Risk of contralateral breast cancer among Asian/Pacific Islander women in the United States

PURPOSE

While breast cancer studies often aggregate Asian/Pacific Islander (API) women, as a single group or exclude them, this population is heterogeneous in terms of genetic background, environmental exposures, and health-related behaviors, potentially resulting in different cancer outcomes. Our purpose was to evaluate risks of contralateral breast cancer (CBC) among subgroups of API women with breast cancer.

METHODS

We conducted a retrospective cohort study of women ages 18 + years diagnosed with stage I-III breast cancer between 2000 and 2016 in the Surveillance, Epidemiology and End Results registries. API subgroups included Chinese, Japanese, Filipina, Native Hawaiian, Korean, Vietnamese, Indian/Pakistani, and other API women. Asynchronous CBC was defined as breast cancer diagnosed in the opposite breast 12 + months after first primary unilateral breast cancer. Multivariable-adjusted subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were estimated and stratified by API subgroups.

RESULTS

From a cohort of 44,362 API women with breast cancer, 25% were Filipina, 18% were Chinese, 14% were Japanese, and 8% were Indian/Pakistani. API women as an aggregate group had increased risk of CBC (SHR 1.15, 95% CI 1.08-1.22) compared to NHW women, among whom Chinese (SHR 1.23, 95% CI 1.08-1.40), Filipina (SHR 1.37, 95% CI 1.23-1.52), and Native Hawaiian (SHR 1.69, 95% CI 1.37-2.08) women had greater risks.

CONCLUSION

Aggregating or excluding API patients from breast cancer studies ignores their heterogeneous health outcomes. To advance cancer health equity among API women, future research should examine inequities within the API population to design interventions that can adequately address their unique differences.

Reduction in Breast Cancer Death With Adjuvant Chemotherapy Among US Women According to Race, Ethnicity, and the 21-Gene Recurrence Score

BACKGROUND

We previously showed the 21-gene breast recurrence score (RS) has lower prognostic accuracy for non-Hispanic Black (NHB) compared with non-Hispanic White (NHW) women with estrogen receptor (ER)-positive/HER2-negative breast cancer. The purpose of this study was to determine the clinical validity of the RS for predicting chemotherapy benefit as recommended in the current NCCN Guidelines for Breast Cancer among women from diverse racial/ethnic groups.

METHODS

Using the SEER Oncotype database, we estimated propensity score-weighted hazard ratios (HRs) and 95% confidence intervals for breast cancer death with chemotherapy for women with ER-positive/HER2-negative, AJCC stages I-II, axillary node-negative, invasive breast cancer according to race/ethnicity.

RESULTS

We included 6,033 (8.2%) Asian/Pacific Islander (API), 5,697 (7.8%) NHB, 6,688 (9.1%) Hispanic, and 54,945 (74.9%) NHW women. Breast cancer death was reduced with chemotherapy for NHB (HR, 0.48, 95% CI, 0.28-0.81), Hispanic (HR, 0.48; 95% CI, 0.25-0.94), and NHW (HR, 0.80; 95% CI, 0.65-0.99) women with an RS of 26 to 100. There was a nonsignificant reduction for API women (HR, 0.59; 95% CI, 0.28-1.24). For women with an RS of 11 to 25, there was no reduction in death for any racial/ethnic group. Among women aged ≤50 years, the reduction in breast cancer death with chemotherapy differed according to race (NHB: HR, 0.37 [95% CI, 0.20-0.67]; NHW: HR, 0.56 [95% CI, 0.44-0.74]; Pinteraction for chemotherapy * race <.0499). An exploratory subgroup analysis found that young NHB women may benefit from chemotherapy at a lower RS cutoff than other women.

CONCLUSIONS

The RS was clinically validated as a predictive biomarker for NHB, Hispanic, and NHW women with ER-positive, axillary node-negative breast cancer, but it may underestimate the benefit of chemotherapy for young NHB women. If this finding is confirmed, the RS cutoff for recommending adjuvant chemotherapy for young NHB women with ER-positive, axillary node-negative breast cancer may need to be lower than for other women.

Evaluating the use of methods to mitigate bias from non-transient medications in the case-crossover design: A systematic review

PURPOSE

The case-crossover design is a self-controlled study design used to compare exposure immediately preceding an event occurrence with exposure in earlier control periods. The design is most suitable for transient exposures in order to avoid biases that can be problematic when using the case-crossover design for non-transient (i.e., chronic) exposures. Our goal was to conduct a systematic review of case-crossover studies and its variants (case-time-control and case-case-time-control) in order to compare design and analysis choices by medication type.

METHODS

We conducted a systematic search to identify recent case-crossover, case-time-control, and case-case-time-control studies focused on medication exposures. Articles indexed in MEDLINE and EMBASE using these study designs that were published between January 2015 and December 2021 in the English language were identified. Reviews, methodological studies, commentaries, articles without medications as the exposure of interest, and articles with no available full text were excluded. Study characteristics including study design, outcome, risk window, control window, reporting of discordant pairs, and inclusion of sensitivity analyses were summarized overall and by medication type. We further evaluated the implementation of recommended methods to account for biases introduced by non-transient exposures among articles that used the case-crossover design on a non-transient exposure.

RESULTS

Of the 2036 articles initially identified, 114 articles were included. The case-crossover was the most common study design (88%), followed by the case-time-control (17%), and case-case-time-control (3%). Fifty-three percent of the articles included only transient medications, 35% included only non-transient medications, and 12% included both. Across years, the proportion of case-crossover articles evaluating a non-transient medication ranged from 30% in 2018 to 69% in 2017. We found that 41% of the articles that evaluated a non-transient medication did not apply any of the recommended methods to account for biases and more than half of which were conducted by authors with no previous publication history of case-crossover studies.

CONCLUSION

Using the case-crossover design to evaluate a non-transient medication remains common in pharmacoepidemiology. Researchers should apply appropriate design and analysis choices when opting to use a case-crossover design with non-transient medication exposures.

Lifestyle change program engagement in real-world clinical practice: a mixed-methods analysis

Participant engagement in structured lifestyle change programs (LCPs) is essential for adopting behaviors that promote weight loss; however, the challenges to, and facilitators that promote, engagement with such programs are not well understood. We conducted a mixed-methods study among real-world LCP participants to assess factors associated with program engagement and to examine the reasons for withdrawal. Using electronic health records (EHR), we identified LCP eligible participants between 2010 and 2017. Multivariable logistic regression was used to assess associations between program engagement and baseline characteristics. Semi-structured interviews with LCP participants were conducted and thematically analyzed to examine reasons for withdrawal. A total of 1,813 LCP participants were included. The median number of sessions attended was 10 of 21-25 sessions. Highest LCP engagement was associated with factors potentially related to self-efficacy/motivation, such as older age, higher baseline weight, prior healthcare utilization and an absence of a history of smoking or depression. Engagement was also negatively associated with being Non-Hispanic Black versus White. The qualitative analysis of the interviews revealed four general themes pertaining to participants' withdrawal: competing priorities, perceived program effectiveness, characteristics of the program, and facilitator-related factors. Taken together, results from this mixed-methods study suggest that motivation and self-efficacy are important for program engagement; future LCP enhancements should incorporate flexible formats that may help participants manage competing priorities and maximize personal and cultural relevance for all racial/ethnic groups, especially those who have not benefitted fully. Furthermore, participants should be encouraged to set realistic goals to manage expectations.

Association of Social Determinants and Tumor Biology With Racial Disparity in Survival From Early-Stage, Hormone-Dependent Breast Cancer

Importance

Black women with hormone receptor-positive breast cancer experience the greatest racial disparity in survival of all breast cancer subtypes. The relative contributions of social determinants of health and tumor biology to this disparity are uncertain.

Objective

To determine the proportion of the Black-White disparity in breast cancer survival from estrogen receptor (ER)-positive, axillary node-negative breast cancer that is associated with adverse social determinants and high-risk tumor biology.

Design, Setting, and Participants

A retrospective mediation analysis of factors associated with the racial disparity in breast cancer death for cases diagnosed between 2004 and 2015 with follow-up through 2016 was carried out using the Surveillance, Epidemiology, and End Results (SEER) Oncotype registry. The study included women in the SEER-18 registry who were aged 18 years or older at diagnosis of a first primary invasive breast cancer tumor that was axillary node-negative and ER-positive, who were Black (Black), non-Hispanic White (White), and for whom the 21-gene breast recurrence score was available. Data analysis took place between March 4, 2021, and November 15, 2022.

Exposures

Census tract socioeconomic disadvantage, insurance status, tumor characteristics including the recurrence score, and treatment variables.

Main Outcomes and Measures

Death due to breast cancer.

