Cryo-EM structures of human Cx36/GJD2 neuronal gap junction channel

Connexin 36 (Cx36) is responsible for signal transmission in electrical synapses by forming interneuronal gap junctions. Despite the critical role of Cx36 in normal brain function, the molecular architecture of the Cx36 gap junction channel (GJC) is unknown. Here, we determine cryo-electron microscopy structures of Cx36 GJC at 2.2-3.6 Å resolutions, revealing a dynamic equilibrium between its closed and open states. In the closed state, channel pores are obstructed by lipids, while N-terminal helices (NTHs) are excluded from the pore. In the open state with pore-lining NTHs, the pore is more acidic than those in Cx26 and Cx46/50 GJCs, explaining its strong cation selectivity. The conformational change during channel opening also includes the α-to-π-helix transition of the first transmembrane helix, which weakens the protomer-protomer interaction. Our structural analyses provide high resolution information on the conformational flexibility of Cx36 GJC and suggest a potential role of lipids in the channel gating.

Rapid remodeling observed at mid-term in-vivo study of a smart reinforced acellular vascular graft implanted on a rat model

BACKGROUND

The poor performance of conventional techniques used in cardiovascular disease patients requiring hemodialysis or arterial bypass grafting has prompted tissue engineers to search for clinically appropriate off-the-shelf vascular grafts. Most patients with cardiovascular disease lack suitable autologous tissue because of age or previous surgery. Commercially available vascular grafts with diameters of < 5 mm often fail because of thrombosis and intimal hyperplasia.

RESULT

Here, we tested tubular biodegradable poly-e-caprolactone/polydioxanone (PCL/PDO) electrospun vascular grafts in a rat model of aortic interposition for up to 12 weeks. The grafts demonstrated excellent patency (100%) confirmed by Doppler Ultrasound, resisted aneurysmal dilation and intimal hyperplasia, and yielded neoarteries largely free of foreign materials. At 12 weeks, the grafts resembled native arteries with confluent endothelium, synchronous pulsation, a contractile smooth muscle layer, and co-expression of various extracellular matrix components (elastin, collagen, and glycosaminoglycan).

CONCLUSIONS

The structural and functional properties comparable to native vessels observed in the neoartery indicate their potential application as an alternative for the replacement of damaged small-diameter grafts. This synthetic off-the-shelf device may be suitable for patients without autologous vessels. However, for clinical application of these grafts, long-term studies (> 1.5 years) in large animals with a vasculature similar to humans are needed.

Chest Pain and Suspected Myocarditis Related to COVID-19 Vaccination in Adolescents-A Case Series

As adolescents started to be vaccinated against coronavirus disease 2019 (COVID-19), suspected myocarditis and pericarditis related to the vaccine were reported in adolescents. According to the Korea Disease Control and Prevention Agency (KDCA), 2,796,270 persons aged 12−18 years were fully vaccinated by December 8. Among these, 9223 adverse events were reported (0.33%). We aimed to elucidate the clinical courses and short-term outcomes for adolescents aged 12−18 with cardiac symptoms and suspected myo- or peri-carditis related to COVID-19 vaccination in South Korea. Methods: We retrospectively collected data on patients ≤ 18 years of age who had suspected myocarditis or pericarditis within 30 days of COVID-19 vaccination, from July 2021 to January 2022. Results: We reported on 40 adolescents in different South Korean provinces at two centers. Twenty-six cases (65%) were male, and the median age was 16 years (range, 13−18; IQR 14.5−17). Twenty-five cases (62.5%) occurred at the first dose, and fifteen (37.5%) occurred after the second dose. Symptoms started at a median of 2 days (range 0−29 days; IQR 1−5 days) after vaccination. The patients were treated with nonsteroidal anti-inflammatory drugs (77.5%), intravenous immunoglobulin (2.5%), glucocorticoids (20%), colchicine (5%), or no therapy (15%). Five patients (12.5%) required intensive care unit admission; one patient needed inotropic/vasoactive support. No patients required extracorporeal membrane oxygenation or died. The median hospital stay was one day (range 0−8 days; IQR 0−2 days). Twenty-one patients (52.5%) had an abnormal electrocardiogram; among these, seven patients had an elevated ST segment, six patients (15%) had decreased ejection fraction (<55%), and LV function was completely recovered in all of them. Conclusions: Most cases of suspected myocarditis after COVID-19 vaccination in adolescents ≤ 18 years had mild symptoms and clinical courses, as well as a complete recovery. Further studies are needed to evaluate long-term outcomes.

Increased risk of cardiovascular diseases in patients with chronic rhinosinusitis: a longitudinal follow-up study using a national health screening cohort

BACKGROUND

Chronic rhinosinusitis (CRS) is one of the most common chronic inflammatory diseases and is characterized by sinonasal inflammation that lasts longer than 12 weeks. Whether the effect of chronic inflammation caused by CRS on cardiovascular diseases (CVDs) is similar to its effect on other inflammatory disorders has not been thoroughly evaluated. We aimed to demonstrate whether CRS patients have a higher prevalence of CVDs, including stroke and ischemic heart disease (IHD).

METHODOLOGY

We compared the prevalence of various comorbidities between CRS and control participants through a case-control cohort study from 2002 to 2015 that included 514,866 participants. CRS (n=6,552) and control (n=26,208) participants who were over 40 years old were selected by matching age, sex, income, and area of residence at a 1:4 ratio.

RESULTS

A stratified Cox proportional hazards model was utilized to assess the hazard ratio (HR) of CRS for stroke and IHD. The HRs for stroke and IHD were significantly increased in CRS patients compared to controls after adjusting for obesity, alcohol consumption, smoking, systolic and diastolic blood pressure, fasting blood glucose, total cholesterol, hemoglobin, and Charlson Comorbidity Index (CCI) scores. The HR of stroke was significantly higher in the absence of nasal polyps than in the presence of nasal polyps. The HR of IHD was significantly increased in the CRS group regardless of the presence of nasal polyps.

CONCLUSIONS

This study showed that CRS participants had a significantly higher prevalence of stroke and IHD.

Acute Immune Response in Venoarterial and Venovenous Extracorporeal Membrane Oxygenation Models of Rats

Although experimental extracorporeal membrane oxygenation (ECMO) animal models have been reported, there are few studies on the immune response to ECMO. We developed the venoarterial (VA) and venovenous (VV) model in rats and serially investigated the changes in the distribution of immune cells. Forty rats underwent both VA and VV modes of ECMO, and blood samples were collected at 1 day before ECMO (D-1), at the end of ECMO run (D+0), and 3 days after the ECMO (D+3). Flow cytometry was used to characterize surface marker expression (CD3, CD4, CD8, CD43, CD45, CD45R, CD161, and His48) on immune cells. Granulocytes were initially activated in both ECMO types and were further reduced but not normalized until 3 days of decannulation. Monocyte and natural killer cells were decreased initially in VA mode. B lymphocytes, helper T lymphocytes, and cytotoxic T lymphocytes also significantly decreased in VA modes after ECMO, but this phenomenon was not prominent in the VV modes. Overall immune cells proportion changed after ECMO run in both modes, and the immunologic balance altered significantly in the VA than in VV mode. Our ECMO model is feasible for the hemodynamic and immunologic research, and further long-term evaluation is needed.

