Relationships between Microbiome and Response to Neoadjuvant Chemoradiotherapy in Rectal Cancer

PURPOSE/OBJECTIVE(S)

Gut microbiome is known to be involved in antitumor immunotherapy and chemotherapy responses; however, few research has focused on the role of gut microbiome in the setting of concurrent chemoradiotherapy (CCRT). In this study, we investigated the tumor microbiome dynamics in patients undergoing neoadjuvant CCRT for locally advanced rectal cancer and sought to determine whether the diversity and composition of microbiome affect treatment response.

MATERIALS/METHODS

A total of 103 samples from 26 patients with locally advanced rectal cancer were collected and 16S ribosomal RNA amplicon sequencing was performed. All patients underwent neoadjuvant CCRT followed by surgical resection between 2008 and 2016. Samples were obtained from both tumor and normal rectal tissue at pre- and post-CCRT. According to the American Joint Committee on Cancer tumor regression grading (TRG) system, patients were divided into responders (TRG 0, 1) and non-responders (TRG 2, 3). We performed diversity, taxonomy, and network analyses to compare responders and non-responders. Then, we established the Bayesian network model to predict treatment response in patients with rectal cancer.

RESULTS

Overall, we detected 1260 microbial genera from 287 families, 132 orders, 56 classes, and 32 phyla in the bacteria kingdom. Between tumor and normal rectal tissues, there was no difference in microbial diversity and composition. On the other hand, there was a significant decrease in diversity and compositional alterations when comparing pre- and post-CCRT samples (all p<0.001). Ten patients (38.5%) were classified as responders and 16 patients (61.5%) were classified as non-responders. In both groups, CCRT significantly reduced microbial diversity and altered their composition, but it was more pronounced in non-responders. In taxonomic analysis of pre-CCRT samples, butyrate-producing bacteria were differentially enriched in responders. Meanwhile, in post-CCRT samples, opportunistic pathogen were overrepresented in non-responders. The network analysis revealed that butyrate-producing bacteria had strong interactions in responders, whereas opportunistic pathogen demonstrated strong interactions in non-responders (Pearson's coefficient>0.5). Finally, five microbes were selected as the optimal set for the response prediction model, which yielded an area under the curve value of 82.33%.

CONCLUSION

CCRT significantly changed the diversity and composition of microbiome, especially in non-responders. Several microbes might be related with treatment response. These findings highlight the potential of microbiome to play an important role as a biomarker in patients with rectal cancer. (NCT02533271).

Treatment Outcomes of Stereotactic Body Radiation Therapy for Pulmonary Metastasis from Sarcoma: A Multicenter, Retrospective Study

PURPOSE/OBJECTIVE(S)

The aim of this study was to evaluate the treatment outcomes and potential dose-response relationship of stereotactic body radiation therapy (SBRT) for pulmonary metastasis of sarcoma.

MATERIALS/METHODS

A retrospective review of 39 patients and 71 lesions treated with SBRT from two institutions was performed. The patients had oligometastatic or oligoprogressive disease, or were receiving palliation. Doses of 20-60 Gy were delivered in 1-5 fractions. The local control per tumor (LCpT) was evaluated according to the biologically effective dose with an α/β ratio of 10 (BED10) of the prescribed dose (BED10 ≥ 100 Gy vs. BED10 < 100 Gy). Clinical outcomes per patient, including local control per patient (LCpP), pulmonary progression-free rate (PPFR), any progression-free rate (APFR), and overall survival (OS) were investigated.

RESULTS

The median follow-up period was 27.2 months. The 1-, 2-, and 3-year LCpT rates for the entire cohort were 100.0%, 88.3%, and 73.6%, respectively. There was no observed difference in LCpT between the two BED10 groups (p = 0.180). The 3-year LCpP, PPFR, APFR, and OS rates were 78.1%, 22.7%, 12.9%, and 83.7%, respectively. Five (12.8%) patients with oligometastasis had long-term disease-free intervals, with a median survival period of 40.7 months. Factors that were associated with a worse prognosis were oligoprogression (vs. oligometastasis), multiple pulmonary metastases, and simultaneous extrathoracic metastasis.

CONCLUSION

SBRT for pulmonary metastasis of sarcoma is effective. Some selected patients may achieve durable response. Considerations of SBRT indication and disease extent may be needed as they may influence the prognosis.

OP0151 PREDICTION OF RADIOGRAPHIC PROGRESSION IN PATIENTS WITH ANKYLOSING SPONDYLITIS: USING GROUP-BASED TRAJECTORY MODELING AND DECISION TREE ANALYSIS

Background

Ankylosing spondylitis (AS) tends to develop at a relatively young age and is characterized by long-term disease progression (1). During that time, various radiographic changes occur in the spine, which eventually lead to disability in the patient’s lifetime (2). Although the duration of the disease, aging, and passage of time are predicted to be highly associated with spinal progression of AS, it is difficult to predict its progression in the spine of patients.

Objectives

We aimed to find ways to predict spinal progression over time in patients with AS and analyze its associated clinical factors.

Methods

Data from the medical records from a single center were extracted between 2001 and 2018. We analyzed the data on patients who fulfilled the modified New York Criteria for AS and had two or more sets of radiographs taken during the observation period. The modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) was estimated by two independent radiologists. Group-based trajectory modeling (GBTM) was used to classify patients into distinct subgroups of longitudinal mSASSS. And when these trajectories and statistically associated factors acted on a patient, which group the patient was most likely to belong to was predicted using a decision tree analysis.

Results

Data on 1,125 patients were analyzed, and the trajectories were evaluated by dividing them into three groups based on duration of the disease. We confirmed that sex, age at diagnosis, ocular involvement and peripheral joint involvement were associated with the classified spinal progression trajectories. AS onset in older age and ocular involvement were associated with worse radiographic progression, while female sex and peripheral joint involvement were associated with slower radiographic progression (Figure 1 and Table 1).

Table 1.

Multivariate logistic regression analysis for predictors of mSASSS progression according to disease duration (class 2 and other classes)

VariablesUnivariateMultivariableOROR 95% CIp-valueOROR 95% CIp-valueLowerUpperLowerUpperSex2.021.392.94<0.0012.411.384.210.002Age at diagnosis (10y)0.500.430.58<0.0010.510.420.61<0.001Ocular involvement0.610.470.80<0.0010.610.440.840.003Peripheral involvement2.141.652.79<0.0012.561.863.52<0.001HLA B27 positivity0.610.321.160.133Smoking*<0.0010.444Ex-smoker0.480.340.62<0.0010.780.521.160.218Smoker0.560.410.73<0.0010.840.571.230.364Baseline BASDAI1.000.921.090.950Baseline ESR1.001.001.000.013Log baseline ESR0.770.700.85<0.0010.780.690.88<0.001Baseline CRP0.980.941.030.476Log baseline CRP0.780.660.910.002¶¶¶¶

Note: Bold text means statistically significant values.

*Analysis with non-smoker as a reference.

¶It was excluded when performing multivariate analysis due to multicollinearity.

Figure 1.

Longitudinal mSASSS trajectory groups for disease duration (A) and decision tree for three trajectory classes (B). (A) Time in month is shown along the x-axis, and logarithmic transformed total mSASSS is shown along the y-axis. The solid line represents the estimated mean in the same-colored area representing the 95% confidence interval. (B) In each terminal node, the class written in bold text is the class representing that node.

Conclusion

We identified three patterns of radiographic progression according to duration of the disease. The progression trend of patients with AS identified in this study is expected to be helpful in the treatment and management of patients in actual clinical settings.

