Actigraphy measures show sleep improvement after parathyroidectomy for primary hyperparathyroidism

IMPORTANCE

The symptoms of primary hyperparathyroidism are often subtle, such as fatigue, mood changes, and sleep disturbances. After parathyroidectomy, patients often report improvement in sleep and mood; however, objective data supporting these improvements is lacking.

OBJECTIVE

This prospective study uses standard measures to objectively and subjectively assess sleep in patients with primary hyperparathyroidism before and after parathyroidectomy.

DESIGN

A longitudinal prospective study was conducted over three one-week-long periods: pre-parathyroidectomy, 1-week post-parathyroidectomy, and three months post-parathyroidectomy. During each time point, patients wore an actigraphy device, recorded a sleep diary, and completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and Depression Anxiety Stress Scale (DASS). Statistical analysis was performed using repeated measures models to compare the average measures among the three time points and test for trends over time.

SETTING

Single institution, tertiary care center.

PARTICIPANTS

Patients with primary hyperparathyroidism from ages 18 to 89 years old.

EXPOSURE

Parathyroidectomy between September 2020 and January 2024.

MAIN OUTCOMES AND MEASURES

Actigraphy data, consensus sleep diary, Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Depression Anxiety Stress Scales - 21 Items (DASS).

RESULTS

Thirty-six patients were enrolled, and 34 patients completed the study. Actigraphy data showed a significant negative trend in average sleep latency (p = 0.045) and average time in bed (p = 0.046). Sleep diary data showed additional differences in the number of awakenings (p = 0.002), wake after sleep onset (p < 0.001), sleep quality (p < 0.001), and sleep efficiency (p = 0.02) among the three time points and/or as a significant negative trend. PSQI and ISI scores were significantly different among the three time points (p = 0.002 and p < 0.001, respectively) and also declined significantly over time (p = 0.008 and p = 0.007, respectively). DASS depression, anxiety, and stress scores were significantly different among the three time points (p < 0.001, p = 0.01, and p < 0.001, respectively), and stress also declined significantly over time (p = 0.005).

CONCLUSION AND RELEVANCE

This study represents the most extensive prospective study demonstrating objective and subjective sleep and mood improvement in patients with primary hyperparathyroidism after parathyroidectomy.

Machine learning analysis of online patient questions regarding breast reconstruction

BACKGROUND

Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction.

METHODS

Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers.

RESULTS

522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?"

CONCLUSIONS

Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

Elective Neck Dissection for cT1-4 N0M0 Head and Neck Verrucous Carcinoma

OBJECTIVE

To investigate the survival benefit of elective neck dissection (END) over neck observation in cT1-4 N0M0 head and neck verrucous carcinoma (HNVC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 National Cancer Database.

METHODS

Patients with surgically resected cT1-4 N0M0 HNVC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were utilized.

RESULTS

Of 1015 patients satisfying inclusion criteria, 223 (22.0%) underwent END. The majority of patients were male (55.4%) and white (91.0%) with disease of the oral cavity (67.6%) classified as low grade (90.0%) and cT1-2 (81.8%). The minority of ENDs (4.0%) detected occult nodal metastases. The rate of END increased from 2006 to 2017 for both cT1-2 (16.3% vs 22.0%, p = .126, R2  = 0.405) and cT3-4 (41.7% vs 70.0%, p = .424, R2  = 0.232) disease but these trends were not statistically significant. Independent predictors of undergoing END included treatment at an academic facility (adjusted odds ratio [aOR]: 1.75, 95% confidence interval [CI]: 1.19-2.55), cT3-4 disease (aOR: 3.31, 95% CI: 2.16-5.07), and tumor diameter (aOR: 1.09, 95% CI: 1.01-1.19) (p < 0.05). The 5-year overall survival (OS) of patients treated with and without END was 71.3% and 70.6%, respectively (p = .661). END did not significantly reduce the 5-year hazard of death (adjusted hazard ratio: 1.25, 95% CI: 0.91-1.71, p = .172). END did not significantly improve 5-year OS in univariate and multivariate analyses stratified by several patient, facility, tumor, and treatment characteristics.

CONCLUSION

END does not confer an appreciable survival benefit in HNVC, even after stratifying univariate and multivariate analyses by several patient, facility, tumor, and treatment characteristics.

LEVEL OF EVIDENCE

Level 4.

Facility volume and survival: Human papilloma virus positive oropharyngeal squamous cell carcinoma

BACKGROUND

To analyze the impact of facility volume on survival for human papilloma virus positive oropharyngeal squamous cell carcinoma (HPV+ OPSCC) patients.

METHODS

Patients treated for HPV+ OPSCC from 2010 to 2017 were queried from the National Cancer Database. Facilities of average annual case volume <50th percentile were categorized as low-volume (LV) and >95th percentile as high-volume (HV).

RESULTS

11,546 were included, with 10,305 patients (89.3 %) treated at LV and 1241 (10.7 %) at HV facilities. A greater proportion of cases involving resection of base of tongue and lingual tonsil were treated at HV (30.3 %) compared to LV (22.3 %) facilities (p < 0.001). Patients treated at a HV facility had greater percentage of clinical T4 (11.2 % vs. 8.6 %, p = 0.001) and N+ disease (90.5 % vs. 85.7 %, p < 0.001) patients. Survival analysis showed no statistically significant difference between five-year overall survival rates by facility volume (p = 0.388) for all patients. On multivariable analysis, facility volume was not associated with survival (HR: 0.968 [0.758-1.235], p = 0.791). These trends were found for both patients undergoing primary surgery or chemoradiotherapy.

CONCLUSION

Our data indicates that patients with HPV+ OPSCC do not experience a survival benefit with treatment at HV facility, suggesting these patients may be adequately treated at LV centers.

Effect of Hospital Safety Net Burden on Survival for Patients With Sinonasal Squamous Cell Carcinoma

OBJECTIVE

To examine factors associated with hospital safety net burden and its impact on survival for patients with sinonasal squamous cell carcinoma (SNSCC).

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database from 2004 to 2016.

METHODS

SNSCC cases were identified in the National Cancer Database. Hospital safety net burden was defined by percentage of uninsured/Medicaid patients treated, namely ≤25% for low-burden hospitals, 26% to 75% for medium-burden hospitals, and >75% for high-burden hospitals (HBHs). Univariate and multivariate analyses were used to investigate patient demographics, clinical characteristics, and overall survival.

RESULTS

An overall 6556 SNSCC cases were identified, with 1807 (27.6%) patients treated at low-burden hospitals, 3314 (50.5%) at medium-burden hospitals, and 1435 (21.9%) at HBHs. On multivariate analysis, Black race (odds ratio [OR], 1.39; 95% CI, 1.028-1.868), maxillary sinus primary site (OR, 1.31; 95% CI, 1.036-1.643), treatment at an academic/research program (OR, 20.63; 95% CI, 8.868-47.980), and treatment at a higher-volume facility (P < .001) resulted in increased odds of being treated at HBHs. Patients with grade III/IV tumor (OR, 0.70; 95% CI, 0.513-0.949), higher income (P < .05), or treatment modalities other than surgery alone (P < .05) had lower odds. Survival analysis showed that hospital safety net burden status was not significantly associated with overall survival (log-rank P = .727).

CONCLUSION

In patients with SNSCC, certain clinicopathologic factors, including Black race, lower income, treatment at an academic/research program, and treatment at facilities in the West region, were associated with treatment at HBHs. Hospital safety net burden status was not associated with differences in overall survival.

LEVEL OF EVIDENCE: 4

Impact of Facility Volume on Patient Safety Indicator Events After Transsphenoidal Pituitary Surgery

OBJECTIVES

To investigate the impact of facility volume on Patient Safety Indicator (PSI) events following transsphenoidal pituitary surgery (TSPS).

STUDY DESIGN

Retrospective database review.

SETTING

National Inpatient Sample database (2003-2011).

