Corrigendum: Korean treatment recommendations for patients with axial spondyloarthritis

[This corrects the article on p. 151 in vol. 30, PMID: 37476674.].

Immunoglobulin G4-related hypertrophic pachymeningitis with an isolated scalp mass mimicking a brain tumor: a case report and literature review

Immunoglobulin G4-related disease (IgG4-RD) is an autoimmune disorder associated with fibroinflammatory conditions that can affect multiple organs. Hallmark histopathological findings of IgG4-RD include lymphocytic infiltration of IgG4-positive plasma cells, storiform fibrosis, and obliterative phlebitis. However, little is known about central nervous system involvement of IgG4-RD. Hypertrophic pachymeningitis (HP) has recently been reported as a manifestation of IgG4-RD, which may have previously been demonstrated in a significant percentage of idiopathic cases. Herein, we report a rare case of a 63-year-old male who presented with a scalp mass that mimicked a brain tumor. He was diagnosed with IgG4-related HP (IgG4-RP) after surgery. This case suggests that awareness of a possibility of IgG4-RP in patients with isolated scalp masses, even in the absence of systemic symptoms, is crucial. A combination of careful history taking, evaluation of serum IgG4-levels and imaging as an initial work-up, followed by tissue biopsy, is important for the differential diagnosis of IgG4-RP, malignancy, and other infectious diseases.

Paradigm shift towards emergency cholecystectomy: one site experience of the Chole-QuiC process

INTRODUCTION

Substantial evidence exists for the superiority of emergency over delayed cholecystectomy for gallstone disease during primary admission. Despite this, emergency surgery rates in the UK remain low compared with other developed countries, with great variation in care across the nation. We aimed to describe the local paradigm shift towards emergency surgery and investigate outcomes.

METHODS

This is a prospective observational study examining patients enrolled onto an emergency cholecystectomy pathway, following the hospital's subscription to the Royal College of Surgeons of England's Cholecystectomy Quality Improvement Collaborative (Chole-QuIC), between 1 December 2021 and 31 January 2023. Multivariate logistical regression models were used to identify patient and hospital factors associated with postoperative outcomes.

RESULTS

Of the 307 suitable acute admissions, 261 (85%) had an emergency cholecystectomy, compared with 5% preceding the Chole-QuIC interventions. Waiting time dropped from 67 to 5 days. A total of 208 (79.7%) patients were primary presentations, 92 (35.2%) were classed Tokyo grade 2 and 142 (54.4%) were obese. A total of 23 (8.8%) patients underwent preoperative endoscopic retrograde cholangiopancreatography, and 26 (10%) patients had a subtotal cholecystectomy. Favourable outcomes (Clavien Dindo ≥3) were observed in first presentations (odds ratio (OR) 0.35; p=0.042) and for operation times within 7 days (OR 0.32; p=0.037), with worse outcomes in BMI ≥35 (OR 3.32; p=0.005) and operation time >7 days (OR 3.11; p=0.037).

CONCLUSION

A paradigm shift towards emergency cholecystectomy benefits both the patient and the service. Positive outcomes are apparent for early operation in patients presenting for the first time and recurrent attendees, with early operation (<7 days) providing the most favourable outcome in a select patient group.

Quantitative interstitial lung disease scores in idiopathic inflammatory myopathies: longitudinal changes and clinical implications

OBJECTIVES

To investigate computer-aided quantitative scores from high-resolution CT (HRCT) images and determine their longitudinal changes and clinical significance in patients with idiopathic inflammatory myopathies (IIMs)-related interstitial lung disease (IIMs-ILD).

METHODS

The clinical data and HRCT images of 80 patients with IIMs who underwent serial HRCT scans at least twice were retrospectively analysed. Quantitative ILD (QILD) scores (%) were calculated as the sum of the extent of lung fibrosis, ground-glass opacity, and honeycombing. The individual time-estimated ΔQILD between two consecutive scans was derived using a linear approximation of yearly changes.

RESULTS

The baseline median QILD (interquartile range) scores in the whole lung were 28.1% (19.1-43.8). The QILD was significantly correlated with forced vital capacity (r = -0.349, P = 0.002) and diffusing capacity for carbon monoxide (r = -0.381, P = 0.001). For ΔQILD between the first two scans, according to the visual ILD subtype, QILD aggravation was more frequent in patients with usual interstitial pneumonia (UIP) than non-UIP (80.0% vs 44.4%, P = 0.013). Multivariable logistic regression analyses identified UIP was significantly related to radiographic ILD progression (ΔQILD >2%, P = 0.015). Patients with higher baseline QILD scores (>28.1%) had a higher risk of lung transplantation or death (P = 0.015). In the analysis of three serial HRCT scans (n = 41), dynamic ΔQILD with four distinct patterns (improving, worsening, convex and concave) was observed.

CONCLUSION

QILD changes in IIMs-ILD were dynamic, and baseline UIP patterns seemed to be related to a longitudinal progression in QILD. These may be potential imaging biomarkers for lung function, changes in ILD severity and prognosis in IIMs-ILD.

Replica symmetry broken states of some glass models

We have studied in detail the M-p balanced spin-glass model, especially the case p=4. These types of model have relevance to structural glasses. The models possess two kinds of broken replica states; those with one-step replica symmetry breaking (1RSB) and those with full replica symmetry breaking (FRSB). To determine which arises requires studying the Landau expansion to quintic order. There are nine quintic-order coefficients, and five quartic-order coefficients, whose values we determine for this model. We show that it is only for 2≤M<2.4714⋯ that the transition at mean-field level is to a state with FRSB, while for larger M values there is either a continuous transition to a state with 1RSB (when M≤3) or a discontinuous transition for M>3. The Gardner transition from a 1RSB state at low temperatures to a state with FRSB also requires the Landau expansion to be taken to quintic order. Our result for the form of FRSB in the Gardner phase is similar to that found when 2≤M<2.4714⋯, but differs from that given in the early paper of Gross et al. [Phys. Rev. Lett. 55, 304 (1985)0031-900710.1103/PhysRevLett.55.304]. Finally we discuss the effects of fluctuations on our mean-field solutions using the scheme of Höller and Read [Phys. Rev. E 101, 042114 (2020)2470-004510.1103/PhysRevE.101.042114] and argue that such fluctuations will remove both the continuous 1RSB transition and discontinuous 1RSB transitions when 8>d≥6 leaving just the FRSB continuous transition. We suggest values for M and p which might be used in simulations to confirm whether fluctuation corrections do indeed remove the 1RSB transitions.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and Kmbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5-12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13-16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Korean treatment recommendations for patients with axial spondyloarthritis

We aimed to develop evidence-based recommendations for treating axial spondylarthritis (axSpA) in Korea. The development committee was constructed, key clinical questions were determined, and the evidence was searched through online databases including MEDLINE, Embase, Cochrane, KoreaMed, and KMbase. Systematic literature reviews were conducted, quality of evidence was determined, and draft recommendations were formulated according to the Grading of Recommendations Assessment, Development, and Evaluations methodology. Recommendations that reached 80% consensus among a voting panel were finalized. Three principles and 21 recommendations were determined. Recommendations 1 and 2 pertain to treatment strategies, regular disease status assessment, and rheumatologist-steered multidisciplinary management. Recommendations 3 and 4 strongly recommend patient education, exercise, and smoking cessation. Recommendations 5~12 address pharmacological treatment of active disease using nonsteroidal anti-inflammatory drugs, glucocorticoids, sulfasalazine, biologics, and Janus kinase inhibitors. Recommendations 13~16 address treatment in stable disease. We suggest against spa and acupuncture as therapies (Recommendation 17). Recommendations 18 and 19 pertain to total hip arthroplasty and spinal surgery. Monitoring of comorbidities and drug toxicities are recommended (Recommendations 20 and 21). Recommendations for axSpA treatment in a Korean context were developed based on comprehensive clinical questions and evidence. These are intended to guide best practice in the treatment of axSpA.

