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Abstract Background Sarcopenia is a major component of geriatric syndrome and associated with poor clinical outcomes and mortality. However, diagnosing sarcopenia in the very elderly is difficult, and data on its epidemiology and devastating effects in this group are scarce. Phase angle (PA) is measured using bioimpedance spectroscopy and known to reflect cellular integrity and health. This study aimed to clarify the impact of sarcopenia and PA on mortality risk in very elderly people living in long‐term care facilities. Methods This prospective cohort study enrolled elderly residents living in nine long‐term care facilities. We collected the participants' data, such as body mass index (BMI), comorbidities and laboratory data, from September to October 2017 and mortality data until October 2019. Nutritional status was evaluated using the Mini Nutritional Assessment (MNA) score, and multifrequency bioimpedance spectroscopy was used to assess body composition including PA. Appendicular skeletal muscle mass was calculated using the body composition monitor‐derived equation of Taiwan's researchers. Sarcopenia was diagnosed using the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) definition (sarcopenia vs. normal group). We divided the participants into two groups according to the median PA value of 3.65° (high vs. low group) and performed multivariate regression analyses to verify the association with mortality risk according to sarcopenia diagnosis or PA group. Results A total of 279 elderly participants were enrolled; of them, 238 (85.3%) were diagnosed with sarcopenia according to EWGSOP2 guidelines. The median patient age was 83 years, 211 (75.6%) were female and the median BMI was 20.4 kg/m2. The sarcopenia group was older than the normal group (84 vs. 81 years; P = 0.002), had a lower mean BMI (19.8 vs. 26.6 kg/m2, P

Abstract Objectives To investigate the frequency of monosodium urate (MSU) crystal deposits on dual-energy computed tomography (DECT) in patients with clinical diagnosis of gout and the factors associated MSU crystal positivity. Methods This study was conducted in patients with clinical diagnosis of gout who underwent DECT. Clinical features were compared between patients with positive and those with negative DECT results. A logistic regression analysis was performed to determine the factors associated with MSU crystal positivity on DECT. Results A total of 148 patients with clinical diagnosis of gout were included, and MSU crystal deposition on DECT was observed in 64 patients (43.3%). The patients with positive DECT results were more likely to have renal insufficiency, longer disease duration, and higher serum urate level than those with negative. In the multivariable analysis, first gout attack (odds ratio 0.462; 95% confidence interval 0.229–0.931, p = 0.031) was associated with a less likely MSU crystal deposit-positive DECT result. In the subgroup analysis of patients with first attack, serum urate level > 8 mg/dL was associated with DECT positivity. Conclusion Of the patients with clinical diagnosis of gout, those with renal insufficiency, longer disease duration, and high serum urate level were more likely to be positive of gout on DECT. First gout attack was associated with less likely to be positive for MSU crystal on DECT. Thus, performing DECT scan in the selected patients who had characteristics that highly probability of DECT positivity could increase positive predictive value.

Background/Aims Because ankylosing spondylitis (AS) mainly affects sacroiliac joints, special attention should be given to normal labour and pregnancy outcomes. Here, we investigate pregnancy outcomes in Korean women with AS. Methods Based on data from the Korean Health Insurance Review and Assessment Service claims database since July 2007, maternal complications were compared between women with AS and 1:10 matched general population by maternal age and year of delivery. Additionally, the 27 deliveries from 21 patients with AS who were seen at a tertiary hospital were retrospectively evaluated using 1:4 matched control group by maternal and gestational age. Results In the population-based cohort, there were 1,293 deliveries in 996 patients with AS. Higher maternal age and more comorbidities were reported than in the general population. However, compared to age and delivery-year matched population, only the rate of Caesarean section (CS) was higher in women with AS (odds ratio, 1.52; 95% confidence interval, 1.36 to 1.70). Incidence of other maternal complications was comparable between women with AS and control subjects. In the hospital-based cohort, the CS rate was higher in women with AS (44.4% vs. 20.4%, p = 0.002). Causes of CS was not different in both groups, including previous uterine surgery. There were no significant differences in foetal outcomes, including growth restriction, foetal malformations and Apgar score. Conclusions CS deliveries were performed more often in women with AS. However, other maternal complications and offspring complications were similar between women with AS and healthy control subjects.

