Surgical safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy: a systematic review and meta-analysis

OBJECTIVES

To assess the safety and effectiveness of bilateral axillo-breast approach robotic thyroidectomy in thyroid tumor.

METHODS

Bilateral axillo-breast approach robotic thyroidectomy and other approaches (open thyroidectomy, transoral robotic thyroidectomy, and bilateral axillo-breast approach endoscopic thyroidectomy) were compared in studies from 6 databases.

RESULTS

Twenty-two studies (8830 individuals) were included. Bilateral axillo-breast approach robotic thyroidectomy had longer operation time, greater cosmetic satisfaction, and reduced transient hypoparathyroidism than conventional open thyroidectomy. Compared to bilateral axillo-breast approach endoscopic thyroidectomy, bilateral axillo-breast approach robotic thyroidectomy had greater amount of drainage, lower chances of transient vocal cord palsy and permanent hypothyroidism, and better surgical completeness (postopertive thyroblobulin level and lymph node removal). Bilateral axillo-breast approach robotic thyroidectomy induced greater postoperative drainage and greater patient dissatisfaction than transoral robotic thyroidectomy.

CONCLUSION

Bilateral axillo-breast approach robotic thyroidectomy is inferior to transoral robotic thyroidectomy in drainage and cosmetic satisfaction but superior to bilateral axillo-breast approach endoscopic thyroidectomy in surgical performance. Its operation time is longer, but its cosmetic satisfaction is higher than open thyroidectomy.

Comparison of Liquid-Based Preparations with Conventional Smears in Thyroid Fine-Needle Aspirates: A Systematic Review and Meta-Analysis

BACKGROUND

To compare conventional smears (CSs) and liquid-based preparations (LBPs) for diagnosing thyroid malignant or suspicious lesions.

METHODS

Studies in the PubMed, SCOPUS, Embase, Web of Science, and Cochrane database published up to December 2023. We reviewed 17 studies, including 15,861 samples.

RESULTS

The diagnostic odds ratio (DOR) for CS was 23.6674. The area under the summary receiver operating characteristic curve (AUC) was 0.879, with sensitivity, specificity, negative predictive value, and positive predictive value of 0.8266, 0.8668, 0.8969, and 0.7841, respectively. The rate of inadequate specimens was 0.1280. For LBP, the DOR was 25.3587, with an AUC of 0.865. The sensitivity, specificity, negative predictive value, and positive predictive value were 0.8190, 0.8833, 0.8515, and 0.8562. The rate of inadequate specimens was 0.1729. For CS plus LBP, the AUC was 0.813, with a lower DOR of 9.4557 compared to individual methods. Diagnostic accuracy did not significantly differ among CS, LBP, and CS plus LBP. Subgroup analysis was used to compare ThinPrep and SurePath. The DORs were 29.1494 and 19.7734. SurePath had a significantly higher AUC.

CONCLUSIONS

There was no significant difference in diagnostic accuracy or proportion of inadequate smears between CS and LBP. SurePath demonstrated higher diagnostic accuracy than ThinPrep. Recommendations for fine-needle aspiration cytology should consider cost, feasibility, and accuracy.

Effectiveness of Radiofrequency Device Treatment for Nasal Valve Collapse in Patients With Nasal Obstruction

OBJECTIVE

Internal nasal valve dysfunction is a prevalent cause of nasal obstruction. This systematic review, along with a Meta-analysis, evaluated the efficacy of temperature-controlled radiofrequency device (RFD) treatment in alleviating nasal obstruction by rectifying nasal valve collapse.

DATA SOURCES

A comprehensive review of studies retrieved from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases (up to December 2022) was conducted.

REVIEW METHODS

We included studies that evaluated the quality of life and nasal obstruction scores before and after RFD treatment. In addition, sham-controlled studies were analyzed.

RESULTS

In total, 451 patients across 8 studies were included in the analysis. Patients who underwent RFD treatment reported a significantly enhanced quality of life 24 months after treatment compared to pretreatment scores. The rates of clinically improved states and positive responses regarding quality of life after treatment were 82% and 91%, respectively. Moreover, the disease-specific quality of life, as assessed by the Nasal Obstruction Symptom Evaluation score, significantly improved.

CONCLUSION

RFD may help improve nasal obstruction symptoms. Further randomized clinical studies on larger cohorts are essential to substantiate its efficacy in enhancing nasal valve function.

Effectiveness of the Posterior Nasal Nerve Cryoablation in Allergic and Non-Allergic Rhinitis

OBJECTIVES

This study assessed the impact of cryoablation of the posterior nasal nerve on symptoms of rhinitis in individuals with allergic rhinitis (AR) and non-allergic rhinitis (NAR).

DATA SOURCES

PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases for studies published up to June 2023.

REVIEW METHODS

Studies that evaluated the quality of life and rhinitis-related symptom scores before and after cryotherapy treatment, as well as sham-controlled studies, were included.

RESULTS

In total, 368 patients from seven studies were analyzed. Patients who underwent cryoablation showed a significant improvement in rhinitis-related symptoms in both NAR and AR. In particular, the most significant improvement was observed in symptoms of rhinorrhea and congestion. Furthermore, cryoablation improved the disease-specific quality of life evaluated using the Rhinoconjunctivitis Quality of Life Questionnaire. The rate of clinical improvement in the total nasal symptom score (total nasal symptom score [TNSS]; >30% reduction from baseline) after cryotherapy was 74%. The change in TNSS score significantly increased over time in NAR patients (p = 0.0041). Therefore, changes in the TNSS score after 12 months of cryotherapy treatment were greater in the NAR group than in the AR group (p = 0.0020), indicating that cryoablation is effective for both types of rhinitis and has better long-term efficacy in NAR than in AR.

CONCLUSIONS

Subjective symptom scores related to rhinitis, particularly for rhinorrhea and congestion, decrease after cryoablation of the posterior nasal nerve. Furthermore, the symptom improvement was greater in NAR than AR. Laryngoscope, 2023.

Comparison of diagnostic performance of two ultrasound risk stratification systems for thyroid nodules: a systematic review and meta-analysis

OBJECTIVES

To assume the ideal cut-off values and diagnostic performance of two thyroid imaging reporting and data systems published by the Korean Thyroid Association/Korean Society of Thyroid Radiology (Korean TI-RADS) and the American Thyroid Association (ATA TI-RADS).

METHODS

Eighteen studies with 25,422 patients from PubMed, SCOPUS, Embase, Web of Science, and Cochrane Library databases up to August 2022. True and false positive and negative values with characteristics were extracted.

RESULTS

The highest area under the receiver operating characteristic curve (AUC) was 0.893 and 0.887 for Korean and ATA TI-RADS. High suspicion was judged as the best cut-off value with the highest AUC based on optimal sensitivity and specificity. In determining the risk of malignant thyroid nodules, high suspicion in Korean and ATA TI-RADS showed sensitivity as 71.3% and 73.5%, specificity as 7.9% and 86.4%, diagnostic odds ratios as 20.0289 and 20.9076, AUC as 0.893 and 0.887. There was no significant difference when directly comparing the diagnostic accuracy of both TI-RADS.

CONCLUSION

The two risk stratification systems had good diagnostic performance with high AUC and no significant differences. The ideal cut-off can depend on the medical condition or thyroid nodules, because the changes of cut-off point may reciprocally alter sensitivity and specificity.

Comparative Effectiveness of Cryotherapy and Radiofrequency Ablation for Chronic Rhinitis: A Systematic Review and Meta-analysis

OBJECTIVES

Multiple minimally invasive techniques for chronic rhinitis treatment focus on posterior nasal nerve ablation. We conducted a systematic review and meta-analysis to evaluate the efficacy of cryotherapy and radiofrequency ablation for alleviating symptoms in patients with allergic and nonallergic rhinitis.

METHODS

We retrieved studies from PubMed, Scopus, Embase, Web of Science, and Cochrane Database up to July 2023. Data on the impact of cryotherapy and radiofrequency ablation on quality of life and symptom ratings of rhinitis were extracted and evaluated.

RESULTS

An analysis of 12 studies involving 788 patients demonstrated significant improvements in quality of life and rhinitis-related symptoms (nasal obstruction, itching, rhinorrhea, and sneezing) in patients treated with cryotherapy or radiofrequency ablation (symptom score at 24 months and quality of life score at 3 months). However, radiofrequency ablation had a more positive effect on nasal symptoms after 3 months than cryotherapy. Nonallergic rhinitis patients responded more favorably to posterior nerve ablation than patients with allergic rhinitis. Both techniques enhanced disease-specific quality of life during the initial 3 months of treatment (cryotherapy, 84.6%; radiofrequency, 81.6%; P=0.564). After 3 months of treatment, a clinical improvement in all nasal symptoms (minimal clinically important difference in the total nasal symptom score: >1.0 points) was seen in 81.8% and 91.9% of patients who underwent cryotherapy and radiofrequency ablation, respectively (P=0.005), suggesting that radiofrequency is more likely to lead to clinical improvement.

CONCLUSION

Rhinitis-associated subjective symptom scores and quality of life may be improved by both cryotherapy and radiofrequency ablation. Ablation was more efficacious than cryotherapy for nasal symptoms in patients with nonallergic rhinitis. To corroborate these findings, further randomized controlled studies directly comparing these two techniques are warranted.

