Integrated molecular and multiparametric MRI mapping of high-grade glioma identifies regional biologic signatures

Sampling restrictions have hindered the comprehensive study of invasive non-enhancing (NE) high-grade glioma (HGG) cell populations driving tumor progression. Here, we present an integrated multi-omic analysis of spatially matched molecular and multi-parametric magnetic resonance imaging (MRI) profiling across 313 multi-regional tumor biopsies, including 111 from the NE, across 68 HGG patients. Whole exome and RNA sequencing uncover unique genomic alterations to unresectable invasive NE tumor, including subclonal events, which inform genomic models predictive of geographic evolution. Infiltrative NE tumor is alternatively enriched with tumor cells exhibiting neuronal or glycolytic/plurimetabolic cellular states, two principal transcriptomic pathway-based glioma subtypes, which respectively demonstrate abundant private mutations or enrichment in immune cell signatures. These NE phenotypes are non-invasively identified through normalized K2 imaging signatures, which discern cell size heterogeneity on dynamic susceptibility contrast (DSC)-MRI. NE tumor populations predicted to display increased cellular proliferation by mean diffusivity (MD) MRI metrics are uniquely associated with EGFR amplification and CDKN2A homozygous deletion. The biophysical mapping of infiltrative HGG potentially enables the clinical recognition of tumor subpopulations with aggressive molecular signatures driving tumor progression, thereby informing precision medicine targeting.

A novel sulfur mustard (HD) vapor inhalation exposure model of pulmonary toxicity for the efficacy evaluation of candidate medical countermeasures

OBJECTIVE

To develop a novel inhalation exposure system capable of delivering a controlled inhaled HD dose through an endotracheal tube to anesthetized rats to investigate the lung pathophysiology and evaluate potential medical countermeasures.

MATERIALS AND METHODS

Target HD vapor exposures were generated by a temperature-controlled vapor generator, while concentration was monitored near real-time by gas chromatography. Animal breathing parameters were monitored real-time by in-line EMKA/SciReq pulmonary analysis system. Individual exposures were halted when the target inhaled doses were achieved. Animals were observed daily for clinical observations and lethality with scheduled termination at 28 days post-exposure. Upon scheduled or unscheduled death, animals underwent a gross necropsy and lung and trachea were collected for histopathology.

RESULTS

Controlled HD concentrations ranged from 60 to 320 mg/m³. Delivered inhaled doses range from 0.3 to 3.20 mg/kg with administered doses within 3% of the target. The 28-day inhaled LD₅₀ is 0.80 mg/kg (95% CI = 0.42-1.18 mg/kg). Post exposure respiratory abnormalities were observed across all dose levels though the higher dose levels had earlier onset and higher frequency of occurrence. Histopathologic alterations were not qualitatively altered in accordance with dose but instead showed a relationship to an animals' time of death, with early deaths demonstrating acute damage and later deaths displaying signs of repair.

DISCUSSION/CONCLUSION

This novel exposure system administers targeted HD inhaled doses to generate a small animal model that can be used to evaluate physiological toxicities of inhaled HD on the lungs and for evaluation of potential medical countermeasure treatments.

Atlantoaxial Osteoarthritis: A Well-Established Entity that Remains Frequently Overlooked

BACKGROUND

Painful atlantoaxial (C1-2) osteoarthritis (AAOA) has been described over 40 years ago. The condition may cause severe pain symptoms and disability related to the unilateral suboccipital pain and, in some cases, occipital neuralgia. One of the greatest challenges with AAOA is making the diagnosis. Diagnosis is commonly missed or delayed when headaches are treated in isolation or when pain is attributed to subaxial spondylosis Case Description: Here we present an illustrative case involving a 67-year-old male presenting with classic painful AAOA. After failing conservative treatments, he was evaluated with morphologic, radiological studies and a diagnostic injection. He was successfully treated with bilateral, navigation guided C1 lateral mass and C2 pedicle screw fixation and fusion.

CONCLUSION

When there is clinical suspicion for painful AAOA, providers have numerous diagnostic modalities, including newer hybrid techniques, that can be used to solidify the diagnosis. When conservative efforts fail, C1-2 fusion is an effective and enduring treatment for most patients. Here, we present an update on pathophysiology, diagnosis, and surgical management.

Is Autologous Stem Cell Transplantation a Safe and Effective Alternative to Whole Brain Radiation as Consolidation Therapy in Patients With Primary Central Nervous System Lymphoma?: A Critically Appraised Topic

BACKGROUND

High-dose chemotherapy followed by autologous stem cell transplantation (HD-ASCT) is a promising alternative to whole brain radiation therapy (WBRT) in the treatment of primary central nervous system lymphoma (PCNSL). The objective of this study was to critically assess current evidence supporting the use of HD-ASCT as first-line consolidative therapy in PCNSL.

METHODS

The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, literature search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom-line conclusions. Participants included consultant and resident neurologists, a medical librarian, clinical epidemiologists, and a content expert in the field of neuro-oncology.

RESULTS

A recent, open-label, noncomparative randomized phase II trial was selected for critical appraisal. This trial evaluated the efficacy and toxicity of consolidative therapy with HD-ASCT and WBRT in PCNSL in 2 separate treatment arms. A total of 140 patients with newly diagnosed PCNSL between the ages of 18 and 60 years were included. The primary endpoint of 2-year progression-free survival was met in 63% of patients in the WBRT arm and 87% in the HD-ASCT arm. Notably, an overall improvement in neurocognitive scores was observed following HD-ASCT, while WBRT was associated with worsened cognitive outcomes.