Abstract Background Infiltration of immune cells into the kidney is one of the key features of lupus nephritis (LN). The presence of immune cells in the urine may be used as a non-invasive biomarker of LN. Here, we aimed to analyze the clinicopathologic significance of urinary CD11c+ macrophages in patients with LN. Methods The numbers and proportions of CD11c+ macrophages in the urine samples of patients with LN at the time of kidney biopsy were examined using flow cytometry. We also examined the association between the levels of urinary CD11c+ macrophages and the clinical and pathologic features of patients with LN. Results Compared with patients without LN or those with non-proliferative LN, patients with proliferative LN had significantly higher numbers and proportions of urinary CD11c+ macrophages, which were strongly correlated with the serum anti-dsDNA antibody titer. The numbers and proportions of urinary CD11c+ macrophages were significantly associated with the values of chronicity indices such as tubular atrophy and interstitial fibrosis. No significant relationships were found between the levels of urinary CD11c+ macrophages and the activity scores, degree of proteinuria, or lupus disease activity. Urinary CD11c+ macrophages were more abundant in patients who did not achieve renal response to induction treatment with immunosuppressants than in those who achieved complete or partial response. The receiver operating characteristic (ROC) curve analysis showed that the number of urinary CD11c+ macrophages was the most powerful predictor of renal response at 6 months (ROC-AUC = 1.00, p = 0.0004). Conclusion The urinary levels of CD11c+ macrophages were closely associated with the chronic pathologic changes of LN and renal response and may thus be used as a novel biomarker in LN.

Background/Aims A substantial portion of gout patients have normal serum urate levels during an acute attack but data on the clinical characteristics and risk of recurrence compared with hyperuricemic patients are limited. Methods In this retrospective cohort study, clinical features of normouricemic and hyperuricemic patients were compared. Multivariate analysis was performed to determine whether normouricemic patients were less likely to have a recurrent attack. Results Among a total of 221 gout patients, 88 (39.8%) had normouricemia during an acute attack. Postsurgical gout (22.7% vs. 6.0%, p < 0.001), hemodialysis initiation (9.1% vs. 2.3%, p = 0.029) and inflammatory activity were higher in normouricemic patients than in hyperuricemic patients. The frequency of renal insufficiency was lower in normouricemic patients (25.0% vs. 53.4%, p < 0.001). However, the recurrence rate of gout attack was not different between the two groups (24.7% vs. 33.0%, p = 0.220). In multivariate analysis, female sex, history of urinary stone, presence of tophi, and use of thiazide were associated with increase of recurrent gout attack, but not with serum urate status during an acute attack (hazard ratio, 1.075; 95% confidence interval, 0.972 to 1.190; p = 0.159). Conclusions Normouricemia during an acute gout attack was more frequently observed in postsurgical episodes, hemodialysis initiation and patients with preserved renal function. While higher inflammatory activity was observed in normouricemic patients, recurrent attack was not associated with serum urate levels during an acute attack. Thus, careful follow-up should be considered in gout patients regardless of serum urate levels during an acute attack.

Objective The purpose of this paper is to describe a participant-driven, online text message-based social support network that emerged from an eLearning nutrition education and supplemental produce intervention. Methods Adults (n = 20) who utilized a safety-net clinic for their healthcare participated in a 12-week smartphone-based nutrition education eLearning program using loaned smartphones. Participants also received a box of fresh produce weekly. Participants received weekly text message reminders to collect their produce, and from this researcher-initiated reminder text, a supportive, participant-led, all-group text message thread commenced. Researchers collected all 471 text messages in this all-group thread and included them in the qualitative content analysis of pre and post intervention focus groups. Results The original design of the eLearning nutrition education program was to asynchronously engage learners with nutrition education resources. However, participants themselves initiated a robust group text message support system through which they shared encouragement, recipes, grocery shopping tips, and images of food they prepared with the produce box amongst themselves for the duration of the 12-week intervention. Conclusion The novel nature by which these participants voluntarily engaged in this peer-to-peer nutrition education-focused text message conversation exemplifies participants becoming agents in their own learning experience and will be used to enhance future eLearning nutrition education experiences developed by our team.

