Publications by authors named "Yen-Ling Lai"

26 Publications

  • Page 1 of 1

Increased risk of second primary malignancies among endometrial cancer survivors receiving surgery alone: A population-based analysis.

Cancer Med 2021 Oct 15;10(19):6845-6854. Epub 2021 Sep 15.

Department of Obstetrics and Gynecology, National Taiwan University, Taipei, Taiwan.

Background: Women with endometrial cancer (EC) have favorable prognoses, leaving them vulnerable to the development of second primary cancers (SPCs). We investigated the SPC risk and survival outcomes among EC patients treated with surgery alone in order to exclude the impact of adjuvant treatment on the results.

Methods: Data from the Taiwan Cancer Registry from 1995 to 2013 were analyzed. Standardized incidence ratios (SIRs) of SPCs among EC survivors were calculated.

Results: Among 7725 women enrolled, 478 developed an SPC. The overall SIR for SPCs in EC survivors was 2.84 (95% confidence interval [CI] 2.59-3.10) compared with the general female population. Women diagnosed with EC at age <50 years had a higher SIR for an SPC than those diagnosed at age ≥50 years (SIR = 4.38 vs. 1.28). The most frequent site of an SPC was the small intestine (SIR = 8.39, 95% CI 2.72-19.58), followed by the kidney (SIR = 4.84, 95% CI 1.78-10.54), and oral cavity (SIR = 4.52, 95% CI 2.17-8.31). Women, regardless of age at EC diagnosis, had significantly higher SIRs for subsequent breast, colorectal, lung, and thyroid cancer, and lymphoma. Women with an SPC had shorter overall survival than those without (5-year: 88.9 vs. 94.2%, 10-year: 71.3 vs. 89.8%, 15-year: 62.3 vs. 86.1%, and 20-year: 47.6 vs. 81.1%, all ps<0.001).

Conclusions: Even women treated for EC with surgery alone, especially young EC survivors, had an increased risk of SPCs. Genetic counseling/testing is recommended for young EC patients, and all are recommended to receive regular surveillance and screening for breast, colorectal, and lung cancers.
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http://dx.doi.org/10.1002/cam4.3861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8495277PMC
October 2021

Gamma Knife Radiosurgery-Based Combination Treatment Strategies Improve Survival in Patients With Central Nervous System Metastases From Epithelial Ovarian Cancer: A Retrospective Analysis of Two Academic Institutions in Korea and Taiwan.

Front Oncol 2021 27;11:719936. Epub 2021 Aug 27.

Division of Gynecologic oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Central nervous system (CNS) metastases from epithelial ovarian cancer (EOC) are rare. We investigated the clinico-pathological prognostic factors of patients with CNS metastases from EOC and compared the outcomes of various treatment modalities. We retrospectively reviewed the records of patients with CNS metastases from EOC between 2000 and 2020. Information on the clinical and pathological characteristics, treatment, and outcomes of these patients was retrieved from Samsung Medical Center and National Taiwan University Hospital. A total of 94 patients with CNS metastases were identified among 6,300 cases of EOC, resulting in an incidence of 1.49%. Serous histological type [hazard ratio (HR): 0.49 (95% confidence interval [CI] 0.25-0.95), =0.03], progressive disease [HR: 2.29 (95% CI 1.16-4.54), =0.01], CNS involvement in first disease relapse [HR: 0.36 (95% CI 0.18-0.70), =0.002], and gamma knife radiosurgery (GKS)-based combination treatment for EOC patients with CNS lesions [HR: 0.59 (95% CI 0.44-0.79), <0.001] significantly impacted survival after diagnosis of CNS metastases. In a subgroup analysis, superior survival was observed in patients with CNS involvement not in first tumor recurrence who underwent GKS-based combination therapeutic regimens. The survival benefit of GKS-based treatment was not significant in patients with CNS involvement in first disease relapse, but a trend for longer survival was still observed. In conclusion, GKS-based combination treatment can be considered for the treatment of EOC patients with CNS metastases. The patients with CNS involvement not in first disease relapse could significantly benefit from GKS-based combination strategies.
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http://dx.doi.org/10.3389/fonc.2021.719936DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429898PMC
August 2021

Factors Influencing the Discordancy Between Intraoperative Frozen Sections and Final Paraffin Pathologies in Ovarian Tumors.

Front Oncol 2021 1;11:694441. Epub 2021 Jul 1.

Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan.

Aim: To retrospectively investigate the pre-operative clinical factors and ultrasonographic features that influence the accuracy of the intraoperative frozen section (IFS) of ovarian tumors.

Patients And Methods: Women with ovarian tumors that underwent IFS in one tertiary medical center were recruited from January 2010 to December 2018. Demographic and clinical data of these women were retrieved from medical records in the hospital's centralized database.

Results: A total of 903 ovarian tumors were enrolled, including 237 (26.2%) benign, 150 (16.6%) borderline tumor, and 516 (57.2%) malignant. The overall accuracy of IFS among all specimens was 89.9%. The sensitivities of IFS in diagnosing borderline tumors (82.0%) and malignant tumors (88.2%) were lower than in diagnosing benign tumors (98.7%, p <0.001, Z-test). The specificity of diagnosing malignant tumors (99.7%) was significantly higher than that of diagnosing benign tumors (94.7%, p <0.001, Z-test). The group with discordant IFS and final paraffin pathology (FPP) had younger age (47.2 ± 14.0 51.5 ± 11.8 years, p = 0.013, Mann-Whitney U test), and higher percentage of early-stage disease (85.2% 65.1%, p = 0.001, chi-square test) and mucinous (39.3% 3.3%) and endometrioid histologic types (34.4% 20.2%) than the concordant group (all by chi-square test). Menopause (OR 0.34, 95% CI 0.15-0.76, p = 0.009), multicystic tumor in ultrasound (OR 2.14, 95% CI 1.14-4.01, p = 0.018), and ascites existence (OR 0.33, 95% CI 0.14-0.82, p = 0.016) were factors related to the discordant IFS by multivariate analysis.

Conclusions: IFS has good accuracy in the diagnosis of ovarian tumors. We recommend more frozen tissue sampling for sonographic multicystic tumors in premenopausal women to improve the accuracy of IFS.
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http://dx.doi.org/10.3389/fonc.2021.694441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8281203PMC
July 2021

The Association of Postoperative Opioid Prescriptions with Patient Outcomes.

