A Systematic Review of Industrial Exoskeletons for Injury Prevention: Efficacy Evaluation Metrics, Target Tasks, and Supported Body Postures

Industrial workplaces expose workers to a high risk of injuries such as Work-related Musculoskeletal Disorders (WMSDs). Exoskeletons are wearable robotic technologies that can be used to reduce the loads exerted on the body's joints and reduce the occurrence of WMSDs. However, current studies show that the deployment of industrial exoskeletons is still limited, and widespread adoption depends on different factors, including efficacy evaluation metrics, target tasks, and supported body postures. Given that exoskeletons are not yet adopted to their full potential, we propose a review based on these three evaluation dimensions that guides researchers and practitioners in properly evaluating and selecting exoskeletons and using them effectively in workplaces. Specifically, evaluating an exoskeleton needs to incorporate: (1) efficacy evaluation metrics based on both subjective (e.g., user perception) and objective (e.g., physiological measurements from sensors) measures, (2) target tasks (e.g., manual material handling and the use of tools), and (3) the body postures adopted (e.g., squatting and stooping). This framework is meant to guide the implementation and assessment of exoskeletons and provide recommendations addressing potential challenges in the adoption of industrial exoskeletons. The ultimate goal is to use the framework to enhance the acceptance and adoption of exoskeletons and to minimize future WMSDs in industrial workplaces.

Small Towns, Big Cities: Rural and Urban Disparities among Hospitalized Patients with COVID-19 in the Central Savannah River Area

Background

There is a lack of data surrounding the impact of coronavirus disease 2019 (COVID-19) among rural and urban communities. This study aims to determine whether there are differences in epidemiologic characteristics and clinical outcomes among individuals with COVID-19 among these communities.

Methods

This was a retrospective analysis of 155 patients admitted to a single-center tertiary academic hospital located in Augusta, Georgia, with a large proportion of hospitalized patients transferred from or residing in rural and urban counties. Hospitalized adult patients were included in the study if they were admitted to AUMC between March 13, 2020, and June 25, 2020, and had a positive polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 regardless of the presence or absence of symptomatology. Demographics, admission data, and 30-day outcomes were examined overall and by geographical variation.

Results

Urban patients were more likely to be admitted to the general medical floor (P = .01), while rural patients were more likely to require an escalation in the level of care within 24 hours of admission (P = .02). In contrast, of the patients who were discharged or expired at day 30, there were no statistically significant differences in either total hospital length of stay or intensive care unit length of stay between the populations.

Conclusions

There may be many social determinants of health that limit a rural patient’s ability to seek prompt medical care and contribute to decompensation within the first 24 hours of admission. This study provides insight into the differences in clinical course among patients admitted from different community settings and when accounting for comorbid conditions.

Bordetella bronchiseptica empyema in patient with chronic alcohol use disorder

Bordetella bronchiseptica is a veterinary pathogen that is rarely isolated in immunocompetent humans, and few cases have been recorded where alcoholism is the primary compromising factor. Furthermore, patients who contracted this pathogen have not been recorded developing a lung empyema that requires thoracic intervention. We present a case of a woman with chronic alcohol use disorder who contracted Bordetella bronchiseptica that required a prolonged course of antibiotics and thoracostomy tube placement.

391. Small Towns, Big Cities: Rural and Urban Disparities Among Hospitalized Patients with COVID-19

Background

More than half of all hospitals in the U.S. are rural hospitals. Frequently understaffed and resource limited, community hospitals serve a population that tends to be older and have less access to care with increased poverty and medical co-morbidities. There is a lack of data surrounding the impact of COVID-19 among rural minority communities. This study seeks to determine rural and urban disparities among hospitalized individuals with COVID-19.

Methods

This is a descriptive, retrospective analysis of the first 155 adult patients admitted to a tertiary hospital with a positive COVID-19 nasopharyngeal PCR test. Augusta University Medical Center serves the surrounding rural and urban counties of the Central Savannah River Area. Rural and urban categories were determined using patient address and county census data. Demographics, comorbidities, admission data and 30-day outcomes were evaluated.

Results

Of the patients studied, 62 (40%) were from a rural county and 93 (60%) were from an urban county. No difference was found when comparing the number of comorbidities of rural vs urban individuals; however, African Americans had significantly more comorbidities compared to other races (p-value 0.02). In a three-way comparison, race was not found to be significantly different among admission levels of care. Rural patients were more likely to require an escalation in the level of care within 24 hours of admission (p-value 0.02). Of the patients that were discharged or expired at day 30, there were no differences in total hospital length of stay or ICU length of stay between the rural and urban populations.

Baseline Characteristics of Hospitalized Patients with COVID-19

Day 30 Outcomes and Characteristics

Level of Care at Time of Admission

Conclusion

This study suggests that patients in rural communities may be more critically ill or are at a higher risk of early decompensation at time of hospitalization compared to patients from urban communities. Nevertheless, both populations had similar lengths of stay and outcomes. Considering this data is from an academic medical center with a large referral area and standardized inpatient COVID-19 management, these findings may prompt further investigations into other disparate outcomes.

