Increased retention of tau PET ligand [18F]-AV1451 in Alzheimer's Disease Psychosis

Psychosis in Alzheimer's disease (AD) represents a distinct disease subtype with a more rapid progression of illness evidenced by an increased velocity of cognitive decline and a hastened mortality. Previous biomarker and post-mortem studies have implicated tau neuropathology as a possible mediator of the accelerated decline in AD psychosis. Tau positron emission tomography (PET) neuroimaging provides the opportunity to evaluate tau pathology in-vivo, so that clinical symptomatology can be correlated with disease pathology. [¹⁸F]-AV1451 (Flortaucipir) is a PET ligand with high affinity for insoluble paired-helical filaments (PHFs) of hyperphosphorylated tau. In order to determine whether the development of psychosis and worsened prognosis in AD is associated with an increased burden of tau pathology that can be identified with tau imaging, we identified subjects within the Alzheimer's disease neuroimaging initiative (ADNI) who had [¹⁸F]-AV1451 imaging at baseline and became psychotic over the course of the study (N = 17) and matched them 1:3 for gender, age, and education to subjects who had [¹⁸F]-AV1451 imaging at baseline and did not become psychotic (N = 50). We compared baseline [¹⁸F]-AV1451 retention, in addition to cognitive and functional baseline and longitudinal change, in those who became psychotic over the course of participation in ADNI with those who did not. Results suggest that increases in tau pathology in frontal, medial temporal, and occipital cortices, visualized with [¹⁸F]-AV1451 binding, are associated with psychosis and a more rapid cognitive and functional decline.

Oral delivery of Hyperimmune bovine serum antibodies against CS6-expressing enterotoxigenic Escherichia coli as a prophylactic against diarrhea

BACKGROUND

. Oral administration of bovine antibodies active against enterotoxigenic Escherichia coli (ETEC) have demonstrated safety and efficacy against diarrhea in human challenge trials. The efficacy of bovine serum immunoglobulins (BSIgG) against recombinant colonization factor CS6 or whole cell ETEC strain B7A was assessed against challenge with the CS6-expressing B7A.

METHODS

. This was a randomized, double-blind, placebo-controlled trial in which healthy adults received oral hyperimmune BSIgG anti-CS6, anti-B7A whole cell killed or non-hyperimmune BSIgG (placebo) in a 1:1:1 ratio then challenged with ETEC B7A. Two days pre-challenge, volunteers began a thrice daily, seven day course of immunoprophylaxis. On day 3, subjects received 1 × 10¹⁰ CFUs of B7A. Subjects were observed for safety and the primary endpoint of moderate-severe diarrhea (MSD).

RESULTS

. A total of 59 volunteers received product and underwent ETEC challenge. The BSIgG products were well-tolerated across all subjects. Upon challenge, 14/20 (70%) placebo recipients developed MSD, compared to 12/19 (63%; p = .74) receiving anti-CS6 BSIgG and 7/20 (35%; p = .06) receiving anti-B7A BSIgG. Immune responses to the ETEC infection were modest across all groups.

CONCLUSIONS

. Bovine-derived serum antibodies appear safe and well tolerated. Antibodies derived from cattle immunized with whole cell B7A provided 50% protection against MSD following B7A challenge; however, no protection was observed in subjects receiving serum antibodies targeting CS6. The lack of observed efficacy in this group may be due to low CS6 surface expression on B7A, the high dose challenge inoculum and/or the use of serum derived antibodies versus colostrum-derived antibodies.

Are there sufficient numbers of low-risk basal cell carcinomas to justify general practitioners (family physicians) carrying out basal cell carcinoma surgery?

BACKGROUND

The incidence of basal cell carcinoma (BCC) is rising within the UK, and poses a significant workload on primary and secondary care services. Greater general practitioner (GP) involvement in the diagnosis and management of BCC has been suggested to reduce this burden. In 2010, the National Institute of Health and Care Excellence (NICE) produced guidelines on the management of low-risk BCCs by GP surgeons.

