Identifying Common Topics in Patient Portal Messages with Unsupervised Natural Language Processing

PURPOSE/OBJECTIVE(S)

Patient portal messaging is an increasingly important form of communication between patients and medical providers. This has become particularly relevant in oncology, where patients undergo intense longitudinal treatments that require frequent communication regarding symptoms, appointments, and diagnostic results. The rise in the volume of these messages has significantly increased the workload of medical providers and consequent physician burn-out. Natural language processing (NLP), particularly transformer-based models, may offer an automated approach to characterize the content of patient messages and improve message triage and routing. In this study, we employed a state-of-the-art language model (Bidirectional Encoder Representations from Transformers; BERT) to identify data-derived categories of representative topics from real-world data thereby providing basic information to build an appropriate routing system.

MATERIALS/METHODS

Patient-generated portal messages sent to a messaging pool for a single institution radiation oncology department from 2014 to 2023 were extracted. BERTopic, an NLP-based topic modeling technique based on BERT was optimized for topic modeling of patient messages. Uniform Manifold Approximation and Projection (UMAP) was used to reduce dimensionality and visualize topic relationships across messages. The BERTopic-identified topic categories were subsequently labeled manually by one of the physician investigators. Differences of number of messages over time were assessed using t-tests.

RESULTS

A total of 47,492 messages were retrieved. The average number of messages per month from a single patient ranged from 1 to 18 (median 1.67, interquartile range 1.0-2.4). The total volume of patient messages showed a ten-fold increase over the study period, with 101 messages per month sent in 2014 and 999 messages per month in 2022 (p<0.001). BERTopic initially identified 35 topics whose relationships and degrees of overlap were visualized by UMAP. Due to physician-identified similarities, these topics were reduced into 13 categories. The most frequent topic category was messages about laboratory tests or imaging studies: 24.3%, followed by messages expressing appreciation: 18.9%, scheduling discussions: 15.6%, symptom-related messages: 11%, and treatment-related messages: 10.7%.

CONCLUSION

Patient portal messages sent to a single institution radiation oncology department have increased dramatically in volume since implementation, corresponding to a broader national trend. NLP successfully identified common subject themes across patient messages, many of which are related to scheduling. This presents potential opportunities to apply NLP to automate message routing in the future.

Immediate Breast Reconstruction Using the Autologous Dermal Flap

INTRODUCTION

Despite the development of breast-conserving surgery in breast cancer treatment, there still remain indications for total mastectomy. Since mastectomy has a significant negative impact on the patients' quality of life, breast reconstruction is increasingly popular. However, for patients with large ptotic breasts who do not choose tissue-based reconstruction techniques and prefer implant-based breast reconstruction, there is no single-stage breast reconstruction technique other than the classic technique using Acellular Dermal Matrix (ADM).

METHODS

This study presents a novel technique for Nipple-Sparing Mastectomy (NSM) and Immediate Breast reconstruction (IBR) in 11 operations (in seven patients) whose treatment decision-making was based on NCCN guidelines. In this technique, the implant/tissue expander is covered by the pectoral muscle in the upper part and an autologous dermal flap in the lower part, replacing an ADM. The dermal flap is created from the de-epithelialized lower mastectomy flap in these large ptotic breasts. Maintaining the nipple-areola complex (NAC) is possible by re-implanting a free nipple split-thickness graft from the NAC of the ipsilateral breast prepared at the beginning of the operation.

RESULTS

All seven patients had large ptotic breasts ranging from C cup to double D in size and grade 2 and higher breast ptosis. The mean BMI of the patients was 28 (range: 26-33). No major complications occurred postoperatively. There were three minor complications, all managed conservatively. Surgical indications were risk reduction surgery in three patients with BRCA mutations and therapeutic in the remaining patients (three multifocal invasive ductal carcinomas and one diffused ductal carcinoma in situ). None of the patients had a previous reduction mammoplasty as preparation for NSM, and all the patients underwent a single operation. No breast tissue remained under the NAC, which is ideal with the NSM technique.

CONCLUSIONS

The proposed technique is excellent for implant-based IBR in patients with large ptotic breasts. It eliminates the use of ADM mesh and reduces the cost and postoperative complication rate associated with ADM. Furthermore, using a free nipple graft technique can eliminate the need for a preparatory mastopexy. This technique can also theoretically reduce the risk of recurrence or new primary breast cancer as there are no remaining ducts beneath the nipple-areola complex.

Prototypic P2X7 Receptor Agonist, BzATP, Induced the Expression of Unfolded Protein Response Genes in Human M1 Macrophages

Purinergic receptors stimulation by adenosine triphosphate (ATP) contributes significantly to macrophage activation, and also macrophage cell death. Upon the macrophage activation, the protein load of the endoplasmic reticulum is increased which is resulted in the activation of unfolded protein response (UPR). In the current study, we aimed to evaluate the connection between prototypic P2X7 receptor agonist, extracellular 2'(3')-O-(4-Benzoylbenzoyl)-ATP (BzATP), and the UPR pathway in macrophages. The monocyte-derived macrophages from blood samples of 14 healthy volunteers were skewed toward M1 macrophages after incubation with LPS and IFN-γ. M1 macrophages were treated with 200 µM BzATP. The expression levels of UPR genes, including CHOP, HERP, GADD34, XBP1, and ATF6 in macrophages before and after treatment were measured using real-time polymerase chain reaction. The results demonstrated that the expression of CHOP, HERP, and ATF6 is significantly decreased and the expression level of GADD34 and XBP1 is significantly increased after M1 polarization. BzATP not only significantly increased the expression levels of CHOP, GADD34, ATF6, and HERP but also significantly decreases the XBP1 expression level in M1 macrophages. The present study showed that BzATP induces cellular stress in M1 macrophages by elevating the expression levels of UPR genes including CHOP, GADD34, ATF6, and reducing cell viability.

The Transition of Mild Cognitive Impairment Over Time: An AV45- and FDG-PET Study of Reversion and Conversion Phenomena

BACKGROUND

Mild cognitive impairment (MCI) is a state between normal cognition and dementia. However, MCI diagnosis does not necessarily guarantee the progression to dementia. Since no previous study investigated brain positron emission tomography (PET) imaging of MCI-- to-normal reversion, we provided PET imaging of MCI-to-normal reversion using the Alzheimer's Disease Neuroimaging Initiative (ADNI) database.