Disclosures

All Authors: No reported disclosures

Fungal Infections of the Gastrointestinal Tract

The thinking about fungi has evolved from unusual agents considered contaminants and colonizers to actual pathogens. Fungi are ubiquitous in nature and are found throughout in association with food, soil, mammals, and insects. Fungi have become important pathogens in animals and humans causing infections extending from superficial disease to disseminated infection. Because the gastrointestinal tract is continually exposed to fungi, it is frequently colonized and infected by numerous yeast and other fungi. It is also the origin of many disseminated fungal infections. The increased incidence of fungal infections has led to the approval and use of novel antifungals.

Mortality under early access to antiretroviral therapy vs. Eswatini's national standard of care: the MaxART clustered randomized stepped-wedge trial

OBJECTIVES

Current WHO guidelines recommend the treatment of all HIV-infected individuals with antiretroviral therapy (ART) to improve survival and quality of life, and decrease infection of others. MaxART is the first implementation trial of this strategy embedded within a government-managed health system, and assesses mortality as a secondary outcome. Because primary findings strongly supported scale-up of the 'treat all' strategy (hereafter Treat All), this analysis examines mortality as an additional indicator of its impact.

METHODS

MaxART was conducted in 14 Eswatinian health clinics through a clinic-based stepped-wedge design, by transitioning clinics from then-national standard of care (SoC) to the Treat All intervention. All-cause, disease-related, and HIV-related mortality were analysed using the Cox proportional hazards model, censoring SoC participants at clinic transition. Median follow-up time among study participants was 292 days. There were 36/2034 deaths in SoC (1.77%) and 49/1371 deaths in Treat All (3.57%).

RESULTS

Between September 2014 and August 2017, 3405 participants were enrolled. In SoC and Treat All interventions, respectively, the multivariable-adjusted 12-month all-cause mortality rates were 1.42% [95% confidence interval (CI): 0.66-2.17] and 1.60% (95% CI: 0.78-2.40), disease-related mortality rates were 1.02% (95% CI: 0.40-1.64) and 1.10% (95% CI: 0.46-1.73), and HIV-related mortality rates were 1.03% (95% CI: 0.40-1.65) and 0.99% (95% CI: 0.40-1.58). Treat All had no impact on all-cause [hazard ratio (HR) = 1.12, 95% CI: 0.58-2.18, P = 0.73], disease-related (HR = 1.04, 95% CI: 0.52-2.11, P = 0.90), or HIV-related mortality (HR = 0.93, 95% CI: 0.46-1.87, P = 0.83).

CONCLUSION

There was no immediate benefit of the Treat All strategy on mortality, nor evidence of harm. Longer follow-up of participants is needed to establish long-term consequences.

2037. Utilization of the T2 Magnetic Resonance in the Early Detection of Invasive Candidiasis

Background

The current gold standard for diagnosing invasive Candida infections is by blood culture, which has low specificity and take up to 2–5 days to grow. T2 magnetic resonance (T2MR) rapidly detects Candida species with high sensitivity/specificity. T2MR identifies five Candida species and reports it in three groups: C. albicans/C. tropicalis, C. parapsilosis, and C. glabrata/C. krusei.

Methods

This was a retrospective quasi-experimental study at the Augusta University Medical Center. Patients with a positive sterile site culture for Candida species and/or T2MR result were reviewed between April 2014 and March 2016 (pre-T2MR group) and April 2016–May 2017 (T2MR group).

Results

The pre-T2MR group consisted of 84 patients who had a Candida species isolated from a sterile site culture. The T2MR group consisted of 396 unique patients for whom there were a total of 549 T2MR tests ordered. Of these, 34 were positive, 466 were negative result, and 49 were invalid result (due to malfunctioning of T2MR). Of the 35 tests that were T2MR negative but sterile site culture positive, 27 (77%) of the cultures isolated a Candida sp. that should be detected by the T2MR but did not. The most common site of isolation for these cultures was intraabdominal (41%), followed by blood (33%). For 23% of these results, sterile site cultures grew a Candida that the T2MR does not detect.

Conclusion

Unfortunately, Candida that grew in sterile site cultures was not always detected by the T2MR, particularly for intraabdominal Candidiasis. T2MR is thought to have high sensitivity and specificity for detecting Candidemia, but in our limited experience, it was found that up to one-third of Candidemias (as diagnosed by blood cultures) were missed by the T2MR. The most common Candida isolate in the T2MR group was C. parapsilosis, which is not typically thought of as a leading cause of invasive candidiasis.

Disclosures

All authors: No reported disclosures.

Information Theory Broadens the Spectrum of Molecular Ecology and Evolution

Information or entropy analysis of diversity is used extensively in community ecology, and has recently been exploited for prediction and analysis in molecular ecology and evolution. Information measures belong to a spectrum (or q profile) of measures whose contrasting properties provide a rich summary of diversity, including allelic richness (q=0), Shannon information (q=1), and heterozygosity (q=2). We present the merits of information measures for describing and forecasting molecular variation within and among groups, comparing forecasts with data, and evaluating underlying processes such as dispersal. Importantly, information measures directly link causal processes and divergence outcomes, have straightforward relationship to allele frequency differences (including monotonicity that q=2 lacks), and show additivity across hierarchical layers such as ecology, behaviour, cellular processes, and nongenetic inheritance.