Ann Surg 2021 Jun 4. Epub 2021 Jun 4.

Department of Surgery, Michigan Medicine, Ann Arbor, Michigan Center for Healthcare Outcomes and Policy, Michigan Medicine, Ann Arbor, Michigan Michigan Opioid Prescribing and Engagement Network, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.

Objective: To compare outcomes after surgery between patients who were not prescribed opioids and patients who were prescribed opioids.

Summary Of Background Data: Postoperative opioid prescriptions carry significant risks. Understanding outcomes among patients who receive no opioids after surgery may inform efforts to reduce these risks.

Methods: We performed a retrospective study of adult patients who underwent surgery between January 1, 2019 and October 31, 2019. The primary outcome was the composite incidence of an emergency department visit, readmission, or reoperation within 30 days of surgery. Secondary outcomes were postoperative pain, satisfaction, quality of life, and regret collected via postoperative survey. A multilevel, mixed-effects logistic regression was performed to evaluate differences between groups.

Results: In a cohort of 22,345 patients, mean age (standard deviation) was 52.1 (16.5) years and 13,269 (59.4%) patients were female. About 3175 (14.2%) patients were not prescribed opioids, of whom 422 (13.3%) met the composite adverse event endpoint compared to 2255 (11.8%) of patients not prescribed opioids (P = 0.015). Patients not prescribed opioids had a similar probability of adverse events {11.7% [95% confidence interval (CI) 10.2%-13.2%] vs 11.9% (95% CI 10.6%-13.3%]}. Among 12,872 survey respondents, patients who were not prescribed an opioid had a similar rate of high satisfaction [81.7% (95% CI 77.3%-86.1%) vs 81.7% (95% CI 77.7%-85.7%)] and no regret [(93.0% (95% CI 90.8%-95.2%) vs 92.6% (95% CI 90.4%-94.7%)].

Conclusions: Patients who were not prescribed opioids after surgery had similar clinical and patient-reported outcomes as patients who were prescribed opioids. This suggests that minimizing opioids as part of routine postoperative care is unlikely to adversely affect patients.
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http://dx.doi.org/10.1097/SLA.0000000000004965DOI Listing
June 2021

Persistent Opioid Use after Ophthalmic Surgery in Opioid-Naive Patients and Associated Risk Factors.

Ophthalmology 2021 Sep 22;128(9):1266-1273. Epub 2021 Apr 22.

W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan. Electronic address:

Purpose: To determine the rate and risk factors for new persistent opioid use after ophthalmic surgery in the United States.

Design: Retrospective claims-based cohort analysis.

Participants: Opioid-naive patients 13 years of age and older who underwent incisional ophthalmic surgery between January 1, 2012, and June 30, 2017, and were included in Optum's de-identified Clinformatics Data Mart database.

Methods: New persistent opioid use was defined as filling an opioid prescription in the 90-day and the 91- to 180-day periods after the surgical procedure. The outcome variable was an initial perioperative opioid prescription fill. Rates of new persistent opioid use were calculated, and multivariate logistic regression models were used to identify variables increasing the risk of new persistent use and refill of an opioid prescription after the initial perioperative prescription in first 30 days.

Main Outcome Measures: New persistent opioid use and refill.

Results: A total of 327 379 opioid-naive patients (mean age, 67 years [standard deviation, 16 years]; 178 067 women [54.4%]) who underwent ophthalmic surgery were examined. Among these patients, 14 841 (4.5%) had an initial perioperative opioid fill. The rate of new persistent opioid use was 3.4% (498 of 14 841 patients) compared with 0.6% (1833 of 312 538 patients) in patients who did not have an initial perioperative opioid fill. After adjusting for patient characteristics, initial perioperative opioid fill was associated independently with increased odds of new persistent use (adjusted odds ratio [OR], 6.21; 95% confidence interval [CI], 5.57-6.91; P < 0.001). Among patients who had filled an initial perioperative prescription, a prescription size of 150 morphine milligram equivalents or more was associated with an increased odds of refill (adjusted OR, 1.87; 95% CI, 1.58-2.22; P < 0.001).

Conclusions: Exposure to opioids in the perioperative period is associated with new persistent use in patients who were previously opioid-naive. This suggests that exposure to opioids is an independent risk factor for persistent use in patients undergoing incisional ophthalmic surgery. Surgeons should be aware of those risks to identify at-risk patients given the current national opioid crisis and to minimize prescribing opioids when possible.
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http://dx.doi.org/10.1016/j.ophtha.2021.04.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384648PMC
September 2021

Post-Acute Care Utilization and Episode of Care Payments Following Common Elective Operations.

Ann Surg 2021 Feb 12. Epub 2021 Feb 12.

*Department of Surgery, University of Michigan, Ann Arbor, MI, USA †Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA ‡University of Michigan Medical School, Ann Arbor, MI, USA.

Objective: To describe post-acute care (PAC) utilization and associated payments for patients undergoing common elective procedures.

Summary Background Data: Utilization and costs of PAC are well described for benchmarked conditions and operations but remain understudied for common elective procedures.

Methods: Cross-sectional study of adult patients in a statewide administrative claims database undergoing elective cholecystectomy, ventral or incisional hernia repair (VIHR), and groin hernia repair from 2012-2019. We used multivariable logistic regression to estimate the odds of PAC utilization, and multivariable linear regression to determine the association of 90-day episode of care payments and PAC utilization.

Results: Among 34,717 patients undergoing elective cholecystectomy, 0.7% utilized PAC resulting in significantly higher payments ($19,047 vs $7,830, p < 0.001). Among 29,826 patients undergoing VIHR, 1.7% utilized PAC resulting in significantly higher payments ($19,766 vs $9,439, p < 0.001). Among 37,006 patients undergoing groin hernia repair, 0.3% utilized PAC services resulting in significantly higher payments ($14,886 vs $8,062, p < 0.001). We found both modifiable and non-modifiable risk factors associated with PAC utilization. Morbid obesity was associated with PAC utilization following VIHR (OR 1.61, 95% CI 1.29-2.02, p < 0.001). Male sex was associated with lower odds of PAC utilization for VIHR (OR 0.43, 95% CI 0.35-0.51, p < 0.001) and groin hernia repair (OR 0.62, 95% CI 0.39-0.98, p = 0.039).