References

[1]Braun A, Saracbasi E, Grifka J, Schnitker J, Braun J. Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain? Ann Rheum Dis. 2011;70(10):1782-7.

[2]Poddubnyy D, Listing J, Haibel H, Knuppel S, Rudwaleit M, Sieper J. Functional relevance of radiographic spinal progression in axial spondyloarthritis: results from the GErman SPondyloarthritis Inception Cohort. Rheumatology (Oxford). 2018;57(4):703-11.

Disclosure of Interests

None declared

Hypervalency in amorphous chalcogenides

The concept of hypervalency emerged as a notion for chemical bonding in molecules to explain the atomic coordination in hypervalent molecules that violates the electron-octet rule. Despite its significance, however, hypervalency in condensed phases, such as amorphous solids, remains largely unexplored. Using ab initio molecular-dynamics simulations, we report here the underlying principles of hypervalency in amorphous chalcogenide materials, in terms of the behaviour of hypervalent structural units, and its implicit relationship with material properties. The origin of a material-dependent tendency towards hypervalency is made evident with the multi-centre hyperbonding model, from which its relationship to abnormally large Born effective charges is also unambiguously revealed. The hyperbonding model is here extended to include interactions with cation s² lone pairs (LPs); such deep-lying LPs can also play a significant role in determining the properties of these chalcogenide materials. The role of hypervalency constitutes an indispensable and important part of chemical interactions in amorphous and crystalline chalcogenide solids.

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.

Pre-operative assessment of facial recess width in paediatric cochlear implant recipients: a radiological study

Background

The location of the vertical segment of the facial nerve varies greatly among patients undergoing otological surgery. Its position relative to the incus determines facial recess width, which has implications for ease of cochlear implantation.

Objective

To investigate the variation in facial nerve depth, relative to the incus, on pre-operative computed tomography in patients undergoing cochlear implantation.

Methods

A retrospective cohort study was conducted of paediatric patients undergoing cochlear implantation at a tertiary referral centre. Distance between the incus short process and facial nerve, in the transverse (medial-lateral) dimension, was measured at six imaging slices, ranging from 1.25 to 7.25 mm below the tip of the incus short process.

Results

Facial nerve depth relative to the incus short process demonstrated significant variability. Among all subjects and at all measurements taken inferior to the incus, the mean dimension between the facial nerve and the incus short process was 1.71 mm.

Conclusion

This paper presents a rapid, repeatable technique to assess the depth of the facial nerve vertical segment on pre-operative computed tomography, as measured relative to the tip of the incus short process. This allows the surgeon to anticipate facial recess width and round window access during cochlear implantation.

Risk factors for local recurrence and long term survival after minimally invasive intersphincteric resection for very low rectal cancer: Multivariate analysis in 161 patients

INTRODUCTION

Intersphincteric resection (ISR) is the ultimate anal-sparing technique as an alternative to abdominoperineal resection in selected patients. Oncological safety is still debated. This study analyses long-term oncological results and evaluates risk factors for local recurrence (LR) and overall survival (OS) after minimally-invasive ISR.

MATERIALS AND METHODS

Retrospective single-center data were collected from a prospectively maintained colorectal database. A total of 161 patients underwent ISR between 2008 and 2018. OS and local recurrence-free survival (LRFS) were assessed using Kaplan-Meier analysis (log-rank test). Risk factors for OS and LRFS were assessed with Cox-regression analysis.

RESULTS

Median follow-up was 55 months. LR occurred in 18 patients. OS and LRFS rates at 1, 3, and 5 years were 96%, 91%, and 80% and 96%, 89%, and 87%, respectively. Tumor size (p = 0.035) and clinical T-stage (p = 0.029) were risk factors for LRFS on univariate analysis. On multivariate analysis, tumor size (HR 2.546 (95% CI: 0.976-6.637); p = 0.056) and clinical T-stage (HR 3.296 (95% CI: 0.941-11.549); p = 0.062) were not significant. Preoperative CEA (p < 0.001), pathological T-stage (p = 0.033), pathological N-stage (p = 0.016) and adjuvant treatment (p = 0.008) were prognostic factors for OS on univariate analysis. Preoperative CEA (HR 4.453 (95% CI: 2.015-9.838); p < 0.001) was a prognostic factor on multivariate analysis.

CONCLUSIONS

This study confirms the oncological safety of minimally-invasive ISR for locally advanced low-lying rectal tumors when performed in experienced centers. Despite not a risk factor for LR, tumor size and, locally advanced T-stage with anterior involvement should be carefully evaluated for optimal surgical strategy. Preoperative CEA is a prognostic factor for OS.

Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study

INTRODUCTION

This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial.

METHODS

Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations.

RESULTS

320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%).

CONCLUSION

After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.

A multicentre comparative study between laparoscopic and open surgery for intussusception in adults

AIM

Intussusception in adults is rare and requires surgery in most cases. While abdominal laparoscopic surgery (LS) is becoming more popular, there are few reports on the outcomes of adult intussusception treated with LS. This study compared the feasibility of LS vs open surgery (OS) for adult intussusception.

METHOD

We reviewed retrospectively the medical records of adult patients with intussusception from three tertiary hospitals between 2000 and 2016. The patients were divided into LS and OS groups, and their surgical outcomes were compared.

RESULTS

Surgery was indicated in 71 patients with intussusception (41 LS and 30 OS). The median age of the patients was 49.0 and 51.5 years in the LS and OS groups, respectively (P = 0.930). Overall, nine (12.7%) patients had a negative laparotomy or laparoscopy with spontaneous reduction of the intussusception. Conversion to OS from LS was necessary in one patient (2.4%). The operative time and intra-operative and postoperative complication rates were not significantly different. However, there were more serious complications such as bowel perforation and major vessel injury in the LS group. The patients in the LS group had a shorter time to first food intake and hospital stay vs patients in the OS group (4.0 vs 6.0 days, P < 0.001, and 7.0 vs 10.5 days, P < 0.001, respectively).

CONCLUSION

LS may be feasible for adult intussusception; there may be more severe intra-operative complications than in OS.

FRI0282 CONVENTIONAL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS THERAPY HAS NO EFFICACY IN SLOWING SPINAL RADIOGRAPHIC PROGRESSION IN ANKYLOSING SPONDYLITIS: RESULTS FROM 18-YEAR LONGITUDINAL DATA

Background:

In the treatment of ankylosing spondylitis (AS), conventional disease-modifying antirheumatic drugs (cDMARDs) are generally recommended only in patients with peripheral arthritis. However in daily clinical practice, sulfasalazine (SSZ) and methotrexate (MTX) have still been considered on the basis of their anti-inflammatory effect when non-steroidal anti-inflammatory drugs (NSAIDs) are not available and when it is difficult to start tumor necrosis factor (TNF) inhibitors. Nonetheless there is few data about the impact of the cDMARDs on the prognosis of spinal progression.

Objectives:

The aim of this study was to investigate the effectiveness of SSZ and MTX on the spinal radiographic progression in patients with AS.

Table 1.

