Reducing the risk of tooth injury in anterior maxillary interdental osteotomy for cleft lip and palate patients using a surgical navigation technique

The aim of this study was to investigate the clinical feasibility of preventing tooth injury from anterior maxillary interdental osteotomy by using a surgical navigation technique. A retrospective review was conducted on cleft lip and palate patients treated with anterior maxillary osteotomy followed by distraction osteogenesis between August 2019 and May 2022. Patients operated on through image guidance were enrolled in the navigation group, while those who were operated on freehand were enrolled in the freehand group. Tooth injuries were identified on postoperative images. Linear and angular deviations of the osteotomy line were measured. Twelve patients were enrolled in the study, seven in the navigation group and five in the freehand group. Altogether, 24 osteotomy lines and 53 adjacent teeth were evaluated. The dental injury rate was 3% in the navigation group and 27% in the freehand group (P = 0.016). The average linear deviations (mean ± standard deviation) were 0.67 ± 0.30 mm and 2.05 ± 1.33 mm, respectively (P < 0.001), while the average angular deviations were 1.67 ± 0.68° and 11.41 ± 7.46°, respectively (P < 0.001). The results suggest that navigation was able to reduce the tooth injury risk compared with freehand interdental osteotomies in crowded dental arches.

An integrated analysis of the anticarcinogenic role of forkhead box protein 1 in oesophageal squamous cell carcinoma

Forkhead box protein 1 (FOXP1) serves as a tumour promoter or suppressor depending on different cancers, but its effect in oesophageal squamous cell carcinoma has not been fully elucidated. This study investigated the role of FOXP1 in oesophageal squamous cell carcinoma through bioinformatics analysis and experimental verification. We determined through public databases that FOXP1 expresses low in oesophageal squamous cell carcinoma compared with normal tissues, while high expression of FOXP1 indicates a better prognosis. We identified potential target genes regulated by FOXP1, and explored the potential biological processes and signalling pathways involved in FOXP1 in oesophageal squamous cell carcinoma through GO and KEGG enrichment, gene co-expression analysis, and protein interaction network construction. We also analysed the correlation between FOXP1 and tumour immune infiltration levels. We further validated the inhibitory effect of FOXP1 on the proliferation of oesophageal squamous cell carcinoma cells through CCK-8, colony formation and subcutaneous tumour formation assays. This study revealed the anticarcinogenic effect of FOXP1 in oesophageal squamous cell carcinoma, which may serve as a novel biological target for the treatment of tumour.

PI3Kα inhibitor GNE-493 triggers antitumor immunity in murine lung cancer by inducing immunogenic cell death and activating T cells

Phosphatidylinositol 3-kinase (PI3K) is frequently hyperactivated in cancer, playing pivotal roles in the pathophysiology of both malignant and immune cells. The impact of PI3K inhibitors on the tumor microenvironment (TME) within lung cancer remains largely unknown. In this study, we explored the regulatory effects of GNE-493, an innovative dual inhibitor of PI3K and mammalian target of rapamycin (mTOR), on the TME of lung cancer. First, through the analysis of The Cancer Genome Atlas-lung squamous cell carcinoma (LUSC) cohort, we found PIK3CA to be related to CD8 T cells, which may affect the overall survival rate of patients by affecting CD8 function. We herein demonstrated that GNE-493 can significantly inhibit tumor cell proliferation and promote cell apoptosis while increasing the expression of the immunogenic death-related molecules CRT and HSP70 using in vitro cell proliferation and apoptosis experiments on the murine KP lung cancer cell line and human A549 lung cancer cell line. Next, through the establishment of an orthotopic tumor model in vivo, it was found that after GNE-493 intervention, the infiltration of CD4+ and CD8+ T cells in mouse lung tumor was significantly increased, and the expression of CRT in tumors could be induced to increase. To explore the mechanisms underlying PI3K inhibition-induced changes in the TME, the gene expression differences of T cells in the control group versus GNE-493-treated KP tumors were analyzed by RNA-seq, and the main effector pathway of anti-tumor immunity was identified. The IFN/TNF family molecules were significantly upregulated after GNE-493 treatment. In summary, our findings indicate that GNE-493 promotes immunogenic cell death in lung cancer cells, and elucidates its regulatory impact on molecules associated with the adaptive immune response. Our study provides novel insights into how PI3K/mTOR inhibitors exert their activity by modulating the tumor-immune interaction.

A 2-Stage Root Analog Implant with Compact Structure, Uniform Roughness, and High Accuracy

Immediate implant placement has the advantages of shortening the operation time, reducing the treatment cycle and cost. At present, this technology has been used widely, but the indications of immediate implantation are still limited. Here, a novel type of root analog implant (RAI) was manufactured by selective laser melting technology to address the limitation. Under optimized condition, RAIs were printed with the internal density of 99.73% and the uniform surface roughness of 11 μm (Sa). Besides, the deviation between RAI specimen and design models is controlled within 0.15 mm after optimizing scanning parameters. The substrate printed could promote human bone marrow stromal cell proliferation, spreading, and osteogenic differentiation. The bone-implant contact (BIC, 75% ± 7%) and bone volume/total volume (BV/TV, 74% ± 7%) of RAIs were significantly higher than that of conventional implants (BIC, 66% ± 5%; BV/TV, 62% ± 5%) in in vivo experiments. Further, customized abutments were designed for the RAIs, improving the masticatory ability of the beagle dogs after crown restoration. This study aims to design a personalized 2-stage RAI with compact structure and uniform roughness, in order to achieve better fracture resistance, initial osseointegration efficiency, and dispersed stress in immediate implantation. It provides a certain guiding value for standardizing the manufacture and clinical application of RAI in immediate implantation.

An objective, quantitative, dynamic assessment of facial movement symmetry changes after orthognathic surgery

The aim of this study was to generate a quantitative dynamic assessment of facial movement symmetry changes after orthognathic surgery. Twenty-five patients diagnosed with skeletal class III malocclusion with facial asymmetry who underwent bimaxillary surgery were recruited. The patients were asked to perform a maximum smile that was recorded using a three-dimensional facial motion capture system preoperatively (T0), 6 months postoperatively (T1), and 12 months postoperatively (T2). Eleven facial landmarks were selected to analyse the cumulative distance and average speed during smiling. The absolute differences for the paired landmarks between the sides were analysed to reflect the symmetry changes. The results showed that the asymmetry index of the cheilions at T2 was significantly lower than that at T0 (P = 0.004), as was the index of the mid-lateral lower lips (P = 0.006). The mean difference in cheilions was 2.13 ± 1.41 mm at T0, 1.33 ± 1.09 mm at T1, and 1.00 ± 0.98 mm at T2. The facial total mobility at T1 was significantly lower than that at T0 (P < 0.001), while the total mobility at T2 was significantly higher than that at T1 (P = 0.012). The orthognathic surgical correction of facial asymmetry was able to improve the associated asymmetry of facial movements.

