Associations between body composition and vertebral fracture risk in postmenopausal women.

INTRODUCTION: Osteoporosis is a metabolic bone disease with low bone mineral density (BMD) and high incidence of vertebral fractures (VFs). Postmenopausal women with osteoporosis have decreased total fat and lean mass. This study aimed to investigate the associations between body composition and VF risk and explore the potential predictor of VF risk in postmenopausal women. METHODS: Enrolled 731 postmenopausal women were referred by various departments and outpatient clinics to assess vertebral status between October 2016 and November 2017. The main measures were total body lean mass, fat mass, and BMD. Patients were divided into osteopenia, osteoporosis, and normal groups based on T-scores. Logistic regression analyses were performed to evaluate associations between body composition parameters and VF. RESULTS: VF was significantly associated with increased age, lower height, and lighter weight in all participants, and higher BMI was observed in VF participants. Participants in the osteoporosis group were older and had lower height, weight, and BMD than those in normal and osteopenia groups. Femoral and total hip T-scores as well as T-scores for lumbar spine were significantly lower in participants with VF than in non-VF participants. Percentage of bone mass was also significantly lower in VF participants compared to that of non-VF participants. Women with increased BMD and lower bone mass had reduced odds for VF occurrence. Bone mass was significantly able to identify VF occurrence. CONCLUSIONS: Body composition analysis discerns differences in the bone status of postmenopausal women with and without VF. The cutoff value of the bone mass might be used effectively as an indicator of risk for VF occurrence.

Diagnostic value of apoptosis biomarkers in severe sepsis-A pilot study.

Severe sepsis is associated with significant mortality and massive immune cell lose, or apoptosis. It is unclear whether plasma apoptosis biomarkers could be used as a diagnostic test for severe sepsis. Forty patients with severe sepsis and 35 healthy controls were enrolled. The percentage and apoptosis of monocytes and lymphocytes were detected by flow cytometric analysis. Plasma levels of tumor necrosis factor (TNF)-α, soluble TNF receptor (sTNFR), soluble Fas (sFas), Fas ligand (FasL), caspase-1, and procalcitonin (PCT) were measured. Plasma caspase-1 level was positively correlated with CD4 lymphocyte apoptosis in controls and patients, and with CD8 lymphocyte apoptosis in all subjects. Plasma FasL level was negatively correlated with CD4 and CD8 lymphocyte apoptosis in all subjects. The sFas/FasL ratio was positively correlated with CD4 and CD8 lymphocyte apoptosis and negatively with monocyte apoptosis in all subjects. Compared with PCT, caspase-1, FasL, and sFas/FasL ratio had better negative predictive value and likelihood ratio for a negative test. PCT had better positive predictive value and likelihood ratio for a positive test. This work demonstrated caspase-1, FasL, and sFas/FasL ratio could be candidates for diagnosis of severe sepsis and their diagnostic value was not inferior to that of PCT.

Risk factors for hospital readmission for COPD after implementation of the GOLD guidelines.

BACKGROUND: Few updated studies have investigated risk factors for readmission for chronic obstructive pulmonary disease (COPD) since the implementation of the latest treatment guidelines. OBJECTIVE: To evaluate a series of potential risk factors for readmission in patients with COPD and in a subgroup with very frequent readmissions after implementation of the Global Initiative for Chronic Obstructive Lung Disease guidelines. DESIGN: Two hundred and fifty patients admitted for acute exacerbation of COPD (AECOPD) were recruited over 1 year. The readmission frequency in the ensuing year following hospital discharge was recorded and analysed against potential risk factors collected during the index admission. RESULTS: In the ensuing year, 183 (73.2%) patients were readmitted at least once for AECOPD. Previous non-invasive ventilation for AECOPD (HR 1.56, 95%CI 1.08-2.26), COPD Assessment Test score (HR 1.03, 95%CI 1.00-1.05), 6-minute walk distance (HR 0.98 per 10 m increase, 95%CI 0.97-0.99) and number of admissions for AECOPD in the previous year (HR 1.11, 95%CI 1.06-1.16) were independently associated with time to first readmission. Subgroup analysis showed that anxiety (OR 3.97, 95%CI 1.49-10.57) was strongly associated with very frequent readmissions (⩾4 in 1 year). CONCLUSIONS: AECOPD is associated with high rates of readmission. Anxiety is a potential modifiable factor associated with very frequent readmissions.

