Intramural ectopic pregnancy: An individual patient data systematic review

Intramural pregnancies (IMP) are very rare and represent about 1% of ectopic pregnancies (EPs). Despite a few reported cases, there is limited awareness & knowledge among sonographers and physicians. Moreover, no established diagnostic or treatment protocol exists for such a condition. This study identifies and synthesizes what is known about IMP, including etiology and pathophysiology, common clinical presentations, imaging features, laparoscopic and hysteroscopic findings, and management. PUBMED and Google Scholar were queried to identify eligible studies. All articles on IMP in human subjects available in English and French languages were included. Other types of ectopic pregnancies, including cesarean scar and cervical ectopic pregnancies, were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and a narrative synthesis approach were used to systematically review the medical literature. 82 cases distributed around 27 countries with an average maternal age of 32.07 years and gestational age of 9.27 weeks were eventually selected for this study. History of curettage was the most common risk factor reported in 30 (36.58%) patients, followed by history of salpingectomy, assisted reproduction with embryo transfer, and previous cesarean delivery, in 10(12.19%), 10(12.19%), and 9(10.97%) patients respectively. Ultrasound was performed in 80(97.56%) cases. Of the 66 reported ultrasound findings, 29 were diagnostic or suggestive of IMP. MRI, laparoscopy (both diagnostic & surgical) and diagnostic hysteroscopy were carried out on 18(21.95%), 36(43.9%) and 22(26.83%) patients respectively. Histopathologic examination mainly performed after surgery was the gold standard for confirming the diagnosis. Management involved conservative (3.65%) approach, medical treatment with methotrexate or potassium chloride (23.17%), and surgical interventions. The latter includes laparoscopic surgery (25.61%), laparotomic surgery (23.17%), and hysterectomy (13.41%). IMP is a rare but potentially lethal clinical entity. A significant proportion of patients are asymptomatic and have no known risk factors. Correlation between clinical history and imaging findings is vital to establish a prompt diagnosis and reduce the risk of a catastrophic outcome.

Action guidance for addressing pollution from inhalational anaesthetics

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well‐being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare‐related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well‐established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action‐oriented recommendations, supported by useful resources and success stories. The CODA‐hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence‐based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.

Incarcerated gravid uterus: A rare but potentially devastating obstetric complication

Incarceration of the gravid uterus is a rare obstetric complication characterized by entrapment of the gravid uterus between the sacral promontory and pubic symphysis. Clinical symptoms are highly variable and may include low back pain, urinary retention, and nausea. A presumptive diagnosis can often be established based on correlation of clinical history and physical examination. However, ultrasound and/or pelvic magnetic resonance imaging are essential for confirmation. Herein, we describe a 30-year-old female who presented with uterine incarceration and discuss the diagnosis, imaging features, and management of this uncommon but important clinical entity.

Contrast-Enhanced Ultrasound Appearance of Hypervirulent Klebsiella pneumoniae Liver Abscesses

There has been a paradigm shift with Klebsiella pneumoniae (KP) emerging as the most frequently isolated bacterium in pyogenic liver abscesses in immunocompetent patients. Colonization of this hypervirulent KP strain has led to community-acquired liver abscesses. Septic seeding to distant sites of the body has been recognized and is strongly associated with diabetes. Contrast-enhanced computed tomographic features have been described. Grayscale ultrasound (US) features remain inconclusive, with variable US appearances. Here we describe the contrast-enhanced US features of KP liver abscesses, which correlated with previously described computed tomographic findings. The use of contrast-enhanced US eliminates the need for radiation exposure.

Clinical Importance and Natural History of Biliary Sludge in Outpatients

OBJECTIVES

Gallbladder sludge is a common diagnosis on routine abdominal sonography, yet its clinical importance is uncertain, especially in outpatients. To determine its natural history and potential future complications in this setting, we reviewed the imaging and clinical histories of nonhospitalized patients with a diagnosis of sludge on sonography.

METHODS

We conducted a retrospective search of our institutional radiology information system for all sonographic reports using the key words "biliary sludge without gallstones" over a 3-year period. For each of the 104 patients with isolated biliary sludge on initial sonography, we reviewed the electronic medical records and all imaging for the development of pancreaticobiliary complications.

RESULTS

We found an overall prevalence of biliary sludge in outpatients of 1.8%. Of the 104 patients reviewed with a mean follow up of 630 days (21 months), 25 developed a pancreaticobiliary complication, including cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis. The most frequent complication was cholecystitis, with a total of 14 diagnoses (12 chronic acalculous and 2 acute with gallstones). An additional 6 patients developed gallstones without cholecystitis features; 4 patients developed pancreatitis; and 1 developed choledocholithiasis. Biliary sludge remained quiescent or resolved in 76% of patients.

CONCLUSIONS

Biliary sludge always represents a pathologic process, but its clinical implications among outpatients have not been previously investigated. Our ambulatory population developed pancreaticobiliary complications at similar rates as prior mixed-patient setting studies. Regardless of the patient setting, biliary sludge is likely of more clinical importance than previously regarded.

