Risk of cardiovascular disease with high-dose versus low-dose use of non-steroidal anti-inflammatory drugs in ankylosing spondylitis

OBJECTIVE

To investigate the risk of cardiovascular disease (CVD) associated with increasing dose of a non-steroidal anti-inflammatory drug (NSAID) in patients with ankylosing spondylitis (AS).

METHODS

Using the Korean National Health Insurance database, patients newly diagnosed with AS without prior CVD between 2010 and 2018 were included in this nationwide cohort study. The primary outcome was CVD, a composite outcome of ischaemic heart disease, stroke or congestive heart failure. Exposure to NSAIDs was evaluated using a time-varying approach. The dose of NSAIDs was considered in each exposure period. Cox proportional hazard regression was used to investigate the risk of CVD associated with NSAID use.

RESULTS

Of the 19 775 patients (mean age, 36 years; 75% were male), 19 706 received NSAID treatment. During follow-up period of 98 290 person-years, 1663 cases of CVD occurred including 1157 cases of ischaemic heart disease, 301 cases of stroke and 613 cases of congestive heart failure. Increasing dose of NSAIDs was associated with incident CVD after adjusting for confounders (adjusted HR (aHR) 1.10; 95% CI 1.08 to 1.13). Specifically, increasing dose of NSAIDs was associated with incident ischaemic heart disease (aHR 1.08; 95% CI 1.05 to 1.11), stroke (aHR 1.09; 95% CI 1.04 to 1.15) and congestive heart failure (aHR 1.12; 95% CI 1.08 to 1.16). The association between NSAID dose and higher CVD risk was consistent in different subgroups.

CONCLUSION

In a real-world AS cohort, higher dose of NSAID treatment was associated with a higher risk of CVD, including ischaemic heart disease, stroke and congestive heart failure.

Cutaneous Serratia marcescens infection in two dogs

We describe two canine cases of cutaneous infection caused by Serratia marcescens. A 2-year-old castrated male mixed dog (Case 1) presented with multiple ulcerations on the dorsal trunk, which were observed 4 days after shampooing. A 4-year-old male wolf shepherd mix dog (Case 2) presented with ulceration and purulent discharge on the nasal bridge. Cytological examination of both cases revealed pyogranulomatous inflammatory cells with rod-like infectious agents identified as S. marcescens in aerobic bacterial culture. Both patients were treated with oral antibiotics and topical chlorhexidine. Case 1 received enrofloxacin 10 mg/kg once daily for 1 week, followed by trimethoprim/sulfamethoxazole 15 mg/kg twice daily for 3 weeks. Case 2 received doxycycline 10 mg/kg twice daily for 4 weeks. No skin lesions were detected 2 weeks after the initial administration. The antibiotics were discontinued after a total 4 weeks of administration, and the skin lesions did not reappear.

High-dose proton pump inhibitor treatment is associated with a higher mortality in cirrhotic patients: A multicentre study

BACKGROUND

Proton pump inhibitors (PPI) are frequently used in patients with cirrhosis.

AIMS

This study aimed to determine whether PPI use is associated with the prognosis of cirrhotic patients.

METHODS

We conducted a multicentre retrospective cohort study involving 1485 patients who had experienced hepatic encephalopathy (HE) from 7 referral centres in Korea. The primary outcome was overall survival and secondary outcomes included the development of cirrhotic complications, including recurrent HE, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and gastrointestinal bleeding. Patients treated with PPI with a mean defined daily dose (mDDD) ≥0.5 (high-dose PPI group) were compared to those treated with PPI of an mDDD < 0.5 (No or low-dose PPI group) for each outcome.

RESULTS

Among 1485 patients (median age, 61 years; male, 61%), 232 were assigned to the high-dose PPI group. High-dose PPI use was independently associated with a higher risk of death (adjusted HR [aHR] = 1.71, 95% confidence interval [CI] = 1.38-2.11, p < 0.001). This result was reproducible after propensity score-matching (PSM) (aHR = 1.90, 95% CI = 1.49-2.44, p < 0.001). High-dose PPI use was an independent risk factor of recurrent HE (before PSM: aHR = 2.04, 95% CI = 1.66-2.51, p < 0.001; after PSM: aHR = 2.16, 95% CI = 1.70-2.74, p < 0.001), SBP (before PSM: aHR = 1.87, 95% CI = 1.43-2.43, p < 0.001; after PSM: aHR = 1.76, 95% CI = 1.31-2.36, p = 0.002), HRS (before PSM: aHR = 1.48, 95% CI = 1.02-2.15, p = 0.04; after PSM: aHR = 1.47, 95% CI = 0.95-2.28, p = 0.09), and gastrointestinal bleeding (before PSM: aHR = 1.46, 95% CI = 1.12-1.90, p = 0.006; after PSM: aHR = 1.74, 95% CI = 1.28-2.37, p < 0.001).

CONCLUSIONS

The use of high-dose PPI was independently associated with increased risks of mortality and cirrhotic complications.

Risk of cardiovascular disease associated with long-term use of non-steroidal anti-inflammatory drugs in ankylosing spondylitis

OBJECTIVE

To examine the risk of cardiovascular disease associated with long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) in a large real-world ankylosing spondylitis (AS) cohort.

METHODS

This nationwide population-based cohort study used data from the Korean National Health Insurance Database. Patients aged ≥18 years old who were newly diagnosed with AS without prior cardiovascular disease between January 2010 and December 2018 were included in this study. Controls without AS were randomly selected by age, sex, and index year. The primary outcome was cardiovascular disease, a composite outcome of ischemic heart disease, stroke, or congestive heart failure. Long-term use of NSAIDs was defined as use of NSAIDs for >365 cumulative defined daily doses. The association between long-term use of NSAIDs and incident cardiovascular disease was examined in both AS and non-AS populations.

RESULTS

Among 19 775 patients with AS and 59 325 matched controls without AS, there were 1,663 and 4,308 incident cases of cardiovascular disease, showing an incidence of 16.9 and 13.8 per 1,000 person-years, respectively. Long-term use of NSAIDs was associated with increased risk of cardiovascular disease in non-AS controls (adjusted hazard ratio [aHR], 1.64; 95% CI, 1.48-1.82). In contrast, long-term use of NSAIDs did not increase the risk of cardiovascular disease in AS patients (aHR, 1.06; 95% CI, 0.94-1.20; adjusted for age, sex, socioeconomic status, body mass index, smoking status, hypertension, diabetes, hyperlipidemia, and tumor necrosis factor inhibitor use).

CONCLUSION

Prolonged NSAID treatment in AS patients may not be as harmful as in the general population regarding cardiovascular risk.

Inverse Propensity Score-Weighted Analysis of Entecavir and Tenofovir Disoproxil Fumarate in Patients with Chronic Hepatitis B: A Large-Scale Multicenter Study

Tenofovir disoproxil fumarate (TDF) is reportedly superior or at least comparable to entecavir (ETV) in preventing hepatocellular carcinoma (HCC) among chronic hepatitis B (CHB) patients; however, it remains controversial. This study aimed to conduct comprehensive comparisons between the two antivirals. CHB patients initially treated with ETV or TDF between 2012 and 2015 at 20 referral centers in Korea were included. The primary outcome was the cumulative incidence of HCC. The secondary outcomes included death or liver transplantation, liver-related outcome, extrahepatic malignancy, development of cirrhosis, decompensation events, complete virologic response (CVR), seroconversion rate, and safety. Baseline characteristics were balanced using the inverse probability of treatment weighting (IPTW). Overall, 4210 patients were enrolled: 1019 received ETV and 3191 received TDF. During the median follow-ups of 5.6 and 5.5 years, 86 and 232 cases of HCC were confirmed in the ETV and TDF groups, respectively. There was no difference in HCC incidence between the groups both before (p = 0.36) and after IPTW was applied (p = 0.81). Although the incidence of extrahepatic malignancy was significantly higher in the ETV group than in the TDF group before weighting (p = 0.02), no difference was confirmed after IPTW (p = 0.29). The cumulative incidence rates of death or liver transplantation, liver-related outcome, new cirrhosis development, and decompensation events were also comparable in the crude population (p = 0.24-0.91) and in the IPTW-adjusted population (p = 0.39-0.80). Both groups exhibited similar rates of CVR (ETV vs. TDF: 95.1% vs. 95.8%, p = 0.38), and negative conversion of hepatitis B e antigen (41.6% vs. 37.2%, p = 0.09) or surface antigen (2.8% vs. 1.9%, p = 0.10). Compared to the ETV group, more patients in the TDF group changed initial antivirals due to side effects, including decreased kidney function (n = 17), hypophosphatemia (n = 20), and osteoporosis (n = 18). In this large-scale multicenter study, ETV and TDF demonstrated comparable effectiveness across a broad range of outcomes in patients with treatment-naïve CHB during similar follow-up periods.

