Prognostic implication of residual inflammatory risk according to disease status in patients treated with percutaneous coronary intervention

Background

Compared with stable angina, acute myocardial infarction (AMI) phenotype is related with the elevated inflammatory activity. However, time-dependent change of inflammatory level and its prognostic implication has not been fully understood according to the disease entity.

Methods

We enrolled total 4,263 patients who underwent percutaneous coronary intervention (PCI) with serial measurement of high-sensitivity C-reactive protein (hsCRP) at on-admission and 1-month post-PCI. The risks of MACE (a composite of death, MI or stroke), and major bleeding were evaluated up to 4 years after procedure.

Results

Compared with the non-AMI group (n=1,887), the AMI group (n=2,376) showed the significant decrease of hs-CRP during 1 month (∇0.5 vs. ∇0.1 mg/L; P<0.001). However, 1-month hs-CRP value still was higher in the AMI group than in the non-AMI group (median: 1.0 vs. 0.9 mg/L; P=0.001). During 1-month follow-up, high vs. low inflammatory risk (upper vs. lower tertile of hs-CRP) was significantly associated with increased rate of MACE in the AMI group (HR: 7.66; 95% CI: 2.29–25.59; P<0.001), but not in the non-AMI group (HR: 0.74; 95% CI: 0.12–4.40; P=0.736). From 1-month to 4-years, patients with high inflammatory risk showed the greater rate of MACE compared to those with low inflammatory risk, in both the AMI (HR: 2.40; 95% CI: 1.73–3.45; P<0.001) and non-AMI (HR: 2.67; 95% CI: 1.80–3.94; P<0.001) groups.

Conclusion

In PCI-treated patients, patients presented with AMI showed the greater values of inflammatory activity and its prognostic implication during the early phase, but combined inflammatory risk appeared similar across the disease entity during the late phase. This result may support that clinical benefit of post-PCI anti-inflammatory treatment would be constant regardless of the disease entity during the stabilized phase.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous coronary intervention in patients with peripheral artery disease and adverse cardiovascular adverse event and bleeding

Background

Peripheral artery disease (PAD) increase the risk of comorbidity and mortality in coronary artery disease (CAD).

Objectives

We evaluate influence of PAD on prognosis in patients undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients included in our dedicated local registry for PCI between January 2011 and December 2016. Presence of PAD was defined by decreased ankle-brachial index (<0.9). Major adverse cardiovascular event (MACE) was defined as a composite of cardiovascular death, non-fatal myocardial infarct, revascularization, and ischemic stroke. Major bleeding was defined as Bleeding Academic Research Consortium 3 or 5.

Results

Among the 4,747 patients who underwent the PCI, 12.9% (n=610) of PAD were identified. Old age (>60 years), renal dysfunction, reduced ejection fraction, and presence of PAD were predictors with both MACE and major bleeding event. Among them, presence of PAD was an independent risk factor of MACE and major bleeding (MACE, HR 8.26, 95% CI 2.33- 29.41, p=0.036; major bleeding, HR 3.11, 95% CI 1.10–10.63, p=0.040, respectively). The MACE and major bleeding rate at 5-year was significantly increased in patients with PAD (MACE, 30.0% vs. 15.8%, log rank test p<0.001; major bleeding, 6.7 vs. 3.6%, log rank test p=0.003, respectively) (Figure).

Conclusion

Presence of PAD was strongly associated with higher rate of long-term MACE and major bleeding. These findings could have a clinical relevance in requiring individualized pharmacologic strategies to reduce the burden of cardiovascular disease.

Funding Acknowledgement

Type of funding sources: None.

Impact of active and stable cancer on survival in patients undergoing percutaneous coronary intervention

Background

With advances in treatment of ischemic heart disease and cancer treatment, use of percutaneous coronary intervention (PCI) in cancer survivors and patients with active cancer (AC) is expanding.

Objectives

The purpose of this study was to determine the impact of cancer on survival and major cardiovascular events (MACE) in a long-term, single-center cohort of patients treated with PCI.

Methods

Patients treated with PCI between January 2010 and December 2017 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. AC was included patients with cancer diagnosed within the past 6 months, patients who had cancer-related therapy within the past 6 months, active metastatic disease, or active recurrence of the cancer. The primary endpoints were 5-year survival and a secondary endpoint was 5-year MACE.

Results

A total of 6,743 patients (age 66±12 years, 68.4% men) treated with PCI were included: 6,404 (95.0%) controls, 245 (3.6%) SC, and 94 (1.4%) AC. Predominant malignancies were gastrointestinal (37.4%), lung (22.7%), and genitourinary cancer (14.7%). No differences were observed between patients with AC, SC and controls regarding 5-year MACE (total MACE, 33.2% vs. 28.1% vs. 17.5%, p=0.072; cardiac death, 13.6% vs. 9.1% vs. 6.7%, p=0.066; non-fatal myocardial infarction, 2.9% vs. 7.5% vs. 7.8%, p=0.820; revascularization, 17.9% vs. 17.6% vs. 11.6%, p=0.794, respectively). Patients with AC and SC had reduced 5-year survival compared with controls (62.0% vs. 81.5% vs. 89.8%, p<0.001) (Figure). AC was associated with a 1.76 (95% CI 1.22 to 2.54, p=0.002) fold increased risk of all-cause 5-year mortality in multivariable adjusted models.

Conclusions

Cumulative incidence of 5-year survival was discriminated by concurrent status of cancer following PCI. Individualized decision making is needed in the routine practice of PCI regarding concurrent cancer-specific treatment and prognosis.

Funding Acknowledgement

Type of funding sources: None.

P1416 Clinical importance of consecutive transthoracic echocardiography in the patients with hypertrophic cardiomyopathy

Funding Acknowledgements

nothing

OnBehalf

nothing

Background

prediction of outcomes Hypertrophic cardiomyopathy (HCM) have been robustly analyzed with echocardiography. However, there is limited data of serial follow-up (FU) transthoracic echocardiography (TTE) to predict outcomes in patients with HCM.

Objectives

This study aim is to discover clinical predictors associated with consecutive TTE follow-up in patients with HCM.

