Exploring the Benefits of 3D-Printed Bolus in Cone Beam CT for Modified Radical Mastectomy Breast Cancer

PURPOSE/OBJECTIVE(S)

To improve the accuracy of superficial dose coverage for patients undergoing modified radical mastectomy (MRM), boluses are frequently applied to the skin surface of targeted region during radiotherapy. The irregular curvature of MRM breast cases results in discrepancies of dosimetry and poor contact. Additionally, the presence of an air gap causes unnecessary high-dose escalation and uncertainty in dose calculation, making the use of commercial flat bolus problematic. This study evaluated the effectiveness of 3D-printed bolus by comparing it to commercial bolus in setup variations and dosimetric compliance through daily cone-beam computed tomography (CBCT) scans.

MATERIALS/METHODS

Ten patients underwent MRM were divided into 2 groups. 5 patients treated with 0.5 cm commercial bolus as group A while the other 5 patients covered by 3D Bolus as group B. 3D bolus was made of polylactic acid filament (PLA) and contoured in advance with thickness of 0.5 cm on the surface of target. Positional errors were recorded through daily image guidance and compared with the images. Both groups had right-sided breast with neck lymph nodes involved and received 50 Gy in 25 fractions using 4 partial arcs of the volumetric modulated arc therapy (VMAT) technique. The CBCTs were recalculated through treatment planning system (TPS) to assess superficial dose coverage. A two-tailed student's t-test was applied.

RESULTS

Groups A and B pitch angles were -0.203 ± 0.837° and 0.334 ± 0.909° (p = 0.0003). Roll angle were 0.313 ± 0.728° and -0.633 ± 1.286° (p = 0.0000013). Yaw angle were -0.034 ± 0.872° and 0.018 ± 0.883° (p = 0.721). There was a trend of differences in the Z-axis and significant statistical differences in the pitch and roll angles due to aligning gel layers directly with group A's body surface, while 3D bolus rigidly adherence to group B's delineated curve. In the planned target volume (PTV), the CI and HI of group A were 0.9448±0.0208 and 1.2061±0.0448, respectively, while 0.9776±0.0144 and 1.1472±0.0206 (p<0.005) were for group B. As for the superficial region, which is defined from body surface to 0.5cm inside PTV, CI and HI of A were 0.8290±0.0599 and 1.4675±0.2434, while for B, they were 0.9753±0.0214 and 1.1330±0.0126, respectively (p<0.005).

CONCLUSION

The study analyzed the results through image comparison and investigated the CI and HI between two types of boluses. The 3D bolus reduces setup errors and improves dose coverage especially when superficial region is concerned. Better consistency of patient repositioning and dosimetry can be achieved and proved by daily assessment of CBCT scan. The customization of 3D bolus with integration of TPS and CT scans provides a solution to the inadequacies of commercial bolus. The results suggest that the use of 3D bolus is a promising development in radiation therapy for MRM breast cancer patients.

The Effectiveness of Music Interventions for Improving Anxiety Symptoms in Cancer Patients Undergoing Radiation Therapy

PURPOSE/OBJECTIVE(S)

Being alone in the treatment room during radiation therapy (RT) often causes anxiety which may lead to treatment failure. The benefit of music interventions in reducing anxiety among cancer patients during RT simulations is still controversial. The goal of this study is to evaluate the effect of music on anxiety symptoms among patients undergoing initial RT and a randomized trial was conducted.

MATERIALS/METHODS

Patients who received RT for the first time were enrolled and were randomly allocated into groups of experiment and control. The questionnaire of mood thermometer (BSRS-5), distress thermometer (DT), and the Beck Anxiety Inventory (BAI-C) and were given before and after RT. We also measured the changes in physiological symptoms for ten consecutive days since the first day of RT. The experimental group was given music during RT, while the control group was not. The generalized linear mixed model was used to estimate the pre-post difference of music interventions on the BSRS-5, DT, and BAI-C compared with control group after considering the random intercept and the unstructured residual variance-covariance matrix.

RESULTS

A total of 50 patients in the experimental group and 50 patients in the control group were enrolled in this study. The satisfaction degree of treatment in the experimental group was 100%, but it was 96% in control group (p = 0.0048). The pre-test BSRS-5 was 3.4±2.3 for the experimental group versus 2.6±2.3 for the control group (p = 0.0815), the post-test BSRS-5 score was significantly reduced in the experimental group (1.6±1.4 for experimental group versus 2.7±2.2 for the control group, p = 0.0057), the significant pre-post difference of BSRS-5 between group was found (p = 0.0024). When the experimental group withdrew from the music intervention, the BSRS-5 rebounded to 3.7±3.0. The pre-test DT was 4.3±1.5 and 3.4±1.7 in the experimental group and control group (p = 0.0051), and the post-test DT score was significantly reduced in the experimental group (2.7±1.2 for the experimental group and 3.5±1.3 for the control group, p = 0.0021), the significant pre-post difference of DT between group was found (p<.0001). When the experimental group withdrew from the music intervention, the DT rebounded to 3.7±1.4. The pre-test BAI-C was 6.7±11.7 and 7.8±8.5 in the experimental group and control group (p = 0.5878), and the post-test BAI-C score was significantly lower in the experimental group (1.7±3.7 for the experimental group and 7.4±8.0 for the control group, p<.0001), however, the pre-post difference of BAI-C between group was not significant (p = 0.0619). When the experimental group withdrew from the music intervention, the BAI-C rebounded to 6.5±8.7. There is a significantly increased systolic blood pressure in the control group compared with the patients had music intervention.

CONCLUSION

This study's results provide evidence that playing music routinely (music intervention) during RT can be an excellent way to relieve patients' anxiety and improve their comfort.

Stereotactic Radiosurgery for Small Intact Brain Metastasis: A Comparative Evaluation of 3 Different Single Fraction Prescription Doses

PURPOSE/OBJECTIVE(S)

While single-fraction stereotactic radiosurgery (SRS) in the treatment of small brain metastases (SBM, ≤ 2 cm) is well established, prescription dosing varies considerably across institutions and clinical trials. The choice of prescription dose is a delicate balance between local failure (LF) and radiation necrosis (RN) risks. In the modern era, historically-established dosing thresholds may no longer be applicable. To evaluate the impact of prescription dose on outcomes, we performed a comparative analysis of patients with SBM treated with definitive SRS using three different prescriptions, at a single tertiary institution.

MATERIALS/METHODS

Consecutive patients with intact SBM treated with SRS from January 2017 and December 2021 were analyzed. Baseline patient characteristics and dosing parameters were abstracted from the medical record. To limit the integral brain dose when treating multiple brain metastases, the institutional practice was to reduce prescription dose as the total number of lesions increased (i.e., 24 Gy for ≤10 lesions, 22 Gy for 11-20, and 20 Gy for >20). A per lesion analysis, where each lesion was followed from the date of SRS to the last follow-up, was conducted with primary endpoints of LF and RN. Gray's test was used to compare the cumulative incidence of the LF and RN, with death as a competing risk. Factors affecting LF were analyzed using Cox hazard regression analysis.

