Interaction between clinicians and artificial intelligence to detect fetal atrioventricular septal defects on ultrasound: how can we optimize collaborative performance?

OBJECTIVES

Artificial intelligence (AI) has shown promise in improving the performance of fetal ultrasound screening in detecting congenital heart disease (CHD). The effect of giving AI advice to human operators has not been studied in this context. Giving additional information about AI model workings, such as confidence scores for AI predictions, may be a way of improving performance further. Our aims were to investigate whether AI advice improved overall diagnostic accuracy (using a single CHD lesion as an exemplar), and to see what, if any, additional information given to clinicians optimized the overall performance of the clinician-AI team.

METHODS

An AI model was trained to classify a single fetal CHD lesion (atrioventricular septal defect, AVSD), using a retrospective cohort of 121,130 cardiac four chamber images extracted from 173 ultrasound scan videos (98 with normal hearts, 75 with AVSD). A ResNet50 model architecture was used. Temperature scaling of model prediction probability was performed on a validation set, and gradient-weighted class activation maps (grad-CAMs) produced. Ten clinicians (two consultant fetal cardiologists, three trainees in pediatric cardiology, and five fetal cardiac sonographers) were recruited from a center of fetal cardiology to participate. Each participant was shown 2000 fetal four chamber images in a random order (1,000 normal and 1,000 AVSD). The dataset was comprised of 500 images, each shown in four conditions: 1) image alone without AI output; 2) image with binary AI classification; 3) image with AI model confidence; 4) image with gradient-weighted class activation map image overlays. The clinicians were asked to classify each image as normal or AVSD.

RESULTS

20,000 image classifications were recorded from 10 clinicians. The AI model alone achieved an accuracy of 0.798 (95% CI 0.760 - 0.832), sensitivity of 0.868 (95% CI 0.834 - 0.902) and specificity of 0.728 (95% CI 0.702 - 0.754, and the clinicians without AI achieved an accuracy of 0.844 (95% CI 0.834 - 0.854), sensitivity of 0.827 (95% CI 0.795 - 0.858) and specificity of 0.861 (95% CI 0.828 - 0.895). Showing a binary (normal or AVSD) AI model output resulted in significant improvement in accuracy to 0.865 (p <0.001). This effect was seen in both experienced and less experienced participants. Giving incorrect AI advice resulted in significant deterioration in overall accuracy from 0.761 to 0.693 (p <0.001), which was driven by an increase in both type I and type II error by the clinicians. This effect was worsened by showing model confidence (accuracy 0.649, p <0.001) or grad-CAM (accuracy 0.644, p <0.001).

CONCLUSIONS

AI has the potential to improve performance when used in collaboration with clinicians, even if the model performance does not reach expert level. Giving additional information about model workings such as model confidence and class activation map image overlays did not improve overall performance, and actually worsened performance for images where the AI model was incorrect. This article is protected by copyright. All rights reserved.

Prognostic value of pulmonary transit time by cardiac magnetic resonance in patients with heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): National Institute for Health Research Leicester Cardiovascular Biomedical Research Centre

Background

Quantifying pulmonary transit time (PTT) from cardiac magnetic resonance (CMR) first pass perfusion imaging is a novel technique for the evaluation of haemodynamic congestion in heart failure. Previous studies have demonstrated that PTT is prolonged in patients with heart failure with reduced ejection fraction (HFrEF) and that it provides independent prognostic information in this patient group. However, the potential diagnostic and prognostic roles of PTT assessment in patients with heart failure with preserved ejection fraction (HFpEF) remain to be established.

Aim

To compare PTT in healthy controls and in patients with HFpEF, and to determine the prognostic value of PTT in HFpEF.

Methods

In a prospective, observational study, HFpEF and age-matched control subjects underwent multi-parametric CMR at 3-Tesla, comprising quantitative left ventricular volumetric assessment using a standard steady-state free precession (SSFP) pulse sequence, and first-pass perfusion imaging at rest using a T1-weighted segmented inversion recovery gradient echo sequence (following injection of 0.04mmol/kg of contrast). PTT was calculated as the time interval between the peaks of signal intensity curves in the right and left ventricular blood pools (defined on the basal slice of the rest perfusion images). The primary endpoint was the composite of death or hospitalisation with heart failure.

Results

88 HFpEF patients (age 73 ± 9 years, 51% male, EF 56.4 ± 5.6%) and 40 controls (age 73 ± 5 years, 43% male, EF 58.5 ± 4.7%) were studied. PTT was comparable in HFpEF patients (7.7 ± 3.8s) and in healthy controls (7.5 ± 1.8, p = 0.69). Normalised to cardiac cycle lengths, PTT remained comparable in HFpEF patients and healthy controls (8.5 ± 4.0 cardiac cycles versus 7.8 ± 1.6 cardiac cycles, respectively, p = 0.19). In the HFpEF group, during median follow-up of 3.4 years, there were 38 events (25 hospitalisations with heart failure, 13 deaths); a significant relationship between survival and PTT was not demonstrated (HR 1.06 [0.99,1.14] for a one-unit increase, p = 0.098).

Conclusion

In HFpEF, PTT is not prolonged compared with PTT in healthy subjects. Unlike in HFrEF, PTT does not appear to be diagnostically or prognostically significant in HFpEF.

