Fraud, specialization, and efficiency in peer review

Reviewers are humans and might be affected by cognitive biases when information overload comes into play. In fact, no amount of scientific training will completely mask the human impulses to partisanship. And the consequence is that authors may receive incorrect editorial decisions in their submissions to peer-reviewed journals. For instance, the journal editor issues a substantial revision when in fact a moderate one would suffice. This would be over-revision in peer review. In this situation, there exists a fraud cost if the journal editor tries to request the author to make a substantial revision when in fact a moderate one would be sufficient. Thus, in this article, we identify a set of conditions under which the peer review process involves equilibrium fraud and over-revision. An equilibrium in peer review is efficient if the first peer-reviewed journal to which the author submits their research paper makes a truthful editorial decision, which the author accepts. When the fraud cost is sufficiently high, there exists an efficient equilibrium. Otherwise, when the fraud cost cannot sustain an efficient equilibrium, it may arise a specialization equilibrium in which the author first submits the manuscript to a top journal which makes a truthful editorial decision. This specialization equilibrium may explain why academic journals with higher quality standards more often attract authors who write articles of higher quality. Finally, when the fraud cost is not too large, we show that a new type of equilibrium emerges in our model, equilibria involving costly fraud, in which the first peer-reviewed journal to which the research paper is submitted always requests substantial revisions. If the review time and the probability of very serious concerns from reviewers were large, the author would prefer to send the research paper to one single peer-reviewed journal even if that would involve over-revision. In the fraud equilibrium, the author’s revision cost is high and independent of the true quality of the manuscript.

Virome Sequencing in Patients With Myocarditis

BACKGROUND

Polymerase chain reaction analyses of cardiac tissues have detected viral sequences in up to 67% of cases of myocarditis. However, viruses have not been implicated in giant cell myocarditis (GCM). Furthermore, efforts to detect viruses implicated in myocarditis have been unsuccessful in more accessible samples such as peripheral blood.

METHODS

We used Virome Capture Sequencing for Vertbrate Viruses (VirCapSeq-VERT), a method that simultaneously screens for all known vertebrate viruses, to investigate viruses in 33 patients with myocarditis. We investigated peripheral blood mononuclear cells (n=24), plasma (n=27), endomyocardial biopsies (n=2), and cardiac tissue samples from explanted hearts (n=13).

RESULTS

Nine patients (27%) had GCM and 4 patients (13%) had fulminant myocarditis. We found the following viruses in the blood of patients with myocarditis: Epstein Barr virus (n=11, 41%), human pegivirus (n=1, 4%), human endogenous retrovirus K (n=27, 100%), and anellovirus (n=15, 56%). All tissue samples from fulminant myocarditis (n=2) and GCM (n=13) contained human endogenous retrovirus K.

CONCLUSIONS

No nucleic acids from viruses previously implicated in myocarditis or other human illnesses were detected in relevant amounts in cardiac tissue samples from GCM or in blood samples from other types of myocarditis. These findings do not exclude a role for viral infection in GCM but do suggest that if viruses are implicated, the mechanism is likely to be indirect rather than due to cytotoxic infection of myocardium.

Deep androgen receptor suppression in prostate cancer exploits sexually dimorphic renal expression for systemic glucocorticoid exposure

BACKGROUND

Enzalutamide and apalutamide are potent next-generation androgen receptor (AR) antagonists used in metastatic and non-metastatic prostate cancer. Metabolic, hormonal and immunologic effects of deep AR suppression are unknown. We hypothesized that enzalutamide and apalutamide suppress 11β-hydroxysteroid dehydrogenase-2 (11β-HSD2), which normally converts cortisol to cortisone, leading to elevated cortisol concentrations, increased ratio of active to inactive glucocorticoids and possibly suboptimal response to immunotherapy. On-treatment glucocorticoid changes might serve as an indicator of active glucocorticoid exposure and resultant adverse consequences.

PATIENTS AND METHODS

Human kidney tissues were stained for AR and 11β-HSD2 expression. Patients in three trials [neoadjuvant apalutamide plus leuprolide, enzalutamide ± PROSTVAC (recombinant poxvirus prostate-specific antigen vaccine) for metastatic castration-resistant prostate cancer (CRPC) and enzalutamide ± PROSTVAC for non-metastatic castration-sensitive prostate cancer] were analyzed for cortisol and its metabolites using liquid chromatography-mass spectrometry (LC-MS/MS). Progression-free survival was determined in the metastatic CRPC study of enzalutamide ± PROSTVAC for those with glucocorticoid changes above and below the median.

RESULTS

Concurrent AR and 11β-HSD2 expression occurs only in the kidneys of men. A statistically significant rise in cortisol concentration, cortisol/cortisone ratio and tetrahydrocortisol/tetrahydrocortisone ratio with AR antagonist treatment occurred uniformly across all three trials. In the trial of enzalutamide ± PROSTVAC for metastatic CRPC, high cortisol/cortisone ratio in the enzalutamide arm was associated with significantly improved progression-free survival. However, in the enzalutamide + PROSTVAC arm, the opposite trend was observed.

CONCLUSION

Enzalutamide and apalutamide treatment toggles renal 11β-HSD2 and significantly increases indicators of and exposure to biologically active glucocorticoids, which is associated with clinical outcomes.