Conclusions: We found both modifiable (e.g. obesity) and non-modifiable (e.g. female sex) patient factors that were associated with PAC. Optimizing patients to reduce PAC utilization requires an understanding of patient risk factors as well as systems and processes to address these factors.
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http://dx.doi.org/10.1097/SLA.0000000000004814DOI Listing
February 2021

Clinical factors associated with prognosis in low-grade serous ovarian carcinoma: experiences at two large academic institutions in Korea and Taiwan.

Sci Rep 2020 11 17;10(1):20012. Epub 2020 Nov 17.

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea.

Low-grade ovarian serous carcinoma (LGSOC) has clinical features different from high-grade serous ovarian carcinoma (HGSOC) accounting for the majority of epithelial ovarian cancer. Because of its rarity, previous studies have only focused on the high-grade disease without considering the differences between the two subtypes. This study aimed to evaluate the effect of the clinical prognostic factors known for HGSOC on survival in patients with LGSOC. Based on the Federation of Gynecology and Obstetrics (FIGO) stage, progression-free survival (PFS) was markedly decreased in advanced disease compared with early disease. For stage I, patients with stage IC had poorer survival than those with stage IA and IB regardless of the number of cycles of adjuvant chemotherapy. For advanced disease, no gross residual disease after primary cytoreductive surgery was significantly associated with longer PFS when compared with gross residual disease. In multivariate analysis for PFS and overall survival (OS), age, preoperative CA-125, time interval from surgery to chemotherapy, and the number of cycles of adjuvant chemotherapy were not associated with prognosis. Complete cytoreduction was the only independent prognostic factor for PFS (HR 2.45, p = 0.045). Our study revealed that the known prognostic factors in HGSOC did not show any effect on the survival in LGSOC except for FIGO stage and complete cytoreduction.
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http://dx.doi.org/10.1038/s41598-020-77075-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672053PMC
November 2020

Preoperative Opioid Use and Mortality After Minor Outpatient Surgery.

JAMA Surg 2020 12;155(12):1169-1171

Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor.

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http://dx.doi.org/10.1001/jamasurg.2020.3623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578914PMC
December 2020

Outcome and Subsequent Pregnancy after Fertility-Sparing Surgery of Early-Stage Cervical Cancers.

Int J Environ Res Public Health 2020 09 28;17(19). Epub 2020 Sep 28.

Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei 100, Taiwan.

We aimed to investigate the outcomes and subsequent pregnancies of early-stage cervical cancer patients who received conservative fertility-sparing surgery. Women with early-stage cervical cancer who underwent conservative or fertility-sparing surgery in a tertiary medical center were reviewed from 2004 to 2017. Each patient's clinicopathologic characteristics, adjuvant therapy, subsequent pregnancy, and outcome were recorded. There were 32 women recruited, including 12 stage IA1 patients and 20 stage IB1 patients. Twenty-two patients received conization/LEEP and the other 10 patients received radical trachelectomy. Two patients did not complete the definite treatment after fertility-sparing surgery. There were 11 women who had subsequent pregnancies and nine had at least one live birth. The live birth rate was 73.3% (11/15). We conclude that patients with early-stage cervical cancer who undergo fertility-sparing surgery can have a successful pregnancy and delivery. However, patients must receive a detailed consultation before surgery and undergo definitive treatment, if indicated, and regular postoperative surveillance.
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http://dx.doi.org/10.3390/ijerph17197103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579067PMC
September 2020

Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older Adults.

J Gen Intern Med 2020 10 3;35(10):2917-2924. Epub 2020 Aug 3.

Section of Plastic Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.

Background: Despite increasing numbers of older adults undergoing surgery and the known risks of opioids, little is known about the potential association between opioid prescribing and serious falls and fall-related injuries after surgery.

Objective: To determine the incidence and risk factors of serious falls and fall-related injuries after elective, outpatient surgery.

Design: Retrospective cohort study of 20% national sample of Medicare claims among beneficiaries ≥ 65 years of age with Medicare Part D claims and who underwent elective outpatient surgery from January 1, 2009, through December 31, 2014.

Participants: Opioid-naïve patients ≥ 65 years undergoing elective, minor, outpatient surgical procedures. The exposure was opioid prescription fills in the perioperative period (i.e., 30 days before up until 3 days after surgery) converted to total oral morphine equivalents (OME) over a period 30 days prior to and 30 days after surgery.

Main Measures: Serious falls and fall-related injuries within 30 days after surgery, examined through Poisson regression analysis with reported fall and fall-related injury rates adjusted for potential confounders.

Key Results: Among 44,247 opioid-naïve surgical patients, 76.3% filled an opioid prescription in the perioperative period. Overall, 0.62% of patients suffered a serious fall or fall-related injury within 30 days after surgery. Risk factors for serious falls or fall-related injuries after surgery included older age (80-84 years: RR 1.64, 95% CI 1.12-2.40; 85 years and older: RR 1.81, 95% CI 1.25-2.86), female sex (RR 3.04, 95% CI 2.29-4.05), Medicaid eligibility (RR 1.63, 95% CI 1.17-2.26), and higher amounts of opioids filled following surgery (≥ 225 OME: RR 2.29, 95% CI 1.72-3.07).

Conclusions: Serious falls after elective, outpatient surgery are uncommon, but correlated with age, sex, Medicaid eligibility, and the amount of opioids filled in the perioperative period. Judicious prescribing of opioids after surgery is paramount and is an opportunity to improve the safety of surgical care among older individuals.
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http://dx.doi.org/10.1007/s11606-020-06015-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572978PMC
October 2020

Sequential Phosphorylation of the Hepatitis C Virus NS5A Protein Depends on NS3-Mediated Autocleavage between NS3 and NS4A.

J Virol 2020 09 15;94(19). Epub 2020 Sep 15.