Severe Periodontal Disease Increases Acute Myocardial Infarction and Stroke: A 10-Year Retrospective Follow-up Study

This study aimed to evaluate the causal association of periodontal disease with acute myocardial infarction (AMI) and stroke, after controlling for various confounders among the Korean population. A retrospective cohort study using the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) was performed during 2002 to 2015 (baseline: 2002 to 2005; follow-up: 2006 to 2015) in the Republic of Korea. A total of 298,128 participants with no history of AMI or stroke were followed up for 10 y. AMI and stroke were defined by a diagnosis using the International Classification of Diseases, 10th Revision (ICD-10) guideline. Periodontal condition was classified into 3 groups (healthy, moderate periodontal disease, severe periodontal disease [SPD]) using the combination of ICD codes, treatment codes in the NHIS, and recommendation of periodontal treatment by the dentists in HEALS. Various confounders, such as sociodemographic, behavioral, systemic, and oral health factors, including hypercholesterolemia, were considered. Multivariable Cox regression analysis was applied to estimate adjusted incidence rate ratio (adjusted hazard ratio [aHR]) based on person-year of periodontal condition for AMI, stroke, and nonfatal major adverse cardiovascular events (MACEs) encompassing AMI or stroke controlling for various confounders. Stratified analyses according to age group, sex, and toothbrushing frequency were also performed. After controlling for various confounders, participants with SPD compared with non-SPD participants had a higher incidence by 11% for AMI (aHR, 1.11; 95% confidence interval [CI], 1.02-1.20), by 3.5% for stroke (aHR, 1.035; 95% CI, 1.01-1.07), and by 4.1% for MACEs (aHR, 1.04; 95% CI, 1.01-1.07). The association of SPD with AMI and MACE was highly modified in females and adults aged 40 to 59 y. In the total Korean population, SPD increased total AMI events by 4.3%, total stroke events by 1.4%, and the total MACEs by 1.6%. Our data confirmed that SPD was causally associated with the new events of AMI and stroke.

Molecular profiling of Asian patients with advanced melanoma receiving check-point inhibitor treatment

Objective

Melanoma is major medical challenge and being able to monitor treatment response is critical. This study aimed to use molecular profiling of Asian patients with advanced melanoma who were receiving treatment with check-point inhibitors (CPIs) to identify novel biomarkers of tumor response.

Methods

Next-generation sequencing (NGS) was performed using tumor specimens collected from 178 Asian patients with metastatic melanoma receiving CPIs. The NGS data and clinical-pathological factors were analyzed for potential genetic biomarkers of tumor response to CPI treatment.

Results

The most common melanoma subtype was acral melanoma (40%), followed by cutaneous melanoma (32%), mucosal melanoma (26%), and others (2%). For calculation of treatment efficacy, 164 of the patients could be evaluated. The overall response rate was 45.7%, of which 41 cases exhibited complete responses (25.0%) and 34 showed partial responses (20.7%). There were no significant differences in tumor responses based on melanoma subtype (P = 0.295). Genetically, NRAS mutations, TP53 mutations, and NF2 deletions were significantly associated with resistance to CPIs (P < 0.05). In contrast, MYC and RPS6KB1 amplifications were associated with responsiveness to CPIs (P < 0.05). Median progression-free survival (PFS) for patients treated with CPIs was 5.9 months (95% CI, 3.8-8.05 months). Univariate analysis identified TP53 and BRAF mutations, NF2 deletions, and BIRC2 amplifications as poor prognostic factors for PFS (P < 0.05).

Conclusions

This study determined the integrated genomic profiles of Asian patients with metastatic melanoma receiving CPIs and identified candidate biomarkers that reflected treatment outcomes.

•

The molecular characterization of Asian melanoma patients receiving check-point inhibitors (CPIs) using NGS has not been reported.

•

NRAS and TP53 mutations and NF2 deletions were significantly associated with resistance to CPIs.

•

MYC and RPS6KB1 amplifications were associated with responsiveness to CPIs.

•

TP53 and BRAF mutations, NF2 deletions, and BIRC2 amplifications were poor prognostic factors for progression-free survival.

•

This is the largest integrated genomic study to date that identifying novel biomarkers of CPIs in Asian melanoma patients.

Considerations in the Development of Small-Diameter Vascular Graft as an Alternative for Bypass and Reconstructive Surgeries: A Review

BACKGROUND

Current design strategies for small diameter vascular grafts (< 6 mm internal diameter; ID) are focused on mimicking native vascular tissue because the commercially available grafts still fail at small diameters, notably due to development of intimal hyperplasia and thrombosis. To overcome these challenges, various design approaches, material selection, and surface modification strategies have been employed to improve the patency of small-diameter grafts.

REVIEW

The purpose of this review is to outline various considerations in the development of small-diameter vascular grafts, including material choice, surface modifications to enhance biocompatibility/endothelialization, and mechanical properties of the graft, that are currently being implanted. Additionally, we have taken into account the general vascular physiology, tissue engineering approaches, and collective achievements of the authors in this area. We reviewed both commercially available synthetic grafts (e-PTFE and PET), elastic polymers such as polyurethane and biodegradable and bioresorbable materials. We included naturally occurring materials by focusing on their potential application in the development of future vascular alternatives.

CONCLUSION

Until now, there are few comprehensive reviews regarding considerations in the design of small-diameter vascular grafts in the literature. Here-in, we have discussed in-depth the various strategies employed to generate engineered vascular graft due to their high demand for vascular surgeries. While some TEVG design strategies have shown greater potential in contrast to autologous or synthetic ePTFE conduits, many are still hindered by high production cost which prevents their widespread adoption. Nonetheless, as tissue engineers continue to develop on their strategies and procedures for improved TEVGs, soon, a reliable engineered graft will be available in the market. Hence, we anticipate a viable TEVG with resorbable property, fabricated via electrospinning approach to hold a greater potential that can overcome the challenges observed in both autologous and allogenic grafts. This is because they can be mechanically tuned, incorporated/surface-functionalized with bioactive molecules and mass-manufactured in a reproducible manner. It is also found that most of the success in engineered vascular graft approaching commercialization is for large vessels rather than small-diameter grafts used as cardiovascular bypass grafts. Consequently, the field of vascular engineering is still available for future innovators that can take up the challenge to create a functional arterial substitute.

Postpartum women’s experience of abuse in childhood, postnatal depression, and thoughts of self-harm

Background

Postnatal depression threatens the health of both mothers and babies. To improve maternal and child health in Seoul, South Korea, a nurse home visitation program for pregnant women and new mothers and babies has been implemented since 2013.

Methods

Cross-sectional data collected from 9,124 mothers while they were visiting a public health center for prenatal services or a nurse was visiting their home within 6 weeks after birth between 2014 and 2018 were analyzed. Mothers were asked whether they had experienced physical, emotional, or sexual abuse in their childhood. Postnatal depression and thoughts of self-harm were measured using the Edinburgh Postnatal Depression Scale (EPDS). Postnatal depression was defined as a total EPDS score of 13 or higher; thoughts of self-harm were defined as a response of “yes, quite often,” “sometimes,” or “hardly ever” to the corresponding item, excluding the response of “never".

Results

Overall, 3.2% of mothers had experienced child abuse; 8.1% experienced postnatal depression and 5.4% reported thoughts of self-harm. Postnatal depression was more common in mothers who had experienced child abuse than among those who had not (24.2% vs. 7.6%). A similar pattern was found for thoughts of self-harm (21.1% vs. 4.9%, respectively). When controlling for mothers’ age, economic status, history of receiving treatment for mental health problems, and other factors, having experienced child abuse was associated with a 2.73-fold increase in the odds of postnatal depression (odds ratio, 2.02-3.70) and a 3.58-fold increase in the odds of thoughts of self-harm (odds ratio, 2.58-4.96).