Multinodular and Vacuolating Posterior Fossa Lesions of Unknown Significance

Multinodular and vacuolating neuronal tumor of the cerebrum is a rare supratentorial brain tumor described for the first time in 2013. Here, we report 11 cases of infratentorial lesions showing similar striking imaging features consisting of a cluster of low T1-weighted imaging and high T2-FLAIR signal intensity nodules, which we referred to as multinodular and vacuolating posterior fossa lesions of unknown significance. No relationship was found between the location of the lesion and clinical symptoms. A T2-FLAIR hypointense central dot sign was present in images of 9/11 (82%) patients. Cortical involvement was present in 2/11 (18%) of patients. Only 1 nodule of 1 multinodular and vacuolating posterior fossa lesion of unknown significance showed enhancement on postcontrast T1WI. DWI, SWI, MRS, and PWI showed no malignant pattern. Lesions did not change in size or signal during a median follow-up of 3 years, suggesting that multinodular and vacuolating posterior fossa lesions of unknown significance are benign malformative lesions that do not require surgical intervention or removal.

Discovery of two highly divergent negative-sense RNA viruses associated with the parasitic nematode, Capillaria hepatica, in wild Mus musculus from New York City

Recent advances in high-throughput sequencing technology have led to a rapid expansion in the number of viral sequences associated with samples from vertebrates, invertebrates and environmental samples. Accurate host identification can be difficult in assays of complex samples that contain more than one potential host. Using unbiased metagenomic sequencing, we investigated wild house mice (Mus musculus) and brown rats (Rattus norvegicus) from New York City to determine the aetiology of liver disease. Light microscopy was used to characterize liver disease, and fluorescent microscopy with in situ hybridization was employed to identify viral cell tropism. Sequences representing two novel negative-sense RNA viruses were identified in homogenates of wild house mouse liver tissue: Amsterdam virus and Fulton virus. In situ hybridization localized viral RNA to Capillaria hepatica, a parasitic nematode that had infected the mouse liver. RNA from either virus was found within nematode adults and unembryonated eggs. Expanded PCR screening identified brown rats as a second rodent host for C. hepatica as well as both nematode-associated viruses. Our findings indicate that the current diversity of nematode-associated viruses may be underappreciated and that anatomical imaging offers an alternative to computational host assignment approaches.

The cerebral angiome: High resolution MicroCT imaging of the whole brain cerebrovasculature in female and male mice

The cerebrovascular system provides crucial functions that maintain metabolic and homeostatic states of the brain. Despite its integral role of supporting cerebral viability, the topological organization of these networks remains largely uncharacterized. This void in our knowledge surmises entirely from current technological limitations that prevent the capturing of data through the entire depth of the brain. We report high-resolution reconstruction and analysis of the complete vascular network of the entire brain at the capillary level in adult female and male mice using a vascular corrosion cast procedure. Vascular network analysis of the whole brain revealed sex-related differences of vessel hierarchy. In addition, region-specific network analysis demonstrated different patterns of angioarchitecture between brain subregions and sex. Furthermore, our group is the first to provide a three-dimensional analysis of the angioarchitecture and network organization in a single reconstructed tomographic data set that encompasses all hierarchy of vessels in the brain of the adult mouse.

Antibodies to Enteroviruses in Cerebrospinal Fluid of Patients with Acute Flaccid Myelitis

Acute flaccid myelitis (AFM) has caused motor paralysis in >560 children in the United States since 2014. The temporal association of enterovirus (EV) outbreaks with increases in AFM cases and reports of fever, respiratory, or gastrointestinal illness prior to AFM in >90% of cases suggest a role for infectious agents. Cerebrospinal fluid (CSF) from 14 AFM and 5 non-AFM patients with central nervous system (CNS) diseases in 2018 were investigated by viral-capture high-throughput sequencing (VirCapSeq-VERT system). These CSF and serum samples, as well as multiple controls, were tested for antibodies to human EVs using peptide microarrays. EV RNA was confirmed in CSF from only 1 adult AFM case and 1 non-AFM case. In contrast, antibodies to EV peptides were present in CSF of 11 of 14 AFM patients (79%), significantly higher than controls, including non-AFM patients (1/5 [20%]), children with Kawasaki disease (0/10), and adults with non-AFM CNS diseases (2/11 [18%]) (P = 0.023, 0.0001, and 0.0028, respectively). Six of 14 CSF samples (43%) and 8 of 11 sera (73%) from AFM patients were immunoreactive to an EV-D68-specific peptide, whereas the three control groups were not immunoreactive in either CSF (0/5, 0/10, and 0/11; P = 0.008, 0.0003, and 0.035, respectively) or sera (0/2, 0/8, and 0/5; P = 0.139, 0.002, and 0.009, respectively).IMPORTANCE The presence in cerebrospinal fluid of antibodies to EV peptides at higher levels than non-AFM controls supports the plausibility of a link between EV infection and AFM that warrants further investigation and has the potential to lead to strategies for diagnosis and prevention of disease.

A viral metagenomic survey identifies known and novel mammalian viruses in bats from Saudi Arabia

Bats are implicated as natural reservoirs for a wide range of zoonotic viruses including SARS and MERS coronaviruses, Ebola, Marburg, Nipah, Hendra, Rabies and other lyssaviruses. Accordingly, many One Health surveillance and viral discovery programs have focused on bats. In this report we present viral metagenomic data from bats collected in the Kingdom of Saudi Arabia [KSA]. Unbiased high throughput sequencing of fecal samples from 72 bat individuals comprising four species; lesser mouse-tailed bat (Rhinopoma hardwickii), Egyptian tomb bat (Taphozous perforatus), straw-colored fruit bat (Eidolon helvum), and Egyptian fruit bat (Rousettus aegyptiacus) revealed molecular evidence of a diverse set of viral families: Picornaviridae (hepatovirus, teschovirus, parechovirus), Reoviridae (rotavirus), Polyomaviridae (polyomavirus), Papillomaviridae (papillomavirus), Astroviridae (astrovirus), Caliciviridae (sapovirus), Coronaviridae (coronavirus), Adenoviridae (adenovirus), Paramyxoviridae (paramyxovirus), and unassigned mononegavirales (chuvirus). Additionally, we discovered a bastro-like virus (Middle East Hepe-Astrovirus), with a genomic organization similar to Hepeviridae. However, since it shared homology with Hepeviridae and Astroviridae at ORF1 and in ORF2, respectively, the newly discovered Hepe-Astrovirus may represent a phylogenetic bridge between Hepeviridae and Astroviridae.