Methods

From 2010 to 2016, 162 patients with HCM were enrolled retrospectively. Concentric LVH and others systolic disease related to wall thickness were excluded. Index TTE (baseline) was measured when firstly admitted in our hospital. FU TTE was analyzed at the end of follow-up, defined as the last recorded value in patients who did not develop events or the last recorded value before events developed.

Results

The average of FU TTE and clinical FU period was 3.7 ± 2.0 years. Clinical outcomes were defined as stroke, syncope, heart failure, arrhythmia and death. Interestingly, only baseline TR V max was a predictor for clinical outcome whereas the others echo parameters were not associated with events (Table 1). KM curve showed the TR Vmax ≥2.5m/s was also significant (log rank = 0.008, Fig 1.)

Conclusions Our study showed short-term FU TTE did not bring clinician with clinical benefits in the aspect of prediction for events. Only baseline TR V max was good correlation with cardiovascular outcomes and even in the survival analysis.

Serial TTE and changed values Total N = 162 index TTE (baseline) FU TTE Change of FU per year event no event p-value event no event p-value event no event p-value IVDd, mm 14 ± 4 15 ± 5 0.500 15 ± 5 14 ± 5 0.758 0.23 ± 0.51 -0.07 ± 1.27 0.200 LVIDd, mm 47 ± 5 48 ± 6 0.256 47 ± 7 48 ± 6 0.560 -0.22 ± 2.79 0.10 ± 2.27 0.444 LVEF, % 62 ± 5 61 ± 7 0.379 61 ± 6 61 ± 10 0.927 -0.43 ± 3.10 -0.04 ± 4.94 0.620 LAVI 43 ± 9 43 ± 8 0.879 57 ± 27 58 ± 23 0.849 0.53 ± 14.5 3.11 ± 7.2 0.134 EA ratio 0.9 ± 0.6 0.9 ± 0.6 0.782 1.0 ± 0.8 0.9 ± 0.6 0.595 -0.02 ± 0.76 0.003 ± 0.027 0.594 DT,ms 196 ± 58 201 ± 62 0.603 203 ± 91 217 ± 89 0.370 17 ± 57 5 ± 40 0.154 septal e` 4.4 ± 2.1 4.2 ± 1.6 0.585 4.4 ± 1.6 4.6 ± 1.7 0.438 0.24 ± 0.91 0.05 ± 0.65 0.190 E of e` 17 ± 11 17 ± 23 0.993 15 ± 9 15 ± 6 0.726 -0.48 ± 4.42 -1.66 ± 22.78 0.728 TR velocity 2.6 ± 0.5 2.4 ± 0.4 0.012 2.7 ± 0.6 2.6 ± 0.4 0.604 0.05 ± 0.30 0.04 ± 0.18 0.905 Max wall thickness 17 ± 3 18 ± 3 0.137 17 ± 4 17 ± 3 0.888 -0.01 ± 2.19 -0.18 ± 1.14 0.522

Abstract P1416 Figure. TR Vmax and CV outcomes in the KM curve

P3637Relationship between serial measurements of NT-proBNP and cardiovascular events in patients with acute coronary syndrome

Background

Increased level of natriuretic peptides has been known as an important predictors of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS). We sought to evaluate clinical implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at initial and follow-up periods.

Methods

Serial NT-proBNP levels (on-admission and one-month post-PCI) were measured in ACS patients undergoing PCI (n=2,290). High NT-proBNP levels were determined according to the predefined age-specific criteria. Patients were stratified into 4 groups according to NT-proBNP levels (on-admission & one-month): (1) normal-normal group (n=1234, 53.9%); (2) high–normal group (n=257, 11.2%); (3) normal-high group (n=376, 16.4%); and (4) high-high group (n=423, 18.5%). Clinical events were defined as all-cause death and MACE (a composite of CV death, non-fatal MI, and ischemic stroke).

Results

With a median follow-up of 35.9 (IQR: 16.8, 54.5) months, all-cause death and MACE were occurred in 4.1% and 7.2%, respectively. NT-proBNP on-admission vs. at one-month did not differ significantly (median 391.6 [IQR: 143.9, 1402.3] vs. median 619.1 [IQR 240.1, 1616.1]; p=0.622), but the prevalence of high NT-proBNP was increased over time (25.3% to 34.9%; p<0.001). The rates of all-cause death and MACE significantly increased only in the high-high group compared with other groups (log-rank test, all p values <0.001, Figure). After adjustment, the high-high group remained significantly risky in terms with the occurrence of all-cause death (HR, 2.99; 95% CI, 1.65 to 5.41; p<0.001) and MACE (HR, 1.96; 95% CI, 1.28 to 3.01; p=0.002).

Figure 1

Conclusion

Serial measurements of NT-proBNP at on-admission and follow-up can help to stratify the risks of all-cause death and adverse CV events following PCI in ACS patients. About two-fifths of patients having high NT-proBNP level during hospitalization can be classified into the low-risk group for all-cause death and adverse CV events.

Acknowledgement/Funding

None

Overexpression of HSP47 in esophageal squamous cell carcinoma: clinical implications and functional analysis

Several biomarkers of esophageal squamous cell carcinoma (ESCC) have been explored to improve the prognosis of this disease. One of these, the 47-kDa heat shock protein (HSP47), has been screened as a potential biomarker by genomic profiling and is known to be overexpressed in some malignant diseases. In this study, we explored the role and evaluated the prognostic value of HSP47 expression in ESCC. The function of this protein was analyzed by assaying proliferation, wound healing, and colony formation in an HSP47-knockdown ESCC line. The prognostic implication of HSP47 expression was analyzed by immunohistochemical staining in 157 surgical specimens. HSP47 expression level and other clinical variables were analyzed using multivariate Cox proportional hazards models. Silencing of the HSP47 gene in the ESCC cell line inhibited cell proliferation and colony formation. HSP47 was highly expressed in ESCC tissue samples, compared with normal esophageal tissues. The level of immunohistochemical staining of HSP47 and pathologic stage were significantly correlated with overall and recurrence-free survival, as shown by multivariate analysis (P = 0.014 and 0.044, respectively). We found that overexpression of HSP47 is associated with poor prognosis in patients with ESCC and that this is consistent with the function of HSP47 in terms of increased cell proliferation and colony formation. These results suggest that HSP47 is a potential prognostic biomarker for ESCC and merits further research for novel diagnostic and therapeutic applications.

