Anastomotic Leakage in Relation to Type of Mesorectal Excision and Defunctioning Stoma Use in Anterior Resection for Rectal Cancer

BACKGROUND

Anastomotic leakage after anterior resection for rectal cancer is more common after total mesorectal excision compared to partial mesorectal excision but might be mitigated by a defunctioning stoma.

OBJECTIVE

The aim is to assess how anastomotic leakage is affected by type of mesorectal excision and defunctioning stoma use.

DESIGN

This is a retrospective multicenter cohort study evaluating anastomotic leakage after anterior resection. Multivariable Cox regression with HRs and 95% CIs was used to contrast mesorectal excision types and defunctioning stoma use with respect to anastomotic leakage, with adjustment for confounding.

SETTINGS

This multicenter study included patients from 11 Swedish hospitals between 2014 and 2018.

PATIENTS

Patients who underwent anterior resection for rectal cancer were included.

MAIN OUTCOMES MEASURES

Anastomotic leakage rates within and after 30 days of surgery are described up to 1 year after surgery.

RESULTS

Anastomotic leakage occurred in 24.2% and 9.0% of 1126 patients operated with total and partial mesorectal excision, respectively. Partial compared to total mesorectal excision was associated with a reduction in leakage, with an adjusted HR of 0.46 (95% CI, 0.29-0.74). Early leak rates within 30 days were 14.9% with and 12.5% without a stoma, whereas late leak rates after 30 days were 7.5% with and 1.9% without a stoma. After adjustment, defunctioning stoma was associated with a lower early leak rate (HR 0.47; 95% CI, 0.28-0.77). However, the late leak rate was nonsignificantly higher in patients with defunctioning stomas (HR 1.69; 95% CI, 0.59-4.85).

LIMITATIONS

This study was limited by its retrospective observational study design.

CONCLUSIONS

Anastomotic leakage is common up to 1 year after anterior resection for rectal cancer, where partial mesorectal excision is associated with a lower leak rate. Defunctioning stomas seem to decrease the occurrence of leakage, although partially by only delaying the diagnosis. See Video Abstract .

FUGA ANASTOMTICA SEGN EL TIPO DE EXCISIN MESORRECTAL Y LA CONFECCIN DE OSTOMA DE PROTECCIN EN LA RESECCIN ANTERIOR POR CNCER DE RECTO

ANTECEDENTES:La fuga anastomótica después de una resección anterior por cáncer de recto es más frecuente después de la excisión total del mesorrecto comparada con la excisión parcial del mismo, pero podría mitigarse con la confección de ostomías de protección.OBJETIVO:El objetivo es evaluar cómo la fuga anastomótica se ve afectada según el tipo de excisión mesorrectal y la confección de una ostomía de protección.DISEÑO:Estudio de cohortes multicéntrico y retrospectivo que evalúa la fuga anastomótica después de la resección anterior. Se aplicó la regresión multivariada de Cox con los índices de riesgo (HR) y los intervalos de confianza (IC) al 95% para contrastar los tipos de excisión mesorrectal y el uso de otomías de protección con respecto a la fuga anastomótica, realizando ajustes respecto a las variables de confusión.AJUSTES:El presente estudio multicéntrico incluyó pacientes de 11 hospitales suecos entre 2014 y 2018.PACIENTES:Se incluyeron todos aquellos sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADOS:Las tasas de fuga anastomótica dentro y después de los 30 días de la cirugía fueron descritos hasta un año mas tarde al acto quirúrgico.RESULTADOS:La fuga anastomótica ocurrió en el 24,2% y el 9,0% de 1126 pacientes operados por excisión total y parcial del mesorrecto respectivamente.La excisión parcial del mesorrecto en comparación con la total se asoció con una reducción de la fuga, HR ajustado de 0,46 (IC del 95 %: 0,29 a 0,74). Las tasas de fuga temprana dentro de los 30 días fueron del 14,9 % con y el 12,5 % sin estoma, mientras que las tasas de fuga tardía después de 30 días fueron del 7,5 % con y el 1,9 % sin estoma.Después del ajuste de variables de confusión, las ostomías de protección se asociaron con una tasa de fuga temprana más baja (HR 0,47; IC 95 %: 0,28-0,77). Sin embargo, la tasa de fuga tardía no fue significativamente mayor en pacientes ostomizados (HR 1,69; IC 95%: 0,59-4,85).LIMITACIONES:Las limitaciones del presente estudio estuvieron vinculadas con el diseño de tipo observacional y retrospectivo.CONCLUSIONES:La fuga anastomótica es común hasta un año después de la resección anterior por cáncer de recto, donde la excisión parcial del mesorrecto se asocia con una menor tasa de fuga. La confección de ostomías de protección parece disminuir la aparición de fuga anastomótica, aunque en parte sólo retrasen el diagnóstico. (Traducción-Dr. Xavier Delgadillo ).

The role of a photographic atlas in reducing unanticipated healthcare utilization following circumcision

INTRODUCTION

Circumcision is a common procedure that can evoke caregiver anxiety in the postoperative period due to unfamiliarity with the healing process. To mitigate unnecessary healthcare utilization such as phone calls and unanticipated clinic or emergency department (ED) visits, photographic atlases have been developed to better prepare caregivers for the recovery process. The objective of our study is to further investigate the efficacy of a photographic atlas in its ability to decrease postoperative healthcare utilization using an increased sample size and extended study period compared to previous studies.

MATERIALS AND METHODS

In this study, we compared a prospective intervention cohort of patients undergoing circumcision at our institution who received a photographic atlas during postoperative teaching to a retrospective cohort of patients who had not received it. Our primary outcome was unanticipated healthcare utilization, defined as postoperative telephone calls and unanticipated presentations to the urology clinic or ED.

RESULTS

The retrospective no-atlas cohort included 105 patients, and the prospective intervention atlas cohort included 80 patients. Both groups were similar with respect to age (p = 0.47) and other demographics. There was no statistically significant difference in healthcare utilization between the no-atlas and atlas cohort. Specifically, we identified no difference in the number of phone calls to clinic staff (12 [11.4%] vs. 11 [13.8%], p = 0.64) or unanticipated postoperative clinic or ED visits (2 [1.9%] vs. 4 [5.0%], p = 0.41).

DISCUSSION

The use of a photographic atlas as part of caregiver support for circumcision patients did not demonstrate a statistically significant reduction in either postoperative phone calls or clinic/ED visits. The decrease in absolute number of caregiver phone calls was minimal (12-11), with a small increase in follow-up presentations (2-4). The lack of significant change may be due to the already infrequent occurrence of these events following circumcision, as demonstrated by the no-atlas cohort. Other potential advantages of the atlas, such as improved caregiver confidence and satisfaction, may have been present, but were not measured in this study.

CONCLUSIONS

Adding to the mixed results of previous studies, these findings do not support that photographic atlases decrease unanticipated healthcare utilization in children undergoing a circumcision. However, utilization was found to be low. Additionally, further studies are needed to determine other significant benefits of this form of education, such as improved caregiver confidence and satisfaction.

Artificial Intelligence Literacy: Developing a Multi-institutional Infrastructure for AI Education

RATIONALE AND OBJECTIVES

To evaluate the effectiveness of an artificial intelligence (AI) in radiology literacy course on participants from nine radiology residency programs in the Southeast and Mid-Atlantic United States.

MATERIALS AND METHODS

A week-long AI in radiology course was developed and included participants from nine radiology residency programs in the Southeast and Mid-Atlantic United States. Ten 30 minutes lectures utilizing a remote learning format covered basic AI terms and methods, clinical applications of AI in radiology by four different subspecialties, and special topics lectures on the economics of AI, ethics of AI, algorithm bias, and medicolegal implications of AI in medicine. A proctored hands-on clinical AI session allowed participants to directly use an FDA cleared AI-assisted viewer and reporting system for advanced cancer. Pre- and post-course electronic surveys were distributed to assess participants' knowledge of AI terminology and applications and interest in AI education.

RESULTS

There were an average of 75 participants each day of the course (range: 50-120). Nearly all participants reported a lack of sufficient exposure to AI in their radiology training (96.7%, 90/93). Mean participant score on the pre-course AI knowledge evaluation was 8.3/15, with a statistically significant increase to 10.1/15 on the post-course evaluation (p= 0.04). A majority of participants reported an interest in continued AI in radiology education in the future (78.6%, 22/28).

CONCLUSION

A multi-institutional AI in radiology literacy course successfully improved AI education of participants, with the majority of participants reporting a continued interest in AI in radiology education in the future.

