The hindbrain and cortico-reticular pathway in adolescent idiopathic scoliosis

AIM

To characterise the corticoreticular pathway (CRP) in a case-control cohort of adolescent idiopathic scoliosis (AIS) patients using high-resolution slice-accelerated readout-segmented echo-planar diffusion tensor imaging (DTI) to enhance the discrimination of small brainstem nuclei in comparison to automated whole-brain volumetry and tractography and their clinical correlates.

MATERIALS AND METHODS

Thirty-four participants (16 AIS patients, 18 healthy controls) underwent clinical and orthopaedic assessments and brain magnetic resonance imaging (MRI) on a 3 T MRI machine. Automated whole-brain volume-based morphometry, tract-based spatial statistics analysis, and manual CRP tractography by two independent raters were performed. Intra-rater and inter-rater agreement of DTI metrics from CRP tractography were assessed by intraclass correlation coefficient. Normalised structural brain volumes and DTI metrics were compared between groups using Student's t-tests. Linear correlation analysis between imaging parameters and clinical scores was also performed.

RESULTS

AIS patients demonstrated a significantly larger pons volume compared to controls (p=0.006). Significant inter-side CRP differences in mean (p=0.02) and axial diffusivity (p=0.01) were found in patients only. Asymmetry in CRP fractional anisotropy significantly correlated with the Cobb angle (p=0.03).

CONCLUSION

Relative pontine hypertrophy and asymmetry in CRP DTI metrics suggest central supranuclear inter-hemispheric imbalance in AIS, and support the role of the CRP in axial muscle tone. Longitudinal evaluation of CRP DTI metrics in the prediction of AIS progression may be clinically relevant.

Prediction of atrial fibrillation in patients with embolic stroke with undetermined source using electrocardiogram deep learning algorithm and clinical risk factors

Background

Combining the artificial intelligence algorithm with the known clinical risk factors may provide enhanced accuracy for prediction of the hidden atrial fibrillation (AF) in patients with embolic stroke with undetermined source (ESUS).

Purpose

We aimed to develop enhanced prediction models for AF with deep learning algorithm (DLA) and clinical predictors in patients with ESUS. The DLA was created to identify the patients with paroxysmal AF based on their electrocardiograms (ECG) during sinus rhythm.

Methods

We analyzed the 221 patients who underwent insertable cardiac monitor (ICM) for AF detection following ESUS. The DLA was previously developed with sinus rhythm ECGs of 10,605 paroxysmal AF patients and 50,522 non-AF patients. The convolutional neural network was used for the DLA. The primary endpoint was defined as any AF episode lasting over 5 min by ICM. The atrial ectopic burden (AEB) was calculated as the percentage of the number of conducted QRS by atrial ectopy on Holter monitoring.

Results

AF (≥5 min) was detected by ICM in 32 patients (14.5%) during follow-up period of 15.1±8.6 months. AF patients had higher AEB (0.199% vs 0.023%, p<0.001), larger left atrial diameters (LAD, 41.2 mm vs 35.7 mm, p<0.001), and larger left atrial volume index (LAVI, 46.4 ml/m2 vs 32.3 ml/m2, p<0.001) than those without AF. The means of calculated probabilities of AF by DLA were higher in patients with AF than those without AF (63.8% vs 40.2%, p<0.001). In the receiver operating characteristic curve analysis, the areas under the curve (AUC) were the highest in DLA (0.824) followed by AEB (0.784), LAVI (0.780), and LAD (0.768). The multivariable model with AEB, LAVI, and DLA demonstrated excellent prediction accuracy for paroxysmal AF (AUC: 0.902, Figure 1)

Conclusions

In patients with ESUS, the DLA outperformed other clinical risk factors for prediction of AF. Combining DLA with AEB, LAD and LAVI could is a potential useful tool to predict AF in ESUS patients.

Funding Acknowledgement

Type of funding sources: None.

Deep learning-based electrocardiogram analysis detecting paroxysmal atrial fibrillation during sinus rhythm in patients with cryptogenic stroke: validation study using implantable cardiac monitoring

Background

Atrial fibrillation (AF) is the most cause of cardioembolic source causing cryptogenic stroke. In these, anticoagulation therapy could reduce recurrence of stroke. However, paroxysmal AF would not be detected even by 24 hours Holter monitoring. Deep learning-based electrocardiogram (ECG) analysis models were recently developed to detect AF during sinus rhythm.

Purpose

We aimed to develop a deep learning algorithm (DLA) to detect AF during sinus rhythm and validate the model in patients with cryptogenic stroke who underwent implantable cardiac monitoring (ICM) to diagnose paroxysmal AF.

Methods

This cohort study involved three hospitals (A, B, and C). We developed a DLA to detect AF using sinus rhythm 10 s 12-lead ECG. We included adult patients aged ≥18 years from hospital A and B. We used development data from AF adult patients who had at least one atrial fibrillation rhythm in the study period (Jan 2016 to Dec 2021) and non-AF patients who had no reference to AF in the ECG and electronic medical record. DLA was based on convolutional neural network (CNN) using 10 s 12-lead. For external validation, the ECGs from 217 patients (hospital C) with cryptogenic stroke who underwent ICM were analyzed by using the DLA for validating the accuracy in the real-world clinical situations.

Results

We included 10,605 AF adult patients and 50,522 non-AF patients as development data. During the internal validation, the area under the curve (AUC) of the final DLA based on CNN was 0.793 (95% Confidence interval 0.778–0.807). In external validation data from cryptogenic stroke patients, the mean ICM duration was 15.1 months, and AF >5 mins was detected in 32 patients (14.5%). The diagnostic accuracy of DLA was 0.793 to detect AF during sinus rhythm, and AUC was 0.824. The sensitivity, specificity, positive predictive value, and negative predictive value of the model were 0.844, 0.784, 0.403, and 0.967, respectively, which outperformed other conventional predictive methods based on clinical factors, such as CHARGE-AF, C2hest, and HATCH.

Conclusions

In this study, DLA accurately detected paroxysmal AF using 12-leads normal sinus rhythm ECG in patients with cryptogenic stroke and outperformed the conventional models. The DLA could be used as a screening tool to identify the cause of stroke in the future.

Funding Acknowledgement

Type of funding sources: None.

The association between diabetes and mortality in young adults presenting with myocardial infarction

Background

The incidence of diabetes mellitus and coronary artery disease continue to rise and collectively comprise two of the most prevalent and costly diseases worldwide. The goal of this study is to report the prognosis of young patients with diabetes presented with acute myocardial infarction (AMI).

Methods

This is a retrospective observational cohort study that included consecutive patients aged 18–45 years who underwent cardiac catheterization for AMI between 2006 and 2016 in an integrated healthcare system in Southern California. The prognosis of patients with diabetes were compared to those without diabetes.

Results

A total of 1,560 patients (average age 40.2±5.3 years, 25.6% female) presenting with AMI were included. Of these 272 (17.4%) had diabetes. Diabetics were older (41.1±4.4 vs 40.0±5.4 years), more likely to be female (32.4% vs 24.1%, p=0.006), Hispanic (51.5% vs 40.5%, p<0.001), have a higher body mass index (BMI) (33.6±7.1 vs 31.2±6.8kg/m2, p<0.001), have hypertension (HTN) (67.6% vs 23.8%, p<0.001), hyperlipidemia (HLD) (78.3% vs 24.1%, p<0.001), peripheral vascular disease (9.9% vs 1.9%, p<0.001), chronic kidney disease (CKD) (23.2% vs 2.7%, p<0.001), hypothyroidism (7% vs 4%, p=0.034), and prior strokes (4.4% vs 2.2%, p=0.034).

On multivariate analysis accounting for other cardiovascular risk factors, the association remained significant (OR 1.82, 95% CI 1.04–3.19, p=0.036). At a median follow-up of 5.8 years (interquartile range 3.7–8.7 years), diabetes was independently associated with increased all-cause mortality (Hazard ratio [HR] 3.10, 95% CI 1.68–5.69, p<0.001) when adjusting for age, sex, race, BMI, HTN, HLD, CKD, hypothyroidism, prior stroke, and ACS etiology. In a propensity score matched cohort, diabetes remained significantly associated with all-cause mortality (HR 5.29, 95% CI 2.34–12.02, p<0.001).

