Intravascular ultrasound-guided optimization for chronic total occlusion-percutaneous coronary intervention with multiple drug-eluting stents

Background

Multiple stenting in the chronic total occlusion (CTO) lesions is frequently required, however associated with poorer clinical outcomes. It is demonstrated that intravascular ultrasound (IVUS)-guided CTO-percutaneous coronary intervention (PCI) is related to a lower risk of adverse clinical events.

Purpose

We aimed to evaluate the clinical impact of stent optimization under IVUS guidance for multiple stenting, comparing with single stenting.

Methods

A total of 916 patients receiving drug-eluting stent (DES) under IVUS guidance were classified into two groups (stent optimization and non-optimization) according to optimization criteria (an absolute expansion criteria; minimal stent area ≥4.9 mm2 and a relative expansion criteria; 80% of mean reference lumen area). Of total population, 314 patients (34.3%) were treated with single stent and 575 patients (62.7%) were treated with multiple stents, respectively. Ischemic-driven target-lesion revascularization (TLR)/reocclusion was evaluated.

Results

Under IVUS guidance, 316 patients (34.5%) met IVUS criteria for stent optimization The achieving rates were 53% in the single stent group and 24% in the multiple stents group, respectively, (p<0.001). During a median of 4.7 years, the multiple stent group showed a significantly higher TLR/reocclusion rate, compared with the single stent group (12.8% vs. 5.2%, adjusted hazard ratio [HR] 2.51, 95% confidence interval [CI] 1.20–5.25, p=0.01). (Figure 1) Meeting both the absolute and relative expansion criteria was associated with a significantly low rate of TLR/reocclusion rate (12.5% vs. 5.2%, adjusted HR 0.34, 95% CI: 0.15–0.79, p=0.01). Under IVUS-guidance, there was no significant difference between multiple stenting and single stenting in case of achieving the optimization criteria (6.5% vs. 4.2%, p=0.11), whereas non-optimization group in the patients with multiple stenting showed a significantly higher rate of TLR/reocclusion, compared with IVUS-optimization group in the patients with single stenting (14.5% vs. 4.2%, p=0.002). (Figure 2)

Conclusions

In CTO-PCI with DES, multiple stenting significantly increased the risk of TLR/reocclusion. IVUS-guided optimization for multiple stenting showed a comparable long-term risk of TLR/reocclusion to single stenting with IVUS optimization. Hence, achieving IVUS expansion criteria may help to reduce the risk of TLR/reocclusion in CTO-PCI with multiple DES overlapping.

Funding Acknowledgement

Type of funding sources: None.

[Targeted therapy of pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome (PAPA): a case report and literature review]

Objective: To analyze the clinical course and targeted therapy of pyogenic sterile arthritis, pyoderma gangrenosum, and acne (PAPA) syndrome. Methods: The clinical history of a 6-year-old boy with PAPA syndrome, who was admitted to Hong Kong University Shenzhen Hospital in September 2017, was reviewed. His genetic diagnosis was confirmed by whole exome sequencing. The response to targeted therapy was evaluated by comparing the inflammatory markers (erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) and serum cytokines (interleukin (IL)-1, IL-6 and tumor necrosis factor-α (TNF-α)) before and after biological agents treatment. For literature review, "PAPA syndrome" and"PSTPIP1 gene"were used as keywords to retrieve papers published from January 1997 to December 2019 from Pubmed, Wanfang and CNKI database. Results: The patient was a 6-year-old boy, admitted to the hospital due to recurrent joint swelling and pain for more than 4 years. Before treatment, the CRP (256 mg/L), ESR (105 mm/1 h) and cytokines including serum TNF-α (7.43 ng/L), IL-1 (<5 ng/L), IL-6 (301 ng/L) were significantly elevated. Culture of the joint effusion was negative, but the IL-6 level was above 1 000 ng/L. MRI showed osteomyelitis at the lower end of the right femur. Gene detection found a heterozygous variation of PSTPIP1 gene (c.748G>A, p.E250K). Arthralgia once alleviated after the initiation of tocilizumab and infliximab, but recurred after 1 year of treatment. Thereafter, the anti-IL-1 receptor antagonist (Anakinra) was commenced, followed by a significant improvement of the arthralgia, and a complete remission during the follow-up. Besides, the level of CRP, ESR, serum TNF-α, IL-1 and IL-6 were all decreased to normal on the last followed up in December 2019. Literature review found 29 articles and 87 patients in total. The initial symptoms included those of arthritis (n=58), pyoderma gangrenosum (n=33), and acne (n=24). Among all the cases, 13 genotypes were confirmed, and 47 variations involved amino acid p.E250. Steroid and/or biological agents were used in most patients. Conclusions: PAPA syndrome should be suspected in children with recurrent pyogenic sterile arthritis, and an early diagnosis could be achieved by genetic test. Targeted treatment with biological agent may control the symptoms effectively. Biological agents can control symptoms of this disorder effectively.

Sex-specific association of urate and levodopa-induced dyskinesia in Parkinson's disease

BACKGROUND AND PURPOSE

As a major antioxidant, uric acid (UA) is known to be associated with the clinical progression of Parkinson's disease (PD). This study investigated whether baseline UA levels are associated with the risk for levodopa-induced dyskinesia (LID) in PD in a sex-dependent manner.

METHODS

In all, 152 patients with de novo PD (78 males and 74 females) who were followed up for >2 years were enrolled. The effect of baseline serum UA levels on LID-free survival was assessed by Cox regression, separately for sex, whilst being adjusted for potential confounding factors. The optimal UA level cut-off value to determine the high-risk group for LID was set using Contal and O'Quigley's method.

RESULTS

Levodopa-induced dyskinesia developed in 23 (29.5%) male patients and 30 (40.5%) female patients. Cox regression showed a significant interaction between UA level and sex. Higher UA levels were associated with a higher risk for LID in male PD patients (hazard ratio 1.380; 95% confidence interval 1.038-1.835; P = 0.027), although this relationship was not observed in female PD patients. The optimal UA level cut-off for LID in male PD was 7.2 mg/dl, and the high UA group had a 5.7-fold higher risk of developing LID than the low UA group.

CONCLUSIONS

Contrary to a presumptive beneficial role of UA, the present study demonstrated that higher UA levels are associated with increased risk of LID occurrence in male patients with PD, suggesting a sex-dependent role of UA in LID.

Cognitive anosognosia is associated with frontal dysfunction and lower depression in Parkinson's disease

BACKGROUND AND PURPOSE

Anosognosia refers to a deficit of self-awareness or impaired insight for cognitive and behavioral problems. Cognitive anosognosia was explored in de novo patients with Parkinson's disease (PD) and its relationship to cognitive function and neuropsychiatric symptoms was investigated.

METHODS

The cross-sectional study enrolled 340 drug-naïve patients with PD. According to the presence of mild cognitive impairment (MCI) and subjective cognitive complaint, patients were classified as patients with cognitive anosognosia (PD-CA, n = 74), with normal cognitive recognition (PD-NR, n = 184) or with cognitive underestimation (PD-CU, n = 82). After controlling for covariates, cognitive performance and neuropsychiatric symptoms were compared between the PD groups.

RESULTS

Cognitive anosognosia was found in 21.8% of patients with de novo PD. The PD-CA group showed poorer performance in all cognitive domains except for attention. Amongst PD patients with MCI, those with cognitive anosognosia showed lower composite z-scores in the Stroop color reading test than those without. The Beck Depression Inventory score in the PD-NR group was lower than that in the PD-CU group and higher than that in the PD-CA group. The Cognitive Complaints Interview score mediated the association between cognitive anosognosia and Beck Depression Inventory score.

CONCLUSIONS

Cognitive anosognosia in PD was associated with greater frontal dysfunction and lower depression. Since cognitive anosognosia has a harmful impact on PD patients and their caregivers due to overestimation of their abilities in everyday life, early identification of cognitive anosognosia in PD is important in management and prognosis.

Improved quantitative assessment of HBV-associated liver fibrosis using second-harmonic generation microscopy with feature selection

BACKGROUND AND AIM

Quantitative assessments of liver fibrosis using second-harmonic generation/two-photon excited fluorescence microscopy provide greater sensitivity and accuracy than collagen proportionate area while eliminating operator-dependent variation in the staining process. In conjunction with sophisticated image analysis algorithms and feature selection, we might reduce the computation cost in future and narrow down the candidates for further clinical studies.

