Mechanical ileus of the small bowel due to an inflamed Meckel's diverticulum with an enterolith - a case report with literature review

BACKGROUND

Meckel's diverticula result from incomplete obliteration and regression of the omphaloenteric duct and are the most common congenital intestinal malformations. Many Meckel's diverticula remain asymptomatic and are discovered as incidental findings. They present a diagnostic challenge.

METHODS

We report the case of a 35-year-old man who presented with an acute abdomen and ileus. Computed tomography of the abdomen showed a mechanical small bowel ileus. There was a calibre jump in the terminal ileum with a round endoluminal definable hyperdense structure of almost 2 cm in diameter.

RESULTS

An exploratory laparoscopy was performed revealing an inflamed Meckel's diverticulum with impacted enterolith as the cause of the intestinal obstruction.

CONCLUSION

In symptomatic Meckel's diverticula, haemorrhage and obstruction are the most common complications. The development of ileus due to a Meckel's diverticulum with an enterolith is considered extremely rare but should be taken into account.

Stage of colorectal cancer diagnosis for immigrants: a population-based retrospective cohort study in Ontario, Canada

BACKGROUND

Colorectal cancer (CRC) is the second most common cause of cancer death in Canada. Immigrants in Ontario, Canada's most populous province, are known to have lower rates of CRC screening, but differences in stage of CRC diagnosis are not known.

METHODS

We utilized linked administrative databases to compare early (stage I-II) versus late (stage III-IV) stage of CRC diagnosis for immigrants versus long-term residents among patients diagnosed in Ontario between 2012 and 2017 (n = 37,717) and examined the association of immigration-related, sociodemographic, and healthcare-related factors with stage.

RESULTS

Almost 45% of those with CRC were diagnosed at a late stage. Immigrants were slightly more likely to be diagnosed at a late stage than their long-term resident counterparts [Adjusted relative risks (ARRs) 1.06 (95% CI 1.02-1.10)], but after adjusting for age and sex, this difference was no longer significant. In fully adjusted models, we observed a higher likelihood of late-stage diagnosis for people with the fewest co-morbidities (ARR 0.86 [95% CI 0.83-0.89]) and those with no visits to primary care (versus a high level of continuity of care) [ARR 1.07 (95% CI 1.03-1.12)].

CONCLUSION

Immigrants were not more likely to have a late-stage CRC diagnosis after adjusting for relevant factors, but access to primary care and healthcare contact was significantly associated with diagnostic stage.

IMPACT

Attachment to a primary care provider who provides regular preventive care may play a role in more favorable stage at diagnosis for CRC and thus should be a healthcare system priority.

Efficacité d’un traitement par lopinavir/ritonavir chez des patients hospitalisés pour pneumopathie précoce à SARS-CoV-2 : une étude rétrospective

Introduction

Actuellement, il n’existe pas de traitement antiviral spécifique pour la prise en charge des pneumopathies sévères à SARS-CoV-2. Le Haut Conseil de santé publique français a recommandé l’utilisation du lopinavir/ritonavir (LPV/RTV) qui a montré une efficacité in vitro contre ce virus. La charge virale atteignant son maximum dans la première semaine de l’infection, l’efficacité de ce traitement est probablement optimale s’il est administré pour des formes de pneumopathies précoces survenant au cours de cette première semaine.

Matériels et méthodes

Nous avons conduit une étude rétrospective à partir des données du dossier patient d’un hôpital de 350 lits, comparant 2 prises en charge des pneumopathies précoces à SARS-CoV-2 : soins de support (SDS) seuls versus SDS associés à un traitement par LPV/RTV (400 mg/100 mg) 2 fois par jour, à l’exclusion de tout autre traitement. Les patients âgés de 18 à 80 ans, hospitalisés pour pneumopathie précoce à SARS-CoV-2 avec PCR positive, en service médecine hors unité de soins intensifs (USI), ayant reçu au moins 48 h de traitement par LPV/RTV débuté dans les 10 jours à partir du début des symptômes ont été inclus dans l’analyse. Le critère de jugement principal était le transfert en USI. Les critères de jugement secondaires étaient : la mortalité hospitalière, la mortalité à j7, la survenue d’un syndrome de détresse respiratoire aigu, et la durée totale d’hospitalisation.

Résultats

Entre le 2 mars et le 12 avril 2020, 59 patients parmi les 225 (26 %) hospitalisés pour infection à SARS-CoV-2 étaient éligibles pour l’analyse. Vingt (34 %) avaient reçu un traitement par LPV/RTV + SDS et 39 (66 %) avaient reçu des SDS seuls. Le délai médian entre le début des symptômes et l’hospitalisation était de 4 jours (IQR [3–6]) et la durée médiane de traitement par LPV/RTV était de 6 jours, (IQR [5–7]). Les 2 groupes étaient comparables en termes de comorbidité (âge [médiane 56 ans, IQR (46–65)], sexe, IMC, diabète, insuffisance cardiaque et respiratoire). Dix patients ont été transférés en USI : 3/29 (15 %) dans le groupe LPV/RTV + SDS et 7/39 (18 %) dans le groupe traitement par SDS seuls (p = 0,37). La mortalité hospitalière était similaire (2 patients dans le groupe SDS seuls et aucun dans le groupe LPV/RTV + SDS, p = 0,4). Nous n’avons pas retrouvé de différence pour les autres critères de jugement. Dans le modèle de régression logistique incluant le sexe, l’âge, et la prise de LPV/RTV, aucun facteur n’était associé de manière significative à une réduction du transfert en USI.

Conclusion

L’utilisation de LPV/RTV dans les pneumopathies précoces à SARS-CoV-2 n’a pas diminué significativement le taux de passage en USI ni la mortalité hospitalière. Nos résultats justifient cependant que la stratégie d’administration précoce d’une thérapie antivirale soit évaluée dans le cadre d’un essai clinique randomisé plus important.