AIM

To assess what proportion of BCCs are suitable for excision by GP surgeons, and to determine the potential demand for GP-led BCC surgery.

METHODS

A retrospective analysis was undertaken of all BCCs excised over 32 months for a population of 795 000 from the West Midlands region, UK. The data collected were reviewed against NICE criteria to determine the number of BCCs suitable for excision by GP surgeons.

RESULTS

In total, 1743 BCCs were excised over 32 months, a BCC excision rate of 82 per 100 000 population per year. Taking into account body site, diameter, histological subtype and other criteria, 3.0% (2.5 per 100,000 per year) of BCCs were considered low-risk according to the national criteria from NICE.

CONCLUSION

Low-risk BCCs suitable for excision by GP surgeons are of low prevalence and it would be difficult for GPs to maintain competencies in BCC surgery. Dermatologists should continue to provide the lead in skin cancer diagnosis, treatment and management.

Disseminated cutaneous Mycobacterium chelonae infection in an immunocompetent host

Mycobacterium chelonae is a rare, rapidly growing, atypical acid-fast bacillus. Disseminated cutaneous infection has been reported in immunocompromised patients. We report an immunocompetent 86-year-old white woman, who presented with an 8-month history of extensive ulcerated abscess-like nodules. Mycobacterial culture confirmed M. chelonae infection and the patient was treated with a combination of clarithromycin and tobramycin. To our knowledge, this is the first reported case of spontaneous, disseminated cutaneous disease occurring in an immunocompetent patient.

Steroid avoidance in two-haplotype-matched living donor renal transplants with basiliximab induction therapy

BACKGROUND

Induction therapy and haplotype matching are utilized to mitigate immunologic risk in renal transplantation. The incidence of acute rejection (AR) of renal allografts has been reported to be as low as 9.3% within the first year among two-haplotype-matched siblings with no induction and triple-drug maintenance immunosuppression. We report our use of basiliximab induction in a series of two-haplotype-matched living donor renal transplants (LDRT).

METHODS

We retrospectively reviewed 25 patients who received a two-haplotype-matched LDRT with basiliximab induction therapy. The primary endpoints were acute rejection (AR) episodes at 6 and 12 months and 1-year patient and graft survival rates. The secondary endpoints were the incidence of delayed graft function (DGF), cytomegalovirus (CMV), and BK virus (BKV).

RESULTS

The rate of AR at 6 months was 0% (0/25) and 4% (1/25) at 12 months. The 1-year graft and patient survival rates were 100%. The incidence of DGF was 4% (1/25), while the incidences of CMV and BKV were 0%.

CONCLUSION

Basiliximab induction therapy with a steroid-sparing regimen yields favorable results in two-haplotype-matched LDRT, including a notable reduction in the rates of AR as compared to triple-drug maintenance immunosuppression without induction. These patients have excellent graft survival with no increased incidences of secondary infections.

Epithelioma cuniculatum: A case report

Epithelioma cuniculatum (carcinoma cuniculatum) is a rare, low-grade verrucous carcinoma of the foot first described in 1954. We present a case report of a 55-year-old man with an enlarging lesion on the sole of his right foot. Despite initial benign pathology the lesion continued to grow, soften in consistency and develop a foul odour. Repeat biopsy showed a well-differentiated squamous cell carcinoma and below-the-knee amputation was required. Epithelioma cuniculatum presents as a slow growing mass on the plantar aspect of the foot. Diagnosis is often delayed and may require multiple biopsies. Lesions rarely metastasise but more commonly invade locally requiring wide surgical excision.