METHODS

We applied comprehensive neuropsychological criteria (NP criteria), consisting of mem- ory, language, and attention/executive function domains, to include patients with a baseline diagno- sis of MCI (n=613). According to the criteria, the year 1 status of the patients was categorized into three groups (reversion: n=105, stable MCI: n=422, conversion: n=86). Demographic, neuropsycho- logical, genetic, CSF, and cognition biomarker variables were compared between the groups. Addi- tionally, after adjustment for confounding variables, the deposition pattern of amyloid-β and cere- bral glucose metabolism were compared between three groups via AV45- and FDG-PET modali- ties, respectively.

RESULTS

MCI reversion rate was 17.1% during one year of follow-up. The reversion group had the lowest frequency of APOE ε4+ subjects, the highest CSF level of amyloid-β, and the lowest CSF levels of t-tau and p-tau. Neuropsychological assessments were also suggestive of better cognitive performance in the reversion group. Patients with reversion to normal state had higher glucose metabolism in bilateral angular and left middle/inferior temporal gyri, when compared to those with stable MCI state. Meanwhile, lower amyloid-β deposition at baseline was observed in the fron- tal and parietal regions of the reverted subjects. On the other hand, the conversion group showed lower cerebral glucose metabolism in bilateral angular and bilateral middle/inferior temporal gyri compared to the stable MCI group, whereas the amyloid-β accumulation was similar between the groups.

CONCLUSIONS

This longitudinal study provides novel insight regarding the application of PET imag- ing in predicting MCI transition over time.

White matter changes in drug-naïve Parkinson's disease patients with impulse control & probable REM sleep behavior disorders

BACKGROUND

According to epidemiological studies, Parkinson's disease (PD) patients with probable REM sleep behavior disorder (pRBD) are more prone to develop impulse control disorders (ICDs), which is shown to be present in drug-naïve PD patients, and vice versa.

OBJECTIVES

To investigate white-matter integrity differences, with and without comorbid pRBD and ICDs.

METHODS

149 de-novo PD patients and 30 age- and gender-matched controls from the Parkinson's Progression Markers Initiative were studied. PD subjects were categorized into four groups with and without these comorbidities. We investigated the white matter integrity differences between these groups.

RESULTS

PDs with only ICDs manifested greater fractional anisotropy (FA) and lower mean diffusivity (MD) in ipsilateral cerebellar connections when compared to controls and to Parkinson's with both comorbid disorders. In contrast, significantly lower FA and higher MD in the ipsilateral fornix-stria-terminalis was observed in PDs with only pRBD compared to controls and to PDs without either comorbid disorder. Also, PDs with only pRBD manifested greater FA in contralateral putamen when compared to controls.

CONCLUSIONS

Our results suggest the presence of an underlying neural network in PDs with ICDs, particularly involving cerebellar connections, which makes the subjects susceptible to pRBD. Lower white-matter integrity in the fornix of PDs with only pRBD suggests a neuropathological pathway specific to sleep behavior disorder, independent of impulse control disorders. Greater white-matter integrity observed in PDs without comorbid ICDs, regardless of their comorbid pRBD status, might reflect compensatory mechanisms. Targeted therapies for this particular neuropathology may help prevent these comorbidities.

Use of multidimensional item response theory methods for dementia prevalence prediction: an example using the Health and Retirement Survey and the Aging, Demographics, and Memory Study

BACKGROUND

Data sparsity is a major limitation to estimating national and global dementia burden. Surveys with full diagnostic evaluations of dementia prevalence are prohibitively resource-intensive in many settings. However, validation samples from nationally representative surveys allow for the development of algorithms for the prediction of dementia prevalence nationally.

METHODS

Using cognitive testing data and data on functional limitations from Wave A (2001-2003) of the ADAMS study (n = 744) and the 2000 wave of the HRS study (n = 6358) we estimated a two-dimensional item response theory model to calculate cognition and function scores for all individuals over 70. Based on diagnostic information from the formal clinical adjudication in ADAMS, we fit a logistic regression model for the classification of dementia status using cognition and function scores and applied this algorithm to the full HRS sample to calculate dementia prevalence by age and sex.

RESULTS

Our algorithm had a cross-validated predictive accuracy of 88% (86-90), and an area under the curve of 0.97 (0.97-0.98) in ADAMS. Prevalence was higher in females than males and increased over age, with a prevalence of 4% (3-4) in individuals 70-79, 11% (9-12) in individuals 80-89 years old, and 28% (22-35) in those 90 and older.

CONCLUSIONS

Our model had similar or better accuracy as compared to previously reviewed algorithms for the prediction of dementia prevalence in HRS, while utilizing more flexible methods. These methods could be more easily generalized and utilized to estimate dementia prevalence in other national surveys.

Efficacy and safety of sulforaphane for treatment of mild to moderate depression in patients with history of cardiac interventions: A randomized, double-blind, placebo-controlled clinical trial

AIM

Depression has been recognized as one of the disorders associated with cardiac interventions such as percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In the present study, we evaluated the efficacy and safety of sulforaphane in treatment of depression induced by cardiac interventions.

METHODS

After initial screening, 66 patients with previous history of at least one cardiac intervention and current mild to moderate depression were randomly assigned to two parallel groups receiving either sulforaphane (n = 33) or placebo (n = 33) for six successive weeks. Efficacy was assessed using the Hamilton Rating Scale for Depression (HAM-D) at baseline and week 2, 4, and 6. Safety of the treatments was checked during the trial period.

RESULTS

Sixty participants completed the clinical trial (n = 30 in each group). Baseline demographic and clinical parameters were all similar among groups. Repeated measures analysis indicated that the sulforaphane group exhibited greater improvement in HAM-D scores throughout the trial (P < 0.001). Response to treatment (≥50% reduction in the HAM-D score) rate was higher in the sulforaphane group at trial endpoint (30% vs 6.67%, P = 0.042). Remission (HAM-D score ≤ 7) rate was also higher in the sulforaphane group; however, the difference was not significant (23.33% vs 3.33%, P = 0.052). Finally, no significant difference was observed between the two groups in terms of frequency of side effects.

