New-onset afebrile seizures in infants: role of neuroimaging

OBJECTIVE

To investigate the presenting characteristics of new-onset afebrile seizures in infants (age 1-24 months) and the yield of neuroimaging.

METHODS

Prospective data were obtained from a standardized evaluation and management plan mandated by a critical care pathway. A total of 317 infants presented with new-onset afebrile seizures between 2001 and 2007. EEG was performed on 90.3%, head CT was obtained on 94%, and MRI was obtained on 57.4%.

RESULTS

We found half of the infants had partial features to their seizures, yet evidence for primary generalized seizures was rare. The majority had more than 1 seizure upon presentation. Seizures in this age group tended to be brief, with 44% lasting less than 1 minute. EEG abnormalities were found in half. One-third of CTs were abnormal, with 9% of all CTs requiring acute medical management. Over half of MRIs were abnormal, with cerebral dysgenesis being the most common abnormality (p < 0.05). One-third of normal CTs had a subsequent abnormal MRI-only 1 resulted in altered medical management.

CONCLUSIONS

Infantile seizures are usually brief, but commonly recurrent, and strong consideration should be made for inpatient observation. Acute imaging with CT can alter management in a small but important number of infants. Due to the superior yield, strong consideration for MRI should be given for all infants, as primary generalized seizures are rare, and there is a high rate of cerebral dysgenesis.

Prospective study of new-onset seizures presenting as status epilepticus in childhood

OBJECTIVE

To characterize children with new-onset seizures presenting as status epilepticus at a tertiary care children's hospital.

METHODS

Prospectively collected data were reviewed from a database derived from a mandated critical care pathway. A total of 1,382 patients presented with new-onset seizures between 2001 and 2007.

RESULTS

A total of 144 patients presented in status epilepticus. The average age was 3.4 years. The majority of seizures (72%) lasted between 21 and 60 minutes. The majority of patients had no significant past medical history; one-fourth had a family history of epilepsy. Five (4%) patients with EEGs had electrographic seizures during the study, captured only with prolonged monitoring. The most common etiology was febrile convulsion, followed by cryptogenic. The most common acute symptomatic cause was CNS infection; the most common remote symptomatic cause was cerebral dysgenesis. Combined CT and MRI provided a diagnosis in 30%. CT was helpful in identifying acute vascular lesions and acute edema, whereas MRI was superior in identifying subtle abnormalities and remote symptomatic etiologies such as dysplasia and mesial temporal sclerosis.

CONCLUSIONS

Children who present in status epilepticus that is not a prolonged febrile convulsion should undergo neuroimaging in the initial evaluation. For any child who presents in status epilepticus and has not yet returned to baseline, the possibility of nonconvulsive status epilepticus should be considered. Although CT is often more widely accepted, especially in the urgent setting, strong consideration for MRI should be given when available, due to the superior yield.

Efficacy and Safety Data of Taiwan Breast Cancer Patients Enrolled in the Lapatinib Expanded Access Program (LEAP)

Background: LEAP is a single-arm, open-label, expanded access study of lapatinib in combination with capecitabine in 42 countries. The primary objective of LEAP was to provide patients with pre-approval access to lapatinib based on positive clinical data from a pivotal Phase III trial.Methods: Enrolled patients had locally advanced or HER2 positive metastatic breast cancer (MBC), progressive disease (PD, by modified RECIST) following prior therapy with anthracycline-, taxane-, and trastuzumab-containing regimens, including some patients previously treated with capecitabine, and were ineligible for ongoing lapatinib trials. Patients received lapatinib (1250 mg/day) and capecitabine (2000 mg/m2/day, days 1-14, every 21 days). Baseline characteristics, including prior therapies, were collected. Response was assessed using RECIST criteria.Results: From Mar 2007 to Sep 2008, 238 patients were enrolled at 10 centers in Taiwan. At the 11 June 2009 data cut-off, data were collected and analyzed for 166 patients. Patients received an average of 5 prior cytotoxic therapies, including trastuzumab and capecitabine.Of 166 patients, 3 (2%) had complete response, 49 (30%) had partial response, 62 (37%) had stable disease, 42 (25%) had PD, and 10 (6%) were unknown. The median duration of treatment was 5.5 mo and the median time to progression was 5.3 mo, respectively. Per protocol, only serious adverse events (SAEs) were reported. Thirty SAEs were reported for 238 patients; 6 (20%) were considered treatment-related by investigators, were not fatal, and included stomatitis (2), vomiting (2), diarrhea (1), and cellulitis (1). As of 11 June 2009, 66 (40%) patients were alive and 149 withdrew from LEAP, the majority (85%) because of progressive disease.Conclusion: Although data were collected retrospectively via case report forms, these results reflect the real world setting in Taiwan for the treatment of erbB2+ MBC patients and confirms that lapatinib, in combination with capecitabine, demonstrates efficacy in this patient population including those who are heavily pretreated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5093.