Conclusions

Mothers should be screened for having experienced child abuse when providing public health perinatal care to improve mothers’ mental health and parenting practices and to promote their children’s growth and development.

Key messages

Child abuse may have a lifelong negative effect on victims, and the effect extends to the next generation’s health and development. Public health policy and interventions to prevent child abuse are needed to tackle health inequality beginning in early childhood.

P313ADGRL2 is an essential surface molecule for cardiac lineage specification and heart development

Background

Specific surface markers that enable monitoring of cell subsets would be valuable for establishing the conditions under which pluripotent stem cells (PSCs) differentiate into cardiac progenitor cells (CPCs) and cardiomyocytes (CMCs).

Methods and results

To verify whether a specific marker is expressed during heart development, we assessed its expression using the CLARITY technique. After immersion in a solution with a refractive index matching that of the CLARITY hybrid, the mouse embryo became transparent. After immunostaining the cleared embryo sample, Adgrl2 was exclusively observed in cardiac cells expressing α-SA at embryonic day E9.5 and E10.5. Our clarified 3D images and movies show that four chambers of the heart are fully developed at E10.5 but not at E9.5. At E9.5, Adgrl2 is observed at the ventricle and atrium, while Adgrl2 is present in all chambers of the heart at E10.5. Next, we performed LacZ (β-Gal) staining in heterozygous Adgrl2 KO embryos to evaluate Adgrl2 expression. As a result, LacZ staining showed that Adgrl2 was predominantly expressed in the heart during the embryonic developmental stage. Adgrl2 knockout in mice was embryonically lethal because of severe heart, but not vascular, defects. To examine the use of Adgrl2 as a bona fide CPC marker during heart development, we tracked Adgrl2 expression during early embryonic development. The heart of Adgrl2−/− embryos at E10.5 exhibited occlusion of the RV, and the expression levels of Gata4 and Nkx2.5 were not as high as those in wild-type and Adgrl2+/− embryos. Interestingly, the heart of Adgrl2−/− embryos, unlike those of wild-type and Adgrl2+/− embryos between E13.5 and E15.5 had a single ventricle revealing a ventricular septal defect. The specific expression pattern of Adgrl2 in PSC-derived cardiac lineage cells as well as in embryonic heart, adult mice, and human heart tissues.

Conclusion

We demonstrate that Adgrl2 plays a pivotal and functional role across all strata of the cardiomyogenic lineage, as early as the precursor stage of heart development. These findings shed light on heart development and regeneration.

Acknowledgement/Funding

Grants from “Strategic Center of Cell and Bio Therapy” (grant number: HI17C2085) and “Korea Research-Driven Hospital” (HI14C1277)

P3479Sequential stimulation and inhibition of lysophosphatidic acid receptor 4 are critical for cardiac differentiation and repair

Background

The clinical application of cell therapy to repair the damaged heart needs to understand the precise differentiation process of stem cells and the characteristics of cardiac progenitor cells.

Purpose

We examined the cardiac-specific markers that expressed on the cell surface and determined their functional significance during cardiac differentiation.

Methods and results

We screened cell-surface expressing proteins on cardiac progenitor cells at differentiation day 3 compared to undifferentiated pluripotent stem cells (PSCs). Among candidates, we identified lysophosphatidic acid receptor 4 (LPAR4) that is a G protein-coupled receptor. During in vitro differentiation of mouse PSCs toward cardiac cells, LPAR4 expression peaked for 3–5 days and then and declined immediately. Also in vivo, LPAR4 was specifically expressed in the early stage of heart development in embryos and disappeared completely in adults, suggesting that stimulatory signal of LPAR4 at an early stage should be shut off for further progression of differentiation. We next have identified the LPAR4 downstream signaling molecule, p38MAPK, by comparing PSCs and LPAR4 knockdown PSCs. In both mouse and human PSCs, ODP (LPAR4 specific agonist) followed by p38MAPK blocker (SB203580) treatment significantly increased cardiac differentiation efficiency. Furthermore, we investigated whether LPAR4 is the maker for adult cardiac progenitor cells. We found that LPAR4-positive cells were rarely present in normal adult mouse hearts, but LPAR4-positive cells were increased when the heart was damaged. LPAR4-positive cells from adult hearts differentiated into cardiomyocytes. After myocardial infarction (MI), the sequential stimulation and inhibition of LPAR4 with ODP and p38MAPK blocker resulted in the reduction of infarct size and improvement of left ventricular dysfunction.

Conclusion

We demonstrated that LPAR4 is a cardiac progenitor-specific marker and its functional significance during cardiac differentiation and regeneration. Our findings provide a new insight in cell-free cardiac repair by the modulation of progenitor-specific downstream signaling.

Acknowledgement/Funding

Grants from “Strategic Center of Cell and Bio Therapy” (grant number: HI17C2085) and “Korea Research-Driven Hospital” (HI14C1277)

Predictive value of a fragmented QRS complex in diagnosing patients with myocardial ischemia

Background

A fragmented QRS complex (fQRS) is caused by conduction abnormalities of the ventricle secondary to myocardial ischemia and/or scar in patients with myocardial infarction. However, the implications of the fQRS in the development of coronary artery disease with myocardial ischemia in those without a scar remain unknown.

Methods

We studied electrocardiograms (ECGs) obtained from 150 patients (60.5 ± 8.5 years, 102 men) with myocardial ischemia, which was confirmed by performing both, a nuclear exercise stress test and coronary angiography. We also studied ECGs obtained from 601 patients (58.5 ± 10.0 years, 315 men) who showed a negative nuclear exercise stress test (control group). Patients in whom the nuclear exercise stress test showed a myocardial scar were excluded.

Results

An fQRS was more commonly observed in patients with myocardial ischemia (n = 48, 32.0%) than in the control group (n = 133, 22.1%) (P = 0.011). The sensitivity, specificity, positive, and negative predictive values of fQRS in diagnosing myocardial ischemia were 32.0, 77.9, 26.5, and 82.1%, respectively. The fQRS (odds ratio 1.580, 95% confidence interval 1.020‐2.446, P = 0.040) was an independent predictor of myocardial ischemia after adjusting for age, sex, current smoking habits, ST‐T changes on ECG, as well as histories of hypertension, diabetes, and dyslipidemia. Moreover, the fQRS showed an incremental prognostic value over conventional risk factors (χ² = 5, P = 0.032) and over a combination of conventional factors and ST‐T changes (χ² = 9, P = 0.014).

Conclusions

The fQRS is a moderately sensitive and independent predictor of myocardial ischemia.

Recurrent Obturator Hernia as a Cause of Nonspecific Abdominal Pain: A Case Report

Many patients visit the emergency department (ED) with abdominal pain. Sometimes, physicians are faced with diagnostic challenges, particularly for older patients. We recently had an elderly female patient who visited the ED several times with non-specific abdominal pain caused by an unusual hernia. One year before, an 81-year-old female visited our ED complaining of abdominal pain radiating to the right inguinal/femoral area. An incarcerated obturator hernia was found on an abdomino-pelvic computed tomography (CT) scan, and she underwent a laparoscopic hernioplasty. However, 1 year later, she revisited complaining of abdominal pain similar to the previous episode. Eventually, the diagnosis of recurrent obturator hernia was made, and a second operation was performed. An obturator hernia may be the cause of non-specific abdominal pain and small bowel obstruction in elderly emaciated females. Recognising the clinical signs and characteristics of this disease is necessary for a prompt diagnosis and treatment.