The disruptive radiologist

Radiologists interact with many individuals during daily practice, including patients, technologists, and other physicians. Some interactions may potentially negatively affect patient care and are termed "disruptive" behaviors. These actions are not uncommon and may begin during training, long before a radiologist enters clinical practice. The causes of disruptive behavior are multifactorial, and it is important that educators and radiologists in practice alike be able to identify them and respond accordingly. An escalated approach for both trainees and practicing radiologists is recommended, with substantial penalties after each incident that can include termination of employment. Training programs and practices must have clearly defined methods for confronting this potentially time-consuming and difficult issue.

Utility of compact ultrasound in a mass surgical selection program in Africa: experience of a sonologist at the MV Africa Mercy Hospital Ship's screening day

Compact ultrasound (US) was introduced in an austere setting with no other available imaging for an annual mass surgical screening day. Compact US examinations were performed on 25 patients from more than 7000 potential patients, as deemed possibly useful by the screening surgeons. Of the 20 patients with recorded data, compact US was helpful in 14 of 20 as a decision-making tool, obviating computed tomography for preoperative planning. Compact US was helpful in most cases, saving resources (computed tomography), technologist time, and radiation risk in this select population.

Image quality in real-time teleultrasound of infant hip exam over low-bandwidth internet links: a transatlantic feasibility study

Evolution of communication systems, especially internet-based technologies, has probably affected Radiology more than any other medical specialty. Tremendous increase in internet bandwidth has enabled a true revolution in image transmission and easy remote viewing of the static images and real-time video stream. Previous reports of real-time telesonography, such as the ones developed for emergency situations and humanitarian work, rely on high compressions of images utilized by remote sonologist to guide and supervise the unexperienced examiner. We believe that remote sonology could be also utilized in teleultrasound exam of infant hip. We tested feasibility of a low-cost teleultrasound system for infant hip and performed data analysis on the transmitted and original images. Transmission of data was accomplished with Remote Ultrasound (RU), a software package specifically designed for teleultrasound transmission through limited internet bandwidth. While image analysis of image pairs revealed statistically significant loss of information, panel evaluation failed to recognize any clinical difference between the original saved and transmitted still images.

Compact ultrasound donations to medical facilities in low-resource countries: a survey-based assessment of the current status and trends

OBJECTIVES

Many ultrasound (US) specialists, independently or as part of institutionally directed teams, have donated compact US equipment and training to rural and urban clinics in low-resource regions. The objective of our study was to assess the scope, impact, and characteristics of these donation and training activities.

METHODS

We designed a 1-page, 10-question survey soliciting responses on donors, equipment, donation sites, training, and follow-up. Physicians and sonographers with qualifying donation experience were located by means of personal references, professional networking, and referral from US manufacturers. Respondents were also solicited at several online sites for medical imagers. The survey was active from May 2010 to March 2011 and was available via an interactive website (www.surveymonkey.com) or as an electronic download directly from the authors.

RESULTS

Fifteen respondents provided data on deployments spanning a 7-year period from 2004 to early 2011. Forty-eight compact US units were donated to sites in 15 different nations on 4 continents; 69% of the units went to sites in Africa. All but 4 sites received initial training. Donated systems were reported as "operational and functional" for all units for which the current status was available.

CONCLUSIONS

Results suggest involvement by a broad variety of participants. The number of successful deployments and excellent equipment durability support the premise that small-scale, individual donation and training activities have the potential for a substantial public health impact. The authors recommend better coordination of effort and the need for additional data.

Transgender female youth and sex work: HIV risk and a comparison of life factors related to engagement in sex work

This study examined the HIV risk behaviors and life experiences of 151 transgender female youth, ages 15–24, in Los Angeles and Chicago. Descriptive analyses and logistic regression modeling were used to identify life factors associated with ever having engaged in sex work. Sixty-seven percent of participants had ever engaged in sex work and 19% self-reported being HIV positive. Many factors were significantly associated with sex work for this sample population. A final multivariate logistic regression model found that lower education status, homelessness, use of street drugs, and perceived social support remained significantly associated with sex work when controlling for other factors. Findings highlight the complex HIV risk environment and suggest a need for sex work initiation research for transgender female youth. HIV prevention efforts for this population need to include broad-based approaches that take into account individual, social, and community-level factors relevant to the lives of transgender female youth.

Compact ultrasound for improving maternal and perinatal care in low-resource settings: review of the potential benefits, implementation challenges, and public health issues

OBJECTIVE

Ultrasound imaging, a front-line diagnostic tool for perinatal care, is rarely available in the developing world, where maternal and newborn mortality rates are starkly higher than elsewhere. The development of portable and inexpensive medical ultrasound machines (compact ultrasound) offers the possibility of broader use of ultrasound. Our objective was to assess the potential benefits and challenges of deploying compact ultrasound in developing countries for improving obstetric health.

METHODS

Existing literature on perinatal care, compact ultrasound, and issues in the deployments of medical technology in low-resource settings was reviewed. Anecdotal evidence was assessed, and the authors' field experiences in Nicaragua and Mali were evaluated as a template for wider deployments.