Effect of music on colonoscopy performance: A propensity score-matched analysis

BACKGROUND

Music has been used to reduce stress and improve task performance during medical therapy.

AIM

To assess the effects of music on colonoscopy performance outcomes.

METHODS

We retrospectively reviewed patients who underwent colonoscopy performed by four endoscopists with popular music. Colonoscopy performance outcomes, such as insertion time, adenoma detection rate (ADR), and polyp detection rate (PDR), were compared between the music and non-music groups. To reduce selection bias, propensity score matching was used.

RESULTS

After one-to-one propensity score matching, 169 colonoscopies were selected from each group. No significant differences in insertion time (4.97 vs 5.17 min, P = 0.795) and ADR (39.1% vs 46.2%, P = 0.226) were found between the two groups. Subgroup analysis showed that the insertion time (3.6 vs 3.8 min, P = 0.852) and ADR (51.1% vs 44.7%, P = 0.488) did not significantly differ between the two groups in experts. However, in trainees, PDR (46.9% vs 66.7%, P = 0.016) and ADR (25.9% vs 47.6%, P = 0.006) were significantly lower in the music than in the non-music group.

CONCLUSION

The current study found that listening to music during colonoscopy did not affect procedure performance. Moreover, it suggested that music may distract trainees from appropriately detecting adenomas and polyps.

Gastric wall abscess after endoscopic submucosal dissection

Gastric wall abscess, a localized form of phlegmonous gastritis, is a rare complication of endoscopic resection. We report the first case of gastric wall abscess developing after endoscopic submucosal dissection in Korea. A 72-year-old woman visited our clinic to receive treatment for gastric adenoma. The patient successfully underwent endoscopic submucosal dissection with no complications. The final diagnosis was well-differentiated tubular adenocarcinoma. We performed follow-up endoscopy 10 weeks later and found a large subepithelial lesion on the posterior wall of the gastric antrum. Abdominal computed tomography revealed hypodense wall thickening and a 5 cm heterogenous multilobular mass in the submucosal layer of the gastric antrum. Submucosal invasion with mucin-producing adenocarcinomas could therefore not be excluded. The patient agreed to undergo additional gastrectomy due to the possibility of a highly malignant lesion. The final diagnosis was acute suppurative inflammation with the formation of multiple abscesses in the mural layers and omentum. The patient was discharged with no complications.

Preclinical development of carrier-free prodrug nanoparticles for enhanced antitumor therapeutic potential with less toxicity

Background

Nanomedicine has emerged as a promising strategy for cancer treatment. The most representative nanomedicine used in clinic is PEGylated liposomal doxorubicin DOXIL^®, which is first FDA-approved nanomedicine. However, several shortcomings, such as low drug loading capacity, low tumor targeting, difficulty in mass production and potential toxicity of carrier materials, have hindered the successful clinical translation of nanomedicines. In this study, we report a preclinical development process of the carrier-free prodrug nanoparticles designed as an alternative formulation to overcome limitations of conventional nanomedicines in the terms of technical- and industrial-aspects.

Results

The carrier-free prodrug nanoparticles (F68-FDOX) are prepared by self-assembly of cathepsin B-specific cleavable peptide (FRRG) and doxorubicin (DOX) conjugates without any additional carrier materials, and further stabilized with Pluronic F68, resulting in high drug loading (> 50%). The precise and concise structure allow mass production with easily controllable quality control (QC), and its lyophilized powder form has a great long-term storage stability at different temperatures (− 4, 37 and 60 °C). With high cathepsin B-specificity, F68-FDOX induce a potent cytotoxicity preferentially in cancer cells, whereas their cytotoxicity is greatly minimized in normal cells with innately low cathepsin B expression. In tumor models, F68-FDOX efficiently accumulates within tumor tissues owing to enhanced permeability and retention (EPR) effect and subsequently release toxic DOX molecules by cathepsin B-specific cleavage mechanism, showing a broad therapeutic spectrum with significant antitumor activity in three types of colon, breast and pancreatic cancers. Finally, the safety of F68-FDOX treatment is investigated after single-/multi-dosage into mice, showing greatly minimized DOX-related toxicity, compared to free DOX in normal mice.

Conclusions

Collectively, these results provide potential preclinical development process of an alternative approach, new formulation of carrier-free prodrug nanoparticles, for clinical translation of nanomedicines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-022-01644-x.

Impact of HBeAg on Hepatocellular Carcinoma Risk During Oral Antiviral Treatment in Patients With Chronic Hepatitis B

BACKGROUND & AIMS

Antiviral treatment from hepatitis B envelope antigen (HBeAg)-positive status may attenuate the integration of hepatitis B virus DNA into the host genome causing hepatocellular carcinoma (HCC). We investigated the impact of HBeAg status at the onset of antiviral treatment on the risk of HCC.

METHODS

The incidence of HCC was evaluated in Korean patients with chronic hepatitis B who started entecavir or tenofovir in either HBeAg-positive or HBeAg-negative phase. The results in the Korean cohort were validated in a Caucasian PAGE-B cohort.

RESULTS

A total of 9143 Korean patients (mean age, 49.2 years) were included: 49.1% were HBeAg-positive and 49.2% had cirrhosis. During follow-up (median, 5.1 years), 916 patients (10.0%) developed HCC. Baseline HBeAg positivity was not associated with the risk of HCC in the entire cohort or cirrhotic subcohort. However, in the non-cirrhotic subcohort, HBeAg positivity was independently associated with a lower risk of HCC in multivariable (adjusted hazard ratio [aHR], 0.41; 95% confidence interval [CI], 0.26-0.66), propensity score-matching (aHR, 0.46; 95% CI, 0.28-0.76), and inverse probability weighting analyses (aHR, 0.44; 95% CI, 0.28-0.70). In the Caucasian cohort (n = 719; mean age, 51.8 years; HBeAg-positive, 20.3%; cirrhosis, 34.8%), HBeAg-positivity was not associated with the risk of HCC either in the entire cohort or cirrhotic subcohort. In the non-cirrhotic subcohort, none of the HBeAg-positive group developed HCC, although the difference failed to reach statistical significance (aHR, 0.21; 95% CI, 0.00-1.67).

CONCLUSIONS

This multinational cohort study implies that HBeAg positivity at the onset of antiviral treatment seems to be an independent factor associated with a lower risk of HCC in patients with chronic hepatitis B without cirrhosis, but not in those with cirrhosis.

Morphologic Changes in Esophageal Body Movement During Bolus Transport After Peroral Endoscopic Myotomy in Type III Achalasia

Background/Aims

The effect of peroral endoscopic myotomy (POEM) on esophageal body movement in achalasia is poorly understood. This study aims to evaluate morphological changes in esophageal body movement after POEM in type III achalasia by analyzing intraluminal ultrasound (US) images in comparison to type I and II achalasia.

Methods

Intraluminal US images and impedance values of the distal esophagus from 47 achalasia patients who underwent POEM or pneumatic dilatation (PD) (30 patients in the POEM group and 17 patients in the PD group) with pre- and post-procedural high-resolution impedance manometry and intraluminal US examinations were analyzed. The muscle thickness (MT), muscle cross-sectional area, lumen cross-sectional area (LCSA), contractility and distensibility indices, swallow-to-distension interval, and distension duration during each bolus transport were analyzed.

Results

The MT increased and LCSA decreased significantly (P < 0.001), but the contractility index was not improved after POEM or PD in type I achalasia. Baseline MT increased and LCSA decreased significantly after POEM and PD in type II achalasia (P < 0.001). In contrast, MT and the swallow-to-distension interval decreased and the distension LCSA/duration and contractility index increased after POEM in type III achalasia (P < 0.001). In contrast to type I and II achalasia, in type III achalasia, these effects were unique to the POEM group.

Conclusions

POEM decreased the esophageal LCSA by decreasing intrabolus pressure without improving contractility in type I and II achalasia. In contrast, POEM increased esophageal body distension and contractility and improved the inhibitory process during bolus transport in type III achalasia.

