Different tumor growth pattern of clinically nonfunctioning pituitary neuroendocrine tumor according to sex and age: a longitudinal study

PURPOSE

Asymptomatic patients with clinically non-functional pituitary neuroendocrine tumors (CNF-PitNETs) are usually followed up. However, the natural course of CNF-PitNETs according to sex and age remains unclear. Therefore, this study assessed growth patterns of CNF-PitNETs according to sex and age.

METHODS

In this longitudinal study, we enrolled 431 consecutive patients with CNF-PitNETs who were treated at Seoul National University Hospital from 1997 to 2021. The patients underwent hormone function testing and visual field testing, and were subsequently followed up with imaging over a median duration of 66 months.

RESULTS

The median age of the patients was 53.0 years, and 37.1% (n = 160) were men. Men were older and harbored more macroadenomas than women. The annual tumor volume change was higher in men than in women (0.21 vs. 0.04 cm3/year, P < 0.001). The estimated cutoff value of age for significant tumor growth was 51 years. In men, the annual tumor volume change was similar across all age groups. In women, those aged ≤ 50 years showed significantly lower annual tumor volume change than those aged > 50 years (0.01, 0.11, and 0.17 cm3/year, P = 0.001). When comparing sexes within the same age group, the annual tumor volume changes was significantly lower for women than for men, only in patients aged ≤ 50 years (0.01 vs. 0.15 cm3/year, P < 0.001).

CONCLUSIONS

Among patients with CNF-PitNET, tumor growth was slower in women aged ≤ 50 years than in men and women aged > 50. These findings may guide the customization of surveillance strategies for CNF-PitNETs according to sex and age.

Comparing Acute Oral Mucosa Toxicity Associated with Minibeam and Conventional Radiotherapy

PURPOSE/OBJECTIVE(S)

Acute oral mucosa toxicity is associated with ulceration, severe pain, and nutritional deficiencies that may lead to treatment interruptions and a decreased quality of life for head and neck cancer patients. Minibeam radiotherapy (MRT) is a type of spatially fractionated radiotherapy that delivers an alternating pattern of sub-millimeter wide peaks of high dose immediately adjacent to much lower valley doses. By delivering a non-uniform dose distribution, MRT allows for elevated peak doses while maintaining extraordinary normal tissue tolerance. In this study, we used an acute oral mucosa toxicity mouse model to test the hypothesis that MRT provides superior tissue sparing compared to conventional radiotherapy (CRT).

MATERIALS/METHODS

A total of 33 female C57BLJ6 mice were randomized by body weight (BW) across two CRT groups (n = 4/group) receiving open field radiation of 16 and 20 Gy and five MRT groups (n = 5/group) receiving peak:valley doses of 48:8, 72:12, 96:16, 96:8, and 152:8 Gy. All radiation was given in one fraction. The CRT groups were irradiated with a 10 mm circular field using a 225 kVp PA x-ray beam encompassing the oral cavity and oropharynx. The MRT groups were irradiated with the same arrangement, but the beam was collimated into 0.5 mm wide minibeams spaced 1.1 mm center-to-center using tungsten collimators of 0.5, 1, and 2.5 mm thickness to deliver peak-to-valley ratios (PVRs) of 6:1, 12:1, and 19:1. Acute effects in the oral mucosa were studied using changes in BW as a surrogate for clinically significant oral mucositis. BWs were measured daily starting on the day of treatment, and BW changes were computed relative to the day of treatment. The toxicity endpoint was defined such that mice losing >20% BW were humanely euthanized.

RESULTS

Doses of 20 Gy CRT and 96:16 Gy MRT were highly toxic, with all animals in these groups reaching the toxicity endpoint between 9-11 days post-RT, compared to only one animal in the 16 Gy CRT group, and no animals in the other MRT groups. The BWs of all surviving animals returned to baseline within 15 days post-RT. The groups 48:8, 96:8, and 152:8 Gy showed similar BW loss and full recovery patterns. Additionally, the groups 48:8, 72:12, and 96:16 Gy showed that, for the same PVR, increasing the valley dose resulted in increased BW loss. Lastly, animals did not tolerate 96:16 Gy, but those in the 96:8 Gy group fully recovered.

CONCLUSION

Despite the extreme toxicity caused by 20 Gy CRT, animals in the MRT groups tolerated peak doses up to 152 Gy when the valley dose was 8 Gy. These results confirm the superior normal tissue sparing capacity of MRT compared to CRT in an oral mucosa mouse model. We delivered tolerable MRT peak doses an order of magnitude larger than toxic CRT doses. Importantly, our results suggest that valley dose is the most useful parameter to assess acute toxicity when using MRT. Our data may prove useful for eventual clinical applications of MRT in head and neck cancers.

Physician and Patient-Reported Outcomes of a Phase III Trial of Ultra-Hypofractionated vs. Moderate Hypofractionated Radiotherapy to the Whole Breast after Breast-Conserving Surgery

PURPOSE/OBJECTIVE(S)

To report a final analysis evaluating physician and patient-reported outcomes of early breast cancer patients receiving moderate hypofractionation or ultra-hypofractionated whole breast radiotherapy (RT).

MATERIALS/METHODS

Between April 4, 2018, and February 11, 2020, patients with localized breast cancer (T1-T3, N0-N1, and M0) managed with breast-conserving surgery (BCS) were enrolled. Patients were randomized to receive whole breast RT with moderate hypofractionation to 40 Gy in 15 fractions (Arm A) or ultra-hypofractionation to 25 Gy in 5 fractions (Arm B). An optional concurrent integrated boost to 48 Gy on Arm A or 30 Gy on Arm B was allowed. Early toxicity (<3 months), late toxicity (> 3 months), quality of life (QOL), cosmesis, Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), and deterioration of cosmesis were analyzed.

RESULTS

One hundred and seven patients were randomized to moderate hypofractionation (n = 54) or ultra-hypofractionation (n = 53). With a median follow-up of 36 months, no significant differences in patient characteristics were noted between the two arms. There were no patients with a grade ≥3 or higher toxicity. Grade 2 toxicities were 7.4% in Arm A and 7.5% in Arm B, and primarily consisted of radiation dermatitis (6 patients), fibrosis (1 patient) and lymphedema (1 patient). The average Harvard Cosmesis score and overall QoL were similar between arms at all time points, with no patients developing cosmetic deterioration. Patient-reported moderate to severe radiation skin burns were more commonly reported in Arm A (21.05%) vs. Arm B (6.25%) at the end of treatment (EOT) (p = 0.078). At EOT, patients receiving moderate hypofractionation had higher mean toxicity scores in breast tenderness (2.66 vs. 1.5, p = 0.018), skin flaking or peeling (0.63 vs. 0.06, p = 0.035), blistering (0.74 vs. 0.06, p = 0.028), pruritis (2.53 vs. 0.87, p < 0.001), erythema (4.24 vs. 2.0, p <0.001), telangiectasias (1.0 vs. 0.28, p = 0.021). Additionally, patients receiving moderate hypofractionation reported significantly worse changes from baseline at EOT in breast tenderness (-2.25 vs. -.86, p = 0.02), telangiectasia (-0.81 vs. 0.18, p = 0.012), skin discoloration (-4.31 vs. -1.04, p < 0.001), skin flaking or peeling (-.55 vs. 0.04, p = 0.053), blistering (-0.82 vs. -0.07, p = 0.033), and pruritus (-2.27 vs. -.67, p = 0.002). There was a return to baseline in all patient-reported breast domains by 3 months (p >0.05) in both arms.

CONCLUSION

Ultra-hypofractionated whole breast irradiation, consisting of 25 Gy in 5 fractions, provided comparable provider assessed toxicity and cosmetic outcomes to 40 Gy in 15 fractions. At the EOT assessment, ultra-hypofractionation had a better patient reported toxicity profile. Our findings provide further evidence to support daily ultra-hypofractionated whole breast radiotherapy as an appropriate treatment option for early-stage breast cancer.

Local Control after Re-Irradiation of Spinal Metastases with Stereotactic Body Radiation Therapy

PURPOSE/OBJECTIVE(S)

Determine local control (LC) rate and risk of vertebral compression fractures (VCFs) and radiation myelitis (RM) for patients receiving re-irradiation of spinal metastases (SMs) using stereotactic body radiation therapy (SBRT) from large single-institutional experience with long follow-up.

