Antiviral activity of shikonin ester derivative PMM-034 against enterovirus 71 in vitro

Human enterovirus 71 (EV71) is the major causative agent of hand, foot, and mouth disease (HFMD), particularly in infants and children below 4 years of age. Shikonin is a bioactive compound with anti-inflammatory, antiviral, and antibacterial activities derived from the roots of the Chinese medicinal herb Lithospermum erythrorhizon. This study aimed to examine the antiviral activity of PMM-034, a shikonin ester derivative, against EV71 in rhabdomyosarcoma (RD) cells. Cytotoxicity of PMM-034 on RD cells was determined using WST-1 assay. Dose- and time-dependent effects of PMM-034 on EV71 replication in RD cells were determined using plaque reduction assay. mRNA expression levels of EV71/VP1 and pro-inflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) were determined by real-time RT-PCR, and EV71/VP1 and phospho-p65 protein expressions were determined by western blot analysis. PMM-034 exhibited only weak cytotoxicity against RD cells. However, PMM-034 exhibited significant antiviral activity against EV71 in RD cells with 50% inhibitory concentration of 2.31 μg/mL. The VP1 mRNA and protein levels were significantly reduced in cells treated with PMM-034. Furthermore, relative mRNA expression levels of IL-1β, IL-6, IL-8, and TNF-α significantly decreased in the cells treated with PMM-034, while the phospho-p65 protein expression was also significantly lower in the treated cells. These results indicated that PMM-034 suppressed the expressions of pro-inflammatory cytokines in RD cells, exhibiting antiviral activity against EV71, as evidenced by the reduced VP1 mRNA and protein levels in PMM-034-treated cells. Thus, PMM-034 is a promising candidate for further development as an EV71 inhibitor.

Coalescence of Macroscopic Flux Ropes at the Subsolar Magnetopause: Magnetospheric Multiscale Observations

We report unambiguous in situ observation of the coalescence of macroscopic flux ropes by the magnetospheric multiscale (MMS) mission. Two coalescing flux ropes with sizes of ∼1  R_{E} were identified at the subsolar magnetopause by the occurrence of an asymmetric quadrupolar signature in the normal component of the magnetic field measured by the MMS spacecraft. An electron diffusion region (EDR) with a width of four local electron inertial lengths was embedded within the merging current sheet. The EDR was characterized by an intense parallel electric field, significant energy dissipation, and suprathermal electrons. Although the electrons were organized by a large guide field, the small observed electron pressure nongyrotropy may be sufficient to support a significant fraction of the parallel electric field within the EDR. Since the flux ropes are observed in the exhaust region, we suggest that secondary EDRs are formed further downstream of the primary reconnection line between the magnetosheath and magnetospheric fields.

Abstract P4-01-02: Diagnostic value of breast specific gamma imaging for breast cancer

In this study, 422 female patients who presented with clinical indications and underwent ultrasound (US), mammography (MMG), and breast specific gamma imaging (BSGI) before surgery during the period from July 2013 to June 2015 were retrospectively reviewed. Twenty-two of the patients had no pathological report available and were excluded. These patients who presented with clinical indications underwent both ultrasound and mammographic examinations initially. If both US and MMG were positive, the patient was recommended for a BSGI examination for pre-surgical planning. A BSGI examination was also recommended for patients with negative or indeterminate mammographic findings.

The diagnostic results were compared with histological examination and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each modality were determined. Combinations of either two or three of the diagnostic results were also reviewed and the corresponding diagnostic indicators calculated. For these combinations, a positive indication on one of the two (or three) diagnostic tests were interpreted as a positive result. The sensitivity of US, MMG, BSGI, the combination of US and MMG, US and BSGI, MMG and BSGI, and the combination of all three together in the diagnosis of breast carcinoma were determined for the 400 patients included in the study and are listed in Table 1, column 1. The specificity, PPV, and NPV for each of these modalities and combinations of modalities were also determined and are shown Table 1, column 2-4.

