Automated model versus treating physician for predicting survival time of patients with metastatic cancer

OBJECTIVE

Being able to predict a patient's life expectancy can help doctors and patients prioritize treatments and supportive care. For predicting life expectancy, physicians have been shown to outperform traditional models that use only a few predictor variables. It is possible that a machine learning model that uses many predictor variables and diverse data sources from the electronic medical record can improve on physicians' performance. For patients with metastatic cancer, we compared accuracy of life expectancy predictions by the treating physician, a machine learning model, and a traditional model.

MATERIALS AND METHODS

A machine learning model was trained using 14 600 metastatic cancer patients' data to predict each patient's distribution of survival time. Data sources included note text, laboratory values, and vital signs. From 2015-2016, 899 patients receiving radiotherapy for metastatic cancer were enrolled in a study in which their radiation oncologist estimated life expectancy. Survival predictions were also made by the machine learning model and a traditional model using only performance status. Performance was assessed with area under the curve for 1-year survival and calibration plots.

RESULTS

The radiotherapy study included 1190 treatment courses in 899 patients. A total of 879 treatment courses in 685 patients were included in this analysis. Median overall survival was 11.7 months. Physicians, machine learning model, and traditional model had area under the curve for 1-year survival of 0.72 (95% CI 0.63-0.81), 0.77 (0.73-0.81), and 0.68 (0.65-0.71), respectively.

CONCLUSIONS

The machine learning model's predictions were more accurate than those of the treating physician or a traditional model.

Early Detection of Molecular Residual Disease in Localized Lung Cancer by Circulating Tumor DNA Profiling

Identifying molecular residual disease (MRD) after treatment of localized lung cancer could facilitate early intervention and personalization of adjuvant therapies. Here, we apply cancer personalized profiling by deep sequencing (CAPP-seq) circulating tumor DNA (ctDNA) analysis to 255 samples from 40 patients treated with curative intent for stage I-III lung cancer and 54 healthy adults. In 94% of evaluable patients experiencing recurrence, ctDNA was detectable in the first posttreatment blood sample, indicating reliable identification of MRD. Posttreatment ctDNA detection preceded radiographic progression in 72% of patients by a median of 5.2 months, and 53% of patients harbored ctDNA mutation profiles associated with favorable responses to tyrosine kinase inhibitors or immune checkpoint blockade. Collectively, these results indicate that ctDNA MRD in patients with lung cancer can be accurately detected using CAPP-seq and may allow personalized adjuvant treatment while disease burden is lowest.Significance: This study shows that ctDNA analysis can robustly identify posttreatment MRD in patients with localized lung cancer, identifying residual/recurrent disease earlier than standard-of-care radiologic imaging, and thus could facilitate personalized adjuvant treatment at early time points when disease burden is lowest. Cancer Discov; 7(12); 1394-403. ©2017 AACR.See related commentary by Comino-Mendez and Turner, p. 1368This article is highlighted in the In This Issue feature, p. 1355.

Analysis of circulating tumor DNA in localized lung cancer for detection of molecular residual disease and personalization of adjuvant strategies

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Background: Identifying localized non-small cell lung cancer (NSCLC) patients with residual disease following curative intent therapy is difficult due to normal tissue changes caused by surgery or radiation and an inability to detect microscopic disease. Analysis of circulating tumor DNA (ctDNA) might enable identification of molecular residual disease (MRD) and personalization of adjuvant treatment approaches but has not been explored in lung cancer. Methods: We applied CAPP-Seq, an ultra-sensitive next-generation sequencing based ctDNA quantitation method, to pre- and post-treatment blood samples from a cohort of 41 patients treated with chemoradiation, radiotherapy or surgery for stage I-III primary lung cancer. Detection of ctDNA at a single MRD time-point within 4 months of treatment completion was compared with surveillance by cross-sectional imaging. Furthermore, we developed an approach for identification of tumor mutation burden based on mutations detected in plasma, leveraging whole exome sequencing data from 1,177 NSCLCs sequenced by TCGA. Results: Median follow-up time was 35 months. Pre-treatment ctDNA was detected in 38 (93%) patients and 19 (46%) had detectable post-treatment ctDNA MRD. MRD+ patients displayed significantly inferior 3-year freedom from progression (0% vs. 92%; HR 38; P < 0.0001) and 3-year overall survival (8% vs. 75%; HR 12; P < 0.0001) than MRD- patients. Detection of ctDNA MRD had positive and negative predictive values for disease progression of 100% and 93%, respectively. Furthermore, we non-invasively identified activating EGFR mutations or high mutational burden (≥5 CAPP-Seq non-synonymous mutations, corresponding to > 200 non-synonymous mutations per exome or > 4 single nucleotide variants per megabase of exome) in 47% of patients with detectable ctDNA MRD, suggesting potentially favorable responses to TKIs and immune checkpoint inhibitors, respectively. Conclusions: Our results indicate that ctDNA analysis accurately detects MRD in localized lung cancer patients and could facilitate personalized adjuvant treatment at early time-points when disease burden is minimal.

Role of KEAP1/NRF2 and TP53 Mutations in Lung Squamous Cell Carcinoma Development and Radiation Resistance

Lung squamous cell carcinoma (LSCC) pathogenesis remains incompletely understood, and biomarkers predicting treatment response remain lacking. Here, we describe novel murine LSCC models driven by loss of Trp53 and Keap1, both of which are frequently mutated in human LSCCs. Homozygous inactivation of Keap1 or Trp53 promoted airway basal stem cell (ABSC) self-renewal, suggesting that mutations in these genes lead to expansion of mutant stem cell clones. Deletion of Trp53 and Keap1 in ABSCs, but not more differentiated tracheal cells, produced tumors recapitulating histologic and molecular features of human LSCCs, indicating that they represent the likely cell of origin in this model. Deletion of Keap1 promoted tumor aggressiveness, metastasis, and resistance to oxidative stress and radiotherapy (RT). KEAP1/NRF2 mutation status predicted risk of local recurrence after RT in patients with non-small lung cancer (NSCLC) and could be noninvasively identified in circulating tumor DNA. Thus, KEAP1/NRF2 mutations could serve as predictive biomarkers for personalization of therapeutic strategies for NSCLCs.