CONCLUSIONS

In young patients with newly diagnosed PCNSL, consolidative therapy with HD-ASCT appears to be associated with less neurocognitive toxicity and may be more effective than WBRT at preventing relapses, however, at the cost of a higher treatment-related mortality.

A circular economic approach to the phytoextraction of Zn from basic oxygen steelmaking filtercake using Lemna minor and CO2

Two billion tonnes of alkaline metallurgical waste is generated per year as a product of industry, mining, and metal processing. Filtercake is one such residue formed as a bi-product of steelmaking. Metal rich bi-products can be both an environmental concern and potential resource. High concentrations of heavy metals, if accessed, could be utilised and reprocessed reducing both pollution and the demand for raw metal ores. Phytoextraction is one such method of recovering metals from contaminated mediums. Research interest in Lemna sp. has grown due to their phytoremediation potential. Facilitated by rapid growth and accumulation of nutrients and metals, Lemna minor has been described as one of the most effective macrophytes for remediating contaminated water. The present study outlines a system using L. minor to extract Zn from filtercake when submerged in static water. To facilitate phytoremediation, CO₂ carbonation can be employed to solubilise elements and utilise this greenhouse gas, another a bi-product of steel industry. The addition of CO₂ to vessels of water containing filtercake lowered the pH from as high as 8.8 to 5.6 and significantly increased Zn in solution compared to vessels receiving no CO₂. Results suggest the potential of L. minor to accumulating 68.7 kg Zn per year from 20.5 Mt. filtercake ha^-1. This system facilitates a circular economy with re-use of multiple existing bi-products. In addition, the potential employment of biomass in biofuel production and use of remediated filtercake in carbon sequestration adds further environmental and socio-economic impact. The extent to which the approach was consistent with circular economy was discussed and its wider integration considered.

Kv1.3 modulates neuroinflammation and neurodegeneration in Parkinson's disease

Characterization of the key cellular targets contributing to sustained microglial activation in neurodegenerative diseases, including Parkinson's disease (PD), and optimal modulation of these targets can provide potential treatments to halt disease progression. Here, we demonstrated that microglial Kv1.3, a voltage-gated potassium channel, was transcriptionally upregulated in response to aggregated α-synuclein (αSynAgg) stimulation in primary microglial cultures and animal models of PD, as well as in postmortem human PD brains. Patch-clamp electrophysiological studies confirmed that the observed Kv1.3 upregulation translated to increased Kv1.3 channel activity. The kinase Fyn, a risk factor for PD, modulated transcriptional upregulation and posttranslational modification of microglial Kv1.3. Multiple state-of-the-art analyses, including Duolink proximity ligation assay imaging, revealed that Fyn directly bound to Kv1.3 and posttranslationally modified its channel activity. Furthermore, we demonstrated the functional relevance of Kv1.3 in augmenting the neuroinflammatory response by using Kv1.3-KO primary microglia and the Kv1.3-specific small-molecule inhibitor PAP-1, thus highlighting the importance of Kv1.3 in neuroinflammation. Administration of PAP-1 significantly inhibited neurodegeneration and neuroinflammation in multiple animal models of PD. Collectively, our results imply that Fyn-dependent regulation of Kv1.3 channels plays an obligatory role in accentuating the neuroinflammatory response in PD and identify Kv1.3 as a potential therapeutic target for PD.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Strategies to Promote ResiliencY (SPRY): a randomised embedded multifactorial adaptative platform (REMAP) clinical trial protocol to study interventions to improve recovery after surgery in high-risk patients

INTRODUCTION

As the population ages, there is interest in strategies to promote resiliency, especially for frail patients at risk of its complications. The physiological stress of surgery in high-risk individuals has been proposed both as an important cause of accelerated age-related decline in health and as a model testing the effectiveness of strategies to improve resiliency to age-related health decline. We describe a randomised, embedded, multifactorial, adaptative platform (REMAP) trial to investigate multiple perioperative interventions, the first of which is metformin and selected for its anti-inflammatory and anti-ageing properties beyond its traditional blood glucose control features.

METHODS AND ANALYSIS

Within a multihospital, single healthcare system, the Core Protocol for Strategies to Promote ResiliencY (SPRY) will be embedded within both the electronic health record (EHR) and the healthcare culture generating a continuously self-learning healthcare system. Embedding reduces the administrative burden of a traditional trial while accessing and rapidly analysing routine patient care EHR data. SPRY-Metformin is a placebo-controlled trial and is the first SPRY domain evaluating the effectiveness of three metformin dosages across three preoperative durations within a heterogeneous set of major surgical procedures. The primary outcome is 90-day hospital-free days. Bayesian posterior probabilities guide interim decision-making with predefined rules to determine stopping for futility or superior dosing selection. Using response adaptative randomisation, a maximum of 2500 patients allows 77%-92% power, detecting >15% primary outcome improvement. Secondary outcomes include mortality, readmission and postoperative complications. A subset of patients will be selected for substudies evaluating the microbiome, cognition, postoperative delirium and strength.

