Search for neutrinoless double-beta decay in 136Xe with EXO-200

We report on a search for neutrinoless double-beta decay of 136Xe with EXO-200. No signal is observed for an exposure of 32.5 kg yr, with a background of ∼1.5×10(-3)  kg(-1) yr(-1)  keV(-1) in the ±1σ region of interest. This sets a lower limit on the half-life of the neutrinoless double-beta decay T(1/2)(0νββ)(136Xe)>1.6×10(25)  yr (90% C.L.), corresponding to effective Majorana masses of less than 140-380 meV, depending on the matrix element calculation.

P4-20-02: Inflammatory Breast Cancer (IBC) in the National Comprehensive Cancer Network (NCCN): The Disease, the Recurrence Pattern and the Outcome

Background

Inflammatory breast cancer (IBC) is a unique clinicopathologic entity that is characterized by rapid progression and aggressive behavior from the onset. The clinical presentation consists of erythema, rapid enlargement of the breast, skin ridging, and a characteristic peau d'orange appearance of the skin secondary to dermal lymphatic tumor involvement. Because of its uncommon presentation leading to frequent misdiagnosis, most reports are from small single institution series which describe a predictable pattern of recurrence in spite of appropriate multidisciplinary treatments. We sought to confirm these observations using the large multi-institutional National Comprehensive Cancer Network (NCCN) outcomes database.

Methods: Patients (pts) with newly diagnosed IBC treated between 1999 and 2009 at 12 participating NCCN institutions were identified. The clinical diagnoses of IBC was based on the AJCC definition and staged as clinical T4d, N0-3, M0-1. The baseline pathological characteristics included histological type, estrogen receptor (ER), progesterone-receptor (PR), and HER-2/neu status. Pts were classified as receiving multimodality therapy if they received two of the following three treatments: surgery (lumpectomy or mastectomy), perioperative (neoadjuvant or adjuvant) systemic therapy, or perioperative radiation therapy.

Results: We identified a cohort of 673 pts with newly diagnosed IBC with a median follow-up of 28.9 months. Of which 195 (29%) had metastatic disease at presentation. The median age at presentation was 52.6 years. Caucasians were 79.4% of the cohort, African American 9.7%, and 11.0% other ethnic groups. Invasive ductal type comprised 84% of histologies. Biomarker assessment revealed ER+ (44.7%), PR+ (34.3%), and Her2/neu+ (33.4%). LVI was documented in 53.3%. Of stage III patients, 75.7% pts received perioperative radiation, 82% received perioperative systemic therapy and 70.7% underwent surgery. All three modalities were received by 64.4% of women. Of the stage III pts, 203 recurred. The most frequent sites of recurrence for were CNS (20.2%), bone (17.2%), chest wall (13.8%), lung (12.3%), liver (11.3%), distant (7.4%) and regional lymph nodes (6.9%). With a median of 30 and 20 months of follow-up for stage III & IV respectively, the median survival was 66 months (95% CI 54–107) for stage III pts and 26 months (95% CI: 22–33) for stage IV Among the 82% of stage III pts who received multimodality therapy, the 5 year and 10 year OS of 62% and 47%.

Discussion: This is a large retrospective multiinstitutional study that confirms the aggressive clinical features, recurrence patterns and adverse prognosis of IBC described in previous single institution series. Even with aggressive multimodal therapy, the long term survival of IBC shorter is than non-IBC. Future investigations are needed to address the aggressive biology of IBC to improve diagnosis and therapy.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-20-02.

Ibn Saud (Abd al‐Aziz ibn Abd al‐Rahman Al Saud) (ca. 1880–1953)

Abd al‐Aziz ibn Abd al‐Rahman Al Saud was born to the Al Saud family — in reality a clan of thousands of people — in Riyadh in the Najd region of central Arabia. He is known in the West as Ibn Saud, ibn being Arabic for “son”; for Arabs, Abd al‐Aziz. He reasserted the power of the Saud family and, for the first time since the early Islamic era, unified most of the Arabian Peninsula in the modern kingdom of Saudi Arabia, created in 1932. He was the greatest of all Saudi rulers. The new state was forged in war as Ibn Saud crushed his rivals, 1902–1929. With the discovery of vast oil reserves in 1937–1938—income from which did not fully come on‐stream until after Ibn Saud's death—Saudi Arabia became one of the world's richest states and after 1945a key player in the politics of the Middle East. US oil companies exploited Saudi oil reserves, beginning a long relationship with the United States, solidified when Ibn Saud met US President Franklin Roosevelt in Egypt in 1945. By the time that the two men met, Saudi Arabia was on her way to becoming one of the world's largest oil producers, with drilling and extraction led by the Arabian American Oil Company (Aramco).