Cardiovascular structure and function assessed by MRI in healthy South Asians compared to White Europeans: a UK Biobank study

Background

There is limited data on ethnic specific comparisons for measures of cardiovascular structure and function in healthy cohorts. Echocardiographic data indicate South Asian's (SAs) have smaller mass and evidence of more concentric remodelling compared to White Europeans (WEs). Furthermore, there is no data published for strain or strain rates.

Purpose

To compare Cardiac Magnetic Resonance (CMR) derived measures of structure and function between age and sex matched healthy SAs and WEs from the UK biobank cohort.

Methods

South Asian and WE participants from the UK Biobank who underwent CMR imaging were included. Individuals with a history of cardiovascular disease, hypertension, obesity (BMI ≥30 kg/m2 in WEs and ≥27 kg/m2 in SAs) and diabetes were excluded. Ethnic groups were matched according to age and sex at recruitment. Cine images (bSSFP) were analysed blinded to participant details using commercially available software. Left ventricular (LV) mass, LV volumes, global longitudinal and circumferential systolic strain (GLS and GCS), together with peak early diastolic strain rates (PEDSR), were obtained. Data distributions were assessed and T-Test or Man Whitney U conducted as appropriate.

Results

Datasets from the UK biobank were screened (n=45000). After applying exclusion criteria, 111 pairs of matched SAs and WEs were available for analysis (n=69 male and n=42 female matched pairs). Mean age of the entire cohort was 58±8 years. Data has been corrected according to body surface area (BSA),(males: WE 2.0±0.1 vs SA 1.8±0.1 m2, p≤0.001; females: WE 1.7±0.2 vs SA 1.6±0.1 m2, p≤0.001). There was no difference in heart rate (males: WE 64.5±9.3 vs SA 65.8±9.6 bpm, p=0.113; females: WE 66.2±7.8 vs SA 69.5±10.3 bpm, p=0.125). Results by sex and ethnicity are displayed in table 1. In males there was no difference in ejection fraction (EF) or indexed LV end diastolic volume (LVEDV). However indexed mass and mass/volume ratio were significantly lower in SAs, and GLS but not GCS was significantly higher than in SAs. Longitudinal PEDSR were significantly higher in SAs than in WE. By contrast, SA females had significantly lower EF with no difference in indexed LVEDV compared to WE females. However, as seen with the males SA females had significantly lower indexed LV mass and mass/volume ratio compared to WE females. Finally, both GLS and GCS were significantly higher in SAs compared to WE females, whereas there was no difference in longitudinal PEDSR.

Conclusion

Substantial differences in cardiovascular structure and function exist between SA and WE ethnic groups, in both men and women. Contrary to previous echocardiographic studies, LV volumes were similar between ethnicities and SA have less, not increased, concentric remodelling than WE. These findings highlight the need for ethnicity and sex-specific healthy reference ranges derived from CMR.

Funding Acknowledgement

Type of funding sources: None.

Proliferative Vasculopathy Associated With Antiphospholipid Antibodies in Patients With Neurological Symptoms

Background

Proliferative vasculopathy (PV) associated antiphospholipid syndrome (APS) in the central nervous system is a rare un(der)recognized form of extra-criteria manifestations of APS. This study investigated the angiographic characteristics of cerebral and cervical arteries in patients with PV associated with antiphospholipid antibodies (aPLs).

Methods

Patients with aPLs, neurologic symptoms and diffuse luminal narrowing on brain or neck magnetic resonance angiography were selected from electronic medical records. Vascular wall and intraluminal pathology were examined by high-resolution vessel wall MR imaging (VW-MRI).

Results

A total of 11 patients (six men and five women) with PV-aPL, of median (interquartile range) age 42 (34–61) years, were included. Median anticardiolipin antibodies IgG titer was 78.9 (28.2–134.0) units and anti-beta 2 glycoprotein I antibodies (aB2GPIs) IgG titer was 227.2 (0.0–1012.1) units. All patients had diffuse luminal narrowing in the carotid basilar and/or cerebral arteries, five in the internal carotid artery (ICA); two each in the middle cerebral artery (MCA) and vertebral artery; and one each in the basilar artery (BA) and posterior cerebral artery. On VW-MRI, four patients showed concentric thickening of the vascular walls of the ICA and/or MCA and two showed mild eccentric wall thickening of the ICA or BA. All patients received antithrombotic treatment. In two patients with extremely high aB2GPIs titer, diffuse narrowing progressed despite treatment with antithrombotic agents on follow-up imaging.

Conclusions

This study suggests that PV-aPL might be a distinct extra-criteria manifestation of APS that can manifest as long-segmental diffuse stenosis of cerebral and cervical arteries. It should be considered in relatively young patients with neurologic symptoms and aPLs.

POS0942 DEVELOPMENT OF PREDICTION MODEL FOR FLARE AFTER TAPERING OF TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background

Tumor necrosis factor inhibitors (TNFi) have become a mainstay of management for axial spondyloarthritis (axSpA). However, it remains unclear whether patients with axSpA should continue the standard-dose TNFi after achieving stable disease activity. Although complete discontinuation of TNFi is followed by early relapse in most cases, several studies documented that reduced doses of TNFi in patients with prolonged low disease activity showed similar effects on disease control and drug survival compared to standard dose of TNFi. One of the main problem in the dose-tapering strategies for TNFi is a selection of the appropriate patient. However, there has been a lack of robust evidence regarding clinical factors predicting the flare after tapering of TNFi in patients with axSpA.

Objectives

This study aims to develop and validate the prediction model to select the patients in whom tapering of TNFi does not lead to flare.

Methods

We used the data from Korean College of Rheumatology Biologics registry, which included a total of 1,730 patients receiving biologic DMARD from 2017 to 2019 in South Korea. In this study, a total of 526 patients who were initially treated with the standard-dose TNFi and tapered the dose after at least 1 year of the treatment were analyzed. Dose quotient (DQ, 0-1) was applied to quantified TNFi used during interval. The main outcome was an occurrence of flare defined as ASDAS-CRP score of ≥2.1 after 1 year of tapering TNFi. To develop the prediction model, clinical factors having relevant association (p < 0.1) with the outcome were first selected as candidate predictors. Logistic regression using a stepwise approach through backward elimination was used for the final model.