The analgesic Efficacy and Safety of Topically Applied Tramadol in Peritonsillar Space During Pediatric Adenotonsillectomy: A Meta-Analysis

OBJECTIVES

To evaluate the efficacy of topically applied tramadol in peritonsillar area for pain control and induction of perioperative morbidity in children undergoing adenotonsillectomy.

METHODS

Two authors independently searched the databases (MEDLINE, SCOPUS, and Cochrane databases) up to April 2022 for randomized controlled trials comparing the efficacy of an intraoperative peritonsillar administered tramadol with placebo or other agents only in pediatric patients. The outcomes were postoperative pain scores, time to take the first pain reducing drugs, and postoperative nausea/vomiting.

RESULTS

Our analysis was based on 17 trials. Peritonsillar administered tramadol significantly reduced postoperative pain at less than 20 minutes (SMD -1.5852, 95% CI [-2.3900; -0.7804]), 1 hour (SMD -1.5811, 95% CI [-2.3400; -0.8222]), 8 hours (SMD -1.0258, 95% CI [-1.8792; -0.1724]), 16 hours (SMD -0.8397, 95% CI [-1.4266; -0.2529]), and 1 day (SMD -1.0110, 95% CI [-1.5213; -0.5007]) and the time to take the first analgesic drug (SMD 1.6565, 95% CI [0.2838; 3.0293]) compared with the placebo. However, tramadol showed no significant difference on postoperative pain relief effects and the time to take the first analgesic drug compared to the other topical agents (bupivacaine, lidocaine, ketamine, and dexamethasone). Tramadol did not cause significant postoperative nausea and vomiting.

CONCLUSIONS

This study demonstrated that intraoperatively applied topical tramadol could control postoperative pain and reduce the analgesic uptake compared with a control. However, the efficacy of tramadol in pain control was similar to other agents in pediatric adenotonsillectomy.

The accuracy and difference of scoring rules and methods to score respiratory event-related leg movements in obstructive sleep apnea patients

OBJECTIVE

To compare manual scoring: 1) to the American Academy of Sleep Medicine (AASM) auto-scoring rules. 2) to the AASM and World Association of Sleep Medicine (WASM) rules, and evaluate the accuracy of the AASM and WASM for respiratory event-related limb movements (RRLM) in diagnostic and continuous positive airway pressure (CPAP) titration polysomnography (PSG).

METHODS

We retrospectively, re-scored diagnostic and CPAP titration PSGs of 16 patients with obstructive sleep apnea (OSA), using manual re-scoring by the AASM (mAASM) and WASM (mWASM) criteria for RRLM, periodic limb movements during sleep (PLMS), and limb movements (LM), which were compared to auto-scoring by the AASM (aAASM).

RESULTS

In diagnostic PSG, significant differences were found in LMs (p < 0.05), RRLM (p = 0.009) and the mean duration of PLMS sequences (p = 0.013). In CPAP titration PSG, there was a significant difference in RRLM (p = 0.008) and PLMS with arousal index (p = 0.036). aAASM underestimated LM and RRLM, especially in severe OSA. Changes in RRLM and PLMS with arousal index between diagnostic and titration PSG were significantly different between aAASM and mAASM, but there was no significant difference between scoring by mAASM and mWASM. The ratio of PLMS and RRLM changes between diagnostic and CPAP titration PSG was 0.257 in mAASM and 0.293 in mWASM.

CONCLUSIONS

In addition to the overestimation of RRLM by mAASM compared to aAASM, mAASM may also be more sensitive than aAASM in detecting RRLM changes in the titration PSG. Despite intuitive differences in the definition of RRLM between AASM and WASM rules, RRLM results between mAASM and mWASM were not significant and about 30% of RRLMs might be scored as PLMS by both scoring rules.

Pneumothorax Induced by Automatic Positive Airway Pressure Therapy for Obstructive Sleep Apnea: A Rare Case Report and Review of the Literature

Positive airway pressure (PAP) therapy is known to be an effective treatment for obstructive sleep apnea (OSA) that does not generally have serious complications. However, pneumothorax following lung barotrauma with the use of PAP has rarely been reported. We recently experienced the case of a 72-year old male patient with chronic obstructive pulmonary disease who developed pneumothorax after the use of automatic PAP (APAP). After 4 months of APAP use with a pressure of 4–8 cm H₂O, he complained of sudden severe dyspnea at midnight. He eventually underwent surgical repair for pneumothorax. After 4 months, continuous PAP with low pressure of 5 cm H₂O was applied without any complications. In summary, we emphasize the risk of barotrauma when PAP is used by OSA patients with lung disease.

Surgical completeness and safety of minimally invasive thyroidectomy in patients with thyroid cancer: A network meta-analysis

BACKGROUND

To assess the surgical outcomes of various minimally invasive and remote-access surgical approaches for thyroid cancer patients.

METHODS

We collected studies from January 2020 to July 2022 in 6 databases. Pairwise and network meta-analyses were performed for outcomes and complications of 9 minimally invasive interventions (minimally invasive video-assisted, endoscopic or robotic bilateral axillo-breast approach, endoscopic or robotic postauricular, endoscopic or robot transaxillary approach, transoral endoscopic thyroidectomy vestibular approach or robotic thyroidectomy) and conventional thyroidectomy (control).

RESULTS

Multiplicity and bilaterality of cancer, lymph node metastasis, and coincidence of thyroiditis showed no significant difference between minimally invasive interventions and control. However, larger tumor size (robotic bilateral axillo-breast approach standardized mean difference -1.3989, 95% confidence interval [-2.1717 to -0.6262]), higher body mass index (robot transaxillary approach standardized mean difference -0.5350, 95% confidence interval [-0.9557 to -0.1144], robotic bilateral axillo-breast approach standardized mean difference -0.2301, 95% confidence interval [-0.4389 to -0.0214]), and frequent extrathyroidal extension (robotic bilateral axillo-breast approach standardized mean difference 0.7435, 95% confidence interval [0.5602-0.9869]) were observed in control. In surgical outcomes and adverse effects, there was no significant difference in hospitalization or retrieved lymph node number between minimally invasive interventions and control. However, longer operative time was observed in the robotic bilateral axillo-breast approach(standardized mean difference 6.5393, 95% confidence interval [5.0476-8.0309]) and transoral robotic thyroidectomy (standardized mean difference 5.4946, 95% confidence interval [2.9984-7.9907]) groups than in control. In surgical completion, the rate of low postoperative serum thyroglobulin, postoperative thyroglobulin level, and postoperative radioactive iodine ablation dose showed no significant difference between minimally invasive interventions and control.

CONCLUSION

Minimally invasive thyroidectomy did not show inferior results compared to conventional thyroidectomy despite the longer operative time. Surgeons need to prudently consider all aspects of patients to determine the proper surgical approach for thyroid cancer.

Diagnostic Performance of ACR and Kwak TI-RADS for Benign and Malignant Thyroid Nodules: An Update Systematic Review and Meta-Analysis

(1) Background: To determine the optimal cut-off values of two risk stratification systems to discriminate malignant thyroid nodules and to compare the diagnostic performance; (2) Methods: True and false positive and negative data were collected, and methodological quality was assessed for forty-six studies involving 39,085 patients; (3) Results: The highest area under the receiver operating characteristic (ROC) curve (AUC) of ACR and Kwak TI-RADS were 0.875 and 0.884. Based on the optimal sensitivity and specificity, the highest accuracy values of ROC curves or diagnostic odds ratios (DOR) were taken as the cut-off values for TR4 (moderate suspicious) and 4B. The sensitivity, specificity, DOR, and AUC by ACR (TR4) and Kwak TI-RADS (4B) for malignancy risk stratification of thyroid nodules were 94.3% and 96.4%; 52.2% and 53.7%; 17.5185 and 31.8051; 0.786 and 0.884, respectively. There were no significant differences in diagnostic accuracy in any of the direction comparisons of the two systems; (4) Conclusions: ACR and Kwak TI-RADS had good diagnostic performances (AUCs > 85%). Although we determined the best cut-off values in individual risk stratification systems based on statistical assessment, clinicians can adjust the optimal cut-off value according to the clinical purpose of the ultrasonography because raising or lowering cut-points leads to reciprocal changes in sensitivity and specificity.

Surgical and Radiological Differences in Intersphenoid Sinus Septation and the Prevalence of Onodi Cells with the Endoscopic Endonasal Transsphenoidal Approach

Background and Objectives: Understanding the anatomical variation in the sphenoid sinus is important to fully expose the sellar floor and clivus. Materials and Methods: The Onodi cell and intersphenoid sinus septation based on preoperative paranasal sinus computed tomography (PNS CT) and the surgical records of 877 patients who underwent the endoscopic endonasal transsphenoidal approach (EETSA) were retrospectively reviewed. Results: An intersphenoid sinus septum (ISS) blocking the clivus was defined as a pseudoclivus. Complete and incomplete pseudoclivuses were found in 2.97% and 10.5% of patients, respectively. Intraoperative and PNS CT ISS findings differed in 17.1% of patients. Misconceptions regarding a ridge or vertical ISS and confusion between an incomplete pseudoclivus and a vertical ISS were common. Conclusions: Because intraoperative and PNS CT findings may differ, anatomical variation in the paraclival area should be evaluated carefully. A pseudoclivus mimicking the clivus is important to attain a fully exposed EETSA surgical view.

