Beneficial Role of Multi-Disciplinary Treatment for Anaplastic Thyroid Cancer with Initial Distant Metastasis

PURPOSE/OBJECTIVE(S)

Anaplastic thyroid cancer (ATC) is a rare, highly aggressive tumor, with median survival around 5 months. Approximately half of the ATC patients presents with distant metastases at diagnosis, showing even more devastating prognosis, yet no outcome analysis had been reported. In this study, we aim to evaluate the clinical outcome of M1 ATC patients, and to define the group of patients who would benefit from local treatment based on multi-disciplinary approach.

MATERIALS/METHODS

A total of 133 histology-confirmed ATC patients underwent protocol-based multidisciplinary treatment including surgery and chemoradiotherapy (CRT) between May 2016 and January 2022. Patients received intensity-modulated radiotherapy of 30 fractions concurrently with paclitaxel on days 1, 8 and 15 every 4 weeks, and lenvatinib was added upon progression. After 18 fractions of CRT, interim response analysis using modified RECIST was conducted for adaptive treatment planning. We reviewed 58 patients with distant metastasis at diagnosis (stage IVC). Overall survival (OS) and progression-free survival (PFS) were measured from the day of diagnosis.

RESULTS

Most common metastatic site was lung (91.4%), followed by bone (31.0%) and brain (5.2%). Lenvatinib was added for 35 patients after any sign of progression. Fourteen patients received upfront surgery (16 debulking and 5 total) followed by adjuvant CRT in 16 patients. Thirty-one patients received upfront CRT with 2 patients receiving total resection after sufficient down-staging. Six (10%) patients could not complete radiotherapy but continued receiving systemic treatment. The median follow-up was 5.9 months. The median and 1-year OS were 6.2 months and 20.5%, and PFS were 3.7 months and 3.5%. Total RT dose over 60 Gy significantly improved median OS (7.5 vs 4.1 months, p = 0.012) and median PFS (4.4 vs 3.0, p = 0.010). Patients with less than 10 initial metastatic tumors showed better median OS (9.1 vs 4.6 months, p = 0.002) but not PFS (5.1 vs 3.6, p = 0.485). At interim analysis, early response (CR, PR and SD) of primary tumor was not associated with survival, while progression of distant metastases showed significantly worse median OS (9.8 vs 4.6 months, p = 0.001). More than 10 metastatic tumors (HR 2.73, 95% CI 1.32-5.66) and stable metastasis at interim analysis (HR 2.39, 95% CI 1.04-5.48) remained as significant factor in the multivariable cox regression analysis. Median OS and PFS of patients with less than 10 metastases showing no progression at interim analysis were 9.1 months, and 5.1 months.

CONCLUSION

Local treatment combined with chemotherapy for M1 ATC patients showed outcome comparable to those of non-metastatic ATC results. Active local treatment should be considered especially for patients with less than 10 metastases, and patients without distant progression in early response evaluation.

Efficacy of Silkworm Pupae Extract on Muscle Strength and Mass in Middle-Aged and Older Individuals: A Randomized, Double-Blind, Placebo-Controlled Trial

OBJECTIVES

We investigated the efficacy and safety of silkworm pupae extract (SWP) consumption for 12 weeks on muscle mass and strength in middle-aged and older individuals with relatively low skeletal muscle mass who do regular low-intensity exercise.

DESIGN

A randomized double-blinded placebo-controlled trial.

PARTICIPANTS

The study was conducted with 54 participants with relatively low skeletal muscle mass (SMM) (64.4 ± 6.1 years; body mass index, 23.8 ± 2.4 kg/m2).

INTERVENTION AND MEASUREMENTS

Participants were randomly assigned to one of two groups: 1000 mg of SWP/day plus regular exercise (SWP group, n=27) or placebo plus regular exercise (placebo group, n=27). All participants were required to engage in 30-60 minutes/day of walking for ≥3 days/week for 12 weeks. The primary outcome was knee extension/flexion strength (Nm), measured at the velocity of 60°/s. Secondary outcomes included body composition, biomarkers (creatine kinase and creatinine), handgrip strength, and quality of life questionnaire.

RESULTS

Both the intention-to-treat (ITT) and per-protocol (PP) analyses revealed no significant impact of SWP on knee strength compared to the placebo group over 12 weeks. On the other hand, the SWP group had significantly greater increases in right-handgrip strength by 1.94 kg (95% CI: 0.08-3.79; p = 0.041) and left-handgrip strength by 1.83 kg (0.25-3.41; p = 0.024) compared to the placebo group in the ITT population, after 12 weeks. Moreover, in the PP population, the SWP group revealed an even greater increase in right-handgrip strength by 2.07 kg (0.15-3. 98; p = 0.035) and left-handgrip strength by 2.21 kg (0.60-3.83; p = 0.008) for the 12-week period. However, this study resulted in a failure to detect significant differences in the body composition, biomarkers, quality of life questionnaire, physical activity, and caloric intake between the groups. None of the participants in the SWP group experienced any significant adverse events. In the placebo group, two participants experienced urticaria and allergic side effects, leading to their withdrawal from the study and two exhibited elevated levels of liver enzyme and increased diastolic blood pressure, respectively at 12 weeks.

CONCLUSION

SWP, in addition to low-intensity exercise, may enhance handgrip strengths in middle-aged and older adults with relatively lower SMM. Future studies need to use a large sample size over longer periods to validate our findings. This trial was registered at clinicaltrials.gov as NCT04994054.

Role of phloretin as a sensitizer to TRAIL‑induced apoptosis in colon cancer

Phloretin is one of the apple polyphenols with anticancer activities. Since tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) serves important roles in inducing apoptosis, the present study examined the effect of phloretin on TRAIL-induced apoptosis in colon cancer cells. Treatment with both phloretin and TRAIL markedly suppressed the survival of cancer cells from several colon cancer cell lines compared with that of cells treated with either TRAIL or phloretin. Additionally, decreased numbers of colonies were observed following addition of phloretin and TRAIL. Furthermore, TRAIL- and phloretin-treated HT-29-Luc cells exhibited decreased luciferase activity. Increased apoptosis was observed in phloretin- and TRAIL-treated HT-29-Luc colon cancer cells, accompanying elevated levels of cleaved poly(ADP-ribose) polymerase, and caspase-3, −8 and −9. The expression levels of MCL1 apoptosis regulator BCL2 family member (Mcl-1) were decreased following addition of phloretin in colon cancer cells. In addition, overexpression of Mcl-1 in phloretin- and TRAIL-treated HT-29-Luc cells resulted in increased cell survival. Treatment of HT-29-Luc cells with a combination of cycloheximide (CHX) and phloretin led to a more prominent decrease in Mcl-1 expression compared with that in cells treated with CHX alone, while Mcl-1 expression was recovered by treatment with MG132. Binding of ubiquitin with Mcl-1 was verified using immunoprecipitation. Intraperitoneal injection of both TRAIL and phloretin into tumor xenografts was associated with a decreased tumor volume compared with that following injection with either TRAIL or phloretin. Overall, the present results suggest a synergistic effect of phloretin on TRAIL-induced apoptosis in colon cancer cells.

A lysosomal enigma CLN5 and its significance in understanding neuronal ceroid lipofuscinosis

Neuronal Ceroid Lipofuscinosis (NCL), also known as Batten disease, is an incurable childhood brain disease. The thirteen forms of NCL are caused by mutations in thirteen CLN genes. Mutations in one CLN gene, CLN5, cause variant late-infantile NCL, with an age of onset between 4 and 7 years. The CLN5 protein is ubiquitously expressed in the majority of tissues studied and in the brain, CLN5 shows both neuronal and glial cell expression. Mutations in CLN5 are associated with the accumulation of autofluorescent storage material in lysosomes, the recycling units of the cell, in the brain and peripheral tissues. CLN5 resides in the lysosome and its function is still elusive. Initial studies suggested CLN5 was a transmembrane protein, which was later revealed to be processed into a soluble form. Multiple glycosylation sites have been reported, which may dictate its localisation and function. CLN5 interacts with several CLN proteins, and other lysosomal proteins, making it an important candidate to understand lysosomal biology. The existing knowledge on CLN5 biology stems from studies using several model organisms, including mice, sheep, cattle, dogs, social amoeba and cell cultures. Each model organism has its advantages and limitations, making it crucial to adopt a combinatorial approach, using both human cells and model organisms, to understand CLN5 pathologies and design drug therapies. In this comprehensive review, we have summarised and critiqued existing literature on CLN5 and have discussed the missing pieces of the puzzle that need to be addressed to develop an efficient therapy for CLN5 Batten disease.

