Multiple synchronous spinal extra-osseous intradural chordomas: is it a distinct entity?

Chordomas are most commonly of extradural origin and are associated with bone destruction. Extra-osseous intradural chordomas are extremely rare and most of the cases described are located near the clivus. We report an extremely rare case of multiple extra-osseous intraspinal chordomas in a 36-year-old male patient with autopsy findings. This case highlights that behaviour of spinal intradural chordomas is not universally low grade, but is variable and aggressive.

Ectopic pregnancy with postcoital contraception – a case report

The incidence of ectopic pregnancies is increasing. Common risk factors are tubal pathology, previous tubal surgery, previous ectopic pregnancy, intrauterine device use and embryo transfer. Levonelle-2, a progesterone-only postcoital contraceptive works by a combination of mechanisms including ovulation inhibition, prevention of fertilization, and inhibition of implantation. It is 85% effective and there have been 12 reported cases of ectopic pregnancy in the UK with its use. It is believed that progesterone slows the intratubal migration of the fertilized ovum. In the case reported here, a woman presented with an ectopic pregnancy after use of Levonelle-2 as postcoital contraception; there were no clinical predisposing risk factors. In the absence of any histological evidence of tubal damage, we suspect that the levonorgestrel from Levonelle-2 could have been responsible for delayed embryo transfer which resulted in the ectopic pregnancy.

Logical inconsistency in comorbid health state preference assessment for prostate cancer

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Background: With increasing need for efficient resource allocation, attention is turning to evidence-based decision making and cost-effectiveness analysis (CEA). Policy decisions depend on quality-adjusted outcomes from such analyses. Even small variations in the health state utilities used to quality adjust can have considerable effects, yet measuring utilities accurately is difficult. A particular challenge in the aging population with high cancer risk is maintaining logical consistency when evaluating comorbid utilities. We define this as ensuring that a single health state (SS) is rated no worse than a health state that adds another SS to that first one to make a comorbid health state (CS). Determining why or by whom this condition fails could improve elicitation practices and CEA for cancer and comorbid diseases. Methods: Men were surveyed at the time of prostate biopsy. SS and CS utility values were elicited via the time-trade off method. Demographic information, current health, and scores on anxiety subscales (HADS and MAX-PC) were collected also. The most prevalent health states associated with prostate cancer in the SEER database were chosen for assessment. CS were combinations of the SS “impotence” with each of incontinence, asymptomatic localized disease, and post-prostatectomy. Regression analysis showed the association of other survey elements to utility inconsistency. Mann-Whitney U-tests determined whether utility values differed by consistency. Results: 68% of respondents rated inconsistently at least once. Marriage and anxiety were correlated with rating inconsistently in univariate logistic analysis (p < 0.01, p < 0.05, respectively). Higher education was independently associated with more consistent answers (p < 0.05). Inconsistent raters had significantly lower utility values for all SS, but not for CS (p < 0.01). Conclusions: Over two thirds of men gave at least one logically inconsistent response across the three CS conditions. Being married, feeling anxious, and having less education were correlated with giving fewer consistent responses. Correcting these inconsistencies may change the results of quality-adjusted analyses. Strategies for eliciting more consistent responses are needed to accurately quality-adjust comorbid health states.

No significant financial relationships to disclose.

Isolation and characterization of densonucleosis virus from Aedes aegypti mosquitoes and its distribution in India

OBJECTIVES

Mosquito densonucleosis viruses (DNVs) are known to persistently infect the insect cell line and mosquito population in nature, causing mortality in mosquitoes. Here we report the isolation and characterization of a DNV from Aedes aegypti and its distribution among different Ae. aegypti populations from India.

METHODS

We screened Ae. aegypti mosquito populations from different states of India by PCR. Virus isolation and purification was performed using a cesium chloride gradient from a positive mosquito colony. Characterization of this isolate was carried out by electron microscopy, Western blot and sequencing.

RESULTS

Electron microscopy showed the presence of parvovirus-like particles, and Western blot showed the presence of 2 viral proteins of 40 and 41 kDa. A total of 3,776 bases of genome were sequenced, which included a 3'UTR of 128 bases, a coding region of 3,507 bases and a 5'UTR of 141 bases. Three open reading frames (ORFs) were identified and characterized. The NIVDNV genome showed 95% similarity with Culex pipiens pallens DNV and 93% similarity with Ae. aegypti DNV.

CONCLUSION

Phylogenetic analysis of all 3 ORFs showed that this new isolate falls in the lineage of Brevidensovirus along with other mosquito DNVs.