Results

Patients’ mean (SD) age was 37.5 (11.9) years, 418 (79.5%) were men, and 474 (90.1%) were HLA-B27 positive. Mean disease duration was 5.0 (6.1) years and 433 (82.3%) were TNF naïve. The mean BASFI and ASDAS-CRP at baseline were 3.4 (2.6) and 3.7 (1.0), respectively. Approximately two-thirds of the patients (65.8%) were initiated TNFi tapering at the first 1 or 2 years from baseline. At the time of TNFi tapering, the mean DQ was 0.67 (0.15) and 381 (72.4%) were prescribed concurrently with NSAIDs, and the mean BASFI and ASDAS-CRP were 1.3 (1.8) and 1.6 (0.9), respectively. During 12 months of follow up starting from the TNFi tapering, 127 (24.1%) experienced the flare. The multivariable analysis revealed that HLA-B27 positivity (OR 0.337; 95% CI 0.161-0.705; p=0.004), inflammatory back pain (OR 2.920; 95% CI 1.283-6.648; p=0.011), ASDAS-CRP at tapering (OR 2.798; 95% CI 2.030-3.856; p<0.001), and BASFI at tapering (OR 1.214; 95% CI 1.051-1.402; p=0.008) were significantly associated with flare. Based on the results of the logistic regression analysis, the predicted probability was calculated by the following formula: P=1/[1+ exp{-(1.088 x HLA-B27 negativity + 1.072 x inflammatory back pain + 1.567 x psoriasis + 0.623 x family history of axSpA + 1.092 x diabetes mellitus + 0.435 x DQ at TNFi tapering + 1.029 x ASDAS-CRP at TNFi tapering + 0.194 x BASFI at TNFi tapering)}]. The best cut-off value of the model to define the flare was 0.2416 (95% CI 0.176, 0.301) with sensitivity 74.0% and with specificity 81.0%. AUC was 0.828 (95% CI 0.786-0.869) indicating a good predication (Figure 1). The internal validation with bootstrapping showed minimal overfitting (estimated AUC 0.794) and good calibration between observed and predicted values (calibration slope 1.110, 95% CI 0.903, 1.317; intercept 0.026, 95% CI -0.091, 0.039).

Figure 1.

Apparent performance of developed model for prediction of flare after 12 months of tumor necrosis factor inhibitors tapering.

Conclusion

We developed the prediction model for the flare after 12 months of TNFi tapering in patients with axSpA. It might be applicable in real world setting, although external validation will be required in the future investigation.

References

[1]Zavada J, et al. Ann Rheum Dis. 2016;75(1):96-102.

Acknowledgements

We greatly thank to the the Clinical Research Committee of the Korean College of Rheumatology and all participating hospitals.

Disclosure of Interests

None declared

POS0068 CHANGES IN QUANTITATIVE INTERSTITIAL LUNG DISEASE SCORES ON HIGH-RESOLUTION CT IN IDIOPATHIC INFLAMMATORY MYOSITIS

Background

The idiopathic inflammatory myopathies (IIM) are autoimmune connective tissue diseases affecting skeletal muscle, skin and other organ systems. IIM-related interstitial lung disease (IIM-ILD) is the most common extra-muscular manifestation, being the leading cause of morbidity and mortality. Several studies have suggested that ILD pattern based on chest high-resolution computed tomography (HRCT) can be related to disease course and treatment response, but the results vary considerably. Moreover, the clinical impact of the quantitative ILD (QILD) score, a validated computer-aided scoring system in assessing ILD severity from HRCT, and its longitudinal changes have not yet been evaluated in IIM-ILD.

Objectives

This study aims to investigate ILD patterns and QILD scores in patients with IIM-ILD, to identify their clinical impact, and to delineate longitudinal changes of QILD measurement.

Methods

A total of 80 patients with IIM (polymyositis 22, and dermatomyositis 58) who underwent at least 2 times of serial HRCT scans were included. Visual ILD patterns were assessed by multiple thoracic radiologists. Quantitative analysis of HRCT was presented as total extent of QILD scores (%) in whole lung and most severe zone. Individual time-estimated ΔQILD score between first 2 visits was derived using a linear approximation of yearly change, where the duration of median (IQR) was 1.0 (0.4-1.6) years in the first 2 HRCT scans.

Results

The median (IQR) age of the patients was 52.0 (43.5-58.5) years and 60 (75.0%) were women. Baseline median score of whole lung-QILD and most severe zone-QILD were 28.1% (19.1-43.8) and 68.0% (45.5-81.8), respectively, and QILD score showed significant correlations with pulmonary function tests (r=-0.349, p=0.002 for % predicted forced vital capacity; and r=-0.381, p=0.001 for % predicted diffusing capacity for carbon monoxide). The individual time-estimated yearly ΔQILD score between first 2 visits presented that approximately half of the patients showed improvement or stability in QILD scores; however, when patients were sorted by visual assessment in ILD subtype on HRCT, approximately two-thirds of the patients with usual interstitial pneumonia (UIP) pattern were aggravated in QILD scores and less than half of subjects with nonspecific interstitial pneumonia and organizing pneumonia were aggravated (Figure 1, 80% for UIP vs. 44.4% for non-UIP, p=0.013). There was no immunosuppressive drugs related to meaningful improvement in QILD scores during first 2 visits. Notably, we observed significant aggravation of QILD scores in tacrolimus users (n=7, median time-estimated whole lung-yarly ΔQILD 20.3 (2.7-38.4)) compared with tacrolimus non-users (n=73, median time estimated whole lung-yearly ΔQILD -1.2 (-8.3-6.5)). Among 80 patients, 6 (7.5%) were died due to various lung complications. Higher baseline QILD scores were noted in deaths (median whole lung-QILD 45.4 (32.9-56.5)) than in survivors (median whole lung-QILD 26.9 (19.0-42.4)), albeit not significant (p=0.084). Poor survival rate was observed in patients with high grade of ground glass opacity by visual assessment in right upper lobe (log-rank test, p=0.042). Among subgroup of patients with 3 serial HRCT scans (n=41), dynamic changes of four distinct patterns (improving, worsening, convex, and concave) were observed.

Figure 1.

Cleveland dot plot of individual time-estimated yearly ΔQILD during fist 2 visits.

Conclusion

The changes in QILD score in IIM-ILD are dynamic and present different by visual assessment. QILD score has the potential for evaluation of the severity changes, prognosis and medication response in patients with IIM-ILD.

References

[1]Tashkin DP, et al. Ann Rheum Dis 2016;75(2):374-81.

7 truncated values in the graph A. NSIP: nonspecific interstitial pneumonia; OP: organizing pneumonia; UIP: usual interstitial pneumonia.

Disclosure of Interests

None declared

Pulmonary arterial hypertension due to antiphospholipid syndrome initially mimicking chronic thromboembolic pulmonary hypertension

Pulmonary arterial hypertension (PAH) is the second most common lung complication in antiphospholipid syndrome (APS) patients. However, the concurrent development of APS-related nonthrombotic PAH is rarely reported. Lack of awareness for group 1 PAH in APS patient may contribute to underdiagnosis of this condition. Herein, we reviewed the case of a 56-year-old female who was diagnosed with PAH related to APS that mimicked chronic thromboembolic pulmonary hypertension (CTEPH). It is crucial to be aware of the possibility of a group 1 PAH diagnosis, even though patients have already been diagnosed with CTEPH. Furthermore, a multidisciplinary approach and serial follow-up right heart catheterization with echocardiography are important to make a timely diagnosis and provide optimal treatment for APS-related PAH in patients with CTEPH-like clinical features.

Evaluation of Serum Matrix Metalloproteinase-3 as an Objective Indicator for the Disease Activity in Rheumatoid Arthritis Patients Treated With Methotrexate Versus Tocilizumab: 24-week Results From a Prospective Randomized Controlled Study

Objective

This study aims to evaluate the change in serum metalloproteinase-3 (MMP-3) following the management of active rheumatoid arthritis (RA) and define the relationships between MMP-3 and disease activity indices.