ETHICS AND DISSEMINATION

The Core Protocol of SPRY REMAP and associated SPRY-Metformin Domain-Specific Appendix have been ethically approved by the Institutional Review Board and are publicly registered. Results will be publicly available to healthcare providers, patients and trial participants following achieving predetermined platform conclusions.

TRIAL REGISTRATION NUMBER

NCT03861767.

Return to Golf, Tennis, and Swimming After Elective Cervical Spine Surgery

Background

After surgery for degenerative cervical spine problems, most patients hope to return to non-competitive sports and other leisure activities. Limited data are available to counsel patients about return to play (RTP) in non-competitive sports after cervical surgery.

Methods

Participants had cervical surgery for degenerative diagnoses from April 1, 2007, to April 1, 2018. Demographic data were collected, and participants were asked to complete a survey regarding sports participation before and after cervical surgery. 

Results

Of the 73 participants who responded to the study, the majority (81.1%) were able to return to one or multiple hobby sports after elective spine surgery. RTP rates at 12 months for golf, tennis, and swimming were 67.6%, 31.2%, and 81.6%, respectively. Younger age and lack of preoperative motor deficit were significant predictors of return to swimming after surgery. After surgery, 54.3% of golfers reported similar or improved levels of play. 

Conclusions

After elective cervical spine surgery, the majority of hobby athletes can expect to return to athletics. The majority of golfers returned to play with similar or improved frequency and quality of play compared to preoperative levels. Future prospective studies will further elucidate factors predicting RTP after different types of elective cervical surgeries.

Changes in the Operative Corridor in Oblique Lumbar Interbody Fusion Between Preoperative Magnetic Resonance Imaging and Intraoperative Cone-Beam Computed Tomography Using Morphometric Analysis

Background

The oblique lumbar interbody fusion or anterior-to-psoas (OLIF/ATP) technique relies on a corridor anterior to the psoas and posterior to the vasculature for lumbar interbody fusion. This is evaluated preoperatively with CT and/or MRI. To date, there have been no studies examining how intraoperative, lateral decubitus positioning may change the dimensions of this corridor when compared to preoperative imaging.

Objective

Our objective was to evaluate changes in the intraoperative corridor in the supine and lateral positions utilizing preoperative and intraoperative imaging.

Methods

We performed a retrospective analysis among patients who have undergone an OLIF/ATP approach at two tertiary care centers from 2016 to 2018 by measuring the distance between the left lateral border of the aorta or iliac vessels and anteromedial border of the psoas muscle from L1-L2 through L4-5 disc spaces. We compared this corridor between supine, preoperative MRI axial and intraoperative CT acquired in the right lateral decubitus position.

Results

Thirty-three patients, 15 of whom were female, were included in our study. The average age of the patients was 65.4 years and the average BMI was 31 kg/m². The results revealed a statistically significant increase (p<.05) in the intraoperative corridor from supine to lateral decubitus positioning at all levels. However, age, BMI, and gender had no statistically significant impact on the preoperative versus intraoperative corridor.

Conclusion

This is the first study to provide objective evidence that lateral decubitus positioning increases the intraoperative corridor for OLIF/ATP. Our study demonstrates that lateral decubitus positioning provides a more favorable corridor for the OLIF/ATP technique from L1-L5 disc levels.

Idiopathic pneumatosis intestinalis secondary to lactulose use in patients with cirrhosis

BACKGROUND AND AIM

Few case reports exist that link lactulose use with pneumatosis intestinalis in cirrhotics. This study investigates the relationship between lactulose use and idiopathic pneumatosis intestinalis in a cohort of cirrhotic patients.

METHODS

This case series considers several notable cases of patients with idiopathic pneumatosis intestinalis and concurrent lactulose use. Idiopathic pneumatosis intestinalis was defined as pneumatosis intestinalis with no identifiable etiology. A cohort of 119 patients with cirrhosis and pneumatosis intestinalis were identified in a tertiary care setting, via chart review by a multidisciplinary team. Eleven of these patients were found to have idiopathic pneumatosis intestinalis. Nine of these patients were being treated with lactulose.

RESULTS

Six out of 9 patients with idiopathic pneumatosis intestinalis that were being treated with lactulose saw resolution of pneumatosis intestinalis following discontinuation of treatment.

CONCLUSIONS

The etiology of idiopathic pneumatosis intestinalis is likely multifactorial, but lactulose might play a preventable role in its formation.

Spondylolysis in Young Athletes: An Overview Emphasizing Nonoperative Management

Lumbar spondylolysis is a unilateral or bilateral defect of the pars interarticularis, an isthmus of bone connecting the superior and inferior facet surfaces in the lumbar spine at a given level. Spondylolysis is common in young athletes participating in sports, particularly those requiring repetitive hyperextension movements. The majority of young athletes are able to return to full sport participation following accurate diagnosis and conservative management, including a structured treatment program. Surgical intervention for isolated pars injuries is seldom necessary. A progressive physical therapy (PT) program is an important component of recovery after sustaining an acute pars fracture. However, there is a paucity of literature detailing PT programs specific to spondylolysis. Here, we provide an overview of the epidemiology, natural history, radiographic evaluation, and management of pars fractures in young athletes. In addition, a detailed description of a physiotherapy program for this population that was developed at a spine center within an academic medical center is provided.

