Post-treatment haemolysis in African children with hyperparasitaemic falciparum malaria; a randomized comparison of artesunate and quinine

Background

Parenteral artesunate is the treatment of choice for severe malaria. Recently, haemolytic anaemia occurring 1 to 3 weeks after artesunate treatment of falciparum malaria has been reported in returning travellers in temperate countries.

Methods

To assess these potential safety concerns in African children, in whom most deaths from malaria occur, an open-labelled, randomized controlled trial was conducted in Kinshasa, Democratic Republic of Congo. 217 children aged between 6 months and 14 years with acute uncomplicated falciparum malaria and parasite densities over 100,000/μL were randomly allocated to intravenous artesunate or quinine, hospitalized for 3 days and then followed for 42 days.

Results

The immediate reduction in haemoglobin was less with artesunate than with quinine: median (IQR) fall at 72 h 1.4 g/dL (0.90–1.95) vs. 1.7 g/dL (1.10–2.40) (p = 0.009). This was explained by greater pitting then recirculation of once infected erythrocytes. Only 5% of patients (in both groups) had a ≥ 10% reduction in haemoglobin after day 7 (p = 0.1). One artesunate treated patient with suspected concomitant sepsis had a protracted clinical course and required a blood transfusion on day 14.

Conclusions

Clinically significant delayed haemolysis following parenteral artesunate is uncommon in African children hospitalised with acute falciparum malaria and high parasitaemias.

Trial registration

ClinicalTrials.gov; Identifier: NCT02092766 (18/03/2014)

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2678-0) contains supplementary material, which is available to authorized users.

Catheter probe endoscopic ultrasonography by using cold lubricating jelly-filled method for esophageal subepithelial tumors

Catheter probe endoscopic ultrasonography (C-EUS) by ultrasonographic jelly-filled method has been used to evaluate esophageal subepithelial tumors (SETs). Ultrasonographic jelly is safe on the skin, but its internal safety has not been demonstrated. The jelly stored at room temperature is easily injected into the esophagus through the instrument channel of the endoscope. However, using jelly stored at room temperature remains problematic because the jelly is drained rapidly. We used cold lubricating jelly and an intravenous extension tube to resolve these problems. In this study, we evaluated the safety and efficacy of cold lubricating jelly-filled method. The medical records of patients who underwent C-EUS by using water or cold lubricating jelly-filled method for esophageal SETs from March 2013 to September 2016 in Gangneung Asan hospital were reviewed. Clinical characteristics and EUS findings were evaluated retrospectively. Image quality and procedure time between water and cold lubricating jelly-filled method were compared retrospectively. This study included 138 patients (74 males, 64 females) with esophageal SET with a mean age of 57.1 ± 11.1 years. Thirty-four patients had lesions in the upper esophagus, 58 patients had lesions in the middle esophagus, and 46 patients had lesions in the lower esophagus. The EUS diagnoses were leiomyoma (82.6%), hemangioma (4.3%), extrinsic compressive lesion (3.6%), granulosa cell tumor (2.9%), ectopic calcification (1.4%), cyst (1.4%), lipoma (0.7%), varix (0.7%), and inconclusive lesion (2.2%). The mean image score in the cold lubricating jelly filled-method group was higher than that in the water-filled method group (3.2 ± 0.7 vs. 2.8 ± 0.7, P = 0.002). The procedure time in the cold lubricating jelly filled-method group was shorter than that in the water-filled method group (10 minutes 27 seconds ± 4 minutes 22 seconds versus 13 minutes 20 seconds ± 6 minutes 20 seconds, P = 0.045). No procedure-related complication was observed. C-EUS using the cold lubricating jelly-filled method seems to provide better image quality and shorter procedure time compared with C-EUS using the water-filled method.

Anti-inflammatory potential of a heat-killed Lactobacillus strain isolated from Kimchi on house dust mite-induced atopic dermatitis in NC/Nga mice

AIMS

Atopic dermatitis (AD) is an allergic skin disease driven by the Th2-prone immune response. Therefore, a fundamental approach to restoring the Th1/Th2 balance is needed to treat AD.

METHODS AND RESULTS

Eighteen different Lactobacillus strains isolated from Kimchi were screened to identify those that stimulated immune cells to secret Th1-type or Th2-type cytokines. Lactobacillus brevis NS1401 induced the greatest IFN-γ and IL-12 secretion and the least IL-4 production among the tested Lactobacillus strains. Furthermore, oral administration of heat-killed NS1401 ameliorated the symptoms of dust mite-induced AD in NC/Nga mice by decreasing the serum IgE level and reducing the number of mast cells and eosinophils in lesions. Also, the size and number of cells in the draining lymph nodes of NS1401-administered mice were significantly reduced. In agreement with these results, secretion of a Th1-type cytokine (IFN-γ) and allergen-specific IgG2a were increased, whereas secretion of Th2-type cytokines (IL-4, IL-5, and IL-10) and allergen-specific IgG1 were decreased upon administration of NS1401 in mice.