Methods

Data from a previously reported a 24-week, randomized controlled trial to investigate efficacy of tocilizumab in active RA refractory to methotrexate were analyzed. The serum level of MMP-3 were measured at week 0, 12, 20, and 24. The changes in MMP-3, and the relationship between MMP-3 and clinical parameters was assessed based on treatment group, methotrexate with or without tocilizumab.

Results

A total of 95 patients were included in this study. The serum MMP-3 significantly decreased and showed similar pattern with other disease activity indices during treatment period in both treatment groups (p<0.001). The MMP-3 was positively correlated with ESR, CRP, DAS28, SDAI, and CDAI for 302 visits throughout 24 weeks (p<0.001). In another correlation analysis to evaluate the treatment effect at 24 week time point, methotrexate group showed significant correlation between serum markers MMP-3 (r=0.321, p=0.043); ESR (r=0.450, p=0.002); and CRP (r=0.536, p<0.001), with DAS28, but tocilizumab group didn't show meaningful correlation between serum markers and DAS28 (p>0.05).

Conclusion

Serum MMP-3 showed positive correlation with disease activity indices in active RA patients. Furthermore, serum MMP-3 significantly decreased from baseline to week 20. As there is no single serum marker that can represent the disease activity particularly in tocilizumab treatment, MMP-3 might be a useful adjunct indicator to evaluate the treatment response in active RA patients.

Utility of the breath-holding test in patients with systemic sclerosis

OBJECTIVES

Cardiopulmonary involvement is a major cause of death in patients with SSc. This study evaluated the clinical utility and reliability of breath-holding test (BHT) in evaluating cardiopulmonary function in patients with SSc.

METHODS

Seventy-two prospectively enrolled patients with SSc underwent BHT and the 6 min walk test (6MWT), along with measurements of the Borg dyspnoea scale and Scleroderma Health Assessment Questionnaire (SHAQ). Data on pulmonary function test and echocardiography were also collected. Validity was assessed based on the correlations between the best BHT and relevant clinical parameters. To assess the reliability of BHT, an additional 31 patients with SSc underwent BHTs twice within 2 week intervals.

RESULTS

Mean (s.d.) best BHT time was 38.4 (15.7) s, and 6MWT distance was 473.5 (95.5) m. BHT showed significant correlations with the Borg dyspnoea scale before (r = -0.367, P < 0.001) and after (r = -0.285, P = 0.016) testing, whereas 6MWT were correlated with the Borg dyspnoea scale after (r = -0.351, P = 0.002) but not before (r = -0.113, P = 0.343) testing. BHT time was correlated with diffusing capacity for carbon monoxide (%, r = 0.426, P < 0.001), forced vital capacity (litres, r = 0.373, P = 0.001), pulmonary arterial systolic pressure (mmHg, r = -0.272, P = 0.031) and SHAQ score (r = -0.470, P < 0.001), but not with left ventricular ejection fraction (%, r = -0.135, P = 0.263). BHT showed excellent reliability, with an intraclass correlation coefficient (2, 1) of 0.943 (95% CI: 0.88, 0.97).

CONCLUSION

BHT, a simple and less time-consuming test, shows excellent reliability and significant correlation with the Borg scale, SHAQ and pulmonary parameters. These results suggest that BHT might be a useful surrogate marker of pulmonary capacity in SSc patients.

TRIAL REGISTRATION NUMBER

NCT04484948.

Cytoplasmic zinc promotes IL-1β production by monocytes and macrophages through mTORC1-induced glycolysis in rheumatoid arthritis

[Figure: see text].

A Case of Overlap Syndrome of Systemic Sclerosis and Cryoglobulinemic Vasculitis With Central Nervous System Involvement

Mixed cryoglobulinemic vasculitis (CV) is occasionally caused by autoimmune diseases including systemic sclerosis. Multiorgan involvement such as skin, kidney, and peripheral nerve involvement is common in mixed CV. However, central nervous system (CNS) involvement is extremely rare. Here, we report a case of overlap syndrome of limited cutaneous systemic sclerosis and mixed cryoglobulinemic vasculitis with CNS involvement. The neurologic deficits and systemic symptoms improved promptly after steroid and cyclophosphamide therapy.

Adapting undergraduate paediatric medical education to the challenges of COVID-19 pandemic: perspective of NUS Medicine

COVID-19 significantly impacted the teaching-learning-assessment activities in many medical schools. In this article, we discuss the impact of COVID-19 on the Yong Loo Lin School of Medicine, National University of Singapore, focusing on paediatric training and the adaptations of the system and the people. The school developed strategies to promptly disseminate information and safety measures to protect all its staff and students. By leveraging on the school’s infrastructure for technology-enabled learning, good-quality medical training and reliable assessments were able to be carried out swiftly. The paediatric curriculum was crafted based on these principles, and it provided distance-based learning with live and interactive sessions to teach core clinical skills. The faculty also tapped on standardised patients to provide consistent and life-like scenarios. Measures were implemented to minimise challenges with technology-enabled learning. Collectively, efforts from the staff, support from the leadership and students’ adaptations tremendously helped to ease the transition.

POS1386 ANGIOGRAPHIC CHARACTERISTICS OF VASCULOPATHY IN PATIENTS WITH CONNECTIVE TISSUE DISEASES

Background:

Vasculopathies are a heterogeneous group of morphologically and pathogenetically distinct vascular diseases. They include both non-inflammatory and inflammatory vasculopathies. Patients with connective tissue disease (CTD), including systemic sclerosis (SSc), dermatomyositis (DM), and polymyositis (PM), can develop a non-thrombotic proliferative vasculopathy (NTPV), a distinctive disease entity characterized by vascular wall proliferation without overt evidence of vascular inflammation and intraluminal thrombosis.

Objectives:

This study aimed to analyze the angiographic features of NTPV in patients with CTD, including SSc, DM, and PM in comparison to polyarteritis nodosa (PAN).

Methods:

Angiograms of 47 extremities (24 upper and 23 lower extremities) of 11 patients with CTD (6 SSc, 4 DM, and 1 PM), and 12 patients with PAN who presented with critical digital ischemia between January 2001 and May 2020 were analyzed. The degree and pattern of stenosis, occlusion, aneurysms, and neovascularization in proximal arteries (defined as arteries above the wrist and ankle) and distal arteries (defined as those at or below the wrist and ankle) were compared between CTD-vasculopathy and PAN.

Results:

Diffuse narrowing was significantly more frequent (66.1% vs. 38.0%; p=0.001), whereas multifocal stenosis was significantly less frequent (6.5% vs. 26.8%, p=0.002) in the CTD group than in the PAN group. All patients with CTD and 72.0% with PAN had diffuse narrowing in the distal arteries (p =0.010). Tapered occlusion was more frequent than abrupt occlusion in patients with CTD (43.5% vs. 11.3%). Abrupt occlusion (11.3% vs. 29.6%, p=0.010) and aneurysm formation (1.6% vs. 11.3%; p=0.037) were significantly less frequent in the CTD than in the PAN group. After 1 year, three patients (27.3%) in the CTD group and seven (58.3%) in the PAN group showed improvements in digital ischemia. Moreover, four patients (36.4%) in the CTD group and two (16.7%) in the PAN group underwent auto- or surgical amputation.

Conclusion:

Patients with CTD-vasculopathy exhibit more frequently diffuse smooth narrowing, tapered occlusion and delayed distal blood flow on conventional angiograms and worse outcomes than with PAN patients. Larger studies are needed to confirm the current findings.