Figure 1: Graph showing signal intensity curves in the right (red) and left (green) ventricular blood pools

Figure 2: Kaplan-Meier plot showing comparable rates of the composite endpoint in patients with PTT greater/less than median PTT (8 cardiac cycles)

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The effect of DAFNE education, continuous subcutaneous insulin infusion, or both in a population with type 1 diabetes in Scotland

AIM

To investigate the effect of DAFNE and continuous subcutaneous insulin infusion in clinical practice.

METHODS

Within NHS Lothian, continuous subcutaneous insulin infusion started in 2004 and DAFNE education began in 2006. We extracted anonymized data from the national database for all those aged > 18 years with type 1 diabetes having a Dose Adjustment For Normal Eating course or continuous subcutaneous insulin infusion start date (n = 4617).

RESULTS

In total, 956 persons received DAFNE education, and 505 had received an insulin pump, 208 of whom had DAFNE education followed by insulin pump. Mean (SD) HbA_1c before DAFNE education was 68 (15) mmol/mol (8.4% [1.4%]) and 66 (13) mmol/mol (8.2% [1.2%]) before continuous subcutaneous insulin infusion. In the year following DAFNE education, the mean fall in within-person HbA_1c was 3.8 mmol/mol (95% CI 4.0 to 3.4; 0.3% [0.4% to 0.3%]). Those with the poorest control (HbA_1c ≥ 85 mmol/mol [9.9%]) experienced the largest decline (15.7 mmol/mol [1.4%]). Those in the lowest HbA_1c band at initiation (< 53 mmol/mmol [7.0%]) experienced a rise. In the year following continuous subcutaneous insulin infusion initiation there was a mean fall in within-person HbA_1c of 6.6 mmol/mol (6.8 to 6.4; 0.6% [0.6% to 0.6%]). In those with the poorest control (HbA_1c ≥ 85 mmol/mol [9.9%]), the mean fall in HbA_1c was 22.2 mmol/mol (23 to 21; 2.0% [2.1% to 1.9%]). Continuous subcutaneous insulin infusion effectiveness was not different with or without DAFNE education. The effects of both interventions were sustained over 5 years.

CONCLUSIONS

Both DAFNE education and insulin pump therapy had the greatest effect on HbA_1c in those with higher baseline values. There was little difference to attained HbA_1c when Dose Adjustment For Normal Eating education was introduced before insulin pump therapy.

Nasal fractures: a dedicated clinic providing reduction under local anaesthesia improves time to manipulation

INTRODUCTION

Guidelines for nasal injury state that assessment should be at 7-10 days post-injury and manipulation within 14 days. We performed a plan, do, study, act improvement cycle to assess whether a dedicated nasal fracture service led to better outcomes.

MATERIALS AND METHODS

A retrospective study was carried out of all patients undergoing manipulation under anaesthesia for nasal trauma between February 2013 and December 2016 in a district general hospital. A dedicated nasal fracture clinic providing manipulation under local anaesthesia was implemented followed by a prospective study of all patients presenting to the clinic between February and November 2017. Main outcome measures included time from injury to otolaryngology assessment, time from injury to manipulation and incidence of secondary septorhinoplasty.

RESULTS

The retrospective series involved 525 patients including 381 males (72.6%) and 144 females (27.4%). Mean time from injury to assessment was 10 days. Mean time from injury to surgery was 14.5 days. Mean time from assessment to surgery was five days. The incidence of septorhinoplasty was 2.3%. The prospective series involved 119 patients including 78 males (65.5%) and 41 females (34.5%). Following implementation of a nasal fracture clinic, mean time from injury to assessment and manipulation was 6.1 days and 5.4% of patients underwent septorhinoplasty for secondary deformity.

DISCUSSION

Implementation of a nasal fracture clinic providing reduction under local anaesthesia reduced the time to assessment and manipulation. The incidence of septorhinoplasty is low following reduction under general or local anaesthesia. Assessment earlier than seven days is feasible and advice for referral can be changed accordingly.

Endotoxin and Bacterial Contamination of Dialysis Center Water and Dialysate; a Cross Sectional Survey

The bacterial and endotoxin levels of purified water and effluent dialysate were examined in a cross section of dialysis centers in the central United States. All samples were collected within a four-hour drive of the University of Louisville and were collected, processed and analyzed by our personnel, to eliminate variability in sample handling. A medium capable of higher bacteria recovery from aqueous environments than those ordinarily employed in clinical assays was used. Endotoxins were determined by a quantitative colorimetric assay.

By the more sensitive bacterial assay 53% of the centers had bacterial counts above the AAMI standard of 200 colony-forming units per ml (CFU/ml) for water and 35% of the centers had bacterial counts above the 2000 CFU/ml standard for dialysate in at least one sampling period. The samples showed 35% and 19% of water and dialysate above the standards, respectively. While there are no standards for endotoxin concentrations in water used to prepare dialysate, 2% of the centers had endotoxin levels in their water above five endotoxin units per ml (5 EU/ml = 1 ng/ml in our assay kit), the limit set by the AAMI standards for reprocessor water. Both bacterial and endotoxin levels tended to be elevated in dialysate, with the highest levels of endotoxin in dialysates posing an obvious potential risk when high-flux dialyzers are used.

Transcriptome comparison of meniscus from patients with and without osteoarthritis

OBJECTIVE

To assess the impact of osteoarthritis (OA) on the meniscus by comparing transcripts and biological processes in the meniscus between patients with and without OA.

DESIGN

RNA microarrays were used to identify transcripts differentially expressed (DE) in meniscus obtained from 12 OA and 12 non-OA patients. The non-OA specimens were obtained at the time of arthroscopic partial meniscectomy. Real-time PCR was performed on selected transcripts. Biological processes and gene-networking was examined computationally. Transcriptome signatures were mapped with 37 OA-related transcripts to evaluate how meniscus gene expression relates to that of OA cartilage.