RESULTS

A total of 1318 SBM in 250 patients received SRS and met the inclusion criteria. The median age was 62 years (range: 18-90), median KPS was 90 (range: 50-100) and 66% were female. The most common primary tumors were lung (55.5%) and breast cancers (26.4%). With a median follow-up of 12 months, 136 (11%) LF in 44 patients and 70 (5.7%) RN events in 46 patients occurred. The actuarial 1-year cumulative rate of LF was lower in lesions treated with 24 Gy (6.4%, 95% CI: 4.7-8.6%) or 22 Gy (5.8%, 95% CI: 3.7-8.7%) compared to 20 Gy (15.4%, 95% CI: 10.9-20.5%) (p<0.01). 22 Gy and 24 Gy prescription doses were associated with a 44% and 52% reduction in risk in LF compared to 20 Gy (HR: 0.56; 95% CI: 0.36-0.9; p = 0.01 and HR: 0.48; 95% CI: 0.31-0.74; p<0.01, respectively). In a subset analysis of radiosensitive tumors, 1-year LF rate was still lower with 24 Gy (7.4%, 95% CI: 5.3-9.9%) and 22 Gy (6.1%, 95% CI: 3.7-9.4%) than 20 Gy (15.7%, 95% CI: 11.2-21%) (p = 0.01). The cumulative 1-year RN rate numerically declined with dose, but was not statistically significantly different, with 3.6% (95% CI: 2.3-5.3%) for 24 Gy, 2.6% (95% CI: 1.3-4.8%) for 22 Gy and 1.4% (95% CI: 0.4-3.7%) for 20 Gy.

CONCLUSION

Patients treated with single fraction SRS to intact SBM were at increased risk of LF with prescription doses of 20 Gy compared to 22-24 Gy, without an increased risk of RN. Even in patients with radiosensitive histologies, higher LF rates were still observed following 20 Gy compared to 22-24 Gy.

Src Kinase Activates Signal Transducer and Activator of Transcription 3 to Enhance Radioresistance in Triple Negative Breast Cancer Cells

PURPOSE/OBJECTIVE(S)

Triple-negative breast cancer (TNBC) is known to be insensitive to radiation therapy, and it requires to development radiosensitizer for TNBC.

MATERIALS/METHODS

We previously established a radioresistant sub-line from MDA-MB-231 cells, called 231-RR, and have demonstrated that 231-RR cells displayed high cancer stem cell (CSC) activity. And 231-RR cells were treated with dasatinib, a Src inhibitor.

RESULTS

In the present study, we discovered that the activation of Src kinase was increased in 231-RR cells. Treatment of dasatinib, an Src inhibitor, sensitized 231-RR cells to radiotherapy, along with the increased p-γH2Axser139, indicated the enhancement of DNA damage. Dasatinib also caused the downregulation of cancer stemness factors, including c-Myc, OCT4, and the Notch intracellular domain, as well as the decrease of phosphorylation of Signal Transducer and Activator of Transcription 3 (STAT3). The treatment of C188-9, a STAT3 inhibitor, also sensitized 231-RR cells toward radiotherapy along with the increased p-γH2Axser139, but without changing the phosphorylation of Src, indicating that STAT3 is a downstream event of Src activation.

CONCLUSION

In conclusion, our data suggests that the inhibitors of Src or STAT3 could function as radiosensitizers or CSC targeting agents for TNBC radiotherapy.

Detection, Identification and Molecular Characterization of the 16SrII-V Subgroup Phytoplasma Strain Associated with Pisum sativum and Parthenium hysterophorus L

Two unrelated plant species, green pea and parthenium weed, harboring typical phytoplasma symptoms, were discovered in Yunlin, Taiwan. Green pea (Pisum sativum.) and parthenium weed (Parthenium hysterophorus L.) are both herbaceous annual plants belonging to the Fabaceae and Asteraceae families, respectively. Displayed symptoms were witches' broom, phyllody and virescence, which are typical indications of phytoplasma infection. Pleomorphic phytoplasma-like bodies were observed under the transmission electron microscope in the sieve elements of symptomatic green pea and parthenium weed. The iPhyClassifier-based virtual RFLP study demonstrated that the phytoplasma associated with the diseased plants belongs to the 16SrII-V subgroup. The disease symptoms of both plants can be explained by the identification of PHYL1 and SAP11 effectors, identical to those of peanut witches' broom phytoplasma. The phytoplasma strains identified in this study present a very close phylogenetic relationship with other 16SrII-V subgroup phytoplasma strains discovered in Taiwan. These results not only convey the local status of the 16SrII-V subgroup phytoplasma strains but also encourage attention to be given to preventing the spread of this threat before it becomes pervasive.

Detection, Identification, and Molecular Characterization of the 16SrII-V Subgroup Phytoplasma Strain Associated with Digera muricata in Taiwan

Digera muricata (L.) Mart. is a pantropical annual herb belonging to the Amaranthaceae family. In August 2021, D. muricata with indicative phytoplasma symptoms of phyllody, witches'-broom, and virescence was discovered adjacent to a peanut field in Mailiao, Yunlin, Taiwan. The causal agent of the observed symptoms was detected and identified by a series of molecular characterizations. Sieve elements of the phloem tissue were perused under the transmission electron microscope and revealed the presence of pleomorphic phytoplasma-like organisms. Nested PCR using phytoplasma universal primer pairs P1/P7 and R16F2n/R16R2 was able to amplify a 1.2-kb DNA fragment for the 16S rRNA gene only from the symptomatic D. muricata. The 16S rRNA-based phylogenetic analysis and the iPhyClassifier-based virtual RFLP further affirmed that the phytoplasma associated with the diseased D. muricata can be classified into the 16SrII-V subgroup. Moreover, displayed evident symptoms were explained by the concomitant detection of PHYL1 and SAP11, the virulence genes responsible for the development of leaf-like flowers and shoot proliferation, respectively. Although phytoplasma infection on the noncrop species does not have a direct economic impact, its role in disease spread and perpetuation is indubitable.

Detection, Identification, and Molecular Characterization of a 16SrII-V Subgroup Phytoplasma Associated with Nicotiana plumbaginifolia

Nicotiana plumbaginifolia Viviani, commonly known as curl-leaved tobacco, is an annual herbaceous plant belonging to Solanaceae family. This plant is native to Mexico, South America, and parts of the Caribbean and has been reported to be present in Taiwan since 2006. In March 2021, N. plumbaginifolia Viviani, found in Yunlin County, Taiwan, was observed to have phyllody, virescence, and witches'-broom, which is consistent with the disease symptoms caused by phytoplasma infection. Samples of the healthy and symptomatic plants were collected for analysis of the causal agent associated with the diseased N. plumbaginifolia Viviani. Under transmission electron microscopy, the phytoplasma-like pleomorphic bodies were found in the sieve tubes of the diseased plants. The 16S ribosomal RNA (rRNA)-based phylogenetic analysis and the iPhyClassifier-based virtual restriction fragment length polymorphism study demonstrated that the phytoplasma identified in this study can be classified into the 16SrII-V subgroup, which is similar to the peanut witches'-broom phytoplasma, a 'Candidatus phytoplasma aurantifolia'-related strain. Further identification of SAP54/PHYL1 and SAP11 homologs in the phytoplasma explain the disease symptoms of phyllody, virescence, and witches'-broom observed in diseased N. plumbaginifolia Viviani. The discovery of new phytoplasma plant hosts has gained scientific importance in light of the attempt to unravel an efficient strategy to fight the rapid spread of this disease, which poses a threat to the agricultural sector and food security in Taiwan.

