Identification of an Optimized Heating and Fast Ion Generation Scheme for the Wendelstein 7-X Stellarator

A Doppler shifted resonance minority species ion cyclotron range of frequency (ICRF) scheme for heating neutral beam ions has been identified and optimized for the Wendelstein 7-X stellarator. Compared with more conventional methods, the synergetic scheme increases the normalized core collisional power transfer to the background plasma, and induces larger concentrations of energetic ions. Simulations in the intricate 3D magnetic stellarator geometry reveal an energetic distribution function that is only weakly anisotropic, and is thus relevant to fast ion and alpha particle driven Alfvén eigenmode experimental preparation. Quasilinear theory and simulations of the Joint European Torus indicate that the excellent confinement properties are due to increased velocity diffusion from ICRF interaction along the magnetic field lines. Agreement is found between SCENIC simulations and Joint European Torus experimental measurements for the total neutron rate and the energy distribution of the fast ions.

Excitation Mechanism of Low-n Edge Harmonic Oscillations in Edge Localized Mode-Free, High Performance, Tokamak Plasmas

The excitation mechanism for low-n edge harmonic oscillations in quiescent H-mode regimes is identified analytically. We show that the combined effect of diamagnetic and poloidal magnetohydrodynamic flows, with the constraint of a Doppler-like effect of the ion flow, leads to the stabilization of short wavelength modes, allowing low-n perturbation to grow. The analysis, performed in tokamak toroidal geometry, includes the effects of large edge pressure gradients, associated with the local flattening of the safety factor and diamagnetic flows, sheared parallel and E×B rotation, and a vacuum region between plasma and the ideal metallic wall. The separatrix also is modeled analytically.

Treatment of ALK-rearranged non-small cell lung cancer: A review of the landscape and approach to emerging patterns of treatment resistance in the Australian context

Since the identification of anaplastic lymphoma kinase (ALK) gene rearrangements in non-small cell lung cancer (NSCLC) in 2005, the treatment of ALK-rearranged NSCLC (ALK+ NSCLC) has evolved at a rapid pace. This molecularly distinct subset of NSCLC has uniquely important biology, clinicopathologic features and mechanisms of drug resistance which impact on the choice of treatment for a patient with this disease. There are multiple ALK tyrosine kinase inhibitors now available in clinical practice with efficacy data continuing to emerge and guide the optimal treatment algorithm. A detailed search of medical databases and clinical trial registries was conducted to capture all relevant articles on this topic enabling an updated detailed overview of the landscape of management of ALK-rearranged NSCLC.

The role of canonical and non-canonical Hedgehog signaling in tumor progression in a mouse model of small cell lung cancer

Hedgehog (Hh) signaling regulates cell fate and self-renewal in development and cancer. Canonical Hh signaling is mediated by Hh ligand binding to the receptor Patched (Ptch), which in turn activates Gli-mediated transcription through Smoothened (Smo), the molecular target of the Hh pathway inhibitors used as cancer therapeutics. Small cell lung cancer (SCLC) is a common, aggressive malignancy with universally poor prognosis. Although preclinical studies have shown that Hh inhibitors block the self-renewal capacity of SCLC cells, the lack of activating pathway mutations have cast doubt over the significance of these observations. In particular, the existence of autocrine, ligand-dependent Hh signaling in SCLC has been disputed. In a conditional Tp53;Rb1 mutant mouse model of SCLC, we now demonstrate a requirement for the Hh ligand Sonic Hedgehog (Shh) for the progression of SCLC. Conversely, we show that conditional Shh overexpression activates canonical Hh signaling in SCLC cells, and markedly accelerates tumor progression. When compared to mouse SCLC tumors expressing an activating, ligand-independent Smo mutant, tumors overexpressing Shh exhibited marked chromosomal instability and Smoothened-independent upregulation of Cyclin B1, a putative non-canonical arm of the Hh pathway. In turn, we show that overexpression of Cyclin B1 induces chromosomal instability in mouse embryonic fibroblasts lacking both Tp53 and Rb1. These results provide strong support for an autocrine, ligand-dependent model of Hh signaling in SCLC pathogenesis, and reveal a novel role for non-canonical Hh signaling through the induction of chromosomal instability.

Mutant p53 upregulates alpha-1 antitrypsin expression and promotes invasion in lung cancer

Missense mutations in the TP53 tumor-suppressor gene inactivate its antitumorigenic properties and endow the incipient cells with newly acquired oncogenic properties that drive invasion and metastasis. Although the oncogenic effect of mutant p53 transcriptome has been widely acknowledged, the global influence of mutant p53 on cancer cell proteome remains to be fully elucidated. Here, we show that mutant p53 drives the release of invasive extracellular factors (the 'secretome') that facilitates the invasion of lung cancer cell lines. Proteomic characterization of the secretome from mutant p53-inducible H1299 human non-small cell lung cancer cell line discovered that the mutant p53 drives its oncogenic pathways through modulating the gene expression of numerous targets that are subsequently secreted from the cells. Of these genes, alpha-1 antitrypsin (A1AT) was identified as a critical effector of mutant p53 that drives invasion in vitro and in vivo, together with induction of epithelial-mesenchymal transition markers expression. Mutant p53 upregulated A1AT transcriptionally through the involvement with its family member p63. Conditioned medium containing secreted A1AT enhanced cell invasion, while an A1AT-blocking antibody attenuated the mutant p53-driven migration and invasion. Importantly, high A1AT expression correlated with increased tumor stage, elevated p53 staining and shorter overall survival in lung adenocarcinoma patients. Collectively, these findings suggest that A1AT is an indispensable target of mutant p53 with prognostic and therapeutic potential in mutant p53-expressing tumors.

