Unusual Coincidence: Concurrent Cast Nephropathy and Lymphoma Infiltration in an Influenza A-Associated Acute Kidney Injury

Acute kidney injury (AKI) poses a substantial challenge in the management of lymphoma patients and is frequently associated with diverse causative factors. Herein, we report an illustrative case involving a 47-year-old male with influenza A infection who developed severe AKI, which was incongruent with his medical history. Laboratory investigations disclosed aberrant immunoglobulin levels and urinary protein excretion, prompting further evaluation. A renal biopsy revealed the presence of infiltrating lymphoid cells and cast nephropathy, raising suspicion of an underlying hematological disorder. A comprehensive diagnostic workup, including positron emission tomography imaging and bone marrow biopsy, culminated in the definitive diagnosis of splenic marginal zone lymphoma. This case highlights the crucial significance of including lymphoma-associated kidney disorders in the evaluation of unexplained AKI, particularly when encountering unconventional clinical and laboratory results. Swift and precise intervention is of utmost importance in attaining positive results in these rare and complex clinical situations. This study underscores the persistent concern of AKI in lymphoma patients, with lymphocytic infiltration and cast nephropathy as notable elements contributing to the intricate nature of this condition.

Faster improvement in outcome scores in posterior stabilised total knee arthroplasty compared to medial congruent system with posterior cruciate ligament retained

Most studies comparing medial pivot to the posterior stabilised (PS) systems sacrifice the PCL. It is unknown whether retaining the PCL in the Medial Congruent (MC) system may provide further benefit compared to the more commonly used PS system. A retrospective review of a single-surgeon's registry data comparing 44 PS and 26 MC with PCL retained (MC-PCLR) TKAs was performed. Both groups had similar baseline demographics. The PS and MC-PCLR groups had similar pre-operative range of motion (ROM) (PS:104º ± 20º vs. MC-PCLR: 101º ± 19º, p = 0.70), Oxford Knee Score (OKS) (PS: 27 ± 6 vs. MC-PCLR: 26 ± 7, p = 0.62), and Knee Society Scoring System (KS) Function Score (KS-FS) (PS: 52 ± 24 vs. MC-PCLR: 56 ± 23, p = 0.49). The pre-operative KS Knee Score (KS-KS) was significantly lower in the PS group (PS: 44 ± 14 vs. MC-PLR: 53 ± 18, p < 0.05). At 12-months post-operation, there was significant improvement in all parameters (p < 0.01). Both groups had similar ROM (PS: 115º ± 13º vs. MC-PCLR: 114º ± 10º, p = 0.98), OKS (PS: 41 ± 5 vs. MC-PCLR: 40 ± 4, p = 0.50), KS-FS (PS: 74 ± 22 vs. MC-PCLR: 77 ± 16, p = 0.78), and KS-KS (PS: 89 ± 10 vs. MC-PCLR: 89 ± 10, p = 0.89). The PS group had significant improvement in all parameters from preoperation to 3-month postoperation (p < 0.05), but not from 3-month to 1-year postoperation (p ≥ 0.05). The MC-PCLR group continued to have significant improvement from 3-month to 1-year postoperation (p < 0.05). Preserving the PCL when using MC may paradoxically cause an undesired additional restrain that slows the recovery process of the patients after TKA. Compared to MC-PCLR, a PS TKA may expect significantly faster improvement at 3 months post operation, although they will achieve similar outcomes at 1-year post operation.

Imaging Guide to Inner Ear Malformations: An Illustrative Review

Inner ear malformation (IEM) with associated sensoryneural hearing loss (SNHL) is a major cause of childhood disability. Computed tomography (CT) and magnetic resonance imaging (MRI) imaging play important and often complementary roles in diagnosing underlying structural abnormalities and surgical planning allows for direct visualization of the cochlear nerve and is the preferred imaging modality prior to cochlear implantation. CT is helpful to assess osseous anatomy and when evaluating children with mixed hearing loss or syndromic associations. When reviewing these cases, it is important for the radiologist to be familiar with the key imaging features. In this article, we will present the imaging findings associated with different inner ear malformations associated with congenital sensorineural hearing loss.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Access to Monomeric Lead(II) Hydrides with Remarkable Thermostability and Their Use in Catalytic Hydroboration of Carbonyl Derivatives

We report on the remarkable stability of unprecedented, monomeric lead(II) hydrides M⁺[LPb(II)H]^- (M[1-H]), where L = 2,6-bis(3,5-diphenylpyrrolyl)pyridine and M = (18-crown-6)potassium or ([2.2.2]-cryptand)potassium. The half-life of [K18c6][1-H] of ∼2 days in tetrahydrofuran at 25 °C is significantly longer than those reported for dimeric lead(II) hydrides supported by bulky terphenyl ligands (few hours at low temperatures), which are the only examples known for lead(II) hydride compounds. The presence of a Pb-H bond in [1-H]^- was unambiguously identified by multinuclear NMR spectroscopy. Remarkably, a ¹H resonance of the hydride ligand was found at δ = 41.43 ppm (¹J_PbH = 1312 Hz). For reactivity study, [1-H]^- serves as an excellent hydroboration catalyst with high turnover numbers and turnover frequencies for several carbonyl compounds.

The impact on renal function after long-term use of anticoagulants in atrial fibrillation patients

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): This study was supported by the research program of the Chang Gung Memorial Hospital.

Objective

Long-term oral anticoagulant should be considered or recommended in patients with atrial fibrillation (AF) and CHA2DS2VASc score ≥1 for stroke prevention. Warfarin and different direct oral anticoagulants (DOACs) are metabolized differently by the kidney. The impact on renal function after long-term use of anticoagulants in the patients with AF remains unclear. This study aimed to compare DOACs and warfarin’s impact on the decline in renal function from a large cohort with AF.

Methods

This study included patients with nonvalvular AF from 2000 to 2018, mainly through the medical history (ICD code) of the Chang Gung Research Database. Baseline estimated glomerular filtration rate (eGFR), follow-up eGFR and the change in eGFR between 2-year eGFR and baseline eGFR were compared between different DOACs and warfarin after propensity score matching. The primary study endpoint was acute kidney injury (AKI).

Results

3657 patients were enrolled in this study and the mean observation time was 3.3 ± 0.9 years. During the observation period, there was a significantly higher incidence of AKI during follow-up in the warfarin group than in the different DOAC groups before and after propensity score matching (before: warfarin vs. DOAC: 9.2% vs. 5.2%, p&lt;0.001; after: warfarin vs. DOAC: 8.9% vs. 4.4%, p&lt;0.001). There was no difference in the incidence of AKI between dabigatran group and anti-factor Xa inhibitor group after propensity score matching. The incidence of AKI was similar among rivaroxaban, apixaban and edoxaban groups after propensity score matching. The change in eGFR between 2-year eGFR and baseline eGFR did not differ between the warfarin and DOAC groups after propensity score matching (warfarin vs. DOAC: -1.27 ± 20.32 vs. -1.94 ± 17.24 mL/min/1.73 m2, p=0.461).

Conclusions

During the mean observation time of 3.3 ± 0.9 years, warfarin was associated with a higher incidence of AKI compared with DOACs. The decline in renal function did not differ among warfarin and different DOAC groups.