Profiling Behavioral and Psychological Symptoms in Children Undergoing Treatment for Spondyloarthritis and Polyarthritis

OBJECTIVE

Few studies examine psychopathology in different juvenile idiopathic arthritis (JIA) subtypes and disease activity states. We aimed to (1) evaluate emotional and behavioral symptoms in children with juvenile spondyloarthritis (SpA) and polyarticular arthritis (PolyA) as compared to a national normative population using the Child Behavior Checklist (CBCL), and (2) evaluate the relationship between CBCL scores and disease activity.

METHODS

Patients with JIA aged 6-17 years with SpA or PolyA were recruited from our pediatric rheumatology clinic from April 2018 to April 2019 and the CBCL and clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10) were completed. Primary outcome measures were CBCL total competence, internalizing, externalizing, and total problems raw scores. We compared outcomes from each group to national CBCL normative data. To investigate the relationship between CBCL scores and disease activity, we ran a generalized linear regression model for all patients with arthritis with cJADAS10 as the main predictor.

RESULTS

There were 111 patients and 1753 healthy controls (HCs). Compared to HCs, patients with SpA or PolyA had worse total competence and internalizing scores. Higher cJADAS10 scores were associated with worse total competence, worse internalizing, and higher total problems scores. Most of these differences reached statistical significance (P < 0.01). Self-harm/suicidality was almost 4-fold higher in patients with PolyA than HCs (OR 3.6, 95% CI 1.3-9.6, P = 0.011).

CONCLUSION

Our study shows that patients with SpA and PolyA with more active disease have worse psychological functioning in activities, school, and social arenas, and more internalized emotional disturbances, suggesting the need for regular mental health screening by rheumatologists.

Relationship between internal accuracy and load-bearing capacity of minimally invasive lithium disilicate occlusal veneers

PURPOSE

To test whether internal accuracy affects the load-bearing capacity of 0.5-mm-thick occlusal veneers made out of milled or heat-pressed lithium disilicate (LS2).

MATERIALS AND METHODS

Extracted human molars (N = 80) were divided into four groups (n = 20 each) depending on the bonding substrate (enamel [E] or dentin [D]) and the fabrication method (milling [CAD] or heat pressing [PRE]) for the occlusal LS2 veneers: (1) E-CAD, (2) D-CAD, (3) E-PRE, or (4) D-PRE. After restoration fabrication, the abutment teeth and the corresponding restorations were scanned and superimposed in order to measure the marginal and internal accuracy. After adhesive cementation, the specimens were thermomechanically aged and thereafter loaded until fracture. The load-bearing capacities (F_max) were measured. F_max and the marginal and internal accuracy between the groups were compared using Kruskal-Wallis test (P < .05) and pairwise group comparisons. In addition, the relationship between F_max and the internal accuracy was analyzed using Spearman rank correlation.

RESULTS

Median F_max values (and first and third quartiles) per group were as follows: 1,495 N (Q1: 932; Q3: 2'318) for E-CAD; 1,575 N (Q1: 1,314; Q3: 1,668) for E-PRE; 1,856 N (Q1: 1,555; Q3: 2,013) for D-CAD; and 1,877 N (Q1: 1,566; Q3: 2,131) for D-PRE. No statistical difference was found between the groups (P = .0981). Overall, the internal accuracy in the areas of the cusp (P < .0007) and fossa (P < .0001) showed significant differences. While no significant differences were detected in the marginal area (P = .3518), a significant correlation with a negative linear relationship was found between the 3D internal accuracy and the F_max values (P = .0007).

CONCLUSION

An increase in the internal accuracy raised the load-bearing capacity of minimally invasive LS2 occlusal veneers. In general, the restorations bonded to dentin in the occlusal regions showed a better accuracy compared to those bonded to enamel.

The Burden of Caring for a Child or Adolescent With Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): An Observational Longitudinal Study

OBJECTIVE

To describe the longitudinal association between disease severity, time established in clinical treatment, and caregiver burden in a community-based patient population diagnosed with pediatric acute-onset neuropsychiatric syndrome (PANS).

METHODS

The study included an observational longitudinal cohort design, with Caregiver Burden Inventories (CBIs) collected between April 2013 and November 2016 at the Stanford PANS multidisciplinary clinic. Inclusion criteria for this study were as follows: pediatric patients meeting strict PANS/pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) diagnostic criteria (n = 187), having a caregiver fill out at least 1 complete CBI during a disease flare (n = 114); and having family who lives locally (n = 97). For longitudinal analyses, only patients whose caregiver had filled out 2 or more CBIs (n = 94 with 892 CBIs) were included. In the study sample, most primary caregivers were mothers (69 [71.1%] of 97), the majority of PANS patients were male (58 [59.8%] of 97), and mean age at PANS onset was 8.8 years.

RESULTS

In a patient's first flare tracked by the clinic, 50% of caregivers exceeded the caregiver burden score threshold used to determine respite need in care receiver adult populations. Longitudinally, flares, compared with quiescence, predicted increases in mean CBI score (6.6 points; 95% CI, 5.1 to 8.0). Each year established in clinic predicted decreased CBI score (-3.5 points per year; 95% CI, -2.3 to -4.6). Also, shorter time between PANS onset and entry into the multidisciplinary clinic predicted greater improvement in mean CBI score over time (0.7 points per year squared; 95% CI, 0.1 to 1.3). Time between PANS onset and treatment with antibiotics or immunomodulation did not moderate the relationship between CBI score and time in clinic.

CONCLUSIONS

PANS caregivers suffer high caregiver burden. Neuropsychiatric disease severity predicts increased caregiver burden. Caregiver burden tends to decrease over time in a group of patients undergoing clinical treatment at a specialty PANS clinic. This decrease could be independent of clinical treatment.

Incidence of psoriasiform diseases secondary to tumour necrosis factor antagonists in patients with inflammatory bowel disease: a nationwide population-based cohort study

BACKGROUND

There are increasing reports of paradoxical psoriasiform diseases secondary to anti-tumour necrosis factor (TNF) agents.

AIMS

To determine the risks of paradoxical psoriasiform diseases secondary to anti-TNF agents in patients with inflammatory bowel disease (IBD).

METHODS

A nationwide population study was performed using the Korea National Health Insurance Claim Data. A total of 50 502 patients with IBD were identified between 2007 and 2016. We compared 5428 patients who were treated with any anti-TNF agent for more than 6 months (anti-TNF group) and 10 856 matched controls who had never taken anti-TNF agents (control group).

RESULTS

Incidence of psoriasis was significantly higher in the anti-TNF group (36.8 per 10 000 person-years) compared to the control group (14.5 per 10 000 person-years) (hazard ratio [HR] 2.357, 95% confidence interval [CI] 1.668-3.331). Palmoplantar pustulosis (HR 9.355, 95% CI 2.754-31.780) and psoriatic arthritis (HR 2.926, 95% CI 1.640-5.218) also showed higher risks in the anti-TNF group. In subgroup analyses, HRs for psoriasis by IBD subtype were 2.549 (95% CI 1.658-3.920) in Crohn's disease and 2.105 (95% CI 1.155-3.836) in ulcerative colitis. Interestingly, men and younger (10-39 years) patients have significantly higher risks of palmoplantar pustulosis (HR 19.682 [95% CI 3.867-100.169] and HR 14.318 [95% CI 2.915-70.315], respectively), whereas women and older (≥40 years) patients showed similar rates between the two groups.

CONCLUSIONS

The risks of psoriasiform diseases are increased by anti-TNF agents in patients with IBD. Among psoriasiform diseases, the risk of palmoplantar pustulosis shows the biggest increase particularly in male and younger patients.

Detection and classification of the breast abnormalities in digital mammograms via regional Convolutional Neural Network

Automatic detection and classification of the masses in mammograms are still a big challenge and play a crucial role to assist radiologists for accurate diagnosis. In this paper, we propose a novel computer-aided diagnose (CAD) system based on one of the regional deep learning techniques: a ROI-based Convolutional Neural Network (CNN) which is called You Only Look Once (YOLO). Our proposed YOLO-based CAD system contains four main stages: mammograms preprocessing, feature extraction utilizing multi convolutional deep layers, mass detection with confidence model, and finally mass classification using fully connected neural network (FC-NN). A set of training mammograms with the information of ROI masses and their types are used to train YOLO. The trained YOLO-based CAD system detects the masses and classifies their types into benign or malignant. Our results show that the proposed YOLO-based CAD system detects the mass location with an overall accuracy of 96.33%. The system also distinguishes between benign and malignant lesions with an overall accuracy of 85.52%. Our proposed system seems to be feasible as a CAD system capable of detection and classification at the same time. It also overcomes some challenging breast cancer cases such as the mass existing in the pectoral muscles or dense regions.