METHODS

We sampled a total of 244 liver specimens from patients with hepatitis B viral infections who underwent liver biopsy or liver resection at the National Taiwan University Hospital. The samples were then imaged using a Genesis (HistoIndex Pte. Ltd, Singapore) system, wherein second-harmonic generation microscopy was used to visualize collagen, and two-photon excited fluorescence microscopy was used to visualize other cell structures. We used 100 morphological features extracted from the images to assess correlations with METAVIR fibrosis scores.

RESULTS

Out of 100 quantitative measurements, 76 showed significant correlation with METAVIR scoring, thereby enabling the statistical discrimination of patients in various stages of the disease. These 76 features were also narrowed down by the nonlinear test to 10 candidate measurements, which can be further investigated in detail.

CONCLUSIONS

Our experimental results showed that the model with 10 selected features can beat the one with second-harmonic generation only, and performed equivalently well compared the model with 76 features, especially for early-stage discrimination. Features presenting significant correlation were used to fit a single combined index in order to predict pathological staging, thereby making it possible to reveal incremental progress during treatment.

224 Malignancy associated pericardial effusion- do we need to drain them all?

On Behalf

Cardiac Team, Department of Medicine, Queen Elizabeth Hospital

Background

Management of significant pericardial effusion in cancer patients is controversial. These patients have poor prognosis, and avoiding unnecessary intervention is important. Close monitoring of symptoms and echocardiogram is often a reasonable option, but inherits risk of cardiac tamponade. Whether pericardial drainage by means of percutaneous pericardiocentesis or surgical pericardiotomy could prevent future deterioration or affect survival is unknown.

Purpose

To evaluate the benefit of elective pericardial drainage in malignancy associated pericardial effusion without echocardiographic or clinical evidence of tamponade effect.

Methods

From 1st Jul 2014 to 31st Dec 2017, all patients with new onset malignancy-associated pericardial effusion with size more than 1cm were retrospectively analyzed. Patients with clinical or echocardiographic evidence of cardiac tamponade were excluded. We compared pericardial drainage versus monitoring for short-term (30-day), mid-term (90-day) and long term (1 year) survival without need for drainage.

Results

101 patients were retrospectively analyzed. 40 (39.6%) patients underwent drainage. Overall median survival free from drainage was 4 months. There were no significant difference in short-term (30-day), mid-term (90-day) and long term (1-year) survival free from drainage or mortality between treatment and monitoring group. Size of pericardial effusion did not predict mortality or future need of drainage. Chemotherapy was associated with improved 30-day mortality (RR 0.53 CI 0.32-0.87 p = 0.025) but not survival free from drainage or longer term mortality.

Conclusion

Close monitoring could be a feasible strategy in cancer patients with significant pericardial effusion without tamponade effect.

Baseline characteristics Factor Drainage (n = 40) monitoring (n = 61) p-value method of drainage pericardiocentesis alone 17 NA pericardiotomy alone 13 both 10 Male 19 (47.5%) 27 (44.3%) 0.749 mean size (cm) 1.93 2.77 &lt;0.001 mean age 60.9 63.1 0.357 on chemotherapy 27 (67.5%) 38 (62.3%) 0.593

Abstract 224 Figure. Survival free from drainage

502 Secondary cardiac lymphoma complicated with tamponade

Introduction

A 72-year-old lady presented with one-week history of palpitation and shortness of breath. She had pyrexia of unknown origin for 4 weeks associated with weight loss. Initial clinical examination revealed sinus tachycardia of 110 beats/min and saturations of 96% on 2L/min oxygen. Neck exam revealed a 2 x 3 cm firm mass at left supraclavicular fossa. Electrocardiogram showed sinus tachycardia at 106 beats/min. There was fixed T wave inversions over anterolateral chest leads and inferior limb leads. Chest radiograph showed enlarged cardiac silhouette and evidence of pulmonary congestion

Procedure

Transthoracic echocardiogram revealed a moderate pericardial effusion with an 8 x 4 cm pericardial mass compressing at the right atrioventricular groove (Figure B & C). Respiratory variation of Doppler mitral and tricuspid inflow velocities suggested cardiac tamponade (Figure A). Inferior vena cava was engorged with impaired inspiratory collapse. Left ventricular size and function were otherwise normal. Urgent pericardiocentesis was performed which yielded 1 litre of light blood stained fluid. Her had subjective improvement of symptoms. There was also resolution of sinus tachycardia and pulmonary congestion. PET/CT scan showed multiple enlarged hypermetabolic lymph nodes in multiple regions above and below the diaphragm, worrisome for malignant lymphoma. Cytological assessment of pericardial fluid showed scattered large lymphoid cells which are immunoreactive to B cell marker CD 20 (Figure E & F). Bone marrow exam showed normal marrow.

First cycle of R-CEOP and intrathecal methotrexate was given. Follow-up echocardiogram in one week after chemotherapy showed complete resolution of pericardial effusion. Prior pericardial mass also showed marked reduction in size (Figure D). No tamponade physiology was present. She tolerated the chemotherapy well with complete resolution of palpitation and shortness of breath. She was discharged from hospital with outpatient follow up and continuation of chemotherapy course.

Discussion

Cardiac tumors are rare and secondary tumors remain the most common etiology. Most of these metastatic tumors arise from solid organs such as lung, breast, kidney, melanoma as well as lymphoma. Echocardiography is a valuable tool both in diagnosis and assessment of hemodynamic significance of cardiac masses. It also aids in diagnosis of associated condition such as pericardial effusion.

In this case, the cardiac tamponade is both contributed by mechanical compression of cardiac mass coupled with moderate pericardial effusion. Successful pericardiocentesis achieved temporary normalization of tamponade physiology and aided in early histological diagnosis of malignant lymphoma with pericardial metastasis. Timely initiation of intensive systemic chemotherapy was the key to rapid tumor size reduction, complete resolution of tamponade physiology and control of recurrent pericardial effusion.

Abstract 502 Figure. Echo & histology

Effects of Alzheimer's disease and Lewy body disease on subcortical atrophy

BACKGROUND AND PURPOSE

Subcortical structures are affected by neurodegeneration in Alzheimer's disease (AD) and Lewy body disease (LBD). Although the co-occurrence of AD and LBD pathologies and their possible interaction have been reported, the effect of AD and LBD on subcortical structures remains unknown. The effects of AD and LBD on subcortical atrophy and their relationship with cognitive dysfunction were investigated.

METHODS

The cross-sectional study recruited 42 patients with pure AD related cognitive impairment (ADCI), 30 patients with pure LBD related cognitive impairment (LBCI), 58 patients with mixed ADCI and LBCI, and 29 normal subjects. A general linear model was used to compare subcortical volume and shape amongst the groups, to investigate the independent and interaction effects of ADCI and LBCI on subcortical shape and volume, and to analyze the relationship between subcortical volume and cognitive dysfunction in each group.

RESULTS

Alzheimer's disease related cognitive impairment and LBCI were independently associated with subcortical atrophies in the hippocampus and amygdala and in the hippocampus and putamen respectively, but their interaction effect was not significant. Compared to the control group, the pure LBCI group exhibited additional local atrophies in the amygdala, caudate and thalamus. Subcortical atrophies correlated differently with cognitive dysfunction according to the underlying causes of cognitive dysfunction.

CONCLUSIONS

The patterns of subcortical atrophies and their correlation with cognitive dysfunction differ according to the underlying AD, LBD or concomitant AD and LBD.

Tuberculosis and diabetes in low and moderate tuberculosis incidence countries

In countries with low and moderate incidence of tuberculosis (TB), the disease tends to concentrate in specific high-risk populations such as people with diabetes mellitus (DM). We review the updated evidence on the association between 1) DM and active TB, and 2) DM and latent tuberculous infection (LTBI), and 3) we summarize the findings on the population-level impact of DM on TB epidemiology, with particular focus on low- and moderate-incidence settings. We conducted an updated review of studies on DM and active TB, and found 11 more cohort studies published after the previous systematic review from 2008. The updated pooled relative risk (RR) (2.03, 95%CI 1.62-2.55) of all the studies was substantially lower than the three-fold risk increase in the previous review. Substantial heterogeneity of RR across studies was found. Possible reasons for such heterogeneity include different levels of residual confounding, the effect of modification by age, and different levels of glycemic control in the population. In a recently published systematic review on DM and LTBI, one cohort study and 12 cross-sectional studies were identified. The results from cross-sectional studies suggest a significant but modestly increased risk of LTBI among patients with DM (pooled odds ratio 1.18, 95%CI 1.06-1.30). We reviewed evidence on the population-level impact of DM on TB epidemiology in studies using population-attributable fraction analysis and infectious disease modelling. Those studies revealed that DM accounted for a substantial TB burden in low- and moderate-incidence countries. Finally, we discussed the complex association of obesity, DM and TB risk and the impact of the global obesity pandemic on TB epidemiology.

