BRCA1/2 mutations in patients with high‐risk breast cancer from Inner Mongolia and Jilin, China, which was a part of a nationwide project on the detection of BRCA1/2 mutations in Chinese patients with hereditary breast cancer.Breast cancer is the most common cancer among women worldwide. Here, we report the prevalence of BRCA1 and BRCA2 and adjacent noncoding regions were screened for mutations based on next‐generation sequencing from collected saliva.According to the criteria, index patients from a total of 245 independent families were initially recruited. All 49 exons of BRCA1/2 variants in 18 of 216 (8.3%) index patients with high‐risk breast cancer. Among these, seven mutations were novel, including four BRCA1 mutations , and three BRCA2 mutations . The BRCA1/2 variants were identified in 14% (8/57) of the patients with triple‐negative breast cancer and in 6.3% (10/159) of the patients with non‐triple‐negative breast cancer. There was no significant difference between the two groups (p = 0.07). A higher frequency for BRCA1 mutations was observed in patients with triple‐negative breast cancer than in those with non‐triple‐negative breast cancer . The frequencies of the BRCA2 mutations were not significantly different between patients with triple‐negative breast cancer and those with non‐triple‐negative breast cancer .We detected 17 BRCA1 mutations than those with non‐triple‐negative breast cancer. In this study, no significant associations between the BRCA1/2 mutation status and age, family history of breast cancer, ovarian cancer, pancreatic cancer and prostate cancer, number of primary lesions, tumor size, or lymph node metastasis were observed.We found that patients with triple‐negative breast cancer had a higher frequency of  BRCA1/2 mutations are identified in approximately 10% of breast cancers  screening of a large sample of Chinese high‐risk breast cancer populations for BRCA1/2 mutations; (b) establishing a database of BRCA1/2 mutations in Chinese breast cancer populations; and (c) establishing a risk model of breast cancer that is associated with BRCA1/2 mutations in Chinese populations.Although there are several studies on 22.1BRCA1/2 mutations were identified in the index patients, their first‐ and second‐degree relatives were screened.Our research has been approved by the ethics committee, under the “Ethical Compliance”, we started the project. According to the U.S. National Comprehensive Cancer Network Genetic/Family High Risk Assessment: Breast and Ovarian Cancer Clinical Practice Guidelines in Oncology  age at diagnosis ≤45 years; (b) age at diagnosis ≤50 years and the presence of ≥2 primary lesions; and (c) meeting one or more of the following family histories: i) age at diagnosis ≤50 years and ≥1 close relative with breast cancer; ii) diagnosed at any age and ≥1 close relative with breast cancer whose age at diagnosis ≤50 years; iii) diagnosed at any age and ≥2 close relatives with breast cancer; iv) diagnosed at any age and ≥1 close relative with epithelial ovarian cancer; v) diagnosed at any age and ≥2 close relatives with pancreatic cancer, and/or prostate cancer ; vi) diagnosed at any age, and ≥1 male close relative with breast cancer; (d) triple‐negative breast cancer and the age at onset was not more than 60 years; and (e) male breast cancer.BRCA1/2 mutation carriers were enrolled only when the mutations in the index patients were confirmed by Sanger sequencing. One to five relatives from each family were enrolled as follows: (a) first‐ and second‐degree female adult relatives (≥18 years) were selected from the same side of the paternal or maternal line according to the family's incidence and (b) first‐ and second‐degree male breast cancer relatives.First‐ and second‐degree relatives of the BRCA1/2 mutations were further enrolled, including the father and mother of Patient 033A; the father, mother, older sister, younger sister, and daughter of Patient 073A; and the mother of Patient 196A. There was no restriction on race and ethnic group during patient enrollment. Approximately 240 patients underwent surgery in our hospital, and five patients were review outpatients in our hospital but underwent surgery in other hospitals.All inpatients and review outpatients in the Department of Breast Surgery assessed by our hospital from April 2010 to March 2017 were recruited into this study. All patients underwent surgical treatment. According to the above inclusion criteria, index patients from a total of 245 independent families were initially recruited. An additional eight first‐ and second‐degree relatives of three index patients who carried the Among the 245 independent families, 12 patients with clinical samples of poor quality and 17 patients who did not meet the criteria for index patients were excluded from this study. A total of 216 index patients were finally enrolled in this study.BRCA1/2 Gene in Chinese Breast Cancer Group). Written informed consent for BRCA1/2 gene testing was obtained from all patients, and the study was approved by the Ethics Committee of the First Hospital of Jilin University .This study was registered at ClinicalTrials.gov .BRCA1 and BRCA2 and adjacent noncoding regions were sequenced. The depth of coverage was over 300×.Genomic DNA was fragmented using a Bioruptor sonication device . A DNA fragment library was constructed according to the Illumina standard protocol . All exons of breast cancer‐related genes were captured with the NimbleGen SeqCap EZ Choice library according to the Roche standard protocol . The quantity of the library was determined with a Bioanalyzer . Paired‐end 100‐bp next‐generation sequencing (NGS) was performed on an Illumina HiSeq 2500 platform (Illumina). A total of 16,000 bp spanning all 49 exons of http://broadinstitute.github.io/picard/). Realignment and recalibration of the reads were performed with the Genome Analysis Toolkit   using the Burrows–Wheeler Aligner software   of the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology. The detected mutations were compared to the Breast Cancer Information Core (BIC) database (http://research.nhgri.nih.gov/Bic/) and the ClinVar database (http://www.ncbi.nlm.nih.gov/clinvar/) to determine whether it is a novel mutation.The GenBank reference sequence and version number for http://enigmaconsortium.org/) , possibly pathogenic , unknown pathogenicity , possibly benign , and benign .According to the International Agency for Research Cancer . The distribution of 33.1Among the 216 index patients, 47 patients had a family history of breast cancer, epithelial ovarian cancer, pancreatic cancer, and/or prostate cancer. The median age at diagnosis was 42 years (range: 21–67 years). Approximately 175 patients had an age at diagnosis ≤45 years . Seven patients had more than two primary tumors, three of whom had bilateral breast cancer. Two breast cancer patients were male. Based on immunohistochemistry, 216 patients were divided into three groups, including 57 patients with triple‐negative breast cancer and 159 patients with non‐triple‐negative breast cancer. There were 200 and 16 patients from Jilin and Inner Mongolia, respectively, including 202 Han patients, nine Mongolian patients, two Korean patients, two Manchu patients, and one Hui patient.3.2BRCA1/2 mutations were detected in 18 of 216 (8.3%) index patients with high‐risk breast cancer. All patients carrying the BRCA1/2 mutations were Han Chinese. Among these 17 mutations, eight mutations were novel and have not been reported in the BIC and/or ClinVar databases, including five BRCA1 mutations  of the 216 patients. Six mutations were known mutations that have been reported in the BIC and/or ClinVar databases, including c.2138C>G, c.2751delC, c.2572C>T, c.3916_3917delTT, c.3841C>T, and c.5194‐2A>G. The other five mutations have not been reported in the BIC and/or ClinVar databases, which included c.1934delC, c.123_124delCAinsAT, c.5093_5096delCTAA, c.5396‐2A>G, and c.2054delinsGAAGAGTAACAAGTAAGAAGAGTAACAAGAAG (Table Eleven BRCA2 pathogenic variants were detected in seven (3.2%) of the 216 patients. Three variants were previously reported, including c.5959C>T, c.8364G>A, and c.464_468delGAGAT. Two patients carried the c.5959C>T mutation. The other three variants were novel, including c.304A>T, c.7552_7553insT, and c.9548_9549insA (Table Six 3.3BRCA1/2 variants were identified in 14% (8/57) of the patients with triple‐negative breast cancer and in 6.3% (10/159) of the patients with non‐triple‐negative breast cancer (Table p = 0.07). A higher frequency for BRCA1 mutations was observed in patients with triple‐negative breast cancer than in those with non‐triple‐negative breast cancer . The frequencies of the BRCA2 mutations were not significantly different between patients with triple‐negative breast cancer and those with non‐triple‐negative breast cancer .The 3.4BRCA1/2 mutation status and age; family history of breast cancer, ovarian cancer, pancreatic cancer and prostate cancer; number of primary lesions; tumor size; and lymph node metastasis  repair, homologous recombination repair, cell cycle regulation, gene transcription regulation, and chromatin stability after DNA damage  have been reported in Chinese populations , leading to loss of BRCA1 protein expression. Studies have shown that the early termination of BRCA1 sequence translation can cause abnormal expression of BRCA1 protein, resulting in the development of breast cancer   was a pathogenic mutation  are located in the region where BRCA1 binds to RAD50 (OMIM accession number 604040). After BRCA1 binds to RAD50, the Rad50/MreII/NbsI complex is recruited to the DNA double‐strand break site, making it easy to repair DNA damage, particularly NHEJ repair . During cell mitosis and meiosis, BRCA1 binds to RAD51, and RAD51 binds to single‐stranded DNA (ssDNA), facilitating homologous recombination to repair HR , the BRC domain , the DNA binding domain (DBD), and the C‐terminus comprising the NLS and cyclin‐dependent kinase  detected in this study were novel (i.e. have not been reported in the literature and have not been recorded in the BIC and ClinVar databases). A frameshift variant c.304_304delA (p.Leu103fs) has been reported in Chinese patients  index patients with high‐risk breast cancer. Among these, eight mutations were novel, including five BRCA1 mutations and three BRCA2 mutations. We found that patients with triple‐negative breast cancer had a higher BRCA1 mutation rate than those with non‐triple‐negative breast cancer. We did not find any significant association between BRCA1/2 mutation status and age; family history of breast cancer, ovarian cancer, pancreatic cancer, and prostate cancer; number of primary lesions; tumor size; and lymph node metastasis.In summary, we detected 17 The authors declare that they have no competing interests.