Effective ion charge (Zeff) measurements and impurity behavior in KSTAR

A visible bremsstrahlung detector array diagnostic system has been developed on the Korea Superconducting Tokamak Advanced Research (KSTAR) to view the whole minor radius in a narrow region of the continuum free of spectral lines. The interference filters coupled with photomultiplier tubes have been employed to determine the effective charge Z_eff by using visible bremsstrahlung data during neutral beam injection in the KSTAR plasma. The Z_eff profiles are typically flat for L-mode plasmas and evolve to hollow profiles during the H mode in the KSTAR. A comparison of the visible bremsstrahlung emission based on the calculated Z_eff profiles is consistent with measured values of Z_eff from a visible spectrometer in the core plasma. The electron temperature is measured by X-ray imaging crystal spectrometry, and electron density needed for the analysis is taken by the assumption of parabolic profiles of these parameters. The line of sight averaged local bremsstrahlung emissivity is determined with low uncertainty, and the radial emissivity is obtained by using the Abel inversion technique. In addition, a dependence of effective charge Z_eff on the line-averaged electron density is evaluated, and Z_eff is also determined to observe the effect of boronization.

Development of a semi-continuous two-stage simultaneous saccharification and fermentation process for enhanced 2,3-butanediol production by Klebsiella oxytoca

Klebsiella oxytoca naturally produces a large amount of 2,3-butanediol (2,3-BD), a promising chemical with wide industrial applications, along with various by-products. Previously, we have developed a metabolically engineered K. oxytoca ΔldhA ΔpflB strain to reduce the formation of by-products. To improve 2,3-BD productivity and examine the stability of K. oxytoca ΔldhA ΔpflB strain for industrial application, a semi-continuous two-stage simultaneous saccharification and fermentation (STSSF) process was developed. The STSSF with the K. oxytoca ΔldhA ΔpflB mutant using cassava as a carbon source could produce 108 ± 3·73 g_(2,3-BD)  l^-1 with a yield of 0·45 g_(2,3-BD)  g_(glucose)^-1 and a productivity of 3·00 g_(2,3-BD) l^-1  h^-1 . No apparent changes in the final titre, yield and productivity of 2,3-BD were observed for up to 20 cycles of STSSF. Also, microbial contamination and spontaneous mutation of the host strain with potential detrimental effects on fermentation efficiency did not occur during the whole fermentation period. These results strongly underpin that the K. oxytoca ΔldhA ΔpflB mutant is stable and that the STSSF process is commercially exploitable.

SIGNIFICANCE AND IMPACT OF THE STUDY

There is growing interest in the production of 2,3-butanediol (2,3-BD) from renewable resources by microbial fermentation because of its wide applications to specialty and commodity chemical industries. Klebsiella oxytoca usually produces 2,3-BD as a major end product during the fermentation of carbohydrates. This is the first study to provide a high-efficiency simultaneous saccharification and 2,3-BD fermentation process. Also, this study proves the stability of a metabolically engineered 2,3-BD overproducing K. oxytoca strain for industrial application.

Comparison of the Analgesic Effect of an Ice Cube versus 4% Lidocaine Cream in Intradermal Antibiotic Skin Testing

Objective

This study was performed to compare the analgesic effect of an ice cube with that of 4% lidocaine cream (L.M.X.4®) for intradermal skin testing.

Methods

In this prospective randomised study, healthy adult volunteers were divided into ice cube and lidocaine analgesic pretreatment groups. Randomisation was performed using a randomisation table in blocks of four. Intradermal skin testing was performed after applying ice in the ice cube group and 5 mg of lidocaine cream in the lidocaine group. After the intradermal skin test, the pain intensity was investigated using the visual analog scale (VAS) on questionnaires. We calculated that a minimum of 24 subjects were required for statistical power of 80% at a significance level of 0.05 (two-sided). The groups' VAS scores were compared using the Mann-Whitney U-test.

Results

The study population consisted of 35 volunteers: 17 in the ice cube group and 18 in the lidocaine group. There were no differences in demographic characteristics between the two groups. The median VAS score was 20 (interquartile range: 0-35) in the ice cube group and 70 (interquartile range: 50-80) in the lidocaine group (p<0.001).

Conclusions

The results suggested the utility of an ice cube as analgesic pretreatment for intradermal skin testing in the emergency department.

First insights into the function of the sawshark rostrum through examination of rostral tooth microwear

Potential roles of the rostrum of sawsharks (Pristiophoridae), including predation and self-defence, were assessed through a variety of inferential methods. Comparison of microwear on the surface of the rostral teeth of sawsharks and sawfishes (Pristidae) show that microwear patterns are alike and suggest that the elongate rostra in these two elasmobranch families are used for a similar purpose (predation). Raman spectroscopy indicates that the rostral teeth of both sawsharks and sawfishes are composed of hydroxyapatite, but differ in their collagen content. Sawfishes possess collagen throughout their rostral teeth whereas collagen is present only in the centre of the rostral teeth of sawsharks, which may relate to differences in ecological use. The ratio of rostrum length to total length in the common sawshark Pristiophorus cirratus was found to be similar to the largetooth sawfish Pristis pristis but not the knifetooth sawfish Anoxypristis cuspidata. Analysis of the stomach contents of P. cirratus indicates that the diet consists of demersal fishes and crustaceans, with shrimp from the family Pandalidae being the most important dietary component. No prey item showed evidence of wounds inflicted by the rostral teeth. In light of the similarities in microwear patterns, rostral tooth chemistry and diet with sawfishes, it is hypothesised that sawsharks use their rostrum in a similar manner for predation (sensing and capturing prey) and possibly for self-defence.

Non-local means filter denoising for DEXA images

Dual high and low energy images of Dual Energy X-ray Absorptiometry (DEXA) suffer from noises due to the use of weak amount of X-rays. Denoising these DEXA images could be a key process to enhance and improve a Bone Mineral Density (BMD) map which is derived from a pair of high and low energy images. This could further improve the accuracy of diagnosis of bone fractures, osteoporosis, and etc. In this paper, we present a denoising technique for dual high and low energy images of DEXA via non-local means filter (NLMF). The noise of dual DEXA images is modeled based on both source and detector noises of a DEXA system. Then, the parameters of the proposed NLMF are optimized for denoising utilizing the experimental data from uniform phantoms. The optimized NLMF is tested and verified with the DEXA images of the uniform phantoms and real human spine. The quantitative evaluation shows the improvement of Signal-to-Noise Ratio (SNR) for the high and low phantom images on the order of 30.36% and 27.02% and for the high and low real spine images on the order of 22.28% and 33.43%, respectively. Our work suggests that denoising via NLMF could be a key preprocessing process for clinical DEXA imaging.

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

OBJECTIVE

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

STUDY DESIGN

Prospective cohort study.

SETTINGS

Tertiary care referral medical centre.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Deformation mechanisms to ameliorate the mechanical properties of novel TRIP/TWIP Co-Cr-Mo-(Cu) ultrafine eutectic alloys

In the present study, the microstructural evolution and the modulation of the mechanical properties have been investigated for a Co-Cr-Mo (CCM) ternary eutectic alloy by addition of a small amount of copper (0.5 and 1 at.%). The microstructural observations reveal a distinct dissimilarity in the eutectic structure such as a broken lamellar structure and a well-aligned lamellar structure and an increasing volume fraction of Co lamellae as increasing amount of copper addition. This microstructural evolution leads to improved plasticity from 1% to 10% without the typical tradeoff between the overall strength and compressive plasticity. Moreover, investigation of the fractured samples indicates that the CCMCu alloy exhibits higher plastic deformability and combinatorial mechanisms for improved plastic behavior. The improved plasticity of CCMCu alloys originates from several deformation mechanisms; i) slip, ii) deformation twinning, iii) strain-induced transformation and iv) shear banding. These results reveal that the mechanical properties of eutectic alloys in the Co-Cr-Mo system can be ameliorated by micro-alloying such as Cu addition.