Table 1 SensitivitySpecificityPPVNPVUS61.389.289.759.8MMG67.594.394.765.2BSGI83.187.991.477.1US & MMG86.884.789.880.6US & BSGI91.382.889.186.1MMG & BSGI92.283.489.585.6US & MMG & BSGI97.579.087.895.4

The population was comprised of 243 patients with 245 malignant lesions and 157 patients with 189 benign lesions. The malignant lesions were primarily infiltrating ductal carcinoma (76%) and ductal carcinoma in situ (14%), with the remaining lesions (10%) being invasive lobular carcinoma, Paget's disease and mixed carcinomas. The benign lesions were primarily fibroadenoma (39%), adenosis (40%) and papilloma (10%), with the remaining lesions (11%) being duct ectasia, inflammation or phyllodes. There were 79 false negative cases by MMG, however, when ultrasound and BSGI were combined, 73 out of 79 were accurately identified. Additionally, there were nine, seventeen and eighteen Ductal Carcinoma in situ (DCIS) misdiagnosed by BSGI, MMG, and ultrasound respectively, but through joint imaging of BSGI+MMG+US; 33 out of 35 were accurately judged.

BSGI is a useful adjunct modality for the diagnosis of breast carcinoma. It is also extremely useful for diagnosis of non-calcified DCIS, and circumvents limitations of mammography in identifying malignant lesion in dense breast. Moreover, it is helpful for improving the diagnosis accuracy of breast carcinoma when BSGI is combined together with MMG and US.

Citation Format: Mallik DK, Zhang H, Shi H, Tan H, Shen L, Hu G, Hu H, Sejdinaj F, Pang Y, Zhu W, Yang W. Diagnostic value of breast specific gamma imaging for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-01-02.

The affordability for patients of a new universal MDR-TB coverage model in China

BACKGROUND

China has piloted a new model of universal coverage for multidrug-resistant tuberculosis (MDR-TB), designed to rationalize hospital use of drugs and tests and move away from fee-for-service payment towards a standard package with financial protection against catastrophic health costs.

OBJECTIVE

To evaluate the affordability to patients of this new model.

DESIGN

This was an observational study of 243 MDR-TB cases eligible for enrolment on treatment under the project. We assessed the affordability of the project from the perspective of households, with a focus on catastrophic costs.

RESULTS

Of the 243 eligible cases, 172 (71%) were enrolled on treatment; of the 71 cases not enrolled, 26 (37%) cited economic reasons. The 73 surveyed cases paid an average of RMB 5977 (US$920) out-of-pocket in search costs incurred outside the pilot model. Within the pilot, they paid another RMB 2094 (US$322) in medical fees and RMB 5230 (US$805) in direct non-medical costs. Despite 90% reimbursement of medical fees, 78% of households experienced catastrophic costs, including indirect costs.

CONCLUSION

The objectives of the pilot model are aligned with health reform in China and universal health coverage globally. Enrollment would almost certainly be higher with 100% reimbursement of medical fees, but patient enablers will be required to truly eliminate catastrophic costs.

Market assessment of tuberculosis diagnostics in China in 2012

OBJECTIVE

To assess the 2012 served available market for tuberculosis (TB) diagnostics in China in the sector served by the China Centre for Disease Control and Prevention (CDC) and the hospital sector in China, including both designated TB hospitals and general hospitals.

DESIGN

Test volumes and unit costs were assessed for tuberculin skin tests, interferon-gamma release assays (IGRAs), smear microscopy, serology, cultures, speciation tests, nucleic-acid amplification tests (NAATs), drug susceptibility tests and adenosine-deaminase tests (ADA). Data were obtained from electronic databases (CDC sector) and through surveys (hospital sector), and were estimated for the two sectors and for the country as a whole. Test costs were estimated by staff at China CDC, and using published literature.

RESULTS

In 2012, the China CDC and hospital sectors performed a total of 44 million TB diagnostic tests at an overall value of US$294 million. Tests used by the CDC sector were smear microscopy, solid and liquid culture and DST, while the hospital sector also used IGRAs, NAATs, ADA and serology. The hospital sector accounted for 76% of the overall test volume and 94% of the market value.

