Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

A randomised controlled trial of compression therapies for the treatment of venous leg ulcers (VenUS 6): study protocol for a pragmatic, multicentre, parallel-group, three-arm randomised controlled trial

BACKGROUND

Venous leg ulcer(s) are common, recurring, open wounds on the lower leg, resulting from diseased or damaged leg veins impairing blood flow. Wound healing is the primary treatment aim for venous leg ulceration, alongside the management of pain, wound exudate and infection. Full (high) compression therapy delivering 40 mmHg of pressure at the ankle is the recommended first-line treatment for venous leg ulcers. There are several different forms of compression therapy available including wraps, two-layer hosiery, and two-layer or four-layer bandages. There is good evidence for the clinical and cost-effectiveness of four-layer bandage and two-layer hosiery but more limited evidence for other treatments (two-layer bandage and compression wraps). Robust evidence is required to compare clinical and cost-effectiveness of these and to investigate which is the best compression treatment for reducing time to healing of venous leg ulcers whilst offering value for money. VenUS 6 will therefore investigate the clinical and cost-effectiveness of evidence-based compression, two-layer bandage and compression wraps for time to healing of venous leg ulcers.

METHODS

VenUS 6 is a pragmatic, multi-centre, three-arm, parallel-group, randomised controlled trial. Adult patients with a venous leg ulcer will be randomised to receive (1) compression wraps, (2) two-layer bandage or (3) evidence-based compression (two-layer hosiery or four-layer bandage). Participants will be followed up for between 4 and 12 months. The primary outcome will be time to healing (full epithelial cover in the absence of a scab) in days since randomisation. Secondary outcomes will include key clinical events (e.g. healing of the reference leg, ulcer recurrence, ulcer/skin deterioration, amputation, admission/discharge, surgery to close/remove incompetent superficial veins, infection or death), treatment changes, adherence and ease of use, ulcer related pain, health-related quality of life and resource use.

DISCUSSION

VenUS 6 will provide robust evidence on the clinical and cost-effectiveness of the different forms of compression therapies for venous leg ulceration. VenUS 6 opened to recruitment in January 2021 and is currently recruiting across 30 participating centres.

TRIAL REGISTRATION

ISRCTN67321719 . Prospectively registered on 14 September 2020.

Long-term exposure to traffic-related air pollution and stroke: A systematic review and meta-analysis

BACKGROUND

Stroke remains the second cause of death worldwide. The mechanisms underlying the adverse association of exposure to traffic-related air pollution (TRAP) with overall cardiovascular disease may also apply to stroke. Our objective was to systematically evaluate the epidemiological evidence regarding the associations of long-term exposure to TRAP with stroke.

METHODS

PubMed and LUDOK electronic databases were searched systematically for observational epidemiological studies from 1980 through 2019 on long-term exposure to TRAP and stroke with an update in January 2022. TRAP was defined according to a comprehensive protocol based on pollutant and exposure assessment methods or proximity metrics. Study selection, data extraction, risk of bias (RoB) and confidence assessments were conducted according to standardized protocols. We performed meta-analyses using random effects models; sensitivity analyses were assessed by geographic area, RoB, fatality, traffic specificity and new studies.

RESULTS

Nineteen studies were included. The meta-analytic relative risks (and 95% confidence intervals) were: 1.03 (0.98-1.09) per 1 μg/m³ EC, 1.09 (0.96-1.23) per 10 μg/m³ PM₁₀, 1.08 (0.89-1.32) per 5 μg/m³ PM_2.5, 0.98 (0.92; 1.05) per 10 μg/m³ NO₂ and 0.99 (0.94; 1.04) per 20 μg/m³ NO_x with little to moderate heterogeneity based on 6, 5, 4, 7 and 8 studies, respectively. The confidence assessments regarding the quality of the body of evidence and separately regarding the presence of an association of TRAP with stroke considering all available evidence were rated low and moderate, respectively.

CONCLUSION

The available literature provides low to moderate evidence for an association of TRAP with stroke.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Understanding the risk of emerging bacterial resistance to over the counter antibiotics in topical sore throat medicines

AIMS

The aims of this study were to explore the development of bacterial resistance and cross-resistance in four common human pathogens following realistic exposure to antibiotics found in over-the-counter (OTC) sore throat medicines: gramicidin, neomycin, bacitracin and tyrothricin.

METHODS AND RESULTS

Bacterial exposure to in-use (concentration in the product before use) and diluted concentration (i.e. during use) of antibiotic where conducted in broth for 24 h or until growth was visible. The changes in bacterial susceptibility profile before and after exposure was determined using standardized ISO microdilution broth. Antibiotic testing was performed according to EUCAST guidelines. We demonstrated that test bacteria were able to survive exposure to the in-use concentrations of some antibiotics used in OTC medicines. Exposure to during use concentrations of bacitracin resulted in stable increase in minimal inhibitory concentration (MIC) (>8-fold) in Staphylococcus aureus and Acinetobacter baumannii. Exposure to tyrothricin resulted in a stable increase in MIC (2·4-fold) in Klebsiella pneumoniae, and exposure to neomycin resulted in a stable increase MIC (5000-fold higher than the baseline) in Streptococcus pyogenes. Clinical cross-resistance to other antibiotics (ciprofloxacin, fusidic acid, gentamicin, cefpodoxime, amoxicillin/clavulanic acid and cefotaxime) was also demonstrated following exposure to bacitracin or tyrothricin. Bacitracin exposure lead to a stable bacterial resistance after 10 passages.

