Noninferiority of Artificial Intelligence-Assisted Analysis of Ki-67 and Estrogen/Progesterone Receptor in Breast Cancer Routine Diagnostics

Image analysis assistance with artificial intelligence (AI) has become one of the great promises over recent years in pathology, with many scientific studies being published each year. Nonetheless, and perhaps surprisingly, only few image AI systems are already in routine clinical use. A major reason for this is the missing validation of the robustness of many AI systems: beyond a narrow context, the large variability in digital images due to differences in preanalytical laboratory procedures, staining procedures, and scanners can be challenging for the subsequent image analysis. Resulting faulty AI analysis may bias the pathologist and contribute to incorrect diagnoses and, therefore, may lead to inappropriate therapy or prognosis. In this study, a pretrained AI assistance tool for the quantification of Ki-67, estrogen receptor (ER), and progesterone receptor (PR) in breast cancer was evaluated within a realistic study set representative of clinical routine on a total of 204 slides (72 Ki-67, 66 ER, and 66 PR slides). This represents the cohort with the largest image variance for AI tool evaluation to date, including 3 staining systems, 5 whole-slide scanners, and 1 microscope camera. These routine cases were collected without manual preselection and analyzed by 10 participant pathologists from 8 sites. Agreement rates for individual pathologists were found to be 87.6% for Ki-67 and 89.4% for ER/PR, respectively, between scoring with and without the assistance of the AI tool regarding clinical categories. Individual AI analysis results were confirmed by the majority of pathologists in 95.8% of Ki-67 cases and 93.2% of ER/PR cases. The statistical analysis provides evidence for high interobserver variance between pathologists (Krippendorff's α, 0.69) in conventional immunohistochemical quantification. Pathologist agreement increased slightly when using AI support (Krippendorff α, 0.72). Agreement rates of pathologist scores with and without AI assistance provide evidence for the reliability of immunohistochemical scoring with the support of the investigated AI tool under a large number of environmental variables that influence the quality of the diagnosed tissue images.

Self-Diffusion in Amorphous Silicon by Local Bond Rearrangements

Experiments on self-diffusion in amorphous silicon (Si) were performed at temperatures between 460 to 600° C. The amorphous structure was prepared by Si ion implantation of single crystalline Si isotope multilayers epitaxially grown on a silicon-on-insulator wafer. The Si isotope profiles before and after annealing were determined by means of secondary ion mass spectrometry. Isothermal diffusion experiments reveal that structural relaxation does not cause any significant intermixing of the isotope interfaces whereas self-diffusion is significant before the structure recrystallizes. The temperature dependence of self-diffusion is described by an Arrhenius law with an activation enthalpy Q=(2.70±0.11)  eV and preexponential factor D_{0}=(5.5_{-3.7}^{+11.1})×10^{-2}  cm^{2} s^{-1}. Remarkably, Q equals the activation enthalpy of hydrogen diffusion in amorphous Si, the migration of bond defects determining boron diffusion, and the activation enthalpy of solid phase epitaxial recrystallization reported in the literature. This close agreement provides strong evidence that self-diffusion is mediated by local bond rearrangements rather than by the migration of extended defects as suggested by Strauß et al. (Phys. Rev. Lett. 116, 025901 (2016)PRLTAO0031-900710.1103/PhysRevLett.116.025901).

Sample size requirements for the design of reliability study: review and new results

The reliability of continuous or binary outcome measures is usually assessed by estimation of the intraclass correlation coefficient (ICC). A crucial step for this purpose is the determination of the required sample size. In this review, we discuss the contributions made in this regard and derive the optimal allocation for the number of subjects k and the number of repeated measurements n that minimize the variance of the estimated ICC. Cost constraints are discussed for both normally and non-normally distributed responses, with emphasis on the case of dichotomous assessments. Tables showing optimal choices of k and n are given along with the guidelines for the efficient design of reliability studies.

QSAR of Nitro-diphenylethers as Inhibitors of Cyclic Photophosphorylation

A number of 25 nitro-diphenylethers have been synthesized and assayed for their inhibitory activity in N-methylphenazonium-methosulfate mediated cyclic photophosphorylation. Their pI50-values were in the range from 3.5 to 5.3. A QSAR-analysis revealed that the lipophilicity of the nitro-diphenylethers as expressed by ∑π played a major role. In addition, the Taft steric parameter Es in positions 6′, 4′ and 2′ (in decreasing order) contributed to the inhibitory activity. For maximal biological activity, positions 4′ and 6′ should be left unsubstituted whereas a bulky substituent is required for position 2′.

Propensity scores used for analysis of cluster randomized trials with selection bias: a simulation study

Cluster randomized trials (CRTs) are often prone to selection bias despite randomization. Using a simulation study, we investigated the use of propensity score (PS) based methods in estimating treatment effects in CRTs with selection bias when the outcome is quantitative. Of four PS-based methods (adjustment on PS, inverse weighting, stratification, and optimal full matching method), three successfully corrected the bias, as did an approach using classical multivariable regression. However, they showed poorer statistical efficiency than classical methods, with higher standard error for the treatment effect, and type I error much smaller than the 5% nominal level.

Biofunctional electrolyte-gated organic field-effect transistors

The surface modification of solution-gated organic field-effect transistors is investigated. The introduction of different surface groups leads to a control of the pH sensitivity, determined by the pKa value of the added surface moiety. Together with the successful demonstration of enzyme modification of the surface, this work reveals the large potential of organic SGFETs for biosensor applications.