Line of Service-Specific Performance and Antibiotic Prescribing Habits Following Introduction of a Two-Step Diagnostic Approach Using NAAT Followed by Enzyme Immunoassay in Cancer Patients with Suspected Clostridium difficile Infection

Background

Patients with cancer are at an increased risk for C. difficile infection (CDI). A two-step approach with a Nucleic Acid Amplification Test (NAAT) followed by enzyme immunoassay (EIA) increases diagnostic sensitivity and specificity and can be used to guide antibiotic therapy. We retrospectively investigated the relative performance of the two-step approach in cancer patients with solid tumors (ST), hematologic malignancies (HS), and hematopoietic stem cell transplant recipients (HSCT).

Methods

We identified 204 patients with a positive NAAT test for CDI as determined by GI multiplex (Biofire) or by Illumigene (Meridian, Bioscience) in whom a reflex EIA was performed for C. difficile A/B toxins between November 2015 and February 2017. Patients were stratified into ST, HM, HSCT groups. We compared the proportion of discordant NAAT+, EIA- results among the three groups. We then compared the clinical presentation and antibiotic use for patients in the NAAT+/EIA- to those with NAAT+/EIA+ results.

Results

Overall an EIA+ result was found in 53 (26%) patients. The proportion of patients with NAAT+/EIA+ results was significantly different between the three lines of service; ST 31/86 (36%), HM 16/62 (26%), and HSCT 6/56 (11%) P < 0.01. A trend towards a higher proportion of positive results was observed for ST compared with the HM group (P = 0.06). Results were similar between the HM and HSCT group. However, patients in the ST were more likely to have a positive EIA when compared with HSCT patients (36% vs. 11% P < 0.01). Clinical presentation and healthcare-association were similar in all three groups regardless of the EIA result. Despite the low proportion of EIA+ confirmatory results, the majority of patients (196/204 96%) received antibiotic therapy targeting CDI. Discontinuation of CDI antibiotics prior to 10 days of therapy was similar in the EIA+ (12%) vs. EIA- (10%).

Conclusion

The relevance of discordant results needs to be interpreted in the context of the line of service/patient care unit. The presence of CDI as determined by NAAT/EIA is low in patients with other potential causes of diarrhea such as in HSCT recipients. A substantial proportion of cancer patients are treated unnecessarily for CDI.

Disclosures

All authors: No reported disclosures.

Ribotypes Matter, Significance of Clostridium difficile Ribotypes in Cancer Patients with Diarrhea

Background

Cancer patients are at increased risk for Clostridium difficile infection (CDI) due to frequent health care contact, chemotherapy, use of antibiotics, and immunosuppression. Distinct ribotypes are associated with CDI adverse outcomes. Ribotypes 14-020 are the predominant ribotypes in many hospitals. We examined the contribution of C. difficile ribotypes to CDI severity, response to therapy and outcomes in this population.

Methods

Demographic and clinical data were collected from 90 cancer patients with a first episode or first recurrence of CDI identified by two-step PCR followed by EIA for A/B toxins. Fluorescent PCR ribotyping (FPCR) was performed on fecal isolates. We identified 27 distinct ribotypes between October 2016 and January 2017. Clinical outcomes were studied in three FPCR subgroups. Group I (GI, n = 27) included F014-020, group II (GII, n = 17) included virulent types 002, 027, 078–126, 244 and group III (GIII, n = 46) included the rest. Treatment failure was defined as no response after at least 3 days of a CDI treatment regimen. CDI severity was determined using Zar’s criteria, presence of bacteremia and ICU stay.

Results

The proportion of patients >50 yrs. old, with health care onset CDI (31%), primary CDI (92.2%), and on active chemotherapy (70%) was similar across the three groups. At presentation, disease severity was similar in all groups; However, patients in GII were more likely to have detectable toxin A/B by EIA compared with GI and GIII (53% vs. 23%, P = 0.015) and higher treatment failure rates (56%) when compared with GI (15% P = 0.007) and GIII (16%, P = 0.004). Bacteremia was more common in GIII (28%) compared with GII (0%) P = 0.041 and GI 7% P = 0.007. Patients in GI experienced fewer complications when compared with those in GIII P = 0.025. No differences in sustained clinical response, recurrence, ICU stay or all cause 90-day mortality were found between the groups.

Conclusion

Cancer patients with CDI due to GII ribotypes are more likely to excrete fecal toxin A/B and fail conventional therapy. In contrast, patients in GI and GIII were more likely to respond to therapy. GI was associated with fewer complications. Of interest, GIII was associated with bacteremia. Evaluation of C. difficile ribotypes is clinically relevant in cancer patients with CDI.

Disclosures

All authors: No reported disclosures.

Abscess formation in ovarian endometriomas after failure of mifepristone-induced abortion

OBJECTIVE

To report a case of abscess formation in bilateral ovarian endometriomas after failure of mifepristone-induced abortion.