Planning and delivery of whole brain radiation therapy with simultaneous integrated boost to brain metastases and synchronous limited-field thoracic radiotherapy using helical tomotherapy: a preliminary experience

Lung cancer is the commonest source of brain metastases, which has been traditionally treated with Whole Brain Radiation Therapy (WBRT) with or without focal boost. We herein report our preliminary experience of the planning and delivery of WBRT with Simultaneous Integrated Boost (SIB) to brain metastases along with synchronous limited-field thoracic radiotherapy using Helical TomoTherapy in four patients with lung cancer. All plans were iteratively optimized for maximal target volume coverage and organ-at-risk (OAR) sparing. Standardized dose metrics were used for plan evaluation. All treated regions were imaged with a megavoltage computed tomography (CT) prior to treatment and co-registered with planning CT for image-guidance. Helical TomoTherapy was able to achieve highly conformal and homogeneous dose distributions with excellent OAR sparing both in the brain and the chest. The mean (standard deviation) Dose Homogeneity Index (DHI) and Conformity Index (CI) was 0.06 (0.01) & 0.79 (0.07); 0.04 (0.02) & 0.57 (0.22); and 0.03 (0.02) & 0.77 (0.06) for whole brain, brain metastases, and chest, respectively. The mean monitor units (MU) per fraction and time taken for delivery were 8595 and 9898 MU and 9.8 and 11.3 minutes for the brain and chest plans, respectively. Although the dosimetric equivalence of SIB to a single fraction radiosurgery might still be questionable, our preliminary experience of WBRT with SIB to individual brain metastases using Helical TomoTherapy has been encouraging. In addition, it allows synchronous irradiation of other involved primary or metastatic sites for palliative effect.

Two hundred living donor kidney transplantations under alemtuzumab induction and tacrolimus monotherapy: 3-year follow-up

Alemtuzumab has been used in off-label studies of solid organ transplantation. We extend our report of the first 200 consecutive living donor solitary kidney transplantations under alemtuzumab pretreatment with tacrolimus monotherapy and subsequent spaced weaning to 3 years of follow-up. We focused especially on the causes of recipient death and graft loss, and the characteristics of rejection. The actuarial 1-, 2- and 3-year patient and graft survivals were 99.0% and 98.0%, 96.4% and 90.8% and 93.3% and 86.3%, respectively. The cumulative incidence of acute cellular rejection (ACR) at the following months was 2%</=6, 9.0%</=12, 16.5%</=18, 19.5%</=24, 23.5%</=30, 24.0%</=36 and 25%</=42. The mean serum creatinine (mg/dL) and glomerular filtration rate (mL/min/1.73 m(2)) at 1 and 3 years were 1.4 +/- 0.6 and 58.7 +/- 21.6 and 1.5 +/- 0.7 and 54.9 +/- 20.9, respectively. Fifty (25%) recipients had a total of 89 episodes of ACR. About 88.7% of ACR episodes were Banff 1, and of those, 82% were steroid-sensitive. Nine (4.5%) recipients had antibody-mediated rejection (AMR). About 76.5% were weaned but only 46% are currently on spaced dose (qod or less) tacrolimus monotherapy, and 94.4% remained steroid-free from the time of transplantation. Infectious complications were uncommon. This experience suggests the 3-year efficacy of this approach.

Effects of pioglitazone and metformin on NEFA-induced insulin resistance in type 2 diabetes

AIMS/HYPOTHESIS

We sought to determine whether pioglitazone and metformin alter NEFA-induced insulin resistance in type 2 diabetes and, if so, the mechanism whereby this is effected.

METHODS

Euglycaemic-hyperinsulinaemic clamps (glucose approximately 5.3 mmol/l, insulin approximately 200 pmol/l) were performed in the presence of Intralipid-heparin (IL/H) or glycerol before and after 4 months of treatment with pioglitazone (n = 11) or metformin (n = 9) in diabetic participants. Hormone secretion was inhibited with somatostatin in all participants.

RESULTS

Pioglitazone increased insulin-stimulated glucose disappearance (p < 0.01) and increased insulin-induced suppression of glucose production (p < 0.01), gluconeogenesis (p < 0.05) and glycogenolysis (p < 0.05) during IL/H. However, glucose disappearance remained lower (p < 0.05) whereas glucose production (p < 0.01), gluconeogenesis (p < 0.05) and glycogenolysis (p < 0.05) were higher on the IL/H study day than on the glycerol study day, indicating persistence of NEFA-induced insulin resistance. Metformin increased (p < 0.001) glucose disappearance during IL/H to rates present during glycerol treatment, indicating protection against NEFA-induced insulin resistance in extrahepatic tissues. However, glucose production and gluconeogenesis (but not glycogenolysis) were higher (p < 0.01) during IL/H than during glycerol treatment with metformin, indicating persistence of NEFA-induced hepatic insulin resistance.

