Radiation Therapy Sensitizes Head-and-Neck Cancer Cells to Killing by Chimeric Antigen Receptor (CAR)-NK Cells Targeting CD70

PURPOSE/OBJECTIVE(S)

CAR-T cell therapy is limited by toxicity, high cost, logistical manufacturing issues in the autologous setting and risk of GVHD in the allogeneic setting. Substitution of T cells with NK cells opens the possibility for an allogeneic off-the-shelf product with a better safety profile. However, the inadequate efficacy of CAR-NK cells against solid tumors can be extrapolated from experience with CAR-T cells. There is limited but promising preclinical evidence that radiation therapy (RT) enhances CAR-T cell tumoricidal activity against solid tumors. However, there is no data examining the potential synergy between RT and CAR-NK cell therapy.

MATERIALS/METHODS

We engineered CAR-NK cells with CD27 receptor as extracellular domain to target its natural ligand CD70, which is overexpressed in head-and-neck cancers (HNSCC). CAR-NK cell killing was assessed real-time through xCELLigence cytotoxicity assays. CD70+ OQ01 human HNSCCs were used for most experiments. FaDu is a CD70- HNSCC (negative ctrl). UMRC3 is a CD70+ kidney cancer cell line (positive ctrl). CD70 expression pre- and post-RT was assessed by flow cytometry and Western blot. Ionizing RT was compared at 5 doses: 0, 1.75, 3.5, 7, and 14 Gy. A single dose of 3.5 Gy was used for most experiments. Post-radiation effects were generally assessed at 3 days or 9 days post-RT. Intracellular staining was used to assess NK cell expression of IFN-γ, CD107a, and TNF-α by flow cytometry. CD27/CD70 interaction blockade was through α-CD27 pre-treatment of CAR-NK cells.

RESULTS

OQ01 HNSCCs heterogeneously express CD70 and are killed by CD70 CAR-NK cells in vitro. Pre-conditioning low-dose RT of 3.5 Gy applied to OQ01 HNSCCs 3 days prior to coculture with NK cells enhances CD70 CAR-NK cell killing, with ∼30% increased cytotoxicity against the tumor cells. Low-dose RT by itself did not induce acute cytolysis. As a possible mechanism for the increased sensitivity of irradiated OQ01 cells to CD70 CAR-NK cells, we found that RT enhances CD70 expression among HNSCCs in a dose-dependent manner. There was no increase in NK cell expression of IFN-γ, CD107a, and TNF-α with exposure to irradiated target cells. CD27/CD70 blockade does not solely abrogate RT-induced sensitization toward CAR-NK cell killing. Despite RT induction of transient increased expression of CD70, which normalizes by 9 days post-RT, there is persistent increase in RT-synergized target cell killing even at this later timepoint. Thus, altogether, RT sensitizes CD70-expressing HNSCC cells to CAR-NK cell killing in vitro.

CONCLUSION

This work represents the first preclinical study to identify the synergy of RT and CAR-NK cell therapy in solid tumors and is the first demonstration of CAR-NK cell activity against human HNSCCs. We show significantly enhanced potency of CAR-NK cells against irradiated tumor cells in vitro. Collectively, this research will be vital to guide efforts expanding into other target antigens and tumor types.

Prognostic role of intermountain risk score (IMRS) in intensive care unit patients with a diagnosis of COVID-19

OBJECTIVE

In this study, we aimed to assess the predictive value of Intermountain Risk Score (IMRS) in intensive care unit (ICU) patients with COVID-19.

PATIENTS AND METHODS

Our retrospective study included the data of 194 patients who were admitted to the COVID-19 ICU of a tertiary care center. COVID-19 diagnoses were made by a positive result from a real-time reverse-transcriptase (RT) polymerase chain reaction (PCR) assay of nasal and pharyngeal swab specimens. Patients who had negative RT-PCR results or who were not admitted to ICU and patients under 18 years old were excluded from the study. Complete blood count, biochemistry panel, and blood gas analysis results were gathered and compiled.

RESULTS

194 ICU patients with COVID-19 (PCR positive) were included in the study. The patients were divided into two groups according to IMRS (if IMRS was <15 in women and <17 in men, patients were included in the non-high-risk group, while patients with IMRS ≥15 in women and ≥17 in men were defined as a high-risk group). Multivariate regression analysis was performed to predict in-hospital mortality. The IMRS [OR: 1.17 (1.08-1.27) p<0.001)] was found to predict in-hospital mortality.

CONCLUSIONS

In this study, we showed that the IMRS score at admission can predict in-hospital mortality in intensive care unit patients with a diagnosis of COVID-19.

Association between Kelch-like ECH-associated protein-1 and GRACE risk score in non-ST elevation myocardial infarction

OBJECTIVE

In this study, we measured the levels of Kelch-like ECH-associated protein 1 (KEAP1), which has the potential antioxidant capacity, among non-ST elevation myocardial infarction (NSTEMI) patients compared with healthy controls. We also investigated the possible association between KEAP1 levels and the GRACE score, which is a universal risk score commonly used for patients with acute myocardial infarction.

PATIENTS AND METHODS

As the patient group, 78 patients admitted to our center with a diagnosis of NSTEMI were included in the study. As the control group, 77 individuals found to have normal coronary arteries after coronary arteriography were included (155 patients in total). GRACE risk scores and left ventricular ejection fractions (LVEFs) were calculated, KEAP1 levels were measured, and the usual blood tests were performed.