Tumour necrosis factor-alpha-induced protein 8 (TNFAIP8) expression associated with cell survival and death in cancer cell lines infected with canine distemper virus

Oncolytic virotherapy is a novel strategy for treatment of cancer in humans and companion animals as well. Canine distemper virus (CDV), a paramyxovirus, has proven to be oncolytic through induction of apoptosis in canine-derived tumour cells, yet the mechanism behind this inhibitory action is poorly understood. In this study, three human mammary tumour cell lines and one canine-derived adenofibrosarcoma cell line were tested regarding to their susceptibility to CDV infection, cell proliferation, apoptosis, mitochondrial membrane potential and expression of tumour necrosis factor-alpha-induced protein 8 (TNFAIP8). CDV replication-induced cytopathic effect, decrease of cell proliferation rates, and >45% of infected cells were considered death and/or under late apoptosis/necrosis. TNFAIP8 and CDVM gene expression were positively correlated in all cell lines. In addition, mitochondrial membrane depolarization was associated with increase in virus titres (p < 0.005). Thus, these results strongly suggest that both human and canine mammary tumour cells are potential candidates for studies concerning CDV-induced cancer therapy.

A phase I/II study of lenalidomide in combination with sunitinib in patients with advanced or metastatic renal cell carcinoma

BACKGROUND

This phase I/II study was conducted to determine the maximum tolerated dose (MTD), safety, and efficacy of lenalidomide plus sunitinib in metastatic renal cell carcinoma (RCC) patients.

PATIENTS AND METHODS

Patients with histologically confirmed, metastatic RCC were treated with 10 mg/day lenalidomide plus 37.5 mg/day sunitinib, orally in 21-day cycles. Doses were escalated to determine the MTD in phase I, with additional patients planned at this dose in phase II. Primary end points were MTD and response rate.

RESULTS

Sixteen patients received a median of 2, 3, and 5 cycles in cohort 1 [lenalidomide 10 mg (days 1-21) and sunitinib 37.5 mg (days 1-21)], cohort 2 [lenalidomide 10 mg (days 1-21) and sunitinib 37.5 mg (days 1-14)], and cohort 3 [lenalidomide 15 mg (days 1-21) and sunitinib 37.5 mg (days 1-14)], respectively. Median treatment durations were 41, 63, and 97 days for lenalidomide; and 41, 57, and 97.5 days for sunitinib. The MTD was found to be continuous dosing of lenalidomide 10 mg/day plus sunitinib 37.5 mg/day for 14 of 21 days. Dose-limiting toxicities included neutropenia, leukopenia, thrombocytopenia, asthenia, atrial fibrillation, and increased transaminases. The most frequent grade 3-4 treatment-emergent adverse events were hematologic, including neutropenia and leukopenia. One patient achieved partial response, and seven had stable disease of which three were confirmed at subsequent tumor assessments. B cells and several T-cell subsets were modulated versus baseline.

CONCLUSION

The dose schedules of lenalidomide and sunitinib evaluated in this study were not well tolerated; cumulative toxicity precluded enrollment at the MTD.

The Potyviridae cylindrical inclusion helicase: a key multipartner and multifunctional protein

A unique feature shared by all plant viruses of the Potyviridae family is the induction of characteristic pinwheel-shaped inclusion bodies in the cytoplasm of infected cells. These cylindrical inclusions are composed of the viral-encoded cylindrical inclusion helicase (CI protein). Its helicase activity was characterized and its involvement in replication demonstrated through different reverse genetics approaches. In addition to replication, the CI protein is also involved in cell-to-cell and long-distance movements, possibly through interactions with the recently discovered viral P3N-PIPO protein. Studies over the past two decades demonstrate that the CI protein is present in several cellular compartments interacting with viral and plant protein partners likely involved in its various roles in different steps of viral infection. Furthermore, the CI protein acts as an avirulence factor in gene-for-gene interactions with dominant-resistance host genes and as a recessive-resistance overcoming factor. Although a significant amount of data concerning the potential functions and subcellular localization of this protein has been published, no synthetic review is available on this important multifunctional protein. In this review, we compile and integrate all information relevant to the current understanding of this viral protein structure and function and present a mode of action for CI, combining replication and movement.