RESULTS

Few published studies directly concerned with compact ultrasound in low-resource settings were found. These, however, in combination with available anecdotal data, support the view that compact ultrasound in less-developed regions is feasible and would result in a relatively low-cost improvement in perinatal care.

CONCLUSIONS

The development of lightweight, portable, and relatively inexpensive ultrasound systems offers a great opportunity for reducing maternal and neonatal mortality in low-resource settings. Evidence-based analysis of compact ultrasound deployments as a public-health response to obstetric needs in less-developed countries has been hampered by limited data in 3 key areas: maternal and perinatal mortality and morbidity in these settings, evaluations of compact ultrasound systems as reliable alternatives to full-sized systems, and the lack of outcomes data based on actual deployments of compact ultrasound for this purpose. Field trials of compact ultrasound on a scale commensurate with public health interventions should be undertaken.

Clinical and immunologic effects of intranodal autologous tumor lysate-dendritic cell vaccine with Aldesleukin (Interleukin 2) and IFN-{alpha}2a therapy in metastatic renal cell carcinoma patients

PURPOSE

To evaluate the clinical and immunologic outcomes of DC (dendritic cell) vaccine with interleukin (IL)-2 and IFN-alpha 2a in metastatic renal cell carcinoma patients.

EXPERIMENTAL DESIGN

Eighteen consented and eligible patients were treated. Peripheral blood monocytes were cultured ex vivo into mature DCs and loaded with autologous tumor lysate. Treatment consisted of five cycles of intranodal vaccination of DCs (1 x 10(7) cells/1 mL Lactated Ringer's solution), 5-day continuous i.v. infusion of IL-2 (18MiU/m2), and three s.c. injections of IFN-alpha 2a (6MiU) every other day. Response Evaluation Criteria in Solid Tumors criteria were used for disease assessment. Correlative immunologic end points included peripheral blood lymphocyte cell phenotype and function as well as peripheral blood anti-renal cell carcinoma antibody and cytokine levels.

RESULTS

All patients received between two and five treatment cycles. Toxicities consisted of known and expected cytokine side effects. Overall objective clinical response rate was 50% with three complete responses. Median time to progression for all patients was 8 months, and median survival has not been reached (median follow up of 37+ months). Treatment-related changes in correlative immunologic end points were noted and the level of circulating CD4(+) T regulatory cells had a strong association with outcome. Pre-IP-10 serum levels approached significance for predicting outcome.

CONCLUSIONS

The clinical and immunologic responses observed in this trial suggest an interaction between DC vaccination and cytokine therapy. Our data support the hypothesis that modulation of inflammatory, regulatory, and angiogenic pathways are necessary to optimize therapeutic benefit in renal cell carcinoma patients. Further exploration of this approach is warranted.

The chorionic bump in an ectopic pregnancy

The chorionic bump, an irregular, convex bulge of the choriodecidual surface into the gestational sac (GS), is a recently described, uncommon abnormality of the 1st-trimester GS and is associated with a guarded prognosis for early pregnancy. The case of this 42-year-old female demonstrates a previously unreported relationship: a transvaginal sonographic finding of a chorionic bump associated with a spontaneous tubal ectopic pregnancy. This might support the hypothesis that the chorionic bump represents a small hematoma that bulges into the GS.

A tele-ultrasound system for real-time medical imaging in resource-limited settings

Ultrasound has great potential as an imaging technology in resource-limited environments. We present a novel tele-ultrasound approach designed to realize that potential by connecting a remote technician to a radiologist. Our preliminary system, based on open-source software and commercial off-the-shelf hardware, uses custom software and a satellite Internet connection to create this link. We also present the results of testing this system in both laboratory and real-world environments.

Clinical impact of systematic genetic sonogram screening in a low-risk population

OBJECTIVE

To determine the clinical impact of a genetic sonogram (GS) on a population at low risk for trisomy 21 (T21).

STUDY DESIGN

A GS evaluating common major and minor markers was created and prospectively applied to consecutive women at 15-20 weeks' gestation presenting for routine ultrasound and at low T21 risk. Prenatal diagnosis (PND) referral occurred if 1 major marker, 2 minor markers, major malformation or choroid plexus cysts (CPCs) were seen. Neonatal outcomes were determined by chart review for neonates born at our institution and by letter for those born elsewhere. Using an ultrasound database, a similar population was identified prior to study inception and the GS retrospectively applied. PND referrals in both periods were confirmed by chart review. The rates of isolated minor marker (IMM), positive GS and PND referrals were compared using chi2 analysis.

RESULTS

IMM detection was unchanged (43 of 434, 10.1%) in the study vs. (23 of 243, 9.5%) control group. Excluding CPCs, 6 of 18 (33.3%) subjects of vs. 2 of 28 (7.1%) controls with IMM were referred for prenatal diagnosis (p < 0.03). The frequency of positive GS was unchanged: 14 of 434 (3.2%) subjects vs. 5 of 243 (2.1%) controls.

CONCLUSION

Currently no prospectively studied, effective ultrasound models exist for screening low-risk populations at 15-20 weeks. A GS with clear criteria for counseling on an increased T21 risk decreased inappropriate referrals without increasing positive screens.