CASE REPORT

A-36-year-old multiparous woman with bilateral ovarian endometriomas conceived spontaneously and received mifepristone to induce an abortion at 35 days' gestation. Fever and lower abdominal pain occurred 28 days after the abortion. The patient then underwent surgical curettage for an incomplete abortion complicated by endometritis. Her symptoms and signs became aggravated, and computed tomography showed a large ovarian abscess. She underwent laparoscopic drainage of the abscess plus the enucleation of the ovarian endometriomas, and received intravenous antibiotic treatment. She resumed menstruation one month later and was doing well at the 11-month follow-up.

CONCLUSION

This case demonstrates the importance of combining antibiotic therapy with mifepristone to induce abortions in women with known ovarian endometriomas.

Human Non-neutralizing HIV-1 Envelope Monoclonal Antibodies Limit the Number of Founder Viruses during SHIV Mucosal Infection in Rhesus Macaques

HIV-1 mucosal transmission begins with virus or virus-infected cells moving through mucus across mucosal epithelium to infect CD4+ T cells. Although broadly neutralizing antibodies (bnAbs) are the type of HIV-1 antibodies that are most likely protective, they are not induced with current vaccine candidates. In contrast, antibodies that do not neutralize primary HIV-1 strains in the TZM-bl infection assay are readily induced by current vaccine candidates and have also been implicated as secondary correlates of decreased HIV-1 risk in the RV144 vaccine efficacy trial. Here, we have studied the capacity of anti-Env monoclonal antibodies (mAbs) against either the immunodominant region of gp41 (7B2 IgG1), the first constant region of gp120 (A32 IgG1), or the third variable loop (V3) of gp120 (CH22 IgG1) to modulate in vivo rectal mucosal transmission of a high-dose simian-human immunodeficiency virus (SHIV-BaL) in rhesus macaques. 7B2 IgG1 or A32 IgG1, each containing mutations to enhance Fc function, was administered passively to rhesus macaques but afforded no protection against productive clinical infection while the positive control antibody CH22 IgG1 prevented infection in 4 of 6 animals. Enumeration of transmitted/founder (T/F) viruses revealed that passive infusion of each of the three antibodies significantly reduced the number of T/F genomes. Thus, some antibodies that bind HIV-1 Env but fail to neutralize virus in traditional neutralization assays may limit the number of T/F viruses involved in transmission without leading to enhancement of viral infection. For one of these mAbs, gp41 mAb 7B2, we provide the first co-crystal structure in complex with a common cyclical loop motif demonstrated to be critical for infection by other retroviruses.

Treatment with immunosuppressive therapy may improve depressive symptoms in patients with inflammatory bowel disease

INTRODUCTION

Recent research suggests a relationship of inflammatory bowel disease (IBD) and depression. Our objective was to evaluate for improvement of depressive symptoms with treatment of IBD using immunosuppressive medications.

METHODS

A retrospective study of consecutive patients with IBD started on immunosuppressive agents [anti-tumor necrosis factor (anti-TNF) or immunomodulator therapy] was conducted. Patients were evaluated if disease activity indices using Harvey Bradshaw Index for Crohn's disease (CD) and Simple Clinical Colitis Disease Activity Index for ulcerative colitis (UC) and depressive indices using Patient Health Questionnaire-9 (PHQ-9) scores were obtained before and at least 30 days after initiation of therapy.

RESULTS

Sixteen patients with UC and 53 patients with CD (all with active disease symptoms) were evaluated over a 60 day median follow-up evaluation (range 30, 140 days). Twenty-two patients started on immunomodulator therapy, and 47 patients started on anti-TNF therapy. Crohn's disease patients had significantly decreased PHQ-9 scores at follow-up [median 9 (range 3, 14) to 4 (1, 8)], with significant decreases only in those started on anti-TNF therapy. Changes in PHQ-9 and CRP were correlated (ρ = 0.38, p < 0.05). In patients with UC, PHQ-9 scores [5 (3, 9) to 2 (0, 5)] were significantly decreased. Percentage at risk of moderate to severe depression (PHQ-9 scores ≥10) was lower after treatment [Crohn's disease 51-18 % (p < 0.05), ulcerative colitis 18-0 %].

CONCLUSION

Depressive scores decreased significantly in patients with IBD treated with immunosuppressive therapy and the number at risk for moderate to severe depression improved significantly.

Bortezomib enhances cancer cell death by blocking the autophagic flux through stimulating ERK phosphorylation

The antitumor activity of an inhibitor of 26S proteasome bortezomib (Velcade) has been observed in various malignancies, including colon cancer, prostate cancer, breast cancer, and ovarian cancer. Bortezomib has been proposed to stimulate autophagy, but scientific observations did not always support this. Interactions between ERK activity and autophagy are complex and not completely clear. Autophagy proteins have recently been shown to regulate the functions of ERK, and ERK activation has been found to induce autophagy. On the other hand, sustained activation of ERK has also been shown to inhibit the maturation step of the autophagy process. In this study, we sought to identify the mechanism of autophagy regulation in cancer cells treated with bortezomib. Our results indicate that bortezomib blocked the autophagic flux without inhibiting the fusion of the autophagosome and lysosome. In ovarian cancer, as well as endometrial cancer and hepatocellular carcinoma cells, bortezomib inhibited protein degradation in lysosomes by suppressing cathepsins, which requires the participation of ERK phosphorylation, but not JNK or p38. Our findings that ERK phosphorylation reduced cathepsins further explain how ERK phosphorylation inhibits the autophagic flux. In conclusion, bortezomib may induce ERK phosphorylation to suppress cathepsin B and inhibit the catalytic process of autophagy in ovarian cancer and other solid tumors. The inhibition of cisplatin-induced autophagy by bortezomib can enhance chemotherapy efficacy in ovarian cancer. As we also found that bortezomib blocks the autophagic flux in other cancers, the synergistic cytotoxic effect of bortezomib by abolishing chemotherapy-related autophagy may help us develop strategies of combination therapies for multiple cancers.

