Impact of the point spread function on maximum standardized uptake value measurements in patients with pulmonary cancer

Maximum standardized uptake value (SUVmax) from fluorodeoxyglucose (FDG) positron emission tomography (PET) scans is a semi quantitative measure that is increasingly used in the clinical practice for diagnostic and therapeutic response assessment purposes. Technological advances such as the implementation of the point spread function (PSF) in the reconstruction algorithm have led to higher signal to noise ratio and increased spatial resolution. The impact on SUVmax measurements has not been studied in clinical setting. We studied the impact of PSF on SUVmax in 30 consecutive lung cancer patients. SUVmax values were measured on PET-computed tomography (CT) scans reconstructed iteratively with and without PSF (respectively high-definition [HD] and non-HD). HD SUVmax values were significantly higher than non-HD SUVmax. There was excellent correlation between HD and non-HD values. Details of reconstruction and PSF implementation in particular have important consequences on SUV values. Nuclear Medicine physicians and radiologists should be aware of the reconstruction parameters of PET-CT scans when they report or rely on SUV measurements.

Dynamics of cohesin subunits in grasshopper meiotic divisions

The cohesin complex plays a key role for the maintenance of sister chromatid cohesion and faithful chromosome segregation in both mitosis and meiosis. This complex is formed by two structural maintenance of chromosomes protein family (SMC) subunits and two non-SMC subunits: an α-kleisin subunit SCC1/RAD21/REC8 and an SCC3-like protein. Several studies carried out in different species have revealed that the distribution of the cohesin subunits along the chromosomes during meiotic prophase I is not regular and that some subunits are distinctly incorporated at different cell stages. However, the accurate distribution of the different cohesin subunits in condensed meiotic chromosomes is still controversial. Here, we describe the dynamics of the cohesin subunits SMC1α, SMC3, RAD21 and SA1 during both meiotic divisions in grasshoppers. Although these subunits show a similar patched labelling at the interchromatid domain of metaphase I bivalents, SMCs and non-SMCs subunits do not always colocalise. Indeed, SA1 is the only cohesin subunit accumulated at the centromeric region of all metaphase I chromosomes. Additionally, non-SMC subunits do not appear at the interchromatid domain in either single X or B chromosomes. These data suggest the existence of several cohesin complexes during metaphase I. The cohesin subunits analysed are released from chromosomes at the beginning of anaphase I, with the exception of SA1 which can be detected at the centromeres until telophase II. These observations indicate that the cohesin components may be differentially loaded and released from meiotic chromosomes during the first and second meiotic divisions. The roles of these cohesin complexes for the maintenance of chromosome structure and their involvement in homologous segregation at first meiotic division are proposed and discussed.

Abstract P1-15-01: Patterns of granulocyte colony stimulating factor (G-CSF) use in elderly breast cancer (BC) patients receiving myelosuppressive chemotherapy

Background: Febrile neutropenia (FN) is a common and potentially serious complication of myelosuppressive chemotherapy treatment in cancer patients. Oncology guidelines recommend primary G-CSF prophylaxis (PPG) in patients with a high risk of developing FN, which is risk >20% based on myelotoxicity of the regimen itself or from a combination of the therapy, older age, comorbidities and disease characteristics (Lyman Cancer 2011). Current patterns of G-CSF use and FN occurrence among elderly patients receiving myelosuppressive chemotherapy for BC have not been previously reported. To determine this, we performed a retrospective analysis using a subset of the Medicare 5% database.

Methods: The Medicare 5% claims data set (includes a representative 5% systematic sample of Medicare beneficiaries) was used to identify BC patients age 65+ initiating chemotherapy between 7/1/2003 and 6/30/2009. Chemotherapy courses were identified for each patient; only the first course was used for this analysis. Using the National Comprehensive Cancer Network guidelines on Myeloid Growth Factors (NCCN V1.2012), chemotherapy course regimens were classified as high risk (HR) or intermediate risk (IR) for FN. Duration of first cycle was from date of first chemotherapy claim to the chemotherapy claim at day 21 or later, which defined the first day of the second cycle, etc., to a maximum of 9 cycles. First administration of G-CSF [filgrastim (NEUPOGEN®) or pegfilgrastim (Neulasta®)] was classified as either PPG (within first 5 days of first cycle), secondary prophylaxis (within first 5 days of second or subsequent cycles), or reactive (day 6 or later of first or subsequent cycles). FN assessed during the chemotherapy course was defined as hospitalization with a code for neutropenia in any position.