025. Prolactin signaling through the short form of its cognate receptor causes severe ovarian defect

Extensive investigations from our laboratory have clarified the action and interaction of estradiol (E) and prolactin (PRL) on corpus luteum (CL) function. Our research has led us to discover and isolate a CL specific gene that encodes a protein we named PRAP, that associates with the intracellular domain of the short form (PRLRS) but not the long form (PRLRL) and whose expression is tightly regulated by E. Our laboratory and others have established that this protein, expressed in CL of every species investigated, is a novel 17 beta hydroxysteroid dehydrogenase (17bHSD-7) whose function is to catalyze the transformation of estrone to E. Our results with cells expressing only PRLRS revealed that PRL acting through PRLRS leads to phosphorylation of PRAP/17bHSD-7 (PRAP/17b) by JAK2 establishing for the first time that a steroidogenic enzyme can be phosphorylated through its association with a membrane bound protein. The association of PRAP/17b with the PRLRS and its phosphorylation leads to its stabilization. To further investigate the role of PRL signaling through PRLRS, we used PRLR(–/–) mice expressing the PRLRS as a transgene. The results obtained were totally unexpected and of great interest. The follicles of the ovaries, expressing PRLRS only, underwent premature development followed by severe granulosa and oocyte death leaving holes surrounding collapsed zona pellucida and premature ovarian failure. The observations that: (1) the expression of PRLRS in the ovaries of PRL null mice leads to inhibition in Foxo3a and of GALT, two proteins whose deletion/mutation causes similar premature ovarian failure; and (2) that GALT promoter activity is stimulated by Foxo3a transcription factor led us to hypothesize that PRL acting through PRLRS prevents the expression of Foxo3a, which normally stimulates GALT transcriptional activity. Absence of Foxo3a then leads to inhibition of GALT and increases in galactose and its metabolites, causing galactose toxicity and granulosa as well as oocyte cell death.

The sample size for a clinical trial: a Bayesian-decision theoretic approach

Using decision theory, what is an appropriate sample size for a clinical trial, with a binary endpoint? We present a program, suitable for actual planning, which, with some extensions, implements Canner's solution to this question. Examples with a discussion are given. Implications of a Bayesian approach are discussed. Bayesian and Neyman--Pearson approaches are compared.

Cytokine networking in lungs of immunocompetent mice in response to inhaled Aspergillus fumigatus

Cytokine networking in the lung in response to inhaled Aspergillus fumigatus was assessed using a murine model of primary pulmonary aspergillosis in immunocompetent Crl:CF-1 mice. Inhalation of virulent A. fumigatus (6 x 10(6) CFU) resulted in the induction of interleukin 18 (IL-18), tumor necrosis factor alpha (TNF-alpha), IL-12, and gamma interferon (IFN-gamma) protein in bronchoalveolar lavage fluid and/or lung tissue. Induction of immunoreactive IL-18 preceded induction of TNF-alpha protein, which preceded induction of immunoreactive IL-12 and IFN-gamma. Real-time reverse transcriptase (RT) PCR analysis of infected lung tissue demonstrated that induction of IL-18 protein also preceded induction of pulmonary TNF-alpha, IL-12, and IFN-gamma mRNAs. Mice were subsequently treated with cytokine-specific neutralizing monoclonal antibodies (MAbs) to the IL-18 receptor (anti-IL-18R MAb), TNF-alpha (anti-TNF-alpha MAb), IL-12 (anti-IL-12 MAb), and/or IFN-gamma (anti-IFN-gamma MAb), and effects on intrapulmonary cytokine activity and growth of A. fumigatus were assessed in infected lung homogenates. Simultaneous neutralization of IL-12 and IL-18 resulted in decreased levels of immunoreactive TNF-alpha, while neutralization of IL-18, TNF-alpha, or IL-12 alone or of IL-18 and IL-12 together resulted in decreased levels of immunoreactive IFN-gamma. Simultaneous neutralization of IL-12 and IL-18 or neutralization of TNF-alpha alone or in combination with IL-12, IL-18, or IFN-gamma also resulted in a significant increase in A. fumigatus CFU in lung tissue. Taken together, these results demonstrate that endogenous IL-18, IL-12, and TNF-alpha, through their modulatory effects on both intrapulmonary cytokine activity and growth of A. fumigatus, play key roles in host defense against primary pulmonary aspergillosis.