CyBorD induction therapy in clinical practice.

Cyclophosphamide, bortezomib and dexamethasone (CyBorD) is a highly active three-drug induction regimen for untreated transplant-eligible multiple myeloma patients. Although CyBorD has been evaluated only in the phase 2 setting in a limited number of patients, its high efficacy and ease of administration have led to its widespread use. Given that clinical trial efficacy can overestimate real-life effectiveness, we reviewed our institutional experience with 109 newly diagnosed patients who were treated with CyBorD in a non-clinical trial setting. After a median of four cycles, overall response rate (ORR) and very good partial response rate or better (⩾VGPR) were 95 and 66%, respectively, comparable to phase 2 studies of CyBorD and other three/four-drug induction regimens. All patients subsequently underwent successful stem cell collection and upgraded responses to ORR 98% and ⩾VGPR 79% post transplant. At a median follow-up of 19.8 months after diagnosis, the 2-year OS probability was 95.3% (95%CI: 89-98). The presence of concurrent plasmacytoma at diagnosis was the only prognostic factor predicting poorer survival (HR=5.56; 95%CI: 0.92-33.74; P=0.03). CyBorD was well-tolerated, with no severe peripheral neuropathy and minimal hematologic toxicity. Therefore, CyBorD is a convenient, well-tolerated, highly effective induction regimen in preparation for autologous SCT in real-life clinical practice.

Basal core promoter mutation is associated with progression to cirrhosis rather than hepatocellular carcinoma in chronic hepatitis B virus infection.

BACKGROUND: As most cases of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) have concurrent cirrhosis, viral factors identified to be associated with HCC might be related to cirrhosis rather than HCC. METHODS: Hepatitis B virus DNA levels, genotypes and precore/basal core promoter (BCP) mutants were compared between cirrhotic HCC and non-cirrhotic HCC patients. Age- and sex-matched case-control studies were performed to identify the risk factors. RESULTS: Hepatitis B virus DNA levels showed no significant difference between non-cirrhotic HCC patients (n=20) and cirrhotic HCC patients (n=140) or 1 : 3 age- and sex-matched cirrhotic HCC patients (n=60), but genotype C and BCP mutant were significantly more prevalent in the latter than in the former. In multiple logistic regression, BCP mutant but not genotype C correlated significantly with the presence of cirrhosis in HCC patients. Compared with inactive carriers (n=60), non-cirrhotic HCC patients (n=20) had significantly higher HBV DNA levels but no difference in HBV genotypes and precore/BCP mutants. Furthermore, HBV DNA levels, the distribution of HBV genotypes and the prevalence of precore/BCP mutants all failed to show any significant difference between cirrhotic HCC patients (n=60) and cirrhotic patients without HCC (n=60). CONCLUSION: Basal core promoter mutant is associated with progression to cirrhosis rather than HCC in chronic HBV infection.

Serial HBV DNA levels in patients with persistently normal transaminase over 10 years following spontaneous HBeAg seroconversion.