METHODS

The National Inpatient Sample was queried for TSPS cases from 2003 to 2011. Facility volume was defined by tertile of average annual number of TSPS procedures performed. PSIs, based on in-hospital complications identified by the Agency of Healthcare Research and Quality, and poor outcomes, such as mortality and tracheostomy, were analyzed.

RESULTS

An overall 16,039 cases were included: 804 had ≥1 PSI and 15,235 had none. A greater proportion of male to female (5.8% vs 4.3%) and Black to White (7.0% vs 4.5%) patients experienced PSIs. There was an increased likelihood of poor outcome (odds ratio [OR], 3.1 [95% CI, 2.5-3.7]; P < .001) and mortality (OR, 30.1 [95% CI, 18.5-48.8]; P < .001) with a PSI. The incidence rates of PSIs at low-, intermediate-, and high-volume facilities were 5.7%, 5.1%, and 4.2%, respectively. Odds of poor outcome with PSIs were greater at low-volume facilities (OR, 3.3 [95% CI, 2.4-4.4]; P < .001) vs intermediate (OR, 3.1 [95% CI, 2.1-4.2]; P < .001) and high (OR, 2.5 [95% CI, 1.7-3.8]; P < .001). Odds of mortality with PSIs were greater at high-volume facilities (OR, 43.0 [95% CI, 14.3-129.4]; P < .001) vs intermediate (OR, 40.0 [95% CI, 18.5-86.4]; P < .001) and low (OR, 17.3 [95% CI, 8.0-37.7]; P < .001).

CONCLUSION

PSIs were associated with a higher likelihood of poor outcome and mortality following TSPS. Patients who experienced PSIs had a lower risk of poor outcome but increased mortality at higher-volume facilities.

Analysis of Care and Outcomes for Epistaxis Weekend Admissions

OBJECTIVES

To study differences in care of patients admitted for epistaxis during the weekend compared to the weekday.

STUDY DESIGN

Retrospective database review.

SETTING

2003 to 2014 National Inpatient Sample.

METHODS

Patients admitted for a primary diagnosis of epistaxis were extracted from the National Inpatient Sample from 2003 to 2014. Univariate and multivariate analyses were applied to assess differences in patient demographics, clinical characteristics, treatment, and outcomes between weekend and weekday admissions.

RESULTS

A total of 39,329 cases were included in our study cohort, with 28,458 weekday admissions and 10,892 weekend admissions. There was no significant difference in patient race, gender, insurance status, hospital ownership status, or location between weekend and weekday admissions (p > .05). Most weekend admissions were emergent (82.2%) and were treated with packing (51.8%). Upon performing logistic regression, the likelihood of emergent admission (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.32-1.51, p < .001) and prolonged length of stay (OR 1.11, 95% CI 1.05-1.17, p < .001) was higher for weekend admissions versus weekday admissions. Moreover, odds of packing for epistaxis were significantly higher (OR 1.14, 95% CI 1.09-1.19, p < .001) on the weekend, while odds of ligation (OR 0.88, 95% CI 0.80-0.97, p = .013) and endovascular arterial embolization (OR 0.74, 95% CI 0.65-0.84, p < .001) were lower. There were no significant differences in in-hospital mortality, patient discharge disposition, and total hospital charges (p > .05).

CONCLUSION

Patients primarily admitted for epistaxis over the weekend were more likely to be emergent, experienced prolonged length of stay, and be treated nonoperatively with packing, than weekday admissions. No significant differences in patient insurance or hospital ownership were identified.

LEVEL OF EVIDENCE: 4

Use of artificial intelligence for the diagnosis of cholesteatoma

Objectives

Accurate diagnosis of cholesteatomas is crucial. However, cholesteatomas can easily be missed in routine otoscopic exams. Convolutional neural networks (CNNs) have performed well in medical image classification, so we evaluated their use for detecting cholesteatomas in otoscopic images.

Study Design

Design and evaluation of artificial intelligence driven workflow for cholesteatoma diagnosis.

Methods

Otoscopic images collected from the faculty practice of the senior author were deidentified and labeled by the senior author as cholesteatoma, abnormal non-cholesteatoma, or normal. An image classification workflow was developed to automatically differentiate cholesteatomas from other possible tympanic membrane appearances. Eight pretrained CNNs were trained on our otoscopic images, then tested on a withheld subset of images to evaluate their final performance. CNN intermediate activations were also extracted to visualize important image features.

Results

A total of 834 otoscopic images were collected, further categorized into 197 cholesteatoma, 457 abnormal non-cholesteatoma, and 180 normal. Final trained CNNs demonstrated strong performance, achieving accuracies of 83.8%-98.5% for differentiating cholesteatoma from normal, 75.6%-90.1% for differentiating cholesteatoma from abnormal non-cholesteatoma, and 87.0%-90.4% for differentiating cholesteatoma from non-cholesteatoma (abnormal non-cholesteatoma + normal). DenseNet201 (100% sensitivity, 97.1% specificity), NASNetLarge (100% sensitivity, 88.2% specificity), and MobileNetV2 (94.1% sensitivity, 100% specificity) were among the best performing CNNs in distinguishing cholesteatoma versus normal. Visualization of intermediate activations showed robust detection of relevant image features by the CNNs.

Conclusion

While further refinement and more training images are needed to improve performance, artificial intelligence-driven analysis of otoscopic images shows great promise as a diagnostic tool for detecting cholesteatomas.

Level of Evidence

3.

A machine learning analysis of patient concerns regarding mastopexy

BACKGROUND

Social media plays an important role in connecting patients and plastic surgeons. We utilized patient inquiries regarding mastopexy from an online social media site to determine the most prevalent patient concerns, while employing a machine-learning algorithm to generate the questions representative of the dataset.

OBJECTIVE

This data allow plastic surgeons to better tailor their preoperative consultations to address common concerns, set realistic expectations, and improve overall satisfaction.

METHODS

A total of 2,011 inquiries from the mastopexy section of Realself.com were obtained using an open-source web crawler. Each inquiry was manually categorized as preoperative or postoperative and classified into subcategories based upon the free text entry. Lastly, questions were analyzed using machine learning to determine ten questions most representative of the inquiry pool.

RESULTS

Of the 2,011 inquiries analyzed, 52.91% were preoperative and 47.09% were postoperative. Most preoperative questions asked about procedure eligibility (309, 29.04%), surgical techniques and logistics (260, 24.44%), and the best type of breast lift for the user (259, 24.34%). Among postoperative questions, questions regarding appearance were the most common (491, 51.85%), followed by symptoms after surgery (197, 19.75%) and behavior allowed/disallowed (145, 15.31%). Appearance was further subcategorized with the most common categories being appearance of the nipple (98, 19.86%), skin discoloration (88, 17.92%), and scarring (74, 15.07%).

CONCLUSION

By utilizing the data that social media websites, like Realself.com, provide, plastic surgeons can better understand common patient concerns. This data aid in optimizing the preoperative consultation process to address the common concerns, recalibrate unrealistic expectations, and improve overall satisfaction.

Racial Disparities in Charges, Length of Stay, and Complications Following Adult Inpatient Epistaxis Treatment

BACKGROUND

Although recent studies have identified an association between race and adverse outcomes in head and neck surgeries, there are limited data examining the impact of racial disparities on adult inpatient outcomes following epistaxis management procedures.

OBJECTIVE

To analyze the association between race and adverse outcomes in hospitalized patients undergoing epistaxis treatment.

METHODS

This retrospective cohort analysis utilized the 2003 to 2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify cases with a primary diagnosis of epistaxis that underwent a procedure for epistaxis control. Cases with missing data were excluded. Higher total charges and prolonged length of stay (LOS) were indicated by values greater than the 75th percentile. Demographics, hospital characteristics, Elixhauser comorbidity score, and complications were compared among race cohorts using univariate chi-square analysis and one-way analysis of variance (ANOVA). The independent effect of race on adverse outcomes was analyzed using multivariate binary logistic regression while adjusting for the aforementioned variables.