Urinary volatile organic compound markers and colorectal anastomotic leakage

AIM

Inflammatory markers such as serum C-reactive protein (CRP) are used as routine markers to detect anastomotic leakage following colorectal surgery. However, CRP is characterized by a relatively low predictive value, emphasizing the need for the development of novel diagnostic approaches. Volatile organic compounds (VOCs) are gaseous metabolic products deriving from all conceivable bodily excrements and reflect (alterations in) the patient's physical status. Therefore, VOCs are increasingly considered as potential non-invasive diagnostic biomarkers. The aim of this study was to assess the diagnostic accuracy of urinary VOCs for colorectal anastomotic leakage.

METHODS

In this explorative multicentre study, urinary VOC profiles of 22 patients with confirmed anastomotic leakage and 27 uneventful control patients following colorectal surgery were analysed by field asymmetric ion mobility spectrometry (FAIMS).

RESULTS

Urinary VOCs of patients with anastomotic leakage could be distinguished from those of control patients with high accuracy: area under the receiver operating characteristics curve 0.91 (95% CI 0.81-1.00, P < 0.001), sensitivity 86% and specificity 93%. Serum CRP was significantly increased in patients with a confirmed anastomotic leak but with lower diagnostic accuracy compared to VOC analysis (area under the receiver operating characteristics curve 0.82, 95% CI 0.68-0.95, P < 0.001). Combining VOCs and CRP did not result in a significant improvement of the diagnostic performance compared to VOCs alone.

CONCLUSION

Analysis by FAIMS allowed for discrimination between urinary VOC profiles of patients with a confirmed anastomotic leak and control patients following colorectal surgery. A superior accuracy compared to CRP and apparently high specificity was observed, underlining the potential as a non-invasive biomarker for the detection of colorectal anastomotic leakage.

A quantitative case study assessment of biophysical and economic effects from altering season of calving in temperate pasture-based dairy systems

In theory, a late winter-early spring calving date in temperate grazing systems best matches pasture supply and herd demand, thereby minimizing the need for nonpasture feeds and maximizing profitability. We used a quantitative case study approach to define the effects of season of calving on biophysical and financial performance in a grazing system without the confounding effects of imported feeds (i.e., milk production directly from grazed pasture). A 2-yr production system experiment was established to quantify the effects of changing onset of seasonal calving (i.e., planned start of calving; PSC) from winter (July in the Southern Hemisphere) to spring (October), summer, (January), or autumn (April) on pasture and animal production and profitability. Eighty Holstein-Friesian cows were randomly allocated to 1 of 4 PSC treatments, each of which had a different PSC [mean calving date of January 10 (JAN), April 10 (APR), July 10 (JUL), or October 10 (OCT)]. Data were analyzed for consistency of treatment response over years using ANOVA procedures with year, PSC treatment, and year × PSC treatment interactions as fixed effects. Collated biological data and financial data extracted from a national economic database were used as fixed variables to model the financial performance for the different treatments. A stochastic risk analysis was undertaken, where historical pasture growth and milk price data were used to estimate the probability distributions for stochastic input variables. Gross farm revenue and operating profit per hectare were modeled under 2 scenarios: (A) milk price did not include a premium for milk supplied during the winter, and (B) milk price included a realistic premium for milk supplied in winter. Annual and seasonal pasture growth did not differ between treatments, but the pasture growth (kg of dry matter/ha) and profile of the JUL treatment best matched the lactation nutrient demand profile. In comparison, profiles for JAN, APR, and OCT calving treatments had periods of greater surplus and deficit due to the time of calving and herd demand relative to the pasture growth profile. As a result, the JAN and OCT treatments conserved more pasture as silage and cows consumed a larger proportion of their annual diet as silage. Although the amount of silage conserved and consumed did not differ between the JUL and APR calving treatments, the timing of the silage consumption was different, with silage making up a greater proportion of the diets in the APR treatment 1 to 90 and 91 to 180 d postcalving and being offered to the JUL calving treatment only 271 to 365 d postcalving. As a result of differences in the quantity and proportion of pasture and pasture silage in the lactating diet, the JUL treatment herd tended to produce greater milk, 4% fat-corrected milk, fat, protein, and lactose yields (kg/cow) than the other PSC treatments, which did not differ from each other. Operating expenses per hectare did not differ materially between calving date scenarios, but operating expenses per kilogram of fat-corrected milk and kilogram of fat and protein were 15 to 20% less in the JUL treatment. With or without a realistic winter milk premium, gross farm revenue and operating profit per hectare were greater in the JUL treatment than in the APR treatment, which had greater revenue and profitability than the remaining 2 calving date treatments. In summary, our results indicate that a PSC in late winter is most profitable in a grazing system not importing feed, with or without a realistic price incentive scheme.

Short communication: Milk fat payment affects the relative profitability of Jersey and Holstein-Friesian cows at optimal comparative stocking rate

Choice of stocking rate and breed of cow are 2 strategic decisions that affect the profitability of pasture-based dairy farm businesses. This study sought to analyze the effects of a range of fat and protein prices on the profitability of the Jersey (J) and Holstein-Friesian (HF) breeds at 2 comparative stocking rates (CSR): 80 kg of body weight (BW) per tonne of dry matter (DM) of feed (CSR80), and 100 kg of BW per tonne of DM of feed (CSR100). Data were obtained from a recently published study, and equations constructed to determine the values for fat and protein at which each breed broke even (profit = NZ$0/ha; at time of writing, NZ$1 = US$0.69 or €0.60), returned equal profit, and exceeded the other breed by 1% or 5%. At CSR100 there were few combinations of fat and protein prices for which HF were more profitable than J. At CSR80, J and HF were equally profitable at a fat price of NZ$5.67 ± NZ$0.20 per kilogram, depending on protein price. The study also highlighted the importance of including volume adjustments in milk price calculations when differences in milk composition exist, as the fat price at which the profitability of HF and J were equal was NZ$1.23/kg lower when volume adjustments were included. The recent increase in the value of fat relative to protein favors J. Farmers should consider the medium- to long-term outlook of fat price when evaluating breed choice for their farm system.