Seed dormancy and germination of Asarum sieboldii, a disjunct relict species in East Asia

Disjunct species in the same genus are a common feature of the flora in the temperate forests of East Asia and eastern North America. This study aimed to evaluate whether the kind of seed dormancy was maintained after species in the genus Asarum (Aristolochiaceae) were separated from their common ancestor. We classified the seed dormancy of Asarum sieboldii, an East Asian species, based on a phenology study and experiments in controlled temperature conditions, and then compared it to that of the previously studied A. canadense, an eastern North American species. The underdeveloped embryo of A. sieboldii grew and germinated (radicle emergence) in autumn but shoot emergence did not occur until the following spring. The seeds of A. sieboldii had deep simple epicotyl morphophysiological dormancy because the seeds with emerged radicle required a relatively long period of cold stratification to break epicotyl dormancy and produce a shoot. Although the seed of A. sieboldii had weaker radicle dormancy and stronger epicotyl dormancy compared to A. canadense, the kind of seed dormancy was the same for the two species. The trait of seed dormancy was inherited from a shared common ancestor and maintained in populations well after the two species (or their ancestors) separated. However, quantitative differences in temperature requirements for radicle and shoot emergence suggest the possibility of adaptation to the environment.

Preferences for life-sustaining treatment in Korean adults: a cross-sectional study

OBJECTIVES

Life-sustaining treatment is any treatment that serves to prolong life without reversing the underlying medical conditions, and includes cardiopulmonary resuscitation, mechanical ventilation, haemodialysis and left ventricular assist devices. This study aimed to investigate the thoughts on life-sustaining treatment of Koreans and to assess the factors associated with deciding to not receive life-sustaining treatment if they develop a terminal disease.

DESIGN

Cross-sectional study.

SETTING

Guro-gu centre for dementia from 1 May 2018 to 31 December 2019.

PARTICIPANTS

In total, 150 individuals participated in this study.

OUTCOME MEASURES

The questionnaire consisted of self-report items with some instructions, demographic characteristics, thoughts on life-sustaining treatment and psychosocial scales. The preferences of the participants were investigated on the assumption that they develop terminal cancer. The psychosocial scales included the Generalised Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Connor-Davidson Resilience Scale and Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

We classified our participants into two groups: individuals who wanted to receive life-sustaining treatment (IRLT) and individuals who wanted to not receive life-sustaining treatment (INLT). There were twice as many participants in the INLT group than there were in the IRLT. In making this decision, the INLT group focused more on physical and mental distress. Additionally, 32.7% of participants responded that terminal status was an optimal time for this decision, but more participants want to decide it earlier. The GAD-7 and PHQ-9 scores were significantly higher in the INLT group than in the IRLT group. However, the INLT group had significantly lower MSPSS family scores.

CONCLUSION

Our findings can help assess issues regarding advance directives and life-sustaining treatment, and will be a reference for designing future studies on this issue.

Associations between Chewing Difficulty, Subjective Cognitive Decline, and Related Functional Difficulties among Older People without Dementia: Focus on Body Mass Index

OBJECTIVE

This study aimed to determine whether chewing difficulty is associated with subjective cognitive decline (SCD) and related functional difficulties by body mass index.

DESIGN

A population-based cross-sectional study.

SETTING AND PARTICIPANTS

A nationwide sample of 54,004 individuals aged ≥65 years from the 2018 Korea Community Health Survey.

MEASUREMENTS

SCD and SCD-related functional difficulties were measured using the cognitive decline module of the Behavioral Risk Factor Surveillance System. Chewing difficulty was assessed based on a self-report questionnaire from an oral health-related behaviors interview survey. BMI was calculated from objective values by measuring height and weight through a physical meter.

RESULTS

Among the 54,004 individuals, the prevalence of SCD in underweight, overweight, and obesity group was 33.6% (n = 806), 30.3% (n = 9,691), and 28.7% (n=5,632) respectively. Chewing difficulty was associated with SCD and SCD-related functional difficulties. This association was more pronounced in underweight (BMI: <18.5 kg/m2) people [underweight: (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.48-1.92); normal weight: OR = 1.13, 95% CI 1.04-1.22; obese: OR = 1.15, 95% CI 1.05-1.27]. Similar trends were demonstrated for SCD-related functional difficulties (underweight: OR = 1.53, 95% CI 1.17-2.01; normal weight: OR = 1.36, 95% CI 1.15-1.63; obese: OR = 1.50, 95% CI 1.22-1.86).

CONCLUSIONS

Chewing difficulty was associated with SCD and SCD-related functional difficulties in older people. Our results suggest that underweight status may play roles in the associations between chewing difficulty and SCD and SCD-related functional difficulties.

Prevalence of Anemia and Its Association with Frailty, Physical Function and Cognition in Community-Dwelling Older Adults: Findings from the HOPE Study

OBJECTIVES

The prevalence of anemia and its impact on frailty and physical function amongst the multiethnic older populations in the Southeast Asian (SEA) countries are often not well studied. Singapore, a nation comprised of multiethnic communities, is one of the most rapidly aging population globally. We aim to evaluate the prevalence of anemia and its impact on frailty, and physical function in Healthy Older People Everyday (HOPE)- an epidemiologic population-based study on community-dwelling older adults in Singapore.

DESIGN

Cross-sectional study.

SETTING

Community.

PARTICIPANTS

480 adults ≥ 65 years old.

MEASUREMENTS

Data were collected from interviewers-administered questionnaires on socio-demographics, FRAIL scale, Mini-Mental State Examination, EQ-5D, Barthel Index, and Lawton index. Hemoglobin concentration and physical assessments, including anthropometry, grip strength, timed up-and-go (TUG) were measured.

RESULTS

The overall prevalence of anemia was 15.2% (73 out of 480). The Indian ethnic group had the highest prevalence of anemia (32%, OR=3.02; 95%CI= 1.23-7.41) with the lowest hemoglobin concentration compared to the overall population (13.0±1.3g/L and 13.5±1.4g/L, p=0.02). Hemoglobin levels and anemia were significantly associated with frailty (OR=2.28; 95% CI=1.02-5.10), low grip strength (OR=1.79; 95% CI=1.01-3.03), ≥ one IADL impairment (OR=2.35; 95% CI=1.39-3.97). Each 1 g/dL increase in hemoglobin was associated with a 6% decrease in frailty odds after adjusting for potential covariates (OR = 0.94, 95% CI: 0.90-0.99). There was a significant difference in the mean TUG between the non-anemic (11.0±3.4 seconds) and anemic (12.3±6.0 seconds, p=0.01) counterparts, but no difference in the number of falls.

CONCLUSION

In our multiethnic Asian population, anemia was adversely associated with frailty, decreased muscle strength, and IADL impairment. Health policies on anemia screening should be employed to avoid or potentially delay or reverse these adverse outcomes associated with anemia. Recognition, evaluation, and treatment of anemia amongst this vulnerable population is warranted.

Risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in Hong Kong

BACKGROUND

Coronavirus disease 2019 (COVID-19) was first reported in Wuhan in December 2019 and has rapidly spread across different cities within and outside China. Hong Kong started to prepare for COVID-19 on 31st December 2019 and infection control measures in public hospitals were tightened to limit nosocomial transmission within healthcare facilities. However, the recommendations on the transmission-based precautions required for COVID-19 in hospital settings vary from droplet and contact precautions, to contact and airborne precautions with placement of patients in airborne infection isolation rooms.

AIM

To describe an outbreak investigation of a patient with COVID-19 who was nursed in an open cubicle of a general ward before the diagnosis was made.

METHOD

Contacts were identified and risk categorized as 'close' or 'casual' for decisions on quarantine and/or medical surveillance. Respiratory specimens were collected from contacts who developed fever, and/or respiratory symptoms during the surveillance period and were tested for SARS-CoV-2.

FINDINGS

A total of 71 staff and 49 patients were identified from contact tracing, seven staff and 10 patients fulfilled the criteria of 'close contact'. At the end of 28-day surveillance, 76 tests were performed on 52 contacts and all were negative, including all patient close contacts and six of the seven staff close contacts. The remaining contacts were asymptomatic throughout the surveillance period.

CONCLUSION

Our findings suggest that SARS-CoV-2 is not spread by an airborne route, and nosocomial transmissions can be prevented through vigilant basic infection control measures, including wearing of surgical masks, hand and environmental hygiene.

A new aortoiliac calcification scoring system to predict grade C anastomotic leak following rectal cancer surgery

BACKGROUND

Aortoiliac calcification may be a surrogate marker of decreased visceral perfusion causing anastomotic leak (AL). The aim of this study was to evaluate the predictive role of aortoiliac calcification for AL after rectal cancer surgery.

METHODS

We enrolled patients with primary rectal cancer who had restorative resection at our institution between January 2013 and December 2015. An aortoiliac calcification score was calculated as the sum of calcification scores at the infrarenal aorta (0: no, 1: ≤ 3 cm, 2: > 3 cm) and the common iliac arteries (0: no, 1: unilateral, 2: bilateral). AL was classified into three grades: grade A, requiring no intervention; grade B, requiring therapeutic intervention without re-laparotomy; and grade C, requiring re-laparotomy. Clinicopathological characteristics were analyzed to identify risk factors for AL.