Chinese never smokers with adenocarcinoma of the lung are younger and have fewer lymph node metastases than smokers

Background

Lung cancers arising in never smokers have been suggested to be substantially different from lung cancers in smokers at an epidemiological, genetic and molecular level. Focusing on non-small cell lung cancer (NSCLC), we characterized lung cancer patients in China looking for demographic and clinical differences between the smoking and never-smoking subgroups.

Methods

In total, 891 patients with NSCLC, including 841 with adenocarcinoma and 50 with squamous cell carcinoma, were recruited in this study. Association of smoking status with demographic and clinical features of NSCLC was determined, and risk factors for lymph node metastasis and TNM stage were evaluated using Multivariate logistic regression analysis.

Results

In patients with adenocarcinoma, never smokers showed a younger age at diagnosis (54.2 ± 12.7vs. 59.3 ± 9.4, p^adjusted<0.001), a lower risk for lymph node metastasis than smokers (7,6% vs. 19.5%, p^adjusted<0.001) and less severe disease as indicated by lower percentages of patients with TNM stage of III or IV (5.5% vs. 14.7%, p^adjusted<0.001 ). By contrast, these associations were not observed in 50 patients with squamous cell carcinoma. Multivariate logistic regression analysis showed that smoking status was a risk factor for lymph node metastasis (OR = 2.70, 95% CI: 1.39–5.31, p = 0.004) but not for TNM stage (OR = 1.18, 95% CI: 0.09–14.43, p = 0.896) in adenocarcinoma.

Conclusion

This study demonstrates that lung adenocarcinoma in never smokers significantly differ from those in smokers regarding both age at diagnosis and risk of lymph node metastasis, supporting the notion that they are distinct entries with different etiology and pathogenesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02199-z.

[Progress of researches on albendazole for treatment of alveolar echinococcosis]

Alveolar echinococcosis, caused by Echinococcus multilocularis infection, is a highly deadly zoonotic parasitic disease. As a benzimidazole compound, albendazole has a strong and broad-spectrum anti-parasitic action. For alveolar echinococcosis patients that are unwilling to receive surgical treatment, lose the timing for surgery, or are intolerant to surgery due to poor physical status, administration of albendazole may delay disease progression. Recently, a large number of advances have been achieved in experimental studies on alveolar echinococcosis. In order to increase the understanding of the therapeutic efficacy of albendazole for alveolar echinococcosis, this review summarizes the advances in albendazole treatment for alveolar echinococcosis, so as to provide insights into the clinical treatment of alveolar echinococcosis with albendazole.

Endoscope-controlled maxillary sinus floor elevation: a review of the literature

A systematic review of the literature was conducted to assess the safety and efficacy of endoscope-assisted maxillary sinus elevation. PubMed, Embase, Web of Science, and the Cochrane database were searched for articles in English. Published studies involving patients who had undergone endoscope-assisted maxillary sinus floor augmentation were selected. The validity of the included articles was evaluated. After going through full texts, a total of 12 studies met the eligibility criteria and were included. It was concluded that endoscope-controlled maxillary sinus floor elevation was a viable and beneficial method, providing direct visualisation of the integrity of the mucosa and placing of bone graft material. The endoscope could be inserted into the maxillary sinus lumen, subantral space below the Schneiderian membrane, or through the alveolar crest. With the endoscope, perforations can be detected and managed precisely. However, high-quality clinical trials are still needed to validate the predictability and advantages of this surgical procedure.

Comparative transcriptome profile analysis of rice varieties with different tolerance to zinc deficiency

Zinc (Zn) is an indispensable element for rice growth. Zn deficiency results in brown blotches and streaks 2-3 weeks after transplanting, as well as stunting, reduced tillering, and low productivity of rice plants. These processes are controlled by different families of expressed genes. A comparative transcriptome profile analysis was conducted using the roots of two Zn deficiency tolerant varieties (UCP122 and KALIBORO26) and two sensitive varieties (IR26 and IR64) by merging data from untreated control (CK) and Zn deficiency treated samples. Results revealed a total of 4,688 differentially expressed genes (DEGs) between the normal Zn and deficient conditions, with 2,702 and 1,489 unique DEGs upregulated and downregulated, respectively. Functional enrichment analysis identified transcription factors (TFs), such as WRKY, MYB, ERF, and bHLH which are important in the regulation of the Zn deficiency response. Furthermore, chitinases, jasmonic acid, and phenylpropanoid pathways were found to be important in the Zn deficiency response. The metal tolerance protein (MTP) genes also appeared to play an important role in conferring tolerance to Zn deficiency. A heavy metal-associated domain-containing protein 7 was associated with tolerance to Zn deficiency and negatively regulated downstream genes. Collectively, our findings provide valuable expression patterns and candidate genes for the study of molecular mechanisms underlying the response to Zn deficiency and for improvements in breeding for tolerance to Zn deficiency in rice.

