Reduce, Replace, Refine: Determining A Posteriori Reference Intervals for Biochemistry in Hermann's Tortoise (Testudo hermanni)

Biochemical and hematological analyses are important for the assessment of animal health. However, for most wild species their use is hindered by the scarcity of reliable reference intervals. Indeed, collecting body fluids (e.g., blood, urine) in free-ranging animals is often technically challenging. Further, sampling many individuals would be essential to consider major sources of variations, such as species, populations, sex, age, and seasons. One alternative, according to the reduction, refinement, and replacement framework, is to establish reference intervals a posteriori using literature survey and unpublished data. We produced reference intervals for free-ranging Hermann's tortoises (Testudo hermanni), using analyses performed on blood samples collected in previous studies and conservation programs conducted in the field between 2010 and 2016 in southern France (n=195 individuals). Thirteen parameters were analyzed: packed-cell volume, blood concentrations of corticosterone, testosterone, glycemia, cholesterol, triglyceride, urea, uric acid, calcium, sodium, potassium, asparagine aminotransferase (AST), and alanine aminotransferases (ALT). Reference intervals for subgroups defined by sex and season were relevant for corticosterone, triglyceride, and calcium (sex) and cholesterol (season). Comparing our results with those obtained in captive individuals in Germany, except for urea and AST levels the intervals from both free-ranging versus captive tortoises were similar, suggesting that reference intervals established from captive individuals may be suitable for free-ranging populations in this species.

New Patterns for Highly Pathogenic Avian Influenza and Adjustment of Prevention, Control and Surveillance Strategies: The Example of France

From 2020 up to summer 2023, there was a substantial change in the situation concerning the high pathogenic avian influenza (HPAI) virus in Europe. This change concerned mainly virus circulation within wildlife, both in wild birds and wild mammals. It involved the seasonality of HPAI detections, the species affected, excess mortality events, and the apparent increased level of contamination in wild birds. The knock-on effect concerned new impacts and challenges for the poultry sector, which is affected by repeated annual waves of HPAI arriving with wild migratory birds and by risks due to viral circulation within resident wild birds across the year. Indeed, exceeding expectations, new poultry sectors and production areas have been affected during the recent HPAI seasons in France. The HPAI virus strains involved also generate considerable concern about human health because of enhanced risks of species barrier crossing. In this article, we present these changes in detail, along with the required adjustment of prevention, control, and surveillance strategies, focusing specifically on the situation in France.

New Advantage in Stereotactic Treatment of Lung and Pancreatic Cancer. Performance of Ultra-High Energy Electron (VHEE) Therapy Adjuvanted to the FLASH Effect: Clinical Implications and Treatment Plans Analysis

PURPOSE/OBJECTIVE(S)

Very High-Energy Electron (VHEE) beams delivered at ultra-high dose rates and hence profiting from the FLASH effect, may be a viable alternative to conventional treatment plans for the treatment of deep-seated tumors. Experimental data support the evidence of a considerable normal tissue sparing effect when treatments are delivered with dose rates much larger (100 times or more) compared to the conventional ones. Lung cancer and pancreatic cancer are considered the two biggest cancer killers. We urgently need more research in these areas, more awareness that support improvement in treatment strategies. To evaluate the potential of FLASH VHEE irradiation in these two clinical situations, we investigated the achievable sparing of healthy tissues and critical dose-limiting structures, with the goal of performing a higher dose prescription.

MATERIALS/METHODS

The study on the potential of VHEE for the stereotactic treatment of pancreatic and lung lesions was carried out on two clinical cases treated with Volumetric Modulated Arc Therapy (VMAT) techniques at University Hospital Campus Bio-Medico of Rome. The Planning Target Volume (PTV) was identified and the constraints on the Organs at Risk (OAR) and details on the irradiation approach were defined. The VHEE plan was designed to optimize the dose delivery to best activate the modelled FLASH effect based on the current experimental knowledge. In particular the impact on a dose threshold to activate the effect was studied. The VHEE treatment plan was based on an accurate Monte Carlo simulation of the electrons interactions and the results achievable with different FLASH effect models were studied. The simulation allowed the estimation of dose maps, which were used as input to an optimization algorithm that modified the fluence of each beam to meet treatment prescriptions in terms of dose to PTV. At the end the VHEE DVH plans were compared to VMAT plans.

RESULTS

The results demonstrated that FLASH therapy with VHEE beams of 70-130 MeV, could represent a promising alternative to standard radiotherapy allowing a comparable sparing of the healthy tissues. In the case of pancreatic cancer, the Dose Volume Histograms (DVH) showed how such a technique can be effective in sparing the duodenum. In case of lung cancers, the result showed how pulmonary tissue sparing can lead to a substantial reduction of pulmonary toxicity in comparison with the VMAT technique.

CONCLUSION

In the case of pancreatic cancer and assuming a non-negligible contribution from the FLASH effect, the DVH showed how the duodenum healthy tissue sparing could allow a higher dose to be prescribed at the target while keeping the constraints respected, improving the therapeutic ratio. In the case of lung cancer, the advantages of the technique are additionally increased by the significant benefit that could be related to the treatment delivery time reduction (<1s) and to the corresponding advantage coming from a reduced organ movement that translates in a lower risk of lung toxicity.

Perspectives in linear accelerator for FLASH VHEE: Study of a compact C-band system

PURPOSE

In order to translate the FLASH effect in clinical use and to treat deep tumors, Very High Electron Energy irradiations could represent a valid technique. Here, we address the main issues in the design of a VHEE FLASH machine. We present preliminary results for a compact C-band system aiming to reach a high accelerating gradient and high current necessary to deliver a Ultra High Dose Rate with a beam pulse duration of 3μs.

METHODS

The proposed system is composed by low energy high current injector linac followed by a high acceleration gradient structure able to reach 60-160 MeV energy range. To obtain the maximum energy, an energy pulse compressor options is considered. CST code was used to define the specifications RF parameters of the linac. To optimize the accelerated current and therefore the delivered dose, beam dynamics simulations was performed using TSTEP and ASTRA codes.

