Risk of malignant melanoma and non-melanoma skin cancer in rheumatoid arthritis patients initiating methotrexate versus hydroxychloroquine: a cohort study

OBJECTIVES

To characterise the incidence rate of skin cancer associated with methotrexate and hydroxychloroquine in older adults with rheumatoid arthritis (RA).

METHODS

RA patients aged ≥65 years who initiated methotrexate or hydroxychloroquine as their first disease modifying antirheumatic drugs (DMARDs). The primary outcome was new occurrence of any skin cancer (i.e. malignant melanoma or non-melanoma skin cancer; NMSC) based on validated algorithms (positive predictive value >83%). Secondary outcomes were malignant melanoma, NMSC, basal cell carcinoma (BCC), and squamous cell carcinoma (SCC). We estimated the incidence rates (IRs) and hazard ratios (HRs) for each outcome in the 1:1 propensity score (PS)-matched methotrexate and hydroxychloroquine groups.

RESULTS

We included 24,577 PS-matched pairs of methotrexate and hydroxychloroquine initiators. Compared with hydroxychloroquine (IR 25.20/1,000 person-years), methotrexate initiators (IR 26.21/1,000 person-years) had a similar risk of any skin cancer [HR 1.03 -(95%CI 0.92, 1.14)] over a mean follow-up of 388 days. The HR (95%CI) associated with methotrexate was 1.39 (0.87, 2.21) for malignant melanoma, 1.01(0.90, 1.12) for NMSC, 1.37 (1.13, 1.66) for BCC, and 0.79 (0.63, 0.99) for SCC compared with hydroxychloroquine.

CONCLUSIONS

In this large cohort of older RA patients initiating methotrexate or hydroxychloroquine as their first DMARD, we found no difference in the risk of skin cancer including malignant melanoma and NMSC. However, for specific components of NMSC, methotrexate initiators had higher risk of BCC but lower risk of SCC compared with hydroxychloroquine initiators.

[Relationship between body mass index and sexual development in Chinese children]

Objective: To investigate the relationship between body mass index (BMI) and sexual development in Chinese children. Methods: A nationwide multicenter and population-based large cross-sectional study was conducted in 13 provinces, autonomous regions and municipalities of China from January 2017 to December 2018. Data on sex, age, height, weight were collected, BMI was calculated and sexual characteristics were analyzed. The subjects were divided into four groups based on age, including ages 3-<6 years, 6-<10 years, 10-<15 years and 15-<18 years. Multiple Logistic regression models were used for evaluating the associations of BMI with sexual development in children. Dichotomous Logistic regression was used to compare the differences in the distribution of early and non-early puberty among normal weight, overweight and obese groups. Curves were drawn to analyze the relationship between the percentage of early puberty and BMI distribution in girls and boys at different Tanner stages. Results: A total of 208 179 healthy children (96 471 girls and 111 708 boys) were enrolled in this study. The OR values of B2, B3 and B4+ in overweight girls were 1.72 (95%CI: 1.56-1.89), 3.19 (95%CI: 2.86-3.57), 7.14 (95%CI: 6.33-8.05) and in obese girls were 2.05 (95%CI: 1.88-2.24), 4.98 (95%CI: 4.49-5.53), 11.21 (95%CI: 9.98-12.59), respectively; while the OR values of G2, G3, G4+ in overweight boys were 1.27 (95%CI: 1.17-1.38), 1.52 (95%CI: 1.36-1.70), 1.88 (95%CI: 1.66-2.14) and in obese boys were 1.27 (95%CI: 1.17-1.37), 1.59 (95%CI: 1.43-1.78), and 1.93 (95%CI: 1.70-2.18) (compared with normal weight Tanner 1 group,all P<0.01). Analysis in different age groups found that OR values of obese girls at B2 stage and boys at G2 stage were 2.02 (95%CI: 1.06-3.86) and 2.32 (95%CI:1.05-5.12) in preschool children aged 3-<6 years, respectively (both P<0.05). And in the age group of 6-10 years, overweight girls had a 5.45-fold risk and obese girls had a 12.54-fold risk of B3 stage compared to girls with normal BMI. Compared with normal weight children, the risk of early puberty was 2.67 times higher in overweight girls, 3.63 times higher in obese girls, and 1.22 times higher in overweight boys, 1.35 times higher in obese boys (all P<0.01). Among the children at each Tanner stages, the percentage of early puberty increased with the increase of BMI, from 5.7% (80/1 397), 16.1% (48/299), 13.8% (27/195) to 25.7% (198/769), 65.1% (209/321), 65.4% (157/240) in girls aged 8-<9, 10-<11 and 11-<12 years, and 6.6% (34/513), 18.7% (51/273), 21.6% (57/264) to 13.3% (96/722), 46.4% (140/302), 47.5% (105/221) in boys aged 9-<10, 12-<13 and 13-<14 years, respectively. Conclusions: BMI is positively correlated with sexual development in both Chinese boys and girls, and the correlation is stronger in girls. Obesity is a risk factor for precocious puberty in preschool children aged 3-<6 years, and 6-<10 years of age is a high risk period for early development in obese girls.

[Changing prevalence of overweight and obesity among Chinese children aged 6-15 from 2009-2019]

Objective: To analyze the trends of overweight and obesity prevalence in Chinese children, aged from 6 to 15 years old among 4 provinces and cities from 2009 to 2019. Methods: Reviewed the national multi-center epidemiological survey data of children from the National Key Technology R&D Program of China during the Eleventh Five-Year Plan (2009 to 2010) and the National Key Research and Development Program of China during the Thirteenth Five-Year Plan (2017 to 2019). The participants' data were selected from four provinces,municipalities and autonomous region,including Beijing, Tianjin (Northern region), Zhejiang (Eastern region), and Guangxi (Southern region). Totally 14 597 pairs of 6-15 year-old children were surveyed. According to the body mass index (BMI) and standard deviation score (SDS) of children among different genders, ages, and regions, t test or chi-square test was used to evaluate the changes in overweight and obesity over a 10-year span. Results: Totally 7 721 pairs of boys and 6 876 pairs of girls were collectted in this study, whose mean age was (10.7±2.5) years. In the past 10 years, the overall BMISDS were 0.39±1.24 and 0.36±1.31 and the overall obesity rate were 11.8% (n=1 773) anel 12.5% (n=1 813) of children in the 4 administrative regions did not have statistically significant differences (all P>0.05). However, the overall overweight rate rose from 17.1% (n=2 496) to 19.1% (n=2 781) (χ²=18.657, P<0.01), and the average annual growth rate was 0.20%. The BMISDS in the Eastern region increased from 0.10±1.07 to 0.19±1.22 (t=-4.095, P<0.01), and the overweight rate and obesity rate increased by 3.8% (n=202) and 3.1% (n=169) respectively (both P<0.01); the BMISDS in the Northern region and the obesity rate did not have statistically significant differences(all P>0.05), but the overweight rate rose from 20.5% (n=1 233) to 22.8% (n=1 365) significantly (χ²=7.431, P<0.01); BMISDS in the Southern region was significantly decreased from 0.30±1.19 to 0.09±1.25 (t=1.426, P<0.01), and the rate of obesity decreased from 9.8% (n=315) to7.9% (n=256) (χ²=6.46, P<0.05), the overweight rate was not stafistically significant (P=0.10), respectively. The obesity rate of boys had risen from 16.4% (n=1 265) to 18.2% (1 407) (χ²=8.997, P<0.01) in the past 10 years, and the overweight rate had risen from 18.0% (n=1 393) to 20.5% (n=1 579) (χ²=14.26, P<0.01). The overweight+obesity rate rose from 34.4% (n=2 658) to 38.7% (n=2 986) (χ²=29.859, P<0.01), and the weight problem in the age group of 8 to 11 years was particularly severe (all P<0.01). The obesity rate of girls dropped from 6.8% (n=468) to 5.9% (n=406) (χ²=4.546, P<0.05), the overweight rate rose from 16.0% (n=1 103) to 17.5% (n=1 202) (χ²=5.006, P<0.05), and the overall overweight+obesity rate rose from 22.8% (n=1 571) to 23.4% (n=1 608) (χ²=0.53, P>0.05). Conclusions: The growth rate of obesity among children in China had slowed down from 2009 to 2019, but the overweight rate was still on the rise. The overall base of overweight and obesity population continued to expand. The weight problem of peri-adolescent boys was particularly prominent. The current status of obesity epidemics in different regions, ages, and genders are significantly different and had their own characteristics. It is necessary to establish a personalized prevention and control strategy.

