Utility of cranial MRI in non-traumatic headache patients with prior negative head CT within 1 month

AIM

To investigate the importance of additional cranial magnetic resonance imaging (cMRI) in non-traumatic headache patients with a prior negative head computed tomography (CT) examination within 1 month.

MATERIALS AND METHODS

This retrospective study analysed 162 adult patients with non-traumatic headache who underwent cMRI within 1 month of a negative initial head CT at the emergency department (ED). The diagnostic yield and false-referral rate were analysed according to the revisit duration (early [≤1 week] versus late [>1-4 weeks] revisits), patient care settings (ED versus outpatient clinics [OPC]), and clinical variables. Subsequent patient management change (PMC), such as admission and treatment (AT) or outpatient clinic treatment (OT), were also investigated.

RESULTS

The overall diagnostic yield of cMRI was 17.3% (28/162) and the false-referral rate was 1.2% (2/162). The diagnostic yield of cMRI was significantly different according to the patient care settings (ED, 24.7% [21/85] versus OPC, 9.1% [7/77]; p=0.02). The diagnostic yield was highest in the ED-early-revisit group (25.4% [18/71]), 45% (9/20) in those with systemic signs, and 46.7% (14/30) in those with symptom change. Among patients with positive cMRI findings, 90% (27/30) received AT and 3.3% (1/30) received OT. Among OPC-revisit-negative cMRI patients, PMC occurred in 0% (0/50).

CONCLUSION

The diagnostic yield of cMRI was relatively high for headache patients who revisited the ED earlier, especially in those with systemic signs or symptom change. Most positive cMRI cases experienced PMC. Negative cMRI in OPC-revisit patients might help clarify the benign nature of a condition.

A Machine Learning-Based Diagnostic Model for Crohn's Disease and Ulcerative Colitis Utilizing Fecal Microbiome Analysis

Recent research has demonstrated the potential of fecal microbiome analysis using machine learning (ML) in the diagnosis of inflammatory bowel disease (IBD), mainly Crohn's disease (CD) and ulcerative colitis (UC). This study employed the sparse partial least squares discriminant analysis (sPLS-DA) ML technique to develop a robust prediction model for distinguishing among CD, UC, and healthy controls (HCs) based on fecal microbiome data. Using data from multicenter cohorts, we conducted 16S rRNA gene sequencing of fecal samples from patients with CD (n = 671) and UC (n = 114) while forming an HC cohort of 1462 individuals from the Kangbuk Samsung Hospital Healthcare Screening Center. A streamlined pipeline based on HmmUFOTU was used. After a series of filtering steps, 1517 phylotypes and 1846 samples were retained for subsequent analysis. After 100 rounds of downsampling with age, sex, and sample size matching, and division into training and test sets, we constructed two binary prediction models to distinguish between IBD and HC and CD and UC using the training set. The binary prediction models exhibited high accuracy and area under the curve (for differentiating IBD from HC (mean accuracy, 0.950; AUC, 0.992) and CD from UC (mean accuracy, 0.945; AUC, 0.988)), respectively, in the test set. This study underscores the diagnostic potential of an ML model based on sPLS-DA, utilizing fecal microbiome analysis, highlighting its ability to differentiate between IBD and HC and distinguish CD from UC.

Enrichment of Activated Fibroblasts as a Potential Biomarker for a Non-Durable Response to Anti-Tumor Necrosis Factor Therapy in Patients with Crohn's Disease

We investigated whether the response to anti-tumor necrosis factor (anti-TNF) treatment varied according to inflammatory tissue characteristics in Crohn's disease (CD). Bulk RNA sequencing (RNA-seq) data were obtained from inflamed and non-inflamed tissues from 170 patients with CD. The samples were clustered based on gene expression profiles using principal coordinate analysis (PCA). Cellular heterogeneity was inferred using CiberSortx, with bulk RNA-seq data. The PCA results displayed two clusters of CD-inflamed samples: one close to (Inflamed_1) and the other far away (Inflamed_2) from the non-inflamed samples. Inflamed_1 was rich in anti-TNF durable responders (DRs), and Inflamed_2 was enriched in non-durable responders (NDRs). The CiberSortx results showed that the cell fraction of activated fibroblasts was six times higher in Inflamed_2 than in Inflamed_1. Validation with public gene expression datasets (GSE16879) revealed that the activated fibroblasts were enriched in NDRs over Next, we used DRs by 1.9 times pre-treatment and 7.5 times after treatment. Fibroblast activation protein (FAP) was overexpressed in the Inflamed_2 and was also overexpressed in the NDRs in both the RISK and GSE16879 datasets. The activation of fibroblasts may play a role in resistance to anti-TNF therapy. Characterizing fibroblasts in inflamed tissues at diagnosis may help to identify patients who are likely to respond to anti-TNF therapy.

Potential Oral Microbial Markers for Differential Diagnosis of Crohn's Disease and Ulcerative Colitis Using Machine Learning Models

Although gut microbiome dysbiosis has been associated with inflammatory bowel disease (IBD), the relationship between the oral microbiota and IBD remains poorly understood. This study aimed to identify unique microbiome patterns in saliva from IBD patients and explore potential oral microbial markers for differentiating Crohn's disease (CD) and ulcerative colitis (UC). A prospective cohort study recruited IBD patients (UC: n = 175, CD: n = 127) and healthy controls (HC: n = 100) to analyze their oral microbiota using 16S rRNA gene sequencing. Machine learning models (sparse partial least squares discriminant analysis (sPLS-DA)) were trained with the sequencing data to classify CD and UC. Taxonomic classification resulted in 4041 phylotypes using Kraken2 and the SILVA reference database. After quality filtering, 398 samples (UC: n = 175, CD: n = 124, HC: n = 99) and 2711 phylotypes were included. Alpha diversity analysis revealed significantly reduced richness in the microbiome of IBD patients compared to healthy controls. The sPLS-DA model achieved high accuracy (mean accuracy: 0.908, and AUC: 0.966) in distinguishing IBD vs. HC, as well as good accuracy (0.846) and AUC (0.923) in differentiating CD vs. UC. These findings highlight distinct oral microbiome patterns in IBD and provide insights into potential diagnostic markers.

Intravascular ultrasound-guided optimization for chronic total occlusion-percutaneous coronary intervention with multiple drug-eluting stents

Background

Multiple stenting in the chronic total occlusion (CTO) lesions is frequently required, however associated with poorer clinical outcomes. It is demonstrated that intravascular ultrasound (IVUS)-guided CTO-percutaneous coronary intervention (PCI) is related to a lower risk of adverse clinical events.

Purpose

We aimed to evaluate the clinical impact of stent optimization under IVUS guidance for multiple stenting, comparing with single stenting.

Methods

A total of 916 patients receiving drug-eluting stent (DES) under IVUS guidance were classified into two groups (stent optimization and non-optimization) according to optimization criteria (an absolute expansion criteria; minimal stent area ≥4.9 mm2 and a relative expansion criteria; 80% of mean reference lumen area). Of total population, 314 patients (34.3%) were treated with single stent and 575 patients (62.7%) were treated with multiple stents, respectively. Ischemic-driven target-lesion revascularization (TLR)/reocclusion was evaluated.