[Endoscopic calcaneoplasty (ECP) in Haglund's syndrome. Indication, surgical technique, surgical findings and results]

INTRODUCTION

Posterior calcaneal exostosis treatment modalities have given rise to many controversial opinions. After failure of the conservative treatment, surgical bursectomy and resection of the calcaneal exostosis are indicated by many authors. But clinical studies also show a high rate of unsatisfactory results with a relative high incidence of complications. The minimally invasive surgical technique by an endoscopic calcaneoplasty (ECP) could be an option to overcome some of these problems.

MATERIAL AND METHOD

Between 1999 und 2010 we operated 164 patients with an age range between 16 and 67 years, 81 males and 83 females. The radiological examination prior to surgery documented in all cases a posterior superior calcaneal exostosis that showed friction to the Achilles tendon. All patients included in the study had no clinical varus of the hind foot, nor cavus deformities. All patients had undergone a trial of conservative treatment for at least 6 months and did not show a positive response. The average follow-up was 46.3 (range: 8-120) months.

RESULTS

According to the Ogilvie-Harris score 71 patients presented good and 84 patients excellent results, while 5 patients showed fair results, and 4 patients only poor results. All the post-operative radiographs showed sufficient resection of the calcaneal spur. In 61 patients the preoperative MRI showed a partial rupture of the Achilles tendon close to the insertion side. In no case could we observe a complete tear at the time of follow-up. Only minor postoperative complications were observed. In many patients we could observe a chondral layer at the posterior aspect of the calcaneus. Close to the intersion the Achilles tendon showed also in many patients a chondroide metaplasia.

CONCLUSION

ECP is an effective and minimally invasive procedure for the treatment of patients with calcaneal exostosis. After a short learning curve the endoscopic exposure is superior to the open technique, has less morbidity, less operating time, and nearly no complications. Moreover, the pathology can be better differentiated.

Impact of CONSORT extension for cluster randomised trials on quality of reporting and study methodology: review of random sample of 300 trials, 2000-8

OBJECTIVE

To assess the impact of the 2004 extension of the CONSORT guidelines on the reporting and methodological quality of cluster randomised trials.

DESIGN

Methodological review of 300 randomly sampled cluster randomised trials. Two reviewers independently abstracted 14 criteria related to quality of reporting and four methodological criteria specific to cluster randomised trials. We compared manuscripts published before CONSORT (2000-4) with those published after CONSORT (2005-8). We also investigated differences by journal impact factor, type of journal, and trial setting.

DATA SOURCES

A validated Medline search strategy. Eligibility criteria for selecting studies Cluster randomised trials published in English language journals, 2000-8.

RESULTS

There were significant improvements in five of 14 reporting criteria: identification as cluster randomised; justification for cluster randomisation; reporting whether outcome assessments were blind; reporting the number of clusters randomised; and reporting the number of clusters lost to follow-up. No significant improvements were found in adherence to methodological criteria. Trials conducted in clinical rather than non-clinical settings and studies published in medical journals with higher impact factor or general medical journals were more likely to adhere to recommended reporting and methodological criteria overall, but there was no evidence that improvements after publication of the CONSORT extension for cluster trials were more likely in trials conducted in clinical settings nor in trials published in either general medical journals or in higher impact factor journals.

CONCLUSION

The quality of reporting of cluster randomised trials improved in only a few aspects since the publication of the extension of CONSORT for cluster randomised trials, and no improvements at all were observed in essential methodological features. Overall, the adherence to reporting and methodological guidelines for cluster randomised trials remains suboptimal, and further efforts are needed to improve both reporting and methodology.

Rectourethral fistula following LDR brachytherapy

Modern LDR brachytherapy has drastically reduced rectal toxicity and decreased the occurrence of rectourethral fistulas to <0.5% of patients. Therefore, symptoms of late-onset sequelae are often ignored initially. These fistulas cause severe patient morbidity and require interdisciplinary treatment. We report on the occurrence and management of a rectourethral fistula which occurred 4 years after (125)I seed implantation.

Behavior pattern A and compliance with antihypertensive treatment

An analysis was performed on cross-sectional data on 512 hypertensive patients to look at the association of behavior pattern A (coronary prone behavior) and compliance with therapy. In a home interview behavior pattern A was assessed by a questionnaire (The Bortner scale), compliance by a vignette, and blood pressure was measured. Noncompliers showed a higher degree of Type A characteristics, that is there was a significant negative association between behavior pattern A and compliance (p = 0.02). It is proposed that a new variable, behavior pattern A, should be considered in future research on compliance.

Sample size calculation for cluster randomized cross-over trials

The cluster randomized cross-over design has been proposed in particular because it prevents an imbalance that may bring into question the internal validity of parallel group cluster trials. We derived a sample size formula for continuous outcomes that takes into account both the intraclass correlation coefficient (representing the clustering effect) and the interperiod correlation (induced by the cross-over design).

Mucoepidermoid carcinoma of palatinal glands with exuberant foreign-body giant cell reaction

A 69-year-old man with a 0.6 cm yellowish polypoid lesion in the lateral soft palate for 2 years is presented. Histological examination of the tumor revealed a small, well-differentiated, mucoepidermoid carcinoma dominated by densely packed cholesterol clefts in association with an exuberant foreign-body reaction with several giant cells. The tumor entity 'mucoepidermoid carcinoma with foreign-body giant cells' might be differentiated from 'mucoepidermoid carcinoma with an osteoclast-like giant cell stromal reaction' because differences in pathogenesis and tumor behavior are assumed.

Lessons from a patient with an unusual hepatic overlap syndrome

BACKGROUND

A 24-year-old white male was diagnosed as having Crohn's disease by clinical, endoscopic and histological assessments, and long-term remission was successfully induced with short-course prednisolone. While the Crohn's disease was still in remission, the patient presented with cholestasis and hyperbilirubinemia but normal alanine aminotransferase levels, negative results for serological tests for infectious causes of hepatopathy and normal gamma-globulin levels.