Ten-Year Experience With Bowel Transplantation at Seoul St. Mary's Hospital

A retrospective review of intestinal transplantation (ITx) at Seoul St. Mary's Hospital was made by collecting clinical data over the past 10 years. Fifteen consecutive cases from 2004 were analyzed. Five children and 10 adults (6 months to 69 years of age) were included. Primary diseases in adults included 4 mesenteric vessel thromboses, 2 strangulations, and 1 each of visceral myopathy, malignant gastrointestinal stromal tumor (GIST), mesenteric lymphangiectasis, and injury. Pediatric cases involved 2 Hirschsprung disease, 2 visceral myopathy, and 1 necrotizing enterocolitis. Three of 7 stomas were closed using a serial transverse enteroplasty procedure before transplantation. The ITx were performed using 3 living-donor Itx, 12 deceased-donor ITx, 14 isolated Itx, and 1 modified multivisceral transplantation. Daclizumab, basiliximab, alemtusumab, or basiliximab with rabbit antithymocyte globulin (rATG) was used for the induction; tacrolimus monotherapy was used as the basic maintenance immunosuppressant; and m-TOR inhibitor was used for renal dysfunction patients. Seven cases of acute cellular rejection were treated with rATG. Three cases of antibody-mediated rejection were treated with rituximab alone or with rituximab and bortezomib combination. There were 4 cases of early mortality within 6 months after Itx. Causes of death were declamping shock, cardiac tamponade with acute cellular rejection, dysmotility, and sepsis. Surgical complications consisted of 1 feeding jejunostomy displacement, and a minor leakage at a colo-colostomy site. One-year survival of the patient and graft was 73.33% (Kaplan-Meier survival curve). Although the total number of ITx is small, its social impact has been remarkable in changing the related laws and reimbursement policy in Korea.

ADHD and executive functioning deficits in OCD youths who hoard

Hoarding is common among youth with obsessive compulsive disorder (OCD), with up to 26% of OCD youth exhibiting hoarding symptoms. Recent evidence from adult hoarding and OCD cohorts suggests that hoarding symptoms are associated with executive functioning deficits similar to those observed in subjects with attention deficit hyperactivity disorder (ADHD). However, while hoarding behavior often onsets during childhood, there is little information about executive function deficits and ADHD in affected children and adolescents. The study sample included 431 youths (ages 6-17 years) diagnosed with OCD who participated in the OCD Collaborative Genetics Study and the OCD Collaborative Genetics Association Study and completed a series of clinician-administered and parent report assessments, including diagnostic interviews and measures of executive functioning (Behavior Rating Inventory of Executive Functioning; BRIEF) and hoarding severity (Hoarding Rating Scale-Interview; HRS-I). 113 youths (26%) had clinically significant levels of hoarding compulsions. Youths with and without hoarding differed significantly on most executive functioning subdomains and composite indices as measured by the parent-rated BRIEF. Groups did not differ in the frequency of full DSM-IV ADHD diagnoses; however, the hoarding group had significantly greater number of inattention and hyperactivity symptoms compared to the non-hoarding group. In multivariate models, we found that overall BRIEF scores were related to hoarding severity, adjusting for age, gender and ADHD symptoms. These findings suggest an association between hoarding and executive functioning deficits in youths with OCD, and assessing executive functioning may be important for investigating the etiology and treatment of children and adolescents with hoarding and OCD.

Effect of metronidazole use on tacrolimus concentrations in transplant patients treated for Clostridium difficile

BACKGROUND

Two case reports suggest that metronidazole treatment for Clostridium difficile infections (CDI) increases tacrolimus (TAC) trough levels. The primary objective of this study was to determine the clinical significance of this potential interaction in transplant patients receiving CDI treatment. Currently, no robust literature exists to estimate a magnitude of pharmacokinetic interaction between metronidazole and TAC.

METHODS

In this retrospective study, the effects of CDI and metronidazole treatment on TAC levels in 52 adult solid organ transplant patients were investigated. The primary outcome was to determine the difference in dose-normalized TAC levels between baseline and symptom resolution in patients treated with metronidazole or vancomycin. The secondary outcome was to determine the difference in dose-normalized TAC levels at baseline and CDI diagnosis.

RESULTS

The average change in log-transformed dose-normalized TAC levels from baseline to symptom resolution was 0.99 for metronidazole (n = 35) and 1.04 for vancomycin (n = 17) treatment. The mean difference between the groups was 0.96 (95% confidence interval: 0.74-1.24). No significant difference was found between dose-normalized TAC levels at CDI diagnosis and baseline (P = 0.37).

CONCLUSION

CDI treatment with metronidazole was not associated with a >30% increase in TAC levels compared with vancomycin. Both treatment groups required TAC dose adjustments to maintain goal TAC levels and those treated with metronidazole did not require a significantly greater dose adjustment.

Effect of microbial inoculant or molasses on fermentative quality and aerobic stability of sawdust-based spent mushroom substrate

In the first experiment, the effect of two novel Lactobacillus plantarum strains was studied on the fermentation of spent mushroom substrate (SMS) through 10d of ensiling. Based on lactic acid production and lactic acid bacteria population, L. plantarum KU5 was identified as the best strain for fermentation with a 5-L bag silo. Spent mushroom substrate was ensiled with 0.5% (v/w) L. plantarum KU5 without or with 5% molasses. Silages treated with microbial inoculant and molasses had the lowest pH and the highest fermentative odors. In a second set of experiments similar to the above 5-L silo study, the simultaneous application of L. plantarum KU5 inoculant and molasses to 80-L silos improved fermentability and aerobic stability of SMS silages. For similar treatment using ton-bag silos, aerobic stability decreased and NH3-N content increased dramatically. In conclusion, sawdust-based SMS for animal use was successfully ensiled with L. plantarum KU5 inoculant and molasses.

Who may benefit from robotic gastrectomy?: A subgroup analysis of multicenter prospective comparative study data on robotic versus laparoscopic gastrectomy

AIMS

Robotic gastrectomy for gastric cancer has been proven to be a feasible and safe minimally invasive procedure. However, our previous multicenter prospective study indicated that robotic gastrectomy is not superior to laparoscopic gastrectomy. This study aimed to identify which subgroups of patients would benefit from robotic gastrectomy rather than from conventional laparoscopic gastrectomy.

METHODS

A prospective multicenter comparative study comparing laparoscopic and robotic gastrectomy was previously conducted. We divided the patients into subgroups according to obesity, type of gastrectomy performed, and extent of lymph node dissection. Surgical outcomes were compared between the robotic and laparoscopic groups in each subgroup.

RESULTS

A total of 434 patients were enrolled into the robotic (n = 223) and laparoscopic (n = 211) surgery groups. According to obesity and gastrectomy type, there was no difference in the estimated blood loss (EBL), number of retrieved lymph nodes, complication rate, open conversion rate, and the length of hospital stay between the robotic and laparoscopic groups. According to the extent of lymph node dissection, the robotic group showed a significantly lower EBL than did the laparoscopic group after D2 dissection (P = 0.021), while there was no difference in EBL in patients that did not undergo D2 dissection (P = 0.365).

CONCLUSION

Patients with gastric cancer undergoing D2 lymph node dissection can benefit from less blood loss when a robotic surgery system is used.

Hoarding in Children With ADHD

OBJECTIVE

Although evidence suggests that hoarding may be associated with symptoms of ADHD, no study has examined this relationship in children.

METHOD

Participants included 99 youth diagnosed with ADHD (and a parent) seen in a general outpatient psychiatry clinic. Children completed the Obsessive-Compulsive Inventory-Child Version, the Revised Child Anxiety and Depression Scale, and the Rosenberg Self-Esteem Scale. Parents completed the Children's Saving Inventory and Vanderbilt ADHD Diagnostic Rating Scale-Parent Version.

RESULTS

Inattentive and hyperactive/impulsive symptoms were the only indicator that differentiated those with and without clinically significant hoarding. Symptoms of ADHD, but not nonhoarding obsessive-compulsive symptoms, significantly predicted hoarding. Inattention and hyperactivity/impulsivity were uniquely associated with individual hoarding features. Hoarding symptoms mediated the relationship between ADHD and oppositionality.

CONCLUSION

These findings contribute to the growing literature about the association between hoarding and ADHD.