CONCLUSIONS

Lactobacillus brevis NS1401 alleviates the symptoms of AD by restoring the Th1/Th2 balance through enhancing Th1-prone immunity.

SIGNIFICANCE AND IMPACT OF THE STUDY

The immunomodulatory function of L. brevis NS1401 may provide effective new therapeutics against AD.

Idiopathic granulomatous mastitis: A diagnostic and therapeutic challenge

BACKGROUND

Idiopathic granulomatous mastitis is a rare benign breast disease of women of reproductive age. It usually presents as a painful mass. Since the etiology is unclear, directed diagnosis and management is lacking.

METHODS

This is a retrospective chart review of 14 patients, over twelve years (2004-2016), identified through query of pathology findings.

RESULTS

Two asymptomatic patients were diagnosed after oncologic breast resection following neoadjuvant chemotherapy. The remaining twelve patients were young (31.7 years, range 23-43 years), predominantly non-white (50% African/African-American, 36% Hispanic, 7% Asian), pregnant within the last five years (86%), with no prior granulomatous disease. Evaluation included breast imaging, microbial cultures and staining, and biopsy. Treatment included antibiotics (57%), corticosteroids (21%), methotrexate (7%), and/or surgery (71%). Imaging suggests segmental masses, possibly abscess.

CONCLUSION

Granulomatous mastitis is uncommon, and difficult to diagnose and manage. We review our experience, the literature, and propose an algorithm for diagnosis and management.

Directionality of non-permissive HLA-DPB1 T-cell epitope group mismatches does not improve clinical risk stratification in 8/8 matched unrelated donor hematopoietic cell transplantation

In 8/8 HLA-matched unrelated donor (UD) hematopoietic cell transplants (HCT), HLA-DPB1 mismatches between alleles from different T-cell epitope (TCE) groups (non-permissive mismatches) are associated with significantly higher risks of mortality compared with those between alleles from the same TCE group (permissive mismatches); however, the relevance of mismatch directionality, that is (host vs graft (uni-directional HvG), graft vs host (uni-directional GvH) or both (bi-directional) in the non-permissive setting is unknown. We show here significantly higher in vitro relative responses (RR) to bi-directional mismatches compared with uni-directional HvG or GvH mismatches in a total of 420 one-way mixed lymphocyte reactions between 10/10 matched pairs (RR 27.5 vs 7.5 vs 15.5, respectively, P<0.001). However, in 3281 8/8 matched UD HCT for leukemia or myelodysplastic syndrome, the hazards of transplant-related mortality (TRM) were similar for uni-directional HvG or GvH mismatches and bi-directional mismatches (hazard ratio (HR) 1.32, P=0.001 vs HR 1.28, P=0.005 and HR 1.34, P=0.046), compared with permissive mismatches. Similar results were observed for overall survival. No statistical differences between the uni- and the bi-directional non-permissive groups were detected in pairwise comparisons for any of the outcomes tested. We conclude that consideration of directionality does not improve risk stratification by non-permissive HLA-DPB1 TCE mismatches in UD searches.

Congenital Vascular Malformations: General Diagnostic Principles

Venous malformation (VM) is the most common congenital vascular malformation (CVM), which usually presents as a single lesion in the majority of cases. It also presents as a mixed lesion combined with other CVMs (e.g. lymphatic malformation and arteriovenous malformation [AVM]). Therefore, the diagnosis of VM should include an appropriate work-up, to not only confirm and characterize the VM as either extratruncular or truncular but also to diagnose or exclude the presence of other CVMs. The diagnosis of VM can be made safely using non-invasive to minimally invasive studies, which can also distinguish VM from infantile haemangioma. Invasive studies, such as venography and arteriography, are generally reserved for therapeutic planning and diagnosis of more virulent CVMs (e.g. AVM). The work-up of VM should include a complete assessment of the extent and severity of the primary VM lesion. In addition, its embryologic origin, as well as its haemodynamic characteristics and secondary effects should also be determined.

Association of fibrinogen level with early neurological deterioration among acute ischemic stroke patients with diabetes

BACKGROUND

Diabetes mellitus (DM) is a risk factor for early neurological deterioration (END) in acute ischemic stroke. The prothrombotic protein fibrinogen is frequently elevated in patients with diabetes, and may be associated with poorer prognoses. We evaluated whether fibrinogen is associated with END in patients with diabetes after acute ischemic stroke.

METHODS

We included 3814 patients from a single hospital database admitted within 72 h of onset of ischemic stroke. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) ≥2 within 7 days post-admission. In the total population (END, n = 661; non-END, n = 3153), univariate and multivariate analyses were performed to assess fibrinogen as an independent predictor for END. We then performed propensity score matching and univariate analyses for DM (END, n = 261; non-END, n = 522) and non-DM populations (END, n = 399; non-END, n = 798). Multiple logistic analyses were performed after matching for fibrinogen as a risk factor in each subgroup.