EphrinB1 promotes cancer cell migration and invasion through the interaction with RhoGDI1

Eph receptors and their corresponding ephrin ligands have been associated with regulating cell–cell adhesion and motility, and thus have a critical role in various biological processes including tissue morphogenesis and homeostasis, as well as pathogenesis of several diseases. Aberrant regulation of Eph/ephrin signaling pathways is implicated in tumor progression of various human cancers. Here, we show that a Rho family GTPase regulator, Rho guanine nucleotide dissociation inhibitor 1 (RhoGDI1), can interact with ephrinB1, and this interaction is enhanced upon binding the extracellular domain of the cognate EphB2 receptor. Deletion mutagenesis revealed that amino acids 327–334 of the ephrinB1 intracellular domain are critical for the interaction with RhoGDI1. Stimulation with an EphB2 extracellular domain-Fc fusion protein (EphB2-Fc) induces RhoA activation and enhances the motility as well as invasiveness of wild-type ephrinB1-expressing cells. These Eph-Fc-induced effects were markedly diminished in cells expressing the mutant ephrinB1 construct (Δ327–334) that is ineffective at interacting with RhoGDI1. Furthermore, ephrinB1 depletion by siRNA suppresses EphB2-Fc-induced RhoA activation, and reduces motility and invasiveness of the SW480 and Hs578T human cancer cell lines. Our study connects the interaction between RhoGDI1 and ephrinB1 to the promotion of cancer cell behavior associated with tumor progression. This interaction may represent a therapeutic target in cancers that express ephrinB1.

Acute endophthalmitis after cataract surgery: 164 consecutive cases treated at a referral center in South Korea

PurposeTo identify prognostic factors in patients referred with endophthalmitis after cataract surgery, and to evaluate the efficacy of primary vitrectomy as an initial management.MethodsOver an eight-year study period, we retrospectively reviewed the medical records of 164 patients who were referred with endophthalmitis following cataract surgery. Treatment generally conformed to standard guidelines, although primary vitrectomy was performed in several eyes with a visual acuity of hand motion or better, depending on the patient's status. Using multivariate analysis, we analyzed outcomes to determine the effect on final visual outcome.ResultsA final visual acuity of ≥20/40 was achieved in 92/164 (56.1%) cases after treatment. Bacterial cultures showed bacterial growth in 89/164 cases (54.3%). Among the various baseline characteristics, old age (P=0.028), poor visual acuity at presentation (P=0.004), gram-negative bacterial infection (P=0.030), and short time between cataract surgery and signs of endophthalmitis (P=0.021) were associated with poor visual outcome. The visual outcome showed no significant difference, in terms of initial treatment feature, between the primary vitrectomy with intraocular antibiotics injection (IOAI) and IOAI-only groups. However, reintervention was significantly less frequent in the primary vitrectomy group than in the IOAI group (12.5 and 32.7%, respectively; P=0.002).ConclusionOld age, poor visual acuity at presentation, type of cultured organism (gram-negative bacteria), and early onset of endophthalmitis after cataract surgery were significantly related to poor visual outcome after endophthalmitis treatment. Primary vitrectomy may decrease the need for reintervention to control infection, although the treatment showed no benefits with regard to visual outcome.

Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Clinical implications of serum galactomannan measurement in patients with acute invasive fungal rhinosinusitis

BACKGROUND

Acute invasive fungal rhinosinusitis (AIFR) is an aggressive opportunistic infection with a high mortality rate. Recently, non-invasive techniques have been introduced for diagnosis of invasive fungal disease. The purpose of this study is to evaluate the diagnostic significance of serum galactomannan measurement in patients with AIFR.

METHODOLOGY

We conducted a retrospective case-control study of 28 patients with AIFR and 36 fungus ball (FB) patients. We evaluated clinical, laboratory, and pathologic findings along with disease course.

RESULTS

In 28 patients with AIFR, there were 21 cases of invasive aspergillosis (IA) and 7 cases of invasive mucormycosis (IM). The control group was comprised of 36 patients with FB. The three-group analysis showed a statistically significant difference among the groups. At the cut-off value of 0.48, the sensitivity and specificity were 71.4% and 93.0%, respectively. Comparison of mean serum galactomannan levels in 5 non-survivors and 9 survivors at initial measurement showed no significant difference, but that became significantly different 1 week later. Statistical analysis showed that the levels of serum galactomannan decreased significantly according to the measurement-point in within survivor-group analysis. The difference in between survivor-groups analysis was also significant.

CONCLUSION

Serum galactomannan measurement seems useful for early diagnosis and discrimination of fungal species in patients with AIFR. In addition, clinical outcomes may be related to the levels and patterns of serum galactomannan, especially in IA. The appropriate measurement of galactomannan might be helpful in treating the patients at high risk for AIFR.

Pure non-gestational choriocarcinoma arising in the ovary

Non-gestational choriocarcinoma (NGCO) is a rare primary ovarian cancer with poor prognosis. It is important to distinguish it from gestational ovarian choriocarcinoma (GCO), because there are different treatment options. However, it is difficult to distinguish the two types by routine histologic, ultrastructural, or immunohistochemical examination. The authors present NGCO in a 41-year-old woman, which was confirmed by DNA polymorphism analysis. All tested microsatellite markers had identical DNA profiles with the same allelic sizes between tumor and normal myometrium of the patient, indicating that both tissues originated from the same person. The results confirmed that the tumor was non-gestational in origin. Although the tumor was large, the authors performed hand- assisted laparoscopic surgical (HALS) staging. After three cycles of combination chemotherapy and surgery, the patient has not had any evidence of disease 48 months after treatment. This case demonstrates the usefulness of HALS staging and DNA polymorphism analysis in NGCO.

Intravitreal anti-vascular endothelial growth factor monotherapy for large submacular hemorrhage secondary to neovascular age-related macular degeneration

PURPOSE

To evaluate the efficacy of anti-vascular endothelial growth factor (VEGF) monotherapy for large submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (nAMD).

METHODS

A total of 49 treatment-naive patients (49 eyes) with large SMH (more than five disc areas (DAs)) secondary to nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly intravitreal anti-VEGF injections, followed by as-needed injections. At the 12-month follow-up, changes in best-corrected visual acuity (BCVA), hemorrhage area, central foveal thickness, and development of vitreous hemorrhage after treatment were evaluated.

RESULTS

The mean SMH area was 13.9 ± 8.8 disk areas (DAs) and mean symptom duration was 7.25 ± 5.9 days at baseline. The mean number of injections was 4.49 ± 1.61. Twelve months after treatment, the mean BCVA significantly improved from 1.14 ± 0.61 logarithm of the minimum angle of resolution (logMAR; 20/276, Snellen equivalent) to 0.82 ± 0.53 logMAR (20/132; P = 0.002). Twenty-four eyes (49%) showed improvement of more than three lines of BCVA at 12 months after treatment. Baseline BCVA (odds ratio (OR), 5.119; 95% confidence interval (CI), 1.993-9.545; P = 0.004), duration of symptoms (OR, 0.727; 95% CI, 0.332-0.952; P = 0.024), hemorrhage area (OR, 0.892; 95% CI, 0.721-0.965; P = 0.011), and baseline central foveal thickness (OR, 0.881; 95% CI, 0.722-0.945; P = 0.032) were significantly associated with good visual acuity 12 months after treatment.