First Report of Laurel Wilt Disease Caused by Raffaelea lauricola on Pondspice in Florida

Laurel wilt is a fungal vascular disease of redbay (Persea borbonia (L.) Spreng) and other plants in the family Lauraceae in the southeastern United States (1). The disease is caused by Raffaelea lauricola T. C. Harr., Fraedrich & Aghayeva, which is vectored by the exotic redbay ambrosia beetle (Xyleborus glabratus Eichhoff) (2). Pondspice (Litsea aestivalis (L.) Fern.) is an obligate wetland shrub listed as endangered in Florida and Maryland and threatened in Georgia (4). On 29 August 2008, 369 of 430 (85%) pondspice trees observed at St. Marks Pond in St. John's County, Florida were dead and/or dying (4). Stem samples were collected from plants with wilted and reddened foliage, entrance holes with boring dust characteristic of ambrosia beetle attack, and dark discoloration in the outer sapwood. Discolored stem sections were surface disinfested for 30 s in a 5% sodium hypochlorite solution and then plated onto cycloheximide streptomycin malt extract agar (1). Smooth, cream-buff, submerge hyphae with uneven margins resembling R. lauricola (2) was observed growing from all sapwood pieces. DNA was extracted from a single isolate (PL 392) and the 18s small subunit rDNA was PCR amplified and sequenced with primers NS1 and NS4 (3), resulting in a 1,026-bp amplicon. A BLASTn search showed identical homology to R. lauricola strain PL 159 (GenBank Accession No. EU257806). The 18s small subunit rDNA sequence was deposited into GenBank (FJ514097). In May 2011, a spore suspension was made by flooding a single-spore culture plate of isolate PL 392 with 2 ml of sterile water, collecting the spores by pipette, and quantification by hemacyometer to 1.5 × 10⁶ spores/ml. Pathogenicity tests were conducted on 1 to 1.5 m tall pondspice plants. Six saplings were wounded by a 3/32-inch drill bit, with four receiving 50 μl of the spore suspension and two serving as water-inoculated controls. All plants were kept in a greenhouse under ambient temperature. Within 21 days, all fungal-inoculated saplings displayed complete canopy wilt, typical of laurel wilt. R. lauricola was later recovered from all four infected plants, completing Koch's postulates. To determine if the vector can reproduce in pondspice, infected stem sections were placed in a plastic rearing box indoors at room temperature, and both callow and mature adult female X. glabratus emerged in October and November 2008. Although laurel wilt has been previously observed on pondspice in South Carolina and Georgia (1), this is the first confirmation of the disease on pondspice in Florida and the first confirmation of the vector from stem material of this host. References: (1) S. W. Fraedrich et al. Plant Dis. 92:215, 2008. (2) T. C. Harrington et al. Mycotaxon 104:399, 2008. (3) M. A. Innis et al. PCR Protocols, A Guide to Methods and Applications. Academic Press. San Diego, CA, 1990. (4) J. A. Surdick and A. M. Jenkins. Pondspice (Litsea aestivalis) Population Status and Response to Laurel Wilt Disease in Northeast Florida. Florida Natural Areas Inventory, Tallahassee, FL, 2009.

Observation of two-neutrino double-beta decay in 136Xe with the EXO-200 detector

We report the observation of two-neutrino double-beta decay in (136)Xe with T(1/2) = 2.11 ± 0.04(stat) ± 0.21(syst) × 10(21) yr. This second-order process, predicted by the standard model, has been observed for several nuclei but not for (136)Xe. The observed decay rate provides new input to matrix element calculations and to the search for the more interesting neutrinoless double-beta decay, the most sensitive probe for the existence of Majorana particles and the measurement of the neutrino mass scale.

A magnetically driven piston pump for ultra-clean applications

A magnetically driven piston pump for xenon gas recirculation is presented. The pump is designed to satisfy extreme purity and containment requirements, as is appropriate for the recirculation of isotopically enriched xenon through the purification system and large liquid xenon time projection chamber of EXO-200. The pump, using sprung polymer gaskets, is capable of pumping more than 16 standard liters per minute of xenon gas with 750 Torr differential pressure.