The feasibility of real-time transmission of sonographic images from a remote location over low-bandwidth Internet links: a pilot study

OBJECTIVE

We sought to show that sonography can be performed in teleconference settings, "telesonography," in which a remotely located sonography interpreter can monitor the examination in real-time and guide the examiner with voice commands while the patient simultaneously undergoes imaging, albeit at low resolution, thus helping to overcome the lack of trained operators in certain areas.

CONCLUSION

This system of image transfer offers the potential for sonography to be performed at a remote underdeveloped region and interpreted in real-time at a distant site by trained radiologists, thereby extending the presence of physicians in virtual space.

Developing a rational tumor vaccine therapy for renal cell carcinoma: immune yin and yang

In patients with progressive malignancy, the natural balance between proinflammatory (Yang) and inhibitory (regulatory or Yin) immune pathways is disrupted and favors cancer-specific immune suppression. Therapy with interleukin 2 (IL-2) can mobilize immune effector cells that recognize and destroy cancer. High-dose IL-2 is the only therapy that has consistently induced complete durable remissions in patients with metastatic renal cell carcinoma (RCC) but only in a few of them. The lack of benefit in most metastatic RCC patients is likely due to the ineffective manipulation of other immune circuits critical in regulating tumor cytotoxic pathways. The limited clinical activity of IL-2, RCC vaccines, and other immune therapies to date leads us to postulate that effective clinical treatment strategies will need to simultaneously enhance proinflammatory pathways and disrupt regulatory pathways. We present preliminary studies in RCC patients to highlight the complexity of the regulatory pathways and our approach to shifting the balance of proinflammatory and regulatory immune pathways using dendritic cell-tumor lysate vaccine followed by cytokine therapy.

Analysis of the acute postoperative pain experience following oral surgery: identification of 'unaffected', 'disabled' and 'depressed, anxious and disabled' patient clusters

BACKGROUND

Pain is defined as both a sensory and an emotional experience. Acute postoperative tooth extraction pain is assessed and treated as a physiological (sensory) pain while chronic pain is a biopsychosocial problem. The purpose of this study was to assess whether psychological and social changes occur in the acute pain state.

METHODS

A biopsychosocial pain questionnaire was completed by 438 subjects (165 males, 273 females) with acute postoperative pain at 24 hours following the surgical extraction of teeth and compared with 273 subjects (78 males, 195 females) with chronic orofacial pain. Statistical methods used a k-means cluster analysis.

RESULTS

Three clusters were identified in the acute pain group: 'unaffected', 'disabled' and 'depressed, anxious and disabled'. Psychosocial effects showed 24.8 per cent feeling 'distress/suffering' and 15.1 per cent 'sad and depressed'. Females reported higher pain intensity and more distress, depression and inadequate medication for pain relief (p < 0.001). Distress and depression were associated with higher pain intensity. The developed questionnaire had tested reliability (test-retest r = 0.89) and estimated validity.

CONCLUSION

Cluster analysis showed constituent groups with a range of psychosocial effects in acute postoperative dental extraction pain and is associated with an increase in pain intensity.

The chorionic bump: a first-trimester pregnancy sonographic finding associated with a guarded prognosis

OBJECTIVE

We describe a series of patients with a previously unreported sonographic finding, the chorionic "bump," which is an irregular, convex bulge from the choriodecidual surface into the first-trimester gestational sac. The pregnancy outcome is investigated in this series of patients and compared with the general population and infertility first-trimester control groups.

METHODS

We prospectively noted a cohort of 15 cases with the chorionic bump on first-trimester sonograms (in a total of 2178 patients) performed over 3 years at our institution (prevalence, 0.7%). We then compared pregnancy outcomes against 2 pregnant control groups (15 general, noninfertility patients and 15 infertility patients) who were maternal age and gestational age matched to our patient group.

RESULTS

The difference in outcomes between the patients with bumps and the healthy control subjects was statistically significant (7 live births versus 13 live births; P < .03), but the difference in outcomes between the patients with bumps and infertility control subjects was not statistically significant (7 live births versus 11 live births; P = .1). Bump size was not correlated with pregnancy outcome. In most patients with serial sonograms, the bump showed evolutionary changes typical for hematoma.

CONCLUSIONS

The finding of a chorionic bump on the first-trimester sonogram is associated with a guarded prognosis for the early pregnancy (live birth rate <50%); it probably represents a small hematoma that bulges into the gestational sac, and, in our series, most patients had a history of infertility treatments.

Multiple endocrine neoplasia 2A due to a unique C609S RET mutation presents with pheochromocytoma and reduced penetrance of medullary thyroid carcinoma

OBJECTIVE

We have identified a large kindred with multiple endocrine neoplasia 2A (MEN 2A) due to a mutation at RET codon 609 that results in a cysteine to serine substitution, a mutation previously identified in only one case in the literature. We characterized the clinical phenotype of the kindred and the biochemical mechanism of this new mutation.