SIGNIFICANCE

We developed an LSCC mouse model involving Trp53 and Keap1, which are frequently mutated in human LSCCs. In this model, ABSCs are the cell of origin of these tumors. KEAP1/NRF2 mutations increase radioresistance and predict local tumor recurrence in radiotherapy patients. Our findings are of potential clinical relevance and could lead to personalized treatment strategies for tumors with KEAP1/NRF2 mutations. Cancer Discov; 7(1); 86-101. ©2016 AACR.This article is highlighted in the In This Issue feature, p. 1.

Pre-treatment non-target lung FDG-PET uptake predicts symptomatic radiation pneumonitis following Stereotactic Ablative Radiotherapy (SABR)

PURPOSE

To determine if pre-treatment non-target lung FDG-PET uptake predicts for symptomatic radiation pneumonitis (RP) following lung stereotactic ablative radiotherapy (SABR).

METHODS

We reviewed a 258 patient database from our institution to identify 28 patients who experienced symptomatic (grade ⩾ 2) RP after SABR, and compared them to 57 controls who did not develop symptomatic RP. We compared clinical, dosimetric and functional imaging characteristics between the 2 cohorts including pre-treatment non-target lung FDG-PET uptake.

RESULTS

Median follow-up time was 26.9 months. Patients who experienced symptomatic RP had significantly higher non-target lung FDG-PET uptake as measured by mean SUV (p < 0.0001) than controls. ROC analysis for symptomatic RP revealed area under the curve (AUC) of 0.74, with sensitivity 82.1% and specificity 57.9% with cutoff mean non-target lung SUV > 0.56. Predictive value increased (AUC of 0.82) when mean non-target lung SUV was combined with mean lung dose (MLD). We developed a 0-2 point model using these 2 variables, 1 point each for SUV > 0.56 or MLD > 5.88 Gy equivalent dose in 2 Gy per fraction (EQD2), predictive for symptomatic RP in our cohort with hazard ratio 10.01 for score 2 versus 0 (p < 0.001).

CONCLUSIONS

Patients with elevated pre-SABR non-target lung FDG-PET uptake are at increased risk of symptomatic RP after lung SABR. Our predictive model suggests patients with mean non-target lung SUV > 0.56 and MLD > 5.88 Gy EQD2 are at highest risk. Our predictive model should be validated in an external cohort before clinical implementation.

Tracheal Diverticulum Following Paratracheal Hypofractionated Radiotherapy in the Setting of Prior and Subsequent Bevacizumab

We present the case of a 63-year-old woman with limited metastatic colorectal cancer to the lungs and liver treated with FOLFIRI-bevacizumab, followed by consolidative hypofractionated radiotherapy to right paratracheal metastatic lymphadenopathy. We treated the right paratracheal site with 60 Gy in 15 fractions (70 Gy equivalent dose in 2 Gy fractions). The patient tolerated the treatment well, and six months later started a five-month course of FOLFIRI-bevacizumab for new metastatic disease. She presented to our clinic six months after completing this, complaining of productive cough with scant hemoptysis, and was found to have localized tracheal wall breakdown and diverticulum in the region of prior high-dose radiation therapy, threatening to progress to catastrophic tracheovascular fistula. This was successfully repaired surgically after a lack of response to conservative measures. We urge caution in treating patients with vascular endothelial growth factor (VEGF) inhibitors in the setting of hypofractionated radiotherapy involving the mucosa of tubular organs, even when these treatments are separated by months. Though data is limited as to the impact of sequence, this may be particularly an issue when VEGF inhibitors follow prior radiotherapy.

Severe Chest Wall Toxicity From Cryoablation in the Setting of Prior Stereotactic Ablative Radiotherapy

We present the case of a 42-year-old woman with metastatic synovial sarcoma of parotid origin, treated definitively with chemoradiation, who subsequently developed oligometastatic disease limited to the lungs. She underwent multiple left and right lung wedge resections and left lower lobectomy, followed by right lower lobe stereotactic ablative radiotherapy (SABR), 54 Gy in three fractions to a right lower lobe lesion abutting the chest wall. Two years later, she was treated with cryoablation for a separate right upper lobe nodule abutting the chest wall. Two months later, she presented with acute shortness of breath, pleuritic chest pain, decreased peripheral blood O2 saturation, and productive cough. A computed tomography (CT) scan demonstrated severe chest wall necrosis in the area of recent cryoablation that, in retrospect, also received a significant radiation dose from her prior SABR. This case demonstrates that clinicians should exercise caution in using cryoablation when treating lung tumors abutting a previously irradiated chest wall.

Note: Drs. Loo and Shah contributed equally as co-senior authors.

Nutritive value, fermentation characteristics, and in situ disappearance kinetics of ensiled warm-season legumes and bahiagrass

This study determined the nutritive value, ensiling characteristics, and in situ disappearance kinetics of bahiagrass (Paspalum notatum Flügge 'Tifton 9'), perennial peanut (Arachis glabrata Benth. 'Florigraze'), annual peanut [Arachis hypogaea (L.) 'FL MDR 98'], cowpea [Vigna unguiculata (L.) Walp. 'Iron clay'], and pigeonpea [Cajanus cajan (L.) Millsp. 'GA-2']. All forages were harvested at maturity stages that optimized dry matter (DM) yield and nutritive value. After harvest, forages were wilted to 45% DM, and 4 replicate bales of each legume and 8 bales of bahiagrass were wrapped in polyethylene and ensiled for 180 d. After each bale was opened, the forage was thoroughly mixed, and representative subsamples were taken for laboratory analysis and in situ incubation. Wilting and ensiling decreased the rumen-undegradable protein, water-soluble carbohydrate, crude protein (CP), and in vitro true digestibility (IVTD) of bahiagrass, perennial peanut, and cowpea, and increased their neutral detergent fiber (NDF) concentrations. Among haylages, CP concentration was greatest for annual peanut, followed by perennial peanut and cowpea, and least for bahiagrass. In contrast, NDF concentration was greater in bahiagrass than in legumes. Pigeonpea had the greatest NDF concentration among legumes and lowest IVTD of all haylages. All haylages were aerobically stable for at least 84 h, but pH was lower in perennial peanut and cowpea than in pigeonpea. Ammonia-N concentrations tended to be greater in legume haylages than in bahiagrass haylage. Butyrate concentration was greater in annual and perennial peanut than in bahiagrass. Total VFA concentration was greater in annual and perennial peanut and cowpea haylages than in bahiagrass haylage. Undegradable DM fractions were greater and extent of DM degradation was lower in bahiagrass and pigeonpea than in other haylages but lag time and degradation rates did not differ. Annual and perennial peanut and cowpea haylages were as aerobically stable and had greater CP, IVTD, and extent of degradation than did bahiagrass haylage; therefore, they are promising forages for dairy cow diets in the southeastern United States.

