Optimal size threshold for PIRADSv2 category 5 upgrade and its positive predictive value: is it predictive of "very high" likelihood of clinically-significant cancer?

AIM

To identify the optimal size metric and threshold for Prostate Imaging Reporting and Data System (PIRADS) 5 upgrade, calculate its positive predictive value (PPV) for clinically-significant prostate cancer (csPCA), and determine if it is indicative of a "very high" likelihood of csPCA.

MATERIALS AND METHODS

One hundred and forty-three PIRADS 4 or 5 lesions were evaluated. Lesion diameters were used to calculate lesion volume (LV). Pearson correlation between maximum lesion diameter (MLD) and LV was calculated. Area under the curve (AUC) for discriminating csPCA (Gleason grade ≥ 3 + 4) was calculated using MLD and LV. Optimal size thresholds (using Youden index) and highly predictive size thresholds were identified for the whole prostate (WP), peripheral zone (PZ), and transitional zone (TZ).

RESULTS

There was high correlation between MLD and LV (r=0.77-0.81), with comparable AUCs for MLD and LV in the identification of csPCA in the WP (0.73, 0.72), PZ (0.73, 0.73), and TZ (0.79, 0.75). Optimal MLD thresholds were 1.4, 1.4, and 1.6 cm in the WP, PZ, and TZ respectively, with PPVs of 76%, 81%, and 69%, respectively. An MLD threshold of 2.7 cm would be needed in the WP to achieve a PPV approaching 90%, with sensitivity decreasing to 10%.

CONCLUSIONS

There is high correlation between MLD and LV with comparable discrimination of csPCA using each. PIRADSv2's 1.5 cm MLD threshold is near the optimal threshold for PIRADS 5 upgrade but has moderate PPV. A much higher threshold would be needed to increase its PPV, with significant sacrifice in sensitivity.

Prediction of Progression After Cervix Cancer Radiotherapy Using a Machine-Learning Model on Pre-Treatment MRI

PURPOSE/OBJECTIVE(S)

MRI may be useful to identify women with cervical cancer at high risk of disease progression to test strategies of treatment intensification. The purpose of this study was to determine the value of a machine-learning model built on pre-treatment MRI for prediction of risk of progression after radiation therapy.

MATERIALS/METHODS

MagneticResonance Imaging (MRI) data for women with cervical cancer was collected from The Cancer Genome Atlas Cervical Squamous Cell Carcinoma and Endocervical Adenocarcinoma Collection (TCGA-CESC) on the Cancer Imaging Archive (TCIA), which reported clinical, treatment, and imaging data from a single institution. 27 patients who had received radiation for cervical cancer were selected for input into a custom 3-D Residual Neural Network (ResNet) model with added custom layers specific to DICOM data in tensorflow python package. One T2 MRI per patient was used to predict recurrence free survival after radiation treatment, where patients were predicted to be "high risk" or "low risk" for disease recurrence as the output of the model. All slices of the T2 MRI were used. The model was validated using five-fold cross validation; 80% of the data was used to train each fold and 20% was used for testing. Final model statistical significance was confirmed through shuffle test at the p < 0.01 level. The clinical outcomes of patients and the model's "low-risk" and "high-risk" prediction were compared.

RESULTS

There were 27 patients in the study with mean age of 51 years (range 29-79). 20 patients had squamous cell carcinoma and 7 patients had adenocarcinoma. The stage breakdown consisted of 9 women IB, 2 IIA, 9 IIB, 2 IIIA, 2 IIIB, and 3 stage IV. 10 women were treated with radiation alone and 17 with chemo-radiation. 5 women received surgery in addition to radiation or chemoradiation. 21 patients received brachytherapy. Median follow-up of patients was 29 months (range 3-64). The model predicted 7 patients as "high risk" for recurrence; all 7 developed a recurrence during follow up. None of the 20 patients predicted to be "low risk" developed disease recurrence. Among all patients in the study, the two-year progression free survival (PFS) was 82.0%. Patients identified as "low risk" and "high risk" by model had two-year PFS of 100% and 43%, respectively. Among patients with recurrence, 3 developed local recurrence and 4 developed distant metastases. The ResNet model achieved cross-validated accuracy of 92% for prediction of progression-free survival (p<0.01).

CONCLUSION

A 3-D ResNet machine-learning model using pretreatment MRI image data can accurately predict clinical outcomes for cervical cancer following radiation therapy. Future work to confirm generalizability should focus on validation with a larger clinical dataset.