Safety and Efficacy of Transoral Robotic Thyroidectomy for Thyroid Tumor: A Systematic Review and Meta-Analysis

Simple Summary

This systemic review and meta-analysis compared and analyzed the safety and effectiveness of transoral robotic thyroidectomy on the thyroid tumor with other thyroid approaches. Transoral robotic thyroidectomy showed similar results to other robotic-assisted thyroid surgeries. Compared to a conventional open thyroidectomy, transoral robotic thyroidectomy had longer operational times and hospitalization days, and worse postoperative pain, but a higher cosmetic satiation score. However, more randomized controlled studies need to be included and analyzed.

Abstract

Background: To assess the safety and effectiveness of transoral robotic thyroidectomy (TORT) in thyroid tumor. Methods: PubMed, Embase, Web of Science, SCOPUS, Cochrane database, and Google Scholar up to June 2022. Studies comparing outcomes and complications between TORT and control groups (robotic bilateral axillo-breast, trans-axillary, postauricular approach, conventional open thyroidectomy (OT), and transoral endoscopic approach) were analyzed. Results: Ten studies of 1420 individuals. The operative time (SMD 1.15, 95%CI [0.48; 1.89]) was significantly longer and the number of retrieved lymph nodes (LNs) (SMD −0.27, 95%CI [−0.39; −0.16]) was fewer in TORT than in the control group. The postoperative cosmetic satisfaction score (SMD 0.60, 95%CI [0.28; 0.92]) was statistically higher in TORT than in the control group. In subgroup analysis, there was no significant difference between robotic surgeries. However, TORT had significantly longer operative times (SMD 2.08, 95%CI [0.95; 3.20]) and fewer retrieved LNs (SMD −0.32, 95%CI [−0.46; −0.17]) than OT. TORT satisfied significantly more patients in cosmetic view. However, it increased hospitalization days and postoperative pain on the operation day and first day compared to OT. Conclusions: TORT is not inferior to other robotic-assisted approaches. Its operation time and hospitalization days are longer and postoperative pain is greater than OT, although its cosmetic satisfaction is high.

Relationships of sphenoid sinus pneumatization with internal carotid artery characteristics

Objective

We explored the clinical significances of the relationships among sphenoid sinus aeration, intersphenoid sinus septum (ISS), and internal carotid artery (ICA).

Methods

We retrospectively reviewed the preoperative paranasal sinus computed tomography scans and the medical charts of 490 patients who were treated by the endoscopic endonasal transsphenoidal approach. We analyzed sphenoid sinus pneumatization, number of ISS, and positional relationships between the ICA and ISS (including ICA prominence and the thickness of surrounding bone).

Results

ISS were often present in the ICAs of patients with presellar pneumatization (36.2%; p = 0.042). Sphenoid sinus pneumatization status significantly differed according to number of ISS (p < 0.001), ICA prominence (p < 0.001), ISS insertion into the ICA (p = 0.042), and distance from ISS to ICA (p = 0.004). When sphenoid sinus aeration was poor, the ICA was not prominent, and the ISS were attached to or lay close to the paraclival ICA.

Conclusions

Patients with presellar pneumatization exhibited less prominent ICAs, and more ISS attached to or near the paraclival ICA, than did other patients. Therefore, particular caution is required when using the endoscopic endonasal transsphenoidal approach to treat patients with poor sphenoid sinus aeration.

Relationship between untreated obstructive sleep apnea and breath hydrogen and methane after glucose load

BACKGROUND

Patients with sleep disturbances have gastrointestinal symptoms. Breath hydrogen (H₂) and methane (CH₄) indicating small intestinal bacterial overgrowth (SIBO) might be related with these symptoms. The study was conducted to assess the link between breath profiles and untreated obstructive sleep apnea (OSA).

METHODS

: This prospective study enrolled consecutive patients with OSA using polysomnography. Heart rate variability (HRV) was used as a measurement for the balance of autonomic nervous system during polysomnography. Glucose breath test (GBT) to evaluate breath H₂ and CH₄ and bowel symptom questionnaire to investigate associated intestinal symptoms were performed.

RESULTS

Among 52 patients with OSA, 16 (30.8%) showed positivity to GBT. Although no significant difference was shown in GBT positivity between patients with healthy controls and patients with OSA (13.3% vs 30.8%, P = 0.109), breath H₂ and CH₄ levels in the OSA group were significantly higher than those in controls (P < 0.05). Flatulence was significantly common in OSA groups with GBT positivity than those without GBT positivity. Multivariate analysis demonstrated that waist-to-hip ratio (odds ratio = 12.889; 95% confidence interval (CI): 1.257-132.200; P = 0.031) and low-to-high-frequency ratio of HRV (odds ratio = 1.476; 95% CI: 1.013-2.151, P = 0.042) are independently related to GBT positivity in patients with OSA.

CONCLUSION

: Elevated breath H₂ or CH₄ after glucose load might not be an uncommon finding in patients with untreated OSA. Abdominal obesity and autonomic imbalance dysfunction are significantly associated with GBT positivity in OSA patients. SIBO could be considered as target for therapeutic management in OSA patients.

[Pregnancy outcomes in patients with adenomyosis with fertility requirements: retrospective analysis of clinical data from real world]

Objective: To retrospectively analyze the pregnancy outcomes of patients with adenomyosis requiring fertility in a single center under real world condition. Methods: From June 2015 to May 2020, 231 cases of pregnancy complicated with adenomyosis diagnosed by ultrasound with fertility requirements were treated in the Women's and Children's Hospital Affiliated to Qingdao University with complete clinical data. And they were divided into three groups according to the treatment of adenomyosis before pregnancy: expectation group, drug group and operation group. The relevant data before pregnancy of the three groups were analyzed, and the pregnancy outcomes of the patients were summarized. According to whether the early pregnancy was treated with medication, the patients who were naturally conceived without symptoms of threatened abortion were divided into observation group and fetus protection group, and the pregnancy outcomes of the two groups were compared. Results: (1) Compared with the expectation group, the ages of patients in the drug group and the operation group were larger [(31.5±1.8) vs (34.1±3.7) vs (36.9±3.6) years old], and the difference was statistically significant (P<0.05). Only 9 patients (11.5%, 9/78) had clinical symptoms in the expectation group, while the patients in the drug group and the operation group had a higher proportion of dysmenorrhea and increased menstrual volume. The uterine volume of the drug group and the operation group were larger than that of the expectation group [(151±46) vs (166±27) vs (97±18) cm³], the difference was statistically significant (P<0.05). 78.6% (33/42) of the operation group were focal adenomyosis. The proportion of natural pregnancy in the expectation group was 97.4% (76/78), and in vitro fertilization and embryo transfer was mainly used in the drug group and the operation group. (2) The abortion rates of the three groups were 48.7% (26/111), 4/17, 67.5% (27/78) respectively. Compared with the drug group and the operation group, the preterm birth rate was lower [55.9% (33/111) vs 11/17 vs 12.5% (5/78)] and the natural delivery rate was higher [44.1% (26/111) vs 4/17 vs 67.5% (27/78)] in the expectation group. (3) There were 89 cases of spontaneous pregnancy without threatened abortion symptoms, including 31 cases in the observation group and 58 cases in the fetus protection group. Compared with the observation group, the abortion rate of patients in the fetus protection group was lower [41.9% (13/31) vs 34.5% (20/58)], and the difference was statistically significant (P<0.05). Conclusions: Patients with adenomyosis who have fertility requirements should be comprehensively evaluated and individualized treatment plans should be given. Pregnancy patients with adenomyosis have a high rate of miscarriage, and they should be included in the management of high-risk pregnant women. Active fetal protection treatment during early pregnancy might improve pregnancy outcomes.

Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study

STUDY OBJECTIVES

Because air leakage from masks is known as a common cause of low adherence to continuous positive airway pressure therapy, we analyzed the risk factors for air leakage related to parameters associated with auto-titrating positive airway pressure, polysomnography, InBody Test, and rhinomanometry.

METHODS

Usage data and medical records of 120 auto-titrating positive airway pressure users were reviewed retrospectively. All patients used a nasal or pillow mask and were carefully monitored at scheduled follow-ups.

RESULTS

Use of a pillow mask, sex (male), age, and abdominal fat percentage were significantly associated with high average air leakage. The higher the auto-titrating positive airway pressure average and mean pressure, the more likely patients exhibited high rates of air leakage. The percentage of patients with high average air leakage increased over time (up to 6 months of follow-up).

CONCLUSIONS

Older male patients using a pillow mask and those with a high abdominal fat percentage and high auto-titrating positive airway pressure may require close follow-up and continuous monitoring for air leakage. Because air leakage from a mask can change over time, mask-sealing capacity should be reassessed and masks should be changed regularly.

CITATION

Kang YJ, Cho J-H, Park C-S. Analysis of risk factors for air leakage in auto-titrating positive airway pressure users: a single-center study. J Clin Sleep Med. 2022;18(1):75-88.