P4733Risk of myocardial infarction with coronary artery bypass grafting versus percutaneous coronary intervention: a systematic review and meta-analysis of fifteen randomised trials

Background

It remains controversial whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) is more effective in the prevention of myocardial infarction (MI). MI has been evaluated only as a secondary endpoint without a focused systematic review in multiple meta-analyses.

Purpose

To compare the risk of MI at the latest follow-up available between CABG versus PCI with stents in patients with multivessel or left main coronary artery disease in a pairwise meta-analysis of randomised controlled trials (RCT).

Methods

We searched EMBASE, Cochrane, and Pubmed databases for articles comparing CABG versus PCI for the treatment of multivessel or left main disease. We utilised random-effects model to calculate pooled risk ratio (RR) and 95% confidence interval (CI). Fifteen trials with a total of 13,592 patients treated with either CABG (n=6,596) or PCI (n=6,996) were eligible and included. A multivariable random-effects meta-regression model, including variables such as age, sex, diabetes mellitus, publication year, follow-up duration, type of stent used, and type of coronary artery disease, was used to explore the source of potential heterogeneity of the primary result.

Results

After a weighted follow-up of 4.3 years, patients treated with CABG had a significantly lower risk of MI than patients treated with PCI (RR 0.75, 95% CI 0.58–0.96, P=0.024, I2=66%). The lower risk of MI with CABG as compared to PCI was more evident during a longer duration of follow-up (≥3 years, RR 0.69, 95% CI 0.52–0.91, P=0.008; ≥5 years, RR 0.64, 95% CI 0.48–0.86, P=0.003) and in diabetic population (RR 0.55, 95% CI 0.44–0.70, P<0.001). There was a statistically meaningful trend toward fewer MIs with CABG with a similar magnitude of risk reduction across patients with left main disease (RR 0.74, 95% CI 0.47–1.15) and multivessel disease (RR 0.72, 95% CI 0.53–0.99). Moderate inter-study heterogeneity could not be explained by the clinical and trial-based variables tested in meta-regression, and is likely because of differences in definitions of MI, risk profile of enrolled patients, and procedural specifics.

Forest plots

Conclusions

In patients undergoing revascularization for multivessel or left main disease, the risk of MI was lower with CABG compared to PCI. The quality assurance for MI definition and treatment-specific procedures should be emphasized for future RCTs.

Clinical relevance of amnestic versus non-amnestic mild cognitive impairment subtyping in Parkinson's disease

BACKGROUND AND PURPOSE

To clarify whether subtyping of amnestic and non-amnestic mild cognitive impairment (MCI) is clinically relevant in Parkinson's disease (PD) by analyzing patterns of neuroimaging and longitudinal cognitive changes.

METHODS

We performed comparative analyses of cortical thickness, hippocampal volume, white matter integrity and resting-state functional connectivity between the patients with de-novo PD with amnestic MCI (PD-aMCI) (n = 50) and non-amnestic MCI (PD-naMCI) (n = 50) subtypes. Additionally, we assessed the longitudinal rate of cognitive decline in each cognitive domain over time and the rate of dementia conversion in patients with de-novo PD-aMCI (n = 125) and PD-naMCI (n = 61).

RESULTS

The demographic data showed that scores in memory domains were lower in the PD-aMCI group compared with the PD-naMCI group. There were no significant differences in cortical thickness, hippocampal volume and white matter integrity between the two groups, although the PD-aMCI group exhibited more cortical thinning and hippocampal atrophy relative to the control group. The PD-aMCI group exhibited increased functional connectivity in the left posterior parietal region with the salience network relative to the PD-naMCI group. The longitudinal cognitive assessment demonstrated that patients with PD-aMCI exhibited a more rapid cognitive decline in frontal/executive function than those with PD-naMCI (P = 0.022). In addition, the PD-aMCI group had a higher risk of dementia conversion than the PD-naMCI group.

CONCLUSIONS

This study suggests that the designation of PD-MCI subtypes based on memory function would highlight the heterogeneity of functional correlates as well as the longitudinal cognitive prognosis.

Evidence for genetic heterogeneity between clinical subtypes of bipolar disorder

We performed a genome-wide association study of 6447 bipolar disorder (BD) cases and 12 639 controls from the International Cohort Collection for Bipolar Disorder (ICCBD). Meta-analysis was performed with prior results from the Psychiatric Genomics Consortium Bipolar Disorder Working Group for a combined sample of 13 902 cases and 19 279 controls. We identified eight genome-wide significant, associated regions, including a novel associated region on chromosome 10 (rs10884920; P=3.28 × 10-8) that includes the brain-enriched cytoskeleton protein adducin 3 (ADD3), a non-coding RNA, and a neuropeptide-specific aminopeptidase P (XPNPEP1). Our large sample size allowed us to test the heritability and genetic correlation of BD subtypes and investigate their genetic overlap with schizophrenia and major depressive disorder. We found a significant difference in heritability of the two most common forms of BD (BD I SNP-h2=0.35; BD II SNP-h2=0.25; P=0.02). The genetic correlation between BD I and BD II was 0.78, whereas the genetic correlation was 0.97 when BD cohorts containing both types were compared. In addition, we demonstrated a significantly greater load of polygenic risk alleles for schizophrenia and BD in patients with BD I compared with patients with BD II, and a greater load of schizophrenia risk alleles in patients with the bipolar type of schizoaffective disorder compared with patients with either BD I or BD II. These results point to a partial difference in the genetic architecture of BD subtypes as currently defined.

Association between dietary fibre intake with cancer and all-cause mortality among 15 740 adults: the National Health and Nutrition Examination Survey III

BACKGROUND

Few prospective studies have examined the longitudinal associations of total dietary fibre intake and water insoluble and soluble fibres with cancer and all-cause mortality. The present study aimed to examine these associations.

METHODS

We studied the effects of total dietary fibre intake and water insoluble and soluble fibres on cancer and all-cause mortality, using data from 15 740 adult participants [mean (SD) age: 44.53 (19.22) years, 46.60% male] in the National Health and Nutrition Examination Survey (NHANES) III, 1988-1994, who had completed a 24-h dietary recall. Death certificate data were obtained up to 2006. Participants had been followed for 13.74 years on average. Cox regression was used to estimate the hazard ratios (HRs) of total dietary, insoluble and soluble fibres on cancer and all-cause mortality, with the first quartile as the reference group, adjusted for demographics, lifestyle and dietary factors.

RESULTS

Relative to those in the first quartile of total fibre intake, only the third quartile was associated with all-cause mortality, with an adjusted HR of 0.87 [95% confidence interval (CI) = 0.79, 0.97, P = 0.021], and cancer mortality, with an adjusted HR of 0.77 (95% CI = 0.61, 0.99, P = 0.05). The third quartile of insoluble fibre intake was associated with cancer mortality, with an adjusted HR of 0.76 (95% CI = 0.60, 0.96, P = 0.023), and colorectal-anal cancer mortality (in grouped data as provided for public use), with an adjusted HR of 0.42 (95% CI = 0.19, 0.91, P = 0.03).

CONCLUSIONS

Dietary fibre showed protective benefits in terms of mortality risk. Investigating the mechanisms and components of dietary fibres underlying the different protective benefits remains an important consideration for research on fibre-mortality risk.

Does serum uric acid act as a modulator of cerebrospinal fluid Alzheimer's disease biomarker related cognitive decline?

BACKGROUND AND PURPOSE

The association of serum uric acid, cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD) and longitudinal cognitive decline was evaluated using the AD Neuroimaging Initiative database.