Dynamic variation in forebrain estradiol levels during song learning

Estrogens shape brain circuits during development, and the capacity to synthesize estrogens locally has consequences for both sexual differentiation and the acute modulation of circuits during early learning. A recently optimized method to detect and quantify fluctuations in brain estrogens in vivo provides a direct means to explore how brain estrogen production contributes to both differentiation and neuromodulation during development. Here, we use this method to test the hypothesis that neuroestrogens are sexually differentiated as well as dynamically responsive to song tutoring (via passive video/audio playback) during the period of song learning in juvenile zebra finches. Our results show that baseline neuroestradiol levels in the caudal forebrain do not differ between males and females during an early critical masculinization window. Instead, we observe a prominent difference between males and females in baseline neuroestradiol that emerges during the subadult stage as animals approach sexual maturity. Second, we observe that fluctuating neuroestradiol levels during periods of passive song tutoring exhibit a markedly different profile in juveniles as compared to adults. Specifically, neuroestrogens in the caudal forebrain are elevated following (rather than during) tutor song exposure in both juvenile males and females, suggesting an important role for the early consolidation of tutor song memories. These results further reveal a circadian influence on the fluctuations in local neuroestrogens during sensory/cognitive tasks. Taken together, these findings uncover several unexpected features of brain estrogen synthesis in juvenile animals that may have implications for secondary masculinization as well as the consolidation of recent sensory experiences.

Long-term disease-free survival in three ovarian cancer patients with a single relapse

Recurrent ovarian cancer with long-term survival is uncommon and often associated with poor prognosis. We report three cases of patients with advanced ovarian cancer who have achieved long-term disease-free survival following a single prior relapse. Case 1 relapsed with a localized bulky tumor and received a complete surgical resection and chemotherapy. Case 2 had a persistent central pelvic tumor after debulking surgery and second-line chemotherapy, and yet achieved excellent control with concurrent chemoradiation to the true pelvis. Case 3 relapsed with paraaortic lymph node metastasis and probable lung metastasis (subsequently negated by positron emission tomography) and received chemotherapy alone. These three patients have since remained disease-free for 13, 12, and seven years, respectively, since their first relapse. We conclude that select patients can obtain long-term disease-free survival after the first relapse by accurate restaging and aggressive multimodality treatment.

The crimson care collaborative: a student-faculty initiative to increase medical students' early exposure to primary care

The current shortage of primary care physicians (PCPs), particularly as more individuals obtain health insurance and seek primary care services, is a growing national concern. The Crimson Care Collaborative (CCC) is a joint student-faculty initiative in post-health-care-reform Massachusetts that was started with the explicit goal of attracting medical students to primary care careers. It fills a niche for student-run clinics, providing evening access to primary care services for patients without a PCP and urgent care services for patients of a Massachusetts General Hospital-affiliated internal medicine clinic, with the aim of decreasing emergency department use in both groups. Unlike other student-run clinics, CCC is integrated into the mainstream health care structure of an existing primary care clinic and, because of universal health insurance coverage in Massachusetts, can bill for its services. In addition to the clinical services offered, the student-run research team evaluates the quality of care and the patients' experiences at the clinic. This article describes the creation and development of CCC, including a brief overview of clinic operations, social services, research, laboratory services, student and patient education programs, and finance. In the wake of the Patient Protection and Affordable Care Act of 2010, CCC is an example of how students can aid the transition to universal health care in the United States and how medical schools can expose students early in their training to primary care and clinic operations.

Sex-specific, rapid neuroestrogen fluctuations and neurophysiological actions in the songbird auditory forebrain

Recent evidence shows that brain-derived steroids such as estrogens ("neuroestrogens") are controlled in a manner very similar to traditional neurotransmitters. The advent of in vivo microdialysis for steroids in songbirds has provided new information about the spatial and temporal dynamics of neuroestrogen changes in a region of the auditory cortex, the caudomedial nidopallium (NCM). Here, experiments using in vivo microdialysis demonstrate that neuroestradiol (E(2)) fluctuations occur within the auditory NCM during presentation of naturalistic auditory and visual stimuli in males but only to the presentation of auditory stimuli in females. These changes are acute (within 30 min) and appear to be specific to the NCM, because similar treatments elicit no changes in E(2) in a nearby mesopallial region or in circulating plasma. Further experiments coupling in vivo steroid microdialysis with extracellular recordings in NCM show that neuroestrogens rapidly boost auditory responses to song stimuli in females, similar to recent observations in males. We also find that the rapid actions of estradiol on auditory responses are fully mimicked by the cell membrane-impermeable estrogen biotinylestradiol, consistent with acute estrogen actions at the neuronal membrane. Thus we conclude that local and acute E(2) flux is regulated by convergent multimodal sensory input, and that this regulation appears to be sex-specific. Second, rapid changes in local E(2) levels in NCM have consequences for the modulation of auditory processing in females and males. Finally, the rapid actions of neuroestrogens on NCM auditory processing appear to be mediated by a nonclassical, membrane-bound estrogen receptor.