Toward a complete cure for chronic hepatitis B: Novel therapeutic targets for hepatitis B virus

Hepatitis B virus (HBV) affects approximately 250 million patients worldwide, resulting in the progression to cirrhosis and hepatocellular carcinoma, which are serious public health problems. Although universal vaccination programs exist, they are only prophylactic and not curative. In the HBV life cycle, HBV forms covalently closed circular DNA (cccDNA), which is the viral minichromosome, in the nuclei of human hepatocytes and makes it difficult to achieve a complete cure with the current nucleos(t)ide analogs and interferon therapies. Current antiviral therapies rarely eliminate cccDNA; therefore, lifelong antiviral treatment is necessary. Recent trials for antiviral treatment of chronic hepatitis B have been focused on establishing a functional cure, defined by either the loss of hepatitis B surface antigen, undetectable serum HBV DNA levels, and/or seroconversion to hepatitis B surface antibody. Novel therapeutic targets and molecules are in the pipeline for early clinical trials aiming to cure HBV infection. The ideal strategy for achieving a long-lasting functional or complete cure might be using combination therapies targeting different steps of the HBV life cycle and immunomodulators. This review summarizes the current knowledge about novel treatments and combination treatments for a complete HBV cure.

Prognostic Implication of Baseline Sarcopenia for Length of Hospital Stay and Survival in Patients With Coronavirus Disease 2019

Background

The impact of sarcopenia on clinical outcomes of coronavirus disease 2019 (COVID-19) is not clearly determined yet. We aimed to investigate the association between baseline sarcopenia and clinical outcomes in patients with COVID-19.

Methods

All hospitalized adult patients with COVID-19 who had baseline chest computed tomography (CT) scans at a Korean university hospital from February 2020 to May 2020 were included. The main outcome was time from hospital admission to discharge. Death was considered as a competing risk for discharge. Baseline skeletal muscle cross-sectional area at the level of the 12th thoracic vertebra was measured from chest CT scans. The lowest quartile of skeletal muscle index (skeletal muscle cross-sectional area divided by height-squared) was defined as sarcopenia.

Results

Of 121 patients (median age, 62 years; 44 men; 29 sarcopenic), 7 patients died and 86 patients were discharged during the 60-day follow-up. Patients with sarcopenia showed a longer time to discharge (median, 55 vs. 28 days; p<0.001) and a higher incidence of death (17.2% vs. 2.2%; p=0.004) than those without sarcopenia. Baseline sarcopenia was an independent predictor of delayed hospital discharge (adjusted hazard ratio [aHR], 0.47; 95% CI, 0.23-0.96), but was not independently associated with mortality in patients with COVID-19 (aHR, 3.80; 95% CI, 0.48-30.26). The association between baseline sarcopenia and delayed hospital discharge was consistent in subgroups stratified by age, sex, comorbidities, and severity of COVID-19.

Conclusion

Baseline sarcopenia was independently associated with prolonged hospital stay in patients with COVID-19. Sarcopenia could be a prognostic marker in COVID-19.

Real-world Effectiveness and Safety of Direct-acting Antiviral Agents in Patients with Chronic Hepatitis C Genotype 2 Infection: Korean Multicenter Study

BACKGROUND

The advancement of treatment with direct-acting antiviral (DAA) agents has improved the cure rate of hepatitis C virus (HCV) infection close to 100%. The aim of our study was to assess the real-world effectiveness and safety of DAA regimens for the treatment of patients with chronic HCV genotype 2.

METHODS

We retrospectively analyzed the clinical data of patients treated with sofosbuvir plus ribavirin (SOF + RBV) or glecaprevir/pibrentasvir (G/P) for chronic HCV genotype 2 infection at seven university hospitals in the Korean southeast region.

RESULTS

SOF + RBV therapy produced an 89% and 98.3% sustained virologic response 12 week (SVR12) after treatment completion in the full analysis set and per-protocol set, respectively, and the corresponding values for G/P therapy were 89.5% and 99.2%, respectively. The difference between the treatments was probably because 6.2% (59/953) of patients in the SOF + RBV group did not complete the treatment and 9.8% (14/143) in the G/P group did not test HCV RNA after treatment completion. Adverse events (A/Es) were reported in 59.7% (569/953) and 25.9% (37/143) of the SOF + RBV and G/P groups, respectively. In the SOF + RBV group, 12 (1.26%) patients discontinued treatment owing to A/Es, whereas no patients discontinued treatment because of A/Es in the G/P group.

CONCLUSION

In both treatment groups, SVR was high when treatment was completed. However, there was a high dropout rate in the SOF + RBV group, and the dropout analysis showed that these were patients with liver cirrhosis (LC; 43/285, 15.1%), especially those with decompensated LC (12/32, 37.5%). Therefore, an early initiation of antiviral therapy is recommended for a successful outcome before liver function declines. Furthermore, patients with decompensated LC who are considered candidates for SOF + RBV treatment should be carefully monitored to ensure that their treatment is completed, especially those with low hemoglobin and high alanine transaminase.

Empirical Treatment With Carbapenem vs Third-generation Cephalosporin for Treatment of Spontaneous Bacterial Peritonitis

BACKGROUND & AIMS

Third-generation cephalosporins (TGCs) are recommended as first-line antibiotics for treatment of spontaneous bacterial peritonitis (SBP). However, antibiotics against multidrug-resistant organisms (such as carbapenems) might be necessary. We aimed to evaluate whether carbapenems are superior to TGC for treatment of SBP.

METHODS

We performed a retrospective study of 865 consecutive patients with a first presentation of SBP (275 culture positive; 103 with TGC-resistant bacterial infections) treated at 7 referral centers in Korea, from September 2013 through January 2018. The primary outcome was in-hospital mortality. We made all comparisons using data from patients whose baseline characteristics were balanced by inverse probability of treatment weighting.

RESULTS

Of patients who initially received empirical treatment with antibiotics, 95 (11.0%) received carbapenems and 655 (75.7%) received TGCs. Among the entire study cohort, there was no significant difference in in-hospital mortality between the carbapenem (25.8%) and TGC (25.3%) groups (adjusted odds ratio [aOR], 0.97; 95% CI, 0.85-1.11; P = .66). In the subgroup of patients with high chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores (score of 7 or greater, n = 314), carbapenem treatment was associated with lower in-hospital mortality (23.1%) than in the TGC group (38.8%) (aOR, 0.84; 95% CI, 0.75-0.94; P=.002). In contrast, among patients with lower CLIF-SOFA scores (n = 436), in-hospital mortality did not differ significantly between the carbapenem group (24.7%) and the TGC group (16.0%) (aOR, 1.06; 95% CI, 0.85-1.32; P = .58).

CONCLUSIONS

For patients with a first presentation of SBP, empirical treatment with carbapenem does not reduce in-hospital mortality compared to treatment with TGCs. However, among critically ill patients (CLIF-SOFA scores ≥7), empirical carbapenem treatment was significantly associated with lower in-hospital mortality than TGCs.

Hepatocellular Carcinoma in Korea: an Analysis of the 2015 Korean Nationwide Cancer Registry

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) is the sixth most common cancer and the second leading cause of cancer-related death in Korea. This study evaluated the characteristics of Korean patients newly diagnosed with HCC in 2015.

METHODS

Data from the Korean Primary Liver Cancer Registry (KPLCR), a representative sample of patients newly diagnosed with HCC in Korea, were analyzed. A total of 1,558 patients with HCC registered in the KPLCR in 2015 were investigated.

RESULTS

The median age was 61.0 years (interquartile range, 54.0-70.0 years), and men accounted for 79.7% of the subjects. Hepatitis B virus infection was the most common underlying liver disease (58.1%). According to the Barcelona Clinic Liver Cancer (BCLC) staging system, stage 0, A, B, C, and D HCCs accounted for 14.2%, 31.5%, 7.6%, 39.0%, and 7.8% of patients, respectively. Transarterial therapy (32.1%) was the most commonly performed initial treatment, followed by surgical resection (23.2%), best supportive care (20.2%), and local ablation therapy (10.7%). Overall, 34.5% of patients were treated in accordance with the BCLC guidelines: 59.2% in stage 0/A, 48.4% in stage B, 18.1% in stage C, and 71.6% in stage D. The 1-, 3-, and 5-year OS rates were 67.1%, 50.9%, and 27.0%, respectively.

CONCLUSIONS

In 2015, approximately 45% of Korean HCC cases were diagnosed at a very early or early stage, and 35% of patients underwent potentially curative initial treatment. BCLC guidance was followed in 34.5% of patients; in patients with stage B or C disease, there was relatively low adherence.