A 2 weeks on and 1 week off schedule of sunitinib is associated with decreased toxicity in metastatic renal cell carcinoma

Treatment of metastatic renal cell carcinoma (mRCC) with sunitinib is often associated with toxicity necessitating dose reduction. Maintaining adequate dosing and drug levels are essential for optimising clinical efficacy. Standard sunitinib schedule is 4 weeks of treatment and 2 weeks of rest (schedule 4/2). Empirically, several mRCC patients at The Cleveland Clinic (CCF) have been changed from schedule 4/2 to 2 weeks of treatment/1 week off (schedule 2/1) after experiencing toxicity, in an attempt to maintain daily dosing. The medical records of 30 mRCC patients on sunitinib who were changed from schedule 4/2 to schedule 2/1 at CCF were retrospectively reviewed. Toxicity on each schedule was recorded during routine clinic visits and graded using Common Toxicity Criteria, version 4.0. 97% of patients on schedule 4/2 had grade 3 or 4 toxicity that led to changing to schedule 2/1. There were no grade 4 toxicities on schedule 2/1, and 27% of patients experienced grade 3 toxicity (p=0.0001). Two of the most common toxicities, fatigue and hand-foot syndrome (HFS), were significantly less frequent on schedule 2/1 than on schedule 4/2 (p=0.0003; p=0.0004, respectively). Median overall treatment duration on schedule 4/2 was 12.6 months (range 1.2 months-5.1 years) and median overall treatment duration on schedule 2/1 was 11.9 months (range 0.9+ to 73.3+ months). Treatment with sunitinib on schedule 2/1 is associated with significantly decreased toxicity in patients who experience grade 3 or greater toxicity on schedule 4/2, and can extend treatment duration considerably. Prospective clinical trials are required to define the optimal sunitinib schedule to balance efficacy and toxicity.

Responses of laboratory-strain Mexican fruit flies,Anastrepha ludens, to combinations of fermenting fruit odor and male-produced pheromone in laboratory bioassays

The attractiveness toA. ludens adults of a combination of odor of fermented chapote fruit and pheromone was compared to attractiveness of both chapote and pheromone in laboratory bioassays. The chemical treatments were tested on 2-day-old and 10- to 12-day-old (sexually immature and mature, respectively), virgin and mated, nonstarved and starved, males and females during the early afternoon when flies were sexually inactive and the late afternoon when sexually mature flies were sexually active. The chapote-pheromone combination was equal to chapote odor alone in attractiveness to males and mated females. Pheromone partially inhibited attraction of immature females to chapote odor. Chapote odor almost completely inhibited attraction of sexually active females to pheromone. The potential for using a combination of chapote and pheromone as a trap bait is discussed.

A novel attractant for Mexican fruit fly,Anastrepha ludens, from fermented host fruit

Chemicals from fermented chapote fruit were identified and evaluated as attractants for hungry adult Mexican fruit flies in laboratory and greenhouse bioassays. Twenty-eight chemicals identified from an attractive gas-chromatography fraction were as attractive as a chapote volatiles extract (CV) when mixed in the same amounts found in CV. Sixteen of the chemicals were slightly attractive to flies when tested individually. A mixture containing 15 of the chemicals by design and the 16th as an impurity, in arbitrary concentrations, was at least as attractive as the original CV. In a series of experiments, the number of chemicals was reduced to three by elimination of unnecessary components. The three-component mixture retained the attractiveness of the 15-component mixture. The three chemicals were 1,8-cineole, ethyl hexanoate, and hexanol (CEH). Attractiveness of the three-chemical mixture was equal to the sum of the attractiveness of the three individual components, suggesting that each chemical binds to a different receptor type that independently elicits partial attraction behavior. Optimal ratios were 10∶1∶1 of the three chemicals, respectively. Optimal test quantities ranged between 0.4-4Μg of 1,8-cineole and 40-400 ng each of ethyl hexanoate and hexanol applied to filter paper in the laboratory bioassays. A neat 10∶1∶1 mixture of the chemicals was 1.8 times more attractive than aqueous solutions ofTorula dried yeast and borax to starved 2-day-old flies when the lures were tested in competing McPhail traps in a large greenhouse cage.

A case of swallow syncope

Swallow syncope, also called deglutition syncope, is a rare disorder triggered by oral intake. Patients often have underlying esophageal or structural heart disease. In some cases, the condition can be treated conservatively by eliminating predisposing factors. We describe the case of a 65-year-old woman without cardiovascular or esophageal disease who presented after a motor vehicle accident that was attributed to syncope while driving and eating. In the hospital, the patient suddenly lost consciousness while eating solid food; complete heart block without ventricular escape was documented on continuous electrocardiographic monitoring. A dual-chamber permanent pacemaker was placed and completely resolved the symptoms. This case illustrates a high-risk manifestation of swallow syncope: asystole resulting from an exaggerated vago-glossopharyngeal reflex.

Specific absorption rate of magnetite nanoparticle powders with and without surrounding organic ligands

Magnetite nanoparticles have been synthesized at different temperatures in order to get nanoparticles of different average sizes. Powders of the synthesized nanoparticles were introduced in a radio frequency electromagnetic apparatus built to perform hyperthermia measurements in laboratory animals. The nanoparticles synthesized at 80 degrees C, the ones giving the largest specific absorption rate values, have been functionalized with different organic ligands to study the influence of functionalization on specific absorption rate values. In all the synthesized nanoparticles, with and without organic surroundings, specific absorption rate measurements have been performed to study the influence of applied magnetic field intensity an frequency.

Off-Pump coronary artery bypass surgery is associated with worse arterial and saphenous vein graft patency and less effective revascularization: Results from the Veterans Affairs Randomized On/Off Bypass (ROOBY) trial

BACKGROUND

The Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial compared clinical and angiographic outcomes in off-pump versus on-pump coronary artery bypass graft (CABG) surgery to ascertain the relative efficacy of the 2 techniques.