Results

The analysis with 60 137 women (mean [IQR] age 58.1 [50-66] years) included 5648 (9.4%) Black women and 54 489 (90.6%) White women. With a median (IQR) follow-up time of 56 (32-86) months, the age-adjusted hazard ratio (HR) for breast cancer death among Black compared with White women was 1.82 (95% CI, 1.51-2.20). Neighborhood disadvantage and insurance status together mediated 19% of the disparity (mediated HR, 1.62; 95% CI, 1.31-2.00; P < .001) and tumor biological characteristics mediated 20% (mediated HR, 1.56; 95% CI, 1.28-1.90; P < .001). A fully adjusted model that included all covariates accounted for 44% of the racial disparity (mediated HR, 1.38; 95% CI, 1.11-1.71; P < .001). Neighborhood disadvantage mediated 8% of the racial difference in the probability of a high-risk recurrence score (P = .02).

Conclusions and Relevance

In this study, racial differences in social determinants of health and indicators of aggressive tumor biology including a genomic biomarker were equally associated with the survival disparity in early-stage, ER-positive breast cancer among US women. Future research should examine more comprehensive measures of socioecological disadvantage, molecular mechanisms underlying aggressive tumor biology among Black women, and the role of ancestry-related genetic variants.

[Health Awareness and Culturally Appropriate Epidemic Prevention Strategy for COVID-19 in Taiwan's Indigenous Townships]

The COVID-19 pandemic has imposed an extremely heavy burden on the medical system in Taiwan. Thus, improving the effectiveness of epidemic prevention efforts and reducing the related burdens on medical staff are critical. Between the initial outbreak of COVID-19 in Taiwan in early 2022 until May of that same year, two townships with high percentages of indigenous (Malayo-Polynesian) residents reported the highest rates of infection nationwide. As the indigenous culture in these and other similar townships differs significantly from Taiwan's mainstream culture, determining how to improve health awareness and provide culturally appropriate treatments during this pandemic in indigenous communities is vital. In the context of Taiwan's indigenous population, this paper addresses the importance of improving health awareness, proposes how to foster a more-friendly health awareness environment, and suggests a strategy for providing effective healthcare under current pandemic conditions. Prevention measures include improving the ability of indigenous citizens to assess the correctness of information provided, improving compliance with epidemic prevention measures, improving knowledge regarding vaccines and rapid screening reagents, and improving the notification process for diagnoses. A culturally appropriate township-based promotion strategy for epidemic prevention should be proposed to increase the effectiveness of epidemic prevention and health promotion to improve health conditions in indigenous communities.

Impact of socioeconomic status and rurality on cancer-specific survival among women with de novo metastatic breast cancer by race/ethnicity

PURPOSE

There are approximately 150,000 women living with metastatic breast cancer (mBC) in the United States. Disparities in de novo mBC incidence and mortality exist across race/ethnicity, socioeconomic status (SES), and rurality. However, how SES and rurality independently impact mBC outcomes across different racial/ethnic groups is not fully understood. The purpose of this study was to determine the impact of SES and rurality on cancer-specific mortality among women with mBC by race/ethnicity.

METHODS

We conducted a large, population-based retrospective cohort study in women aged 18 + years diagnosed with de novo mBC using the Surveillance, Epidemiology and End Results Census Tract-level SES and Rurality Database (2000-2015). Associations between SES/rurality and cancer-specific mortality were determined using Fine and Gray regression models. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) by race/ethnicity and hormone receptor (HR) status were calculated.

RESULTS

A cohort of 33,976 women were included with the majority being White (67%), 17% Black, 0.4% American Indian/Alaskan Native, 6% Asian/Pacific Islander, and 10% Latina/Hispanic. We observed the greatest increased risk of BC mortality among Black women with HR-negative mBC residing in neighborhoods with lower SES (lowest versus highest quintile: SHR 1.38, 95% CI 1.00-1.90) and in rural areas compared to urban areas (SHR 1.27, 95% CI 1.01-1.59).

CONCLUSION

Overall, BC-specific survival among women with de novo mBC differs by race/ethnicity, with the greatest adverse impacts of SES and rurality affecting Black women with HR-negative disease.

Abstract 775: Racial and ethnic differences in the impacts of rurality on cancer-specific survival among women with de novo metastatic breast cancer

Background: The interaction of racial/ethnic and geographic disparities in determining breast cancer (BC) outcomes is not fully understood. Our purpose was to examine racial and ethnic differences in and the impact of rurality on breast cancer specific mortality among women diagnosed with metastatic BC in the U.S.

Methods: We conducted a large, population-based cohort study using the Surveillance, Epidemiology, and End Results rurality database of women ages 18+ years diagnosed with de novo metastatic BC between 2000 and 2015. Our main exposure of interest was U.S. Department of Agriculture Rural Urban Commuting Area categories, and our outcome of interest was BC-specific mortality. We collected information on demographic and clinical characteristics, including molecular subtypes, treatment, survival and cause of death. We determined associations between rurality and BC-specific mortality in Fine and Gray regression models and calculated subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) accounting for competing risks of death and with adjustment for age, year of diagnosis, hormone receptor (HR) status, treatment, marital status and insurance status. We calculated overall and race specific SHR estimates to understand racial/ethnic differences in impacts of rurality on BC mortality and performed stratified analyses by HR status.

Results: From an overall cohort of 31,991 de novo metastatic BC patients with a median age of 60 years, there were 29,069 patients in urban commuting areas vs. 2,922 in rural areas. Compared to rural areas, lower proportions of non-Hispanic white (65% vs. 81%) and Asian/Pacific islander (0.3% vs. 0.9%) patients, and higher proportions of Black (17% vs. 10%) and Hispanic (10% vs. 5%) patients lived in urban areas. Metastatic BC patients living in urban commuting areas were more likely to receive surgery compared to rural (56% vs. 48%) and have a positive joint HR status (12% vs. 9%), but were similar with respect to radiation (33% vs. 33%) and chemotherapy (53% vs. 51%). Overall, women living in rural areas had a modestly higher risk of BC-specific mortality (adjusted SHR 1.01, 95% CI 1.00-1.02); however, the impact of rurality differed by race/ethnicity and HR status. Among white women with HR-positive metastatic BC, rurality was associated with an increased risk of BC mortality (SHR 1.09, 95% CI 1.03-1.15). Among Black women with HR-negative metastatic BC, we observed the greatest increased risk of BC mortality associated with rurality (SHR 1.27, 95% CI 1.01-1.59).

Conclusion: BC-specific survival among women with de novo metastatic disease differs by race/ethnicity and geography with the greatest adverse impacts of rurality affecting Black women with HR-negative BC.

Citation Format: Mary H. Smart, Hsiao-Ching Huang, Ashwini Zolekar, Huiwen Deng, Colin C. Hubbard, Kent Hoskins, Naomi Y. Ko, Gregory S. Calip. Racial and ethnic differences in the impacts of rurality on cancer-specific survival among women with de novo metastatic breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 775.

Abstract 2628: Racial differences in the impact of socioeconomic status on cancer-specific survival in multiple myeloma

Background: Multiple myeloma (MM) incidence and outcomes differ across racial/ethnic groups in the United States. Interactions between socioeconomic status (SES) with ethnicity in MM incidence and survival outcomes are not well understood. Our objective was to evaluate disparities in cancer-specific survival of patients diagnosed with MM by race/ethnicity.

Methods: We conducted a population-based retrospective cohort study of patients ages 20+ years diagnosed with MM between 2000 and 2015 using Surveillance, Epidemiology and End Results, Census Tract-level SES and Rurality Database. SES was defined using the National Cancer Institute's time-dependent composite score developed by Yost et al. (2001). Yost index quintiles were where the 1st and 5th quintiles representing the lowest and highest SES categories respectively. Cumulative incidence functions were used to analyze cancer-specific survival across strata racial/ethnic and SES and equality of functions was determined using Gray's test. Subdistribution hazard ratios (SHR) and 95% confidence intervals (CI) were calculated using the Fine and Gray regression models adjusted for age, sex, year of diagnosis, marital status, insurance status, and treatment with chemotherapy. Race-specific risk estimates were stratified by age (&lt;65 and 65+ years).

Results: Overall, 58,095 MM patients were included in our analysis among whom 63.0% were non-Hispanic White, 19.5% were Black, 0.3% were American Indian/Alaskan Native, 5.8% were Asian/Pacific Islander and 11.4% were Hispanic. Compared to White MM patients (median age 69 years), Black (64 years), American Indian/Alaskan Native (64 years), Asian/Pacific Islander (67 years) and Hispanic (64 years) patients were younger on average. A higher proportion of Black (42.8%) and Hispanic (27.9%) MM patients were in the lowest SES quintile compared to White (10.6%), American Indian/Alaskan Native (15.2%), and Asian/Pacific Islander (8.9%) MM patients. Cumulative incidence functions for cancer-specific survival were significantly different across SES quintiles (P &lt; 0.0001) and racial/ethnic groups (P &lt; 0.0001). Overall, MM patients in the lowest SES quintile had a significantly increased risk of MM-specific mortality (SHR: 1.28, 95% CI 1.21-1.36) compared to patients in the highest quintile. Risk estimates comparing the lowest to the highest quintile of SES were higher among Black (SHR 1.39, 95% CI 1.08-1.77), Hispanic (SHR: 1.78, 95% CI 1.21-2.63), and White (SHR 1.44, 95% CI 1.23-1.69) MM patients ages &lt;65 years at diagnosis.