RESULTS

The VHEE parameters Linac suitable to satisfy FLASH criteria were simulated. Preliminary results allow to obtain a maximum energy of 160 MeV, with a peak current of 200 mA, which corresponds to a charge of 600 nC.

CONCLUSIONS

A promising preliminary design of VHEE linac for FLASH RT has been performed. Supplementary studies are on going to complete the characterization of the machine and to manufacture and test the RF prototypes.

Selection rules for the orbital angular momentum of optically produced THz radiation

In this work, we theoretically study the transduction of orbital angular momentum (OAM) l for infrared pump lasers into the THz domain. In the case of optical rectification, the transduction of OAM occurs only through a spin-orbit interaction, with the selection rule on the OAM l=0 valid for any kind of polarization of the pump, which means that there is no transfer of OAM along the propagation axis. In difference frequency generation, the selection rule for the difference Δl between the OAM of the pump fields with linear or circular polarization is l=Δl, whereas l ranges from Δl-2 to Δl+2 in cases of both radial and azimuthal polarization. Moreover, for THz generation in the latter case, the high diffraction obtained with tightly focused pumps yields l tending to Δl±2, while l tends to zero in the opposite case of large pump beams.

Evaluation of the intra- and inter-method agreement of brain MRI segmentation software packages: A comparison between SPM12 and FreeSurfer v6.0

PURPOSE

The lack of inter-method agreement can produce inconsistent results in neuroimaging studies. We evaluated the intra-method repeatability and the inter-method reproducibility of two widely-used automatic segmentation methods for brain MRI: the FreeSurfer (FS) and the Statistical Parametric Mapping (SPM) software packages.

METHODS

We segmented the gray matter (GM), the white matter (WM) and subcortical structures in test-retest MRI data of healthy volunteers from Kirby-21 and OASIS datasets. We used Pearson's correlation (r), Bland-Altman plot and Dice index to study intra-method repeatability and inter-method reproducibility. In order to test whether different processing methods affect the results of a neuroimaging-based group study, we carried out a statistical comparison between male and female volume measures.

RESULTS

A high correlation was found between test-retest volume measures for both SPM (r in the 0.98-0.99 range) and FS (r in the 0.95-0.99 range). A non-null bias between test-retest FS volumes was detected for GM and WM in the OASIS dataset. The inter-method reproducibility analysis measured volume correlation values in the 0.72-0.98 range and the overlap between the segmented structures assessed by the Dice index was in the 0.76-0.83 range. SPM systematically provided significantly greater GM volumes and lower WM and subcortical volumes with respect to FS. In the male vs. female brain volume comparisons, inconsistencies arose for the OASIS dataset, where the gender-related differences appear subtler with respect to the Kirby dataset.

CONCLUSIONS

The inter-method reproducibility should be evaluated before interpreting the results of neuroimaging studies.

Temporal Narrowing of Neutrons Produced by High-Intensity Short-Pulse Lasers

The production of neutron beams having short temporal duration is studied using ultraintense laser pulses. Laser-accelerated protons are spectrally filtered using a laser-triggered microlens to produce a short duration neutron pulse via nuclear reactions induced in a converter material (LiF). This produces a ∼3  ns duration neutron pulse with 10(4)  n/MeV/sr/shot at 0.56 m from the laser-irradiated proton source. The large spatial separation between the neutron production and the proton source allows for shielding from the copious and undesirable radiation resulting from the laser-plasma interaction. This neutron pulse compares favorably to the duration of conventional accelerator sources and should scale up with, present and future, higher energy laser facilities to produce brighter and shorter neutron beams for ultrafast probing of dense materials.

Topology of megagauss magnetic fields and of heat-carrying electrons produced in a high-power laser-solid interaction

The intricate spatial and energy distribution of magnetic fields, self-generated during high power laser irradiation (at Iλ^{2}∼10^{13}-10^{14}  W.cm^{-2}.μm^{2}) of a solid target, and of the heat-carrying electron currents, is studied in inertial confinement fusion (ICF) relevant conditions. This is done by comparing proton radiography measurements of the fields to an improved magnetohydrodynamic description that fully takes into account the nonlocality of the heat transport. We show that, in these conditions, magnetic fields are rapidly advected radially along the target surface and compressed over long time scales into the dense parts of the target. As a consequence, the electrons are weakly magnetized in most parts of the plasma flow, and we observe a reemergence of nonlocality which is a crucial effect for a correct description of the energetics of ICF experiments.

The contribution of sublingual immunotherapy to the achievement of control in birch-related mild persistent asthma: a real-life randomised trial

BACKGROUND

Asthma control represents the main goal of asthma management and different strategies aim to avoid the long term downsides of inhaled corticosteroids. We investigated in real-life conditions the contribution of sublingual immunotherapy in achieving the control of birch-related mild persistent asthma compared to two usual step-up therapeutic options.

METHODS

A three-year open randomised study included 84 asthmatics, uncontrolled during the previous birch pollen season, despite a treatment with budesonide 400μg/day. Patients randomly received budesonide 800μg/day, budesonide 1600μg/day, budesonide 400μg/day plus montelukast 10μg/day and budesonide 400μg/day plus carbamylated allergoid of betulaceae pre-coseasonally. Asthma Control test, combined allergy symptoms and medications score, albuterol consumption, lung function, nasal eosinophils and nasal steroids usage were assessed as changes from the first to last pollen season.

RESULT

Seventy-six patients concluded the study. All options, except budesonide 800μg/day, produced an improvement of mean monthly Asthma Control test (p<0.05). Patients undergoing low-dose budesonide plus immunotherapy achieved, after three years, an appreciable control (ACT mean score 24). A significant improvement was seen in all groups for allergy symptoms plus medications and bronchial reactivity. Albuterol consumption and lung function improved in all but the first group. Only budesonide plus immunotherapy reduced nasal eosinophils and nasal steroids usage. Two mild self-resolving adverse events were reported.