Association of clinical covariates and DMARD intervals with the rate of mSASSS change

VariableMultivariate analysisModel 1Model 2β (95% CI)pβ (95% CI)pOn-DMARD intervals-0.081 (-0.276 to 0.115)0.418On-SSZ intervals-0.001 (-0.211 to 0.189)0.913On-MTX intervals-0.180 (-0.439 to 0.078)0.172Sex (female)-0.449 (-0.782 to -0.117)0.008-0.440 (-0.775 to -0.105)0.010Age0.012 (-0.001 to 0.026)0.0610.012 (-0.001 to 0.025)0.076Eye involvement0.572 (0.264 to 0.880)< 0.0010.577 (0.268 to 0.886)< 0.001Peripheral joint involvement-0.508 (-0.810 to -0.206)0.001-0.513 (-0.817 to -0.210)0.001HLA-B27 positivity††NSAIDs††Glucocorticoids††ESR (log)0.176 (0.087 to 0.265)< 0.0010.178 (0.088 to 0.268)< 0.001BASDAI (square root)††

†Not included in the model because the value did not show potentially significant association in univariate analysis (p > 0.1).

Methods:

A total of 301 patients who have been treated with cDMARDs were enrolled from 1,280 patients in a single center cohort during 18 years of follow up. For each patient, time intervals of periods were created according to the prescription records. ‘On-DMARD’ intervals were time intervals of periods with SSZ or MTX treatment and ‘off-DMARD’ intervals were time intervals of periods without both SSZ and MTX treatment. The intervals were the periods excluding the treatment periods of TNF inhibitors. Radiographic progression was evaluated by the rate of Modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS) change, an increase or decrease of mSASSS change per year. A generalized estimating equation models with adjustment for confounding covariates were used to evaluate the efficacy of cDMARDs on the radiographic progression.

Results:

The number of 732 on-DMARD intervals and 1,027 off-DMARD intervals were obtained. Among the on-DMARD intervals, the proportion of intervals treated with SSZ (on-SSZ intervals), MTX (on-MTX intervals) and both of them (on-SSZ/MTX intervals) were 96.2%, 19.9% and 16.1%, respectively. In the multivariable regression analysis, there was no significant decrease in the rate of mSASSS change during cDMARDs therapy (β = -0.081, p = 0.418) (Table 1). And the mean rate of mSASSS change were 0.61 during on-DMARD intervals and 0.69 during off-DMARD intervals after adjustment of other covariates.

Conclusion:

Treatment with cDMARDs in AS did not show significant impact in retarding spinal progression. In patients with AS, treatment with biologics rather than cDMARDs may be more effective in slowing radiographic progression.

Disclosure of Interests:

None declared

SAT0575 POSITIVE QuantiFERON-TB GOLD TEST AND SEROCONVERSION OF QunatiFERON-TB GOLD TEST IS ASSOCIATED WITH INCREASED RISK OF THE DEVELOPMENT OF ACTIVE TUBERCULOSIS IN PATIENTS WITH ANKYLOSING SPONDYLITIS: RESULTS FROM A REAL-WORLD DATA OVER 20 YEARS

Background:

With the promising efficacy and the prevalent use of anti-tumor necrosis factor-α (TNF) agents in managing AS, the risk for reactivation of latent tuberculosis infection (LTBI) still is a concern. Although guidelines include the screening and treatment of LTBI prior to the initiation of anti-TNF agent by QuantiFERON-TB Gold (QFT-G) or tuberculin test, there is a lack of evidence whether treatment of LTBI before initiation of anti-TNF agent may reduce the risk of reactivation to the same as LTBI patient without anti-TNF agent or anti-TNF agent users without LTBI. Furthermore, evidence on the need for follow-up testing and the association between seroconversion and the development of active tuberculosis is also limited.

Objectives:

This study aims to investigate the real-world impact of QFT-G test on the development of active tuberculosis in patients with AS.

Methods:

This retrospective study investigated 2,930 patients who had a diagnosis of AS and conducted QFT-G testing during the period of March 1998 to June 2019. 191 patients with history of treatment for LTBI or acute tuberculosis prior to the first QFT-G test and 157 patients whose hospital visits or prescription was less than 3 were excluded. Observational period was defined from the firs QFT-G test to the last hospital visit of development of active tuberculosis. The screening for development of active tuberculosis was conducted by reviewing the diagnosis, prescription of anti-tuberculosis medication, chest images and electronic medical record. Treatment of LTBI was defined when a patient was prescribed isoniazid for at least 220 for 12 months, rifampin for at least 90 days for 6 months, or concurrently prescribed isoniazid and rifampin for at least 70 days for 4 months. Wilcoxon rank-sum test, chi-square test and cox-proportional hazard analysis were performed.

Results:

A total of 2687 patients (median age 32.7 years, 78.4% male, anti-TNF agent user 16.7%) were included. Baseline QFT-G was positive in 426 (20.3%) patients, and 15 active tuberculosis was observed [Incidence rate 1.5/1000 person years (PY)]. Compared with baseline QFT-G (-) patients, baseline QFT-G (+) patients were older (41.2 years vs. 31.3 years, p<0.001) and they were accompanied with more active tuberculosis (4.4/1000PY vs. 1.0/1000PY) despite the less usage of anti-TNF agents (38.5% vs 45.8%, p=0.006). The observational period, sex, and medication utilization pattern except anti-TNF agent were similar between two groups. Multivariable analysis showed that QFT-G (+) test increases the risk of active tuberculosis more than 10 times [adjusted hazard ration 17.0, 95% confidence interval (CI) 5.1-56.8, p<0.001] after adjusting age, sex and the usage of anti-TNF agents.

Then we conducted subgroup analysis on 965 patients with baseline QFT-G (-) and follow-up QFT-G tests. Seroconversion was documented in 65 patients (6.7%). Active tuberculosis was observed in 4 patients, and seroconversion was occurred before the development of active tuberculosis in all patients. The incidence of active tuberculosis in seroconversion patients were 10.5/1000PY.

Conclusion:

QFT-G (+) and QFT-G seroconversion is associated with increased risk of the development of active tuberculosis in patients with AS.

Figure 1.

Overview of patient flow

Disclosure of Interests:

None declared

SAT0592 MORTALITY AND CAUSE OF DEATH IN KOREAN PATIENTS WITH RHEUMATOID ARTHRITIS: BASED ON A LARGE COHORT

Background:

Rheumatoid arthritis (RA) is a common chronic inflammatory disease characterized by arthritis of multiple joints. Although the use of corticosteroid and extra-articular complications may lead increased mortality of patients with RA and it have been confirmed by hundreds of studies, the prognosis of RA has improved over the past decades with the introduction of biologics disease-modifying anti-rheumatic drugs and treat-to-target strategy. Along with the increase of overall survival of RA, the needs for re-assessment of actual life expectancy in patients with RA have also been increased.

Objectives:

To investigate the cause and the risk of death of Korean patients with RA in a large RA cohort.

Methods:

We analyzed patients in Hanyang BAE RA cohort who fulfilled the American College of Rheumatology criteria. A total of 2,355 patients were enrolled from October 2001 to December 2015. Mortality data were derived by linking with data from the Korean National Statistical Office and date and cause death were identified. Standardized Mortality Ratio (SMR) was estimated by dividing the observed deaths by the expected number of deaths of age- and sex- matched general population. Confidence intervals were calculated based on the Poisson distribution.

Table 1.