RESULTS

KEAP1 levels were significantly higher among the NSTEMI patients compared to the healthy control group (671.1 ± 120.7 vs. 262.7 ± 105.7, p < 0.001). We also found a moderate positive correlation between KEAP1 levels and GRACE risk scores among patients with NSTEMI (r = +0.521, p < 0.001). Additionally, a negative correlation between KEAP1 levels and LVEFs was detected (r = -0.264, p < 0.001).

CONCLUSIONS

Elevated KEAP1 levels have the potential to be used as a risk factor for NSTEMI in terms of clinical adverse events and poor prognosis at admission.

POS1245 REVERSAL OF DECLINE IN HUMORAL RESPONSE TO BNT162b2 mRNA COVID-19 VACCINE AFTER BOOSTER ADMINISTRATION IN AUTOIMMUNE INFLAMMATORY RHEUMATOID DISEASES (AIRD) PATIENTS

Background

Previous studies proved that mRNA vaccinations against SARS CoV2 induced significant humoral responses in AIRD patients (pts). However, the humoral response was blunted in pts treated with CD20 depleting antibodies. There are limited data regarding the long-term outcome of the humoral response and the contribution of the booster vaccine, in immunosuppressed AIRD pts.

Objectives

To assess the long-term outcome of the humoral response to mRNA vaccine against SARS CoV2, in AIRD pts treated with immunomodulating drugs, and the contribution of the booster vaccination.

Methods

Consecutive pts treated at the Rheumatology Institute at Rambam Hospital who received their first SARS-CoV-2 (Pfizer) vaccine were recruited to the study, at their routine visit. The visit included AIRD activity assessment and questioning regarding vaccine side effects. We performed serology test 4-6 weeks and 24 weeks after receiving the second dose of vaccine. Pts who received the booster (3rd vaccine) were invited for serology tests 4-8 weeks afterwards. The immunomodulating treatment was not modified, either before or after the vaccination. IgG Antibodies (Ab) against SARS COV2 virus were detected using the SARS-Cov-2 IgG II Quant (Abbott) assay based on a chemiluminescent microparticle immunoassay (CMIA) on the ARCHITECT ci8200system from Abbott. This assay is measuring IgG antibodies against the spike receptor-binding domain (S-RBD) of the virus. The test was considered positive above 50 AU/ml.

Results

262 pts (mean age(SD) 57(13), disease duration 11.2(7.4), were recruited. The cohort included 152 pts with inflammatory joint disease, 26 pts with systemic lupus erythematosus, 62 pts with other connective tissue disease and 22 pts with vasculitis; 27 % received csDMARDs only, 35% - b/tsDMARDs only, 30% - combined therapy (csDMARDs+b/tsDMARDs) and 26% received steroids. 225 pts (86%) were seropositive for IgG Ab against SARS CoV2 virus (median 2832.5 AU/ml, IQR 58-29499). 37 (14%) pts had negative tests, 23 (62.2%) of them were rituximab treated.

The IgG levels correlated with the medication used to treat the AIRD, the patients’ age but not with the type of the AIRD (Figure 1). 24 weeks afterwards, the median IgG level dropped to 282 AU/ml and 15% of the pts with previous seropositive tests became negative. The booster administration (Pfizer) significantly augmented the humoral response (median 8328 AU/ml, IQR 375-40000). De novo serologic response was observed in 10 out of 37 pts (4/23 rituximab treated pts).

Figure 1.

The reported side effects of the vaccine were minor (muscle sore, headache, low grade fever). The AIRD remained stable in all pts following all three vaccinations.

Conclusion

Although the vast majority of AIRD pts developed a substantial humoral response following the administration of the second dose of the Pfizer mRNA vaccine against SARS CoV2 virus, the humoral response significantly declined 24 weeks afterwards. An enhanced response was obtained after the third booster vaccination. Only minor side effects were reported and no apparent impact on AIRD activity was noted. Notably, 62% of the non-responders were treated with B cell depleting agents.

Acknowledgements

We would like to thank Mrs Tsofnat Margi and Mrs Sarit Elkouby for organisational support.

Disclosure of Interests

None declared

A rare tumor case in an adult patient with neurofibromatosis: Lumbar ependymoma

In patients with type 1 neurofibromatosis (NF1), there is an increased susceptibility to tumor development in the central nervous system due to the loss of neurofibromin, an inactivator of the protooncogene Ras. NF1 has a broad clinical spectrum,which includes spinal tumors. Although the most common intramedullary tumor of the spinal cord in adults is ependymoma, few patients with NF1 accompanied by spinal ependymoma have been reported to date, and the localization of the tumors is cervical and thoracic in these cases. In this study, we report the case of a patient with NF1 presenting to our clinic with low back pain and gait disturbance. The patient had an intradural extramedullary ependymoma at the L2-3 vertebra level. This report is the first case of NF1 with spinal ependymoma localized in the lumbar region.

Potential role of the geriatric nutritional risk index as a novel risk factor for the development of non-valvular atrial fibrillation in patients with heart failure

PURPOSE

The geriatric nutritional risk index (GNRI) is a simple and objective nutritional assessment tool for elderly patients. Lower GNRI values are associated with a worse prognosis in heart failure with reduced ejection fraction (HFrEF). Our aim is to investigate the relationship between malnutrition and follow-up cardiovascular (CV) events in HFrEF.