Results

Under IVUS guidance, 316 patients (34.5%) met IVUS criteria for stent optimization The achieving rates were 53% in the single stent group and 24% in the multiple stents group, respectively, (p<0.001). During a median of 4.7 years, the multiple stent group showed a significantly higher TLR/reocclusion rate, compared with the single stent group (12.8% vs. 5.2%, adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.20–5.25, p=0.01). (Figure 1) Meeting both the absolute and relative expansion criteria was associated with a significantly low rate of TLR/reocclusion rate (12.5% vs. 5.2%, adjusted HR 0.34, 95% CI: 0.15–0.79, p=0.01). Under IVUS-guidance, there was no significant difference between multiple stenting and single stenting in case of achieving the optimization criteria (6.5% vs. 4.2%, p=0.11), whereas non-optimization group in the patients with multiple stenting showed a significantly higher rate of TLR/reocclusion, compared with IVUS-optimization group in the patients with single stenting (14.5% vs. 4.2%, p=0.002). (Figure 2)

Conclusions

In CTO-PCI with DES, multiple stenting significantly increased the risk of TLR/reocclusion. IVUS-guided optimization for multiple stenting showed a comparable long-term risk of TLR/reocclusion to single stenting with IVUS optimization. Hence, achieving IVUS expansion criteria may help to reduce the risk of TLR/reocclusion in CTO-PCI with multiple DES overlapping.

Funding Acknowledgement

Type of funding sources: None.

Low Intake of Choline Is Associated with Diminished Strength and Lean Mass Gains in Older Adults

OBJECTIVES

Choline is an essential micronutrient for many physiological processes related to exercise training including biosynthesis of acetylcholine. Though dietary choline intake has been studied in relation to endurance training and performance, none have studied it during resistance exercise training (RET) in older adults. The objective of the study was to examine the relationship between choline intake and muscle responses to RET in older adults.

METHODS

Forty-six, 60-69-year-old individuals (M=19, F=27) underwent 12 weeks of RET (3x/week, 3 sets, 8-12 reps, 75% of maximum strength [1RM], 8 exercises). Body composition (DEXA) and 1RM tests were performed before and after training. After analyzing 1,656 diet logs (3x/week, 46 participants, 12 weeks), participants' mean choline intakes were categorized into three groups: Low (2.9-5.5 mg/kg lean/d), Med-Low (5.6-8.0 mg/kg lean/d), or Adequate (8.1-10.6 mg/kg lean/d). These correspond to <50%, ~63%, and ~85% of Adequate Intake (AI) for choline, respectively.

RESULTS

Gains in composite strength (leg press + chest press 1RM) were significantly lower in the Low group compared with the other groups (Low: 30.9 ± 15.1%, Med-Low: 70.3 ± 48.5%, Adequate: 81.9 ± 68.4%; p=0.004). ANCOVA with cholesterol, protein, or other nutrients did not alter this result. Reduced gains in lean mass were also observed in the Low group, compared with higher choline intake of 5.6-10.6 mg/kg lean/d (1.3 ± 0.6% vs. 3.2 ± 0.6%, p<0.05).

CONCLUSION

These data suggest that this population of older adults does not consume adequate choline and lower choline intake is negatively and independently associated with muscle responses to RET.

Development of a Machine Learning Model to Distinguish between Ulcerative Colitis and Crohn's Disease Using RNA Sequencing Data

Crohn’s disease (CD) and ulcerative colitis (UC) can be difficult to differentiate. As differential diagnosis is important in establishing a long-term treatment plan for patients, we aimed to develop a machine learning model for the differential diagnosis of the two diseases using RNA sequencing (RNA-seq) data from endoscopic biopsy tissue from patients with inflammatory bowel disease (n = 127; CD, 94; UC, 33). Biopsy samples were taken from inflammatory lesions or normal tissues. The RNA-seq dataset was processed via mapping to the human reference genome (GRCh38) and quantifying the corresponding gene models that comprised 19,596 protein-coding genes. An unsupervised learning model showed distinct clusters of four classes: CD inflammatory, CD normal, UC inflammatory, and UC normal. A supervised learning model based on partial least squares discriminant analysis was able to distinguish inflammatory CD from inflammatory UC after pruning the strong classifiers of normal CD vs. normal UC. The error rate was minimal and affected only two components: 20 and 50 genes for the first and second components, respectively. The corresponding overall error rate was 0.147. RNA-seq analysis of tissue and the two components revealed in this study may be helpful for distinguishing CD from UC.

70 Availability of Personal Protective Equipment in NHS Hospitals During COVID-19: A National Survey

Introduction

The continuous supply of personal protective equipment (PPE) in the National Health Service (NHS) is paramount in order to sustain a safe level of staffing and to reduce transmission of COVID-19 to patients, public and staff.

Method

A 16-question survey was created to assess the availability and personal thoughts of healthcare professionals regarding PPE supply in England. The survey was distributed via social media (Facebook © and Twitter ©) to all UK COVID-19 healthcare professional groups, with responses collected over 3 weeks in March 2020 during the beginning of the pandemic.

Results

A total of 121 responses from physicians in 35 different hospitals were collected (105 inpatient wards, 16 from intensive care units). In inpatient wards, eye and face protection were unavailable to 19.1% of respondents. Masks were available to 97.7% of respondents and gloves in all respondents (100%). Body protection was available primarily as a plastic apron (83.8%). All of respondents working in intensive care had access to full-body PPE, except FFP3 respirator masks (available in 87.5%). PPE is ‘Always’ available for 29.8% of all respondents, and ‘Never’ or ‘Almost Never’ in 11.6%. There was a statistically significant difference between London and non-London responders that ‘Always’ had PPE available (43.9% versus 19.0%, p = 0.003).

Conclusions

This is the first survey to evaluate PPE supply in England during the COVID-19 pandemic. Our survey demonstrated an overall lack of PPE volume supply in the UK, with preferential distribution in London. Eye and full body protection are in most lack of supply.

Detection of SARS-CoV-2 in Fecal Samples From Patients With Asymptomatic and Mild COVID-19 in Korea

BACKGROUND & AIMS

Although coronavirus disease 2019 (COVID-19) is characterized by fever and respiratory symptoms, some patients have no or mild symptoms. Severe acute respiratory syndrome-coronavirus (SARS-CoV-2) has been detected in feces of patients. We investigated gastrointestinal symptoms and shedding of virus into feces of patients with asymptomatic or mild COVID-19.

METHODS

We collected data from 46 patients (median age, 26 y; 46% men) with asymptomatic or mild COVID-19 (without fever and pneumonia) and prolonged respiratory shedding of SARS-CoV-2, quarantined from April 4, 2020, through April 24, 2020, in Korea. Respiratory specimens included upper respiratory specimens (nasopharyngeal and oropharyngeal swabs) and lower respiratory specimens (sputum), and were collected twice per week. The median interval between COVID-19 diagnosis to the start of fecal sample collection was 37 days (range, 29-41 d); 213 stool specimens were collected from 46 patients. We used real-time reverse-transcription polymerase chain reaction to detect SARS-CoV-2 in the respiratory and fecal specimens.

RESULTS

Gastrointestinal manifestations were observed in 16 of the 46 patients (35%); diarrhea was the most common (15%), followed by abdominal pain (11%), dyspepsia (11%), and nausea (2%). Virus RNA was detected in feces from 2 patients without gastrointestinal symptoms (4%). Mean cycle threshold values from the time of quarantine to the time of fecal collection tended to be lower in patients with virus detected in fecal samples than in patients without virus in fecal samples (29.91 vs 33.67 in the first week, 29.47 vs 35.71 in the fifth week, respectively). Shedding of virus into feces persisted until day 50 after diagnosis; fecal samples began to test negative before or at approximately the time that respiratory specimens also began to test negative.

CONCLUSIONS

In an analysis of fecal and respiratory specimens from patients with COVID-19 in quarantine in Korea, we found that the gastrointestinal tract could be a route of transmission of SARS-CoV-2 even in patients with asymptomatic or mild disease, with no gastrointestinal symptoms. The viral load of the respiratory specimens appears be related to shedding of the virus into feces in this group of patients.