Conclusion

Diabetes is an independent predictor of increased mortality in young adults <45 years old presenting with AMI.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): KAISER PERMANENTE LOS ANGELES MEDICAL CENTER

O-086 End-to-end deep learning for recognition of ploidy status using time-lapse videos

Study question

Our Retrospective study is to investigate an end-to-end deep learning model in identifying ploidy status through raw time-lapse video.

Summary answer

Our deep learning model demonstrates a proof of concept and potential in recognizing the ploidy status.

What is known already

Since the time-lapse system has been introduced into the IVF lab, the relationship between morphogenetic and ploidy status has been often discussed. However, the result has not yet reached a united conclusion due to some limitations such as human labeling. Besides the statistical approach, deep learning models have been utilized for ploidy prediction. As such approaches are single image-based, the performance remains unpromising as previous statistical-based research. Therefore, in order to move further toward clinical application, better research design and approach are needed.

Study design, size, duration

A retrospective analysis of the time-lapse videos and chromosomal status from 690 biopsied blastocysts cultured in a time-lapse incubator (EmbryoScope+, Vitrolife) between January 2017 and August 2018 in the Lee Women’s Hospital were assessed. The ploidy status of the blastocyst was derived from the PGT-A using high-resolution next-generation sequencing (hr-NGS). Embryo videos were obtained after normal fertilization through the intracytoplasmic sperm injection or conventional insemination.

Participants/materials, setting, methods

By randomly dividing the data into 80% and 20%, we developed our deep learning model based on Two-Stream Inflated 3D ConvNets(I3D) network. This model was trained by the 80% time-lapse videos and the PGT-A result. The remaining 20% has been tested by feeding the time-lapse video as input and the PGT-A prediction as output. Ploidy status was classified as Group 1 (aneuploidy) and Group 2 (euploidy and mosaicism).

Main results and the role of chance

Time-lapse videos were divided into 3-time partitions: day 1, day 1 to 3, and day 1 to 5. Deep learning models have been fed by RGB and optical flow. Combining 3 different time partitions with RGB, optical flow, and fused result from RGB and optical flow, we received nine sets of test results. According to the results, the longest time partition with the fusion method has the highest AUC result as 0.74, which appeared higher than the other eight experimental settings with a maximum increase of 0.17.

Limitations, reasons for caution

The present study is retrospective and future prospective research would help us to identify more key factors and improve this model. In addition, expanding sample size combined with cross-centered validation will also be considered in our future approach.

Wider implications of the findings

Group 1 and Group 2 approach provided deselection of aneuploidy embryos, while future deep learning approaches toward high mosaicism, low mosaicism, and euploidy will be needed, in order to provide a better clinical application.

Trial registration number

CS18082

P–009 A modified sperm chromatin dispersion test, LensHooke® R10, for quick and accurate determination of human sperm DNA fragmentation

Study question

The performance and efficiency of the LensHooke® R10 test kit were evaluated by the clinical examination for precision, accuracy, and time.

Summary answer

The LensHooke® R10 based on sperm chromatin dispersion test offers not only quick testing for sperm DNA fragmentation but also reliable and accurate test results.

What is known already

Sperm chromatin dispersion (SCD) test, one of the most commonly used testing for sperm DNA fragmentation (SDF), can be conducted promptly and without the need for expensive laboratory instruments. However, the main disadvantage of the SCD test is inter-observer variability in categorizing the size of characteristics halos surrounding the core of sperm. Moreover, it takes more than one hour to accomplish whole assay procedures making this testing an inefficient diagnostic tool. These may hinder its broad availability among andrology laboratories or prevent it from being routinely used for the evaluation of male infertility.

Study design, size, duration

A total of 108 participants was included in this prospective study. Data was collected from the reproductive medicine center between June and December 2020.

Participants/materials, setting, methods

This study included 108 consecutive male partners of couples attending for assisted reproductive treatment. SDF was simultaneously tested by using LensHooke® R10 (R10) and Halosperm® G2 (G2) respectively. We evaluated the correlation and agreement between two SCD-based test kits. The repeatability and reproducibility of the SCD kits were assessed by intra-and inter-observer agreement experiments. The sensitivity, specificity, positive predictive value, negative predictive value for the R10 was determined by receiver operator characteristics (ROC) curve analysis.

Main results and the role of chance

The R10 produced more clear sperm core and dispersed chromatin, therefore highly recognizable images can be easily and accurately categorized when scoring of SDF. It took 50% less time for SDF testing by the R10 compared to the G2 (38.26 ± 9.85 minutes vs. 76.52 ± 19.7 minutes, P < 0.0001). The SDF% results showed a strong correlation for the R10 and G2 with Spearman’s coefficients of rank correlation (rho) above 0.8 (P < 0.0001, N = 108). The R10 showed 89.8% accuracy with 87.9% sensitivity, 90.8% specificity, 82.9% PPV, and 93.7% NPV on the measurement of SDF% at the threshold value of 22%. Intraclass correlation coefficients (ICC) >0.9 showed a strong agreement between two observers on the testing of SDF using the R10. ICC >0.9 showed a high intra-observer agreement within 4 repeated testing on SDF using the R10. The R10 showed an intra-observer’s precision of coefficient variation, CV < 10% for SDF%. In addition, SDF% test results obtained by the R10 for asthenospermic (31.8% ± 16.7%), teratospermic (22.9% ± 14.4%), and oligoasthenoteratozoospermic samples (36.6% ± 14.4%) were significantly higher than that observed in normozoospermic samples (15.3% ± 10.2%, p < 0.05), was comparable with the G2.

Limitations, reasons for caution

The sample size of 4 semen specimens used to evaluate the intra-and inter-observer agreement was a limitation. Besides, evaluating the relationship between the SDF and clinical outcome of ART is necessary for further study.

Wider implications of the findings: The new in vitro diagnostics reagent, LensHooke® R10, is a simple and quick test kit that offers reliable and accurate test results of sperm DNA fragmentation, can be routinely used in male infertility evaluation.

Trial registration number

CS2–20012

Identification of the pigment and its role in UV resistance in Paecilomyces variotii, a Chernobyl isolate, using genetic manipulation strategies

Fungi produce secondary metabolites that are not directly involved in their growth, but often contribute to their adaptation to extreme environmental stimuli and enable their survival. Conidial pigment or melanin is one of the secondary metabolites produced naturally by a polyketide synthesis (PKS) gene cluster in several filamentous fungi and is known to protect these fungi from extreme radiation conditions. Several pigmented or melanized fungi have been shown to grow under extreme radiation conditions at the Chernobyl nuclear accident site. Some of these fungi, including Paecilomyces variotii, were observed to grow towards the source of radiation. Therefore, in this study, we wanted to identify if the pigment produced by P. variotii, contributes to providing protection against radiation condition. We first identified the PKS gene responsible for synthesis of pigment in P. variotii and confirmed its role in providing protection against UV irradiation through CRISPR-Cas9 mediated gene deletion. This is the first report that describes the use of CRISPR methodology to create gene deletions in P. variotii. Further, we showed that the pigment produced by this fungus, was not inhibited by DHN-melanin pathway inhibitors, indicating that the fungus does not produce melanin. We then identified the pigment synthesized by the PKS gene of P. variotii, as a naptho-pyrone Ywa1, by heterologously expressing the gene in Aspergillus nidulans. The results obtained will further aid in understanding the mechanistic basis of radiation resistance.

Relationship Between Sexual Function and Pelvic Floor and Hip Muscle Strength in Women With Stress Urinary Incontinence

INTRODUCTION

The pelvic floor muscle (PFM) could affect female sexual functions. The hip muscles are morphologically and functionally linked to PFM and are important elements of female sexual attraction.

AIM

To determine the relationship between female sexual function and hip muscle strength and PFM functions in women with stress urinary incontinence (SUI).