In patients with Crohn’s disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD.To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public.A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states  by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method.p < 0.05).Responses of 206 patients  and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse  contains supplementary material, which is available to authorized users. Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract, often characterised by potentially debilitating symptoms such as abdominal pain, rectal bleeding, diarrhoea, fatigue and urgency . PerianaFew HRQoL studies have elicited health utilities for CD health states using a direct method . UtilitiUtility studies in CD were mostly conducted about 2 decades ago before or in the early era of biological drugs –20, ofteThe present study was designed to (1) generate utilities for common CD health states featuring luminal or luminal and concomitant perianal disease from the perspective of patients and members of the general public; (2) compare utilities for luminal CD to those when parallel perianal symptoms are present; (3) explore the impact of perspectives on health utilities, and (4) determine whether utilities are related to respondents’ demographics, health status or clinical characteristics.Two cross-sectional surveys were undertaken. First, a paper-based survey was conducted with patients diagnosed with CD regardless of having perianal fistulising disease. The second, Internet-based, survey included members of the general population. Permission for conducting the study was granted by the National Scientific and Ethical Committee (Reference no. 49548-4/2016/EKU). An informed consent form was signed by all participants.Data were collected between October 2016 and September 2017. Consecutive outpatients over 18 years from three academic gastroenterology departments and an inflammatory bowel diseases (IBD) centre in Hungary were enrolled in the study. The survey comprised of a paper-based questionnaire, the first part of which was completed by the patients, and the second by their gastroenterologist. Patients were asked about their socio-demographic characteristics and health status. CD-related pain intensity was recorded on a horizontal visual analogue scale (VAS) with the endpoints of ‘no pain at all’ (= 0) and ‘pain as bad as it could be’ (= 10).In the second part of the survey, gastroenterologists provided data about the medical history, clinical characteristics and treatments of their patients. Gastroenterologists assessed disease severity using Crohn’s Disease Activity Index (CDAI) and Perianal Disease Activity Index (PDAI) , 24. TheInternet-based questionnaires were completed between November 2017 and March 2018. A convenience sample of the general population (aged ≥ 18 years) was recruited from the campus of Corvinus University of Budapest to participate in the survey. Participation was voluntary, anonymous and no remuneration was offered. The questionnaire collected data on socio-demographic characteristics of the respondents as well as their prior knowledge about CD . All questions of the online survey were mandatory, so respondents could not proceed to the next question without answering the previous one.Four health state vignettes were designed: severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD). The descriptions were developed by a group of IBD experts and health economists experienced in utility assessment. The final vignettes combined a description of living with CD including intestinal symptoms, abdominal pain, fistula symptoms, sleep, extraintestinal symptoms, eating, work/school, and leisure and social activities . The descriptions were presented from a first-person perspective in a table format, as an earlier study reported that patients strongly prefer this format over narrative health state descriptions . SubjectAll TTO tasks were self-administered. The TTO method elicits HRQoL or utility values for imperfect health states by asking respondents to make a trade off between quality and length of life . We opteTTO utilities were calculated according to the following formula:U = (10 − 2)/10 = 0.8. Therefore, TTO utilities in this study were anchored on 0 (death) and 1 .Suppose, for example, a respondent indicated to exchange 2 years, yielding t test and χ2 test. All non-missing TTO responses were included in the primary data analysis. Descriptive statistics  of utilities were computed. A paired t test was used to test the difference between TTO utilities for hypothetical health states. TTO utilities within subgroups of patients were compared by Student’s t test or analysis of variance (ANOVA), where applicable.Socio-demographic and clinical characteristics of the patient and general population groups were compared using a Student’s p < 0.05 was considered statistically significant. Data were analysed using Stata 13 .We performed random-effects linear regression models to explore demographic, clinical and other possible predictors of utilities for hypothetical health states. Before running the models, the following participants were excluded: (1) non-traders , (2) who indicated the same value for all health states, (3) who had more than two missing TTO responses out of the four hypothetical health states and (4) who indicated a logical inconsistency . Determinants of utilities for current health were analysed by ordinary least squares regression. No exclusions were applied before the regression analysis of utilities for current health. All the statistics were two-sided, and n = 7 for sCD, n = 7 for mCD, n = 9 for sPFCD, n = 13 for mPFCD and n = 5 for current health. There were no missing responses in the general population sample.Overall, 206 patients with CD and 221 adults from the general population participated in the study. There were a total of 41 (4.0%) missing TTO responses from patients: Table More than two-thirds of the general population sample have never heard about CD. Altogether, 16.7% have read or heard about CD from the internet/media/newspapers, 8.6% learned about CD as they were being employed in healthcare, 4.1% had a family member or acquaintance suffering from CD and 3.6% indicated to be diagnosed with CD (Table Table p < 0.001).Table For each health state, the proportion of patients not willing to give up any time  is presented in Table p < 0.01). There was no statistically significant difference in TTO scores for the two mild health states between the two groups.Mean TTO utilities from patients were higher for the two severe health states compared to the general public (p = 0.013). Previous non-resection (0.76 ± 0.33) or both resection and non-resection (0.75 ± 0.37) surgeries were associated with lower mean TTO values (p = 0.023). Differences between groups based on CDAI score also showed a trend towards statistical significance.Table p = 0.005). One-point increase in disease severity on CDAI resulted in a 0.001 decrease in utilities (p = 0.036). Employment status of patients had a significant impact on utilities, those working full time indicated lower values by 0.071 (p = 0.020).Supplementary material S3 demonstrates the results of regression models about predictors of TTO utilities. Patients’ utilities for the hypothetical health states were decreased by 0.012 with 1-point increase in body mass index (BMI) (p < 0.001). Patients who previously had a non-resection surgery due to CD rated hypothetical health states to 0.095 lower (p = 0.015). Patients who were retired valued their current health utility lower by 0.176, while those who were students gave higher values by, on average, 0.106.With respect to patients’ current health, each 1-point increase in pain intensity on a VAS  was associated with a 0.032 decrease in TTO utilities (p = 0.018). People who had a family member or acquaintance diagnosed with CD valued health states higher , while disability pensioners rated them to be lower by 0.174 (p = 0.021).Among members of the general public, TTO values for hypothetical health states increased by 0.002 with every 1-year increase in age and by 0.003 with every 1-year increase in subjective life expectancy  .The TTO seems to be superior to indirect utility assessment when it comes to PFCD. As shown by earlier studies, the EQ-5D-3L or EQ-5D-5L questionnaires could not distinguish between subgroups of CD patients based on perianal disease , 34. We In many countries including the US, Canada, the UK, the Netherlands and Hungary a general population perspective is recommended in the context of economic evaluations, while other countries, such as Sweden, recommend the patient perspective –42. TherThe assessment of HRQoL is advocated in guidelines for the management of PFCD by professional societies such as the European Crohn’s and Colitis Organisation (ECCO) and the American College of Gastroenterology (ACG) –49. HoweOverall, the results of this study well reflect the severity of different health states of CD, and highlight the additional HRQoL burden of living with perianal fistulising disease. It seems that the TTO method offers an accurate assessment of HRQoL in patients with PFCD, often not captured by health status questionnaires. Utilities from the present study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas and to establish a solid basis for cost-effectiveness analyses to compare treatment strategies.Supplementary material 1 (PDF 217 kb)Supplementary material 2 (PDF 231 kb)Supplementary material 3 (PDF 234 kb)Below is the link to the electronic supplementary material.


We comprehensively evaluated the in vivo genotoxicity of PCH on hematopoietic cells of male MutaMouse transgenic rodents using a study design that facilitated assessments of micronuclei and Pig‐a mutation in circulating erythrocytes, and lacZ mutant frequencies in bone marrow. Mice were orally exposed to PCH  for 28 consecutive days. Blood samples collected 2 days after cessation of treatment exhibited significant dose‐related induction of micronuclei in both immature and mature erythrocytes. Bone marrow and blood collected 3 and 70 days after cessation of treatment also showed significantly elevated mutant frequencies in both the lacZ and Pig‐a assays even at the lowest dose tested. PCH‐induced lacZ and Pig‐a (immature and mature erythrocytes) mutant frequencies were highly correlated, with R2 values ≥0.956, with the exception of lacZ vs. Pig‐a mutants in mature erythrocytes at the 70‐day time point (R2 = 0.902). These results show that PCH is genotoxic in vivo and demonstrate that the complex metabolism and resulting genotoxicity of PCH is best evaluated in intact animal models. Our results further support the concept that multiple biomarkers of genotoxicity, especially hematopoietic cell genotoxicity, can be readily combined into one study provided that adequate attention is given to manifestation times. Environ. Mol. Mutagen. 