Patient characteristics associated with use of TNF vs interleukin inhibitors as first-line biologic treatment for psoriatic arthritis

BACKGROUND: Previous studies have examined treatment patterns among patients who use tumor necrosis factor (TNF) inhibitors for psoriatic arthritis (PsA). However, little data exist for a comparison between the TNF inhibitor treatment pattern and that of newly available biologics such as interleukin (IL)-12/23 or 17 inhibitors in the United States. OBJECTIVES: To (a) examine patient characteristics and their association with initiation of TNF inhibitors vs IL-12/23 or 17 inhibitors among PsA patients and (2) compare treatment persistence of PsA patients who initiated TNF inhibitors vs IL-12/23 or 17 inhibitors as first-line biologic treatment in a real-world setting in the United States. METHODS: Using claims data from MarketScan (2013-2017), we identified a cohort of PsA patients who initiated TNF inhibitors or IL-12/23 or 17 inhibitors. The primary outcome was treatment persistence, defined as continuous use of the index drug at 1 year, regardless of refill gaps. The secondary outcome was treatment persistence with high adherence at 1 year (ie, refill gaps ≤ 30 days). Multivariable logistic regression was used to assess the association between patient characteristics and treatment initiation and persistent use of TNF inhibitors vs IL-12/23 or 17 inhibitors. RESULTS: We identified 3,180 TNF inhibitor initiators and 214 IL-12/23 or 17 inhibitor initiators. Initiators of IL-12/23 or 17 inhibitors had more comorbidities than TNF inhibitor initiators. The proportion of patients with treatment persistence was 53.0% in TNF inhibitor initiators and 53.7% in IL-12/23 or 17 inhibitor initiators; 37.1% of TNF inhibitor users and 24.8% of IL-12/23 or 17 inhibitor users were treatment persistent with high adherence. There was no difference in 1-year treatment persistence between the 2 groups after adjusting for baseline characteristics (adjusted odds ratio [aOR] for TNF inhibitors vs IL-12/23 or 17 inhibitors: 0.86, 95% CI = 0.63-1.15). However, use of TNF inhibitors was associated with a greater treatment persistence with high adherence compared with use of IL-12/23 or 17 inhibitors (aOR = 1.61, 95% CI = 1.15-2.26). CONCLUSIONS: PsA patients who initiated an IL 12/23 or 17 inhibitor had a greater comorbidity burden compared with those who initiated TNF inhibitors. Treatment persistence was similar between the 2 groups, whereas medication adherence was higher with TNF inhibitors than with IL 12/23 or 17 inhibitors during the first year of treatment. DISCLOSURES: This study was funded by an investigator-initiated research grant from Pfizer, Inc (grant number: WI235988). The content is solely the responsibility of the authors. The sponsor was given the opportunity to make nonbinding comments on a draft of the manuscript. Publication of the manuscript was not contingent on approval by the sponsor. Kim has received research grants to the Brigham and Women's Hospital from Roche, AbbVie, and Bristol-Myers Squibb for unrelated topics. Merola is a consultant and/or investigator for BMS, AbbVie, Dermavant, Lilly, Novartis, Janssen, UCB, Sun Pharma, and Pfizer. Jin, Chen, Lee, and Landon have nothing to disclose.

Identification of Acute Giant Cell Arteritis in Real-World Data Using Administrative Claims-Based Algorithms

Objective

The objective of this study was to validate claims‐based algorithms for identifying acute giant cell arteritis (GCA) that will help generate real‐world evidence on comparative effectiveness research and epidemiologic studies. Among patients identified by the GCA algorithm, we further investigated whether GCA flares could be detected by using claims data.

Methods

We developed five claims‐based algorithms based on a combination of International Classification of Diseases, Ninth Revision (ICD‐9) diagnosis codes, specialist visits, and dispensed medications using Medicare Parts A, B, and D linked to electronic medical records (2006‐2014). Acute cases of GCA were determined by chart review using the treating physician’s diagnosis of GCA as the gold standard. Among the patients identified with acute GCA, we assessed if a GCA flare occurred during the year after initial diagnosis.

Results

The number of patients identified by each algorithm ranged from 220 to 896. Positive predictive values (PPVs) of the algorithms ranged from 60.7% to 84.8%. Requirement for disease‐specific workups, multiple diagnosis codes, or specialist visits improved the PPVs. The highest PPV (84.8%) was noted in an algorithm that required two or more diagnosis codes of GCA from inpatient, emergency department, or outpatient rheumatology visits plus a prednisone‐equivalent dose greater than or equal to 40 mg/day occurring 14 days before or after the second ICD‐9 diagnosis date, with the cumulative days’ supply greater than or equal to 14 days. Among patients identified as having GCA, 18.2% of patients had definite evidence of a flare and 25% had a potential flare.

Conclusion

A claims‐based algorithm requiring two or more ICD‐9 diagnosis codes from inpatient, emergency department, or outpatient rheumatology visits and high‐dose glucocorticoid dispensing can be a useful tool to identify acute GCA cases in large administrative claims databases.

Real-world patterns of pegloticase use for treatment of gout: descriptive multidatabase cohort study

OBJECTIVE

Pegloticase is used in severe refractory gout or in cases of intolerance to other urate-lowering therapies. We sought to evaluate the patterns of pegloticase use in the USA and the incidence of safety outcomes.

METHODS

We conducted a retrospective descriptive study using data from two US commercial insurance claims databases (2010-2018). We identified new initiators of pegloticase with ≥1 gout diagnosis code in the 365-day baseline period prior to pegloticase initiation. We measured the number and duration of pegloticase infusions. We assessed the risk of anaphylaxis or anaphylactoid reactions, cardiovascular events, including myocardial infarction or stroke, and hospitalisation for heart failure (new onset or exacerbations) while undergoing pegloticase therapy.

RESULTS

Among 2.9 million patients with ≥1 diagnosis of gout, we identified only 483 (179 in Optum and 304 in MarketScan) pegloticase initiators. The mean age and % female was 55.6 years, 10.9% for MarketScan and 60.6 years and 17.3% for Optum. Hypertension was present in up to 85%, diabetes mellitus in 38%, chronic kidney disease in 46% and heart failure in 21% of the patients. The median number of infusions was four and the duration of therapy was 3 months. During the mean 0.5-year follow-up time on pegloticase, there were 3 (0.6%) anaphylaxis, 7 (1.4%) composite cardiovascular, 31 (6.4%) heart failure hospitalisations and 3 (0.6%) deaths.

CONCLUSION

Pegloticase is rarely used in gout, and the median duration of pegloticase therapy was 3 months. There were few anaphylaxis events captured in this claims-based study, while heart failure hospitalisations were common.

Comparative Risks of Cardiovascular Disease in Patients With Systemic Lupus Erythematosus, Diabetes Mellitus, and in General Medicaid Recipients

OBJECTIVE

Cardiovascular disease (CVD) risk is elevated in patients with systemic lupus erythematosus (SLE) and diabetes mellitus (DM), but whether risk of CVD in patients with SLE is as high as in those with DM is unknown. The present study was undertaken to compare CVD risks between patients with SLE and DM and general population US Medicaid recipients.

METHODS

In a cohort study, we identified age- and sex-matched adults (1:2:4) with SLE or DM and those from the general population using Medicaid Analytic eXtract, 2007-2010. We collected data on baseline sociodemographic factors, comorbidities, and medications. We used Cox regression models to calculate hazard ratios (HRs) of hospitalized nonfatal CVD events (combined myocardial infarction [MI] and stroke) and MI and stroke separately, accounting for competing risk of death and adjusting for covariates. We compared risks in age-stratified models.

RESULTS

We identified 40,212 SLE patients, 80,424 DM patients, and 160,848 general population patients; 92.5% were female, and the mean ± SD age was 40.3 ± 12.1 years. Nonfatal CVD incidence rate per 1,000 person-years was 8.99 for patients with SLE, 7.07 for those with DM, and 2.36 for the general population. Nonfatal CVD risk was higher in SLE compared to DM (HR 1.27 [95% confidence interval (95% CI) 1.15-1.40]), driven by excess risk at ages 18-39 years (HR 2.22 [95% CI 1.81-2.71]). Patients with SLE had higher risk of CVD compared to the general population (HR 2.67 [95% CI 2.38-2.99]).

CONCLUSION

SLE patients had a 27% higher risk of nonfatal CVD events compared to age- and sex-matched patients with DM and more than twice the risk of the Medicaid general population. The highest relative risk occurred at ages 18-39 years. These high risks merit aggressive evaluation for modifiable factors and research to identify prevention strategies.

Use of biologic or targeted-synthetic disease-modifying anti-rheumatic drugs and risk of diabetes treatment intensification in patients with rheumatoid arthritis and diabetes mellitus

OBJECTIVES

Given that RA treatment might affect the severity of diabetes mellitus (DM), we compared the risk of DM treatment intensification in patients with both RA and DM newly initiating a biologic DMARD or tofacitinib.

METHODS

Using claims data from the IBM MarketScan database (2005-2016), we identified patients aged ≥18 years with RA who initiated abatacept, a TNF inhibitor (TNFi), rituximab, tocilizumab or tofacitinib. Patients were required to have type 1 or type 2 DM and to use at least one antidiabetic drug at baseline. We assessed DM treatment intensification (i.e. addition of a new insulin or non-insulin antidiabetic medication). We also assessed non-insulin antidiabetic medication switching events.