Fyn kinase regulates misfolded α-synuclein uptake and NLRP3 inflammasome activation in microglia

Persistent microglia-mediated neuroinflammation is a major pathophysiological contributor to the progression of Parkinson's disease (PD), but the cell-signaling mechanisms governing chronic neuroinflammation are not well understood. Here, we show that Fyn kinase, in conjunction with the class B scavenger receptor CD36, regulates the microglial uptake of aggregated human α-synuclein (αSyn), which is the major component of PD-associated Lewy bodies. αSyn can effectively mediate LPS-independent priming and activation of the microglial NLRP3 inflammasome. Fyn kinase regulates both of these processes; it mediates PKCδ-dependent NF-κB-p65 nuclear translocation, leading to inflammasome priming, and facilitates αSyn import into microglia, contributing to the generation of mitochondrial reactive oxygen species and consequently to inflammasome activation. In vivo experiments using A53T and viral-αSyn overexpression mouse models as well as human PD neuropathological results further confirm the role of Fyn in NLRP3 inflammasome activation. Collectively, our study identifies a novel Fyn-mediated signaling mechanism that amplifies neuroinflammation in PD.

Non-Invasive Detection of Anastomotic Leakage Following Esophageal and Pancreatic Surgery by Urinary Analysis

BACKGROUND

Esophagectomy or pancreaticoduodenectomy is the standard surgical approach for patients with tumors of the esophagus or pancreatic head. Postoperative mortality is strongly correlated with the occurrence of anastomotic leakage (AL). Delay in diagnosis leads to delay in treatment, which ratifies the need for development of novel and accurate non-invasive diagnostic tests for detection of AL. Urinary volatile organic compounds (VOCs) reflect the metabolic status of an individual, which is associated with a systemic immunological response. The aim of this study was to determine the diagnostic accuracy of urinary VOCs to detect AL after esophagectomy or pancreaticoduodenectomy.

METHODS

In the present study, urinary VOCs of 63 patients after esophagectomy (n = 31) or pancreaticoduodenectomy (n = 32) were analyzed by means of field asymmetric ion mobility spectrometry. AL was defined according to international study groups.

RESULTS

AL was observed in 15 patients (24%). Urinary VOCs of patients with AL after pancreaticoduodenectomy could be distinguished from uncomplicated controls, area under the curve 0.85 (95% CI 0.76-0.93), sensitivity 76%, and specificity 77%. However, this was not observed following esophagectomy, area under the curve 0.51 (95% CI 0.37-0.65).

CONCLUSION

In our study population AL following pancreaticoduodenectomy could be discriminated from uncomplicated controls by means of urinary VOC analysis, NTC03203434.

Risk stratification of symptomatic patients suspected of colorectal cancer using faecal and urinary markers

AIM

Faecal markers, such as the faecal immunochemical test for haemoglobin (FIT) and faecal calprotectin (FCP), have been increasingly used to exclude colorectal cancer (CRC) and colonic inflammation. However, in those with lower gastrointestinal symptoms there are considerable numbers who have cancer but have a negative FIT test (i.e. false negative), which has impeded its use in clinical practice. We undertook a study of diagnostic accuracy CRC using FIT, FCP and urinary volatile organic compounds (VOCs) in patients with lower gastrointestinal symptoms.

METHOD

One thousand and sixteen symptomatic patients with suspected CRC referred by family physicians were recruited prospectively in accordance with national referring protocol. A total of 562 patients who completed colonic investigations, in addition to providing stool for FIT and FCP as well as urine samples for urinary VOC measurements, were included in the final outcome measures.

RESULTS

The sensitivity and specificity for CRC using FIT was 0.80 [95% confidence interval (CI) 0.66-0.93] and 0.93 (CI 0.91-0.95), respectively. For urinary VOCs, the sensitivity and specificity for CRC was 0.63 (CI 0.46-0.79) and 0.63 (CI 0.59-0.67), respectively. However, for those who were FIT-negative CRC (i.e. false negatives), the addition of urinary VOCs resulted in a sensitivity of 0.97 (CI 0.90-1.0) and specificity of 0.72 (CI 0.68-0.76).

CONCLUSIONS

When applied to the FIT-negative group, urinary VOCs improve CRC detection (sensitivity rises from 0.80 to 0.97), thus showing promise as a second-stage test to complement FIT in the detection of CRC.

