Health care transition for cerebral palsy with intellectual disabilities: A systematic review.

OBJECTIVE: Today, most individuals with cerebral palsy are adults who need a paediatric-to-adult health care transition. However, many remain in paediatric care for treatment of adult-onset health issues. Therefore, a systematic review based on the 'Triple Aim' framework was performed to determine the status of paediatric-to-adult health care transition for people with cerebral palsy. A comprehensive evaluation of transitional care was proposed for using this framework. It consists of 'experience of care', meaning satisfaction with the care, 'population health', meaning the well-being of patients, and 'cost', meaning cost-effectiveness. METHOD: Electronic database (PubMed) searches were performed. The inclusion criteria were original articles published between 1990 and 2020. The search terms used in this study were ('cerebral palsy' AND 'transition to adult health care') OR ('cerebral palsy' AND 'transition'). The study type had to be epidemiological, case report, case-control, and cross-sectional, but not qualitative. The outcomes of the studies were categorised into 'care experience', 'population health', and 'cost', according to the Triple Aim framework. RESULTS: Thirteen articles met the abovementioned inclusion criteria. Few studies have examined the effect of the intervention of transition for young adults with cerebral palsy. Participants in some studies had no intellectual disability. Young adults were dissatisfied with the 'care experience', 'population health', and 'cost' and had unmet health needs and inadequate social participation. INTERPRETATION: Further transition intervention studies with a comprehensive assessment and proactive involvement of individuals are warranted. The presence of an intellectual disability should be considered.

Sternal Metastasis of Brain Meningioma - A Case Report.

BACKGROUND: Metastases of meningiomas are infrequent and the site of extracranial metastasis such as the bone is extremely rare. CASE REPORT: A 75-year-old male had a history of five sessions of surgery and gamma-knife treatment for brain meningioma over a period of 29 years. He visited our hospital because he noticed a swelling in his anterior chest 2 years and 6 months after the final treatment. After an open biopsy, histopathological analysis revealed the mass to be a metastatic grade II meningioma. We resected the tumor along with the sternum, ribs, pleura, and pericardium. The patient had recurrences in the thoracic cavity and pericardium postoperatively and received radiation therapy. He also had metastasis in the abdominal cavity, which spread rapidly. CONCLUSION: We report on a rare instance of metastasis to the sternum in a case of atypical meningioma, showing rapid growth and invasion after long-term treatment.

Gradient subthalamic neurodegeneration and tau pathology in the hypoglossal nucleus as essential pathological markers of progressive supranuclear palsy - Richardson syndrome.

Progressive supranuclear palsy - Richardson syndrome (PSP-RS) was first described in 1964 by Steele et al. Tau pathology has not been reported in the hypoglossal nuclei of PSP-RS patients, whereas Steele et al. described gliosis with no remarkable neuronal losses in the hypoglossal nucleus. This study aimed to investigate the distribution and degree of tau pathology-associated neurodegeneration, with an emphasis on the hypoglossal nucleus, in patients with PSP-RS. Six clinicopathologically proven PSP-RS cases were included in this study. All patients were clinicopathologically and immunohistochemically re-evaluated. This study confirmed the following neuropathological characteristics of PSP-RS: (1) neurodegeneration usually affects the striatonigral system and cerebellar dentate nucleus; (2) the cerebellar afferent system in PSP-RS is affected by absent-to-mild neurodegeneration; and (3) the extent of tau distribution throughout the central nervous system is greater than the extent of neurodegeneration. Furthermore, we found that subthalamic neurodegeneration was more prominent in the ventromedial region than in the dorsolateral region. Nevertheless, the tau pathology showed no remarkable differences between these two sites. Interestingly, the tau pathology was frequently observed in the hypoglossal nuclei of PSP-RS patients. Gradient neurodegeneration of the subthalamus and tau pathology in the hypoglossal nucleus could be regarded as essential pathological features of PSP-RS.

Randomized clinical trial of extensive intraoperative peritoneal lavage versus standard treatment for resectable advanced gastric cancer (CCOG 1102 trial).