60:505–512, 2019. © 2018 Her Majesty the Queen in Right of CanadaProcarbazine hydrochloride (PCH) is a DNA‐reactive hematopoietic carcinogen with potent and well‐characterized clastogenic activity. However, there is a paucity of  Procarbazine hydrochloride (PCH) is a hydrazine derivative that is reemerging as a useful drug that in combination with other anti‐neoplastic agents is effective at treating several malignancies, especially gliomas and Hodgkin's lymphoma  assay. Together with the rodent bioassay data and occurrences of therapy‐related tumors noted above, the weight of evidence provided by in vivo data implies that PCH is a carcinogen with a genotoxic mode of action that clearly involves clastogenicity, with some evidence of mutagenicity as well. Based on these findings, the mutagenic potential of PCH deserves more analysis and consideration, including an assessment of the impact of longer exposure duration, different sampling times, and a comparison of different genetic endpoints within the same experimental system.PCH appears to be a particularly effective O6‐methyl‐guanine adducts . Hank's balanced salt solution (HBSS) was purchased from MediaTech, Herndon, VA. Reagents used for flow cytometric micronucleus scoring  were from In Vivo Mouse MicroFlow® Kits (Litron Laboratories).PCH  was purchased from Sigma‐Aldrich, Oakville, ON, Canada. Lympholyte®‐Mammal cell separation reagent was purchased from CedarLane, Burlington, NC. Anti‐PE MicroBeads, LS Columns, and a QuadroMACS™ separator were from Miltenyi Biotec, Bergisch Gladbach, Germany. CountBright™ absolute count beads and fetal bovine serum (FBS) were purchased from Invitrogen, Carlsbad, CA. Anticoagulant solution, buffered salt solution, nucleic acid dye solution (contains SYTO® 13), anti‐CD24‐PE, and anti‐CD61‐PE were from Mouse Blood lacZ assay, phenyl‐beta‐D‐galactopyranoside  was purchased from G‐Biosciences, St Louis, MO; proteinase K was from Invitrogen, Burlington, ON, Canada; packaging extract kits were from Agilent Technologies, Mississauga, ON, Canada; all other chemicals were purchased from Sigma‐Aldrich.For the ad libitum throughout the acclimation and experimental periods. PCH was prepared in phosphate buffered saline (PBS) on each treatment day and was administered via oral gavage in a volume of 0.003 mL/kg body weight/administration. Dose levels were 0, 6.25, 12.5, or 25 mg/kg/day and exposure occurred on study Days 1 through 28 (n = 4 for controls and 8 per treatment group per time point). The top dose level used in the main study was based on a pilot dose range‐finding study that demonstrated that a dose of 50 mg/kg/day resulted in a body weight loss that approached what would be considered excessive toxicity and grossly affected testis weight .Experiments were conducted with the oversight of the Health Canada Ottawa Animal Care Committee, which approved all animal procedures. Male MutaMouse rodents were obtained from a colony maintained at Health Canada. Mice were allowed to acclimate for approximately 10 days, and their age at the start of the treatment was between 10 and 12 weeks. Pretreatment blood samples were not collected prior to study initiation. Water and food were available lacZ and Pig‐a assays. Approximately 60 μL of peripheral blood was collected from the facial vein and immediately combined with 350 μL of anticoagulant from the MicroFlowBASIC Kit . Following MicroFlowBASIC Kit instructions, anticoagulated blood samples were fixed with ice‐cold methanol and stored at −80°C. After 5 days, fixed blood samples were centrifuged, rinsed, and transferred to a long‐term storage solution. Coded specimens were shipped to Litron for analysis of micronucleated cell frequency as described below.For the micronucleus assay, peripheral blood was collected 2 days after the end of the exposure period (referred to hereafter as 28 + 2d) from the same groups of animals euthanized the next day  for the Pig‐a and lacZ assays, respectively, were collected at 28 + 3d and 70 days (28 + 70d) after cessation of treatment. At each time point, animals were euthanized by cardiac puncture under isoflurane anesthesia. The femurs were removed and the bone marrow was flushed out in 1 mL of PBS, pelleted via brief centrifugation, resuspended in 100 μL of PBS and flash frozen in liquid nitrogen, and finally stored at −80°C. Following blood collection via cardiac puncture, 400 μL of blood was immediately transferred to a 0.5 mL K2‐EDTA‐coated microtainer obtained from Litron and maintained at 4°C until being placed in an ExactPak shipping container and shipped on ice overnight to Litron for analysis of Pig‐a mutant cell frequencies as described below.Peripheral blood and bone marrow for the In Vivo Mouse MicroFlow Kit manual. This methodology has been described in detail elsewhere , micronucleated immature, and mature (normochromatic) erythrocytes  were determined for coded blood samples collected at the 28 + 2d time point. To prepare samples for flow cytometric analysis, blood was washed out of methanol fixative and incubated with antibodies and other reagents as specified in the LacZ mutant frequencies were determined on coded bone marrow samples collected at 28 + 3d and 28 + 70d. Bone marrow total genomic DNA was extracted according to Gingerich et al. , plated on medium containing 0.3% (w/v) P‐Gal and incubated overnight at 37°C. Mutant frequency was calculated as the ratio of mutant plaque forming units (pfu) to total pfu. The DNA from two mice (a control and one middle dose at 28 + 3d) did not pack well and produced no colonies; while two mice (one from the low dose and one from the middle dose) had to be euthanized before tissue collection at 28 + 70d because of rectal prolapse.The P‐Gal positive selection assay was used for determining Pig‐a mutant phenotype cell frequencies were determined on coded blood samples collected at 28 + 3d and 28 + 70d. Methods for processing mouse blood for Pig‐a measurements have been described  as well as the frequency of mutant phenotype erythrocytes (RBCCD24‐) was determined for each sample. An Instrument Calibration Standard was generated on each day data acquisition occurred. These samples contained a high prevalence of mutant‐mimic cells and provided a means to define the location of GPI anchor‐deficient erythrocytes .The incidence of MN‐RET, MN‐NCE, and RET are expressed as frequency percent. The formulas used to calculate RETr et al.  and the CD24‐ and RETCD24‐ frequencies relative to concurrent vehicle control mice, Dunnett's multiple comparison t‐tests were performed using JMP software's one‐way ANOVA platform . With the exception of the %RET endpoint, each test was performed at the 5% level using a one‐tailed test to identify significant increases relative to vehicle control. In the case of %RET, the tests were two‐tailed in order to determine whether a significant treatment‐related increase or decrease occurred. Also, note that as similar frequencies were observed for vehicle control mice across every endpoint and both time points, we pooled these data to achieve a larger negative control group size.To evaluate the effect that PCH treatment may have had on %MN‐RET, %MN‐NCE, %RET, and RBCP > 0.05; JMP's ANOVA platform). The following transformations were applied to fulfill this requirement: %MN‐RET and %MN‐NCE values were cube root transformed; and RBCCD24‐, RETCD24‐, and lacZ mutation frequencies were log10 transformed.Prior to performing the parametric tests described above, Levene's tests were used to verify the equality of variances in the samples . This was done for both RBCCD24‐vs. lacZ mutant frequencies, and RETCD24‐vs. lacZ mutant frequencies.Pearson correlation coefficients were calculated for Pig‐a, and lacZ mutations in the hematopoietic system of MutaMouse males at different time points after cessation of a 28‐day exposure to PCH. No significant reduction in body weight was observed at the end of the 4 weeks of exposure, or at the later time point (data not shown).We evaluated the induction of MN, P < 0.05), even at the low and middle dose levels that were not observed to appreciably affect erythropoiesis , respectively. These effects were sustained at 28 + 70d, with fold increases of 1.6‐, 2.5‐, and 5.0‐ at the low, medium, and high dose  particularly in those tissues that are prone to develop tumors following PCH exposure . In our experiments, we demonstrated that a strong mutagenic response in the bone marrow is occurring at much lower doses, as even at the lowest PCH dose studied  resulted in significant induction of bone marrow lacZ and blood Pig‐a mutation. These results show that PCH elicits a robust mutagenic response in the bone marrow even at doses that do not produce cytotoxicity. While Phonethepswath et al.  between lacZ mutant frequencies in bone marrow and Pig‐a mutant RET and RBC at the early time point . At the later time point , the correlation between the two assays was still very strong (R2 = 0.996) when comparing lacZ mutant frequencies with Pig‐a mutant RET. The correlation was slightly lower between mutant lacZ bone marrow cells and Pig‐a mutant RBC (R2 = 0.902), a result that reinforces expert recommendations to study both RET and RBC cohorts for Pig‐a mutation  can be verified, this approach represents an efficient and cost‐effective means of obtaining valuable safety data that includes mode of action information that has not traditionally been collected due to technical and cost considerations.In summary, our data agree with previous studies that found PCH exerts potent clastogenic activity. Furthermore, detection of its mutagenic potential is also readily observed when more careful analysis, particularly in terms of dosing protocol and harvest times, are followed. The advantage of combining the lacZ analyses, and prepared coded blood samples for shipment to Litron. C.M. and S.D.D. performed statistical analyses, and all of the authors contributed to data interpretation and writing the manuscript.F.M., C.Y., S.D. and C.M. designed these studies. F.M. and C.Y. secured funding for the study. C.M. executed the In Vivo MicroFlow®); Litron hold patents for scoring GPI anchor‐deficient erythrocytes and sells kits based on this technology (In Vivo MutaFlow®).S.D.D is an employee of Litron Laboratories. Litron holds patents covering flow cytometric methods for scoring micronucleated erythrocytes and sells kits based on this technology (LacZ mutant frequencies (MFs) in the bone marrow of MutaMouse males, 3 and 70 days after the end of a 28‐day exposure to procarbazine.Supplemental TABLE 1 Click here for additional data file.


The development of social behavior could be affected by stressful parenting. The mineralocorticoid receptor, one of the two main receptors for the stress hormone cortisol, plays a vital role in adequate responses to stress. Therefore, the effects of stressful parenting on social development  may be moderated by functional genetic variation in mineralocorticoid receptor haplotypes . A group of 343 adolescents  was followed from the age of 13 until 24 years. Growth curve analyses showed lower levels of prosocial behaviors and a slower increase in empathic concern and perspective taking in adolescents who reported more stressful parenting. In contrast, relatively higher levels of prosocial behavior, empathic concern and perspective taking were present in combination with stress resilient mineralocorticoid receptor haplotypes. Despite sex differences in social development with earlier social development for girls, no consistent sex differences were found with regard to mineralocorticoid receptor haplotypes. The current study showed that genetic variation in mineralocorticoid receptor impacts the social development during adolescence and young adulthood. Adolescents increasingly become better in perspective taking  differentially affect MR activity and expression and thereby the functionality, as they affect the maximal transactivation and protein expression . Attrition rates were low, with 72.3% of the adolescents participating at all waves. Little’s (2 (χ2/df) of 1.04, indicating no systematic differences between participants with complete data and participants with partially missing data. For the growth curve analysis Mplus version 8 with Full Information Maximum Likelihood was used to handle missing data (Muthén and Muthén Participants were 343 adolescents (55.7% boys) from the center and west of The Netherlands with a mean age of 13 years (SD = .4) at Wave 1. They all attended the first grade of secondary school at the first wave of data collection in 2006. The adolescents were followed longitudinally until age 24 as part of the longitudinal community study RADAR-Young (Research on Adolescent Development And Relationships). Of the 522 adolescents participating in this study, 417 (80%) volunteered to take part in an intensive lab study during which saliva was collected for genotyping. An additional 74 adolescents were removed due to genotyping exclusion criteria, most of them (54 adolescents) as they were from another ethnic background, according to their genes. Therefore, 343 adolescents were successfully genotyped around age 17 of whom 7.1% were from low SES. All participants were Dutch, except from two coming originally from England. Adolescents from the genetic sample did not differ from adolescents from the total sample on sex, age, parental psychological control, childhood trauma, prosocial behavior, empathic concern, or perspective taking , and biannually for the final 3 waves. During the home visits, adolescents completed questionnaires. For the 9Prosocial behavior was measured with the Prosocial Behavior scale, a 10-item subscale of the Dutch version of the Self-report of Aggression and Social Behavior Measure , using the HardyWeinberg package in R (Graffelman p = 0.45), rs5522 was not in HWE (p = 0.003). Subsequently, SNPHAP  and