Prokineticin-2 promotes chemotaxis and alternative A2 reactivity of astrocytes

Astrocyte reactivity is disease- and stimulus-dependent, adopting either a proinflammatory A1 phenotype or a protective, anti-inflammatory A2 phenotype. Recently, we demonstrated, using cell culture, animal models and human brain samples, that dopaminergic neurons produce and secrete higher levels of the chemokine-like signaling protein Prokineticin-2 (PK2) as a compensatory protective response against neurotoxic stress. As astrocytes express a high level of PK2 receptors, herein, we systematically characterize the role of PK2 in astrocyte structural and functional properties. PK2 treatment greatly induced astrocyte migration, which was accompanied by a shift in mitochondrial energy metabolism, a reduction in proinflammatory factors, and an increase in the antioxidant genes Arginase-1 and Nrf2. Overexpression of PK2 in primary astrocytes or in the in vivo mouse brain induced the A2 astrocytic phenotype with upregulation of key protective genes and A2 reactivity markers including Arginase-1 and Nrf2, PTX3, SPHK1, and TM4SF1. A small-molecule PK2 agonist, IS20, not only mimicked the protective effect of PK2 in primary cultures, but also increased glutamate uptake by upregulating GLAST. Notably, IS20 blocked not only MPTP-induced reductions in the A2 phenotypic markers SPHK1 and SCL10a6 but also elevation of the of A1 marker GBP2. Collectively, our results reveal that PK2 regulates a novel neuron-astrocyte signaling mechanism by promoting an alternative A2 protective phenotype in astrocytes, which could be exploited for development of novel therapeutic strategies for PD and other related chronic neurodegenerative diseases. PK2 signals through its receptors on astrocytes and promotes directed chemotaxis. PK2-induced astrocyte reactivity leads to an increase in antioxidant and anti-inflammatory proteins while increasing glutamate uptake, along with decreased inflammatory factors. © 2018 Wiley Periodicals, Inc.

Time to get Personal: A Framework for Personalized Targeting of Oxidative Stress in Neurotoxicity and Neurodegenerative Disease

The annual cost for neurological disorders in the United States was $789 billion in 2014, and with an aging population these numbers are expected to significantly increase in the next 50 years [1]. Neurodegenerative diseases make up a significant portion of these costs. Neurodegenerative diseases are characterized by the loss of neuronal populations in specific regions of the brain. Although the cause is still unknown for most of these diseases, both genetic and environmental factors are thought to play important roles. There are multiple convergent mechanisms underlying the unique susceptibility of neurons to degeneration, including aging, inflammation, mitochondrial dysfunction, and oxidative stress. Oxidative stress (OS) is of particular importance because evidence indicates that the neuronal populations lost in neurodegenerative diseases are particular susceptible to OS. OS is a complex neurotoxic mechanism that arises from excessive generation of free radicals such as reactive oxygen species (ROS), reduction in anti-oxidant factors, or a combination of the two. A complex interplay between the endogenous susceptibility of the brain, genetic factors, and environmental exposures leads to the harmful generation of OS in the brain and contributes significantly to the initiation and/or progression of neurodegeneration. Unfortunately, therapeutics for neurodegenerative diseases have consistently failed in clinical trials. Thus, a better understanding of the interplay between genetic susceptibility and common molecular mechanisms of environmental contributors to OS generation could aid in elucidation of novel therapeutic strategies for neurodegenerative diseases. This review will explore the current picture of oxidative stress in the brain as it relates to neurotoxicity, specifically exploring common mechanisms behind the endogenous susceptibility of the brain to OS, genetic susceptibility and environmental exposures leading to neurotoxicity, to identify precision/personalized medicine approaches for improving therapeutic outcome.

Epigenetic regulation of astrocyte function in neuroinflammation and neurodegeneration

Epigenetic mechanisms control various functions throughout the body, from cell fate determination in development to immune responses and inflammation. Neuroinflammation is one of the prime contributors to the initiation and progression of neurodegeneration in a variety of diseases, including Alzheimer's and Parkinson's diseases. Because astrocytes are the largest population of glial cells, they represent an important regulator of CNS function, both in health and disease. Only recently have studies begun to identify the epigenetic mechanisms regulating astrocyte responses in neurodegenerative diseases. These epigenetic mechanisms, along with the epigenetic marks involved in astrocyte development, could elucidate novel pathways to potentially modulate astrocyte-mediated neuroinflammation and neurotoxicity. This review examines the known epigenetic mechanisms involved in regulation of astrocyte function, from development to neurodegeneration, and links these mechanisms to potential astrocyte-specific roles in neurodegenerative disease with a focus on potential opportunities for therapeutic intervention.

Alternative microglial activation is associated with cessation of progressive dopamine neuron loss in mice systemically administered lipopolysaccharide

Inflammation arising from central and/or peripheral sources contributes to the pathogenesis of multiple neurodegenerative diseases including Parkinson's disease (PD). Emerging data suggest that differential activation of glia could lead to the pathogenesis and progression of PD. Here, we sought to determine the relationship between lipopolysaccharide (LPS) treatment, loss of dopaminergic neurons and differential activation of glia. Using a model of repeated injections with LPS (1mg/kg, i.p. for 4days), we found that LPS induced a 34% loss of dopamine neurons in the substantia nigra 19days after initiation of treatment, but no further cell loss was observed at 36days. LPS induced a strong pro-inflammatory response with increased mRNA expression of pro-inflammatory markers, including tumor necrosis factor-α (4.8-fold), inducible nitric oxide synthase (2.0-fold), interleukin-1 beta (8.9-fold), interleukin-6 (10.7-fold), and robust glial activation were observed at 1day after final dose of LPS. These pro-inflammatory genes were then reduced at 19days after treatment, when there was a rise in the anti-inflammatory genes Ym1 (1.8-fold) and arginase-1 (2.6-fold). Additionally, 36days after the last LPS injection there was a significant increase in interleukin-10 (2.1-fold) expression. The qPCR data results were supported by protein data, including cytokine measurements, western blotting, and immunofluorescence in brain microglia. Taken together, these data demonstrate that progressive neurodegeneration in the substantia nigra following LPS is likely arrested by microglia shifting to an anti-inflammatory phenotype. Thus, strategies to promote resolution of neuroinflammation may be a promising avenue to slow the progressive loss of dopamine neurons in PD.