Low-Dose Chest CT for the Diagnosis of COVID-19—A Systematic, Prospective Comparison With PCR

BACKGROUND

Only limited evidence has been available to date on the accuracy of systematic low-dose chest computed tomography (LDCT) use in the diagnosis of COVID-19 in patients with non-specific clinical symptoms.

METHODS

The COVID-19 Imaging Registry Study Aachen (COVID-19-Bildgebungs-Register Aachen, COBRA) collects data on imaging in patients with COVID-19. Two of the COBRA partner hospitals (RWTH Aachen University Hospital and Dueren Hospital) systematically perform reverse transcriptase polymerase chain reaction (RT-PCR) from nasopharyngeal swabs as well as LDCT in all patients presenting with manifestations that are compatible with COVID-19. In accordance with the COV-RADS protocol, the LDCT scans were prospectively evaluated before the RT-PCR findings were available in order to categorize the likelihood of COVID-19.

RESULTS

From 18 March to 5 May 2020, 191 patients with COVID-19 manifestations (117 male, age 65 ± 16 years) underwent RT-PCR testing and LDCT. The mean time from the submission of the sample to the availability of the RT-PCR findings was 491 minutes (interquartile range [IQR: 276-1066]), while that from the performance of the CT to the availability of its findings was 9 minutes (IQR: 6-11). A diagnosis of COVID-19 was made in 75/191 patients (39%). The LDCT was positive in 71 of these 75 patients and negative in 106 of the 116 patients without COVID-19, corresponding to 94.7% sensitivity (95% confidence interval [86.9; 98.5]), 91.4% specificity [84.7; 95.8], positive and negative predictive values of 87.7% [78.5; 93.9] and 96.4% [91.1; 98.6], respectively, and an AUC (area under the curve) of 0.959 [0.930; 0.988]. The initial RT-PCR test results were falsely negative in six patients, yielding a sensitivity of 92.0% [83.4; 97.0]; these six patients had positive LDCT findings. 47.4% of the LDCTs that were negative for COVID-19 (55/116) exhibited pathological pulmonary changes, including infiltrates, that were correctly distinguished from SARS-CoV-2 related changes.

CONCLUSION

In patients with symptoms compatible with COVID-19, LDCT can esablish the diagnosis of COVID-19 with comparable sensitivity to RT-PCR testing. In addition, it offers a high specificity for distinguishing COVID-19 from other diseases associated with the same or similar clinical symptoms. We propose the systematic use of LDCT in addition to RT-PCR testing because it helps correct false-negative RT-PCR results, because its results are available much faster than those of RT-PCRtesting, and because it provides additional diagnostic information useful for treatment planning regardless of the type of the infectious agent.

Phylogenetic position of the Drosophila fima and dentissima lineages, and the status of the D. melanogaster species group

The subgenus Sophophora of Drosophila, which includes D. melanogaster, is an important model for the study of molecular evolution, comparative genomics, and evolutionary developmental biology. Numerous phylogenetic studies have examined species relationships in the well-known melanogaster, obscura, willistoni, and saltans species groups, as well as the relationships among these clades. In contrast, other species groups of Sophophora have been relatively neglected and have not been subjected to molecular phylogenetic analysis. Here, we focus on the endemic African Drosophila fima and dentissima lineages. We find that both these clades fall within the broadly defined melanogaster species group, but are otherwise distantly related to each other. The new phylogeny supports pervasive divergent and convergent evolution of male-specific grasping structures (sex combs). We discuss the implications of these results for defining the boundaries of the melanogaster species group, and weigh the relative merits of "splitting" and "lumping" approaches to the taxonomy of this key model system.

Awake tracheotomy in a patient with stridor and dyspnoea caused by a sizeable malignant thyroid tumor: a case report and short review of the literature

Individual airway management is mandatory in patients with large goiters undergoing thyroid surgery. Preoperative endoscopic airway evaluation and imaging studies can support clinical decision making. Awake tracheotomy can be an effective and reasonable airway management strategy in such patients.

Impact of toll-like-receptor-9 (TLR9) deficiency on visceral adipose tissue adipokine expression during chronic DSS-induced colitis in mice

BACKGROUND

Studies postulate an involvement of adipokines in inflammatory gastrointestinal diseases. Leptin-deficient ob/ob mice as well as TLR9-deficient mice have a more moderate course of chronic DSS-induced colitis (DSS-CC) and adipocytes do express functional TLR9 molecules.

MATERIAL AND METHODS

Adipokine mRNA expression in visceral adipose tissue of mice before and after the induction of DSS-CC was investigated. Experiments were performed in both TLR9(wt/wt) and TLR9(-/-) mice. In vitro, the effect of TLR9 blocking peptide on leptin and visfatin protein secretion was studied in 3T3-L1 adipocytes.

RESULTS

Induction of DSS-CC led to an upregulation of leptin mRNA expression in TLR9(wt/wt) mice, while TLR9(-/-) animals showed a significant reduction of leptin expression even below baseline. While visfatin expression remained unchanged in TLR9(wt/wt) animals, TLR9(-/-) mice exhibited a significant induction during DSS-CC. CTRP-3 expression was reduced after colitis induction only in TLR9(-/-) animals. Of note, IL-6 expression levels remained unchanged, while CXCL1/KC and cyclophilin A expression was reduced in DSS-CC. Inhibition of TLR9 signaling by using TLR9 blocking peptide led to reduced leptin protein secretion into cell culture supernatants in 3T3-L1 adipocytes, while visfatin protein secretion was enhanced.

CONCLUSIONS

DSS-CC leads to differential adipokine expression profiles in the visceral fat pad in TLR9(wt/wt) vs. TLR9(-/-) mice. In vitro, inhibition of TLR9 signaling induces visfatin secretion while inhibiting leptin secretion in adipocytes. Thus, visceral adipokines are regulated by intact TLR9 signaling pathway and a specific interplay between the leptin- and the TLR9-pathways might be of pathophysiological importance in chronic intestinal inflammation.