CONCLUSIONS

Intravitreal anti-VEGF monotherapy is a valuable treatment option for large SMH secondary to nAMD.

The reliability and accuracy of measuring anteversion of the acetabular component on plain anteroposterior and lateral radiographs after total hip arthroplasty

There is no single standardised method of measuring the orientation of the acetabular component on plain radiographs after total hip arthroplasty. We assessed the reliability and accuracy of three methods of assessing anteversion of the acetabular component for 551 THAs using the PolyWare software and the methods of Liaw et al, and of Woo and Morrey. All measurements of the three methods had excellent intra- and inter-observer reliability. The values of the PolyWare software, which determines version of the acetabular component by edge detection were regarded as the reference standard. Although the PolyWare software and the method of Liaw et al were similarly precise, the method of Woo and Morrey was significantly less accurate (p < 0.001). The method of Liaw et al seemed to be more accurate than that of Woo and Morrey when compared with the measurements using the PolyWare software. If the qualified lateral radiograph was selected, anteversion measured using the method of Woo and Morrey was considered to be relatively reliable.

Left ventricular non-compaction progression to dilated cardiomyopathy following acute myocarditis in an early infant twin

Left ventricular non-compaction (LVNC), previously termed "spongy myocardium", is an abnormal interruption of myocardial compaction in early embryogenesis. It is now considered to be an important etiology of pediatric cardiomyopathy. Here, we report a case of 3-month-old twins with acute viral myocarditis, in which one of the twins, who had LVNC that progressed rapidly to dilated cardiomyopathy (DCMP) even after maximal medical therapy. The twin without LVNC recovered almost completely after supportive medical therapy. Although several reports have suggested that genetic abnormalities are associated with this disease, genetic research is needed to confirm this. This is the first report of LVNC in twins at 3 months of age who developed DCMP following acute fulminant myocarditis. In addition, this report highlights the fact that LVNC can be an important cause of DCMP, which can be rapidly aggravated after acute viral myocarditis during early infancy.

Beyond consolidation: auto-SCT and immunotherapy for plasma cell myeloma

Autologous hematopoietic cell transplantation (auto-HCT) is the standard consolidation therapy for plasma cell myeloma patients following induction therapy. Auto-HCT improves disease-free survival (DFS), but is generally not curative. The allogeneic HCT experience demonstrated that T-cell immunotherapy can confer long-term DFS. Preclinical and clinical data indicate that myeloma-associated Ags elicit humoral and cellular immune responses (IRs) in myeloma patients. These findings strongly suggest that the immunotherapeutic strategies, including immune checkpoint inhibitors, therapeutic cancer vaccines and adoptive cellular therapies, are promising avenues of clinical research that may be most applicable in the minimal residual disease state following auto-HCT. These strategies are designed to prime or augment antimyeloma IRs and promote a 'host-vs-myeloma' effect that may result in durable DFS. Innovative clinical trials investigating immune checkpoint inhibitors and cancer vaccines have demonstrated that robust immunity against myeloma-associated Ags can be elicited in the setting of auto-HCT. A diverse array of immunotherapeutic strategies have entered clinical trials in myeloma, including PD-1/PD-L1 inhibitors, DC/myeloma cell fusion vaccines and adoptive chimeric Ag receptor T-cell therapy, and further investigation of combinations of immunologic and pharmaceutical agents are expected in the near future. In this review, we will discuss the preclinical data supporting immunotherapy in auto-HCT for myeloma, clinical investigation of these strategies and the future prospects of immunotherapy in pursuit of the goal of curative therapy.

Total anomalous pulmonary venous return in siblings

Total anomalous pulmonary venous return (TAPVR) is a rare and critical congenital vascular anomaly that requires an early operation. However, initial symptoms of TAPVR may be non-specific, and cardiovascular findings may be minimal. The heart may not be enlarged and there is often no cardiac murmur. Without cardiac murmur, these symptoms are similar to those of respiratory distress syndrome in newborns. Therefore, a high degree of suspicion and an early diagnosis of TAPVR are important. This condition generally occurs without a family history and has a low recurrence rate, but several familial cases, including siblings, have been reported worldwide. Additionally, several chromosomal or gene abnormalities associated with TAPVR have been reported. In the case presented here, two brothers with a 6-year age gap were diagnosed with TAPVR. Surgery was performed without cardiac or neurological complications. This is the first report on TAPVR in siblings in Korea.

Concomitant ALK translocation and EGFR mutation in lung cancer: a comparison of direct sequencing and sensitive assays and the impact on responsiveness to tyrosine kinase inhibitor

BACKGROUND

Epidermal growth factor receptor (EGFR) mutation and anaplastic lymphoma kinase (ALK) translocation are considered mutually exclusive in nonsmall-cell lung cancer (NSCLC). However, sporadic cases having concomitant EGFR and ALK alterations have been reported. The present study aimed to assess the prevalence of NSCLCs with concomitant EGFR and ALK alterations using mutation detection methods with different sensitivity and to propose an effective diagnostic and therapeutic strategy.

PATIENTS AND METHODS

A total of 1458 cases of lung cancer were screened for EGFR and ALK alterations by direct sequencing and flourescence in situ hybridization (FISH), respectively. For the 91 patients identified as having an ALK translocation, peptide nucleic acid (PNA)-clamping real-time PCR, targeted next-generation sequencing (NGS), and mutant-enriched NGS assays were carried out to detect EGFR mutation.

RESULTS

EGFR mutations and ALK translocations were observed in 42.4% (612/1445) and 6.3% (91/1445) of NSCLCs by direct sequencing and FISH, respectively. Concomitant EGFR and ALK alterations were detected in four cases, which accounted for 4.4% (4/91) of ALK-translocated NSCLCs. Additional analyses for EGFR using PNA real-time PCR and ultra-deep sequencing by NGS, mutant-enriched NGS increased the detection rate of concomitant EGFR and ALK alterations to 8.8% (8/91), 12.1% (11/91), and 15.4% (14/91) of ALK-translocated NSCLCs, respectively. Of the 14 patients, 3 who were treated with gefitinib showed poor response to gefitinib with stable disease in one and progressive disease in two patients. However, eight patients who received ALK inhibitor (crizotinib or ceritinib) showed good response, with response rate of 87.5% (7/8 with partial response) and durable progression-free survival.

CONCLUSIONS

A portion of NSCLC patients have concomitant EGFR and ALK alterations and the frequency of co-alteration detection increases when sensitive detection methods for EGFR mutation are applied. ALK inhibitors appear to be effective for patients with co-alterations.

The association of radiographic progression with serum R-spondin 1 (RSPO1) levels or Dickkopf-1 (DKK1)/RSPO1 ratios in rheumatoid arthritis patients: clinical evidence for reciprocal inhibition between DKK1 and RSPO1

OBJECTIVES

To investigate the clinical implications of serum levels of R-spondin 1 (RSPO1), a natural antagonist for Dickkopf-1 (DKK1), and of DKK1/RSPO1 ratios in rheumatoid arthritis (RA) patients.