RESULTS

We included 10 019 patients with RA and DM initiating a biologic DMARD or tofacitinib. Baseline insulin use was the highest in rituximab initiators (44%) and lowest in tofacitinib initiators (35%). The incidence rate per 1000 person-years for DM treatment intensification ranged from 148.2 (tofacitinib) to 198.0 (rituximab). The risk of DM treatment intensification was similar between abatacept and TNFi [hazard ratio (HR) 0.97, 95% CI: 0.82, 1.15], rituximab (HR 0.99, 95% CI: 0.79, 1.23) and tocilizumab (HR 0.94, 95% CI: 0.74, 1.19), but lower for tofacitinib compared with abatacept (HR 0.67, 95% CI: 0.50, 0.90). The risk of non-insulin DM treatment switching was not different between abatacept and other biologic DMARDs.

CONCLUSION

In patients with both RA and DM, we found no difference in the risk of DM treatment switching or intensification after initiating abatacept vs TNFi, rituximab and tocilizumab, whereas the risk appeared to be lower for tofacitinib.

Assessing the Risk for Gout With Sodium-Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes: A Population-Based Cohort Study

BACKGROUND

Hyperuricemia is common in patients with type 2 diabetes mellitus and is known to cause gout. Sodium-glucose cotransporter-2 (SGLT2) inhibitors prevent glucose reabsorption and lower serum uric acid levels.

OBJECTIVE

To compare the rate of gout between adults prescribed an SGLT2 inhibitor and those prescribed a glucagon-like peptide-1 (GLP1) receptor agonist.

DESIGN

Population-based new-user cohort study.

SETTING

A U.S. nationwide commercial insurance database from March 2013 to December 2017.

PATIENTS

Persons with type 2 diabetes newly prescribed an SGLT2 inhibitor were 1:1 propensity score matched to patients newly prescribed a GLP1 agonist. Persons were excluded if they had a history of gout or had received gout-specific treatment previously.

MEASUREMENTS

The primary outcome was a new diagnosis of gout. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of the primary outcome and 95% CIs.

RESULTS

The study identified 295 907 adults with type 2 diabetes mellitus who were newly prescribed an SGLT2 inhibitor or a GLP1 agonist. The gout incidence rate was lower among patients prescribed an SGLT2 inhibitor (4.9 events per 1000 person-years) than those prescribed a GLP1 agonist (7.8 events per 1000 person-years), with an HR of 0.64 (95% CI, 0.57 to 0.72) and a rate difference of -2.9 (CI, -3.6 to -2.1) per 1000 person-years.

LIMITATION

Unmeasured confounding, missing data (namely incomplete laboratory data), and low baseline risk for gout.

CONCLUSION

Adults with type 2 diabetes prescribed an SGLT2 inhibitor had a lower rate of gout than those prescribed a GLP1 agonist. Sodium-glucose cotransporter-2 inhibitors may reduce the risk for gout among adults with type 2 diabetes mellitus, although future studies are necessary to confirm this observation.

PRIMARY FUNDING SOURCE

Brigham and Women's Hospital.

Risk of Diabetes Mellitus in Patients with Juvenile Idiopathic Arthritis

OBJECTIVE

To examine the risk of type 1 diabetes (T1D) associated with juvenile idiopathic arthritis (JIA).

METHODS

Using the IBM MarketScan database, we compared JIA patients with asthma patients and healthy individuals for the risk of incident T1D.

RESULTS

We included patients with 15,210 JIA, 76,050 patients with asthma, and 76,050 healthy individuals matched 1:5 on age, sex, and index date. After adjustment for confounders, the multivariable HR of T1D associated with JIA was 1.48 (95% CI 0.86-2.56) versus asthma and 1.81 (95% CI 1.03-3.17) versus healthy individuals.

CONCLUSION

JIA appears to be associated with an increased risk of T1D compared to patients with asthma and healthy children.

Risk of Hospitalized Infection and Initiation of Abatacept Versus Tumor Necrosis Factor Inhibitors Among Patients With Rheumatoid Arthritis: A Propensity Score-Matched Cohort Study

OBJECTIVE

We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi).

METHODS

Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection.

RESULTS

We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes.

CONCLUSION

In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.

Atrial Fibrillation/flutter Hospitalizations among US Medicaid Recipients with and without Systemic Lupus Erythematosus

OBJECTIVE

Systemic lupus erythematosus (SLE) is a multisystem chronic inflammatory autoimmune disease with high prevalence of several risk factors for atrial fibrillation/flutter (AF). However, the incidence and risk of AF in SLE have not been well quantified.

METHODS

We used the United States Medicaid Analytic eXtract from 2007 to 2010 to identify beneficiaries aged 18-65 years, with prevalent SLE, each matched by age and sex to 4 non-SLE general Medicaid recipients. We estimated the incidence rates (IR) per 1000 person-years (PY) for AF hospitalizations and used multivariable Cox regression to estimate the HR for AF hospitalization.

RESULTS

We identified 46,876 US Medicaid recipients with SLE, and 187,504 age- and sex-matched non-SLE controls (93% female; mean age 41.5 ± 12.2 yrs). Known AF risk factors such as hypertension (HTN), cardiovascular disease (CVD), and kidney disease were more prevalent in patients with SLE. During a mean followup of 1.9 ± 1.1 years for SLE, and 1.8 ± 1.1 years for controls, the IR per 1000 PY for AF was 1.4 (95% CI 1.1-1.6) among patients with SLE and 0.7 (95% CI 0.6-0.8) among non-SLE controls. In age- and sex-matched and race-adjusted Cox models, the HR for AF was 1.79 (95% CI 1.43-2.24); after adjustment for baseline HTN and CVD, the adjusted HR was reduced to 1.17 (95% CI 0.92-1.48).

CONCLUSION

SLE was associated with a doubled rate of hospitalization for AF compared to age- and sex-matched general Medicaid patients. In a race-adjusted model, the risk was 80% higher. However, the AF risk factors HTN and CVD were more prevalent among patients with SLE and accounted for the excess risk.

Lipid Testing and Statin Prescriptions Among Medicaid Recipients With Systemic Lupus Erythematosus or Diabetes Mellitus and the General Medicaid Population

OBJECTIVE

Cardiovascular disease (CVD) risks in systemic lupus erythematosus (SLE) are similar to those in diabetes mellitus (DM). We investigated whether the numbers of lipid tests and statin prescriptions in patients with SLE are comparable with those in patients with DM and those in individuals without either disease.

METHODS

Using Analytic eXtract files from 29 states for 2007-2010, we identified a cohort of US Medicaid beneficiaries, ages 18-65 years, with prevalent SLE. Each SLE patient was matched for age and sex with 2 patients with DM and 4 individuals in the general Medicaid population who did not have either SLE or DM. We compared the proportions of patients in each cohort who received ≥1 lipid test and ≥1 statin prescription during 1-year follow-up. We used multivariable logistic regression to calculate the odds of lipid testing and receiving prescriptions for statins and conditional logistic regression to compare the matched cohorts.

RESULTS

We identified 3 Medicaid cohorts: 25,950 patients with SLE, 51,900 patients with DM, and 103,800 Medicaid recipients without either condition. In these cohorts, lipid testing was performed in 24% of patients in the SLE group, 43% of patients in the DM group, and 16% of individuals in the group with neither condition, and statin prescriptions were dispensed in 11%, 33%, and 7% of these groups, respectively. SLE patients were 66% less likely (odds ratio [OR] 0.34, 95% confidence interval [95% CI] 0.34-0.35) to have lipid tests and 82% less likely (OR 0.18, 95% CI 0.18-0.18) to fill a statin prescription compared with DM patients. SLE patients were also less likely (OR 0.89, 95% CI 0.84-0.94) to fill a statin prescription compared with individuals in the general Medicaid population.

CONCLUSION

Despite having an elevated risk of CVD, SLE patients received less lipid testing and received fewer statin prescriptions compared with age- and sex-matched DM patients and individuals in the general Medicaid population; this gap should be a target for improvement.

[Research progress in saliva collection, analysis and its relationship with oral diseases]

As one of the major body fluid, saliva has various components that can shift according to the systemic health state. With the atraumatic way of collection, saliva can be a promising media to help the detection of oral diseases. With the development of salivaomics and the application of unbiased, highly sensitive, and high throughout separation techniques for salivary components, there's now more possibilities for effective identification of biomarkers correlated with oral diseases. This review aimed to introduce the current state of saliva collection and detection techniques as well as their correlation with oral diseases, hoping to provide evidence for further research.