METHODS AND RESULTS

From February 2002 to May 2007, the ROOBY trial randomized 2203 patients to off-pump versus on-pump CABG. Follow-up angiography was obtained in 685 off-pump (62%) and 685 on-pump (62%) patients. Angiograms were analyzed (blinded to treatment) for FitzGibbon classification (A=widely patent, B=flow limited, O=occluded) and effective revascularization. Effective revascularization was defined as follows: All 3 major coronary territories with significant disease were revascularized by a FitzGibbon A-quality graft to the major diseased artery, and there were no new postanastomotic lesions. Off-pump CABG resulted in lower FitzGibbon A patency rates than on-pump CABG for arterial conduits (85.8% versus 91.4%; P=0.003) and saphenous vein grafts (72.7% versus 80.4%; P<0.001). Fewer off-pump patients were effectively revascularized (50.1% versus 63.9% on-pump; P<0.001). Within each major coronary territory, effective revascularization was worse off pump than on pump (all P≤0.001). The 1-year adverse cardiac event rate was 16.4% in patients with ineffective revascularization versus 5.9% in patients with effective revascularization (P<0.001).

CONCLUSIONS

Off-pump CABG resulted in significantly lower FitzGibbon A patency for arterial and saphenous vein graft conduits and less effective revascularization than on-pump CABG. At 1 year, patients with less effective revascularization had higher adverse event rates.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00032630.

Safety and efficacy of dual-axis rotational coronary angiography vs. standard coronary angiography

OBJECTIVE

To determine the safety and efficacy of dual-axis rotational coronary angiography (DARCA) by directly comparing it to standard coronary angiography (SA).

BACKGROUND

Standard coronary angiography (SA) requires numerous fixed static images of the coronary tree and has multiple well-documented limitations. Dual-axis rotational coronary angiography (DARCA) is a new rotational acquisition technique that entails simultaneous LAO/RAO and cranial/caudal gantry movement. This technological advancement obtains numerous unique images of the left or right coronary tree with a single coronary injection. We sought to assess the safety and efficacy of DARCA as well as determine DARCA's adequacy for CAD screening and assessment.

METHODS

Thirty patients underwent SA following by DARCA. Contrast volume, radiation dose (DAP) and procedural time were recorded for each method to assess safety. For DARCA acquisitions, blood pressure (BP), heart rate (HR), symptoms and any arrhythmias were recorded. All angiograms were reviewed for CAD screening adequacy by two independent invasive cardiologists.

RESULTS

Compared to SA, use of DARCA was associated with a 51% reduction in contrast, 35% less radiation exposure, and 18% shorter procedural time. Both independent reviewers noted DARCA to be at least equivalent to SA with respect to the ability to screen for CAD.

CONCLUSION

DARCA represents a new angiographic technique which is equivalent in terms of image quality and is associated with less contrast use, radiation exposure, and procedural time than SA.

Retrograde approach to recanalization of complex tibial disease

A significant proportion (~ 20%) of patients with complex tibial artery occlusions cannot be treated using a conventional antegrade approach. We report our experience using the retrograde approach for the treatment of complex tibial artery occlusive disease using retrograde pedal/tibial access in 13 limbs from 12 patients. Retrograde pedal/tibial access was achieved in all cases (facilitated by surgical cutdown in one case), and procedural success was achieved in 11 of 13 limbs (85%). Based on this experience, a discussion of clinical and technical aspects of the retrograde pedal/tibial approach is provided, and a new classification for tibial artery occlusive disease is proposed.

Influence of nuchal cord on ductus venosus assessment at 11 to 13 + 6 weeks' gestation

OBJECTIVES

To assess the influence of the presence of nuchal cord (NC) on the evaluation of the fetal ductus venosus flow velocity waveform (DV-FVW).

METHODS

This prospective study included 1174 normal non-selected singleton pregnancies between 11 and 13 + 6 weeks' gestation. We recorded the presence or absence of NC around the fetal neck, and assessed its relationship with the qualitative assessment and quantitative measurement of the DV-FVW.

RESULTS

We observed NC around the fetal neck in 6.73% of cases and detected reversed flow of the a-wave of the DV-FVW in 2.98% of cases. In the group without NC, 21 of 1095 had reversed flow in the DV-FVW (1.9%; 95% CI, 1.28-3.02), whereas in the group with NC, 14 of 79 had reversed flow in the DV-FVW (17.7%; 95% CI, 16.67-40.35). We found a lower pulsatility index in fetuses without NC in comparison to those with NC (P < 0.001). We also found an association between the presence of NC and an increased occurrence of absent and reversed a-wave of the flow velocity waveforms (P < 0.001). On multivariate logistic regression analysis, a much higher occurrence of reversed DV-FVW a-wave was detected in fetuses with NC and smaller crown-rump length, and a much higher occurrence of absent DV-FVW a-wave was found in fetuses with NC and a higher maternal body mass index.

CONCLUSIONS

The presence of NC modifies the sonographic findings in the qualitative and quantitative evaluation of the DV-FVW.

Adenoviral targeting of gene expression to tumors

Using biochemical, imaging and histological methods, we employed transcriptional targeting to increase the specificity of tumor gene expression in vivo for intravenously administered recombinant adenovirus vectors. Surprisingly, the relative specificity of tumor expression in comparison to other tissues was increased for a constitutively expressing recombinant adenovirus, AdCMVLuc, by simply reducing the viral dose. Even at lower doses, however, the high frequency of viral infection and transgene expression in the liver using constitutive promoters still represents a substantial problem. To further augment tumor specificity, we constructed a series of adenoviruses expressing luciferase from several other promoters and tested their ability to selectively transcribe genes in tumor cells both in vitro and in vivo. Constitutively active viral promoters (RSV, SRα) varied widely in their tumor selectivity, but hypoxia-responsive promoters (carbonic anhydrase 9, PAI-1, SOD2, and several chimeric constructs) demonstrated the most tumor-selective expression. Our results show that tumor targeting to HT1080 fibrosarcomas was readily achieved using transcriptional targeting mechanisms. We attribute the relatively high level of gene transfer and expression in HT1080 tumors in vivo to increased viral access to the tumor, presumably due to discontinuities in tumor vasculature and augmented expression from stress-responsive promoters in the hypoxic and inflammatory tumor microenvironment.