BACKGROUND: A survival benefit of extensive intraoperative peritoneal lavage (EIPL) has been reported in patients with gastric cancer with positive peritoneal cytology. The hypothesis of this study was that EIPL may reduce peritoneal recurrence in patients with advanced gastric cancer who undergo surgery with curative intent. METHODS: This was an open-label, multi-institutional, randomized, phase 3 trial to assess the effects of EIPL versus standard treatment after curative gastrectomy for resectable gastric cancer of T3 status or above. The primary endpoint was disease-free survival (DFS); secondary endpoints were overall survival, peritoneal recurrence-free survival and incidence of adverse events. RESULTS: Between July 2011 and January 2014, 314 patients were enrolled from 15 institutions and 295 patients were analysed (145 and 150 in the EIPL and no-EIPL groups respectively). The 3-year DFS rate was 63·9 (95 per cent c.i. 55·5 to 71·2) per cent in the EIPL group and 59·7 (51·3 to 67·1) per cent in the control group (hazard ratio (HR) 0·81, 95 per cent c.i. 0·57 to 1·16; P = 0·249). The 3-year overall survival rate was 75·0 (67·1 to 81·3) per cent in the EIPL group and 73·7 (65·9 to 80·1) per cent in the control group (HR 0·91, 0·60 to 1·37; P = 0·634). Peritoneal recurrence-free survival was not significantly different between the two groups (HR 0·92, 0·62 to 1·36; P = 0·676). No intraoperative complications related to EIPL were observed. CONCLUSION: EIPL did not improve survival or peritoneal recurrence in patients who underwent gastrectomy for advanced gastric cancer. Registration number: 000005907 (http://www.umin.ac.jp/ctr/index.htm).

ANTECEDENTES: Se ha descrito que un lavado peritoneal extenso intraoperatorio (extensive intraoperative peritoneal lavage, EIPL) proporciona un beneficio en la supervivencia en pacientes con cáncer gástrico con citología peritoneal positiva. La hipótesis de este estudio era que el EIPL podría disminuir la recidiva peritoneal en pacientes con cáncer gástrico avanzado sometidos a cirugía con intención curativa. MÉTODOS: Ensayo clínico fase 3, abierto, multicéntrico y aleatorizado para evaluar los efectos de un lavado peritoneal extenso intraoperatorio (EIPL) frente a tratamiento estándar tras gastrectomía curativa por cáncer gástrico ≥T3 resecable. La variable de resultado primaria fue la supervivencia libre de enfermedad (disease-free survival, DFS), y las variables de resultado secundarias fueron la supervivencia global (overall survival, OS), la supervivencia libre de recidiva peritoneal y la incidencia de efectos adversos. RESULTADOS: Entre julio de 2011 y enero de 2014, se reclutaron 314 pacientes de 15 instituciones y se analizaron los datos de 295 pacientes (145 en el grupo con EIPL y 150 en el grupo sin EIPL). La DFS a los 3 años fue 63,9% (i.c. del 95% 55,5-71,2) en el grupo con EIPL y 59,7% (i.c. del 95% 51,3-67,1) en el grupo control (cociente de riesgos instantáneos, hazard ratio, HR 0,81 (i.c. del 95% 0,57-1,16), P = 0,249). La OS a los 3 años fue 75,0% (i.c. del 95% 67,1-81,3) en el grupo con EIPL y 73,7% (i.c. del 95% 65,9-80,1) en el grupo control (HR 0,91 i.c. del 95% 0,60-1,37), P = 0,634). No se observaron diferencias estadísticamente significativas entre los dos grupos en la supervivencia libre de recidiva peritoneal (P = 0,676, HR 0,92 (i.c. del 95% 0,62-1,36). No se observaron complicaciones intraoperatorias relacionadas con EIPL. CONCLUSIÓN: El EIPL no mejoró la supervivencia o la recidiva peritoneal en pacientes sometidos a gastrectomía por cáncer gástrico avanzado.

The influence of compressive forces across the patellofemoral joint on patient-reported outcome after bi-cruciate stabilized total knee arthroplasty.