Baseline Retinal Examinations in Patients With Systemic Lupus Erythematosus Newly Initiating Hydroxychloroquine Treatment in a US Medicaid Systemic Lupus Erythematosus Population, 2000-2010

OBJECTIVE

Baseline retinal examinations have long been recommended for patients beginning treatment with hydroxychloroquine (HCQ), but it is unknown how well this guideline is followed. We investigated baseline eye examinations among US SLE patients enrolled in Medicaid in whom HCQ treatment was newly initiated.

METHODS

Using billing codes, we identified SLE patients ages 18-65 years who were enrolled in Medicaid and residing in the 29 most populated US states, from 2000 to 2010. New users of HCQ were identified by filled prescriptions, with none filled in the preceding 12 months. Retinal examinations that were performed within 30 days before to 1 year after the index prescription were identified. We examined the proportions of patients receiving retinal examinations over the study years and compared the characteristics of those who did and those who did not receive examinations, using bivariable and multivariable logistic regression models.

RESULTS

Among 12,755 SLE patients newly starting HCQ treatment, 32.5% received baseline dilated eye examinations. The proportions of patients receiving baseline eye examinations did not significantly change from 2000 to 2010 (31.0-34.4%; P for linear trend = 0.12). Factors associated with an increased likelihood of having an examination included female sex, Asian versus white race, and a higher number of laboratory tests performed during the preceding year. Compared with white patients, lower proportions of black and Native American patients with SLE had baseline retinal examinations.

CONCLUSION

Only one-third of patients with SLE enrolled in Medicaid and in whom HCQ was newly initiated received the recommended baseline retinal examinations, and this proportion did not significantly increase from 2000 to 2010. The sociodemographic variation in this recommended care has been observed for other recommended medical care in SLE and requires both further investigation and interventions to address it.

Use of prescription opioids among patients with rheumatic diseases compared to patients with hypertension in the USA: a retrospective cohort study

OBJECTIVE

Long-term opioid prescribing has increased amid concerns over effectiveness and safety of its use. We examined long-term prescription opioid use among patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA) and ankylosing spondylitis (AS), compared with patients with hypertension (HTN).

METHODS

We used Truven MarketScan, a US commercial claims database (2003-2014) and identified RA, SLE, PsA and AS cohorts, each matched by age and sex to patients with HTN. We compared long-term opioid prescription use during 1 year of follow-up and used multivariable Poisson regression model to estimate the relative risk (RR) of receiving opioid prescriptions based on underlying disease cohort.

RESULTS

We identified 181 710 RA (mean age 55.3±13.1, 77% female), 45 834 SLE (47.1±13.1, 91% female), 30 307 PsA (49.7±11.5, 51% female), 7686 AS (44.6±12.0, 39% female) and parallel numbers of age-matched and sex-matched patients with HTN. The proportion of patients receiving long-term opioid prescriptions, and other measures of opioid prescriptions were higher among rheumatic disease cohorts and highest in patients with AS. AS was associated with the highest RR of receiving long-term opioid prescriptions (RR 2.73, 95% CI 2.60 to 2.87) versus HTN, while RRs were 2.21 (2.16 to 2.25) for RA, 1.94 (1.87 to 2.00) for PsA and 1.82 (1.77 to 1.88) for SLE.

CONCLUSIONS

Patients with rheumatic disease have higher rates of long-term opioid prescriptions, and patients with AS have the highest risk of receiving opioid prescriptions versus patients with HTN. Further studies investigating the effectiveness of disease-targeted treatments on decreasing opioid use in these four rheumatic diseases may provide strategies for reducing prescription opioids.

Heart failure risk in systemic lupus erythematosus compared to diabetes mellitus and general medicaid patients

BACKGROUND

Patients with systemic lupus erythematosus (SLE) have a similar risk of myocardial infarction as those with diabetes mellitus (DM). Whether the risk of heart failure (HF) in SLE is similar to the elevated risk in DM is unknown. We sought to estimate the rates and risks for HF hospitalization among US Medicaid patients with SLE and to compare them to those for DM and the general Medicaid population.

METHODS

Using U.S. Medicaid data from 2007-2010, we identified patients with SLE or DM, and a matched cohort from the general Medicaid population and calculated incidence rates (IR), incidence rate ratios (IRR) and adjusted hazard ratios (HR) of a first HF hospitalization.

RESULTS

We identified 37,902 SLE (93% female, mean age 40.1 ± 12.1), 76,657 DM (93% female, mean age 40.0 ± 12.1), and 158,695 general Medicaid patients (93% female, mean age 40.2 ± 12.1). The IR per 1000-person years was 6.9 (95% CI 6.3-7.5) for SLE, 6.6 (95% CI 6.2-7.0) for DM, and 1.6 (95% CI 1.5-1.8) for general Medicaid patients. The highest IRR compared to general Medicaid was seen among SLE patients in age group 18-39 (14.7, 95% CI 13.9-15.5). Multivariable-adjusted HRs for HF compared to general Medicaid population were similar for SLE (2.7, 95% CI 2.3-3.1) and DM (3.0, 95% CI 2.6-3.4).

CONCLUSION

The incidence of HF among SLE patients was 2.7-fold higher than general Medicaid patients, and similar to DM. Further investigation into the biologic mechanism of HF among SLE compared to non-SLE and DM patients may shed light on the findings of this study.

[Analysis of four carnitine-acylcarnitine translocase deficiency cases caused by homozygous mutation of SLC25A20 c.199-10T> G]

Objective: To investigate the clinical, biochemical and genetic features of four carnitine-acylcarnitine translocase deficiency cases. Methods: Four cases diagnosed with carnitine-acylcarnitine translocase deficiency from Guangxi Maternal and Child Health Hospital were studied. DNA was extracted from dry blood filter for gene analysis. SLC25A20 gene analysis was performed in 1 case and the whole exon sequence analysis was performed in 3 cases. Results: Retrospective study on unrelated carnitine-acylcarnitine translocase deficiency patients, the age of onset was 1-28 d, the age of death were 1.5-30 d, main clinical features were hypoglycemia (4 cases), arrhythmia (2 cases), sudden death (2 cases). Biochemical test showed hypoglycemia (1.2-2.0 mmol/L) , elevated creatine kinase (955-8 361 U/L) and creatine kinase isozyme(199-360 U/L), normal or decreased free carnitine level (3.70-27.07 μmol/L) , elevated long-chain acylcarnitine (palmityl carnitine 1.85-14.84 μmol/L). The gene tests showed that all 4 cases carried SLC25A20 gene c.199-10T> G homozygous mutation, inherited from their parents. By analyzing the haplotype, we found that the mutation loci of C. 199-10T> G were all in the same haplotype. Conclusion: The c.199-10T> G mutation is an important molecular cause of carnitine-acylcarnitine translocase deficiency, which has relatively high frequency in Guangxi population, and is related to the founder effect.

[Genetic analysis for 5 congenital hypothyroidism patients due to dyshormonogenesis]

OBJECTIVE

To analyze molecular characteristics of 5 congenital hypothyroidism (CH) patients due to dyshormonogenesis.

METHOD

We enrolled 5 CH patients due to dyshormonogenesis who were identified in Newborn Screening Center of Guangxi Zhuang Autonomous Region, China. Blood samples were collected from the patients and their parents, and genomic DNA was extracted from peripheral blood leukocytes. All exons of DUOX2, TG, TPO and NIS gene together with their exon-intron boundaries were screened by next-generation sequencing. Specimens from 100 normal controls were tested for these novel variations.

RESULT

No TPO, NIS or TG gene mutations were identified. Direct sequencing of the DUOX2 gene revealed that patient 1 had a compound heterozygote for c. 3340delC and p. R683L, patient 2 was homozygous for p. K530X and patient 3 was a heterozygote for p. E879K. Both biallelic and monoallelic heterozygous mutations in DUOX2 were associated with transient CH. Novel mutations included c. 3340delC and p. R683L, analysis of 100 healthy subjects without thyroid disease did not show the same change.

CONCLUSION

Genetic analysis of TPO, NIS, DUOX2 and TG gene in 5 unrelated CH patients with thyroid dyshormonogenesis revealed two novel DUOX2 mutations, both were biallelic and monoallelic heterozygous mutations in DUOX2 associated with transient CH.

Unfolded protein response suppresses cisplatin-induced apoptosis via autophagy regulation in human hepatocellular carcinoma cells

It has been shown that drug resistance is extremely common in hepatocellular carcinoma (HCC) and is one of the major problems in HCC chemotherapy. However, the detailed mechanisms remain largely unknown. We have previously shown that endoplasmic reticulum (ER) stress is involved in the tumorigenesis of HCC. Here, we demonstrated that the unfolded protein response (UPR) inhibits cisplatin-induced HCC cell apoptosis. In HCC cells, cisplatin treatment triggers the UPR, which subsequently inhibits cisplatin-induced apoptosis. Importantly, mild ER stress precondition suppresses the sensitivity of HCC cells to cisplatin-induced apoptosis through autophagy regulation. Furthermore, heat-shock protein 27 (Hsp27) is involved in the cytoprotective role of the UPR in cisplatin-induced apoptosis. We also demonstrated that Hsp27 inhibits cisplatin- induced HCC cell death through autophagy activation. Taken together, our results indicate that the UPR inhibits cisplatin-induced apoptosis in HCC cells, at least in part, by Hsp27-mediated autophagy activation.