Alterations of insulin-like growth factor-1 receptor gene copy number and protein expression are common in non-small cell lung cancer

Aims

Insulin-like growth factor-1 receptor (IGF1R) is a tyrosine kinase membrane receptor involved in tumourigenesis that may be a potential therapeutic target. We aimed to investigate the incidence and prognostic significance of alterations in IGF1R copy number, and IGF1R protein expression in resected primary non-small cell lung cancer (NSCLC), and lymph node metastases.

Methods

IGF1R gene copy number status was evaluated by chromogenic silver in situ hybridisation and IGF1R protein expression was evaluated by immunohistochemistry in tissue microarray sections from a retrospective cohort of 309 surgically resected NSCLCs and results were compared with clinicopathological features, including EGFR and KRAS mutational status and patient survival.

Results

IGF1R gene copy number status was positive (high polysomy or amplification) in 29.2% of NSCLC, and 12.1% exhibited IGF1R gene amplification. High IGF1R expression was found in 28.3%. There was a modest correlation between IGF1R gene copy number and protein expression (r=0.2, p<0.05). Alterations of IGF1R gene copy number and protein expression in primary tumours were significantly associated with alterations in lymph node metastases (p<0.01). High IGF1R gene copy number and protein expression was significantly higher in squamous cell carcinomas (SCC) compared with other subtypes of NSCLC (p<0.05). There were no other associations between IGF1R status and other clinicopathological features including patient age, gender, smoking status, tumour size, stage, grade, EGFR or KRAS mutational status or overall survival.

Conclusions

High IGF1R gene copy number and protein overexpression are frequent in NSCLC, particularly in SCCs, but they are not prognostically relevant.

Correlation of BRAF and NRAS mutation status with outcome, site of distant metastasis and response to chemotherapy in metastatic melanoma

BACKGROUND

The prognostic significance of BRAF and NRAS mutations in metastatic melanoma patients remains uncertain, with several studies reporting conflicting results, often biased by the inclusion of patients treated with BRAF and MEK (MAPK) inhibitors. We therefore interrogated a historical cohort of patients free of the confounding influence of MAPK inhibitor therapy.

METHODS

Patients with available archival tissue first diagnosed with metastatic melanoma between 2002 and 2006 were analysed. Mutational analysis was performed using the OncoCarta Panel. Patient characteristics, treatment outcome and survival were correlated with BRAF/NRAS mutation status.

RESULTS

In 193 patients, 92 (48%) melanomas were BRAF-mutant, 39 (20%) were NRAS-mutant and 62 (32%) were wild-type for BRAF/NRAS mutations (wt). There was no difference in response to chemotherapy based on mutation status (35-37%). The distant disease-free interval (DDFI) was significantly shorter in patients with wt melanoma (27.9 months vs 35.1 for BRAF and 49.1 for NRAS) although this was not significant in multivariate analysis. Survival from stage IV melanoma diagnosis was not significantly different based on mutation status. The DDFI was significantly shorter in patients with BRAF(V600K/R) versus BRAF(V600E) melanoma in univariate and multivariate analyses.

CONCLUSIONS

BRAF and NRAS mutation status does not influence survival in metastatic melanoma.

Phosphorylated Akt expression is a prognostic marker in early-stage non-small cell lung cancer

AIMS

To determine the prognostic significance of pAkt expression in order to identify high-risk stage IB patients with non-small cell lung cancer (NSCLC) in an exploratory study.

METHODS

We identified 471 consecutive patients with stage IB primary NSCLC according to the American Joint Commission on Cancer 6th edition tumour-node-metastasis (TNM) staging system, who underwent surgical resection between 1990 and 2008. Patients who received neoadjuvant or adjuvant treatments were excluded. Pathology reports were reviewed, and pathological characteristics were extracted. Expression of phosphorylated Akt (pAkt) in both cytoplasmic and nuclear locations was assessed by immunohistochemistry, and clinicopathological factors were analysed against 10-year overall survival using Kaplan-Meier and Cox proportional hazards model.

RESULTS

455 (96.6%) cancers were adequate for pAkt immunohistochemical analysis. The prevalence of pAkt expression in the cytoplasm and nucleus of the cancers was 60.7% and 43.7%, respectively. Patients whose cancers expressed higher levels of cytoplasmic pAkt had a trend towards longer overall survival than those with lower levels (p=0.06). Conversely, patients whose cancers expressed higher levels of nuclear pAkt had a poorer prognosis than those with lower levels of expression (p=0.02). Combined low cytoplasmic/high nuclear expression of pAkt was an independent predictor of overall survival (HR=2.86 (95% CI 1.35 to 6.04); p=0.006) when modelled with age (HR=1.05 (95% CI 1.03 to 1.07); p<0.001), extent of operation (HR=2.11 (95% CI 1.48 to 3.01); p<0.001), visceral pleural invasion (HR=1.63 (95% CI 1.24 to 2.15); p<0.001), gender, tumour size, histopathological type and grade (p>0.05).

CONCLUSIONS

Level of expression of pAkt in the cytoplasm and nucleus is an independent prognostic factor that may help to select patients with high-risk disease.

EGFR mutant-specific immunohistochemistry has high specificity and sensitivity for detecting targeted activating EGFR mutations in lung adenocarcinoma

AIM

We assessed the diagnostic accuracy of epidermal growth factor receptor (EGFR) mutant-specific antibodies for detecting two common activating EGFR mutations.

METHODS

Immunohistochemical expression of mutation-specific antibodies against EGFR exon 19 deletion E746-A750 ((c.2235_2249del15 or c.2236_2250del15, p. Glu746_Ala750del) and exon 21 L858R point mutation (c.2573T>G, p.Leu858Arg) were assessed in a cohort of 204 resected early stage node negative lung adenocarcinomas, and protein expression was compared with DNA analysis results from mass spectrometry analysis.