METHODS

A retrospective study was performed on 362 patients with HFrEF. The baseline GNRI was calculated at the first visit. The patients were divided into three groups according to the GNRI: >98, no-risk group; 92 to ≤98, low risk group; 82 to <92, moderate‑to‑high‑risk group. The study endpoint was a composite of follow-upCV events, including all-cause mortality, non-valvular atrial fibrillation (NVAF) , need for cardioverter defibrillator (ICD) therapy, HfrEF‑related hospitalizations and need for percutaneous coronary interventions (PCIs).

RESULTS

Follow-up data showed that the group with moderate-to-high risk had a significantly higher incidence of NVAF, PCIs and all-cause mortality compared to other groups (p<0.001, p: 0.026 and p0.05). Mean GNRI value was 83.3 in NVAF patients and 101.1 in patients without NVAF (p<0.001). Kaplan Meier survival analysis showed that patients from the group with moderate-to-high risk had a significantly worse survival rate (p < 0.001). In the multivariate Cox regression analysis, the group with moderate-to‑high risk (HR=3.872) and ICD implantations (HR=4.045) were associated with increased mortality.

CONCLUSION

The GNRI value may have a potential role for predicting future events, especially NVAF in patients with HfrEF (Tab. 4, Fig. 2, Ref. 27).

Erratum: Azimuthal Anisotropy of K_{S}^{0} and Λ+Λ[over ¯] Production at Midrapidity from Au+Au Collisions at sqrt[s]_{NN}=130 GeV [Phys. Rev. Lett. 89, 132301 (2002)]

This corrects the article DOI: 10.1103/PhysRevLett.89.132301.

Erratum: Azimuthal Anisotropy at the Relativistic Heavy Ion Collider: The First and Fourth Harmonics [Phys. Rev. Lett. 92, 062301 (2004)]

This corrects the article DOI: 10.1103/PhysRevLett.92.062301.

3D evaluation of tooth crown size ın unilateral cleft lip and palate patients

Aim

The aim of this retrospective study is to evaluate and compare the 3-dimensional (3D) crown sizes of the left and right sides of upper and lower dental arches in patients with unilateral cleft lip and palate (UCLP).

Materials and Methods

Dental casts of 94 patients all in permanent dentition were included in this study. Dental casts were divided into three groups as 36 casts with unilateral left cleft lip and palate (ULCLP), 18 casts with unilateral right cleft lip and palate (URCLP), and 40 casts without cleft (control). Mesiodistal (MD), buccolingual (BL), and gingiva incisal (GI) values of each tooth were measured by scanning the dental models with a high-precision optical 3D scanner. Paired t-test and independent t-test were used for statistical analysis.

Results

U1 MD, U6 MD (P = 0.001) and BL (P = 0.01), L3 GI (P = 0.05) were greater in UCLP patients on the non-cleft side while U1 GI, L1 BL, L5 MD (P = 0.001), L4 MD, and BL (P = 0.01) values were found to be greater on the cleft side. Comparison of the cleft-sides and the control group showed that MD, BL, and GI dimensions of teeth on the cleft sides were generally found to be smaller, excluding the UR7 GI values for URCLP group (P = 0.05).

Conclusion

In the measurements of teeth size, reliable and repeatable results were acquired through 3D software. Tooth size asymmetries can occur non-syndromic UCLP patients in both jaws. MD, BL, and GI dimensions of teeth are mostly found to be smaller in patients with CLP.

Diagnostic utility of oxidative and non-oxidative markers for spontaneous bacterial peritonitis in non-malign ascites

OBJECTIVE

In this study, we aimed to investigate the diagnostic availability of oxidant and antioxidant parameters in ascites for spontaneous bacterial peritonitis (SBP).

MATERIAL AND METHODS

This study was carried out between July and October 2018 with 25 patients with SBP and 24 patients without SBP. Patients with acute infection, those taking vitamin supplements and antioxidant medication, smoking and drinking alcohol, and patients without ascites culture were excluded from the study.

RESULTS

In patients with SBP compared those without SBP median paraoxonase (3.1 vs 15.6 ; p <0.001), median stimulated paraoxonase (12.6 vs 53.1 ; p <0.001), median arylesterase (769,9 vs 857,5 ; p = 0,003) and median catalase (10 vs 22,2 ; p = 0,003) were found to be lower and median myeloperoxidase (8.1 vs 1.1 ; p <0.001) were found to be higher. There was a positive correlation between paraoxonase levels and stimulated paraoxonase levels, arylesterase levels and catalase levels, there was a negative correlation between paraoxonase levels and myeloperoxidase levels. Paraoxonase levels 3.7 and lower, stimulated paraoxonase levels 25.8 and lower, arylesterase levels 853.4 and lower, catalase levels 11.8 and lower and myeloperoxidase levels 2.7 and more predicted the the presence of SBP with high specificity and high sensitivity. Paraoxonase and stimulated paraoxo-nase levels were found to have superior performance in predicting the presence of SBP compared to arylesterase levels (p <0.05).

CONCLUSION

In this study it was shown that paraoxonase, stimulated paraoxonase, arylesterase, catalase and myeloperoxidase activities can be used for the diagnosis and severity of SBP.

Monocyte/HDL ratio predicts hypertensive complications

OBJECTIVE

We aimed to investigate whether a simple and easily calculated parameter such as monocyte/ HDL ratio (MHR) may be used in predicting non-dipper (NDHT)-dipper HT (DHT) end organ damage.