MATERIALS/METHODS

Retrospectively identified patients receiving re-irradiation SBRT (rSBRT, 1, 3, or 5 fractions) to SMs previously treated with radiation therapy (RT) and having follow up imaging to assess local control. 1 fraction patients typically received 20-24 Gy and 16-18 Gy to the high- and low-risk planning target volumes (PTVs), respectively, and 27-39 Gy and 21-24 Gy for the 3 fraction patients, with a single level of 50 Gy for 5 fractions. Patient and treatment characteristics for previous RT (pRT) and rSBRT were collected, including histology and dose-volume histogram statistics (DVH). Kaplan-Meier estimates of overall survival (OS), and cumulative incidence (competing with death) of local failure with death as a competing risk was computed for the whole cohort and stratified by radioresistance of histology, and risk of VCF for RM (for treatments at L1 and above) and 95% confidence intervals. Equivalent dose in 2 Gy fractions (EQD2) for PTV and spinal cord (SC) DVH statistics was computed for each individual course and cumulatively, using a/b = 10 Gy for tumor and 2 Gy for SC.

RESULTS

Identified 107 lesions in 91 patients. 48 (45%) had radioresistant histologies. For all patients, at 1 and 2 years, respectively OS was 64% (55-74%) and 43% (34-55%), LC was 88% (81-94%) and 85% (78-91%) with median follow-up of 52 months (Table 1). OS and LC were not significantly different between radiosensitivity groups (p>0.05). Risk of VCF at 1 and 2 years was 7% (3-13%) and 9% (4-16%). RM was identified in 1 patient, who received 30 Gy in 5 fractions to T1, and had 1-fraction rSBRT 21 months later. SC Dmax was 31.5 Gy for pRT and 10.4 Gy, for rSBRT, resulting in total SC EQD2 of 73 Gy. RM was confirmed on MRI 8 months after rSBRT. Cumulative RM risk at 8 months after rSBRT was estimated at 1% (0-4%). Median EQD2 for the minimum dose to the high and low risk PTVs were 17.7 Gy (interquartile range, IQR, 13.0-27.6 Gy) and 13.7 Gy (IQR, 10.8-19.3 Gy) for rSBRT, and maximum EQD to SC for previous RT, rSBRT, and cumulatively was 38 Gy (IQR, 30-41 Gy), 27 Gy (IQR, 22-36 Gy), and 65 Gy (IQR, 54-73 Gy).Re-irradiation of spinal metastasis with SBRT can be delivered safely and provide high rates of local control, including for radioresistant tumors, as demonstrated with the longest reported follow-up in this setting.

CONCLUSION

Re-irradiation of SM with SBRT provides high rates of LC even for radioresistant tumors, and low risk of VCF and RM, based on the longest reported follow-up in this setting.

Assessment of Minimum Dose as a Strong Predictor of Local Failure after Spine SBRT

PURPOSE/OBJECTIVE(S)

Stereotactic body radiation therapy (SBRT) has demonstrated robust clinical benefits in carefully selected patients, improving local control and even overall survival (OS). Even so, a wide range of dose-fractionation schemes are used in clinical practice. We seek to assess a large database to determine clinical and dosimetric predictors of local failure after spine SBRT.

MATERIALS/METHODS

From a large institutional database, spine SBRT treatments with subsequent imaging follow-up to assess local control were identified. Patients were treated with a simultaneous integrated boost technique using 1 or 3 fractions, generally delivering 20-24 Gy in 1 fraction to the high dose volume and 16 Gy to the low dose volume (or 30-36 Gy and 24 Gy for 3 fraction treatments). Exclusions included: lack of imaging follow-up, proton therapy, and benign primary histologies. Statistical analyses included Cox proportional hazards analyses and the robust log-rank statistic for cut-point analysis. The cumulative incidence of local failure with death as a competing risk was considered as the primary endpoint.

RESULTS

A total of 522 eligible spine SBRT treatments (68% single fraction) were identified in 377 unique patients. Patients had a median OS of 43.7 months (95% confidence interval: 34.3-54.4). The cumulative incidence of local failure was 19.3% (15.3-23.2) at 1 year and 25.6% (21.1-29.9) at 2 years. Univariate analysis identified that the minimum dose (normalized for the prescription dose) was a strong predictor of local failure (p = 0.0093). Among patients treated with a single fraction, statistical significance was maintained (p = 0.024). No other dosimetric factors were predictive of local failure. In a cut point analysis, the log-rank statistic was maximized at 15.8 Gy minimum dose for single-fraction treatment (HR = 0.51, 95% CI: 0.34 - 0.75, p = 0.0009). Cumulative incidence of local failure was 15.1% (9.8-20.2) vs. 24.7% (17.2-31.5) at 1 year using this cut-off. Comparable local control was demonstrated with a minimum dose of 14 Gy (HR = 0.57, 95%: 0.37 - 0.87, p = 0.009), with reduced local control with lower minimum doses. Among a range of clinical factors assessed, only epidural and soft tissue involvement were predictive of local failure (HR = 1.80 and 1.98, respectively). Multivariable analyses incorporating soft tissue involvement, epidural extension, and multilevel disease confirmed the 15.8 Gy cutoff for single fraction cases (HR = 0.58, 95% CI: 0.38-0.88, p = 0.011).

CONCLUSION

Spine SBRT offers favorable local control using a range of dose-fractionation schemes; however, minimum dose has a strong association with local control, unlike any other dosimetric factors tested. Furthermore, statistical significance was maintained even when considering epidural extension and potential limitations from dose to the spinal cord. Our data suggests that the minimum dose should be prioritized during treatment planning, ideally to at least 14 - 15.8 Gy for single fraction.

PSMA-Positive Extracellular Vesicles Predict Disease Recurrence in Oligometastatic Castration-Sensitive Prostate Cancer Treated with Stereotactic Ablative Radiotherapy: Analysis of the ORIOLE trial

PURPOSE/OBJECTIVE(S)

Stereotactic ablative radiation therapy (SABR) can prolong progression free survival in oligometastatic prostate cancer (omPC) patients. However, predictive tools to identify those who will benefit from SABR are necessary. Our group was the first to demonstrate that plasma levels of prostate cancer-derived extracellular vesicles (ProstEVs) correlate with tumor burden and predict disease progression in omPC after SABR. Herein, we conducted a blinded validation study using plasma samples from the ORIOLE randomized phase 2 clinical trial in castration-sensitive patients.

MATERIALS/METHODS

Plasma samples from 46 omPC patients from the Baltimore ORIOLE trial: a 2:1 ratio randomization to SABR vs observation (NCT02680587). Baseline PSMA+ ProstEV levels were measured by standardized and calibrated nanoscale flow cytometry using fluorescent PSMA antibodies. Median ProstEV levels was used as cut-off for low and high levels. Kaplan-Meier curves and Cox regression models were used to determine the association of ProstEV levels with clinical outcomes [PSA progression-free survival (psaPFS) and radiographic distant progression free survival (rPFS)].

RESULTS

No association was observed between number of metastatic lesions or baseline PSA and plasma ProstEV levels. The rPFS for patients treated with SABR was 29.6 months. The rPFS for patients treated with SABR with high and low ProstEV levels were 11.1 months and 36 months, respectively (Hazard Ratio: 2.85; 95% CI, 1.01-7.48; P = 0.02). The psaPFS for patients treated with SABR was 11.9 months. The psaPFS for patients with high and low ProstEV levels were 5.9 months and 24.3 months, respectively (HR: 2.44; 95% CI, 1.00-5.94; P = 0.03).

CONCLUSION

ProstEVs is the first blood biomarker of tumor burden that can prognosticate the risk of disease recurrence in omPC patients treated with SABR. While biomarker-guided trials are warranted, our validation study strengthens the clinical value of ProstEVs for personalized radiation therapy.