Intake, digestibility, and nitrogen retention by sheep supplemented with warm-season legume hays or soybean meal

The increasing cost of feed supplements necessitates evaluation of alternatives for ruminant livestock grazing poor quality warm-season grasses. This study determined how supplementing bahiagrass hay (Paspalum notatum Flügge cv. Pensacola) with soybean [Glycine max (L.) Merr.] meal or warm-season legume hays affected intake, digestibility, and N utilization by lambs. Dorper x Katadhin crossbred lambs (30.6 +/- 5.5 kg; n = 42) were fed bahiagrass hay (73.8% NDF, 8.1% CP) for ad libitum intake and supplemented with nothing (control), soybean meal, or hays of annual peanut [Arachis hypogaea (L.) cv. Florida MDR98; 46.2% NDF, 14.7% CP], cowpea [Vigna unguiculata (L.) Walp. cv. Iron clay; 62.2% NDF, 11.7% CP], perennial peanut (Arachis glabrata Benth. cv. Florigraze; 43.3% NDF, 15.2% CP), pigeonpea [Cajanus cajan (L.) Millsp. cv. GA-2; 78.6% NDF, 12.2% CP], or soybean (cv. Pioneer 97B52; 59.0% NDF, 13.5% CP). Legume hays were supplemented at 50% of total diet DM, and soybean meal was supplemented at a level (4.25% of diet DM) that matched the average dietary CP content (10.8%) of the legume hay-supplemented diets. The cowpea, pigeonpea, and soybean were harvested at respective maturities that maximized DM yield and nutritive value, and the peanuts were first cuttings. Diets were fed to 6 lambs per treatment for 2 consecutive 21-d periods. Supplementation with hays of annual and perennial peanut, cowpea, and soybean increased (P < 0.01) DMI vs. control, but apparent DM digestibility was only increased (P = 0.03) by supplementation with annual or perennial peanut hay. Compared with the control, N intake, digestibility, and retention were increased (P < 0.01) by supplementation with legume hay or soybean meal. Responses were greatest when annual or perennial peanut hays were fed. Ruminal ammonia concentration was increased (P < 0.01) by all legume hay supplements vs. the control. Microbial N synthesis and ruminally degraded OM were increased (P = 0.03) by perennial and annual peanut hay supplementation, but efficiency of microbial synthesis was not different (P = 0.52) among diets. Unlike other supplements, annual and perennial peanut hays increased DM and N intake and digestibility and improved microbial N synthesis; therefore, they were the best supplements for the bahiagrass hay under the conditions of this study.

Intake, digestibility, and nitrogen retention by sheep supplemented with warm-season legume haylages or soybean meal

The high cost of commercial supplements necessitates evaluation of alternatives for ruminant livestock fed poor quality warm-season grasses. This study determined how supplementing bahiagrass haylage (Paspalum notatum Flügge cv. Tifton 9) with soybean [Glycine max (L.) Merr.] meal or warm-season legume haylages affected the performance of lambs. Forty-two Dorper x Katadhin lambs (27.5 +/- 5 kg) were fed for ad libitum intake of bahiagrass haylage (67.8% NDF, 9.6% CP) alone (control) or supplemented with soybean meal (18.8% NDF, 51.4% CP) or haylages of annual peanut [Arachis hypogaea (L.) cv. Florida MDR98; 39.6% NDF, 18.7% CP], cowpea [Vigna unguiculata (L.) Walp. cv. Iron clay; 44.1% NDF, 16.0% CP], perennial peanut (Arachis glabrata Benth. cv. Florigraze; 40.0% NDF, 15.8% CP), or pigeonpea [Cajanus cajan (L.) Millsp. cv. GA-2; 65.0% NDF, 13.7% CP]. Haylages were harvested at the optimal maturity for maximizing yield and nutritive value, wilted to 45% DM, baled, wrapped in polyethylene plastic, and ensiled for 180 d. Legumes were fed at 50% of the dietary DM, and soybean meal was fed at 8% of the dietary DM to match the average CP concentration (12.8%) of legume haylage-supplemented diets. Lambs were fed each diet for a 14-d adaptation period and a 7-d data collection period. Each diet was fed to 7 lambs in period 1 and 4 lambs in period 2. Pigeonpea haylage supplementation decreased (P < 0.01) DM and OM intake and digestibility vs. controls. Other legume haylages increased (P < 0.05) DM and OM intake vs. controls; however, only soybean meal supplementation increased (P = 0.01) DM digestibility. All supplements decreased (P = 0.05) NDF digestibility. Except for pigeonpea haylage, all supplements increased (P < 0.01) N intake, digestibility, and retention, and the responses were greatest (P = 0.04) with soybean meal supplementation. Microbial N synthesis was reduced (P = 0.02) by pigeonpea haylage supplementation, but unaffected (P = 0.05) by other supplements. Efficiency of microbial protein synthesis was unaffected (P = 0.05) by diet. Ruminal ammonia concentration was increased (P = 0.01) by all supplements, but only soybean meal and annual peanut haylage increased (P < 0.03) plasma urea-N concentrations. Perennial peanut, annual peanut, and cowpea haylages are promising protein supplements for growing lambs.

