Association of liver fibrosis with extrahepatic cancer in steatotic liver disease patients with PNPLA3 I148M GG genotype

The impacts of patatin-like phospholipase domain-containing protein 3 (PNPLA3) I148M-rs738409, methylenetetrahydrofolate reductase (MTHFR) Ala222Val-rs1801133, and aldehyde dehydrogenase 2 (ALDH2) Glu504Lys-rs671 on the outcomes of Taiwanese patients with steatotic liver disease (SLD) have remained elusive. An 8-year prospective cohort study of patients with (n = 546) and without (n = 580) SLD (controls) was undertaken in a Taiwanese tertiary care center. The 546 SLD patients comprised 306 (56.0%) men and 240 (44.0%) women with mean ages of 53.3 and 56.4 years, respectively. Compared with the controls, SLD patients had an increased frequency of the PNPLA3 I148M-rs738409 GG genotype (25.5 vs. 5.9%, p = 0.001). Among the SLD patients, 236 (43.1%) suffered cardiovascular events, 52 (9.5%) showed extrahepatic cancers, 13 (2.38%) experienced hepatic events, including hepatocellular carcinoma (n = 3, 0.5%) and liver cirrhosis (n = 8, 1.47%), and none died. The Fibrosis-4 (FIB-4) scores were associated with extrahepatic cancer (hazard ratio [HR] 1.325; 95% confidence interval [CI], 1.038-1.691) and cirrhosis development (HR 1.532; 95% CI, 1.055-2.224), and the PNPLA3 I148M-rs738409 G allele (β = 0.158, 95% CI, 0.054-0.325) was associated with the FIB-4 score. Stratified analyses showed that the impact of the FIB-4 score on extrahepatic cancer development was evident only in SLD patients with the PNPLA3 I148M-rs738409 GG genotype (HR 1.543; 95% CI, 1.195-1.993) and not in patients with the GC or CC genotype. Moreover, the ALDH2 Glu504Lys-rs671 G allele had a dose-dependent effect on alcoholism, and the MTHFR and ALDH2 genotypes were not significantly associated with SLD patient outcomes. In conclusion, special vigilance should be exercised for emerging extrahepatic cancer in SLD patients with the PNPLA3 I148M-rs738409 GG genotype and high FIB-4 scores.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Breast Cancer Survivors’ Preferences and Barriers Related to ICT-Based Diet and Physical Activity Interventions

Objectives

To establish the preferences and perceived barriers related to physical activity and diet programming of breast cancer survivors (BCS) to inform the development of Information and Communication Technology (ICT)-based lifestyle interventions.

Methods

This was a cross-sectional study of 197 BSC aged 18 years or older and diagnosed with ductal carcinoma in situ (DCIS) or Stage I-IV breast cancer. The BCS were recruited during routine oncology appointments at a Midwestern cancer center. A survey was conducted to query survivors’ level of interest in, preferences for, and perceived barriers to participating in an exercise and dietary intervention program, with a specific emphasis on ICT-based programming.

Results

Overall, 85% of BCS reported they would consider participating in exercise and diet intervention research. Approximately 45% of participants reported that they had received diet and/or exercise information as part of their cancer care. However, only 15% of the participants received such information from healthcare professionals with the appropriate expertise (e.g., Dietitian, Exercise Specialist). Over two-thirds of the participants reported frequent use of mobile devices and the internet, and 80% indicated comfort using these devices (e.g., tablet, smart phone). The top three preferred formats for an ICT-based diet and exercise intervention program were “website”, “mobile apps” and “e-mails”. Older participants (>60 years) were more likely to report a preference for e-mails while younger participants (<60 years) were more likely to report a preference for websites or mobile apps. The most common perceived barriers to participation in a lifestyle intervention included fatigue, family responsibility and work.

Conclusions

Most BCS in this study were interested in exercise and diet interventions and would be comfortable with an ICT-based format with a preference for delivery via websites, mobile apps or e-mails. Future ICT-based lifestyle interventions should be designed with consideration of BCS’ age, barriers, facilitators and other characteristics.