[Comparison of different critical care scoring systems in prognosis evaluation of heat stroke]

Objective: To evaluate the prognostic value of different critical care scoring systems in 28-day survival rate of patients with heat stroke. Methods: A retrospective analysis was conducted on the clinical data of 71 patients with heat stroke admitted to the department of emergency medicine of Beijing Luhe Hospital. Capital Medical University from July 2015 to September 2018. The general information and the worst values of vital signs and related pathophysiological indicators within 24 hours were collected and the sequential organ failure assessment (SOFA) , multiple organ dysfunction (MODS) , simplified acute physiological scoreⅡ (SAPS Ⅱ) and acute physiology and chronic health evaluationⅡ (APACHE Ⅱ) were calculated. The patients were divided into the survival group (n=45) and the non-survival group (n=26) according to 28-day prognosis, and the clinical data and scores of the two groups were compared.The ROC curve was drawn to analyze the evaluation value of each scoring system on the survival rate of patients at 28-day. Kaplan-Meier method was used to plot the survival curve of patients. Results: There were no significant differences in age, sex, vital signs and laboratory parameters between two groups (P>0.05) . In non-survival patients, SOFA, SAPS Ⅱ, APACHE Ⅱ scores were significantly elevated in the survival group (P<0.05) . ROC curve analysis showed that the area under ROC curve (AUC) of SOFA score for predicting 28-day survival rate was the highest, which was significantly higher than the APACHE Ⅱ, SAPS Ⅱ, MODS score. When the best cut-off value of SOFA score was 9.0, the sensitivity was 84.6%, and the specificity was 71.1%. Kaplan-Meier survival analysis showed that 28-day survival rate after hospital discharge in patients with SOFA score<9 (n=27) was significantly higher than that in patients with SOFA score ≥9.0 (χ(2)=1.0, P<0.01) . Conclusion: SOFA, APACHE Ⅱ, SAPS Ⅱ on admission have been proved to have good prognostic ability to predict 28-day prognosis in heat stroke patients. Among them, SOFA score system has more accurate prediction value.

Skip N2 Metastasis in Pulmonary Adenocarcinoma: Good Prognosis Similar to N1 Disease

INTRODUCTION

The prognostic effect and mechanism of skip N2 lung cancer remain unclear. Our study aimed to elucidate the influence of skip N2 on overall survival (OS) and disease-free survival (DFS) compared with N1 and non-skip N2 in patients with lung adenocarcinoma.

PATIENTS AND METHODS

Patients with lung adenocarcinoma and lymph node involvement between May 2011 and December 2015 were retrospectively analyzed. The outcomes of skip N2 patients were compared with N1 and non-skip N2 patients. Prognosis was further investigated according to the N status in different adenocarcinoma subtypes. Univariate and multivariate analyses were carried out to define independent risk factors for OS and DFS.

RESULTS

A total of 456 patients with lung adenocarcinoma, 169 with N1 disease, 81 with skip N2 disease, and 206 with non-skip N2 disease, were enrolled in this study. All tumors were invasive adenocarcinoma, and the predominant subtypes were acinar in 252, papillary in 42, solid in 119, micropapillary in 20, and invasive mucinous adenocarcinoma in 23 patients. The DFS and OS of N1 and skip N2 diseases were similar and significantly better than those of patients with non-skip N2 disease. The prognosis according to lymph node status was significantly different in acinar-predominant subtypes in terms of both OS and DFS.

CONCLUSIONS

Skip N2 disease has a similar prognosis to N1 disease and is significantly better than that of non-skip N2 disease in relation to OS and DFS. Skip N2 has a prognostic advantage in patients with the acinar-predominant subtype.

Log odds of positive lymph nodes predicts survival in patients treated with neoadjuvant therapy followed by esophagectomy

BACKGROUND AND OBJECTIVES

We aimed to evaluate the efficacy of the log odds of positive lymph nodes (LODDS) in survival prediction of patients with esophageal carcinoma receiving neoadjuvant therapy, compared with N descriptor and positive lymph node ratio (LNR).

METHODS

Patients with esophageal carcinoma receiving neoadjuvant therapy from 2004 to 2015 were reviewed in Surveillance, Epidemiology, and End Results database. The receiver operating characteristics curve and area under the curve (AUC) were used to compare discriminatory power among N descriptor, LNR, and LODDS. The goodness of fit was measured using the -2 log-likelihood ratio (-2LLR).

RESULTS

About 2239 patients with a 22 months median follow-up and a 37.8% 5-year overall survival rate were included. LODDS had the best discriminatory power and goodness of fit (LODDS vs N descriptor, AUC 0.666 vs 0.626, -2LLR 15 680.402 vs 15 746.162; LODDS vs LNR, AUC 0.666 vs 0.635, -2LLR 15 680.402 vs 15 712.379; all P < .001). LODDS was the best for fewer than 15 lymph nodes retrieved (LODDS vs N descriptor, AUC 0.652 vs 0.618, P < .001; LODDS vs LNR, AUC 0.652 vs 0.625, P = .005). The prognosis of patients without metastatic nodes could be discriminated by LODDS.

CONCLUSIONS

LODDS could better predict survival of patients with esophageal carcinoma receiving neoadjuvant therapy.

Clinical characteristics, diagnosis, treatment, and prognostic factors of pulmonary mucosa-associated lymphoid tissue-derived lymphoma

Primary pulmonary mucosa‐associated lymphoid tissue‐derived (MALT) lymphoma is a rare disease with a favorable prognosis. However, its clinical characteristics, diagnosis, treatment, and prognoses remain unclear. We retrospectively analyzed 80 patients with pathologically confirmed MALT lymphoma from 2006 to 2018. The clinical characteristics, diagnosis, treatments, and prognoses of all the 80 patients were recorded. Patients were stratified into surgery and biopsy groups, respectively, to evaluate the role of surgery in the diagnosis and treatment of MALT lymphoma. The prognoses were compared between different clinical characteristics and treatments. Pathological diagnoses were confirmed by surgery, bronchoscopy, and percutaneous biopsy. Thirty patients were treated by surgery. While MALT lymphoma was only diagnosed by bronchofiberoscopy or bercutaneous biopsy in four of 18 patients in the surgery group who underwent the procedure. Six patients received adjuvant chemotherapy and one patient received involved‐field radiotherapy in surgery group. Thirty‐one patients were treated with chemotherapy alone, one patient was treated with radiotherapy, one patient received only symptomatic and supportive treatment, and waiting and watching without treatment were recommended in 17 patients in biopsy group. Eight patients died during follow‐up and the 5‐year survival rate was 87.1%. Tumor number, treatment, and age were prognostic factors for overall survival (OS), but age was the only independent prognostic factor according to multivariate analysis. While, tumor number was the only prognostic factor in the analysis about progression‐free survival (PFS). No significant difference was found in OS or PFS between patients treated with and without surgical resection. MALT lymphoma is an indolent disease with favorable treatment outcome. Tumor number is associated with PFS and age is the only significant prognostic factor for pulmonary MALT lymphoma patients because of its indolent nature, but surgery still plays an important role in the diagnosis and treatment of MALT lymphoma.