Combined liquid and solid-phase extraction improves quantification of brain estrogen content

Accuracy in quantifying brain-derived steroid hormones ("neurosteroids") has become increasingly important for understanding the modulation of neuronal activity, development, and physiology. Relative to other neuroactive compounds and classical neurotransmitters, steroids pose particular challenges with regard to isolation and analysis, owing to their lipid solubility. Consequently, anatomical studies of the distribution of neurosteroids have relied primarily on the expression of neurosteroid synthesis enzymes. To evaluate the distribution of synthesis enzymes vis-à-vis the actual steroids themselves, traditional steroid quantification assays, including radioimmunoassays, have successfully employed liquid extraction methods (e.g., ether, dichloromethane, or methanol) to isolate steroids from microdissected brain tissue. Due to their sensitivity, safety, and reliability, the use of commercial enzyme-immunoassays (EIA) for laboratory quantification of steroids in plasma and brain has become increasingly widespread. However, EIAs rely on enzymatic reactions in vitro, making them sensitive to interfering substances in brain tissue and thus producing unreliable results. Here, we evaluate the effectiveness of a protocol for combined, two-stage liquid/solid-phase extraction (SPE) as compared to conventional liquid extraction alone for the isolation of estradiol (E(2)) from brain tissue. We employ the songbird model system, in which brain steroid production is pronounced and linked to neural mechanisms of learning and plasticity. This study outlines a combined liquid-SPE protocol that improves the performance of a commercial EIA for the quantification of brain E(2) content. We demonstrate the effectiveness of our optimized method for evaluating the region specificity of brain E(2) content, compare these results to established anatomy of the estrogen synthesis enzyme and estrogen receptor, and discuss the nature of potential EIA interfering substances.

Regulation of ovarian cancer progression by microRNA-187 through targeting Disabled homolog-2

MicroRNAs (miRNAs) play important roles in tumorigenesis by regulating oncogenes and tumor-suppressor genes. In this study, miR-187 and miR-200a were found to be expressed at higher levels in ovarian cancers than in benign tumors. In patients with ovarian cancer, however, higher levels of miR-187 and miR-200a expression were paradoxically associated with better OS and recurrence-free survival. Further, multivariate analysis showed that miR-187 served as an independent prognostic factor for patients with ovarian cancer (n=176). Computational prediction and microarray results indicated that miR-187 directly targeted Disabled homolog-2 (Dab2), and luciferase reporter assays confirmed that the target site of miR-187 was located at the 3'-UTR of the Dab2 gene. Generally considered as a tumor-suppressor gene, Dab2 may actually promote tumor progression in advanced cancers through epithelial-to-mesenchymal transition (EMT). Ectopic expression of miR-187 in cancer cells promoted cell proliferation, but continued overexpression of miR-187 suppressed Dab2 and inhibited migration. Suppression of miR-187 upregulated Dab2, which, by inhibiting E-cadherin levels while stimulating vimentin and phospho-FAK levels, promoted EMT. Reduced ovarian cancer Dab2 histoscores correlated with high miR-187 levels and improved outcomes of patients. Collectively, these results demonstrate distinct dual roles of Dab2 in cell proliferation and tumor progression. In the initial steps of tumorigenesis, upregulated miR-187 suppresses Dab2, promoting cell proliferation. During the later stages, however, continued increased levels of miR-187 inhibits the Dab2-dependent EMT that is associated with tumor invasiveness, which is presumed to be the reason why cancers with high miR-187 levels were associated with better survivals.

Successful salvage treatment of recurrent endometrial cancer with multiple lung and abdominal metastases

The prognosis of recurrent endometrial carcinoma is generally poor except for isolated vaginal or pelvic relapse without previous radiation. Recurrences associated with infield failure or distant metastasis carry a poor prognosis. We report a case of recurrent endometrial carcinoma treated with cytoreductive surgery, targeted radiation to lung metastasis defined by CT and PET and adjuvant chemo-hormone therapy followed by maintenance progestin therapy with a good outcome. This case implied that chemo-hormone therapy with targeted radiation should be evaluated in recurrent endometrial cancer with positive progesterone receptor for salvage treatment.

Identifying LRRC16B as an oncofetal gene with transforming enhancing capability using a combined bioinformatics and experimental approach

Oncofetal genes are expressed in embryos or fetuses, are downregulated or undetectable in adult tissues, and then re-expressed in tumors. Known oncofetal genes, such as AFP, GCB, FGF18, IMP-1 and SOX1, often have important clinical applications or pivotal biological functions. To find new oncofetal-like genes, we used the public information of expressed sequence tags to systematically analyze gene expression patterns and identified a novel oncofetal-like gene, LRRC16B. It increased the proliferation, anchorage-independent growth and tumorigenesis of transformed cells in xenografts, possibly through its effects on cyclin B1 protein levels. These findings exemplify the feasibility of using bioinformatics to find new oncofetal-like genes and suggest that more genes with important functional roles will be uncovered in the candidate gene list.

