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This is a case report of a uterine cancer with the International Federation of Gynecology and Obstetrics staging 3c2 with the initial clinical presentation of postmenopausal vaginal bleeding in August 2015. Endometrium biopsy showed invasive nests of poorly differentiated grade 3 endometrioid adenocarcinoma. The patient received robotic surgery including total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymph node dissection, para-aortic lymph node dissection, and washing cytology. The final pathology showed an endometrioid carcinoma with myometrium invasion up to 85% and para-aortic and pelvic lymph nodes invasion. The patient received six courses of adjuvant chemotherapy (paclitaxel and carboplatin) with concurrent chemoradiotherapy after the surgery. Later, immunotherapy with Picibanil (OK-432) and interleukin-2 (IL-2) was given, and cancer did not recur for 34 months until tumor recurrence at the liver dome and bilateral lung was noted by positron-emission tomography scan in July 2018. The patient received laparoscopic surgery for intra-abdominal tumor excision in December 2018, and the tumor found extended to the right diaphragm, liver surface, omentum, bilateral flank to pelvic peritoneum, Douglas pouch, and upper rectum. We continued the immunotherapy with OK-432, IL-2, Aldara cream (imiquimod), and later on, virotherapy (human papillomavirus vaccine). The immune risk profiles showed T–cells' proliferation and alteration of the Th1/Th2 activation after immunotherapy and virotherapy. Proctectomy with colon-anal anastomosis and cytoreduction surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) (doxorubicin and paclitaxel) was performed in January 2019. After the surgery, the patient received chemotherapy (topotecan, paclitaxel, lipodox, and carboplatin) and continued the immunotherapy. The immune risk profiles showed CD4, CD4/CD8 increase after HIPEC and immunotherapy. The patient continued the therapy until May 2020.

BackgroundFor women undergoing in vitro fertilization (IVF), the clinical benefit of embryo transfer at the blastocyst stage (Day 5) versus cleavage stage (Day 3) remains controversial. The purpose of this study is to compare the implantation rate, clinical pregnancy rate and odds of live birth of Day 3 and Day 5 embryo transfer, and more importantly, to address the issue that patients were chosen to receive either transfer protocol due to their underlying clinical characteristics, i.e., confounding by indication.MethodsWe conducted a retrospective cohort study of 9,090 IVF cycles collected by Lee Women’s Hospital in Taichung, Taiwan from 1998 to 2014. We utilized the method of propensity score matching to mimic a randomized controlled trial (RCT) where each patient with Day 5 transfer was matched by another patient with Day 3 transfer with respect to other clinical characteristics. Implantation rate, clinical pregnancy rate, and odds of live birth were compared for women underwent Day 5 transfer and Day 3 transfer to estimate the causal effects. We further investigated the causal effects in subgroups by stratifying age and anti-Mullerian hormone (AMH).ResultsOur analyses uncovered an evidence of a significant difference in implantation rate (p=0.04) favoring Day 5 transfer, and showed that Day 3 and Day 5 transfers made no difference in both odds of live birth (p=0.27) and clinical pregnancy rate (p=0.11). With the increase of gestational age, the trend toward non-significance of embryo transfer day in our result appeared to be consistent for subgroups stratified by age and AMH, while all analyses stratified by age and AMH were not statistically significant.ConclusionsWe conclude that for women without strong indications for Day 3 or Day 5 transfer, there is a small significant difference in implantation rate in favor of Day 5 transfer. However, the two protocols have indistinguishable outcomes on odds of live birth and clinical pregnancy rate.

Purpose Uterine fibroids are benign gynecologic tumors and commonly occur in women by the age of 50. Women with symptomatic uterine fibroids generally receive surgical intervention, while they do not favor the invasive therapies. To evaluate the feasibility and safety of a novel magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) modality, ArcBlate, in the treatment of uterine fibroids. Methods Nine patients with uterine fibroids and one patient with adenomyosis were treated with ArcBlate MRgHIFU. Tumor size and quality of life were evaluated postoperatively at 1 and 3 months by magnetic resonance imaging (MRI) and the 36-Item Short Form Survey (SF-36), respectively. Results All patients completed the ArcBlate MRgHIFU procedure and there were no treatment-related adverse effects either during the procedure or during the 3 months of follow-up. Despite limiting the ablation volume to under 50% of the treated fibroid volume as a safety precaution, tumor volumes were markedly reduced in four patients by 15.78–58.87% at 3-month post-treatment. Moreover, SF-36 scale scores had improved at 3 months from baseline by 2–8 points in six patients, indicating relief of symptoms and improved quality of life. Conclusion This study evidence demonstrates the safety and feasibility of ArcBlate MRgHIFU and suggests its potential for treating uterine fibroids.

Background: Obesity is associated with poor prognosis in breast cancer patients. This study aimed to evaluate the effect of obesity measured by body mass index (BMI) on survival of Taiwanese breast cancer patients in a single institution. Methods: We observed 5000 patients who were diagnosed with stage I-III breast cancer between 1990 and 2005. Information on BMI at diagnosis, and clinical follow-up for disease recurrence and death, up to 20 years post-diagnosis were available. BMI (in kg/m2) categories included normal weight (BMI

Few studies have analyzed the discrepancy between breast pathologic complete response (B-pCR) and axillary node pCR (N-pCR) rates and their impact on survival outcomes in different intrinsic subtypes of early breast cancer after neoadjuvant chemotherapy (NAC). We retrospectively reviewed B-pCR, N-pCR, and total (breast and axillary node) pCR (T-pCR) after NAC to assess the discrepancy and outcomes between 2005 and 2017. A total of 968 patients diagnosed with cT1-4c, N1-2, and M0 breast cancer were enrolled in the study. The median age was 49 years and the median follow-up time was 45 months. Of these patients, 213 achieved T-pCR, 31 achieved B-pCR with axillary node pathologic non-complete response (N-non pCR), 245 achieved N-pCR with breast pathologic non-complete response (B-non pCR), and 479 achieved total (breast and axillary node) pathologic non-complete response (T-non pCR) after NAC. The highest B-pCR and N-pCR rates were found in the hormone receptor-negative, human epidermal growth factor receptor 2-positive HR(-)HER2(+) subtype, while the lowest B-pCR rate was found in the HR(+)HER2(-) subtype. The N-pCR rate was correlated to the B-pCR rate (P

Background To evaluate the use of a human fibrin glue (Tisseel) for minor bleeding control and approximation of ovarian defect during transvaginal natural orifice ovarian cystectomy (TNOOC) of benign and non-endometriotic ovarian tumors. Methods A total of 125 women with benign and non-endometriotic ovarian tumors who underwent TNOOC between May 2011 and January 2020: 54 with the aid of Tisseel and 71 with traditional suture for hemostasis and approximation of ovarian defect. Surgical outcomes such as length of surgery, operative blood loss, postoperative pain score, and postoperative hospital stay were recorded. Before and immediately (10 days) and at 6 months after the procedure, serum anti-Müllerian hormone (AMH) levels were also determined. Results Complete hemostasis and approximation of ovarian defect were achieved in all cases. No significant difference was noted in the operating time, operative blood loss, postoperative pain scores after 12, 24 and 48 h, length of postoperative stay, and baseline AMH levels between the two groups. The operation did not have a negative effect on the immediate and 6-month postoperative AMH levels in the suture group. However, the decline in the AMH levels was significant immediately after surgery in the Tisseel group, nevertheless, no significant difference was noted in the AMH levels at 6 months (3.3 vs. 1.7 mg/mL; p = 0.042, adjusted p = 0.210). Conclusion The use of Tisseel in TNOOC of benign and non-endometriotic ovarian tumors without suturing the ovarian tissue is clinically safe and feasible.