Funding Sources

USDA-NIFA Hatch Project 1,011,487

Cortical involvement in the StartReact effect

The rapid release of prepared movements by a loud acoustic stimulus capable of eliciting a startle response has been termed the StartReact effect (Valls-Solé et al., 1999), and premotor reaction times (PMTs) of <70 ms are often observed. Two explanations have been given for these short latency responses. The subcortical storage and triggering hypothesis suggests movements that can be prepared in advance of a "go" signal are stored and triggered from subcortical areas by a startling acoustic stimulus (SAS) without cortical involvement. Alternatively, it has been hypothesized that the SAS can trigger movements from cortical areas through a faster pathway ascending from subcortical structures. Two experiments were designed to examine the possible role of the primary motor cortex in the StartReact effect. In Experiment 1, we used suprathreshold transcranial magnetic stimulation (TMS) during the reaction time (RT) interval to induce a cortical silent period in the contralateral primary motor cortex (M1). Thirteen participants performed 20° wrist extension movements as fast as possible in response to either a control stimulus (82 dB) or SAS (124 dB). PMTs for startle trials were faster than for control trials, while TMS significantly delayed movement onset compared to No TMS or Sham TMS conditions. In Experiment 2, we examined the StartReact effect in a highly cortically represented action involving speech of a consonant-vowel (CV) syllable. Similar to previous work examining limb movements, a robust StartReact effect was found. Collectively, these experiments provide evidence for cortical (M1) involvement in the StartReact effect.

Certification of international allied professionals in cardiac pacing and electrophysiology: Opportunities?

Allied professionals with diverse backgrounds and training are essential to the delivery of quality care to patients with heart rhythm disorders. There is a growing worldwide demand for defined educational requirements and certification pathways to ensure uniformity of knowledge and competence of those practicing in electrophysiology. The present viewpoint article reviews the current deficiencies of education and training, and advocates for the establishment of certification pathways by professional societies.

Compound and double mutations in patients with hypertrophic cardiomyopathy: implications for genetic testing and counselling

OBJECTIVE

To report the frequency of single and multiple gene mutations in an Australian cohort of patients with hypertrophic cardiomyopathy (HCM).

METHODS

Genetic screening of seven HCM genes (beta-MHC, MyBP-C, cTnT, cTnI, ACTC, MYL2, and MYL3) was undertaken in 80 unrelated probands. Screening was by denaturing high performance liquid chromatography and direct DNA sequencing. Clinical data were collected on all patients and on genotyped family members.

RESULTS

26 mutations were identified in 23 families (29%). Nineteen probands (24%) had single mutations (11 beta-MHC, 4 MyBP-C, 3 cTnI, 1 cTnT). Multiple gene mutations were identified in four probands (5%): one had a double mutation and the others had compound mutations. Six of 14 affected individuals from multiple mutation families (43%) experienced a sudden cardiac death event, compared with 10 of 55 affected members (18%) from single mutation families (p = 0.05). There was an increase in septal wall thickness in patients with compound mutations (mean (SD): 30.7 (3.1) v 24.4 (7.4) mm; p<0.05).

CONCLUSIONS

Multiple gene mutations occurring in HCM families may result in a more severe clinical phenotype because of a "double dose" effect. This highlights the importance of screening the entire panel of HCM genes even after a single mutation has been identified.

Incidence and Risk Factors for Immune Reconstitution Inflammatory Syndrome in an Ethnically Diverse HIV Type 1-Infected Cohort

BACKGROUND

It is estimated that 10%-25% of patients who start highly active antiretroviral therapy (HAART) experience immune reconstitution inflammatory syndrome (IRIS). Our objective was to determine the incidence, clinical spectrum, and predictors of IRIS in an ethnically diverse cohort of patients initiating HAART.

METHODS

A retrospective study of all patients starting HAART between 1 January 2000 and 31 August 2002 at a human immunodeficiency virus (HIV) clinic in London was performed. All laboratory measurements and data on antiretroviral therapies were obtained from the clinic database. Medical records were reviewed to identify clinical events consistent with IRIS during the 6 months after HAART was initiated.