CONCLUSIONS

Sulforaphane could safely improve depressive symptoms induced by cardiac interventions. Further clinical trials with larger sample sizes and longer follow-up periods are warranted to confirm our results.

Melatonin improves learning and memory of mice with chronic social isolation stress via an interaction between microglia polarization and BDNF/TrkB/CREB signaling pathway

Chronic social isolation stress (SIS) could impair learning and memory-related behaviors. Herein, we investigated the efficacy of Melatonin in treatment of memory despair and also its possible underlying mechanism of action in an animal model of SIS. For this purpose, mice were allocated to two opposing conditions, including social condition (SC) and isolated condition (IC), for five weeks. The study consisted of three groups, including saline-treated SC, saline-treated IC, Melatonin-treated IC (10 mg/kg/day for five successive days). At the end of the isolation period, mice underwent three neurobehavioral tests: passive avoidance (PA), Morris water maze (MWM), and Y maze (YM) tests. Hippocampus samples were obtained and the expressions of BDNF, TrkB, phosphorylated TrkB (pTrkB), CREB, phosphorylated CREB (pCREB), as well as M1 and M2 microglia were assessed. Interpreting the behavioral tests, we found that isolated mice showed lower freezing response in the PA test, lower number of novel arm visits in the YM, and higher escape latency and less time spent in the target quadrant in the MWM, when compared to SC rodents (P values < 0.001). The isolated group had higher M1/M2 relative ratio (P < 0.001), as well as lower concentrations of BDNF mRNA (p < 0.001) and protein (P < 0.001), TrkB protein (P = 0.035), CREB mRNA (P < 0.001) and protein (P = 0.012), pTrkB (P < 0.001), and pCREB (P = 0.035). However, Melatonin relatively reversed the behavioral, cellular, and molecular effects of SIS. Taken together, melatonin therapy could alleviate memory impairment through switching microglial polarization from M1 to M2 phenotype along with altered expression and function in the BDNF/TrkB/CREB signaling pathway.

Does Pregnenolone Adjunct to Risperidone Ameliorate Irritable Behavior in Adolescents With Autism Spectrum Disorder: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial?

OBJECTIVES

Pregnenolone is a neurosteroid with modulatory effects on γ-aminobutyric acid neurotransmission. Here, we aimed to evaluate the effectiveness and safety of pregnenolone add-on to risperidone in adolescents with autism spectrum disorders (ASD).

METHODS

Sixty-four ASD patients were randomly allocated to receive either pregnenolone (n = 32) or matching placebo (n = 32) in addition to risperidone. The Aberrant Behavior Checklist-Community Edition scale was used to evaluate the behavioral status of patients at baseline, week 5, and the trial end point. The change in score of irritability subscale was the primary outcome. Frequency of adverse effects due to trial medications was compared between the treatment groups.

RESULTS

Fifty-nine patients completed the trial (30 in pregnenolone and 29 in the placebo arm). Baseline characteristics of both treatment groups were similar (P > 0.05). Repeated measures analysis was suggestive of greater exhibited improvement for the pregnenolone group on irritability, stereotypy, and hyperactivity subscales of the Aberrant Behavior Checklist-Community Edition over the trial period (F = 3.84, df = 1.96, P = 0.025; F = 4.29, df = 1.39, P = 0.029; F = 6.55, df = 1.67, P = 0.004, respectively). Nonetheless, the alterations in lethargy and inappropriate speech domains scores were similar for both arms (F = 0.93, df = 1.49, P = 0.375; F = 1.10, df = 1.60, P = 0.325, respectively). There was no significant difference in frequency as well as severity of adverse effects between the 2 groups.

CONCLUSIONS

Pregnenolone adjunct to risperidone could attenuate core features associated with ASD.

Resveratrol adjunct to methylphenidate improves symptoms of attention-deficit/hyperactivity disorder: a randomized, double-blinded, placebo-controlled clinical trial

Current pharmacological approaches have failed to provide complete remission for patients with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aimed to evaluate the efficacy and tolerability of resveratrol (that have been shown to have antioxidative, anti-inflammatory, and anti-apoptotic effects) as an adjunct to methylphenidate in pharmacologic treatment of ADHD. This 8-week, double-blinded, placebo-controlled trial randomized 66 participants to receive either 500 mg/day resveratrol or matched placebo in addition to methylphenidate. ADHD symptoms were evaluated in the patients using the Parent and Teacher versions of ADHD-Rating Scale (ADHD-RS) at three measurement points with time intervals of 4 weeks. Furthermore, the tolerability of the treatment strategies was systematically compared. Repeated measures analysis demonstrated a significant effect for time-treatment interaction on all three subscales of the Parent ADHD-RS during the trial period (total: p = 0.015; inattention: p = 0.032; hyperactivity/impulsivity: p = 0.036). Nevertheless, the effect for time-treatment interaction was not significant for the Teacher version of ADHD-RS (total: F = 0.81, df = 1.33, p = 0.401; inattention: F = 0.57, df = 1.37, p = 0.507; hyperactivity/impulsivity: F = 0.65, df = 1.34, p = 0.466). The frequencies of complications in the treatment groups were similar. Resveratrol administration for a duration of 8 weeks improved characteristic symptoms in patients with ADHD according to their parents. Further investigations containing larger sample sizes, longer supplementation periods, and dose-response evaluations are required to replicate these findings in ADHD children more confidently.

Biological Features of Reversion from Mild Cognitive Impairment to Normal Cognition: A Study of Cerebrospinal Fluid Markers and Brain Volume

BACKGROUND

Mild cognitive impairment (MCI) is a transitional condition between normal cognition and dementia. Although a significant proportion of the population with MCI experience reversion to normal cognition, it is still poorly understood.

OBJECTIVE

This study was designed to extend the present evidence regarding the difference between stable and reverting MCI by including whole brain atrophy measures as possible parameters involved.

METHODS

405 patients diagnosed with MCI at baseline were selected. After one-year follow-up period, 337 patients (83.2%) were categorized as stable MCI and 68 patients (16.8%) reverted to cognitively normal status (reversion group). Several baseline biomarkers including cerebrospinal fluid (CSF) biomarkers of AD, including Aβ42, t-tau, and p-tau and MRI-based atrophy measurements were compared.

