebral artery (MCA) infarcts (OR 10.0; 95%CI 4.1 to 24.3), and Glasgow coma score (GCS) less than 9(OR 3.8; 95%CI 1.03 to 14.3). Infection was the commonest complication observed. Patients with diabetes mellitus, poor GCS and large MCA infarcts had a higher risk of developing complications.

The impact of diabetes mellitus on in-hospital stroke mortality

BACKGROUND AND PURPOSE

Diabetes mellitus is a strong risk factor for stroke. However, the prognosis in terms of mortality after a stroke is still unclear, especially in diabetic patients. The main purpose of this study was to compare and evaluate the features of stroke in patients having diabetes mellitus with those without diabetes mellitus and to identify factors that influence survival following a stroke.

SUBJECTS AND METHODS

In a prospective hospital-based study consecutive patients with acute ischaemic stroke were enrolled. A single observer, using predefined diagnostic criteria recorded the demographics, risk factors and the type of stroke and deaths that occurred during the in-patient period.

RESULTS

One hundred and sixty-three patients with acute ischaemic stroke were enrolled in the study. Type 2 diabetes mellitus was present in 90 (55.2%) patients. Diabetes was a significant independent predictor of mortality (OR 4.88; 95%CI 1.25-19.1). Among the diabetic patients middle cerebral artery (MCA) territory infarct (OR 34.8, 95%CI 4.5-269.4) and Glasgow coma score (GCS) less than 9 (OR 12.3, 95%CI 3.7-198.1) were independent predictors of mortality.

CONCLUSIONS

MCA infarcts and poor conscious level increase the mortality in diabetic patients with stroke. Mortality is also significantly related to a high level of blood glucose at admission.

The predictors of early infection after an acute ischaemic stroke

BACKGROUND AND PURPOSE

Infection is a frequent complication after an acute stroke and may affect stroke outcome. We identified predictors of early infection, type of infection, their relation to initial disability, and the eventual outcome during the inpatient period.

METHODS

This was a study of patients with acute ischaemic stroke admitted to Universiti Kebangsaan Malaysia Hospital from June 2000 to January 2001. A single observer, using pre-defined diagnostic criteria recorded information on demography, the type, time of onset, and frequency of infections that occurred during the inpatient period.

RESULTS

One hundred and sixty three patients with acute ischaemic stroke were enrolled in the study. Early infection was observed in 26 (16%) patients. The infections observed were pneumonia (12.3%), and urinary tract infection (3.7%). Using multivariate analysis, the independent predictors of early infection were Barthel index (BI) less than 5 (OR 4.23; 95% CI 1.70 to 5.11), middle cerebral artery (MCA) territory infarcts (OR 4.91; 95%CI 1.57 to 8.82), and a Glasgow coma score (GCS) less than 9 (OR 5.12; 95% CI 2.98 to 15.52). The presence of early infection increased mortality (OR 14.83; 95% CI 4.31 to 51.07).

CONCLUSIONS

Severe disability, large MCA infarct and poor GCS independently predict the development of early infection.

The use of nerve conduction studies in determining the short-term outcome of Bell's palsy

Bell's palsy is a common neurological problem causing considerable loss of self-esteem among patients. A prospective observational study was conducted to determine the short-term outcome of Bell's palsy at 1 month and 2 months after the onset and the relationship between these outcomes with facial nerve degeneration. We also determined if gender, age, diabetes, systolic and diastolic blood pressure influence the severity of facial nerve degeneration and the clinical outcome at 2 months after the onset. After clinically grading the newly diagnosed unilateral Bell's palsy patients using the House-Brackmann facial nerve grading system, nerve conduction studies of the facial nerve were done to determine the severity of facial nerve degeneration. The recovery of the facial paralysis was clinically graded again at the end of 1 month and 2 months from the onset. A total of 37 patients were recruited. There was a strong positive correlation between facial nerve degeneration and the clinical outcome of Bell's palsy at 1 month (r = 0.794; p < 0.0005) and 2 months (r = 0.732; p < 0.0005) after the onset. There was no significant correlation between either the facial nerve degeneration or the clinical outcome at 2 months with the patients' age (p = 0.288 and p = 0.799 respectively), systolic blood pressure (p = 0.425 and p = 0.933 respectively) or diastolic blood pressure (p = 0.243 and p = 0.579 respectively). Neither the severity of facial nerve degeneration nor the clinical outcome at 2 months were significantly different between male and female patients (p = 0.460 and p = 0.725 respectively) or diabetic and non-diabetic patients (p = 0.655 and p = 0.655 respectively).