METHODS

A total of 42 women with SUI were recruited in this study. Female sexual function was measured using the pelvic organ prolapse urinary incontinence sexual function questionnaire (PISQ). PFM functions were measured using a perineometer. Hip muscle strength was measured using a Smart KEMA tension sensor. The relationship between female sexual function and PFM function and hip muscle strength was assessed using Pearson correlation coefficients and multiple regression analyses with forward selection.

MAIN OUTCOME MEASURES

PISQ score, PFM functions (strength and endurance), and strength of hip extensor, abductor, and adductor were the main outcome measures.

RESULTS

For the behavioral/emotive domain in the PISQ, hip extensor strength (r = 0.452), PFM strength (r = 0.441), PFM endurance (r = 0.362), and hip adductor strength (r = 0.324) were significantly correlated and hip extensor strength emerged in multiple regression. For the physical domain in the PISQ, hip abductor strength (r = 0.417), PFM endurance (r = 0.356), hip adductor strength (r = 0.332), and PFM strength (r = 0.322) were significantly correlated and hip abductor strength entered in multiple regression. For partner-related domain in the PISQ, hip adductor (r = 0.386) and abductor strength (r = 0.314) were significantly correlated and hip adductor strength appeared in multiple regression. For the PISQ total score, hip extensor strength (r = 0.484), PFM endurance (r = 0.470), hip adductor strength (r = 0.424), hip abductor strength (r = 0.393), and PFM strength (r = 0.387) were significantly correlated and hip extensor strength and PFM endurance emerged in multiple regression.

CONCLUSION

The female sexual function could be related to not only PFM functions but also hip muscle strength in women with SUI. Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Relationship Between Sexual Function and Pelvic Floor and Hip Muscle Strength in Women With Stress Urinary Incontinence. Sex Med 2021;9:100325.

Effects of subinhibitory concentrations of chlorhexidine and mupirocin on biofilm formation in clinical meticillin-resistant Staphylococcus aureus

BACKGROUND

The effects of subinhibitory concentrations (sub-MICs) of antibacterial agents on the biofilm-forming ability of Staphylococcus aureus require further study.

AIM

To investigate the effects of sub-MICs of chlorhexidine and mupirocin on biofilm formation in clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates.

METHODS

MRSA isolates were collected from patients with bloodstream infections at a tertiary care hospital. The basal level of biofilm formation and biofilm induction by sub-MICs of chlorhexidine and mupirocin were evaluated by measuring biofilm mass stained with Crystal Violet.

FINDINGS

Of the 112 MRSA isolates tested, 63 (56.3%) and 44 (39.3%) belonged to sequence type (ST)5 and ST72 lineages, respectively, which are the predominant healthcare- and community-associated clones in South Korea. ST5 isolates were more likely to have chlorhexidine MIC ≥4 (73.0% vs 29.5%), resistance to mupirocin (23.8% vs 0%), agr dysfunction (73.0% vs 9.1%), and qacA/B gene (58.7% vs 2.3%) compared to ST72 isolates. The basal level of biofilm formation ability was frequently stronger in ST72 isolates compared to ST5 isolates (77.3% vs 12.7%). Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in 56.3% and 53.6%, respectively, of all isolates. Biofilm induction was more prevalent in ST5 isolates (85.7% for chlorhexidine, 69.8% for mupirocin) than in ST72 isolates (15.9% for chlorhexidine, 27.3% for mupirocin).

CONCLUSION

Sub-MICs of chlorhexidine and mupirocin promoted biofilm formation in half of the clinical MRSA isolates. Our results suggest that ST5 MRSA biofilm can be induced together with some other bacterial virulent factors following exposure to chlorhexidine, which might confer a survival advantage to this clone in the healthcare environment.

A multicentre, randomized, double-masked, parallel group, vehicle-controlled phase IIb study to evaluate the safety and efficacy of 1% and 3% topical minocycline gel in patients with papulopustular rosacea

Background

Papulopustular rosacea is characterized by chronic facial erythema and inflammatory facial lesions. Minocycline has anti‐inflammatory properties which may be effective in the treatment of rosacea inflammatory lesions.

Objectives

To assess the safety and efficacy of once‐daily topical minocycline gel 1% and 3% in patients with papulopustular rosacea.

Methods

This was a prospective, 12‐week, double‐blinded study conducted at 26 sites in the United States; 270 patients with papulopustular rosacea and 12–40 inflammatory lesions were randomized to minocycline 1%, minocycline 3% or vehicle. The primary endpoint was the mean change in inflammatory lesions at week 12. Key secondary endpoints included success on an Investigator's Global Assessment (IGA).

Results

Baseline mean lesion counts were 24·6, 25·1 and 24·3 in the minocycline 1%, minocycline 3% and vehicle groups, respectively; at week 12, the counts had decreased by 12·6, 13·1 and 7·9, respectively. Minocycline significantly decreased lesions, compared with the vehicle [P = 0·01, 95% confidence interval (CI) 7·9 to 0·9, for minocycline 1%; P = 0·007, 95% CI 8·3 to 1·3, for minocycline 3%]. The proportion of patients achieving IGA success was 39% in the minocycline 1% arm [P = 0·34, odds ratio (OR) 1·396 and OR 95% CI 0·71 to 2·75 vs. vehicle], 46% in the minocycline 3% arm (P = 0·04, OR 2·03 and OR 95% CI 1·04 to 3·95 vs. vehicle) and 31% in the vehicle arm.

Conclusions

Minocycline topical gel appears to be safe and tolerable at concentrations of 1% and 3%, and both concentrations significantly decreased inflammatory lesion counts, with a significantly larger proportion of patients achieving IGA success at week 12 in the minocycline 3% arm. These findings support further evaluation of minocycline gel for treating inflammatory lesions associated with papulopustular rosacea.

Linked Comment: Hampton. Br J Dermatol 2020; 183:412–413.

What is already known about this topic?

Papulopustular rosacea is characterized by inflammatory facial lesions and chronic erythema of the face.

Oral minocycline has been reported to have efficacy in the treatment of inflammatory lesions of papulopustular rosacea.

What does this study add?

The study shows that a topical gel preparation of minocycline significantly decreased the number of inflammatory lesions and significantly improved the Investigator's Global Assessment score in patients with papulopustular rosacea.

This may offer a topical therapeutic alternative to oral doxycycline or oral minocycline for the treatment of inflammatory lesions in papulopustular rosacea, with potentially fewer systemic side‐effects, owing to lower systemic drug exposure.

Linked Comment: Hampton. Br J Dermatol 2020; 183:412–413.

Plain language summary available online

Accuracy of point-of-care ultrasound by pediatric emergency physicians for testicular torsion

INTRODUCTION

Acute scrotum is a common presentation to the pediatric emergency department, and ultrasound is frequently used to narrow the differential diagnosis. Point-of-care ultrasound (POCUS) is increasingly used by urologists and emergency physicians and could potentially be used to detect pediatric testicular torsion.

OBJECTIVES

This study aimed to determine the accuracy of POCUS by pediatric emergency physicians in diagnosing testicular torsion and the agreement between point-of-care ultrasound and final diagnosis for other causes of acute scrotum.

STUDY DESIGN

A chart review of patients presenting to the study emergency department who received POCUS by a pediatric emergency physician, as well as radiology department ultrasound and/or surgery, was performed. Charts were reviewed for POCUS diagnoses, final diagnoses, and imaging time metrics.

RESULTS

A total of 120 patients met study criteria, with 12 cases of testicular torsion. The diagnostic accuracy of POCUS for testicular torsion is described in the summary table. For all causes of acute scrotum, point-of-care ultrasound agreed with final diagnosis in 70% (95% confidence interval [CI] 62-78%) of cases, and more experienced point-of-care ultrasound users displayed higher agreement with final diagnosis. Point-of-care ultrasound results were generated a median of 73 min (Q1 = 51, Q3 = 112) before radiology department ultrasound results.