Comparison of demographic and clinical characteristics of analyzed patients

TotalDied patientsSurvivorsP value(n=2,355)(n=225)(n=2,130)Age at onset41.8 ± 12.849.7 ± 12.741.0 ± 12.5<0.001Age at enrollment50.8 ± 12.363.3 ± 9.449.5 ± 11.8<0.001Male265 (11.3)42 (18.7)223 (10.5)<0.001Disease duration18.1 ± 10.420.7 ± 10.917.8 ± 10.3<0.001Observation period9.0 ± 4.47.0 ± 3.69.2 ± 4.5<0.001Smoking<0.001 Never smoker1,953 (83.9)161 (74.9)1,792 (84.8) Former smoker212 (9.1)36 (16.7)176 (8.3) Current smoker164 (7.0)18 (8.4)146 (6.9)Comorbidity Hypertension330 (14.0)63 (28.0)267 (12.5)<0.001 Diabetes mellitus106 (4.5)24 (10.7)82 (3.9)<0.001

*Values are number (%) or mean ± standard deviation. ** Missing data were excluded from analysis.

Results:

Over the observation period, 225 deaths were reported. The age at enrollment was 50.8 ± 12.3 years and disease duration was 18.1 ± 10.4 years. The most common cause of death was malignancy (40 cases) followed by respiratory disease (38 cases), cardiovascular disease (32 cases) and musculoskeletal disease (21 cases). Total SMR was increased [1.7, 95% CI 1.5-2.0] but age- and sex- adjusted SMR was not increased [SMR 1.0, (95% CI 0.9-1.1)]. When we classify patients by age conduct subgroup analysis, sex-adjusted SMR was also similar with that of general population by all group: the adjusted SMR in patients aged 15-39, aged 40-59 and aged over 60 were 0.7 (observed death 1, expected death 1.5, 95% CI 0-2.0), 0.9 (observed death 29, expected death 32 95% CI 0.6-1.3), and 0.9 (observed death 195, expected death 221.0, 95% CI 0.8-1.0), respectively. Compared with survivors, patients who died were more likely to be male (18.7% vs. 10.5%, p<0.001) and they had an older age of onset of RA (49.7 years vs. 41.0 years, p<0.001). Died patients were more likely to be current smoker or ever smoker (25.1% vs. 15.2%, p<0.001) and accompanied by more comorbidities including hypertension (28.0% vs. 12.5%, p<0.001) and diabetes mellitus (10.7% vs. 3.9%, p<0.001).

Conclusion:

The overall age- and sex- matched SMR of patients with RA was similar with that of general population. However, compared with survivors, patients who died were more likely to be male, diagnosed with RA at older age, more likely to be smoker, and they have more hypertension and diabetes mellitus. Therefore, attention should be paid not only to RA itself but also managing comorbidities to improve the survival of patients with RA.

Disclosure of Interests:

None declared

Risk factors outperform intracranial large artery stenosis predicting unfavorable outcomes in patients with stroke

Background

This study examined how intracranial large artery stenosis (ILAS), symptomatic and asymptomatic ILAS, and risk factors affect unfavorable outcome events after medical treatment in routine clinical practice.

Methods

This was a 24-month prospective observational study of consecutively recruited stroke patients. All participants underwent magnetic resonance angiography, and their clinical characteristics were assessed. Outcome events were vascular outcome, recurrent stroke, and death. Cox regression analyses were performed to identify potential factors associated with an unfavorable outcome, which included demographic and clinical characteristics, the risk factors, and stenosis status.

Results

The analysis included 686 patients; among them, 371 were assessed as ILAS negative, 231 as symptomatic ILAS, and 84 as asymptomatic ILAS. Body mass index (p < .05), hypertension (p = .01), and old infarction (p = .047) were factors relating to vascular outcomes. Hypertension was the only factor for recurrent stroke (p = .035). Poor glomerular filtration rate (< 30 mL/min/1.73 m²) (p = .011) and baseline National Institutes of Health Stroke Scale scores (p < .001) were significant predictors of death.

Conclusions

This study extended previous results from clinical trials to a community-based cohort study by concurrently looking at the presence/absence of stenosis and a symptomatic/asymptomatic stenotic artery. Substantiated risk factors rather than the stenosis status were predominant determinants of adverse outcome. Although the degree of stenosis is often an indicator for treatment, we suggest risk factors, such as hypertension and renal dysfunction, should be monitored and intensively treated.

Peanut allergy and oral immunotherapy

Peanut allergy is the commonest cause of food-induced anaphylaxis in the world, and it can be fatal. There have been many recent improvements to achieve safe methods of peanut desensitisation, one of which is to use a combination of anti-immunoglobulin E and oral immunotherapy. We have treated 27 patients with anti-immunoglobulin E and oral immunotherapy, and report on the outcomes and incidence of adverse reactions encountered during treatment. The dose of peanut protein tolerated increased from a median baseline of 5 to 2000 mg after desensitisation, which is substantially more than would be encountered through accidental ingestion. The incidence of adverse reactions during the escalation phase of oral immunotherapy was 1.8%, and that during the maintenance phase was 0.6%. Most adverse reactions were mild; three episodes were severe enough to warrant withdrawal from oral immunotherapy, but none required epinephrine injection. Preliminary data suggest that unresponsiveness is lost when daily ingestion of peanuts is stopped after the maintenance period.

Emulsified polycolloid substrate biobarrier for benzene and petroleum-hydrocarbon plume containment and migration control - A field-scale study

The objective of this field-scale study was to assess the effectiveness of applying an emulsified polycolloid substrate (EPS; containing cane molasses, soybean oil, and surfactants) biobarrier in the control and remediation of a petroleum-hydrocarbon plume in natural waters. An abandoned petrochemical manufacturing facility site was contaminated by benzene and other petroleum products due to a leakage from a storage tank. Because benzene is a petroleum hydrocarbon with a high migration ability, it was used as the target compound in the field-scale study. Batch partition and sorption experiment results indicated that the EPS to water partition coefficient for benzene was 232 mg/mg at 25 °C. This suggests that benzene had a higher sorption affinity to EPS, which decreased the benzene concentrations in groundwater. The EPS solution was pressure-injected into three remediation wells (RWs; 150 L EPS in 800 L groundwater). Groundwater samples were collected from an upgradient background well, two downgradient monitor wells (MWs), and the three RWs for analyses. EPS injection increased total organic carbon (TOC) concentrations (up to 786 mg/L) in groundwater, which also resulted in the formation of anaerobic conditions. An abrupt drop in benzene concentration (from 6.9 to below 0.04 mg/L) was observed after EPS supplementation in the RWs due to both sorption and biodegradation mechanisms. Results show that the EPS supplement increased total viable bacteria and enhanced bioremediation efficiency, which accounted for the observed decrease in benzene concentration. The first-order decay rate in RW1 increased from 0.003 to 0.023 d^-1 after EPS application. Injection of EPS resulted in significant growth of indigenous bacteria, and 23 petroleum-hydrocarbon-degrading bacterial species were detected, which enhanced the in situ benzene biodegradation efficiency. Results demonstrate that the EPS biobarrier can effectively contain a petroleum-hydrocarbon plume and prevent its migration to downgradient areas, which reduces the immediate risk presented to downgradient receptors.

Application of an emulsified polycolloid substrate biobarrier to remediate petroleum-hydrocarbon contaminated groundwater

Emulsified polycolloid substrate (EPS) was developed and applied in situ to form a biobarrier for the containment and enhanced bioremediation of a petroleum-hydrocarbon plume. EPS had a negative zeta potential (-35.7 mv), which promoted its even distribution after injection. Batch and column experiments were performed to evaluate the effectiveness of EPS on toluene containment and biodegradation. The EPS-to-water partition coefficient for toluene (target compound) was 943. Thus, toluene had a significant sorption affinity to EPS, which caused reduced toluene concentration in water phase in the EPS/water system. Groundwater containing toluene (18 mg/L) was pumped into the three-column system at a flow rate of 0.28 mL/min, while EPS was injected into the second column to form a biobarrier. A significant reduction of toluene concentration to 0.1 mg/L was observed immediately after EPS injection. This indicates that EPS could effectively contain toluene plume and prevent its further migration to farther downgradient zone. Approximately 99% of toluene was removed after 296 PVs of operation via sorption, natural attenuation, and EPS-enhanced biodegradation. Increase in total organic carbon and bacteria were also observed after EPS supplement. Supplement of EPS resulted in a growth of petroleum-hydrocarbon degrading bacteria, which enhanced the toluene biodegradation.