Bulky Di(1-adamantyl)phosphinous Acid-Ligated Pd(II) Precatalysts for Suzuki Reactions of Unreactive Aryl Chlorides

Di(1-adamantyl)phosphine oxide (SPO-Ad: Ad2P(V)(=O)H), a stable tautomer of di(1-adamantyl)phosphinous acid (PA-Ad: Ad2P(III)-OH), was employed to synthesize two new PA-Ad-coordinated complexes, POPd-Ad and POPd2-Ad. POPd-Ad was easily transformed from POPd2-Ad in acetonitrile, and the [M - H]- ion of the deprotonated POPd-Ad was observed in the electrospray ionization-mass spectrum of POPd2-Ad. Both complexes are effective precatalysts for the Suzuki reaction of aryl chlorides. The reduction of Pd(II) in POPd-Ad and POPd2-Ad by arylboronic acid was examined, and the ideal Pd-to-PA ratio in the Suzuki reaction was found to be 1:1. The effect of temperature on the catalytic yields was studied to examine the possible ligation state of the active species and the dimer-to-monomer process of POPd2-Ad. Mononuclear and mono-ligated Pd species was assumed to be catalytically active. The electronic and steric effects of PA-Ad were slightly better than those reported for PA-tBu ( t Bu2P(III)-OH). Density functional theory calculations were performed to evaluate the formation of mono-ligated and mononuclear Pd species from POPd-Ad and POPd2-Ad. Furthermore, the reaction time and catalyst loading could be reduced for the reported POPd1-tBu precatalyst using the optimized reaction conditions for POPd-Ad. The complexes synthesized in this extensive study will complement the existing SPO-coordinated POPd series of precatalysts.

More Evidence for Teriparatide after Fixation of Atypical Femoral Fractures: Report of Four Cases

Atypical femoral fractures (AFF) have low union rates. The use of teriparatide has been advocated for the post-operative healing of AFF, but the evidence is limited to case reports and some series due to its low incidence.

We present a case series of four female patients to support the use of teriparatide after the surgical fixation of their AFF. Three of the patients had a complete AFF and one had an incomplete fracture. Their mean age was 70 (52 - 87) years, mean body mass index 24.6 (18.3 - 29.3), mean bone mineral density T-score of -2.3 (-4.8/-1.0), with a prior history of anti-resorptive therapy with bisphosphonates and denosumab.

Teriparatide was started at an average of 8 (2-18) days post-fixation, with 20mcg daily for six months. Immediate full weight-bearing was permitted in three patients, while one was non-weight bearing for two months. The mean time to union was 12 (10 - 14) weeks. No side effects were observed over a mean follow-up of 58 (50 – 72) weeks.

The use of teriparatide facilitated the quick union of AFF after surgical fixation. It appeared to be safe and promoted fracture healing in AFF.

The 12-hour shift: radiographers' perspectives and its applicability during a pandemic

Introduction

Traditionally, shift work for radiographers at our institution comprised of three shift patterns – morning (8am-2pm), afternoon (2pm–9pm) and night (9pm-8am). However, when COVID-19 was first detected in Singapore in January 2020, the 12-h shift was introduced for better team segregation and deployment to meet the service needs of the Emergency Department. The 12-h shift consisted of the day (9am-9pm) and night (9pm-9am) shifts. While the 12-h shift is common to nursing practices, it is new to the radiography profession within the study centre. This study explores the radiographers' perspectives of the new shift and the impact of shift patterns on radiographers' wellness and work performance compared to the original three shift patterns.

Methods

A mixed-methods design study was adopted for this single-centre evaluation. An anonymous online questionnaire was administered to radiographers who had experienced both shift types. Additionally, the number of radiographers who had taken sick leave, and images rejected and accepted from the X-ray consoles were retrospectively collected to measure the impact of the new shift.

Results

Radiographers experienced fatigue and appreciated the longer rest days associated with the 12-h shift. Additionally, the sick leave rates and image reject counts were more favourable with the 12-h shift pattern.

Conclusion

The findings indicate that the extended shift hours are effective during a pandemic but may result in radiographer burnout during a prolonged outbreak.

Implications for practice

Studying these variables will provide an effective starting point in understanding the efficacy and applicability of a 12-h shift system during pandemic periods.

Overview of rapid mitigating strategies in Singapore during the COVID-19 pandemic

This article describes the rapid mitigation strategies in addressing the rising number of coronavirus disease 2019 (COVID-19) cases in Singapore. Learning from the severe acute respiratory syndrome experience in 2003, early preparation started in January 2020 when Wuhan was declared as the epicentre of the epidemic. The government had constructed a three-pronged approach which includes travel, healthcare and community measures to curb the spread of COVID-19.

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This article describes the preparations and rapid mitigation strategies in addressing the rocketing number of coronavirus disease 2019 (COVID-19) cases in Singapore.

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The government had constructed a three-pronged approach which includes travel, healthcare and community measures to curb the spread of COVID-19.

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Careful and thoughtful planning with successive rapid executions were necessary to balance the profound impact of the socio-economic activities and the healthcare system.

Highly Crosslinked Polyethylene Tibial Post Fracture in the Unafflicted Limb of a Patient with Unilateral Lower Limb Poliomyelitis: A Case Report

We present a unique case of tibial post fracture of a posterior-stabilised total knee arthroplasty (PS-TKA) using highly crosslinked polyethylene (HXLPE) in the unafflicted limb of a patient who had poliomyelitis. The tibial post is an upright structure perpendicular to the PE insert articular surface which articulates with the cam of the femoral component to prevent excessive posterior translation of the tibia. We explore the choice of PS polyethylene (PE) inserts in patients with neuromuscular disorders (NMD). A 74-year old gentleman presented with recurrent knee pain seven years after the index PS-TKA with HXLPE. The TKA was performed on the unafflicted left limb (contralateral to the weak side affected by poliomyelitis). The posterior drawer test was positive. During the single-stage revision surgery, the HXLPE tibial post was noted to be broken. The liner was replaced with a thicker non-HXLPE. The patient achieved an excellent outcome at one-year post-surgery. This is the first report of HXLPE tibial post fracture in the unaffected knee of a patient with NMD affecting the lower limb. The HXLPE's reduced resistance to fatigue crack propagation might not be suitable in PS-TKA where there might be focal stress points on the tibial post, which was amplified in this case as it was the limb that the patient most depended on. When managing end-stage osteoarthritis with TKA in the unafflicted knee of a patient with NMD causing lower limb weakness, the selection of polyethylene material in PS-TKA may need more consideration than previously thought.

Three-dimensional collective charge excitations in electron-doped copper oxide superconductors

High-temperature copper oxide superconductors consist of stacked CuO₂ planes, with electronic band structures and magnetic excitations that are primarily two-dimensional^1,2, but with superconducting coherence that is three-dimensional. This dichotomy highlights the importance of out-of-plane charge dynamics, which has been found to be incoherent in the normal state^3,4 within the limited range of momenta accessible by optics. Here we use resonant inelastic X-ray scattering to explore the charge dynamics across all three dimensions of the Brillouin zone. Polarization analysis of recently discovered collective excitations (modes) in electron-doped copper oxides^5-7 reveals their charge origin, that is, without mixing with magnetic components^5-7. The excitations disperse along both the in-plane and out-of-plane directions, revealing its three-dimensional nature. The periodicity of the out-of-plane dispersion corresponds to the distance between neighbouring CuO₂ planes rather than to the crystallographic c-axis lattice constant, suggesting that the interplane Coulomb interaction is responsible for the coherent out-of-plane charge dynamics. The observed properties are hallmarks of the long-sought 'acoustic plasmon', which is a branch of distinct charge collective modes predicted for layered systems^8-12 and argued to play a substantial part in mediating high-temperature superconductivity^10-12.

Differences in the oral health status and oral hygiene practices according to the extent of post-stroke sequelae

Oral health and hygiene are crucial parameters in stroke patients. However, few studies have evaluated the oral health status and oral hygiene practices according to the level of function in stroke patients. The aim of this study was to evaluate the oral health status and oral hygiene practices according to ambulation and personal hygiene levels in patients with stroke. Data from the fifth (2010-2012) and sixth (2013-2015) editions of the Korea National Health and Nutrition Examination Survey (KNHANES) for 6 years were combined. A total of 700 stroke patients were enrolled in our study. Subjective oral health was significantly poorer in patients who experienced a moderate problem with walking (adjusted OR [AOR], 1.68; 95% CI, 1.21-2.33) and bed-bound patients (AOR, 2.92; 95% CI, 1.01-8.44) than in patients who could walk without difficulty. Patients who were unable to bathe or dress independently exhibited a significantly higher risk of dental caries than did those who could perform the same activities unassisted. The probability of brushing teeth ≥2 times daily was 69% lower in bed-bound patients (AOR, 0.31; 95% CI, 0.11-0.87) than in patients who could walk without difficulty and 76% lower in patients who were unable to bathe or dress independently (AOR, 0.24; 95% CI, 0.09-0.62) than in those who could perform the same activities without difficulty. There were differences in oral health status and oral hygiene practices, according to ambulation level and functional independence, in the stroke patient group. These results indicate the need for oral care for stroke patients who exhibit ambulatory and functional limitations.