Value of a statistical life in road safety: a benefit-transfer function with risk-analysis guidance based on developing country data

We model a value of statistical life (VSL) transfer function for application to road-safety engineering in developing countries through an income-disaggregated meta-analysis of scope-sensitive stated preference VSL data. The income-disaggregated meta-analysis treats developing country and high-income country data separately. Previous transfer functions are based on aggregated datasets that are composed largely of data from high-income countries. Recent evidence, particularly with respect to the income elasticity of VSL, suggests that the aggregate approach is deficient because it does not account for a possible change in income elasticity across income levels. Our dataset (a minor update of the OECD database published in 2012) includes 123 scope-sensitive VSL estimates from developing countries and 185 scope-sensitive estimates from high-income countries. The transfer function for developing countries gives VSL=1.3732E-4×(GDP per capita)(∧)2.478, with VSL and GDP per capita expressed in 2005 international dollars (an international dollar being a notional currency with the same purchasing power as the U.S. dollar). The function can be applied for low- and middle-income countries with GDPs per capita above $1268 (with a data gap for very low-income countries), whereas it is not useful above a GDP per capita of about $20,000. The corresponding function built using high-income country data is VSL=8.2474E+3×(GDP per capita)(∧).6932; it is valid for high-income countries but over-estimates VSL for low- and middle-income countries. The research finds two principal significant differences between the transfer functions modeled using developing-country and high-income-country data, supporting the disaggregated approach. The first of these differences relates to between-country VSL income elasticity, which is 2.478 for the developing country function and .693 for the high-income function; the difference is significant at p<0.001. This difference was recently postulated but not analyzed by other researchers. The second difference is that the traffic-risk context affects VSL negatively in developing countries and positively in high-income countries. The research quantifies uncertainty in the transfer function using parameters of the non-absolute distribution of relative transfer errors. The low- and middle-income function is unbiased, with a median relative transfer error of -.05 (95% CI: -.15 to .03), a 25th percentile error of -.22 (95% CI: -.29 to -.19), and a 75th percentile error of .20 (95% CI: .14 to .30). The quantified uncertainty characteristics support evidence-based approaches to sensitivity analysis and probabilistic risk analysis of economic performance measures for road-safety investments.

Short-term regulation of Visfatin release in vivo by oral lipid ingestion and in vitro by fatty acid stimulation

Visfatin represents a new adipokine secreted by visceral adipose tissue and possibly regulating insulin sensitivity. Data on the regulation of visfatin are sparse and contradictory. Our study investigates the regulation of serum visfatin concentrations in healthy and non-diabetic subjects in response to the ingestion of a newly developed oral lipid solution (OLI) in vivo. Furthermore, the effects of a broad spectrum of fatty acids on adipocytic visfatin release were investigated in vitro.100 (42 male and 58 female) healthy volunteers were included in the study. Anthropometric and laboratory parameters (lipoproteins, glucose, insulin, C-peptide) were measured after an overnight fast at 0 h and 2 h, 4 h, and 6 h after OLI. 3T3-L1 preadipocytes were differentiated into mature adipocytes and stimulated with increasing doses of 10 different fatty acids, and the release of visfatin into the supernatants was measured by ELISA.Serum triglycerides significantly rose after OLI. This was accompanied by a significant decrease of glucose, insulin and C-peptide. Serum visfatin levels significantly decreased after OLI. Fasting visfatin levels were negatively correlated with fasting glucose levels. Of the 5 saturated fatty acids tested, only palmitic acid exerted significant effects by strongly downregulating visfatin release by about 66%. The mono-unsaturated fatty acids palmitoleic acid and oleic acid exerted opposite effects decreasing/increasing visfatin release, respectively. Both of the poly-unsaturated fatty acids linoleic acid and arachidonic acid decreased visfatin release.Oral lipid ingestion is a physiological regulator of systemic visfatin release. Fatty acids differentially regulate visfatin release in vitro.

Quick test of ultrasonic transducer arrays radiating in air using B-mode-images

This paper describes a statistical procedure working on ultrasound B-mode images that were recorded with the transducer array radiating in air. From the digital image data, a gray value profile was generated using a computer program. A statistical procedure was developed to examine if there are significant deviations from the mean. They occur, for example, when single piezoelements are severely damaged or completely out of function. The entire technique was tested using an ultrasonic imaging system (SonixTouch, Ultrasonix Medical Corporation, Richmond, Canada) in which individual elements or groups of elements can be turned off via firmware. A failure of as large as two out of 128 elements was detectable.

How perfect are you with defective probes? Information on the results of the mini-trial on technical quality assurance during the "Ultraschall 2012" conference in Davos

This article deals with the technical quality assurance of ultrasound B-systems. As part of a mini-trial during the Dreiländertreffen in Davos "Ultrasound 2012", we addressed the question as to whether physicians can detect faulty probes spontaneously during live scanning B-mode. For this purpose a special diagnostic device had been prepared so that groups of piezoelectric elements in the array were without function. Then the images had to be characterized by test persons without knowledge of the faulty elements. The results show that a deterioration of the image could be detected starting at five disabled elements. Due to the small number of test persons, our statements are only preliminary.

Regulation and function of C1Q/TNF-related protein-5 (CTRP-5) in the context of adipocyte biology

BACKGROUND AND AIM

The C1q/TNF-related protein (CTRP) family represents a growing family of adiponectin paralogous proteins. CTRP-5 was detected in adipose tissue of mice and plays a role in the context of the metabolic syndrome. It was the aim to investigate the detailed expression profile of CTRP-5 in a variety of adipocytic cells and to determine whether CTRP-5 circulates in human serum. Moreover, regulation and function of CTRP-5 was studied in the context of adipocyte biology.