RESULTS

We identified 168 transcripts significantly DE between OA (75 elevated, 93 repressed) and non-OA samples (≥1.5-fold). Among these, CSN1S1, COL10A1, WIF1, and SPARCL1 were the most prominent transcripts elevated in OA meniscus, POSTN and VEGFA were most highly repressed in OA meniscus. Transcripts elevated in OA meniscus represented response to external stimuli, cell migration and cell localization while those repressed in OA meniscus represented histone deacetylase activity (related to epigenetics) and skeletal development. Numerous long non-coding RNAs (lncRNAs) were DE between the two groups. When segregated by OA-related transcripts, two distinct clustering patterns appeared: OA meniscus appeared to be more inflammatory while non-OA meniscus exhibited a "repair" phenotype.

CONCLUSIONS

Numerous transcripts with potential relevance to the pathogenesis of OA are DE in OA and non-OA meniscus. These data suggest an involvement of epigenetically regulated histone deacetylation in meniscus tears as well as expression of lncRNAs. Patient clustering based on transcripts related to OA in articular cartilage confirmed distinct phenotypes between injured (non-OA) and OA meniscus.

Pain and compression neuropathy in primary inguinal hernia

PURPOSE

Enlargement of the ilioinguinal nerve at the external inguinal ring is observed in 34% of patients undergoing primary open inguinal herniorrhaphy; in 88% of patients it occurs at the fascial edge where the hernia mushrooms with abdominal pressure. Compression neuropathy occurs near many anatomical nerve constriction sites and is associated with enlargement of the peripheral nerve accompanied by sensory changes.

METHODS

In this prospective study, Carolina Comfort Scale (CCS) questionnaire data was collected for 35 primary hernia repairs. Each patient underwent primary inguinal herniorrhaphy that included ilioinguinal neurectomy. All nerves were sampled proximal to the external inguinal ring. Any nerves with grossly increased overall diameter to any degree distal to the external ring were additionally sampled in the thickened portions. A neuropathologist performed histologic evaluation of the H&E-stained cross sections.

RESULTS

Paired comparison of proximal and distal nerves revealed a greater overall diameter and greater measured nerve-specific diameter in distal nerve segments. Nerves with increased overall diameter were also found to have a statistically significant positive correlation with four of eight pain measures. Additionally, increased nerve-specific diameter correlates with increased pain on four of eight pain values, but age effect on nerve diameter blunts this finding.

CONCLUSIONS

Increased preoperative CCS pain values in primary open inguinal hernia are significantly correlated with gross enlargement of the overall diameter and nerve-specific diameter of the ilioinguinal nerve beyond the external inguinal ring. This is consistent with a compression neuropathy.

Minimal important improvement thresholds for the six-minute walk test in a knee arthroplasty cohort: triangulation of anchor- and distribution-based methods

Background

The 6-minute walk test (6MWT) is a commonly used metric for measuring change in mobility after knee arthroplasty, however, what is considered an improvement after surgery has not been defined. The determination of important change in an outcome assessment tool is controversial and may require more than one approach. This study, nested within a combined randomised and observational trial, aimed to define a minimal important improvement threshold for the 6MWT in a knee arthroplasty cohort through a triangulation of methods including patient-perceived anchor-based thresholds and distribution-based thresholds.

Methods

Individuals with osteoarthritis performed a 6MWT pre-arthroplasty then at 10 and 26 weeks post-surgery. Each rated their perceived improvement in mobility post-surgery on a 7-point transition scale anchored from “much better” to “much worse”. Based on these responses the cohort was dichotomised into ‘improved’ and ‘not improved’. The thresholds for patient-perceived improvements were then identified using two receiver operating curve methods producing sensitivity and specificity indices. Distribution-based change thresholds were determined using two methods utilising effect size (ES). Agreement between the anchor- and distribution-based methods was assessed using kappa.

Results

One hundred fifty-eight from 166 participants in the randomised cohort and 222 from 243 in the combined randomised and observational cohort were included at 10 and 26 weeks, respectively. The slightly or more patient-perceived improvement threshold at 26 weeks (an absolute improvement of 26 m) was the only one to demonstrate sensitivity and specificity results both better than chance. At 10- and 26-weeks, the ES based on the mean change score divided by the baseline standard deviation (SD), was an absolute change of 24.5 and 37.9 m, respectively. The threshold based on a moderate ES (a 0.5 SD of the baseline score) was a change of 55.0 and 55.4 m at 10- and 26-weeks, respectively. The level of agreement between the 26-week anchor-based and distribution-based minimal absolute changes was very good (k = 0.88 (95 % CI 0.81 0.95)).

Conclusion

A valid threshold of improvement for the 6MWT can only be proposed for changes identified from baseline to 26 weeks post-surgery. The level of agreement between anchor- and distribution-based methods indicates that a true minimal or more threshold of meaningful improvement following surgery is likely within the ranges proposed by the triangulation of all four methods, that is, 26 to 55 m.

Early-life metal exposure and schizophrenia: A proof-of-concept study using novel tooth-matrix biomarkers

BACKGROUND

Despite evidence for the effects of metals on neurodevelopment, the long-term effects on mental health remain unclear due to methodological limitations. Our objective was to determine the feasibility of studying metal exposure during critical neurodevelopmental periods and to explore the association between early-life metal exposure and adult schizophrenia.