Clinical Factors Predictive of a Better Prognosis of Pulmonary Metastasectomy for Hepatocellular Carcinoma

BACKGROUND

The lung is the most common site of extrahepatic metastasis of hepatocellular carcinoma (HCC). The aim of this study was to identify prognostic factors for pulmonary metastasectomy of HCC.

METHODS

One hundred three patients who underwent pulmonary metastasectomy for HCC between January 2005 and December 2016 were retrospectively evaluated. Patient demographic data and characteristics of the primary tumors and pulmonary metastasis were investigated to identify factors significantly correlated with prognosis.

RESULTS

Of 103 patients, 75 (72.8%) had 1 site pulmonary metastasis, 22 (21.4%) had 2, and 6 (5.8%) had 3 or more. Liver recurrence at the time of pulmonary metastasectomy was noted in 34 patients. The estimated 5-year overall survival rate was 38.5% after pulmonary metastasectomy. Univariate prognostic analysis showed that liver recurrence at the time of pulmonary metastasectomy, extent of resection, laterality of pulmonary metastasis, tumor location, number of metastatic sites, and metastatic tumor size were significantly associated with favorable overall survival after pulmonary metastasectomy. Multivariate analysis revealed that liver recurrence at the time of pulmonary metastasectomy and the number of metastatic sites were independent prognostic factors. Subgroup analysis with a combination of these 2 independent prognostic factors revealed 5-year overall survival rates for patients with 0, 1, and 2 risk factors of 58.5%, 23.8%, and 0.0%, respectively.

CONCLUSIONS

Pulmonary metastasectomy is a safe and effective treatment for well-selected patients with pulmonary metastasis of HCC. Liver recurrence at the time of pulmonary metastasectomy and the number of metastatic sites were identified as independent prognostic factors. The number of risk factors significantly influenced patient survival.

Risk and prognostic nomograms for hepatocellular carcinoma with newly-diagnosed pulmonary metastasis using SEER data

Purpose

This research aimed to identify risk factors of pulmonary metastasis (PM) from hepatocellular carcinoma (HCC) and prognostic factors of patients with PM from HCC at initial diagnosis.

Methods

Patients diagnosed with HCC between 2010 and 2015 were reviewed retrospectively in the Surveillance, Epidemiology, and End Results (SEER) database. Patients with PM from HCC at initial diagnosis were identified from the entire cohort. Predictors for PM from HCC were identified by multivariate logistic regression analysis. Independent prognostic factors for patients with PM were determined by univariate and multivariate Cox regression analysis. Nomograms were also constructed for quantifying risk of metastasis and overall survival estimation visually.

Results

Our research included 30,641 patients diagnosed with HCC, of whom 1,732 cases were with PM from HCC at initial diagnosis. The risk factors causing PM from HCC were age (P = 0.001), race (P < 0.001), primary tumor size (P < 0.001), T stage (P < 0.001), N stage (P < 0.001), alpha-fetoprotein (P < 0.001), bone metastasis (P < 0.001), brain metastasis (P < 0.001), and intrahepatic metastasis (P < 0.001). The significantly prognostic factors for overall survival were age (P = 0.014), T stage (P = 0.009), surgical approach (P < 0.001), and chemotherapy (P < 0.001). Harrell’s C-index statistics of two nomograms were 0.768 and 0.687 respectively, indicating satisfactory predictive power.

Conclusions

This research provided evaluation of risk factors and prognosis for patients with PM from HCC. Two nomograms we developed can be convenient individualized tools to facilitate clinical decision-making.

Incremental clinical and economic burden of suspected respiratory infections due to multi-drug-resistant Pseudomonas aeruginosa in the United States

BACKGROUND

Multi-drug resistant (MDR) Pseudomonas aeruginosa can negatively affect patients and hospitals.

AIM

To evaluate excess mortality and cost burden among patients hospitalized with suspected respiratory infections due to MDR P. aeruginosa vs patients with non-MDR P. aeruginosa in 78 United States (US) hospitals.

METHODS

This study analyzed electronically captured microbiological and outcomes data of patients hospitalized with non-duplicate P. aeruginosa isolates from respiratory sources collected ≥3 days after admission to identify hospital-onset MDR or non-MDR P. aeruginosa per the Centers for Disease Control and Prevention definition. The risk of multi-drug resistance was estimated on mortality, length of stay (LOS), cost, operation gain/loss, and 30-day readmission. A sensitivity analysis was conducted utilizing a cohort with pharmacy data available.

FINDINGS

Of 523 MDR and 1381 non-MDR P. aeruginosa cases, unadjusted mortality was 23.7% vs 18.0% and multi-variable-adjusted mortality was 20.0% (95% confidence interval (CI): 14.3-27.2%) vs 15.5% (95% CI: 11.2-20.9%; P=0.026), the average adjusted excess LOS was 6.7 days (P<0.001); excess cost per case was US$22,370 higher (P=0.002) and operational loss per case was US$10,661 (P=0.024) greater, and the multi-variable adjusted readmission rate was 16.2% (95% CI: 11.2-22.9%) vs 11.1% (95% CI: 7.8-15.6%; P=0.006). The sensitivity analysis yielded similar results.

CONCLUSIONS

Compared with suspected infections due to non-MDR P. aeruginosa, patients with MDR P. aeruginosa had higher risk of mortality, readmission, and longer LOS, as well as US$20,000 incremental cost and >US$10,000 incremental net loss per case after controlling for patient and hospital characteristics.

Risks of colorectal neoplasms and cardiovascular thromboembolic events after the combined use of selective COX-2 inhibitors and aspirin with 5-year follow-up: a meta-analysis

AIM

We aimed to evaluate the association between selective COX-2 inhibitors (coxibs) and the risk of colorectal neoplasms and vascular events with and without low-dose aspirin.

METHOD

We searched for randomized controlled trials and comparative studies in PubMed, EMBASE and Cochrane Library databases using pertinent key terms. Risk ratios (RRs) were calculated for each study with a fixed- or random-effects model.