Impact of chemical peeling combined with negative pressure on human skin

OBJECTIVE

In vivo changes in skin barrier function after chemical peeling with alpha hydroxyacids (AHAs) have been previously reported. However, the additional effects of physical treatment with chemical agents on skin barrier function have not been adequately studied. This study measured the degree of acute skin damage and the time required for skin barrier repair using non-invasive bioengineering methods in vivo with human skin to investigate the additional effect of a 4% AHA chemical jet accelerated at supersonic velocities.

METHODS

Thirteen female subjects (average age: 29.54 ± 4.86 years) participated in this study. The faces of the subjects were divided into half according to the block randomization design and were then assigned to receive AHA peeling alone or AHA peeling combined with pneumatic pressure on each side of the face. Transepidermal water loss (TEWL), skin colour and skin blood flow were evaluated at baseline and at 30 min, 2, 5 and 7 days after treatment.

RESULTS

The TEWL and skin blood flow were significantly increased after 30 min in chemodermabrasion compared with chemical peeling alone (P < 0.05). The TEWL and skin blood flow recovered to baseline after 2 days, and TEWL was significantly decreased at 7 days compared with chemical peeling alone (P < 0.05).

CONCLUSIONS

Chemodermabrasion can temporarily impair skin barriers, but it is estimated that it can enhance the skin barrier function after 7 days compared to the use of a chemical agent alone. In addition, chemodermabrasion has a more effective impact in the dermis and relatively preserves the skin barrier.

A proposal of a standardized protocol to evaluate waterproof effect of eyeliner and mascara

OBJECTIVE

Eye make-up products must have waterproofing properties to make sure that their colours do not smudge or wash away easily and remain intact despite water or perspiration. Until now, most research has focused on composition and components of make-up products and not on the level of waterproof. This study aimed to find methods to assess the waterproof degree of eyeliners and mascaras and determine the suitability of these methods.

METHODS

Twenty female subjects were selected to test the waterproof of eyeliners, whereas 20 sets of false eyelashes were used to evaluate the waterproof of mascaras. For evaluating water-resistant properties, after test sites where eyeliners and mascaras were applied were immersed in water and natural drying for over 20 min (not artificial drying by drier etc.), L* value of the eyeliners applied on the forearm before and after the immersions, and intensity analysis values of mascaras applied on the false eyelashes were used to calculate the mean percentage waterproof removal ratio (%WPR). A product was hypothesized to be water resistant if the value for the mean %WPR was ≤50%.

RESULTS

The non-waterproof eyeliners were not waterproof if their mean %WPR was >50%, whereas the waterproof eyeliners were waterproof if their mean %WPR was <50%. For mascaras, the mean %WPR was <50% after 1- to 2-h marks after immersion in water for both non-waterproof and waterproof products. After 3-4 h, the mean %WPR for the non-waterproof mascaras was >50%, rendering them not waterproof, whereas the mean %WPR for the waterproof mascaras was <50%, making them waterproof.

CONCLUSION

We have evaluated the waterproof properties by analysing photographed images of the test sites where eyeliners and mascaras were applied. Results of the comparison between non-waterproof and waterproof eyeliners and mascaras, and the methods used, in particular, will be found useful in evaluating waterproof of other make-up products.

Complications in Stent-Assisted Endovascular Therapy of Ruptured Intracranial Aneurysms and Relevance to Antiplatelet Administration: A Systematic Review

BACKGROUND AND PURPOSE

Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms.

MATERIALS AND METHODS

A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms.

RESULTS

Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%-13.6%), 5.4% (95% CI, 4.1%-7.2%), and 3.6% (95% CI, 2.6%-5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms.

CONCLUSIONS

On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.

Analysis of comedone, sebum and porphyrin on the face and body for comedogenicity assay

BACKGROUND/PURPOSE

Many ingredients used in cosmetics evoke a comedogenic response. Rabbit ear model (REM) is a useful method that can replace human in examining materials and products in early developmental stage. However, a number of studies pointed out its disadvantage that it overreacts to comedogenic materials. The purpose of this study was to find the most appropriate region for evaluating comedogenicity in human skin.

METHODS

Sixty-six female subjects (age 32.48 ± 10 years; range 20-52 years) with mild to moderate facial acne lesions were included in this study. The whole face, upper chest, and back of volunteers were photographed. Lesion (closed and open comedones) counting, instrumentation of sebum secretion level, and analysis of porphyrin number were performed. The entire study was performed under environmental conditions of specific relative temperature and humidity, controlled and maintained identically for each volunteer.

RESULTS

In case of closed comedone, forehead showed a significant correlation with frontal cheek, lateral cheek, chin, and upper back. Meanwhile, significant correlations were observed between frontal cheek and chin as well as lateral cheek and chest. As for open comedone, forehead showed a significant correlation with chin site. A significant correlation was also observed between front cheek and lateral cheek as well as between upper chest and back. Analyzing the correlation between the occurrence of comedones and sebum in each region, a significant correlation between closed comedone and sebum was observed in frontal and lateral cheek. Analyzing the correlation between the occurrence of comedones and porphyrine in each region, a significant correlation between open comedone and porphyrin was observed in chin.

CONCLUSION

When evaluating the comedogenicity of cosmetics ingredients or products, this study recommends using both of the methods of testing on back and directly testing on face according to the characteristics of the materials. In case of mild potent ingredients or products in particular, verification through usability test that the directly test on face will help securing reliability.

The effect of physically applied alpha hydroxyl acids on the skin pore and comedone

OBJECTIVE

Alpha hydroxy acids (AHA) have been recognized as commonly used therapy for acne. Our studies examined whether an additional effect of physical treatment using chemical peeling combined with negative pressure and compared with AHA treatment only occurs in acne-prone subjects.