METHODS

We analyzed childhood-shed teeth from nine individuals with schizophrenia and five healthy controls. We investigated the association between exposure to lead (Pb(2+)), manganese (Mn(2+)), cadmium (Cd(2+)), copper (Cu(2+)), magnesium (Mg(2+)), and zinc (Zn(2+)), and schizophrenia, psychotic experiences, and intelligence quotient (IQ). We reconstructed the dose and timing of early-life metal exposures using laser ablation inductively coupled plasma mass spectrometry.

RESULTS

We found higher early-life Pb(2+) exposure among patients with schizophrenia than controls. The differences in log Mn(2+) and log Cu(2+) changed relatively linearly over time to postnatal negative values. There was a positive correlation between early-life Pb(2+) levels and psychotic experiences in adulthood. Moreover, we found a negative correlation between Pb(2+) levels and adult IQ.

CONCLUSIONS

In our proof-of-concept study, using tooth-matrix biomarker that provides direct measurement of exposure in the fetus and newborn, we provide support for the role of metal exposure during critical neurodevelopmental periods in psychosis.

KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study

OBJECTIVE

The prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors.

DESIGN

Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale <87.5 and ≥2 of: KOOSpain <86.1, KOOSsymptoms <85.7, KOOSADL <86.8, or KOOSsports/rec <85.0; (2) KOOSpain subscale score ≤72 (≥2 standard deviations below population mean); (3) 10-point KOOSpain drop from 2 to 6 years. Proportional odds models (alpha ≤ 0.05) were used.

RESULTS

1761 patients of median age 23 years, median body mass index (BMI) 24.8 kg/m(2) and 56% male met inclusion, with 87% (1530/1761) and 86% (1506/1761) follow-up at 2 and 6 years, respectively. At 6 years, n = 592 (39%), n = 131 (9%) and n = 169 (12%) met criteria for models #1 through #3, respectively. The most consistent and strongest independent risk factor at both time-points was subsequent ipsilateral knee surgery. Low 2-year Marx activity score increased the odds of a painful knee at 6 years.

CONCLUSIONS

Significant knee pain is prevalent after ACLR; with those who undergo subsequent ipsilateral surgery at greatest risk. The relationship between pain and structural OA warrants further study.

Construction of a fetal spatio-temporal cortical surface atlas from in utero MRI: Application of spectral surface matching

In this study, we construct a spatio-temporal surface atlas of the developing cerebral cortex, which is an important tool for analysing and understanding normal and abnormal cortical development. In utero Magnetic Resonance Imaging (MRI) of 80 healthy fetuses was performed, with a gestational age range of 21.7 to 38.9 weeks. Topologically correct cortical surface models were extracted from reconstructed 3D MRI volumes. Accurate correspondences were obtained by applying a joint spectral analysis to cortices for sets of subjects close to a specific age. Sulcal alignment was found to be accurate in comparison to spherical demons, a state of the art registration technique for aligning 2D cortical representations (average Fréchet distance≈0.4 mm at 30 weeks). We construct consistent, unbiased average cortical surface templates, for each week of gestation, from age-matched groups of surfaces by applying kernel regression in the spectral domain. These were found to accurately capture the average cortical shape of individuals within the cohort, suggesting a good alignment of cortical geometry. Each spectral embedding and its corresponding cortical surface template provide a dual reference space where cortical geometry is aligned and a vertex-wise morphometric analysis can be undertaken.

Meniscal repair with concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year follow-up

BACKGROUND

Meniscal repair is commonly performed concurrently with anterior cruciate ligament reconstruction (ACLR) in the acutely injured knee. No large-scale, prospective multicenter studies have evaluated the long-term success and patient-oriented outcomes after combined ACLR and meniscal repair.

PURPOSE

To define the operative success and patient-oriented outcome scores 6 years after combined meniscal repair and ACLR.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All ipsilateral primary ACLR and meniscal repair cases from a multicenter study group between 2002 and 2004 were selected. Validated patient-oriented outcome instruments were completed at 3 time points: preoperatively and then 2 and 6 years after the index procedure. Subsequent ipsilateral knee reoperations were confirmed by operative reports to evaluate for the failure of meniscal repairs.

RESULTS

In total, 286 patients with 1440 primary ACLRs underwent concurrent meniscal repairs (298 meniscal repairs). Of these, 235 (82.2%) were available for follow-up at 6 years (154 medial, 72 lateral, and 9 both lateral and medial meniscal repairs). Repaired menisci most commonly involved the peripheral one third of the meniscus (84%); patterns were typically longitudinal (84%) or displaced bucket-handle (10%), with a mean length of 16.5 ± 5.8 mm. Overall, the meniscal repair failure rate was 14% (medial: 21/154; lateral: 10/72; both: 2/9) at 6 years. Medial repairs failed earlier than lateral repairs (2.1 vs 3.7 years, respectively; P = .01). Significant improvements in outcome scores were sustained at 6-year follow-up. No differences in the suture number or type were detected between repair failures and successes. The rate of meniscal reoperations was higher in patients who underwent repair compared with those who did not have an identified meniscal injury at the time of ACLR (P < .01.

CONCLUSION

Concurrent meniscal repair with ACLR is associated with failure rates approximating 14% at 6-year follow-up. Improvements in patient-oriented outcome scores were sustained at 6-year follow-up. Surgeons may expect good clinical outcomes 6 years after combined ACLR and meniscal repair.