RESULTS

There were 583 patients. Three-hundred forty-five (59.2%) had an aortoiliac calcification score ≥ 3, and 37 (6.3%) patients experienced AL, in 30 cases (5.1%) grade C AL. Patients with an aortoiliac calcification score ≥ 3 had a higher incidence of grade C AL (6.7% vs. 2.9%, p = 0.045). Multivariate logistic regression analysis revealed that an aortoiliac calcification score ≥ 3 was an independent risk factor for grade C AL (odds ratio = 2.669, 95% confidence interval 1.066-6.686, p = 0.036).

CONCLUSIONS

Aortoiliac calcification may be considered a risk factor for grade C AL after rectal cancer surgery.

Stacking Fault Energy Analyses of Additively Manufactured Stainless Steel 316L and CrCoNi Medium Entropy Alloy Using In Situ Neutron Diffraction

Stacking fault energies (SFE) were determined in additively manufactured (AM) stainless steel (SS 316 L) and equiatomic CrCoNi medium-entropy alloys. AM specimens were fabricated via directed energy deposition and tensile loaded at room temperature. In situ neutron diffraction was performed to obtain a number of faulting-embedded diffraction peaks simultaneously from a set of (hkl) grains during deformation. The peak profiles diffracted from imperfect crystal structures were analyzed to correlate stacking fault probabilities and mean-square lattice strains to the SFE. The result shows that averaged SFEs are 32.8 mJ/m2 for the AM SS 316 L and 15.1 mJ/m2 for the AM CrCoNi alloys. Meanwhile, during deformation, the SFE varies from 46 to 21 mJ/m2 (AM SS 316 L) and 24 to 11 mJ/m2 (AM CrCoNi) from initial to stabilized stages, respectively. The transient SFEs are attributed to the deformation activity changes from dislocation slip to twinning as straining. The twinning deformation substructure and atomic stacking faults were confirmed by electron backscatter diffraction (EBSD) and transmission electron microscopy (TEM). The significant variance of the SFE suggests the critical twinning stress as 830 ± 25 MPa for the AM SS 316 L and 790 ± 40 MPa for AM CrCoNi, respectively.

P799 The echocardiographic and clinical characteristics of Fabry patients without overt left ventricular hypertrophy but progressing despite on enzyme replacement therapy

Background

Fabry disease (FD) is X-linked genetic disorder caused by the deficiency or absent activity of lysosomal α- galactosidase. When the heart is involved, progressive left ventricular hypertrophy (LVH) is the key feature. Although, LVH is not present in all subjects, some of them progress with LVH despite enzyme replacement therapy (ERT). The present study aimed to evaluate the characteristics of patient of FD without overt LVH, but progresses with their left ventricular mass index (LVMI).

Method : This study includes subjects carrying genetic mutations for FD without LVH (n = 12) in a single tertiary center. ‘Decreasing LVMI group (Group1)’ was defined when pre-ERT LVMI minus last LVMI value obtained by echocardiography was positive, and when negative, defined as ‘Increasing LVMI group (Group 2)’. The baseline characteristics and echocardiographic parameters including global strain was analyzed.

Result : Total 6 patients were classified as Group 1 and 2 each. The median age at diagnosis for male was 21 vs 27 for each group, and 21 vs 31 for female. The median follow-up duration was 4.0 vs 5.7 yr. The antibody formation for replaced enzyme was 3 for Group 2 and any family member who developed overt LVH was much 1 vs 3 for group 1 vs 2. Initial 3 plane GLS was worse and showed trend to drop in Group 2.

Conclusion : In the Fabry patients get worse with their LVMI but still not developed overt LVH despite enzyme replacement therapy, there are some clinical and echo-parameter difference. These findings could suggest insufficient enzyme replacement therapy.

Group 1 (n = 6) Group 2 (n = 6) Female/Male 4/2 3/3 Age of at Dx (Female) (median) 21 28 Age of at Dx (Male) (median) 21 31 F/U duration (median) 4.0 yrs 5.7 yrs Antibody formation 0 3 Any Overt LVH family Genotype c.56T &gt; C c.40-11T &gt; A, 782_delG, c.658C &gt; T Initial LVMI (Median) 98.2g/m2 70.9g/m2 Initial GLS (3P) -19 -17.8 Continuously elevated LysoGb3 2 4 Proteinuria &gt;300mg 1 3 (1 preparing HD)

Developing Children's Oral Health Assessment Toolkits Using Machine Learning Algorithm

OBJECTIVES

Evaluating children's oral health status and treatment needs is challenging. We aim to build oral health assessment toolkits to predict Children's Oral Health Status Index (COHSI) score and referral for treatment needs (RFTN) of oral health. Parent and Child toolkits consist of short-form survey items (12 for children and 8 for parents) with and without children's demographic information (7 questions) to predict the child's oral health status and need for treatment.

METHODS

Data were collected from 12 dental practices in Los Angeles County from 2015 to 2016. We predicted COHSI score and RFTN using random Bootstrap samples with manually introduced Gaussian noise together with machine learning algorithms, such as Extreme Gradient Boosting and Naive Bayesian algorithms (using R). The toolkits predicted the probability of treatment needs and the COHSI score with percentile (ranking). The performance of the toolkits was evaluated internally and externally by residual mean square error (RMSE), correlation, sensitivity and specificity.

RESULTS

The toolkits were developed based on survey responses from 545 families with children aged 2 to 17 y. The sensitivity and specificity for predicting RFTN were 93% and 49% respectively with the external data. The correlation(s) between predicted and clinically determined COHSI was 0.88 (and 0.91 for its percentile). The RMSEs of the COHSI toolkit were 4.2 for COHSI (and 1.3 for its percentile).

CONCLUSIONS

Survey responses from children and their parents/guardians are predictive for clinical outcomes. The toolkits can be used by oral health programs at baseline among school populations. The toolkits can also be used to quantify differences between pre- and post-dental care program implementation. The toolkits' predicted oral health scores can be used to stratify samples in oral health research.

KNOWLEDGE TRANSFER STATEMENT

This study creates the oral health toolkits that combine self- and proxy- reported short forms with children's demographic characteristics to predict children's oral health and treatment needs using Machine Learning algorithms. The toolkits can be used by oral health programs at baseline among school populations to quantify differences between pre and post dental care program implementation. The toolkits can also be used to stratify samples according to the treatment needs and oral health status.

Feasibility of a guided participation discharge program for very preterm infants in a neonatal intensive care unit: a randomized controlled trial

Background

Previous studies showed that parents of very preterm infants expressed feelings of incompetence and experienced high levels of stress upon the discharge of their infants. We conducted a systematic review of seven studies and observed potential benefits for parental outcomes when using discharge interventions that adopted guided participation (GP). More evidence is needed on the effective doses of discharge interventions underpinned by the principles of GP.

Aim

To investigate the feasibility and preliminarily estimate the effects on parental competence and stress outcomes of a newly developed, nurse-led, GP discharge program for mothers of very preterm infants.

Methods

A two-arm randomized controlled trial was conducted in a neonatal intensive care unit (NICU). Mothers of infants with gestational ages of ≤32 weeks who had no congenital malformations and did not need to undergo major surgeries were recruited. All mothers were the primary caregivers to their infants. The intervention group received a nurse-led GP discharge intervention (three structured 30- to 60-min GP sessions and one follow-up phone call). The control group received usual care. The parental outcomes were measured using the Parenting Sense of Competence Scale (C-PSOC) and Perceived Stress Scale (C-PSS) at baseline (T0), on the day of discharge (T1), after the follow-up phone call (within 72 h after discharge) (T2), and 1 month after discharge (T3). The outcomes were analyzed using generalized estimating equations based on intention-to-treat principles.

Results

Thirty infant–mother dyads were recruited. Greater improvements in the C-PSOC score were observed in the intervention group than in the control group at T1 and T2, although these differences were statistically insignificant. The intervention group exhibited greater improvements than the control group in the C-PSS scores at T1, T2, and T3, although these differences were also not statistically significant.

Conclusions

The findings suggest that a GP discharge intervention could improve parenting competence and stress among mothers with very preterm infants. The absence of adverse events suggests that the GP discharge intervention could be feasibly implemented in NICU settings. This feasibility study was not powered to determine the effectiveness of the intervention but is anticipated to lay the foundation for a future full-scale study.

Trial registration

ClinicalTrials.gov Identifier: NCT03668912. Date of registration: 13 September 2018 (retrospectively registered).

Pulmonary function is implicated in the prognosis of metastatic non-small cell lung cancer but not in extended disease small cell lung cancer

Background

The impacts of pulmonary function in patients with metastatic non-small cell lung cancer (NSCLC) and extended disease stage small cell lung cancer (SCLC-ED) treated with palliative chemotherapy remain to still be determined.

Methods

Results of spirometry performed in 449 patients with either stage IV NSCLC (n=313) or SCLC-ED (n=136) at diagnosis were reviewed retrospectively. Overall survival (OS) was estimated using the Kaplan-Meier method and compared via a log-rank test. Multivariate analysis was performed using a Cox proportional hazards regression model.

