Chronic obstructive pulmonary disease trajectory: severe exacerbations and dynamic change in health-related quality of life

BACKGROUND

The life trajectory of chronic obstructive pulmonary disease (COPD) remains unknown.

PATIENTS AND METHODS

We collected data from two populations. In the first cohort, we recruited 375 patients with COPD from our hospital, and 1440 repeated assessments of quality of life (QoL) using the European Quality of Life-5 Dimensions questionnaire from 2006 to 2020. We analysed their dynamic changes using the kernel-smoothing method. The second cohort comprised 27 437 patients from the National Health Insurance (NHI) dataset with their first severe acute exacerbations (AEs) requiring hospitalisation from 2008 to 2017 were analysed for their long-term course of AEs. We employed a Cox hazard model to analyse the predictors for mortality or AEs.

RESULTS

Cohorts from our hospital and NHI were male predominant (93.6 and 83.5%, respectively). After the first severe AE, the course generally comprised three phases. The first was a 1-year period of elevated QoL, followed by a 2-year prolonged stable phase with a slowly declining QoL. After the second AE, the final phase was characterised by a rapid decline in QoL. For NHI cohort, 2712 died during the 11-year follow-up, the frequency of the first AE was approximately 5 per 10 000 per day. The median time from the first to the second AE was 3 years, which decreased to less than 6 and 3 months from 4th to 5th and 8th to 9th AE, respectively. The frequency of AE was increased 10-fold and 15-fold and risk of subsequent AE was increased 12-fold and 20-fold after the 6th and the 10th AE, relative to the first. Male gender, heart failure comorbidities were associated with the risk of subsequent AE and death.

CONCLUSIONS

The life trajectory of COPD includes the accelerated frailty phase, as well as elevated health and prolonged stable phase after the first AE.

Kindergarten Visual-Perceptual and Motor Skills and Behavioral Traits Predict First-Grade Chinese Handwriting Legibility and Speed

IMPORTANCE

Clarifying the relationship between kindergarteners' characteristics and their future handwriting performance is beneficial for the early detection of children at risk of handwriting difficulties.

OBJECTIVE

To determine which visual-perceptual and motor skills and behavioral traits significantly predict kindergartners' Chinese handwriting legibility and speed in the first grade.

DESIGN

One-year longitudinal, observational design.

SETTING

Kindergarten and elementary schools.

PARTICIPANTS

One hundred six kindergarten children (53 boys and 53 girls; ages 5 or 6 yr) were recruited.

OUTCOMES AND MEASURES

The participants completed two subtests of the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition, Test of Visual Perceptual Skills-Third Edition, Beery-Buktenica Developmental Test of Visual-Motor Integration (Beery™ VMI), and the Attention-Deficit/Hyperactivity Disorder Test-Chinese Version in kindergarten. Their handwriting legibility (character accuracy and construction) and speed were assessed by investigator-developed Chinese handwriting tests in the first grade.

RESULTS

Multivariate regression analyses indicated the independent predictive power of spatial relationships (p = .042) and inattention (p = .004) for character accuracy. Visual-motor integration (VMI; p = .008) and inattention (p = .002) were the key predictors of character construction. Manual dexterity (p = .001) was the only significant predictor of writing speed.

CONCLUSIONS AND RELEVANCE

Kindergarteners who perform poorly in spatial relationships, VMI, manual dexterity, and attention are likely to have less legible Chinese handwriting and slow writing speed in first grade. Plain-Language Summary: Children's visual-perceptual and motor skills and behavioral traits in kindergarten can predict their Chinese handwriting legibility and speed in first grade. This study found that kindergarteners who performed poorly in spatial relationships, VMI, manual dexterity, and attention were likely to have less legible Chinese handwriting and slow writing speed in the first grade.