METHOD

Serum DKK1 and RSPO1 levels were measured in 102 RA patients and 39 age- and gender-matched healthy controls. In addition, DKK1 and RSPO1 levels were determined prior to and 3 months after anti-tumour necrosis factor alpha (anti-TNF-α) therapy in 15 RA patients. Clinical and laboratory data and baseline radiographs of the hands and feet were obtained. Serial radiographs were evaluated in 83 RA patients. Radiographic joint damage was assessed by the modified Sharp/van der Heijde score (SHS).

RESULTS

Serum RSPO1 levels were significantly reduced whereas serum DKK1 levels and DKK1/RSPO1 ratios were significantly increased in RA patients compared with controls (all p < 0.0001). Anti-TNF-α treatment significantly suppressed DKK1/RSPO1 ratios (p < 0.01). In contrast to DKK1 or RSPO1 levels, the ratios were significantly associated with erosive disease, elevated acute phase reactants, Disease Activity Score in 28 joints (DAS28) > 3.2, and radiographic progression rate (all p < 0.05). Although the RA patients with radiographic progression exhibited significantly increased DKK1 and reduced RSPO1 levels (p < 0.05), only the DKK1/RSPO1 ratio (log-transformed) was found to be a significant predictor of subsequent radiographic progression [odds ratio (OR) 2.07, p < 0.01].

CONCLUSIONS

In this study, the presence of RSPO1 in the circulation was shown for the first time. Our results suggest that the serum DKK1/RSPO1 ratio represents a better predictor of structural progression than either DKK1 or RSPO1 levels alone in RA patients.

Ascites associated with uterine leiomyoma in a 22-year-old woman with systemic lupus erythematosus

Ascites in systemic lupus erythematosus (SLE) patients has a variety of etiologies, which usually require different treatment options. Our case was a 22-year-old patient with an unusual combination of ascites, uterine leiomyoma and SLE. The patient presented with painless ascites of an inflammatory nature. However, the ascites was not related to peritonitis and SLE disease activity. The ascites disappeared following laparotomy and tumor resection without additional medication. Gynecologic benign tumors including uterine leiomyoma can be the cause of ascites in SLE patients. Clinicians should be aware of that possibility in case painless ascites occurs in females with SLE.

Comparison of alfuzosin 10 mg with or without propiverine 10 mg, 20 mg in men with lower urinary tract symptom and an overactive bladder: randomised, single-blind, prospective study

PURPOSE

The efficacy and safety of treatment with alfuzosin 10 mg plus propiverine 10 or 20 mg in men with lower urinary tract symptoms (LUTS) and an overactive bladder were investigated.

MATERIALS AND METHODS

In this parallel-arm, prospective, multicentre, single-blind study, men who were ≥ 40 years old, had an International Prostate Symptom Score (IPSS) of ≥ 8, an Overactive Bladder Symptom Score (OABSS) of ≥ 3 and an OABSS urgency item score of ≥ 2 were randomised in a 1 : 1 :1 ratio to receive alfuzosin 10 mg alone (Group A) or with propiverine 10 mg (Group B) or 20 mg (Group C) for 8 weeks. Four and 8 weeks after commencing treatment, OABSS was measured along with IPSS, maximal urinary flow rate (Qmax ) and postvoid residual volume (PVR). Adverse events were recorded.

RESULTS

A total of 135 men, including 43 in Group A, 48 in Group B and 44 in Group C, completed the study. Relative to baseline, all groups demonstrated significant reductions in OABSS and the IPSS after eight treatment weeks (p < 0.005). The improvement of OABSS in Group C was significantly greater than Group A and B (Group A: 0.70 ± 1.94; Group B: 2.50 ± 2.98; Group C: 4.30 ± 3.40; p < 0.005). An observed improvement of Qmax and PVR in the three groups did not achieve statistical significance. Overall adverse event rates were higher in Group C but not significant compared with others.

CONCLUSION

In patients with LUTS and overactive bladder, combined therapy with alfuzosin 10 mg plus propiverine 20 mg was significantly more effective than alfuzosin monotherapy and propiverine 10 mg combined therapy in terms of improving OABSS while not significantly affecting Qmax or PVR.

Meigs' syndrome with elevated serum CA 125 level in a case of ovarian fibrothecoma

Meigs' syndrome is the association of benign ovarian tumor, pleural effusion, and ascites. Meigs' syndrome with marked elevated CA 125 is a rare clinical entity and only 42 cases have been reported. Although there is difficulty in discerning the diagnosis of Meigs' syndrome from that of an ovarian malignancy, it should be considered in the differential diagnosis in postmenopausal patients with an ovarian mass, hydrothorax, ascites, and elevated CA 125. In this report, the authors present the case of a 52-year-old postmenopausal woman with ovarian fibrothecoma, pleural effusion, ascites, and elevated CA 125 (319.2 IU/ml). Exploratory laparotomy with total hysterectomy and bilateral salpingo-oophorectomy was performed, and the pathologic diagnosis was ovarian fibrothecoma. After the surgery, the pleural effusion disappeared spontaneously and the CA 125 became normal. The authors also summarized other cases of Meigs' syndrome with elevated CA 125, and reviewed the mechanism of elevation of CA 125, ascites, and pleural effusion.

Evaluation of inferior turbinate outfracture outcomes using computed tomography

BACKGROUND

Outfracture of the inferior turbinate (IT) presents numerous advantages, but it is generally believed that the lateralized IT will resume its original position. The purpose of this study was to evaluate the outcome of IT outfracture objectively using computed tomography (CT).

METHODOLOGY

Fifteen patients who underwent bilateral IT outfracture for the removal of pituitary adenomas by the endonasal approach were enrolled. The angles between the lateral wall of the nasal cavity (NC) and IT on both sides were measured from CT scans before and at least 6 months after operation. In addition, we evaluated the effects of variables including age, thickness of IT attachment site and width of the nasal floor, on the angles.

RESULTS

Regardless of the side where a Hardy retractor was placed, the angle between the lateral wall of the NC and IT decreased significantly within 6 months after the outfracture compared to preoperative values on both sides. Other variables showed no significant correlations with the angle between the IT and the lateral wall of the NC.

CONCLUSION

The outfracture procedure effectively lateralized the IT and it maintained that position for at least 6 months after the operation.

First Report of Leaf Spot in Farfugium japonicum Caused by Alternaria tenuissima in Korea