PATIENTS AND DESIGN

The index case, a 42-year-old woman, presented with pheochromocytoma. We screened 29 family members for the presence of the mutation. Of the 15 mutation-positive family members, 11 agreed to undergo further evaluation by physical examination, calcium and pentagastrin-stimulated calcitonin levels, measurement of urinary metanephrines, adrenal imaging and serum calcium levels. Biochemical characterization of the mutation was by transient transfection of human neuroblastoma cells and Western blot analysis.

RESULTS

This kindred demonstrated an inheritance pattern consistent with autosomal dominant pheochromocytoma. Strikingly, no clinically evident case of medullary thyroid cancer (MTC) was observed among mutation-positive family members. Thyroidectomy in six cases revealed C-cell hyperplasia in all and microscopic MTC in two cases. Transfection experiments using human neuroblastoma cells showed that the mutant RET, unlike the wild-type receptor, is constitutively phosphorylated in the absence of ligand, and thus resembles other previously characterized MEN 2A mutations.

CONCLUSIONS

The identification of a new mutation causing a MEN 2A phenotype that features pheochromocytoma and the surprising absence of clinically apparent MTC has significant implications for carriers of this mutation and provides further insights into the genotype-phenotype correlation in MEN 2A.

Waveguide surface plasmon resonance studies of surface reactions on gold electrodes

We describe the fabrication and characterisation of gold-coated graded index channel waveguide sensors designed for simultaneous electrochemical and surface plasmon resonance studies. The active sensing electrode area is a thin gold film between 0.5 and 5 mm in length and 200 microm wide deposited on top of a 3 microm wide waveguide which forms one arm of a Y-junction while the other arm of the Y-junction serves as a reference. Using these devices we have measured simultaneously the changes in transmittance through the device whilst carrying out cyclic voltammetry in either sulfuric or perchloric acid solution or during the deposition of an UPD layer of copper at the gold surface. In all cases we obtain stable and reproducible results which demonstrate the very high sensitivity of the devices to sub-monolayer changes occurring at the gold electrode surface. The response of these integrated optoelectrochemical devices is discussed in terms of a numerical model for the propagation of light within the waveguide structure.

Waveguide surface plasmon resonance sensor for electrochemically controlled surface reactions

Electrochemical oxidation of the surface of a thin gold film overlaid on an optical waveguide and placed in a cell containing sulfuric acid is monitored by integrated optical surface plasmon resonance (IOSPR) combined with cyclic voltammetry. Waveguide transmittance correlates well with the charge transferred to and from the electrode to oxidize and reduce the surface, with a 60% reduction in transmittance being observed for complete formation of the surface oxide. IOSPR sensors combined with electrochemical measurement and control show potential for sensitive and robust integrated multisensors for electroactive species.

What I need to know about anthrax today

The US Department of Defense has been concerned about the use of anthrax as a biological weapon by an enemy on US troops for a number of years. This is the reason why the military has embarked on a vaccination program for its forces deployed to regions of the world, which are considered high-risk areas. These areas have been in the Southwest Asia-Persian Gulf region as well as the Korean Peninsula. Many intelligence personnel have also been concerned about the possibility of biological agents being used by terrorists in the Continental United States. The recent anthrax incidents in Florida and elsewhere in the United States have significantly heightened concerns along these lines, especially following the terrorist attacks on the World Trade Center and the Pentagon on September 11th. The death of a Florida businessman, identification of infection in one of his co-workers, evidence of exposure and in some instances, cutaneous infection in some others, as well as evidence of contamination in their buildings, raised further concerns of the possibility of terrorist activity using biological warfare in this country. It is somewhat ironic that a disease that you probably haven't heard about since medical school has become the focus of national attention. Our goal in this communication is to refresh your understanding of what anthrax is and what you need to know about it today since anthrax is counted among the weapons of mass destruction. As a member of the medical profession, you will need to know what to look for in patients and how to treat them if they are contaminated with this biological agent. You will also have to serve as the "front line" of the public health system and alert the police and public health agencies.

Phase I pilot trial of the bispecific antibody MDXH210 (anti-Fc gamma RI X anti-HER-2/neu) in patients whose prostate cancer overexpresses HER-2/neu

The goal of this study was to evaluate, in patients with prostate cancer, the toxicity profile and biologic activity of the bispecific antibody MDXH210, which has specificity for the non-ligand-binding site of the high-affinity immunoglobulin G receptor (Fc gamma RI) and the extracellular domain of the HER-2/neu proto-oncogene product. Patients with prostate cancer that expressed HER-2/neu were entered into a phase I dose-escalation trial of MDXH210. Patients received an intravenous infusion MDXH210 during a period of 2 h three times per week for 2 weeks and were monitored for toxicity. Pharmacokinetic and pharmacodynamic parameters were measured and included the biologic end points of monocyte-bound MDXH210, cytokine production, and clinical response. Seven patients were treated with MDXH210 doses ranging from 1 to 8 mg/m2. In general, MDXH210 was well tolerated, with only mild infusion-related malaise, fever, chills, and myalgias. No dose-limiting toxic effects were observed. Biologic effects included induction of low plasma concentrations of tumor necrosis factor-alpha and interleukin-6 observed immediately after MDXH210 infusion and 70% saturation of circulating monocyte-associated Fc gamma RI with MDXH210 at a dose level of 4 to 8 mg/m2. Five of six patients had stable prostate-specific antigen levels during the course of 40 days or more. Circulating plasma HER-2/neu levels decreased by 80% at days 12 and 29 (p = 0.03 and 0.06, respectively, by the Wilcoxon signed rank test). MDXH210 can be given safely to patients with HER-2/neu-positive prostate cancer in doses of at least 8 mg/m2. At the doses studied, biologic activity was demonstrated and characterized by binding of MDXH210 to circulating monocytes, release of monocyte-derived cytokines, a decrease in circulating HER-2/neu, and short-term stabilization of prostate-specific antigen levels.