Reversion of Gut Microbiota during the Recovery Phase in Patients with Asymptomatic or Mild COVID-19: Longitudinal Study

Patients with COVID-19 have been reported to experience gastrointestinal symptoms as well as respiratory symptoms, but the effects of COVID-19 on the gut microbiota are poorly understood. We explored gut microbiome profiles associated with the respiratory infection of SARS-CoV-2 during the recovery phase in patients with asymptomatic or mild COVID-19. A longitudinal analysis was performed using the same patients to determine whether the gut microbiota changed after recovery from COVID-19. We applied 16S rRNA amplicon sequencing to analyze two paired fecal samples from 12 patients with asymptomatic or mild COVID-19. Fecal samples were selected at two time points: during SARS-CoV-2 infection (infected state) and after negative conversion of the viral RNA (recovered state). We also compared the microbiome data with those from 36 healthy controls. Microbial evenness of the recovered state was significantly increased compared with the infected state. SARS-CoV-2 infection induced the depletion of Bacteroidetes, while an abundance was observed with a tendency to rapidly reverse in the recovered state. The Firmicutes/Bacteroidetes ratio in the infected state was markedly higher than that in the recovered state. Gut dysbiosis was observed after infection even in patients with asymptomatic or mild COVID-19, while the composition of the gut microbiota was recovered after negative conversion of SARS-CoV-2 RNA. Modifying intestinal microbes in response to COVID-19 might be a useful therapeutic alternative.

Schwannoma of the sinonasal tract: case report with review of the literature

Schwannomas of the sinonasal tract are rare, accounting for <4% of head and neck schwannomas. We report the case of a 61-year-old male who presented with unilateral nasal symptoms. Examination and imaging revealed a unilateral polyp at the level of the middle turbinate, with an initial biopsy suggestive of an inflammatory polyp. Due to the persistence of the patient's symptoms and his polyp despite medical therapy, endoscopic nasal polypectomy was performed. The histology surprisingly showed a schwannoma. No further interventions were carried out, and the patient remains disease-free 6 months postoperatively. A review of the literature comprising 60 cases is included. An optimal clinical approach to the investigation and management of schwannomas of the sinonasal tract is subsequently discussed.

Exocyst subunit Exo70B2 is linked to immune signaling and autophagy

During the immune response, activation of the secretory pathway is key to mounting an effective response, while gauging its output is important to maintain cellular homeostasis. The Exo70 subunit of the exocyst functions as a spatiotemporal regulator by mediating numerous interactions with proteins and lipids. However, a molecular understanding of the exocyst regulation remains challenging. We show that, in Arabidopsis thaliana, Exo70B2 behaves as a bona fide exocyst subunit. Conversely, treatment with the salicylic acid (SA) defence hormone analog benzothiadiazole (BTH), or the immunogenic peptide flg22, induced Exo70B2 transport into the vacuole. We reveal that Exo70B2 interacts with AUTOPHAGY-RELATED PROTEIN 8 (ATG8) via two ATG8-interacting motives (AIMs) and its transport into the vacuole is dependent on autophagy. In line with its role in immunity, we discovered that Exo70B2 interacted with and was phosphorylated by the kinase MPK3. Mimicking phosphorylation had a dual impact on Exo70B2: first, by inhibiting localization at sites of active secretion, and second, it increased the interaction with ATG8. Phosphonull variants displayed higher effector-triggered immunity (ETI) and were hypersensitive to BTH, which induce secretion and autophagy. Our results suggest a molecular mechanism by which phosphorylation diverts Exo70B2 from the secretory into the autophagy pathway for its degradation, to dampen secretory activity.

Poultry Professionals' Perception of Participation in Voluntary Disease Mapping and Monitoring Programs in the United States: A Cluster Analysis

The development and implementation of disease mapping and monitoring programs can be useful tools for rapid communication and control of endemic and epidemic infectious diseases affecting the food animal industry. Commercial livestock producers have traditionally been reluctant to share information related to animal health, challenging the large-scale implementation of such monitoring and mapping programs. The main objective of this study was to assess the perception of poultry professionals toward disease mapping and monitoring programs and to identify groups of poultry professionals with similar perceptions and attitudes toward these projects. We conducted a survey to identify the perceived risks and benefits to be able to properly address them and encourage industry participation in the future. An anonymous online survey was developed and distributed to poultry professionals through industry and professional associations. The participant's demographic information and perceptions of risk and benefits from participation on voluntary poultry disease mapping and monitoring programs were collected. Multiple correspondence analysis and hierarchical clustering on principal components were performed to identify groups of professionals with similar characteristics. A total of 63 participants from 21 states filled out the survey. The cluster analysis yielded two distinct groups of respondents, each including approximately 50% of respondents. Cluster 1 subjects could be characterized as optimistic, perceiving major benefits of sharing farm-level poultry disease information. However, they also had major concerns, mostly related to potential accidental data release and providing competitive advantages to rival companies. Cluster 2 subjects were characterized as perceiving a lesser degree of benefits from sharing farm-level poultry disease information. This second cluster mostly included production and service technicians. The roles and perceptions of risk and benefits of the participants contributed significantly to cluster assignment, while the represented commodity and geographic location in the United States did not. Successful development of voluntary poultry disease mapping and monitoring programs in the future will require that different sectors of poultry professionals be approached in different manners in order to highlight the benefits of the programs and to achieve maximum participation.

Differentially Abundant Bacterial Taxa Associated with Prognostic Variables of Crohn's Disease: Results from the IMPACT Study

Limited studies have examined the intestinal microbiota composition in relation to Crohn's disease (CD) prognosis. We analyzed the differences in microbial communities and relevant metabolic pathways associated with prognostic variables in patients with CD. We applied 16S rRNA gene sequencing to analyze a cohort of 1110 CD and healthy control (HC) fecal samples. We categorized patients with CD into good (CD-G), intermediate (CD-I) and poor (CD-P) prognosis groups, according to the history of using biologics and intestinal resection. Microbiota α-diversity decreased more in CD-P than CD-G and CD-I. Microbiota ß-diversity in CD-P differed from that in CD-G and CD-I. Thirteen genera and 10 species showed differential abundance between CD-G and CD-P groups. Escherichia coli (p = 0.001) and species Producta (p = 0.01) and genera Lactobacillus (p = 0.003) and Coprococcus (p = 0.01) consistently showed differences between CD-G and CD-P groups after adjusting for confounding variables. Functional profiling suggested that the microbial catabolic pathways and pathways related to enterobacterial common antigen and lipopolysaccharide biosynthesis were better represented in the CD-P group than in the CD-G group, and E. coli were the top contributors to these pathways. CD prognosis is associated with altered microbiota composition and decreased diversity, and E. coli might be causally involved in CD progression, and may have adapted to live in inflammatory environments.

Interstitial lung disease and risk of mortality: 11-year nationwide population-based study

BACKGROUND

Patients with interstitial lung disease (ILD) constitute a substantial disease burden. Although ILD outcomes have been investigated, the risk of death due to ILD has not been studied in the light of confounders and comorbidities. In this nationwide, 11-year longitudinal, population-based study, we aimed to discover if ILD is an independent risk factor for mortality.

DESIGN

Data on 1 031 392 (2.2%) randomly selected subjects from 47 279 373 Korean residents were collected from the 2002 Korean National Health Insurance database. The ILD group comprised patients with an initial diagnosis of ILD between January 2003 and December 2007. Each patient was followed until 2013. We used Cox proportional hazard regression analyses to calculate the risk of death adjusted for comorbidities and confounders.

RESULTS

ILD developed in 783 of the 303 385 subjects during the 5-year period (51 per 100 000 person-years). Death occurred in 157 (23.2%) cases and 272 controls (10.4%). ILD was significantly associated with the risk of death (hazard ratio 2.1, 95% confidence interval [CI] 1.6-2.7) and for those aged 40-59, 60-69 and 70 years. A high proportion of patients with ILD died due to respiratory causes.

CONCLUSION

ILD patients had a significantly higher risk of death than matched controls, after adjustment for potential confounders and comorbidities.