CONCLUSION

China has a very large TB diagnostic market that encompasses a wide range of diagnostic tests, with the majority being performed in Chinese hospitals.

Mesenchymal Cell Community Effect in Whole Tooth Bioengineering

In vitro expanded cell populations can contribute to bioengineered tooth formation but only as cells that respond to tooth-inductive signals. Since the success of whole tooth bioengineering is predicated on the availability of large numbers of cells, in vitro cell expansion of tooth-inducing cell populations is an essential requirement for further development of this approach. We set out to investigate if the failure of cultured mesenchyme cells to form bioengineered teeth might be rescued by the presence of uncultured cells. To test this, we deployed a cell-mixing approach to evaluate the contributions of cell populations to bioengineered tooth formation. Using genetically labeled cells, we are able to identify the formation of tooth pulp cells and odontoblasts in bioengineered teeth. We show that although cultured embryonic dental mesenchyme cells are unable to induce tooth formation, they can contribute to tooth induction and formation if combined with noncultured cells. Moreover, we show that teeth can form from cell mixtures that include embryonic cells and populations of postnatal dental pulp cells; however, these cells are unable to contribute to the formation of pulp cells or odontoblasts, and at ratios of 1:1, they inhibit tooth formation. These results indicate that although in vitro cell expansion of embryonic tooth mesenchymal cells renders them unable to induce tooth formation, they do not lose their ability to contribute to tooth formation and differentiate into odontoblasts. Postnatal pulp cells, however, lose all tooth-inducing and tooth-forming capacity following in vitro expansion, and at ratios >1:3 postnatal:embryonic cells, they inhibit the ability of embryonic dental mesenchyme cells to induce tooth formation.

Loss of Dnmt3b accelerates MLL-AF9 leukemia progression

Acute myeloid leukemia (AML) is a heterogeneous hematopoietic disorder with a poor prognosis. Abnormal DNA methylation is involved in the initiation and progression of AML. The de novo methyltransferases Dnmt3a and Dnmt3b are responsible for the generation of genomic methylation patterns. While DNMT3A is frequently mutated in hematological malignancies, DNMT3B is rarely mutated. Although it has been previously reported that Dnmt3b functions as a tumor suppressor in a mouse model of Myc-induced lymphomagenesis, its function in AML is yet to be determined. In this study, we demonstrated that deletion of Dnmt3b accelerated the progression of MLL-AF9 leukemia by increasing stemness and enhancing cell cycle progression. Gene profiling analysis revealed upregulation of the oncogenic gene set and downregulation of the cell differentiation gene set. Furthermore, loss of Dnmt3b was able to synergize with Dnmt3a deficiency in leukemia development. Taken together, these results demonstrate that Dnmt3b plays a tumor suppressive role in MLL-AF9 AML progression, thereby providing new insights into the roles of DNA methylation in leukemia development.

Novel integrative methodology for engineering large liver tissue equivalents based on three-dimensional scaffold fabrication and cellular aggregate assembly

A novel engineering methodology for organizing a large liver tissue equivalent was established by intergrating both 'top down' and 'bottom up' approaches. A three-dimensional (3D) scaffold was engineered comprising 43 culture chambers (volume: 11.63 cm(3)) assembled in a symmetrical pattern on 3 layers, a design which enables further scaling up of the device to a clinically significant size (volume: 500 cm(3)). In addition, an inter-connected flow channel network was designed and proved to homogenously deliver culture medium to each chamber with the same pressure drop. After fabrication using nylon-12 and a selective laser sintering process, co-cultured cellular aggregates of human hepatoma Hep G2 and TMNK-1 cells were loosely packed into the culture chambers with biodegradable poly-L-lactic acid fibre pieces for 9 days of perfusion culture. The device enabled increased hepatic function and well-maintained cell viability, demonstrating the importance of an independent medium flow supply for cell growth and function provided by the current 3D scaffold. This integrative methodology from the macro- to the micro-scale provides an efficient way of arranging engineered liver tissue with improved mass transfer, making it possible to further scale up to a construct with clinically relevant size while maintaining high per-volume-based physiological function in the near future.