RESULTS

Fibrinogen levels were higher in the END group than in the non-END group (367 ± 156 mg/dL vs. 347 ± 122 mg/dL, p = 0.002), though they were not associated with END in logistic regression analyses. Fibrinogen levels were found to be an independent predictor for END, but only in the DM population (fibrinogen levels 300-599 mg/dL, odds ratio: 1.618, 95% confidence interval: 1.037-2.525, p = 0.034, fibrinogen levels ≥600 mg/dL, 2.575, 1.018-6.514, p = 0.046; non-DM population, p = 0.393). The diabetes-fibrinogen interaction for the entire cohort was p = 0.101.

CONCLUSIONS

Elevated fibrinogen is dose-dependently associated with END in patients with diabetes following acute ischemic stroke.

Intratumoural heterogeneity measured using FDG PET and MRI is associated with tumour-stroma ratio and clinical outcome in head and neck squamous cell carcinoma

AIM

To evaluate the association between the tumour-stroma ratio and intratumoural heterogeneity measured using 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) and magnetic resonance imaging (MRI), and further investigate the prognostic significance of imaging biomarkers in head and neck squamous cell carcinoma (HNSCC).

MATERIALS AND METHODS

Textural-based imaging parameters of the primary tumour were extracted in 44 patients. In addition, the difference between the minimum and maximum apparent diffusion coefficient (ADC) values (ADCdiff) was calculated on MRI. The relationships between the tumour-stroma ratio and imaging parameters were evaluated. The associations between imaging parameters and recurrence-free survival (RFS) were assessed using Cox proportional hazard regression models.

RESULTS

Coarseness (r=-0.382) on PET and ADCdiff (r=0.534) on MRI were significantly correlated with the proportion of stroma. The best imaging biomarkers for the 2-year RFS prediction were coarseness (AUC=0.741) and ADCdiff (AUC=0.779). Multivariate analysis showed that coarseness (hazard ratio=10.549, 95% confidence interval=2.544-43.748, p=0.001) was an independent prognostic factor for RFS.

CONCLUSION

Heterogeneity imaging parameters are significantly associated with the tumour-stroma ratio. These imaging biomarkers may help to facilitate the risk stratification for tumour recurrence in HNSCC.

Abstract P2-01-32: Second sentinel lymph node biopsy for patients with local recurrence after breast cancer surgery

Background: Sentinel lymph node biopsy(SLNB) has become standard procedure for primary breast cancer patients who have no tumor metastasis in sentinel lymph node(SLN). In this study, we evaluated feasibility and pathologic outcomes of second SLNB in patients with locally recurrent breast cancer and their follow-up results.

Methods: From January 2008 to December 2015, 114 patients underwent operation for locally recurrent breast cancer. In 42 patients of them, lymphatic mapping was performed for second SLNB. When SLN was visualized in lymphangiography, SLNB was performed. In the cases where SLN metastasis was confirmed, axillary lymph node dissection(ALND) was performed. Follow-up studies were performed every 6 months for 5 years and then annually.

Results: The mean interval to local recurrence from the initial surgery of breast cancer was 64.6±53.1 months. In 38 of 42 patients(90.5%), lymphatic mapping was successfully performed. There was no significant difference of success rate of lymphatic mapping according to previous operation method of breast and axilla or history of radiation therapy.

Aberrant lymphatic pathway was observed in 15 of 38 patients(39.5%). The rate of aberrant lymphatic pathway was higher in patients who underwent ALND previously then in patients who underwent SLNB only(81.8% vs 22.2%, p=0.001). In 6 patients who previously underwent ALND followed by radiation therapy, all their lymphatic pathway was altered. There was no significant difference of the rate of aberrant lymphatic pathway according to previous operation method of breast.

Of 38 patients in whom lymphatic mapping was successfully performed, 37 patients underwent SLNB. SLNs were identified in 31 patients(83.8%). There was no significant difference of success rate of SLNB according to previous operation method of breast and axilla or history of radiation therapy.

Of 31 patients whose SLNs were identified, 4 patients(12.9%) had tumor metastasis in their SLN. Among them, 3 patients underwent ALND but SLN was the only lymph node(LN) in which tumor metastasis was confirmed. The other patient underwent no further ALND because ipsilateral internal mammary LNs were only LNs in which tumor metastasis was confirmed in frozen section biopsy and micrometastasis was additionally confirmed in only one contralateral axillary LN in permanent biopsy.

The mean follow-up period after operation for local recurrence was 33.0±24.5 months. There were 10 cases(23.8%) of loco-regional recurrence or distant metastasis at 14 months of mean follow-up. Among them, one patient had ipsilateral axillary recurrence solitary at 11 months of follow-up. The patient underwent breast conserving surgery and SLNB for primary breast cancer which stage was I. Second SLNB for local recurrence was tried at 48 months after first operation but SLN was not identified. Because there was no evidence of axillary LN metastasis in preoperative image study, no further ALND was performed.

Conclusion: Second SLNB should be considered for patients with locally recurrent breast cancer because occult LN metastasis could be identified in the ipsilateral axilla or other site through aberrant lymphatic pathway. Further studies are needed to verify accuracy of axillary staging using second SLNB and also its oncologic safety.