Problems in the definition, interpretation, and evaluation of genetic heterogeneity

Suppose that we wish to classify families with multiple cases of disease into one of three categories: those that segregate mutations of a gene of interest, those which segregate mutations of other genes, and those whose disease is due to nonhereditary factors or chance. Among families in the first two categories (the hereditary families), we wish to estimate the proportion, p, of families that segregate mutations of the gene of interest. Although this proportion is a commonly accepted concept, it is well defined only with an unambiguous definition of "family." Even then, extraneous factors such as family sizes and structures can cause p to vary across different populations and, within a population, to be estimated differently by different studies. Restrictive assumptions about the disease are needed, in order to avoid this undesirable variation. The assumptions require that mutations of all disease-causing genes (i) have no effect on family size, (ii) have very low frequencies, and (iii) have penetrances that satisfy certain constraints. Despite the unverifiability of these assumptions, linkage studies often invoke them to estimate p, using the admixture likelihood introduced by Smith and discussed by Ott. We argue against this common practice, because (1) it also requires the stronger assumption of equal penetrances for all etiologically relevant genes; (2) even if all assumptions are met, estimates of p are sensitive to misspecification of the unknown phenocopy rate; (3) even if all the necessary assumptions are met and the phenocopy rate is correctly specified, estimates of p that are obtained by linkage programs such as HOMOG and GENEHUNTER are based on the wrong likelihood and therefore are biased in the presence of phenocopies. We show how to correct these estimates; but, nevertheless, we do not recommend the use of parametric heterogeneity models in linkage analysis, even merely as a tool for increasing the statistical power to detect linkage. This is because the assumptions required by these models cannot be verified, and their violation could actually decrease power. Instead, we suggest that estimation of p be postponed until the relevant genes have been identified. Then their frequencies and penetrances can be estimated on the basis of population-based samples and can be used to obtain more-robust estimates of p for specific populations.

Clinical application of the SADL scale in private practice II: predictive validity of fitting variables. Satisfaction with Amplification in Daily Life

Predictive validity of 44 independent variables and their interactions with Satisfaction with Amplification in Daily Life (SADL) scores was assessed. SADL scores were influenced by patient age, years of hearing aid experience, hours of use per day, perceived hearing difficulty, pure-tone average, hearing aid style, processor type, and manufacturer's invoice cost. The relative importance of these variables to SADL measures was complex and very small, but the variables and their squares and interactions improved r2 predictions of SADL Global and subscale scores in a separate stepwise multiple linear regression procedure by 12 to 33 percent compared to SADL norms alone. More research with additional variables is needed to develop a clinically useful model for predicting wearer satisfaction. Clinically, SADL scores yield subscale-specific patterns of satisfaction and dissatisfaction that help in intervention planning and serve as graphic "snapshots" of satisfaction status. A series of patient profiles are presented illustrating the potential usefulness of the SADL in predicting hearing aid satisfaction. With its good construct and psychometric properties, the SADL could serve as a gold standard for satisfaction outcomes and a basis for development of a predictive model of hearing aid fitting success.

Observation of X-ray lines from a gamma-ray burst (GRB991216): evidence of moving ejecta from the progenitor

We report on the discovery of two emission features observed in the x-ray spectrum of the afterglow of the gamma-ray burst (GRB) of 16 December 1999 by the Chandra X-ray Observatory. These features are identified with the Ly(alpha) line and the narrow recombination continuum by hydrogenic ions of iron at a redshift z = 1.00 +/- 0.02, providing an unambiguous measurement of the distance of a GRB. Line width and intensity imply that the progenitor of the GRB was a massive star system that ejected, before the GRB event, a quantity of iron approximately 0.01 of the mass of the sun at a velocity approximately 0.1 of the speed of light, probably by a supernova explosion.