DISCUSSION

Scrotal POCUS performed by pediatric emergency physicians appears to be an accurate tool to detect testicular torsion in children with acute scrotum and saves time compared with radiology ultrasound. The study results may not be generalizable to hospitals without a multidisciplinary POCUS system for quality assurance and image sharing. Future work on POCUS for acute scrotum should investigate its impact on patient outcomes, cost-effectiveness, and family satisfaction.

CONCLUSION

Point-of-care ultrasound by pediatric emergency physicians is accurate for detecting testicular torsion in children with acute scrotum and could expedite diagnosis of this time-sensitive condition.

Efficient identification of fungal antimicrobial principles by tandem MS and NMR database

The continuous re-isolation of the known and non-applicable compounds that is time-consuming and wasting resources is still a critical problem in the discovery of bioactive entities from natural resources.

To efficiently address the problem, high performance liquid chromatography-diode array detector-microfractionation (HPLC-DAD-microfractionation) guided by disk agar diffusion assay was developed, and the active compounds were further identified using the tandem mass spectrometry (MS/MS)-based molecular networking. Of 150 fungal strains screened, the methanolic extracts of Phoma herbarum PPM7487, Cryptosporiopsis ericae PPM7405, and Albifimbria verrucaria PPM945 exhibited potent antimicrobial activity against Candida albicans SC5314 and Cryptococcus neoformans H99 in the preliminary agar diffusion assay. The concept of OSMAC (one strain many compounds) was employed in the fungal cultures in order to enrich the diversity of the 2^nd metabolites in this study. HPLC coupled with off-line bioactivity-directed profiling of the extracts enabled a precise localization of the compounds responsible for the conspicuous antimicrobial activity. The purified active compounds were identified based mainly on MS/MS database, and further supported by ¹³C nuclear magnetic resonance (NMR) spectral data compared to the literatures. In addition to nineteen known compounds, a new trichothecene derivative 1, namely trichoverrin D, was isolated and identified through this protocol. The antifungal activities of all the pure isolates were evaluated, and the structure activity relationships were also inferred. This report has demonstrated the combination of HPLC microfractination and MS/MS coupled by NMR spectral dereplication for speeding up the antimicrobial natural products discovery process.

Clinical impacts of delayed central venous catheter removal according to the severity of comorbidities in patients with candidaemia

BACKGROUND

The effects of early central venous catheter (CVC) removal on the clinical outcomes of patients with candidaemia remain controversial. This study evaluated the impact of delayed CVC removal on mortality according to the severity of comorbidities in patients with candidaemia.

METHODS

Patients with candidaemia in a tertiary care hospital between January 2010 and December 2017 were included retrospectively. The severity of comorbidities was classified as low [Charlson Comorbidity Index (CCI) score ≤3] or high (CCI score ≥4). Cases with removal of CVC >2 days after the onset of candidaemia or without CVC removal were classified as having delayed CVC removal.

RESULTS

In total, 239 patients with candidaemia were included, excluding 18 who died within 2 days of onset of candidaemia. Of these, 149 had low CCI scores and 90 had high CCI scores. Septic shock [adjusted odds ratio (aOR)=9.5] and delayed CVC removal (aOR=4.7) were significantly associated with increased 30-day mortality, whereas Candida parapsilosis infection (aOR=0.2) and cerebrovascular disease (aOR=0.3) were associated with decreased 30-day mortality, in patients with low CCI scores. Septic shock (aOR=13.0) was the only risk factor for 30-day mortality in those with high CCI scores. Delayed CVC removal was associated with increased 30-day mortality in patients with low CCI scores (50.0% vs 20.3%; P=0.001), but not in those with high CCI scores (50.0% vs 47.9%; P=0.87).

CONCLUSION

Early CVC removal may improve the survival of patients with candidaemia and low CCI scores, but no such protective effect was evident in those with high CCI scores.

Phomaketide A Inhibits Lymphangiogenesis in Human Lymphatic Endothelial Cells

Lymphangiogenesis is an important biological process associated with cancer metastasis. The development of new drugs that block lymphangiogenesis represents a promising therapeutic strategy. Marine fungus-derived compound phomaketide A, isolated from the fermented broth of Phoma sp. NTOU4195, has been reported to exhibit anti-angiogenic and anti-inflammatory effects. However, its anti-lymphangiogenic activity has not been clarified to date. In this study, we showed that phomaketide A inhibited cell growth, migration, and tube formation of lymphatic endothelial cells (LECs) without an evidence of cytotoxicity. Mechanistic investigations revealed that phomaketide A reduced LECs-induced lymphangiogenesis via vascular endothelial growth factor receptor-3 (VEGFR-3), protein kinase Cδ (PKCδ), and endothelial nitric oxide synthase (eNOS) signalings. Furthermore, human proteome array analysis indicated that phomaketide A significantly enhanced the protein levels of various protease inhibitors, including cystatin A, serpin B6, tissue factor pathway inhibitor (TFPI), and tissue inhibitor matrix metalloproteinase 1 (TIMP-1). Importantly, phomaketide A impeded tumor growth and lymphangiogenesis by decreasing the expression of LYVE-1, a specific marker for lymphatic vessels, in tumor xenograft animal model. These results suggest that phomaketide A may impair lymphangiogenesis by suppressing VEGFR-3, PKCδ, and eNOS signaling cascades, while simultaneously activating protease inhibitors in human LECs. We document for the first time that phomaketide A inhibits lymphangiogenesis both in vitro and in vivo, which suggests that this natural product could potentially treat cancer metastasis.

Switching to tenofovir vs continuing entecavir for hepatitis B virus with partial virologic response to entecavir: a randomized controlled trial

Entecavir 0.5 mg (ETV) is widely used among treatment-naïve chronic hepatitis B (CHB) patients. However, 10%-30% of patients show partial virologic response (PVR) to the drug. If the hepatitis B virus (HBV) continues to replicate, the underlying liver disease may progress. Herein, we compared the efficacy of switching to tenofovir disoproxil fumarate (TDF) with that of continuing ETV in CHB patients with PVR to ETV. This was an open-label randomized controlled trial including CHB patients who had been receiving 0.5 mg of ETV for >12 months, but who still had detectable HBV DNA levels of >60 IU/mL without known resistance to ETV. Sixty patients were enrolled and 45 qualified for the study: Twenty-two patients were randomly assigned into the TDF group and 23 into the ETV group. After 12 months of treatment, the virologic response rate (HBV DNA <20 IU/mL) was significantly higher in the TDF group than in the ETV group, as measured using per-protocol analysis (55% vs 20%; P = .022) and intention-to-treat analysis (50% vs 17.4%; P = .020). The reduction in HBV DNA was greater (-1.13 vs -0.67 log₁₀ IU/mL; P = .024), and the mean HBV DNA level was lower (1.54 vs 2.01 log₁₀ IU/mL; P = .011) in the TDF group than in the ETV group. In conclusion, to achieve optimal response in CHB patients with PVR to ETV, switching to TDF would be a better strategy than continuing ETV. Appropriate modification of therapy would further improve the outcome of chronic HBV infection.

Comparison of molecular diagnosis with serum markers and synovial fluid analysis in patients with prosthetic joint infection

AIMS

The aim of this study was to compare the results of 16S/28S rRNA sequencing with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and synovial fluid analysis in the diagnosis of prosthetic joint infection (PJI).

PATIENTS AND METHODS

Between September 2015 and August 2016, 214 consecutive patients were enrolled. In the study population, there were 25 patients with a PJI and 189 controls. Of the PJI patients, 14 (56%) were women, and the mean age at the time of diagnosis was 65 years (38 to 83). The ESR and CRP levels were measured, and synovial fluid specimens were collected prospectively. Synovial fluid was subjected to reverse transcription polymerase chain reaction (RT-PCR)/sequence analysis targeting the 16S/28S rRNA, and to conventional culture. Laboratory personnel who were blind to the clinical information performed all tests. The diagnosis of PJI was based on the criteria of the Musculoskeletal Infection Society.