CONCLUSIONS

For patients with respiratory allergy due to birch pollen and mild persistent asthma, sublingual immunotherapy added to low-dose inhaled corticosteroids appears effective in maintaining long-term seasonal asthma control, representing a safe opportunity to reduce the cumulative amount of delivered corticosteroids.

Characterization of the THz radiation source at the Frascati linear accelerator

The linac driven coherent THz radiation source at the SPARC-LAB test facility is able to deliver broadband THz pulses with femtosecond shaping. In addition, high peak power, narrow spectral bandwidth THz radiation can be also generated, taking advantage of advanced electron beam manipulation techniques, able to generate an adjustable train of electron bunches with a sub-picosecond length and with sub-picosecond spacing. The paper reports on the manipulation, characterization, and transport of the electron beam in the bending line transporting the beam down to the THz station, where different coherent transition radiation spectra have been measured and studied with the aim to optimize the THz radiation performances.

Five year prognosis of an Italian cohort of juvenile acute myocardial infarction patients

AIM

The aim of this study was to describe the five-year prognosis of an Italian cohort of patients following acute myocardial infarction (AMI) occurred at age ≤ 45 years and to investigate the potential role of risk predictors for future cardiovascular events (CVE).

METHODS

The study enrolled 112 consecutive patients aged ≤ 45 years admitted to our Coronary Care Unit between March 1995 and January 2007 because of AMI. Clinical characteristics, extent of coronary vessel disease by angiogram and cardiovascular risk factors (including diet, physical activity, alcohol and coffee consumption) were registered.

RESULTS

Complete follow-up data was available for 104 (93%) patients with a duration of follow-up of 5.3 (2.9-7.6) years. Twenty-four (23%) patients presented with a new CVE: 16 (15%) angina pectoris, 6 (6%) recurrent AMI, one heart failure and one cardiac death. One in every five patients presented left ventricle systolic function below 50%. Multivariate analysis (Cox proportional regression model) proved physical activity as an independent predictor of new CVE occurrence (P=0.014). Patients who practised moderate aerobic physical activity for at least two hours per week following AMI had significantly higher event-free survival compared with inactive controls (P=0.029).

CONCLUSION

Five-year prognosis of juvenile AMI is poor, with one in every five patients presenting a new CVE. Based on the present cohort of patients physical activity following first event plays a relevant prognostic role, supporting the need of careful lifestyle counselling.

Experimental demonstration of emittance compensation with velocity bunching

In this Letter we report the first experiments aimed at the simultaneous demonstration of the emittance compensation process and velocity bunching in a high brightness electron source, the SPARC photoinjector in INFN-LNF. While a maximum compression ratio up to a factor 14 has been observed, in a particular case of interest a compression factor of 3, yielding a slice current of 120 A with less than 2 microm slice emittance, has been measured. This technique may be crucial in achieving high brightness beams in photoinjectors aiming at optimized performance of short wavelength single-pass free electron lasers or other advanced applications in laser-plasma accelerators.

A cardioplegia circuit with versatility: the 'ReVerse' system. How to do it

Various methods of cardioplegia administration have been used in cardiac surgery: crystalloid, blood and mixed crystalloid/blood. Each of these types of cardioplegia administration typically needs a different circuit. This may correspond to an increase in cost and the time needed to change the circuit if required. When various modifications are performed on the circuit, this also increases the risk of contamination. In order to simplify the management of differing cardioplegia circuits, we devised one circuit for all solutions in all situations by adding one modification. The ReVerse cardioplegia circuit system is a description of a two-pump cardioplegia circuit which is adaptable to either blood or crystalloid cardioplegia. The change from one mode to another requires a manoeuvre of two clamps, allowing the blood solution to travel through shunt tubing into the apposite pumphead. In our experience the versatility of this circuit is a fast, safe method to administrate all types of cardioplegia solution, saving the space taken up by storing multiple circuits.

Percutaneous aortic valve replacement in two cases at high surgical risk: procedural details and implications for patient selection

The morbidity and mortality burden of heart valve disease is increasing in the developing world, especially among the elderly. Whereas surgery remains the standard of care in fit patients with degenerative aortic stenosis, percutaneous aortic valve replacement could become an effective alternative to surgery in selected higher risk patients. The authors report on two women with aortic stenosis, both at high surgical risk (an 81-year-old female with coronary artery and cerebro-vascular disease, and a 70-year-old female with end-stage cirrhosis), in whom percutaneous valve replacement was effectively performed by means of transfemoral access and retrograde CoreValve Re-valving System implantation. Two major post-procedural complications occurred, both effectively managed, in the second patient: a third degree atrio-ventricular block (requiring permanent pace-maker implantation) and bleeding from the right femoral artery access (requiring implantation of two covered stents and blood transfusion). Despite the increased baseline risk, both patients were discharged asymptomatic, the first twelve days and the other three weeks after admission. In the authors' experience percutaneous aortic valve replacement can be performed with reasonable safety in patient with severe aortic stenosis at high surgical risk.

Direct measurement of the double emittance minimum in the beam dynamics of the sparc high-brightness photoinjector

In this Letter we report the first experimental observation of the double emittance minimum effect in the beam dynamics of high-brightness electron beam generation by photoinjectors; this effect, as predicted by the theory, is crucial in achieving minimum emittance in photoinjectors aiming at producing electron beams for short wavelength single-pass free electron lasers. The experiment described in this Letter was performed at the SPARC photoinjector site, during the first stage of commissioning of the SPARC project. The experiment was made possible by a newly conceived device, called an emittance meter, which allows a detailed and unprecedented study of the emittance compensation process as the beam propagates along the beam pipe.