Unique T-cell Sub-Population Shifts after SBPT and Nivolumab in Platinum Refractory HNC: Biomarker Correlates from ROR1771

PURPOSE/OBJECTIVE(S)

ROR1771 was a clinical trial investigating the use of stereotactic body proton radiotherapy (SBPT) and nivolumab in recurrent platinum refractory head and neck squamous cell carcinoma (HNSCC). The planned analysis of T-cell subpopulation and biomarker response is herein presented.

MATERIALS/METHODS

Patients with metastatic histologically confirmed HNSCC from any primary site received 2 cycles of nivolumab followed by SBPT to 1-2 selected target lesion(s) (hilar/lung: 8 of 12 patients), followed by maintenance nivolumab. Peripheral blood mononuclear cells were isolated pre-/post-treatment. Flow cytometry identified T-cell subpopulations. Single Cell 5' Gene Expression (GEX) and V(D)J T Cell Receptor libraries were prepared using Single Cell Immune Profiling. Seurat (v4.1.1) was used to identify cell type clusters, and differential expression post-filtration was evaluated using the Wilcoxon Rank Sum test.

RESULTS

A total of 12 patients were eligible for analysis, with one alive at time of analysis, 52 months from start of treatment. Median overall survival here was 12.5 months vs. 7.5-months on CheckMate 141. SBPT ranged from 35-50 Gy. Sequential changes in T-cell populations from baseline were noted with initiation of nivolumab, driving decrease in tumor-reactive (TTR; CD11ahighPD1+CD8+), central memory (TCM; CCR7+CD45RA-), and effector T-cells (TEF; CCR7-CD45RA-). TTR and TCM increased following SBPT, with greatest increase (3.5x TTR and 5.2x TCM) in the surviving patient. An average of 68 genes with significant differential expression between timepoints (p<0.0001) demonstrated RNA gene expression changes across all cell subtypes, including ribosomal (RPL and RPS) genes, ACTB, FTL, MALAT1, and others. This averaged 113 genes across all timepoints in the surviving patient, with peak following nivolumab induction. On T-cell receptor (TCR) analysis of this patient, the predominant clonotype diversity changed substantially following nivolumab. Following SBPT, clonotype diversity again changed to include a milieu seen neither at baseline nor with nivolumab alone. These TCRs persisted for approximately 2 weeks following SBPT before returning to resemble the nivolumab-induced TCR diversity alone, coinciding with disease recurrence.

CONCLUSION

ROR1771 demonstrated overall survival favorably comparable to CheckMate 141. Biomarker analysis of peripheral blood samples demonstrated significant shifts in T-cell subpopulations and underlying gene expression to nivolumab and then to SBPT administration. SBPT to a target lesion changed TCR clonotypes within the peripheral blood beyond those seen with nivolumab administration, with fading of these TCR clonotypes coinciding with recurrence. SBPT in combination with nivolumab may drive systemic immunologic change above that induced by nivolumab alone and warrants further investigation.

Hydrothorax Due to Extravasation of Intravenous Contrast after Power Injection through Right Subclavian Catheter

We report a case of hydrothorax after receiving intravenous (IV) contrast material by power injector through right subclavian central venous catheter (CVC) line. A 38-year-old woman presented to the local emergency department with hypotension after a pedestrian accident. After resuscitation, CVC was inserted into her right subclavian vein and fluid was administered well before computed tomography (CT) enhancement. Contrast-enhanced CT scan showed a large amount of extravasation of contrast material and fluid collection in the thoracic and pericardial cavities which was not shown in non-enhanced CT scan. During operation, vascular perforation was found in right subclavian vein. This case highlights that emergency physicians must keep in mind the possibility of vessel injury after CVC insertion and contrast material is preferably injected via peripheral IV access.

A Randomised, Cross over Study Using a Mannequin Model to Evaluate the Effects on CPR Quality of Real-Time Audio-Visual Feedback Provided by a Smartphone Application

Objective

To evaluate the effect of real time feedback provided by smartphone application on cardiopulmonary resuscitation (CPR) performance.

Methods

Participants were randomised in two groups based on whether chest compression with or without the assistance of the smartphone application. Both groups performed hands-only CPR on a mannequin for 4 minutes. Data on CPR performance of both groups was compared. To assess the reliability the feedback value, we compared the CPR data from Skillmeter and data from smartphone. A questionnaire survey to participants about the usefulness of the application was also evaluated.

Results

Twenty-one subjects were recruited for the study. We found no significant difference in mean chest compression rate (103.3±5.0/min vs. 107.1±1.7/min; p=0.133) and depth between the two groups (47.3 [39.3, 56.2] mm vs. 45.8 [40.3, 49.9] mm; p=0.085). The proportion of adequate compression depth over the total compression was significantly higher in the group using the smartphone (38.1% vs. 22.2%; p=0.034). The CPR data displayed on smartphone application in mannequin's chest was not different from Skillmeter software. The majority of the participants considered the application easy to use, but holding the smartphone during CPR hampered compression.

Conclusions

Real-time audio-visual feedback on CPR depth and rate using a smartphone application can help to maintain the adequate chest compression depth in prolonged CPR. A better method to hold the smartphone may maximise the feedback effect on CPR quality. (Hong Kong j.emerg.med. 2014;21:153-160)

The effect of low-volatile organic compounds, water-based paint on aggravation of allergic disease in schoolchildren

Whether indoor painting aggravates preexisting allergic diseases remains unclear. We aimed to evaluate the impact of new classroom painting on aggravation of asthma, allergic rhinitis (AR), and atopic dermatitis (AD) in children. Studied school was previously painted with conventional water-based paint 20 years ago and had natural ventilation system. We identified a total of 172 children aged 10-12 years with allergic diseases in 17 classrooms, which were allocated to newly painted rooms with low-volatile organic compounds (VOC), water-based paint, or existing rooms. After painting, there was no intervention or internal airflow to influence indoor air environment in both classrooms. We prospectively assessed the symptom severity and serious events of allergic diseases between both classrooms at baseline and after one and eight weeks after painting. At one and eight weeks, there were no significant changes in the Childhood Asthma Control Test scores, the fractional nitric oxide levels, lung function in asthmatic children in either classroom. There were also no significant changes in the severity score of AR or AD, or serious events in all allergic diseases. These findings suggest classroom painting with this new paint at the levels encountered in this study might not be a major aggravating factor for school-aged children with allergic diseases.

Abstract OT2-03-03: A randomized trial of 15 fraction vs 25 fraction pencil beam scanning proton radiotherapy after mastectomy in patients requiring regional nodal irradiation

Background: Post-mastectomy radiotherapy improves survival in women with node-positive breast cancer. Pencil beam scanning proton therapy is attractive due to potential to reduce the dose to the heart and lungs compared with traditional photon techniques while improving conformality and limiting skin dose compared with passively scanned proton therapy. The optimal dose and fractionation for pencil-beam scanning proton therapy remains unknown.

Trial Design: This is a multi-center open label phase II randomized controlled trial to determine the safety of 15 fraction vs 25 fraction pencil beam scanning proton radiotherapy after mastectomy in patients requiring regional nodal irradiation.

Eligibility Criteria: Patients ≥ 18 years with primary, non-inflammatory invasive breast cancer who have undergone mastectomy with or without immediate reconstruction and chest wall and regional nodal irradiation planned.

Aims: To determine whether the 24 month complication rate (defined as grade 3 or greater late adverse events, and unplanned surgical intervention in patients who undergo mastectomy with reconstruction) of 15 fraction chest wall and regional node pencil beam scanning proton radiotherapy is acceptable relative to 25 fraction chest wall and regional nodal pencil beam scanning proton radiotherapy and worthy of further investigation.

Statistical methods: The study is designed as a non-inferiority/superiority “hybrid” design using the approach of Freidlin et al. It is Using a one-sided type I error rate of 0.05 (corresponding equivalently to constructing a 1-sided 95% confidence limit), 72 evaluable patients will have 80% power to reject the null hypothesis that the 24-month complication rate in the experimental arm is higher than that of the control arm by more than 10% (i.e. rule out inferiority) under the alternative hypothesis that the complication rate in the experimental arm is 5% less than that of the control arm (i.e. superiority). However, the design will have only 41% power when the two treatment arms are equivalent (i.e. the complication rate is 10% for both arms).

Accrual: The study opened in June 2016. Five of a planned eighty-two patients have been accrued to date.

