Increased retention of tau PET ligand [18F]-AV1451 in Alzheimer's Disease Psychosis

Psychosis in Alzheimer's disease (AD) represents a distinct disease subtype with a more rapid progression of illness evidenced by an increased velocity of cognitive decline and a hastened mortality. Previous biomarker and post-mortem studies have implicated tau neuropathology as a possible mediator of the accelerated decline in AD psychosis. Tau positron emission tomography (PET) neuroimaging provides the opportunity to evaluate tau pathology in-vivo, so that clinical symptomatology can be correlated with disease pathology. [¹⁸F]-AV1451 (Flortaucipir) is a PET ligand with high affinity for insoluble paired-helical filaments (PHFs) of hyperphosphorylated tau. In order to determine whether the development of psychosis and worsened prognosis in AD is associated with an increased burden of tau pathology that can be identified with tau imaging, we identified subjects within the Alzheimer's disease neuroimaging initiative (ADNI) who had [¹⁸F]-AV1451 imaging at baseline and became psychotic over the course of the study (N = 17) and matched them 1:3 for gender, age, and education to subjects who had [¹⁸F]-AV1451 imaging at baseline and did not become psychotic (N = 50). We compared baseline [¹⁸F]-AV1451 retention, in addition to cognitive and functional baseline and longitudinal change, in those who became psychotic over the course of participation in ADNI with those who did not. Results suggest that increases in tau pathology in frontal, medial temporal, and occipital cortices, visualized with [¹⁸F]-AV1451 binding, are associated with psychosis and a more rapid cognitive and functional decline.

Impact of Home-Delivered Meals on Nutrition Status and Nutrient Intake among Older Adults in Central Texas

OBJECTIVE

This study aimed to measure changes in nutrition risk and nutrient intake after older adults received home-delivered meals (HDM) for 3 months.

DESIGN

This study used a pre-posttest study design, with data collected before and after 3 months of HDM services.

SETTING

Two HDM programs that serve the metropolitan areas of Austin and San Antonio, Texas.

PARTICIPANTS

Study participants were aged 60 years or older, without dementia or terminal illness, and receiving HDM in Austin, Texas and San Antonio, Texas for 3 months.

MEASUREMENTS

The Nutrition Screening Initiative (NSI) and Mini Nutrition Assessment-Short Form (MNA-SF) were used to assess nutritional risk. The National Cancer Institute Diet History Questionnaire II (DHQ II) was used to assess nutrient intake over the past month.

RESULTS

After receiving 3 months of HDM, nutrition status significantly improved as measured by the NSI and MNA-SF. More participants met or exceeded the recommended dietary allowances (RDA) for magnesium and zinc after receiving HDM compared to before receiving HDM. Dietary supplement intake was associated with a higher nutritional risk.

CONCLUSION

Improvements in nutrition status were found after 3 months of receiving HDM, whereas intake of most nutrients did not change significantly. Results of this study provide further evidence that HDM can reduce nutritional risk of older adults, and may inform HDM programs on the differences of NSI and/or MNA-SF to assess nutritional risk of clients.

Trimodality treatment versus surgery alone for esophageal cancer. A stratified analysis with minimally invasive pretreatment staging

BACKGROUND

Accurate pretreatment staging of esophageal cancer (EC) is important in the evaluation and comparison of results of different treatment modalities. Few studies using minimally invasive staging techniques for this purpose have been reported. We previously demonstrated the usefulness of the thoracoscopic/laparoscopic (Ts/Ls) technique in pretreatment staging of EC. This study was conducted to evaluate the impact of trimodality based on pretreatment Ts/Ls staging diagnosis on EC.

METHODS

A retrospective study was performed on 2 groups of EC patients. Group A (44 patients) underwent pretreatment Ts/Ls staging and had trimodality treatment. Preoperative therapy consisted of concurrent chemotherapy (5-FU + cisplatinum) and radiotherapy. Group B (33 patients) underwent surgery alone. The study focused on stratified comparison of patterns of recurrence and survival in different pretreatment surgical T, N, and TNM stage categories.