all 2-way and 3-way interaction terms were included as independent variables to investigate the direct and moderating role of MR. Six different growth curve models were estimated in which all growth factors (intercept and piecewise slopes) were predicted at the same time, with either parental psychological control or childhood trauma as stress variable and separate models for each indicator of social behavior: prosocial behavior, empathic concern, and perspective taking.r = .46, p < .001), whereas the number of MR CA haplotypes was not related to the level of parental psychological control , or childhood trauma .Table r = .09 to r = .48. Boys and girls did not differ on the reported level of parental psychological control  = 2.45, p = .118, r = .08) or childhood trauma  = .06, p = .800, r = .01). Moreover, the number of MR CA haplotypes was not different for boys and girls  = .57, p = .450, r = .04).Table 2(1.54) = 38.01, p < .001 for prosocial behavior; ∆χ2(1.18) = 45.85, p < .001 for empathic concern; ∆χ2(1.20) = 50.67, p < .001 for perspective taking), and that the model fit of the cubic model was better than the quadratic model and linear model for all three measures  = 22.67, p < .001 for quadratic, ∆χ2(1.40) = 62.72, p < .001 for linear; empathic concern: ∆χ2(1.18) = 53.38, p < .001 for quadratic, ∆χ2(1.18) = 99.24, p < .001 for linear; perspective taking: ∆χ2(1.02) = 81.71, p < .001 for quadratic, ∆χ2(1.10) = 131.02, p < .001 for linear). In the transformation of these cubic models to piecewise models, for all three models the knots were identified at Wave 4 (age 16) and Wave 7 , indicating that the effects of the predictors on the different latent factors can be reliably estimated.The model comparisons of the growth curves with two, three, and four latent factors revealed that model fit of the quadratic model was better than the linear model . This suggests that during this period, empathic concern increased more in boys with more MR CA haplotypes than in boys with fewer MR CA haplotypes, while the opposite pattern was seen in girls.Results of the model with childhood trauma (see Table p = .070) in combination with a marginally significant interaction effect on the slope between age 20 and 24 for psychological control x MR (p = .070) and for sex x psychological control x MR (p = .064). These findings suggest that for adolescent who experienced high levels of psychological control, mainly during late adolescence and early adulthood MR CA had positive effects on their perspective taking development. Besides, in both the model with childhood trauma and psychological control there were significant main effects of sex on the intercept and on the slopes of perspective taking between age 13 and 16  and between age 16 and 20. These results are in line with the sex differences in the growth model without MR and stress as predictors.Results of the model with childhood trauma as stress factor showed a slower increase in perspective taking between age 13 and 16 for adolescents with higher levels of childhood trauma  plays a role in stress responsiveness by balancing glucocorticoid levels in the brain  for indicators of social behavior corresponds with earlier studies in which MR was pharmacologically stimulated and resulted in increased empathic concern  over the course of adolescence for the development of empathic concern and perspective taking, while for prosocial behavior the effects of the MR CA haplotype were already evident at the beginning of adolescence. The period at which MR CA haplotype affected the indicators of social behaviors most, corresponds to those points during adolescence at which these behaviors showed the main development. During these so called ‘developmental switch points’ . This might suggest that parents who have better stress regulation show relatively less stressful parenting towards their child, and at the same time have children with a MR haplotype that makes them better able to regulate the stressful parenting. However, in our study we did not find a relation between MR haplotype and stressful parenting, which makes it unlikely that heritability of MR-genes would have confounded our findings. Moreover, given the hypothesis driven set-up of this study, there was no independent sample taken into account to replicate the findings, while this is currently standard in gene-environment studies. It is of note that one of the SNPs, rs5522, was not in HWE and that we cannot exclude possible genotyping errors. Importantly, however, a previous study showed that approximately 10% of genotype-phenotype associations deviated from HWE (Trikalinos et al. Adolescence is characterized by rapid social development (Tousignant et al.


RAS, AKT1, and PIK3CA mutations), cell‐cycle , and unclassified . These subtypes differed in survival analysis, with good, intermediate, and poor progression‐free survival in the unclassified, cell‐cycle, and RAS/PI3K/AKT subgroups, respectively, among the Guangzhou, Hong Kong, and combined cohorts . We have uncovered genetic subtypes of NPC with distinct mutations and/or copy number changes, reflecting discrete paths of NPC tumorigenesis and providing a roadmap for developing new prognostic biomarkers and targeted therapies.The aim of this study was to use whole‐exome sequencing to derive a molecular classifier for nasopharyngeal carcinoma (NPC) and evaluate its clinical performance. We performed whole‐exome sequencing on 82 primary NPC tumors from Sun Yat‐sen University Cancer Center (Guangzhou cohort) to obtain somatic single‐nucleotide variants, indels, and copy number variants. A novel molecular classifier was then developed and validated in another NPC cohort . Survival analysis was estimated by the Kaplan‐Meier method and compared using the log‐rank test. Cox proportional hazards model was adopted for univariate and multivariate analyses. We identified three prominent NPC genetic subtypes: RAS/PI3K/AKT (based on  Currently, the tumor‐lymph node‐metastasis (TNM) staging system is the key clinical tool for prognostication, risk stratification, and making treatment decisions. Although patients of the same TNM stage receive similar treatments, their clinical outcomes vary greatly. Similarly, a previous study found comparable relative survival rates between undifferentiated and differentiated subtypes according to the World Health Organization histological classification.BRAF V600E and activating KRAS mutations are associated with metastasis, leading to poor survival.Proper classification is essential for physicians to properly assign treatments and evaluate clinical outcomes. In the past 2 decades, researchers have found gene expression profiling is altered between cancer patients and healthy controls.To gain further insight into the genetic heterogeneity of primary NPC and to establish a DNA‐based molecular classifier capable of performing multiple‐gene classification for prognostic and therapeutic stratification, we performed whole‐exome sequencing (WES) on 82 formalin‐fixed paraffin‐embedded NPC tumors as a discovery cohort (Guangzhou NPC Cohort [GZNPC]). The WES data of 99 external NPC cases (Hong Kong NPC Cohort [HKNPC]) were used as an independent validation cohort.22.1Between July 2007 and December 2012, we obtained 82 primary NPC tumor tissues and corresponding blood samples from the Department of Pathology and Biobank at Sun Yat‐sen University Cancer Center . All specimens were independently reviewed by two pathologists to determine World Health Organization histological classification and tumor cellularity. NPC specimens with >50% tumor cellularity were used for sectioning, nucleic acid extraction, and library preparation. Additionally, 99 NPC patients from a Hong Kong study were used as the validation cohort (HKNPC).2.2XT protocol  with minor modifications. Briefly, 2 μg of tumor DNA and 200 ng of control DNA were fragmented by ultrasonication , and fragments were captured using SureSelectXT Human All Exon V5+UTRs 75M . Quantities and sizes of the libraries were determined using a Qubit fluorescence detector  and an Agilent Bioanalyzer 2100, respectively. Finally, WES libraries were hybridized to an Illumina HiSeq PE Cluster Kit and SBS kit v4 for enrichment and were sequenced by 150 paired‐end read lengths on an Illumina Hiseq 1500 sequencing platform including a dual eight‐base index barcode according to the manufacturer's protocols . The WES raw sequence data reported have been deposited in the Genome Sequence Archive, Beijing Institute of Genomics (BIG), Chinese Academy of Sciences,http://bigd.big.ac.cn/gsa/s/29XtNNXW.Details of DNA isolation methods are provided in the online Data 2.3bam files with preprocessing and detection of somatic SNVs and indels (≤50 bp) are described in the online Data P values were generated using the Benjamini–Hochberg method, and q‐values were used to rank significantly altered pathways. The CNVkit (v.0.7.12.dev0) was used for somatic CNV analysis.Analyses of WES data were performed to identify somatic alterations in each tumor, including somatic SNVs, indels, and CNVs. DNA from peripheral blood were used as references to filter germline variants. Procedures for generating 2.4Mutation Annotation Format (MAF) files, including SNVs, indels, and CNVs derived from the 99 HKNPC tumors as an independent validation cohort2.5P value less than 0.05.The median follow‐up for GZNPC (n = 82) for overall survival (OS) and progression‐free survival (PFS) was 48 and 31 months (range: 7‐94 and 1‐63 months), respectively. Overall, 36 of 82 (43.9%) patients progressed, and 12 (14.6%) died. Survival analysis was conducted with the Kaplan–Meier method. OS and PFS probabilities were analyzed by either the log‐rank test or Cox proportional regression hazards models. All statistical analyses were performed using Stata 14.0  and GraphPad Prism 5 . Comparisons of data between the enrolled groups were performed with the Wilcoxon rank‐sum test unless otherwise specified. The R package was used to perform correlations of genomic status and clinical features such as age, sex, and clinical stage. The Database for Annotation, Visualization and Integrated Discovery (DAVID) v6.8 was used for the genes with cellular functions and pathways analysis.33.1P = 0.0071, Figure To comprehensively profile somatic mutations, 82 NPC tumors and corresponding germline DNA were sequenced. Consequently, 10980 nonsilent somatic mutations in 6193 genes were discovered, including nonsynonymous SNVs, indels, stop gains/losses, and splicing mutations Figure . We thenTP53, KRAS, NRAS, AKT1, BAP1, and PIK3CA. Apart from these known cancer‐related genes, there were several new and important mutations that might affect NPC etiology and tumorigenesis  with a ParsSNP score >0.1 in 15 NPC patients. The functional role of this mutation in NPC will require further study. The U2AF1 mutation  that was discovered in one case was previously reported to be a somatic mutation in colorectal cancer.IDH1 mutation , which is rare in head and neck cancers but frequently occurs in gliomaIDH1 is associated with insensitivity to histone deacetylase inhibitors, irrespective of the specific mutation.We then applied ParsSNP to the GZNPC dataset of 10986 mutations. To narrow the focus, we only considered mutations with ParsSNP scores ≥0.07 Table . This prs Figure A. We dids Figure B. Intereetions p.2_226del EGFR, NRAS, MEF2A, HRAS, KRAS, RAC1, P < 0.001, Figure HRAS  was observed in one case. This was confirmed to be only present in metastatic sites of oral carcinoma and sensitive to BEZ‐235  and trametinib (MEK1/2 inhibitor), as reported by Akiyama et al.RAC1 mutation (exon3: R68H) that was identified to be pathogenic in colon cancerA prominently altered pathway in NPC is the MAPK signaling pathway , LTBR , and MYC  were recurrently amplified , CDKN1A (6p21.31), EDN1 (6p24.1), and E2F3 (6p22.3), are associated with cell proliferation  was found in our cohort, consistent with previous fluorescence in situ hybridization findings.FHIT (3p14.1‐p14.3) and other NPC‐related tumor suppressor genesPTPRG and HepaCAM deletions were newly detected in NPC patients . In this cohort, the most frequent deletion occurred in the chr9p21 region, spanning CDKN2A and CDKN2B . Chr13q deletions were frequently found in these 82 NPC patients and had previously been identified as allelic loss in a few studies.Several NPC patients in this cohort had deletions