Clinical feasibility of a fully automated 3D reconstruction of rotational coronary X-ray angiograms

BACKGROUND

Although fixed view x-ray angiography remains the primary technique for anatomic imaging of coronary artery disease, the known shortcomings of 2D projection imaging may limit accurate 3D vessel and lesion definition and characterization. A recently developed method to create 3D images of the coronary arteries uses x-ray projection images acquired during a 180 degrees C-arm rotation and continuous contrast injection followed by ECG-gated iterative reconstruction. This method shows promise for providing high-quality 3D reconstructions of the coronary arteries with no user interaction but requires clinical evaluation.

METHODS AND RESULTS

The reconstruction strategy was evaluated by comparing the reconstructed 3D volumetric images with the 2D angiographic projection images from the same 23 patients to ascertain overall image quality, lesion visibility, and a comparison of 3D quantitative coronary analysis with 2D quantitative coronary analysis. The majority of the resulting 3D volume images were rated as having high image quality (66%) and provided the physician with additional clinical information such as complete visualization of bifurcations and unobtainable views of the coronary tree. True-positive lesion detection rates were high (90 to 100%), whereas false-positive detection rates were low (0 to 8.1%). Finally, 3D quantitative coronary analysis showed significant similarity with 2D quantitative coronary analysis in terms of lumen diameters and provided vessel segment length free from the errors of foreshortening.

CONCLUSIONS

Fully automated reconstruction of rotational coronary x-ray angiograms is feasible, produces 3D volumetric images that overcome some of the limitations of standard 2D angiography, and is ready for further implementation and study in the clinical environment.

Computer assistance for solving imaging problems

Medical imaging has moved into an era of digital files and processing of images to yield three-dimensional models and reconstructions. This development has opened up opportunities to apply computer techniques in traditional imaging tasks. Two of the most common imaging tasks are those to correct the two-dimensional projection problems of foreshortening of lesions and of vessel overlap. This article explores the use of computers to assist in these tasks, to create databases for guiding decision making, to provide graphics to assist the physician, and to simulate cardiovascular procedures.

Effect of feed type and feeding frequency on macrophage functions in tilapia (Oreochromis niloticus L.)

In fresh water recirculation systems the type of feed and feeding frequency have a direct effect on water quality, growth, fish welfare and the response of the immune system. Four types of feed with different sources of plant protein (soybean concentrate, sunflower meal, corn gluten and pea) were provided at two feeding frequencies (two and eight times day(-1)) to observe effects on growth, cortisol levels and innate immunity (macrophage phagocytosis and respiratory burst) on tilapia in early stages of growth (2-10 g). Growth and cortisol parameters were quite similar among the groups of tilapia fed the different diets and frequencies at the end of the feeding period. Phagocytosis and respiratory burst were also very similar with the four feed types. However, macrophages from fish fed twice day(-1) were much less efficient in clearing bacteria after 24 h than the groups fed eight times day(-1). Our results suggest that an increased feeding frequency may confer a higher resistance to disease.

Use of the Boomerang catalyst advantage closure device to facilitate complex multistaged percutaneous revascularization procedures for the treatment of critical limb ischemia

An increasing spectrum of complex peripheral arterial disease may be successfully treated using percutaneous revascularization techniques. A pair of challenging peripheral revascularization procedures in patients with critical limb ischemia is presented, where an array of interventional tools and techniques were required, and the off-label use of the Boomerang catalyst system closure device was important in managing a variety of complex arterial access issues and ultimately allowing procedural success.

Enhanced stent visualization: a case series demonstrating practical applications during PCI

BACKGROUND

Visualization of coronary stents is increasingly challenging due to the reduction in stent strut thickness to improve deliverability. On the other hand stent expansion and precise implantation in the target vessel are important in optimizing short and long-term outcomes of stent-based revascularization. Stentboost Subtract is a novel X-ray technique that improves visualization of deployed stents in the coronary arteries. Using motion compensation and integration of multiple non-contrast projection images from a fixed gantry position, this new technique depicts stent morphology allowing assessment of stent expansion and extent of overlap with adjacent stents. We present a case series in which enhanced stent visualization (ESV) facilitated interventions.

METHODS

The clinical and angiographic characteristics of 6 cases utilizing ESV were reviewed. All ESV acquisitions in this case series utilized an 8 in. field of view (FOV), 3 ml/sec. for a total of 6 ml of contrast, and placement of balloon markers in the region of interest.

RESULTS

The cases presented significantly facilitated the identification of bifurcation stenting techniques, precise stent positioning, stent underexpansion and assisted with defining stent-vessel wall relationship that was additive to intravascular ultrasound.

CONCLUSIONS

ESV is a novel tool used in coronary interventions that facilitates non-invasive assessment of stent positioning, expansion and stent-vessel interactions. This inexpensive ESV technique is complimentary to IVUS and in some cases obviates its need.