Effect of ractopamine-hydrochloride and trenbolone acetate on longissimus muscle fiber area, diameter, and satellite cell numbers in cull beef cows1

The objective of this study was to evaluate the effects of coadministration of ractopamine-HCl (RAC) and trenbolone acetate plus estradiol (TBA) on LM fiber cross-sectional area (CSA), diameter, fiber-associated myonuclei, and satellite cell number. Culled crossbred beef cows (n = 98; 11 +/- 1.8 yr old; BCS 4.3 +/- 0.03) from a single ranch in south Florida were fed a concentrate diet for 92 d in a 2 x 2, randomized block design. Cows were blocked by BW on arrival into light (initial BW = 369.75 +/- 2.68 kg and end BW = 501.96 +/- 6.90 kg) and heavy (initial BW = 418.31 +/- 2.75 kg and end BW = 522.15 +/- 7.09 kg) groups before assignment to treatment. Factors included dietary treatment (0 or 15 ppm) and implant status (0 or 80 mg of trenbolone acetate + 16 mg of estradiol). Ractopamine was provided in the diet to 2 pens or half the treatments during the final 35 d of feeding. Cows were slaughtered on d 92. Forty-eight hours postmortem, the 6th-rib portions of the LM were obtained from 10 randomly selected carcasses from each treatment group (n = 40). Cryosections (12 mum) were immunostained for dystrophin and myosin heavy chain I or II for the measurement of fiber CSA and type, respectively. Fiber-associated nuclei and satellite cell numbers were measured in serial cryosections. There was a RAC x TBA interaction (P < 0.05). Type I fiber CSA and diameter were increased (P < 0.05) by TBA and RAC. Type I CSA and diameter were larger (P < 0.05) in TBA + RAC than RAC only. Type II fiber CSA and diameter were not affected by TBA (P = 0.48), RAC (P = 0.15), or TBA + RAC (P = 0.60). Satellite cell numbers and fiber-associated nuclei were not affected (P > 0.05) by implant status or ractopamine supplementation. These results indicate that TBA and RAC preferentially increase the size of type I fibers in cull cows.

Comparison of agar plate and real-time PCR on enumeration of Lactobacillus, Clostridium perfringens and total anaerobic bacteria in dog faeces

AIMS

To compare agar plate and real-time PCR methods on enumeration of total anaerobic bacteria, Lactobacillus and Clostridium perfringens in dog faeces.

METHODS AND RESULTS

Thirty-two faecal specimens from Labrador retriever dogs were used to compare agar plate and real-time PCR enumeration methods for Lactobacillus, C. perfringens and total anaerobic bacteria. Total anaerobic bacteria, C. perfringens and Lactobacillus of faeces were counted (as CFU g(-1) faeces) for 48-h incubation at 37 degrees C in an anaerobic gas chamber on genus-selective media. Total genomic DNA from samples was extracted by the QIAamp DNA stool mini kit. The quantification of DNA (as DNA copy per gram faeces) by real-time PCR was performed with a LightCycler system with the QuantiTect SYBR green PCR kit for PCR amplification. The results indicated that there was a significant correlation between CFU and DNA copy of Lactobacillus (R2 = 0.78, P < 0.01) and total anaerobic bacteria (R2 = 0.21, P < 0.05); but no correlation was found between CFU and DNA copy of C. perfringens. The regression equations for Lactobacillus and total anaerobic bacteria were log(DNA copy) = 0.83 x log(CFU) + 1.43 and log(DNA copy) = 1.62 x log(CFU) - 6.32 respectively.

CONCLUSIONS

The real-time PCR method could be used to enumerate Lactobacillus within 2 days when compared with plating method which requires 5-6 days.

SIGNIFICANCE AND IMPACT OF THE STUDY

The real-time PCR method and the primer set for Lactobacillus spp. harboured in the dog intestine can be used for rapid enumeration of lactobacilli and monitoring of the faecal Lactobacillus community.

Vitamin E supplementation of newly arrived feedlot calves1,2

Seven hundred fifteen crossbred (primarily British) calves purchased in southern Oklahoma and northern Texas auction barns were received at the Willard Sparks Beef Research Center, Stillwater, OK, and used to study effects of duration (days) of vitamin E feeding during a 42-d receiving period on animal performance, health, and serum cholesterol and vitamin E concentrations. Upon arrival, calves were blocked by load (seven loads), sorted by BW (light, n = 4 pens per load; and heavy, n = 4 pens per load), and assigned randomly to one of four dietary treatments (n = 2 pens per load; 14 pens per treatment). Experimental diets were formulated to provide 2,000 IU.calf(-1).d(-1) of supplemental vitamin E (dl-alpha-tocopherol acetate) for 0 (CON), 7 (E7), 14 (E14), or 28 (E28) d. Vitamin E was delivered in a pelleted supplement that was added to the basal diet in decreasing concentrations as DMI increased (2.0 kg of DMI = 6%; 4.0 kg of DMI = 4%; and 6.0 kg of DMI = 2%). Serum samples were collected on d 0, 14, 28, and 42 for determination of cholesterol, alpha-tocopherol (d 0, 28, and 42), and antibody (IgG) concentrations. Duration of vitamin E supplementation did not affect ADG (0.98 kg/d; P = 0.56) or G:F (0.189; P = 0.87). Serum cholesterol concentrations decreased (day effect; P < 0.001) for all treatments from d 0 (average = 127 mg/100 mL) to 14 (average = 62 mg/100 mL). Serum alpha-tocopherol decreased (day effect; P < 0.001) from d 0 (5.2 microg/mL) to 28 (1.8 microg/mL); however, on d 28, a greater (P < 0.001) serum alpha-tocopherol concentration was observed for E28 (3.4 microg/mL) calves than for CON (1.1 microg/mL), E7 (1.2 microg/mL), or E14 (1.5 microg/mL) calves. Respiratory disease was diagnosed in 64.6% of calves in this study. Medical costs were less (P = 0.08) for calves fed vitamin E for 28 d (4.88 dollars/calf) than for calves fed the control diet (6.29 dollars/calf). Carcass characteristics were not affected (P = 0.19 to 0.88) by dietary treatments. Supplemental vitamin E formulated for 2,000 IU.calf(-1).d(-1) had little influence on performance and overall health status of calves under our experimental conditions; however, the increased serum concentrations of alpha-tocopherol when vitamin E was fed for 28 d suggests that any potential effects of vitamin E on health status might be time-dependent.

Quantitative measures of the palate using enhanced electropalatography

Electropalatography (EPG) is a useful tool for investigating tongue dynamics in experimental phonetic research and speech therapy. However, data provided by EPG are a two-dimensional representation in which all absolute positional information is lost. This paper presents an enhanced EPG (eEPG) system which uses digitised palate shape data to display the tongue-palate contact pattern in three dimensions. The palate shapes are obtained using a colour-encoded structured light three-dimensional digitisation system. The three-dimensional palate shape is displayed on a Silicon Graphics workstation as a surface made up of polygons represented by a quadrilateral mesh. EPG contact patterns are superimposed on to the three-dimensional palate shape by displaying the relevant polygons in a different colour. By using this system, differences in shape between individual palates, apparent on visual inspection of the actual palates, are also apparent in the image on screen. Further, methods have been devised for computing absolute distances along paths lying on the palate surface. Combining this with calibrated palate shape data allows accurate measurements to be made between contact locations on the palate. These have been validated with manual measurements. In addition, vocal tract areas in the oral cavity have been estimated by using the absolute measurements on the palate for a given contact pattern, and assuming a flat tongue profile in the uncontacted area.