in tumor suppressor genes. A recurrent loss of 3.3RAS, AKT1 and PIK3CA mutations, (b) a cell‐cycle subgroup  with high rates of CDKN2A/CDKN2B deletions and CDKN1B and CCND1 amplifications, and (c) an unclassified subgroup  with dominant mutations in epigenetic regulators and the Notch signaling pathway. In the unclassified subgroup, apart from previously reported mutations in epigenetic regulators in multiple cancers, including KMT2C, KMT2D, KMT2B, PRDM2, NCOR2, KAT6B, and EP300, in this cohort, we also found new recurrent mutations in epigenetic regulators, including CREBBP and PRDM16  and unclassified  subgroups were primarily enriched in nonkeratinizing and undifferentiated carcinomas Figure A. We est4Nasopharyngeal carcinoma is a highly heterogeneous malignancy with various outcomes even among patients with the same clinical stages and/or histopathological classifications. This study proposed three novel NPC subcategories based on gene sets with somatic SNVs, indels, and CNVs: (a) an unclassified subgroup, (b) a cell‐cycle subgroup, and (c) a RAS/PI3K/AKT subgroup, revealing that different mutagenic processes are operative through NPC development.PIK3CA mutations.KRAS‐mutant nonsmall cell lung cancer and colorectal cancer.Abnormalities in the RAS/PI3K/AKT and cell cycle pathways result in dysregulated kinase activity and malignant transformation. Recent studies have shown good responses to a selective pan‐AKT inhibitor in phase I/II open‐label study in advanced solid malignancies, including breast and gynecologic cancers, with CCND1 and CDK4/6) suggest the potential of therapeutic inhibition of cyclin‐dependent kinases. Several studies have shown that cell lines with elevated CCND1 and decreased CDKN2A (p16) expression are the most sensitive to CDK4/6 inhibitors.CCND1 amplification and/or CDKN2A (p16) loss. We observed that the majority of NPC patients harbored loss of CDKN2A/2B and/or CCND1 amplification, suggesting this subset of NPC patients could benefit from CDK4/6 inhibitors.“Copy‐number‐driven” findings have been described in ovarian, breast, and lung cancer, and frequently recurrent amplifications and deletions of oncogenes and tumor suppressor genes, respectively, were observed in NPC. Frequent amplifications of cell cycle genes (CREBBP and PRDM2, have been separately identified as epigenetic regulators that could be targets in juvenile myelomonocytic leukemiaEpigenetic regulators are frequently mutated in cancers, including NPC.Previous studies have reported that aberrant activation of the Notch signaling pathway can be detected in the majority of NPC samples and that inhibition of Notch signaling pathway enhances sensitivity to cisplatin/radiotherapy in EBV‐positive NPC patients and cell lines.Tumor mutation burden is an emerging biomarker to predict sensitivity to immune checkpoint inhibitors and has been demonstrated to be associated with response to anti‐PD‐1/PD‐L1 immunotherapy.This study provided the descripted genomic alterations in NPC patients in Guangzhou; further evaluated the clinical applications of the molecular classifier that derived from the high‐throughput tumor sequencing. The newly found genes mutations and CNVs required deeper investigation and additional systematic studies to fully assess the clinical cancer genomics long‐term effects on patients' outcome. The continue studies include a more detailed, longitudinal follow‐up. Additionally, tumor profiling data sharing within those incorporate laboratories and institutions engaged is essential to fully functionalize the potential across multiple centers in Guangzhou, to deeper mining their existing data sets.It is important to note that the sample size of this study was relatively small, limiting the resolution power. Ideally, larger cohorts can be assembled to validate the findings of this study and make this classifier more detailed. Furthermore, prospective trials should be designed to determine whether the subgroups specified herein predict activity of corresponding targeted therapies.In conclusion, we proposed a novel classifier based on somatic SNVs, indels, and CNVs in NPC patients that showed prognostic value. Importantly, our findings provide a clinical classification system that can be therapeutically exploited. Each NPC patient subgroup has distinct features that may be associated with sensitivities to targeted agents; thus, specific treatments for each subgroup may improve clinical outcomes.The authors declare that they have no competing interests.JYS and YXZ designed the study and interpreted data. HYW and FL wrote the manuscript and interpreted data. XYL, XHY, YMG, HYW, and NL analyzed WES data. HYW collected samples and conducted WES. JXB interpreted data. All authors read and approved the final manuscript. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file.


Few studies have investigated the effect of dexmedetomidine on postoperative nausea and vomiting (PONV) in patients underwent gynecological laparoscopic surgery. We investigated if adding dexmedetomidine to a morphine-based patient-controlled analgesia (PCA) could decrease the incidence of PONV in this high-risk patient population.In this prospective, randomized, double-blind and placebo-controlled study, 122 patients underwent gynecological laparoscopic surgery were assigned into two groups. Patients in the dexmedetomidine group (Group Dex) received a loading dose of dexmedetomidine 0.4 μg/kg before the end of surgery, followed by morphine 0.5 mg/ml plus dexmedetomidine 1 μg/ml for postoperative i.v. PCA. Patients in the control group (Group Ctrl) received normal saline before the end of surgery, followed by morphine 0.5 mg/ml alone for postoperative i.v. PCA. PCA pump was programmed as followed: bolus dose 2 ml, lockout interval 8 min and background infusion at a rate of 1 ml/h. The primary outcome was the incidence of nausea and vomiting within the first postoperative 24 h.P = 0.204), PONV score, time to first onset of PONV, or the need for rescue antiemetics within the first postoperative 24 h between the two groups, the incidence of nausea and total PONV during the first 2 h period was significantly lower in the Group Dex than in the Group Ctrl . More patients in Group Dex were over sedated or had bradycardia during the PACU compared with Group Ctrl .Although there were no significant differences in regard to the total incidence of PONV (41.0% vs 52.5%, Our protocol in which dexmedetomidine was administered postoperatively – after a loading dose – to intravenous PCA morphine in patients undergoing gynecological laparoscopic surgery, had only early antiemetic effects, while no clinically meaningful antiemetic effect could be evidenced within the first 24 h after surgery.Chictr.org.cn: ChiCTR1800017172. Date registered: 07/16/2018.Current control trial registered at  Postoperative nausea and vomiting (PONV) is an unpleasant experience and distressing adverse events after general anesthesia, especially in the first 24 h postoperatively .PatientsDexmedetomidine is a highly selective α2-adrenoreceptor agonist which has sedative, anxiolytic, analgesic, sympatholytic properties and minimal depression of respiratory function. Due to benefits such as maintaining haemodynamic stability, reducing opioid consumption and improving the quality of recovery, it has been widely used in clinical anesthesia, postoperative analgesia and sedation in the intensive care unit . Two metIn our previous study, we demonstrated that intraoperative supplemental use of dexmedetomidine resulted in a lower incidence of nausea during the first 2 h postoperatively for patients undergoing gynecological laparoscopic surgery . IntraopA recent study found that adding dexmedetomidine to a fentanyl-based PCA reduced the frequency and severity of postoperative nausea during the time interval 1to 3 h postoperatively in patients underwent lumbar spinal surgery .Thus, in this prospective, randomized, double-blind study, we aimed to evaluate the efficacy of adjunctive dexmedetomidine to morphine-based analgesia for PONV prophylaxis in women undergoin gelective gynecological laparoscopic surgery. Our primary hypothesis was that adding dexmedetomidine to a morphine-based PCA would reduce PONV in this patient population in comparison to only morphine-based PCA.Chictr.org.cn, Number ChiCTR1800017172, on July 162,018, http://www.chictr.org.cn/usercenter.aspx. Ethical approval for this study was provided by the Ethics Committee of Peking University First Hospital, Peking, China  on 25 July 2018. Written informed content was obtained from all patients before enrollment.This prospective,randomized, double-blind clinical trial was performed between August 2018 to December 2018 at Peking University First Hospital. The trial was registered at − 2, (5) known sick sinus syndrome, severe bradycardia (heart rate < 50 beats per minute), or severe atrioventricular block without pacemaker before surgery, (6) pre-existing of severe hepatic disease (Child-Pugh class C), (7) pre-existing of chronic renal failure , (8) Neo-adjuvant chemoradiotherapy before surgery, (9) alcoholism or drug abuse, (10) any regimen of antiemetic, glucocorticoids or psychotropic drugs which are known to have an influence on the occurrence of PONV within 24 h before surgery.We used the methodology previously described by our recent study .Particip− 1 with or without dexmedetomidine 1 μg ml− 1. Study drugs were prepared according to the randomization results by a study coordinator. Anesthesiologist and the investigator responsible for the study outcomes assesssment were blinded.Random numbers were generated by computer software in a 1:1 ratio. Patients were randomized to receive morphine 0.5 mg ml− 1 dexmedetomidine was given by intravenous infusion 0.5 h before the end of surgery. PCA was begun with 0.5 mg ml− 1 morphine plus 1 μg ml− 1 dexmedetomidine in 100 ml normal saline. While for patients in the control group (Group Ctrl), normal saline was given 0.5 h before the end of surgery, and PCA was begun with 0.5 mg ml− 1 morphine in 100 ml normal saline. For all patients, PCA was programmed to deliver a 2 ml bolus on-demand with a lockout time of 8 min and a background infusion at a rate of 1 ml h− 1.For patients in the dexmedetomidine group (Group Dex), an initial loading dose of 0.4 μg kgThe investigator assessing patients outcomes was blinded to group assignment and blinding was maintained throughout the study period.No pre-medication was administered before induction. Routine monitoring included non-invasive blood pressure, pulse oximetry, electocadiogram, Bispectral index and end-tidal carbon dioxide partial pressure were applied intraoperatively.