CONCLUSIONS

Our results indicate that OTC antibiotic medicines have the potential to drive resistance and cross-resistance in vitro.

SIGNIFICANCE AND IMPACT OF THE STUDY

Tackling antibiotic resistance is a high worldwide priority. It is widely accepted that the overuse and misuse of antibiotics increase the risk of the development and spread of antibiotic resistance within communities. A number of OTC sore throat products, widely available across the world for topical use in respiratory indications, contain locally delivered antibiotics. Our findings showed that these antibiotics in OTC medicines present a risk for emerging cross-resistance in a number of bacterial respiratory pathogens.

Breaking Bad: An Assessment of Ophthalmologists' Interpersonal Skills and Training on Delivering Bad News

Purpose This article aims to assess ophthalmologists' practice patterns, experiences, and self-perceived skills when delivering bad news to patients and to compare this to patients' experience and preferences in receiving bad news from ophthalmologists.

Design/Methods This is a prospective cross-sectional survey study of two populations: (1) Attending ophthalmologists and current ophthalmologists-in-training (N = 202) at accredited ophthalmology residency programs in the United States and Canada. (2) Patients (N = 151) 18 years of age and older at a single academic center who had received bad news from their ophthalmologist. An e-mail was sent to ophthalmology department chairs and resident program directors requesting that they distribute an online survey to their faculty, fellows, and residents. Patients were recruited from the clinics at an academic center and completed a self-administered survey before their scheduled appointments. Both populations were surveyed on their experience in breaking and receiving bad news, respectively. Questions were rated on a standard five-point Likert scale, and mean score was calculated for statistical comparison. The primary outcome variable was the quantitative rating (Likert scale 1–5) of physicians' communication skills when delivering bad news from physicians and patients' responses.

Results Patients rated their physicians higher than physicians rated themselves with regard to ability to deliver bad news (mean score of 4.23 vs. 3.48, p < 0.01). Multivariate analysis showed frequent delivery of bad news (mean score of 3.66 for once per day, 3.53 for per week, 3.40 for once per month, and 3.22 for once per year, linear trend; p = 0.004) and years of practice were associated with better self-perceived ability to deliver bad news (mean score of 3.75 for ≥15 years, 3.48 for <15 years, and 3.30 for residents/fellows, linear trend; p < 0.001). Having received formal training in breaking bad news was associated with better perceived ability score, yet not statistically significant (3.51 vs. 3.39, p = 0.31). Most patients (97.5%) and physicians (92.1%) believe delivering bad news can be taught.

Conclusion Physicians and patients agree that skills of delivering bad news can be learned. Patients are less critical of their physicians' ability to deliver bad news than physicians are themselves. Further study of best methods to deliver bad news is clearly indicated for the field of ophthalmology.

Abstract P1-06-05: Expansion of tumor initiating cells is mediated by tumor microenvironment in breast cancer metastasis

Background: Breast cancer metastasis which ultimately results in breast cancer death, is an event believed to be initiated by the migration of tumor initiating cells (TIC) from the primary tumor to niches for micrometastatic disease. Recent data suggests the tumor microenvironment promotes TIC. The clinical relevance of secreted factors from the microenvironment on TIC surrogate, mammosphere (MS) formation and MS sensitivity to drug therapy was investigated using breast cancer patient fluids inherently conditioned by the tumor microenvironment: post-operative seromas and malignant pleural effusions.

Methods: Fluids from 48 patients with breast cancer (15 seromas and 33 pleural effusions) and mesenchymal stem cells (MSC) from healthy donors were collected on IRB approved protocols. Cellular components were eliminated from patient-derived fluids using density-gradient centrifugation. MSC conditioned media (MSC-CM) was collected from 3D cultures of primary MSC. Luminex multiplex array platform was used to characterize 79 cytokine and growth factor components of all fluids. In addition, MSC-CM and patient-derived fluids were added to cultures of breast cancer cell lines: MCF-7, an estrogen receptor (ER)-positive cell line; SUM149, a triple-negative inflammatory breast cancer cell line; and SUM159, a triple-negative metaplastic breast cancer cell line and MS forming efficiency was examined.