Obsessive-Compulsive Personality Traits in Youth with Obsessive-Compulsive Disorder

While interest in the relationship between obsessive-compulsive disorder (OCD) and obsessive compulsive personality disorder has increased, there are currently no studies that have examined the presence of obsessive compulsive personality traits (OCPTs) in youth. The current study sought to determine the latent factors and psychometric properties of a modified version of the Childhood Retrospective Perfectionism Questionnaire (CHIRP) and examine the correlates of specific OCPTs (e.g., rigidity, perfectionism) in youth with OCD. Participants included 96 treatment-seeking youth diagnosed with primary OCD (and a parent). Parents and youth completed measures of OCPTs, OCD severity, depression, and disability. A confirmatory factor analysis of the modified CHIRP resulted in a two-factor model: perfectionism and preoccupation with details. The CHIRP and its subscales demonstrated acceptable internal consistency and preliminary evidence for convergent and divergent validity. Obsessive compulsive traits in youth were also found to be associated with the checking, symmetry and contamination symptom dimensions.

Can Transabdominal Cervical Length Measurement Exclude Short Cervix?

OBJECTIVE

This study aims to determine if transabdominal (TA) cervical length may be used to rule out a short cervix on transvaginal (TV) ultrasound.

STUDY DESIGN

We conducted a prospective cohort study of women undergoing routine anatomic survey at 17 to 23 weeks gestation. TA and TV cervical length measurements were obtained in each patient. A short cervix was defined as TV cervical length < 30 mm. Predictive characteristics were calculated for different cutoff values of TA cervical length.

RESULTS

There were 404 patients enrolled, a TA cervical length could not be obtained in 83 women (20.6%) and 318 women had both TA and TV measurements. Of those, 14 (4.4%) had a TV cervical length < 30 mm. TA cervical length measurement ≥ 35 mm excluded the possibility of TV cervical length < 30 mm (negative predictive value, 99.5%; 95% confidence interval [CI], 97.4; 100%). In our cohort, 67.6% (95% CI, 62.2; 72.7%) of TV ultrasounds could have been avoided using a TA cervical length cutoff of ≥ 5 mm.

CONCLUSION

ATA cervical length of at least 35 mm excludes a short cervix of < 30 mm. While TA cervical length screening may not be feasible in 1 in 5 women, it may be used to decrease the burden of universal TV cervical length screening.

Evaluation of a commercial orthopaedic metal artefact reduction tool in radiation therapy of patients with head and neck cancer

OBJECTIVE

To assess the image quality and dosimetric effects of the Philips orthopaedic metal artefact reduction (OMAR) (Philips Healthcare System, Cleveland, OH) function for reducing metal artefacts on CT images of head and neck (H&N) patients.

METHODS

11 patients and a custom-built phantom with metal bead inserts (alumina, titanium, zirconia and chrome) were scanned. The image was reconstructed in two ways: with and without OMAR (OMAR and non-OMAR image). The mean and standard deviation values of CT Hounsfield unit (HU) for selected regions of interest of each case were investigated for both images. Volumetric modulated arc therapy plans were generated for all cases. Gamma analysis of each dose distribution pair in the patient (1%/1 mm criteria) and phantom (2%/2 mm and 3%/3 mm criteria) images was performed. The film measurements in phantom for two metal beads were conducted for evaluating the calculated dose on both OMAR and non-OMAR images.

RESULTS

In the OMAR images, noise values were generally reduced, and the mean HU became closer to the reference value (measured from patients without metal implants) in both patient and phantom cases. Although dosimetric difference was insignificant for the eight closed-mouth patients (γ = 99.4 ± 0.5%), there was a large discrepancy in dosimetric calculation between OMAR and non-OMAR images for the three opened-mouth patients (γ = 91.1%, 94.8% and 96.6%). Moreover, the calculated dose on the OMAR image is closer to the real delivered dose on a radiochromic film than was the dose from the non-OMAR image.

CONCLUSION

The OMAR algorithm increases the accuracy of CT HU and reduces the noise such that the entire radiation treatment planning process can be improved, especially for contouring and segmentation.

ADVANCES IN KNOWLEDGE

OMAR reconstruction is appropriate for the radiotherapy planning process of H&N patients, particularly of patients who use a bite block.

The effect of MLC speed and acceleration on the plan delivery accuracy of VMAT

OBJECTIVE

To determine a new metric utilizing multileaf collimator (MLC) speeds and accelerations to predict plan delivery accuracy of volumetric modulated arc therapy (VMAT).

METHODS

To verify VMAT delivery accuracy, gamma evaluations, analysis of mechanical parameter difference between plans and log files, and analysis of changes in dose-volumetric parameters between plans and plans reconstructed with log files were performed with 40 VMAT plans. The average proportion of leaf speeds ranging from l to h cm s(-1) (Sl-h and l-h = 0-0.4, 0.4-0.8, 0.8-1.2, 1.2-1.6 and 1.6-2.0), mean and standard deviation of MLC speeds were calculated for each VMAT plan. The same was carried out for accelerations in centimetre per second squared (Al-h and l-h = 0-4, 4-8, 8-12, 12-16 and 16-20). The correlations of those indicators to plan delivery accuracy were analysed with Spearman's correlation coefficient (rs).

RESULTS

The S1.2-1.6 and mean acceleration of MLCs showed generally higher correlations to plan delivery accuracy than did others. The highest rs values were observed between S1.2-1.6 and global 1%/2 mm (rs = -0.698 with p < 0.001) as well as mean acceleration and global 1%/2 mm (rs = -0.650 with p < 0.001). As the proportion of MLC speeds and accelerations >0.4 and 4 cm s(-2) increased, the plan delivery accuracy of VMAT decreased.

CONCLUSION

The variations in MLC speeds and accelerations showed considerable correlations to VMAT delivery accuracy.

ADVANCES IN KNOWLEDGE

As the MLC speeds and accelerations increased, VMAT delivery accuracy reduced.

Living with tics: reduced impairment and improved quality of life for youth with chronic tic disorders

Pharmacological and behavioral interventions have focused on reducing tic severity to alleviate tic-related impairment for youth with chronic tic disorders (CTDs), with no existing intervention focused on the adverse psychosocial consequences of tics. This study examined the preliminary efficacy of a modularized cognitive behavioral intervention ("Living with Tics", LWT) in reducing tic-related impairment and improving quality of life relative to a waitlist control of equal duration. Twenty-four youth (ages 7-17 years) with Tourette Disorder or Chronic Motor Tic Disorder and psychosocial impairment participated. A treatment-blind evaluator conducted all pre- and post-treatment clinician-rated measures. Youth were randomly assigned to receive the LWT intervention (n=12) or a 10-week waitlist (n=12). The LWT intervention consisted of up to 10 weekly sessions targeted at reducing tic-related impairment and developing skills to manage psychosocial consequences of tics. Youth in the LWT condition experienced significantly reduced clinician-rated tic-impairment, and improved child-rated quality of life. Ten youth (83%) in the LWT group were classified as treatment responders compared to four youth in the waitlist condition (33%). Treatment gains were maintained at one-month follow-up. Findings provide preliminary data that the LWT intervention reduces tic-related impairment and improves quality of life for youth with CTDs.

Effect of By-product Feed-based Silage Feeding on the Performance, Blood Metabolites, and Carcass Characteristics of Hanwoo Steers (a Field Study)

This study was conducted to determine the effects of feeding by-product feed (BF)-based silage on the performance, blood metabolite parameters, and carcass characteristics of Hanwoo steers. The BF-based silage was composed of 50% spent mushroom substrate, 21% recycled poultry bedding, 15% cut ryegrass straw, 10.8% rice bran, 2% molasses, 0.6% bentonite, and 0.6% microbial additive (on a wet basis), and ensiled for over 5 d. Fifteen steers were allocated to three diets during the growing and fattening periods (3.1 and 9.8 months, respectively): a control diet (concentrate mix and free access to rice straw), a 50% BF-based silage diet (control diet+50% of maximum BF-based silage intake), and a 100% BF-based silage diet (the same amount of concentrate mix and ad libitum BF-based silage). The BF-based silage was fed during the growing and fattening periods, and was replaced with larger particles of rice straw during the finishing period. After 19.6 months of the whole period all the steers were slaughtered. Compared with feeding rice straw, feeding BF-based silage tended (p = 0.10) to increase the average daily gain (27%) and feed efficiency (18%) of the growing steers, caused by increased voluntary feed intake. Feeding BF-based silage had little effect on serum constituents, electrolytes, enzymes, or the blood cell profiles of fattening steers, except for low serum Ca and high blood urea concentrations (p<0.05). Feeding BF-based silage did not affect cold carcass weight, yield traits such as back fat thickness, longissimus muscle area, yield index or yield grade, or quality traits such as meat color, fat color, texture, maturity, marbling score, or quality grade. However, it improved good quality grade (1⁺ and 1⁺⁺) appearance rates (60% for the control group vs 100% for the BF-based silage-fed groups). In conclusion, cheap BF-based silage could be successfully used as a good quality roughage source for beef cattle.