The diagnostic value of detecting sudden smell loss among asymptomatic COVID-19 patients in early stage: The possible early sign of COVID-19

IMPORTANCE

The newly emerged coronavirus disease 19 (COVID-19), is threatening the world. Olfactory or gustatory dysfunction is reported as one of the symptoms worldwide. As reported so far, different clinical features have been reported according to outbreak sites and gender; most of the patients, who complained of anosmia or hyposmia, were Europeans. We had a fast review for novel articles about COVID-19 infection and olfactory function.

OBSERVATIONS

Rapid reviews for COVID-19 or other viral infection and olfactory and/or gustatory dysfunctions were done in this review. Up to date, a lot of reports have shown that olfactory dysfunction is related to viral infections but no exact mechanism, clinical course, and definite treatment have been discovered, which is also same in COVID-19. In general, intranasal steroid (INS) and oral steroid for short time help improve the recovery of the olfactory function in case of olfactory dysfunction after virus infection. Considering severe respiratory complications and immunocompromised state of COVID-19, the use of steroid should be limited and cautious because we do not have enough data to support the usage of steroid to treat olfactory dysfunction in the clinical course of COVID-19.

CONCLUSIONS AND RELEVANCE

In the days of pandemic COVID-19, we should keep in mind that olfactory dysfunctions, even without other upper respiratory infection or otolaryngologic symptoms, might be the early signs of COVID-19.

Nanoparticle-based delivery of an anti-proliferative metal chelator to tumor cells

This paper describes the preparation and characterization of polymeric nanoparticles loaded with a potent anti-tumor metal chelator, Di-2-pyridylketone-4,4-dimethyl-3-thiosemicarbazone (Dp44mT) for delivery to cancer cells. Metal chelators have been increasingly studied for their anti-cancer properties that rely on the high demand of neoplastic cells for iron. Dp44mT has previously shown great antiproliferative characteristics in several cancers including breast cancer and melanoma. To further expand the application of this highly cytotoxic agent for cancer treatment and to enable its specific delivery to malignant cells, here we apply nano-scale particles (NPs) of biodegradable poly(lactic-co-glycolide) (PLGA) for encapsulation of Dp44mT and evaluate its effectiveness in vitro. The results demonstrated that Dp44mT was efficiently encapsulated in PLGA particles. Resulting NPs were uniform in size and shape and had good colloidal stability. Moreover, Dp44mT encapsulation in PLGA enhanced the water solubility of this agent. Lastly, the present formulation showed high level of cytotoxicity in glioma cells. Together, these results show the potential of PLGA NPs as a nano-carrier for Dp44mT with no apparent impact on the anti-tumor activity of this compound.

Abstract P6-07-19: An alteration of hormonal receptor status throughout tumor progression related to prognosis in breast cancer patients

Purpose

We aimed to identify whether hormonal receptors change throughout tumor progression, because this may influence management and influence prognosis in breast cancer patients.

Patients and Methods

From the institution's database, we collected data of 963 patients who developed relapse during their follow-ups. To determine estrogen receptor(ER) and progesterone receptor (PR), we retrospectively reviewed immunohistochemical(IHC) results in both primary and relapsed tumors.

Results

Among a total of 963 patients, 280 and 683 patients experienced locoregional relapse only and distant metastasis irrespective of locoreginal relapse, respectively. ER in 650 patients and PR in 590 patients from both primary tumor and relapse were identified, revealing a change in 157 (24.2%) and 154 (26.1%) patients, respectively. In patients with distant metastasis, assessment of ER and PR showed an alteration in 86 and 56 patients, respectively. The overall survival related to the change of ER and PR status in primary tumor and relapse was significantly different (log rank, P&lt;0.001 in both ER and PR status). In addition, women with hormone receptors negative primary tumors that changed to hormone receptors positive tumors who received anti-hormonal therapy after relapse showed a statistically significant good overall survival (p&lt;0.001) compared with women who had constant ER-negative tumors.(cox regression, hazard ratio 2.32 ; 95% CI, 1.91 to 3.01)

Conclusion

The breast cancer showed alterations of hormone receptor status throughout tumor progression, hat were related to the strategy of treatment and significantly influences survival. Therefore, investigations of hormone receptor at relapse are essential and helpful in breast cancer patient management.

Citation Format: Lee E-S, Kim J, Yoo T-K, Kim Y, Han J, Kang YJ, Choi J, Rhu J, Lee H-B, Han W, Noh D-Y, Moon H-G. An alteration of hormonal receptor status throughout tumor progression related to prognosis in breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-07-19.

Invagination of the Sphenoid Sinus Mucosa after Endoscopic Endonasal Transsphenoidal Approach and Its Significance

Objective

To describe the clinical features of invagination of the sphenoid sinus mucosa (ISM) and compare them with other similar cases using a visual analog scale (VAS) to assess the various nasal symptoms and to discuss its clinical significance and means of prevention.

Study Design

Retrospective chart review at a tertiary referral center.

Methods

Between 2010 and 2015, 8 patients who had undergone EETSA surgery displayed postoperative ISM. The comparison group consisted of 147 patients who underwent the same surgical procedures and were diagnosed with the same diseases. Pre- or postoperative paranasal sinus computed tomography (PNS CT) and VAS were performed and subsequently analyzed.

Results

The clinical features of ISM of the sphenoid sinus showed sellar floor invagination and regenerated inverted ingrowing sphenoid mucosa on endoscopic imaging. PNS CT also showed a bony defect and invaginated air densities at the sellar turcica. Pre- and postoperative VAS scores revealed that the ISM group had much less of an improvement in headaches after surgery than that of the comparison group (p = 0.049).

Conclusion

ISM may occur because of a change in pressure, sphenoid mucosal status, or arachnoid membrane status. Moreover, ISM is related to improvements in headaches. Therefore, EETSA patients should avoid activities that cause rapid pressure changes during the healing process. In addition, sellar reconstruction that is resistant to physical pressure changes should be mandated despite the absence of an intraoperative CSF leak.

Abstract P5-08-23: Ki-67 expression is not a valuable predictive prognostic factor when progesterone receptor expression is high in estrogen receptor-positive breast cancer

Background

Immunohistochemistry markers are recognized as a predictive prognostic factor for women with breast cancer. Ki-67 and progesterone receptor (PgR) expression are reported to be independently associated with breast cancer prognosis. Some studies report high Ki-67 expression as a negative predictive marker. Whereas other studies report tendency of similar survival between high and low Ki67 cancers when PgR expression is high. In this study, we examined the prognostic significance of Ki-67 expression under PgR expression status.

Methods

The records of 2,366 patients were retrospectively reviewed. The patients underwent surgery for primary breast cancer from July 2009 to December 2012 at a single institution. We studied the prognostic significance of Ki-67 expression under PgR expression. We used 20% and 10% as the cut-off value for PgR and Ki-67, respectively. The end point was recurrence-free survival (RFS) evaluated by use of Kaplan-Meier analysis.

Result

Of the 2,366 analyzed patients, the median follow-up time was 43 months. During follow-up, 44 patients had recurrence, loco-regional recurrence developed in 23 patients and distant recurrence developed in 21 patients. In patients with low PgR expression, high Ki-67 expression group showed significantly worse prognosis compared to low Ki-67 expression group (p=0.005). On the other hand, no significant difference was shown between low and high Ki-67 expression group when PgR expression was high (p=0.637). Also multivariate analysis demonstrated that high Ki-67 expression was an independent prognostic factor only when PgR expression was low. (95% confidence interval [CI], 1.35-10.48; p=0.011)

Conclusion

This is the largest reported study that prognostic significance of Ki-67 expression is defined by PgR expression. Our study presents that high Ki-67 expression is inversely correlated with recurrence risk in early breast cancer patients only under low PgR expression. At high PgR expression, Ki-67 expression has no influence on breast cancer prognosis. Therefore, attention should be paid to correlation between PgR and Ki-67 expression.

Citation Format: Han JH, Kang YJ, Han W, Lee H-B, Kim Y, Yoo T-K, Moon H-G, Noh D-Y. Ki-67 expression is not a valuable predictive prognostic factor when progesterone receptor expression is high in estrogen receptor-positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-08-23.

Abstract P6-04-02: Identification of ESR1 splice variants associated with prognosis in estrogen receptor positive breast cancer

Background: Splice variants play a major role in carcinogenesis and disease progression. It is well known that androgen receptor splice variants are associated with resistance to prostate cancer treatment. Estrogen receptor (ER)-positive breast cancers constitute about 70% of all breast cancers and have better prognosis compared to ER-negative cancers. However, there are ER-positive breast cancers that acquire resistance to anti-estrogen therapy, and 12-55% of those tumors were shown to possess ESR1 mutations. The aim of this study was to identify common splice variants in the ESR1 gene and investigate their association with disease outcome.

Methods: Whole transcriptome sequencing was performed on breast cancer specimens from 120 invasive breast cancer patients who underwent operation at Seoul National University Hospital (SNUH) and data from SNUH, GEO, and The Cancer Genome Atlas (TCGA) was used for normal breast tissue sequencing. Exon-exon junctions were identified on aligned RNA sequencing data and was used to construct exon graphs. Splice variant candidates were selected from exon graphs and were merged according to variant subtypes of samples. Subtypes were accessed differentially in relation to how frequent the junctions appear in tumor samples and common exon skipping types with frequent junctions were identified. TCGA RNA sequencing data was then used to search for the common exon skipping subtypes detected from SNUH RNA sequencing data.