INVESTIGATIONS

Repeated laboratory and serological tests, ultrasonography, endoscopic retrograde cholangiopancreatographies, CT scan, magnetic resonance cholangiopancreatography and liver biopsies.

DIAGNOSIS

Autoimmune hepatitis-primary sclerosing cholangitis (AIH-PSC) overlap syndrome on the background of PSC with a rare course of sequential manifestations of the different disease components.

MANAGEMENT

Combined immunosuppression with prednisolone and treatment with ursodeoxycholic acid (UDCA), endoscopic treatment of dominant stenoses, bile duct stent implantation, and close follow-up.

Methods for the statistical analysis of binary data in split-mouth designs with baseline measurements

Many split-mouth trials are characterized by the pairing of site-specific outcome and baseline data within each segment of a subject's mouth. However when the response variable of interest is binary, methods of statistical analysis for this design are not well developed. In this paper we present several analytic approaches that may be taken to the resulting data, showing how the efficiency of statistical inferences can be improved by appropriately incorporating the baseline information. The advantages and disadvantages of the different approaches are discussed in the context of an example from the published literature. The results from a limited simulation study are also presented.

Evaluation of an epilepsy education program for Grade 5 students: a cluster randomized trial

OBJECTIVE

Epilepsy is a common and often highly stigmatized disorder. Several international organizations indicate a need to assess the stigma that exists and to develop and evaluate interventions to dispel myths about epilepsy.

METHODS

A stratified cluster randomized controlled trial evaluated whether an epilepsy education program (intervention) increases knowledge of and positive attitudes about epilepsy in Grade 5 students (ages 9-11). The study also investigated characteristics of the individuals (gender, language spoken at home, familiarity with epilepsy) and schools (Catholic vs public, size of school, and school level socioeconomic status) that affect epilepsy knowledge and attitudes. We assessed epilepsy knowledge and attitudes at baseline and 1 month following the program using a 33-item questionnaire.

RESULTS

In total, 24 schools (783 individuals) were cluster randomized. Those in the intervention group had an average 11.8-point increase (95% confidence interval (CI)=11.4-12.5) in knowledge 1 month following the program, compared with the control group increase of 2.2 points (95% CI=1.8-2.6) out of a total of 57 points. For attitudes, the intervention group had a mean increase of 8.15 points (95% CI=4.70-11.60), compared with the control group increase of 1.64 points (95% CI=-0.84-4.42) out of a total of 50 points. The intervention was responsible for 63% of the variation in postprogram epilepsy knowledge and 28% of the variation in postprogram attitudes about epilepsy.

CONCLUSIONS

The epilepsy education program was associated with a significant increase in epilepsy knowledge and positive attitudes in the intervention group 1 month later compared with the control group.

Bivariate models for co-aggregation of dichotomous traits in twins

The study of twins is widely used for research into genetic and environmental influences on human traits. Study designs in which independent samples of monozygotic and dizygotic twins are compared with respect to their similarity have focused on single binary trait. However, the risk of co-occurrence of more than one disease in twins is a parameter of interest to genetic epidemiologists and other investigators. For example, they may be interested in assessing the genetic and environmental etiologies of reading deficits (RD) and attention deficit hyperactivity disorder (ADHD) and their co-morbidity. In this paper, we present statistical methodology for the estimation of twin similarity with respect to two dichotomous traits measured on each member of the twin pair. For two sample problems, several test procedures that account for the correlation between twins and the correlation between traits are presented. An example based on the Australian population-based twin registry published data is given to illustrate the methodology.

Developments in cluster randomized trials and Statistics in Medicine

The design and analysis of cluster randomized trials has been a recurrent theme in Statistics in Medicine since the early volumes. In celebration of 25 years of Statistics in Medicine, this paper reviews recent developments, particularly those that featured in the journal. Issues in design such as sample size calculations, matched paired designs, cohort versus cross-sectional designs, and practical design problems are covered. Developments in analysis include modification of robust methods to cope with small numbers of clusters, generalized estimation equations, population averaged and cluster specific models. Finally, issues on presenting data, some other clustering issues and the general problem of evaluating complex interventions are briefly mentioned.

[High-grade osteosarcoma of the maxillary sinus. A case report]

BACKGROUND

Osteosarcoma of the jaw (JOS) constituting 5% to 13% of all osteosarcoma is a locally aggressive malignant mesenchymal tumor with high tendency to local recurrence and the ability to produce tumor osteoid. Compared to osteosarcoma of the remaining skeleton (SOS) JOS metastasizes relatively rarely and relatively late. It differs significantly from SOS in its biological behaviour.

CASE REPORT

The presented case deals with a 60-year-old male patient suffering from a newly occurred polypous mucosal tumor of the right-sided maxillary alveolar ridge bioptically diagnosed as a granulation tissue polyp first. After transmaxillary resection of the tumor and consultation of a bone tumor reference center the final diagnosis of a high-grade chondroblastic osteosarcoma could be made. The recommended radical resection of the tumor was declined by the patient because of the expected cosmetic consequences. After surgical reduction of the rapidly growing sarcoma chemotherapy according to the COOS/EURO-B.O.S.S. protocol was initiated at a stage when computed tomography showed diffuse metastatic disease to the lungs. Chemotherapy could delay the progress of the disease only temporarily. The patient died from respiratory insufficiency.

CONCLUSION

In JOS radical surgical resection is the therapy of first choice. For substantiation of the diagnosis and central registration of the cases a bone tumor reference center should be contacted.