Hong Kong Institute of Allergy and Hong Kong Society for Paediatric Immunology Allergy & Infectious Diseases joint consensus statement 2018 on vaccination in egg-allergic patients

Vaccination of egg-allergic individuals has been a historical concern, particularly for influenza and measles-mumps-rubella-varicella vaccines that are developed in chicken egg embryos or chicken cell fibroblasts. The egg proteins in these vaccines were believed to trigger an immediate allergic reaction in egg-allergic individuals. However, recently published international guidelines have updated their recommendations and now state that these vaccines can be safely administered to egg-allergic individuals. This joint consensus statement by the Hong Kong Institute of Allergy and the Hong Kong Society for Paediatric Immunology Allergy & Infectious Diseases summarises the updates and provides recommendations for local general practitioners and paediatricians. Hong Kong Institute of Allergy and Hong Kong Society for Paediatric Immunology Allergy & Infectious Diseases joint consensus statement 2018 on vaccination in egg-allergic patients Background.

Ab initio computer simulations of non-equilibrium radiation-induced cascades in amorphous Ge2Sb2Te5

Ion irradiation corresponds to a process that involves the production of non-equilibrium cascades in the host material, and the atomistic modelling of such events in glasses is challenging. Here, non-equilibrium cascades in amorphous Ge₂Sb₂Te₅ phase-change memory material have been investigated by means of first-principles molecular-dynamics simulations. A stochastic boundary-conditions approach is employed to treat the thermal nature of the cascades and drive the modelled system back to equilibrium in a natural way, while four different initial thermal-spike energies are considered. A comprehensive analysis of the cascade evolution is presented with respect to the kinetic profile and the dynamics of the cascade inside the glass structure. The modelling results show that the instantaneous maximum kinetic energy decays rapidly with time, and that the time-scale of the ballistic phase of the cascade inside the glass model is very short. The quality of the implemented approach is validated through a comparison of the calculated structure factor for the modelled glasses with experimental data from the literature. Analysis of the bonding for all the species in the glass structure highlights particular structural modifications in the connectivity of the amorphous network due to the simulated cascade.

The effects of global warming on allergic diseases

Global warming is a public health emergency. Substantial scientific evidence indicates an unequivocal rising trend in global surface temperature that has caused higher atmospheric levels of moisture retention leading to more frequent extreme weather conditions, shrinking ice volume, and gradually rising sea levels. The concomitant rise in the prevalence of allergic diseases is closely related to these environmental changes because warm and moist environments favour the proliferation of common allergens such as pollens, dust mites, molds, and fungi. Global warming also stresses ecosystems, further accelerating critical biodiversity loss. Excessive carbon dioxide, together with the warming of seawater, promotes ocean acidification and oxygen depletion. This results in a progressive decline of phytoplankton and fish growth that in turn promotes the formation of larger oceanic dead zones, disrupting the food chain and biodiversity. Poor environmental biodiversity and a reduction in the microbiome spectrum are risk factors for allergic diseases in human populations. While climate change and the existence of an allergy epidemic are closely linked according to robust international research, efforts to mitigate these have encountered strong resistance because of vested economic and political concerns in different countries. International collaboration to establish legally binding regulations should be mandatory for forest protection and energy saving. Lifestyle and behavioural changes should also be advocated at the individual level by focusing on low carbon living; avoiding food wastage; and implementing the 4Rs: reduce, reuse, recycle, and replace principles. These lifestyle measures are entirely consistent with the current recommendations for allergy prevention. Efforts to mitigate climate change, preserve biodiversity, and prevent chronic diseases are interdependent disciplines.

Water-adaptive and repeatable self-healing polymers bearing bulky urea bonds

A crosslinked copolymer having a reversible covalent bond between a bulky amine and an isocyanate presents reshapable, repeatable, and water-adaptive self-healing properties.

Genetically modified foods and allergy

2015 marked the 25th anniversary of the commercial use and availability of genetically modified crops. The area of planted biotech crops cultivated globally occupies a cumulative two billion hectares, equivalent to twice the land size of China or the United States. Foods derived from genetically modified plants are widely consumed in many countries and genetically modified soybean protein is extensively used in processed foods throughout the industrialised countries. Genetically modified food technology offers a possible solution to meet current and future challenges in food and medicine. Yet there is a strong undercurrent of anxiety that genetically modified foods are unsafe for human consumption, sometimes fuelled by criticisms based on little or no firm evidence. This has resulted in some countries turning away food destined for famine relief because of the perceived health risks of genetically modified foods. The major concerns include their possible allergenicity and toxicity despite the vigorous testing of genetically modified foods prior to marketing approval. It is imperative that scientists engage the public in a constructive evidence-based dialogue to address these concerns. At the same time, improved validated ways to test the safety of new foods should be developed. A post-launch strategy should be established routinely to allay concerns. Mandatory labelling of genetically modified ingredients should be adopted for the sake of transparency. Such ingredient listing and information facilitate tracing and recall if required.

MRI audit of complications in intracranial stenosis treated with Wingspan device

OBJECTIVES

To evaluate the safety and efficacy of the Wingspan device for the treatment of symptomatic intracranial atherosclerotic stenosis (ICAS).

METHODS

We audited a prospective ongoing database of consecutive patients who received Wingspan stenting between January 2013 and December 2015. All patients underwent MRI to audit any complications during the early follow-up period. We focused on the clinical demographics, lesion characteristics, treatment results, and periprocedural complications. Functional outcomes were measured with the modified Rankin Scale (mRS) at discharge and after 3 months.

RESULTS

Intracranial stenting was performed in 50 patients (100%). Mean stenosis pre-stenting was 76.5±13.1% and post-stenting residual stenosis was 19.8±13.8%. The overall 30-day rate of procedure-related complications was 6.0% (3/50). Two patients (4%) developed in-stent restenosis, one of whom had a dissection at the middle cerebral artery. Interestingly, on the follow-up MRI scan there was a high incidence of asymptomatic diffusion-weighted imaging (DWI) hyperintensities, 46% (23/50) presumed to be due to microembolic causes. At the 90-day, 180-day, and 1-year follow-up, three patients had further strokes resulting in a total complication rate of 12%. 92% had excellent outcomes (mRS 0-1) and only one patient had deterioration of his mRS score.

CONCLUSIONS

ICAS treated by Wingspan stenting using pre-placement balloon angioplasty appears safe and effective with a high technical success rate and favorable outcomes. There is a high incidence of asymptomatic DWI hyperintensites post-procedure, but these do not appear to result in long-term sequelae.