Total and unbound darunavir pharmacokinetics in pregnant women infected with HIV-1: results of a study of darunavir/ritonavir 600/100 mg administered twice daily

Objectives

Antiretroviral therapy during pregnancy is recommended to reduce the risk of mother-to-child transmission of HIV and for maternal care management. Physiological changes during pregnancy can affect pharmacokinetics, potentially altering pharmacological activity. We therefore evaluated the pharmacokinetics of twice-daily (bid) darunavir in HIV-1-infected pregnant women.

Methods

HIV-1-infected pregnant women receiving an antiretroviral regimen containing darunavir/ritonavir 600/100 mg bid were enrolled in this study. Total and unbound darunavir and total ritonavir plasma concentrations were obtained over 12 h during the second and third trimesters and postpartum. Total darunavir and ritonavir plasma concentrations were determined using a validated high-performance liquid chromatography tandem mass spectrometry assay and unbound darunavir was determined using ¹⁴C-darunavir-fortified plasma. Pharmacokinetic parameters were derived using noncompartmental analysis.

Results

Data were available for 14 women. The area under the plasma concentration–time curve from 0 to 12 h (AUC_12h) for total darunavir was 17–24% lower during pregnancy than postpartum. The AUC_12h for unbound darunavir was minimally reduced during pregnancy vs. postpartum. The minimum plasma concentration (C_min) of total and unbound darunavir was on average 43–86% and 10–14% higher, respectively, during pregnancy vs. postpartum. The antiviral response (< 50 HIV-1 RNA copies/mL) was 33% at baseline and increased to 73–90% during treatment; the percentage CD4 count increased over time. One serious adverse event was reported (increased transaminase). All 12 infants born to women remaining in the study at delivery were HIV-1-negative; four of these infants were premature.

Conclusions

Total darunavir exposure decreased during pregnancy. No clinically relevant change in unbound (active) darunavir occurred during pregnancy, suggesting that no dose adjustment is required for darunavir/ritonavir 600/100 mg bid in pregnant women.

Development of one-cell ovine embryos in two culture media under two gas atmospheres

The objective of this study was to develop a successful system for culturing one-cell ovine embryos through several cleavage divisions. One hundred and four one-cell embryos were collected from synchronized, FSH-treated ewes 48 hr after the onset of estrus and randomly placed in one of four culture treatments. The effect of glucose supplementation and reduced oxygen tension (20% vs. 5%) on embryo development was studied. Embryo development was quantitated by a cleavage index based on the number of completed cell divisions. The number of embryos completing at least two cell divisions when cultured in Brinster's Pyruvate Medium (BPM) was 7 26 and 9 26 , under 5% CO(2) in air and 90% N(2), 5% CO(2), 5% O(2), respectively, while 22 26 and 20 26 embryos divided when cultured in BPM supplemented with 0.1% glucose (BPM-G) under similar atmospheres. Mean cleavage indices for embryos cultured in BPM were 1.2 and 1.6 under 5% CO(2) in air and 90% N(2), 5% CO(2), 5% O(2), respectively, while embryos cultured in BPM-G had mean cleavage indices of 4.6 and 4.0, respectively. Results of this study indicate that one-cell ovine embryos can be successfully cultured through several cleavage divisions. Glucose supplementation was beneficial for one-cell ovine embryo development. Reducing the oxygen tension from 20 to 5% had no effect on embryo development, and there was no media x gaseous atmosphere interaction.

Effects of time on feed and post-mortem aging on palatability and lipid composition of crossbred Wagyu beef

Twenty-seven Wagyu-sired steers were fed for 90 (14 steers) or 170 (13 steers) days to study the effects of time on feed on palatability and fatty acid composition, and the effects of post-mortem aging time (2, 4 or 10 days) on palatability. Hot carcass weight, fat thickness, longissimus dorsi muscle area, yield grade, estimated kidney, pelvic and heart fat and maturity score were increased (p < 0.05) by an additional 80 days on the high concentrate feed, but marbling was not changed (p > 0.05). Feeding the high concentrate diet for 170 days increased Warner-Bratzler shear force values (p < 0.05) and tended to decrease tenderness (p > 0.05), flavor intensity and connective tissue scores. For the 90 day feeding group, 4 days of aging improved connective tissue score (p < 0.05) and tended to increase (p > 0.05) tenderness scores and decrease shear force, compared with 2 days of aging. For the 170 day feeding group, 10 days of aging improved (p < 0.05) shear force and all sensory attributes except flavor intensity, compared to 2 days of aging. An additional 80 days on feed decreased (p < 0.05) stearic acid and total saturated fatty acids (SFA) and generally increased (p < 0.05) monounsaturated fatty acids (MUFA), polyunsaturated fatty acids (PUFA), MUFA:SFA, and PUFA:SFA in subcutaneous fat and longissimus dorsi muscle. The cholesterol content of fat and muscle increased (p < 0.05) as time on feed increased. Ninety days on a high concentrate diet was adequate for yearling crossbred Wagyu steers to produce highly acceptable carcasses. The additional 80 days on feed produced little or no overall benefit and the steers became overfinished and less tender. Ten days post-mortem aging improved (p < 0.05) all palatability attributes except flavor intensity.