Results: Of the 120 tumor samples, 50 were clinically ER-positive by immunohistochemistry. Among exon paths logically possible, 125 paths were not observed in normal breast tissues. Exon 4-5 junction was the most commonly observed junction in the tumor samples. In a search for exon skipping type that results in missing ligand-binding domain of ER, three exon skipping types were identified. Exon skipping with exon 5-10 junction (type 1), exon 9-12 junction (type 2), and exon 10-12 (type 3) was seen in 4 (8%), 4 (8%), and 10 (20%) ER-positive samples, respectively. Retrospective medical chart review of the 18 patients showed recurrence in 4 (100%), 2 (50%), and 4 (40%) patients with type 1, 2, and 3 exon skipping, respectively. Evaluation of TCGA RNA sequencing data of 872 ER-positive samples suggested exon 4-5 junction as the most common junction. A search for exon skipping types in TCGA revealed 1 (0.1%), 9 (1.0%), and 454 (52.1%) samples with type 1, 2, and 3 exon skipping, respectively. However, none of the patients with type 1 or 2 had metastasis or had expired. Of the 454 patients with type 3 exon skipping, 54 patients had died, constituting 61.4% of 88 mortalities in the whole ER-positive population.

Conclusion: Certain splice variants of ESR1 gene yields exon skipping subtypes commonly observed in the ER-positive breast cancer. Estrogen receptor-positive breast cancer with these exon skipping types resulting in a missing ligand-binding domain of ER may be associated with poorer disease outcome. Further investigation is warranted to validate the role of ESR1 exon skipping subtypes in the disease progression of breast cancer.

Citation Format: Lee H-B, Han W, Ko S, Kim M-S, Lim S, Lee K-M, Kang YJ, Han JH, Kim Y, Yoo T-K, Moon H-G, Noh D-Y, Kim S, Han W. Identification of ESR1 splice variants associated with prognosis in estrogen receptor positive breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-04-02.

Abstract P2-02-15: Discovery of putative circulating tumor cells through somatic mutation profile of epithelial cell adhesion molecule positive single cells from blood of metastatic breast cancer patients

Background: Circulating tumor cell (CTC) enumeration provides prognostic information for chemotherapy in metastatic breast cancer. However, due to its rarity and heterogeneity, it is difficult to distinguish true CTCs from normal blood cells and perform genomic analysis on them for use in therapeutic strategies. The main application of most currently available CTC detection systems consists of an enumeration of putative CTCs without further analysis. The aim of this study was to evaluate the feasibility of single cell picking and target sequencing of epithelial cell adhesion molecule (EpCAM)-positive cells for detecting CTCs.

Methods: Whole blood sampled from metastatic breast cancer patients who were newly diagnosed with metastasis or who had disease progression during palliative treatment were used for this study. After applying IsoFlux Circulating Tumor Cell Enrichment Kit (Fluxion, South San Francisco, CA, USA), single CTC candidates were picked from a pool of EpCAM-positive cells. Genomic DNA from the picked cells was whole genome amplified and target sequencing was performed using Ion AmpliSeq™ Cancer Hotspot Panel (Life Technologies, Carlsbad, CA, USA). Target sequencing reads were mapped to human genome reference (hg19) using BWA-MEM (0.7.10). Single nucleotide variants (SNVs) were annotated using dbSNP, Variome Data 0.2, and COSMIC databases.

Results: A total of 172 EpCAM-positive cells were selected according to size and EpCAM status from whole blood of 11 patients. The remaining cells were grouped into a pooled sample for each patient. The mean read depth of the target genes was 13455×. A mean 7.82 mutations as determined by SNVs listed in the COSMIC database but not in dbSNP and Variome Data 0.2 were detected in each patient. Cells with multiple mutated genes, or those with a mutated gene repeatedly observed in another cell from the same patient were judged to be putative CTCs. At least 2 putative CTCs were detected in 7 patients while no CTCs were detected in 2 patients. Mutated genes observed in the putative CTCs were ABL1, AKT1, APC, CDH1, CDKN2A, ERBB2, FGFR3, HRAS, IDH1, JAK2, KDR, NPM1, RB1, RET, SMARCB1, STK11, and TP53.

Conclusions: Potential CTCs were successfully identified by single cell picking and target sequencing of EpCAM-positive cells from whole blood of metastatic breast cancer patients. Unique mutations not detected in other single cells and pooled samples can be used to distinguish putative CTCs from normal cells. Genomic profiling of corresponding primary tumor and metastatic site biopsy is warranted to verify the CTCs and investigate their role in disease progression.

Citation Format: Lee H-B, Jeon S, Kim BC, Jho S, Kim J, Kang YJ, Yoo T-K, Han JH, Kim Y, Im S-A, Moon H-G, Noh D-Y, Han W. Discovery of putative circulating tumor cells through somatic mutation profile of epithelial cell adhesion molecule positive single cells from blood of metastatic breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-02-15.

Genetic diversity and taxonomic status of Gymnocypris chilianensis based on the mitochondrial DNA cytochrome b gene

In order to study the genetic diversity and taxonomic status of Gymnocypris chilianensis on a molecular level, the mitochondrial DNA cytochrome b gene was sequenced for 74 individuals of G. chilianensis from two locations (Heihe River and Shule River) and 42 individuals of its affinis species Gymnocypris przewalskii. Analyses of genetic diversity and sequence differences were conducted for these samples, combined with the analysis of 30 homologous sequences of another affinis species Gymnocypris eckloni, which were downloaded from GenBank. The results showed that both the haplotype diversity (h = 0.9820) and nucleotide diversity (π= 0.0039) of the Shule River G. chilianensis were lower than the other populations, thus, the Shule River G. chilianensis should be prioritized for protection because of its lower genetic diversity level. The results of sequence analysis showed that the genetic distance between the Heihe River G. chilianensis population and the Shule River G. chilianensis population was 0.0064, and the genetic distance between these two populations and the G. przewalskii population was 0.0838 and 0.0810, respectively. The genetic distance between the two G. chilianensis populations and the G. eckloni population was 0.0805 and 0.0778, respectively. Analysis of sequence differences indicates that G. chilianensis is sufficiently diverged from G. przewalskii and G. eckloni to the extent that it has reached species level, thus, G. chilianensis can be considered an independent species of Gymnocypris.

The relationship between mast cell density and tumour grade in transitional cell carcinoma of the bladder

This study investigated the relationship between mast cell numbers and the grade of bladder transitional cell carcinoma (TCC). Bladder TCC biopsies were obtained via transurethral resection and 45 stage T1 specimens were included in the study. Specimens were sorted into two groups, low grade (grade I) and high grade (grades II and III). Samples were stained using haematoxylin and eosin, toluidine blue and immunohistochemical staining for tryptase. Mast cells were examined by light microscopy and cell density was recorded. Mast cell density was significantly higher in high-grade TCC than low-grade TCC. There was also a significant relationship between the number of mast cells identified using toluidine blue staining or immunohistochemical staining for tryptase. Detailed studies of mast cell function will enable the development of more effective antitumour therapies via mast cell manipulation.

Molecular cloning and characterization of the STAT gene in Hyphantria cunea haemocytes

A new insect member of the signal transducer and activator of transcription (STAT) family of transcription factors, Hyphantria cunea STAT (HcSTAT), was cloned from the lepidopteran H. cunea. The domain involved in DNA interaction and the Src homology 2 (SH2) domain were well conserved. During all developmental stages, the gene was expressed at a low level in the haemocytes, fat body cells, midgut, epidermis and Malpighian tubules. The haemocytes and Malpighian tubules showed transcriptional activation of HcSTAT upon Gram-negative and Gram-positive bacterial challenges. These challenges increased the induction and nuclear translocation of the HcSTAT protein that recognizes a STAT target site in H. cunea haemocytes. In vivo treatment with sodium orthovanadate translocated HcSTAT to the haemocyte nucleus. This study shows the involvement of the haemocyte Janus kinase/STAT pathway after microbial infection in lepidopteran insects.

Treatment guidelines for isolated dissection of the superior mesenteric artery based on follow-up CT findings

OBJECTIVES

The treatment guidelines for isolated superior mesenteric artery dissection (SMAD) are not well established. The purpose of this study was to report a single-centre series of SMAD and propose treatment guidelines.

MATERIALS AND METHODS

Between November 2004 and December 2009, 30 patients were diagnosed with SMAD. We retrospectively reviewed their medical records.

RESULTS

The subjects included 26 men and four women, with a mean age of 55.1 years. The chief complaint was abdominal pain in 17 patients, whereas 13 patients were asymptomatic. The mean follow-up was 38.3 months. The radiographic findings included intimal flap with a false lumen in 20 patients and intramural haematoma in 10 patients. The treatments included observation in 18 patients, anticoagulation in five patients, stenting in six patients and surgery in one patient. During follow-up (mean 15.6 months), there was no change in the computed tomography scans of seven patients, improvement was observed in four patients and complete resolution was observed in four patients. All patients, including the symptomatic patients, remained asymptomatic during follow-up.