PI3K/Akt promotes GRP78 accumulation and inhibits endoplasmic reticulum stress-induced apoptosis in HEK293 cells

The potential pro-survival role of phosphatidylinositol 3-kinase (PI3K)/Akt during endoplasmic reticulum stress has been well-characterized. However, the detailed mechanisms remain largely unknown. Here, we showed that PI3K/Akt inhibition promoted endoplasmic reticulum stress-induced apoptosis in a glucose-regulated protein 78 (GRP78)-dependent manner. During endoplasmic reticulum stress, high levels of Akt phosphorylation were sustained for at least 18 h in HEK293 cells. Importantly, PI3K/Akt enhanced GRP78 accumulation through increasing its stability following endoplasmic reticulum stress. Furthermore, Akt1, but not Akt2 or Akt3, was involved in GRP78 stability regulation. These results suggest that PI3K/Akt inhibits endoplasmic reticulum stress-induced apoptosis in HEK293 cells, at least in part, by promoting GRP78 protein stability.

Associations between VHL genotype and clinical phenotype in familial von Hippel-Lindau disease

BACKGROUND

Von Hippel-Lindau (VHL) disease is an autosomal dominant hereditary disorder associated with tumours and cysts in the central nervous system (CNS) and other visceral organs. Germline mutations in the VHL gene on chromosome 3p25-26 are considered the cause of this disease.

MATERIALS AND METHODS

We studied six patients with VHL disease and their relatives. Loss of heterozygosity (LOH) was determined by five flanking microsatellite polymorphic markers in the VHL locus. Multiplex ligation-dependent probe amplification (MLPA) and quantitative real-time polymerase chain reaction (qPCR) amplification were used to detect the genomic deletions. Single-strand conformation polymorphism (SSCP) analysis was applied to test for sequence variations.

RESULTS

Three germline deletions in the VHL gene (142.9, 53.3 and 3.3 kb) were found by MLPA. These deletions were defined clearly by qPCR analyses. The142.9 kb germline deletion was significantly associated with patients with CNS haemangioblastomas (P < 0.01 by Fisher's exact test), and one missense mutation (Gln209Arg) was detected from a patient with a pancreatic cyst in the same family. LOH was also detected from a patient with bilateral renal cell carcinomas.

CONCLUSION

Diverse genetic conditions are associated with the clinical manifestations of VHL disease. Genomic deletions that can be detected by MLPA or qPCR are major causes for this syndrome. Missense mutations and LOH accompanying the disease lead to complex clinical symptoms and genotypic determination can facilitate a clinical diagnosis because of their strong association.

mRNA differential display identification of thyroid hormone-responsive protein (THRP) gene in association with early phase of long-term potentiation

The process of long-term potentiation (LTP) consists of the early induction and late maintenance phases. Few studies have examined the cellular mechanisms underlying these two phases; their respective mRNA expression profiles have not yet been elucidated. Here we used the technique of PCR differential display to identify genes that are differentially expressed between the early and late phases of LTP in vivo. Our results indicated that the cDNA fragment corresponding to one mRNA with preferentially increased expression during the early, but not late, phase of LTP encodes the rat thyroid hormone-responsive protein (THRP) gene. In situ hybridization analysis confirmed the results obtained from the PCR differential display. Prior NMDA receptor blockade with MK801 prevented induction of LTP and decreased THRP mRNA expression in the dentate gyrus, as assayed by quantitative RT-PCR analysis. THRP antisense oligonucleotide treatment before tetanic stimulation also prevented induction of LTP. However, when THRP antisense oligonucleotide was administered after induction of LTP, it did not affect expression and maintenance of LTP. THRP is known to be responsive to thyroid hormone. Our results indicate that direct thyroid hormone (T3) injection into the dentate gyrus produces a long-lasting enhancement of synaptic efficacy of these neurons. T3 injection also markedly increased THRP mRNA expression in the dentate gyrus. Taken together, our results suggest that THRP mRNA expression plays an important role in the early phase, but not the late phase, of LTP and that both THRP and thyroid hormone are involved in synaptic plasticity in hippocampal neurons.

Management of oral and maxillofacial radiology clinics in Taiwan's dental schools

OBJECTIVES

To investigate management of Taiwanese dental school Oral and Maxillofacial Radiology (OMFR) clinics and to suggest alternative management strategies.

METHODS

A management questionnaire was designed for the faculty responsible for teaching the Oral and Maxillofacial Radiology curriculum.

RESULTS

Data from all seven Taiwanese schools indicated inadequate supervision of the prescription of radiological examinations in the absence of guidelines. Most schools are understaffed and not properly equipped. There is a significant shortage of trained dentists in the field of OMFR. In some schools no dentist is involved in the management of OMFR clinics. Some aspects of quality assurance procedures should be enhanced. An average of 21.4% of films were reported lost, with the highest rate at 40%, demonstrating serious problems in image archiving. Clinician satisfaction with clinic management averaged 74.3%, with a minimum of 50%.

CONCLUSION

A set of standards is recommended by the Taiwanese OMFR Association after reviewing the survey findings. Prescription for OMFR examination should be supervised by licensed clinicians, and there is a need for guidelines. Trained and dedicated personnel should be assigned for the management of OMFR clinics. More quality assurance procedures should be performed. A computer-based image archiving system is desirable.

The relationship between radiologic interpretation and root tip fracture during tooth extraction performed by junior clinicians

OBJECTIVES

The purpose of this study was to analyze the relationship between root tip fracture and radiologic interpretation of root morphology on periapical radiographs during third molar extraction performed by junior clinicians.

METHODS

Before tooth extraction, periapical radiographs of 107 patients with 116 third molars were evaluated by junior clinicians, all with less than 5 years of clinical experience. Radiologic interpretations of root morphology-including number, curvature, fusion, and accessory root-were recorded before each extraction. The clinicians were also asked to estimate the possibility of root fracture on a Visual Analogue Scale before the procedure. The exact morphology of the extracted teeth was recorded after the extraction for the purpose of comparison.

RESULTS

Twenty-nine of 116 teeth extracted were not correctly interpreted in at least 1 of the morphologic categories surveyed. The average expected fracture rate of nonfractured teeth was 23.1%, whereas the average expected fracture rate of fractured teeth was a significantly higher 50.3%. Misinterpretation of root morphology on radiographs decreased with increased clinical experience. Senior residents had the lowest misinterpretation and fracture rate. Logistic regression analysis showed that fracture is most closely related to the estimated fracture rate (4.95) and is also significantly related to underestimation of root curvature (0.95; 24.56 with 2 df of chi-square, P = .0001).

CONCLUSIONS

Misinterpretation of root morphology on radiographs occurred in 25% of the teeth. Root curvature was the most misinterpreted item studied. Fracture was most closely related to the estimated fracture rate. Junior clinicians in this study expected that only 50% of the fractured teeth would fracture, reflecting a general underestimation of root tip fracture. Further study should be performed to evaluate how to increase the accuracy of root curvature interpretation.

Determination of 8-Oxoguanine in Individual Cell Nucleus of Gamma-Irradiated Mammalian Cells

8-Oxoguanine, through its ability to mispair bases other than cytosine, is assumed to be one of the most potent premutagenic lesions in nuclear DNA damaged by reactive oxygen radicals. In this study, we examine whether the presence of residual 8-oxoguanine can be detected in mammalian cells after exposure to ionizing radiation. MOLT-4 human leukemia cells and CHO-K1 Chinese hamster cells were acutely irradiated in vitro with 0, 0.2, 0.4, 0.6 and 1.0 Gy gamma radiation at room temperature. The amounts of 8-oxoguanine and total DNA in the cell nucleus were detected by fluorescein-isothiocyanate (FITC)-labeled avidin, which binds specifically and directly to 8-oxoguanine, and propidium iodide, respectively. The intensity ratios between these two fluorescent dyes were then taken as indices to measure the content of 8-oxoguanine within individual cells. We found an apparent dose-dependent increase in the amount of 8-oxoguanine accumulated in cells of both lines. Moreover, the content of 8-oxoguanine decreased from 2 to 20 h after irradiation in CHO-K1 cells, which may reflect the time-dependent repair processes at the 8-oxoguanine lesions. This novel approach may provide a sensitive tool for in situ measurement of 8-oxoguanine in cells or even in the human body after exposure to ionizing radiation.

Group learning factors in a problem-based course in oral radiology

OBJECTIVES

To assess the development of group dynamics in students who participated in a problem-based learning (PBL) course in oral radiology and to evaluate the influence of the facilitators' experience.