METHODS

In 271 healthy subjects, 596 mild cognitive impairment patients and 197 AD patients, serum uric acid and CSF AD biomarkers were measured at baseline, and Mini-Mental State Examination and AD Assessment Scale - Cognitive Subscale (ADAS-cog) were assessed serially (mean duration, 2.9 years). The effect of uric acid on longitudinal cognitive decline was evaluated using linear mixed effect models for Mini-Mental State Examination and ADAS-cog scores in female and male subjects separately, with possible confounders controlled (model 1). To determine the effects of uric acid independent of CSF biomarker (Aβ1-42 or tau) and to test whether the detrimental effects of CSF biomarker differ according to uric acid, CSF biomarker and its interaction with uric acid were further included in model 1 (model 2).

RESULTS

Higher levels of uric acid were associated with slower cognitive decline, particularly in the mild cognitive impairment and dementia subgroups, and more prominently in female subjects. Model 2 with CSF Aβ1-42 showed that higher levels of uric acid were associated with a slower cognitive decline and alleviated the detrimental effect of Aβ1-42 on cognitive decline. Model 2 with CSF tau showed that higher levels of uric acid alleviated the detrimental effect of tau on cognitive decline in female subjects but not in male subjects.

CONCLUSION

Higher levels of uric acid had protective effects on longitudinal cognitive decline independent of and interactively with CSF AD biomarkers.

Different Functional and Microstructural Changes Depending on Duration of Mild Cognitive Impairment in Parkinson Disease

BACKGROUND AND PURPOSE

The higher cortical burden of Lewy body and Alzheimer disease-type pathology has been reported to be associated with a faster onset of cognitive impairment of Parkinson disease. So far, there has been a few studies only about the changes of gray matter volume depending on duration of cognitive impairment in Parkinson disease. Therefore, our aim was to evaluate the different patterns of structural and functional changes in Parkinson disease with mild cognitive impairment according to the duration of parkinsonism before mild cognitive impairment.

MATERIALS AND METHODS

Fifty-nine patients with Parkinson disease with mild cognitive impairment were classified into 2 groups on the basis of shorter (<1 year, n = 16) and longer (≥1 year, n = 43) durations of parkinsonism before mild cognitive impairment. Fifteen drug-naïve patients with de novo Parkinson disease with intact cognition were included for comparison. Cortical thickness, Tract-Based Spatial Statistics, and seed-based resting-state functional connectivity analyses were performed. Age, sex, years of education, age at onset of parkinsonism, and levodopa-equivalent dose were included as covariates.

RESULTS

The group with shorter duration of parkinsonism before mild cognitive impairment showed decreased fractional anisotropy and increased mean and radial diffusivity values in the frontal areas compared with the group with longer duration of parkinsonism before mild cognitive impairment (corrected P < .05). The group with shorter duration of parkinsonism before mild cognitive impairment showed decreased resting-state functional connectivity in the default mode network area when the left or right posterior cingulate was used as a seed, and in the dorsolateral prefrontal areas when the left or right caudate was used as a seed (corrected P < .05). The group with longer duration of parkinsonism before mild cognitive impairment showed decreased resting-state functional connectivity mainly in the medial prefrontal cortex when the left or right posterior cingulate was used as a seed, and in the parieto-occipital areas when the left or right caudate was used as a seed (corrected P < .05). No differences in cortical thickness were found in all group contrasts.

CONCLUSIONS

Resting-state functional connectivity and WM alterations might be useful imaging biomarkers for identifying changes in patients with Parkinson disease with mild cognitive impairment according to the duration of parkinsonism before mild cognitive impairment. The functional and microstructural substrates may topographically differ depending on the rate of cognitive decline in these patients.

Cerebral Microbleeds in Patients with Dementia with Lewy Bodies and Parkinson Disease Dementia

BACKGROUND AND PURPOSE

The burden of amyloid β is greater in patients with dementia with Lewy bodies than in those with Parkinson disease dementia, and an increased amyloid β load is closely related to a higher incidence of cerebral microbleeds. Here, we investigated the prevalence and topography of cerebral microbleeds in patients with dementia with Lewy bodies and those with Parkinson disease dementia to examine whether cerebral microbleeds are more prevalent in patients with dementia with Lewy bodies than in those with Parkinson disease dementia.

MATERIALS AND METHODS

The study population consisted of 42 patients with dementia with Lewy bodies, 88 patients with Parkinson disease dementia, and 35 controls who underwent brain MR imaging with gradient recalled-echo. Cerebral microbleeds were classified as deep, lobar, or infratentorial.

RESULTS

The frequency of cerebral microbleeds was significantly greater in patients with dementia with Lewy bodies (45.2%) than in those with Parkinson disease dementia (26.1%) or in healthy controls (17.1%; P = .017). Lobar cerebral microbleeds were observed more frequently in the dementia with Lewy bodies group (40.5%) than in the Parkinson disease dementia (17%; P = .004) or healthy control (8.6%; P = .001) group, whereas the frequencies of deep and infratentorial cerebral microbleeds did not differ among the 3 groups. Logistic regression analyses revealed that, compared with the healthy control group, the dementia with Lewy bodies group was significantly associated with the presence of lobar cerebral microbleeds after adjusting for age, sex, nonlobar cerebral microbleeds, white matter hyperintensities, and other vascular risk factors (odds ratio, 4.39 [95% CI, 1.27-15.25]). However, compared with the healthy control group, the Parkinson disease dementia group was not significantly associated with lobar cerebral microbleeds.

CONCLUSIONS

This study showed that patients with dementia with Lewy bodies had a greater burden of cerebral microbleeds and exhibited a lobar predominance of cerebral microbleeds than did patients with Parkinson disease dementia.

Risks and predictors of osteoporosis in patients with inflammatory bowel diseases in an Asian population: a nationwide population-based cohort study

BACKGROUND

We investigated the inflammatory bowel disease (IBD) specific predictors of osteoporosis and pathological fracture by analysing the Taiwan National Health Insurance Research Database.

METHODS

Totally, we enrolled 3141 IBD patients and 12,564 age- and sex-matched controls. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of osteoporosis and pathological fracture in both cohorts.

RESULTS

Inflammatory bowel disease patients had significantly higher comorbidity-adjusted rates of osteoporosis and pathological fracture compared with controls [adjusted hazard ratio (aHR), 1.31; 95% CI, 1.09-1.60, p = 0.004]. Further analysis indicated that women (aHR, 1.36; 95% CI, 1.09-1.70, p = 0.008), middle-aged patients (aHR, 1.74; 95% CI, 1.25-2.41, p = 0.001), patients with Crohn's disease (aHR, 1.33; 95% CI, 1.09-1.64, p = 0.006) and patients without comorbidities (aHR, 1.81; 95% CI, 1.23-2.67, p = 0.003) exhibited excessive risks of osteoporosis. Moreover, patients requiring hospitalisation for IBD exhibited the highest risk of developing osteoporosis (aHR, 4.46; 95% CI, 2.74-7.27, p < 0.001) and pathological fracture (aHR, 17.1; 95% CI, 5.78-50.9, p < 0.001).

CONCLUSIONS

Patients with IBD, particularly women, middle-aged patients and patients without comorbidities, are associated with a long-term risk of osteoporosis. The risks of osteoporosis and pathological fracture were highest in patients requiring hospitalisation for IBD.

Multi-locus genome-wide association analysis supports the role of glutamatergic synaptic transmission in the etiology of major depressive disorder

Major depressive disorder (MDD) is a common psychiatric illness characterized by low mood and loss of interest in pleasurable activities. Despite years of effort, recent genome-wide association studies (GWAS) have identified few susceptibility variants or genes that are robustly associated with MDD. Standard single-SNP (single nucleotide polymorphism)-based GWAS analysis typically has limited power to deal with the extensive heterogeneity and substantial polygenic contribution of individually weak genetic effects underlying the pathogenesis of MDD. Here, we report an alternative, gene-set-based association analysis of MDD in an effort to identify groups of biologically related genetic variants that are involved in the same molecular function or cellular processes and exhibit a significant level of aggregated association with MDD. In particular, we used a text-mining-based data analysis to prioritize candidate gene sets implicated in MDD and conducted a multi-locus association analysis to look for enriched signals of nominally associated MDD susceptibility loci within each of the gene sets. Our primary analysis is based on the meta-analysis of three large MDD GWAS data sets (total N=4346 cases and 4430 controls). After correction for multiple testing, we found that genes involved in glutamatergic synaptic neurotransmission were significantly associated with MDD (set-based association P=6.9 × 10(-4)). This result is consistent with previous studies that support a role of the glutamatergic system in synaptic plasticity and MDD and support the potential utility of targeting glutamatergic neurotransmission in the treatment of MDD.