Feasibility of simultaneous development of laparoscopic and robotic pancreaticoduodenectomy

Laparoscopic (LPD) and robotic pancreaticoduodenectomy (RPD) are both challenging procedures. The feasibility and safety of simultaneously developing LPD and RPD remain unreported. We retrospectively reviewed the data of patients undergoing LPD or RPD between 2014 and 2021. A total of 114 patients underwent minimally invasive pancreaticoduodenectomy (MIPD): 39 LPDs and 75 RPDs. The learning process of LPD and RPD were similar. The cutoff points of the learning curve were LPD, 13th patient (the 27th patient of MIPD), and RPD, 18th patient (the 31st patient of MIPD) according the cumulative sum analysis of operative time. A decrease in the operative time was associated with the case sequence (p < 0.001) but not with the surgical approach (p = 0.36). The overall surgical outcomes were comparable between both the LPD and RPD groups. When evaluating the learning curve impact on MIPD, LPD had higher major complication (≧ Clavien-Dindo grade III), bile leak and wound infection rates in the pre-learning curve phase than those in the after-learning curve phase, while RPD had similar surgical outcomes between two phases. Simultaneous development of LPD and RPD is feasible and safe for experienced surgeons, with similar learning process and comparable surgical outcomes.

The Proper Use and Reporting of Survival Analysis and Cox Regression

BACKGROUND

Survival analyses are heavily used to analyze data in which the time to event is of interest. The purpose of this paper is to introduce some fundamental concepts for survival analyses in medical studies.

METHODS

We comprehensively review current survival methodologies, such as the nonparametric Kaplan-Meier method used to estimate survival probability, the log-rank test, one of the most popular tests for comparing survival curves, and the Cox proportional hazard model, which is used for building the relationship between survival time and specific risk factors. More advanced methods, such as time-dependent receiver operating characteristic, restricted mean survival time, and time-dependent covariates are also introduced.

RESULTS

This tutorial is aimed toward covering the basics of survival analysis. We used a neurosurgical case series of surgically treated brain metastases from non-small cell lung cancer patients as an example. The survival time was defined from the date of craniotomy to the date of patient death.

CONCLUSIONS

This work is an attempt to encourage more investigators/medical practitioners to use survival analyses appropriately in medical research. We highlight some statistical issues, make recommendations, and provide more advanced survival modeling in this aspect.

Developing a Nomogram Model to Predict the Risk of Poor Chinese Handwriting in First Grade

IMPORTANCE

Few predictive models for later handwriting difficulties have been developed for kindergarteners.

OBJECTIVE

To develop a nomogram for the purpose of detecting the risk of later poor Chinese handwriting among Taiwanese kindergarteners.

DESIGN

One-year prospective longitudinal, observational study.

SETTING

Kindergarten and elementary school.

PARTICIPANTS

One hundred fifty-six kindergarteners were included. In first grade, they were grouped into the normal and poor handwriting groups on the basis of handwriting performance in first grade.

OUTCOMES AND MEASURES

Participants received fine motor (FM), visual-perceptual (VP), and visual-motor integration tests in kindergarten and handwriting assessments in first grade.

RESULTS

Logistic regression results indicated that younger age at school entry and lower scores on measures of FM and VP in kindergarten increased the risk for later poor handwriting. The area under the receiver operating characteristic curve in the nomogram built with these risk factors was .75, indicating that the nomogram had acceptable diagnostic value.

CONCLUSIONS AND RELEVANCE

This nomogram could be used as a screening tool to detect kindergarteners at risk of poor Chinese handwriting in first grade.

WHAT THIS ARTICLE ADDS

This study is the first to establish a nomogram constructed with significant predictors in kindergarten of a child's probability of poor handwriting later in first grade. This predictive nomogram may help occupational therapists, educators, and parents identify at-risk kindergarteners early for the purpose of early interventions to prevent later poor Chinese handwriting.

Comparative predictive ability of visit-to-visit HbA1c variability measures for microvascular disease risk in type 2 diabetes

BACKGROUND

To assess the associations of various HbA1c measures, including a single baseline HbA1c value, overall mean, yearly updated means, standard deviation (HbA1c-SD), coefficient of variation (HbA1c-CV), and HbA1c variability score (HVS), with microvascular disease (MVD) risk in patients with type 2 diabetes.