The migration patterns of two versions of the Furlong cementless femoral stem: a randomised, controlled trial using radiostereometric analysis

We have evaluated the difference in the migration patterns over two years of two cementless stems in a randomised, controlled trial using radiostereophotogrammetric analysis (RSA). The implants studied were the Furlong HAC stem, which has good long-term results and the Furlong Active stem, which is a modified version of the former designed to minimise stress concentrations between the implant and bone, and thus to improve fixation. A total of 23 Furlong HAC and 20 Furlong Active stems were implanted in 43 patients. RSA examinations were carried out immediately post-operatively and at six, 12 and 24 months post-operatively. The subsidence during the first year in the Furlong HAC stem, was approximately one-third that of the Furlong Active stem, the measured mean subsidence of the femoral head at six months being 0.27 mm (95% confidence interval (CI) 0.03 to 0.51) and 0.99 mm (95% CI 0.38 to 1.60), respectively (p = 0.03). One Active stem continued to subside during the second year. All hips, regardless of the type of stem were clinically successful as judged by the Oxford hip score and a derived pain score without any distinction between the two types of stem. The initial stability of the Furlong Active stem was not as good as the established stem which might compromise osseo-integration to the detriment of long-term success. The changes in the geometry of the stem, to minimise stress have affected the attainment of initial stability.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

AIM

Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

METHOD

Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction.

RESULTS

Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores.

CONCLUSION

This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.

Patient satisfaction with lower gastrointestinal endoscopy: doctors, nurse and nonmedical endoscopists

AIM

Assessment of patient satisfaction with lower gastrointestinal endoscopy (LGE) comprising colonoscopy and flexible sigmoidoscopy is gaining increasing importance. We have now trained non healthcare professionals such as nonmedical endoscopists (NMEs) to perform LGE to overcome shortage of trained endoscopists. The aim of this study was to prospectively determine patient satisfaction, factors affecting satisfaction with LGE and to compare with nurses, NME and medical endoscopists, in terms of patient satisfaction.

METHOD

Consecutive patients undergoing LGE answered specially developed patient satisfaction questionnaire at discharge and 24 h thereafter. This questionnaire was a modification of m-Group Health Association of America questionnaire. Construct and face validity of questionnaire were tested by an expert group. Demographic and clinical data was prospectively collected. Multivariate regression analysis was performed to determine factors influencing patient satisfaction.

RESULTS

Some 503 patients were surveyed after LGE. Examinations were performed by nurse (n = 105), doctor (n = 191), or NMEs (n = 155). There were no differences between three groups in terms of completion rates/complications. No differences were detected between endoscopists in patient rating for overall satisfaction (P = 0.6), technical skills (P = 0.58), communication skills (P = 0.61) or interpersonal skills (0.59). Multivariate regression analysis showed that higher preprocedure anxiety, history of pelvic operations/hysterectomy and higher pain scores were associated with adverse patient satisfaction and preprocedure anxiety, history of hysterectomy and female gender were associated with higher pain scores.

CONCLUSION

This study has shown that there are no differences in patient satisfaction with LGE performed by nurse, doctor or NME. The most important factor affecting patient satisfaction is degree of discomfort/pain experienced by patient.

First Occurrence of Laurel Wilt Disease Caused by Raffaelea lauricola on Redbay Trees in Mississippi