Genome-wide association study in a Swedish population yields support for greater CNV and MHC involvement in schizophrenia compared with bipolar disorder

Schizophrenia (SCZ) and bipolar disorder (BD) are highly heritable psychiatric disorders with overlapping susceptibility loci and symptomatology. We conducted a genome-wide association study (GWAS) of these disorders in a large Swedish sample. We report a new and independent case-control analysis of 1507 SCZ cases, 836 BD cases and 2093 controls. No single-nucleotide polymorphisms (SNPs) achieved significance in these new samples; however, combining new and previously reported SCZ samples (2111 SCZ and 2535 controls) revealed a genome-wide significant association in the major histocompatibility complex (MHC) region (rs886424, P=4.54 × 10(-8)). Imputation using multiple reference panels and meta-analysis with the Psychiatric Genomics Consortium SCZ results underscored the broad, significant association in the MHC region in the full SCZ sample. We evaluated the role of copy number variants (CNVs) in these subjects. As in prior reports, deletions were enriched in SCZ, but not BD cases compared with controls. Singleton deletions were more frequent in both case groups compared with controls (SCZ: P=0.003, BD: P=0.013), whereas the largest CNVs (>500 kb) were significantly enriched only in SCZ cases (P=0.0035). Two CNVs with previously reported SCZ associations were also overrepresented in this SCZ sample: 16p11.2 duplications (P=0.0035) and 22q11 deletions (P=0.03). These results reinforce prior reports of significant MHC and CNV associations in SCZ, but not BD.

The in vitro protection of human decay accelerating factor and hDAF/heme oxygenase-1 transgenes in porcine aortic endothelial cells against sera of Formosan macaques

To mitigate hyperacute rejection, pigs have been generated with alpha-Gal transferase gene knockout and transgenic expression of human decay accelerating factor (hDAF), MCP, and CD59. Additionally, heme-oxygenase-1 (HO-1) has been suggested to defend endothelial cells. Sera (MS) (0%, 1%, 5%, 10%, and 15%) from Formosan macaques (Macaca cyclopis, MC), an Old World monkey wildly populated in Taiwan, was used to test the protective in vitro, effects of hDAF or hDAF/hHO-1 on porcine aortic endothelial cells (pAEC) derived from hDAF(+), hDAF(+)/hHO-1(+), and hDAF(+)/hHO-1(-) and 1 nontransgenic pAEC. Ten percent human serum (HS) served as a positive control. When MS addition increased to 10% or 15%, all transgenic pAEC exhibited a greater survival than nontransgenic pAEC. Noticeably, 15% MS reduced survived to <10% versus >40% in nontransgenic and transgenic pAEC, respectively. These results revealed that hDAF exerted protective effects against MC complement activation. However, comparing with 10% MS and HS in pAEC of nontransgenic pigs, the survivability was higher in HS, suggesting that complement activation by MS was more toxic than that by HS. Furthermore, hDAF(+)/hHO-1(+) showed no further protection against effects of MS on transgenic pAEC.

Paroxysmal choreodystonic disorders

Paroxysmal choreodystonic disorders or paroxysmal dyskinesias are a heterogeneous group of movement disorders characterized by recurrent attacks of abnormal involuntary movements. They are classified into four categories according to the precipitant, duration of attacks, and etiology: (1) paroxysmal kinesigenic dyskinesia (PKD), in which attacks are brief and induced by sudden voluntary movements; (2) paroxysmal nonkinesigenic dyskinesia (PNKD), in which attacks occur spontaneously; (3) paroxysmal exertion-induced dyskinesia (PED), in which attacks are brought on by prolonged exercise; and (4) paroxysmal hypnogenic dyskinesia (PHD), in which attacks occur during sleep. Among them, PHD is currently known to be a form of mesial frontal-lobe epilepsy, and has been given the term "autosomal-dominant nocturnal frontal lobe epilepsy" (ANDFLE) in some familiar cases with an autosomal-dominant inheritance. The clinical, etiological and pathophysiological features of PKD, PNKD, and PED are reviewed.

Neuroanatomic basis of amnestic MCI differs in patients with and without Parkinson disease

OBJECTIVE

To explore the neuroanatomic basis of amnestic mild cognitive impairment (aMCI) in patients with Parkinson disease (PD; aMCI-PD(+)) and without PD (aMCI-PD(-)).

METHODS

A total of 119 patients with aMCI (aMCI-PD(-), n = 78, and aMCI-PD(+), n = 41) underwent T1-weighted MRI, and the image data were analyzed using voxel-based morphometry.

RESULTS

No significant differences in demographic characteristics or general cognition were found between patients with aMCI-PD(-) and aMCI-PD(+). Comparisons of neuropsychological tests between groups revealed that patients with aMCI-PD(-) had lower scores in delayed verbal and visual recognition memory, whereas visuospatial dysfunction was more severe in patients with aMCI-PD(+). Gray matter (GM) density in the right temporal and posterior cingular cortices was significantly lower in the aMCI-PD(-) group compared with controls. In contrast, GM density in the aMCI-PD(+) group was significantly lower in the precuneus and left prefrontal and primary motor areas relative to controls. A direct comparison between groups showed that decreased GM density in aMCI-PD(-) relative to aMCI-PD(+) was localized in the right temporal and anterior prefrontal areas, whereas decreased GM density in aMCI-PD(+) relative to aMCI-PD(-) was involved in the bilateral precuneus, left primary motor, and right parietal areas. Memory decline was correlated with temporal area atrophy in aMCI-PD(-) and with posterior cingulate cortex atrophy in aMCI-PD(+).

CONCLUSIONS

Our data suggest that different neuroanatomic systems underlie memory dysfunction in patients with aMCI-PD(-) and aMCI-PD(+).

Heart rate variability during hemodialysis and following renal transplantation

Previous studies have shown awareness of uremic dysfunction in end-stage renal disease (ESRD) patients. Dysautonomia in ESRD patients may be reversible after renal transplantation. We used a power spectral analysis (PSA) of heart rate variability (HRV) to assess alterations of autonomic activity in 14 controls and 14 nondiabetic hemodialysis ESRD patients who had undergone renal transplantation. Compared with matched control subjects, the power frequency determinations of low frequency (LF; 3.42 ln(ms(2)) vs 6.38 ln(ms(2)); P < .05 high frequency (HF; 2.29 ln(ms(2)) vs 5.27 ln(ms(2)); P < .05)), and total power (TP; 5.39 ln(ms(2)) vs 7.53 ln(ms(2)); P < .05) were significantly suppressed in ESRD patients undergoing hemodialysis. ESRD patients showed significantly improved HRV after renal transplantation. After renal transplantation, there was no significant difference in the TP (6.82 ln(ms(2)) vs 7.53 ln(ms(2)); P = .15) component between measurements in both patient subgroups. We further divided the ESRD patients into 2 groups based on their pretransplantation HRV, observing alterations in HRV after renal transplantation. Patients with significantly improved HRV were those with more suppressed HRV before transplantation (HF <3 In(ms(2)). Autonomic dysfunction in ESRD patients was not irreversible even if severe, and recovery was observed as early as 6 months after transplantation.

Analysis of the factors influencing living kidney donation: the experience in National Taiwan University Hospital

INTRODUCTION

Kidney transplantation provides a choice of active treatment for patients with chronic renal failure. However, the sources of organs are limited; therefore, living kidney donation is an alternative source. The regulation of organ donation in Taiwan stipulates that living organ donation is restricted to living related recipients. We sought to investigate factors that influenced or prevented individuals from living kidney donation in our center.

MATERIALS AND METHODS

From January 2005 to December 2008, there were 266 potential candidates who underwent evaluation for living kidney donation in our center.

RESULTS

Among the potential candidates, most were spouses (n=85, 31.9%), followed by parents (n=67, 25.1%), siblings (n=62, 23.3%), and children (n=40, 15%). Eventually, 124 candidates (47%) completed organ donation, most of whom were siblings (n=39, 31.5%), then parents (n=38, 30.6%), spouses (n=26), and children (n=18). Most donors were females, including mothers and sisters. The most frequent reason to not donate was unwillingness, due to potential influences on their health, economic stress due to suspension of their job, and objection of family members. In 34 candidates (23.9%), adverse health factors of potential candidates prohibited them from donating, including age, chronic medical illness, hepatitis carrier status, severe depression, or mental retardation. Among 59 potential donor-recipient pairs with incompatible ABO blood types or highly sensitized to potential donors, 22 candidates completed living kidney donation.