Conclusion: Low SES level is independently associated with poor MM-specific survival. However, the impacts of SES on MM-specific survival differ by race/ethnicity and age with the greatest increased risk observed in younger Black, Hispanic, and White patients.

Citation Format: Huiwen Deng, Ashwini Zolekar, Hsiao-Ching Huang, Mary H. Smart, Colin C. Hubbard, Brian C. Chiu, Pritesh R. Patel, Karen Sweiss, Gregory S. Calip. Racial differences in the impact of socioeconomic status on cancer-specific survival in multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2628.

Relationship Between Motor Skills and Language Abilities in Children With Autism Spectrum Disorder

OBJECTIVES

Few studies have examined the relationship between language abilities and specific motor skills in toddlers with autism spectrum disorder (ASD). The aim of this study was to compare the relationship of receptive language (RL) and expressive language (EL) abilities with motor functioning in toddlers with ASD aged 24 to 36 months and their peers with typical development (TD). Furthermore, the study compared multidimensional motor functioning in toddlers with ASD with delayed RL and EL development and toddlers with ASD and typical RL and EL development. The predictive powers of the motor skills were examined for the group with delayed RL and EL development.

METHODS

The language abilities of 38 toddlers with ASD and 38 age-matched toddlers with TD were evaluated using the Receptive and Expressive Language Subscales of the Mullen Scale of Early Learning, and their motor skills were assessed using the Peabody Developmental Motor Scales, Second Edition.

RESULTS

Significant correlations between language ability and motor functioning were observed in the ASD and TD groups. The ASD group with delayed RL and EL development had lower scores for multidimensional motor functioning than the ASD group with typical RL and EL development and the TD group. Moreover, the risks of delayed EL and RL development could be predicted by the lower motor scores in toddlers with ASD.

CONCLUSIONS

The positive correlation between language abilities and motor functioning in toddlers with ASD indicated potential connections between the early onsets of motor and speech-language impairments in these toddlers.

IMPACT

The results may have implications for the development of motor-based interventions targeting language development in young children with ASD.

[Health of Indigenous People and Cultural Sovereignty: Developing the Competence of Culture Safety Instructors Under the Long-Term Care 2.0 Program]

Taiwan`s various ethnic groups, including 16 indigenous groups, represent disparate distinct cultures and backgrounds. In long-term care, culturally safe services that reflect cultural expectations and practices must be provided to older-adult recipients of care. As frontline healthcare workers face practical challenges in providing these services appropriately, "cultural safety instructors" may be used to help facilitate indigenous cultural care. Therefore, it is vital to develop the role function and cultural competence of these instructors. In this article, related instructor qualifications, course contents, and expected results of an indigenous cultural safety instruction program are presented based on the theory of cultural competence and cultural safety. In addition, relevant perspectives on cultural safety instructors and their cross-cultural competence specific to indigenous peoples, including Dimitrov and Haque (2016) and Leininiger (1996), are integrated. It is hoped that this study promotes reflection and provides a reference on practice and policies related to long-term care for indigenous people.

Effectiveness of a Group-Based Lifestyle Change Program Versus Usual Care: An Electronic Health Record, Propensity Score-Matched Cohort Study

INTRODUCTION

Translational lifestyle change programs for community and clinical settings have been available for a decade, yet there are limited data on their comparative effectiveness. This study examines the effectiveness of a Centers for Disease Control and Prevention-aligned lifestyle change program relative to usual care in clinical practice.

METHODS

This was an electronic health record-based retrospective cohort study conducted in a community-based healthcare system. Investigators identified adult program participants and usual-care patients in the electronic health record between 2010 and 2018 and defined their index date (baseline) as the first lifestyle change program encounter or a random encounter date, respectively. Participants were matched 1:2 to usual-care patients on baseline demographics and clinical characteristics using propensity-score methods. Changes in body weight and blood pressure were examined from baseline through 24 months.

RESULTS

The authors identified 2,833 program participants and 438,432 usual-care patients meeting study eligibility criteria. A total of 2,833 program participants were matched to 4,776 usual-care patients; the average age was 54 years, and 80% of the participants were female. Program participation was associated with a 1.9- and 1.6-fold higher prevalence of clinically meaningful (≥5%) weight loss at 12- and 24-month follow-up than usual care and a higher prevalence of blood pressure control at 12 months but not at 24 months. Patients without type 2 diabetes at baseline had more pronounced outcomes than those with type 2 diabetes.

CONCLUSIONS

This study demonstrates the effectiveness of an evidence-based, Centers for Disease Control and Prevention-aligned lifestyle change program in reducing cardiometabolic risk factors compared with usual care in clinical practice, with long-term reductions in weight and transient reductions in blood pressure.

Statin utilization and low-density lipoprotein cholesterol in statin-treated patients with atherosclerotic cardiovascular disease: Trends from a community-based health care delivery system, 2002-2016

BACKGROUND

A better understanding of patterns in statin utilization and low-density lipoprotein cholesterol (LDL-C) among patients with atherosclerotic cardiovascular disease (ASCVD) in a clinical practice setting is needed.

OBJECTIVES

The objective of this study was to examine statin utilization and LDL-C among new statin users with ASCVD.

METHODS

This retrospective study used an electronic health record database from a community-based health care system. We identified ASCVD patients ≥21 years of age with a new statin prescription during the study period (2002-2016). Outcomes included high-intensity statin therapy (HIST) prescribing at treatment initiation, medication adherence (defined as proportion of days covered ≥0.80), statin therapy titrations rates, and changes in LDL-C during follow-up.

RESULTS

Among 6199 eligible patients, mean follow-up was 16.8 months. At treatment initiation, 16.6% of patients received HIST. Approximately 53% of patients were adherent to statin regimens. Mean percent reduction in LDL-c was 25% during follow-up; 18% of patients, overall, and 30% of those initiating on HIST attained LDL-C reductions >50%. Rates of statin intensity-level increases were 8.4 per 100 person-years. HIST prescribing increased over time, beginning after generic atorvastatin availability and preceded treatment guidelines by two years. Initiation on HIST, higher adherence, and treatment intensification during follow-up were independent predictors of attaining LDL-C goals of <70 mg/dL or <100 mg/dL.

CONCLUSIONS

In a community-based health care system, modest LDL-C lowering for secondary ASCVD prevention is likely driven by suboptimal adherence and low HIST prescribing and treatment intensification rates. Clinician and patient education are needed to reduce clinical inertia and improve medication adherence to better manage ASCVD.

Multidimensional Developments and Free-Play Movement Tracking in 30- to 36-Month-Old Toddlers With Autism Spectrum Disorder Who Were Full Term

BACKGROUND

Few studies have investigated multidimensional developments and free-play movement performance in toddlers with an early diagnosis of autism spectrum disorder (ASD).

OBJECTIVE

This study compared cognitive, motor, and behavioral developments and free-play movement performance in toddlers with ASD who were full term (FT-ASD), toddlers who were full term and are typically developing (FT-TD), and toddlers who were born preterm and had a very low birth weight (VLBW-PT).

DESIGN

This was a prospective cross-sectional study.

METHODS

Forty-five 30- to 36-month-old age-matched toddlers were recruited and divided into FT-ASD, FT-TD, and VLBW-PT groups. Their developments were examined using the Mullen Scales of Early Learning; the Peabody Developmental Motor Scales, Second Edition; the Child Behavior Checklist for Ages 1.5 to 5; and the Repetitive Behavior Scale-Revised. In addition, the toddlers' free-play movements were tracked in laboratory settings using an automatic movement tracking system.

RESULTS

Toddlers with FT-ASD exhibited lower cognitive and motor scores and a higher degree of behavioral problems compared with toddlers with FT-TD or VLBW-PT. Furthermore, the movement tracking data in a free-play setting revealed that toddlers with FT-ASD displayed a higher degree of turning velocity, a higher moving time, and a higher frequency of moving toward the peripheral region compared with toddlers with FT-TD or VLBW-PT. Moreover, several motor developmental and movement-tracking indicators were found to correlate with behavioral problems and cognitive scores in toddlers with FT-ASD.

LIMITATIONS

The study results may have been affected by the small sample size, the cross-sectional design, and tracking only the whole body without subtle movements or segmental motions.

CONCLUSIONS

The findings suggest varied aspects of co-occurring developmental conditions and movement-based problems in toddlers with FT-ASD. Using standardized and sensitive measures for the early assessment of perceptuo-motor impairments is necessary for timely early intervention for such toddlers.