P923Feasibility of the transcatheter mitral valve repair as the rescue therapy for patients with severe mitral regurgitation and endangered heart failure

Background

For those who carry high or prohibitive surgical risk, the transcatheter edge-to edge mitral valve repair using MitraClip has been a safe and effective treatment for severe mitral regurgitation (MR). In patients with severe MR and cardiogenic shock under hemodynamic supporting devices, emergent surgical mitral valve interventions carry extremely high risk for peri-operative morbidities and mortalities. The feasibility and efficacy of emergent MitraClip to rescue patients in critical conditions remains elucidate.

Methods

Patients with severe MR were evaluated by the heart team and those with high or prohibitive surgical risks were referred to receive MitraClip procedures. Emergent MitraClip were conducted in patients with unstable hemodynamics and under mechanical or inotropic support. The hemodynamic measures, transthoracic echocardiography, transesophageal echocardiography, and blood tests were performed before MitraClip procedures. Procedural success was defined as having mild mitral regurgitation immediately after MitraClip, and patients were free from in-hospital mortality. Clinical and echocardiographic outcomes were followed by telephones and clinics.

Results

Among 50 consecutive patients (74.7±11.2 years, 74% male), 8 emergent MitraClip procedures were conducted to rescue patients with cardiogenic shock. Extracorporeal membrane oxygenation were used in 2 patients and intra-aortic balloon pump were applied in 4 patients (50%). The rest of 4 patients received continuous inotropic agent administration. Compare to those who underwent elective procedures, patients underwent emergent MitraClip had higher surgical risk profile (Euroscore II 34.8% vs 5.1% and STS score 19.7% vs 5.1%), poorer renal function and higher right atrial pressure. There was no peri-procedural death, myocardial infarction, stroke or any adverse events requiring emergent cardiac surgery in both groups. Mild mitral regurgitation was achieved in 87.5% patients from the emergent group and 95.2% patients in the elective group (P=0.514). In follow up, there were 5 deaths (three in the emergent group), including 2 non-cardiovascular deaths. The Kaplan-Meier analysis showed patients who underwent emergent procedures have poorer long-term survival rate as compare to those who received elective procedures. (P value = 0.008).

Conclusions

When open-heart surgery is not feasible and deferred due to excessive risk, trans-catheter mitral valve repair is an alternative way to rescue patients in cardiogenic shock status. The emergent MitraClip procedure may provide comparable safety and efficacy in treating patients with severe MR and unstable hemodynamics.

P4733Risk of myocardial infarction with coronary artery bypass grafting versus percutaneous coronary intervention: a systematic review and meta-analysis of fifteen randomised trials

Background

It remains controversial whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is more effective in the prevention of myocardial infarction (MI). MI has been evaluated only as a secondary endpoint without a focused systematic review in multiple meta-analyses.

Purpose

To compare the risk of MI at the latest follow-up available between CABG versus PCI with stents in patients with multivessel or left main coronary artery disease in a pairwise meta-analysis of randomised controlled trials (RCT).

Methods

We searched EMBASE, Cochrane, and Pubmed databases for articles comparing CABG versus PCI for the treatment of multivessel or left main disease. We utilised random-effects model to calculate pooled risk ratio (RR) and 95% confidence interval (CI). Fifteen trials with a total of 13,592 patients treated with either CABG (n=6,596) or PCI (n=6,996) were eligible and included. A multivariable random-effects meta-regression model, including variables such as age, sex, diabetes mellitus, publication year, follow-up duration, type of stent used, and type of coronary artery disease, was used to explore the source of potential heterogeneity of the primary result.

Results

After a weighted follow-up of 4.3 years, patients treated with CABG had a significantly lower risk of MI than patients treated with PCI (RR 0.75, 95% CI 0.58–0.96, P=0.024, I2=66%). The lower risk of MI with CABG as compared to PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52–0.91, P=0.008; ≥5 years, RR 0.64, 95% CI 0.48–0.86, P=0.003) and in diabetic population (RR 0.55, 95% CI 0.44–0.70, P<0.001). There was a statistically meaningful trend toward fewer MIs with CABG with a similar magnitude of risk reduction across patients with left main disease (RR 0.74, 95% CI 0.47–1.15) and multivessel disease (RR 0.72, 95% CI 0.53–0.99). Moderate inter-study heterogeneity could not be explained by the clinical and trial-based variables tested in meta-regression, and is likely because of differences in definitions of MI, risk profile of enrolled patients, and procedural specifics.

Forest plots

Conclusions

In patients undergoing revascularization for multivessel or left main disease, the risk of MI was lower with CABG compared to PCI. The quality assurance for MI definition and treatment-specific procedures should be emphasized for future RCTs.

Anaesthetic Management of Planned or Emergency Endovascular Stent Graft Surgery for Thoracic Aneurysms and Dissections

We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.

High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance Spectroscopy for the Metabolic Assessment of Acute Rejection After Cardiac Transplantation in Rats

PURPOSE

To evaluate the potential of high-resolution magic angle spinning (HR-MAS) ¹H nuclear magnetic resonance (NMR) spectroscopy for metabolite characterization and the differentiation of acute rejection after heart transplantation in rat models.

METHODS

We transplanted syngeneic heart grafts from Lewis rats (n = 4) and allogeneic heart grafts from F344 rats (n = 4) heterotopically into Lewis recipients. On day 7 postoperatively, the transplanted hearts were harvested for ex vivo ¹H NMR spectroscopy and HR-MAS ¹H NMR spectroscopy. ¹H NMR spectroscopy and HR-MAS ¹H NMR spectroscopy were performed at 4.7 T and 11.7 T, respectively. Metabolomic profiles contributing to the differentiation of allogeneic and syngeneic graft groups were statistically assessed by orthogonal partial least squares discriminant analysis (OPLS/O2PLS-DA). Metabolite concentrations were normalized by total spectral intensities and were compared using Mann-Whitney U tests.

RESULTS

One allogeneic graft that showed extensive necrotic change suggesting graft failure was excluded from the statistical analysis of the NMR spectroscopy. In the 4.7-T ¹H NMR spectroscopy, the creatine peak was decreased in the allogeneic group. The PLS-DA and OPLS/O2PLS-DA score plot demonstrated good discrimination of the allogeneic graft group from syngeneic graft group. The concentrations of creatine, myo-inositol, glucose, niacinamide, hypoxanthine, inosine, and glutamine were significantly decreased in the allogeneic graft group, whereas the concentrations of glycine, phosphoethanolamine, xanthine, sn-glycero-3-phosphocholine, leucine, valine, and tyrosine were significantly increased (P < .05).

CONCLUSIONS

HR-MAS ¹H NMR spectroscopy can metabolically characterize the acute rejection of heart transplantation.

Effectiveness of an intensive treatment programme combining prolonged exposure and eye movement desensitization and reprocessing for severe post-traumatic stress disorder

Background: There is room for improvement regarding the treatment of severe post-traumatic stress disorder (PTSD). Intensifying treatment to increase patient retention is a promising development. Objective: The aim of this study was to determine the effectiveness of an intensive trauma-focused treatment programme over 8 days for individuals suffering from severe PTSD. Method: Treatment was provided for 347 PTSD patients (70% women; mean age = 38.32 years, SD = 11.69) and consisted of daily sessions of prolonged exposure and eye movement desensitization and reprocessing (EMDR) therapy (16 sessions in total), physical activity, and psycho-education. All participants had experienced multiple traumas, including sexual abuse (74.4%), and suffered from multiple comorbidities (e.g. 87.5% had a mood disorder). Suicidal ideation was frequent (73.9%). PTSD symptom severity was assessed by both clinician-rated [Clinician Administered PTSD Scale (CAPS)] and self-report [PTSD Symptom Scale Self Report (PSS-SR) and Impact of Event Scale (IES)] inventories. For a subsample (n = 109), follow-up data at 6 months were available. Results: A significant decline in symptom severity was found (e.g. CAPS intention-to-treat sample Cohen's d = 1.64). At post-treatment, 82.9% showed a clinically meaningful response and 54.9% a loss of diagnosis. Dropout was very low (2.3%). Conclusions: Intensive trauma-focused treatment programmes including prolonged exposure, EMDR therapy, and physical activity can be effective for patients suffering from severe PTSD and are associated with low dropout rates.