GCIP Is a Tumor Suppressor in Breast Cancer

Background: GCIP protein is a HLH-leucine zipper (HLH-LZ) proteins without basic DNA-binding region, which was identified to be a cyclin D1-binding protein and also was recognized as a human homologue of MAID protein (HHM). Recently, GCIP was found to function as a tumor suppressor in liver and colon tumorigenesis. In this study, we examined in vitro the functional role of GCIP in various breast cancer cell lines.Material and Methods: GCIP-directed siRNA construct was prepared and stable downregulation of GCIP in epithelial-like and nonaggressive/differentiated breast cancer cell line, MCF-7, were selected. In addition, two aggressive/ invasive breast cancer cells (MDA-MB231 and MDA-MB435s) that exhibit low levels of endogenous GCIP expression were transfected with p3x-GCIP-flag, respectively and stable GCIP-re-expressing transfectants were selected. The phalloidin staining cell morphology and functional assays with these stable GCIP downregulating or GCIP re-expressing were performed to characterize the biological effects of GCIP.Results: Stable MCF-7 cells with down-regulated GCIP expression acquired a mesenchymal-like shape and exhibited increased colony formation, migration and invasion capabilities. Furthermore, this was found to be associated with the loss of membrane E-cadherin and increased expression of the mescenchymal marker vimentin. In addition, both the stable MDA-MB231 and MDA-MB435s with GCIP-re-expression acquired an epithelial-like shape and exhibited decreased colony formation, migration and invasion capabilities.Conclusion: our previous study found that decreased expression of GCIP in breast carcinomas compared with normal ductal epithelium (P &lt; 0.001). In this study, we present evidence that GCIP inactivation contributes to the enhanced migratory and invasive capacity of MCF-7 and that GCIP re-expression inhibits a wild range of cellular functions related to the malignant properties of MDA-MB231 and MDA-MB435s, confirming that GCIP is a tumor suppressor in breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3158.

Load transfer characteristics of unilateral distal extension removable partial dentures with polyacetal resin supporting components

BACKGROUND

To photoelastically examine load transfer by unilateral distal extension removable partial dentures with supporting and retentive components made of the lower stiffness polyacetal resins.

METHODS

A mandibular photoelastic model, with edentulous space distal to the right second premolar and missing the left first molar, was constructed to determine the load transmission characteristics of a unilateral distal extension base removable partial denture. Individual simulants were used for tooth structure, periodontal ligament, and alveolar bone. Three designs were fabricated: a major connector and clasps made from polyacetal resin, a metal framework as the major connector with polyacetal resin clasp and denture base, and a traditional metal framework I-bar removable partial denture. Simulated posterior bilateral and unilateral occlusal loads were applied to the removable partial dentures.

RESULTS

Under bilateral and left side unilateral loading, the highest stress was observed adjacent to the left side posterior teeth with the polyacetal removable partial denture. The lowest stress was seen with the traditional metal framework. Unilateral loads on the right edentulous region produced similar distributed stress under the denture base with all three designs but a somewhat higher intensity with the polyacetal framework.

CONCLUSIONS

The polyacetal resin removable partial denture concentrated the highest stresses to the abutment and the bone. The traditional metal framework I-bar removable partial denture most equitably distributed force. The hybrid design that combined a metal framework and polyacetal clasp and denture base may be a viable alternative when aesthetics are of primary concern.