METHODS

70 NDHT and 73 DHT patient groups were included in the study according to ambulatory blood pressure screening results. Basic laboratory parameters and spot urine samples were evaluated. Transthoracic echocardiography and ophthalmological examination were performed for end-organ damages.

RESULTS

The MHR among the groups was higher in the NDHT group; which was statistically significant (p≤0.001). In the NDHT group, albumin, creatinine, protein values, protein/creatinine ratio in the spot urine were significantly higher than in the DHT group (p≤0.05). Left ventricular hypertrophy (LVH) and retinopathy were also more frequently observed in the NDHT group (p≤0.001 and p=0.001, respectively). MHR in patients with LVH and retinopathy was significantly higher than in those without these complications (p=0.001).

CONCLUSION

Easy to use, non-invasive and simple calculation, MHR can be used to predict end organ damage in hypertensive cases, and can be also used to distinguish between DHT/NDHT groups. This data supports the role of inflammation (Tab. 7, Ref. 14).

Prolactin levels in drug-naïve first episode nonaffective psychosis patients compared with healthy controls. Sex differences

Recent studies have found hyperprolactinemia in first episode psychotic patients that had not previously received antipsychotic treatment (drug-naïve). Our goal was to learn whether there were differences in baseline prolactin concentrations between drug-naïve psychotic patients and healthy controls, as well as to study possible gender differences in the prolactin elevation. A cross-sectional study was conducted that included 61 drug-naïve psychosis patients and 45 healthy controls (aged between 14-55 years old). A blood sample was extracted between 8 and 10 a.m. Prolactin levels and TSH were determined. The Perceived Stress Scale (PSS) was conducted across the sample. This study showed significantly higher levels of prolactin in drug-naïve patients compared to healthy controls. These results were maintained after controlling prolactin levels for sex, age, THC consumption, baseline TSH, and PSS. A significant correlation between prolactin and PSS was not observed. Significant differences in prolactin levels between men and women were not observed. These results are clinically important because if elevated baseline prolactin levels are detected in these patients, it will be necessary to initiate neuroleptics that do not increase this hormone. There was no evidence that stress was related to an increase in prolactin at the onset of psychosis.

Single- versus double-layer closure of the caesarean (uterine) scar in the prevention of gynaecological symptoms in relation to niche development - the 2Close study: a multicentre randomised controlled trial

BACKGROUND

Double-layer compared to single-layer closure of the uterus after a caesarean section (CS) leads to a thicker myometrial layer at the site of the CS scar, also called residual myometrium thickness (RMT). It possibly decreases the development of a niche, which is an interruption of the myometrium at the site of the uterine scar. Thin RMT and a niche are associated with gynaecological symptoms, obstetric complications in a subsequent pregnancy and delivery and possibly with subfertility.

METHODS

Women undergoing a first CS regardless of the gestational age will be asked to participate in this multicentre, double blinded randomised controlled trial (RCT). They will be randomised to single-layer closure or double-layer closure of the uterine incision. Single-layer closure (control group) is performed with a continuous running, unlocked suture, with or without endometrial saving technique. Double-layer closure (intervention group) is performed with the first layer in a continuous unlocked suture including the endometrial layer and the second layer is also continuous unlocked and imbricates the first. The primary outcome is the reported number of days with postmenstrual spotting during one menstrual cycle nine months after CS. Secondary outcomes include surgical data, ultrasound evaluation at three months, menstrual pattern, dysmenorrhea, quality of life, and sexual function at nine months. Structured transvaginal ultrasound (TVUS) evaluation is performed to assess the uterine scar and if necessary saline infusion sonohysterography (SIS) or gel instillation sonohysterography (GIS) will be added to the examination. Women and ultrasound examiners will be blinded for allocation. Reproductive outcomes at three years follow-up including fertility, mode of delivery and complications in subsequent deliveries will be studied as well. Analyses will be performed by intention to treat. 2290 women have to be randomised to show a reduction of 15% in the mean number of spotting days. Additionally, a cost-effectiveness analysis will be performed from a societal perspective.

DISCUSSION

This RCT will provide insight in the outcomes of single- compared to double-layer closure technique after CS, including postmenstrual spotting and subfertility in relation to niche development measured by ultrasound.

TRIAL REGISTRATION

Dutch Trial Register ( NTR5480 ). Registered 29 October 2015.

Evaluation of pentraxin-3 in familial Mediterranean fever patients during attack and attack-free periods

INTRODUCTION

Pentraxin-3 (PTX-3) is a prototype of pentraxin proteins that have been shown to be involved in acute phase response. In this study, we aimed to investigate the relationship between PTX-3 levels and familial Mediterranean fever (FMF) disease, and to evaluate PTX-3 as a novel diagnostic marker of FMF.

METHOD

Forty-three male patients diagnosed with FMF and 42 healthy individuals were included in the study. Patients with other inflammatory diseases and patients who used drugs having anti-inflammatory properties were excluded from the research. Blood samples were obtained during both attack and attack-free periods.

RESULTS

Patient attack periods were confirmed by combining physical examination and elevation of acute phase reactants. Acute phase reactants were significantly higher in attack versus attack-free periods (p < 0.01), however PTX-3 levels were not significantly different between the two periods. Additionally, PTX-3 levels in FMF patients were higher than in controls in both attack (917.29 ± 725.29 vs 451.83 ± 291.95, p < 0.01) and attack-free periods (748.23 ± 487.53 vs 451.83 ± 291.95, p < 0.01).