RESULTS

Of seven cases with L858R point mutation, six were positive by immunohistochemistry (IHC). There were three false positive cases using L858R IHC (sensitivity 85.7%, specificity 98.5%, positive predictive value 66.7%, negative predictive value 99.5%). All seven E746-A750 exon 19 deletions identified by mutation analysis were positive by IHC. Four additional cases were positive for exon 19 IHC but negative by mutation analysis. The sensitivity of exon 19 IHC for E746-A750 was 100%, specificity 98.0%, positive predictive value 63.6% and negative predictive value 100%.

CONCLUSIONS

Mutant-specific EGFR IHC has good specificity and sensitivity for identifying targeted activating EGFR mutations. Although inferior to molecular genetic analysis of the EGFR gene, IHC is highly specific and sensitive for the targeted EGFR mutations. The antibodies are likely to be of clinical value in cases where limited tumour material is available, or in situations where molecular genetic analysis is not readily available.

Magnetic reconnection triggering magnetohydrodynamic instabilities during a sawtooth crash in a Tokamak plasma

Thomson scattering measurements with subcentimeter spatial resolution have been made during a sawtooth crash in a Mega Ampere Spherical Tokamak fusion plasma. The unparalleled resolution of the temperature profile has shed new light on the mechanisms that underlie the sawtooth. As magnetic reconnection occurs, the temperature gradient at the island boundary increases. The increased local temperature gradient is sufficient to make the helical core unstable to ideal magnetohydrodynamic instabilities, thought to be responsible for the rapidity of the collapse.

Tokamak magnetohydrodynamic equilibrium states with axisymmetric boundary and a 3D helical core

Magnetohydrodynamic (MHD) equilibrium states with imposed axisymmetric boundary are computed in which a spontaneous bifurcation develops to produce an internal three-dimensional (3D) configuration with a helical structure in addition to the standard axisymmetric system. Equilibrium states with similar MHD energy levels are shown to develop very different geometric structures. The helical equilibrium states resemble saturated internal kink mode structures.

DLEC1 and MLH1 promoter methylation are associated with poor prognosis in non-small cell lung carcinoma

The significance of chromosome 3p gene alterations in lung cancer is poorly understood. This study set out to investigate promoter methylation in the deleted in lung and oesophageal cancer 1 (DLEC1), MLH1 and other 3p genes in 239 non-small cell lung carcinomas (NSCLC). DLEC1 was methylated in 38.7%, MLH1 in 35.7%, RARβ in 51.7%, RASSF1A in 32.4% and BLU in 35.3% of tumours. Any two of the gene alterations were associated with each other except RARβ. DLEC1 methylation was an independent marker of poor survival in the whole cohort (P=0.025) and in squamous cell carcinoma (P=0.041). MLH1 methylation was also prognostic, particularly in large cell cancer (P=0.006). Concordant methylation of DLEC1/MLH1 was the strongest independent indicator of poor prognosis in the whole cohort (P=0.009). However, microsatellite instability and loss of MLH1 expression was rare, suggesting that MLH1 promoter methylation does not usually lead to gene silencing in lung cancer. This is the first study describing the prognostic value of DLEC1 and MLH1 methylation in NSCLC. The concordant methylation is possibly a consequence of a long-range epigenetic effect in this region of chromosome 3p, which has recently been described in other cancers.

Prognostic significance of DNA repair proteins MLH1, MSH2 and MGMT expression in non-small-cell lung cancer and precursor lesions

Aims

To investigate the role of DNA repair proteins and their prognostic significance in non-small-cell lung cancer (NSCLC).

Methods and results

A retrospective analysis of 108 cases of stage I–II NSCLC was undertaken. Immunohistochemical expression of DNA repair proteins MLH1, MSH2 and MGMT was assessed using tissue microarrays of paraffin-embedded samples of invasive carcinoma and precursor lesions. Results were analysed in relation to clinicopathological parameters and patient survival. Reduced expression of MLH1 was found in 58.5% of tumours and occurred less frequently in poorly differentiated tumours (P = 0.044) and large cell carcinomas (P = 0.004). MSH2 and MGMT expression was reduced in 18.1% and 77.8% of cases, respectively. There was an inverse relationship between MLH1 and MSH2 expression (P = 0.012). Normal expression of MLH1, MSH2 and MGMT was found in all cases of squamous metaplasia and squamous dysplasia. Only a single case of carcinoma in situ (12.5%) showed reduced MLH1, none showed reduced MSH2 and 25% showed reduced MGMT. Survival analyses showed no prognostic significance based on expression of MLH1 (P = 0.92), MSH2 (P = 0.78) or MGMT (P = 0.57).

Conclusions

Reduction in expression of DNA repair proteins MLH1, MSH2 and MGMT is relatively common in NSCLC, appears to be a late event in the development of invasive malignancy and does not influence survival in this patient cohort.

Cooper W A, Kohonen-Corish M R J, Chan C, Kwun S Y, McCaughan B, Kennedy C, Sutherland R L & Lee C-S (2008) Histopathology52, 613–622

Prognostic significance of DNA repair proteins MLH1, MSH2 and MGMT expression in non-small-cell lung cancer and precursor lesions

"Rhabdoid meningioma" lacking malignant features. Report of two cases

We report 2 cases of meningiomas with rhabdoid morphology but lacking histological features of malignancy. Both occurred in adult women, one arising from the superior surface of the tentorium and the other in the Sylvian fissure. The tumors showed light microscopic, immunohistochemical and ultrastructural evidence of meningothelial differentiation together with diffuse or focal areas exhibiting rhabdoid morphology. The rhabdoid areas were characterized by cells with large cytoplasmic eosinophilic inclusions and large eccentric nuclei. Both cases showed areas with sheet-like growth and one had macronucleoli and brain invasion. The same case showed areas of necrosis that most likely related to pre-operative arterial embolization. Unlike most cases reported in the literature, these "rhabdoid meningiomas" lacked significant mitotic activity or other atypical features. The diagnostic and prognostic significance of this tumor entity is discussed along with a review of the literature.