Results: Our results show that pleural effusions and seromas are enriched for factors also secreted by MSC such as MCP-1, GRO, IL-6, and VEGF-A. We found remarkable similarities regarding the cytokines and growth factors profile in pleural effusions and seromas. Both patient-derived fluids have comparable amount of Angiopoetin-2, Leptin, TNF-beta, VEGF, IL-2, IL-3, IL-4 and IL-10. EGF, TNF-alpha, IL-1, IL-6, IL-8 and IL-16 were significantly different between pleural effusions and seromas. Seroma fluid from bilateral drains in a patient with an invasive cancer and a contralateral benign mastectomy had very similar cytokine concentrations. Moreover, MSC-CM and pleural fluids from ER-positive and ER-negative patients increased the MS formation efficiency of both triple-negative cell lines while seroma fluids from ER-positive and ER-negative patients increased the MS formation efficiency of ER-positive cell line MCF-7. Finally, we evaluated the impact of a panel of drugs (simvastatin, pravastatin and erlotinib) on cell cultures grown with MSC-CM and patient-derived fluids. We found that the effect of chemotherapies on MS formation can be attenuated by patient-derived fluids.

Conclusions: Seroma and pleural effusion fluids from breast cancer patients have similar cytokine profiles, change MS formation efficiency of standard breast cancer cell models, and mediate sensitivity to therapy. Here we demonstrate that host and microenvironmental factors are critical for determining resistance to therapy and may be independent of obvious tumor related factors. Future studies will investigate the prognostic implications of factors that promote TIC survival in the fluid tumor microenvironment.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-06-05.

Certification of vitamins and carotenoids in SRM 3280 multivitamin/multielement tablets

A new multivitamin/multielement dietary supplement Standard Reference Material (SRM) has been issued by the National Institute of Standards and Technology (NIST), with certified and reference concentration values for 13 vitamins, 24 elements, and 2 carotenoids. The constituents have been measured by multiple analytical methods with data contributed by NIST and by collaborating laboratories. This effort included the first use of isotope dilution mass spectrometry for value assignment of both fat-soluble vitamins (FSVs) and water-soluble vitamins (WSVs). Excellent agreement was obtained among the methods, with relative expanded uncertainties for the certified concentration values typically ranging from <2% to 15% for vitamins.

Tissue engineered tumor models

Many research programs use well-characterized tumor cell lines as tumor models for in vitro studies. Because tumor cells grown as three-dimensional (3-D) structures have been shown to behave more like tumors in vivo than do cells growing in monolayer culture, a growing number of investigators now use tumor cell spheroids as models. Single cell type spheroids, however, do not model the stromal-epithelial interactions that have an important role in controlling tumor growth and development in vivo. We describe here a method for generating, reproducibly, more realistic 3-D tumor models that contain both stromal and malignant epithelial cells with an architecture that closely resembles that of tumor microlesions in vivo. Because they are so tissue-like we refer to them as tumor histoids. They can be generated reproducibly in substantial quantities. The bioreactor developed to generate histoid constructs is described and illustrated. It accommodates disposable culture chambers that have filled volumes of either 10 or 64 ml, each culture yielding on the order of 100 or 600 histoid particles, respectively. Each particle is a few tenths of a millimeter in diameter. Examples of histological sections of tumor histoids representing cancers of breast, prostate, colon, pancreas and urinary bladder are presented. Potential applications of tumor histoids include, but are not limited to, use as surrogate tumors for pre-screening anti-solid tumor pharmaceutical agents, as reference specimens for immunostaining in the surgical pathology laboratory and use in studies of invasive properties of cells or other aspects of tumor development and progression. Histoids containing nonmalignant cells also may have potential as "seeds" in tissue engineering. For drug testing, histoids probably will have to meet certain criteria of size and tumor cell content. Using a COPAS Plus flow cytometer, histoids containing fluorescent tumor cells were analyzed successfully and sorted using such criteria.

Hyperthermia Sensitizes Breast Cancer Stem Cells to Radiation Therapy

Background In cancer, metastatic disease and recurrence are hypothesized to result, at least in part, from the residual cancer stem cells (CSCs), also referred to as tumor-initiating cells(TICs), which evade initial treatment. In several genetically engineered mouse models that resemble human breast cancer, the tumor subpopulation CD29+/CD24+/lin- has been shown to be more tumorigenic as compared to other subpopulations by in vitro and in vivo assays. We and others have demonstrated that the tumorigenic CD29+/CD24+/lin- subpopulation repairs radiation-induced DNA strand breaks more efficiently than the other subpopulations. Therefore, we hypothesized that hyperthermia, a documented means of inhibiting DNA repair, may radiosensitize CSCs to radiation therapy(RT) by delaying and inhibiting the repair of DNA strand breaks. Methods To test this hypothesis, we assayed for tumorigenic CD29+/CD24+/lin- cells in p53null mouse mammary tumor model with and without radiation, and in combination with hyperthermia (42°C) administered as optically-activated gold nanoparticles. We then determined if there was a decrease in functional CSCs by FACS analysis and limiting dilution transplantation assays. Results These studies confirmed that CD29+/CD24+/lin- cells were more radiation resistant and that their relative proportion was increased after RT, as compared to the other cell populations. However, the addition of hyperthermia increased the sensitivity of the CD29+/CD24+/lin- subpopulation to radiation. Radiation treatment alone in vivo resulted in a decrease in tumor size, but the percentage of tumorigenic cells increased as compared to untreated controls. In contrast, following post-treatment with 20 minutes of local hyperthermia, using intravenously administered optically activated gold nanoparticles, a larger regression in tumor size was observed, without a concomitant increase in the percentage of CD29+/CD24+/lin- tumorigenic cells. Using the functional limiting dilution transplantation assay to assay for CSCs, we showed that 48 hours after treatment cells derived from tumors treated with RT exhibited an increased frequency of TICs as compared to untreated controls, and tumors treated with radiation and hyperthermia. In addition, clonogenic survival assays of this tumorigenic subpopulation had consistent results with the in vivo data. Conclusion These results suggest that localized hyperthermia serves as a simple strategy to selectively sensitize the radioresistant subpopulation of CSCs to enhance their response to radiation therapy. The mechanisms responsible for these effects of hyperthermia are currently under investigation. Supported by grant NCI R01 CA112305 and CA16303.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 506.