Study Objective This study was designed to evaluate the learning curve of transvaginal natural orifice surgery (NOS) for adnexal tumors based on the type of procedure (adnexectomy or cystectomy). Design Retrospective cohort study. Setting Tertiary-care university hospital. Patients One hundred thirty-six women with adnexal tumors. Interventions A series of 136 consecutive transvaginal NOS for adnexal tumor were performed between April 2011 and June 2016. Eighty-five patients (62.5%) had undergone cystectomy, and 51 patients (37.5%) had undergone adnexectomy. Measurements and Main Results The transvaginal NOS procedures included vaginal, endoscopic, single-port access techniques and were divided into 2 categories: adnexectomy and cystectomy. Operating time was electronically recorded and was defined as the time from the creation of a posterior colpotomy incision until the complete closure of the posterior colpotomy opening. The average operating time for the cystectomy and adnexectomy groups was 42.7 and 37.7 minutes, respectively (p = .015). The learning curve was analyzed using the cumulative summation method and showed that 36 cases were needed to achieve proficiency in transvaginal NOS for ovarian cystectomy. However, there was no significant cut-off point to determine the number of patients who had undergone adnexectomy. Conclusion A well-trained gynecologic endoscopist can achieve surgical proficiency in transvaginal NOS cystectomy after 36 cases. It is suggested that the surgical transvaginal NOS procedure should begin with adnexectomy rather than with cystectomy to avoid initial technical challenges.

Background. To evaluate the feasibility and applicability of using office hysteroscopy in women with intact hymen. Methods. We recruited 836 patients with intact hymen with different indications who underwent diagnostic hysteroscopy without anesthesia in an outpatient setting from 2007 to 2016 at Chang Gung Memorial Hospital at Linkou. Results. Patients’ mean age was 35 ± 10.6 years (range 3–69 years). Most patients (86.4%) with postmenopausal bleeding had intrauterine lesions, and they were especially at high risk (50%) for endometrial hyperplasia or malignancy. Five hundred thirty (63.3%) patients had histologic findings confirming concordance between hysteroscopic and histologic findings. Submucosal myoma had the highest concordance (96.3%), whereas endometrial hyperplasia had the lowest concordance (50%). Forty-eight patients (5.7%) had endometrial hyperplasia, and 35 patients (4.2%) had endometrial malignancy. Two patients who were thought to have nonspecific endometrial thickening actually had endometrial pathology. Conclusions. Hysteroscopy through vaginoscopic approach is feasible and well-tolerated in the patients with intact hymen. This outpatient procedure provides accurate evaluation of lesions of the genital tract and should be considered in patients without a history of intercourse.

Purpose Sentinel lymph node biopsy (SLNB) is the standard management for clinically node-negative cutaneous melanoma patients. This study aimed to evaluate the role of SLNB in Taiwanese melanoma patients and in particular, patients with acral lentiginous melanoma (ALM). Patients and methods We retrospectively analyzed the clinicopathological characteristics and survival outcomes of the patients who underwent primary surgery followed by either SLNB or nodal observation at the Linkou Chang Gung Memorial Hospital from January 2000 to December 2011. Results Among the total of 209 patients, 127 underwent SLNB and 51 underwent nodal observation only after primary surgery. There were no significant differences in clinicopathological features between the two groups except that patients who underwent SLNB were older and had a higher rate of ALM than those under nodal observation. The median follow-up time was 43.5 months until July 2013. The patients who underwent SLNB had significantly better disease-free survival (DFS) (57.1 vs 18.7 months, p 2 mm, or ulceration. Conclusion SLNB was associated with favorable outcomes in patients with clinically node-negative cutaneous melanoma, particularly in Taiwanese patients with ALM, Breslow thickness ≤2 mm, and nonulcerated melanoma.

Natural disasters have negative health impacts on patients who need dialysis in affected areas. Severely affected areas are usually rural, with limited basic infrastructure and a population without optimal dialysis-specific care after a disaster. A population-based longitudinal case–cohort study enrolled 715,244 adults from the National Health Insurance Registry who lived in areas affected by a major natural disaster, Typhoon Morakot, in 2009. The observation period was from 2008 to 2011. A total of 13,268 patients (1.85%) had a history of end-stage renal disease (ESRD). Of the ESRD patients, 1264 patients (9.5%) received regular dialysis. Only eight patients missed dialysis sessions in the first month after the disaster. Compared to the moderately affected areas, the incidences of acute cerebrovascular and cardiovascular diseases were higher in patients in severely affected areas. Male dialysis patients aged 45–75 years had a higher mortality rate than that of the general population. Among the affected adults receiving regular dialysis, patients with diabetes (adjusted hazard ratio (aHR): 1.58, 95% confidence interval (CI): 1.20–2.08) or a history of cerebrovascular disease (aHR: 1.58, 95% CI: 1.12–2.21), chronic obstructive pulmonary disease (COPD) or asthma (aHR: 1.99, 95% CI: 1.24–3.17) in moderately affected areas had significantly elevated mortality rates. Additionally, among dialysis patients living in severely affected areas, those with a history of cerebrovascular disease (aHR: 4.52 95% CI: 2.28–8.79) had an elevated mortality rate. Early evacuation plans and high-quality, accessible care for cardiovascular and cerebrovascular diseases are essential to support affected populations before and after disasters to improve dialysis patients’ health outcomes.

Objectives: This study examines the practice of the regulation of Standards for Medical Exposure Quality Assurance (SMEQA) in Taiwan based on on-site quality audit for radiation therapy systems from 2016 to 2019. Methods: 81 radiation therapy departments, 141 linacs, 9 γ knife systems, 34 high dose rate brachytherapy systems, 20 Tomotherapys, and 6 Cyberknives were audited yearly. Data collection and analysis for each institute’s documents including QA procedure, ion chamber and electrometer calibration reports, and a questionnaire relating to machine type and staffing, were requested first and reviewed by auditors. On-site SMEQA core item measurements, including beam output, beam profile and energy constancy for external beam therapy systems, and the source strength, positioning, and timer accuracy for brachytherapy systems were audited second. More than 300 photon beams and more than 400 electron beams were measured each year. Results: There were approximately 8.9 radiotherapy units per million population, and 1.2 medical physicists per unit in Taiwan. For the output measurements, more than 78 and 75% of the photon beams and electron beams, respectively, from linacs were with deviations within ±1.0%. Photon beams have lower beam quality measurement deviations than electron beams. Including in-plane and cross-plane measurements, more than 90 and 85% photon and electron beams, respectively, were with flatness consistency within 1.0%. All audit measurements were within the SMEQA acceptance criteria. Conclusions: According to SMEQA regulations on-site QA audits were successfully carried out from 2016 to 2019 for all Taiwan radiotherapy units. The measurement results showed high quality machine performance in Taiwan. Advances in knowledge: Dosimetry audits with directly acquired measurement readings have lower uncertainties; allow immediate feedback, discussion, and adjustment in a timely manner. In addition to regulation system establishment and education and training implementation, the machine quality is closely related to machine maintenance implementation.

Background Real-world clinical data on psoriasis patients receiving different biological agents is needed, especially in Asian populations. Objectives Our aim is to compare and analyze the efficacy and safety profile of four biological agents (etanercept, adalimumab, ustekinumab and secukinumab) in a real-world setting in Taiwan. Methods We retrospectively analyzed the clinical data of all patients with moderate-to-severe plaque psoriasis (Psoriasis Area and Severity Index (PASI) ≥ 10) who received etanercept, adalimumab, ustekinumab or secukinumab between January 2011 and December 2018 in a tertiary hospital in Taiwan. Results A total of 119 treatment episodes in 75 patients were included in this study. Ustekinumab was used in 49 treatment episodes, followed by secukinumab in 46 treatment episodes, adalimumab in 14 treatment episodes and etanercept in 10 treatment episodes. The proportion of the biologic-naïve was highest in etanercept (100%) and lowest in secukinumab (23.9%). The PASI-75, -90 and -100 were the highest in secukinumab (91.3%, 82.6%, 41.3%, respectively), followed by ustekinumab (79.6%, 44.9%, 16.3%), adalimumab (64.3%, 28.6%, 7.1%) and etanercept (50.0%, 30.0%, 0%). The rate of adverse events that required treatment was highest for secukinumab (15.2%), followed by adalimumab (14.3%), ustekinumab (8.2%), and etanercept (0%), including 4 cases of infections, 2 cases of cardiovascular diseases and 4 cases of cancers. Conclusions This real world data showed differential efficacy and safety of the four biological agents.