RESULTS

Eight clinical studies with 44 566 subjects were eligible. The use of coxib significantly reduced the overall risk of colorectal neoplasms by 21% (RR = 0.79, 95% CI 0.70-0.89; P = 0.000). The chemopreventive effect of coxibs was beneficial in the first year (RR = 0.74, 95% CI 0.58-0.94; P = 0.013), marginal in the third year (RR = 0.79, 95% CI 0.63-1.01; P = 0.059) and counterproductive in the fifth year (RR = 1.65, 95% CI 1.23-2.21; P = 0.001). Compared with the use of aspirin alone, combined use of coxib and aspirin for 3 years increased the risk of a colorectal neoplasm by 80% in the fifth year (RR = 1.80, 95% CI 1.22-2.66; P = 0.003) but decreased by 79% and 30%, respectively, the risks of cardiovascular thromboembolic events (RR = 1.79, 95% CI 1.33-2.41; P = 0.0001) and renal impairment/hypertension (RR = 1.30, 95% CI 1.09-1.54; P = 0.003) caused by coxib use alone.

CONCLUSION

Coxibs may reduce the overall risk of colorectal neoplasms, but the chemopreventive effects are attenuated over time. When participants take low-dose aspirin simultaneously, coxibs may not be useful for chemoprevention of colorectal neoplasm.

Attributable clinical and economic burden of carbapenem-non-susceptible Gram-negative infections in patients hospitalized with complicated urinary tract infections

BACKGROUND

Gram-negative complicated urinary tract infections (cUTIs) can have serious consequences for patients and hospitals.

AIM

To examine the clinical and economic burden attributable to Gram-negative carbapenem-non-susceptible (C-NS; resistant/intermediate) infections compared with carbapenem-susceptible (C-S) infections in 78 US hospitals.

METHODS

All non-duplicate C-NS and C-S urine source isolates were analysed. A subset had principal diagnosis ICD-9-CM codes denoting cUTI. Collection time (<3 vs ≥3 days after admission) determined isolate classification as community or hospital onset. Mortality, 30-day re-admissions, length of stay (LOS), hospital cost and net gain/loss in US dollars were determined for C-NS and C-S cases, with the C-NS-attributable burden estimated through propensity score matching. Three subgroups with adequate patient numbers were analysed: cUTI principal diagnosis, community onset; other principal diagnosis, community onset; and other principal diagnosis, hospital onset.

FINDINGS

The C-NS-attributable mortality risk was significantly higher (58%) for the other principal diagnosis, hospital-onset subgroup alone (odds ratio 1.58, 95% confidence interval 1.14-2.20; P < 0.01). The C-NS-attributable risk for 30-day re-admission ranged from 29% to 55% (all P < 0.05). The average attributable economic impact of C-NS was 1.1-3.9 additional days LOS (all P < 0.05), US$1512-10,403 additional total cost (all P < 0.001) and US$1582-11,848 net loss (all P < 0.01); overall burden and C-NS-attributable burden were greatest in the other principal diagnosis, hospital-onset subgroup.

CONCLUSION

Greater clinical and economic burden was observed in propensity-score-matched patients with C-NS infections compared with C-S infections, regardless of whether cUTI was the principal diagnosis, and this burden was most severe in hospital-onset infections.

A novel three-dimensional printed guiding device for electrode implantation of sacral neuromodulation

AIM

The aim was to test the feasibility of a novel three-dimensional (3D) printed guiding device for electrode implantation of sacral neuromodulation (SNM).

METHOD

A 3D printed guiding device for electrode implantation was customized to patients' anatomy of the sacral region. Liquid photopolymer was selected as the printing material. The details of the device designation and prototype building are described. The guiding device was used in two patients who underwent SNM for intractable constipation. Details of the procedure and the outcomes are given.

RESULTS

With the help of the device, the test needle for stimulation was placed in the target sacral foramen successfully at the first attempt of puncture in both patients. The time to implant a tined SNM electrode was less than 20 min and no complications were observed. At the end of the screening phase, symptoms of constipation were relieved by more than 50% in both patients and permanent stimulation was established.

CONCLUSION

The customized 3D printed guiding device for implantation of SNM is a promising instrument that facilitates a precise and quick implantation of the electrode into the target sacral foramen.

Aberrant Thalamocortical Connectivity in Juvenile Myoclonic Epilepsy

The purpose of this study was to investigate the functional connectivity (FC) of thalamic subdivisions in patients with juvenile myoclonic epilepsy (JME). Resting state functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) data were acquired from 22 JME and 25 healthy controls. We first divided the thalamus into eight subdivisions by performing independent component analysis on tracking fibers and clustering thalamus-related FC maps. We then analyzed abnormal FC in each subdivision in JME compared with healthy controls, and we investigated their associations with clinical features. Eight thalamic sub-regions identified in the current study showed unbalanced thalamic FC in JME: decreased FC with the superior frontal gyrus and enhanced FC with the supplementary motor area in the posterior thalamus increased thalamic FC with the salience network (SN) and reduced FC with the default mode network (DMN). Abnormalities in thalamo-prefrontocortical networks might be related to the propagation of generalized spikes with frontocentral predominance in JME, and the network connectivity differences with the SN and DMN might be implicated in emotional and cognitive defects in JME. JME was also associated with enhanced FC among thalamic sub-regions and with the basal ganglia and cerebellum, suggesting the regulatory role of subcortical nuclei and the cerebellum on the thalamo-cortical circuit. Additionally, increased FC with the pallidum was positive related with the duration of disease. The present study provides emerging evidence of FC to understand that specific thalamic subdivisions contribute to the abnormalities of thalamic-cortical networks in JME. Moreover, the posterior thalamus could play a crucial role in generalized epileptic activity in JME.