Institute of Biochemistry and Molecular Biology, College of Medicine, National Taiwan University, Taipei, Taiwan

Replication of the genotype 2 hepatitis C virus (HCV) requires hyperphosphorylation of the nonstructural protein NS5A. It has been known that NS5A hyperphosphorylation results from the phosphorylation of a cluster of highly conserved serine residues (S2201, S2208, S2211, and S2214) in a sequential manner. It has also been known that NS5A hyperphosphorylation requires an NS3 protease encoded on one single NS3-5A polyprotein. It was unknown whether NS3 protease participates in this sequential phosphorylation process. Using an inventory of antibodies specific to S2201, S2208, S2211, and S2214 phosphorylation, we found that protease-dead S1169A mutation abrogated NS5A hyperphosphorylation and phosphorylation at all serine residues measured, consistent with the role of NS3 in NS5A sequential phosphorylation. These effects were not rescued by a wild-type NS3 protease provided in by another molecule. Mutations (T1661R, T1661Y, or T1661D) that prohibited proper cleavage at the NS3-4A junction also abolished NS5A hyperphosphorylation and phosphorylation at all serine residues, whereas mutations at the other cleavage sites, NS4A-4B (C1715S) or NS4B-5A (C1976F), did not. In fact, any combinatory mutations that prohibited NS3-4A cleavage (T1661Y/C1715S or T1661Y/C1976F) abrogated NS5A hyperphosphorylation and phosphorylation at all serine residues. In the C1715S/C1976F double mutant, which resulted in an NS4A-NS4B-NS5A fusion polyprotein, a hyperphosphorylated band was observed and was phosphorylated at all serine residues. We conclude that NS3-mediated autocleavage at the NS3-4A junction is critical to NS5A hyperphosphorylation at S2201, S2208, S2211, and S2214 and that NS5A hyperphosphorylation could occur in an NS4A-NS4B-NS5A polyprotein. For ca. 20 years, the HCV protease NS3 has been implicated in NS5A hyperphosphorylation. We now show that it is the NS3-mediated cleavage at the NS3-4A junction that permits NS5A phosphorylation at serines 2201, 2208, 2211, and 2214, leading to hyperphosphorylation, which is a necessary condition for genotype 2 HCV replication. We further show that NS5A may already be phosphorylated at these serine residues right after NS3-4A cleavage and before NS5A is released from the NS4A-5A polyprotein. Our data suggest that the dual-functional NS3, a protease and an ATP-binding RNA helicase, could have a direct or indirect role in NS5A hyperphosphorylation.
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http://dx.doi.org/10.1128/JVI.00420-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495366PMC
September 2020

The Association Between Preoperative Opioid Exposure and Prolonged Postoperative Use.

Ann Surg 2021 Nov;274(5):e410-e416

University of Michigan, Department of Surgery, Ann Arbor, Michigan.

Objective: To determine the effect of nonchronic, periodic preoperative opioid use on prolonged opioid fills after surgery.

Background: Nonchronic, periodic opioid use is common, but its effect on prolonged postoperative opioid fills is not well understood. We hypothesize greater periodic opioid use before surgery is correlated with persistent postoperative use.

Methods: We used a national private insurance claims database, Optum's de-identifed Clinformatics Data Mart Database, to identify adults undergoing general, gynecologic, and urologic surgical procedures between 2008 and 2015 (N = 191,043). We described patterns of opioid fills based on dose, recency, duration, and continuity to categorize preoperative opioid exposure. Patients with chronic use were excluded. Our primary outcome was persistent postoperative use, defined as filling an opioid prescription between 91- and 180-days post-discharge. The association between preoperative opioid use and persistent use was determined using multivariable logistic regression, controlling for clinical covariates.

Results: In the year before surgery, 41% of patients had nonchronic, periodic opioid fills. Compared with other risk factors, patterns of preoperative fills were most strongly correlated with persistent postoperative opioid use. Patients with recent intermittent use were significantly more likely to have prolonged fills after surgery compared with opioid-naïve patients [minimal use: odds ratio (OR): 2.0, 95% confidence interval (CI) 1.89-2.03; remote intermittent: OR 4.7, 95% CI 4.46-4.93; recent intermittent: OR 12.2, 95% CI 11.49-12.90].

Conclusions: Patients with nonchronic, periodic opioid use before surgery are vulnerable to persistent postoperative opioid use. Identifying opioid use before surgery is a critical opportunity to optimize care after surgery.
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http://dx.doi.org/10.1097/SLA.0000000000003723DOI Listing
November 2021

New persistent opioid use after acute opioid prescribing in pregnancy: a nationwide analysis.

Am J Obstet Gynecol 2020 10 23;223(4):566.e1-566.e13. Epub 2020 Mar 23.

School of Nursing, Women's Studies Department, University of Michigan, Ann Arbor, MI.

Objective: To evaluate the association between opioid prescribing during pregnancy and new persistent opioid use in the year following delivery.

Materials And Methods: This nationwide retrospective cohort study included patients aged 12-55 years in Optum's deidentified Clinformatics Data Mart Database who were undergoing vaginal delivery or cesarean delivery from 2008 to 2016, with continuous enrollment from 2 years before birth to 1 year postdischarge. Women were included if they were opioid naive in pregnancy (ie, did not fill an opioid prescription 2 years to 9 months before delivery) and did not undergo a procedure within the year after discharge. The exposure was filling an opioid prescription in pregnancy. The primary outcome was new persistent opioid use, defined as a pharmacy claim for ≥1 opioid prescription between 4 and 90 days postdischarge and ≥1 prescription between 91 and 365 days postdischarge. Clinical and demographic covariates were included. Analyses included descriptive statistics and multivariable logistic regression, adjusting for clinical and demographic covariates.

Results: Of 158,425 childbirths identified, 101,013 (63.8%) were by vaginal delivery and 57,412 (36.2%) cesarean delivery. Among all patients, 6.0% (9429) filled an opioid prescription during pregnancy. The factors associated with filling an opioid in pregnancy were having a nondelivery procedure in pregnancy (adjusted odds ratio, 9.60; 95% confidence interval, 8.81-10.47) and having an emergency room visit during pregnancy (adjusted odds ratio, 2.48; 95% confidence interval, 2.37-2.59). Of women who received an opioid in pregnancy, 4% (379) developed new persistent opioid use. The factors most associated with new persistent opioid use were receiving an opioid prescription during pregnancy (adjusted odds ratio, 3.45; 95% confidence interval, 3.04-3.92) and filling a peripartum opioid prescription (1 week prior to 3 days postdischarge) adjusted odds ratio, 2.28, 95% confidence interval (2.02-2.57). Though having a procedure during pregnancy was associated with increased receipt of an opioid prescription, it was also associated with reduced new persistent opioid use (adjusted odds ratio, 0.72; 95% confidence interval, 0.52-0.99).