Citation Format: Mutter RW, Park SS, Hieken TJ, Vargas CE, Mei-Yin PC, Kathryn RJ, Hector VR, Kimberly CS, Elizabeth YS, Daniel VW. A randomized trial of 15 fraction vs 25 fraction pencil beam scanning proton radiotherapy after mastectomy in patients requiring regional nodal irradiation [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT2-03-03.

Simultaneous robotic low anterior resection and prostatectomy for adenocarcinoma of rectum and prostate: initial case report

Background

We report a case of synchronous rectal and prostate cancer treated successfully with simultaneous da Vinci robotic-assisted low anterior resection of the rectum and robotic-assisted laparoscopic radical prostatectomy to address both cancers.

Case presentation

Recently, minimally invasive surgical techniques using da Vinci robot^® system (Intuitive Surgical, Sunnyvale, USA) were introduced as curative surgical modality of prostate and rectal malignancies. Herein, we report an initial case of simultaneous robotic low anterior resection and robotic prostatectomy for adenocarcinoma of rectum and prostate sharing a considerable number of port sites.

Conclusion

Simultaneous robotic-assisted low anterior resection could be performed with robotic-assisted radical prostatectomy safely and effectively in synchronous rectal and prostate cancer.

Temporal and spatial discordance of programmed cell death-ligand 1 expression and lymphocyte tumor infiltration between paired primary lesions and brain metastases in lung cancer

The tumor microenvironments of paired primary lung cancers and brain metastases are significantly different, such that many of the metastases lose PD-L1 expression, lymphocyte infiltration or both with greater discrepancies over time. The spatial and temporal heterogeneity of PD-L1 expression may limit its use as a tissue-based predictive biomarker in lung cancer.

Background

The dynamics of PD-L1 expression may limit its use as a tissue-based predictive biomarker. We sought to expand our understanding of the dynamics of PD-L1 expression and tumor-infiltrating lymphocytes (TILs) in patients with lung cancer-related brain metastases.

Experimental design

Paired primary lung cancers and brain metastases were identified and assessed for PD-L1 and CD3 expression by immunohistochemistry. Lesions with 5% or greater PD-L1 expression were considered positive. Agreement statistics and the χ² or Fisher's exact test were used for analysis.

Results

We analyzed 146 paired lesions from 73 cases. There was disagreement of tumor cell PD-L1 expression in 10 cases (14%, κ = 0.71), and disagreement of TIL PD-L1 expression in 19 cases (26%, κ = 0.38). Most paired lesions with discordant tumor cell expression of PD-L1 were obtained 6 or more months apart. When specimens were categorized using a proposed tumor microenvironment categorization scheme based on PD-L1 expression and TILs, there were significant changes in the classifications because many of the brain metastases lacked either PD-L1 expression, tumor lymphocyte infiltration or both even when they were present in the primary lung cancer specimens (P = 0.009).

Conclusions

We identified that there are significant differences between the tumor microenvironment of paired primary lung cancers and brain metastases. When physicians decide to treat patients with lung cancer with a PD-1 or PD-L1 inhibitor, they must do so in the context of the spatial and temporal heterogeneity of the tumor microenvironment.

Effect of inhalers on the development of haemoptysis in patients with non-cystic fibrosis bronchiectasis

BACKGROUND

The association of inhaler use with haemoptysis has rarely been reported in patients with non-cystic fibrosis (CF) bronchiectasis.

OBJECTIVE

To elucidate the effect of inhaler use on the development of haemoptysis in patients with non-CF bronchiectasis.

METHODS

In a case-crossover study of 192 non-CF bronchiectasis patients with a history of haemoptysis and inhaler use, the risk of haemoptysis associated with the use of inhalers was elucidated. Two inhaled corticosteroids/long-acting β₂-agonists (ICS/LABA), one long-acting muscarinic antagonist and one short-acting β₂-agonist (SABA) were evaluated. The case and control periods were defined respectively as 030 and 180210 days before haemoptysis.

RESULTS

The risk of haemoptysis during the case period was 3.51 times higher than during the control period with any use of inhalers (95%CI 1.966.28). The results of clinically significant haemoptysis showed good agreement with those of total events. These associations were consistent with the sensitivity analyses. In the sub-analysis according to inhaler type, ICS/LABA and SABA were significantly associated with an increased risk of haemoptysis (aOR 2.62, 95%CI 1.255.45; aOR 2.51, 95%CI 2.235.15).

CONCLUSIONS

In patients with non-CF bronchiectasis, the use of inhalers, especially including 2-agonist, was associated with an increased risk of haemoptysis.

Disseminated mucormycosis with myocardial involvement in a renal transplant recipient

We report the case of a renal transplant recipient with pulmonary and splenic mucormycosis whose demise was accelerated by a myocardial abscess. Once pulmonary and splenic mucormycosis was diagnosed, liposomal amphotericin B was started and immunosuppressant treatments were discontinued. The pulmonary cavities regressed during treatment, but new myocardial and peri-allograft abscesses developed. The myocardial abscess diffusely infiltrated the left ventricular wall and was associated with akinesia, which led to sudden cardiac arrest. This case demonstrates a rare manifestation of mucormycosis and highlights the fatality and invasiveness of this infection.

Clinical applications of next-generation sequencing-based gene panel in patients with muscular dystrophy: Korean experience

Muscular dystrophy (MD) is a genetically and clinically heterogeneous group of disorders. Here, we performed targeted sequencing of 18 limb-girdle MD (LGMD)-related genes in 35 patients who were highly suspected of having MD. We identified one or more pathogenic variants in 23 of 35 patients (65.7%), and a genetic diagnosis was performed in 20 patients (57.1%). LGMD2B was the most common LGMD type, followed by LGMD1B, LGMD2A, and LGMD2G. Among the three major LGMD types in this group, LGMD1B was correlated with the lowest creatine kinase (CK) levels and the earliest onset, whereas LGMD2B was correlated with the highest CK levels and the latest onset. Thus, next-generation sequencing-based gene panels can be a helpful tool for the diagnosis of MDs, particularly in young children and those displaying atypical symptoms.

Unintentional secondary exogenous corticosteroid exposure and central serous chorioretinopathy

PURPOSE

The purpose of this study is to describe a possible association between unintentional secondary exogenous corticosteroid exposure and central serous chorioretinpathy (CSCR).

METHODS

A retrospective review of three patients diagnosed with CSCR in one or both eyes and a history of possible unintentional secondary corticosteroid exposure. Clinical history, exam findings, optical coherence tomography, fluorescein angiography, and clinical course were reviewed.

RESULTS

Three patients, who did not use corticosteroids, reported suspected unintentional secondary corticosteroid exposure from living with family members or partners using dermatologic corticosteroid cream and/or inhalers frequently. Two of the three patients had a history of recurrent CSCR, one patient involving both eyes. After taking precautions to avoid secondary corticosteroid exposure, all three patients had complete resolution of CSCR without further recurrence during follow-up ranging from 2 to 4 years.

CONCLUSIONS

Patients with CSCR should be queried for both primary and possible unintentional secondary routes of corticosteroid exposure, which may contribute to this condition.

Wound infections and healing: are they contributing factors for carcinogenesis?

The link between inflammation and tumourisation has long been considered as a key event in clinical cancer development. Inflammation and inflammatory diseases can be caused by many factors including infectious agents, altered genetics and various degrees of injuries from simple cuts to traumatic wounds, such as those suffered in battlefield. Improved management of all wound types is critical in protecting affected individuals against the development of tumourisation cues, which may potentially lead to cancer development. There have been numerous studies on the mechanism of inflammation-induced tumourisation. Thus, in this mini review, we summarised evidence demonstrating the potential link between infectious agents and their moonlight proteins, wounding, trauma, overactive repair mechanisms, and carcinogenesis.