References:

[1]Kahaleh MB. Vascular involvement in systemic sclerosis (SSc). Clin Exp Rheumatol. 2004;22(3 Suppl 33):S19-23.

[2]Lee JS, Kim H, Lee EB, Song YW, Park JK. Nonthrombotic proliferative vasculopathy associated with antiphospholipid antibodies: A case report and literature review. Mod Rheumatol. 2019;29(2):388-92.

Figure 1.

Angiographic features of CTD-vasculopathy and PAN.

Arteries in the (A) upper extremities and (B) lower extremities of patients with CTD-vasculopathy and PAN. Diffuse narrowing is indicated by white arrowheads; tapered occlusion by white arrows; multifocal stenosis by black arrowheads; abrupt occlusion by black arrows; aneurysmal changes by empty arrows; grade 2 tortuosity by white stars; and grade 3 tortuosity by black stars. CTD, connective tissue disease; PAN, polyarteritis nodosa.

Table 1.

Comparison of angiographic parameters between CTD-vasculopathy and PAN.

CTD (upper 14, lower 8)PAN (upper 10, lower 15)p-valueTotal number of images6271Shoulder/elbow/wrist and hand11/14/148/10/10Femoral/knee/ankle and foot7/8/813/15/15Stenosis Diffuse narrowing41/62 (66.1%)27/71 (38.0%)0.001  Focal stenosis13/62 (21.0%)10/71 (14.1%)0.295  Multifocal stenosis4/62 (6.5%)19/71 (26.8%)0.002Occlusion Tapered occlusion27/62 (43.5%)23/71 (32.4%)0.185  Abrupt occlusion7/62 (11.3%)21/71 (29.6%)0.010Aneurysm1/62 (1.6%)8/71 (11.3%)0.037Neovascularization in muscular branchTortuosity  Grade 145/62 (72.6%)30/68 (39.1%)0.002  Grade 211/62 (17.7%)14/68 (23.9%)  Grade 36/62 (9.7%)24/68 (37.0%)

Tortuosity grade 1, normal; grade 2, mild to moderate; grade 3, severe (hypertortuosity). CTD, connective tissue disease; PAN, polyarteritis nodosa.

Disclosure of Interests:

Jina Yeo: None declared, Eun-Ah Park: None declared, Eun Bong Lee Consultant of: Pfizer, Grant/research support from: GC Pharma and Handok Inc., Yeong Wook Song: None declared, Jin Kyun Park: None declared

POS0856 CLINICAL UTILITY OF BREATH-HOLDING TEST FOR MEASURING CARDIOPULMONARY FUNCTION IN PATIENTS WITH SYSTEMIC SCLEROSIS

Background:

Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are major causes of death in systemic sclerosis (SSc). Six-minute-walk test (6MWT) is a standard outcome measure for exercise capacity in cardiopulmonary diseases. However, the results of 6MWT may not reflect real cardiopulmonary function of SSc patients in whom musculoskeletal system is frequently inflicted.

Objectives:

This study aimed to evaluate the clinical utility of breath-holding test (BHT) in evaluating cardiopulmonary function in SSc patients, as compared with 6MWT.

Methods:

Seventy-two patients with SSc were prospectively enrolled and underwent BHT and 6MWT with measurement of Borg score and Scleroderma Health Assessment Questionnaire (SHAQ). Data on diffusing capacity for carbon monoxide (DLCO, %), forced vital capacity (FVC, % and liters), and ejection fraction and pulmonary arterial systolic pressure (PASP) measured by transthoracic echocardiography (TTE), were also collected. For BHT, participants were required to make a maximum expiration followed by a maximum inspiration and to hold the breath as long as possible at maximum inspiratory level. This procedure was repeated three times, with 5-minute intervals. 6MWT was performed according to the American Thoracic Society guidelines. Pearson’s correlation test was applied to demonstrate the relationship between BHT results and each clinical parameter.

Results:

Among 72 (66 female) patients, mean (SD) age was 57.1 (11.1) years, modified Rodnan skin score 10.6 (10.5), SHAQ 0.64 (0.61) and 6MWT distance 473.5 (95.5) m. Mean BHT time was 35.05 (14.90) sec at the first time, 38.92 (16.14) sec at the second time, and 41.11 (17.71) sec at the third time. The BHT time showed a statistically significant negative correlation with Borg scale (pre-test, r = -0.336, p = 0.002; post-test, r = -0.252, p = 0.034; Figure 1 and Table 1), while 6MWT showed a negative correlation with only post-test Borg scale (pre-test, r = -0.113 p = 0.343; post-test, r = -0.351 p = 0.002; Table 1). The BHT time was positively correlated with DLCO (%, r = 0.409, p < 0.001) and FVC (liters, r = 0.402, p < 0.001) (Table 1). We also found a statistically significant correlation between BHT time and SHAQ score (r = -0.451, p < 0.001; Table 1). However, EF and PASP by TTE showed no significant relationship with BHT time (EF, r = -0.108, p = 0.374; PASP, r = -0.246, p = 0.054; Table 1).

Table 1.

Pearson’s correlation coefficients (r) for the relation between BHT and clinical parameters in comparison to 6MWT.

Pre-test Borg scalePost-test Borg scaleDLCO(%)FVC(L)FVC(%)FVC/DLCOEF(%)PSAP(mm Hg)SHAQ (score)BHT (sec)-0.366**-0.252*0.409***0.402**0.191-0.244***-0.108-0.246-0.451***6MWT (m)-0.113-0.351**0.297*0.321**0.063-0.250*0.137-0.354**-0.531***

BHT, breath-holding test; 6MWT, 6-minute-walk test; DLCO, diffusing capacity for carbon monoxide; FVC, forced vital capacity; EF, ejection fraction estimated by transthoracic echocardiography; SHAQ, Scleroderma Health Assessment Questionnaire

.* p < 0.05, ** p < 0.01, *** p < 0.001

Figure 1.

Association of Borg dyspnea scale with breath-holding time.

Conclusion:

The BHT is a simple, safe, and less time-consuming test, reflective of pulmonary parameters and SHAQ, as compared with 6MWT. Our results suggest that the BHT might be a useful surrogate marker of cardiopulmonary capacity in SSc patients.

References:

[1]Villalba WO, Sampaio-Barros PD, Pereira MC, Cerqueira EM, Leme CA, Jr., Marques-Neto JF, et al. Six-minute walk test for the evaluation of pulmonary disease severity in scleroderma patients. Chest. 2007;131(1):217-22.

[2]Garin MC, Highland KB, Silver RM, Strange C. Limitations to the 6-minute walk test in interstitial lung disease and pulmonary hypertension in scleroderma. J Rheumatol. 2009;36(2):330-6.

[3]Barnai M, Laki I, Gyurkovits K, Angyan L, Horvath G. Relationship between breath-hold time and physical performance in patients with cystic fibrosis. Eur J Appl Physiol. 2005;95(2-3):172-8.

Acknowledgements:

This study would not have been possible without help from research assistant, Sung-Soon Cho.

Disclosure of Interests:

Jina Yeo: None declared, Mi Hyeon Kim: None declared, Jun Won Park: None declared, Jin Kyun Park: None declared, Eun Bong Lee Consultant of: Pfizer, Grant/research support from: GC Pharma and Handok Inc.

Outcomes and Risk Factors of Systolic Pulmonary Artery Pressure Progression in Patients with Systemic Rheumatic Diseases: Follow-up Results from a Korean Registry

Objectives

This study aims to investigate the outcomes and risk factors associated with the progression of systolic pulmonary artery pressure (sPAP) in patients with systemic rheumatic diseases.