Adult offspring perspectives on parental hoarding behaviors

Hoarding disorder (HD) is characterized by difficulty discarding unneeded items and the accumulation of items within living spaces and is associated with significant functional impairment and distress. Along with the negative impact of hoarding on the individual, HD is substantially impairing for family members, and linked to disruptions in family functioning. The present study utilized a path model analysis to examine the associations between an array of hoarding variables hypothesized to impact family functioning and parent-offspring relationships in 150 adult-aged children of hoarders who responded to online requests to participate in a research study. It was hypothesized that increased hoarding severity, decreased insight, and increased family accommodation (i.e., act of family members facilitating or assisting in hoarding behaviors) would be associated with decreased family functioning, decreased quality of parent-offspring relationships, and increased offspring impairment. Results from the path model revealed that family functioning mediated the relationship between hoarding severity and parent-offspring relationship. Diminished insight in the hoarding parent (as reported by the offspring) was associated with increased familial conflict and family functioning partially mediated the relationship between insight and quality of parent-offspring relationship. Increased family accommodation was significantly associated with increased impairment (work, social, and family domains) in offspring of hoarders.

Neuropsychological performance across symptom dimensions in pediatric obsessive compulsive disorder

BACKGROUND

Few studies have examined neuropsychological functioning among youth with obsessive compulsive disorder (OCD), with inconclusive results. Although methodological differences may contribute to inconsistent findings, clinical factors may also account for differential performance. Symptom dimensions are associated with specific patterns of genetic transmission, comorbidity, and treatment outcome, and may also be uniquely associated with neuropsychological performance. This study examined differences in cognitive sequelae and neurocognitive impairment across symptom dimensions among youth with OCD.

METHOD

Participants included 93 treatment-seeking youth diagnosed with OCD. A trained clinician administered the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) to parents and children together. Afterward, youth completed a battery of neuropsychological tests that assessed nonverbal memory and fluency, verbal memory, verbal fluency, verbal learning, processing speed, and inhibition/switching.

RESULTS

Across five symptom dimensions, youth exhibiting Hoarding symptoms (χ(2) = 5.21, P = .02) and Symmetry/Ordering symptoms had a greater occurrence of cognitive sequelae (χ(2) = 4.86, P = .03). Additionally, youth with Symmetry/Ordering symptoms had a greater magnitude of cognitive impairment (Mann-Whitney U = 442.50, Z = -2.49, P < .02), with specific deficits identified on nonverbal fluency (P < .01), processing speed (P < .01), and inhibition and switching (P < .02).

CONCLUSIONS

Neuropsychological deficits identified in youth with Hoarding and Symmetry/Ordering symptoms may suggest that these symptoms have characteristics specific to neurocognitive impairment. Alternatively, symptoms associated with these dimensions may impede youth's performance during testing. Findings advise neuropsychological testing for youth with symptoms on either of these dimensions when concerns about neuropsychological and/or academic impairment are present.

New conformity indices based on the calculation of distances between the target volume and the volume of reference isodose

OBJECTIVE

To present conformity indices (CIs) based on the distance differences between the target volume (TV) and the volume of reference isodose (VRI).

METHODS

The points on the three-dimensional surfaces of the TV and the VRI were generated. Then, the averaged distances between the points on the TV and the VRI were calculated (CIdistance). The performance of the presented CIs were evaluated by analysing six situations, which were a perfect match, an expansion and a reduction of the distance from the centroid to the VRI compared with the distance from the centroid to the TV by 10%, a lateral shift of the VRI by 3 cm, a rotation of the VRI by 45° and a spherical-shaped VRI having the same volume as the TV. The presented CIs were applied to the clinical prostate and head and neck (H&N) plans.

RESULTS

For the perfect match, CIdistance was 0 with 0 as the standard deviation (SD). When expanding and reducing, CIdistance was 10 and -10 with SDs <1.3, respectively. With shifting and rotating of the VRI, the CIdistance was almost 0 with SDs >11. The average value of the CIdistance in the prostate and H&N plans was 0.13 ± 7.44 and 6.04 ± 23.27, respectively.

CONCLUSION

The performance of the CIdistance was equal or better than those of the conventional CIs.

ADVANCES IN KNOWLEDGE

The evaluation of target conformity by the distances between the surface of the TV and the VRI could be more accurate than evaluation with volume information.

Development of an applicator for eye lens dosimetry during radiotherapy

OBJECTIVE

To develop an applicator for in vivo measurements of lens dose during radiotherapy.

METHODS

A contact lens-shaped applicator made of acrylic was developed for in vivo measurements of lens dose. This lens applicator allows the insertion of commercially available metal oxide semiconductor field effect transistors (MOSFETs) dosemeters. CT images of an anthropomorphic phantom with and without the applicator were acquired. Ten volumetric modulated arc therapy plans each for the brain and the head and neck cancer were generated and delivered to an anthropomorphic phantom. The differences between the measured and the calculated doses at the lens applicator, as well as the differences between the measured and the calculated doses at the surface of the eyelid were acquired.

RESULTS

The average difference between the measured and the calculated doses with the applicator was 3.1 ± 1.8 cGy with a micro MOSFET and 2.8 ± 1.3 cGy with a standard MOSFET. The average difference without the lens applicator was 4.8 ± 5.2 cGy with the micro MOSFET and 5.7 ± 6.5 cGy with the standard MOSFET. The maximum difference with the micro MOSFET was 10.5 cGy with the applicator and 21.1 cGy without the applicator. For the standard MOSFET, it was 6.8 cGy with the applicator and 27.6 cGy without the applicator.

CONCLUSION

The lens applicator allowed reduction of the differences between the calculated and the measured doses during in vivo measurement for the lens compared with in vivo measurement at the surface of the eyelid.

ADVANCES IN KNOWLEDGE

By using an applicator for in vivo dosimetry of the eye lens, it was possible to reduce the measurement uncertainty.

Does d-Cycloserine Augmentation of CBT Improve Therapeutic Homework Compliance for Pediatric Obsessive-Compulsive Disorder?

Clinical studies in adults and children with obsessive-compulsive disorder (OCD) have shown that d-cycloserine (DCS) can improve treatment response by enhancing fear extinction learning during exposure-based psychotherapy. Some have hypothesized that improved treatment response is a function of increased compliance and engagement in therapeutic homework tasks, a core component of behavioral treatment. The present study examined the relationship between DCS augmented cognitive-behavioral therapy (CBT) and homework compliance in a double-blind, placebo controlled trial with 30 youth with OCD. All children received 10 CBT sessions, the last seven of which included exposure and response prevention paired with DCS or placebo dosed 1 h before the session started. Results suggested that DCS augmented CBT did not predict improved homework compliance over the course of treatment, relative to the placebo augmented CBT group. However, when groups were collapsed, homework compliance was directly associated with treatment outcome. These findings suggest that while DCS may not increase homework compliance over time, more generally, homework compliance is an integral part of pediatric OCD treatment outcome.

Novel approaches in treatment of pediatric anxiety

Pediatric anxiety disorders have high prevalence rates and morbidity and are associated with considerable functional impairment and distress. They may be predictors for the development of other psychiatric disorders and, without intervention, are more likely to persist into adulthood. While evidence-based pharmacological and behavioral interventions are currently available, there remains a sizable subset of youth who remain only partially treatment-responsive and therefore symptomatic following treatment. Novel methods of treatment, pharmacologic and non-pharmacologic, including acceptance and commitment therapy (ACT), attention bias modification (ABM), d-cycloserine (DCS) augmentation of cognitive behavioral treatment (CBT), and glutamatergic agents such as riluzole, are briefly introduced and discussed.