Development of a genetic marker set to diagnose aspirin-exacerbated respiratory disease in a genome-wide association study

We developed a genetic marker set of single nucleotide polymorphisms (SNPs) by summing risk scores of 14 SNPs showing a significant association with aspirin-exacerbated respiratory disease (AERD) from our previous 660 W genome-wide association data. The summed scores were higher in the AERD than in the aspirin-tolerant asthma (ATA) group (P=8.58 × 10(-37)), and were correlated with the percent decrease in forced expiratory volume in 1 s after aspirin challenge (r(2)=0.150, P=5.84 × 10(-30)). The area under the curve of the scores for AERD in the receiver operating characteristic curve was 0.821. The best cutoff value of the summed risk scores was 1.01328 (P=1.38 × 10(-32)). The sensitivity and specificity of the best scores were 64.7% and 85.0%, respectively, with 42.1% positive and 93.4% negative predictive values. The summed risk score may be used as a genetic marker with good discriminative power for distinguishing AERD from ATA.

Detection of Trypanosoma cruzi DNA in blood by PCR is associated with Chagas cardiomyopathy and disease severity

BACKGROUND

The significance of detection of Trypanosoma cruzi DNA in blood of antibody-positive patients for risk of development of Chagas heart disease is not well established. The objective of this study was to compare detection of T. cruzi DNA with known clinical and laboratory markers of Chagas cardiomyopathy (CC) severity.

METHODS

This is a case-control study nested within a retrospective cohort developed in Brazil to understand the natural history of Chagas disease. The study enrolled 499 T. cruzi seropositive blood donors (SP-BD) and 488 frequency matched seronegative control donors (SN-BD) who had donated between 1996 and 2002, and 101 patients with clinically diagnosed CC. In 2008-2010 all enrolled subjects underwent a health questionnaire, medical examination, electrocardiograms and echocardiograms and polymerase chain reaction (PCR) analyses. A blinded panel of three cardiologists adjudicated the outcome of CC. Trypanosoma cruzi kinetoplast minicircle sequences were amplified by real-time PCR using an assay with a sensitivity of one parasite per 20 mL of blood. All testing was performed on coded samples.

RESULTS

Rates of PCR detection of T. cruzi DNA were significantly (P = 0.003) higher in CC patients and SP-BD diagnosed with CC (79/105 [75.2 %]) compared with SP-BD without CC (143/279 [51.3%]). The presence of parasitaemia was significantly associated with known markers of disease progression such as QRS and QT interval duration, lower left ventricular ejection fraction, higher left ventricular index mass, and elevated troponin and NTpro-BNP levels.

CONCLUSION

Trypanosoma cruzi PCR positivity is associated with presence and severity of cardiomyopathy, suggesting a direct role of parasite persistence in disease pathogenesis.

Allergy in Hong Kong: an unmet need in service provision and training

Many children in Hong Kong have allergic diseases and epidemiological data support a rising trend. Only a minority of children will grow out of their allergic diseases, so the heavy clinical burden will persist into adulthood. In an otherwise high-quality health care landscape in Hong Kong, allergy services and training are a seriously unmet need. There is one allergy specialist for 1.5 million people, which is low not only compared with international figures, but also compared with most other specialties in Hong Kong. The ratio of paediatric and adult allergists per person is around 1:460 000 and 1:2.8 million, respectively, so there is a severe lack of adult allergists, while the paediatric allergists only spend a fraction of their time working with allergy. There are no allergists and no dedicated allergy services in adult medicine in public hospitals. Laboratory support for allergy and immunology is not comprehensive and there is only one laboratory in the public sector supervised by accredited immunologists. These findings clearly have profound implications for the profession and the community of Hong Kong and should be remedied without delay. Key recommendations are proposed that could help bridge the gaps, including the creation of two new pilot allergy centres in a hub-and-spoke model in the public sector. This could require recruitment of specialists from overseas to develop the process if there are no accredited allergy specialists in Hong Kong who could fulfil this role.

Relative adrenal insufficiency in chronic liver disease: its prevalence and effects on long-term mortality

BACKGROUND

The relationship between relative adrenal insufficiency (RAI) and chronic liver disease is unclear.

AIM

To determine the frequency with which RAI is observed in noncritically ill patients at various stages of chronic liver disease, and the correlation between RAI and disease severity and long-term mortality.

METHODS

In total, 71 non-critically ill patients with liver cirrhosis (n = 54) and chronic hepatitis (n = 17) were evaluated prospectively. A short stimulation test (SST) with 250 μg of corticotrophin was performed to detect RAI. RAI was defined as an increase in serum cortisol of <9 μg/dL in patients with a basal total cortisol of <35 μg/dL.

RESULTS

RAI was observed in only 13 (24.1%) of 54 patients with cirrhosis. Compared to those without RAI, cirrhotic patients with RAI had significantly higher Child-Turcotte-Pugh score (10.3 ± 1.7 vs. 7.1 ± 1.8, mean ± s.d., P < 0.001) and Model for End-Stage Liver Disease score (14.5 ± 6.6 vs. 9.4 ± 3.7, P = 0.017). The cortisol response to corticotropin was negatively correlated with the severity of cirrhosis (P < 0.05). In addition, the mortality rate was higher in cirrhotic patients with RAI (69.2%) than in those without RAI (4.9%; P < 0.001) during the follow-up period of 20.1 ± 13.5 months (range, 5.8-51.1 months). The cumulative 1-year survival rates in cirrhotic patients with and without RAI were 69.2% and 95.0%, respectively (P = 0.05), while the corresponding cumulative 3-year survival rates were 0% and 95.0% (P < 0.001).

CONCLUSIONS

Relative adrenal insufficiency is more commonly observed in those with severe cirrhosis, and is clearly associated with more advanced liver disease and a shortened long-term survival. This suggests that relative adrenal insufficiency is an independent prognostic factor in non-critically ill patients with cirrhosis.

Immunotherapy for peanut allergy

Peanut allergy is one of the commonest food hypersensitivities causing fatal or near-fatal reactions. There is, currently, no preventive treatment and the incidence of severe allergic reactions during peanut desensitisation has limited its clinical use. Anti-immunoglobulin E therapy has been shown to be effective in preventing peanut-induced reactions but it does not result in long-term tolerance. Two important advances have recently been reported. One involves gradual oral introduction of peanut protein to desensitise, whereas the other approach uses a combination of anti-immunoglobulin E and oral peanut immunotherapy. Both approaches could offer a way to desensitise with a far greater margin of safety than has, hitherto, been reported. This article provides an overview of the literature on peanut immunotherapy and describes the experience in a small group of children in Hong Kong who were treated successfully using anti-immunoglobulin E combined with oral peanut desensitisation.

Technical tips and issues of biliary stenting, focusing on malignant hilar obstruction

In patients with inoperable hilar cholangiocarcinoma (HCCA), palliative endoscopic or percutaneous drainage provides benefits in terms of symptomatic improvement and quality of life. Endoscopic biliary stent placement is considered the gold standard, with metal stents preferred over plastic stents in patients with more than three months of life expectancy. However, the endoscopic management of advanced hilar obstruction is often more challenging and complex than distal malignant biliary obstructions. Recently, the Asia-Pacific working group on hepatobiliary cancers produced consensus recommendations on the use of endoscopic vs. percutaneous drainage and unilateral vs. bilateral drainage in the management of HCCA. However, these guidelines must be weighed against context-specific information, such as the volume of liver drainage required, life expectancy of the patient, and the available expertise. In this literature review, we describe the issues commonly encountered during endoscopic biliary stenting for malignant hilar obstruction and provide technical guidance to improve success rates and patient outcomes.