METHODS

The chemical peeling agent used 4% of an AHA solution (mixture of 1000 mL of carbonated water, 20 mL of glycolic acid and 20 mL of lactic acid). All subjects' faces were randomly divided into test and control groups. The test group was treated with chemical peeling combined with a physical effect, and the control group applied chemical peeling alone. For the 23 healthy females (average age: 30.17 ± 5.06 year), we measured sebum output level by light transmission, pore area and number by optical image analyser, and comedone counting before treatment and at 1, 2 and 4 weeks after a single treatment.

RESULTS

Compared to the before treatment, whiteheads and blackheads were significantly decreased at 1, 2 and 4 weeks in the test group (P < 0.05), but for the control group, whiteheads and blackheads showed a tendency to decrease at 1, 2 and 4 weeks. Also at 1 week, whiteheads and blackheads of the test group significantly decreased compared to the control group (P < 0.05). Pore area and number significantly decreased at 1 week (P < 0.05), and the sebum output level was significantly decreased at 4 weeks (P < 0.05) only in the test group, which did not show any significant group difference for individual parameters.

CONCLUSION

4% AHA solution combined with a physical effect had rapidly improving effects on whiteheads and blackheads synergistically. Combined physical therapy may have more impact on pore size and seborrhoea.

The impact of depression and somatic symptoms on treatment outcomes in patients with chronic prostatitis/chronic pelvic pain syndrome: a preliminary study in a naturalistic treatment setting

AIM

The aim of this study was to evaluate the impact of depression and somatic symptoms on treatment outcomes in Korean male patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) attending a routine clinical practice.

METHODS

This was a 12-week prospective observational study (n = 80). The Korean version of the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) to measure the severity of CP/CPPS, the Korean version of the Patient Health Questionnaire-9 (PHQ-9) to assess depression, the Korean version of the Patient Health Questionnaire-15 (PHQ-15) to evaluate somatisation and the Korean version of the EuroQol Questionnaire-5 Dimensions (EQ-5D), specifically the EQ-5D utility index and the EQ-5D visual analogue scale (EQ-5D VAS), to assess quality of life, were utilised and given at baseline and week 12. The primary and secondary end-points in this study were changes in the NIH-CPSI total score from baseline to week 12 according to depression and somatisation.

RESULTS

The change in NIH-CPSI total score was significantly higher in those without depression than in those with depression (p = 0.003), with a magnitude of difference of 2.8. The responder rate (a ≥ 4 point decrease in NIH-CPSI total score from baseline) was significantly higher in those without depression (42.9%) than in those with depression (17.2%, p = 0.023). However, significant differences were not observed between the two groups in the other outcome measures or in all study outcomes between subjects with or without somatisation. A logistic regression analysis revealed that the presence or absence of depression may be a principal predictor of response to treatment.

CONCLUSION

These preliminary results indicate that depression may have a negative impact on treatment outcome and is a likely predictor of response to treatment in patients with CP/CPPS. However, additional studies with adequate power and improved design are necessary to further support the present findings.

A quantitative evaluation method of skin texture affected by skin ageing using replica images of the cheek

OBJECTIVE

Skin texture is a fine structure of skin surface where the hill and furrow were crossed to form a star shape. This study was performed to establish a quantitative evaluation method of skin texture affected by skin ageing using replica images of the cheek.

METHODS

After producing replicas of the left cheek areas of 80 female subjects, representative replica images were chosen to establish six-level facial skin texture index. Using this new index, skin texture of different-aged subjects was visually assessed by multiple examiners. The number of star configurations was also analysed using the same replica images. Other factors contributing to skin texture, such as skin elasticity, roughness, dermal density, moisture and gloss, were also analysed.

RESULTS

The concordance between skin texture scores evaluated by three researchers was high (0.896), and there was a high correlation between skin texture score and age (r = 0.642). The number of star configurations showed high correlations with skin texture scores (r = 0.753) and with age (r = 0.776). Skin texture scores were highly correlated with skin roughness and dermal density, but not with moisture, gloss and elasticity.

CONCLUSION

This study suggests that visual grading of skin texture score based on new facial skin texture index and quantification of star configurations will be useful in evaluating skin ageing.

The seasonal variation in skin hydration, sebum, scaliness, brightness and elasticity in Korean females

BACKGROUND/PURPOSE

Age, gender, regional, and ethnic differences influence skin conditions. The purpose of this study was to observe the effects of environments, especially the air temperature, relative humidity, air pressure, duration of sunshine, and precipitation on skin, and the seasonal variation in skin hydration, sebum, scales, brightness, and elasticity in Korean females.

METHODS

The study included 89 Korean subjects, aged 29.7 ± 6.2 years. The five skin biophysical parameters (skin hydration, sebum, scales, brightness, and elasticity) were measured at six sites: forehead, under the eye, frontal cheek, crow's foot, lateral cheek, and inner forearm. Skin hydration was measured using the Corneometer® CM 825. Skin sebum was measured with Sebumeter® SM 815. Skin scaliness was measured with Visioscan® VC 98. Skin brightness (L* value) was measured by using Spectrophotometer. A suction chamber device, Cutometer® MPA 580, was used to measure the skin elasticity. The measurements were performed every month for 13 months, from April 2007 to April 2008.

RESULTS

There were significantly seasonal variations in environmental factors. The air temperature was the lowest in January (-1.7°C), and the highest in August (26.5°C). The relative humidity was the lowest in February (46%), and the highest in July and August (75%). There was a negative correlation between skin scaliness and three environmental factors such as air temperature, relative humidity, and highest precipitation. There was a positive correlation between skin scaliness and two environmental factors such as air pressure and duration of sunshine. Elasticity was correlated with air temperature positively and with air pressure negatively.

CONCLUSION

The correlations shown between the skin biophysical parameters and environmental factors demonstrate that the skin biophysical parameters are affected by environmental factors.

Twelve-month medication persistence in men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

AIMS

This study aimed to assess patients' baseline characteristics and provider factors influencing the continuation of medication for 12 months in patients who were newly diagnosed with benign prostatic hyperplasia (BPH).