Host Genetic Associations with Salivary Microbiome in Oral Cancer

Despite the growing recognition of a host genetic effect on shaping gut microbiota composition, the genetic determinants of oral microbiota remain largely unexplored, especially in the context of oral diseases. Here, we performed a microbiome genome-wide association study in 2 independent cohorts of patients with oral squamous cell carcinoma (OSCC, n = 144 and 67) and an additional group of noncancer individuals (n = 104). Besides oral bacterial dysbiosis and signatures observed in OSCC, associations of 3 loci with the abundance of genus-level taxa and 4 loci with β diversity measures were detected (q < 0.05) at the discovery stage. The most significant hit (rs10906082 with the genus Lachnoanaerobaculum, P = 3.55 × 10^-9 at discovery stage) was replicated in a second OSCC cohort. Moreover, the other 2 taxonomical associations, rs10973953 with the genus Kingella (P = 1.38 × 10^-9) and rs4721629 with the genus Parvimonas (P = 3.53 × 10^-8), were suggestive in the meta-analysis combining 2 OSCC cohorts. Further pathway analysis revealed that these loci were enriched for genes in regulation of oncogenic and angiogenic responses, implicating a genetic anchor to the oral microbiome in estimation of casual relationships with OSCC. Our findings delineate the role of host genotypes in influencing the structure of oral microbial communities.

Using the Goldilocks Principle to model coral ecosystem engineering

The occurrence and proliferation of reef-forming corals is of vast importance in terms of the biodiversity they support and the ecosystem services they provide. The complex three-dimensional structures engineered by corals are comprised of both live and dead coral, and the function, growth and stability of these systems will depend on the ratio of both. To model how the ratio of live : dead coral may change, the ‘Goldilocks Principle’ can be used, where organisms will only flourish if conditions are ‘just right’. With data from particle imaging velocimetry and numerical smooth particle hydrodynamic modelling with two simple rules, we demonstrate how this principle can be applied to a model reef system, and how corals are effectively optimizing their own local flow requirements through habitat engineering. Building on advances here, these approaches can be used in conjunction with numerical modelling to investigate the growth and mortality of biodiversity supporting framework in present-day and future coral reef structures.

Tipping the immunostimulatory and inhibitory DAMP balance to harness immunogenic cell death

Induction of tumor cell death is the therapeutic goal for most anticancer drugs. Yet, a mode of drug-induced cell death, known as immunogenic cell death (ICD), can propagate antitumoral immunity to augment therapeutic efficacy. Currently, the molecular hallmark of ICD features the release of damage-associated molecular patterns (DAMPs) by dying cancer cells. Here, we show that gemcitabine, a standard chemotherapy for various solid tumors, triggers hallmark immunostimualtory DAMP release (e.g., calreticulin, HSP70, and HMGB1); however, is unable to induce ICD. Mechanistic studies reveal gemcitabine concurrently triggers prostaglandin E2 release as an inhibitory DAMP to counterpoise the adjuvanticity of immunostimulatory DAMPs. Pharmacological blockade of prostaglandin E2 biosythesis favors CD103+ dendritic cell activation that primes a Tc1-polarized CD8+ T cell response to bolster tumor rejection. Herein, we postulate that an intricate balance between immunostimulatory and inhibitory DAMPs could determine the outcome of drug-induced ICD and pose COX-2/prostaglandin E2 blockade as a strategy to harness ICD.

Threeflower Tickclover (Desmodium triflorum) is a New Host for Peanut Witches' Broom Phytoplasma, a 16SrII-V Subgroup Strain in Taiwan

Three-flower Tick-clover (Desmodium triflorum) is a perennial herbaceous plant that belongs to the family of Leguminosae. Threeflower tickclover widely grows at mid-low altitude regions in Taiwan and is commonly used as a traditional herbal medicine for the treatment of dysmenorrheal, muscle spasm, cough, pain and poisoning. In March 2020, disease symptoms such as little leaf, phyllody, virescence, and witches' broom were observed on threeflower tickclover at the sansheng community park in Mailiao, Yunlin County, Taiwan. Similar disease symptoms were observed on peanut infected with peanut witches' broom (PnWB) phytoplasma grown in the same area (Liu et al. 2015). Leaf samples collected from the healthy and symptomatic threeflower tickclover were used to extract total DNA and protein for PCR and western blotting assays, respectively. Nested PCR was performed with the phytoplasma universal primer pairs P1/P7 followed by R16F2n/R16R2 for the amplification of 16S ribosomal RNA (rRNA) gene (Lee et al. 1993). A specific DNA fragment of expected size (1.2 kb) for 16S rRNA was only amplified from leaf samples of symptomatic threeflower tickclover. The nucleotide sequence of the amplified DNA fragment using primer pairs P1/P7 was deposited into the GenBank (accession no. MT452308). Blast analysis revealed that MT452308 shares 100% identity with that of GenBank accession NZ_AMWZ01000008 (complement [31109 to 32640]) of phytoplasma associated with PnWB disease (Chung et al. 2013). Based on the virtual RFLP pattern of MT452308 generated by iPhyClassifier, the phytoplasma detected in symptomatic threeflower tickclover could be classified into the 16SrII-V subgroup. For western blotting, the polyclonal antibody raised against Imp protein of purple coneflower witches' broom phytoplasma (Chien et al. 2020), which is identical with that (accession no. ADD59806) of PnWB phytoplasma, was used. An expected signal of 19 kDa specific for Imp was only detected in threeflower tickclover exhibiting disease symptoms. Subsequent assays including PCR, DNA sequencing and western blotting further confirmed that the gene encoding a SAP11-like protein (accession no. EMR14684) identified in PnWB phytoplasma was also found in samples of symptomatic threeflower tickclover, and shares 100% identity with each other. Our results indicate that threeflower tickclover, a common weed in Taiwan, may act as an alternative natural host for PnWB phytoplasma, and contributes to the spreading of phytoplasma disease.

Ixeris Chinensis is a New Host for Peanut Witches' Broom Phytoplasma, a 16SrII-V Subgroup Strain in Taiwan

Ixeris chinensis (Thunb. ex Thunb.) Nakai, a perennial herbaceous plant that belongs to the family of Asteraceae, is widely distributed at mid-low altitude regions in Taiwan. I. chinensis is commonly used as traditional herbal medicine for the treatment of inflammation, bronchitis, pneumonia, and diarrhea. In March 2020, disease symptoms such as shoot proliferation, phyllody, virescence, purple top, and witches' broom were observed on I. chinensis at the sansheng community park in Mailiao, Yunlin County, Taiwan. Totally, eight I. chinensis plants were checked and half of them were symptomatic. These disease symptoms are similar to those associated with peanut witches' broom (PnWB) disease identified in the same area (Liu et al. 2015). Three samples mixed with leaf, stem, and flower were tested including one healthy and two symptomatic I. chinensis. The total DNA of each sample was extracted and examined by nested PCR for the amplification of 16S rDNA with the phytoplasma universal primer pairs P1/P7 followed by R16F2n/R16R2 (Lee et al. 1993). A specific signal of expected size (1.2 kb) for 16S rDNA was only detected in the symptomatic I. chinensis, but not in healthy I. chinensis. The nucleotide sequence (accession no. MT416114) of the amplified DNA fragment using primer pairs P1/P7 from symptomatic I. chinensis is identical to that of GenBank accession NZ_AMWZ01000008 (complement [31109 to 32640]) of phytoplasma associated with PnWB disease (Chung et al. 2013). Analysis of the virtual RFLP pattern of MT416114 generated by iPhyClassifier revealed that the phytoplasma detected in symptomatic I. chinensis belongs to a 16SrII-V subgroup. The total protein of each sample was also extracted and examined by western blotting using the polyclonal antibody raised against Imp protein of purple coneflower witches' broom phytoplasma (Chien et al. 2020), which is identical with that (accession no. ADD59806) of PnWB phytoplasma. An expected signal of 19 kDa specific for Imp was detected in symptomatic I. chinensis, but not in healthy I. chinensis. Subsequent PCR, DNA sequencing and western blotting assays further confirmed that the gene encoding a SAP11-like protein was only detected in symptomatic I. chinensis, and shares 100% identity with that (accession no. EMR14684) of PnWB phytoplasma. Our results indicate that PnWB phytoplasma causes disease in I. chinensis, a common weed, which may act as an alternative natural host and facilitate the spreading of phytoplasma disease in Taiwan.