Dynamic Internet-Mediated Team-Based Case Management of High-Frequency Emergency Department Users

Introduction

We assessed whether a strategy using dynamic, internet-mediated, team-based case management could reduce the number of subsequent emergency department (ED) visits by frequent ED users.

Methods

Patients who attended the ED three or more times within 72 hours in June 2010 were identified. These cases were divided into the pain management or chronic disease group according to their chief complaint. Patients were assessed by expert panels, and initial care plans were developed and posted on an internal website. Thereafter, each emergency physician could follow or adjust the care plans dynamically via the internal website according to the patient's condition and use the website to communicate results. Care plans were revised by the team according to the patient's clinical situation as it changed. Patient ED visits over the subsequent six months were monitored.

Results

Fourteen cases were enrolled in the study, seven in each group. The mean number of visits per patient per month in the pain management and chronic disease groups decreased from 14.9 to 5.79 (p=0.031) and 6.1 to 2.9 (p<0.001) visits per month after the intervention, respectively. The overall mean number of visits per patient per month decreased from 10.5 to 4.36 (p=0.004), a decrease of 6.14 visits (58.27%).

Conclusions

Dynamic internet-mediated team-based case management may help to reduce subsequent visits in patients who frequently visit the ED. (Hong Kong j.emerg.med. 2014;21:161-166)

Clinical judgement perplexed by initially undisclosed use of herbal medicine and unexpected cross-reactivity of immunoassay

We report a case of symptomatic bradycardia caused by consumption of a Chinese herbal medicine which was initially undisclosed to the attending emergency physician. The scientific name of the herb is Panax japonicus. Electrocardiogram revealed sinus bradycardia. Laboratory tests were normal except for the detection of a high serum digoxin level. Further interrogation of the patient eventually disclosed ingestion of the herb which, however, did not contain any digoxin. Other active ingredients in the herb include various types of ginsenoside. These are digoxin-like substances that had caused the observed false-positive detection of digoxin by fluorescence polarization immunoassay due to cross-reactivity. Our case-report provides an important insight about a blind-spot in the field of laboratory medicine (clinical pathology), namely, the false positive detection of digoxin due to crossreactivity in the immunoassay when we come across digoxin-like substances in clinical scenarios, which has barely received attention in the medical literature. It also conveys a clear educational message that with full understanding of the laboratory methodology and its mechanistic rationale there are actually some tricks-of-the-trade that allow us to optimize the specificity of the biochemical tests and the treatment of digoxin-like substances overdose.

Rapid manufacturing techniques in the development of an axial blood pump impeller

This paper presents a comparison of manufacturing techniques used in the development of an axial blood pump impeller. In this development process the impeller was designed and its performance was evaluated with the aid of computational fluid dynamics (CFD). Prototypes of those designs where the CFD results show promise were needed in sufficient quantities at a low cost for experimental validation of the CFD results. As the impeller is less than 16 mm in diameter with a maximum blade thickness of about 1.5 mm, innovative manufacturing techniques are explored in this paper to determine the best process for quick fabrication of prototypes that are dimensionally accurate, structurally robust and low in cost. Four rapid prototyping techniques were explored. The completed parts were compared on the basis of manufacturing time, quality and strength of parts obtained, manufacturing cost and also in vitro performances. Based on these studies, it was concluded that selective laser sintering (SLS) is the most appropriate method for the quick production of prototype parts for evaluation of pump performance.

Antibiotic resistance and plasmid profiling of Vibrio spp. in tropical waters of Peninsular Malaysia

Vibrio species isolated from four different sampling stations in the west coast of Peninsular Malaysia were screened for their antimicrobial resistance and plasmid profiles. A total of 138 isolates belonging to 15 different species were identified. Vibrio campbellii, V. parahaemolyticus, V. harveyi, and V. tubiashii were found to predominance species at all stations. High incidence of erythromycin, ampicillin, and mecillinam resistance was observed among the Vibrio isolates. In contrast, resistance against aztreonam, cefepime, streptomycin, sulfamethoxazole, and sulfonamides was low. All the Vibrio isolates in this study were found to be susceptible to imipenem, norfloxacin, ofloxacin, chloramphenicol, trimethoprim/sulfamethoxazole, and oxytetracycline. Ninety-five percent of the Vibrio isolates were resistant to one or more different classes of antibiotic, and 20 different resistance antibiograms were identified. Thirty-two distinct plasmid profiles with molecular weight ranging from 2.2 to 24.8 kb were detected among the resistance isolates. This study showed that multidrug-resistant Vibrio spp. were common in the aquatic environments of west coast of Peninsular Malaysia.

Incidence of idiopathic pulmonary fibrosis in Korea based on the 2011 ATS/ERS/JRS/ALAT statement

OBJECTIVE

To estimate the annual incidence rate of interstitial lung disease (ILD) and idiopathic pulmonary fibrosis (IPF) in Korea.

DESIGN

A retrospective cohort design using the Korean Health Insurance Review and Assessment Service (HIRA) database spanned the period from January 2008 to December 2012. Patients with ILD and IPF were identified based on the International Classification of Disease-10 (ICD-10) diagnosis and procedure codes. Definition 1 is code J84 (ILD); Definition 2 is code J84 plus high-resolution computed tomography (HRCT), bronchoalveolar lavage (BAL) or lung biopsy; Definition 3 is code J84.1 (ILD with fibrosis); Definition 4 is code J84.1 and HRCT, BAL or lung biopsy; and Definition 5 is code J84.1A (IPF), and was specifically implemented for IPF.

RESULTS

The incidence rates of ILD per 100,000 population based on Definitions 1-5 were respectively 48.5, 32.2, 16.2, 11.4 and 1.7.

CONCLUSION

The incidence of ILD with fibrosis was approximately 23% of overall ILD incidence. IPF incidence was approximately 10% of the incidence of ILD with fibrosis. Based on the new ATS/ERS/JRS/ALAT statement published in 2011, the incidence rate of IPF was 1.7/100,000.

Neurovascular Interactions in the Neurologically Compromised Neonatal Brain

Neurological brain injuries such as hypoxic ischaemic encephalopathy (HIE) and associated conditions such as seizures have been associated with poor developmental outcome in neonates. Our limited knowledge of the neurological and cerebrovascular processes underlying seizures limits their diagnosis and timely treatment. Diffuse optical tomography (DOT) provides haemodynamic information in the form of changes in concentration of de/oxygenated haemoglobin, which can improve our understanding of seizures and the relationship between neural and vascular processes. Using simultaneous EEG-DOT, we observed distinct haemodynamic changes which are temporally correlated with electrographic seizures. Here, we present DOT-EEG data from two neonates clinically diagnosed as HIE. Our results highlight the wealth of mutually-informative data that can be obtained using DOT-EEG techniques to understand neurovascular coupling in HIE neonates.

Prevalence of pre-sarcopenia and sarcopenia in Hong Kong Chinese geriatric patients with hip fracture and its correlation with different factors

INTRODUCTION

Sarcopenia and osteoporosis are age-related declines in the quantity of muscle and bone, respectively. Both contribute in disability, fall, and hip fracture in the elderly. This study reported the prevalence of sarcopenia in Chinese geriatric patients with hip fracture, and the correlation between relative appendicular skeletal muscle mass index and other factors.