Earlier studies addressing the hepatitis B virus (HBV) DNA cut-off level for inactive chronic HBV infection largely involved patients with normal alanine aminotransferase (ALT) for only 1-2 years and based on a single time HBV DNA assay. This study was conducted to address this issue using serial HBV DNA assays in patients with persistently normal ALT (PNALT) over 10 years following spontaneous hepatitis B e antigen (HBeAg) seroconversion. Serial serum specimens (mean 9 samples per patient) of 62 patients with PNALT and no disease progression over 10 years (median 18.1 years) after spontaneous HBeAg seroconversion were assayed for HBV DNA. Excluding assays within 1 year after HBeAg seroconversion, 21% and 82.3% of the patients with PNALT had HBV DNA levels persistently lower than 4 log(10) and 5 log(10) copies/mL, respectively, and only 8% had a level ≥ 5 log(10) copies/mL in at least two assays. Of the 27 patients with PNALT defined by ALT <30 U/L for male and <19 U/L for female, only 33% had serum HBV DNA level persistently <4 log(10) copies/mL. There was no significant difference in the serial HBV DNA changes among patients with different gender, HBV genotype or age at HBeAg seroconversion. Liver biopsy in nine patients invariably showed minimal necroinflammation and one showed Ishak fibrosis score 4. These results suggest that 5 log(10) copies/mL (20,000 IU/mL) is a more appropriate cut-off HBV DNA level for inactive chronic HBV infection in the setting of PNALT.

Pictorial review of mucopolysaccharidosis with emphasis on MRI features of brain and spine.

Mucopolysaccharidosis (MPS) is an inherited metabolic disorder of childhood, characterised by progressive multisystem involvement predominantly affecting the skeletal system leading to skeletal dysplasia. Mental retardation, neuropathy and cardiomyopathy may occur in the most severely affected patients, leading to progressive disability and death in their early third to fourth decades. The purpose of this paper is to illustrate the typical imaging features of different types of MPS, in particular the MR features of the brain and spine in MPS, which are expected to be encountered by radiologists more frequently in their clinical practice as a result of prolonged life expectancy for those with MPS with recent advances in therapeutic interventions. The treatment options and outcomes for MPS patients are also briefly discussed.

Prevalence and cardiovascular disease risk differences for erectile dysfunction patients by three metabolic syndrome definitions.

There is growing evidence of a link between ED, metabolic syndrome (MS) and cardiovascular disease (CVD). The study was to explore the prevalence of MS using three different definitions (World Health Organization (WHO), International Diabetes Foundation (IDF) and Adult Treatment Panel III (ATP III)), and to compare the association of CVD in ED outpatients using these definitions. This study enrolled 254 participants with a mean age of 55.3 ± 0.9 years (range, 21 to 81 years) with ED as diagnosed by International Index of Erectile Function score. All participants underwent MS evaluation based on the three criteria. Differences of MS prevalence, demographical characteristics, biochemical profiles, pro-inflammatory and inflammatory markers, echocardiographic characteristics and the association with Framingham cardiac risk score (FCRS) were compared. The presence of diabetes mellitus (DM) in the WHO group and high waist girth in the IDF group were significant because of the necessity of respective criteria. The MS prevalence in the WHO, IDF and ATP III groups was 30.7, 34.3 and 36.6%, respectively (P = 0.367). The degrees of agreement among each definition were substantial to perfect. No significant findings in echocardiographic characteristics, biochemical, inflammatory and pro-inflammatory markers were noted. The FCRS showed borderline nonsignificant difference (17.9 ± 0.4, 16.8 ± 0.4 and 16.9 ± 0.4, P = 0.079); however, the FCRS was more closely correlated with the WHO than with the IDF and ATP III (Spearman's correlation coefficients were 0.522, 0.531 and 0.462, respectively; P = 0.021). In patients < 55 years of age and those who smoke, the Spearman's correlation in the WHO group was significantly higher than in the IDF and ATP III groups. The prevalence of the MS using different definitions in ED patients was not different. The WHO-defined MS was more closely associated with CVD.