Patterns of COVID-19 on computed tomography imaging

PURPOSE

As the designated tertiary referral centre for infectious diseases in Hong Kong, our hospital received the city's first group of patients diagnosed with coronavirus disease 2019 (COVID-19). Herein, we studied the earliest patients admitted to our centre in order to clarify the typical radiological findings, particularly computed tomography (CT) findings, associated with COVID-19.

METHODS

From 22 January 2020 to 29 February 2020, 19 patients with confirmed COVID-19 underwent high-resolution or conventional CT scans of the thorax in our centre. The CT imaging findings of these patients with confirmed COVID-19 in Hong Kong were reviewed in this study.

RESULTS

Ground-glass opacities (GGO) with peripheral subpleural distribution were found in all patients (100%). No specific zonal predominance was observed. All lobes were involved in 16 (84.2%) patients, focal subsegmental consolidations were observed in 14 (73.7%) patients, and interlobular septal thickening was present in 12 (63.2%) patients. No mediastinal lymph node enlargement, centrilobular nodule, or pleural effusion was detected in any of the patients. Other imaging features present in several patients include bronchial dilatation, bronchial wall thickening, and crazy-paving patterns.

CONCLUSIONS

Peripheral subpleural GGO without zonal predominance in the absence of centrilobular nodule, pleural effusion, and lymph node enlargement were consistent findings in patients with confirmed COVID-19. The observed radiological patterns on CT scans can help identify COVID-19 and assess affected patients in the context of the ongoing outbreak.

Lilac Tasselflower (Emilia sonchifolia) is a New Host for Peanut Witches' Broom Phytoplasma, a 16SrII-V Subgroup Strain in Taiwan

Lilac tasselflower (Emilia sonchifolia) is an annual herbaceous plant that belongs to the family of Asteraceae. Lilac tasselflower is widely distributed at mid-low altitude regions in Taiwan, and is commonly used as traditional herbal medicine for the treatment of inflammation, rheumatism, dysentery, and analgesic. In March 2020, disease symptoms such as shoot proliferation, phyllody, and witches' broom were observed on lilac tasselflower at the sansheng community park in Mailiao, Yunlin County, Taiwan. Totally, four lilac tasselflower plants were checked and half of them were symptomatic. At the same area, similar symptoms associated with peanut witches' broom (PnWB) disease were observed (Liu et al. 2015). Samples including one healthy and two symptomatic lilac tasselflower were collected for total DNA and protein extraction used for PCR and western blotting assays, respectively. First, two sets of phytoplasma universal primer pairs P1/P7 and R16F2n/R16R2 were used to perform nested PCR for detection of 16S ribosomal RNA (rRNA) gene (Lee et al. 1993). A specific signal of expected size (1.2 kb) for 16S rRNA was only detected in samples of lilac tasselflower exhibiting disease symptoms. The amplified DNA fragment using primer pairs P1/P7 was partially sequenced (accession no. MT420682) with P1 and a nested primer (5'-GGGTCTTTACTGACGCTGAGG-3'). The 1.4 kb nucleotide sequence shares 100% identity with that of GenBank accession NZ_AMWZ01000008 (complement [31109 to 32640]) of phytoplasma associated with PnWB disease (Chung et al. 2013). Further analysis by iPhyClassifier, the virtual RFLP pattern of MT420682 confirmed that the phytoplasma detected in symptomatic lilac tasselflower could be classified into the 16SrII-V subgroup. For western blotting, total protein of each sample was examined using the polyclonal antibody raised against Imp protein of purple coneflower witches' broom phytoplasma (Chien et al. 2020), which shares 100% identity with that (accession no. ADD59806) of PnWB phytoplasma. A specific signal of expected size (19 kDa) for Imp was detected in symptomatic lilac tasselflower, but not in healthy lilac tasselflower. Subsequent PCR, DNA sequencing and western blotting assays further confirmed that the gene encoding a SAP11-like protein detected in samples of lilac tasselflower exhibiting disease symptoms is identical to that (accession no. EMR14684) of PnWB phytoplasma. Our results indicated that lilac tasselflower, which is recognized as a common weed in Taiwan, may facilitate the spreading of phytoplasma disease by acting as an alternative natural host for PnWB phytoplasma.

Poly(acrylamide-co-acrylic acid) gel polymer electrolyte incorporating with water-soluble sodium sulfide salt for quasi-solid-state quantum dot-sensitized solar cell

Rapid decay of photoanode, leakage from sealant, and evaporation of electrolyte are always the major concerns of quantum dot-sensitized solar cells (QDSCs) based on liquid electrolyte. Subsequently, gel polymer electrolyte (GPE) appears as an attractive solution in addition to lower cost, lighter weight, and flexibility. Poly(acrylamide- co-acrylic acid) (PAAm-PAA) is of special interest to act as a polymer host to entrap liquid electrolyte because it provides high transparency, good gelatinizing properties, and excellent compatibility with the liquid electrolyte. In this work, the electrical and transport properties of PAAm-PAA GPE incorporating with water-soluble sodium sulfide were characterized by impedance spectroscopy. An increment of ionic conductivity was observed with the incorporation of ethylene carbonate (EC) and potassium chloride (KCl). The highest room temperature ionic conductivity of PAAm-PAA GPE is 70.82 mS·cm−1. QDSC based on PAAm-PAA GPE with the composition of 1.3 wt% of KCl, 0.9 wt% of EC, 55.3 wt% of PAAm-PAA, 38.5 wt% of sodium sulfide, and 4.0 wt% of sulfur can present up to 1.80% of light-to-electricity conversion efficiency.