MATERIAL AND METHODS

CTRP-5 serum levels were measured in 50 healthy subjects by ELISA. Genotype analysis was performed by direct sequencing in 200 probands. CTRP-5 mRNA and protein expression was analyzed by RT-PCR, real-time RT-PCR and Western blot. Recombinant CTRP-5 and fatty acids were used for stimulation experiments in 3T3-L1 adipocytes. siRNA-mediated knockdown of CTRP-3 was performed during adipocyte differentiation.

RESULTS

CTRP-5 mRNA and protein was strongly expressed in a wide variety of human and murine adipocytic cells and was induced during adipocyte differentiation. Saturated fatty acids increased CTRP-5 expression in adipocytes. siRNA-mediated cellular knockdown of CTRP-3 in adipocytes resulted in an upregulation of CTRP-5 expression. CTRP-5 inhibited the release of resistin and adiponectin dose-dependently. CTRP-5 circulates abundantly in human sera with a broad interindividual variation. The SNP 1014 T/A was not associated with type 2 diabetes mellitus in 200 Caucasian probands.

CONCLUSIONS

CTRP-5 might be a novel adipokine that circulates abundantly in human sera. CTRP-5 is functionally involved in adipocyte biology and there might exist a counter-regulatory connection with its family member, CTRP-3.

The novel adipokine C1q/TNF-related protein-3 is expressed in human adipocytes and regulated by metabolic and infection-related parameters

BACKGROUND

The growing family of C1Q/TNF-related proteins is characterized by structural homologies to the anti-inflammatory adipokine adiponectin. CTRP-3 was recently reported to function as an anti-inflammatory LPS-antagonist in vitro.

MATERIAL AND METHODS

Human subcutaneous and visceral adipocytes and murine 3T3-L1 adipocytes were used for analysis of CTRP-3 expression and function. Western blot analysis of CTRP-3, siRNA mediated knockdown of CTRP-3, Oil red O staining, assessment of basal and epinephrine-induced lipolysis, ELISA-based measurements of supernatant chemokines, recombinant CTRP-3 protein expression, and Staphylococcus aureus (S. aureus) infection assays were used.

RESULTS

CTRP-3 is expressed in subcutaneous and visceral adipocytes. CTRP-3 is positively regulated by insulin, whereas chronic LPS-exposure inhibits terminal adipocyte differentiation and CTRP-3 expression. Intracellular infection of adipocytes by S. aureus also decreases CTRP-3 expression. As demonstrated by siRNA-mediated cellular knockdown of CTRP-3 in adipocytes, CTRP-3 regulates resistin secretion and lipolysis.

CONCLUSION

CTRP-3 is expressed in human adipocytes and plays an important role in adipocyte physiology such as lipolysis and adipokine secretion. Both, metabolic factors and infection/inflammation-related factors regulate CTRP-3 expression.

Investigation of the suitability of tissue phantoms for testing the constancy of ultrasonic transducer arrays in quality assurance

PURPOSE

To ensure high quality ultrasound diagnostics, proper functioning of the devices used is a necessary prerequisite. Ultrasound transducers have proven to be the most failure-prone part of the signal chain. Their technical monitoring is possible in principle with the help of tissue phantoms. The background of the present study is to determine which type of phantoms and which measurement parameters are best suited to a consistency test as part of routine quality assurance of ultrasound imaging systems.

MATERIALS AND METHODS

A classic wire-type phantom (ATS Mod. 539, ATS Labs Bridgeport, USA) and a 3 D cyst phantom (TCC, Timelkam, Austria) were used for the studies and comparative tests were conducted between intact transducers and those in which faults had been simulated. The collected measurement data show a relatively large scatter. Therefore, statistical analysis methods were used, and the discrimination analysis proved to be a useful tool.

RESULTS

Local failures which arise, e. g. due to the breakdown of individual piezoelectric elements or element groups in the transducer array, can be detected with the help of the gray value targets of the ATS phantom, but only in those cases in which the error-affected sound field part actually overlaps with the target under consideration. The TCC phantom is not suitable for the detection of such errors. Global transducer failures, i. e. those that affect the entire array, can even be detected with both types of phantoms.

CONCLUSION

When the emphasis of quality assessment is on the detection of local defects in the array that make up the largest part of the transducer faults, studies with conventional phantoms are only of limited value.

Overdiagnosis of a typical carcinoid tumor as an adenocarcinoma of the lung: a case report and review of the literature

Background

Overdiagnosis of bronchopulmonary carcinoid tumors together with overtreatment can cause serious postoperative consequences for the patient. We report of a patient with a typical bronchopulmonary carcinoid tumor, which was initially misdiagnosed and treated as an adenocarcinoma of the lung. GnrH receptors and the associated Raf-1/MEK/ERK-1/2-pathway are potential targets for analogs in cancer treatment. We suspected a correlation between the lack of tumor growth, application of leuprolide and the Raf-1/MEK/ERK-1/2-pathway. Therefore, we examined GnrH receptor status in the examined specimen.

Case presentation

In 2010 a 77 year-old male patient was shown to have a tumor mass of about 1.7 cm diameter in the inferior lobe of the left lung. Since 2005, this tumor had hitherto been known and showed no progression in size. The patient suffered from prostate cancer 4 years ago and was treated with TUR-P, radiation therapy and the application of leuprolide. We conducted an explorative thoracotomy with atypical segment resection. The first histological diagnosis was a metastasis of prostate cancer with lymphangiosis carcinomatosa. After several immunohistochemical stainings, the diagnosis was changed to adenocarcinoma of the lung. We conducted a re-thoracotomy with lobectomy and systematic lymphadenectomy 12 days later. The tumor stage was pT1 N0 MX G2 L1 V0 R0. Further immunohistochemical studies were performed. We received the results 15 days after the last operation. The diagnosis was ultimately changed to typical carcinoid tumor without any signs of lymphatic vessel invasion. The patient recovered well from surgery, but still suffers from dyspnea and lack of physical performance. Lung function testing revealed no evidence of impairment.