1H NMR visible lipids are induced by phosphonium salts and 5-fluorouracil in human breast cancer cells

Cationic lipophilic phosphonium salts (CLPS) selectively accumulate in the mitochondria of neoplastic cells and inhibit mitochondrial function. The effects of the CLPS p-(triphenylphosphoniummethyl) benzaldehyde chloride (drug A), and [4-(hydrazinocarboxy)-1-butyl] tris-(4-dimethylaminophenyl) phosphonium chloride (drug B), on human breast cells of differing biological properties were assessed using growth inhibition assays and 1H NMR. Drug A and, to a lesser extent, drug B demonstrated selective growth inhibition of the highly tumorigenic DU4475 breast carcinoma cell line compared to the transformed HBL-100 human breast cell line. However, in contrast to previous studies using other cell lines, no synergistic activity was found when the drugs were used in combination. 1H NMR demonstrated significant increases in mobile lipid acyl chain resonances in both cell lines treated with cytotoxic doses (IC50, 48 h) of the drugs used either alone or in combination. Two-dimensional NMR revealed accompanying decreases in phosphocholine/Lys levels in HBL-100 cells treated with A, B, or a 1:1 combination A+B at the IC50, and in DU4475 cells treated with drug A (IC50). This was accompanied by significant increases in cho/Lys ratios with IC50 A or combination A+B treatment. Similar spectra were observed in cells treated with 5-fluorouracil but not methotrexate, indicating that mobile lipid accumulation is a general but not universal response to cytotoxic insult.

Management of bronchopleural fistula after lobectomy

Bronchopleural fistula after lobectomy is fortunately a rare complication. In years past, this complication was encountered far more frequently. However, the morbidity associated with this complication is still significant. Bronchopleural fistulas develop in patients who are at increased risk of surgical morbidity because of their concomitant medical problems or as a result of chemotherapy for lung cancer or immunosuppression in transplant patients. These patients often present in a moribund, septic state, making their treatment even more difficult. Nevertheless, evaluation and management of these patients should proceed in a logical stepwise fashion. Evaluation of the patient with a bronchopleural fistula should proceed in a logical, stepwise manner form diagnosis to pulmonary rehabilitation.

In vivo hemodynamic, histologic, and antimineralization characteristics of the Mosaic bioprosthesis

BACKGROUND

Performance of bioprosthetic valves is limited by tissue degeneration due to calcification with reduced performance and longevity. The Mosaic bioprosthetic valve (Medtronic Heart Valves, Inc, Minneapolis, MN) combines zero pressure fixation, antimineralization properties of alpha-amino oleic acid (AOA), and a proven stent design. We tested the hypothesis that AOA treatment of Mosaic valves improves hemodynamics, antimineralization properties, and survival in a chronic ovine model.

METHODS

Mitral valves were implanted in juvenile sheep with Mosaic valves with AOA treatment (n = 8) or without AOA treatment (non-AOA, n = 8), or Hancock I (HAN, n = 4) tissue valves, and explanted at 20 postoperative weeks.

RESULTS

Survival was equivalent in AOA and non-AOA (140 +/- 0.4 and 129 +/- 30 days), but was significantly less in HAN (82 +/- 35). Leaflet calcium (microgCa/mg tissue) was less in AOA (9.6 +/- 13.9; p < 0.05 versus non-AOA and HAN) than non-AOA (96.3 +/- 63.8) and HAN (130.8 +/- 43.2). Explant valve orifice area (cm2) was significantly preserved in the AOA group compared with the non-AOA group (1.5 +/- 0.7 vs 0.8 +/- 0.3; p < 0.05 versus non-AOA and HAN).

CONCLUSIONS

We conclude that AOA treatment of Mosaic valves reduces leaflet calcification and valve gradient in juvenile sheep, and that the Mosaic design and fixation features may offer survival advantages that must be confirmed in extended trials.

The surgical spectrum of pulmonary neuroendocrine neoplasms

OBJECTIVES

The purpose of this study is to review our experience with the spectrum of neuroendocrine neoplasms of the lung with emphasis on the histopathologic classification and surgical therapy of each class of neoplasm.

DESIGN

This retrospective review covers the entire spectrum of neuroendocrine neoplasms of the lung over an 11-year period (January 1985 to December 1995) in a university hospital setting. Only patients who underwent surgical resection were included in this review.

PATIENTS

During this period, a total of 77 patients underwent lung resection for the following neuroendocrine neoplasms: typical carcinoid (TC), 50 patients; atypical carcinoid (AC), 5 patients; large cell neuroendocrine carcinoma (LCNEC), 9 patients; mixed large-small cell neuroendocrine carcinoma (LSNEC), 4 patients; or small cell neuroendocrine carcinoma (SCC), 9 patients. There were 37 men (48.1%) and 40 women (51.9%) among the patients, with a mean age of 57.9 years (range, 14 to 87 years).

INTERVENTIONS

Primary surgical resection consisted of the following procedures: 52 lobectomies (67.5%); 10 pneumonectomies (13%); 13 limited resections (16.9%); 1 left main bronchus sleeve resection; and 1 carinal resection. Six patients had the following concomitant procedures: pericardiectomy, 2 patients; mediastinoscopy, 1 patient; chest wall resection, 1 patient; stapling blebs, 1 patient; and transdiaphragmatic liver biopsy, 1 patient. Four patients underwent bilobectomies, and two patients underwent multiple wedge resections.

RESULTS

The hospital mortality rate was 2.6% (2 of 77 patients), and both patients died of pulmonary failure. Follow-up was obtained in 62 of 77 patients (80.9%) for an average of 38.1 months (range, 2 to 132 months). There were a total of 13 deaths, and 8 were disease-related (LCNEC, 4 deaths; SCC, 2 deaths; LSNEC, 1 death; and AC tumor, 1 death. The mean disease-free intervals for patients with these neoplasms were the following: TC tumor, 41.3 months; AC tumor, 20 months; LCNEC, 20.4 months; LSNEC, 25 months; and SCC, 48 months. The overall 3-year survival rate was 45.2% (28 of 62 patients).