Fuel-Composition Dependent Reactor Antineutrino Yield at RENO

We report a fuel-dependent reactor electron antineutrino (ν[over ¯]_{e}) yield using six 2.8 GW_{th} reactors in the Hanbit nuclear power plant complex, Yonggwang, Korea. The analysis uses 850 666 ν[over ¯]_{e} candidate events with a background fraction of 2.0% acquired through inverse beta decay (IBD) interactions in the near detector for 1807.9 live days from August 2011 to February 2018. Based on multiple fuel cycles, we observe a fuel ^{235}U dependent variation of measured IBD yields with a slope of (1.51±0.23)×10^{-43}  cm^{2}/fission and measure a total average IBD yield of (5.84±0.13)×10^{-43}  cm^{2}/fission. The hypothesis of no fuel-dependent IBD yield is ruled out at 6.6σ. The observed IBD yield variation over ^{235}U isotope fraction does not show significant deviation from the Huber-Mueller (HM) prediction at 1.3 σ. The measured fuel-dependent variation determines IBD yields of (6.15±0.19)×10^{-43} and (4.18±0.26)×10^{-43}  cm^{2}/fission for two dominant fuel isotopes ^{235}U and ^{239}Pu, respectively. The measured IBD yield per ^{235}U fission shows the largest deficit relative to the HM prediction. Reevaluation of the ^{235}U IBD yield per fission may mostly solve the reactor antineutrino anomaly (RAA) while ^{239}Pu is not completely ruled out as a possible contributor to the anomaly. We also report a 2.9 σ correlation between the fractional change of the 5 MeV excess and the reactor fuel isotope fraction of ^{235}U.

Measurement of Reactor Antineutrino Oscillation Amplitude and Frequency at RENO

The RENO experiment reports more precisely measured values of θ_{13} and |Δm_{ee}^{2}| using ∼2200 live days of data. The amplitude and frequency of reactor electron antineutrino (ν[over ¯]_{e}) oscillation are measured by comparing the prompt signal spectra obtained from two identical near and far detectors. In the period between August 2011 and February 2018, the far (near) detector observed 103 212 (850 666) ν[over ¯]_{e} candidate events with a background fraction of 4.8% (2.0%). A clear energy and baseline dependent disappearance of reactor ν[over ¯]_{e} is observed in the deficit of the measured number of ν[over ¯]_{e}. Based on the measured far-to-near ratio of prompt spectra, we obtain sin^{2}2θ_{13}=0.0896±0.0048(stat)±0.0047(syst) and |Δm_{ee}^{2}|=[2.68±0.12(stat)±0.07(syst)]×10^{-3}  eV^{2}.

Life-Threatening Bleeding from the Pubic Branch of the Inferior Epigastric Artery after Pubic Ramus Fracture

Isolated pubic ramus fracture with concurrent life-threatening bleeding caused by injury to the inferior epigastric artery (IEA) or its branches has rarely been reported and can frequently be overlooked. This paper reports two cases of isolated pubic ramus fracture with concomitant injury to the pubic branch of the IEA, causing serious bleeding and hemodynamic instability. Pelvic angiography showed leakage of contrast from the pubic branch of the IEA. The complication in both cases was successfully treated with transcatheter arterial embolisation.

Kernohan-Woltman Notch Phenomenon Caused by Acute Traumatic Subdural Haematoma

A 27-year-old man suffered from right hemiparesis after a closed head injury. Computed tomography (CT) revealed a right hemisphere subdural haematoma with midline structure shifted to the left. The CT finding was believed to be mislabeled because the site of haematoma did not correlate with an ipsilateral hemiparesis. Magnetic resonance imaging revealed a right transtentorial uncal herniation and a small lesion within left cerebral peduncle, suggesting Kernohan-Woltman notch phenomenon (KWNP). KWNP has been rarely seen in patients with acute traumatic subdural haemorrhage. Anatomical small maximum tentorial notch width is the possible anatomical factor predisposing our patient to this phenomenon. (Hong Kong j.emerg.med. 2014;21:116-119)

Do laryngoscopic findings reflect the characteristics of reflux in patients with laryngopharyngeal reflux?

OBJECTIVE

To analyse the association between 24-hour multichannel intraluminal impedance-pH (24-h MII-pH) parameters and each item of the reflux finding score (RFS) to determine whether the laryngoscopic findings of the RFS could reflect the characteristics of reflux in patients with laryngopharyngeal reflux (LPR).

STUDY DESIGN

Prospective cohort study.

SETTINGS

Tertiary care referral medical centre.

PARTICIPANTS

Patients complaining of LPR symptoms were evaluated via a 24-hour MII-pH. Among them, 99 patients whose LPR was confirmed via 24-hour MII-pH were enrolled in this study.

MAIN OUTCOME MEASURES

Correlations between RFS ratings and 24-hour MII-pH parameters were evaluated and compared between patients with or without each laryngoscopic finding used in the RFS.

RESULTS

Subglottic oedema had a statistically significant positive correlation with number of non-acid LPR and non-acid full column reflux events. Ventricular obliteration and posterior commissure hypertrophy showed a significant correlation with non-acid exposure time and total reflux exposure time. We also found a significant correlation between granuloma/granulation score and number of acid LPR events. The numbers of non-acid LPR and full column reflux events in patients with subglottic oedema were significantly higher than those without subglottic oedema.

CONCLUSION

Among the laryngoscopic findings used in the RFS, subglottic oedema is specific for non-acid reflux episodes, and granuloma/granulation is specific for acid reflux episodes.

Locoregional relapse after gastrectomy with D2 lymphadenectomy for gastric cancer

BACKGROUND

Risk for and site of locoregional relapse have not been well studied in patients undergoing gastrectomy with D2 lymphadenectomy for gastric cancer.

METHODS

Patients who had undergone gastrectomy with D2 lymphadenectomy for gastric cancer between 2004 and 2007 were identified from an institutional database. The locoregional relapse rate was estimated by competing risk analysis, and risk groups were derived according to locoregional relapse risk using recursive partitioning analysis (RPA). The locations of nodal relapses were evaluated according to Japanese Classification of Gastric Carcinoma criteria.

RESULTS

Some 2618 patients were included. With a median follow-up of 78·0 (range 28·5-122·6) months, relapse was diagnosed in 471 of 2618 patients (18·0 per cent). The cumulative incidence of locoregional relapse at 5 years was 8·5 (95 per cent c.i. 7·4 to 9·6) per cent. The 5-year locoregional recurrence rates for high-risk (N3), intermediate-risk (N1-2) and low-risk (N0) groups were 32·4, 12·3 and 1·7 per cent respectively (P < 0·001). Among patients with regional relapse, 90·4 per cent had involvement outside the D2 dissected area, and the most commonly involved site was station 16b1. This pattern was maintained in the RPA risk groups (P = 0·329).

CONCLUSION

Locoregional relapse at 5 years after gastrectomy with D2 lymphadenectomy was 8·5 per cent, and was most often seen outside the D2 dissected area.

Rapidly progressing central-type primitive neuroectodermal tumor of the ovary: a case report

Primitive neuroectodermal tumors (PNET) belong to a group of highly malignant tumors comprised of small round cells of neu- roectodermal origin. These tumors can be either of peripheral-type (Ewing family tumors/PNET) or central-type. A number of case re- ports have described PNET involving the gynecologic organs and the prognosis is generally poor. The authors describe the case of a 53-year-old woman with a rapidly progressing central-type PNET of the ovary.

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Self-Assembled Silica Nanostructures: Simultaneous Discrimination of Handedness, Pitch and Diameter of Helical Silica Nanotubes

The left- and right-handed helical silica nanostructures were obtained with the aid of organic templates, the formation of the nanostructures might follow a co-operation self-assembly mechanism. The chirality of the organogel self-assemblies was successfully transcribed in to the silica. The helical pitch and pore size of the silica nanotubes sensitively depended on the optical purity of the neutral gelator in the reaction mixtures.