Lactate dehydrogenase isoenzyme patterns as a method of pregnancy detection in cattle

The objective of this study was to evaluate serum lactate dehydrogenase isoenzyme patterns in open and pregnant Holstein and Hereford cows as a method of detecting pregnancy. Serum samples were collected from 26 Holstein and 13 Hereford cows and lactate dehydrogenase isoenzyme patterns were examined by electrophoresis and quantitated by scanning densitometry. Lactate dehydrogenase isoenzyme(4) and LDH(5) were found in higher concentration (P </= .05) in pregnant versus open Holstein cows. Twelve of 14 and 10 of 12 Holstein cows were correctly diagnosed as being pregnant and open, respectively by examining differences in serum concentrations of isoenzymes LDH(4) and LDH(5). Pregnancy was detected as early as 36 days of gestation. No differences were found in serum LDH isoenzyme patterns between pregnant and open Hereford cows. However, differences (P </= .05) in concentration of all five LDH isoenzymes were observed between Holstein and Hereford cows, which may lend insight into the metabolic significance of the elevation of LDH(4) and LDH(5) in pregnancy. The results suggest that elevation of serum LDH(4) and LDH(5) may be used as a means of pregnancy detection in the Holstein but not the Hereford cow.

Effect of sperm exposure time on in vitro fertilization and embryo development of bovine oocytes matured in vitro

This study was designed to investigate the effect of sperm exposure time on the fertilization rate and subsequent developmental capacity of bovine oocytes matured in vitro. Cumulus oocyte complexes (COCs) obtained from 2 to 6 mm follicles were matured for 24 h in TCM-199 supplemented with fetal bovine serum (FBS) and hormones (FSH, LH and estradiol 17-beta). In vitro fertilization (IVF) was performed by incubating 15 to 20 matured oocytes with 1 x 10(6) percoll separated frozen-thawed spermatozoa in 1 ml of IVF-TL medium for either 4, 8, 12, 16, 20, 24 or 28 h. Following sperm exposure for different periods of times, the presumptive zygotes were co-cultured with Buffalo Rat Liver cells (BRLC) monolayers in CZB medium without glucose, a simple semi-defined medium developed for mouse embryo culture, for 3 d post-insemination and then in M199/FBS (TCM-199-HEPES supplemented with 20% heat-treated FBS and 1 mM sodium pyruvate) for 5 d. The fertilization rates differed significantly among the 7 treatment groups, with higher frequencies obtained by co-incubation of gametes for 20, 24 or 28 h (67 to 76%) than for 4, 8 and 12 h (26 to 54.5%), with 16 h (57%) being intermediate. However, the length of sperm exposure time did not significantly affect subsequent embryo development, although an increasing trend was noted from 4 h to 20 h. The number of fertilized oocytes at 3 d post-insemination cleaving to 2- to 4-cell vs 8-cell stage was not different among treatment groups. Development of 8-cell embryos to morulae and blastocysts did not differ among the treatment groups. These data suggest that the optimum duration of sperm-oocyte incubation is 24 h, and periods shorter than 16 h may result in a reduced fertilization rate.

The ability of fetal calf serum, new-born calf serum and normal steer serum to promote the in vitro development of bovine morulae

The objective of this study was to compare fetal calf serum, new-born calf serum and normal steer serum as medium supplements in the development of bovine morulae in vitro . Bovine morulae were cultured in Hams F-10 tissue culture medium (HF-10) supplemented with 5% or 10% (v/v) fetal calf serum (FCS), new-born calf serum (NBCS) or normal steer serum (NSS). Embryos were recovered at slaughter from mixed bred donor cows of mixed breeding following estrus synchronization with prostaglandin and superovulation with follicle stimulating hormone. A total of 88 morulae were recovered, washed in HF-10 + 1% Bovine Serum Albumin and randomly assigned to treatments. Embryos were cultured in microdrops of medium under paraffin oil at 37 degrees C in a 5% CO(2) humidified atmosphere. Observations for stage of development were made every 24 hours. In vitro development was analyzed by assigning to each embryo a value of 0-5 based on the most advanced stage reached (0= no development, 5= development to a hatched blastocyst). Analysis of variance of these data revealed a significant treatment effect (P<.001) while no level effect or treatment x level interaction was apparent. Comparison of treatment means by Duncans new mulitple range test showed that NSS was superior to NBCS (P<.05) which was in turn superior to FCS (P<.05) as supplements of HF-10 in promoting the in vitro development of bovine morulae.

Structural changes in freshwater fish and chironomids exposed to bacterial exotoxins

Mass fish mortalities have been reported in the past decade from British waters, often coinciding with blooms of filamentous actinobacteria, particularly strains of Streptomyces griseus. The present study has shown that some fractions of the exudate of S. griseus, prepared after a series of high pressure liquid chromatography (HPLC) separations, and analysed with liquid chromatography mass spectrometry (LC-MS), induced pathological changes to the gills of carp and/or tench fry following exposure under laboratory conditions up to 96 h Similar changes were induced by streptomycin, a secondary metabolite of S. griseus, and these included loss of microridging and fusion of secondary lamellae, with carp fry in the case of the exudate of S. griseus being more sensitive than tench fry, especially with exposure to fraction 9 and selected sub-fractions of 9. Some deformities using a severity index were also observed in the head capsule of larvae of the non-biting midge Chironomus riparius, including loss and splitting of teeth on the mentum. The results are discussed in relation to further identification of metabolites derived from samples of the organic filtrate of S. griseus and implications for the functioning of freshwater ecosystems.