Plasmonic nanorod metamaterials for biosensing

Label-free plasmonic biosensors rely either on surface plasmon polaritons or on localized surface plasmons on continuous or nanostructured noble-metal surfaces to detect molecular-binding events. Despite undisputed advantages, including spectral tunability, strong enhancement of the local electric field and much better adaptability to modern nanobiotechnology architectures, localized plasmons demonstrate orders of magnitude lower sensitivity compared with their guided counterparts. Here, we demonstrate an improvement in biosensing technology using a plasmonic metamaterial that is capable of supporting a guided mode in a porous nanorod layer. Benefiting from a substantial overlap between the probing field and the active biological substance incorporated between the nanorods and a strong plasmon-mediated energy confinement inside the layer, this metamaterial provides an enhanced sensitivity to refractive-index variations of the medium between the rods (more than 30,000 nm per refractive-index unit). We demonstrate the feasibility of our approach using a standard streptavidin-biotin affinity model and record considerable improvement in the detection limit of small analytes compared with conventional label-free plasmonic devices.

The temporal pattern of mortality responses to ambient ozone in the APHEA project

BACKGROUND

The temporal pattern of effects of summertime ozone (O(3)) in total, cardiovascular and respiratory mortality were investigated in 21 European cities participating in the APHEA-2 (Air Pollution and Health: a European Approach) project, which is fundamental in determining the importance of the effect in terms of life loss.

METHODS

Data from each city were analysed separately using distributed lag models with up to 21 lags. City-specific air pollution estimates were regressed on city-specific covariates to obtain overall estimates and to explore sources of possible heterogeneity.

RESULTS

Stronger effects on respiratory mortality that extend to a period of 2 weeks were found. A 10 microg/m(3) increase in O(3) was associated with a 0.36% (95% CI -0.21% to 0.94%) increase in respiratory deaths for lag 0 and with 3.35% (95% CI 1.90% to 4.83%) for lags 0-20. Significant adverse health effects were found of summer O(3) (June-August) on total and cardiovascular mortality that persist up to a week, but are counterbalanced by negative effects thereafter.

CONCLUSIONS

The results indicate that studies on acute health effects of O(3) using single-day exposures may have overestimated the effects on total and cardiovascular mortality, but underestimated the effects on respiratory mortality.

Optical nonlocalities and additional waves in epsilon-near-zero metamaterials

We analyze the optical properties of plasmonic nanorod metamaterials in the epsilon-near-zero regime and show, both theoretically and experimentally, that the performance of these composites is strongly affected by nonlocal response of the effective permittivity tensor. We provide the evidence of interference between main and additional waves propagating in the room-temperature nanorod metamaterials and develop an analytical description of this phenomenon. Additional waves are present in the majority of low-loss epsilon-near-zero structures and should be explicitly considered when designing applications of epsilon-near-zero composites, as they represent a separate communication channel.

Optical transmission measurements of silver, silver-gold alloy and silver-gold segmented nanorods in thin film alumina

Silver nanorods have been grown by electrodeposition into thin film porous alumina. Transmission measurements show two peaks related to the transverse and longitudinal resonance of the nanorods. The behaviour of the longitudinal resonance peak is found to vary with nanorod length and the spectral position to depend on nanorod diameter. As the distance between the nanorods is decreased a small blue-shift of the longitudinal peak is observed. Depositing a small gold cap on top of the silver nanorods causes a red-shift of the longitudinal peak whilst, conversely, the longitudinal peak of gold nanorod arrays is comparatively insensitive to the deposition of a silver cap. Gold-silver alloy nanorods were also deposited from a mixed salt bath and a linear dependence of the transverse peak position on alloy composition was observed.

Guided plasmonic modes in nanorod assemblies: strong electromagnetic coupling regime

We demonstrate that the coupling between plasmonic modes of oriented metallic nanorods results in the formation of an extended (guided) plasmonic mode of the nanorod array. The electromagnetic field distribution associated to this mode is found to be concentrated between the nanorods within the assembly and propagates normally to the nanorod long axes, similar to a photonic mode waveguided by an anisotropic slab. This collective plasmonic mode determines the optical properties of nanorod assemblies and can be tuned in a wide spectral range by changing the nanorod array geometry. This geometry represents a unique opportunity for light guiding applications and manipulation at the nanoscale as well as sensing applications and development of molecular plasmonic devices.