Phase-conjugate fluorozirconate fiber laser operating at 800 nm

We report phase-conjugate feedback into a fluorozirconate optical fiber amplifier at infrared wavelengths. By using a semiconductor laser diode at 807 nm, a grating is established in photorefractive BaTiO(3) that, in the ring configuration, provides feedback into the amplifier necessary for laser action. Once written, the grating is self-sustaining, and lasing is observed even after the laser diode is removed.

Left ventricular diastolic and systolic performance during chronic experimental aortic regurgitation

To study the time course of left ventricular structural and functional responses to chronic aortic regurgitation, aortic regurgitation was surgically induced in rabbits, and Doppler echocardiography was performed preoperatively and serially postoperatively for up to 2.5 yr. Twenty-five New Zealand White rabbits underwent surgical induction of aortic regurgitation and 13 control animals underwent sham operation. Left ventricular endocardial and epicardial surfaces were digitized from M-mode echocardiograms to measure the rates of change of cavity dimensions and wall thicknesses during diastolic relaxation and systolic contraction. Aortic regurgitant animals developed left ventricular dilatation and eccentric hypertrophy that remained relatively stable throughout the follow-up period. Compared with baseline values, left ventricular mass increased 120% and left ventricular internal dimension at end diastole increased 40%, whereas posterior wall thickness at end diastole and fractional shortening remained relatively stable. Left ventricular diastolic performance was enhanced at 6 mo after operation, a finding associated with increased volume load and heart rate following induction of aortic regurgitation. Diastolic performance was then reduced at 12 mo after operation and demonstrated no further decline throughout the remainder of the follow-up period. In contrast, left ventricular systolic performance was not altered following operation and remained preserved until the final assessment at up to 2.5 yr. Thus alterations in diastolic performance occurred without impairment of systolic performance during long-term follow-up of chronic experimental aortic regurgitation.

Evaluation of the efficacy of Broilact in preventing infection of broiler chicks with Salmonella enteritidis PT4

A study was conducted to evaluate treatment of day-old broiler chicks with Broilact, a live-culture preparation, for preventing intestinal colonization by a non-host-specific Salmonella (S. enteritidis PT4, with high resistance to nalidixic acid). Newly hatched broiler chicks were sprayed with Broilact at a commercial hatchery and delivered on the same day to Huntingdon Research Centre. Control chicks from the same source (i.e. chicks not treated with Broilact) were sent separately. Chicks were maintained in floor pens in groups of 40. The challenge was introduced by means of seeder birds infected with S. enteritidis PT4 (nalr) at a nominal dose level of 10(4) CFU per bird (3 seeder birds per pen of 40 contact birds). Groups of birds were killed 7, 28 and 40 days after challenge, and in each case caecal contents were examined culturally for the test organism. A total of 18 deaths occurred including 13 untreated contact birds, 3 Broilact-treated contact birds and 2 seeder birds. These were attributed to the experimental infection. Results of the examination of caecal contents from untreated control birds indicated that the challenge organism was successfully established in contact chicks via the seeder birds. The overall results for birds treated with Broilact showed a clear protective effect, with little indication of any significant infection by the challenge organism. It was concluded therefore that under the conditions of this study, Broilact was largely effective in preventing intestinal colonization by the non-host-specific s. enteritidis PT4.

Noninvasive laser-based blood pressure measurement in rabbits

To obtain serial blood pressure measurements without trauma in rabbits, we developed a laser-based method which permits noninvasive determination of systolic and diastolic arterial blood pressure. The ease and accuracy of this method were evaluated over a range of blood pressures in five New Zealand White rabbits. Laser-based pressures from the central ear artery were compared with cannula-based pressures from the contralateral central ear artery. Pressures were measured before and during infusions of saline (control), nitroprusside, or epinephrine, and following induction of anesthesia. Noninvasive measurements correlated highly with direct measurements (systole: r = 0.89; diastole: r = 0.93). The difference between the non-invasive and direct pressure measurements during saline, nitroprusside, and epinephrine infusions, and following anesthesia, respectively, were (mean +/- SD, systole/diastole): 4.2 +/- 2.4 (P = NS)/9.3 +/- 1.4 (P less than .001), 4.1 +/- 1.6 (P less than .02)/3.2 +/- 1.1 (P less than .01), 0.6 +/- 2.4 (P = NS)/-3.0 +/- 2.7 (P = NS), and -5.1 +/- 2.9 (P = NS)/0.3 +/- 1.3 (P = NS). The noninvasive method did not result in observable agitation of the animals. To optimize results, visual inspection was required to assure that the instrument's diaphragm was not deformed or dried from previous use, and that the diaphragm was placed over the center of the arterial lumen. It was also necessary to dim room lights and to direct heating lights away from the ears to avoid degrading light signal quality. These results, albeit involving a small number of animals, indicate the potential utility of this method in the study of chronic pathophysiological processes requiring long-term repeated determination of systolic and diastolic blood pressure.

Graves' ophthalmopathy--a clinical review

Graves' ophthalmopathy occurs in 2% to 7% of patients with Graves' disease with the major manifestations being proptosis, ophthalmoplegia, optic neuropathy and/or eyelid retraction. Although autoimmune in nature, the precise pathophysiology is unknown. The course of the ophthalmopathy is not influenced by the mode of treatment of the hyperthyroidism. In addition to restoration of the euthyroid state, the aims of treatment include relief of eye pain, correction of extraocular muscle dysfunction, protection of visual acuity and improvement of appearance. Specific therapy depends on the severity of the ophthalmopathy and varies from lubricating eye drops in mild disease to high-dose steroids and radiotherapy or decompressive surgery in severe cases.