Alterations in mechanical properties of the patellar tendon is associated with pain in athletes with patellar tendinopathy

PURPOSE

To compare tendon strain and stiffness between athletes with patellar tendinopathy and healthy controls, and explore whether the intensity of pain and dysfunction were related to the mechanical properties of the tendon.

METHODS

Thirty-four male athletes with patellar tendinopathy and 13 healthy controls matched by age and activity levels were recruited. The in vivo mechanical properties of the patellar tendon were examined by ultrasonography and dynamometry. In subjects with patellar tendinopathy, the intensities of self-perceived pain (maximal pain in the past 7 days and pain during a single-legged declined-squat test) using the visual analogue scale and the assessment of functional disability using the Victorian Institute of Sport Assessment-patellar questionnaire, were collected.

RESULTS

In subjects with patellar tendinopathy, tendon strain was significantly reduced by 22% (8.9 ± 3.7 vs. 14.3 ± 4.7%, P = 0.005) when compared with healthy controls. There was no significant group difference in tendon stiffness (P = 0.27). Significant negative correlations between tendon strain and the maximal self-perceived pain over 7 days (r = -0.37, P = 0.03), and pain during a single-legged declined-squat test (r = -0.37, P = 0.03) were detected. A trend of significant positive correlation was found between tendon stiffness and pain during a single-legged declined-squat test (r = 0.30, P = 0.09).

CONCLUSION

Our findings show that tendon strain is reduced in athletes with patellar tendinopathy, and a lower tendon strain is associated with a greater magnitude of pain perceived.

Accuracy and Trending of Continuous Noninvasive Hemoglobin Monitoring in Patients Undergoing Liver Transplantation

BACKGROUND

Shift in large fluid volumes and massive blood loss during liver transplantation frequently leads to rapid changes in hemoglobin (Hb) concentration; thus, to ensure adequate tissue oxygenation, accurate and rapid determination of Hb concentration is essential in transplant recipients. The Radical-7 Pulse CO-Oximeter provides a noninvasive and continuous way to monitor Hb concentration (SpHb) in real time and is an ideal candidate for use during liver transplantation. In this study, we assessed the relationship between SpHb and total Hb (tHb) obtained from arterial blood samples during surgery.

METHODS

Forty patients undergoing liver transplantation were enrolled in this study. tHb and time-matched SpHb were measured at 5 different phases throughout surgery. Paired SpHb and tHb levels were assessed using linear regression, Bland-Altman analysis, and the Critchley polar plot method.

RESULTS

A total of 161 paired measurements with sufficient signal quality were analyzed. The correlation between SpHb and tHb was 0.59 (P < .001). Bland-Altman analysis revealed that a bias between SpHb and tHb was 2.28 g/dL, and limits of agreement (LoA) were from -0.78 to 5.34 g/dL. Trending analysis showed that 87% of data were located within the acceptable trending area, indicating that the trending ability was not satisfied.

CONCLUSIONS

The Radical-7 Pulse CO-Oximeter was not sufficient to monitor Hb levels and trends during liver transplantation surgery in our cohort. In particular, in critical patients and in those with low Hb levels, invasive Hb measurement should be used for assessment.

Mitochondrial DNA variants as genetic risk factors for Parkinson disease

BACKGROUND AND PURPOSE

Investigation of the relationship between mitochondrial DNA (mtDNA) variants and Parkinson disease (PD) remains an issue awaiting more supportive evidence. Moreover, an affirming cellular model study is also lacking.

METHODS

The index mtDNA variants and their defining mitochondrial haplogroup were determined in 725 PD patients and 744 non-PD controls. Full-length mtDNA sequences were also conducted in 110 cases harboring various haplogroups. Cybrid cellular models, composed by fusion of mitochondria-depleted rho-zero cells and donor mitochondria, were used for a rotenone-induced PD simulation study.

RESULTS

Multivariate logistic regression analysis revealed that subjects harboring the mitochondrial haplogroup B5 have resistance against PD (odds ratio 0.50, 95% confidence interval 0.32-0.78; P = 0.002). Furthermore, a composite mtDNA variant group consisting of A10398G and G8584A at the coding region was found to have resistance against PD (odds ratio 0.50, 95% confidence interval 0.33-0.78; P = 0.001). In cellular studies, B4 and B5 cybrids were selected according to their higher resistance to rotenone, in comparison with cybrids harboring other haplogroups. The B5 cybrid, containing G8584A/A10398G variants, showed more resistance to rotenone than the B4 cybrid not harboring these variants. This is supported by findings of low reactive oxygen species generation and a low apoptosis rate in the B5 cybrid, whereas a higher expression of autophagy was observed in the B4 cybrid particularly under medium dosage and longer treatment time with rotenone.

CONCLUSIONS

Our studies, offering positive results from clinical investigations and cybrid experiments, provide data supporting the role of variant mtDNA in the risk of PD.

Serum preadipocyte factor 1 concentrations and risk of developing diabetes: a nested case-control study

AIM

To determine whether preadipocyte factor 1 could be a predictive marker for the development of diabetes in people without diabetes at baseline.

METHODS

We conducted a population-based, nested case-control study of individuals who progressed to diabetes (n = 43) or prediabetes (n = 345) and control participants matched on age, sex and fasting plasma glucose concentration, who maintained normal glucose tolerance (n = 389) during a 4-year follow-up using data from the Chungju Metabolic disease Cohort Study. Circulating levels of preadipocyte factor 1 were measured using an enzyme-linked immunosorbent assay.

RESULTS

Baseline serum preadipocyte factor 1 levels showed a stepwise decrease across the glucose tolerance status groups at follow-up (normal glucose tolerance: 10.02 ± 3.02 ng/ml; prediabetes: 9.48 ± 3.35 ng/ml; diabetes: 8.66 ± 3.29 ng/ml; P for trend, 0.0151). Individuals whose fasting plasma glucose level had increased or whose homeostasis model assessment of β-cell function had decreased at follow-up showed significantly lower levels of preadipocyte factor 1 compared with their control group counterparts. After adjusting for age, BMI, fasting plasma glucose, serum insulin levels, systolic blood pressure and triglycerides, the incidence of diabetes was nearly threefold higher in the lowest vs. the upper three quartiles of circulating preadipocyte factor 1 (relative risk 2.794; 95% CI 1.188-6.571; P = 0.0185). Notably, these findings were significant in women but not in men.

CONCLUSIONS

Levels of circulating preadipocyte factor 1 may be a useful biomarker for identifying women at high risk of developing diabetes.

Ginger Essential Oil Ameliorates Hepatic Injury and Lipid Accumulation in High Fat Diet-Induced Nonalcoholic Fatty Liver Disease

The objective of this study was to investigate the hepatoprotective efficacy and mechanism of action of ginger essential oil (GEO) against the development of nonalcoholic fatty liver disease (NAFLD). Mice were maintained on either a control diet or high-fat diet (HFD) supplemented with GEO (12.5, 62.5, and 125 mg/kg) or citral (2.5 and 25 mg/kg) for 12 weeks. We demonstrated that GEO and its major component (citral) lowered HFD-induced obesity in a dose-dependent manner, accompanied by anti-hyperlipidemic effects by reducing serum free fatty acid, triglyceride, and total cholesterol levels. Moreover, liver histological results showed that administration of 62.5 and 125 mg/kg GEO and 25 mg/kg citral significantly reduced hepatic lipid accumulation. Further assessment by Western blotting and investigation of the lipid metabolism revealed that hepatic protein expression of sterol regulatory element-binding protein-1c (SREBP-1c), acetyl-CoA carboxylase (ACC), fatty acid synthase (FAS), 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), and cytochrome P450 2E1 (CYP2E1) were down-regulated by GEO and citral, indicating that GEO and citral suppressed HFD-stimulated lipid biosynthesis and oxidative stress. Furthermore, GEO and citral effectively enhanced the antioxidant capacities and reduced inflammatory response in mouse liver, which exerted protective effects against steatohepatitis. Collectively, GEO and citral exhibited potent hepatoprotective effects against NAFLD induced by HFD in obese mice. Thus, GEO might be an effective dietary supplement to ameliorate NAFLD-related metabolic diseases, and citral could play a vital role in its management.