Citation Format: Park JY, Song JH, Choi JE, Lee SJ. Second sentinel lymph node biopsy for patients with local recurrence after breast cancer surgery [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 P2-01-32.

Abstract OT1-01-12: A phase II, multicenter, randomized trial of eribulin plus gemcitabine (EG) vs. paclitaxel plus gemcitabine (PG) in patients with HER2-negative metastatic breast cancer as first-line chemotherapy

Background: Metastatic breast cancer (MBC) is an incurable disease and is needed to improve effective chemotherapy. Paclitaxel plus Gemcitabine (PG) combination chemotherapy is one of the preferred chemotherapeutic regimens for patients with MBC, and was found to be proper as a maintenance chemotherapy regimen with survival benefit and feasible toxicity profile. Eribulin mesylate is a non-taxane inhibitor of microtubule dynamics of the halichondrin class of antineoplastic drugs. A recent pooled analysis of two phase II studies with eribulin showed improved overall survival in in various patient subgroups with advanced/metastatic breast cancer who had previously received an anthracycline and a taxane. Furthermore, eribulin may have rational benefit compared with paclitaxel in terms of neurotoxicity. Therefore, Eribulin plus Gemcitabine (EG) combination chemotherapy may have less neurotoxocity comparing to PG.

Trial Design: Prospective randomized phase 2, open-label, two-arm, multi-center study comparing EG chemotherapy with PG chemotherapy for patients with HER-2 negative MBC as first-line chemotherapy.

Eligibility Criteria: Histologically confirmed breast cancer patients, at least 19 years of age, with no prior history of chemotherapy for metastatic, recurrent breast cancer with evaluable lesions (as per RECIST, 1.1) who have adequate hematologic, renal, and hepatic function. Patients either may or may not have a prior anthracycline containing regimen. Prior hormonal therapy as a treatment of metastatic disease is allowed.

Specific Aims:

The primary efficacy endpoint of the trial is Progression-Free Survival (PFS). The secondary efficacy endpoints are: Time to Treatment Failure (TTF); Overall Survival (OS); neuropathic scale (FACT for Taxane QOL assessment); toxicity; duration of response; Objective Response Rate (ORR); Clinical Benefit Rate. The exploratory endpoint of the study includes pharmacogenetic profile.

Statistical Methods:

The initial sample size of the present study was determined based on the data derived from a previous trial on PG maintenance chemotherapy design; 6-month PFS is 70% for PG chemotherapy. This design was hypothesized that EG chemotherapy would not be inferior to PG chemotherapy. Thus, estimated PFS for each arm is 70%. Based on this estimate, we would plan to recruit a total of 100 patients (50 per arm). Considering drop-out rate of 10%, total 112 MBC patients planned to be enrolled.

Present Accrual and Target Accrual:Enrollment has been completed as of March, 2016 with a target enrollment of 112 patients.

Contact information:Kyung Hae Jung MD, Ph.D. khjung@amc.seoul.kr

ClinicalTrials.gov Identifier: NCT02263495.

Citation Format: Park YH, Im S-A, Sohn JH, Lee KS, Chae YS, Lee KH, Kim J-H, Im Y-H, Ahn JS, Kim T-Y, Lee K-H, Kim S-B, Ahn J-H, Kim GM, Park IH, Lee SJ, Han HS, Kim SH, Jung KH. A phase II, multicenter, randomized trial of eribulin plus gemcitabine (EG) vs. paclitaxel plus gemcitabine (PG) in patients with HER2-negative metastatic breast cancer as first-line chemotherapy [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 OT1-01-12.

Abstract P1-11-13: Re-excision rate in breast conservation surgery after neoadjuvant chemotherapy

Background : The goal of neoadjuvant chemotherapy is to reduce tumor size and convert mastectomy to breast-conservation surgery (BCS). In response to neoadjuvant chemotherapy, the regression rate and pattern of breast cancer is variable. And the re-excision rate to secure negative resection margin is reported limitedly in this case. The purpose of this study was to compare the re-excision rate and BCS success rate of patients who received and who did not received neoadjuvant chemotherapy.

Method : In this retrospective cohort study, between January 2009 and December 2012, total 256 women were included who had clinical T2 breast cancer and were planed to receive BCS as initial operation or neoadjuvant chemotherapy. Fifty-nine patients of them received neoadjuvant chemotherapy. Clinical data were collected including age, preoperative or initial clinical tumor size, mammographic microcalcifications, ultrasound multifocality and axillary nodal status, retrospectively. In the resected specimen from BCS, we reviewed the pathologic tumor size, multifocality, histologic type, hormone receptor and Her-2-neu status, ki67, DCIS and EIC component. The re-excision rate and BCS success rate were investigated. Univariate analysis and regression model were used for identify clinicopathologic factors associated with re-excision. To reduce the effect of selection bias, propensity score matching-based anaylsis was also performed.