Percutaneous Trans-splenic Obliteration for Duodenal Variceal bleeding: A Case Report

Duodenal varices are a serious complication of portal hypertension. Bleeding from duodenal varices is rare, but when bleeding does occur, it is massive and can be fatal. Unfortunately, the optimal therapeutic modality for duodenal variceal bleeding is unclear. This paper presents a patient with duodenal variceal bleeding that was managed successfully using percutaneous trans-splenic variceal obliteration (PTVO). A 56-year-old man with a history of alcoholic cirrhosis presented with a 6-day history of melena. Emergency esophagogastroduodenoscopy revealed a large, bluish mass with a nipple sign in the second portion of the duodenum. Coil embolization of the duodenal varix was performed via a trans-splenic approach (i.e., PTVO). The patient no longer complained of melena after treatment. The duodenal varix was no longer visible at the follow-up esophagogastroduodenoscopy performed three months after PTVO. The use of PTVO might be a viable option for the treatment of duodenal variceal bleeding.

Prognostic impact of concurrent nonalcoholic fatty liver disease in patients with chronic hepatitis B-related hepatocellular carcinoma

BACKGROUND AND AIM

As the prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing globally, patients with both NAFLD and chronic hepatitis B (CHB)-related hepatocellular carcinoma (HCC) is also frequently found. This study aimed to investigate the clinical impact of concurrent NAFLD on the prognosis of patients with CHB-related HCC.

METHODS

Patients with CHB-related HCC who underwent surgical resection were consecutively selected from August 2009 to December 2013. The association between histologically proven concurrent NAFLD and clinical outcomes were analyzed. Propensity score (PS) matching was adapted to adjust for baseline characteristics. We also investigated the presence of nonalcoholic steatohepatitis (NASH) among patients with NAFLD and its association with clinical outcomes.

RESULTS

Among 338 CHB-related HCC patients selected, 196 patients (58.0%) were diagnosed with concurrent NAFLD. The median follow-up duration was 74.9 months. The patients with NAFLD tended to have better recurrence-free survival (RFS; log-rank, P = 0.16) and had significantly better overall survival (OS; log-rank, P = 0.004) than those without NAFLD. However, the survival benefit of the concurrent NAFLD was not significant in a multivariable Cox analysis (adjusted hazard ratio, 0.94; 95% confidence interval, 0.51-1.73, P = 0.84) or an analysis after PS matching (log-rank, P = 0.57). Regarding the presence or absence of NASH, no differences in the RFS (log-rank, P = 0.61) and OS (log-rank, P = 0.26) were found.

CONCLUSIONS

Concurrent NAFLD was not associated with both RFS and OS in patients with CHB-related HCC after adjusting for baseline characteristics. Moreover, NAFLD patients with NASH did not have significantly different clinical outcomes compared with NAFLD patients without NASH.

Plasma Long Noncoding RNA LeXis is a Potential Diagnostic Marker for Non-Alcoholic Steatohepatitis

Non-invasive diagnostic markers are needed to ease the diagnosis of non-alcoholic steatohepatitis (NASH) among patients with non-alcoholic fatty liver disease (NAFLD). The long noncoding RNA (lncRNA) LeXis is related to cholesterol metabolism and hepatic steatosis in mice, and its batch genome conversion in humans is TCONS_00016452. Here, we aimed to evaluate the potential of lncRNA LeXis as a non-invasive diagnostic marker for NASH. We analyzed a total of 44 NAFLD patients whose diagnosis was confirmed by a pathologist through analysis of a percutaneous liver biopsy. The expression of LeXis in the plasma of NAFLD patients with and without NASH was compared using quantitative real-time polymerase chain reaction. The expression of plasma LeXis was significantly higher in patients with NASH than in those with NAFL (8.2 (5.0-14.9); 4.6 (4.0-6.6), p = 0.025). The area under the receiver operating characteristic curve was 0.743 (95% CI 0.590-0.895, p < 0.001), and a sensitivity of 54.3% and specificity of 100% could be achieved for NASH diagnosis. Low LeXis was independently associated with NASH diagnosis in patients with NAFLD (p = 0.0349, odds ratio = 22.19 (5% CI, 1.25-395.22)). Therefore, circulating lncRNA LeXis could be a potential non-invasive diagnostic biomarker for NASH.

Hepatocellular Carcinoma in Korea between 2012 and 2014: an Analysis of Data from the Korean Nationwide Cancer Registry

BACKGROUND/AIMS

Considering the high prevalence and mortality of hepatocellular carcinoma (HCC) in Korea, accurate statistics for HCC are important. We evaluated the characteristics of Korean patients with newly diagnosed HCC.

METHODS

We retrospectively evaluated data from the Korean Primary Liver Cancer Registry (KPLCR). The baseline characteristics, treatment modalities, and overall survival (OS) of 4,572 patients with HCC registered in the KPLCR between 2012 and 2014 were investigated.

RESULTS

At the time of HCC diagnosis, the median age was 60.0 years, with male predominance (79.6%). Hepatitis B virus infection was the most common etiology (59.1%). The rates of Barcelona Clinic Liver Cancer (BCLC) stages 0, A, B, C, and D at diagnosis were 3.9%, 36.9%, 12.5%, 39.4%, and 7.3%, respectively. The proportion of very early or early stage HCC at diagnosis (BCLC stage 0 or A) in the 2012-2014 cohort was significantly lower than that in the 2008-2011 cohort (40.8% vs. 48.3%, P<0.001). Transarterial therapy (37.5%) was the most commonly performed initial treatment, followed by surgical resection (19.8%), best supportive care (19.1%), and local ablation (10.6%). The median OS was 2.9 years, and the 1-, 3-, and 5-year OS rates were 67.7%, 49.3% and 41.9%, respectively. The OS rate of the 2012-2014 cohort was significantly higher than that of the 2008-2011 cohort (log-rank, P<0.001).

CONCLUSIONS

The OS of HCC patients registered in the KPLCR between 2012 and 2014 significantly improved. Nevertheless, as about half of the HCC patients were diagnosed at an advanced stage, vigorous and optimized HCC screening strategies should be implemented.

Tumor-Targeting Glycol Chitosan Nanoparticles for Image-Guided Surgery of Rabbit Orthotopic VX2 Lung Cancer

Theranostic nanoparticles can deliver therapeutic agents as well as diverse imaging agents to tumors. The enhanced permeation and retention (EPR) effect is regarded as a crucial mechanism for the tumor-targeted delivery of nanoparticles. Although a large number of studies of the EPR effect of theranostic nanoparticles have been performed, the effect of the change in the body size of the host on the EPR effect is not fully understood. In this regard, comparative research is needed on the behavior of nanoparticles in large animals for developing the nanoparticles to the clinical stage. In this study, we prepared fluorophore (indocyanine green (ICG) or cyanine 5.5 (Cy5.5))-conjugated glycol chitosan nanoparticles (CNPs) for comparing the tumor-targeting efficacy in VX2 tumor-bearing mouse and rabbit models. As expected, the CNPs formed nano-sized spherical nanoparticles and were stable for 8 days under aqueous conditions. The CNPs also exhibited dose-dependent cellular uptake into VX2 tumor cells without cytotoxicity. The half-life of the near-infrared fluorescence (NIRF) signals in the blood were 3.25 h and 4.73 h when the CNPs were injected into mice and rabbits, respectively. Importantly, the CNPs showed excellent tumor accumulation and prolonged biodistribution profiles in both the VX2 tumor-bearing mouse and rabbit models, wherein the tumor accumulation was maximized at 48 h and 72 h, respectively. Based on the excellent tumor accumulation of the CNPs, finally, the CNPs were used in the image-guided surgery of the rabbit orthotopic VX2 lung tumor model. The lung tumor tissue was successfully removed based on the NIRF signal from the CNPs in the tumor tissue. This study shows that CNPs can be potentially used for tumor theragnosis in small animals and large animals.

Influence of proton pump inhibitor or rebamipide use on gut microbiota of rheumatoid arthritis patients

Objective

Patients with rheumatoid arthritis (RA) commonly use gastrointestinal (GI) protective drugs for treatment and prevention of peptic ulcer disease. However, how these drugs affect gut microbiota is unknown in RA patients. The objective of this study was to examine the gut microbiota of RA patients according to their use of GI protective drugs, such as proton pump inhibitors (PPIs), H2-receptor antagonists, and rebamipide.