Farfugium japonicum (L.) Kitam (common name: Leopard plant) is known as a medical herb and belongs to family Asteraceae (1). In June 2012, a leaf spot disease was observed on the leaf surface of F. japonicum at a forest research plot Jinju, Gyeongnam province, Korea. More than 95% of F. japonicum plants were infected and leaf spot symptom appeared in the regions under our investigation. Light brownish symptoms initially developed and the spot size gradually increased and turned dark brown with an irregular shape as the disease progressed (spot size 1 to 10 mm in diameter). At the late stage of disease, spots became hollow and completely dehydrated. The infected leaves were easily crumbled, possibly due to dryness. To isolate the causal agent, the infected leaves were surface disinfected and pieces of leaves were placed on water agar (WA). Nine isolates were isolated from 10 pieces of the infected leaves. Fungi mycelia from the WA were transferred on potato dextrose agar (PDA) and incubated at 28°C for 7 days. The colonies were purple navy to black and conidia spores developed on the media. The morphological characteristics of spores were multi-septate, dark brown, pyriform, and 6.7 to 12.8 × 22.2 to 38.4 μm. The spores had 1 to 4 transverse and 0 to 3 longitudinal septa. The morphological characteristics of the isolates showed considerably similar to well-known Alternaria tenuissima (2). The leaf spot disease caused by A. cinerariae of F. japonicum was reported from Japan (3). Spores of A. cinerariae are golden brown to brown with 3 to 9 transverse and 0 to 6 longitudinal septa and are 87.5 × 28.7 μm (avg.) (3). To verify pathogenicity of the isolate, the pure cultured fungi on the PDA medium was taken (4 mm in diameter) and placed on healthy leaves of Leopard plant. The artificially inoculated leaves were placed on wet filter paper in Petri dishes and incubated at 25°C and 80% humidity. At 7 days after inoculation, similar disease symptoms developed on 8 out of 10 infected Leopard plant leaves. The pathogen was reisolated from artificially infected leaves. To identify in molecular biology level, genomic DNA was extracted and the ITS-rDNA region was amplified using universal primers ITS1 and ITS4. The amplified PCR product was purified and sequenced (528 bp) with ITS1 and ITS4 primers for both directions and then deposited in GenBank (Accession No. KC415611.1). The BLAST search showed that it matched previously reported A. tenuissima with 100% identity. To the best of our knowledge, this is the first report of Leopard plant leaf spot disease in Korea. References: (1) E. Y. Kim et al. J. Ethnopharmacol. 146:40, 2013. (2) E. G. Simmons. Page 1 in: Alternaria Biology, Plant Diseases and Metabolites. J. Chelchowski and A. Visconti, eds. Elsevier, Amsterdam, 1992. (3) T. Sakoda et al. Res. Bull. Pl. Prot. Japan 46:73, 2010.

Association of C-reactive protein and interleukin-6 with new-onset fatigue in the Whitehall II prospective cohort study

BACKGROUND

Although basic research on neuroimmune interactions suggests that inflammatory processes may play a role in the development of fatigue, population-based evidence on this association is limited. This study examined whether plasma C-reactive protein (CRP) and interleukin-6 (IL-6), biomarkers of systemic inflammation, predict fatigue onset.

METHOD

The Whitehall II study is a large-scale cohort study conducted in 20 civil service departments in London. Plasma CRP and IL-6 were measured in 4847 non-fatigued participants at phase 3 (1991-1993, aged 39-63 years). Fatigue was assessed using the Vitality subscale of the 36-item Short Form Health Survey (SF-36) at phase 3 and phase 4 (1995-1996).

RESULTS

During a mean follow-up of 3.1 years, 957 new fatigue cases (19.7%) were identified using the pre-established cut-off score of ≤ 50 on the Vitality subscale. CRP values were dichotomized as low (<1.0 mg/l ) or high (≥ 1.0 mg/l) using the Centers for Disease Control/American Heart Association recommendations. Similarly, IL-6 values were also dichotomized as low (<1.5 pg/ml) or high (≥ 1.5 pg/ml). After full adjustment for sociodemographic and biobehavioral covariates, the odds ratios for new-onset fatigue were 1.28 [95% confidence interval (CI) 1.09-1.49, p = 0.003] for high CRP and 1.24 (95% CI 1.06-1.45, p = 0.008) for high IL-6. Similar results were found when CRP and IL-6 were treated as continuous variables.

CONCLUSIONS

Plasma CRP and IL-6 were prospectively associated with new-onset fatigue, supporting the hypothesis that low-grade inflammation has a role in the development of fatigue.

Efficacy of vasectomy reversal according to patency for the surgical treatment of postvasectomy pain syndrome

This study was conducted to assess outcomes (according to patency) of vasectomy reversal (VR) in qualified patients with postvasectomy pain syndrome (PVPS). A total of 32 patients with PVPS undergoing VR between January 2000 and May 2010 were examined retrospectively. Of these, 68.8% (22/32) completed a study questionnaire, either onsite at the outpatient clinic or via telephone interview. Preoperative clinical findings, preoperative and postoperative visual analogue scale (VAS) pain scores, patency and pregnancy rate and overall patient satisfaction were analyzed. For the latter, a four-point rating of (1) cure, (2) improvement, (3) no change or (4) recurrence was used. The mean age was 45.09±4.42 years and the mean period of follow-up was 3.22 years (0.74-7.41). Patency rates were 68.2% (15/22) and pregnancy rates were 36.4% (8/22). The mean VAS was 6.64±1.00 preoperatively and 1.14±0.71 postoperatively (P<0.001). The difference in the mean preoperative and postoperative VAS was 6.00±1.25 (4-8) in the patency group and 4.43±0.98 (3-6) in the no patency group (P=0.011). A significant difference in procedural satisfaction with surgical outcome was observed between patency and no patency groups (P=0.014). In conclusion, in PVPS patients requiring VR, a significant difference was observed between the patency and no patency groups in terms of pain reduction and the degree of patient procedural satisfaction.

Effects of a priming dose of fentanyl during anaesthesia on the incidence and severity of fentanyl-induced cough in current, former and non-smokers

Fentanyl is commonly used during anaesthesia and can cause fentanyl-induced cough (FIC). This study investigated whether a priming dose of fentanyl reduced FIC, and determined the factors associated with increased risk of FIC. Subjects undergoing elective surgery under general anaesthesia (n = 800) were randomized into four groups: group 1 received 2 μg/kg fentanyl bolus; groups 2, 3 and 4 received a priming dose of fentanyl 0.5 μg/kg followed by 1.5 μg/kg after 1, 2 or 3 min, respectively. The incidence of FIC was 17.0%, 10.0%, 12.5% and 11.5% for groups 1, 2, 3 and 4, respectively, with no significant between-group differences in FIC incidence or severity. The mean FIC onset time was 22 s. Former smokers were 2.91 times more likely than current smokers to experience cough. A fentanyl priming dose did not reduce the incidence and severity of FIC. Former smokers were hyper-reactive to fentanyl compared with current smokers.

Recanalization with Wingspan stent for acute middle cerebral artery occlusion in failure or contraindication to intravenous thrombolysis: a feasibility study

BACKGROUND AND PURPOSE

Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent.

MATERIALS AND METHODS

We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results.

RESULTS

Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4-21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0-13). At discharge, an mRS of ≤ 3 was achieved in all patients and an mRS of ≤ 2 was achieved in 7 patients (70%).

CONCLUSIONS

This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.

Posterior Reversible Encephalopathy Syndrome in Early Postpartum Woman

There have been reports about posterior reversible encephalopathy syndrome (PRES) associated with pregnancy, especially peripartum. However, the pathophysiology of PRES is not still clear. Tonic-clonic seizure occurred during early postpartum in a woman with the tendency toward pre-eclampsia developed after vaginal delivery followed by emergency cesarean hysterectomy. Postictal findings included headache, loss of vision, and short-term memory loss and magnetic resonance imaging (MRI) findings suggesting PRES were noted. Neurologic symptoms and cerebral lesions were gradually improved with immediate supportive managements.

Intravitreal bevacizumab and ranibizumab injections for patients with polypoidal choroidal vasculopathy

PURPOSE

To compare the effectiveness of intravitreal injection of bevacizumab and ranibizumab in patients with treatment-naïve polypoidal choroidal vasculopathy (PCV).