Abstract P5-16-07: Non-anthracycline-containing docetaxel plus cyclophosphomide was inferior to docetaxel, anthracycline and cyclophosphomide in neoadjuvant treatment of triple negative or HER2 positive breast cancer: Long term follow-up result from NATT study

This abstract was not presented at the symposium.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Cyclin G2 inhibits epithelial-to-mesenchymal transition by disrupting Wnt/β-catenin signaling

Epithelial ovarian cancer (EOC) has the highest mortality rate among gynecological malignancies owing to poor screening methods, non-specific symptoms and limited knowledge of the cellular targets that contribute to the disease. Cyclin G2 is an unconventional cyclin that acts to oppose cell cycle progression. Dysregulation of the cyclin G2 gene (CCNG2) in a variety of human cancers has been reported; however, the role of cyclin G2 in tumorigenesis remains unclear. In this study, we investigated the function of cyclin G2 in EOC. In vitro and in vivo studies using several EOC-derived tumor cell lines revealed that cyclin G2 inhibited cell proliferation, migration, invasion and spheroid formation, as well as tumor formation and invasion. By interrogating cDNA microarray data sets, we found that CCGN2 mRNA is reduced in several large cohorts of human ovarian carcinoma when compared with normal ovarian surface epithelium or borderline tumors of the ovary. Mechanistically, cyclin G2 was found to suppress epithelial-to-mesenchymal transition (EMT), as demonstrated by the differential regulation of various EMT genes, such as Snail, Slug, vimentin and E-cadherin. Moreover, cyclin G2 potently suppressed the Wnt/β-catenin signaling pathway by downregulating key Wnt components, namely LRP6, DVL2 and β-catenin, which could be linked to inhibition of EMT. Taken together, our novel findings demonstrate that cyclin G2 has potent tumor-suppressive effects in EOCs by inhibiting EMT through attenuating Wnt/β-catenin signaling.

Feeding glycerol-enriched yeast culture improves lactation performance, energy status, and hepatic gluconeogenic enzyme expression of dairy cows during the transition period

This study aimed to evaluate the effects of feeding glycerol-enriched yeast culture (GY) on feed intake, lactation performance, blood metabolites, and expression of some key hepatic gluconeogenic enzymes in dairy cows during the transition period. Forty-four multiparous transition Holstein cows were blocked by parity, previous 305-d mature equivalent milk yield, and expected calving date and randomly allocated to 4 dietary treatments: Control (no additive), 2 L/d of GY (75.8 g/L glycerol and 15.3 g/L yeast), 150 g/d of glycerol (G; 0.998 g/g glycerol), and 1 L/d of yeast culture (Y; 31.1 g/L yeast). All additives were top-dressed and hand mixed into the upper one-third of the total mixed ration in the morning from -14 to +28 d relative to calving. Results indicated that the DMI, NE intake, change of BCS, and milk yields were not affected by the treatments ( > 0.05). Supplementation of GY or Y increased milk fat percentages, milk protein percentages, and milk protein yields relative to the Control or G group ( < 0.05). Cows fed GY or G had higher glucose levels and lower β-hydroxybutyric acid (BHBA) and NEFA levels in plasma than cows fed the Control ( < 0.05) and had lower NEFA levels than cows fed Y ( < 0.05). On 14 d postpartum, cows fed GY or G had higher enzyme activities, mRNA, and protein expression of cytosolic phosphoenolpyruvate carboxykinase (PEPCK-C; < 0.05); higher enzyme activities ( < 0.05) and a tendency toward higher mRNA expression ( < 0.10) of glycerol kinase (GK); and a tendency toward higher enzyme activities of pyruvate carboxylase (PC) in the liver ( < 0.10) when compared with cows fed Control or Y. The enzyme activities, mRNA, and protein expression of PEPCK-C, PC, and GK did not differ between cows fed GY and G ( > 0.10). In conclusion, dietary GY or Y supplementation increased the milk fat and protein content of the cows in early lactation and GY or G supplementation improved the energy status as indicated by greater plasma glucose and lower plasma BHBA and NEFA concentrations and upregulated the hepatic gluconeogenic enzymes of dairy cows during the transition period. Feeding cows with a GY mixture in the peripartum period combined the effects of yeast on lactation performance and the effects of glycerol on energy status in dairy cows.

Role of thalamic nuclei in the modulation of Fos expression within the cerebral cortex during hypertonic saline-induced muscle nociception

It has been proposed that thalamic mediodorsal (MD) and ventromedial (VM) nuclei form thalamic 'nociceptive discriminators' in discrimination of nociceptive afferents, and specifically govern endogenous descending facilitation and inhibition. The present study conducted in rats was to explore the role of thalamic MD and VM nuclei in modulation of cerebral neuronal activities by means of detection of spatiotemporal variations of Fos expression within the cerebral cortex. Following a unilateral intramuscular injection of 5.8% saline into the gastrocnemius muscle, Fos expression within the bilateral, different areas of the cerebral cortex except S2 was significantly increased (P<0.05). Particularly, the increases in Fos expression within the cingulate cortex and the insular cortex occurred at 0.5h, 4h and reached the peak level at 4h, 16h, respectively. Electrolytic lesion of the contralateral thalamic MD and VM nuclei significantly blocked the 5.8% saline intramuscularly induced increases in Fos expression within the bilateral cingulate and insular cortices, respectively. Additionally, the 5.8% saline-induced Fos expression in the cingulate cortex and the insular cortex were dose-dependently attenuated by microinjection of μ-opioid antagonist β-funaltrexamine hydrochloride into the thalamic MD and VM nuclei. It is suggested that (1) the neural circuits of 'thalamic MD nucleus - cingulate cortex' and 'thalamic VM nucleus - insular cortex' form two distinct pathways in the endogenous control of nociception, (2) mirror or contralateral pain is hypothesized to be related to cross-talk of neuronal activities within the bilateral cerebral cortices modulated by μ-opioid receptors within the thalamic MD and VM nuclei.

Feeding glycerol-enriched yeast culture improves performance, energy status, and heat shock protein gene expression of lactating Holstein cows under heat stress

This study was conducted to evaluate the effects of supplemental common yeast culture (CY) and glycerol-enriched yeast culture (GY) on performance, plasma metabolites, antioxidant status, and heat shock protein 70 (HSP70) mRNA expression in lactating Holstein cows under heat stress. During summer months, 30 healthy multiparous lactating cows (parity 3.25 ± 0.48; 60 ± 13 d in milk [DIM]; 648 ± 57 kg BW; an average milk yield of 33.8 ± 1.6 kg/d) were blocked by parity, previous milk yield, and DIM and randomly allocated to 3 dietary treatments: no supplemental yeast culture (Control), 1 L/d of CY (33.1 g yeast) per cow, and 2 L/d of GY (153.2 g glycerol and 31.6 g yeast) per cow. During the 60-d experiment, values of air temperature and relative humidity inside the barn were recorded hourly every 3 d to calculate temperature-humidity index (THI). Weekly rectal temperatures (RT) and respiration rates and daily DMI and milk yield were recorded for all cows. Milk and blood samples were taken twice monthly, and BW and BCS were obtained on d 0 and 60. In this experiment, THI values indicated cows experienced a moderate heat stress. Cows supplemented with CY and GY had greater yields of milk, energy-corrected milk and milk fat, and milk fat percent but lower HSP70 mRNA expression in peripheral blood lymphocytes than Control cows (P < 0.05). Supplementing CY and GY tended (P < 0.15) to decrease RT at 1400 h, increase milk protein yield and erythrocyte glutathione, and reduce plasma urea nitrogen compared with Control. Lower plasma NEFA concentration and HSP70 mRNA expression in peripheral blood lymphocytes (P < 0.05) and tendencies towards greater plasma glucose concentration (P = 0.11) but less BW loss (P = 0.14) were observed in GY relative to CY cows. In conclusion, either CY or GY supplementation partially mitigated the negative effects of heat stress on performance and HSP70 mRNA expression of lactating cows, and GY supplementation provided additional improvements in energy status and HSP70 gene expression of lactating cows.