Background: Several studies have been conducted on factors associated with mortality in idiopathic inflammatory myopathies (IIMs), but few studies have assessed prognostic factors for steroid-free remission in IIM. We investigated the various clinical factors, including body measurements, that affect IIM treatment outcomes. Methods: Patients who were newly diagnosed with IIM between 2000 and 2018 were included. Steroid-free remission was defined as at least 3 months of normalisation of muscle enzymes and no detectable clinical disease activity. The factors associated with steroid-free remission were evaluated by a Cox regression analysis. Results: Of the 106 IIM patients, 35 displayed steroid-free remission during follow-up periods. In the multivariable Cox regression analyses, immunosuppressants’ early use within 1 month after diagnosis [hazard ratio (HR) 6.21, 95% confidence interval (CI) 2.61–14.74, p

Abstract Using direct conversion technology, normal adult somatic cells can be routinely switched from their original cell type into specific differentiated cell types by inducing the expression of differentiation‐related transcription factors. In this study, normal human dermal fibroblasts (NHDFs) are directly converted into cardiomyocyte‐like cells by drug and gene delivery using carboxymethylcellulose (CMC) nanoparticles (CiCMC‐NPs). CMC‐based multifunctional nanogels containing specific cardiomyocyte‐related genes are designed and fabricated, including GATA4, MEF2C, and TBX5 (GMT). However, GMT alone is insufficient, at least in vitro, in human fibroblasts. Hence, to inhibit proliferation and to induce differentiation, 5‐azacytidine (5‐AZA) is conjugated to the hydroxyl group of CMC in CiCMC‐NPs containing GMT; in addition, the CMC is coated with polyethylenimine. It is confirmed that the CiCMC‐NPs have nanogel properties, and that they exhibit the characteristic effects of 5‐AZA and GMT. When CiCMC‐NPs‐containing 5‐AZA and GMT are introduced into NHDFs, cardiomyocyte differentiation is initiated. In the reprogrammed cells, the mature cardiac‐specific markers cardiac troponin I and α‐actinin are expressed at twofold to threefold higher levels than in NHDFs. Engineered cells transplanted into live hearts exhibit active pumping ability within 1 day. Histology and immunohistology of heart tissue confirm the presence of transplanted engineered NHDF cells at injection sites.

Abstract Background During differentiation of stem cells, it is recognized that molecular mechanisms of transcription factors manage stem cells towards the intended lineage. In this study, using microarray-based technology, gene expression profiling was examined during the process of chondrogenic differentiation of human mesenchymal stem cells (hMSCs). To induce chondrogenic differentiation of hMSCs, the cationic polymer polyethyleneimine (PEI) was coupled with the synthetic glucocorticoid dexamethasone (DEX). DEX/PEI could be polyplexed with anionic plasmid DNAs (pDNAs) harboring the chondrogenesis-inducing factors SOX5, SOX6, and SOX9. These are named differentiation-inducing nanoparticles (DI-NPs). Methods A DI-NP system for inducing chondrogenic differentiation was designed and characterized by dynamic light scattering and scanning electron microscopy (SEM). Chondrogenic induction of hMSCs was evaluated using various tools such as reverse-transcription polymerase chain reaction (RT-PCR), Western blotting, confocal fluorescent microscopy, and immunohistochemistry analysis. The gene expression profiling of DI-NP-treated hMSCs was performed by microarray analysis. Results The hMSCs were more efficiently transfected with pDNAs using DI-NPs than using PEI. Moreover, microarray analysis demonstrated the gene expression profiling of hMSCs transfected with DI-NPs. Chondrogenic factors including SOX9, collagen type II (COLII), Aggrecan, and cartilage oligometric matrix protein (COMP) were upregulated while osteogenic factors including collagen type I (COLI) was downregulated. Chondrogenesis-induced hMSCs were better differentiated as assessed by RT-PCR, Western blotting analyses, and immunohistochemistry. Conclusion DI-NPs are good gene delivery carriers and induce chondrogenic differentiation of hMSCs. Additionally, comprehensive examination of the gene expression was attempted to identify specific genes related to differentiation by microarray analysis. Graphical abstract