Failure to restore sagittal tibiotalar alignment in total ankle arthroplasty: Its relationship to the axis of the tibia and the positioning of the talar component

The purpose of this study was to evaluate the change in sagittal tibiotalar alignment after total ankle arthroplasty (TAA) for osteoarthritis and to investigate factors affecting the restoration of alignment. This retrospective study included 119 patients (120 ankles) who underwent three component TAA using the Hintegra prosthesis. A total of 63 ankles had anterior displacement of the talus before surgery (group A), 49 had alignment in the normal range (group B), and eight had posterior displacement of the talus (group C). Ankles in group A were further sub-divided into those in whom normal alignment was restored following TAA (41 ankles) and those with persistent displacement (22 ankles). Radiographic and clinical results were assessed. Pre-operatively, the alignment in group A was significantly more varus than that in group B, and the posterior slope of the tibial plafond was greater (p < 0.01 in both cases). The posterior slope of the tibial component was strongly associated with restoration of alignment: ankles in which the alignment was restored had significantly less posterior slope (p < 0.001). An anteriorly translated talus was restored to a normal position after TAA in most patients. We suggest that surgeons performing TAA using the Hintegra prosthesis should aim to insert the tibial component at close to 90° relative to the axis of the tibia, hence reducing posterior soft-tissue tension and allowing restoration of normal tibiotalar alignment following surgery.

Improved real-world glycaemic outcomes with liraglutide versus other incretin-based therapies in type 2 diabetes

AIM

Liraglutide (LIRA) once-daily has provided greater A1C reductions than either exenatide (EXEN) twice-daily or sitagliptin (SITA) once-daily in head-to-head trials. The objective of this analysis is to compare the real-world clinical effectiveness of these agents in the USA.

METHODS

Using the IMS Health (Alexandria, VA, USA) integrated claims database, A1C outcomes in patients aged ≥ 18 years with type 2 diabetes (T2D) who initiated either LIRA, EXEN or SITA (including SITA/metformin) were retrospectively compared. Patients included in the analysis had ≥ 1 prescription for LIRA, EXEN or SITA between January and December 2010 (index period) and persisted with their index treatment regimens for 6 months post-index. Outcomes included changes in A1C from baseline (45 days pre-index through 7 days post-index) to follow-up [6 months post-index (± 45)] and the proportion of patients reaching A1C<7%. Multivariable regression models adjusted for confounding factors (e.g. age, comorbidities, baseline A1C and background antidiabetic therapy).

RESULTS

The predicted change in A1C from baseline was greater for LIRA patients compared with both SITA (-1.08 vs. -0.68%; treatment difference 0.40%, p < 0.0001) and EXEN (-1.08 vs. -0.75%; treatment difference 0.32%, p < 0.001). Predicted A1C goal achievement, derived from the multivariate logistic regression model, was higher with LIRA compared with both SITA [64.4% (95% confidence interval, CI: 63.5-65.3) vs. 49.4% (95% CI: 48.5-50.4); p < 0.0001] and EXEN [64.4% (95% CI: 63.5-65.3) vs. 53.6% (95% CI: 52.6-54.6); p < 0.0001].

CONCLUSIONS

In clinical practice, LIRA was associated with significantly greater reductions in A1C and improved glycaemic goal attainment compared with either EXEN or SITA among adult patients with T2D.

Staging accuracy of endoscopic ultrasound performed by nonexpert endosonographers in patients with resectable esophageal squamous cell carcinoma: is it possible?

The accuracy of endoscopic ultrasound (EUS) is operator-dependent. According to learning curve study, the accuracy of EUS T-staging for esophageal cancer has been reported to be greater in an investigator who had performed at least 100 EUS examinations. We determined comparative study regarding T-staging accuracy of EUS for esophageal squamous cell carcinoma between expert and nonexpert endoscopic ultrasonographers. We retrospectively identified 73 consecutive patients with esophageal squamous cell carcinoma who underwent EUS and endoscopic mucosal resection, endoscopic submucosal dissection, or surgery. EUS was performed by expert (Group 1) and nonexpert (Group 2) endoscopic ultrasonographers in multitertiary hospitals. Groups 1 and 2 were 37 and 36 patients during 2005-2011, respectively. Forty-two patients (57.5%) of the overall patients underwent surgical exploration. Correct endoscopic ultrasonographic T-staging of Group 1 was observed in 34 (91.9%) patients, while that of Group 2 was observed in 26 (72.2%) patients. And there was significant difference in correct endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.035). The incorrect endoscopic ultrasonographic T-staging of Group 1 were three cases that were overstaging (8.1%), but in Group 2 there were seven overstaging (19.4%) and three understaging (8.3%). There was no significant difference in overstaging or understaging of incorrect endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.528). This study first provides evidence that endoscopic ultrasonographic T-staging of nonexpert endoscopic ultrasonographers was inferior to be correct, compared with that of expert endoscopic ultrasonographers. EUS staging for esophageal cancer should be performed by expert endoscopic ultrasonographers to provide appropriate management strategy.

Vertical-cavity and randomly scattered lasing from different thicknesses of epitaxial ZnO films grown on Y₂O₃-buffered Si (111)

Two different types of lasing modes, vertical Fabry-Perot cavity and random lasing, were observed in ZnO epi-films of different thicknesses grown on Si (111) substrates. Under optical excitation at room temperature by a frequency tripled Nd:YVO₄ laser with wavelength of 355 nm, the lasing thresholds are low due to high crystalline quality of the ZnO epitaxial films, which act as microresonators. For the thick ZnO layer (1,200 nm), its lasing action is originated from the random scattering due to the high density of crack networks developed in the thick ZnO film. However, the low crack density of the thin film (555 nm) fails to provide feedback loops essential for random scattering. Nevertheless, even the lower threshold lasing is achieved by the Fabry-Perot cavity formed by two interfaces of the thin ZnO film. The associated lasing modes of the thin ZnO film can be characterized as the transverse Gaussian modes attributed to the smooth curved surfaces.

Health-related quality of life in haemophilia patients with inhibitors and their caregivers

Data on the health-related quality of life (HRQoL) of congenital haemophilia patients with inhibitors (CHwI) and their caregivers are limited. To understand the association between patient demo-graphics/clinical characteristics with HRQoL among CHwI patients and caregivers, a survey was developed to assess HRQoL with haemophilia-specific QoL questionnaires (HAEMO-QoL/HAEM-A-QoL). In the cross-sectional study, paper-pencil questionnaires were mailed to 261 US CHwI patients/caregivers in July 2010. Descriptive analyses were performed to characterize HRQoL by age and to identify drivers of impairment, from both patient/caregiver perspectives. HRQoL scores were transformed on a scale of 0-100, with higher scores indicating higher impairment in HRQoL. Ninety-seven respondents completed the HRQoL assessment. HRQoL impairment was higher in adult patients. In children ages 8-16 years, mean HAEMO-QoL total score was 33.8 (SD = 15.5), and 35.0 (SD = 16.1) in children ages 4-7 years; for adult patients the mean HAEM-A-QoL total score was 42.2 (SD = 14.8). Adults reported highest impairment in the 'sports/leisure' subscale (Mean = 62.5, SD = 18.7), whereas patients 8-16 years reported highest impairment in the 'physical health' subscale (Mean = 50.8, SD = 30.5).Caregivers of patients ages 4-7 years reported greatest impairment within the 'family' subscale (Mean = 55.6, SD = 19.4). Caregivers were ''considerably/very much'' bothered by their child's inhibitors and reported higher QoL impairment for their child than parents who were not bothered. Within ChwI patients, HRQoL impairments increased with age and existed across a range of physical/psychosocial domains. In addition, caregiver burden also affected the perceived HRQoL of paediatric CHwI patients. Additional research is considered necessary to further understand the support caregivers need while caring for children with CHwI.