CONCLUSION

This report will emphasize the classification, surgical management, and treatment considerations of pulmonary neuroendocrine neoplasms. Despite the poor overall prognosis in high-grade neuroendocrine tumors of the lung, surgery remains a viable adjunct in the early stages of this disease.

Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis

BACKGROUND

Multiple organ failure after deep hypothermic circulatory arrest (DHCA) may occur secondary to endothelial dysfunction and apoptosis. We sought to determine if DHCA causes endothelial dysfunction and apoptosis in brain, kidney, lungs, and other tissues.

METHODS

Anesthetized pigs on cardiopulmonary bypass were: (1) cooled to 18 degrees C, and had their circulation arrested (60 minutes) and reperfused at 37 degrees C for 90 minutes (DHCA, n = 8); or (2) time-matched normothermic controls on bypass (CPB, n = 6). Endothelial function in cerebral, pulmonary, and renal vessels was assessed by vasorelaxation responses to endothelial-specific bradykinin (BK) or acetylcholine (ACh), and smooth muscle-specific nitroprusside.

RESULTS

In vivo transcranial vasorelaxation responses to ACh were similar between the two groups. In small-caliber cerebral arteries, endothelial relaxation (BK) was impaired in CPB vs DHCA (maximal 55% +/- 2% [p < 0.05] vs 100% +/- 6%). Pulmonary artery ACh responses were comparable between CPB (110% +/- 10%) and DHCA (83% +/- 6%), but responses in pulmonary vein were impaired in DHCA (109% +/- 3%, p < 0.05) relative to CPB (137% +/- 6%). In renal arteries, endothelial (ACh) responses were impaired in DHCA (71% +/- 13%) relative to CPB (129% +/- 14%). Apoptosis (DNA laddering) occurred primarily in duodenal tissue, with a greater frequency in DHCA (56%, p < 0.05) compared with normothermic CPB (17%) and nonbypass controls (0%).

CONCLUSIONS

DHCA is associated with endothelial dysfunction in cerebral microvessels but not in the in vivo transcranial vasculature; in addition, endothelial dysfunction was noted in large-caliber renal arteries and pulmonary veins. DHCA is also associated with duodenal apoptosis. Vascular endothelial dysfunction and apoptosis may be involved in the pathophysiology of multisystem organ failure after DHCA.

Penetrating cardiac trauma at an urban trauma center: a 22-year perspective

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

Latency alterations of the auditory brainstem response in audiogenic seizure-prone Long-Evans rats

Audiogenic seizure susceptibility in the normally seizure-resistant Long-Evans rat may result from altered processing in the auditory pathway. Representative waveform latencies of the auditory brainstem responses (ABR) were recorded to examine generator alterations at different levels of the auditory neuraxis. Male Long-Evans rats primed for audiogenic seizures (AGS) on PND 14 with a 10 kHz pure tone at 120 dB SPL for 8 min were tested for AGS on PND 28 with 120 dB SPL continuous white noise. Primed subjects displayed wild running culminating in clonic convulsions. Following behavioral testing at 4-6 months, vertex recordings of ABR waves Ia-VI were made in anesthetized subjects using pure tone stimulus bursts. AGS subjects showed marginally elevated ABR thresholds. Shorter ABR wave latencies were elicited in AGS subjects for peripheral and central auditory components with stimulus intensities above 50 dB PeSPL at 8 and 40 kHz. Interpeak intervals were reduced for waves Ia-V and III-V in AGS subjects. These results reveal that intense sound stimulation during a sensitive period of development later reduces processing time at higher intensity levels.

Estrogen treatment and age effects on auditory brainstem responses in the post-breeding Long-Evans rat

The auditory brainstem response (ABR) was recorded from 20-month-old Long Evans hooded female rats to determine if latency reductions occur from estrogen replacement. The ABR in these post-breeding age rats was also examined for reductions in response latencies as a function of adult age. Tone pip stimuli (8 and 40 kHz) were presented at 21, 51, or 81 s(-1). Aging control and ovariectomized animals showed slower response latencies for waves Ib-VI than young adults for 8 and 40 kHz stimulation at 21 s(-1). Increased stimulus rate resulted in longer latencies for all waves at 20 months. In contrast to hormone treatment effects in young adults, ABR latencies in post-breeding age estrogen-treated animals were not reduced, consistent with a general decrease in CNS responsiveness to estrogen steroids associated with age. The results also suggest that sensorineural modifications in the auditory system which prolong ABR latencies can occur early in the aging process of adult female subjects.

Modifying risk for extracorporeal circulation: trial of four antiinflammatory strategies

BACKGROUND

Despite recent rediscovery of beating heart cardiac surgical techniques, extracorporeal circulation remains appropriate for most heart operations. To minimize deleterious effects of cardiopulmonary bypass, antiinflammatory strategies have evolved.

METHODS

Four state-of-the-art strategies were studied in a prospective, randomized, preoperatively risk stratified, 400-patient study comprising primary (n = 358), reoperative (n = 42), coronary (n = 307), valve (n = 27), ascending aortic (n = 9), and combined operations (n = 23). Groups were as follows: standard, roller pump, membrane oxygenator, methylprednisolone (n = 112); aprotinin, standard plus aprotinin (n = 109); leukocyte depletion, standard plus a leukocyte filtration strategy (n = 112); and heparin-bonded circuitry, centrifugal pumping with surface modification (n = 67).