CONCLUSION

In this study, we showed that PTX-3 levels, in both FMF attack and attack-free periods, were significantly higher than in the control group. Finally, PTX-3 may be a promising biomarker for FMF diagnosis and may predict FMF attacks (Tab. 2, Fig. 2, Ref. 18).

The novel diagnostic marker in low-LVEF heart failure patients

OBJECTIVE

The structural and compositional changes in the myocardium seem to have a major role in the development of heart failure (HF).Imbalance between production and degradation in extracellular collagen results in increase of collagen synthesis biomarkers in the circulation as the carboxy-terminal propeptide of type I procollagen (PIP). Here we aimed to determine role of PIP in the diagnosis of chronic HF.

MATERIAL AND METHODS

87 patients with HF group and 80 healthy subjects were enrolled into the study. Echocardiographic examination was performed.At the beginning of the study, serum B type natriuretic peptide (BNP), PIP, high sensitive C-reactive protein (hs-CRP) were measured . The subjects were followed for one year then after.

RESULTS

Average PIP value of HF group was significantly higher than that of the control group (p < 0.001). Both hs-CRP and BNP values were well correlated to PIP values (p < 0.001). In the HF group, PIP value of patients who died at the end of one year was similar to that of patients who survived at the end of first year.

CONCLUSION

PIP may not mirror acute events in follow-up of chronic heart failure but it is a very beneficial biomarker in diagnosis of low-LVEF heart failure with high sensitivity and specificity (Tab. 2, Fig. 1, Ref. 16).

Prognostic Utility of Hypokalemia in Cirrhotic Patients

BACKGROUND AND AIM

We researched the relationships between serum potassium level and prognostic scores and complications of cirrhosis, and mortality.

METHODS

This study was performed retrospectively in Turkish High Specialty Training and Research Hospital between 2009 and 2015. Patients who had missing patient files and electrolyte disorder for another reason, showed complications at the time of application and were using diuretics were excluded from the study.

RESULTS

218 patients were included in the study. During the follow-up period, 23.4% (n: 51) of the entire population passed away. Compared to the patients who survived, the patients who passed away had higher HCC and HES development rate, mean Child-Pugh and MELD score and lower mean blood potassium level. The stepwise multivariable Cox regression model which included significant independent predictors showed that ChildPugh score (HR: 1.29; p <0.001), MELD score (HR:1.13; p= 0.006), and potassium level (HR: 0.18; p< 0.001) were independent predictors of mortality. The cut off value for potassium level in predicting mortality was found to be ≤ 3.4 mmol/L with 80.4% sensitivity and 100% specificity. Compared to the patients with a potassium level > 3.4 mmol/L, the patients with a potassium level ≤ 3.4 mmol/L had higher mortality rate, HCC and HES development rate, mean Child-Pugh and mean MELD scores.

CONCLUSION

Hypokalemia is an important prognostic factor in cirrhotic patients.

Laparoscopy in the management of lumboperitoneal shunt catheter in obese patients with pseudotumor cerebri

Lumboperitoneal shunts are widely used for the treatment of patients diagnosed with pseudotumor cerebri (PTC). Obesity is a risk factor for PTC. In particular, catheter migration out of the abdominal cavity is more commonly observed in morbidly obese patients. The aim of this study was to discuss the underlying mechanisms of catheter migration and treatment modalities in morbidly obese patients with PTC. The present study included four morbidly obese patients. All cases had undergone the previous laparotomy for insertion of a distal catheter into the abdominal cavity. In three cases, migration of the distal catheter out of the abdominal cavity was observed. Migration of the proximal tip of the catheter out of the spinal canal was observed in the fourth case. In all cases, laparoscopic revision surgeries were performed. During revision surgery, a catheter tunnel was prepared immediately over the external oblique fascia to obtain the shortest and deepest tunnel, and a distal catheter was inserted by laparoscopic guidance posterolaterally, i.e., through the postaxillary line. None of the patients developed any complications during the follow-up period of 4 years. We recommend laparoscopic insertion of distal catheters through the postaxillary line into the abdominal cavity using as short a catheter route as possible. Thus, tension and traction on the catheter due to abdominal movements can be decreased in morbidly obese patients to prevent catheter migration.

Israel transcutaneous bilirubin nomogram predicts significant hyperbilirubinemia

OBJECTIVE

We constructed a transcutaneous bilirubin (TcB) nomogram to represent major sectors of the Israeli population. We studied the risk of hyperbilirubinemia, defined as meeting the requirements for phototherapy, per percentile risk category.

STUDY DESIGN

Newborns ⩾36 weeks gestation were tested daily for TcB, using Drager JM-103 devices, during birth hospitalization. A nomogram was constructed and divided into four risk groups and validated by calculating the need for phototherapy for each group.

RESULTS

A total of 3303 measurements were performed on 1059 consecutive newborns including Ashkenazi, Sephardic and mixed Ashkenazi/Sephardic Jews, Arab and Ethiopian Jewish. Phototherapy risk increased progressively and more than 100-fold, from 0/225 in the <40th percentile group through 27/120 (22.5%) for those >95th percentile (relative risk (95% confidence interval) 102 (6 to 1669) for those >95th percentile compared with those <40th percentile). The optimal risk for discriminating the need for phototherapy was >75th percentile (sensitivity 93.33, specificity 59.47).