Death-associated protein kinase 1 has a critical role in aberrant tau protein regulation and function

The presence of tangles composed of phosphorylated tau is one of the neuropathological hallmarks of Alzheimer's disease (AD). Tau, a microtubule (MT)-associated protein, accumulates in AD potentially as a result of posttranslational modifications, such as hyperphosphorylation and conformational changes. However, it has not been fully understood how tau accumulation and phosphorylation are deregulated. In the present study, we identified a novel role of death-associated protein kinase 1 (DAPK1) in the regulation of the tau protein. We found that hippocampal DAPK1 expression is markedly increased in the brains of AD patients compared with age-matched normal subjects. DAPK1 overexpression increased tau protein stability and phosphorylation at multiple AD-related sites. In contrast, inhibition of DAPK1 by overexpression of a DAPK1 kinase-deficient mutant or by genetic knockout significantly decreased tau protein stability and abolished its phosphorylation in cell cultures and in mice. Mechanistically, DAPK1-enhanced tau protein stability was mediated by Ser71 phosphorylation of Pin1, a prolyl isomerase known to regulate tau protein stability, phosphorylation, and tau-related pathologies. In addition, inhibition of DAPK1 kinase activity significantly increased the assembly of MTs and accelerated nerve growth factor-mediated neurite outgrowth. Given that DAPK1 has been genetically linked to late onset AD, these results suggest that DAPK1 is a novel regulator of tau protein abundance, and that DAPK1 upregulation might contribute to tau-related pathologies in AD. Therefore, we offer that DAPK1 might be a novel therapeutic target for treating human AD and other tau-related pathologies.

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

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

High-resolution impedance manometry facilitates assessment of pharyngeal residue and oropharyngeal dysphagic mechanisms

The utility of high-resolution impedance manometry (HRIM) for evaluating oropharyngeal dysphagia (OPD) has been investigated. These approaches are limited because of the sophisticated methodology. A method of transforming HRIM into a simple and useful diagnostic tool for evaluating OPD is needed. A videofluoroscopic swallowing study (VFSS) and HRIM were performed by independent blinded examiners in 26 consecutive healthy volunteers (12 men; median age, 56.5 years) and 10 OPD patients (five men; median age, 59.5 years). Upper esophageal sphincter (UES) relaxation parameters were measured using a standard HRIM protocol. Peristalsis and bolus transit of the pharyngoesophageal (PE) segment were assessed using an HRIM-modified protocol in which the catheter was pulled back 10 cm. PE bolus transits were evaluated with an impedance contour pattern (linear vs. stasis) method. A significant difference was observed between the manometric measures of healthy volunteers and OPD patients for only the duration of pharyngeal contraction (0.49 ± 0.19 vs. 0.76 ± 0.33 s, P = 0.04). The percentage agreement and kappa value for detecting pharyngeal residue between the VFSS and the impedance analysis were 100% and 1.00, respectively. HRIM allowed for comprehensive assessment of abnormal pharyngeal components that caused pharyngeal residue on VFSS in two patients; reduced base of the tongue versus weak pharyngeal contraction in one, and reduced relaxation of the UES versus reduced laryngeal elevation in the remaining patient. Our findings demonstrated that HRIM using a simple methodology (i.e., pull-back of the catheter) detected pharyngeal residue through a simple analysis of the impedance contour pattern (linear vs. stasis). Furthermore, HRIM facilitated a comprehensive assessment of OPD mechanisms and recognition of subtle abnormalities not yet visible to the naked eye on VFSS.

Pelvic congestion syndrome diagnosed using endoscopic ultrasonography

Pelvic congestion syndrome (PCS) presents with a non-cyclic pelvic pain lasting more than six months in duration in premenopausal women. Pelvic ultrasonography or computed tomography is usually the first imaging modality used to evaluate patients with suspected PCS. PCS is confirmed by visible congestion of the pelvic veins on selective ovarian venography. To our knowledge, the role of endoscopic ultrasonography (EUS) has not been reported. EUS showed multiple dilated structures especially on left side around the uterus and ovaries, which are compatible with other radiological investigations of PCS Although PCS is not typical areas within the scope of practice of endosonographers, it is useful to be familiar with the findings. We report a case of PCS that was diagnosed with the aid of EUS.

A carcinoid tumour arising within a tailgut cyst: a diagnostic challenge

A 49-year-old man was referred with constipation that had lasted for a few months. On colonoscopy, a subepithelial tumour more than 4 cm in size was seen in the rectum. He underwent endoscopic ultrasound and pelvic magnetic resonance imaging. He was preoperatively diagnosed with a rectal duplication cyst based on imaging studies. However, the final histopathologic diagnosis after transanal excision of the rectal mass was rectal carcinoid tumour with tailgut cyst. Tailgut cysts are very rare congenital lesions in the presacral area and are most often discovered incidentally in middle-aged women. It is difficult to distinguish the imaging appearance of tailgut cysts from that of many other retrorectal cysts. Malignant transformation of tailgut cysts has been estimated to occur in 2 to 13% of cases. We report the diagnostic difficulties encountered in a case of carcinoid tumour arising from a tailgut cyst in a male patient.

The effect of the posterior slope of the tibial plateau osteotomy with a rotational error on tibial component malalignment in total knee replacement

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement.

Cite this article: Bone Joint J 2013;95-B:1201–3.

Primary and revision efficacy of cross-wired metallic stents for endoscopic bilateral stent-in-stent placement in malignant hilar biliary strictures

BACKGROUND AND STUDY AIMS

Endoscopic bilateral drainage for inoperable malignant hilar biliary strictures (HBS) using metal stents is considered to be technically difficult. Furthermore, endoscopic revision of bilateral stenting after occlusion can be challenging. This study was performed to evaluate the long-term efficacy of endoscopic bilateral stent-in-stent placement of cross-wired metallic stents in high-grade malignant HBS and planned endoscopic bilateral revision.

PATIENTS AND METHODS

A total of 84 patients with inoperable high-grade malignant HBS were enrolled from three academic tertiary referral centers. Two cross-wired metal stents were inserted using a bilateral stent-in-stent placement method. Bilateral endoscopic revision was also performed during follow-up using either identical metal stents or plastic stents. The main outcome measurements were technical and functional success, complications, stent patency, and endoscopic revision efficacy.

RESULTS

The technical and clinical success rates of endoscopic bilateral stent-in-stent placement of cross-wired metallic stents were 95.2% (80/84) and 92.9% (78/84), respectively. Median patency (range) and survival were 238 days (10-429) and 256 days (10-1130), respectively. Obstruction of primary bilateral stents occurred in 30.8% (24/78) of patients with functionally successful stent placement. The technical and clinical success rates of planned bilateral endoscopic revision for occluded stents were 83.3% (20/24) and 79.2% (19/24), respectively. For revision, bilateral metallic stents were placed in 11 patients (55.0%); the remaining patients received plastic stents.

CONCLUSIONS

Palliative endoscopic bilateral stent-in-stent placement of cross-wired metallic stents was effective in patients with inoperable HBS. Revision endoscopic bilateral stenting may be feasible and successful in cases where the primary deployed metal stents are occluded.

Generalized Predictive Observer-Controller For Injection Moulding

In this paper, a generalized predictive observer-controller (GPOC) is developed for injection moulding with input delay and non-measurable states. First, based on a general state-space model with time delay and subject to process disturbances, a generalized predictive control (GPC) is appropriately formulated with a steady-state Kalman filter. Second, important and useful closed-loop characteristics relating to the stability and robustness of the proposed controller are provided. Finally, the proposed scheme is applied to the injection moulding to improve the control performance.