Purpose: This study examines the practice of the regulation of Standards for Medical Exposure Quality Assurance (SMEQA) in Taiwan based on on-site quality audit for radiation therapy systems from 2016 to 2019. Methods and Materials: about 81 radiation therapy departments, 141 medical linear accelerators, 9 gamma knifes, 34 high dose rate brachytherapy systems, 20 Tomotherapys and 6 Cyberknives were audited yearly. The inspection was implemented in two stages. Data collection and analysis for each institute’s documents including QA operating procedure, ion chamber and electrometer calibration reports, and a questionnaire relating to machine type and staffing, were requested first and reviewed by specially trained auditors. On-site measurements of SMEQA core items, including beam output, beam profile and energy constancy for external beam therapy systems, and the source strength, positioning and timer accuracy for brachytherapy systems were audited second. More than 300 photon beams were measured from linacs, Gamma knives, Cyberknives and Tomotherapys, and more than 400 electron beams from linacs each year.Results: The radiation treatment resource is about 8.9 therapy machines or 7.5 MV/MeV/ion beam therapy machines per million population, respectively, and there are on average about 1.20 medical physicists per radiation therapy unit in Taiwan. There were more than 78% and 75% of photon and electron beams respectively from linacs with deviations measured to the stated reference-point dose within 1.0%. Photon beams have lower beam quality measurement deviations than electron beams, and more than 90% of photon beams from linacs were within 1.0%. Including in-plane and cross-plane measurements, more than 90% and 85% of photon and electron beams respectively with flatness consistency within 1.0%. Beam symmetry as an absolute value has more than 75% of measurements within 1.0%. All audit measurements in this study were within the SMEQA acceptance criteria.Conclusions: On-site machine QA audits have been implemented from 2016 to 2019 for all radiation therapy units each year. The measurement results have shown a high quality machine performance in Taiwan.

This study was designed to evaluate the learning curve of applying Seprafilm (modified hyaluronic acid and carboxymethylcellulose; Genzyme, Cambridge, MA, USA) during laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy. In this retrospective cohort study, 35 patients who underwent laparoscopic hysterectomy or subtotal hysterectomy with or without adnexectomy were enrolled. The Seprafilm was cut into 4 pieces, rolled up with a trimmed plastic sleeve and delivered through an incision wound made for the 5-mm ancillary trocar. The membrane was unrolled and placed on the rough surface after hysterectomy or subtotal hysterectomy with or without adnexectomy. The time from the insertion of the first piece of membrane into the abdominal cavity to the complete removal of the trimmed plastic sleeve was recorded. The median time for Seprafilm placement was 3 min. The learning curve was analyzed using the power-law method and suggested that 10 cases were required to achieve proficiency in the procedure. The presence of adnexectomy was significantly associated with the time required for Seprafilm placement (P

Brown adipose tissue (BAT) is an exclusive tissue of nonshivering thermogenesis. It is fueled by lipids and glucose and involved in energy and metabolic homeostasis. Intrauterine exposure to hyperglycemia during gestational diabetes mellitus may result in abnormal fetal development and metabolic phenotypes in adulthood. However, whether intrauterine hyperglycemia influences the development of BAT is unknown. In this study, mouse embryos were exposed to the intrauterine hyperglycemia environment by injecting streptozocin into pregnant mice at 1 d post coitum (dpc). The structure of BAT was examined by hematoxylin and eosin staining and immunohistochemical analysis. The glucose uptake in BAT was measured in vivo by [18F]-fluoro-2-deoxyglucose-micro-positron emission tomography. The gene expression in BAT was determined by real-time PCR, and the 5'-C-phosphate-G-3' site-specific methylation was quantitatively analyzed. Intrauterine hyperglycemia exposure resulted in the impaired structure of BAT and decreased glucose uptake function in BAT in adulthood. The expressions of the genes involved in thermogenesis and mitochondrial respiratory chain in BAT, such as Ucp1, Cox5b, and Elovl3, were down-regulated by intrauterine hyperglycemia exposure at 18.5 dpc and at 16 wk of age. Furthermore, higher methylation levels of Ucp1, Cox5b, and Elovl3 were found in offspring of mothers with streptozotocin-induced diabetes. Our results provide the evidence for enduring inhibitory effects of intrauterine hyperglycemia on BAT development in offspring. Intrauterine hyperglycemia is associated with increased DNA methylation of the BAT specific genes in offspring, which support an epigenetic involvement.-Yu, D.-Q., Lv, P.-P., Yan, Y.-S., Xu, G.-X., Sadhukhan, A., Dong, S., Shen, Y., Ren, J., Zhang, X.-Y., Feng, C., Huang, Y.-T., Tian, S., Zhou, Y., Cai, Y.-T., Ming, Z.-H., Ding, G.-L., Zhu, H., Sheng, J.-Z., Jin, M., Huang, H.-F. Intrauterine exposure to hyperglycemia retards the development of brown adipose tissue.

Objective This study aimed to determine the effects of diet-induced paternal obesity on cognitive function in mice offspring. Methods Male mice (F0) were randomized to receive either a control diet (10 kcal% fat) or a high-fat diet (HFD; 60 kcal% fat) for 10 weeks before being mated with normal females to generate F1 offspring. Male F1 offspring were mated with normal females to generate F2 offspring. Behavioral tests were used to assess cognitive functions in F1 and F2 offspring. Reduced representation bisulfite sequencing was used to the explore mechanisms of epigenetic inheritance. Results HFD-induced paternal obesity resulted in cognitive impairments in F1 offspring, potentially due, at least in part, to increased methylation of the BDNF gene promoter, which was inherited from F0 spermatozoa. BDNF/tyrosine receptor kinase B signaling was associated with cognitive impairments in HFD-fed F1 offspring. However, there were no significant changes in F2 offspring. Conclusions The findings provide evidence of intergenerational effects of paternal obesity on cognitive function in offspring occurring via epigenetic spermatozoan modifications.

Background A variety of different types of exercise are promoted to improve muscle strength and physical performance in older people. Objective We aimed to determine the relative effects of resistance training, endurance training and whole-body vibration on lean body mass, muscle strength and physical performance in older people. Design A systematic review and network meta-analysis. Subjects Adults aged 60 and over. Methods Evidence from randomised controlled trials of resistance training, endurance training and whole-body vibration were combined. The effects of exercise interventions on lean body mass, muscle strength and physical performance were evaluated by conducting a network meta-analysis to compare multiple interventions and usual care. Risk of bias of included studies was assessed using the Cochrane Collaboration's tool. A meta-regression was performed to assess potential effect modifiers. Results Data were obtained from 30 trials involving 1,405 participants (age range: 60-92 years). No significant differences were found between the effects of exercise or usual care on lean body mass. Resistance training (minimum 6 weeks duration) achieved greater muscle strength improvement than did usual care (12.8 kg; 95% confidence interval [CI]: 8.5-17.0 kg). Resistance training and whole-body vibration were associated with greater physical performance improvement compared with usual care (2.6 times greater [95% CI: 1.3-3.9] and 2.1 times greater [95% CI: 0.5-3.7], respectively). Conclusions Resistance training is the most effect intervention to improve muscle strength and physical performance in older people. Our findings also suggest that whole-body vibration is beneficial for physical performance. However, none of the three exercise interventions examined had a significant effect on lean body mass.