Laurel wilt is a lethal, nonnative vascular wilt disease of redbay (Persea borbonia), sassafras (Sassafras albidum), and other trees in the Lauraceae (1,4). It is caused by a fungus (Raffaelea lauricola) and transmitted by the redbay ambrosia beetle (Xyleborus glabratus), a nonnative insect first detected in Georgia in 2002 (1,2). Since introduction of the pathogen and vector (presumably from Asia), laurel wilt has caused extensive mortality to redbays in Georgia, Florida, and South Carolina (1). In June 2009, a landowner in Gautier, MS reported dead redbay trees. Signs and symptoms were identical to those reported for laurel wilt along the Atlantic Coast (wilted, bronze red foliage, and dark gray-to-black vascular discoloration) (1). Infected trees have subsequently been confirmed in and near the Pascagoula River Basin. Size of infected redbays ranged from 5 to 20 cm (diameter at breast height). No heavily decomposed or fallen redbays were noted. Many individual specimens exhibited extensive drying of stem wood and dry, wilted, light brown foliage. This indicates that introduction to the area may have occurred within the last 3 years. X. glabratus adults were collected (30°26'44.45″N, 88°39'41.83″W) in a Lindgren funnel trap baited with phoebe and manuka oil lures. Beetle identification was confirmed by USDA-APHIS, and voucher specimens were submitted to the Smithsonian National Museum of Natural History and the Mississippi Entomological Museum. Symptomatic redbay wood chips from the same location were surface sterilized and plated on cycloheximide-streptomycin malt agar and R. lauricola was isolated. A 1,026-bp portion of 18S rDNA (GenBank No. GQ996063) was amplified by PCR and sequenced using primers NS1 and NS4. BLASTn searches revealed perfect homology to R. lauricola isolate PL 697 (GQ329704). Two isolates of R. lauricola were recovered and prepared into separate spore suspensions (1 × 10⁸ CFU/ml). Each isolate was inoculated into two healthy redbays. The inoculated redbays were placed in a growth chamber with two water-only controls. All inoculated plants, and none of the controls, exhibited wilt symptoms and died within 20 days. R. lauricola was recovered from the discolored sapwood of the inoculated plants, completing Koch's postulates. A model prediction for the natural dispersion of X. glabratus and R. lauricola estimated that these organisms may not reach Mississippi for 10 to 15 years (3). The current detection of laurel wilt in Mississippi is substantially ahead of this estimate. Currently, no records of laurel wilt have been reported from western Georgia, all of Alabama, or the panhandle of Florida. Confirmed locations in Mississippi are in Jackson County, along the Interstate 10 corridor and the Pascagoula River drainage. Due to the relatively large extent of the infestation (~64 km², including hundreds of infected trees) eradication is not being attempted. Surveys, remote sensing, and phylogeographic analysis are underway to delineate the extent of infestation and discover the mode of introduction. The current outbreak of laurel wilt in Mississippi is likely the result of human transport of infested wood, either from Asia as a separate, new introduction or from previously infested areas in the southeastern United States. References: (1) S. W Fraedrich et al. Plant Dis. 92:215, 2008. (2) T. C. Harrington et al. Mycotaxon 104:399, 2008. (3) F. Koch and W. Smith. Environ. Entomol. 37:442, 2008. (4) J. A. Smith et al. Plant Dis. 93:198, 2009.

On-line interprofessional learning: introducing constructivism through enquiry-based learning and peer review

Interest in on-line methods of learning has accelerated in recent years. There has also been an interest in developing student-centred approaches to learning and interprofessional education. This paper illustrates the issues in designing a large (more than 700 students), on-line, inter-professional module for third year, undergraduate students drawn from nine professional healthcare courses and from four campus sites. It uses an enquiry-based learning approach. The learning theories of Piaget, Vygotsky and Schön are integrated with the on-line frameworks of Salmon and Collis et al., together with conclusions drawn from the literature and our own experiences, to produce a design that encourages students to learn through participation, re-iteration, peer-review and reflection. Consideration is given to improving student motivation and attitudes towards change, both in the design and the delivery of the module.

Randomized clinical trial of Entonox versus midazolam-fentanyl sedation for colonoscopy

BACKGROUND

Intravenous sedation for colonoscopy is associated with cardiorespiratory complications and delayed recovery. The aim of this randomized clinical trial was to compare the efficacy of Entonox (50 per cent nitrous oxide and 50 per cent oxygen) and intravenous sedation using midazolam-fentanyl for colonoscopy.

METHODS

Some 131 patients undergoing elective colonoscopy were included. Patients completed a Hospital Anxiety and Depression questionnaire, letter cancellation tests and pain scores on a 100-mm visual analogue scale before, immediately after the procedure and at discharge. They also completed a satisfaction survey at discharge and 24 h after the procedure.

RESULTS

Sixty-five patients were randomized to receive Entonox and 66 to midazolam-fentanyl. Completion rates were similar (94 versus 92 per cent respectively; P = 0.513). Patients receiving Entonox had a shorter time to discharge. They reported significantly less pain (mean score 16.7 versus 40.1; P < 0.001), and showed better recovery of psychomotor function immediately after the procedure and at discharge. Patient satisfaction was higher among patients who received Entonox (median score 96 versus 89; P = 0.001).

CONCLUSION

Entonox provides better pain relief and faster recovery than midazolam-fentanyl and so is more effective for colonoscopy.