METHODS

This case series was conducted in Kowloon West Cluster Orthopaedic Rehabilitation Centre in Hong Kong. Data of all geriatric patients with primary hip fracture admitted to the above Centre from June to December 2014 were studied. Isometric grip strength, the maximal handgrip strength, was measured using a JAMAR hand dynamometer. Body composition including appendicular and whole-body lean body mass was measured using dual-energy X-ray absorptiometry. Pearson's correlation was used to examine the correlation between relative appendicular skeletal muscle mass index and other factors.

RESULTS

A total of 239 patients with a mean age of 82 years were included in the study. Stratifying patients as male or female, the mean (± standard deviation) hand grip strength was 20.6 ± 7.3 kg and 13.6 ± 4.5 kg, the mean relative appendicular skeletal muscle mass index was 5.72 ± 0.83 kg/m(2) and 4.87 ± 0.83 kg/m(2), and the mean hip bone mineral density was 0.696 ± 0.13 g/cm(2) and 0.622 ± 0.12 g/cm(2), respectively. The prevalence of sarcopenia based on relative appendicular skeletal muscle mass index and hand grip strength according to the Asian Working Group for Sarcopenia definition was 73.6% in males and 67.7% in females. According to the European Working Group on Sarcopenia definition, the prevalence of pre-sarcopenia was 20.8% in males and 12.4% in females. Relative appendicular skeletal muscle mass index was positively correlated with hand grip strength, body weight, hip bone mineral density, body mass index, and total fat mass in males; and hand grip strength, body weight, body height, body mass index, and total fat mass in females. Except for body height in females, all correlations were statistically significant.

CONCLUSION

The prevalence of sarcopenia was very high in geriatric hip fracture patients, and much higher than that in community-dwelling elderly population. Apart from the need to prescribe osteoporosis medicine, sarcopenia screening and treatment should be offered and is essential to reduce subsequent fall, subsequent fracture, fracture-related complications and economic burden to Hong Kong.

Immunogenicity and protective efficacy of the norovirus P particle-M2e chimeric vaccine in chickens

The ectodomain of the influenza matrix protein 2 (M2e) is highly conserved across strains and has been shown to be a promising candidate for universal influenza vaccine in the mouse model. In this study, we tested immune response and protective efficacy of a chimeric norovirus P particle containing the avian M2e protein against challenges with three avian influenza (AI) viruses (H5N2, H6N2, H7N2) in chickens. Two-week-old specific pathogen free chickens were vaccinated 3 times with an M2e-P particle (M2e-PP) vaccine via the subcutaneous (SQ) route with oil adjuvant, and transmucosal routes (intranasal, IN; eye drop, ED; microspray, MS) without adjuvant. M2e-PP vaccination via the SQ route induced significant IgG antibody responses which were increased by each booster vaccination. In groups vaccinated via IN, ED or MS, neither IgG nor IgA responses were detected from sera or nasal washes of immunized birds. The M2e-PP vaccination via the SQ route significantly reduced the virus shedding in the trachea and the cloaca for all three challenge viruses. Despite the absence of detectable IgG and IgA responses in birds vaccinated with the M2e-PP via intranasal routes, a similar level of reduction in virus shedding was observed in the IN group compared to the SQ group. Our results supports that the universal vaccine approach using M2e-based vaccine can provide cross-protection against challenge viruses among different HA subtypes although the efficacy of the vaccine should be enhanced further to be practical. Better understanding of the protective immune mechanism will be critical for the development of an M2e-based vaccine in chickens.

Regulation of oncogene expression in T-DNA-transformed host plant cells

Virulent Agrobacterium tumefaciens strains integrate their T-DNA into the plant genome where the encoded agrobacterial oncogenes are expressed and cause crown gall disease. Essential for crown gall development are IaaH (indole-3-acetamide hydrolase), IaaM (tryptophan monooxygenase) and Ipt (isopentenyl transferase), which encode enzymes for the biosynthesis of auxin (IaaH, IaaM) and cytokinin (Ipt). Although these oncogenes are well studied as the tumor-inducing principle, nothing is known about the regulation of oncogene expression in plant cells. Our studies show that the intergenic regions (IGRs) between the coding sequences (CDS) of the three oncogenes function as promoters in plant cells. These promoters possess a eukaryotic sequence organization and cis-regulatory elements for the binding of plant transcription factors. WRKY18, WRKY40, WRKY60 and ARF5 were identified as activators of the Ipt promoter whereas IaaH and IaaM is constitutively expressed and no transcription factor further activates their promoters. Consistent with these results, the wrky triple mutant plants in particular, develops smaller crown galls than wild-type and exhibits a reduced Ipt transcription, despite the presence of an intact ARF5 gene. WRKY40 and WRKY60 gene expression is induced by A. tumefaciens within a few hours whereas the ARF5 gene is transcribed later during crown gall development. The WRKY proteins interact with ARF5 in the plant nucleus, but only WRKY40 together with ARF5 synergistically boosts the activation of the Ipt promoter in an auxin-dependent manner. From our data, we propose that A. tumefaciens initially induces WRKY40 gene expression as a pathogen defense response of the host cell. The WRKY protein is recruited to induce Ipt expression, which initiates cytokinin-dependent host cell division. With increasing auxin levels triggered by ubiquitous expression of IaaH and IaaM, ARF5 is activated and interacts with WRKY40 to potentiate Ipt expression and balance cytokinin and auxin levels for further cell proliferation.

Crown gall development requires the expression of agrobacterial genes in the plant host. These genes are transferred by the T-DNA of the plant pathogen Agrobacterium tumefaciens and include the oncogenes IaaH, IaaM and Ipt, which, according to the tumor-inducing principle, are essential for crown gall development. The oncogenes are involved in auxin and cytokinin production. This results, when at appropriate hormone ratios, in enhanced cell proliferation. The T-DNA transformation process and the encoded oncogene enzymes have been intensively studied, but knowledge of oncogene expression in plant cells and the regulatory host factors is missing. We set out to fill this gap, providing evidence that expression of the Ipt gene is host-cell controlled, whereas the IaaH and IaaM genes are ubiquitously expressed at low levels in T-DNA transformed tissue. This is achieved by A. tumefaciens, which first hijacks transcription factors of the plant pathogen response pathway to activate Ipt oncogene expression and initiates cell proliferation. With increasing auxin levels during the infection process, a transcription factor of the auxin-signaling pathway is recruited, potentiating Ipt gene expression. Thus, for crown gall development, two host-signaling pathways are combined through the interaction of transcription factors that adjust the ratio of cytokinin to auxin.

Targeted proteomics analysis of protein degradation in plant signaling on an LTQ-Orbitrap mass spectrometer

Targeted proteomics has become increasingly popular recently because of its ability to precisely quantify selected proteins in complex cellular backgrounds. Here, we demonstrated the utility of an LTQ-Orbitrap Velos Pro mass spectrometer in targeted parallel reaction monitoring (PRM) despite its unconventional dual ion trap configuration. We evaluated absolute specificity (>99%) and sensitivity (100 amol on column in 1 μg of total cellular extract) using full and mass range scans as survey scans together with data-dependent (DDA) and targeted MS/MS acquisition. The instrument duty cycle was a critical parameter limiting sensitivity, necessitating peptide retention time scheduling. We assessed synthetic peptide and recombinant peptide standards to predict or experimentally determine target peptide retention times. We applied optimized PRM to protein degradation in signaling regulation, an area that is receiving increased attention in plant physiology. We quantified relative abundance of selected proteins in plants that are mutant for enzymatic components of the N-end rule degradation (NERD) pathway such as the two tRNA-arginyl-transferases ATE1 and ATE2 and the two E3 ubiquitin ligases PROTEOLYSIS1 and 6. We found a number of upregulated proteins, which might represent degradation targets. We also targeted FLAGELLIN SENSITIVE2 (FLS2), a pattern recognition receptor responsible for pathogen sensing, in ubiquitin ligase mutants to assay the attenuation of plant immunity by degradation of the receptor.