Conclusion

The use of several immunohistochemical markers, careful evaluation of hematoxylin-eosin sections and the Ki-67 labelling index are important tools in discriminating between carcinoids and other bronchopulmonary carcinomas. Although we could not detect GnrH-receptors in the examined specimen, there may be individual differences in expression. GnrH receptor profiles in typical and atypical carcinoids should be scrutinized. This could lead to new therapeutical options, since the GnrH receptor has already been described on atypical carcinoids. Clinically tested drugs such as leuprolide could come to use.

Type 2 diabetes and lipoprotein metabolism affect LPS-induced cytokine and chemokine release in primary human monocytes

AIMS/HYPOTHESIS

Obesity and insulin resistance are characterized by a chronic and low grade state of inflammation and the pro-inflammatory response of monocytes is affected in type 2 diabetes mellitus (T2D). We aimed to investigate whether LPS-induced monocytic cytokine and chemokine release depends on serum lipoprotein parameters in T2D patients.

METHODS

Primary human monocytes were isolated from 29 patients with known T2D and from 20 healthy volunteers. Anthropometric and disease-related parameters such as age, gender, BMI, WHR, diabetes duration, diabetes complications, and diabetes control (HbA1c) were documented. Monocytes were stimulated for 18 h with LPS (1 μg/ml). Unstimulated monocytes served as control. The supernatant concentrations of CCL2, CCL3, CCL4, CCL5, MIF and resistin were measured by ELISA.

RESULTS

LPS-stimulation significantly (p<0.001) increased CCL chemokine and resistin concentrations in healthy controls and in patients with T2D, whereas MIF release was not affected in both groups. LPS-induced CCL2 and resistin concentrations were significantly higher in T2D patients when compared to healthy controls. In T2D patients, LPS-induced CCL3 concentration was higher in males when compared to females (p=0.039) and supernatant resistin concentration upon stimulation with LPS showed a significant and positive correlation with age (r=0.6; p=0.001). LPS-induced CCL2 concentration was significantly and positively correlated with serum triglyceride concentration (r=0.4; p=0.009) in T2D patients. Furthermore, LPS-induced CCL4 concentration was significantly and positively correlated with total (r=0.4; p=0.035) and LDL cholesterol (r=0.4; p=0.033) concentration.

CONCLUSIONS

LPS responsiveness of monocytes is altered in T2D and is affected by the respective serum lipoprotein metabolism.

Does clinical pretest probability influence image quality and diagnostic accuracy in dual-source coronary CT angiography?

RATIONALE AND OBJECTIVES

To prospectively evaluate the influence of the clinical pretest probability assessed by the Morise score onto image quality and diagnostic accuracy in coronary dual-source computed tomography angiography (DSCTA).

MATERIALS AND METHODS

In 61 patients, DSCTA and invasive coronary angiography were performed. Subjective image quality and accuracy for stenosis detection (>50%) of DSCTA with invasive coronary angiography as gold standard were evaluated. The influence of pretest probability onto image quality and accuracy was assessed by logistic regression and chi-square testing. Correlations of image quality and accuracy with the Morise score were determined using linear regression.

RESULTS

Thirty-eight patients were categorized into the high, 21 into the intermediate, and 2 into the low probability group. Accuracies for the detection of significant stenoses were 0.94, 0.97, and 1.00, respectively. Logistic regressions and chi-square tests showed statistically significant correlations between Morise score and image quality (P < .0001 and P < .001) and accuracy (P = .0049 and P = .027). Linear regression revealed a cutoff Morise score for a good image quality of 16 and a cutoff for a barely diagnostic image quality beyond the upper Morise scale.

CONCLUSION

Pretest probability is a weak predictor of image quality and diagnostic accuracy in coronary DSCTA. A sufficient image quality for diagnostic images can be reached with all pretest probabilities. Therefore, coronary DSCTA might be suitable also for patients with a high pretest probability.

Fatty acids as metabolic mediators in innate immunity

BACKGROUND

Increasing data support the hypothesis of a local and systemic crosstalk between adipocytes and monocytes mediated by fatty acids. The aim of this study was to characterize the immunomodulatory effects of a large panel of fatty acids on cytokines and chemokines in monocytic THP-1 cells and primary human monocytes. We tested whether anti-inflammatory fatty acids are able to inhibit the binding of lipopolysaccharide (LPS) to its receptor, toll-like receptor/MD-2 (TLR4/MD-2).

MATERIALS AND METHODS

Resistin, monocyte chemoattractant protein-1 (MCP-1) and tumour necrosis factor (TNF) were measured by enzyme-linked immunosorbent assay. Proteins were analysed by Western blot. A designed Flag-tagged TLR4/MD-2 fusion protein (LPS trap) was used to investigate the effect of fatty acids on binding of LPS to its receptor. In 30 patients with type 2 diabetes mellitus (T2D), the correlation of serum triglyceride levels with LPS-induced monocyte activation was analysed.

RESULTS

Eleven fatty acids investigated exerted differential effects on the monocytic release of cytokines and chemokines. Eicosapentaenoic acid had potent anti-inflammatory effects on human primary monocytes and THP-1 cells; 100 and 200 microM eicosapentaenoic acid dose-dependently inhibited LPS binding to the LPS trap. LPS-induced release of monocytic MCP-1 and TNF was significantly and positively correlated with serum triglyceride levels in 30 patients with T2D.

CONCLUSIONS

Monocytic activation is differentially regulated by fatty acids and depends on triglyceride levels in T2D. The main finding of the present study shows that eicosapentaenoic acid inhibits the specific binding of LPS to TLR4/MD-2. Eicosapentaenoic acid represents a new anti-inflammatory LPS-antagonist.