RESULTS

Participants with stable MCI demonstrated greater brain atrophy as well as lower Aβ and higher tau proteins in the CSF. The atrophy rate was found to be associated with CSF biomarkers merely in the stable group, after adjustment for confounding variables.

CONCLUSION

These findings provide novel evidence regarding the biological perspective of the reversion phenomenon in individuals with MCI.

The interplay between gut microbiota and autism spectrum disorders: A focus on immunological pathways

Autism spectrum disorders (ASD) are a group of neurodevelopmental disorders characterized by impairments in social and cognitive activities, stereotypical and repetitive behaviors and restricted areas of interest. A remarkable proportion of ASD patients represent immune dysregulation as well as gastrointestinal complications. Hence, a novel concept has recently emerged, addressing the possible intercommunication between the brain, the immune system, the gut and its commensals. Here, we provide an overview of how gut microbes and their metabolites are associated with neurobehavioral features of ASD through various immunologic mechanisms. Moreover, we discuss the potential therapeutic options that could modify these features.

The Association Between REM Sleep Behavior Disorder and Autonomic Dysfunction in Parkinson's Disease

BACKGROUND

REM behavior disorder (RBD) can occur in the context of neurodegenerative alpha-synucleinopathies, such as Parkinson's disease (PD). PD patients with RBD (PD-pRBD) represent more severe symptoms and signs compared with those without RBD (PD-nRBD). On another note, autonomic dysfunction in PD patients is categorized as one of the most prominent non-motor symptoms and has been lately the field of interest in research.

OBJECTIVE

In the current study, we longitudinally studied autonomic dysfunction in PD-pRBD and PD-nRBD groups.

METHOD

This study was conducted on 420 drug-naïve PD patients selected from the Parkinson's Progression Markers Initiative database. The RBD Screening Questionnaire was used to define the presence of probable RBD. SCOPA-AUT was used to assess autonomic dysfunction. Additionally, dopamine transporter deficits on [123I] FP-CIT SPECT imaging was performed for all of the patients.

RESULTS

Out of 420 PD patients, 158 individuals (37.6%) were considered to have probable RBD (PD-pRBD) and others without RBD (PD-nRBD). Except for pupillomotor function, all the autonomic symptoms were significantly more severe in PD-pRBD group. In PD-nRBD group, caudate striatal binding ratio was negatively correlated with SCOPA-AUT scores, while no significant correlation was observed in PD-pRBD group. Finally, there was a significant difference considering the longitudinal changes of SCOPA-AUT total between PD-pRBD and PD-nRBD groups, suggesting a more severe autonomic decline in PD-pRBD patients.

CONCLUSION

Our results indicate that PD-pRBD patients have more severe autonomic dysfunction. These results support the theory that PD patients can be categorized based on the clinical presentation, possibly representing differences in the disease pathophysiology.

Resveratrol Adjunct Therapy for Negative Symptoms in Patients With Stable Schizophrenia: A Double-Blind, Randomized Placebo-Controlled Trial

BACKGROUND

Patients with schizophrenia can generally manifest a broad variety of primary negative symptoms. The current study aimed to assess the efficacy and tolerability of resveratrol add-on therapy in the treatment of negative symptoms in patients with stable schizophrenia.

METHODS

In a randomized, double-blind, and placebo-controlled setting, schizophrenia patients were assigned to receive either 200 mg/d resveratrol or matched placebo in addition to a stable dose of risperidone for 8 weeks. Patients were assessed using the positive and negative syndrome scale, the extrapyramidal symptom rating scale, and Hamilton Depression Rating Scale over the trial period. The primary outcome was considered as the change in positive and negative subscale score from baseline to week 8 between the treatment arms.

RESULTS

A total 52 patients completed the trial (26 in each arm). Baseline characteristics of both groups were statistically similar (P  > .05). Despite the statistically similar behavior of positive symptoms between the groups across time (Greenhouse-Geisser corrected: F = 1.76, df = 1.88, P = .180), the resveratrol group demonstrated greater improvement in negative, general psychopathology, and total scores (Greenhouse-Geisser corrected: F = 12.25, df = 2.04, P < .001; F = 5.42, df = 1.56, P = .011; F = 7.64, df = 1.48, P = .003). HDRS scores and its changes, ESRS score, and frequency of other complications were not significantly different between resveratrol and placebo groups.

CONCLUSION

Adding resveratrol to risperidone can exhibit remarkable efficacy and safety in terms of management of schizophrenia-related negative symptoms.

Application of muscle ultrasound for the evaluation of patients with amyotrophic lateral sclerosis: An observational cross-sectional study

INTRODUCTION

We evaluated the association between muscle ultrasound, number of motor units, and clinical parameters, and assessed their utility for distinguishing amyotrophic lateral scleorisis (ALS) patients from healthy individuals.

METHODS

Three muscle pairs (abductor pollicis brevis, abductor digiti minimi, and tibialis anterior) of 18 ALS patients and 18 controls underwent muscle ultrasound (echointensity and thickness) and assessment of motor unit number index (MUNIX). The clinical and functional status of participants were also assessed.

RESULTS

Mean age of the patients was 53.8 ± 12.1 years, and score on the ALS Functional Rating Scale-Revised was 38.9 ± 4.1. Echointensity of all tested muscles of ALS participants was significantly higher than that of controls, but there was no significant difference in muscle thickness. Muscle echointensity correlated significantly with clinical and electrophysiological parameters.

CONCLUSION

Echointensity of muscles was highly associated with clinical scales and MUNIX, confirming its relevance as an ancillary diagnostic test in ALS patients.