Patients and methods

A total of 532 patients (73 males, 459 females; median age 49 years; interquartile range (IQR), 36 to 62 years) registered with the Registry of Pulmonary Hypertension Associated with Rheumatic Diseases were included. Mortality curves were constructed using the Kaplan- Meier method and comparisons were performed using the log-rank test. A paired t-test was performed to evaluate the patients with markedly elevated sPAP between baseline and follow-up.

Results

The average follow-up duration was 31 months (IQR, 9 to 60 months). Of the patients, 196 had follow-up echocardiographs at least one year later. We defined the sPAP over 60 mmHg as markedly elevated. Patients in the increased sPAP above 60 mmHg at follow-up and persistently markedly elevated sPAP were associated with worse outcomes in all-cause mortality and pulmonary arterial hypertension-related mortality (p<0.001). In patients with systemic sclerosis, the majority of patients remained static within their pressure group or rose progressively: the patients with markedly elevated sPAP at follow-up were higher than those at baseline (32% versus 15%, p<0.01). In patients with mixed connective tissue disease (MCTD) or rheumatoid arthritis (RA), the majority of patients remained static within their pressure group or gradually improved: the patients with markedly elevated sPAP at follow-up were lower than those at baseline (RA=14% versus 29%, MCTD=5% versus 16%, p<0.05).

Conclusion

Persistently high sPAP or increase of sPAP over 60 mmHg at follow-up was associated with increased mortality. There were some differences in the progression of sPAP according to the underlying rheumatic diseases.

An Updated Meta-analysis on the Risk of Urologic Cancer in Patients with Systemic Lupus Erythematosus

BACKGROUND

The risk of urologic cancers in patients with systemic lupus erythematosus (SLE) remains uncertain. We investigated the association between SLE and incident urologic cancers through a systematic review and meta-analysis.

METHODS

We searched the PubMed, EMBASE, and the Cochrane Library to identify articles that recorded prostate, bladder, or kidney cancers in SLE patients from inception to August 31, 2018. We included observational, case-control, or cohort studies with no language restriction. Two investigators screened and extracted the data independently.

RESULTS

Fourteen cohort studies with 83,860 SLE patients were finally analyzed. Overall, SLE patients were at increased risk of bladder cancer (hazard ratio [HR], 1.92; 95% confidence interval [CI], 1.15-3.21) but not of prostate or kidney cancer. However, subgroup analyses showed a reduced risk of prostate cancer in <10-year follow-up studies (HR, 0.68; 95% CI, 0.51-0.89) and an elevated risk of kidney cancer in patients with SLE in Western studies (HR, 2.00; 95% CI, 1.02-3.92), community-based studies (HR, 4.54; 95% CI, 2.17-9.52), prospective studies (HR, 6.84; 95% CI, 2.71-17.26), <10-year follow-up studies (HR, 1.88; 95% CI, 1.38-2.57), and low-quality studies (HR, 2.05; 95% CI, 1.50-2.80).

CONCLUSION

This study indicates that SLE increases the risk of bladder cancer but not prostate or kidney cancer. Well-designed long-term studies are required to confirm these associations.

Possible instability of one-step replica symmetry breaking in p-spin Ising models outside mean-field theory

The fully connected Ising p-spin model has for p>2 a discontinuous phase transition from the paramagnetic phase to a stable state with one-step replica symmetry breaking (1RSB). However, simulations in three dimension do not look like these mean-field results and have features more like those which would arise with full replica symmetry breaking (FRSB). To help understand how this might come about we have studied in the fully connected p-spin model the state of two-step replica symmetry breaking (2RSB). It has a free energy degenerate with that of 1RSB, but the weight of the additional peak in P(q) vanishes. We expect that the state with full replica symmetry breaking (FRSB) is also degenerate with that of 1RSB. We suggest that finite-size effects will give a nonvanishing weight to the FRSB features, as also will fluctuations about the mean-field solution. Our conclusion is that outside the fully connected model in the thermodynamic limit, FRSB is to be expected rather than 1RSB.

Risk of pancreatic cancer in patients with systemic lupus erythematosus: a meta-analysis

OBJECT

Accumulating evidences suggest that the incidence of several cancers is higher in systemic lupus erythematosus (SLE) than in general population. However, the finding on pancreatic cancer risk is inconsistent. This meta-analysis aimed to determine whether SLE patients are at risk for pancreatic cancer.

METHODS

We searched PubMed, Embase, and the Cochrane database to screen the studies meeting our criteria. The hazard ratios (HRs) and its 95% confidence interval (CIs) were calculated from a meta-analysis.

RESULTS

Eleven cohort studies were included in the final analysis. Overall, patients with SLE had an increased risk of pancreatic cancer (HR = 1.42, CI = 1.32-1.53). In subgroup analysis, hospital-based (HR = 1.43, CI = 1.32-1.54), retrospective (HR = 1.42, CI = 1.32-1.54), over 10 years followed (HR = 1.44, CI = 1.33-1.55), and low-quality studies (HR = 1.42, CI = 1.31-1.53) remained robust. Significant publication bias was not observed among the studies (p = 0.533).

CONCLUSIONS

The synthesized evidence from our meta-analysis demonstrated that SLE was associated with increased risk for pancreatic cancer. A well-designed, long-period followed study is needed to confirm this association. Key Points • Cancer incidence in SLE patients is increasing, but the data concerning pancreatic cancer remains inconclusive. • Our meta-analysis indicated that the risk of pancreatic cancer was significantly increased in SLE patients. • A well-designed, long-period followed study is needed to confirm the association.

Disparate effects of antibiotics on hypertension

Gut microbiota are associated with a variety of complex polygenic diseases. The usage of broad-spectrum antibiotics by patients affected by such diseases is an important environmental factor to consider, because antibiotics, which are widely prescribed to curb pathological bacterial infections, also indiscriminately eliminate gut commensal microbiota. However, the extent to which antibiotics reshape gut microbiota and per se contribute to these complex diseases is understudied. Because genetics play an important role in predisposing individuals to these modern diseases, we hypothesize that the extent to which antibiotics influence complex diseases depends on the host genome and metagenome. The current study tests this hypothesis in the context of hypertension, which is a serious risk factor for cardiovascular diseases. A 3 × 2 factorial design was used to test the blood pressure (BP) and microbiotal effects of three different antibiotics, neomycin, minocycline, and vancomycin, on two well-known, preclinical, genetic models of hypertension, the Dahl salt-sensitive (S) rat and the spontaneously hypertensive rat (SHR), both of which develop hypertension, but for different genetic reasons. Regardless of the class, oral administration of antibiotics increased systolic blood pressure of the S rat, while minocycline and vancomycin, but not neomycin, lowered systolic blood pressure in the SHR. These disparate BP effects were accompanied by significant alterations in gut microbiota. Our study highlights the need to consider an individualized approach for the usage of antibiotics among hypertensives, as their BP could be affected differentially based on their individual genetic and microbiotal communities.