RESULTS

Analysis of variance, linear and logistic regression, and Pearson correlation were applied. Actual mortality (2.3%) was less than half the risk stratification predicted mortality (5.7%). The treatment strategies effectively attenuated markers of the inflammatory response to extracorporeal circulation. Compared with the other groups the heparin-bonded circuit had highly significantly decreased complement activation (p = 0.00001), leukocyte filtration blunted postpump leukocytosis (p = 0.043), and the aprotinin group had less fibrinolysis (p = 0.011). Primary end points, length of stay, and hospital charges, were positively correlated with operation type, age, pump time, body surface area, stroke, pulmonary sequelae, predicted risk for stroke, predicted risk for mortality, and risk strata/treatment group interaction (p = 0.0001). In low-risk patients, leukocyte filtration reduced length of stay by 1 day (p = 0.02) and mean charges by $2,000 to $6,000 (p = 0.05). For high-risk patients, aprotinin reduced mean length of stay up to 10 fewer days (p = 0.02) and mean charges by $6,000 to $48,000 (p = 0.0007).

CONCLUSIONS

These pharmacologic and mechanical strategies significantly attenuated the inflammatory response to extracorporeal circulation. This translated variably into improved patient outcomes. The increased cost of treatment was offset for selected strategies through the added value of significantly reduced risk.

Validation of surgeon-performed emergency abdominal ultrasonography in pediatric trauma patients

BACKGROUND/PURPOSE

The focused assessment for the sonographic evaluation of trauma patients (FAST) in adults is effective in detecting intraperitoneal and intrapericardial fluid and can be performed quickly by surgeons in the emergency department (ED). The authors sought to validate the accuracy of FAST performed by surgeons during ED resuscitation of pediatric trauma patients.

METHODS

Patients were assigned to one of three groups based on standard clinical criteria: immediate surgery, abdominal computed tomography (CT), or observation alone. FAST was then performed in the ED by a surgery resident (postgraduate year 3 or higher) or an attending trauma surgeon. Four views were used to assess the possible presence of fluid in the pericardial, subphrenic, subhepatic, and pelvic spaces. Time needed to conduct FAST was noted. Presence of peritoneal or pericardial fluid by FAST was compared with that determined by CT or surgery. Sensitivity, specificity, and predictive values were calculated. For those who did not undergo CT or surgery, FAST findings were compared with the clinical course.

RESULTS

Technically adequate studies could be performed on 192 of 196 eligible children. Their ages ranged from 3 months to 14 years (mean, 6.9 years); 119 were boys (62%), and 188 (98%) had sustained a blunt injury. FAST was performed in a mean time of 3.9 minutes (range, 1-17 minutes). All FAST examinations were reviewed by our senior surgeon-sonographer (GSR). Interrater agreement between the performing and reviewing surgeon-sonographer was 100%. Sixty (31%) patients underwent either abdominal CT (n = 56; mean Injury Severity Score (ISS), 9.6) or immediate operation (n = 4; mean ISS, 18.8). Of the 10 patients with verified presence of intraperitoneal fluid, eight had positive and two had false-negative FAST examination results. Of the 50 patients with verified absence of intraperitoneal fluid, none had a positive FAST (ie, no false-positives); sensitivity was 80%; specificity, 100%; predictive value positive, 100%; predictive value negative, 96%. None of the 132 patients followed up clinically without CT or surgery (mean ISS, 4.5) had fluid documented by FAST, and all did well.

CONCLUSIONS

The focused assessment for the sonographic evaluation of pediatric blunt trauma patients performed by surgical residents and attendings in the ED rapidly and accurately predicted the presence or absence of intraperitoneal fluid. The FAST is a potentially valuable tool to rapidly prioritize the need for laparotomy in the child with multiple injuries and extraabdominal sources of bleeding.

Induction of magnetic resonance-visible lipid in a transformed human breast cell line by tetraphenylphosphonium chloride

Proton magnetic resonance spectroscopy (1H MRS) and DNA flow cytometry were used to monitor the effects of the cationic lipophilic phosphonium salt and potential antineoplastic agent tetraphenylphosphonium chloride (TPP) on the transformed human breast cell line HBL-100. TPP treatment for 48 hr was cytostatic at low concentrations and cytotoxic at higher concentrations with an IC50 of 55 microM as measured by Trypan blue exclusion. At micromolar concentrations, TPP caused a significant increase in the methylene MR signal arising from mobile lipid as measured by the ratio of the lipid CH2 peak height to either the CH3 peak height (internal referencing) or the peak height for p-aminobenzoic acid (PABA) as an external reference in a co-axial capillary within the sample. Over the same concentration range, TPP caused a slowing of passage through S phase as demonstrated by a significant depletion of cells in G2/M phase with a concurrent but non-significant increase in cells in S. Time-dependent increases in MR-visible lipid were observed with 2 microM TPP treatment, and the removal of TPP from the culture medium caused no significant reduction in mobile lipid. Two-dimensional 1H-1H COSY spectra of TPP-treated HBL-100 cells revealed concentration-dependent increases in cross-peak volume ratios arising from lipid acyl chains relative to both internal (lysine, polyamines) and external (PABA) standards. Increases in choline and glycerophosphocholine cross-peak volume ratios were observed, indicating that the catabolism or rearrangement of phospholipids may be responsible for the observed MR-visible lipid increases.

Auditory brainstem responses after ovariectomy and estrogen replacement in rat

Previous work has suggested possible influences of ovarian hormones on evoked potentials in the auditory system. The aim of this project was to study the effects of ovariectomy and subsequent administration of estrogen replacement on the auditory brainstem response and the middle latency response. Groups of 90 day-old Long-Evans hooded rats were anesthetized for bilateral ovariectomies (ovex) and recordings made 3 weeks later. During the week prior to recordings some ovariectomized groups received subcutaneous injections of 10, 100 or 500 micrograms/kg Premarin in peanut oil, and other unoperated animals received vehicle injections. Recordings from vertex/chin using needle electrodes and pure tone stimulus parameters were made under Rompun/Ketamine. The results using 40 kHz tone stimuli showed that mean latencies for ovex animals were longer than animals in the 100 micrograms/kg Premarin group for waves 1a, 1an, 1b, 11, 111, 111n, and 1V/V. Other posthoc comparisons at 40 kHz stimulation revealed differences between control and 100 micrograms/kg Premarin groups for latencies of waves 1b, 1bn, 11 and 111. Latency reduction appeared for waves 1b, 1bn, 11 and 111 for the 10 ovex group, but only at wave 11 for the 500 ovex group, compared to ovex-only animals. Data from 8 kHz stimulation also demonstrated significant differences between the ovex and ovex 100 groups at waves 1bn and Vn. Observations of interpeak latency differences, especially between waves 1a and 11, suggested central as well as cochlear involvement in hormone action.(ABSTRACT TRUNCATED AT 250 WORDS)