RESULTS

The 3-year disease free survival of Group A was 40.8% with a median survival of 32.0 months, it was 43.6% with a median survival of 23.6 months in Group B. The difference was not significant (p=0.87). There was no difference in recurrence pattern between the 2 groups. Patients with squamous cell carcinoma in Group A had no local recurrence during the follow-up period while those in Group B had a high local recurrence rate of 40% (p<0.005). When stratified by T factor, patients with locally advanced T stage (T3-4) in Group A had a lower distant recurrence rate than their counterpart patients in Group B (9.1 vs 38.5%, p=0.03), they had a better survival but the difference was not significant (3-year disease free survival: 41.7 vs 17.9%, p=0.14). There were no significant differences in recurrence pattern and survival in different N categories and TNM stages between 2 groups. Multivariate analysis showed that only pretreatment surgical N status was an independent prognostic factor for the whole group (p=0.02).

CONCLUSIONS

Pretreatment Ts/Ls staging can provide accurate staging information for EC patients. Trimodality treatment was successful in local control for patients with squamous cell carcinoma. It was effective in reducing distant recurrence and might prolong survival in patients with advanced T stages. Pretreatment lymph node status was the most important prognosticator regardless of treatment modality. Pretreatment pathological staging should be included in the future clinical trials on multimodality treatments in EC patients.

Accurate lymph node assessment prior to trimodality therapy for esophageal carcinoma

PURPOSE

The diagnosis of esophageal carcinoma has historically been associated with a poor prognosis. Recently, investigators have reported improved outcomes for this patient population with the use of trimodality therapy. These results have fueled the debate regarding which patients may benefit from this aggressive treatment course. This retrospective analysis was conducted in order to evaluate the importance of regional lymph node involvement, determined by surgical staging before the initiation of therapy.

PATIENTS AND MATERIALS

Between July 1991 and June 1999, 45 patients underwent surgical staging with thoracoscopy and/or laparoscopy followed by induction chemoradiation and surgical resection. All patients underwent consultation in our thoracic multidisciplinary clinic. Thoracoscopy included nodal sampling from American Thoracic Society levels 5, 6, 8, and 9 within the mediastinum. Laparoscopy included inspection of the liver and nodal sampling from the lesser curvature and the celiac axis. Preoperative chemoradiation consisted of two cycles of 5-fluorouracil (1000 mg/M2) and cisplatin (100 mg/M2) weeks 1 and 4 with 50.4 Gy. Radiotherapy was delivered at 1.8 Gy/fraction with 39.6 Gy being delivered to the large-field and 10.8 Gy to a small-field boost. The routine surgical procedure was an Ivor-Lewis esophagectomy performed 4 to 6 weeks after completion of induction therapy.

RESULTS

The median follow up was 24 months for all patients. The median overall survival was 23 months, with 1-, 2-, and 3-year survivals of 64%, 42%, and 34%, respectively. Thirty patients had pathological evidence of lymph node disease before therapy. The pathological complete response rate for the entire group was 51%. Node-positive patients had a path complete response rate of 14%, as compared with 59% for those who were NO. The median survival for these two groups was 15 months versus 35 months. Patients whose nodes were cleared by chemoradiation had a 3-year survival of 40%, whereas all patients with persistent nodal disease were dead by 2 years. Twenty-one patients have experienced recurrence of their disease. Thirteen patients had evidence of distant metastasis only, three local only, and five with both.

CONCLUSION

Trimodality therapy offers patients with esophageal cancer an opportunity for long-term survival. Our experience has shown that minimally invasive pretreatment surgical staging provides useful information that can predict complete response and can help in the selection of appropriate patients for aggressive therapy.

Pretreatment surgical lymph node staging predicts results of trimodality therapy in esophageal cancer

OBJECTIVE

Prediction of responders to induction therapy in esophageal cancer (EC) patients is important. In this study, we evaluated the role of thoracoscopic/laparoscopic (Ts/Ls) staging in prediction of treatment response and survival in EC patients with trimodality treatment.

METHODS

Retrospective study of EC patients who had undergone Ts/Ls staging and received trimodality treatment at the University of Maryland Medical Center and the Baltimore Veterans Administration Hospitals from July, 1991 to December, 1999. Preoperative therapy consisted of concurrent chemotherapy (5-FU + cisplatinum) and radiotherapy.

RESULTS

Forty-four EC patients who underwent pretreatment Ts/Ls staging during the study period were able to complete concurrent chemoradiotherapy followed by surgical resection. There were 36 men and 8 women aged 40 to 77 (median age 62). Twenty-seven (61.4%) patients were found to have lymph node metastasis by surgical staging. Fourteen patients (31.8%) had a pathologic complete response. Patients with positive lymph nodes had a lower response rate than those with negative lymph nodes (14.8% vs. 58.8%, P=0.006). Other clinicopathologic features including gender, weight loss, clinical TNM stage, surgical T stage, and histology did not correlate with treatment response. Univariate analysis showed that weight loss and treatment response were important prognostic factors for disease-free survival (P=0.01 and P=0.02, respectively). Histology, surgical N stage and surgical TNM stage appeared to be associated with prognosis (P=0.067-0.097). Multivariate analysis revealed that only surgical N status and weight loss were significant prognostic factors (P=0.05, and P=0.006, respectively).