− 1 midazolam, 2 mg kg− 1 propofol, and target controlled infusion of remifentanil with an effect-site concentration of 3 ng ml− 1. Rocuronium was administered to facilitate laryngeal mask airway insertion. Total intravenous anesthesia was provided with propofol and remifentanil. Bispectral index was maintained between 40 and 60 during surgery and blood pressure was adjusted within ±20% from baseline. Mechanical ventilation was maintained with a mixture of oxygen and air (FiO2 0.5) and an end-tidal carbon dioxide partial pressure was adjusted between 35 and 55 mmHg intraoperatively. Lactated Ringer’s solution was infused at a rate of 6 ml kg− 1 h− 1 throughout the surgery.All patients received dexamethasone 5 mg before induction. General anesthesia was induced intravenously with 0.03 mg kg− 1 and parecoxib sodium 40 mg were administered 0.5 h before the end of surgery. Residual neuromuscular block was reversed with neostigmine (0.04 mg kg− 1) and atropine (0.02 mg kg− 1) at the end of the surgery.Morphine 0.1 mg kgUpon completion of surgery, laryngeal mask airway was removed and the patient was transferred to the post-anesthesia care unit (PACU) for 1 hour monitoring. The patient-controlled analgesia pump was started and continued until 24 h after surgery.Data were collected by research personnel who were blinded to the randomization and not involved in the clinical care. The 24 h observation period started at the time of removal of the laryngeal mask airway. The researcher assessed the patients at 2, 6 and 24 h postoperatively. Baseline characteristics of patientssuch as previous history of PONV, chronic smoking, primary risk score for PONV, co-existing systemic diseases and concurrent medication were recorded. Intra-operative parameters including duration of anesthesia and surgery, doses of anesthetics and analgesics, and total fluid administered were collected. Postoperative data including presence and severity of nausea and vomiting, visual analogue scale (VAS) pain scores, the cumulative dose of PCA morphine, requirement for rescue antiemetics, vital signs, sedation scores, and any adverse events were documented.The primary outcome was the incidence of PONV over the first 24 h postoperative hours. Patients who experienced at least one episode of nausea, vomiting or retching or any combination of these during the first 24 h after surgery were considered to have PONV. Patients were asked to rate their degree of nausea using a four-point scale  , 15. PosThe secondary outcomes included the VAS scores at 2, 6 and 24 h after surgery, the total 24 h morphine consumption, and the occurrence of adverse events during PACU stay. Pain intensity was assessed at PACU, 2 h, 6 h and 24 h postoperatively using an 11-point VAS on which 0 indicated no pain and 10 indicated the worst pain imaginable. In the PACU, supplemental morphine bolus of 2 mg i.v. was administered for moderate pain (VAS ≥4). Sedation levels were assessed using the Ramsay sedation scale . Over sedation was defined as a sedation score ≥ 4 .AgitatioStudy sample size was calculated according to our previous studies , 8. In oχ2 test or the Fisher’s exact test as appropriate. Continuous data are expressed as means (standard deviation [SD]) or medians (interquartile range [IQR]) and were analyzed with the unpaired Student’s t-test or Mann–Whitney U test as appropriate. A two-sided P value less than 0.05 was considered statistically significant. Statistical analysis was performed using the SPSS 22.0 software .Categorical data are expressed as number (percentage) and were analysed using the Between August 2018 and December 2018, a total of 128 patients were enrolled and six patients were excluded from the analysis. As a result, 122 patients completed the study: 61 in each group, a flowchart is shown in Fig. P = 0.204)  and 32(52.5%), P = 0.031). We did not find any differences in the incidence of nausea, vomiting and total PONV during the 2-6 h and 6-24 h, PONV score, time to first PONV and the requirement of rescue antiemetics between two groups  and 15(24.6%), P = 0.009), but the cumulative consumption of morphine for the total 24 h after surgery was not significantly different between the groups. The percentage of over sedation and bradycardia during the PACU stay was significantly higher in the Group Dex than in the Group Ctrl . There were no differences between the two groups regarding VAS score at everytime point, the incidence of shivering, agitation and requiring rescue analgesic in the PACU  mg and 14.3 (2.1) mg respectively in this minimally invasive surgery. In Lin and colleagues’ study , they alIn our previous research about this PONV susceptible patient population, we found that intraoperative use of dexmedetomidine reduced the incidence of early nausea but not vomiting within 24 h after gynecological laparoscopic surgery . While iSong and colleagues  investigThe stimulation of nausea and vomiting originates from the inputs of visceral, vestibular and chemoreceptor trigger areas, which are mediated by serotonin, dopamine, histamine and acetylcholine, respectively. Nauseogenic stimulus activates nucleus suchas amugdala, putamen and locus coeruleus, which converted into fear conditioning and emotional triggering. This eventually leads to a strong sensation of nausea . In our Dexmedetomidine may increase the risk of postoperative bradycardia .When dex− 1) was relatively small in PCA. Further dose finding studies of dexmedetomidine are required to confirm the optimal efficacy and safety outcomes for these PONV susceptible patients.There are several limitations of this study. First, in our study PCA was programmed to deliver bolus with a background basal infusion of morphine with or without dexmedetomidine. This continuous infusion dose of morphine might have masked the difference of opioid demands between groups. Second, we only chose one dose and the concentration of dexmedetomidine (1 μg mlIn conclusion, our protocol in which dexmedetomidine was administered postoperatively – after a loading dose – to intravenous PCA morphine in patients undergoing gynecological laparoscopic surgery, had only early antiemetic effects, while no clinically meaningful antiemetic effect could be evidenced within the first 24 h after surgery.


It is important to consider hypoglycemia for glycemic control in elderly patients with type 2 diabetes. Continuous blood glucose monitoring system is an effective method to investigate blood glucose fluctuation. This study examined hypoglycemia frequency using continuous blood glucose monitoring system in older patients with type 2 diabetes.A total of 70 patients with type 2 diabetes aged >65 years, receiving oral treatment only and having a glycated hemoglobin (HbA1c) level of <8% were enrolled. Flash glucose monitoring system was used for the device. Patients were classified into three groups according to the type of medicine administered, in addition to other oral hypoglycemics, and were compared: (i) those taking sulfonylureas (SU); (ii) those taking glinides; and (iii) those who did not take either SU or glinides.There was a significant positive correlation between the coefficient of variation and hypoglycemic frequency in all the patients, and a significant negative correlation between HbA1c and hypoglycemia in those receiving SU. When hypoglycemia was defined as glucose levels <54 mg/dL and <70 mg/dL, the cut‐off HbA1c values for developing hypoglycemia were 6.3% and 6.7%, sensitivity was 75.0% and 76.2%, and specificity was 90.9% and 77.6%, respectively.Geriatr Gerontol Int 2019; 19: 1030–1035.In older patients with type 2 diabetes receiving SU, hypoglycemic frequency increases with decreases in HbA1c level. In particular, in patients with HbA1c levels of <6.3% receiving SU, it is necessary to consider medication modification.  With an increasing older population, Japan has been transitioning into a super‐aging society. As older individuals with diabetes tend to experience cognitive deterioration and physical dysfunction, management and evaluation of their disease is imperative. Individual selection of the optimum treatment while considering cognitive function, activities of daily living, economic situation, psychological condition and so on is necessary for achieving glycemic control. In Japan, new guidelines on the treatment of diabetes in older individuals have been formulated on the basis of the “Glycemic Targets for Elderly Patients with Diabetes.” In this guideline, older adults were classified into three categories according to cognitive function and activities of daily living, while the target glycated hemoglobin HbA1c) was set according to the presence or absence of drugs that might cause severe hypoglycemia .c was setThe present prospective observational study included patients who visited Tokyo Medical University Hospital, Tokyo, Japan, between 1 May 2017 and 31 August 2018. All patients provided written informed consent after information regarding the study procedure and content had been provided. This study was approved by the Ethics Review Committee (No: 2017–055), and was carried out in accordance with the Declaration of Helsinki.Patients were classified into three groups depending on whether they were receiving oral medication (SU or glinides) that was highly likely to cause hypoglycemia among those aged >65 years with type 2 diabetes. In addition to other oral hypoglycemics, group S comprised those taking SU, group G comprised those taking glinides and group N comprised those taking neither SU nor glinides. The selection criteria for patients were as follows: (i) patients with an HbA1c of <8% within the past 3 months; (ii) those who had been receiving oral hypoglycemics for at least 6 months and had not altered their medication within the past 3 months; and (iii) those who agreed to participate in this study. Patients receiving insulin or glucagon‐like peptide‐1 receptor agonists were excluded. Flash glucose monitoring (FGM) was carried out for 14 consecutive days, after which blood glucose fluctuations were analyzed.FreeStyle Libre Pro, an FGM device used for CGM, can measure glucose concentrations in subcutaneous interstitial fluid every minute and record the representative value every 15 min (96 times a day). The main features of this device include: (i) its inexpensiveness; (ii) its long‐term measurement capability (14 days) using one sensor; and (iii) non‐necessity for corrections during self‐monitoring of blood glucose.For each group, the mean blood glucose, standard deviation (SD), coefficient of variation (CV), mean of daily difference in blood glucose (MODD), hypoglycemia frequency, and hyperglycemia frequency were compared and examined. Mean was the mean of recorded blood glucose levels, SD was the SD of daily blood glucose levels, CV was the SD divided by the mean blood glucose levels and MODD was the average difference between blood glucose levels at the same time of 2 days. MODD was calculated for two consecutive days, and their average values were used for analysis. Hypoglycemia and hyperglycemia were defined as blood glucose levels <54 and ≥180 mg/dL, respectively.The sample size was calculated based on studies of CGM including insulin treatment, because there are few similar studies using CGM in people with type 2 diabetes aged >65 years receiving only oral medication.spss Statistics version 24  was used for statistical analysis. The data are presented as mean ± SD or median (25th–75th percentile). Data were analyzed with the Kolmogorov–Smirnov and Shapiro–Wilk tests to determine their distributions. Statistical significance between groups was calculated in normally distributed data using Student's t‐test for independent samples or a one‐way analysis of variance, and in non‐normally distributed data using Kruskal–Wallis, Mann–Whitney U‐test and a one‐way analysis of variance on ranks using Bonferroni corrections for multiple comparisons. In addition, the correlation between HbA1c and hypoglycemic frequency was determined using Spearman's correlation coefficient. The significance level of all statistical tests was set at 5%. To determine the cut‐off value at which HbA1c causes hypoglycemia, a ROC curve was plotted to calculate the sensitivity, specificity and area under the curve.IBM 2. Among them, 30 patients were receiving SU and 10 were receiving glinides. Regarding SU, 25 patients received glimepiride and five received gliclazide at mean doses of 0.73 ± 0.39 and 32 ± 11 mg/day, respectively. Meanwhile, regarding glinides, nine patients received mitiglinide and one received repaglinide at mean doses of 27.8 ± 4.4 and 0.75 mg/day, respectively.Of the 80 patients included in the present study, 10 dropped out. Ultimately, 70 patients with FGM data were analyzed. The baseline patient characteristics at the start of the study and parameters of each patient group are summarized in Table P mg/day = 0.041). Group S had significantly higher SD values than group G (P = 0.005). Groups S and N had significantly higher CV than group G . Group S had significantly higher MODD than group G (P = 0.011). Hypoglycemia was not observed in group G. Hypoglycemia frequency was not significantly different between groups S and N. Hyperglycemia frequency was significantly higher in group S than that in group N . Groups S and N had no correlation between SD/MODD and hypoglycemia frequency . Furthermore, seven patients had hypoglycemia in group N, of whom six (85.7%) were receiving dipeptidyl peptidase‐4 inhibitors and four (57.1%) were receiving biguanide. There were no other medications. The average hypoglycemia frequency in patients receiving dipeptidyl peptidase‐4 inhibitor in group N was 0.30 ± 0.19%, that in patients not receiving dipeptidyl peptidase‐4 inhibitor was 0.31% and there was no significant difference between the two groups. The average hypoglycemia frequency in patients receiving biguanide was 0.29 ± 0.18%, and that in patients not receiving biguanide was 0.31 ± 0.20%; there was no significant difference between the two groups.Overall, nine patients had hypoglycemia in group S, five of whom were treated with glimepiride and four with