A pilot trial of non-invasive home ventilation after acidotic respiratory failure in chronic obstructive pulmonary disease.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) who survive an episode of acute hypercapnic respiratory failure (AHRF) after treatment with non-invasive ventilation (NIV) have a high risk of recurrent AHRF. We hypothesised that continuation of NIV at home in these patients would reduce the likelihood of recurrent AHRF. METHODS: A pilot prospective randomised controlled study was designed to compare continuation of active home NIV and continuous positive airway pressure (CPAP) 5 cm H(2)O (controls) in COPD patients who had survived an episode of AHRF treated with acute NIV. Patients with significant obstructive sleep apnoea, non-COPD causes of AHRF, adverse psychosocial circumstances and serious comorbidities were excluded. The primary end-point was recurrent AHRF requiring acute NIV, intubation or resulting in death in the first year. RESULTS: Twenty-three patients were randomised to receive home NIV and 24 received CPAP. There was no significant difference in the baseline characteristics between the two study groups. The proportion of patients developing recurrent AHRF in the NIV and the CPAP groups was 38.5% vs. 60.2% at 1 year (P = 0.039). Four and eight patients, respectively, were withdrawn from the CPAP and NIV groups before the end of the pre-defined study duration. CONCLUSIONS: In selected COPD patients with AHRF treated with acute NIV, continuation with home NIV is associated with a lower risk of recurrent severe COPD exacerbation with AHRF when compared with CPAP.

Major haemoptysis in Hong Kong: aetiologies, angiographic findings and outcomes of bronchial artery embolisation.

SETTING: Tertiary referral centres. OBJECTIVE: To provide comprehensive updates on the aetiologies, angiographic findings and outcomes of bronchial artery embolisation (BAE) for life-threatening haemoptysis in Hong Kong. DESIGN: Retrospective review of clinical records of consecutive patients presenting with life-threatening haemoptysis from 2000 to 2006. RESULTS: There were 3006 admissions due to haemoptysis involving 2260 patients during the study period; of these, 251 patients had life-threatening haemoptysis. Pulmonary tuberculosis (PTB) (active or inactive) and bronchiectasis were the main underlying causes. BAE was attempted in 167 patients. There was a high prevalence of bilateral bronchial arterial abnormalities (31.7%), presence of abnormal non-bronchial arteries (41.3%) and presence of broncho-pulmonary shunt (38.9%). BAE had a high immediate success rate of 95.7%, with a 5-year recurrence rate of 45.0%. Recurrent life-threatening haemoptysis was independently associated with past history of haemoptysis (P = 0.024), presence of broncho-pulmonary shunt (P = 0.013), and incomplete embolisation (P = 0.002). Complications were uncommon (<5%) and self-limiting. CONCLUSIONS: In Hong Kong, about one tenth of admissions due to haemoptysis were life-threatening. PTB and bronchiectasis were the major causes. Complications due to BAE were uncommon and self-limiting, with super-selective catheters.

Surveillance of cardiovascular risk factors for outpatients in different erectile dysfunction severity.

We determined the association between the severity of erectile dysfunction (ED) and traditional cardiovascular risk factors, including metabolic syndrome (MS). A total of 141 ED patients were divided into three groups on the basis of ED severity, which was determined using the International Index of Erectile Function (IIEF) scores. The prevalence of MS among the ED patients was 32.6%. Significantly lower IIEF scores were noted in patients with MS than in patients without MS (7.6+/-6.4 vs 11.6+/-7.4, P=0.003). As assessed by the anthropometric indices of body mass index, waist circumference and waist-to-hip ratio, obesity was detected in 58.9, 54.6 and 32.6% of the patients, respectively. Of the 141 patients, 39 had mild, 24 had moderate and 78 had severe ED. Statistically significant differences were noted among the different ED severity groups with regard to the presence of hypertension, systolic blood pressure, presence of MS and number of MS components. Multivariate analysis showed that the odds ratio for high-low-density lipoprotein (LDL) cholesterol level in moderate and severe ED, determined with reference to mild ED, were 9.346 and 6.452, respectively. The presence of MS, number of MS components, and certain traditional cardiovascular risk factors, particularly high-LDL cholesterol level and hypertension, may influence the severity of ED.