Adiponectin downregulates CD163 whose cellular and soluble forms are elevated in obesity

BACKGROUND

CD163 is a monocyte/macrophage specific receptor whose soluble form (sCD163) is elevated in inflammatory diseases. Obesity is associated with chronic inflammation and low adiponectin, an anti-inflammatory adipokine. Adiponectin, 5-aminoimidazole-4-carboxamide-1-4-ribofuranoside (AICAR) and metformin activate the AMP-kinase that exerts anti-inflammatory effects, and the influence of adiponectin and these drugs on monocytic CD163 was analysed, and cellular and sCD163 were determined in obesity and type 2 diabetes.

MATERIALS AND METHODS

Monocytes were incubated with adiponectin, AICAR or metformin. Furthermore, monocytes and serum were obtained from type 2 diabetic patients (T2D), overweight (defined as a body mass index > or = 25 kg m(-2)) and normal-weight (NW) controls. CD163 was analysed by immunoblot and sCD163 was measured by enzyme-linked immunosorbent assay in the supernatants of the monocytes and in serum.

RESULTS

In monocytes, adiponectin reduced cellular and surface CD163, whereas sCD163 was not altered in the corresponding supernatants. Further, metformin and AICAR downregulated CD163. Monocytic CD163 was higher in T2D and obesity, whereas sCD163 in the supernatants was not elevated and neither correlated with serum sCD163 nor systemic adiponectin. There was a positive correlation of monocytic sCD163 with serum but not with monocytic IL-6. In the serum of obese controls and T2D patients, sCD163 was significantly higher compared to NW donors and was positively associated with systemic IL-6.

CONCLUSIONS

This study indicates that monocytic CD163 and systemic sCD163 are elevated in T2D and obesity. Adiponectin reduces CD163 in vitro, but additional factors related to obesity like IL-6 may be more relevant in vivo.

Accuracy of dual-source CT in the characterisation of non-calcified plaque: use of a colour-coded analysis compared with virtual histology intravascular ultrasound

Non-invasive assessment of plaque volume and composition is important for risk stratification and long-term studies of plaque stabilisation. Our aim was to evaluate dual-source computed tomography (DSCT) and colour-coded analysis in the quantification and classification of coronary atheroma. DSCT and virtual histology intravascular ultrasound (IVUS-VH) were prospectively performed in 14 patients. 22 lesions were compared in terms of plaque volume, maximal per cent vessel stenosis and percentages of fatty, fibrous or calcified components. Plaque characterisation was performed with software that automatically segments luminal or outer vessel boundaries and uses CT attenuation for a colour-coded plaque analysis. Good correlation was found for per cent vessel stenosis in DSCT (53+/-13%) and IVUS (51+/-14%; r(2) = 0.70). Mean volumes for entire plaque and non-calcified atheroma were 68.5+/-33 mm(3) and 56.7+/-30 mm(3), respectively, in DSCT and 60.8+/-29 mm(3) and 55.8+/-26 mm(3), respectively, in IVUS. Mean percentages of fatty, fibrous or calcified components were 28.2+/-6%, 53.2+/-9% and 18.7+/-13%, respectively, in DSCT and 29.9+/-5%, 55.3+/-12% and 14.4+/-9%, respectively, in IVUS-VH. Significant overestimation was present for the entire plaque and the volume of calcified plaque (p = 0.03; p = 0.0004). Although good correlation with IVUS was obtained for the entire plaque (r(2) = 0.76) and non-calcified plaque volume (r(2) = 0.84), correlation proved very poor and insignificant for percentage plaque composition. Interclass correlation coefficients for non-calcified plaque volume and percentages of fatty, fibrous or calcified components were 0.99, 0.99, 0.95 and 0.98, respectively, and intraclass coefficients were 0.98, 0.93, 0.98 and 0.99, respectively. We found that using Hounsfield unit-based analysis, DSCT allows for accurate quantification of non-calcified plaque. Although percentage plaque composition proves highly reproducible, it is not correlated with IVUS-VH.

Peritoneal fluid adipokines: ready for prime time?

BACKGROUND

Visceral adipose tissues secret a variety of adipokines; however, it is not known whether they are present in the peritoneal fluid. It was the aim of this study to investigate peritoneal fluid concentrations of novel (cartonectin, omentin) and classical adipokines (leptin, adiponectin, resistin, visfatin) in patients with ascites.

MATERIAL AND METHODS

Ninety-six patients (71 men and 25 women) undergoing paracentesis were included. Of these, 76 suffered from liver cirrhosis. Adipokines were measured by enzyme-linked immunosorbent assay or Western blot.

RESULTS

Each adipokine was detected in ascites with a broad range. Serum-ascites ratios (SAR) correlated with clinical and laboratory parameters. The main variables influencing peritoneal fluid adipokine concentrations were body mass index (BMI), local inflammation, systemic inflammation and serum adipokine concentrations. Resistin was significantly higher in patients with peritonitis and showed a positive correlation with peripheral leucocytes (white blood cell count). Leptin was correlated with the underlying disease. Visfatin correlated with peripheral white blood cell and C-reactive protein levels. Omentin expression was correlated with ascitic leucocyte count, ascitic albumin concentration and low albumin SAR. BMI was correlated positively with ascitic leptin levels and cartonectin protein levels.

CONCLUSIONS

Peritoneal fluid adipokine concentrations are characterized by individual SARs, depend on the presence of peritonitis, and correlate with underlying disease, BMI and systemic inflammation. The data open a new field of research on the role of the peritoneum and visceral adipokines in gastrointestinal diseases.

Hip fractures in users of first- vs. second-generation bisphosphonates

This study compared population hip fracture rates for women with a prior fragility fracture who were treated with first-generation versus second-generation bisphosphonate therapies. The observational study found that, relative to women treated with etidronate, a first-generation bisphosphonate, women treated with the second-generation therapies 'alendronate' or 'risedronate' were equally likely to be admitted to hospital for hip fracture. Our findings must be confirmed in large randomized head-to-head controlled trials.