Erionite and asbestos differently cause transformation of human mesothelial cells

Malignant mesothelioma (MM) is an aggressive tumor associated with environmental or occupational exposure to asbestos fibers. Erionite is a fibrous zeolite, morphologically similar to asbestos and it is assumed to be even more carcinogenic. Onset and progression of MM has been suggested as the result of the cooperation between asbestos and other cofactors, such as SV40 virus infection. Nevertheless, several cases of MM were associated with environmental exposure to erionite in Turkey, where SV40 was never isolated in MM specimens. We show here that erionite is poorly cytotoxic, induces proliferating signals and high growth rate in human mesothelial cells (HMC). Long term exposure to erionite, but not to asbestos fibers, transforms HMC in vitro, regardless of the presence of SV40 sequences, leading to foci formation in cultured monolayers. Cells derived from foci display constitutive activation of Akt, NF-kappaB and Erk1/2, show prolonged survival and a deregulated cell cycle, involving cyclin D1 and E overexpression. Our results reveal that erionite is able per se to turn HMC into transformed highly proliferating cells and disclose the carcinogenic properties of erionite, prompting for a careful evaluation of environmental exposure to these fibers. The genetic predisposition to the effect of erionite is a separate subject for investigation.

[Smoking while driving and its consequences on road safety]

The study was focused on the risk assessment of distraction of smoking habits while driving vehicles. We have compared the results with the data about driving distraction using mobile phone without voice devices. We video-recorded 10 smokers, 4 male and 6 female, smoking while driving a car The average of measured driving distraction of smokers is about 12 seconds. It means to cover a distance of 160 metres with a speed of 50 Km/h. Comparing to the use of mobile phone, the data of driving distraction show a duration of 10.6 seconds, that means to cover a distance of 150 metres at the speed of 50 Km/h. This result suggest that cigarette smoking produces a remarkable risk for road safety, more than the mobile phone use. In addiction to the conditions that produce a considerable driving distraction of smokers, we underline a demonstrated shortage of oxygen, the presence of carbon monoxide and hight concentration offine particulate in the air breathed inside the vehicle. We also consider another aspect related to smoking habits while driving vehicles: the environmental damage. In fact throwing cigarette outside, while the vehicle is moving, is the prevalent reason of setting fire to the edge of the road. This study proposes to make changes in the laws and regulation on road safety in order to fine smokers behaviour during vehicle driving. Furthermore it seems necessary to promote public information about those risks among people.

Hypofibrinogenaemia caused by a novel FGG missense mutation (W253C) in the gamma chain globular domain impairing fibrinogen secretion

BACKGROUND

Inherited disorders of fibrinogen are rare and affect either the quantity (hypofibrinogenaemia and afibrinogenaemia) or the quality of the circulating fibrinogen (dysfibrinogenaemia). Extensive allelic heterogeneity has been found for all three disorders: in congenital afibrinogenaemia >30 mutations, the majority in FGA, have been identified in homozygosity or in compound heterozygosity. Several mutations have also been identified in patients with hypofibrinogenaemia; many of these are heterozygous carriers of afibrinogenaemia null mutations.

OBJECTIVE

To report the case of a patient from Slovakia diagnosed with hypofibrinogenaemia characterised by fibrinogen concentrations of around 0.7 g/l.

RESULTS

The patient was found to be heterozygous for a novel missense mutation W253C (W227C in the mature protein) in the C-terminal globular domain of the fibrinogen gamma chain. Co-expression of the W253C FGG mutant cDNA (fibrinogen Bratislava) in combination with wild-type FGA and FGB cDNAs showed that fibrinogen molecules containing the mutant gamma chain can assemble intracellularly but are not secreted into the media, confirming the causative nature of the identified mutation.

CONCLUSIONS

Current analysis of fibrinogen Bratislava indicates that the domains important for the processes of hexamer assembly and hexamer secretion should not be considered as strictly restricted to one or other fibrinogen chain.

Observation of anomalously large spectral bandwidth in a high-gain self-amplified spontaneous emission free-electron laser

Observation of ultrawide bandwidth, up to 15% full-width, high-gain operation of a self-amplified spontaneous emission free-election laser (SASE FEL) is reported. This type of lasing is obtained with a strongly chirped beam (deltaE/E approximately 1.7%) emitted from the accelerator. Because of nonlinear pulse compression during transport, a short, high current bunch with strong mismatch errors is injected into the undulator, giving high FEL gain. Start-to-end simulations reproduce key features of the measurements and provide insight into mechanisms, such as angular spread in emitted photon and electron trajectory distributions, which yield novel features in the radiation spectrum.

The Sp family of transcription factors in the regulation of the human and mouse MUC2 gene promoters

Modulation of mucin gene expression is an important component both in the early steps of colon cancer development and in later tumor progression. Previous work from our laboratory and others has suggested that the Sp family of transcription factors may play an important role in the regulation of the human MUC2 gene. To determine whether this was an essential element, we extended our work to the cloning and analysis of 3.5 kb of the 5'-flanking region of the mouse Muc2 (mMuc2) gene. Comparative analysis between the mouse and human MUC2 promoter regions has identified a strong sequence homology between the mouse and human genes, including the presence of GC-rich boxes, the location and composition of which are maintained in the mouse and human genes. We show that these GC boxes are binding sites for Sp-family transcription factors and are functionally important since mithramycin, an inhibitor of Sp1/Sp3 binding, blocks MUC2 gene expression in HT29 cells. Furthermore, by a combination of gel shift analysis and site-directed mutagenesis, we have identified the relative contribution of individual GC boxes, and of the factors they bind, to the regulation of the mouse Muc2 promoter, which appears to be different in the mouse and human genes. Finally, we demonstrate by overexpressing Sp1 and Sp3 that the functional difference between the proximal promoter region of the MUC2 gene in the two species is not attributable to differential ability of this region to bind members of the Sp family of transcription factors, but rather to the different anatomy of the individual GC boxes in the mouse and human proximal promoters.