CONCLUSIONS

Most patients with SMAD can be successfully managed with conservative treatment. Surgical treatment or percutaneous intervention can be reserved for patients with severe mesenteric ischaemia and those for whom the initial conservative treatment fails.

Multiple copies of 16s rRNA gene affect the restriction patterns and DGGE profile as revealed by analysis of genome database

The use of 16S rRNA gene has been a "golden" method to determine the diversity of microbial communities in environmental samples, phylogenetic relationships of prokaryotes and taxonomic position of newly isolated organisms. However due to the presence of multiple heterogeneous 16S rRNA gene copies in many strains, the interpretation of microbial ecology via 16S rRNA sequences is complicated. Purpose of present paper is to demonstrate the extent to which the multiple heterogeneous 16S rRNA gene copies affect RFLP patterns and DGG E profiles by using the genome database. In present genome database, there are 782 bacterial strains in total whose genomes have been completely sequenced and annotated. Among the total strains, 639 strains (82%) possess multiple 16S rRNA gene copies, 415 strains (53%) whose multiple copies are heterogeneous in sequences as revealed by alignment, 236 strains (30%) whose multiple copies show different restrict patterns by CSP61 + Hinfl, MspI + Rsal or HhaI as analyzed in silico. Polymorphisms of the multiple copies in certain strains were further characterized by G + C% and phylogentic distances based on the sequences of V3 region, which are linked to DGGE patters. Polymorphisms of a few strains were shown as examples. Using artificial communities, it is demonstrated that the presence of multiple heterogeneous 16S rRNA gene copies potentially leads to over-estimation of the diversity of a community. It is suggested that care must be taken when interpreting 16S rRNA-based RFLP and DGGE data and profiling an environmental community.

Sequence analysis of an isolate of minute virus of canines in China reveals the closed association with bocavirus

In the present study, we have cloned and sequenced the nearly-full-length genome of minute virus of canines (MVC), SH26, in China. The genome of MVC, 5,132 nucleotides (nts) in length, contains three open reading frames (ORFs), which are 2,325-bp of NS1, 561-bp of NP1 and 2,112-bp of VP1/VP2 encoding three proteins of 774, 186 and 703 residues, respectively. Predicted amino acids sequence of NS1 of MVC has 44% identity with human bocavirus (HBoV) and human boacvirus 2 (HBoV2), NP1 has 48 and 45% identity with HBoV and HBoV2, VP1/VP2 has 45 and 46% identity with HBoV and HBoV2, respectively. Phylogenetic analysis showed that the present Chinese MVC strain was also closely clustered with the previous American and Japanese MVC isolates, and MVCs formed a different branch together with bovine parvovirus and HBoVs from other parvoviruses classified into Parvovirinae.

Comparative analysis of two attacin genes from Hyphantria cunea

A full-length clone corresponding to attacin was isolated from a cDNA library made from fat body of immunized Hyphantria cunea larvae. This newly isolated attacin B shows characteristics different from those previously reported for attacin A. The two attacin cDNAs encode precursor proteins of 233 and 248 amino acid residues, respectively. The two attacins show 45.9% identity at the amino acid level, and 35.2% identity at the nucleotide level. Attacins A and B of H. cunea show significant identities with the attacins of Lepidoptera. Attacin B is a typical glycine-rich protein, while attacin A is leucine-rich. Attacin B is expressed from last instar larvae to adult, while attacin A showed stage-specific expression during the prepupal and pupal stages. Attacins A and B are predicted to have different secondary structure in that attacin A has no tendency to form helices but attacin B contains a substantial number of helices. Attacin A is induced at a trace level in infected larvae, while attacin B is strongly induced against Gram-positive and negative bacteria, fungi, and viruses. The attacin B transcripts were detected in fat body, epidermis and hemocytes after injection with Escherichia coli, Citrobacter freundii, or Candida albicans, but not in the midgut and Malpighian tubule. Recombinant attacin A showed no antibacterial activity, while recombinant attacin B showed strong antibacterial activity in proportion to the amount of the protein injected.

The anti-diabetic effects of ethanol extract from two variants of Artemisia princeps Pampanini in C57BL/KsJ-db/db mice

The anti-diabetic effects of two variants of Artemisia princeps Pampanini, sajabalssuk (SB) and sajuarissuk (SS), were investigated in type 2 diabetic animal using their ethanol extracts. Male C57BL/KsJ-db/db (db/db) mice were divided into control, SB ethanol extract (SBE), SS ethanol extract (SSE), or rosiglitazone (RG) groups and their age-matched littermates (db/+) were used. Supplementation of the SBE (0.171 g/100g diet), SSE (0.154 g/100g diet), and RG (0.005 g/100g diet) improved glucose and insulin tolerance and significantly lowered blood glycosylated hemoglobin levels, as compared to the control group. Plasma insulin, C-peptide and glucagon levels in db/db mice were higher in the db/+ mice, however these values were significantly lowered by SBE, SSE or RG-supplement. Hepatic GK activity was significantly lower in the db/db mice than in the db/+ mice, while hepatic G6Pase activity was vice versa. Supplementation of SBE, SSE and RG reversed these hepatic glucose-regulating enzyme activities. In addition, SBE and SSE markedly increased the hepatic glycogen content and muscle ratio as compared to the control group, but they did not alter the food intake, body weight and plasma leptin level. The RG group, however, showed a significant increase in the food intake, body weight and plasma leptin. These results suggest that SBE and SSE exert an anti-diabetic effect in type 2 diabetic mice.

Oxidative stress and diabetic cardiomyopathy: a brief review

Diabetes is a serious public health problem. Improvements in the treatment of noncardiac complications from diabetes have resulted in heart disease becoming a leading cause of death in diabetic patients. Several cardiovascular pathological consequences of diabetes such as hypertension affect the heart to varying degrees. However, hyperglycemia, as an independent risk factor, directly causes cardiac damage and leads to diabetic cardiomyopathy. Diabetic cardiomyopathy can occur independent of vascular disease, although the mechanisms are largely unknown. Previous studies have paid little attention to the direct effects of hyperglycemia on cardiac myocytes, and most studies, especially in vitro, have mainly focused on the molecular mechanisms underlying pathogenic alterations in vascular smooth-muscle cells and endothelial cells. Thus, a comprehensive understanding of the mechanisms of diabetic cardiomyopathy is urgently needed to develop approaches for the prevention and treatment of diabetic cardiac complications. This review provides a survey of current understanding of diabetic cardiomyopathy. Current consensus is that hyperglycemia results in the production of reactive oxygen and nitrogen species, which leads to oxidative myocardial injury. Alterations in myocardial structure and function occur in the late stage of diabetes. These chronic alterations are believed to result from acute cardiac responses to suddenly increased glucose levels at the early stage of diabetes. Oxidative stress, induced by reactive oxygen and nitrogen species derived from hyperglycemia, causes abnormal gene expression, altered signal transduction, and the activation of pathways leading to programmed myocardial cell deaths. The resulting myocardial cell loss thus plays a critical role in the development of diabetic cardiomyopathy. Advances in the application of various strategies for targeting the prevention of hyperglycemia-induced oxidative myocardial injury may be fruitful.

Zinc inhibition of caspase-3 activation does not protect HeLa cells from apoptotic cell death

Zinc is proposed to be antiapoptotic for it has been shown to inhibit late events of apoptotic pathways such as Ca(2+)/Mg(2+)-dependent endonuclease cleavage of chromatin DNA, poly-ADP ribose polymerase cleavage, and caspase-3 activity. Because caspase-3 is a critical executioner caspase in apoptosis, this study was undertaken to examine specifically a correlation between zinc inhibition of caspase-3 activation and apoptosis in HeLa cells. Cultured HeLa cells were exposed to 100 microM ZnCl(2) for 1 h prior to 12 h treatment with 1.0 microM doxorubicin (DOX), an important anticancer agent that causes apoptosis in a wide variety of tumor cells. Western blot analysis of HeLa cells treated with DOX for 12 h revealed that DOX caused proteolytic activation of caspase-3 and zinc inhibited this activation. Interestingly, zinc did not inhibit DOX-induced apoptosis as measured by a terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay. Furthermore, a microculture tetrazolium assay confirmed that cell death occurred in the presence of zinc. These results demonstrate that zinc specifically inhibits DOX-induced activation of caspase-3 in HeLa cells, but does not suppress DOX-induced apoptosis or otherwise cell death, thus suggesting DOX-induced caspase-3 activation may not play a major role in overall cell death and/or non-caspase-3 pathways are involved in DOX-induced apoptosis in HeLa cells.