Results: 885 courses with high FN risk and 1046 with IR FN risk were identified. The HR cohort was younger (71.4 vs 74.5 yrs) and had fewer comorbidities than the IR cohort. Selected aspects of G-CSF use patterns are summarized in the table. Among HR courses, 11.8% had ≥1 FN hospitalization and 2.1% had 2+; among IR courses 5.6% had ≥1 and 0.4% had 2+.

Conclusion: NCCN recommends PPG be used with HR regimens and older age (notably >65 yr), an important risk factor for developing severe neutropenic complications. Despite this, PPG was used for elderly breast cancer patients in only 52% of chemotherapy courses with high risk of FN and in 10% of IR courses. More than 10% of patients with a HR regimen had an FN hospitalization. Careful attention to FN risk factors, including regimen and patient age, is needed when planning treatment strategy.

Nonalcoholic fatty liver disease: the hepatic metabolic syndrome

PURPOSE

To examine a case of nonalcoholic fatty liver disease (NAFLD) and review the incidence, pathophysiology, appropriate diagnostic procedures and imaging, clinical considerations, and treatment options.

DATA SOURCES

Findings from the history, physical examination, and diagnostic testing of a 39-year-old man with elevated liver enzymes presenting to the hepatology clinic; a search of evidence-based literature in the PubMed and CINAHL database with the terms "fatty liver,""nonalcoholic fatty liver disease," and "nonalcoholic steatohepatitis."

CONCLUSIONS

NAFLD is the deposition of fat in the liver that can progress to nonalcoholic steatohepatitis, resulting in fibrosis and cirrhosis. The exact pathophysiology is unknown, but risk factors can include those criteria associated with metabolic syndrome. NAFLD is a diagnosis of exclusion and can lead to serious health consequences if it is not identified and interventions are not implemented promptly. Treatment options remain limited but currently focus on weight loss, exercise, and diet.

IMPLICATION FOR PRACTICE

The clinician must include the spectrum of NAFLD in the differential diagnosis for any patient with elevated liver enzymes. The key actions for diagnosing NAFLD are identifying risk factors and ordering appropriate testing for confirmation. These considerations will lead to early diagnosis and implementation of treatment interventions.

Distribution of repetitive DNAs and the hybrid origin of the red vizcacha rat (Octodontidae)

Great genome size (GS) variations described in desert-specialist octodontid rodents include diploid species ( Octomys mimax and Octodontomys gliroides ) and putative tetraploid species ( Tympanoctomys barrerae and Pipanacoctomys aureus ). Because of its high DNA content, elevated chromosome number, and gigas effect, the genome of T. barrerae is claimed to have resulted from tetraploidy. Alternatively, the origin of its GS has been attributed to the accumulation of repetitive sequences. To better characterize the extent and origin of these repetitive DNA, self-genomic in situ hybridization (self-GISH), whole-comparative genomic hybridization (W-CGH), and conventional GISH were conducted in mitotic and meiotic chromosomes. Self-GISH on T. barrerae mitotic plates together with comparative self-GISH (using its closest relatives) discriminate a pericentromeric and a telomeric DNA fraction. As most of the repetitive sequences are pericentromeric, it seems that the large GS of T. barrerae is not due to highly repeated sequences accumulated along chromosomes arms. W-CGH using red-labeled P. aureus DNA and green-labeled O. mimax DNA simultaneously on chromosomes of T. barrerae revealed a yellow-orange fluorescence over a repetitive fraction of the karyotype. However, distinctive red-only fluorescent signals were also detected at some centromeres and telomeres, indicating closer homology with the DNA sequences of P. aureus. Conventional GISH using an excess of blocking DNA from either P. aureus or O. mimax labeled only a fraction of the T. barrerae genome, indicating its double genome composition. These data point to a hybrid nature of the T. barrerae karyotype, suggesting a hybridization event in the origin of this species.

Apathy and Its Nonpharmacological Treatment in Dementia

Apathy is the most common behavioral symptom in Alzheimer’s disease. Apathy has been defined as a state characterized by simultaneous diminution in the overt behavioral, cognitive, and emotional concomitants of goal-directed behavior. In that sense, apathy refers to impairments in motor, cognitive, and emotional functions. To date, there is little empirical foundation for how these three levels interact in patients suffering from apathy. We describe here neurobiological foundations as well as clinical correlations between the severity of apathy and impairments in motor, cognitive, and emotional functions. Furthermore, we present a literature review of the nonpharmacological treatment options of apathy in dementia. We suggest that focusing on the motor, cognitive, and emotional aspects of apathy may help to implement successful treatment strategies. Multimodal, individualized approaches, including the use of physical activation and biography-based information to motivate dementia patients, seem to be of high relevance.