METHODS

This study was conducted in patients with newly diagnosed lower urinary tract symptoms (LUTS)/BPH (age ≥ 40) who received either one or a combination of the two pharmacological classes of drugs (alpha-blockers or 5-alpha-reductase inhibitors) from January 2008 to January 2010. Patient demographics and clinical data were assessed from the electronic patient records and telephone surveys. Persistence was defined as continuation of all BPH medications prescribed at the start of the first treatment. Logistic regression analysis was used to evaluate the association between 12-month persistence and patient or provider factors.

RESULTS

Of the 789 newly diagnosed LUTS/BPH patients, 670 (84.9%) were included in the study. Twelve-month persistence for LUTS/BPH medication was 36.6%. Independent predictors of 12-month medication persistence included larger prostate volume, higher prostate specific antigen, having an adequate income and a good patient-doctor relationship. Important reasons for discontinuation were resolved symptoms (31.1%), no improvement in symptoms (23.7%) and adverse events (20.0%).

CONCLUSIONS

About two-thirds of newly diagnosed LUTS/BPH patients discontinued medications within 1 year of starting treatment. We found several potential patient and provider factors associated with persistence, which could be exploited to increase continuation of treatment in future clinical settings.

Primary irritation index and safety zone of cosmetics: retrospective analysis of skin patch tests in 7440 Korean women during 12 years

BACKGROUND

Cosmetics are products used over long periods by the public, and their safety is very important. Several types of human tests are used widely for the evaluation of cosmetics including single patch tests, in-use tests, human repeated insult patch test (HRIPT). However, there is no clear and well-defined published objective and standardized criteria for primary skin irritation in regard to the large variety of cosmetic products.

METHODS

This study analysed human patch tests conducted from May 2001 to December 2012 with 4606 materials of prototype or finished cosmetic products on 7440 normal Korean women aged 18-60 years. The tested products were patched under occlusion for 24 or 48 h, and skin tolerance was assessed twice at 30 min and 24 h after patch removal using a 5-step scale according to the CTFA guidelines.

RESULTS

Human patch tests for cosmetics were performed of 4606 cases, and 30-33 subjects participated in each case. The response in each case was calculated based on total subject number, skin reaction intensity and the number of respondents. The calculated response was standardized using the z-score, and a safety zone was provided in terms of human primary irritation in accordance with the human skin reaction evaluation criteria and usage or formula of cosmetics.

CONCLUSIONS

This study established the safety criteria for irritation in the cosmetics field.

Successful endosaccular coiling after a balloon occlusion test of the caudal channel of a double origin of the posterior inferior cerebellar artery originating from the aneurysm neck

Therapeutic strategies for unruptured aneurysms in elective procedures must be carefully planned with respect to safety. We describe the case of a patient who presented with an unruptured aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA), a rare variant of aberrant origin. A three-dimensional rotational angiogram clearly showed that the aneurysm incorporated the origin of the DOPICA caudal channel, which was more dominant than the cranial one. The aneurysm was completely obliterated using detachable coils after a balloon occlusion test (BOT) of the caudal channel was conducted to confirm the tolerance of the patient following sudden interruption of the more prominent flow coming from the caudal channel of the DOPICA. This report affirms the need to suspect anomalies associated with a DOPICA that predispose to intracranial aneurysms and highlights the potential role of a BOT in pretreatment hemodynamic evaluations of unusual aneurysms accompanying a particular developmental anomaly.

Effects of repeated dosing with Udenafil (Zydena) on cognition, somatization and erection in patients with erectile dysfunction: a pilot study

The PDE5 inhibitors have recently been found to have cognitive-enhancing effects in animal models. To investigate the efficacy of repeated dosing with a PDE5 inhibitor on cognitive function and somatization in patients with erectile dysfunction, 27 patients with erectile dysfunction received udenafil (100 mg) at 3-day intervals for 2 months. The international index of erectile function-5 (IIEF-5), a cognitive battery (the Korean version of mini-mental state examination (K-MMSE), the frontal assessment battery (K-FAB), the Seoul verbal learning test) and a physical health questionnaire-15 (PHQ-15) were performed at baseline and at 2 months, following the administration of udenafil. The patients were divided on the basis of their IIEF-5 score into responders (change>7) and non-responders. The mean IIEF-5 score was significantly increased after treatment (7.92 ± 3.83 to 16.33 ± 4.75, P<0.001). The scores of K-MMSE (27.03 ± 1.58 to 28.07 ± 1.57, P=0.001), K-FAB (13.65 ± 1.96 to 15.41 ± 1.85, P<0.001) and PHQ-15 (18.92 ± 4.96 to 17.63 ± 4.75, P=0.003) were significantly improved after treatment. In addition, the responders (n=16) had more improved cognitive function (r=0.603, P=0.001) and somatization (r=-0.402, P=0.038) than non-responders (n=11). Repeated dosing with a PDE5 inhibitor seems to improve cognitive function and somatization, as well as erectile function in patients with erectile dysfunction.

Relationship between clinical features of facial dry skin and biophysical parameters in Asians

There have been few reports classifying the biophysical characteristics of Korean women with healthy skin. Consequently, the aim of this study was to find the most useful parameters for categorizing skin types based on a clinical assessment. One hundred and three female volunteers, aged 20-59, participated in this study. We conducted a self-evaluation questionnaire, a clinical assessment of the facial skin, and non-invasive measurements on the cheek under controlled environmental conditions. The questionnaire survey indicated that 72% of respondents had dry skin. However, results of the clinical assessment focusing on skin roughness and scaling of the cheek showed that 6 subjects had very dry skin (6%), 29 had dry skin (28%) and 68 had normal skin with sufficient moisture (66%). We analysed the correlation between the clinical assessment and biophysical parameters. As a result, we obtained six biophysical parameters that had relatively higher correlations with clinical assessment than other parameters. Our study provided general information about the physiological characteristics of normal skin in Korean women and suggested useful parameters for characterizing dry skin.

Significance of smoking history and FDG uptake for pathological N2 staging in clinical N2-negative non-small-cell lung cancer

BACKGROUND

This study was conducted to evaluate whether smoking history and the standardized uptake value (SUV) of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) uptake are associated with unexpected pathological N2 status (pN2) in non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We analyzed the data of 220 patients who underwent surgical resection with clinical N2-negative status on computed tomography (CT) and positron emission tomography (PET)-CT. The maximum SUV of primary tumor was chosen for logistic analysis.