RESULTS

Of the 83 356 cases of epistaxis included, 80.3% were White, 12.5% Black, and 7.2% Hispanic. Black patients had increased odds of urinary/renal complications (odds ratio [OR] 2.148, 95% confidence interval [CI] 1.797-2.569, P < .001) compared to White patients. Additionally, Black patients experienced higher odds of prolonged LOS (OR 1.227, 95% CI 1.101-1.367, P < .001) and higher total charges (OR 1.257, 95% CI 1.109-1.426, P < .001) compared to White patients. Similarly, Hispanic patients were more likely to experience urinary/renal complications (OR 1.605, 95% CI 1.244-2.071, P < .001), higher total charges (OR 1.519, 95% CI 1.302-1.772, P < .001), and prolonged LOS (OR 1.157, 95% CI 1.007-1.331, P = .040) compared to White patients.

CONCLUSION

Race is an important factor associated with an increased incidence of complications in hospitalized patients treated for epistaxis.

Analysis of the Treatment and Survival of Sinonasal Extramedullary Plasmacytoma

BACKGROUND

While extramedullary plasmacytomas are infrequently encountered plasma cell malignancies, most cases occur in the head and neck, with a predilection for the sinonasal cavity. Due to the rarity of this disease, the majority of studies on sinonasal extramedullary plasmacytoma (SN-EMP) are case reports or small retrospective case series.

OBJECTIVE

To investigate the impact of patient, disease, and treatment factors on the survival of patients with SN-EMP.

METHODS

The National Cancer Database was queried for all patients with SN-EMP between 2004-2016 (N = 381 cases). Univariate and multivariate analyses were used to examine patient demographics, tumor characteristics, and survival.

RESULTS

The majority of SN-EMP patients were over 60 years old (57.0%), male (69.8%), and white (86.2%). The most common treatment modality was radiotherapy alone (38.6%), followed by surgery plus radiotherapy (37.8%). Five-year overall survival was 74.0% and median survival was 9.1 years. Accounting for patient demographics and tumor characteristics in a multivariate model, the following groups had worse prognosis: 60 and older (HR 1.99, p = 0.031) and frontal sinus primary site (HR 11.56, p = 0.001). Patients who received no treatment (HR 3.89, p = 0.013), chemotherapy alone (HR 5.57, p = 0.008) or radiotherapy plus chemotherapy (HR 2.82, p = 0.005) had significantly lower survival than patients who received radiotherapy alone. Patients who received surgery with radiotherapy (HR 0.57, p = 0.039) had significantly higher survival than patients who received radiotherapy alone.

CONCLUSION

In patients with SN-EMP five-year overall survival was found to be 74.0% with decreased survival associated with a frontal sinus primary site and being aged 60 or older. Patients receiving no treatment, chemotherapy alone, or radiotherapy with chemotherapy was associated with lower survival. Receiving surgery plus radiotherapy was associated with the highest five-year overall survival.

Applying Machine Learning to Determine Popular Patient Questions About Mentoplasty on Social Media

PURPOSE

Patient satisfaction in esthetic surgery often necessitates synergy between patient and physician goals. The authors aim to characterize patient questions before and after mentoplasty to reflect the patient perspective and enhance the physician-patient relationship.

METHODS

Mentoplasty reviews were gathered from Realself.com using an automated web crawler. Questions were defined as preoperative or postoperative. Each question was reviewed and characterized by the authors into general categories to best reflect the overall theme of the question. A machine learning approach was utilized to create a list of the most common patient questions, asked both preoperatively and postoperatively.

RESULTS

A total of 2,012 questions were collected. Of these, 1,708 (84.9%) and 304 (15.1%) preoperative and postoperative questions, respectively. The primary category for patients preoperatively was "eligibility for surgery" (86.3%), followed by "surgical techniques and logistics" (5.4%) and "cost" (5.4%). Of the postoperative questions, the most common questions were about "options to revise surgery" (44.1%), "symptoms after surgery" (27.0%), and "appearance" (26.3%). Our machine learning approach generated the 10 most common pre- and postoperative questions about mentoplasty. The majority of preoperative questions dealt with potential surgical indications, while most postoperative questions principally addressed appearance.

CONCLUSIONS

The majority of mentoplasty patient questions were preoperative and asked about eligibility of surgery. Our study also found a significant proportion of postoperative questions inquired about revision, suggesting a small but nontrivial subset of patients highly dissatisfied with their results. Our 10 most common preoperative and postoperative question handout can help better inform physicians about the patient perspective on mentoplasty throughout their surgical course. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Assessing Patient Satisfaction Following Blepharoplasty Using Social Media Reviews

BACKGROUND

Because patient satisfaction is a significant qualitative consideration in measuring aesthetic surgery outcome, it is important to characterize the individual factors that shape the patient perspective about blepharoplasty.

OBJECTIVES

This study analyzed reviews by blepharoplasty patients on the aesthetic surgery social media platform RealSelf.com to determine which aspects of the surgical process have the most significant impact on patient satisfaction.

METHODS

Blepharoplasty reviews were gathered from RealSelf.com with an automated web crawler. These reviews were characterized as positive or negative, then given a specific category that more specifically defined the theme of the review. Additional variables, including the specialty of the reviewed physician and any patient self-reported ratings, were documented.

RESULTS

A total of 1991 reviews pertaining to blepharoplasty were collected. Among reviews with self-reported "worth it" ratings, 93.5% were positive. Following categorization of all reviews, 1865 (93.7%) were positive and 126 (6.3%) were negative. Of the positive reviews, the most common overall themes were bedside manner (n = 899, 48.2%), aesthetic result (n = 859, 46.1%), and overall comfort (n = 58, 3.1%). Among negative reviews, most pertained to aesthetic result (n = 100, 79.4%), and bedside manner (n = 14, 11.1%). The most frequently encountered physician specialties performing blepharoplasty were plastic surgery (n = 1101, 55.3%), ophthalmology (n = 634, 31.8%), and otolaryngology (n = 69, 3.5%).

CONCLUSIONS

The majority of reviews were positive. The most prominent factor driving positive reviews was bedside manner, followed by aesthetic results. Negative reviews were most frequently attributed to suboptimal aesthetic results. Most blepharoplasties in our study cohort were performed by plastic and oculoplastic surgeons.

Impact of Social Determinants of Health on Stereotactic Radiotherapy for Vestibular Schwannoma

OBJECTIVES/HYPOTHESIS

Linear accelerator (LINAC) and Gamma Knife (GK) are common stereotactic radiation therapies for treating vestibular schwannoma (VS). There is currently limited literature examining specific demographic and socioeconomic factors, which influence the type of stereotactic radiation therapy a patient with VS receives.

STUDY DESIGN

Retrospective database review.

METHODS

The National Cancer Database was queried for cases of VS between 2004 and 2016. Patient demographic characteristics were compared using chi-squared and t-tests between GK and LINAC treated groups. Multivariate regression analysis was performed to assess predictors of stereotactic radiation therapy received.

RESULTS

Of the 6,208 included patients, 5,306 (85.5%) received GK and 902 (14.5%) received LINAC. The mean age of GK patients was significantly lower than that of LINAC patients (58.0 vs. 59.7, P < .001). Individuals treated with GK had greater proportions of private insurance (P < .001) and incomes greater than $63,332 (P = .003). A greater proportion of GK patients were treated in academic centers (P < .001), in high-volume facilities (P < .001), in metropolitan areas (P < .001), and in the Northeastern United States (P < .001). On multivariate logistic regression analysis, region, metropolitan area, facility type, tumor size, and distance traveled by patients independently predict receipt of GK versus LINAC.