Anatomic study of the middle genicular artery

PURPOSE

To study the anatomy of the middle genicular artery and thus mitigate the risk of vascular injury in knee surgery.

METHODS

The course, anatomic relations, and variations of the middle genicular artery in 8 cadavers (4 men and 4 women) were studied.

RESULTS

The middle genicular artery originated from the anterolateral surface of the popliteal artery in the popliteal fossa, 3 to 5 cm proximal to the joint line either alone or having a common origin with the lateral genicular artery. Its diameter varied from 2 to 4 mm and it was 3 to 5 cm long. It was accompanied by 2 venae comitantes. This vascular bundle, including the middle genicular artery, ran distally, anterior to the popliteal artery, and posterior to the joint capsule, sandwiched between them. Distally it pierced the posterior joint capsule and became intra-articular. The relation of the middle genicular artery to the popliteal artery altered with the position of the knee joint. This alteration was secondary to the distal gliding of the popliteal artery with knee flexion. The middle geniculate artery formed an angle of 15 to 30 degrees to the popliteal artery when the knee was extended, which became almost a right angle when the knee was flexed past 90 degrees.

CONCLUSION

Care must be taken when arthroscopic or open intra-articular surgery is performed in the posterior part of the knee joint using chondrotomes and saws, particularly with limited vision. Sharp dissection and diathermy under direct vision should be safer.

Confocal chromoscopic endomicroscopy is superior to chromoscopy alone for the detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis

BACKGROUND

The diagnosis of intraepithelial neoplasia is pivotal for ongoing clinical management decisions in ulcerative colitis. Previous studies have compared the diagnostic yield of endomicroscopy with conventional "white light" endoscopy and hence the overall objective increase of endomicroscopy targeted biopsies as compared to chromoscopy guided alone is not apparent.

AIMS

We performed a prospective randomised controlled study to compare the diagnostic yield of intraepithelial neoplasia and cancer in patients undergoing ulcerative colitis screening using chromoscopy assisted endomicroscopy (group A) versus pan-colonic chromoscopy assisted colonoscopy (group B).

METHODS

Patients were randomised in a 1:1 ratio to undergo screening colonoscopy using either chromoscopic endomicroscopy or chromoscopy alone with targeted biopsies. Circumscribed lesions were characterised using endomicroscopy and chromoscopy with pit pattern analysis. Targeted biopsies in addition to conventional 10 cm quadrantic biopsies were taken. Primary outcome addressed the number of intraepithelial neoplasias detected in each group.

RESULTS

Endomicroscopy targeted biopsies significantly increased the yield of intraepithelial neoplasia as compared to pan-chromoscopy and biopsy alone (p<0.001) and also increased the yield of high-grade dysplastic lesions (p<0.001). Endomicroscopy targeted biopsies increased the diagnostic yield of intraepithelial neoplasia as compared to chromoscopy guided biopsies alone by 2.5-fold.

CONCLUSIONS

This is the first randomised controlled study to show the true clinical benefit of endomicroscopy for the in vivo detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis surveillance colonoscopy. Endomicroscopy with targeted biopsy may potentially be the "gold standard" for the detection of intraepithelial neoplasia in ulcerative colitis.

Confocal chromoscopic endomicroscopy is superior to chromoscopy alone for the detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis

BACKGROUND

The diagnosis of intraepithelial neoplasia is pivotal for ongoing clinical management decisions in ulcerative colitis. Previous studies have compared the diagnostic yield of endomicroscopy with conventional "white light" endoscopy and hence the overall objective increase of endomicroscopy targeted biopsies as compared to chromoscopy guided alone is not apparent.

AIMS

We performed a prospective randomised controlled study to compare the diagnostic yield of intraepithelial neoplasia and cancer in patients undergoing ulcerative colitis screening using chromoscopy assisted endomicroscopy (group A) versus pan-colonic chromoscopy assisted colonoscopy (group B).

METHODS

Patients were randomised in a 1:1 ratio to undergo screening colonoscopy using either chromoscopic endomicroscopy or chromoscopy alone with targeted biopsies. Circumscribed lesions were characterised using endomicroscopy and chromoscopy with pit pattern analysis. Targeted biopsies in addition to conventional 10 cm quadrantic biopsies were taken. Primary outcome addressed the number of intraepithelial neoplasias detected in each group.

RESULTS

Endomicroscopy targeted biopsies significantly increased the yield of intraepithelial neoplasia as compared to pan-chromoscopy and biopsy alone (p<0.001) and also increased the yield of high-grade dysplastic lesions (p<0.001). Endomicroscopy targeted biopsies increased the diagnostic yield of intraepithelial neoplasia as compared to chromoscopy guided biopsies alone by 2.5-fold.

CONCLUSIONS

This is the first randomised controlled study to show the true clinical benefit of endomicroscopy for the in vivo detection and characterisation of intraepithelial neoplasia in chronic ulcerative colitis surveillance colonoscopy. Endomicroscopy with targeted biopsy may potentially be the "gold standard" for the detection of intraepithelial neoplasia in ulcerative colitis.