Identification of novel mutations in the VPS33B gene involved in arthrogryposis, renal dysfunction, and cholestasis syndrome

Arthrogryposis, renal dysfunction, and cholestasis (ARC) syndrome is an autosomal recessive disorder caused by mutations in the VPS33B and VIPAS39. Here, we report novel mutations identified in four patients with ARC syndrome. We analyzed the entire coding regions of the VPS33B and VIPAS39 genes by direct sequencing. To detect novel splice site mutations, mRNA transcripts were analyzed by reverse transcription-polymerase chain reaction (RT-PCR) and sequencing. All four patients had compound heterozygous variants in the VPS33B gene. One patient had a previously reported splice site variant with unknown significance, c.239+5G>A, and a novel nonsense mutation, c.621G>A. The other three patients had the c.403+2T>A mutation, and each of them carried one of the splice site variants, c.239+5G>A or c.499-11G>A. c.239+5G>A and c.499-11G>A created novel splice sites which resulted in abnormal transcripts. No significant VIPAS39 mutation was detected in all patients. In patients suspected with ARC syndrome, mutation analysis of the VPS33B gene should be employed as a primary diagnostic test before performing invasive testing procedures such as organ biopsies. Performing mRNA analysis can be useful in predicting the pathogenic phenotype when the mutation seems to affect a normal splicing mechanism.

Effects of combination of rice straw with alfalfa pellet on milk productivity and chewing activity in lactating dairy cows

An experiment was conducted to determine the effects of diets containing coarse-texture rice straw and small particle size alfalfa pellets as a part of total mixed ration (TMR) on milk productivity and chewing activity in lactating dairy cows. Sixteen multiparous Holstein dairy cows (670±21 kg body weight) in mid-lactation (194.1±13.6 days in milk) were randomly assigned to TMR containing 50% of timothy hay (TH) or TMR containing 20% of rice straw and 30% of alfalfa pellet mixture (RSAP). Geometric mean lengths of TH and RSAP were found to be 5.8 and 3.6, respectively. Dry matter intake, milk yield and milk composition were measured. Moreover, eating and ruminating times were recorded continuously using infrared digital camcorders. Milk yield and milk composition were not detected to have significant differences between TH and RSAP. Dry matter intake (DMI) did not significantly differ for cows fed with TH or RSAP. Although particle size of TH was larger than RSAP, eating, ruminating and total chewing time (min/d or min/kg of DMI) on TH and RSAP were similar. Taken together, our results suggest that using a proper amount of coarse-texture rice straw with high value nutritive alfalfa pellets may stimulate chewing activity in dairy cows without decreasing milk yield and composition even though the quantity of rice straw was 40% of TH.

Preoperative erythropoietin administration in patients with prostate cancer undergoing radical prostatectomy without transfusion

Purpose

In this study, we administered erythropoietin preoperatively to patients who underwent open radical prostatectomy without transfusion to increase their hemoglobin levels and investigated the efficacy of this procedure.

Materials and Methods

We evaluated 62 patients who underwent open radical prostatectomy performed by the same surgeon between June 2005 and January 2011. The 22 patients who refused transfusion were assigned to group 1; the patients who accepted transfusion were assigned to group 2. Before surgery, we administered erythropoietin beta to group 1 patients whose hemoglobin levels were <12 g/dL and retrospectively compared the clinical data of the two groups. We used the t-test and the chi-square test for statistical analysis.

Results

Mean preoperative hemoglobin levels in group 1 after erythropoietin administration (14.5 g/dL) were significantly higher than those in group 2 (13.59 g/dL, p=0.003). Moreover, the difference in the mean hemoglobin levels before and after surgery for group 1 patients (3.55 g/dL) significantly exceeded that for group 2 patients (2.08 g/dL, p=0.000). Additional analysis revealed no statistically significant differences in perioperative complications between the groups.

Conclusions

Preoperative erythropoietin administration increased the safety margin of hemoglobin levels, and this strategy worked sufficiently well in our experience.

Systematic review and meta-analysis of robotic surgery compared with conventional laparoscopic and open resections for gastric carcinoma

BACKGROUND

Robot-assisted gastrectomy (RAG) has been developed in the hope of improving surgical quality and overcoming the limitations of conventional laparoscopically assisted gastrectomy (LAG) and open gastrectomy (OG) for gastric cancer. The aim of this study was to determine the extent of evidence in support of these ideals.

METHODS

A systematic review of the three operation types (RAG, LAG and OG) was carried out to evaluate short-term outcomes including duration of operation, retrieved lymph nodes, estimated blood loss, resection margin status, technical postoperative complications and hospital stay.

RESULTS

Nine non-randomized observational clinical studies involving 7200 patients satisfied the eligibility criteria. RAG was associated with longer operating times than LAG and OG (weighted mean difference 61.99 and 65.73 min respectively; P ≤ 0.001). The number of retrieved lymph nodes and the resection margin length in RAG were comparable with those of LAG and OG. Estimated blood loss as significantly less in RAG than in OG (P = 0.002), but not LAG. Mean hospital stay for RAG was similar to that for LAG (P = 0.14). In contrast, hospital stay was significantly shorter, by a mean of 2.18 days, for RAG compared with OG (P < 0.001). Postoperative complications were similar for all three operative approaches.

CONCLUSION

Short-term oncological outcomes of RAG were comparable with those of the other approaches. LAG was a shorter procedure and less expensive than RAG. Future studies involving RAG should focus on minimizing duration of operation and reducing cost.

Germline mutations and genotype-phenotype correlations in patients with apparently sporadic pheochromocytoma/paraganglioma in Korea

The aim of our study was to assess the frequency of germline mutations and develop the genetic testing strategy in patients with apparently sporadic pheochromocytoma/paraganglioma (PPGL) in Korea. We included 53 patients diagnosed with non-syndromic PPGL without a family history of PPGLs in three referral centers from 2004 to 2011. Succinate dehydrogenase complex B (SDHB), SDHD, Von Hippel-Lindau (VHL), and rearranged during transfection (RET) genes were examined by direct sequencing and multiple ligation-dependent probe amplification. The study patients were composed of 26 men and 27 women, and mean age was 50.1 ± 13.5 years. The frequency of germline mutations was 13.2% (7/53): RET (n = 2), VHL (n = 1), SDHB (n = 2), and SDHD (n = 2). Six of seven mutation carriers were diagnosed before the age of 50. One of two patients harboring an SDHB mutation had malignant PPGLs. One patient with multifocal head and neck paraganglioma (PGL) and pheochromocytoma (PHEO) carried a SDHD mutation. The carriers of germline mutations in patients with apparently sporadic PPGL were 13.2% in our study. We recommend genetic testing in patients below 50 years and SDHD genetic testing in patients with multifocal PPGLs. In malignant PPGLs, SDHB genetic testing may be performed.

Enhancement of the stabilization in white organic light-emitting diodes utilizing a color conversion layer containing CdSe/ZnS quantum dots

White organic light emitting diodes (WOLEDs) were fabricated utilizing blue emitting organic light emitting diodes and color conversion layers containing CdSe/ZnS quantum dots (QDs). The best color purity of the WOLEDs was achieved by using the red and green QDs ratio of 1:9.5. Commission Internationale de l'Eclairage coordinates of the WOLEDs slightly shifted from (0.35, 0.33) to (0.35, 0.32) with increasing applied voltage from 9 to 14 V, indicative of a deep stabilized white color. Color tunable mechanisms of WOLEDs with a color conversion layer containing CdSe/ZnS QDs are described on the basis of the experimental results.

Total artificial heart in the pediatric patient with biventricular heart failure

Mechanical circulatory support emerged for the pediatric population in the late 1980s as a bridge to cardiac transplantation. The Total Artificial Heart (TAH-t) (SynCardia Systems Inc., Tuscon, AZ) has been approved for compassionate use by the Food and Drug Administration for patients with end-stage biventricular heart failure as a bridge to heart transplantation since 1985 and has had FDA approval since 2004. However, of the 1,061 patients placed on the TAH-t, only 21 (2%) were under the age 18. SynCardia Systems, Inc. recommends a minimum patient body surface area (BSA) of 1.7 m(2), thus, limiting pediatric application of this device. This unique case report shares this pediatric institution's first experience with the TAH-t. A 14-year-old male was admitted with dilated cardiomyopathy and severe biventricular heart failure. The patient rapidly decompensated, requiring extracorporeal life support. An echocardiogram revealed severe biventricular dysfunction and diffuse clot formation in the left ventricle and outflow tract. The decision was made to transition to biventricular assist device. The biventricular failure and clot formation helped guide the team to the TAH-t, in spite of a BSA (1.5 m(2)) below the recommendation of 1.7 m(2). A computed tomography (CT) scan of the thorax, in conjunction with a novel three-dimensional (3D) modeling system and team, assisted in determining appropriate fit. Chest CT and 3D modeling following implantation were utilized to determine all major vascular structures were unobstructed and the bronchi were open. The virtual 3D model confirmed appropriate device fit with no evidence of compression to the left pulmonary veins. The postoperative course was complicated by a left lung opacification. The left lung anomalies proved to be atelectasis and improved with aggressive recruitment maneuvers. The patient was supported for 11 days prior to transplantation. Chest CT and 3D modeling were crucial in assessing whether the device would fit, as well as postoperative complications in this smaller pediatric patient.