Effects of combined insulin-sulfonylurea therapy in type II patients

We conducted a double-blind crossover study to determine which patient characteristics best predict a beneficial response to combined insulin-glyburide therapy. Glyburide (15 mg/day) or placebo was added to the treatment regimen of 31 insulin-treated type II (non-insulin-dependent) diabetic subjects. During glyburide therapy, there was a significant improvement in glycemic control with a reduction in glycosylated hemoglobin from 9.9 +/- 1.3 to 9.1 +/- 1.3% (P less than .001). Patients who responded had higher fasting C-peptide levels (P less than .001) and shorter durations of insulin therapy (P less than .01) than those who did not respond. Glyburide withdrawal was associated with a greater than expected deterioration in glycemic control. Patients on insulin therapy for greater than 8 yr are unlikely to benefit significantly from the addition of glyburide to their treatment regimen.

Candidiasis-endocrinopathy syndrome with progressive myopathy

A women suffering from the candidiasis-endocrinopathy syndrome, developed severe myopathy in her fourth decade and died from it at the age of 37 years. Associated conditions were hypoparathyroidism, vitiligo, chronic mucocutaneous candidiasis, short stature, intellectual disability, ovarian failure and alopecia totalis. Muscle biopsy findings were non-specific with focal atrophy of type 2 fibres. Serum immunoglobulin levels were normal. The only demonstrable abnormalities of her immune system were impaired T-cell function and antibody production by B-cells (detectable to smooth muscle, mitochondria and gastric parietal cells). The T-cell abnormality may have been part of a more generalized cell defect, resulting from an unidentified genetic abnormality, whilst the circulating antibodies could have been a response to tissue damage. There was no convincing evidence of primary autoimmune damage.

Hypertrophic and functional response to experimental chronic aortic regurgitation

Aortic regurgitation was induced by retrograde perforation of an aortic valve cusp under hemodynamic guidance in 12 New Zealand White rabbits. Regurgitant fraction was documented by electromagnetic flow probe and six sham-operated animals served as controls. Two-dimensional, M-mode and Doppler echocardiography was performed pre-operatively and serially post-operatively for 3 to 6 months. Animals with aortic regurgitation developed progressive left ventricular dilatation and eccentric hypertrophy. Left ventricular internal dimension at end-diastole and left ventricular mass were increased from baseline values by 41 and 94% (P less than 0.001), respectively; fractional shortening was stable while end-systolic stress increased 50% (P less than 0.01. Thus, acutely induced aortic regurgitation in rabbits results in a chronic model which may be appropriate for stimulation of the hypertrophic response to aortic regurgitation in humans.

Reduced adrenal androgens in patients with myotonic dystrophy

Endocrine disturbances associated with myotonic dystrophy (MD) include testicular atrophy, hyperinsulinemic glucose intolerance, thyroid abnormalities, and low or low normal urinary 17-ketosteroid (17-KS) excretion. Since the major circulating precursors of urinary 17-KS are dehydroepiandrosterone sulfate (DHAS) and dehydroepiandrosterone (DHA), a decrease in adrenal androgen production has been suggested. This possibility was studied in 19 MD patients and 19 age- and sex-matched normal subjects. Each patient had a 24-h urine collection for 17-KS and cortisol determinations, a 4-h iv infusion of 25 micrograms tetracosactrin with serial measurements of serum DHAS, DHA, and cortisol, and an insulin-induced hypoglycemia test. Sixteen patients had 0800 and 2400 h serum collections for cortisol estimations. Serum DHAS [1.0 +/- 0.5 (+/- SD) vs. 3.9 +/- 1.9 mumol/liter; P less than 0.0005] and DHA (5.9 +/- 2.7 vs. 11.0 +/- 7.1 nmol/liter; P less than 0.005) levels were significantly lower in MD patients than in normal subjects; cortisol levels were higher (540 +/- 222 vs. 394 +/- 128 nmol/liter; P less than 0.01), almost certainly a reflection of stress. A normal diurnal cortisol rhythm was found in all 16 subjects. Cortisol responses to insulin-induced hypoglycemia were normal, increasing from 345 +/- 243 nmol/liter to a maximum of 831 +/- 282 nmol/liter. Urinary 17-KS excretion was low or low normal, while urinary cortisol levels were normal in 18 and mildly elevated in 1 patient. There was a significant correlation between 17-KS and DHAS levels (r = 0.46; P less than 0.05). DHAS, DHA, and cortisol responses to tetracosactrin infusion were similar in patients and normal subjects. It is concluded that 1) in MD patients, serum DHAS and DHA concentrations are significantly lower than those in normal subjects, explaining the frequent reports of low or low normal 17-KS excretion; 2) the reduced DHAS and DHA concentrations are most likely due to decreased production rather than increased clearance; and 3) glucocorticoid production is normal.

Quantitative bone histology in the hypercalcemia of malignant disease

Quantitative bone histology was studied in 23 patients with malignant hypercalcemia (MH) due to carcinoma (16) or immunoproliferative disease (7). Plasma calcium was 3.37 +/- 0.47 (mean +/- SD) mmol/liter. Bone resorbing surface (RS) was measured using a sensitive histochemical stain to identify osteoclasts. In the MH patients with carcinoma, the RS was 3.1 +/- 2.6% compared to 1.0 +/- 0.3% in controls (P less than 0.02). In the myeloma patients it was 2.3 +/- 1.7%, and in normocalcemic patients with malignant disease 0.8 +/- 1.1%. RS did not correlate with serum PTH, and several high RS values were associated with undetectable PTH. RS correlated with forming surface (FS) in MH patients (r = 0.44, P less than 0.05) and controls (r = 0.68, P less than 0.005), but there was a greater RS relative to FS in MH patients than in controls (P less than 0.005). "Excess" RS in the MH patients was calculated by subtracting the RS accounted for by the measured FS, using the relationship defined by the controls. Bone loss, as reflected in urinary calcium excretion, correlated weakly with excess RS (r = 0.44, P less than 0.05) but was high even when excess RS was zero. Thus, the histological findings do not account for the bone loss, and additional resorption around bone metastases is likely; the results of this study are consistent with a humoral substance produced by the malignant tissue causing generalized bone resorption in addition to bone dissolution around metastases.