RESULTS

Seventy-two patients (33%) had never smoked. The SUV ranged from 1.0 to 29.0 (median 9.1). In univariate analysis, adenocarcinomas (P = 0.019), female gender (P = 0.010), N1 on CT (P = 0.025), and N1 PET-CT (P = 0.001) were associated with a high probability of pN2. The proportion of pN2 in never smokers was higher than in ever smokers (26% versus 10% respectively; P = 0.002). The SUV remained on a multivariate logistic model (odds ratio 1.1; 95% confidence interval 1.0-1.2; P = 0.010) and it had a better predictive value in never smokers than in ever smokers (P = 0.017).

CONCLUSIONS

This study indicates an association between smoking history and pN2 in clinically negative N2 NSCLC. The different roles of FDG uptake were also suggested based on smoking history.

An unusual case of knee locking

Knee locking is an incapacitating condition that requires urgent orthopaedic intervention. The most common cause is meniscal injury, followed by torn anterior cruciate ligament, osteochondral loose bodies and foreign bodies in the joint space. This report describes a patient who had an unusual case of left knee locking. After clinical examination and radiological investigations, the provisional diagnosis was a lateral meniscal tear, which was not visible on magnetic resonance imaging. Diagnostic arthroscopy of the left knee revealed a 1-cm yellowish lump on the medial meniscus, and the histology revealed pigmented villonodular synovitis. The menisci and cruciate ligaments were intact.

Management and clinical outcome of acute basilar artery dissection

BACKGROUND AND PURPOSE

There have been inconsistencies on the prognosis and controversies as to the proper management of acute basilar artery dissection. The aim of this study was to evaluate acute basilar artery dissection and its outcome after management.

MATERIALS AND METHODS

A total of 21 patients (mean age, 53 years; range, 24-78 years) with acute basilar artery dissection were identified between January 2001 and October 2007. Clinical presentation, management, and outcomes were retrospectively evaluated.

RESULTS

The patients presented with subarachnoid hemorrhage (n = 10), brain stem ischemia (n = 10), or stem compression sign (n = 1). Ruptured basilar artery dissections were treated by stent placement with coiling (n = 4), single stent placement (n = 3), or conservatively (n = 3). Of the patients treated with endovascular technique, 6 had favorable outcome (modified Rankin scale [mRS], 0-2) and the remaining patient, who was treated by single stent placement, died from rebleeding. All 3 conservatively managed patients experienced rebleeding, of whom 2 died and the other was moderately disabled. Unruptured basilar artery dissections were treated conservatively (n = 7) or by stent placement (n = 4). Of the patients with unruptured basilar artery dissection, 9 had favorable outcome and the remaining 2 patients, both of whom were conservatively managed, had poor outcome because of infarct progression. The group with the ruptured basilar artery dissection revealed a higher mortality rate than the group with the unruptured dissection (30% vs 0%). The group treated with endovascular means revealed more favorable outcome than the group that was treated with conservative measures (90.9% vs 50%).

CONCLUSION

The ruptured basilar artery dissections were at high risk for rebleeding, resulting in a grave outcome. Stent placement with or without coiling may be considered to prevent rebleeding in ruptured basilar dissections and judiciously considered in unruptured dissections with signs of progressive brain stem ischemia.

No association of high-risk human papillomavirus with esophageal squamous cell carcinomas among Koreans, as determined by polymerase chain reaction

The incidence of esophageal squamous cell carcinoma varies greatly with race and geographic location. It has been suggested that human papillomavirus (HPV) is involved in the pathogenesis of esophageal cancers, and that the incidence of esophageal cancers associated with HPV depends on the geographic location of the patient population. In studies performed on tumor specimens collected from areas with a low incidence of esophageal squamous cell carcinomas, HPV infection was detected in only a small percentage of tumors, whereas studies performed on specimens obtained from areas with a high incidence of esophageal squamous cell carcinomas provided strong evidence that HPV plays a significant role in esophageal carcinogenesis. To elucidate the putative role of HPV infection in the etiology of esophageal cancer in Korea, a total of 129 formalin-fixed, paraffin-embedded tumor specimens, eight fresh tumor tissues and 40 normal esophageal tissues were screened for HPV infection by polymerase chain reaction using consensus primers for HPV types 16, 18, 31, 33, 35, 52b and 58 and type 16-specific primers. SiHa cell line, formalin-fixed, paraffin-embedded cervical squamous cell carcinoma specimens were used as positive controls for HPV infection. Fragments of human beta-globin gene, which served as the internal controls, were successfully amplified from 102 of the 129 cancer specimens and from all the normal and fresh cancer tissues, while consensus and type 16-specific primers failed to detect HPV DNA sequences in any of the esophageal samples. The DNA extracted from the SiHa cell line and uterine cervical cancers were positive when both the consensus and type-specific primers were used. The results of this study suggest that HPV is not associated with esophageal carcinogenesis in Korea.

Seizure control of Gamma Knife radiosurgery for non-hemorrhagic arteriovenous malformations

OBJECTIVES

Although radiosurgery has been found to be a safe and effective alternative treatment, seizure outcome of arteriovenous malformation (AVM) radiosurgery has not been documented in detail. We report the effect of Gamma Knife radiosurgery (GKRS) on seizures associated with AVMs and discuss the various factors that influence the prognosis.

MATERIAL AND METHODS

Between 1992 and 2004, 246 patients were treated with GKRS for AVMs at Kyung-Hee medical center. Forty five (17.0%) patients have non-hemorrhagic AVMs and presenting symptom was seizure. Two patients of all were excluded from this study due to loss of follow-up after radiosurgery. In this study, retrospective analysis of clinical characteristics, radiologic findings, radiosurgical seizure outcome were performed.