The failing Fontan: what’s NEXT…?

The Fontan procedure represents the final stage of the transition to single ventricle physiology. Conversion of very complex congenital heart anatomy, such as hypoplastic left heart syndrome, double-outlet right ventricle or double-inlet left ventricle, to a single ventricle has grown in popularity as morbidity and mortality have improved. As these patients grow, survivors are at risk for impaired ventricular dysfunction, plastic bronchitis, protein-losing enteropathy and late failure. Late failing Fontan patients represent a particularly vexing scenario for clinicians, as the only durable treatment option is cardiac transplantation. However, in the short-term, some of these patients require support beyond medical management, with mechanical circulatory support via extracorporeal life support or a ventricular assist device. We report the successful bridge of an adolescent female post-Fontan conversion with late severe cardiac failure. The patient was initially resuscitated with extracorporeal life support, transitioned to a single Berlin Heart EXCOR® ventricular assist device and, subsequently, underwent successful cardiac transplantation.

Primary adenocarcinoma of the rete testis with preceding detection of unilateral hydronephrosis

Primary adenocarcinoma of the rete testis is a rare malignant testicular tumor with a poor prognosis. Here we report the case of a 54-year-old man with right hydronephrosis that was detected before the diagnosis of the primary testicular lesion. During the evaluation of the right hydronephrosis by use of abdominopelvic computed tomography, a painless, hard, solid lesion was found on the right testis. The patient underwent radical orchiectomy, and the pathologic examination revealed an adenocarcinoma of the rete testis. Multiple metastases were present at the time of diagnosis. The patient received combined chemotherapy after the surgery but lived only 8 months after the initial diagnosis.

Diagnostic accuracy of Xpert® MTB/RIF on bronchoscopy specimens in patients with suspected pulmonary tuberculosis

OBJECTIVE

To determine the diagnostic accuracy of the Xpert® MTB/RIF assay using samples obtained through bronchoscopy in patients with suspected pulmonary tuberculosis (PTB).

DESIGN

We retrospectively reviewed the records of patients with suspected PTB for whom the Xpert MTB/RIF assay was performed on bronchoscopy specimens. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of active PTB were calculated for acid-fast bacilli (AFB) smear microscopy and the Xpert assay using culture of Mycobacterium tuberculosis from sputum or bronchoscopy specimens as a reference standard.

RESULTS

A total of 132 patients were included in the final analysis. Of these, 38 had culture-confirmed PTB. The sensitivity of the Xpert assay using bronchial washing or bronchoalveolar lavage (BAL) fluid for the diagnosis of PTB was 81.6%, and specificity was 100%. The PPV and NPV were 100% and 92.1%, respectively. The sensitivity and specificity of AFB smear microscopy were respectively 13.2% and 98.8%.

CONCLUSION

The Xpert assay on bronchoscopy specimens provided an accurate diagnosis of PTB in patients who had a negative AFB smear or who could not produce sputum.

Listening to music during cystoscopy decreases anxiety, pain, and dissatisfaction in patients: a pilot randomized controlled trial

PURPOSE

To determine whether listening to music during cystoscopy decreases anxiety, pain, and dissatisfaction among patients and results in a more comfortable and better-tolerated procedure.

MATERIALS AND METHODS

Seventy male patients who underwent rigid cystoscopy between May 2011 and December 2011 were randomized into the following: no music (Group I, n=35) or classical music during procedure (Group II, n=35). Before cystoscopy, lidocaine gel was instilled in the urethra, and both groups viewed their procedures on a video monitor. Anxiety levels were quantified according to the State-Trait Anxiety Inventory. A visual analog scale (0-10) was used for a self-assessment of satisfaction, discomfort, and willingness among patients to repeat the cystoscopy.

RESULTS

Demographic characteristics, mean age, procedure duration, and procedure indications were statistically similar between the two groups. The mean anxiety level and mean pain score of Group II were significantly lower than those of Group I (p<0.001 for both). Group II also carried a significant greater mean satisfaction score compared with Group I (p<0.001). Statistically significant differences were detected between groups in the postprocedural pulse rate and the systolic blood pressure (p=0.012 and p=0.008, respectively), whereas preprocedure pulse rate and systolic blood pressure were similar.

CONCLUSIONS

Listening to music during rigid cystoscopy significantly reduces feelings of pain, discomfort, and dissatisfaction. Music can serve as a simple, inexpensive, and effective adjunct to sedation during cystoscopy. We recommend the application of music during rigid cystoscopy for clinical use.

Efficacy of Periprostatic Anesthesia according to Lidocaine Dose during Transrectal Ultrasound-Guided Biopsy of the Prostate

PURPOSE

The aim of this study was to evaluate the efficacy of periprostatic lidocaine injection according to lidocaine dose during transrectal ultrasound-guided prostate biopsy.

MATERIALS AND METHODS

The subjects of this study were 92 patients who had undergone transrectal ultrasound-guided 12-core biopsy of the prostate. The patients were randomly assigned to three groups: group 1 (n=31, no lidocaine injection), group 2 (n=30, periprostatic injection of 10 ml 1% lidocaine), and group 3 (n=31, periprostatic injection of 20 ml 1% lidocaine). The patients were assessed for pain by use of a 10-point visual analogue scale (VAS) and for other complications after the procedure.

RESULTS

The mean VAS scores of groups 1 through 3 were 0.93±0.89, 1.32±1.37, and 1.13±1.10, respectively. There were no statistically significant differences between the three groups. However, the mean VAS score of the biopsy pain was 5.0±1.48, 3.93±1.94, and 3.60±2.15, in the same groups, respectively, with statistically significant differences between group 1 and the other groups. Patients in groups 2 and 3 reported significantly less biopsy pain than did group 1 patients (p=0.004, 0.021), with no statistically significant difference in VAS score between groups 2 and 3 (p=0.533). With respect to post-biopsy complications, there were no significant differences in the incidence of hematuria, hematospermia, rectal bleeding, or infection among the three groups.

CONCLUSIONS

Periprostatic injection of local anesthesia with lidocaine was associated with significantly less pain than in the absence of anesthesia. Furthermore, a 20-ml dose of lidocaine produced no better pain control than did a 10-ml lidocaine dose for prostate biopsy.

Transcriptome correlation analysis identifies two unique craniosynostosis subtypes associated with IRS1 activation

The discovery of causal mechanisms associated with nonsyndromic craniosynostosis has proven to be a difficult task due to the complex nature of the disease. In this study, differential transcriptome correlation analysis was used to identify two molecularly distinct subtypes of nonsyndromic craniosynostosis, termed subtype A and subtype B. In addition to unique correlation structure, subtype A was also associated with high IGF pathway expression, whereas subtype B was associated with high integrin expression. To identify a pathologic link between altered gene correlation/expression and the disease state, phosphorylation assays were performed on primary osteoblast cell lines derived from cases within subtype A or subtype B, as well as on primary osteoblast cell lines with novel IGF1R variants previously reported by our lab (Cunningham ML, Horst JA, Rieder MJ, Hing AV, Stanaway IB, Park SS, Samudrala R, Speltz ML. Am J Med Genet A 155A: 91-97, 2011). Elevated IRS1 (pan-tyr) and GSK3β (ser-9) phosphorylation were observed in two novel IGF1R variants with receptor L domain mutations. In subtype A, a hypomineralization phenotype coupled with decreased phosphorylation of IRS1 (ser-312), p38 (thr-180/tyr-182), and p70S6K (thr-412) was observed. In subtype B, decreased phosphorylation of IRS1 (ser-312) as well as increased phosphorylation of Akt (ser-473), GSK3β (ser-9), IGF1R (tyr-1135/tyr-1136), JNK (thr-183/tyr-187), p70S6K (thr-412), and pRPS6 (ser-235/ser-236) was observed, thus implicating the activation of IRS1-mediated Akt signaling in potentiating craniosynostosis in this subtype. Taken together, these results suggest that despite the stimulation of different pathways, activating phosphorylation patterns for IRS1 were consistent in cell lines from both subtypes and the IGF1R variants, thus implicating a key role for IRS1 in the pathogenesis of nonsyndromic craniosynostosis.