The maritime industry has witnessed several accidents worldwide. These disasters have raised the awareness of both researchers and policy makers about the importance of risk assessment and safety in marine transportation and seaport operation. This study aims at clarifying the determinants of maritime risk involved in seaport operation, based on theoretical foundations and empirical findings. From the RBV and SEM estimations, we could identify infrastructure and operational efficiency as important tangible and intangible resources, respectively, to decrease maritime risk and increase traffic volume. TCE was applied to explain theoretically the importance of operational efficiency to consignors, forwarders, and shipping companies in terms of using seaports. From the Institutional Theory, various risks involved in seaport operation could be enhanced where external institutions are uncertain or unstable. Keywords: Maritime Risk, Seaport, RBV, TCE, Institutional Theory

The purpose of this study is to verify the carrier's liability limitation through analyzing two cases. According to the court judgments in the two cases, if the accident occurs during the shipment without issuance of Bill of Lading (B/L), the reverse-side clause of B/L does not apply to the calculation of damage, and the law of the country most closely related to both parties is set as the governing law. The absence of a timely B/L often occurs in transport practice due to the complicated nature of transport practice. So, through analyzing the court judgments in the two cases, this study recommends that transport parties take precautions. First, in order to reduce and settle disputes arising from the absence of evidence of transportation contracts, it is necessary to issue a received B/L bearing in mind the risk of accidents occurring during the shipment process. Second, the use of a Sea Waybill (SWB) which can be issued after the receipt of a cargo shipment, can be an alternative, except when a Letter of Credit (L/C) requires a B/L. Finally, expanding the function of the Commercial Invoice (C/I) to allow it to serve as evidence of the contract of carriage by inserting the contract of carriage phrase into the C/I when the B/L is not issued could be an alternative. Keywords: Limitation of Liability of Carrier, Governing Law, Bill of Lading

Contracts bind the parties of a contract to the terms of the agreement. When one party breaches the contract, the other party can suffer losses and claim damages, to be recovered from the breaching person. To measure the damage, three measures are used: expectation damage, reliance damage (wasted expenditure), and restitution. In this study, we have attempted to verify the concept of measure of damage and the recovery criteria of reliance damage, based on three cases. Furthermore, this paper discusses the direction of court judgments regarding the criteria measuring reliance damage through case analysis. The two recent cases of CJ Logistics and Fulton showed that the court considers causation and mitigation as criteria for wasted expenditure (reliance damage) under British law. Further case research regarding causation and mitigation under the marine transport contract and charterparty is needed to establish the trend in court judgments and then to provide countermeasures to the parties.

Abstract Objectives Although the importance of tissue‐resident memory T (TRM) cells in organ‐specific chronic inflammation has been recognised, little is known about their role in rheumatoid arthritis (RA). Here, we examined the characteristics of synovial fluid CD8+ T cells that express canonical TRM markers CD69 and CD103, and their role in the pathogenesis of RA. Methods Synovial fluid mononuclear cells (SFMCs) were obtained from patients with RA. Flow cytometric analysis of surface markers and cytotoxic molecules of CD8+ T cells was performed. TCR repertoire of CD8+ T cells was analysed by TCRVβ CDR3 sequencing. Citrullination with the formation of neutrophil extracellular trap (NET) was evaluated by immunofluorescence staining. Results The frequency of CD8+ T cells was increased in SFMCs, and these CD8+ T cells were primarily comprised of CD45RA‐ memory T cells expressing CD69 and/or CD103. CD69+CD8+ T cells exhibited TRM phenotypes, including upregulation of CXCR6, CD49a and CD101, and downregulation of S1PR1 and KLF2. TCR repertoire analysis showed that these cells were an oligoclonally expanded population with increased expression of cytotoxic molecules. The treatment of neutrophils with supernatant from IL‐15‐stimulated CD69+CD8+ T cells induced perforin‐mediated histone citrullination and NET formation irrespective of their CD103 expression. The frequency of perforin‐expressing cells among CD69+CD8+ T cells in SFMCs was significantly higher in patients with anti‐citrullinated protein antibody (ACPA) than in those without ACPA. Conclusion CD69+CD8+ T cells in the SFMCs of RA patients exhibit TRM‐like features. These cells may participate in the pathogenesis of RA via perforin‐mediated citrullination.