Inhibition of phosphodiesterase IV enzyme improves locomotor and sensory complications of spinal cord injury via altering microglial activity: Introduction of Roflumilast as an alternative therapy

Despite the great search for an effective approach to minimize secondary injury in spinal cord injury (SCI) setting, there have been limited advances. Roflumilast is a selective inhibitor of phosphodiesterase 4 with potent anti-inflammatory properties. Here, we sought to explore Roflumilast efficacy in the improvement of locomotor and sensory deficits of SCI. In an animal setting, 50 male rats were randomly assigned to five groups: an SCI group receiving Placebo, three SCI groups receiving Roflumilast at the doses of 0.25, 0.5, and 1 mg/kg prior to T9 vertebra laminectomy, and a sham-operated group. Locomotor, mechanical, and thermal activities were evaluated for 28 days. At the end of the study, spinal cord samples were taken to assess the relative ratio of microglial subtypes, including M1 and M2, histopathological changes, levels of pro-inflammatory (TNF-α and IL-1β) and anti-inflammatory (IL-10) biomarkers, and cAMP level. Repeated measure analysis revealed significant effect for time-treatment interaction on locomotion [F (24, 270) = 280.7, p < 0.001], thermal sensitivity [F (16, 180) = 4.35, p < 0.001], and mechanical sensitivity [F (16, 180) = 7.96, p < 0.001]. As expected, Roflumilast significantly increased the expression of spinal cAMP. H&E staining exhibited lesser histopathological disruptions in Roflumilast-treated rodents. We also observed a significant reduction in the M1/M2 ratio (p values < 0.001) as well as in pro-inflammatory biomarkers following the administration of Roflumilast to the injured rats. Furthermore, IL-10 level was increased in rodents receiving 1 mg/kg of the reagent. In conclusion, the increased spinal cAMP following Roflumilast therapy might attenuate neuroinflammation via altering microglial activity; therefore, it could be considered as an alternative therapeutic agent for SCI complications.

ERAP1 polymorphisms interactions and their association with Behçet's disease susceptibly: Application of Model-Based Multifactor Dimension Reduction Algorithm (MB-MDR)

BACKGROUND

Behçet's disease (BD) is a chronic multi-systemic vasculitis with a considerable prevalence in Asian countries. There are many genes associated with a higher risk of developing BD, one of which is endoplasmic reticulum aminopeptidase-1 (ERAP1). In this study, we aimed to investigate the interactions of ERAP1 single nucleotide polymorphisms (SNPs) using a novel data mining method called Model-based multifactor dimensionality reduction (MB-MDR).

METHODS

We have included 748 BD patients and 776 healthy controls. A peripheral blood sample was collected, and eleven SNPs were assessed. Furthermore, we have applied the MB-MDR method to evaluate the interactions of ERAP1 gene polymorphisms.

RESULTS

The TT genotype of rs1065407 had a synergistic effect on BD susceptibility, considering the significant main effect. In the second order of interactions, CC genotype of rs2287987 and GG genotype of rs1065407 had the most prominent synergistic effect (β = 12.74). The mentioned genotypes also had significant interactions with CC genotype of rs26653 and TT genotype of rs30187 in the third-order (β = 12.74 and β = 12.73, respectively).

CONCLUSION

To the best of our knowledge, this is the first study investigating the interaction of a particular gene's SNPs in BD patients by applying a novel data mining method. However, future studies investigating the interactions of various genes could clarify this issue.

Activation of adenosine A2A receptor induced interleukin-23 mRNA expression in macrophages of ankylosing spondylitis patients

BACKGROUND

Ankylosing spondylitis (AS) is an auto-inflammatory debilitating disorder with a complex pathogenesis. The adenosinergic pathway is an immunologic regulating pathway with a potential role in AS pathophysiology. In the present study, we have aimed to investigate the influence of A_2A adenosine receptor (A_2AAR) activation on tumor necrosis factor-α (TNF-α) and interleukin-23 (IL-23) expression and secretion by monocyte-generated macrophages of AS patients.

METHODS

Whole-blood separated monocytes were extracted from 14 AS patients and 14 healthy controls. Macrophages were differentiated by macrophage colony-stimulating factor (M-CSF), and surface markers were confirmed by flow cytometer. Cells were treated with CGS-21680 as a known agonist of A_2AAR. Analysis of ADORA2A, TNFA, and IL23A gene expression was performed by SYBR green real-time PCR. The concentration of secreted cytokines was also measured by ELISA kits.

RESULTS

Based on our analysis, CGS-21680 significantly decreased TNF-α secretion by monocyte-derived macrophages of AS patients. Moreover, A_2AAR agonist increased the IL23A mRNA expression level in monocyte-derived macrophages of AS patients considerably. Whereas, CGS-21680 did not have any influence on macrophages of healthy individuals.

CONCLUSION

According to our results, it appears that A_2AAR activation can increase IL-23 secretion by monocyte-derived macrophages of AS patients. Although the TNF-α reducing effect of A_2AAR agonists can be a potential target in AS treatment, robust increasing of IL-23 should be considered as the undesirable effect of these agents.

P2 receptors mRNA expression profiles in macrophages from ankylosing spondylitis patients and healthy individuals

BACKGROUND

Ankylosing spondylitis (AS) is a multifactorial rheumatic disease which mainly involves the axial skeleton. Macrophages and extracellular nucleotides have been shown to contribute to the inflammation process in autoimmune diseases. Membrane-bound purinergic P2 receptors might be involved in the modulation of immune cells in AS. Therefore, we aimed to analyze the messenger RNA (mRNA) expression of P2 receptors in the macrophages of AS patients and healthy controls.

METHODS

Twenty-three AS patients and 23 age- and sex-matched healthy individuals were included in our study. Whole blood-separated monocytes of study participants were stimulated by macrophage colony-stimulating factor for 7 days and differentiated to macrophages. Monocyte and macrophage markers were analyzed by flow cytometry. SYBR green real-time polymerase chain reaction was used to measure the relative expression levels of P2RX₁ , P2RX₂ , P2RX₃ , P2RX₄ , P2RX₅ , P2RX₆ , P2RX₇ , P2RY₁ , P2RY₂ , P2RY₄ , P2RY₆ , P2RY₁₁ , P2RY₁₂ , P2RY₁₃ , P2RY₁₄ , and PANX1 genes.

RESULTS

P2RY₁₃ and P2RY₆ genes had the highest expression levels in macrophages among P2RY genes. P2RY₁ mRNA expression was significantly down-regulated (-1.75 fold) and P2RY₁₄ was up-regulated (2.6 fold) in macrophages of AS patients compared to healthy individuals. P2RX₄ gene had the highest expression in monocyte-derived macrophages, followed by P2RX₇ and P2RX₁  genes. There was no significant difference in P2X receptor mRNA expression level between macrophages of AS patients and healthy individuals.