Factors associated with oral health inequalities in Korean adolescents

Aim

The purpose of this study was to identify factors related to socioeconomic differences in oral health behavior and oral symptom experience in Korean adolescents using the 2017 Korea Youth Risk Behavior Web-Based Survey(KYRBS).

Methods

From the national 2017 KYRBS, which was approved by the Research Ethics Review Committee of the Korea Centers for Disease Control and Prevention, 61,874 adolescents aged 12-18 years were selected as participants of the present study. Toothbrushing, gum bleeding and toothache experience were selected as dependent variables, and subjective socioeconomic status (SES) was used as a measure of SES. For statistical analysis, complex samples logistic regression analysis was performed using SAS 9.3 (PROC SURVEYLOGISTIC).

Results

The Odds Ratio (OR) for toothbrushing variable in the highest SES group was 1.78 (95% CI: 1.68-1.88). The OR for the bleeding gums in the lowest SES group was 1.28 (95% CI: 1.21-1.36). Academic factors accounted for 19% of socioeconomic differences in toothbrushing, and psychological factors accounted for 36-49% of socioeconomic differences in oral symptoms.

Conclusions

Adolescent oral health inequalities were associated with a variety of factors including health behaviors, psychological factors, family and academic factors. Thus, oral health promotion of adolescents can be achieved by integrating relevant factors, which can be effective when based on schools.

Key messages

Social gradient in oral health behavior and oral symptoms of Korean adolescents persist when adjusted for behavioural, psychosocial and material factors. Because oral health in adolescents is linked to overall health, health promotion can be achieved when oral health inequalities are integrated and mediated within the overall health domain.

miR526b and miR655 Induce Oxidative Stress in Breast Cancer

In eukaryotes, overproduction of reactive oxygen species (ROS) causes oxidative stress, which contributes to chronic inflammation and cancer. MicroRNAs (miRNAs) are small, endogenously produced RNAs that play a major role in cancer progression. We established that overexpression of miR526b/miR655 promotes aggressive breast cancer phenotypes. Here, we investigated the roles of miR526b/miR655 in oxidative stress in breast cancer using in vitro and in silico assays. miRNA-overexpression in MCF7 cells directly enhances ROS and superoxide (SO) production, detected with fluorescence assays. We found that cell-free conditioned media contain extracellular miR526b/miR655 and treatment with these miRNA-conditioned media causes overproduction of ROS/SO in MCF7 and primary cells (HUVECs). Thioredoxin Reductase 1 (TXNRD1) is an oxidoreductase that maintains ROS/SO concentration. Overexpression of TXNRD1 is associated with breast cancer progression. We observed that miR526b/miR655 overexpression upregulates TXNRD1 expression in MCF7 cells, and treatment with miRNA-conditioned media upregulates TXNRD1 in both MCF7 and HUVECs. Bioinformatic analysis identifies two negative regulators of TXNRD1, TCF21 and PBRM1, as direct targets of miR526b/miR655. We validated that TCF21 and PBRM1 were significantly downregulated with miRNA upregulation, establishing a link between miR526b/miR655 and TXNRD1. Finally, treatments with oxidative stress inducers such as H₂O₂ or miRNA-conditioned media showed an upregulation of miR526b/miR655 expression in MCF7 cells, indicating that oxidative stress also induces miRNA overexpression. This study establishes the dynamic functions of miR526b/miR655 in oxidative stress induction in breast cancer.

New mesh-type phantoms and their dosimetric applications, including emergencies

Committee 2 of the International Commission on Radiological Protection (ICRP) has constructed mesh-type adult reference computational phantoms by converting the voxel-type ICRP Publication 110 adult reference computational phantoms to a high-quality mesh format, and adding those tissues that were below the image resolution of the voxel phantoms and therefore not included in the Publication 110 phantoms. The new mesh phantoms include all the necessary source and target tissues for effective dose calculations, including the 8-40-µm-thick target layers of the alimentary and respiratory tract organs, thereby obviating the need for supplemental organ-specific stylised models (e.g. respiratory airways, alimentary tract organ walls and stem cell layers, lens of the eye, and skin basal layer). To see the impact of the new mesh-type reference phantoms, dose coefficients for some selected external and internal exposures were calculated and compared with the current reference values in ICRP Publications 116 and 133, which were calculated by employing the Publication 110 phantoms and the supplemental stylised models. The new mesh phantoms were also used to calculate dose coefficients for industrial radiography sources near the body, which can be used to estimate the organ doses of the worker who is accidentally exposed by an industrial radiography source; in these calculations, the mesh phantoms were deformed to reflect the size of the worker, and also to evaluate the effect of posture on dose coefficients.