Treatment of chronic hepatitis delta with pegylated interferon-alpha2b

BACKGROUND/AIMS

Chronic hepatitis D is difficult to treat. The present pilot study investigated the efficacy and tolerability of pegylated (PEG)-interferon (IFN)-alpha2b in chronic hepatitis D.

PATIENTS AND METHODS

Twelve patients with chronic hepatitis D were prospectively treated with 1.5 microg/kg PEG-IFN-alpha2b for 48 weeks and followed for 24 weeks. Sustained response (SR) was defined as undetectable hepatitis delta virus (HDV) RNA by reverse transcriptase-polymerase chain reaction and normalization of alanine aminotransferase (ALT) at 6 months after treatment. Investigations included HDV RNA kinetics, determination of hepatitis B virus (HBV) and HDV genotypes and histological evaluation.

RESULTS

An SR was achieved in two out of 12 of patients (17%). The negative predictive value of a less than 3 log HDV RNA decrease at month 6 was 100%. The positive predictive value of a more than 3 log HDV RNA decrease at month 6 was 67%. A marked ALT reduction at the end of treatment was observed in responders and nonresponders. Ishak histological score was comparable at baseline and significantly improved in responders compared with nonresponders at the end of follow-up (13.5 vs. 8.0; P<0.02).

CONCLUSION

The present study indicates that PEG-IFN-alpha2b is a promising treatment option in chronic hepatitis D. Nonresponders could be identified by a less than 3 log decrease of HDV RNA at 6 months of treatment.

Hodgkin disease-like posttransplantation lymphoproliferative disorder of donor origin in a renal allograft recipient

Posttransplantation lymphoproliferative disorder (PTLD) develops in 1.6% of renal allograft recipients. More than 90% are of recipient origin. There are only a few reports of Hodgkin disease-like PTLD in allograft patients. We report the case of a Hodgkin disease-like PTLD of donor origin in a 16-year-old renal allograft recipient. Fourteen months after transplantation, an increasing inhomogeneous structure in the hilar region of the transplanted kidney became apparent and was excised. Histological examination showed Hodgkin- and Sternberg-Reed-like cells. Immunostaining showed CD20-positive and CD15-negative cells and Epstein-Barr virus (EBV) involvement (EBV-encoded small nonpolyadenylated RNA and EBV-determined nuclear antigen 2). DNA fingerprinting analysis proved the lymphoma to be of donor origin. Treatment consisted of nephrectomy, discontinuation of immunosuppression therapy, and local radiation. Three years after lymphoma removal, the patient was still without relapse and underwent retransplantation with stable function of the second allograft for more than 2 years now.

Expression analysis of mammaglobin A (SCGB2A2) and lipophilin B (SCGB1D2) in more than 300 human tumors and matching normal tissues reveals their co-expression in gynecologic malignancies

Background

Mammaglobin A (SCGB2A2) and lipophilin B (SCGB1D2), two members of the secretoglobin superfamily, are known to be co-expressed in breast cancer, where their proteins form a covalent complex. Based on the relatively high tissue-specific expression pattern, it has been proposed that the mammaglobin A protein and/or its complex with lipophilin B could be used in breast cancer diagnosis and treatment. In view of these clinical implications, the aim of the present study was to analyze the expression of both genes in a large panel of human solid tumors (n = 309), corresponding normal tissues (n = 309) and cell lines (n = 11), in order to evaluate their tissue specific expression and co-expression pattern.

Methods

For gene and protein expression analyses, northern blot, dot blot hybridization of matched tumor/normal arrays (cancer profiling arrays), quantitative RT-PCR, non-radioisotopic RNA in situ hybridization and immunohistochemistry were used.

Results

Cancer profiling array data demonstrated that mammaglobin A and lipophilin B expression is not restricted to normal and malignant breast tissue. Both genes were abundantly expressed in tumors of the female genital tract, i.e. endometrial, ovarian and cervical cancer. In these four tissues the expression pattern of mammaglobin A and lipophilin B was highly concordant, with both genes being down-, up- or not regulated in the same tissue samples. In breast tissue, mammaglobin A expression was down-regulated in 49% and up-regulated in 12% of breast tumor specimens compared with matching normal tissues, while lipophilin B was down-regulated in 59% and up-regulated in 3% of cases. In endometrial tissue, expression of mammaglobin A and lipophilin B was clearly up-regulated in tumors (47% and 49% respectively). Both genes exhibited down-regulation in 22% of endometrial tumors. The only exceptions to this concordance of mammaglobin A/lipophilin B expression were normal and malignant tissues of prostate and kidney, where only lipophilin B was abundantly expressed and mammaglobin A was entirely absent. RNA in situ hybridization and immunohistochemistry confirmed expression of mammaglobin A on a cellular level in endometrial and cervical cancer and their corresponding normal tissues.

Conclusion

Altogether, these data suggest that expression of mammaglobin A and lipophilin B might be controlled in different tissues by the same regulatory transcriptional mechanisms. Diagnostic assays based on mammaglobin A expression and/or the mammaglobin A/lipophilin B complex appear to be less specific for breast cancer, but with a broader spectrum of potential applications, which includes gynecologic malignancies.

[Effective data collection in cancer research: an all-in-one database solution]

Tissue banks containing human malignant and benign tissue have become highly important for modem cancer research. They provide an excellent source of information with respect to pathological states and processes. Nowadays tissue samples can be examined using a broad variety of molecular biology methods, at the levels of DNA, RNA and protein. However, these new possibilities impose great expectations from the user side towards tissue banks and their associated databases. Nowadays a database that only manages tissue samples is not timely anymore. In fact a modern database should be capable of registering arbitraty amounts of tissue relevant information in an easily searchable way. In order to simplify the often complicated and time consuming process of data collection, we have developed a software solution that centralizes various aspects of tumor tissue banking. The main task of this software is not only to administer tissue samples but also to provide a centralized data platform for scientists which support their research. To achieve our goals we have constructed a tissue database which is supported by an Oracle System. The access to this database has been made possible with a light-weight, self-developed Java Client Program. The system possesses high levels of security and the access to information in the database is strictly controlled by preset permissions. A flexible search mechanism is also readily available for speedy data extraction according to various criteria. This solution provides us with an "All-in-one" tool for the purpose of flexible and efficient data collection and management in cancer research.