Thyroid abnormalities in patients with myotonic dystrophy

Myotonic dystrophy (MD) is a systemic genetic disorder predominantly affecting musculature. Although endocrine disturbances have been described, data relating to thyroid gland involvement are sparse and conflicting. To further investigate this aspect, twenty MD patients and twenty age-and sex-matched controls were studied. All were clinically euthyroid and there were no significant differences between circulating levels (mean +/- SD) of T4 (101 . 5 +/- 28.2 v. 103 . 8 +/- 27 . 7 nmol/l), T3 (1 . 86 +/- 0 . 57 v. 2 . 15 +/- 0 . 47 nmol/l), rT3 (0 . 39 +/- 0 . 14 v. 0 . 42 +/- 0 . 09) nmol/l) or TSH (2 . 6 +/- 0 . 5 v. 2 . 4 +/- 0 . 8 mu/l) or between T3 resin uptakes (97 +/- 8 v. 98 +/- 11%). TSH responses following TRH stimulation were significantly less in the MD patients (323 +/- 141 v. 529 +/- 240%; P less than 0.0025). The mean maximum TSH levels achieved were 6 . 7 +/- 3 . 6 mu/l (MD) and 17 . 1 +/- 7 . 2 mu/l (controls); P less than 0.005. Two patients had multinodular goitres (MNG) and one a single thyroid nodule. Thyroid scans were normal except for patchy uptake in the two MNG patients. There was no abnormal incidence of circulating thyroid microsomal or thyroglobulin antibodies, and thyrotrophin binding inhibitory immunoglobulin levels were normal in four patients. It is concluded that in MD: 1 palpable thyroid gland abnormalities occur with increased frequency, 15% (three/twenty) in the present study and 20% (twenty/102 case reports) from a review of the literature; 2 TSH responses to TRH are significantly reduced; 3 circulating thyroid hormone levels are usually normal.

Studies of the ideal [H+] for perfusional preservation

The neutral point of water, being a function of its dissociation constant, is temperature dependent. This is also true of protein-buffered solutions such as perfusates. In organ preservation these facts have been long ignored and, as a result, perfusions have been carried out in a relatively acidotic environment. These studies evaluated the effects of correcting the pH partially or completely for the level of hypothermia involved in perfusional preservation. The findings both in rabbits and dogs were that a pH of 7.4 (measured at 7 C) is dangerously close to the pH below which there is rapid deterioration of function. On the other hand, perfusate pHs up to 7.75 in dogs and 8.25 in rabbits were tolerated at no detriment. As a result, the recommendation is made to carry out hypothermic organ perfusion at a pH well above 7.4; 7.60 or 7.65 seems reasonable.

The relationship of adrenal androgens to the secretory patterns for cortisol, prolactin, and growth hormone during early puberty

Serum concentrations of dehydroepiandrosterone (DHA), dehydroepiandrosterone sulfate (DHA-sulfate), cortisol, prolactin, and growth hormone were measured at half-hour intervals for 24 hr in five healthy children aged 8--13 yr. Their adolescent development was assessed by clinical staging, plus determinations of serum FSH, LH, testosterone and estradiol during both wakefulness and sleep. Correlative analysis indicates that there was synchronous secretion of DHA and cortisol, implying regulation of both by ACTH. With advancing age and sexual maturation, there was a progressive rise in mean serum DHA and DHA-sulfate levels, but no similar change in serum cortisol concentrations. There was evidence for enhanced secretion of both growth hormone and prolactin during sleep in all subjects (including one who was hyperprolactinemic), but there was no obvious relationship between levels of these pituitary hormones and the early pubertal rise in adrenal androgens.

Effect of ovine prolactin on serum somatomedin bioactivity in hypophysectomized female rats

Ovine prolactin (oPRL) increased serum somatomedin (SM) bioactivity in hypophysectomized female rats. ACTH, in small but not large doses, augmented this oPRL effect. These results suggest that in the female rat PRL may regulate SM production. Adrenal factors may variably modulate SM production or serum SM bioactivity.

Prolactin-secreting tumors and hypogonadism in 22 men

We studied 22 men with prolactin-secreting pituitary tumors and hypogonadism. Twenty complained of impotence, nine had visual impairment, and three experienced galactorrhea. None of the 17 patients undergoing operation or radiotherapy, or both, were subsequently normoprolactinemic. In all 13 patients treated with bromocryptine major clinical improvement was associated with a decrease in serum prolactin levels and in nine with an increase in serum testosterone. Two patients receiving testosterone replacement therapy showed improved potency only after bromocryptine was administered. The results indicate that hyperprolactinemia frequently induces hypogonadism in men, that bromocryptine ameliorates symptoms of disease previously unchanged by operation or radiotherapy, and that the impotence observed may not be solely the result of hypogonadism.

Nursing-mediated prolactin and luteinizing hormone secretion during puerperal lactation

Alterations in plasma prolactin (PRL) concentrations in response to nursing in puerperally lactating women are often significant beyond the 90th postpartum day, yet the increment appears unrelated to the frequency or duration of the nursing stimulus. Tonic gonadotropin secretion is low, assuming a more episodic secretory pattern either when the frequency of breast-feeding is reduced or when weaning takes place. Significant increments in peripheral concentrations of luteinizing hormone can be seen in response to weaning coincident with a fall in peripheral plasma PRL concentration. At the same time, peripheral estrogen concentrations increase, suggesting that a specific set point for ovarian responsiveness to gonadotropins exists. Whether this set point is related solely to the peripheral concentration of gonadotropins or whether it is also related to the peripheral PRL concentration is not known at this time.

Hormonal changes in girls with precocious adrenarche: a possible role for estradiol or prolactin

Serum concentrations of dehydroepiandrosterone, DHA sulfate, estradiol, and prolactin in 20 girls with precocious adrenarche were compared with those of healthy girls of varying age and degrees of breast and sex hair development. Production of adrenal androgens, as reflected by serum DHA and DHA-sulfate concentrations, was significantly increased in PA above that in age-matched control subjects. Surprisingly, in spite of their lack of breast growth, the patients with PA also had serum estradiol levels that were higher than in the prepubertal girls and similar to those found in girls with both breast and pubic hair development. Serum prolactin concentrations in the patients with PA were not increased over those of the age-matched (less than 8 years) prepubertal girls. In the older prepubertal ( greater than 8 years) and early pubertal girls serum prolactin levels were lower. The finding of increased estradiol levels suggests that precocious adrenarche is not a distinct endocrine entity, but merely represents a variant of early adolescence in which estrogen secretion is sufficient to influence adrenal 3beta-hydroxysteroid dehydrogenase activity with a resultant rise in DHA production, but not sufficient to produce clinically apparent breast changes. The data do not support a similar role for prolactin.