Results

The presence of chronic obstructive pulmonary disease (COPD) was not a risk factor for OS in either NSCLC or SCLC. However, NSCLC patients with COPD with a forced expiratory volume in one second (FEV1) value of less than 80% predicted were associated with a worse OS in both univariate and multivariate analyses [hazard ratio (HR): 1.43; 95% confidence interval (CI): 1.04-1.97; P=0.03]. Intriguingly, only the OS of NSCLC patients treated with chemotherapeutic agents was affected by the airflow limitation FEV1 value of less than 80% predicted (P=0.02). Patients with an FEV1 value of less than 80% predicted treated with targeted agents were not associated with OS (P=0.24). On the other hand, NSCLC patients with COPD were significantly linked to the occurrence of pulmonary complications during palliative therapy (P=0.01) but not associated with death resulting from pulmonary complications (P=0.22).

Conclusions

Careful attention is required when chemotherapeutic agents are administered to patients with metastatic NSCLC with accompanying COPD with a FEV1 value of less than 80% predicted.

P1711The association of multidisciplinary team approach with clinical outcomes in patients with acute myocardial infarction underwent veno-arterial extracorporeal membrane oxygenation

Background

Multidisciplinary team approach is necessary for the management of critically-ill patients. However, limited data are available on the impact of specialized extracorporeal membrane oxygenation (ECMO) team on clinical outcomes in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock.

Objectives

This study aimed to identify whether specialized ECMO team is associated with improved in-hospital mortality in AMI patients underwent venoarterial ECMO.

Methods

A total of 255 AMI patients underwent venoarterial ECMO from May 2004 to July 2018 were enrolled. In January 2014, multidisciplinary ECMO team was founded at our institution. Eligible patients were classified into pre-ECMO team group (n=131) and post-ECMO team group (n=124). The primary outcome was in-hospital mortality.

Results

In-hospital mortality (54.2% vs. 33.9%, p=0.002) and cardiac intensive care unit mortality (45.0% vs. 25.0%, p=0.001) were significantly lower after the implantation of multidisciplinary ECMO team (pre ECMO team vs. post-ECMO team). On binary logistic regression model, the multidisciplinary ECMO team approach was associated with lower risk of in-hospital mortality (odds ratio 0.36, 95% confidence interval 0.19–0.67, p=0.001). Incidence of all-cause mortality (58.3% vs. 35.2%, p<0.001) and rehospitalization due to heart failure (28.2% vs. 6.4%, p=0.001) at 6-months follow-up were also significantly lower in the post-ECMO team group than in the pre-ECMO team group.

Clinical outcomes Variables Total (N=255) Pre-ECMO team (N=131) Post-ECMO team (N=124) P value In-hospital mortality 113 (44.3) 71 (54.2) 42 (33.9) 0.002 Cardiovascular death 90 (35.3) 59 (45.0) 31 (25.0) 0.001 Noncardiovascular death 23 (9.0) 12 (9.2) 11 (8.9) >0.99 Cardiac intensive care unit mortality 106 (41.6) 68 (51.9) 38 (30.6) 0.001 Successful weaning of ECMO 169 (66.3) 75 (57.3) 94 (75.8) 0.002 Data are presented as n (%). Abbreviations: ECMO, extracorporeal membrane oxygenation.

Incidence of death, readmission for HF

Conclusions

The multidisciplinary ECMO team approach was associated with improved clinical outcomes in AMI patients complicated by cardiogenic shock. Our data support that specialized ECMO team is indispensable to improve outcomes in patients with AMI with refractory cardiogenic shock.

P800Proposal of an algorithm for the diagnosis of hypertension by using out-of-office blood pressure measurements

Background and purpose

Based on the data of patients who measured office BP (OBP) in controlled condition, home BP (HBP), and 24-hour ambulatory BP (24hABP) for diagnosis of hypertension, we developed and validated a diagnostic algorithm for hypertension.

Methods

Patients who have high BP (≥140/90 mmHg) at the outpatient clinic were referred to measure OBP in controlled condition, HBP and 24hABP. The OBP was measured three times at each visit for 3 days in controlled condition by using a validated oscillometric device. HBP was measured for 7 days in triplicates every morning and evening. The 24hABP was measured on the 8th day. Same study protocol was used for development and validation population.

Results

In the development of algorithm, 319 patients were recruited and data of 256 patients (51.8±9.7 years, 119 men) with valid HBP and 24hABP measurements were analyzed. In the validation of algorithm, 300 patients were recruited and data of 257 patients (52.4±9.8 years, 126 men) with valid HBP and 24hABP measurements were analyzed. In the development population, the prevalence of masked hypertension was 19.5% (n=50) and most of them (n=47, 94%) was in the range of 130–139/80–89 mmHg. The BP in the range of 130–144/80–94 mmHg was defined as the grey zone of OBP, because prevalence of white-coat hypertension was lowered to 1.6% from 4.3% with threshold of 145/95 mmHg. The diagnostic sensitivity, specificity, positive and negative predictive value of OBP was improved to 97.4%, 76.5, 96.5% and 81.3% after excluding the grey zone of OBP (n=125). The diagnostic agreement between 24hABP and HBP in the grey zone of OBP was 64%. The diagnostic sensitivity, specificity, positive and negative predictive value of HBP were 88.8%, 74.7, 93.5% and 61.5% after excluding the grey zone of HBP (130–134/80–84 mmHg, n=28). Based upon these results, we developed a diagnostic algorithm for hypertension by using on out-of-office BP measurements to improved diagnostic accuracy of hypertension (Figure). In the validation population, the developed algorithm showed similar diagnostic accuracy.

Diagnostic algorithm for hypertension

Conclusion

For accurate diagnosis of hypertension, OBP measurement according to guidelines and 24hABP measurement to grey zone of OBP is preferred. To improve diagnostic accuracy of HBP measurement, 24hABP measurement to grey zone of HBP is required.

Acknowledgement/Funding

Part of this study was supported by a grand from Dong-A ST Co. Ltd., Seoul, Korea.

1423Adherence to triple component antihypertensive regimen is higher in single-pill combination than two-pill regimen: data from a randomized controlled trial using medication event monitoring system

Background

Simplicity of regimen is known to be an important determinant of medication adherence and using single-pill combination (SPC) in hypertension treatment resulted in better adherence and persistence than free-equivalent combination. However, this finding has been studied only in dual-component antihypertensive treatments and in observational studies using medication possession ratio as an index of adherence. Medication event monitoring system (MEMS) is considered to be the gold standard in estimating medication adherence.

Purpose

To investigate the superiority in adherence of triple-component SPC compared to equivalent two-pill regimen using MEMS

Methods

This is a multi-center open-label randomized controlled trial. Inclusion criteria were hypertensive patients whose clinic blood pressure is not adequately controlled (systolic >140 mmHg or diastolic >90 mmHg) with combination antihypertensive regimen comprising two of three classes (angiotensin receptor blocker, calcium channel blocker and thiazide diuretics) for at least 4 weeks. Eligible patients were randomized either to single-pill (triple-component SPC, olmesartan/amlodipine/ hydrochlorothiazide 20/5/12.5 mg) or two-pill (dual-component SPC + one free pill, olmesartan/hydrochlorothiazide 20/12.5 mg + amlodipine 5 mg) groups and maintained for 12 weeks. Medications were dispensed in MEMS. Primary outcomes were the difference of percentage of dose taken (PDT) and percentage of days with prescribed dose taken correctly (PDTc) between single- and two-pill therapy, calculated from MEMS data.

Results

From 8 hospitals, 146 hypertensive patients were randomized into single- and two-pill groups. Final analysis was done in 65 and 66 patients in each group from which adherence index could be obtained. Baseline clinical characteristics of the two groups were not different. The single-pill group had significantly higher PDT and PDTc compared to the two-pill group. (median (25–75 percentile) (%), PDT 95.1 (87.9 - 100.0) vs 91.2 (79.8 - 96.5); PDTc 93.1 (79.8 - 96.5) vs 91.3 (70.7 - 96.4), p = both 0.04, by Wilcoxon rank sum test)

Percent dose taken

Conclusion

Single-pill combination of triple-component antihypertensive regimen showed superior adherence compared to equivalent two-pill therapy. Reducing pill burden by using SPC is a relevant strategy to enhance the adherence to multi-drug antihypertensive therapy.

Acknowledgement/Funding

Daiichi-Sankyo

Child and Parent Demographic Characteristics and Oral Health Perceptions Associated with Clinically Measured Oral Health

OBJECTIVE

To examine child and parent reports about the child's oral health and assess the associations of these reports with clinical assessments of oral health status by dental examiners.

METHODS

Surveys with 139 items for children and 133 items for parents were administered by Audio Computer-Assisted Self-Interview Software. In addition, the Children's Oral Health Status Index (COHSI) was computed from a dental examination.

RESULTS

A total of 334 families with children ages 8 to 17 y participated at 12 dental practices in Los Angeles County. Ordinary least squares regression models were estimated separately for child and parent surveys to identify items uniquely associated with the COHSI. Ten of 139 items the children reported regarding their oral health were associated with the COHSI. The strongest associations were found for child's age, aesthetic factors (straight teeth and pleased with teeth), and cognitive factors related to perception of dental appearance (pleased/happy with the look of the child's mouth, teeth, and jaws). Nine of 133 parent items about the child's oral health were associated with the COHSI in the parent model, notably being a single parent, parent's gender, parent born in the United States, pleased or happy with the look of their child's teeth, and accessing the Internet.