Liver Transplantation in a Patient With CD40 Ligand Deficiency and Hyper-IgM Syndrome: Clinical and Immunological Assessments

Monoclonal antibodies that disrupt CD40-CD40 ligand (CD40L) interactions are likely to have use in human transplantation. However, the extent of the immunosuppressive effects of CD40-CD40L blockade in humans is unknown. Hyper-IgM syndrome (HIGM) is a rare primary immunodeficiency syndrome characterized by defects in the CD40-CD40L pathway, severe immune deficiency (IgG), and high or normal IgM levels. However, the effects of CD40L deficiency on T- and natural killer (NK)-cell function is not established. Here, we present a patient with HIGM syndrome who underwent liver transplantation for hepatitis C virus infection. Posttransplantation, NK-cell antibody-dependent cytokine release (γ-interferon) to alloantigens and T cell responses to viral antigens and mitogens were assessed and showed normal CD4⁺ , CD8⁺ , and NK-cell responses. We also examined antibody-dependent cellular cytotoxicity against a CD40⁺ and HLA-expressing cell line. These experiments confirmed that the patient's NK cells were equivalent to those of normal subjects in mediating antibody-dependent cellular cytotoxicity despite the absence of CD40-CD40L interactions. Mitogenic stimulation of the patient's peripheral blood mononuclear cells showed no expression of CD40L on T and NK cells compared with increased expression in normal subjects. Taken together, these data suggest that absence of CD40L expression is responsible for aberrant B cell immunity but had little impact on NK- and T cell immune responses in vitro.

Metabolic response of glioblastoma to superselective intra-arterial cerebral infusion of bevacizumab: a proton MR spectroscopic imaging study

BACKGROUND AND PURPOSE

SIACI of bevacizumab has emerged as a promising novel therapy in the treatment of recurrent GB. This study assessed the potential of (1)H-MRS as an adjunctive technique in detecting metabolic changes reflective of antiproliferative effects of targeted infusion of bevacizumab in the treatment of GB.

MATERIALS AND METHODS

Eighteen patients enrolled in a phase I/II study of SIACI of bevacizumab for treatment of recurrent GB were included. Concurrent MR imaging and (1)H-MRS scans were performed before and after treatment. Five distinct morphologic ROIs were evaluated for structural and metabolic changes on MR imaging and (1)H-MRS, which included enhancing, nonenhancing T2 hyperintense signal abnormality, and multiple control regions. Pre- and post-SIACI of bevacizumab peak areas for NAA, tCho, tCr, as well as tCho/tCr and tCho/NAA ratios, were derived for all 5 ROIs and compared using the Wilcoxon signed-rank test.

RESULTS

A significant median decrease of 25.99% (range -55.76 to 123.94; P = .006) in tCho/NAA was found post-SIACI of bevacizumab relative to pretreatment values in regions of enhancing disease. A trend-level significant median decrease of 6.45% (range -23.71 to 37.67; P = .06) was noted in tCho/NAA posttreatment in regions of nonenhancing T2-hyperintense signal abnormality.

CONCLUSIONS

The results of this (1)H-MRS analysis suggest that GB treatment with SIACI of bevacizumab may be associated with a direct antiproliferative effect, as demonstrated by significant reductions of tCho/NAA after the intervention.

Experimental constraints on left-right symmetric models from muon decay

The TWIST Collaboration has completed a new measurement of the energy-angle spectrum of positrons from the decay of highly polarized muons. A simultaneous measurement of the muon decay parameters ρ, δ, and P(μ)(π)ξ tests the standard model in a purely leptonic process and provides improved limits for relevant extensions to the standard model. Specifically, for the generalized left-right symmetric model |(g(R)/g(L))ζ|<0.020 and (g(L)/g(R))m(2)>578  GeV/c(2), both 90% C.L.

A new symptom-based questionnaire for predicting the presence of asthma

BACKGROUND

Early diagnosis and treatment of asthma is important for improving health and minimizing the social and economic burden of the disease. A simple questionnaire would provide a convenient and timesaving tool to help physicians diagnose asthma.