Conclusion: Women who receive an opioid prescription during pregnancy are more likely to experience new persistent opioid use. Maternity care providers must balance pain management in pregnancy with potential risks of opioids.
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http://dx.doi.org/10.1016/j.ajog.2020.03.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508788PMC
October 2020

Preoperative Opioid Use and Readmissions Following Surgery.

Ann Surg 2020 Mar 13. Epub 2020 Mar 13.

Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI.

Objective: To assess the association between preoperative opioid exposure and readmissions following common surgery.

Summary Background Data: Preoperative opioid use is common, but its effect on opioid-related, pain-related, respiratory-related, and all-cause readmissions following surgery is unknown.

Methods: We analyzed claims data from a 20% national Medicare sample of patients ages ≥ 65 with Medicare Part D claims undergoing surgery between January 1, 2009 and November 30, 2016. We grouped patients by the dose, duration, recency, and continuity of preoperative opioid prescription fills. We used logistic regression to examine the association between prior opioid exposure and 30-day readmissions, adjusted for patient risk factors and procedure type.

Results: Of 373,991 patients, 168,579 (45%) filled a preoperative opioid prescription within 12 months of surgery, ranging from minimal to chronic high use. Preoperative opioid exposure was associated with higher rate of opioid-related readmissions, compared with naive patients [low: aOR=1.63, 95% CI=1.26-2.12; high: aOR=3.70, 95% CI=2.71-5.04]. Preoperative opioid exposure was also associated with higher risk of pain-related readmissions [low: aOR=1.27, 95% CI=1.23-1.32; high: aOR=1.62, 95% CI=1.53-1.71] and respiratory-related readmissions [low: aOR=1.10, 95% CI=1.05-1.16; high: aOR=1.44, 95% CI=1.34-1.55]. Low, moderate, and high chronic preoperative opioid exposures were predictive of all-cause readmissions (low: OR 1.09, 95% CI: 1.06-1.12); high: OR 1.23, 95% CI: 1.18-1.29).

Conclusions: Higher levels of preoperative opioid exposure are associated with increased risk of readmissions after surgery. These findings emphasize the importance of screening patients for preoperative opioid exposure and creating risk mitigation strategies for patients.
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http://dx.doi.org/10.1097/SLA.0000000000003827DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935087PMC
March 2020

BTLA blockade enhances Cancer therapy by inhibiting IL-6/IL-10-induced CD19 B lymphocytes.

J Immunother Cancer 2019 11 21;7(1):313. Epub 2019 Nov 21.

Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, 100, Taiwan.

Background: The standard treatment for epithelial ovarian carcinoma (EOC) is surgery followed by platinum/paclitaxel-based chemotherapy, but the overall survival rate is poor. The purpose of this study was to investigate the therapeutic potential of chemotherapy combined with inhibition of B and T lymphocyte attenuator (BTLA) for clinical use to treat EOC.

Methods: Initially, we evaluated the potential application of chemotherapy combined with anti-BTLA antibody in an animal model. We then analyzed the distribution and regulation of BTLA expression on immunocytes in vitro. Finally, we examined the correlation between BTLA expression levels in cancerous tissues and prognosis in 254 EOC cases.

Results: The combination of chemotherapy and anti-BTLA antibody for inhibiting BTLA significantly reduced peritoneal tumor volume and extended survival in tumor-bearing mice. In addition, BTLA could be identified mostly on B lymphocytes, especially on CD19 B cells, rather than on T lymphocytes and natural killer cells. Under regulation of interleukins 6 and 10, more BTLACD19 B lymphocytes could be induced through AKT and STAT3 signaling pathways. Detectable BTLA expression in ovarian cancerous tissues was associated with worse disease-free and overall survivals of EOC patients.

Conclusions: BTLA detected in cancerous tissues can predict poor outcome of EOC patients. Inhibition of BTLA combined with chemotherapy can elevate immune activation and generate potent anti-tumor effects. Thus, the combination of chemotherapy and anti-BTLA antibody may hold potential clinical application for the treatment of EOC patients.

Trial Registration: The Trial Registration Number was NCT00854399.
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http://dx.doi.org/10.1186/s40425-019-0744-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868712PMC
November 2019

Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women.

JAMA Netw Open 2019 07 3;2(7):e197863. Epub 2019 Jul 3.

Department of Surgery, University of Michigan, Ann Arbor.

Importance: Research has shown an association between opioid prescribing after major or minor procedures and new persistent opioid use. However, the association of opioid prescribing with persistent use among women after vaginal delivery or cesarean delivery is less clear.

Objective: To assess the association between opioid prescribing administered for vaginal or cesarean delivery and rates of new persistent opioid use among women.

Design, Setting, And Participants: This retrospective cohort study used national insurance claims data for 988 036 women from a single private payer from January 1, 2008, to December 31, 2016. Participants included reproductive age, opioid-naive women with 1 year of continuous enrollment before and after delivery. For participants with multiple births, only the first birth was included.

Exposures: Peripartum opioid prescription (1 week before delivery to 3 days after discharge) captured by pharmacy claims, including prescription timing and size in oral morphine equivalents. Multivariable adjusted odds ratios were estimated using regression models.

Main Outcomes And Measures: Rates of new persistent opioid use, defined as pharmacy claims for 1 or more opioid prescription 4 to 90 days after discharge and 1 or more prescription 91 to 365 days after discharge among women who filled peripartum opioid prescriptions.

Results: In total, 308 226 deliveries were included: 195 013 (63.3%) vaginal deliveries and 113 213 (36.7%) cesarean deliveries. Participant mean (SD) age was 31.3 (5.3) years, and 70 567 (51.0%) were white patients. Peripartum opioid prescriptions were filled by 27.0% of women with vaginal deliveries and 75.7% of women with cesarean deliveries. Among them, 1.7% of those with vaginal deliveries and 2.2% with cesarean deliveries had new persistent opioid use. By contrast, among women not receiving a peripartum opioid prescription, 0.5% with vaginal delivery and 1.0% with cesarean delivery had new persistent opioid use. From 2008 to 2016, opioid prescription fills decreased for vaginal deliveries from 26.9% to 23.8% (P < .001) and for cesarean deliveries from 75.5% to 72.6% (P < .001), and fewer women had new persistent use (vaginal delivery, from 2.2% to 1.1%; P < .001; cesarean delivery, from 2.5% to 1.3%; P < .001). The strongest modifiable factor associated with new persistent opioid use after delivery was filling an opioid prescription before delivery (adjusted odds ratio, 1.40; 95% CI, 1.05-1.87). For vaginal deliveries, receiving a prescription equal to or more than 225 oral morphine equivalents was associated with new persistent opioid use (adjusted odds ratio, 1.25; 95% CI, 1.06-1.48). Women who underwent cesarean delivery and had a hysterectomy were more likely to develop persistence (AOR, 2.75; 95% CI, 1.33-5.70), although women who underwent a nonelective (AOR, 0.97; 95% CI, 0.88-1.07) or repeat cesarean (AOR, 1.45; 95% CI, 0.93-2.28) were not more likely. For cesarean deliveries, risk factors were associated with patient attributes such as tobacco use (adjusted odds ratio, 1.82; 95% CI, 1.56-2.11), psychiatric diagnoses, history of substance use (adjusted odds ratio, 1.43; 95% CI, 1.10-1.86), and pain conditions.