Revision ACL reconstruction outcomes: MOON cohort

Many clinicians believe that the results of revision anterior cruciate ligament (ACL) reconstruction compare unfavorably with primary ACL reconstruction. However, few prospective studies have evaluated revision ACL reconstruction using validated patient-based metrics. This study was performed to evaluate and compare the results of revision ACL reconstruction and primary ACL reconstruction. The Multicenter Orthopaedic Outcomes Network consortium is an NIH-funded, hypothesis-driven, multicenter prospective cohort study of patients undergoing ACL reconstruction. All patients preoperatively complete a series of validated patient-oriented questionnaires. At scheduled 2-year follow-up all patients are given the same series of questionnaires to complete. The study evaluated the results of 2-year follow-up of revision ACL reconstruction performed in 2001. Parameters evaluated included Marx activity level, Knee Injury and Osteoarthritis Outcome Score (KOOS), and International Knee Documentation Committee (IKDC) scores. For this study 446 subjects met inclusion criteria; 2-year follow-up was obtained on 393 (88%). The study group consisted of 55% males with median age of 22 years. There were 33 revision ACL reconstruction cases, for which follow-up was available for 29 (88%). Median baseline Marx (interquartile range) was 12 (8 to 16) and 12 (6 to 16) for the primary ACL reconstruction and revision ACL reconstruction groups, respectively (p= 0.81). At 2 years, median Marx was 9 (4 to 13) and 5 (0 to 10) for the primary ACL reconstruction and revision ACL reconstruction groups, respectively (p= 0.03). Median 2-year IKDC was 75.9 (revision) versus 83.9 (primary) (p=0.003). Median KOOS subscale Knee Related Quality of Life (KRQOL) at 2 years was 62.5 (revision) versus 75 (primary) (p < 0.001), subscale Sports and Recreation was 75 (revision) and 85 (primary) (p = 0.005), subscale Pain was 83.3 (revision) and 91.7 (primary) (p= 0.002). Marx activity score declined at 2-year follow-up in revision ACL reconstruction compared with primary ACL reconstruction. IKDC and KRQOL were significantly decreased in revision ACL reconstruction compared with primary ACL reconstruction at 2-year followup. Revision ACL reconstruction resulted in a significantly worse outcome as measured by these patient-based measures at 2 years.

Lipid and endothelium-related genes, ambient particulate matter, and heart rate variability--the VA Normative Aging Study

BACKGROUND

Many studies have shown that exposures to air pollution are associated with cardiovascular events, although the mechanism remains to be clarified. To identify whether exposures to ambient particles act on autonomic function via the lipid/endothelial metabolism pathway, whether effects of particulate matter <2.5 mum in aerodynamic diameter (PM(2.5)) on heart rate variability (HRV) were modified by gene polymorphisms related to those pathways were evaluated.

METHODS

HRV and gene data from the Normative Aging Study and PM(2.5) from a monitor located a kilometre from the examination site were used. A mixed model was fitted to investigate the associations between PM(2.5) and repeated measurements of HRV by gene polymorphisms of apolipoprotein E (APOE), lipoprotein lipase (LPL) and vascular endothelial growth factor (VEGF) adjusting for potential confounders chosen a priori.

RESULTS

A 10 microg/m(3) increase in PM(2.5) in the 2 days before the examination was associated with 3.8% (95% CI 0.2% to 7.4%), 7.8% (95 CI 0.4% to 15.3%) and 10.6% (95% CI 1.8% to 19.4%) decreases of the standard deviation of normal-to-normal intervals, the low frequency and the high frequency, respectively. Overall, carriers of wild-type APOE, LPL and VEGF genes had stronger effects of particles on HRV than those with hetero- or homozygous types. Variations of LPL-N291S, LPL-D9N and APOE-G113C significantly modified effects of PM(2.5) on HRV.

CONCLUSION

Associations between PM(2.5) and HRV were modified by gene polymorphisms of APOE, LPL and VEGF; the biological metabolism remains to be identified.

Mass mortality and its environmental and evolutionary consequences

The latest Mesozoic and earliest Tertiary sediments at Deep Sea Drilling Project site 524 provide an amplified record of environmental and biostratographic changes at the end of Cretaceous. Closely spaced samples, representing time intervals as short as 10(2) or 10(3) years, were analyzed for their bulk carbonate and trace-metal compositions, and for oxygen and carbon isotopic compositions. The data indicate that at the end of Cretaceous, when a high proportion of the ocean's planktic organisms were eliminated, an associated reduction in productivity led to a partial transfer of dissolved carbon dioxide from the oceans to the atmosphere. This resulted in a large increase of the atmospheric carbon dioxide during the next 50,000 years, which is believed to have caused a temperature rise revealed by the oxygen-isotope data. The lowermost Tertiary sediments at site 524 include fossils with Cretaceous affinities, which may include both reworked individuals and some forms that survived for a while after the catastrophe. Our data indicate that many of the Cretaceous pelagic organisms became extinct over a period of a few tens of thousands of years, and do not contradict the scenario of cometary impact as a cause of mass mortality in the oceans, as suggested by an iridium anomaly at the Cretaceous-Tertiary boundary.