METHODS

At the beginning and end of the course, students in three consecutive years (1997, 1998 and 1999) responded to a group learning factor questionnaire designed to measure group dynamics (engagement, interpersonal relationships, lack of commitment and disruptive behaviour, interpersonal learning and self-presentation). The answers were analysed with paired t-test and the effects of the facilitator's seniority, expertise in oral radiology, experience of PBL and single or rotating facilitators assessed.

RESULTS

Most groups in the three years reported above average group dynamic scores. There were significant changes in group dynamics. In the 1997 class, interpersonal relationships improved (P=0.014). In the 1998 class, interpersonal learning (P=0.021) and engagement (P=0.009) increased significantly, while disruptive behaviour decreased (P=0.031). In the 1999 class, lack of commitment and disruptive behaviour decreased (P=0.014). Groups led by a junior faculty member with no previous experience of PBL show less commitment and more disruptive behaviour.

CONCLUSIONS

More commitment and less disruptive behaviour and improved engagement, interpersonal relationships and self-presentation were found in a PBL course in oral radiology. Facilitators should have prior exposure to PBL to avoid disruptive behaviour among the students.

Integration of the digital imaging and communications in medicine standard into an oral and maxillofacial image management and communication system

OBJECTIVE

The purpose of this study was to provide developmental information about digital imaging and communications in medicine (DICOM) support applications for an image management and communication system (IMACS).

STUDY DESIGN

An oral and maxillofacial radiology IMACS that uses a proprietary image format was implemented in March 1997 in a general hospital dental clinic that supports more than 100 cubicles. DICOM was implemented into this system in 1998.

RESULTS

In March 1997, the clinic directly began processing oral and maxillofacial radiographs with digital image acquisition devices or converted them into proprietary digital format with a film digitizer. The digital images could then be viewed at workstations in the 11 different divisions of the department. A DICOM module was implemented to convert proprietary images into DICOM in June 1998. After the release of DICOM Supplement 32 on a digital x-ray, DICOM was implemented into the oral and maxillofacial radiology IMACS with a DICOM server and browser in June 1999. We describe the steps we took to implement this system in our institution with a brief report on the evaluation of this system.

CONCLUSION

We implemented a DICOM oral and maxillofacial IMACS that complies with the American College of Radiology and the National Electrical Manufacturers Association Standard DICOM, version 3.0. Most DICOM service classes and roles are supported.

Comparison of landmark identification in traditional versus computer-aided digital cephalometry

The aim of this study was to assess landmark identification on digital images in comparison with those obtained from original radiographs. Ten cephalometric radiographs were selected randomly. Seven orthodontic residents identified 19 cephalometric landmarks on both the original radiographs and the digital images. To assess the concordance between landmarks identified on the original radiographs and on their digital counterparts, the x, y coordinates for each landmark in the 2 modalities were transformed with the identical references. The placement differences for 19 landmarks between 2 methods were calculated and their components in horizontal and vertical directions were analyzed respectively. Multivariate analysis of variance showed that the "cephalometric radiograph" and "landmark" variation had greater influence than that from "method" (landmark identification on digital / original radiograph). It was also noted that the differences of landmark identification between original radiographs and their digital counterparts were statistically significant. The landmarks with significant differences of horizontal component on the x-axis were Me, Gn, ANS, PNS, LIA. The differences were generally under 1 mm with the exception of Or, Me, PNS, LIA. The landmarks with significant differences of vertical component on the y-axis were Po, Or, Gn. The inter-observer error for each landmark in digital images was generally larger than that in the original radiographs. However, statistically significant differences of inter-observer errors between 2 modalities were only found for 4 of the 19 landmarks. These 4 landmarks, Po, Ar, ANS, and UM, should be scrutinized more carefully during potential applications of digital cephalometry.

Splice site mutation in the type VII collagen gene (COL7A1) in a Taiwanese family with recessive dystrophic epidermolysis bullosa

BACKGROUND AND PURPOSE

Generalized recessive dystrophic epidermolysis bullosa (RDEB) is a severe inherited disease, in which patients suffer from blistering and scarring of the skin and mucous membranes after minor mechanical trauma. Tight genetic linkage has been established to the type VII collagen gene (COL7A1) at 3p21. The purpose of this study was to identify mutations in COL7A1 in one Taiwanese pedigree with generalized RDEB.

METHODS

Genomic DNA was used as the template for polymerase chain reaction (PCR) amplification of all 118 COL7A1 exons and the flanking splice junctions. PCR was followed by heteroduplex analysis of the products by single-strand conformation polymorphism (SSCP) studies, and direct nucleotide sequencing was used to search for mutations, which were verified by restriction endonuclease digestion.

RESULTS

We identified a homozygous intronic splice-site at the +1 position of intron 5 (682 + 1G-->A) of COL7A1 in the affected individual. His parents, who were cousins, were not affected by this disease. The mother was heterozygous for the mutation; the father had died before the study, of unrelated causes. This mutation results in a frameshift and downstream stop codons on both alleles, indicating an absence of functional protein. Restriction endonuclease BspHI can be used to verify this mutation and screen other members in the same family.

CONCLUSIONS

These molecular findings offer a genetic explanation for the skin fragility in this Taiwanese patient with RDEB. The immediate benefits gained by elucidating mutations in family members include the ability to assess whether they are carriers of this disease and the ability to use this DNA-based method for prenatal testing in subsequent pregnancies.

Correlation of genetic instability with mismatch repair protein expression and p53 mutations in non-small cell lung cancer

To examine the etiological association of genetic instability in lung tumorigenesis, we investigated the frequency of microsatellite instability (MI) of eight dinucleotide repeat markers in 68 patients with non-small cell lung cancer. Twenty-eight patients (41.2%) evidenced instability in multiple tested microsatellite markers ranging from 3-7 and were defined as MI-positive patients. MI occurred more frequently in patients suffering from squamous cell lung carcinoma (P = 0.004). We examined the association between MI and expression of hMLH1 mismatch repair protein by immunohistochemical analysis of hMLH1 protein in paraffin-embedded tumors from 64 patients. Twenty MI-positive patients (76.9%) had no expression of hMLH1 protein. The data showed that MI was associated with altered hMLH1 expression (P = 0.03). To examine the role of genetic instability in the previous identified small intragenic deletion of the p53 gene, we explored the association between MI and p53 gene mutations. All patients, except one, containing small intragenic deletion in p53 gene showed MI (P = 0.018). In addition, we found that MI was not associated with the prognosis. Our data suggest that MI plays a significant role in non-small cell lung cancer tumorigenesis in Taiwan and that MI is associated with the altered expression of hMLH1 mismatch repair protein. In addition, MI may be involved in frequent small intragenic deletions of p53 gene.

Greater tuberosity osteotomy for treatment of impinge rotator cuff tear

Forty-two consecutive patients in whom an impingement of rotator cuff tear had been treated with greater tuberosity osteotomy and repair were evaluated by relief of pain, return of range of motion and strength of shoulder. The oriental acromion is thin and easy to break during the traditional acromioplasty procedures. When the decompression is achieved by osteotomy on the greater tuberosity which is the common location of cuff tear, not only is adequate decompression achieved but also the coracoacromial ligament is preserved. Comparison of the results of greater tuberosity osteotomy with those of previous acromioplasty studies shows they are mostly similar. At present, these techniques can be recommended for use by Chinese orthopaedic surgeons who have to deal with the typical oriental bony structures.

An electronic survey of opinions on the compatibility of current X-ray generators with intra-oral digital X-ray systems

OBJECTIVES

To assess opinions on the compatibility of current X-ray generators with intra-oral digital X-ray systems.

METHODS

A questionnaire was posted in both English and in Japanese on oral and maxillofacial radiology electronic bulletin boards. The questionnaire was also mailed to selected researchers and manufacturers in oral and maxillofacial radiology. The replies were evaluated to determine opinion on the current and future status of digital intra-oral imaging with special reference to their compatibility with current X-ray generators.

RESULTS

Seventy-one replies were received from 19 countries: 39% from Japan and Korea, 27% from North America, 25% from Europe and 8% from the rest of the world. Eighty per cent of respondents were from academia, 15% from industry and the remainder largely in private practice. Respondents' experience was equally divided between solid state, mainly charge-coupled devices (CCDs) and photostimulable phosphor (IP) technologies. Sixty-eight per cent considered that current X-ray generators are compatible with intra-oral digital systems and many believed this was due to their gray scale flexibility. Twenty-eight per cent believed that existing X-ray generators are inconsistent with low exposure times. Many of the replies suggested that in future pixel size would decrease and bit depth and receptor sensitivity increase.

CONCLUSIONS

Most respondents are happy to use existing X-ray generators with digital X-ray systems. However, they also believe that increased sensitivity of receptors could lead to more stringent designs of X-ray generators to ensure more reliable outputs in the low exposure range.