The interaction of serum testosterone levels and androgen receptor CAG repeat polymorphism on the risk of erectile dysfunction in aging Taiwanese men

Testosterone has been found to play important roles in men's sexual function. However, the effects of testosterone can be modulated by androgen receptor (AR) CAG repeat polymorphism. It could also contribute to the risk of erectile dysfunction (ED). The aim of this study is to evaluate the interaction of serum testosterone levels and AR CAG repeat polymorphism on the risk of ED in aging Taiwanese men. This cross-sectional data of Taiwanese men older than 40 years were collected from a free health screening held between August 2010 and August 2011 in Kaohsiung city, Taiwan. All participants completed a health questionnaires included five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptoms Score, received a detailed physical examination and provided 20 cm3 whole blood samples for biochemical and genetic evaluation. The IIEF-5 was used to evaluate ED. Serum albumin, total testosterone (TT), and sex hormone-binding globulin levels were measured. Free testosterone level was calculated. AR gene CAG repeat polymorphism was determined by direct sequencing. Finally, 478 men with the mean age of 55.7 ± 4.8 years were included. When TT levels were above 330 ng/dL, the effect of testosterone level on erectile function seemed to reach a plateau and a significantly negative correlation between AR CAG repeat length and the score of IIEF-5 was found (r = -0.119, p = 0.034). After adjusting for other covariates, the longer AR CAG repeat length was still an independent risk factor for ED in subjects with TT above 330 ng/dL (p = 0.006), but not in TT of 330 ng/dL or below. In conclusion, both serum testosterone levels and AR CAG repeat polymorphism can influence erectile function concomitantly. In subjects with normal TT concentration, those with longer AR CAG repeat lengths have a higher risk of developing ED.

Ministry of Health Clinical Practice Guidelines: Diabetes Mellitus

The Ministry of Health (MOH) have updated the clinical practice guidelines on Diabetes Mellitus to provide doctors and patients in Singapore with evidence-based treatment for diabetes mellitus. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Diabetes Mellitus, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Lipoprotein lipase variants interact with polyunsaturated fatty acids for obesity traits in women: replication in two populations

BACKGROUND AND AIMS

Lipoprotein lipase (LPL) is a candidate gene for obesity based on its role in triglyceride hydrolysis and the partitioning of fatty acids towards storage or oxidation. Whether dietary fatty acids modify LPL associated obesity risk is unknown.

METHODS AND RESULTS

We examined five single nucleotide polymorphisms (SNPs) (rs320, rs2083637, rs17411031, rs13702, rs2197089) for potential interaction with dietary fatty acids for obesity traits in 1171 participants (333 men and 838 women, aged 45-75 y) of the Boston Puerto Rican Health Study (BPRHS). In women, SNP rs320 interacted with dietary polyunsaturated fatty acids (PUFA) for body mass index (BMI) (P = 0.002) and waist circumference (WC) (P = 0.001) respectively. Higher intake of PUFA was associated with lower BMI and WC in homozygotes of the major allele (TT) (P = 0.01 and 0.005) but not in minor allele carriers (TG and GG). These interactions were replicated in an independent population, African American women of the Atherosclerosis Risk in Communities (ARIC) study (n = 1334).

CONCLUSION

Dietary PUFA modulated the association of LPL rs320 with obesity traits in two independent populations. These interactions may be relevant to the dietary management of obesity, particularly in women.

Phosphorylation of coat protein by protein kinase CK2 regulates cell-to-cell movement of Bamboo mosaic virus through modulating RNA binding

In this study, we investigated the fine regulation of cell-to-cell movement of Bamboo mosaic virus (BaMV). We report that the coat protein (CP) of BaMV is phosphorylated in planta at position serine 241 (S241), in a process involving Nicotiana benthamiana casein kinase 2α (NbCK2α). BaMV CP and NbCK2α colocalize at the plasmodesmata, suggesting that phosphorylation of BaMV may be involved in its movement. S241 was mutated to examine the effects of temporal and spatial dysregulation of phosphorylation on i) the interactions between CP and viral RNA and ii) the regulation of cell-to-cell movement. Replacement of S241 with alanine did not affect RNA binding affinity but moderately impaired cell-to-cell movement. A negative charge at position 241 reduced the ability of CP to bind RNA and severely interfered with cell-to-cell movement. Deletion of residues 240 to 242 increased the affinity of CP to viral RNA and dramatically impaired cell-to-cell movement. A threonine at position 241 changed the binding preference of CP toward genomic RNA and inhibited cell-to-cell movement. Together, these results reveal a fine regulatory mechanism for the cell-to-cell movement of BaMV, which involves the modulation of RNA binding affinity through appropriate phosphorylation of CP by NbCK2α.

NLRP3 inflammasome activation by mitochondrial ROS in bronchial epithelial cells is required for allergic inflammation

Abnormality in mitochondria has been suggested to be associated with development of allergic airway disorders. In this study, to evaluate the relationship between mitochondrial reactive oxygen species (ROS) and NLRP3 inflammasome activation in allergic asthma, we used a newly developed mitochondrial ROS inhibitor, NecroX-5. NecroX-5 reduced the increase of mitochondrial ROS generation in airway inflammatory cells, as well as bronchial epithelial cells, NLRP3 inflammasome activation, the nuclear translocation of nuclear factor-κB, increased expression of various inflammatory mediators and pathophysiological features of allergic asthma in mice. Finally, blockade of IL-1β substantially reduced airway inflammation and hyperresponsiveness in the asthmatic mice. These findings suggest that mitochondrial ROS have a critical role in the pathogenesis of allergic airway inflammation through the modulation of NLRP3 inflammasome activation, providing a novel role of airway epithelial cells expressing NLRP3 inflammasome as an immune responder.

Heterogeneity of mucosal mast cell infiltration in subgroups of patients with esophageal chest pain

BACKGROUND

Although there is growing evidence that an increase in mucosal mast cells (MMCs) in the small and large intestine is associated with visceral hypersensitivity, few studies have evaluated MMCs in humans with esophageal symptoms. The aim of this study was to investigate esophageal MMC distribution in patients with non-cardiac chest pain (NCCP) and to examine the association between the number of gut MMCs and other functional gastrointestinal disorders.

METHODS

Forty-two consecutive NCCP patients and 10 healthy controls completed a questionnaire for bowel symptoms, chest pain intensity score, and psychologic depression. Esophageal, duodenal, and rectal MMCs were identified immunohistochemically and quantified by image analysis.

KEY RESULTS

Numbers of MMCs were significantly higher in NCCP patients vs healthy controls (11.8 ± 5.6 vs 7.6 ± 3.7 MMCs/high-power field, p = 0.026). In comparison of subgroups classified by 24-h impedance-pH monitoring, esophageal MMC counts were highest in the hypersensitive esophagus group (p < 0.01) and were also significantly increased in the functional chest pain group (p < 0.05). A positive correlation between esophageal and duodenal MMC counts was observed in patients with functional dyspepsia (FD; Spearman ρ = 0.604, p = 0.037). In particular, patients with clinical overlap with irritable bowel syndrome showed a strong positive correlation between esophageal and rectal MMC numbers (Spearman ρ = 0.857, p = 0.010).

CONCLUSIONS & INFERENCES

Among NCCP patients, increased MMC infiltration occurs in subgroups with hypersensitive esophagus and functional chest pain. In subpopulations with overlap with FD or irritable bowel syndrome, esophageal MMC counts demonstrated significant positive correlations with duodenal or rectal MMC counts.