CONCLUSIONS/INTERPRETATION

We conclude that pioglitazone improves both the hepatic and the extrahepatic action of insulin but does not prevent NEFA-induced insulin resistance. In contrast, whereas metformin prevents NEFA-induced extrahepatic insulin resistance, it does not protect against NEFA-induced hepatic insulin resistance.

Thermal and non-thermal fluctuations in active polar gels

We discuss general features of noise and fluctuations in active polar gels close to and away from equilibrium. We use the single-component hydrodynamic theory of active polar gels built by Kruse and coworkers to describe the cytoskeleton in cells. Close to equilibrium, we calculate the response function of the gel to external fields and introduce Langevin forces in the constitutive equations with correlation functions respecting the fluctuation-dissipation theorem. We then discuss the breakage of the fluctuation-dissipation theorem due to an external field such as the activity of the motors. Active gels away from equilibrium are considered at the scaling level. As an example of application of the theory, we calculate the density correlation function (the dynamic structure factor) of a compressible active polar gel and discuss possible instabilities.

Encouraging experience of concomitant Temozolomide with radiotherapy followed by adjuvant Temozolomide in newly diagnosed glioblastoma multiforme: single institution experience

The purpose of this study was to report our experience with concomitant and adjuvant temozolomide (TMZ) with radiotherapy in patients with newly diagnosed glioblastoma multiforme (GBM). Forty-two newly diagnosed histopathologically proven patients with GBM underwent maximal safe resection followed by external radiotherapy to a total dose of 60 Gy in 30 fractions over 6 weeks along with concomitant oral TMZ (75 mg/m2) daily followed by adjuvant TMZ for 5 days every 28 days for six cycles (150 mg/m2 for the first cycle and 200 mg/m2 for rest of the cycles). Patients were monitored clinicoradiologically as per standard practice. Patients were 13-69 years of age with a median age of 49.5 years (31 males, 11 females). Fifty per cent of patients underwent a gross total resection of tumour, 43% had partial resection, and 7% an open or stereotactic biopsy only. 53% of the patients had a post-operative Karnofsky Performance Score (KPS) of 60-80%. All patients received concomitant radiation and TMZ with 74% of the patients completing six cycles of adjuvant TMZ. At a median follow-up of 12.5 months, the 1- and 2-year survival was 67 and 29%, respectively. The median overall and progression-free survival was 16.4 and 14.9 months respectively. Patients with pretreatment KPS of >80% had significantly better overall survival as compared with those having KPS<or=80% (median survival 22.12 vs. 11.97 months; p=0.026). Treatment was generally well tolerated with 9% of patients developing grade 3 anaemia, 2% grade 3 leucopoenia, and 7% patients grade 3 or 4 thrombocytopenia respectively during the treatment. At last follow-up, among the surviving patients, 30% had a maintained KPS greater than 90%. Concomitant radiotherapy and TMZ followed by adjuvant TMZ prolongs survival in patients with glioblastoma multiforme and is well tolerated in our patient population.

Inhibition of ERK attenuates autophagy and potentiates tumour necrosis factor-alpha-induced cell death in MCF-7 cells

The role of autophagy in cell death is under considerable debate. The process of autophagy has been shown to lead to either cell survival or cell death depending on cell type and stimulus. In the present study, we determined the contribution of ERK1/2 signalling to autophagy and cell death induced by tumour necrosis factor-α (TNF) in MCF-7 breast cancer cells. Treatment of MCF-7 cells with TNF caused a time-dependent increase in ERK1/2 activity. There was an induction of autophagy and cleavage of caspase-7, -8, -9 and PARP. Pharmacological inhibition of ERK1/2 phosphorylation with U0126 or PD98059 resulted in a decrease in TNF-induced autophagy that was accompanied by an increase in cleavage of caspase-7, -8, -9 and PARP Furthermore, inhibition of ERK1/2 signalling resulted in decreased clonogenic capacity of MCF-7 cells. These data suggest that TNF-induces autophagy through ERK1/2 and that inhibition of autophagy increases cellular sensitivity to TNF.