Cochlear implants (CIs) provide speech perception to adults with severe-to-profound hearing loss, but the acoustic signal remains severely degraded. Limited access to pitch cues is thought to decrease sensitivity to prosody in CI users, but co-occurring changes in intensity and duration may provide redundant cues. The current study investigates how listeners use these cues to infer discourse prominence. CI users and normal-hearing (NH) listeners were presented with sentences varying in prosody (accented vs. unaccented words) while their eye-movements were measured to referents varying in discourse status (given vs. new categories). In Experiment 1, all listeners inferred prominence when prosody on nouns distinguished categories (“SANDAL” → not sandwich). In Experiment 2, CI users and NH listeners presented with natural speech inferred prominence when prosody on adjectives implied contrast across both categories and properties (“PINK horse” → not the orange horse). In contrast, NH listeners presented with simulated CI (vocoded) speech were sensitive to acoustic differences in prosody, but did not use these cues to infer discourse status. Together, this suggests that exploiting redundant cues for comprehension varies with the demands of language processing and prior experience with the degraded signal.

Background/Purpose Typhoon Morakot in August 2009 caused significant damages and health and socio-economic impacts in Taiwan. Therefore, we evaluated the mental health status of adult and patients who lived in the affected area after the disaster. Methods An observational, prospective population-based study was conducted. Adults living in the affected area were selected as the affected population in the National Health Insurance Database from January 2008 to December 2011. Prevalence and incidence of stress-associated illnesses, such as insomnia, anxiety, depressive, adjustment and mood disorders, post-traumatic stress disorder (PTSD) in the psychiatry department were analysed after the disaster. Results A total of 897,689 adult patients were studied. Of the affected population without pre-existing chronic mental health illness, the monthly visits for stress-associated illnesses, such as insomnia, anxiety, depressive disorders and PTSD increased about twice after the disaster in elderly and non-elderly groups. Comparing to the non-elderly group, the elderly group has more increased in the incidence of insomnia (356% vs. 318% increase) and depressive disorders (308% vs. 245%) but was affected to a lesser extent increase in the anxiety (269% vs. 307%), PTSD, episodic mood disorders (82% vs. 158%), and adjustment reaction (160% vs. 202%). Conclusion The mental health statuses of patients who experienced a major natural disaster deteriorated in the elderly population after the disaster. However, we still need pay more attentions on the elderly of the affected population to decrease the risk for insomnia and depressive disorders after the disaster.

This report describes a simple technique using conventional instrumentation for the placement of Seprafilm, a sodium hyaluronate or carboxymethylcellulose absorbable barrier for adhesion prevention. A total of 378 women with uterine myomas undergoing laparoscopic myomectomies had 737 Seprafilm pieces placed. Seprafilm sheet was softened through exposure to room air for 5 minutes, cut into 4 pieces (length, 5-10 mm), rolled up alongside a plastic sheet cut from a camera drape cover, and gently placed at the right paracolic gutter. The Seprafilm pieces unfolded semiautomatically on release and were then placed on the uterus. The median time to apply per Seprafilm piece was 1 (range: 0.8-3.5) minute. We failed to place 16 pieces (16 of 737, 2.2%) in 11 patients. Virginal status, myoma weight, and the number of removed myomas were the risk factors of failed placement. Our technique for Seprafilm placement during laparoscopic myomectomy is simple and safe.

Aim To examine the effects of a simplified reablement program on physical function and quality of life in hospitalized older patients. Methods The randomized controlled trial enrolled 114 older patients aged ≥65 years who, 2 weeks before admission, had been able to walk independently. Patients randomized to the reablement group received supervision and assistance to carry out the simplified reablement program 30 min daily during their hospital stay. Patients in the reminding group received only oral encouragement to continue the reablement program for 30 min daily. The control group received only usual care that included medical intervention consistent with the patient's diagnosis. The main outcome was improvement in physical function, including the modified version of the Katz Activities of Daily Living (ADL) score, Timed Up and Go test (TUG) and Hand Grip Strength (HGS). Secondary outcomes included the EuroQoL 5 Dimension (EQ-5D) Questionnaire and Visual Analog Scale (VAS). Results The intervention had no significant effect on the Katz ADL score. However, a significant within-group improvement in TUG occurred in the reminding group and reablement group. In addition, a significant time-dependent improvement in HGS occurred only in the reablement group. With respect to secondary outcomes, the EQ5D score improved significantly only in the reablement group at 3 months after discharge. Conclusions The simplified reablement program may be beneficial to optimize physical function and improve quality of life in hospitalized older patients. It is recommended that health professionals should assist or encourage older patients to do simplified reablement during their hospital stay. Geriatr Gerontol Int 2020; 20: 436-442.

Background No data are available to assess the learning curve for transvaginal natural orifice transluminal endoscopic hysterectomy for non-prolapsed uteri in benign gynecologic diseases. The lack of exposure to transvaginal natural orifice transluminal endoscopic hysterectomy during training, in addition to a poorly defined learning curve, further deters interested physicians from applying this technique to daily practice. The aim of this study was to evaluate the learning curve and perioperative outcome of transvaginal natural orifice transluminal endoscopic hysterectomy by an experienced endoscopist. Methods A total of 240 cases of transvaginal natural orifice transluminal endoscopic hysterectomies with or without adnexectomy for various benign gynecologic diseases were included. Demographic data and various perioperative parameters were reviewed from the prospectively collected database. Operative time was set as a surrogate marker for surgical competency. The learning curve was evaluated using the cumulative sum method. Results The overall mean operative time (OT) was 76.5 min ± 22.4. Four unique phases of the learning curve were derived using cumulative sum analysis: the mean OT of phase I (the initial learning curve of 20 cases) was 86.3 ± 23.7 min, phase II (acquisition of competence of 80 cases) was 71.0 ± 21.4 min, phase III (proficiency and plateau of 80 cases) was 76.0 ± 20.4 min, and phase IV (post-learning in which more challenging cases were managed) was 81.3 ± 23.6 min. No major complications were encountered. One case in phase III converted to laparoscopy due to difficulty in performing anterior colpotomy. Conclusion Our data demonstrated four distinct phases of the learning curve of transvaginal natural orifice transluminal endoscopic hysterectomy. In a well-trained endoscopist, surgical competence in transvaginal natural orifice transluminal endoscopic hysterectomy can be reached after 20 cases. Electronic supplementary material The online version of this article (10.1186/s12893-019-0554-0) contains supplementary material, which is available to authorized users.

Nipple-sparing mastectomy (NSM) and immediate breast reconstruction has been proven to be a safe and reliable procedure in selected breast cancer patients with better aesthetic outcome. Robot-assisted nipple-sparing mastectomy (R-NSM), facilitated by articulated instruments and 3-dimensional camera, further allows mastectomy and reconstruction to be accomplished through a smaller incision over the lateral chest wall with complete preservation of the breast skin envelope without anterior scar. The small incision of R-NSM has limited the reconstructions to be implant- or small pedicle flap-based. Perforator flaps, with the most natural-looking and permanent results, have never been applied in R-NSM. In this preliminary report, microsurgical breast reconstruction with free deep inferior epigastric artery perforator (DIEP) flap (N=1) or profunda artery perforator (PAP) flaps (N=2) were performed successfully along with R-NSM. One patient had nipple-areolar excision due to positive nipple margin under frozen section, but the reconstructed nipple using PAP flap skin paddle successfully concealed the peri-areolar scar. Two patients received post-mastectomy radiotherapy (PMRT) because of more extensive cancer involvement. The flaps tolerated PMRT well without contracture or compromised aesthetic results. Microsurgical breast reconstruction is feasible after R-NSM and provides additional oncological and aesthetical advantages. Compared to breast implants, autologous tissue tolerates radiotherapy better and can be transferred safely when PMRT is required. These novel approaches brought robot-assisted mastectomy to its next level with wider clinical applications free of restriction to early breast cancer. Larger series report and longer follow-up should be anticipated to prove its clinical value.