Influence of polymorphism at p53, CYP1A1 and GSTM1 loci on p53 mutation and association of p53 mutation with prognosis in lung cancer

BACKGROUND

We previously found that the majority (9/11) of p53 tumor suppressor gene mutations in 60 lung cancer patients in Taiwan were small intragenic deletions and nonsense mutations. To gain insights into the possible etiologic factors involved in these mutations and the prognostic significance of p53 gene mutations in lung cancer in Taiwan, we investigated the influence of polymorphism at p53, cytochrome p450 1A1 (CYP1A1) and glutathione S-transferase M1 (GSTM1) loci on p53 gene mutation, and the association of p53 gene mutation with prognosis in these lung cancer patients.

METHODS

The polymorphism of these genes was determined by polymerase chain reaction followed by restriction enzyme digestion. The Pearson chi 2 test was used to compare allelic distributions between lung cancer patients and controls. The log-rank test was used to assess the significance of the survival differences between patients with and without p53 mutations.

RESULTS

There was no significant difference with respect to the genotype distribution of p53, CYP1A1 and GSTM1 polymorphisms between patients with and without p53 mutations, although a tendency toward increasing frequency of the wild-type homozygote genotype of p53 polymorphism was noted in lung cancer patients containing p53 mutations. We further analyzed the association of p53 mutation with prognoses in lung cancer patients for whom postoperative survival data were available. The estimated median survival times for patients with and without p53 mutation were 25 and 28 months, respectively. There was no significant correlation between p53 mutation and survival.

CONCLUSIONS

Our data suggest that p53 gene mutation may not be associated with polymorphisms of p53, CYP1A1 and GSTM1 genes, and it may have no significant effect on the prognosis of lung cancer patients in Taiwan.

Prognostic significance of p53 codon 72 polymorphism in lung carcinomas

Lung cancer is the leading cause of cancer death in Taiwan. Potential molecular markers associated with cancer susceptibility and prognosis are the genes involved in tumorigenesis. Therefore, we investigated the association of p53 codon 72 polymorphism with prognosis in 114 lung cancer patients. The estimated median survival times for patients with proline (Pro)/Pro, arginine (Arg)/Arg, and Arg/Pro genotypes were 25, 26 and 36 months, respectively. We also found that patients with the Pro/Pro genotype had a worse prognosis compared with those with Arg/Pro genotypes, especially for patients with squamous cell lung cancer (P = 0.013), male patients (P = 0.028) and those aged 60-69 years (P = 0.052). In patients with early stage lung cancer, patients with Pro/Pro and Arg/Arg genotypes had a tendency for a worse prognosis than those with the Arg/Pro genotype (P = 0.057). Our data suggest that p53 codon 72 polymorphism may be a potential prognostic factor in certain sub groups of lung cancer patients in Taiwan.

Radiographic evaluation of glenohumeral kinematics: a muscle fatigue model

The purpose of this study was to document the effect of muscle fatigue on glenohumeral kinematics. Twelve male volunteers without shoulder disease and with an average age of 27 years were studied. Glenohumeral anteroposterior radiographs were taken at 45 degrees intervals as the arm was abducted in the plane of the scapula from 0 degree to 135 degrees. This series of radiographs was performed both before and immediately after the subject performed a series of deltoid and rotator cuff fatiguing exercises. The average humeral head position or translation before and after muscle fatigue for each arm angle was compared. For all subjects, before fatigue, the position of the humeral head was below the center of the glenoid for all angles of abduction. There was essentially no change in position of the humeral head in the prefatigue state, as the arm was abducted from 0 degree to 135 degrees with no more than an average 0.3 mm of total humeral head excursion. After fatigue, excursion of the humeral head increased to an average of 2.5 mm between the tested positions. The position of the humeral head with the arm at 0 degree of abduction was lower or had migrated inferiorly compared with the rested state, with an average 1.2 mm significant increase in inferior translation. With the initiation of abduction, the humeral head demonstrated significant superior migration or translation in all positions tested. This result has important implications for conservative treatment of shoulder impingement and underscores the importance of rehabilitation to maximize the endurance and strength of the rotator cuff musculature.

p53 codon 72 polymorphism in Taiwanese lung cancer patients: association with lung cancer susceptibility and prognosis

An association between the BstUI (Pro/Pro) genotype of the p53 codon 72 polymorphism and lung cancer has been reported previously (X. Jin et al., Carcinogenesis (Lond.), 16: 2205-2208, 1995). However, the genotype distribution of p53 codon 72 polymorphism as well as the association of this polymorphism with lung cancer risk and prognosis remain undefined in the Taiwanese population. Therefore, we investigated the genotype distribution of p53 codon 72 polymorphism in 194 lung cancer patients and 152 noncancer controls. The genotype frequencies in Taiwanese noncancer controls were 0.56 (Arg) and 0.44 (Pro). Chi2 analysis indicated significant differences in genotype distribution of p53 from other reports in Swedish (P < 0.001), Spanish (P < 0.001), Caucasians in the United States (P = 0.002), and African-Americans (P = 0.027). In addition, our data suggest that the Pro allele of the p53 codon 72 polymorphism increased the risk of lung cancer among female Taiwanese. The female patients with genotype Pro/Pro showed a significantly increased odds ratio (3.14; confidence interval, 1.48-6.64; P = 0.003) of having lung adenocarcinoma, compared with normal controls with the other genotypes. Patients with the Pro/Pro genotype had an odds ratio of 2.63 (confidence interval, 1.22-5.68; P = 0.01) higher than those with the other genotypes to be diagnosed with lung cancer at the early ages. We further investigated the association of p53 codon 72 polymorphism with prognosis in 133 lung cancer patients. Patients with the Pro/Pro genotype tended to have poorer prognosis than those with the Arg/Pro genotype (P = 0.05, by the log-rank test). Our data suggested that p53 codon 72 polymorphism may play a role in cancer susceptibility and prognosis in specific classes of lung cancer patients in Taiwan.

Analysis of K-ras gene mutations in lung carcinomas: correlation with gender, histological subtypes, and clinical outcome

PURPOSE

Lung cancer is respectively the leading and second-leading cause of cancer deaths among women and men in Taiwan. The commonest pathological type of lung carcinoma found in Taiwan is adenocarcinoma. and it has been documented that K-ras oncogene mutation occurs in a subset of lung adenocarcinoma. We therefore investigated the mutation spectrum and clinicopathological significance of K-ras oncogene mutations in lung cancer patients in Taiwan.

METHODS

The lung tumors were surgically resected from 84 lung cancer patients. DNA was isolated and the mutation spectrum was examined by direct sequencing. These data were also correlated with the clinicopathological characteristics of patients.

RESULTS

K-ras gene mutations were detected in 5 cases among the 84 patients investigated (6.0%). The majority of mutations occurred in exon 1 (80%, 4 of 5) and were located mainly in codons 12 and 13. Two patients had G x C --> T x A transversions and 2 patients had G x C --> A x T transitions. Notably, 1 patient had a G x C base-pair deletion from the contiguous G x C base pairs located between codons 68 and 69. All mutations occurred in male patients who were smokers. The incidences of K-ras gene mutation among male and female patients with adenocarcinoma were 13% and 0% respectively. Patients with K-ras gene mutation survived for shorter periods than those without mutations (P = 0.08, by the log-rank test).

CONCLUSIONS

The incidence of K-ras gene mutations for male and female patients with adenocarcinoma was 13% and 0% respectively. Thus, the role of K-ras in the development of lung adenocarcinoma among Chinese men who are predominantly smokers is not significantly different from that in other populations worldwide. However, K-ras mutations may not be associated with adenocarcinoma among women in Taiwan, who are virtually all nonsmokers.

Implementation of an oral and maxillofacial radiology image management and communication system

OBJECTIVES

To implement an oral and maxillofacial radiology image management and communication system (OMFR IMACS) in the School of Dentistry, National Taiwan University.

METHODS

An OMFR IMACS has been implemented over 3 years in three phases: (1) Establishment of an OMFR image processing laboratory for research and graduate student training; (2) Installation of network infrastructure and (3) Total system integration.

RESULTS AND CONCLUSIONS

Intraoral, panoramic, cephalometric, and TMJ radiographs are directly processed with digital image acquisition devices or are converted into a digital format for viewing via UTP cable through FastEthernet in the eleven different divisions of the school. The system archives about 400 Mb of imaging data daily, representing 80% of the workload of the OMFR Division. The system is now used parallel to the conventional film-library system and has been integrated as part of the oral health service.

The effects of projection geometry and trabecular texture on estimated fractal dimensions in two alveolar bone models

OBJECTIVES

To study the effects of trabecular texture and projection geometry on estimates of fractal dimensions from simulated alveolar bone.

METHODS

Two models, one scale-variant and the other relatively scale-invariant, were used. Projections of 2-D slices through both the models were calculated, a uniform series of projections computed for the angular orientations between (0 degree and 180 degrees). Results of the 128 stacked projections are the projection of the 3-D object from different angles. Power spectra were produced by calculating the squared magnitude from the data and plotted as the logarithm of the power against the logarithm of the frequency, to give the fractal dimension.