Altered phenotype of HT29 colonic adenocarcinoma cells following expression of the DCC gene

On 18q, frequently deleted in late stage colorectal cancers, a gene, Deleted in Colon Cancer (DCC), has been identified and postulated to play a role as a tumor suppressor gene. DCC is retained in the majority of mucinous tumors, which produce high levels of mucins, and seems to be preferentially expressed in intestinal goblet cells. To investigate whether DCC is related to mucin expression and can modulate the transformed phenotype, we introduced a full-length DCC cDNA into HT29 cells, which can be induced in vitro to express MUC2, the gene that encodes the major colonic mucin. Expression of DCC did not modulate constitutive or induced expression of MUC2, nor did DCC induce a mature goblet cell phenotype. However, HT29 clones expressing high and low levels of DCC protein showed a significant decrease in cell proliferation and tumorigenicity. Furthermore, increased shedding and an elevated rate of spontaneous apoptosis were associated with higher levels of expression of DCC. In summary, while restoration of DCC expression in a human colon carcinoma cell line did not influence expression of differentiation markers, DCC expression did affect the growth and tumorigenic properties of the cells suggesting that DCC can modulate the malignant phenotype of colon cancer.

A city-wide outbreak of a multiple-drug-resistant strain of Mycobacterium tuberculosis in New York

SETTING

Incident patients with active tuberculosis (TB) resistant to two or more drugs in New York City hospitals in 1992.

OBJECTIVE

To examine the New York-wide distribution of Public Health Research Institute (PHRI) strain W of Mycobacterium tuberculosis, an extremely drug-resistant strain identified by a 17-band Southern hybridization pattern using IS6110, during the peak tuberculosis year of 1992. We also compared strain W with other strains frequently observed in New York.

DESIGN

Blinded retrospective study of stored M. tuberculosis cultures by restriction fragment length polymorphism (RFLP) DNA fingerprinting, and chart review.

RESULTS

We found 112 cultures with the strain W fingerprint and 8 variants in 21 hospitals among incident patients hospitalized in 1992. Almost all isolates were resistant to four first-line drugs and kanamycin. This single strain made up at least 22% of New York City multiple-drug-resistant (MDR) TB in 1992, far more than any other strain. Almost all W-strain cases were acquired immune deficiency syndrome (AIDS) patients. The cluster is the most drug-resistant cluster identified in New York and the largest IS6110 fingerprint cluster identified anywhere to date.

CONCLUSION

Because recommended four-drug therapy will not sterilise this very resistant strain, there was a city-wide nosocomial outbreak of W-strain TB in the early 1990s among New York AIDS patients. Other frequently seen strains were either also very resistant, or, surprisingly, pansusceptible. Individual MDR strains can be spread widely in situations where AIDS and TB are both common.

Organization and regulatory aspects of the human intestinal mucin gene (MUC2) locus

The human MUC2 gene maps to chromosome 11p15, where three additional mucin genes have been located, and encodes the most abundant gastrointestinal mucin normally expressed in the intestinal goblet cell lineage. However, in pathological conditions, including colorectal cancer, MUC2 can be abnormally expressed. Therefore, it is of considerable interest to understand the regulation of the MUC2 gene and how the mechanism is altered in colon cancer. Toward this goal, we have isolated a group of overlapping clones (contig) spanning 85 kilobases harboring the entire MUC2 locus, including sequences located upstream of the gene. Detection of two DNase I-hypersensitive sites in the 5' region of the MUC2 gene suggests the presence of DNA regulatory elements. To better characterize this region, we have sequenced 12 kilobases of the upstream region and analyzed it for functional activity by cloning portions of it into a luciferase reporter vector and assaying for promoter/enhancer activity using a transient transfection assay. A fragment from the AUG translational initiation codon +1 to -848 confers maximal transcriptional activity in several intestinal cell lines. Elements located further upstream exert a negative effect on the expression of the reporter gene when tested in conjunction with homologous or heterologous promoters. The same pattern of expression is observed when the MUC2/luciferase constructs are transfected into HeLa cells, which do not express the endogenous MUC2 gene. However, the level of activity in HeLa cells is at least an order of magnitude higher, suggesting that additional sequences singularly or in combination are responsible for the tissue- and cell lineage-specific expression of MUC2. Finally, we have identified an additional mucin-like gene (MUCX), located upstream of MUC2. We show that this MUCX gene, that is transcribed in opposite orientation to that of MUC2, is expressed with a pattern distinct from that of MUC2, yet similar to that of MUC5B and MUC6, two additional mucin genes located at chromosome 11p15. Recent information on the order of the mucin genes at chromosome 11p15 suggests that MUCX may be MUC6, one of the already identified mucin genes, or a novel one, yet to be fully characterized.

Performance of a system to determine EMS dispatch priorities

Inappropriate use of emergency medical services (EMS) for nonemergencies strains EMS resources and limits efficiency. Protocol-driven dispatch systems attempt to correct the imbalance that exists between demand and available resources by prioritizing 911 calls. This study compared dispatch priority decisions with apparent patient need, based on emergency department (ED) presentation, by matching 320 ED charts with corresponding EMS dispatch and run information. The priorities assigned by the system based on dispatch information were compared with those assigned by a three-member panel of physicians based on ED presentation. The physicians and dispatchers agreed on the need for advanced life support (ALS) versus basic life support (BLS) transport 74% of the time. There was only 43% agreement on the more detailed 4-level classification system. The system assigned the highest level of dispatch utilizing combined ALS and first responders to a significantly greater degree than did the physicians. It was concluded that protocol systems for setting dispatch priorities utilize EMS resources to a higher degree than actually required based on ED presentation.