Rate and frequency interactions in the auditory brainstem response of the adult rat

Tone pip stimuli were used at different repetition rates to examine influences upon auditory brainstem response components. Rate increases to 80.1/s result in significant latency increases in waves IV and V at all test frequencies. Rate effects occur in rostral brainstem response components which show frequency related latencies different from wave I. Amplitude measures decline at higher repetition rates for waves I and IV at most test frequencies. Rate effects are most pronounced at 8 kHz stimulation which is around the optimal behavioral frequency in rat. At higher rates the second peak of wave I is enhanced at 8 kHz, whereas the third peak of wave I at 40 kHz disappears. These results demonstrate that tone-specific stimuli provide sensitive measures of latency, amplitude and wave morphology of components of the auditory brainstem response as a function of stimulus repetition.

Comparison of SSPL90 selection procedures

Recommended SSPL90 values were determined at 500, 1000, and 2000 Hz for 16 subjects with mild-to-moderate sensorineural hearing losses using six different selection procedures, including an Upper Limit of Comfortable Listening (ULCL) and threshold-based procedure by Cox (1988), a threshold-based procedure by Seewald and Ross (1988), and loudness discomfort procedures by Berger (1988), McCandless and Lyregaard (1983), and Hawkins et al (1987) and Libby (1985). Statistically significant differences were found among the procedures at 500 and 2000 Hz. Analysis of individual data showed that while some subjects obtained similar recommended SSPL90s across the procedures, others showed dramatically different values.

Effect of reference microphone location and loudspeaker azimuth on probe tube microphone measurements

The effects of loudspeaker azimuth and reference microphone location on probe tube microphone measures were assessed. The real ear unaided response (REUR), real ear aided response (REAR), and real ear insertion response (REIR) were obtained on a KEMAR. Aided measures were obtained with both a behind-the-ear and an in-the-ear hearing aid. All three measurements were affected by changes in the loudspeaker azimuth and reference microphone location. Responses obtained with a 90 degree loudspeaker azimuth or with the reference microphone located at-the-ear revealed greater disparity than those obtained under other conditions. Most of the differences occurred at frequencies above 2000 Hz, with measurements utilizing the behind-the-ear hearing aid showing greater dispersion. These results suggest that the location of the loudspeaker and the reference microphone are important variables when utilizing probe tube microphone measurements.

Comparisons among SPLs in real ears, 2 cm3 and 6 cm3 couplers

Sound pressure levels (SPLs) were measured in the ear canals of 30 adult subjects with standard audiometric earphones (TDH-39) and insert earphones (Etymotic ER-3A) and compared to those generated in 2 cm3 and 6 cm3 couplers. Transfer functions are shown for real ear to 2 cm3 coupler, real ear to 6 cm3 coupler, 6 cm3 to 2 cm3 coupler, and dB HL under standard earphones to 2 cm3 coupler SPL. In general, the data agreed rather well with published transfer functions that in most cases were derived by adding together a series of partial transfer functions from various studies. The conversion values from dB HL to 2 cm3 coupler SPL could be useful in selection of certain hearing aid parameters, but the intersubject variability may limit their usefulness somewhat.

Auditory brainstem responses to tonal stimuli in young and aging rats

The auditory brain stem response (ABR) was studied in young adult and aged rats using 3,8 and 40 kHz tone pips. The expected inverse relationship between frequency and latency was observed in the younger group for waves I, II and III, while the response to the highest frequency stimulus had the longest latency at wave V. Absolute latencies for waves I through V each showed age-related increments with more pronounced changes occurring to 3 and 40 kHz stimuli than to the frequency of maximum sensitivity (8 kHz). Threshold increases with age for the highest frequency approximately doubled those for the lower frequencies. Examination of interpeak intervals (IPI) I-III, III-V and I-V revealed aging effects. The largest IPI I-V increment occurred to 3 kHz stimulation which reflects changes at both I-III and III-V sub-intervals. These results demonstrate electrophysiological correlates of aging due to transformations in the peripheral auditory system coupled with alterations in brainstem auditory pathways.

Use of probe tube microphone measurements in hearing aid selection for children: some initial clinical experiences

Some initial experiences are described in which ear canal probe tube microphone measurements are used to determine hearing aid settings for children. Decisions are based upon ideas developed by Seewald and Ross (in Amplification for the Hearing Impaired, New York: Grune & Stratton, 1988: 213-267) and Seewald, Ross, and Stelmachowicz (J Acad Rehab Aud 1987;20:25-37) in which the long term spectrum of speech is amplified to desired sensation levels. Case results from four children are used to demonstrate the application and usefulness of the procedure.

A comparison of three HA-1 couplers

The use of 2-cm3 couplers for measuring the output of an ER-3A earphone has been recommended. The purpose of this study was to compare the acoustic output of three commonly available couplers and to study the intra- and inter-examiner reliability with which those measurements may be performed. While the repeatability of measurements, at least for clinical purposes, was good even for hand-held coupling of the earphone to the couplers, differences between couplers were observed. These differences were influenced by the positioning of the sound-outlet orifice relative to the interior, top wall of the couplers' cavities. A recommendation for 2-cm3 coupler calibration of the ER-3A earphone using a commonly available adapter was made.