Clinical application of the satisfaction with amplification in daily life scale in private practice I: statistical, content, and factorial validity

Statistical, content, and factorial validity of the Satisfaction with Amplification in Daily Life (SADL) scale was assessed. SADL subscales closely correspond to four satisfaction domains. Subjective benefit is a key component of satisfaction, but other nonauditory factors contribute to wearer satisfaction, notably telephone use and appearance. Results confirm the SADLs psychometric properties and verify its use to validate hearing aid fitting satisfaction in private practice settings for a general patient population at 1-year postfitting. Interim SADL norms may be refined as more SADL data are obtained for different patient populations, hearing aid types, and fitting environments.

In vitro and in vivo activities of SCH 56592 (posaconazole), a new triazole antifungal agent, against Aspergillus and Candida

SCH 56592 (posaconazole), a new triazole antifungal agent, was tested in vitro, and its activity was compared to that of itraconazole against 39 Aspergillus strains and to that of fluconazole against 275 Candida and 9 Cryptococcus strains. The SCH 56592 MICs for Aspergillus ranged from </=0.002 to 0.5 microg/ml, and those of itraconazole ranged from </=0.008 to 1 microg/ml. The SCH 56592 MICs for Candida and Cryptococcus strains ranged from </=0. 004 to 16 microg/ml, and those of fluconazole ranged from </=0.062 to >64 microg/ml. SCH 56592 showed excellent activity against Aspergillus fumigatus and Aspergillus flavus in a pulmonary mouse infection model. When administered therapeutically, the 50% protective doses (PD(50)s) of SCH 56592 ranged from 3.6 to 29.9 mg/kg of body weight, while the PD(50)s of SCH 56592 administered prophylactically ranged from 0.9 to 9.0 mg/kg; itraconazole administered prophylactically was ineffective (PD(50)s, >75 mg/kg). SCH 56592 was also very efficacious against fluconazole-susceptible, -susceptible dose-dependent, or -resistant Candida albicans strains in immunocompetent or immunocompromised mouse models of systemic infection. The PD(50)s of SCH 56592 administered therapeutically ranged from 0.04 to 15.6 mg/kg, while the PD(50)s of SCH 56592 administered prophylactically ranged from 1.5 to 19.4 mg/kg. SCH 56592 has excellent potential for therapy against serious Aspergillus or Candida infections.

Penile Kaposi's sarcoma preceded by chronic penile lymphoedema

Kaposi's sarcoma localized to the penis with striking lymphoedema is extraordinary. We report a middle-aged Haitian man who was human herpesvirus-8 seropositive, without evidence of immunosuppression or human immunodeficiency virus infection. He was first seen with Kaposi's sarcoma of 6 months duration localized to his penis, preceded by a 3-year history of chronic penile lymphoedema. His tumour regressed completely after radiotherapy. We propose that chronic lymphoedema in this patient predisposed to the development of Kaposi's sarcoma.

Multipoint linkage analysis. A cautionary note

Multipoint linkage analysis is commonly used to evaluate linkage of a disease to multiple markers in a small region. Multipoint analysis is particularly powerful when the IBD relations of family members at the trait locus are ambiguous. The increased power arises because, unlike single-marker analyses, multipoint analysis uses haplotype information from several markers to infer the IBD relations. We wish to temper this advantage with a cautionary note: multipoint analysis is sensitive to power loss due to misspecification of intermarker distances. Such misspecification is especially problematic when dealing with closely spaced markers. We present computer simulations comparing the power of single-point and multipoint analyses, both when IBD relations are ambiguous, and when the intermarker distances are misspecified. We conclude that when evaluating markers in a small region to confirm or refute previous findings, a situation in which p values of modest statistical significance are important, single marker analyses may provide more reliable measures of the strength of support for linkage than multipoint statistics.