METHODS

A total of 66 and 60 eyes of 121 consecutive patients who received intravitreal bevacizumab (1.25 mg) or ranibizumab (0.5 mg) injection for treatment of PCV were retrospectively reviewed. After initial three loading injections by month, injection was performed as needed. Main outcome measures included best corrected visual acuity (BCVA), foveal center thickness (FCT) as assessed by spectral domain optical coherence tomography (SD-OCT), and change in polypoidal lesion on indocyanine green angiography (ICGA).

RESULTS

At 12 months, average number of injections was 4.72±1.84 in the bevacizumab group and 5.52±1.54 in the ranibizumab group. Mean logarithm of the minimum angle of resolution of BCVA from baseline at 12 months after injection improved by 0.11 in the bevacizumab group (P=0.02) and by 0.14 in the ranibizumab group (P=0.01). Average FCT decreased from 368±62.48 to 298±40.77 μm in the bevacizumab group (P=0.01) and from 371±50.79 to 286±36.93 μm in the ranibizumab group (P=0.01). Polyp regression rate was 24.2% (16 eyes out of 66 eyes) in the bevacizumab group and 23.3% (14 eyes out of 60 eyes) in the ranibizumab group. There was no statistically significant difference in BCVA improvement achieved, FCT improvement achieved, and polyp regression rate between groups.

CONCLUSION

Intravitreal injections of bevacizumab and ranibizumab have similar effects in stabilization of visual acuity, macular edema, and regression of polypoidal complex with PCV eyes.

Effect of warfarin withdrawal on thrombolytic treatment in patients with ischaemic stroke

BACKGROUND AND PURPOSE

  Abruptly discontinuing warfarin may induce a rebound prothrombotic state. Thrombolytic agents may also paradoxically induce prothrombotic conditions, which include platelet activation and thrombin generation. Therefore, prothrombotic states may be enhanced by withdrawing warfarin in patients under thrombolytic treatment. This study was aimed to determine whether patients with warfarin withdrawal have different clinical outcomes from those without warfarin use after thrombolytic treatment.

METHODS

  A total of 148 consecutive patients with atrial fibrillation who were not on anticoagulants at admission and who received thrombolysis were included in this study. We compared the outcomes between a warfarin withdrawal group and a no-warfarin group.

RESULTS

  Fourteen patients (9.5%) were included in the warfarin withdrawal group. Although baseline National Institute of Health Stroke Scale (NIHSS) scores, recanalization rates, and hemorrhage frequencies did not differ between the groups, the warfarin withdrawal group showed poorer outcomes. Increased NIHSS scores during the first 7days were more frequent in the warfarin withdrawal group (57.1% vs. 26.9%, P=0.029). The median percent improvement in NIHSS scores at 24h after thrombolysis was also lower in the warfarin withdrawal group. After adjusting for covariates, warfarin withdrawal was a strong predictor of poor functional outcome at 3months (modified Rankin score≥3) (odds ratio, 17.067, 95% CI 2.703-107.748).

CONCLUSIONS

  Discontinuing warfarin was associated with early neurologic deterioration and poor long-term outcomes after thrombolytic treatment.

The different infarct patterns between adulthood-onset and childhood-onset moyamoya disease

BACKGROUND AND PURPOSE

The pattern of infarctions based on the findings of diffusion-weighted image was assessed, and it was also investigated whether there are any age-specific differences in patients with moyamoya disease (MMD).

METHODS

The subjects were 66 consecutive patients with MMD who had an acute cerebral infarction. Each ischaemic lesion was categorised into one of seven patterns (gyral, atypical territorial, honeycomb, classic territorial, multiple-dot, borderzone, deep lacunar) based on diffusion-weighted image findings. The patterns were compared between adulthood-onset MMD (A-MMD, ≥20 years old, 34 patients) and childhood/adolescent-onset MMD (C-MMD, <20 years old, 32 patients) according to their ages of infarct presentation.

RESULTS

A total of 91 infarct patterns were observed from 66 patients. The gyral, atypical territorial, and honeycomb patterns, which are not usually seen in conventional stroke patients, were common in MMD (68.1%). Among all patterns, a gyral pattern was most common (40/91, 44.0%). Borderzone and deep lacunar patterns were infrequent. Gyral and borderzone patterns were more frequently seen in the C-MMD group, whereas a honeycomb pattern was not seen in young patients. Honeycomb pattern was more common at advanced vascular stages. Infarctions confined to the cortex were more common in the C-MMD group (26/32, 75.0%) than in A-MMD patients (14/34, 41.2%).

CONCLUSIONS

Moyamoya disease showed various characteristic and age-specific infarct patterns. Different infarct patterns between the A-MMD and C-MMD groups may be associated with age-specific vulnerability of the brain to ischaemia, stage of arteriopathy or changes of abnormal collateral pathways.

Evaluation of the usefulness of the fetal femur length with respect to gestational age to detect Down syndrome in Korean subjects

OBJECTIVE

We investigated the usefulness of shortening of the fetal femur length (FL) to predict Down syndrome at different gestational ages in Korean subjects.

METHODS

This study involved 110 Korean Down syndrome fetuses and 602 randomly selected euploid controls. The expected FL for any biparietal diameter (BPD) was calculated based on the control group data. Subjects were divided into four groups according to gestational age periods: 14-18 weeks; 19-23 weeks; 24-28 weeks and 29-36 weeks. The value of measured/expected FL ratio to predict Down syndrome was analyzed for each group.

RESULTS

The values of FL for any BPD in Down syndrome patients were significantly different from those in the control group (p < 0.001). A low ratio of measured/expected FL increased the risk of fetal Down syndrome (p < 0.001) with a mean measured/expected FL in Down syndrome of 0.907 (SD 0.075). At a fixed false positive rate of 5%, the sensitivities of FL were lower than 32.8% (95% CI 0.705-0.915) in three second trimester groups, and 71.1% (95% CI 0.924-0.997) in the third trimester group.

CONCLUSION

Short FL is a poor marker of Down syndrome in the second trimester in Korean subject. It may be used as a screening marker only in the third trimester.

Socioeconomic differentials in cause-specific mortality among 1.4 million South Korean public servants and their dependents

BACKGROUND

A growing number of investigations have explored the contribution of cause of death to socioeconomic inequalities in mortality in Europe and North America, but few such studies have been performed on Asian populations.

OBJECTIVES

To analyse the socioeconomic inequality of cause-specific death rates from both an absolute and relative perspective, and to evaluate the contribution of cause of death to total mortality inequality in South Korea.

METHODS

Data were obtained from public servant health insurance beneficiary records. 1,403,297 subjects aged 35-64 years were followed for 9 years. Health insurance premium levels were used as a socioeconomic position indicator. The outcome variables were all-cause, 11 broad causes and 41 specific causes of death. Mortality differentials were examined using cause-specific age-adjusted mortality, relative indices of inequality, and slope inequality indices.

RESULTS

Graded inverse associations between income and mortality were found for most, but not all, specific causes of death. The major contributors to income differentials in total mortality in men were liver disease (15.4%), stroke (12.8%), land transport accidents (10.0%), lung cancer (7.1%) and liver cancer (7.0%). In women, stroke (30.7%), diabetes (9.1%), land transport accidents (6.6%), liver cancer (6.0%) and liver disease (5.1%) were important. Conclusions The contribution of the cause of death to socioeconomic inequality in mortality in South Korea differed from Western countries. To develop a policy to reduce the magnitude of socioeconomic inequality, an understanding of the major causes of death that contribute to mortality inequality is required.