The aim of this study was to measure whether participating in Supplemental Nutrition Assistance Program – Education (SNAP-Ed) interventions is associated with changes in meeting recommendations for healthy eating and food resource management behaviours, such as shopping, among low-income children, adolescents, and adults in eight states in the US Southeast. The study used a one-group pre-test post-test design, analysing aggregate data on nutrition and shopping behaviours collected during Federal Fiscal Year 17 from SNAP-Ed direct education in community settings. Twenty-five implementing agencies in Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee provided aggregated data on program participants. Because survey questions differed, agencies followed standard recoding guidelines. The number of participants varied depending on the indicator; the maximum number was n 43 303 pre-tests, n 43 256 post-test. Participants were significantly more likely to consume more than one kind of fruit (pooled relative risk (RR), 1⋅10; 95% confidence interval (CI), 1⋅09–1⋅11) and more than one kind of vegetable (pooled RR, 1⋅14; 95% CI, 1⋅12–1⋅15) after the intervention than before. On average, participants consumed 0⋅34 cups more of fruit per day (95% CI, 0⋅31–0⋅37), and 0⋅22 cups more of vegetables per day (95% CI, 0⋅19–0⋅25) after the intervention, compared to before. About 701 policy, systems, and environmental changes for nutrition supports were reported. This study suggests that SNAP-Ed direct education is associated with positive behaviour changes in the US Southeast. It provides a methodology that can inform data aggregation efforts across unique SNAP-Ed programs or other similar nutrition education programs to report on the collective impact.

With the increasing use of computed tomography (CT), incidental breast lesions are detected more frequently. When interpreting chest CT findings, it is important for radiologists to carefully review the breast to recognize any abnormal findings that could affect patient management. The purpose of this study is to discuss incidental breast lesions on chest CT with ultrasonography correlation that may be encountered in routine clinical practice.

An increasing number of patients are treated in the intensive care unit (ICU) due to advances in medicine. Usually, healthcare professionals decide on the patient’s care in order to save the patient’s life. Sometimes, these actions conflict with patients’ rights and autonomy. For example, the application of restraint in incompetent patients in the ICU violates patients’ rights to freedom and self-decision. We reviewed the definition, prevalence, patterns, predictors, and guideline of restraints in the ICU setting.

Through the vehicle of community engagement, and with a commitment to ecological sustainability, the University of Georgia has made a series of efforts to support a growing local food movement through education, research, and service. This paper focuses on the development of a comprehensive after-school garden program with direct links to the university via interdisciplinary service-learning mechanisms. The university is located in a county with one of the highest poverty rates in the nation. With a commitment to creating innovative, community-empowered approaches to addressing poverty and related food insecurity, an interdisciplinary group of university faculty, in collaboration with community partners, came together to develop a sustainable after-school garden program. Students from three disciplines (foods and nutrition, horticulture, and social work) are placed in after-school sites to work with elementary school students to establish, support, and grow food gardens. This paper discusses the development process of the program. Anecdotal successes, challenges, and opportunities between, within, and across various systems are explored.

BACKGROUND: A limited amount of research, primarily conducted in Western countries, has suggested that higher socioeconomic status (SES) is associated with higher risk of eating disorders (EDs). However, little is known about this association in Asian countries. We examined the association of SES with disturbed eating behavior (DEB) and related factors in Korean adolescents. SUBJECTS: A nationwide online panel survey was conducted in a sample of adolescents (n = 6,943, 49.9% girls). DEB was measured with the 26-item Eating Attitudes Test (EAT-26). Participants who scored ≥20 on the EAT-26 were considered to have DEB. Participants' SES was determined based on self-reported household economic status. RESULTS: The prevalence of DEB was 12.7%: 10.5% among boys and 14.8% among girls. Both boys and girls with DEB were more likely to perceive themselves as obese, experience higher levels of stress, and have lower academic achievement. The risk for DEB was significantly higher in boys of higher SES than in those of middle SES (OR = 1.45, 95%CI = 1.05-1.99 for high SES; OR = 5.16, 95%CI: 3.50-7.61 for highest SES). Among girls, higher risk of DEB was associated with the highest and lowest SES (OR = 1.52, 95%CI: 1.13-2.06 for lowest SES; OR = 2.22, 95%CI: 1.34-3.68 for highest SES). CONCLUSIONS: Despite the lower prevalence of obesity in Korea compared with Western countries, the prevalence of DEB in Korean adolescents was high, especially among girls. Moreover, the association between SES and DEB followed a U-shaped curve for girls and a J-shaped curve for boys.