RESULTS

A total of 199 patients were included, of whom 50.8% were male, 59.3% were black African, 29.1% were white, and 10.5% were black Caribbean. The median baseline CD4 cell count and HIV RNA load were 174x10(6) cells/L (interquartile range [IQR], 82-285x10(6) cells/L) and 37,830 copies/mL (IQR, 4809-149,653 copies/mL), respectively. Forty-four patients (22.7%) experienced an IRIS event at a median of 12 weeks after HAART initiation (IQR, 4-24 weeks after initiation); 22 events (50%) involved genital herpes, 10 (23%) involved genital warts, 4 (9.0%) involved molluscum contagiosum, and 4 (9.0%) involved varicella zoster virus infection. Five patients had mycobacterial infections, 4 had hepatitis B, 1 had Pneumocystis jirovecci infection, and 1 had Kaposi sarcoma. The strongest independent predictors of IRIS were younger age at initiation of HAART (P=.003), baseline CD4 cell percentage of <10% (odds ratio [OR], 2.97; IQR, 1.17-7.55) compared with >15%, and ratio of CD4 cell percentage to CD8 cell percentage of <0.15 (OR, 3.45; 95% confidence interval, 1.27-9.1) compared with >0.3.

CONCLUSIONS

Approximately one-quarter of patients who start HAART experience an IRIS event. The majority are dermatological, in particular genital herpes and warts. Patients with advanced immunodeficiency at HAART initiation are at greatest risk of developing IRIS and should be appropriately screened and monitored.

Delayed diagnosis of cervical cancer in young women

This study aims to determine whether women under 35 years presenting with cervical cancer experience delays between presentation and diagnosis. All women referred with cervical cancer to the gynaecological cancer centre for the North London Cancer Network from January 2002 to December 2004 were identified retrospectively. Clinical presentation and time interval from symptoms to diagnosis were compared between women under and women over 35 years. A total of 105 women were included. Median age at diagnosis was 45 years (range 23--88). Twenty-two women (19%) were under 35 years at presentation and 17 had persistent symptoms prior to diagnosis. Median time from initial presentation to diagnosis in this group was 9 months (range 3--24 months); significantly longer than in the older group (9 vs 2 months; p=0.0009). Although cervical cancer is relatively rare in young women, diagnosis should be considered in symptomatic women as delay can limit treatment options.

Dose properties of a laser accelerated electron beam and prospects for clinical application

Laser wakefield acceleration (LWFA) technology has evolved to where it should be evaluated for its potential as a future competitor to existing technology that produces electron and x-ray beams. The purpose of the present work is to investigate the dosimetric properties of an electron beam that should be achievable using existing LWFA technology, and to document the necessary improvements to make radiotherapy application for LWFA viable. This paper first qualitatively reviews the fundamental principles of LWFA and describes a potential design for a 30 cm accelerator chamber containing a gas target. Electron beam energy spectra, upon which our dose calculations are based, were obtained from a uniform energy distribution and from two-dimensional particle-in-cell (2D PIC) simulations. The 2D PIC simulation parameters are consistent with those reported by a previous LWFA experiment. According to the 2D PIC simulations, only approximately 0.3% of the LWFA electrons are emitted with an energy greater than 1 MeV. We studied only the high-energy electrons to determine their potential for clinical electron beams of central energy from 9 to 21 MeV. Each electron beam was broadened and flattened by designing a dual scattering foil system to produce a uniform beam (103%>off-axis ratio>95%) over a 25 x 25 cm2 field. An energy window (deltaE) ranging from 0.5 to 6.5 MeV was selected to study central-axis depth dose, beam flatness, and dose rate. Dose was calculated in water at a 100 cm source-to-surface distance using the EGS/BEAM Monte Carlo algorithm. Calculations showed that the beam flatness was fairly insensitive to deltaE. However, since the falloff of the depth-dose curve (R10-R90) and the dose rate both increase with deltaE, a tradeoff between minimizing (R10-R90) and maximizing dose rate is implied. If deltaE is constrained so that R10-R90 is within 0.5 cm of its value for a monoenergetic beam, the maximum practical dose rate based on 2D PIC is approximately 0.1 Gy min(-1) for a 9 MeV beam and 0.03 Gy min(-1) for a 15 MeV beam. It was concluded that current LWFA technology should allow a table-top terawatt (T3) laser to produce therapeutic electron beams that have acceptable flatness, penetration, and falloff of depth dose; however, the dose rate is still 1%-3% of that which would be acceptable, especially for higher-energy electron beams. Further progress in laser technology, e.g., increasing the pulse repetition rate or number of high energy electrons generated per pulse, is necessary to give dose rates acceptable for electron beams. Future measurements confirming dosimetric calculations are required to substantiate our results. In addition to achieving adequate dose rate, significant engineering developments are needed for this technology to compete with current electron acceleration technology. Also, the functional benefits of LWFA electron beams require further study and evaluation.