[Pulmonary artery: angiographic technique optimization with magnetic resonance]

The authors optimized the Magnetic Resonance Angiography (MRA) technique for the study of the different portions of the pulmonary artery-i.e., the common trunk, right and left main arteries and the lobar, segmental and subsegmental branches. Twenty volunteers were examined with MRA of the pulmonary arteries with a 1-T superconductive magnet (Impact) and the time-of-flight (TOF) technique. The volunteers were divided into two groups by age (ranges: 20-40 and 41-70 years). The trunk and main branches were studied with the 2D TOF technique, while 2D TOF images were compared with 3D TOF images in the study of peripheral (lobar, segmental and subsegmental) branches. The images were processed with the maximum intensity projection (MIP). In the statistical comparison between 2D and 3D TOF images, the t-test was used (p < 0.05). The 2D TOF images acquired on the sagittal oblique and coronal planes, with presaturation pulses, permitted optimal depiction of the trunk and of the right and left branches in all the volunteers. Both 2D and 3D TOF images yielded excellent images in the study of the lobar branches. In the volunteers under 40 years of age, 3D TOF sequences visualized the peripheral (segmental and subsegmental) vessels better than 2D TOF sequences (451 vs. 361); the difference was statistically significant. In the volunteers over 41 years of age, the ratio was reversed: 467 for 2D TOF vs. 362 for 3D TOF sequences; again, the difference was statistically significant. The correct integration of 2D and 3D TOF sequences, according to the different segments of the pulmonary artery and to patients' age, permitted the complete and accurate visualization of the pulmonary arteries with MRA.

[Diagnostic pitfalls in magnetic resonance angiography]

The authors report on their clinical experience with Magnetic Resonance angiography (MRA) pitfalls. January, 1989, to February, 1995, six hundred MRA examinations were performed in different vascular districts, with a 1.5-T superconductive magnet, the time-of-flight (TOF) technique and 2D and 3D acquisitions. Intracranial arteries, epiaortic vessels and renal arteries were studied with FISP 3D sequences; intracranial veins, thoracic vessels, vena cava and pelvic vessels were studied with FISP 2D sequences. Pitfalls were observed in 56 of 600 MRA exams (9.3%). Of 56 pitfalls, 26 (46.4%) were in epiaortic vessels, 15 (26.7%) in intracranial vessels, 6 (10.7%) in renal arteries, 6 (10.7%) in thoracic vessels, 1 (1.7%) in the inferior vena cava and 2 (3.5%) in iliac vessels. Stenoses were overestimated in 21 patients and underestimated in three; 16 patients were misdiagnosed and 16 were false positives. As for cerebral vascular lesions, 5 aneurysms and 7 transverse sinus thromboses were false positives, while 3 lesions were misdiagnosed as venous angiomas. As for 26 MRA exams of thoracic vessels, stenoses were overestimated in 16 patients and underestimated in 10 patients with subclavian steal syndrome, where the left vertebral artery was misinterpreted as occluded. In 6 MRA exams of thoracic vessels, 1 patient was misdiagnosed as having an aneurysm and 5 patients were misdiagnosed as having lung cancer infiltrating aorta and superior vena cava. As for renal vessels, 2 normal renal arteries were misdiagnosed as false positives and 4 stenoses were overestimated. In the inferior vena cava, a partial agenesis was misinterpreted as thrombosis. In 2 MRA exams of iliac vessels, a stenosis and a thrombosis were misinterpreted as false positives. Our experience suggests that MRA pitfalls are caused by the incorrect use of the various techniques. The pitfalls we observed can be classified as caused by three types of artifacts: saturation, turbulence and paramagnetic substance artifacts.

Patterns of expression of lineage-specific markers during the in vitro-induced differentiation of HT29 colon carcinoma cells

The four different cell types present in the mature colon, absorptive enterocytes, mucus-secreting goblet cells, Paneth cells, and enteroendocrine cells, are believed to derive from a common precursor, the stem cell, anchored near the base of the crypt. Stem cell descendants undergo several rounds of cell division, creating a pool of transit cells that are committed to differentiation. The mechanisms by which committed cells are allocated to the different cell lineages of the intestine are poorly understood. We have used the colon carcinoma cell line HT29 and Cl.16E cells, a clonal derivative of HT29 cells, to investigate the regulation and pattern of expression of several markers (MUC2, MUC3, carcinoembryonic antigen, and alkaline phosphatase) that are associated with a more differentiated phenotype and that, in the mature cells, are lineage restricted. HT29 cells can express, upon exposure to the appropriate inducers, distinct intestinal specific markers; they are, therefore, considered multipotent, similar to the stem cells of the crypt. Conversely, Cl.16E cells are lineage restricted and respond to cell contact inhibition by expressing a fully differentiated goblet cell phenotype. We show that, in HT29 cells, different inducers (12-O-tetradecanoylphorbol-13-acetate, forskolin, and sodium butyrate) modulate specific sets of markers. Forskolin induces the expression of both MUC2 and MUC3, whereas 12-O-tetradecanoylphorbol-13-acetate is capable of inducing only MUC2, and sodium butyrate, only MUC3 gene expression. Carcinoembryonic antigen, a marker common to enterocytes and goblet cells; can be induced by all the agents, whereas the alkaline phosphatase gene, the expression of which is characteristic of enterocytes, is responsive solely to sodium butyrate treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergence of fluoroquinolone-resistant tuberculosis in New York City

22 patients infected with fluoroquinolone-resistant Mycobacterium tuberculosis in New York City were identified between January, 1991, and November, 1993. In 16 patients resistance arose as a result of inadequate or inappropriate treatment. 6 patients had primary infection with fluoroquinolone-resistant organisms; 5 acquired the organisms nosocomially. Seven distinct patterns of restriction-fragment length polymorphism were identified in isolates from 21 patients. Fluoroquinolones should be restricted to patients with multidrug-resistant disease or intolerance to other antituberculosis drugs. All patients with multidrug-resistant tuberculosis should be on directly observed therapy.

[Artifacts in magnetic resonance angiography]

This study was aimed at assessing and classifying the incidence of Magnetic Resonance Angiography (MRA) artifacts using the 2D and 3D time-of-flight (TOF) technique.