CONCLUSION

These child and parent survey items have potential to be used to assess oral health status for groups of children in programs and practices in lieu of dental screenings.

KNOWLEDGE TRANSLATION STATEMENT

The paper's results inform the development of a toolkit that can be used by schools, public health agencies, and dental programs to identify children with low oral health status based on parents' and children's responses to survey items across demographic, physical, mental, and social domains. These survey items can be used to inform parents of the desirability of proactively addressing inadequacies in their child's oral health status, enabling them to more rationally address dental needs.

Abstract P3-12-12: Impact of regional nodal irradiation for breast cancer patients with supraclavicular and/or internal mammary lymph node involvement: A multicenter, retrospective study (KROG 16-14)

Purpose: To evaluate the treatment outcomes of radiotherapy (RT) for breast cancer with ipsilateral supraclavicular (SCL) and/or internal mammary (IMN) lymph node involvement.

Methods: A total of 353 patients from 11 institutions were included. One hundred and thirty-six patients had SCL involvement, 148 had IMN involvement, and 69 had both. All patients received neoadjvant systemic therapy followed by breast conserving surgery or mastectomy, and postoperative RT to whole breast/chest wall. As for regional lymph node irradiation, SCL RT was given to 344 patients, and IMN RT to 236 patients. The median RT dose was 50.4 Gy.

Results: The median follow-up duration was 61 months (range, 7-173). In-field progression was present in SCL (n=20) and/or IMN (n=7). The 5-year disease-free survival (DFS) and overall survival rates were 57.8% and 75.1%, respectively. On multivariate analysis, both SCL/IMN involvement, number of axillary lymph node ≥4, triple negative subtype, and mastectomy were significant adverse prognosticators for DFS (p = 0.022, 0.001, 0.001, and 0.004, respectively). Regarding the impact of regional nodal irradiation, SCL RT dose ≥54 Gy was not associated with DFS (5-yr rate, 52.9% vs. 50.9%, p = 0.696) in SCL-involved patients, and the receipt of IMN RT was not associated with DFS (5-yr rate, 56.1% vs. 78.1%, p = 0.099) in IMN-involved patients.

Conclusion: Neoadjuvant chemotherapy followed by surgery and postoperative RT achieved an acceptable in-field regional control rate in patients with SCL and/or IMN involvement. However, a higher RT dose to SCL or IMN RT was not associated with the improved DFS in these patients.

Citation Format: Kim K, Jeong Y, Shin KH, Kim JH, Ahn SD, Kim SS, Suh C-O, Kim YB, Choi DH, Park W, Cha J, Chun M, Lee DS, Lee SY, Kim JH, Park HJ. Impact of regional nodal irradiation for breast cancer patients with supraclavicular and/or internal mammary lymph node involvement: A multicenter, retrospective study (KROG 16-14) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-12.

Incidence and Risk Factors of Immediate Hypersensitivity Reactions Associated With Low-Osmolar Iodinated Contrast Media: A Longitudinal Study Based on a Real-Time Monitoring System

OBJECTIVES

We investigated the incidence of immediate hypersensitivity reaction (HSR) caused by different types of low-osmolar contrast media (LOCM) and cumulative exposure to LOCM.

METHODS

This cohort study included all consecutive patients who underwent LOCM-enhanced computed tomography from 2012 through 2014. We assessed 5 LOCM (iobitridol, iohexol, iomeprol, iopamidol, and iopromide). All patients were monitored for adverse events, and new symptoms and signs were recorded in real time using the Contrast Safety Monitoring and Management System (CoSM2oS).

RESULTS

The overall incidence of immediate HSR to LOCM was 0.97% (2004 events resulting from 205 726 exposures). Incidence differed significantly depending on whether the patient had a previous history of HSR to LOCM (0.80% in patients with no history and 16.99% in patients with a positive history of HSR to LOCM, P=.001). The incidence of HSR to individual LOCM ranged from 0.72% (iohexol) to 1.34% (iomeprol), although there were no significant differences across the 5 LOCM. A longitudinal analysis demonstrated that the incidence of HSR increased gradually with more frequent previous exposure to LOCM (HR=2.006 [95%CI, 1.517-2.653], P<.001). However, this cumulative increase in risk was observed in patients who had experienced HSR to LOCM, but not in those who had not.

CONCLUSION

The incidence of HSR did not differ significantly across the 5 LOCM assessed in the study. Repeated exposure to LOCM did not increase the risk of HSR among patients who had never experienced HSR to LOCM.

Right Upper Lobe Collapse Secondary to an Anomalous Bronchus after Endotracheal Intubation for Routine Surgery

Perioperative hypoxaemia is a common but serious problem with well recognised causes. However, an anomalous bronchus causing lobar collapse as a cause is seldom mentioned. A healthy young male patient was anaesthetised for a knee operation. He required reintubation immediately postoperatively for hypoxia. He was found to have right upper lobe collapse. Fibreoptic examination of the trachea demonstrated an anomalous bronchus as the cause. Intra-operatively, the endotracheal tube had been inserted too deeply and the bronchial orifice had been obstructed by the tip. It took several hours for the lung to re-expand. Greater awareness of this potential complication is needed.

Alternative technique or mitigating strategy for sevoflurane-induced neurodegeneration: a randomized controlled dose-escalation study of dexmedetomidine in neonatal rats

Background

Brain injury in newborn animals from prolonged anaesthetic exposure has raised concerns for millions of children undergoing anaesthesia every yr. Alternative anaesthetic techniques or mitigating strategies are urgently needed to ameliorate potentially harmful effects. We tested dexmedetomidine, both as a single agent alternative technique and as a mitigating adjuvant for sevoflurane anaesthesia.

Methods

Neonatal rats were randomized to three injections of dexmedetomidine (5, 25, 50, or 100 µg kg -1 every 2 h), or 6 h of 2.5% sevoflurane as a single agent without or with dexmedetomidine (1, 5, 10, or 20 µg kg -1 every 2 h). Heart rate, oxygen saturation, level of consciousness, and response to pain were assessed. Cell death was quantified in several brain regions.

Results

Dexmedetomidine provided lower levels of sedation and pain control than sevoflurane. Exposure to either sevoflurane or dexmedetomidine alone did not cause mortality, but the combination of 2.5% sevoflurane and dexmedetomidine in doses exceeding 1 µg kg -1 did. Sevoflurane increased apoptosis in all brain regions; supplementation with dexmedetomidine exacerbated neuronal injury, potentially as a result of ventilatory or haemodynamic compromise. Dexmedetomidine by itself increased apoptosis only in CA2/3 and the ventral posterior nucleus, but not in prefrontal cortex, retrosplenial cortex, somatosensory cortex, subiculum, lateral dorsal thalamic nucleaus, or hippocampal CA1.

Conclusions

We confirm previous findings of sevoflurane-induced neuronal injury. Dexmedetomidine, even in the highest dose, did not cause similar injury, but provided lesser degrees of anaesthesia and pain control. No mitigation of sevoflurane-induced injury was observed with dexmedetomidine supplementation, suggesting that future studies should focus on anaesthetic-sparing effects of dexmedetomidine, rather than injury-preventing effects.

Functional Outcomes of Fragility Fracture Integrated Rehabilitation Management in Sarcopenic Patients after Hip Fracture Surgery and Predictors of Independent Ambulation

OBJECTIVES

To compare the changes in the functional level of patients with versus without sarcopenia who received by fragility fracture integrated rehabilitation management (FIRM) after hip fracture (HF) surgery over a 6-month follow-up period and to identify variables influencing independent ambulation (IA) at 6 months after HF.

DESIGN

Prospective observational study.

SETTING

Three in-hospital rehabilitation setting.

PARTICIPANTS

Patients older than 65 years of age (N=80) categorized by the presence of sarcopenia.

INTERVENTION

The FIRM program during the-2 week hospital stay after surgery.

MEASUREMENTS

Main outcomes for ambulatory function (Koval score, Functional Ambulatory Category) and other secondary outcomes were measured at rehabilitation admission, at discharge, at 3 months and 6 months after surgery. Other secondary outcomes were measured. The possibility of IA at 6 months after surgery were also investigated.

RESULTS

Sarcopenia and non-sarcopenia patients did not differ significantly in terms of changes in ambulation or other functions over a 6-month follow-up (p < 0.001 or p = 0.001). The two groups did not differ significantly in terms of final functional status (6 months). The IA ratios of the two groups did not significantly differ at 6 months after surgery (sarcopenia [54.3%] and non-sarcopenia [64.5%]). IA before fracture (p = 0.039) and age (≥80 years) (p = 0.03) were independent predictors and sarcopenia was not a predictor for the possibility of IA at 6-months after surgery.