CONCLUSION

The risk of significant hyperbilirubinemia increased progressively with increasing percentile. Newborns >75th percentile groups are at high risk for phototherapy and should be closely monitored.

Tp-e interval and Tp-e/QT ratio in patients with celiac disease

OBJECTIVES

Celiac disease is a chronic immune-mediated disease of the small intestine. It has been known that dilated cardiomyopathy and ischemic coronary artery disease have become more frequent in patients with celiac disease. The aim of the study was to assess Tp-e interval and Tp-e/QT ratio in patients with celiac disease.

MATERIAL AND METHODS

This study was conducted at a single center in collaboration with gastroenterology and cardiology clinics. Between January 2014 and June 2015, a total of 76 consecutive patients were enrolled (38 patients with celiac disease and 38 control subjects). Tp-e interval, Tp-e/QT and Tp-e/QTc ratio were measured from the 12-lead electrocardiogram.

RESULTS

Tp-e interval (64.2±11.0 vs. 44.5±6.0; p<0.001), Tp-e/QT ratio (0.18±0.02 vs. 0.13±0.02; p<0.001) and Tp-e/QTc ratio (0.16±0.02 vs. 0.11±0.01; p<0.001) were significantly higher in patients with celiac disease than control subjects. There was a significant positive correlation between Tp-e/QTc ratio and disease duration in patients with celiac disease (r=0.480, p=0.003) and also there was a significant positive correlation between Tp-e/QTc ratio and erythrocyte sedimentation rate (r=0.434, p<0.001).

CONCLUSIONS

Our study showed that Tp-e interval, Tp-e/QT and Tp-e/QTc ratios were increased in patients with celiac disease. Whether these changes increase the risk of ventricular arrhythmia deserve further studies.

Factors associated with increased irisin levels in the type 1 diabetes mellitus

OBJECTIVE

The aim of the present study was to determine the irisin levels in patients with the type 1 diabetes mellitus (T1DM) and to examine the relation of irisin levels with the inflammation and autoimmunity.

METHODS

This study included 35 cases diagnosed with T1DM and 36 healthy volunteers. Antiglutamic acid decarboxylase (anti-GAD), islet cell antibody (ICA), and insulin autoantibody levels were measured in patients at the time when they were included into the study and recorded from the patient files. Serum irisin levels were measured by ELISA kit.

RESULTS

The median irisin levels were determined higher in T1DM group compared to the control one (6.8 ng/ml vs. 4.8 ng/ml, p=0.022; respectively). Median irisin levels were higher in anti-GAD (p=0.022) and ICA (p=0.044) positive groups compared to negative groups. In T1DM group, irisin levels displayed positive correlation with glycosylated hemoglobin (HbA1c) (r=0.377, p<0.001) and anti-GAD (r=0.392, p=0.020) and negative correlation with creatinine (r=-0390, p=0.021). In multivariate regression model, HbA1c (B±SE: 2.76±17683, p<0.001), and anti-GAD (B±SE: 2.311±0.610, p=0.001) were determined as independent predictors for predicting the irisin levels.

CONCLUSION

In patients with T1DM, which chronic inflammation and autoimmunity take part in their etiopathogenesis, anti-GAD levels were an independent risk factor for the irisin. Th is may suggest that factors such as inflammation and autoimmunity can be effective in the synthesis of irisin.

Influence of different irrigation and nitrogen levels on crude oil and fatty acid composition of maize (

The effect of irrigation and nitrogen fertilizer levels on the crude oil and fatty acid composition of maize cultivars was studied. Three levels of irrigation (50, 75 and 100% of field capacity) and nitrogen (100, 200 and 300 kg·ha-1) were used for treatment groups. After harvest, the crude oils were extracted and fatty acid profiles were determined by Gas Chromatography system. The study was repeated for two years and the interaction effects of fertilizer and irrigation were determined. Our results show that the crude oil content was affected positively by the fertilizer and the irrigation applications. As expected, the most abundant fatty acid was linoleic and the harvest year did not alter it. The highest linoleic acid content value was obtained with a 50% field capacity and 300 kg·ha-1 fertilizer treatment combination. In addition, fatty acid contents varied with the changing of interaction effects except for myristic and palmitic acid. Oleic acid was the second abundant fatty acid in the oil samples and the lowest oleic acid value was obtained with a 50% field capacity and 300 kg·ha-1 fertilizer treatment combination. Oleic acid content tended to increase with 75% field capacity but 100% field capacity treatment decreased in it.

Heme oxygenase-1 promoter polymorphisms: do they modulate neonatal hyperbilirubinemia?

The role of genetic factors in the modulation of serum bilirubin levels and the pathophysiology of neonatal hyperbilirubinemia is being increasingly recognized. Heme oxygenase-1 (HO-1) is the rate-limiting enzyme by which heme is catabolized to biliverdin and thence to bilirubin, with the simultaneous release of equimolar quantities of ferrous iron (Fe³⁺) and carbon monoxide. Polymorphisms of the HO-1 gene promoter may modulate transcriptional activity, thereby augmenting or attenuating HO-1 expression with resultant modulation of the production of bilirubin. Few studies have related these polymorphisms to neonatal bilirubin metabolism and have reported conflicting results. In this clinical review, we surveyed the role of HO-1 gene promoter polymorphisms in the control of bilirubin production and further considered their role, if any, in the pathophysiology of neonatal hyperbilirubinemia.