CONCLUSIONS

Our results indicate that AS patients show altered expression levels of P2 receptor genes. Moreover, these changes might be associated with disease activity and patients' status.

Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Cross Oncoplastic Breast Surgery Technique; A Good Choice for Tumors Located Far From Nipple Areola Complex

Background: Although various Oncoplastic Breast Surgery (OBS) techniques have been introduced for varied sizes of the breast and locations of tumors , surgeons are still faced with serious challenges for tumors which have developed in special anatomic part of the breast. A good instance of these challenges is the tumors located far from Nipple Areola Complex (NAC) especially in the upper inner quadrant. We aimed to assess the application of newly introduced OBS technique (Cross Technique) in these situations. Methods: The data of 95 patients who suffered from breast cancer and operated with Cross method were assessed in this prospective survey. Data was gathered regarding demographic variables, the size, location, and pathologic characteristics of tumors, patients' BMI and breast circumference and cup size. The patients were recruited to the study according to inclusion and exclusion criteria and the study protocol which was approved by the research deputy of department of surgery, Tehran University of Medical Sciences. Data was presented in a descriptive method.Results: Nighty-five patients underwent oncoplastic breast surgery using the Cross method from November 2015 to May 2018. Patients had a mean age of 48.2 ranging from 25 to 70 years. The patients had a wide range of breast circumference and cup size (70 to 95 for the breast circumference and A to E for the cup size). Clear surgical margin was obtained in 93 cases according to the permanent pathology reports. The complications were seen in 5 patients all managed conservatively (2 slight hematoma and three ischemic skin flaps). The most common histologic type was insitu and invasive ductal carcinoma (DCIS-IDC). Mean tumor size was 22.7 mm with standard deviation of 9.2mm, most of which were positive for estrogen receptor (ER)/progesterone receptor (PR). As the surgery of axilla, six lymph nodes were excised on average and 22 patients had axillary lymph node involvement.Conclusion: The Cross method is not only a reliable choice for tumors located in the UIQ, but it can also be applied safely for tumors in UOQ and upper central part of the breast, although the best application for the technique is the tumors located far from nipple areola complex.

The relationship between cognitive function and body mass index in multiple sclerosis patients

BACKGROUND

Many patients with multiple sclerosis (MS) endure cognitive impairment, which affects their everyday life and lowers their life quality. It has been demonstrated that obesity can result in poor cognitive performance in healthy individuals through various mechanisms. Therefore, we aimed at assessing the association between body mass index (BMI) and cognitive function in MS patients, using minimal assessment of cognitive functions in MS (MACFIMS) battery.

METHOD

This study included eighty-one patients with relapsing-remitting MS (RRMS). After collecting the demographic data, patients' height and weight were measured in order to calculate BMI. Then, MACFIMS battery was administered in one session, after obtaining information using expanded disability status scale (EDSS).

RESULTS

Paced Auditory Serial Addition Test (PASAT) and Symbol Digit Modalities Test (SDMT) scores were negatively correlated with BMI (P values are equal to 0.005 and 0.037, respectively). PASAT score correlated with BMI after controlling for sex, age, and EDSS, but SDMT score did not correlate. Nevertheless, no significant variation was observed in the BMI level among individuals having MS with or without cognitive deficit.

CONCLUSION

We have shown that, BMI is associated with poor cognitive performance in some tests which, MACFIMS battery was included. This could suggest that obesity might be an important factor, which have effect on the cognitive performance.

White Matter Tract Alterations in Drug-Naïve Parkinson's Disease Patients With Excessive Daytime Sleepiness

Excessive daytime sleepiness (EDS) is relatively frequent in patients with Parkinson's disease (PD), having a prominent burden on patients' quality of life and causing dangerous events such as motor-vehicle accidents. Previous studies have indicated the role of certain neural tracts in the pathophysiology of sleep disturbances, especially in PD patients. We hypothesized that white matter integrity and connectivity might be altered in patients with PD and EDS. Therefore, this study investigated brain white matter microstructure alterations in patients with Parkinson's disease with EDS (PD-EDS) compared to healthy controls and PD patients without EDS (PD-nEDS). Diffusion MRI connectometry was used to carry out group analysis between PD patients with and without EDS and healthy individuals. EDS in PD patients is associated with decreased connectivity in the left and right fornix, left and right inferior longitudinal fasciculus (ILF), left inferior and middle cerebellar peduncles in comparison to PD-nEDS group. These differences between PD-EDS and PD-nEDS patients reflects microstructural changes with respect to sleep-related circuits, which can pave the way for future investigations considering EDS pathogenesis in Parkinson's disease.

Epistatic Interaction of ERAP1 and HLA-B*51 in Iranian Patients with Behçet's Disease

Behçet's Disease (BD) pathogenesis remains unclear, but some genetic loci and environmental factors are proposed to play a role. Here, we investigate the association of the endoplasmic reticulum aminopeptidase-1 (ERAP1) gene variants and HLA-B*51 with BD susceptibility and clinical manifestations in Iranian patients. In the study, 748 BD patients and 776 healthy individuals were included. The MGB-TaqMan Allelic Discrimination method was used to genotype 10 common missense single nucleotide polymorphisms (SNPs) and one intronic SNP in the ERAP1 gene region. We found no significant association between the 11 SNPs and BD in allelic and genotypic association tests. However, rs30187 showed the strongest association with BD in the recessive genotype model of the risk T allele in HLA-B*51 carriers. Although this became insignificant after correcting for multiple comparisons, the homozygous rs30187 risk allele genotype (TT) increased disease susceptibility in HLA-B*51 carriers in epistasis analysis, and the rs30187 TT recessive genotype showed a significant association with risk of cardiac involvement in the all patients and articular involvements in HLA-B*51 positive patients. Our findings suggest that gene-gene interactions between HLA-B*51 and ERAP1 variants is important for BD development, however, ERAP1 variants which interact with HLA-B*51 may differ among disease phenotypes or populations.