RESULTS

There were 32 male and 11 female with age ranging from 10 to 74 years (mean 35 years). Type of seizure included: general tonic clonic (n = 28); focal motor or sensory (n = 7); partial complex (n = 8). The location of AVM was temporal (n = 18); frontal (n = 9); deep seated (n = 7): parietal (n = 5); occipital (n = 4). Follow-up period was from 8 months to 12 years (mean 46 months). Mean volume was 6.2 cc (2.7-20), mean marginal and maximal dosage was 19.5 (17-26) and 36.6 Gy (13-50). During follow-up after radiosurgical treatment, 23 (53.5%) of 43 patients were seizure-free, 10 (23.3%) had significant improvement, were unchanged in 8 (18.6%) and aggravated in 2 (4.6%) patients. In 33 patients, follow-up angiography or MRI was performed. Complete obliteration was achieved in 16 (49.0%) patients, partial obliteration in 13 (39.0%). Four were unchanged (12.0%). Of 33 patients with follow-up performed, 26 were followed for over 2 years. Eleven (84.6%) of 13 patients with complete obliteration were seizure-free (p < 0.005). Four (36.3%) of 13 with partial obliteration and unchanged remained seizure-free. Fifteen patients had experienced intractable seizure before radiosurgery. After radiosurgery, seizures disappeared in 8 (53%) patients. Seizure frequently decreased in 5 (33%) and 2 patients (14%) were unchanged but none was aggravated. Five (71%) of 7 patients with complete obliteration were seizure-free and 2 (40%) of 5 patients with partial obliteration were seizure-free.

CONCLUSION

Up to now, controversy about resective surgery or radiosurgery as treatment of seizure related to AVMs still remains. In this study, we experienced that Gamma Knife radiosurgery is commonly performed to treat AVMs and can improve symptomatic seizure associated with AVMs. To clarify the mechanism of seizure control in AVMs radiosurgery is difficult, but it seems to be closely related to hemodynamic effects after radiosurgery.

Gastrointestinal stromal tumors: overview of pathologic features, molecular biology, and therapy with imatinib mesylate

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors develop at any site but are most commonly reported in the stomach. They originate from the neoplastic transformation of the intestinal pacemaker cell, the interstitial cell of Cajal. GISTs strongly express the receptor tyrosine kinase KIT and have mutations in the KIT gene, most frequently in exon 11 encoding the intracellular juxtamembranous region. Expression of KIT is seen in almost all GISTs, regardless of the site of origin, histologic appearance, or biologic behavior, and is therefore regarded as one of the key diagnostic markers. Distinction from smooth muscle tumors, such as leiomyosarcomas, and other mesenchymal tumors is very important because of prognostic differences and therapeutic strategies. Predicting the biologic behavior of GISTs is often difficult by conventional pathologic examination; tumor size and mitotic rate are the most important prognostic indicators. The prognostic significance of KIT mutations is controversial and thus far has not been clearly linked with biologic behavior. KIT mutations are associated with tumor development, and cytogenetic aberrations are associated with tumor progression. The pathogenesis of GISTs involves a gain-of-function mutation in the KIT proto-oncogene, leading to ligand-independent constitutive activation of the KIT receptor. KIT-wild-type GISTs have shown mutually exclusive platelet-derived growth factor receptor (PDGFR) mutation and activation. The use of imatinib mesylate (also known as Gleevec or STI-571) has greatly increased the therapeutic efficacy for this otherwise chemotherapy-resistant tumor. GISTs with very low levels of KIT expression may respond to imatinib mesylate therapy if the receptors are activated by specific mechanisms. KIT-activating mutations fall into two groups: the regulatory type and the enzymatic site type. The regulatory type of mutation is conserved at the imatinib binding site, whereas the enzymatic site mutation has a structurally changed drug-binding site, resulting in drug resistance. Resistance to the drug is the major cause of treatment failure in cancer therapy, emphasizing the need for researchers to understand KIT signaling pathways so as to identify new therapeutic targets. This review summarizes the pathologic features of GISTs, recent advances in understanding their molecular and biologic features, and therapy with imatinib mesylate.

A novel class of highly potent, selective, and non-peptidic inhibitor of Ras farnesyltransferase (FTase)

Design, synthesis and structure-activity relationship of a class of aryl pyrroles as farnesyltransferase inhibitors are described. In vitro and in vivo evaluation of a panel of these inhibitors led to identification of 2 (LB42908) as a highly potent (IC(50)=0.9 nM against H-Ras and 2.4 nM against K-Ras) antitumor agent that is currently undergoing preclinical studies.

3-Aryl-4-aryloyl-1-(1H-imidazol-5-yl)methylpyrrole, a novel class of farnesyltransferase inhibitors

Design, synthesis and structure-activity relationship of a class of 3-aryl-4-aryloyl-1-(1H-imidazol-5-yl)methylpyrroles as farnesyltransferase inhibitors are described. Compound 7 inhibits farnesyltransferase with an IC(50) value of 4.6 nM.

Rapamycin impairs recovery from acute renal failure: role of cell-cycle arrest and apoptosis of tubular cells

The immunosuppressive effect of rapamycin is mediated by inhibition of interleukin-2-stimulated T cell proliferation. We report for the first time that rapamycin also inhibits growth factor-induced proliferation of cultured mouse proximal tubular (MPT; IC(50) ~1 ng/ml) cells and promotes apoptosis of these cells by impairing the survival effects of the same growth factors. On the basis of these in vitro data, we tested the hypothesis that rapamycin would impair recovery of renal function after ischemic acute renal failure induced in vivo by renal artery occlusion (RAO). Rats given daily injections of rapamycin or vehicle were subjected to RAO or sham surgery. Rapamycin had no effect on the glomerular filtration rate (GFR) of sham-operated animals. In rats subjected to RAO, GFR fell to comparable levels 1 day later in vehicle- and rapamycin-treated rats (0.25 +/- 0.08 and 0.12 +/- 0.05 ml. min(-1). 300 g(-1), respectively) (P = not significant). In vehicle-treated rats subjected to RAO, GFR increased to 0.61 +/- 0.08 ml. min(-1). 300 g(-1) on day 3 (P < 0.02 vs. day 1) and then rose further to 0.99 +/- 0.09 ml. min(-1). 300 g(-1) on day 4 (P < 0.02 vs. day 3). By contrast, GFR did not improve in rapamycin-treated rats subjected to RAO over the same time period. Rapamycin also increased apoptosis of tubular cells while markedly reducing their proliferative response after RAO. Furthermore, rapamycin inhibited activation of 70-kDa S6 protein kinase (p70(S6k)) in cultured MPT cells as well as in the renal tissue of rats subjected to RAO. We conclude that rapamycin severely impairs the recovery of renal function after ischemia-reperfusion injury. This effect appears to be due to the combined effects of increased tubular cell loss (via apoptosis) and profound inhibition of the regenerative response of tubular cells. These effects are likely mediated by inhibition of p70(S6k).