Ion-exchanged tapered-waveguide laser in neodymium-doped BK7 glass

We report what is to our knowledge the first operation of a planar dielectric tapered-waveguide laser. The waveguide laser is fabricated by potassium-ion exchange in Nd(3+) -doped BK7 glass and consists of a single-mode channel waveguide of a few micrometers' width followed by a linear taper up to a broad region with a width of ~180microm . A slope efficiency of 42% is found both in the tapers and in standard channel waveguides fabricated upon the same substrate, indicating that the tapers and the channels have similar internal losses; hence the low-loss nature of the tapered beam expansion. The output from either end of the tapered structure is found to be nearly diffraction limited.

Prevalence and significance of heterogeneous testes revealed on sonography: ex vivo sonographic-pathologic correlation

OBJECTIVE

Heterogeneous or mottled testes in middle-aged or elderly men are often encountered on sonography. To determine the prevalence, cause, and significance of this finding, we examined 50 testes (25 pairs) from autopsy specimens with sonography and gross and microscopic pathology.

SUBJECTS AND METHODS

Testicles were obtained at autopsy from a series of 25 male cadavers (age range, 16-80 years; mean, 62 years). Eight subjects had a history of cancer. Ex vivo sonography was performed and two board-certified radiologists graded the testis by consensus as normal, heterogeneous, or "other abnormality" (cyst, dilated rete, echogenic focus, or halo). Microscopic pathology was obtained in all abnormal (sonographic or gross pathologic) testes. The severity of tubular sclerosis (atrophy) was graded on a scale of 0-3+ by a uropathologist. RESULTS; No testicular tumors were detected. Sonography revealed normal testes in 33 specimens, heterogeneous in seven specimens, and other in 10 specimens (one cyst, two dilated rete, three halos, and seven echogenic foci). Histology revealed that all seven cases of mottled or heterogeneous testis corresponded to extensive (grades 2 and 3) regions of tubular sclerosis (atrophy). A new sonographic finding of the "halo" was attributable to a thickened, adherent tunica albuginea.

CONCLUSION

The prevalence of heterogeneous testes in this elderly population was 14% and represented seminiferous tubule atrophy and sclerosis. The prevalence of clinically occult testicular cancer or metastases in this autopsy subject group was nil. Older patients with a mottled or heterogeneous testis, normal color Doppler flow, and no palpable abnormality probably do not need sonographic follow-up.

Clinical outcome in female patients with pelvic pain and normal pelvic US findings

PURPOSE

To understand the clinical outcome in patients with pelvic pain and negative pelvic ultrasonographic (US) findings.

MATERIALS AND METHODS

Data from 86 female patients with pelvic pain and normal pelvic US findings seen in a US section over a 15-month period were evaluated 6-21 months after US. Medical chart review follow-up was available in 86 patients, and telephone interview follow-up was conducted in 85 patients. We collected data on the outcome of pain; subsequent imaging, treatment, and surgery; and the duration of pain before US.

RESULTS

Pelvic pain improved or resolved in 66 (77%) of the 86 patients. In the group with acute or subacute pain (duration </= 6 months), 62 (86%) of the 72 patients (19 with acute pain and 53 with subacute pain) had improvement or resolution of symptoms. In the group with chronic pain (duration > 6 months), seven (50%) of the 14 patients had improved symptoms. Further imaging (13 studies) was performed in nine patients: Twelve studies were normal, and one computed tomographic scan (1 month after the first US examination) showed diverticulitis. Eleven patients underwent 19 surgical procedures (endometrial sampling, hysteroscopy, laparoscopy, or hysterectomy). Four demonstrated clinically important disease (endometriosis and pelvic varices, endometriosis, adenomyosis, or pelvic adhesions).

CONCLUSION

The majority of patients with pelvic pain and normal pelvic US findings had improvement or resolution of their symptoms, and those with acute or subacute pain were more likely to report improvement or resolution of pain than those with chronic pain. The yield of further imaging studies was low, and disease was identified in a minority of patients.