Autonomic dysfunction and white matter microstructural changes in drug-naïve patients with Parkinson's disease

BACKGROUND

Autonomic dysfunction (AD) is one of the non-motor features of Parkinson's disease (PD). Some symptoms tend to occur in the early stages of PD. AD also has a great impact on patient's quality of life. In this study, we aimed to discover the association between AD (Scales for Outcomes in Parkinson's disease-Autonomic, SCOPA-AUT) and microstructural changes in white matter tracts in drug-naïve early PD patients to elucidate the central effects of autonomic nervous system impairments.

METHOD

In total, this study included 85 subjects with PD recruited from the Parkinson's Progression Markers Initiative (PPMI) database. Among the 85 PD patients, 38 were in Hoehn & Yahr stage 1 (HY1PD) and 47 were in stage 2 (HY2PD). Diffusion magnetic resonance imaging (DMRI) data were reconstructed in the MNI space using q-space diffeomorphic reconstruction to obtain the spin distribution function. The spin distribution function (SDF) values were used in DMRI connectometry analysis. We investigated through diffusion MRI connectometry the structural correlates of white matter tracts with SCOPA-AUT subscores and total score.

RESULTS

Connectometry analysis also revealed positive association with white matter density in bilateral corticospinal tract in HY1PD patients and negative association in genu of corpus callosum (CC) and, bilateral cingulum in both groups. In addition, there were associations between gastrointestinal, sexual, thermoregulatory and urinary items and structural brain connectivity in PD.

CONCLUSION

Our study reveals positive correlation, suggesting neural compensations in early PD. Cingulum and CC tracts have well-known roles in PD pathology, compatible with our findings that bring new insights to specific areas of AD and its role in central nervous system (CNS) neurodegeneration, paving the way for using prodromal makers in the diagnosis and treatment of PD.

Longitudinal Alterations of Alpha-Synuclein, Amyloid Beta, Total, and Phosphorylated Tau in Cerebrospinal Fluid and Correlations Between Their Changes in Parkinson's Disease

Background: Parkinson's disease (PD) is characterized by proteinopathies and these proteinopathies seem to interact synergistically and lead to protein aggregations and changes in protein cerebrospinal fluid (CSF) levels. In this study, we aimed to explore the longitudinal changes of CSF a lpha-synuclein (α-syn), total tau (t-tau), phosphorylated tau (p-tau), and beta-amyloid (Aβ_1-42) and their relationships with each other and with baseline clinical entities like REM sleep behavior disorder (RBD), cognitive impairment, motor symptoms, and olfaction dysfunction. Method: One hundred and twelve non-demented PD patients and 110 controls were recruited from Parkinson's Progression Markers Initiative (PPMI).We used a linear mixed model within groups to assess longitudinal protein changes over 6 and 12 months and a random regression coefficient within the linear mixed model to investigate the correlation between proteins and their baseline clinical characteristics. Results: P-tau was lower in PDs only at baseline, but during a year, p-tau increased more rapidly in PDs than controls. Aβ_1-42 was not significantly different between groups at any separate timepoint; however, when assessed longitudinally, Aβ_1-42 showed significant changes in both groups. Conversely, t-tau and α-syn differed significantly between groups, but their longitudinal changes were not significant in either of the groups. Moreover, all proteins' baseline levels, except p-tau, could determine estimated longitudinal tau changes. Baseline RBDSQ scores but not UPDRS III, MoCA, or UPSIT scores were predictive of longitudinal increase in α-syn levels. Conclusion: Longitudinal changes in levels of CSF proteins are related to each other and could help researchers further understand PD pathology. In addition, RBD seems to be a potential prognostic factor for PD progression. However, in order to reach a consensus, longer follow-up times are required.

Microstructural Changes in Patients With Parkinson's Disease Comorbid With REM Sleep Behaviour Disorder and Depressive Symptoms

The diagnosis of Parkinson's disease (PD) is currently anchored on clinical motor symptoms, which appear more than 20 years after initiation of the neurotoxicity. Extra-nigral involvement in the onset of PD with probable nonmotor manifestations before the development of motor signs, lead us to the preclinical (asymptomatic) or prodromal stages of the disease (various nonmotor or subtle motor signs). REM sleep behavior disorder (RBD) and depression are established prodromal clinical markers of PD and predict worse motor and cognitive outcomes. Nevertheless, taken by themselves, these markers are not yet claimed to be practical in identifying high-risk individuals. Combining promising markers may be helpful in a reliable diagnosis of early PD. Therefore, we aimed to detect neural correlates of RBD and depression in 93 treatment-naïve and non-demented early PD by means of diffusion MRI connectometry. Comparing four groups of PD patients with or without comorbid RBD and/or depressive symptoms with each other and with 31 healthy controls, we found that these two non-motor symptoms are associated with lower connectivity in several white matter tracts including the cerebellar peduncles, corpus callosum and long association fibers such as cingulum, fornix, and inferior longitudinal fasciculus. For the first time, we were able to detect the involvement of short association fibers (U-fibers) in PD neurodegenerative process. Longitudinal studies on larger sample groups are needed to further investigate the reported associations.

Association Between Peripheral Inflammation and DATSCAN Data of the Striatal Nuclei in Different Motor Subtypes of Parkinson Disease

The interplay between peripheral and central inflammation has a significant role in dopaminergic neural death in nigrostriatal pathway, although no direct assessment of inflammation has been performed in relation to dopaminergic neuronal loss in striatal nuclei. In this study, the correlation of neutrophil to lymphocyte ratio (NLR) as a marker of peripheral inflammation to striatal binding ratios (SBRs) of DAT SPECT images in bilateral caudate and putamen nuclei was calculated in 388 drug-naïve early PD patients [288 tremor dominant (TD), 73 postural instability and gait difficulty (PIGD), and 27 indeterminate] and 148 controls. NLR was significantly higher in PD patients than in age- and sex-matched healthy controls, and showed a negative correlation to SBR in bilateral putamen and ipsilateral caudate in all PD subjects. Among our three subgroups, only TD patients showed remarkable results. A positive association between NLR and motor severity was observed in TD subgroup. Besides, NLR could negatively predict the SBR in ipsilateral and contralateral putamen and caudate nuclei in tremulous phenotype. Nonetheless, we found no significant association between NLR and other clinical and imaging findings in PIGD and indeterminate subgroups, supporting the presence of distinct underlying pathologic mechanisms between tremor and non-tremor predominant PD at early stages of the disease.