Development of auditory brainstem response to tone pip stimuli in the rat

The course of development of the auditory brainstem response (ABR) in rat was examined. Pure tone pip stimuli of 3, 8 and 40 kHz at intensities up to 106 dB sound pressure level peak equivalent were presented to anesthetized rats on postnatal days (PND) 9, 10, 12, 14, 16, 20, 24, 36, 70 and 96. The peak-to-peak amplitude and the order of appearance of each wave was examined at each stimulus parameter. The first response to presentation of an auditory stimulus was observed on PND 12. This response was demonstrated to be of non-neural origin and presumed to be a summating potential representing hair cell function in the cochlea. The first neural responses, observed on PND 14, to 3- and 8-kHz tones only, appeared as two or more waves. High-frequency (40 kHz) tones did not elicit any substantive neural response on PND 14, but neural activity to this stimulus was observed consistently by PND 16. By PND 20, 4 waves were present consistently at all test frequencies, and by PND 36 the full adult complement of 5 vertex positive waves was recorded. The frequency-dependent sequential appearance of waves during development lends support to data charting the development of frequency mapping in the cochlea. The amplitude of waves I and II at 8 kHz decreased as the animal matured, while waves III-V generally showed an initial increase in amplitude at all test frequencies through PND 24 followed by a gradual amplitude decrease to adult levels. Possible sources for developmental changes in amplitude are discussed.

Delayed feedback audiometry: reliability of repeated measures

The test-retest reliability of hearing thresholds at 1000 Hz measured by a delayed auditory feedback procedure was compared with the reliability of thresholds obtained with voluntary responses to the same signal in 10 adults with normal hearing sensitivity. Thresholds for each procedure were obtained three times on each of 5 different days. Although the delayed feedback procedure yielded estimates of threshold which averaged 4.6 dB greater than those estimated by voluntary responses (p less than 0.05), there was no evidence that experience over time resulted in a change for the poorer in the precision of the test.

Stimulus artefact reduction systems for the TDH-49 headphone in the recording of auditory evoked potentials

Standard audiometric transducers, such as the TDH-49, produce an electrical artefact which interferes with the recording of the early auditory evoked potentials. The sources of these artefacts have been identified as the capacitive and inductive coupling of the transducer and its leads to the recording electrodes. Artefacts were recorded using an artificial head with an M2-Cz electrode array for 500- and 3-kHz tone pips and positive, negative, and alternating polarity clicks at Peak Equivalent Sound Pressure Levels from 60 dB (positive click and 3-kHz tone pip) to 90 dB (alternating polarity click). The artefacts grew linearly with increases in intensity. Shifts in the Visual Detection Threshold of the artefacts produced by various conditions of shielding the transducer and its leads were explored. Acceptable reductions in artefact magnitude were obtained by enclosing the transducer in either an aluminium or mu-metal case connected through a braided-wire shield of the transducer leads to earth ground. Lesser reductions were achieved by the use of antiphase cancellation. The combination of the latter and the aluminum and mu-metal cases did not produce greater shifts in the visual detection threshold than the use of the aluminum and mu-metal cases alone. The fabrication of a pair of shielded enclosures is described and data are presented which show that they do not adversely affect the acoustic output of the headphones.

Pure tone delayed auditory feedback: effect of instructions

This study compared the effect of instructions to the subject upon key tapping performance with pure-tone delayed auditory feedback. One set of instructions stressed the importance of maintaining tapping rate whereas a second set emphasized consistency of the pattern. A third set stressed rate and pattern equality. The results lead to the recommendation that instructions stress equally both rate and pattern consistency.

Combining auditory and visual stimuli in the adaptive testing of speech discrimination

This investigation determined the feasibility of using both auditory and visual stimuli in the adaptive testing of speech discrimination. Thirty-six adults with normal hearing and vision were subjects. Using the adaptive methodology known as the Doublet technique, speech-discrimination testing using monosyllabic word lists from the Northwestern University Auditory Test No. 6 (NU-6) (Tillman and Carhart, 1966) was performed at the target levels of 29.3 and 70.7% for both auditory-only and auditory-visual conditions. The results indicated that a specific discrimination score could be obtained under more adverse listening conditions with the addition of visual cues. The contribution of visual cues was constant for the two target scores. The adaptive technique at the 29.3 and 70.7% targets was reliable for both the auditory-only and auditory-visual conditions. Constant level testing showed good agreement with the adaptive technique for the auditory-visual condition. In conclusion, the use of standard error calculations is useful in determining measurement errors and the effects of an aural rehabilitation program.

Pure tone delayed auditory feedback. Effect of hearing loss on disruption of tapping performance

Pure tone delayed auditory feedback audiometry was administered to 20 veterans with normal hearing at 1 kHz and a sensorineural hearing loss associated with noise exposure at 4 kHz. Absolute and relative time errors as well as pattern errors were analyzed for the group and for each individual. Mean data showed no difference between error measures for the two frequencies. However, individual data revealed that errors in the subjects' performance occurred at a level slightly closer to threshold at the frequency with the hearing loss (4 kHz) than at the frequency at which hearing was normal (1 kHz).

Filter effect of earmold venting: comparison of electroacoustic and psychoacoustic methods of evaluation

The filter effect of venting an earmold was evaluated by measuring the coupler-acoustic and threshold responses to open versus closed earmolds. In the coupler-acoustic technique the effect of venting was determined by measuring the output of the experimental earmolds seated on a modified 2-cc coupler with a specified signal impressed upon the earphone. The real ear threshold technique called for the determination of threshold by five listeners for the same earphone-earmold system. The data indicated that the difference between the coupler and threshold measures were of the same order of magnitude as the difference seen by other investigators reporting coupler and real ear-probe tube microphone measures. It was concluded that the threshold technique provides the same general description of the effects of venting an earmold as does the probe tube technique and should thus provide a useful method for determination of the filter effects produced by the venting of an earmold.