EMR using dextrose solution versus sodium hyaluronate for colorectal Paris type I and 0-II lesions: a randomized endoscopist-blinded study

BACKGROUND AND AIMS

Loss of mucosal 'lift' prior to submucosal dissection or endoscopic mucosal resection (EMR) increases the risk of complications. We conducted a randomized controlled trial comparing dextrose solution with sodium hyaluronic acid (SHA) for the EN BLOC resection of Paris type I/0-II and lateral spreading lesions of the colorectum.

PATIENTS AND METHODS

Patients with Paris type I/0-II or lateral spreading tumor lesions of < 30 mm were randomized in a 1 : 1 ratio to undergo EMR using either dextrose solution or SHA. The primary study outcome was complete resection. Secondary outcomes were endoscopic complications (i. e. perforation or bleeding) and polyp recurrence rates.

RESULTS

A total of 174 patients were randomized. R0 resection was achieved in 59 of the 82 lesions (72 %) in the dextrose group and 56 of the 81 lesions (69 %) in the SHA group ( P > 0.1), with no significant difference in median lesion diameter ( P > 0.1). The median number of post resection surveillance colonoscopies was 3 (range 2 - 7) in the dextrose group and 4 (range 2 - 6) in the SHA group ( P = NS). The median post index EMR resection follow-up period was 20 months (range 4 - 26) in the DS group and 18 months (range 3 - 22) in the SHA group ( P = NS). Recurrence rates were 1/82 (1.21 %) in the dextrose group and 1/81 (1.23 %) in the SHA group ( P = NS).

CONCLUSIONS

EMR using dextrose solution is as effective as SHA in terms of resection completion, recurrence rates, and complications.

Achieving R0 resection in the colorectum using endoscopic submucosal dissection

BACKGROUND

Endoscopic mucosal resection is established for the removal of non-invasive colorectal tumours smaller than 20 mm but is unsatisfactory for larger lesions. Endoscopic submucosal dissection (ESD) enables en bloc resection of lesions larger than 20 mm. A UK-based prospective feasibility study of ESD for colorectal tumours was undertaken; primary endpoints were R0 resection, safety and recurrence.

METHODS

Patients with Paris 0-II adenomas or laterally spreading tumours (LSTs) greater than 20 mm in diameter were enrolled between November 2004 and August 2006. Lesions were assessed by chromoscopy and high-frequency ultrasonography. Dysplasia, resection status, 30-day complication rates and recurrence after ESD were recorded.

RESULTS

ESD was performed in 42 of 56 identified patients; en bloc resection was possible in 33. Fourteen Paris 0-II lesions and 28 LSTs were identified; 40 were dysplastic adenomas and two adenocarcinomas. R0 resection was achieved in 31 patients (74 per cent). The 30-day mortality rate was 0 per cent. Perforation occurred in one patient and uncomplicated bleeding in five. The 6-month cure rate was 81 per cent (34 of 42 patients).

CONCLUSION

High cure rates are achievable using ESD for Paris 0-II adenomas and LSTs greater than 20 mm in diameter, with R0 resection possible in most patients. ESD is feasible throughout the colorectum with no increase in complication rates. It should be considered for selected Tim/T1 N0 colorectal lesions.

SCOTROC 2A: carboplatin followed by docetaxel or docetaxel-gemcitabine as first-line chemotherapy for ovarian cancer

The feasibility of sequential carboplatin followed by docetaxel-based therapy for untreated ovarian cancer was determined. Patients received four q3w cycles of carboplatin AUC 7, then four q3w cycles of either docetaxel 100 mg m(-2) (day 1) (arm A); docetaxel 75 mg m(-2) (day 8) and gemcitabine 1250 mg m(-2) (days 1,8) (arm B) or docetaxel 25 mg m(-2) and gemcitabine 800 mg m(-2) (both given weekly (days 1,8,15)) (arm C). A total of 44 patients were randomised to each treatment arm. None of the arms demonstrated an eight cycle completion rate (70.5/72.7/45.5% in arms A/B/C, respectively), which was statistically greater than 60% (P=0.102, P=0.056, P=0.982) which was our formal feasibility criteria, although only the completion rate in arm C was clearly worse than this level. The overall response rate (ORR) after carboplatin was 65.7% in 70 evaluable patients. In evaluable patients, ORRs after docetaxel-based cycles were: arm A 84.0% (21 out of 25); arm B 77.3% (17 out of 22); arm C 69.6% (16 out of 23). At follow-up (median 30 months), median progression-free survival times were: arm A 15.5 months (95% CI: 10.5-20.6); arm B 18.1 months (95% CI: 15.9-20.3); arm C, 13.7 months (95% CI: 12.8-14.6). Neutropenia was the predominant grade 3-4 haematological toxicity: 77.8/85.7/54.4% in arms A/B/C, respectively. Dyspnoea was markedly increased in both gemcitabine-containing arms (P=0.001) but was worse in arm C. Although just failing to rule out eight cycle completion rates less than 60%, within the statistical limitations of these small cohorts, the overall results for arms A and B are encouraging. Larger phase III studies are required to test these combinations.