Statin Dosing Instructions, Medication Adherence, and Low-Density Lipoprotein Cholesterol: a Cohort Study of Incident Statin Users

BACKGROUND

Robust evidence is lacking on optimal timing of statin administration and its impact on patient outcomes.

OBJECTIVE

This study aims to evaluate among incident statin users the relationship between those prescribed evening vs. daily dosing instructions, medication adherence, and changes in low-density lipoprotein cholesterol (LDL-c).

DESIGN

This is an observational cohort study at Sutter Health, a community-based healthcare system, 2010-2016.

PARTICIPANTS

Patients were ≥ 35 years of age as of the first statin prescription (baseline), with 12 to 36 months of electronic health record activity before and after baseline. Incident use was defined as no statin prescription in 12 months prior to baseline.

MAIN MEASURES

Differences in medication adherence (proportion of days covered ≥ 0.80) over 12 months from baseline and mean change in LDL-c between 12 and 24 months from baseline were measured using regression modeling, adjusting for baseline demographics and clinical, prescriber, and statin characteristics.

KEY RESULTS

Among 31,252 patients with valid statin prescriptions between 2010 and 2016, 5099 eligible incident statin users (mean age, 63 years) were identified, of whom 53% were prescribed evening and 47% daily dosing instructions. No difference in likelihood of statin adherence over 12 months was observed for evening vs. daily dosing (adjusted odds ratio [OR] 0.90; 95% CI 0.75, 1.08). No differences were observed in mean change in LDL-c (adjusted mean difference 1.42 mg/dL; 95% CI - 1.02, 3.89) or likelihood of attaining LDL-c < 70 mg/dL (adjusted OR 0.83; 95% CI 0.67, 1.04) for evening vs. daily dosing over a mean of 19 months follow-up.

CONCLUSIONS

Among incident statin users from a real-world clinical setting, those with daily and evening dosing instructions had similar adherence rates and mean changes in LDL-c. Given potential clinical equipoise for evening and daily dosing, clinicians should consider patient-tailored statin dosing instructions to reduce potentially unnecessary regimen complexity.

P1604Validating previously reported Brugada syndrome-associated common variants identified in caucasian population in the Han Chinese BrS cohort in Taiwan: SADS-BrS registry

Background

Brugada syndrome (BrS) is a sudden arrhythmic death. The prevalence of BrS is higher in the Southeast Asian populations than that in Caucasian patients. A previous genome-wide association study (GWAS) has reported 13 SNPs significantly associated with BrS. However, no study was performed to validate whether these SNPs are enriched in BrS patients in Han Chinese (HC).

Purpose

Evaluating the common variants previously reported in Caucasian BrS patients could be generalized to HC BrS patients in Taiwan

Methods

We genotyped 200 unrelated BrS patients using Affymetrix TWB Array (N=653,291 SNPs, a customized array for HC in Taiwan). The controls are obtained from the Taiwan Biobank (N ≈ 16,000) using the same array. An imputation workflow was shown in Figure 1. To confirm the accuracy of the imputed genotype of each variant, Sanger sequencing was performed in 10% of randomly selected cases.

Results

Among the 3 most important common variants (rs11708996 in SCN5A, rs10428132 in SCN10A and rs9388451 in HEY2/NCOA7) reported in the previous GWAS mainly conducted in Caucasian BrS patients, 2 of them (rs10428132 and rs9388451) were successfully replicated in the HC population in Taiwan (P<0.01). We also found that the differences of minor allele frequency (dMAF: the MAF of cases minus the MAF of controls) of the two variants were relatively smaller between the BrS cases and healthy controls in HC population compared with that in Caucasian populations (dMAF, rs9388451: 0.15 (Caucasian) vs −0.07 (HC); rs10428132: 0.28 (Caucasian) vs 0.11 (HC)). For the remaining 10 common variants reaching genome-wide significance (P=5×10–8) in Caucasian BrS patients, 9 of them were also significantly enriched in the HC BrS patients after the Bonferroni correction (P<0.05/12=0.0042). We next analyzed the variants identified in the previous GWAS on ECG traits (PR interval, QRS duration, QTc interval, and heart rate) in the Caucasian population. Among the reported 75 variants associated with ECG traits, 5 common variants (rs6798015 (PR), rs1760876 (QRS), rs6795970 (PR/QRS), rs2074238 (QTc) and rs314370 (heart rate)) were significant after Bonferroni correction (P<0.05/75=0.00066).

Figure 1

Conclusions

The preliminary results indicated that 85% of common variants of SCN10A and HEY2/NCOA7 previously reported in Caucasian BrS patients are replicated in BrS patients in the HC population but not the common variant of SCN5A (rs11708996). Furthermore, the common variants of SCN10A and HEY2/NCOA7 related to cardiac depolarization or repolarization may also contribute to the development of BrS.

Acknowledgement/Funding

NTUH 106-S3469, NTUH106-S3458 and NTUH 106-018

Longitudinal Weight Outcomes From a Behavioral Lifestyle Intervention in Clinical Practice

PURPOSE

The purpose of this electronic health record (EHR)-based retrospective cohort study was to characterize a population of patients participating in a 12-month, lifestyle change program in a community-based health system and to examine longitudinal weight outcomes.

METHODS

Program participants were identified in the EHRs of a health care delivery system across 18 sites between 2010 and 2017. Outcomes were mean weight change and proportion of patients with ≥5% weight loss through 24 months from program initiation.

RESULTS

Among 4463 program participants, 3156 met study eligibility criteria, with a mean ± SD age of 53.5 ± 13.1 years; 77.7% were women. Mean baseline weight ± SD was 101.3 ± 23.8 kg. Three main cardiometabolic risk groups were identified: prediabetes/high risk for diabetes (47.3%), overweight/obese in the absence of elevated diabetes risk (27.2%), and existing diabetes (23.9%). Maximal mean weight loss was 3.9% at 6 months from baseline. At 12 and 24 months from baseline, mean weight loss was 3.2% and 2.3%, respectively, with 31% and 29% of participants attaining ≥5% weight loss. Long-term weight outcomes were similar across risk groups.

CONCLUSIONS

A lifestyle change program in a clinical practice setting is associated with modest weight loss, sustained through 24 months, among participants with a range of cardiometabolic risk factors. More than one-quarter of participants achieve ≥5% weight loss, regardless of cardiometabolic risk.

Postnatal self-care experience of Truku women’s traditions and mainstream acculturation and reconstruction in Taiwan

Purpose

The preservation and disappearance of indigenous people’s traditional knowledge system, under mainstream social culture immersion and fusion, have presented a dynamic and changing acculturation interactive relationship impacting Truku women’s health concepts. Thus, the purpose of this paper is to explore how the traditional Gaya knowledge system and mainstream culture confinement care model affect the beliefs and behaviours of postpartum self-care amongst contemporary Truku women.

Design/methodology/approach

An ethnographic semi-structured method, based on cultural care factors and the Leininger Sunrise Model, was conducted to interview 17 Truku women with childbearning experience in eastern Taiwan. As data were collected, UDIST Vivo 11.0 software was applied for analysis.

Findings

Amongst the three knowledge system categories, namely, traditional, mainstream and reconstruction, the traditional knowledge system, including Gaya norms, provides the overall cultural value of a Truku family. While taboo is inherited through the experience of the elders, the mainstream knowledge system favours the Han. However, the reconstruction knowledge system highlights the “functional” response strategies based on Truku women’s comfort and conveniences.

Originality/value

Limited relevant studies have focused on the health and postpartum self-care knowledge of ethnic Truku women in Taiwan. The results are expected to provide clinical medical personnel with a reference and strengthen cultural sensitivity and the ability to implement the cultural congruency care of postpartum indigenous women in Taiwan.

[Applying Intelligent Technology in Gender Competence Training for Nurses]

Despite an increased focus on the healthcare rights of people of different genders and the establishment of gender policies related to healthcare in Taiwan, the promotion of gender rights in nursing education and clinical care remains unsatisfactory. Given the increasingly diversified nature of healthcare systems and nursing knowledge bases, many experienced nurses have expressed the need for self-growth through continuing education and in-service training. The professional knowledge required of nurses increases continuously, and gender issues have received little attention in conventional nursing education. Consequently, gender education has been overlooked because of insufficient teaching time and a lack of qualified teachers. In promoting online courses for nurses, the government should focus on the different nursing care needs of different genders and sexual orientations as well as design online courses based on intelligent technology that satisfy the desire of nurses to improve their gender competence. This study adopts an intelligent technology perspective in order to highlight the importance of gender competence for nurses and to propose incorporating augmented reality into case scenarios that facilitate the creation of online healthcare courses and teaching materials that enhance gender competence. This approach may effectively resolve the problem of teachers having insufficient time to provide gender education effectively. Nurses must possess diverse gender perspectives and reinforce their gender competence and cross-disciplinary integration capabilities in order to provide appropriate care for patients of different gender identities and sexual orientations.