A randomized phase II trial comparing two different sequence combinations of autologous vaccine and human recombinant interferon gamma and human recombinant interferon alpha2B therapy in patients with metastatic renal cell carcinoma: clinical outcome and analysis of immunological parameters

PURPOSE

The clinical observation of spontaneous regression in patients with renal cell carcinoma (RCC) and the response to various immunotherapeutic therapies strongly suggest a role for the host immune system in this disease. Prior studies showed that sequential administration of interferon (IFN) gamma and IFN alpha to RCC patients was safe. Clinical responses as well as immune changes in the peripheral blood mononuclear cell compartment were observed. Autologous tumor cell vaccines (AV) have also demonstrated activity in renal cell carcinoma. We hypothesize that the addition of AV to sequential IFN gamma and a therapy might improve the tumor-specific immune response by providing an appropriate source of antigen in the appropriate cytokine environment. To our knowledge, this is the first trial using AV combined with IFN alpha and IFN gamma. The purpose of this study was to evaluate the feasibility of manufacturing and administering (AV) from resected tumor samples, and administration of AV with combination IFN gamma and IFN alpha therapy. Finally, the impact on immunological parameters of these treatment options was assessed.

MATERIALS AND METHODS

Patients with metastatic RCC were randomly assigned to receive AV plus bCG along with a sequential administration of IFN gamma and a either together or after initiation of vaccine. Toxicity and clinical responses were evaluated. Modulations of the immune system were investigated by analyzing phenotype, cytokine mRNA expression, T cell proliferation and cytotoxicity in the peripheral blood mononuclear cell compartment.

RESULTS

Fourteen patients with metastatic renal cell carcinoma were enrolled in this study; 9 were available for response evaluation. In a 70 day period, 3 (33%) showed mixed responses, 5 (56%) stable disease and 1 (11%) progression of disease. Toxicities were consistent with previous clinical reports. In the flow-cytometry phenotype analysis, stimulation of distinct subsets of circulating T-lymphocytes and a decrease of CD8+ T cell subsets was demonstrated. T-cell proliferation to allogeneic tumor cell stimulation improved following treatment. IL-4 and IL-5 mRNA levels were reduced in all patients after treatment. Patients who responded to treatment did not produce any IL-4 mRNA at all, before or after treatment.

CONCLUSIONS

AV with IFNgamma and IFNalpha therapy might induce a MHC class-mediated cytotoxic T lymphocyte (CTL) response. We suggest that adequate therapy might direct T cell response toward a Th1 type response. We hypothesize a state of improved immune readiness in patients who might eventually respond to immunotherapy.

Sensitivity enhancement of integrated optical sensors by use of thin high-index films

The proportion of power carried in the superstrate medium by the guided modes of integrated optical waveguides can be increased by the addition of a thin high-index film. Enhanced refractive-index sensing is demonstrated with channel waveguide Mach-Zehnder interferometers with Ta(2)O(5) overlays. Sensitivity increases by a factor greater than 50, and a detection limit better than 5 x 10(-7) is obtained. This approach is broadly applicable to sensing at waveguide surfaces where the strength of evanescent fields dictates performance.

Consistency of retrospective triage decisions as a standardised instrument for audit

OBJECTIVES

To determine the level of agreement between senior medical staff when asked to perform retrospective case note review of nursing triage decisions, both before and after development of a consensus approach.

METHODS

Four medical reviewers independently allocated triage categories to 50 emergency department patients after review of their case notes. They were blind to the identity of the triage nurse and their triage categorisation. The process was repeated twice, firstly after agreement on a consensus approach and then using formal guidelines.

RESULTS

Agreement between reviewers was initially fair to moderate (kappa = 0.27 to 0.53). This failed to improve after development of a consensus approach (kappa = 0.29 to 0.57). There was a trend towards better agreement when guidelines were used but agreement was still only moderate (kappa = 0.31 to 0.63).

CONCLUSIONS

Audit of nurse triage categorisation by senior medical staff performing case note review has only fair to moderate consistency between reviewers. Use of this technique will result in frustration among those whose performance is being audited if they recognise inconsistency in the standard they are compared against.

The Australian health system: continuity and change

The health of Australians, with the exception of Aboriginals and Torres Strait Islanders, compares favourably with other industrialised nations. Since 1984, universal access for citizens to medical and public hospital services has been achieved under a national Health Insurance Scheme called Medicare, partially funded by a 1.4 percent levy on all taxpayers. Medicare found early widespread support from the electorate but continues to be buffeted by a minority coalition of some medical associations, private health insurers, and conservative "libertarian" politicians. Over the decade since its inception, Medicare has provided stability in maintaining total health costs around 8 percent of GDP. This has been largely due to capping hospital costs via Commonwealth-State agreements. Medicare has failed in the past five years to contain medical costs which have increased proportionally with increases in the medical workforce. This article examines the structure and performance of Medicare and its role within Australia's overall health system. Benefits of a universal access insurance program are outlined together with challenges associated with inequities in health status, geography, aging of the population, burgeoning technology, ideological diversity, and an economic climate requiring cost containment and favouring privatisation and the role of the market. It can be concluded that, despite these challenges, universal access to health care is here to stay. Australia's Medicare program has become popular with the electorate.