Methods

Fecal samples were obtained from 15 healthy controls (HCs) and 32 RA patients who were receiving PPI, H2-receptor antagonist, or rebamipide. Bacterial DNA was extracted from the fecal samples and 16S rRNA sequencing was performed. Microbial composition and function were analyzed using QIIME and PICRUSt.

Results

RA patients showed reduced diversity and altered composition of the gut microbiota compared with HCs. Gut microbiota of RA patients receiving acid-suppressing drugs, particularly PPI, was distinct from that of RA patients receiving rebamipide (PPI versus rebamipide, p=0.005). Streptococcus was enriched in RA patients receiving PPI, whereas Clostridium bolteae was enriched in RA patients receiving rebamipide. Gut microbiota of PPI-users was highly expressing the microbial functional pathway involved in virulence factors production. This featured microbial function was positively correlated with the relative abundance of Streptococcus, the differentially abundant taxa of PPI-users.

Conclusions

Gut microbiota of RA patients receiving PPI was distinguished from those receiving rebamipide. Enriched virulent function in gut microbiota of PPI-users suggests that PPIs should not be overprescribed in RA patients.

Development of an in vitro submerged culture system to synthesize epidermal ceramides in canine keratinocytes

Ceramides (CERs) in the stratum corneum (SC) are known to play a crucial role in determining skin barrier function in dogs. We aimed to develop an in vitro culture system that synthesized epidermal CER classes to better understand the synthesis of CER classes in canine SC-. Canine keratinocyte cells (MSCEK) at appropriate confluency were incubated with high Ca²⁺ (1.8 mM CaCl₂) supplemented serum-free medium. Eight days post Ca²⁺ application, the surface of cultured MSCEK was broadly stained with anti-loricrin antibody implying that the keratinocytes had stratified into stratum granulosum. MSCEK cells synthesized heterogenous epidermal CERs, similar to those seen during the stratification of canine keratinocytes. CER fractions obtained from MSCEK cells were comparable to those from canine SC, including CER[EOS] (combination of ω-hydroxy fatty acids and sphingosines), CER[NP] (combination of non-hydroxy fatty acids and phytosphingosines), and CER[EOP] (combination of ω-hydroxy fatty acids and phytosphingosines), all of which are lowered in the SC during canine atopic dermatitis. Thus, the present study provides a simple culture system as a tool for in-depth analysis of CER production in canine keratinocytes.

Tumor Marker-Based Definition of the Transarterial Chemoembolization-Refractoriness in Intermediate-Stage Hepatocellular Carcinoma: A Multi-Cohort Study

Background: For patients with hepatocellular carcinoma (HCC), the definition of refractoriness to transarterial chemoembolization (TACE), which might make them a candidate for systemic therapy, is still controversial. We aimed to derive and validate a tumor marker-based algorithm to define the refractoriness to TACE in patients with intermediate-stage HCC. Methods: This multi-cohort study was comprised of patients who underwent TACE for treatment-naïve intermediate-stage HCC. We derived a prediction model for overall survival (OS) using the pre- and post-TACE model to predict tumor recurrence after living donor liver transplantation (MoRAL) (i.e., MoRAL score = 11×√protein induced by vitamin K absence-II + 2×√alpha-fetoprotein), which was proven to reflect both tumor burden and biologic aggressiveness of HCC in the explant liver, from a training cohort (n = 193). These results were externally validated in both an independent hospital cohort (from two large-volume centers, n = 140) and a Korean National Cancer Registry sample cohort (n = 149). Results: The changes in MoRAL score (ΔMoRAL) after initial TACE was an independent predictor of OS (MoRAL-increase vs. MoRAL-non-increase: adjusted hazard ratio (HR) = 2.18, 95% confidence interval (CI) = 1.37–3.46, p = 0.001; median OS = 18.8 vs. 37.8 months). In a subgroup of patients with a high baseline MoRAL score (≥89.5, 25th percentile and higher), the prognostic impact of ΔMoRAL was more pronounced (MoRAL-increase vs. MoRAL-non-increase: HR = 3.68, 95% CI = 1.54–8.76, p < 0.001; median OS = 9.9 vs. 37.4 months). These results were reproduced in the external validation cohorts. Conclusion: The ΔMoRAL after the first TACE, a simple and objective index, provides refined prognostication for patients with intermediate-stage HCC. Proceeding to a second TACE may not provide additional survival benefits in cases of a MoRAL-increase after the first TACE in patients with a high baseline MoRAL score (≥89.5), who might be candidates for systemic therapy.

Quality of information on the Internet for Korean patients with inflammatory bowel disease

BACKGROUND/AIMS

The Internet is the main resource for health-related information. The incidence of inflammatory bowel disease (IBD) is rapidly increasing in Asian countries. However, the quality of websites for IBD available in this region has not been evaluated. We aimed to evaluate the quality of the information on IBD obtained from Korean websites.

METHODS

Using the terms "Crohn's disease" or "ulcerative colitis," websites were selected from those obtained with the three most renowned search engines in Korea; 60 websites from the results of each engine were chosen. The websites were classified into institutional, commercial, charitable, supportive, or alternative medicine types according to the characteristics of each site. The websites were evaluated regarding content quality using the validated DISCERN instrument and the Journal of the American Medical Association benchmarks.

RESULTS

The median score of all the websites according to the DISCERN instrument was 32 (interquartile range, 25 to 47) out of 80, indicating an insufficient overall quality of information. The alternative medicine sites scored the lowest, whereas the institutional sites scored the highest (p < 0.05). The quality of information was significantly different among the search engines (p = 0.028). The rank of appearance in the Google search result did not correlate with the quality level of the information.

CONCLUSION

The quality of information on the Internet regarding IBD varied according to the website type and search engine. Accreditation and quality assurance systems should be implemented for websites to ensure that the public and patients obtain accurate information on IBD.

Prognosis of surgical hernia repair in cirrhotic patients with refractory ascites

BACKGROUND

Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites.

METHOD

From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair.

RESULTS

This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050-3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery.

CONCLUSION

In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.

Additional fibrate treatment in UDCA-refractory PBC patients

BACKGROUND & AIMS

There is no proven treatment for ursodeoxycholic acid (UDCA)-refractory primary biliary cholangitis (PBC) other than obeticholic acid. Although fibrates have been reported to improve biochemical parameters, the long-term effects remain unclear. This study evaluated the effect of fibrate on clinical outcomes of UDCA-refractory PBC.

METHODS

Patients whose alkaline phosphatase (ALP) was not normalized with at least 13 mg/kg of UDCA treatment for >1 year were included from two tertiary referral centres. The primary outcome was ALP normalization. Secondary outcomes included the development of cirrhosis and hepatic deterioration. Immortal time bias was adjusted using the Mantel-Byar method.

RESULTS

A total of 100 UDCA-refractory PBC patients were included: 71 patients received UDCA alone (the UDCA group) and 29 patients received UDCA plus additional fibrate treatment of 160 mg/d fenofibrate or 400 mg/d bezafibrate (the fibrate/UDCA group). During the follow-up period, the probability of ALP normalization was significantly higher in the fibrate/UDCA group (hazard ratio [HR] = 5.00, 95% confidence interval = 2.87-8.27, P < 0.001). Among 58 non-cirrhotic patients (43 in the UDCA group and 15 in the fibrate/UDCA group), 19 patients (44.1%) in the UDCA group and none in the fibrate/UDCA group developed cirrhosis (HR = 0.12, P = 0.04). Hepatic deterioration (Child-Pugh score increase or signs of decompensated cirrhosis) occurred in 17 patients (23.9%) of the UDCA group and none in the fibrate/UDCA group in which the difference was significant (HR = 0.12, P = 0.04).

CONCLUSIONS

In patients with UDCA-refractory PBC, additional fibrate treatment is associated with a higher probability of ALP normalization and a lower risk of cirrhosis development and hepatic deterioration.

Adjuvant cytokine-induced killer cell immunotherapy for hepatocellular carcinoma: a propensity score-matched analysis of real-world data

BACKGROUND

Several randomized controlled trials have shown that adjuvant immunotherapy with autologous cytokine-induced killer (CIK) cells prolongs recurrence-free survival (RFS) after curative treatment for hepatocellular carcinoma (HCC). We investigated the efficacy of adjuvant immunotherapy with activated CIK cells in real-world clinical practice.