RESULTS

A total of 25 patients had a confirmed PJI. In 20 cases of monomicrobial PJI, the PCR products could be perfectly matched with the 16S/28S rRNA genes specific for different species of bacteria provided by sequence analysis. Of the five polymicrobial cases of PJI, 16S/28S rRNA PCR sequence analysis failed to identify the concordant bacteria species. In the 189 control patients, there was one false-positive RT-PCR result. The sensitivity and specificity of the molecular diagnosis method were 100% (95% confidence interval (CI) 85.7 to 100) and 99.5% (95% CI 97.1 to 99.9), respectively, whereas the positive and negative predictive values of PCR were 96.1% (95% CI 79.6 to 99.9) and 100% (95% CI 98.1 to 100), respectively. The PCR results were significantly better than serological diagnostic methods (p = 0.004 and p = 0.010 for ESR and CRP, respectively), the synovial fluid white blood cell (WBC) count (p = 0.036), and percentage of polymorphonuclear cells (PMN%) (p = 0.014).

CONCLUSION

Stepwise RT-PCR and sequence analysis of the 16S/28S rRNA carried out under stringent laboratory conditions achieved highly sensitive and specific results for the differentiation between aseptic and septic joints undergoing arthroplasty. Sequence analysis successfully identified bacterial strains in monomicrobial infections but failed to identify molecular targets in polymicrobial infections. Further refinement of the protocols to identify the bacteria in polymicrobial infections is needed. Cite this article: Bone Joint J 2018;100-B:1345-51.

Impaired finger dexterity and nigrostriatal dopamine loss in Parkinson's disease

Impaired finger dexterity occurs in Parkinson's disease (PD) and has been considered a limb-kinetic apraxia associated with primary sensory cortical dysfunction. To study the role of nigrostriatal dopamine loss and elementary parkinsonian motor deficits in impaired finger dexterity of PD. Thirty-two right-handed untreated PD patients and 30 right-handed healthy controls were included. All patients underwent [¹⁸F] FP-CIT positron emission tomography studies. We examined the associations among unilateral coin rotation (CR) score, Unified Parkinson's Disease Rating Scale (UPDRS) subscores for bradykinesia and rigidity of the corresponding arm, and contralateral regional striatal dopamine transporter (DAT) uptake. We also measured the effect of oral levodopa dose on CR scores and UPDRS subscores. PD patients performed worse than controls on the CR task. Unilateral arm UPDRS bradykinesia scores were associated with DAT uptake in the contralateral putamen. The left CR score was associated with left arm bradykinesia and rigidity scores and DAT uptake in the right posterior putamen, whereas no such associations were found for the right CR score. There was a significant effect of handedness on the association of putamen DAT uptake with CR scores, but not with UPDRS subscores. An oral levodopa challenge improved CR scores and UPDRS subscores on both sides. Impaired finger dexterity in PD is related to elementary parkinsonian motor deficits and nigrostriatal dopamine loss. Impaired dominant hand dexterity associated with nigrostriatal dopamine loss seems to be compensated to some extent by the dominant cerebral cortex specialized for controlling precise finger movements.

Clinical impact of delayed catheter removal for patients with central-venous-catheter-related Gram-negative bacteraemia

BACKGROUND

Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infection (CRBSI), and the prevalence of multi-drug-resistant strains is rising rapidly. This study evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with Gram-negative CRBSI.

METHODS

Between January 2007 and December 2016, patients with Gram-negative bacteraemia and CVC placement, from two tertiary care hospitals, were included retrospectively. Cases with CVC removal more than three days after onset of bacteraemia or without CVC removal were classified as having delayed CVC removal.

RESULTS

In total, 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable) and 34 had Gram-negative bacteraemia from another source (non-CRBSI). Enterobacteriaceae were less common pathogens in patients with CRBSI than in patients with non-CRBSI (11.5% vs 41.3%; P<0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs 11.8%; P=0.01) in patients with Gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs 14.3%; P>0.99). Delayed CVC removal [odds ratio (OR) 6.8], multi-drug-resistant (MDR) Gram-negative bacteraemia (OR 6.3) and chronic renal failure (OR 11.1) were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs 18.2%; P=0.03), but not in the non-MDR group (11.1% vs 0%; P=0.43).

CONCLUSION

CVCs should be removed early to improve clinical outcomes in patients with Gram-negative CRBSI, especially in settings where MDR isolates are prevalent.

Early administration of neuraminidase inhibitors in adult patients hospitalized for influenza does not benefit survival: a retrospective cohort study

The administration of neuraminidase inhibitors (NAIs) within 2 days after the onset of symptoms (early NAI therapy) has been shown to reduce mortality in adult patients with severe influenza. However, there is no sufficiently solid evidence supporting the effectiveness of early NAI therapy on mortality. We reviewed the clinical data from 506 adult patients who were hospitalized for influenza between March 2010 and March 2014, to investigate the impact of early NAI therapy on mortality. Nearly one-third of the study patients were infected with influenza B (influenza A, influenza B, and co-infection of both in 68.8%, 28.1%, and 3.2%, respectively), and were diagnosed using the polymerase chain reaction (PCR) method (33.6%). Less than half (233, 46.0%) had received early NAI therapy. Patients with early NAI therapy were admitted to the hospital earlier, more frequently infected with influenza A, and more frequently diagnosed using rapid influenza detection tests compared to those without early NAI therapy. Although patients without early NAI therapy presented with more serious clinical manifestations, such as an initial symptom of dyspnea, pneumonia, and intensive care unit admission, than those with early NAI therapy, the in-hospital mortality of the former (2.9%, 8/273) did not differ from that of the latter (3.4%, 8/233) (p = 0.75). We did not find a reduction in mortality associated with early NAI therapy in adult patients hospitalized for influenza. Further clinical studies including a large number of influenza B-infected patients with virus identification using PCR methodology rather than viral culture may be required to confirm the beneficial impact of early NAI therapy on mortality.

Angiogenesis Inhibitors and Anti-Inflammatory Agents from Phoma sp. NTOU4195

Seven new polyketides, phomaketides A-E (1-5) and pseurotins A₃ (6) and G (7), along with the known compounds FR-111142, pseurotins A, A₁, A₂, D, and F₂, 14-norpseurotin A, α-carbonylcarbene, tyrosol, cyclo(-l-Pro-l-Leu), and cyclo(-l-Pro-l-Phe), were purified from the fermentation broth and mycelium of the endophytic fungal strain Phoma sp. NTOU4195 isolated from the marine red alga Pterocladiella capillacea. The structures were established through interpretation of spectroscopic data. The antiangiogenic and anti-inflammatory effects of 1-7 and related analogues were evaluated using human endothelial progenitor cells (EPCs) and lipopolysaccharide (LPS)-activated murine macrophage RAW264.7 cells, respectively. Of the compounds tested, compound 1 exhibited the most potent antiangiogenic activity by suppressing the tube formation of EPCs with an IC₅₀ of 8.1 μM, and compound 3 showed the most selective inhibitory activity of LPS-induced NO production in RAW264.7 macrophages with an IC₅₀ value of 8.8 μM.

Terpenoids from the Fermented Broths of Coprinellus radians

One new sesquiterpenoid, namely coprinol (1), along with guanacastanes J (2), E (3) and N (4), were isolated from the ethyl acetate extracts of the fermented broths of the fungal strain Coprinellus radians#1168. Their structures were elucidated on the basis of spectroscopic data analysis. The growth inhibitory activities against A549 of 1-4 were evaluated, and only 4 exhibited moderate growth inhibitory activity with a GI50 value of 18.2 μM compared with fluorouracil (GI50 = 3.6 μM). All the compounds were also subjected to antifungal assay against Candida albicans ATCC 18804, C. albicans SC-5314, Cryptococcus neoformans ATCC 13690 and Saccharomyces cerevisiae ATCC 2345; all showed mild antifungal activity with MIC values of 128.0 μg/mL for 1-3 and 64.0 μg/mL for 4 in comparison with amphotericin B (MIC = 0.25 μg/mL) and ketoconazole (MIC = 1.0 μg/mL).