gliclazide. The average hypoglycemia frequency in patients receiving glimepiride was 0.67 ± 0.81%, and that in patients receiving gliclazide was 1.40% ± 0.65%. There was no significant difference between the two groups (The present study examined whether or not a difference in hypoglycemia frequency was present among older patients with type 2 diabetes receiving only oral hypoglycemics with and without SU and glinides. Our results showed that hypoglycemia frequency during FGM significantly increased as HbA1c decreased in group S. Although there was no significant difference, the frequency of hypoglycemia tended to be especially higher among those receiving SU. A significant correlation was found between CV and hypoglycemia frequency in groups S and N, which indicates that the hypoglycemia frequency is higher as the blood glucose fluctuation width is larger. Additionally, ROC analysis showed that the cut‐off value at which HbA1c causes hypoglycemia in older patients with type 2 diabetes receiving only oral treatment was 6.3% when hypoglycemia was defined as glucose levels <54 mg/dL, and 6.7% when hypoglycemia was defined as glucose levels <70 mg/dL. This value is roughly similar to the HbA1c lower limit indicated in the “Japanese Clinical Practice Guideline for Diabetes 2016,” further confirming the usefulness of the guideline.According to previous reports, studies that analyzed blood glucose variability by self‐monitoring of blood glucose and CGM also point out that CV, SD, daily low blood glucose level and mean blood glucose level are better predictors of hypoglycemia than HbA1cHypoglycemia has been one of the many concerning side‐effects among patients receiving insulin, SU and glinides. Hypoglycemia among older individuals can lead to falls, bone fractures, depression, arrhythmias and reduced quality of life, with severe hypoglycemia being a risk factor for dementia and cognitive decline.SU and glinides promote insulin secretion and exert a hypoglycemic effect through the same mechanism of action. The difference between the two drugs is that glinides have a more rapid effect with a shorter half‐life in some cases. Glinides, therefore, increase insulin secretion earlier and lower postprandial hyperglycemia. Given that its effects also subside more rapidly, fewer cases of prolonged hypoglycemia have been observed with glinides than with SU.In addition, the frequency of hypoglycemia was higher in group N than in group G. In previous studies, it has already been reported that hypoglycemia can occur even if SU or glinides are not administered. In the present study, one cause for the result might be that patients with hypoglycemia in group N had a lower average HbA1c level than other patients. Furthermore, we considered that the low hypoglycemia frequency found in group G is related to the effect of the small sample size or differences in background, such as insulin secretion and complications.Although no significant difference was found, the incidence of night‐time hypoglycemia was higher in group N than in group S, although the reason for this outcome remains unclear. However, the present study was carried out on an outpatient basis without any lifestyle restrictions; therefore, it can be presumed that there is an influence of environment wherein food amount, meal time and exercise amount are not constant.There were some limitations to this research plan. The main limitation in the present study is that the sample size was relatively small, which might affect the results of the analyses. The study registration period was limited, and the number of patients registered within the period decreased, especially in group G. Additionally, as selection bias, provided that patients who agreed to wear FGM devices had high nutritional guidance, regularly attended diabetes classes and were highly interested in their own blood sugar management, differences in adherence could be present compared with other patients. Furthermore, at the beginning of the study, we did not obtain information about diabetes complications, such as microangiopathy or macrovascular disorders, disease duration, or endogenous insulin secretion; therefore, we could not analyze the effects of these parameters on hypoglycemia. Problems with the FGM equipment itself were also present. Reports have shown several advantages for FGM, which include its non‐requirement of self‐monitoring of blood glucose for blood sugar management, its simplicity and accuracy, improved diabetes control, and discovery of unrecognized hypoglycemia.In conclusion, the present study found a negative correlation between hypoglycemia frequency and HbA1c in older Japanese patients with type 2 diabetes receiving SU, suggesting that hypoglycemia frequency increases as HbA1c decreases. This study also determined that the cut‐off value at which HbA1c causes hypoglycemia was 6.3% when hypoglycemia was defined as glucose levels <54 mg/dL, or 6.7% when hypoglycemia was defined as glucose levels <70 mg/dL. Therefore, especially when receiving SU, once HbA1c values fall to <6.3% or <6.7%, more attention should be given to hypoglycemia, the presence of which might prompt the modification of medication.The authors declare no conflict of interest.


Little is known regarding the dynamic interactions between fathers and mothers in families of children with autism spectrum disorder (ASD) during the parenting process. This study used an actor–partner interdependence mediation (APIMeM) model to investigate the intrapersonal and interpersonal effects of emotion dysregulation and parenting stress on parenting behaviors among 211 pairs  of Chinese parents of children with ASD. The results indicated that for both fathers and mothers, there were significant indirect actor effects of parental emotion dysregulation on parents’ own parenting behaviors through their own parenting stress. However, no significant direct or indirect partner effect was found in the analyses. These findings suggest that the emotional parenting dynamics occurred on the individual rather than the dyadic level in these families. Raising a child with autism spectrum disorder (ASD) can exert tremendous stress on parents  might influence their parenting stress, nor has the research ventured far into more direct links between parenting stress and parenting behaviors in families of children with ASD, especially considering these family processes in a dyadic manner. This lack of literature might be accounted by the common practice in ASD research of avoiding potentially negative depictions of parents. This avoidance may be due to the historically discarded refrigerator mother hypothesis, which blamed parents, especially mothers, as the primary cause of their children’s ASD  and therefore influence an individual’s parenting outcomes  often influence one another’s thoughts, emotions, and behaviors, it is optimal to use an actor–partner interdependence model in the study of dyadic relations  with a clinical record of DSM-IV-TR diagnosis of ASD from qualified psychiatrists. The mean age at ASD diagnosis was 4.97 years (SD = 1.38), and the mean time elapsed since diagnosis was 5.37 years (SD = 2.66). Couples who failed to respond to more than 90% of the questionnaire items and those with children aged outside of this range  were excluded from analysis.A total of 226 families with children attending special education schools from 15 provinces in mainland China participated voluntarily. All the couples were parents  of children aged 7–12 years  with information reported by both the fathers  and mothers . A total of 210 mothers and 204 fathers identified themselves as biological parents. Regarding locations, 37% of the families (N = 77) were from rural areas , and 63% of the families (N = 134) were from urban areas . 56.4% of the families reported a yearly household income lower than 72,000 Chinese yuan ; 19.9% of the families reported a yearly household income of 72,000–120,000 Chinese yuan ; 11.8% of the families reported a yearly household income of 120,000–240,000 Chinese yuan ; and 7.1% reported a yearly household income greater than 240,000 Chinese yuan . According to the 2017 China national family yearly income standards  the child’s gender, age, age when he or she was identified as having ASD, and whether the child with ASD was the only child, (2) the parents’ age, occupation, income, and educational background, and (3) the parents’ satisfaction with their marriage, self-evaluation of their status as parents, and their relationship with the child and the child’s grandparents. Additionally, the parents reported their child’s academic performance and daily living skills on a 4-point Likert scale . The children’s academic performance was included as a control variable because academic achievement is particularly emphasized in mainland China given longstanding cultural values regarding academics (Hesketh and Ding 2005). Therefore, parenting aspects of interest in the current study might be confounded with academic performance.Parental emotion regulation was measured by the DERS. This 36-item self-report scale used a 5-point Likert-type response scale ranging from 1  to 5 , with higher total scores representing greater difficulties with emotion regulation. The DERS provides a comprehensive assessment of parents’ overall emotion regulation difficulties as well as difficulties in six specific dimensions, including accepting emotional responses , impulse control , lack of emotional awareness , lack of emotional clarity , accessing emotion regulation strategies , and engaging in goal-directed behavior when emotionally aroused . The current study only examined parents’ overall emotion regulation difficulties. The Chinese version of the DERS has demonstrated good psychometric properties , difficult child , and dysfunctional parent–child interaction . A 1- to 5-point Likert scale format  was used, with higher scores on the total scale representing a higher degree of parenting stress. The Chinese version of the PSI-SF has demonstrated good reliability and validity . The items ask parents to report their behaviors toward their children and are grouped into two domains: care  and overprotection . Optimal parental bonding behaviors were assessed using the sum of the parental care items and the reverse-scored parental overprotection items . The higher the optimal score, the more likely the parents’ behaviors are to promote bonding with their children and indicate adaptive parenting. The Chinese PBI has demonstrated good reliability in previous studies with families from similar cultural backgrounds , and missing data were handled using the full-information maximum likelihood in Mplus 7.0  in Figs. The descriptive statistics of the study variables for the mothers and fathers are shown in Table The Pearson’s correlations among the study variables and demographic data are shown in Table In addition, several demographic variables were significantly correlated with the study variables. As shown in Table Based on the correlational results, the children’s daily living skills and academic performance were controlled for paternal and maternal parenting stress. Only the child’s status and children’s academic performance were controlled for parental care. The children’s daily living skills, academic performance, household income, and paternal education level were controlled for parental overprotection. The children’s daily living skills, academic performance and paternal educational level were controlled for parental optimal bonding in later analyses.As shown in Table χ2[12] = 46.94, p < .001), the model with parental overprotection as the outcome variable , and the model with parental optimal parenting as an outcome variable . Therefore, the distinguishing APIMeM was estimated in the following analyses  = 2.53, p = .639, CFI = 1.000, TLI = 1.041, RMSEA = .000, SRMR = .010.For the model with parents’ parental care as the outcome variable, children’s daily living skills and academic performance were controlled for paternal and maternal parenting stress, and only child status and academic performance were controlled for parental care, as mentioned above. The model fit the data, β =− .07, SE = .04, p = .058, 95% CI = . No other actor/partner-level indirect effect was found.As shown in Fig. χ2(4) = 4.07, p = .396, CFI = 1.000, TLI = .998, RMSEA = .009, SRMR = .014.For the model with parental overprotection