AIMS: Patellofemoral problems are a common complication of total knee arthroplasty. A high compressive force across the patellofemoral joint may affect patient-reported outcome. However, the relationship between patient-reported outcome and the intraoperative patellofemoral contact force has not been investigated. The purpose of this study was to determine whether or not a high intraoperative patellofemoral compressive force affects patient-reported outcome. PATIENTS AND METHODS: This prospective study included 42 patients (42 knees) with varus-type osteoarthritis who underwent a bi-cruciate stabilized total knee arthroplasty and in whom the planned alignment was confirmed on 3D CT. Of the 42 patients, 36 were women and six were men. Their mean age was 72.3 years (61 to 87) and their mean body mass index (BMI) was 24.4 kg/m 2 (18.2 to 34.3). After implantation of the femoral and tibial components, the compressive force across the patellofemoral joint was measured at 10°, 30°, 60°, 90°, 120°, and 140° of flexion using a load cell (Kyowa Electronic Instruments Co., Ltd., Tokyo, Japan) manufactured in the same shape as the patellar implant. Multiple regression analyses were conducted to investigate the relationship between intraoperative patellofemoral compressive force and patient-reported outcome two years after implantation. RESULTS: No patient had anterior knee pain after total knee arthroplasty. The compressive force across the patellofemoral joint at 140°of flexion was negatively correlated with patient satisfaction (R 2 = 0.458; ß = -0.706; p = 0. 041) and Forgotten Joint Score-12 (FJS-12; R 2 = .378; ß = -0.636; p = 0. 036). The compressive force across the patellofemoral joint at 60° of flexion was negatively correlated with the patella score (R 2 = 0.417; ß = -0.688; p = 0. 046). CONCLUSION: Patient satisfaction, FJS-12, and patella score were affected by the patellofemoral compressive force at 60° and 140° of flexion. Reduction of the patellofemoral compressive forces at 60° and 140° of flexion angle during total knee arthroplasty may improve patient-reported outcome, but has no effect on anterior knee pain.

Usefulness of dyssynchrony indices based on two-dimensional speckle tracking echocardiography in a canine model of left bundle branch block.

INTRODUCTION: Determine the usefulness of dyssynchrony indices derived from two-dimensional speckle tracking echocardiography for the detection of mechanical dyssynchrony in a canine model of left bundle branch block. ANIMALS: Ten healthy beagles. MATERIALS AND METHODS: Segmental, time-radial strain curves were obtained using two-dimensional speckle tracking echocardiography. The maximum difference and standard deviation of the time to peak radial strain for six predefined segments (MaxD-TpSR and 6SD-TpSR) were calculated, together with the left ventricular dyssynchrony by radial strain (DysSR), before and after ablation of the left bundle branch block. Receiver operating characteristic curve analysis was performed using dogs after ablation as positive controls. RESULTS: After ablation, all dogs showed multiple peaks in at least one segment on the time-radial strain curve, while all dyssynchrony indices increased significantly (MaxD-TpSR from 16.25 ± 16.04 [mean ± standard deviation] to 44.4 ± 26.18 ms, 6SD-TpSR from 7.59 ± 7.40 to 19.62 ± 11.91 ms, and DysSR from 4.20 ± 2.12 to 10.87± 2.92%, p<0.05). In receiver operating characteristic curve analysis, the areas under the curve for MaxD-TpSR, 6SD-TpSR, and DysSR were 0.825, 0.800, and 0.980, respectively. CONCLUSIONS: Left ventricular dyssynchrony by radial strain can detect mechanical dyssynchrony with higher sensitivity and specificity than dyssynchrony indices, based on the time to peak radial strain.

Myocardial torsional deformations in cats with hypertrophic cardiomyopathy using two-dimensional speckle-tracking echocardiography.

OBJECTIVES: The objective of our study was to quantitatively measure systolic torsional deformations in cats with hypertrophic cardiomyopathy (HCM) and in controls. ANIMALS: Twenty-six client-owned cats with HCM and 14 healthy cats. HCM cats were categorized based on their symptoms (asymptomatic and symptomatic) and with or without left ventricular outflow tract obstruction (obstructive and non-obstructive). METHODS: The cats were examined for myocardial deformations using two-dimensional speckle-tracking echocardiography and were evaluated for peak systolic rotation and the rotation rate at each basal and apical view. Cats were also evaluated for the peak systolic torsion and torsion rate. RESULTS: The peak systolic apical rotation and torsion were higher in asymptomatic and symptomatic cats with HCM than in control cats. Also, the peak systolic apical rotation, apical rotation rate, torsion, and torsion rate were higher in cats with obstructive HCM than in control cats. CONCLUSIONS: Myocardial torsional deformations assessed by two-dimensional speckle-tracking echocardiography may be useful for evaluating compensatory myocardial function of HCM.