[Clinical research about needle-tract assisted standard percutaneous nephrolithotomy for the treatment of complicated upper urinary tract calculi]

Objective: To investigate the safety and efficacy of needle-tract assisted standard percutaneous nephrolithotomy (PCNL) for the treatment of complicated upper urinary tract calculi. Methods: The clinical data of 1 562 patients with complicated upper urinary calculi who received standard PCNL from December 2013 to December 2017 at Department of Urology, the First Affiliated Hospital of Xiamen University were retrospectively analyzed. There were large residual stones in 256 patients through B-ultrasound exploration after standard PCNL, could't be detected with nephoscope in standard PCNL tracts. 16 F mini PCNL tract were established in 120 cases for treatment of residual stones, while needle-tract were established in order to guide nephroscope to find residual stones in 126 cases. Needle-tract were transferred to 16 F mini PCNL tract for treatment of residual stones in 10 patients if these residual stones could't be detected through needle-tract. Operation time, change of hemoglobin level after operation, incidence of postoperative complications, time of hospitalization and rate of stone clearance were measured in two groups. The statistical methods used included t test, Wilcoxon rank sum test, and χ² test. Results: There were 1 to 3 mini tracts (M(Q_R): 1(1)) established in the mini tracts group and 1 to 7 needle-tracts (M(Q_R): 3(2)) established in the needle-tract group (Z=-10.57, P=0.000). Compared with mini tract group, the operation time ((62.0±18.0) minutes vs. (84.0±15.5) minutes, t=10.242, P=0.000), hospitalization time ((4.40±0.86) days vs. (5.20±0.81) days, t=7.570, P=0.049), hemoglobin dropped ((1.31±0.47) g/L vs. (2.74±0.63) g/L, t=20.12, P=0.000), and incidence of postoperative complications (7.9% (10/126) vs. 19.2% (23/120), χ²=6.674, P=0.01) of needle-tract group were lower, while postoperative stone clearance rate was higher (89.7% vs. 76.7%, χ²=7.497, P=0.006). No perioperative severe complications such as pleural injury, pneumatothorax, perforation of renal, trauma of abdominal organ occurred in two groups. Conclusion: Needle-tract assisted standard PCNL for the treatment of complicated upper urinary calculi can significantly improve stone clearance rate, reduce operation time, decrease risk of kidney and surrounding organs damage.

[Visual impact of sub-tenon's anesthesia during surgery for retinal detachment]

Objective: To investigate the visual impact and influence factors of sub-Tenon's anesthesia in retinal detachment patients during pars plana vitrectomy (PPV) or combined phacoemulsification and PPV surgery. Methods: In this prospective case series study, 104 consecutive patients who underwent PPV or combined phacoemulsification and PPV under sub-Tenon's anesthesia between October 2012 and December 2013 were enrolled. Intraoperatively, the patients were asked whether they could see the light of the operating microscope or not at 5 minutes after sub-Tenon's anesthesia, and at the end of phacoemulsification, core vitreous removal, peripheral vitreous removal and the whole surgery, with their contralateral eyes being covered tightly and no photobleaching. The best corrected visual acuity and visual evoked potentials were examined and compared with each other preoperatively and at 1.5 months and 3 months postoperatively. Chi-square test was used to compare the detection rate of amaurosis between different modus operandi and whether covered contra-lateral eye. Student-t test was used to compare the difference of age and preoperative BCVA between the patients with or without experienced amaurois. Lastly, BCVA between different times were tested by one-way ANOVA analysis. Results: Without covering the contralateral eyes, the incidence of no light perception in various surgical steps was 0%, while it was 72.1%(75/104), 93.8%(75/80), 96.2%(100/104), 96.2%(100/104) and 86.5%(90/104) at the five timepoints, respectively, when the contralateral eyes were covered tightly. The incidence was 51.9%(54/104), 85.0%(68/80), 85. 6%(89/104), 84.6%(69/104) and 66.3%(88/104), respectively, after photobleaching was excluded. Approximately 95.2%(99/104) of patients reported no light perception at least once, 54.5%(54/99) reported no light perception 5 minutes after sub-Tenon's anesthesia, and 30.3%(30/99) recovered light perception when the surgery was finished. All eyes recovered to at least light perception on the first postoperative day. The best corrected visual acuity and visual evoked potentials at 1.5 months and 3 months postoperatively were significantly better than those before surgery. The BCVA was 1.75±0.78 preoperative, 0.96±0.63 1.5 months after operation, and 0.92±0.57 3 months after operation. There was a significant statistical difference between preoperative BCVA and postoperative BCVA (F=50.61, P<0.01) . In patients without waveform detection preoperatively, PVEP waveform could be found in 43.6% and 61.4% of the pactients at 1.5 months and 3 months after operation respectively. In those had certain waveform preoperatively, PVEP amplitudes rise significantly after surgery (t(1.5)=-2.69, t(3)=-2.97, P<0.05) . Conclusions: No light perception was detected in various surgical steps of vitrectomy under sub-Tenon's anesthesia in most patients. The blocking of optic nerve conduction may be caused by sub-Tenon' s anesthesia. Photobleaching can also have some effect. The incidence of no light perception during the surgery was not correlated with preoperative visual acuity, age and gender. Moreover, the effect was transient and harmless to visual function.(Chin J Ophthalmol, 2017, 53: 332-337).

[Reflection on the Health and Gender Mainstreaming of Indigenous Women in Taiwan]

Gender and race issues have caused rapid cultural and societal changes to affect the healthcare of indigenous women, which involves complicated, cultural meanings. The present paper begins by outlining the gender perspective and then elaborates on the present gender mainstreaming and status of indigenous women's healthcare in Taiwan. Furthermore, this paper identifies the current difficulties experienced by Taiwanese indigenous women, including those related to the lack of adequate healthcare data and gender analyses on indigenous women and the lack of regular research on healthcare strategies for indigenous women. Therefore, the present paper proposes to establish health policy references that are gender and race sensitive. The health policy not only addresses racial and gender concerns regarding healthcare information but also focuses on the analysis of indigenous healthcare information. Indigenous women's health concerns are discussed here within the framework of healthcare policy through the perspective of gender mainstreaming. Additionally, we will analyze and evaluate the effects of gender in order to establish inspection and management processes that integrate the concept of gender into policy development and implementation, thus promoting relevant health policies. During the processes of planning, implementing, and evaluating healthcare policies, women should unite to contribute toward indigenous women's health policies and gender mainstreaming.

The impact of abnormal muscle tone from hemiplegia on reclining wheelchair positioning: a sliding and pressure evaluation

BACKGROUND

Little is known about the influence of existing muscle tone abnormality on the sitting posture of stroke patients in reclining wheelchairs.

AIM

To investigate the impact of muscle tone abnormality from hemiplegia on the forward sliding and pressure of stroke patients while sitting in reclining wheelchairs.

DESIGN

Experimental study.

SETTING

The Assistive Devices/Technology Center at the Rehabilitation Department of hospital.

POPULATION

14 able-bodied elders and nonambulatory elderly stroke patients with flaccid (N.=12) or spastic hemiplegia (N.=13) participated in this study. Of the 12 patients with flaccid hemiplegia, 8 suffered from left-sided hemiplegia and 4 from right-sided hemiplegia. Of the 13 patients with spastic hemiplegia, 6 suffered from left-sided hemiplegia and 7 from right-sided hemiplegia.

METHODS

We performed 3 reclining cycles in wheelchairs with conventional seats and V-shaped seats for each participant. The sliding along the backrest (BS) plane and the seat (SS) plane, mean sitting pressure (MP), and sacral peak pressure (SPP) of the participants were recorded. The Kruskal-Wallis test was used to compare the difference in BS, SS, MP, and SPP between able-bodied elders and stroke patients.

RESULTS

The BS, SS, and SPP during repetitive reclining were generally greatest in flaccid hemiplegic participants, followed by spastic hemiplegic participants, and finally by able-bodied participants. There was no significant difference in MP among three subject groups on both conventional seats and V-shaped seats in most comparisons. Able-bodied participants' buttocks tended to slide forward on conventional seats but backward on V-shaped seats, whereas hemiplegic participants' buttocks slid forward on both seat types.

CONCLUSION

Stroke patients with flaccid hemiplegia are the most vulnerable to sacral sitting and higher sacral pressure in reclining wheelchairs, followed by patients with spastic hemiplegia. There is a difference in the displacement pattern between participants with normal muscle tone and those with abnormal muscle tone during wheelchair positioning. People who have hemiplegia with spasticity do not have incremental forward sliding with repetitive reclining in the same way as those who have a flaccid hemiplegia.

CLINICAL REHABILITATION IMPACT

The findings are valuable for wheelchair prescription and caregiver education.