MATERIALS AND METHODS

from 300 MRA examinations performed January 1991 through April 1993, we selected the first 10 examinations for each vascular region which exhibited an artifact. Many kinds of artifacts were considered, i.e., hardware, sequence, magnetic susceptibility, patient and maximum intensity projection (MIP) artifacts. A superconductive 1.5-T magnet (Magnetom, Siemens) was used, with 2D and 3D TOF acquisitions.

RESULTS

the quantitative analysis of artifact frequency showed that in the intracranial vessels (2D and 3D TOF sequences) the most common artifacts are saturation (30%) and magnetic susceptibility (30%) artifacts. As for neck vessels (3D TOF sequences), turbulence (40%) and lack of inclusion (30%) artifacts are the most common ones. In thoracic vessels (2D TOF sequences), MIP (50%) and ghost (30%) artifacts are the most common ones, while in the abdominal aorta (2D TOF sequences) magnetic susceptibility (20%), voluntary movement (20%), peristalsis (20%) and MIP (20%) artifacts occurred most frequently. Saturation (30%) and respiratory movement (30%) artifacts were the most common ones in the study of the renal arteries (3D TOF sequences), while MIP artifacts prevailed (40%) in the inferior vena cava (2D TOF sequences). Finally, MIP (40%) and patient movement (30%) artifacts were the most frequent ones in the study of the lower limbs (2 TOF sequences).

CONCLUSIONS

in 2D and 3D TOF studies, being familiar with artifacts and their physical principles helps avoid image misinterpretation so that, if no technical means can prevent an artifact from occurring, at least it will not become a diagnostic pitfall.

[The torcular Herophili: the diagnostic pitfalls in TOF 3D magnetic resonance angiography]

The authors report on a diagnostic pitfall which is often observed in magnetic resonance angiography (MRA) of intracranial vessels (time-of-flight 3D)--i.e., the absence of one of the two transverse sinuses. Fifty patients underwent MRA of the intracranial vessels with the TOF 3D (FISP) and the TOF 2D (FISP) techniques. Five patients were affected with sinus stenosis. MRA was performed with a 1.5-T superconductive magnet and a circular head coil. All patients underwent Magnetic Resonance Angiography with FISP 2D sequences (FA 40 degrees, TR 40 ms, TE 12 ms) acquired on coronal plane as well as FISP 3D (FA 15 degrees, TR 30 ms, TE 7 ms) acquired on axial plane. In the patients in whom FISP 2D sequences correctly demonstrated the whole confluence of sinuses, FISP 3D sequences always depicted the upper sagittal sinus, while the right transverse sinus was seen in 84.4% (38/45) of cases and the left transverse sinus in 24.2% (11/45) of cases. In the patients with a stenosis in the confluence of sinuses, FISP 3D sequences demonstrated two false-positive cases with respect to FISP 2D. The statistical analysis (McNemar test) of the results demonstrated the difference between 2D and 3D sequences in the detection of the two transverse sinuses to be statistically significant: p < 0.01 for the right transverse sinus and p < 0.001 for the left transverse sinus. In the study of the intracranial vessels (TOF 3D technique) the absence of one of the two transverse sinuses is suggestive of a diagnostic pitfall; the combination of 3D and 2D sequences answers this diagnostic question.

Schinzel-Giedion syndrome

We describe a female infant with the Schinzel-Giedion syndrome. Features present in 11 patients include coarse face, midface retraction, urogenital anomalies, poor skull vault mineralisation and variable anomalies of the long bones. Outcome is poor and mental retardation is the rule among survivors. Prenatal diagnosis seems unreliable. Facial features change dramatically with age and diagnosis is likely to be easily missed beyond the neonatal period. No metabolic defect has been detected. Inheritance is probably autosomal recessive.

[Cerebrovascular pathology. Comparison of magnetic resonance and magnetic resonance angiography]

After making the visualization of the intracranial circulation possible without contrast media, the radiologist is now evaluating the diagnostic role of the different techniques of MRA. Attempts are also being made to characterize the main patterns of intracranial vascular diseases. The authors examined, with 3D TOF MRA, 40 patients presenting with 50 vascular lesions on MRI scans. Twenty of 40 patients were also studied with angiography. Seventeen aneurysms were detected, together with 3 stenoses of the cerebral arteries, 13 arteriovenous malformations, 12 dolichobasilar arteries, 3 postoperative and 2 post-embolization controls. MRI was performed with a superconductive magnet (1.5 T), a dedicated coil and gradient-echo 3D TOF FT sequences. The refocused sequence for flux, FISP 3DFT, required the following parameters: TR = 0.04 s, TE = 10 ms, flip angle = 15 degrees, 256 x 256 matrix, 1 acquisition. The 64-80 mm volume along the axial plane was divided so that an actual 1-mm thickness was excited. In post-processing, the maximum-intensity projection was employed on the axial plane 0 degrees-90 degrees (15 degrees interval). In the various conditions, the results obtained with MRA were correlated and compared with MRI findings. MRA provided useful additional information in 27.4% of cases in the study of aneurysms, arteriovenous malformations, vascular occlusion and dolichobasilar arteries, as well as in the follow-up of these lesions. MRA is currently suggested in the evaluation of cerebral circulation and is considered a complementary technique to MRI. MRA is also to be used preliminary to angiography.

[Magnetic resonance angiography of the intracranial vessels. Technique and anatomy]

Fifty volunteers were studied by means of MR angiography of the intracranial vessels, with a 1.5 T Siemens Magnetom. The technical features of the most employed MR angiographic techniques were analyzed. The inflow technique was tested with refocused gradient-echo sequences for the FISP 3DFT flow and a dedicate coil. The study was aimed at evaluating the resolution power of each technique and at identifying the most useful rotations and angles for each chosen vessels. The acquisition volume of the gradient-echo sequence was positioned on the axial plane with sella turcica in the center. TR was set at 0.04 s, TE at 10 ms, and flip angle was 15 degrees. A 256 x 256 matrix was used, and an 80-mm acquisition volume, with 64 partitions. The chosen images were rotated on the axial and sagittal planes 0 degrees-180 degrees. The results showed that both rotation planes and their relative angles allow the visualization of all the vessels. To reduce post-processing time, with immediate availability of computer keyboard, a standardization is suggested with 0 degrees-180 degrees rotations on the axial plane, with 15 degrees interval and 0 degrees-45 degrees rotations on the sagittal plane, with 15 degrees interval. The main limitation of this method is its spatial resolution, which was 1.2 mm in rotations and acquisitions on the axial plane and 1 mm in acquisitions on the axial plane rotated on the sagittal plane.