INTRODUCTION

Few studies have examined hip fracture outcomes among users of first- versus second-generation bisphosphonates. We compared hip fracture rates among elderly women with a history of fracture dispensed first- and second-generation bisphosphonates, hypothesizing that hip fracture rates would be higher among users of first- versus second-generation bisphosphonates after adjusting for confounders.

METHODS

Administrative data from Ontario, Canada from 01 April 1998 to 31 March 2002 was used to identify population-based bisphosphonate-naïve cohorts of subjects age 66 years and older initiated on first- (etidronate plus calcium; n = 19,127) or second-generation (alendronate or risedronate; n = 1,460) bisphosphonates. Multivariate Cox proportional hazard models were used for analysis.

RESULTS

During over 23,000 person-years of follow-up, we observed 293 hospital admissions for first hip fracture. The unadjusted event rates yielded approximately 12.5 hospital admissions for hip fracture per 1,000 person-years of follow-up in each study group. Relative to the etidronate plus calcium group, females in the alendronate or risedronate group were equally likely to be admitted for hip fracture (adjusted rate ratio [aRR] = 1.0; 95% CI 0.6-1.6).

CONCLUSIONS

The findings of this study suggest similar rates of hip fracture between the first- and second-generation bisphosphonates when used continuously among elderly females with a prior history of fracture.

First performance evaluation of a dual-source CT (DSCT) system

We present a performance evaluation of a recently introduced dual-source computed tomography (DSCT) system equipped with two X-ray tubes and two corresponding detectors, mounted onto the rotating gantry with an angular offset of 90 degrees . We introduce the system concept and derive its consequences and potential benefits for electrocardiograph [corrected] (ECG)-controlled cardiac CT and for general radiology applications. We evaluate both temporal and spatial resolution by means of phantom scans. We present first patient scans to illustrate the performance of DSCT for ECG-gated cardiac imaging, and we demonstrate first results using a dual-energy acquisition mode. Using ECG-gated single-segment reconstruction, the DSCT system provides 83 ms temporal resolution independent of the patient's heart rate for coronary CT angiography (CTA) and evaluation of basic functional parameters. With dual-segment reconstruction, the mean temporal resolution is 60 ms (minimum temporal resolution 42 ms) for advanced functional evaluation. The z-flying focal spot technique implemented in the evaluated DSCT system allows 0.4 mm cylinders to be resolved at all heart rates. First clinical experience shows a considerably increased robustness for the imaging of patients with high heart rates. As a potential application of the dual-energy acquisition mode, the automatic separation of bones and iodine-filled vessels is demonstrated.

Clinical evaluation of a computer simulated prediction model of contrast enhancement of the liver in spiral CT

OBJECTIVE

A software program was developed simulating a compartmental model of blood circulation based on differential equations. The aim of this study was to compare software-simulated levels of hepatic enhancement with the true values in patients and to test how many patients reach the simulated hepatic enhancement level.

METHODS

As software program the CT application software carebolus 2 (Siemens, Forchheim, Germany) was used. Hepatic contrast-enhancement curves were simulated prior to CT examinations to evaluate a patient specific time delay after contrast application. At the time delay, when the simulation curve showed an enhancement threshold of 40 Hounsfield Units (HU), the CT spiral scan was started applying 120 ml contrast media with 2 ml/s. The simulated curves were compared with the empiric curves of each patient.

RESULTS

25 of 28 patients (89%) achieved 40 HU. The mean enhancement of empiric patients curves was 46.32 +/- 11.9 HU, the mean simulated enhancement was 46.62 +/- 4.3 HU S.D. (P= 0.48). 4.4 values per patient liver could be compared with the simulation curve (122 points for 28 patients): 50% of the patient curves were within a range of 5 HU compared with the simulation curve.

CONCLUSION

Software simulation of contrast enhancement curves of the liver is a feasible and valuable method to predict individual liver enhancement curves. Improvements concerning the integration of cardiovascular parameters and preexisting liver parenchymal diseases into the simulation software have to be arranged.

Effects of tamoxifen on transcriptional level of transforming growth factor beta (TGF-beta) isoforms 1 and 2 in tumor tissue during primary treatment of patients with breast cancer

Tamoxifen action in breast cancer is believed to be mediated in part by regulation of transforming growth factor beta (TGF-beta) isoforms in tumor tissue. However, the pattern of this regulation and its relation ship to clinical data are not yet clearly understood. Tumor tissue was derived from 10 patients with breast cancer before and following primary treatment with tamoxifen over a period of 1-12 days, preceding tumor ectomy. Each tissue sample was processed for semiquantitative assessment of the mRNA expression levels of the TGF-beta isoforms 1 and 2 using competitive RT-PCR. The results of mRNA quantification were then related to the estrogen receptor-alpha (ER-alpha) and progesterone receptor (PR) status of the tumors as well as to the clinical course during the first 5-6 postoperative years in patients who additionally received adjuvant tamoxifen therapy. TGF-beta 1 mRNA and TGF-beta 2 mRNA expression was detectable in all examined samples. During treatment with tamoxifen, the TGF-beta 2 mRNA level changed in 8 cases, increasing seven times and decreasing once, whereas the TGF-beta 1 mRNA level changed in only two cases, increasing once and decreasing once. Our data do not provide evidence of a strong correlation between the occurrence of tamoxifen-related induction of TGF-beta 2 mRNA expression and the ER-alpha or PR status. The prediction sensitivity of the response to adjuvant therapy, to which relapse-free survival during post-operative follow-up over 5-6 years was attributed, increased when the tamoxifen-related up-regulation of the TGF-beta 2 mRNA level was considered to predict response, in addition to the ER-alpha- and/or PR-rich receptor status. We conclude that tamoxifen predominantly induces an up-regulation of TFG-beta 2 expression on the transcriptional level in breast cancer, which may predict clinical response independently of the ER-alpha/PR status in some cases.