METHODS

A total of 59 patients who had undergone curative surgical resection or radiofrequency ablation for stage I or II HCC, and subsequently received adjuvant CIK cell immunotherapy at two large-volume centers in Korea were retrospectively included. Propensity score matching with a 1:1 ratio was conducted to avoid possible bias, and 59 pairs of matched control subjects were also generated. The primary endpoint was RFS and the secondary endpoints were overall survival and safety.

RESULTS

The median follow-up duration was 28.0 months (interquartile range, 22.9-42.3 months). In a univariable analysis, the immunotherapy group showed significantly longer RFS than the control group (hazard ratio [HR], 0.42; 95% CI, 0.22-0.80; log-rank P = 0.006). The median RFS in the control group was 29.8 months, and the immunotherapy group did not reach a median RFS. A multivariable Cox proportional hazard analysis showed that immunotherapy was an independent predictor for HCC recurrence (adjusted HR, 0.38; 95% CI, 0.20-0.73; P = 0.004). The overall incidence of adverse events in the immunotherapy group was 16/59 (27.1%) and no patient experienced a grade 3 or 4 adverse event.

CONCLUSIONS

The adjuvant immunotherapy with autologous CIK cells after curative treatment safely prolonged the RFS of HCC patients in a real-world setting.

Clinical significance of microRNA-21 expression in disease progression of patients with hepatocellular carcinoma

AIM

Aberrant microRNA (miR) expression is associated with hepatocellular carcinoma (HCC).

MATERIALS & METHODS

Here, we investigated the clinical significance of miR-21 and miR-31 for HCC-specific prognostic effect. HCC patients (n = 93) who underwent liver biopsy or surgical resection were enrolled, and HCC tissues and paired adjacent nontumor liver tissues were collected and analyzed for miRs expression.

RESULTS

MiR-21 expression was significantly upregulated in HCC tissues relative to nontumor tissues. Both miR-21 and miR-31 expression in HCC tissues did not predict overall survival; however, miR-21 was considered an independent predictor of disease progression together with portal vein thrombosis and higher Barcelona Clinical Liver Cancer stage.

CONCLUSION

Elevated miR-21 expression might represent a biomarker for HCC prognosis.

Abstract 2471: Clinical significance of noncoding circHIPK3 RNA in human hepatocellular carcinoma

Background and Aim: Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, with poor prognosis and high risk of recurrence. Previous studies have shown that various microRNAs (miRNAs) are frequently dysregulated in HCC, which contributes to cancer development and progression. Nonetheless, the regulation mechanism of miRNAs is still unclear. Circular noncoding RNA (circRNA) is highly conserved and stable covalently closed RNA circles with gene-regulatory potential. Recently, one abundant circRNA from HIPK3 gene, circHIPK3, has been identified, and its function has been elucidated as multiple miRNAs sponge. Thus, we aimed to investigate the clinical relevance of circHIPK3 in HCC.

Materials and Methods: We analyzed clinical specimens from 152 pairs of HCC and corresponding normal liver (NL) tissues. Total RNAs were isolated from clinical tissues using Qiagen kit. CircHIPK3 expression levels were determined by quantitative real-time PCR (qRT-PCR), and its expression was normalized with GAPDH. In addition, we analyzed the correlation between circHIPK3 expression and various clinicopathologic features of HCC patients.

Results: CircHIPK3 expression was significantly downregulated in HCC tissues compared to corresponding NL tissues (P=0.036). In HCC patients, circHIPK3 expression was strongly suppressed in more advanced tumors (P&lt;0.001). Further correlation analysis showed that circHIPK3 expression was significantly associated with T stage (P&lt;0.001), TNM stage (P&lt;0.001), BCLC stage (P&lt;0.001), and alpha-fetoprotein (AFP) expression (P=0.033).

Conclusions: We have determined clinical significances of circHIPK3 expression in HCC, which may provide clinical evidence for the potential of circHIPK3 as novel markers for diagnosis and predicting prognosis in HCC patients.

Citation Format: Gyeonghwa Kim, Jun Sik Yoon, Se Young Jang, Soo Young Park, Won Young Tak, Young-Oh Kweon, Keun Hur. Clinical significance of noncoding circHIPK3 RNA in human hepatocellular carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2471.

A multicentre, open, investigator-initiated phase IV clinical trial to evaluate the efficacy and safety of ingenol mebutate gel, 0·015% on the face and scalp, and 0·05% on the trunk and extremities, in Korean patients with actinic keratosis (PERFECT)

BACKGROUND

Ingenol mebutate gel is a novel, field-directed topical treatment for actinic keratosis (AK). Most pivotal studies have targeted Western populations. No clinical study has been conducted to investigate its efficacy and safety in Asian populations.

OBJECTIVES

To evaluate the efficacy and safety of ingenol mebutate gel for treating AK of face/scalp and trunk/extremities in a large Asian (Korean) population.

PATIENTS AND METHODS

In this multicentre, open-label, interventional, parallel-group, prospective phase IV study (PERFECT, trial registration no.: NCT02716714), the eligible patients were allocated into either the face/scalp or the trunk/extremities group, according to their selected treatment area location. After application of ingenol mebutate gel, the participants were followed up for 6 months. The primary efficacy endpoint was complete clearance (CC) of AK lesions in the selected treatment area at day 57. Quality of life was evaluated using Skindex-29. Safety endpoints included local skin responses, scar, pigmentation, pain and adverse events.

RESULTS

In total, 78·1% [95% confidence interval (CI) 66·86-86·92%] of subjects had CC at day 57, with 76·6% (95% CI 64·31-86·25%) in the face/scalp group and 88·9% (95% CI 51·75-99·72%) in the trunk/extremities group. Among them, CC was sustained in 88·9% (48 of 54, 95% CI 77·37-95·81%) at month 6. The local skin responses significantly increased 1 day after the treatment compared with baseline, and decreased afterwards. Among the total subjects, 7·8% (6 of 77) had hyperpigmentation on the application area. Scars were not reported.

CONCLUSIONS

Ingenol mebutate is effective for the treatment of AK in Asians, with tolerable safety profiles.

Effect of the sexual abstinence period recommended by the World Health Organization on clinical outcomes of fresh embryo transfer cycles with normal ovarian response after intracytoplasmic sperm injection

This study was to investigate whether the sexual abstinence period (SAP) recommended by the World Health Organization (WHO) affects clinical outcomes. We compared the rate of clinical outcomes between 2-7 and ≥8 days of SAP in first fresh embryo transfer after intracytoplasmic sperm injection (ICSI) in groups of young maternal age (YMA: <38 years) and old maternal age (OMA: ≥38 years). We conducted a retrospective study of 449 first ICSI cycles with a normal ovarian response. SAP was identified before collecting the semen samples. Semen analysis was performed based on the guidelines recommended by WHO (2010). Sperm preparation was made using the swim-up method. Patients' baseline characteristics in the YMA and OMA groups did not differ. The rates of fertilisation, top-quality embryos on day 3, biochemical pregnancy, clinical pregnancy, ongoing pregnancy, abortion and implantation per cycle were not significantly different between 2-7 and ≥8 days of SAP in the YMA or OMA group. In conclusion, SAP beyond the recommended period by WHO was not associated with the rates of a lower fertilisation and pregnancy in human in vitro fertilisation (IVF). We think that a new criterion of SAP for clinical application in human IVF needs to be considered by WHO.

Effect of topical loteprednol etabonate with lid hygiene on tear cytokines and meibomian gland dysfunction in prosthetic eye wearers

PurposeTo assess tear cytokine levels and clinical outcomes in meibomian gland dysfunction (MGD) in the blind eye of patients wearing an ocular prosthesis after 2 months of treatment with topical loteprednol etabonate and eyelid scrubs with warm compresses.Patients and methodsThis study included patients with MGD wearing a unilateral ocular prosthesis for more than 1 year. All patients topically received 0.5% loteprednol etabonate and were instructed to scrub their eyelids with warm compresses on the prosthetic eye for 2 months. We evaluated tear cytokine levels using Multiplex Bead Immunoassays, performed biomicroscopic examination of the lid margins and meibomian gland, conducted meibography imaging, and assessed MGD-related ocular symptoms using a questionnaire for the prosthetic eye before and 2 months after treatment.ResultsThirty consecutive patients were included. There were significant reductions in the levels of interleukin (IL)-6, interferon-γ, monocyte chemotactic protein-1, IL-8, tumor necrosis factor-α, and IL-1β (P<0.001 for each cytokine). Moreover, there were improvements in ocular symptoms (P=0.001), lid margin abnormalities (P<0.001), meibomian gland expressibility (P<0.001) and meibography findings (P=0.037).ConclusionTopical loteprednol etabonate in conjunction with eyelid scrubs and warm compresses were effective in treating MGD in prosthetic eye wearers. Furthermore, tear cytokine measurements may serve as an additional approach for evaluating the efficacy of anti-inflammatory treatment for MGD in prosthetic eye wearers.