Drug-induced eosinophilic pneumonia in a patient with Crohn's disease: diagnosis and treatment using fraction of exhaled nitric oxide

Oral 5-aminosalicylic acid agents (mesalazine and sulfasalazine) and azathioprine are the mainstays of treatment for inflammatory bowel disease. Reports of pulmonary toxicity induced by oral 5-aminosalicylic acid agents or azathioprine in patients with inflammatory bowel disease are very rare; to date, only 38 cases have been reported worldwide. We, herein, report a case involving a 26-year-old man who was diagnosed with eosinophilic pneumonia after using mesalazine and azathioprine for the treatment of Crohn's disease and recovered after treatment. We also found that the fraction of exhaled nitric oxide level was elevated in this patient. After treatment, the fraction of exhaled nitric oxide level decreased and the symptoms improved. The present case shows that fraction of exhaled nitric oxide is related to the disease activity and treatment effectiveness of druginduced eosinophilic pneumonia.

Characteristics of CSF Velocity-Time Profile in Posttraumatic Syringomyelia

BACKGROUND AND PURPOSE

The development of syringomyelia has been associated with changes in CSF flow dynamics in the spinal subarachnoid space. However, differences in CSF flow velocity between patients with posttraumatic syringomyelia and healthy participants remains unclear. The aim of this work was to define differences in CSF flow above and below a syrinx in participants with posttraumatic syringomyelia and compare the CSF flow with that in healthy controls.

MATERIALS AND METHODS

Six participants with posttraumatic syringomyelia were recruited for this study. Phase-contrast MR imaging was used to measure CSF flow velocity at the base of the skull and above and below the syrinx. Velocity magnitudes and temporal features of the CSF velocity profile were compared with those in healthy controls.

RESULTS

CSF flow velocity in the spinal subarachnoid space of participants with syringomyelia was similar at different locations despite differences in syrinx size and locations. Peak cranial and caudal velocities above and below the syrinx were not significantly different (peak cranial velocity, P = .9; peak caudal velocity, P = 1.0), but the peak velocities were significantly lower (P < .001, P = .007) in the participants with syringomyelia compared with matched controls. Most notably, the duration of caudal flow was significantly shorter (P = .003) in the participants with syringomyelia.

CONCLUSIONS

CSF flow within the posttraumatic syringomyelia group was relatively uniform along the spinal canal, but there are differences in the timing of CSF flow compared with that in matched healthy controls. This finding supports the hypothesis that syrinx development may be associated with temporal changes in spinal CSF flow.

Clinicopathologic Similarities of the Main and Minor Lesions of Synchronous Multiple Early Gastric Cancer

The detection rate of early gastric cancer (EGC) is increasing due to improvements in diagnostic methods, but synchronous multiple EGC (SMEGC) remains a major problem. Therefore, we investigated the characteristics of and the correlation between the main and minor lesions of SMEGC. We retrospectively reviewed the medical records of patients with EGC between April 2008 and May 2013. The main lesion was defined as the one with the greatest invasion depth. If lesions had the same invasion depth, the tumor diameter was used to define the main lesion. Of 963 patients who had treatment for EGC, 37 patients with SMEGC were analyzed. The main and minor lesions showed a significant positive correlation of size (r = 0.533, P = 0.001). The main and minor lesions of SMEGC showed the same vertical and horizontal locations at 70.3% and 64.9%, respectively (P = 0.002 and P = 0.002). Macroscopic types were identical in 67.6% (P < 0.001), and 32.4% had identical macroscopic type and location. The main and minor lesions had identical characteristics of invasion depth, presence of lymphovascular invasion (LVI), and differentiation in 78.4%, 83.8%, and 83.8%, respectively. Differentiation, LVI, and invasion depth (microscopic characteristics) were simultaneously the same in 62.2%. The location, macroscopic type, and 3 microscopic characteristics were matched in 27%. The main and minor lesions of SMEGC have similar clinicopathologic characteristics. Therefore, the possibility of SMEGC should not be neglected in cases of EGC, considering an understanding of the characteristics and association of lesions.

Lung cancer risk test trial: study design, participant baseline characteristics, bronchoscopy safety, and establishment of a biospecimen repository

BACKGROUND

The Lung Cancer Risk Test (LCRT) trial is a prospective cohort study comparing lung cancer incidence among persons with a positive or negative value for the LCRT, a 15 gene test measured in normal bronchial epithelial cells (NBEC). The purpose of this article is to describe the study design, primary endpoint, and safety; baseline characteristics of enrolled individuals; and establishment of a bio-specimen repository.

METHODS/DESIGN

Eligible participants were aged 50-90 years, current or former smokers with 20 pack-years or more cigarette smoking history, free of lung cancer, and willing to undergo bronchoscopic brush biopsy for NBEC sample collection. NBEC, peripheral blood samples, baseline CT, and medical and demographic data were collected from each subject.

DISCUSSION

Over a two-year span (2010-2012), 403 subjects were enrolled at 12 sites. At baseline 384 subjects remained in study and mean age and smoking history were 62.9 years and 50.4 pack-years respectively, with 34% current smokers. Obstructive lung disease (FEV1/FVC <0.7) was present in 157 (54%). No severe adverse events were associated with bronchoscopic brushing. An NBEC and matched peripheral blood bio-specimen repository was established. The demographic composition of the enrolled group is representative of the population for which the LCRT is intended. Specifically, based on baseline population characteristics we expect lung cancer incidence in this cohort to be representative of the population eligible for low-dose Computed Tomography (LDCT) lung cancer screening. Collection of NBEC by bronchial brush biopsy/bronchoscopy was safe and well-tolerated in this population. These findings support the feasibility of testing LCRT clinical utility in this prospective study. If validated, the LCRT has the potential to significantly narrow the population of individuals requiring annual low-dose helical CT screening for early detection of lung cancer and delay the onset of screening for individuals with results indicating low lung cancer risk. For these individuals, the small risk incurred by undergoing once in a lifetime bronchoscopic sample collection for LCRT may be offset by a reduction in their CT-related risks. The LCRT biospecimen repository will enable additional studies of genetic basis for COPD and/or lung cancer risk.

TRIAL REGISTRATION

The LCRT Study, NCT 01130285, was registered with Clinicaltrials.gov on May 24, 2010.

Ground-state energy of the q-state Potts model: The minimum modularity

A wide range of interacting systems can be described by complex networks. A common feature of such networks is that they consist of several communities or modules, the degree of which may quantified as the modularity. However, even a random uncorrelated network, which has no obvious modular structure, has a finite modularity due to the quenched disorder. For this reason, the modularity of a given network is meaningful only when it is compared with that of a randomized network with the same degree distribution. In this context, it is important to calculate the modularity of a random uncorrelated network with an arbitrary degree distribution. The modularity of a random network has been calculated [Reichardt and Bornholdt, Phys. Rev. E 76, 015102 (2007)PLEEE81539-375510.1103/PhysRevE.76.015102]; however, this was limited to the case whereby the network was assumed to have only two communities, and it is evident that the modularity should be calculated in general with q(≥2) communities. Here we calculate the modularity for q communities by evaluating the ground-state energy of the q-state Potts Hamiltonian, based on replica symmetric solutions assuming that the mean degree is large. We found that the modularity is proportional to 〈sqrt[k]〉/〈k〉 regardless of q and that only the coefficient depends on q. In particular, when the degree distribution follows a power law, the modularity is proportional to 〈k〉^{-1/2}. Our analytical results are confirmed by comparison with numerical simulations. Therefore, our results can be used as reference values for real-world networks.

The entrapped and unravelled coronary wire

No abstract available.