The dysfunctions of complement factor H in lupus nephritis

OBJECTIVE

Our previous study showed that plasma levels of factor H (FH) were significantly decreased in patients with lupus nephritis and reflected lupus nephritis activity. The aim of this study was to further investigate in vitro biofunctions of plasma FH in patients with lupus nephritis.

METHODS

FH was purified from the first run of plasma exchange in four active lupus nephritis patients and two non-renal involvement systemic lupus erythematosus (SLE) patients, and plasma from two healthy controls. Then, the biofunctions of the purified FH were analyzed. In addition, FH exons sequencing analysis was performed.

RESULTS

Homogeneous FH was purified from the plasma fractions and the purity of the purified FH was comparable to the commercial FH. The abilities of FH binding with C3b and mCRP, and its protecting abilities from the lysis of sheep erythrocytes, from No. 3 and No. 4 lupus nephritis patients, decreased significantly compared with those in normal controls. The purified FH from lupus nephritis patients Nos. 2-4 could not induce the phagocytosis of late apoptotic cells significantly compared with normal controls. All four lupus nephritis patients had the known SNP rs1061147 (SCR5, A307A), rs1061170 (SCR7, Y402H), CM050194 (SCR20, S1191W) and CM010322 (SCR20, V1197A), which might be associated with the above dysfunctions.

CONCLUSIONS

Dysfunctions of FH, including the regulations of complement alternative pathway and the clearance of apoptotic cells, were found in some active lupus nephritis patients, which were associated with their clinical phenotypes. The FH SNPs might contribute to the dysfunctions of FH in patients with lupus nephritis.

Effect of dendritic cell vaccine therapy on lymphocyte subpopulation in refractory primary brain tumor

BACKGROUND

Dendritic cell (DC)-based immunotherapy has the potential to induce an antitumor response within the immunologically privileged brain.

AIMS

The aim of this study was to evaluate the short-term effect of DC vaccine therapy on lymphocyte subsets in patients with refractory primary brain tumor.

MATERIALS AND METHODS

Eighteen cases with refractory primary brain tumor who refused any treatment against tumor within 6 months of the therapy, were referred to one medicine center, from January 2011 to October 2012. All patients received 1 × 10(7) tumor lysate-pulsed DC vaccinations both intradermal injection and intravenous infusion 3 times/week.

RESULTS

There were increases of lymphocytes CD8+ (P = 0.002) and CD56+ (P = 4.207E-10), but no change of lymphocytes CD3+ (P = 0.651). Six patients were positive response of delayed-type hypersensitivity. There were improving of appetite in 14 cases and increasing of physical strength 17 cases.

CONCLUSIONS

DC vaccine has the potential for inducing an immune cytotoxic effect directed toward tumor cells.

Intranasal insulin protects against substantia nigra dopaminergic neuronal loss and alleviates motor deficits induced by 6-OHDA in rats