Chronic norovirus infection in pediatric hematopoietic stem cell transplant recipients: a cause of prolonged intestinal failure requiring intensive nutritional support

Norovirus infection is a major cause of nonbacterial gastroenteritis. In immunocompetent individuals the illness caused by norovirus is mostly self limiting. Excretion of norovirus has been reported to be prolonged in the immunocompromised including adult HSCT recipients. We report a case series of 13 children who received HSCT and required prolonged parenteral and enteral nutrition due to severe gut dysfunction accompanying protracted norovirus excretion that was monitored by RT-PCR. The median duration of viral excretion was 150 days (range 60-380) and the eventual clearance of norovirus from feces was closely associated with donor T cell recovery in the peripheral blood. There was no disease manifestation beyond the gut but the severity and length of norovirus associated illness suggests that HSCT should be delayed where possible in patients excreting the virus prior to conditioning therapy.

Caries control in health service practice

It is suggested that it makes sense for dentists providing care for individual patients to take account of caries risk (as assessed by presentation of active, non-cavitated lesions) when deciding how to allocate time and effort of themselves and their staff. However, there is a question as to how realistic it is to ask the dental team to provide a full diagnostic assessment and all the preventive treatment required for a patient for the payment provided by 1 UDA. It is to be hoped that one or more of the Steele pilots will come up with a practical solution for controlling caries in NHS practice.

Incomplete synapsis and chiasma localization: the chicken or the egg?

In the present study, and as a sincere tribute from the Cytogenetics teams from Madrid to Professor Máximo Drets on his 80th birthday, we have analyzed and compared 3 different grasshopper species with different synaptic patterns, a standard pattern, a second pattern with synapsis restricted to the proximal regions, and a third pattern with synapsis restricted to the distal regions. In the 3 species we have thoroughly analyzed the relationships among cohesin axis morphogenesis, formation of double strand breaks (DSBs) and recombination initiation. Our results demonstrate that in every case recombination initiation precedes synapsis, and that there is a direct relationship between the absence of meiotic recombination and the existence of particular unsynapsed chromosomal regions during prophase I. Based on our results we propose and discuss the mechanisms underlying the existence of incomplete synapsis and the localization of chiasma in wild species.

A comparison of treatment outcomes for moxifloxacin versus ofloxacin/metronidazole for first-line treatment of uncomplicated non-gonococcal pelvic inflammatory disease

Large randomized controlled trials support the efficacy of moxifloxacin for the treatment of uncomplicated pelvic inflammatory disease (PID). This study compares the clinical outcome and tolerability of treatment with moxifloxacin 400 mg once a day or ofloxacin 400 mg plus metronidazole 400 mg both twice daily in patients diagnosed with PID. A retrospective case-notes review was performed on patients diagnosed clinically with PID before and after local guidelines were changed to recommend moxifloxacin as first-line treatment for uncomplicated PID. Before the guidelines changed, 114/134 (85%) patients received the recommended first-line therapy versus 206/257 (80%) after the change, P = 0.3. There was no difference in the clinical outcomes between the two groups; significant improvement/resolved 77% versus 70%; marginal improvement 3% versus 11%; no change/worse 20% versus 18%, P = 0.14. Moxifloxacin is confirmed to be an effective alternative to ofloxacin/metronidazole for the treatment of PID in a large urban genitourinary clinic setting.

A graphic framework for teaching critical appraisal of randomised controlled trials

Students of evidence-based medicine often try unsuccessfully to commit to memory a particular critical appraisal framework (often lengthy), or they have to depend on pocket cards and are lost without them. We have described a pedagogic aid: a flow diagram of an RCT, which has been developed over years of teaching residents. This diagram focuses on the steps in an RCT, and by drawing arrows, it highlights the biases possible at each step. This diagram serves as a framework on which the list of critical appraisal questions can be hung and is easy to remember.