Mechanically and structurally robust sulfonated block copolymer membranes for water purification applications

The effective removal of ionic pollutants from contaminated water using negatively charged nanofiltration membranes is demonstrated. Block copolymers comprising polystyrene (PS) and partially hydrogenated polyisoprene (hPI) were synthesized by varying chain architectures. A one step procedure of cross-linking (hPI blocks) and sulfonation reactions (PS chains) was then carried out, which was revealed as an effective method to enhance mechanical integrity of membranes while hydrophilic sulfonated chains remain intact. In particular, the control of chain architecture allows us to create a synergetic effect on optimizing charge densities of the membrane, water permeability, and mechanical integrity under water purification conditions. The best performing membrane can almost completely (>99%) reject various divalent cations and also show NO(3)(-) rejection > 85% and Na(+) rejection > 87%. Well defined nanostructures (tens of nanometers) as well as the periodically arranged water domains (a few nanometers) within hydrophilic phases of the hydrated membranes were confirmed by in situ neutron scattering experiments.

Nutritional status of children living with HIV and receiving antiretroviral (ARV) medication in the Klang Valley, Malaysia

INTRODUCTION

Nutrition and HIV are closely related. Any immune impairment as a result of HIV leads to malnutrition, which in turn, can also lead to reduced immunity, thus contributing to a more rapid progression to AIDS.

METHODS

This cross-sectional study determined the nutritional status of children living with HIV and are receiving antiretroviral medication in the Klang Valley. A total of 95 children aged one to eighteen years old were recruited between September 2008 and February 2009. Data collected included socio-economic status, anthropometric measurements, dietary intake, medical history and serum levels of selected micronutrients specific for immunity.

RESULTS

The mean age of the children was 8.4 +/- 3.9 years and the mean duration on antiretroviral medications was 68.3 +/- 38.3 months. Anthropometric assessment found that 9.5% of the children were underweight and 31.6% were overweight. In contrast, 20.8% were stunted and 14.6% severely stunted. Biochemical indicators showed that 10.4% had deficiency in vitamin A while 12.5% had deficiency in selenium. Total cholesterol and HDL-C levels were found to be low in 30.5% and 10.5% of the children respectively.

CONCLUSION

Dietary assessment showed almost all the children did not achieve the recommended energy intake for their age groups and almost half of the children did not achieve the RNI for selenium and vitamin A. This study provides an insight on the nutritional status of children living with HIV.

What is the best predictor of the atherogenic LDL subclass phenotype 'pattern B' in patients with type 2 diabetes mellitus?

BACKGROUND

The atherogenic lipoprotein phenotype 'pattern B' comprises a predominance of small-dense low-density lipoprotein (sdLDL). Gradient gel electrophoresis (GGE) is considered a 'gold standard' method for identifying this phenotype, but is impractical for routine laboratory use. The low-density lipoprotein cholesterol:apolipoprotein-B (LDL-C:Apo-B) ratio has been advocated as a surrogate marker for sdLDL and a direct assay for sdLDL has recently become available. We compared the sdLDL assay and LDL-C:Apo-B with more established lipid parameters to predict the presence of 'pattern B' phenotype.

METHOD

Blood was collected from 97 fasted subjects on three separate occasions. Total cholesterol, triglyceride, Apo-B and sdLDL were measured; LDL- and HDL-cholesterol were determined after ultracentrifugation. The predominant LDL particle size and phenotype were assigned by GGE.

RESULTS

'Pattern B' phenotype was identified in 36% of samples. Peak particle size showed a positive correlation with HDL-cholesterol and a negative correlation with triglyceride and Apo-B. Receiver operating curve (ROC) analysis showed triglyceride:HDL-C ratio and triglyceride alone to be the best predictors of 'pattern B' phenotype, with area under the curve (AUC) being 0.87 and 0.84, respectively. AUCs for sdLDL (0.74) and LDL-C:Apo-B (0.71) were significantly lower (P < 0.05). A high sdLDL concentration had the greatest specificity (95%) and positive predictive value (74%) for 'pattern B' phenotype, but low sensitivity (43%).

CONCLUSION

Direct measurement of sdLDL provided the most specific predictor of 'pattern B' phenotype, whereas triglyceride:HDL-C ratio or triglycerides alone, parameters readily available in most laboratories, were the best predictors by ROC analysis.

Influences on self-evaluation during a clinical skills programme for nurses

Education has moved from teacher to student-centred practices. Increasing emphasis is placed on 'life-long' learning in the context of a rapidly changing knowledge base. Self-evaluation is seen as one strategy to facilitate student-centred continuous professional development. The literature, however, suggests that learners' ability to self-assess is mixed, and little is known regarding how students perform self-assessment. This study focussed on senior nurses undertaking a scenario-based clinical skills course. Learners were asked to self-evaluate several times during the course. This research explored the influences on using the self-evaluation exercise. The study drew upon grounded theory methodology and was influenced by constructionist and postmodernist theories. Three methods of data collection were used: semi-structured interviews, observation of supervision sessions and recording of the numerical self-evaluation ratings. Multiple interviews with students (n = 14) and the educational supervisor (n = 1) were conducted. Thematic analysis and data collection were conducted iteratively. The study found that feeling confident and stating that confidence were not necessarily the same. Feeling confident was complex, influenced by changing perceptions of clinical skills and credibility. Changing frames of reference were used to judge feelings of confidence. Stating confidence appeared to be socially negotiated, influenced by social acceptability considerations such as modesty and the need to show progress over time. The discourses of empowerment and surveillance were influential and self-evaluation is discussed using Foucault's theory of governmentality, illustrating how learners can be both empowered and controlled through self-evaluation. Further consideration of the socially constructed nature of self-evaluations would benefit both educational practice and future research.

Genistein and daidzein prevent diabetes onset by elevating insulin level and altering hepatic gluconeogenic and lipogenic enzyme activities in non-obese diabetic (NOD) mice

BACKGROUND

Non-obese diabetic (NOD) mice are regarded as being excellent animal models of human type 1 diabetes or insulin dependent diabetes (IDDM). This study investigated the beneficial effects of genistein and daidzein on IDDM, an autoimmune disease.

METHODS

Female NOD mice were divided into control, genistein (0.02%, w/w) and daidzein (0.02%, w/w) groups. Blood glucose level, plasma biomarkers, hepatic glucose and lipid regulating enzyme activities and pancreas immunohistochemistry analysis were examined after a 9-week experimental period.

RESULTS

Blood glucose levels of genistein and daidzein groups were 40 and 36% of control value at the end of study (9th week). The genistein and daidzein supplements increased insulin/glucagon ratio and C-peptide level with preservation of insulin staining beta-cell of pancreas in the NOD mice. In the liver, genistein and daidzein supplements resulted in lowering glucose-6-phosphatase (G6Pase) and phosphoenolpyruvate carboxykinase (PEPCK) activities, while increasing two lipogenic enzymes activities, malic enzyme and glucose-6-phosphate dehydrogenase (G6PD), compared to the control group. Significantly, genistein and daidzein supplementation lowered the activities of fatty acid beta-oxidation and carnitine palmitoyltransferase (CPT) in these mice. Genistein and daidzein also improved plasma triglyceride and free fatty acid (FFA) concentrations compared to the control group.

CONCLUSIONS

These results suggest that genistein and daidzein play important roles in regulation of glucose homeostasis in type 1 diabetic mice by down-regulating G6Pase, PEPCK, fatty acid beta-oxidation and CPT activities, while up-regulating malic enzyme and G6PD activities in liver with preservation of pancreatic beta-cells. The supplementation of genistein and daidzein are seemingly helpful for preventing IDDM onset.