A descriptive summary of New Jersey's 1985 burn population

Data obtained from the New Jersey State Department of Health on the 1985 hospitalized patients with burns and data collected from the National Burn Victim Foundation's standard burn reporting form were analyzed to gather information about the epidemiology of burns. Children (0 to 4 years of age) continue to be the largest percentage of the 0- to 18-year-old age group who sustain burn injuries, and 67% of those injuries are sustained by children under the age of 5. Males accounted for 69% of the total burn population; 58% of admissions were white; 69% of patients were admitted for partial-thickness burns, and 31% were admitted for full-thickness burns; the largest primary payer was third-party payers; and 92% of patients with burns were discharged to home or self-care. Data were also analyzed by examination of selected age groups to determine individual needs of specific groups. An analysis of burn injuries reported to the National Burn Victim Foundation confirmed previous reports that the home is the most likely place for a burn injury to occur and that flame and scald injuries predominate; scald injuries comprise 50% of all sustained burns. Gasoline vapors accounted for 54% of burn injuries caused by flames. The data supported efforts to develop programs that address the needs of the urban child, the 17- to 19-year-old age groups, and the elderly. The information that was collected served to redefine objectives for burn prevention programs.

[Magnetic resonance angiography of the neck vessels: technique and anatomy]

The authors identified the standard projections for studying neck vessels with magnetic resonance angiography. Sixty volunteers underwent angio-MR of the arterial neck vessels with FISP 3D FT sequences obtained on the coronal and sagittal planes. The gradient-echo sequence (FISP 3D FT) was acquired with TR = 0.04-0.08 s and TE = 15 ms, with 25 degrees flip angle. Single excitated slices of thickness ranging from 1-2 mm were included in the acquisition volume. These sequences were subsequently processed by the maximum intensity projection method. Two radiologists examined our results to choose the optimal projections. We used a semiquantitative scale which allowed us to distinguish 3 different diagnostic levels for each projection: well-visualized vessels, poorly-visualized, and non-visualized ones. For each section axial rotations were performed ranging from 0 degree to 180 degrees, with 15 degrees intervals. On the coronal plane, rotations from -45 degrees to 45 degrees were the optimal ones to visualize the studied vessels. The 0 degree-15 degrees-30 degrees-45 degrees-135 degrees-165 degrees-180 degrees projections allowed the common carotids to be clearly demonstrated together with the vertebral arteries. The other projections appeared to be useless for diagnostic purposes. On the sagittal plane, rotations from 60 degrees to 120 degrees were the optimal ones. The 90 degrees projection allowed the demonstration of all the big arterial vessels of the neck, including carotid bifurcation and internal and external carotids. The assessment of the optimal diagnostic projections for angio-MR of the neck vessels is helpful to reduce post-processing time. As a matter of fact, the immediate visualization, during the examination, of the standard projections allows further acquisitions to be obtained--if needed--to try to solve specific diagnostic doubts.

[Aortic insufficiency caused by valvular dysplasia in childhood. Apropos of 3 cases]

Three patients whose aortic incompetence (A.I.) was recognized in childhood, have had an angiographic study 10, 9 and 4 years, respectively, following the first clinical diagnosis of their valvular disease. A.I. was related, in all three cases, to a dysplastic valve ("floppy valve syndrome"); in none of them was there an abnormal dilatation of ascending aorta. In our opinion, the absence of an abnormal aortic root dilatation separates our cases from those in whom aortic regurgitation is part of Marfan's syndrome, either in its full form or in the "forme fruste". From the clinical viewpoint, the presence of a normal ascending aorta could explain the mild course of these cases, as compared to the rapid progression observed in Marfan's syndrome. In the attempt to differentiate the two types of dysplastic valvular disease from an etiologic viewpoint, we suggest that the basic problem in our patients could be an alteration of the valvular connective tissue development, rather than a genetic disorder, like the one possibly responsible for Marfan's syndrome.

Clinical evaluation of the MICRO-ID, API 20E, and conventional media systems for identification of Enterobacteriacea

MICRO-ID (General Diagnostics, Morris Plains, N.J.) is a new kit system designed for the identification of Enterobacteriaceae in 4 h. It consists of 15 biochemical tests of paper disks. Each test is in its own compartment in a molded plastic tray. Only one reagent need be added to the system (2 drops of 20% KOH, which is added to the Voges-Proskauer test). Based on the pattern of positive and negative biochemical test results, a five-digit octal code number is calculated. An identification is derived from a computer-generated identification manual. A study was conducted to compare three systems-the MICRO-ID 4-h and the API 20E (Analytab Products Inc., Plainview, N.Y.) 18- to 24-h systems and a conventional media system-to measure the ability of each to identify members of the family Enterobacteriaceae. Comparison tables, rather than simple percentage agreement tables, were generated to define the particular strengths and weaknesses of each system and allow the laboratory to best use the data. The MICRO-ID compared quite favorably with conventional media. MICRO-ID yielded incorrect identifications with 1.5% of the isolates tested (API 20E, 4.7% misidentification rate). Half the MICRO-ID misidentifications occurred when the system identified a Citrobacter diversus as a lysine-negative Escherichia coli; all gave one octal number. A direct comparison of the MICRO-ID and API 20E was of limited value because percentage agreements were merely the sums of the errors of each. The ease of inoculation, the requirement for the addition of only one reagent, and the 4-h capability make the MICRO-ID system an extremely attractive development in the field of bacterial identification.