CONCLUSION

Differences in patient demographics and other social determinants of health influence choice of GK versus LINAC therapy for VS patients. Future studies focused on addressing barriers to care, which may influence postprocedural quality of life and clinical outcomes associated with these two treatments are necessary to better understand the impact of these social differences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Trends in HPV Testing for Patients With Sinonasal Squamous Cell Carcinoma: A National Analysis

OBJECTIVE

The objective of this study was to analyze national trends in human papillomavirus (HPV) testing for patients diagnosed with sinonasal squamous cell carcinoma (SNSCC).

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database (2010-2016).

METHODS

Cases from 2010 to 2016 with a primary SNSCC diagnosis and known HPV testing status were extracted from the National Cancer Database. Univariate and multivariate analyses were then performed to assess differences in socioeconomic, hospital, and tumor characteristics between tested and nontested patients.

RESULTS

A total of 2308 SNSCC cases were collected, with 1210 (52.4%) HPV tested and 1098 (47.6%) not tested. On univariate analyses, patient age, insurance, income quartile, population density, treatment facility location, and tumor grade were significantly associated with HPV testing status. After multivariate logistic regression modeling, living in a suburban area had lower odds of HPV testing as compared with living in urban areas (odds ratio, 0.74 [95% CI, 0.55-0.99]; P = .041), while tumor grade III/IV had higher odds than grade I (odds ratio, 1.73 [95% CI, 1.29-2.33]; P < .001). HPV-tested patients had a similar 5-year overall survival to nontested patients (48.3% vs 45.3%, log-rank P = .405). A sharp increase in HPV testing rates was observed after 2010 (P < .001).

CONCLUSION

Among patients with SNSCC, those with high-grade tumors were more likely to be tested for HPV, while patients with a suburban area of residence were less likely. Additionally, there was no significant survival benefit to HPV testing, with tested and nontested groups having similar overall survival.

LEVEL OF EVIDENCE

4.

Inpatient Sinus Surgery Patient Morbidity and Outcomes: A National Analysis

OBJECTIVES/HYPOTHESIS

To investigate the morbidity and mortality of patients undergoing endoscopic sinus surgery (ESS) in the inpatient setting.

STUDY DESIGN

Retrospective database review.

METHODS

The Nationwide Inpatient Sample was queried for all ESS between 2008 and 2014. Using All Patients Refined Diagnosis Related Groups (APR-DRG) codes, cases with APR-DRG codes under Major Diagnostic Category 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat) were designated as patients with primary otolaryngology diagnoses undergoing ESS (ORL), and all other codes were designated as patients with non-otolaryngology pathologies as their primary reason for admission but undergoing ESS (non-ORL). A univariate analysis and a logistic regression were used to compare patient demographics, comorbidities, disease severity, and mortality.

RESULTS

There were 8,305 ORL patients and 6,342 non-ORL patients. ORL patients were more likely to be elective admissions (61.3% vs. 48.5%, P < .001), have a deviated nasal septum (17.9% vs. 12.3%, P < .001), nasal polyps (15.8% vs. 5.0%, P < .001), obstructive sleep apnea (10.7% vs. 5.2%, P < .001), and pulmonary disease (15.9% vs. 10.5%, P < .001). Non-ORL patients had a higher likelihood of in-hospital mortality (odds ratio [OR] 6.22, 95% confidence interval [CI] 3.29-11.78, P < .001), length of stay in the highest quartile (OR 2.43, 95% CI 2.16-2.74, P < .001), and a higher proportion had APR-DRG subclasses indicating extreme severity of illness (19.3% vs. 4.3%, P < .001) or extreme risk of mortality (12.5% vs. 2.0%, P < .001).

CONCLUSION

Patients undergoing ESS in the inpatient setting have a higher than expected mortality rate which can be associated with a non-otolaryngology pathology as the primary reason for their admission.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Characterizing Patient Questions Before and After Rhinoplasty on Social Media: A Big Data Approach

BACKGROUND

As an aesthetic surgery, a successful rhinoplasty is often assessed by patient satisfaction, subject to a diverse array of qualitative factors including patient expectations and happiness with care provided. While substantial effort has been dedicated to understanding patients' post-operative concerns, addressing patients' pre-operative questions has been comparatively less studied. This study analysed pre- and post-operative questions about rhinoplasty on social media to gain insights into patients' concerns and develop targeted educational material.

METHODS

The most viewed rhinoplasty questions on Realself.com, a social media platform for discussions about cosmetic surgeries, were collected and analysed. Questions were then stratified into pre- and post-operative and further assigned categories based on common topics found in the data. Using a machine learning approach, the most common pre- and post-operative questions were determined.

RESULTS

2014 rhinoplasty questions were collected in total, with 957 pre-operative and 1057 post-operative. The most commonly asked pre-operative questions were about appearance (n = 441, 46.1%), function (n = 102, 10.7%), and cost (n = 94, 9.8%). The most commonly asked post-operative questions were about appearance (n = 502, 47.5%), behaviour allowed/disallowed (n = 283, 26.8%), and symptoms after surgery (n = 235, 22.2%). An educational handout with the 10 most common pre- and post-operative questions was developed using machine learning analysis, with the majority of questions about appearance.

CONCLUSIONS

Patients primarily expressed concern about appearance when asking questions about rhinoplasty on social media, along with other aspects of their pre- and post-operative course. The educational handout developed by this study can be applied to address commonly asked patient questions during pre-operative education.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Exploratory analysis on the association of mental health disorders with in-hospital postoperative complications and mortality in head and neck cancer surgery

BACKGROUND

The objective was to assess the association of mental health disorders with in-hospital complication and mortality rates in patients undergoing head and neck cancer surgery.

METHODS

In this exploratory retrospective study, the Nationwide Inpatient Sample was queried from 2003 to 2014 for all patients with a diagnosis of head and neck cancer who underwent surgery. Univariate cross-tabulation, logistic regression, and propensity score matching (PSM) were used to compare demographics, procedure-related variables, and in-hospital postoperative complications and mortality between patients with and without selected comorbid mental health disorders.

RESULTS

Of 39 600 included patients, 3390 (8.6%) had a selected comorbid mental health disorder diagnosis. After PSM, patients with selected mental health disorders had increased risk of overall medical complications on multivariable analysis (OR 1.28 [CI 1.12-1.46], P < 0.001) but not overall surgical complications or mortality.

CONCLUSIONS

Patients with a mental health disorder diagnosis have increased risk of in-hospital medical, certain surgical, and total complications.

Extranodal Extension as an Indicator for Sinonasal Squamous Cell Carcinoma Prognosis

OBJECTIVE

Although extranodal extension (ENE) is a known indicator of poor prognosis for head and neck malignancies, its value as an indicator for sinonasal squamous cell carcinoma (SCC) has not been well characterized. This study seeks to assess the usefulness of ENE as a prognostic marker for sinonasal SCC.

STUDY DESIGN

Retrospective database review.

SETTING

National Cancer Database from 2010 to 2015.

METHODS

The National Cancer Database was queried from 2010 to 2015 for all patients with sinonasal SCC with available ENE status (n = 355). These cases were divided into those with pathologically confirmed ENE (n = 146) and those without ENE (n = 209). Univariate and multivariate analyses were used to examine survival differences and predictors of ENE status.

RESULTS

Most patients with ENE were ≥60 years old (61.7%), male (61.6%), and white (83.6%). Patients aged 60 to 69 and 80+ years were more likely to have ENE than those under 60 years (P < .05). Patients with ENE had worse 1-year overall survival than those without ENE (58.2% vs 70.8%, log-rank P = .008). After multivariate regression, however, there was no survival difference detected between ENE-positive and ENE-negative cases (hazard ratio, 1.14 [0.775-1.672], P = .508).

CONCLUSION

ENE status did not have a significant effect on survival in patients with sinonasal SCC. Thus, ENE alone may not necessarily be a helpful indicator for sinonasal SCC prognosis.