Integrated optical surface plasmon resonance immunoprobe for simazine detection

This paper presents the detailed design and characterisation of a regenerable integrated optical surface plasmon resonance immunoprobe as a detector for the triazine herbicide simazine. A sensor design theoretically optimised for use in the aqueous environment is presented and its fabrication described. Experimental results on the sensitivity to changes in bulk refractive index of the analyte and on non-specific binding of ovalbumin are presented. Binding inhibition immunoassays were conducted for simazine and the lower limit of detection determined to be 0.16 microgram/l using anti-simazine IgG antibodies and 0.11 microgram/l using anti-simazine Fab fragments. A sample test cycle of 20 min was established.

Focal aneurysmal dilatation of subchorionic vessels simulating chorioangioma

Subchorionic vascular aneurysms of the placenta are rare lesions and may present confusion with chorioangioma or focal mesenchymal dysplasia on sonography. To our knowledge, the findings of placental aneurysms have not been reported in the ultrasound literature. We present a case with detailed sonographic evaluation, including spectral and color Doppler and pathological analysis, that was mistaken for chorioangioma prenatally. Knowledge of this benign entity may allow the sonologist to recommend conservative management in similar cases.

Interactive 3-dimensional computerized tomography reconstruction in evaluation of the living renal donor

PURPOSE

We evaluated the efficacy of helical computerized tomography and a software program capable of 3-dimensional (D) reconstruction in assessment of the living renal donor.

MATERIALS AND METHODS

A total of 20 consecutive patients (40 renal units) were evaluated using computer software and anatomical findings were assessed. Patient time and charges were compared with renal angiography and excretory urography (IVP).

RESULTS

A total of 25 anomalies were identified in 21 kidneys using 3-D imaging. Accessory arteries were seen in 13 kidneys. Abnormal venous anatomy was found in 7 kidneys, including circumaortic renal veins in 2, multiple veins in 4 and a renal vein that drained into the gonadal vein in 1. Collecting system anomalies included a bifid pelvis and a duplicate ureter in 1 case each. Benign cysts were noted in 3 kidneys. Three patients were excluded from study due to persistent hypertension, death of the recipient before transplantation and bilateral aberrant vasculature, respectively. Intraoperative findings of the 17 kidneys removed for transplantation correlated with those demonstrated on 3-D reconstruction. Total preoperative imaging charges were decreased 50% compared to renal angiography and IVP, and the procedure related discomfort and potential morbidity were reduced significantly. Procedure time was reduced from 7 hours to 30 minutes with no resultant mandatory time off work or periprocedure restrictions in patient diet and/or activity.

CONCLUSIONS

The enhanced 3-D computerized tomography reformation and reconstruction process appears to be as accurate as renal angiography for arterial anatomy, and more sensitive than renal angiography and IVP in evaluating venous and parenchymal anatomy. This software program provides superior and interactive imaging at substantially lower cost with minimal patient time, discomfort and morbidity.

Prostate seed implant quality assessment using MR and CT image fusion

PURPOSE

After a seed implant of the prostate, computerized tomography (CT) is ideal for determining seed distribution but soft tissue anatomy is frequently not well visualized. Magnetic resonance (MR) images soft tissue anatomy well but seed visualization is problematic. We describe a method of fusing CT and MR images to exploit the advantages of both of these modalities when assessing the quality of a prostate seed implant.

METHODS AND MATERIALS

Eleven consecutive prostate seed implant patients were imaged with axial MR and CT scans. MR and CT images were fused in three dimensions using the Pinnacle 3.0 version of the ADAC treatment planning system. The urethra and bladder base were used to "line up" MR and CT image sets during image fusion. Alignment was accomplished using translation and rotation in the three ortho-normal planes. Accuracy of image fusion was evaluated by calculating the maximum deviation in millimeters between the center of the urethra on axial MR versus CT images. Implant quality was determined by comparing dosimetric results to previously set parameters.

RESULTS

Image fusion was performed with a high degree of accuracy. When lining up the urethra and base of bladder, the maximum difference in axial position of the urethra between MR and CT averaged 2.5 mm (range 1.3-4.0 mm, SD 0.9 mm). By projecting CT-derived dose distributions over MR images of soft tissue structures, qualitative and quantitative evaluation of implant quality is straightforward.

CONCLUSIONS

The image-fusion process we describe provides a sophisticated way of assessing the quality of a prostate seed implant. Commercial software makes the process time-efficient and available to any clinical practice with a high-quality treatment planning system. While we use MR to image soft tissue structures, the process could be used with any imaging modality that is able to visualize the prostatic urethra (e.g., ultrasound).

Secondary ion yields produced by keV atomic and polyatomic ion impacts on a self-assembled monolayer surface

A suite of keV polyatomic or 'cluster' projectiles was used to bombard unoxidized and oxidized self-assembled monolayer surfaces. Negative secondary ion yields, collected at the limit of single ion impacts, were measured and compared for both molecular and fragment ions. In contrast to targets that are orders of magnitude thicker than the penetration range of the primary ions, secondary ion yields from polyatomic projectile impacts on self-assembled monolayers show little to no enhancement when compared with monatomic projectiles at the same velocity. This unusual trend is most likely due to the structural arrangement and bonding characteristics of the monolayer molecules with the Au(111). Copyright 1999 John Wiley & Sons, Ltd.