Determination of pentose phosphate and Embden-Meyerhof pathway activities in bovine embryos

Quantitative determination was made of the activity of pentose phosphate pathway (PPP) and Embden-Meyerhof pathway (EMP) in individual bovine embryos from the six-cell to the hatched blastocyst stage. Embryos were collected from superovulated cross-bred heifers and classified into good and poor categories. A single embryo in 1 microl of medium was mixed with 2 microl of medium containing 3 to 30 nCi radiolabeled glucose previously placed on a detached lid of the 1.5-ml polypropylene microcentrifugé vial. The lid was then fitted to its vial which had been loaded in advance with 1.5 ml of 0.1 N NaOH. Vials were then incubated at 37 degrees C for 3 h. At the end of the incubation period, a 1.5-ml NaOH trap was inverted and placed into a 20-ml scintillation vial containing 10 ml of aqueous counting solution and counted in a liquid scintillation spectrophotometer. The PPP activity in good-quality embryos was greatest at the six-cell stage and decreased with increasing embryo development. The EMP activity showed the reverse trend. Poor- quality embryos had a lower glucose metabolism and higher PPP activity. Similar measurements were made on embryos following 24 h of culture, and total glucose metabolism and percentage of PPP activity were increased. In conclusion, these data suggest that in good quality bovine embryos total glucose utilization is low until 16-cell stage, with PPP being the predominant pathway. Total glucose utilization increases significantly at the morula stage; EMP activity increases with increasing embryo development; and PPP activity increases significantly in poor quality embryos and in embryos 24 h in culture.

Toxic effects of Streptomyces griseus spores and exudate on gill pathology of freshwater fish

Many unexplained fish-kills in British waters are considered microbial in origin and a large proportion of field sites contains elevated concentrations of filamentous actinobacteria. The present study has shown that a strain of Streptomyces griseus, isolated from field sites, elicits pathological changes to the gills of fish under laboratory conditions which mirror those found in situ. These changes include hyperplasia leading to fusion of the secondary lamellae and loss of microridging on the filamental epithelium of the primary lamellae. Juveniles of up to six fish species were exposed to spore suspensions or exudate of S. griseus in the range of 1 x 10(2)-1 x 10(6)spores ml(-1) for up to 96 h. The exudate was more potent than the spores and there was a positive correlation between exudate concentration and the rate and extent of fish gill pathology with bream and rainbow trout being more sensitive than carp, tench and roach. The results are discussed in the context of recognising and managing potential fish mortalities caused by microbial toxins.

HLA A and B locus antigens in patients with unexplained hepatitis following halothane anaesthesia

HLA A and B locus antigens were determined in 17 patients who had recovered from unexplained hepatitis following halothane anaesthesia. The greatest deviations from expected frequencies were observed with A1, A11 and BW22, but these differences were not statistically significant when the P values were corrected for the number of antigens tested. Although a larger series might show such deviations to be significantly different, HLA typing is of no predictive value in determining those at risk to hepatitis following repeated halothane exposure.

Spontaneous Patchiness in a Host-Parasitoid Integrodifference Model

Observations of a host-parasitoid interaction in which victims are significantly less motile than their exploiters suggest the possibility of stable spatial pattern in a fairly homogeneous environment. Findings of pattern formation in continuous-time models are not fully able to account for this behavior. Those findings often rely on questionable biological conditions, and more fundamentally, the continuous nature of time in such models does not reflect the reality of the observed interaction. In this paper, we introduce a discrete-time spatial model of the interaction. The final state of our model is often a striking spatial pattern, similar to those observed. We analyze the model, describe its transient behavior, and find the conditions under which these spatial patterns occur, as well as an estimate of maximum possible patch size under those conditions. We also discuss the existence of such conditions in the natural system.

Suppression of HOX A cluster genes inhibits proliferation and induces cell death in human mixed-lineage leukemias

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Background: Leukemias harboring translocations of the mixed lineage leukemia locus (MLL) are generally associated with poor clinical prognosis. Using gene expression profiling we and others have previously shown that Homeobox (HOX) A cluster genes are highly expressed in leukemias with MLL rearrangements. Methods: Here we studied the role of aberrant HOXA9 expression in human MLL- rearranged and non-rearranged leukemias utilizing an shRNA mediated knockdown approach. Results: Three different shRNA constructs targeting human HOXA9 were synthesized and stably introduced into t(9;11) MOLM14 cells utilizing a lentiviral vector system. 75–80% HOXA9 RNA knockdown was confirmed by quantitative PCR and Western Blot analysis. In a panel of 17 AML/ALL cell lines (7 MLL rearranged, 10 non rearranged), HOXA9 directed shRNA inhibited cell proliferation starting as early as 48h after transduction, and induced apoptosis beginning at 72h. Interestingly, impaired cell proliferation and induction of apoptosis was significantly higher in the MLL rearranged cell lines (mean viability: 51.88%) than in the non-rearranged cells (mean viability: 90.98%; p=0.007) and also significantly correlated with the baseline HOXA9 mRNA expression before knockdown (R= 0.8, p=0.00017). We then further analyzed the effect of HOXA9 knockdown in MLL rearranged and non-rearranged primary human AML cells. Similar to our findings in cell lines, a marked induction of cell death was observed, which was significantly higher in leukemias with an MLL translocation (p=0.005) and also significantly correlated with the baseline HOXA9 mRNA expression (R= 0.8, p=0.001). Next, the in vivo effect of HOXA9 knockdown was assessed by transplanting luciferase-expressing SEMK2 (t4;11) cells into SCID-beige mice followed by in vivo bioluminescent imaging. Leukemia burden was significantly reduced in HOXA9 shRNA treated mice (n=10) with a peak difference at day 15 (p=0.000059) shortly before mice of the control group (n=10) succumbed from overt leukemia. At this point all mice of the HOXA9 shRNA treated group were still healthy with no signs of leukemia. Conclusions: Taken together our data implicates that depletion of HOXA9 might be a novel approach for targeted therapy in human MLL rearranged leukemias.

No significant financial relationships to disclose.