Conclusions And Relevance: The results of the present study suggested that opioid prescribing and new persistent use after vaginal delivery or cesarean delivery have decreased since 2008. However, modifiable prescribing patterns were associated with persistent opioid use for patients who underwent vaginal delivery, and risk factors following cesarean delivery mirrored those of other surgical conditions. Judicious opioid prescribing and preoperative risk screening may be opportunities to decrease new persistent opioid use after childbirth.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.7863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661716PMC
July 2019

Clear Cell Carcinoma of the Abdominal Wall as a Rare Complication of General Obstetric and Gynecologic Surgeries: 15 Years of Experience at a Large Academic Institution.

Int J Environ Res Public Health 2019 02 14;16(4). Epub 2019 Feb 14.

Department of Obstetrics and Gynecology; National Taiwan University Hospital, Taipei 100, Taiwan.

The objective of this article was to report the clinicopathological characteristics, treatment modalities, and outcomes of patients with clear cell carcinoma (CCC) of the abdominal wall. Medical records of six patients diagnosed with CCC of the abdominal wall between May 2003 and May 2018 at the National Taiwan University Hospital were reviewed. All patients had prior obstetric or gynecologic surgeries. The primary clinical presentation was enlarging abdominal masses at previous surgical scars. Four patients underwent initial/primary surgeries with/without adjuvant chemotherapy. One patient received neoadjuvant chemotherapy followed by surgical intervention and adjuvant chemotherapy, the other received chemotherapy and sequential radiotherapy without any surgical intervention. Two of four patients undergoing initial/primary surgeries had disease recurrence and the remaining two cases without initial surgery experienced disease progression during primary treatment. Inguinal lymph nodes were the most frequent sites of recurrence. In conclusion, previous obstetric or gynecologic surgery can be a risk factor for CCC of the abdominal wall. Complete resection of abdominal wall tumor and suspected intra-abdominal lesions with hysterectomy and bilateral inguinal lymph nodes dissection may be the primary treatment. Adjuvant chemotherapy would be considered for potential benefits. For patients without bilateral inguinal lymph nodes dissection, careful inguinal lymph node palpation during postoperative surveillance is necessary. More cases are still needed to elucidate the clinical management of this disease.
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http://dx.doi.org/10.3390/ijerph16040552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6406533PMC
February 2019

Torsion of pedunculated subserous uterine leiomyoma: A rare complication of a common disease.

Taiwan J Obstet Gynecol 2018 Apr;57(2):300-303

Department of Obstetrics and Gynecology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Oncology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. Electronic address:

Objective: To evaluate the clinical presentations, diagnosis, management, and outcomes of torsion of the pedunculated subserous uterine leiomyoma.

Materials And Methods: We retrospectively reviewed medical records of patients with subserous uterine leiomyomas undergoing surgeries at National Taiwan University Hospital from January 2001 to December 2015.

Results: Five cases of torsion of pedunculated subserous uterine leiomyoma were identified. All presented with sudden onset abdominal pain. Two patients received emergent surgeries, the other three cases received scheduled surgeries. The postoperative courses of these five women were uneventful without sequelae.

Conclusions: Torsion of pedunculated subserous uterine leiomyoma is rare. Accurately diagnosing it prior to surgery is a major challenge. It should be one of the differential diagnosis in patients with uterine leiomyoma presenting with acute abdomen.
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http://dx.doi.org/10.1016/j.tjog.2018.02.021DOI Listing
April 2018

NTF3 Is a Novel Target Gene of the Transcription Factor POU3F2 and Is Required for Neuronal Differentiation.

Mol Neurobiol 2018 Nov 16;55(11):8403-8413. Epub 2018 Mar 16.

Inflammation Research & Drug Development Center, Changhua Christian Hospital, No. 135 Nanxiao Street, Changhua, 500, Taiwan.

POU-homeodomain transcription factor POU3F2 is a critical transcription factor that participates in neuronal differentiation. However, little is known about its downstream mediators. Here genome-wide analyses of a human neuronal differentiation cell model, NT2D1, suggested neurotrophin-3 (NTF3), a key mediator of neuronal development during the early neurogenic period, as a putative regulatory target of POU3F2. Western blot, cDNA microarray, and real-time quantitative PCR analyses showed that POU3F2 and NTF3 were upregulated during neuronal differentiation. Next-generation-sequence-based POU3F2 chromatin immunoprecipitation-sequencing and genome-wide in silico prediction demonstrated that POU3F2 binds to the NTF3 promoter during neuronal differentiation. Furthermore, unidirectional deletion or mutation of the binding site of POU3F2 in the NTF3 promoter decreased promoter-driven luciferase activity, indicating that POU3F2 is a positive regulator of NTF3 promoter activity. While NTF3 knockdown resulted in decreased viability and differentiation of NT2D1 cells, and POU3F2 knockdown downregulated NTF3 expression, recombinant NTF3 significantly rescued viable neuronal cells from NTF3- or POU3F2-knockdown cell cultures. Moreover, immunostaining showed colocalization of POU3F2 and NTF3 in developing mouse neurons. Thus, our data suggest that NTF3 is a novel target gene of POU3F2 and that the POU3F2/NTF3 pathway plays a role in the process of neuronal differentiation.
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http://dx.doi.org/10.1007/s12035-018-0995-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153716PMC
November 2018

Transcervical double-balloon catheter as an alternative and salvage method for medical termination of pregnancy in midtrimester.