OBJECTIVE

The senior author developed a simple, pre-interview screening questionnaire--the Asthma Screening Questionnaire (ASQ)--consisting of 6 questions. The present report provides performance evidence that the ASQ is a reliable instrument for diagnosing asthma in adults.

METHODS

Participants were asthmatics or controls, aged 18 to 65 years. All participants completed the questionnaire (self-administered and physician-administered), and underwent spirometry and a methacholine challenge test (if there was no reversibility during initial spirometry). Sensitivity, specificity, and positive and negative predictive values were calculated for each question, and the total scores of asthmatics were compared with those of controls. The degree of agreement between the self-administered and the physician-administered questionnaire was calculated.

RESULTS

The main symptoms discriminating asthmatics from controls were cough more than average (88% vs 0%), cough from chest (72% vs 0%), shortness of breath with exercise (84% vs 16%), and chest tightness when lying down (72% vs 4%). A cutoff point of total score > or = 4 was associated with the highest combination of sensitivity (96%) and specificity (100%). Substantial agreement was observed between the self-administered and the physician-administered questionnaire (kappa statistic, 0.56-1.00; P<.0001).

CONCLUSIONS

The ASQ is a simple, inexpensive, and efficient pre-interview screening tool to diagnose asthma.

Measurement of the Michel parameter rho in muon decay

The TWIST Collaboration has measured the Michel parameter rho in normal muon decay, mu(+)--> e(+)nu(e)nu (mu). In the standard model, rho = 3/4. Deviations from this value imply mixing of left- and right-handed muon and electron couplings. We find rho=0.750 80+/-0.000 32(stat) +/- 0.000 97(syst) +/- 0.000 23, where the last uncertainty represents the dependence of rho on the Michel parameter eta. This result sets new limits on the W(L)-W(R) mixing angle in left-right symmetric models.

Defects in pulmonary vasculature and perinatal lung hemorrhage in mice heterozygous null for the Forkhead Box f1 transcription factor

Decreased pulmonary expression of Forkhead Box f1 (Foxf1) transcription factor was associated with lethal alveolar hemorrhage in 55% of the Foxf1 +/- newborn mice. The severity of the pulmonary abnormalities correlates with the levels of Foxf1 mRNA. Defects in alveolarization and vasculogenesis were observed in subsets of the Foxf1 +/- mice with relatively low levels of expression from the normal Foxf1 allele. Lung hemorrhage was coincident with disruption of the mesenchymal-epithelial cell interfaces in the alveolar and bronchiolar regions of the lung parenchyma and was associated with increased apoptosis and reduced surfactant protein B (SP-B) expression. Finally, the lung defect associated with the Foxf1 +/- mutation was accompanied by reduced expression of vascular endothelial growth factor (VEGF), the VEGF receptor 2 (Flk-1), bone morphogenetic protein 4 (Bmp-4), and the transcription factors of the Brachyury T-Box family (Tbx2-Tbx5) and Lung Kruppel-like Factor. Reduction in the level of Foxf1 caused neonatal pulmonary hemorrhage and abnormalities in alveologenesis, implicating this transcription factor in the regulation of mesenchyme-epithelial interaction critical for lung morphogenesis.

Differential expression of forkhead box transcription factors following butylated hydroxytoluene lung injury

The forkhead box (Fox) proteins are a growing family of transcription factors that have important roles in cellular proliferation and differentiation and in organ morphogenesis. The Fox family members hepatocyte nuclear factor (HNF)-3beta (Foxa2) and HNF-3/forkhead homolog (HFH)-8 (FREAC-1, Foxf1) are expressed in adult pulmonary epithelial and mesenchymal cells, respectively, but these cells display only low expression levels of the proliferation-specific HFH-11B gene (Trident, Foxm1b). The regulation of these Fox transcription factors in response to acute lung injury, however, has yet to be determined. We report here on the use of butylated hydroxytoluene (BHT)-mediated lung injury to demonstrate that HFH-11 protein and RNA levels were markedly increased throughout the period of lung repair. The maximum levels of HFH-11 were observed by day 2 following BHT injury when both bronchiolar and alveolar epithelial cells were undergoing extensive proliferation. Although BHT lung injury did not alter epithelial cell expression of HNF-3beta, a 65% reduction in HFH-8 mRNA levels was observed during the period of mesenchymal cell proliferation. HFH-8-expressing cells were colocalized with platelet endothelial cell adhesion molecule-1-positive alveolar endothelial cells and with alpha-smooth muscle actin-positive peribronchiolar smooth muscle cells.