Terpenoids from the Fermented Broths of Coprinellus radians

One new sesquiterpenoid, namely coprinol (1), along with guanacastanes J (2), E (3) and N (4), were isolated from the ethyl acetate extracts of the fermented broths of the fungal strain Coprinellus radians ≠1168. Their structures were elucidated on the basis of spectroscopic data analysis. The growth inhibitory activities against A549 of 1-4 were evaluated, and only 4 exhibited moderate growth inhibitory activity with a GI₅₀ value of 18.2 μM compared with fluorouracil (GI₅₀ = 3.6 μM). All the compounds were also subjected to antifungal assay against Candida albicans ATCC 18804, C. albicans SC-5314, Cryptococcus neoformans ATCC 13690 and Saccharomyces cerevisiae ATCC 2345; all showed mild antifungal activity with MIC values of 128.0 μg/mL for 1-3 and 64.0 μg/mL for 4 in comparison with amphotericin B (MIC = 0.25 μg/mL) and ketoconazole (MIC = 1.0 μg/mL).

Prescribing Pattern of Antidepressants in Children and Adolescents: Findings from the Research on Asia Psychotropic Prescription Pattern

OBJECTIVE

Pharmacotherapy of depression in children and adolescents is complex. In the absence of research into the efficacy and safety of antidepressants in this group of patients, their off-label prescription is common. This paper aimed to illustrate the prescription pattern of antidepressants in children and adolescents from major psychiatric centres in Asia.

METHODS

The Research on Asia Psychotropic Prescription Pattern on Antidepressants worked collaboratively in 2013 to study the prescription pattern of antidepressants in Asia using a unified research protocol and questionnaire. Forty psychiatric centres from 10 Asian countries / regions participated and 2321 antidepressant prescriptions were analysed.

RESULTS

A total of 4.7% antidepressant prescriptions were for children and adolescents. Fluoxetine, sertraline, and escitalopram were the most common antidepressants prescribed for children and adolescents. Almost one-third (30.3%) of prescriptions were for diagnoses other than depressive and anxiety disorders. There was less antidepressant polypharmacy and concomitant use of benzodiazepine, but more concomitant use of antipsychotics in children and adolescents compared with adults.

CONCLUSION

Off-label use of antidepressants in children and adolescents was reported by 40 Asian psychiatric institutions that participated in the study. In-service education and regulatory mechanisms should be reinforced to ensure efficacy and safety of antidepressants in children and adolescents.

Evaluation of salivary function by sialoscintigraphy in locally advanced nasopharyngeal cancer patients after intensity modulated radiotherapy

PURPOSE

This study aimed to evaluate the salivary gland function changes by sialoscintigraphy in locally advanced nasopharyngeal cancer (NPC) after intensity modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Salivary function was assessed by sialoscintigraphy. Quantitative sialoscintigraphy was performed in 24 NPC patients prior to and after IMRT. Results were categorized in four groups according to the duration of treatment. The sialoscintigraphy parameters were examined.

RESULTS

Sialoscintigraphy showed a significant difference in the secretion of each interval groups. The parameters of scintigraphy, except maximum accumulation (MA) of submandibular glands, decreased first after radiotherapy, and then recovered. However, the MA of submandibular glands was continuously downhill after radiation.

CONCLUSIONS

The sialoscintigraphy parameters of each gland changed with the different radiation dose and follow-up intervals. The salivary function was influenced after radiotherapy in locally advanced NPC, especially, in the submandibular gland. Strategies to improve the salivary function should be assessed.

Antidepressant Prescription Pattern in the Presence of Medical Co-morbidity: REAP-AD 2013 Study

OBJECTIVE

To evaluate the prescription pattern of antidepressants in patients with medical co-morbidity from major psychiatric centres in Asia.

METHODS

The Research on Asian Psychotropic Prescription Pattern for Antidepressants (REAP-AD 2013) collected data from 42 psychiatric centres in 10 Asian countries and regions. Antidepressant prescriptions of 2320 patients with various psychiatric disorders were evaluated. Of these, 370 patients who had specified medical co-morbidities formed the study cohort.

RESULTS

Escitalopram (20%) and mirtazapine (20%) were the most commonly prescribed antidepressants in patients with medical co-morbidity followed by sertraline (16%), trazodone (15%), and paroxetine (12%). Overall, more than half (52%; 247/476) of prescriptions comprised selective serotonin reuptake inhibitors. Slightly less than two-thirds (63%; n = 233) of patients received at least 1 selective serotonin reuptake inhibitor. In addition, 79% of patients were prescribed only 1 antidepressant. The mean number of antidepressants used per patient was 1.25 (standard deviation, 0.56). There were subtle differences in the most preferred antidepressant across medical illnesses such as diabetes mellitus, liver dysfunction, acid peptic disease, and cerebrovascular disease. Differences were also seen in prescription patterns across different countries.

CONCLUSION

Although selective serotonin reuptake inhibitors formed the bulk of antidepressant prescriptions in the presence of medical co-morbidity, mirtazapine was also commonly used in the presence of medical co-morbidities. Specified medical morbidities do influence the selection of antidepressants.

New Furanone and Sesquiterpene from the Pericarp of Calocedrus formosana

One new γ-lactone, namely calolactone (1), together with one new drimane-type sesquiterpene, namely caloterpene (2), were isolated from the pericarp of Calocedrus formosana Florin. Their structures were elucidated by spectroscopic and mass spectrometric analysis.

[(18)F] FP-CIT PET study in parkinsonian patients with leukoaraiosis

BACKGROUNDS

Leukoaraiosis may present with slowly progressive parkinsonism indistinguishable from primary degenerative parkinsonism. Both leukoaraiosis and degenerative parkinsonism are an age-related disorder. Thus, comorbidity is expected to be common in elderly patients with parkinsonism. However, no systematic study has been reported on the clinical features indicating concomitant nigrostriatal dopaminergic denervation (NDD) in parkinsonian patients with leukoaraiosis.

METHODS

We performed [(18)F] FP-CIT positron emission tomography studies in 42 consecutive parkinsonian patients with diffuse leukoaraiosis, but no basal ganglia vascular lesions.

RESULTS

Twenty (48%) of the 42 patients had coexisting NDD. Compared to parkinsonian patients with isolated leukoaraiosis, those with coexisting NDD more frequently had asymmetric onset. They had similar degree of parkinsonian motor deficits in the legs, but greater rigidity and resting tremor in the arms. Consequently, they had less prominent lower body parkinsonism. They more frequently showed favorable response to levodopa treatment. They had similar burden of regional and total leukoaraiosis. Among a variety of clinical variables and MRI findings, only asymmetric onset and more than 30% improvement in UPDRS motor score by levodopa treatment were valuable indicators of coexisting NDD.

CONCLUSIONS

We would like to recommend dopaminergic functional imaging studies for all parkinsonian patients with leukoaraiosis. Further studies are needed to confirm sensitivity and specificity of asymmetric onset and good levodopa response for the prediction of coexisting NDD in a different group of parkinsonian patients with leukoaraiosis.

Characterizing the patterns of clonal selection in circulating tumor DNA from patients with colorectal cancer refractory to anti-EGFR treatment

INTRODUCTION

KRAS and EGFR ectodomain-acquired mutations in patients with metastatic colorectal cancer (mCRC) have been correlated with acquired resistance to anti-EGFR monoclonal antibodies (mAbs). We investigated the frequency, co-occurrence, and distribution of acquired KRAS and EGFR mutations in patients with mCRC refractory to anti-EGFR mAbs using circulating tumor DNA (ctDNA).

PATIENTS AND METHODS

Sixty-two post-treatment plasma and 20 matching pretreatment archival tissue samples from KRAS (wt) mCRC patients refractory to anti-EGFR mAbs were evaluated by high-sensitivity emulsion polymerase chain reaction for KRAS codon 12, 13, 61, and 146 and EGFR 492 mutations.