The 2015 dengue outbreak in southern Taiwan turned into a public health emergency, resulting in a large-scale mobilization of personnel from the emergency department (ED) services operating in and near full capacity to assist with the outbreak. This study aimed to assess a rapid independent clinic-based service (RCS), which was set up and designed to relieve the overcrowding of the regular ambulatory and emergency services during an epidemic of dengue. This is a retrospective cross-sectional study. National Cheng Kung University Hospital, Tainan, Taiwan. Patients with positive test results were enrolled and reviewed to evaluate the efficacy of RCS implementation between August and October 2015. The case-treatment rates stratified by length of stay (LOS) were used to examine the performance of the RCS that was set up outside the ED and designed to relieve the overcrowding of the regular ambulatory and emergency services. Patients with dengue-like illnesses may arrive at the hospital and require optimal ED triage and management thereafter. Although the outbreak resulted in a shortage of spare space in the ED, a proper response from the hospital administration would ameliorate the work overload of the staff and would not decrease the quality of care for critical patients. An early and restrictive intensive intervention was beneficial to health care facilities during a dengue outbreak. Further planning and training of the RCS could be crucial for hospital preparedness for infectious disease outbreaks.

Natural disasters have negative health impacts on chronic diseases in affected populations. Severely affected areas are usually rural areas with limited basic infrastructure and a population have that has limited access to optimal healthcare after a disaster. Patients with cardiovascular diseases are required to maintain quality care, especially after disasters. A population-based case-control study enrolled adults from the National Health Insurance Registry who had ischemic heart disease and cerebrovascular disease histories and lived in the area affected by Typhoon Morakot in 2009. Monthly medical visits for acute cerebrovascular and ischemic heart diseases markedly increased at approximately 1&ndash, 2 months after the typhoon. Survival analysis during the two years following the typhoon indicated a significant increase in mortality in adults with an acute ischemic heart disease history who lived in the severely affected area. Mortality hazard analysis showed that among affected adults with previous cerebrovascular diseases and acute ischemic heart diseases, patients with diabetes (adjusted hazard ratio [HR]: 1.3&ndash, 1.7), Chronic Kidney Disease (CKD) (adjusted HR: 2.0&ndash, 2.7), chronic obstructive pulmonary diseases (COPD) and asthma (adjusted HR: 1.7&ndash, 2.1), liver cirrhosis (adjusted HR: 2.3&ndash, 3.3) and neoplasms (adjusted HR: 1.1&ndash, 2.1) had significantly increased mortality rates. Consequently, high-quality and accessible primary healthcare plans should be made available to maintain and support affected populations after disasters.

Background: Extensive studies have demonstrated that sleep is an important modulator of cardiovascular and metabolic diseases. However, its impact on renal function remains uncertain. Methods: A total of 26,249 adults aged ≥20 years were recruited through voluntary health examinations in Taiwan. Sleep duration was self-reported by questionnaire. Proteinuria was graded semi-quantitatively by dipstick urine test. The associations of sleep duration with proteinuria and estimated glomerular filtration rate (eGFR) were analyzed. Results: After an average follow-up period of 2.62 years, the crude hazard ratio (HR) for proteinuria progression were 1.92 (95% CI 1.22–3.03), 1.23 (95% CI 1.09–1.39), and 1.18 (95% CI 1.00–1.39) for those with sleep duration < 4, 4–6, and > 8 h compared to those with sleep duration of 6–8 h (the reference group), respectively. The HR remained significant for those with sleep duration < 4 h (adjusted HR 1.65 [95% CI 1.05–2.61]) and 4–6 h (adjusted HR 1.19 [95% CI 1.06–1.35]) after adjustment for age, sex, blood pressure, fasting glucose, body mass index, cholesterols, triglycerides, uric acids, physical activity, smoking, alcohol consumption, income/educational levels, and baseline eGFR. However, eGFR was not significantly different among different sleep duration groups. Discussion: This result indicates short sleep duration is independently associated with the progression of proteinuria.

Overexpression of receptor tyrosine kinase-like orphan receptor (ROR1) in a variety of human malignancies is associated with aggressive behaviour. Therapeutic agents targeting ROR1 have shown promising results in vivo and in vitro studies. In breast cancer, high-level expression of ROR1 mRNA is associated with high-grade tumours and metastasis. We investigated the prevalence and prognostic significance of ROR1 expression in triple negative breast cancer (TNBC). ROR1 was immunohistochemically stained on full-face sections of 210 TNBC patient samples. Forty-seven TNBC cases (22.4 %) showed strong ROR1 expression, which was associated with shorter disease-free survival (DFS; P = 0.00015), distant metastasis-free survival (DMFS; P = 0.00013) and overall survival (OS; P = 0.026) in univariate analyses. Results were confirmed by multivariate analysis. Seventy TNBC cases (33.3 %) with medullary features showed longer OS (P = 0.00013). We divided the whole series into two subgroups based on the presence or absence of medullary features. Strong ROR1 expression retained a predictive value of shorter DFS and DMFS in both subgroups. Our study suggests that strong ROR1 expression might be an independent adverse prognostic factor in TNBC patients and may serve as a potential marker for patient selection in ROR1-targeted therapy. More large-scale studies are needed to clarify its potential usefulness.

The purpose of this study was to compare the safety and efficacy of an electrothermal bipolar vessel sealing device (LigaSure™) and traditional electrical cauterization in laparoscopic myomectomy (LM). A total of 756 patients with symptomatic uterine myomas who underwent LM were reviewed retrospectively. A total of 225 cases of LM using LigaSure™ (LML group) were compared with a control group treated with traditional electrical cauterization (LME group) under propensity-matched analysis. Outcome measures for both groups were compared, such as operative time, blood loss (BL), complications, need for blood transfusion, hospital expenses, and hospital stay. Six subgroups were divided according to main myoma size and energy source. No cases required switching to abdominal myomectomy. The number of myomas removed, BL, need for blood transfusion, and complications were not significantly different, whereas hospital stay was longer in the LME group than in the LML group and total hospital expenses were higher in the LML group (p < 0.001). The overall operation duration was significantly longer in the LML group but was not significantly different for main myoma >10 cm (LML vs LME, 121.58 ± 41.77 vs 121.69 ± 44.95, p = 0.99); this likely reflects the operative efficiency on using LigaSure™ to manage large tumors. Significant linear correlations between myoma weight and operative time and BL were seen in both groups. Conventional diathermy is more effective for small-to-medium myomas. Use of the LigaSure™ was efficient for myomas >10 cm.

ObjectiveOur aim was to investigate the outcomes and prognostic factors after treatment failure of endometrial cancer.MethodsA total of 923 endometrial cancer patients were treated between 2000 and 2010, of which 109 experienced treatment failure. Treatment failure was defined as relapse after complete removal of all cancerous lesions or persistent/progressive disease despite treatment. Variables including clinicopathological features at initial treatment, type of primary treatment, failure pattern, salvage treatment, and outcomes were analyzed. Kaplan-Meier survival curves were compared with log-rank test. Cox proportional hazards regression model was used to identify significant prognostic factors.ResultsEighteen cases with persistent/progressive disease died shortly from primary diagnosis (1–23 months). The remaining 91 patients had recurrences in vagina only (8.8%), pelvis (3.3%), distant (63.7%), and combined pelvic-distant sites (24.2%). Median time to recurrence was 13.3 months (3.2–97.2 months). The median follow-up after recurrence of survivors was 60.5 months (10.6–121.7 months). The median survival after recurrence (SAR) was 20.3 months (1.9–121.7 months) with 5-year SAR rate of 32.4%. By multivariate analysis, initial stage II to IV (hazards ratio [HR], 3.41; 1.53–7.60;P= 0.003), type II histology (HR, 2.50; 1.28–4.90;P= 0.008), positive peritoneal cytology (HR, 2.23; 1.07–4.68;P= 0.033), and recurrence at multiple sites (HR, 2.51; 1.30–4.84;P= 0.006) were significantly associated with poor SAR. The 5-year SAR rates in patients with solitary vaginal, nodal/liver, or pulmonary/bony recurrence were 83.3%, 50.5%, and 24.2%, respectively. Ten cases with resectable or irradiatable recurrence at multiple sites or multiple relapses attained SAR greater than 5 years after multimodality salvage therapy.ConclusionsInitial stage II to IV, type 2 histology, positive cytology, and recurrence at multiple sites were significant poor prognostic factors. Curative intent salvage therapy remains a viable option for cases with resectable or irradiatable multiple recurrences and solitary distant metastasis.