Gene expression profile and enrichment pathways in different stages of bladder cancer

Bladder cancer is a highly heterogeneous neoplasm. We examined the gene expression profile in 3 bladder cancer stages (Ta, T1, T2) using expression microarray analysis of 40 bladder tumors. Differentially expressed genes were found by the t-test, with <0.005 as the significance threshold. KEGG pathway-enrichment analysis was used to study the signaling pathways of the genes. We found 36 genes that could be used as molecular markers for predicting the transition from Ta-T1 to T1-T2. Among these, 11 overlapped between Ta-T1 and T1-T2 stages. Six genes were down-regulated at the Ta-T1 stage, but were up-regulated at the T1-T2 stage (ANXA5, ATP6V1B2, CTGF, GEM, IL13RA1, and LCP1); 5 genes were up-regulated at the Ta-T1 stage, but down-regulated at the T1-T2 stage (ACPP, GNL1, RIPK1, RAPGEF3, and ZER1). Another 25 genes changed relative expression levels at the T1-T2 stage. These genes (including COL1A1, COL1A2, FN1, ITGA5, LGALS1, SPP1, VIM, POSTN, and COL18A1) may be involved in bladder cancer progression by affecting extracellular matrix-receptor interaction and focal adhesion. The cytokine-cytokine receptor interaction, neuroactive ligand-receptor interaction, and calcium-signaling pathway were associated with bladder cancer progression at both the Ta-T1 and T1-T2 stages.

Comparison of the pharmacokinetics of imipenem after intravenous and intrathecal administration in rabbits

BACKGROUND

Intrathecal administration of antibiotics has potentially high effectiveness for the treatment for severe intracranial infections, particularly nosocomial meningitis. The use of intrathecal injection of antibiotics has been reported mostly in case reports. However, there is sparse data regarding the pharmacokinetics of antibiotics after intrathecal administration.

AIM

This study investigated whether intrathecal injection is an effective method for the administration of imipenem.

MATERIALS AND METHODS

The pharmacokinetics of imipenem after intrathecal and intravenous administration of 1:1 imipenem: cilastatin (IMI/CIL) to rabbits were compared.

RESULTS

The AUC0-t in the cerebrospinal fluid for intrathecal administration was approximately twice that of an equal dose of intravenous administration at doses of 0.35, 0.7, and 1.4 mg/kg. Brain concentrations of imipenem after intrathecal injection were three times greater than observed after intravenous injection and remained high for at least 8 hours post-injection. Elimination of imipenem after administration by either route was primarily via urine, but a transient surge of imipenem in bile and intestinal tissue was observed.

CONCLUSIONS

Results indicate that there is a clinical potential for intrathecally administered IMI/CIL. Further studies are warranted to investigate the potential for seizure and to assess the translatability of the rabbit model to human treatment.

RNAi-mediated knockdown of pituitary tumor- transforming gene-1 (PTTG1) suppresses the proliferation and invasive potential of PC3 human prostate cancer cells

Pituitary tumor-transforming gene-1 (PTTG1) is a proto-oncogene that promotes tumorigenesis and metastasis in numerous cell types and is overexpressed in a variety of human tumors. We have demonstrated that PTTG1 expression was up-regulated in both human prostate cancer specimens and prostate cancer cell lines. For a more direct assessment of the function of PTTG1 in prostate tumorigenesis, RNAi-mediated knockdown was used to selectively decrease PTTG1 expression in PC3 human prostate tumor cells. After three weeks of selection, colonies stably transfected with PTTG1-targeted RNAi (the knockdown PC3 cell line) or empty vector (the control PC3 cell line) were selected and expanded to investigate the role of PTTG1 expression in PC3 cell growth and invasion. Cell proliferation rate was significantly slower (28%) in the PTTG1 knockdown line after 6 days of growth as indicated by an MTT cell viability assay (P < 0.05). Similarly, a soft agar colony formation assay revealed significantly fewer (66.7%) PTTG1 knockdown PC3 cell colonies than control colonies after three weeks of growth. In addition, PTTG1 knockdown resulted in cell cycle arrest at G1 as indicated by fluorescence-activated cell sorting. The PTTG1 knockdown PC3 cell line also exhibited significantly reduced migration through Matrigel in a transwell assay of invasive potential, and down-regulation of PTTG1 could lead to increased sensitivity of these prostate cancer cells to a commonly used anticancer drug, taxol. Thus, PTTG1 expression is crucial for PC3 cell proliferation and invasion, and could be a promising new target for prostate cancer therapy.

Genetic map construction and QTL mapping of resistance to blackleg (Leptosphaeria maculans) disease in Australian canola (Brassica napus L.) cultivars

Genetic map construction and identification of quantitative trait loci (QTLs) for blackleg resistance were performed for four mapping populations derived from five different canola source cultivars. Three of the populations were generated from crosses between single genotypes from the blackleg-resistant cultivars Caiman, Camberra and (AV)Sapphire and the blackleg-susceptible cultivar Westar(10). The fourth population was derived from a cross between genotypes from two blackleg resistant varieties (Rainbow and (AV)Sapphire). Different types of DNA-based markers were designed and characterised from a collection of 20,000 EST sequences generated from multiple Brassica species, including a new set of 445 EST-SSR markers of high value to the international community. Multiple molecular genetic marker systems were used to construct linkage maps with locus numbers varying between 219 and 468, and coverage ranging from 1173 to 1800 cM. The proportion of polymorphic markers assigned to map locations varied from 70 to 89% across the four populations. Publicly available simple sequence repeat markers were used to assign linkage groups to reference nomenclature, and a sub-set of mapped markers were also screened on the Tapidor x Ningyou (T x N) reference population to assist this process. QTL analysis was performed based on percentage survival at low and high disease pressure sites. Multiple QTLs were identified across the four mapping populations, accounting for 13-33% of phenotypic variance (V (p)). QTL-linked marker data are suitable for implementation in breeding for disease resistance in Australian canola cultivars. However, the likelihood of shifts in pathogen race structure across different geographical locations may have implications for the long-term durability of such associations.