928. Barriers to Hepatitis C Elimination in an Urban Clinic Offering Integrated HIV/HCV Treatment

Background

Treatment of Hepatitis C virus (HCV) infection for persons with Human Immunodeficiency Virus (HIV) is dependent on consistent outpatient follow-up. We sought to identify factors that are associated with lower HCV treatment rates in HIV/HCV co-infected patients followed at Rutgers Infectious Diseases Practice (IDP), an integrated urban clinic.

Methods

Retrospective chart reviews were conducted for HIV/HCV co-infected patients treated at IDP in Newark, New Jersey between January 2017 and July 2018. We assessed factors associated with lack of HCV treatment in this practice. Data collected included demographics, HIV disease markers, liver function tests, HCV treatment history and response. Factors with p< 0.05, age and race were included in the multivariate analysis.

Results

We included 317 HIV/HCV co-infected patients with at least one visit between January 2017 and July 2018. Fifty eight percent were male, 79% black, 10% hispanic, 6% white, and 5% other; 21% reported heterosexual and 79% drug use (injection and non-injection) as their HIV risk factor The median CD4 was 522 cells/cm3, and 74% of patients had HIV viral load (VL) < 40 copies/ml. HCV treatment was started at IDP in 142 (45%) and of those 87% were cured. Data are awaited on 6%. Univariate analyses showed those not treated for HCV were more likely to be born female (57% vs 42%), have a CD4 count < 200 cells/cm3 (9% vs 27%), HIV VL >40 copies/ml (43% vs 17%), currently (58% vs 30%) or previously (89% vs 74%) used drugs, and have a higher APRI score (0.43 vs 1.6). Multivariate logistic regression showed that patients with untreated HCV were more likely to be female (OR 2.93, p< 0.001), report current drug/alcohol use (OR 2.43, p=0.004), and have HIV VL ≥40 copies/ml (OR 2.11, p< 0.001).

Table 1: Demographics/Risk Factors of Study Group

Table 2: Laboratory Studies

Table 3: Logistic Regression of Significant HCV Treatment Factors

Conclusion

Our results show that despite the availability of integrated treatment programs, concerted efforts need to be made for patients at high risk for not receiving HCV treatment, and who therefore remain at high risk for complications from HCV. Provider perceptions may play a role in withholding treatment for those with high HIV VL and current drug or alcohol use; whereas the rationale for why women were less likely to be treated is less clear and may be related to trauma and other factors not captured by this project that may negatively impact their access to care.

Disclosures

All Authors: No reported disclosures

High-quality thulium iron garnet films with tunable perpendicular magnetic anisotropy by off-axis sputtering - correlation between magnetic properties and film strain

Thulium iron garnet (TmIG) films with perpendicular magnetic anisotropy (PMA) were grown on gadolinium gallium garnet (GGG) (111) substrates by off-axis sputtering. High-resolution synchrotron radiation X-ray diffraction studies and spherical aberration-corrected scanning transmission electron microscope (Cs-corrected STEM) images showed the excellent crystallinity of the films and their sharp interface with GGG. Damping constant of TmIG thin film was determined to be 0.0133 by frequency-dependent ferromagnetic resonance (FMR) measurements. The saturation magnetization (Ms) and the coercive field (Hc) were obtained systematically as a function of the longitudinal distance (L) between the sputtering target and the substrate. A 170% enhancement of PMA field (H⊥) was achieved by tuning the film composition to increase the tensile strain. Moreover, current-induced magnetization switching on a Pt/TmIG structure was demonstrated with an ultra-low critical current density (jc) of 2.5 × 106 A/cm2, an order of magnitude smaller than the previously reported value. We were able to tune Ms, Hc and H⊥ to obtain an ultra-low jc of switching the magnetization, showing the great potential of sputtered TmIG films for spintronics.

Strongly exchange-coupled and surface-state-modulated magnetization dynamics in Bi2Se3/yttrium iron garnet heterostructures

Harnessing the spin–momentum locking of topological surface states in conjunction with magnetic materials is the first step to realize novel topological insulator-based devices. Here, we report strong interfacial coupling in Bi₂Se₃/yttrium iron garnet (YIG) bilayers manifested as large interfacial in-plane magnetic anisotropy (IMA) and enhancement of damping probed by ferromagnetic resonance. The interfacial IMA and damping enhancement reaches a maximum when the Bi₂Se₃ film approaches its two-dimensional limit, indicating that topological surface states play an important role in the magnetization dynamics of YIG. Temperature-dependent ferromagnetic resonance of Bi₂Se₃/YIG reveals signatures of the magnetic proximity effect of T_C as high as 180 K, an emerging low-temperature perpendicular magnetic anisotropy competing the high-temperature IMA, and an increasing exchange effective field of YIG steadily increasing toward low temperature. Our study sheds light on the effects of topological insulators on magnetization dynamics, essential for the development of topological insulator-based spintronic devices.

Understanding the effects of topological insulators on magnetization dynamics of adjacent magnetic materials is essential for novel spintronic devices. Here, Fanchiang et al. report thickness dependence of interfacial in-plane magnetic anisotropy and damping enhancement in Bi₂Se₃/yttrium iron garnet (YIG) bilayers, indicating an important role of topological surface states in the magnetization dynamics of YIG.

The complex interplay among bacterial motility and virulence factors in different Escherichia coli infections

Motility mediated by the flagella of Escherichia coli is important for the bacteria to move toward host cells. Here, we present the relationship among bacterial motility, virulence factors, antimicrobial susceptibility, and types of infection. A total of 231 clinical E. coli isolates from different infections were collected and analyzed. Higher-motility strains (motility diameter ≥6.6 mm) were more common in spontaneous bacterial peritonitis (SBP) (SBP 59 %, colonization 32 %, urinary tract infection 16 %, urosepsis 34 %, and biliary tract infection 29 %; p < 0.0001). Compared with the higher-motility group, there was a higher prevalence of afa and ompT genes (p = 0.0160 and p = 0.0497, respectively) in E. coli strains with lower motility. E. coli isolates with higher and lower motility were in different phylogenetic groups (p = 0.018), with a lower prevalence of A and B1 subgroups in higher-motility strains. Also, the patterns of virulence factors and antibiotic susceptibility of E. coli isolates derived from various infections were significantly different. This study demonstrates that the prevalence of higher-motility strains was greater in E. coli isolates from SBP compared to other types of infection. Various types of E. coli infection were associated with differences in bacterial motility, virulence factors, and antibiotic susceptibility. More bacterial virulence factors may be necessary for the development of extraintestinal infections caused by E. coli isolates with lower motility.

Clinical and microbiological characteristics of Klebsiella pneumoniae from community-acquired recurrent urinary tract infections

Understanding the pathogenesis of recurrent urinary tract infection (RUTI) and whether it is attributable to reinfection with a new strain or relapse with the primary infecting strain is of considerable importance. Because previous studies regarding community-acquired Klebsiella pneumoniae RUTI are inconclusive, we undertook this study to evaluate the characteristics of the host and the bacterial agent K. pneumoniae in RUTI. A prospective study was designed, using consecutive patients diagnosed with community-acquired K. pneumoniae-related UTI from January 2007 to December 2009. Of the total 468 consecutive episodes, we found 7 patients with RUTI. All the patients with RUTI were elderly (median, 74 years), with diabetes (100 %, 7 out of 7). Clinical K. pneumoniae isolates derived from the same patients with RUTI revealed identical genomic fingerprints, indicating that K. pneumoniae UTI relapsed despite appropriate antibiotic therapy. The antimicrobial resistance, growth curve and biofilm formation of the recurrent isolates did not change. K. pneumoniae strains causing RUTI had more adhesion and invasiveness than the colonization strains (p < 0.01). When we compared the recurrent strains with the community-acquired UTI strains, the prevalence of diabetes mellitus was significant (100 % vs 53.7 %, p = 0.03) in the RUTI group. Our data suggest that K. pneumoniae strains might be able to persist within the urinary tract despite appropriate antibiotic treatment, and the greater adhesion and invasiveness in the recurrent strains may play an important role in recurrent infections.