CONCLUSION

Although laparoscopic nephrectomy for living kidney donation decreases the discomfort and hospital stay after donation, we can only promote living kidney donation if we can deal with the possible factors that prohibit candidates from living kidney donation, such as morbidity after organ donation, anxiety, or other factors. After analyzing those factors, we must also develop a protocol to closely follow the living kidney donors to ensure their health status and relieve their anxiety.

Randomized clinical trial of single-incision laparoscopic cholecystectomy versus minilaparoscopic cholecystectomy

BACKGROUND

Transumbilical single-incision laparoscopic cholecystectomy (SILC) and minilaparoscopic cholecystectomy (MLC) are both increasingly being used to treat symptomatic gallstones. The present study compared SILC and MLC with respect to outcome in a prospective randomized trial.

METHODS

Seventy patients with symptomatic cholelithiasis were randomized to SILC or MLC (35 in each group). The primary outcome measure was postoperative pain. Secondary outcomes were duration of operation, complications, postoperative analgesic requirements, length of hospital stay, cosmetic result, wound length and time to return to work.

RESULTS

Surgical complications, postoperative pain scores, analgesic requirements and time to return to work were similar for both procedures. Statistically significant advantages of SILC were a shorter hospital stay, shorter total wound length and better cosmetic appearance. Duration of operation was significantly shorter for MLC.

CONCLUSION

SILC is superior to MLC in terms of cosmetic outcome, but not in postoperative pain and requirement for analgesics.

Stabilization of blood methylmalonic acid level in methylmalonic acidemia after liver transplantation

Methylmalonic acidemia with complete mutase deficiency (mut(0) type) is an inborn error of metabolism with high mortality and morbidity. LT has been suggested to be a solution to this disease, but elevation of urinary and blood MMA was still observed after LT. In this study, we measured dry blood spot MMA and its precursor propionyl-carnitine (C3-carnitine) for mut(0) patients. The results revealed that when C3-carnitine rose during metabolic stress, MMA rose exponentially (up to 1000 micromol/L) in patients who did not undergo LT. In patients who underwent LT, MMA rose to 100-200 micromol/L when C3-carnitine reached 10-20 micromol/L. However, when C3-carnitine rose further to 40-50 micromol/L, MMA levels just stayed put. Therefore, LT stabilized blood MMA level, though there might be a threshold for blood MMA clearance by the donor liver. This finding should be critical to understand the long-term outcome for LT in methylmalonic acidemia.

Acute lobar nephronia in a renal allograft: a case report and literature review

We report a diabetic renal transplant recipient who presented with fever and right lower quadrant abdominal pain. Acute appendicitis was considered initially and she underwent emergent appendectomy. However, persistent symptoms postoperatively made us perform an imaging study to identify the problems. Abdominal and pelvic computed tomography disclosed several focal wedge-shaped lesions of low attenuation in the renal allograft. Acute lobar nephronia was successfully managed with parenteral antibiotics. The patient recovered without any sequela. A renal allograft in the right iliac fossa complicates the diagnosis among acute renal infection, malignancy, acute rejection, and even acute appendicitis. Biopsy of the renal allograft is sometimes needed due to clinically ambiguous imaging results. In this report, we not only detail the clinical course of such a rare case, but also review the previous 3 cases of acute lobar nephronia in renal allografts in the literature.

Human leukocyte antigen-DR matching improved skin graft survival from transgenic pigs to accommodate SCID mice reconstituted with human peripheral blood mononuclear cells

The shortage of human organs has encouraged scientists to develop genetically modified pigs for xenotransplantation, such as CD55 or CD46, and CD59 transgenesis as well as alpha-galactosyl transferase gene knockouts. In allotransplantation, the match of human leukocyte antigen class II (HLA-II) may improve graft survival although the role of HLA-II in xenotransplantation is unknown. HLA-II transgenic pigs, including DP, DQ, and DR, have been successfully generated and HLA-DR15+ transgenic pig skin pieces grafted onto severe congenital immunodeficiency (SCID) mice reconstituted intraperitoneally with HLA-DR15+ or HLA-DR15(-) human peripheral blood mononuclear cells (hPBMCs). This study sought to develop an animal model to evaluate the effects of HLA-DR matching on xenograft survival. Human CD4+ and CD8+ were detected from days 7 to 29 after hPBMC reconstitution in SCID mice. Both CD4+ and CD8+ cells of HLA-DR15(-) reconstituted SCID mice were significantly higher at day 29 postgrafting compared with HLA-DR15+ reconstituted SCID mice. An HLA-DR15+ transgenic pig dermal graft survived and integrated into SCID mice reconstituted with hPBMCs/HLA-DR15+ as proven by the histopathological finding that the collagen layer remained intact with little lymphocytic response. In contrast, the transgenic pig dermal graft showed more collagen disruption as well as mild to moderate lymphocytic infiltration when reconstituted in an hPBMC/HLA-DR15(-) SCID mouse. The results suggested that HLA-DR matching eased xenograft rejection; however, it was not yet clear that the response was mediated by T cells.

Aberrant middle turbinate masquerading as a nasopharyngeal mass

We present a unique variant of the middle turbinate that extends posteriorly through the choana to wrap around the posterior free edge of the nasal septum. The embryology and anatomy of the lateral nasal wall and the nasal septum are reviewed.

The impact of human ABO blood groups on human xenoreactive antibody-mediated cytotoxicity and the protective effect of human decay-accelerating factors exogene on swine endothelium

Swine tissue can express antigens similar to human A/B blood types. We evaluated whether the variation in human blood type influences the human xenoreactive antibody-mediated cytotoxicity and modifies the protective effect of human decay-accelerating factor (hDAF) exogene, a complement activation regulator, on swine endothelium.

METHODS

Pig aortic endothelial cells were harvested form normal and hDAF transgenic pigs. Cellular viability was evaluated with an MTT assay.

RESULTS

As compared with that of other human blood types, human serum from blood type O donors induced more prominent cytotoxicity on swine endothelial cells both from hDAF transgenic or normal pigs (P < .05). In addition, this difference of xenoreactive antibody-induced cytotoxicity between treatment with O and other human blood type sera was more evident in hDAF transgenic swine endothelial cells than those of normal pigs (P < .05). The hDAF exogene can significantly protect the endothelial cells from human xenoreactive antibody-mediated cytotoxicty when treated with human serum from AB blood type (P < .05). Our data demonstrated that human ABO blood type significantly affected human xenoreactive antibody-induced cytotoxicity, which may modulate the protective effect of hDAF exogene expression on swine endothelial cells.

Increased cochlear fluid-attenuated inversion recovery signal in patients with vestibular schwannoma

BACKGROUND AND PURPOSE

Elevated protein levels have been reported in perilymph of patients with vestibular schwannoma. Fluid-attenuated inversion recovery (FLAIR) imaging is sensitive to high protein contents in fluids. The purpose of this study was to investigate if in patients with unilateral vestibular schwannoma, cochlear FLAIR signal intensity on the affected side is increased compared with the unaffected side and control subjects.

MATERIALS AND METHODS

Fifteen patients with unilateral vestibular schwannoma and 25 age-matched control subjects (without a history of hearing loss) were retrospectively evaluated. All patients and controls had routine 5-mm FLAIR and T1- and T2-weighted imaging of the brain. The signal intensity of both cochleae was evaluated by placing a small region of interest on FLAIR images. The signal intensity of the brain stem was also determined by placing a second region of interest. A ratio of cochlear signal intensity to brain stem signal intensity (CIBI ratio) was determined. A t test was used to compare the CIBI ratios.

RESULTS

In patients, the mean CIBI ratio of the affected side was 0.89 +/- 0.18, and that of the unaffected side was 0.57 +/- 0.12. In control subjects, it was 0.51 +/- 0.07. The CIBI ratio of the affected side was significantly higher compared with the unaffected side (P < .001) and compared with control subjects (P < .001).

CONCLUSION

Patients with vestibular schwannoma have increased cochlear FLAIR signal intensity on the affected side compared with the unaffected side and healthy subjects.

Diffusion tensor imaging in patients with essential tremor

BACKGROUND AND PURPOSE

The traditional paradigm has regarded essential tremor (ET) as a benign disorder. However, recent clinical, neuroimaging, and neuropathologic studies suggest that ET may be a progressive neurologic disorder. Based on clinicopathologic findings that cerebellum and its outflow are the key structures in ET and degeneration of gray matter in cerebellum is followed by consequent wallerian degeneration of white matter (WM) fibers, the aim of the present study was to investigate changes in anisotropy in patients with ET.