La música como método alternativo en la modificación de la conducta del niño durante el tratamiento dental

El manejo de la ansiedad en un niño es un aspecto crítico del procedimiento dental. Por esta razón, muchas técnicas que envuelven métodos no farmacológicos han sido usadas para manejar la conducta del niño en el consultorio dental. El propósito del presente estudio fue evaluar el empleo de la música como una herramienta en la modificación de la conducta del niño, a fin de obtener un mayor grado de colaboración y satisfacción durante el tratamiento dental. La muestra estuvo constituida por 50 niños de 3 a 9 años de edad, todos ellos seleccionados al azar yatendidos en el área de Odontología Pediátrica Post-grado de la Clínica Estomatológica Central (CEC) de la Universidad Peruana Cayetano Heredia (UPCH). Todos los pacientes fueron diagnosticados con lesiones de caries dental y pulpitis irreversible. Fue un ensayo clínico de tipo comparativo. Los resultados no mostraron diferencias significativas en la conducta de los niños hacia el tratamiento dental, entre aquellos que escucharon música y aquellos que no lo hicieron. Los niños que recibieron música presentaron un mayor porcentaje de satisfacción del tratamiento.(AU)

Chronic hepatitis B virus infection acquired in childhood: special emphasis on prognostic and therapeutic implication of delayed HBeAg seroconversion.

In high endemic areas of hepatitis B virus (HBV) infection, the vast majority of infection is acquired perinatally or during early childhood. The age of the patient is, therefore, almost equivalent to the duration of HBV infection. The natural history of chronic HBV infection consists of three chronological phases: immune tolerance, immune clearance and low replicative phases. The prevalence of hepatitis B e antigen (HBeAg) in asymptomatic HBV carriers is around 90% before 15 years of age, and decreases remarkably to less than 10% after 40 years of age. The immune clearance phase is characterized by a series of hepatitis flares and remissions. These will be followed eventually by HBeAg seroconversion, which is usually accompanied by remission of liver disease and confers favourable outcome. However, patients with persistent HBeAg seropositivity over 40 years of age are associated with a significantly higher risk for progression to cirrhosis than those with HBeAg seroconversion before 40 years of age, and thus should be considered as patients with 'delayed' HBeAg seroconversion. Antiviral or immunomodulatory therapy should be considered seriously for these patients.

Does increased body mass index with hepatic steatosis contribute to seroclearance of hepatitis B virus (HBV) surface antigen in chronic HBV infection?

BACKGROUND: Overweight and hepatic steatosis have been increasingly recognized recently. This study aimed to test whether substantial amount of fatty infiltration in liver, which may interfere with cytoplasmic distribution of hepatitis B surface antigen (HBsAg), can contribute to HBsAg seroclearance in HBsAg carriers. METHODS: Clinical and laboratory data including ultrasound grading of hepatic steatosis were studied in 54 HBsAg carriers with HBsAg seroclearance, and the results were compared with 108 age- and sex-matched carriers with HBsAg persistence. RESULTS: Body mass index and ultrasound grading of hepatic steatosis were significantly higher in HBsAg carriers with HBsAg seroclearance than in those with HBsAg persistence. The degrees of hepatic steatosis correlated significantly with body mass index (P<0.001). The prevalence of mild hepatic steatosis showed no significant difference (33% (18/54) vs 31% (33/108), P=0.72), but moderate-severe hepatic steatosis was significantly more prevalent in patients with HBsAg seroclearance (33% (18/54) vs 13% (17/108), P=0.01). HBsAg carriers with moderate and severe hepatic steatosis were associated with a 3.2-fold (95% confidence interval: 1.2-8.4, P=0.02) and 3.9-fold (95% confidence interval: 1.1-14.2, P=0.04), respectively, increased odds of HBsAg seroclearance compared to those without hepatic steatosis. CONCLUSION: Moderate-severe hepatic steatosis may contribute to HBsAg seroclearance in HBsAg carriers.

Comparison of long-term effects of lymphoblastoid interferon alpha and recombinant interferon alpha-2a therapy in patients with chronic hepatitis B.