CONCLUSIONS

The FIRM program was effective for promoting functional recovery in older patients with fragility HF, either with or without sarcopenia. The present findings provide evidence of the pressing need for integrated rehabilitation management in fragility fracture care to improve functional recovery in patients with sarcopenia.

Bone mineral density in osteoporotic patients with pyogenic vertebral osteomyelitis: effect of early versus late treatment for osteoporosis

Patients with pyogenic vertebral osteomyelitis (PVO) are at greater risk of bone loss. However, treatment guidelines for bone loss have been lacking. Early bisphosphonate treatment within 6 weeks after PVO diagnosis was significantly associated with superior outcome in femoral BMD at 2-year follow-up, compared to that with late treatment.

INTRODUCTION

Due to absence of concern and proper guidelines, management of bone loss or osteoporosis in PVO is often neglected or delayed. A retrospective cohort study was planned to investigate differences in bone mineral density (BMD) in PVO patients with osteoporosis according to the timing of osteoporosis treatment.

METHODS

The PVO cohort consisted of 192 patients with osteoporosis who visited our institution between January 2003 and March 2015 and received bisphosphonate treatment for osteoporosis. According to the interval between PVO diagnosis and initiation of bisphosphonate, the patients were divided into three groups: group A (within 6 weeks after PVO diagnosis), group B (between 6 weeks and 3 months after diagnosis), and group C (more than 3 months after PVO diagnosis).

RESULTS

The percent increase in total femoral BMD in group A was significantly larger than that in group B at 2-year follow-up (p = 0.036). Similarly, the percent increase in trochanteric (p = 0.008) and total femoral (p = 0009) BMD in group A was significantly larger than that in group C at 2-year follow-up. Even after multivariate adjustment, total femoral BMD changes were significantly associated with the treatment group. Group B (odds ratio = 2.824, p = 0.013) and group C (odds ratio = 3.591, p = 0.001) were more significantly associated with total femoral BMD decreases at 2-year follow-up compared with group A.

CONCLUSIONS

Early bisphosphonate treatment within 6 weeks after PVO diagnosis (group A) was significantly associated with superior outcome in femoral BMD at 2-year follow-up, compared to that with late treatment (groups B and C).

Liver Transplant Waitlist Outcomes and the Allocation of Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception Points at a Low-Volume Center

BACKGROUND

Organ scarcity continues to be the main problem limiting the number of liver transplants performed. Outcomes of patients waitlisted for an organ in an Asian country with low organ donation rate have not been well evaluated. Our current policy of allocating 15 exception points to patients with hepatocellular carcinoma (HCC) to render them competitive for a transplant also requires review.

METHODS

The waiting list registry and the organ transplant registry of a single institution in Asia were reviewed from December 2005 to June 2016 for all patients who underwent liver transplantation. Patient characteristics and outcomes of waitlist dropouts were evaluated. Statistical analyses were performed using SPSS version 20.0.

RESULTS

One hundred seventy-three patients were waitlisted for a deceased donor liver-only transplant. The most common etiology of liver disease was hepatitis B, followed by cholestatic diseases. Approximately half of the patients had HCC (45.6%). Priority listing for transplant comprised 15.6% of cases. Median Model for End-Stage Liver Disease (MELD) at listing was 15, and median waiting time to transplant was 17 weeks (interquartile range = 6.5-43.5). Overall, 89 (51.4%) patients underwent liver transplantation and 68 (39.3%) dropped out. For patients with HCC, the most common cause of dropout was progression beyond University of California San Francisco transplant criteria (62.5%). The cumulative incidence of dropout at 3 months among patients with HCC who received exception MELD scores was 11%. This was higher than those listed with physiologic MELD of 14-16 points (7%) but lower than those with 17-19 points (16%).

CONCLUSIONS

Hepatitis B-related liver disease and HCC comprise the majority of patients listed for liver transplant. Dropout rates are high and this is due to the lack of donor organs. The current policy of allocating 15 exception MELD points to patients with HCC within transplant criteria may underestimate the dropout risk of patients with HCC in our population.

Multidrug-resistant organism carriage among residents from residential care homes for the elderly in Hong Kong: a prevalence survey with stratified cluster sampling

INTRODUCTION

A point prevalence survey was conducted to study the epidemiology of and risk factors associated with multidrug-resistant organism carriage among residents in residential care homes for the elderly (RCHEs).

METHODS

A total of 20 RCHEs in Hong Kong were selected by stratified single-stage cluster sampling. All consenting residents aged ≥65 years from the selected RCHEs were surveyed by collection of nasal swab, axillary swab, rectal swab or stool on one single day for each home. Specimens were cultured and analysed for methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Acinetobacter (MDRA, defined as concomitant resistant to fluoroquinolones, carbapenems, aminoglycosides, cephalosporins and beta-lactam with or without beta-lactamase inhibitors), vancomycin-resistant Enterococcus (VRE), and carbapenemase-producing Enterobacteriaceae (CPE). One third of the MRSA-positive samples were selected at random for molecular typing; all positive MDRA, VRE and CPE samples were tested for molecular typing. Demographic and health information of residents including medical history, history of hospitalisation, antimicrobial usage, and use of indwelling catheters were collected to determine any associated risk factors.

RESULTS

Samples of 1028 residents from 20 RCHEs were collected. Prevalence of MRSA was estimated as 30.1% (95% confidence interval [CI]=25.1%-35.6%) and MDRA 0.6% (95% CI=0.1%-4.1%). No residents carried VRE nor CPE. Residents living in privately run RCHEs were associated with MRSA carriage. Non-Chinese residents were associated with MRSA carriage with borderline significance.

CONCLUSIONS

This survey provided information about multidrug-resistant organism carriage among RCHE residents. This information will enable us to formulate targeted surveillance and control strategies for multidrug-resistant organisms.

Overexpression of Romo1 is an unfavorable prognostic biomarker and a predictor of lymphatic metastasis in non-small cell lung cancer patients

Introduction

Reactive oxygen species modulator-1 (Romo1) is a protein that modulates levels of reactive oxygen species (ROS) and has been reported to affect cancer cell invasion and proliferation via persistent inflammation. Several studies have demonstrated the clinical application of Romo1 as a prognostic marker in non-small cell lung cancer (NSCLC); however, there have been no studies investigating the mechanism by which Romo1 adversely affects the prognosis of these patients.

Methods

We examined Romo1, ROS, and vascular endothelial growth factor (VEGF) in tumor tissues immunohistochemically. We conducted survival analyses of patients who had curative resection (n=30) in accordance with clinical parameters including levels of Romo1 expression.

Results

Romo1 levels were associated with serologic inflammatory markers and high lymphatic metastatic tendencies. Significantly longer disease-free survival (68.7 vs 24.2 months, P=0.031) and overall survival (92.7 vs 51.6 months) were observed in the group with low Romo1 compared with high Romo1. Survival outcomes were also significantly associated with serologic inflammatory markers. Spearman’s correlation analyses demonstrated significant positive correlations of Romo1 expression with VEGF-C (P=0.008, R=0.478) and ROS (P=0.016, R=0.436) in tumor samples.

Conclusion

The current study demonstrates that Romo1 induces lymphatic metastasis of NSCLC by modulating persistent inflammation and oxidative stress (ROS)/VEGF signaling. Lymphatic metastasis associated with elevated Romo1 was shown to be a key reason for unfavorable survival rates.

Upregulation of EphB3 in gastric cancer with acquired resistance to a FGFR inhibitor

Amplification of fibroblast growth factor receptor2 (FGFR2) has been regarded as a druggable target in gastric cancer (GC). Despite known potential of AZD4547, a selective inhibitor of FGFR 1-3, to suppress tumorigenic effects of activated FGFR2, resistance to the targeted agent has been an unresolved issue. This study was performed to elucidate the mechanism of AZD4547 resistance in GC cells. SNU-16 cells were used to establish an AZD4547-resistant GC cell line, SNU-16R. Elevated phosphorylation of EphB3 was confirmed using the Human Phospho-Receptor Tyrosine Kinase Array kit. A tyrosine kinase inhibitor (TKI) of EphB3 was used to investigate the effects of suppressed EphB3 activity in the SNU-16R cell line. SNU-16R cells exhibited upregulated phosphorylation of EphB3. Treatment of SNU-16R cells with the EphB3 TKI resulted in induction of apoptosis, decreased cellular viability, and cell cycle arrest at sub-G1 phase. SNU-16R cells expressed upregulated levels of N-cadherin, vimentin, Snail, matrix metalloproteinase 2 (MMP-2), and MMP-9, and reduced levels of E-cadherin, characteristic of epithelial to mesenchymal transition (EMT). Matrigel invasion assay also demonstrated the increased invasiveness of SNU-16R cells. EphB3 TKI treatment inhibited EMT of SNU-16R cells. Activation of mammalian target of rapamycin (mTOR) through the Ras-ERK1/2 pathway was suggested as the signal transduction mechanism downstream EphB3 by showing enhanced phosphorylation of Raf-1, MEK1/2, ERK1/2, mTOR and its downstream substrates in SNU-16R cells. As expected, EphB3 TKI decreased phosphorylation of these proteins. Our data suggest phosphorylation of mTOR through signaling by EphB3 is a potential mechanism of AZD4547 resistance in GC cells.