Stroke volume variation derived by arterial pulse contour analysis is a good indicator for preload estimation during liver transplantation

BACKGROUND

Accurate determination of preload during liver transplantation is essential. Continuous right ventricular end diastolic volume index (RVEDVI) has been shown to be a better preload indicator during liver transplantation than the filling pressures. However, recent evidence has shown that dynamic variables, in this case stroke volume variation (SVV), are also good indicators of preload responsiveness. In this study, we evaluated the correlation between SVV, which we derived from arterial pulse contour analysis and RVEDVI.

METHODS

In this study, we looked for possible relationships between SVV obtained through FloTrac/Vigileo monitor, central venous pressure (CVP), pulmonary arterial occlusion pressure (PAOP), and RVEDVI in 30 patients undergoing liver transplantation. Measurements were taken at 11 defined points during different phases across liver transplantation. Each set of measurement was taken during a steady state, which means at least 15 minutes elpased after any changes occured in either the infusion rate of catecholamines or ventilator settings. Pearson's test was used for correlation estimation.

RESULTS

There was a statistically significant (P<.01) relationship between SVV and RVEDVI with a correlation coefficient of -0.87. The correlations between CVP (r=0.42), PAOA (r=0.46), and RVEDVI were less strong.

CONCLUSION

We conclude that SVV is a good indicator for preload estimation during liver transplantation. A higher SVV value is associated with a more hypovolemic fluid status.

Probable Blastomyces dermatitidis infection in a young rat

A 21-week-old male untreated control SHR/NCrlNarl rat was found dead during an experiment. Grossly, pulmonary lesions were characterized by multifocal to coalescing firm gray-white nodules randomly scattered on the surface. Microscopically, bronchopneumonia was found with pyogranulomas containing neutrophils, macrophages, and numerous thick-walled yeast cells. Yeast cells, 5 to 25 μm in diameter, with no branching of hyphae were observed by staining with hematoxylin and eosin, Diff-Quik, and periodic acid-Schiff. Furthermore, polymerase chain reaction (PCR) using panfungal and nested PCR primers were used for detection of Blastomyces dermatitidis DNA in the lung tissue. After sequencing and matching with DNA sequences in the GenBank, the sample showed a similarity of 94.6% and 97% to Ajellomyces dermatitidis (B. dermatitidis), respectively. On the basis of these results, probable pulmonary blastomycosis was diagnosed. The origin of the infection in the colony rat is undetermined.

Deformation measurement of individual cells in large populations using a single-cell microchamber array chip

We analyze the deformability of individual red blood cells (RBCs) using SiCMA technology. Our approach is adequate to quickly measure large numbers of individual cells in heterogeneous populations. Individual cells are trapped in a large-scale array of micro-wells, and dielectrophoretic (DEP) force is applied to deform the cells. The simple structures of micro-wells and DEP electrodes facilitate the analysis of thousands of RBCs in parallel. This unique method allows the correlation of red cell deformation with cell surface and cytosolic characteristics to define the distribution of individual cellular characteristics in heterogeneous populations.

Uses and abuses of paediatric electroencephalography

OBJECTIVE

To investigate whether requests for standard paediatric electroencephalograms accord with guideline recommendations, subsequent changes in clinical management according to reported results, and extent to which the service meets waiting time targets.

DESIGN

Case series.

SETTING

Regional hospital, Hong Kong.

PATIENTS

All patients aged less than 18 years who underwent electroencephalography between December 2009 and February 2010.

MAIN OUTCOME MEASURES

Appropriateness of the electroencephalogram request and the impact of its findings on clinical management.

RESULTS

A total of 109 patients were recruited, but requests for standard electroencephalograms were considered 'inappropriate' with respect to guidelines in 44% of the patients, of which 50% were made to diagnose 'funny turns'. The standard electroencephalogram contributed to the diagnosis or management in only 28% of patients. In all of the latter, the request for an electroencephalogram had been appropriate. Nonspecialists made referrals for 86% of the patients. Inadequate information was provided in 66% of the requests. Standard electroencephalograms were performed within guideline targets, the wait being less than 4 weeks in 95% of requests.

CONCLUSION

An effective electroencephalogram service was being provided, though abuses were common. These were mainly because of misconceptions regarding the role and limitations of standard electroencephalograms. Through an educative, non-confrontational approach, and with time to explain guideline recommendations to clinicians, sustainable change in practice could be achieved so as to benefit patients, clinicians, and service provision.

Patient/caregiver perceived benefits and barriers to elective orthopedic surgery (EOS) in patients with congenital hemophilia with inhibitors

OBJECTIVE

Congenital hemophilia patients with inhibitors are at greater risk for developing arthropathy and orthopedic complications compared to those without inhibitors. Elective orthopedic surgeries (EOS) may be an option for these patients and may provide long-term cost savings due to reduced bleed frequency. However, patient motivations and goals for undergoing or delaying such surgeries are not well understood. A US-based patient/caregiver survey was designed to describe inhibitor patient experiences and outcomes following EOS and to develop a comprehensive understanding of patient preferences for EOS, which are lacking in the literature.

METHODS

The paper-pencil questionnaire was mailed to 261 US inhibitor patients/caregivers and included history and timing of EOS, quality-of-life (QoL) and potential benefits of and barriers to receiving EOS. Univariate/bivariate descriptive analyses were performed to characterize those with/without a history of EOS.

RESULTS

For 103 subjects who responded, the mean age was 20.9 years. Approximately 25% (n = 26) of respondents underwent EOS, most commonly on the knee (21, 81%); 73.1% of surgery recipients reported the surgery improved or greatly improved their QoL based on single-item response. The highest ranked perceived benefits were less pain, fewer bleeds, and improved mobility. However, the leading concerns reported were lack of improved mobility (62.2%), fear of uncontrolled bleeding (61.3%), and surgical complications, such as blood clot (60.0%).

LIMITATIONS

The study consisted of a small sample size, primarily due to the difficulty in trying to reach inhibitor patients or their caregivers, thereby restricting inferential and stratification analysis.

CONCLUSIONS

QoL improved for most inhibitor patients who reported having EOS. For those considering surgery, there is optimism about the potential benefits, but realistic concerns associated with bleed control and post-op complications.

P1-08-21: Demographic and Clinical Characteristics of Metastatic Breast Cancer Patients and Biomarker-Based Prevalence in the UK, Germany, France, Spain and Italy (EU-5)

Background: Much peer-reviewed literature focuses on metastatic breast cancer (mBC) treatment regimens. However, research around mBC patients’ demographic/clinical characteristics across Europe is limited. This study compared such mBC characteristics as well as biomarker-based prevalence across the EU-5.

Methods: IMS LifeLink™ Oncology Analyzer (OA) database, based upon practicing oncologist surveys, was used to identify mBC patients aged ≥18 between 01/2005-06/2010. The study investigated the distribution of mBC population based on age, biomarker, co-morbidities and stage at diagnosis. This study also estimated the proportion of patients, and sites of metastasis, by lines of drug therapies (LOT).

Results: A total of 186,640 mBC patients were identified — Germany (30.2%), France (22.4%), UK (21.2%), Italy (17.7%) and Spain (8.4%). The majority of patients were aged 61–70yrs (24%-32%), except in Spain (22.3% aged 71–80yrs). Proportion of mBC patients with ≥1 co-morbid condition were highest in Germany (36.3%), followed by Spain (32.8%), UK (31.5%), Italy (27.6%) and France (20.1%), with diabetes (12.9−23.9%) and cardiac dysfunction (5.2−21.7%) being most prevalent. The distribution of mBC patients by biomarker status was 53.9% HER-/HR+, 17.8% HER+/HR+, 11.1% HER+/HR- and 17.2% triple negative, and was similar amongst the EU5 countries. The top three metastatic sites were bone (54.4%), lung (36.0%) and liver (32.7%), with proportion of bone metastasis increasing from 1st LOT (38.1%) to 4th LOT (69.6%). Almost 50% of the mBC patients were diagnosed at Stage IV, 14% at Stage III, 26% at Stage II and 6% at Stage I. Of all mBC patients, 93% received 1st LOT, 31% received 2nd LOT, 27% received 3rd LOT and 6.8% received 4thLOT.