MATERIALS AND METHODS

Fractional anisotropy (FA) images were generated from DTI data acquired at 1.5T in 10 patients with ET compared with 8 control subjects by using statistical parametric mapping to make voxel-by-voxel comparisons.

RESULTS

Compared with the control subjects, the patients with ET exhibited significantly reduced FA (P(uncorrected) < .005) in the anterolateral portion of the right pons and decreased FA in the bilateral cerebellum, left retrorubral area of the midbrain, and bilateral deep WM, including the orbitofrontal, lateral frontal, parietal, and temporal WM.

CONCLUSION

This study demonstrates that structural changes in the WM are extensive in patients with ET, supporting the findings of previous functional neuroimaging and pathologic studies.

Antioxidant and pro-oxidant properties of chlorhexidine and its interaction with calcium hydroxide solutions

AIM

To evaluate the antioxidant and pro-oxidant properties of chlorhexidine (CHX).

METHODOLOGY

The scavenging and generation of reactive oxygen species (ROS) by CHX in the presence or absence of saturated Ca(OH)(2) solutions was evaluated. The reaction emitted chemiluminescence in the presence of lucigenin thus was determined by a luminometer to evaluate the levels of ROS production. Changes in DNA conformation were analysed by agarose gel electrophoresis. Paired Student's t-test was used to compare the difference between groups.

RESULTS

Chlorhexidine (0.00002-0.02%) effectively scavenged 56-88% of the superoxide radicals generated by the xanthine/xanthine oxidase reaction. Through analysis of PUC18 DNA conformation changes, CHX was shown to be a mild scavenger of hydroxyl radicals generated by H(2)O(2) plus FeCl(2). However, CHX (>0.083%) decreased the mobility of PUC18 plasmid DNA with potential production of DNA-DNA cross-link and severe DNA breaks (presence of DNA smear) at further higher concentrations. Furthermore, CHX induced ROS production including H(2)O(2) and superoxide radicals in 0.1N NaOH (pH = 12.76) or Ca(OH)(2) (pH = 12.5) solutions.

CONCLUSION

Chlorhexidine exhibited both antioxidant and pro-oxidant properties under different conditions. These events are possibly involved in the killing of root canal and periodontal microorganisms when CHX and Ca(OH)(2) were used in combination or separately. Potential genotoxicity and tissue damage when extruded into the periradicular tissue and at higher concentrations should be considered during periodontal and endodontic practice.

A comparison of cerebral glucose metabolism in Parkinson's disease, Parkinson's disease dementia and dementia with Lewy bodies

Parkinson's disease dementia (PDD) and dementia with Lewy bodies (DLB) share many similar aspects, and making a clinical diagnosis of one disorder over the other relies heavily on an arbitrary criterion, so-called 1-year rule. This study was designed to search for any difference of metabolic patterns in these two disorders using F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) images. We enrolled 16 patients with PD, 13 patients with PDD, and seven patients with DLB. FDG PET was performed, and images were reconstructed by iterative reconstruction using the computed tomography (CT) images, and were normalized to a standard template. Statistical comparison between groups were performed on a voxel-by-voxel basis using t-statistics (two-sample t-test). Compared with the patients with PD, both PDD and DLB patients showed similar patterns of decreased metabolism in bilateral inferior and medial frontal lobes, and right parietal lobe (P(uncorrected) < 0.001). In a direct comparison, DLB patients had significant metabolic decrease (p(uncorrected) < 0.005) in the anterior cingulate compared with those with PDD. These findings support the concept that PDD and DLB have similar underlying neurobiological characteristics, and that they can be regarded as a spectrum of Lewy body disorders.

Autologous mesenchymal stem cell therapy delays the progression of neurological deficits in patients with multiple system atrophy

We evaluated the feasibility and safety of therapy with mesenchymal stem cells (MSCs) through consecutively intra-arterial and three repeated intravenous injections and compared the long-term prognosis between MSC-treated (n=11) and control multiple system atrophy (MSA) patients (n=18). The MSC-treated patients showed significantly greater improvement on the unified MSA rating scale (UMSARS) than the control patients at all visits throughout the 12-month study period. Orthostasis in UMSARS I items and cerebellar dysfunction-related items of UMSARS II items were significantly different in favor of MSC treatment compared to controls. Serial positron emission tomography scan in the MSC-treated group showed that increased fluorodeoxyglucose uptake from baseline was noted in cerebellum and frontal white matters. No serious adverse effects related to MSC therapy occurred. This study demonstrated that MSC therapy in patients with MSA was safe and delayed the progression of neurological deficits with achievement of functional improvement in the follow-up period.

Clinicopathological differences between hepatitis B viral genotype B- and C-related resectable hepatocellular carcinoma

Clinical and pathogenic differences exist between hepatitis B viral (HBV) genotypes B and C, and genotype C has a higher risk of hepatocellular carcinoma (HCC) development than genotype B. The aim of this study was to investigate whether HBV genotypes B and C influence the clinicopathological features of patients with resectable HCC. Stored serum samples from 193 patients with resectable HBV-related HCC were tested for HBV genotypes by a molecular method. Of 193 patients undergoing resection of HCC, 107 (55%) and 86 (45%) were infected with genotypes B and C, respectively. Compared with genotype C patients, genotype B patients were less likely to be associated with liver cirrhosis (33%vs 51%, P = 0.01). Pathologically, genotype B patients had a higher rate of solitary tumour (94%vs 86%, P = 0.048) and more satellite nodules (22%vs 12%, P = 0.05) than genotype C patients. Our results indicate that genotype B-related HCC is less associated with liver cirrhosis and has a higher frequency of solitary tumour as well as more satellite nodules than genotype C-related HCC. These characteristics may contribute to the recurrence patterns and prognosis of HBV-related HCC in patients with genotype B or C infection.

Elective laparoscopically assisted sigmoidectomy for the sigmoid volvulus

BACKGROUND

The laparoscopic approach for the treatment of sigmoid volvulus has been a rare surgical indication. This phase 2 study investigated the feasibility and surgical outcomes of elective laparoscopic surgery for sigmoid volvulus.

METHODS

Patients with sigmoid volvulus were first offered colonoscopic decompression for their acute colonic obstruction. If the colonic decompression was successful, complete bowel preparation was performed, followed by elective laparoscopically assisted sigmoidectomy. The details of the laparoscopic procedures are shown in the video. Briefly, the redundant sigmoid colon is totally mobilized by a laparoscopic medial-to-lateral dissection sequence, after which it is exteriorized, transected, and reconstructed by end-to-end anastomosis. In the authors' experience, the medial-to-lateral approach is highly efficient for the laparoscopic mobilization of the redundant sigmoid colon. We believe that the longer the lateral abdominal wall attachment of the sigmoid colon is preserved, the better the exposure and the easier the dissection. If the risk of anastomotic leakage is considered high in a specific case, protective ileostomy is selectively preformed. Before entering the current study, the patients were well informed about the advantages and disadvantages of laparoscopic surgery. The enrollment of patients was selective according to the appropriate eligibility criteria. This study was approved by the Institutional Review Board of the National Taiwan University Hospital. The patients' clinicopathologic data and surgical outcomes were prospectively evaluated.