RESULTS

Plasma analyses showed newly detectable EGFR and KRAS mutations in 5/62 [8%; 95% confidence interval (CI) 0.02-0.18] and 27/62 (44%; 95% CI 0.3-0.56) samples, respectively. KRAS codon 61 and 146 mutations were predominant (33% and 11%, respectively), and multiple EGFR and/or KRAS mutations were detected in 11/27 (41%) cases. The percentage of mutant allele reads was inversely correlated with time since last treatment with EGFR mAbs (P = 0.038). In the matching archival tissue, these mutations were detectable as low-allele-frequency clones in 35% of patients with plasma mutations after treatment with anti-EGFR mAbs and correlated with shorter progression-free survival (PFS) compared with the cases with no new mutations (3.0 versus 8.0 months, P = 0.0004).

CONCLUSION

Newly detected KRAS and/or EGFR mutations in plasma ctDNA from patients refractory to anti-EGFR treatment appear to derive from rare, pre-existing clones in the primary tumors. These rare clones were associated with shorter PFS in patients receiving anti-EGFR treatment. Multiple simultaneous mutations in KRAS and EGFR in the ctDNA and the decline in allele frequency after discontinuation of anti-EGFR therapy in a subset of patients suggest that several resistance mechanisms can co-exist and that relative clonal burdens may change over time. Monitoring treatment-induced genetic alterations by sequencing ctDNA could identify biomarkers for treatment screening in anti-EGFR-refractory patients.

Rheumatoid arthritis patients with hip fracture: a nationwide study

SUMMARY

The study was to investigate the outcomes of rheumatoid arthritis (RA) patients with hip fractures with a large-scale, population-based, nationwide, case-cohort study using the Taiwan National Health Insurance database. The group has hip fractures at a younger age, higher complication, and mortality rate, which indicate that early intervention is necessary.

INTRODUCTION

This study seeks to evaluate the incidence, mortality, and complication rates in RA patients with hip fractures, using a nationwide database.

METHODS

Data were collected from the National Health Insurance Research Database of Taiwan. The study group included 117,129 patients with hip fractures diagnosed from January 2004 to December 2010. Matching based on the propensity of RA patients was used. In total, 1,088 hip fractures were reported among patients with RA. Patients with hip fractures were divided into two groups: those without RA (controls) and those with RA (RA group). The incidence of hip fracture and mortality and complication rates after the hip fracture were then compared between the two groups.

RESULTS

RA patients had a significantly higher incidence of hip fracture (3,260/100,000 person-years) compared with the general population (72/100,000 person-years). Hip fractures occurred significantly earlier among RA patients (70.6±5.3 years) compared with the control group (76.1±6.2 years). Cumulative mortality rates at 6-month and 1-year follow-up were significantly higher among patients in the RA group (9.47 and 18.47%) compared to the controls (8.47 and 13.62%) and among RA patients without hip fractures (3.24 and 6.16%). There was a significantly higher incidence of osteomyelitis after hip fracture among the RA group than among the body mass index-, comorbidity-, age-, and sex-matched patients in the control group.

CONCLUSIONS

Compared to patients without RA, those with RA have a higher incidence of hip fractures at a relatively younger age and with higher complication and mortality rates. Steroid and disease-modifying anti-rheumatic drugs, the most common medicine in Taiwanese RA patients, might contribute to the high incidence of fracture and post-op infection. Appropriate early intervention to prevent hip fractures in RA patients is a critical issue in rheumatology care.

Liquid antibiotics in bone cement: an effective way to improve the efficiency of antibiotic release in antibiotic loaded bone cement

Objectives

The objective of this study was to compare the elution characteristics, antimicrobial activity and mechanical properties of antibiotic-loaded bone cement (ALBC) loaded with powdered antibiotic, powdered antibiotic with inert filler (xylitol), or liquid antibiotic, particularly focusing on vancomycin and amphotericin B.

Methods

Cement specimens loaded with 2 g of vancomycin or amphotericin B powder (powder group), 2 g of antibiotic powder and 2 g of xylitol (xylitol group) or 12 ml of antibiotic solution containing 2 g of antibiotic (liquid group) were tested.

Results

Vancomycin elution was enhanced by 234% in the liquid group and by 12% in the xylitol group compared with the powder group. Amphotericin B elution was enhanced by 265% in the liquid group and by 65% in the xylitol group compared with the powder group. Based on the disk-diffusion assay, the eluate samples of vancomycin-loaded ALBC of the liquid group exhibited a significantly larger inhibitory zone than samples of the powder or the xylitol group. Regarding the ALBCs loaded with amphotericin B, only the eluate samples of the liquid group exhibited a clear inhibitory zone, which was not observed in either the xylitol or the powder groups. The ultimate compressive strength was significantly reduced in specimens containing liquid antibiotics.

Conclusions

Adding vancomycin or amphotericin B antibiotic powder in distilled water before mixing with bone cement can significantly improve the efficiency of antibiotic release than can loading ALBC with the same dose of antibiotic powder. This simple and effective method for preparation of ALBCs can significantly improve the efficiency of antibiotic release in ALBCs.

Cite this article: Bone Joint Res 2014;3:246–51.

Acupuncture for surgical conditions: an overview of systematic reviews

AIM

Several systematic reviews (SRs) of acupuncture for surgical conditions have recently been published with sometimes contradicting results. The aim of this overview was to summarise recent SRs of acupuncture for surgical conditions.

METHOD

Thirteen electronic databases were searched for relevant reviews published since 2000. Data were extracted by two independent reviewers according to predefined criteria.

RESULTS

Twelve SRs met our inclusion criteria. They related to the prevention or treatment of postoperative nausea and vomiting as well as to surgical or postoperative pain. Their results were far from uniform, and several caveats need to be considered.

CONCLUSION

The evidence is insufficient to suggest that acupuncture is an effective intervention in surgical settings. More rigorous research seems warranted. This protocol was registered with PROSPERO database (registration number: CRD42013004817).

Aliphatic phenolic ethers from Trichobotrys effusa

Four novel aliphatic phenolic ethers, namely, trichoethers A-D (1-4), possessing a unique C11-O-C10 skeleton, together with coriloxin, zythiostromic acid A, radicicol, and 3,5-dihydroxytoluene were isolated from the ethyl acetate extracts of the fermented broths of Trichobotrys effusa YMJ1179. The structures of all the compounds were determined based on spectroscopic data analysis. The configurations of 1-4 were established by J values and NOESY and compared with published data. Compounds 1-4 and radicicol exhibited growth-inhibitory activities against the A549 non-small-cell lung cancer cell line with GI50 values of 25.61, 19.32, 16.19, 24.31, and 1.43 μM, respectively, in comparison with 5-fluorouracil (GI50 = 4.55 μM).

An intrauterine catch-up growth regimen increases food intake and post-natal growth in rats

Nutritional conditions during the intrauterine stage are an important developmental programming factor that can affect the growth and metabolic status during foetal development and permanently alter the phenotypes of newborn offspring and adults. This study was performed to examine the effects of intrauterine catch-up growth (IUCG) on food intake, post-natal body growth and the metabolic status of offspring and growing rats. Control pregnant rats were fed ad libitum during the entire gestation period. For the IUCG regimen, pregnant rats were fed 50% of the food of the controls from pregnancy days 4 through 11 (8 days), followed by ad libitum feeding from pregnancy days 12 through parturition. The birth weight of offspring was not affected by the IUCG regimen. At weaning, offspring from each treatment group were assigned to two groups and given either a normal diet or high-fat diet (HFD) for 12 weeks until 103 days of age. In the normal diet group, the IUCG offspring showed a 9.0% increase (P < 0.05) in total food intake, were 11.2% heavier (p < 0.05) at 103 days of age and had an 11.0% greater (p < 0.05) daily weight gain compared with control offspring. The IUCG regimen did not affect body glucose and lipid metabolism. After exposure to the HFD, the IUCG regimen has not exacerbated metabolic disorders. In conclusion, our findings suggest that the IUCG nutritional regimen during pregnancy can increase the food intake and post-natal body growth of offspring without inducing metabolic disorders such as obesity and insulin resistance. The IUCG nutritional regimen might be used to improve the food intake and post-natal body growth of domestic animals.