METHODS

Linked data between National Cheng Kung University Hospital and Taiwan's National Health Insurance Research Database were utilized to identify the study cohort. The primary outcome was the composite MVD events (retinopathy, nephropathy, or neuropathy) occurring during the study follow-up. Cox model analyses were performed to assess the associations between HbA1c measures and MVD risk, with adjustment for patients' baseline HbA1c, demographics, comorbidities/complications, and treatments.

RESULTS

In the models without adjustment for baseline HbA1c, all HbA1c variability and mean measures were significantly associated with MVD risk, except HVS. With adjustment for baseline HbA1c, HbA1c-CV had the strongest association with MVD risk. For every unit of increase in HbA1c-CV, the MVD risk significantly increased by 3.42- and 2.81-fold based on the models without and with adjustment for baseline HbA1c, respectively. The associations of HbA1c variability and mean measures with MVD risk in patients with baseline HbA1c < 7.5% (58 mmol/mol) were stronger compared with those in patients with baseline HbA1c ≥ 7.5% (58 mmol/mol).

CONCLUSIONS

HbA1c variability, especially HbA1c-CV, can supplement conventional baseline HbA1c measure for explaining MVD risk. HbA1c variability may play a greater role in MVD outcomes among patients with relatively optimal baseline glycemic control compared to those with relatively poor baseline glycemic control.

Frequent loss of heterozygosity in early non-small cell lung cancers at chromosome 9p21 proximal to the CDKN2a gene

Deletions involving the chromosome 9p21 region have been reported as frequent events in non-small cell lung cancer (NSCLC). To investigate potential tumor-suppressor gene (TSG) loci within the 9p21 region, which also harbors the candidate TSG locus CDKN2a, we studied 32 cases of primary NSCLC for loss of heterozygosity (LOH). Tumor and paired normal lung cells were microdissected from lung tissue imprints and all samples screened using PCR-LOH analysis with 15 9p markers. In addition, 3 NSCLC cell lines and their matched normal lung and tumor DNA were similarly analyzed. LOH at the marker D9S259, which is proximal to the CDKN2a locus, was found most frequently (52%), while LOH at D9S942, the marker closest (5 kb) to the CDKN2a gene, was seen in only 17%. Homozygous loss of markers close to CDKN2a was, however, detected in 2 of the 3 cell lines and one accompanying tumor sample. We propose that a TSG in the region of deletion proximal to the CDKN2a gene within 9p21 may play a significant role in the pathogenesis and progression of NSCLC.

Allele-specific loss in chromosome 9p loci in preneoplastic lesions accompanying non-small-cell lung cancers

BACKGROUND

Carcinogenesis is a multistep process, which may begin as a consequence of chromosomal changes. Deletions in the short arm of chromosome 9 (9p) have been observed in lung carcinomas. In addition, morphologically recognizable preneoplastic lesions, frequently multiple in number, precede onset of invasive carcinomas.

PURPOSE

We tested for deletions and loss of heterozygosity (LOH) at 9p loci in preneoplastic and neoplastic foci in lungs of patients with non-small-cell lung carcinomas (NSCLCs).

METHODS

Seven archival, paraffin-embedded, surgically resected NSCLC specimens were selected. They were predominantly from patients with adenocarcinomas and contained multiple preneoplastic lesions, including hyperplasia, metaplasia, dysplasia, and carcinoma in situ (CIS). Fifty-three histologically identified preneoplastic and malignant lesions present in bronchi, bronchioles, and alveoli were precisely microdissected from stained tissue sections with a micromanipulator. Stromal lymphocytes were used to determine constitutional heterozygosity. The specimens were analyzed for LOH using polymerase chain reaction-based assays for polymorphism in dinucleotide repeats (microsatellite markers) in interferon alfa (IFNA) and D9S171 loci on 9p.