Comparison of whole-body MRI and bone scintigraphy in the detection of bone metastases in renal cancer

This study aims to compare the sensitivity of whole-body MRI with bone scintigraphy in the detection of bone metastases in patients with renal cancer. A prospective study was carried out in 47 patients with renal cancer (mean age 62 years, range 29-79 years). All patients had assessment of the skeleton with whole-body bone scintigraphy (with technetium-99m methylene diphosphonate) and whole-body MRI (coronal T(1) weighted and short tau inversion recovery sequences). The number and sites of bony metastases were assessed on each imaging investigation independently. Sites of extra-osseous metastasis on MRI were also noted. The imaging findings were correlated with other imaging modalities and follow-up. 15 patients (32%) had bone metastases at 34 different sites. Both scintigraphy and MRI were highly specific (94% and 97%, respectively), but the sensitivity of MRI (94%) was superior (p = 0.007) to that of scintigraphy (62%). MRI identified more metastases in the spine and appendicular skeleton, whereas scintigraphy showed more lesions in the skull/facial and thoracic bones. MRI identified extra-osseous metastases in 33 patients (70%), these were mainly lung and retroperitoneal in site. Whole-body MRI is a more sensitive method for detection of bone metastases in renal cancer than bone scintigraphy, and also allows the assessment of soft-tissue disease.

Decision-making in patients with advanced cancer compared with amyotrophic lateral sclerosis

AIM

Patients with advanced cancer need information about end-of-life treatment options in order to make informed decisions. Clinicians vary in the frequency with which they initiate these discussions.

PATIENTS AND METHODS

As part of a long-term longitudinal study, patients with an expected 2-year survival of less than 50% who had advanced gastrointestinal or lung cancer or amyotrophic lateral sclerosis (ALS) were interviewed. Each patient's medical record was reviewed at enrollment and at 3 months for evidence of the discussion of patient wishes concerning ventilator support, artificial nutrition and hydration (ANH), resuscitation (DNR) and hospice care. A Kaplan-Meier analysis was also performed and 2-year survival calculated.

RESULTS

60 cancer and 32 ALS patients were enrolled. ALS patients were more likely than cancer patients to have evidence of discussion about their wishes for ventilator support (31% vs 0%, p<0.001), ANH (38% vs 0%, p<0.001), DNR (25% vs 0%, p<0.001) and hospice care (22% vs 5%, p = 0.03). At 6 months, 91% of ALS patients were alive compared with 62% of cancer patients; at 2 years, 63% of ALS patients were alive compared with 23% of cancer patients (p<0.001).

CONCLUSIONS

Cancer patients were less likely than ALS patients to have had documented advanced care planning discussions despite worse survival. This may reflect perceptions that ALS has a more predictable course, that advanced cancer has a greater number of treatment options, or differing views about hope. Nevertheless, cancer patients may be less adequately prepared for end-of-life decision-making.

The quality of nutritional information available on popular websites: a content analysis

The overall purpose of this study was to increase knowledge and understanding of the new informational landscape that is emerging on the Internet in relation to nutritional health content in order to provide policy makers with better communication and health promotion tools. We identified the sites most used by Canadians to access nutrition information and conducted content analyses to identify the sources of this nutritional information as well as its quality by systematic comparison with the main guidelines published in the Canada Food Guide. We found that commercial websites accounted for 80% of visits and time spent on seeking health and nutrition information. We also found uneven messaging about fruit and vegetable intake as well as consistent messaging undermining the 'eat a variety of foods' message, which is a central component of the Canada Food Guide. On the positive side, inappropriate or incongruent advice about salt, coffee and alcohol intake was virtually non-existent and advice congruent with the guide was found three times more often than incongruent advice. Finally, the site offering the best advice was a non-commercial government-based site. This site differed from the commercial sites not so much in its ability to deliver the 'right' advice but more in its ability to exclude articles with poor and misleading advice on their sites.

Dyserythropoiesis in homozygous haemoglobin C disease

Electron microscope studies of the bone marrow of three patients with homozygous haemoglobin C (HbC) disease have shown marked ultrastructural abnormalities in several of the polychromatic erythroblasts and marrow reticulocytes and the presence of phagocytosed erythroblasts within the macrophages. Such abnormalities were not found in the bone marrow of three patients with sickle cell anaemia indicating that the abnormalities represented a feature of HbC disease rather than a disturbance secondary to peripheral haemolysis. The characteristic ultrastructural finding in the polychromatic erythroblasts in HbC disease was the presence of grossly-disorganized nuclei showing multiple intranuclear clefts, the loss of parts of the nuclear membrane, oozing of nuclear material into the cytoplasm and an alteration of the structure and stainability of the nuclear chromatin. It is proposed that both the dyserythropoiesis and ineffective erythropoiesis in HbC disease may have resulted from the formation in vivo of very small aggregates of HbC within erythropoietic cells.