To compare the long-term effect of natural lymphoblastoid interferon-alpha (IFN-alpha nl) and recombinant IFN-alpha 2a therapy in patients with chronic hepatitis B, 210 patients in two trials were followed-up for 1.1-15.5 years following the end of therapy. They included 34 patients who received placebo (control), 67 treated with IFN-alpha nl (36 after prednisolone priming) and 109 treated with IFN-alpha 2a (56 after prednisolone priming). The cumulative sustained response was higher in patients who had been treated with IFN-alpha nl after prednisolone priming than was exhibited using IFN-alpha nl alone, IFN-alpha 2a alone or the placebo (P < 0.05), or IFN-alpha 2a following prednisolone priming (P = 0.052) at the end of 11 years. Hepatocellular carcinoma (HCC) was detected in 1.5% of the IFN-alpha nl group, 3.7% of the IFN-alpha 2a group and 14.7% of the control group (control vs IFN-alpha nl or IFN-alpha 2a, P < 0.05). The cumulative HCC development was higher in the control group than in the IFN-alpha nl group (P < 0.002) and the IFN-alpha 2a group (P = 0.06). The cumulative survival rate was lower in the control group than in the IFN-alpha nl group (P < 0.01) and the IFN-alpha 2a group (P = 0.02). Multivariate analysis revealed that IFN-alpha nl therapy and female gender are significant predictors of sustained response; preexisting cirrhosis, age at entry and IFN therapy are significant factors in both HCC development and survival. In conclusion, IFN-alpha nl treatment may have a better long-term effect on hepatitis B virus (HBV) clearance than IFN-alpha 2a and placebo, and IFN therapy may provide better long-term beneficial effects than placebo in terms of HBV clearance, reduction of HCC and prolonged survival.

Acute hepatitis C virus (HCV) infection in chronic carriers of hepatitis B virus (HBV): the impact of underlying active HBV replication on persistence of HCV infection and antibody responses to HCV.

BACKGROUND AND AIMS: The aim of this study was to assess whether underlying chronic hepatitis B virus (HBV) infection interferes with persistence of hepatitis C virus (HCV) infection and humoral immune responses to HCV in acute HCV infection. METHODS: Serial sera from 12 patients with acute HCV infection (group A) and 12 hepatitis B surface antigen (HBsAg) carriers with acute HCV infection (seven anti-hepatitis B e antigen (anti-HBe) positive (group B1) and five hepatitis B e antigen (HBeAg) positive (group B2)) were tested for HCV RNA by polymerase chain reaction, and anti-HCV by third generation enzyme immunoassay and confirmatory assay. Serial serum samples from HBsAg carriers were also tested for HBeAg, anti-HBe, and HBV DNA by hybridisation assay. RESULTS: Persistent HCV viraemia for more than six months was significantly more frequent in groups A (83%) and B1 (86%) than in group B2 (0%). Anti-HCV was detected in 100% and 86% of group A and group B1 one month after onset while only one group B2 patient was transiently anti-HCV positive 1-2 months after onset. Of the latter, three had anti-core 1 less than two months after onset while no patient responded to other HCV antigens. Overall, of six HBsAg carriers with acute self limiting HCV infection, only one had transient anti-HCV and three had transient anti-core 1. HBV DNA became undetectable transiently in four and persistently in one group B2 patient. CONCLUSION: The presence of active HBV replication can inhibit the persistence of HCV infection and antibody responses to HCV. Acute HCV infection in HBsAg carriers with active HBV replication usually presents transient HCV viraemia with poor antibody responses to HCV.

Observation of a hybrid spin resonance

A new type of spin depolarization resonance has been observed at the Brookhaven Alternating Gradient Synchrotron (AGS). This spin resonance is identified as a strong closed-orbit sideband around the dominant intrinsic spin resonance. The strength of the resonance was proportional to the 9th harmonic component of the horizontal closed orbit and proportional to the vertical betatron oscillation amplitude. This "hybrid" spin resonance cannot be overcome by the partial snake at the AGS, but it can be corrected by the harmonic orbit correctors.