Spectrum of prostate cancer in the Singapore General Hospital (1980 to 1985)

INTRODUCTION

Serum prostate specific antigen (PSA) testing has contributed to a dramatic rise in the incidence of prostate cancer diagnosed in the last decade in the West as well as in Singapore. Now prostate cancer is ranked as the sixth commonest cancer among men in Singapore. To form the basis for comparisons and to assess the trends and impact of these changes, we analysed the presentation, disease characteristics and outcome of treatment of patients with prostate cancer diagnosed in the pre-PSA era at the Singapore General Hospital (SGH).

MATERIALS AND METHODS

Of the 149 patients (1980 to 1985) registered in the database, 134 (90%) records with full follow-up data were available for the analysis. All patients were diagnosed and managed at SGH. Follow-up and death data were collected through clinic visit, phone interviews of the patients, relatives, family physicians and the death registry. Survival analysis was carried out using the Kaplan-Meier product limit method.

RESULTS

The mean age at diagnosis was 69.8 years. There were no significant changes with reference to each year during 1980 to 1985 and the mean number of diagnoses per year was 22.3. Of the 134 patients, 86% had either retention of urine or severe lower urinary tract symptoms and 14% had metastatic disease at presentation. Most histological diagnosis was made during prostatectomy; wherein 82% was found with transurethral resection of the prostate (TURP) and 12% in open prostatectomy, respectively. Pathological analysis during diagnosis revealed that 72.4% patients had metastatic disease. Of which, 57.5% had high-grade (Gleason > 7) tumours. Among these, 82% underwent TURP to relieve urinary obstruction, while 26.1% received local irradiation to the prostate. Majority had hormone therapy shortly after diagnosis in the form of orchidectomy or oral diethylstilbestrol (76.1%). The median crude survival (26 months) was minimal for metastatic patients.

CONCLUSION

The spectrum of prostate cancer in the pre-PSA era was characterised by high stages of high-grade disease, with very limited opportunity for successful treatment and hence survival.

Fine needle aspiration cytology of late-stage callus in stress fracture. A case report

BACKGROUND

Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone lesions when combined with careful radiologic and clinical evaluation. The cytologic features of callus have not been described before in the English-language literature.

CASE

An 18-year-old female presented with a pain in the right lower leg that had been present for two months. Clinical and radiologic findings suggested either stress fracture or periosteal osteosarcoma. The aspiration specimen showed individually scattered, oval cells with moderate amounts of pale pink cytoplasm. The cells contained a single eccentrically located nucleus with evenly distributed, fine chromatin. Osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of benign bone-forming lesion, compatible with callus in fracture, was made. The diagnosis of late-stage callus was confirmed by subsequent histologic examination.

CONCLUSION

Typical cases of stress fracture do not need histologic examination, but some cases may be confused with benign and malignant bone tumors. The typical and unique cytologic features of late-stage callus combined with clinical and radiologic findings may prevent the use of more invasive diagnostic procedures and can be a choice for management.

Chondrosarcoma of the proximal femur with myxoid degeneration mistaken for chondromyxoid fibroma in a young adult. A case report

BACKGROUND

Fine needle aspiration cytology (FNAC) is effective in the diagnosis of bone tumors when combined with careful radiologic and clinical evaluation. However, cases where clinical or radiologic findings are atypical or unusual may lead to an erroneous diagnosis.

CASE

A 19-year-old male presented with a pain in the left hip area that had been slowly progressive over a 10-month period. Clinical and radiologic findings suggested either giant cell tumor or chondroblastoma. The smeared aspiration specimen showed loosely cohesive, oval to round cells with moderate amounts of pale pink cytoplasm admixed with pinkish-blue, chondromyxoid material. The individual cells contained a single nucleus with evenly distributed, fine chromatin. A few osteoclastic giant cells were scattered in the smears. A cytologic diagnosis of myxoid lesion with a few giant cells, suspicious for chondromyxoid fibroma, was made. The diagnosis of chondrosarcoma was made by subsequent histologic examination.

CONCLUSION

Absence of the usual clinicoradiologic features of chondrosarcoma combined with an unusual cytologic presentation in this case led to a misdiagnosis. In most centers, FNAC has achieved undisputed status as a diagnostic tool, and cytologic diagnosis often forms the basis of the therapeutic protocol. However, at some sites FNAC diagnosis is more problematic. Awareness of the limitations and pitfalls of FNAC is just as important as knowledge of the scope of FNAC in bone tumors. Tumors with chondromyxoid features provide particular difficulties.

Cytokine dysregulation induced by apoptotic cells is a shared characteristic of murine lupus

Of the multiple murine models of autoimmunity, the three most closely resembling human systemic lupus erythematosus (SLE) are the MRL/lpr, New Zealand Black/White F(1), and male BXSB. Although these strains share many disease characteristics, no common cellular defect has previously been found in prediseased mice from all these strains. We show in this study that macrophages from prediseased mice of all three SLE-prone strains, as well as macrophages from mice whose genomes contribute to the development of SLE (MRL/+, New Zealand White, New Zealand Black, female BXSB, and LG/J), have an identical and profound defect in cytokine expression that is triggered by apoptotic cells. Strikingly, none of 13 nonautoimmune strains tested exhibited this defect. Given that apoptotic Ags have been increasingly recognized as the target of autoantibodies, a defect in cytokine expression that is triggered by apoptotic cells has broad potential to upset the balance between tolerance and immunity.