Weekly injection of teriparatide for bone ingrowth after cementless total knee arthroplasty.

PURPOSE: To compare bone mineral density (BMD) in patients with or without weekly injection of teriparatide to promote bone ingrowth after cementless total knee arthroplasty (TKA). METHODS: Records of 8 men and 32 women (mean age, 75.6 years) who underwent cementless TKA for medial knee osteoarthritis with (n=20) or without (n=20) once-weekly subcutaneous/hypodermic injection of teriparatide for 48 weeks were reviewed. BMD and bone volume/total volume (BV/TV) of the bone-prosthesis interface of the proximal tibia in 6 regions of interest (ROI) were assessed at 3, 6, 9, and 12 months using multi-detector computed tomography. RESULTS: Patients with or without weekly injection of teriparatide after cementless TKA were comparable in terms of baseline characteristics and pre- and post-operative knee range of motion and Knee Society knee and function scores. In ROI 1 (medial), ROI 3 (anteromedial), and ROI 4 (posteromedial), the BV/TV increased throughout the postoperative period in patients with weekly injection of teriparatide and declined after 6 months in patients without weekly injection of teriparatide. These 3 ROIs of the 2 groups differed significantly only in BMD at 6, 9, and 12 months. In ROI 2 (lateral), ROI 5 (anterolateral), and ROI 6 (posterolateral), both BV/TV and BMD showed a decreasing trend, and these 3 ROIs of the 2 groups did not differ significantly. CONCLUSION: Weekly injection of teriparatide after cementless TKA promoted bone ingrowth mostly in the medial aspect of the bone-prosthesis interface.

Functional outcomes and patient satisfaction after vascularized osteocutaneous scapula flap reconstruction of the mandible in patients with benign or cancerous tumours.

Pre- and postoperative longitudinal assessment of oral functions including masticatory force, masticatory ability with solids, speech intelligibility, and subjective satisfaction was conducted for patients who underwent vascularized osteocutaneous scapula flap reconstruction after mandibulectomy. Postoperative changes in oral function and patient satisfaction were examined in relation to tumour type (i.e., cancerous vs. benign). A change in masticatory force was associated with a reduction in the number of occlusal support zones after surgery and clearly differed by tumour type. Despite all patients showing reduced masticatory force postoperatively, all were satisfied with the improvements in eating and chewing, which were greater in patients with benign tumours than in those with cancerous tumours. Although both groups of patients expressed satisfaction with the aesthetic appearance after surgery, patients with cancerous tumours were more satisfied. However, both groups showed decreased speech intelligibility scores and lower satisfaction with speech after surgery. Preoperative support in the form of reassurance and helping to alleviate anxiety about postoperative appearance would be beneficial for all patients, with additional support provided based on the specific tumour type.

Dobutamine stress echocardiography for assessment of systolic function in dogs with experimentally induced mitral regurgitation.

BACKGROUND: Systolic dysfunction is associated with poor outcomes in dogs with myxomatous mitral valve disease. However, assessment of systolic variables by conventional echocardiographic methods is difficult in these dogs because of mitral regurgitation (MR). HYPOTHESIS: We hypothesized that assessment of systolic function by dobutamine stress may identify systolic dysfunction in dogs with MR, and that 2-dimensional speckle-tracking echocardiography (2D-STE) could quantitatively evaluate myocardial function. ANIMALS: Anesthetized dogs with experimentally induced MR. METHODS: Dogs were examined for systolic myocardial deformations using 2D-STE during dobutamine infusion before and 3 and 6 months after MR induction. We evaluated peak systolic rotation and rotation rate in each basal and apical view; peak systolic torsion and torsion rate were also calculated. RESULTS: Invasive peak positive first derivatives of left ventricular pressure (dp/dt) were significantly decreased in dogs 6 months after induction of MR compared with pre-MR results. After 3 and 6 months of MR, dogs had diminished peak systolic torsion values and torsion rates in response to dobutamine infusion compared with pre-MR results (3 months, P < .001 and P = .006; 6 months, P = .003 and P = .021). These results were significantly correlated with overall invasive dp/dt (r = 0.644, P < .001; r = 0.696, P < .001). CONCLUSIONS AND CLINICAL IMPORTANCE: Decreased torsion during dobutamine infusion in dogs with MR may reflect latent systolic dysfunction. Dobutamine infusion, therefore, may be useful for the assessment of systolic function in dogs with MR.