Comparison of the reliability of two hydronephrosis grading systems: the Society for Foetal Urology grading system vs. the Onen grading system

AIM

To compare the reliability of the conventional ultrasonography grading system for hydronephrosis as suggested by the Society for Fetal Urology (SFU) in 1993 and that developed by Onen in 2007.

MATERIALS AND METHODS

One hundred and eighty kidneys in 90 paediatric patients were assessed by four radiologists using each of the two grading systems twice. The SFU system was graded 0-4 (0 = no hydronephrosis; 1 = visualized only renal pelvis; 2 = plus a few caliceal dilatation; 3 = all calyceal dilatation; 4 = plus parenchymal thinning). The Onen system was graded 0-4 (0 = no hydronephrosis; 1 = only renal pelvic dilatation; 2 = plus caliceal dilatation; 3 = plus <50% renal parenchymal loss; 4 = plus >50% renal parenchymal loss). Cohen's kappa statistic was used to estimate intra- and interobserver agreement. The weighted least-squares approach was used to compare the intra-observer agreement, and bootstrapping was used to compare the interobserver agreement between the two systems.

RESULTS

Intra-observer agreement was substantial to almost perfect in both the SFU (κ 0.79-0.95) and the Onen (κ 0.66-0.97) grading system without difference. The overall interobserver agreement was substantial in both the SFU (κ 0.61-0.68) and the Onen (κ 0.66-0.76) grading system. However, interobserver agreement was fair to moderate for SFU grades 1 and 2 and Onen grades 2 and 3.

CONCLUSION

Both the SFU and Onen grading system are reliable with good intra- and interobserver agreement. However, decreased interobserver agreement was demonstrated for SFU grades 1 and 2 and Onen grades 2 and 3.

Inhibitory effect of tianeptine on catagen induction in alopecia areata-like lesions induced by ultrasonic wave stress in mice

BACKGROUND

Alopecia areata (AA) is characterized by rapid and complete hair loss in one or multiple areas of the scalp. Stress is an important triggering factor in AA.

AIM

To identify the inhibitory effect of tianeptine on catagen induction in C57BL/6 mice with AA-like lesions induced by ultrasonic wave stress (UWS).

METHODS

The mice were divided into four groups. Group 1 received oral tianeptine before and after UWS; group 2 received oral tianeptine only after UWS; group 3 was given UWS treatment only; and group 4 (negative control group) was not given any treatment. Phototrichigraphy and dermatoscopy were used for assessment. Histological analysis was performed using haematoxylin and eosin, toluidine blue, Masson trichrome and Verhoeff-van Gieson stains. Immunohistochemical analysis was also performed. The level of apoptosis and expression of neuropeptides in the skin were assessed by terminal deoxynucleotidyl transferase dUTP nick end labelling and immunofluorescence assays.

RESULTS

Mice in group 1 had an increased rate of hair growth and greater hair-shaft thickness compared with mice in groups 2 and 3. In addition, mice in group 1 had a higher number of anagen hair follicles, increased synthesis of collagen and elastic fibres, decreased mast-cell degranulation, reduction in cell apoptosis in hair follicles, and recovery of vitamin D receptor expression. Expression of neuropeptides (substance P, calcitonin gene-related peptide) was not altered.

CONCLUSIONS

Tianeptine might play a role in suppressing catagen induction in a stress-induced AA mouse model.

Severe dietary lysine restriction affects growth and body composition and hepatic gene expression for nitrogen metabolism in growing rats

Dietary lysine restriction may differentially affect body growth and lipid and nitrogen metabolism, depending on the degree of lysine restriction. This study was conducted to examine the effect of dietary lysine restriction on growth and lipid and nitrogen metabolism with two different degree of lysine restriction. Isocaloric amino acid-defined diets containing 1.4% lysine (adequate), 0.70% lysine (50% moderate lysine restriction) and 0.35% lysine (75% severe lysine restriction) were fed from the age of 52 to 77 days for 25 days in male Sprague-Dawley rats. The 75% severe lysine restriction increased (p < 0.05) food intake, but retarded (p < 0.05) growth, increased (p < 0.05) liver and muscle lipid contents and abdominal fat accumulation, increased (p < 0.05) blood urea nitrogen levels and mRNA levels of the serine-synthesizing 3-phosphoglycerate dehydrogenase gene, but decreased (p < 0.05) urea cycle arginase gene mRNA levels. In contrast, the 50% lysine restriction did not significantly (p > 0.05) affect body growth and lipid and nitrogen metabolism. Our results demonstrate that severe 75% lysine restriction has detrimental effects on body growth and deregulate lipid and nitrogen metabolism.

Development of an early psychosis intervention system in Korea: focus on the continuing care system for first-episode psychosis treatment in Seoul

Providing intensive psychosocial intervention within the 5-year critical period following the first psychotic episode is important for both symptomatic and functional recovery. Recently, community mental health centres in Korea have begun to shift their main roles from care of those with chronic schizophrenia to early detection of and interventions for those with first-episode psychosis. This pioneering approach was initiated by the Seoul Mental Health Center, which established a community network, formed a clinical consortium with hospitals and clinics, and developed guidelines for early psychosis detection and management and for the Social Treatment for Early Psychosis (STEP) programme. The One-STEP programme, provided during hospitalisation, has been especially efficient in obtaining a high acceptance rate for community services. Several key issues are discussed with regard to the successful establishment of the close partnership between community mental health centres and hospitals / clinics.

Patterns of pncA mutations in drug-resistant Mycobacterium tuberculosis isolated from patients in South Korea

BACKGROUND

Pyrazinamide (PZA), one of the most effective anti-tuberculosis drugs, becomes toxic to Mycobacterium tuberculosis when converted to pyrazinoic acid by pyrazinamidase (PZase). PZA resistance is caused mainly by the loss of enzyme activity by mutation.

OBJECTIVE

To investigate the patterns of pncA mutations in PZA-resistant mycobacteria isolated from South Korean patients.

METHODS

Mycobacterial isolates with clinically proven drug resistance were cultured to determine susceptibility to anti-tuberculosis agents. pncA mutations were recognised by sequencing and compared with the relevant wild-type DNA sequence.

RESULTS

Among 108 isolates, 102 were successfully cultured and underwent drug susceptibility testing; all were multidrug-resistant (MDR). pncA mutations were found in 86 cultured isolates (85.1%): 55 (84.6%) in MDR and 31 (86.1%) in extensively drug-resistant isolates. Substitution of a single nucleotide was most common. The most frequent mutations were a deletion that caused a frameshift at nucleotide (nt) 71, a substitution at nt 403 and a substitution at nt 11. Combined, these accounted for ≈ 40% of all mutations. However, 15 samples (14.9%) with defective PZase activity showed no mutation.

CONCLUSION

pncA mutation in M. tuberculosis is a major mechanism of PZA resistance in MDR isolates from patients in South Korea. The patterns of mutation might be more scattered and diverse. DNA-based diagnosis of PZA resistance has potential for the rapid detection of drug resistance.

Practice patterns and opening pressure measurements using fluoroscopically guided lumbar puncture

BACKGROUND AND PURPOSE

Evidenced-based protocols for fluoroscopically guided LP do not exist. This study analyzed the fluoroscopically guided LP techniques currently used by practicing neuroradiologists.

MATERIALS AND METHODS

An anonymous Web-based survey was e-mailed to members of ASNR. The results were compiled and tabulated on a spreadsheet.

RESULTS

A total of 577 neuroradiologists completed the survey. Most neuroradiologists perform fluoroscopically guided LPs with the patient in the prone position by using a 22-ga needle at the L2-L3 or L3-L4 intervertebral space. The OP measurement technique is quite variable. Only a minority of patients are rotated to the left LD position for OP measurement. Most neuroradiologists observe patients for 1-2 hours after the procedure and require strict bed rest.

CONCLUSIONS

Most neuroradiologists have similar protocols for thecal sac puncture. Normative adult OP data exist only for the LD position, and the accuracy of prone OP measurements is not known. We found that the OP measurement technique is not consistent and a standard protocol is warranted.