Seasonal confounding in air pollution and health time-series studies: effect on air pollution effect estimates

A major statistical challenge in air pollution and health time-series studies is to adequately control for confounding effects of time-varying covariates. Daily health outcome counts are most commonly analysed by Poisson regression models, adjusted for overdispersion, with air pollution levels included as a linear predictor and smooth functions for calendar time and weather variables to adjust for time-varying confounders. Various smoothers have been used so far, but the optimal strategy for choosing smoothers and their degree of smoothing remains controversial. In this work, we evaluate the performance of various smoothers with different criteria for choosing the degree of smoothing in terms of bias and efficiency of the air pollution effect estimate in a simulation study. The evaluated approaches were also applied to real mortality data from 22 European cities. The simulation study imitated a multi-city study. Data were generated from a fully parametric model. Model selection methods which optimize prediction may lead to increased biases in the air pollution effect estimate. Minimization of the absolute value of the sum of the partial autocorrelation function of the model's residuals (PACF), as a criterion to choose the degree of smoothness, gave the smallest biases. The penalized splines (PS) method with a large number of effective dfs (e.g. 8-12 per year) could be used as the basic, relatively conservative, analysis whereas the PS and natural splines in combination with PACF could be applied to provide a reasonable range of the effect estimate.

A phase IIA study of the topoisomerase I inhibitor, exatecan mesylate (DX-8951f), administered at two different dose schedules in patients with platinum- and taxane-resistant/refractory ovarian cancer

OBJECTIVES

There is an urgent need for new agents with activity in platinum- and taxane-resistant epithelial ovarian cancer. Exatecan mesylate is a novel topoisomerase I inhibitor with potent activity against ovarian cancer in vitro. A multicentre phase IIA study was conducted in patients with platinum- and taxane-resistant epithelial ovarian cancer.

PATIENTS AND METHODS

Fifty-seven patients with bidimensionally measurable ovarian cancer, previously exposed to platinum and taxanes, whose disease had relapsed within 6 months of platinum-containing chemotherapy were randomised to one of two intravenous schedules of exatecan mesylate; 0.3 mg/m(2) daily for 5 days every 3 weeks (Arm A) or 2.1 mg/m(2) weekly for 3 weeks out of 4 (Arm B).

RESULTS

There were no responses in the weekly arm and a radiological response rate of 5.3% (95% CI 0.3-21.8%) in the daily arm. Principal toxicities were myelosuppression and emesis. Grade 3/4 neutropenia occurred in 29% of patients in Arm A and 6% patients in Arm B. Seventy-one percent of patients in Arm A required red cell transfusions while on treatment.

CONCLUSIONS

Exatecan is well tolerated in this poor prognosis group of patients but only has modest single agent activity when administered in a daily regimen.

Investigating the dose-response relation between air pollution and total mortality in the APHEA-2 multicity project

BACKGROUND

Several recent studies have reported significant health effects of air pollution even at low levels of air pollutants, but in most of these studies linear non-threshold relations were assumed.

AIMS

To investigate the NO2 mortality dose-response association in nine cities participating in the APHEA-2 project using two different methods: the meta-smooth and the cubic spline method.

METHODS

The meta-smooth method developed by Schwartz and Zanobetti is based on combining individual city non-parametric smooth curves; the cubic spline method developed within the APHEA-2 project combines individual city estimates of cubic spline shaped dose-response relations. The meta-smooth method is easier and faster to implement, but the cubic spline method is more flexible for further investigation of possible heterogeneity in the dose-response curves among cities.

RESULTS

In the range of the pollutant common to all cities the two methods gave similar and comparable curves. Using the cubic spline method it was found that smoking prevalence acts as an effect modifier with larger NO2 effects on mortality at lower smoking prevalence.

CONCLUSIONS

The NO2-mortality association in the cities included in the present analysis, could be adequately estimated using the linear model. However, investigation of the city specific dose-response curves should precede the application of linear models.

Long-term follow-up confirms a survival advantage of the paclitaxel-cisplatin regimen over the cyclophosphamide-cisplatin combination in advanced ovarian cancer

Two independent and consecutive randomized clinical trials, conducted by the American Gynecological Oncology Group and by an European-Canadian Intergroup, have shown superiority, in clinical response rate, progression-free survival, and overall survival, of a cisplatin-paclitaxel regimen over cisplatin-cyclophosphamide given as first-line chemotherapy for women with advanced epithelial ovarian cancer. The results of these studies, published with a median follow-up of about 3 years, have been updated with a 6.5-year follow-up: In each case, an 11% absolute gain in survival favoring the paclitaxel arm is shown; this advantage remains both statistically and clinically significant and supports a role for paclitaxel in frontline chemotherapy for advanced ovarian cancer.