Conclusion: In the EU-5, mBC patients were primarily elderly and HER-/HR+. The burden of bone metastasis was higher in later LOTs. Following the 1st LOT, fewer patients moved to subsequent treatments. Additional research on EU-5 clinical practice patterns is warranted.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-08-21.

A cross-ethnic comparison on incidence of suicide

BACKGROUND

Suicide rates vary widely across nations and ethnic groups. This study aims to explore potential factors contributing to inter-ethnic differences in suicide rates.

METHOD

Study subjects came from a case-control psychological autopsy study conducted in Taiwan, including 116 consecutive suicides from two aboriginal groups and Taiwanese Han; 113 of them each matched with two living controls. Gender-, age- and method-specific suicide rates, population attributable fraction (PAF) of suicide for five major risk factors, help-seeking before suicide and emergency medical aid after suicide were compared between the three ethnic groups.

RESULTS

One aboriginal group (the Atayal) had significantly higher adjusted rate ratios (RR) of suicide than the other aboriginal group (the Ami) [RR 0.20, 95% confidence intervals (CI) 0.12-0.34] and the Han (RR 0.26, 95% CI 0.16-0.40). Such differences can be explained by higher PAFs of suicide for three major risk factors (substance dependence, PAF 47.6%, 95% CI 25.5-64.2; emotionally unstable personality disorder, PAF 52.7%, 95% CI 32.8-69.0; family history of suicidal behaviour, PAF 43.5%, 95% CI 23.2-60.2) in this group than in the other two groups. This higher suicide rate was substantially reduced from 68.2/100 000 per year to 9.1/100 000 per year, comparable with the other two groups, after stepwise removal of the effects of these three risk factors. Suicide rates by self-poisoning were also significantly higher in this group than in the other two groups.

CONCLUSIONS

Higher rates of specific risk factors and use of highly lethal pesticides for suicide contributed to the higher suicide rate in one ethnic group in Taiwan. These findings have implications for developing ethnicity-relevant suicide prevention strategies.

Cost-effectiveness of liraglutide versus rosiglitazone, both in combination with glimepiride in treatment of type 2 diabetes in the US

BACKGROUND

Many patients with type 2 diabetes mellitus (T2DM) are not able to maintain adequate HbA(1c) control (<7.0%), even at maximal dosage levels of one or two oral agents, and are at increased risk for diabetes-related complications.

OBJECTIVE

To estimate the cost-effectiveness of a once-daily GLP-1 analog Victoza [Novo Nordisk] versus a thiazolidinedione (TZD), rosiglitazone in patients with T2DM. Both treatment groups included background therapy with glimepiride.

RESEARCH DESIGN AND METHODS

The CORE Diabetes Model (CDM) was used to project and compare 35-year clinical and economic outcomes associated with liraglutide 1.2 mg + glimepiride and liraglutide 1.8 mg + glimepiride versus rosiglitazone 4 mg + glimepiride. Baseline cohort characteristics (HbA(1c) (8.4%), age, duration of disease, sex, body-mass index (BMI), blood pressure, and lipids) were based on the Liraglutide Effect and Action in Diabetes-1 (LEAD-1) trial.

OUTCOMES

Primary outcomes included life expectancy (LE), quality-adjusted life-years (QALYs), total costs and incremental cost-effectiveness ratios (ICERs). results: When compared to rosiglitazone, liraglutide 1.2 mg and 1.8 mg increased mean LE by 0.968 and 1.041 years, and QALYs by 0.764 and 0.837, respectively. Total lifetime costs increased by $26,094 for liraglutide 1.2 mg versus rosiglitazone, and by $47,041 for liraglutide 1.8 mg versus rosiglitazone. ICERs for liraglutide 1.2 mg versus rosiglitazone and 1.8 mg versus rosiglitazone were $34,147 and $56,190, respectively.

CONCLUSIONS

Compared to rosiglitazone 4 mg plus glimepiride, liraglutide (particularly at the 1.2-mg dose) plus glimepiride is a cost-effective treatment option for improving glucose control in T2DM. Limitations include the projection of short term efficacy results from randomized control trials to longer time horizons. In addition, clinical acceptance and overall use of rosiglitazone in the treatment of diabetes has continued to fall since publication of the clinical trial upon which this modeling analyses was based.

Split-liver transplantation in 2 adults: significance of caudate lobe outflow reconstruction in left lobe recipient: case report

Split-liver transplantation is a well-known procedure for increasing the donor pool. The procedure is commonly used in 1 adult and 1 child, but is less commonly performed in 2 adults because of technical difficulty and poor outcome in left-lobe recipients. Preservation of caudate lobe function is important in recipients with borderline graft-recipient weight ratio to achieve better results. Herein, we report a case in which caudate lobe outflow was reconstructed in a left lobe with a caudate lobe graft in split-liver transplantation in 2 adults.

Health-related quality of life and productivity impact in haemophilia patients with inhibitors

To measure health-related quality of life (HRQL), its determinants, and its association with patient and caregiver productivity among a sample of haemophilia patients with inhibitors in the United States (US). Data on demographical and clinical characteristics, treatment patterns, HRQL (SF-12v2), and productivity outcomes were reported for 53 patients. Mean SF-12v2 domain and mental (MCS) and physical (PCS) component summary scores were assessed and compared with US norms. Regression analyses explored the association of patient and treatment factors with HRQL and productivity. Patients' mean age was 20.7 years (SD = 18.8), 88.5% were type A, and 39.6% received on-demand therapy as their only mode of treatment. Mean PCS was significantly lower than the US norm (PCS, 39.9, P < 0.01) and mean MCS showed no significant difference (MCS, 49.9, P = ns). On-demand treatment (B = -0.336, P < 0.05) and number of haemorrhages (B = -0.366, P < 0.05) were negatively associated with PCS; and PCS was associated with patients' missed work or school days [incidence rate ratio (IRR) = 0.93, P < 0.001] and perceived impact on daily activities (OR = 0.72, P < 0.05). Younger age (IRR = 0.91, P < 0.01), lower PCS (IRR = 0.94, P < 0.01), more haemorrhages (IRR = 1.05, P < 0.05), and surgery (IRR = 2.74, P < 0.05) were associated with fewer patients' productive days. Physical functioning among inhibitor patients in the US is compromised and is negatively associated with their daily activities and productivity. These data suggest a positive association of prophylactic and immunotolerance therapy with HRQL, specifically physical impairment.

Acute treatment costs of intracerebral hemorrhage and ischemic stroke in Argentina

BACKGROUND AND PURPOSE

Stroke is the third leading cause of death in Argentina, yet little information exists on the acute treatment provided for stroke or its costs. This study estimates the national costs of the acute treatment of first-ever intracerebral hemorrhage (ICH) and ischemic stroke (IS) in Argentina.

METHODS

Retrospective hospital-based inception study design using data on resource use and costs from high-volume stroke centers in Argentina, and published population-based incidence data. Treatment provided at two large urban hospitals were evaluated in all patients admitted with a first-ever stroke between 1 January 2004 and 31 August 2006, and costs were assigned using appropriate unit cost data for all resource use. Cost estimates in Argentinian pesos were converted to US dollars ($) using the 2005 purchasing power parity index. National costs of acute treatment for incident strokes were estimated by extrapolation of average costs estimates to national incidence data. Assumptions of the average cost of stroke treatment on a national scale were examined in sensitivity analysis.