RESULTS

All seven cases were constitutionally heterozygous for one or both microsatellite markers. Five of seven cases had LOH at one or both 9p loci in the invasive primary cancers (doubly informative cases). Four of these five cases also revealed LOH in preneoplastic foci. In the doubly informative cases, LOH was detected in five (38%) of 13 foci of hyperplasia, four (80%) of five foci of dysplasia, and three (100%) of three CIS lesions. LOH was detected in preneoplastic lesions from all regions of the respiratory tract, including bronchi, bronchioles, and alveoli, and involved five different cell types. The identical allele was lost from both the preneoplastic lesions and the corresponding tumors (12 of 12 lesions, 17 of 17 comparisons), a phenomenon we have referred to as "allele-specific mutation." Statistical analyses employing a cumulative binomial test demonstrated that the probabilities of such findings occurring by chance are 2.4 x 10(-4) and 7.6 x 10(-6), respectively. From comparisons with the previously published data on other chromosomal abnormalities in the same tissue specimens, it appears that LOH at 3p and 9p loci occurred early in the hyperplasia stage, but the ras gene point mutations were relatively late, at the CIS stage.

CONCLUSIONS

LOH at 9p loci occurs at the earliest stage in the pathogenesis of lung cancer and involves all regions of the respiratory tract. LOH in NSCLC is not random but targets a specific allele in individuals. Studying preneoplastic lesions may help identify intermediate markers for risk assessment and chemoprevention.

K-ras mutations are a relatively late event in the pathogenesis of lung carcinomas

We investigated preneoplastic lesions associated with lung cancer to determine at what stage in lung carcinogenesis K-ras mutations appear. We selected six archival lung cancer resection cases that had ras mutations. We precisely microdissected 74 relevant areas from paraffin-embedded sections. K-ras mutations at codons 12, 13, and 61 were determined by the designed restriction fragment length polymorphism method using mismatched nested primers and confirmed by direct sequencing. All samples of invasive and metastatic cancers had K-ras mutations, as did four of five lesions of noninvasive cancer. Mutations were detected in only 1 of 12 dysplastic lesions and were absent from hyperplastic and normal-appearing cells. In all cases, the specific point mutations and the mutational pattern in the tumors, metastases, and the corresponding noninvasive lesions were identical. These results indicate that K-ras mutations arise relatively late in the pathogenesis of lung cancer and may be associated with the appearance of the malignant phenotype.

Detection of dysplasia and carcinoma in situ by ratio fluorometry

Fluorescence bronchoscopy was performed in 82 volunteers recruited from occupational groups at risk of exposure to asbestos and/or diesel fumes to determine whether differences in tissue autofluorescence between normal and malignant bronchial tissues can be used to improve the sensitivity of standard fiberoptic bronchoscopy in detecting dysplasic and carcinoma in situ (CIS). This study consisted of 25 nonsmokers, 40 exsmokers, and 17 current smokers with mean ages of 52, 55, and 49 yr, respectively. Tissue autofluorescence was induced by a blue light from an He-Cd laser coupled to the illumination channel of the bronchoscope and analyzed by a ratiofluorometer. One or more sites of moderate or severe dysplasia were found in 12% of the exsmokers and current smokers but in none of the nonsmoker volunteers. CIS was found in two of the exsmokers. The sensitivity of fluorescence bronchoscopy (86%) was found to be 50% better than that of conventional white-light bronchoscopy (52%) in detecting dysplasia and CIS. Pre- and post-bronchoscopy sputum cytology failed to detect these precancerous lesions. Our results suggest that fluorescence bronchoscopy may be an important new method that can improve the ability to detect and localize precancerous and/or CIS lesions.

Corneal sensation in retinal detachment surgery

We compared the rate of recovery of corneal sensation in two randomly selected groups of patients with rhegmatogenous retinal detachment whose eyes were otherwise healthy. One of the groups underwent removal of the epithelium and, and the other was characterized by nonremoval of the epithelium. The corneal sensations were measured serially with an esthesiometer. The return of corneal sensation occurred sooner in the nonremoval group than in the removal group in the early postoperative period, but at three months, the difference was negligible.

Neovascular glaucoma in a patient with X-linked juvenile retinoschisis

A patient with X-linked juvenile retinoschisis was followed from age 5 years. At age 15 he developed rubeosis iridis and neovascular glaucoma in one eye, resulting in no light perception. A review of the literature revealed this case to be the first reported association of X-linked juvenile retinoschisis and neovascular glaucoma.