The family partners for health study: a cluster randomized controlled trial for child and parent weight management

OBJECTIVE

The purpose of this study was to test a two-phased nutrition and exercise education, coping skills training, and exercise intervention program for overweight or obese low-income ethnic minority 2nd to 4th grade children and their parents in rural North Carolina, USA.

METHODS

A cluster randomized controlled trial was carried out with 358 children (7-10 years) and a parent for each child (n=358). General linear mixed models were used to determine the effects of the intervention on weight, adiposity, health behaviors, and eating and exercise self-efficacy by examining changes in children and parents from baseline to completion of the study (18 months).

RESULTS

At 18 months, children in the experimental group did not have a significantly decreased body mass index (BMI) percentile (P=0.470); however, they showed a reduction in the growth rate of their triceps (P=0.001) and subscapular skinfolds (P<0.001) and an improvement in dietary knowledge (P=0.018) and drank less than one glass of soda per day (P=0.052) compared with the control group. Parents in the experimental group had decreased BMI (P=0.001), triceps (P<0.001) and subscapular skinfolds (P<0.001) and increased nutrition (P=0.003) and exercise (P<0.001) knowledge and more often drank water or unsweetened drinks (P=0.029). At 18 months, children in the experimental group did not show significant improvement in eating (P=0.956) or exercise self-efficacy (P=0.976). Experimental parents demonstrated improved socially acceptable eating self-efficacy (P=0.013); however, they did not show significant improvement in self-efficacy pertaining to emotional eating (P=0.155) and exercise (P=0.680).

CONCLUSION

The results suggest that inclusion of children and parents in the same intervention program is an effective way to decrease adiposity and improve nutrition behaviors in both children and parents and improve weight and eating self-efficacy in parents.

"Not just right experiences" in patients with Tourette syndrome: complex motor tics or compulsions?

Tourette syndrome (TS) is a chronic tic disorder often accompanied by specific obsessive-compulsive symptoms (OCS) or full-blown obsessive-compulsive disorder (OCD). Repetitive behaviours are commonly reported by patients with TS, who experience the urge to perform an action until it has been done "just right". This study investigated the clinical correlates of "not just right experiences" (NJREs) in this clinical population. A standardised battery of self-report psychometric measures was administered to 71 adult patients with TS recruited from a specialist TS clinic. NJREs were systematically screened for using the Not Just Right Experiences-Questionnaire Revised (NJRE-QR). The vast majority of patients in our clinical sample (n=57, 80%) reported at least one NJRE. Patients diagnosed with TS and co-morbid OCD/OCS (n=42, 59%) reported a significantly higher number of NJREs compared to TS patients without OCD/OCS. The strongest correlation was found between NJRE-QR scores and self-report measures of compulsivity. NJREs appear to be intrinsic to the clinical phenomenology of patients with TS and can present with higher frequency in the context of co-morbid OCD/OCS, suggesting they are more related to compulsions than tics.

Role of riverine colloids in macronutrient and metal partitioning and transport, along an upland-lowland land-use continuum, under low-flow conditions

An assessment is made of the role of riverine colloids in macronutrient (nitrogen, phosphorus and carbon), metal and trace element partitioning and transport, for five rivers in the Ribble and Wyre catchments in north-western England, under baseflow/near-baseflow conditions. Cross-flow ultrafiltration was used to separate colloidal (<0.45 µm >1 kDa) and truly dissolved (<1 kDa) fractions from river water. Clear patterns were observed, along the upland-lowland land use continuum, in the partitioning and transport of macronutrients and metals between the colloidal, truly dissolved and acid-available particulate (>0.45 μm, suspended) fractions. Of these operationally-defined fractions measured, colloids were generally more important for both macronutrient and metal transport in the upland than in the lowland rivers. The results suggest that organic moieties in truly dissolved form from sewage effluent may have a greater capacity to chelate metals. Organic-rich colloids in the upland moorlands and metal oxide colloidal precipitates in the industrial rivers had a higher capacity for binding metals than the colloidal fractions in the urban and agricultural lowland rivers. Aggregation of these colloids may provide an important mechanism for formation of larger suspended particulates, accounting for a higher degree of metal enrichment in the acid-available particulate fractions of the upland moorland and lowland industrial rivers, than in the lowland agricultural and urban rivers. This mechanism of transfer of contaminants to larger aggregates via colloidal intermediates, known as 'colloidal pumping' may also provide a mechanism for particulate P formation and the high proportion of P being transported in the particulate fraction in the uplands. The cross-flow ultrafiltration data also allowed refinement of partition coefficients, by accounting for colloids within the solids phase and replacing the filtered (<0.45 μm) fraction with the truly dissolved (<1 kDa) concentrations. These provided a clearer description of the controls on metal and P partitioning along the upland-lowland continuum.