TFAP2C governs the luminal epithelial phenotype in mammary development and carcinogenesis

Molecular subtypes of breast cancer are characterized by distinct patterns of gene expression that are predictive of outcome and response to therapy. The luminal breast cancer subtypes are defined by the expression of ER-alpha (ERα)-associated genes, many of which are directly responsive to the Transcription Factor Activator Protein 2C (TFAP2C). TFAP2C participates in a gene regulatory network controlling cell growth and differentiation during ectodermal development and regulating ESR1/ERα and other luminal cell-associated genes in breast cancer. TFAP2C has been established as a prognostic factor in human breast cancer, however, its role in the establishment and maintenance of the luminal cell phenotype during carcinogenesis and mammary gland development have remained elusive. Herein, we demonstrate a critical role for TFAP2C in maintaining the luminal phenotype in human breast cancer and in influencing the luminal cell phenotype during normal mammary development. Knockdown of TFAP2C in luminal breast carcinoma cells induced EMT with morphological and phenotypic changes characterized by a loss of luminal-associated gene expression and a concomitant gain of basal-associated gene expression. Conditional knockout of the mouse homolog of TFAP2C, Tcfap2c, in mouse mammary epithelium driven by MMTV-Cre promoted aberrant growth of the mammary tree leading to a reduction in the CD24^hi/CD49f^mid luminal cell population and concomitant gain of the CD24^mid/CD49f^hi basal cell population at maturity. Our results establish TFAP2C as a key transcriptional regulator for maintaining the luminal phenotype in human breast carcinoma. Furthermore, Tcfap2c influences development of the luminal cell type during mammary development. The data suggest that TFAP2C plays an important role in regulated luminal specific genes and may be a viable therapeutic target in breast cancer.

Combined mesophilic anaerobic and thermophilic aerobic digestion process for high-strength food wastewater to increase removal efficiency and reduce sludge discharge

In this study, a process that combines the mesophilic anaerobic digestion (MAD) process with thermophilic aerobic digestion (TAD) for high-strength food wastewater (FWW) treatment was developed to examine the removal of organic matter and methane production. All effluent discharged from the MAD process was separated into solid and liquid portions. The liquid part was discarded and the sludge part was passed to the TAD process for further degradation. Then, the digested sludge from the TAD process was recycled back to the MAD unit to achieve low sludge discharge from the combined process. The reactor combination was operated in two phases: during Phase I, 40 d of total hydraulic retention time (HRT) was applied; during Phase II, 20 d was applied. HRT of the TAD process was fixed at 5 d. For a comparison, a control process (single-stage MAD) was operated with the same HRTs of the combined process. Our results indicated that the combined process showed over 90% total solids, volatile solids and chemical oxygen demand removal efficiencies. In addition, the combined process showed a significantly higher methane production rate than that of the control process. Consequently, the experimental data demonstrated that the combined MAD-TAD process was successfully employed for high-strength FWW treatment with highly efficient organic matter reduction and methane production.

Abstract P1-08-35: Androgen receptor expression and changes in serum dehydroepiandrosterone sulfate levels in locally advanced breast cancer patients who received neoadjuvant chemotherapy

Purpose: The associations between androgen receptor (AR) expression, serum dehydroepiandrosterone-sulfate (DHEA-S) level and response to neoadjuvant chemotherapy (NCT) were investigated in locally advanced breast cancer patients who received NCT.

Methods: Between May 2008 and April 2013, a total of 346 patients underwent NCT mainly based on anthracycline with or without taxane regimens. Biomarkers including AR were immunohistochemically determined using biopsy specimens before NCT and tumors with ≥ 1% nuclear staining were considered positive for AR. Changes in serum DHEA-S levels before and after NCT were examined by chemiluminescent immunoassay (Access DHEA-S, Beckman Coulter, Inc., Brea, CA) in 205 (59.2%) patients. Pathologic complete response (pCR) was defined as the absence of residual invasive carcinomas in the surgical specimens of breast and lymph nodes. Breast cancer subtypes were categorized by immunohistochemistry of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), and Ki-67.

Results: Mean age at diagnosis was 49.7 years (range, 26–76). Clinical tumor size was ≥ 2cm in 243 (70.2%) patients and 318 (91.9%) showed node-positive disease at initial presentation. AR-positive tumor was determined in 195 (56.4%) patients and 95 (27.5%) achieved pCR after NCT. AR-negative tumors were significantly associated with grade III, ER-negative, PR-negative, HER2-negative, high Ki-67 index, and triple-negative subtype tumors. By univariate logistic regression analysis, AR-negative tumor showed significantly higher odds ratio of 1.650 (95% CI, 1.026–2.654; p-value, 0.039) for achievement of pCR. Nevertheless, not AR status but breast cancer subtype, longer duration of NCT and use of targeted agents remained to be significant for pCR by multivariate model. In the analysis of subgroup by breast cancer subtypes, AR-negative tumor was associated with pCR in 75 patients with the low proliferative luminal A subtype, while AR-positive tumor achieved higher pCR in 59 patients with the HER2-positive luminal B subtype. In 205 patients available for serum DHEA-S levels, there was no difference in DHEA-S between pCR and non-pCR groups, although a trend of decrease in DHEA-S after NCT was noted among postmenopausal AR-positive or luminal A subtype women who achieved pCR.

Conclusions: AR expression might predict pCR in locally advanced breast cancer patients who undergo NCT, but this implication could be different according to breast cancer subtypes. Clinical significance of changes in serum DHEA-S levels during NCT remains to be elucidated.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-35.

Risk factors for post-operative venous thromboembolism in patients with a malignancy of the lower limb

It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery. Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb.

Adenovirus-mediated overexpression of Tcfe3 ameliorates hyperglycaemia in a mouse model of diabetes by upregulating glucokinase in the liver

AIMS/HYPOTHESIS

Transcription factor E3 (TFE3) has been shown to increase insulin sensitivity by activating insulin-signalling pathways. However, the role of TFE3 in glucose homeostasis is not fully understood. Here, we explored the possible therapeutic potential of TFE3 for the control of hyperglycaemia using a streptozotocin-induced mouse model of diabetes.

METHODS

We achieved overabundance of TFE3 in streptozotocin mice by administering an adenovirus (Ad) or adeno-associated virus serotype 2 (AAV2). We also performed an oral glucose tolerance test (OGTT) and insulin tolerance test (ITT). To explore molecular mechanisms of blood glucose control by TFE3, transcriptional studies on the regulation of genes involved in hepatic glucose metabolism were performed using quantitative real-time PCR and chromatin immunoprecipitation assay. The binding site of TFE3 in the liver Gck gene promoter was identified using deletion and site-specific mutation studies.

RESULTS

Overabundance of TFE3 resulted in reduced hyperglycaemia as shown by the OGTT and ITT in streptozotocin-treated mice. We observed that TFE3 can upregulate Gck in a state of insulin deficiency. However, glucose-6-phosphatase and cytosolic phosphoenolpyruvate carboxykinase mRNA levels were decreased by Ad-mediated overexpression of Tcfe3. Biochemical studies revealed that the anti-hyperglycaemic effect of TFE3 is due to the upregulation of Gck. In primary cultured hepatocytes, TFE3 increased expression of Gck mRNA. Conversely, small interfering RNA-mediated knockdown of TFE3 resulted in a decrease in Gck mRNA.

CONCLUSIONS/INTERPRETATION

This study demonstrates that TFE3 counteracts hyperglycaemia in streptozotocin-treated mice. This effect could be due to the upregulation of Gck by binding of TFE3 to its cognitive promoter region.

Abstract P1-01-23: Increased Diagnostic Performance of Sentinel Lymph Node Biopsy Combined with Radiologic-pathologic Factors After Neoadjuvant Chemotherapy in Breast Cancer Patients with Cytologically Proven Node Metastasis at Diagnosis

Background: It is undetermined whether sentinel lymph node biopsy (SLNB) is feasible and accurate for predicting final nodal status after neoadjuvant chemotherapy (NCT) in breast cancer patients with cytologically proven node metastasis at the time of diagnosis, although currently completion node dissection is a standard surgical procedure for the management of axilla. The aim of this study was to investigate diagnostic performance of SLNB after NCT in this subgroup.

Methods: Of 374 patients with T1-T3 breast cancer who received NCT, 178 had initially biopsy proven axillary/supraclavicular metastasis and subsequently underwent SLNB using radioisotope alone followed by completion node dissection between 2008 and 2011. Detection rate, sensitivity, false negative rate (FNR), negative predictive value (NPV), and accuracy of SLNB were retrospectively analyzed and it was explored using regression analysis whether combination with clinicopathologic factors improved performance.

Results: At initial presentation, 60.7% of patients were cT2 stage and 88.2% treated with concurrent or sequential anthracycline plus taxane preoperatively. SLNB was successfully performed in 169 (94.9%) patients. The mean number of sentinel and regional nodes retrieved was 2.1 ± 1.6 and 12.8 ± 6.3, respectively. Tumoral non-responder and extensive residual nodal disease were significantly associated with detection failure of SLNB. Conversion to node-negative disease was noted in 69 (40.8%) patients. Sensitivity, FNR, NPV, and accuracy of SLNB were 78.0%, 22.0%, 75.8%, and 87.0%, respectively and diagnostic performance increased when ≥ 3 sentinel nodes were evaluated. By logistic regression model, tumoral and nodal responder, absent lymphovascular invasion (LVI), estrogen receptor (ER)-negativity, and HER2-positivity were significantly associated with node-negative disease after NCT. Area under the receiver operating characteristic curve increased from 0.890 to 0.949 when considering radiologic-pathologic factors and FNR was the lowest value of 14.3% in 46 patients with tumoral responder, absent LVI, and ER-negative tumor.