Effects of dietary levels of glycine, threonine and protein on threonine efficiency and threonine dehydrogenase activity in hepatic mitochondria of chicks

This study was carried out to evaluate the relationship between threonine (Thr) efficiency and Thr dehydrogenase (TDG) activity as an indicator of Thr oxidation on chicks fed with levels of diets (CP [17.5% and 21.5%] and Thr [3.8 and 4.7 g/100 g CP]; glycine [Gly][0.64% and 0.98%] and true digestible Thr [dThr] [0.45% and 0.60%]). Calculation of the Thr efficiency was based on N-balance data and an exponential N-utilization model, and TDG activity was determined as accumulation of aminoacetone and Gly during incubation of hepatic mitochondria. This study found that in the liver of chicks who received a diet containing up to 0.79% Thr (4.7 g Thr/100 g of CP) in the 17.5% CP diet, no significant (p>0.05) effect on TDG activity was observed. However, significantly (p = 0.014) increased TDG activity was observed with a diet containing 21.5% CP (4.7 g Thr/100 g of CP) and the efficiency of Thr utilization showed a significant (p = 0.001) decrease, indicating the end of the Thr limiting range. No significant (p>0.05) effect on the total TDG activity and accumulation of Gly was observed with addition of Gly to a diet containing 0.45% dThr. In addition, addition of Gly to a diet containing 0.60% dThr also did not result in a change in accumulation of Gly. Due to an increase in accumulation of aminoacetone, an elevated effect on total TDG activity was also observed. No significant (p>0.05) reduction in the efficiency of Thr utilization was observed after addition of Gly at the level of 0.45% dThr. However, significantly (p<0.001) reduced efficiency of Thr utilization was observed after addition of Gly at the level of 0.60% dThr. Collectively, we found that TDG was stimulated not only by addition of Thr and protein to the diet, but also by addition of Gly, and efficiency of Thr utilization was favorably affected by addition of Gly at the level near to the optimal Thr concentration. In addition, no metabolic requirement of Gly through the TDG pathway was observed with almost the same accumulation of Gly and a slight increase in TDG activity by addition of Gly. Thus, our findings suggest that determination of TDG activity and parameter of efficiency of Thr utilization may be useful for evaluation of dietary Thr level.

A case of prolonged fever and a diagnosis obscured by an opaque sinus

Prolonged fever in patients can be a diagnostic challenge. Clinicians generally consider infectious diseases, malignant diseases and collagen vascular diseases as possible causes of pyrexia of unknown origin (PUO). Even after extensive evaluation as many as 15 percent of patients with prolonged fever may remain undiagnosed. This case report describes subacute thyroiditis as a cause of prolonged fever and documents how that diagnosis was finally made after 40 days of fever.

Transection of the obturator nerve by an electrosurgical instrument and its immediate repair during laparoscopic pelvic lymphadenectomy: a case report

Obturator nerve injury seldom occurs in gynecologic surgery. However, gynecologic oncologic surgery, including pelvic lymph node dissection, increases the risk of this type of injury. Microsurgical techniques are usually performed for the repair of the nerve injury. Herein the authors report a case of obturator nerve injury caused by an electrosurgical instrument during laparoscopic pelvic lymphadenectomy, and its prompt repair by laparoscopic procedure in a 44-year-old patient with cervical cancer.

Randomised, double-blind trial of carboplatin and paclitaxel with daily oral cediranib or placebo in patients with advanced non-small cell lung cancer: NCIC Clinical Trials Group study BR29

INTRODUCTION

This randomised double-blind placebo-controlled study evaluated the addition of cediranib, an inhibitor of vascular endothelial growth factor receptors 1-3, to standard carboplatin/paclitaxel chemotherapy in advanced non-small cell lung cancer.

METHODS

Eligible patients received paclitaxel (200mg/m(2)) and carboplatin (area under the concentration time curve 6) intravenously every 3 weeks. Daily oral cediranib/placebo 20mg was commenced day 1 of cycle 1 and continued as monotherapy after completion of 4-6 cycles of chemotherapy. The primary end-point of the study was overall survival (OS). The trial would continue to full accrual if an interim analysis (IA) for progression-free survival (PFS), performed after 170 events of progression or death in the first 260 randomised patients, revealed a hazard ratio (HR) for PFS of ⩽ 0.70.

RESULTS

The trial was halted for futility at the IA (HR for PFS 0.89, 95% confidence interval [CI] 0.66-1.20, p = 0.45). A final analysis was performed on all 306 enrolled patients. The addition of cediranib increased response rate ([RR] 52% versus 34%, p = 0.001) but did not significantly improve PFS (HR 0.91, 95% CI 0.71-1.18, p = 0.49) or OS (HR 0.94, 95% CI 0.69-1.30, p=0.72). Cediranib patients had more grade 3 hypertension, diarrhoea and anorexia.

CONCLUSIONS

The addition of cediranib 20mg daily to carboplatin/paclitaxel chemotherapy increased RR and toxicity, but not survival.

The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism

OBJECTIVE

Wider application of CT angiography (CTA) improves the diagnosis of acute pulmonary embolism (PE). It also permits the visualisation of saddle embolism (SE), namely thrombi, which are located at the bifurcation of the main pulmonary artery. The aim of this study was to assess the prevalence of SE and whether SE predicts a complicated clinical course in patients with non-high-risk PE.

METHODS

In total, 297 consecutive patients with non-high-risk PE confirmed using CTA in the emergency department were studied. The presence of SE and its ability to predict the occurrence of major adverse events (MAEs) within 1 month were determined.

RESULTS

Of the 297 patients, 27 (9.1%) had an SE. The overall mortality at 1 month was 12.5%; no significant difference was observed between the SE and non-SE groups (18.5% vs 11.9%, p=0.32). However, patients with SE were more likely to receive thrombolytic therapy (29.6% vs 8.1%, p<0.01) and had significantly more MAEs (59.3% vs 25.6%, p<0.01).

CONCLUSION

At the time of diagnosis, SE, as determined using CTA, is associated with the development of MAE within 1 month. It may be a simple method for risk stratification of patients with non-high-risk PE.

ADVANCES IN KNOWLEDGE

The prognosis of patients with SE, especially those who are haemodynamically stable, is unclear. This study shows that patients with SE, determined with CTA, is associated with the development of MAE.

Association of KIR genes and HLA-C alleles with HPV-related uterine cervical disease in Korean women

This study investigated whether killer-cell immunoglobulin-like receptor (KIR) genes and human leukocyte antigen (HLA)-C alleles, receptors and ligands of natural killer cells are associated with the development of human papillomavirus (HPV)-related cervical disease in Korean women. Blood samples from 132 women with HPV-related cervical disease and 159 women without HPV infection were collected for genotyping of KIR genes and HLA-C alleles. Although no relationship was found between KIR genes and HPV-related cervical disease, a significant relationship was found between HLA-C alleles as ligands of KIR and HPV-related cervical disease. Women with HPV-related cervical disease were found to be significantly more likely to carry HLA-C*0303, particularly those with HPV 16 or 18 infection, and less likely to carry HLA-C*01 compared to women without HPV infection. HLA-C*0303 was found to confer susceptibility to HPV-related cervical disease, whereas HLA-C*01 was found to confer a protective effect against HPV-related cervical disease.

Suppression of PU.1-linked TLR4 expression by cilostazol with decrease of cytokine production in macrophages from patients with rheumatoid arthritis

BACKGROUND AND PURPOSE

The present study assessed the effects of cilostazol on LPS-stimulated TLR4 signal pathways in synovial macrophages from patients with rheumatoid arthritis (RA). These effects were confirmed in collagen-induced arthritis (CIA) in mice.