Protection of substantia nigra (SN) dopaminergic (DA) neurons by neurotrophic factors (NTFs) is one of the promising strategies in Parkinson's disease (PD) therapy. A major clinical challenge for NTF-based therapy is that NTFs need to be delivered into the brain via invasive means, which often shows limited delivery efficiency. The nose to brain pathway is a non-invasive brain drug delivery approach developed in recent years. Of particular interest is the finding that intranasal insulin improves cognitive functions in Alzheimer's patients. In vitro, insulin has been shown to protect neurons against various insults. Therefore, the current study was designed to test whether intranasal insulin could afford neuroprotection in the 6-hydroxydopamine (6-OHDA)-based rat PD model. 6-OHDA was injected into the right side of striatum to induce a progressive DA neuronal lesion in the ipsilateral SN pars compact (SNc). Recombinant human insulin was applied intranasally to rats starting from 24h post lesion, once per day, for 2 weeks. A battery of motor behavioral tests was conducted on day 8 and 15. The number of DA neurons in the SNc was estimated by stereological counting. Our results showed that 6-OHDA injection led to significant motor deficits and 53% of DA neuron loss in the ipsilateral side of injection. Treatment with insulin significantly ameliorated 6-OHDA-induced motor impairments, as shown by improved locomotor activity, tapered/ledged beam-walking performance, vibrissa-elicited forelimb-placing, initial steps, as well as methamphetamine-induced rotational behavior. Consistent with behavioral improvements, insulin treatment provided a potent protection of DA neurons in the SNc against 6-OHDA neurotoxicity, as shown by a 74.8% increase in tyrosine hydroxylase (TH)-positive neurons compared to the vehicle group. Intranasal insulin treatment did not affect body weight and blood glucose levels. In conclusion, our study showed that intranasal insulin provided strong neuroprotection in the 6-OHDA rat PD model, suggesting that insulin signaling may be a novel therapeutic target in broad neurodegenerative disorders.

Diagnostic dilemma: treatment outcomes of tuberculosis patients with inconsistent rifampicin susceptibility

OBJECTIVE

A retrospective clinical trial to evaluate treatment outcomes in adults with smear-positive tuberculosis (TB) and discordant rifampicin (RMP) resistance results.

DESIGN

A total of 2156 smear-positive TB patients underwent both conventional and Genechip drug susceptibility testing (DST) for RMP resistance. All 49 patients with discordant results treated with either a first-line or second-line regimen were analysed.

RESULTS

Of 30 Type I cases (Genechip-resistant, conventional DST-susceptible) receiving the first-line regimen, 4 had a favourable outcome and 5 failed treatment. The 21 remaining Type I cases were treated with the second-line regimen, of whom 18 had a favourable outcome. Second-line regimen thus resulted in significantly more favourable outcomes than first-line treatment (P = 0.032). Among Type II cases (Genechip-susceptible, conventional DST-resistant), 13/19 received the first-line regimen, and 7 had a favourable outcome. The six Type II cases treated with the second-line regimen all had favourable outcomes.

CONCLUSION

Patients with discordant RMP DST results who receive second-line regimens may have a better clinical response than those treated with the first-line regimen. Patients infected with fluoroquinolone-resistant Mycobacterium tuberculosis strains were observed to have a significantly higher treatment failure rate.

Altered mesenchymal niche cells impede generation of normal hematopoietic progenitor cells in leukemic bone marrow

Degeneration of normal hematopoietic cells is a shared feature of malignant diseases in the hematopoietic system. Previous studies have shown the exhaustion of hematopoietic progenitor cells (HPCs) in leukemic marrow, whereas hematopoietic stem cells (HSCs) remain functional upon relocation to non-leukemic marrow. However, the underlying cellular mechanisms, especially the specific niche components that are responsible for the degeneration of HPCs, are unknown. In this study, we focused on murine bone mesenchymal stem cells (MSCs) and their supporting function for normal hematopoietic cells in Notch1-induced acute T-cell lymphocytic leukemia (T-ALL) mice. We demonstrate that the proliferative capability and differentiation potential of T-ALL MSCs were impaired due to accelerated cellular senescence. RNA-seq analysis revealed significant transcriptional alterations in leukemic MSCs. After co-cultured with the MSCs from T-ALL mice, a specific inhibitory effect on HPCs was defined, whereas in vivo repopulating potential of normal HSCs was not compromised. Furthermore, osteoprotegerin was identified as a cytokine to improve the function of T-ALL MSCs and to enhance normal HPC output via the p38/ERK pathway. Therefore, this study reveals a novel cellular mechanism underlying the inhibition of HPC generation in T-ALL. Leukemic MSCs may serve as a cellular target for improving normal hematopoietic regeneration therapeutically.