Long-term follow-up confirms a survival advantage of the paclitaxel–cisplatin regimen over the cyclophosphamide–cisplatin combination in advanced ovarian cancer

Two independent and consecutive randomized clinical trials, conducted by the American Gynecological Oncology Group and by an European–Canadian Intergroup, have shown superiority, in clinical response rate, progression-free survival, and overall survival, of a cisplatin–paclitaxel regimen over cisplatin–cyclophosphamide given as first-line chemotherapy for women with advanced epithelial ovarian cancer. The results of these studies, published with a median follow-up of about 3 years, have been updated with a 6.5-year follow-up: In each case, an 11% absolute gain in survival favoring the paclitaxel arm is shown; this advantage remains both statistically and clinically significant and supports a role for paclitaxel in frontline chemotherapy for advanced ovarian cancer.

Respiratory effects of sulphur dioxide: a hierarchical multicity analysis in the APHEA 2 study

BACKGROUND

Sulphur dioxide (SO(2)) was associated with hospital admissions for asthma in children in the original APHEA study, but not with other respiratory admissions.

AIMS

To assess the association between daily levels of SO(2) and daily levels of respiratory admissions in a larger and more recent study.

METHODS

Time series of daily counts of hospital emergency admissions were constructed for asthma at ages 0-14 years and 15-64 years, COPD and asthma, and all respiratory admissions at ages 65+ years in the cities of Birmingham, London, Milan, Paris, Rome, Stockholm, and in the Netherlands for periods of varying duration between the years 1988 and 1997. A two stage hierarchical modelling approach was used. In the first stage generalised additive Poisson regression models were fitted in each city controlling for weather and season. These results were then combined across cities in a second stage ecological regression that looked at potential effect modifiers.

RESULTS

For an increase of 10 micro g/m(3) of SO(2) the daily number of admissions for asthma in children increased 1.3% (95% CI 0.4% to 2.2%). Effect modification among cities by levels of other air pollutants or temperature was not found. The SO(2) effect disappeared after controlling for PM(10) or CO, but correlation among these pollutants was very high. Other respiratory admissions were not associated with SO(2).

CONCLUSION

SO(2) is associated with asthma admissions in children, indicating that reduction in current air pollution levels could lead to a decrease in the number of asthma admissions in children in Europe.

Near-field imaging of ultrathin magnetic films with in-plane magnetization

A new approach to near-field magneto-optical imaging was developed capable of visualization of in-plane magnetization of ultrathin magnetic structures. The approach relies on the magneto-optical effect specific for thin magnetic layers and employs near-field transmission measurements of longitudinal and/or transverse magneto-optical effect arising from the presence of thin film interfaces. The near-field magneto-optical contrast of in-plane domain structure of ultrathin Co film has been demonstrated in different polarization configurations.

Creutzfeldt-Jakob disease associated with a deletion of two repeats in the prion protein gene

A two-octapeptide repeat deletion of the prion protein gene has been recently observed in a patient with a 2-year history of dementia and a clinical diagnosis of possible Creutzfeldt-Jakob disease (CJD). The authors report a similar deletion in a patient with a definitive diagnosis of CJD. Since the two-repeat deletion has not been observed in large, population-based studies, the two cases suggest that this deletion is a new pathogenic mutation associated with CJD.

Short-term effects of particulate air pollution on cardiovascular diseases in eight European cities

STUDY OBJECTIVE

As part of the APHEA project this study examined the association between airborne particles and hospital admissions for cardiac causes (ICD9 390-429) in eight European cities (Barcelona, Birmingham, London, Milan, the Netherlands, Paris, Rome, and Stockholm). All admissions were studied, as well as admissions stratified by age. The association for ischaemic heart disease (ICD9 410-413) and stroke (ICD9 430-438) was also studied, also stratified by age.

DESIGN

Autoregressive Poisson models were used that controlled for long term trend, season, influenza epidemics, and meteorology to assess the short-term effects of particles in each city. The study also examined confounding by other pollutants. City specific results were pooled in a second stage regression to obtain more stable estimates and examine the sources of heterogeneity.

MAIN RESULTS

The pooled percentage increases associated with a 10 micro g/m(3) increase in PM(10) and black smoke were respectively 0.5% (95% CI: 0.2 to 0.8) and 1.1% (95% CI: 0.4 to 1.8) for cardiac admissions of all ages, 0.7% (95% CI: 0.4 to 1.0) and 1.3% (95% CI: 0.4 to 2.2) for cardiac admissions over 65 years, and, 0.8% (95% CI: 0.3 to 1.2) and 1.1% (95% CI: 0.7 to 1.5) for ischaemic heart disease over 65 years. The effect of PM(10) was little changed by control for ozone or SO(2), but was substantially reduced (CO) or eliminated (NO(2)) by control for other traffic related pollutants. The effect of black smoke remained practically unchanged controlling for CO and only somewhat reduced controlling for NO(2).

CONCLUSIONS

These effects of particulate air pollution on cardiac admissions suggest the primary effect is likely to be mainly attributable to diesel exhaust. Results for ischaemic heart disease below 65 years and for stroke over 65 years were inconclusive.