Taiwan J Obstet Gynecol 2017 Feb;56(1):77-80

Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University, Taipei, Taiwan.

Objective: Termination of pregnancy in midtrimester can be performed surgically or medically. The aim of this study was to evaluate the medical methods, and the additional efficacy of using a transcervical double-balloon catheter in midtrimester termination.

Materials And Methods: In this retrospective study, we included 167 pregnant women admitted during the period from January 1, 2011, to June 31, 2015, who were between 14 weeks and 28 weeks of gestation, and underwent intended termination of pregnancy at our center. Each of the 167 patients was allocated to either the cervical ripening balloon (CRB) group (with double-balloon catheter) or the non-CRB (without double-balloon catheter) group, by the choice or preference of the patient and her attending physician. Termination of pregnancy in the CRB group (72 patients) was conducted by placing a transcervical double-balloon catheter (COOK CRB), with both the uterine and vaginal balloons inflated with 30-80 mL of normal saline, and held in place for 12 hours, whereas in the non-CRB group (95 patients) vaginal and oral misoprostol alone were administered.

Results: There were no significant differences between the CRB and non-CRB groups with regard to induction-to-delivery time (23.1 hours vs. 21.1 hours) and successful abortion rate within 30 hours (80.0% vs. 83.7%). There were no severe complications in both groups.

Conclusion: There was no significant additional benefit of using a double-balloon catheter in midtrimester termination of pregnancy, although the technique was considered simple and generally well-tolerated. Placing a transcervical double-balloon catheter could be the primary method, or one of the alternative medical methods if the patient and/or obstetrician prefers no operation.
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http://dx.doi.org/10.1016/j.tjog.2015.12.024DOI Listing
February 2017

MK-2206 induces apoptosis of AML cells and enhances the cytotoxicity of cytarabine.

Med Oncol 2015 Jul 19;32(7):206. Epub 2015 Jun 19.

Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan,

Genetic alterations in the PI3K/AKT cascade have been linked to various human cancers including acute myeloid leukemia (AML) and have emerged to be promising targets for treatment. In this study, we explored the molecular mechanism and clinical implication of a specific allosteric AKT inhibitor, MK-2206, in the treatment of AML. Four leukemia cell lines, MV-4-11, MOLM-13, OCI/AML3, and U937, were used. Apoptosis and cell cycle distribution were determined by flow cytometry analysis. Expression of anti-apoptotic protein family and glycogen synthase kinase 3β (GSK3β) signaling was determined by western blotting. Drug combination effects of MK-2206 with cytarabine were evaluated by cell proliferation assay, and the combination index values were calculated by CompuSyn software. MK-2206 had no effect on normal peripheral blood mononuclear cells, but induced G1-phase arrest and apoptosis in leukemia cells. Among anti-apoptotic Bcl-2 family members, only myeloid cell leukemia-1 (Mcl-1) was significantly suppressed. Mcl-1 suppression by MK-2206 was closely associated with decreased GSK3β phosphorylation at Ser9, an event leads to GSK3β activation. Furthermore, the effect of MK-2206 on Mcl-1 downregulation was abolished by GSK3β inhibitor, lithium chloride and proteasome inhibitor, MG-132, suggesting that MK-2206 acted through a GSK3β-mediated, proteasome-dependent protein degradation. In addition, co-administration of MK-2206 with cytarabine could enhance the cytotoxic efficacy of cytarabine in leukemia cell lines. In conclusion, we have demonstrated that MK-2206 is an active agent in AML and its efficacy as in combination with cytarabine is implicated.
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http://dx.doi.org/10.1007/s12032-015-0650-7DOI Listing
July 2015

Hypermethylation of the TGF-β target, ABCA1 is associated with poor prognosis in ovarian cancer patients.

Clin Epigenetics 2015 14;7. Epub 2015 Jan 14.

Department of Life Science, National Chung Cheng University, 168 University Road, Min-Hsiung, Chia-Yi 621, Taiwan ; Institute of Molecular Biology, National Chung Cheng University, Min-Hsiung, Chia-Yi, Taiwan.

Background: The dysregulation of transforming growth factor-β (TGF-β) signaling plays a crucial role in ovarian carcinogenesis and in maintaining cancer stem cell properties. Classified as a member of the ATP-binding cassette (ABC) family, ABCA1 was previously identified by methylated DNA immunoprecipitation microarray (mDIP-Chip) to be methylated in ovarian cancer cell lines, A2780 and CP70. By microarray, it was also found to be upregulated in immortalized ovarian surface epithelial (IOSE) cells following TGF-β treatment. Thus, we hypothesized that ABCA1 may be involved in ovarian cancer and its initiation.

Results: We first compared the expression level of ABCA1 in IOSE cells and a panel of ovarian cancer cell lines and found that ABCA1 was expressed in HeyC2, SKOV3, MCP3, and MCP2 ovarian cancer cell lines but downregulated in A2780 and CP70 ovarian cancer cell lines. The reduced expression of ABCA1 in A2780 and CP70 cells was associated with promoter hypermethylation, as demonstrated by bisulfite pyro-sequencing. We also found that knockdown of ABCA1 increased the cholesterol level and promoted cell growth in vitro and in vivo. Further analysis of ABCA1 methylation in 76 ovarian cancer patient samples demonstrated that patients with higher ABCA1 methylation are associated with high stage (P = 0.0131) and grade (P = 0.0137). Kaplan-Meier analysis also found that patients with higher levels of methylation of ABCA1 have shorter overall survival (P = 0.019). Furthermore, tissue microarray using 55 ovarian cancer patient samples revealed that patients with a lower level of ABCA1 expression are associated with shorter progress-free survival (P = 0.038).

Conclusions: ABCA1 may be a tumor suppressor and is hypermethylated in a subset of ovarian cancer patients. Hypermethylation of ABCA1 is associated with poor prognosis in these patients.
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http://dx.doi.org/10.1186/s13148-014-0036-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307187PMC
January 2015

Systems biology of meridians, acupoints, and chinese herbs in disease.

Evid Based Complement Alternat Med 2012 18;2012:372670. Epub 2012 Oct 18.

Department of Life Science, National Taiwan University, No. 1, Section 4, Roosevelt Road, Taipei 106, Taiwan.