An exploration of Pap smear history and behavior of patients with newly diagnosed cervical cancer in Taiwan

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Background: The national health insurance policy has provided a yearly Pap smear for women >= 30 years old since 1994 in Taiwan, yet the coverage rate is still unsatisfactory. The purpose of this study is (1) to investigate the Pap smear screening history of women newly diagnosed with cervical cancer and (2) to examine factors that influence participation in Pap smear screening program in these women. Methods: Patients primarily treated for cervical cancer at Chang Gung Memorial Hospital between November 2006 and June 2007 were enrolled into this prospective study. Questionnaires included (1) socio-demographic data, and (2) knowledge on Pap smear and cervical cancer. Results: Two hundred sixty-nine patients were eligible for analysis. The median age was 51 years old (range, 25–83). Of the 269 patients, 147 (54.6%) had never had a Pap smear before diagnosis, and 35 (13.0%) did not know about Pap smear. Socio-demographic factors that significantly influenced number of previous Pap smear screening (0 vs >=1) were education level, income less than 600 U.S. dollars per month, menopaused, multiple sexual partners, and increase number of sexual partners of the male consort. Of the 147 never received Pap women, the most common reasons were thought that Pap smear screening was not necessary (46.3%), embarrassment (42.0%), busy (43.5%), and worry about the screening findings (20.4%). Of the 122 patients who have received Pap smear, 56.6% patients thought that Pap smear screening was necessary, 35.2% patients worried about the disease, 24.6% were alert on their check-ups, and 20.5% did the screening for the convenience to nearby clinics. Conclusions: Public health organizations in Taiwan should put more efforts to provide women in low education level, low income and multiple sexual partners with information on Pap smear.

No significant financial relationships to disclose.

Anticancer oncolytic activity of respiratory syncytial virus

Oncolytic virotherapy is an emerging bio-therapeutic platform for cancer treatment, which is based on selective infection/killing of cancer cells by viruses. Herein we identify the human respiratory syncytial virus (RSV) as an oncolytic virus. Using prostate cancer models, we show dramatic enhancement of RSV infectivity in vitro in the androgen-independent, highly metastatic PC-3 human prostate cancer cells compared to the non-tumorigenic RWPE-1 human prostate cells. The oncolytic efficiency of RSV was established in vivo using human prostate tumor xenografts in nude mice. Intra-tumoral and intra-peritoneal injections of RSV led to a significant regression of prostate tumors. Furthermore, enhanced viral burden in PC-3 cells led to selective destruction of PC-3 cancer cells in vitro and in xenograft tumors in vivo due to apoptosis triggered by the down-regulation of NF-κB activity (and the resulting loss of anti-apoptotic function of NF-κB) in RSV-infected PC-3 cells. The intrinsic (mitochondrial) pathway constitutes the major apoptotic pathway; however, the death-receptor-dependent extrinsic pathway, mediated by the paracrine/autocrine action of tumor necrosis factor-α produced from infected cells, also partly contributed to apoptosis. Thus, the oncolytic property of RSV can potentially be exploited to develop targeted therapeutics for the clinical management of prostate tumors.

Force spectroscopy of hepatocytic extracellular matrix components

We present atomic force microscopy and force spectroscopy data of live hepatocytes (HEPG2/C3A liver cell line) grown in Eagle's Minimum Essential Medium, a complex solution of salts and amino acids commonly used for cell culture. Contact-mode imaging and force spectroscopy of this system allowed correlation of cell morphology and extracellular matrix (ECM) properties with substrate properties. Force spectroscopy analysis of cellular "footprints" indicated that the cells secrete large polymers (e.g., 3.5mum contour length and estimated MW 1000kDa) onto their substrate surface. Although definitive identification of the polymers has not yet been achieved, fluorescent-labeled antibody staining has specified the presence of ECM proteins such as collagen and laminin in the cellular footprints. The stretched polymers appear to be much larger than single molecules of known ECM components, such as collagen and heparan sulfate proteoglycan, thus suggesting that the cells create larger entangled, macromolecular structures from smaller components. There is strong evidence which suggests that the composition of the ECM is greatly influenced by the hydrophobicity of the substrate surface, with preferential production and/or adsorption of larger macromolecules on hydrophobic surfaces.