Long-term efficacy of miglustat in paediatric patients with Niemann-Pick disease type C

Niemann-Pick disease type C (NP-C) is a rare inherited neurovisceral disease characterized by progressive neurological manifestations. Oral miglustat was first approved for the treatment of children and adults with NP-C in Europe in 2009. There are still relatively few published data on the long-term efficacy and safety of miglustat in patients with NP-C in clinical practice. We report the effects of up to 6 years of treatment with miglustat 100 mg t.i.d. in five children. Overall, 3/5 patients displayed progressive dysphagia before starting miglustat, and 4/5 showed marked cognitive and/or motor impairment. The mean age at treatment start was 11.6 years, and the median (range) duration of therapy so far is 4 (4.1 to 6.1) years. No treatment dose alterations were required, but therapy was interrupted for 1-3 months at least once in all patients due to supply issues. Swallowing function was stabilised during miglustat therapy, with no significant increase in Han dysphagia scale or aspiration-penetration index scores among four evaluable patients (p > 0.05). Scores on the mini-mental state examination indicated an improvement in cognitive function during the first 3-6 months of miglustat therapy, followed by stabilisation up to 5 years. Ambulatory function remained stable for at least the first 2 years of treatment in most patients, but there was a trend towards deterioration thereafter, possibly related to treatment interruptions. The safety/tolerability profile of miglustat was similar to previous clinical studies, although reports of gastrointestinal disturbances were rare. Overall, miglustat appeared to stabilise key parameters of neurological disease progression.

Role of K1 capsule antigen in cirrhotic patients with Escherichia coli spontaneous bacterial peritonitis in southern Taiwan

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications in patients with cirrhosis. This study aimed to investigate the prevalence of SBP caused by Escherichia coli isolates with or without the K1 capsule antigen in cirrhotic patients and the outcome. From January 2004 to January 2012, a total of 54 and 41 E. coli strains derived from patients with SBP and intestinal perforation (IP), respectively, were included for comparison in this study. Bacterial characteristics including phylogenetic groups, K1 capsule antigen, and 14 virulence factor genetic determinants, as well as data regarding patient characteristics, clinical manifestations, and in-hospital deaths, were collected and analyzed. The prevalence of the K1 capsule antigen gene neuA was more common in SBP isolates compared to IP isolates (28 % vs. 10 %, p = 0.0385). Phylogenetic groups B2 and group D were dominant in E. coli isolates with and without the K1 capsule antigen, respectively. The prevalence of virulence factors genes papG II, ompT, and usp was higher in E. coli K1 strains. There were 26 deaths (48 %) during hospitalization. Presence of the K1 capsule antigen in E. coli isolates was significantly associated with in-hospital death in cirrhotic patients with SBP (42 % vs. 14 %, p = 0.0331). This study demonstrates a higher prevalence of the K1 capsule antigen in E. coli SBP compared to E. coli peritonitis caused by IP. There were significant associations between the K1 capsule antigen and in-hospital mortality and bacterial virulence in cirrhotic patients with E. coli SBP.

PapG II adhesin in the establishment and persistence of Escherichia coli infection in mouse kidneys

Most human pyelonephritogenic Escherichia coli express the PapG II adhesin. However, the role of the PapG II adhesin in enhancing the establishment and persistence of E. coli infection in the kidney is controversial. A pyelonephritogenic strain, EC114, which possesses one copy of the papG II gene, but without other virulence factors (such as S/F1C-fimbriae, hemolysin, and cytotoxic necrotizing factor 1) was selected for the construction of a papG II mutant. The resulting papG II mutant was confirmed by polymerase chain reaction, Southern hybridization, and agglutination assay, and designated as MEC114. We compared MEC114 with the parental strain (EC114) for colonization ability in the bladder and kidney of female BALB/c mice, which were challenged transurethrally with 50 microl of a low (5x10(4) CFU (colony-forming unit)) or high (5x10(8) CFU) dose of EC114 or MEC114 and assessed 1, 3, and 7 days after inoculation. Geometric means of quantitative bacterial counts in the kidney were significantly decreased when challenged with MEC114 on day 3 after inoculation, at both low and high dose (P<0.05), as compared with EC114. On the seventh day, both strains were mainly cleared from the kidney. Renal biopsy showed a similar degree of inflammatory response to both strains 1, 3, and 7 days after inoculation. In brief, the PapG II adhesin can enhance the early establishment of E. coli infection in the kidney, but the bacteria do not maintain infection owing to the host immune response.

A novel application of an anaerobic membrane process in wastewater treatment

The applications of membrane processes in anaerobic biological wastewater treatment still have some limitations due to severe membrane scaling and fouling, although they have been proven to achieve superior COD removal and biomass retention. An innovative anaerobic membrane process for wastewater treatment was conducted to control the membrane scaling problems. The process comprises an anaerobic reactor, an aerobic reactor, and a membrane separation tank. Anaerobic sludge from a full-scale UASB reactor treating food wastewater was inoculated to anaerobic and aerobic reactor to purify synthetic wastewater consisting of glucose and sodium acetate. The anaerobic reactor was operated in a sludge bed type without three-phase separator. The aerobic reactor can eliminate residual organics from the anaerobic reactor effluent using facultative microorganisms. To provide solid-liquid separation, hollow fiber ultrafiltration module was submerged in the separation tank. The results clearly show that the anaerobic membrane process combined methanogenic and aerobic COD reduction is a stable system. No fatal scaling was found after two months of operation even without chemical cleaning for the membrane. It was also found that inorganic precipitates formed in the aerobic reactor were reduced due to CO2 stripping in aerobic reactor. Another important finding was that the inorganic precipitates were entrapped into facultative aerobes floc. The ash/SS ratio of aerobes floc increased from 0.17 to 0.55 after 50 days of operation, which confirms this phenomenon. Based on our investigation, the new process can control scaling effectively to extend the membrane application in anaerobic treatment.

Glycopeptide antibiotic biosynthesis: enzymatic assembly of the dedicated amino acid monomer (S)-3,5-dihydroxyphenylglycine

Four proteins, DpgA-D, required for the biosynthesis by actinomycetes of the nonproteinogenic amino acid monomer (S)-3,5-dihydroxyphenylglycine (Dpg), that is a crosslinking site in the maturation of vancomycin and teicoplanin antibiotic scaffolds, were expressed in Escherichia coli, purified in soluble form, and assayed for enzymatic activity. DpgA is a type III polyketide synthase, converting four molecules of malonyl-CoA to 3,5-dihydroxyphenylacetyl-CoA (DPA-CoA) and three free coenzyme A (CoASH) products. Almost no turnover was observed for DpgA until DpgB was added, producing a net k(cat) of 1-2 min(-1) at a 3:1 ratio of DpgB:DpgA. Addition of DpgD gave a further 2-fold rate increase. DpgC had the unusual catalytic capacity to convert DPA-CoA to 3,5-dihydroxyphenylglyoxylate, which is a transamination away from Dpg. DpgC performed a net CH(2) to C=O four-electron oxidation on the Calpha of DPA-CoA and hydrolyzed the thioester linkage with a k(cat) of 10 min(-1). Phenylacetyl-CoA was also processed, to phenylglyoxylate, but with about 500-fold lower k(cat)/K(M). DpgC showed no activity in anaerobic incubations, suggesting an oxygenase function, but had no detectable bound organic cofactors or metals. A weak enoyl-CoA hydratase activity was detected for both DpgB and DpgD.

Decreased predominance of papG class II allele in Escherichia coli strains isolated from adults with acute pyelonephritis and urinary tract abnormalities

PURPOSE

We compared the genotypes of fimbriae or adhesions of Escherichia coli causing acute pyelonephritis in adults with and without urinary tract abnormalities.