Comparison of 18FDG-PET with CT scans in the evaluation of patients with residual and recurrent Hodgkin's lymphoma

The reliable assessment of residual masses after treatment as well as of new lesions suspected for relapse remains a diagnostic problem in patients with Hodgkin's disease (HD). The current study compares the results obtained by CT scan to FDG-PET imaging in a blind analysis with respect to the viability of residual masses and in case of suspected relapse. Between 1/94 and 10/99, 47 comparisons of PET and corresponding CT scans - 26 comparisons in 24 patients with residual tumors and 21 comparisons in 20 patients with suspected relapse of HD - were evaluated by independent reviewers blinded to he results of each other. Patients with primary diagnosis had been treated within trials of the German HD Trial study group. Relapsed patients received intensified salvage chemotherapy regimens. PET was assessed visually and by quantifying glucose uptake (SUV). Changes in size of tumor lesions as well as contrast medium enhancement served as criteria for assessment by CT scans. Results were validated either by histologic examination of a resected mass or biopsy (n=17) or by a clinical follow-up over 6 months following treatment (n=30). In 26 cases with residual lesions FDG-PET showed an increased tracer uptake in 8, 7 of which were true positive (TP) and 1 false positive (FP). Eighteen cases were classified as being negative (no viable HD), 17 true negative (TN) and 1 FN. In the blinded reading of the corresponding CT scans, 10 cases with residual lesions were considered to contain vital lymphoma (2 TP, 8 FP). Sixteen CT scans were classified as negative (10 TP, 6 FN). The resulting sensitivity and specificity of PET were 87.5% and 94.4% in contrast to only 25% and 56% for CT scans. The positive and negative predictive values of PET and CT scans were 87.5% and 94.4% and 20% and 62.5%, respectively. In patients with suspected relapse, sensitivity and positive predictive value for the diagnosis of the relapse were 100% and 86%, respectively, yielding the same results for both methods. FDG-PET performed in HD patients with residual masses appears to offer important additional information regarding the presence of viable HD in these residual lesions. In patients with suspected relapse of HD, FDG-PET seems not to offer any information over CT scans. Using SUVs is not superior to visual assessment of PET alone.

[Optimizing image reconstruction timing for the RR interval in imaging coronary arteries with multi-slice computerized tomography]

PURPOSE

Multislice spiral CT is a newly developed technology that allows the non-invasive detection of coronary stenoses and plaques. The acquired raw data are reconstructed at a given time point in the RR interval of the heart cycle. Thus, determination of this time point is a key factor for picture quality and for reliable diagnostic results. This study was performed to investigate the optimal time point for reconstruction within the RR interval.

MATERIALS AND METHODS

The coronary arteries of 13 patients were examined with CT. Raw data were reconstructed 250, 350, 450 and 550 ms before the following R wave (absolute reverse retrospective ECG gating) for each patient. Data were then analyzed with a volume rendering mode on a SIEMENS 3 D-Virtuoso workstation. A total of 91 segments (segments 1 and 2 of the RCA, segments 5, 6, 7 and proximal and distal parts of segment 11) were assessed and image quality was classified.

RESULTS

Visualization of the left main coronary artery was of a good quality at all time points, segments 6 and 7 of the LAD as well as the proximal and distal parts of segment 11 of the RCX had the best quality at 450 ms absolute reverse retrospective ECG gating. The segments 1 and 2 of the RCA were of best quality 550% ms absolute reverse to the R peak.

CONCLUSIONS

Classification of image quality of coronary artery CT scans after retrospectively ECG gated reconstruction is highly determined by the time point of reconstruction in the heart cycle. The optimization of this time point increases diagnostic accuracy and helps to avoid misinterpretation due to image artifacts.

Prophenoloxidase as a Reporter of Gene Expression in Drosophila

We have developed a novel reporter for the analysis of gene expression using a Drosophilaprophenoloxidase (proPO) gene. We have expressed proPO in transgenic flies using the GAL4-UAS system and characterized ectopic expression in imaginal discs. proPO staining is fast and robust, requiring only inexpensive reagents, and performs similarly to β-galactosidase (β-gal) staining. Double staining using UAS-proPO and β-gal reporters is straightforward and provides a convenient method for examining the expression of two genes simultaneously.

Waste gas exposure to sevoflurane and nitrous oxide during anaesthesia using the oesophageal-tracheal Combitube small adult

Exposure to sevoflurane (SEV) and nitrous oxide during ventilation using a Combitube (37Fr) small adult (SA) was compared with waste gas exposure using conventional endotracheal tubes. Trace concentrations of SEV and nitrous oxide were assessed using a direct reading spectrometer during 40 gynaecological laparoscopic procedures under general anaesthesia. Measurements were made at the patients' mouth and in the anaesthetists' breathing zone. Mean (SD) concentrations of SEV and nitrous oxide measured at the patients' mouth were comparable in the Combitube SA (SEV 0.6 (0.2) p.p.m.; nitrous oxide 9.7 (8.5) p.p.m.) and endotracheal tube group (SEV 1.2 (0.8) p.p.m.; nitrous oxide 17.2 (10.6) p.p.m.). These values caused comparable contamination of the anaesthetists' breathing zone (SEV 0.6 (0.2) p.p.m. and nitrous oxide 4.3 (3.7) p.p.m. for the Combitube SA group, compared with SEV 0.5 (0.2) p.p.m. and nitrous oxide 4.1 (1.8) p.p.m. for the endotracheal tube group). We conclude that the use of the Combitube SA during positive pressure ventilation is not necessarily associated with increased waste gas exposure, especially when air conditioning and scavenging devices are available.