Conclusions: SLNB was technically feasible but solely showed higher FNR in this study. Improved diagnostic performance of SLNB combined with radiologic-pathologic characteristics suggests possible clinical value of SLNB after NCT in highly selected patients with node metastasis at diagnosis.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-01-23.

Abstract P2-05-03: Mouse double minute 2 nuclear expression as a prognostic marker in patients with breast cancer

BACKGROUND: Mouse double minute 2 (Mdm2) is a negative regulator of tumor suppressor, p53, thus Mdm2 expression may play a role in cancer development and prognosis, however, the definite role of Mdm2 in breast cancer is unclear. The aim of the study is to evaluate the correlation between Mdm2 expression and prognosis of breast cancer.

METHODS: Mdm2 expression was determined from immunohistochemistry of tissue microarrays of 865 patients with breast cancer who underwent surgery. Clinicopathologic characteristics and survival data were analyzed using a univariate and multivariate analysis. Mdm2 expression was categorized into 3 groups: negative; no Mdm2 expression in nucleus and cytoplasm, cytoplasm-positive; cytoplasmic expression of Mdm2, nucleus-positive; nuclear with or without cytoplastimc expression of Mdm2.

RESULTS: Negative, cytoplasm-positive, and nucleus-positive groups were observed in 59.2%, 10.9%, and 29.9% of patients, respectively. Nucleus-positive group was associated with young age, high grade, negativity of estrogen and progesterone receptor, HER2 positivity, and high Ki-67 index. With median 86.0 follow-up months, nucleus-positive group showed poorer disease-free survival and overall survival than negative and cytoplasm-positive groups. In multivariate analysis, cytoplsmic expression of Mdm2 was not significantly associated with survival, whereas nuclear expression of Mdm2 was related to poor prognosis. (HR, 1.44; 95% CI, 1.041–1.993 for DFS; HR, 1.546; 95% CI, 1.060–2.255 for OS)

CONCLUSIONS: Nuclear expression of Mdm2 was an independent prognostic factor in patients with breast cancer. Patterns of Mdm2 expression in tumor cell should be rendered in the evaluation of Mdm2 in breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-05-03.

Elevated levels of preoperative CA 15-3 and CEA serum levels have independently poor prognostic significance in breast cancer

BACKGROUND

To evaluate the prognostic value of preoperative tumor markers, cancer antigen 15-3 (CA 15-3) and carcinoembryonic antigen (CEA), in breast cancers.

PATIENTS AND METHODS

Preoperative CA 15-3 and CEA levels of 1681 patients were measured. The association of both tumor markers levels with clinicopathological parameters and outcomes was investigated by univariate and multivariate analyses.

RESULTS

Among 1681 patients, elevated preoperative CA15-3 and CEA levels were identified in 176 and 131 patients, respectively. Higher preoperative CA 15-3 and CEA levels were significantly associated with a larger tumor size, axillary node metastases, and advanced stage. Patients with elevated CA 15-3 and CEA levels showed worse survival, even in stage-matched analysis. Patients with normal levels of both CA15-3 and CEA showed better survival than those with one or both markers levels elevated. In multivariate analysis, elevated preoperative CA 15-3 and CEA levels were independent prognostic factors. The statistical significance of elevated preoperative tumor markers levels on survival was solidified with longer follow-up and larger study population.

CONCLUSIONS

Elevated preoperative CA 15-3 and CEA levels are associated with tumor burden and showed independent prognostic significance. Therefore, new treatment strategies are necessary for patients with elevated preoperative CA 15-3 and CEA levels in clinical practice.

RapidArc vs intensity-modulated radiation therapy for hepatocellular carcinoma: a comparative planning study

OBJECTIVE

The purpose of this study is to compare the dose-volumetric results of RapidArc (RA Varian Medical Systems, Palo Alto, CA) with those of intensity-modulated radiation therapy (IMRT) for hepatocellular carcinoma.

METHODS

20 patients previously treated for hepatocellular carcinoma were the subjects of this planning study. 10 patients were treated for portal vein tumour thrombosis (Group A), and 10 patients for primary liver tumour (Group B). Prescription dose to the planning target volume was 54 Gy in 30 fractions, and the planning goal was to deliver more than 95% of prescribed dose to at least 95% of planning target volume.

RESULTS

In Group A, mean doses to liver were increased with RA vs IMRT (22.9 Gy vs 22.2 Gy, p=0.0275). However, V(30 Gy) of liver was lower in RA vs IMRT (31.1% vs 32.1%, p=0.0283). In Group B, in contrast, neither mean doses nor V(30 Gy) of liver significantly differed between the two plans. V(35 Gy) of duodenum and V(20 Gy) of kidney were decreased with RA in Groups A and B, respectively (p=0.0058 and 0.0124, respectively). Both maximal doses to spinal cord and monitor unit were significantly lower in the RA plan, regardless of the group.

CONCLUSION

The dose-volumetric results of RA vs IMRT were different according to the different target location within the liver. In general, RA tended to be more effective in the sparing of non-liver organs at risk such as duodenum, kidney, and/or spinal cord. Moreover, RA was more efficient in the treatment delivery than IMRT in terms of total monitor unit used.

Cervical cerclage: one stitch or two?

OBJECTIVE

We sought to determine whether routine placement of a second stitch at the time of cervical cerclage improves its efficacy.

STUDY DESIGN

This is a retrospective cohort study of patients who had cervical cerclage placement at a single institution. Operative reports, ultrasound images, and delivery records were reviewed. Pregnancy outcomes of patients receiving a two-stitch cerclage were compared with those who received a one-stitch cerclage, with a primary outcome of spontaneous preterm delivery at <35 weeks' gestation. Univariable, multivariable, and Kaplan-Meier survival analyses were performed.

RESULTS

Of 146 patients, 63 had two stitches and 83 had one. Baseline characteristics and indications for cerclage were similar except for differences in history of prior cerclage and multiple gestations. The two-stitch approach was associated with a greater median cerclage height (20 mm versus 17 mm, p = 0.008), but there was no difference in spontaneous preterm delivery at <35 weeks' gestation (47.6% versus 41.0%, adjusted odds ratio 1.22, p = 0.630).

CONCLUSION

A two-stitch approach to cervical cerclage increases cerclage height, but may not improve efficacy.

PET/CT and MRI of intra-osseous haemangioma of the tibia

Intra-osseous haemangioma is a rare, benign neoplasm that usually involves the vertebrae and craniofacial bones. Furthermore, its occurrence in the long bones is extremely rare. We report the findings of fluorine-18-fludeoxyglucose ((18)F-FDG) positron emission tomography (PET)/CT and MRI in a patient with intra-osseous haemangioma in the proximal tibia, who was initially misdiagnosed as having a malignancy based on (18)F-FDG PET/CT. (18)F-FDG PET/CT showed a well-marginated osteolytic lesion with abnormal FDG uptake. The mass demonstrated low signal intensity on T(1) weighted MRI. On T(2) weighted images, the lesion appeared as a cluster of high signal intensity lobules and showed strong enhancement on contrast-enhanced T(1) weighted images. Surgical curettage was performed and histopathological examination of the excised tissue confirmed a cavernous haemangioma.

Living With Tics

Available treatment for chronic tic disorders (CTD) focuses on the reduction of tics but often does not directly address the psychosocial impairment associated with tics. There is empirical support for a new psychosocial intervention to reduce tics and their related impairment, but this treatment has not yet been applied to adults with CTD. With this in mind, the authors report on the case of “Jim,” a 22-year-old male with significantly impairing tic symptoms. Following 10 sessions of weekly cognitive-behaviorally oriented therapy combining habit reversal training, distress tolerance, cognitive restructuring, and problem solving, Jim exhibited marked improvement in tic severity as illustrated by a decrease in his score on the total tic score of the Yale Global Tic Severity Scale from 16 at baseline to 8 at posttreatment. Therapeutic gains were maintained at 4-month follow-up. This case study provides preliminary support for the use of a psychosocial intervention for addressing coping with CTD in young adults.