Vertical root fractures in adjacent maxillary premolars: an endodontic-prosthetic perplexity

Vertical root fractures in endodontically treated teeth occur frequently in teeth or roots in which their mesiodistal dimension is narrow, such as the maxillary upper premolars. Two cases of vertical root fractures in two adjacent maxillary reconstructed teeth are presented. As in many cases of vertical root fractures, the primary diagnosis was of endodontic treatment failure. The final diagnosis of the fractures was made either by the radiograph showing separation of root segments in one case, or by surgical exploration in the other. In both cases, tooth extraction was unavoidable.

The value of chest CT scan in the work-up of head and neck cancers

The systemic work-up of patients with head and neck cancers includes a routine chest x-ray and panendoscopy. In patients with a high risk for head and neck cancers, such as heavy smokers and drinkers, a high incidence of second upper aerodigestive tract tumors is expected, in addition to the risk of metastatic spread from their primary neoplasm. In this study, we evaluated the contribution of a chest CAT in patients with negative plain chest x-rays. Twenty-four consecutive patients with head and neck cancers were entered. All patients had locally advanced disease. Nine of the 24 patients (37.5%) had positive findings on their chest CAT scans. All lesions detected by CAT, except for one, were biopsied and reported as squamous cell carcinomas. All these patients had T3 and T4 lesions and only one was N0. Three of these lesions were considered to be metastatic and four more were believed to be second primary lung tumors. In two patients, the nature of the lesions was not determined. In conclusion, because of the high incidence of positive lung CAT scans in this group of patients, we recommend a chest CAT for work-up prior to initiating any definitive therapy for their head and neck cancers.

The role of nasal chemical senses in garter snake response to airborne odor cues from prey

Garter snakes increase tongue-flick rates in the presence of airborne odorants (amyl acetate, limonene, earthworm wash vapor, fish water vapor, earthworms, goldfish) but not water vapor. Main olfactory (MO) nerve lesions result in loss of this tongue-flick rate elevation in the presence of airborne odorants. Vomeronasal (VN) nerve lesions result in a diminution of tongue-flick rate elevation. Garter snakes discriminate between the 2 arms of a maze containing airborne earthworm odor as compared with a blank control. Following MO nerve lesions, snakes fail to make this discrimination. Following VN nerve lesions or VN duct suture, snakes are initially able to make the discrimination but may eventually cease to prefer the prey-odor side of the maze and may stop eating prey rewards. These results support the idea that airborne odorants are detected by the main MO system and that such detection does not require a functional VN system.

Evaluating and improving pressure ulcer care: the VA experience with administrative data

BACKGROUND

A number of state initiatives are using databases originally developed for nursing home reimbursements to assess the quality of care. Since 1991 the Department of Veterans Affairs (VA; Washington, DC) has been using a long term care administrative database to calculate facility-specific rates of pressure ulcer development. This information is disseminated to all 140 long term care facilities as part of a quality assessment and improvement program.

DATA ON PRESSURE ULCER DEVELOPMENT

Assessments are performed on all long term care residents on April 1 and October 1, as well as at the time of admission or transfer to a long term care unit. Approximately 18,000 long term care residents are evaluated in each six-month period; the VA rate of pressure ulcer development is approximately 3.5%. Reports of the rates of pressure ulcer development are then disseminated to all facilities, generally within two months of the assessment date.

IMPLICATIONS FOR OTHER QUALITY IMPROVEMENT EFFORTS

The VA's more than five years' experience in using administrative data to assess outcomes for long term care highlights several important issues that should be considered when using outcome measures based on administrative data. These include the importance of carefully selecting the outcome measure, the need to consider the structure of the database, the role of case-mix adjustment, strategies for reporting rates to small facilities, and methods for information dissemination.

CONCLUSION

Attention to these issues will help ensure that results from administrative databases lead to improvements in the quality of care.