Role of the NO/cGMP/K(ATP) pathway in the protective effects of sildenafil against ethanol-induced gastric damage in rats

BACKGROUND AND PURPOSE

Sildenafil is a selective inhibitor of cGMP-specific phosphodiesterase. Sildenafil, acting via NO-dependent mechanisms, prevents indomethacin-induced gastropathy. Activation of ATP-sensitive potassium channels (K(ATP)) is involved in gastric defence. Our objective was to evaluate the role of the NO/cGMP/K(ATP) pathway in the protective effects of sildenafil against ethanol-induced gastric damage.

EXPERIMENTAL APPROACH

Rats were treated with L-NAME (1 or 3 mg kg(-1), i.p.) or with L-arginine (200 mg kg(-1), i.p.) + L-NAME (3 mg kg(-1), i.p.), the guanylate cyclase inhibitor, ODQ (10 mg kg(-1), i.p.), glibenclamide (0.1, 0.3, 1 or 3 mg kg(-1), i.p.) or with glibenclamide (1 mg kg(-1), i.p.) + diazoxide (3 mg kg(-1), i.p.). After thirty minutes, the rats received sildenafil (1 mg kg(-1), by gavage), followed by intragastric instillation of absolute ethanol (4 ml kg(-1)) to induce gastric damage. One hour later, gastric damage (haemorrhagic or ulcerative lesions) was measured with a planimetry programme. Samples of stomach were also taken for histopathological assessment and for assays of tissue glutathione and haemoglobin.

KEY RESULTS

Sildenafil significantly reduced ethanol-induced gastric damage in rats. L-NAME alone, without L-arginine, significantly reversed the protection afforded by sildenafil. Inhibition of guanylate cyclase by ODQ completely abolished the gastric protective effect of sildenafil against ethanol-induced gastric damage. Glibenclamide alone reversed sildenafil's gastric protective effect. However, glibenclamide plus diazoxide did not alter the effects of sildenafil.

CONCLUSIONS

Sildenafil had a protective effect against ethanol-induced gastric damage through the activation of the NO/cGMP/K(ATP) pathway.

Percutaneous closure of an iatrogenic ventricular septal defect following mechanical aortic valve replacement using the transseptal technique

Iatrogenic ventricular septal defects (VSDs) following aortic valve replacement are relatively uncommon and are challenging to close percutaneously given their typical proximity to the prosthetic valve. We describe the successful percutaneous closure of an iatrogenic VSD in a patient with a recent mechanical AVR using the transseptal approach.

Percutaneous closure of a para-prosthetic aorto-right ventricular fistula

A 60-year-old woman with increasing dyspnea was found to have a para-prosthetic aorto-right ventricular fistula during post-operative evaluation. Due to her multiple sternotomies, she was considered to be high risk for open surgical repair and referred for percutaneous intervention. A 6/4 mm Amplatzer occluder device (AGA Medical, Golden Valley, MN) was successfully delivered across the fistula with excellent immediate angiographic results.

Prognostic factors associated with long-term survival in previously untreated metastatic renal cell carcinoma

PURPOSE

To identify prognostic factors (PF) for long-term survival in metastatic renal cell carcinoma (RCC) patients.

METHODS

We retrospectively reviewed a metastatic RCC database at the Cleveland Clinic Foundation consisting of 358 previously untreated patients who were enrolled in institutional review board-approved clinical trials of immunotherapy and/or chemotherapy at our institution from 1987 to 2002. In order to identify patient characteristics associated with long-term survival, we compared 226 'short-term' survivors [defined as overall survival (OS) <2 years] with 31 'long-term' survivors (OS >or=5 years).

RESULTS

Using logistic regression models, four adverse PF were identified as independent predictors of long-term survival: hemoglobin less than the lower limit of normal, greater than two metastatic sites, involved kidney (left), and Eastern Cooperative Oncology Group (ECOG) performance status (PS). Using the number of poor prognostic features present, three distinct risk groups could be identified. Patients with 0 or 1 adverse prognostic feature present had an observed likelihood of long-term survival of 32% (21/66) compared with 9% (8/91) for patients with two adverse features present and only 1% (1/93) for patients with more than two adverse features.

CONCLUSIONS

Independent predictors of long-term survival in previously untreated metastatic RCC include baseline hemoglobin level, number of involved sites, involved kidney, and ECOG PS. Incorporation of these factors into a simple prognostic scoring system enables three distinct groups of patients to be identified.

Initial clinical experience of selective coronary angiography using one prolonged injection and a 180° rotational trajectory

OBJECTIVE

Evaluate the safety of prolonged coronary injections during a rotational acquisition covering 180 degrees.

BACKGROUND

Rotational angiography has been adapted to coronary angiography and shown to reduce radiation and contrast exposure. Three-dimensional (3D) reconstructions and other advanced applications require imaging over a 180 degrees -arc with a single but longer injection of larger contrast volumes.

METHODS

Thirty patients referred for angiography were enrolled. Blood pressure (BP), heart rate (HR), symptoms, and ectopy were recorded before-and-after injections.

RESULTS

Pre and post-injection HRs for the LCA/RCA were not statistically different (LCA-pre-injection 63+/-13 bpm vs. LCA-post-injection 62+/-11 bpm, P=0.54 and RCA-pre-injection 65+/-12 bpm vs. RCA-post-injection 65+/-10, P=0.88). Central aortic pressure values were not statistically different for the RCA injections (RCA-systolic-pre-injection 118+/-14 mm Hg vs. RCA-systolic-post-injection 112+/-25 mm Hg, P=0.15, and RCA diastolic-pre-injection 69+/-9 mm Hg vs. RCA-diastolic-post-injection 60+/-10 mm Hg, P=0.88) but were statistically significant for the LCA injections (LCA systolic-pre-injection 122+/-19 mm Hg vs. LCA-systolic-post-injection 116+/-17 mm Hg, P=0.0004, and LCA-diastolic-pre-injection 69+/-10 mm Hg vs. LCA-diastolic-post-injection 65+/-9 mm Hg, P=0.0007). There were no symptoms or electrical events documented during or immediately post-injection.