Clinical significance of lncRNA-ATB expression in human hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a worldwide health problem and it is important to understand the mechanistic roles of the biomolecules involved in its pathogenesis. Long non-coding RNAs (lncRNAs) are frequently and aberrantly expressed in various human cancers and are known to play a role in cancer pathogenesis. The aim of this study was to analyze the expression of lncRNA-ATB in HCC and investigate the implications for prognoses.

In total, 100 samples of HCC tissues and their corresponding, adjacent, non-cancerous liver tissues were collected. Total RNAs were extracted and the expression levels of lncRNA-ATB were measured by qRT-PCR. The association of lncRNA expression with clinicopathological features and patient survival were then analyzed.

LncRNA-ATB was significantly upregulated in HCC tissues compared with the levels in corresponding non-cancerous tissues. Expression of lncRNA-ATB was significantly associated with portal vein thrombosis, intrahepatic or extrahepatic metastases, mUICC stage, and the BCLC stage. Large tumors (> 5 cm, HR = 3.851, 95% CI = 1.431–10.364, p = 0.008) and higher lncRNA-ATB expression (HR = 4.158, 95% CI = 1.226–14.107, p = 0.022) were the significant prognostic factors for overall survival.

With this novel evidence of the involvement of lncRNA-ATB in HCC pathogenesis and clinical features, lncRNA-ATB can be concluded to have potential as a biomarker for the prognosis of HCC and as a targeted therapy for afflicted patients.

Preoperative clinical features of reactivated of Graves' orbitopathy after orbital decompression

PurposeTo investigate the incidence and preoperative clinical features of reactivated Graves' orbitopathy (GO) after orbital decompression.MethodsThis study included patients with GO who underwent orbital decompression for disfiguring proptosis and not compressive optic neuropathy and received postoperative follow-up care for more than 12 months. Patients who experienced active inflammatory signs within 6 months of decompression were excluded from analysis. The demographic characteristics, ophthalmic manifestations, and biochemical parameters of the patients were analyzed for association with reactivation of GO by logistic regression analysis.ResultsOut of the 92 patients included in this study, seven (7.6%) experienced reactivation of GO after orbital decompression. The mean time interval between surgery and reactivation of GO was 36.3±14.3 weeks. Univariate logistic regression analysis identified age, existing smoking habits, and modified NOSPECS and Gorman scores as significant factors for the reactivation of GO. The results of multivariate logistic regression analysis revealed that smoking and modified NOSPECS and Gorman scores were associated with the reactivation of GO.ConclusionsQuitting smoking is important for the prevention of reactivation of GO after orbital decompression. Patients with severe symptoms, especially those with restrictive myopathy, should be carefully monitored for reactivation of GO after orbital decompression.

Impaired RBC deformability is associated with diabetic retinopathy in patients with type 2 diabetes

AIM

Red blood cell (RBC) deformability, the ability of RBCs to change shape under stress, is known to be decreased in type 2 diabetes (T2D). However, as yet little is known of the association between RBC deformability and diabetic complications in T2D. For this reason, this study has investigated the association between RBC deformability and diabetic complications.

METHODS

In this cross-sectional study, 452 T2D patients were initially enrolled. RBC deformability was measured using a microfluidic ektacytometer and expressed as an elongation index at 3Pa (EI@3Pa, %).

RESULTS

A final total of 373 patients (mean age: 60.04±11.93 years; males: 201) were included in the study. When categorized into quartiles of RBC deformability, the lower EI@3Pa groups had higher glycated haemoglobin (HbA_1c), triglycerides and prevalence of diabetic retinopathy compared with the higher quartiles (P<0.05 for trend). In particular, the EI@3Pa was significantly lower in patients with retinopathy than in those without retinopathy (30.53±1.95 vs 31.20±1.53, P=0.001). Between the lowest EI@3Pa quartile (Q1) to the highest (Q4, reference), the odds ratio (OR) for Q1 was 2.81 (95% CI: 1.21-6.49, P=0.004 for trend), after adjusting for age, gender, presence of hypertension and smoking, duration of diabetes, HbA_1c, glomerular filtration rate and triglycerides.

CONCLUSION

In terms of diabetic complications, the lowest EI@3Pa group was closely associated with only the risk of diabetic retinopathy in our study. These results suggest that RBC deformability might be contributory to the development of the microvascular complication.

The use of statins for the treatment of depression in patients with acute coronary syndrome

This study aimed to investigate the effect of statins for the treatment of depression in individuals with acute coronary syndrome (ACS). We used 1-year follow-up data of a 24-week double-blind, placebo-controlled trial of escitalopram and a naturalistic prospective observational cohort study. Of 446 participants with comorbid depressive disorders and ACS at baseline, 300 participated in a randomised escitalopram trial and the remaining 146 participated in a naturalistic observational study. The participants in the two studies were approached for a 1-year follow-up investigation. Treatment response rates, defined as a ⩾ 50% reduction in the Hamilton Depression Rating Scale (HAM-D) and Beck Depression Inventory (BDI) scores, were used as the outcome variables. In the escitalopram trial, both HAM-D and BDI response rates were highest in patients taking escitalopram and statins together and lowest in patients receiving neither medication. Logistic regression analyses revealed that statin use was significantly associated with higher response rates on both the HAM-D and BDI at 1 year, whereas no such associations were found for escitalopram. In the naturalistic observational study, the response rates at 1 year did not differ significantly by statin use. Instead, the HAM-D response rate was significantly higher in patients taking lipophilic statins than in those who did not. In conclusion, statins may be effective for the treatment of depression independent of medical status and escitalopram use, and they may potentiate the antidepressant action of serotonergic antidepressants in patients with ACS.

Comparison of two- and three-point sutures for advancing the levator aponeurosis in Asian eyelids

PURPOSE

To compare the functional and cosmetic outcomes of two- and three-point sutures for advancing the levator aponeurosis in blepharoptosis surgery on Asians.

PATIENTS AND METHODS

This retrospective study examined 60 Asian patients with blepharoptosis who had undergone advancement of the levator aponeurosis: 34 patients (46 eyelids) had ptosis correction using the two-point suture technique and 26 patients (41 eyelids) had ptosis correction using the three-point suture technique. The postoperative marginal reflex distance (MRD1), lid height difference, and eyelid contour were evaluated.

RESULTS

Twenty-seven (79.4%) of the 34 patients in the two-point group and 19 (73.1%) of 26 patients in the three-point group had a postoperative MRD1 of 2-4 mm, lids within 0.5 mm of each other, and a satisfactory eyelid contour; this difference was not significant. The rate of reoperation did not differ significantly between the two groups.

CONCLUSION

Two- and three-point sutures for advancing the levator aponeurosis were equally effective for correcting blepharoptosis in Asians.

Short-term effects of topical cyclosporine A 0.05% (Restasis) in long-standing prosthetic eye wearers: a pilot study

PURPOSE

Long-standing prosthetic eye wearing induces ocular surface inflammation. We investigated the short-term effects of topical cyclosporine A 0.05% (Restasis) in patients with ocular discomfort resulting from long-standing prosthetic eye wearing.

METHODS

This was a prospective, interventional case series. Patients who were unilateral prosthetic eye wearers over a period of 5 years were enrolled at a single institution from March to July 2013. The subjects were instructed to instill topical cyclosporine A 0.05% twice per day. Measurements were made pre-treatment and after 1 and 3 months of treatment. Outcome measures were the ocular symptom score, the lid margin abnormality score, the Schirmer test, and the tear meniscus amount, using Fourier-domain optical coherence tomography.

RESULTS

In total, 20 consecutive patients (mean age: 60.1 years, 8 males, 12 females) were included. Ocular symptoms were improved after treatment for 1 month in all patients (ocular symptom score pre-treatment 76.83 vs 46.75 after treatment; P<0.001). There was no statistically significant difference in lid margin abnormality score or tear meniscus amount. The Schirmer test results were improved after treatment for 3 months (pre- and after treatment, 6.70 vs 11.40; P<0.001).

CONCLUSIONS

Topical cyclosporine A 0.05% showed a satisfactory effect in long-standing prosthetic eye wearers. Ocular symptoms were markedly relieved in all subjects after treatment for 1 month.