Alemtuzumab pre-conditioning with tacrolimus monotherapy in pediatric renal transplantation

We employed antibody pre-conditioning with alemtuzumab and posttransplant immunosuppression with low-dose tacrolimus monotherapy in 26 consecutive pediatric kidney transplant recipients between January 2004 and December 2005. Mean recipient age was 10.7 +/- 5.8 years, 7.7% were undergoing retransplantation, and 3.8% were sensitized, with a PRA >20%. Mean donor age was 32.8 +/- 9.2 years. Living donors were utilized in 65% of the transplants. Mean cold ischemia time was 27.6 +/- 6.4 h. The mean number of HLA mismatches was 3.3 +/- 1.3. Mean follow-up was 25 +/- 8 months. One and 2 year patient survival was 100% and 96%. One and 2 year graft survival was 96% and 88%. Mean serum creatinine was 1.1 +/- 0.6 mg/dL, and calculated creatinine clearance was 82.3 +/- 29.4 mL/min/1.73 m(2). The incidence of pre-weaning acute rejection was 11.5%; the incidence of delayed graft function was 7.7%. Eighteen (69%) of the children were tapered to spaced tacrolimus monotherapy, 10.5 +/- 2.2 months after transplantation. The incidence of CMV, PTLD and BK virus was 0%; the incidence of posttransplant diabetes was 7.7%. Although more follow-up is clearly needed, antibody pre-conditioning with alemtuzumab and tacrolimus monotherapy may be a safe and effective regimen in pediatric renal transplantation.

Cryptococcosis in liver and kidney transplant recipients receiving anti-thymocyte globulin or alemtuzumab

Rabbit anti-thymocyte globulin (ATG) and alemtuzumab have been used for induction or preconditioning and for the treatment of acute rejection in organ transplant recipients in many centers. Such regimens may lead to a substantial decline in the CD4 lymphocyte count to levels seen in other population groups at high risk of cryptococcosis. In view of this, we examined the impact of such therapy on the cumulative incidence of cryptococcosis among liver and kidney recipients. A total of 834 liver and 727 kidney transplants were performed during the study period. Seven hundred and eighty-one patients did not receive ATG or alemtuzumab; 646 received 1 dose of either drug, and 134 patients received 2 doses of either drug. The cumulative incidence of cryptococcosis was 0.26% (2/781) among those who did not receive ATG or alemtuzumab; 0.3% (2/646) among those who received only 1 dose, and 2.24% (3/134) among those who received 2 doses (P=0.03). There were 5 cases of cryptococcosis in liver recipients and 2 in kidney recipients. There were 3 cases of cryptococcal meningitis, 3 of pneumonia, and 1 of disseminated disease. The 2 kidney recipients had meningitis. Diagnosis occurred at a median of 255 days (range 7-517) after transplantation. The mortality rate was 14.2%. We conclude that the use of 1 dose of ATG or alemtuzumab is not associated with an increased cumulative incidence of cryptococcosis, but that those patients receiving 2 doses are at increased risk.

Chronic allograft nephropathy score before sirolimus rescue predicts allograft function in renal transplant patients

Chronic allograft nephropathy (CAN) is a major indication for initiation of sirolimus (SRL) in renal transplantation (TX) to prevent deterioration of renal function. We evaluated whether the CAN score at time of sirolimus rescue (SRL-R) predicts renal allograft function. CAN score is the sum of the following 4 categories: glomerulopathy (cg, 0-3), interstitial fibrosis (ci, 0-3), tubular atrophy (ct, 0-3), and vasculopathy (cv, 0-3). This is a retrospective cohort study of renal transplant recipients from July 2001 to March 2004. Immunosuppression consisted of preconditioning with rabbit anti-thymocyte globulin or alemtuzumab and maintenance with tacrolimus (TAC) monotherapy with spaced weaning, if applicable, SRL-R was achieved by conversion from TAC, or by addition to reduced doses of TAC. Ninety patients received SRL. Thirty-three of these patients met the inclusion criteria of the following: (1) receipt of SRL for >6 months, and (2) follow-up of > or =6 months. There were 16 patients in the low-CAN (0-4) group and 17 patients in the high-CAN (>4) group. Cockcroft-Gault (C-G) glomerular filtration rate (GFR) was calculated at SRL-R and at 1, 3, 6, and 12 months. The DeltaGFR was significantly better in the low-CAN group at 1, 3, and 6 months. A trend toward an improved DeltaGFR was present at 12 months in the low-CAN group (P = .16). CAN scoring at the time of SRL-R predicts recovery of renal allograft function (as measured using DeltaGFR), and should be used in preference to biochemical markers (Cr and C-G GFR), which may not be reliable predictors.