A 26-year-old woman presented with lower abdominal pain for days. Human chorionic gonadotropin measured 2096 mIU/mL. Transvaginal ultrasound revealed no intrauterine pregnancy, but a heterogeneous 2.5cm x 2.1cm mass was adjacent to the right ovary, suggesting ectopic pregnancy. After medical therapy methotrexate 50mg/m 2 intramuscularly failed, laparoscopy found an omental mass with right tubal fimbriae attached. The left Fallopian tube and both ovaries appeared normal. Histopathology diagnosed omental pregnancy. Abdominal pregnancy accounts for only 1% of all ectopic pregnancies, with omental implantation being rarest. Abdominal pregnancy can be primary or secondary and may be difficult to distinguish from tubal pregnancy with implantation near the adnexa. Laparoscopy for omental pregnancy in a stable patient appears feasible and reproducible.

e12101 Background: The pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) correlates with better outcome in specific subtype of breast cancer and the axillary nodal pCR (N-pCR) rate are more common than breast pCR (B-pCR). While only a few studies to compare the survival in terms of B-pCR and N-pCR, and no study compare between the outcome for those non pCR either in breast or axillary node. Methods: A cohort of 968 cytologically proved nodal metastatic breast cancer (cT1~4N1~2) received NAC in a single medical center between 2005~2017 were analyzed retrospectively. NAC regimen included anthracycline and taxanes in all patients, Trastuzumab was used in 308(70.3%) HER2(+) patients. The percentage of both breast and axillary pCR (T-pCR) 、B-pCR and N-pCR were compared in different subtypes. The impact of T-pCR、B-pCR and N-pCR to DFS and OS were analyzed using univariate and multivariate Cox proportional hazard model. Results: The median follow-up time was 45 months. The median age was 49 years old, average tumor size was 4.2cm, and 543 (56.1%) patients were N1 disease. 382(39.5%) patients were HR(+) HER2(-), 222(22.9%)were HR(+)HER2(+),216(22.3%) were HR(-)HER2(+) and 148(15.3%) were HR(-)HER2(-). After NAC, T-pCR was found in 213 (22.0%) patients, B-pCR and N non-pCR in 31 patients, N-pCR and B non-pCR in 245 patients and T non-pCR in 479 patients. N-pCR rate(47.3%) were significantly higher than B-pCR(25.2%) and this trend found in all subtypes ( P

The present study aimed to determine the association between levels of the gender hormones, follicle-stimulating hormone (FSH), luteinizing hormone (LH), progesterone (P) and prolactin (PRL), and two breast cancer molecular markers, human epidermal growth factor receptor 2 (Her-2) and Ki67, in post-menopausal patients with breast cancer. A retrospective study of the serum hormone levels of FSH, LH, P and PRL and the expression status of Her-2 and Ki67 was performed using 187 post-menopausal females with breast cancer. Her-2+ breast cancer patients exhibited higher serum FSH levels compared with Her-2− patients (69.47±3.219 vs. 58.56±1.516 IU/l). The patients with high Ki67 expression [immunohistochemistry (IHC), 3+] displayed higher FSH (72.51±4.616 vs. 60.53±1.476 IU/l) and LH (32.33±1.916 vs. 26.98±0.8852 IU/l) levels than those with lower Ki67 expression. No correlation was identified between the FSH, LH, P and PRL hormone levels, tumor stages and lymphovascular invasion (LVI). In conclusion, a higher serum FSH level was identified in Her-2+ post-menopausal patients with breast cancer. Higher serum FSH and LH levels were also observed in breast cancer patients with high Ki67 expression. FSH and LH may function in the progression of breast cancer.

Purpose To study the prognostic value of human papillomavirus (HPV) genotypes in patients with advanced cervical cancer treated with radiation therapy (RT) alone or concurrent chemoradiation therapy (CCRT). Methods and Materials Between August 1993 and May 2000, 327 patients with advanced squamous cell carcinoma of the cervix (International Federation of Gynecology and Obstetrics stage III/IVA or stage IIB with positive lymph nodes) were eligible for this study. HPV genotypes were determined using the Easychip® HPV genechip. Outcomes were analyzed using Kaplan-Meier survival analysis and the Cox proportional hazards model. Results We detected 22 HPV genotypes in 323 (98.8%) patients. The leading 4 types were HPV16, 58, 18, and 33. The 5-year overall and disease-specific survival estimates for the entire cohort were 41.9% and 51.4%, respectively. CCRT improved the 5-year disease-specific survival by an absolute 9.8%, but this was not statistically significant ( P =.089). There was a significant improvement in disease-specific survival in the CCRT group for HPV18-positive (60.9% vs 30.4%, P =.019) and HPV58-positive (69.3% vs 48.9%, P =.026) patients compared with the RT alone group. In contrast, the differences in survival with CCRT compared with RT alone in the HPV16-positive and HPV-33 positive subgroups were not statistically significant ( P =.86 and P =.53, respectively). An improved disease-specific survival was observed for CCRT treated patients infected with both HPV16 and HPV18, but these differenced also were not statistically significant. Conclusions The HPV genotype may be a useful predictive factor for the effect of CCRT in patients with advanced squamous cell carcinoma of the cervix. Verifying these results in prospective trials could have an impact on tailoring future treatment based on HPV genotype.

The objective of this study was to explore whether hyperandrogenism induces epigenetic alterations of peroxisome proliferator-activated receptor gamma 1 (PPARG1), nuclear corepressor 1 (NCOR1), and histone deacetylase 3 (HDAC3) genes in granulosa cells (GCs) of polycystic ovary syndrome (PCOS) women and whether these alterations are involved in the ovarian dysfunction induced by hyperandrogenism. Thirty-two infertile PCOS women and 147 infertile women with tubal blockage were recruited. PCOS women were divided into the hyperandrogenism (HA) PCOS group (n = 13) and nonhyperandrogenism (N-HA) PCOS group (n = 19). Sixty female Sprague-Dawley rats were used for PCOS model establishment. In GCs of HA PCOS women, PPARG1 mRNA expression was lower, whereas NCOR1 and HDAC3 mRNA expression were higher than N-HA PCOS women and controls (P

Patients with cervical cancer and supraclavicular lymph nodes (SLN) recurrence have a poor but heterogeneous prognosis. The aim of this study was to identify potential prognostic factors - including FDG-PET results - that may affect survival and treatment outcomes in patients with this group of patients.Between January 2001 and December 2008, we identified a total of 31 consecutive patients with cervical cancer who had evidence of SLN recurrence. All participants underwent FDG-PET. Survival was measured from the date of documented SLN recurrence. The latency period was defined as the length of time from the date of first diagnosis to the date of SLN recurrence.The median follow-up time was 22.8 months (range: 4.7-105.1). The 3- and 5-year survival rates were 41% and 27.3%, respectively. Patients with intermediate SUV values (between 4.3 and 8) had a significantly better prognosis than subjects with both high (8) or low (4.3) SUV values (p=0.004). Latency period2 years, SCC-Ag levels ≥ 4ng/mL, recurrence extend beyond SLN, and SUV of4.38 were significant adverse prognostic factors by multivariate analysis. The 3-year overall survival (OS) rate of patients carrying 0-1 adverse prognostic factors was 90% (low-risk group), while 3-year OS rates for intermediate-risk group (2 factors) and high-risk group (3-4 factors) were 30% and 0%, respectively (p=0.001).Our results justify the use of PET (accurate extent of relapse and SUV) as a prognostic tool in patients with cervical cancer and SLN recurrence.