The comparison of femoral and radial arterial blood pressures during pediatric liver transplantation

BACKGROUND

Orthotopic liver transplantation (OLT) is frequently associated with dramatic hemodynamic changes; thus, it is critical to accurately monitor blood pressure. Although comparisons between femoral arterial blood pressure (FABP) and radial arterial blood pressure (RABP) have been reported in adult liver recipients, we compared FABP with RABP in pediatric recipients.

METHODS

Thirty-five pediatric liver recipients younger than 13 years of age were included in this prospective, observational study. We measured simultaneous FABP and RABP in the femoral and radial arteries at nine time points during the procedure, including: baseline (after anesthetic induction); 1 hour thereafter; 30 minutes after the beginning of the anhepatic period as well as 0, 1, 3, 5, 15, and 60 minutes after graft reperfusion.

RESULTS

Of the 35 pediatric liver recipients, 2 infants and 1 13-month-old child were excluded from the analysis because of radial arterial catheter malfunction. The remaining 32 patients including 16 infants and 16 children all showed significantly higher systolic and mean FABP than RABP during most stages of pediatric OLT. Overall diastolic FABP measurements were similar to diastolic RABP throughout the study.

CONCLUSIONS

Systolic and mean FABP were significantly higher than RABP during most stages of pediatric OLT. Radial arterial catheter malfunctions were not uncommon during pediatric OLT. Our results indicated that it is useful to cannulate the femoral artery to accurately and reliably measure arterial blood pressure to detect hemodynamic instability during pediatric OLT.

Effect of multispecies probiotics on irritable bowel syndrome: a randomized, double-blind, placebo-controlled trial

BACKGROUND AND AIM

The efficacy of treatment with multispecies probiotics on irritable bowel syndrome (IBS) symptoms and the alterations of gut microbiota in patients who have taken probiotics were investigated.

METHODS

This randomized, double-blind, placebo-controlled trial involved 49 IBS patients (probiotics: 25, placebo: 24) diagnosed according to the Rome III criteria. Patients were randomly assigned to two groups: either to receive multispecies probiotics (a mixture of Bifidobacterium longum, B. bifidum, B. lactis, Lactobacillus acidophilus, L. rhamnosus, and Streptococcus thermophilus) twice a day for 4 weeks or to receive a placebo twice a day for 4 weeks. The primary efficacy end-point was the proportion of participants whose IBS symptoms were substantially relieved at week 4. Secondary end-points were the intensity of abdominal pain/discomfort, bloating, stool frequency/consistency, alterations in fecal microflora over the 4 weeks. Fecal microflora were analyzed in 34 patients (probiotics: 17, placebo: 17) by quantitative real-time polymerase chain reaction assays.

RESULTS

The proportion of patients whose IBS symptoms were substantially relieved at week 4 was significantly higher in the probiotics group than in the placebo group: 68.0% (17/25) versus 37.5% (9/24) (P < 0.05). Secondary end-points such as improvement in abdominal pain/discomfort and bloating occurred in the probiotics group but not in the placebo group. Fecal analysis revealed that B. lactis, L. rhamnosus, and S. thermophilus had increased significantly in the probiotics group after 4 weeks and that B. lactis had increased in the placebo group.

CONCLUSIONS

Multispecies probiotics are effective in IBS patients and induce the alterations in the composition of intestinal microbiota.

Xanthogranulomatous inflammation in terminal ileum presenting as an appendiceal mass: case report and review of the literature

Xanthogranulomatous inflammation (XGI) is a rare benign inflammatory disease characterized by aggregation of lipid-laden foamy macrophages. This disease entity has been described in various organs but most commonly in the kidney and gallbladder. The occurrence of this disease in the lower gastrointestinal tract is extremely rare. Its clinical importance is that it can be misdiagnosed as an infiltrative cancer. In this case report, a 52-year-old male complained of right lower quadrant abdominal pain for a period of 3 months. Abdominal computed tomography revealed appendiceal mass and colonoscopy revealed multiple erythematous nodular lesions in the terminal ileum and appendiceal orifice, mimicking appendiceal cancer. Right hemicolectomy was done and the pathological specimen revealed XGI of the terminal ileum. To our knowledge, this is the first case of XGI in terminal ileum presenting as abdominal pain and the appendiceal mass on radiologic findings.

A case of acute suppurative thyroiditis with thyrotoxicosis in an elderly patient

Acute suppurative thyroiditis (AST) is a rare condition, as the thyroid gland is relatively resistant to infection. Thyroid function tests are usually normal in AST. A few cases of AST associated with thyrotoxicosis have been reported in adults. We report a case of AST that was associated with thyrotoxicosis in a 70-year-old woman. We diagnosed AST with thyroid ultrasonography and fine needle aspiration of pus. The patient improved after surgical intervention and had no anatomical abnormality. Fine needle aspiration is the best method for the difficult task of differentiating malignancy and subacute thyroiditis from AST with thyrotoxicosis. Earlier diagnosis and proper treatment for AST might improve the outcome.

Effects of synchronization of carbohydrate and protein supply in total mixed ration with korean rice wine residue on ruminal fermentation, nitrogen metabolism and microbial protein synthesis in holstein steers

Three Holstein steers in the growing phase, each with a ruminal cannula, were used to test the hypothesis that the synchronization of the hourly rate of carbohydrate and nitrogen (N) released in the rumen would increase the amount of retained nitrogen for growth and thus improve the efficiency of microbial protein synthesis (EMPS). In Experiment 1, in situ degradability coefficients of carbohydrate and N in feeds including Korean rice wine residue (RWR) were determined. In Experiment 2, three total mixed ration (TMR) diets having different rates of carbohydrate and N release in the rumen were formulated using the in situ degradability of the feeds. All diets were made to contain similar contents of crude protein (CP) and neutral detergent fiber (NDF) but varied in their hourly pattern of nutrient release. The synchrony index of the three TMRs was 0.51 (LS), 0.77 (MS) and 0.95 (HS), respectively. The diets were fed at a restricted level (2% of the animal’s body weight) in a 3×3 Latin-square design. Synchronizing the hourly supply of energy and N in the rumen did not significantly alter the digestibility of dry matter, organic matter, crude protein, NDF or acid detergent fiber (ADF) (p>0.05). The ruminal NH₃-N content of the LS group at three hours after feeding was significantly higher (p<0.05) than that of the other groups; however, the mean values of ruminal NH₃-N, pH and VFA concentration among the three groups were not significantly different (p>0.05). In addition, the purine derivative (PD) excretion in urine and microbial-N production (MN) among the three groups were not significantly different (p>0.05). In conclusion, synchronizing dietary energy and N supply to the rumen did not have a major effect on nutrient digestion or microbial protein synthesis (MPS) in Holstein steers.

Indigo carmine-induced hypotension in patients undergoing general anaesthesia

Indigo carmine is a blue dye that is widely applied to localise ureteral orifices. It is generally believed to be a safe, biologically inert substance, and hypotensive reactions are extremely rare. However, we experienced three cases of indigo carmine-induced hypotension within a period of two weeks.

Biologic characteristics of bone marrow-derived mesenchymal stem cells from a patient with thalassemia syndrome

INTRODUCTION

Mesenchymal stem cells (MSCs) are capable of self-renewal and differentiating morphologically and functionally into several mesenchymal tissues. There have been contrasting data on whether MSCs are altered in various hematologic disorders.

METHODS

We isolated bone marrow (BM)-derived MSCs from a patient with thalassemia syndrome to compare phenotypic and functional characteristics to those from normal healthy donor.

RESULTS

No differences were observed between MSCs from thalassemia syndrome (T-MSCs) and those from normal healthy donor in terms of morphology, phenotype, karyotype, multidifferentiation capacity. In mixed lymphocyte reaction, T-MSCs strongly inhibited the proliferation of allogeneic T cells in association with reduced proportion of CD3(+), CD4(+), and CD8(+) cells. Furthermore, the fraction of Treg cells was increased under the culture with T-MSCs, suggesting that T-MSCs exert normal immunomodulatory function. In addition, T-MSCs expressed hematopoietic cytokines and supported hematopoiesis, which was comparable to those from normal BM-derived MSCs.

CONCLUSION

T-MSCs exhibited normal phenotype, karyotype as well as normal immunomodulatory function, and autologous MSCs from patients with thalassemia syndrome may be an attractive source of stem cell in terms of hematopoietic support as well as immunomodulatory activity.