Results : Of the 256 patients, 178 patients (90.4%, 178/197) received BCS finally in neoadjuvant group and 56 patients (94.9%, 56/59) in non-neoadjuvant group (p=0.406). There was no statistical difference in the re-excision rate between two groups (35.6% (21/59) in neoadjuvant group vs 34.0% (67/197) in non-neoadjuvant group, p=0.946). In propensity-matched cohorts (N=118), the re-excision rate was same in two groups (35.6% (21/59) in neoadjuvant group vs 35.6% (21/59) in non-neoadjuvant group, p=1.000). BCS success rate was higher in neoadjuvant group(94.9% 56/59) than non-neoadjuvant group (86.4%(51/59)), but there was no statistical difference (p=0.205). In this cohorts, clinicopathologic factors associated with re-excision were pathologic multifocality (OR=4.56, p=0.0142), high ki67 (≥50%) (OR=0.7, p=0.0243) and DCIS component (OR=2.67, p=0.0261) in logistic regression model.

Conclusion: This study showed neoadjuvant chemotherapy could increase the BCS success rate but could not decrease the re-excision rate. The re-excision rate is more associated with pathologic finding rather than effect of neoadjuvant chemotherapy.

Citation Format: Song JH, Park JY, Choi JE, Bae YK, Lee SJ. Re-excision rate in breast conservation surgery after neoadjuvant chemotherapy [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 P1-11-13.

Non-structural cancellous bone graft and headless compression screw fixation for treatment of scaphoid waist non-union

PURPOSE

Scaphoid fracture commonly occurs around the mid-third of the scaphoid, and non-union of this fracture has several treatment options. The authors performed autologous cancellous bone graft from the iliac crest and headless compression screw fixation for the treatment of Mack-Lichtman type II scaphoid waist non-union. The purpose of this study was to determine whether this procedure was effective in achieving bony union and restoration of alignment.

METHODS

Medical records and radiographs of 30 patients who underwent cancellous bone graft and headless compression screw fixation for non-union of scaphoid waist fracture were retrospectively reviewed. There were 28 men and 2 women, with a mean age of 32.8 years (range: 21-63). The mean time to surgery was 10 months (range: 3-25) and mean follow-up was 37.5 months (range: 15-52). The authors analyzed bony union, lateral intrascaphoid angle, scapholunate angle, radiolunate angle and scaphoid length on radiographs and evaluated the Modified Mayo wrist score (MMWS) as a functional outcome.

RESULTS

Bony union was achieved in all cases. The lateral intrascaphoid angle improved from 40° to 32° (P<0.001). The scapholunate angle also improved from 61° to 56° (P=0.009). The radiolunate angle decreased from 8° to 4° (P=0.048) and scaphoid length increased from 22mm to 26mm (P<0.001) postoperatively. Wrist motion and MMWS improved significantly at last follow-up. However, there were no significant differences between scaphoid deformity correction angle and pre- to post-operative difference in MMWS.

CONCLUSIONS

Non-structural autologous cancellous bone graft from the iliac crest and headless screw fixation provided reliable results and can be one of the effective treatment options for patients with symptomatic Mack-Lichtman type II non-union in the mid-third of the scaphoid.

LEVEL OF EVIDENCE

Level III.

Distinctive patterns on CT angiography characterize acute internal carotid artery occlusion subtypes

Noninvasive computed tomography angiography (CTA) is widely used in acute ischemic stroke, even for diagnosing various internal carotid artery (ICA) occlusion sites, which often need cerebral digital subtraction angiography (DSA) confirmation. We evaluated whether clinical outcomes vary depending on the DSA-based occlusion sites and explored correlating features on baseline CTA that predict DSA-based occlusion site.We analyzed consecutive patients with acute ICA occlusion who underwent DSA and CTA. Occlusion site was classified into cervical, cavernous, petrous, and carotid terminus segments by DSA confirmation. Clinical and radiological features associated with poor outcome at 3 months (3-6 of modified Rankin scale) were analyzed. Baseline CTA findings were categorized according to carotid occlusive shape (stump, spearhead, and streak), presence of cervical calcification, Willisian occlusive patterns (T-type, L-type, and I-type), and status of leptomeningeal collaterals (LMC).We identified 49 patients with occlusions in the cervical (n = 17), cavernous (n = 22), and carotid terminus (n = 10) portions: initial NIH Stroke Scale (11.4 ± 4.2 vs 16.1 ± 3.7 vs 18.2 ± 5.1; P < 0.001), stroke volume (27.9 ± 29.6 vs 127.4 ± 112.6 vs 260.3 ± 151.8 mL; P < 0.001), and poor outcome (23.5 vs 77.3 vs 90.0%; P < 0.001). Cervical portion occlusion was characterized as rounded stump (82.4%) with calcification (52.9%) and fair LMC (94.1%); cavernous as spearhead occlusion (68.2%) with fair LMC (86.3%) and no calcification (95.5%); and terminus as streak-like occlusive pattern (60.0%) with poor LMC (60.0%), and no calcification (100%) on CTA.Our study indicates that acute ICA occlusion can be subtyped into cervical, cavernous, and terminus. Distinctive findings on initial CTA can help differentiate ICA-occlusion subtypes with specific characteristics.