Metallothionein inhibits doxorubicin-induced mitochondrial cytochrome c release and caspase-3 activation in cardiomyocytes

Previous studies using transgenic mice in which metallothionein (MT) was overexpressed only in the heart have demonstrated that MT protects from oxidative cardiac injury induced by doxorubicin (DOX), an important anticancer agent. MT cardioprotection is associated with its antiapoptotic effect. The present study was undertaken to test the hypothesis that MT suppresses DOX-induced apoptosis through inhibition of mitochondrial cytochrome c release and caspase-3 activation. Primary cultures of cardiomyocytes isolated from the hearts of transgenic neonatal mice and nontransgenic controls were treated with DOX at a clinically relevant concentration (1.0 microM) for varying time periods. Apoptosis was detected in nontransgenic cardiomyocyte cultures by terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling and Annexin V-fluorescein isothiocyanate binding. This apoptotic effect was significantly suppressed in the MT-overexpressing transgenic cardiomyocytes. Western blot analysis revealed that DOX caused mitochondrial cytochrome c release. Furthermore, caspase-3 activation was observed. The activation of this apoptotic pathway by DOX was dramatically inhibited in the MT-overexpressing cardiomyocytes. To elucidate the role of reactive oxygen species (ROS) in the activation of the cytochrome c-mediated caspase-3 activation pathway, the intracellular levels of ROS and their localization were detected by fluorescent confocal microscopy. Mitochondrial ROS concentrations were dramatically elevated by DOX in nontransgenic cardiomyocytes. This elevation was completely inhibited almost in the MT-overexpressing cardiomyocytes. Thus, these results demonstrate that MT suppresses DOX-induced apoptosis in cardiomyocytes through, at least in part, inhibition of the cytochrome c-mediated apoptotic pathway.

The predictive parameters of erythropoietin hyporesponsiveness in patients on continuous ambulatory peritoneal dialysis

BACKGROUND

The present study was aimed at investigating the predictive parameters of erythropoietin (epoetin) hyporesponsiveness in patients on continuous ambulatory peritoneal dialysis (CAPD).

METHODS

We studied 40 patients with end-stage renal disease who had been receiving CAPD for at least 6 months and epoetin therapy for at least more than 2 months. Pearson's simple correlation and multiple stepwise linear regression analysis was used to discover what parameter can predict epoetin resistance. We expressed epoetin resistance index (ERI) as weekly epoetin dose/hematocrit/body weight'. The dose of epoetin is titrated by about 25% every 2 to 4 weeks to maintain a target hematocrit level between 33% and 36%.

RESULTS

We analyzed the relationship between ERI and other predictive parameters by Pearson's correlation. These results showed ERI has a statistically significant correlation with transferrin saturation (TS) (r = -0.327, p = 0.042), total weekly Kt/Vurea (r = -0.423, p = 0.018), serum albumin level (r = -0.458, p = 0.003), normalized protein catabolic rate (nPCR) (r = -0.479, p = 0.006), normalized protein equivalent of total nitrogen appearance (nPNA) (r = -0.488, p = 0.005) and serum C-reactive protein (CRP) (r = 0.332, p = 0.036). Regression analysis was performed using stepwise linear regression for multiple variables to discover the most independent variable which is correlated with ERI. ERI was entered as a dependent variable, whereas the other parameters (age, duration of peritoneal dialysis, serum albumin level, CRP, serum ferritin, total weekly Kt/Vurea, nPCR, nPNA, serum iPTH, serum aluminium, TS) were entered as independent variables. This analysis showed CRP is the most significant variable and, if CRP is excluded, nPNA is the significant variable. CRP has a statistically significant correlation with serum albumin level (r = -0.418, p = 0.007) and total weekly Kt/Vurea (r = -0.366, p = 0.043). High CRP group has more increased level of ERI (p < 0.05), age (p < 0.05) and serum creatinine level (p < 0.05) than normal control, but more decreased level of serum albumin (p < 0.01) and serum iron levels (p < 0.05).

CONCLUSION

These results indicate that CRP is the most important predictor of epoetin hyporesponsiveness.

Inhibition of hypoxia/reoxygenation-induced apoptosis in metallothionein-overexpressing cardiomyocytes

To study possible mechanisms for metallothionein (MT) inhibition of ischemia-reperfusion-induced myocardial injury, cardiomyocytes isolated from MT-overexpressing transgenic neonatal mouse hearts and nontransgenic controls were subjected to 4 h of hypoxia (5% CO2-95% N2, glucose-free modified Tyrode's solution) followed by 1 h of reoxygenation in MEM + 20% fetal bovine serum (FBS) (5% CO2-95% air), and cytochrome c-mediated caspase-3 activation apoptotic pathway was determined. Hypoxia/reoxygenation-induced apoptosis was significantly suppressed in MT-overexpressing cardiomyocytes, as measured by both terminal deoxynucleotidyl transferase-mediated deoxyuridine 5-triphosphate nick-end labeling and annexin V-FITC binding. In association with apoptosis, mitochondrial cytochrome c release, as determined by Western blot, was observed to occur in nontransgenic cardiomyocytes. Correspondingly, caspase-3 was activated as determined by laser confocal microscopic examination with the use of FITC-conjugated antibody against active caspase-3 and by enzymatic assay. The activation of this apoptotic pathway was significantly inhibited in MT-overexpressing cells, as evidenced by both suppression of cytochrome c release and inhibition of caspase-3 activation. The results demonstrate that MT suppresses hypoxia/reoxygenation-induced cardiomyocyte apoptosis through, at least in part, inhibition of cytochrome c-mediated caspase-3 activation.

Attenuation of doxorubicin chronic toxicity in metallothionein-overexpressing transgenic mouse heart

Previous studies have shown that cardiac-specific metallothionein (MT)-overexpressing transgenic mice are highly resistant to acute cardiotoxicity induced by doxorubicin (DOX), a most effective anticancer agent. However, cumulative dose-dependent chronic cardiotoxicity attributable to long-term administration of DOX is a significant clinical problem. Because MT is a potent antioxidant and oxidative stress is critically involved in DOX-induced heart injury, the present study was undertaken to test the hypothesis that MT also provides protection against DOX chronic cardiotoxicity. Transgenic mice containing high levels of cardiac MT and nontransgenic controls were treated with a cumulative dose of 40 mg/kg of DOX in 10 equal i.v. injections over a period of 7 weeks. Three weeks after the last injection, the mice were killed for an analysis of cardiotoxicity. As compared with nontransgenic controls, DOX-induced cardiac hypertrophy was significantly inhibited in the transgenic mice. Light microscopic examination revealed that DOX-induced myocardial morphological changes were markedly suppressed or almost eliminated in the transgenic mice. Under electron microscopy, extensive sarcoplasmic vacuolization and severe disruption of mitochondrial fine structure were observed in nontransgenic cardiomyocytes, but almost no sarcoplasmic vacuolization was observed, and the mitochondrial structural changes were almost completely prevented in the transgenic cardiomyocytes. The results thus indicate that MT elevation is a highly effective approach to prevent chronic cardiomyopathy attributable to DOX. This study also suggests that oxidative stress is critically involved in the DOX-induced chronic cardiotoxicity.

Molecular and cellular mechanisms of cardiotoxicity

Cardiotoxicity resulting from detrimental environmental insults has been recognized for a long time. However, extensive studies of the mechanisms involved had not been undertaken until recent years. Advances in molecular biology provide powerful tools and make such studies possible. We are gathering information about cellular events, signaling pathways, and molecular mechanisms of myocardial toxicologic responses to environmental toxicants and pollutants. Severe acute toxic insults cause cardiac cell death instantly. In the early response to mild environmental stimuli, biochemical changes such as alterations in calcium homeostasis occur. These may lead to cardiac arrhythmia, which most often is reversible. Prolonged stimuli activate transcription factors such as activator protein-1 through elevation of intracellular calcium and the subsequent activation of calcineurin. Upregulation by activated transcription factors of hypertrophic genes results in heart hypertrophy, which is a short-term adaptive response to detrimental factors. However, further development of hypertrophy will lead to severe and irreversible cardiomyopathy, and eventually heart failure. From cardiac hypertrophy to heart failure, myocardial cells undergo extensive biochemical and molecular changes. Cardiac hypertrophy causes tissue hypoperfusion, which activates compensatory mechanisms such as production of angiotensin II and norepinephrine. Both further stimulate cardiac hypertrophy and, importantly, activate counterregulatory mechanisms including overexpression of atrial natriuretic peptide and b-type natriuretic peptide, and production of cytokines such as tumor necrosis factor-alpha. This counterregulation leads to myocardial remodeling as well as cell death through apoptosis and necrosis. Cell death through activation of mitochondrial factors and other pathways constitutes an important cellular mechanism of heart failure. Our current knowledge of cardiotoxicity is limited. Further extensive studies are warranted for a comprehensive understanding of this field.

Metallothionein inhibits peroxynitrite-induced DNA and lipoprotein damage

Previous studies have demonstrated that metallothionein functions as an antioxidant that protects against oxidative DNA, protein, and lipid damage induced by superoxide anion, hydrogen peroxide, hydroxyl radical, and nitric oxide. The present study was undertaken to test the hypothesis that metallothionein also protects from DNA and lipoprotein damage induced by peroxynitrite, an important reactive nitrogen species that causes a diversity of pathological processes. A cell-free system was used. DNA damage was detected by the mobility of plasmid DNA in electrophoresis. Oxidation of low density lipoprotein was measured by a thiobarbituric acid-reactive substance, which was confirmed by lipid hydroperoxide assay. Plasmid DNA damage and low density lipoprotein oxidation were induced by 3-morpholinosydnomine, which produces peroxynitrite through the reaction between nitric oxide and superoxide anion or by synthesized peroxynitrite directly. DNA damage by 3-morpholinosydnomine was prevented by both metallothionein and superoxide dismutase, whereas the damage caused by peroxynitrite was prevented by metallothionein only. The oxidation of low density lipoprotein by 3-morpholinosydnomine and peroxynitrite was also significantly inhibited by metallothionein. This study thus demonstrates that metallothionein may react directly with peroxynitrite to prevent DNA and lipoprotein damage induced by this pathological reactive nitrogen species.