An exploration of Pap smear history and behavior of patients with newly diagnosed cervical cancer in Taiwan

e20582

Background: The national health insurance policy has provided a yearly Pap smear for women >= 30 years old since 1994 in Taiwan, yet the coverage rate is still unsatisfactory. The purpose of this study is (1) to investigate the Pap smear screening history of women newly diagnosed with cervical cancer and (2) to examine factors that influence participation in Pap smear screening program in these women. Methods: Patients primarily treated for cervical cancer at Chang Gung Memorial Hospital between November 2006 and June 2007 were enrolled into this prospective study. Questionnaires included (1) socio-demographic data, and (2) knowledge on Pap smear and cervical cancer. Results: Two hundred sixty-nine patients were eligible for analysis. The median age was 51 years old (range, 25–83). Of the 269 patients, 147 (54.6%) had never had a Pap smear before diagnosis, and 35 (13.0%) did not know about Pap smear. Socio-demographic factors that significantly influenced number of previous Pap smear screening (0 vs >=1) were education level, income less than 600 U.S. dollars per month, menopaused, multiple sexual partners, and increase number of sexual partners of the male consort. Of the 147 never received Pap women, the most common reasons were thought that Pap smear screening was not necessary (46.3%), embarrassment (42.0%), busy (43.5%), and worry about the screening findings (20.4%). Of the 122 patients who have received Pap smear, 56.6% patients thought that Pap smear screening was necessary, 35.2% patients worried about the disease, 24.6% were alert on their check-ups, and 20.5% did the screening for the convenience to nearby clinics. Conclusions: Public health organizations in Taiwan should put more efforts to provide women in low education level, low income and multiple sexual partners with information on Pap smear.

No significant financial relationships to disclose.

A review of the epidemiology of cancers at the University Teaching Hospital, Lusaka, Zambia

This is a retrospective study based on pathology reports of specimens reviewed at the University Teaching Hospital (UTH) pathology laboratory in Lusaka, Zambia, from January 1997 to December 2005. UTH is the main reference hospital in Zambia and has a catchment area covering 1.3 million people. The most common cancer among men was Kaposi's sarcoma followed by cancer of the eye, soft tissue sarcomas and cancer of the prostate. The most common cancer among women was cancer of the cervix, followed by cancer of the eye, cancer of the breast and Kaposi's sarcoma. Non-Hodgkin's lymphoma is the fifth most common cancer in both men and women. There has been a significant change in the pattern of malignancies at the UTH over the last 20 years, with an increase in Kaposi's sarcoma, cancer of the cervix and cancer of the eye.

Subtotal colectomy for toxic and fulminant colitis in the era of immunosuppressive therapy

OBJECTIVE

Prolonged use of immunosuppressive medication to avoid surgery is becoming more common in patients with inflammatory bowel disease, with severe or fulminant colitis. The effect of immunosuppression on postoperative outcomes was reviewed.

METHOD

Patients undergoing subtotal colectomy (STC) for fulminant or toxic colitis from 1992 to 2006 were studied to define the effect of immunosuppression (IS) on postoperative complications (POCs). Patient characteristics, diagnosis, operative indication, details of surgery, use of IS, and POC's were reviewed and univariate and multivariate analysis was performed.

RESULTS

Eighty-nine patients were studied (55 males). Seventy-two (91%) patients had fulminant colitis and 17 (20%) had toxic colitis. The preoperative diagnosis was ulcerative colitis in 74, indeterminate in 10, and Crohn's disease in five patients. Eighty-two (92%) patients were on some form of immunosuppression, and 14 had a perforation at surgery. Thirty-nine (43.8%) patients experienced a POC. There was no operative mortality. Univariate analysis identified perforation (P = 0.048) and length of surgery (P = 0.002) as predictive of POCs, while multivariate analysis failed to identify a predictor of complications.

CONCLUSION

There was no association between immunosuppression and postoperative complications. Complications in this setting are a result of the severity of the inflammatory bowel disease.

Early childhood infection by human herpesvirus 8 in Zambia and the role of human immunodeficiency virus type 1 coinfection in a highly endemic area

Kaposi's sarcoma occurs at high incidence among Zambian adults and children, but there is a paucity of data on human herpesvirus 8 (HHV-8) incidence and routes of infection, especially in children. Between 1998 and 2004, the authors conducted a prospective study of viral transmission in a cohort of 684 children in Lusaka, Zambia, to estimate the annual incidence of HHV-8 from birth through 48 months of age. Maternal and pediatric human immunodeficiency virus type 1 (HIV-1) infection status was also determined. The results, based on 1,532 child-years of follow-up, showed that HHV-8 seroconversion occurs early in life. The incidence rate of HHV-8 seroconversion was 13.8 infections per 100 child-years by 48 months of age. HIV-1-infected children were at substantially higher risk for HHV-8 seroconversion (adjusted hazard ratio = 4.60, 95% confidence interval: 2.93, 7.22). Maternal HIV-1 and HHV-8 infection status were not independently associated with risk of HHV-8 seroconversion in the child. HHV-8 antibody titers in children followed at all consecutive time points revealed sero-reversion of HHV-8 antibodies, with undetectable titers in some children at one or more time points after seroconversion. These results demonstrate that cross-sectional serologic screening probably underestimates true HHV-8 seroprevalence in young Zambian children because of fluctuations in detectable antibody titers.