Genetic and QTL analyses of seed dormancy and preharvest sprouting resistance in the wheat germplasm CN10955

The inheritance and genetic linkage analysis for seed dormancy and preharvest sprouting (PHS) resistance were carried out in an F8 recombinant inbred lines (RILs) derived from the cross between "CN19055" (white-grained, PHS-resistant) with locally adapted Australian cultivar "Annuello" (white-grained, PHS-susceptible). Seed dormancy was assessed as germination index (GI7) while assessment for preharvest sprouting resistance was based on whole head assay (sprouting index, SI) and visibly sprouted seeds (VI). Segregation analysis of the F2, F3 data from the glasshouse and the RIL population in 2004 and 2005 field data sets indicated that seed dormancy and PHS resistance in CN19055 is controlled by at least two genes. Heritabilities for GI7 and VI were high and moderate for SI. The most accurate method for assessing PHS resistance was achieved using VI and GI7 while SI exhibited large genotype by environment interaction. Two quantitative trait loci (QTLs) QPhs.dpivic.4A.1 and QPhs.dpivic.4A.2 were identified. On pooled data across four environments, the major QTL, QPhs.dpivic.4A.2, explained 45% of phenotypic variation for GI7, 43% for VI and 20% for SI, respectively. On the other hand, QPhs.dpivic.4A.1 which accounted for 31% of the phenotypic variation in GI7 in 2004 Horsham field trial, was not stable across environments. Physical mapping of two SSR markers, Xgwm937 and Xgwm894 linked to the major QTL for PHS resistance, using Chinese Spring deletions lines for chromosome 4AS and 4AL revealed that the markers were located in the deletion bins 4AL-12 and 4AL-13. The newly identified SSR markers (Xgwm937/Xgwm894) showed strong association with seed dormancy and PHS resistance in a range of wheat lines reputed to possess PHS resistance. The results suggest that Xgwm937/Xgwm894 could be used in marker-assisted selection (MAS) for incorporating preharvest sprouting resistance into elite wheat cultivars susceptible to PHS.

Designing an optimal marker-based pedigree selection strategy for parent building in barley in the presence of repulsion linkage, using computer simulation

Pyramiding multiple desirable genes is an important method for the development of improved breeding materials and/or new cultivars. When the number of genes to be pyramided is many, or the genes are tightly linked in repulsion, it is practically impossible to recover the desirable recombinants in a single generation using a realistic population size, and repeated selection at several generations is required. The availability of markers tightly linked to the desirable genes makes it possible to conduct effective individual selection at early generations. This reduces the number of lines tested in the later generations and increases the desirable genotype frequency in the selected progeny. Computer simulation was used to develop such a marker-based pedigree selection strategy for the development of a barley line that contains 6 desired genes from 3 parental breeding lines (HS078 (H): 221222; PI366444 (P): 212222; Sloop Vic. (S): 122111; with 1 and 2 representing desirable and undesirable alleles, respectively), using the top cross H/P//S. The 6 genes targetted contribute to photoperiod sensitivity, Russian wheat aphid resistance, leaf rust resistance, boron tolerance, earliness per se, and cereal cyst nematode resistance. Under the assumption that perfect markers were available for all the 6 genes, a TC1 population of 300 plants was required to obtain 3 or more lines of the best genotype ‘211222/122111’, in which 3 loci were fixed for the desirable alleles, while the remaining 3 were kept as heterozygous. When single seed descent was used from the TC2 generation until complete homozygosity, the probability of obtaining lines of the desirable genotype (fixed for the desirable alleles at all 6 loci) was low due to the tight repulsion linkage between some of the genes. About 4000 individuals would be required to ensure with 99% probability the recovery of at least 1 line with the desirable genotype. The total number of lines that would need to be genotyped would be at least 5000. When the pedigree method was used in all test-cross generations, many schemes resulted in more lines of the fixed desirable genotype by genotyping fewer lines. The various options were compared using the genetic simulation software module QuLine, based on the QU-GENE simulation platform. The optimum scheme in terms of high success rate and relatively low genotyping costs consisted of the following steps: (1) in TC1 genotyping of 300 individuals allows for 3 or more individuals with the genotype ‘211222/122111’ to be identified; (2) in the TC2 individuals that are fixed for 3 loci and segregating for the remaining 3, loci can be selected from among 500 TC2 plants; (3) in the TC3, 50 or more individuals per TC3 line are genotyped for the 3 segregating loci, and individuals fixed for 5 loci and segregating for the 6th locus can be detected (genotyping is only needed for the segregating loci); (4) 25 individuals per TC4 line are genotyped for the single remaining segregating locus and several individuals of the desirable genotype (111111/111111) are finally selected. The desirable line is then obtained by collecting selfed seed from the selected TC4 plants. Using this scheme, on average, 320 desired TC5 lines were obtained by genotyping fewer than 2000 lines. When markers were tightly linked to the target genes but not diagnostic (perfect), not only was more genotyping required, but also appropriate phenotyping at the end of the marker selection process was necessary to confirm the presence of all the target genes. Under the assumption that recombination between marker and target gene was 5%, the best selection scheme identified, on average, 30 fixed desirable lines by genotyping 8000 lines and phenotyping 700 TC5 lines. If double haploid lines were produced from the F1 generation between H and P, and marker and phenotypic screening were conducted, followed by crossing of the individual with the target 2 loci in desired homozygous allelic status with parent S, the total amount of genotyping and phenotyping could be halved. This study showed that genetic simulation allows for numerous strategies to be compared using real data, and to develop an optimal crossing and selection strategy to combine desired alleles in the most effective and efficient way. This approach could likewise be used in other marker-assisted breeding programs.