Alteration of a single amino acid changes the substrate specificity of dihydroflavonol 4-reductase

Many plant species exhibit a reduced range of flower colors due to the lack of an essential gene or to the substrate specificity of a biosynthetic enzyme. Petunia does not produce orange flowers because dihydroflavonol 4-reductase (DFR) from this species, an enzyme involved in anthocyanin biosynthesis, inefficiently reduces dihydrokaempferol, the precursor to orange pelargonidin-type anthocyanins. The substrate specificity of DFR, however, has not been investigated at the molecular level. By analyzing chimeric DFRs of Petunia and Gerbera, we identified a region that determines the substrate specificity of DFR. Furthermore, by changing a single amino acid in this presumed substrate-binding region, we developed a DFR enzyme that preferentially reduces dihydrokaempferol. Our results imply that the substrate specificity of DFR can be altered by minor changes in DFR.

Spiral ganglion neurons are protected from degeneration by GDNF gene therapy

Perceptual benefits from the cochlear prosthesis are related to the quantity and quality of the patient's auditory nerve population. Multiple neurotrophic factors, such as glial cell line-derived neurotrophic factor (GDNF), have been shown to have important roles in the survival of inner ear auditory neurons, including protection of deafferented spiral ganglion cells (SGCs). In this study, GDNF gene therapy was tested for its ability to enhance survival of SGCs after aminoglycoside/diuretic-induced insult that eliminated the inner hair cells. The GDNF transgene was delivered by adenoviral vectors. Similar vectors with a reporter gene (lacZ) insert served as controls. Four or seven days after bilateral deafening, 5 microl of an adenoviral suspension (Ad-GDNF or Ad-lacZ) or an artificial perilymph was injected into the left scala tympani of guinea pigs. Animals were sacrificed 28 days after deafening and their inner ears prepared for SGC counts. Adenoviral-mediated GDNF transgene expression enhanced SGC survival in the left (viral-treated) deafened ears. This observation suggests that GDNF is one of the survival factors in the inner ear and may help maintain the auditory neurons after insult. Application of GDNF and other survival factors via gene therapy has great potential for inducing survival of auditory neurons following hair cell loss.

Phytochrome signalling is mediated through nucleoside diphosphate kinase 2

Because plants are sessile, they have developed intricate strategies to adapt to changing environmental variables, including light. Their growth and development, from germination to flowering, is critically influenced by light, particularly at red (660 nm) and far-red (730 nm) wavelengths. Higher plants perceive red and far-red light by means of specific light sensors called phytochromes(A-E). However, very little is known about how light signals are transduced to elicit responses in plants. Here we report that nucleoside diphosphate kinase 2 (NDPK2) is an upstream component in the phytochrome signalling pathway in the plant Arabidopsis thaliana. In animal and human cells, NDPK acts as a tumour suppressor. We show that recombinant NDPK2 in Arabidopsis preferentially binds to the red-light-activated form of phytochrome in vitro and that this interaction increases the activity of recombinant NDPK2. Furthermore, a mutant lacking NDPK2 showed a partial defect in responses to both red and farred light, including cotyledon opening and greening. These results indicate that NDPK2 is a positive signalling component of the phytochrome-mediated light-signal-transduction pathway in Arabidopsis.

Coexpression of a defensin gene and a thionin-like via different signal transduction pathways in pepper and Colletotrichum gloeosporioides interactions

The anthracnose fungus, Colletotrichum gloeosporioides, interacts incompatibly with the ripe fruit of pepper (Capsicum annuum). It interacts compatibly with the unripe-mature fruit. We isolated a defensin gene, jl-l, and a thionin-like gene, PepThi, expressed in the incompatible interaction by using an mRNA differential display method. Both genes were developmentally regulated during fruit ripening, organ-specifically regulated, and differentially induced during the compatible and incompatible interactions. Expression of the PepThi gene was rapidly induced in the incompatible-ripe fruit upon fungal infection. The fungus-inducible PepThi gene is highly inducible only in the unripe fruit by salicylic acid. In both ripe and unripe fruit, it was induced by wounding, but not by jasmonic acid. Expression of the jl-l gene is enhanced by jasmonic acid in the unripe fruit but suppressed in the ripe fruit. These results suggest that both small and cysteine-rich protein genes are induced via different signal transduction pathways during fruit ripening to protect the reproductive organs against biotic and abiotic stresses.