Newly diagnosed primary hypothyroidism applicant with massive pericardial effusion and acute renal failure

OBJECTIVE

While non-symptomatic pericardial effusion is seen in primary hypothyroidism, massive pericardial effusion is a very rare finding. In the literature, newly diagnosed primary hypothyroidism cases presenting with massive pericardial effusion or acute renal failure are present, but we did not encounter any case first presenting with combination of two signs. In this case report, primary hypothyroidism case that presenting with massive pericardial effusion and acute renal failure will be discussed. Subject and Results. Forty-eight years old male patient was hospitalized with shortness of breath, chest pain, swelling of the eyelids and bilateral limbs complaints. On chest radiograph heart shadow was deleted, pleural effusion was present until the middle zone of the left lung. Biochemical parameters (urea, creatinine, alanine aminotransferase aspartate aminotransferase, lactate dehydrogenase, sodium, potassium, creatine kinase, Troponin I, CK-MB, erythrocyte sedimentation rate, c-reactive protein) and thyroid stimulating hormone (TSH, 52.6 μg/ml), free triiodothyronine (T3, 0.61pg/ml), free thyroxine (T4, 0.12 ng/dl), anti thyroperoxydase (343 IU/ml), anti thyroglobulin (1604 IU/ml), were analyzed. The patient underwent pericardiocentesis. Levothyroxine treatment started with a dose of 0.05 mg per day and increased gradually until the optimum dose provided. At the end of the third month, the values of TSH, free T4, and free T3 were measured (2.3 μg/ml, 1.1 ng/dl, 2.54 pg/ml, respectively). The patient recovered completely and pericardial effusion was not detected in echocardiography.

CONCLUSION

Massive PE and acute renal failure due to primary hypothyroidism is a rare clinical condition. Primary hypothyroidism should be kept in mind in patients with symptoms like shortness of breath, chest pain, and generalized edema; moreover, when acute renal failure and PE were detected. It should be considered that patient's biochemical parameters can improve starting from the two weeks after levothyroxine treatment started with pericardiocentesis in severe symptomatic patients.

Physical Property Relationships and Chemical Factors Affecting Flex Fatigue Characteristics of Flexible Urethane Foam

A statistical study of the standard flex fa tigue test methods to determine variations due to method and position of foam sample is reported. The effect of preflexing was also investigated. Certain physical properties of flexible urethane foams have been shown to have a significant bearing on the flex fatigue characteristics. Correlation between hystere sis loss, indentation load deflection, density, "Sac" Factor, etc., and load loss after flexing are discussed. A simple method of predicting flex fatigue characteristics of urethane foam is described.

The relationship of chemical variables in the formulation and their effect on flex fa tigue is discussed in detail.

Amended Classification of the Open Abdomen

BACKGROUND

In 2009, a classification system for the open abdomen was introduced. The aim of such a classification is to aid the (1) description of the patient's clinical course; (2) standardization of clinical guidelines for guiding open abdomen management; and (3) facilitation of comparisons between studies and heterogeneous patient populations, thus serving as an aid in clinical research.

METHODS

As part of the revision of the definitions and clinical guidelines performed by the World Society of the Abdominal Compartment Syndrome, this 2009 classification system was amended following a review of experiences in teaching and research and published as part of updated consensus statements and clinical practice guidelines in 2013. Among 29 articles citing the 2009 classification system, nine were cohort studies. They were reviewed as part of the classification revision process. A total of 542 patients (mean: 60, range: 9-160) had been classified. Two problems with the previous classification system were identified: the definition of enteroatmospheric fistulae, and that an enteroatmospheric fistula was graded less severe than a frozen abdomen.

RESULTS

The following amended classification was proposed: Grade 1, without adherence between bowel and abdominal wall or fixity of the abdominal wall (lateralization), subdivided as follows: 1A, clean; 1B, contaminated; and 1C, with enteric leak. An enteric leak controlled by closure, exteriorization into a stoma, or a permanent enterocutaneous fistula is considered clean. Grade 2, developing fixation, subdivided as follows: 2A, clean; 2B, contaminated; and 2C, with enteric leak. Grade 3, frozen abdomen, subdivided as follows: 3A clean and 3B contaminated. Grade 4, an established enteroatmospheric fistula, is defined as a permanent enteric leak into the open abdomen, associated with granulation tissue.

CONCLUSIONS

The authors believe that, with these changes, the requirements on a functional and dynamic classification system, useful in both research and training, will be fulfilled. We encourage future investigators to apply the system and report on its merits and constraints.

[Memorandum 'Development of health services research in Bavaria from the perspective of the Bavarian State Working Group 'Health Services Research (LAGeV)': status quo - potential - strategies']

The aim of the memorandum on the development of health services research (HSR) in Bavaria is to operationalise the global objectives of the State Working Group "Health Services Research" (LAGeV) and to collectively define future topics, specific implementation steps, methods as well as ways of working for the future course of the LAGeV. The LAGeV is an expert committee that integrates and links the competencies of different actors from science, politics and health care regarding HSR and facilitates their cooperation. The memorandum is based on an explorative survey among the LAGeV members, which identified the status quo of health services research in Bavaria, potential for development, important constraints, promoting factors, specific recommendations as well as future topics for the further development of HSR in Bavaria. From the perspective of the LAGeV members, the 12 most important future topics are: 1) Interface and networking research, 2) Innovative health care concepts, 3) Health care for multimorbid patients, 4)Health care for chronically ill patients, 5) Evaluation of innovations, processes and technologies, 6) Patient orientation and user focus, 7) Social and regional inequalities in health care, 8) Health care for mentally ill patients, 9) Indicators of health care quality, 10) Regional needs planning, 11) Practical effectiveness of HSR and 12) Scientific use of routine data. Potential for development of HSR in Bavaria lies a) in the promotion of networking and sustainable structures, b) the establishment of an HSR information platform that bundles information and results in regard to current topics and aims to facilitate cooperation as well as c) in the initiation of measures and projects. The latter ought to pinpoint health care challenges and make recommendations regarding the improvement of health care and its quality. The cooperation and networking structures that were established with the LAGeV should be continuously expanded and be used to work on priority topics in order to achieve the global objectives of the LAGeV.