Efficacy of unilateral nerve sparing in radical perineal prostatectomy

AIM

We determine the efficacy of unilateral nerve-sparing radical perineal prostatectomy in preserving the sexual function.

PATIENTS AND METHODS

Ninety-two patients with histologically confirmed unilateral prostate cancer were scheduled for contralateral nerve preservation. The perioperative morbidity was assessed using the patients' chart reviews. Postoperative health-related quality of life, urinary continence, and potency were evaluated prospectively with questionnaires provided before surgery and then after 6, 12, and 24 months.

RESULTS

Unilateral nerve preservation was performed in 88 of the 92 patients. Due to extensive scarring or prostatic size, the procedure was terminated as regular radical prostatectomy in 4 other patients. The perioperative complication rate was low and of minor significance, except in 1 patient who experienced a significant myoglobulinuria due to a prolonged procedure. Blood transfusions were necessary in 5 (5.4%) patients. Ureteral reimplantation was performed in 1 patient because of ureteral stricture. Positive surgical margins were present in 12 (18%) of 67 pT2 patients and in 8 (35%) of 23 pT3 patients. A proportion of 48% (15/31) of the patients followed for more than 24 months and who had a good erectile function prior to surgery reported unassisted sexual intercourse. However, only 4 of these patients were completely satisfied with all aspects of sexual performance, as asked in a short version of the International Index of Erectile Function questionnaire.

CONCLUSIONS

Unilateral nerve-sparing radical perineal prostatectomy is technically feasible and yields excellent results in terms of potency preservation for prostates <60 ml. However, the quality of erections is decreased, even in patients with erections sufficient for intercourse. Hence, appropriate sexual counseling in conjunction with medical therapy should be offered to all patients.

Synchronous occurrence of a follicular, papillary and medullary thyroid carcinoma in a recurrent goiter

The simultaneous occurrence of different types of thyroid carcinoma in a single patient is an unusual event. We report the case of a 52-year-old man with the history of two previous thyroid operations for benign goiters, who developed a recurrent goiter. The patient was referred to our department for thyroidectomy. In the pathohistological examination the specimen showed a 5 cm follicular carcinoma and a 0.3 cm papillary microcarcinoma in the right lobe as well as a 1.5 cm medullary carcinoma in the left lobe. All tumors were clearly separated from each other, representing the pure entity of each type. Postoperatively, RET germline mutation was ruled out by sequence analysis of peripheral blood leucocytes. Postoperative I-131-radioiodine scan showed multiple lung and liver metastases, while calcitonin was negative. There is no known common cause of these three different tumor types and they developed most independently from each other. The personal history of our patient was interesting in two aspects: (1) he suffered a period of severe staphylococcal sepsis with temporal immunosuppression and (2) he worked for long years as a coremaker in a foundry. This work represented possible long term exposure to inhalative carcinogenous toxins like hydrazine, which caused thyroid parafollicular cell adenomas in an animal model.

Access of HTB, main metabolite of triflusal, to cerebrospinal fluid in healthy volunteers

OBJECTIVE

Triflusal has been shown to exert neuroprotective effects by downregulating molecules considered responsible for the development of Alzheimer's disease (AD). The aim of this study was to develop a population pharmacokinetic model to characterize plasma and cerebrospinal fluid (CSF) pharmacokinetics of the main active metabolite of triflusal-HTB (2-hydroxy-4-trifluoro-methylbenzoic acid)-in healthy volunteers.

METHODS

Data from two studies were combined. Study A: subjects received single oral doses of triflusal 900 mg. Triflusal and HTB plasma concentrations were extensively measured. Study B: triflusal 600 mg once daily was administered orally for 14 days. HTB plasma and CSF concentrations were determined in healthy volunteers. Population pharmacokinetic modeling was performed using NONMEM.

RESULTS

A one-compartmental model with rapid first-order absorption for triflusal and first-order formation of HTB best described plasma concentrations. Triflusal elimination rate constant was 50 times faster than that estimated for the metabolite. CSF concentrations of HTB ranged between 0.011 microg/ml and 0.341 microg/ml. A CSF-plasma partition coefficient of 0.002 and a k(e0) value of 0.059 h(-1) were estimated by means of population modeling.

CONCLUSION

In the present study in healthy volunteers, HTB penetrated into the CSF in a range of concentrations experimentally proven to have protective effects in AD. These concentrations suggest that triflusal could be used in the treatment of central nervous system diseases in doses similar to those used in cardiovascular diseases. Access to the CSF compartment was characterized by a slow equilibrium rate constant and a low CSF-plasma partition coefficient.

M. Behçet mit gastrointestinaler Beteiligung ohne Hinweis einer chronisch-entzündlichen Darmerkrankung

A case of a 32-year-old male patient with lower gastrointestinal bleeding is reported as an initial manifestation of Behçet's disease. The early diagnosis of this chronic-systemic disease is often very difficult, in particular with regard to the differentiation from chronic inflammatory bowel diseases. In addition, lower gastrointestinal bleeding is a rare manifestation of Behçet's disease. An immunosuppressive therapy was initiated and the course of the disease with recurrent oral ulcerations gave evidence for the diagnosis. Further bleeding episodes or other gastrointestinal symptoms have not been observed during a follow-up period of 36 months. The diagnostic problems and the therapeutic management of the disease are discussed in relation to neighbouring entities.