Evolution of heart rate control after transplantation: conduction versus autonomic innervation

In cardiac transplantation, the donor organ is not initially innervated and demonstrates decreased heart rate variability (HRV). However, HRV may improve after several months. The mechanism for HRV improvement has not been elucidated; autonomic "reinnervation" of the donor heart has been proposed. The role of atrioatrial conduction from recipient to donor organ has not been evaluated. We prospectively evaluated cardiac transplant patients with a limited electrophysiology study at the time of their surveillance biopsies. Recordings were made of recipient and donor signals, observing conduction properties between recipient and donor atria. Holter recordings were analyzed and HRV was determined using spectral analysis techniques, recording mean RR interval, low-frequency power (LF), high-frequency power (HF), and the LF/HF ratio. These were compared to published norms. From November 1999 to May 2000, 21 patients (6 female) who underwent cardiac transplantation participated at a median age of 101 months (range, 4.1-217 months). Time posttransplant ranged from 26 days to 71 months. Holter data were available for 20 patients and demonstrated dissociated P waves in 13 (65%). The mean heart rate on Holter was 111 beats per minute (bpm) (range, 85-161 bpm). We were able to record distinct recipient atrial signals in 16 of 21 (76%) patients. The average recipient tissue heart rate was 55% that of the donor heart rate. We documented atrioatrial association in only 1 patient. HRV did not reach normal values for most patients and did not increase with time posttransplantation. The LF values were in the normal range for most patients, whereas 3 patients had normal HF values and 2 patients had values just below normal. Recipients of heart transplantation have a predominantly sympathetic influence of HRV. These preliminary data suggest that atrioatrial conduction does not play a role in reestablishing normal heart rate control following pediatric cardiac transplantation.

Cryptococcal meningitis in pediatric systemic lupus erythematosus

Cryptococcal meningitis is an uncommon but often fatal complication of systemic lupus erythematosus (SLE). We report on a 13-year-old girl with SLE using high-dose prednisolone for several months, presented to us with low grade fever, intermittent vomiting and headache. Physical examination, including papilloedema and meningeal irritation, was unremarkable. Serum and cerebrospinal fluid (CSF) cryptococcal antigen titer was 1: 128 by latex agglutination method. CSF culture yielded Cryptococcus neoformans. We used amphotericin B deoxycholate (a cumulative dose of 1.95 gm) and fluconazole (200 mg day-1) for 6 weeks. Clinical response was good. Then, we continued fluconazole 200 mg per qd as suppressive therapy for thirty-four months. There were no neurological sequelae or relapse after 20-month follow-up. Timely diagnosis and effective antifungal therapy could improve the prognosis of cryptococcal meningitis in SLE patients.

Spontaneous activity in developing ferret visual cortex in vivo

Multi-electrode extracellular recordings in area 17 of awake behaving ferrets were conducted to characterize the pattern of spontaneous activity in the developing visual cortex before eye opening. A linear array of 16 microwire electrodes was used to record extracellular neuronal activity across a 3.2 mm strip of visual cortex between postnatal days 22 and 28. Whereas synchronous bursts of activity were observed at all recording sites, cross-correlation analysis revealed that the timing of spike activity at all electrodes was not precisely correlated. Correlated activity between cortical sites exhibited a patchy organization having long-range components. Long-range correlated activity was observed between cortical patches that were separated by a mean distance of 1 mm. The spatial pattern of correlated activity persisted during transient lateral geniculate nucleus (LGN) activity block, indicating that long-range correlated activity is generated by intrinsic circuits within the cortex, independent of LGN input activity. These results demonstrate an innate patchy organization of correlated spontaneous activity within the cortex during the early development of cortical functional and anatomical organization.