MATERIALS AND METHODS

We studied a total of 92 E. coli strains isolated from 54 patients with acute pyelonephritis and a normal urinary tract, and 38 with urinary tract abnormalities. Of those with urinary tract abnormalities 13 with moderate to severe hydronephrosis were also considered a separate group for the purpose of analysis. The genes of 7 known fimbriae or adhesins of E. coli were detected by the polymerase chain reaction, including the papG class I to III alleles (PapG adhesins of P-fimbriae), sfa/foc (S-/F1C-fimbriae), fimH (type 1 fimbriae), and afa (afimbrial adhesin). Virulence genes associated with APN were identified by comparing the prevalence of each of these 7 genes in E. coli strains from 54 patients with acute pyelonephritis with a normal urinary tract to the prevalence in the strains from 37 patients with acute cystitis using univariate and multivariate analysis. Differences in the prevalence of the genes associated with acute pyelonephritis and the incidence of underlying illness were then compared in the 3 acute pyelonephritis groups.

RESULTS

On univariate and multivariate analysis the papG class II allele was the only virulence gene associated with acute pyelonephritis (p <0.0001 and 0.001, respectively). No significant difference was noted in the prevalence of underlying medical disease in the 3 acute pyelonephritis groups. The papG class II allele was significantly less predominant in E. coli strains isolated from acute pyelonephritis cases with versus without urinary tract abnormalities (76% versus 93%, p = 0.03). The incidence of the papG class II allele in patients with urinary tract abnormalities and moderate to severe hydronephrosis was less than in those without urinary tract abnormalities (69% versus 93%, p = 0.04).

CONCLUSIONS

Our results imply that the papG class II allele has an important role in E. coli infection in patients with acute pyelonephritis and a normal urinary tract, while urinary tract abnormalities and/or obstruction may permit ascending infection of E. coli strains with lower adhesive ability.

Real-time PCR for rapid genotyping of angiotensin-converting enzyme insertion/deletion polymorphism

OBJECTIVE

To develop a real-time PCR technique for detection of the insertion/deletion (I/D) polymorphism of angiotensin-converting enzyme (ACE) gene.

DESIGN AND METHODS

Three primers were designed for performing real-time PCR in the presence of SYBR Green I as flurochrome followed by melting curve analysis. Forty human genomic DNA that have been genotyped by two-rounds of conventional PCR were used for evaluation of this technique.

RESULTS

Melting curve analysis indicated the melting peak at 73.9 degrees C and 76.2 degrees C corresponding to the presence of I and D alleles, respectively. Comparable genotyping results were obtained by both conventional and real-time PCR. Besides, the mistyping of ID allele individuals by the first run of conventional PCR were accurately genotyped by single-tube real time PCR.

CONCLUSIONS

The real-time PCR method presented in this study provides a rapid and sensitive way for genotyping of ACE gene that may be suitable for large-scale clinical and epidemiologic study.

Induction of disabled-2 gene during megakaryocyte differentiation of k562 cells

Megakaryocyte differentiation is often accompanied by the changes of gene expression pattern. Here we reported that the expression of DAB2, a putative adaptor protein in cell signaling, was induced at the protein and mRNA levels upon 12-O-tetradecanoylphorbol-13-acetate-mediated megakaryocyte differentiation of human chronic myeloid leukemic K562 cells. On the other hand, the differentiation agents DMSO and retinoic acid had no effect on DAB2 expression. Analysis of promoter activity with the human DAB2 luciferase reporter constructs suggested that the regulation is partially at the transcriptional level. The responsive sequences located within an 80-bp DAB2 promoter region. To determine the involvement of MEK1-p42/p44 MAPK pathway in mediating DAB2 gene expression, we have performed the following experiments and found that (i) there was sustained activation of p42/p44 MAPK, but not p38 MAPK, upon K562 cells differentiation; (ii) application of MEK1 inhibitor U0126 reduced the expression of DAB2 protein, mRNA and promoter activity, as well as cell differentiation; (iii) constitutively active MEK1 increased DAB2 promoter activity; and (iv) dominant negative ERK2 abolished constitutively active MEK1-induced DAB2 promoter activity. Taken together, our results indicate that DAB2 gene is induced upon megakaryocyte differentiation by the MEK1-p42/p44 MAPK pathway and may define a new role of DAB2 in hematopoietic cell differentiation.

Assessing relocation strategies of urban air quality monitoring stations by GA-based compromise programming

This paper presents a GA-based compromise programming technique for assessing the relocation strategy of urban air quality monitoring network with respect to the multi-objective and multi-pollutant design criteria. While the impact of conservative, quasi-stable, and reactive pollutants are considered in the design principles via a simulation analysis, cost, effectiveness, and efficiency characteristics are postulated in the optimization process. Therefore, technical coverage for illustrating the needs of siting air quality monitoring stations (AQMS) includes both the air quality simulation and optimization modeling analyses in a two-stage analytical framework simultaneously. It starts from determining the spatial interrelationship among those candidate sites using various types of air quality simulation models as an integrated means. And the outputs drawn from the simulation models can then be used as the required inputs in the compromise programming model in order to screen all those siting alternatives that may satisfy the planning goals subject to the essential constraints throughout the multi-objective optimization process. For the illustrating purposes, a series of technical settings for finding the optimal relocation scenarios of AQMS were examined in the case study for the city of Kaohsiung in South Taiwan where the long-term violations of official standards of ozone and particulates turn out to be critical. It not only expresses the ideas of relocation strategy but also indicates how to utilize those alternatives in the decision-making process for improving the functionality of air quality monitoring in the urban environment. Experience gained in this study clearly indicates that the more the number of pollutants and objectives considered simultaneously, the higher the number of candidate sites to be selected in the relocation strategy.

25-hydroxyvitamin D-1alpha-hydroxylase in normal and malignant colon tissue

Vitamin D affects calcium metabolism and prevents proliferation of colon cells in vitro. In human beings the main circulating form of vitamin D is 25-hydroxyvitamin D; to regulate calcium homoeostasis, this form must be converted to 1alpha, 25-dihydroxyvitamin D by 1alpha-hydroxylation in the kidney with 25-hydroxyvitamin D-1alpha-hydroxylase. Cultured transformed colon cancer cells can convert 25-hydroxyvitamin D(3) to 1alpha,25-dihydroxyvitamin D(3). We identified messenger RNA (mRNA) for 25-hydroxyvitamin D-1alpha-hydroxylase in normal colon tissue and in malignant and adjacent normal colon tissue. These findings support the notion that vitamin D might have a role in cell growth regulation and cancer protection, and might be the explanation for why the risk of dying from colorectal cancer is highest in areas with the least amount of sunlight.

A nucleus-localization-deficient mutant serves as a dominant-negative inhibitor of gut-enriched Krüppel-like factor function

Cancer cells differ from normal cells in many aspects, including loss of differentiation and uninhibited cell proliferation. Recent studies have suggested that gut-enriched Krüppel-like factor (GKLF) played an important role in the regulation of cell growth in the colon. Studies from this laboratory have shown that GKLF protein predominantly expressed in the cytoplasm but not the nucleus of colon cancer cells, suggesting that impaired nuclear translocation of GKLF might contribute to cancer formation. In this report, a region containing putative nuclear localization signal (NLS) of GKLF (PKRGRR; amino acids 385-390) was investigated. Mutation of KR to WT had no effect on the inhibitory properties of GKLF on cyclin D1 promoter activity and [(3)H]thymidine uptake in HT-29 cells, whereas mutation of RR to GL abolished GKLF function completely. Additional mutation analyses demonstrated that Arg(390) is the most critical moiety within this region that mediated GKLF function and its nucleus localization. Cotransfection of Arg(390) mutant (RR/RS) completely inhibited wild-type GKLF function, and GFP-RR/RS GKLF fusion proteins failed to translocate to the nucleus. The results from this study demonstrate that Arg(390) confers the NLS of GKLF and that the nucleus-localization-deficient mutant serves as dominant-negative inhibitor of GKLF function.