Effects of triiodothyronine administration in patients with chronic renal failure

Clinically euthyroid patients with severe, chronic, non-thyroidal illnesses usually have decreased serum total and absolute free T3 concentrations. Since T3 is the metabolically more active of the two thyroid hormones, it has been suggested that these patients may be hypothyroid and thus may benefit from T3 therapy. To test this hypothesis, five patients with chronic renal failure requiring maintenance haemodialysis were treated with 5 microgram T3 eight hourly, increasing at three weekly intervals to 10 microgram eight hourly, 20 microgram eight hourly and finally 30 microgram eight hourly. The mean +/- SD serum T3 level did not change over the 12 week period (1.42 +/- 0.17 vs. 1.41 +/- 0.26 nmoll-1 whilst the mean serum T4 and TSH levels fell from 87.0 +/- 15.2 to 47.5 +/- 18.8 nmoll-1 and 1.9 +/- 0.9 to 1.3 +/- 1.6 mUl-1 respectively. Only the change in T4 levels was significant (P less than 0.005). A significant decrease in mean serum T4 levels was apparent even after the treatment period with 5 microgram T3 eight hourly (87.0 +/- 15.2 vs. 51.2 +/- 15.7; P less than 0.005). The mean fasting serum triglyceride level fell from 1.16 +/- 0.74 to 0.94 +/- 0.74 mmoll-1 (P less than 0.05) and the mean fasting serum cholesterol level fell from 6.06 +/- 1.13 to 4.69 +/- 1.10 mmoll-1 (P less than 0.05). There were no subjective improvements in any of the patients. From the marked changes in serum T4 levels during the administration of T3, it is concluded that, prior to treatment, the patients were biochemically euthyroid and not hypothyroid and thus did not require T3 therapy.

Adrenocortical function in hyperprolactinemic women

To study the effects of prolactin (PRL) on adrenocortical function in humans, dehydroepiandrosterone (DHA), dehydroepiandrosterone sulfate (DHAS), androstenedione (delta) and testosterone (T) were measured in serum obtained from 35 hyperprolactinemic women with galactorrhea and amenorrhea before and after treatment with bromocriptine-induced fall in mean PRL levels from 82 +/- 8 (SE) to 14 +/- 2 ng/ml (n = 39, P less than 0.0005), DHAS fell from 322 +/- 21 to 237 +/- 21 microgram/dl (n = 39); P less than 0.0005), DHA fell from 492 +/- 47 to 378 +/- 30 ng/dl (n = 39; P less than 0.01) while T (n = 16) and delta (n = 13) levels were unchanges (44 +/- 4 vs. 49 +/- 4 ng/dl and 280 +/- 55 vs. 236 +/- 40 ng/dl, respectively). In addition, 4 women were infused iv with 25 microgram synthetic ACTH over 4 h and serial blood samples drawn while hyperprolactinemic, and again 2-4 months later following normalization of PRL levels by bromocriptine. Although pre-infusion levels of DHAS were lower when PRL levels were normalized, no significant differences in responses of circulating DHAS, DHA, T, cortisol and 17-hydroxyprogesterone concentrations were detected between the two infusions. Since DHAS is virtually an exclusive product of the adrenal cortex, and since high PRL levels appear to inhibit ovarian steroid production, the findings suggest that hyperprolactinemia selectively stimulates adrenocortical androgen production.

Circulating thyroid hormone levels in children

Extensive use of radioimmunoassay for routine measurement of serum thyroid hormones in paediatric thyroid disorders showed inconsistencies between laboratory results based upon adult criteria and clinical observation. To resolve this disparity, serum triiodothyronine (T3) and thyroxine (T4) levels were measured by radioimmunoassay in 354 healthy children aged between 3 weeks and 17 years. The mean serum T3 concentration in children up to 10 years of age was 1·94±0·35 ng/ml (SD) which was higher than the mean serum T3 of 1·37±0·25 ng/ml in healthy adults. Similarly, the mean serum T4 of 10±2·5 μg/100 ml was higher than the adult mean serum T4 of 8·5±1·5 μg/100 ml. Neither concentration changed significantly from 3 weeks to 10 years of age, nor was there any sex difference. In girls serum T3 and T4 concentrations declined gradually from age 10 to maturity. A perimenarcheal nadir observed in the T4 data was thought to reflect the joint effects of the age-dependent fall in circulating T4 and the concomitant oestrogen-dependent rise in thyroxine-binding globulin. In boys the decline in serum T3 occurred approximately 2 years later than in the girls. These observations show that the normal ranges for serum T3 and T4 in children are higher than those in adults and that reference to normal adult ranges may lead to misclassification in diagnosis and monitoring of paediatric thyroid disorders.

Inhibition of conversion of thyroxine to triiodothyronine in patients with severe chronic illness

Many clinically euthyroid patients with severe, chronic, non-throidal illnesses (i.e. sick euthyroid patients) have very low circulating concentrations of total and absolute free triiodothyronine (T3), low-normal concentrations of total thyroxine (T4), elevated concentrations of absolute free T4, and circulating concentrations of thyrotrophin (TSH) that are either normal or subnormal. This study was undertaken to elucidate the mechanism of the low circulating T3 concentrations. The disappearance rate of 125 I-T3 from the circulation of five representative sick euthyroid patients was studied and found to be slower, but not significantly so, compared with three control subjects, thus excluding an increased destruction rate as the cause of the low T3 levels. A selective decrease of T3 secretion from the thyroid gland of these patients was also excluded by the results of TSH stimulation tests. Inhibition of extra-thyroidal conversion of T4 to T3 was suggested by studies of the thyroid function in a hypothyroid woman with a Grade IV lymphoma on T4 replacement therapy. When the lymphoma was in remission, her circulating T3 concentration was 2-55 nmol/l but when it relapsed it fell to 0-55 nmol/l. The T4 concentrations were 124-7 nmol/l and 126 nmol/1 respectively. Decreased monodeiodination of T4 to T3 in sick euthyroid patients was confirmed by paper chromatography of extracted serum obtained 48 h after an i.v. injection of 125 I-T4 into two severely ill patients from the intensive therapy unit and a control subject. Peaks of radioactivity corresponding to 125 I-T4 and 125 I-T3 were detected in the control subject, but only a single peak corresponding to 125 I-T4 was detected in the ill patients.

P-wave abnormalities in hyperthyroidism

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