Aggressive pulmonary calcification developed after living donor kidney transplantation in a patient with primary hyperparathyroidism.

Metastatic pulmonary calcification, defined as calcium deposition in the intact lung, is commonly seen in patients with chronic renal failure, and it is known to be a benign clinical condition when detected by chance in an asymptomatic patient. Here we report the case of a 33-year-old woman who developed rapid and aggressive metastatic pulmonary calcification shortly after a living donor kidney transplantation, which induced acute antibody-mediated rejection. The patient's metastatic pulmonary calcification was successfully improved by extensive treatment for graft rejection, the correction of her accompanying primary hyperparathyroidism, and medical treatment with a bisphosphonate and sodium thiosulfate. Aggressive pulmonary calcification is reported as a rare complication seen in patients who have undergone a failed renal transplantation. A failed renal graft and accompanying secondary hyperparathyroidism seem to accelerate metastatic calcification. Most of the patients who develop aggressive pulmonary calcification suffer from the rapid progression of dyspnea and occasionally fever, and they die of respiratory failure. Pulmonary calcification should be considered in a patient developing dyspnea and unexplained pulmonary infiltrate, especially in the context of renal graft rejection; otherwise the prognosis of the patient will be very poor.

Left ventricular geometrical differences in dogs with various stages of myxomatous mitral valve disease.

OBJECTIVES: To evaluate left ventricular geometry in dogs with various stages of myxomatous mitral valve disease. METHODS: Ninety-seven dogs with myxomatous mitral valve disease classified by the International Small Animal Cardiac Health Council system and 20 weight- and age-matched healthy dogs. Left ventricular long-axis to short-axis ratio, sphericity index in end-diastole and end-systole, left ventricular wall thickness to internal dimension ratio and relative wall thickness were assessed. RESULTS: The diastolic sphericity index was lower in classes Ib, II and III than in healthy dogs (P=0·003, P<0·001 and P<0·001) and was also lower in class III than in classes Ia, Ib and class II dogs (P<0·001, P<0·001 and P=0·002). The relative wall thickness was lower in classes II and III than in class Ia (P=0·003 and P<0·001), class Ib (P=0·004 and P<0·001), and healthy dogs (P<0·001 and P<0·001) and was also lower in class III than in class II (P=0·005). CLINICAL SIGNIFICANCE: Sphericity index and relative wall thickness are simple methods for assessing left ventricular geometry using two-dimensional echocardiography that may be useful in myxomatous mitral valve disease dogs as part of risk stratification.

Is patella eversion during total knee arthroplasty crucial for gap adjustment and soft-tissue balancing?

INTRODUCTION: Assessment of soft-tissue balance by the gap technique in Total Knee Arthroplasty (TKA) impacts femoral component rotation positioning. Proper femoral component rotation is a critical factor in TKA, both for adequate patellar tracking and in achieving a symmetrical flexion gap. Soft tissue balance assessment and gap measurements are performed at 90° flexion and with the patella everted in conventional TKA; during MIS-TKA, this step is performed with the patella in situ. We therefore investigated intraoperative joint gap parameters at 90° flexion with and without patellar eversion during conventional TKA, so as to better understand the influence of this intraoperative patellar position factor on final ligament balance. HYPOTHESIS: Conducting TKA without patellar eversion increases both gap size and gap inclination. PATIENTS AND METHODS: Twenty-four osteoarthritic knees were included in the study. Joint gap size and inclination were measured intraoperatively on a knee in 90° flexion, with and without patellar eversion. RESULTS: The joint gap with patella in situ (17.0±3.4 mm) was significantly greater than with patellar eversion (15.4±3.0 mm), as was gap inclination at 90° flexion with the patella in situ (4.9±3.1°) compared to with patellar eversion (4.0±2.9°). DISCUSSION: The flexion gap inclination obtained without patellar eversion was steeper than with patellar eversion. This induced more externally rotated femoral positioning in absence of patellar eversion. These results ought to be taken into account by surgeons considering switching from conventional to MIS-TKA.

A pilot study of social competence assessment using interaction rating scale advanced.