Unexpected power-law stress relaxation of entangled ring polymers

After many years of intense research, most aspects of the motion of entangled polymers have been understood. Long linear and branched polymers have a characteristic entanglement plateau and their stress relaxes by chain reptation or branch retraction, respectively. In both mechanisms, the presence of chain ends is essential. But how do entangled polymers without ends relax their stress? Using properly purified high-molar-mass ring polymers, we demonstrate that these materials exhibit self-similar dynamics, yielding a power-law stress relaxation. However, trace amounts of linear chains at a concentration almost two decades below their overlap cause an enhanced mechanical response. An entanglement plateau is recovered at higher concentrations of linear chains. These results constitute an important step towards solving an outstanding problem of polymer science and are useful for manipulating properties of materials ranging from DNA to polycarbonate. They also provide possible directions for tuning the rheology of entangled polymers.

124 A THREE-DIMENSIONAL IN VITRO IMPLANTATION MODEL WITH NONHUMAN PRIMATE EMBRYOS AND EXTRACELLULAR MATRIX UNDER VARIOUS CULTURE CONDITIONS

The need for blastocyst culture and post-implantation embryo research has emerged in the past few years. Our objective is to evaluate a novel in vitro model to study implantation and placenta formation in vitro with rhesus macaque embryos under various culture conditions. A novel nonhuman primate in vitro 3-D system can provide cues for implantation and interaction with the extracellular environment not available in 2-D planar models. Optimization of such a model can be tested with diverse culture environments. We developed and evaluated an in vitro 3-D implantation model utilizing IVF-derived, blastocyst-stage rhesus macaque embryos embedded in 3-D Matrigel droplets cultured with different feeder cells and media. Signs of implantation including enlargement of the embryo mass, invasion and proliferation of trophectoderm cell layers, cystic formation, and cellular outgrowths derived from the embryo were initiated within the first week post-embedding. Trophoblast structures with protrusion and branches growing from the surface of embryo implants were observed. Immunohistochemical staining for chorionic gonadotropin (CG) combined with immunoassays for CG and progesterone indicated differentiation of trophoblastic cell lineages. In addition, we found morphological factors, such as proliferation of embryonic and extraembryonic structures, as well as initiation of protrusions interacting with the extracellular matrix, to predict successful establishment of prolonged embryo development. We further evaluated effects of different types of feeder cells and media combinations, and found that a combination of BRL, Ishikawa cells, and human uterine fibroblasts, provided an optimized culture microenvironment to promote peri-implantation embryo development and hormone secretion including CG and progesterone. In conclusion, we have established a 3-D in vitro system modeling implantation initiation, and demonstrating the capability of the embryo to interact with the extracellular matrix. Further studies will facilitate the methodology of peri-implantation blastocyst culture and accelerate our understanding of nonhuman primate embryo development, with potential for insights into early pregnancy loss and related pathologies. The present study and future directions may be extended to provide retrospective views on blastocyst selection for embryo transfer in assisted reproductive technology. This study was funded by NIH grants RR000167, RR21876, and HD053926.

Inhibition of HIV-1 replication with designed miRNAs expressed from RNA polymerase II promoters

Small interfering RNA (siRNA) mediates sequence-specific RNA cleavage and represents a potential approach to treat the infection of human immunodeficiency virus (HIV). Expression of a single siRNA species frequently led to the emergence of HIV escape variants. Thus, multiple siRNAs targeted to different regions in the HIV-1 genome may be required. However, overexpression of different anti-HIV siRNA genes from multiple pol III promoters can induce cell toxicity, thus may not be a viable option in the setting of human gene therapy trials. In the current study, we evaluated the strategy of using pol II promoters to drive the expression of siRNAs against HIV-1. We replaced the stem sequence in the stem-loop structure of the well-characterized miR-30a with siRNA sequences and showed that designed microRNA (miRNA) could be expressed from pol II promoters. We demonstrated efficient inhibition of HIV-1 replication with such designed miRNA, but the efficacy was directly correlated with the expression level. Both the vector copy number and the promoter strength directly affected the ability of the siRNA to inhibit HIV-1 replication. We also showed that a combination of pol II and pol III promoters to express two different siRNAs increased the efficacy against HIV-1 replication without comprising cell viability.