EXPERIMENTAL APPROACH

Expression of TLR4, PU.1, NF-κB p65 and IκBα on synovial fluid macrophages from RA patients was determined by Western blotting, and cytokines were measured by ELISA. Anti-arthritic effects were evaluated in CIA mice.

KEY RESULTS

Intracellular cAMP was concentration-dependently raised by cilostazol (1-100 μM). Cilostazol significantly suppressed LPS-stimulated increase of TLR4 expression by blocking PU.1 transcriptional activity in RA macrophages. In addition, cilostazol decreased LPS-induced myeloid differentiation factor 88 (MyD88) expression, but not that of TNF receptor-associated factor 6 (TRAF6). Cilostazol also suppressed IkBα degradation and NF-κB p65 nuclear translocation. Moreover, LPS-induced increase of cytokine production (TNF-α, IL-1β) was inhibited by cilostazol, an effect which was accompanied by suppression of IκBα degradation, and NF-κB p65 nuclear translocation. However, expression of anti-inflammatory IL-10 was elevated by cilostazol and forskolin/IBMX. In mice with CIA, post-treatment with cilostazol (30 mg kg⁻¹ day⁻¹) decreased expression of TLR4 in knee joints in association with decreased recruitment of macrophages. Consequently, synovial inflammation, proteoglycan depletion and bone erosion were significantly inhibited by cilostazol treatment.

CONCLUSIONS AND IMPLICATIONS

Cilostazol down-regulated LPS-stimulated PU.1-linked TLR4 expression and TLR4/MyD88/NF-κB signal pathways, and then suppressed inflammatory cytokine production in synovial macrophages from RA patients. Also cilostazol markedly inhibited the severity of CIA in mice.

Diagnostic value of CA125 as a predictor of recurrence in advanced ovarian cancer

PURPOSE

The aim of this study was to establish the guidelines for detecting early recurrences of advanced epithelial ovarian cancer by use of the CA-125 level.

MATERIALS AND METHODS

Eighty-five of the patients who met the inclusion criteria were enrolled in this study. The authors examined 25 incremental changes of CA125 from one to 25 IU/ml, and compared the CA-125 value with other prognostic factors. Increases in the CA-125 level from the nadir level were expressed as CA-125- increments.

RESULTS

Among the 25 increments, a CA-125-8 (eight IU/ml) was selected as the predictor that was the most efficient and time-effective. CA-125-8 had a sensitivity of 91.5%, a specificity of 84.6%, a positive predictive value of 93.1%, a negative predictive value of 81.5%, an efficiency of 89.4%. and a median lead-time of 68.5 days (p <0.0001).

CONCLUSION

The authors suggest the incremented CA-125-8 as a predictor of recurrent advanced ovarian cancer.

Epidemiological classification of infectious bronchitis virus isolated in Korea between 1986 and 1997

Forty Korean isolates and four reference strains of infectious bronchitis virus (IBV) were classified by reverse transcriptase-polymerase chain reaction and restriction fragment length polymorphism (RFLP) analysis. Each Korean isolate was isolated from different types of commercial chicken flocks between 1986 and 1997. RFLP patterns of an amplified DNA fragment (1722 bp) containing the S1 gene of IBV digested by restriction enzyme HaeIII showed that the 40 Korean isolates were classified into five genotypes, I to V. Six of them belonged to genotype I which had the same HaeIII and XcmI cleavage patterns with Massachusetts type (H120 and M41) but the other four genotypes had a different HaeIII cleavage pattern from the four reference IBV strains used in this study. Genotype III seemed to be the major type as 29 of the 40 isolates belonged to this type which was consistently found in the chicken flocks since 1990. On the other hand, genotypes II, IV and V were found in the field only in 1986, 1995 and 1995, respectively. Five isolates selected from each of the five genotypes were inoculated into 1-day-old specific-pathogen-free chicks to evaluate their pathogenicity. Genotype III induced 50% mortality as well as severe renal urate deposition on the kidneys but the other four genotypes only showed respiratory distress at 1 to 2 days after inoculation. Live H120 vaccine protected chicks against challenge with isolates selected from genotype I, but not genotypes IV to V. A live KM91p120 strain selected from major genotype III did protect chicks against challenge with isolates from genotype III, in addition to other genotypes, including two recent isolates of genotypes IV and V.

Learning in fully recurrent neural networks by approaching tangent planes to constraint surfaces

In this paper we present a new variant of the online real time recurrent learning algorithm proposed by Williams and Zipser (1989). Whilst the original algorithm utilises gradient information to guide the search towards the minimum training error, it is very slow in most applications and often gets stuck in local minima of the search space. It is also sensitive to the choice of learning rate and requires careful tuning. The new variant adjusts weights by moving to the tangent planes to constraint surfaces. It is simple to implement and requires no parameters to be set manually. Experimental results show that this new algorithm gives significantly faster convergence whilst avoiding problems like local minima.

Intrarectal administration of mCRAMP-encoding plasmid reverses exacerbated colitis in Cnlp(-/-) mice

Cathelicidin is a pleiotropic host defense peptide secreted by epithelial and immune cells. Whether endogenous cathelicidin is protective against ulcerative colitis, however, is unclear. Here we sought to delineate the role of endogenous murine cathelicidin (mCRAMP) and the therapeutic efficacy of intrarectal administration of mCRAMP-encoding plasmid in ulcerative colitis using dextran sulfate sodium (DSS)-challenged cathelicidin-knockout (Cnlp(-/-)) mice as a model. Cnlp(-/-) mice had more severe symptoms and mucosal disruption than the wild-type mice in response to DSS challenge. The tissue levels of interleukin-1β and tumor necrosis factor-α, myeloperoxidase activity and the number of apoptotic cells were increased in the colon of DSS-challenged Cnlp(-/-) mice. Moreover, mucus secretion and mucin gene expression were impaired in Cnlp(-/-) mice. All these abnormalities were reversed by the intrarectal administration of mCRAMP or mCRAMP-encoding plasmid. Taken together, endogenous cathelicidin may protect against ulcerative colitis through modulation of inflammation and mucus secretion.

The autophagic paradox in cancer therapy

Autophagy, hallmarked by the formation of double-membrane bound organelles known as autophagosomes, is a lysosome-dependent pathway for protein degradation. The role of autophagy in carcinogenesis is context dependent. As a tumor-suppressing mechanism in early-stage carcinogenesis, autophagy inhibits inflammation and promotes genomic stability. Moreover, disruption of autophagy-related genes accelerates tumorigenesis in animals. However, autophagy may also act as a pro-survival mechanism to protect cancer cells from various forms of cellular stress. In cancer therapy, adaptive autophagy in cancer cells sustains tumor growth and survival in face of the toxicity of cancer therapy. To this end, inhibition of autophagy may sensitize cancer cells to chemotherapeutic agents and ionizing radiation. Nevertheless, in certain circumstances, autophagy mediates the therapeutic effects of some anticancer agents. Data from recent studies are beginning to unveil the apparently paradoxical nature of autophagy as a cell-fate decision machinery. Taken together, modulation of autophagy is a novel approach for enhancing the efficacy of existing cancer therapy, but its Janus-faced nature may complicate the clinical development of autophagy modulators as anticancer therapeutics.

Aggressive angiomyxoma of the vulva treated by using a gonadotropin-releasing hormone agonist: a case report

A rare case of a 38-year-old woman with progesterone receptor-positive aggressive angiomyxoma is presented. She underwent local excision and was treated with a gonadotropin-releasing hormone agonist as adjuvant therapy, and is free of disease 20 months after.

A case of bilateral ovarian synchronous tumors (left ovarian serous papillary adenocarcinoma and right ovarian malignant mixed Müllerian tumor)

Synchronous bilateral ovarian cancer is extremely rare and there is no established guideline for management. A case of a 58-year-old multiparous woman with bilateral ovarian synchronous malignant tumors is presented. The clinical consideration and treatment of related cases are discussed.