Histochemical distribution and expression of aquaporin 1 in the peritoneum of patients undergoing peritoneal dialysis: relation to peritoneal transport

BACKGROUND

Aquaporin 1 (AQP-1) channels have been claimed to be responsible for osmotically driven free-water movement across the peritoneal membrane. Data about AQP-1 expression and its location in the human peritoneum related to clinical findings concerning ultrafiltration (UF) and free-water transport are still lacking.

METHODS

Fifty-seven peritoneal biopsy specimens obtained from peritoneal dialysis (PD) patients were investigated. AQP-1 expression was detected by means of immunohistochemistry and a semiquantitative scoring system. Histological findings were related to peritoneal transport properties measured by means of an extended peritoneal equilibration test (PET) using dextran 70 as a volume marker.

RESULTS

AQP-1 expression in the peritoneum was detected in both vascular endothelial cells (capillaries and small venules; score, 2.96 +/- 0.92) and the mesothelial cell layer (score, 2.31 +/- 1.54). There was significantly greater AQP-1 expression in vascular endothelial cells of patients showing increased thickness of the submesothelial fibrous layer of the peritoneum greater than 400 microm compared with less than 400 microm. Free-water transport through AQP-1 was 42% +/- 12% from total UF after 1 hour. There was a significant correlation between AQP-1 expression and free-water transport after 1 hour of equilibration with 3.86% glucose in the PET (r = 0.753; P < 0.001).

CONCLUSION

Our data indicate that AQP-1 is located not only in the endothelial cell layer of capillaries and small vessels in the peritoneum of PD patients, but also in the mesothelial cell layer. AQP-1 expression correlated with free-water transport after 1 hour of equilibration, reaching a significant part from total UF at this time.

Distinction between intestinal metaplasia in the cardia and in Barrett's esophagus: the role of histology and immunohistochemistry

Intestinal metaplasia in Barrett's esophagus (BIM) is a precancerous condition, whereas the carcinogenic potential of intestinal metaplasia of the cardia (CIM) is uncertain. Although clinically important, histological distinction between both conditions by endoscopic biopsies is considered problematic. In the present study, 4-mm samples of BIM (n=31) and CIM (n=9) were selected from esophagectomy specimens that had been resected for esophageal cancer. Slides were coded and stained with hematoxylin and eosin (H&E), Alcian blue-periodic acid-Schiff (PAS), cytokeratins (CK) 7 and 20, and CD10, which labels the intestinal brush border. The predictive value of these stains for the recognition of BIM and CIM was evaluated independently by two senior pathologists. With the use of H&E-stained slides exclusively, BIM samples were categorized correctly in 93.5% and 83.9% of cases (pathologists 1 and 2, respectively), and CIM samples, in 100% and 88.9% of cases. Alcian blue-PAS-positive goblet cells were identified by both investigators in all BIM and CIM samples. BIM-typical CK 7 and 20 immunostaining pattern was identified in 90.3%/83.9% of BIM but only in 11.1%/11.1% of CIM. CD10-positive brush border was present in 32.3%/25.8% of BIM and in 88.9%/88.9% of CIM. When HE-stained slides and immunohistologically stained slides were used together for tissue recognition, BIM were categorized correctly in 90.3%/80.6% of cases, and CIM, in 88.9%/88.9% of cases. In conclusion, BIM and CIM can be usually distinguished on the basis of HE sections. CK 7 and CK 20 expression pattern analysis discriminates correctly between BIM and CIM in the majority of cases. CD10-positive intestinal brush border is present in the majority of CIM but only in a minority of BIM. However, immunohistochemical investigations could not improve the diagnostic accuracy of HE histology alone.

Indocyanine green video angiographies help to identify burns requiring operation

The key decision in the treatment of thermal injuries is the determination of the depth of the burn wound and the resultant decision on treatment options. The trend in the treatment of deep dermal and full thickness burns is toward very early excision and grafting to reduce the risk of infection, decrease scar formation, shorten hospital stay, and thereby reducing costs. Traditionally, this has involved serial clinical examinations, which involves primarily subjective judgment. Various objective examination techniques, supplementing the clinical diagnosis, have been suggested, but none has yet achieved widespread clinical acceptance. It has frequently been postulated that the blood flow in injured tissue indicates the extent of tissue damage. In this study, the clinical and scientific impact of indocyanine green (ICG) video angiography was tested in 20 patients. A wide range of depth of injury and etiology was included and analyzed. In all cases considered, video angiography was possible. The measurements and observations correlated well with the actual burn depth, which was assessed clinically (pre- and intraoperative assessment) and histologically (biopsies). In conclusion, ICG video angiography seems to be a practical method to describe vascular patency in a burn wound. The results indicate that ICG fluorescence angiography is a practical, accurate, and effective adjunct to clinical methods for estimating burn wound depth and thereby to assist in the rational assessment of treatment options. Furthermore, it allows an objective, qualitative and quantitative observation of the dynamic changes in burn wound depth, which are observed during the acute post-burn period, thereby indicating optimal timing of the first operation.