Abstract TP21: Is Presence of Diabetes Mellitus a Key Prognostic Factor among Patients Receiving Endovascular Treatment for Acute Ischemic Stroke?

Introduction: Given the recent positive endovascular therapy trials for acute ischemic stroke (AIS), this therapeutic strategy is now being increasingly incorporated into routine clinical practice. Identifying prognostic factors among AIS patients receiving endovascular revascularization treatments (ERT) in the real world could be important for clinicians and patients. While the impact of diabetes mellitus (DM) on IV thrombolytic outcomes after AIS has been extensively investigated, there is a paucity of data assessing effects of DM on ERT outcomes after AIS. We evaluated the impact of comorbid DM on ERT for AIS.

Methods: From Jan 2011 to Feb 2016, patients with AIS who underwent ERT for cervicocephalic occlusions were consecutively enrolled into the Acute Stroke due to Intracranial Atherosclerotic occlusion and Neurointervention - Korean Retrospective (ASIAN KR) registry from 3 hospitals. Patients were excluded if onset to puncture time over 8 hours, in-hospital stroke, or unavailable 3-month mRS. DM was diagnosed if a patient had the history, or hemoglobin A1c on admission was over 6.5. Univariate analysis was performed to compare the characteristics between DM and non-DM population. Multiple logistic regression analysis was used to validate the effect of comorbid DM on 3 month outcomes.

Results: Of 721 patients, 667 (93%) were finally included, with 233 DM patients and 434 non-DM patients. In the univariate analysis, comorbidity with hypertension (71.2% vs. 58.3%, p=0.001) and dyslipidemia (36.7% vs. 26.7%, p=0.012) were more frequent in the DM population. Periprocedural factors such as target vessels, intravenous thrombolysis, and final reperfusion grades did not differ. Good outcomes with mRS 0-2 were less frequent in the DM population (43.3% vs. 53.7%, p=0.011). In the logistic regression analysis adjusting age, male sex, initial NIHSS, premorbid mRS, hypertension history, atrial fibrillation, intravenous thrombolysis, onset to puncture time and successful reperfusion, DM was an independent predictor of poor outcomes (mRS 3-6; 1.933, 1.274-2.933, p=0.002).

Conclusion: In patients receiving ERT for AIS due to cervicocephalic artery occlusions, the presence of DM as a comorbidity confers greater odds of a poor functional outcome.

Female patients display poorer burn-specific quality of life 12 months after a burn injury

INTRODUCTION

Although gender differences in morbidity and mortality have been measured in patients with moderate to severe burn injury, little attention has been directed at gender effects on health-related quality of life (HRQoL) following burn injury. The current study was therefore conducted to prospectively measure changes in HRQoL for males and females in a sample of burn patients.

METHODS

A total of 114 adults who received treatment at a statewide burns service for a sustained burns injury participated in this study. Instruments measuring generic health status (Short Form 36 Medical Outcomes Survey version 2), burn-specific HRQoL (Burns Specific Health Scale-Brief), psychological distress (Kessler Psychological Distress Scale) and alcohol use (Alcohol Use Disorders Identification Tool) were prospectively measured at 3, 6 and 12 months post-burn.

RESULTS

In the 12 months post-injury, female patients showed overall poorer physical (p=0.01) and mental health status (p<0.001), greater psychological distress (p<0.001), and greater difficulty with aspects of burn-specific HRQoL: body image (p<0.001), affect (p<0.001), interpersonal functioning (p=0.005), heat sensitivity (p=0.01) and treatment regime (p=0.01). While significant interaction effects suggested that female patients had more improvement in difficulties with treatment regime (p=0.007), female patients continued to report greater difficulty with multiple aspects of physical and psychosocial health status 12 months post-injury.

CONCLUSION

Even though demographic variables, injury characteristics and burn care interventions were similar across genders, following burn injury female patients reported greater impairments in generic and burn-specific HRQoL along with psychological morbidity, when compared to male patients. Urgent clinical and research attention utilising an evidence-based research framework, which incorporates the use of larger sample sizes, the use of validated instruments to measure appropriate outcomes, and a commitment to monitoring long-term care, can only improve burn-care.

Effective therapeutic strategy for massive retroperitoneal hematoma after conization: arterial embolization and pigtail catheter insertion

The loop electrosurgical excision procedure (LEEP) is commonly used to remove cervical intraepithelial neoplasia (CIN) because of its safety profile and likelihood of fewer complications. The authors report a rare case of massive retroperitoneal bleeding combined with hypovolemic shock after LEEP conization. Vessel injury was detected by angiographic computed tomography (CT) and embolization of the uterine artery was successfully performed to achieve hemostasis by an intervention radiologist. A pigtail catheter was subsequently inserted for the drainage of the large retroperitoneal hematoma. The patient did not show any further hemorrhage and recovered safely from hypovolemic shock. Th present case demonstrates a successful multidisciplinary and minimal invasive approach to manage retroperitoneal bleeding with uterine artery embolization. Thus, it should be considered a potential treatment option for hemostasis.