First Report of Laurel Wilt Disease Caused by a Raffaelea sp. on Avocado in Florida

Laurel wilt is a vascular disease of redbay (Persea borbonia (L.) Spreng.) and other plants in the family Lauraceae in the southeastern United States. It is caused by a fungus (Raffaelea sp.) that is vectored by a non-native insect of Asian origin, the redbay ambrosia beetle (Xyleborus glabratus Eichhoff) (1). Since the initial detection of the redbay ambrosia beetle near Savannah, GA in 2002, laurel wilt has caused widespread mortality of redbay in Georgia, South Carolina, and Florida (1). In September 2007, an avocado (Persea americana Mill.) tree planted approximately 10 years earlier in a residential neighborhood in Jacksonville, FL was discovered to be infected with laurel wilt. The crown was in various stages of decline, including upper branches that were dead and leafless, those with wilted and drooping foliage, and those with healthy foliage. Removal of bark from wilted branch sections revealed black-to-brown streaks of discoloration in the sapwood and a few ambrosia beetle holes from which the discoloration extended into the adjacent wood. A Raffaelea sp. was isolated from discolored wood samples by surface sterilizing wood chips by submersion in a 5% sodium hypochlorite solution for 30 s and plating them on cycloheximide streptomycin malt agar (2). Small subunit (18S) sequences from the rDNA were amplified by PCR and sequenced with primers NS1 and NS4 (3). BLASTn searches revealed homology to Raffaelea sp. C2203 (GenBank Accession No. EU123076, 100% similarity, e-value of 0.0, and a total score of 1,886), which is known to be the causal agent of laurel wilt (1). The small-subunit rDNA sequence for this isolate has been deposited into GenBank and has been assigned accession No. EU257806. Pathogenicity of the laurel wilt pathogen on Persea spp. in growth chamber trials has been previously demonstrated (1). Laurel wilt is of concern to the commercial avocado industry and is a potential threat to the Lauraceae elsewhere in the Americas. References: (1) S. W. Fraedrich et al. Plant Dis. 92:215, 2008. (2) T. C. Harrington. Mycologia 73:1123, 1981. (3) T. J. White et al. Page 315 in: PCR Protocols, a Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, CA, 1990.

Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review

Atrial fibrillation (AF) is associated with an increased stroke risk that may be reduced by therapeutic anticoagulation. However, anticoagulation is associated with an increased risk of bleeding that in some patients may outweigh the benefits in reducing the risk of stroke. We systematically reviewed the literature for risk factors of anticoagulation-related bleeding complications in patients with AF, as part of the formulation of recently published national guidelines for the management of AF. We identified nine studies that reported anticoagulation-related bleeding complications in AF patients. The following patient characteristics were identified as having supporting evidence for being risk factors for anticoagulation-related bleeding complications: advanced age, uncontrolled hypertension, history of myocardial infarction or ischaemic heart disease, cerebrovascular disease, anaemia or a history of bleeding, and the concomitant use of other drugs such as antiplatelet agents. The presence of diabetes mellitus, controlled hypertension and gender were not identified as significant risk factors. Some of the risk factors for anticoagulation-related bleeding are also indications for the use of anticoagulants in AF patients. There is a need for further research in this area to help physicians to balance the risks and benefits of anticoagulation in AF patients.

Primary and secondary neural networks of auditory prepulse inhibition: a functional magnetic resonance imaging study of sensorimotor gating of the human acoustic startle response

Feedforward inhibition deficits have been consistently demonstrated in a range of neuropsychiatric conditions using prepulse inhibition (PPI) of the acoustic startle eye-blink reflex when assessing sensorimotor gating. While PPI can be recorded in acutely decerebrated rats, behavioural, pharmacological and psychophysiological studies suggest the involvement of a complex neural network extending from brainstem nuclei to higher order cortical areas. The current functional magnetic resonance imaging study investigated the neural network underlying PPI and its association with electromyographically (EMG) recorded PPI of the acoustic startle eye-blink reflex in 16 healthy volunteers. A sparse imaging design was employed to model signal changes in blood oxygenation level-dependent (BOLD) responses to acoustic startle probes that were preceded by a prepulse at 120 ms or 480 ms stimulus onset asynchrony or without prepulse. Sensorimotor gating was EMG confirmed for the 120-ms prepulse condition, while startle responses in the 480-ms prepulse condition did not differ from startle alone. Multiple regression analysis of BOLD contrasts identified activation in pons, thalamus, caudate nuclei, left angular gyrus and bilaterally in anterior cingulate, associated with EMG-recorded sensorimotor gating. Planned contrasts confirmed increased pons activation for startle alone vs 120-ms prepulse condition, while increased anterior superior frontal gyrus activation was confirmed for the reverse contrast. Our findings are consistent with a primary pontine circuitry of sensorimotor gating that interconnects with inferior parietal, superior temporal, frontal and prefrontal cortices via thalamus and striatum. PPI processes in the prefrontal, frontal and superior temporal cortex were functionally distinct from sensorimotor gating.