Development of a Semiselective Medium for Detection of Nalanthamala psidii, Causal Agent of Wilt of Guava

Guava wilt, caused by Nalanthamala psidii, has become an important disease of guava (Psidium guajava) in Taiwan since the 1970s. This study was conducted to develop a semiselective medium for detecting N. psidii in soil and in tissues of diseased guava trees. Among 9 carbon and 21 nitrogen compounds tested in a modified Czapek-Dox medium, the most effective carbon and nitrogen sources for mycelial growth of N. psidii were sucrose and glycine, respectively. Among eight fungicides tested, iprodione at 5 μg ml^-1 and azoxystrobin at 1 μg ml^-1 were the most effective fungicides for detection of N. psidii in artificially infested soil or in naturally infected guava debris. Based on the requirement for carbon and nitrogen sources and response to fungicides, a semiselective medium designated as modified sucrose-glycine semiselective medium (mSGSSM) was developed for isolation of N. psidii, using the modified Czapek-Dox medium containing 3% sucrose, 0.3% glycine, iprodione at 5 μg ml^-1, azoxystrobin at 1 μg ml^-1, streptomycin at 200 μg ml^-1, and neomycin at 200 μg ml^-1. Colonies of N. psidii on mSGSSM at 30°C for 5 to 10 days were white to orange with sparse aerial hyphae. N. psidii was detected more accurately and efficiently on mSGSSM than on other media, including potato dextrose agar, modified Nash-Snyder medium, and modified Czapek-Dox medium. This semiselective medium is effective in detection of N. psidii from various parts of diseased guava trees and in soil; therefore, it would be a useful medium for etiological, ecological, and epidemiological studies of guava wilt.

Effects of polymorphisms in six candidate genes on phenytoin maintenance therapy in Han Chinese patients

AIM

The present study aimed to investigate the associations between variants in pharmacokinetic- and pharmacodynamic-related genes with the dosages, concentrations and concentration-dose ratios (CDRs) of phenytoin (PHT).

METHODS & RESULTS

Eleven genetic polymorphisms in the six candidate genes were detected in 269 epileptic patients under maintenance PHT monotherapy by real-time PCR and PCR-RFLP. Results of a bivariate analysis demonstrated that among tested polymorphisms, carriers of the variant CYP2C9*3 tended to require significantly lower maintenance PHT dosages than wild-type carriers (p < 0.0001); on the other hand, carriers of the variants CYP2C9*3 or CYP2C19*3 revealed significantly higher CDRs than wild-type carriers (p < 0.004). In a further multivariate analysis, variants in SCN1A, CYP2C9, CYP2C19 and ABCB1 genes were significantly associated with CDRs of PHT under adjustment of age, gender and epilepsy classifications (adjusted r(2) = 20.07%).

CONCLUSION

The results of present study indicated that polygenic analysis may provide useful information in PHT therapy optimization.

Association of polymorphisms in EPHX1, UGT2B7, ABCB1, ABCC2, SCN1A and SCN2A genes with carbamazepine therapy optimization

AIM

Carbamazepine (CBZ) is one of the most widely used antiepileptic drugs. The aim of the present study is to investigate the impacts of polymorphisms in genes related to pharmacokinetic and pharmacodynamic pathways of CBZ on the large interindividual variability in dosages and concentrations.

METHODS & RESULTS

Genetic polymorphisms in the candidate genes were detected in 234 epileptic patients under maintenance CBZ monotherapy by real-time PCR and PCR-RFLP. Results of statistical analysis demonstrated that carriers of the variant SCN1A IVS5-91G>A and EPHX1 c.337T>C allele tended to require higher CBZ dosages and lower ln(concentration-dose ratios) than noncarriers (p < 0.0001) and the homozygous carriers also seemed to require higher CBZ dosages and lower ln(concentration-dose ratios) (p < 0.0001). In addition, the multiple regression model of concentration-dose ratio of CBZ also revealed that genetic variants in SCN1A, EPHX1 and UGT2B7 genes interactively affect the concentration-dose ratio of CBZ (adjusted r(2) = 55%).

CONCLUSION

The present study identified genetic factors associated with CBZ therapy optimization and provided useful information for individualized CBZ therapy in epileptic patients. Further studies in larger populations are needed to confirm our results.

Control of postharvest Botrytis fruit rot of strawberry by volatile organic compounds of Candida intermedia

A study was conducted to identify volatile organic compounds or volatiles produced by Candida intermedia strain C410 using gas chromatography-mass spectrometry, and to determine efficacy of the volatiles of C. intermedia in suppression of conidial germination and mycelial growth of Botrytis cinerea and control of Botrytis fruit rot of strawberry. Results showed that, among 49 volatiles (esters, alcohols, alkenes, alkanes, alkynes, organic acids, ketones, and aldehydes) identified from C. intermedia cultures on yeast extract peptone dextrose agar, two compounds, 1,3,5,7-cyclooctatetraene and 3-methyl-1-butanol, were the most abundant. Synthetic chemicals of 1,3,5,7-cyclooctatetraene; 3-methyl-1-butanol; 2-nonanone; pentanoic acid, 4-methyl-, ethyl ester; 3-methyl-1-butanol, acetate; acetic acid, pentyl ester; and hexanoic acid, ethyl ester were highly inhibitory to conidial germination and mycelial growth of B. cinerea. Inhibition of conidial germination and mycelial growth of B. cinerea by volatiles of C. intermedia was also observed. Meanwhile, results showed that incidence and severity of Botrytis fruit rot of strawberry was significantly (P < 0.01) reduced by exposure of the strawberry fruit to the volatiles from C. intermedia cultures or C. intermedia-infested strawberry fruit. These results suggest that the volatiles of C. intermedia C410 are promising biofumigants for control of Botrytis fruit rot of strawberry.

Applying preoperative multidetector computed tomography to bilateral coronary artery fistulas

Coronary artery fistula arising from both the right coronary artery and the circumflex coronary artery is rare. A 28-year-old woman with non-insulin-dependent diabetes mellitus and end-stage renal disease who was on regular hemodialysis complained of recent progressive exertional dyspnea. Congestive heart failure was diagnosed during work-up for simultaneous kidney and pancreas transplantation. Bilateral coronary fistulas draining into the coronary sinus were found by coronary angiography and further characterized by multidetector computed tomography followed by 3D reconstruction preoperatively. The operation was performed smoothly without heart arrest.

Bound states of one-, two-, and three-dimensional solitons in complex Ginzburg-Landau equations with a linear potential

We analyze interactions between moving dissipative solitons in one- and multidimensional cubic-quintic complex Ginzburg-Landau equations with a linear potential and effective viscosity. The interactions between the solitons are analyzed by using balance equations for the energy and momentum. We demonstrate that the separation between two solitons forming a bound state decreases with the increase of the slope of the linear potential.

LOUPE-ASSISTED MODIFIED ONE-LAYER VASOVASOSTOMY

Several studies indicate that microsurgical modified one-layer vasovasostomy is comparable to the two-layer anastomosis with respect to patency and pregnancy rates. The objective of this study was to determine the feasibility and result of modified one-layer vasovasostomy under loupe magnification only. Thirty-two patients aged 28 to 64 years (mean 41.3 +/- 6 years) underwent vasovasostomy at CGMH from July 1997 to June 2002, with all operations being a modified on-layer anastomosis created with the aid of a 3 x loupe. The estimated duration of vasectomy ranged from 4 months to 27 years, with a mean of 9.2 +/- 4.8 years. Postoperative semen analysis and pregnancy were examined. Each patient was followed up at 1,4, and 12 weeks postoperatively. The total operation time ranged from 118 to 228 minutes (average 150 +/- 35 minutes). There was no operation-related complication such as hematoma or wound infection. The patency rate was 89% (25/28), and the pregnancy rate at 2 years or more of follow-up was 39% (11/28). The patency and pregnancy rates were similar to those obtained in most studies of microsurgical vasovasostomy. For uncomplicated vasectomy reversal, this simple loupe-assisted modified one-lyer vasovasostomy seems to provide an adequate anastomosis.

HIGH INGUINAL LOUPE-ASSISTED VARICOCELECTOMY FOR SUBFERTILE MEN WITH VARICOCOCELES: TECHNICAL FEASIBILITY, CLINICAL OUTCOMES AND COMPLICATIONS

254 consecutive patients underwent high inguinal loupe-assisted varicocelectomy. All patients had at least a one year history of infertility with abnormal semen parameters and physical examination and/or color Doppler ultrasound proven varicocele. To facilitate the procedure, an x 3.0 loupe was used during spermatic cord dissection near or at level of internal inguinal ring. Semen analysis and physical examination were performed at 3 monthly intervals. No intra-operative complications occurred. The most common post-operative complications were transient scrotal pain and stitch reaction, occurring in 12% and 4% of men, respectively. Only one permanent and two transient hydroceles were observed. Recurrent or persistent varicocele was identified by physical examination and color Doppler in 5 varicocelectomies (1.4%), and by color Doppler only in 6 varicocelectomies (1.7%). Sperm motility increased from 30 +/- 8% to 46 +/- 20%, and sperm concentration. (10(6)/cc) increased from 24 +/- 18 to 41 +/- 28. The one-year pregnancy rate was 37%. High inguinal loupe-assisted varicocelectomy is a safe, simple, and effective treatment for varicocele.