Purpose. The purpose of this paper is to clarify the validity of the Interaction Rating Scale Advanced (IRSA) as an evidence-based practical index of social skills. Methods. The participants in our study were 17 high school students. The participants completed the five-minute interaction session and were observed using the IRSA. Their teacher evaluated their social competence based on regular observation in school. Results. The results indicated the high correlation between IRSA scores and teacher's practical evaluation. IRSA can measure social competence with high validity. Conclusion. The IRSA provides further evidence of the fact that in order to study social competence development, it is important to evaluate various features of the interaction like IRSA subscales.

Enhancement of bone formation in an experimental bony defect using ferumoxide-labelled mesenchymal stromal cells and a magnetic targeting system.

We used interconnected porous calcium hydroxyapatite ceramic to bridge a rabbit ulnar defect. Two weeks after inducing the defect we percutaneously injected rabbit bone marrow-derived mesenchymal stromal cells labelled with ferumoxide. The contribution of an external magnetic targeting system to attract these cells into the ceramic and their effect on subsequent bone formation were evaluated. This technique significantly facilitated the infiltration of ferumoxide-labelled cells into ceramic and significantly contributed to the enhancement of bone formation even in the chronic phase. As such, it is potentially of clinical use to treat fractures, bone defects, delayed union and nonunion.

Possible contribution of hyalocytes to idiopathic epiretinal membrane formation and its contraction.

AIM: To address the cellular components and the contractile mechanisms of the idiopathic epiretinal membrane (ERM). METHODS: Ten surgically removed ERMs were fixed in 4% paraformaldehyde and analysed by whole-mount immunohistochemistry with anti-glial fibrillar acidic protein (GFAP) and alpha smooth-muscle actin (alphaSMA) antibodies. Type I collagen gel contraction assay, an established wound-healing assay in vitro, was performed using cultured bovine hyalocytes or normal human astrocytes (NHA) to evaluate the contractile property of the cells in the presence of tissue growth factor (TGF)-beta2. The expression of alphaSMA was also analysed by western blot analysis to examine myofibroblastic transdifferentiation of the cells. Vitreous-induced collagen gel contraction was also evaluated. RESULTS: All membranes were composed of alphaSMA immunopositive cells in contracted foci and GFAP immunopositive cells in the periphery. No apparent double positive cells were observed in any membranes examined. Cultured hyalocytes showed overexpression of alphaSMA and hypercontraction of collagen gels in response to TGF-beta2, while glial cells showed marginal change. The vitreous from ERM patients also caused overexpression of alphaSMA and hypercontraction of the gels embedding hyalocytes, which were almost completely inhibited in the presence of anti-TGF-beta2 neutralising antibody. CONCLUSIONS: Hyalocytes might be one of the critical components of ERM mediating its contractile property through the effect of TGF-beta2 in the vitreous fluid.

A phase II study of radical surgery followed by postoperative chemotherapy with S-1 for gastric carcinoma with free cancer cells in the peritoneal cavity (CCOG0301 study).

BACKGROUND: Patients with gastric cancer who have positive cytologic results for cancer cells in peritoneal washings (CY1) have poor outcomes, even in the absence of other distant metastases. A standard treatment for such patients remains to be established. METHODS: We conducted a phase II trial with the 2-year survival rate as the primary endpoint. Patients who had gastric cancer with CY1 status but no other residual disease received postoperative chemotherapy with S-1 (1M tegafur-0.4M gimestat-1M otastat potassium) at a daily dose of 80mg/m(2) for 4 weeks, followed by 2 weeks of rest. This cycle was continued until disease progression or intolerable adverse events. D2 dissection was the recommended surgical procedure; splenectomy could be omitted at the discretion of the surgeon. Accrual of 50 patients was planned, and a 2-year survival rate of more than 36% was needed to exceed the historical control. RESULTS: Forty-eight patients were enrolled, among whom 47 were assessable for survival and 46 for adverse reactions. Median overall survival was 705 days, and progression-free survival was 376 days. The 2-year survival rate was 47%. Median time to treatment failure was 288 days. Neutropenia was the commonest > or = grade 3 toxicity (6 patients), and anorexia was the most frequent > or = grade 2 non-hematologic toxicity (10 patients). CONCLUSIONS: Gastrectomy followed by S-1 monotherapy resulted in survival that surpassed historical data and can serve as an active control treatment for future trials in patients who have gastric cancer with CY1 status in the Far East.