RESULTS

In the scale-variant model, the alveolar trabecular texture produced with a relatively thicker cylindrical diameter yielded a smaller fractal dimension (t = 8.44, P = 0.00). Linear regression analysis showed that the correlation between projection angle and the resulting fractal dimension was low for both the thicker cylinder (r = 0.02, P = 0.82), and for thinner cylinder (r = 0.02, P = 0.84). The scale-invariant model, also yielded a relatively smaller estimated fractal dimension (t = 7.23, P = 0.00). However, the correlation between projection angle and the resulting estimate of the fractal dimension was found to be low for both trabecular configurations (r = 0.10, P = 0.29 and r = 0.07, P = 0.45 respectively).

CONCLUSIONS

Fractal dimensions increased when the diameter of the simulated cylindrical trabeculae decreased irrespective of the differences in self-similarity. The degree to which they varied with projection angle was relatively less for the scale-invariant (self-similar) model. However, fractal dimensions changed significantly with projection geometry.

High frequency of deletion mutations in p53 gene from squamous cell lung cancer patients in Taiwan

Lung cancer is the leading and second-leading cause of cancer deaths among women and men in Taiwan, respectively. However, the molecular mechanisms involved in lung tumorigenesis in Taiwan remain poorly defined. A study that analyzed the mutation spectrum of the p53 tumor suppressor gene in 35 female lung cancer patients in Hong Kong showed that a high proportion of the mutations observed were deletions, suggesting the possible involvement of a distinct mutagenic factor(s) in Chinese female lung cancer patients (Y. Takagi et al., Cancer Res., 55: 5354-5357, 1995). Therefore, to gain insight into the role of the p53 tumor suppressor gene and possible etiological factors in lung tumorigenesis in Taiwan, we investigated the mutation spectra of exons 4-11 in the p53 tumor suppressor gene of 60 lung cancer patients in Taiwan. These data were also correlated with clinical pathological characteristics of patients. Lung tumors were surgically resected, genomic DNA was isolated, and their mutation spectra were examined using PCR/single-strand conformational polymorphism analysis and direct sequencing. The frequency of p53 gene mutation was 18% (11 of 60). However, distinct patterns of p53 gene mutation were observed. Seven of 11 mutations detected (64%) were deletions of 1-12 bp at G:C bp or at bp in the immediate vicinity of repetitive sequences and/or tandem repeat sequences. In addition, two patients (2 of 11, 18%) exhibited nonsense mutations. In contrast to the frequent occurrence of missense mutations in the p53 gene reported in the literature, the majority (82%) of the mutations in lung cancer patients in Taiwan were nonmissense mutations, ie., deletions and nonsense mutations. Immunohistochemical staining indicated that p53 mutations including non-in-frame deletions and nonsense mutations all resulted in no expression of p53 protein. Notably, mutations occurred more frequently in patients suffering from squamous cell carcinoma (SQ). Nine of 31 SQ patients (29%) exhibited deletions or nonsense mutations, suggesting that deletions and nonsense mutations in the p53 gene are involved in the formation of SQ in Taiwan. In addition, mutations occurred more frequently in patients with stage III or IV lung cancer. However, mutations were not correlated with patients' smoking habits. Our data suggest that p53 gene mutation involved in the formation of SQ and distinct environmental factor(s) and/or genetic factor(s) that induced specific short deletions in repeat sequences may be involved in lung tumorigenesis in Taiwan.

Subtalar arthrodesis for subtalar arthritis

Primary subtalar arthritis is not common except in cases of generalized arthritis such as rheumatoid arthritis. The majority of subtalar arthritis results from intraarticular calcaneal fractures. Arthrodesis seems to be the only way to solve this problem. Thirteen patients (15 feet) were treated with subtalar arthrodesis at KMCH. Preoperative diagnosis included 13 feet with traumatic arthritis secondary to a calcaneal fracture, one foot with rheumatoid arthritis and one foot with primary osteoarthritis. The mean follow up period was 24.9 months. Lateral approach without fibular osteotomy was done with decompression if there was entrapment syndrome and the arthrodesis were accomplished with use of staples for internal fixation. Eleven (85%) of the patients were satisfied with the results. Objectively, the results were excellent after 11 arthrodesis (73%), good or fair after three (20%), and poor after one (7%). There was no nonunion. Complications occurred in 1 patient who developed superficial wound infection, and in 1 patient with staple loosening. Though there was no case of nonunion, the fusion time was rather long. This might have been due to the fixation method because staples can not provide compression force which accelerates union. We believe subtalar arthrodesis is appropriate for isolated subtalar arthritis unless there are associated talonavicular or calcaneocuboid arthritis in which case triple arthrodesis will be more appropriate.

Salvage operation for neglected ankle fractures

From 1986 to 1993, 49 cases of untreated or poorly treated ankle fractures who received salvage surgery were followed up for an average of 36.4 months. The patients included 31 males & 18 females with an average age of 41.6y/o and the time interval from initial injury to reconstructive surgery average due 17.6 months. They were classified and treated according to their grade of reduction and degree of arthrosis. The surgical methods included arthrotomy & joint debridement, revised open reduction, lower tibial osteotomy and ankle arthrodesis, depending on different individual conditions. After surgery, all cases had symptomatic relief and functional improvement with an average score increased from 26.3 preoperatively to 86.8 at follow up. The goals of ankle fractures is as articular fractures, they are treated by surgical anatomic reduction with rigid fixation as early as possible in order to provide good functional results. Nevertheless they are varied in neglected ankle fractures according to their individual conditions: open reductions were performed on cases with no or little arthritic change even though arthrosis might occur later because, if necessary, future conversion to osteotomy or arthrodesis would be easier. As for late cases with advanced arthritis, ankle arthrodesis were done by compressive arthrodesis with necessary bone graft to secure fusion in an optimal position.

Digitizing of radiographs with a roller-type CCD scanner

OBJECTIVES

Roller-type scanners can be used to digitize radiographs. This study evaluated the physical performance of a roller-type scanner with regard to dynamic range, scan reproducibility, and homogeneity.

METHODS

A VXR-12 (Vidar System Corp., Herndon, Va.) roller-type scanner with imaging editing software Paint Shop Pro (JASC Inc., Minnetonka, Minn.) was used to digitize a step tablet image on Kodak T-MAT G films (Kodak, Rochester, N.Y.). The step tablet image was scanned at various locations and with different scanning settings. The pixel values of the resulting image were analyzed. The step tablet image was also scanned by a Wellhofer WD 102 Filmdensitometer (Wellhofer Dosimetrie, Schwarzenbruck, Germany) to measure the optical densities of the steps on the film for comparison.

RESULTS

With the use of the default scanning settings the digitized images had pixel values distributed in a similar dynamic range to that of the film densitometer. This scanner produced consistent images with different scanning positions, different orientation of the images, and different power states of the scanner.

CONCLUSIONS

This roller-type scanner has a similar dynamic range to that of the film densitometer. The operating condition of the scanner is stable, and the resulting image is not significantly affected by the scanning positions. This type of scanner should be suitable for digitizing dental x-ray films, although the limiting scanning resolution might not be sufficient for some diagnostic purposes.

Surgical treatment of complete acromioclavicular separations

A retrospective study of fifty-two patients (48 cases followed up), with Allman-Tossy grade III acromioclavicular separations, who were treated with coracoclavicular reconstruction by Mersilene prosthetic substitute (Mersilene tape with polyester suture, 5 mm wide, 30 cm, Ethicon), was carried out. The average follow up was 38 months, with the longest being 10 years, and the shortest being 8 months. The average age of the patients was 32 years, with a range from 20 to 62 years. Two groups were divided by age. Although the younger age group showed better results than the elder one in pain, range of motion and return to previous occupation or sports, the overall outcome was satisfactory in 41 of 48 (86%) followed patients. For the grade III acromioclavicular separation patients, surgical reconstruction with Mersilene looping provides a reliable result including use of the arm for sports or repetitive work.

Detection of small differences in mass using a direct digital dental X-ray system

OBJECTIVES

To evaluate experimentally how in direct digital radiography heterogenous detector response may influence the depiction of small mass differences.

METHODS

A step wedge of a bone-simulating resin was imaged at 70 kVp using RadioVisioGraphy ZHR 32000. Exposure time and step wedge position on the detector varied. The pixel values of the stored images of the step wedge were converted to luminance values of the displayed images.

RESULTS

The relationship between pixel and luminance values was non-linear. The difference in luminance between adjacent steps varied with position of step wedge. Regardless of position, there was an increase in difference of luminance between steps with increasing exposure. A greater relative change in luminance was consequently seen in the thinner parts of the step wedge. The failure to perceive individual steps of the wedge in its thicker parts was related to insufficient relative change in luminance between steps.

CONCLUSIONS

The heterogeneous response of the detector resulted in a varying ability to depict small mass changes over the detector area.