First Report of Onion Bulb Rot Caused by Botrytis aclada in China

During the spring of 2006, onion bulbs with gray mold symptoms on the surface were observed in a few supermarkets in Wuhan, China. Onions mummified as they decayed. Further surveys of five randomly selected batches of onion bulbs in one of the supermarkets indicated that the disease occurred in all batches and the disease incidence ranged from 6 to 50%. Eight diseased onion bulbs were collected arbitrarily and isolations were made using homemade potato dextrose agar (PDA). Single-spore cultures of the isolated Botrytis sp. were established and maintained on PDA plates at 20°C. The 10-day-old PDA cultures of all of these isolates were gray and covered with abundant beige, ovoid- or oblong-shaped conidia, which were budded from terminal ampullae formed on dichotomously branching conidiophores. Conidia from these isolates measured 7.6 to 10.4 μm long and 4.2 to 5.6 μm wide, with an average of 8.4 × 5.0 μm. No sclerotia were produced from any of these PDA cultures after incubation at 20°C for 30 days. Morphological characteristics of colonies and conidia of these isolates were similar to Botrytis aclada according to the description made by Yohalem et al. (3). Inoculation of healthy onion bulbs with one of the eight fungal strains, OnionBc-15, resulted in gray mold symptoms similar to those observed in the supermarkets. Microscopic examinations showed that the size and shape of conidia that formed on the surface of diseased bulbs of onion were identical to the size and shape of conidia of OnionBc-15, indicating that this isolate can cause onion bulb rot. The isolate OnionBc-15 was further characterized by molecular techniques. Genomic DNA was extracted from mycelia of this strain and used as a template for amplification of two previously reported DNA regions, the internal transcribed spacer (ITS) region of the ribosomal RNA genes and the L45-550 sequence (1), which can be used to distinguish B. aclada and two closely related species, B. allii and B. byssoidea (3). Universal primers ITS1 and ITS4 were used to amplify the ITS region (2). A 539-bp DNA sequence was generated, cloned, and sequenced (GenBank Accession No. EU093077). The sequence contained two SphI restriction sites and was 99% identical in nucleotides to that of B. aclada strain PRI006 (GenBank Accession No. AJ716295). It is different from B. allii and B. byssoidea, which have only one SphI restriction site for the ITS1/ITS4-amplified DNA sequence (2). The Botrytis-specific primers, BA2f and BA1r, were used to amplify the L45-550 sequence (2). A 413-bp DNA sequence was generated, cloned, and sequenced. The sequence did not contain any ApoI restriction sites. This is also similar to B. aclada, but different from B. allii and B. byssoidea, which contains one ApoI restriction site in the BA2f/BA1r-amplified DNA sequence (2,3). On the basis of morphological characteristics and the two molecular features, it is concluded that the isolate OnionBc-15 belongs to B. aclada. To our knowledge, this is the first report on the occurrence of B. aclada causing onion bulb rot in China. References: (1) K. Nielsen and D. S. Yohalem. Mycologia 93:264, 2001. (2) K. Nielsen et al. Plant Dis. 86:682, 2002. (3) D. S. Yohalem et al. Mycotaxon 85:175, 2003.

Imaging of human aortic atherosclerotic plaques by polarization-sensitive optical coherence tomography

Optical coherence tomography (OCT) is analogous to ultrasound imaging except that it uses infrared light instead of sound. Polarization-sensitive optical coherence tomography (PS-OCT) combines the advantages of OCT and provides additional image contrast of the tested sample. We demonstrate this technique for imaging of back-reflected light, birefringence, and fast-axis orientation simultaneously in different kinds of atherosclerosis plaque. This in vitro study suggests birefringence changes in plaque are due to the prominent deposition of collagen or cholesterol by correlating PS-OCT images with histology. Thus the combination of high resolution structural imaging and birefringence detection make PS-OCT a potentially powerful tool for early assessment of atherosclerosis appearance and prediction of plaque rupture.

First Report of the Purple Variant of Curtobacterium flaccumfaciens pv. flaccumfaciens, Causal Agent of Bacterial Wilt of Bean, in Canada

Bacterial wilt of bean (Phaseolus vulgaris L.) caused by the yellow and orange variants of Curtobacterium flaccumfaciens pv. Flaccumfaciens (Hedges) Collins & Jones was found in western Canada in 2002 (1). A purple variant was found in a pooled sample of discolored cull seeds of great northern bean (cv. US1140) from a crop grown near Bow Island, Alberta, Canada in 2005. Bacterial colonies isolated from purple seed using modified Burkholder's agar (MBA) (3) were convex, glistening, and smooth edged with blue pigment diffusing into the medium. Three isolates (V154, V155, and V254) were identified with conventional tests (2), carbohydrate oxidation (GP Microplates, Biolog Inc., Hayward, CA), and cellular fatty acids (CFA) (MIDI, Inc., Newark, DE). All were grampositive, motile, aerobic rods with yellow colonies producing extracellular blue pigment on MBA when grown at 20 ± 2°C. Bacterial isolates grew at 27°C but grew weakly at 37°C. They were positive for catalase and hydrolysis of hippurate and indoxyl acetate and negative for urease, gelatin liquification, and oxidase. CFA profiles were approximately 48% 15:0 anteiso, 40% 17:0 anteiso, 7% 16:0 iso, and 3% 15:0 iso; with 17:1 anteiso A variable but <1%. Many carbohydrates were oxidized in the Biolog microplates with little acid production. The results match C. flaccumfaciens (2) and the MIDI and Biolog databases, as well as the purple variant of C. flaccumfaciens found in Nebraska, the only previous report of this variant (4). The pathogenicity of the three isolates was tested. Seeds of great northern (cv. US1140) and navy (cv. Morden003) beans were soaked in a bacterial suspension (1 × 10⁸ CFU/ml) or distilled water (control) for 1 h, planted in Cornell mix in root trainers, incubated at 28/22°C (16-h day/8-h night) in a growth cabinet for 14 days, and examined for seedling wilt. The test had three replicates per treatment and 20 seeds per replicate in a completely randomized design. All three isolates were pathogenic to both bean cultivars. The wilt incidences were 51, 57, and 56% on US1140 and 64, 76, and 69% on Morden003 for isolates V154, V155, and V254, respectively. The purple variant of C. flaccumfaciens was reisolated from hypocotyls of wilted seedlings but not from healthy controls. The experiment was repeated using the reisolated bacteria and the results were similar to the first experiment, thus fulfilling Koch's postulates. To our knowledge, this is the first report of the purple variant of C. flaccumfaciens pv. flaccumfaciens in Canada. References: (1) T. F. Hsieh et al. Plant Dis. 86:1275, 2002. (2) K. Komagata et al. Page 1313 in: Bergey's Manual of Systematic Bacteriology. Vol. 2. Williams and Wilkens, Baltimore, MD, 1986. (3) G. A. Nelson and G. Semeniuk. Phytopathology 54:330, 1964. (4) M. L. Schuster et al. Can. J. Microbiol. 14:423, 1968.

Selection responses in duration of fertility and its consequences on hatchability in the intergeneric crossbreeding of ducks

1. From 1992 to 2003, selected (S) and control lines (C) of the laying Brown Tsaiya duck (Anas platyrhynchos) were simultaneously maintained under the same standardised conditions of feeding and management. 2. The selection objective was to increase the number of fertile eggs after a single artificial insemination (AI) with pooled Muscovy semen. From generations G1 to G11, 2452 and 2022 female ducks, in S and C lines, respectively, were measured and recorded. In the S line, the percentage selected varied between 20.2 and 34.3% in females and between 7.2 and 20.8% in males. 3. Selection for number of fertile eggs had a correlated effect of increasing the parameter tau of the logistic curves which fitted the daily variations (d 2 to 15) in fertility or hatchability on the basis of eggs set. The differences S-C for the estimates of the times of half maximal fertility and hatchability increased by 0.41 and 0.37 d per generation between G1 and G11, respectively. 4. The highest increases of fertility per day rates after a single AI were observed between d 5 and 11. Moreover, in the selected line, fertility rate was higher than, or equal to, 90% in d 2 from G8. The same tendencies were observed for the changes in the evolution of hatchability on the basis of eggs set. 5. Selection increased fertility and hatchability according to the egg set rates, especially for d 2 to 8 after AI. Hatchability of fertile eggs was not impaired, confirming that selection for one AI per week was possible in this strain of laying ducks.