Cytokine-induced p38 activation feedback regulates the prolonged activation of AKT cell survival pathway initiated by reactive oxygen species in response to UV irradiation in human keratinocytes

A previous study has shown that UV activates the PI3K/AKT cell survival pathway while inducing cell death in human skin in vivo and cultured human keratinocytes in vitro, and yet the upstream pathway leading to the activation of AKT has not been thoroughly investigated. In this study we found that UV-induced phosphorylation of p38 and AKT in a time-dependent manner. The phosphorylation of p38 started at 5 min post UV irradiation, peaked at about 30 min, and remained elevated up to 2 h. The phosphorylation of AKT started at 15 min post UV treatment, peaked at about 1 h, and remained elevated up to 2 h. We also found that H2O2 induced phosphorylation of p38 and AKT in a time- dependent manner. Pretreatment with NAC abolished UV-induced AKT phosphorylation, suggesting the involvement of reactive oxygen species in AKT activation. Interestingly, SB203085, a known p38 inhibitor, had partially inhibited UV-induced AKT phosphorylation. Further studies showed that cytokines such as TNF-alpha and IL-1beta induced AKT phosphorylation in a time-dependent manner. Pretreatment with SB203085 inhibited IL-1beta-induced p38 and AKT phosphorylation. Collectively, our data suggest that UV activation of PI 3-kinase/AKT pathway is initiated by ROS and prolonged by feedback activation of p38 induced by released cytokines in response to UV irradiation in cultured human keratinocytes.

Arsenite activation of P13K/AKT cell survival pathway is mediated by p38 in cultured human keratinocytes

BACKGROUND

Arsenic has been considered as a carcinogen. Recently the issue of arsenic in drinking water raised an unprecedented social concern on human health, and yet the molecular mechanisms through which arsenic induces cancer remain unknown. Activation of cell survival pathway leading to the activation of eNOS has been associated with various types of cancer. The objective of this study was to investigate the pathway leading to the activation of eNOS in response to arsenite using human keratinocytes.

MATERIALS AND METHODS

Cultured keratinocytes (HaCat cells) were exposed to arsenite with or without pretreatment of various inhibitors. Western blot analysis was performed to determine the activation of p38, AKT, eNOS. EGFR tyrosine phosphorylation was detected by immunoprecipitation and Western blot analysis. pNPP assay was used to measure phosphatase activity in cell lysate. FACS analysis was performed for the determination of generation of reactive oxygen species.

RESULTS

Arsenite induced the activation of AKT at both Ser473 and Thr308, and its downstream effector eNOS in cultured human keratinocytes. Arsenite also induced phosphorylation of p38. PI-3-kinase inhibitors, Wortmannin and LY294002 inhibited arsenite-induced phosphorylation of AKT and eNOS but had no effect on phosphorylation of p38. Interestingly, however, SB203580, a known p38 inhibitor, completely inhibited arsenite-induced phosphorylation of AKT and eNOS. Arsenite induced generation of reactive oxygen species and inactivated phosphatase activity, but did not activate EGF receptor tyrosine phosphorylation.

CONCLUSIONS

Collectively, our data indicate that arsenite induces activation of AKT and eNOS, via PI-3-kinase and p38 pathway, likely bypassing the activation of EGF receptor in cultured human keratinocytes.

Bone mineral density in young female Chinese dancers

To evaluate of the effect of dancing on bone mineral density (BMD) we compared 29 Chinese girls who had been receiving regular ballet training for at least 6 years with a control group of 20 nonathletic sex- and age-matched Chinese girls. BMD was measured at the second to fourth lumbar spine and at the right femoral neck using a commercial dual-energy X-ray absorptiometer (DEXA). There were no significant differences in either measured BMD or spinal BMD after adjusting for body weight (body mass index). Adjusted BMD of the femoral neck, however, showed significant differences (P <0.05). Results revealed that the ballet dancers were significantly thinner than the control group and the negative effect of a lower bodyweight may neutralize the positive effect of ballet dancing on BMD, especially in the femoral neck.