Decompression surgery and intraoperative radiation therapy (IORT) for metastatic spinal tumors

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Background: Metastatic spinal tumors often cause spinal cord compression and jeopardize the quality of life of the patients much. To decrease the local symptomatic recurrence rate, we have been adding IORT to decompression surgery. Methods: For those patients whose life expectancy was more than 6 months were eligible for this treatment. Posterior decompression by laminectomy of the involved vertebrae was performed. Following decompression, the patient was irradiated the lesions intraoperatively with electrons generated from Microtron by shielding the spinal cord with lead plate. The central aspects of the vertebrae were irradiated by scattered electrons detouring from the edge of the lead shield up to 40% of the administered dose. Following IORT, posterior instrumentation was performed. External beam radiotherapy might be added pre- and/or postoperatively when considered necessary. Results: 108 patients were treated between 1992–2005. There were 58 males and 50 females. Age ranged from 26 to 85 with a median of 62.5. By primary sites, 26 breast, 24 kidney, 18 colorectum, 17 lung 12 prostate and 11 thyroid cases were included. Irradiated spines were cervical in 6, thoracic in 76, and lumbar/sacral in 27. Overall median follow-up period was 12.7months. Median IORT dose was 20Gy (range 15–26Gy) and median electron energy was 16MeV (range 11–22MeV). There were 37 cases with preoperative RT and 41 cases with postoperative RT. Overall median survival time was 14.5months (breast 15.3, kidney 22.6, colorectum 5.7, lung 6.2, prostate 31.6, thyroid 60.6months). Neurological response rate was 73.1%. Ambulatory rates were 87.0% for success and 80.6% for rescue by Klimo's definition(2005). There were only 8 symptomatic relapses (7%). As for major complications, only one myelopathy has been observed. Conclusions: Decompression surgery and IORT for metastatic spinal tumors with impending spinal cord compression was a promising treatment modality with excellent local control and neurological response rate and with minimal toxicity especially for those patients with long-term prognosis.

No significant financial relationships to disclose.

The telemedicine and teleconsultation system application in clinical medicine

Telemedicine and teleconsultation are the application and development of the telecommunication networks. Health experts can solve problems by using the electronic and communication technologies without distance limitation. In this study, we try to develop the telemedicine and teleconsultation system between local site and consulting expert site. Two applications of this system in clinical medicine are discussed. The system at each site has a workstation including a cable modem or ADSL connection, a monitor, a web camera, speakers, a microphone for communication, and NetMeeting application software. The first application in this study is to develop a school-based intervention program by using this system for high-risk school-age children in one of the earthquake-struck areas. The preliminary result of this study is that the telemedicine and teleconsultation system is more effective than traditional consultation and supervision. Moreover, we can apply this system in training local volunteers, educators, and welfare workers. Meanwhile, we can save lots of cost and time since we don't need to travel between the local site and the expert site. In the end of this study, the second application of this system in SARS case treatment was also discussed.

Biofilm formation by and antifungal susceptibility of Candida isolates from urine

Biofilm formation (BF) in the setting of candiduria has not been well studied. We determined BF and MIC to antifungals in Candida spp. isolates grown from urine samples of patients and performed a retrospective chart review to examine the correlation with risk factors. A total of 67 Candida spp. isolates were grown from urine samples from 55 patients. The species distribution was C. albicans (54%), C. glabrata (36%), and C. tropicalis (10%). BF varied greatly among individual Candida isolates but was stable in sequential isolates during chronic infection. BF also depended on the growth medium and especially in C. albicans was significantly enhanced in artificial urine (AU) compared to RPMI medium. In nine of the C. albicans strains BF was 4- to 10-fold higher in AU, whereas in three of the C. albicans strains and two of the C. glabrata strains higher BF was measured in RPMI medium than in AU. Determination of the MICs showed that planktonic cells of all strains were susceptible to amphotericin B (AMB) and caspofungin (CASPO) and that three of the C. glabrata strains and two of the C. albicans strains were resistant to fluconazole (FLU). In contrast, all biofilm-associated adherent cells were resistant to CASPO and FLU. The biofilms of 14 strains (28%) were sensitive to AMB (MIC(50) of <1 mug/ml). Correlation between degree of BF and MIC of AMB was not seen in RPMI grown biofilms but was present when grown in AU. A retrospective chart review demonstrated no correlation of known risk factors of candiduria with BF in AU or RPMI. We conclude that BF is a stable characteristic of Candida strains that varies greatly among clinical strains and is dependent on the growth medium. Resistance to AMB is associated with higher BF in AU, which may represent the more physiologic medium to test BF. Future studies should address whether in vitro BF can predict treatment failure in vivo.