Dendritic cell vaccine treatment of advanced de novo colorectal cancer in renal transplant patients

Objective: The clinical outcome, especial the immunologic responses to cancer and graft, of dendritic cell (DC) vaccine in the treatment of advanced de novo colorectal cancer (CRC) in renal transplant patients was investigated in this study. Materials and Methods: 7 patients were received 1 cycle tumor lysate pulsed autologous DC vaccine. The positive cell-mediated cytotoxicity responses to DC vaccine against CRC cell in two out of 7 patients were seen by delayed type hypersensitivity (DTH) test. The positive cell-mediated cytotoxicity responses to DC vaccine against normal kidney cell in all 7 patients were not seen by DTH tests and no notable change of renal function during and after vaccination. Conclusions: DC vaccine has emerged as a promising new strategy in the treatment of advanced de novo CRC in renal transplant patients and DC vaccines have become an attractive therapeutic option, developing immune responses specific against CRC cell, achieving clinical efficacy without graft failure.

Linezolid in the treatment of extensively drug-resistant tuberculosis

PURPOSE

To investigate the linezolid (LZD) treatment outcome and correlation between in vitro susceptibility to LZD and clinical outcome.

METHODS

We retrospectively reviewed records of tuberculosis (TB) patients who received treatment with linezolid between March 2012 and February 2013.

RESULTS

A total of 43 extensively drug-resistant (XDR) TB patients identified by drug susceptibility testing were enrolled in this study, including 15 (34.9 %) received LZD as part of individualized treatment regimens. Among the 43 XDR TB patients, 15 patients (34.9 %) obtained favorable clinical outcome, including 9 (60.0 %) from LZD group and 6 (21.4 %) from control group without LZD. Statistical analysis revealed that the percentage of favorable outcomes of LZD group was significantly higher than that of control group (P = 0.011). Furthermore, we analyzed the LZD minimum inhibitory concentrations of Mycobacterium tuberculosis (MTB) isolates from patients in LZD group and identified 4 (26.7 %) resistant to LZD. All of the patients with LZD resistance harbored adverse clinical outcome, while most of the patients infected with LZD sensitive MTB harbored favorable clinical outcome (81.8 %, 9/11). Statistical analysis revealed that the percentage of favorable outcome among the patients with LZD resistance was statistically lower than that among the LZD susceptible group (P = 0.011).

CONCLUSION

This study demonstrates that linezolid has efficacy against XDR pulmonary TB patients, even in shorter duration of administration. The XDR TB patients infected with LZD-resistant isolates were more likely to obtain the adverse clinical outcome under the treatment of regimen containing LZD.

Genetic profile of tuberculosis among the migrant population in Fujian Province, China

SETTING

The Fujian District in China has a high migrant worker population. Although tuberculosis (TB) among migrants is a serious threat to public health in Fujian, little is known about the molecular characteristics of TB isolates in this population.

OBJECTIVE

To investigate the genetic profile of TB among the migrant population in Fujian.

RESULTS

Our study enrolled 243 pulmonary TB patients registered in Fujian. Our data demonstrated that the Beijing genotype was the most common genotype in Fujian, and that the proportion of migrants with the Beijing genotype was significantly higher than that of permanent residents. Furthermore, the population structure of Mycobacterium tuberculosis strains in Fujian was diverse, with no difference in the distribution of mycobacterial interspersed repetitive units-variable number of tandem repeat (MIRU-VNTR) subgroups between the migrant and permanent populations. In addition, the discriminatory power of MIRU-VNTR in this study was higher than that found in other regions of China, possibly due to the high percentage of migrants in Fujian.

CONCLUSION

The Beijing genotype was the predominant genotype in Fujian. TB strains isolated from this migrant population revealed a genetic profile similar to that of the permanent population. Improvement in public medical and insurance programmes for migrants might be crucial in the effective control of TB in Fujian.

Gene-expression data integration to squamous cell lung cancer subtypes reveals drug sensitivity

BACKGROUND

Squamous cell lung cancer (SqCC) is the second most common type of lung cancer in the United States. Previous studies have used gene-expression data to classify SqCC samples into four subtypes, including the primitive, classical, secretory and basal subtypes. These subtypes have different survival outcomes, although it is unknown whether these molecular subtypes predict response to therapy.