Outcome of antenatally diagnosed cardiac rhabdomyoma: case series and a meta-analysis

OBJECTIVES

Rhabdomyoma, the most common primary fetal cardiac tumor, is often associated with tuberous sclerosis (TS). We aimed to evaluate outcome in cases diagnosed with fetal cardiac rhabdomyoma.

METHODS

This study presents 11 cases with fetal cardiac rhabdomyoma. In addition, all relevant published cases of antenatally diagnosed cardiac rhabdomyoma since 1982 were identified from MEDLINE. We evaluated the following risk factors associated with clinical impact and perinatal outcome: family history of TS, gestational age at diagnosis, tumor size, site and number of tumors, tumor progression, and associated intracardiac and extracardiac anomalies.

RESULTS

In this meta-analysis, 138 cases, including nine newly added by us, were categorized into Group A (107 live babies) and Group B (16 neonatal deaths and 15 intrauterine fetal deaths). Univariate analysis showed that large cardiac tumors (P < 0.0001), fetal dysrhythmia (P < 0.0001) and hydrops (P < 0.0001) were strong predictors of neonatal outcome. Tumor size >or= 20 mm (relative risk (RR), 20.6; 95% CI, 2.2-195.9; P = 0.009) and fetal dysrhythmia (RR, 13.6; 95% CI, 2.9-62.3; P = 0.001) were significantly associated with neonatal morbidity. TS, present in 85/133 (63.9%) cases, was significantly associated with multiple cardiac tumors (P < 0.0001) and family history of TS (P = 0.02).

CONCLUSIONS

Large tumor size and hydrops are significantly associated with poor neonatal outcome, whereas family history of TS and multiple fetal cardiac tumors are associated with TS. Any sonographic detection of a fetal cardiac tumor should warrant further investigation for the possible presence of associated disorders.

Phaeochromocytoma crisis--a rare indication for extracorporeal membrane oxygenation

We report on a case of phaeochromocytoma whose initial presentation mimicked an acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation was used for the management of refractory cardiogenic shock and massive lung oedema. Suspicion and diagnosis of a phaeochromocytoma were made due to its unique clinical presentation during extracorporeal membrane oxygenation. Stabilisation of the crisis and recovery of cardiopulmonary function were achieved using the support of extracorporeal membrane oxygenation. This case highlights the difficulty in the differential diagnosis of cardiogenic shock secondary to phaeochromocytoma and the important role of extracorporeal membrane oxygenation can have in the successful resuscitation and management of these patients.

Prognostic factors and adjuvant therapy in uterine carcinosarcoma

PURPOSE OF INVESTIGATION

The objective of this retrospective study was to investigate prognostic variables and impact of adjuvant therapy in uterine carcinosarcoma.

METHODS

The clinical information and pathological confirmation were reviewed for cases with uterine carcinosarcoma from 1984 to 2005. A total of 45 patients were eligible for analysis.

RESULTS

The median follow-up for survivors was 84 months. Five-year overall survival and progression-free survival (PFS) rates were 36.5% and 33.8%, respectively for Stage I-IV. Distant site metastasis with/without pelvic failure occurred in 83.3% of those with recurrence/progression. By multivariate analysis, older age (p = 0.001) and more than half of myometrial invasion (p = 0.002) were significant predictors of death, while only myometrial invasion (p = 0.022) was significantly associated with PFS. Stratified analyses demonstrated a monotonic trend of chemotherapy or chemoradiation to decrease death.

CONCLUSIONS

Our results suggested that age and depth of myometrial invasion were significant prognostic factors, and chemotherapy or chemoradiation seemed to be beneficial for uterine carcinosarcoma.

Supraclavicular lymph node metastases in cervical cancer

PURPOSE OF INVESTIGATION

To evaluate the outcome and prognostic factors of patients with supraclavicular lymph node (SCLN) involvement at primary diagnosis.

METHODS

We reviewed the medical records of cervical cancer patients primarily treated at Chang Gung Memorial Hospital between 1987 and 2005. Thirty-three patients with histologically confirmed SCLN metastasis at primary diagnosis were eligible for analysis. Clinical and pathological features were analyzed for association with outcome.

RESULTS

The 3- and 5-year survival rates of patients with SCLN metastasis were 16.5% and 16.5%, respectively. Multivariate analysis showed the serum level of squamous cell carcinoma antigen (SCC-Ag) < 15 ng/ml at initial diagnosis (p = 0.021) and staging/restaging including [18F] fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) (p = 0.006) to be associated with a better prognosis.

CONCLUSION

Primary SCLN metastasis in cervical cancer is not incurable. The benefit from PET findings might help in selecting appropriate patients for curative primary and/or salvage treatment.