The Xpert® MTB/RIF assay evaluation in South Korea, a country with an intermediate tuberculosis burden

SETTING

A central hospital laboratory in South Korea.

OBJECTIVE

To evaluate the usefulness of the Xpert® MTB/RIF assay in a country with an intermediate tuberculosis burden.

DESIGN

A total of 71 real-time polymerase chain reaction-positive sputum sediments were tested within 24 h by the Xpert MTB/RIF assay. Mycobacterium tuberculosis detection was compared with smear microscopy and culture. Rifampicin (RMP) resistance was compared with a culture-based method and rpoB gene sequencing. We also assessed the limit of detection for mutant proportions and time savings in diagnosis.

RESULTS

The Xpert MTB/RIF assay detected M. tuberculosis in 71 (100%) specimens (32 smear-positive, 39 smear-negative). This assay showed 100% (62/62) concordance with drug resistance confirmed by culture and 98.4% (61/62) concordance with sequencing. A specimen containing approximately 50% of mutant p.His526Tyr was falsely interpreted as wild-type bacilli by this assay. The minimal detection ratio was 5:1 of mutant vs. wild-type cells. The median time saved was 18.5 days (range 9-30) for the diagnosis of M. tuberculosis and 81.5 days (65-136) for RMP susceptibility in smear-negative, culture-positive patients.

CONCLUSIONS

The Xpert MTB/RIF assay showed high sensitivity in detecting M. tuberculosis with information on RMP resistance, and had a more rapid time to diagnosis compared to conventional tests; however, the location and amount of mutation may affect test sensitivity.

Paradoxical response in HIV-negative patients with pleural tuberculosis: a retrospective multicentre study

OBJECTIVE

To evaluate the incidence, clinical characteristics and predicting factors for the development of paradoxical response in human immunodeficiency virus negative patients with isolated pleural tuberculosis (TB).

DESIGN

A multicentre, retrospective cohort study including 458 patients who were diagnosed and treated with isolated pleural TB between March 2005 and February 2010.

RESULTS

Paradoxical response developed in 72 patients (16%) with isolated pleural TB. The mean time to development of paradoxical response was 8.8 ± 6.4 weeks after initiation of anti-tuberculosis treatment. The main presentation of paradoxical response was aggravation of pre-existing pleural effusion in 58 patients (81%). However, the majority of the patients who developed paradoxical response had no associated symptoms (n = 49, 68%). In multiple logistic regression analysis, development of paradoxical response was independently associated with the proportion of eosinophils (adjusted OR 1.293, 95%CI 1.077-1.553) and protein concentrations (adjusted OR 0.590, 95%CI 0.397-0.878) in the pleural fluid at the time of diagnosis.

CONCLUSION

Paradoxical response developed in 16% of the patients approximately 2 months after initiation of anti-tuberculosis treatment, presenting with aggravation of pre-existing pleural effusion. Development of paradoxical response was associated with the proportion of eosinophils and protein concentrations in the pleural fluid at the time of diagnosis.

Prediction of atomic force microscope probe dynamics through the receptance coupling method

The increased growth in the use of tip-based sensing, manipulations, and fabrication of devices in atomic force microscopy (AFM) necessitates the accurate prediction of the dynamic behavior of the AFM probe. The chip holder, to which the micro-sensing device is attached, and the rest of the AFM system can affect the overall dynamics of the probe. In order to consider these boundary effects, we propose a novel receptance coupling method to mathematically combine the dynamics of the AFM setup and probe, based on the equilibrium and compatibility conditions at the joint. Once the frequency response functions of displacement over force at the tool tip are obtained, the dynamic interaction forces between the tip and the sample in nanoscale can be determined by measuring the probe tip displacement.

Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus

We reviewed the outcome of distal chevron metatarsal osteotomy without tendon transfer in 19 consecutive patients (19 feet) with a hallux varus deformity following surgery for hallux valgus. All patients underwent distal chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release. The mean hallux valgus angle improved from -11.6° pre-operatively to 4.7° postoperatively, the mean first-second intermetatarsal angle improved from -0.3° to 3.3° and the distal metatarsal articular angle from 9.5° to 2.3° and the first metatarsophalangeal joints became congruent post-operatively in all 19 feet. The mean relative length ratio of the metatarsus decreased from 1.01 to 0.99 and the mean American Orthopaedic Foot and Ankle Society score improved from 77 to 95 points. In two patients the hallux varus recurred. One was symptom-free but the other remained symptomatic after a repeat distal chevron osteotomy. There were no other complications. We consider that distal chevron metatarsal osteotomy with a medial wedge osteotomy and medial capsular release is a useful procedure for the correction of hallux varus after surgery for hallux valgus.

A case of systemic polyarteritis nodosa involving bronchial artery

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis involving predominantly medium-sized muscular arteries. It commonly involves skin, kidney, cardiovascular system, gastrointestinal system, and neurological system. But bronchial artery involvement of PAN is rarely identified. We report a case of PAN with initial presentation of hemoptysis. On admission, chest radiograph and chest CT angiography revealed no focus of bleeding. Angiography showed a bronchial artery aneurysm and multiple arterial aneurysms in both renal, hepatic, mesenteric and branches of small bowel arteries. These findings were compatible with the diagnosis of PAN. The patient was started on steroid and cyclophosphamide.

Investigation of the intervertebral disc and fused joint dynamics through experimental modal analysis and the receptance coupling method

Identification of intervertebral disc (IVD) dynamics is important in understanding the spine mechanism and behavior. This paper experimentally identifies the dynamics of the bovine caudal IVD using experimental modal analysis and the inverse receptance coupling method. Experimental modal analysis was performed on free-free mounted bovine caudal vertebrae joined by an IVD and a fused IVD joint. Shear, rotational, and axial dynamics of the joints are identified by curve fitting of the frequency response functions, and identifying the damping ratio, stiffness, and modal frequency in each axis. The identified dynamics are compared with the IVD joints with and without fusion. Results provide important insight into IVD dynamics and fused IVD dynamics. This method can be extended to identify human IVD joint dynamics.

Comprehensive mutational analysis of BRCA1/BRCA2 for Korean breast cancer patients: evidence of a founder mutation

The BRCA1 and BRCA2 genes are the strongest susceptibility genes identified for breast cancer worldwide. However, BRCA1/BRCA2 have been incompletely investigated due to their large size and the genomic rearrangements that occasionally occur within them. Here we performed a comprehensive mutational analysis for BRCA1/BRCA2 in 206 Korean patients with breast cancer. We analyzed all exons and flanking regions of BRCA1/BRCA2 by direct sequencing and screened deletions or duplications involving BRCA1/BRCA2 by multiplex ligation-dependent probe amplification. We reconstructed haplotypes using intragenic single nucleotide polymorphisms (SNPs) to investigate the possibility of a founder effect among recurrent mutations. In our series, 38 patients (18.4%) had one or more BRCA1/BRCA2 mutations including 10 novel ones. Three additional patients carried novel distinct unclassified variants with potentially harmful effects. No large deletions or duplications involving BRCA1/BRCA2 were identified in our series. Haplotype analyses and allele separation suggested that the most frequent mutation in Koreans, BRCA2:c.7480C>T, might have originated from a common ancestor. BRCA1/BRCA2 mutations were more frequent in a group with family history, bilateral cancer or multiple site cancer than in a group without the risk factors described or an unknown risk group. In contrast, mutation frequencies in the early-onset cancer group were not higher than in the unknown risk group. Our results will be helpful to understand the mutation spectrum in BRCA1/BRCA2 genes and establish a genetic screening strategy. In addition, this study suggests the possibility of the first true founder mutation of BRCA1/BRCA2 identified in the Korean population.