METHODS

Here, we analysed RNAseq data of 178 SqCC tumour samples and characterised the features of the different SqCC subtypes to define signature genes and pathway alterations specific to each subtype. Further, we compared the gene-expression features of each molecular subtype to specific time points in models of airway development. We also classified SqCC-derived cell lines and their reported therapeutic vulnerabilities.

RESULTS

We found that the primitive subtype may come from a later stage of differentiation, whereas the basal subtype may be from an early time. Most SqCC cell lines responded to one of five anticancer drugs (Panobinostat, 17-AAG, Irinotecan, Topotecan and Paclitaxel), whereas the basal-type cell line EBC-1 was sensitive to three other drugs (PF2341066, AZD6244 and PD-0325901).

CONCLUSION

Compared with the other three subtypes of cell lines, the secretory-type cell lines were significantly less sensitive to the five most effective drugs, possibly because of their low proliferation activity. We provide a bioinformatics framework to explore drug repurposing for cancer subtypes based on the available genomic profiles of tumour samples, normal cell types, cancer cell lines and data of drug sensitivity in cell lines.

Application of a global reference for fetal-weight and birthweight percentiles in predicting infant mortality

OBJECTIVE

To determine whether the recently published A global reference for fetal-weight and birthweight percentiles (Global Reference) improves small- (SGA), appropriate- (AGA), and large-for-gestational-age (LGA) definitions in predicting infant mortality.

DESIGN

Population-based cohort study.

SETTING

The US Linked Livebirth and Infant Death records between 1995 and 2004.

POPULATION

Singleton births with birthweight >500 g born at 24-41 weeks of gestation.

METHODS

We compared infant mortality rates of SGA, AGA, and LGA infants classified by three different references: the Global Reference; a commonly used birthweight reference; and Hadlock's ultrasound reference.

MAIN OUTCOME MEASURES

Infant mortality rates.

RESULTS

Among 33 997 719 eligible liveborn singleton births, 25% of preterm and 9% of term infants were classified differently for SGA, AGA, and LGA by the Global Reference and the birthweight reference. The Global Reference indicated higher mortality rates in preterm SGA and preterm LGA infants than the birthweight reference. The mortality rate was considerably higher in infants classified as preterm SGA by the Global Reference but not by the birthweight reference, compared with the corresponding infants classified by the birthweight reference but not by the Global Reference (105.7 versus 12.9 per 1000, RR 8.17, 95% CI 7.38-9.06). Yet, the differences in mortality rates were much smaller in term infants than in preterm infants. Black infants had a particularly higher mortality rate than other races in AGA and LGA preterm and term infants.

CONCLUSIONS

In respect to the commonly used birthweight reference, the Global Reference increases the identification of infant deaths by improved classification of abnormal newborn size at birth, and these advantages were more obvious in preterm than in term infants.

Lymphoepithelioma-like gastric carcinoma: an unusual consequence of Epstein-Barr virus infection in an HIV-infected woman

Lymphoepithelioma-like-gastric carcinoma (LEL-GC) is an Epstein-Barr virus (EBV)-associated neoplasm of the stomach reported to have a better prognosis than conventional gastric adenocarcinoma. Unlike other EBV-associated malignancies, particularly lymphoproliferative disorders and undifferentiated nasopharyngeal carcinoma, for which risk has been shown to increase in human immunodeficiency virus (HIV) infection, LEL-GC remains rare; only one HIV-infected patient with LEL-GC has been reported previously. We describe an aggressive case of EBV-associated LEL-GC in a woman co-infected with HIV 1 and hepatitis C virus. In situ hybridization of an endoscopic biopsy specimen for EBV-encoded small RNA confirmed the presence of this agent exclusively in the gastric cancer cells. Our patient had recently started antiretroviral therapy, suggesting that immune reconstitution may have been a factor in presentation of this tumour.