Little evidence can be found about the long-term outcome of breast cancer patients after axillary lymph node recurrence (ALNR) and its survival benefit after different kinds of management. The present study intends to evaluate the risk factors associated with axillary recurrence after definite surgery for primary breast cancer. The prognosis after ALNR and particularly outcome of different management methods also were studied.We retrospectively reviewed data from 4,473 patients who were diagnosed with primary breast cancer and received surgical intervention in a single institute from January 1990 to December 2002. Medical files were reviewed and data on survival were updated annually. Risk factors and prognosis of patients with axillary recurrence were analyzed. Breast-cancer-specific survival of patients with ALNR and outcomes after different management methods also were studied.After a median follow-up of 70.2 months, axillary recurrence developed in 0.8% of patients. Factors associated with ALNR included: age younger than 40 years, medial tumor location, no initial standard level III axillary dissection, and not receiving hormonal therapy. The 5-year breast-cancer-specific survival after ALNR was 57.9%. For patients who received further axillary dissection, the 5-year survival rate was 82.5% compared with 44.9% for patients who did not receive further dissection.ALNR is a rare event in treating breast cancer. Young age at diagnosis and medially located tumor are associated with higher risk, but standardized initial axillary dissection to level II and adjuvant hormonal therapy is protective against ALNR. In patients with ALNR, the outcome is not dismal and survival may be improved if further axillary dissection is given.

Purpose To study the outcomes of patients with adenocarcinoma/adenosquamous carcinoma (AC/ASC) of the cervix primarily treated with radiotherapy (RT), identify the prognostic factors, and evaluate the efficacy of concurrent chemoradiotherapy (CCRT) or salvage surgery. Methods and Materials A total of 148 patients with Stage I-IVA AC/ASC of cervix after full-course definitive RT were included. Of the 148 patients, 77% had advanced stage disease. Treatment failure was categorized as either distant or local failure. Local failure was further separated into persistent tumor or local relapse after complete remission. The effectiveness of CCRT with cisplatin and/or paclitaxel was examined, and the surgical salvage rate for local failure was reviewed. Results The 5-year relapse-free survival rate was 68%, 38%, 49%, 30%, and 0% for those with Stage IB/IIA nonbulky, IB/IIA bulky, IIB, III, and IVA disease, respectively, and appeared inferior to that of those with squamous cell carcinoma of the cervix treated using the same RT protocol. Incomplete tumor regression after RT, a low hemoglobin level, and positive lymph node metastasis were independent poor prognostic factors for relapse-free survival. CCRT with weekly cisplatinum did not improve the outcome for our AC/ASC patients. Salvage surgery rescued 30% of patients with persistent disease. Conclusion Patients with AC/ASC of the cervix primarily treated with RT had inferior outcomes compared to those with squamous cell carcinoma. Incomplete tumor regression after RT was the most important prognostic factor for local failure. Salvage surgery for patients with persistent tumor should be encouraged for selected patients. Our results did not demonstrate a benefit of CCRT with cisplatin for this disease.

Objective To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis. Data Sources PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017. Study Selection We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis. Data Extraction The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement. Data Synthesis Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84). Conclusions For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted.

The fermented culture broth of Antrodia camphorata (A. camphorata) has been shown to promote cell cycle arrest and apoptosis of human estrogen-nonresponsive MDA-MB-231 cells. Herein, we demonstrate that non-cytotoxic concentrations (20-80 μg/mL) of A. camphorata markedly inhibited the invasion/migration of highly metastatic MDA-MB-231 cells as shown by an in vitro transwell and a wound-healing repair assay. The results of a gelatin zymography assay showed that A. camphorata suppressed the activity of matrix metalloproteinase (MMP)-9 and urokinase plasminogen activator (uPA). Western blot results demonstrated that treatment with A. camphorata decreased the expression of MMP-9, MMP-2, uPA, uPA receptor (uPAR) and vascular endothelial growth factor (VEGF); while the expression of the endogenous inhibitors of these proteins, i.e., tissue inhibitors of MMP (TIMP-1 and TIMP-2), and plasminogen activator inhibitor (PAI)-1, increased. Further investigation revealed that A. camphorata suppressed the phosphorylation of ERK1/2, p38, and JNK1/2. A. camphorata treatment also led to a dose-dependent inhibition on NF-κB binding and activation. This is the first report confirming the anti-metastatic activity of this potentially beneficial mushroom against human breast cancer.

e12506Background: To clarify whether the Asia-Pacific breast cancer patients get small decline mortality in comparison to American white, we compared the survival differences between 2 decades(2000...

Small-cell cervical cancer (SCCC) is rare and prone to metastasize. We conducted a prospective study to evaluate the role of (18)F-FDG PET in the management of this aggressive malignancy.Patients with untreated primary, histologically confirmed SCCC were enrolled. (18)F-FDG PET (or PET/CT) was performed immediately after MRI or CT, for primary staging, monitoring response to treatment or restaging when there was suspicion of recurrence. The clinical impact of PET was determined on a scan basis.A total of 25 patients were recruited and 43 PET scans were performed. The PET images were obtained for primary staging (25 patients), monitoring response (10 patients) and restaging when there was suspicion of recurrence (8 patients). The median follow-up time in event-free patients was 109.3 months (range 97.5 - 157.7 months). A positive impact of PET was found in 8 (18.6 %) of the 43 scans, which included detection of additional regions of distal lymph node (LN) metastasis (one primary staging scan, two restaging scans), bone metastasis (two primary staging scans, one monitoring response scan), and exclusion of false-positive lesions on MRI (one primary staging scan, one restaging scan). On the other hand, one negative impact was recorded as one false-positive lesion on a restaging PET scan. One positive impact was noted for monitoring response (bone metastasis). The impact of three scans was indeterminate. The positive impact of down-staging in avoiding overtreatment but finding additional distal LN (except one on restaging) or bone metastases had no beneficial effect on long-term survival.The results of this preliminary study suggest that PET is useful in the management of SCCC. PET could have more value in detecting occult metastases if future novel therapies are able to offer better control of extensive SCCC.

Accumulating evidence suggests that aquaporins (AQPs) may facilitate tumor development. The molecular pathways connecting the pathological functions of AQPs are unclear and need to be better defined. This study aimed to investigate whether AQP3, one of the AQPs expressed highly in breast cancer, had any clinical implication in estrogen-receptor (ER) positive breast cancer and explore the regulatory mechanisms of AQP3 in estrogen-related breast cancer progression. Here we show that AQP3 is an important enforcer of migration and invasion in breast cancer. We, for the first time, reported that ER-positive breast cancer tissues obtained from premenopausal patients had higher AQP3 expression when compared to those obtained from postmenopausal patients. Estrogen directly upregulates AQP3 by activating ERE in the promoter of the AQP3 gene. The upregulation of AQP3 can influence the expression of molecules related to epithelial-mesenchymal transition and the reorganization of actin-cytoskeleton, resulting in enhancement of cell migration and invasion in ER-positive breast cancer cells.

e12503 Background: The pathologic complete response (pCR) rate in primary tumor and axillary node after different chemotherapy regimens of neoadjuvant chemotherapy (NAC) in HER2 positive breast cancer (BC) is unknown, the impact of pCR on disease free survival (DFS) and overall survival (OS) is still controversial. Methods: A cohort of 350 HER2 positive BC (296 cytologically proved axillary node metastasis) received NAC with different regimens, antracyclin with taxotere (AT), docetaxel with transtuzumab (DT) and docetaxel with transtuzumab and pertuzumab( DTP) between 2005 and 2016 in a large medical center were analyzed retrospectively. The impact of pCR rates of breast and axillary node on DFS and OS were analyzed. Results: Of 350 women with HER2 positive BC received NAC, median age was 50 years(18~93), median tumor size was 4.3 cm, the pCR rates of breast and axillary node were 16.2% and 28.7% ( P= 0.018) in patients received AT( n= 130) , 47.6% and 66.9% ( P= 0.00028 ) in patients received DT( n= 191) ,65.5% and 77.8% ( P= 0.372 ) in patients received DTP( n= 29), respectively. The 5-year DFS were 79.3% and 66.0% ( p= 0.0023), 5-year OS were 89.5% and 76.6% ( P= 0.0201) in patients with breast pCR and non-pCR, respectively. The 5-year DFS were 75.7% and 58.4% ( P= 0.00037), 5-year OS were 85.7% and 72.6% ( P= 0.0024) in axillary pCR and non-pCR patients, respectively. The 5-year DFS were 79.3% and 75.7% ( P= 0.430), and 5-year OS were 89.5% and 85.7% ( P= 0.695) in breast and axillary pCR, respectively . The 5-year DFS in breast pCR whom received targeted therapy (DT and DTP groups) was significantly better than whom not received targeted therapy (AT groups), 85.3% and 65.0% ( P= 0.039), respectively Conclusions: Higher pCR rate in axillary node than breast was found in this cohort. Either pCR in axillary node or breast was associated with improved DFS and OS, but no difference of DFS and OS between breast and axillary pCR . The 5-year DFS in breast pCR received targeted therapy were significantly better than breast pCR patients received chemotherapy alone.