Cross-sectional imaging of nodal metastases in the abdomen and pelvis

Accurate nodal staging is important for the management of patients with abdominal and pelvic malignancies. Local and nodal staging using cross-sectional imaging can influence treatment planning. The measurement of nodal size is still the most widely used criteria for discriminating between benign and malignant nodes. However, knowledge of the pathways of nodal spread, the treatment history, and careful analysis of nodal characteristics can improve nodal assessment. An appreciation of normal structures that may simulate nodal disease is also important. The potential for further improving nodal staging accuracy by positron emission tomography and magnetic resonance lymphography is discussed.

When is pancreatitis considered to be of biliary origin and what are the implications for management?

Acute pancreatitis is a disease caused by gallstones in 40-60% of patients. Identification of these patients is extremely important, since there are specific therapeutic interventions by endoscopic sphincterotomy and/or cholecystectomy. The combination of trans-abdominal ultrasound (stones in the gallbladder and/or main bile duct) and elevated serum alanine transaminase (circa >60 IU/l within 48 h of presentation) indicates gallstones as the cause in the majority of patients with acute pancreatitis. In the presence of a severe attack this is a strong indication for intervention by endoscopic sphincterotomy. The presence of a significant main bile duct dilatation is also strongly indicative of gallstones and should prompt the use of endoluminal ultrasonography: >8 mm diameter with gallbladder in situ, or >10 mm following cholecystectomy if aged <70 years and >12 mm, respectively, if > or = 70 years. In mild pancreatitis surgically fit patients should be treated by cholecystectomy, and intra-operative cholangiography, as pre-operative biliary imaging is not efficient in this setting. Patients who are not fit for cholecystectomy should undergo prophylactic endoscopic sphincterotomy to prevent further attacks. In the post-acute-phase, pancreatitis patients in whom the aetiology is uncertain should undergo endoluminal ultrasonography. Thisis the most sensitive method for the detection of cholelithiasis and choledocholithiasis and may reveal alternative aetiological factors such as a small ampullary or pancreatic cancer. A number of recent studies have shown that bile crystal analysis, a marker for microlithiasis, increases the yield of positive results over and above endoluminal ultrasonography, and should be considered as part of the modern investigative algorithm.

Salinity adaptation and gene profiling analysis in the European eel (Anguilla anguilla) using microarray technology

The life cycle of the European eel (Anguilla anguilla) includes two long migratory periods, when the newly hatched leptocephali larvae drift on ocean currents from the Sargasso Sea to the shores of Western Europe and then again up to 30 years later when adult eels swim back to their place of birth for reproductive purposes. Prior to the migration from fresh water (FW) to sea water (SW) adult yellow eels undergo various anatomical and physiological adaptations (silvering) which promote sexual development and aid the transition to increased environmental salinities. The aim of this study was to identify and characterise changes in gene expression within the major osmoregulatory tissues of the eel which enable these fish to make the physiological adaptations required for transfer to SW environments. In particular, changes in the expression of the FW-adapting hormone prolactin were correlated with differential expression of known osmoregulatory important genes within the gill, intestine and kidney following the acclimation of eels to SW. Various tissues were sampled from individual fish at selected intervals over a 5-month period following FW/SW transfer and RNA was isolated. Suppressive subtractive hybridization (SSH) was used for enrichment of differentially expressed genes. Microarrays comprising 6144 cDNAs spotted in triplicate, from brain, gill, intestine and kidney libraries (1536 randomly selected clones per tissue library), were hybridized with appropriate targets and analysed. Microarray results were validated using known genes implicated in osmoregulation, such as prolactin, growth hormone, Na, K-ATPase and some unknown genes, the role of which in osmoregulation needs to be elucidated.