Bupivacaine Induces Apoptosis via ROS in the Schwann Cell Line

Local anesthetics have been generally accepted as being safe. However, recent clinical trials and basic studies have provided strong evidence for the neurotoxicity of local anesthetics, especially through apoptosis. We hypothesized that local anesthetics cause neural complications through Schwann cell apoptosis. Among local anesthetics tested on the Schwann cell line, RT4-D6P2T, bupivacaine significantly induced cell death, measured by the methyl tetrazolium (MTT) assay, in a dose- (LD50 = 476 μM) and time-dependent manner. The bupivacaine-induced generation of reactive oxygen species (ROS), which was initiated within 5 hrs and preceded the activation of caspase-3 and poly ADP-ribose polymerase (PARP) degradation, was suggested to trigger apoptosis, exhibited by Hoechst 33258 nuclear staining and DNA fragmentation. Furthermore, concomitant block of ROS by anti-oxidants significantly inhibited bupivacaine-induced apoptosis. Among the local anesthetics for peripheral neural blocks, bupivacaine induced apoptosis in the Schwann cell line, which may be associated with ROS production.

Desipramine Inhibits Na+/H+ Exchanger in Human Submandibular Cells

A common and significant side-effect of the antidepressant desipramine is xerostomia (dry mouth). We investigated the effect of desipramine on Na+/H+ exchanger, which is an important modulator of salivary secretion. In dissociated human submandibular acinar cells, desipramine inhibited intracellular pH recovery in a concentration-dependent manner. Likewise, 5-(N-ethyl-N-isopropyl)amiloride (EIPA), a Na+/H+ exchanger inhibitor, had the same effect as desipramine, whereas the effect of 4,4′-diisothiocyanostilbene-2,2′-disulphonic acid (DIDS), a Na+/HCO3− co-transporter inhibitor, was not dramatic. Although desipramine is known to inhibit catecholamine re-uptake, desipramine also inhibited pH recovery in the human submandibular gland cell line, HSG cells, which lack nerve inputs. Our results suggest that desipramine directly inhibits Na+/H+ exchange in human submandibular glands without the involvement of catecholamine re-uptake, revealing the cellular mechanism of desipramine-evoked xerostomia.

Primary esophageal mucosa-associated lymphoid tissue lymphoma diagnosed by using stacked forceps biopsy

Non-Hodgkin lymphoma involving the esophagus is very rare. Only a few cases have been reported in the English literature to date, and it accounts for less than 1% of all cases of gastrointestinal lymphoma. As this malignancy manifests as a submucosal tumor, pathological diagnosis by using a simple endoscopic biopsy alone is difficult. Therefore, surgical biopsy, endoscopic mucosal resection, and endoscopic ultrasound-guided fine-needle aspiration have been used in most cases. Herein, we report a case of esophageal mucosa-associated lymphoid tissue lymphoma in a 49-year-old man, which involved the use of a stacked forceps biopsy to obtain adequate samples for pathological analysis; the use of the stacked forceps biopsy method is unlike those used in previous cases. The patient received cyclophosphamide, vincristine, and prednisolone chemotherapy; he achieved a complete response. In addition, we review the literature relevant to this case.

Confounding factors affecting the National Institutes of Health (NIH) chronic Graft-Versus-Host Disease Organ-Specific Score and global severity

The 2005 NIH chronic GVHD (cGVHD) organ severity is based on the assessment of current status regardless of whether abnormalities are due to GVHD. The score assignment does not require knowledge of past manifestations, attribution or whether cGVHD is still active. The aim of this study is to describe confounding factors affecting organ scores in patients with cGVHD. The study included 189 consecutive cGVHD patients evaluated at our center in 2013. Providers completed the NIH 0-3 organ-specific scoring evaluation with two questions added for each organ to identify abnormalities that were (i) not attributed to cGVHD or (ii) attributed to cGVHD plus other causes. Abnormalities attributed to causes other than GVHD were recorded. Eighty (14%) abnormalities were not attributed to cGVHD in at least one organ, and 41 (7%) abnormalities were attributed to cGVHD plus other causes in at least one organ. A total of 436 (78%) abnormalities were attributed only to cGVHD. Abnormalities not attributed to cGVHD were observed most frequently in the lung, gastrointestinal tract and skin. Most common abnormalities included pre-transplant condition, sequelae from GVHD, deconditioning, infections and medications. Our results support the 2014 NIH consensus recommendation to consider attribution when scoring organ abnormalities.