Sirolimus reduces the risk of significant hepatic fibrosis after liver transplantation for hepatitis C virus: a single-center experience

INTRODUCTION

Hepatitis C virus (HCV) recurrence following orthotopic liver transplantation is an expected outcome in all patients transplanted for a primary diagnosis of HCV. HCV recurrence has been shown to be associated with graft fibrosis and graft loss. Recent studies suggest that sirolimus (SRL) therapy may slow or inhibit hepatic fibrosis following liver transplant in patients positive for HCV at the time of transplant.

METHODS

Among 313 patients who underwent orthotopic liver transplantation for HCV between 2000 and 2009, 251 qualified for inclusion in the study. Per protocol liver biopsies were performed on all patients at 1 year following liver transplantation and/or at the time of a clinical diagnosis of HCV recurrence. Biopsies were scored for fibrosis using the Batts-Ludwig staging system (0-4); significant fibrosis was defined as fibrosis ≥ stage 2.

RESULTS

Overall, there was no difference in overall survival or graft loss in the SRL compared with the control group. Multivariate analysis revealed SRL therapy to be associated with decreased odds of significant hepatic fibrosis at year 1 postoperatively and over the study duration.

CONCLUSIONS

This retrospective, single-center study showed sirolimus-based immunosuppression to be associated with a lower risk of significant graft fibrosis, both at year 1 and throughout the study period, following liver transplantation in HCV-infected recipients.

Relationship between coronary in-stent restenosis and plasma urotensin II level

AIM

In-stent restonosis is an important limitation for coronary stenting. The cause of in-stent restenosis is neointimal hyperplasia developed from smooth muscle and matrix. We aimed to investigate the association between urotensin II (U-II) and in-stent restenosis after coronary stenting, which causes endothelial and muscle proliferation and accumulation of collagen.

METHODS

Total 153 patient was enrolled to the study who meet criteria for angiographic indication underwent coronary artery angiography. All patients have history undergone for coronary stent implantation 3 to 9 months ago. In-stent restenosis is identified as ≥50% narrowing inside the stent. In-stent restenosis was observed in 73 and remaining of 80 patients revealed no critical lesion in stent on angiographic evaluation. Plasma level measurement of U-II was performed in all subjects.

RESULTS

Urotensin II levels were found to be significantly higher in Group I compared to Group II (1.44±0.74 ng/mL and 1.21±0.59 ng/mL, respectively, P=0.03). In a subgroup analysis, U-II levels were significantly higher in group I than group II in patients treated with bare metal stent (BMS) (1.50±0.76 ng/mL and 1.18±0.56 ng/mL, P=0.016); however, there was not significant change in patients treated with drug-eluted stent (1.26±0.64 ng/mL and 1.27±0.63 ng/mL, P=0.9). Multivariate statistical significance: negative correlation was found between in-stent restenosis and renin-angiotensin-system (RAS) blocker usage (P=0.040) and right coronary artery (RCA) lesion interventions (P=0.018).

CONCLUSION

This study revealed high plasma U-II level might be accepted as a risk factors for in-stent restenosis with BMS. In-stent restenosis is less developed after RCA interventions and taking drug of RAS blockages. Our study findings need to be confirmed in further studies.

Vaginal birth after a caesarean section: the development of a Western European population-based prediction model for deliveries at term

OBJECTIVE

To develop and internally validate a model that predicts the outcome of an intended vaginal birth after caesarean (VBAC) for a Western European population that can be used to personalise counselling for deliveries at term.

DESIGN

Registration-based retrospective cohort study.

SETTING

Five university teaching hospitals, seven non-university teaching hospitals, and five non-university non-teaching hospitals in the Netherlands.

POPULATION

A cohort of 515 women with a history of one caesarean section and a viable singleton pregnancy, without a contraindication for intended VBAC, who delivered at term.

METHODS

Potential predictors for a vaginal delivery after caesarean section were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques.

MAIN OUTCOME MEASURES

Predictors for VBAC. For model validation, the area under the receiver operating characteristic curve (AUC) for discriminative capacity and calibration-per-risk-quantile for accuracy were calculated.

RESULTS

A total of 371 out of 515 women had a VBAC (72%). Variables included in the model were: estimated fetal weight greater than the 90(th) percentile in the third trimester; previous non-progressive labour; previous vaginal delivery; induction of labour; pre-pregnancy body mass index; and ethnicity. The AUC was 71% (95% confidence interval, 95% CI = 69-73%), indicating a good discriminative ability. The calibration plot shows that the predicted probabilities are well calibrated, especially from 65% up, which accounts for 77% of the total study population.

CONCLUSION

We developed an appropriate Western European population-based prediction model that is aimed to personalise counselling for term deliveries.