[Contrast-enhanced sonography using Levovist is decisive for staging and therapeutic schedule in hepatocellular carcinoma]

In a 65-year-old female patient, B-mode sonography detected a single focal lesion in the right liver lobe with a diameter < 3 cm. Histopathologic examination revealed a low differentiated hepatocellular carcinoma (HCC; G3). Tumor staging was performed by CT (computed tomography) scan and Resovist MRI (magnetic resonance imaging). Both examinations found a single liver lesion without signs of additional focal hepatic lesions. In addition, phase-inversion sonography in the late phase was performed using the ultrasound contrast agent Levovist. This examination of late-phase Levovist uptake detected more than five additional focal hepatic lesions in the right liver lobe, which were invisible by CT scan and Resovist MRI. This finding of multiloculated HCC was very important to decide on the patient's correct therapy. While liver transplantation is the treatment of choice in single HCC < 3 cm, it is contraindicated in multicentric HCC. In the patient described here, hemihepatectomy of the right liver lobe was performed. The histopathologic examination of the resected liver confirmed the diagnosis of multicentric HCC, which was noninvasively diagnosed only by contrast-enhanced sonography, but not by CT scan or MRI.

Hydrocortisone improved haemodynamics and fluid requirement in surviving but not non-surviving of severely burned patients

Recent studies have shown that administration of hydrocortisone may lead to a reduction of catecholamines and to an improved outcome in septic patients. However, there are no data on the use of hydrocortisone in burn patients although in these patients reduction of vasopressors might be even more crucial for outcome due to improvement of skin perfusion. This study presents the first results on the impact of hydrocortisone administration in norepinephrine dependent severely burned patients. In a prospective cohort study fourteen consecutive severely burned patients received, 12h after norepinephrine dependency, a hydrocortisone bolus of 100mg followed by 0.18mg/(kgh) hydrocortisone. The course of the necessary norepinephrine dose, as well as the fluid balance was documented 12h prior and after the first dosage of hydrocortisone. Statistical analysis showed an unexpected increase of the required norepinephrine dosage. A statistical post hoc evaluation of surviving and non-surviving patients revealed a significant increase of norepinephrine in non-survivors whereas in survivors it was possible to reduce norepinephrine significantly. Furthermore, the median fluid requirement of surviving patients could be significantly reduced whereas in the group of non-survivors there was no change of volume needed. Our data suggests that hydrocortisone might be useful in selected patients with severe burn injuries. However, patients not responding to hydrocortisone administrations seem to have a poor prognosis. Our findings are in contrast to previously published data on septic patients, in whom hydrocortisone administration resulted in a reduction of norepinephrine. In burned patients the severity of trauma seems to have more profound influence on the pathophysiological mechanism of sepsis. Due to the high number of non-responders, the potential immune suppression and impaired wound healing caused by the side effects of hydrocortisone, further selection criteria seem to be necessary. A short ACTH-test might be considered prior to hydrocortisone administration to select patients who might benefit from this therapy. In summary, further prospective controlled studies will be necessary to establish hydrocortisone in the routine therapy of severely burned patients.

Combination treatment of IFNalpha2b and ribavirin in patients with chronic hepatitis C and persistently normal ALTs

Combination therapy of interferon-alpha2b and ribavirin was prospectively evaluated in 20 patients with chronic replicative hepatitis and persistently normal ALTs. Patients with normal ALTs on three or more occasions within 6 months received interferon-alpha2b 3 MU three times a week with ribavirin 1000-1200 mg everyday for 12 months and had a follow-up of 6 months. HCV genotype 1 was found in 16, and HCV genotype 2 or 3 in 4 patients. No patient experienced an ALT elevation during therapy. Ten of 20 patients (50%) cleared virus at the end of treatment. In an intent-to-treat analysis, a sustained virological response (SR) was achieved in 8 of 20 patients (40%). Nonresponse occurred in 5 patients. Relapse and breakthrough were seen in 2 patients each. Treatment was discontinued in 3 patients due to side effects. Interferon (IFN) ribavirin combination therapy is effective in patients with normal ALTs and appears superior to IFN monotherapy.

HFE mutations and chronic hepatitis C: H63D and C282Y heterozygosity are independent risk factors for liver fibrosis and cirrhosis

BACKGROUND/AIMS

The impact of heterozygous HFE mutations on the course of chronic hepatitis C and iron indices was studied.

METHODS

Ferritin, transferrin saturation (TS), serum iron, C282Y and H63D mutations were determined in 401 patients with chronic hepatitis C virus (HCV) infection and 295 healthy controls. Liver histologies were available in 217 and HCV genotypes in 339 patients.

RESULTS

Allele frequencies of the C282Y and H63D mutation did not differ between HCV patients and healthy controls (6.95 vs. 6.2%; 14.75 vs. 16.4%; n.s.). HFE heterozygous HCV patients had higher ferritin (349+/-37 vs. 193+/-15 microg/l; P<0.0005), TS (38+/-2 vs. 32+/-1%; P<0.0005), serum iron (144+/-6 vs. 121+/-3 microg/dl; P<0.0005), semiquantitative liver iron staining (0.26+/-0.07 vs. 0.09+/-0.03; P<0.006) and fibrosis scores (1.9+/-0.2 vs. 1.4+/-0.1; P<0.003) compared to HFE wildtypes. By multivariate regression analysis odds ratios for liver cirrhosis were 5.9 (confidence interval (CI) 1.6-22.6; P<0.009) for C282Y heterozygotes and 2.9 (CI 1.0-8.4; P<0.05) for H63D heterozygotes compared to HFE wildtypes. Considering all HFE heterozygous HCV patients, odds ratios of 3.6 (CI 1.4-9.3; P<0.009) for cirrhosis and 3.1 (CI 1.3-7.3; P<0.009) for fibrosis were calculated.

CONCLUSIONS

C282Y or H63D heterozygosity is an independent risk factor for liver fibrosis and cirrhosis in HCV infected individuals. Screening for HFE mutations should be considered in HCV infection.