Effect of hypothermia treatment on gentamicin pharmacokinetics in neonates with hypoxic-ischaemic encephalopathy: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Hypothermia is the current standard therapy for asphyxiated neonates with hypoxic-ischaemic encephalopathy (HIE). Gentamicin is used for the empirical treatment of early-onset neonatal sepsis. We investigated the influence of hypothermia treatment on gentamicin pharmacokinetics and suggested the appropriate dosing recommendations for gentamicin in neonates with HIE receiving hypothermia treatment.

METHODS

We searched studies published until February 2017 in MEDLINE using PubMed, EMBASE and the Cochrane Library. Three independent reviewers screened the literature and extracted data from each study. All of the studies that reported the blood concentrations or pharmacokinetic parameters of gentamicin in hypothermic neonates with HIE were included in this review. Articles were excluded if they were not original research.

RESULT AND DISCUSSION

A total of 8 observational studies met the inclusion criteria. Meta-analyses were performed in which the mean difference of gentamicin for the trough concentration and clearance between hypothermic and normothermic neonates were 0.81 mg/L (95% confidence interval [-0.07, 1.69]) and -0.21 mL/kg/min (95% confidence interval [-0.31, -0.12]), respectively. The factors affecting gentamicin clearance in hypothermic neonates with HIE were gestational age, birthweight and serum creatinine.

WHAT IS NEW AND CONCLUSION

Gentamicin clearance is decreased in neonates with HIE receiving hypothermia treatment compared to those not receiving hypothermia treatment. Modified gentamicin dosing regimens are required to avoid potential toxicity related to higher concentrations during hypothermia treatment.

Twitter as a place where people meet to make suicide pacts

OBJECTIVES

To examine how Twitter is used as a place where people seek others to make suicide pacts.

STUDY DESIGN

This is an exploratory quantitative study.

METHODS

We used Twitter application programming interfaces to collect all Korean tweets containing the term 'suicide pact' between October 16, 2017 and November 30, 2017. A Python program and human coders were employed to further identify tweets that aimed to seek others to make a suicide pact and analyze the content of each tweet. Poisson regression analysis was used to examine the characteristics of the tweets that attracted more replies.

RESULTS

During the data collection period comprising 43 days, 1702 tweets posted by 551 users were aimed to find others to make suicide pacts. Many of the tweets contained detailed information such as the name of city, gender and age of the user, preferred contact method, and preferred gender of a partner. The number of replies to a tweet seeking a suicide pact varied according to the types of the information contained in the tweet.

CONCLUSIONS

The results of this study indicate that Twitter might be an attractive place where people try to meet others to make a suicide pact. Thus, the government should try to prevent cases of suicides caused by suicide pacts made via Twitter.

Treatment efficiency and stability of skeletal Class III malocclusion with a surgery-first approach

OBJECTIVES

To compare treatment duration in skeletal Class III malocclusion patients managed with a 2-step treatment (surgery-first approach, SFA) and conventional 3-step treatment, and to compare stability of surgical outcomes between segmentation and non-segmentation in the 2-step treatment group.

SETTING AND SAMPLE POPULATION

The sample population consisted of 37 patients who completed orthognathic surgery (OGS) and orthodontic correction at the Charm Aesthetic Surgery Clinic (Taipei, Taiwan) between 2012 and 2015. Of these, 26 received 2-step treatment and 11 received 3-step treatment.

MATERIALS AND METHODS

To compare treatment efficiency and stability, three time points were analysed: T₀ , before treatment (before OGS in the 2-step group and before orthodontic treatment in the 3-step group); T₁ , after OGS but before orthodontic correction (cone beam computed tomography (CBCT) was obtained within 2 weeks of OGS); and T₂ , after orthodontic correction (CBCT was obtained on the day of bracket removal). The post-OGS (T₁ ) CBCT items were individually superimposed on the pre-treatment (T₀ ) CBCT items to determine the distance of B point migration.

RESULTS

A significant difference was found in treatment times between 2-step treatment and conventional 3-step treatment. In addition, no significant difference was found when comparing B-X (mm) and B-Y (mm) at T₂ -T₁ for the segmentation and non-segmentation groups.

CONCLUSIONS

Using SFA for skeletal Class III malocclusions saves approximately 6 months of treatment time over 3-step treatment; the stability of the segmentation group was comparable to that of the non-segmentation group, a result that is possibly associated with the fixation of 2 miniplates.

Abstract P5-20-14: Cardiotoxicity in 1 year of treatment with reference trastuzumab and its biosimilar candidate CT-P6 in HER2 positive early stage breast cancer (EBC) patients

Background CT-P6 is a proposed biosimilar to reference trastuzumab. This trial (NCT02162667) evaluated the similarity of CT-P6 and reference trastuzumab for both efficacy and safety in HER2 positive EBC patients. The primary endpoint, pathological complete response (pCR) rate was entirely within the pre-defined equivalence margin (Stebbing et al., Lancet Oncology 2017). Efficacy and safety were similar between the two treatment groups. We aimed to investigate the cardiotoxicity in the 1 year treatment and follow-up period.

Methods A total of 549 patients with HER2 positive EBC were randomized to receive CT-P6 (n=271) or reference trastuzumab (n=278) in combination with docetaxel (Cycles 1-4) and 5-fluorouracil, epirubicin and cyclophosphamide (FEC, Cycles 5-8) in the neoadjuvant setting. CT-P6 or reference trastuzumab was administered at 8 mg/kg (Cycle 1 only) followed by 6 mg/kg every 3 weeks. After surgery, patients received monotherapy of CT-P6 or reference trastuzumab up to 10 cycles in the adjuvant setting. Left ventricular ejection fraction (LVEF) was evaluated by ECHO or MUGA at baseline, every 3 or 4 cycles during treatment and every 6 months thereafter. If LVEF decreased by ≥10 points from baseline and &lt;50%, a reassessment was performed within 3 weeks and the patient was withdrawn from the study treatment if the cardiac toxicity was confirmed.

Results Median follow-up period was 19 months. In total, 96% of patients completed 8 cycles of taxane and anthracycline combination therapy during the neoadjuvant period and 90% of patients in each group received 1-year treatment of CT-P6 or reference trastuzumab.

The relative dose intensity of study drug was similar, indicating good tolerability of CT-P6 and reference trastuzumab (97.5% and 97.3% during the neoadjuvant period; 98.5% and 98.8% during the adjuvant period). Docetaxel and FEC combination therapies were administered approximately 96% of dose intensity in the two groups.

All patients had normal LVEF (≥55%) at baseline. Mean LVEF value was maintained more than 60% during 1-year treatment and follow-up period. Heart failure cases with LVEF decrease (≥10 points from baseline and &lt;50%) were reported to be similar between two groups. Three patients in each group were withdrawn due to LVEF decrease. Adverse events of cardiac disorders were reported to be similar between two groups. All cases were mild or moderate except two cases.

Table 1. Summary of heart failure with LVEF decrease and cardiotoxicity CT-P6 (N=271)Reference Trastuzumab (N=278)LVEF decrease ≥ 10 points and below 50%9 (3.3%)7 (2.5%)- Asymptomatic9 (3.3%)6 (2.1%)- Symptomatic01 (0.4%)- Confirmed2 (0.7%)4 (1.4%)- Withdrawn3 (1.1%)3 (1.1%)Cardiac disorder by AEs31 (11.4%)38 (13.7%)- Grade 1 to 230 (11.0%)37 (13.3%)- Grade 3 to 51 (0.4%)11 (0.4%)21 Grade 3 of Adams-Strokes syndrome occurring 5 months after the completion of 1-year treatment; 2 Grade 5 of acute myocardial infarction occurring 10 days after Cycle 1 of the neoadjuvant therapy

Conclusions Combination therapy of CT-P6 with taxane/anthracycline and monotherapy of CT-P6 over 1 year period were well tolerated and cardiotoxicity was similar to reference trastuzumab.

Citation Format: Esteva FJ, Chung HC, Royce ME, Lee SY, Lee SJ, Stebbing J. Cardiotoxicity in 1 year of treatment with reference trastuzumab and its biosimilar candidate CT-P6 in HER2 positive early stage breast cancer (EBC) patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-20-14.

Altered expression of microRNA during fracture healing in diabetic rats

OBJECTIVES

Diabetes mellitus (DM) is known to impair fracture healing. Increasing evidence suggests that some microRNA (miRNA) is involved in the pathophysiology of diabetes and its complications. We hypothesized that the functions of miRNA and changes to their patterns of expression may be implicated in the pathogenesis of impaired fracture healing in DM.

METHODS

Closed transverse fractures were created in the femurs of 116 rats, with half assigned to the DM group and half assigned to the control group. Rats with DM were induced by a single intraperitoneal injection of streptozotocin. At post-fracture days five, seven, 11, 14, 21, and 28, miRNA was extracted from the newly generated tissue at the fracture site. Microarray analysis was performed with miRNA samples from each group on post-fracture days five and 11. For further analysis, real-time polymerase chain reaction (PCR) analysis was performed at each timepoint.