Esophageal mucosal mast cell infiltration and changes in segmental smooth muscle contraction in noncardiac chest pain

Mast cells release potent mediators that alter enteric nerve and smooth muscle functions and may contribute to the pathogenesis of functional gastrointestinal disorders. The goal of this study was to determine if mucosal mast cell infiltration was associated with smooth muscle segmental changes in esophageal contraction. All patients with noncardiac chest pain (NCCP) were divided into two groups consisting of patients with non-erosive reflux disease or functional chest pain (FCP) according to the results of ambulatory 24 hours esophageal pH monitoring and high-resolution manometry. Pressure-volume (PV) was calculated by multiplying the length of the esophageal segment, duration of the contraction, and mean pressure over the entire space-time box (P mean). Quantification of mast cells was performed in five consecutive nonoverlapping immunostained sections. Spearman correlation analysis showed that the distal segment PV correlated with the mast cell count in all of the patients combined and in patients with FCP with correlation coefficients of 0.509 and 0.436, respectively (P = 0.004 and P = 0.042). Similar findings were observed for the segmental ratio of distal to proximal smooth muscle PV in all patients and in patients with FCP (correlation coefficients 0.566; P = 0.001 and correlation coefficients 0.525; P = 0.012, respectively). Mucosal mast cell infiltration was associated with distal esophageal contraction as a key pathophysiologic factor of NCCP.

BAX inhibitor-1-associated V-ATPase glycosylation enhances collagen degradation in pulmonary fibrosis

Endoplasmic reticulum (ER) stress is considered one of the pathological mechanisms of idiopathic pulmonary fibrosis (IPF). Therefore, we examined whether an ER stress regulator, Bax inhibitor-1 (BI-1), regulates collagen accumulation, which is both a marker of fibrosis and a pathological mechanism of fibrosis. The presence of BI-1 inhibited the transforming growth factor-β1-induced epithelial-mesenchymal transition of epithelial pulmonary cells and bleomycin-induced pulmonary fibrosis in a mouse model by enhancing collagen degradation, most likely by enhanced activation of the lysosomal V-ATPase through glycosylation. We also found a correlation between post-translational glycosylation of the V-ATPase and its associated chaperone, calnexin, in BI-1-overexpressing cells. BI-1-induced degradation of collagen through lysosomal V-ATPase glycosylation and the involvement of calnexin were confirmed in a bleomycin-induced fibrosis mouse model. These results highlight the regulatory role of BI-1 in IPF and reveal for the first time the role of lysosomal V-ATPase glycosylation in IPF.

Two key arginine residues in the coat protein of Bamboo mosaic virus differentially affect the accumulation of viral genomic and subgenomic RNAs

The interactions between viral RNAs and coat proteins (CPs) are critical for the efficient completion of infection cycles of RNA viruses. However, the specificity of the interactions between CPs and genomic or subgenomic RNAs remains poorly understood. In this study, Bamboo mosaic virus (BaMV) was used to analyse such interactions. Using reversible formaldehyde cross-linking and mass spectrometry, two regions in CP, each containing a basic amino acid (R99 and R227, respectively), were identified to bind directly to the 5' untranslated region of BaMV genomic RNA. Analyses of the alanine mutations of R99 and R227 revealed that the secondary structures of CP were not affected significantly, whereas the accumulation of BaMV genomic, but not subgenomic, RNA was severely decreased at 24 h post-inoculation in the inoculated protoplasts. In the absence of CP, the accumulation levels of genomic and subgenomic RNAs were decreased to 1.1%-1.5% and 33%-40% of that of the wild-type (wt), respectively, in inoculated leaves at 5 days post-inoculation (dpi). In contrast, in the presence of mutant CPs, the genomic RNAs remained about 1% of that of wt, whereas the subgenomic RNAs accumulated to at least 87%, suggesting that CP might increase the accumulation of subgenomic RNAs. The mutations also restricted viral movement and virion formation in Nicotiana benthamiana leaves at 5 dpi. These results demonstrate that R99 and R227 of CP play crucial roles in the accumulation, movement and virion formation of BaMV RNAs, and indicate that genomic and subgenomic RNAs interact differently with BaMV CP.

A Fas-associated via death domain promoter polymorphism (rs10898853, -16C/T) as a risk factor for papillary thyroid cancer

PURPOSE

To determine whether a Fas-associated via death domain (FADD) promoter single-nucleotide polymorphism (SNP) is associated with susceptibility to papillary thyroid cancer (PTC) and clinicopathological features of PTC.

METHODS

To identify a possible association with PTC, 94 patients with PTC and 346 healthy controls were recruited. One promoter SNP (rs10898853, -16C/T) was analyzed by direct sequencing. Multiple logistic regression models (co-dominant, dominant, recessive, and log-additive models) were applied, and odds ratios (ORs), 95% confidence intervals (CIs), and p values were calculated.

RESULTS

The genotype of the promoter SNP (rs10898853) of FADD was found to be significantly associated with PTC in the co-dominant model 2 (T/T vs. C/C; p = 0.002, OR = 2.80, 95% CI = 1.39-5.65), the recessive model (p = 0.003, OR = 2.21, 95% CI = 1.31-3.71), and the log-additive model (p = 0.002, OR = 1.71, 95% CI = 1.20-2.44). Allele frequency analysis showed that the C allele of rs10898853 was significantly associated with an increased risk of PTC (p = 0.002, OR = 1.67, 95% CI = 1.21-2.32).

CONCLUSIONS

Our results suggest that the FADD promoter polymorphism is associated with susceptibility to PTC.

Routine computerised tomography in patients with acute supraglottitis for the diagnosis of epiglottic abscess: is it necessary?--a prospective, multicentre study

OBJECTIVES

To evaluate the predictive factor of epiglottic abscess and to investigate whether routine computerised tomography (CT) in patients with acute supraglottitis are necessary.

DESIGN

A prospective and multicentre study.

SETTINGS

Tertiary care referral medical centre.

PARTICIPANTS

A total of 202 patients with suspected acute supraglottitis were enrolled. All patients underwent CT to confirm the presence of abscess.

MAIN OUTCOME MEASURES

The patients' characteristics, symptoms at presentation, laryngoscopic findings of epiglottic swelling and arytenoid swelling by scope classification and initial laboratory finding were analysed.

RESULTS

Of 202 patients, 158 (78%) had acute supraglottitis and 44 (22%) had epiglottic abscess. There was no significant difference in age between the acute supraglottitis group and the epiglottic abscess group. Men were significantly more frequent in the epiglottic abscess group than females (P = 0.042). When comparing the symptom at presentation, the patients with epiglottic abscess complained of voice change more frequently (P = 0.003). Moderate or severe epiglottic swelling in scope classification was significantly associated with epiglottic abscess (P < 0.001). In logistic regression analysis, voice change [OR = 2.64, 95% CI = 1.29-5.40, P = 0.008] and moderate or severe epiglottic swelling in laryngoscopic findings [OR = 3.94, 95% CI = 1.63-9.53, P = 0.002] were independent predictive factors for epiglottic abscess. The positive predictive values of voice change and moderate or severe epiglottic swelling were 33% and 30%, respectively. The negative predictive values of voice change and moderate or severe epiglottic swelling were 15% and 9%, respectively.

CONCLUSIONS

Routine CT might be suggested for diagnosis of epiglottic abscess in the patients with acute supraglottitis, because of the poor predictive values of symptoms and signs.