Spinocerebellar ataxia type 17 mutation as a causative and susceptibility gene in parkinsonism

OBJECTIVE

To investigate the role of spinocerebellar ataxia type 17 (SCA17) in the development of parkinsonism.

METHOD

We screened 1,155 parkinsonian patients (931 with Parkinson disease and 224 with multiple system atrophy) and 400 normal subjects for SCA17. 99mTc-TRODAT-1 SPECT was used to evaluate the striatal dopamine transporter (DAT) status.

RESULTS

Trinucleotide expansion in the SCA17 gene was found in 10 parkinsonian patients (8 with Parkinson disease, 2 with multiple system atrophy) using 42 repeats as an upper normal limit. The repeat sizes in the patients ranged from 43 to 46, which are considered to be low-range expansions. All patients had interrupted sequences. Three probands and three asymptomatic carriers underwent 99mTc-TRODAT-1 SPECT. Striatal DAT binding was markedly reduced in all probands and mildly decreased in one asymptomatic carrier. Among the 400 normal control subjects, there was one individual with an expansion of 44 repeats, another with 43 repeats, and two with 42 repeats. Striatal DAT binding was decreased not only in the control subjects with 44 or 43 repeats, but in ones with 42 repeats, suggesting that an expansion as low as 42 repeats might constitute a susceptibility gene for parkinsonism.

CONCLUSIONS

Low-range expansion of the SCA17 gene is not a rare genetic cause of parkinsonism without ataxia in our population. Reduced penetrance or variable expressivity in low-range expansion might be an explanation for the blurred cutoff point for normal expansion in SCA17.

Associations of the variation in the porcine myogenin gene with muscle fibre characteristics, lean meat production and meat quality traits

Pig breeding is aimed at improving lean meat production ability as well as meat quality, and muscle fibre characteristics may be important for enhancing these traits. Therefore, new molecular markers have been demanded for selecting lean meat production ability and meat quality in live animals. Myogenin belongs to the MyoD gene family, and is a candidate gene responsible for muscle fibre characteristics. We identified a new single nucleotide polymorphism (SNP) site in the 5' upstream region of the myogenin gene (nucleotides C and T). A total of 252 pigs of three breeds were genotyped by polymerase chain reaction-restriction fragment length polymorphism using BspCNI. Additionally, they were genotyped for the previously detected MspI site in the 3'-flanking region (alleles A and B). The CCBB diplotype had the highest frequency over breeds, followed by TCBB and CCAB. The other diplotypes were not found in studied pigs. Association analysis performed for the markers found that the TCBB diplotype has desirable effects on the total number of fibres (p < 0.002), fibre cross-sectional area (p < 0.06), and loin eye area (p < 0.001) than the other diplotypes. Moreover, the diplotype had the highest muscle pH value (p < 0.07) and all meat quality traits were near the upper limit of the normal range as a reddish pink, firm and non-exudative (RFN) pork. Therefore, we suggest that selection for the myogenin diplotypes could improve total muscle fibre number, size and lean meat production ability with good meat quality.

Reactive oxygen species in rats with chronic post-ischemia pain

BACKGROUND

An emerging theme in the study of the pathophysiology of persistent pain is the role of reactive oxygen species (ROS). In the present study, we examined the hypothesis that the exogenous supply of antioxidant drugs during peri-reperfusion would attenuate pain induced by ischemia/reperfusion (IR) injury. We investigated the analgesic effects of three antioxidants administered during peri-reperfusion using an animal model of complex regional pain syndrome-type I consisting of chronic post-ischemia pain (CPIP) of the hind paw.

METHODS

Application of a tight-fitting tourniquet for a period of 3 h produced CPIP in male Sprague-Dawley rats. Low-dose allopurinol (4 mg/kg), high-dose allopurinol (40 mg/kg), superoxide dismutase (SOD, 4000 U/kg), N-nitro-L-arginine methyl ester (L-NAME, 10 mg/kg), or SOD (4000 U/kg)+L-NAME (10 mg/kg) was administered intraperitoneally just after tourniquet application and at 1 and 2 days after reperfusion for 3 days. The effects of antioxidants in rats were investigated using mechanical and cold stimuli. Each group consisted of seven rats.

RESULTS

Allopurinol caused significant alleviation in mechanical and cold allodynia for a period of 4 weeks in rats with CPIP. Both SOD and L-NAME, which were used to investigate the roles of superoxide (O2(-)) and nitric oxide (NO) in pain, also attenuated neuropathic-like pain symptoms in rats for 4 weeks.

CONCLUSIONS

Our findings suggest that O2(-) and NO mediate IR injury-induced chronic pain, and that ROS scavengers administered during the peri-reperfusion period have long-term analgesic effects.

Evaluation of semi-interpenetrating polymer networks composed of chitosan and poloxamer for wound dressing application

We have elsewhere reported the work on the preparation of semi-interpenetrating polymer networks (SIPNs) composed of chitosan (CS) and poloxamer to improve the mechanical strength of CS sponge. This study focuses on evaluation of the CS/poloxamer SIPNs to intend for wound dressing application and the efficacy of dehydroepiandrosterone (DHEA)-loaded CS/poloxamer SIPNs in the wound model studies. The properties required for ideal wound dressing, such as equilibrium water content (EWC), water absorption (A(w)), water vapor transmission rate (WVTR), and evaporative water loss, were examined. The CS/poloxamer SIPNs were found to have a water content of 90% of their weight which could prevent the wound bed from accumulation of exudates and also have excellent water adsorption. The WVTR of CS/poloxamer SIPNs was found to be 2,508.2+/-65.7gm(-2)day(-1), indicating that the SIPNs can maintain a moist environment over wound bed in moderate to heavily exuding wound which enhances epithelial cell migration during the healing process. Also, the CS/poloxamer SIPNs in vitro assessment showed proper biodegradation and low cytotoxicity for wound dressing application. The wound healing efficacy of CS/poloxamer SIPNs as a wound dressing was evaluated on experimental full thickness wounds in a mouse model. It was found that the wounds covered with CS/poloxamer SIPNs or DHEA-loaded CS/poloxamer SIPNs were completely filled with new epithelium without any significant adverse reactions after 3 weeks. The results thus indicate that CS/poloxamer SIPNs could be employed in the future as potential wound dressing materials.

Investigation of the association between 677C>T and 1298A>C 5,10-methylenetetra- hydrofolate reductase gene polymorphisms and normal-tension glaucoma

PURPOSE

Homozygous polymorphism of the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene and resultant hyperhomocysteinaemia have been established as an independent risk factor for vascular diseases. There are evidences that vascular abnormalities are involved in the pathogenesis and progression of normal-tension glaucoma (NTG). In the present study, we were to find out the associations between 677C>T and 1298A>C polymorphisms of the MTHFR gene and NTG.

METHODS

This was a retrospective, case-controlled study enrolling 78 NTG patients and 100 controls. DNA from peripheral blood lymphocytes was extracted and the genotypes of polymorphisms (677C>T and 1298A>C) in the MTHFR gene were determined using PCR followed by restriction enzyme digestion. The frequencies of the polymorphic genotypes in the patients with NTG and controls were compared.

RESULTS

The frequencies of the polymorphisms of the MTHFR gene (677C>T and 1298A>C) in the NTG patients were not significantly different from those of controls. But the younger NTG patients (age at diagnosis < or = 45 years) showed significantly higher prevalence of 677C>T polymorphism than the older NTG patients (age at diagnosis > 45 years) (TT genotype, 38.9 vs 11.9%, P=0.006, OR=4.71, 95% CI=1.49-14.9) and than the younger control subgroup (TT genotype, 38.9 vs 6.1%, P=0.001, OR=9.86, 95% CI=2.23-42.4).

CONCLUSIONS

The 677C>T polymorphism was significantly associated with NTG in the younger patients, while 1298A>C polymorphism was not. This suggests that 677C>T polymorphism of the MTHFR gene can be a genetic risk factor of NTG in Korean population.