Diffusion tensor imaging in patients with acute onset of neuropsychiatric systemic lupus erythematosus: a prospective study of apparent diffusion coefficient, fractional anisotropy values, and eigenvalues in different regions of the brain

PURPOSE

To investigate whether apparent diffusion coefficient (ADC), fractional anisotropy (FA), and eigenvalues in neuropsychiatric systemic lupus erythematosus (NPSLE) patients differ from those of healthy controls.

MATERIAL AND METHODS

Eight NPSLE patients (aged 23-55 years, mean 42.9 years) and 20 healthy age-matched controls (aged 22-59 years, mean 44.4 years) underwent conventional brain magnetic resonance (MR) and diffusion tensor imaging (DTI). The ADC, FA, principal eigenvalue (lambda parallel), and the corresponding average perpendicular eigenvalue (lambda perpendicular) (=(lambda2+lambda3)/2) were measured in selected regions of normal appearing gray and white matter brain parenchyma. For statistical evaluation of differences between the two groups, a Student's t-test was used. The P value for statistical significance was set to P=0.0025 after Bonferroni correction for multiple measurements.

RESULTS

Significantly increased ADC values were demonstrated in normal-appearing areas in the insular cortex (P<0.001), thalamus (P<0.001), and the parietal and frontal white matter (P<0.001 and P<0.001, respectively) in NPSLE patients. Significantly decreased FA values were demonstrated in normal-appearing thalamus (P<0.001), corpus callosum (P=0.002), and in the parietal and frontal white matter (P<0.001 and P<0.001, respectively) in NPSLE patients compared to healthy controls. The lambda perpendicular was significantly higher in several of these regions in NPSLE patients compared to healthy controls.

CONCLUSION

Our study demonstrates alterations in normal-appearing gray and white matter brain parenchyma of patients with NPSLE by means of abnormal ADC, FA, and eigenvalues. These alterations may be based on loss of tissue integrity in part due to demyelination. It is possible that DTI in the future could assist in the diagnosis of NPSLE and possibly help to further elucidate the pathogenesis of NPSLE.

APOE genotypes in African American female multiple sclerosis patients

Multiple sclerosis (MS) is a chronic inflammatory CNS disorder, resulting in progressive neurological dysfunction. The disease has a higher incidence in Caucasian Americans (CA) than African Americans (AA); however, the latter may have a more aggressive disease course. We used cluster analysis to determine whether there is a difference in disease progression between the races and whether the APOE AND APOC1 genotypes influence the disease progression. AA female patients were younger and had a higher progression index and MS severity score than CA female MS patients. AA females who were APOE 4/4, 2/4, or 2/3 and APOC1 AA had a younger age-of-onset, had primarily a relapsing remitting disease course, with a higher progression index and MS severity score, as assessed by cluster analysis. Cluster analysis also indicated that CA female patients were of two groups. One group was younger, had the APOE 3/3 genotype with relapsing remitting less severe disease. The second CA group was older, had the APOE 3/4 or 2/3 genotypes with more of the secondary progressive more severe disease phenotype. Thus, the AA MS female patients who were APOE 4 carriers had an earlier age-of-onset and more severe disease course than CA MS female patients.

Bortezomib in relapsed multiple myeloma complicated by extramedullary plasmacytomas

A 58-year-old man suffered relapse of multiple myeloma complicated by large intra-abdominal extramedullary plasmacytomas and severe hepatic impairment secondary to biliary obstruction. Previous treatment had included two types of combination chemotherapy and high-dose therapy with autologous stem cell transplant. Combination therapy with bortezomib and dexamethasone resulted in partial response of the plasmacytomas and complete resolution of his hepatic impairment. Extramedullary plasmacytomas are rare. This report lends support to the efficacy of bortezomib in the treatment of plasmacytoma and describes the safe use of bortezomib despite hepatic upset.

Dual diagnoses of hereditary hyperferritinaemia-cataract syndrome and hereditary haemochromatosis

A 30-year-old woman was found to have hyperferritinaemia after presenting with menorrhagia and lethargy. Serum iron studies did not confirm iron overload. Further investigations revealed two distinct genetic mutations of iron haemostasis--homozygosity for C282Y mutation of the HFE gene on chromosome 6 and heterozygosity for A40G mutation in the iron response element of ferritin light chain on chromosome 19. These mutations are responsible for the diseases hereditary haemochromatosis (autosomal recessive) and hereditary hyperferritinaemia-cataract syndrome (autosomal dominant) respectively. This is the first description of such a patient.