Inverted meiosis: the true bugs as a model to study

Most of the meiotic literature is based on species with monocentric chromosomes, however meiosis in protoctist, plant and animal species with holocentric chromosomes is less characterized. In some cases, an inverted meiotic sequence is claimed to occur, in which segregation of homologs is postponed until the second meiotic division. Additionally, other features also deserve interest, namely: (i) the different behavior of sex chromosomes if compared to that of the autosomes; (ii) the absence of a canonical kinetochore structure; (iii) the restriction of the kinetic activity to the chromosomal ends; (iv) the variations in the orientation of bivalents at the division plate, and (v) the possible occurrence of chiasma terminalization. Here we summarize the current knowledge on these topics in the meiosis of Hemiptera (Heteroptera) and present novel results that illustrate some of the special features mentioned above. We also point out the necessity of reviewing the term 'inverted meiosis' and propose some future prospects to study this peculiar meiosis.

Costs of treatment of Swiss patients with HIV on antiretroviral therapy in hospital-based and general practice-based care: a prospective cohort study

Some ambulant people with HIV are cared for primarily by their general practitioner and some in an outpatient clinic. Costs and patterns of care in these settings were studied in 65 such patients based in Zürich, from a limited societal perspective (excluding patient costs) based on medical resource use. Antiretroviral therapy (ART), other medications and patient variables were collected prospectively, and non-medication resources (professional time and investigations) and treatment history data were collected from medical records and by record linkage to the Swiss HIV Cohort Study database. Cost differences between the settings were estimated using multiple regression, controlling for differences in case-mix. ART comprised 80% of the total cost, non-medication costs 15% and non-ART medications 5%. Total costs were higher in the outpatient clinic (estimated additional cost after controlling for case-mix = 3489 Swiss Francs per year at 1999 prices, 95% confidence interval 742 to 6236, p=0.017). The difference was accounted for by higher ART costs in the outpatient clinic, not through a tendency to use more expensive drugs or higher doses but rather through the use of more drugs concurrently. Differences in ART prescribing patterns between the doctors in the outpatient clinic and the general practitioners were considerable and appear worthy of further investigation.

Genomewide linkage scan for obsessive-compulsive disorder: evidence for susceptibility loci on chromosomes 3q, 7p, 1q, 15q, and 6q

Obsessive-compulsive disorder (OCD) is the tenth most disabling medical condition worldwide. Twin and family studies implicate a genetic etiology for this disorder, although specific genes have yet to be identified. Here, we present the first large-scale model-free linkage analysis of both extended and nuclear families using both 'broad' (definite and probable diagnoses) and 'narrow' (definite only) definitions of OCD. We conducted a genome-scan analysis of 219 families collected as part of the OCD Collaborative Genetics Study. Suggestive linkage signals were revealed by multipoint analysis on chromosomes 3q27-28 (P=0.0003), 6q (P=0.003), 7p (P=0.001), 1q (P=0.003), and 15q (P=0.006). Using the 'broad' OCD definition, we observed the strongest evidence for linkage on chromosome 3q27-28. The maximum overall Kong and Cox LODall score (2.67) occurred at D3S1262 and D3S2398, and simulation based P-values for these two signals were 0.0003 and 0.0004, respectively, although for both signals, the simulation-based genome-wide significance levels were 0.055. Covariate-linkage analyses implicated a possible role of gene(s) on chromosome 1 in increasing the risk for an earlier onset form of OCD. We are currently pursuing fine mapping in the five regions giving suggestive signals, with a particular focus on 3q27-28. Given probable etiologic heterogeneity in OCD, mapping gene(s) involved in the disorder may be enhanced by replication studies, large-scale family-based linkage studies, and the application of novel statistical methods.

X and B chromosomes display similar meiotic characteristics in male grasshoppers

We have analysed the chromosome organisation and the location and temporal appearance of different proteins in X and B chromosomes in the grasshopper Eyprepocnemis plorans throughout the first meiotic prophase. We have used adult males that carry a B chromosome collected in natural Spanish populations. The scaffold organisation has been analysed by means of silver stained chromatid cores. In addition, we have detected by immunolabelling the presence of phosphoepitopes, the ensemble of cohesin axes, the location of histone gamma-H2AX, and recombinase Rad51. Our observations demonstrate that X and B chromosomes share similarities in chromatin organisation and in the expression of the tested proteins, which strongly differ from those of the autosomes. These results could be interpreted either as a support to the hypothesis that the Bs analysed here originated from the X chromosome, and/or that their chromatin composition and precocious condensation could determine their meiotic behaviour.