RESULTS

The acute care of 167 patients with stroke was thoroughly evaluated from hospital admission to hospital discharge. Mean length of hospital stay was 35.4 days for ICH and 13.0 days for IS. Ninety-one percent of the patients with ICH and 68% of the patients with IS were admitted to an ICU for a mean length of stay (LOS) of 12.9 +/- 20.3 and 3.6 +/- 5.9 days respectively. Mean total costs of initial hospitalization were $12,285 (SD +/-14,336) for ICH and $3888 (SD +/-4018) for IS. Costs differed significantly by Glasgow Coma Scale (GCS) score at admission, development of pneumonia and infections during hospitalization, and functional outcome at hospital discharge. Aggregate national healthcare expenditures for acute treatment of incident ICH were $194.2m (range 97.1-388.4) and $239.9m for IS (range 119.9-479.7).

CONCLUSION

The direct hospital costs of incident ICH and IS in Argentina are substantial and primarily driven by stroke severity, in-hospital complications and clinical outcomes. With the expected increase in the incidence of stroke over the coming decades, these results emphasize the need for effective preventive and acute medical care.

Timely confirmation of gastro-esophageal reflux disease via pH monitoring: estimating budget impact on managed care organizations

BACKGROUND

Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States.

METHODS

A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypothetical MCO with 10 000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitoring were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules.

RESULTS

An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236,363 from $238,086, while increases were observed in pH monitoring (from $16 739 to $21 973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs.

CONCLUSIONS

Timely and increased use of pH monitoring as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.

Physicians' preferences towards coagulation factor concentrates in the treatment of Haemophilia with inhibitors: a discrete choice experiment

This study sought to identify attributes of treatment important to haematologists in making their decisions regarding optimal care for inhibitor patients in the United States. A conjoint analysis using a discrete choice experiment was conducted to elicit factors that are most important to haematologists. Twelve product attributes were chosen based on published literature and expert opinion: risk of human viral infections, possibility that the titre of the inhibitor may rise, reduction in the likelihood of dose-related thromboembolic events, the number of infusions required to stop haemorrhage, infusion preparation time, infusion time, infusion volume, time required to stop bleeding, time required to alleviate pain, prophylaxis use, ability to undergo major surgery and cost of medications. Thirty haematologists completed the questionnaires via face-to-face interviews at a scientific meeting in April 2006. Data were analysed using a multinomial logit model to obtain the relative importance of each attribute. Responding haematologists had considerable experience in treating haemophilia patients with inhibitors (average : 13 +/- 9 years). 'Time required to stop bleeding' was the most important factor affecting treatment decisions [relative importance (RI) = 16.3%]. Physicians also preferred treatments that resulted in quick pain relief [RI = 12.9%], reduced the possibility that the titre of inhibitor may rise [RI = 12.8%], required fewer number of infusions to stop a haemorrhage [RI = 12.7%] and reduced the risk of human viral infection [RI = 10.8%]. This study revealed that certain clinical outcomes attributes are the most preferred and important. These findings can assist decision makers in their assessments of optimal first-line care.

Expressed transcripts associated with high rates of egg production in chicken ovarian follicles

The purpose of this study was to characterize differentially expressed transcripts associated with varying rates of egg production in Taiwan country chickens. Ovarian follicles were isolated from two strains of chicken which showed low (B) or high (L2) rates of egg production, then processed for RNA extraction and cDNA library construction. Three thousand and eight forty clones were randomly selected from the cDNA library and amplified by PCR, then used in microarray analysis. Differentially expressed transcripts (P<0.05, log(2)> or = 1.75) were sequenced, and aligned using GenBank. This analysis revealed 20 non-redundant sequences which corresponded to known transcripts. Eight transcripts were expressed at a higher level in ovarian tissue prepared from chicken strain B, and 12 transcripts were expressed at a higher level in L2 birds. These differential patterns of expression were confirmed by semi-quantitative RT-PCR. We show that transcripts of cyclin B2 (cycB2), ferritin heavy polypeptide 1 (FTH1), Gag-Pol polyprotein, thymosin beta4 (TB4) and elongation factor 1 alpha1 (EEF1A1) were enriched in B strain ovarian follicles. In contrast, thioredoxin (TXN), acetyl-CoA dehydrogenase long chain (ACADL), inhibitor of growth family member 4 (ING4) and annexin II (ANXA2) were expressed in at higher levels in the L2 strain. We suggest that our approach may lead to the isolation of effective molecular markers that can be used in selection programs in Taiwan country chickens.

Association of serum protein levels with egg productivity in Taiwan red-feathered country chickens

This study investigated the relationship between serum protein levels and egg productivity in Taiwan red-feathered country chickens (TRFCC). The total egg numbers of TRFCC (n=157) were recorded from 25 to 48 weeks of age. Serum samples were collected at 24 and 35 weeks of age, then classified by total egg number into four groups according to mean+/-1S.D. Serum X protein levels were evaluated by protein chip technology and with an insulin-like growth factor-I (IGF-I) immunoassay. Other serum proteins (apolipoprotein A-I, ovotransferrin and vitellogenin) were found at different levels between the most productive and the least productive groups of TRFCC, were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and were quantified by age. The results showed that levels of vitellogenin were positively correlated with total egg number at 24 and at 35 weeks old (p<0.01). Levels of apolipoprotein A-I and an IGF-1-related marker (termed X protein) in serum at 35 weeks old were correlated with total egg number (p<0.01). Serum ovotransferrin levels remained constant regardless of total egg number. To investigate the concentration differences among the four groups of TRFCC, serum protein levels of each group were analyzed by one-way ANOVA. The results showed that those protein levels, except for ovotransferrin, in the least productive group significantly differed from the other three groups (p<0.05). Although the correlation between those protein levels and the total egg number was not significant at the time of initial egg production, the selection strategy of those protein levels at later stages of egg production should provide a screening model to improve selection.

Heat shock protein 72 overexpression protects against hyperthermia, circulatory shock, and cerebral ischemia during heatstroke

This study extends our earlier studies in rats by applying our heatstroke model to a new species. Additionally, transgenic mice are used to examine the role of heat shock protein (HSP) 72 in experimental heatstroke. Transgenic mice that were heterozygous for a porcine HSP70i gene ([+]HSP72), transgene-negative littermate controls ([−]HSP72), and normal Institute of Cancer Research strain mice (ICR) under pentobarbital sodium anesthesia were subjected to heat stress (40°C) to induce heatstroke. In [−]HSP72 or ICR, the values for mean arterial pressure, the striatal blood flow, and the striatal Po2after the onset of heatstroke were significantly lower than those in preheat controls. The core and brain temperatures, the extracellular concentrations of ischemic and injury markers in the striatum, and the striatal neuronal damage scores were significantly greater than those in the preheat controls. In [−]HSP72 or ICR, the body temperatures, cell ischemia content, and injury marker in the striatum were significantly higher, and the mean arterial pressure, striatal blood flow, and striatal Po2concentration were significantly lower during heatstroke than in [+]HSP72. Accordingly, the latency and the survival times for [+]HSP72 significantly exceeded those of [−]HSP72 or ICR. These results demonstrate that the overexpression of HSP72 in multiple organs improves survival during heatstroke by reducing hyperthermia, circulatory shock, and cerebral ischemia and damage in mice.

Volatilisation of diacetylmorphine: in vitro simulation of 'chasing the dragon'

In preparation for a trial on co-prescription of heroin to chronic treatment-resistant addicts, a pharmaceutical dosage form for smokable heroin was developed. During development of this product (a mixture of diacetylmorphine and caffeine), in vitro experiments were performed simulating 'chasing the dragon': the technique used by addicts for inhalation of heroin after volatilisation. Samples were heated on aluminium foil using a heating device and the vapours were collected and analysed using a HPLC-UV method. The recovery of diacetylmorphine and caffeine in vapours was studied after volatilisation of different powder mixtures at temperatures between 200 and 350 degrees C. Furthermore, the volatilisation set-up was combined with an Andersen sampler to determine the sizes of aerosol particles. Only small differences in recovery of diacetylmorphine and caffeine were found between temperatures and between powder mixtures: 46-62% of diacetylmorphine from the sample was recovered in vapour and 65-83% of caffeine. The only degradation product detected in vapour was 6-acetylmorphine (4.1-7.1%). In the temperature range studied, temperature mainly influenced the volatilisation rate. Mass median aerodynamic diameters of aerosols from diacetylmorphine-containing samples ranged from 1.8-4.1 microm; 45-60% of each sample was recovered as aerosol particles <5 microm. Volatilising pharmaceutical smokable heroin resulted in sufficient amounts of diacetylmorphine in vapour and in particles suitable for effective deposition in the lungs.