An ultra-low power (ULP) bandage-type ECG sensor for efficient cardiac disease management

This paper proposed an ultra-low power bandage-type ECG sensor (the size: 76 × 34 × 3 (mm(3)) and the power consumption: 1 mW) which allows for a continuous and real-time monitoring of a user's ECG signals over 24h during daily activities. For its compact size and lower power consumption, we designed the analog front-end, the SRP (Samsung Reconfigurable Processor) based DSP of 30 uW/MHz, and the ULP wireless RF of 1 nJ/bit. Also, to tackle motion artifacts(MA), a MA monitoring technique based on the HCP (Half-cell Potential) is proposed which resulted in the high correlation between the MA and the HCP, the correlation coefficient of 0.75 ± 0.18. To assess its feasibility and validity as a wearable health monitor, we performed the comparison of two ECG signals recorded form it and a conventional Holter device. As a result, the performance of the former is a little lower as compared with the latter, although showing no statistical significant difference (the quality of the signal: 94.3% vs 99.4%; the accuracy of arrhythmia detection: 93.7% vs 98.7%). With those results, it has been confirmed that it can be used as a wearable health monitor due to its comfortability, its long operation lifetime and the good quality of the measured ECG signal.

293 EFFECT OF MEDIUM TYPE FOR CULTURE OF ADIPOSE-DERIVED MESENCHYMAL STEM CELLS ON PRE-IMPLANTATION DEVELOPMENT OF CLONED EMBRYOS

Mesenchymal stem cells (MSC) have been known as useful donor cells for somatic cell nuclear transfer (SCNT). It has been suggested that the culture condition of donor cells causes different results on preimplantation development of SCNT embryos. In this study, we investigated the patterns of gene expression of adipose-derived mesenchymal stem cells (ad-MSC) in different culture media (DMEM and RKME), and examined the effect of ad-MSC, with the gene expression changed, used as donor cells on the preimplantation development of cloned embryos. Canine ad-MSC were isolated from fat tissue of 3-year-old female beagle and were cultured in DMEM supplemented with 10% fetal bovine serum (MSC-DMEM) and RKME (MSC-MSC) provided from RNL Bio Corp. (Seoul, Korea). Total RNA was extracted from ad-MSC cultured in each culture medium. After synthesising cDNA of each sample, quantitative RT-PCR was done according to the Takara Bio Inc. guidelines and using the 7300 Real Time PCR Cycler System (Applied Biosystems, Carlsbad, CA, USA). The level of all tested gene transcription was normalized to β-actin expression levels. The relative quantification of gene expression was analysed by the 2–ΔΔCt method. The data from all experiments were analysed by Student’s t-test using a statistical analysis GraphPad Prism 4.02 (GraphPad Software Inc., San Diego, CA, USA). Significance was determined at P < 0.05. The stemness, the reprogramming-related gene expression level of donor cells of MSC-DMEM and MSC-MSC were compared. In order to confirm the effect of MSC cultured in 2 different culture media on somatic cell nuclear transfer, we performed interspecies somatic cell nuclear transfer (iSCNT). The enucleated bovine oocytes were injected, respectively, with donor cells of MSC-DMEM and MSC-MSC, and were fused by electrofusion. The iSCNT embryos were cultured in modified SOF at 38.5°C for 7 days in an atmosphere of 5% CO2 and 5% O2, and the developmental ability of iSCNT embryos was observed under the microscope. The MSC-MSC contained a significantly higher amount of Sox2, Nanog, Oct4, Stella, HDAC1, DNMT1, and MeCP2 than the MSC-DMEM, whereas the amount of Rex1 was not different in either MSC-MSC or MSC-DMEM. In the development ability of iSCNT embryos, MSC-DMEM embryos resulted in a 16-cell embryo formation rate that was higher than that of MSC-MSC embryos (9.09 and 5.30%, respectively; P < 0.05). However, the blastocyst formation rate was not different between MSC-DMEM embryos and MSC-MSC embryos (4.5 and 3.2%, respectively; P > 0.05). These results demonstrate that the gene expression of ad-MSC can be modified, by culture media, into a state where reprogramming is easily done. Even so, ad-MSC with gene expression changed by culture medium did not influence the developmental ability of blastocysts. In conclusion, the alteration of gene-related stemness and reprogramming in canine ad-MSC would not be able to effectively control reprogramming in SCNT. This study was supported by RDA (#PJ0089752012), RNL Bio (#550-20120006), IPET (#311062-04-1-SB010), Research Institute for Veterinary Science, and Nestlé Purina Korea.

Interleukin-25 promotes basic fibroblast growth factor expression by human endothelial cells through interaction with IL-17RB, but not IL-17RA

BACKGROUND

Unlike other IL-17 family members, the Th2-derived cytokine IL-25 (IL-17E) induces (promotes) Th2 responses. One or both of the two receptors for IL-25 (IL-17RA, IL-17RB) is expressed on inflammatory cells and tissue structural cells, suggesting that in addition to promoting Th2-type inflammation IL-25 may also act on structural cells at sites of Th2-type inflammation such as in the asthmatic bronchial mucosa to promote remodelling changes.

OBJECTIVE

Our previous studies showed elevated expression of IL-25 and IL-17RB immunoreactivity in asthmatic airways with co-localization of the latter to endothelial cells. We therefore hypothesized that IL-25 acts on endothelial cells through this receptor to induce production of the key angiogenic and remodelling cytokine basic fibroblast growth factor (bFGF).

METHODS

Polymerase chain reaction (PCR) immunocytochemistry/immunohistochemistry and ELISA were employed to detect expression of IL-17RB, IL-17RA and bFGF by human vascular endothelial cells (HUVEC) and immunoreactivity for IL-25 and bFGF in asthmatic bronchial biopsies. Receptor-blocking antibodies, PCR and an in vitro angiogenesis assay were used to investigate whether IL-25 acts on IL-17RB or IL-17RA to induce bFGF expression and angiogenesis. PCR was also employed to investigate the signalling pathways involved in IL-25-mediated bFGF expression.

RESULTS

HUVEC constitutively expressed IL-17RB, IL-17RA and bFGF. Production of the latter was further increased by IL-25, but attenuated after blockade of the IL-17RB, but not the IL-17RA receptor. Neutralization of endogenous VEGF and bFGF completely abrogated IL-25-induced angiogenesis which was also inhibited by blocking IL-17RB, but not IL-17RA. The PI3K-specific inhibitor LY294002 also completely attenuated IL-25-induced bFGF expression. Immunoreactivity for IL-25 and bFGF was elevated in the asthmatic bronchial mucosa and the expression of each correlated with the other.

CONCLUSIONS AND CLINICAL RELEVANCE

Our data support the hypothesis that IL-25 contributes to elevated bFGF in asthmatic airways by acting on the endothelial cell IL-17RB receptor through PI3K-signalling pathways. Targeting the pathways might benefit therapy of airways remodelling.

Further results on adaptive control for a class of nonlinear systems using neural networks

Zhang et al. presented an excellent neural-network (NN) controller for a class of nonlinear control designs. The singularity issue is completely avoided. Based on a modified Lyapunov function, their lemma illustrates the existence of an ideal control which is important in establishing the NN approximator. In this paper, we provide a Lyapunov function to realize an alternative ideal control which is more direct and simpler. The major contributions of this paper are divided into two parts. First, it proposes a control scheme which results in a smaller dimensionality of NN than that of Zhang et al. In this way, the proposed NN controller is easier to implement and more reliable for practical purposes. Second, by removing certain restrictions from the design reported by Zhang et al., we further develop a new NN controller, which can be applied to a wider class of systems.