as the outcome variable, the children’s daily living skills and academic performance were controlled for paternal and maternal parenting stress, and the children’s daily living skills, academic performance, household income and paternal educational level were controlled for parental overprotection, as mentioned. The model fit the data, β =.08, SE = .04, p = .024, 95% CI = . In addition, the indirect effect of maternal emotion dysregulation on their own overprotection through maternal parenting stress was marginally significant, β =.08, SE = .04, p = .058, 95% CI = . None of the other actor/partner-level indirect effects was significant.As shown in Fig. χ2(2) = 2.07, p = .356, CFI = 1.000, TLI = .996, RMSEA = .013, SRMR = .014.When optimal parenting was investigated as the outcome variable, the children’s daily living skills and academic performance were controlled for paternal and maternal parenting stress; children’s daily living skills, academic performance, and paternal educational level were controlled for this model based on correlational results. The model showed a good fit, As shown in Fig. β =− .08, SE = .04, p = .043, 95% CI = ; for fathers, β = − .09, SE = .04, p = .030, 95% CI = ) but not through their spouses’ parenting stress.The mediation analyses  to investigate the potential spillover and crossover effects within families of children with ASD. The findings of the current study improve our understanding of how emotional factors contribute to parenting stress and how emotional factors are associated with the behaviors of fathers and mothers when parenting their children with ASD. These results have important implications for potential targeted intervention programs for parents of children with ASD, that the emotion regulation training programs for parents may decrease perceived parenting stress and thus promote more adaptive parenting behaviors toward children with ASD.First, the correlational results suggested nonindependence between fathers and mothers. Specifically, significant correlations were found between fathers and mothers for emotion dysregulation, parenting stress and parenting behaviors . Therefore, it is important to assess fathers’ and mothers’ influences in the same model to understand the potential spillover and crossover effects in the families of children with ASD. In addition, the correlational results suggested that Chinese mothers’ heightened levels of difficulties with emotion regulation were associated with an increase of their own parenting stress but not that of their spouses, while when fathers reported more difficulties with emotion regulation, both parents’ reported higher perceived stress when providing care to their children with ASD. We also found significant correlations between Chinese parenting stress and both parents’ care, overprotection and optimal parenting behaviors. The only exception was the link between maternal stress and paternal care; specifically, mothers’ parenting stress was not significantly associated with their spouses’ care behaviors. These correlational results suggest that fathers and mothers may have differential roles within family systems when co-parenting children with ASD  within the family systems could directly influence those individuals’ relationship with their child . One possible explanation is that unlike in other groups of children , the distinct challenges associated with ASD might lead these Chinese parents to be overly occupied with dealing with their children’s core symptoms and mediating the children’s social interactions  to overcome the issues with social desirability and response bias and create a more comprehensive picture.Second, other covariates, such as child intellectual abilities, should be considered. Unfortunately, we were not able to obtain the children’s IQ information. Although we included child academic performance, which is strongly correlated with intellectual abilities in children with ASD ; however, whether overprotection can always be considered a negative parenting characteristic should be considered with caution. Future studies are strongly encouraged to improve our understanding of this parenting behavior in families of children with ASD. Lastly, although our study was not designed in a cross-cultural manner, this emerging evidence suggests that future studies should include measures of culturally relevant constructs  during their investigations.In summary, our results support the existence of spillover effects (but not crossover effects) in the relationships among parental emotion regulation, parenting stress and parenting behaviors. The present study contributes to the literature in several important ways. First, our study is among the first to investigate the mechanisms of the links between emotion regulation and parenting behaviors by including both parents’ parenting stress as mediators. Second, it examined these relationships using dyadic analysis, enabling an examination of whether potential family processes  exist under stricter control. Third, our findings further indicate the need to provide family-centered support to both mothers and fathers to enhance their roles in parenting children with ASD in China (Hu et al.


An 11‐year‐old female spayed Golden Retriever presented for an incidentally found liver mass. The hepatic mass and intra‐abdominal lymph nodes had a marked heterogeneous T‐cell population and far fewer numbers of small clonal B cells. This T‐cell‐rich small B‐cell lymphoma had a unique histological pattern and indolent clinical course. Five days prior to presentation, she was evaluated at a veterinary clinic for a one‐day history of pollakiuria. At that visit, the patient was mildly painful on abdominal palpation. An abdominal ultrasound revealed a 5.2 × 5.0 cm round hypoechoic mass in the left lateral liver lobe, and a hypoechoic rounded structure possibly associated with the right middle liver lobe. A urinalysis collected by cystocentesis revealed two to three struvite crystals per high powered field and mild proteinuria, with no white blood cells or bacteria visualized. Empirical treatment with amoxicillin led to rapid resolution of her urinary signs. A complete blood count (CBC) and serum biochemistry profile were unremarkable. The patient had a history of bilateral elbow osteoarthritis and cranial cruciate ligament injury in both stifles and was enrolled in an ongoing CSU‐VTH clinical trial using mesenchymal stem cell therapy for dogs with osteoarthritis. Current medications included amoxicillin, and tramadol, amantadine, Metacam, fish oil, Dasuquin, and Cosequin for osteoarthritis.On physical examination at the CSU‐VTH, the patient was bright and alert with a normal appetite and energy level. She was obese with a body condition score of 8/9. She had a weight bearing lameness of her left forelimb, localized to the elbow. No abnormalities were appreciated on abdominal palpation and peripheral lymph nodes palpated normally. An abdominal ultrasound at the CSU‐VTH confirmed the rounded, hypoechoic, heterogeneous, well‐vascularized hepatic mass on the left lateral aspect, measuring 4.5 × 5.7 cm. Thoracic radiographs were unremarkable.3Ultrasound‐guided fine needle aspiration of the hepatic mass was performed using a 22 gauge needle. Cytology revealed large numbers of lymphocytes which were predominantly intermediate‐sized, with smaller numbers of small lymphocytes Figure . IntermeFlow cytometric immunophenotyping was performed on a fine needle aspirate from the hepatic mass Figure A, using One month after detection of the hepatic mass, the patient returned for abdominal exploratory surgery and liver lobectomy. A preoperative abdominal ultrasound found a second discrete mass in the left lateral liver lobe, which was hypoechoic and heterogeneous, measuring 3.1 × 4.9 cm. The previously described hepatic mass was unchanged. A CBC and serum biochemistry profile were unremarkable. The left lateral liver lobe containing the two discrete masses was surgically excised ,which was most likely attributed to inflammation. A low reticulocyte hemoglobin content (CHr)  also supported an inflammatory process.At both 4 months and 1 year following surgical excision of the hepatic masses and lymph nodes, the patient was restaged with abdominal ultrasound, CBC, serum biochemistry profile, and urinalysis, which revealed no recurrence of lymphoma. There were no hepatic masses detected by ultrasound, and the lymph nodes were of normal size and echotexture. She had a grade II (low‐grade) cutaneous mast cell tumor completely excised from her neck 10 months after initial presentation. Twenty months after initial presentation, the patient presented with a four‐day history of epistaxis, and CBC revealed a severe thrombocytopenia  with elevated mean platelet volume  and moderate normocytic, mildly hypochromic nonregenerative anemia . No abnormalities were detected on serum biochemistry profile, and there was a mild hyperlactemia  on the venous blood gas. Thoracic radiographs were unremarkable. Abdominal ultrasound revealed multiple well‐defined, round, hyperechoic, and hypoechoic heterogeneous masses in the liver, measuring up to 2.8 cm in diameter. The hepatic masses were not aspirated due to the severe thrombocytopenia. Cytology from a bone marrow aspirate revealed marked megakaryocytic hyperplasia, most consistent with ongoing loss, consumption, or destruction of platelets, and mild erythroid hyperplasia, possibly an early response to the anemia. Lymphocytes in the bone marrow were small and mature and accounted for 2.2% of total nucleated cells, which is considered normal. A serum ELISA test did not detect antibodies to 5This report describes a case of indolent small B‐cell lymphoma with marked T‐cell infiltrates, forming solitary masses in the liver, and affecting intra‐abdominal lymph nodes. The histological pattern of this tumor does not fit clearly into the WHO classification system,T‐cell‐rich large B‐cell lymphoma (TCRLBL) was considered given the marked T‐cell infiltrate in this case. In TCRLBL, the clonal B‐cell population can account for 10% or less of the total cell population and at least 50% of the total cell population is composed of T cells.Two other B‐cell lymphoma subtypes that can have a rich T‐cell infiltrate in people are extranodal marginal zone lymphoma and follicular lymphoma.Other differentials for mature small B‐cell neoplasms with an abnormal T‐cell component were also considered, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL),Finally, due to the heterogeneous lymphocyte population, autoimmune lymphoproliferative syndrome (ALPS) was also considered. ALPS is a disorder described in people in which lymphocyte homeostasis is disrupted, resulting in nonmalignant lymphoproliferation in the lymph node, liver, and/or spleen, including expansions of CD4−/CD8− T cells.The clonal immunoglobulin gene rearrangement in this case is consistent with B‐cell lymphoma. Pseudoclonal PCR results are possible when a sample contains a minor population of B cells, but the clonal product was reproducible in duplicate reactions, supporting a diagnosis of B‐cell malignancy.This case report describes a small B‐cell lymphoma with a marked T‐cell infiltrate in a dog, with an indolent clinical course, which was apparently cured by surgical excision of the hepatic masses and affected lymph nodes. The anatomic distribution, histological pattern, and clinical course of this case appear unusual for both veterinary and human medicine. Although several lymphoma subtypes were considered for further classification, the histological pattern and clinical features of this case did not appear to fit well with a current subtype. This case also highlights the utility of additional diagnostics, including flow cytometry and PARR, for identifying the reactive and clonal components of a lymphoid neoplasm and obtaining an accurate diagnosis.None declared.EDR: pathologist, collected and analyzed data, performed the literature review, and wrote the manuscript; KLH: pathologist, analyzed data, performed the literature review, and wrote parts of the manuscript; BOB: oncologist, involved in the patient’s care; DMS: pathologist, analyzed data; ACA: performed flow cytometry and clonality testing, analyzed data; PRA: pathologist, involved in data analysis and manuscript preparation. All authors involved in the revision and final approval of the manuscript.