Acute pancreatitis following antilymphocyte globulin therapy in a renal transplant recipient

Acute pancreatitis is a rare complication following OKT3 therapy, which to our knowledge has never been reported in patients treated with antilymphocyte globulin (ALG). We herein report a case of a kidney transplantation patient who developed acute pancreatitis 2 days after treatment with ALG for grade IIb acute rejection. The symptoms subsided after discontinuing this drug. Resumption of ALG therapy triggered another episode of acute pancreatitis. Therefore, the clinical course strongly suggests that ALG was the etiological factor of acute pancreatitis in this particular patient.

Stellate transformation of invasive trophoblast: a distinct phenotype of trophoblast that is involved in decidual vascular remodelling and controlled invasion during pregnancy

BACKGROUND

Successful implantation relies on the tightly regulated invasion of extravillous trophoblasts (EVTs). However, little is known about their phenotypic differentiation and relevant motile behaviour. Furthermore, the cell-cell interactions between EVTs and decidual arterioles during physiological transformation are also poorly understood.

METHODS

A total of 128 decidual specimens from early and late gestations containing components of EVTs and spiral arterioles were investigated using immunohistochemistry and periodic acid-Schiff reaction.

RESULTS

Unipolar, tadpole-like EVTs are observed throughout the interstitial area, with a tendency to decrease along the invasive pathway. The stellate differentiation of the EVTs is identified around and inside decidual arterioles or in the third-trimester myometrium. Furthermore, stellate transformation of EVTs precedes its interactions with the decidual arteriole. These specialized stellate trophoblasts invade and infiltrate the tunica media, accompanying lacuna formation inside the vessel wall and perturbation of actin fibre alignment of the tunica media.

CONCLUSION

Stellate transformation of trophoblasts may explain controlled invasion of EVTs and probably plays a key role in initiating cell-cell interaction in decidual vascular remodelling.

Deep-vein thrombosis rates after major orthopedic surgery in Asia. An epidemiological study based on postoperative screening with centrally adjudicated bilateral venography

BACKGROUND

The incidence of postsurgical venous thromboembolism is thought to be low in Asian ethnic populations.

OBJECTIVE

We studied the incidence of deep-vein thrombosis (DVT) in Asian patients undergoing major orthopedic surgery of the lower limbs.

PATIENTS/METHODS

We performed a prospective epidemiological study in 19 centers across Asia (China, Indonesia, South Korea, Malaysia, Philippines, Taiwan, and Thailand) in patients undergoing elective total hip replacement (THR), total knee replacement (TKR) or hip fracture surgery (HFS) without pharmacological thromboprophylaxis. The primary endpoint was the rate of DVT of the lower limbs documented objectively with bilateral ascending venography performed 6-10 days after surgery using a standardized technique and evaluated by a central adjudication committee unaware of local interpretation.

RESULTS

Overall, of 837 Asian patients screened for this survey, 407 (48.6%, aged 20-99 years) undergoing THR (n = 175), TKR (n = 136) or HFS (n = 96) were recruited in 19 centers. DVT was diagnosed in 121 of 295 evaluable patients [41.0%, (95% confidence interval (CI): 35.4-46.7)]. Proximal DVT was found in 30 patients [10.2% (7.0-14.2)]. Total DVT and proximal DVT rates were highest in TKR patients (58.1% and 17.1%, respectively), followed by HFS patients (42.0% and 7.2%, respectively), then THR patients (25.6% and 5.8%, respectively). DVT was more frequent in female patients aged at least 65 years. Pulmonary embolism was clinically suspected in 10 of 407 patients (2.5%) and objectively confirmed in two (0.5%).

CONCLUSIONS

The rate of venographic thrombosis in the absence of thromboprophylaxis after major joint surgery in Asian patients is similar to that previously reported in patients in Western countries.

Effects of dexamethasone on peripheral blood mononuclear cell phenotype in weanling piglets

The aim of this study was to evaluate the effect of dexamethasone treatment on the immune system of weanling piglets. Piglets were administered dexamethasone (DEX; 1mg/kg, IM) every 12h for 2 consecutive days (short-term experiment) or DEX (1mg/kg, IM) daily for 2 weeks (long-term experiment). The relative percentage of CD8(+) T cells in peripheral blood mononuclear cells (PBMCs) was significantly decreased (P<0.05) in both short- and long-term DEX-treated groups compared to their control groups. The percentage of IgM(+) cells in PBMCs of the long-term DEX-treated group was greatly increased (P<0.05) in comparison to the control group. The results of this study indicate that short-term DEX-treatment increases leucocyte function; however, long-term DEX-treatment depresses leucocyte function, especially that of CD8(+) T cells.

Successful heart transplantation after 13 hours of donor heart ischemia with the use of HTK solution: a case report

INTRODUCTION

For heart transplantation (HTx), the recommended ischemic time (IT) for donor heart is not to exceed 6 hours. Though Dr Christiaan Barnard used a donor heart with IT of 16 hours, 50 minutes with a portable hypothermic perfusion system in 1981, the recorded IT of donor hearts reported recently is 8 hours, with no adverse effects.

CASE REPORT

The patient, a 14-year-old boy of blood type O, was diagnosed with cardiomyopathy at age 12. In early September 2003, the patient was recommended for HTx. His condition deteriorated 18 days later with low CO, elevated pulmonary vascular resistance, and frequent ventricular tachycardia, further complicated by pneumonia and multiorganism infections, which were contraindications for HTx. On September 22, 2003, a donor heart of blood type O was available 370 km away. Another patient of blood type B with severe heart failure was matched for the HTx. During the intervening time, another donor heart of blood type B became available locally. We matched the type B donor heart to the type B recipient. Since the type O donor heart seemed to be wasted, we performed HTx for the boy. Though preserved for 12 hours in cold cardioplegia, the donor heart was implanted with biatrial anastomosis that took 1 hour. The total IT of this donor heart was 13 hours. The recipient recovered and was discharged 3 months later.

CONCLUSIONS

The IT of 13 hours for this donor heart is believed to be a world record. Our experience demonstrates that preservation time of donor heart may exceed 6 hours.

Successful heart transplantation after 13 hours of donor heart ischemia with the use of HTK solution: a case report

INTRODUCTION

For heart transplantation (HTx), the recommended ischemic time (IT) for donor heart is not to exceed 6 hours. Though Dr Christiaan Barnard used a donor heart with IT of 16 hours, 50 minutes with a portable hypothermic perfusion system in 1981, the recorded IT of donor hearts reported recently is 8 hours, with no adverse effects.

CASE REPORT

The patient, a 14-year-old boy of blood type O, was diagnosed with cardiomyopathy at age 12. In early September 2003, the patient was recommended for HTx. His condition deteriorated 18 days later with low CO, elevated pulmonary vascular resistance, and frequent ventricular tachycardia, further complicated by pneumonia and multiorganism infections, which were contraindications for HTx. On September 22, 2003, a donor heart of blood type O was available 370 km away. Another patient of blood type B with severe heart failure was matched for the HTx. During the intervening time, another donor heart of blood type B became available locally. We matched the type B donor heart to the type B recipient. Since the type O donor heart seemed to be wasted, we performed HTx for the boy. Though preserved for 12 hours in cold cardioplegia, the donor heart was implanted with biatrial anastomosis that took 1 hour. The total IT of this donor heart was 13 hours. The recipient recovered and was discharged 3 months later.

CONCLUSIONS

The IT of 13 hours for this donor heart is believed to be a world record. Our experience demonstrates that preservation time of donor heart may exceed 6 hours.