The effects of statins on the clinical outcomes of Clostridium difficile infection in hospitalised patients

BACKGROUND

An association between exposure to statin drugs and favourable treatment outcomes for various types of infections has been established.

AIM

To determine the clinical characteristics and treatment outcomes of Clostridium difficile infection (CDI) among hospitalised patients taking statin drugs.

METHODS

The medical records were reviewed for consecutive in-patients with CDI confirmed by positive toxin assay (A or B), C. difficile culture, or the presence of pseudomembrane on endoscopy. Treatment success was defined as the resolution of diarrhoea within 6 days of therapy. The primary end points were assessed by average symptom recovery time and treatment response (success or failure).

RESULTS

Among 949 patients, the overall response to metronidazole was 91.9%. The baseline characteristics showed some differences between statin users and statin non-users with respect to mean disease severity score. In the multivariate analysis, successful treatment response was significantly associated with the absence of exposure to proton pump inhibitors (PPIs) (OR = 0.690, 95% CI = 0.513-0.929, P = 0.014) and with exposure to statins (OR = 1.449, 95% CI = 1.015-2.070, P = 0.041). Contrary to the treatment response, univariate and multivariate analyses failed to show that exposure to PPIs or statins affected symptom recovery times. Sixty-day CDI recurrence rates for those patients with statin exposure were significantly lower compared with those patients without statin exposure (3% vs. 7.3%, respectively; RR = 0.393, 95% CI = 0.167-0.926, P = 0.033).

CONCLUSION

Prior statin exposure in patients with C. difficile infection is associated with a successful response to treatment.

Interleukin 22 polymorphisms and papillary thyroid cancer

BACKGROUND

IL22RA1 (Interleukin 22 receptor-alpha 1), a member of the class II cytokine receptor family, mediates diverse biologic activities and appears to be important in pathogen defense, wound healing, and tissue reorganization. Polymorphisms in genes encoding inflammatory cytokines are associated with increased cancer risk.

AIM

The aim of this study was to evaluate the association between the single nucleotide polymorphisms (SNP) in the IL22 and IL22RA1 and papillary thyroid cancer (PTC), and to assess the relationship between the SNP in the IL22 and IL22RA1 and the clinical parameters of PTC.

MATERIAL AND METHODS

Study enrolled experimental group of 94 PTC patients and 213 controls. PTC patients were grouped and compared for clinical PTC parameters. One promoter SNP of IL22, -429C/T (rs2227485), and one SNP of IL22RA1, Arg518Gly (rs3795299) were analyzed using direct sequencing. Genetic data were analyzed using Helixtree, SNPAnalyzer Pro, SNPStats, and Haploview.

RESULTS

A SNP in IL22 (rs2227485) was significantly associated with PTC (codominant2 model [C/C vs T/T], odds ratio (OR) 2.39, 95% confidence interval (CI) 1.21-4.71, p=0.012; dominant model, OR 1.89, 95% CI 1.08-3.31, p=0.022). The allele T frequency of rs2227485 in IL22 was also associated with PTC (OR 1.59, 95% CI 1.13-2.25, p=0.009). According to clinical parameters, rs2227485 of IL22 was associated with number of cancers (dominant model, OR 3.03, 95% CI 1.02-9.01, p=0.035). By haplotype analysis, TG was associated with PTC (codominant model, OR 1.52, 95% CI 1.07-2.16, p=0.019; dominant model, OR 1.91, 95% CI 1.13- 3.24, p=0.015). Genotype and allele analysis of rs3795299 in IL22RA1 showed no significant differences between PTC patients and controls.

CONCLUSION

The rs2227485 SNP in IL22 might be associated with the risk and the multifocality of PTC.

Outcomes associated with concordance of oral antidiabetic drug treatments to prescribing information in patients with type 2 diabetes mellitus and chronic kidney disease

OBJECTIVES

This retrospective study aims to examine the association between prescribing information (PI)-concordant oral antidiabetic drug (OAD) treatment and clinical and economic outcomes in patients with type 2 diabetes mellitus and stages 3-5 chronic kidney disease (CKD).

METHODS

The study used a large, national administrative claims database with laboratory findings to identify patients with a diagnosis of diabetes and indication of stages 3-5 CKD (first observed indication as the index date) between 1/1/2005 and 30/06/2009. OADs prescribed during 6 months following the index date (baseline period) were evaluated and patients were considered non-PI-concordant if any did not meet the recommendations regarding patients with renal impairment. Glycemic control and measures of healthcare costs (standardized to 2010 US dollars using the Consumer Price Index) and resource utilization were assessed during the 12 months following the baseline period. Severe hypoglycemic events were assessed after the baseline period until lost to follow-up. Regression analyses were performed after adjusting for demographic and clinical characteristics.

RESULTS

Among the 3300 patients included in the study, 2454 (74.4%) were non-PI-concordant. The non-PI-concordant patients had higher risk of severe hypoglycemic events identified in all settings (HR = 1.35, 95% CI: 1.10-1.67) and events identified in inpatient hospital setting (HR = 2.51, 95% CI: 1.49-4.22), were more likely to have inpatient hospital admissions (OR = 1.27, 95% CI: 1.02-1.57), and were less likely to have glycemic control (OR = 0.56, 95% CI: 0.44-0.71). Annual diabetes-related cost was $1638 higher in the non-PI-concordant cohort (p = 0.0048).

LIMITATION

The retrospective cohort design does not allow for conclusions to be drawn on the causal effect of PI-concordant use based on the associations observed.

CONCLUSION

Our findings suggest PI-concordant treatment to be associated with better clinical and diabetes-associated economic outcomes. Future research is warranted to confirm the associations found in this study.

Longitudinal patterns of analgesic and central acting drug use and associated effectiveness in fibromyalgia

BACKGROUND

We describe the changing pattern of analgesic and new central acting drug (NCAD) use (pregabalin, duloxetine, milnacipran) in fibromyalgia and measure NCAD effectiveness in clinical practice.

METHODS

About 3123 US adult patients with fibromyalgia participated in an 11-year longitudinal study of fibromyalgia outcomes. We assessed severity-adjusted treatment prevalence and measured the effect of any use of NCAD on pain and fatigue, and functional status using the Health Assessment Questionnaire (HAQ) disability index.

RESULTS

In 2010, 46.7% of patients used opioids, including 12.5% who used strong opioids. During the 11 years, severity-adjusted strong opioid use increased from 6.3% to 11.7% and any opioid use from 40.0% to 46.6%. Nonsteroidal anti-inflammatory drug (NSAID) use decreased from 74% to 44%. Tricyclic use dropped in half, from 27% to 15%, while NCAD use increased from less than 10% to 39%. The estimated 25th and 50th percentiles for NCAD discontinuation time were 1 and 2.5 years. Overall pain, fatigue and HAQ scores were unchanged over the 11 years. For patients treated with NCAD, pain scores were reduced significantly by 0.17 (0.03, 0.30) units following the start of NCAD, an improvement of 2.8%. Some sensitivity analyses showed improvements of up to 4.3%. There was no significant improvement in fatigue or functional status.

CONCLUSIONS

There is a changing pattern of drug treatment in fibromyalgia, consisting mostly of decreased NSAID and amitriptyline use and an increase in NCAD. Drug costs are substantially higher because of NCAD use, but we found no evidence of clinical benefit for NCAD compared with prior therapy.