White Mold of Houndstongue (Cynoglossum officinale) Caused by Sclerotinia sclerotiorum in Canada

Houndstongue (Cynoglossum officinale L.) is a rangeland weed introduced into Canada from Eurasia, and it can be highly toxic to livestock feeding in pastures (3). During 2004, houndstongue plants near Creston, BC, Canada developed water-soaked lesions with white mycelia and black sclerotia on leaves and crowns. Isolations from diseased leaf tissues and sclerotia on potato dextrose agar (PDA) at 20°C for 5 to 7 days produced fungal colonies with formation of black sclerotia 5 to 10 mm in diameter. A single hyphal tip isolate from houndstongue. Ss-HT-C. was compared with a sunflower isolate of S. sclerotiorum, sun-87 (1), for morphology and pathogenicity. For apothecial production, Ss-HT-C and sun-87 were grown on PDA in petri dishes at 10°C for 10 weeks, and sclerotia produced were harvested, placed on moist vermiculite in petri dishes, and incubated at 20°C under light for 3 weeks. Mature apothecia were excised, stained with acid fuchsin, mounted on slides, and examined for asci and ascospores with a microscope. There were no morphological differences between Ss-HT-C and sun-87, each producing an ascus with eight binucleate, elliptical ascospores, measuring 4 × 10 μm (width × length), supporting the identity of Ss-HT-C as S. sclerotiorum (2,4). For pathogenicity tests of Ss-HT-C and sun-87, mycelial plugs (8 mm in diameter) were removed from the margin of colonies grown on PDA for 5 days at 20°C, and placed on leaves of C. officinale plants that were grown in a greenhouse (20 ± 4°C) to the rosette stage. Inoculated plants were covered with clear plastic bags, kept in the same greenhouse for 3 days, and the diameters of the leaf lesions developed at inoculation sites were measured. The experiment was run twice with 30 plants per isolate and five leaves per plant. Uninoculated plants covered with plastic bags were used as controls. Experiments used a completely randomized design. Results of leaf inoculations showed that Ss-HT-C and sun-87 were pathogenic to hound-stongue. There was no statistical difference between isolates or trials. The frequency of leaves with lesions was 90% for Ss-HT-C and 93% for sun-87. The mean leaf lesion diameters were 32 and 35 mm for Ss-HT-C and sun-87, respectively. Leaves of control plants remained healthy. S. sclerotiorum was reisolated from leaves with lesions, but not from controls. After 14 to 21 days, new sclerotia, 5 to 10 mm in diameter, were formed on leaves of inoculated plants. The plants eventually died. This study confirms that S. sclerotiorum is the causal agent for the disease of hound-stongue in Canada, and to our knowledge, this is the first world record of infection of this weed by S. sclerotiorum. References: (1) H. C. Huang and G. C. Kozub. Plant Prot. Bull. 31:333, 1989. (2) L. Kohn, Phytopathology 69:881, 1979. (3) J. A. Pfister et al. J. Range Manag. 45:254, 1992. (4) J. A. L. Wong and H. J. Willetts, J. Gen. Microbiol. 112:29, 1979.

A double-blind comparison of the efficacy and tolerability of telmisartan 40-80 mg vs. losartan 50-100 mg in Taiwanese hypertensive patients

A multicentre, randomised, double-blind, double-dummy, parallel-group, dose-titration study was conducted to determine the efficacy and tolerability of telmisartan 40-80 mg once daily compared with losartan 50-100 mg once daily in 180 Taiwanese patients with mild-to-moderate essential hypertension. After an initial 2-week placebo run-in phase, patients were randomised in a double-blind, double-dummy fashion to receive either telmisartan 40 mg or losartan 50 mg. If blood pressure control (diastolic blood pressure [DBP] <90 mmHg or > or = 10 mmHg reduction in DBP) was achieved after 4 weeks, the dose was maintained for the second 4 weeks of the active treatment phase; if not, the dose was doubled to telmisartan 80 mg or losartan 100 mg, respectively, for the second 4 weeks of double-blind treatment. Telmisartan 40-80 mg (n = 86) was as effective as losartan 50-100 mg (n = 90) in reducing trough seated DBP (11.1 vs. 8.7 mmHg, p = 0.144), and was significantly more effective than losartan in reducing trough seated systolic blood pressure (SBP) (22.1 vs. 16.5 mmHg, p = 0.032) and standing SBP (21.0 vs. 16.3 mmHg, p = 0.033). Significantly fewer patients treated with telmisartan than those treated with losartan required uptitration after 4 weeks' treatment (32.6% vs. 61.5%, p = 0.001). Both telmisartan and losartan were well tolerated.

Effect of anti-hypertensive drug dose frequency on the clinic-home blood pressure difference in patients with stage 1 treated hypertension

Clinic blood pressure (CBP) is generally used for diagnosis and treatment monitoring in hypertension, but target organ damage correlates more closely with home blood pressure (HBP). Eliminating the clinic-home blood pressure difference (CHBPD) would make conventional CBP a more accurate alternative to HBP. This prospective, randomized, open trial compared the effect of a once-daily versus a twice-daily regimen of anti-hypertensive therapy on CHBPD. After a 2-week wash-out period, 85 confirmed stage 1 hypertensive patients were randomized to receive 2 mg trichlormethiazide daily in one (40 subjects) or two (45 subjects) daily doses for 3 weeks. CBP and HBP measurements were taken during the third week of treatment and the CHBPD calculated. After treatment, the systolic and diastolic CHBPD values were significantly greater in the once-daily regimen than in the twice-daily regimen. Conventional CBP should not be used as an alternative to HBP for evaluating prognosis and monitoring anti-hypertensive therapy when using a once-daily regimen.

Biological Control of Blossom Blight of Alfalfa Caused by Botrytis cinerea Under Environmentally Controlled and Field Conditions

Fungal and bacterial antagonists were tested for their inhibition of sporulation of Botrytis cinerea on detached alfalfa florets. Clonostachys rosea, Gliocladium catenulatum, and Trichoderma atroviride were evaluated for protecting young blossoms and pods of alfalfa from infection by B. cinerea in vitro. C. rosea was further tested to control pod rot and seed rot caused by B. cinerea under field conditions. The results showed that four of the tested antagonists, C. rosea, G. catenulatum, T. atroviride, and Trichothecium roseum, could inhibit sporulation by B. cinerea on detached alfalfa florets. Both C. rosea and G. catenulatum were effective in suppression of infection of alfalfa pods by B. cinerea when inoculated on fresh petals of alfalfa at the anthesis stage, and their efficacy was greater than that of Trichoderma atroviride. A significant suppression of B. cinerea by C. rosea and G. catenulatum on pods and seed of alfalfa was observed when they were inoculated on senescent petals at the pod-development stage. Results of a field trial indicated that C. rosea applied to upper parts of alfalfa plants significantly suppressed pod rot and seed rot caused by B. cinerea, and significantly increased seed production of alfalfa in each of 3 years. These studies show that C. rosea has potential as a biocontrol agent for control of alfalfa blossom blight caused by B. cinerea.

Dose-rate scaling factor estimation of THOR BNCT test beam

In 1998, an epithermal neutron test beam was designed and constructed at the Tsing Hua Open-Pool Reactor (THOR) for the purpose of preliminary dosimetric experiments in boron neutron capture therapy (BNCT). A new epithermal neutron beam was designed at this facility, and is currently under construction, with clinical trials targeted in late 2004. Depth dose-rate distributions for the THOR BNCT test beam have been measured by means of activation foil and dual ion chamber techniques. Neutron and structure-induced gamma spectra measured at the test beam exit were configured into a source function for the Monte Carlo-based treatment planning code NCTPlan. Dose-rate scaling factors (DRSFs) were determined to normalize computationally derived dose-rate distributions with experimental measurements in corresponding mathematical and physical phantoms, and to thus enable accurate treatment planning using the NCTPlan code. A similar approach will be implemented in characterizing the new THOR epithermal beam in preparation for clinical studies. This paper reports the in-phantom calculated and experimental dosimetry comparisons and derived DRSFs obtained with the THOR test beam.

Observation of large CP violation and evidence for direct CP violation in B0-->pi(+)pi(-) decays

We report the first observation of CP violation in B0-->pi(+)pi(-) decays based on 152x10(6) gamma (4S)-->BB decays collected with the Belle detector at the KEKB asymmetric-energy e(+)e(-) collider. We reconstruct a B0-->pi(+)pi(-) CP eigenstate and identify the flavor of the accompanying B meson from its decay products. From the distribution of the time intervals between the two B meson decay points, we obtain A(pipi)=+0.58+/-0.15(stat)+/-0.07(syst) and S(pipi)=-1.00+/-0.21(stat)+/-0.07(syst). We rule out the CP-conserving case, A(pipi)=S(pipi)=0, at a level of 5.2 standard deviations. We also find evidence for direct CP violation with a significance at or greater than 3.2 standard deviations for any S(pipi) value.