Cymbidium hybrida dihydroflavonol 4-reductase does not efficiently reduce dihydrokaempferol to produce orange pelargonidin-type anthocyanins

Some angiosperms are limited to a range of possible flower colors. This limitation can be due to the lack of an anthocyanin biosynthetic gene or to the substrate specificity of a key anthocyanin biosynthetic enzyme, dihydroflavonol 4-reductase (DFR). Cymbidium hybrida orchid flowers primarily produce cyanidin-type (pink to red) anthocyanins and lack the pelargonidin-type (orange to brick-red) anthocyanins. To investigate the underlying molecular mechanism of this flower color range, we cloned a Cymbidium DFR gene and transformed it into a DFR- petunia line. We found that the Cymbidium DFR did not efficiently reduce dihydrokaempferol (DHK), which is an essential step for pelargonidin production. Phylogenetic analysis of a number of DFR sequences indicate that the inability to catalyze DHK reduction has occurred at least twice during angiosperm evolution. Our results indicate that developing a pelargonidin-type orange flower color in Cymbidium may require the transformation of a DFR gene that can efficiently catalyze DHK reduction.

Visualization and flow of platelets and leukocytes in vivo in rat retinal and choroidal vessels

PURPOSE

To directly visualize the flow of leukocytes in choroidal vessels and the flow of platelets in retinal vessels in a rat without incision by fluorescein leukocyte angiography (FLA) using a scanning laser ophthalmoscope (SLO).

METHODS

Blood was withdrawn from a tail vein of a Sprague-Dawley rat with a tuberculin syringe traced with sodium heparin and mixed with sodium fluorescein. The fluorescent plasma layer was diluted with saline solution, centrifuged and then the overlying plasma discarded. The remaining cell suspension was diluted with saline to create the original hematocrit, then infused into the vein of the same rat while performing fluorescein angiography with an SLO. The angiographic image was recorded on a videotape using time-lapsed photography.

RESULTS

Fluorescent platelets were detected and the flow within the retinal vessels traced over time. Fluorescent leukocytes in the choroidal vessels were also detected and the flow of a leukocyte was traced and its relative velocities were plotted against the time sequence. The relative size and fluorescence intensities of the platelets and leukocytes in the angiographic image corresponded well with the smear of the blood preparation.

CONCLUSIONS

FLA using an SLO can be used to detect the flow of platelets in the retinal vessels and the flow of leukocytes in the choroidal vessels in the experimental rat eye model.

Intravenous phosphate repletion regimen for critically ill patients with moderate hypophosphatemia

OBJECTIVE

To document the safety and efficacy of an intravenous phosphate repletion regimen that is more aggressive than recommended by previously published guidelines, in intensive care unit (ICU) patients with hypophosphatemia.

DESIGN

Prospective evaluation of rapid, intravenous phosphate repletion in eligible patients.

SETTING

Surgical ICU in a teaching hospital.

PATIENTS

Patients with a serum phosphorus concentration of < 2 mg/dL (< 0.65 mmol/L) while in the ICU.

INTERVENTIONS

Enrolled patients received 15 mmol of sodium phosphate in 100 mL of 0.9% sodium chloride, infused intravenously over a period of 2 hrs. Patients with a serum potassium concentration of < 3.5 mmol/L received potassium phosphate, if no other potassium supplementation was ordered. The same dose could be repeated to a maximum of 45 mmol in a 24-hr period if either the 6-hr or follow-up (18- to 24-hr) postinfusion serum phosphorus remained < 2 mg/dL (< 0.65 mmol). Serum electrolytes, renal function, vital signs, and reflexes were closely monitored.

MEASUREMENTS AND MAIN RESULTS

Eleven patients enrolled had baseline serum phosphorus values of 1.6 to 1.9 mg/dL (0.51 to 0.61 mmol/L). The serum phosphorus value immediately postinfusion was 2.3 to 5.3 mg/dL (0.74 to 1.7 mmol/L). Only one patient had a 6-hr postinfusion serum phosphorus of < 2 mg/dL (< 0.65 mmol/L), requiring two additional doses. Two other patients each required a second dose. Serum phosphorus was corrected in other patients with a single dose. No significant changes were noted in serum calcium, magnesium, or potassium concentrations, urine output, vital signs, or reflexes throughout the repletion period.