The study was to explore whether auricular acupressure (AA) can relieve anxiety during the period from trans-vaginal oocyte retrieval to the embryo transfer in IVF treatment and whether AA can improve the outcomes of IVF. 305 infertile patients with tubal blockage who were referred for IVF were included. The women were randomized into a control group with 102 cases, a Sham-AA group with 102 cases and an AA group with 101 cases. The anxiety levels were rated with Spielberger's State Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale. Data of clinical pregnancy rate (CPR), implantation rate (IR) and live birth rate (LBR) were obtained. The levels of neuropeptide Y (NPY) and transforming growth factor alpha (TGF-alpha) in the follicular fluids were detected with ELISA. After treatment, in AA group, the levels of state anxiety, preoperative anxiety and need-for-information were significantly lower, whereas CPR, IR, LBR and NPY levels in the follicular fluids were markedly higher than Sham-AA group and control group. We concluded that AA could help to reduce anxiety levels associated with IVF and improves the outcomes of IVF partly through increasing the levels of NPY in the follicular fluids.

Aristolochic acid-associated nephropathy (AAN) has been identified as a separate entity of progressive tubulo-interstitial nephropathy. Its characteristic pathologi- cal findings, including hypocellular interstitial fibrosis, intimal thickening of interlobular and afferent arterioles with glomeruli sparing or mild sclerosis, have been identified. Many cases of AAN in adults have been reported in Taiwan as well as throughout the world, but it has seldom been described in children. We report on a 10-year-old boy who presented with severe anemia, Fanconi' ss yndrome, and progressive renal failure. Renal biopsy revealed typical findings of AAN. Aristolochic acids I and II were identified from a Chinese herb mixture ingested by the boy. AAN was diagnosed after otheretiologies had been excluded. The case demonstrates the hazards of Chinese herbs with regard to children's health in Taiwan and suggests that more attention should be paid to this issue.

Renal cell carcinoma (RCC) originates in the lining of the proximal convoluted tubule and accounts for approximately 3% of adult malignancies. The RCC incidence rate increases annually and is twofold higher in males than in females. Female hormones such as estrogen may play important roles during RCC carcinogenesis and result in significantly different incidence rates between males and females. In this study, we found that estrogen receptor β (ERβ) was more highly expressed in RCC cell lines (A498, RCC-1, 786-O, ACHN, and Caki-1) than in breast cancer cell lines (MCF-7 and HBL-100); however, no androgen receptor (AR) or estrogen receptor α (ERα) could be detected by western blot. In addition, proliferation of RCC cell lines was significantly decreased after estrogen (17-β-estradiol, E2) treatment. Since ERβ had been documented to be a potential tumor suppressor gene, we hypothesized that estrogen activates ERβ tumor suppressive function, which leads to different RCC incidence rates between males and females. We found that estrogen treatment inhibited cell proliferation, migration, invasion, and increased apoptosis of 786-O (high endogenous ERβ), and ERβ siRNA-induced silencing attenuated the estrogen-induced effects. Otherwise, ectopic ERβ expression in A498 (low endogenous ERβ) increased estrogen sensitivity and thus inhibited cell proliferation, migration, invasion, and increased apoptosis. Analysis of the molecular mechanisms revealed that estrogen-activated ERβ not only remarkably reduced growth hormone downstream signaling activation of the AKT, ERK, and JAK signaling pathways but also increased apoptotic cascade activation. In conclusion, this study found that estrogen-activated ERβ acts as a tumor suppressor. It may explain the different RCC incidence rates between males and females. Furthermore, it implies that ERβ may be a useful prognostic marker for RCC progression and a novel developmental direction for RCC treatment improvement.

Background Our aims were to evaluate the genotype distribution of human papillomavirus (HPV) and the correlation between HPV parameters and clinicopathological/treatment variables with prognosis in cervical adeno-adenosquamous carcinoma (AD/ASC). Patients and methods Consecutive patients who received primary treatment for cervical AD/ASC International Federation of Gynecology and Obstetrics (FIGO) stages I–IV between 1993 and 2008 were retrospectively reviewed. Prognostic models were constructed and followed by internal validation with bootstrap resampling. Results A total of 456 AD/ASC patients were eligible for HPV genotyping, while 452 were eligible for survival analysis. HPV18 was detected in 51.5% and HPV16 in 36.2% of the samples. Age >50 years old, FIGO stages III–IV and HPV16-negativity were significantly related to cancer relapse, and age >50, FIGO stages III–IV, HPV16-negativity and HPV58-positivity were significant predictors for cancer-specific survival (CSS) by multivariate analyses. HPV16-positivity was also significantly associated with good prognosis in those receiving primary radiotherapy or concurrent chemoradiation (RT/CCRT) (CSS: hazard ratio 0.41, 95% confidence interval 0.21–0.78). Patients with FIGO stages I–II and HPV16-negative AD/ASC treated with primary RH-PLND had significantly better CSS (p Conclusions Age >50 years old, FIGO stages III–IV and HPV16-negativity were significant poor prognostic factors in cervical AD/ASC. Patients with HPV16-negative tumour might better be treated with primary surgery (e.g. radical hysterectomy for stages I–II and pelvic exenteration for stage IVA). Those with unresectable HPV16-negative tumour (stage IIIB) should undergo CCRT in combination with novel drugs. The inferences of a single-institutional retrospective study require prospective studies to confirm.

Purpose To compare clinical behaviors and treatment outcomes between patients with squamous cell carcinoma (SCC) and adenocarcinoma/adenosquamous carcinoma (AC/ASC) of the cervix treated with radical hysterectomy (RH) and adjuvant radiotherapy (RT) or concurrent chemoradiotherapy (CCRT). Methods and Materials A total of 318 Stage IB–IIB cervical cancer patients, 202 (63.5%) with SCC and 116 (36.5%) with AC/ASC, treated by RH and adjuvant RT/CCRT, were included. The indications for RT/CCRT were deep stromal invasion, positive resection margin, parametrial invasion, or lymph node (LN) metastasis. Postoperative CCRT was administered in 65 SCC patients (32%) and 80 AC/ASC patients (69%). Patients with presence of parametrial invasion or LN metastasis were stratified into a high-risk group, and the rest into an intermediate-risk group. The patterns of failure and factors influencing survival were evaluated. Results The treatment failed in 39 SCC patients (19.3%) and 39 AC/ASC patients (33.6%). The 5-year relapse-free survival rates for SCC and AC/ASC patients were 83.4% and 66.5%, respectively ( p = 0.000). Distant metastasis was the major failure pattern in both groups. After multivariate analysis, prognostic factors for local recurrence included younger age, parametrial invasion, AC/ASC histology, and positive resection margin; for distant recurrence they included parametrial invasion, LN metastasis, and AC/ASC histology. Compared with SCC patients, those with AC/ASC had higher local relapse rates for the intermediate-risk group but a higher distant metastasis rate for the high-risk group. Postoperative CCRT tended to improve survival for intermediate-risk but not for high-risk AC/ASC patients. Conclusions Adenocarcinoma/adenosquamous carcinoma is an independent prognostic factor for cervical cancer patients treated by RH and postoperative RT. Concurrent chemoradiotherapy could improve survival for intermediate-risk, but not necessarily high-risk, AC/ASC patients.

e12041 Background: To investigate the efficacy of local control modalities, including modified neck dissection (ND) and radiotherapy (RT) in addition to systemic chemotherapy (CT) in terms of dista...