RESULTS

Between August 2001 and April, 2005, a total of 14 patients (10 men and 4 women) with sigmoid volvulus were treated with the described procedure. The age distribution of the patients was 68.4 +/- 12.2 years. The attack of sigmoid volvulus was the first episode for eight patients, the second episode for 4 patients, and the third episode (or more) for two patients. The body mass index (BMI) of the patients was 26.8 +/- 4.4 kg/m(2). The physical status (classification of American Society of Anesthesiology [ASA]) was 1 for five patients, 2 for eight patients, and 3 for 1 patient. During the laparoscopy, all the patients presented with the pathognomonic findings of sigmoid volvulus including redundant sigmoid colon, narrow sigmoid mesenteric pedicle, and mesosigmoiditis with mesenteric fibrosis and scarring, as shown in the video. The length of the resected colon was 32 +/- 6 cm. The operation time was 194.6 +/- 32.4 min, and the blood loss was 44.0 +/- 12.4 ml. The abdominal wound consisted of four 5 to 12 mm working ports and a 5 cm major wound for exteriorization of the sigmoid colon. Some surgeons have shown that a sigmoid volvulus can be resected through a 5-cm left lower quadrant incision with very little mobilization of the colon because of its redundancy. In this context, the laparoscopic approach competed with the minilaparotomy method in terms of adequate sigmoid resection, lysis of mesosigmoid adhesion, and tension-free colorectal anastomosis. Protective ileostomy was performed for the only patient with a physical status of ASA 3. There was no mortality in this case series. However, pneumonia developed postoperatively in one patient, acute myocardial infarction in one patient, and wound infection in two patients. Excluding the two patients who experienced postoperative pneumonia and acute myocardial infarction, the duration of the postoperative ileus was 48 +/- 12 h, the postoperative hospitalization was 7 +/- 1 days, and the degree of postoperative pain was 3.5 +/- 0.5 according to the visual analog scale. The return to partial activity required 18 +/- 2.5 days, and the return to full activity required 28.4 +/- 5.6 days. As compared with the overall costs for a conventional sigmoid colectomy, which are completely covered by the National Bureau of Health Insurance of Taiwan, the expenses for the patients undergoing laparoscopic procedures were significantly higher by approximately 24,000.0 NT dollars +/- 2,635.0 (1 U.S. dollar = 32 NT dollars). These higher expenses must be borne by the patients themselves.

CONCLUSION

Considering that patients with sigmoid volvulus often are elderly and chronically ill, laparoscopic elective surgery after a successful colonoscopic decompression may be a good choice for a selected group of patients in terms of minimized surgical complications and quick convalescence.

Stathmin overexpression cooperates with p53 mutation and osteopontin overexpression, and is associated with tumour progression, early recurrence, and poor prognosis in hepatocellular carcinoma

Stathmin, a major microtubule-depolymerizing protein, is involved in cell cycle progression and cell motility. This study aimed to elucidate its role in the progression, early tumour recurrence (ETR), and prognosis of hepatocellular carcinoma (HCC). Stathmin mRNA was overexpressed in 88/156 (56%) resected, unifocal, primary HCCs, while p53 mutation was present in 72 (46%) and osteopontin mRNA overexpression in 79 (51%). Stathmin mRNA expression exhibited high concordance (93%) with protein expression in 107 cases examined by immunohistochemistry. Stathmin overexpression correlated with high alpha-fetoprotein (>200 ng/ml, p = 0.02), larger tumour size (>5 cm, p = 0.012), high tumour grade (p < 0.0002), high tumour stage (stage IIIA-IV) with vascular invasion and various degrees of intrahepatic metastasis (p < 1 x 10(-8)), ETR (p = 0.003), and lower 5-year survival (p = 0.0007). Stathmin protein expression was often more intense in the peripheral regions of tumour trabeculae, tumour borders, and portal vein tumour thrombi. Stathmin overexpression correlated with p53 mutation (p = 0.017) and osteopontin overexpression (p = 1 x 10(-8)), both of which were associated with vascular invasion (both p < 0.0001) and poorer prognosis (p < 0.0004 and p = 0.0004, respectively). Regardless of the status of p53 mutation or osteopontin expression, stathmin overexpression was associated with higher vascular invasion (all p < 0.0001). Approximately 90% of HCCs harbouring stathmin overexpression with concomitant p53 mutation or osteopontin overexpression exhibited vascular invasion, and hence the lowest 5-year survival, p = 0.00018 and p = 0.0009, respectively. However, we did not find that stathmin overexpression exerted prognostic impact independent of tumour stage. In conclusion, stathmin expression correlates with metastatic potential, is an important prognostic factor for HCC, and may serve as a useful marker to predict ETR.

The hDAF Exogene Protects Swine Endothelial and Peripheral Blood Mononuclear Cells From Xenoreactive Antibody Mediated Cytotoxicity in hDAF Transgenic Pigs

Xenoreactive antibody-induced complement activation and cytotoxicity poses a major obstracle to xenograft survival in humans. Previously, we have generated transgenic pigs carrying the hDAF exogene to help overcome this problem. In this study, we examined whether the hDAF exogene in various swine cells shows an equally protective effect for the complement-mediated cytotoxicity induced by human xenoreactive antibodies. Pig peripheral blood mononuclear cells (PBMCs) and aortic endothelial cells (PAECs) were used as targets. Fresh human serum was harvested from a single healthy human donor as the source of human xenoreactive antibodies and complement. The target cells cocultured with medium containing various concentrations of human serum for 24 hours were evaluated using the 3-[4,5-dimethylthiaolyl]-2,5-diphenyl-tetrazolium bromide assay for cellular viability. We observed that xenoreactive antibody plus human complement-mediated cellular cytoxicity dose-dependently correlated with the concentration of human serum in the culture medium. As compared with the PBMCs from the normal pigs, PBMCs from hDAF transgenic pigs showed significantly better survival after treatment with human serum (P < .05). Similarly, the survival of PAECs from the hDAF transgenic pig were also significantly higher than that from normal pigs (P < .05). Our data demonstrated a protective effect from human xenoreactive antibodies and complement-mediated cytoxicity of hDAF exogenes in pig PBMCs and PAECs. These observations support the clinical value of the hDAF transgenic pig as an organ donor in xenotransplantation.

Attitude Toward Living Donor Liver Transplantation in Taiwan

OBJECTIVES

The purpose of this study was to investigate the attitudes and characteristics of donors for living donor liver transplantation (LDLT).

METHODS

This retrospective study was performed by a mailing or by telephone using a questionnaire. LDLT donors were recruited from a teaching hospitals located in a metropolitan area of northern Taiwan. The 11-item attitude questionnaire was specifically developed from the literature review with coordinator, physician, and donor feedback. Donors were asked to rate the queries on a 5-point Likert intensity scale.

RESULTS

The 47 LDLT donors included 28 (60%) women and 19 (40%) men. Most of the LDLT donors were aged less than 30 years old (n = 24, 51%) with (n = 12, 26%) between 31 and 40 years, and 11 (23%) more than 41 years. Self-perceived health status was poor (n = 4, 9%), not bad (n = 22, 47%), good (n = 19, 40%), or very good (n = 2, 4%). The top five LDLT donor attitudes were recognition of liver donation (n = 42, 89%), recognition of brain donation (n = 41, 88%), a hero (n = 35, 75%), honor to be a donor (n = 35, 5%), and improved relationship with recipient after donation (n = 33, 70%). The best person to suggest organ donation to a family was ranked as the doctors related to transplantation (n = 41, 88%), transplantation nurse coordinator (n = 40, 85%), social worker (n = 23, 49%), and doctor unrelated to transplantation (n = 17, 17%).

CONCLUSION

This study revealed positive attitudes toward donation. Some data afford insight to the decision-making procedure. Donor concerns may help professionals provide better interventions in the future.

Simultaneous Heart and Kidney Transplantation for Combined Cardiac and Renal Failure

Simultaneous heart and kidney transplantation (SHKT) is feasible for combined cardiac and renal failure. Herein we reviewed our 10-year experience in SHKT. Six patients underwent SHKT from June 1995 to December 2004. Their ages ranged from 13 to 63 years old with a mean of 45.5 +/- 15.8 years. They were all men except one girl, who was the youngest (aged 13) who suffered from dilated cardiomyopathy with congestive heart failure and chronic renal failure due to systemic lupus erythematosus. Because of aggravating heart failure, she changed from hemodialysis to peritoneal dialysis. Because of intractable heart failure, she underwent SHKT from a 24-year-old female donor. All received hemodialysis before SHKT. The indications for heart transplantation included dilated cardiomyopathy (n = 3), ischemic cardiomyopathy (n = 1), cardiac allograft vasculopathy (n = 1), and cardiac allograft failure (n = 1). The immunosuppressive protocol and rejection surveillance were these employed for heart transplantation. No operative mortality was noted in this study. The 1-year and 5-year survival rates were the same, 83%. The 10-year survival rate was 55%. No cardiac or renal allograft rejection was noted. No renal allograft loss was noted. There were two late mortalities: the one, who underwent redo heart transplantation for coronary artery vasculopathy died of cardiac allograft failure 1 year after SHKT. The other patient died of massive ischemic necrosis of the intestine at 6 years after SHKT. Our experience showed that SHKT had good short- and long-term results without increasing immunosuppressive doses. End-stage failure of either the heart or the kidney did not preclude heart plus kidney transplantation.