A comparison of propofol and sevoflurane anaesthesia: effects on aortic blood flow velocity and middle cerebral artery blood flow velocity

We compared systemic (aortic) blood flow and cerebral blood flow velocity in 30 patients randomly allocated to receive either propofol or sevoflurane anaesthesia. Cerebral blood flow velocity (CBFv) was measured in the middle cerebral artery using transcranial Doppler. Systemic blood flow velocity (SBFv) was measured in the aorta using transthoracic Doppler sonography at the level of the aortic valve. Bispectral index (BIS) was used to measure the depth of anaesthesia. Measurements were made in the awake patient and repeated during propofol or sevoflurane anaesthesia, with BIS measurements of 40-50. The effects of SBFv on CBFv were estimated by calculating the cerebral/systemic blood flow velocity-index (CsvI). A CsvI value of 100 indicating a 1 : 1 relationship between CBFv and SBFv. The results demonstrated that propofol anaesthesia produced a significantly greater reduction in CsvI than did sevoflurane anaesthesia [propofol: 60 (19); sevoflurane: 83 (16), p = 0.009, t-test]. This suggests a direct reduction in CBFv independent of SBFv during propofol anaesthesia. The greater reduction of CBFv occurring during propofol anaesthesia may be due to lower cerebral metabolic demand compared with sevoflurane anaesthesia at comparable depths of anaesthesia.

Histopathology of the gastroesophageal junction: a study on 36 operation specimens

The entire gastroesophageal junction of 36 patients who had been operated for squamous cell carcinoma of the upper or middle esophagus was examined. Hematoxylin and eosin-stained slides were evaluated by two pathologists for the following histologic details: minimal and maximal length of cardiac mucosa (CM) and oxyntocardiac mucosa (OCM, mixture of cardiac and fundic glands), degree of inflammation in CM and OCM, and presence of intestinal metaplasia or pancreatic metaplasia. Sections of gastric corpus mucosa were evaluated for the presence of gastritis and infection; sections of esophageal squamous epithelium were evaluated for the presence of reflux esophagitis. CM was present in the entire circumference of the gastroesophageal junction in 20 cases, in parts of the circumference in 15 cases, and entirely absent in one case. The maximal length per case ranged between 1 and 15 mm (median 5 mm). OCM was circumferentially present in 22 cases and partially present in 14 cases. The maximal length ranged between 2 and 24 mm (median 7 mm). Locations of CM/OCM over submucosal esophageal glands or squamous epithelium-lined ducts, both indicating a location in the esophagus, were found in eight cases (22%) and in four cases (11%), respectively. In 18 cases (50%) intestinal metaplasia was present in CM/OCM; pancreatic metaplasia was found in 22 cases (61%). A statistically not significant trend for increase of minimal length of CM, OCM, and the sum of both was found in the presence of gastroesophageal reflux disease. Neither the presence of intestinal metaplasia nor of pancreatic metaplasia in CM/OCM was correlated with gastroesophageal reflux disease. In conclusion, the high variability in length, the frequent occurrence of intestinal metaplasia and pancreatic metaplasia, and the frequent extension into the esophagus suggest that CM/OCM is a dynamic structure that probably mirrors the influence of underlying gastroesophageal diseases. Because of the short length and incomplete circumferential extension of CM/OCM, future endoscopic-bioptic investigations will probably have to be based on more extensive sampling of the gastroesophageal junction.

Patient versus injury factors as predictors of pain and disability six months after a distal radius fracture

A prospective cohort of 120 patients with distal radius fractures completed a baseline evaluation that determined their age, sex, education level, injury compensation status, AO fracture type, prereduction radial shortening, and postreduction radial shortening. Six months later patients self-reported pain and disability using the Patient-Rated Wrist Evaluation, and were tested for physical impairment (grip, wrist range of motion, and dexterity). Univariate and forward stepwise regression analyses agreed that the most influential predictor of pain and disability at 6 months was injury compensation. Patient education level and prereduction radial shortening also contributed predictive information (R squared = 25%). Wrist impairment was moderately correlated with patient reported pain and disability (r = 0.50). Both impairment and disability measures are required to fully describe outcomes. Further work is required to delineate additional factors that contribute to outcome.

Current and future challenges in the design and analysis of cluster randomization trials

Randomized trials in which the unit of randomization is a community, worksite, school or family are becoming widely used in the evaluation of life-style interventions for the prevention of disease. The increasing interest in adopting a cluster randomization design is being matched by rapid methodological developments. In this paper we describe several of these developments. Brief mention is also made of issues related to economic analysis and to the planning and conduct of meta-analyses for cluster randomization trials. Recommendations for reporting are also discussed.

Meta-analyses in systematic reviews of randomized controlled trials in perinatal medicine: comparison of fixed and random effects models

There is a need for empirical work comparing the random effects model with the fixed effects model in the calculation of a pooled relative risk in the meta-analysis in systematic reviews of randomized controlled trials. Such comparisons are particularly important when trial results are heterogeneous. We considered 84 independent meta-analyses in which each trial included a set of different women/newborns. These meta-analyses were included in systematic reviews published in the Cochrane Library's pregnancy and childbirth module. Twenty-one of these 84 meta-analyses demonstrated statistical heterogeneity at p<0.10. The random effects model estimates showed wider confidence intervals, particularly in those meta-analyses showing heterogeneity in the trial results. The summary relative risk for the random effects model tended to show a larger protective treatment effect than the fixed effects model in the heterogeneous meta-analyses. In this set of meta-analyses, statistical evaluation of publication bias cannot be shown to account for heterogeneity. Our empirical conclusion is that there may be opposing effects if the random effects model is used in the meta-analysis of clinical trials showing heterogeneity in the results: stronger treatment effects reflected in the summary relative risk, but wider confidence intervals about this summary measure.