CONCLUSION

This study demonstrates the feasibility and safety of longer coronary injections. There were no significant HR changes, clinically insignificant pressure changes, and no adverse reactions. Additional studies will be needed to assure its safety in a larger and clinically more varied patient population.

Simultaneous multivessel acute drug-eluting stent thrombosis

Stent thrombosis (ST) in the era of bare metal stents (BMS) using high-pressure stent deployment and combined anti-platelet therapy is an uncommon but feared complication. There is concern for an elevated risk of stent thrombosis (ST) with drug-eluting stents (DES). We describe a case of simultaneous multivessel drug-eluting stent thrombosis 8 h after deployment of paclitaxel-eluting stents in the right coronary (RCA) and left anterior descending (LAD) arteries.

Rotational angiography (RA) and three-dimensional imaging (3-DRA): an available clinical tool

Being able to accurately choose an optimal view for stent positioning, non foreshortened length and to avoid side branches is imperative during therapeutic procedures. Traditional imaging limitations may include the selection of an incorrectly sized stent, inaccurate placement, and/or the need for additional stents. With the use of newer acquisition techniques and three-dimensional (3-D) modeling/reconstructions this can be minimized. We present a case in which with the assistance of 3-D and its computer derived optimal view, and optimal length, a significant amount of vessel foreshortening was eliminated therefore improving the procedural outcome.

3D Reconstruction of Coronary Stents in Vivo Based on Motion Compensated X-Ray Angiograms

A new method is introduce for the three-dimensional (3D) reconstruction of the coronary stents in-vivo utilizing two-dimensional projection images acquired during rotational angiography (RA). The method is based on the application of motion compensated techniques to the acquired angiograms resulting in a temporal snapshot of the stent within the cardiac cycle. For the first time results of 3D reconstructed coronary stents in vivo, with high spatial resolution are presented. The proposed method allows for a comprehensive and unique quantitative 3D assessment of stent expansion that rivals current x-ray and intravascular ultrasound techniques.

Application of GFP-tagged Plum pox virus to study Prunus-PPV interactions at the whole plant and cellular levels

The Sharka disease caused by the potyvirus Plum pox virus (PPV) is one of the most serious viral diseases affecting stone fruit trees. The study of PPV/Prunus interaction under greenhouse controlled conditions is space, time, labor consuming. While the PPV/Prunus interactions are now quite well known at the whole plant level, few data however are available on the interactions between the virus and the Prunus host plants at the cellular level. Using a green fluorescent protein (GFP)-tagged M type PPV strain, combined to an in vitro inoculation procedure, we developed a novel tool to track PPV invasion in Prunus persica (peach) cv. GF305 and Prunus armeniaca (apricot) cv. Screara susceptible hosts. Different graft combinations were performed using in vitro-maintained healthy or GFP-tagged PPV infected 'GF305' and 'Screara'. Contact for 30 days in grafts between the inoculum and the genotype to be tested were found sufficient to allow the systemic spread of the recombinant virus: fluorescence from GFP-tagged PPV could easily be detected in the entire plant under a binocular microscope allowing quick and reliable sorting of infected plants. Using a fluorescence stereomicroscopy or confocal microscopy, GFP could also be observed in stem cross-sections especially in epidermis and pith cells. In vitro grafting inoculation with GFP-tagged PPV provides a new and powerful tool to facilitate mid-term virus maintenance. Moreover, this tool will be of special importance in the study of PPV infection dynamics in Prunus, allowing as well precise observations of cellular events related to PPV/Prunus interactions.

Effects of Buprenorphine on Cardiac Repolarization in a Patient with Methadone-Related Torsade de Pointes

Torsade de pointes is a rare but potentially fatal ventricular arrhythmia that is often triggered by drugs that prolong the rate-corrected QT (QTc) interval. This arrhythmia has been attributed to levacetylmethadol and methadone, synthetic opioids used to treat heroin addiction. Levacetylmethadol, a derivative of methadone, is being withdrawn from the United States market because its use waned after a black box warning was issued to require electrocardiographic monitoring. Therefore, methadone and buprenorphine are the only opioids available for the treatment of heroin addiction. To our knowledge, the cardiac safety of buprenorphine in patients with methadone-related QTc prolongation has not been described. We report a patient who developed torsade de pointes while receiving high-dose methadone and was successfully inducted onto buprenorphine under close medical supervision. No clinically important QTc prolongation was observed in the acute setting or during follow-up. This observation suggests that buprenorphine may be a safe alternative to oral methadone in patients with opioid addiction who develop torsade de pointes.

Tramadol-associated pericarditis

Tramadol, marketed as Ultram in the United States, is as a non-scheduled narcotic analgesic based on its low abuse liability. It is indicated for the treatment of moderately severe pain; however, multiple adverse effects have been reported with its use including seizures, anaphylaxis, angioedema, bronchospasm, and serotonin syndrome. An association between tramadol and pericarditis has not been previously reported. We describe the case of an 88 year-old male who developed acute pericarditis 2 days following tramadol initiation. The temporal relationship between drug initiation and pericarditis as well as the resolution of symptoms upon drug discontinuation suggested a potential association. Although pericarditis has not been described with tramadol administration, clinicians should be aware of a possible association.