RESULTS

Microarray analysis showed that there were 14 miRNAs at day five and 17 miRNAs at day 11, with a greater than twofold change in the DM group compared with the control group. Among these types of miRNA, five were selected based on a comparative and extended literature review. Real-time PCR analysis revealed that five types of miRNA (miR-140-3p, miR-140-5p, miR-181a-1-3p, miR-210-3p, and miR-222-3p) were differentially expressed with changing patterns of expression during fracture healing in diabetic rats compared with controls.

CONCLUSIONS

Our findings provide information to further understand the pathology of impaired fracture healing in a diabetic rat model. These results may allow the potential development of molecular therapy using miRNA for the treatment of impaired fracture healing in patients with DM.Cite this article: S. Takahara, S. Y. Lee, T. Iwakura, K. Oe, T. Fukui, E. Okumachi, T. Waki, M. Arakura, Y. Sakai, K. Nishida, R. Kuroda, T. Niikura. Altered expression of microRNA during fracture healing in diabetic rats. Bone Joint Res 2018;7:139-147. DOI: 10.1302/2046-3758.72.BJR-2017-0082.R1.

Metformin enhances TRAIL-induced apoptosis by Mcl-1 degradation via Mule in colorectal cancer cells

Metformin is an anti-diabetic drug with a promising anti-cancer potential. In this study, we show that subtoxic doses of metformin effectively sensitize human colorectal cancer (CRC) cells to tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL), which induces apoptosis. Metformin alone did not induce apoptosis, but significantly potentiated TRAIL-induced apoptosis in CRC cells. CRC cells treated with metformin and TRAIL showed activation of the intrinsic and extrinsic pathways of caspase activation. We attempted to elucidate the underlying mechanism, and found that metformin significantly reduced the protein levels of myeloid cell leukemia 1 (Mcl-1) in CRC cells and, the overexpression of Mcl-1 inhibited cell death induced by metformin and/or TRAIL. Further experiments revealed that metformin did not affect mRNA levels, but increased proteasomal degradation and protein stability of Mcl-1. Knockdown of Mule triggered a significant decrease of Mcl-1 polyubiquitination. Metformin caused the dissociation of Noxa from Mcl-1, which allowed the binding of the BH3-containing ubiquitin ligase Mule followed by Mcl-1ubiquitination and degradation. The metformin-induced degradation of Mcl-1 required E3 ligase Mule, which is responsible for the polyubiquitination of Mcl-1. Our study is the first report indicating that metformin enhances TRAIL-induced apoptosis through Noxa and favors the interaction between Mcl-1 and Mule, which consequently affects Mcl-1 ubiquitination.

Longitudinal thermal heterogeneity in rivers and refugia for coldwater species: effects of scale and climate change

Climate-change driven increases in water temperature pose challenges for aquatic organisms. Predictions of impacts typically do not account for fine-grained spatiotemporal thermal patterns in rivers. Patches of cooler water could serve as refuges for anadromous species like salmon that migrate during summer. We used high-resolution remotely sensed water temperature data to characterize summer thermal heterogeneity patterns for 11,308 km of 2^nd- to 7^th-order rivers throughout the Pacific Northwest and northern California (USA). We evaluated (1) water temperature patterns at different spatial resolutions, (2) the frequency, size, and spacing of cool thermal patches suitable for Pacific salmon (i.e., contiguous stretches ≥0.25 km, ≤15°C and ≥2°C cooler than adjacent water), and (3) potential influences of climate change on availability of cool patches. Thermal heterogeneity was nonlinearly related to the spatial resolution of water temperature data, and heterogeneity at fine resolution (<1 km) would have been difficult to quantify without spatially continuous data. Cool patches were generally >2.7 and <13.0 km long, and spacing among patches was generally >5.7 and <49.4 km. Thermal heterogeneity varied among rivers, some of which had long uninterrupted stretches of warm water ≥20°C, and others had many smaller cool patches. Our models predicted little change in future thermal heterogeneity among rivers, but within-river patterns sometimes changed markedly compared to contemporary patterns. These results can inform long-term monitoring programs as well as near-term climate-adaptation strategies.

Anatomical distribution and detection rate of colorectal neoplasms according to age in the colonoscopic screening of a Korean population

Purpose

Because data as a basis for the determination of proper age and modality for screening of colorectal neoplasms is lacking, we evaluated detection rates and anatomical distribution of colorectal neoplasms according to age in healthy individuals who underwent total colonoscopy for health checkup.

Methods

A total of 16,100 cases that had received the colonoscopic examination from January to December in 2014 were analyzed. The total number of individuals who received total colonoscopy were divided by the number of individuals harboring colorectal adenoma to calculate the detection rate of colorectal adenoma. Individuals ≤50 years old were classified as young-age group and aged >50 were old-age group. Differences in anatomical locations of colorectal neoplasms were analyzed in the 2 age groups by chi-square test. Risk factors for colorectal adenoma in each age group were analyzed using univariate and multivariate logistic regression analyses.

Results

Detection rates of colorectal adenoma were 13.7% in all cases and 12.8% for those in their 40's. The main anatomical location of colorectal adenoma was proximal colon in both age groups (P < 0.001). Hyperplastic polyp was mainly distributed to the distal colon in both age groups (P < 0.001). Distal colon was the major site for colorectal cancer in the old-age group (P = 0.001). Proximal location of neoplasms was a risk factor for colorectal adenoma in both age groups with multivariate analysis.

Conclusion

These data could be the bases for earlier initiation of screening for colorectal neoplasms with total colonoscopy to detect clinically significant colorectal polyps.

Effect of roflumilast on airway remodelling in a murine model of chronic asthma

BACKGROUND

Airway remodelling is associated with irreversible, or partially reversible, airflow obstruction and ultimately unresponsiveness to asthma therapies such as corticosteroids. Roflumilast is a selective phosphodiesterase-4 inhibitor that has an anti-inflammatory effect in chronic obstructive pulmonary disease (COPD).

OBJECTIVE

The objective of this study was to study the effect of roflumilast on airway inflammation and remodelling in a murine model of chronic asthma.

METHODS

BALB/c mice sensitized to ovalbumin (OVA) were chronically exposed to intranasal OVA administration twice a week for additional 3 months. Roflumilast was administered orally during the intranasal OVA challenge. A lung fibroblast cell line was used in the proliferation assay.

RESULTS

Compared with control mice, mice chronically exposed to OVA developed eosinophilic airway inflammation, airway hyper-responsiveness (AHR), and exhibited features of airway remodelling. Administration of roflumilast significantly inhibited airway inflammation and AHR. Roflumilast also significantly decreased goblet cell hyperplasia and pulmonary fibrosis, which are parameters of airway remodelling. The levels of interleukin (IL)-4, IL-5, and IL-13 in the bronchoalveolar lavage (BAL) fluids were significantly lower in the roflumilast group. In vitro, roflumilast significantly inhibited stem cell factor (SCF)-induced cell proliferation of fibroblasts. The SCF concentration and mRNA expression in a murine model also significantly decreased with roflumilast treatment.

CONCLUSIONS

These results suggest that the administration of roflumilast regulates airway inflammation, AHR, and airway remodelling in a model of chronic asthma. The beneficial effects from roflumilast may be related to the SCF/c-kit pathway.

Prognostic significance of interim 18 F-fluorodeoxyglucose positron emission tomography-computed tomography volumetric parameters in metastatic or recurrent gastric cancer

AIM

To evaluate the prognostic role of interim analysis of 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) volumetric parameters in patients with recurrent or metastatic advanced gastric cancer (AGC) treated with fluoropyrimidine-based palliative chemotherapy.

METHODS

Forty-four patients who underwent baseline and interim PET/CT scanning during palliative chemotherapy were analyzed retrospectively. Initial and change of metabolic parameters (MP) - metabolic tumor volume (MTV), tumor lesion glycolysis (TLG) and maximum and mean standardized uptake values (SUV) were measured with PET/CT. Metabolic change was measured by ∆MP (%)  =  (MP_interim  - MP_initial )/MP _initial   ×  100. Independent t-test was employed to compare values of initial, interim and change of metabolic parameters between each response group. Log-rank test was employed for univariate analysis, and multivariate analysis was performed using the Cox proportional hazards regression model to determine independently significant prognostic factors.

RESULTS

Reduced percentage values of maximum and mean SUV on interim PET/CT and initial values of volumetric parameters (MTV and TLG) were significant predicting factors to response to fluoropyrimidine-based palliative chemotherapy. The decreased percentage values of metabolic parameters as well as maximum and mean SUV with receiver operating characteristic (ROC) curve determined cut-off points were significant prognostic factors for overall survival and progression-free survival in univariate and multivariate analyses.

CONCLUSION

Measurement of metabolic decrease of volumetric parameters by interim PET/CT analysis is useful to determine the prognosis of patients with recurrent or metastatic AGC.