The clinical use of small-dose tetracaine spinal anesthesia for transurethral prostatectomy

In a double-blinded study, we compared conventional dose tetracaine (8 mg), small-dose tetracaine (4 mg) with added fentanyl and epinephrine, and small-dose tetracaine (4 mg) with added fentanyl subarachnoid anesthesia. Forty-five patients scheduled for transurethral resection of prostate (TURP) under subarachnoid anesthesia were randomly assigned to Group 1 (8 mg hyperbaric tetracaine), Group 2 (4 mg hyperbaric tetracaine, 10 microg fen-tanyl, and 0.2 mg epinephrine), and Group 3 (4 mg hyperbaric tetracaine, 10 microg fentanyl, and 0.2 mL saline). Evaluations were performed after spinal anesthesia. Subarachnoid block was successful in all patients except one in Group 1, who required general anesthesia by mask. The median peak sensory levels 10 min after the induction of spinal anesthesia in Group 1 was T8, which was significantly higher than Group 2 and Group 3 (P < 0.05). The time of sensory and motor recovery in Group 3 was less than in Groups 1 and 2 (P < 0.05). Hypotension was observed in four patients in Group 1 and none in Groups 2 and 3. We conclude that small-dose 4-mg hyperbaric tetracaine plus 10 microg fentanyl might provide adequate anesthesia and fewer side effects for TURP when compared with the conventional (8 mg) dose.

IMPLICATIONS

Small-dose hyperbaric tetracaine (4 mg with 10 microg fentanyl added) may provide adequate anesthesia and fewer side effects for transurethral resection of the prostate.

Detection rate of Actinobacillus actinomycetemcomitans on the permanent 1st molars of primary school children in Taiwan by polymerase chain reaction

BACKGROUND, AIMS

Actinobacillus actinomycetemcomitans (Aa) has been implicated as the putative micro-organism for localized juvenile periodontitis (LJP). The most distinct clinical features of LJP include severe angular bony defects of the mesial sides of permanent first molars and the onset of disease during puberty. Currently, no large-scale studies have been performed which address the change in detection rates of Aa on the mesial sides of permanent 1st molars following eruption and up to puberty.

METHOD

In this study, subgingival plaque samples were taken from the mesial pockets of 2 randomly selected permanent 1st molars from 328 primary school children and 50 adult staff, and analyzed by polymerase chain reaction (PCR) to detect Aa.

RESULTS

The results showed a 5.5% prevalence rate of Aa which increased after the eruption of 1st molars and peaked near puberty. There were no significant differences in the detection rates of Aa among different groups in terms of gender, plaque index (PII), and gingival index (GI); however, the higher detection rates of Aa were significantly associated with increased probing depths at p<0.05.

CONCLUSION

PCR analysis of the subgingival plaques demonstrated a prevalence of Aa which peaked near puberty, suggesting that Aa may be important for LJP in Taiwan.

Correlation of histologic subtypes and replication error phenotype with comparative genomic hybridization in gastric cancer

To characterize phenotypic and genotypic changes in gastric cancer (GC), DNA copy number aberrations (CNAs) were assessed in 53 tumors using comparative genomic hybridization (CGH) and correlated with clinicopathologic characteristics and status of TP53 and replication error (RER). The number of CNAs per tumor was 6.8 (gain 5.3, loss 1.5), and the number of changes was significantly higher in tumors with advanced stage, TP53 mutation, and without RER than in those with early stage (7.7 vs. 3.0), no TP53 mutations (12.4 vs. 4.8) or RER phenotype (8.2 vs. 2.6). Frequent abnormalities included gains on chromosomal arms 8q (43%), 6q (26%), 11q (26%), 13q (24%), 7p (23%), 17q (23%), and 20q (23%), and losses on chromosomal arms 16q (26%), 19p (23%), 5q (19%), 3p (15%), 4q(15%), and 1p (15%). Advanced GC demonstrated a higher prevalence of gains of 8q (51% vs. 10%, P < 0.05) and loss of 16q (33% vs. 0%, P < 0.05) than early GC. Gains on 8q (64% vs. 20%, P < 0.05), 17q (39% vs. 4%, P < 0.05) and losses on 3p (25% vs. 4%, P = 0.05) and 5q (32% vs. 4%, P < 0.05) were higher in intestinal GC than in diffuse GC. On the other hand, gains on 13q were more common in the diffuse type (40% vs. 11%, P < 0.05). As compared with noncardia cancer, cardia cancer showed more gains on 7p (58% vs. 12%, P < 0.05) and 20q (58% vs. 12%, P < 0.05) and more losses on 4q (50% vs. 5%, P < 0.05). The finding of histology-related aberrations and the combination of CGH and molecular data thus provide additional evidence suggesting genetic heterogeneity of GC.

Detection of putative periodontal pathogens in non-insulin-dependent diabetes mellitus and non-diabetes mellitus by polymerase chain reaction

It has been assumed that there is a relationship between periodontal diseases and diabetes mellitus, however the putative periodontal microorganisms in non-diabetes mellitus (non-DM) individuals and non-insulin-dependent diabetes mellitus (NIDDM) patients have not been well studied. In this study, the detection rates of 5 putative periodontal pathogens: Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Eikenella corrodens, Treponema denticola, and Candida albicans by polymerase chain reaction (PCR) between NIDDM and non-DM adults were compared. A total of 246 adults were randomly recruited and periodontal parameters including: plaque index (P1I), gingival index (GI), probing depth (PD) and attachment level (AL) were recorded. Subgingival plaque samples were collected by sterile curettes from the most diseased and healthy sites based on PD and AL. The differences in periodontal parameters and microbiological data in healthy and diseased sites between non-DM and NIDDM patients were compared by chi-square analysis. The results showed no significant differences in age, gender, GI, P1I, PD, and prevalence of the 5 microorganisms between the NIDDM and the non-diabetic groups. However, except for A. actinomycetemcomitans, the prevalence of the periodontal microorganisms tested was significantly higher (p <0.001) in diseased sites than in the healthy sites in both groups. The P1I, GI, PD and AL were significantly higher in T. denticola positive sites than in negative sites. The results suggested that P. gingivalis, T. denticola, E. corrodens and C. albicans may play important roles in the periodontitis of both NIDDM and non-DM individuals, however the etiology of periodontitis in both groups may not be different from each other.

Purification, priming, and catalytic acylation of carrier protein domains in the polyketide synthase and nonribosomal peptidyl synthetase modules of the HMWP1 subunit of yersiniabactin synthetase

The 207-kDa polyketide synthase (PKS) module (residues 1-1895) and the 143-kDa nonribosomal peptidyl synthetase (NRPS) module (1896-3163) of the 350-kDa HMWP1 subunit of yersiniabactin synthetase have been expressed in and purified from Escherichia coli in soluble forms to characterize the acyl carrier protein (ACP) domain of the PKS module and the homologous peptidyl carrier protein (PCP(3)) domain of the NRPS module. The apo-ACP and PCP domains could be selectively posttranslationally primed by the E. coli ACPS and EntD phosphopantetheinyl transferases (PPTases), respectively, whereas the Bacillus subtilis PPTase Sfp primed both carrier protein domains in vitro or during in vivo coexpression. The holo-NRPS module but not the holo-PKS module was then selectively aminoacylated with cysteine by the adenylation domain embedded in the HMWP2 subunit of yersiniabactin synthetase, acting in trans. When the acyltransferase (AT) domain of HMWP1 was analyzed for its ability to malonylate the holo carrier protein domains, in cis acylation was first detected. Then, in trans malonylation of the excised holo-ACP or holo-PCP(3)-TE fragments by HMWP1 showed both were malonylated with a 3:1 catalytic efficiency ratio, showing a promiscuity to the AT domain.