Meridians, acupoints, and Chinese herbs are important components of traditional Chinese medicine (TCM). They have been used for disease treatment and prevention and as alternative and complementary therapies. Systems biology integrates omics data, such as transcriptional, proteomic, and metabolomics data, in order to obtain a more global and complete picture of biological activity. To further understand the existence and functions of the three components above, we reviewed relevant research in the systems biology literature and found many recent studies that indicate the value of acupuncture and Chinese herbs. Acupuncture is useful in pain moderation and relieves various symptoms arising from acute spinal cord injury and acute ischemic stroke. Moreover, Chinese herbal extracts have been linked to wound repair, the alleviation of postmenopausal osteoporosis severity, and anti-tumor effects, among others. Different acupoints, variations in treatment duration, and herbal extracts can be used to alleviate various symptoms and conditions and to regulate biological pathways by altering gene and protein expression. Our paper demonstrates how systems biology has helped to establish a platform for investigating the efficacy of TCM in treating different diseases and improving treatment strategies.
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http://dx.doi.org/10.1155/2012/372670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483864PMC
November 2012

Functional characterization of Trip10 in cancer cell growth and survival.

J Biomed Sci 2011 Feb 7;18:12. Epub 2011 Feb 7.

Human Epigenomics Center, Department of Life Science, Institute of Molecular Biology and Institute of Biomedical Science, National Chung Cheng University, Chia-Yi, Taiwan.

Background: The Cdc42-interacting protein-4, Trip10 (also known as CIP4), is a multi-domain adaptor protein involved in diverse cellular processes, which functions in a tissue-specific and cell lineage-specific manner. We previously found that Trip10 is highly expressed in estrogen receptor-expressing (ER+) breast cancer cells. Estrogen receptor depletion reduced Trip10 expression by progressively increasing DNA methylation. We hypothesized that Trip10 functions as a tumor suppressor and may be involved in the malignancy of ER-negative (ER-) breast cancer. To test this hypothesis and evaluate whether Trip10 is epigenetically regulated by DNA methylation in other cancers, we evaluated DNA methylation of Trip10 in liver cancer, brain tumor, ovarian cancer, and breast cancer.

Methods: We applied methylation-specific polymerase chain reaction and bisulfite sequencing to determine the DNA methylation of Trip10 in various cancer cell lines and tumor specimens. We also overexpressed Trip10 to observe its effect on colony formation and in vivo tumorigenesis.

Results: We found that Trip10 is hypermethylated in brain tumor and breast cancer, but hypomethylated in liver cancer. Overexpressed Trip10 was associated with endogenous Cdc42 and huntingtin in IMR-32 brain tumor cells and CP70 ovarian cancer cells. However, overexpression of Trip10 promoted colony formation in IMR-32 cells and tumorigenesis in mice inoculated with IMR-32 cells, whereas overexpressed Trip10 substantially suppressed colony formation in CP70 cells and tumorigenesis in mice inoculated with CP70 cells.

Conclusions: Trip10 regulates cancer cell growth and death in a cancer type-specific manner. Differential DNA methylation of Trip10 can either promote cell survival or cell death in a cell type-dependent manner.
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http://dx.doi.org/10.1186/1423-0127-18-12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3044094PMC
February 2011

ACTION live: using process evaluation to describe implementation of a worksite wellness program.

J Occup Environ Med 2010 Jan;52 Suppl 1:S14-21

Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112, USA.

Objectives: Process evaluation is a necessary component of randomized controlled field trials. This is a descriptive article that reviews process evaluation for the ACTION Wellness Program for Elementary School Personnel.

Methods: : Methods included self-report by participants, documentation by program staff, and school administrator report. Variables evaluated were program dose, fidelity and reach, exposure to materials and activities, and school factors that could influence program implementation and outcomes.

Results: Dose and exposure were high across intervention schools and intervention years. Reach was variable across schools and activities. Schools on the East Bank of the Mississippi River generally had slightly better reach than schools on the West Bank. Some nutrition activities had higher levels of participation than physical activities.

Conclusions: High program dose reflected good effort and cooperation by program staff and schools. A disconnect between exposure and reach showed that high exposure did not always translate to high participation.
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http://dx.doi.org/10.1097/JOM.0b013e3181c81adeDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897048PMC
January 2010

Transfer of dioxin risk between nine major municipal waste incinerators in Taiwan.

Environ Int 2002 Apr;28(1-2):103-10

Graduate Institute of Environmental Engineering, College of Engineering, National Taiwan University, Taipei.

The objective of this study was to assess site-specific carcinogenic risks of incinerator-emitted dioxins and risk transfers among the areas covered by nine municipal incinerators in Taiwan. We used actual emission data and the industrial source complex short-term model (ISCST3) to determine the dioxin impact areas within the 8 x 8-km simulation regions surrounding the incinerators. We then used multimedia model to estimate cancer risks in individual impact areas for two exposure scenarios, which were sufficient (SFP) and insufficient food production (IFP) for residents' consumption in each impact area. We also used information of food supply and consumption between impact areas to calculate risk transfers among these nine incinerators. We found that dioxins' carcinogenic risks ranged from 1.4 x 10(-8) (Incinerator F) to 7.1 x 10(-5) (Incinerator A) for the nine incinerators under the exposure scenario of SFP, and ranged from 8.7 x 10(-8) (Incinerator D) to 1.1 X 10(-6) (Incinerator E) under the exposure scenario of IFP. The food ingestion was the main exposure pathway, which accounted for 64-99% of total dioxin risks among nine impact areas. For the nine major food items consumed by residents in the impact areas, eggs (14-35%) and chicken (11-26%) were two main routes of dioxin exposure in the SFP scenario, while chicken (8-78%) and vegetables (0.2-81%) were two main routes of dioxin exposure in the IFP scenario. Significant risks of dioxins were transferred among incinerators, which accounted for up to 88% among the incinerators. Incinerator E was the major risk-exporting source to six Incinerators C, D, F, G, H, and I. For these six incinerators, Incinerator E accounted for their 51-88% imported risks. We concluded that risk transfers among incinerators through routes of food consumption should be considered in assessing health risks associated with incinerator-emitted dioxins in Taiwan. We should place high priority on implementing control measures to lower dioxin emissions in important food-exporting areas like Incinerator E. We should also emphasize analyzing dioxin contents in eggs, chicken, and vegetables in order to improve dioxin-related health risk assessments in the future.
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http://dx.doi.org/10.1016/s0160-4120(02)00013-2DOI Listing
April 2002
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