CONCLUSIONS

All patients were successfully repleted using the described protocol without any significant adverse effects. This repletion regimen may have widespread applicability in the ICU setting.

Creatinine clearance of early detection of posttraumatic renal dysfunction

Acute renal failure develops insidiously in the presence of normal urine output and vital signs. A prospective study was carried out to find whether renal impairment can be detected in the immediate postoperative period and to determine the renal function test best predicting the development of renal dysfunction. Forty patients with multiple trauma who required more than 10 units of blood and had a systolic blood pressure less than 80 mmHg on admission were studied. Creatinine clearance (Ccr), free-water clearance (CH2O), fractional excretion of Na+, blood urea nitrogen (BUN), urine flow rate, and vital signs were measured and compared in seven patients who developed renal dysfunction within a week of trauma (Group 1) and 33 patients who maintained normal renal function (Group 2). In all Group 1 patients Ccr remained less than 25 ml/min and CH2O greater than -15 ml/h for 6 h following surgery. None of the Group 2 patients had Ccr less than 25 ml/min for longer than 4 h following surgery. However, CH2O values were greater than -15 ml/h in 15 of the 33 Group 2 patients during the first 24 postoperative hours. Ccr values less than 25 ml/min were present, despite normal urine flow rate and blood pressure, in patients who subsequently developed renal dysfunction. Patients who have Ccr values less than 25 ml/min within 6 h following trauma and surgery may develop renal dysfunction, and some of them may proceed to acute renal failure. CH2O was not as good a predictor of development of renal dysfunction as Ccr.

Assessment of cardiac and respiratory function during surgery on patients with acute quadriplegia

Cardiorespiratory function was assessed in 22 mechanically ventilated patients who underwent surgery within an average of 4.8 days following traumatic spinal cord injury at C3-7. A fluid challenge technique was used to derive right and left ventricular function curves and to assist in choice of therapy from four possible outcome responses. Both right and left ventricular stroke work increased but left ventricular stroke work was still lower than normal in six (27%) of 22 patients despite elevation of cardiac filling pressures. Pulmonary vascular resistance fell, but systemic vascular resistance was unchanged following fluid challenge. Respiratory function, including intrapulmonary shunt, lung/thorax compliance, dead space, and arterial pO2 and pCO2, were unchanged by fluid administration averaging 520 ml of plasma protein fraction in 12 minutes. The Bainbridge reflex was inoperative. There was no correlation between anesthetic agent, level or type of neurological deficit, and cardiorespiratory function. Left ventricular function was impaired so the use of peripheral vasoconstrictors that elevate systemic vascular resistance should be avoided in the management of spinal shock. Instead, myocardial depressants should be reduced and fluid replacement used to optimize cardiac function. Elevation of central venous or pulmonary capillary wedge pressures to 18 mm Hg should be used to reverse hypotension, acidosis, low venous pO2, or oliguria before institution of centrally acting inotropic therapy in the management of acute spinal cord injury.

Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure

Chest physiotherapy (CPT) is used frequently in the ICU, but there is little available information that quantitates its effect on cardiac or respiratory function. Nineteen mechanically ventilated patients with post-traumatic respiratory failure were studied before, immediately after, and 2 h after CPT was used to manage secretion retention. Cardiac index was unchanged, but there was an immediate decrease in intrapulmonary shunt, followed 2 h later by an increase in lung/thorax compliance. We did not find the reduced cardiac output reported by others. The reasons for this may include use of different CPT techniques, a young patient population (mean age 32.4 yr), and mechanical ventilation with positive end-expiratory pressure. CPT did not produce the deleterious cardiopulmonary changes associated with bronchoscopy, and it reduced retained lung secretions without producing hypoxemia. Intrapulmonary shunt and lung/thorax compliance were significantly improved, but the long-term clinical effect of these changes is unknown.

Massive diuresis after acute renal failure

Polyuria, peaking at 2000 ml/h, was seen in a patient after resuscitation of hemorrhagic shock and a brief period of oliguria. This unusual polyuria appears to be a consequence of renal tubular dysfunction that persisted after glomerular filtration rate had returned to normal.