CONCLUSIONS

Surgical Ts/Ls staging provides accurate evaluation of tumor spread in EC patients. Pretreatment N status was the single most important predictor of response to induction treatment as well as a reliable prognosticator of survival.

Managing our way to higher service-sector productivity

In the two decades following World War II, U.S. productivity grew at an annual rate of 3%. But since the beginning of the 1970s, it has grown at only about 1%. Had the earlier rate been sustained, the gross domestic product would now be about $11 trillion instead of about $6.5 trillion. That extra $4.5 trillion per year in economic output would have had a profound impact on a wide range of social and economic problems. What is preventing a productivity revival in the U.S. economy? Clearly not the manufacturing sector, which has rebounded since the early 1980s. The service sector, on the other hand, has seen productivity growth rates stagnate during the same period. Why? Michael van Biema and Bruce Greenwald believe that the usual explanations are incomplete and have resulted in some serious misconceptions. The authors point out the limitations of those explanations and offer one of their own. They lay the blame in two places: the ineffectiveness of many service-sector managers at improving productivity and the inherent complexity of the sector itself. The authors argue that the problem is not a lack of resources; rather, it is that service sector companies operate below their potential. If managers focused on putting the existing technologies, labor force, and capital stock to work, rapid productivity growth would follow. Although the service sector is complex, the authors believe that managers would do well to apply the same tools, techniques, and policies that have been so effective in manufacturing sector. Doing so would help them keep their eye on the ball - the efficiency of basic operations.

Computed radiography in neonatal and pediatric intensive care units: a comparison of 2.5 K x 2 K soft-copy images vs digital hard-copy film

OBJECTIVE

The goal of the study was to determine whether soft-copy images on high-resolution monitors (2.5 K x 2 K) are suitable for primary interpretation of images from pediatric and neonatal intensive care units. The hypotheses were that hard and soft images yield similar diagnostic information, and that both residents and faculty radiologists can use monitors effectively. Previous reports have produced conflicting results; the need for larger sample sizes has been emphasized.

MATERIALS AND METHODS

One thousand one hundred and four images produced by computed radiography using the Kodak Ectascan Imagelink system were prospectively analyzed by two pediatric radiologists, one reading hard copy and the other soft copy of the same images. Bias was controlled by equal distribution of modalities between observers and by daily alternation of modality. Hard- and soft-copy observations of presence or absence of nine specific tubes and nine specific diagnostic findings were compared. Interobserver differences between pediatric radiologists and radiology residents were studied on additional images. The kappa statistic was used to evaluate the level of agreement for all observations.

RESULTS

There was excellent agreement between hard and soft copy interpretation for each tube and diagnostic finding (kappa values 0.93-1.0) and excellent interobserver agreement between two pediatric radiologists (kappa values 0.84-1.0). The level of agreement between radiology residents and pediatric radiologist was excellent for the most objective findings. All results were statistically significant (p < 0.001).

CONCLUSION

High resolution soft-copy images are suitable for primary interpretation in patients in pediatric and neonatal intensive care units.

Barretts carcinoma in a 25-year-old man with point mutation of the p53 tumor suppressor gene

Barrett's esophagus is a recognized risk factor for adenocarcinoma of the esophagus. Dysplasia in Barrett's epithelium is considered a precursor to malignancy. Several tumor suppressor genes, including p53, have recently been implicated in the pathogenesis of esophageal adenocarcinoma. However, the interval between the development of Barrett's esophagus, dysplasia, and frank malignancy is usually very long. A case of adenocarcinoma of the esophagus arising from Barrett's esophagus in a 25-year-old man is discussed. Point mutation in exon 8 of p53 was discovered in this patient's tumor and surrounding dysplastic Barrett's mucosa. To our knowledge, this is the youngest reported case of Barrett's-associated esophageal adenocarcinoma in the medical literature. It suggests that acquired somatic mutations in tumor suppressor genes may occur early in life and that these mutations may contribute to the development of dysplasia and cancer in Barrett's esophagus.