Novel HLA-DP region susceptibility loci associated with severe acute GvHD

Despite HLA allele matching, significant acute GvHD remains a major barrier to successful unrelated donor BMT. We conducted a genome-wide association study (GWAS) to identify recipient and donor genes associated with the risk of acute GvHD. A case-control design (grade III-IV versus no acute GvHD) and pooled GWA approach was used to study European-American recipients with hematological malignancies who received myeloablative conditioning non-T-cell-depleted first transplantation from HLA-A, -B, -C, -DRB1, -DQB1 allele level (10/10) matched unrelated donors. DNA samples were divided into three pools and tested in triplicate using the Affymetrix Genome-wide SNP Array 6.0. We identified three novel susceptibility loci in the HLA-DP region of recipient genomes that were associated with III-IV acute GvHD (rs9277378, P=1.58E-09; rs9277542, P=1.548E-06 and rs9277341, P=7.718E-05). Of these three single nucleotide polymorphisms (SNPs), rs9277378 and rs9277542 are located in non-coding regions of the HLA-DPB1 gene and the two are in strong linkage disequilibrium with two other published SNPs associated with acute GvHD, rs2281389 and rs9277535. Eighteen other recipient SNPs and 3 donor SNPs with a high level of significance (8E-07 or lower) were found. Our report contributes to emerging data showing clinical significance of the HLA-DP region genetic markers beyond structural matching of DPB1 alleles.

Hemodynamic contribution of transdural collateral flow in adult patients with moyamoya disease

To evaluate the hemodynamic contributions of collateral flow in adult patients with moyamoya disease, neurological deterioration or fluctuation during admission, Suzuki grade, various collateral routes, lesion volume, cerebral blood flow (CBF), and their associations were analyzed. Thirty patients (60 cerebral hemispheres, mean age 45 ± 25 years, and 73.3 % female) who were diagnosed with moyamoya disease or syndrome were enrolled over 3 years. Moyamoya stages from each hemisphere were stratified according to the Suzuki's criteria through six-vessel angiography into internal carotid arteries (ICAs), external carotid arteries (ECAs), and vertebral arteries (VAs). Collateral routes were categorized into the circle of Willis, leptomeningeal, and transdural. The volume of ipsilateral infarction was analyzed by magnetic resonance imaging. CBF volume was measured using color-coded duplex sonography. Suzuki's grade was inversely correlated with flow volume of the ICAs (p < 0.001), whereas no association was found with that of the ECAs (p = 0.445) or VAs (p = 0.096). Among hemispheres with ≥ grade 3 (n = 36), patients with transdural ECA collateral flow had less neurological deterioration or fluctuation (0.0 vs. 30.8 %, p = 0.047), smaller lesion volume (2.4 ± 3.6 vs. 27.6 ± 59.3 mL, p = 0.041), lower ICA flow (88.4 ± 45.9 vs. 146.2 ± 121.7 mL/min, p = 0.022), higher ECA flow (205.7 ± 77.7 vs. 135.9 ± 52.7 mL/min, p = 0.046), and a higher ECA/ICA flow volume ratio (31.8 ± 92.8 vs. 1.7 ± 1.9, p = 0.024). Our results suggest that ICA flow volume is inversely correlated with Suzuki grade, and that transdural ECA collaterals appear to be an important detour in adult patients with advanced stage moyamoya disease, suggesting a protector against an impending ischemic attack.

Beliefs and ideologies linked with approval of corporal punishment: a content analysis of online comments

This study employs a novel strategy for identifying points of resistance to education efforts aimed at reducing rates of child physical abuse and use of corporal punishment (CP). We analyzed online comments (n = 581) generated in response to media coverage of a study linking CP with increased child aggression. Most comments (71%) reflected approval of hitting children for disciplinary purposes. Reasons for this approval were rooted in beliefs linking the use of CP with positive or neutral outcomes such as: 'I was spanked and I am okay', spanking improves child behavior, spanking is more effective than other forms of discipline and spanking is not abuse. However, also linked with approval were more macro-ideological beliefs about society such as: today's generation is worse off than previous ones, outside interference with parenting is wrong, one cause leads to an outcome, justifications for hitting children rooted in religious doctrine, bad parents cannot control their children and children have too much power. Our results suggest a need to better translate and disseminate empirical findings regarding the negative effects of CP to the public in a way that is highly sensitive to parents' needs to feel in control and effective when parenting.

YKL-40 in allogeneic hematopoietic cell transplantation after AML and myelodysplastic syndrome

YKL-40, also called chitinase-3-like-1 protein, is an inflammatory biomarker that has been associated with disease severity in inflammatory and malignant diseases, including AML, multiple myeloma and lymphomas. The objective of the current study was to assess the prognostic value of pretransplant recipient and donor plasma YKL-40 concentrations in patients with AML (n=624) or myelodysplastic syndrome (n=157) treated with allogeneic hematopoietic cell transplantation (HCT). In recipients, the plasma YKL-40 concentrations were increased when the HCT-comorbidity index was ⩾5 (P=0.028). There were no significant associations between plasma YKL-40 concentrations in recipients and any outcome measures. In donors with YKL-40 plasma concentrations above the age-adjusted 95th percentile, a trend toward increased grade II-IV acute GvHD in recipients was observed (adjusted hazard ratio 1.39 (95% confidence interval 1.00-1.94), P=0.050), with no significant associations with overall survival, treatment-related mortality or relapse. In conclusion, our study shows that YKL-40 does not aid risk stratification of patients undergoing allogeneic HCT, but suggests that YKL-40 may aid donor selection when multiple, otherwise equal, donors are available.