Generation and characterization of a novel tetravalent bispecific antibody that binds to hepatitis B virus surface antigens

Hepatitis B virus (HBV) infection is a worldwide public health problem affecting about 350 million people. HBV envelope contains three surface antigens, called pre-S1, pre-S2 and S. For the prophylaxis of HBV infection, only an anti-S monoclonal antibody was tested for the protective efficacy against HBV infection, but it was shown to be incomplete. In addition, some immune escape mutants carrying mutations on the S antigen were reported. Therefore, a multivalent bispecific antibody rather than a single monoclonal antibody would be more beneficial for the prophylaxis of HBV infection. We have generated a novel tetravalent bispecific antibody with two binding sites for each of the S and pre-S2 antigens. Each of the antigen-binding sites was composed of a single-chain Fv (ScFv). The tetravalent antibody was generated by constructing a single gene encoding a single-chain protein. This protein consisted of an anti-S ScFv whose carboxyl end was tethered, through a 45 amino acid linker, to the amino terminus of anti-preS2 ScFv that in turn was joined to the hinge region of human gamma1 constant region. The single-chain protein was expressed in Chinese hamster ovary cells and secreted in culture supernatant as a homodimeric molecule. The tetravalent bispecific antibody showed both anti-S and anti-pre-S2 binding activities. In addition, the binding affinity of the bispecific antiboy for HBV particles was greater than that of either parental antibody. The tetravalent bispecific antibody is a potentially useful reagent for the prevention and treatment of HBV infection.

A humanized anti--4-1BB monoclonal antibody suppresses antigen-induced humoral immune response in nonhuman primates

The interaction of 4-1BB and its ligand plays an important role in the regulation of T-cell-mediated immune responses. In this study, the authors examined the effect of a humanized anti--4-1BB monoclonal antibody (H4B4) on ovalbumin-induced immune responses in baboons. Previously, a mouse monoclonal antibody, 4B4 against the human 4-1BB molecule, was generated and characterized. Based on this antibody, a humanized version of 4B4 monoclonal antibody was constructed and the resultant antibody, H4B4, showed full recovery of the binding activity of the original antibody 4B4: a 1.5-fold increase in affinity for 4-1BB. In addition, H4B4 mediated antibody-dependent cellular cytotoxicity of activated human peripheral blood T cells and CEM cells in a dose-dependent manner. Weekly administration of H4B4 at doses of 1 or 4 mg/kg could suppress immunoglobulin G production against ovalbumin. This was not a result of the overall immune suppression, because the numbers of B and T cells and the total immunoglobulin G production were not altered during treatment with H4B4. These findings suggest that treatment with H4B4 may be a valid therapeutic approach to control unwanted immune responses in persons with autoimmune diseases.

Suppression by metallothionein of doxorubicin-induced cardiomyocyte apoptosis through inhibition of p38 mitogen-activated protein kinases

Cardiomyopathy induced by doxorubicin (DOX) has long been a major impediment of clinical applications of this effective anticancer agent. Previous studies have shown that cardiac-specific metallothionein (MT)-overexpressing transgenic mice are highly resistant to DOX-induced cardiotoxicity. To investigate cellular and molecular mechanisms by which MT participates in this cytoprotection, transgenic mice containing high levels of cardiac MT and non-transgenic controls were treated intraperitoneally with DOX at a single dose of 15 mg/kg and sacrificed on the 4th day after treatment. Myocardial apoptosis was detected by a terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling assay and confirmed by electron microscopy of immunogold staining of apoptotic nuclei. Dual staining of cardiac alpha-sarcomeric actin using an immunohistochemical method further identified apoptotic myocytes. Apoptosis was significantly inhibited in the transgenic myocardium. The anti-apoptotic effect of MT was further revealed in primary cultures of neonatal mouse cardiomyocytes. Furthermore, DOX activated p38 mitogen-activated protein kinase (MAPK), which was critically involved in the apoptotic process, as demonstrated by inhibition of DOX-induced apoptosis by a p38-specific inhibitor, SB203580. Both DOX-induced p38 MAPK activation and apoptosis were dramatically inhibited in the transgenic cardiomyocytes. The results thus demonstrate that DOX induces apoptosis in cardiomyocytes both in vivo and in vitro and MT suppresses this effect through at least in part inhibition of p38 MAPK activation.

Metallothionein inhibits myocardial apoptosis in copper-deficient mice: role of atrial natriuretic peptide

Dietary copper restriction causes heart hypertrophy in animal models. Several studies have indicated that this cardiomyopathy is mediated by oxidative stress. Metallothionein (MT), a low molecular weight and cysteine-rich protein, functions in protecting the heart from oxidative injury. We therefore used a cardiac-specific MT-overexpressing transgenic mouse model to test the hypothesis that MT inhibits copper deficiency-induced heart hypertrophy. Dams of both transgenic pups and non-transgenic littermates were fed a copper-adequate or copper-deficient diet, starting on the fourth day post-delivery, and the weanling mice were continued on the dams' diets until they were killed. Heart hypertrophy developed in copper-deficient pups by the fourth week of the combined pre- and post-weaning feeding and aggressively progressed until the end of the experiment (6 weeks). MT overexpression did not prevent the occurrence of heart hypertrophy, but inhibited the progression of this cardiomyopathy, which correlated with its suppression of cardiac lipid peroxidation. Corresponding to the progression of heart hypertrophy, myocardial apoptosis and atrial natriuretic peptide (ANP) production in the left ventricle were detected in non-transgenic copper-deficient mice; these effects were significantly suppressed in transgenic copper-deficient mice. Measurement of apoptosis by TUNEL assay and Annexin V-FITC confocal microscopy in primary cultures of cardiomyocytes revealed that ANP was largely responsible for the myocyte apoptosis and that MT inhibited ANP-induced apoptosis. The data clearly demonstrate that elevation of MT in the heart inhibits oxidative injury and suppresses the progression of heart hypertrophy in copper deficiency, although it does not block its initiation. The results suggest that MT inhibits the transition from heart hypertrophy to failure by suppressing apoptosis through inhibition of both cardiac ANP production and its apoptotic effect.

Immunocytochemical localization of metallothionein and its relation to doxorubicin toxicity in transgenic mouse heart

Previous studies using a cardiac-specific metallothionein-overexpressing transgenic mouse model have demonstrated that metallothionein protects the heart from doxorubicin toxicity. The present study was undertaken to determine cellular and subcellular distribution of metallothionein and located the antioxidant action of this protein in the transgenic heart. Using light microscopic immunoperoxidase method, it was identified that the overexpressed metallothionein is localized exclusively in cardiomyocytes. The electron microscopic immunogold method revealed that elevated metallothionein is in nucleus, myofibers, and sarcoplasm. In contrast with these distributions, metallothionein in nontransgenic myocardium was undetectable by immunoperoxidase light microscopy and was seldom found in nucleus and myofibers by immunogold electron microscopy. Treatment with doxorubicin induced cytoplasmic vacuolization and severe damages in myofilaments and nucleus in nontransgenic myocardium. The most prominent injury, however, occurred in mitochondria, including striking size and shape changes, focal swelling and loss of cristae. These damages were rarely found in the doxorubicin-treated transgenic myocardium. In particular, the internal morphology of mitochondria was maintained essentially normal, although metallothionein was not localized in this compartment in transgenic hearts. This study thus demonstrates that although the subcellularly localized action of metallothionein is important, it also plays a significant role in protection against oxidative injury by doxorubicin in remote organelles.

Cellular and subcellular localization of catalase in the heart of transgenic mice

Previous studies have described a cardiac-specific, catalase-overexpressing transgenic mouse model that was used to study myocardial oxidative injury. This study was undertaken to demonstrate cellular and subcellular localization of catalase in the hearts of transgenic mice. By the light microscopic immunoperoxidase method, we found that the overexpressed catalase was exclusively localized in cardiomyocytes. The ratios of immunoreactive cardiomyocytes in the heart were quite different among three transgenic lines examined but agreed with the elevated levels of catalase activity. In the cardiac blood vessels, positive cells were found in the walls of pulmonary veins and the vena cava, which consist of cardiomyocytes, but not in the pulmonary arteries, aorta, or cardiac valves. The electron microscopic immunogold method revealed that the elevated catalase was in sarcoplasm, nucleus, and peroxisomes, but not in mitochondria. In contrast to these distributions, catalase in the non-transgenic cardiomyocytes was in peroxisomes only. In addition, the number and size of peroxisomes in the transgenic cardiomyocytes were markedly increased, but no other ultrastructural changes were observed in comparison with those of non-transgenic mice. These results demonstrated that the elevated catalase in transgenic mouse heart is localized in cardiomyocytes and is distributed to peroxisomal and extraperoxisomal, but not mitochondrial, compartments.