Manganese in the upper Severn mid-Wales

The concentrations of manganese (Mn) in the Upper River Severn (the Plynlimon catchments) are examined in relation to rainfall, cloud water, throughfall, stemflow and stream water concentrations where there is over 20 years of monitoring data available. Manganese concentrations are particularly low in rainfall and cloud water, with maximum concentrations occurring under low volumes of catch due to atmospheric "washout" of contaminants and dry deposition. There is strong Mn enrichment in throughfall and stemflow and this is probably linked to cycling through the vegetation. Manganese in the streams and groundwaters are primarily supplied from within-catchment sources. The highest concentrations occur within the tree canopy probably due to element cycling and in groundwaters due to mobilisation from the rock. Manganese concentrations in streams are at their lowest during spring and summer following long dry spells, with rapid increases following subsequent rain. There is no clear long-term trend in Mn concentration in the streams although there are increases in Mn concentrations for years when there is extensive felling of spruce plantation forest and in 1995 following a more extensive dry period. New high resolution monitoring picks up the effects of the rising limb of the hydrograph when concentrations rapidly increase, diurnal patterns during summer low-flow periods and contrasting dynamics between moorland and forested catchments.

The biogeochemistry of arsenic in a remote UK upland site: trends in rainfall and runoff, and comparisons with urban rivers

Ten years of monitoring of rainfall and streams in the remote acidic and acid sensitive moorland and afforested moorland of upland mid-Wales reveals concentrations of arsenic (As) typically <1 µg L(-1). On average, the lowest concentrations occur within rainfall and they have declined over time probably in response to reductions in global emissions. There is a corresponding reduction within the streams except for forested systems where concentrations up to doubled following clear-fell. Within the streams there are both annual cycling and diurnal cycling of As. The annual cycling gives maxima during the summer months and this probably reflects the importance of groundwater inputs and mineralisation/desorption from the surface soil layers. Correspondingly, the diurnal cycling occurs during the summer months at low flow periods with As concentrations highest in the afternoon/evening. For the urban/industrial basins of northern England with historically a much higher As deposition, land contamination and effluent discharges, comparative data indicate As concentrations around three fold higher: strong seasonal patterns are observed for the same reasons as with the uplands. Across the sites, the As concentrations are over an order of magnitude lower than that of environmental concern. Nonetheless, the results clearly show the effects of declining emissions on rainfall deposition and some indication of areas of historic contamination. Arsenic is mainly present in the <0.45 fraction, but cross-flow filtration indicates that approx. 43% is in the colloidal phase at the clean water sites, and 16% in the colloidal phase at the contaminated sites. Part of this colloidal component may well be associated with organic carbon.

New insights into the pathogenesis and treatment of necrotizing enterocolitis: Toll-like receptors and beyond

Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in the preterm infant. The dismal results of current treatment for NEC highlight the urgent need for greater understanding of the pathogenesis of this disease, and the importance of discovering novel, molecular-specific therapies for it. Current dogma indicates that NEC development reflects an abnormal response by the premature infant to the microbial flora that colonizes the gastrointestinal tract, although the mechanisms that mediate these abnormal bacterial-enterocyte interactions and the reasons for the particularly increased susceptibility of the premature infant to the development of NEC remain incompletely explained. Recent evidence has shed light on an emerging role for the Toll-like receptors (TLRs) of the innate immune system as central players in the pathways that signal in response to enteric bacteria resulting in the development of NEC. We now review recent advances in the field of NEC and identify several exciting potential avenues for novel treatments by focusing on abnormal TLR4 signaling in the premature intestine in the pathogenesis of NEC. In so doing, we seek to offer new hope to the patients and their families who are affected by this devastating disorder.

Characterization of phosphorus sources in rural watersheds

Correct identification of P sources in rural watersheds is critical for the development of cost-effective measures to combat agriculturally-driven eutrophication. The chemical composition of various storm runoff types (field surface runoff, field drain outfalls, roads, farmyards, and septic tanks) and the receiving streams in three micro (<10 km(2)) watersheds of varying agricultural intensity were monitored over a 2-yr period. Mean weekly stream soluble reactive phosphorus (SRP) and total phosphorus (TP) concentrations increased from 29 and 69 microg L(-1), respectively in the watershed with the lowest intensity agriculture to 382 and 503 microg L(-1), respectively in the watershed with high intensity agriculture and a village sewage treatment works. Concentrations of TP in storm runoff varied by up to two orders of magnitude reflecting the complex origins, routing, and composition of contributing source areas. Application of the DESPRAL test suggested field runoff TP concentrations were influenced by both P and organic matter in soil. However, runoff from impervious surfaces (farmyard and roads), and/or influenced by septic tank discharges, was significantly more concentrated (0.08-16 mg TP L(-1), mean >>1 mg L(-1)) than surface and subsurface runoff from cultivated land and pasture (0.02-3.6 mg TP L(-1), mean <1 mg L(-1)), and/or contained a significantly greater proportion (>50% vs. <50%) of P in dissolved forms. It is concluded that P sources associated with the functioning of rural communities (impervious surfaces, detergents, and wastewater) may be more ecologically relevant than those associated with agriculture and should be better quantified and controlled to avoid localized eutrophication impacts.