White Matter Tract Alterations in Drug-Naïve Parkinson's Disease Patients With Impulse Control Disorders

Impulse control disorders (ICDs) are relatively frequent in patients with Parkinson’s disease (PD), although it is still unclear whether an underlying pathological process plays a significant role in the development of ICD in PD apart from dopaminergic replacement therapy. In this study, we have investigated alterations of white matter tract in drug-naïve PD patients with ICDs via diffusion MRI connectometry. Our results showed that disrupted connectivity in the complex network of dynamic connections between cerebellum, basal ganglia, cortex, and its spinal projections serves as the underlying neuropathology of ICD in PD not interfered with the contribution of dopaminergic replacement therapy. These findings provide the first evidence on involved white matter tracts in the neuropathogenesis of ICD in drug-naïve PD population, supporting the hypothesis that neural disturbances intrinsic to PD may confer an increased risk for ICDs. Future studies are needed to validate the attribution of the impaired corticocerebellar network to impulsivity in PD.

Association between rs6759298 and Ankylosing Spondylitis in Iranian Population

BACKGROUND

Ankylosing Spondylitis (AS) is a chronic autoinflammatory Spondyloarthropathy (SpA) which is characterized by sacroiliitis, which progresses to the axial skeleton. It seems that non-Human Leukocyte Antigen (HLA) and also HLA-B27 are associated with the susceptibility and pathogenesis of the disease. The recent Ge-nome-Wide Association Studies (GWASs) have reported intergenic rs6759298 to be associated with AS etiology. The aim of this study was investigation of the rs6759298 polymorphism in Iranian AS patients. In addition, probable correlations with clinical indices and manifestations were considered.

METHODS

This study included 403 patients with AS. The control group consisted of 506 healthy individuals who were matched for sex, age, and ethnicity with AS group. Genotyping of rs6759298 was determined using the Amplification-Refractory Mutation System-Polymerase Chain Reaction (ARMS-PCR).

RESULTS

The GG genotype and G allele were found to be significantly more prevalent in the patient group in comparison to the control group [(p=2×10^-6 and 7.44×10^-9; OR (95% CI) =2.16 (1.56-2.98) and 1.73 (1.43-2.08)], respectively.

CONCLUSION

No associations were found between patients with three genotypes and any disease manifestations or clinical indices. This investigation confirmed a highly significant association of rs6759298 with disease susceptibility, with no effect on disease progress or clinical presentations. Since rs6759298 belongs to the 2p15 gene desert, further studies would elucidate the exact role of this polymorphism in the pathogenesis of AS.

Serum Insulin-Like Growth Factor-1 in Parkinson's Disease; Study of Cerebrospinal Fluid Biomarkers and White Matter Microstructure

Background: Growing evidence shows that impaired signaling of Insulin-like Growth Factor-1 (IGF-1) is associated with neurodegenerative disorders, such as Parkinson's disease (PD). However, there is still controversy regarding its proinflammatory or neuroprotective function. In an attempt to elucidate the contribution of IGF-1 in PD, we aimed to discover the relation between serum IGF-1 levels in drug-naïve early PD patients and cerebrospinal fluid (CSF) biomarkers as well as microstructural changes in brain white matter. Methods: The association between quartiles of serum IGF-1 levels and CSF biomarkers (α-synuclein, dopamine, amyloid-β_1-42, total tau, and phosphorylated tau) was investigated using adjusted regression models in 404 drug-naïve early PD patients with only mild motor manifestations and 188 age- and sex-matched healthy controls (HC) enrolled in the Parkinson's Progression Markers Initiative (PPMI). By using region of interest analysis and connectometry approach, we tracked the white matter microstructural integrity and diffusivity patterns in a subgroup of study participants with available diffusion MRI data to investigate the association between subcomponents of neural pathways with serum IGF-1 levels. Results: PD patients had higher levels of IGF-1 compared to HC, although not statistically significant (mean difference: 3.60, P = 0.44). However, after adjustment for possible confounders and correction for False Discovery Rate (FDR), IGF-1 was negatively correlated with CSF α-synuclein, total and phosphorylated tau levels only in PD subjects. The imaging analysis proved a significant negative correlation (FDR corrected P-value = 0.013) between continuous levels of serum IGF-1 in patients with PD and the connectivity, but not integrity, in following fibers while controlling for age, sex, body mass index, depressive symptoms, education years, cognitive status and disease duration: middle cerebellar peduncle, cingulum, genu and splenium of the corpus callosum. No significant association was found between brain white matter microstructral measures or CSF markers of healthy controls and levels of IGF-1. Conclusion: Altered connectivity in specific white matter structures, mainly involved in cognitive and motor deterioration, in association with higher serum IGF-1 levels might propose IGF-1 as a potential associate of worse outcome in response to higher burden of α-synucleinopathy and tauopathy in PD.

HBV reactivation in rheumatic diseases patients under therapy: A meta-analysis

BACKGROUND

Hepatitis B is one of the most common infectious diseases worldwide. In patients undergoing immunosuppressive therapy such as rheumatic diseases, reactivation of hepatitis B virus (HBV) is considered clinically important. This systematic review and meta-analysis were performed to determine the prevalence rate of HBV reactivation in rheumatic patients from different parts of the world.

METHODS

The authors performed a systematic literature review from several reliable databases including Scopus, ISI Web of Science and PubMed. Furthermore, the keywords of this research were "Hepatitis B virus", "Rheumatic diseases", "HBV reactivation", "Anti-TNF", "DMARDs" and "Biologic agents".

RESULTS

The authors selected 30 studies out of 983 for the present review. The overall estimation of the prevalence of HBV reactivation was 1.4 (95% confidence interval (CI): 1.3-1.6). Also, the heterogeneity in estimating the pooled prevalence among the studies was shown; Cochran Q test, P < 0.001, I² = 99.9%. It should be noted that max and min reactivation rate of HBV were in Italy and France respectively.

CONCLUSIONS

Rheumatic disease patients with resolved hepatitis B should be tightly monitored for possible HBV reactivation by elevation of liver enzymes and HBV DNA levels.